2020 formulary - blue cross blue shield of ri · i you must generally use network pharmacies to use...

H4152_2020formulary_C

2020 Formulary ( List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

This formulary was updated on . For more recent information or other questions, please contact the Medicare Concierge Team, at (401) 277-2958 or 1-800-267-0439 (TTY users should call 711) from October 1 - March 31, seven days a week, 8:00 a.m. to 8:00 p.m. April 1 - September 30, Monday through Friday, 8:00 a.m. to 8:00 p.m.; Saturday & Sunday, 8:00 a.m. to noon. You can use our automated answering system outside of these hours.

This information is available for free in other languages. Please call the Medicare Concierge Team for more information.

This information is also available in large print English and large print Spanish.

Esta información está disponible gratis en otros idiomas. Si desea obtener información adicional, llame a Equipo de Consejería de Medicare al (401) 277-2958 o 1-800-267-0439 (los usuarios de TTY deben llamar al 711), los siete días de la semana del 1 de octubre al 31 de marzo, de 8:00 a. m. a 8:00 p. m. Del 1 de abril al 30 de septiembre, puede llamar de lunes a viernes de 8:00 a. m. a 8:00 p. m., y los sábados y domingos, de 8:00 a. m. hasta el mediodía. Fuera de estos horarios, puede utilizar el sistema automatizado de respuesta, o visite bcbsri.com/medicare. El Servicio al cliente también tiene servicios de intérprete de idiomas gratis disponibles para las personas que no hablan inglés.

Note to existing members: This formulary (drug list) has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this formulary refers to “we,” “us,” or “our,” it means Blue Cross & Blue Shield of Rhode Island. When it refers to “plan” or “our plan,” it means BlueCHiP for Medicare or HealthMate for Medicare.

This document includes a list of the drugs covered by our plan and is current as of . For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages

BlueCHiP for Medicare Advance (HMO)BlueCHiP for Medicare Value (HMO-POS)BlueCHiP for Medicare Standard with Drugs (HMO)BlueCHiP for Medicare Extra (HMO-POS)BlueCHiP for Medicare Plus (HMO)BlueCHiP for Medicare Preferred (HMO-POS)HealthMate for Medicare (PPO)

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You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copays/coinsurance may change on January 1, 2020, and from time to time during the year.

What is the BlueCHiP for Medicare or HealthMate for Medicare Formulary?A formulary is a list of covered drugs selected by BlueCHiP for Medicare or HealthMate for Medicare in consultation with a team of healthcare providers, which represent the prescription therapies believed to be a necessary part of a quality treatment program. BlueCHiP for Medicare or HealthMate for Medicare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a BlueCHiP for Medicare or HealthMate for Medicare 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 formulary (drug list) 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 the steps you may take to request an exception, and you can also find information in the section below titled “How do I request an exception to the BlueCHiP for Medicare or HealthMate for Medicare Formulary?”

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

• Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. We may also make changes based on new clinical guidelines. If we remove drugs from our formulary, or 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 members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member 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 BlueCHiP for Medicare or HealthMate for Medicare Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 formulary 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

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remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year.

The enclosed formulary is current as of . To get updated information about the drugs covered by BlueCHiP for Medicare or HealthMate for Medicare, please contact us. Our contact information appears on the front and back cover pages. You can find the most up-to-date BlueCHiP for Medicare and HealthMate for Medicare formularies on bcbsri.com/medicare. Posted formularies are updated on a monthly basis and in the event of a mid-year non-maintenance formulary change. You can also contact our Medicare Concierge Team with questions or to receive a printed version of the document.

How do I use the formulary?There are two ways to find your drug within the formulary:

Medical conditionThe formulary begins on page 1. The drugs in this formulary 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 Agents.” If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Alphabetical listingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page . The Index provides an alphabetical list of all of the drugs included in this formulary. 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 Index and find the name of your drug in the first column of the list.

What are generic drugs? BlueCHiP for Medicare or HealthMate for Medicare 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: BlueCHiP for Medicare or HealthMate for Medicare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from BlueCHiP for Medicare or HealthMate for Medicare before you fill your prescriptions. If you don’t get approval, BlueCHiP for Medicare or HealthMate for Medicare may not cover the drug.

• Quantity limits: For certain drugs, BlueCHiP for Medicare or HealthMate for Medicare limits the amount of the drug that BlueCHiP for Medicare or HealthMate for Medicare will cover. For example, BlueCHiP for Medicare or HealthMate for Medicare provides 30 per prescription for alfuzosin. This may be in addition to a standard one-month or three-month supply.

• Step therapy: In some cases, BlueCHiP for Medicare or HealthMate for Medicare 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, BlueCHiP for Medicare or HealthMate for Medicare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, BlueCHiP for Medicare will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs on bcbsri.com/medicare. 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 formulary, appears on the front and back cover pages.

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You can ask BlueCHiP for Medicare or HealthMate for Medicare 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 BlueCHiP for Medicare or HealthMate for Medicare formulary?” on page for information about how to request an exception.

What if my drug is not on the formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact the Medicare Concierge Team and ask if your drug is covered. If you learn that BlueCHiP for Medicare or HealthMate for Medicare does not cover your drug, you have two options:• You can ask the Medicare Concierge Team for a

list of similar drugs that are covered by BlueCHiP for Medicare or HealthMate for Medicare. When you receive the list, show it to your doctor and ask them to prescribe a similar drug that is covered by BlueCHiP for Medicare or HealthMate for Medicare.

• You can ask BlueCHiP for Medicare or HealthMate for Medicare to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the BlueCHiP for Medicare or HealthMate for Medicare Formulary?You can ask BlueCHiP for Medicare or HealthMate for Medicare 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 formulary. 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 cover a formulary drug at a lower cost-sharing level. (If this drug is not on the specialty tier.) If approved this would lower the amount you must pay for your drug.)

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

Medicare 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.

Generally, BlueCHiP for Medicare or HealthMate for Medicare will only approve your request for an exception if the alternative drugs included on the plan’s formulary, 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 formulary or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician 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 continuing member in our plan you may be taking drugs that are not on our formulary. Or you may be taking a drug that is on our formulary 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 formulary 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 in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary 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

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will not pay for these drugs, even if you have been a member 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 formulary 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 formulary exception.

You may have changes that take you from one treatment setting to another. During this level of care change, drugs may be prescribed that are not covered by your plan. If this happens, you and your doctor must use your plan’s exception and appeals processes. However, when you are admitted to, or discharged from, a long-term care setting, you may not have access to the drugs you were previously given. You may get a refill upon admission or discharge to prevent a gap in care.

For more informationFor more detailed information about your BlueCHiP for Medicare or HealthMate for Medicare prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about BlueCHiP for Medicare or HealthMate for Medicare, please contact us. Our

contact information, along with the date we last updated the formulary, 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 medicare.gov.

BlueCHiP for Medicare or HealthMate for Medicare’s FormularyThe formulary that begins on the next page provides coverage information about the drugs covered by BlueCHiP for Medicare or HealthMate for Medicare. If you have trouble finding your drug in the list, turn to the Index that begins on page .

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., JANUVIA) and generic drugs are listed in lower-case italics (e.g., lidocaine).

The information in the Requirements/Limits column tells you if BlueCHiP for Medicare or HealthMate for Medicare has any special requirements for coverage of your drug.

All drugs included in this formulary are available via mail order benefit. Contact your plan for details.

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BlueCHiP for Medicare or HealthMate for Medicare 5-Tier Formulary1 = Preferred generic drugs

2 = Generic drugs

3 = Preferred brand drugs

4 = Non-preferred brand drugs

5 = Specialty drugs

BD = Drugs that may be covered under Medicare Part B or Part D depending on the circumstance. These

drugs require prior authorization to determine coverage under Part B or Part D. Information may need to be provided that describes the use or the place where the drug is received to determine coverage.

PA = Prior authorization, refer to page II for more information.

QL = Quantity limits, refer to page II for more information.

ST = Step therapy, refer to page II for more information.

* = Limited distribution drug. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or contact the Medicare Concierge Team (contact information is located on the front or back cover).

# = High-risk medication (HRM). Medicine that may be unsafe in patients greater than 65 years of age. Our formulary does include coverage for some of these drugs, but alternatives may be found in lower copay tiers. Please discuss with your doctor if there are alternatives to these medications that would be appropriate for you to use.

^ = BlueCHiP for Medicare or HealthMate for Medicare Preferred provides additional coverage of these drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.

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2020 Dosage Form Abbreviations Key

act actuation mcg microgram

ad adsorbed meq milliequivalent

aer, aero aerosol misc miscellaneous

ba, breath act, breath activ breath activated mg milligram

bau bioequivalent allergy units ml milliliter

cal calcium mu million units

cap capsules nebu nebules

cd continuous delivery NF non-formulary

chew tab chewable tablets odt orally disintegrating tablets

conc concentrate oin, oint ointment

conj conjugate op, ophth ophthalmic

cr controlled-release pah pulmonary arterial hypertension

crys crystals pak pack

disint, disintegr disintegrating pow, powd powder

dr delayed-release pf preservative-free

deter deterrent pfu plaque forming units

ec enteric coated pmdd premenstrual dysphoric disorder

el, elu enzyme-linked immunosorbent assay pref prefilled

er, extend-release, extended, extended rel, xr extended-release recomb recombinant

ext extract sl sublingual

g, gm gram sol, soln solution

gu genitourinary suppos suppositories

hr hour sus, susp suspension

ig immune globulinsr sustained-release

ir index of reactivity

inh, inhal inhalation syr syringe

inj injection tab, tabs tablets

im intramuscular td transdermal

iv intravenous tl translingual

l liter unt unit

lf flocculation units va vaginal

liqd liquidvac vaccine

la long acting

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You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

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Drug Name Drug Tier Requirements/LimitsAnalgesicsABSTRAL - fentanyl citrate sl tab 100 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 200 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 300 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 400 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 600 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 800 mcg 5 PA, QL (120 tablets/30 days)acetaminophen w/ codeine soln 120-12 mg/5ml 3 QL (2700 mls/30 days)acetaminophen w/ codeine tab 300-15 mg 3 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-30 mg 3 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-60 mg 3 QL (180 tablets/30 days)butalbital-acetaminophen tab 50-325 mg# 3 QL (180 tablets/30 days)butalbital-acetaminophen-caffeine cap 50-300-40 mg# 3 QL (180 capsules/30 days)butalbital-acetaminophen-caffeine cap 50-325-40 mg# 3 QL (180 capsules/30 days)butalbital-acetaminophen-caffeine tab 50-325-40 mg# 3 QL (180 tablets/30 days)butalbital-aspirin-caffeine cap 50-325-40 mg# 3 QL (180 capsules/30 days)BUTORPHANOL TARTRATE - butorphanol tartrate inj 1 mg/ml 3butorphanol tartrate inj 2 mg/ml 3butorphanol tartrate nasal soln 10 mg/ml 3 QL (87.5 mls/30 days)celecoxib cap 50 mg^ 2 QL (60 capsules/30 days)celecoxib cap 100 mg^ 2 QL (60 capsules/30 days)celecoxib cap 200 mg^ 2 QL (60 capsules/30 days)celecoxib cap 400 mg^ 2 QL (30 capsules/30 days)codeine sulfate tab 60 mg 3 QL (180 tablets/30 days)codeine sulfate tab 30 mg 3 QL (180 tablets/30 days)diclofenac potassium tab 50 mg^ 2 QL (120 tablets/30 days)diclofenac sodium gel 1%^ 2 PAdiclofenac sodium tab delayed release 25 mg^ 2 QL (240 tablets/30 days)diclofenac sodium tab delayed release 50 mg^ 2 QL (120 tablets/30 days)diclofenac sodium tab delayed release 75 mg^ 2 QL (60 tablets/30 days)diclofenac sodium tab er 24hr 100 mg^ 2 QL (60 tablets/30 days)diclofenac w/ misoprostol tab delayed release 50-0.2 mg^ 2 QL (120 tablets/30 days)diclofenac w/ misoprostol tab delayed release 75-0.2 mg^ 2 QL (90 tablets/30 days)EC-NAPROXEN - naproxen tab ec 375 mg^ 2 QL (120 tablets/30 days)EC-NAPROXEN - naproxen tab ec 500 mg^ 2 QL (90 tablets/30 days)etodolac cap 200 mg^ 2 QL (150 capsules/30 days)etodolac cap 300 mg^ 2 QL (90 capsules/30 days)etodolac tab er 24hr 400 mg^ 2 QL (60 tablets/30 days)

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Drug Name Drug Tier Requirements/Limitsetodolac tab er 24hr 500 mg^ 2 QL (60 tablets/30 days)etodolac tab er 24hr 600 mg^ 2 QL (30 tablets/30 days)etodolac tab 400 mg^ 2 QL (60 tablets/30 days)etodolac tab 500 mg^ 2 QL (60 tablets/30 days)fentanyl citrate lozenge on a handle 200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 400 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 800 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl td patch 72hr 12 mcg/hr 3 PA, QL (15 patches/30 days)fentanyl td patch 72hr 25 mcg/hr 3 PA, QL (15 patches/30 days)fentanyl td patch 72hr 37.5 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 50 mcg/hr 3 PA, QL (15 patches/30 days)fentanyl td patch 72hr 62.5 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 75 mcg/hr 3 PA, QL (15 patches/30 days)fentanyl td patch 72hr 87.5 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 100 mcg/hr 3 PA, QL (15 patches/30 days)flurbiprofen tab 50 mg^ 2 QL (180 tablets/30 days)flurbiprofen tab 100 mg^ 2 QL (90 tablets/30 days)hydrocodone-acetaminophen soln 7.5-325 mg/15ml 3 QL (3600 mls/30 days)hydrocodone-acetaminophen tab 10-325 mg 3 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-325 mg 3 QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-325 mg 3 QL (180 tablets/30 days)hydrocodone-ibuprofen tab 5-200 mg 3 QL (150 tablets/30 days)hydrocodone-ibuprofen tab 7.5-200 mg 3 QL (150 tablets/30 days)hydrocodone-ibuprofen tab 10-200 mg 4 QL (150 tablets/30 days)hydromorphone hcl inj 2 mg/ml 3 BDhydromorphone hcl liqd 1 mg/ml 3 QL (1440 mls/30 days)hydromorphone hcl preservative free inj 2 mg/ml 3 BDhydromorphone hcl preservative free inj 10 mg/ml 3 BDhydromorphone hcl tab 2 mg 3 QL (180 tablets/30 days)hydromorphone hcl tab 4 mg 3 QL (180 tablets/30 days)hydromorphone hcl tab 8 mg 3 QL (180 tablets/30 days)ibuprofen susp 100 mg/5ml^ 2ibuprofen tab 400 mg^ 1 QL (240 tablets/30 days)ibuprofen tab 600 mg^ 1 QL (150 tablets/30 days)ibuprofen tab 800 mg^ 1 QL (120 tablets/30 days)

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Drug Name Drug Tier Requirements/LimitsLAZANDA - fentanyl citrate nasal spray 100 mcg/act 5 PA, QL (30 bottles/30 days)LAZANDA - fentanyl citrate nasal spray 300 mcg/act 5 PA, QL (30 bottles/30 days)LAZANDA - fentanyl citrate nasal spray 400 mcg/act 5 PA, QL (30 bottles/30 days)LEVORPHANOL TARTRATE - levorphanol tartrate tab 3 mg 5 QL (120 tablets/30 days)levorphanol tartrate tab 2 mg 5 QL (120 tablets/30 days)meloxicam tab 7.5 mg^ 1 QL (60 tablets/30 days)meloxicam tab 15 mg^ 1 QL (30 tablets/30 days)methadone hcl tab 5 mg 3 QL (180 tablets/30 days)methadone hcl tab 10 mg 3 QL (360 tablets/30 days)morphine sulfate inj pf 0.5 mg/ml 3 BDmorphine sulfate inj pf 1 mg/ml 3 BDmorphine sulfate oral soln 10 mg/5ml 3 QL (2700 mls/30 days)morphine sulfate oral soln 20 mg/5ml 3 QL (1350 mls/30 days)morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 3 QL (270 mls/30 days)morphine sulfate tab er 15 mg 3 PA, QL (90 tablets/30 days)morphine sulfate tab er 30 mg 3 PA, QL (90 tablets/30 days)morphine sulfate tab er 60 mg 3 PA, QL (90 tablets/30 days)morphine sulfate tab er 100 mg 3 PA, QL (90 tablets/30 days)morphine sulfate tab er 200 mg 3 PA, QL (90 tablets/30 days)morphine sulfate tab 15 mg 3 QL (240 tablets/30 days)morphine sulfate tab 30 mg 3 QL (180 tablets/30 days)nabumetone tab 500 mg^ 2 QL (120 tablets/30 days)nabumetone tab 750 mg^ 2 QL (60 tablets/30 days)naproxen sodium tab 275 mg^ 2 QL (150 tablets/30 days)naproxen sodium tab 550 mg^ 2 QL (90 tablets/30 days)naproxen susp 125 mg/5ml 3 QL (1800 mls/30 days)naproxen tab ec 375 mg^ 2 QL (120 tablets/30 days)naproxen tab ec 500 mg^ 2 QL (90 tablets/30 days)naproxen tab 250 mg^ 1 QL (180 tablets/30 days)naproxen tab 375 mg^ 1 QL (120 tablets/30 days)naproxen tab 500 mg^ 1 QL (90 tablets/30 days)oxaprozin tab 600 mg^ 2 QL (90 tablets/30 days)OXYCODONE HCL ER - oxycodone hcl tab er 12hr deter 10 mg 3 PA, QL (60 tablets/30 days)OXYCODONE HCL ER - oxycodone hcl tab er 12hr deter 15 mg 3 PA, QL (60 tablets/30 days)OXYCODONE HCL ER - oxycodone hcl tab er 12hr deter 20 mg 3 PA, QL (60 tablets/30 days)OXYCODONE HCL ER - oxycodone hcl tab er 12hr deter 30 mg 3 PA, QL (60 tablets/30 days)OXYCODONE HCL ER - oxycodone hcl tab er 12hr deter 40 mg 3 PA, QL (60 tablets/30 days)OXYCODONE HCL ER - oxycodone hcl tab er 12hr deter 60 mg 3 PA, QL (120 tablets/30 days)

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Drug Name Drug Tier Requirements/LimitsOXYCODONE HCL ER - oxycodone hcl tab er 12hr deter 80 mg 3 PA, QL (120 tablets/30 days)oxycodone hcl tab 5 mg 3 QL (360 tablets/30 days)oxycodone hcl tab 10 mg 3 QL (180 tablets/30 days)oxycodone hcl tab 15 mg 3 QL (180 tablets/30 days)oxycodone hcl tab 20 mg 3 QL (180 tablets/30 days)oxycodone hcl tab 30 mg 3 QL (180 tablets/30 days)oxycodone w/ acetaminophen tab 2.5-325 mg 3 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 5-325 mg 3 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 7.5-325 mg 3 QL (240 tablets/30 days)oxycodone w/ acetaminophen tab 10-325 mg 3 QL (180 tablets/30 days)oxycodone-aspirin tab 4.8355-325 mg 3 QL (360 tablets/30 days)piroxicam cap 10 mg^ 2 QL (60 capsules/30 days)piroxicam cap 20 mg^ 2 QL (30 capsules/30 days)sulindac tab 150 mg^ 2 QL (60 tablets/30 days)sulindac tab 200 mg^ 2 QL (60 tablets/30 days)TENCON - butalbital-acetaminophen tab 50-325 mg# 3 QL (180 tablets/30 days)TOLMETIN SODIUM - tolmetin sodium cap 400 mg 3 QL (120 capsules/30 days)tramadol hcl tab er 24hr 100 mg 3 PA, QL (30 tablets/30 days)tramadol hcl tab er 24hr 200 mg 3 PA, QL (30 tablets/30 days)tramadol hcl tab er 24hr 300 mg 3 PA, QL (30 tablets/30 days)tramadol hcl tab 50 mg 3 QL (240 tablets/30 days)tramadol-acetaminophen tab 37.5-325 mg 3 QL (240 tablets/30 days)XTAMPZA ER - oxycodone cap er 12hr abuse-deterrent 9 mg 3 PA, QL (60 capsules/30 days)XTAMPZA ER - oxycodone cap er 12hr abuse-deterrent 13.5 mg 3 PA, QL (60 capsules/30 days)XTAMPZA ER - oxycodone cap er 12hr abuse-deterrent 18 mg 3 PA, QL (60 capsules/30 days)XTAMPZA ER - oxycodone cap er 12hr abuse-deterrent 27 mg 3 PA, QL (60 capsules/30 days)XTAMPZA ER - oxycodone cap er 12hr abuse-deterrent 36 mg 3 PA, QL (60 capsules/30 days)AnestheticsLIDOCAINE HCL - lidocaine hcl laryngotracheal soln 4%^ 2lidocaine hcl local inj 1% 3lidocaine hcl local preservative free inj 1% 3lidocaine hcl soln 4%^ 2 PA, QL (150 mls/30 days)lidocaine hcl urethral/mucosal gel prefilled syringe 2%^ 2 PA, QL (150 mls/30 days)lidocaine hcl urethral/mucosal gel 2%^ 2 PA, QL (150 mls/30 days)lidocaine hcl viscous soln 2%^ 2lidocaine oint 5% 3 PA, QL (100 grams/30 days)lidocaine patch 5% 3 PA, QL (90 patches/30 days)lidocaine-prilocaine cream 2.5-2.5% 3 PA, QL (60 grams/30 days)

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Drug Name Drug Tier Requirements/LimitsAnti-Addiction/Substance Abuse Treatment Agentsacamprosate calcium tab delayed release 333 mg^ 2buprenorphine hcl sl tab 2 mg^ 2 QL (90 tablets/30 days)buprenorphine hcl sl tab 8 mg^ 2 QL (90 tablets/30 days)buprenorphine hcl-naloxone hcl sl film 2-0.5 mg^ 2 QL (120 films/30 days)buprenorphine hcl-naloxone hcl sl film 4-1 mg^ 2 QL (30 films/30 days)buprenorphine hcl-naloxone hcl sl film 8-2 mg^ 2 QL (60 films/30 days)buprenorphine hcl-naloxone hcl sl film 12-3 mg^ 2 QL (60 films/30 days)buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg^ 2 QL (120 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 8-2 mg^ 2 QL (90 tablets/30 days)bupropion hcl (smoking deterrent) tab er 12hr 150 mg^ 2CHANTIX - varenicline tartrate tab 0.5 mg 3CHANTIX - varenicline tartrate tab 1 mg 3CHANTIX CONTINUING MONTH PACK - varenicline tartrate tab

1 mg3

CHANTIX STARTING MONTH PACK - varenicline tartrate tab0.5 mg x 11 & tab 1 mg x 42 pack

3

disulfiram tab 250 mg^ 2disulfiram tab 500 mg^ 2NALOXONE HCL - naloxone hcl soln cartridge 0.4 mg/ml^ 2NALOXONE HCL - naloxone hcl soln prefilled syringe 2 mg/2ml^ 2naloxone hcl inj 0.4 mg/ml^ 2naloxone hcl inj 4 mg/10ml^ 2naltrexone hcl tab 50 mg^ 2NARCAN - naloxone hcl nasal spray 4 mg/0.1ml 3NICOTROL INHALER - nicotine inhaler system 10 mg (4 mg

delivered)4

NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/spray) 4SUBLOCADE - buprenorphine extended release soln pref syr

100 mg/0.5ml5

SUBLOCADE - buprenorphine extended release soln pref syr300 mg/1.5ml

5

VIVITROL - naltrexone for im extended release susp 380 mg 5Antibacterialsamikacin sulfate inj 500 mg/2ml (250 mg/ml) 3amikacin sulfate inj 1 gm/4ml (250 mg/ml) 3amoxicillin (trihydrate) cap 250 mg^ 1amoxicillin (trihydrate) cap 500 mg^ 1amoxicillin (trihydrate) for susp 125 mg/5ml^ 1amoxicillin (trihydrate) for susp 200 mg/5ml^ 2

2020


Drug Name Drug Tier Requirements/Limitsamoxicillin (trihydrate) for susp 250 mg/5ml^ 2amoxicillin (trihydrate) for susp 400 mg/5ml^ 2amoxicillin (trihydrate) tab 500 mg^ 1amoxicillin (trihydrate) tab 875 mg^ 1amoxicillin & k clavulanate for susp 200-28.5 mg/5ml^ 2amoxicillin & k clavulanate for susp 400-57 mg/5ml^ 2amoxicillin & k clavulanate for susp 600-42.9 mg/5ml^ 2amoxicillin & k clavulanate tab 250-125 mg^ 2amoxicillin & k clavulanate tab 500-125 mg^ 2amoxicillin & k clavulanate tab 875-125 mg^ 2AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin & k

clavulanate chew tab 200-28.5 mg3

AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin & kclavulanate chew tab 400-57 mg

3

AMPICILLIN - ampicillin cap 500 mg^ 2ampicillin & sulbactam sodium for inj 3 (2-1) gm 3AMPICILLIN SODIUM - ampicillin sodium for iv soln 1 gm 3ampicillin sodium for inj 250 mg 3ampicillin sodium for inj 500 mg 3ampicillin sodium for inj 1 gm 3ampicillin sodium for inj 2 gm 3ampicillin sodium for iv soln 2 gm 3ampicillin sodium for iv soln 10 gm 3AMPICILLIN-SULBACTAM - ampicillin & sulbactam sodium for iv

soln 3 (2-1) gm3

AZITHROMYCIN - azithromycin powd pack for susp 1 gm 3azithromycin for susp 100 mg/5ml^ 2azithromycin for susp 200 mg/5ml^ 2azithromycin iv for soln 500 mg 3azithromycin tab 250 mg^ 2azithromycin tab 500 mg^ 2azithromycin tab 600 mg^ 2aztreonam for inj 1 gm 3aztreonam for inj 2 gm 3BICILLIN L-A - penicillin g benzathine intramuscular susp 600000

unit/ml4

BICILLIN L-A - penicillin g benzathine intramuscular susp 1200000unit/2ml

4

BICILLIN L-A - penicillin g benzathine intramuscular susp 2400000unit/4ml

4

2020


7

Drug Name Drug Tier Requirements/Limitscefaclor cap 250 mg^ 2cefaclor cap 500 mg^ 2cefadroxil cap 500 mg^ 2cefadroxil for susp 250 mg/5ml^ 2cefadroxil for susp 500 mg/5ml^ 2cefadroxil tab 1 gm^ 2CEFAZOLIN SODIUM - cefazolin sodium for iv soln 1 gm 3CEFAZOLIN SODIUM - cefazolin sodium-dextrose iv solution

1 gm/50ml-4%3

cefazolin sodium for inj 500 mg 3cefazolin sodium for inj 1 gm 3cefazolin sodium for inj 10 gm 3CEFAZOLIN SODIUM/DEXTROSE - cefazolin sodium for iv soln

1 gm and dextrose 4% (50 ml)3

cefdinir cap 300 mg^ 2cefdinir for susp 125 mg/5ml^ 2cefdinir for susp 250 mg/5ml^ 2CEFEPIME - cefepime hcl iv soln 1 gm/50ml 3CEFEPIME - cefepime hcl iv soln 2 gm/100ml 3cefepime hcl for inj 1 gm 3cefepime hcl for inj 2 gm 3CEFEPIME/DEXTROSE - cefepime hcl for iv soln 1 gm and

dextrose 5% (50 ml)3

CEFEPIME/DEXTROSE - cefepime hcl for iv soln 2 gm anddextrose 5% (50 ml)

3

cefixime cap 400 mg^ 2CEFOTAXIME SODIUM - cefotaxime sodium for inj 500 mg 3cefotaxime sodium for inj 1 gm 3CEFOXITIN SODIUM - cefoxitin sodium iv for soln 1 gm and

dextrose 4% (50 ml)3

CEFOXITIN SODIUM - cefoxitin sodium iv for soln 2 gm anddextrose 2.2% (50 ml)

3

cefoxitin sodium for inj 10 gm 3cefoxitin sodium for iv soln 1 gm 3cefoxitin sodium for iv soln 2 gm 3cefpodoxime proxetil for susp 50 mg/5ml^ 2cefpodoxime proxetil for susp 100 mg/5ml^ 2cefpodoxime proxetil tab 100 mg^ 2cefpodoxime proxetil tab 200 mg^ 2cefprozil for susp 125 mg/5ml^ 2

2020


Drug Name Drug Tier Requirements/Limitscefprozil for susp 250 mg/5ml^ 2cefprozil tab 250 mg^ 2cefprozil tab 500 mg^ 2ceftazidime for inj 1 gm 3ceftazidime for inj 2 gm 3ceftazidime for inj 6 gm 3CEFTAZIDIME/DEXTROSE - ceftazidime for iv soln 1 gm and

dextrose 5% (50ml)3

CEFTAZIDIME/DEXTROSE - ceftazidime for iv soln 2 gm anddextrose 5% (50ml)

3

CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE - ceftriaxonesodium in dextrose inj 20 mg/ml

3

CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE - ceftriaxonesodium in dextrose inj 40 mg/ml

3

CEFTRIAXONE SODIUM - ceftriaxone sodium (bulk) for inj 100 gm 3ceftriaxone sodium for inj 250 mg 3ceftriaxone sodium for inj 500 mg 3ceftriaxone sodium for inj 1 gm 3ceftriaxone sodium for inj 2 gm 3ceftriaxone sodium for inj 10 gm 3ceftriaxone sodium for iv soln 1 gm 3ceftriaxone sodium for iv soln 2 gm 3CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 1 gm

and dextrose 3.74% 50 ml3

CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 2 gmand dextrose 2.22% 50 ml

3

cefuroxime axetil tab 250 mg^ 2cefuroxime axetil tab 500 mg^ 2cefuroxime sodium for inj 750 mg 3cefuroxime sodium for inj 7.5 gm 3cefuroxime sodium for iv soln 1.5 gm 3cephalexin cap 250 mg^ 1cephalexin cap 500 mg^ 1cephalexin cap 750 mg^ 2cephalexin for susp 125 mg/5ml^ 2cephalexin for susp 250 mg/5ml^ 2CHLORAMPHENICOL SODIUM SUCCINATE - chloramphenicol

sodium succinate for iv inj 1 gm3

ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) 3CIPROFLOXACIN HCL - ciprofloxacin hcl tab 100 mg 3

2020


9

Drug Name Drug Tier Requirements/Limitsciprofloxacin hcl tab 250 mg^ 1ciprofloxacin hcl tab 500 mg^ 1ciprofloxacin hcl tab 750 mg^ 2ciprofloxacin 200 mg/100ml in d5w 3ciprofloxacin 400 mg/200ml in d5w 3CLARITHROMYCIN - clarithromycin for susp 125 mg/5ml^ 2CLARITHROMYCIN - clarithromycin for susp 250 mg/5ml 3clarithromycin tab er 24hr 500 mg^ 2clarithromycin tab 250 mg^ 2clarithromycin tab 500 mg^ 2clindamycin hcl cap 75 mg^ 2clindamycin hcl cap 150 mg^ 1clindamycin hcl cap 300 mg^ 2clindamycin phosphate gel 1%^ 2clindamycin phosphate in d5w iv soln 300 mg/50ml 3clindamycin phosphate in d5w iv soln 600 mg/50ml 3clindamycin phosphate in d5w iv soln 900 mg/50ml 3clindamycin phosphate inj 300 mg/2ml 3clindamycin phosphate inj 600 mg/4ml 3clindamycin phosphate inj 900 mg/6ml 3clindamycin phosphate inj 9 gm/60ml 3clindamycin phosphate iv soln 300 mg/2ml 3clindamycin phosphate iv soln 600 mg/4ml 3clindamycin phosphate iv soln 900 mg/6ml 3clindamycin phosphate lotion 1%^ 2clindamycin phosphate soln 1%^ 2clindamycin phosphate swab 1%^ 2clindamycin phosphate vaginal cream 2%^ 2CLINDAMYCIN/SODIUM CHLORIDE - clindamycin phosphate in

nacl 0.9% iv soln 300 mg/50ml3

CLINDAMYCIN/SODIUM CHLORIDE - clindamycin phosphate innacl 0.9% iv soln 600 mg/50ml

3

CLINDAMYCIN/SODIUM CHLORIDE - clindamycin phosphate innacl 0.9% iv soln 900 mg/50ml

3

colistimethate sod for inj 150 mg 5DALVANCE - dalbavancin hcl for iv soln 500 mg 5daptomycin for iv soln 500 mg 5demeclocycline hcl tab 150 mg 3demeclocycline hcl tab 300 mg 3

2020


Drug Name Drug Tier Requirements/Limitsdicloxacillin sodium cap 250 mg^ 2dicloxacillin sodium cap 500 mg^ 2DIFICID - fidaxomicin tab 200 mg 5doxycycline hyclate cap 50 mg^ 2doxycycline hyclate cap 100 mg^ 2doxycycline hyclate for inj 100 mg 3doxycycline hyclate tab 20 mg^ 2doxycycline hyclate tab 100 mg^ 2doxycycline monohydrate cap 50 mg^ 2doxycycline monohydrate cap 75 mg 3doxycycline monohydrate cap 100 mg^ 2doxycycline monohydrate cap 150 mg 3doxycycline monohydrate tab 50 mg^ 2doxycycline monohydrate tab 75 mg^ 2doxycycline monohydrate tab 100 mg^ 2doxycycline monohydrate tab 150 mg^ 2ertapenem sodium for inj 1 gm 4ERYTHROCIN LACTOBIONATE - erythromycin lactobionate for inj

500 mg4

ERYTHROCIN STEARATE - erythromycin stearate tab 250 mg 4erythromycin ethylsuccinate for susp 200 mg/5ml 3erythromycin ethylsuccinate for susp 400 mg/5ml 3erythromycin pads 2%^ 2erythromycin soln 2%^ 2erythromycin tab delayed release 250 mg 4erythromycin tab delayed release 333 mg 4erythromycin tab delayed release 500 mg 4erythromycin tab 250 mg 3erythromycin tab 500 mg 3gentamicin in saline inj 1.2 mg/ml 3gentamicin sulfate inj 10 mg/ml 3gentamicin sulfate inj 40 mg/ml 3GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE - gentamicin in

saline inj 1 mg/ml3

GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE - gentamicin insaline inj 1.6 mg/ml

3

imipenem-cilastatin intravenous for soln 250 mg 3imipenem-cilastatin intravenous for soln 500 mg 3IMPAVIDO - miltefosine cap 50 mg 5

2020


11

Drug Name Drug Tier Requirements/LimitsISOTONIC GENTAMICIN - gentamicin in saline inj 0.8 mg/ml 3levofloxacin in d5w iv soln 250 mg/50ml 3levofloxacin in d5w iv soln 500 mg/100ml 3levofloxacin in d5w iv soln 750 mg/150ml 3levofloxacin iv soln 25 mg/ml 3levofloxacin oral soln 25 mg/ml^ 2levofloxacin tab 250 mg^ 1levofloxacin tab 500 mg^ 1levofloxacin tab 750 mg^ 1LINEZOLID - linezolid in sodium chloride iv soln

600 mg/300ml-0.9%4

linezolid for susp 100 mg/5ml 5 PAlinezolid iv soln 600 mg/300ml (2 mg/ml) 4linezolid tab 600 mg 3 PAmeropenem iv for soln 500 mg 3meropenem iv for soln 1 gm 3MEROPENEM/SODIUM CHLORIDE - meropenem & sodium

chloride 0.9% for iv soln 500 mg/50ml3

MEROPENEM/SODIUM CHLORIDE - meropenem & sodiumchloride 0.9% for iv soln 1 gm/50ml

3

methenamine hippurate tab 1 gm^ 2METRONIDAZOLE - metronidazole in nacl 0.74% iv soln

500 mg/100ml3

METRONIDAZOLE - metronidazole iv soln 5 mg/ml 3metronidazole cap 375 mg 3metronidazole in nacl 0.79% iv soln 500 mg/100ml 3metronidazole tab 250 mg^ 2metronidazole tab 500 mg^ 2metronidazole vaginal gel 0.75%^ 2minocycline hcl cap 50 mg^ 2minocycline hcl cap 75 mg^ 2minocycline hcl cap 100 mg^ 2minocycline hcl tab 50 mg^ 2minocycline hcl tab 75 mg 3minocycline hcl tab 100 mg^ 2MOXIFLOXACIN HCL - moxifloxacin hcl iv solution 400 mg/250ml 3moxifloxacin hcl tab 400 mg^ 2moxifloxacin hcl 400 mg/250ml in sodium chloride 0.8% inj 3NAFCILLIN - nafcillin sodium in dextrose inj 1 gm/50ml 3

2020


Drug Name Drug Tier Requirements/LimitsNAFCILLIN - nafcillin sodium in dextrose inj 2 gm/100ml 3NAFCILLIN SODIUM - nafcillin sodium for inj 10 gm 5NAFCILLIN SODIUM - nafcillin sodium for iv soln 1 gm 3NAFCILLIN SODIUM - nafcillin sodium for iv soln 2 gm 3nafcillin sodium for inj 1 gm 3nafcillin sodium for inj 2 gm 3nafcillin sodium for iv soln 10 gm 5neomycin sulfate tab 500 mg^ 2NEOMYCIN/POLYMYXIN B SULFATES - neomycin-polymyxin b gu

irrigation soln3

nitrofurantoin macrocrystalline cap 50 mg# 3nitrofurantoin macrocrystalline cap 100 mg# 3nitrofurantoin monohydrate macrocrystalline cap 100 mg# 3nitrofurantoin susp 25 mg/5ml# 3ofloxacin tab 400 mg^ 2paromomycin sulfate cap 250 mg 3penicillin g potassium for inj 5000000 unit 3penicillin g potassium for inj 20000000 unit 3PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g

potassium inj 20000 unit/ml in dextrose4

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 40000 unit/ml in dextrose

3

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 60000 unit/ml in dextrose

3

PENICILLIN G SODIUM - penicillin g sodium for inj 5000000 unit 3PENICILLIN V POTASSIUM - penicillin v potassium for soln

125 mg/5ml^2

PENICILLIN V POTASSIUM - penicillin v potassium for soln250 mg/5ml^

2

penicillin v potassium tab 250 mg^ 1penicillin v potassium tab 500 mg^ 2piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm) 3piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm) 3piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) 3SIVEXTRO - tedizolid phosphate for iv soln 200 mg 5SIVEXTRO - tedizolid phosphate tab 200 mg 5 PASTREPTOMYCIN SULFATE - streptomycin sulfate for inj 1 gm 3sulfacetamide sodium lotion 10%^ 2SULFADIAZINE - sulfadiazine tab 500 mg 3sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml 3

2020


13

Drug Name Drug Tier Requirements/Limitssulfamethoxazole-trimethoprim susp 200-40 mg/5ml^ 2sulfamethoxazole-trimethoprim tab 400-80 mg^ 1sulfamethoxazole-trimethoprim tab 800-160 mg^ 1SUPRAX - cefixime chew tab 100 mg 3SUPRAX - cefixime chew tab 200 mg 3SYNERCID - quinupristin-dalfopristin for inj 500 mg (150-350 mg) 5TAZICEF - ceftazidime for iv soln 1 gm 3TAZICEF - ceftazidime for iv soln 2 gm 3TEFLARO - ceftaroline fosamil for iv soln 400 mg 5TEFLARO - ceftaroline fosamil for iv soln 600 mg 5tetracycline hcl cap 250 mg 3tetracycline hcl cap 500 mg 3tigecycline for iv soln 50 mg 5TOBRAMYCIN SULFATE - tobramycin sulfate inj 10 mg/ml 3TOBRAMYCIN SULFATE - tobramycin sulfate inj 2 gm/50ml

(40 mg/ml)3

tobramycin sulfate for inj 1.2 gm 3tobramycin sulfate inj 80 mg/2ml (40 mg/ml) 3tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) 3trimethoprim tab 100 mg^ 2VANCOMYCIN HCL - vancomycin hcl for iv soln 100 gm 3vancomycin hcl cap 125 mg 3 QL (120 capsules/30 days)vancomycin hcl cap 250 mg 3 QL (240 capsules/30 days)vancomycin hcl for iv soln 500 mg 3vancomycin hcl for iv soln 750 mg 3vancomycin hcl for iv soln 1 gm 3vancomycin hcl for iv soln 5 gm 3vancomycin hcl for iv soln 10 gm 3VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl-dextrose iv

soln 500 mg/100ml-5%4

VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl-dextrose ivsoln 750 mg/150ml-5%

4

VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl-dextrose ivsoln 1 gm/200ml-5%

4

VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv soln250 mg

4

VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv soln1.25 gm

4

VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv soln1.5 gm

4

2020


Drug Name Drug Tier Requirements/LimitsZOSYN - piperacillin sod-tazobactam na for inj 3.375 gm

(3-0.375 gm)4

ZOSYN - piperacillin sod-tazobactam sod for inj 2.25 gm(2-0.25 gm)

4

ZOSYN - piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) 4ZOSYN - piperacillin sod-tazobactam sod in dex iv soln

2-0.25gm/50ml4

ZOSYN - piperacillin sod-tazobactam sod in dex iv soln4-0.5gm/100ml

4

ZOSYN - piperacillin sod-tazobactam sod in dex iv sol3-0.375gm/50ml

4

AnticonvulsantsAPTIOM - eslicarbazepine acetate tab 200 mg 5APTIOM - eslicarbazepine acetate tab 400 mg 5APTIOM - eslicarbazepine acetate tab 600 mg 5APTIOM - eslicarbazepine acetate tab 800 mg 5BANZEL - rufinamide susp 40 mg/ml 5BANZEL - rufinamide tab 200 mg 4BANZEL - rufinamide tab 400 mg 5BRIVIACT - brivaracetam iv soln 50 mg/5ml 4BRIVIACT - brivaracetam oral soln 10 mg/ml 5BRIVIACT - brivaracetam tab 10 mg 5BRIVIACT - brivaracetam tab 25 mg 5BRIVIACT - brivaracetam tab 50 mg 5BRIVIACT - brivaracetam tab 75 mg 5BRIVIACT - brivaracetam tab 100 mg 5carbamazepine cap er 12hr 100 mg^ 2carbamazepine cap er 12hr 200 mg^ 2carbamazepine cap er 12hr 300 mg^ 2carbamazepine chew tab 100 mg^ 2carbamazepine susp 100 mg/5ml^ 2carbamazepine tab er 12hr 100 mg^ 2carbamazepine tab er 12hr 200 mg^ 2carbamazepine tab er 12hr 400 mg 3carbamazepine tab 200 mg^ 2CELONTIN - methsuximide cap 300 mg 4clobazam suspension 2.5 mg/ml 4 PA, QL (480 mls/30 days)clobazam tab 10 mg^ 2 PA, QL (60 tablets/30 days)clobazam tab 20 mg^ 2 PA, QL (60 tablets/30 days)DIASTAT ACUDIAL - diazepam rectal gel delivery system 10 mg 4 QL (5 twin pack(s)/30 days)

2020


15

Drug Name Drug Tier Requirements/LimitsDIASTAT ACUDIAL - diazepam rectal gel delivery system 20 mg 4 QL (5 twin pack(s)/30 days)DIASTAT PEDIATRIC - diazepam rectal gel delivery system 2.5 mg 4 QL (5 twin pack(s)/30 days)DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system

2.5 mg4 QL (5 twin pack(s)/30 days)

DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system10 mg

4 QL (5 twin pack(s)/30 days)

DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system20 mg

4 QL (5 twin pack(s)/30 days)

DILANTIN - phenytoin sodium extended cap 30 mg 3divalproex sodium cap delayed release sprinkle 125 mg^ 2divalproex sodium tab delayed release 125 mg^ 2divalproex sodium tab delayed release 250 mg^ 2divalproex sodium tab delayed release 500 mg^ 2divalproex sodium tab er 24 hr 250 mg^ 2divalproex sodium tab er 24 hr 500 mg^ 2EPIDIOLEX - cannabidiol soln 100 mg/ml* 5 PAethosuximide cap 250 mg^ 2ethosuximide soln 250 mg/5ml^ 2felbamate susp 600 mg/5ml 5felbamate tab 400 mg 3felbamate tab 600 mg 4fosphenytoin sodium inj 100 mg/2ml 3fosphenytoin sodium inj 500 mg/10ml 3FYCOMPA - perampanel susp 0.5 mg/ml 5FYCOMPA - perampanel tab 2 mg 4FYCOMPA - perampanel tab 4 mg 5FYCOMPA - perampanel tab 6 mg 5FYCOMPA - perampanel tab 8 mg 5FYCOMPA - perampanel tab 10 mg 5FYCOMPA - perampanel tab 12 mg 5gabapentin cap 100 mg^ 2 QL (1080 capsules/30 days)gabapentin cap 300 mg^ 2 QL (360 capsules/30 days)gabapentin cap 400 mg^ 2 QL (270 capsules/30 days)gabapentin oral soln 250 mg/5ml^ 2 QL (2160 mls/30 days)gabapentin tab 600 mg^ 2 QL (180 tablets/30 days)gabapentin tab 800 mg^ 2 QL (135 tablets/30 days)lamotrigine tab chewable dispersible 5 mg^ 2lamotrigine tab chewable dispersible 25 mg^ 2lamotrigine tab 25 mg^ 2

2020


Drug Name Drug Tier Requirements/Limitslamotrigine tab 100 mg^ 1lamotrigine tab 150 mg^ 1lamotrigine tab 200 mg^ 1levetiracetam in sodium chloride iv soln 500 mg/100ml 3levetiracetam in sodium chloride iv soln 1000 mg/100ml 3levetiracetam in sodium chloride iv soln 1500 mg/100ml 3levetiracetam inj 500 mg/5ml (100 mg/ml) 3levetiracetam oral soln 100 mg/ml^ 2levetiracetam tab 250 mg^ 2levetiracetam tab 500 mg^ 2levetiracetam tab 750 mg^ 2levetiracetam tab 1000 mg^ 2oxcarbazepine susp 300 mg/5ml (60 mg/ml) 3oxcarbazepine tab 150 mg^ 2oxcarbazepine tab 300 mg^ 2oxcarbazepine tab 600 mg^ 2PEGANONE - ethotoin tab 250 mg 4phenobarbital elixir 20 mg/5ml# 4PHENOBARBITAL SODIUM - phenobarbital sodium inj 65 mg/ml# 4PHENOBARBITAL SODIUM - phenobarbital sodium inj 130 mg/ml# 4phenobarbital tab 15 mg# 4phenobarbital tab 16.2 mg# 4phenobarbital tab 30 mg# 4phenobarbital tab 32.4 mg# 4phenobarbital tab 60 mg# 4phenobarbital tab 64.8 mg# 4phenobarbital tab 97.2 mg# 4phenobarbital tab 100 mg# 4phenytoin chew tab 50 mg^ 2phenytoin sodium extended cap 100 mg^ 2phenytoin sodium extended cap 200 mg^ 2phenytoin sodium extended cap 300 mg^ 2phenytoin susp 125 mg/5ml^ 2pregabalin cap 25 mg 3 QL (90 capsules/30 days)pregabalin cap 50 mg 3 QL (90 capsules/30 days)pregabalin cap 75 mg 3 QL (90 capsules/30 days)pregabalin cap 100 mg 3 QL (90 capsules/30 days)pregabalin cap 150 mg 3 QL (90 capsules/30 days)

2020


17

Drug Name Drug Tier Requirements/Limitspregabalin cap 200 mg 3 QL (90 capsules/30 days)pregabalin cap 225 mg 3 QL (60 capsules/30 days)pregabalin cap 300 mg 3 QL (60 capsules/30 days)pregabalin soln 20 mg/ml 3 QL (900 mls/30 days)primidone tab 50 mg^ 2primidone tab 250 mg^ 2SPRITAM - levetiracetam tab disintegrating soluble 250 mg 4SPRITAM - levetiracetam tab disintegrating soluble 500 mg 4SPRITAM - levetiracetam tab disintegrating soluble 750 mg 4SPRITAM - levetiracetam tab disintegrating soluble 1000 mg 4SYMPAZAN - clobazam oral film 5 mg 5 PA, QL (240 films/30 days)SYMPAZAN - clobazam oral film 10 mg 5 PA, QL (60 films/30 days)SYMPAZAN - clobazam oral film 20 mg 5 PA, QL (60 films/30 days)tiagabine hcl tab 2 mg 3tiagabine hcl tab 4 mg 4tiagabine hcl tab 12 mg 4tiagabine hcl tab 16 mg 4topiramate sprinkle cap 15 mg^ 2topiramate sprinkle cap 25 mg^ 2topiramate tab 25 mg^ 1topiramate tab 50 mg^ 1topiramate tab 100 mg^ 2topiramate tab 200 mg^ 2valproate sodium inj 100 mg/ml 3valproate sodium oral soln 250 mg/5ml^ 2valproic acid cap 250 mg^ 2vigabatrin powd pack 500 mg* 5 QL (180 packets/30 days)vigabatrin tab 500 mg* 5 QL (180 tablets/30 days)VIMPAT - lacosamide iv inj 200 mg/20ml (10 mg/ml) 3VIMPAT - lacosamide oral solution 10 mg/ml 3VIMPAT - lacosamide tab 50 mg 3VIMPAT - lacosamide tab 100 mg 3VIMPAT - lacosamide tab 150 mg 3VIMPAT - lacosamide tab 200 mg 3zonisamide cap 25 mg^ 2zonisamide cap 50 mg^ 2zonisamide cap 100 mg^ 2

2020


Drug Name Drug Tier Requirements/LimitsAntidementia Agentsdonepezil hydrochloride orally disintegrating tab 5 mg^ 2donepezil hydrochloride orally disintegrating tab 10 mg^ 2donepezil hydrochloride tab 5 mg^ 1donepezil hydrochloride tab 10 mg^ 1donepezil hydrochloride tab 23 mg^ 2ERGOLOID MESYLATES - ergoloid mesylates tab 1 mg# 3GALANTAMINE HYDROBROMIDE - galantamine hydrobromide

oral soln 4 mg/ml3

galantamine hydrobromide cap er 24hr 8 mg^ 2galantamine hydrobromide cap er 24hr 16 mg^ 2galantamine hydrobromide cap er 24hr 24 mg^ 2galantamine hydrobromide tab 4 mg^ 2galantamine hydrobromide tab 8 mg^ 2galantamine hydrobromide tab 12 mg^ 2memantine hcl oral solution 2 mg/ml 4 PAmemantine hcl tab 5 mg^ 2 PAmemantine hcl tab 10 mg^ 2 PAmemantine hcl tab 5 mg (28) & 10 mg (21) titration pak^ 2 PArivastigmine tartrate cap 1.5 mg^ 2rivastigmine tartrate cap 3 mg^ 2rivastigmine tartrate cap 4.5 mg^ 2rivastigmine tartrate cap 6 mg^ 2rivastigmine td patch 24hr 4.6 mg/24hr 3rivastigmine td patch 24hr 9.5 mg/24hr 3rivastigmine td patch 24hr 13.3 mg/24hr 3Antidepressantsamitriptyline hcl tab 10 mg# 3amitriptyline hcl tab 25 mg# 3amitriptyline hcl tab 50 mg# 3amitriptyline hcl tab 75 mg# 3amitriptyline hcl tab 100 mg# 3amitriptyline hcl tab 150 mg# 3AMOXAPINE - amoxapine tab 25 mg# 3AMOXAPINE - amoxapine tab 50 mg# 3AMOXAPINE - amoxapine tab 100 mg# 3AMOXAPINE - amoxapine tab 150 mg# 3bupropion hcl tab er 12hr 100 mg^ 2 QL (90 tablets/30 days)bupropion hcl tab er 12hr 150 mg^ 2 QL (60 tablets/30 days)

