2020 cigna comprehensive drug list (formulary)€¦ · for your drug in the covered drugs index...

This drug list was updated in May 2020. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-668-3813 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m. local time, or visit www.CignaMedicare.com. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal. HPMS Approved Formulary File Submission ID 20087, Version Number 12 INT_20_76977_C_Final_3e

Plan coveredCigna-HealthSpring Achieve (HMO C-SNP)

Please read: This document contains information about all of the drugs we cover in this plan.

2020 CIGNA COMPREHENSIVE DRUG LIST (Formulary)

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What is the Cigna Comprehensive Drug List?A drug list is a list of covered drugs selected by Cigna in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Cigna will generally cover the drugs listed in our drug list as long as the drug is medically necessary, the prescription is filled at a Cigna network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Drug List (formulary) change?Most changes in drug coverage happen on January 1, but we may add or remove drugs on the drug list during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes.Changes that can affect you this year. In the below cases, you will be affected by coverage changes during the year:• New generic drugs. We may immediately remove a brand

name drug on our drug list if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our drug list, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. – If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and

you can also find information in the section entitled “How do I request an exception to the Cigna Drug List?”

• Drugs removed from the market. If the Food and Drug Administration (FDA) deems a drug on our drug list to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our drug list and provide notice to customers who take the drug.

• Other changes. We may make other changes that affect customers currently taking a drug. For instance, we may add a generic drug that is not new to the market to replace a brand name drug currently on the drug list or add new restrictions to the brand name drug or move it to a different cost-sharing tier.). Or we may make changes based on new clinical guidelines and/or studies. If we remove drugs from our drug list, add prior authorization, quantity limits, and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected customers of the change at least 30 days before the change becomes effective, or at the time the customer requests a refill of the drug, at which time the customer will receive a 30-day supply of the drug. – If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Cigna’s Drug List?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with

Note to existing customers: This drug list has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Cigna. When it refers to “plan” or “our plan,” it means Cigna-HealthSpring Achieve (HMO C-SNP).

This document includes a list of the drugs (formulary) for our plans, which is current as of May 2020. For an updated drug list, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during the year.

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no new restrictions for those customers taking them for the remainder of the coverage year. The enclosed drug list is current as of May 2020. To get updated information about the drugs covered by Cigna, please contact us. Our contact information appears on the front and back cover pages. If there are significant changes made to the printed drug list within the covered year, you may be notified by mail identifying the changes. Drug lists located on our website are reviewed and updated on a monthly basis.

How do I use the Drug List? There are two ways to find your drug within the drug list:Medical ConditionThe drug list begins on page 7. The drugs in this drug list are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “CARDIOVASCULAR, HYPERTENSION / LIPIDS”. If you know what your drug is used for, look for the category name in the list that begins on page 7. Then look under the category name for your drug. Covered Drug IndexIf you are not sure what category to look under, you should look for your drug in the Covered Drugs Index that begins on page 56. The Covered Drugs Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Covered Drug Index and find the name of your drug in the drug name column of the list.

What are generic drugs?Cigna covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Cigna requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval from Cigna before you fill these prescriptions. If you don’t get approval, Cigna may not cover the drug.

• Quantity Limits: For certain drugs, Cigna limits the amount of the drug that Cigna will cover. For example, Cigna allows for 1 tablet per day for candesartan 32mg. This applies to a standard one-month supply (for total quantity of 30 per 30 days) or three-month supply (for total quantity of 90 per 90 days).

• Step Therapy: In some cases, Cigna requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Cigna may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Cigna will then cover Drug B.

• Non-Extended Days Supply: For certain drugs, Cigna limits the amount of the drug that Cigna will cover to only a 30-day supply or less, at one time. For example, customers who have not had any recent fill of opioid pain medications within the past 120 days (referred to as “opioid naïve”) are limited to a maximum of 7 days’ supply of opioid pain medication. Customers who have received a recent fill of an opioid pain medication (not opioid naïve) are limited to up to a month’s supply of that medication at one time. Other high cost drugs may be subject to a non-extended day supply restriction, as well.

You can find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.You can ask Cigna to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Cigna drug list?” on page 3 for information about how to request an exception.

Options for Maintenance MedicationsTaking the medications prescribed by your doctor (or other prescriber) is important to your health. We are committed to helping you control your chronic conditions by making it easy for you to receive your maintenance medications. There are several ways we can work together to accomplish this goal:• Talk with your doctor about whether a 90-day supply of your

ongoing, stable medications may be appropriate. Taking these medications every day as prescribed is important for

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your overall health, and getting 90-day prescriptions of these medications can help ensure that you do not miss a dose.

• You can receive a 90-day supply at most retail pharmacies or through one of our mail-order pharmacies.

• Talk to your pharmacist if you are experiencing any new challenges with your maintenance medications.

How can I use my prescription drug coverage to save money on my medications?There may be opportunities for you to save money on your medications using your Cigna coverage.• Ask your doctor (or other prescriber) if there are any lower-

cost generic alternatives available for any of your current medications.

• Some plans may offer a $0 copay for Tier 1 and 2 generic drugs filled at a preferred retail and/or mail-order pharmacies. Check the Drug Tier and Cost-share Tables on page 5 to see if your plan offers these savings.

• Explore whether the ‘CMS Extra Help’ program may offer additional financial support for your medications.

• If your medication is not covered in the Cigna drug list, talk with your doctor about alternative medications which are covered in the drug list.

What if my drug is not on the Drug List?If your drug is not included in this drug list, you should first contact Customer Service and ask if your drug is covered. If you learn that Cigna does not cover your drug, you have two options:• You can ask Customer Service for a list of similar drugs that

are covered by Cigna. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Cigna.

• You can ask Cigna to make an exception and cover your drug. See the next section for information about how to request an exception.

How do I request an exception to the Cigna Drug List?You can ask Cigna to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.• You can ask us to cover a drug even if it is not on our drug

list. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Cigna limits the

amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

• You can ask us to provide a tiering exception for a higher cost-sharing drug to be covered at a lower cost-sharing tier under following circumstances: – If the drug you’re taking is a brand name drug you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains brand name alternatives for treating your condition.

– If the drug you’re taking is a generic drug you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains either brand or generic alternatives for treating your condition.

– If the drug you’re taking is a biological product you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains biological product alternatives for treating your condition.

These exceptions would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not in our drug list, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier.

Generally, Cigna will only approve your request for an exception if the alternative drugs included in our drug list, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a drug list, tiering or utilization restriction exception. When you request a drug list, tiering or utilization restriction exception you should submit a statement from your prescriber or doctor supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or existing customer in our plan you may be taking drugs that are not on our drug list. Or, you may be taking a drug

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that is on our drug list but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a drug list exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug up to a 30-day supply, in certain cases during the first 90 days you are a customer of our plan.For each of your drugs that is not on our drug list or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs without a drug list exception, even if you have been a customer of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not on our drug list or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a drug list exception. In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning, such as level-of-care changes due to discharge from a hospital to a nursing facility or to a home, Cigna will allow a one-time 31-day supply (unless the prescription is written for fewer days). Cigna’s Drug ListThe comprehensive drug list that begins on page 7, provides coverage information about all of the drugs covered by Cigna. If you have trouble finding your drug in the list, turn to the Covered Drug Index that begins on page 56.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., TRELEGY ELLIPTA) and generic drugs are listed in lower-case italics (e.g., candesartan).The information in the Requirements/Limits column tells you if Cigna has any special requirements for coverage of your drug. We provide quantity limits on certain drugs which are indicated with a QL in the Covered Drugs by Category list on page 7 along with the amount dispensed per the days supplied. (For example: candesartan 32mg QL 30/30; this means the drug candesartan 32mg is limited to 30 tablets per 30 days. For 90-day supplies, this quantity limit would be expanded to 90 tablets per 90 days).

What is a preferred network pharmacy?If your plan has preferred network pharmacies, you will typically save money by using these pharmacies. Your prescription drug costs (like a copay or coinsurance) will typically be less at a preferred network pharmacy because it has a preferred agreement with your plan. If you need help finding a network pharmacy, please call Customer Service at 1-800-668-3813 (TTY 711), or you can visit www.CignaMedicare.com for the most current Pharmacy Directory.

For more information

For more detailed information about your Cigna prescription drug coverage, please review your Evidence of Coverage and other plan materials.If you have questions about Cigna, please contact us. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

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Drug Tier and Cost-Share TableThe following table represents the plan name, plan service area, the drug tier number as it appears on the drug list, and the cost-share amount for that tier number. Tier 1 is for Preferred Generic drugs. Tier 2 is for Generic drugs. Tier 3 is for Preferred Brand drugs. Tier 4 is for Non-Preferred drugs. Tier 5 is for Specialty tier drugs. Tier 6 is for Cigna-HealthSpring Achieve (HMO) plans only and is referred to as Select Diabetic drugs. Please refer to the following chart. You may also refer to your Evidence of Coverage document for additional details.Cigna is not always able to keep all generic medications in the Preferred Generic and Generic drug tiers, and some generic

medications may be in Tier 3, Tier 4, Tier 5, or Tier 6. Keep in mind that the name “Tier 3: Preferred Brand Drugs” is just a description of the majority of the drugs in the tier. It does not mean that there are only brand drugs in that tier.For customers receiving Extra Help: Your Low Income Subsidy (LIS) copay level will be based on how the Food and Drug Administration (FDA) classifies certain drugs. Due to this, a generic drug may receive a preferred brand copay, or a preferred brand drug may receive a generic drug copay. Please see your LIS Rider for additional information on these copay levels. Or call Customer Service for further clarification regarding a specific drug.

To locate your drug cost, please refer to the table(s) below to find your service area and the Medicare Advantage plan in which you are currently enrolled or would like to enroll.Cigna uses preferred network pharmacies. See your Pharmacy Directory or visit www.CignaMedicare.com to search for a preferred retail or mail-order pharmacy near you.

Service Area: Mid-Atlantic H2108-029 – Cigna-HealthSpring Achieve (HMO C-SNP): District of Columbia; Kent, New Castle and Sussex, Delaware

Drug Tier

Preferred Retail Cost-Sharing

Standard Retail Cost-Sharing

Preferred Mail-Order Cost-Sharing

Standard Mail-Order Cost-Sharing

30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 DaysTier 1: Preferred Generic Drugs $4 / $8 / $8 $9 / $18 / $18 $4 / $8 / $0 $9 / $18 / $18Tier 2: Generic Drugs $15 / $30 / $30 $20 / $40 / $40 $15 / $30 / $0 $20 / $40 / $40Tier 3: Preferred Brand Drugs $42 / $84 / $126 $47 / $94 / $141 $42 / $84 / $126 $47 / $94 / $141Tier 4: Non-Preferred Drugs $95 / $190 / $285 $100 / $200 / $300 $95 / $190 / $285 $100 / $200 / $300Tier 5: Specialty Tier 27% (30 days) 27% (30 days) 27% (30 days) 27% (30 days)Tier 6: Select Diabetic Drugs $5 / $10 / $10 $6 / $12 / $12 $5 / $10 / $10 $6 / $12 / $12

Service Area: MarylandH2108-030 – Cigna-HealthSpring Achieve (HMO C-SNP): Anne Arundel, Baltimore, Baltimore City and Harford, Maryland

Drug Tier






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Service Area: PennsylvaniaH3949-024 – Cigna-HealthSpring Achieve (HMO C-SNP): Bucks, Chester, Delaware, Lancaster, Montgomery and Philadelphia, Pennsylvania

Drug Tier






My MedicationsIn this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug list pages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before this page and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer Service at 1-800-668-3813, 7 days a week, 8 a.m. – 8 p.m. local time. TTY users can call 711.

My Medications Page Number in the Drug List Cost-Share through Cigna

Drug List Key:B/D – This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending on circumstances.NDS – Non-extended day supply medication. This drug is only available as a 30-day supply or less.PA – This drug requires prior authorization

QL – This drug has quantity limitsST – This drug has step therapy requirementsGenerally all medications in the drug list are available through mail-order, except when special circumstances or situations prohibit mailing a particular medication to your home.

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Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drugQL = Quantity Limits listed as (qty/days) ST = Step Therapy rules applyPA = Prior Authorization may be required B/D = Drugs covered under Medicare Part B or Part DNDS = Non-extended day supply medication You can find more information on the symbols by going to page 6.

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ANTI - INFECTIVES

ANTIFUNGAL AGENTSABELCET 5 PA; NDSAMBISOME 5 PA; NDSamphotericin b 4 PAcaspofungin 5 PA; NDSclotrimazole mucous membrane

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CRESEMBA ORAL 5 NDSfluconazole 2fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml

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flucytosine 5 NDSgriseofulvin microsize 4griseofulvin ultramicrosize 4itraconazole oral capsule 4 PA; QL (120/30)itraconazole oral solution 5 PA; NDSketoconazole oral 2MYCAMINE 5 NDSNOXAFIL ORAL SUSPENSION 5 PA; QL (600/30);

NDSNOXAFIL ORAL TABLET, DELAYED RELEASE (DR/EC)

5 PA; QL (96/30); NDS

nystatin oral suspension 2nystatin oral tablet 2POSACONAZOLE ORAL TABLET,DELAYED RELEASE (DR/EC)

5 PA; QL (96/30); NDS

terbinafine hcl oral 2voriconazole intravenous 5 PA; NDSvoriconazole oral suspension for reconstitution

5 PA; QL (300/30); NDS

voriconazole oral tablet 4 PAANTIVIRALSabacavir oral solution 3 QL (960/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

abacavir oral tablet 4 QL (60/30)abacavir-lamivudine 3 QL (30/30)abacavir-lamivudine-zidovudine 5 QL (60/30); NDSacyclovir oral capsule 2acyclovir oral suspension 200 mg/5 ml

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acyclovir oral tablet 2acyclovir sodium intravenous solution

4 B/D PA

adefovir 5 QL (30/30); NDSamantadine hcl 3APTIVUS 5 QL (120/30); NDSAPTIVUS (WITH VITAMIN E) 5 QL (285/28); NDSatazanavir oral capsule 150 mg 4 QL (30/30)atazanavir oral capsule 200 mg 5 QL (60/30); NDSatazanavir oral capsule 300 mg 5 QL (30/30); NDSATRIPLA 5 QL (30/30); NDSBARACLUDE ORAL SOLUTION

4 QL (630/30)

BIKTARVY 5 QL (30/30); NDSCIMDUO 5 QL (30/30); NDSCOMPLERA 5 QL (30/30); NDSCRIXIVAN ORAL CAPSULE 200 MG

4 QL (270/30)

CRIXIVAN ORAL CAPSULE 400 MG

4 QL (180/30)

DELSTRIGO 5 QL (30/30); NDSDESCOVY 5 QL (30/30); NDSdidanosine oral capsule,delayed release(dr/ec) 200 mg, 250 mg, 400 mg

4 QL (30/30)

DOVATO 5 QL (30/30); NDSEDURANT 5 QL (30/30); NDSefavirenz oral capsule 200 mg 3 QL (120/30)efavirenz oral capsule 50 mg 3 QL (180/30)efavirenz oral tablet 5 QL (30/30); NDS

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nevirapine oral tablet 3 QL (60/30)nevirapine oral tablet extended release 24 hr 100 mg

3 QL (90/30)

nevirapine oral tablet extended release 24 hr 400 mg

3 QL (30/30)

NORVIR ORAL POWDER IN PACKET

4 QL (360/30)

NORVIR ORAL SOLUTION 3 QL (480/30)NORVIR ORAL TABLET 4 QL (360/30)ODEFSEY 5 QL (30/30); NDSoseltamivir 3PIFELTRO 5 QL (30/30); NDSPREZCOBIX 5 QL (30/30); NDSPREZISTA ORAL SUSPENSION

5 QL (400/30); NDS

PREZISTA ORAL TABLET 150 MG

4 QL (180/30)


5 QL (60/30); NDS


3 QL (210/30)


5 QL (30/30); NDS

RESCRIPTOR ORAL TABLET 4 QL (180/30)RETROVIR INTRAVENOUS 4REYATAZ ORAL POWDER IN PACKET

5 QL (180/30); NDS

ribavirin oral capsule 3 QL (168/28)ribavirin oral tablet 200 mg 3rimantadine 2ritonavir 3 QL (360/30)SELZENTRY ORAL SOLUTION

5 QL (1610/26); NDS

SELZENTRY ORAL TABLET 150 MG, 75 MG

5 QL (60/30); NDS

SELZENTRY ORAL TABLET 25 MG

4 QL (240/30)

SELZENTRY ORAL TABLET 300 MG

5 QL (120/30); NDS

stavudine oral capsule 3 QL (60/30)STRIBILD 5 QL (30/30); NDSSYMFI 5 QL (30/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

EMTRIVA ORAL CAPSULE 3 QL (30/30)EMTRIVA ORAL SOLUTION 3 QL (680/28)entecavir 4 QL (30/30)EPCLUSA 5 PA; QL (28/28);

NDSEPIVIR HBV ORAL SOLUTION 4EVOTAZ 5 QL (30/30); NDSfamciclovir 3 QL (60/30)fosamprenavir 5 QL (120/30); NDSFUZEON SUBCUTANEOUS RECON SOLN

5 QL (60/30); NDS

GENVOYA 5 QL (30/30); NDSHARVONI 5 PA; QL (28/28);

NDSINTELENCE ORAL TABLET 100 MG, 200 MG

5 QL (60/30); NDS

INTELENCE ORAL TABLET 25 MG

4 QL (120/30)

INVIRASE ORAL TABLET 5 QL (120/30); NDSISENTRESS HD 5 QL (60/30); NDSISENTRESS ORAL POWDER IN PACKET

4 QL (60/30)

ISENTRESS ORAL TABLET 5 QL (120/30); NDSISENTRESS ORAL TABLET,CHEWABLE 100 MG

5 QL (180/30); NDS

ISENTRESS ORAL TABLET,CHEWABLE 25 MG

3 QL (180/30)

JULUCA 5 NDSKALETRA ORAL TABLET 100-25 MG

3 QL (300/30)

KALETRA ORAL TABLET 200-50 MG

5 QL (120/30); NDS

lamivudine oral solution 3 QL (900/30)lamivudine oral tablet 100 mg, 300 mg

3 QL (30/30)

lamivudine oral tablet 150 mg 3 QL (60/30)lamivudine-zidovudine 3 QL (60/30)LEXIVA ORAL SUSPENSION 4 QL (1575/28)lopinavir-ritonavir 3 QL (480/30)MAVYRET 5 PA; QL (84/28);

NDSnevirapine oral suspension 3 QL (1200/30)

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cefaclor oral tablet extended release 12 hr

3

cefadroxil oral capsule 3cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

3

cefadroxil oral tablet 3cefazolin 4cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml

4

CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/100 ML

4

cefdinir oral capsule 2cefdinir oral suspension for reconstitution

3

CEFEPIME IN DEXTROSE 5% 4cefepime in dextrose,iso-osm 4cefepime injection 4cefixime oral capsule 4 QL (30/30)cefixime oral suspension for reconstitution

4

cefotetan 4CEFOTETAN IN DEXTROSE, ISO-OSM

4

cefoxitin 4cefoxitin in dextrose, iso-osm 4cefpodoxime 2cefprozil 2ceftazidime 4CEFTAZIDIME IN D5W 4ceftriaxone in dextrose,iso-os 4ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SYMFI LO 5 QL (30/30); NDSSYMTUZA 5 QL (30/30); NDSSYNAGIS 5 PA; NDStenofovir disoproxil fumarate 4 QL (30/30)TIVICAY ORAL TABLET 10 MG 4 QL (60/30)TIVICAY ORAL TABLET 25 MG, 50 MG

5 QL (60/30); NDS

TRIUMEQ 5 QL (30/30); NDSTROGARZO 5 B/D PA; NDSTRUVADA 5 QL (30/30); NDSTYBOST 3 QL (30/30)valacyclovir oral tablet 1 gram 2 QL (120/30)valacyclovir oral tablet 500 mg 2 QL (60/30)valganciclovir 5 NDSVEMLIDY 5 NDSVIDEX 2 GRAM PEDIATRIC 4 QL (1200/30)VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 125 MG

4

VIRACEPT ORAL TABLET 250 MG

5 QL (270/30); NDS

VIRACEPT ORAL TABLET 625 MG

5 QL (120/30); NDS

VIREAD ORAL POWDER 5 QL (240/30); NDSVIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

5 QL (30/30); NDS

VOSEVI 5 PA; QL (30/30); NDS

XOFLUZA 4zidovudine oral capsule 3 QL (180/30)zidovudine oral syrup 3 QL (1680/28)zidovudine oral tablet 3 QL (60/30)CEPHALOSPORINScefaclor oral capsule 2cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

3

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml

3

erythromycin ethylsuccinate oral suspension for reconstitution 400 mg/5 ml

5 NDS

erythromycin ethylsuccinate oral tablet

3

erythromycin oral tablet 4erythromycin oral tablet,delayed release (dr/ec)

3

MISCELLANEOUS ANTIINFECTIVESalbendazole 5 NDSALINIA ORAL SUSPENSION FOR RECONSTITUTION

5 QL (180/30); NDS

ALINIA ORAL TABLET 5 QL (20/10); NDSamikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml

4

ARIKAYCE 5 PA; NDSatovaquone 4atovaquone-proguanil 2aztreonam injection recon soln 1 gram

3

aztreonam injection recon soln 2 gram

5 NDS

bacitracin intramuscular 4CAPASTAT 4CAYSTON 5 PA; QL (84/56);

NDSchloramphenicol sod succinate 4chloroquine phosphate 2clindamycin hcl 2CLINDAMYCIN IN 0.9% SOD CHLOR

4

clindamycin in 5% dextrose 4clindamycin palmitate hcl 4clindamycin pediatric 4clindamycin phosphate injection 4clindamycin phosphate intravenous solution 600 mg/4 ml

4

COARTEM 4 QL (24/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CEFTRIAXONE INJECTION RECON SOLN 100 GRAM

4

ceftriaxone intravenous 4cefuroxime axetil oral tablet 2cefuroxime sodium injection recon soln 750 mg

4

cefuroxime sodium intravenous 4cephalexin oral capsule 250 mg, 500 mg

1

cephalexin oral suspension for reconstitution

2

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML

4

tazicef 4TEFLARO 5 NDSERYTHROMYCINS / OTHER MACROLIDESazithromycin intravenous 4azithromycin oral packet 3azithromycin oral suspension for reconstitution

2

azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack)

2

azithromycin oral tablet 600 mg 2 QL (60/30)clarithromycin oral suspension for reconstitution

3

clarithromycin oral tablet 2clarithromycin oral tablet extended release 24 hr

2

DIFICID 5 PA; QL (20/10); NDS

e.e.s. 400 oral tablet 3ERYPED 400 5 NDSery-tab oral tablet,delayed release (dr/ec) 250 mg

3

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG, 500 MG

3

erythrocin (as stearate) oral tablet 250 mg

3

ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG

4

11



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MEROPENEM-0.9% SODIUM CHLORIDE

4

metro i.v. 4metronidazole in nacl (iso-os) 4metronidazole oral tablet 1NEBUPENT 3 B/D PA; QL (1/28)neomycin 2ORBACTIV 5 QL (3/30); NDSparomomycin 4PASER 4PENTAM 3pentamidine inhalation 3 B/D PA; QL (1/28)pentamidine injection 3polymyxin b sulfate 4praziquantel 4PRIFTIN 4PRIMAQUINE 3pyrazinamide 3quinine sulfate 4 PA; QL (42/7)rifabutin 3rifampin intravenous 4rifampin oral 2RIFATER 4SIRTURO 4 PA; QL (188/365)SIVEXTRO INTRAVENOUS 5 B/D PA; QL (6/28);

NDSSIVEXTRO ORAL 5 QL (6/28); NDSstreptomycin 4SYNERCID 5 NDStigecycline 5 NDSTOBI PODHALER 5 QL (1568/365);

NDStobramycin in 0.225% nacl 5 B/D PA; QL

(280/28); NDStobramycin sulfate 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

colistin (colistimethate na) 4CYCLOSERINE 2dapsone oral 3DAPTOMYCIN INTRAVENOUS RECON SOLN 350 MG

5 B/D PA; NDS

daptomycin intravenous recon soln 500 mg

5 B/D PA; NDS

DARAPRIM 5 QL (90/30); NDSEMVERM 5 NDSertapenem 4ethambutol 3FIRVANQ 4gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml

4

GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML

4

gentamicin injection solution 40 mg/ml

4

gentamicin sulfate (ped) (pf) 4hydroxychloroquine 2imipenem-cilastatin 4isoniazid oral solution 3isoniazid oral tablet 2ivermectin oral 3lincomycin 4linezolid in dextrose 5% 4linezolid oral suspension for reconstitution

5 QL (1800/30); NDS

linezolid oral tablet 3 QL (60/30)linezolid-0.9% sodium chloride 4mefloquine 2meropenem 4

12


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nafcillin 4nafcillin in dextrose iso-osm 4oxacillin injection 4penicillin g potassium 4penicillin v potassium oral recon soln

1

penicillin v potassium oral tablet 250 mg

1

penicillin v potassium oral tablet 500 mg

2

pfizerpen-g 4PIPERACILLIN-TAZOBACTAM INTRAVENOUS RECON SOLN 13.5 GRAM

4

piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

4

ZOSYN IN DEXTROSE (ISO-OSM)

4

ZOSYN INTRAVENOUS RECON SOLN 2.25 GRAM, 3.375 GRAM

4

QUINOLONESBAXDELA 4 QL (28/14)ciprofloxacin 4ciprofloxacin hcl oral tablet 100 mg

3

ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg

2

ciprofloxacin in 5% dextrose 4levofloxacin in d5w 4levofloxacin intravenous 4levofloxacin oral solution 4levofloxacin oral tablet 2moxifloxacin oral 4MOXIFLOXACIN-SOD.ACE,SUL-WATER

4

moxifloxacin-sod.chloride(iso) 4SULFAS / RELATED AGENTSsulfadiazine 3sulfamethoxazole-trimethoprim intravenous

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TRECATOR 3VANCOMYCIN IN 0.9% SODIUM CHL INTRAVENOUS PIGGYBACK

4

VANCOMYCIN IN DEXTROSE 5% INTRAVENOUS PIGGYBACK

4

VANCOMYCIN INJECTION 4vancomycin intravenous recon soln 1,000 mg, 10 gram, 250 mg, 5 gram, 500 mg, 750 mg

4

VANCOMYCIN INTRAVENOUS RECON SOLN 1.25 GRAM, 1.5 GRAM

4

vancomycin oral capsule 125 mg

3 QL (40/10)

vancomycin oral capsule 250 mg

3 QL (80/10)

vancomycin oral recon soln 2VANCOMYCIN-WATER INJECT (PEG)

4

XIFAXAN ORAL TABLET 550 MG

5 PA; QL (90/30); NDS

PENICILLINSamoxicillin oral capsule 1amoxicillin oral suspension for reconstitution

1

amoxicillin oral tablet 2amoxicillin oral tablet,chewable 125 mg, 250 mg

2

amoxicillin-pot clavulanate oral suspension for reconstitution

2

amoxicillin-pot clavulanate oral tablet

2

amoxicillin-pot clavulanate oral tablet extended release 12 hr

4

amoxicillin-pot clavulanate oral tablet,chewable

2

ampicillin oral capsule 500 mg 2ampicillin sodium 4ampicillin-sulbactam 4BICILLIN L-A 4dicloxacillin 2

13



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nitrofurantoin macrocrystal 2nitrofurantoin monohyd/m-cryst 2trimethoprim 2

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTSleucovorin calcium injection recon soln

4

leucovorin calcium injection solution 10 mg/ml

4

leucovorin calcium oral 3mesna 4 B/D PAMESNEX ORAL 5 NDSXGEVA 5 PA; QL (1.7/28);

NDSANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGSabiraterone 5 PA; QL (120/30);

NDSABRAXANE 5 PA; NDSAFINITOR 5 PA; QL (28/28);

NDSAFINITOR DISPERZ 5 PA; QL (56/28);

NDSALECENSA 5 PA; QL (240/30);

NDSALIMTA 5 PA; NDSALIQOPA 5 PA; QL (3/28); NDSALKERAN 4ALUNBRIG ORAL TABLET 180 MG, 90 MG

5 PA; QL (30/30); NDS

ALUNBRIG ORAL TABLET 30 MG

5 PA; QL (180/30); NDS

ALUNBRIG ORAL TABLETS,DOSE PACK

5 PA; QL (60/365); NDS

anastrozole 2ARSENIC TRIOXIDE INTRAVENOUS SOLUTION 1 MG/ML

4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sulfamethoxazole-trimethoprim oral suspension

4

sulfamethoxazole-trimethoprim oral tablet

1

sulfatrim 4TETRACYCLINESdemeclocycline 3doxy-100 4doxycycline hyclate intravenous 4doxycycline hyclate oral capsule

1

doxycycline hyclate oral tablet 100 mg

1

doxycycline hyclate oral tablet 20 mg

2

doxycycline monohydrate oral capsule 100 mg, 50 mg

2

DOXYCYCLINE MONOHYDRATE ORAL CAPSULE,IR - DELAY REL,BIPHASE

4

doxycycline monohydrate oral suspension for reconstitution

2

doxycycline monohydrate oral tablet

3

minocycline oral capsule 2minocycline oral tablet 2mondoxyne nl oral capsule 100 mg, 75 mg

3

morgidox 1NUZYRA INTRAVENOUS 4 QL (15/14)NUZYRA ORAL 4 QL (30/14)tetracycline 2URINARY TRACT AGENTSmethenamine hippurate 2MONUROL 4nitrofurantoin 4

14


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3)

5 PA; QL (112/28); NDS

COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY)

5 PA; QL (84/28); NDS

COPIKTRA 5 PA; QL (60/30); NDS

COSMEGEN 5 B/D PA; NDSCOTELLIC 5 PA; QL (63/28);

NDScyclophosphamide intravenous 5 B/D PA; NDScyclophosphamide oral capsule 3 B/D PAcyclosporine intravenous 4 PAcyclosporine modified 4 PAcyclosporine oral capsule 4 PACYRAMZA 5 PA; NDSDARZALEX 5 PA; NDSdaunorubicin intravenous solution

4 B/D PA

DAURISMO ORAL TABLET 100 MG

5 PA; QL (30/30); NDS

DAURISMO ORAL TABLET 25 MG

5 PA; QL (60/30); NDS

DROXIA 3ELIGARD 4 PA; QL (1/30)ELIGARD (3 MONTH) 4 PA; QL (1/90)ELIGARD (4 MONTH) 4 PA; QL (1/120)ELIGARD (6 MONTH) 4 PA; QL (1/180)ELZONRIS 5 B/D PA; NDSEMCYT 4ENHERTU 5 PA; NDSENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG

4 PA

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 4 MG

5 PA; NDS

ERIVEDGE 5 PA; QL (28/28); NDS

ERLEADA 5 PA; NDSerlotinib oral tablet 100 mg, 150 mg

5 PA; QL (30/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

arsenic trioxide intravenous solution 2 mg/ml

4 B/D PA

ASTAGRAF XL 4 PAAVASTIN 5 PA; NDSAYVAKIT 5 PA; QL (30/30);

NDSAZASAN 3 PAazathioprine 2 PAazathioprine sodium 4 PABALVERSA ORAL TABLET 3 MG

5 PA; QL (90/30); NDS

BALVERSA ORAL TABLET 4 MG

5 PA; QL (60/30); NDS

BALVERSA ORAL TABLET 5 MG

5 PA; QL (30/30); NDS

BAVENCIO 5 PA; NDSBENDEKA 5 B/D PA; QL (8/21);

NDSBESPONSA 5 PA; NDSbexarotene 5 PA; NDSbicalutamide 2BORTEZOMIB 5 PA; QL (14/21);

NDSBOSULIF 5 PA; NDSBRAFTOVI 5 PA; QL (180/30);

NDSBRUKINSA 5 PA; NDSbusulfan 5 B/D PA; NDSBUSULFEX 5 B/D PA; NDSCABOMETYX ORAL TABLET 20 MG, 60 MG

5 PA; QL (30/30); NDS

CABOMETYX ORAL TABLET 40 MG

5 PA; QL (60/30); NDS

CALQUENCE 5 PA; QL (60/30); NDS

CAPRELSA ORAL TABLET 100 MG

5 PA; QL (60/30); NDS

CAPRELSA ORAL TABLET 300 MG

5 PA; QL (30/30); NDS

COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1)

5 PA; QL (56/28); NDS

15



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

GLEOSTINE ORAL CAPSULE 100 MG

4

HALAVEN 5 PA; NDSHERCEPTIN HYLECTA 5 PA; NDSHERCEPTIN INTRAVENOUS RECON SOLN 150 MG

5 PA; NDS

hydroxyurea 2IBRANCE 5 PA; QL (21/28);

NDSICLUSIG ORAL TABLET 15 MG

5 PA; QL (60/30); NDS

ICLUSIG ORAL TABLET 45 MG

5 PA; QL (30/30); NDS

IDHIFA 5 PA; QL (30/30); NDS

imatinib oral tablet 100 mg 5 PA; QL (180/30); NDS

imatinib oral tablet 400 mg 5 PA; QL (60/30); NDS

IMBRUVICA ORAL CAPSULE 140 MG

5 PA; QL (120/30); NDS

IMBRUVICA ORAL CAPSULE 70 MG

5 PA; QL (30/30); NDS

IMBRUVICA ORAL TABLET 5 PA; QL (30/30); NDS

IMFINZI 5 PA; NDSINFUGEM 5 B/D PA; NDSINLYTA ORAL TABLET 1 MG 5 PA; QL (180/30);

NDSINLYTA ORAL TABLET 5 MG 5 PA; QL (120/30);

NDSINREBIC 5 PA; QL (120/30);

NDSIRESSA 5 PA; QL (30/30);

NDSirinotecan 4 B/D PAISTODAX 5 PA; NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

erlotinib oral tablet 25 mg 5 PA; QL (60/30); NDS

etoposide intravenous 3 B/D PAeverolimus (antineoplastic) 5 PA; QL (28/28);

NDSEVOMELA 5 PA; NDSexemestane 2 QL (60/30)FARYDAK ORAL CAPSULE 10 MG, 20 MG

5 PA; QL (6/21); NDS

FASLODEX 5 B/D PA; QL (30/30); NDS

FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG

5 B/D PA; QL (4/365); NDS

FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG

4 B/D PA; QL (1/28)

fludarabine 4 B/D PAflutamide 2FOLOTYN 5 B/D PA; NDSfulvestrant 5 B/D PA; QL (30/30);

NDSGAZYVA 5 PA; NDSgemcitabine intravenous recon soln

4 B/D PA

gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml)

4 B/D PA

GEMCITABINE INTRAVENOUS SOLUTION 100 MG/ML

5 B/D PA; NDS

gengraf oral capsule 100 mg, 25 mg

4 PA

gengraf oral solution 4 PAGILOTRIF 5 PA; QL (30/30);

NDSGLEOSTINE ORAL CAPSULE 10 MG, 40 MG

3

16


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LUPRON DEPOT (4 MONTH) 5 PA; QL (1/112); NDS

LUPRON DEPOT (6 MONTH) 5 PA; QL (1/168); NDS

LUPRON DEPOT-PED 5 PA; QL (1/30); NDSLUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG

5 PA; QL (1/84); NDS

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG

5 PA; QL (1/112); NDS

LYNPARZA ORAL TABLET 5 PA; QL (120/30); NDS

LYSODREN 5 NDSMATULANE 5 NDSmegestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml)

3 PA

megestrol oral tablet 3 PAMEKINIST ORAL TABLET 0.5 MG

5 PA; QL (90/30); NDS

MEKINIST ORAL TABLET 2 MG

5 PA; QL (30/30); NDS

MEKTOVI 5 PA; QL (180/30); NDS

melphalan 4 B/D PAmelphalan hcl 5 B/D PA; NDSmercaptopurine 2methotrexate sodium (pf) 4methotrexate sodium injection 4methotrexate sodium oral 2MVASI 5 PA; NDSmycophenolate mofetil (hcl) 4 PAmycophenolate mofetil oral capsule

2 PA

mycophenolate mofetil oral suspension for reconstitution

5 PA; NDS

mycophenolate mofetil oral tablet

2 PA

mycophenolate sodium 2 PAMYLOTARG 5 PA; NDSNERLYNX 5 PA; QL (180/30);

NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

JAKAFI 5 PA; QL (60/30); NDS

KADCYLA 5 PA; NDSKANJINTI 5 PA; NDSKEYTRUDA INTRAVENOUS SOLUTION

5 PA; NDS

KISQALI 5 PA; QL (63/28); NDS

KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG

5 PA; QL (49/28); NDS


5 PA; QL (70/28); NDS


5 PA; QL (91/28); NDS

KYPROLIS 5 B/D PA; NDSLENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 4 MG

5 PA; QL (30/30); NDS

LENVIMA ORAL CAPSULE 12 MG/DAY (4 MG X 3), 18 MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY(10 MG X 2-4 MG X 1)

5 PA; QL (90/30); NDS

LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2)

5 PA; QL (60/30); NDS

letrozole 2LEUKERAN 4leuprolide subcutaneous kit 4 PALIBTAYO 5 PA; QL (7/21); NDSLONSURF ORAL TABLET 15-6.14 MG

5 PA; QL (100/28); NDS

LONSURF ORAL TABLET 20-8.19 MG

5 PA; QL (80/28); NDS

LORBRENA ORAL TABLET 100 MG

5 PA; QL (30/30); NDS

LORBRENA ORAL TABLET 25 MG

5 PA; QL (90/30); NDS

LUMOXITI 5 PA; NDSLUPRON DEPOT 5 PA; QL (1/30); NDSLUPRON DEPOT (3 MONTH) 5 PA; QL (1/84); NDS

17



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

REVLIMID ORAL CAPSULE 10 MG, 2.5 MG, 5 MG

5 PA; QL (28/28); NDS

REVLIMID ORAL CAPSULE 15 MG, 20 MG, 25 MG

5 PA; QL (21/28); NDS

RITUXAN 5 PA; NDSRITUXAN HYCELA 5 PA; NDSROMIDEPSIN 5 PA; NDSROZLYTREK ORAL CAPSULE 100 MG

5 PA; QL (150/30); NDS

ROZLYTREK ORAL CAPSULE 200 MG

5 PA; QL (90/30); NDS

RUBRACA 5 PA; QL (120/30); NDS

RUXIENCE 5 PA; NDSRYDAPT 5 PA; QL (224/28);

NDSSANDIMMUNE ORAL SOLUTION

4 PA

SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

5 PA; NDS

SIGNIFOR 5 PA; QL (60/30); NDS

SIMULECT 5 B/D PA; NDSsirolimus oral solution 5 PA; NDSsirolimus oral tablet 4 PASOLTAMOX 5 NDSSOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML

5 PA; QL (0.5/28); NDS

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 60 MG/0.2 ML

5 PA; QL (0.2/28); NDS

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 90 MG/0.3 ML

5 PA; QL (0.3/28); NDS

SPRYCEL 5 PA; QL (30/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NEXAVAR 5 PA; QL (120/30); NDS

nilutamide 5 QL (60/30); NDSNINLARO 5 PA; QL (3/28); NDSNUBEQA 5 PA; QL (120/30);

NDSNULOJIX 5 PA; QL (26/28);

NDSoctreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml

4 PA

octreotide acetate injection solution 50 mcg/ml

3 PA

ODOMZO 5 PA; QL (30/30); NDS

OGIVRI 5 PA; NDSOPDIVO 5 PA; QL (80/28);

NDSpaclitaxel 4 B/D PAPADCEV 5 PA; NDSPERJETA 5 PA; NDSPIQRAY ORAL TABLET 200 MG/DAY (200 MG X 1)

5 PA; QL (28/28); NDS

PIQRAY ORAL TABLET 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X 2)

5 PA; QL (56/28); NDS

POMALYST 5 PA; QL (21/28); NDS

POTELIGEO 5 PA; NDSPROGRAF INTRAVENOUS 4 PAPROGRAF ORAL GRANULES IN PACKET

4 PA

PURIXAN 5 PA; QL (300/30); NDS

RAPAMUNE ORAL SOLUTION 5 PA; NDS

18


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TREANDA INTRAVENOUS RECON SOLN 100 MG

5 B/D PA; NDS

TREANDA INTRAVENOUS RECON SOLN 25 MG

5 B/D PA; QL (8/21); NDS

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 11.25 MG

5 PA; QL (1/84); NDS


5 PA; QL (1/168); NDS


5 PA; QL (1/28); NDS

tretinoin (chemotherapy) 5 NDSTRIPTODUR 5 PA; QL (1/168);

NDSTRISENOX INTRAVENOUS SOLUTION 2 MG/ML

4 B/D PA

TRUXIMA 5 PA; NDSTYKERB 5 PA; QL (180/30);

NDSUNITUXIN 5 PA; NDSVECTIBIX 5 PA; NDSVELCADE 5 PA; QL (14/21);

NDSVENCLEXTA ORAL TABLET 10 MG

3 PA; QL (60/30)

VENCLEXTA ORAL TABLET 100 MG

5 PA; QL (120/30); NDS

VENCLEXTA ORAL TABLET 50 MG

3 PA; QL (30/30)

VENCLEXTA STARTING PACK 5 PA; QL (84/365); NDS

VERZENIO 5 PA; QL (60/30); NDS

vincasar pfs intravenous solution 1 mg/ml

4 B/D PA

vincristine 4 B/D PAvinorelbine 4 B/D PAVITRAKVI ORAL CAPSULE 100 MG

5 PA; QL (60/30); NDS

VITRAKVI ORAL CAPSULE 25 MG

5 PA; QL (180/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

STIVARGA 5 PA; QL (120/28); NDS

SUTENT 5 PA; QL (28/28); NDS

SYNRIBO 5 PA; QL (28/28); NDS

TABLOID 4tacrolimus oral 2 PATAFINLAR 5 PA; QL (120/30);

NDSTAGRISSO 5 PA; QL (30/30);

NDSTALZENNA 5 PA; QL (90/30);

NDStamoxifen 2TARGRETIN TOPICAL 5 PA; QL (60/30);

NDSTASIGNA ORAL CAPSULE 150 MG, 200 MG

5 PA; QL (112/28); NDS

TASIGNA ORAL CAPSULE 50 MG

5 PA; QL (420/30); NDS

TAZVERIK 5 PA; NDSTECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML)

5 PA; QL (20/21); NDS

TECENTRIQ INTRAVENOUS SOLUTION 840 MG/14 ML (60 MG/ML)

5 PA; QL (28/28); NDS

temsirolimus 5 B/D PA; QL (4/28); NDS

THALOMID ORAL CAPSULE 100 MG, 150 MG, 50 MG

5 PA; QL (28/28); NDS

THALOMID ORAL CAPSULE 200 MG

5 PA; QL (56/28); NDS

thiotepa 4 PATIBSOVO 5 PA; QL (60/30);

NDStoposar 3 B/D PAtopotecan intravenous recon soln

5 NDS

toremifene 5 QL (30/30); NDSTORISEL 5 B/D PA; QL (4/28);

NDSTRAZIMERA 5 PA; NDS

19



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ZORTRESS ORAL TABLET 0.5 MG

5 PA; QL (120/30); NDS

ZORTRESS ORAL TABLET 0.75 MG, 1 MG

5 PA; QL (60/30); NDS

ZYDELIG 5 PA; QL (60/30); NDS

ZYKADIA ORAL TABLET 5 PA; QL (140/28); NDS

ZYTIGA ORAL TABLET 500 MG

5 PA; QL (60/30); NDS

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTSAPTIOM ORAL TABLET 200 MG

5 QL (180/30); NDS

APTIOM ORAL TABLET 400 MG

5 QL (90/30); NDS

APTIOM ORAL TABLET 600 MG, 800 MG

5 QL (60/30); NDS

BANZEL ORAL SUSPENSION 5 PA; QL (2400/30); NDS

BANZEL ORAL TABLET 5 PA; NDSBRIVIACT ORAL SOLUTION 4 QL (600/30)BRIVIACT ORAL TABLET 4 QL (60/30)carbamazepine oral capsule, er multiphase 12 hr

2

carbamazepine oral suspension 100 mg/5 ml

2

carbamazepine oral tablet 2carbamazepine oral tablet extended release 12 hr

2

carbamazepine oral tablet,chewable

2

CELONTIN ORAL CAPSULE 300 MG

3

clobazam oral suspension 5 QL (480/30); NDSclobazam oral tablet 10 mg 4 QL (60/30)clobazam oral tablet 20 mg 5 QL (60/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VITRAKVI ORAL SOLUTION 5 PA; QL (300/30); NDS

VIZIMPRO 5 PA; QL (30/30); NDS

VOTRIENT 5 PA; QL (120/30); NDS

VYXEOS 5 B/D PA; NDSXALKORI 5 PA; QL (60/30);

NDSXATMEP 4 PAXOSPATA 5 PA; QL (90/30);

NDSXPOVIO ORAL TABLET 100 MG/WEEK (20 MG X 5)

5 PA; QL (20/28); NDS

XPOVIO ORAL TABLET 160 MG/WEEK (20 MG X 8)

5 PA; QL (32/28); NDS


5 PA; QL (12/28); NDS


5 PA; QL (16/28); NDS

XTANDI 5 PA; QL (120/30); NDS

YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML)

5 PA; QL (80/21); NDS

YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML)

5 PA; NDS

YONDELIS 5 PA; NDSYONSA 5 PA; QL (120/30);

NDSZEJULA 5 PA; QL (90/30);

NDSZELBORAF 5 PA; QL (240/30);

NDSZIRABEV 5 PA; NDSZOLINZA 5 QL (120/30); NDSZORTRESS ORAL TABLET 0.25 MG

4 PA; QL (60/30)

20


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lamotrigine oral tablet, chewable dispersible

2

lamotrigine oral tablet,disintegrating

2

levetiracetam in nacl (iso-os) 4levetiracetam intravenous 4levetiracetam oral 2LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG, 82.5 MG

3 QL gabapentin oral tablet 800 mg 2lamotrigine oral tablet 2lamotrigine oral tablet extended release 24hr

2

21



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

carbidopa-levodopa oral tablet extended release

3

carbidopa-levodopa oral tablet,disintegrating

2

carbidopa-levodopa-entacapone

3

entacapone 4 QL (240/30)NEUPRO 4pramipexole oral tablet 2pramipexole oral tablet extended release 24 hr 0.375 mg, 0.75 mg, 1.5 mg

4 QL (90/30)

pramipexole oral tablet extended release 24 hr 2.25 mg, 3 mg, 3.75 mg, 4.5 mg

4 QL (30/30)

rasagiline 3ropinirole oral tablet 2RYTARY 4 STselegiline hcl 3tolcapone 5 NDStrihexyphenidyl 2 PAMIGRAINE / CLUSTER HEADACHE THERAPYAIMOVIG AUTOINJECTOR 3 PA; QL (1/30)dihydroergotamine nasal 4 PA; QL (8/30)ergotamine-caffeine 3 QL (40/28)migergot 5 QL (20/28); NDSnaratriptan 3 QL (18/28)rizatriptan 3 QL (36/28)sumatriptan 4 QL (18/28)sumatriptan succinate oral 2 QL (18/28)sumatriptan succinate subcutaneous cartridge

4 QL (8/28)

sumatriptan succinate subcutaneous pen injector

4 QL (8/28)

sumatriptan succinate subcutaneous solution

4 QL (8/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SPRITAM ORAL TABLET FOR SUSPENSION 750 MG

4 QL (120/30)

SYMPAZAN 5 PA; QL (60/30); NDS

tiagabine 4topiramate oral capsule, sprinkle

2

topiramate oral tablet 2TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 25 MG, 50 MG

4 QL (30/30)

TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 200 MG

5 QL (60/30); NDS

valproic acid 2valproic acid (as sodium salt) oral solution

2

VALTOCO 5 PA; QL (10/30); NDS

vigabatrin 5 PA; QL (180/30); NDS

vigadrone 5 PA; QL (180/30); NDS

VIMPAT INTRAVENOUS 4 QL (1200/30)VIMPAT ORAL SOLUTION 4 QL (1200/30)VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG

4 QL (60/30)

VIMPAT ORAL TABLET 50 MG 4 QL (120/30)zonisamide 2ANTIPARKINSONISM AGENTSAPOKYN 5 PA; QL (60/30);

NDSbenztropine injection 4benztropine oral 2 PAbromocriptine 4carbidopa 4carbidopa-levodopa oral tablet 2

22


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

rivastigmine tartrate 4 QL (60/30)TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG

5 PA; QL (14/30); NDS

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46)

5 PA; QL (120/365); NDS

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 240 MG

5 PA; QL (60/30); NDS

tetrabenazine oral tablet 12.5 mg

5 PA; QL (90/30); NDS

tetrabenazine oral tablet 25 mg 5 PA; QL (120/30); NDS

TYSABRI 5 PA; QL (15/28); NDS

MUSCLE RELAXANTS / ANTISPASMODIC THERAPYbaclofen oral tablet 10 mg, 5 mg

1

baclofen oral tablet 20 mg 2cyclobenzaprine oral tablet 10 mg, 5 mg

3 PA

dantrolene oral 3methocarbamol oral 2 PApyridostigmine bromide oral syrup

5 NDS

pyridostigmine bromide oral tablet 60 mg

3

pyridostigmine bromide oral tablet extended release

3

regonol 4tizanidine oral capsule 4tizanidine oral tablet 2NARCOTIC ANALGESICSacetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml

2 QL (2700/30); NDS

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg

2 QL (360/30); NDS

acetaminophen-codeine oral tablet 300-60 mg

2 QL (180/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml

4 QL (8/28)

MISCELLANEOUS NEUROLOGICAL THERAPYAUSTEDO ORAL TABLET 12 MG, 9 MG

5 PA; QL (120/30); NDS

AUSTEDO ORAL TABLET 6 MG

5 PA; QL (60/30); NDS

COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML

5 PA; QL (30/30); NDS

COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML

5 PA; QL (12/28); NDS

dalfampridine 3 PA; QL (60/30)donepezil oral tablet 10 mg 2 QL (60/30)donepezil oral tablet 23 mg 4 QL (30/30)donepezil oral tablet 5 mg 2 QL (30/30)donepezil oral tablet,disintegrating 10 mg

2 QL (60/30)

donepezil oral tablet,disintegrating 5 mg

2 QL (30/30)

FIRDAPSE 5 PA; NDSgalantamine oral capsule,ext rel. pellets 24 hr

4 QL (30/30)

galantamine oral solution 4 QL (200/30)galantamine oral tablet 4 QL (60/30)GILENYA ORAL CAPSULE 0.5 MG

5 PA; QL (30/30); NDS

memantine oral capsule,sprinkle,er 24hr

4 PA; QL (30/30)

memantine oral solution 2 PA; QL (300/30)memantine oral tablet 10 mg 2 PA; QL (60/30)memantine oral tablet 5 mg 2 PA; QL (90/30)memantine oral tablets,dose pack

3 PA; QL (98/365)

NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK

3 PA; QL (56/365)

NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR

3 PA

NUEDEXTA 4 PA; QL (60/30)OCREVUS 5 PA; NDSrivastigmine 4 QL (30/30)

23



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml)

3 NDS

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml

3 QL (2700/30); NDS

HYDROCODONE-ACETAMINOPHEN ORAL TABLET 10-300 MG, 7.5-300 MG

3 QL (180/30); NDS

hydrocodone-acetaminophen oral tablet 10-325 mg, 7.5-325 mg

3 QL (180/30); NDS

hydrocodone-acetaminophen oral tablet 5-325 mg

3 QL (360/30); NDS

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg

3 QL (150/30); NDS

hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml, 2 mg/ml

4 NDS

hydromorphone injection solution 2 mg/ml

4 NDS

hydromorphone injection syringe 1 mg/ml, 2 mg/ml, 4 mg/ml

4 NDS

hydromorphone oral liquid 3 QL (1200/30); NDShydromorphone oral tablet 2 mg, 4 mg

3 QL (180/30); NDS

hydromorphone oral tablet 8 mg

3 QL (120/30); NDS

ibuprofen-oxycodone 3 QL (28/30); NDSINFUMORPH P/F 4 B/D PA; QL

(200/30); NDSlorcet (hydrocodone) 3 QL (360/30); NDSlorcet hd 3 QL (180/30); NDSlorcet plus oral tablet 7.5-325 mg

3 QL (180/30); NDS

methadone injection solution 4 QL (150/30); NDSmethadone intensol 3 QL (500/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ascomp with codeine 4 PA; QL (180/30)buprenorphine hcl injection solution

4 QL (150/30)

buprenorphine hcl injection syringe

4 QL (150/30); NDS

buprenorphine hcl sublingual 4 PA; QL (90/30)BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR

4 QL (4/28); NDS

buprenorphine transdermal patch weekly 7.5 mcg/hour

4 QL (4/28); NDS

butalbital compound w/codeine 4 PA; QL (180/30)butalbital-acetaminop-caf-cod 4 PA; QL (180/30)butalbital-acetaminophen-caff oral capsule

3 PA; QL (180/30)

butalbital-acetaminophen-caff oral tablet 50-325-40 mg

3 PA; QL (180/30)

butalbital-aspirin-caffeine oral capsule

4 PA; QL (180/30)

DURAMORPH (PF) 4 B/D PA; QL (180/30); NDS

endocet oral tablet 10-325 mg 3 QL (180/30); NDSendocet oral tablet 2.5-325 mg, 5-325 mg

3 QL (360/30); NDS

endocet oral tablet 7.5-325 mg 3 QL (240/30); NDSfentanyl 4 QL (10/30); NDSfentanyl citrate (pf) injection solution

4 B/D PA; NDS

fentanyl citrate (pf) intravenous syringe 100 mcg/2 ml (50 mcg/ml)

4 B/D PA; NDS

fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 800 mcg

5 PA; QL (120/30); NDS

fentanyl citrate buccal lozenge on a handle 200 mcg, 400 mcg, 600 mcg

4 PA; QL (120/30); NDS

24


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

morphine intravenous syringe 4 mg/ml

4 B/D PA; QL ; NDS

25



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sulindac 2tramadol oral tablet 50 mg 2 QL (240/30); NDStramadol-acetaminophen 3 QL (240/30); NDSVIVITROL 5 PA; NDSZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 11.4-2.9 MG

3 QL (30/30)

ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG

3 QL (90/30)

PSYCHOTHERAPEUTIC DRUGSABILIFY MAINTENA 5 QL (1/28); NDSalprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg

2 QL (120/30)

alprazolam oral tablet 2 mg 2 QL (150/30)alprazolam oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg

3 QL (90/30)

alprazolam oral tablet,disintegrating 2 mg

3 QL (150/30)

amitriptyline 3 PAamoxapine 3aripiprazole oral solution 3 QL (900/30)aripiprazole oral tablet 3 QL (30/30)aripiprazole oral tablet,disintegrating

5 QL (60/30); NDS

ARISTADA INITIO 5 QL (4.8/365); NDSARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML

5 QL (3.9/56); NDS

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML

5 QL (1.6/28); NDS


5 QL (2.4/28); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

diclofenac sodium oral 2diclofenac sodium topical drops 4 QL (450/28)diclofenac sodium topical gel 1%

3 QL (1000/30)

diflunisal 2ec-naproxen 2etodolac 4flurbiprofen oral tablet 100 mg 2ibu 1ibuprofen oral suspension 2ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

meloxicam oral tablet 1nabumetone 2nalbuphine injection solution 10 mg/ml

4 QL (180/30); NDS

nalbuphine injection solution 20 mg/ml

4 QL (90/30); NDS

naloxone injection solution 2naloxone injection syringe 1 mg/ml

2

naltrexone 2naproxen oral suspension 3naproxen oral tablet 1naproxen oral tablet,delayed release (dr/ec)

2

naproxen sodium oral tablet 275 mg, 550 mg

4

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION

3 QL (4/30)

oxaprozin 4salsalate 2SUBOXONE SUBLINGUAL FILM 12-3 MG

3 QL (60/30)

SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG, 8-2 MG

3 QL (90/30)

26


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clozapine oral tablet,disintegrating 12.5 mg, 25 mg

4

clozapine oral tablet,disintegrating 150 mg

4 QL (180/30)

clozapine oral tablet,disintegrating 200 mg

5 QL (120/30); NDS

desipramine 3desvenlafaxine succinate oral tablet extended release 24 hr 100 mg

4 QL (120/30)

desvenlafaxine succinate oral tablet extended release 24 hr 25 mg, 50 mg

4 QL (30/30)

dexmethylphenidate oral tablet 10 mg, 2.5 mg

3 QL (60/30)

dexmethylphenidate oral tablet 5 mg

3 QL (120/30)

dextroamphetamine oral capsule, extended release 10 mg

4 QL (180/30)


4 QL (120/30)


4 QL (60/30)

dextroamphetamine oral solution

4 QL (1800/30)

dextroamphetamine oral tablet 4 QL (180/30)dextroamphetamine-amphetamine oral capsule,extended release 24hr

4 QL (60/30)

dextroamphetamine-amphetamine oral tablet 10 mg

3 QL (180/30)

dextroamphetamine-amphetamine oral tablet 12.5 mg, 30 mg, 7.5 mg

3 QL (60/30)


3 QL (120/30)


3 QL (90/30)


3 QL (360/30)

diazepam injection syringe 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS


5 QL (3.2/28); NDS

armodafinil 4 PA; QL (30/30)atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg

4 QL (60/30)

atomoxetine oral capsule 100 mg, 60 mg, 80 mg

4 QL (30/30)

BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG

3 QL (30/30)

BELSOMRA ORAL TABLET 5 MG

3 QL (60/30)

bupropion hcl oral tablet 100 mg

3 QL (120/30)

bupropion hcl oral tablet 75 mg 3 QL (180/30)bupropion hcl oral tablet extended release 24 hr 150 mg

3 QL (90/30)

bupropion hcl oral tablet extended release 24 hr 300 mg

3 QL (30/30)

bupropion hcl oral tablet sustained-release 12 hr 100 mg, 200 mg

3 QL (60/30)

bupropion hcl oral tablet sustained-release 12 hr 150 mg

3 QL (90/30)

buspirone 2CAPLYTA 5 ST; QL (30/30);

NDSchlorpromazine injection 4chlorpromazine oral 2citalopram oral solution 3 QL (600/30)citalopram oral tablet 10 mg 1 QL (120/30)citalopram oral tablet 20 mg 1 QL (60/30)citalopram oral tablet 40 mg 1 QL (90/30)clomipramine 3 PAclonidine hcl oral tablet extended release 12 hr

4 QL (120/30)

clorazepate dipotassium oral tablet 15 mg, 3.75 mg

3 QL (180/30)

clorazepate dipotassium oral tablet 7.5 mg

3 QL (360/30)

clozapine oral tablet 3clozapine oral tablet,disintegrating 100 mg

4 QL (270/30)

27



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluoxetine oral capsule,delayed release(dr/ec)

3 QL (4/28)

fluoxetine oral solution 2 QL (600/30)fluoxetine oral tablet 10 mg, 20 mg

2

fluphenazine decanoate 4fluphenazine hcl injection 4fluphenazine hcl oral concentrate

4

fluphenazine hcl oral elixir 4fluphenazine hcl oral tablet 2fluvoxamine oral tablet 2GEODON INTRAMUSCULAR 4 QL (6/30)GUANIDINE 3haloperidol decanoate 4haloperidol lactate injection 4haloperidol lactate oral 2haloperidol oral tablet 0.5 mg, 1 mg, 2 mg, 5 mg

1

haloperidol oral tablet 10 mg, 20 mg

2

HETLIOZ 5 PA; QL (30/30); NDS

imipramine hcl 3 PAINVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML

5 QL (0.75/28); NDS

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML

5 QL (1/28); NDS

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML

5 QL (1.5/28); NDS


4 QL (0.25/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

diazepam oral solution 5 mg/5 ml (1 mg/ml)

2 QL (1200/30)

diazepam oral tablet 2 QL (120/30)doxepin oral capsule 3 PAdoxepin oral concentrate 3 PAdoxepin oral tablet 3 QL (30/30)DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG

4 QL (180/30)

DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 30 MG, 40 MG

4 QL (90/30)

DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 60 MG

4 QL (60/30)

duloxetine oral capsule,delayed release(dr/ec) 20 mg

2 QL (180/30)


2 QL (90/30)


2 QL (60/30)

EMSAM 5 QL (30/30); NDSescitalopram oxalate oral solution

3 QL (600/30)

escitalopram oxalate oral tablet 2FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG

4 ST; QL (60/30)

FANAPT ORAL TABLET 10 MG, 12 MG, 6 MG, 8 MG

5 ST; QL (60/30); NDS

FANAPT ORAL TABLETS,DOSE PACK

4 ST; QL (16/365)

FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK

4 ST; QL (56/365)

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR

4 ST; QL (30/30)

fluoxetine oral capsule 2

28


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

mirtazapine oral tablet,disintegrating

2 QL (30/30)

molindone 2nefazodone 3nortriptyline 2NUPLAZID ORAL CAPSULE 5 PA; QL (30/30);

NDSNUPLAZID ORAL TABLET 10 MG

5 PA; QL (30/30); NDS

olanzapine intramuscular 4 QL (30/30)olanzapine oral tablet 10 mg, 2.5 mg, 5 mg

2 QL (120/30)

olanzapine oral tablet 15 mg, 20 mg

2 QL (60/30)

olanzapine oral tablet 7.5 mg 2 QL (30/30)olanzapine oral tablet,disintegrating

3 QL (30/30)

olanzapine-fluoxetine 4 QL (30/30)oxazepam 2 QL (120/30)paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg

4 ST; QL (30/30)

paliperidone oral tablet extended release 24hr 6 mg

4 ST; QL (60/30)

paroxetine hcl oral tablet 10 mg 1 QL (60/30)paroxetine hcl oral tablet 20 mg 1 QL (90/30)paroxetine hcl oral tablet 30 mg, 40 mg

2 QL (60/30)

paroxetine hcl oral tablet extended release 24 hr 12.5 mg

3 QL (30/30)

paroxetine hcl oral tablet extended release 24 hr 25 mg, 37.5 mg

3 QL (60/30)

PAXIL ORAL SUSPENSION 4 ST; QL (900/30)perphenazine 4perphenazine-amitriptyline 4 PAPERSERIS 5 QL (1/30); NDSphenelzine 3pimozide 3protriptyline 4quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

2 QL (90/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS


5 QL (0.5/28); NDS

INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML

5 QL (0.88/90); NDS


5 QL (1.32/90); NDS


5 QL (1.75/90); NDS


5 QL (2.63/90); NDS

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG

5 QL (30/30); NDS

LATUDA ORAL TABLET 80 MG 5 QL (60/30); NDSlithium carbonate 2lorazepam injection 4lorazepam intensol 3 QL (150/30)lorazepam oral concentrate 3 QL (150/30)lorazepam oral tablet 0.5 mg, 1 mg

2 QL (120/30)

lorazepam oral tablet 2 mg 2 QL (150/30)loxapine succinate 2maprotiline 4MARPLAN 4 QL (180/30)metadate er 3 QL (90/30)methylphenidate hcl oral tablet 3 QL (90/30)methylphenidate hcl oral tablet extended release

3 QL (90/30)

methylphenidate hcl oral tablet extended release 24hr 18 mg, 18 mg (bx rating)

3 QL (120/30)

methylphenidate hcl oral tablet extended release 24hr 27 mg, 27 mg (bx rating), 54 mg, 54 mg (bx rating)

3 QL (30/30)

methylphenidate hcl oral tablet extended release 24hr 36 mg, 36 mg (bx rating)

3 QL (60/30)

mirtazapine oral tablet 2

29



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

thiothixene 4tranylcypromine 4trazodone 2trifluoperazine 3trimipramine 4 PATRINTELLIX 4 ST; QL (30/30)venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg

2 QL (60/30)

venlafaxine oral capsule,extended release 24hr 75 mg

2 QL (90/30)

venlafaxine oral tablet 2VERSACLOZ 4 QL (540/30)VIIBRYD ORAL TABLET 4 ST; QL (30/30)VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)

4 ST; QL (60/365)

VRAYLAR ORAL CAPSULE 5 ST; QL (30/30); NDS

VRAYLAR ORAL CAPSULE,DOSE PACK

4 ST; QL (14/365)

XYREM 5 PA; QL (540/30); NDS

zaleplon oral capsule 10 mg 3 QL (60/30)zaleplon oral capsule 5 mg 3 QL (30/30)ziprasidone hcl 3 QL (60/30)zolpidem oral tablet 3 QL (30/30)ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG

4 QL (2/28)

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG

5 QL (2/28); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

quetiapine oral tablet 300 mg, 400 mg

2 QL (60/30)

quetiapine oral tablet extended release 24 hr 150 mg, 200 mg

3 QL (30/30)

quetiapine oral tablet extended release 24 hr 300 mg, 400 mg, 50 mg

3 QL (60/30)

ramelteon 3REXULTI 5 QL (30/30); NDSRISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML

4 QL (2/28)

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 50 MG/2 ML

5 QL (2/28); NDS

risperidone oral solution 2 QL (240/30)risperidone oral tablet 2risperidone oral tablet,disintegrating 0.25 mg, 1 mg, 2 mg, 3 mg

3 QL (60/30)

risperidone oral tablet,disintegrating 0.5 mg, 4 mg

3 QL (120/30)

SAPHRIS 4 QL (60/30)SECUADO 4 QL (30/30)sertraline oral concentrate 2 QL (300/30)sertraline oral tablet 100 mg, 25 mg

2 QL (60/30)

sertraline oral tablet 50 mg 2 QL (120/30)SILENOR 3 QL (30/30)temazepam oral capsule 15 mg, 30 mg

2 QL (60/365)

temazepam oral capsule 22.5 mg, 7.5 mg

3 QL (60/365)

thioridazine 3

30


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

bisoprolol fumarate 2bisoprolol-hydrochlorothiazide 1bumetanide injection 4bumetanide oral 2BYSTOLIC 3candesartan oral tablet 16 mg, 4 mg, 8 mg

1 QL (60/30)

candesartan oral tablet 32 mg 1 QL (30/30)candesartan-hydrochlorothiazid 1cartia xt 2carvedilol 1carvedilol phosphate 3chlorothiazide oral tablet 500 mg

2

chlorothiazide sodium 4chlorthalidone oral tablet 25 mg, 50 mg

2

clonidine hcl oral tablet 0.1 mg, 0.2 mg

1

clonidine hcl oral tablet 0.3 mg 2clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr

3 QL (4/28)

clonidine transdermal patch weekly 0.3 mg/24 hr

3 QL (8/28)

DEMSER 5 PA; NDSdiltiazem hcl intravenous 4diltiazem hcl oral capsule,extended release 12 hr

2

diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 420 mg

2

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg

2

diltiazem hcl oral tablet 2diltiazem hcl oral tablet extended release 24 hr

2

dilt-xr 2doxazosin 2EDARBI 4 ST; QL (30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG

5 QL (1/28); NDS

CARDIOVASCULAR, HYPERTENSION / LIPIDS

ANTIARRHYTHMIC AGENTSamiodarone intravenous solution

4 B/D PA

amiodarone oral 2dofetilide 3flecainide 2lidocaine (pf) intravenous syringe

4

mexiletine 2MULTAQ 3 QL (60/30)pacerone oral tablet 100 mg, 200 mg, 400 mg

2

propafenone oral capsule,extended release 12 hr

4

propafenone oral tablet 2quinidine sulfate oral tablet 2sorine 2sotalol af 2sotalol oral 2SOTYLIZE 4ANTIHYPERTENSIVE THERAPYacebutolol 2aliskiren 4 QL (30/30)amiloride 2amiloride-hydrochlorothiazide 2amlodipine 1amlodipine-benazepril 1amlodipine-valsartan 1amlodipine-valsartan-hcthiazid 1atenolol 1atenolol-chlorthalidone 1benazepril 1benazepril-hydrochlorothiazide 1betaxolol oral 2BIDIL 3 QL (180/30)

31



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

moexipril 1nadolol 3nadolol-bendroflumethiazide oral tablet 80-5 mg

3

nicardipine intravenous solution 4nicardipine oral 2nifedipine oral tablet extended release

2 QL (60/30)

nifedipine oral tablet extended release 24hr

2 QL (60/30)

nimodipine 4nisoldipine 4olmesartan 1olmesartan-hydrochlorothiazide 1perindopril erbumine 1phenoxybenzamine 5 NDSpindolol 1prazosin 3propranolol oral capsule,extended release 24 hr

3

propranolol oral solution 2propranolol oral tablet 1propranolol-hydrochlorothiazid 2quinapril 1quinapril-hydrochlorothiazide 1ramipril 1REMODULIN 5 B/D PA; NDSspironolactone 1spironolacton-hydrochlorothiaz 2taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg

2

TEKTURNA HCT 4 QL (30/30)telmisartan oral tablet 20 mg, 40 mg

1 QL (30/30)

telmisartan oral tablet 80 mg 1 QL (60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

EDARBYCLOR 4 STenalapril maleate 1enalapril-hydrochlorothiazide 1ethacrynate sodium 4felodipine 2fosinopril 1 QL (60/30)fosinopril-hydrochlorothiazide 1 QL (120/30)furosemide injection 2furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

2

furosemide oral tablet 1hydralazine injection 4hydralazine oral 2hydrochlorothiazide 1indapamide 1irbesartan oral tablet 150 mg 1 QL (60/30)irbesartan oral tablet 300 mg, 75 mg

1 QL (30/30)

irbesartan-hydrochlorothiazide 1 QL (30/30)isradipine 3labetalol oral 2lisinopril 1lisinopril-hydrochlorothiazide 1losartan 1 QL (60/30)losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg

1 QL (30/30)

losartan-hydrochlorothiazide oral tablet 50-12.5 mg

1 QL (60/30)

matzim la 2methyldopa 4metolazone 2metoprolol succinate 1metoprolol ta-hydrochlorothiaz 2metoprolol tartrate oral 1minoxidil oral 2

32


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ELIQUIS 3ELIQUIS DVT-PE TREAT 30D START

3

enoxaparin subcutaneous solution

3

enoxaparin subcutaneous syringe 100 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml

3

enoxaparin subcutaneous syringe 120 mg/0.8 ml, 150 mg/ml

4

fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

5 NDS

fondaparinux subcutaneous syringe 2.5 mg/0.5 ml

4

heparin (porcine) in 5% dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)

4

heparin (porcine) in nacl (pf) 4heparin (porcine) injection solution

3

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml

4

heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml

4

HEPARIN, PORCINE (PF) INJECTION SYRINGE 5,000 UNIT/ML

4

jantoven 1pentoxifylline 2PRADAXA 4 QL (60/30)prasugrel 4 QL (30/30)PROMACTA ORAL POWDER IN PACKET 12.5 MG

5 PA; QL (360/30); NDS

PROMACTA ORAL POWDER IN PACKET 25 MG

5 PA; NDS

PROMACTA ORAL TABLET 5 PA; QL (30/30); NDS

warfarin 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

telmisartan-amlodipine 1 QL (30/30)telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-25 mg

1 QL (30/30)

telmisartan-hydrochlorothiazid oral tablet 80-12.5 mg

1 QL (60/30)

terazosin 1tiadylt er 2timolol maleate oral 4torsemide oral 2trandolapril 1treprostinil sodium 5 B/D PA; NDStriamterene-hydrochlorothiazid oral capsule 37.5-25 mg

1

triamterene-hydrochlorothiazid oral tablet

1

UPTRAVI 5 PA; NDSvalsartan oral tablet 160 mg, 40 mg, 80 mg

1 QL (60/30)

valsartan oral tablet 320 mg 1 QL (30/30)valsartan-hydrochlorothiazide 1 QL (30/30)verapamil intravenous solution 4verapamil oral capsule, 24 hr er pellet ct

2

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg

2

VERAPAMIL ORAL CAPSULE,EXT REL. PELLETS 24 HR 360 MG

3

verapamil oral tablet 1verapamil oral tablet extended release

2

COAGULATION THERAPYaminocaproic acid oral 4aspirin-dipyridamole 4 QL (60/30)BRILINTA 3 QL (60/30)cilostazol 2clopidogrel oral tablet 300 mg 2 QL (2/365)clopidogrel oral tablet 75 mg 2COUMADIN ORAL 4dipyridamole oral 3 PA

33



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

pravastatin oral tablet 40 mg 1 QL (60/30)prevalite 2REPATHA 3 PA; QL (3/28)REPATHA PUSHTRONEX 3 PA; QL (3.5/28)REPATHA SURECLICK 3 PA; QL (3/28)rosuvastatin 1 QL (30/30)simvastatin oral tablet 1 QL (30/30)VASCEPA ORAL CAPSULE 0.5 GRAM

3 QL (240/30)

VASCEPA ORAL CAPSULE 1 GRAM

3 QL (120/30)

MISCELLANEOUS CARDIOVASCULAR AGENTSCORLANOR ORAL TABLET 4 PA; QL (60/30)digitek 2digox 2digoxin oral solution 50 mcg/ml (0.05 mg/ml)

3 QL (150/30)

digoxin oral tablet 2ENTRESTO 3 QL (60/30)ranolazine 4 QL (60/30)NITRATESisosorbide dinitrate oral tablet 3isosorbide mononitrate 2minitran 2nitroglycerin intravenous 4 B/D PAnitroglycerin sublingual 2nitroglycerin transdermal patch 24 hour

2

nitroglycerin translingual spray,non-aerosol

4

DERMATOLOGICALS/TOPICAL THERAPY

ANTIPSORIATIC / ANTISEBORRHEICacitretin 4 PAcalcipotriene scalp 3calcipotriene topical cream 4 QL (120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

XARELTO 3LIPID/CHOLESTEROL LOWERING AGENTSatorvastatin oral tablet 10 mg, 20 mg, 80 mg

1 QL (30/30)

atorvastatin oral tablet 40 mg 1 QL (60/30)cholestyramine (with sugar) 2cholestyramine light 2colesevelam 3colestipol 3ezetimibe 2 QL (30/30)ezetimibe-simvastatin 4 QL (30/30)fenofibrate micronized oral capsule 130 mg, 43 mg

4

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

3

fenofibrate nanocrystallized oral tablet 145 mg, 48 mg

3

fenofibrate oral capsule 4fenofibrate oral tablet 160 mg, 54 mg

2

fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg

4 QL (30/30)

fenofibric acid (choline) oral capsule,delayed release(dr/ec) 45 mg

4 QL (60/30)

gemfibrozil 2LIVALO 3 QL (30/30)lovastatin 1 QL (60/30)niacin oral tablet 500 mg 2niacin oral tablet extended release 24 hr

2

niacor 2omega-3 acid ethyl esters 4 QL (120/30)pravastatin oral tablet 10 mg, 20 mg, 80 mg