2020


19

Drug Name Drug Tier Requirements/Limitsbupropion hcl tab er 12hr 200 mg^ 2 QL (60 tablets/30 days)bupropion hcl tab er 24hr 150 mg^ 2 QL (90 tablets/30 days)bupropion hcl tab er 24hr 300 mg^ 2 QL (30 tablets/30 days)bupropion hcl tab 75 mg^ 2 QL (60 tablets/30 days)bupropion hcl tab 100 mg^ 2 QL (120 tablets/30 days)citalopram hydrobromide oral soln 10 mg/5ml^ 2 QL (600 mls/30 days)citalopram hydrobromide tab 10 mg^ 1 QL (45 tablets/30 days)citalopram hydrobromide tab 20 mg^ 1 QL (45 tablets/30 days)citalopram hydrobromide tab 40 mg^ 1 QL (30 tablets/30 days)clomipramine hcl cap 25 mg# 4clomipramine hcl cap 50 mg# 4clomipramine hcl cap 75 mg# 4desipramine hcl tab 10 mg# 3desipramine hcl tab 25 mg# 3desipramine hcl tab 50 mg# 3desipramine hcl tab 75 mg# 3desipramine hcl tab 100 mg# 3desipramine hcl tab 150 mg# 3desvenlafaxine succinate tab er 24hr 25 mg^ 2 QL (30 tablets/30 days)desvenlafaxine succinate tab er 24hr 50 mg^ 2 QL (30 tablets/30 days)desvenlafaxine succinate tab er 24hr 100 mg^ 2 QL (30 tablets/30 days)DOXEPIN HCL - doxepin hcl cap 150 mg# 3doxepin hcl cap 10 mg# 3doxepin hcl cap 25 mg# 3doxepin hcl cap 50 mg# 3doxepin hcl cap 75 mg# 3doxepin hcl cap 100 mg# 3doxepin hcl conc 10 mg/ml# 3duloxetine hcl enteric coated pellets cap 20 mg^ 2 QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 30 mg^ 2 QL (90 capsules/30 days)duloxetine hcl enteric coated pellets cap 60 mg^ 2 QL (60 capsules/30 days)EMSAM - selegiline td patch 24hr 6 mg/24hr 5EMSAM - selegiline td patch 24hr 9 mg/24hr 5EMSAM - selegiline td patch 24hr 12 mg/24hr 5escitalopram oxalate soln 5 mg/5ml^ 2 QL (600 mls/30 days)escitalopram oxalate tab 5 mg^ 1 QL (45 tablets/30 days)escitalopram oxalate tab 10 mg^ 1 QL (45 tablets/30 days)escitalopram oxalate tab 20 mg^ 1 QL (30 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsFETZIMA - levomilnacipran hcl cap er 24hr 20 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 40 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 80 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 120 mg 4 QL (30 capsules/30 days)FETZIMA TITRATION PACK - levomilnacipran hcl cap er 24hr 20 &

40 mg therapy pack4 QL (28 capsules/28 days)

FLUOXETINE DR - fluoxetine hcl cap delayed release 90 mg^ 2 QL (4 capsules/28 days)fluoxetine hcl cap 10 mg^ 1 QL (90 capsules/30 days)fluoxetine hcl cap 20 mg^ 1 QL (120 capsules/30 days)fluoxetine hcl cap 40 mg^ 2 QL (60 capsules/30 days)fluoxetine hcl solution 20 mg/5ml^ 2 QL (600 mls/30 days)fluoxetine hcl tab 10 mg^ 2 QL (90 tablets/30 days)fluoxetine hcl tab 20 mg^ 2 QL (120 tablets/30 days)fluvoxamine maleate tab 25 mg^ 2 QL (30 tablets/30 days)fluvoxamine maleate tab 50 mg^ 2 QL (30 tablets/30 days)fluvoxamine maleate tab 100 mg^ 2 QL (90 tablets/30 days)imipramine hcl tab 10 mg# 3imipramine hcl tab 25 mg# 3imipramine hcl tab 50 mg# 3MAPROTILINE HCL - maprotiline hcl tab 25 mg 3 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 50 mg 3 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 75 mg 3 QL (90 tablets/30 days)MARPLAN - isocarboxazid tab 10 mg 4mirtazapine orally disintegrating tab 15 mg^ 2 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 30 mg^ 2 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 45 mg^ 2 QL (30 tablets/30 days)mirtazapine tab 7.5 mg^ 2 QL (30 tablets/30 days)mirtazapine tab 15 mg^ 1 QL (45 tablets/30 days)mirtazapine tab 30 mg^ 1 QL (30 tablets/30 days)mirtazapine tab 45 mg^ 2 QL (30 tablets/30 days)NEFAZODONE HCL - nefazodone hcl tab 100 mg 3NEFAZODONE HCL - nefazodone hcl tab 150 mg 3nefazodone hcl tab 250 mg^ 2nefazodone hcl tab 50 mg^ 2NEFAZODONE HYDROCHLORIDE - nefazodone hcl tab 200 mg 3NORTRIPTYLINE HCL - nortriptyline hcl soln 10 mg/5ml# 3nortriptyline hcl cap 10 mg# 3nortriptyline hcl cap 25 mg# 3nortriptyline hcl cap 50 mg# 3

2020


21

Drug Name Drug Tier Requirements/Limitsnortriptyline hcl cap 75 mg# 3paroxetine hcl tab 10 mg# 3 PA, QL (45 tablets/30 days)paroxetine hcl tab 20 mg# 3 PA, QL (30 tablets/30 days)paroxetine hcl tab 30 mg# 3 PA, QL (60 tablets/30 days)paroxetine hcl tab 40 mg# 3 PA, QL (45 tablets/30 days)PAXIL - paroxetine hcl oral susp 10 mg/5ml# 4 PA, QL (900 mls/30 days)phenelzine sulfate tab 15 mg^ 2protriptyline hcl tab 5 mg# 3protriptyline hcl tab 10 mg# 3sertraline hcl oral concentrate for solution 20 mg/ml^ 2 QL (300 mls/30 days)sertraline hcl tab 25 mg^ 1 QL (45 tablets/30 days)sertraline hcl tab 50 mg^ 1 QL (45 tablets/30 days)sertraline hcl tab 100 mg^ 1 QL (60 tablets/30 days)SPRAVATO 56MG DOSE - esketamine hcl nasal soln 28 mg/device

x 2 (56 mg dose pack)5 PA, QL (16 bottles/28 days)

SPRAVATO 84MG DOSE - esketamine hcl nasal soln 28 mg/devicex 3 (84 mg dose pack)

5 PA, QL (24 bottles/28 days)

tranylcypromine sulfate tab 10 mg 3trazodone hcl tab 50 mg^ 1trazodone hcl tab 100 mg^ 1trazodone hcl tab 150 mg^ 2trazodone hcl tab 300 mg^ 2trimipramine maleate cap 25 mg# 3trimipramine maleate cap 50 mg# 3trimipramine maleate cap 100 mg# 3TRINTELLIX - vortioxetine hbr tab 5 mg 4 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 10 mg 4 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 20 mg 4 QL (30 tablets/30 days)venlafaxine hcl cap er 24hr 37.5 mg^ 1 QL (60 capsules/30 days)venlafaxine hcl cap er 24hr 75 mg^ 2 QL (90 capsules/30 days)venlafaxine hcl cap er 24hr 150 mg^ 2 QL (30 capsules/30 days)venlafaxine hcl tab er 24hr 37.5 mg^ 2 QL (60 tablets/30 days)venlafaxine hcl tab er 24hr 75 mg 3 QL (90 tablets/30 days)venlafaxine hcl tab er 24hr 150 mg^ 2 QL (30 tablets/30 days)venlafaxine hcl tab 25 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 37.5 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 50 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 75 mg^ 2 QL (90 tablets/30 days)venlafaxine hcl tab 100 mg^ 2 QL (90 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsVIIBRYD - vilazodone hcl tab 10 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 20 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 40 mg 4 QL (30 tablets/30 days)VIIBRYD STARTER PACK - vilazodone hcl tab starter kit 10 (7) &

20 (23) mg4 QL (1 kit/30 days)

Antiemeticsaprepitant capsule therapy pack 80 & 125 mg 3 BDaprepitant capsule 40 mg 3 BDaprepitant capsule 80 mg 3 BDaprepitant capsule 125 mg 3 BDCHLORPROMAZINE HCL - chlorpromazine hcl inj 25 mg/ml 4 PACHLORPROMAZINE HCL - chlorpromazine hcl inj 50 mg/2ml 3 PAchlorpromazine hcl tab 10 mg 3 PAchlorpromazine hcl tab 25 mg 3 PAchlorpromazine hcl tab 50 mg 4 PAchlorpromazine hcl tab 100 mg 4 PAchlorpromazine hcl tab 200 mg 4 PAdronabinol cap 2.5 mg 3 BDdronabinol cap 5 mg 4 BDdronabinol cap 10 mg 4 BDEMEND - fosaprepitant dimeglumine for iv infusion 150 mg 4fosaprepitant dimeglumine for iv infusion 150 mg 4granisetron hcl inj 1 mg/ml 3granisetron hcl inj 4 mg/4ml (1 mg/ml) 3granisetron hcl tab 1 mg 3 BDmeclizine hcl tab 12.5 mg# 3meclizine hcl tab 25 mg# 3ondansetron hcl inj 4 mg/2ml (2 mg/ml) 3ondansetron hcl inj 40 mg/20ml (2 mg/ml) 3ondansetron hcl oral soln 4 mg/5ml^ 2 BDondansetron hcl tab 4 mg^ 2 BDondansetron hcl tab 8 mg^ 2 BDondansetron hcl tab 24 mg^ 2 BDondansetron orally disintegrating tab 4 mg^ 2 BDondansetron orally disintegrating tab 8 mg^ 2 BDpalonosetron hcl iv soln pref syr 0.25 mg/5ml 5palonosetron hcl iv soln 0.25 mg/5ml 5PALONOSETRON HYDROCHLORIDE - palonosetron hcl iv soln

0.25 mg/2ml5

2020


23

Drug Name Drug Tier Requirements/Limitsperphenazine tab 2 mg 3 PAperphenazine tab 4 mg 3 PAperphenazine tab 8 mg 3 PAperphenazine tab 16 mg 3 PAPROCHLORPERAZINE EDISYLATE - prochlorperazine edisylate

inj 50 mg/10ml3

prochlorperazine edisylate inj 10 mg/2ml 3prochlorperazine maleate tab 5 mg 3prochlorperazine maleate tab 10 mg 3prochlorperazine suppos 25 mg 3promethazine hcl suppos 12.5 mg# 3 PApromethazine hcl suppos 25 mg# 3 PApromethazine hcl syrup 6.25 mg/5ml# 3 PApromethazine hcl tab 12.5 mg# 3 PApromethazine hcl tab 25 mg# 3 PApromethazine hcl tab 50 mg# 3 PAAntifungalsAMBISOME - amphotericin b liposome iv for susp 50 mg 5 BDAMPHOTERICIN B - amphotericin b for iv soln 50 mg 3 BDcaspofungin acetate for iv soln 50 mg 5caspofungin acetate for iv soln 70 mg 5ciclopirox gel 0.77%^ 2ciclopirox olamine cream 0.77%^ 2ciclopirox olamine susp 0.77%^ 2ciclopirox shampoo 1%^ 2ciclopirox solution 8%^ 2clotrimazole cream 1%^ 2clotrimazole troche 10 mg^ 2CRESEMBA - isavuconazonium sulfate cap 186 mg 5 PACRESEMBA - isavuconazonium sulfate for iv soln 372 mg 5 PAeconazole nitrate cream 1%^ 2fluconazole for susp 10 mg/ml^ 2fluconazole for susp 40 mg/ml^ 2fluconazole in dextrose inj 200 mg/100ml 3fluconazole in dextrose inj 400 mg/200ml 3fluconazole in nacl 0.9% inj 200 mg/100ml 3fluconazole in nacl 0.9% inj 400 mg/200ml 3fluconazole tab 50 mg^ 2fluconazole tab 100 mg^ 2

2020


Drug Name Drug Tier Requirements/Limitsfluconazole tab 150 mg^ 2fluconazole tab 200 mg^ 2flucytosine cap 250 mg 5flucytosine cap 500 mg 5griseofulvin microsize susp 125 mg/5ml 3griseofulvin ultramicrosize tab 125 mg 3griseofulvin ultramicrosize tab 250 mg 3itraconazole cap 100 mg 3ketoconazole cream 2%^ 2ketoconazole shampoo 2%^ 2ketoconazole tab 200 mg^ 2MYCAMINE - micafungin sodium for iv soln 50 mg 5MYCAMINE - micafungin sodium for iv soln 100 mg 5NOXAFIL - posaconazole iv soln 300 mg/16.7ml (18 mg/ml) 4 PANOXAFIL - posaconazole susp 40 mg/ml 5 PANOXAFIL - posaconazole tab delayed release 100 mg 5 PAnystatin cream 100000 unit/gm^ 2nystatin oint 100000 unit/gm^ 2nystatin susp 100000 unit/ml^ 2nystatin tab 500000 unit^ 2nystatin topical powder 100000 unit/gm^ 2posaconazole tab delayed release 100 mg 5 PAterbinafine hcl tab 250 mg^ 1TERCONAZOLE - terconazole vaginal cream 0.8% 3terconazole vaginal cream 0.4%^ 2terconazole vaginal suppos 80 mg^ 2voriconazole for inj 200 mg 3 PAvoriconazole for susp 40 mg/ml 5 PAvoriconazole tab 50 mg 5 PAvoriconazole tab 200 mg 5 PAAntigout Agentsallopurinol sodium for inj 500 mg 3allopurinol tab 100 mg^ 1allopurinol tab 300 mg^ 1colchicine w/ probenecid tab 0.5-500 mg^ 2COLCRYS - colchicine tab 0.6 mg 3probenecid tab 500 mg^ 2

2020


25

Drug Name Drug Tier Requirements/LimitsAntimigraine AgentsAIMOVIG - erenumab-aooe subcutaneous soln auto-injector 70 mg/

ml3 PA, QL (2 pens/30 days)

AIMOVIG - erenumab-aooe subcutaneous soln auto-injector140 mg/ml

3 PA, QL (1 pen/30 days)

EMGALITY - galcanezumab-gnlm subcutaneous soln auto-injector120 mg/ml

3 PA, QL (2 pens/30 days)

EMGALITY - galcanezumab-gnlm subcutaneous soln prefilled syr100 mg/ml

3 PA, QL (3 syringes/30 days)

EMGALITY - galcanezumab-gnlm subcutaneous soln prefilled syr120 mg/ml


ergotamine w/ caffeine tab 1-100 mg 3MIGERGOT - ergotamine w/ caffeine suppos 2-100 mg 5MIGRANAL - dihydroergotamine mesylate nasal spray 4 mg/ml 3 QL (8 mls/28 days)naratriptan hcl tab 1 mg^ 2 QL (18 tablets/30 days)naratriptan hcl tab 2.5 mg^ 2 QL (18 tablets/30 days)rizatriptan benzoate oral disintegrating tab 5 mg^ 2 QL (18 tablets/30 days)rizatriptan benzoate oral disintegrating tab 10 mg^ 2 QL (18 tablets/30 days)rizatriptan benzoate tab 5 mg^ 2 QL (18 tablets/30 days)rizatriptan benzoate tab 10 mg^ 2 QL (18 tablets/30 days)sumatriptan nasal spray 5 mg/act 3 QL (12 units (2

packages)/30 days)sumatriptan nasal spray 20 mg/act 4 QL (12 units (2

packages)/30 days)SUMATRIPTAN SUCCINATE - sumatriptan succinate solution

prefilled syringe 6 mg/0.5ml3

sumatriptan succinate inj 6 mg/0.5ml 3sumatriptan succinate solution auto-injector 4 mg/0.5ml 3sumatriptan succinate solution auto-injector 6 mg/0.5ml 4sumatriptan succinate solution cartridge 4 mg/0.5ml 3sumatriptan succinate solution cartridge 6 mg/0.5ml 4sumatriptan succinate tab 25 mg^ 2 QL (18 tablets/30 days)sumatriptan succinate tab 50 mg^ 2 QL (18 tablets/30 days)sumatriptan succinate tab 100 mg^ 2 QL (18 tablets/30 days)Antimyasthenic AgentsGUANIDINE HCL - guanidine hcl tab 125 mg 3pyridostigmine bromide oral soln 60 mg/5ml 5pyridostigmine bromide tab er 180 mg 4pyridostigmine bromide tab 60 mg^ 2AntimycobacterialsCAPASTAT SULFATE - capreomycin sulfate for inj 1 gm 4

2020


Drug Name Drug Tier Requirements/Limitscycloserine cap 250 mg 5dapsone tab 25 mg^ 2dapsone tab 100 mg^ 2ethambutol hcl tab 100 mg^ 2ethambutol hcl tab 400 mg^ 2ISONIAZID - isoniazid inj 100 mg/ml 3isoniazid tab 100 mg^ 1isoniazid tab 300 mg^ 1PASER - aminosalicylic acid er granules packet 4 gm 3PRIFTIN - rifapentine tab 150 mg 4pyrazinamide tab 500 mg 3rifabutin cap 150 mg 4rifampin cap 150 mg^ 2rifampin cap 300 mg^ 2rifampin for inj 600 mg 5SIRTURO - bedaquiline fumarate tab 100 mg* 5TRECATOR - ethionamide tab 250 mg 4Antineoplasticsabiraterone acetate tab 250 mg 5 PA, QL (120 tablets/30 days)ABRAXANE - paclitaxel protein-bound particles for iv susp 100 mg 5 PAADRIAMYCIN - doxorubicin hcl for inj 10 mg 4 BDADRIAMYCIN - doxorubicin hcl for inj 50 mg 4 BDAFINITOR - everolimus tab 2.5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 7.5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 10 mg 5 PA, QL (30 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 2 mg 5 PA, QL (60 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 3 mg 5 PA, QL (90 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 5 mg 5 PA, QL (60 tablets/30 days)ALECENSA - alectinib hcl cap 150 mg* 5 PA, QL (240 capsules/30 days)ALIMTA - pemetrexed disodium for iv soln 100 mg 5 PAALIMTA - pemetrexed disodium for iv soln 500 mg 5 PAALIQOPA - copanlisib hcl for iv soln 60 mg 5 PAALUNBRIG - brigatinib tab initiation therapy pack 90 mg & 180 mg* 5 PA, QL (30 tablets/30 days)ALUNBRIG - brigatinib tab 30 mg* 5 PA, QL (120 tablets/30 days)ALUNBRIG - brigatinib tab 90 mg* 5 PA, QL (30 tablets/30 days)ALUNBRIG - brigatinib tab 180 mg* 5 PA, QL (30 tablets/30 days)anastrozole tab 1 mg^ 2

2020


27

Drug Name Drug Tier Requirements/LimitsARRANON - nelarabine iv soln 5 mg/ml 5 PAarsenic trioxide iv soln 10 mg/10ml (1 mg/ml) 4arsenic trioxide iv soln 12 mg/6ml (2 mg/ml) 5ARZERRA - ofatumumab conc for iv infusion 100 mg/5ml* 5 PAARZERRA - ofatumumab conc for iv infusion 1000 mg/50ml* 5 PAAVASTIN - bevacizumab iv soln 100 mg/4ml (for infusion)* 5 PAAVASTIN - bevacizumab iv soln 400 mg/16ml (for infusion)* 5 PABALVERSA - erdafitinib tab 3 mg 5 PA, QL (90 tablets/30 days)BALVERSA - erdafitinib tab 4 mg 5 PA, QL (60 tablets/30 days)BALVERSA - erdafitinib tab 5 mg 5 PA, QL (30 tablets/30 days)BAVENCIO - avelumab soln for iv infusion 200 mg/10ml (20 mg/ml) 5 PABELEODAQ - belinostat for iv inj 500 mg 5 PABENDEKA - bendamustine hcl iv soln 100 mg/4ml (25 mg/ml) 5BESPONSA - inotuzumab ozogamicin for iv soln 0.9 mg 5 PAbexarotene cap 75 mg 5 PAbicalutamide tab 50 mg^ 2bleomycin sulfate for inj 15 unit 3 BDbleomycin sulfate for inj 30 unit 3 BDBLINCYTO - blinatumomab for iv infusion 35 mcg* 5 BD, PABOSULIF - bosutinib tab 100 mg 5 PA, QL (180 tablets/30 days)BOSULIF - bosutinib tab 400 mg 5 PA, QL (30 tablets/30 days)BOSULIF - bosutinib tab 500 mg 5 PA, QL (30 tablets/30 days)BRAFTOVI - encorafenib cap 75 mg 5 PA, QL (180 capsules/30 days)busulfan inj 6 mg/ml 5CABOMETYX - cabozantinib s-malate tab 20 mg* 5 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 40 mg* 5 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 60 mg* 5 PA, QL (30 tablets/30 days)CALQUENCE - acalabrutinib cap 100 mg* 5 PA, QL (60 capsules/30 days)CAPRELSA - vandetanib tab 100 mg* 5 PA, QL (60 tablets/30 days)CAPRELSA - vandetanib tab 300 mg* 5 PA, QL (30 tablets/30 days)carboplatin iv soln 50 mg/5ml 3carboplatin iv soln 150 mg/15ml 3carboplatin iv soln 450 mg/45ml 3carboplatin iv soln 600 mg/60ml 3carmustine for inj 100 mg 4CISPLATIN - cisplatin inj 200 mg/200ml (1 mg/ml) 3cisplatin inj 50 mg/50ml (1 mg/ml) 3cisplatin inj 100 mg/100ml (1 mg/ml) 3

2020


Drug Name Drug Tier Requirements/Limitscladribine iv soln 10 mg/10ml (1 mg/ml) 5 BDclofarabine iv soln 1 mg/ml 5COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100

dose) kit*5 PA, QL (56 capsules/28 days)

COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140dose) kit*

5 PA, QL (112 capsules/28 days)

COMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60 mg dose)kit*


COPIKTRA - duvelisib cap 15 mg 5 PA, QL (56 capsules/28 days)COPIKTRA - duvelisib cap 25 mg 5 PA, QL (56 capsules/28 days)COTELLIC - cobimetinib fumarate tab 20 mg* 5 PA, QL (63 tablets/28 days)cyclophosphamide cap 25 mg 3 BDcyclophosphamide cap 50 mg 3 BDcyclophosphamide for inj 500 mg 5cyclophosphamide for inj 1 gm 5cyclophosphamide for inj 2 gm 5CYRAMZA - ramucirumab iv soln 100 mg/10ml (for infusion)* 5 PACYRAMZA - ramucirumab iv soln 500 mg/50ml (for infusion)* 5 PACYTARABINE - cytarabine inj 20 mg/ml 3 BDcytarabine inj pf 20 mg/ml 3 BDcytarabine inj pf 100 mg/ml 3 BDDACARBAZINE - dacarbazine for inj 100 mg 4dacarbazine for inj 200 mg 3dactinomycin for inj 0.5 mg 5DARZALEX - daratumumab iv soln 100 mg/5ml* 5 PADARZALEX - daratumumab iv soln 400 mg/20ml* 5 PAdaunorubicin hcl iv soln 20 mg/4ml 3DAUNORUBICIN HYDROCHLORIDE - daunorubicin hcl iv soln

50 mg/10ml3

DAURISMO - glasdegib maleate tab 25 mg 5 PA, QL (60 tablets/30 days)DAURISMO - glasdegib maleate tab 100 mg 5 PA, QL (30 tablets/30 days)decitabine for inj 50 mg 5dexrazoxane hcl for inj 250 mg 5dexrazoxane hcl for inj 500 mg 5DOCETAXEL - docetaxel for inj conc 200 mg/10ml (20 mg/ml) 5docetaxel for inj conc 20 mg/ml 5docetaxel for inj conc 80 mg/4ml (20 mg/ml) 5docetaxel for inj conc 160 mg/8ml (20 mg/ml) 5docetaxel soln for iv infusion 20 mg/2ml 5

2020


29

Drug Name Drug Tier Requirements/Limitsdocetaxel soln for iv infusion 80 mg/8ml 5docetaxel soln for iv infusion 160 mg/16ml 5doxorubicin hcl for inj 10 mg 4 BDdoxorubicin hcl for inj 50 mg 4 BDdoxorubicin hcl inj 2 mg/ml 3 BDdoxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml 5 BD, PAELITEK - rasburicase for iv soln 1.5 mg 5ELITEK - rasburicase for iv soln 7.5 mg 5EMCYT - estramustine phosphate sodium cap 140 mg 5EMPLICITI - elotuzumab for iv soln 300 mg 5 PAEMPLICITI - elotuzumab for iv soln 400 mg 5 PAepirubicin hcl iv soln 50 mg/25ml (2 mg/ml) 3epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) 3ERBITUX - cetuximab iv soln 100 mg/50ml (2 mg/ml) 5 PAERBITUX - cetuximab iv soln 200 mg/100ml (2 mg/ml) 5 PAERIVEDGE - vismodegib cap 150 mg* 5 PA, QL (30 capsules/30 days)ERLEADA - apalutamide tab 60 mg* 5 PA, QL (120 tablets/30 days)erlotinib hcl tab 25 mg 5 PA, QL (60 tablets/30 days)erlotinib hcl tab 100 mg 5 PA, QL (30 tablets/30 days)erlotinib hcl tab 150 mg 5 PA, QL (30 tablets/30 days)ERWINAZE - asparaginase erwinia chrysanthemi for inj 10000 unit 5ETHYOL - amifostine for inj 500 mg 5ETOPOPHOS - etoposide phosphate iv for inj 100 mg 4etoposide inj 100 mg/5ml (20 mg/ml) 3etoposide inj 500 mg/25ml (20 mg/ml) 3etoposide inj 1 gm/50ml (20 mg/ml) 3EVOMELA - melphalan hcl for inj 50 mg (propylene glycol (pg) free) 5exemestane tab 25 mg 3FARYDAK - panobinostat lactate cap 10 mg* 5 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 15 mg* 5 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 20 mg* 5 PA, QL (6 capsules/21 days)FASLODEX - fulvestrant inj 250 mg/5ml 5 PAfludarabine phosphate for inj 50 mg 3fludarabine phosphate inj 25 mg/ml 3fluorouracil iv soln 500 mg/10ml (50 mg/ml) 3 BDfluorouracil iv soln 1 gm/20ml (50 mg/ml) 3 BDfluorouracil iv soln 2.5 gm/50ml (50 mg/ml) 3 BDfluorouracil iv soln 5 gm/100ml (50 mg/ml) 3 BD

2020


Drug Name Drug Tier Requirements/Limitsflutamide cap 125 mg^ 2FOLOTYN - pralatrexate iv inj 20 mg/ml 5 PAFOLOTYN - pralatrexate iv inj 40 mg/2ml 5 PAfulvestrant inj 250 mg/5ml 5 PAGAZYVA - obinutuzumab soln for iv infusion 1000 mg/40ml (25 mg/

ml)5 PA

gemcitabine hcl for inj 200 mg 3gemcitabine hcl for inj 1 gm 3gemcitabine hcl for inj 2 gm 3gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml) 3gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml) 3gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml) 3GILOTRIF - afatinib dimaleate tab 20 mg* 5 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 30 mg* 5 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 40 mg* 5 PA, QL (30 tablets/30 days)GLEOSTINE - lomustine cap 10 mg 4GLEOSTINE - lomustine cap 40 mg 4GLEOSTINE - lomustine cap 100 mg 5HALAVEN - eribulin mesylate inj 1 mg/2ml (0.5 mg/ml) 5 PAHERCEPTIN - trastuzumab for iv soln 150 mg* 5 PAHERCEPTIN HYLECTA - trastuzumab-hyaluronidase-oysk inj

600-10000 mg-unit/5ml*5 PA

hydroxyurea cap 500 mg^ 2IBRANCE - palbociclib cap 75 mg* 5 PA, QL (21 capsules/28 days)IBRANCE - palbociclib cap 100 mg* 5 PA, QL (21 capsules/28 days)IBRANCE - palbociclib cap 125 mg* 5 PA, QL (21 capsules/28 days)ICLUSIG - ponatinib hcl tab 15 mg* 5 PA, QL (60 tablets/30 days)ICLUSIG - ponatinib hcl tab 45 mg* 5 PA, QL (30 tablets/30 days)idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 5idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 5idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 5IDHIFA - enasidenib mesylate tab 50 mg* 5 PA, QL (30 tablets/30 days)IDHIFA - enasidenib mesylate tab 100 mg* 5 PA, QL (30 tablets/30 days)IFEX - ifosfamide for inj 3 gm 4IFOSFAMIDE - ifosfamide for inj 3 gm 4ifosfamide for inj 1 gm 3ifosfamide iv inj 1 gm/20ml (50 mg/ml) 3ifosfamide iv inj 3 gm/60ml (50 mg/ml) 3imatinib mesylate tab 100 mg 5 PA, QL (90 tablets/30 days)

2020


31

Drug Name Drug Tier Requirements/Limitsimatinib mesylate tab 400 mg 5 PA, QL (60 tablets/30 days)IMBRUVICA - ibrutinib cap 70 mg* 5 PA, QL (30 capsules/30 days)IMBRUVICA - ibrutinib cap 140 mg* 5 PA, QL (120 capsules/30 days)IMBRUVICA - ibrutinib tab 140 mg* 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 280 mg* 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 420 mg* 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 560 mg* 5 PA, QL (30 tablets/30 days)IMFINZI - durvalumab soln for iv infusion 120 mg/2.4ml (50 mg/ml) 5 PAIMFINZI - durvalumab soln for iv infusion 500 mg/10ml (50 mg/ml) 5 PAIMLYGIC - talimogene laherparepvec intralesional inj 1000000 unit/

ml4

IMLYGIC - talimogene laherparepvec intralesional inj 100000000unit/ml

5

INLYTA - axitinib tab 1 mg* 5 PA, QL (180 tablets/30 days)INLYTA - axitinib tab 5 mg* 5 PA, QL (120 tablets/30 days)INREBIC - fedratinib hcl cap 100 mg 5 PA, QL (120 capsules/30 days)IRESSA - gefitinib tab 250 mg* 5 PA, QL (30 tablets/30 days)IRINOTECAN - irinotecan hcl inj 500 mg/25ml (20 mg/ml) 3irinotecan hcl inj 40 mg/2ml (20 mg/ml) 3irinotecan hcl inj 100 mg/5ml (20 mg/ml) 3ISTODAX (OVERFILL) - romidepsin for iv inj 10 mg 5 PAIXEMPRA KIT - ixabepilone for iv infusion 15 mg 5IXEMPRA KIT - ixabepilone for iv infusion 45 mg 5JAKAFI - ruxolitinib phosphate tab 5 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 10 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 15 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 20 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 25 mg* 5 PA, QL (60 tablets/30 days)JEVTANA - cabazitaxel inj 60 mg/1.5ml (for iv infusion) 5 PAKADCYLA - ado-trastuzumab emtansine for iv soln 100 mg 5 PAKADCYLA - ado-trastuzumab emtansine for iv soln 160 mg 5 PAKANJINTI - trastuzumab-anns for iv soln 420 mg 5 PAKEYTRUDA - pembrolizumab iv soln 100 mg/4ml (25 mg/ml) 5 PAKISQALI - ribociclib succinate tab pack 200 mg daily dose 5 PA, QL (21 tablets/28 days)KISQALI - ribociclib succinate tab pack 400 mg daily dose (200 mg

tab)5 PA, QL (42 tablets/28 days)

KISQALI - ribociclib succinate tab pack 600 mg daily dose (200 mgtab)

5 PA, QL (63 tablets/28 days)

KISQALI FEMARA 200 DOSE - ribociclib 200 mg dose (200 mgtab) & letrozole 2.5 mg tbpk


2020


Drug Name Drug Tier Requirements/LimitsKISQALI FEMARA 400 DOSE - ribociclib 400 mg dose (200 mg

tab) & letrozole 2.5 mg tbpk5 PA, QL (70 tablets/28 days)

KISQALI FEMARA 600 DOSE - ribociclib 600 mg dose (200 mgtab) & letrozole 2.5 mg tbpk


KYPROLIS - carfilzomib for inj 10 mg 5 PAKYPROLIS - carfilzomib for inj 30 mg 5 PAKYPROLIS - carfilzomib for inj 60 mg 5 PALARTRUVO - olaratumab soln for iv infusion 190 mg/19ml (10 mg/

ml)5 PA

LARTRUVO - olaratumab soln for iv infusion 500 mg/50ml (10 mg/ml)

5 PA

LENVIMA 10 MG DAILY DOSE - lenvatinib cap therapy pack10 mg*


LENVIMA 12MG DAILY DOSE - lenvatinib cap therapy pack 4(3) mg*


LENVIMA 14 MG DAILY DOSE - lenvatinib cap therapy pack 10 &4 mg*


LENVIMA 18 MG DAILY DOSE - lenvatinib cap therapy pack 10 &4 (2) mg*


LENVIMA 20 MG DAILY DOSE - lenvatinib cap therapy pack 10(2) mg*


LENVIMA 24 MG DAILY DOSE - lenvatinib cap therapy pack 10 (2)& 4 mg*


LENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack 4 mg* 5 PA, QL (30 capsules/30 days)LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 4

(2) mg*5 PA, QL (60 capsules/30 days)

letrozole tab 2.5 mg^ 2LEUCOVORIN CALCIUM - leucovorin calcium inj 100 mg/10ml

(10 mg/ml)4

LEUCOVORIN CALCIUM - leucovorin calcium tab 10 mg 3LEUCOVORIN CALCIUM - leucovorin calcium tab 15 mg 3leucovorin calcium for inj 50 mg 3leucovorin calcium for inj 100 mg 3leucovorin calcium for inj 200 mg 3leucovorin calcium for inj 350 mg 3leucovorin calcium for inj 500 mg 3leucovorin calcium inj 500 mg/50ml (10 mg/ml) 4leucovorin calcium tab 5 mg^ 2leucovorin calcium tab 25 mg 3LEUKERAN - chlorambucil tab 2 mg 5LIBTAYO - cemiplimab-rwlc iv soln 350 mg/7ml (50 mg/ml)* 5 PALONSURF - trifluridine-tipiracil tab 15-6.14 mg 5 PA, QL (100 tablets/28 days)

2020


33

Drug Name Drug Tier Requirements/LimitsLONSURF - trifluridine-tipiracil tab 20-8.19 mg 5 PA, QL (80 tablets/28 days)LORBRENA - lorlatinib tab 25 mg 5 PA, QL (90 tablets/30 days)LORBRENA - lorlatinib tab 100 mg 5 PA, QL (30 tablets/30 days)LUMOXITI - moxetumomab pasudotox-tdfk for iv soln 1 mg* 5 PALYNPARZA - olaparib tab 100 mg* 5 PA, QL (120 tablets/30 days)LYNPARZA - olaparib tab 150 mg* 5 PA, QL (120 tablets/30 days)MARQIBO - vincristine sulfate liposome iv susp 5 mg/31ml

(0.16 mg/ml)5

MATULANE - procarbazine hcl cap 50 mg* 5 PAMEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg* 5 PA, QL (90 tablets/30 days)MEKINIST - trametinib dimethyl sulfoxide tab 2 mg* 5 PA, QL (30 tablets/30 days)MEKTOVI - binimetinib tab 15 mg 5 PA, QL (180 tablets/30 days)melphalan hcl for inj 50 mg 5mercaptopurine tab 50 mg^ 2mesna inj 100 mg/ml 3MESNEX - mesna tab 400 mg 5mitomycin for iv soln 5 mg 4mitomycin for iv soln 20 mg 5mitomycin for iv soln 40 mg 5mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) 3mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) 3mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) 3MVASI - bevacizumab-awwb iv soln 100 mg/4ml (for infusion) 5 PAMVASI - bevacizumab-awwb iv soln 400 mg/16ml (for infusion) 5 PAMYLOTARG - gemtuzumab ozogamicin for iv soln 4.5 mg 5 PANERLYNX - neratinib maleate tab 40 mg* 5 PA, QL (180 tablets/30 days)NEXAVAR - sorafenib tosylate tab 200 mg* 5 PA, QL (120 tablets/30 days)nilutamide tab 150 mg 5NINLARO - ixazomib citrate cap 2.3 mg 5 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 3 mg 5 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 4 mg 5 PA, QL (3 capsules/28 days)NIPENT - pentostatin for inj 10 mg 5NUBEQA - darolutamide tab 300 mg 5 PA, QL (120 tablets/30 days)ODOMZO - sonidegib phosphate cap 200 mg* 5 PA, QL (30 capsules/30 days)ONCASPAR - pegaspargase inj 750 unit/ml 5ONIVYDE - irinotecan hcl liposome iv inj 43 mg/10ml (4.3 mg/ml) 5 PAOPDIVO - nivolumab iv soln 40 mg/4ml 5 PAOPDIVO - nivolumab iv soln 100 mg/10ml 5 PAOPDIVO - nivolumab iv soln 240 mg/24ml 5 PA

2020


Drug Name Drug Tier Requirements/Limitsoxaliplatin for iv inj 50 mg 5oxaliplatin for iv inj 100 mg 5oxaliplatin iv soln 50 mg/10ml 3oxaliplatin iv soln 100 mg/20ml 3PACLITAXEL - paclitaxel iv conc 150 mg/25ml (6 mg/ml) 3paclitaxel iv conc 30 mg/5ml (6 mg/ml) 3paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) 3paclitaxel iv conc 300 mg/50ml (6 mg/ml) 3PANRETIN - alitretinoin gel 0.1% 5PERJETA - pertuzumab soln for iv infusion 420 mg/14ml (30 mg/

ml)*5 PA

PIQRAY 200MG DAILY DOSE - alpelisib tab therapy pack 200 mgdaily dose


PIQRAY 250MG DAILY DOSE - alpelisib tab pack 250 mg dailydose (200 mg & 50 mg tabs)


PIQRAY 300MG DAILY DOSE - alpelisib tab pack 300 mg dailydose (2x150 mg tab)


POLIVY - polatuzumab vedotin-piiq for iv solution 140 mg 5 PAPOMALYST - pomalidomide cap 1 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 2 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 3 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 4 mg* 5 PA, QL (21 capsules/28 days)PORTRAZZA - necitumumab iv soln 800 mg/50ml (16 mg/ml)* 5 PAPOTELIGEO - mogamulizumab-kpkc iv soln 20 mg/5ml (4 mg/ml) 5 PAPROLEUKIN - aldesleukin for iv soln 22000000 unit 5PURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/ml)* 5REVLIMID - lenalidomide caps 2.5 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 5 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 10 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 15 mg* 5 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 20 mg* 5 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 25 mg* 5 PA, QL (21 capsules/28 days)RITUXAN - rituximab iv soln 100 mg/10ml* 5 PARITUXAN - rituximab iv soln 500 mg/50ml* 5 PARITUXAN HYCELA - rituximab-hyaluronidase human inj

1400-23400 mg-unit/11.7ml*5 PA

RITUXAN HYCELA - rituximab-hyaluronidase human inj1600-26800 mg-unit/13.4ml*

5 PA

RUBRACA - rucaparib camsylate tab 200 mg* 5 PA, QL (120 tablets/30 days)RUBRACA - rucaparib camsylate tab 250 mg* 5 PA, QL (120 tablets/30 days)

2020


35

Drug Name Drug Tier Requirements/LimitsRUBRACA - rucaparib camsylate tab 300 mg* 5 PA, QL (120 tablets/30 days)RYDAPT - midostaurin cap 25 mg 5 PA, QL (240 capsules/30 days)SOLTAMOX - tamoxifen citrate oral soln 10 mg/5ml 5SPRYCEL - dasatinib tab 20 mg 5 PA, QL (90 tablets/30 days)SPRYCEL - dasatinib tab 50 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 70 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 80 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 100 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 140 mg 5 PA, QL (30 tablets/30 days)STIVARGA - regorafenib tab 40 mg* 5 PA, QL (84 tablets/28 days)SUTENT - sunitinib malate cap 12.5 mg 5 PA, QL (90 capsules/30 days)SUTENT - sunitinib malate cap 25 mg 5 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 37.5 mg 5 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 50 mg 5 PA, QL (30 capsules/30 days)SYNRIBO - omacetaxine mepesuccinate for inj 3.5 mg 5 PATABLOID - thioguanine tab 40 mg 4TAFINLAR - dabrafenib mesylate cap 50 mg* 5 PA, QL (120 capsules/30 days)TAFINLAR - dabrafenib mesylate cap 75 mg* 5 PA, QL (120 capsules/30 days)TAGRISSO - osimertinib mesylate tab 40 mg* 5 PA, QL (30 tablets/30 days)TAGRISSO - osimertinib mesylate tab 80 mg* 5 PA, QL (30 tablets/30 days)TALZENNA - talazoparib tosylate cap 0.25 mg* 5 PA, QL (90 capsules/30 days)TALZENNA - talazoparib tosylate cap 1 mg* 5 PA, QL (30 capsules/30 days)tamoxifen citrate tab 10 mg^ 2tamoxifen citrate tab 20 mg^ 2TARGRETIN - bexarotene gel 1% 5TASIGNA - nilotinib hcl cap 50 mg 5 PA, QL (120 capsules/30 days)TASIGNA - nilotinib hcl cap 150 mg 5 PA, QL (120 capsules/30 days)TASIGNA - nilotinib hcl cap 200 mg 5 PA, QL (120 capsules/30 days)TECENTRIQ - atezolizumab iv soln 840 mg/14ml* 5 PATECENTRIQ - atezolizumab iv soln 1200 mg/20ml* 5 PATEMODAR - temozolomide for iv soln 100 mg 5temsirolimus soln for iv infusion 25 mg/ml 5THALOMID - thalidomide cap 50 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 100 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 150 mg 5 PA, QL (60 capsules/30 days)THALOMID - thalidomide cap 200 mg 5 PA, QL (60 capsules/30 days)thiotepa for inj 15 mg 5TIBSOVO - ivosidenib tab 250 mg 5 PA, QL (60 tablets/30 days)

2020


Drug Name Drug Tier Requirements/Limitstopotecan hcl for inj 4 mg 4topotecan hcl inj 4 mg/4ml (for infusion) 4toremifene citrate tab 60 mg 5TREANDA - bendamustine hcl for iv soln 25 mg 5TREANDA - bendamustine hcl for iv soln 100 mg 5tretinoin cap 10 mg 5 PATRISENOX - arsenic trioxide iv soln 12 mg/6ml (2 mg/ml) 5TURALIO - pexidartinib hcl cap 200 mg 5 PA, QL (120 capsules/30 days)TYKERB - lapatinib ditosylate tab 250 mg* 5 PA, QL (180 tablets/30 days)UNITUXIN - dinutuximab iv soln 17.5 mg/5ml (3.5 mg/ml) 5 PAVALCHLOR - mechlorethamine hcl gel 0.016%* 5VECTIBIX - panitumumab iv soln 100 mg/5ml 5 PAVECTIBIX - panitumumab iv soln 400 mg/20ml 5 PAVELCADE - bortezomib for inj 3.5 mg 5 PAVENCLEXTA - venetoclax tab 10 mg* 3 PA, QL (60 tablets/30 days)VENCLEXTA - venetoclax tab 50 mg* 5 PA, QL (30 tablets/30 days)VENCLEXTA - venetoclax tab 100 mg* 5 PA, QL (180 tablets/30 days)VENCLEXTA STARTING PACK - venetoclax tab therapy starter

pack 10 & 50 & 100 mg*5 PA, QL (1 pack (42

tablets)/28 days)VERZENIO - abemaciclib tab 50 mg* 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 100 mg* 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 150 mg* 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 200 mg* 5 PA, QL (60 tablets/30 days)VINBLASTINE SULFATE - vinblastine sulfate inj 1 mg/ml 3 BDvincristine sulfate iv soln 1 mg/ml 3 BDvinorelbine tartrate inj 10 mg/ml 3vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) 3VITRAKVI - larotrectinib sulfate cap 25 mg 5 PA, QL (180 capsules/30 days)VITRAKVI - larotrectinib sulfate cap 100 mg 5 PA, QL (60 capsules/30 days)VITRAKVI - larotrectinib sulfate oral soln 20 mg/ml 5 PA, QL (300 mls/30 days)VIZIMPRO - dacomitinib tab 15 mg* 5 PA, QL (30 tablets/30 days)VIZIMPRO - dacomitinib tab 30 mg* 5 PA, QL (30 tablets/30 days)VIZIMPRO - dacomitinib tab 45 mg* 5 PA, QL (30 tablets/30 days)VOTRIENT - pazopanib hcl tab 200 mg* 5 PA, QL (120 tablets/30 days)VYXEOS - daunorubicin-cytarabine liposome for iv inj 44-100 mg 5 PAXALKORI - crizotinib cap 200 mg* 5 PA, QL (60 capsules/30 days)XALKORI - crizotinib cap 250 mg* 5 PA, QL (60 capsules/30 days)XOSPATA - gilteritinib fumarate tablet 40 mg 5 PA, QL (90 tablets/30 days)

2020


37

Drug Name Drug Tier Requirements/LimitsXPOVIO 100 MG ONCE WEEKLY - selinexor tab therapy pack

20 mg (100 mg once weekly)5 PA, QL (1 box/28 days)

XPOVIO 60 MG ONCE WEEKLY - selinexor tab therapy pack20 mg (60 mg once weekly)

5 PA, QL (1 box/28 days)

XPOVIO 80 MG ONCE WEEKLY - selinexor tab therapy pack20 mg (80 mg once weekly)


XPOVIO 80 MG TWICE WEEKLY - selinexor tab therapy pack20 mg (80 mg twice weekly)


XTANDI - enzalutamide cap 40 mg* 5 PA, QL (120 capsules/30 days)YERVOY - ipilimumab soln for iv infusion 50 mg/10ml (5 mg/ml)* 5 PAYERVOY - ipilimumab soln for iv infusion 200 mg/40ml (5 mg/ml)* 5 PAYONDELIS - trabectedin for inj 1 mg 5 PAYONSA - abiraterone acetate tab 125 mg* 5 PA, QL (120 tablets/30 days)ZALTRAP - ziv-aflibercept iv soln 100 mg/4ml (for infusion) 5 PAZALTRAP - ziv-aflibercept iv soln 200 mg/8ml (for infusion) 5 PAZANOSAR - streptozocin for inj 1 gm 4ZEJULA - niraparib tosylate cap 100 mg* 5 PA, QL (90 capsules/30 days)ZELBORAF - vemurafenib tab 240 mg* 5 PA, QL (240 tablets/30 days)ZOLINZA - vorinostat cap 100 mg 5 PA, QL (120 capsules/30 days)ZYDELIG - idelalisib tab 100 mg* 5 PA, QL (60 tablets/30 days)ZYDELIG - idelalisib tab 150 mg* 5 PA, QL (60 tablets/30 days)ZYKADIA - ceritinib cap 150 mg* 5 PA, QL (90 capsules/30 days)ZYKADIA - ceritinib tab 150 mg* 5 PA, QL (90 tablets/30 days)ZYTIGA - abiraterone acetate tab 500 mg* 5 PA, QL (60 tablets/30 days)Antiparasiticsalbendazole tab 200 mg 5ALINIA - nitazoxanide for susp 100 mg/5ml 5ALINIA - nitazoxanide tab 500 mg 5atovaquone susp 750 mg/5ml 5atovaquone-proguanil hcl tab 62.5-25 mg^ 2atovaquone-proguanil hcl tab 250-100 mg^ 2BENZNIDAZOLE - benznidazole tab 12.5 mg 4BENZNIDAZOLE - benznidazole tab 100 mg 4CHLOROQUINE PHOSPHATE - chloroquine phosphate tab

250 mg3

chloroquine phosphate tab 500 mg^ 2COARTEM - artemether-lumefantrine tab 20-120 mg 4DARAPRIM - pyrimethamine tab 25 mg 5hydroxychloroquine sulfate tab 200 mg^ 2ivermectin tab 3 mg^ 2

2020


Drug Name Drug Tier Requirements/LimitsLINDANE - lindane shampoo 1% 3malathion lotion 0.5% 3MEFLOQUINE HCL - mefloquine hcl tab 250 mg^ 2NEBUPENT - pentamidine isethionate for nebulization soln 300 mg 4 BDPENTAM 300 - pentamidine isethionate for soln 300 mg 4pentamidine isethionate for soln 300 mg 3permethrin cream 5% 3praziquantel tab 600 mg 4primaquine phosphate tab 26.3 mg 3Antiparkinson Agentsamantadine hcl cap 100 mg^ 2amantadine hcl syrup 50 mg/5ml^ 2amantadine hcl tab 100 mg^ 2APOKYN - apomorphine hcl soln cartridge 30 mg/3ml* 5 PA, QL (60 mls/30 days)benztropine mesylate tab 0.5 mg# 3 PAbenztropine mesylate tab 1 mg# 3 PAbenztropine mesylate tab 2 mg# 3 PAbromocriptine mesylate cap 5 mg 3bromocriptine mesylate tab 2.5 mg^ 2carbidopa & levodopa orally disintegrating tab 10-100 mg^ 2carbidopa & levodopa orally disintegrating tab 25-100 mg^ 2carbidopa & levodopa orally disintegrating tab 25-250 mg^ 2carbidopa & levodopa tab er 25-100 mg^ 2carbidopa & levodopa tab er 50-200 mg^ 2carbidopa & levodopa tab 10-100 mg^ 2carbidopa & levodopa tab 25-100 mg^ 2carbidopa & levodopa tab 25-250 mg^ 2carbidopa tab 25 mg 4CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-

entacapone tabs 12.5-50-200 mg4

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 18.75-75-200 mg

3

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 25-100-200 mg

4


4


4

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 50-200-200 mg

4

2020


39

Drug Name Drug Tier Requirements/Limitsentacapone tab 200 mg 3INBRIJA - levodopa inhal powder cap 42 mg 5 PA, QL (300 capsules/30 days)pramipexole dihydrochloride tab 0.125 mg^ 1pramipexole dihydrochloride tab 0.25 mg^ 1pramipexole dihydrochloride tab 0.5 mg^ 1pramipexole dihydrochloride tab 0.75 mg^ 2pramipexole dihydrochloride tab 1 mg^ 1pramipexole dihydrochloride tab 1.5 mg^ 2rasagiline mesylate tab 0.5 mg 4rasagiline mesylate tab 1 mg 4ropinirole hydrochloride tab 0.25 mg^ 2ropinirole hydrochloride tab 0.5 mg^ 2ropinirole hydrochloride tab 1 mg^ 2ropinirole hydrochloride tab 2 mg^ 2ropinirole hydrochloride tab 3 mg^ 2ropinirole hydrochloride tab 4 mg^ 2ropinirole hydrochloride tab 5 mg^ 2RYTARY - carbidopa & levodopa cap er 23.75-95 mg 4RYTARY - carbidopa & levodopa cap er 36.25-145 mg 4RYTARY - carbidopa & levodopa cap er 48.75-195 mg 4RYTARY - carbidopa & levodopa cap er 61.25-245 mg 4selegiline hcl cap 5 mg^ 2selegiline hcl tab 5 mg^ 2tolcapone tab 100 mg 5AntipsychoticsADASUVE - loxapine aerosol powder breath activated 10 mg 4 PAaripiprazole oral solution 1 mg/ml 4 QL (750 mls/30 days)aripiprazole orally disintegrating tab 10 mg 5 QL (60 tablets/30 days)aripiprazole orally disintegrating tab 15 mg 5 QL (60 tablets/30 days)aripiprazole tab 2 mg 3 QL (45 tablets/30 days)aripiprazole tab 5 mg 3 QL (45 tablets/30 days)aripiprazole tab 10 mg 3 QL (30 tablets/30 days)aripiprazole tab 15 mg 3 QL (30 tablets/30 days)aripiprazole tab 20 mg 3 QL (30 tablets/30 days)aripiprazole tab 30 mg 3 QL (30 tablets/30 days)ARISTADA - aripiprazole lauroxil im er susp prefilled syr