1 QL (30/30)

34


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PANRETIN 5 NDSPICATO TOPICAL GEL 0.015% 4 QL (3/56)PICATO TOPICAL GEL 0.05% 4 QL (2/56)pimecrolimus 4 QL (100/90)podofilox 2REGRANEX 5 PA; NDSSANTYL 3silver sulfadiazine 3ssd 3tacrolimus topical 3 QL (100/90)TOLAK 4VALCHLOR 5 PA; QL (60/30);

NDSZTLIDO 4 PA; QL (90/30)THERAPY FOR ACNEamnesteem 4avita 4 PAclaravis 4clindacin etz topical swab 2clindacin p 2clindamycin phosphate topical gel

3

CLINDAMYCIN PHOSPHATE TOPICAL GEL, ONCE DAILY

3

clindamycin phosphate topical lotion

4

clindamycin phosphate topical solution

3

clindamycin phosphate topical swab

2

ery pads 3erythromycin with ethanol topical gel

3

erythromycin with ethanol topical solution

2

erythromycin-benzoyl peroxide 4isotretinoin 4metronidazole topical 3myorisan 4rosadan topical cream 3rosadan topical gel 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

calcipotriene topical ointment 4 QL (120/30)calcitriol topical 4selenium sulfide topical lotion 2SKYRIZI SUBCUTANEOUS SYRINGE KIT

5 PA; QL (2/28); NDS

STELARA SUBCUTANEOUS SOLUTION

5 PA; QL (0.5/28); NDS

STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML

5 PA; QL (0.5/28); NDS

STELARA SUBCUTANEOUS SYRINGE 90 MG/ML

5 PA; QL (1/28); NDS

MISCELLANEOUS DERMATOLOGICALSacyclovir topical cream 5 QL (5/30); NDSacyclovir topical ointment 4 QL (30/30)ammonium lactate 2DENAVIR 5 QL (5/30); NDSDUPIXENT 5 PA; NDSfluorouracil topical cream 0.5% 5 NDSfluorouracil topical cream 5% 3fluorouracil topical solution 2glydo 3 QL (60/30)imiquimod topical cream in metered-dose pump

5 NDS

imiquimod topical cream in packet

3

lidocaine (pf) injection solution 4lidocaine hcl injection solution 4lidocaine hcl laryngotracheal 2lidocaine hcl mucous membrane jelly

3 QL (60/30)

lidocaine hcl mucous membrane jelly in applicator

3 QL (60/30)

lidocaine hcl mucous membrane solution 4% (40 mg/ml)

2

lidocaine topical adhesive patch,medicated 5%

4 PA; QL (90/30)

lidocaine topical ointment 4 QL (50/30)lidocaine viscous 1lidocaine-prilocaine topical cream

4 QL (30/30)

methoxsalen 4

35



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nystatin topical powder 2nystatin-triamcinolone 4 QL (60/28)nystop 2TOPICAL CORTICOSTEROIDSala-cort topical cream 1% 1alclometasone 2betamethasone dipropionate 3betamethasone valerate topical cream

2

betamethasone valerate topical foam

3

betamethasone valerate topical lotion

2

betamethasone valerate topical ointment

2

betamethasone, augmented 2clobetasol scalp 2 QL (100/28)clobetasol topical cream 2 QL (120/28)clobetasol topical foam 4 QL (100/28)clobetasol topical gel 2 QL (120/28)clobetasol topical ointment 2 QL (120/28)clobetasol topical shampoo 4 QL (236/28)clobetasol-emollient topical cream

2 QL (120/28)

clobetasol-emollient topical foam

4

CLOCORTOLONE PIVALATE 4clodan 4 QL (236/28)desonide 3desoximetasone topical cream 4desoximetasone topical gel 4desoximetasone topical ointment

4

fluocinolone and shower cap 3fluocinolone topical cream 2fluocinolone topical oil 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tazarotene 4TAZORAC TOPICAL CREAM 4TAZORAC TOPICAL GEL 4 QL (100/30)tretinoin microspheres 4 PAtretinoin topical cream 0.025%, 0.05%, 0.1%

4 PA

tretinoin topical topical gel 0.01%

3 PA

tretinoin topical topical gel 0.025%, 0.05%

4 PA

zenatane 4TOPICAL ANTIBACTERIALSgentamicin topical 3mupirocin 2mupirocin calcium 4sulfacetamide sodium (acne) 3TOPICAL ANTIFUNGALSciclodan topical solution 3ciclopirox topical cream 3 QL (90/28)ciclopirox topical shampoo 3 QL (120/28)ciclopirox topical solution 3ciclopirox topical suspension 3clotrimazole topical cream 2clotrimazole topical solution 2 QL (30/28)clotrimazole-betamethasone topical cream

2 QL (45/28)

clotrimazole-betamethasone topical lotion

2 QL (60/28)

econazole 3 QL (85/28)ketoconazole topical cream 2 QL (60/28)ketoconazole topical shampoo 2 QL (120/28)naftifine topical cream 3 QL (60/28)NAFTIN TOPICAL GEL 3nyamyc 2nystatin topical cream 2 QL (30/28)nystatin topical ointment 2 QL (30/28)

36


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TOPICAL SCABICIDES / PEDICULICIDESlindane topical shampoo 3malathion 4permethrin topical cream 2

DIAGNOSTICS / MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONSlactated ringers irrigation 4neomycin-polymyxin b gu 4PHYSIOLYTE 4PHYSIOSOL IRRIGATION 4ringer’s irrigation 4tis-u-sol pentalyte 4MISCELLANEOUS AGENTSacamprosate 2anagrelide 2ARALAST NP 5 B/D PA; NDSAURYXIA 4 PA; QL (360/30)CARBAGLU 5 PA; NDSCARNITOR INTRAVENOUS 4 B/D PACHEMET 5 NDSCLINIMIX 4.25%/D5W SULFIT FREE

4 B/D PA

d10%-0.45% sodium chloride 4 B/D PAd2.5%-0.45% sodium chloride 4 B/D PAd5% and 0.9% sodium chloride 4d5%-0.45% sodium chloride 4deferasirox oral tablet 360 mg, 90 mg

5 NDS

dextrose 10% and 0.2% nacl 4 B/D PADEXTROSE 10% IN WATER (D10W)

4 B/D PA

dextrose 20% in water (d20w) 4 B/D PAdextrose 25% in water (d25w) 4 B/D PAdextrose 30% in water (d30w) 4 B/D PAdextrose 40% in water (d40w) 4 B/D PADEXTROSE 5% IN WATER (D5W) INTRAVENOUS PARENTERAL SOLUTION

4

dextrose 5% in water (d5w) intravenous piggyback

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluocinolone topical ointment 2fluocinolone topical solution 2fluocinonide topical cream 0.05%

2

fluocinonide topical cream 0.1% 4fluocinonide topical gel 2 QL (120/30)fluocinonide topical ointment 3 QL (120/30)fluocinonide topical solution 3 QL (120/30)fluticasone propionate topical cream

2

fluticasone propionate topical ointment

2

halobetasol propionate topical cream

3

halobetasol propionate topical ointment

3

hydrocortisone butyrate topical cream

4

hydrocortisone butyrate topical ointment

3

hydrocortisone butyrate topical solution

3

hydrocortisone butyr-emollient 4hydrocortisone topical cream 1%, 2.5%

1

hydrocortisone topical lotion 2.5%

2

hydrocortisone topical ointment 1%, 2.5%

2

hydrocortisone valerate 3hydrocortisone-min oil-wht pet 2mometasone topical 2prednicarbate topical ointment 2triamcinolone acetonide topical cream 0.025%, 0.5%

2

triamcinolone acetonide topical cream 0.1%

1

triamcinolone acetonide topical lotion

2

triamcinolone acetonide topical ointment

2

triderm topical cream 0.1% 1

37



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sodium chloride irrigation 4sodium phenylbutyrate 5 PA; NDSsodium polystyrene (sorb free) 3sodium polystyrene sulfonate oral powder

3

sps (with sorbitol) 3trientine 5 QL (240/30); NDSVELPHORO 4 QL (180/30)VELTASSA 3water for irrigation, sterile 4XIAFLEX 5 PA; NDSZEMAIRA 5 B/D PA; NDSzoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml

4 B/D PA; QL (100/365)

SMOKING DETERRENTSbupropion hcl (smoking deter) 3 QL (60/30)CHANTIX 3CHANTIX CONTINUING MONTH BOX

3

CHANTIX STARTING MONTH BOX

3

NICOTROL 4NICOTROL NS 4 QL (30/30)

EAR, NOSE / THROAT MEDICATIONS

MISCELLANEOUS AGENTSazelastine nasal 3 QL (30/25)chlorhexidine gluconate mucous membrane

1

ipratropium bromide nasal spray,non-aerosol 0.03%

2 QL (30/30)

ipratropium bromide nasal spray,non-aerosol 42 mcg (0.06%)

2 QL (45/30)

oralone 3paroex oral rinse 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dextrose 5%-lactated ringers 4 B/D PAdextrose 5%-0.2% sod chloride 4dextrose 5%-0.3% sod.chloride 4dextrose 50% in water (d50w) 4 B/D PAdextrose 70% in water (d70w) 4dextrose with sodium chloride 4disulfiram 2FERRIPROX 5 PA; NDSINCRELEX 4 PAJADENU 5 NDSJADENU SPRINKLE 5 NDSkionex (with sorbitol) 3levocarnitine (with sugar) 2levocarnitine oral solution 100 mg/ml

2

levocarnitine oral tablet 2LOKELMA 3midodrine 2nitisinone 5 NDSNORTHERA ORAL CAPSULE 100 MG

5 PA; QL (90/30); NDS

NORTHERA ORAL CAPSULE 200 MG, 300 MG

5 PA; QL (180/30); NDS

ORFADIN 5 NDSpilocarpine hcl oral 3PROLASTIN-C 5 B/D PA; NDSRENVELA ORAL POWDER IN PACKET

3 QL (180/30)

RENVELA ORAL TABLET 3 QL (540/30)riluzole 3SEVELAMER CARBONATE ORAL POWDER IN PACKET

4 QL (180/30)

SEVELAMER CARBONATE ORAL TABLET

4 QL (540/30)

sodium chloride 0.9% intravenous

4

38


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

prednisolone oral solution 15 mg/5 ml

3

prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 15 mg/5 ml (5 ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

3

prednisone intensol 4prednisone oral solution 2prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg

1 B/D PA

prednisone oral tablet 50 mg 2 B/D PAprednisone oral tablets,dose pack

1

SOLU-CORTEF ACT-O-VIAL (PF)

4

triamcinolone acetonide injection

2

ANTITHYROID AGENTSmethimazole oral tablet 10 mg, 5 mg

2

propylthiouracil 3DIABETES THERAPYacarbose oral tablet 100 mg, 25 mg

6 QL (90/30)

acarbose oral tablet 50 mg 6 QL (180/30)ALCOHOL PADS 6BAQSIMI 3BD PEN NEEDLE 6 QL(200/30)BYDUREON BCISE 4 QL (4/28)BYDUREON SUBCUTANEOUS PEN INJECTOR

4 QL (4/28)

CYCLOSET 4 QL (180/30)FARXIGA ORAL TABLET 10 MG

6 QL (30/30)

FARXIGA ORAL TABLET 5 MG 6 QL (60/30)GAUZE PADS 2 X 2 6glimepiride oral tablet 1 mg 1 QL (240/30)glimepiride oral tablet 2 mg 1 QL (120/30)glimepiride oral tablet 4 mg 1 QL (60/30)glipizide oral tablet 10 mg 1 QL (120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

triamcinolone acetonide dental 3MISCELLANEOUS OTIC PREPARATIONSacetic acid otic (ear) 2flac otic oil 4fluocinolone acetonide oil 4hydrocortisone-acetic acid 2OTIC STEROID / ANTIBIOTICCIPRO HC 3CIPRODEX 3CORTISPORIN-TC 4neomycin-polymyxin-hc otic (ear)

3

ENDOCRINE/DIABETES

ADRENAL HORMONEScortisone 4DEPO-MEDROL 4dexamethasone intensol 4dexamethasone oral elixir 2dexamethasone oral solution 2dexamethasone oral tablet 0.5 mg, 0.75 mg, 4 mg

1

dexamethasone oral tablet 1 mg, 1.5 mg, 2 mg, 6 mg

2

dexamethasone sodium phos (pf) injection solution

4

dexamethasone sodium phosphate injection solution

4

fludrocortisone 2hydrocortisone oral 3MEDROL ORAL TABLET 2 MG 3methylprednisolone 2methylprednisolone acetate 4methylprednisolone sodium succ injection recon soln 125 mg, 40 mg

4

methylprednisolone sodium succ intravenous recon soln 1,000 mg

4 QL (8/30)

methylprednisolone sodium succ intravenous recon soln 500 mg

4 QL (12/30)

39



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HUMULIN N NPH U-100 INSULIN

6

HUMULIN R REGULAR U-100 INSULN

6

HUMULIN R U-500 (CONC) INSULIN

6 B/D PA

HUMULIN R U-500 (CONC) KWIKPEN

6

INSULIN PEN NEEDLE 6 QL (200/30)INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML

6 QL (200/30)

INVOKAMET 4 QL (60/30)INVOKAMET XR 4 QL (60/30)INVOKANA 4 QL (30/30)JANUMET 6 QL (60/30)JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG

6 QL (30/30)

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG

6 QL (60/30)

JANUVIA 6 QL (30/30)JARDIANCE 6 QL (30/30)JENTADUETO 6 QL (60/30)JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG

6 QL (60/30)

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG

6 QL (30/30)

LANTUS SOLOSTAR U-100 INSULIN

3

LANTUS U-100 INSULIN 3LEVEMIR FLEXTOUCH U-100 INSULN

3

LEVEMIR U-100 INSULIN 3metformin oral tablet 1,000 mg 1 QL (75/30)metformin oral tablet 500 mg 1 QL (150/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

glipizide oral tablet 5 mg 1 QL (240/30)glipizide oral tablet extended release 24hr 10 mg

1 QL (60/30)

glipizide oral tablet extended release 24hr 2.5 mg

1 QL (240/30)

glipizide oral tablet extended release 24hr 5 mg

1 QL (120/30)

glipizide-metformin oral tablet 2.5-250 mg

1 QL (240/30)

glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg

1 QL (120/30)

GLUCAGEN HYPOKIT 3GLUCAGON (HCL) EMERGENCY KIT

3

GLUCAGON EMERGENCY KIT (HUMAN)

3

GLYXAMBI 6 QL (30/30)GVOKE SYRINGE 3HUMALOG JUNIOR KWIKPEN U-100

6

HUMALOG KWIKPEN INSULIN

6

HUMALOG MIX 50-50 INSULN U-100

6

HUMALOG MIX 50-50 KWIKPEN

6

HUMALOG MIX 75-25 KWIKPEN

6

HUMALOG MIX 75-25(U-100)INSULN

6

HUMALOG U-100 INSULIN 6HUMULIN 70/30 U-100 INSULIN

6

HUMULIN 70/30 U-100 KWIKPEN

6

HUMULIN N NPH INSULIN KWIKPEN

6

40


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TOUJEO MAX U-300 SOLOSTAR

3

TOUJEO SOLOSTAR U-300 INSULIN

3

TRADJENTA 6 QL (30/30)TRESIBA FLEXTOUCH U-100 3TRESIBA FLEXTOUCH U-200 3TRESIBA U-100 INSULIN 3TRULICITY 6 QL (2/28)V-GO 20 3V-GO 30 3V-GO 40 3VICTOZA 2-PAK 6 QL (9/30)VICTOZA 3-PAK 6 QL (9/30)XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG

6 QL (30/30)

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG, 5-500 MG

6 QL (60/30)

XULTOPHY 100/3.6 3 ST; QL (15/30)MISCELLANEOUS HORMONESALDURAZYME 5 PA; NDSANADROL-50 5 PA; NDScabergoline 3calcitonin (salmon) 3calcitriol intravenous solution 1 mcg/ml

4

calcitriol oral 2CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

5 B/D PA; NDS

CHORIONIC GONADOTROPIN, HUMAN INTRAMUSCULAR

4 PA

cinacalcet oral tablet 30 mg, 60 mg

4 QL (60/30)

cinacalcet oral tablet 90 mg 4 QL (120/30)danazol 4desmopressin injection 4desmopressin nasal spray with pump

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

metformin oral tablet 850 mg 1 QL (90/30)metformin oral tablet extended release 24 hr 500 mg (generic for glucophage xr)

1 QL (120/30)

metformin oral tablet extended release 24 hr 750 mg (generic for glucophage xr)

1 QL (60/30)

metformin oral tablet extended release (osm) 24 hr 1000mg, 500mg (generic for fortamet)

1 QL (60/30)

miglitol 6 QL (90/30)nateglinide oral tablet 120 mg 1 QL (90/30)nateglinide oral tablet 60 mg 1 QL (180/30)NEEDLES, INSULIN DISP.,SAFETY

6 QL (200/30)

NOVOFINE PEN NEEDLE 6 QL(200/30)NOVOTWIST PEN NEEDLE 6 QL(200/30)OMNIPOD 5 PACK 3 QL(30/30)OMNIPOD DASH 5 PACK 3 QL(30/30)OMNIPOD STARTER KIT 3 QL(1/365)OZEMPIC 6 QL (3/28)pioglitazone oral tablet 15 mg 1 QL (90/30)pioglitazone oral tablet 30 mg, 45 mg

1 QL (30/30)

pioglitazone-metformin 1 QL (90/30)PROGLYCEM 4repaglinide oral tablet 0.5 mg, 1 mg

1 QL (120/30)

repaglinide oral tablet 2 mg 1 QL (240/30)RIOMET 6 QL (750/30)SOLIQUA 100/33 3 ST; QL (18/30)SYMLINPEN 120 5 PA; QL (10.8/28);

NDSSYMLINPEN 60 5 PA; QL (6/30); NDSSYNJARDY 6 QL (60/30)SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG

6 QL (60/30)

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 25-1,000 MG

6 QL (30/30)

TECHLITE PEN NEEDLE 6 QL(200/30)

41



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SYNAREL 5 PA; NDStestosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml (1 ml)

3

TESTOSTERONE CYPIONATE INTRAMUSCULAR OIL 200 MG/ML

3

testosterone enanthate 4testosterone transdermal gel 4 PA; QL (300/30)testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1%)

4 PA; QL (300/30)

testosterone transdermal gel in packet 1% (25 mg/2.5gram), 1% (50 mg/5 gram)

4 PA; QL (300/30)

zoledronic acid intravenous solution

4 B/D PA; QL (15/21)

THYROID HORMONESlevothyroxine oral 1levoxyl oral tablet 100 mcg, 112 mcg, 175 mcg

3

LEVOXYL ORAL TABLET 125 MCG, 137 MCG, 150 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

3

liothyronine oral 2SYNTHROID 3THYROLAR-1 3THYROLAR-1/2 3THYROLAR-1/4 3THYROLAR-2 3THYROLAR-3 3UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

3

unithroid oral tablet 137 mcg 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

desmopressin nasal spray,non-aerosol

4

desmopressin oral 3doxercalciferol intravenous 4doxercalciferol oral capsule 0.5 mcg

4 QL (90/30)

doxercalciferol oral capsule 1 mcg

4 QL (240/30)

doxercalciferol oral capsule 2.5 mcg

4 QL (120/30)

ELAPRASE 5 PA; NDSFABRAZYME 5 B/D PA; NDSKORLYM 5 PA; QL (120/30);

NDSKUVAN 5 PA; NDSLUMIZYME 5 PA; NDSMIACALCIN INJECTION 5 NDSmiglustat 5 QL (90/30); NDSNAGLAZYME 5 PA; NDSNATPARA 5 PA; QL (2/28); NDSoxandrolone oral tablet 10 mg 4 PA; QL (60/30)oxandrolone oral tablet 2.5 mg 3 PA; QL (120/30)pamidronate 4 B/D PAparicalcitol oral capsule 1 mcg, 2 mcg

2

paricalcitol oral capsule 4 mcg 4SAMSCA ORAL TABLET 15 MG

5 PA; QL (30/30); NDS

SAMSCA ORAL TABLET 30 MG

5 PA; QL (60/30); NDS

SENSIPAR ORAL TABLET 30 MG, 60 MG

4 QL (60/30)

SENSIPAR ORAL TABLET 90 MG

4 QL (120/30)

SOMAVERT 5 PA; QL (30/30); NDS

STIMATE 5 NDS

42


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dronabinol 4 PA; QL (60/30)EMEND ORAL SUSPENSION FOR RECONSTITUTION

4 B/D PA

enulose 2GATTEX 30-VIAL 5 PA; NDSGATTEX ONE-VIAL 5 PA; NDSgavilyte-c 2gavilyte-g 2gavilyte-n 2generlac 2granisetron (pf) intravenous solution 1 mg/ml (1 ml)

4 B/D PA

granisetron hcl intravenous 4 B/D PAgranisetron hcl oral 3 B/D PA; QL (30/30)hydrocortisone rectal 3hydrocortisone topical cream with perineal applicator

1

lactulose oral solution 2LINZESS 3 QL (30/30)meclizine oral tablet 12.5 mg, 25 mg

2

mesalamine oral capsule,extended release 24hr

3 QL (120/30)

mesalamine oral tablet,delayed release (dr/ec) 1.2 gram

4 QL (120/30)

mesalamine rectal enema 4mesalamine with cleansing wipe

4

metoclopramide hcl injection solution

4

metoclopramide hcl oral solution

2

metoclopramide hcl oral tablet 2OCALIVA 5 PA; QL (30/30);

NDSondansetron 1 B/D PAondansetron hcl (pf) 4ondansetron hcl intravenous 4ondansetron hcl oral solution 3 B/D PA; QL

(450/30)ondansetron hcl oral tablet 1 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

GASTROENTEROLOGY

ANTIDIARRHEALS / ANTISPASMODICSatropine injection solution 0.4 mg/ml

4

atropine injection syringe 0.05 mg/ml, 0.1 mg/ml

4

dicyclomine oral capsule 1dicyclomine oral solution 3dicyclomine oral tablet 1diphenoxylate-atropine oral liquid

3

diphenoxylate-atropine oral tablet

2

GLYCOPYRROLATE (PF) IN WATER INJECTION

4

glycopyrrolate (pf) in water intravenous syringe 0.4 mg/2 ml (0.2 mg/ml)

4

glycopyrrolate injection 4glycopyrrolate oral 2loperamide oral capsule 2propantheline 4MISCELLANEOUS GASTROINTESTINAL AGENTSalosetron oral tablet 0.5 mg 4 PA; QL (60/30)alosetron oral tablet 1 mg 5 PA; QL (60/30);

NDSAMITIZA 3 QL (60/30)aprepitant 4 B/D PAAPRISO 3 QL (120/30)balsalazide 4budesonide oral capsule,delayed,extend.release

4

budesonide oral tablet,delayed and ext.release

5 NDS

colocort 3compro 2constulose 2CREON 3cromolyn oral 3CYSTADANE 5 NDS

43



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT

3

ULCER THERAPYCARAFATE ORAL SUSPENSION

4

esomeprazole magnesium oral capsule,delayed release(dr/ec)

3 QL (60/30)

famotidine oral tablet 20 mg, 40 mg

2

lansoprazole oral capsule,delayed release(dr/ec)

3 QL (60/30)

misoprostol 3nizatidine oral capsule 2omeprazole oral capsule,delayed release(dr/ec)

2 QL (60/30)

pantoprazole oral 1 QL (60/30)ranitidine hcl oral syrup 2ranitidine hcl oral tablet 150 mg, 300 mg

2

sucralfate oral suspension 4sucralfate oral tablet 2

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGSACTIMMUNE 5 PA; NDSARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 300 MCG/ML, 60 MCG/ML

5 PA; QL (4/28); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

OSMOPREP 4palonosetron intravenous solution 0.25 mg/5 ml

5 B/D PA; NDS

peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram

2

peg-electrolyte 2PENTASA 3PLENVU 4prochlorperazine 2prochlorperazine edisylate 4prochlorperazine maleate oral 2procto-med hc 2procto-pak 2proctosol hc topical 2proctozone-hc 2RECTIV 4 QL (30/30)RELISTOR SUBCUTANEOUS SOLUTION

5 PA; NDS

RELISTOR SUBCUTANEOUS SYRINGE

5 PA; NDS

RENFLEXIS 5 PASANCUSO 5 QL (4/28); NDSscopolamine base 4 QL (10/30)sulfasalazine 2SUPREP BOWEL PREP KIT 3trilyte with flavor packets 2TRULANCE 4ursodiol 3VIBERZI 4 PA; QL (60/30)VIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT

4 NDS

VIOKACE ORAL TABLET 20,880-78,300- 78,300 UNIT

5 NDS

44


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML

5 PA; NDS

INTRON A INJECTION RECON SOLN

5 NDS

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML

5 NDS

INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML

4

LEUKINE INJECTION RECON SOLN

5 PA; NDS

MOZOBIL 5 QL (9.6/30); NDSREBIF (WITH ALBUMIN) 5 PA; QL (6/28); NDSREBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML

5 PA; QL (6/28); NDS

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6)

5 PA; QL (8.4/365); NDS

REBIF TITRATION PACK 5 PA; QL (8.4/365); NDS

RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

4 PA; QL (12/28)

RETACRIT INJECTION SOLUTION 40,000 UNIT/ML

5 PA; QL (6/28); NDS

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG

5 PA; QL (4/28); NDS

ZARXIO 5 PA; NDSZIEXTENZO 5 PA; NDSVACCINES / MISCELLANEOUS IMMUNOLOGICALSACTHIB (PF) 3ADACEL(TDAP ADOLESN/ADULT)(PF)

3 QL (0.5/365)

ATGAM 4 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML

4 PA; QL (4/28)

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 40 MCG/0.4 ML

4 PA; QL (1.6/28)

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML

5 PA; QL (2/28); NDS


5 PA; QL (1.2/28); NDS


5 PA; QL (1.6/28); NDS


4 PA; QL (1.68/28)


5 PA; QL (2.4/28); NDS

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 500 MCG/ML

5 PA; QL (1/21); NDS


4 PA; QL (1.2/28)

ARCALYST 5 PA; NDSAVONEX INTRAMUSCULAR PEN INJECTOR KIT

5 PA; QL (1/28); NDS

AVONEX INTRAMUSCULAR SYRINGE KIT

5 PA; QL (1/28); NDS

BETASERON SUBCUTANEOUS KIT

5 PA; QL (14/28); NDS

GENOTROPIN 5 PA; NDSGENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML

4 PA

45



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PROQUAD (PF) 3 QL (2/365)QUADRACEL (PF) 3RABAVERT (PF) 3 B/D PARECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML

3 B/D PA; QL (3/365)

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 5 MCG/0.5 ML

3 B/D PA

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE

3 B/D PA; QL (3/365)

ROTARIX 3ROTATEQ VACCINE 3SHINGRIX (PF) 3 QL (2/999)STAMARIL (PF) 3 QL (1/999)TDVAX 3TENIVAC (PF) INTRAMUSCULAR SYRINGE

3 QL (0.5/28)

TETANUS,DIPHTHERIA TOX PED(PF)

3

TRUMENBA 3TWINRIX (PF) INTRAMUSCULAR SYRINGE

3

TYPHIM VI 3VAQTA (PF) 3VARIVAX (PF) 3 QL (1/365)VARIZIG INTRAMUSCULAR SOLUTION

4 QL (12/30)

YF-VAX (PF) 3ZOSTAVAX (PF) 3 QL (1/999)

MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPYallopurinol 1colchicine oral capsule 3 QL (60/30)colchicine oral tablet 4 QL (120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

BCG VACCINE, LIVE (PF) 3BEXSERO 3BOOSTRIX TDAP 3 QL (0.5/365)BOTOX 4 PADAPTACEL (DTAP PEDIATRIC) (PF)

3

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

3 B/D PA; QL (8/365)

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

3 B/D PA; QL (3/365)

fomepizole 5 NDSGAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10%), 10 GRAM/100 ML (10%), 20 GRAM/200 ML (10%), 5 GRAM/50 ML (10%)

5 B/D PA; NDS

GAMUNEX-C 5 B/D PA; NDSGARDASIL 9 (PF) 3 QL (1.5/365)HAVRIX (PF) 3HIBERIX (PF) 3HIZENTRA SUBCUTANEOUS SOLUTION

5 B/D PA; NDS

IMOVAX RABIES VACCINE (PF)

3 B/D PA

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

3

IPOL 3IXIARO (PF) 3KINRIX (PF) 3MENACTRA (PF) INTRAMUSCULAR SOLUTION

3

MENVEO A-C-Y-W-135-DIP (PF)

3

M-M-R II (PF) 3 QL (2/365)PEDIARIX (PF) 3PEDVAX HIB (PF) 3

46


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML

5 PA; QL (2/28); NDS

HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML

5 PA; QL (4/28); NDS

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML

5 PA; QL (6/365); NDS

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML

5 PA; QL (4/365); NDS

HUMIRA(CF) PEN CROHNS-UC-HS

5 PA; QL (6/365); NDS

HUMIRA(CF) PEN PSOR-UV-ADOL HS

5 PA; QL (6/365); NDS

HUMIRA(CF) PEN SUBCUTANEOUS INJECTOR KIT 40 MG/0.4 ML

5 PA; QL (4/28); NDS

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML

5 PA; QL (2/28); NDS

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 40 MG/0.4 ML

5 PA; QL (4/28); NDS

leflunomide 2ORENCIA 5 PA; QL (4/28); NDSORENCIA CLICKJECT 5 PA; QL (4/28); NDSpenicillamine 5 NDSRIDAURA 4RINVOQ 5 PA; QL (30/30);

NDSXELJANZ 5 PA; QL (60/30);

NDSXELJANZ XR 5 PA; QL (30/30);

NDS

OBSTETRICS / GYNECOLOGY

ESTROGENS / PROGESTINSALORA 3 PA; QL (8/28)camila 2deblitane 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

FEBUXOSTAT 3 ST; QL (30/30)MITIGARE 3 QL (60/30)probenecid 2probenecid-colchicine 2OSTEOPOROSIS THERAPYalendronate oral tablet 10 mg, 5 mg

1 QL (30/30)

alendronate oral tablet 35 mg, 70 mg

1 QL (4/28)

BINOSTO 4FORTEO 5 PA; QL (2.4/28);

NDSibandronate oral 1 QL (1/28)PROLIA 4 QL (1/180)raloxifene 2 QL (30/30)risedronate oral tablet 150 mg 3 QL (1/30)risedronate oral tablet 30 mg, 5 mg

3 QL (30/30)

risedronate oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack)

3 QL (4/28)

TYMLOS 5 PA; QL (1.56/30); NDS

OTHER RHEUMATOLOGICALSBENLYSTA INTRAVENOUS RECON SOLN 120 MG

5 PA; QL (30/28); NDS

BENLYSTA INTRAVENOUS RECON SOLN 400 MG

5 PA; QL (9/28); NDS

DEPEN TITRATABS 5 NDSENBREL MINI 5 PA; QL (8/28); NDSENBREL SUBCUTANEOUS RECON SOLN

5 PA; QL (8/28); NDS

ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5)

5 PA; QL (4.08/28); NDS

ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML)

5 PA; QL (8/28); NDS

ENBREL SURECLICK 5 PA; QL (8/28); NDSHUMIRA PEN 5 PA; QL (4/28); NDSHUMIRA PEN CROHNS-UC-HS START

5 PA; QL (12/365); NDS

HUMIRA PEN PSOR-UVEITS-ADOL HS

5 PA; QL (8/365); NDS

47



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg

3 PA

PREMARIN INJECTION 4PREMARIN ORAL 3 PAPREMARIN VAGINAL 3progesterone micronized 2sharobel 2yuvafem 4 QL (18/28)MISCELLANEOUS OB/GYNclindamycin phosphate vaginal 3metronidazole vaginal 3terconazole 3tranexamic acid oral 3vandazole 3ORAL CONTRACEPTIVES / RELATED AGENTSafirmelle 2altavera (28) 2alyacen 1/35 (28) 2alyacen 7/7/7 (28) 2amethia 2amethia lo 2amethyst (28) 2apri 2aranelle (28) 2ashlyna 2aubra 2aubra eq 2aurovela 1.5/30 (21) 2aurovela 1/20 (21) 2aurovela 24 fe 2aurovela fe 1.5/30 (28) 2aurovela fe 1-20 (28) 2aviane 2ayuna 2azurette (28) 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML

4

DEPO-ESTRADIOL 4DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML

4 QL (10/28)

dotti 2 PA; QL (8/28)DUAVEE 4 PA; QL (30/30)errin 2estradiol oral 2 PAestradiol transdermal patch semiweekly

2 PA; QL (8/28)

estradiol transdermal patch weekly

2 PA; QL (4/28)

estradiol vaginal cream 4estradiol vaginal tablet 4 QL (18/28)estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml

4

ESTRING 4 QL (1/90)fyavolv 3 PAheather 2hydroxyprogesterone caproate 5 PA; NDSincassia 2jencycla 2lyza 2medroxyprogesterone intramuscular suspension

4

medroxyprogesterone intramuscular syringe

2

medroxyprogesterone oral 1MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

3 PA

MENOSTAR 3 PA; QL (4/28)nora-be 2norethindrone (contraceptive) 2norethindrone acetate 2

48


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

jasmiel (28) 2jolessa 2juleber 2junel 1.5/30 (21) 2junel 1/20 (21) 2junel fe 1.5/30 (28) 2junel fe 1/20 (28) 2junel fe 24 2kaitlib fe 2kalliga 2kariva (28) 2kelnor 1/35 (28) 2kelnor 1-50 2kurvelo (28) 2l norgest/e.estradiol-e.estrad 2larin 1.5/30 (21) 2larin 1/20 (21) 2larin 24 fe 2larin fe 1.5/30 (28) 2larin fe 1/20 (28) 2larissia 2layolis fe 2leena 28 2lessina 2levonest (28) 2levonorgestrel-ethinyl estrad 2levonorg-eth estrad triphasic 2levora-28 2lillow (28) 2lojaimiess 2loryna (28) 2low-ogestrel (28) 2lo-zumandimine (28) 2lutera (28) 2marlissa (28) 2melodetta 24 fe 2mibelas 24 fe 2microgestin 1.5/30 (21) 2microgestin 1/20 (21) 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

balziva (28) 2bekyree (28) 2blisovi 24 fe 2blisovi fe 1.5/30 (28) 2blisovi fe 1/20 (28) 2briellyn 2camrese 2camrese lo 2caziant (28) 2chateal (28) 2chateal eq (28) 2cryselle (28) 2cyclafem 1/35 (28) 2cyclafem 7/7/7 (28) 2cyred 2cyred eq 2dasetta 1/35 (28) 2dasetta 7/7/7 (28) 2daysee 2desog-e.estradiol/e.estradiol 2desogestrel-ethinyl estradiol 2drospirenone-e.estradiol-lm.fa 2drospirenone-ethinyl estradiol 2elinest 2ELLA 3emoquette 2enpresse 2enskyce 2estarylla 2ethynodiol diac-eth estradiol 2falmina (28) 2fayosim 2femynor 2gianvi (28) 2hailey 2hailey 24 fe 2introvale 2isibloom 2jaimiess 2

49



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

syeda 2tarina 24 fe 2tarina fe 1/20 (28) 2tarina fe 1-20 eq (28) 2tilia fe 2tri femynor 2tri-estarylla 2tri-legest fe 2tri-linyah 2tri-lo-estarylla 2tri-lo-marzia 2tri-lo-mili 2tri-lo-sprintec 2tri-mili 2tri-previfem (28) 2tri-sprintec (28) 2trivora (28) 2tri-vylibra 2tri-vylibra lo 2tydemy 2velivet triphasic regimen (28) 2vienva 2viorele (28) 2volnea (28) 2vyfemla (28) 2vylibra 2wera (28) 2wymzya fe 2zarah 2zovia 1/35e (28) 2zumandimine (28) 2

OPHTHALMOLOGY

ANTIBIOTICSak-poly-bac 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

microgestin fe 1.5/30 (28) 2microgestin fe 1/20 (28) 2mili 2mono-linyah 2necon 0.5/35 (28) 2nikki (28) 2noreth-ethinyl estradiol-iron 2norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg

2

norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1.5 mg-30 mcg (21)/75 mg (7)

2

norethindrone-e.estradiol-iron oral tablet,chewable

2

norgestimate-ethinyl estradiol 2nortrel 0.5/35 (28) 2nortrel 1/35 (21) 2nortrel 1/35 (28) 2nortrel 7/7/7 (28) 2ocella 2ogestrel (28) 3orsythia 2philith 2pimtrea (28) 2pirmella 2portia 28 2previfem 2reclipsen (28) 2rivelsa 2setlakin 2simliya (28) 2simpesse 2sprintec (28) 2sronyx 2

50


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

azelastine ophthalmic (eye) 2BLEPHAMIDE 3BLEPHAMIDE S.O.P. 3cromolyn ophthalmic (eye) 2CYSTARAN 5 PA; QL (60/28);

NDSepinastine 3EYLEA 5 PA; NDSLACRISERT 4olopatadine ophthalmic (eye) 3PAZEO 3PHOSPHOLINE IODIDE 4pilocarpine hcl ophthalmic (eye) drops 1%, 2%, 4%

3

RESTASIS 3 QL (60/30)RESTASIS MULTIDOSE 3 QL (11/30)sulfacetamide sodium ophthalmic (eye) drops

2

sulfacetamide-prednisolone 2XIIDRA 3 QL (60/30)NON-STEROIDAL ANTI-INFLAMMATORY AGENTSbromfenac 4diclofenac sodium ophthalmic (eye)

2

flurbiprofen sodium 2ketorolac ophthalmic (eye) 2PROLENSA 3ORAL DRUGS FOR GLAUCOMAacetazolamide 3acetazolamide sodium 4methazolamide 4OTHER GLAUCOMA DRUGSAZOPT 3bimatoprost ophthalmic (eye) 2 QL (5/30)COMBIGAN 3dorzolamide 2dorzolamide-timolol 2latanoprost 2LUMIGAN OPHTHALMIC (EYE) DROPS 0.01%

3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

AZASITE 3bacitracin ophthalmic (eye) 2bacitracin-polymyxin b ophthalmic (eye)

2

BESIVANCE 4CILOXAN OPHTHALMIC (EYE) OINTMENT

3

ciprofloxacin hcl ophthalmic (eye)

2

erythromycin ophthalmic (eye) 2gentak ophthalmic (eye) ointment

2

gentamicin ophthalmic (eye) drops

2

moxifloxacin ophthalmic (eye) drops

3

NATACYN 3neomycin-bacitracin-polymyxin 2neomycin-polymyxin-gramicidin 2neo-polycin 2ofloxacin ophthalmic (eye) 2ofloxacin otic (ear) 2polycin 2polymyxin b sulf-trimethoprim 2tobramycin 2TOBREX OPHTHALMIC (EYE) OINTMENT

4

ANTIVIRALStrifluridine 3ZIRGAN 3BETA-BLOCKERSbetaxolol ophthalmic (eye) 3carteolol 2levobunolol ophthalmic (eye) drops 0.5%

1

timolol maleate ophthalmic (eye) drops

1

TIMOLOL MALEATE OPHTHALMIC (EYE) GEL FORMING SOLUTION

4

MISCELLANEOUS OPHTHALMOLOGICSatropine ophthalmic (eye) drops 3

51



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

brimonidine ophthalmic (eye) drops 0.15%

3

brimonidine ophthalmic (eye) drops 0.2%

2

RESPIRATORY AND ALLERGY

ANTIHISTAMINE / ANTIALLERGENIC AGENTSdesloratadine oral tablet 2diphenhydramine hcl injection solution 50 mg/ml

4

epinephrine injection auto-injector

2 QL (2/30)

EPIPEN 3 QL (2/30)EPIPEN 2-PAK 3 QL (2/30)EPIPEN JR 3 QL (2/30)EPIPEN JR 2-PAK 3 QL (2/30)hydroxyzine hcl oral tablet 3 PAlevocetirizine oral solution 4 QL (300/30)levocetirizine oral tablet 2 QL (120/30)phenadoz rectal suppository 12.5 mg

4

promethazine oral 2 PApromethazine rectal suppository 12.5 mg, 25 mg

4

promethegan rectal suppository 25 mg, 50 mg

4

PULMONARY AGENTSacetylcysteine 3 B/D PAADEMPAS 5 PA; QL (90/30);

NDSADVAIR DISKUS 3 QL (60/30)ADVAIR HFA 3 QL (12/30)albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (generic for proair)

4 QL (17/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

RHOPRESSA 4 STROCKLATAN 4 STSIMBRINZA 4TRAVATAN Z 3travoprost 3ZIOPTAN (PF) 4 QL (30/30)STEROID-ANTIBIOTIC COMBINATIONSneomycin-bacitracin-poly-hc 3neomycin-polymyxin b-dexameth

2

neomycin-polymyxin-hc ophthalmic (eye)

2

neo-polycin hc 3PRED-G 3PRED-G S.O.P. 3TOBRADEX OPHTHALMIC (EYE) OINTMENT

3

tobramycin-dexamethasone 3ZYLET 3STEROIDSdexamethasone sodium phosphate ophthalmic (eye)

2

DUREZOL 3fluorometholone 3INVELTYS 4LOTEMAX 4LOTEMAX SM 4PRED MILD 3prednisolone acetate 3prednisolone sodium phosphate ophthalmic (eye)

1

SYMPATHOMIMETICSALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1%

4

apraclonidine 3

52


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION

3 QL (240/30)

FLOVENT HFA AEROSOL INHALER 110 MCG/ACTUATION

3 QL (12/30)


3 QL (24/30)


3 QL (10.6/30)

flunisolide nasal spray,non-aerosol 25 mcg (0.025%)

3 QL (50/30)

fluticasone propionate nasal 2 QL (16/30)icatibant 5 PA; QL (18/30);

NDSINCRUSE ELLIPTA 3 QL (30/30)ipratropium bromide inhalation 2 B/D PAipratropium-albuterol 2 B/D PAKALYDECO 5 PA; QL (60/30);

NDSlevalbuterol hcl 4 B/D PAlevalbuterol tartrate 3 QL (30/30)metaproterenol oral syrup 3mometasone nasal 3 QL (34/30)montelukast oral granules in packet

3 QL (30/30)

montelukast oral tablet 2 QL (30/30)montelukast oral tablet,chewable

2 QL (30/30)

OFEV 5 PA; QL (60/30); NDS

OPSUMIT 5 PA; QL (30/30); NDS

ORKAMBI ORAL GRANULES IN PACKET

5 PA; QL (56/28); NDS

ORKAMBI ORAL TABLET 5 PA; QL (120/30); NDS

PERFOROMIST 3 B/D PA; QL (120/30)

PROAIR HFA 3 QL (17/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ALBUTEROL SULFATE INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION (GENERIC FOR PROVENTIL)

4 QL (13.4/30)

albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (generic for ventolin)

4 QL (36/30)

albuterol sulfate inhalation solution for nebulization

2 B/D PA

albuterol sulfate oral syrup 2albuterol sulfate oral tablet 3albuterol sulfate oral tablet extended release 12 hr

2

ambrisentan 5 PA; QL (30/30); NDS

ANORO ELLIPTA 3 QL (60/30)ARNUITY ELLIPTA 3 QL (30/30)ATROVENT HFA 4 QL (25.8/30)bosentan 5 PA; QL (60/30);

NDSBREO ELLIPTA 3 QL (60/30)BROVANA 4 B/D PAbudesonide inhalation 4 B/D PACINRYZE 5 PA; QL (20/30);

NDSCOMBIVENT RESPIMAT 3 QL (8/30)cromolyn inhalation 2 B/D PA; QL

(240/30)DALIRESP 4 PA; QL (30/30)ESBRIET ORAL CAPSULE 5 PA; QL (270/30);

NDSESBRIET ORAL TABLET 267 MG

5 PA; QL (270/30); NDS

ESBRIET ORAL TABLET 801 MG

5 PA; QL (90/30); NDS

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION

3 QL (60/30)

53



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG

3 QL (30/30)

oxybutynin chloride oral syrup 1 QL (600/30)oxybutynin chloride oral tablet 1oxybutynin chloride oral tablet extended release 24hr

2 QL (60/30)

solifenacin 2 QL (30/30)tolterodine oral capsule,extended release 24hr

3 QL (30/30)

tolterodine oral tablet 3TOVIAZ 3 QL (30/30)BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPYalfuzosin 2 QL (30/30)dutasteride 2 QL (30/30)dutasteride-tamsulosin 4 QL (30/30)finasteride oral tablet 5 mg 2 QL (30/30)tamsulosin 2 QL (60/30)MISCELLANEOUS UROLOGICALSbethanechol chloride 2CYSTAGON 4ELMIRON 4K-PHOS ORIGINAL 4potassium citrate 4RENACIDIN IRRIGATION SOLUTION 1980.6 MG-59.4 MG-980.4MG/30ML

4

VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTEScalcium acetate(phosphat bind) 2klor-con 2KLOR-CON 10 3KLOR-CON 8 3klor-con m10 1klor-con m20 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PROAIR RESPICLICK 3 QL (2/30)PULMICORT 4 B/D PAPULMOZYME 5 B/D PA; QL

(150/30); NDSRUCONEST 5 PA; QL (8/30); NDSSEREVENT DISKUS 3 QL (60/30)sildenafil (pulmonary arterial hypertension) oral tablet

3 PA; QL (90/30)

terbutaline 4THEO-24 4theophylline oral tablet extended release 12 hr

3

theophylline oral tablet extended release 24 hr

3

TRACLEER ORAL TABLET FOR SUSPENSION

5 PA; NDS

TRELEGY ELLIPTA 3 QL (60/30)VENTAVIS 5 PA; QL (270/30);

NDSVENTOLIN HFA 4 QL (36/30)XHANCE 4 ST; QL (16/30)XOLAIR SUBCUTANEOUS RECON SOLN

5 PA; QL (6/28); NDS

XOLAIR SUBCUTANEOUS SYRINGE

5 PA; QL (5/28); NDS

XOPENEX 4 B/D PAXOPENEX CONCENTRATE 4 B/D PAYUPELRI 4 B/D PAzafirlukast 3 QL (60/30)

UROLOGICALS

ANTICHOLINERGICS / ANTISPASMODICSdarifenacin 4flavoxate 2MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG

3 QL (60/30)

54


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l

4 B/D PA

POTASSIUM CHLORIDE-D5-0.9%NACL

4 B/D PA

ringer’s intravenous 4 B/D PAsodium bicarbonate intravenous syringe 10 meq/10 ml (8.4%), 7.5% (0.9 meq/ml), 8.4% (1 meq/ml)

4

sodium chloride 0.45% intravenous parenteral solution

4

sodium chloride 3% 4sodium chloride 5% 4sodium chloride intravenous 4TPN ELECTROLYTES 4 B/D PAMISCELLANEOUS NUTRITION PRODUCTSAMINOSYN II 10% 4 B/D PAAMINOSYN II 15% 4 B/D PAAMINOSYN-PF 10% 4 B/D PAAMINOSYN-PF 7% (SULFITE-FREE)

4 B/D PA

CLINIMIX 5%/D15W SULFITE FREE

4 B/D PA

CLINIMIX 4.25%/D10W SULF FREE

4 B/D PA

CLINIMIX 5%-D20W(SULFITE-FREE)

4 B/D PA

CLINIMIX E 4.25%/D10W SUL FREE

4 B/D PA

CLINISOL SF 15% 4 B/D PAelectrolyte-48 in d5w 4 B/D PAFREAMINE HBC 6.9% 4 B/D PAfreamine iii 10% 4 B/D PAHEPATAMINE 8% 4 B/D PAINTRALIPID INTRAVENOUS EMULSION 20%, 30%

4 B/D PA

KABIVEN 4 B/D PANEPHRAMINE 5.4% 4 B/D PANORMOSOL-M IN 5% DEXTROSE

4 B/D PA

NORMOSOL-R PH 7.4 4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lactated ringers intravenous 4 B/D PAMAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/100 ML

4 B/D PA

magnesium sulfate in water 4 B/D PAmagnesium sulfate injection 4 B/D PANORMOSOL-R 4 B/D PANORMOSOL-R IN 5% DEXTROSE

4 B/D PA

PHOSLYRA 4POTASSIUM CHLORID-D5-0.45%NACL INTRAVENOUS PARENTERAL SOLUTION 10 MEQ/L, 20 MEQ/L, 40 MEQ/L

4 B/D PA

potassium chlorid-d5-0.45%nacl intravenous parenteral solution 30 meq/l

4 B/D PA

potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

4 B/D PA

potassium chloride in 5% dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l

4 B/D PA

potassium chloride in lr-d5 4 B/D PApotassium chloride in water intravenous piggyback

4 B/D PA

potassium chloride intravenous 4 B/D PApotassium chloride oral capsule, extended release

2

potassium chloride oral liquid 4potassium chloride oral packet 2potassium chloride oral tablet extended release

1

potassium chloride oral tablet,er particles/crystals

1

potassium chloride-0.45% nacl 4 B/D PAPOTASSIUM CHLORIDE-D5-0.2%NACL INTRAVENOUS PARENTERAL SOLUTION 20 MEQ/L

4 B/D PA

potassium chloride-d5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l

4 B/D PA

55



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NUTRILIPID 4 B/D PAPERIKABIVEN 4 B/D PAPLENAMINE 4 B/D PAPREMASOL 10% 4 B/D PAPROCALAMINE 3% 4 B/D PAPROSOL 20% 4 B/D PATRAVASOL 10% 4 B/D PATROPHAMINE 10% 4 B/D PATROPHAMINE 6% 4 B/D PAVITAMINS / HEMATINICSfluoride (sodium) oral tablet 1fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

1

PRENATAL VITAMIN ORAL TABLET

3

56

DRUG PAGE DRUG PAGE DRUG PAGE

Covered Drugs Index

Aabacavir-lamivudine . . . . . . . . . . . . . . . . 7abacavir-lamivudine-zidovudine . . . . . 7abacavir oral solution . . . . . . . . . . . . . . . 7abacavir oral tablet . . . . . . . . . . . . . . . . . 7ABELCET . . . . . . . . . . . . . . . . . . . . . . . . . . 7ABILIFY MAINTENA . . . . . . . . . . . . . . . 25abiraterone . . . . . . . . . . . . . . . . . . . . . . . . 13ABRAXANE . . . . . . . . . . . . . . . . . . . . . . . 13acamprosate . . . . . . . . . . . . . . . . . . . . . . 36acarbose oral tablet 50 mg . . . . . . . . . 38acarbose oral tablet 100 mg, 25 mg . 38acebutolol . . . . . . . . . . . . . . . . . . . . . . . . . 30acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml . . . . . . . . . . . . 22acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg . . . . . . . 22acetaminophen-codeine oral tablet 300-60 mg . . . . . . . . . . . . . . . . . . 22acetazolamide . . . . . . . . . . . . . . . . . . . . . 50acetazolamide sodium . . . . . . . . . . . . . 50acetic acid otic (ear) . . . . . . . . . . . . . . . 38acetylcysteine . . . . . . . . . . . . . . . . . . . . . 51acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . . 33ACTHIB (PF) . . . . . . . . . . . . . . . . . . . . . . 44ACTIMMUNE . . . . . . . . . . . . . . . . . . . . . 43acyclovir oral capsule . . . . . . . . . . . . . . . 7acyclovir oral suspension 200 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . . 7acyclovir oral tablet . . . . . . . . . . . . . . . . . 7acyclovir sodium intravenous solution . . . . . . . . . . . . . . . . 7acyclovir topical cream . . . . . . . . . . . . . 34acyclovir topical ointment . . . . . . . . . . 34ADACEL (TDAP ADOLESN/ADULT)(PF) . . . . . 44adefovir . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7ADEMPAS . . . . . . . . . . . . . . . . . . . . . . . . 51ADVAIR DISKUS . . . . . . . . . . . . . . . . . . 51

ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . . 51AFINITOR . . . . . . . . . . . . . . . . . . . . . . . . 13AFINITOR DISPERZ . . . . . . . . . . . . . . . 13afirmelle . . . . . . . . . . . . . . . . . . . . . . . . . . 47AIMOVIG AUTOINJECTOR . . . . . . . . 21ak-poly-bac . . . . . . . . . . . . . . . . . . . . . . . 49ala-cort topical cream 1% . . . . . . . . . . 35albendazole . . . . . . . . . . . . . . . . . . . . . . . 10albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (generic for proair) . . . . . . . . . . . . . . . . . 51ALBUTEROL SULFATE INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION (GENERIC FOR PROVENTIL) . . . . . 52albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (generic for ventolin) . . . . . . . . . . . . . . . 52albuterol sulfate inhalation solution for nebulization . . . . . . . . . . . . 52albuterol sulfate oral syrup . . . . . . . . . 52albuterol sulfate oral tablet . . . . . . . . . 52albuterol sulfate oral tablet extended release 12 hr . . . . . . . . . . . . 52alclometasone . . . . . . . . . . . . . . . . . . . . . 35ALCOHOL PADS . . . . . . . . . . . . . . . . . . 38ALDURAZYME . . . . . . . . . . . . . . . . . . . . 40ALECENSA . . . . . . . . . . . . . . . . . . . . . . . 13alendronate oral tablet 10 mg, 5 mg . 46alendronate oral tablet 35 mg, 70 mg . . . . . . . . . . . . . . . . . . . . . 46alfuzosin . . . . . . . . . . . . . . . . . . . . . . . . . . 53ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 13ALINIA ORAL SUSPENSION FOR RECONSTITUTION . . . . . . . . . . 10ALINIA ORAL TABLET . . . . . . . . . . . . . 10ALIQOPA . . . . . . . . . . . . . . . . . . . . . . . . . 13aliskiren . . . . . . . . . . . . . . . . . . . . . . . . . . . 30ALKERAN . . . . . . . . . . . . . . . . . . . . . . . . 13allopurinol . . . . . . . . . . . . . . . . . . . . . . . . . 45ALORA . . . . . . . . . . . . . . . . . . . . . . . . . . . 46alosetron oral tablet 0.5 mg . . . . . . . . 42

alosetron oral tablet 1 mg . . . . . . . . . . 42ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1% . . . . . . . . . . . . . . . 51alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg . . . . . . . . . . . . . 25alprazolam oral tablet 2 mg . . . . . . . . 25alprazolam oral tablet, disintegrating 0.25 mg, 0.5 mg, 1 mg . . . . . . . . . . . . . . . . . . . . . . 25alprazolam oral tablet, disintegrating 2 mg . . . . . . . . . . . . . . . . 25altavera (28) . . . . . . . . . . . . . . . . . . . . . . 47ALUNBRIG ORAL TABLET 30 MG . 13ALUNBRIG ORAL TABLET 180 MG, 90 MG . . . . . . . . . . . . . . . . . . . 13ALUNBRIG ORAL TABLETS, DOSE PACK . . . . . . . . . . . . . . . . . . . . . . 13alyacen 1/35 (28) . . . . . . . . . . . . . . . . . . 47alyacen 7/7/7 (28) . . . . . . . . . . . . . . . . . 47amantadine hcl . . . . . . . . . . . . . . . . . . . . . 7AMBISOME . . . . . . . . . . . . . . . . . . . . . . . . 7ambrisentan . . . . . . . . . . . . . . . . . . . . . . . 52amethia . . . . . . . . . . . . . . . . . . . . . . . . . . . 47amethia lo . . . . . . . . . . . . . . . . . . . . . . . . . 47amethyst (28) . . . . . . . . . . . . . . . . . . . . . 47amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml . . . . . . . . 10amiloride . . . . . . . . . . . . . . . . . . . . . . . . . . 30amiloride-hydrochlorothiazide . . . . . . 30aminocaproic acid oral . . . . . . . . . . . . . 32AMINOSYN II 10% . . . . . . . . . . . . . . . . 54AMINOSYN II 15% . . . . . . . . . . . . . . . . 54AMINOSYN-PF 7% (SULFITE-FREE) . . . . . . . . . . . . . . . . . . 54AMINOSYN-PF 10% . . . . . . . . . . . . . . . 54amiodarone intravenous solution . . . 30amiodarone oral . . . . . . . . . . . . . . . . . . . 30AMITIZA . . . . . . . . . . . . . . . . . . . . . . . . . . 42amitriptyline . . . . . . . . . . . . . . . . . . . . . . . 25amlodipine . . . . . . . . . . . . . . . . . . . . . . . . 30amlodipine-benazepril . . . . . . . . . . . . . 30amlodipine-valsartan . . . . . . . . . . . . . . . 30

57


Covered Drugs Index

armodafinil . . . . . . . . . . . . . . . . . . . . . . . . 26ARNUITY ELLIPTA . . . . . . . . . . . . . . . . 52ARSENIC TRIOXIDE INTRAVENOUS SOLUTION 1 MG/ML . . . . . . . . . . . . . . . . . . . . . . . . . . 13arsenic trioxide intravenous solution 2 mg/ml . . . . . . . . . . . . . . . . . . . 14ascomp with codeine . . . . . . . . . . . . . . 23ashlyna . . . . . . . . . . . . . . . . . . . . . . . . . . . 47aspirin-dipyridamole . . . . . . . . . . . . . . . 32ASTAGRAF XL . . . . . . . . . . . . . . . . . . . . 14atazanavir oral capsule 150 mg . . . . . . 7atazanavir oral capsule 200 mg . . . . . . 7atazanavir oral capsule 300 mg . . . . . . 7atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 30atenolol-chlorthalidone . . . . . . . . . . . . . 30ATGAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 44atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg . . . . . . . 26atomoxetine oral capsule 100 mg, 60 mg, 80 mg . . . . . . . . . . . . . 26atorvastatin oral tablet 10 mg, 20 mg, 80 mg . . . . . . . . . . . . . . 33atorvastatin oral tablet 40 mg . . . . . . . 33atovaquone . . . . . . . . . . . . . . . . . . . . . . . 10atovaquone-proguanil . . . . . . . . . . . . . . 10ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . . . 7atropine injection solution 0.4 mg/ml . 42atropine injection syringe 0.05 mg/ml, 0.1 mg/ml . . . . . . . . . . . . . 42atropine ophthalmic (eye) drops . . . . 50ATROVENT HFA . . . . . . . . . . . . . . . . . . 52aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47aubra eq . . . . . . . . . . . . . . . . . . . . . . . . . . 47aurovela 1.5/30 (21) . . . . . . . . . . . . . . . 47aurovela 1/20 (21) . . . . . . . . . . . . . . . . . 47aurovela 24 fe . . . . . . . . . . . . . . . . . . . . . 47aurovela fe 1.5/30 (28) . . . . . . . . . . . . . 47aurovela fe 1-20 (28) . . . . . . . . . . . . . . 47AURYXIA . . . . . . . . . . . . . . . . . . . . . . . . . 36AUSTEDO ORAL TABLET 6 MG . . . 22

ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 300 MCG/ML, 60 MCG/ML . . . . . . . . . 43ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 40 MCG/0.4 ML . . . 44ARANESP (IN POLYSORBATE) INJECTION SYRINGE 25 MCG/0.42 ML . . . . . . . . . . . . . . . . . . 44ARANESP (IN POLYSORBATE) INJECTION SYRINGE 60 MCG/0.3 ML . . . . . . . . . . . . . . . . . . . 44ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML . . . . . . . . . . . . . . . . . . 44ARANESP (IN POLYSORBATE) INJECTION SYRINGE 150 MCG/0.3 ML . . . . . . . . . . . . . . . . . . 44ARANESP (IN POLYSORBATE) INJECTION SYRINGE 200 MCG/0.4 ML . . . . . . . . . . . . . . . . . . 44ARANESP (IN POLYSORBATE) INJECTION SYRINGE 300 MCG/0.6 ML . . . . . . . . . . . . . . . . . . 44ARANESP (IN POLYSORBATE) INJECTION SYRINGE 500 MCG/ML . 44ARCALYST . . . . . . . . . . . . . . . . . . . . . . . 44ARIKAYCE . . . . . . . . . . . . . . . . . . . . . . . . 10aripiprazole oral solution . . . . . . . . . . . 25aripiprazole oral tablet . . . . . . . . . . . . . 25aripiprazole oral tablet,disintegrating . 25ARISTADA INITIO . . . . . . . . . . . . . . . . . 25ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML . . . . . . . . . 25ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML . . . . . . . . . . . 25ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML . . . . . . . . . . . 25ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML . . . . . . . . . . . 26

amlodipine-valsartan-hcthiazid . . . . . 30ammonium lactate . . . . . . . . . . . . . . . . . 34amnesteem . . . . . . . . . . . . . . . . . . . . . . . 34amoxapine . . . . . . . . . . . . . . . . . . . . . . . . 25amoxicillin oral capsule . . . . . . . . . . . . 12amoxicillin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 12amoxicillin oral tablet . . . . . . . . . . . . . . 12amoxicillin oral tablet,chewable 125 mg, 250 mg . . . . . . . . . . . . . . . . . . . 12amoxicillin-pot clavulanate oral suspension for reconstitution . . . . . . . 12amoxicillin-pot clavulanate oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 12amoxicillin-pot clavulanate oral tablet,chewable . . . . . . . . . . . . . . . 12amoxicillin-pot clavulanate oral tablet extended release 12 hr . . 12amphotericin b . . . . . . . . . . . . . . . . . . . . . 7ampicillin oral capsule 500 mg . . . . . . 12ampicillin sodium . . . . . . . . . . . . . . . . . . 12ampicillin-sulbactam . . . . . . . . . . . . . . . 12ANADROL-50 . . . . . . . . . . . . . . . . . . . . . 40anagrelide . . . . . . . . . . . . . . . . . . . . . . . . 36anastrozole . . . . . . . . . . . . . . . . . . . . . . . 13ANORO ELLIPTA . . . . . . . . . . . . . . . . . . 52APOKYN . . . . . . . . . . . . . . . . . . . . . . . . . . 21apraclonidine . . . . . . . . . . . . . . . . . . . . . . 51aprepitant . . . . . . . . . . . . . . . . . . . . . . . . . 42apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47APRISO . . . . . . . . . . . . . . . . . . . . . . . . . . 42APTIOM ORAL TABLET 200 MG . . . 19APTIOM ORAL TABLET 400 MG . . . 19APTIOM ORAL TABLET 600 MG, 800 MG . . . . . . . . . . . . . . . . . . 19APTIVUS . . . . . . . . . . . . . . . . . . . . . . . . . . 7APTIVUS (WITH VITAMIN E). . . . . . . . 7ARALAST NP . . . . . . . . . . . . . . . . . . . . . 36aranelle (28) . . . . . . . . . . . . . . . . . . . . . . 47ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML . . . . . . . . . . 44

58


Covered Drugs Index

BEXSERO . . . . . . . . . . . . . . . . . . . . . . . . 45bicalutamide . . . . . . . . . . . . . . . . . . . . . . 14BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . . 12BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30BIKTARVY . . . . . . . . . . . . . . . . . . . . . . . . . 7bimatoprost ophthalmic (eye) . . . . . . . 50BINOSTO . . . . . . . . . . . . . . . . . . . . . . . . . 46bisoprolol fumarate . . . . . . . . . . . . . . . . 30bisoprolol-hydrochlorothiazide . . . . . . 30BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . . 50BLEPHAMIDE S.O.P. . . . . . . . . . . . . . . 50blisovi 24 fe . . . . . . . . . . . . . . . . . . . . . . . 48blisovi fe 1.5/30 (28) . . . . . . . . . . . . . . . 48blisovi fe 1/20 (28) . . . . . . . . . . . . . . . . . 48BOOSTRIX TDAP . . . . . . . . . . . . . . . . . 45BORTEZOMIB . . . . . . . . . . . . . . . . . . . . 14bosentan . . . . . . . . . . . . . . . . . . . . . . . . . . 52BOSULIF . . . . . . . . . . . . . . . . . . . . . . . . . 14BOTOX . . . . . . . . . . . . . . . . . . . . . . . . . . . 45BRAFTOVI . . . . . . . . . . . . . . . . . . . . . . . . 14BREO ELLIPTA . . . . . . . . . . . . . . . . . . . 52briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . . 32brimonidine ophthalmic (eye) drops 0.2% . . . . . . . . . . . . . . . . . . 51brimonidine ophthalmic (eye) drops 0.15% . . . . . . . . . . . . . . . . . 51BRIVIACT ORAL SOLUTION . . . . . . . 19BRIVIACT ORAL TABLET . . . . . . . . . . 19bromfenac . . . . . . . . . . . . . . . . . . . . . . . . 50bromocriptine . . . . . . . . . . . . . . . . . . . . . 21BROVANA . . . . . . . . . . . . . . . . . . . . . . . . 52BRUKINSA . . . . . . . . . . . . . . . . . . . . . . . 14budesonide inhalation . . . . . . . . . . . . . . 52budesonide oral capsule, delayed,extend.release . . . . . . . . . . . . 42budesonide oral tablet, delayed and ext.release . . . . . . . . . . . . 42bumetanide injection . . . . . . . . . . . . . . . 30bumetanide oral . . . . . . . . . . . . . . . . . . . 30

BALVERSA ORAL TABLET 4 MG . . . 14BALVERSA ORAL TABLET 5 MG . . . 14balziva (28) . . . . . . . . . . . . . . . . . . . . . . . 48BANZEL ORAL SUSPENSION . . . . . 19BANZEL ORAL TABLET . . . . . . . . . . . 19BAQSIMI . . . . . . . . . . . . . . . . . . . . . . . . . . 38BARACLUDE ORAL SOLUTION . . . . 7BAVENCIO . . . . . . . . . . . . . . . . . . . . . . . . 14BAXDELA . . . . . . . . . . . . . . . . . . . . . . . . . 12BCG VACCINE, LIVE (PF) . . . . . . . . . 45BD PEN NEEDLE . . . . . . . . . . . . . . . . . 38bekyree (28) . . . . . . . . . . . . . . . . . . . . . . 48BELSOMRA ORAL TABLET 5 MG . . 26BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG . . . . . . . . . . . . . 26benazepril . . . . . . . . . . . . . . . . . . . . . . . . . 30benazepril-hydrochlorothiazide . . . . . 30BENDEKA . . . . . . . . . . . . . . . . . . . . . . . . 14BENLYSTA INTRAVENOUS RECON SOLN 120 MG . . . . . . . . . . . . 46BENLYSTA INTRAVENOUS RECON SOLN 400 MG . . . . . . . . . . . . 46benztropine injection . . . . . . . . . . . . . . . 21benztropine oral . . . . . . . . . . . . . . . . . . . 21BESIVANCE . . . . . . . . . . . . . . . . . . . . . . 50BESPONSA . . . . . . . . . . . . . . . . . . . . . . . 14betamethasone, augmented . . . . . . . . 35betamethasone dipropionate . . . . . . . 35betamethasone valerate topical cream . . . . . . . . . . . . . . . . . . . . . . 35betamethasone valerate topical foam . . . . . . . . . . . . . . . . . . . . . . . 35betamethasone valerate topical lotion . . . . . . . . . . . . . . . . . . . . . . . 35betamethasone valerate topical ointment . . . . . . . . . . . . . . . . . . . 35BETASERON SUBCUTANEOUS KIT . 44betaxolol ophthalmic (eye) . . . . . . . . . 50betaxolol oral . . . . . . . . . . . . . . . . . . . . . . 30bethanechol chloride . . . . . . . . . . . . . . . 53bexarotene . . . . . . . . . . . . . . . . . . . . . . . . 14

AUSTEDO ORAL TABLET 12 MG, 9 MG . . . . . . . . . . . . . . . . . . . . . . 22AVASTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 14aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47avita . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34AVONEX INTRAMUSCULAR PEN INJECTOR KIT . . . . . . . . . . . . . . . 44AVONEX INTRAMUSCULAR SYRINGE KIT . . . . . . . . . . . . . . . . . . . . . 44ayuna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47AYVAKIT . . . . . . . . . . . . . . . . . . . . . . . . . . 14AZASAN . . . . . . . . . . . . . . . . . . . . . . . . . . 14AZASITE . . . . . . . . . . . . . . . . . . . . . . . . . . 50azathioprine . . . . . . . . . . . . . . . . . . . . . . . 14azathioprine sodium . . . . . . . . . . . . . . . 14azelastine nasal . . . . . . . . . . . . . . . . . . . 37azelastine ophthalmic (eye) . . . . . . . . 50azithromycin intravenous . . . . . . . . . . . 10azithromycin oral packet . . . . . . . . . . . 10azithromycin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 10azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack) . . . . . . . . . . . 10azithromycin oral tablet 600 mg . . . . . 10AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . . 50aztreonam injection recon soln 1 gram . . . . . . . . . . . . . . . . . 10aztreonam injection recon soln 2 gram . . . . . . . . . . . . . . . . . 10azurette (28) . . . . . . . . . . . . . . . . . . . . . . 47

Bbacitracin intramuscular . . . . . . . . . . . . 10bacitracin ophthalmic (eye) . . . . . . . . . 50bacitracin-polymyxin b ophthalmic (eye) . . . . . . . . . . . . . . . . . . . 50baclofen oral tablet 10 mg, 5 mg . . . . 22baclofen oral tablet 20 mg . . . . . . . . . . 22balsalazide . . . . . . . . . . . . . . . . . . . . . . . . 42BALVERSA ORAL TABLET 3 MG . . . 14

59


Covered Drugs Index

carbidopa . . . . . . . . . . . . . . . . . . . . . . . . . 21carbidopa-levodopa-entacapone . . . . 21carbidopa-levodopa oral tablet . . . . . 21carbidopa-levodopa oral tablet,disintegrating . . . . . . . . . . . . . . . . 21carbidopa-levodopa oral tablet extended release . . . . . . . . . . . . . . . . . . 21CARNITOR INTRAVENOUS . . . . . . . 36carteolol . . . . . . . . . . . . . . . . . . . . . . . . . . 50cartia xt . . . . . . . . . . . . . . . . . . . . . . . . . . . 30carvedilol . . . . . . . . . . . . . . . . . . . . . . . . . 30carvedilol phosphate . . . . . . . . . . . . . . . 30caspofungin . . . . . . . . . . . . . . . . . . . . . . . . 7CAYSTON . . . . . . . . . . . . . . . . . . . . . . . . 10caziant (28) . . . . . . . . . . . . . . . . . . . . . . . 48cefaclor oral capsule . . . . . . . . . . . . . . . . 9cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml . . . . . . . . . . . 9cefaclor oral tablet extended release 12 hr . . . . . . . . . . . . . 9cefadroxil oral capsule . . . . . . . . . . . . . . 9cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . . 9cefadroxil oral tablet . . . . . . . . . . . . . . . . 9cefazolin . . . . . . . . . . . . . . . . . . . . . . . . . . . 9cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml . . . . . . . . . 9CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/100 ML . . . . . . 9cefdinir oral capsule . . . . . . . . . . . . . . . . 9cefdinir oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . . 9CEFEPIME IN DEXTROSE 5% . . . . . . 9cefepime in dextrose,iso-osm . . . . . . . 9cefepime injection . . . . . . . . . . . . . . . . . . 9cefixime oral capsule . . . . . . . . . . . . . . . 9cefixime oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . . 9

BYDUREON SUBCUTANEOUS PEN INJECTOR . . . . . . . . . . . . . . . . . . . 38BYSTOLIC . . . . . . . . . . . . . . . . . . . . . . . . 30

Ccabergoline . . . . . . . . . . . . . . . . . . . . . . . 40CABOMETYX ORAL TABLET 20 MG, 60 MG . . . . . . . . . . . . 14CABOMETYX ORAL TABLET 40 MG . . . . . . . . . . . . . . . . . . . 14calcipotriene scalp . . . . . . . . . . . . . . . . . 33calcipotriene topical cream . . . . . . . . . 33calcipotriene topical ointment . . . . . . . 34calcitonin (salmon) . . . . . . . . . . . . . . . . . 40calcitriol intravenous solution 1 mcg/ml . . . . . . . . . . . . . . . . . . 40calcitriol oral . . . . . . . . . . . . . . . . . . . . . . . 40calcitriol topical . . . . . . . . . . . . . . . . . . . . 34calcium acetate(phosphat bind) . . . . . 53CALQUENCE . . . . . . . . . . . . . . . . . . . . . 14camila . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46camrese . . . . . . . . . . . . . . . . . . . . . . . . . . 48camrese lo . . . . . . . . . . . . . . . . . . . . . . . . 48candesartan-hydrochlorothiazid . . . . 30candesartan oral tablet 16 mg, 4 mg, 8 mg . . . . . . . . . . . . . . . . . 30candesartan oral tablet 32 mg . . . . . . 30CAPASTAT . . . . . . . . . . . . . . . . . . . . . . . . 10CAPLYTA . . . . . . . . . . . . . . . . . . . . . . . . . 26CAPRELSA ORAL TABLET 100 MG 14CAPRELSA ORAL TABLET 300 MG 14CARAFATE ORAL SUSPENSION . . 43CARBAGLU . . . . . . . . . . . . . . . . . . . . . . . 36carbamazepine oral capsule, er multiphase 12 hr . . . . . . . . . . . . . . . . 19carbamazepine oral suspension 100 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . 19carbamazepine oral tablet . . . . . . . . . . 19carbamazepine oral tablet,chewable . 19carbamazepine oral tablet extended release 12 hr . . . . . . . . . . . . 19

buprenorphine hcl injection solution . 23buprenorphine hcl injection syringe . 23buprenorphine hcl sublingual . . . . . . . 23buprenorphine-naloxone sublingual film 2-0.5 mg, 4-1 mg, 8-2 mg . . . . . . 24buprenorphine-naloxone sublingual film 12-3 mg . . . . . . . . . . . . 24buprenorphine-naloxone sublingual tablet . . . . . . . . . . . . . . . . . . . 24buprenorphine transdermal patch weekly 7.5 mcg/hour . . . . . . . . . 23BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR . . . . . 23bupropion hcl oral tablet 75 mg . . . . . 26bupropion hcl oral tablet 100 mg . . . . 26bupropion hcl oral tablet extended release 24 hr 150 mg . . . . . . . . . . . . . . 26bupropion hcl oral tablet extended release 24 hr 300 mg . . . . . . . . . . . . . . 26bupropion hcl oral tablet sustained-release 12 hr 100 mg, 200 mg . . . . . . 26bupropion hcl oral tablet sustained-release 12 hr 150 mg . . . . . . . . . . . . . . 26bupropion hcl (smoking deter) . . . . . . 37buspirone . . . . . . . . . . . . . . . . . . . . . . . . . 26busulfan . . . . . . . . . . . . . . . . . . . . . . . . . . 14BUSULFEX . . . . . . . . . . . . . . . . . . . . . . . 14butalbital-acetaminop-caf-cod . . . . . . 23butalbital-acetaminophen-caff oral capsule . . . . . . . . . . . . . . . . . . . . . . . 23butalbital-acetaminophen-caff oral tablet 50-325-40 mg . . . . . . . . . . . 23butalbital-aspirin-caffeine oral capsule . . . . . . . . . . . . . . . . . . . . . . . 23butalbital compound w/codeine . . . . . 23butorphanol tartrate injection solution 1 mg/ml . . . . . . . . . . . . . . . . . . . 24butorphanol tartrate injection solution 2 mg/ml . . . . . . . . . . . . . . . . . . . 24butorphanol tartrate nasal . . . . . . . . . . 24BYDUREON BCISE . . . . . . . . . . . . . . . 38