441 mg/1.6ml5 QL (1 syringe/28 days)

ARISTADA - aripiprazole lauroxil im er susp prefilled syr662 mg/2.4ml

5 QL (1 syringe/28 days)

2020


Drug Name Drug Tier Requirements/LimitsARISTADA - aripiprazole lauroxil im er susp prefilled syr

882 mg/3.2ml5 QL (1 syringe/28 days)

ARISTADA - aripiprazole lauroxil im er susp prefilled syr1064 mg/3.9ml


ARISTADA INITIO - aripiprazole lauroxil im er susp prefilled syr675 mg/2.4ml


clozapine orally disintegrating tab 12.5 mg 3 QL (90 tablets/30 days)clozapine orally disintegrating tab 25 mg 3 QL (270 tablets/30 days)clozapine orally disintegrating tab 100 mg 3 QL (270 tablets/30 days)clozapine tab 25 mg 3 QL (90 tablets/30 days)clozapine tab 50 mg 3 QL (90 tablets/30 days)clozapine tab 100 mg 3 QL (270 tablets/30 days)clozapine tab 200 mg 3 QL (120 tablets/30 days)FANAPT - iloperidone tab 1 mg 4 QL (60 tablets/30 days)FANAPT - iloperidone tab 2 mg 4 QL (60 tablets/30 days)FANAPT - iloperidone tab 4 mg 4 QL (60 tablets/30 days)FANAPT - iloperidone tab 6 mg 5 QL (60 tablets/30 days)FANAPT - iloperidone tab 8 mg 5 QL (60 tablets/30 days)FANAPT - iloperidone tab 10 mg 5 QL (60 tablets/30 days)FANAPT - iloperidone tab 12 mg 5 QL (60 tablets/30 days)FANAPT TITRATION PACK - iloperidone tab 1 mg & 2 mg & 4 mg

& 6 mg titration pak4 QL (7 packs (56 tablets)/28 days)

fluphenazine decanoate inj 25 mg/ml 3 PAFLUPHENAZINE HCL - fluphenazine hcl inj 2.5 mg/ml 3 PAFLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml 3 PAfluphenazine hcl tab 1 mg 3 PAfluphenazine hcl tab 2.5 mg 3 PAfluphenazine hcl tab 5 mg 3 PAfluphenazine hcl tab 10 mg 3 PAFLUPHENAZINE HYDROCHLORIDE - fluphenazine hcl elixir

2.5 mg/5ml3 PA

GEODON - ziprasidone mesylate for inj 20 mg 4 QL (60 vials/30 days)haloperidol decanoate im soln 50 mg/ml 3 PAhaloperidol decanoate im soln 100 mg/ml 3 PAhaloperidol lactate inj 5 mg/ml 3 PAhaloperidol lactate oral conc 2 mg/ml^ 2 PAhaloperidol tab 0.5 mg^ 2 PAhaloperidol tab 1 mg^ 2 PAhaloperidol tab 2 mg^ 2 PAhaloperidol tab 5 mg^ 2 PA

2020


41

Drug Name Drug Tier Requirements/Limitshaloperidol tab 10 mg^ 2 PAhaloperidol tab 20 mg^ 2 PAINVEGA SUSTENNA - paliperidone palmitate er susp pref syr

39 mg/0.25ml4 QL (1 kit/28 days)

INVEGA SUSTENNA - paliperidone palmitate er susp pref syr78 mg/0.5ml

5 QL (1 kit/28 days)



INVEGA SUSTENNA - paliperidone palmitate er susp pref syr156 mg/ml




INVEGA TRINZA - paliperidone palmitate er susp pref syr273 mg/0.875ml








LATUDA - lurasidone hcl tab 20 mg 5 QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 40 mg 5 QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 60 mg 5 QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 80 mg 5 QL (60 tablets/30 days)LATUDA - lurasidone hcl tab 120 mg 5 QL (30 tablets/30 days)loxapine succinate cap 5 mg^ 2 PAloxapine succinate cap 10 mg^ 2 PAloxapine succinate cap 25 mg^ 2 PAloxapine succinate cap 50 mg^ 2 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 5 mg 3 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 10 mg 3 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 25 mg 3 PANUPLAZID - pimavanserin tartrate cap 34 mg* 5 PA, QL (30 capsules/30 days)NUPLAZID - pimavanserin tartrate tab 10 mg* 5 PA, QL (30 tablets/30 days)olanzapine for im inj 10 mg 3 QL (90 vials/30 days)olanzapine orally disintegrating tab 5 mg^ 2 QL (30 tablets/30 days)olanzapine orally disintegrating tab 10 mg^ 2 QL (30 tablets/30 days)olanzapine orally disintegrating tab 15 mg^ 2 QL (30 tablets/30 days)olanzapine orally disintegrating tab 20 mg^ 2 QL (30 tablets/30 days)olanzapine tab 2.5 mg^ 2 QL (45 tablets/30 days)olanzapine tab 5 mg^ 2 QL (45 tablets/30 days)

2020


Drug Name Drug Tier Requirements/Limitsolanzapine tab 7.5 mg^ 2 QL (45 tablets/30 days)olanzapine tab 10 mg^ 2 QL (45 tablets/30 days)olanzapine tab 15 mg^ 2 QL (30 tablets/30 days)olanzapine tab 20 mg^ 2 QL (30 tablets/30 days)paliperidone tab er 24hr 1.5 mg 3 QL (30 tablets/30 days)paliperidone tab er 24hr 3 mg 4 QL (30 tablets/30 days)paliperidone tab er 24hr 6 mg 4 QL (60 tablets/30 days)paliperidone tab er 24hr 9 mg 5 QL (30 tablets/30 days)PERSERIS - risperidone subcutaneous for er susp prefilled syr

90 mg5 QL (1 syringe/30 days)

PERSERIS - risperidone subcutaneous for er susp prefilled syr120 mg


PIMOZIDE - pimozide tab 1 mg^ 2PIMOZIDE - pimozide tab 2 mg^ 2quetiapine fumarate tab er 24hr 50 mg^ 2 QL (60 tablets/30 days)quetiapine fumarate tab er 24hr 150 mg^ 2 QL (30 tablets/30 days)quetiapine fumarate tab er 24hr 200 mg^ 2 QL (30 tablets/30 days)quetiapine fumarate tab er 24hr 300 mg^ 2 QL (60 tablets/30 days)quetiapine fumarate tab er 24hr 400 mg^ 2 QL (60 tablets/30 days)quetiapine fumarate tab 25 mg^ 2 QL (120 tablets/30 days)quetiapine fumarate tab 50 mg^ 2 QL (120 tablets/30 days)quetiapine fumarate tab 100 mg^ 2 QL (120 tablets/30 days)quetiapine fumarate tab 200 mg^ 2 QL (120 tablets/30 days)quetiapine fumarate tab 300 mg^ 2 QL (60 tablets/30 days)quetiapine fumarate tab 400 mg^ 2 QL (60 tablets/30 days)REXULTI - brexpiprazole tab 0.25 mg 5 QL (30 tablets/30 days)REXULTI - brexpiprazole tab 0.5 mg 5 QL (30 tablets/30 days)REXULTI - brexpiprazole tab 1 mg 5 QL (30 tablets/30 days)REXULTI - brexpiprazole tab 2 mg 5 QL (30 tablets/30 days)REXULTI - brexpiprazole tab 3 mg 5 QL (30 tablets/30 days)REXULTI - brexpiprazole tab 4 mg 5 QL (30 tablets/30 days)RISPERDAL CONSTA - risperidone microspheres for im extended

rel susp 12.5 mg4 QL (2 vials/28 days)

RISPERDAL CONSTA - risperidone microspheres for im extendedrel susp 25 mg

5 QL (2 vials/28 days)

RISPERDAL CONSTA - risperidone microspheres for im extendedrel susp 37.5 mg


RISPERDAL CONSTA - risperidone microspheres for im extendedrel susp 50 mg


RISPERIDONE ODT - risperidone orally disintegrating tab 0.25 mg 3 QL (60 tablets/30 days)

2020


43

Drug Name Drug Tier Requirements/Limitsrisperidone orally disintegrating tab 0.5 mg 3 QL (60 tablets/30 days)risperidone orally disintegrating tab 1 mg 3 QL (60 tablets/30 days)risperidone orally disintegrating tab 2 mg 3 QL (60 tablets/30 days)risperidone orally disintegrating tab 3 mg 3 QL (60 tablets/30 days)risperidone orally disintegrating tab 4 mg 3 QL (120 tablets/30 days)risperidone soln 1 mg/ml^ 2 QL (480 mls/30 days)risperidone tab 0.25 mg^ 2 QL (60 tablets/30 days)risperidone tab 0.5 mg^ 2 QL (60 tablets/30 days)risperidone tab 1 mg^ 2 QL (60 tablets/30 days)risperidone tab 2 mg^ 2 QL (60 tablets/30 days)risperidone tab 3 mg^ 2 QL (60 tablets/30 days)risperidone tab 4 mg^ 2 QL (120 tablets/30 days)SAPHRIS - asenapine maleate sl tab 2.5 mg 4 QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 5 mg 4 QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 10 mg 4 QL (60 tablets/30 days)thioridazine hcl tab 10 mg 3 PAthioridazine hcl tab 25 mg 3 PAthioridazine hcl tab 50 mg 3 PAthioridazine hcl tab 100 mg 3 PAthiothixene cap 1 mg^ 2 PAthiothixene cap 2 mg^ 2 PAthiothixene cap 5 mg^ 2 PAthiothixene cap 10 mg^ 2 PAtrifluoperazine hcl tab 1 mg 3 PAtrifluoperazine hcl tab 2 mg 3 PAtrifluoperazine hcl tab 5 mg 3 PAtrifluoperazine hcl tab 10 mg 3 PAVERSACLOZ - clozapine susp 50 mg/ml 5 QL (540 mls/30 days)VRAYLAR - cariprazine hcl cap 1.5 mg 4 QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 3 mg 4 QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 4.5 mg 4 QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 6 mg 4 QL (30 capsules/30 days)ziprasidone hcl cap 20 mg^ 2 QL (90 capsules/30 days)ziprasidone hcl cap 40 mg^ 2 QL (90 capsules/30 days)ziprasidone hcl cap 60 mg^ 2 QL (60 capsules/30 days)ziprasidone hcl cap 80 mg^ 2 QL (60 capsules/30 days)ZYPREXA RELPREVV - olanzapine pamoate for extended rel im

susp 210 mg5 QL (2 vials/28 days)

2020


Drug Name Drug Tier Requirements/LimitsZYPREXA RELPREVV - olanzapine pamoate for extended rel im

susp 300 mg5 QL (2 vials/28 days)

ZYPREXA RELPREVV - olanzapine pamoate for extended rel imsusp 405 mg

5 QL (1 vial/28 days)

Antispasticity Agentsbaclofen tab 10 mg^ 2baclofen tab 20 mg^ 2dantrolene sodium cap 25 mg^ 2dantrolene sodium cap 50 mg^ 2dantrolene sodium cap 100 mg^ 2tizanidine hcl cap 2 mg^ 2tizanidine hcl cap 4 mg^ 2tizanidine hcl cap 6 mg 3tizanidine hcl tab 2 mg^ 2tizanidine hcl tab 4 mg^ 2Antiviralsabacavir sulfate soln 20 mg/ml 3 QL (960 mls/30 days)abacavir sulfate tab 300 mg 3 QL (60 tablets/30 days)abacavir sulfate-lamivudine tab 600-300 mg 4 QL (30 tablets/30 days)abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg 5 QL (60 tablets/30 days)acyclovir cap 200 mg^ 2acyclovir oint 5% 3 PAacyclovir sodium iv soln 50 mg/ml 3 BDacyclovir susp 200 mg/5ml 3acyclovir tab 400 mg^ 2acyclovir tab 800 mg^ 2adefovir dipivoxil tab 10 mg 5APTIVUS - tipranavir cap 250 mg 5 QL (120 capsules/30 days)APTIVUS - tipranavir oral soln 100 mg/ml 5 QL (380 mls/30 days)atazanavir sulfate cap 150 mg 5 QL (30 capsules/30 days)atazanavir sulfate cap 200 mg 5 QL (60 capsules/30 days)atazanavir sulfate cap 300 mg 5 QL (30 capsules/30 days)ATRIPLA - efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg 5 QL (30 tablets/30 days)BARACLUDE - entecavir oral soln 0.05 mg/ml 5BIKTARVY - bictegravir-emtricitabine-tenofovir af tab 50-200-25 mg 5 QL (30 tablets/30 days)cidofovir iv inj 75 mg/ml 5CIMDUO - lamivudine-tenofovir disoproxil fumarate tab 300-300 mg 5 QL (30 tablets/30 days)COMPLERA - emtricitabine-rilpivirine-tenofovir df tab

200-25-300 mg5 QL (30 tablets/30 days)

CRIXIVAN - indinavir sulfate cap 200 mg 3 QL (270 capsules/30 days)

2020


45

Drug Name Drug Tier Requirements/LimitsCRIXIVAN - indinavir sulfate cap 400 mg 3 QL (180 capsules/30 days)DELSTRIGO - doravirine-lamivudine-tenofovir df tab

100-300-300 mg5 QL (30 tablets/30 days)

DENAVIR - penciclovir cream 1% 5DESCOVY - emtricitabine-tenofovir alafenamide fumarate tab

200-25 mg5 QL (30 tablets/30 days)

didanosine delayed release capsule 200 mg^ 2 QL (30 capsules/30 days)didanosine delayed release capsule 250 mg^ 2 QL (30 capsules/30 days)didanosine delayed release capsule 400 mg 3 QL (30 capsules/30 days)DOVATO - dolutegravir sodium-lamivudine tab 50-300 mg 5 QL (30 tablets/30 days)EDURANT - rilpivirine hcl tab 25 mg 5 QL (30 tablets/30 days)efavirenz cap 50 mg^ 2 QL (90 capsules/30 days)efavirenz cap 200 mg 5 QL (120 capsules/30 days)efavirenz tab 600 mg 5 QL (30 tablets/30 days)EMTRIVA - emtricitabine caps 200 mg 4 QL (30 capsules/30 days)EMTRIVA - emtricitabine soln 10 mg/ml 4 QL (850 mls/30 days)entecavir tab 0.5 mg 4entecavir tab 1 mg 4EPCLUSA - sofosbuvir-velpatasvir tab 400-100 mg 5 PAEPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv) 3EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg 5 QL (30 tablets/30 days)famciclovir tab 125 mg^ 2famciclovir tab 250 mg^ 2famciclovir tab 500 mg^ 2fosamprenavir calcium tab 700 mg 5 QL (120 tablets/30 days)FUZEON - enfuvirtide for inj 90 mg 5 QL (60 vials/30 days)ganciclovir sodium for inj 500 mg 3 BDGENVOYA - elvitegrav-cobic-emtricitab-tenofov af tab

150-150-200-10 mg5 QL (30 tablets/30 days)

HARVONI - ledipasvir-sofosbuvir tab 90-400 mg 5 PAINTELENCE - etravirine tab 25 mg 4 QL (120 tablets/30 days)INTELENCE - etravirine tab 100 mg 5 QL (60 tablets/30 days)INTELENCE - etravirine tab 200 mg 5 QL (60 tablets/30 days)INTRON A - interferon alfa-2b inj 6000000 unit/ml 5INTRON A - interferon alfa-2b inj 10000000 unit/ml 5INTRON A - interferon alfa-2b for inj 10000000 unit 5INTRON A - interferon alfa-2b for inj 18000000 unit 5INTRON A - interferon alfa-2b for inj 50000000 unit 5INVIRASE - saquinavir mesylate tab 500 mg 5 QL (120 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsISENTRESS - raltegravir potassium chew tab 25 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 100 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium packet for susp 100 mg 4 QL (60 packets/30 days)ISENTRESS - raltegravir potassium tab 400 mg 5 QL (60 tablets/30 days)ISENTRESS HD - raltegravir potassium tab 600 mg 5 QL (60 tablets/30 days)JULUCA - dolutegravir sodium-rilpivirine hcl tab 50-25 mg 5 QL (30 tablets/30 days)KALETRA - lopinavir-ritonavir tab 100-25 mg 4 QL (300 tablets/30 days)KALETRA - lopinavir-ritonavir tab 200-50 mg 5 QL (120 tablets/30 days)lamivudine oral soln 10 mg/ml^ 2 QL (960 mls/30 days)lamivudine tab 100 mg (hbv) 3lamivudine tab 150 mg^ 2 QL (60 tablets/30 days)lamivudine tab 300 mg^ 2 QL (30 tablets/30 days)lamivudine-zidovudine tab 150-300 mg 3 QL (60 tablets/30 days)LEDIPASVIR/SOFOSBUVIR - ledipasvir-sofosbuvir tab 90-400 mg 5 PALEXIVA - fosamprenavir calcium susp 50 mg/ml 4 QL (1800 mls/30 days)lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 5 QL (480 mls/30 days)MAVYRET - glecaprevir-pibrentasvir tab 100-40 mg 5 PAnevirapine susp 50 mg/5ml 3 QL (1200 mls/30 days)nevirapine tab er 24hr 100 mg 3 QL (90 tablets/30 days)nevirapine tab er 24hr 400 mg 3 QL (30 tablets/30 days)nevirapine tab 200 mg^ 2 QL (60 tablets/30 days)NORVIR - ritonavir oral soln 80 mg/ml 4 QL (480 mls/30 days)NORVIR - ritonavir powder packet 100 mg 4 QL (360 packets/30 days)ODEFSEY - emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg 5 QL (30 tablets/30 days)oseltamivir phosphate cap 30 mg^ 2oseltamivir phosphate cap 45 mg^ 2oseltamivir phosphate cap 75 mg^ 2oseltamivir phosphate for susp 6 mg/ml 3PEGASYS - peginterferon alfa-2a inj 180 mcg/ml 5 PAPEGASYS - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PAPEGASYS PROCLICK - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PAPIFELTRO - doravirine tab 100 mg 5 QL (30 tablets/30 days)PREVYMIS - letermovir tab 240 mg 5 QL (30 tablets/30 days)PREVYMIS - letermovir tab 480 mg 5 QL (30 tablets/30 days)PREZCOBIX - darunavir-cobicistat tab 800-150 mg 5 QL (30 tablets/30 days)PREZISTA - darunavir ethanolate susp 100 mg/ml 5 QL (400 mls/30 days)PREZISTA - darunavir ethanolate tab 75 mg 4 QL (300 tablets/30 days)PREZISTA - darunavir ethanolate tab 150 mg 4 QL (180 tablets/30 days)

2020


47

Drug Name Drug Tier Requirements/LimitsPREZISTA - darunavir ethanolate tab 600 mg 5 QL (60 tablets/30 days)PREZISTA - darunavir ethanolate tab 800 mg 5 QL (30 tablets/30 days)REBETOL - ribavirin soln 40 mg/ml 4RELENZA DISKHALER - zanamivir aero powder breath activated

5 mg/blister4

RESCRIPTOR - delavirdine mesylate tab 200 mg 4 QL (180 tablets/30 days)RETROVIR IV INFUSION - zidovudine iv soln 10 mg/ml 4REYATAZ - atazanavir sulfate oral powder packet 50 mg 5 QL (240 packets/30 days)RIBASPHERE - ribavirin tab 400 mg 5RIBASPHERE - ribavirin tab 600 mg 5RIBASPHERE RIBAPAK - ribavirin tab therapy pack 400 mg

(800 mg daily dose)5

RIBASPHERE RIBAPAK - ribavirin tab therapy pack 600 mg(1200 mg daily dose)

5

ribavirin cap 200 mg^ 2ribavirin tab 200 mg^ 2ritonavir tab 100 mg 3 QL (360 tablets/30 days)SELZENTRY - maraviroc oral soln 20 mg/ml 5 QL (1840 mls/30 days)SELZENTRY - maraviroc tab 25 mg 4 QL (240 tablets/30 days)SELZENTRY - maraviroc tab 75 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 150 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 300 mg 5 QL (120 tablets/30 days)SOFOSBUVIR/VELPATASVIR - sofosbuvir-velpatasvir tab

400-100 mg5 PA

SOVALDI - sofosbuvir tab 400 mg 5 PAstavudine cap 15 mg^ 2 QL (60 capsules/30 days)stavudine cap 20 mg^ 2 QL (60 capsules/30 days)stavudine cap 30 mg^ 2 QL (60 capsules/30 days)stavudine cap 40 mg^ 2 QL (60 capsules/30 days)STRIBILD - elvitegrav-cobic-emtricitab-tenofovdf tab


SYLATRON - peginterferon alfa-2b for inj kit 200 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 300 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 600 mcg 5 PASYMFI - efavirenz-lamivudine-tenofovir df tab 600-300-300 mg 5 QL (30 tablets/30 days)SYMFI LO - efavirenz-lamivudine-tenofovir df tab 400-300-300 mg 5 QL (30 tablets/30 days)SYMTUZA - darunavir-cobic-emtricitab-tenofov af tab


tenofovir disoproxil fumarate tab 300 mg 4 QL (30 tablets/30 days)TIVICAY - dolutegravir sodium tab 10 mg 4 QL (60 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsTIVICAY - dolutegravir sodium tab 25 mg 5 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 50 mg 5 QL (60 tablets/30 days)TRIUMEQ - abacavir-dolutegravir-lamivudine tab 600-50-300 mg 5 QL (30 tablets/30 days)TROGARZO - ibalizumab-uiyk iv soln 200 mg/1.33ml (150 mg/ml) 5 QL (14 vials/28 days)TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab


TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab133-200 mg

5 QL (30 tablets/30 days)





TYBOST - cobicistat tab 150 mg 3 QL (30 tablets/30 days)valacyclovir hcl tab 500 mg^ 2valacyclovir hcl tab 1 gm^ 2valganciclovir hcl for soln 50 mg/ml 5valganciclovir hcl tab 450 mg 5VIDEX - didanosine for soln 2 gm 4 QL (1200 mls/30 days)VIDEX - didanosine for soln 4 gm 4 QL (1200 mls/30 days)VIDEX EC - didanosine delayed release capsule 125 mg 4 QL (30 capsules/30 days)VIDEX EC - didanosine delayed release capsule 200 mg 4 QL (30 capsules/30 days)VIDEX EC - didanosine delayed release capsule 250 mg 4 QL (30 capsules/30 days)VIDEX EC - didanosine delayed release capsule 400 mg 4 QL (30 capsules/30 days)VIEKIRA PAK - ombitas-paritapre-riton & dasab tab pak 12.5-75-50

& 250 mg5 PA

VIRACEPT - nelfinavir mesylate tab 250 mg 5 QL (270 tablets/30 days)VIRACEPT - nelfinavir mesylate tab 625 mg 5 QL (120 tablets/30 days)VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/gm 5 QL (240 grams/30 days)VIREAD - tenofovir disoproxil fumarate tab 150 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 200 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 250 mg 5 QL (30 tablets/30 days)VOSEVI - sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mg 5 PAXOFLUZA - baloxavir marboxil tab therapy pack 20 (2) mg (40 mg

dose)4

XOFLUZA - baloxavir marboxil tab therapy pack 40 (2) mg (80 mgdose)

4

ZEPATIER - elbasvir-grazoprevir tab 50-100 mg 5 PAzidovudine cap 100 mg^ 2 QL (180 capsules/30 days)zidovudine syrup 10 mg/ml 3 QL (1920 mls/30 days)zidovudine tab 300 mg^ 2 QL (60 tablets/30 days)

2020


49

Drug Name Drug Tier Requirements/LimitsAnxiolyticsalprazolam tab 0.25 mg 3 QL (120 tablets/30 days)alprazolam tab 0.5 mg 3 QL (120 tablets/30 days)alprazolam tab 1 mg 3 QL (120 tablets/30 days)alprazolam tab 2 mg 3 QL (150 tablets/30 days)buspirone hcl tab 5 mg^ 1buspirone hcl tab 7.5 mg^ 2buspirone hcl tab 10 mg^ 1buspirone hcl tab 15 mg^ 1buspirone hcl tab 30 mg^ 2clonazepam orally disintegrating tab 0.125 mg^ 2 QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.25 mg^ 2 QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.5 mg^ 2 QL (90 tablets/30 days)clonazepam orally disintegrating tab 1 mg^ 2 QL (90 tablets/30 days)clonazepam orally disintegrating tab 2 mg^ 2 QL (300 tablets/30 days)clonazepam tab 0.5 mg^ 1 QL (120 tablets/30 days)clonazepam tab 1 mg^ 1 QL (120 tablets/30 days)clonazepam tab 2 mg^ 1 QL (300 tablets/30 days)clorazepate dipotassium tab 3.75 mg^ 2 PA, QL (120 tablets/30 days)clorazepate dipotassium tab 7.5 mg^ 2 PA, QL (360 tablets/30 days)clorazepate dipotassium tab 15 mg^ 2 PA, QL (180 tablets/30 days)DIAZEPAM - diazepam oral soln 1 mg/ml 3 PA, QL (1200 mls/30 days)diazepam conc 5 mg/ml^ 2 PA, QL (240 mls/30 days)diazepam tab 2 mg^ 1 PA, QL (120 tablets/30 days)diazepam tab 5 mg^ 1 PA, QL (120 tablets/30 days)diazepam tab 10 mg^ 1 PA, QL (120 tablets/30 days)hydroxyzine hcl syrup 10 mg/5ml# 3 PAhydroxyzine hcl tab 10 mg# 3 PAhydroxyzine hcl tab 25 mg# 3 PAhydroxyzine hcl tab 50 mg# 3 PAlorazepam tab 0.5 mg^ 1 PA, QL (120 tablets/30 days)lorazepam tab 1 mg^ 1 PA, QL (120 tablets/30 days)lorazepam tab 2 mg^ 1 PA, QL (150 tablets/30 days)Bipolar AgentsLITHIUM - lithium oral solution 8 meq/5ml 3lithium carbonate cap 150 mg^ 2lithium carbonate cap 300 mg^ 1lithium carbonate cap 600 mg^ 2lithium carbonate tab er 300 mg^ 2

2020


Drug Name Drug Tier Requirements/Limitslithium carbonate tab er 450 mg^ 2lithium carbonate tab 300 mg^ 2Blood Glucose Regulatorsacarbose tab 25 mg^ 2 QL (360 tablets/30 days)acarbose tab 50 mg^ 2 QL (180 tablets/30 days)acarbose tab 100 mg^ 2 QL (90 tablets/30 days)ALCOHOL SWABS 3BASAGLAR KWIKPEN - insulin glargine soln pen-injector 100 unit/

ml4 QL (20 pens/30 days)

BYDUREON BCISE - exenatide extended release susp auto-injector 2 mg/0.85ml

3 QL (4 pens/28 days), ST

BYDUREON PEN - exenatide extended release for susp pen-injector 2 mg

3 QL (4 pens/28 days), ST

CYCLOSET - bromocriptine mesylate tab 0.8 mg 4 QL (180 tablets/30 days)GAUZE PADS 2" X 2" 3glimepiride tab 1 mg^ 1 QL (240 tablets/30 days)glimepiride tab 2 mg^ 1 QL (120 tablets/30 days)glimepiride tab 4 mg^ 1 QL (60 tablets/30 days)glipizide tab er 24hr 2.5 mg^ 1 QL (240 tablets/30 days)glipizide tab er 24hr 5 mg^ 1 QL (120 tablets/30 days)glipizide tab er 24hr 10 mg^ 1 QL (60 tablets/30 days)glipizide tab 5 mg^ 1 QL (240 tablets/30 days)glipizide tab 10 mg^ 1 QL (120 tablets/30 days)glipizide-metformin hcl tab 2.5-250 mg^ 1 QL (240 tablets/30 days)glipizide-metformin hcl tab 2.5-500 mg^ 1 QL (120 tablets/30 days)glipizide-metformin hcl tab 5-500 mg^ 1 QL (120 tablets/30 days)GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg 3GLUCAGON EMERGENCY KIT - glucagon (rdna) for inj kit 1 mg 3GLYXAMBI - empagliflozin-linagliptin tab 10-5 mg 4 QL (30 tablets/30 days)GLYXAMBI - empagliflozin-linagliptin tab 25-5 mg 4 QL (30 tablets/30 days)HUMALOG - insulin lispro inj 100 unit/ml 3 QL (60 mls/30 days)HUMALOG - insulin lispro soln cartridge 100 unit/ml 3 QL (20 cartridges/30 days)HUMALOG JUNIOR KWIKPEN - insulin lispro soln pen-injector 100

unit/ml (0.5 unit dial)3 QL (20 pens/30 days)

HUMALOG KWIKPEN - insulin lispro soln pen-injector 100 unit/ml(1 unit dial)

3 QL (20 pens/30 days)

HUMALOG KWIKPEN - insulin lispro soln pen-injector 200 unit/ml 3 QL (20 pens/30 days)HUMALOG MIX 50/50 - insulin lispro protamine & lispro inj 100

unit/ml (50-50)3 QL (6 vials/30 days)

HUMALOG MIX 50/50 KWIKPEN - insulin lispro prot & lispro suspen-inj 100 unit/ml (50-50)


2020


51

Drug Name Drug Tier Requirements/LimitsHUMALOG MIX 75/25 - insulin lispro prot & lispro inj 100 unit/ml

(75-25)3 QL (6 vials/30 days)

HUMALOG MIX 75/25 KWIKPEN - insulin lispro prot & lispro suspen-inj 100 unit/ml (75-25)


HUMULIN N - insulin nph (human) (isophane) inj 100 unit/ml 3 QL (60 mls/30 days)HUMULIN N KWIKPEN - insulin nph (human) (isophane) susp pen-

injector 100 unit/ml3 QL (20 pens/30 days)

HUMULIN R - insulin regular (human) inj 100 unit/ml 3 QL (60 mls/30 days)HUMULIN R U-500 (CONCENTRATE) - insulin regular (human) inj

500 unit/ml3 BD

HUMULIN R U-500 KWIKPEN - insulin regular (human) soln pen-injector 500 unit/ml


HUMULIN 70/30 - insulin nph isophane & regular human inj 100unit/ml (70-30)

3 QL (60 mls/30 days)

HUMULIN 70/30 KWIKPEN - insulin nph & regular susp pen-inj 100unit/ml (70-30)


INSULIN INJECTION DEVICE 3INSULIN SYRINGE/NEEDLE 3INVOKAMET - canagliflozin-metformin hcl tab 50-500 mg 3 QL (120 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-500 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-1000 mg 3 QL (60 tablets/30 days)INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr


INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr50-1000 mg






INVOKANA - canagliflozin tab 100 mg 3 QL (90 tablets/30 days)INVOKANA - canagliflozin tab 300 mg 3 QL (30 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-500 mg 3 QL (60 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-500 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 100-1000 mg 3 QL (30 tablets/30 days)JANUVIA - sitagliptin phosphate tab 25 mg 3 QL (120 tablets/30 days)JANUVIA - sitagliptin phosphate tab 50 mg 3 QL (60 tablets/30 days)JANUVIA - sitagliptin phosphate tab 100 mg 3 QL (30 tablets/30 days)JARDIANCE - empagliflozin tab 10 mg 3 QL (60 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsJARDIANCE - empagliflozin tab 25 mg 3 QL (30 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-500 mg 4 QL (60 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-850 mg 4 QL (60 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-1000 mg 4 QL (60 tablets/30 days)JENTADUETO XR - linagliptin-metformin hcl tab er 24hr

2.5-1000 mg4 QL (60 tablets/30 days)

JENTADUETO XR - linagliptin-metformin hcl tab er 24hr 5-1000 mg 4 QL (30 tablets/30 days)KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr

2.5-1000 mg3 QL (60 tablets/30 days)

KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr 5-500 mg 3 QL (30 tablets/30 days)KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr


LANTUS - insulin glargine inj 100 unit/ml 3 QL (6 vials/30 days)LANTUS SOLOSTAR - insulin glargine soln pen-injector 100 unit/ml 3 QL (20 pens/30 days)LEVEMIR - insulin detemir inj 100 unit/ml 3 QL (6 vials/30 days)LEVEMIR FLEXTOUCH - insulin detemir soln pen-injector 100 unit/

ml3 QL (20 pens/30 days)

metformin hcl tab er 24hr 500 mg^ 1 QL (120 tablets/30 days)metformin hcl tab er 24hr 750 mg^ 1 QL (60 tablets/30 days)metformin hcl tab 500 mg^ 1 QL (150 tablets/30 days)metformin hcl tab 850 mg^ 1 QL (90 tablets/30 days)metformin hcl tab 1000 mg^ 1 QL (75 tablets/30 days)nateglinide tab 60 mg^ 1 QL (180 tablets/30 days)nateglinide tab 120 mg^ 1 QL (90 tablets/30 days)ONGLYZA - saxagliptin hcl tab 2.5 mg 3 QL (60 tablets/30 days)ONGLYZA - saxagliptin hcl tab 5 mg 3 QL (30 tablets/30 days)OZEMPIC - semaglutide soln pen-inj 0.25 or 0.5 mg/dose

(2 mg/1.5ml)3 QL (1 pen/28 days), ST

OZEMPIC - semaglutide soln pen-inj 1 mg/dose (2 mg/1.5ml) 3 QL (2 pens/28 days), STpioglitazone hcl tab 15 mg^ 1 QL (90 tablets/30 days)pioglitazone hcl tab 30 mg^ 1 QL (30 tablets/30 days)pioglitazone hcl tab 45 mg^ 1 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-2 mg^ 1 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-4 mg^ 1 QL (30 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-500 mg^ 1 QL (90 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-850 mg^ 1 QL (90 tablets/30 days)PROGLYCEM - diazoxide susp 50 mg/ml 4repaglinide tab 0.5 mg^ 1 QL (960 tablets/30 days)repaglinide tab 1 mg^ 1 QL (480 tablets/30 days)repaglinide tab 2 mg^ 1 QL (240 tablets/30 days)

2020


53

Drug Name Drug Tier Requirements/LimitsSYMLINPEN 120 - pramlintide acetate pen-inj 2700 mcg/2.7ml

(1000 mcg/ml)5

SYMLINPEN 60 - pramlintide acetate pen-inj 1500 mcg/1.5ml(1000 mcg/ml)

5

SYNJARDY - empagliflozin-metformin hcl tab 5-500 mg 3 QL (120 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 5-1000 mg 3 QL (60 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 12.5-500 mg 3 QL (60 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 12.5-1000 mg 3 QL (60 tablets/30 days)SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr


SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr10-1000 mg


SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr12.5-1000 mg


SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr25-1000 mg


TOUJEO MAX SOLOSTAR - insulin glargine soln pen-injector 300unit/ml (2 unit dial)


TOUJEO SOLOSTAR - insulin glargine soln pen-injector 300 unit/ml (1 unit dial)


TRADJENTA - linagliptin tab 5 mg 4 QL (30 tablets/30 days)TRESIBA - insulin degludec inj 100 unit/ml 3 QL (6 vials/30 days)TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 100

unit/ml3 QL (20 pens/30 days)

TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 200unit/ml


TRULICITY - dulaglutide soln pen-injector 0.75 mg/0.5ml 3 QL (4 pens/28 days), STTRULICITY - dulaglutide soln pen-injector 1.5 mg/0.5ml 3 QL (4 pens/28 days), STVICTOZA - liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) 3 QL (1 package/30 days), STBlood Products/Modifiers/Volume Expandersanagrelide hcl cap 0.5 mg^ 2anagrelide hcl cap 1 mg^ 2ARANESP ALBUMIN FREE - darbepoetin alfa soln inj 25 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 40 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 60 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 100 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 200 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 300 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe

10 mcg/0.4ml4 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe25 mcg/0.42ml

4 PA

2020


Drug Name Drug Tier Requirements/LimitsARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe

40 mcg/0.4ml4 PA


5 PA


5 PA


5 PA


5 PA


5 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe500 mcg/ml

5 PA

aspirin-dipyridamole cap er 12hr 25-200 mg 3azacitidine for inj 100 mg 5BEVYXXA - betrixaban maleate cap 40 mg 4 QL (43 capsules/42 days)BEVYXXA - betrixaban maleate cap 80 mg 4 QL (43 capsules/42 days)BRILINTA - ticagrelor tab 60 mg 3BRILINTA - ticagrelor tab 90 mg 3cilostazol tab 50 mg^ 2cilostazol tab 100 mg^ 2clopidogrel bisulfate tab 75 mg^ 1COUMADIN - warfarin sodium tab 1 mg 4COUMADIN - warfarin sodium tab 2 mg 4COUMADIN - warfarin sodium tab 2.5 mg 4COUMADIN - warfarin sodium tab 3 mg 4COUMADIN - warfarin sodium tab 4 mg 4COUMADIN - warfarin sodium tab 5 mg 4COUMADIN - warfarin sodium tab 6 mg 4COUMADIN - warfarin sodium tab 7.5 mg 4COUMADIN - warfarin sodium tab 10 mg 4dipyridamole tab 25 mg# 3dipyridamole tab 50 mg# 3dipyridamole tab 75 mg# 3ELIQUIS - apixaban tab 2.5 mg 3 QL (60 tablets/30 days)ELIQUIS - apixaban tab 5 mg 3 QL (74 tablets/30 days)ELIQUIS STARTER PACK - apixaban tab 5 mg 3 QL (74 tablets/30 days)enoxaparin sodium inj 30 mg/0.3ml 3 QL (30 syringes/90 days)enoxaparin sodium inj 40 mg/0.4ml 3 QL (30 syringes/90 days)

2020


55

Drug Name Drug Tier Requirements/Limitsenoxaparin sodium inj 60 mg/0.6ml 3 QL (30 syringes/90 days)enoxaparin sodium inj 80 mg/0.8ml 3 QL (30 syringes/90 days)enoxaparin sodium inj 100 mg/ml 3 QL (30 syringes/90 days)enoxaparin sodium inj 120 mg/0.8ml 3 QL (30 syringes/90 days)enoxaparin sodium inj 150 mg/ml 3 QL (30 syringes/90 days)enoxaparin sodium inj 300 mg/3ml 3 QL (10 vials/90 days)EPOGEN - epoetin alfa inj 2000 unit/ml 4 PAEPOGEN - epoetin alfa inj 3000 unit/ml 4 PAEPOGEN - epoetin alfa inj 4000 unit/ml 4 PAEPOGEN - epoetin alfa inj 10000 unit/ml 4 PAEPOGEN - epoetin alfa inj 20000 unit/ml 5 PAfondaparinux sodium subcutaneous inj 2.5 mg/0.5ml 3 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 5 mg/0.4ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 10 mg/0.8ml 5 QL (30 syringes/90 days)FULPHILA - pegfilgrastim-jmdb soln prefilled syringe 6 mg/0.6ml 5 PAGRANIX - tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml 5 PAGRANIX - tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml 5 PAGRANIX - tbo-filgrastim subcutaneous inj 300 mcg/ml 5 PAGRANIX - tbo-filgrastim subcutaneous inj 480 mcg/1.6ml (300 mcg/

ml)5 PA

HEPARIN SODIUM - heparin sodium (porcine) inj soln pref syr5000 unit/0.5ml

3

HEPARIN SODIUM - heparin sodium (porcine) pf inj 5000 unit/ml 3heparin sodium (porcine) inj 1000 unit/ml 3heparin sodium (porcine) inj 5000 unit/ml 3heparin sodium (porcine) inj 10000 unit/ml 3heparin sodium (porcine) inj 20000 unit/ml 3heparin sodium (porcine) pf inj 5000 unit/0.5ml 3HEPARIN SODIUM/D5W - heparin sodium (porcine)-dextrose iv sol

20000 unit/500ml-5%3

LEUKINE - sargramostim lyophilized for inj 250 mcg 5 PAMOZOBIL - plerixafor subcutaneous inj 24 mg/1.2ml (20 mg/ml) 5NIVESTYM - filgrastim-aafi inj 300 mcg/ml 5 PANIVESTYM - filgrastim-aafi inj 480 mcg/1.6ml (300 mcg/ml) 5 PANIVESTYM - filgrastim-aafi soln prefilled syringe 300 mcg/0.5ml 5 PANIVESTYM - filgrastim-aafi soln prefilled syringe 480 mcg/0.8ml 5 PAPRADAXA - dabigatran etexilate mesylate cap 75 mg 4 QL (60 capsules/30 days)PRADAXA - dabigatran etexilate mesylate cap 110 mg 4 QL (71 capsules/90 days)

2020


Drug Name Drug Tier Requirements/LimitsPRADAXA - dabigatran etexilate mesylate cap 150 mg 4 QL (60 capsules/30 days)prasugrel hcl tab 5 mg 3prasugrel hcl tab 10 mg 3PROCRIT - epoetin alfa inj 2000 unit/ml 4 PAPROCRIT - epoetin alfa inj 3000 unit/ml 4 PAPROCRIT - epoetin alfa inj 4000 unit/ml 4 PAPROCRIT - epoetin alfa inj 10000 unit/ml 4 PAPROCRIT - epoetin alfa inj 20000 unit/ml 5 PAPROCRIT - epoetin alfa inj 40000 unit/ml 5 PAPROMACTA - eltrombopag olamine powder pack for susp 12.5 mg* 5 PAPROMACTA - eltrombopag olamine tab 12.5 mg* 5 PAPROMACTA - eltrombopag olamine tab 25 mg* 5 PAPROMACTA - eltrombopag olamine tab 50 mg* 5 PAPROMACTA - eltrombopag olamine tab 75 mg* 5 PARETACRIT - epoetin alfa-epbx inj 2000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 3000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 4000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 10000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 40000 unit/ml 4 PAtranexamic acid iv soln 1000 mg/10ml (100 mg/ml) 3tranexamic acid tab 650 mg^ 2UDENYCA - pegfilgrastim-cbqv soln prefilled syringe 6 mg/0.6ml 5 PAwarfarin sodium tab 1 mg^ 1warfarin sodium tab 2 mg^ 1warfarin sodium tab 2.5 mg^ 1warfarin sodium tab 3 mg^ 1warfarin sodium tab 4 mg^ 1warfarin sodium tab 5 mg^ 1warfarin sodium tab 6 mg^ 2warfarin sodium tab 7.5 mg^ 1warfarin sodium tab 10 mg^ 1XARELTO - rivaroxaban tab 2.5 mg 3 QL (60 tablets/30 days)XARELTO - rivaroxaban tab 10 mg 3 QL (30 tablets/30 days)XARELTO - rivaroxaban tab 15 mg 3 QL (60 tablets/30 days)XARELTO - rivaroxaban tab 20 mg 3 QL (30 tablets/30 days)XARELTO STARTER PACK - rivaroxaban tab starter therapy pack

15 mg & 20 mg3 QL (51 tablets/30 days)

ZONTIVITY - vorapaxar sulfate tab 2.08 mg 4

2020


57

Drug Name Drug Tier Requirements/LimitsCardiovascular Agentsacebutolol hcl cap 200 mg^ 2acebutolol hcl cap 400 mg^ 2acetazolamide cap er 12hr 500 mg 3acetazolamide tab 125 mg 3acetazolamide tab 250 mg 3aliskiren fumarate tab 150 mg 3 QL (30 tablets/30 days)aliskiren fumarate tab 300 mg 3 QL (30 tablets/30 days)amiloride & hydrochlorothiazide tab 5-50 mg^ 2amiloride hcl tab 5 mg^ 2amiodarone hcl tab 200 mg^ 1amiodarone hcl tab 400 mg^ 2amlodipine besylate tab 2.5 mg^ 1amlodipine besylate tab 5 mg^ 1amlodipine besylate tab 10 mg^ 1amlodipine besylate-benazepril hcl cap 2.5-10 mg^ 1amlodipine besylate-benazepril hcl cap 5-10 mg^ 1amlodipine besylate-benazepril hcl cap 5-20 mg^ 1amlodipine besylate-benazepril hcl cap 5-40 mg^ 1amlodipine besylate-benazepril hcl cap 10-20 mg^ 1amlodipine besylate-benazepril hcl cap 10-40 mg^ 1amlodipine besylate-valsartan tab 5-160 mg^ 1 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 5-320 mg^ 1 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-160 mg^ 1 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-320 mg^ 1 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg^ 1 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg^ 1 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg^ 1 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg^ 1 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg^ 1 QL (30 tablets/30 days)atenolol & chlorthalidone tab 50-25 mg^ 2atenolol & chlorthalidone tab 100-25 mg^ 2atenolol tab 25 mg^ 2atenolol tab 50 mg^ 2atenolol tab 100 mg^ 2atorvastatin calcium tab 10 mg^ 1 QL (45 tablets/30 days)atorvastatin calcium tab 20 mg^ 1 QL (45 tablets/30 days)atorvastatin calcium tab 40 mg^ 1 QL (45 tablets/30 days)

2020


Drug Name Drug Tier Requirements/Limitsatorvastatin calcium tab 80 mg^ 1 QL (30 tablets/30 days)benazepril & hydrochlorothiazide tab 5-6.25 mg^ 1benazepril & hydrochlorothiazide tab 10-12.5 mg^ 1benazepril & hydrochlorothiazide tab 20-12.5 mg^ 1benazepril & hydrochlorothiazide tab 20-25 mg^ 1benazepril hcl tab 5 mg^ 1benazepril hcl tab 10 mg^ 1benazepril hcl tab 20 mg^ 1benazepril hcl tab 40 mg^ 1betaxolol hcl tab 10 mg^ 2betaxolol hcl tab 20 mg^ 2bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg^ 1bisoprolol & hydrochlorothiazide tab 5-6.25 mg^ 1bisoprolol & hydrochlorothiazide tab 10-6.25 mg^ 1bisoprolol fumarate tab 5 mg^ 2bisoprolol fumarate tab 10 mg^ 2bumetanide inj 0.25 mg/ml 3bumetanide tab 0.5 mg^ 2bumetanide tab 1 mg^ 2bumetanide tab 2 mg^ 2BYSTOLIC - nebivolol hcl tab 2.5 mg 4BYSTOLIC - nebivolol hcl tab 5 mg 4BYSTOLIC - nebivolol hcl tab 10 mg 4BYSTOLIC - nebivolol hcl tab 20 mg 4candesartan cilexetil tab 4 mg^ 1 QL (60 tablets/30 days)candesartan cilexetil tab 8 mg^ 1 QL (60 tablets/30 days)candesartan cilexetil tab 16 mg^ 1 QL (60 tablets/30 days)candesartan cilexetil tab 32 mg^ 1 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg^ 1 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg^ 1 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-25 mg^ 1 QL (30 tablets/30 days)captopril tab 12.5 mg^ 1captopril tab 25 mg^ 1captopril tab 50 mg^ 1captopril tab 100 mg^ 1carvedilol tab 3.125 mg^ 1carvedilol tab 6.25 mg^ 1carvedilol tab 12.5 mg^ 1

2020


59

Drug Name Drug Tier Requirements/Limitscarvedilol tab 25 mg^ 1CHLOROTHIAZIDE - chlorothiazide tab 250 mg 3chlorothiazide tab 500 mg^ 2chlorthalidone tab 25 mg^ 2chlorthalidone tab 50 mg^ 2cholestyramine light powder packets 4 gm^ 2cholestyramine light powder 4 gm/dose^ 2cholestyramine powder packets 4 gm^ 2cholestyramine powder 4 gm/dose^ 2choline fenofibrate cap dr 45 mg^ 2 QL (60 capsules/30 days)choline fenofibrate cap dr 135 mg^ 2 QL (30 capsules/30 days)clonidine hcl tab 0.1 mg^ 1clonidine hcl tab 0.2 mg^ 1clonidine hcl tab 0.3 mg^ 1clonidine td patch weekly 0.1 mg/24hr^ 2clonidine td patch weekly 0.2 mg/24hr^ 2clonidine td patch weekly 0.3 mg/24hr^ 2colestipol hcl granule packets 5 gm^ 2colestipol hcl granules 5 gm^ 2colestipol hcl tab 1 gm^ 2CORLANOR - ivabradine hcl oral soln 5 mg/5ml 3 PA, QL (600 mls/30 days)CORLANOR - ivabradine hcl tab 5 mg 3 PA, QL (60 tablets/30 days)CORLANOR - ivabradine hcl tab 7.5 mg 3 PA, QL (60 tablets/30 days)DEMSER - metyrosine cap 250 mg 5DIGOXIN - digoxin oral soln 0.05 mg/ml# 3 QL (150 mls/30 days)digoxin tab 125 mcg (0.125 mg)#^ 2 QL (30 tablets/30 days)digoxin tab 250 mcg (0.25 mg)# 3 QL (30 tablets/30 days)diltiazem hcl cap er 24hr 120 mg^ 2diltiazem hcl cap er 12hr 60 mg^ 2diltiazem hcl cap er 12hr 90 mg^ 2diltiazem hcl cap er 12hr 120 mg^ 2diltiazem hcl cap er 24hr 180 mg^ 2diltiazem hcl cap er 24hr 240 mg^ 2diltiazem hcl coated beads cap er 24hr 120 mg^ 2diltiazem hcl coated beads cap er 24hr 180 mg^ 2diltiazem hcl coated beads cap er 24hr 240 mg^ 2diltiazem hcl coated beads cap er 24hr 300 mg^ 2diltiazem hcl coated beads cap er 24hr 360 mg 3

2020


Drug Name Drug Tier Requirements/Limitsdiltiazem hcl coated beads tab er 24hr 180 mg^ 2diltiazem hcl coated beads tab er 24hr 240 mg^ 2diltiazem hcl coated beads tab er 24hr 300 mg^ 2diltiazem hcl coated beads tab er 24hr 360 mg^ 2diltiazem hcl coated beads tab er 24hr 420 mg^ 2diltiazem hcl extended release beads cap er 24hr 120 mg^ 2diltiazem hcl extended release beads cap er 24hr 180 mg^ 2diltiazem hcl extended release beads cap er 24hr 240 mg^ 2diltiazem hcl extended release beads cap er 24hr 300 mg^ 2diltiazem hcl extended release beads cap er 24hr 360 mg 3diltiazem hcl extended release beads cap er 24hr 420 mg^ 2diltiazem hcl tab 30 mg^ 2diltiazem hcl tab 60 mg^ 2diltiazem hcl tab 90 mg^ 2diltiazem hcl tab 120 mg^ 2dofetilide cap 125 mcg (0.125 mg) 4dofetilide cap 250 mcg (0.25 mg) 4dofetilide cap 500 mcg (0.5 mg) 4doxazosin mesylate tab 1 mg^ 2 QL (60 tablets/30 days)doxazosin mesylate tab 2 mg^ 2 QL (60 tablets/30 days)doxazosin mesylate tab 4 mg^ 2 QL (60 tablets/30 days)doxazosin mesylate tab 8 mg^ 2 QL (60 tablets/30 days)enalapril maleate & hydrochlorothiazide tab 5-12.5 mg^ 1enalapril maleate & hydrochlorothiazide tab 10-25 mg^ 2enalapril maleate tab 2.5 mg^ 1enalapril maleate tab 5 mg^ 1enalapril maleate tab 10 mg^ 1enalapril maleate tab 20 mg^ 1ENTRESTO - sacubitril-valsartan tab 24-26 mg 3 QL (60 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 49-51 mg 3 QL (60 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 97-103 mg 3 QL (60 tablets/30 days)eplerenone tab 25 mg^ 2eplerenone tab 50 mg^ 2ezetimibe tab 10 mg^ 2 QL (30 tablets/30 days)felodipine tab er 24hr 2.5 mg^ 2felodipine tab er 24hr 5 mg^ 2felodipine tab er 24hr 10 mg^ 2fenofibrate micronized cap 67 mg^ 2 QL (30 capsules/30 days)