60


Covered Drugs Index

CLINDAMYCIN IN 0.9% SOD CHLOR . . . . . . . . . . . . . . . . . . . . . . 10clindamycin in 5% dextrose . . . . . . . . 10clindamycin palmitate hcl . . . . . . . . . . . 10clindamycin pediatric . . . . . . . . . . . . . . 10clindamycin phosphate injection . . . . 10clindamycin phosphate intravenous solution 600 mg/4 ml . . . 10clindamycin phosphate topical gel . . 34CLINDAMYCIN PHOSPHATE TOPICAL GEL, ONCE DAILY . . . . . . 34clindamycin phosphate topical lotion . . . . . . . . . . . . . . . . . . . . . . . 34clindamycin phosphate topical solution . . . . . . . . . . . . . . . . . . . . 34clindamycin phosphate topical swab . . . . . . . . . . . . . . . . . . . . . . . 34clindamycin phosphate vaginal . . . . . 47CLINIMIX 4.25%/D5W SULFIT FREE . . . . . . . . . . . . . . . . . . . . . 36CLINIMIX 4.25%/D10W SULF FREE . . . . . . . . . . . . . . . . . . . . . . . 54CLINIMIX 5%/D15W SULFITE FREE . . . . . . . . . . . . . . . . . . . 54CLINIMIX 5%-D20W (SULFITE-FREE) . . . . . . . . . . . . . . . . . . 54CLINIMIX E 4.25%/D10W SUL FREE . . . . . . . . . . . . . . . . . . . . . . . . 54CLINISOL SF 15% . . . . . . . . . . . . . . . . 54clobazam oral suspension . . . . . . . . . . 19clobazam oral tablet 10 mg . . . . . . . . . 19clobazam oral tablet 20 mg . . . . . . . . . 19clobetasol-emollient topical cream . . 35clobetasol-emollient topical foam . . . 35clobetasol scalp . . . . . . . . . . . . . . . . . . . 35clobetasol topical cream . . . . . . . . . . . 35clobetasol topical foam . . . . . . . . . . . . . 35clobetasol topical gel . . . . . . . . . . . . . . 35clobetasol topical ointment . . . . . . . . . 35clobetasol topical shampoo . . . . . . . . 35CLOCORTOLONE PIVALATE . . . . . . 35clodan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

chlorpromazine injection . . . . . . . . . . . 26chlorpromazine oral . . . . . . . . . . . . . . . . 26chlorthalidone oral tablet 25 mg, 50 mg . . . . . . . . . . . . . . . . . . . . . 30cholestyramine light . . . . . . . . . . . . . . . 33cholestyramine (with sugar) . . . . . . . . 33CHORIONIC GONADOTROPIN, HUMAN INTRAMUSCULAR . . . . . . . 40ciclodan topical solution . . . . . . . . . . . . 35ciclopirox topical cream . . . . . . . . . . . . 35ciclopirox topical shampoo . . . . . . . . . 35ciclopirox topical solution . . . . . . . . . . . 35ciclopirox topical suspension . . . . . . . 35cilostazol . . . . . . . . . . . . . . . . . . . . . . . . . . 32CILOXAN OPHTHALMIC (EYE) OINTMENT . . . . . . . . . . . . . . . . . 50CIMDUO . . . . . . . . . . . . . . . . . . . . . . . . . . . 7cinacalcet oral tablet 30 mg, 60 mg . 40cinacalcet oral tablet 90 mg . . . . . . . . 40CINRYZE . . . . . . . . . . . . . . . . . . . . . . . . . 52CIPRODEX . . . . . . . . . . . . . . . . . . . . . . . 38ciprofloxacin . . . . . . . . . . . . . . . . . . . . . . . 12ciprofloxacin hcl ophthalmic (eye) . . . 50ciprofloxacin hcl oral tablet 100 mg . 12ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg . . . . . . . . . . . 12ciprofloxacin in 5% dextrose . . . . . . . . 12CIPRO HC . . . . . . . . . . . . . . . . . . . . . . . . 38citalopram oral solution . . . . . . . . . . . . 26citalopram oral tablet 10 mg . . . . . . . . 26citalopram oral tablet 20 mg . . . . . . . . 26citalopram oral tablet 40 mg . . . . . . . . 26claravis . . . . . . . . . . . . . . . . . . . . . . . . . . . 34clarithromycin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 10clarithromycin oral tablet . . . . . . . . . . . 10clarithromycin oral tablet extended release 24 hr . . . . . . . . . . . . 10clindacin etz topical swab . . . . . . . . . . 34clindacin p . . . . . . . . . . . . . . . . . . . . . . . . 34clindamycin hcl . . . . . . . . . . . . . . . . . . . . 10

cefotetan . . . . . . . . . . . . . . . . . . . . . . . . . . . 9CEFOTETAN IN DEXTROSE, ISO-OSM . . . . . . . . . . . . . . . . . . . . . . . . . . 9cefoxitin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9cefoxitin in dextrose, iso-osm . . . . . . . . 9cefpodoxime . . . . . . . . . . . . . . . . . . . . . . . 9cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . . 9ceftazidime . . . . . . . . . . . . . . . . . . . . . . . . . 9CEFTAZIDIME IN D5W . . . . . . . . . . . . . 9ceftriaxone in dextrose,iso-os . . . . . . . 9ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg . . . . . . . . . . . . 9CEFTRIAXONE INJECTION RECON SOLN 100 GRAM . . . . . . . . . 10ceftriaxone intravenous . . . . . . . . . . . . 10cefuroxime axetil oral tablet . . . . . . . . 10cefuroxime sodium injection recon soln 750 mg . . . . . . . . . . . . . . . . . 10cefuroxime sodium intravenous . . . . . 10celecoxib . . . . . . . . . . . . . . . . . . . . . . . . . . 24CELONTIN ORAL CAPSULE 300 MG . . . . . . . . . . . . . . . . 19cephalexin oral capsule 250 mg, 500 mg . . . . . . . . . . . . . . . . . . . 10cephalexin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 10CEREZYME INTRAVENOUS RECON SOLN 400 UNIT . . . . . . . . . . 40CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . . 37CHANTIX CONTINUING MONTH BOX . . . . . . . . . . . . . . . . . . . . . 37CHANTIX STARTING MONTH BOX . 37chateal (28) . . . . . . . . . . . . . . . . . . . . . . . 48chateal eq (28) . . . . . . . . . . . . . . . . . . . . 48CHEMET . . . . . . . . . . . . . . . . . . . . . . . . . 36chloramphenicol sod succinate . . . . . 10chlorhexidine gluconate mucous membrane . . . . . . . . . . . . . . . . 37chloroquine phosphate . . . . . . . . . . . . . 10chlorothiazide oral tablet 500 mg . . . 30chlorothiazide sodium . . . . . . . . . . . . . . 30

61


Covered Drugs Index

cyclophosphamide oral capsule . . . . 14CYCLOSERINE . . . . . . . . . . . . . . . . . . . 11CYCLOSET . . . . . . . . . . . . . . . . . . . . . . . 38cyclosporine intravenous . . . . . . . . . . . 14cyclosporine modified . . . . . . . . . . . . . . 14cyclosporine oral capsule . . . . . . . . . . 14CYRAMZA . . . . . . . . . . . . . . . . . . . . . . . . 14cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48cyred eq . . . . . . . . . . . . . . . . . . . . . . . . . . 48CYSTADANE . . . . . . . . . . . . . . . . . . . . . 42CYSTAGON . . . . . . . . . . . . . . . . . . . . . . . 53CYSTARAN . . . . . . . . . . . . . . . . . . . . . . . 50

Dd2.5%-0.45% sodium chloride . . . . . . 36d5%-0.45% sodium chloride . . . . . . . . 36d5% and 0.9% sodium chloride . . . . . 36d10%-0.45% sodium chloride . . . . . . 36dalfampridine . . . . . . . . . . . . . . . . . . . . . . 22DALIRESP . . . . . . . . . . . . . . . . . . . . . . . . 52danazol . . . . . . . . . . . . . . . . . . . . . . . . . . . 40dantrolene oral . . . . . . . . . . . . . . . . . . . . 22dapsone oral . . . . . . . . . . . . . . . . . . . . . . 11DAPTACEL (DTAP PEDIATRIC) (PF) . 45DAPTOMYCIN INTRAVENOUS RECON SOLN 350 MG . . . . . . . . . . . . 11daptomycin intravenous recon soln 500 mg . . . . . . . . . . . . . . . . . 11DARAPRIM . . . . . . . . . . . . . . . . . . . . . . . 11darifenacin . . . . . . . . . . . . . . . . . . . . . . . . 53DARZALEX . . . . . . . . . . . . . . . . . . . . . . . 14dasetta 1/35 (28) . . . . . . . . . . . . . . . . . . 48dasetta 7/7/7 (28) . . . . . . . . . . . . . . . . . . 48daunorubicin intravenous solution . . 14DAURISMO ORAL TABLET 25 MG . 14DAURISMO ORAL TABLET 100 MG . 14daysee . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48deblitane . . . . . . . . . . . . . . . . . . . . . . . . . . 46deferasirox oral tablet 360 mg, 90 mg . . . . . . . . . . . . . . . . . . . . 36

colchicine oral capsule . . . . . . . . . . . . . 45colchicine oral tablet . . . . . . . . . . . . . . . 45colesevelam . . . . . . . . . . . . . . . . . . . . . . . 33colestipol . . . . . . . . . . . . . . . . . . . . . . . . . . 33colistin (colistimethate na) . . . . . . . . . . 11colocort . . . . . . . . . . . . . . . . . . . . . . . . . . . 42COMBIGAN . . . . . . . . . . . . . . . . . . . . . . . 50COMBIVENT RESPIMAT . . . . . . . . . . 52COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) . . . . . . 14COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) . 14COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3) . 14COMPLERA . . . . . . . . . . . . . . . . . . . . . . . 7compro . . . . . . . . . . . . . . . . . . . . . . . . . . . 42constulose . . . . . . . . . . . . . . . . . . . . . . . . 42COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML . . . . . . . . . . . . . . 22COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML . . . . . . . . . . . . . . 22COPIKTRA . . . . . . . . . . . . . . . . . . . . . . . 14CORLANOR ORAL TABLET . . . . . . . 33cortisone . . . . . . . . . . . . . . . . . . . . . . . . . . 38CORTISPORIN-TC . . . . . . . . . . . . . . . . 38COSMEGEN . . . . . . . . . . . . . . . . . . . . . . 14COTELLIC . . . . . . . . . . . . . . . . . . . . . . . . 14COUMADIN ORAL . . . . . . . . . . . . . . . . 32CREON . . . . . . . . . . . . . . . . . . . . . . . . . . . 42CRESEMBA ORAL . . . . . . . . . . . . . . . . . 7CRIXIVAN ORAL CAPSULE 200 MG . . 7CRIXIVAN ORAL CAPSULE 400 MG . . 7cromolyn inhalation . . . . . . . . . . . . . . . . 52cromolyn ophthalmic (eye) . . . . . . . . . 50cromolyn oral . . . . . . . . . . . . . . . . . . . . . . 42cryselle (28) . . . . . . . . . . . . . . . . . . . . . . . 48cyclafem 1/35 (28) . . . . . . . . . . . . . . . . . 48cyclafem 7/7/7 (28) . . . . . . . . . . . . . . . . 48cyclobenzaprine oral tablet 10 mg, 5 mg . . . . . . . . . . . . . . . . . 22cyclophosphamide intravenous . . . . . 14

clomipramine . . . . . . . . . . . . . . . . . . . . . . 26clonazepam oral tablet 0.5 mg, 1 mg . . . . . . . . . . . . . . . . . . . . . . 20clonazepam oral tablet 2 mg . . . . . . . 20clonazepam oral tablet, disintegrating 0.125 mg, 0.25 mg, 0.5 mg . . . . . . . . . . . . . . . . . . . 20clonazepam oral tablet, disintegrating 1 mg . . . . . . . . . . . . . . . . 20clonazepam oral tablet, disintegrating 2 mg . . . . . . . . . . . . . . . . 20clonidine hcl oral tablet 0.1 mg, 0.2 mg . . . . . . . . . . . . . . . . . . . . 30clonidine hcl oral tablet 0.3 mg . . . . . 30clonidine hcl oral tablet extended release 12 hr . . . . . . . . . . . . 26clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr . . 30clonidine transdermal patch weekly 0.3 mg/24 hr . . . . . . . . . . . . . . . 30clopidogrel oral tablet 75 mg . . . . . . . 32clopidogrel oral tablet 300 mg . . . . . . 32clorazepate dipotassium oral tablet 7.5 mg . . . . . . . . . . . . . . . . . . 26clorazepate dipotassium oral tablet 15 mg, 3.75 mg . . . . . . . . . 26clotrimazole-betamethasone topical cream . . . . . . . . . . . . . . . . . . . . . . 35clotrimazole-betamethasone topical lotion . . . . . . . . . . . . . . . . . . . . . . . 35clotrimazole mucous membrane . . . . . 7clotrimazole topical cream . . . . . . . . . . 35clotrimazole topical solution . . . . . . . . 35clozapine oral tablet . . . . . . . . . . . . . . . 26clozapine oral tablet, disintegrating 12.5 mg, 25 mg . . . . . . 26clozapine oral tablet, disintegrating 100 mg . . . . . . . . . . . . . . 26clozapine oral tablet, disintegrating 150 mg . . . . . . . . . . . . . . 26clozapine oral tablet, disintegrating 200 mg . . . . . . . . . . . . . . 26COARTEM . . . . . . . . . . . . . . . . . . . . . . . . 10

62


Covered Drugs Index

dextrose 70% in water (d70w) . . . . . . 37dextrose with sodium chloride . . . . . . 37DIASTAT . . . . . . . . . . . . . . . . . . . . . . . . . . 20DIASTAT ACUDIAL RECTAL KIT 5-7.5-10 MG . . . . . . . . . . 20DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20 MG . . 20diazepam injection syringe . . . . . . . . . 26diazepam oral solution 5 mg/5 ml (1 mg/ml) . . . . . . . . . . . . . . . 27diazepam oral tablet . . . . . . . . . . . . . . . 27diazepam rectal kit 2.5 mg . . . . . . . . . 20diazepam rectal kit 5-7.5-10 mg . . . . 20diazepam rectal kit 12.5-15-17.5-20 mg . . . . . . . . . . . . . . . . 20diclofenac potassium . . . . . . . . . . . . . . 24diclofenac sodium ophthalmic (eye) . . 50diclofenac sodium oral . . . . . . . . . . . . . 25diclofenac sodium topical drops . . . . 25diclofenac sodium topical gel 1% . . . 25dicloxacillin . . . . . . . . . . . . . . . . . . . . . . . . 12dicyclomine oral capsule . . . . . . . . . . . 42dicyclomine oral solution . . . . . . . . . . . 42dicyclomine oral tablet . . . . . . . . . . . . . 42didanosine oral capsule, delayed release(dr/ec) 200 mg, 250 mg, 400 mg . . . . . . . . . . . . 7DIFICID . . . . . . . . . . . . . . . . . . . . . . . . . . . 10diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . . 25digitek . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33digox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33digoxin oral solution 50 mcg/ml (0.05 mg/ml) . . . . . . . . . . . . 33digoxin oral tablet . . . . . . . . . . . . . . . . . . 33dihydroergotamine nasal . . . . . . . . . . . 21DILANTIN 30 MG . . . . . . . . . . . . . . . . . . 20diltiazem hcl intravenous . . . . . . . . . . . 30diltiazem hcl oral capsule, extended release 12 hr . . . . . . . . . . . . 30diltiazem hcl oral capsule, extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg . . . . . . . . . . . 30

dexamethasone sodium phosphate injection solution . . . . . . . . 38dexamethasone sodium phosphate ophthalmic (eye) . . . . . . . . 51dexmethylphenidate oral tablet 5 mg . . . . . . . . . . . . . . . . . . . . . . . . 26dexmethylphenidate oral tablet 10 mg, 2.5 mg . . . . . . . . . . . . . . . 26dextroamphetamine-amphetamine oral capsule,extended release 24hr . . 26dextroamphetamine-amphetamine oral tablet 5 mg . . . . . . . . . . . . . . . . . . . . 26dextroamphetamine-amphetamine oral tablet 10 mg . . . . . . . . . . . . . . . . . . 26dextroamphetamine-amphetamine oral tablet 12.5 mg, 30 mg, 7.5 mg . . 26dextroamphetamine-amphetamine oral tablet 15 mg . . . . . . . . . . . . . . . . . . 26dextroamphetamine-amphetamine oral tablet 20 mg . . . . . . . . . . . . . . . . . . 26dextroamphetamine oral capsule, extended release 5 mg . . . . . . . . . . . . . 26dextroamphetamine oral capsule, extended release 10 mg . . . . . . . . . . . 26dextroamphetamine oral capsule, extended release 15 mg . . . . . . . . . . . 26dextroamphetamine oral solution . . . 26dextroamphetamine oral tablet . . . . . 26dextrose 5%-0.2% sod chloride . . . . . 37dextrose 5%-0.3% sod.chloride . . . . . 37DEXTROSE 5% IN WATER (D5W) INTRAVENOUS PARENTERAL SOLUTION . . . . . . . . . 36dextrose 5% in water (d5w) intravenous piggyback . . . . . . . . . . . . . 36dextrose 5%-lactated ringers . . . . . . . 37dextrose 10% and 0.2% nacl . . . . . . . 36DEXTROSE 10% IN WATER (D10W) . 36dextrose 20% in water (d20w) . . . . . . 36dextrose 25% in water (d25w) . . . . . . 36dextrose 30% in water (d30w) . . . . . . 36dextrose 40% in water (d40w) . . . . . . 36dextrose 50% in water (d50w) . . . . . . 37

DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML . 47DELSTRIGO . . . . . . . . . . . . . . . . . . . . . . . 7demeclocycline . . . . . . . . . . . . . . . . . . . . 13DEMSER . . . . . . . . . . . . . . . . . . . . . . . . . 30DENAVIR . . . . . . . . . . . . . . . . . . . . . . . . . 34DEPEN TITRATABS . . . . . . . . . . . . . . . 46DEPO-ESTRADIOL . . . . . . . . . . . . . . . 47DEPO-MEDROL . . . . . . . . . . . . . . . . . . 38DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML. . . . . . . . . 47DESCOVY . . . . . . . . . . . . . . . . . . . . . . . . . 7desipramine . . . . . . . . . . . . . . . . . . . . . . . 26desloratadine oral tablet . . . . . . . . . . . 51desmopressin injection . . . . . . . . . . . . . 40desmopressin nasal spray, non-aerosol . . . . . . . . . . . . . . . . . . . . . . . 41desmopressin nasal spray with pump . . . . . . . . . . . . . . . . . . . . . . . . . 40desmopressin oral . . . . . . . . . . . . . . . . . 41desog-e.estradiol/e.estradiol . . . . . . . 48desogestrel-ethinyl estradiol . . . . . . . . 48desonide . . . . . . . . . . . . . . . . . . . . . . . . . . 35desoximetasone topical cream . . . . . 35desoximetasone topical gel . . . . . . . . 35desoximetasone topical ointment . . . 35desvenlafaxine succinate oral tablet extended release 24 hr 25 mg, 50 mg . . . . . . . . . . . . . . . . 26desvenlafaxine succinate oral tablet extended release 24 hr 100 mg . . . . . . . . . . . . . . . . . . . . . . 26dexamethasone intensol . . . . . . . . . . . 38dexamethasone oral elixir . . . . . . . . . . 38dexamethasone oral solution . . . . . . . 38dexamethasone oral tablet 0.5 mg, 0.75 mg, 4 mg . . . . . . . . . . . . . 38dexamethasone oral tablet 1 mg, 1.5 mg, 2 mg, 6 mg . . . . . . . . . . 38dexamethasone sodium phos (pf) injection solution . . . . . . . . . . . . . . . 38

63


Covered Drugs Index

EDURANT . . . . . . . . . . . . . . . . . . . . . . . . . 7e.e.s. 400 oral tablet . . . . . . . . . . . . . . . 10efavirenz oral capsule 50 mg . . . . . . . . 7efavirenz oral capsule 200 mg . . . . . . . 7efavirenz oral tablet . . . . . . . . . . . . . . . . . 7ELAPRASE . . . . . . . . . . . . . . . . . . . . . . . 41electrolyte-48 in d5w . . . . . . . . . . . . . . . 54ELIGARD . . . . . . . . . . . . . . . . . . . . . . . . . 14ELIGARD (3 MONTH) . . . . . . . . . . . . . 14ELIGARD (4 MONTH) . . . . . . . . . . . . . 14ELIGARD (6 MONTH) . . . . . . . . . . . . . 14elinest . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48ELIQUIS . . . . . . . . . . . . . . . . . . . . . . . . . . 32ELIQUIS DVT-PE TREAT 30D START . . . . . . . . . . . . . . . . 32ELLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48ELMIRON . . . . . . . . . . . . . . . . . . . . . . . . . 53ELZONRIS . . . . . . . . . . . . . . . . . . . . . . . . 14EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . . 14EMEND ORAL SUSPENSION FOR RECONSTITUTION . . . . . . . . . . 42emoquette . . . . . . . . . . . . . . . . . . . . . . . . 48EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 27EMTRIVA ORAL CAPSULE . . . . . . . . . 8EMTRIVA ORAL SOLUTION . . . . . . . . 8EMVERM . . . . . . . . . . . . . . . . . . . . . . . . . 11enalapril-hydrochlorothiazide . . . . . . . 31enalapril maleate . . . . . . . . . . . . . . . . . . 31ENBREL MINI . . . . . . . . . . . . . . . . . . . . . 46ENBREL SUBCUTANEOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . 46ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5) . . . . . . 46ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML) . . . . . . . 46ENBREL SURECLICK . . . . . . . . . . . . . 46endocet oral tablet 2.5-325 mg, 5-325 mg . . . . . . . . . . . . . 23endocet oral tablet 7.5-325 mg . . . . . 23endocet oral tablet 10-325 mg . . . . . . 23

doxycycline hyclate oral tablet 100 mg . . . . . . . . . . . . . . . . . . . . . 13doxycycline monohydrate oral capsule 100 mg, 50 mg . . . . . . . . . . . . 13DOXYCYCLINE MONOHYDRATE ORAL CAPSULE,IR - DELAY REL,BIPHASE . . . . . . . . . . . . . . . . . . . . 13doxycycline monohydrate oral suspension for reconstitution . . . . . . . 13doxycycline monohydrate oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 13DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG . . . . . . . . . . . . 27DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 30 MG, 40 MG . . . . 27DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 60 MG . . . . . . . . . . . . 27dronabinol . . . . . . . . . . . . . . . . . . . . . . . . 42drospirenone-e.estradiol-lm.fa . . . . . . 48drospirenone-ethinyl estradiol . . . . . . 48DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . . 14DUAVEE . . . . . . . . . . . . . . . . . . . . . . . . . . 47duloxetine oral capsule,delayed release(dr/ec) 20 mg . . . . . . . . . . . . . . . 27duloxetine oral capsule,delayed release(dr/ec) 30 mg . . . . . . . . . . . . . . . 27duloxetine oral capsule,delayed release(dr/ec) 60 mg . . . . . . . . . . . . . . . 27DUPIXENT . . . . . . . . . . . . . . . . . . . . . . . . 34DURAMORPH (PF) . . . . . . . . . . . . . . . . 23DUREZOL . . . . . . . . . . . . . . . . . . . . . . . . 51dutasteride . . . . . . . . . . . . . . . . . . . . . . . . 53dutasteride-tamsulosin . . . . . . . . . . . . . 53

Eec-naproxen . . . . . . . . . . . . . . . . . . . . . . . 25econazole . . . . . . . . . . . . . . . . . . . . . . . . . 35EDARBI . . . . . . . . . . . . . . . . . . . . . . . . . . 30EDARBYCLOR . . . . . . . . . . . . . . . . . . . . 31

diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 420 mg . . . . . . . . . . . 30diltiazem hcl oral tablet . . . . . . . . . . . . . 30diltiazem hcl oral tablet extended release 24 hr . . . . . . . . . . . . 30dilt-xr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30diphenhydramine hcl injection solution 50 mg/ml . . . . . . . . . 51diphenoxylate-atropine oral liquid . . . 42diphenoxylate-atropine oral tablet . . . 42dipyridamole oral . . . . . . . . . . . . . . . . . . 32disulfiram . . . . . . . . . . . . . . . . . . . . . . . . . 37divalproex . . . . . . . . . . . . . . . . . . . . . . . . . 20dofetilide . . . . . . . . . . . . . . . . . . . . . . . . . . 30donepezil oral tablet 5 mg . . . . . . . . . . 22donepezil oral tablet 10 mg . . . . . . . . . 22donepezil oral tablet 23 mg . . . . . . . . . 22donepezil oral tablet, disintegrating 5 mg . . . . . . . . . . . . . . . . 22donepezil oral tablet, disintegrating 10 mg . . . . . . . . . . . . . . . 22dorzolamide . . . . . . . . . . . . . . . . . . . . . . . 50dorzolamide-timolol . . . . . . . . . . . . . . . . 50dotti . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47DOVATO . . . . . . . . . . . . . . . . . . . . . . . . . . . 7doxazosin . . . . . . . . . . . . . . . . . . . . . . . . . 30doxepin oral capsule . . . . . . . . . . . . . . . 27doxepin oral concentrate . . . . . . . . . . . 27doxepin oral tablet . . . . . . . . . . . . . . . . . 27doxercalciferol intravenous . . . . . . . . . 41doxercalciferol oral capsule 0.5 mcg . . . . . . . . . . . . . . . . . . . 41doxercalciferol oral capsule 1 mcg . . . . . . . . . . . . . . . . . . . . . 41doxercalciferol oral capsule 2.5 mcg . . . . . . . . . . . . . . . . . . . 41doxy-100 . . . . . . . . . . . . . . . . . . . . . . . . . . 13doxycycline hyclate intravenous . . . . 13doxycycline hyclate oral capsule . . . . 13doxycycline hyclate oral tablet 20 mg . . . . . . . . . . . . . . . . . . . . . . . 13

64


Covered Drugs Index

ethacrynate sodium . . . . . . . . . . . . . . . . 31ethambutol . . . . . . . . . . . . . . . . . . . . . . . . 11ethosuximide . . . . . . . . . . . . . . . . . . . . . . 20ethynodiol diac-eth estradiol . . . . . . . . 48etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . 25etoposide intravenous . . . . . . . . . . . . . 15everolimus (antineoplastic) . . . . . . . . . 15EVOMELA . . . . . . . . . . . . . . . . . . . . . . . . 15EVOTAZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 8exemestane . . . . . . . . . . . . . . . . . . . . . . . 15EYLEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50ezetimibe . . . . . . . . . . . . . . . . . . . . . . . . . 33ezetimibe-simvastatin . . . . . . . . . . . . . . 33

FFABRAZYME . . . . . . . . . . . . . . . . . . . . . 41falmina (28) . . . . . . . . . . . . . . . . . . . . . . . 48famciclovir . . . . . . . . . . . . . . . . . . . . . . . . . 8famotidine oral tablet 20 mg, 40 mg . . . . . . . . . . . . . . . . . . . . . 43FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG . . . . . . . . . . . . . . . . 27FANAPT ORAL TABLET 10 MG, 12 MG, 6 MG, 8 MG . . . . . . . 27FANAPT ORAL TABLETS, DOSE PACK . . . . . . . . . . . . . . . . . . . . . . 27FARXIGA ORAL TABLET 5 MG . . . . 38FARXIGA ORAL TABLET 10 MG . . . 38FARYDAK ORAL CAPSULE 10 MG, 20 MG . . . . . . . . . . . . . . . . . . . . 15FASLODEX . . . . . . . . . . . . . . . . . . . . . . . 15fayosim . . . . . . . . . . . . . . . . . . . . . . . . . . . 48FEBUXOSTAT . . . . . . . . . . . . . . . . . . . . 46felbamate oral suspension . . . . . . . . . 20felbamate oral tablet . . . . . . . . . . . . . . . 20felodipine . . . . . . . . . . . . . . . . . . . . . . . . . 31femynor . . . . . . . . . . . . . . . . . . . . . . . . . . . 48fenofibrate micronized oral capsule 130 mg, 43 mg . . . . . . . . . . . . 33fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg . . . . 33

ery-tab oral tablet,delayed release (dr/ec) 250 mg . . . . . . . . . . . . . 10ERY-TAB ORAL TABLET, DELAYED RELEASE (DR/EC) 333 MG, 500 MG . . . . . . . . . 10erythrocin (as stearate) oral tablet 250 mg . . . . . . . . . . . . . . . . . 10ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG . . . . . . . . . . . . 10erythromycin-benzoyl peroxide . . . . . 34erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . 10erythromycin ethylsuccinate oral suspension for reconstitution 400 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . 10erythromycin ethylsuccinate oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 10erythromycin ophthalmic (eye) . . . . . . 50erythromycin oral tablet . . . . . . . . . . . . 10erythromycin oral tablet, delayed release (dr/ec) . . . . . . . . . . . . 10erythromycin with ethanol topical gel . . . . . . . . . . . . . . . . . . . . . . . . . 34erythromycin with ethanol topical solution . . . . . . . . . . . . . . . . . . . . 34ESBRIET ORAL CAPSULE . . . . . . . . 52ESBRIET ORAL TABLET 267 MG . . 52ESBRIET ORAL TABLET 801 MG . . 52escitalopram oxalate oral solution . . 27escitalopram oxalate oral tablet . . . . . 27esomeprazole magnesium oral capsule,delayed release(dr/ec) . . . . . 43estarylla . . . . . . . . . . . . . . . . . . . . . . . . . . 48estradiol oral . . . . . . . . . . . . . . . . . . . . . . 47estradiol transdermal patch semiweekly . . . . . . . . . . . . . . . . . 47estradiol transdermal patch weekly . 47estradiol vaginal cream . . . . . . . . . . . . 47estradiol vaginal tablet . . . . . . . . . . . . . 47estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml . . . . . . . . . . . . . 47ESTRING . . . . . . . . . . . . . . . . . . . . . . . . . 47

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE . . . . . . 45ENGERIX-B (PF) INTRAMUSCULAR SYRINGE . . . . . . 45ENHERTU . . . . . . . . . . . . . . . . . . . . . . . . 14enoxaparin subcutaneous solution . . 32enoxaparin subcutaneous syringe 100 mg/ml, 30 mg/0.3 ml, 40 mg/ 0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml . 32enoxaparin subcutaneous syringe 120 mg/0.8 ml, 150 mg/ml . . . . . . . . . . 32enpresse . . . . . . . . . . . . . . . . . . . . . . . . . . 48enskyce . . . . . . . . . . . . . . . . . . . . . . . . . . . 48entacapone . . . . . . . . . . . . . . . . . . . . . . . 21entecavir . . . . . . . . . . . . . . . . . . . . . . . . . . . 8ENTRESTO . . . . . . . . . . . . . . . . . . . . . . . 33enulose . . . . . . . . . . . . . . . . . . . . . . . . . . . 42ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG . . . . . . . . . . . . . . . . . . . . 14ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 4 MG . . . . . . . . . . . . . . . . . . . . . . . 14EPCLUSA . . . . . . . . . . . . . . . . . . . . . . . . . 8EPIDIOLEX . . . . . . . . . . . . . . . . . . . . . . . 20epinastine . . . . . . . . . . . . . . . . . . . . . . . . . 50epinephrine injection auto-injector . . 51EPIPEN . . . . . . . . . . . . . . . . . . . . . . . . . . . 51EPIPEN 2-PAK . . . . . . . . . . . . . . . . . . . . 51EPIPEN JR . . . . . . . . . . . . . . . . . . . . . . . 51EPIPEN JR 2-PAK . . . . . . . . . . . . . . . . . 51epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20EPIVIR HBV ORAL SOLUTION . . . . . 8ergotamine-caffeine . . . . . . . . . . . . . . . 21ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . . 14ERLEADA . . . . . . . . . . . . . . . . . . . . . . . . 14erlotinib oral tablet 25 mg . . . . . . . . . . 15erlotinib oral tablet 100 mg, 150 mg . . 14errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47ertapenem . . . . . . . . . . . . . . . . . . . . . . . . 11ery pads . . . . . . . . . . . . . . . . . . . . . . . . . . 34ERYPED 400 . . . . . . . . . . . . . . . . . . . . . 10

65


Covered Drugs Index

fluphenazine hcl oral elixir . . . . . . . . . . 27fluphenazine hcl oral tablet . . . . . . . . . 27flurbiprofen oral tablet 100 mg . . . . . . 25flurbiprofen sodium . . . . . . . . . . . . . . . . 50flutamide . . . . . . . . . . . . . . . . . . . . . . . . . . 15fluticasone propionate nasal . . . . . . . . 52fluticasone propionate topical cream . . . . . . . . . . . . . . . . . . . . . . 36fluticasone propionate topical ointment . . . . . . . . . . . . . . . . . . . 36fluvoxamine oral tablet . . . . . . . . . . . . . 27FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . . 15fomepizole . . . . . . . . . . . . . . . . . . . . . . . . 45fondaparinux subcutaneous syringe 2.5 mg/0.5 ml . . . . . . . . . . . . . . 32fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml . . . . . . . . . 32FORTEO . . . . . . . . . . . . . . . . . . . . . . . . . . 46fosamprenavir . . . . . . . . . . . . . . . . . . . . . . 8fosinopril . . . . . . . . . . . . . . . . . . . . . . . . . . 31fosinopril-hydrochlorothiazide . . . . . . 31FREAMINE HBC 6.9% . . . . . . . . . . . . . 54freamine iii 10% . . . . . . . . . . . . . . . . . . . 54fulvestrant . . . . . . . . . . . . . . . . . . . . . . . . . 15furosemide injection . . . . . . . . . . . . . . . 31furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) . . . . 31furosemide oral tablet . . . . . . . . . . . . . . 31FUZEON SUBCUTANEOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . . 8fyavolv . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47FYCOMPA ORAL SUSPENSION . . . 20FYCOMPA ORAL TABLET 2 MG, 4 MG, 6 MG . . . . . . . . . . . . . . . . 20FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG . . . . . . . . . . . . . . 20

Ggabapentin oral capsule 100 mg, 400 mg . . . . . . . . . . . . . . . . . . . 20

FLOVENT HFA AEROSOL INHALER 44 MCG/ACTUATION . . . . 52FLOVENT HFA AEROSOL INHALER 110 MCG/ACTUATION . . . 52FLOVENT HFA AEROSOL INHALER 220 MCG/ACTUATION . . 52fluconazole . . . . . . . . . . . . . . . . . . . . . . . . . 7fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml . . . . . . 7flucytosine . . . . . . . . . . . . . . . . . . . . . . . . . 7fludarabine . . . . . . . . . . . . . . . . . . . . . . . . 15fludrocortisone . . . . . . . . . . . . . . . . . . . . 38flunisolide nasal spray, non-aerosol 25 mcg (0.025%) . . . . . . 52fluocinolone acetonide oil . . . . . . . . . . 38fluocinolone and shower cap . . . . . . . 35fluocinolone topical cream . . . . . . . . . . 35fluocinolone topical oil . . . . . . . . . . . . . 35fluocinolone topical ointment . . . . . . . 36fluocinolone topical solution . . . . . . . . 36fluocinonide topical cream 0.1% . . . . 36fluocinonide topical cream 0.05% . . . 36fluocinonide topical gel . . . . . . . . . . . . . 36fluocinonide topical ointment . . . . . . . 36fluocinonide topical solution . . . . . . . . 36fluoride (sodium) oral tablet . . . . . . . . 55fluoride (sodium) oral tablet, chewable 1 mg (2.2 mg sod. fluoride) . . . . . . . . . . . . . . 55fluorometholone . . . . . . . . . . . . . . . . . . . 51fluorouracil topical cream 0.5% . . . . . 34fluorouracil topical cream 5% . . . . . . . 34fluorouracil topical solution . . . . . . . . . 34fluoxetine oral capsule . . . . . . . . . . . . . 27fluoxetine oral capsule, delayed release(dr/ec) . . . . . . . . . . . . . 27fluoxetine oral solution . . . . . . . . . . . . . 27fluoxetine oral tablet 10 mg, 20 mg . 27fluphenazine decanoate . . . . . . . . . . . . 27fluphenazine hcl injection . . . . . . . . . . 27fluphenazine hcl oral concentrate . . . 27

fenofibrate nanocrystallized oral tablet 145 mg, 48 mg . . . . . . . . . . 33fenofibrate oral capsule . . . . . . . . . . . . 33fenofibrate oral tablet 160 mg, 54 mg . . . . . . . . . . . . . . . . . . . . 33fenofibric acid (choline) oral capsule,delayed release(dr/ec) 45 mg . . . . . . . . . . . . . . . 33fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg . . . . . . . . . . . . . 33fentanyl . . . . . . . . . . . . . . . . . . . . . . . . . . . 23fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 800 mcg . . . . . . . . . . . . . . . 23fentanyl citrate buccal lozenge on a handle 200 mcg, 400 mcg, 600 mcg . . . . . . . . . . . . . . . . . 23fentanyl citrate (pf) injection solution . 23fentanyl citrate (pf) intravenous syringe 100 mcg/2 ml (50 mcg/ml) . . 23FERRIPROX . . . . . . . . . . . . . . . . . . . . . . 37FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR. . . . . . 27FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK . . . . . . . . . . . 27finasteride oral tablet 5 mg . . . . . . . . . 53FIRDAPSE . . . . . . . . . . . . . . . . . . . . . . . . 22FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG . . . . . . . . . . . . . 15FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG . . . . . . . . . . . . 15FIRVANQ . . . . . . . . . . . . . . . . . . . . . . . . . 11flac otic oil . . . . . . . . . . . . . . . . . . . . . . . . 38flavoxate . . . . . . . . . . . . . . . . . . . . . . . . . . 53flecainide . . . . . . . . . . . . . . . . . . . . . . . . . 30FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION . 52FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION . . . . . . . . . . . . 52

66


Covered Drugs Index

glycopyrrolate injection . . . . . . . . . . . . . 42glycopyrrolate oral . . . . . . . . . . . . . . . . . 42GLYCOPYRROLATE (PF) IN WATER INJECTION . . . . . . . . . . . . 42glycopyrrolate (pf) in water intravenous syringe 0.4 mg/2 ml (0.2 mg/ml) . . . . . . . . . . . . 42glydo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34GLYXAMBI . . . . . . . . . . . . . . . . . . . . . . . . 39granisetron hcl intravenous . . . . . . . . . 42granisetron hcl oral . . . . . . . . . . . . . . . . 42granisetron (pf) intravenous solution 1 mg/ml (1 ml) . . . . . . . . . . . . . 42griseofulvin microsize . . . . . . . . . . . . . . . 7griseofulvin ultramicrosize . . . . . . . . . . . 7GUANIDINE . . . . . . . . . . . . . . . . . . . . . . . 27GVOKE SYRINGE . . . . . . . . . . . . . . . . . 39

Hhailey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48hailey 24 fe . . . . . . . . . . . . . . . . . . . . . . . 48HALAVEN . . . . . . . . . . . . . . . . . . . . . . . . . 15halobetasol propionate topical cream . . . . . . . . . . . . . . . . . . . . . . 36halobetasol propionate topical ointment . . . . . . . . . . . . . . . . . . . 36haloperidol decanoate . . . . . . . . . . . . . 27haloperidol lactate injection . . . . . . . . 27haloperidol lactate oral . . . . . . . . . . . . . 27haloperidol oral tablet 0.5 mg, 1 mg, 2 mg, 5 mg . . . . . . . . . . 27haloperidol oral tablet 10 mg, 20 mg . . . . . . . . . . . . . . . . . . . . . 27HARVONI . . . . . . . . . . . . . . . . . . . . . . . . . . 8HAVRIX (PF) . . . . . . . . . . . . . . . . . . . . . . 45heather . . . . . . . . . . . . . . . . . . . . . . . . . . . 47heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml . . . . . . . . . . . . . . . . . 32

gentak ophthalmic (eye) ointment . . . 50gentamicin injection solution 40 mg/ml . . . . . . . . . . . . . . . . . . 11GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML . . . . 11gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml . . . . . . . . 11gentamicin ophthalmic (eye) drops . . . . . . . . . . . . . . . . . . . . . . . . 50gentamicin sulfate (ped) (pf) . . . . . . . . 11gentamicin topical . . . . . . . . . . . . . . . . . 35GENVOYA . . . . . . . . . . . . . . . . . . . . . . . . . 8GEODON INTRAMUSCULAR . . . . . . 27gianvi (28) . . . . . . . . . . . . . . . . . . . . . . . . 48GILENYA ORAL CAPSULE 0.5 MG . 22GILOTRIF . . . . . . . . . . . . . . . . . . . . . . . . . 15GLEOSTINE ORAL CAPSULE 10 MG, 40 MG . . . . . . . . . . 15GLEOSTINE ORAL CAPSULE 100 MG . . . . . . . . . . . . . . . . 15glimepiride oral tablet 1 mg . . . . . . . . . 38glimepiride oral tablet 2 mg . . . . . . . . . 38glimepiride oral tablet 4 mg . . . . . . . . . 38glipizide-metformin oral tablet 2.5-250 mg . . . . . . . . . . . . . . . . . . 39glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg . . . . . . . 39glipizide oral tablet 5 mg . . . . . . . . . . . 39glipizide oral tablet 10 mg . . . . . . . . . . 38glipizide oral tablet extended release 24hr 2.5 mg . . . . . . . . . . . . . . . 39glipizide oral tablet extended release 24hr 5 mg . . . . . . . . . . . . . . . . . 39glipizide oral tablet extended release 24hr 10 mg . . . . . . . . . . . . . . . . 39GLUCAGEN HYPOKIT . . . . . . . . . . . . 39GLUCAGON EMERGENCY KIT (HUMAN) . . . . . . . . . . . . . . . . . . . . . 39GLUCAGON (HCL) EMERGENCY KIT . . . . . . . . . . . . . . . . . 39

gabapentin oral capsule 300 mg . . . . 20gabapentin oral solution . . . . . . . . . . . . 20gabapentin oral tablet 600 mg . . . . . . 20gabapentin oral tablet 800 mg . . . . . . 20galantamine oral capsule, ext rel. pellets 24 hr . . . . . . . . . . . . . . . . 22galantamine oral solution . . . . . . . . . . . 22galantamine oral tablet . . . . . . . . . . . . . 22GAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10%), 10 GRAM/ 100 ML (10%), 20 GRAM/200 ML (10%), 5 GRAM/50 ML (10%) . . . . . . 45GAMUNEX-C . . . . . . . . . . . . . . . . . . . . . 45GARDASIL 9 (PF) . . . . . . . . . . . . . . . . . 45GATTEX 30-VIAL . . . . . . . . . . . . . . . . . . 42GATTEX ONE-VIAL . . . . . . . . . . . . . . . 42GAUZE PADS 2 X 2 . . . . . . . . . . . . . . . 38gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . . 42gavilyte-g . . . . . . . . . . . . . . . . . . . . . . . . . 42gavilyte-n . . . . . . . . . . . . . . . . . . . . . . . . . 42GAZYVA . . . . . . . . . . . . . . . . . . . . . . . . . . 15gemcitabine intravenous recon soln . 15gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) . . . . . . . . . 15GEMCITABINE INTRAVENOUS SOLUTION 100 MG/ML . . . . . . . . . . . . 15gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . . 33generlac . . . . . . . . . . . . . . . . . . . . . . . . . . 42gengraf oral capsule 100 mg, 25 mg . 15gengraf oral solution . . . . . . . . . . . . . . . 15GENOTROPIN . . . . . . . . . . . . . . . . . . . . 44GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML . . . . . . . . . . . . . . . . . . . 44GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML . . . . . . . . . . . . . . . . . . . . . 44

67


Covered Drugs Index

hydrocortisone butyrate topical ointment . . . . . . . . . . . . . . . . . . . 36hydrocortisone butyrate topical solution . . . . . . . . . . . . . . . . . . . . 36hydrocortisone butyr-emollient . . . . . . 36hydrocortisone-min oil-wht pet . . . . . . 36hydrocortisone oral . . . . . . . . . . . . . . . . 38hydrocortisone rectal . . . . . . . . . . . . . . 42hydrocortisone topical cream 1%, 2.5% . . . . . . . . . . . . . . . . . . . . . . . . . 36hydrocortisone topical cream with perineal applicator . . . . . . . . . . . . 42hydrocortisone topical lotion 2.5% . . 36hydrocortisone topical ointment 1%, 2.5% . . . . . . . . . . . . . . . . 36hydrocortisone valerate . . . . . . . . . . . . 36hydromorphone injection solution 2 mg/ml . . . . . . . . . . . . . . . . . . . 23hydromorphone injection syringe 1 mg/ml, 2 mg/ml, 4 mg/ml . . 23hydromorphone oral liquid . . . . . . . . . . 23hydromorphone oral tablet 2 mg, 4 mg . . . . . . . . . . . . . . . . . . . . . . . . 23hydromorphone oral tablet 8 mg . . . . 23hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml, 2 mg/ml . . . . . . . . . . . . . . . . . 23hydroxychloroquine . . . . . . . . . . . . . . . . 11hydroxyprogesterone caproate . . . . . 47hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . 15hydroxyzine hcl oral tablet . . . . . . . . . . 51

Iibandronate oral . . . . . . . . . . . . . . . . . . . 46IBRANCE . . . . . . . . . . . . . . . . . . . . . . . . . 15ibu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25ibuprofen oral suspension . . . . . . . . . . 25ibuprofen oral tablet 400 mg, 600 mg, 800 mg . . . . . . . . . . . 25ibuprofen-oxycodone . . . . . . . . . . . . . . 23icatibant . . . . . . . . . . . . . . . . . . . . . . . . . . 52ICLUSIG ORAL TABLET 15 MG . . . . 15

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML . . . . . . . . . . . . . . . . . . . . . 46HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 40 MG/0.4 ML . . . . . . . 46HUMIRA PEN . . . . . . . . . . . . . . . . . . . . . 46HUMIRA PEN CROHNS- UC-HS START . . . . . . . . . . . . . . . . . . . . 46HUMIRA PEN PSOR- UVEITS-ADOL HS . . . . . . . . . . . . . . . . . 46HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML . . 46HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML . . . . . . . 46HUMULIN 70/30 U-100 INSULIN . . . 39HUMULIN 70/30 U-100 KWIKPEN . . 39HUMULIN N NPH INSULIN KWIKPEN . . . . . . . . . . . . . . . . . . . . . . . . . 39HUMULIN N NPH U-100 INSULIN . . 39HUMULIN R REGULAR U-100 INSULN . . . . . . . . . . . . . . . . . . . . 39HUMULIN R U-500 (CONC) INSULIN . . . . . . . . . . . . . . . . . . 39HUMULIN R U-500 (CONC) KWIKPEN . . . . . . . . . . . . . . . . 39hydralazine injection . . . . . . . . . . . . . . . 31hydralazine oral . . . . . . . . . . . . . . . . . . . 31hydrochlorothiazide . . . . . . . . . . . . . . . . 31hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml . . . . . . . . . . 23hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml) . . . . 23hydrocodone-acetaminophen oral tablet 5-325 mg . . . . . . . . . . . . . . . 23HYDROCODONE- ACETAMINOPHEN ORAL TABLET 10-300 MG, 7.5-300 MG . . . . . . . . . . . 23hydrocodone-acetaminophen oral tablet 10-325 mg, 7.5-325 mg . . . . . . 23hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg . . 23hydrocortisone-acetic acid . . . . . . . . . 38hydrocortisone butyrate topical cream . . . . . . . . . . . . . . . . . . . . . . 36

heparin (porcine) in 5% dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) . . . . . 32heparin (porcine) injection solution . . 32heparin (porcine) in nacl (pf) . . . . . . . . 32heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml . . . . . . . . . . . 32HEPARIN, PORCINE (PF) INJECTION SYRINGE 5,000 UNIT/ML . . . . . . . . . . . . . . . . . . . . 32HEPATAMINE 8% . . . . . . . . . . . . . . . . . 54HERCEPTIN HYLECTA . . . . . . . . . . . . 15HERCEPTIN INTRAVENOUS RECON SOLN 150 MG . . . . . . . . . . . . 15HETLIOZ . . . . . . . . . . . . . . . . . . . . . . . . . 27HIBERIX (PF) . . . . . . . . . . . . . . . . . . . . . 45HIZENTRA SUBCUTANEOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 45HUMALOG JUNIOR KWIKPEN U-100 . . . . . . . . . . . . . . . . . . 39HUMALOG KWIKPEN INSULIN . . . . 39HUMALOG MIX 50-50 INSULN U-100 . . . . . . . . . . . . . . . . . . . . 39HUMALOG MIX 50-50 KWIKPEN. . . 39HUMALOG MIX 75-25 KWIKPEN. . . 39HUMALOG MIX 75-25 (U-100)INSULN . . . . . . . . . . . . . . . . . . . 39HUMALOG U-100 INSULIN . . . . . . . . 39HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML . . . . . . . 46HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML- 40 MG/0.4 ML . . . . . . . . . . . . . . . . . . . . . 46HUMIRA(CF) PEN CROHNS-UC-HS . . . . . . . . . . . . . . . . . . 46HUMIRA(CF) PEN PSOR-UV-ADOL HS . . . . . . . . . . . . . . . 46HUMIRA(CF) PEN SUBCUTANEOUS INJECTOR KIT 40 MG/0.4 ML . . . . . . . . . . . . . . . . . 46

68


Covered Drugs Index

ISENTRESS ORAL TABLET . . . . . . . . 8ISENTRESS ORAL TABLET, CHEWABLE 25 MG . . . . . . . . . . . . . . . . 8ISENTRESS ORAL TABLET, CHEWABLE 100 MG . . . . . . . . . . . . . . . 8isibloom . . . . . . . . . . . . . . . . . . . . . . . . . . . 48isoniazid oral solution . . . . . . . . . . . . . . 11isoniazid oral tablet . . . . . . . . . . . . . . . . 11isosorbide dinitrate oral tablet . . . . . . 33isosorbide mononitrate . . . . . . . . . . . . . 33isotretinoin . . . . . . . . . . . . . . . . . . . . . . . . 34isradipine . . . . . . . . . . . . . . . . . . . . . . . . . 31ISTODAX . . . . . . . . . . . . . . . . . . . . . . . . . 15itraconazole oral capsule . . . . . . . . . . . . 7itraconazole oral solution . . . . . . . . . . . . 7ivermectin oral . . . . . . . . . . . . . . . . . . . . 11IXIARO (PF) . . . . . . . . . . . . . . . . . . . . . . 45

JJADENU . . . . . . . . . . . . . . . . . . . . . . . . . . 37JADENU SPRINKLE . . . . . . . . . . . . . . . 37jaimiess . . . . . . . . . . . . . . . . . . . . . . . . . . . 48JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . . 16jantoven . . . . . . . . . . . . . . . . . . . . . . . . . . 32JANUMET . . . . . . . . . . . . . . . . . . . . . . . . 39JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG . . . . . . . . . . . . . . . . . . . . . . . . 39JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG . . 39JANUVIA . . . . . . . . . . . . . . . . . . . . . . . . . 39JARDIANCE . . . . . . . . . . . . . . . . . . . . . . 39jasmiel (28) . . . . . . . . . . . . . . . . . . . . . . . 48jencycla . . . . . . . . . . . . . . . . . . . . . . . . . . . 47JENTADUETO . . . . . . . . . . . . . . . . . . . . 39JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG . . 39JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG . . 39jolessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48juleber . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML . . . . . . . . . . . . . . . . . . . . 27INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML . . . . . . . . . . . . . . . . . . . . . 28INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML . . . . . . . . . . . . . . . . . . . 27INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML . . . . . . . . . . . . . . . . . . . . . . . 27INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML . . . . . . . . . . . . . . . . . . . . 27INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML . . . . . . . 28INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML . . . . . . . 28INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML . . . . . . . . 28INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML . . . . . . . 28INVELTYS . . . . . . . . . . . . . . . . . . . . . . . . 51INVIRASE ORAL TABLET . . . . . . . . . . 8INVOKAMET . . . . . . . . . . . . . . . . . . . . . . 39INVOKAMET XR . . . . . . . . . . . . . . . . . . 39INVOKANA . . . . . . . . . . . . . . . . . . . . . . . 39IPOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45ipratropium-albuterol . . . . . . . . . . . . . . . 52ipratropium bromide inhalation . . . . . 52ipratropium bromide nasal spray, non-aerosol 0.03% . . . . . . . . . . . . . . . . 37ipratropium bromide nasal spray, non-aerosol 42 mcg (0.06%) . . . . . . . 37irbesartan-hydrochlorothiazide . . . . . 31irbesartan oral tablet 150 mg . . . . . . . 31irbesartan oral tablet 300 mg, 75 mg . 31IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 15irinotecan . . . . . . . . . . . . . . . . . . . . . . . . . 15ISENTRESS HD . . . . . . . . . . . . . . . . . . . . 8ISENTRESS ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . . 8

ICLUSIG ORAL TABLET 45 MG . . . . 15IDHIFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15imatinib oral tablet 100 mg . . . . . . . . . 15imatinib oral tablet 400 mg . . . . . . . . . 15IMBRUVICA ORAL CAPSULE 70 MG . . . . . . . . . . . . . . . . . 15IMBRUVICA ORAL CAPSULE 140 MG . . . . . . . . . . . . . . . . 15IMBRUVICA ORAL TABLET . . . . . . . . 15IMFINZI . . . . . . . . . . . . . . . . . . . . . . . . . . . 15imipenem-cilastatin . . . . . . . . . . . . . . . . 11imipramine hcl . . . . . . . . . . . . . . . . . . . . . 27imiquimod topical cream in metered-dose pump . . . . . . . . . . . . . 34imiquimod topical cream in packet . . 34IMOVAX RABIES VACCINE (PF) . . . 45incassia . . . . . . . . . . . . . . . . . . . . . . . . . . . 47INCRELEX . . . . . . . . . . . . . . . . . . . . . . . . 37INCRUSE ELLIPTA . . . . . . . . . . . . . . . . 52indapamide . . . . . . . . . . . . . . . . . . . . . . . 31INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION . 45INFUGEM . . . . . . . . . . . . . . . . . . . . . . . . . 15INFUMORPH P/F. . . . . . . . . . . . . . . . . . 23INLYTA ORAL TABLET 1 MG . . . . . . . 15INLYTA ORAL TABLET 5 MG . . . . . . . 15INREBIC . . . . . . . . . . . . . . . . . . . . . . . . . . 15INSULIN PEN NEEDLE . . . . . . . . . . . . 39INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML . . . . . . . . 39INTELENCE ORAL TABLET 25 MG . 8INTELENCE ORAL TABLET 100 MG, 200 MG . . . . . . . . . . . . . . . . . . . 8INTRALIPID INTRAVENOUS EMULSION 20%, 30% . . . . . . . . . . . . . 54INTRON A INJECTION RECON SOLN . . . . . . . . . . . . . . . . . . . . 44INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML . . . 44INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML . . 44introvale . . . . . . . . . . . . . . . . . . . . . . . . . . 48

69


Covered Drugs Index

leflunomide . . . . . . . . . . . . . . . . . . . . . . . 46LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 4 MG . . . . 16LENVIMA ORAL CAPSULE 12 MG/DAY (4 MG X 3), 18 MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY (10 MG X 2-4 MG X 1) . . . . . . . . . . . . . 16LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2) . . . . . . . . . . . . . 16lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48letrozole . . . . . . . . . . . . . . . . . . . . . . . . . . 16leucovorin calcium injection recon soln . . . . . . . . . . . . . . . . . . . . . . . . . 13leucovorin calcium injection solution 10 mg/ml . . . . . . . . . . . . . . . . . . 13leucovorin calcium oral . . . . . . . . . . . . . 13LEUKERAN . . . . . . . . . . . . . . . . . . . . . . . 16LEUKINE INJECTION RECON SOLN . . . . . . . . . . . . . . . . . . . . 44leuprolide subcutaneous kit . . . . . . . . 16levalbuterol hcl . . . . . . . . . . . . . . . . . . . . 52levalbuterol tartrate . . . . . . . . . . . . . . . . 52LEVEMIR FLEXTOUCH U-100 INSULN . . . . . . . . . . . . . . . . . . . . 39LEVEMIR U-100 INSULIN . . . . . . . . . 39levetiracetam in nacl (iso-os) . . . . . . . 20levetiracetam intravenous . . . . . . . . . . 20levetiracetam oral . . . . . . . . . . . . . . . . . 20levobunolol ophthalmic (eye) drops 0.5% . . . . . . . . . . . . . . . . . . 50levocarnitine oral solution 100 mg/ml . . . . . . . . . . . . . . . . . . . . . . . . 37levocarnitine oral tablet . . . . . . . . . . . . 37levocarnitine (with sugar) . . . . . . . . . . . 37levocetirizine oral solution . . . . . . . . . . 51levocetirizine oral tablet . . . . . . . . . . . . 51levofloxacin in d5w . . . . . . . . . . . . . . . . 12levofloxacin intravenous . . . . . . . . . . . 12levofloxacin oral solution . . . . . . . . . . . 12levofloxacin oral tablet . . . . . . . . . . . . . 12

klor-con m20 . . . . . . . . . . . . . . . . . . . . . . 53KORLYM . . . . . . . . . . . . . . . . . . . . . . . . . . 41K-PHOS ORIGINAL . . . . . . . . . . . . . . . 53kurvelo (28) . . . . . . . . . . . . . . . . . . . . . . . 48KUVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . 41KYPROLIS . . . . . . . . . . . . . . . . . . . . . . . . 16

Llabetalol oral . . . . . . . . . . . . . . . . . . . . . . 31LACRISERT . . . . . . . . . . . . . . . . . . . . . . 50lactated ringers intravenous . . . . . . . . 54lactated ringers irrigation . . . . . . . . . . . 36lactulose oral solution . . . . . . . . . . . . . . 42lamivudine oral solution . . . . . . . . . . . . . 8lamivudine oral tablet 100 mg, 300 mg . . . . . . . . . . . . . . . . . . . . 8lamivudine oral tablet 150 mg . . . . . . . 8lamivudine-zidovudine . . . . . . . . . . . . . . 8lamotrigine oral tablet . . . . . . . . . . . . . . 20lamotrigine oral tablet, chewable dispersible . . . . . . . . . . . . . . 20lamotrigine oral tablet,disintegrating . 20lamotrigine oral tablet extended release 24hr . . . . . . . . . . . . . 20lansoprazole oral capsule, delayed release(dr/ec) . . . . . . . . . . . . . 43LANTUS SOLOSTAR U-100 INSULIN . . . . . . . . . . . . . . . . . . . . 39LANTUS U-100 INSULIN . . . . . . . . . . 39larin 1.5/30 (21) . . . . . . . . . . . . . . . . . . . 48larin 1/20 (21) . . . . . . . . . . . . . . . . . . . . . 48larin 24 fe . . . . . . . . . . . . . . . . . . . . . . . . . 48larin fe 1.5/30 (28) . . . . . . . . . . . . . . . . . 48larin fe 1/20 (28) . . . . . . . . . . . . . . . . . . . 48larissia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48latanoprost . . . . . . . . . . . . . . . . . . . . . . . . 50LATUDA ORAL TABLET 80 MG . . . . 28LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG . . . . 28layolis fe . . . . . . . . . . . . . . . . . . . . . . . . . . 48leena 28 . . . . . . . . . . . . . . . . . . . . . . . . . . 48

JULUCA . . . . . . . . . . . . . . . . . . . . . . . . . . . 8junel 1.5/30 (21) . . . . . . . . . . . . . . . . . . . 48junel 1/20 (21) . . . . . . . . . . . . . . . . . . . . . 48junel fe 1.5/30 (28) . . . . . . . . . . . . . . . . . 48junel fe 1/20 (28) . . . . . . . . . . . . . . . . . . 48junel fe 24 . . . . . . . . . . . . . . . . . . . . . . . . . 48

KKABIVEN . . . . . . . . . . . . . . . . . . . . . . . . . 54KADCYLA . . . . . . . . . . . . . . . . . . . . . . . . 16kaitlib fe . . . . . . . . . . . . . . . . . . . . . . . . . . . 48KALETRA ORAL TABLET 100-25 MG . 8KALETRA ORAL TABLET 200-50 MG . 8kalliga . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48KALYDECO . . . . . . . . . . . . . . . . . . . . . . . 52KANJINTI . . . . . . . . . . . . . . . . . . . . . . . . . 16kariva (28) . . . . . . . . . . . . . . . . . . . . . . . . 48kelnor 1/35 (28) . . . . . . . . . . . . . . . . . . . 48kelnor 1-50 . . . . . . . . . . . . . . . . . . . . . . . . 48ketoconazole oral . . . . . . . . . . . . . . . . . . . 7ketoconazole topical cream . . . . . . . . 35ketoconazole topical shampoo . . . . . 35ketorolac ophthalmic (eye) . . . . . . . . . 50KEYTRUDA INTRAVENOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 16KINRIX (PF) . . . . . . . . . . . . . . . . . . . . . . . 45kionex (with sorbitol) . . . . . . . . . . . . . . . 37KISQALI . . . . . . . . . . . . . . . . . . . . . . . . . . 16KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY (200 MG X 1)-2.5 MG . . . . . . . . . . . . . . 16KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY (200 MG X 2)-2.5 MG . . . . . . . . . . . . . . 16KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY (200 MG X 3)-2.5 MG . . . . . . . . . . . . . . 16klor-con . . . . . . . . . . . . . . . . . . . . . . . . . . . 53KLOR-CON 8 . . . . . . . . . . . . . . . . . . . . . 53KLOR-CON 10 . . . . . . . . . . . . . . . . . . . . 53klor-con m10 . . . . . . . . . . . . . . . . . . . . . . 53

70


Covered Drugs Index

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG . . . . . . . . . . . 16LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG . . . . . . . . . . . . . . 16lutera (28) . . . . . . . . . . . . . . . . . . . . . . . . . 48LYNPARZA ORAL TABLET . . . . . . . . . 16LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG, 82.5 MG . . . . . . . . . . . 20LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 330 MG . . . . . . . . . . . . . . . . . . . . 20LYRICA ORAL CAPSULE 75 MG . . . 20LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG . . . 20LYRICA ORAL CAPSULE 225 MG, 300 MG . . . . . . . . . . . . . . . . . . 20LYRICA ORAL SOLUTION . . . . . . . . . 20LYSODREN . . . . . . . . . . . . . . . . . . . . . . . 16lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

MMAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/100 ML . . . . . . . . . . . . . . . . . . 54magnesium sulfate injection . . . . . . . . 54magnesium sulfate in water . . . . . . . . 54malathion . . . . . . . . . . . . . . . . . . . . . . . . . 36maprotiline . . . . . . . . . . . . . . . . . . . . . . . . 28marlissa (28) . . . . . . . . . . . . . . . . . . . . . . 48MARPLAN . . . . . . . . . . . . . . . . . . . . . . . . 28MATULANE . . . . . . . . . . . . . . . . . . . . . . . 16matzim la . . . . . . . . . . . . . . . . . . . . . . . . . 31MAVYRET . . . . . . . . . . . . . . . . . . . . . . . . . 8meclizine oral tablet 12.5 mg, 25 mg . . . . . . . . . . . . . . . . . . . . 42MEDROL ORAL TABLET 2 MG . . . . . 38medroxyprogesterone intramuscular suspension . . . . . . . . . . 47

l norgest/e.estradiol-e.estrad . . . . . . . 48lojaimiess . . . . . . . . . . . . . . . . . . . . . . . . . 48LOKELMA . . . . . . . . . . . . . . . . . . . . . . . . 37LONSURF ORAL TABLET 15-6.14 MG . . . . . . . . . . . . . . . . . . . . . . . 16LONSURF ORAL TABLET 20-8.19 MG . . . . . . . . . . . . . . . . . . . . . . . 16loperamide oral capsule . . . . . . . . . . . . 42lopinavir-ritonavir . . . . . . . . . . . . . . . . . . . 8lorazepam injection . . . . . . . . . . . . . . . . 28lorazepam intensol . . . . . . . . . . . . . . . . 28lorazepam oral concentrate . . . . . . . . 28lorazepam oral tablet 0.5 mg, 1 mg . 28lorazepam oral tablet 2 mg . . . . . . . . . 28LORBRENA ORAL TABLET 25 MG . 16LORBRENA ORAL TABLET 100 MG . 16lorcet hd . . . . . . . . . . . . . . . . . . . . . . . . . . 23lorcet (hydrocodone) . . . . . . . . . . . . . . . 23lorcet plus oral tablet 7.5-325 mg . . . 23loryna (28) . . . . . . . . . . . . . . . . . . . . . . . . 48losartan . . . . . . . . . . . . . . . . . . . . . . . . . . . 31losartan-hydrochlorothiazide oral tablet 50-12.5 mg . . . . . . . . . . . . . . . . . . 31losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg . . . . . 31LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . . 51LOTEMAX SM . . . . . . . . . . . . . . . . . . . . 51lovastatin . . . . . . . . . . . . . . . . . . . . . . . . . 33low-ogestrel (28) . . . . . . . . . . . . . . . . . . 48loxapine succinate . . . . . . . . . . . . . . . . . 28lo-zumandimine (28) . . . . . . . . . . . . . . . 48LUMIGAN OPHTHALMIC (EYE) DROPS 0.01% . . . . . . . . . . . . . . 50LUMIZYME . . . . . . . . . . . . . . . . . . . . . . . 41LUMOXITI . . . . . . . . . . . . . . . . . . . . . . . . 16LUPRON DEPOT . . . . . . . . . . . . . . . . . 16LUPRON DEPOT (3 MONTH) . . . . . . 16LUPRON DEPOT (4 MONTH) . . . . . . 16LUPRON DEPOT (6 MONTH) . . . . . . 16LUPRON DEPOT-PED . . . . . . . . . . . . 16

levonest (28) . . . . . . . . . . . . . . . . . . . . . . 48levonorgestrel-ethinyl estrad . . . . . . . 48levonorg-eth estrad triphasic . . . . . . . 48levora-28 . . . . . . . . . . . . . . . . . . . . . . . . . . 48levothyroxine oral . . . . . . . . . . . . . . . . . . 41levoxyl oral tablet 100 mcg, 112 mcg, 175 mcg . . . . . . . 41LEVOXYL ORAL TABLET 125 MCG, 137 MCG, 150 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG . . . . . . . . . . . . . . . . . 41LEXIVA ORAL SUSPENSION . . . . . . . 8LIBTAYO . . . . . . . . . . . . . . . . . . . . . . . . . . 16lidocaine hcl injection solution . . . . . . 34lidocaine hcl laryngotracheal . . . . . . . 34lidocaine hcl mucous membrane jelly . . . . . . . . . . . . . . . . . . . . 34lidocaine hcl mucous membrane jelly in applicator . . . . . . . . 34lidocaine hcl mucous membrane solution 4% (40 mg/ml) . . 34lidocaine (pf) injection solution . . . . . . 34lidocaine (pf) intravenous syringe . . . 30lidocaine-prilocaine topical cream . . . 34lidocaine topical adhesive patch,medicated 5% . . . . . . . . . . . . . . . 34lidocaine topical ointment . . . . . . . . . . 34lidocaine viscous . . . . . . . . . . . . . . . . . . 34lillow (28) . . . . . . . . . . . . . . . . . . . . . . . . . 48lincomycin . . . . . . . . . . . . . . . . . . . . . . . . 11lindane topical shampoo . . . . . . . . . . . 36linezolid-0.9% sodium chloride . . . . . 11linezolid in dextrose 5% . . . . . . . . . . . . 11linezolid oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . . . . 11linezolid oral tablet . . . . . . . . . . . . . . . . . 11LINZESS . . . . . . . . . . . . . . . . . . . . . . . . . . 42liothyronine oral . . . . . . . . . . . . . . . . . . . 41lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . 31lisinopril-hydrochlorothiazide . . . . . . . 31lithium carbonate . . . . . . . . . . . . . . . . . . 28LIVALO . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

71


Covered Drugs Index

methylprednisolone sodium succ injection recon soln 125 mg, 40 mg . 38methylprednisolone sodium succ intravenous recon soln 1,000 mg . . . 38methylprednisolone sodium succ intravenous recon soln 500 mg . . . . . 38metoclopramide hcl injection solution . . . . . . . . . . . . . . . . . . . 42metoclopramide hcl oral solution . . . . 42metoclopramide hcl oral tablet . . . . . . 42metolazone . . . . . . . . . . . . . . . . . . . . . . . 31metoprolol succinate . . . . . . . . . . . . . . . 31metoprolol ta-hydrochlorothiaz . . . . . 31metoprolol tartrate oral . . . . . . . . . . . . . 31metro i.v. . . . . . . . . . . . . . . . . . . . . . . . . . . 11metronidazole in nacl (iso-os) . . . . . . 11metronidazole oral tablet . . . . . . . . . . . 11metronidazole topical . . . . . . . . . . . . . . 34metronidazole vaginal . . . . . . . . . . . . . . 47mexiletine . . . . . . . . . . . . . . . . . . . . . . . . . 30MIACALCIN INJECTION . . . . . . . . . . . 41mibelas 24 fe . . . . . . . . . . . . . . . . . . . . . . 48microgestin 1.5/30 (21) . . . . . . . . . . . . 48microgestin 1/20 (21) . . . . . . . . . . . . . . 48microgestin fe 1.5/30 (28) . . . . . . . . . . 49microgestin fe 1/20 (28) . . . . . . . . . . . . 49midodrine . . . . . . . . . . . . . . . . . . . . . . . . . 37migergot . . . . . . . . . . . . . . . . . . . . . . . . . . 21miglitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40miglustat . . . . . . . . . . . . . . . . . . . . . . . . . . 41mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49minitran . . . . . . . . . . . . . . . . . . . . . . . . . . . 33minocycline oral capsule . . . . . . . . . . . 13minocycline oral tablet . . . . . . . . . . . . . 13minoxidil oral . . . . . . . . . . . . . . . . . . . . . . 31mirtazapine oral tablet . . . . . . . . . . . . . 28mirtazapine oral tablet, disintegrating . . . . . . . . . . . . . . . . . . . . . . 28misoprostol . . . . . . . . . . . . . . . . . . . . . . . 43MITIGARE . . . . . . . . . . . . . . . . . . . . . . . . 46MITIGO (PF) . . . . . . . . . . . . . . . . . . . . . . 24

metformin oral tablet 500 mg . . . . . . . 39metformin oral tablet 850 mg . . . . . . . 40metformin oral tablet extended release 24 hr 500 mg (generic for glucophage xr) . . . . . . . . . 40metformin oral tablet extended release 24 hr 750 mg (generic for glucophage xr) . . . . . . . . . 40metformin oral tablet extended release (osm) 24 hr 1000mg, 500mg (generic for fortamet) . . . . . . . 40methadone injection solution . . . . . . . 23methadone intensol . . . . . . . . . . . . . . . . 23methadone oral concentrate . . . . . . . . 24methadone oral solution 5 mg/5 ml . 24methadone oral solution 10 mg/5 ml . 24methadone oral tablet 5 mg . . . . . . . . 24methadone oral tablet 10 mg . . . . . . . 24methazolamide . . . . . . . . . . . . . . . . . . . . 50methenamine hippurate . . . . . . . . . . . . 13methimazole oral tablet 10 mg, 5 mg . . . . . . . . . . . . . . . . . . . . . . . 38methocarbamol oral . . . . . . . . . . . . . . . 22methotrexate sodium injection . . . . . . 16methotrexate sodium oral . . . . . . . . . . 16methotrexate sodium (pf) . . . . . . . . . . . 16methoxsalen . . . . . . . . . . . . . . . . . . . . . . 34methyldopa . . . . . . . . . . . . . . . . . . . . . . . 31methylphenidate hcl oral tablet . . . . . 28methylphenidate hcl oral tablet extended release . . . . . . . . . . . . . . . . . . 28methylphenidate hcl oral tablet extended release 24hr 18 mg, 18 mg (bx rating) . . . . . . . . . . . 28methylphenidate hcl oral tablet extended release 24hr 27 mg, 27 mg (bx rating), 54 mg, 54 mg (bx rating) . . . . . . . . . . . . . . . . . . 28methylphenidate hcl oral tablet extended release 24hr 36 mg, 36 mg (bx rating) . . . . . . . . . . . 28methylprednisolone . . . . . . . . . . . . . . . . 38methylprednisolone acetate . . . . . . . . 38

medroxyprogesterone intramuscular syringe . . . . . . . . . . . . . . 47medroxyprogesterone oral . . . . . . . . . 47mefloquine . . . . . . . . . . . . . . . . . . . . . . . . 11megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml) . . . . . . . . . . . 16megestrol oral tablet . . . . . . . . . . . . . . . 16MEKINIST ORAL TABLET 0.5 MG . . 16MEKINIST ORAL TABLET 2 MG . . . . 16MEKTOVI . . . . . . . . . . . . . . . . . . . . . . . . . 16melodetta 24 fe . . . . . . . . . . . . . . . . . . . . 48meloxicam oral tablet . . . . . . . . . . . . . . 25melphalan . . . . . . . . . . . . . . . . . . . . . . . . . 16melphalan hcl . . . . . . . . . . . . . . . . . . . . . 16memantine oral capsule, sprinkle,er 24hr . . . . . . . . . . . . . . . . . . . . 22memantine oral solution . . . . . . . . . . . . 22memantine oral tablet 5 mg . . . . . . . . 22memantine oral tablet 10 mg . . . . . . . 22memantine oral tablets,dose pack . . 22MENACTRA (PF) INTRAMUSCULAR SOLUTION . . . . 45MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG . . . . . . . 47MENOSTAR . . . . . . . . . . . . . . . . . . . . . . 47MENVEO A-C-Y-W-135-DIP (PF) . . . 45mercaptopurine . . . . . . . . . . . . . . . . . . . . 16meropenem . . . . . . . . . . . . . . . . . . . . . . . 11MEROPENEM-0.9% SODIUM CHLORIDE . . . . . . . . . . . . . . 11mesalamine oral capsule, extended release 24hr . . . . . . . . . . . . . 42mesalamine oral tablet, delayed release (dr/ec) 1.2 gram . . . 42mesalamine rectal enema . . . . . . . . . . 42mesalamine with cleansing wipe . . . . 42mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13MESNEX ORAL . . . . . . . . . . . . . . . . . . . 13metadate er . . . . . . . . . . . . . . . . . . . . . . . 28metaproterenol oral syrup . . . . . . . . . . 52metformin oral tablet 1,000 mg . . . . . 39