2020


61

Drug Name Drug Tier Requirements/Limitsfenofibrate micronized cap 134 mg^ 2 QL (30 capsules/30 days)fenofibrate micronized cap 200 mg^ 2 QL (30 capsules/30 days)fenofibrate tab 48 mg^ 2 QL (60 tablets/30 days)fenofibrate tab 54 mg^ 2 QL (60 tablets/30 days)fenofibrate tab 145 mg^ 2 QL (30 tablets/30 days)fenofibrate tab 160 mg^ 2 QL (30 tablets/30 days)flecainide acetate tab 50 mg^ 2flecainide acetate tab 100 mg^ 2flecainide acetate tab 150 mg^ 2fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg^ 1fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg^ 1fosinopril sodium tab 10 mg^ 1fosinopril sodium tab 20 mg^ 1fosinopril sodium tab 40 mg^ 1furosemide inj 10 mg/ml 3furosemide oral soln 10 mg/ml^ 2furosemide tab 20 mg^ 1furosemide tab 40 mg^ 1furosemide tab 80 mg^ 1gemfibrozil tab 600 mg^ 2 QL (60 tablets/30 days)hydralazine hcl tab 10 mg^ 1hydralazine hcl tab 25 mg^ 2hydralazine hcl tab 50 mg^ 2hydralazine hcl tab 100 mg^ 2hydrochlorothiazide cap 12.5 mg^ 1hydrochlorothiazide tab 12.5 mg^ 1hydrochlorothiazide tab 25 mg^ 1hydrochlorothiazide tab 50 mg^ 1indapamide tab 1.25 mg^ 2indapamide tab 2.5 mg^ 2irbesartan tab 75 mg^ 1 QL (30 tablets/30 days)irbesartan tab 150 mg^ 1 QL (30 tablets/30 days)irbesartan tab 300 mg^ 1 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 150-12.5 mg^ 1 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 300-12.5 mg^ 1 QL (30 tablets/30 days)ISOSORBIDE DINITRATE - isosorbide dinitrate tab 30 mg 3isosorbide dinitrate tab 5 mg^ 2isosorbide dinitrate tab 10 mg^ 2

2020


Drug Name Drug Tier Requirements/Limitsisosorbide dinitrate tab 20 mg^ 2isosorbide mononitrate tab er 24hr 30 mg^ 2isosorbide mononitrate tab er 24hr 60 mg^ 2isosorbide mononitrate tab er 24hr 120 mg^ 2isosorbide mononitrate tab 10 mg^ 2isosorbide mononitrate tab 20 mg^ 2isradipine cap 2.5 mg^ 2isradipine cap 5 mg^ 2labetalol hcl tab 100 mg^ 2labetalol hcl tab 200 mg^ 2labetalol hcl tab 300 mg^ 2LIDOCAINE HCL - lidocaine hcl (cardiac) iv pf soln pref syr

50 mg/5ml(1%)4

LIDOCAINE HCL - lidocaine hcl (cardiac) iv soln pref syr 50 mg/5ml(1%)

4

lisinopril & hydrochlorothiazide tab 10-12.5 mg^ 1lisinopril & hydrochlorothiazide tab 20-12.5 mg^ 1lisinopril & hydrochlorothiazide tab 20-25 mg^ 1lisinopril tab 2.5 mg^ 1lisinopril tab 5 mg^ 1lisinopril tab 10 mg^ 1lisinopril tab 20 mg^ 1lisinopril tab 30 mg^ 1lisinopril tab 40 mg^ 1losartan potassium & hydrochlorothiazide tab 50-12.5 mg^ 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-12.5 mg^ 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-25 mg^ 1 QL (30 tablets/30 days)losartan potassium tab 25 mg^ 1 QL (60 tablets/30 days)losartan potassium tab 50 mg^ 1 QL (60 tablets/30 days)losartan potassium tab 100 mg^ 1 QL (30 tablets/30 days)lovastatin tab 10 mg^ 1 QL (60 tablets/30 days)lovastatin tab 20 mg^ 1 QL (60 tablets/30 days)lovastatin tab 40 mg^ 1 QL (60 tablets/30 days)methazolamide tab 25 mg 3methazolamide tab 50 mg 3metolazone tab 2.5 mg^ 2metolazone tab 5 mg^ 2metolazone tab 10 mg^ 2metoprolol & hydrochlorothiazide tab 50-25 mg^ 2

2020


63

Drug Name Drug Tier Requirements/Limitsmetoprolol & hydrochlorothiazide tab 100-25 mg^ 2metoprolol succinate tab er 24hr 25 mg^ 2metoprolol succinate tab er 24hr 50 mg^ 2metoprolol succinate tab er 24hr 100 mg^ 2metoprolol succinate tab er 24hr 200 mg^ 2metoprolol tartrate tab 25 mg^ 1metoprolol tartrate tab 50 mg^ 1metoprolol tartrate tab 100 mg^ 1MEXILETINE HCL - mexiletine hcl cap 150 mg 3MEXILETINE HCL - mexiletine hcl cap 200 mg 3MEXILETINE HCL - mexiletine hcl cap 250 mg 3midodrine hcl tab 2.5 mg^ 2midodrine hcl tab 5 mg^ 2midodrine hcl tab 10 mg^ 2minoxidil tab 2.5 mg^ 2minoxidil tab 10 mg^ 2moexipril hcl tab 7.5 mg^ 1moexipril hcl tab 15 mg^ 1MULTAQ - dronedarone hcl tab 400 mg 3nadolol tab 20 mg^ 2nadolol tab 40 mg^ 2nadolol tab 80 mg^ 2niacin tab er 500 mg^ 2 QL (30 tablets/30 days)niacin tab er 750 mg^ 2 QL (60 tablets/30 days)niacin tab er 1000 mg^ 2 QL (60 tablets/30 days)nicardipine hcl cap 20 mg^ 2nicardipine hcl cap 30 mg^ 2nifedipine tab er 24hr 30 mg^ 2nifedipine tab er 24hr 60 mg^ 2nifedipine tab er 24hr 90 mg^ 2nifedipine tab er 24hr osmotic release 30 mg^ 2nifedipine tab er 24hr osmotic release 60 mg^ 2nifedipine tab er 24hr osmotic release 90 mg^ 2nimodipine cap 30 mg 5NISOLDIPINE ER - nisoldipine tab er 24hr 25.5 mg 3nisoldipine tab er 24hr 8.5 mg 3nisoldipine tab er 24hr 17 mg 3nisoldipine tab er 24hr 34 mg 3

2020


Drug Name Drug Tier Requirements/LimitsNITRO-BID - nitroglycerin oint 2% 3nitroglycerin sl tab 0.3 mg^ 2nitroglycerin sl tab 0.4 mg^ 2nitroglycerin sl tab 0.6 mg^ 2nitroglycerin td patch 24hr 0.1 mg/hr^ 2nitroglycerin td patch 24hr 0.2 mg/hr^ 2nitroglycerin td patch 24hr 0.4 mg/hr^ 2nitroglycerin td patch 24hr 0.6 mg/hr^ 2nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)^ 2NORTHERA - droxidopa cap 100 mg* 5 PANORTHERA - droxidopa cap 200 mg* 5 PANORTHERA - droxidopa cap 300 mg* 5 PAolmesartan medoxomil tab 5 mg^ 1 QL (60 tablets/30 days)olmesartan medoxomil tab 20 mg^ 1 QL (30 tablets/30 days)olmesartan medoxomil tab 40 mg^ 1 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg^ 1 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg^ 1 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg^ 1 QL (30 tablets/30 days)omega-3-acid ethyl esters cap 1 gm^ 2pentoxifylline tab er 400 mg^ 2perindopril erbumine tab 2 mg^ 1perindopril erbumine tab 4 mg^ 1perindopril erbumine tab 8 mg^ 1phenoxybenzamine hcl cap 10 mg 5pindolol tab 5 mg^ 2pindolol tab 10 mg^ 2pravastatin sodium tab 10 mg^ 1 QL (45 tablets/30 days)pravastatin sodium tab 20 mg^ 1 QL (45 tablets/30 days)pravastatin sodium tab 40 mg^ 1 QL (45 tablets/30 days)pravastatin sodium tab 80 mg^ 1 QL (30 tablets/30 days)prazosin hcl cap 1 mg^ 2prazosin hcl cap 2 mg^ 2prazosin hcl cap 5 mg^ 2propafenone hcl cap er 12hr 225 mg 3propafenone hcl cap er 12hr 325 mg 4propafenone hcl cap er 12hr 425 mg 4propafenone hcl tab 150 mg^ 2propafenone hcl tab 225 mg^ 2

2020


65

Drug Name Drug Tier Requirements/Limitspropafenone hcl tab 300 mg^ 2propranolol hcl cap er 24hr 60 mg^ 2propranolol hcl cap er 24hr 80 mg^ 2propranolol hcl cap er 24hr 120 mg^ 2propranolol hcl cap er 24hr 160 mg^ 2propranolol hcl inj 1 mg/ml 3propranolol hcl tab 10 mg^ 2propranolol hcl tab 20 mg^ 2propranolol hcl tab 40 mg^ 2propranolol hcl tab 60 mg^ 2propranolol hcl tab 80 mg^ 2quinapril hcl tab 5 mg^ 1quinapril hcl tab 10 mg^ 1quinapril hcl tab 20 mg^ 1quinapril hcl tab 40 mg^ 1quinapril-hydrochlorothiazide tab 10-12.5 mg^ 1quinapril-hydrochlorothiazide tab 20-12.5 mg^ 1quinapril-hydrochlorothiazide tab 20-25 mg^ 1quinidine gluconate tab er 324 mg 3QUINIDINE SULFATE - quinidine sulfate tab 200 mg 3QUINIDINE SULFATE - quinidine sulfate tab 300 mg 3ramipril cap 1.25 mg^ 1ramipril cap 2.5 mg^ 1ramipril cap 5 mg^ 1ramipril cap 10 mg^ 1ranolazine tab er 12hr 500 mg 3 QL (60 tablets/30 days)ranolazine tab er 12hr 1000 mg 3 QL (60 tablets/30 days)RECTIV - nitroglycerin oint 0.4% 4REPATHA - evolocumab subcutaneous soln prefilled syringe

140 mg/ml3 PA, QL (2 syringes/28 days)

REPATHA PUSHTRONEX SYSTEM - evolocumab subcutaneoussoln cartridge/infusor 420 mg/3.5ml

3 PA, QL (1 system/30 days)

REPATHA SURECLICK - evolocumab subcutaneous soln auto-injector 140 mg/ml

3 PA, QL (2 pens/28 days)

rosuvastatin calcium tab 5 mg^ 1 QL (45 tablets/30 days)rosuvastatin calcium tab 10 mg^ 1 QL (45 tablets/30 days)rosuvastatin calcium tab 20 mg^ 1 QL (45 tablets/30 days)rosuvastatin calcium tab 40 mg^ 1 QL (30 tablets/30 days)simvastatin tab 5 mg^ 1 QL (45 tablets/30 days)

2020


Drug Name Drug Tier Requirements/Limitssimvastatin tab 10 mg^ 1 QL (45 tablets/30 days)simvastatin tab 20 mg^ 1 QL (60 tablets/30 days)simvastatin tab 40 mg^ 1 QL (45 tablets/30 days)simvastatin tab 80 mg^ 1 QL (30 tablets/30 days)sotalol hcl (afib/afl) tab 80 mg^ 2sotalol hcl (afib/afl) tab 120 mg^ 2sotalol hcl (afib/afl) tab 160 mg^ 2sotalol hcl tab 80 mg^ 2sotalol hcl tab 120 mg^ 2sotalol hcl tab 160 mg^ 2sotalol hcl tab 240 mg^ 2spironolactone & hydrochlorothiazide tab 25-25 mg^ 2spironolactone tab 25 mg^ 2spironolactone tab 50 mg^ 2spironolactone tab 100 mg^ 2TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-12.5 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-25 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-12.5 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-25 mg 3 QL (30 tablets/30 days)telmisartan tab 20 mg^ 1 QL (30 tablets/30 days)telmisartan tab 40 mg^ 1 QL (30 tablets/30 days)telmisartan tab 80 mg^ 1 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 40-12.5 mg^ 1 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-12.5 mg^ 1 QL (60 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-25 mg^ 1 QL (30 tablets/30 days)terazosin hcl cap 1 mg^ 1 QL (90 capsules/30 days)terazosin hcl cap 2 mg^ 1 QL (60 capsules/30 days)terazosin hcl cap 5 mg^ 1 QL (60 capsules/30 days)terazosin hcl cap 10 mg^ 1 QL (60 capsules/30 days)TIMOLOL MALEATE - timolol maleate tab 10 mg 3TIMOLOL MALEATE - timolol maleate tab 20 mg 3timolol maleate tab 5 mg^ 2torsemide tab 5 mg^ 1torsemide tab 10 mg^ 1torsemide tab 20 mg^ 1torsemide tab 100 mg^ 2trandolapril tab 1 mg^ 1trandolapril tab 2 mg^ 1

2020


67

Drug Name Drug Tier Requirements/Limitstrandolapril tab 4 mg^ 1triamterene & hydrochlorothiazide cap 37.5-25 mg^ 1triamterene & hydrochlorothiazide tab 37.5-25 mg^ 1triamterene & hydrochlorothiazide tab 75-50 mg^ 1valsartan tab 40 mg^ 1 QL (60 tablets/30 days)valsartan tab 80 mg^ 1 QL (60 tablets/30 days)valsartan tab 160 mg^ 1 QL (60 tablets/30 days)valsartan tab 320 mg^ 1 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 80-12.5 mg^ 1 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-12.5 mg^ 1 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-25 mg^ 1 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 320-12.5 mg^ 1 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 320-25 mg^ 1 QL (30 tablets/30 days)VASCEPA - icosapent ethyl cap 0.5 gm 3VASCEPA - icosapent ethyl cap 1 gm 3verapamil hcl cap er 24hr 120 mg^ 2verapamil hcl cap er 24hr 180 mg^ 2verapamil hcl cap er 24hr 200 mg^ 2verapamil hcl cap er 24hr 240 mg^ 2verapamil hcl cap er 24hr 300 mg^ 2VERAPAMIL HCL ER - verapamil hcl cap er 24hr 100 mg 4VERAPAMIL HCL SR - verapamil hcl cap er 24hr 360 mg^ 2verapamil hcl tab er 120 mg^ 2verapamil hcl tab er 180 mg^ 2verapamil hcl tab er 240 mg^ 2verapamil hcl tab 40 mg^ 2verapamil hcl tab 80 mg^ 1verapamil hcl tab 120 mg^ 1VYNDAMAX - tafamidis cap 61 mg 5 PA, QL (30 capsules/30 days)VYNDAQEL - tafamidis meglumine (cardiac) cap 20 mg 5 PA, QL (120 capsules/30 days)Central Nervous System Agentsamphetamine-dextroamphetamine cap er 24hr 5 mg 3 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 10 mg 3 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 15 mg 3 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 20 mg 3 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 25 mg 3 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 30 mg 3 QL (30 capsules/30 days)amphetamine-dextroamphetamine tab 5 mg 3 QL (60 tablets/30 days)

2020


Drug Name Drug Tier Requirements/Limitsamphetamine-dextroamphetamine tab 7.5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 10 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 12.5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 15 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 20 mg 3 QL (90 tablets/30 days)amphetamine-dextroamphetamine tab 30 mg 3 QL (60 tablets/30 days)atomoxetine hcl cap 10 mg 3 QL (60 capsules/30 days)atomoxetine hcl cap 18 mg 3 QL (60 capsules/30 days)atomoxetine hcl cap 25 mg 3 QL (60 capsules/30 days)atomoxetine hcl cap 40 mg 3 QL (60 capsules/30 days)atomoxetine hcl cap 60 mg 3 QL (30 capsules/30 days)atomoxetine hcl cap 80 mg 3 QL (30 capsules/30 days)atomoxetine hcl cap 100 mg 3 QL (30 capsules/30 days)AUBAGIO - teriflunomide tab 7 mg* 5 PA, QL (30 tablets/30 days)AUBAGIO - teriflunomide tab 14 mg* 5 PA, QL (30 tablets/30 days)AVONEX - interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)AVONEX PEN - interferon beta-1a im auto-injector kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)BETASERON - interferon beta-1b for inj kit 0.3 mg 5 PA, QL (15 vials/

syringes/30 days)clonidine hcl tab er 12hr 0.1 mg 3 QL (120 tablets/30 days)dalfampridine tab er 12hr 10 mg 5 PAdexmethylphenidate hcl tab 2.5 mg 3 QL (60 tablets/30 days)dexmethylphenidate hcl tab 5 mg 3 QL (60 tablets/30 days)dexmethylphenidate hcl tab 10 mg 3 QL (60 tablets/30 days)dextroamphetamine sulfate cap er 24hr 5 mg 3 QL (90 capsules/30 days)dextroamphetamine sulfate cap er 24hr 10 mg 3 QL (120 capsules/30 days)dextroamphetamine sulfate cap er 24hr 15 mg 3 QL (120 capsules/30 days)dextroamphetamine sulfate tab 5 mg 3 QL (90 tablets/30 days)dextroamphetamine sulfate tab 10 mg 3 QL (180 tablets/30 days)fluoxetine hcl (pmdd) tab 10 mg^ 2GILENYA - fingolimod hcl cap 0.5 mg 5 PA, QL (30 capsules/30 days)glatiramer acetate soln prefilled syringe 20 mg/ml 5 PA, QL (30 syringes/30 days)glatiramer acetate soln prefilled syringe 40 mg/ml 5 PA, QL (12 syringes/28 days)MAYZENT - siponimod fumarate tab 0.25 mg 5 PA, QL (120 tablets/30 days)MAYZENT - siponimod fumarate tab 2 mg 5 PA, QL (30 tablets/30 days)methylphenidate hcl tab er 20 mg 3 QL (90 tablets/30 days)methylphenidate hcl tab 5 mg 3 QL (90 tablets/30 days)methylphenidate hcl tab 10 mg 3 QL (90 tablets/30 days)methylphenidate hcl tab 20 mg 3 QL (90 tablets/30 days)

2020


69

Drug Name Drug Tier Requirements/LimitsNUEDEXTA - dextromethorphan hbr-quinidine sulfate cap

20-10 mg3 PA, QL (60 capsules/30 days)

PLEGRIDY - peginterferon beta-1a soln pen-injector 125 mcg/0.5ml 5 PA, QL (2 syringes/28 days)PLEGRIDY - peginterferon beta-1a soln prefilled syringe

125 mcg/0.5ml5 PA, QL (2 syringes/28 days)

PLEGRIDY STARTER PACK - peginterferon beta-1a soln pen-inj63 & 94 mcg/0.5ml pack


PLEGRIDY STARTER PACK - peginterferon beta-1a soln pref syr63 & 94 mcg/0.5ml pack


riluzole tab 50 mg 3TECFIDERA - dimethyl fumarate capsule delayed release 120 mg 5 PA, QL (60 capsules/30 days)TECFIDERA - dimethyl fumarate capsule delayed release 240 mg 5 PA, QL (60 capsules/30 days)TECFIDERA STARTER PACK - dimethyl fumarate capsule dr

starter pack 120 mg & 240 mg5 PA, QL (60 capsules/30 days)

tetrabenazine tab 12.5 mg 5 PA, QL (240 tablets/30 days)tetrabenazine tab 25 mg 5 PA, QL (120 tablets/30 days)TYSABRI - natalizumab for iv inj conc 300 mg/15ml* 5 PADental and Oral Agentschlorhexidine gluconate soln 0.12%^ 1KEPIVANCE - palifermin for iv inj 6.25 mg 5pilocarpine hcl tab 5 mg^ 2pilocarpine hcl tab 7.5 mg^ 2triamcinolone acetonide dental paste 0.1%^ 2Dermatological Agentsacitretin cap 10 mg 3acitretin cap 17.5 mg 3acitretin cap 25 mg 3alclometasone dipropionate cream 0.05%^ 2 QL (120 grams/30 days)alclometasone dipropionate oint 0.05%^ 2 QL (120 grams/30 days)AUGMENTED BETAMETHASONE DIPROPIONATE -

betamethasone dipropionate augmented gel 0.05%3 QL (200 grams/28 days)

azelaic acid gel 15% 3AZELEX - azelaic acid cream 20% 4benzoyl peroxide-erythromycin gel 5-3% 3betamethasone dipropionate augmented cream 0.05%^ 2 QL (200 grams/28 days)betamethasone dipropionate augmented lotion 0.05%^ 2 QL (210 mls/30 days)betamethasone dipropionate augmented oint 0.05%^ 2 QL (200 grams/28 days)betamethasone dipropionate cream 0.05%^ 2 QL (135 grams/30 days)betamethasone dipropionate lotion 0.05%^ 2 QL (120 mls/30 days)betamethasone dipropionate oint 0.05%^ 2 QL (135 grams/30 days)

2020


Drug Name Drug Tier Requirements/Limitsbetamethasone valerate cream 0.1%^ 2 QL (135 grams/30 days)betamethasone valerate lotion 0.1%^ 2 QL (120 mls/30 days)betamethasone valerate oint 0.1%^ 2 QL (135 grams/30 days)calcipotriene cream 0.005% 3calcipotriene oint 0.005% 3calcipotriene soln 0.005% (50 mcg/ml) 3CARAC - fluorouracil cream 0.5% 5clindamycin phosphate-benzoyl peroxide gel 1-5% 3clobetasol propionate cream 0.05%^ 2 QL (210 grams/28 days)clobetasol propionate emollient base cream 0.05%^ 2 QL (210 grams/28 days)clobetasol propionate gel 0.05%^ 2 QL (210 grams/28 days)clobetasol propionate oint 0.05%^ 2 QL (210 grams/28 days)clobetasol propionate soln 0.05%^ 2 QL (200 mls/28 days)clotrimazole w/ betamethasone cream 1-0.05%^ 2clotrimazole w/ betamethasone lotion 1-0.05%^ 2desonide cream 0.05%^ 2 QL (120 grams/30 days)desonide lotion 0.05% 3 QL (118 mls/30 days)desonide oint 0.05%^ 2 QL (120 grams/30 days)desoximetasone cream 0.05% 3 QL (120 grams/30 days)desoximetasone cream 0.25%^ 2 QL (120 grams/30 days)desoximetasone gel 0.05% 3 QL (120 grams/30 days)desoximetasone oint 0.25%^ 2 QL (120 grams/30 days)diclofenac sodium (actinic keratoses) gel 3% 4diflorasone diacetate oint 0.05% 3 QL (120 grams/30 days)FINACEA - azelaic acid foam 15% 3fluocinolone acetonide cream 0.01%^ 2 QL (120 grams/30 days)fluocinonide cream 0.05%^ 2 QL (120 grams/30 days)fluocinonide emulsified base cream 0.05%^ 2 QL (120 grams/30 days)fluocinonide gel 0.05%^ 2 QL (120 grams/30 days)fluocinonide oint 0.05%^ 2 QL (120 grams/30 days)fluocinonide soln 0.05%^ 2 QL (120 mls/30 days)FLUOROURACIL - fluorouracil cream 0.5% 5FLUOROURACIL - fluorouracil soln 2%^ 2FLUOROURACIL - fluorouracil soln 5%^ 2fluorouracil cream 5%^ 2fluticasone propionate cream 0.05%^ 2 QL (120 grams/30 days)fluticasone propionate oint 0.005%^ 2 QL (120 grams/30 days)gentamicin sulfate cream 0.1%^ 2

2020


71

Drug Name Drug Tier Requirements/Limitsgentamicin sulfate oint 0.1%^ 2halobetasol propionate cream 0.05%^ 2 QL (200 grams/28 days)halobetasol propionate oint 0.05%^ 2 QL (200 grams/28 days)hydrocortisone butyrate cream 0.1%^ 2 QL (135 grams/30 days)hydrocortisone butyrate hydrophilic lipo base cream 0.1%^ 2 QL (120 grams/30 days)hydrocortisone butyrate oint 0.1%^ 2 QL (135 grams/30 days)hydrocortisone butyrate soln 0.1%^ 2 QL (120 mls/30 days)hydrocortisone cream 1%^ 1hydrocortisone cream 2.5%^ 2 QL (454 grams/30 days)hydrocortisone lotion 2.5%^ 2 QL (118 mls/30 days)hydrocortisone oint 1%^ 1hydrocortisone oint 2.5%^ 1 QL (454 grams/30 days)hydrocortisone valerate cream 0.2%^ 2 QL (120 grams/30 days)hydrocortisone valerate oint 0.2%^ 2 QL (120 grams/30 days)imiquimod cream 5%^ 2 PAisotretinoin cap 10 mg 3isotretinoin cap 20 mg 3isotretinoin cap 30 mg 3isotretinoin cap 40 mg 3lactic acid (ammonium lactate) cream 12%^ 2lactic acid (ammonium lactate) lotion 12%^ 2methoxsalen rapid cap 10 mg 5metronidazole cream 0.75%^ 2metronidazole gel 0.75%^ 2metronidazole gel 1% 3metronidazole lotion 0.75%^ 2mometasone furoate cream 0.1%^ 2 QL (135 grams/28 days)mometasone furoate oint 0.1%^ 2 QL (135 grams/28 days)mometasone furoate solution 0.1% (lotion)^ 2 QL (120 mls/30 days)mupirocin oint 2%^ 2nystatin-triamcinolone cream 100000-0.1 unit/gm-%^ 2nystatin-triamcinolone oint 100000-0.1 unit/gm-%^ 2ORACEA - doxycycline (rosacea) cap delayed release 40 mg 4PICATO - ingenol mebutate gel 0.015% 3 QL (3 tubes/30 days)PICATO - ingenol mebutate gel 0.05% 3 QL (2 tubes/30 days)pimecrolimus cream 1% 4 PApodofilox soln 0.5%^ 2PREDNICARBATE - prednicarbate cream 0.1%^ 2 QL (120 grams/30 days)

2020


Drug Name Drug Tier Requirements/LimitsPREDNICARBATE - prednicarbate oint 0.1%^ 2 QL (120 grams/30 days)REGRANEX - becaplermin gel 0.01% 5 PA, QL (15 grams/30 days)SANTYL - collagenase oint 250 unit/gm 3 QL (180 grams/30 days)selenium sulfide lotion 2.5%^ 2silver sulfadiazine cream 1%^ 2SOOLANTRA - ivermectin cream 1% 3tacrolimus oint 0.03% 3 PAtacrolimus oint 0.1% 3 PAtazarotene cream 0.1% 3 PATAZORAC - tazarotene cream 0.05% 4 PATAZORAC - tazarotene gel 0.05% 4 PATAZORAC - tazarotene gel 0.1% 4 PAtretinoin cream 0.025%^ 2 PAtretinoin cream 0.05% 3 PAtretinoin cream 0.1% 3 PAtretinoin gel 0.01%^ 2 PAtretinoin gel 0.025%^ 2 PAtriamcinolone acetonide cream 0.025%^ 1 QL (454 grams/30 days)triamcinolone acetonide cream 0.1%^ 1 QL (454 grams/30 days)triamcinolone acetonide cream 0.5%^ 2 QL (454 grams/30 days)triamcinolone acetonide lotion 0.025%^ 2 QL (120 mls/30 days)triamcinolone acetonide lotion 0.1%^ 2 QL (120 mls/30 days)triamcinolone acetonide oint 0.025%^ 2 QL (454 grams/30 days)triamcinolone acetonide oint 0.1%^ 2 QL (454 grams/30 days)triamcinolone acetonide oint 0.5%^ 2 QL (120 grams/30 days)Electrolytes/Minerals/Metals/Vitaminsamino acid infusion 6% 3 BDamino acid infusion 15% 3 BDAURYXIA - ferric citrate tab 1 gm (210 mg ferric iron) 5 PA, QL (360 tablets/30 days)calcium acetate cap 667 mg^ 2calcium acetate tab 667 mg^ 2CARBAGLU - carglumic acid tab 200 mg* 5 PACHEMET - succimer cap 100 mg 5deferasirox tab for oral susp 125 mg 5 PAdeferasirox tab for oral susp 250 mg 5 PAdeferasirox tab for oral susp 500 mg 5 PAdextrose inj 5% 3dextrose inj 10% 3

2020


73

Drug Name Drug Tier Requirements/LimitsDEXTROSE 2.5%/NACL 0.45% - dextrose 2.5% w/ sodium chloride

0.45%3

dextrose 5% in lactated ringers 3dextrose 5% w/ sodium chloride 0.2% 3dextrose 5% w/ sodium chloride 0.33% 3dextrose 5% w/ sodium chloride 0.45% 3dextrose 5% w/ sodium chloride 0.9% 3fomepizole inj 1 gm/ml (for iv infusion) 5FOSRENOL - lanthanum carbonate oral powder pack 750 mg 5 QL (180 packets/30 days)FOSRENOL - lanthanum carbonate oral powder pack 1000 mg 5 QL (120 packets/30 days)HEPATAMINE - amino acid infusion 8% 3 BDINTRALIPID - fat emulsion plant based iv emulsion 20% 4 BDJADENU - deferasirox tab 90 mg* 5 PAJADENU - deferasirox tab 180 mg* 5 PAJADENU - deferasirox tab 360 mg* 5 PAJADENU SPRINKLE - deferasirox granules packet 90 mg* 5 PAJADENU SPRINKLE - deferasirox granules packet 180 mg* 5 PAJADENU SPRINKLE - deferasirox granules packet 360 mg* 5 PAKCL 0.15%/D5W/NACL 0.225% - kcl 20 meq/l (0.15%) in dextrose

5% & nacl 0.225% inj3

kcl 20 meq/l (0.15%) in nacl 0.45% inj 3kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj 3kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj 3kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj 3kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj 3kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj 3lactated ringer's solution 3lanthanum carbonate chew tab 500 mg 5 QL (90 tablets/30 days)lanthanum carbonate chew tab 750 mg 5 QL (180 tablets/30 days)lanthanum carbonate chew tab 1000 mg 5 QL (120 tablets/30 days)levocarnitine oral soln 1 gm/10ml (10%)^ 2levocarnitine tab 330 mg^ 2magnesium sulfate inj 50% 3NORMOSOL-M IN D5W - electrolyte-m in d5w soln 4NUTRILIPID - fat emulsion plant based iv emulsion 20% 4 BDPHOSLYRA - calcium acetate oral soln 667 mg/5ml 3potassium chloride cap er 8 meq^ 2potassium chloride cap er 10 meq^ 2

2020


Drug Name Drug Tier Requirements/LimitsPOTASSIUM CHLORIDE ER - potassium chloride tab er 20 meq

(1500 mg)4

potassium chloride inj 2 meq/ml 3potassium chloride microencapsulated crys er tab 10 meq^ 2potassium chloride microencapsulated crys er tab 20 meq^ 2potassium chloride oral soln 10% (20 meq/15ml) 3potassium chloride tab er 8 meq (600 mg)^ 2potassium chloride tab er 10 meq^ 2potassium chloride 20 meq/l (0.15%) in dextrose 5% inj 3POTASSIUM CHLORIDE/DEXTROSE - potassium chloride 40

meq/l (0.3%) in dextrose 5% inj3

POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS -potassium chloride 20 meq/l (0.15%) in d5w lactated ringers

3

POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS -potassium chloride 40 meq/l (0.3%) in d5w lactated ringers

4

POTASSIUM CHLORIDE/DEXTROSE/SODIUM CHLORIDE - kcl20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj

3

potassium citrate tab er 5 meq (540 mg)^ 2potassium citrate tab er 10 meq (1080 mg)^ 2potassium citrate tab er 15 meq (1620 mg)^ 2SAMSCA - tolvaptan tab 15 mg 5 PASAMSCA - tolvaptan tab 30 mg 5 PAsevelamer carbonate packet 0.8 gm 5 QL (270 packets/30 days)sevelamer carbonate packet 2.4 gm 5 QL (90 packets/30 days)sevelamer carbonate tab 800 mg 4 QL (270 tablets/30 days)sodium chloride irrigation soln 0.9%^ 2sodium chloride iv soln 0.45% 3sodium chloride iv soln 0.9% 3sodium chloride preservative free inj 0.9% 3sodium polystyrene sulfonate oral susp 15 gm/60ml^ 2sodium polystyrene sulfonate powder^ 2sodium polystyrene sulfonate rectal susp 30 gm/120ml^ 2trientine hcl cap 250 mg 5 PA, QL (240 capsules/30 days)VELPHORO - sucroferric oxyhydroxide chew tab 500 mg 5 QL (180 tablets/30 days)VELTASSA - patiromer sorbitex calcium for susp packet 8.4 gm 5VELTASSA - patiromer sorbitex calcium for susp packet 16.8 gm 5VELTASSA - patiromer sorbitex calcium for susp packet 25.2 gm 5water for irrigation, sterile irrigation soln^ 2Gastrointestinal Agentsalosetron hcl tab 0.5 mg 5 PA, QL (60 tablets/30 days)

2020


75

Drug Name Drug Tier Requirements/Limitsalosetron hcl tab 1 mg 5 PA, QL (60 tablets/30 days)AMITIZA - lubiprostone cap 8 mcg 3 PAAMITIZA - lubiprostone cap 24 mcg 3 PACHENODAL - chenodiol tab 250 mg* 5 PACIMETIDINE HCL - cimetidine hcl soln 300 mg/5ml^ 2cimetidine tab 200 mg^ 2cimetidine tab 300 mg^ 2cimetidine tab 400 mg^ 2cimetidine tab 800 mg^ 2cromolyn sodium oral conc 100 mg/5ml 3dicyclomine hcl cap 10 mg# 3 PAdicyclomine hcl tab 20 mg# 3 PAesomeprazole magnesium cap delayed release 20 mg^ 2 QL (30 capsules/30 days)esomeprazole magnesium cap delayed release 40 mg^ 2 QL (30 capsules/30 days)ESOMEPRAZOLE SODIUM - esomeprazole sodium for

intravenous soln 20 mg3

esomeprazole sodium for intravenous soln 40 mg 3famotidine for susp 40 mg/5ml^ 2famotidine inj 20 mg/2ml 3famotidine inj 40 mg/4ml 3famotidine inj 200 mg/20ml 3famotidine tab 20 mg^ 1famotidine tab 40 mg^ 1GATTEX - teduglutide (rdna) for inj kit 5 mg* 5 PAglycopyrrolate tab 1 mg^ 2glycopyrrolate tab 2 mg^ 2lactulose (encephalopathy) solution 10 gm/15ml^ 2lactulose solution 10 gm/15ml^ 2lansoprazole cap delayed release 15 mg^ 2 QL (30 capsules/30 days)lansoprazole cap delayed release 30 mg^ 2 QL (30 capsules/30 days)LINZESS - linaclotide cap 72 mcg 3 PALINZESS - linaclotide cap 145 mcg 3 PALINZESS - linaclotide cap 290 mcg 3 PAloperamide hcl cap 2 mg^ 2methscopolamine bromide tab 2.5 mg^ 2methscopolamine bromide tab 5 mg^ 2metoclopramide hcl inj 5 mg/ml 3metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)^ 2metoclopramide hcl tab 5 mg^ 1

2020


Drug Name Drug Tier Requirements/Limitsmetoclopramide hcl tab 10 mg^ 1misoprostol tab 100 mcg^ 2misoprostol tab 200 mcg^ 2MOVIPREP - peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln

100 gm4

MYALEPT - metreleptin for subcutaneous inj 11.3 mg* 5 PANEXIUM - esomeprazole magnesium for delayed release susp

packet 5 mg4 QL (30 packets/30 days)

NEXIUM - esomeprazole magnesium for delayed release susppacket 10 mg

4 QL (30 packets/30 days)





NEXIUM - esomeprazole magnesium for delayed release susppack 2.5 mg


nizatidine cap 150 mg^ 2nizatidine cap 300 mg^ 2omeprazole cap delayed release 10 mg^ 2 QL (30 capsules/30 days)omeprazole cap delayed release 20 mg^ 1 QL (60 capsules/30 days)omeprazole cap delayed release 40 mg^ 1 QL (60 capsules/30 days)pantoprazole sodium ec tab 20 mg^ 1 QL (30 tablets/30 days)pantoprazole sodium ec tab 40 mg^ 1 QL (60 tablets/30 days)pantoprazole sodium for iv soln 40 mg 3peg 3350-kcl-sod bicarb-nacl for soln 420 gm^ 2peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm^ 2peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm^ 2PYLERA - bismuth subcit-metronidazole-tetracycline cap

140-125-125 mg5

rabeprazole sodium ec tab 20 mg^ 2 QL (30 tablets/30 days)ranitidine hcl syrup 15 mg/ml (75 mg/5ml)^ 2ranitidine hcl tab 150 mg^ 1ranitidine hcl tab 300 mg^ 1RELISTOR - methylnaltrexone bromide inj 8 mg/0.4ml (20 mg/ml) 5 PARELISTOR - methylnaltrexone bromide inj 12 mg/0.6ml (20 mg/ml) 5 PARELISTOR - methylnaltrexone bromide tab 150 mg 5 PAsucralfate tab 1 gm^ 2SUPREP BOWEL PREP KIT - sod sulfate-pot sulf-mg sulf oral sol

17.5-3.13-1.6 gm/177ml4

ursodiol cap 300 mg 4ursodiol tab 250 mg^ 2

2020


77

Drug Name Drug Tier Requirements/Limitsursodiol tab 500 mg^ 2XIFAXAN - rifaximin tab 550 mg 5 PA, QL (90 tablets/30 days)Genetic or Enzyme Disorder: Replacement, Modifiers, TreatmentALDURAZYME - laronidase soln for iv infusion 2.9 mg/5ml (500

unit/5ml)*5

CEREZYME - imiglucerase for inj 400 unit* 5 PACREON - pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit 3CREON - pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000

unit3

CREON - pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000unit

3

CREON - pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000unit

3

CREON - pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit

3

CRYSVITA - burosumab-twza inj 10 mg/ml 5 PACRYSVITA - burosumab-twza inj 20 mg/ml 5 PACRYSVITA - burosumab-twza inj 30 mg/ml 5 PACYSTADANE - betaine powder for oral solution 5CYSTAGON - cysteamine bitartrate cap 50 mg* 4 PACYSTAGON - cysteamine bitartrate cap 150 mg* 4 PAELAPRASE - idursulfase soln for iv infusion 6 mg/3ml (2 mg/ml) 5ELELYSO - taliglucerase alfa for inj 200 unit* 5 PAFABRAZYME - agalsidase beta for iv soln 5 mg* 5FABRAZYME - agalsidase beta for iv soln 35 mg* 5KUVAN - sapropterin dihydrochloride powder packet 100 mg* 5 PAKUVAN - sapropterin dihydrochloride powder packet 500 mg* 5 PAKUVAN - sapropterin dihydrochloride soluble tab 100 mg* 5 PALUMIZYME - alglucosidase alfa for iv soln 50 mg* 5miglustat cap 100 mg* 5 PA, QL (90 capsules/30 days)NAGLAZYME - galsulfase soln for iv infusion 1 mg/ml* 5nitisinone cap 2 mg* 5nitisinone cap 5 mg* 5nitisinone cap 10 mg* 5OCALIVA - obeticholic acid tab 5 mg* 5 PA, QL (30 tablets/30 days)OCALIVA - obeticholic acid tab 10 mg* 5 PA, QL (30 tablets/30 days)ORFADIN - nitisinone cap 2 mg* 5ORFADIN - nitisinone cap 5 mg* 5ORFADIN - nitisinone cap 10 mg* 5ORFADIN - nitisinone cap 20 mg* 5

2020


Drug Name Drug Tier Requirements/LimitsORFADIN - nitisinone susp 4 mg/ml* 5PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe

2.5 mg/0.5ml5 PA

PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe10 mg/0.5ml

5 PA

PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe20 mg/ml

5 PA

PROLASTIN-C - alpha1-proteinase inhibitor (human) for iv soln1000 mg*

5 PA

PROLASTIN-C - alpha1-proteinase inhibitor (human) inj1000 mg/20ml*

5 PA

REVCOVI - elapegademase-lvlr im soln 2.4 mg/1.5ml (1.6 mg/ml) 5sodium phenylbutyrate oral powder 3 gm/teaspoonful 5 PAsodium phenylbutyrate tab 500 mg 5 PASTRENSIQ - asfotase alfa subcutaneous inj 18 mg/0.45ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 28 mg/0.7ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 40 mg/ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 80 mg/0.8ml* 5 PAVPRIV - velaglucerase alfa for inj 400 unit 5 PAZENPEP - pancrelipase (lip-prot-amyl) dr cap 3000-10000-14000

unit3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap 5000-17000-24000unit

3


3


3


3


3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap40000-126000-168000 unit

3

Genitourinary Agentsalfuzosin hcl tab er 24hr 10 mg^ 2 QL (30 tablets/30 days)bethanechol chloride tab 5 mg^ 2bethanechol chloride tab 10 mg^ 2bethanechol chloride tab 25 mg^ 2bethanechol chloride tab 50 mg^ 2D-PENAMINE - penicillamine tab 125 mg 5DEPEN TITRATABS - penicillamine tab 250 mg 5dutasteride cap 0.5 mg^ 2 QL (30 capsules/30 days)

2020


79

Drug Name Drug Tier Requirements/Limitsdutasteride-tamsulosin hcl cap 0.5-0.4 mg^ 2 QL (30 capsules/30 days)finasteride tab 5 mg^ 1 QL (30 tablets/30 days)methylergonovine maleate tab 0.2 mg 5MYRBETRIQ - mirabegron tab er 24 hr 25 mg 4 QL (30 tablets/30 days)MYRBETRIQ - mirabegron tab er 24 hr 50 mg 4 QL (30 tablets/30 days)oxybutynin chloride syrup 5 mg/5ml^ 2 QL (600 mls/30 days)oxybutynin chloride tab er 24hr 5 mg^ 2 QL (30 tablets/30 days)oxybutynin chloride tab er 24hr 10 mg^ 2 QL (90 tablets/30 days)oxybutynin chloride tab er 24hr 15 mg^ 2 QL (60 tablets/30 days)oxybutynin chloride tab 5 mg^ 2 QL (120 tablets/30 days)silodosin cap 4 mg 3 QL (30 capsules/30 days)silodosin cap 8 mg 3 QL (30 capsules/30 days)solifenacin succinate tab 5 mg 4 QL (30 tablets/30 days)solifenacin succinate tab 10 mg 4 QL (30 tablets/30 days)tamsulosin hcl cap 0.4 mg^ 2 QL (60 capsules/30 days)tolterodine tartrate cap er 24hr 2 mg^ 2 QL (30 capsules/30 days)tolterodine tartrate cap er 24hr 4 mg^ 2 QL (30 capsules/30 days)tolterodine tartrate tab 1 mg^ 2 QL (60 tablets/30 days)tolterodine tartrate tab 2 mg^ 2 QL (60 tablets/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 4 mg 3 QL (30 tablets/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 8 mg 3 QL (30 tablets/30 days)trospium chloride cap er 24hr 60 mg^ 2 QL (30 capsules/30 days)trospium chloride tab 20 mg^ 2 QL (60 tablets/30 days)Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)ACTHAR - corticotropin inj gel 80 unit/ml* 5 PACORTISONE ACETATE - cortisone acetate tab 25 mg 3DEXAMETHASONE - dexamethasone soln 0.5 mg/5ml^ 2DEXAMETHASONE - dexamethasone tab 1 mg 3DEXAMETHASONE - dexamethasone tab 2 mg 3dexamethasone elixir 0.5 mg/5ml^ 2dexamethasone sodium phosphate inj 4 mg/ml 3dexamethasone sodium phosphate inj 20 mg/5ml 3dexamethasone sodium phosphate inj 120 mg/30ml 3dexamethasone tab therapy pack 1.5 mg (21)^ 1dexamethasone tab therapy pack 1.5 mg (35)^ 1dexamethasone tab therapy pack 1.5 mg (51)^ 1dexamethasone tab 0.5 mg^ 1dexamethasone tab 0.75 mg^ 1

2020


Drug Name Drug Tier Requirements/Limitsdexamethasone tab 1.5 mg^ 1dexamethasone tab 4 mg^ 2dexamethasone tab 6 mg^ 2fludrocortisone acetate tab 0.1 mg^ 2hydrocortisone tab 5 mg^ 2hydrocortisone tab 10 mg^ 2hydrocortisone tab 20 mg^ 2methylprednisolone sod succ for inj 40 mg 3methylprednisolone sod succ for inj 125 mg 3methylprednisolone sod succ for inj 1000 mg 3methylprednisolone tab therapy pack 4 mg (21)^ 2methylprednisolone tab 4 mg^ 2methylprednisolone tab 8 mg^ 2methylprednisolone tab 16 mg^ 2methylprednisolone tab 32 mg^ 2prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base)^ 2prednisolone sod phosphate oral soln 15 mg/5ml^ 2prednisolone syrup 15 mg/5ml^ 2PREDNISONE - prednisone oral soln 5 mg/5ml 3PREDNISONE - prednisone tab 50 mg 3prednisone tab therapy pack 5 mg (21)^ 2prednisone tab therapy pack 5 mg (48)^ 2prednisone tab therapy pack 10 mg (21)^ 2prednisone tab therapy pack 10 mg (48)^ 2prednisone tab 1 mg^ 2prednisone tab 2.5 mg^ 1prednisone tab 5 mg^ 2prednisone tab 10 mg^ 2prednisone tab 20 mg^ 1Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)CHORIONIC GONADOTROPIN - chorionic gonadotropin for im inj

10000 unit3 PA

desmopressin acetate inj 4 mcg/ml 3desmopressin acetate nasal spray soln 0.01% 3desmopressin acetate nasal spray soln 0.01% (refrigerated) 3desmopressin acetate tab 0.1 mg^ 2desmopressin acetate tab 0.2 mg^ 2EGRIFTA - tesamorelin acetate for inj 1 mg* 5 PAEGRIFTA - tesamorelin acetate for inj 2 mg* 5 PA

2020


81

Drug Name Drug Tier Requirements/LimitsINCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml)* 5OMNITROPE - somatropin for inj 5.8 mg 5 PAOMNITROPE - somatropin inj 5 mg/1.5ml 5 PAOMNITROPE - somatropin inj 10 mg/1.5ml 5 PAPREGNYL W/DILUENT BENZYL ALCOHOL/NACL -

chorionic gonadotropin for im inj 10000 unit3 PA

STIMATE - desmopressin acetate nasal soln 1.5 mg/ml 5Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)ANADROL-50 - oxymetholone tab 50 mg 5 PAANDRODERM - testosterone td patch 24hr 2 mg/24hr 3 PA, QL (30 patches/30 days)ANDRODERM - testosterone td patch 24hr 4 mg/24hr 3 PA, QL (30 patches/30 days)COMBIPATCH - estradiol-norethindrone ace td pttw 0.05-0.14 mg/

day#4

COMBIPATCH - estradiol-norethindrone ace td pttw 0.05-0.25 mg/day#

4

danazol cap 50 mg 3 PAdanazol cap 100 mg 3 PAdanazol cap 200 mg 3 PADEPO-PROVERA - medroxyprogesterone acetate im susp 400 mg/

ml4

desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) 3desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg 3desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg 3DIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%)# 4DIVIGEL - estradiol td gel 0.5 mg/0.5gm (0.1%)# 4DIVIGEL - estradiol td gel 0.75 mg/0.75gm (0.1%)# 4DIVIGEL - estradiol td gel 1 mg/gm (0.1%)# 4drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg 3drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451 mg 3drospirenone-ethinyl estradiol tab 3-0.02 mg 3drospirenone-ethinyl estradiol tab 3-0.03 mg 3DUAVEE - conjugated estrogens-bazedoxifene tab 0.45-20 mg# 4ELLA - ulipristal acetate tab 30 mg 3estradiol & norethindrone acetate tab 0.5-0.1 mg# 3estradiol & norethindrone acetate tab 1-0.5 mg# 3estradiol tab 0.5 mg# 3estradiol tab 1 mg# 3estradiol tab 2 mg# 3estradiol td patch twice weekly 0.025 mg/24hr# 4estradiol td patch twice weekly 0.0375 mg/24hr# 4

2020


Drug Name Drug Tier Requirements/Limitsestradiol td patch twice weekly 0.05 mg/24hr# 4estradiol td patch twice weekly 0.075 mg/24hr# 4estradiol td patch twice weekly 0.1 mg/24hr# 4estradiol td patch weekly 0.025 mg/24hr# 3estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)# 3estradiol td patch weekly 0.05 mg/24hr# 3estradiol td patch weekly 0.06 mg/24hr# 3estradiol td patch weekly 0.075 mg/24hr# 3estradiol td patch weekly 0.1 mg/24hr# 3estradiol vaginal cream 0.1 mg/gm^ 2estradiol vaginal tab 10 mcg^ 2ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg 3ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg 3HYDROXYPROGESTERONE CAPROATE - hydroxyprogesterone

caproate im in oil 1.25 gm/5ml5

hydroxyprogesterone caproate im in oil 250 mg/ml 5levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) 3levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) 3levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg 3levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg 3levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg 3levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg 3levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg 3medroxyprogesterone acetate im susp prefilled syr 150 mg/ml 3medroxyprogesterone acetate im susp 150 mg/ml 3medroxyprogesterone acetate tab 2.5 mg^ 1medroxyprogesterone acetate tab 5 mg^ 1medroxyprogesterone acetate tab 10 mg^ 2megestrol acetate susp 40 mg/ml# 3 PAmegestrol acetate tab 20 mg# 3 PAmegestrol acetate tab 40 mg# 3 PAMENEST - esterified estrogens tab 0.3 mg# 3MENEST - esterified estrogens tab 0.625 mg# 3MENEST - esterified estrogens tab 1.25 mg# 3METHYLTESTOSTERONE - methyltestosterone cap 10 mg 5 PAnorethindrone & ethinyl estradiol tab 0.4 mg-35 mcg 3norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg 3norethindrone & ethinyl estradiol tab 1 mg-35 mcg 3norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg 3

2020


83

Drug Name Drug Tier Requirements/Limitsnorethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg 3norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg 3norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg 3norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg 3norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg 3norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg 3norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) 3norethindrone acetate tab 5 mg^ 2norethindrone tab 0.35 mg 3norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg 3norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg 3norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg 3norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg 3norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg 3norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg 3oxandrolone tab 2.5 mg 3 PAoxandrolone tab 10 mg 5 PAPREMARIN - estrogens, conjugated vaginal cream 0.625 mg/gm 3PREMARIN - estrogens, conjugated tab 0.3 mg# 3PREMARIN - estrogens, conjugated tab 0.45 mg# 3PREMARIN - estrogens, conjugated tab 0.625 mg# 3PREMARIN - estrogens, conjugated tab 0.9 mg# 3PREMARIN - estrogens, conjugated tab 1.25 mg# 3PREMPHASE - conj est 0.625(14)/conj est-medroxypro ac tab

0.625-5mg(14)#3

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.3-1.5 mg#

3


3


3

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.625-5 mg#

3

progesterone micronized cap 100 mg^ 2progesterone micronized cap 200 mg^ 2raloxifene hcl tab 60 mg^ 2testosterone cypionate im inj in oil 100 mg/ml 3 PAtestosterone cypionate im inj in oil 200 mg/ml 3 PAtestosterone enanthate im inj in oil 200 mg/ml 3 PAtestosterone td gel 12.5 mg/act (1%) 3 PA, QL (4 pump bottles/30 days)

2020


Drug Name Drug Tier Requirements/Limitstestosterone td gel 25 mg/2.5gm (1%) 3 PA, QL (90 packets/30 days)testosterone td gel 50 mg/5gm (1%) 3 PA, QL (60 units/30 days)testosterone td gel 20.25 mg/1.25gm (1.62%) 3 PA, QL (30 packets/30 days)testosterone td gel 40.5 mg/2.5gm (1.62%) 3 PA, QL (60 packets/30 days)testosterone td gel 20.25 mg/act (1.62%) 3 PA, QL (2 pump bottles/30 days)testosterone td soln 30 mg/act 4 PA, QL (2 pump bottles/30 days)Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium tab 25 mcg (levo-t, levoxyl, unithroid)^ 2levothyroxine sodium tab 50 mcg (levo-t, levoxyl, unithroid)^ 2levothyroxine sodium tab 75 mcg (levo-t, levoxyl, unithroid)^ 2levothyroxine sodium tab 88 mcg (levo-t, levoxyl, unithroid)^ 2levothyroxine sodium tab 100 mcg (levo-t, levoxyl, unithroid)^ 2levothyroxine sodium tab 112 mcg (levo-t, levoxyl, unithroid)^ 2levothyroxine sodium tab 125 mcg (levo-t, levoxyl, unithroid)^ 2levothyroxine sodium tab 137 mcg (levo-t, levoxyl, unithroid)^ 2levothyroxine sodium tab 150 mcg (levo-t, levoxyl, unithroid)^ 2levothyroxine sodium tab 175 mcg (levo-t, levoxyl, unithroid)^ 2levothyroxine sodium tab 200 mcg (levo-t, levoxyl, unithroid)^ 2levothyroxine sodium tab 300 mcg (levo-t, unithroid)^ 2liothyronine sodium tab 5 mcg^ 2liothyronine sodium tab 25 mcg^ 2liothyronine sodium tab 50 mcg^ 2SYNTHROID - levothyroxine sodium tab 25 mcg 3SYNTHROID - levothyroxine sodium tab 50 mcg 3SYNTHROID - levothyroxine sodium tab 75 mcg 3SYNTHROID - levothyroxine sodium tab 88 mcg 3SYNTHROID - levothyroxine sodium tab 100 mcg 3SYNTHROID - levothyroxine sodium tab 112 mcg 3SYNTHROID - levothyroxine sodium tab 125 mcg 3SYNTHROID - levothyroxine sodium tab 137 mcg 3SYNTHROID - levothyroxine sodium tab 150 mcg 3SYNTHROID - levothyroxine sodium tab 175 mcg 3SYNTHROID - levothyroxine sodium tab 200 mcg 3SYNTHROID - levothyroxine sodium tab 300 mcg 3Hormonal Agents, Suppressant (Adrenal)KORLYM - mifepristone tab 300 mg* 5 PA, QL (120 tablets/30 days)LYSODREN - mitotane tab 500 mg 3Hormonal Agents, Suppressant (Pituitary)cabergoline tab 0.5 mg^ 2

2020


85

Drug Name Drug Tier Requirements/LimitsELIGARD - leuprolide acetate (3 month) for subcutaneous inj kit

22.5mg4

ELIGARD - leuprolide acetate (4 month) for subcutaneous inj kit30 mg

4

ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit45 mg

4

ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 mg 4FIRMAGON - degarelix acetate for inj 80 mg 4FIRMAGON - degarelix acetate for inj 120 mg 5leuprolide acetate inj kit 5 mg/ml 5LUPRON DEPOT (1-MONTH) - leuprolide acetate for inj kit

3.75 mg5

LUPRON DEPOT (1-MONTH) - leuprolide acetate for inj kit 7.5 mg 5LUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for inj

kit 11.25 mg5

LUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for injkit 22.5 mg

5

LUPRON DEPOT (4-MONTH) - leuprolide acetate (4 month) for injkit 30 mg

5

LUPRON DEPOT (6-MONTH) - leuprolide acetate (6 month) for injkit 45 mg

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 7.5 mg

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 11.25 mg

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 15 mg

5

LUPRON DEPOT-PED (3-MONTH) - leuprolide acetate (3 month)for inj pediatric kit 11.25 mg

5

LUPRON DEPOT-PED (3-MONTH) - leuprolide acetate (3 month)for inj pediatric kit 30 mg

5

octreotide acetate inj 50 mcg/ml (0.05 mg/ml) 3 PAoctreotide acetate inj 100 mcg/ml (0.1 mg/ml) 3 PAoctreotide acetate inj 200 mcg/ml (0.2 mg/ml) 3 PAoctreotide acetate inj 500 mcg/ml (0.5 mg/ml) 3 PAoctreotide acetate inj 1000 mcg/ml (1 mg/ml) 5 PASIGNIFOR - pasireotide diaspartate inj 0.3 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.6 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.9 mg/ml* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 10 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 20 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 30 mg* 5 PA

2020


Drug Name Drug Tier Requirements/LimitsSIGNIFOR LAR - pasireotide pamoate for im er susp 40 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 60 mg* 5 PASOMATULINE DEPOT - lanreotide acetate extended release inj

60 mg/0.2ml5 PA

SOMATULINE DEPOT - lanreotide acetate extended release inj90 mg/0.3ml

5 PA

SOMATULINE DEPOT - lanreotide acetate extended release inj120 mg/0.5ml

5 PA

SOMAVERT - pegvisomant for inj 10 mg* 5 PASOMAVERT - pegvisomant for inj 15 mg* 5 PASOMAVERT - pegvisomant for inj 20 mg* 5 PASOMAVERT - pegvisomant for inj 25 mg* 5 PASOMAVERT - pegvisomant for inj 30 mg* 5 PASYNAREL - nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) 5TRELSTAR MIXJECT - triptorelin pamoate for im susp 3.75 mg 5 PATRELSTAR MIXJECT - triptorelin pamoate for im susp 11.25 mg 5 PATRELSTAR MIXJECT - triptorelin pamoate for im susp 22.5 mg 5 PAHormonal Agents, Suppressant (Thyroid)methimazole tab 5 mg^ 1methimazole tab 10 mg^ 2propylthiouracil tab 50 mg^ 2Immunological AgentsACTHIB - haemophilus b polysaccharide conjugate vaccine for inj 3ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000

unit/0.5ml)*5 PA

ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml 3ARCALYST - rilonacept for inj 220 mg* 5 PAATGAM - lymphocyte immune globulin anti-thymocyte g inj 50 mg/

ml(eq)5 BD

AZASAN - azathioprine tab 75 mg 3 BDAZASAN - azathioprine tab 100 mg 3 BDAZATHIOPRINE - azathioprine sodium for inj 100 mg 3 BDazathioprine tab 50 mg^ 2 BDBCG VACCINE - bcg vaccine inj 3BENLYSTA - belimumab for iv soln 120 mg 5 PABENLYSTA - belimumab for iv soln 400 mg 5 PABENLYSTA - belimumab subcutaneous solution auto-injector

200 mg/ml5 PA

BENLYSTA - belimumab subcutaneous solution prefilled syringe200 mg/ml

5 PA

2020


87

Drug Name Drug Tier Requirements/LimitsBEXSERO - meningococcal vac b (recomb omv adjuv) inj prefilled

syringe3

BOOSTRIX - tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml

3

CABLIVI - caplacizumab-yhdp for inj kit 11 mg 5CINRYZE - c1 esterase inhibitor (human) for iv inj 500 unit* 5 PA, QL (20 vials/30 days)COSENTYX - secukinumab subcutaneous pref syr 150 mg/ml

(300 mg dose)*5 PA

COSENTYX - secukinumab subcutaneous soln prefilled syringe150 mg/ml*

5 PA

COSENTYX SENSOREADY PEN - secukinumab subcutaneousauto-inj 150 mg/ml (300 mg dose)*

5 PA

COSENTYX SENSOREADY PEN - secukinumab subcutaneoussoln auto-injector 150 mg/ml*

5 PA

cyclosporine cap 25 mg 3 BDcyclosporine cap 100 mg 4 BDcyclosporine iv soln 50 mg/ml 3 BDcyclosporine modified cap 50 mg 3 BDcyclosporine modified cap 25 mg^ 2 BDcyclosporine modified cap 100 mg^ 2 BDcyclosporine modified oral soln 100 mg/ml 3 BDDAPTACEL - diph, acellular pert & tet tox inj 15 lf-23 mcg-5 lf/0.5ml 3DIPHTHERIA/TETANUS TOXOIDS ADSORBED - diphtheria-

tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml3

DUPIXENT - dupilumab subcutaneous soln prefilled syringe200 mg/1.14ml

5 PA

DUPIXENT - dupilumab subcutaneous soln prefilled syringe300 mg/2ml

5 PA

ENBREL - etanercept for subcutaneous inj 25 mg 5 PAENBREL - etanercept subcutaneous soln prefilled syringe

25 mg/0.5ml5 PA

ENBREL - etanercept subcutaneous soln prefilled syringe 50 mg/ml 5 PAENBREL MINI - etanercept subcutaneous solution cartridge 50 mg/

ml5 PA

ENBREL SURECLICK - etanercept subcutaneous solution auto-injector 50 mg/ml

5 PA

ENGERIX-B - hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml 3 BDENGERIX-B - hepatitis b vaccine (recombinant) susp 20 mcg/ml 3 BDGAMMAGARD LIQUID - immune globulin (human) iv or

subcutaneous soln 1 gm/10ml5 BD, PA

GAMMAGARD LIQUID - immune globulin (human) iv orsubcutaneous soln 2.5 gm/25ml

5 BD, PA

2020


Drug Name Drug Tier Requirements/LimitsGAMMAGARD LIQUID - immune globulin (human) iv or

subcutaneous soln 5 gm/50ml5 BD, PA

GAMMAGARD LIQUID - immune globulin (human) iv orsubcutaneous soln 10 gm/100ml

5 BD, PA


5 BD, PA


5 BD, PA

GAMMAGARD S/D - immune globulin (human) iv for soln 5 gm 5 BD, PAGAMMAGARD S/D - immune globulin (human) iv for soln 10 gm 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 5 gm/100ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 10 gm/200ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 20 gm/400ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 5 gm/50ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 10 gm/100ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 20 gm/200ml 5 BD, PAGAMUNEX-C - immune globulin (human) iv or subcutaneous soln

1 gm/10ml5 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln2.5 gm/25ml

5 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln5 gm/50ml

5 BD, PA


5 BD, PA


5 BD, PA


5 BD, PA

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac imsusp

3

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vacsusp pref syr

3

HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj2000 unit*

5 PA, QL (24 vials/30 days)

HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj3000 unit*

5 PA, QL (16 vials/30 days)

HAVRIX - hepatitis a vaccine inj susp 720 el unit/0.5ml 3HAVRIX - hepatitis a vaccine inj susp 1440 el unit/ml 3HIBERIX - haemophilus b polysaccharide conjugate vac for inj

10 mcg3

HUMIRA - adalimumab prefilled syringe kit 10 mg/0.1ml 5 PAHUMIRA - adalimumab prefilled syringe kit 10 mg/0.2ml 5 PAHUMIRA - adalimumab prefilled syringe kit 20 mg/0.2ml 5 PA

2020


89

Drug Name Drug Tier Requirements/LimitsHUMIRA - adalimumab prefilled syringe kit 20 mg/0.4ml 5 PAHUMIRA - adalimumab prefilled syringe kit 40 mg/0.8ml 5 PAHUMIRA - adalimumab prefilled syringe kit 40 mg/0.4ml 5 PAHUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -

adalimumab prefilled syringe kit 40 mg/0.8ml5 PA

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -adalimumab prefilled syringe kit 80 mg/0.8ml

5 PA

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -adalimumab prefilled syringe kit 80 mg/0.8ml & 40 mg/0.4ml

5 PA

HUMIRA PEN - adalimumab pen-injector kit 40 mg/0.8ml 5 PAHUMIRA PEN - adalimumab pen-injector kit 40 mg/0.4ml 5 PAHUMIRA PEN-CD/UC/HS STARTER - adalimumab pen-injector kit

40 mg/0.8ml5 PA

HUMIRA PEN-CD/UC/HS STARTER - adalimumab pen-injector kit80 mg/0.8ml

5 PA

HUMIRA PEN-PS/UV STARTER - adalimumab pen-injector kit40 mg/0.8ml

5 PA

HUMIRA PEN-PS/UV STARTER - adalimumab pen-injector kit80 mg/0.8ml & 40 mg/0.4ml

5 PA

icatibant acetate inj 30 mg/3ml 5 PA, QL (6 syringes/30 days)ILARIS - canakinumab subcutaneous inj 150 mg/ml* 5 PAIMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj 3 BDINFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml 3IPOL INACTIVATED IPV - poliovirus vaccine, ipv injection 3IXIARO - japanese encephalitis vaccine inactivated adsorbed inj 3KINERET - anakinra subcutaneous soln prefilled syringe

100 mg/0.67ml5 PA

KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj 3leflunomide tab 10 mg^ 2leflunomide tab 20 mg^ 2M-M-R II - measles-mumps-rubella virus vaccines for inj soln 3MENACTRA - meningococcal (a, c, y, and w-135) conjugate

vaccine inj3

MENVEO - meningococcal (a, c, y, and w-135) oligo conj vac for inj 3METHOTREXATE SODIUM - methotrexate sodium inj

250 mg/10ml (25 mg/ml)^2

methotrexate sodium for inj 1 gm^ 2methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)^ 2methotrexate sodium inj pf 250 mg/10ml (25 mg/ml)^ 2methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml)^ 2methotrexate sodium inj 50 mg/2ml (25 mg/ml)^ 2

2020


Drug Name Drug Tier Requirements/Limitsmethotrexate sodium tab 2.5 mg^ 2mycophenolate mofetil cap 250 mg^ 2 BDmycophenolate mofetil for oral susp 200 mg/ml 5 BDmycophenolate mofetil hcl for iv soln 500 mg 3 BDmycophenolate mofetil tab 500 mg^ 2 BDmycophenolate sodium tab dr 180 mg 4 BDmycophenolate sodium tab dr 360 mg 4 BDNULOJIX - belatacept for iv infusion 250 mg 5 BDORENCIA - abatacept for iv soln 250 mg 5 PAORENCIA - abatacept subcutaneous soln prefilled syringe

50 mg/0.4ml5 PA

ORENCIA - abatacept subcutaneous soln prefilled syringe87.5 mg/0.7ml

5 PA

ORENCIA - abatacept subcutaneous soln prefilled syringe 125 mg/ml

5 PA

ORENCIA CLICKJECT - abatacept subcutaneous soln auto-injector125 mg/ml

5 PA

OTEZLA - apremilast tab starter therapy pack 10 mg & 20 mg &30 mg*

5 PA

OTEZLA - apremilast tab 30 mg* 5 PAPEDIARIX - diph-tetanus tox-acell pert-hepatitis b-polio ipv vac inj 3PEDVAX HIB - haemophilus b polysaccharide conj vac im susp

7.5 mcg/0.5 ml3

PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac forim susp

3

PROGRAF - tacrolimus inj 5 mg/ml 4 BDPROGRAF - tacrolimus packet for susp 0.2 mg 4 BDPROGRAF - tacrolimus packet for susp 1 mg 4 BDPROQUAD - measles-mumps-rubella-varicella virus vaccines for

susp3

QUADRACEL - diph-tetanus tox ad-acell pert & polio virus, ipv vacinj

3

RABAVERT - rabies vaccine, pcec for inj 3 BDRECOMBIVAX HB - hepatitis b vaccine (recombinant) susp

5 mcg/0.5ml3 BD

RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp10 mcg/ml

3 BD

RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp40 mcg/ml

3 BD

RENFLEXIS - infliximab-abda for iv inj 100 mg 5 PARIDAURA - auranofin cap 3 mg 5RINVOQ - upadacitinib tab er 24hr 15 mg 5 PA

2020


91

Drug Name Drug Tier Requirements/LimitsROTARIX - rotavirus vaccine, live for oral susp 3ROTATEQ - rotavirus vaccine, live oral pentavalent soln 3SANDIMMUNE - cyclosporine oral soln 100 mg/ml 4 BDSHINGRIX - zoster vac recombinant adjuvanted for im inj

50 mcg/0.5ml3 QL (2 vaccines/lifetime)

SIMULECT - basiliximab for iv soln 10 mg 5 BDSIMULECT - basiliximab for iv soln 20 mg 5 BDsirolimus oral soln 1 mg/ml 5 BDsirolimus tab 0.5 mg 3 BDsirolimus tab 1 mg 4 BDsirolimus tab 2 mg 5 BDSKYRIZI - risankizumab-rzaa sol prefilled syringe 2 x 75 mg/0.83ml

kit5 PA

STAMARIL - yellow fever vaccine for inj suspension 3STELARA - ustekinumab inj 45 mg/0.5ml 5 PASTELARA - ustekinumab iv soln 130 mg/26ml (5 mg/ml) (for iv

infusion)5 PA

STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml 5 PASTELARA - ustekinumab soln prefilled syringe 90 mg/ml 5 PASYLVANT - siltuximab for iv infusion 100 mg 5SYLVANT - siltuximab for iv infusion 400 mg 5SYNAGIS - palivizumab im soln 50 mg/0.5ml* 5SYNAGIS - palivizumab im soln 100 mg/ml* 5tacrolimus cap 0.5 mg^ 2 BDtacrolimus cap 1 mg^ 2 BDtacrolimus cap 5 mg 3 BDTDVAX - tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml 3 BDTENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu 3 BDTHYMOGLOBULIN - anti-thymocyte globulin for iv soln 25 mg

(lymphocyte ig)5 BD

TREMFYA - guselkumab soln pen-injector 100 mg/ml 5 PATREMFYA - guselkumab soln prefilled syringe 100 mg/ml 5 PATRUMENBA - meningococcal group b vac (recomb) im susp

prefilled syr3

TWINRIX - hep a-hep b vaccine susp pref syr 720-20 elu-mcg/ml 3TYPHIM VI - typhoid vi polysaccharide intramuscular vac inj

25 mcg/0.5ml3

VAQTA - hepatitis a vaccine inj susp 25 unit/0.5ml 3VAQTA - hepatitis a vaccine inj susp 50 unit/ml 3

2020


Drug Name Drug Tier Requirements/LimitsVARIVAX - varicella virus vac live for subcutaneous inj 1350

pfu/0.5ml3

XATMEP - methotrexate oral soln 2.5 mg/ml 4 BDXELJANZ - tofacitinib citrate tab 5 mg 5 PAXELJANZ - tofacitinib citrate tab 10 mg 5 PAXOLAIR - omalizumab for inj 150 mg* 5 PAXOLAIR - omalizumab subcutaneous soln prefilled syringe

75 mg/0.5ml*5 PA

XOLAIR - omalizumab subcutaneous soln prefilled syringe 150 mg/ml*

5 PA

YF-VAX - yellow fever vaccine subcutaneous inj 3ZORTRESS - everolimus tab 0.25 mg 5 BDZORTRESS - everolimus tab 0.5 mg 5 BDZORTRESS - everolimus tab 0.75 mg 5 BDZORTRESS - everolimus tab 1 mg 5 BDZOSTAVAX - zoster vaccine live for subcutaneous susp 19400

unit/0.65ml3 QL (1 vaccine/lifetime)

Inflammatory Bowel Disease AgentsAPRISO - mesalamine cap er 24hr 0.375 gm 4 QL (120 capsules/30 days)balsalazide disodium cap 750 mg^ 2budesonide delayed release particles cap 3 mg 4 QL (90 capsules/30 days)DIPENTUM - olsalazine sodium cap 250 mg 5hydrocortisone enema 100 mg/60ml^ 2hydrocortisone rectal cream 1%^ 1hydrocortisone rectal cream 2.5%^ 2mesalamine cap dr 400 mg 3 QL (180 capsules/30 days)mesalamine enema 4 gm 4mesalamine rectal enema 4 gm & cleanser wipe kit 4mesalamine suppos 1000 mg 3mesalamine tab delayed release 800 mg 4 QL (180 tablets/30 days)mesalamine tab delayed release 1.2 gm 4 QL (120 tablets/30 days)PENTASA - mesalamine cap er 250 mg 4 QL (480 capsules/30 days)PENTASA - mesalamine cap er 500 mg 4 QL (240 capsules/30 days)sulfasalazine tab delayed release 500 mg^ 2sulfasalazine tab 500 mg^ 2Metabolic Bone Disease Agentsalendronate sodium tab 5 mg^ 1 QL (30 tablets/30 days)alendronate sodium tab 10 mg^ 1 QL (120 tablets/30 days)alendronate sodium tab 35 mg^ 1 QL (4 tablets/28 days)alendronate sodium tab 70 mg^ 1 QL (4 tablets/28 days)

2020


93

Drug Name Drug Tier Requirements/Limitscalcitonin (salmon) nasal soln 200 unit/act^ 2CALCITRIOL - calcitriol inj 1 mcg/ml 3calcitriol cap 0.25 mcg^ 2calcitriol cap 0.5 mcg^ 2calcitriol oral soln 1 mcg/ml 3cinacalcet hcl tab 30 mg 5 PAcinacalcet hcl tab 60 mg 5 PAcinacalcet hcl tab 90 mg 5 PAFORTEO - teriparatide (recombinant) inj 600 mcg/2.4ml 5 PAibandronate sodium iv soln 3 mg/3ml 3ibandronate sodium tab 150 mg^ 2 QL (1 tablet/28 days)MIACALCIN - calcitonin (salmon) inj 200 unit/ml 5NATPARA - parathyroid hormone (recombinant) for inj cartridge

25 mcg*5 PA, QL (2 cartridges/28 days)

NATPARA - parathyroid hormone (recombinant) for inj cartridge50 mcg*

5 PA, QL (2 cartridges/28 days)





paricalcitol cap 1 mcg 3paricalcitol cap 2 mcg 3paricalcitol cap 4 mcg 3paricalcitol iv soln 2 mcg/ml 3paricalcitol iv soln 5 mcg/ml 3PROLIA - denosumab inj soln prefilled syringe 60 mg/ml 4 PArisedronate sodium tab delayed release 35 mg^ 2 QL (4 tablets/28 days)risedronate sodium tab 5 mg^ 2 QL (30 tablets/30 days)risedronate sodium tab 30 mg^ 2 QL (30 tablets/30 days)risedronate sodium tab 35 mg^ 2 QL (4 tablets/28 days)risedronate sodium tab 150 mg^ 2 QL (1 tablet/28 days)TYMLOS - abaloparatide subcutaneous soln pen-injector

3120 mcg/1.56ml5 PA

XGEVA - denosumab inj 120 mg/1.7ml 5 PAzoledronic acid inj conc for iv infusion 4 mg/5ml 3zoledronic acid iv soln 5 mg/100ml 3Ophthalmic AgentsALPHAGAN P - brimonidine tartrate ophth soln 0.1% 3azelastine hcl ophth soln 0.05%^ 2AZOPT - brinzolamide ophth susp 1% 4

2020


Drug Name Drug Tier Requirements/LimitsBACITRACIN - bacitracin ophth oint 500 unit/gm 3bacitracin-polymyxin b ophth oint^ 2bacitracin-polymyxin-neomycin-hc ophth oint 1%^ 2BESIVANCE - besifloxacin hcl ophth susp 0.6% 4betaxolol hcl ophth soln 0.5%^ 2BETOPTIC-S - betaxolol hcl ophth susp 0.25% 4bimatoprost ophth soln 0.03%^ 2brimonidine tartrate ophth soln 0.15%^ 2brimonidine tartrate ophth soln 0.2%^ 2BROMFENAC - bromfenac sodium ophth soln 0.09% (once-daily)^ 2carteolol hcl ophth soln 1%^ 2ciprofloxacin hcl ophth soln 0.3%^ 2COMBIGAN - brimonidine tartrate-timolol maleate ophth soln

0.2-0.5%3

cromolyn sodium ophth soln 4%^ 2CYSTARAN - cysteamine hcl ophth soln 0.44%* 5 PADEXAMETHASONE SODIUM PHOSPHATE - dexamethasone

sodium phosphate ophth soln 0.1%3

diclofenac sodium ophth soln 0.1%^ 2dorzolamide hcl ophth soln 2%^ 2dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml^ 2DUREZOL - difluprednate ophth emulsion 0.05% 3epinastine hcl ophth soln 0.05%^ 2erythromycin ophth oint 5 mg/gm^ 2fluorometholone ophth susp 0.1%^ 2FLURBIPROFEN SODIUM - flurbiprofen sodium ophth soln 0.03% 3GENTAK - gentamicin sulfate ophth oint 0.3%^ 2gentamicin sulfate ophth soln 0.3%^ 2ILEVRO - nepafenac ophth susp 0.3% 3ketorolac tromethamine ophth soln 0.4%^ 2ketorolac tromethamine ophth soln 0.5%^ 2LACRISERT - artificial tear ophth insert 4latanoprost ophth soln 0.005%^ 2levobunolol hcl ophth soln 0.5%^ 1LUMIGAN - bimatoprost ophth soln 0.01% 3MOXEZA - moxifloxacin hcl ophth soln 0.5% (2 times daily) 4moxifloxacin hcl ophth soln 0.5%^ 2NATACYN - natamycin ophth susp 5% 4neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin^ 2

2020


95

Drug Name Drug Tier Requirements/Limitsneomycin-polymyxin-dexamethasone ophth oint 0.1%^ 2neomycin-polymyxin-dexamethasone ophth susp 0.1%^ 2NEOMYCIN/POLYMYXIN/GRAMICIDIN - neomycin-polymy-

gramicid op sol 1.75-10000-0.025mg-unt-mg/ml^2

ofloxacin ophth soln 0.3%^ 2olopatadine hcl ophth soln 0.1%^ 2olopatadine hcl ophth soln 0.2%^ 2PAZEO - olopatadine hcl ophth soln 0.7% 3PHOSPHOLINE IODIDE - echothiophate iodide ophth for soln

0.125%4

pilocarpine hcl ophth soln 1%^ 2pilocarpine hcl ophth soln 2%^ 2pilocarpine hcl ophth soln 4%^ 2polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%^ 1PREDNISOLONE ACETATE - prednisolone acetate ophth susp 1% 4PROLENSA - bromfenac sodium ophth soln 0.07% 4RESTASIS - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (60 vials/30 days)RESTASIS MULTIDOSE - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (2 bottles/30 days)RHOPRESSA - netarsudil dimesylate ophth soln 0.02% 3 STSIMBRINZA - brinzolamide-brimonidine tartrate ophth susp 1-0.2% 3sulfacetamide sodium ophth soln 10%^ 2sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%^ 2timolol maleate ophth soln 0.25%^ 1timolol maleate ophth soln 0.5%^ 1timolol maleate ophth soln 0.5% (once-daily)^ 2TIMOLOL MALEATE OPHTHALMIC GEL FORMING - timolol

maleate ophth gel forming soln 0.25%^2

TIMOLOL MALEATE OPHTHALMIC GEL FORMING - timololmaleate ophth gel forming soln 0.5%^

2

TOBRADEX - tobramycin-dexamethasone ophth oint 0.3-0.1% 4tobramycin ophth soln 0.3%^ 2tobramycin-dexamethasone ophth susp 0.3-0.1%^ 2TRAVATAN Z - travoprost ophth soln 0.004% 3TRIFLURIDINE - trifluridine ophth soln 1% 3Otic Agentsacetic acid otic soln 2%^ 2fluocinolone acetonide (otic) oil 0.01%^ 2hydrocortisone w/ acetic acid otic soln 1-2%^ 2neomycin-polymyxin-hc otic soln 1%^ 2neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%^ 2

2020


Drug Name Drug Tier Requirements/Limitsofloxacin otic soln 0.3%^ 2Respiratory Tract/Pulmonary Agentsacetylcysteine inhal soln 10%^ 2 BDacetylcysteine inhal soln 20%^ 2 BDADEMPAS - riociguat tab 0.5 mg* 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1 mg* 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1.5 mg* 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2 mg* 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2.5 mg* 5 PA, QL (90 tablets/30 days)ADVAIR DISKUS - fluticasone-salmeterol aer powder ba

100-50 mcg/dose3 QL (1 inhaler/30 days)

ADVAIR DISKUS - fluticasone-salmeterol aer powder ba250-50 mcg/dose

3 QL (1 inhaler/30 days)

ADVAIR DISKUS - fluticasone-salmeterol aer powder ba500-50 mcg/dose


ADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21 mcg/act 3 QL (1 canister/30 days)ADVAIR HFA - fluticasone-salmeterol inhal aerosol 115-21 mcg/act 3 QL (1 canister/30 days)ADVAIR HFA - fluticasone-salmeterol inhal aerosol 230-21 mcg/act 3 QL (1 canister/30 days)ALBUTEROL SULFATE ER - albuterol sulfate tab er 12hr 4 mg^ 2ALBUTEROL SULFATE ER - albuterol sulfate tab er 12hr 8 mg^ 2albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)^ 2 BDalbuterol sulfate soln nebu 0.5% (5 mg/ml)^ 2 BDalbuterol sulfate soln nebu 0.63 mg/3ml^ 2 BDalbuterol sulfate soln nebu 1.25 mg/3ml^ 2 BDalbuterol sulfate syrup 2 mg/5ml^ 2albuterol sulfate tab 2 mg 3albuterol sulfate tab 4 mg 3ambrisentan tab 5 mg* 5 PA, QL (30 tablets/30 days)ambrisentan tab 10 mg* 5 PA, QL (30 tablets/30 days)ANORO ELLIPTA - umeclidinium-vilanterol aero powd ba

62.5-25 mcg/inh3 QL (1 package/30 days)

ARNUITY ELLIPTA - fluticasone furoate aerosol powder breathactiv 50 mcg/act

3 QL (30 blisters/30 days)





ASMANEX HFA - mometasone furoate inhal aerosol suspension100 mcg/act

3 QL (1 canister/30 days)

ASMANEX HFA - mometasone furoate inhal aerosol suspension200 mcg/act


2020


97

Drug Name Drug Tier Requirements/LimitsASMANEX TWISTHALER 120 METERED DOSES - mometasone

furoate inhal powd 220 mcg/inh3 QL (1 canister/30 days)

ASMANEX TWISTHALER 14 METERED DOSES - mometasonefuroate inhal powd 220 mcg/inh










ATROVENT HFA - ipratropium bromide hfa inhal aerosol 17 mcg/act

4 QL (2 canisters/30 days)

azelastine hcl nasal spray 0.1% (137 mcg/spray)^ 2 QL (2 bottles/30 days)azelastine hcl nasal spray 0.15% (205.5 mcg/spray)^ 2 QL (2 bottles/30 days)bosentan tab 62.5 mg* 5 PA, QL (60 tablets/30 days)bosentan tab 125 mg* 5 PA, QL (60 tablets/30 days)BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba

100-25 mcg/inh3 QL (1 package/30 days)

BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba200-25 mcg/inh

3 QL (1 package/30 days)

budesonide inhalation susp 0.25 mg/2ml 4 BDbudesonide inhalation susp 0.5 mg/2ml 4 BDbudesonide inhalation susp 1 mg/2ml 3 BDcaffeine citrate oral soln 60 mg/3ml^ 2CLEMASTINE FUMARATE - clemastine fumarate tab 2.68 mg# 3 PACOMBIVENT RESPIMAT - ipratropium-albuterol inhal aerosol soln

20-100 mcg/act4 QL (2 canisters/30 days)

cromolyn sodium soln nebu 20 mg/2ml 3 BDDALIRESP - roflumilast tab 250 mcg 4 PA, QL (30 tablets/30 days)DALIRESP - roflumilast tab 500 mcg 4 PA, QL (30 tablets/30 days)diphenhydramine hcl inj 50 mg/ml 3DULERA - mometasone furoate-formoterol fumarate aerosol

100-5 mcg/act4 QL (1 canister/30 days)

DULERA - mometasone furoate-formoterol fumarate aerosol200-5 mcg/act


epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) 3epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) (generic

for EpiPen 2-Pak)3

ESBRIET - pirfenidone cap 267 mg* 5 PA, QL (270 capsules/30 days)ESBRIET - pirfenidone tab 267 mg* 5 PA, QL (270 tablets/30 days)

2020


Drug Name Drug Tier Requirements/LimitsESBRIET - pirfenidone tab 801 mg* 5 PA, QL (90 tablets/30 days)FLOVENT DISKUS - fluticasone propionate aer pow ba 50 mcg/

blister3 QL (1 inhaler/30 days)

FLOVENT DISKUS - fluticasone propionate aer pow ba 100 mcg/blister


FLOVENT DISKUS - fluticasone propionate aer pow ba 250 mcg/blister

3 QL (4 inhalers/30 days)

FLOVENT HFA - fluticasone propionate hfa inhal aero 44 mcg/act(50/valve)


FLOVENT HFA - fluticasone propionate hfa inhal aer 110 mcg/act(125/valve)


FLOVENT HFA - fluticasone propionate hfa inhal aer 220 mcg/act(250/valve)


fluticasone propionate nasal susp 50 mcg/act^ 2 QL (1 bottle/30 days)FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-

salmeterol aer powder ba 55-14 mcg/act^2 QL (1 inhaler/30 days)

FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-salmeterol aer powder ba 113-14 mcg/act^


FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-salmeterol aer powder ba 232-14 mcg/act^


INCRUSE ELLIPTA - umeclidinium br aero powd breath act62.5 mcg/inh


ipratropium bromide inhal soln 0.02%^ 2 BDipratropium bromide nasal soln 0.03% (21 mcg/spray)^ 2 QL (2 bottles/30 days)ipratropium bromide nasal soln 0.06% (42 mcg/spray)^ 2 QL (3 bottles/30 days)KALYDECO - ivacaftor packet 25 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor packet 50 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor packet 75 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor tab 150 mg 5 PA, QL (60 tablets/30 days)levocetirizine dihydrochloride tab 5 mg^ 1mometasone furoate nasal susp 50 mcg/act^ 2 QL (2 bottles/30 days)montelukast sodium chew tab 4 mg^ 2montelukast sodium chew tab 5 mg^ 2montelukast sodium oral granules packet 4 mg^ 2montelukast sodium tab 10 mg^ 1OFEV - nintedanib esylate cap 100 mg* 5 PA, QL (60 capsules/30 days)OFEV - nintedanib esylate cap 150 mg* 5 PA, QL (60 capsules/30 days)olopatadine hcl nasal soln 0.6%^ 2 QL (1 bottle/30 days)OPSUMIT - macitentan tab 10 mg* 5 PA, QL (30 tablets/30 days)ORALAIR - grass mixed pollen ext sl tab 300 ir 4 PA, QL (30 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor granules packet 100-125 mg* 5 PA, QL (60 packets/30 days)

2020


99

Drug Name Drug Tier Requirements/LimitsORKAMBI - lumacaftor-ivacaftor granules packet 150-188 mg* 5 PA, QL (60 packets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 100-125 mg* 5 PA, QL (120 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 200-125 mg* 5 PA, QL (120 tablets/30 days)PROAIR HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (36 grams/30 days)PROAIR RESPICLICK - albuterol sulfate aer pow ba 108 mcg/act 3 QL (2 canisters/30 days)PULMOZYME - dornase alfa inhal soln 1 mg/ml 5 BDQVAR REDIHALER - beclomethasone diprop hfa breath act inh aer

40 mcg/act3 QL (1 canister/30 days)

QVAR REDIHALER - beclomethasone diprop hfa breath act inh aer80 mcg/act


REMODULIN - treprostinil inj soln 20 mg/20ml (1 mg/ml)* 5 BDREMODULIN - treprostinil inj soln 50 mg/20ml (2.5 mg/ml)* 5 BDREMODULIN - treprostinil inj soln 100 mg/20ml (5 mg/ml)* 5 BDREMODULIN - treprostinil inj soln 200 mg/20ml (10 mg/ml)* 5 BDribavirin for inhal soln 6 gm 5SEREVENT DISKUS - salmeterol xinafoate aer pow ba 50 mcg/

dose3 QL (1 inhaler/30 days)

sildenafil citrate tab 20 mg 3 PA, QL (90 tablets/30 days)SPIRIVA HANDIHALER - tiotropium bromide monohydrate inhal

cap 18 mcg3 QL (30 capsules/30 days)

SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhalaerosol 1.25 mcg/act


SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhalaerosol 2.5 mcg/act


STIOLTO RESPIMAT - tiotropium br-olodaterol inhal aero soln2.5-2.5 mcg/act


SYMBICORT - budesonide-formoterol fumarate dihyd aerosol80-4.5 mcg/act


SYMBICORT - budesonide-formoterol fumarate dihyd aerosol160-4.5 mcg/act


SYMDEKO - tezacaftor-ivacaftor 50-75 mg & ivacaftor 75 mg tabtbpk


SYMDEKO - tezacaftor-ivacaftor 100-150 mg & ivacaftor 150 mgtab tbpk


tadalafil tab 20 mg (pah) 5 PA, QL (60 tablets/30 days)terbutaline sulfate tab 2.5 mg 3terbutaline sulfate tab 5 mg 3theophylline tab er 12hr 300 mg^ 2theophylline tab er 12hr 450 mg^ 2theophylline tab er 24hr 400 mg^ 2theophylline tab er 24hr 600 mg^ 2

2020


Drug Name Drug Tier Requirements/Limitstobramycin nebu soln 300 mg/5ml 5 BDTRACLEER - bosentan tab for oral susp 32 mg* 5 PA, QL (120 tablets/30 days)TRELEGY ELLIPTA - fluticasone-umeclidinium-vilanterol aepb

100-62.5-25 mcg/inh3 QL (60 blisters/30 days)

treprostinil inj soln 20 mg/20ml (1 mg/ml)* 5 BDtreprostinil inj soln 50 mg/20ml (2.5 mg/ml)* 5 BDtreprostinil inj soln 100 mg/20ml (5 mg/ml)* 5 BDtreprostinil inj soln 200 mg/20ml (10 mg/ml)* 5 BDUPTRAVI - selexipag tab therapy pack 200 mcg (140) & 800 mcg

(60)*5 PA, QL (1 pack (200

tablets)/28 days)UPTRAVI - selexipag tab 200 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 400 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 600 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 800 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1000 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1200 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1400 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1600 mcg* 5 PA, QL (60 tablets/30 days)VENTAVIS - iloprost inhalation solution 10 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTAVIS - iloprost inhalation solution 20 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (36 grams/30 days)XOPENEX HFA - levalbuterol tartrate inhal aerosol 45 mcg/act 4 QL (2 canisters/30 days)zafirlukast tab 10 mg^ 2zafirlukast tab 20 mg^ 2Skeletal Muscle Relaxantscyclobenzaprine hcl tab 5 mg# 3 PAcyclobenzaprine hcl tab 10 mg# 3 PAmethocarbamol tab 500 mg# 3methocarbamol tab 750 mg# 3Sleep Disorder Agentsarmodafinil tab 50 mg 3 PA, QL (30 tablets/30 days)armodafinil tab 150 mg 3 PA, QL (30 tablets/30 days)armodafinil tab 200 mg 3 PA, QL (30 tablets/30 days)armodafinil tab 250 mg 3 PA, QL (30 tablets/30 days)BELSOMRA - suvorexant tab 5 mg 3 QL (30 tablets/30 days)BELSOMRA - suvorexant tab 10 mg 3 QL (30 tablets/30 days)BELSOMRA - suvorexant tab 15 mg 3 QL (30 tablets/30 days)BELSOMRA - suvorexant tab 20 mg 3 QL (30 tablets/30 days)HETLIOZ - tasimelteon capsule 20 mg* 5 PA, QL (30 capsules/30 days)

2020


101

Drug Name Drug Tier Requirements/Limitsmodafinil tab 100 mg 3 PA, QL (30 tablets/30 days)modafinil tab 200 mg 3 PA, QL (30 tablets/30 days)SILENOR - doxepin hcl tab 3 mg 3 QL (30 tablets/30 days)SILENOR - doxepin hcl tab 6 mg 3 QL (30 tablets/30 days)temazepam cap 15 mg 3 QL (30 capsules/30 days)temazepam cap 30 mg 3 QL (30 capsules/30 days)XYREM - sodium oxybate oral solution 500 mg/ml* 5 PA, QL (540 mls/30 days)zaleplon cap 5 mg# 3 QL (30 capsules/30 days)zaleplon cap 10 mg# 3 QL (60 capsules/30 days)zolpidem tartrate tab 5 mg# 3 QL (30 tablets/30 days)zolpidem tartrate tab 10 mg# 3 QL (30 tablets/30 days)

2020

102

INDEX

Aabacavir sulfate-lamivudine tab 600-300

mg................................................................................44abacavir sulfate-lamivudine-zidovudine tab

300-150-300 mg........................................................44abacavir sulfate soln 20 mg/ml.................................. 44abacavir sulfate tab 300 mg.......................................44abiraterone acetate tab 250 mg.................................26ABRAXANE...................................................................26ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1acamprosate calcium tab delayed release 333

mg..................................................................................5acarbose tab 100 mg.................................................. 50acarbose tab 25 mg.................................................... 50acarbose tab 50 mg.................................................... 50acebutolol hcl cap 200 mg..........................................57acebutolol hcl cap 400 mg..........................................57acetaminophen w/ codeine soln 120-12

mg/5ml.......................................................................... 1acetaminophen w/ codeine tab 300-15

mg..................................................................................1acetaminophen w/ codeine tab 300-30

mg..................................................................................1acetaminophen w/ codeine tab 300-60

mg..................................................................................1acetazolamide cap er 12hr 500 mg...........................57acetazolamide tab 125 mg......................................... 57acetazolamide tab 250 mg......................................... 57acetic acid otic soln 2%.............................................. 95acetylcysteine inhal soln 10%.................................... 96acetylcysteine inhal soln 20%.................................... 96acitretin cap 10 mg......................................................69acitretin cap 17.5 mg...................................................69acitretin cap 25 mg......................................................69ACTHAR........................................................................79ACTHIB..........................................................................86ACTIMMUNE................................................................ 86acyclovir cap 200 mg.................................................. 44acyclovir oint 5%..........................................................44acyclovir sodium iv soln 50 mg/ml.............................44acyclovir susp 200 mg/5ml......................................... 44acyclovir tab 400 mg................................................... 44acyclovir tab 800 mg................................................... 44ADACEL........................................................................ 86

ADASUVE..................................................................... 39adefovir dipivoxil tab 10 mg........................................44ADEMPAS..................................................................... 96ADEMPAS..................................................................... 96ADEMPAS..................................................................... 96ADEMPAS..................................................................... 96ADEMPAS..................................................................... 96ADRIAMYCIN............................................................... 26ADRIAMYCIN............................................................... 26ADVAIR DISKUS..........................................................96ADVAIR DISKUS..........................................................96ADVAIR DISKUS..........................................................96ADVAIR HFA.................................................................96ADVAIR HFA.................................................................96ADVAIR HFA.................................................................96AFINITOR......................................................................26AFINITOR......................................................................26AFINITOR......................................................................26AFINITOR......................................................................26AFINITOR DISPERZ................................................... 26AFINITOR DISPERZ................................................... 26AFINITOR DISPERZ................................................... 26AIMOVIG....................................................................... 25AIMOVIG....................................................................... 25albendazole tab 200 mg............................................. 37ALBUTEROL SULFATE ER....................................... 96ALBUTEROL SULFATE ER....................................... 96albuterol sulfate soln nebu 0.083% (2.5

mg/3ml).......................................................................96albuterol sulfate soln nebu 0.5% (5 mg/

ml)................................................................................96albuterol sulfate soln nebu 0.63

mg/3ml........................................................................ 96albuterol sulfate soln nebu 1.25

mg/3ml........................................................................ 96albuterol sulfate syrup 2 mg/5ml................................96albuterol sulfate tab 2 mg...........................................96albuterol sulfate tab 4 mg...........................................96alclometasone dipropionate cream

0.05%..........................................................................69alclometasone dipropionate oint

0.05%..........................................................................69ALCOHOL SWABS......................................................50ALDURAZYME............................................................. 77ALECENSA................................................................... 26alendronate sodium tab 10 mg.................................. 92alendronate sodium tab 35 mg.................................. 92alendronate sodium tab 5 mg.................................... 92alendronate sodium tab 70 mg.................................. 92alfuzosin hcl tab er 24hr 10 mg................................. 78ALIMTA.......................................................................... 26ALIMTA.......................................................................... 26

2020

103

ALINIA............................................................................37ALINIA............................................................................37ALIQOPA....................................................................... 26aliskiren fumarate tab 150 mg....................................57aliskiren fumarate tab 300 mg....................................57allopurinol sodium for inj 500 mg...............................24allopurinol tab 100 mg.................................................24allopurinol tab 300 mg.................................................24alosetron hcl tab 0.5 mg............................................. 74alosetron hcl tab 1 mg................................................ 75ALPHAGAN P...............................................................93alprazolam tab 0.25 mg.............................................. 49alprazolam tab 0.5 mg................................................ 49alprazolam tab 1 mg....................................................49alprazolam tab 2 mg....................................................49ALUNBRIG....................................................................26ALUNBRIG....................................................................26ALUNBRIG....................................................................26ALUNBRIG....................................................................26amantadine hcl cap 100 mg.......................................38amantadine hcl syrup 50 mg/5ml...............................38amantadine hcl tab 100 mg........................................38AMBISOME...................................................................23ambrisentan tab 10 mg............................................... 96ambrisentan tab 5 mg................................................. 96amikacin sulfate inj 1 gm/4ml (250 mg/

ml)..................................................................................5amikacin sulfate inj 500 mg/2ml (250 mg/

ml)..................................................................................5amiloride & hydrochlorothiazide tab 5-50

mg................................................................................57amiloride hcl tab 5 mg.................................................57amino acid infusion 15%.............................................72amino acid infusion 6%...............................................72amiodarone hcl tab 200 mg........................................57amiodarone hcl tab 400 mg........................................57AMITIZA.........................................................................75AMITIZA.........................................................................75amitriptyline hcl tab 100 mg....................................... 18amitriptyline hcl tab 10 mg..........................................18amitriptyline hcl tab 150 mg....................................... 18amitriptyline hcl tab 25 mg..........................................18amitriptyline hcl tab 50 mg..........................................18amitriptyline hcl tab 75 mg..........................................18amlodipine besylate-benazepril hcl cap 10-20

mg................................................................................57amlodipine besylate-benazepril hcl cap 10-40

mg................................................................................57amlodipine besylate-benazepril hcl cap 2.5-10

mg................................................................................57amlodipine besylate-benazepril hcl cap 5-10

mg................................................................................57

amlodipine besylate-benazepril hcl cap 5-20mg................................................................................57

amlodipine besylate-benazepril hcl cap 5-40mg................................................................................57

amlodipine besylate tab 10 mg..................................57amlodipine besylate tab 2.5 mg.................................57amlodipine besylate tab 5 mg.................................... 57amlodipine besylate-valsartan tab 10-160

mg................................................................................57amlodipine besylate-valsartan tab 10-320



mg................................................................................57amlodipine-valsartan-hydrochlorothiazide tab

10-160-12.5 mg.........................................................57amlodipine-valsartan-hydrochlorothiazide tab

10-160-25 mg............................................................57amlodipine-valsartan-hydrochlorothiazide tab

10-320-25 mg............................................................57amlodipine-valsartan-hydrochlorothiazide tab

5-160-12.5 mg...........................................................57amlodipine-valsartan-hydrochlorothiazide tab

5-160-25 mg.............................................................. 57AMOXAPINE.................................................................18AMOXAPINE.................................................................18AMOXAPINE.................................................................18AMOXAPINE.................................................................18AMOXICILLIN/CLAVULANATE

POTASSIUM................................................................ 6AMOXICILLIN/CLAVULANATE

POTASSIUM................................................................ 6amoxicillin (trihydrate) cap 250 mg..............................5amoxicillin (trihydrate) cap 500 mg..............................5amoxicillin (trihydrate) for susp 125

mg/5ml.......................................................................... 5amoxicillin (trihydrate) for susp 200



mg/5ml.......................................................................... 6amoxicillin (trihydrate) tab 500 mg...............................6amoxicillin (trihydrate) tab 875 mg...............................6amoxicillin & k clavulanate for susp 200-28.5

mg/5ml.......................................................................... 6amoxicillin & k clavulanate for susp 400-57

mg/5ml.......................................................................... 6amoxicillin & k clavulanate for susp 600-42.9

mg/5ml.......................................................................... 6

2020

104

amoxicillin & k clavulanate tab 250-125mg..................................................................................6



amphetamine-dextroamphetamine cap er 24hr 10mg................................................................................67






amphetamine-dextroamphetamine tab 10mg................................................................................68

amphetamine-dextroamphetamine tab 12.5mg................................................................................68





amphetamine-dextroamphetamine tab 7.5mg................................................................................68

AMPHOTERICIN B......................................................23AMPICILLIN.................................................................... 6ampicillin & sulbactam sodium for inj 3 (2-1)

gm..................................................................................6AMPICILLIN SODIUM................................................... 6ampicillin sodium for inj 1 gm.......................................6ampicillin sodium for inj 250 mg...................................6ampicillin sodium for inj 2 gm.......................................6ampicillin sodium for inj 500 mg...................................6ampicillin sodium for iv soln 10 gm..............................6ampicillin sodium for iv soln 2 gm................................6AMPICILLIN-SULBACTAM........................................... 6ANADROL-50............................................................... 81anagrelide hcl cap 0.5 mg.......................................... 53anagrelide hcl cap 1 mg............................................. 53anastrozole tab 1 mg...................................................26ANDRODERM.............................................................. 81ANDRODERM.............................................................. 81ANORO ELLIPTA.........................................................96APOKYN........................................................................38

aprepitant capsule 125 mg.........................................22aprepitant capsule 40 mg........................................... 22aprepitant capsule 80 mg........................................... 22aprepitant capsule therapy pack 80 & 125

mg................................................................................22APRISO......................................................................... 92APTIOM......................................................................... 14APTIOM......................................................................... 14APTIOM......................................................................... 14APTIOM......................................................................... 14APTIVUS....................................................................... 44APTIVUS....................................................................... 44ARANESP ALBUMIN FREE.......................................53ARANESP ALBUMIN FREE.......................................53ARANESP ALBUMIN FREE.......................................53ARANESP ALBUMIN FREE.......................................53ARANESP ALBUMIN FREE.......................................53ARANESP ALBUMIN FREE.......................................53ARANESP ALBUMIN FREE.......................................53ARANESP ALBUMIN FREE.......................................53ARANESP ALBUMIN FREE.......................................54ARANESP ALBUMIN FREE.......................................54ARANESP ALBUMIN FREE.......................................54ARANESP ALBUMIN FREE.......................................54ARANESP ALBUMIN FREE.......................................54ARANESP ALBUMIN FREE.......................................54ARANESP ALBUMIN FREE.......................................54ARCALYST....................................................................86aripiprazole orally disintegrating tab 10

mg................................................................................39aripiprazole orally disintegrating tab 15

mg................................................................................39aripiprazole oral solution 1 mg/ml..............................39aripiprazole tab 10 mg................................................ 39aripiprazole tab 15 mg................................................ 39aripiprazole tab 20 mg................................................ 39aripiprazole tab 2 mg...................................................39aripiprazole tab 30 mg................................................ 39aripiprazole tab 5 mg...................................................39ARISTADA.....................................................................39ARISTADA.....................................................................39ARISTADA.....................................................................40ARISTADA.....................................................................40ARISTADA INITIO........................................................40armodafinil tab 150 mg............................................. 100armodafinil tab 200 mg............................................. 100armodafinil tab 250 mg............................................. 100armodafinil tab 50 mg............................................... 100ARNUITY ELLIPTA......................................................96ARNUITY ELLIPTA......................................................96ARNUITY ELLIPTA......................................................96ARRANON.................................................................... 27