72


Covered Drugs Index

nafcillin in dextrose iso-osm . . . . . . . . 12naftifine topical cream . . . . . . . . . . . . . . 35NAFTIN TOPICAL GEL . . . . . . . . . . . . 35NAGLAZYME . . . . . . . . . . . . . . . . . . . . . 41nalbuphine injection solution 10 mg/ml . . . . . . . . . . . . . . . . . . 25nalbuphine injection solution 20 mg/ml . . . . . . . . . . . . . . . . . . 25naloxone injection solution . . . . . . . . . 25naloxone injection syringe 1 mg/ml . 25naltrexone . . . . . . . . . . . . . . . . . . . . . . . . 25NAMZARIC ORAL CAP, SPRINKLE,ER 24HR DOSE PACK . 22NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR . . . 22naproxen oral suspension . . . . . . . . . . 25naproxen oral tablet . . . . . . . . . . . . . . . 25naproxen oral tablet, delayed release (dr/ec) . . . . . . . . . . . . 25naproxen sodium oral tablet 275 mg, 550 mg . . . . . . . . . . . . . 25naratriptan . . . . . . . . . . . . . . . . . . . . . . . . 21NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION . . . . . 25NATACYN . . . . . . . . . . . . . . . . . . . . . . . . . 50nateglinide oral tablet 60 mg . . . . . . . 40nateglinide oral tablet 120 mg . . . . . . 40NATPARA . . . . . . . . . . . . . . . . . . . . . . . . . 41NAYZILAM . . . . . . . . . . . . . . . . . . . . . . . . 20NEBUPENT . . . . . . . . . . . . . . . . . . . . . . . 11necon 0.5/35 (28) . . . . . . . . . . . . . . . . . . 49NEEDLES, INSULIN DISP.,SAFETY . . . . . . . . . . . . . . . . . . . . 40nefazodone . . . . . . . . . . . . . . . . . . . . . . . 28neomycin . . . . . . . . . . . . . . . . . . . . . . . . . 11neomycin-bacitracin-poly-hc . . . . . . . . 51neomycin-bacitracin-polymyxin . . . . . 50neomycin-polymyxin b-dexameth . . . 51neomycin-polymyxin b gu . . . . . . . . . . 36neomycin-polymyxin-gramicidin . . . . 50neomycin-polymyxin-hc ophthalmic (eye) . . . . . . . . . . . . . . . . . . . 51

morphine oral solution 10 mg/5 ml . . 24morphine oral solution 20 mg/5 ml (4 mg/ml) . . . . . . . . . . . . . . 24MORPHINE ORAL TABLET . . . . . . . . 24morphine oral tablet extended release . . . . . . . . . . . . . . . . . . 24morphine (pf) injection solution 0.5 mg/ml, 1 mg/ml . . . . . . . . . . . . . . . . 24morphine (pf) intravenous patient control.analgesia soln . . . . . . . 24moxifloxacin ophthalmic (eye) drops . . 50moxifloxacin oral . . . . . . . . . . . . . . . . . . 12MOXIFLOXACIN-SOD. ACE,SUL-WATER . . . . . . . . . . . . . . . . . 12moxifloxacin-sod.chloride(iso) . . . . . . 12MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . . 44MULTAQ . . . . . . . . . . . . . . . . . . . . . . . . . . 30mupirocin . . . . . . . . . . . . . . . . . . . . . . . . . 35mupirocin calcium . . . . . . . . . . . . . . . . . 35MVASI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16MYCAMINE . . . . . . . . . . . . . . . . . . . . . . . . 7mycophenolate mofetil (hcl) . . . . . . . . 16mycophenolate mofetil oral capsule . 16mycophenolate mofetil oral suspension for reconstitution . . . . . . . 16mycophenolate mofetil oral tablet . . . 16mycophenolate sodium . . . . . . . . . . . . 16MYLOTARG . . . . . . . . . . . . . . . . . . . . . . . 16myorisan . . . . . . . . . . . . . . . . . . . . . . . . . . 34MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG . . . . . . . . . . . . . . . . . . . . . 53MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG . . . . . . . . . . . . . . . . . . . . . 53

Nnabumetone . . . . . . . . . . . . . . . . . . . . . . . 25nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31nadolol-bendroflumethiazide oral tablet 80-5 mg . . . . . . . . . . . . . . . . . 31nafcillin . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

M-M-R II (PF) . . . . . . . . . . . . . . . . . . . . . 45moexipril . . . . . . . . . . . . . . . . . . . . . . . . . . 31molindone . . . . . . . . . . . . . . . . . . . . . . . . . 28mometasone nasal . . . . . . . . . . . . . . . . 52mometasone topical . . . . . . . . . . . . . . . 36mondoxyne nl oral capsule 100 mg, 75 mg . . . . . . . . . . . . . . . . . . . . 13mono-linyah . . . . . . . . . . . . . . . . . . . . . . . 49montelukast oral granules in packet . 52montelukast oral tablet . . . . . . . . . . . . . 52montelukast oral tablet,chewable . . . 52MONUROL . . . . . . . . . . . . . . . . . . . . . . . 13morgidox . . . . . . . . . . . . . . . . . . . . . . . . . . 13morphine concentrate oral solution . 24MORPHINE INJECTION SOLUTION 2 MG/ML . . . . . . . . . . . . . . 24MORPHINE INJECTION SOLUTION 4 MG/ML . . . . . . . . . . . . . . 24MORPHINE INJECTION SOLUTION 5 MG/ML . . . . . . . . . . . . . . 24morphine injection solution 8 mg/ml . . 24MORPHINE INJECTION SOLUTION 10 MG/ML . . . . . . . . . . . . . 24morphine injection syringe 2 mg/ml . 24morphine injection syringe 4 mg/ml . 24morphine injection syringe 5 mg/ml . 24morphine injection syringe 8 mg/ml . 24morphine injection syringe 10 mg/ml . 24MORPHINE INTRAVENOUS SOLUTION 4 MG/ML . . . . . . . . . . . . . . 24MORPHINE INTRAVENOUS SOLUTION 8 MG/ML . . . . . . . . . . . . . . 24morphine intravenous solution 10 mg/ml . . . . . . . . . . . . . . . . . . 24morphine intravenous syringe 2 mg/ml . . . . . . . . . . . . . . . . . . . 24morphine intravenous syringe 4 mg/ml . . . . . . . . . . . . . . . . . . . 24MORPHINE INTRAVENOUS SYRINGE 8 MG/ML . . . . . . . . . . . . . . . 24MORPHINE INTRAVENOUS SYRINGE 10 MG/ML . . . . . . . . . . . . . . 24

73


Covered Drugs Index

NUZYRA INTRAVENOUS . . . . . . . . . . 13NUZYRA ORAL . . . . . . . . . . . . . . . . . . . 13nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . . 35nystatin oral suspension . . . . . . . . . . . . 7nystatin oral tablet . . . . . . . . . . . . . . . . . . 7nystatin topical cream . . . . . . . . . . . . . . 35nystatin topical ointment . . . . . . . . . . . 35nystatin topical powder . . . . . . . . . . . . . 35nystatin-triamcinolone . . . . . . . . . . . . . . 35nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

OOCALIVA . . . . . . . . . . . . . . . . . . . . . . . . . 42ocella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49OCREVUS . . . . . . . . . . . . . . . . . . . . . . . . 22octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml . . . . . . . . . . . 17octreotide acetate injection solution 50 mcg/ml . . . . . . . . . . . . . . . . . 17ODEFSEY . . . . . . . . . . . . . . . . . . . . . . . . . 8ODOMZO . . . . . . . . . . . . . . . . . . . . . . . . . 17OFEV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52ofloxacin ophthalmic (eye) . . . . . . . . . 50ofloxacin otic (ear) . . . . . . . . . . . . . . . . . 50ogestrel (28) . . . . . . . . . . . . . . . . . . . . . . 49OGIVRI . . . . . . . . . . . . . . . . . . . . . . . . . . . 17olanzapine-fluoxetine . . . . . . . . . . . . . . 28olanzapine intramuscular . . . . . . . . . . . 28olanzapine oral tablet 7.5 mg . . . . . . . 28olanzapine oral tablet 10 mg, 2.5 mg, 5 mg . . . . . . . . . . . . . . . 28olanzapine oral tablet 15 mg, 20 mg . 28olanzapine oral tablet,disintegrating . 28olmesartan . . . . . . . . . . . . . . . . . . . . . . . . 31olmesartan-hydrochlorothiazide . . . . 31olopatadine ophthalmic (eye) . . . . . . . 50omega-3 acid ethyl esters . . . . . . . . . . 33omeprazole oral capsule, delayed release(dr/ec) . . . . . . . . . . . . . 43

nora-be . . . . . . . . . . . . . . . . . . . . . . . . . . . 47noreth-ethinyl estradiol-iron . . . . . . . . 49norethindrone acetate . . . . . . . . . . . . . . 47norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg . . . . . . . . . 47norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg . 49norethindrone (contraceptive) . . . . . . 47norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1.5 mg-30 mcg (21)/75 mg (7) . . . . . . 49norethindrone-e.estradiol-iron oral tablet,chewable . . . . . . . . . . . . . . . 49norgestimate-ethinyl estradiol . . . . . . 49NORMOSOL-M IN 5% DEXTROSE 54NORMOSOL-R . . . . . . . . . . . . . . . . . . . . 54NORMOSOL-R IN 5% DEXTROSE . 54NORMOSOL-R PH 7.4 . . . . . . . . . . . . 54NORTHERA ORAL CAPSULE 100 MG . . . . . . . . . . . . . . . . 37NORTHERA ORAL CAPSULE 200 MG, 300 MG . . . . . . . 37nortrel 0.5/35 (28) . . . . . . . . . . . . . . . . . 49nortrel 1/35 (21) . . . . . . . . . . . . . . . . . . . 49nortrel 1/35 (28) . . . . . . . . . . . . . . . . . . . 49nortrel 7/7/7 (28) . . . . . . . . . . . . . . . . . . . 49nortriptyline . . . . . . . . . . . . . . . . . . . . . . . 28NORVIR ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . . 8NORVIR ORAL SOLUTION . . . . . . . . . 8NORVIR ORAL TABLET . . . . . . . . . . . . 8NOVOFINE PEN NEEDLE . . . . . . . . . 40NOVOTWIST PEN NEEDLE . . . . . . . 40NOXAFIL ORAL SUSPENSION . . . . . 7NOXAFIL ORAL TABLET, DELAYED RELEASE (DR/EC) . . . . . . 7NUBEQA . . . . . . . . . . . . . . . . . . . . . . . . . 17NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . . 22NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . . 17NUPLAZID ORAL CAPSULE . . . . . . . 28NUPLAZID ORAL TABLET 10 MG . . 28NUTRILIPID . . . . . . . . . . . . . . . . . . . . . . . 55

neomycin-polymyxin-hc otic (ear) . . . 38neo-polycin . . . . . . . . . . . . . . . . . . . . . . . 50neo-polycin hc . . . . . . . . . . . . . . . . . . . . . 51NEPHRAMINE 5.4% . . . . . . . . . . . . . . . 54NERLYNX . . . . . . . . . . . . . . . . . . . . . . . . 16NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . . 21nevirapine oral suspension . . . . . . . . . . 8nevirapine oral tablet . . . . . . . . . . . . . . . 8nevirapine oral tablet extended release 24 hr 100 mg . . . . . . . . . . . . . . . 8nevirapine oral tablet extended release 24 hr 400 mg . . . . . . . . . . . . . . . 8NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . . . 17niacin oral tablet 500 mg . . . . . . . . . . . 33niacin oral tablet extended release 24 hr . . . . . . . . . . . . . . . . . . . . . . 33niacor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33nicardipine intravenous solution . . . . 31nicardipine oral . . . . . . . . . . . . . . . . . . . . 31NICOTROL . . . . . . . . . . . . . . . . . . . . . . . 37NICOTROL NS . . . . . . . . . . . . . . . . . . . . 37nifedipine oral tablet extended release . . . . . . . . . . . . . . . . . . 31nifedipine oral tablet extended release 24hr . . . . . . . . . . . . . 31nikki (28) . . . . . . . . . . . . . . . . . . . . . . . . . . 49nilutamide . . . . . . . . . . . . . . . . . . . . . . . . . 17nimodipine . . . . . . . . . . . . . . . . . . . . . . . . 31NINLARO . . . . . . . . . . . . . . . . . . . . . . . . . 17nisoldipine . . . . . . . . . . . . . . . . . . . . . . . . 31nitisinone . . . . . . . . . . . . . . . . . . . . . . . . . 37nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . 13nitrofurantoin macrocrystal . . . . . . . . . 13nitrofurantoin monohyd/m-cryst . . . . . 13nitroglycerin intravenous . . . . . . . . . . . 33nitroglycerin sublingual . . . . . . . . . . . . . 33nitroglycerin transdermal patch 24 hour . . . . . . . . . . . . . . . . . . . . . 33nitroglycerin translingual spray, non-aerosol . . . . . . . . . . . . . . . . . . . . . . . 33nizatidine oral capsule . . . . . . . . . . . . . 43

74


Covered Drugs Index

peg-electrolyte . . . . . . . . . . . . . . . . . . . . 43penicillamine . . . . . . . . . . . . . . . . . . . . . . 46penicillin g potassium . . . . . . . . . . . . . . 12penicillin v potassium oral recon soln . . . . . . . . . . . . . . . . . . . . 12penicillin v potassium oral tablet 250 mg . . . . . . . . . . . . . . . . . 12penicillin v potassium oral tablet 500 mg . . . . . . . . . . . . . . . . . 12PENTAM . . . . . . . . . . . . . . . . . . . . . . . . . . 11pentamidine inhalation . . . . . . . . . . . . . 11pentamidine injection . . . . . . . . . . . . . . 11PENTASA . . . . . . . . . . . . . . . . . . . . . . . . . 43pentoxifylline . . . . . . . . . . . . . . . . . . . . . . 32PERFOROMIST . . . . . . . . . . . . . . . . . . . 52PERIKABIVEN . . . . . . . . . . . . . . . . . . . . 55perindopril erbumine . . . . . . . . . . . . . . . 31PERJETA . . . . . . . . . . . . . . . . . . . . . . . . . 17permethrin topical cream . . . . . . . . . . . 36perphenazine . . . . . . . . . . . . . . . . . . . . . 28perphenazine-amitriptyline . . . . . . . . . 28PERSERIS . . . . . . . . . . . . . . . . . . . . . . . . 28pfizerpen-g . . . . . . . . . . . . . . . . . . . . . . . . 12phenadoz rectal suppository 12.5 mg . . . . . . . . . . . . . . . 51phenelzine . . . . . . . . . . . . . . . . . . . . . . . . 28phenobarbital oral elixir . . . . . . . . . . . . 20phenobarbital oral tablet . . . . . . . . . . . 20phenoxybenzamine . . . . . . . . . . . . . . . . 31phenytoin oral suspension . . . . . . . . . 20phenytoin oral tablet,chewable . . . . . 20phenytoin sodium extended . . . . . . . . 20philith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49PHOSLYRA . . . . . . . . . . . . . . . . . . . . . . . 54PHOSPHOLINE IODIDE . . . . . . . . . . . 50PHYSIOLYTE . . . . . . . . . . . . . . . . . . . . . 36PHYSIOSOL IRRIGATION . . . . . . . . . 36PICATO TOPICAL GEL 0.05% . . . . . 34PICATO TOPICAL GEL 0.015% . . . . 34PIFELTRO . . . . . . . . . . . . . . . . . . . . . . . . . 8

oxycodone oral solution . . . . . . . . . . . . 24oxycodone oral tablet . . . . . . . . . . . . . . 24oxymorphone oral tablet extended release 12 hr . . . . . . . . . . . . 24OZEMPIC . . . . . . . . . . . . . . . . . . . . . . . . . 40

Ppacerone oral tablet 100 mg, 200 mg, 400 mg . . . . . . . . . . . 30paclitaxel . . . . . . . . . . . . . . . . . . . . . . . . . . 17PADCEV . . . . . . . . . . . . . . . . . . . . . . . . . . 17paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg . . . 28paliperidone oral tablet extended release 24hr 6 mg . . . . . . . . . . . . . . . . . 28palonosetron intravenous solution 0.25 mg/5 ml . . . . . . . . . . . . . . 43pamidronate . . . . . . . . . . . . . . . . . . . . . . . 41PANRETIN . . . . . . . . . . . . . . . . . . . . . . . . 34pantoprazole oral . . . . . . . . . . . . . . . . . . 43paricalcitol oral capsule 1 mcg, 2 mcg . . . . . . . . . . . . . . . . . . . . . . 41paricalcitol oral capsule 4 mcg . . . . . . 41paroex oral rinse . . . . . . . . . . . . . . . . . . 37paromomycin . . . . . . . . . . . . . . . . . . . . . . 11paroxetine hcl oral tablet 10 mg . . . . 28paroxetine hcl oral tablet 20 mg . . . . 28paroxetine hcl oral tablet 30 mg, 40 mg . . . . . . . . . . . . . . . . . . . . . 28paroxetine hcl oral tablet extended release 24 hr 12.5 mg . . . . . . . . . . . . . . 28paroxetine hcl oral tablet extended release 24 hr 25 mg, 37.5 mg . . . . . . 28PASER . . . . . . . . . . . . . . . . . . . . . . . . . . . 11PAXIL ORAL SUSPENSION . . . . . . . 28PAZEO . . . . . . . . . . . . . . . . . . . . . . . . . . . 50PEDIARIX (PF) . . . . . . . . . . . . . . . . . . . . 45PEDVAX HIB (PF) . . . . . . . . . . . . . . . . . 45peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram . . . . 43PEGANONE . . . . . . . . . . . . . . . . . . . . . . 20

OMNIPOD 5 PACK . . . . . . . . . . . . . . . . 40OMNIPOD DASH 5 PACK. . . . . . . . . . 40OMNIPOD STARTER KIT . . . . . . . . . . 40ondansetron . . . . . . . . . . . . . . . . . . . . . . . 42ondansetron hcl intravenous . . . . . . . 42ondansetron hcl oral solution . . . . . . . 42ondansetron hcl oral tablet . . . . . . . . . 42ondansetron hcl (pf) . . . . . . . . . . . . . . . 42OPDIVO . . . . . . . . . . . . . . . . . . . . . . . . . . 17OPSUMIT . . . . . . . . . . . . . . . . . . . . . . . . . 52oralone . . . . . . . . . . . . . . . . . . . . . . . . . . . 37ORBACTIV . . . . . . . . . . . . . . . . . . . . . . . 11ORENCIA . . . . . . . . . . . . . . . . . . . . . . . . . 46ORENCIA CLICKJECT . . . . . . . . . . . . 46ORFADIN . . . . . . . . . . . . . . . . . . . . . . . . . 37ORKAMBI ORAL GRANULES IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 52ORKAMBI ORAL TABLET . . . . . . . . . . 52orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . . 49oseltamivir . . . . . . . . . . . . . . . . . . . . . . . . . 8OSMOPREP . . . . . . . . . . . . . . . . . . . . . . 43oxacillin injection . . . . . . . . . . . . . . . . . . 12oxandrolone oral tablet 2.5 mg . . . . . 41oxandrolone oral tablet 10 mg . . . . . . 41oxaprozin . . . . . . . . . . . . . . . . . . . . . . . . . 25oxazepam . . . . . . . . . . . . . . . . . . . . . . . . . 28oxcarbazepine . . . . . . . . . . . . . . . . . . . . 20oxybutynin chloride oral syrup . . . . . . 53oxybutynin chloride oral tablet . . . . . . 53oxybutynin chloride oral tablet extended release 24hr . . . . . . . . . . . . . 53oxycodone-acetaminophen oral tablet 2.5-300 mg . . . . . . . . . . . . . . 24oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg . . . 24oxycodone-acetaminophen oral tablet 7.5-325 mg . . . . . . . . . . . . . . 24oxycodone-acetaminophen oral tablet 10-325 mg . . . . . . . . . . . . . . 24oxycodone-aspirin . . . . . . . . . . . . . . . . . 24oxycodone oral concentrate . . . . . . . . 24

75


Covered Drugs Index

prazosin . . . . . . . . . . . . . . . . . . . . . . . . . . 31PRED-G . . . . . . . . . . . . . . . . . . . . . . . . . . 51PRED-G S.O.P. . . . . . . . . . . . . . . . . . . . 51PRED MILD . . . . . . . . . . . . . . . . . . . . . . . 51prednicarbate topical ointment . . . . . . 36prednisolone acetate . . . . . . . . . . . . . . 51prednisolone oral solution 15 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . . 38prednisolone sodium phosphate ophthalmic (eye) . . . . . . . . . . . . . . . . . . . 51prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 15 mg/5 ml (5 ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) . . . . . . . . . . . . . . . . . . . . . . 38prednisone intensol . . . . . . . . . . . . . . . . 38prednisone oral solution . . . . . . . . . . . . 38prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg . . 38prednisone oral tablet 50 mg . . . . . . . 38prednisone oral tablets,dose pack . . 38pregabalin oral capsule 75 mg . . . . . . 20pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg . . . . . 20pregabalin oral capsule 225 mg, 300 mg . . . . . . . . . . . . . . . . . . . 20pregabalin oral solution . . . . . . . . . . . . 20PREMARIN INJECTION . . . . . . . . . . . 47PREMARIN ORAL . . . . . . . . . . . . . . . . . 47PREMARIN VAGINAL . . . . . . . . . . . . . 47PREMASOL 10% . . . . . . . . . . . . . . . . . . 55PRENATAL VITAMIN ORAL TABLET . . . . . . . . . . . . . . . . . . . . 55prevalite . . . . . . . . . . . . . . . . . . . . . . . . . . 33previfem . . . . . . . . . . . . . . . . . . . . . . . . . . 49PREZCOBIX . . . . . . . . . . . . . . . . . . . . . . . 8PREZISTA ORAL SUSPENSION . . . . 8PREZISTA ORAL TABLET 75 MG . . . 8PREZISTA ORAL TABLET 150 MG . . 8PREZISTA ORAL TABLET 600 MG . . 8PREZISTA ORAL TABLET 800 MG . . 8PRIFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 11

POTASSIUM CHLORIDE-D5-0.2% NACL INTRAVENOUS PARENTERAL SOLUTION 20 MEQ/L . . . . . . . . . . . . . 54potassium chloride-d5-0.2% nacl intravenous parenteral solution 30 meq/l, 40 meq/l . . . . . . . . . 54potassium chloride-d5-0.3% nacl intravenous parenteral solution 20 meq/l . . . . . . . . . . . . . . . . . . 54POTASSIUM CHLORIDE- D5-0.9%NACL . . . . . . . . . . . . . . . . . . . . 54potassium chloride in 0.9% nacl intravenous parenteral solution 20 meq/l, 40 meq/l . . . . . . . . . 54potassium chloride in 5% dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l . . . . . . . 54potassium chloride in lr-d5 . . . . . . . . . 54potassium chloride intravenous . . . . . 54potassium chloride in water intravenous piggyback . . . . . . . . . . . . . 54potassium chloride oral capsule, extended release . . . . . . . . . 54potassium chloride oral liquid . . . . . . . 54potassium chloride oral packet . . . . . 54potassium chloride oral tablet, er particles/crystals . . . . . . . . . . . . . . . . 54potassium chloride oral tablet extended release . . . . . . . . . . . . 54potassium citrate . . . . . . . . . . . . . . . . . . 53POTELIGEO . . . . . . . . . . . . . . . . . . . . . . 17PRADAXA . . . . . . . . . . . . . . . . . . . . . . . . 32pramipexole oral tablet . . . . . . . . . . . . . 21pramipexole oral tablet extended release 24 hr 0.375 mg, 0.75 mg, 1.5 mg . . . . . . . . . 21pramipexole oral tablet extended release 24 hr 2.25 mg, 3 mg, 3.75 mg, 4.5 mg . . . . 21prasugrel . . . . . . . . . . . . . . . . . . . . . . . . . . 32pravastatin oral tablet 10 mg, 20 mg, 80 mg . . . . . . . . . . . . . . 33pravastatin oral tablet 40 mg . . . . . . . 33praziquantel . . . . . . . . . . . . . . . . . . . . . . . 11

pilocarpine hcl ophthalmic (eye) drops 1%, 2%, 4% . . . . . . . . . . . 50pilocarpine hcl oral . . . . . . . . . . . . . . . . . 37pimecrolimus . . . . . . . . . . . . . . . . . . . . . . 34pimozide . . . . . . . . . . . . . . . . . . . . . . . . . . 28pimtrea (28) . . . . . . . . . . . . . . . . . . . . . . . 49pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 31pioglitazone-metformin . . . . . . . . . . . . . 40pioglitazone oral tablet 15 mg . . . . . . 40pioglitazone oral tablet 30 mg, 45 mg . . . . . . . . . . . . . . . . . . . . . 40piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram . . . . . . . . . . . . . . . 12PIPERACILLIN-TAZOBACTAM INTRAVENOUS RECON SOLN 13.5 GRAM . . . . . . . . . . . . . . . . . . . . . . . 12PIQRAY ORAL TABLET 200 MG/DAY (200 MG X 1) . . . . . . . . 17PIQRAY ORAL TABLET 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X 2) . . . . . . . . 17pirmella . . . . . . . . . . . . . . . . . . . . . . . . . . . 49PLENAMINE . . . . . . . . . . . . . . . . . . . . . . 55PLENVU . . . . . . . . . . . . . . . . . . . . . . . . . . 43podofilox . . . . . . . . . . . . . . . . . . . . . . . . . . 34polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50polymyxin b sulfate . . . . . . . . . . . . . . . . 11polymyxin b sulf-trimethoprim . . . . . . 50POMALYST . . . . . . . . . . . . . . . . . . . . . . . 17portia 28 . . . . . . . . . . . . . . . . . . . . . . . . . . 49POSACONAZOLE ORAL TABLET,DELAYED RELEASE (DR/EC) . . . . . . . . . . . . . . . . . 7POTASSIUM CHLORID-D5- 0.45%NACL INTRAVENOUS PARENTERAL SOLUTION 10 MEQ/L, 20 MEQ/L, 40 MEQ/L . . . 54potassium chlorid-d5-0.45%nacl intravenous parenteral solution 30 meq/l . . . . . . . . . . . . . . . . . . 54potassium chloride-0.45% nacl . . . . . 54

76


Covered Drugs Index

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/ 0.2ML-22 MCG/0.5ML (6) . . . . . . . . . . 44REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/ 0.5 ML, 44 MCG/0.5 ML . . . . . . . . . . . 44REBIF TITRATION PACK . . . . . . . . . . 44REBIF (WITH ALBUMIN) . . . . . . . . . . . 44reclipsen (28) . . . . . . . . . . . . . . . . . . . . . 49RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 5 MCG/0.5 ML . . . . . . . . . . . . . . . . . . . . 45RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML . . . . . . . . . . 45RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE . . . . . . 45RECTIV . . . . . . . . . . . . . . . . . . . . . . . . . . . 43regonol . . . . . . . . . . . . . . . . . . . . . . . . . . . 22REGRANEX . . . . . . . . . . . . . . . . . . . . . . 34RELISTOR SUBCUTANEOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 43RELISTOR SUBCUTANEOUS SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . . 43REMODULIN . . . . . . . . . . . . . . . . . . . . . . 31RENACIDIN IRRIGATION SOLUTION 1980.6 MG- 59.4 MG-980.4MG/30ML . . . . . . . . . . . 53RENFLEXIS . . . . . . . . . . . . . . . . . . . . . . . 43RENVELA ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 37RENVELA ORAL TABLET . . . . . . . . . . 37repaglinide oral tablet 0.5 mg, 1 mg . . 40repaglinide oral tablet 2 mg . . . . . . . . 40REPATHA . . . . . . . . . . . . . . . . . . . . . . . . . 33REPATHA PUSHTRONEX . . . . . . . . . 33REPATHA SURECLICK . . . . . . . . . . . . 33RESCRIPTOR ORAL TABLET . . . . . . 8RESTASIS . . . . . . . . . . . . . . . . . . . . . . . . 50RESTASIS MULTIDOSE . . . . . . . . . . . 50RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML . . . . 44

propylthiouracil . . . . . . . . . . . . . . . . . . . . 38PROQUAD (PF) . . . . . . . . . . . . . . . . . . . 45PROSOL 20% . . . . . . . . . . . . . . . . . . . . . 55protriptyline . . . . . . . . . . . . . . . . . . . . . . . 28PULMICORT . . . . . . . . . . . . . . . . . . . . . . 53PULMOZYME . . . . . . . . . . . . . . . . . . . . . 53PURIXAN . . . . . . . . . . . . . . . . . . . . . . . . . 17pyrazinamide . . . . . . . . . . . . . . . . . . . . . . 11pyridostigmine bromide oral syrup . . 22pyridostigmine bromide oral tablet 60 mg . . . . . . . . . . . . . . . . . . . . . . . 22pyridostigmine bromide oral tablet extended release . . . . . . . . . . . . 22

QQUADRACEL (PF) . . . . . . . . . . . . . . . . 45quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg . . . . . 28quetiapine oral tablet 300 mg, 400 mg . . . . . . . . . . . . . . . . . . . 29quetiapine oral tablet extended release 24 hr 150 mg, 200 mg . . . . . . 29quetiapine oral tablet extended release 24 hr 300 mg, 400 mg, 50 mg . . . . . . . . . . . . . . . . . . . . 29quinapril . . . . . . . . . . . . . . . . . . . . . . . . . . 31quinapril-hydrochlorothiazide . . . . . . . 31quinidine sulfate oral tablet . . . . . . . . . 30quinine sulfate . . . . . . . . . . . . . . . . . . . . . 11

RRABAVERT (PF) . . . . . . . . . . . . . . . . . . 45raloxifene . . . . . . . . . . . . . . . . . . . . . . . . . 46ramelteon . . . . . . . . . . . . . . . . . . . . . . . . . 29ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . . 31ranitidine hcl oral syrup . . . . . . . . . . . . 43ranitidine hcl oral tablet 150 mg, 300 mg . . . . . . . . . . . . . . . . . . . 43ranolazine . . . . . . . . . . . . . . . . . . . . . . . . . 33RAPAMUNE ORAL SOLUTION . . . . 17rasagiline . . . . . . . . . . . . . . . . . . . . . . . . . 21

PRIMAQUINE . . . . . . . . . . . . . . . . . . . . . 11primidone . . . . . . . . . . . . . . . . . . . . . . . . . 20PROAIR HFA . . . . . . . . . . . . . . . . . . . . . 52PROAIR RESPICLICK . . . . . . . . . . . . . 53probenecid . . . . . . . . . . . . . . . . . . . . . . . . 46probenecid-colchicine . . . . . . . . . . . . . . 46PROCALAMINE 3% . . . . . . . . . . . . . . . 55prochlorperazine . . . . . . . . . . . . . . . . . . 43prochlorperazine edisylate . . . . . . . . . 43prochlorperazine maleate oral . . . . . . 43procto-med hc . . . . . . . . . . . . . . . . . . . . . 43procto-pak . . . . . . . . . . . . . . . . . . . . . . . . 43proctosol hc topical . . . . . . . . . . . . . . . . 43proctozone-hc . . . . . . . . . . . . . . . . . . . . . 43progesterone micronized . . . . . . . . . . . 47PROGLYCEM . . . . . . . . . . . . . . . . . . . . . 40PROGRAF INTRAVENOUS . . . . . . . . 17PROGRAF ORAL GRANULES IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 17PROLASTIN-C . . . . . . . . . . . . . . . . . . . . 37PROLENSA . . . . . . . . . . . . . . . . . . . . . . . 50PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 46PROMACTA ORAL POWDER IN PACKET 12.5 MG . . . . . . . . . . . . . . 32PROMACTA ORAL POWDER IN PACKET 25 MG . . . . . . . . . . . . . . . . 32PROMACTA ORAL TABLET . . . . . . . . 32promethazine oral . . . . . . . . . . . . . . . . . 51promethazine rectal suppository 12.5 mg, 25 mg . . . . . . . . 51promethegan rectal suppository 25 mg, 50 mg . . . . . . . . . . 51propafenone oral capsule, extended release 12 hr . . . . . . . . . . . . 30propafenone oral tablet . . . . . . . . . . . . 30propantheline . . . . . . . . . . . . . . . . . . . . . 42propranolol-hydrochlorothiazid . . . . . 31propranolol oral capsule, extended release 24 hr . . . . . . . . . . . . 31propranolol oral solution . . . . . . . . . . . 31propranolol oral tablet . . . . . . . . . . . . . . 31

77


Covered Drugs Index

SECUADO . . . . . . . . . . . . . . . . . . . . . . . . 29selegiline hcl . . . . . . . . . . . . . . . . . . . . . . 21selenium sulfide topical lotion . . . . . . 34SELZENTRY ORAL SOLUTION . . . . . 8SELZENTRY ORAL TABLET 25 MG . 8SELZENTRY ORAL TABLET 150 MG, 75 MG . . . . . . . . . . . . . . . . . . . . 8SELZENTRY ORAL TABLET 300 MG . . . . . . . . . . . . . . . . . . . 8SENSIPAR ORAL TABLET 30 MG, 60 MG . . . . . . . . . . . . . . . . . . . . 41SENSIPAR ORAL TABLET 90 MG . . 41SEREVENT DISKUS . . . . . . . . . . . . . . 53sertraline oral concentrate . . . . . . . . . . 29sertraline oral tablet 50 mg . . . . . . . . . 29sertraline oral tablet 100 mg, 25 mg . . . . . . . . . . . . . . . . . . . . 29setlakin . . . . . . . . . . . . . . . . . . . . . . . . . . . 49SEVELAMER CARBONATE ORAL POWDER IN PACKET . . . . . . . 37SEVELAMER CARBONATE ORAL TABLET . . . . . . . . . . . . . . . . . . . . 37sharobel . . . . . . . . . . . . . . . . . . . . . . . . . . 47SHINGRIX (PF) . . . . . . . . . . . . . . . . . . . 45SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . . 17sildenafil (pulmonary arterial hypertension) oral tablet . . . . . . . . . . . 53SILENOR . . . . . . . . . . . . . . . . . . . . . . . . . 29silver sulfadiazine . . . . . . . . . . . . . . . . . 34SIMBRINZA . . . . . . . . . . . . . . . . . . . . . . . 51simliya (28) . . . . . . . . . . . . . . . . . . . . . . . 49simpesse . . . . . . . . . . . . . . . . . . . . . . . . . 49SIMULECT . . . . . . . . . . . . . . . . . . . . . . . . 17simvastatin oral tablet . . . . . . . . . . . . . . 33sirolimus oral solution . . . . . . . . . . . . . . 17sirolimus oral tablet . . . . . . . . . . . . . . . . 17SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . . 11SIVEXTRO INTRAVENOUS . . . . . . . . 11SIVEXTRO ORAL . . . . . . . . . . . . . . . . . 11SKYRIZI SUBCUTANEOUS SYRINGE KIT . . . . . . . . . . . . . . . . . . . . . 34

ritonavir . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8RITUXAN . . . . . . . . . . . . . . . . . . . . . . . . . 17RITUXAN HYCELA . . . . . . . . . . . . . . . . 17rivastigmine . . . . . . . . . . . . . . . . . . . . . . . 22rivastigmine tartrate . . . . . . . . . . . . . . . . 22rivelsa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49rizatriptan . . . . . . . . . . . . . . . . . . . . . . . . . 21ROCKLATAN . . . . . . . . . . . . . . . . . . . . . . 51ROMIDEPSIN . . . . . . . . . . . . . . . . . . . . . 17ropinirole oral tablet . . . . . . . . . . . . . . . . 21rosadan topical cream . . . . . . . . . . . . . 34rosadan topical gel . . . . . . . . . . . . . . . . 34rosuvastatin . . . . . . . . . . . . . . . . . . . . . . . 33ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . . 45ROTATEQ VACCINE . . . . . . . . . . . . . . 45roweepra . . . . . . . . . . . . . . . . . . . . . . . . . . 20roweepra xr . . . . . . . . . . . . . . . . . . . . . . . 20ROZLYTREK ORAL CAPSULE 100 MG . . . . . . . . . . . . . . . . 17ROZLYTREK ORAL CAPSULE 200 MG . . . . . . . . . . . . . . . . 17RUBRACA . . . . . . . . . . . . . . . . . . . . . . . . 17RUCONEST . . . . . . . . . . . . . . . . . . . . . . 53RUXIENCE . . . . . . . . . . . . . . . . . . . . . . . 17RYDAPT . . . . . . . . . . . . . . . . . . . . . . . . . . 17RYTARY . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Ssalsalate . . . . . . . . . . . . . . . . . . . . . . . . . . 25SAMSCA ORAL TABLET 15 MG . . . . 41SAMSCA ORAL TABLET 30 MG . . . . 41SANCUSO . . . . . . . . . . . . . . . . . . . . . . . . 43SANDIMMUNE ORAL SOLUTION . . 17SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON . . . . . . . . . . . . . . . . . . . . . . 17SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . . 34SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . . 29scopolamine base . . . . . . . . . . . . . . . . . 43