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105

arsenic trioxide iv soln 10 mg/10ml (1 mg/ml)................................................................................27

arsenic trioxide iv soln 12 mg/6ml (2 mg/ml)................................................................................27

ARZERRA..................................................................... 27ARZERRA..................................................................... 27ASMANEX HFA............................................................96ASMANEX HFA............................................................96ASMANEX TWISTHALER 120 METERED

DOSES....................................................................... 97ASMANEX TWISTHALER 14 METERED





DOSES....................................................................... 97aspirin-dipyridamole cap er 12hr 25-200

mg................................................................................54atazanavir sulfate cap 150 mg...................................44atazanavir sulfate cap 200 mg...................................44atazanavir sulfate cap 300 mg...................................44atenolol & chlorthalidone tab 100-25

mg................................................................................57atenolol & chlorthalidone tab 50-25 mg.................... 57atenolol tab 100 mg.....................................................57atenolol tab 25 mg.......................................................57atenolol tab 50 mg.......................................................57ATGAM.......................................................................... 86atomoxetine hcl cap 100 mg...................................... 68atomoxetine hcl cap 10 mg........................................ 68atomoxetine hcl cap 18 mg........................................ 68atomoxetine hcl cap 25 mg........................................ 68atomoxetine hcl cap 40 mg........................................ 68atomoxetine hcl cap 60 mg........................................ 68atomoxetine hcl cap 80 mg........................................ 68atorvastatin calcium tab 10 mg.................................. 57atorvastatin calcium tab 20 mg.................................. 57atorvastatin calcium tab 40 mg.................................. 57atorvastatin calcium tab 80 mg.................................. 58atovaquone-proguanil hcl tab 250-100

mg................................................................................37atovaquone-proguanil hcl tab 62.5-25

mg................................................................................37atovaquone susp 750 mg/5ml....................................37ATRIPLA........................................................................ 44ATROVENT HFA..........................................................97AUBAGIO...................................................................... 68AUBAGIO...................................................................... 68

AUGMENTED BETAMETHASONEDIPROPIONATE....................................................... 69

AURYXIA.......................................................................72AVASTIN........................................................................27AVASTIN........................................................................27AVONEX........................................................................ 68AVONEX PEN.............................................................. 68azacitidine for inj 100 mg............................................54AZASAN........................................................................ 86AZASAN........................................................................ 86AZATHIOPRINE........................................................... 86azathioprine tab 50 mg............................................... 86azelaic acid gel 15%................................................... 69azelastine hcl nasal spray 0.1% (137 mcg/

spray)..........................................................................97azelastine hcl nasal spray 0.15% (205.5 mcg/

spray)..........................................................................97azelastine hcl ophth soln 0.05%................................ 93AZELEX......................................................................... 69AZITHROMYCIN............................................................ 6azithromycin for susp 100 mg/5ml...............................6azithromycin for susp 200 mg/5ml...............................6azithromycin iv for soln 500 mg................................... 6azithromycin tab 250 mg...............................................6azithromycin tab 500 mg...............................................6azithromycin tab 600 mg...............................................6AZOPT........................................................................... 93aztreonam for inj 1 gm.................................................. 6aztreonam for inj 2 gm.................................................. 6BBACITRACIN................................................................ 94bacitracin-polymyxin b ophth oint.............................. 94bacitracin-polymyxin-neomycin-hc ophth oint

1%............................................................................... 94baclofen tab 10 mg......................................................44baclofen tab 20 mg......................................................44balsalazide disodium cap 750 mg............................. 92BALVERSA....................................................................27BALVERSA....................................................................27BALVERSA....................................................................27BANZEL.........................................................................14BANZEL.........................................................................14BANZEL.........................................................................14BARACLUDE................................................................ 44BASAGLAR KWIKPEN............................................... 50BAVENCIO.................................................................... 27BCG VACCINE.............................................................86BELEODAQ.................................................................. 27BELSOMRA................................................................ 100BELSOMRA................................................................ 100BELSOMRA................................................................ 100

2020

106

BELSOMRA................................................................ 100benazepril & hydrochlorothiazide tab 10-12.5

mg................................................................................58benazepril & hydrochlorothiazide tab 20-12.5

mg................................................................................58benazepril & hydrochlorothiazide tab 20-25

mg................................................................................58benazepril & hydrochlorothiazide tab 5-6.25

mg................................................................................58benazepril hcl tab 10 mg............................................ 58benazepril hcl tab 20 mg............................................ 58benazepril hcl tab 40 mg............................................ 58benazepril hcl tab 5 mg.............................................. 58BENDEKA..................................................................... 27BENLYSTA.................................................................... 86BENLYSTA.................................................................... 86BENLYSTA.................................................................... 86BENLYSTA.................................................................... 86BENZNIDAZOLE..........................................................37BENZNIDAZOLE..........................................................37benzoyl peroxide-erythromycin gel

5-3%............................................................................69benztropine mesylate tab 0.5 mg.............................. 38benztropine mesylate tab 1 mg..................................38benztropine mesylate tab 2 mg..................................38BESIVANCE..................................................................94BESPONSA.................................................................. 27betamethasone dipropionate augmented cream

0.05%..........................................................................69betamethasone dipropionate augmented lotion

0.05%..........................................................................69betamethasone dipropionate augmented oint

0.05%..........................................................................69betamethasone dipropionate cream

0.05%..........................................................................69betamethasone dipropionate lotion

0.05%..........................................................................69betamethasone dipropionate oint

0.05%..........................................................................69betamethasone valerate cream 0.1%....................... 70betamethasone valerate lotion 0.1%.........................70betamethasone valerate oint 0.1%............................70BETASERON................................................................ 68betaxolol hcl ophth soln 0.5%.................................... 94betaxolol hcl tab 10 mg...............................................58betaxolol hcl tab 20 mg...............................................58bethanechol chloride tab 10 mg.................................78bethanechol chloride tab 25 mg.................................78bethanechol chloride tab 50 mg.................................78bethanechol chloride tab 5 mg...................................78BETOPTIC-S.................................................................94BEVYXXA......................................................................54

BEVYXXA......................................................................54bexarotene cap 75 mg................................................ 27BEXSERO..................................................................... 87bicalutamide tab 50 mg...............................................27BICILLIN L-A...................................................................6BICILLIN L-A...................................................................6BICILLIN L-A...................................................................6BIKTARVY..................................................................... 44bimatoprost ophth soln 0.03%................................... 94bisoprolol & hydrochlorothiazide tab 10-6.25

mg................................................................................58bisoprolol & hydrochlorothiazide tab 2.5-6.25

mg................................................................................58bisoprolol & hydrochlorothiazide tab 5-6.25

mg................................................................................58bisoprolol fumarate tab 10 mg................................... 58bisoprolol fumarate tab 5 mg..................................... 58bleomycin sulfate for inj 15 unit................................. 27bleomycin sulfate for inj 30 unit................................. 27BLINCYTO.....................................................................27BOOSTRIX....................................................................87bosentan tab 125 mg.................................................. 97bosentan tab 62.5 mg................................................. 97BOSULIF....................................................................... 27BOSULIF....................................................................... 27BOSULIF....................................................................... 27BRAFTOVI.....................................................................27BREO ELLIPTA............................................................ 97BREO ELLIPTA............................................................ 97BRILINTA.......................................................................54BRILINTA.......................................................................54brimonidine tartrate ophth soln 0.15%...................... 94brimonidine tartrate ophth soln 0.2%........................ 94BRIVIACT......................................................................14BRIVIACT......................................................................14BRIVIACT......................................................................14BRIVIACT......................................................................14BRIVIACT......................................................................14BRIVIACT......................................................................14BRIVIACT......................................................................14BROMFENAC...............................................................94bromocriptine mesylate cap 5 mg..............................38bromocriptine mesylate tab 2.5 mg........................... 38budesonide delayed release particles cap 3

mg................................................................................92budesonide inhalation susp 0.25

mg/2ml........................................................................ 97budesonide inhalation susp 0.5

mg/2ml........................................................................ 97budesonide inhalation susp 1 mg/2ml.......................97bumetanide inj 0.25 mg/ml......................................... 58bumetanide tab 0.5 mg............................................... 58

2020

107

bumetanide tab 1 mg.................................................. 58bumetanide tab 2 mg.................................................. 58buprenorphine hcl-naloxone hcl sl film 12-3

mg..................................................................................5buprenorphine hcl-naloxone hcl sl film 2-0.5

mg..................................................................................5buprenorphine hcl-naloxone hcl sl film 4-1

mg..................................................................................5buprenorphine hcl-naloxone hcl sl film 8-2

mg..................................................................................5buprenorphine hcl-naloxone hcl sl tab 2-0.5

mg..................................................................................5buprenorphine hcl-naloxone hcl sl tab 8-2

mg..................................................................................5buprenorphine hcl sl tab 2 mg......................................5buprenorphine hcl sl tab 8 mg......................................5bupropion hcl (smoking deterrent) tab er 12hr 150

mg..................................................................................5bupropion hcl tab 100 mg...........................................19bupropion hcl tab 75 mg.............................................19bupropion hcl tab er 12hr 100 mg............................. 18bupropion hcl tab er 12hr 150 mg............................. 18bupropion hcl tab er 12hr 200 mg............................. 19bupropion hcl tab er 24hr 150 mg............................. 19bupropion hcl tab er 24hr 300 mg............................. 19buspirone hcl tab 10 mg............................................. 49buspirone hcl tab 15 mg............................................. 49buspirone hcl tab 30 mg............................................. 49buspirone hcl tab 5 mg............................................... 49buspirone hcl tab 7.5 mg............................................ 49busulfan inj 6 mg/ml.................................................... 27butalbital-acetaminophen-caffeine cap 50-300-40

mg..................................................................................1butalbital-acetaminophen-caffeine cap 50-325-40

mg..................................................................................1butalbital-acetaminophen-caffeine tab 50-325-40

mg..................................................................................1butalbital-acetaminophen tab 50-325

mg..................................................................................1butalbital-aspirin-caffeine cap 50-325-40

mg..................................................................................1BUTORPHANOL TARTRATE.......................................1butorphanol tartrate inj 2 mg/ml................................... 1butorphanol tartrate nasal soln 10 mg/

ml................................................................................... 1BYDUREON BCISE.....................................................50BYDUREON PEN........................................................ 50BYSTOLIC.....................................................................58BYSTOLIC.....................................................................58BYSTOLIC.....................................................................58BYSTOLIC.....................................................................58

Ccabergoline tab 0.5 mg............................................... 84CABLIVI......................................................................... 87CABOMETYX............................................................... 27CABOMETYX............................................................... 27CABOMETYX............................................................... 27caffeine citrate oral soln 60 mg/3ml...........................97calcipotriene cream 0.005%.......................................70calcipotriene oint 0.005%............................................70calcipotriene soln 0.005% (50 mcg/ml).....................70calcitonin (salmon) nasal soln 200 unit/

act................................................................................93CALCITRIOL.................................................................93calcitriol cap 0.25 mcg................................................ 93calcitriol cap 0.5 mcg...................................................93calcitriol oral soln 1 mcg/ml........................................93calcium acetate cap 667 mg...................................... 72calcium acetate tab 667 mg....................................... 72CALQUENCE................................................................27candesartan cilexetil-hydrochlorothiazide tab 16-12.5

mg................................................................................58candesartan cilexetil-hydrochlorothiazide tab 32-12.5

mg................................................................................58candesartan cilexetil-hydrochlorothiazide tab 32-25

mg................................................................................58candesartan cilexetil tab 16 mg................................. 58candesartan cilexetil tab 32 mg................................. 58candesartan cilexetil tab 4 mg................................... 58candesartan cilexetil tab 8 mg................................... 58CAPASTAT SULFATE..................................................25CAPRELSA................................................................... 27CAPRELSA................................................................... 27captopril tab 100 mg....................................................58captopril tab 12.5 mg...................................................58captopril tab 25 mg......................................................58captopril tab 50 mg......................................................58CARAC.......................................................................... 70CARBAGLU.................................................................. 72carbamazepine cap er 12hr 100 mg......................... 14carbamazepine cap er 12hr 200 mg......................... 14carbamazepine cap er 12hr 300 mg......................... 14carbamazepine chew tab 100 mg..............................14carbamazepine susp 100 mg/5ml..............................14carbamazepine tab 200 mg........................................14carbamazepine tab er 12hr 100 mg.......................... 14carbamazepine tab er 12hr 200 mg.......................... 14carbamazepine tab er 12hr 400 mg.......................... 14CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................38CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................38

2020

108

CARBIDOPA/LEVODOPA/ENTACAPONE..........................................................38




carbidopa & levodopa orally disintegrating tab10-100 mg..................................................................38



carbidopa & levodopa tab 10-100 mg....................... 38carbidopa & levodopa tab 25-100 mg....................... 38carbidopa & levodopa tab 25-250 mg....................... 38carbidopa & levodopa tab er 25-100

mg................................................................................38carbidopa & levodopa tab er 50-200

mg................................................................................38carbidopa tab 25 mg................................................... 38carboplatin iv soln 150 mg/15ml................................ 27carboplatin iv soln 450 mg/45ml................................ 27carboplatin iv soln 50 mg/5ml.................................... 27carboplatin iv soln 600 mg/60ml................................ 27carmustine for inj 100 mg...........................................27carteolol hcl ophth soln 1%........................................ 94carvedilol tab 12.5 mg.................................................58carvedilol tab 25 mg....................................................59carvedilol tab 3.125 mg...............................................58carvedilol tab 6.25 mg.................................................58caspofungin acetate for iv soln 50 mg...................... 23caspofungin acetate for iv soln 70 mg...................... 23cefaclor cap 250 mg......................................................7cefaclor cap 500 mg......................................................7cefadroxil cap 500 mg...................................................7cefadroxil for susp 250 mg/5ml....................................7cefadroxil for susp 500 mg/5ml....................................7cefadroxil tab 1 gm........................................................ 7CEFAZOLIN SODIUM................................................... 7CEFAZOLIN SODIUM................................................... 7CEFAZOLIN SODIUM/DEXTROSE............................ 7cefazolin sodium for inj 10 gm..................................... 7cefazolin sodium for inj 1 gm....................................... 7cefazolin sodium for inj 500 mg................................... 7cefdinir cap 300 mg....................................................... 7cefdinir for susp 125 mg/5ml........................................7cefdinir for susp 250 mg/5ml........................................7CEFEPIME...................................................................... 7CEFEPIME...................................................................... 7CEFEPIME/DEXTROSE............................................... 7

CEFEPIME/DEXTROSE............................................... 7cefepime hcl for inj 1 gm.............................................. 7cefepime hcl for inj 2 gm.............................................. 7cefixime cap 400 mg..................................................... 7CEFOTAXIME SODIUM................................................7cefotaxime sodium for inj 1 gm.................................... 7CEFOXITIN SODIUM.................................................... 7CEFOXITIN SODIUM.................................................... 7cefoxitin sodium for inj 10 gm...................................... 7cefoxitin sodium for iv soln 1 gm................................. 7cefoxitin sodium for iv soln 2 gm................................. 7cefpodoxime proxetil for susp 100

mg/5ml.......................................................................... 7cefpodoxime proxetil for susp 50

mg/5ml.......................................................................... 7cefpodoxime proxetil tab 100 mg.................................7cefpodoxime proxetil tab 200 mg.................................7cefprozil for susp 125 mg/5ml...................................... 7cefprozil for susp 250 mg/5ml...................................... 8cefprozil tab 250 mg......................................................8cefprozil tab 500 mg......................................................8CEFTAZIDIME/DEXTROSE......................................... 8CEFTAZIDIME/DEXTROSE......................................... 8ceftazidime for inj 1 gm.................................................8ceftazidime for inj 2 gm.................................................8ceftazidime for inj 6 gm.................................................8CEFTRIAXONE/DEXTROSE....................................... 8CEFTRIAXONE/DEXTROSE....................................... 8CEFTRIAXONE IN ISO-OSMOTIC

DEXTROSE................................................................. 8CEFTRIAXONE IN ISO-OSMOTIC

DEXTROSE................................................................. 8CEFTRIAXONE SODIUM............................................. 8ceftriaxone sodium for inj 10 gm..................................8ceftriaxone sodium for inj 1 gm....................................8ceftriaxone sodium for inj 250 mg................................8ceftriaxone sodium for inj 2 gm....................................8ceftriaxone sodium for inj 500 mg................................8ceftriaxone sodium for iv soln 1 gm.............................8ceftriaxone sodium for iv soln 2 gm.............................8cefuroxime axetil tab 250 mg....................................... 8cefuroxime axetil tab 500 mg....................................... 8cefuroxime sodium for inj 7.5 gm.................................8cefuroxime sodium for inj 750 mg................................8cefuroxime sodium for iv soln 1.5 gm..........................8celecoxib cap 100 mg................................................... 1celecoxib cap 200 mg................................................... 1celecoxib cap 400 mg................................................... 1celecoxib cap 50 mg......................................................1CELONTIN.................................................................... 14cephalexin cap 250 mg.................................................8cephalexin cap 500 mg.................................................8

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109

cephalexin cap 750 mg.................................................8cephalexin for susp 125 mg/5ml..................................8cephalexin for susp 250 mg/5ml..................................8CEREZYME.................................................................. 77CHANTIX......................................................................... 5CHANTIX......................................................................... 5CHANTIX CONTINUING MONTH

PACK.............................................................................5CHANTIX STARTING MONTH PACK.........................5CHEMET........................................................................72CHENODAL.................................................................. 75CHLORAMPHENICOL SODIUM

SUCCINATE.................................................................8chlorhexidine gluconate soln 0.12%..........................69CHLOROQUINE PHOSPHATE................................. 37chloroquine phosphate tab 500 mg...........................37CHLOROTHIAZIDE..................................................... 59chlorothiazide tab 500 mg.......................................... 59CHLORPROMAZINE HCL..........................................22CHLORPROMAZINE HCL..........................................22chlorpromazine hcl tab 100 mg..................................22chlorpromazine hcl tab 10 mg....................................22chlorpromazine hcl tab 200 mg..................................22chlorpromazine hcl tab 25 mg....................................22chlorpromazine hcl tab 50 mg....................................22chlorthalidone tab 25 mg............................................ 59chlorthalidone tab 50 mg............................................ 59cholestyramine light powder 4 gm/

dose............................................................................ 59cholestyramine light powder packets 4

gm................................................................................59cholestyramine powder 4 gm/dose............................59cholestyramine powder packets 4 gm.......................59choline fenofibrate cap dr 135 mg............................. 59choline fenofibrate cap dr 45 mg............................... 59CHORIONIC GONADOTROPIN................................80ciclopirox gel 0.77%.................................................... 23ciclopirox olamine cream 0.77%................................23ciclopirox olamine susp 0.77%...................................23ciclopirox shampoo 1%............................................... 23ciclopirox solution 8%..................................................23cidofovir iv inj 75 mg/ml.............................................. 44cilostazol tab 100 mg.................................................. 54cilostazol tab 50 mg.................................................... 54CIMDUO........................................................................ 44CIMETIDINE HCL........................................................ 75cimetidine tab 200 mg.................................................75cimetidine tab 300 mg.................................................75cimetidine tab 400 mg.................................................75cimetidine tab 800 mg.................................................75cinacalcet hcl tab 30 mg.............................................93cinacalcet hcl tab 60 mg.............................................93

cinacalcet hcl tab 90 mg.............................................93CINRYZE.......................................................................87ciprofloxacin 200 mg/100ml in d5w............................. 9ciprofloxacin 400 mg/200ml in d5w............................. 9ciprofloxacin for oral susp 500 mg/5ml (10%) (10

gm/100ml).....................................................................8CIPROFLOXACIN HCL.................................................8ciprofloxacin hcl ophth soln 0.3%.............................. 94ciprofloxacin hcl tab 250 mg.........................................9ciprofloxacin hcl tab 500 mg.........................................9ciprofloxacin hcl tab 750 mg.........................................9CISPLATIN.................................................................... 27cisplatin inj 100 mg/100ml (1 mg/ml).........................27cisplatin inj 50 mg/50ml (1 mg/ml).............................27citalopram hydrobromide oral soln 10

mg/5ml........................................................................ 19citalopram hydrobromide tab 10 mg..........................19citalopram hydrobromide tab 20 mg..........................19citalopram hydrobromide tab 40 mg..........................19cladribine iv soln 10 mg/10ml (1 mg/

ml)................................................................................28CLARITHROMYCIN.......................................................9CLARITHROMYCIN.......................................................9clarithromycin tab 250 mg............................................ 9clarithromycin tab 500 mg............................................ 9clarithromycin tab er 24hr 500 mg...............................9CLEMASTINE FUMARATE........................................ 97CLINDAMYCIN/SODIUM CHLORIDE.........................9CLINDAMYCIN/SODIUM CHLORIDE.........................9CLINDAMYCIN/SODIUM CHLORIDE.........................9clindamycin hcl cap 150 mg......................................... 9clindamycin hcl cap 300 mg......................................... 9clindamycin hcl cap 75 mg........................................... 9clindamycin phosphate-benzoyl peroxide gel

1-5%............................................................................70clindamycin phosphate gel 1%.................................... 9clindamycin phosphate in d5w iv soln 300

mg/50ml........................................................................ 9clindamycin phosphate in d5w iv soln 600

mg/50ml........................................................................ 9clindamycin phosphate in d5w iv soln 900

mg/50ml........................................................................ 9clindamycin phosphate inj 300 mg/2ml....................... 9clindamycin phosphate inj 600 mg/4ml....................... 9clindamycin phosphate inj 900 mg/6ml....................... 9clindamycin phosphate inj 9 gm/60ml......................... 9clindamycin phosphate iv soln 300

mg/2ml.......................................................................... 9clindamycin phosphate iv soln 600

mg/4ml.......................................................................... 9clindamycin phosphate iv soln 900

mg/6ml.......................................................................... 9

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clindamycin phosphate lotion 1%................................ 9clindamycin phosphate soln 1%...................................9clindamycin phosphate swab 1%.................................9clindamycin phosphate vaginal cream

2%..................................................................................9clobazam suspension 2.5 mg/ml............................... 14clobazam tab 10 mg....................................................14clobazam tab 20 mg....................................................14clobetasol propionate cream 0.05%..........................70clobetasol propionate emollient base cream

0.05%..........................................................................70clobetasol propionate gel 0.05%................................70clobetasol propionate oint 0.05%.............................. 70clobetasol propionate soln 0.05%..............................70clofarabine iv soln 1 mg/ml.........................................28clomipramine hcl cap 25 mg...................................... 19clomipramine hcl cap 50 mg...................................... 19clomipramine hcl cap 75 mg...................................... 19clonazepam orally disintegrating tab 0.125

mg................................................................................49clonazepam orally disintegrating tab 0.25

mg................................................................................49clonazepam orally disintegrating tab 0.5

mg................................................................................49clonazepam orally disintegrating tab 1

mg................................................................................49clonazepam orally disintegrating tab 2

mg................................................................................49clonazepam tab 0.5 mg.............................................. 49clonazepam tab 1 mg..................................................49clonazepam tab 2 mg..................................................49clonidine hcl tab 0.1 mg..............................................59clonidine hcl tab 0.2 mg..............................................59clonidine hcl tab 0.3 mg..............................................59clonidine hcl tab er 12hr 0.1 mg................................ 68clonidine td patch weekly 0.1 mg/24hr......................59clonidine td patch weekly 0.2 mg/24hr......................59clonidine td patch weekly 0.3 mg/24hr......................59clopidogrel bisulfate tab 75 mg..................................54clorazepate dipotassium tab 15 mg...........................49clorazepate dipotassium tab 3.75 mg....................... 49clorazepate dipotassium tab 7.5 mg......................... 49clotrimazole cream 1%................................................23clotrimazole troche 10 mg.......................................... 23clotrimazole w/ betamethasone cream

1-0.05%...................................................................... 70clotrimazole w/ betamethasone lotion

1-0.05%...................................................................... 70clozapine orally disintegrating tab 100

mg................................................................................40clozapine orally disintegrating tab 12.5

mg................................................................................40

clozapine orally disintegrating tab 25mg................................................................................40

clozapine tab 100 mg..................................................40clozapine tab 200 mg..................................................40clozapine tab 25 mg....................................................40clozapine tab 50 mg....................................................40COARTEM.....................................................................37codeine sulfate tab 30 mg............................................ 1codeine sulfate tab 60 mg............................................ 1colchicine w/ probenecid tab 0.5-500

mg................................................................................24COLCRYS..................................................................... 24colestipol hcl granule packets 5 gm.......................... 59colestipol hcl granules 5 gm.......................................59colestipol hcl tab 1 gm................................................ 59colistimethate sod for inj 150 mg................................. 9COMBIGAN...................................................................94COMBIPATCH.............................................................. 81COMBIPATCH.............................................................. 81COMBIVENT RESPIMAT........................................... 97COMETRIQ...................................................................28COMETRIQ...................................................................28COMETRIQ...................................................................28COMPLERA.................................................................. 44COPIKTRA....................................................................28COPIKTRA....................................................................28CORLANOR..................................................................59CORLANOR..................................................................59CORLANOR..................................................................59CORTISONE ACETATE..............................................79COSENTYX.................................................................. 87COSENTYX.................................................................. 87COSENTYX SENSOREADY PEN............................ 87COSENTYX SENSOREADY PEN............................ 87COTELLIC.....................................................................28COUMADIN...................................................................54COUMADIN...................................................................54COUMADIN...................................................................54COUMADIN...................................................................54COUMADIN...................................................................54COUMADIN...................................................................54COUMADIN...................................................................54COUMADIN...................................................................54COUMADIN...................................................................54CREON..........................................................................77CREON..........................................................................77CREON..........................................................................77CREON..........................................................................77CREON..........................................................................77CRESEMBA.................................................................. 23CRESEMBA.................................................................. 23CRIXIVAN......................................................................44

2020

111

CRIXIVAN......................................................................45cromolyn sodium ophth soln 4%................................94cromolyn sodium oral conc 100

mg/5ml........................................................................ 75cromolyn sodium soln nebu 20 mg/2ml.................... 97CRYSVITA.....................................................................77CRYSVITA.....................................................................77CRYSVITA.....................................................................77cyclobenzaprine hcl tab 10 mg................................ 100cyclobenzaprine hcl tab 5 mg.................................. 100cyclophosphamide cap 25 mg................................... 28cyclophosphamide cap 50 mg................................... 28cyclophosphamide for inj 1 gm.................................. 28cyclophosphamide for inj 2 gm.................................. 28cyclophosphamide for inj 500 mg..............................28cycloserine cap 250 mg..............................................26CYCLOSET...................................................................50cyclosporine cap 100 mg............................................87cyclosporine cap 25 mg..............................................87cyclosporine iv soln 50 mg/ml....................................87cyclosporine modified cap 100 mg............................ 87cyclosporine modified cap 25 mg.............................. 87cyclosporine modified cap 50 mg.............................. 87cyclosporine modified oral soln 100 mg/

ml.................................................................................87CYRAMZA.....................................................................28CYRAMZA.....................................................................28CYSTADANE................................................................ 77CYSTAGON.................................................................. 77CYSTAGON.................................................................. 77CYSTARAN...................................................................94CYTARABINE............................................................... 28cytarabine inj pf 100 mg/ml........................................ 28cytarabine inj pf 20 mg/ml.......................................... 28DDACARBAZINE............................................................ 28dacarbazine for inj 200 mg.........................................28dactinomycin for inj 0.5 mg........................................ 28dalfampridine tab er 12hr 10 mg................................68DALIRESP.....................................................................97DALIRESP.....................................................................97DALVANCE......................................................................9danazol cap 100 mg....................................................81danazol cap 200 mg....................................................81danazol cap 50 mg......................................................81dantrolene sodium cap 100 mg................................. 44dantrolene sodium cap 25 mg....................................44dantrolene sodium cap 50 mg....................................44dapsone tab 100 mg................................................... 26dapsone tab 25 mg......................................................26DAPTACEL....................................................................87

daptomycin for iv soln 500 mg..................................... 9DARAPRIM................................................................... 37DARZALEX................................................................... 28DARZALEX................................................................... 28daunorubicin hcl iv soln 20 mg/4ml........................... 28DAUNORUBICIN HYDROCHLORIDE......................28DAURISMO...................................................................28DAURISMO...................................................................28decitabine for inj 50 mg.............................................. 28deferasirox tab for oral susp 125 mg.........................72deferasirox tab for oral susp 250 mg.........................72deferasirox tab for oral susp 500 mg.........................72DELSTRIGO................................................................. 45demeclocycline hcl tab 150 mg....................................9demeclocycline hcl tab 300 mg....................................9DEMSER....................................................................... 59DENAVIR.......................................................................45DEPEN TITRATABS.................................................... 78DEPO-PROVERA........................................................ 81DESCOVY.....................................................................45desipramine hcl tab 100 mg.......................................19desipramine hcl tab 10 mg......................................... 19desipramine hcl tab 150 mg.......................................19desipramine hcl tab 25 mg......................................... 19desipramine hcl tab 50 mg......................................... 19desipramine hcl tab 75 mg......................................... 19desmopressin acetate inj 4 mcg/ml...........................80desmopressin acetate nasal spray soln

0.01%..........................................................................80desmopressin acetate nasal spray soln 0.01%

(refrigerated).............................................................. 80desmopressin acetate tab 0.1 mg............................. 80desmopressin acetate tab 0.2 mg............................. 80desogest-eth estrad & eth estrad tab 0.15-0.02/0.01

mg(21/5)..................................................................... 81desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg................................................................................81

desogestrel & ethinyl estradiol tab 0.15 mg-30mcg..............................................................................81

desonide cream 0.05%............................................... 70desonide lotion 0.05%.................................................70desonide oint 0.05%....................................................70desoximetasone cream 0.05%...................................70desoximetasone cream 0.25%...................................70desoximetasone gel 0.05%........................................ 70desoximetasone oint 0.25%....................................... 70desvenlafaxine succinate tab er 24hr 100

mg................................................................................19desvenlafaxine succinate tab er 24hr 25

mg................................................................................19

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112

desvenlafaxine succinate tab er 24hr 50mg................................................................................19

DEXAMETHASONE.................................................... 79DEXAMETHASONE.................................................... 79DEXAMETHASONE.................................................... 79dexamethasone elixir 0.5 mg/5ml..............................79DEXAMETHASONE SODIUM

PHOSPHATE.............................................................94dexamethasone sodium phosphate inj 120

mg/30ml......................................................................79dexamethasone sodium phosphate inj 20

mg/5ml........................................................................ 79dexamethasone sodium phosphate inj 4 mg/

ml.................................................................................79dexamethasone tab 0.5 mg........................................79dexamethasone tab 0.75 mg......................................79dexamethasone tab 1.5 mg........................................80dexamethasone tab 4 mg...........................................80dexamethasone tab 6 mg...........................................80dexamethasone tab therapy pack 1.5 mg

(21)..............................................................................79dexamethasone tab therapy pack 1.5 mg

(35)..............................................................................79dexamethasone tab therapy pack 1.5 mg

(51)..............................................................................79dexmethylphenidate hcl tab 10 mg............................68dexmethylphenidate hcl tab 2.5 mg...........................68dexmethylphenidate hcl tab 5 mg..............................68dexrazoxane hcl for inj 250 mg..................................28dexrazoxane hcl for inj 500 mg..................................28dextroamphetamine sulfate cap er 24hr 10

mg................................................................................68dextroamphetamine sulfate cap er 24hr 15

mg................................................................................68dextroamphetamine sulfate cap er 24hr 5

mg................................................................................68dextroamphetamine sulfate tab 10 mg......................68dextroamphetamine sulfate tab 5 mg........................68DEXTROSE 2.5%/NACL 0.45%................................ 73dextrose 5% in lactated ringers................................. 73dextrose 5% w/ sodium chloride 0.2%...................... 73dextrose 5% w/ sodium chloride

0.33%..........................................................................73dextrose 5% w/ sodium chloride

0.45%..........................................................................73dextrose 5% w/ sodium chloride 0.9%...................... 73dextrose inj 10%.......................................................... 72dextrose inj 5%.............................................................72DIASTAT ACUDIAL......................................................14DIASTAT ACUDIAL......................................................15DIASTAT PEDIATRIC..................................................15DIAZEPAM.................................................................... 49

diazepam conc 5 mg/ml..............................................49DIAZEPAM RECTAL GEL.......................................... 15DIAZEPAM RECTAL GEL.......................................... 15DIAZEPAM RECTAL GEL.......................................... 15diazepam tab 10 mg....................................................49diazepam tab 2 mg......................................................49diazepam tab 5 mg......................................................49diclofenac potassium tab 50 mg.................................. 1diclofenac sodium (actinic keratoses) gel

3%............................................................................... 70diclofenac sodium gel 1%.............................................1diclofenac sodium ophth soln 0.1%...........................94diclofenac sodium tab delayed release 25

mg..................................................................................1diclofenac sodium tab delayed release 50

mg..................................................................................1diclofenac sodium tab delayed release 75

mg..................................................................................1diclofenac sodium tab er 24hr 100 mg........................1diclofenac w/ misoprostol tab delayed release 50-0.2

mg..................................................................................1diclofenac w/ misoprostol tab delayed release 75-0.2

mg..................................................................................1dicloxacillin sodium cap 250 mg................................ 10dicloxacillin sodium cap 500 mg................................ 10dicyclomine hcl cap 10 mg......................................... 75dicyclomine hcl tab 20 mg..........................................75didanosine delayed release capsule 200

mg................................................................................45didanosine delayed release capsule 250

mg................................................................................45didanosine delayed release capsule 400

mg................................................................................45DIFICID..........................................................................10diflorasone diacetate oint 0.05%................................70DIGOXIN........................................................................59digoxin tab 125 mcg (0.125 mg)................................59digoxin tab 250 mcg (0.25 mg).................................. 59DILANTIN...................................................................... 15diltiazem hcl cap er 12hr 120 mg.............................. 59diltiazem hcl cap er 12hr 60 mg.................................59diltiazem hcl cap er 12hr 90 mg.................................59diltiazem hcl cap er 24hr 120 mg.............................. 59diltiazem hcl cap er 24hr 180 mg.............................. 59diltiazem hcl cap er 24hr 240 mg.............................. 59diltiazem hcl coated beads cap er 24hr 120

mg................................................................................59diltiazem hcl coated beads cap er 24hr 180

mg................................................................................59diltiazem hcl coated beads cap er 24hr 240

mg................................................................................59

2020

113

diltiazem hcl coated beads cap er 24hr 300mg................................................................................59

diltiazem hcl coated beads cap er 24hr 360mg................................................................................59

diltiazem hcl coated beads tab er 24hr 180mg................................................................................60





diltiazem hcl extended release beads cap er 24hr120 mg....................................................................... 60






diltiazem hcl tab 120 mg.............................................60diltiazem hcl tab 30 mg...............................................60diltiazem hcl tab 60 mg...............................................60diltiazem hcl tab 90 mg...............................................60DIPENTUM....................................................................92diphenhydramine hcl inj 50 mg/ml.............................97DIPHTHERIA/TETANUS TOXOIDS

ADSORBED...............................................................87dipyridamole tab 25 mg.............................................. 54dipyridamole tab 50 mg.............................................. 54dipyridamole tab 75 mg.............................................. 54disulfiram tab 250 mg....................................................5disulfiram tab 500 mg....................................................5divalproex sodium cap delayed release sprinkle 125

mg................................................................................15divalproex sodium tab delayed release 125



mg................................................................................15divalproex sodium tab er 24 hr 250 mg.....................15divalproex sodium tab er 24 hr 500 mg.....................15DIVIGEL.........................................................................81DIVIGEL.........................................................................81DIVIGEL.........................................................................81

DIVIGEL.........................................................................81DOCETAXEL.................................................................28docetaxel for inj conc 160 mg/8ml (20 mg/

ml)................................................................................28docetaxel for inj conc 20 mg/ml................................. 28docetaxel for inj conc 80 mg/4ml (20 mg/

ml)................................................................................28docetaxel soln for iv infusion 160

mg/16ml......................................................................29docetaxel soln for iv infusion 20

mg/2ml........................................................................ 28docetaxel soln for iv infusion 80

mg/8ml........................................................................ 29dofetilide cap 125 mcg (0.125 mg)............................60dofetilide cap 250 mcg (0.25 mg).............................. 60dofetilide cap 500 mcg (0.5 mg)................................ 60donepezil hydrochloride orally disintegrating tab 10

mg................................................................................18donepezil hydrochloride orally disintegrating tab 5

mg................................................................................18donepezil hydrochloride tab 10 mg........................... 18donepezil hydrochloride tab 23 mg........................... 18donepezil hydrochloride tab 5 mg..............................18dorzolamide hcl ophth soln 2%..................................94dorzolamide hcl-timolol maleate ophth soln 22.3-6.8

mg/ml.......................................................................... 94DOVATO........................................................................ 45doxazosin mesylate tab 1 mg.................................... 60doxazosin mesylate tab 2 mg.................................... 60doxazosin mesylate tab 4 mg.................................... 60doxazosin mesylate tab 8 mg.................................... 60DOXEPIN HCL............................................................. 19doxepin hcl cap 100 mg..............................................19doxepin hcl cap 10 mg................................................19doxepin hcl cap 25 mg................................................19doxepin hcl cap 50 mg................................................19doxepin hcl cap 75 mg................................................19doxepin hcl conc 10 mg/ml.........................................19doxorubicin hcl for inj 10 mg...................................... 29doxorubicin hcl for inj 50 mg...................................... 29doxorubicin hcl inj 2 mg/ml.........................................29doxorubicin hcl liposomal inj (for iv infusion) 2 mg/

ml.................................................................................29doxycycline hyclate cap 100 mg................................10doxycycline hyclate cap 50 mg..................................10doxycycline hyclate for inj 100 mg.............................10doxycycline hyclate tab 100 mg.................................10doxycycline hyclate tab 20 mg...................................10doxycycline monohydrate cap 100 mg......................10doxycycline monohydrate cap 150 mg......................10doxycycline monohydrate cap 50 mg........................10doxycycline monohydrate cap 75 mg........................10

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114

doxycycline monohydrate tab 100 mg...................... 10doxycycline monohydrate tab 150 mg...................... 10doxycycline monohydrate tab 50 mg.........................10doxycycline monohydrate tab 75 mg.........................10D-PENAMINE............................................................... 78dronabinol cap 10 mg................................................. 22dronabinol cap 2.5 mg................................................ 22dronabinol cap 5 mg....................................................22drospirenone-ethinyl estradiol tab 3-0.02

mg................................................................................81drospirenone-ethinyl estradiol tab 3-0.03

mg................................................................................81drospirenone-ethinyl estrad-levomefolate tab

3-0.02-0.451 mg........................................................81drospirenone-ethinyl estrad-levomefolate tab

3-0.03-0.451 mg........................................................81DUAVEE........................................................................ 81DULERA........................................................................ 97DULERA........................................................................ 97duloxetine hcl enteric coated pellets cap 20

mg................................................................................19duloxetine hcl enteric coated pellets cap 30

mg................................................................................19duloxetine hcl enteric coated pellets cap 60

mg................................................................................19DUPIXENT.................................................................... 87DUPIXENT.................................................................... 87DUREZOL..................................................................... 94dutasteride cap 0.5 mg............................................... 78dutasteride-tamsulosin hcl cap 0.5-0.4

mg................................................................................79EEC-NAPROXEN............................................................. 1EC-NAPROXEN............................................................. 1econazole nitrate cream 1%.......................................23EDURANT..................................................................... 45efavirenz cap 200 mg..................................................45efavirenz cap 50 mg....................................................45efavirenz tab 600 mg...................................................45EGRIFTA....................................................................... 80EGRIFTA....................................................................... 80ELAPRASE................................................................... 77ELELYSO.......................................................................77ELIGARD.......................................................................85ELIGARD.......................................................................85ELIGARD.......................................................................85ELIGARD.......................................................................85ELIQUIS.........................................................................54ELIQUIS.........................................................................54ELIQUIS STARTER PACK......................................... 54ELITEK...........................................................................29

ELITEK...........................................................................29ELLA...............................................................................81EMCYT.......................................................................... 29EMEND..........................................................................22EMGALITY.................................................................... 25EMGALITY.................................................................... 25EMGALITY.................................................................... 25EMPLICITI.....................................................................29EMPLICITI.....................................................................29EMSAM..........................................................................19EMSAM..........................................................................19EMSAM..........................................................................19EMTRIVA.......................................................................45EMTRIVA.......................................................................45enalapril maleate & hydrochlorothiazide tab 10-25

mg................................................................................60enalapril maleate & hydrochlorothiazide tab 5-12.5

mg................................................................................60enalapril maleate tab 10 mg.......................................60enalapril maleate tab 2.5 mg......................................60enalapril maleate tab 20 mg.......................................60enalapril maleate tab 5 mg.........................................60ENBREL........................................................................ 87ENBREL........................................................................ 87ENBREL........................................................................ 87ENBREL MINI...............................................................87ENBREL SURECLICK................................................ 87ENGERIX-B.................................................................. 87ENGERIX-B.................................................................. 87enoxaparin sodium inj 100 mg/ml..............................55enoxaparin sodium inj 120 mg/0.8ml........................ 55enoxaparin sodium inj 150 mg/ml..............................55enoxaparin sodium inj 300 mg/3ml............................55enoxaparin sodium inj 30 mg/0.3ml...........................54enoxaparin sodium inj 40 mg/0.4ml...........................54enoxaparin sodium inj 60 mg/0.6ml...........................55enoxaparin sodium inj 80 mg/0.8ml...........................55entacapone tab 200 mg..............................................39entecavir tab 0.5 mg....................................................45entecavir tab 1 mg.......................................................45ENTRESTO...................................................................60ENTRESTO...................................................................60ENTRESTO...................................................................60EPCLUSA......................................................................45EPIDIOLEX................................................................... 15epinastine hcl ophth soln 0.05%................................94epinephrine solution auto-injector 0.15 mg/0.3ml

(1:2000)...................................................................... 97epinephrine solution auto-injector 0.3 mg/0.3ml

(1:1000) (generic for EpiPen 2-Pak)...................... 97epirubicin hcl iv soln 200 mg/100ml (2 mg/

ml)................................................................................29

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115

epirubicin hcl iv soln 50 mg/25ml (2 mg/ml)................................................................................29

EPIVIR HBV..................................................................45eplerenone tab 25 mg.................................................60eplerenone tab 50 mg.................................................60EPOGEN....................................................................... 55EPOGEN....................................................................... 55EPOGEN....................................................................... 55EPOGEN....................................................................... 55EPOGEN....................................................................... 55ERBITUX....................................................................... 29ERBITUX....................................................................... 29ERGOLOID MESYLATES...........................................18ergotamine w/ caffeine tab 1-100 mg........................25ERIVEDGE....................................................................29ERLEADA......................................................................29erlotinib hcl tab 100 mg.............................................. 29erlotinib hcl tab 150 mg.............................................. 29erlotinib hcl tab 25 mg.................................................29ertapenem sodium for inj 1 gm.................................. 10ERWINAZE................................................................... 29ERYTHROCIN LACTOBIONATE...............................10ERYTHROCIN STEARATE........................................ 10erythromycin ethylsuccinate for susp 200

mg/5ml........................................................................ 10erythromycin ethylsuccinate for susp 400

mg/5ml........................................................................ 10erythromycin ophth oint 5 mg/gm.............................. 94erythromycin pads 2%.................................................10erythromycin soln 2%..................................................10erythromycin tab 250 mg............................................ 10erythromycin tab 500 mg............................................ 10erythromycin tab delayed release 250

mg................................................................................10erythromycin tab delayed release 333

mg................................................................................10erythromycin tab delayed release 500

mg................................................................................10ESBRIET....................................................................... 97ESBRIET....................................................................... 97ESBRIET....................................................................... 98escitalopram oxalate soln 5 mg/5ml..........................19escitalopram oxalate tab 10 mg.................................19escitalopram oxalate tab 20 mg.................................19escitalopram oxalate tab 5 mg...................................19esomeprazole magnesium cap delayed release 20

mg................................................................................75esomeprazole magnesium cap delayed release 40

mg................................................................................75ESOMEPRAZOLE SODIUM...................................... 75esomeprazole sodium for intravenous soln 40

mg................................................................................75

estradiol & norethindrone acetate tab 0.5-0.1mg................................................................................81

estradiol & norethindrone acetate tab 1-0.5mg................................................................................81

estradiol tab 0.5 mg.....................................................81estradiol tab 1 mg........................................................81estradiol tab 2 mg........................................................81estradiol td patch twice weekly 0.025

mg/24hr...................................................................... 81estradiol td patch twice weekly 0.0375




mg/24hr...................................................................... 82estradiol td patch weekly 0.025

mg/24hr...................................................................... 82estradiol td patch weekly 0.0375 mg/24hr (37.5

mcg/24hr)................................................................... 82estradiol td patch weekly 0.05 mg/24hr.................... 82estradiol td patch weekly 0.06 mg/24hr.................... 82estradiol td patch weekly 0.075

mg/24hr...................................................................... 82estradiol td patch weekly 0.1 mg/24hr...................... 82estradiol vaginal cream 0.1 mg/gm........................... 82estradiol vaginal tab 10 mcg...................................... 82ethambutol hcl tab 100 mg.........................................26ethambutol hcl tab 400 mg.........................................26ethosuximide cap 250 mg...........................................15ethosuximide soln 250 mg/5ml.................................. 15ethynodiol diacetate & ethinyl estradiol tab 1 mg-35

mcg..............................................................................82ethynodiol diacetate & ethinyl estradiol tab 1 mg-50

mcg..............................................................................82ETHYOL........................................................................ 29etodolac cap 200 mg.....................................................1etodolac cap 300 mg.....................................................1etodolac tab 400 mg......................................................2etodolac tab 500 mg......................................................2etodolac tab er 24hr 400 mg........................................ 1etodolac tab er 24hr 500 mg........................................ 2etodolac tab er 24hr 600 mg........................................ 2ETOPOPHOS............................................................... 29etoposide inj 100 mg/5ml (20 mg/ml)........................29etoposide inj 1 gm/50ml (20 mg/ml).......................... 29etoposide inj 500 mg/25ml (20 mg/ml)......................29EVOMELA..................................................................... 29EVOTAZ.........................................................................45exemestane tab 25 mg............................................... 29ezetimibe tab 10 mg....................................................60

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116

FFABRAZYME................................................................ 77FABRAZYME................................................................ 77famciclovir tab 125 mg................................................45famciclovir tab 250 mg................................................45famciclovir tab 500 mg................................................45famotidine for susp 40 mg/5ml...................................75famotidine inj 200 mg/20ml........................................ 75famotidine inj 20 mg/2ml.............................................75famotidine inj 40 mg/4ml.............................................75famotidine tab 20 mg...................................................75famotidine tab 40 mg...................................................75FANAPT.........................................................................40FANAPT.........................................................................40FANAPT.........................................................................40FANAPT.........................................................................40FANAPT.........................................................................40FANAPT.........................................................................40FANAPT.........................................................................40FANAPT TITRATION PACK....................................... 40FARYDAK......................................................................29FARYDAK......................................................................29FARYDAK......................................................................29FASLODEX................................................................... 29felbamate susp 600 mg/5ml....................................... 15felbamate tab 400 mg................................................. 15felbamate tab 600 mg................................................. 15felodipine tab er 24hr 10 mg...................................... 60felodipine tab er 24hr 2.5 mg..................................... 60felodipine tab er 24hr 5 mg........................................ 60fenofibrate micronized cap 134 mg........................... 61fenofibrate micronized cap 200 mg........................... 61fenofibrate micronized cap 67 mg............................. 60fenofibrate tab 145 mg................................................61fenofibrate tab 160 mg................................................61fenofibrate tab 48 mg.................................................. 61fenofibrate tab 54 mg.................................................. 61fentanyl citrate lozenge on a handle 1200

mcg................................................................................2fentanyl citrate lozenge on a handle 1600





mcg................................................................................2fentanyl td patch 72hr 100 mcg/hr...............................2fentanyl td patch 72hr 12 mcg/hr................................. 2

fentanyl td patch 72hr 25 mcg/hr................................. 2fentanyl td patch 72hr 37.5 mcg/hr..............................2fentanyl td patch 72hr 50 mcg/hr................................. 2fentanyl td patch 72hr 62.5 mcg/hr..............................2fentanyl td patch 72hr 75 mcg/hr................................. 2fentanyl td patch 72hr 87.5 mcg/hr..............................2FETZIMA....................................................................... 20FETZIMA....................................................................... 20FETZIMA....................................................................... 20FETZIMA....................................................................... 20FETZIMA TITRATION PACK......................................20FINACEA....................................................................... 70finasteride tab 5 mg.....................................................79FIRMAGON...................................................................85FIRMAGON...................................................................85flecainide acetate tab 100 mg....................................61flecainide acetate tab 150 mg....................................61flecainide acetate tab 50 mg...................................... 61FLOVENT DISKUS......................................................98FLOVENT DISKUS......................................................98FLOVENT DISKUS......................................................98FLOVENT HFA.............................................................98FLOVENT HFA.............................................................98FLOVENT HFA.............................................................98fluconazole for susp 10 mg/ml................................... 23fluconazole for susp 40 mg/ml................................... 23fluconazole in dextrose inj 200

mg/100ml....................................................................23fluconazole in dextrose inj 400

mg/200ml....................................................................23fluconazole in nacl 0.9% inj 200

mg/100ml....................................................................23fluconazole in nacl 0.9% inj 400

mg/200ml....................................................................23fluconazole tab 100 mg...............................................23fluconazole tab 150 mg...............................................24fluconazole tab 200 mg...............................................24fluconazole tab 50 mg.................................................23flucytosine cap 250 mg............................................... 24flucytosine cap 500 mg............................................... 24fludarabine phosphate for inj 50 mg..........................29fludarabine phosphate inj 25 mg/ml.......................... 29fludrocortisone acetate tab 0.1 mg............................ 80fluocinolone acetonide (otic) oil 0.01%..................... 95fluocinolone acetonide cream 0.01%........................ 70fluocinonide cream 0.05%.......................................... 70fluocinonide emulsified base cream

0.05%..........................................................................70fluocinonide gel 0.05%................................................70fluocinonide oint 0.05%...............................................70fluocinonide soln 0.05%..............................................70fluorometholone ophth susp 0.1%.............................94

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FLUOROURACIL......................................................... 70FLUOROURACIL......................................................... 70FLUOROURACIL......................................................... 70fluorouracil cream 5%................................................. 70fluorouracil iv soln 1 gm/20ml (50 mg/

ml)................................................................................29fluorouracil iv soln 2.5 gm/50ml (50 mg/

ml)................................................................................29fluorouracil iv soln 500 mg/10ml (50 mg/

ml)................................................................................29fluorouracil iv soln 5 gm/100ml (50 mg/

ml)................................................................................29FLUOXETINE DR........................................................ 20fluoxetine hcl (pmdd) tab 10 mg................................ 68fluoxetine hcl cap 10 mg.............................................20fluoxetine hcl cap 20 mg.............................................20fluoxetine hcl cap 40 mg.............................................20fluoxetine hcl solution 20 mg/5ml.............................. 20fluoxetine hcl tab 10 mg..............................................20fluoxetine hcl tab 20 mg..............................................20fluphenazine decanoate inj 25 mg/ml........................40FLUPHENAZINE HCL.................................................40FLUPHENAZINE HCL.................................................40fluphenazine hcl tab 10 mg........................................ 40fluphenazine hcl tab 1 mg.......................................... 40fluphenazine hcl tab 2.5 mg....................................... 40fluphenazine hcl tab 5 mg.......................................... 40FLUPHENAZINE HYDROCHLORIDE...................... 40FLURBIPROFEN SODIUM.........................................94flurbiprofen tab 100 mg.................................................2flurbiprofen tab 50 mg................................................... 2flutamide cap 125 mg..................................................30FLUTICASONE PROPIONATE/

SALMETEROL.......................................................... 98FLUTICASONE PROPIONATE/

SALMETEROL.......................................................... 98FLUTICASONE PROPIONATE/

SALMETEROL.......................................................... 98fluticasone propionate cream 0.05%.........................70fluticasone propionate nasal susp 50 mcg/

act................................................................................98fluticasone propionate oint 0.005%........................... 70fluvoxamine maleate tab 100 mg...............................20fluvoxamine maleate tab 25 mg.................................20fluvoxamine maleate tab 50 mg.................................20FOLOTYN......................................................................30FOLOTYN......................................................................30fomepizole inj 1 gm/ml (for iv infusion)......................73fondaparinux sodium subcutaneous inj 10

mg/0.8ml.....................................................................55fondaparinux sodium subcutaneous inj 2.5

mg/0.5ml.....................................................................55

fondaparinux sodium subcutaneous inj 5mg/0.4ml.....................................................................55

fondaparinux sodium subcutaneous inj 7.5mg/0.6ml.....................................................................55

FORTEO........................................................................93fosamprenavir calcium tab 700 mg........................... 45fosaprepitant dimeglumine for iv infusion 150

mg................................................................................22fosinopril sodium & hydrochlorothiazide tab 10-12.5

mg................................................................................61fosinopril sodium & hydrochlorothiazide tab 20-12.5

mg................................................................................61fosinopril sodium tab 10 mg....................................... 61fosinopril sodium tab 20 mg....................................... 61fosinopril sodium tab 40 mg....................................... 61fosphenytoin sodium inj 100 mg/2ml.........................15fosphenytoin sodium inj 500 mg/10ml.......................15FOSRENOL.................................................................. 73FOSRENOL.................................................................. 73FULPHILA..................................................................... 55fulvestrant inj 250 mg/5ml...........................................30furosemide inj 10 mg/ml..............................................61furosemide oral soln 10 mg/ml...................................61furosemide tab 20 mg................................................. 61furosemide tab 40 mg................................................. 61furosemide tab 80 mg................................................. 61FUZEON........................................................................45FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15Ggabapentin cap 100 mg.............................................. 15gabapentin cap 300 mg.............................................. 15gabapentin cap 400 mg.............................................. 15gabapentin oral soln 250 mg/5ml.............................. 15gabapentin tab 600 mg............................................... 15gabapentin tab 800 mg............................................... 15GALANTAMINE HYDROBROMIDE.......................... 18galantamine hydrobromide cap er 24hr 16

mg................................................................................18galantamine hydrobromide cap er 24hr 24

mg................................................................................18galantamine hydrobromide cap er 24hr 8

mg................................................................................18galantamine hydrobromide tab 12 mg...................... 18galantamine hydrobromide tab 4 mg.........................18galantamine hydrobromide tab 8 mg.........................18

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GAMMAGARD LIQUID............................................... 87GAMMAGARD LIQUID............................................... 87GAMMAGARD LIQUID............................................... 88GAMMAGARD LIQUID............................................... 88GAMMAGARD LIQUID............................................... 88GAMMAGARD LIQUID............................................... 88GAMMAGARD S/D......................................................88GAMMAGARD S/D......................................................88GAMMAPLEX............................................................... 88GAMMAPLEX............................................................... 88GAMMAPLEX............................................................... 88GAMMAPLEX............................................................... 88GAMMAPLEX............................................................... 88GAMMAPLEX............................................................... 88GAMUNEX-C................................................................ 88GAMUNEX-C................................................................ 88GAMUNEX-C................................................................ 88GAMUNEX-C................................................................ 88GAMUNEX-C................................................................ 88GAMUNEX-C................................................................ 88ganciclovir sodium for inj 500 mg.............................. 45GARDASIL 9.................................................................88GARDASIL 9.................................................................88GATTEX.........................................................................75GAUZE PADS 2" X 2".................................................50GAZYVA.........................................................................30gemcitabine hcl for inj 1 gm....................................... 30gemcitabine hcl for inj 200 mg...................................30gemcitabine hcl for inj 2 gm....................................... 30gemcitabine hcl inj 1 gm/26.3ml (38 mg/

ml)................................................................................30gemcitabine hcl inj 200 mg/5.26ml (38 mg/

ml)................................................................................30gemcitabine hcl inj 2 gm/52.6ml (38 mg/

ml)................................................................................30gemfibrozil tab 600 mg............................................... 61GENTAK........................................................................ 94gentamicin in saline inj 1.2 mg/ml............................. 10GENTAMICIN SULFATE/0.9% SODIUM

CHLORIDE.................................................................10GENTAMICIN SULFATE/0.9% SODIUM

CHLORIDE.................................................................10gentamicin sulfate cream 0.1%..................................70gentamicin sulfate inj 10 mg/ml................................. 10gentamicin sulfate inj 40 mg/ml................................. 10gentamicin sulfate oint 0.1%...................................... 71gentamicin sulfate ophth soln 0.3%...........................94GENVOYA.....................................................................45GEODON.......................................................................40GILENYA....................................................................... 68GILOTRIF......................................................................30GILOTRIF......................................................................30

GILOTRIF......................................................................30glatiramer acetate soln prefilled syringe 20 mg/

ml.................................................................................68glatiramer acetate soln prefilled syringe 40 mg/

ml.................................................................................68GLEOSTINE..................................................................30GLEOSTINE..................................................................30GLEOSTINE..................................................................30glimepiride tab 1 mg....................................................50glimepiride tab 2 mg....................................................50glimepiride tab 4 mg....................................................50glipizide-metformin hcl tab 2.5-250 mg.....................50glipizide-metformin hcl tab 2.5-500 mg.....................50glipizide-metformin hcl tab 5-500 mg........................ 50glipizide tab 10 mg...................................................... 50glipizide tab 5 mg.........................................................50glipizide tab er 24hr 10 mg.........................................50glipizide tab er 24hr 2.5 mg........................................50glipizide tab er 24hr 5 mg...........................................50GLUCAGEN HYPOKIT............................................... 50GLUCAGON EMERGENCY KIT............................... 50glycopyrrolate tab 1 mg.............................................. 75glycopyrrolate tab 2 mg.............................................. 75GLYXAMBI.................................................................... 50GLYXAMBI.................................................................... 50granisetron hcl inj 1 mg/ml......................................... 22granisetron hcl inj 4 mg/4ml (1 mg/ml)......................22granisetron hcl tab 1 mg.............................................22GRANIX......................................................................... 55GRANIX......................................................................... 55GRANIX......................................................................... 55GRANIX......................................................................... 55griseofulvin microsize susp 125

mg/5ml........................................................................ 24griseofulvin ultramicrosize tab 125 mg......................24griseofulvin ultramicrosize tab 250 mg......................24GUANIDINE HCL.........................................................25HHAEGARDA.................................................................. 88HAEGARDA.................................................................. 88HALAVEN...................................................................... 30halobetasol propionate cream 0.05%........................71halobetasol propionate oint 0.05%............................ 71haloperidol decanoate im soln 100 mg/

ml.................................................................................40haloperidol decanoate im soln 50 mg/

ml.................................................................................40haloperidol lactate inj 5 mg/ml................................... 40haloperidol lactate oral conc 2 mg/ml........................40haloperidol tab 0.5 mg................................................ 40haloperidol tab 10 mg................................................. 41

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haloperidol tab 1 mg....................................................40haloperidol tab 20 mg................................................. 41haloperidol tab 2 mg....................................................40haloperidol tab 5 mg....................................................40HARVONI...................................................................... 45HAVRIX..........................................................................88HAVRIX..........................................................................88HEPARIN SODIUM......................................................55HEPARIN SODIUM......................................................55HEPARIN SODIUM/D5W............................................55heparin sodium (porcine) inj 10000 unit/

ml.................................................................................55heparin sodium (porcine) inj 1000 unit/



ml.................................................................................55heparin sodium (porcine) pf inj 5000

unit/0.5ml....................................................................55HEPATAMINE............................................................... 73HERCEPTIN................................................................. 30HERCEPTIN HYLECTA.............................................. 30HETLIOZ..................................................................... 100HIBERIX........................................................................ 88HUMALOG.................................................................... 50HUMALOG.................................................................... 50HUMALOG JUNIOR KWIKPEN.................................50HUMALOG KWIKPEN.................................................50HUMALOG KWIKPEN.................................................50HUMALOG MIX 50/50.................................................50HUMALOG MIX 50/50 KWIKPEN............................. 50HUMALOG MIX 75/25.................................................51HUMALOG MIX 75/25 KWIKPEN............................. 51HUMIRA.........................................................................88HUMIRA.........................................................................88HUMIRA.........................................................................88HUMIRA.........................................................................89HUMIRA.........................................................................89HUMIRA.........................................................................89HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.......................................................89HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.......................................................89HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.......................................................89HUMIRA PEN............................................................... 89HUMIRA PEN............................................................... 89HUMIRA PEN-CD/UC/HS STARTER........................89HUMIRA PEN-CD/UC/HS STARTER........................89HUMIRA PEN-PS/UV STARTER...............................89HUMIRA PEN-PS/UV STARTER...............................89

HUMULIN 70/30...........................................................51HUMULIN 70/30 KWIKPEN....................................... 51HUMULIN N..................................................................51HUMULIN N KWIKPEN.............................................. 51HUMULIN R..................................................................51HUMULIN R U-500 (CONCENTRATE).....................51HUMULIN R U-500 KWIKPEN...................................51hydralazine hcl tab 100 mg........................................ 61hydralazine hcl tab 10 mg.......................................... 61hydralazine hcl tab 25 mg.......................................... 61hydralazine hcl tab 50 mg.......................................... 61hydrochlorothiazide cap 12.5 mg...............................61hydrochlorothiazide tab 12.5 mg................................61hydrochlorothiazide tab 25 mg...................................61hydrochlorothiazide tab 50 mg...................................61hydrocodone-acetaminophen soln 7.5-325

mg/15ml........................................................................ 2hydrocodone-acetaminophen tab 10-325

mg..................................................................................2hydrocodone-acetaminophen tab 5-325

mg..................................................................................2hydrocodone-acetaminophen tab 7.5-325

mg..................................................................................2hydrocodone-ibuprofen tab 10-200 mg.......................2hydrocodone-ibuprofen tab 5-200 mg......................... 2hydrocodone-ibuprofen tab 7.5-200 mg......................2hydrocortisone butyrate cream 0.1%........................ 71hydrocortisone butyrate hydrophilic lipo base cream

0.1%............................................................................71hydrocortisone butyrate oint 0.1%.............................71hydrocortisone butyrate soln 0.1%............................ 71hydrocortisone cream 1%...........................................71hydrocortisone cream 2.5%........................................71hydrocortisone enema 100 mg/60ml.........................92hydrocortisone lotion 2.5%......................................... 71hydrocortisone oint 1%............................................... 71hydrocortisone oint 2.5%............................................ 71hydrocortisone rectal cream 1%................................ 92hydrocortisone rectal cream 2.5%.............................92hydrocortisone tab 10 mg...........................................80hydrocortisone tab 20 mg...........................................80hydrocortisone tab 5 mg............................................. 80hydrocortisone valerate cream 0.2%.........................71hydrocortisone valerate oint 0.2%............................. 71hydrocortisone w/ acetic acid otic soln

1-2%............................................................................95hydromorphone hcl inj 2 mg/ml....................................2hydromorphone hcl liqd 1 mg/ml..................................2hydromorphone hcl preservative free inj 10 mg/

ml................................................................................... 2hydromorphone hcl preservative free inj 2 mg/

ml................................................................................... 2

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hydromorphone hcl tab 2 mg....................................... 2hydromorphone hcl tab 4 mg....................................... 2hydromorphone hcl tab 8 mg....................................... 2hydroxychloroquine sulfate tab 200 mg.................... 37HYDROXYPROGESTERONE

CAPROATE................................................................82hydroxyprogesterone caproate im in oil 250 mg/

ml.................................................................................82hydroxyurea cap 500 mg............................................ 30hydroxyzine hcl syrup 10 mg/5ml.............................. 49hydroxyzine hcl tab 10 mg..........................................49hydroxyzine hcl tab 25 mg..........................................49hydroxyzine hcl tab 50 mg..........................................49Iibandronate sodium iv soln 3 mg/3ml........................93ibandronate sodium tab 150 mg................................ 93IBRANCE.......................................................................30IBRANCE.......................................................................30IBRANCE.......................................................................30ibuprofen susp 100 mg/5ml.......................................... 2ibuprofen tab 400 mg.................................................... 2ibuprofen tab 600 mg.................................................... 2ibuprofen tab 800 mg.................................................... 2icatibant acetate inj 30 mg/3ml.................................. 89ICLUSIG........................................................................ 30ICLUSIG........................................................................ 30idarubicin hcl iv inj 10 mg/10ml (1 mg/

ml)................................................................................30idarubicin hcl iv inj 20 mg/20ml (1 mg/

ml)................................................................................30idarubicin hcl iv inj 5 mg/5ml (1 mg/ml).....................30IDHIFA............................................................................30IDHIFA............................................................................30IFEX............................................................................... 30IFOSFAMIDE................................................................ 30ifosfamide for inj 1 gm.................................................30ifosfamide iv inj 1 gm/20ml (50 mg/ml)..................... 30ifosfamide iv inj 3 gm/60ml (50 mg/ml)..................... 30ILARIS............................................................................89ILEVRO..........................................................................94imatinib mesylate tab 100 mg.................................... 30imatinib mesylate tab 400 mg.................................... 31IMBRUVICA.................................................................. 31IMBRUVICA.................................................................. 31IMBRUVICA.................................................................. 31IMBRUVICA.................................................................. 31IMBRUVICA.................................................................. 31IMBRUVICA.................................................................. 31IMFINZI..........................................................................31IMFINZI..........................................................................31

imipenem-cilastatin intravenous for soln 250mg................................................................................10

imipenem-cilastatin intravenous for soln 500mg................................................................................10

imipramine hcl tab 10 mg........................................... 20imipramine hcl tab 25 mg........................................... 20imipramine hcl tab 50 mg........................................... 20imiquimod cream 5%...................................................71IMLYGIC........................................................................ 31IMLYGIC........................................................................ 31IMOVAX RABIES (H.D.C.V.)...................................... 89IMPAVIDO..................................................................... 10INBRIJA......................................................................... 39INCRELEX.................................................................... 81INCRUSE ELLIPTA..................................................... 98indapamide tab 1.25 mg............................................. 61indapamide tab 2.5 mg............................................... 61INFANRIX......................................................................89INLYTA...........................................................................31INLYTA...........................................................................31INREBIC........................................................................ 31INSULIN INJECTION DEVICE...................................51INSULIN SYRINGE/NEEDLE.....................................51INTELENCE.................................................................. 45INTELENCE.................................................................. 45INTELENCE.................................................................. 45INTRALIPID.................................................................. 73INTRON A.....................................................................45INTRON A.....................................................................45INTRON A.....................................................................45INTRON A.....................................................................45INTRON A.....................................................................45INVEGA SUSTENNA.................................................. 41INVEGA SUSTENNA.................................................. 41INVEGA SUSTENNA.................................................. 41INVEGA SUSTENNA.................................................. 41INVEGA SUSTENNA.................................................. 41INVEGA TRINZA..........................................................41INVEGA TRINZA..........................................................41INVEGA TRINZA..........................................................41INVEGA TRINZA..........................................................41INVIRASE......................................................................45INVOKAMET.................................................................51INVOKAMET.................................................................51INVOKAMET.................................................................51INVOKAMET.................................................................51INVOKAMET XR..........................................................51INVOKAMET XR..........................................................51INVOKAMET XR..........................................................51INVOKAMET XR..........................................................51INVOKANA....................................................................51INVOKANA....................................................................51

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IPOL INACTIVATED IPV.............................................89ipratropium bromide inhal soln 0.02%.......................98ipratropium bromide nasal soln 0.03% (21 mcg/

spray)..........................................................................98ipratropium bromide nasal soln 0.06% (42 mcg/

spray)..........................................................................98irbesartan-hydrochlorothiazide tab 150-12.5

mg................................................................................61irbesartan-hydrochlorothiazide tab 300-12.5

mg................................................................................61irbesartan tab 150 mg.................................................61irbesartan tab 300 mg.................................................61irbesartan tab 75 mg................................................... 61IRESSA..........................................................................31IRINOTECAN................................................................31irinotecan hcl inj 100 mg/5ml (20 mg/

ml)................................................................................31irinotecan hcl inj 40 mg/2ml (20 mg/ml).................... 31ISENTRESS..................................................................46ISENTRESS..................................................................46ISENTRESS..................................................................46ISENTRESS..................................................................46ISENTRESS HD...........................................................46ISONIAZID.................................................................... 26isoniazid tab 100 mg................................................... 26isoniazid tab 300 mg................................................... 26ISOSORBIDE DINITRATE..........................................61isosorbide dinitrate tab 10 mg....................................61isosorbide dinitrate tab 20 mg....................................62isosorbide dinitrate tab 5 mg......................................61isosorbide mononitrate tab 10 mg............................. 62isosorbide mononitrate tab 20 mg............................. 62isosorbide mononitrate tab er 24hr 120

mg................................................................................62isosorbide mononitrate tab er 24hr 30

mg................................................................................62isosorbide mononitrate tab er 24hr 60

mg................................................................................62ISOTONIC GENTAMICIN........................................... 11isotretinoin cap 10 mg.................................................71isotretinoin cap 20 mg.................................................71isotretinoin cap 30 mg.................................................71isotretinoin cap 40 mg.................................................71isradipine cap 2.5 mg..................................................62isradipine cap 5 mg..................................................... 62ISTODAX (OVERFILL)................................................31itraconazole cap 100 mg............................................ 24ivermectin tab 3 mg.....................................................37IXEMPRA KIT...............................................................31IXEMPRA KIT...............................................................31IXIARO...........................................................................89

JJADENU........................................................................ 73JADENU........................................................................ 73JADENU........................................................................ 73JADENU SPRINKLE................................................... 73JADENU SPRINKLE................................................... 73JADENU SPRINKLE................................................... 73JAKAFI...........................................................................31JAKAFI...........................................................................31JAKAFI...........................................................................31JAKAFI...........................................................................31JAKAFI...........................................................................31JANUMET......................................................................51JANUMET......................................................................51JANUMET XR...............................................................51JANUMET XR...............................................................51JANUMET XR...............................................................51JANUVIA........................................................................51JANUVIA........................................................................51JANUVIA........................................................................51JARDIANCE..................................................................51JARDIANCE..................................................................52JENTADUETO.............................................................. 52JENTADUETO.............................................................. 52JENTADUETO.............................................................. 52JENTADUETO XR....................................................... 52JENTADUETO XR....................................................... 52JEVTANA.......................................................................31JULUCA.........................................................................46KKADCYLA......................................................................31KADCYLA......................................................................31KALETRA...................................................................... 46KALETRA...................................................................... 46KALYDECO...................................................................98KALYDECO...................................................................98KALYDECO...................................................................98KALYDECO...................................................................98KANJINTI.......................................................................31KCL 0.15%/D5W/NACL 0.225%................................73kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45%

inj................................................................................. 73kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2%


inj................................................................................. 73kcl 20 meq/l (0.15%) in nacl 0.45% inj......................73kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45%


inj................................................................................. 73

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KEPIVANCE..................................................................69ketoconazole cream 2%..............................................24ketoconazole shampoo 2%........................................ 24ketoconazole tab 200 mg........................................... 24ketorolac tromethamine ophth soln

0.4%............................................................................94ketorolac tromethamine ophth soln

0.5%............................................................................94KEYTRUDA...................................................................31KINERET....................................................................... 89KINRIX........................................................................... 89KISQALI.........................................................................31KISQALI.........................................................................31KISQALI.........................................................................31KISQALI FEMARA 200 DOSE...................................31KISQALI FEMARA 400 DOSE...................................32KISQALI FEMARA 600 DOSE...................................32KOMBIGLYZE XR........................................................52KOMBIGLYZE XR........................................................52KOMBIGLYZE XR........................................................52KORLYM........................................................................84KUVAN...........................................................................77KUVAN...........................................................................77KUVAN...........................................................................77KYPROLIS.................................................................... 32KYPROLIS.................................................................... 32KYPROLIS.................................................................... 32Llabetalol hcl tab 100 mg..............................................62labetalol hcl tab 200 mg..............................................62labetalol hcl tab 300 mg..............................................62LACRISERT.................................................................. 94lactated ringer's solution............................................. 73lactic acid (ammonium lactate) cream

12%............................................................................. 71lactic acid (ammonium lactate) lotion

12%............................................................................. 71lactulose (encephalopathy) solution 10

gm/15ml......................................................................75lactulose solution 10 gm/15ml....................................75lamivudine oral soln 10 mg/ml................................... 46lamivudine tab 100 mg (hbv)......................................46lamivudine tab 150 mg................................................46lamivudine tab 300 mg................................................46lamivudine-zidovudine tab 150-300 mg.................... 46lamotrigine tab 100 mg............................................... 16lamotrigine tab 150 mg............................................... 16lamotrigine tab 200 mg............................................... 16lamotrigine tab 25 mg................................................. 15lamotrigine tab chewable dispersible 25

mg................................................................................15

lamotrigine tab chewable dispersible 5mg................................................................................15

lansoprazole cap delayed release 15mg................................................................................75

lansoprazole cap delayed release 30mg................................................................................75

lanthanum carbonate chew tab 1000 mg(elemental)................................................................. 73

lanthanum carbonate chew tab 500mg................................................................................73

lanthanum carbonate chew tab 750mg................................................................................73

LANTUS.........................................................................52LANTUS SOLOSTAR..................................................52LARTRUVO...................................................................32LARTRUVO...................................................................32latanoprost ophth soln 0.005%.................................. 94LATUDA.........................................................................41LATUDA.........................................................................41LATUDA.........................................................................41LATUDA.........................................................................41LATUDA.........................................................................41LAZANDA........................................................................ 3LAZANDA........................................................................ 3LAZANDA........................................................................ 3LEDIPASVIR/SOFOSBUVIR...................................... 46leflunomide tab 10 mg.................................................89leflunomide tab 20 mg.................................................89LENVIMA 10 MG DAILY DOSE.................................32LENVIMA 12MG DAILY DOSE..................................32LENVIMA 14 MG DAILY DOSE.................................32LENVIMA 18 MG DAILY DOSE.................................32LENVIMA 20 MG DAILY DOSE.................................32LENVIMA 24 MG DAILY DOSE.................................32LENVIMA 4 MG DAILY DOSE...................................32LENVIMA 8 MG DAILY DOSE...................................32letrozole tab 2.5 mg.....................................................32LEUCOVORIN CALCIUM...........................................32LEUCOVORIN CALCIUM...........................................32LEUCOVORIN CALCIUM...........................................32leucovorin calcium for inj 100 mg.............................. 32leucovorin calcium for inj 200 mg.............................. 32leucovorin calcium for inj 350 mg.............................. 32leucovorin calcium for inj 500 mg.............................. 32leucovorin calcium for inj 50 mg................................ 32leucovorin calcium inj 500 mg/50ml (10 mg/

ml)................................................................................32leucovorin calcium tab 25 mg.................................... 32leucovorin calcium tab 5 mg.......................................32LEUKERAN...................................................................32LEUKINE....................................................................... 55leuprolide acetate inj kit 5 mg/ml............................... 85

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LEVEMIR.......................................................................52LEVEMIR FLEXTOUCH..............................................52levetiracetam inj 500 mg/5ml (100 mg/

ml)................................................................................16levetiracetam in sodium chloride iv soln 1000

mg/100ml....................................................................16levetiracetam in sodium chloride iv soln 1500

mg/100ml....................................................................16levetiracetam in sodium chloride iv soln 500

mg/100ml....................................................................16levetiracetam oral soln 100 mg/ml.............................16levetiracetam tab 1000 mg......................................... 16levetiracetam tab 250 mg........................................... 16levetiracetam tab 500 mg........................................... 16levetiracetam tab 750 mg........................................... 16levobunolol hcl ophth soln 0.5%................................ 94levocarnitine oral soln 1 gm/10ml

(10%).......................................................................... 73levocarnitine tab 330 mg............................................ 73levocetirizine dihydrochloride tab 5 mg.....................98levofloxacin in d5w iv soln 250

mg/50ml......................................................................11levofloxacin in d5w iv soln 500

mg/100ml....................................................................11levofloxacin in d5w iv soln 750

mg/150ml....................................................................11levofloxacin iv soln 25 mg/ml..................................... 11levofloxacin oral soln 25 mg/ml..................................11levofloxacin tab 250 mg..............................................11levofloxacin tab 500 mg..............................................11levofloxacin tab 750 mg..............................................11levonorgestrel & ethinyl estradiol (91-day) tab

0.15-0.03 mg............................................................. 82levonorgestrel & ethinyl estradiol tab 0.15 mg-30

mcg..............................................................................82levonorgestrel & ethinyl estradiol tab 0.1 mg-20

mcg..............................................................................82levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg........................82levonorgestrel-ethinyl estradiol (continuous) tab

90-20 mcg..................................................................82levonorg-eth est tab 0.1-0.02mg(84) & eth est tab

0.01mg(7)...................................................................82levonorg-eth est tab 0.15-0.03mg(84) & eth est tab

0.01mg(7)...................................................................82LEVORPHANOL TARTRATE....................................... 3levorphanol tartrate tab 2 mg....................................... 3levothyroxine sodium tab 100 mcg (levo-t, levoxyl,

unithroid).....................................................................84levothyroxine sodium tab 112 mcg (levo-t, levoxyl,

unithroid).....................................................................84

levothyroxine sodium tab 125 mcg (levo-t, levoxyl,unithroid).....................................................................84






levothyroxine sodium tab 300 mcg (levo-t,unithroid).....................................................................84




LEXIVA...........................................................................46LIBTAYO........................................................................ 32LIDOCAINE HCL............................................................4LIDOCAINE HCL..........................................................62LIDOCAINE HCL..........................................................62lidocaine hcl local inj 1%...............................................4lidocaine hcl local preservative free inj

1%..................................................................................4lidocaine hcl soln 4%.....................................................4lidocaine hcl urethral/mucosal gel 2%.........................4lidocaine hcl urethral/mucosal gel prefilled syringe

2%..................................................................................4lidocaine hcl viscous soln 2%.......................................4lidocaine oint 5%............................................................4lidocaine patch 5%.........................................................4lidocaine-prilocaine cream 2.5-2.5%........................... 4LINDANE....................................................................... 38LINEZOLID....................................................................11linezolid for susp 100 mg/5ml.................................... 11linezolid iv soln 600 mg/300ml (2 mg/

ml)................................................................................11linezolid tab 600 mg.................................................... 11LINZESS........................................................................75LINZESS........................................................................75LINZESS........................................................................75liothyronine sodium tab 25 mcg.................................84liothyronine sodium tab 50 mcg.................................84liothyronine sodium tab 5 mcg................................... 84lisinopril & hydrochlorothiazide tab 10-12.5

mg................................................................................62lisinopril & hydrochlorothiazide tab 20-12.5

mg................................................................................62

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lisinopril & hydrochlorothiazide tab 20-25mg................................................................................62

lisinopril tab 10 mg...................................................... 62lisinopril tab 2.5 mg..................................................... 62lisinopril tab 20 mg...................................................... 62lisinopril tab 30 mg...................................................... 62lisinopril tab 40 mg...................................................... 62lisinopril tab 5 mg.........................................................62LITHIUM........................................................................ 49lithium carbonate cap 150 mg....................................49lithium carbonate cap 300 mg....................................49lithium carbonate cap 600 mg....................................49lithium carbonate tab 300 mg.....................................50lithium carbonate tab er 300 mg................................49lithium carbonate tab er 450 mg................................50LONSURF..................................................................... 32LONSURF..................................................................... 33loperamide hcl cap 2 mg............................................ 75lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/

ml)................................................................................46lorazepam tab 0.5 mg................................................. 49lorazepam tab 1 mg.................................................... 49lorazepam tab 2 mg.................................................... 49LORBRENA.................................................................. 33LORBRENA.................................................................. 33losartan potassium & hydrochlorothiazide tab

100-12.5 mg.............................................................. 62losartan potassium & hydrochlorothiazide tab 100-25

mg................................................................................62losartan potassium & hydrochlorothiazide tab

50-12.5 mg.................................................................62losartan potassium tab 100 mg..................................62losartan potassium tab 25 mg....................................62losartan potassium tab 50 mg....................................62lovastatin tab 10 mg....................................................62lovastatin tab 20 mg....................................................62lovastatin tab 40 mg....................................................62loxapine succinate cap 10 mg....................................41loxapine succinate cap 25 mg....................................41loxapine succinate cap 50 mg....................................41loxapine succinate cap 5 mg......................................41LUMIGAN...................................................................... 94LUMIZYME....................................................................77LUMOXITI......................................................................33LUPRON DEPOT (1-MONTH)...................................85LUPRON DEPOT (1-MONTH)...................................85LUPRON DEPOT (3-MONTH)...................................85LUPRON DEPOT (3-MONTH)...................................85LUPRON DEPOT (4-MONTH)...................................85LUPRON DEPOT (6-MONTH)...................................85LUPRON DEPOT-PED (1-MONTH)..........................85LUPRON DEPOT-PED (1-MONTH)..........................85

LUPRON DEPOT-PED (1-MONTH)..........................85LUPRON DEPOT-PED (3-MONTH)..........................85LUPRON DEPOT-PED (3-MONTH)..........................85LYNPARZA....................................................................33LYNPARZA....................................................................33LYSODREN...................................................................84Mmagnesium sulfate inj 50%........................................ 73malathion lotion 0.5%..................................................38MAPROTILINE HCL.................................................... 20MAPROTILINE HCL.................................................... 20MAPROTILINE HCL.................................................... 20MARPLAN..................................................................... 20MARQIBO......................................................................33MATULANE...................................................................33MAVYRET..................................................................... 46MAYZENT......................................................................68MAYZENT......................................................................68meclizine hcl tab 12.5 mg...........................................22meclizine hcl tab 25 mg..............................................22medroxyprogesterone acetate im susp 150 mg/

ml.................................................................................82medroxyprogesterone acetate im susp prefilled syr

150 mg/ml.................................................................. 82medroxyprogesterone acetate tab 10

mg................................................................................82medroxyprogesterone acetate tab 2.5

mg................................................................................82medroxyprogesterone acetate tab 5

mg................................................................................82MEFLOQUINE HCL.....................................................38megestrol acetate susp 40 mg/ml..............................82megestrol acetate tab 20 mg..................................... 82megestrol acetate tab 40 mg..................................... 82MEKINIST......................................................................33MEKINIST......................................................................33MEKTOVI.......................................................................33meloxicam tab 15 mg....................................................3meloxicam tab 7.5 mg...................................................3melphalan hcl for inj 50 mg........................................ 33memantine hcl oral solution 2 mg/ml.........................18memantine hcl tab 10 mg...........................................18memantine hcl tab 5 mg............................................. 18memantine hcl tab 5 mg (28) & 10 mg (21) titration

pak...............................................................................18MENACTRA.................................................................. 89MENEST........................................................................82MENEST........................................................................82MENEST........................................................................82MENVEO....................................................................... 89mercaptopurine tab 50 mg......................................... 33

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MEROPENEM/SODIUM CHLORIDE........................11MEROPENEM/SODIUM CHLORIDE........................11meropenem iv for soln 1 gm...................................... 11meropenem iv for soln 500 mg.................................. 11mesalamine cap dr 400 mg........................................92mesalamine enema 4 gm........................................... 92mesalamine rectal enema 4 gm & cleanser wipe

kit................................................................................. 92mesalamine suppos 1000 mg.................................... 92mesalamine tab delayed release 1.2

gm................................................................................92mesalamine tab delayed release 800

mg................................................................................92mesna inj 100 mg/ml...................................................33MESNEX........................................................................33metformin hcl tab 1000 mg.........................................52metformin hcl tab 500 mg...........................................52metformin hcl tab 850 mg...........................................52metformin hcl tab er 24hr 500 mg............................. 52metformin hcl tab er 24hr 750 mg............................. 52methadone hcl tab 10 mg.............................................3methadone hcl tab 5 mg............................................... 3methazolamide tab 25 mg.......................................... 62methazolamide tab 50 mg.......................................... 62methenamine hippurate tab 1 gm..............................11methimazole tab 10 mg.............................................. 86methimazole tab 5 mg.................................................86methocarbamol tab 500 mg..................................... 100methocarbamol tab 750 mg..................................... 100METHOTREXATE SODIUM.......................................89methotrexate sodium for inj 1 gm.............................. 89methotrexate sodium inj 50 mg/2ml (25 mg/

ml)................................................................................89methotrexate sodium inj pf 1000 mg/40ml (25 mg/



ml)................................................................................89methotrexate sodium tab 2.5 mg............................... 90methoxsalen rapid cap 10 mg....................................71methscopolamine bromide tab 2.5 mg......................75methscopolamine bromide tab 5 mg......................... 75methylergonovine maleate tab 0.2 mg......................79methylphenidate hcl tab 10 mg..................................68methylphenidate hcl tab 20 mg..................................68methylphenidate hcl tab 5 mg....................................68methylphenidate hcl tab er 20 mg............................. 68methylprednisolone sod succ for inj 1000

mg................................................................................80methylprednisolone sod succ for inj 125

mg................................................................................80

methylprednisolone sod succ for inj 40mg................................................................................80

methylprednisolone tab 16 mg...................................80methylprednisolone tab 32 mg...................................80methylprednisolone tab 4 mg.....................................80methylprednisolone tab 8 mg.....................................80methylprednisolone tab therapy pack 4 mg

(21)..............................................................................80METHYLTESTOSTERONE........................................ 82metoclopramide hcl inj 5 mg/ml................................. 75metoclopramide hcl soln 5 mg/5ml (10

mg/10ml).....................................................................75metoclopramide hcl tab 10 mg...................................76metoclopramide hcl tab 5 mg.....................................75metolazone tab 10 mg................................................ 62metolazone tab 2.5 mg............................................... 62metolazone tab 5 mg...................................................62metoprolol & hydrochlorothiazide tab 100-25

mg................................................................................63metoprolol & hydrochlorothiazide tab 50-25

mg................................................................................62metoprolol succinate tab er 24hr 100




mg................................................................................63metoprolol tartrate tab 100 mg...................................63metoprolol tartrate tab 25 mg.....................................63metoprolol tartrate tab 50 mg.....................................63METRONIDAZOLE...................................................... 11METRONIDAZOLE...................................................... 11metronidazole cap 375 mg.........................................11metronidazole cream 0.75%.......................................71metronidazole gel 0.75%............................................ 71metronidazole gel 1%..................................................71metronidazole in nacl 0.79% iv soln 500

mg/100ml....................................................................11metronidazole lotion 0.75%........................................ 71metronidazole tab 250 mg..........................................11metronidazole tab 500 mg..........................................11metronidazole vaginal gel 0.75%...............................11MEXILETINE HCL....................................................... 63MEXILETINE HCL....................................................... 63MEXILETINE HCL....................................................... 63MIACALCIN...................................................................93midodrine hcl tab 10 mg............................................. 63midodrine hcl tab 2.5 mg............................................ 63midodrine hcl tab 5 mg............................................... 63MIGERGOT...................................................................25

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miglustat cap 100 mg..................................................77MIGRANAL....................................................................25minocycline hcl cap 100 mg.......................................11minocycline hcl cap 50 mg......................................... 11minocycline hcl cap 75 mg......................................... 11minocycline hcl tab 100 mg........................................11minocycline hcl tab 50 mg..........................................11minocycline hcl tab 75 mg..........................................11minoxidil tab 10 mg..................................................... 63minoxidil tab 2.5 mg.................................................... 63mirtazapine orally disintegrating tab 15

mg................................................................................20mirtazapine orally disintegrating tab 30

mg................................................................................20mirtazapine orally disintegrating tab 45

mg................................................................................20mirtazapine tab 15 mg................................................ 20mirtazapine tab 30 mg................................................ 20mirtazapine tab 45 mg................................................ 20mirtazapine tab 7.5 mg............................................... 20misoprostol tab 100 mcg............................................ 76misoprostol tab 200 mcg............................................ 76mitomycin for iv soln 20 mg....................................... 33mitomycin for iv soln 40 mg....................................... 33mitomycin for iv soln 5 mg..........................................33mitoxantrone hcl inj conc 20 mg/10ml (2 mg/

ml)................................................................................33mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/

ml)................................................................................33mitoxantrone hcl inj conc 30 mg/15ml (2 mg/

ml)................................................................................33M-M-R II........................................................................ 89modafinil tab 100 mg.................................................101modafinil tab 200 mg.................................................101moexipril hcl tab 15 mg...............................................63moexipril hcl tab 7.5 mg..............................................63MOLINDONE HYDROCHLORIDE............................ 41MOLINDONE HYDROCHLORIDE............................ 41MOLINDONE HYDROCHLORIDE............................ 41mometasone furoate cream 0.1%............................. 71mometasone furoate nasal susp 50 mcg/

act................................................................................98mometasone furoate oint 0.1%..................................71mometasone furoate solution 0.1%

(lotion).........................................................................71montelukast sodium chew tab 4 mg..........................98montelukast sodium chew tab 5 mg..........................98montelukast sodium oral granules packet 4

mg................................................................................98montelukast sodium tab 10 mg..................................98morphine sulfate inj pf 0.5 mg/ml.................................3morphine sulfate inj pf 1 mg/ml....................................3

morphine sulfate oral soln 100 mg/5ml (20 mg/ml)..................................................................................3

morphine sulfate oral soln 10 mg/5ml......................... 3morphine sulfate oral soln 20 mg/5ml......................... 3morphine sulfate tab 15 mg..........................................3morphine sulfate tab 30 mg..........................................3morphine sulfate tab er 100 mg...................................3morphine sulfate tab er 15 mg..................................... 3morphine sulfate tab er 200 mg...................................3morphine sulfate tab er 30 mg..................................... 3morphine sulfate tab er 60 mg..................................... 3MOVIPREP................................................................... 76MOXEZA........................................................................94MOXIFLOXACIN HCL................................................. 11moxifloxacin hcl 400 mg/250ml in sodium chloride

0.8% inj.......................................................................11moxifloxacin hcl ophth soln 0.5%.............................. 94moxifloxacin hcl tab 400 mg.......................................11MOZOBIL...................................................................... 55MULTAQ........................................................................ 63mupirocin oint 2%........................................................ 71MVASI............................................................................ 33MVASI............................................................................ 33MYALEPT...................................................................... 76MYCAMINE...................................................................24MYCAMINE...................................................................24mycophenolate mofetil cap 250 mg...........................90mycophenolate mofetil for oral susp 200 mg/

ml.................................................................................90mycophenolate mofetil hcl for iv soln 500

mg................................................................................90mycophenolate mofetil tab 500 mg........................... 90mycophenolate sodium tab dr 180 mg......................90mycophenolate sodium tab dr 360 mg......................90MYLOTARG.................................................................. 33MYRBETRIQ.................................................................79MYRBETRIQ.................................................................79Nnabumetone tab 500 mg...............................................3nabumetone tab 750 mg...............................................3nadolol tab 20 mg........................................................63nadolol tab 40 mg........................................................63nadolol tab 80 mg........................................................63NAFCILLIN....................................................................11NAFCILLIN....................................................................12NAFCILLIN SODIUM...................................................12NAFCILLIN SODIUM...................................................12NAFCILLIN SODIUM...................................................12nafcillin sodium for inj 1 gm........................................12nafcillin sodium for inj 2 gm........................................12nafcillin sodium for iv soln 10 gm.............................. 12

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NAGLAZYME................................................................77NALOXONE HCL........................................................... 5NALOXONE HCL........................................................... 5naloxone hcl inj 0.4 mg/ml............................................5naloxone hcl inj 4 mg/10ml...........................................5naltrexone hcl tab 50 mg.............................................. 5naproxen sodium tab 275 mg.......................................3naproxen sodium tab 550 mg.......................................3naproxen susp 125 mg/5ml.......................................... 3naproxen tab 250 mg.................................................... 3naproxen tab 375 mg.................................................... 3naproxen tab 500 mg.................................................... 3naproxen tab ec 375 mg...............................................3naproxen tab ec 500 mg...............................................3naratriptan hcl tab 1 mg..............................................25naratriptan hcl tab 2.5 mg...........................................25NARCAN..........................................................................5NATACYN......................................................................94nateglinide tab 120 mg............................................... 52nateglinide tab 60 mg..................................................52NATPARA...................................................................... 93NATPARA...................................................................... 93NATPARA...................................................................... 93NATPARA...................................................................... 93NEBUPENT...................................................................38NEFAZODONE HCL....................................................20NEFAZODONE HCL....................................................20nefazodone hcl tab 250 mg........................................20nefazodone hcl tab 50 mg..........................................20NEFAZODONE HYDROCHLORIDE.........................20NEOMYCIN/POLYMYXIN/

GRAMICIDIN............................................................. 95NEOMYCIN/POLYMYXIN B

SULFATES................................................................. 12neomycin-bacitrac zn-polymyx

5(3.5)mg-400unt-10000unt op oin..........................94neomycin-polymyxin-dexamethasone ophth oint

0.1%............................................................................95neomycin-polymyxin-dexamethasone ophth susp

0.1%............................................................................95neomycin-polymyxin-hc otic soln 1%........................ 95neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000

unit/ml-1%.................................................................. 95neomycin sulfate tab 500 mg.....................................12NERLYNX......................................................................33nevirapine susp 50 mg/5ml........................................ 46nevirapine tab 200 mg................................................ 46nevirapine tab er 24hr 100 mg...................................46nevirapine tab er 24hr 400 mg...................................46NEXAVAR......................................................................33NEXIUM.........................................................................76NEXIUM.........................................................................76

NEXIUM.........................................................................76NEXIUM.........................................................................76NEXIUM.........................................................................76niacin tab er 1000 mg................................................. 63niacin tab er 500 mg................................................... 63niacin tab er 750 mg................................................... 63nicardipine hcl cap 20 mg...........................................63nicardipine hcl cap 30 mg...........................................63NICOTROL INHALER................................................... 5NICOTROL NS............................................................... 5nifedipine tab er 24hr 30 mg...................................... 63nifedipine tab er 24hr 60 mg...................................... 63nifedipine tab er 24hr 90 mg...................................... 63nifedipine tab er 24hr osmotic release 30

mg................................................................................63nifedipine tab er 24hr osmotic release 60

mg................................................................................63nifedipine tab er 24hr osmotic release 90

mg................................................................................63nilutamide tab 150 mg.................................................33nimodipine cap 30 mg.................................................63NINLARO.......................................................................33NINLARO.......................................................................33NINLARO.......................................................................33NIPENT..........................................................................33NISOLDIPINE ER........................................................ 63nisoldipine tab er 24hr 17 mg.................................... 63nisoldipine tab er 24hr 34 mg.................................... 63nisoldipine tab er 24hr 8.5 mg................................... 63nitisinone cap 10 mg................................................... 77nitisinone cap 2 mg..................................................... 77nitisinone cap 5 mg..................................................... 77NITRO-BID....................................................................64nitrofurantoin macrocrystalline cap 100

mg................................................................................12nitrofurantoin macrocrystalline cap 50

mg................................................................................12nitrofurantoin monohydrate macrocrystalline cap 100

mg................................................................................12nitrofurantoin susp 25 mg/5ml....................................12nitroglycerin sl tab 0.3 mg.......................................... 64nitroglycerin sl tab 0.4 mg.......................................... 64nitroglycerin sl tab 0.6 mg.......................................... 64nitroglycerin td patch 24hr 0.1 mg/hr.........................64nitroglycerin td patch 24hr 0.2 mg/hr.........................64nitroglycerin td patch 24hr 0.4 mg/hr.........................64nitroglycerin td patch 24hr 0.6 mg/hr.........................64nitroglycerin tl soln 0.4 mg/spray (400 mcg/

spray)..........................................................................64NIVESTYM....................................................................55NIVESTYM....................................................................55NIVESTYM....................................................................55

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NIVESTYM....................................................................55nizatidine cap 150 mg.................................................76nizatidine cap 300 mg.................................................76norethindrone & ethinyl estradiol-fe chew tab 0.4

mg-35 mcg.................................................................82norethindrone & ethinyl estradiol-fe chew tab 0.8

mg-25 mcg.................................................................83norethindrone & ethinyl estradiol tab 0.4 mg-35

mcg..............................................................................82norethindrone & ethinyl estradiol tab 0.5 mg-35

mcg..............................................................................82norethindrone & ethinyl estradiol tab 1 mg-35

mcg..............................................................................82norethindrone ace & ethinyl estradiol-fe tab 1.5

mg-30 mcg.................................................................83norethindrone ace & ethinyl estradiol-fe tab 1 mg-20

mcg..............................................................................83norethindrone ace & ethinyl estradiol tab 1.5 mg-30

mcg..............................................................................83norethindrone ace & ethinyl estradiol tab 1 mg-20

mcg..............................................................................83norethindrone ace-ethinyl estradiol-fe tab 1 mg-20

mcg (24).....................................................................83norethindrone acetate tab 5 mg.................................83norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35

mg-mcg.......................................................................83norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35

mg-mcg.......................................................................83norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35

mg-mcg.......................................................................83norethindrone tab 0.35 mg......................................... 83norgestimate & ethinyl estradiol tab 0.25 mg-35

mcg..............................................................................83norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg.........................83norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg.........................83norgestrel & ethinyl estradiol tab 0.3 mg-30

mcg..............................................................................83NORMOSOL-M IN D5W............................................. 73NORTHERA.................................................................. 64NORTHERA.................................................................. 64NORTHERA.................................................................. 64NORTRIPTYLINE HCL............................................... 20nortriptyline hcl cap 10 mg......................................... 20nortriptyline hcl cap 25 mg......................................... 20nortriptyline hcl cap 50 mg......................................... 20nortriptyline hcl cap 75 mg......................................... 21NORVIR.........................................................................46NORVIR.........................................................................46NOXAFIL....................................................................... 24NOXAFIL....................................................................... 24

NOXAFIL....................................................................... 24NUBEQA........................................................................33NUEDEXTA...................................................................69NULOJIX........................................................................90NUPLAZID.....................................................................41NUPLAZID.....................................................................41NUTRILIPID.................................................................. 73nystatin cream 100000 unit/gm..................................24nystatin oint 100000 unit/gm...................................... 24nystatin susp 100000 unit/ml......................................24nystatin tab 500000 unit..............................................24nystatin topical powder 100000 unit/

gm................................................................................24nystatin-triamcinolone cream 100000-0.1 unit/gm-

%..................................................................................71nystatin-triamcinolone oint 100000-0.1 unit/gm-

%..................................................................................71OOCALIVA....................................................................... 77OCALIVA....................................................................... 77octreotide acetate inj 1000 mcg/ml (1 mg/

ml)................................................................................85octreotide acetate inj 100 mcg/ml (0.1 mg/




ml)................................................................................85ODEFSEY..................................................................... 46ODOMZO...................................................................... 33OFEV............................................................................. 98OFEV............................................................................. 98ofloxacin ophth soln 0.3%...........................................95ofloxacin otic soln 0.3%.............................................. 96ofloxacin tab 400 mg...................................................12olanzapine for im inj 10 mg........................................ 41olanzapine orally disintegrating tab 10

mg................................................................................41olanzapine orally disintegrating tab 15



mg................................................................................41olanzapine tab 10 mg..................................................42olanzapine tab 15 mg..................................................42olanzapine tab 2.5 mg.................................................41olanzapine tab 20 mg..................................................42olanzapine tab 5 mg....................................................41

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olanzapine tab 7.5 mg.................................................42olmesartan medoxomil-hydrochlorothiazide tab

20-12.5 mg.................................................................64olmesartan medoxomil-hydrochlorothiazide tab

40-12.5 mg.................................................................64olmesartan medoxomil-hydrochlorothiazide tab

40-25 mg....................................................................64olmesartan medoxomil tab 20 mg............................. 64olmesartan medoxomil tab 40 mg............................. 64olmesartan medoxomil tab 5 mg............................... 64olopatadine hcl nasal soln 0.6%................................ 98olopatadine hcl ophth soln 0.1%................................95olopatadine hcl ophth soln 0.2%................................95omega-3-acid ethyl esters cap 1 gm.........................64omeprazole cap delayed release 10

mg................................................................................76omeprazole cap delayed release 20

mg................................................................................76omeprazole cap delayed release 40

mg................................................................................76OMNITROPE................................................................ 81OMNITROPE................................................................ 81OMNITROPE................................................................ 81ONCASPAR.................................................................. 33ondansetron hcl inj 40 mg/20ml (2 mg/

ml)................................................................................22ondansetron hcl inj 4 mg/2ml (2 mg/

ml)................................................................................22ondansetron hcl oral soln 4 mg/5ml.......................... 22ondansetron hcl tab 24 mg.........................................22ondansetron hcl tab 4 mg...........................................22ondansetron hcl tab 8 mg...........................................22ondansetron orally disintegrating tab 4

mg................................................................................22ondansetron orally disintegrating tab 8

mg................................................................................22ONGLYZA......................................................................52ONGLYZA......................................................................52ONIVYDE...................................................................... 33OPDIVO.........................................................................33OPDIVO.........................................................................33OPDIVO.........................................................................33OPSUMIT...................................................................... 98ORACEA........................................................................71ORALAIR.......................................................................98ORENCIA...................................................................... 90ORENCIA...................................................................... 90ORENCIA...................................................................... 90ORENCIA...................................................................... 90ORENCIA CLICKJECT............................................... 90ORFADIN.......................................................................77ORFADIN.......................................................................77