RETACRIT INJECTION SOLUTION 40,000 UNIT/ML . . . . . . . 44RETROVIR INTRAVENOUS . . . . . . . . 8REVLIMID ORAL CAPSULE 10 MG, 2.5 MG, 5 MG . . . . . . . . . . . . . 17REVLIMID ORAL CAPSULE 15 MG, 20 MG, 25 MG . . . . . . . . . . . . . 17REXULTI . . . . . . . . . . . . . . . . . . . . . . . . . . 29REYATAZ ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . . 8RHOPRESSA . . . . . . . . . . . . . . . . . . . . . 51ribavirin oral capsule . . . . . . . . . . . . . . . . 8ribavirin oral tablet 200 mg . . . . . . . . . . 8RIDAURA . . . . . . . . . . . . . . . . . . . . . . . . . 46rifabutin . . . . . . . . . . . . . . . . . . . . . . . . . . . 11rifampin intravenous . . . . . . . . . . . . . . . 11rifampin oral . . . . . . . . . . . . . . . . . . . . . . . 11RIFATER . . . . . . . . . . . . . . . . . . . . . . . . . . 11riluzole . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37rimantadine . . . . . . . . . . . . . . . . . . . . . . . . 8ringer’s intravenous . . . . . . . . . . . . . . . . 54ringer’s irrigation . . . . . . . . . . . . . . . . . . . 36RINVOQ . . . . . . . . . . . . . . . . . . . . . . . . . . 46RIOMET . . . . . . . . . . . . . . . . . . . . . . . . . . 40risedronate oral tablet 30 mg, 5 mg . 46risedronate oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack) . . . 46risedronate oral tablet 150 mg . . . . . . 46RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML . . . . . . . . 29RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 50 MG/2 ML . . . . . . . . . . 29risperidone oral solution . . . . . . . . . . . . 29risperidone oral tablet . . . . . . . . . . . . . . 29risperidone oral tablet, disintegrating 0.5 mg, 4 mg . . . . . . . . 29risperidone oral tablet,disintegrating 0.25 mg, 1 mg, 2 mg, 3 mg . . . . . . . . . 29

78


Covered Drugs Index

sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml . . 22SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML . . 10SUPREP BOWEL PREP KIT . . . . . . . 43SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . . 18syeda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG . . . . . . . . . . . 44SYMFI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8SYMFI LO . . . . . . . . . . . . . . . . . . . . . . . . . 9SYMLINPEN 60 . . . . . . . . . . . . . . . . . . . 40SYMLINPEN 120 . . . . . . . . . . . . . . . . . . 40SYMPAZAN . . . . . . . . . . . . . . . . . . . . . . . 21SYMTUZA . . . . . . . . . . . . . . . . . . . . . . . . . 9SYNAGIS . . . . . . . . . . . . . . . . . . . . . . . . . . 9SYNAREL . . . . . . . . . . . . . . . . . . . . . . . . 41SYNERCID . . . . . . . . . . . . . . . . . . . . . . . 11SYNJARDY . . . . . . . . . . . . . . . . . . . . . . . 40SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG . . . . . . . . 40SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 25-1,000 MG . 40SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . . 18SYNTHROID . . . . . . . . . . . . . . . . . . . . . . 41

TTABLOID . . . . . . . . . . . . . . . . . . . . . . . . . 18tacrolimus oral . . . . . . . . . . . . . . . . . . . . 18tacrolimus topical . . . . . . . . . . . . . . . . . . 34TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . . 18TAGRISSO . . . . . . . . . . . . . . . . . . . . . . . . 18TALZENNA . . . . . . . . . . . . . . . . . . . . . . . 18tamoxifen . . . . . . . . . . . . . . . . . . . . . . . . . 18tamsulosin . . . . . . . . . . . . . . . . . . . . . . . . 53TARGRETIN TOPICAL . . . . . . . . . . . . 18tarina 24 fe . . . . . . . . . . . . . . . . . . . . . . . . 49tarina fe 1/20 (28) . . . . . . . . . . . . . . . . . 49tarina fe 1-20 eq (28) . . . . . . . . . . . . . . 49TASIGNA ORAL CAPSULE 50 MG . 18

sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49ssd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34STAMARIL (PF) . . . . . . . . . . . . . . . . . . . 45stavudine oral capsule . . . . . . . . . . . . . . 8STELARA SUBCUTANEOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 34STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML . . . . . . . . . . . 34STELARA SUBCUTANEOUS SYRINGE 90 MG/ML . . . . . . . . . . . . . . 34STIMATE . . . . . . . . . . . . . . . . . . . . . . . . . 41STIVARGA . . . . . . . . . . . . . . . . . . . . . . . . 18streptomycin . . . . . . . . . . . . . . . . . . . . . . 11STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . . . 8SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG, 8-2 MG . . . 25SUBOXONE SUBLINGUAL FILM 12-3 MG . . . . . . . . . . . . . . . . . . . . . 25sucralfate oral suspension . . . . . . . . . 43sucralfate oral tablet . . . . . . . . . . . . . . . 43sulfacetamide-prednisolone . . . . . . . . 50sulfacetamide sodium (acne) . . . . . . . 35sulfacetamide sodium ophthalmic (eye) drops . . . . . . . . . . . . . 50sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . 12sulfamethoxazole-trimethoprim intravenous . . . . . . . . . . . . . . . . . . . . . . . 12sulfamethoxazole-trimethoprim oral suspension . . . . . . . . . . . . . . . . . . . 13sulfamethoxazole-trimethoprim oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 13sulfasalazine . . . . . . . . . . . . . . . . . . . . . . 43sulfatrim . . . . . . . . . . . . . . . . . . . . . . . . . . 13sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . 25sumatriptan . . . . . . . . . . . . . . . . . . . . . . . 21sumatriptan succinate oral . . . . . . . . . 21sumatriptan succinate subcutaneous cartridge . . . . . . . . . . . . 21sumatriptan succinate subcutaneous pen injector . . . . . . . . . 21sumatriptan succinate subcutaneous solution . . . . . . . . . . . . . 21

sodium bicarbonate intravenous syringe 10 meq/10 ml (8.4%), 7.5% (0.9 meq/ml), 8.4% (1 meq/ml) . . . . . 54sodium chloride 0.9% intravenous . . 37sodium chloride 0.45% intravenous parenteral solution . . . . . 54sodium chloride 3% . . . . . . . . . . . . . . . . 54sodium chloride 5% . . . . . . . . . . . . . . . . 54sodium chloride intravenous . . . . . . . . 54sodium chloride irrigation . . . . . . . . . . . 37sodium phenylbutyrate . . . . . . . . . . . . . 37sodium polystyrene (sorb free) . . . . . 37sodium polystyrene sulfonate oral powder . . . . . . . . . . . . . . . . . . . . . . . 37solifenacin . . . . . . . . . . . . . . . . . . . . . . . . 53SOLIQUA 100/33 . . . . . . . . . . . . . . . . . . 40SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . . 17SOLU-CORTEF ACT-O-VIAL (PF) . . 38SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 60 MG/0.2 ML . . . . . . . . . . . . . . . . . . . . . 17SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 90 MG/0.3 ML . . . . . . . . . . . . . . . . . . . . . 17SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML . . . . . . . . . . . . . . . . . . . . 17SOMAVERT . . . . . . . . . . . . . . . . . . . . . . . 41sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30sotalol af . . . . . . . . . . . . . . . . . . . . . . . . . . 30sotalol oral . . . . . . . . . . . . . . . . . . . . . . . . 30SOTYLIZE . . . . . . . . . . . . . . . . . . . . . . . . 30spironolactone . . . . . . . . . . . . . . . . . . . . 31spironolacton-hydrochlorothiaz . . . . . 31sprintec (28) . . . . . . . . . . . . . . . . . . . . . . . 49SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG . . . . . . . . . . . . . . . . . . 20SPRITAM ORAL TABLET FOR SUSPENSION 750 MG . . . . . . . 21SPRYCEL . . . . . . . . . . . . . . . . . . . . . . . . 17sps (with sorbitol) . . . . . . . . . . . . . . . . . . 37

79


Covered Drugs Index

tigecycline . . . . . . . . . . . . . . . . . . . . . . . . 11tilia fe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49timolol maleate ophthalmic (eye) drops . . . . . . . . . . . . . . . . . . . . . . . . 50TIMOLOL MALEATE OPHTHALMIC (EYE) GEL FORMING SOLUTION. . 50timolol maleate oral . . . . . . . . . . . . . . . . 32tis-u-sol pentalyte . . . . . . . . . . . . . . . . . . 36TIVICAY ORAL TABLET 10 MG . . . . . 9TIVICAY ORAL TABLET 25 MG, 50 MG . . . . . . . . . . . . . . . . . . . . . 9tizanidine oral capsule . . . . . . . . . . . . . 22tizanidine oral tablet . . . . . . . . . . . . . . . 22TOBI PODHALER . . . . . . . . . . . . . . . . . 11TOBRADEX OPHTHALMIC (EYE) OINTMENT . . . . . . . . . . . . . . . . . 51tobramycin . . . . . . . . . . . . . . . . . . . . . . . . 50tobramycin-dexamethasone . . . . . . . . 51tobramycin in 0.225% nacl . . . . . . . . . 11tobramycin sulfate . . . . . . . . . . . . . . . . . 11TOBREX OPHTHALMIC (EYE) OINTMENT . . . . . . . . . . . . . . . . . 50TOLAK . . . . . . . . . . . . . . . . . . . . . . . . . . . 34tolcapone . . . . . . . . . . . . . . . . . . . . . . . . . 21tolterodine oral capsule, extended release 24hr . . . . . . . . . . . . . 53tolterodine oral tablet . . . . . . . . . . . . . . 53topiramate oral capsule, sprinkle . . . 21topiramate oral tablet . . . . . . . . . . . . . . 21toposar . . . . . . . . . . . . . . . . . . . . . . . . . . . 18topotecan intravenous recon soln . . . 18toremifene . . . . . . . . . . . . . . . . . . . . . . . . 18TORISEL . . . . . . . . . . . . . . . . . . . . . . . . . 18torsemide oral . . . . . . . . . . . . . . . . . . . . . 32TOUJEO MAX U-300 SOLOSTAR . . 40TOUJEO SOLOSTAR U-300 INSULIN . . . . . . . . . . . . . . . . . . . . 40TOVIAZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 53TPN ELECTROLYTES . . . . . . . . . . . . . 54TRACLEER ORAL TABLET FOR SUSPENSION . . . . . . . . . . . . . . . 53

tenofovir disoproxil fumarate . . . . . . . . 9terazosin . . . . . . . . . . . . . . . . . . . . . . . . . . 32terbinafine hcl oral . . . . . . . . . . . . . . . . . . 7terbutaline . . . . . . . . . . . . . . . . . . . . . . . . 53terconazole . . . . . . . . . . . . . . . . . . . . . . . 47testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml (1 ml) . . . . 41TESTOSTERONE CYPIONATE INTRAMUSCULAR OIL 200 MG/ML 41testosterone enanthate . . . . . . . . . . . . 41testosterone transdermal gel . . . . . . . 41testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1%) . . . . . . . . . . . 41testosterone transdermal gel in packet 1% (25 mg/2.5gram), 1% (50 mg/5 gram) . . . . . . . . . . . . . . . . 41TETANUS,DIPHTHERIA TOX PED(PF) . . . . . . . . . . . . . . . . . . . . . 45tetrabenazine oral tablet 12.5 mg . . . 22tetrabenazine oral tablet 25 mg . . . . . 22tetracycline . . . . . . . . . . . . . . . . . . . . . . . . 13THALOMID ORAL CAPSULE 100 MG, 150 MG, 50 MG . . . . . . . . . . 18THALOMID ORAL CAPSULE 200 MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 18THEO-24 . . . . . . . . . . . . . . . . . . . . . . . . . 53theophylline oral tablet extended release 12 hr . . . . . . . . . . . . 53theophylline oral tablet extended release 24 hr . . . . . . . . . . . . 53thioridazine . . . . . . . . . . . . . . . . . . . . . . . 29thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . . 18thiothixene . . . . . . . . . . . . . . . . . . . . . . . . 29THYROLAR-1 . . . . . . . . . . . . . . . . . . . . . 41THYROLAR-1/2 . . . . . . . . . . . . . . . . . . . 41THYROLAR-1/4 . . . . . . . . . . . . . . . . . . . 41THYROLAR-2 . . . . . . . . . . . . . . . . . . . . . 41THYROLAR-3 . . . . . . . . . . . . . . . . . . . . . 41tiadylt er . . . . . . . . . . . . . . . . . . . . . . . . . . 32tiagabine . . . . . . . . . . . . . . . . . . . . . . . . . . 21TIBSOVO . . . . . . . . . . . . . . . . . . . . . . . . . 18

TASIGNA ORAL CAPSULE 150 MG, 200 MG . . . . . . . . . . . . . . . . . . 18tazarotene . . . . . . . . . . . . . . . . . . . . . . . . 35tazicef . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10TAZORAC TOPICAL CREAM . . . . . . 35TAZORAC TOPICAL GEL . . . . . . . . . . 35taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg . . . . . . . . . . . . . . . . . . . 31TAZVERIK . . . . . . . . . . . . . . . . . . . . . . . . 18TDVAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 45TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) . . . . . . . . . . . . . . . . . . . . . . . 18TECENTRIQ INTRAVENOUS SOLUTION 840 MG/14 ML (60 MG/ML) . . . . . . . . . . . . . . . . . . . . . . . 18TECFIDERA ORAL CAPSULE,DELAYED RELEASE (DR/EC) 120 MG . . . . . . . . . . . . . . . . . . 22TECFIDERA ORAL CAPSULE,DELAYED RELEASE (DR/EC) 120 MG (14)- 240 MG (46) . 22TECFIDERA ORAL CAPSULE,DELAYED RELEASE (DR/EC) 240 MG . . . . . . . . . . . . . . . . . . 22TECHLITE PEN NEEDLE . . . . . . . . . . 40TEFLARO . . . . . . . . . . . . . . . . . . . . . . . . . 10TEKTURNA HCT . . . . . . . . . . . . . . . . . . 31telmisartan-amlodipine . . . . . . . . . . . . . 32telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-25 mg . . . 32telmisartan-hydrochlorothiazid oral tablet 80-12.5 mg . . . . . . . . . . . . . . 32telmisartan oral tablet 20 mg, 40 mg . . . . . . . . . . . . . . . . . . . . . 31telmisartan oral tablet 80 mg . . . . . . . 31temazepam oral capsule 15 mg, 30 mg . . . . . . . . . . . . . . . . . . . . . 29temazepam oral capsule 22.5 mg, 7.5 mg . . . . . . . . . . . . . . . . . . . 29temsirolimus . . . . . . . . . . . . . . . . . . . . . . 18TENIVAC (PF) INTRAMUSCULAR SYRINGE . . . . . . 45

80


Covered Drugs Index

TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 200 MG . . . . . . . . . . 21TROPHAMINE 6% . . . . . . . . . . . . . . . . 55TROPHAMINE 10% . . . . . . . . . . . . . . . 55TRULANCE . . . . . . . . . . . . . . . . . . . . . . . 43TRULICITY . . . . . . . . . . . . . . . . . . . . . . . 40TRUMENBA . . . . . . . . . . . . . . . . . . . . . . 45TRUVADA . . . . . . . . . . . . . . . . . . . . . . . . . 9TRUXIMA . . . . . . . . . . . . . . . . . . . . . . . . . 18TWINRIX (PF) INTRAMUSCULAR SYRINGE . . . . . . 45TYBOST . . . . . . . . . . . . . . . . . . . . . . . . . . . 9tydemy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . . 18TYMLOS . . . . . . . . . . . . . . . . . . . . . . . . . . 46TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . . 45TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . . 22

UUNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG . . . . . . . . . . . . . . . . . 41unithroid oral tablet 137 mcg . . . . . . . 41UNITUXIN . . . . . . . . . . . . . . . . . . . . . . . . 18UPTRAVI . . . . . . . . . . . . . . . . . . . . . . . . . 32ursodiol . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Vvalacyclovir oral tablet 1 gram . . . . . . . 9valacyclovir oral tablet 500 mg . . . . . . 9VALCHLOR . . . . . . . . . . . . . . . . . . . . . . . 34valganciclovir . . . . . . . . . . . . . . . . . . . . . . . 9valproic acid . . . . . . . . . . . . . . . . . . . . . . . 21valproic acid (as sodium salt) oral solution . . . . . . . . . . . . . . . . . . . . . . . 21valsartan-hydrochlorothiazide . . . . . . 32valsartan oral tablet 160 mg, 40 mg, 80 mg . . . . . . . . . . . . . 32

triamcinolone acetonide topical cream 0.025%, 0.5% . . . . . . . . 36triamcinolone acetonide topical lotion . . . . . . . . . . . . . . . . . . . . . . . 36triamcinolone acetonide topical ointment . . . . . . . . . . . . . . . . . . . 36triamterene-hydrochlorothiazid oral capsule 37.5-25 mg . . . . . . . . . . . 32triamterene-hydrochlorothiazid oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 32triderm topical cream 0.1% . . . . . . . . . 36trientine . . . . . . . . . . . . . . . . . . . . . . . . . . . 37tri-estarylla . . . . . . . . . . . . . . . . . . . . . . . . 49tri femynor . . . . . . . . . . . . . . . . . . . . . . . . 49trifluoperazine . . . . . . . . . . . . . . . . . . . . . 29trifluridine . . . . . . . . . . . . . . . . . . . . . . . . . 50trihexyphenidyl . . . . . . . . . . . . . . . . . . . . 21tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . . 49tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . . . 49tri-lo-estarylla . . . . . . . . . . . . . . . . . . . . . . 49tri-lo-marzia . . . . . . . . . . . . . . . . . . . . . . . 49tri-lo-mili . . . . . . . . . . . . . . . . . . . . . . . . . . 49tri-lo-sprintec . . . . . . . . . . . . . . . . . . . . . . 49trilyte with flavor packets . . . . . . . . . . . 43trimethoprim . . . . . . . . . . . . . . . . . . . . . . . 13tri-mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49trimipramine . . . . . . . . . . . . . . . . . . . . . . . 29TRINTELLIX . . . . . . . . . . . . . . . . . . . . . . 29tri-previfem (28) . . . . . . . . . . . . . . . . . . . 49TRIPTODUR . . . . . . . . . . . . . . . . . . . . . . 18TRISENOX INTRAVENOUS SOLUTION 2 MG/ML . . . . . . . . . . . . . . 18tri-sprintec (28) . . . . . . . . . . . . . . . . . . . . 49TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . . . . 9trivora (28) . . . . . . . . . . . . . . . . . . . . . . . . 49tri-vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . 49tri-vylibra lo . . . . . . . . . . . . . . . . . . . . . . . 49TROGARZO . . . . . . . . . . . . . . . . . . . . . . . 9TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 25 MG, 50 MG . . . . . 21

TRADJENTA . . . . . . . . . . . . . . . . . . . . . . 40tramadol-acetaminophen . . . . . . . . . . . 25tramadol oral tablet 50 mg . . . . . . . . . 25trandolapril . . . . . . . . . . . . . . . . . . . . . . . . 32tranexamic acid oral . . . . . . . . . . . . . . . 47tranylcypromine . . . . . . . . . . . . . . . . . . . 29TRAVASOL 10% . . . . . . . . . . . . . . . . . . 55TRAVATAN Z . . . . . . . . . . . . . . . . . . . . . . 51travoprost . . . . . . . . . . . . . . . . . . . . . . . . . 51TRAZIMERA . . . . . . . . . . . . . . . . . . . . . . 18trazodone . . . . . . . . . . . . . . . . . . . . . . . . . 29TREANDA INTRAVENOUS RECON SOLN 25 MG . . . . . . . . . . . . . 18TREANDA INTRAVENOUS RECON SOLN 100 MG . . . . . . . . . . . . 18TRECATOR . . . . . . . . . . . . . . . . . . . . . . . 12TRELEGY ELLIPTA . . . . . . . . . . . . . . . 53TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 3.75 MG . . . . . . 18TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 11.25 MG . . . . . 18TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG . . . . . . 18treprostinil sodium . . . . . . . . . . . . . . . . . 32TRESIBA FLEXTOUCH U-100 . . . . . 40TRESIBA FLEXTOUCH U-200 . . . . . 40TRESIBA U-100 INSULIN . . . . . . . . . . 40tretinoin (chemotherapy) . . . . . . . . . . . 18tretinoin microspheres . . . . . . . . . . . . . 35tretinoin topical cream 0.025%, 0.05%, 0.1% . . . . . . . . . . . . . . 35tretinoin topical topical gel 0.01% . . . 35tretinoin topical topical gel 0.025%, 0.05% . . . . . . . . . . . . . . . . . . . . 35triamcinolone acetonide dental . . . . . 38triamcinolone acetonide injection . . . 38triamcinolone acetonide topical cream 0.1% . . . . . . . . . . . . . . . . 36

81


Covered Drugs Index

VIOKACE ORAL TABLET 20,880-78,300- 78,300 UNIT . . . . . . . 43viorele (28) . . . . . . . . . . . . . . . . . . . . . . . . 49VIRACEPT ORAL TABLET 250 MG . . 9VIRACEPT ORAL TABLET 625 MG . . 9VIREAD ORAL POWDER . . . . . . . . . . . 9VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG . . . . . . . . . . 9VITRAKVI ORAL CAPSULE 25 MG . 18VITRAKVI ORAL CAPSULE 100 MG . 18VITRAKVI ORAL SOLUTION . . . . . . . 19VIVITROL . . . . . . . . . . . . . . . . . . . . . . . . . 25VIZIMPRO . . . . . . . . . . . . . . . . . . . . . . . . 19volnea (28) . . . . . . . . . . . . . . . . . . . . . . . . 49voriconazole intravenous . . . . . . . . . . . . 7voriconazole oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . . 7voriconazole oral tablet . . . . . . . . . . . . . 7VOSEVI . . . . . . . . . . . . . . . . . . . . . . . . . . . 9VOTRIENT . . . . . . . . . . . . . . . . . . . . . . . . 19VRAYLAR ORAL CAPSULE . . . . . . . . 29VRAYLAR ORAL CAPSULE, DOSE PACK . . . . . . . . . . . . . . . . . . . . . . 29vyfemla (28) . . . . . . . . . . . . . . . . . . . . . . . 49vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49VYXEOS . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Wwarfarin . . . . . . . . . . . . . . . . . . . . . . . . . . . 32water for irrigation, sterile . . . . . . . . . . 37wera (28) . . . . . . . . . . . . . . . . . . . . . . . . . 49wymzya fe . . . . . . . . . . . . . . . . . . . . . . . . 49

XXALKORI . . . . . . . . . . . . . . . . . . . . . . . . . 19XARELTO . . . . . . . . . . . . . . . . . . . . . . . . . 33XATMEP . . . . . . . . . . . . . . . . . . . . . . . . . . 19XELJANZ . . . . . . . . . . . . . . . . . . . . . . . . . 46XELJANZ XR . . . . . . . . . . . . . . . . . . . . . 46XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . . 53VENTOLIN HFA . . . . . . . . . . . . . . . . . . . 53verapamil intravenous solution . . . . . 32verapamil oral capsule, 24 hr er pellet ct . . . . . . . . . . . . . . . . . . . 32verapamil oral capsule, ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg . . . . . . . . . . . 32VERAPAMIL ORAL CAPSULE,EXT REL. PELLETS 24 HR 360 MG . . . . . 32verapamil oral tablet . . . . . . . . . . . . . . . 32verapamil oral tablet extended release . . . . . . . . . . . . . . . . . . 32VERSACLOZ . . . . . . . . . . . . . . . . . . . . . 29VERZENIO . . . . . . . . . . . . . . . . . . . . . . . 18V-GO 20 . . . . . . . . . . . . . . . . . . . . . . . . . . 40V-GO 30 . . . . . . . . . . . . . . . . . . . . . . . . . . 40V-GO 40 . . . . . . . . . . . . . . . . . . . . . . . . . . 40VIBERZI . . . . . . . . . . . . . . . . . . . . . . . . . . 43VICTOZA 2-PAK . . . . . . . . . . . . . . . . . . . 40VICTOZA 3-PAK . . . . . . . . . . . . . . . . . . . 40VIDEX 2 GRAM PEDIATRIC . . . . . . . . 9VIDEX EC ORAL CAPSULE, DELAYED RELEASE (DR/EC) 125 MG . . . . . . . . . . . . . . . . . . . 9vienva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49vigabatrin . . . . . . . . . . . . . . . . . . . . . . . . . 21vigadrone . . . . . . . . . . . . . . . . . . . . . . . . . 21VIIBRYD ORAL TABLET . . . . . . . . . . . 29VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) . . . . . . 29VIMPAT INTRAVENOUS . . . . . . . . . . . 21VIMPAT ORAL SOLUTION . . . . . . . . . 21VIMPAT ORAL TABLET 50 MG . . . . . 21VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG . . . . . . . . . 21vincasar pfs intravenous solution 1 mg/ml . . . . . . . . . . . . . . . . . . . 18vincristine . . . . . . . . . . . . . . . . . . . . . . . . . 18vinorelbine . . . . . . . . . . . . . . . . . . . . . . . . 18VIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT . . . . . . . 43

valsartan oral tablet 320 mg . . . . . . . . 32VALTOCO . . . . . . . . . . . . . . . . . . . . . . . . . 21VANCOMYCIN IN 0.9% SODIUM CHL INTRAVENOUS PIGGYBACK . 12VANCOMYCIN IN DEXTROSE 5% INTRAVENOUS PIGGYBACK . . . . . . 12VANCOMYCIN INJECTION . . . . . . . . 12vancomycin intravenous recon soln 1,000 mg, 10 gram, 250 mg, 5 gram, 500 mg, 750 mg . . . . . . . . . . . 12VANCOMYCIN INTRAVENOUS RECON SOLN 1.25 GRAM, 1.5 GRAM . . . . . . . . . . . . . . . . . . . . . . . . 12vancomycin oral capsule 125 mg . . . 12vancomycin oral capsule 250 mg . . . 12vancomycin oral recon soln . . . . . . . . 12VANCOMYCIN-WATER INJECT (PEG) . . . . . . . . . . . . . . . . . . . . 12vandazole . . . . . . . . . . . . . . . . . . . . . . . . . 47VAQTA (PF) . . . . . . . . . . . . . . . . . . . . . . . 45VARIVAX (PF) . . . . . . . . . . . . . . . . . . . . . 45VARIZIG INTRAMUSCULAR SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 45VASCEPA ORAL CAPSULE 0.5 GRAM . . . . . . . . . . . . . . . . . . . . . . . . 33VASCEPA ORAL CAPSULE 1 GRAM . . . . . . . . . . . . . . . . . . . . . . . . . . 33VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . . . 18VELCADE . . . . . . . . . . . . . . . . . . . . . . . . 18velivet triphasic regimen (28) . . . . . . . 49VELPHORO . . . . . . . . . . . . . . . . . . . . . . . 37VELTASSA . . . . . . . . . . . . . . . . . . . . . . . . 37VEMLIDY . . . . . . . . . . . . . . . . . . . . . . . . . . 9VENCLEXTA ORAL TABLET 10 MG . 18VENCLEXTA ORAL TABLET 50 MG . 18VENCLEXTA ORAL TABLET 100 MG . 18VENCLEXTA STARTING PACK . . . . 18venlafaxine oral capsule,extended release 24hr 75 mg . . . . . . . . . . . . . . . . 29venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg . . . . . . 29venlafaxine oral tablet . . . . . . . . . . . . . . 29

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Covered Drugs Index

ZORTRESS ORAL TABLET 0.75 MG, 1 MG . . . . . . . . . . . 19ZOSTAVAX (PF) . . . . . . . . . . . . . . . . . . . 45ZOSYN IN DEXTROSE (ISO-OSM) 12ZOSYN INTRAVENOUS RECON SOLN 2.25 GRAM, 3.375 GRAM . . . 12zovia 1/35e (28) . . . . . . . . . . . . . . . . . . . 49ZTLIDO . . . . . . . . . . . . . . . . . . . . . . . . . . . 34ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 11.4-2.9 MG . . . . . . . . . 25ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG . . . . . . . . . . . . 25zumandimine (28) . . . . . . . . . . . . . . . . . 49ZYDELIG . . . . . . . . . . . . . . . . . . . . . . . . . 19ZYKADIA ORAL TABLET . . . . . . . . . . 19ZYLET . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG . . 29ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG . . 29ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG . . 30ZYTIGA ORAL TABLET 500 MG . . . . 19

yuvafem . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Zzafirlukast . . . . . . . . . . . . . . . . . . . . . . . . . 53zaleplon oral capsule 5 mg . . . . . . . . . 29zaleplon oral capsule 10 mg . . . . . . . . 29zarah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49ZARXIO . . . . . . . . . . . . . . . . . . . . . . . . . . 44zebutal oral capsule 50-325-40 mg . 24ZEJULA . . . . . . . . . . . . . . . . . . . . . . . . . . 19ZELBORAF . . . . . . . . . . . . . . . . . . . . . . . 19ZEMAIRA . . . . . . . . . . . . . . . . . . . . . . . . . 37zenatane . . . . . . . . . . . . . . . . . . . . . . . . . . 35ZENPEP ORAL CAPSULE, DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT . . . . . . . . 43zidovudine oral capsule . . . . . . . . . . . . . 9zidovudine oral syrup . . . . . . . . . . . . . . . 9zidovudine oral tablet . . . . . . . . . . . . . . . 9ZIEXTENZO . . . . . . . . . . . . . . . . . . . . . . 44ZIOPTAN (PF) . . . . . . . . . . . . . . . . . . . . . 51ziprasidone hcl . . . . . . . . . . . . . . . . . . . . 29ZIRABEV . . . . . . . . . . . . . . . . . . . . . . . . . 19ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . . 50zoledronic acid intravenous solution . . . . . . . . . . . . . . . 41zoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml . . . . . . . . . . . . . . . . . . . . . . . 37ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . . 19zolpidem oral tablet . . . . . . . . . . . . . . . . 29zonisamide . . . . . . . . . . . . . . . . . . . . . . . . 21ZORTRESS ORAL TABLET 0.5 MG . . . . . . . . . . . . . . . . . . . 19ZORTRESS ORAL TABLET 0.25 MG . . . . . . . . . . . . . . . . . . 19

XHANCE . . . . . . . . . . . . . . . . . . . . . . . . . . 53XIAFLEX . . . . . . . . . . . . . . . . . . . . . . . . . . 37XIFAXAN ORAL TABLET 550 MG . . 12XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG, 5-500 MG . . . . . . . . . . . . 40XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG . . . . . . . . . . 40XIIDRA . . . . . . . . . . . . . . . . . . . . . . . . . . . 50XOFLUZA . . . . . . . . . . . . . . . . . . . . . . . . . . 9XOLAIR SUBCUTANEOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . 53XOLAIR SUBCUTANEOUS SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . . 53XOPENEX . . . . . . . . . . . . . . . . . . . . . . . . 53XOPENEX CONCENTRATE . . . . . . . 53XOSPATA . . . . . . . . . . . . . . . . . . . . . . . . . 19XPOVIO ORAL TABLET 60 MG/WEEK (20 MG X 3) . . . . . . . . . 19XPOVIO ORAL TABLET 80 MG/WEEK (20 MG X 4) . . . . . . . . . 19XPOVIO ORAL TABLET 100 MG/WEEK (20 MG X 5) . . . . . . . . 19XPOVIO ORAL TABLET 160 MG/WEEK (20 MG X 8) . . . . . . . . 19XTAMPZA ER . . . . . . . . . . . . . . . . . . . . . 24XTANDI . . . . . . . . . . . . . . . . . . . . . . . . . . . 19XULTOPHY 100/3.6 . . . . . . . . . . . . . . . 40XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

YYERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) . . . . . . . . . . . . . . . . . . . . . . . . 19YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML) . . . . . . . . . . . . . . . . . . . . . . . . 19YF-VAX (PF) . . . . . . . . . . . . . . . . . . . . . . 45YONDELIS . . . . . . . . . . . . . . . . . . . . . . . . 19YONSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 19YUPELRI . . . . . . . . . . . . . . . . . . . . . . . . . 53

83

Notes

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Notes

85

Notes

86

Notice of Nondiscrimination: Discrimination is Against the Law

Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Cigna: Provides free aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreterso Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:o Qualified interpreterso Information written in other languages

If you need these services, contact Customer Service at 1-800-668-3813, 8 a.m.–8 p.m., 7 days a week.

If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Cigna Attn: Customer Grievances PO Box 2888 Houston, TX 77252-2888 Phone: 1-800-668-3813 (TTY 711) Fax: 1-888-586-9946.

You can file a grievance in writing by mail or fax. If you need help filing a grievance, Customer Service is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. Call 1-800-668-3813 (TTY 711), 8 a.m.–8 p.m., 7 days a week. ATENCIÓN: si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-668-3813 (TTY 711), 8 a.m.–8 p.m , 7 días de la semana. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal.

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87

Notificación Contra la Discriminación: La Discriminación es Contra la Ley

Cigna cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Cigna no excluye a las personas ni las trata de forma diferente debido a su origen étnico, color, nacionalidad, edad, discapacidad o sexo.

Cigna: • Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera

eficaz con nosotros, como los siguientes:o Intérpretes de lenguaje de señas capacitados.o Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos).

• Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes:o Intérpretes capacitados.o Información escrita en otros idiomas.

Si necesita recibir estos servicios, comuníquese con Servicio al Cliente al 1-800-668-3813, 8 a.m. – 8 p.m., 7 días de la semana.

Si considera que Cigna no le proporcionó estos servicios o lo discriminó de otra manera por motivos de origen étnico, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a la siguiente persona:

Cigna Attn: Customer Grievances PO Box 2888 Houston, TX 77252-2888 Teléfono: 1-800-668-3813 (TTY 711) Fax: 1-888-586-9946.

Puede presentar el reclamo escrito por correo postal o fax. Si necesita ayuda para hacerlo, Servicio al Cliente está a su disposición para brindársela.

También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles) del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera electrónica a través de Office for Civil Rights Complaint Portal (Oficina de Derechos Civiles portal de quejas), disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, por correo postal a la siguiente dirección o por teléfono a los números que figuran a continuación:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)Puede obtener los formularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html.

Todos los productos y servicios de Cigna se brindan exclusivamente por o a través de subsidiarias operativas de Cigna Corporation. El nombre de Cigna, los logotipos, y otras marcas de Cigna son propiedad de Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. Call 1-800-668-3813 (TTY 711), 8 a.m.–8 p.m., 7 days a week. ATENCIÓN: si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-668-3813 (TTY 711), 8 a.m.–8 p.m, 7 días de la semana. Cigna-HealthSpring tiene contrato con Medicare para planes PDP, planes HMO y PPO en ciertos estados, y con ciertos programas estatales de Medicaid. La inscripción en Cigna-HealthSpring depende de la renovación de contrato.

INT_17_49135S Alternate Format 09302016

88Y0036_17_50169 ACCEPTED 17_MLI_MAPD

English – ATTENTION: If you speak English, language assistance services, free of charge are available to you. Call 1-800-668-3813 (TTY 711).

Spanish – ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-668-3813 (TTY 711).

Chinese – 1-800-668-3813 (TTY 711)

Vietnamese – CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-668-3813 (TTY 711).

French Creole – ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-668-3813 (TTY 711).

Korean – 1-800-668-3813 (TTY 711)

Polish – UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-668-3813 (TTY 711).

French – ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-668-3813 (ATS 711).

Arabic – 1-800-668-3813 اتصل برقم. ، فإن خدمات المساعدة اللغویة تتوافر لك بالمجاناللغة العربیةإذا كنت تتحدث : ملحوظة )TTY 711.(

Russian – ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-668-3813 (телетайп 711).

Tagalog – PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-668-3813 (TTY 711).

Farsi/Persian – . توجھ: اگر بھ زبان فارسی گفتگو می کنید، تسھیالت زبانی بصورت رایگان برای شما فراھم می باشد . تماس بگیرید (711 :TTY) 1-800-668-3813 با

German – ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-668-3813 (TTY 711).

Portuguese – ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-668-3813 (TTY 711).

Italian – ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-668-3813 (TTY 711).

Japanese – 1-800-668-3813 (TTY 711)

Navajo – D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1-800-668-3813 (TTY 711).

Gujarati – �યાન આપો: જો તમે �જુરાતી બોલતા હો તો િન:��ુક ભાષા સહાય સેવાઓ તમારા માટ� �પલ�� છે. ફોન કરો 1-800-668-3813 (TTY 711).

Urdu توجہ دیں: اگرآپ اردو زبان بولتے ہیں تو آپ کےلئے زبان معاون خدمات مفت میں دستیاب ہیں۔ کال کریں 1-800-668-3813 (TTY 711)

This drug list was updated in May 2020. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-668-3813 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m. local time, or visit www.CignaMedicare.com. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc.© 2019 Cigna 929079 e

CignaMedicare.com

1-800-668-3813 (TTY 711) October 1 – March 31, 8:00 a.m. – 8:00 p.m. local time, 7 days a week. From April 1 – September 30, Monday – Friday, 8:00 a.m. – 8:00 p.m. local time. Messaging service used weekends, after hours, and on federal holidays.

2020 cigna comprehensive drug list (formulary)€¦ · for your drug in the covered drugs index...

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