ORFADIN.......................................................................77ORFADIN.......................................................................77ORFADIN.......................................................................78ORKAMBI......................................................................98ORKAMBI......................................................................99ORKAMBI......................................................................99ORKAMBI......................................................................99oseltamivir phosphate cap 30 mg..............................46oseltamivir phosphate cap 45 mg..............................46oseltamivir phosphate cap 75 mg..............................46oseltamivir phosphate for susp 6 mg/

ml.................................................................................46OTEZLA.........................................................................90OTEZLA.........................................................................90oxaliplatin for iv inj 100 mg.........................................34oxaliplatin for iv inj 50 mg...........................................34oxaliplatin iv soln 100 mg/20ml..................................34oxaliplatin iv soln 50 mg/10ml....................................34oxandrolone tab 10 mg............................................... 83oxandrolone tab 2.5 mg..............................................83oxaprozin tab 600 mg....................................................3oxcarbazepine susp 300 mg/5ml (60 mg/

ml)................................................................................16oxcarbazepine tab 150 mg.........................................16oxcarbazepine tab 300 mg.........................................16oxcarbazepine tab 600 mg.........................................16oxybutynin chloride syrup 5 mg/5ml..........................79oxybutynin chloride tab 5 mg..................................... 79oxybutynin chloride tab er 24hr 10 mg......................79oxybutynin chloride tab er 24hr 15 mg......................79oxybutynin chloride tab er 24hr 5 mg........................79oxycodone-aspirin tab 4.8355-325 mg........................4OXYCODONE HCL ER.................................................3OXYCODONE HCL ER.................................................3OXYCODONE HCL ER.................................................3OXYCODONE HCL ER.................................................3OXYCODONE HCL ER.................................................3OXYCODONE HCL ER.................................................3OXYCODONE HCL ER.................................................4oxycodone hcl tab 10 mg..............................................4oxycodone hcl tab 15 mg..............................................4oxycodone hcl tab 20 mg..............................................4oxycodone hcl tab 30 mg..............................................4oxycodone hcl tab 5 mg................................................4oxycodone w/ acetaminophen tab 10-325

mg..................................................................................4oxycodone w/ acetaminophen tab 2.5-325

mg..................................................................................4oxycodone w/ acetaminophen tab 5-325

mg..................................................................................4oxycodone w/ acetaminophen tab 7.5-325

mg..................................................................................4

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OZEMPIC...................................................................... 52OZEMPIC...................................................................... 52PPACLITAXEL.................................................................34paclitaxel iv conc 100 mg/16.7ml (6 mg/

ml)................................................................................34paclitaxel iv conc 300 mg/50ml (6 mg/

ml)................................................................................34paclitaxel iv conc 30 mg/5ml (6 mg/ml).....................34paliperidone tab er 24hr 1.5 mg.................................42paliperidone tab er 24hr 3 mg....................................42paliperidone tab er 24hr 6 mg....................................42paliperidone tab er 24hr 9 mg....................................42palonosetron hcl iv soln 0.25 mg/5ml........................22palonosetron hcl iv soln pref syr 0.25

mg/5ml........................................................................ 22PALONOSETRON

HYDROCHLORIDE.................................................. 22PALYNZIQ..................................................................... 78PALYNZIQ..................................................................... 78PALYNZIQ..................................................................... 78PANRETIN.....................................................................34pantoprazole sodium ec tab 20 mg........................... 76pantoprazole sodium ec tab 40 mg........................... 76pantoprazole sodium for iv soln 40 mg..................... 76paricalcitol cap 1 mcg................................................. 93paricalcitol cap 2 mcg................................................. 93paricalcitol cap 4 mcg................................................. 93paricalcitol iv soln 2 mcg/ml....................................... 93paricalcitol iv soln 5 mcg/ml....................................... 93paromomycin sulfate cap 250 mg..............................12paroxetine hcl tab 10 mg............................................ 21paroxetine hcl tab 20 mg............................................ 21paroxetine hcl tab 30 mg............................................ 21paroxetine hcl tab 40 mg............................................ 21PASER........................................................................... 26PAXIL............................................................................. 21PAZEO........................................................................... 95PEDIARIX......................................................................90PEDVAX HIB................................................................ 90peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236

gm................................................................................76peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240

gm................................................................................76peg 3350-kcl-sod bicarb-nacl for soln 420

gm................................................................................76PEGANONE..................................................................16PEGASYS..................................................................... 46PEGASYS..................................................................... 46PEGASYS PROCLICK................................................46

penicillin g potassium for inj 20000000unit...............................................................................12

penicillin g potassium for inj 5000000unit...............................................................................12

PENICILLIN G POTASSIUM INDEXTROSE............................................................... 12



PENICILLIN G SODIUM............................................. 12PENICILLIN V POTASSIUM...................................... 12PENICILLIN V POTASSIUM...................................... 12penicillin v potassium tab 250 mg............................. 12penicillin v potassium tab 500 mg............................. 12PENTACEL....................................................................90PENTAM 300................................................................38pentamidine isethionate for soln 300

mg................................................................................38PENTASA...................................................................... 92PENTASA...................................................................... 92pentoxifylline tab er 400 mg....................................... 64perindopril erbumine tab 2 mg................................... 64perindopril erbumine tab 4 mg................................... 64perindopril erbumine tab 8 mg................................... 64PERJETA.......................................................................34permethrin cream 5%..................................................38perphenazine tab 16 mg.............................................23perphenazine tab 2 mg............................................... 23perphenazine tab 4 mg............................................... 23perphenazine tab 8 mg............................................... 23PERSERIS.................................................................... 42PERSERIS.................................................................... 42phenelzine sulfate tab 15 mg.....................................21phenobarbital elixir 20 mg/5ml...................................16PHENOBARBITAL SODIUM...................................... 16PHENOBARBITAL SODIUM...................................... 16phenobarbital tab 100 mg...........................................16phenobarbital tab 15 mg.............................................16phenobarbital tab 16.2 mg..........................................16phenobarbital tab 30 mg.............................................16phenobarbital tab 32.4 mg..........................................16phenobarbital tab 60 mg.............................................16phenobarbital tab 64.8 mg..........................................16phenobarbital tab 97.2 mg..........................................16phenoxybenzamine hcl cap 10 mg............................64phenytoin chew tab 50 mg......................................... 16phenytoin sodium extended cap 100

mg................................................................................16phenytoin sodium extended cap 200

mg................................................................................16

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phenytoin sodium extended cap 300mg................................................................................16

phenytoin susp 125 mg/5ml....................................... 16PHOSLYRA...................................................................73PHOSPHOLINE IODIDE.............................................95PICATO..........................................................................71PICATO..........................................................................71PIFELTRO..................................................................... 46pilocarpine hcl ophth soln 1%.................................... 95pilocarpine hcl ophth soln 2%.................................... 95pilocarpine hcl ophth soln 4%.................................... 95pilocarpine hcl tab 5 mg..............................................69pilocarpine hcl tab 7.5 mg.......................................... 69pimecrolimus cream 1%..............................................71PIMOZIDE..................................................................... 42PIMOZIDE..................................................................... 42pindolol tab 10 mg....................................................... 64pindolol tab 5 mg......................................................... 64pioglitazone hcl-glimepiride tab 30-2

mg................................................................................52pioglitazone hcl-glimepiride tab 30-4

mg................................................................................52pioglitazone hcl-metformin hcl tab 15-500

mg................................................................................52pioglitazone hcl-metformin hcl tab 15-850

mg................................................................................52pioglitazone hcl tab 15 mg..........................................52pioglitazone hcl tab 30 mg..........................................52pioglitazone hcl tab 45 mg..........................................52piperacillin sod-tazobactam na for inj 3.375 gm

(3-0.375 gm)..............................................................12piperacillin sod-tazobactam sod for inj 2.25 gm

(2-0.25 gm)................................................................ 12piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5

gm).............................................................................. 12PIQRAY 200MG DAILY DOSE...................................34PIQRAY 250MG DAILY DOSE...................................34PIQRAY 300MG DAILY DOSE...................................34piroxicam cap 10 mg..................................................... 4piroxicam cap 20 mg..................................................... 4PLEGRIDY.................................................................... 69PLEGRIDY.................................................................... 69PLEGRIDY STARTER PACK..................................... 69PLEGRIDY STARTER PACK..................................... 69podofilox soln 0.5%..................................................... 71POLIVY..........................................................................34polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1%...................................................................... 95POMALYST...................................................................34POMALYST...................................................................34POMALYST...................................................................34POMALYST...................................................................34

PORTRAZZA................................................................ 34posaconazole tab delayed release 100

mg................................................................................24POTASSIUM CHLORIDE/DEXTROSE.....................74POTASSIUM CHLORIDE/DEXTROSE/LACTATED

RINGERS...................................................................74POTASSIUM CHLORIDE/DEXTROSE/LACTATED

RINGERS...................................................................74POTASSIUM CHLORIDE/DEXTROSE/SODIUM

CHLORIDE.................................................................74potassium chloride 20 meq/l (0.15%) in dextrose 5%

inj................................................................................. 74potassium chloride cap er 10 meq............................ 73potassium chloride cap er 8 meq...............................73POTASSIUM CHLORIDE ER.....................................74potassium chloride inj 2 meq/ml................................ 74potassium chloride microencapsulated crys er tab 10

meq............................................................................. 74potassium chloride microencapsulated crys er tab 20

meq............................................................................. 74potassium chloride oral soln 10% (20

meq/15ml).................................................................. 74potassium chloride tab er 10 meq............................. 74potassium chloride tab er 8 meq (600

mg).............................................................................. 74potassium citrate tab er 10 meq (1080



mg).............................................................................. 74POTELIGEO................................................................. 34PRADAXA..................................................................... 55PRADAXA..................................................................... 55PRADAXA..................................................................... 56pramipexole dihydrochloride tab 0.125

mg................................................................................39pramipexole dihydrochloride tab 0.25




mg................................................................................39pramipexole dihydrochloride tab 1 mg...................... 39prasugrel hcl tab 10 mg..............................................56prasugrel hcl tab 5 mg................................................ 56pravastatin sodium tab 10 mg....................................64pravastatin sodium tab 20 mg....................................64pravastatin sodium tab 40 mg....................................64pravastatin sodium tab 80 mg....................................64

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praziquantel tab 600 mg............................................. 38prazosin hcl cap 1 mg.................................................64prazosin hcl cap 2 mg.................................................64prazosin hcl cap 5 mg.................................................64PREDNICARBATE.......................................................71PREDNICARBATE.......................................................72PREDNISOLONE ACETATE......................................95prednisolone sod phosphate oral soln 15

mg/5ml........................................................................ 80prednisolone sod phosph oral soln 6.7 mg/5ml (5

mg/5ml base).............................................................80prednisolone syrup 15 mg/5ml...................................80PREDNISONE.............................................................. 80PREDNISONE.............................................................. 80prednisone tab 10 mg................................................. 80prednisone tab 1 mg................................................... 80prednisone tab 2.5 mg................................................ 80prednisone tab 20 mg................................................. 80prednisone tab 5 mg................................................... 80prednisone tab therapy pack 10 mg

(21)..............................................................................80prednisone tab therapy pack 10 mg

(48)..............................................................................80prednisone tab therapy pack 5 mg (21).................... 80prednisone tab therapy pack 5 mg (48).................... 80pregabalin cap 100 mg............................................... 16pregabalin cap 150 mg............................................... 16pregabalin cap 200 mg............................................... 17pregabalin cap 225 mg............................................... 17pregabalin cap 25 mg................................................. 16pregabalin cap 300 mg............................................... 17pregabalin cap 50 mg................................................. 16pregabalin cap 75 mg................................................. 16pregabalin soln 20 mg/ml........................................... 17PREGNYL W/DILUENT BENZYL ALCOHOL/

NACL.......................................................................... 81PREMARIN................................................................... 83PREMARIN................................................................... 83PREMARIN................................................................... 83PREMARIN................................................................... 83PREMARIN................................................................... 83PREMARIN................................................................... 83PREMPHASE............................................................... 83PREMPRO.................................................................... 83PREMPRO.................................................................... 83PREMPRO.................................................................... 83PREMPRO.................................................................... 83PREVYMIS....................................................................46PREVYMIS....................................................................46PREZCOBIX................................................................. 46PREZISTA..................................................................... 46PREZISTA..................................................................... 46

PREZISTA..................................................................... 46PREZISTA..................................................................... 47PREZISTA..................................................................... 47PRIFTIN.........................................................................26primaquine phosphate tab 26.3 mg...........................38primidone tab 250 mg................................................. 17primidone tab 50 mg................................................... 17PROAIR HFA................................................................99PROAIR RESPICLICK................................................ 99probenecid tab 500 mg............................................... 24PROCHLORPERAZINE EDISYLATE....................... 23prochlorperazine edisylate inj 10

mg/2ml........................................................................ 23prochlorperazine maleate tab 10 mg.........................23prochlorperazine maleate tab 5 mg...........................23prochlorperazine suppos 25 mg................................ 23PROCRIT...................................................................... 56PROCRIT...................................................................... 56PROCRIT...................................................................... 56PROCRIT...................................................................... 56PROCRIT...................................................................... 56PROCRIT...................................................................... 56progesterone micronized cap 100 mg.......................83progesterone micronized cap 200 mg.......................83PROGLYCEM............................................................... 52PROGRAF.....................................................................90PROGRAF.....................................................................90PROGRAF.....................................................................90PROLASTIN-C..............................................................78PROLASTIN-C..............................................................78PROLENSA...................................................................95PROLEUKIN................................................................. 34PROLIA..........................................................................93PROMACTA.................................................................. 56PROMACTA.................................................................. 56PROMACTA.................................................................. 56PROMACTA.................................................................. 56PROMACTA.................................................................. 56promethazine hcl suppos 12.5 mg............................ 23promethazine hcl suppos 25 mg................................23promethazine hcl syrup 6.25 mg/5ml........................ 23promethazine hcl tab 12.5 mg....................................23promethazine hcl tab 25 mg.......................................23promethazine hcl tab 50 mg.......................................23propafenone hcl cap er 12hr 225 mg........................ 64propafenone hcl cap er 12hr 325 mg........................ 64propafenone hcl cap er 12hr 425 mg........................ 64propafenone hcl tab 150 mg...................................... 64propafenone hcl tab 225 mg...................................... 64propafenone hcl tab 300 mg...................................... 65propranolol hcl cap er 24hr 120 mg.......................... 65propranolol hcl cap er 24hr 160 mg.......................... 65

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propranolol hcl cap er 24hr 60 mg.............................65propranolol hcl cap er 24hr 80 mg.............................65propranolol hcl inj 1 mg/ml......................................... 65propranolol hcl tab 10 mg...........................................65propranolol hcl tab 20 mg...........................................65propranolol hcl tab 40 mg...........................................65propranolol hcl tab 60 mg...........................................65propranolol hcl tab 80 mg...........................................65propylthiouracil tab 50 mg.......................................... 86PROQUAD.................................................................... 90protriptyline hcl tab 10 mg.......................................... 21protriptyline hcl tab 5 mg............................................ 21PULMOZYME............................................................... 99PURIXAN.......................................................................34PYLERA.........................................................................76pyrazinamide tab 500 mg........................................... 26pyridostigmine bromide oral soln 60

mg/5ml........................................................................ 25pyridostigmine bromide tab 60 mg............................ 25pyridostigmine bromide tab er 180 mg......................25QQUADRACEL................................................................90quetiapine fumarate tab 100 mg................................42quetiapine fumarate tab 200 mg................................42quetiapine fumarate tab 25 mg..................................42quetiapine fumarate tab 300 mg................................42quetiapine fumarate tab 400 mg................................42quetiapine fumarate tab 50 mg..................................42quetiapine fumarate tab er 24hr 150

mg................................................................................42quetiapine fumarate tab er 24hr 200



mg................................................................................42quetiapine fumarate tab er 24hr 50 mg.....................42quinapril hcl tab 10 mg............................................... 65quinapril hcl tab 20 mg............................................... 65quinapril hcl tab 40 mg............................................... 65quinapril hcl tab 5 mg..................................................65quinapril-hydrochlorothiazide tab 10-12.5

mg................................................................................65quinapril-hydrochlorothiazide tab 20-12.5

mg................................................................................65quinapril-hydrochlorothiazide tab 20-25

mg................................................................................65quinidine gluconate tab er 324 mg............................ 65QUINIDINE SULFATE................................................. 65QUINIDINE SULFATE................................................. 65QVAR REDIHALER..................................................... 99

QVAR REDIHALER..................................................... 99RRABAVERT................................................................... 90rabeprazole sodium ec tab 20 mg............................. 76raloxifene hcl tab 60 mg............................................. 83ramipril cap 1.25 mg....................................................65ramipril cap 10 mg.......................................................65ramipril cap 2.5 mg......................................................65ramipril cap 5 mg.........................................................65ranitidine hcl syrup 15 mg/ml (75

mg/5ml).......................................................................76ranitidine hcl tab 150 mg............................................ 76ranitidine hcl tab 300 mg............................................ 76ranolazine tab er 12hr 1000 mg.................................65ranolazine tab er 12hr 500 mg...................................65rasagiline mesylate tab 0.5 mg.................................. 39rasagiline mesylate tab 1 mg..................................... 39REBETOL......................................................................47RECOMBIVAX HB....................................................... 90RECOMBIVAX HB....................................................... 90RECOMBIVAX HB....................................................... 90RECTIV..........................................................................65REGRANEX.................................................................. 72RELENZA DISKHALER.............................................. 47RELISTOR.....................................................................76RELISTOR.....................................................................76RELISTOR.....................................................................76REMODULIN................................................................ 99REMODULIN................................................................ 99REMODULIN................................................................ 99REMODULIN................................................................ 99RENFLEXIS.................................................................. 90repaglinide tab 0.5 mg................................................ 52repaglinide tab 1 mg....................................................52repaglinide tab 2 mg....................................................52REPATHA...................................................................... 65REPATHA PUSHTRONEX SYSTEM........................65REPATHA SURECLICK.............................................. 65RESCRIPTOR.............................................................. 47RESTASIS.....................................................................95RESTASIS MULTIDOSE.............................................95RETACRIT.....................................................................56RETACRIT.....................................................................56RETACRIT.....................................................................56RETACRIT.....................................................................56RETACRIT.....................................................................56RETROVIR IV INFUSION...........................................47REVCOVI...................................................................... 78REVLIMID......................................................................34REVLIMID......................................................................34REVLIMID......................................................................34REVLIMID......................................................................34

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REVLIMID......................................................................34REVLIMID......................................................................34REXULTI........................................................................42REXULTI........................................................................42REXULTI........................................................................42REXULTI........................................................................42REXULTI........................................................................42REXULTI........................................................................42REYATAZ.......................................................................47RHOPRESSA............................................................... 95RIBASPHERE...............................................................47RIBASPHERE...............................................................47RIBASPHERE RIBAPAK.............................................47RIBASPHERE RIBAPAK.............................................47ribavirin cap 200 mg....................................................47ribavirin for inhal soln 6 gm........................................ 99ribavirin tab 200 mg.....................................................47RIDAURA...................................................................... 90rifabutin cap 150 mg....................................................26rifampin cap 150 mg....................................................26rifampin cap 300 mg....................................................26rifampin for inj 600 mg................................................ 26riluzole tab 50 mg........................................................ 69RINVOQ.........................................................................90risedronate sodium tab 150 mg................................. 93risedronate sodium tab 30 mg................................... 93risedronate sodium tab 35 mg................................... 93risedronate sodium tab 5 mg..................................... 93risedronate sodium tab delayed release 35

mg................................................................................93RISPERDAL CONSTA................................................ 42RISPERDAL CONSTA................................................ 42RISPERDAL CONSTA................................................ 42RISPERDAL CONSTA................................................ 42RISPERIDONE ODT................................................... 42risperidone orally disintegrating tab 0.5

mg................................................................................43risperidone orally disintegrating tab 1




mg................................................................................43risperidone soln 1 mg/ml............................................ 43risperidone tab 0.25 mg..............................................43risperidone tab 0.5 mg................................................ 43risperidone tab 1 mg................................................... 43risperidone tab 2 mg................................................... 43risperidone tab 3 mg................................................... 43risperidone tab 4 mg................................................... 43

ritonavir tab 100 mg.................................................... 47RITUXAN.......................................................................34RITUXAN.......................................................................34RITUXAN HYCELA......................................................34RITUXAN HYCELA......................................................34rivastigmine tartrate cap 1.5 mg................................ 18rivastigmine tartrate cap 3 mg....................................18rivastigmine tartrate cap 4.5 mg................................ 18rivastigmine tartrate cap 6 mg....................................18rivastigmine td patch 24hr 13.3

mg/24hr...................................................................... 18rivastigmine td patch 24hr 4.6 mg/24hr.....................18rivastigmine td patch 24hr 9.5 mg/24hr.....................18rizatriptan benzoate oral disintegrating tab 10

mg................................................................................25rizatriptan benzoate oral disintegrating tab 5

mg................................................................................25rizatriptan benzoate tab 10 mg.................................. 25rizatriptan benzoate tab 5 mg.................................... 25ropinirole hydrochloride tab 0.25 mg.........................39ropinirole hydrochloride tab 0.5 mg...........................39ropinirole hydrochloride tab 1 mg.............................. 39ropinirole hydrochloride tab 2 mg.............................. 39ropinirole hydrochloride tab 3 mg.............................. 39ropinirole hydrochloride tab 4 mg.............................. 39ropinirole hydrochloride tab 5 mg.............................. 39rosuvastatin calcium tab 10 mg................................. 65rosuvastatin calcium tab 20 mg................................. 65rosuvastatin calcium tab 40 mg................................. 65rosuvastatin calcium tab 5 mg................................... 65ROTARIX.......................................................................91ROTATEQ......................................................................91RUBRACA.....................................................................34RUBRACA.....................................................................34RUBRACA.....................................................................35RYDAPT........................................................................ 35RYTARY.........................................................................39RYTARY.........................................................................39RYTARY.........................................................................39RYTARY.........................................................................39SSAMSCA........................................................................74SAMSCA........................................................................74SANDIMMUNE............................................................. 91SANTYL.........................................................................72SAPHRIS.......................................................................43SAPHRIS.......................................................................43SAPHRIS.......................................................................43selegiline hcl cap 5 mg............................................... 39selegiline hcl tab 5 mg................................................ 39selenium sulfide lotion 2.5%.......................................72

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SELZENTRY.................................................................47SELZENTRY.................................................................47SELZENTRY.................................................................47SELZENTRY.................................................................47SELZENTRY.................................................................47SEREVENT DISKUS...................................................99sertraline hcl oral concentrate for solution 20 mg/

ml.................................................................................21sertraline hcl tab 100 mg............................................ 21sertraline hcl tab 25 mg.............................................. 21sertraline hcl tab 50 mg.............................................. 21sevelamer carbonate packet 0.8 gm......................... 74sevelamer carbonate packet 2.4 gm......................... 74sevelamer carbonate tab 800 mg..............................74SHINGRIX..................................................................... 91SIGNIFOR..................................................................... 85SIGNIFOR..................................................................... 85SIGNIFOR..................................................................... 85SIGNIFOR LAR............................................................85SIGNIFOR LAR............................................................85SIGNIFOR LAR............................................................85SIGNIFOR LAR............................................................86SIGNIFOR LAR............................................................86sildenafil citrate tab 20 mg..........................................99SILENOR.....................................................................101SILENOR.....................................................................101silodosin cap 4 mg.......................................................79silodosin cap 8 mg.......................................................79silver sulfadiazine cream 1%......................................72SIMBRINZA...................................................................95SIMULECT.................................................................... 91SIMULECT.................................................................... 91simvastatin tab 10 mg.................................................66simvastatin tab 20 mg.................................................66simvastatin tab 40 mg.................................................66simvastatin tab 5 mg................................................... 65simvastatin tab 80 mg.................................................66sirolimus oral soln 1 mg/ml.........................................91sirolimus tab 0.5 mg.................................................... 91sirolimus tab 1 mg....................................................... 91sirolimus tab 2 mg....................................................... 91SIRTURO.......................................................................26SIVEXTRO.................................................................... 12SIVEXTRO.................................................................... 12SKYRIZI.........................................................................91sodium chloride irrigation soln 0.9%......................... 74sodium chloride iv soln 0.45%................................... 74sodium chloride iv soln 0.9%..................................... 74sodium chloride preservative free inj

0.9%............................................................................74sodium phenylbutyrate oral powder 3 gm/

teaspoonful.................................................................78

sodium phenylbutyrate tab 500 mg........................... 78sodium polystyrene sulfonate oral susp 15

gm/60ml......................................................................74sodium polystyrene sulfonate powder.......................74sodium polystyrene sulfonate rectal susp 30

gm/120ml....................................................................74SOFOSBUVIR/VELPATASVIR...................................47solifenacin succinate tab 10 mg.................................79solifenacin succinate tab 5 mg...................................79SOLTAMOX...................................................................35SOMATULINE DEPOT................................................86SOMATULINE DEPOT................................................86SOMATULINE DEPOT................................................86SOMAVERT.................................................................. 86SOMAVERT.................................................................. 86SOMAVERT.................................................................. 86SOMAVERT.................................................................. 86SOMAVERT.................................................................. 86SOOLANTRA................................................................72sotalol hcl (afib/afl) tab 120 mg..................................66sotalol hcl (afib/afl) tab 160 mg..................................66sotalol hcl (afib/afl) tab 80 mg....................................66sotalol hcl tab 120 mg.................................................66sotalol hcl tab 160 mg.................................................66sotalol hcl tab 240 mg.................................................66sotalol hcl tab 80 mg...................................................66SOVALDI....................................................................... 47SPIRIVA HANDIHALER.............................................. 99SPIRIVA RESPIMAT....................................................99SPIRIVA RESPIMAT....................................................99spironolactone & hydrochlorothiazide tab 25-25

mg................................................................................66spironolactone tab 100 mg.........................................66spironolactone tab 25 mg........................................... 66spironolactone tab 50 mg........................................... 66SPRAVATO 56MG DOSE........................................... 21SPRAVATO 84MG DOSE........................................... 21SPRITAM.......................................................................17SPRITAM.......................................................................17SPRITAM.......................................................................17SPRITAM.......................................................................17SPRYCEL......................................................................35SPRYCEL......................................................................35SPRYCEL......................................................................35SPRYCEL......................................................................35SPRYCEL......................................................................35SPRYCEL......................................................................35STAMARIL.....................................................................91stavudine cap 15 mg...................................................47stavudine cap 20 mg...................................................47stavudine cap 30 mg...................................................47stavudine cap 40 mg...................................................47

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STELARA...................................................................... 91STELARA...................................................................... 91STELARA...................................................................... 91STELARA...................................................................... 91STIMATE....................................................................... 81STIOLTO RESPIMAT.................................................. 99STIVARGA.....................................................................35STRENSIQ....................................................................78STRENSIQ....................................................................78STRENSIQ....................................................................78STRENSIQ....................................................................78STREPTOMYCIN SULFATE...................................... 12STRIBILD...................................................................... 47SUBLOCADE.................................................................. 5SUBLOCADE.................................................................. 5sucralfate tab 1 gm......................................................76sulfacetamide sodium lotion 10%.............................. 12sulfacetamide sodium ophth soln 10%..................... 95sulfacetamide sodium-prednisolone ophth soln

10-0.23(0.25)%..........................................................95SULFADIAZINE............................................................ 12sulfamethoxazole-trimethoprim iv soln 400-80

mg/5ml........................................................................ 12sulfamethoxazole-trimethoprim susp 200-40

mg/5ml........................................................................ 13sulfamethoxazole-trimethoprim tab 400-80

mg................................................................................13sulfamethoxazole-trimethoprim tab 800-160

mg................................................................................13sulfasalazine tab 500 mg............................................92sulfasalazine tab delayed release 500

mg................................................................................92sulindac tab 150 mg...................................................... 4sulindac tab 200 mg...................................................... 4sumatriptan nasal spray 20 mg/act........................... 25sumatriptan nasal spray 5 mg/act..............................25SUMATRIPTAN SUCCINATE.....................................25sumatriptan succinate inj 6 mg/0.5ml........................25sumatriptan succinate solution auto-injector 4

mg/0.5ml.....................................................................25sumatriptan succinate solution auto-injector 6

mg/0.5ml.....................................................................25sumatriptan succinate solution cartridge 4

mg/0.5ml.....................................................................25sumatriptan succinate solution cartridge 6

mg/0.5ml.....................................................................25sumatriptan succinate tab 100 mg............................ 25sumatriptan succinate tab 25 mg...............................25sumatriptan succinate tab 50 mg...............................25SUPRAX........................................................................13SUPRAX........................................................................13SUPREP BOWEL PREP KIT.....................................76

SUTENT........................................................................ 35SUTENT........................................................................ 35SUTENT........................................................................ 35SUTENT........................................................................ 35SYLATRON................................................................... 47SYLATRON................................................................... 47SYLATRON................................................................... 47SYLVANT.......................................................................91SYLVANT.......................................................................91SYMBICORT.................................................................99SYMBICORT.................................................................99SYMDEKO.................................................................... 99SYMDEKO.................................................................... 99SYMFI............................................................................ 47SYMFI LO..................................................................... 47SYMLINPEN 120......................................................... 53SYMLINPEN 60............................................................53SYMPAZAN...................................................................17SYMPAZAN...................................................................17SYMPAZAN...................................................................17SYMTUZA..................................................................... 47SYNAGIS.......................................................................91SYNAGIS.......................................................................91SYNAREL......................................................................86SYNERCID....................................................................13SYNJARDY................................................................... 53SYNJARDY................................................................... 53SYNJARDY................................................................... 53SYNJARDY................................................................... 53SYNJARDY XR............................................................ 53SYNJARDY XR............................................................ 53SYNJARDY XR............................................................ 53SYNJARDY XR............................................................ 53SYNRIBO...................................................................... 35SYNTHROID.................................................................84SYNTHROID.................................................................84SYNTHROID.................................................................84SYNTHROID.................................................................84SYNTHROID.................................................................84SYNTHROID.................................................................84SYNTHROID.................................................................84SYNTHROID.................................................................84SYNTHROID.................................................................84SYNTHROID.................................................................84SYNTHROID.................................................................84SYNTHROID.................................................................84TTABLOID........................................................................35tacrolimus cap 0.5 mg.................................................91tacrolimus cap 1 mg....................................................91tacrolimus cap 5 mg....................................................91tacrolimus oint 0.03%..................................................72

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tacrolimus oint 0.1%.................................................... 72tadalafil tab 20 mg (pah).............................................99TAFINLAR..................................................................... 35TAFINLAR..................................................................... 35TAGRISSO.................................................................... 35TAGRISSO.................................................................... 35TALZENNA....................................................................35TALZENNA....................................................................35tamoxifen citrate tab 10 mg........................................35tamoxifen citrate tab 20 mg........................................35tamsulosin hcl cap 0.4 mg..........................................79TARGRETIN..................................................................35TASIGNA....................................................................... 35TASIGNA....................................................................... 35TASIGNA....................................................................... 35tazarotene cream 0.1%...............................................72TAZICEF........................................................................ 13TAZICEF........................................................................ 13TAZORAC......................................................................72TAZORAC......................................................................72TAZORAC......................................................................72TDVAX........................................................................... 91TECENTRIQ................................................................. 35TECENTRIQ................................................................. 35TECFIDERA..................................................................69TECFIDERA..................................................................69TECFIDERA STARTER PACK...................................69TEFLARO......................................................................13TEFLARO......................................................................13TEKTURNA HCT......................................................... 66TEKTURNA HCT......................................................... 66TEKTURNA HCT......................................................... 66TEKTURNA HCT......................................................... 66telmisartan-hydrochlorothiazide tab 40-12.5

mg................................................................................66telmisartan-hydrochlorothiazide tab 80-12.5

mg................................................................................66telmisartan-hydrochlorothiazide tab 80-25

mg................................................................................66telmisartan tab 20 mg................................................. 66telmisartan tab 40 mg................................................. 66telmisartan tab 80 mg................................................. 66temazepam cap 15 mg............................................. 101temazepam cap 30 mg............................................. 101TEMODAR.................................................................... 35temsirolimus soln for iv infusion 25 mg/

ml.................................................................................35TENCON..........................................................................4TENIVAC....................................................................... 91tenofovir disoproxil fumarate tab 300

mg................................................................................47terazosin hcl cap 10 mg..............................................66

terazosin hcl cap 1 mg................................................66terazosin hcl cap 2 mg................................................66terazosin hcl cap 5 mg................................................66terbinafine hcl tab 250 mg..........................................24terbutaline sulfate tab 2.5 mg.....................................99terbutaline sulfate tab 5 mg........................................99TERCONAZOLE...........................................................24terconazole vaginal cream 0.4%................................24terconazole vaginal suppos 80 mg............................24testosterone cypionate im inj in oil 100 mg/

ml.................................................................................83testosterone cypionate im inj in oil 200 mg/

ml.................................................................................83testosterone enanthate im inj in oil 200 mg/

ml.................................................................................83testosterone td gel 12.5 mg/act (1%)........................ 83testosterone td gel 20.25 mg/1.25gm

(1.62%)....................................................................... 84testosterone td gel 20.25 mg/act

(1.62%)....................................................................... 84testosterone td gel 25 mg/2.5gm (1%)......................84testosterone td gel 40.5 mg/2.5gm

(1.62%)....................................................................... 84testosterone td gel 50 mg/5gm (1%).........................84testosterone td soln 30 mg/act...................................84tetrabenazine tab 12.5 mg..........................................69tetrabenazine tab 25 mg.............................................69tetracycline hcl cap 250 mg........................................13tetracycline hcl cap 500 mg........................................13THALOMID....................................................................35THALOMID....................................................................35THALOMID....................................................................35THALOMID....................................................................35theophylline tab er 12hr 300 mg................................99theophylline tab er 12hr 450 mg................................99theophylline tab er 24hr 400 mg................................99theophylline tab er 24hr 600 mg................................99thioridazine hcl tab 100 mg........................................ 43thioridazine hcl tab 10 mg.......................................... 43thioridazine hcl tab 25 mg.......................................... 43thioridazine hcl tab 50 mg.......................................... 43thiotepa for inj 15 mg.................................................. 35thiothixene cap 10 mg.................................................43thiothixene cap 1 mg...................................................43thiothixene cap 2 mg...................................................43thiothixene cap 5 mg...................................................43THYMOGLOBULIN......................................................91tiagabine hcl tab 12 mg.............................................. 17tiagabine hcl tab 16 mg.............................................. 17tiagabine hcl tab 2 mg.................................................17tiagabine hcl tab 4 mg.................................................17TIBSOVO.......................................................................35

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tigecycline for iv soln 50 mg.......................................13TIMOLOL MALEATE................................................... 66TIMOLOL MALEATE................................................... 66TIMOLOL MALEATE OPHTHALMIC GEL

FORMING.................................................................. 95TIMOLOL MALEATE OPHTHALMIC GEL

FORMING.................................................................. 95timolol maleate ophth soln 0.25%..............................95timolol maleate ophth soln 0.5%................................95timolol maleate ophth soln 0.5% (once-

daily)............................................................................95timolol maleate tab 5 mg............................................ 66TIVICAY......................................................................... 47TIVICAY......................................................................... 48TIVICAY......................................................................... 48tizanidine hcl cap 2 mg............................................... 44tizanidine hcl cap 4 mg............................................... 44tizanidine hcl cap 6 mg............................................... 44tizanidine hcl tab 2 mg................................................44tizanidine hcl tab 4 mg................................................44TOBRADEX...................................................................95tobramycin-dexamethasone ophth susp

0.3-0.1%..................................................................... 95tobramycin nebu soln 300 mg/5ml.......................... 100tobramycin ophth soln 0.3%.......................................95TOBRAMYCIN SULFATE........................................... 13TOBRAMYCIN SULFATE........................................... 13tobramycin sulfate for inj 1.2 gm................................13tobramycin sulfate inj 1.2 gm/30ml (40 mg/

ml)................................................................................13tobramycin sulfate inj 80 mg/2ml (40 mg/

ml)................................................................................13tolcapone tab 100 mg................................................. 39TOLMETIN SODIUM..................................................... 4tolterodine tartrate cap er 24hr 2 mg.........................79tolterodine tartrate cap er 24hr 4 mg.........................79tolterodine tartrate tab 1 mg.......................................79tolterodine tartrate tab 2 mg.......................................79topiramate sprinkle cap 15 mg...................................17topiramate sprinkle cap 25 mg...................................17topiramate tab 100 mg................................................17topiramate tab 200 mg................................................17topiramate tab 25 mg.................................................. 17topiramate tab 50 mg.................................................. 17topotecan hcl for inj 4 mg........................................... 36topotecan hcl inj 4 mg/4ml (for

infusion)...................................................................... 36toremifene citrate tab 60 mg...................................... 36torsemide tab 100 mg................................................. 66torsemide tab 10 mg................................................... 66torsemide tab 20 mg................................................... 66torsemide tab 5 mg......................................................66

TOUJEO MAX SOLOSTAR........................................53TOUJEO SOLOSTAR..................................................53TOVIAZ.......................................................................... 79TOVIAZ.......................................................................... 79TRACLEER.................................................................100TRADJENTA................................................................. 53tramadol-acetaminophen tab 37.5-325

mg..................................................................................4tramadol hcl tab 50 mg................................................. 4tramadol hcl tab er 24hr 100 mg..................................4tramadol hcl tab er 24hr 200 mg..................................4tramadol hcl tab er 24hr 300 mg..................................4trandolapril tab 1 mg................................................... 66trandolapril tab 2 mg................................................... 66trandolapril tab 4 mg................................................... 67tranexamic acid iv soln 1000 mg/10ml (100 mg/

ml)................................................................................56tranexamic acid tab 650 mg.......................................56tranylcypromine sulfate tab 10 mg............................ 21TRAVATAN Z................................................................ 95trazodone hcl tab 100 mg...........................................21trazodone hcl tab 150 mg...........................................21trazodone hcl tab 300 mg...........................................21trazodone hcl tab 50 mg.............................................21TREANDA..................................................................... 36TREANDA..................................................................... 36TRECATOR...................................................................26TRELEGY ELLIPTA...................................................100TRELSTAR MIXJECT..................................................86TRELSTAR MIXJECT..................................................86TRELSTAR MIXJECT..................................................86TREMFYA......................................................................91TREMFYA......................................................................91treprostinil inj soln 100 mg/20ml (5 mg/

ml)............................................................................. 100treprostinil inj soln 200 mg/20ml (10 mg/

ml)............................................................................. 100treprostinil inj soln 20 mg/20ml (1 mg/

ml)............................................................................. 100treprostinil inj soln 50 mg/20ml (2.5 mg/

ml)............................................................................. 100TRESIBA....................................................................... 53TRESIBA FLEXTOUCH.............................................. 53TRESIBA FLEXTOUCH.............................................. 53tretinoin cap 10 mg......................................................36tretinoin cream 0.025%............................................... 72tretinoin cream 0.05%................................................. 72tretinoin cream 0.1%................................................... 72tretinoin gel 0.01%.......................................................72tretinoin gel 0.025%.....................................................72triamcinolone acetonide cream

0.025%........................................................................72

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triamcinolone acetonide cream 0.1%........................72triamcinolone acetonide cream 0.5%........................72triamcinolone acetonide dental paste

0.1%............................................................................69triamcinolone acetonide lotion 0.025%..................... 72triamcinolone acetonide lotion 0.1%..........................72triamcinolone acetonide oint 0.025%........................ 72triamcinolone acetonide oint 0.1%.............................72triamcinolone acetonide oint 0.5%.............................72triamterene & hydrochlorothiazide cap 37.5-25

mg................................................................................67triamterene & hydrochlorothiazide tab 37.5-25

mg................................................................................67triamterene & hydrochlorothiazide tab 75-50

mg................................................................................67trientine hcl cap 250 mg............................................. 74trifluoperazine hcl tab 10 mg......................................43trifluoperazine hcl tab 1 mg........................................43trifluoperazine hcl tab 2 mg........................................43trifluoperazine hcl tab 5 mg........................................43TRIFLURIDINE.............................................................95trimethoprim tab 100 mg.............................................13trimipramine maleate cap 100 mg............................. 21trimipramine maleate cap 25 mg............................... 21trimipramine maleate cap 50 mg............................... 21TRINTELLIX..................................................................21TRINTELLIX..................................................................21TRINTELLIX..................................................................21TRISENOX....................................................................36TRIUMEQ......................................................................48TROGARZO..................................................................48trospium chloride cap er 24hr 60 mg.........................79trospium chloride tab 20 mg.......................................79TRULICITY....................................................................53TRULICITY....................................................................53TRUMENBA.................................................................. 91TRUVADA......................................................................48TRUVADA......................................................................48TRUVADA......................................................................48TRUVADA......................................................................48TURALIO....................................................................... 36TWINRIX........................................................................91TYBOST........................................................................ 48TYKERB........................................................................ 36TYMLOS........................................................................93TYPHIM VI.................................................................... 91TYSABRI....................................................................... 69UUDENYCA.....................................................................56UNITUXIN......................................................................36UPTRAVI..................................................................... 100

UPTRAVI..................................................................... 100UPTRAVI..................................................................... 100UPTRAVI..................................................................... 100UPTRAVI..................................................................... 100UPTRAVI..................................................................... 100UPTRAVI..................................................................... 100UPTRAVI..................................................................... 100UPTRAVI..................................................................... 100ursodiol cap 300 mg....................................................76ursodiol tab 250 mg.....................................................76ursodiol tab 500 mg.....................................................77Vvalacyclovir hcl tab 1 gm............................................ 48valacyclovir hcl tab 500 mg........................................48VALCHLOR................................................................... 36valganciclovir hcl for soln 50 mg/ml.......................... 48valganciclovir hcl tab 450 mg.....................................48valproate sodium inj 100 mg/ml.................................17valproate sodium oral soln 250 mg/5ml.................... 17valproic acid cap 250 mg............................................17valsartan-hydrochlorothiazide tab 160-12.5

mg................................................................................67valsartan-hydrochlorothiazide tab 160-25

mg................................................................................67valsartan-hydrochlorothiazide tab 320-12.5

mg................................................................................67valsartan-hydrochlorothiazide tab 320-25

mg................................................................................67valsartan-hydrochlorothiazide tab 80-12.5

mg................................................................................67valsartan tab 160 mg...................................................67valsartan tab 320 mg...................................................67valsartan tab 40 mg.....................................................67valsartan tab 80 mg.....................................................67VANCOMYCIN HCL.................................................... 13vancomycin hcl cap 125 mg.......................................13vancomycin hcl cap 250 mg.......................................13vancomycin hcl for iv soln 10 gm.............................. 13vancomycin hcl for iv soln 1 gm.................................13vancomycin hcl for iv soln 500 mg............................ 13vancomycin hcl for iv soln 5 gm.................................13vancomycin hcl for iv soln 750 mg............................ 13VANCOMYCIN HCL IN DEXTROSE.........................13VANCOMYCIN HCL IN DEXTROSE.........................13VANCOMYCIN HCL IN DEXTROSE.........................13VANCOMYCIN HYDROCHLORIDE..........................13VANCOMYCIN HYDROCHLORIDE..........................13VANCOMYCIN HYDROCHLORIDE..........................13VAQTA........................................................................... 91VAQTA........................................................................... 91VARIVAX........................................................................92

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VASCEPA...................................................................... 67VASCEPA...................................................................... 67VECTIBIX...................................................................... 36VECTIBIX...................................................................... 36VELCADE......................................................................36VELPHORO.................................................................. 74VELTASSA.................................................................... 74VELTASSA.................................................................... 74VELTASSA.................................................................... 74VENCLEXTA.................................................................36VENCLEXTA.................................................................36VENCLEXTA.................................................................36VENCLEXTA STARTING PACK................................ 36venlafaxine hcl cap er 24hr 150 mg.......................... 21venlafaxine hcl cap er 24hr 37.5 mg......................... 21venlafaxine hcl cap er 24hr 75 mg............................ 21venlafaxine hcl tab 100 mg........................................ 21venlafaxine hcl tab 25 mg...........................................21venlafaxine hcl tab 37.5 mg....................................... 21venlafaxine hcl tab 50 mg...........................................21venlafaxine hcl tab 75 mg...........................................21venlafaxine hcl tab er 24hr 150 mg........................... 21venlafaxine hcl tab er 24hr 37.5 mg..........................21venlafaxine hcl tab er 24hr 75 mg............................. 21VENTAVIS................................................................... 100VENTAVIS................................................................... 100VENTOLIN HFA......................................................... 100verapamil hcl cap er 24hr 120 mg.............................67verapamil hcl cap er 24hr 180 mg.............................67verapamil hcl cap er 24hr 200 mg.............................67verapamil hcl cap er 24hr 240 mg.............................67verapamil hcl cap er 24hr 300 mg.............................67VERAPAMIL HCL ER..................................................67VERAPAMIL HCL SR..................................................67verapamil hcl tab 120 mg........................................... 67verapamil hcl tab 40 mg............................................. 67verapamil hcl tab 80 mg............................................. 67verapamil hcl tab er 120 mg.......................................67verapamil hcl tab er 180 mg.......................................67verapamil hcl tab er 240 mg.......................................67VERSACLOZ................................................................ 43VERZENIO....................................................................36VERZENIO....................................................................36VERZENIO....................................................................36VERZENIO....................................................................36VICTOZA....................................................................... 53VIDEX............................................................................ 48VIDEX............................................................................ 48VIDEX EC..................................................................... 48VIDEX EC..................................................................... 48VIDEX EC..................................................................... 48VIDEX EC..................................................................... 48

VIEKIRA PAK................................................................48vigabatrin powd pack 500 mg.................................... 17vigabatrin tab 500 mg................................................. 17VIIBRYD.........................................................................22VIIBRYD.........................................................................22VIIBRYD.........................................................................22VIIBRYD STARTER PACK......................................... 22VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VINBLASTINE SULFATE............................................36vincristine sulfate iv soln 1 mg/ml..............................36vinorelbine tartrate inj 10 mg/ml.................................36vinorelbine tartrate inj 50 mg/5ml (10 mg/

ml)................................................................................36VIRACEPT.................................................................... 48VIRACEPT.................................................................... 48VIREAD..........................................................................48VIREAD..........................................................................48VIREAD..........................................................................48VIREAD..........................................................................48VITRAKVI...................................................................... 36VITRAKVI...................................................................... 36VITRAKVI...................................................................... 36VIVITROL........................................................................ 5VIZIMPRO..................................................................... 36VIZIMPRO..................................................................... 36VIZIMPRO..................................................................... 36voriconazole for inj 200 mg........................................ 24voriconazole for susp 40 mg/ml.................................24voriconazole tab 200 mg............................................ 24voriconazole tab 50 mg...............................................24VOSEVI..........................................................................48VOTRIENT.................................................................... 36VPRIV............................................................................ 78VRAYLAR...................................................................... 43VRAYLAR...................................................................... 43VRAYLAR...................................................................... 43VRAYLAR...................................................................... 43VYNDAMAX.................................................................. 67VYNDAQEL...................................................................67VYXEOS........................................................................36Wwarfarin sodium tab 10 mg.........................................56warfarin sodium tab 1 mg...........................................56warfarin sodium tab 2.5 mg........................................56warfarin sodium tab 2 mg...........................................56warfarin sodium tab 3 mg...........................................56warfarin sodium tab 4 mg...........................................56

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warfarin sodium tab 5 mg...........................................56warfarin sodium tab 6 mg...........................................56warfarin sodium tab 7.5 mg........................................56water for irrigation, sterile irrigation

soln..............................................................................74XXALKORI....................................................................... 36XALKORI....................................................................... 36XARELTO...................................................................... 56XARELTO...................................................................... 56XARELTO...................................................................... 56XARELTO...................................................................... 56XARELTO STARTER PACK.......................................56XATMEP........................................................................ 92XELJANZ.......................................................................92XELJANZ.......................................................................92XGEVA...........................................................................93XIFAXAN........................................................................77XOFLUZA......................................................................48XOFLUZA......................................................................48XOLAIR..........................................................................92XOLAIR..........................................................................92XOLAIR..........................................................................92XOPENEX HFA..........................................................100XOSPATA...................................................................... 36XPOVIO 100 MG ONCE WEEKLY............................37XPOVIO 60 MG ONCE WEEKLY..............................37XPOVIO 80 MG ONCE WEEKLY..............................37XPOVIO 80 MG TWICE WEEKLY.............................37XTAMPZA ER................................................................. 4XTAMPZA ER................................................................. 4XTAMPZA ER................................................................. 4XTAMPZA ER................................................................. 4XTAMPZA ER................................................................. 4XTANDI.......................................................................... 37XYREM........................................................................101YYERVOY........................................................................37YERVOY........................................................................37YF-VAX.......................................................................... 92YONDELIS.................................................................... 37YONSA.......................................................................... 37Zzafirlukast tab 10 mg.................................................100zafirlukast tab 20 mg.................................................100zaleplon cap 10 mg...................................................101zaleplon cap 5 mg..................................................... 101ZALTRAP.......................................................................37ZALTRAP.......................................................................37ZANOSAR..................................................................... 37

ZEJULA..........................................................................37ZELBORAF................................................................... 37ZENPEP........................................................................ 78ZENPEP........................................................................ 78ZENPEP........................................................................ 78ZENPEP........................................................................ 78ZENPEP........................................................................ 78ZENPEP........................................................................ 78ZENPEP........................................................................ 78ZEPATIER..................................................................... 48zidovudine cap 100 mg...............................................48zidovudine syrup 10 mg/ml.........................................48zidovudine tab 300 mg................................................48ziprasidone hcl cap 20 mg..........................................43ziprasidone hcl cap 40 mg..........................................43ziprasidone hcl cap 60 mg..........................................43ziprasidone hcl cap 80 mg..........................................43zoledronic acid inj conc for iv infusion 4

mg/5ml........................................................................ 93zoledronic acid iv soln 5 mg/100ml........................... 93ZOLINZA........................................................................37zolpidem tartrate tab 10 mg..................................... 101zolpidem tartrate tab 5 mg....................................... 101zonisamide cap 100 mg..............................................17zonisamide cap 25 mg................................................17zonisamide cap 50 mg................................................17ZONTIVITY....................................................................56ZORTRESS...................................................................92ZORTRESS...................................................................92ZORTRESS...................................................................92ZORTRESS...................................................................92ZOSTAVAX....................................................................92ZOSYN...........................................................................14ZOSYN...........................................................................14ZOSYN...........................................................................14ZOSYN...........................................................................14ZOSYN...........................................................................14ZOSYN...........................................................................14ZYDELIG....................................................................... 37ZYDELIG....................................................................... 37ZYKADIA....................................................................... 37ZYKADIA....................................................................... 37ZYPREXA RELPREVV............................................... 43ZYPREXA RELPREVV............................................... 44ZYPREXA RELPREVV............................................... 44ZYTIGA..........................................................................37

Nondiscrimination and Language Assistance

I

English: If you, or someone you’re helping, has questions about Blue Cross & Blue Shield of Rhode Island, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-800-267-0439.

Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Blue Cross & Blue Shield of Rhode Island, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-800-267-0439.

Portuguese: Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Blue Cross & Blue Shield of Rhode Island, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-800-267-0439.

Chinese: Blue Cross & Blue Shield of Rhode Island .

1-800-267-0439.

French Creole: Si oumenm oswa yon moun w ap ede gen kesyon konsènan Blue Cross & Blue Shield of Rhode Island, se dwa w pou resevwa asistans ak enfòmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avèk yon entèprèt, rele nan 1-800-267-0439.

Cambodian-Mon-Khmer: Blue Cross & Blue Shield of Rhode Island

1-800-267-0439.

French: Si vous, ou quelqu’un que vous êtes en train d’aider, a des questions à propos de Blue Cross & Blue Shield of Rhode Island, vous avez le droit d’obtenir de l’aide et l’information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-800-267-0439.

Italian: Se tu o qualcuno che stai aiutando avete domande su Blue Cross & Blue Shield of Rhode Island, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un interprete, puoi chiamare 1-800-267-0439.

Blue Cross & Blue Shield of Rhode Island (BCBSRI) complies with applicable Federal civil rights laws and does not discriminate or treat people differently on the basis of race, color, national origin, age, disability, or sex. BCBSRI provides free aids and services to people with disabilities and to people whose primary language is not English when such services are necessary to communicate effectively with us.If you need these services, contact us at 1-800-267-0439 TTY: 711.If you believe that BCBSRI 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: Director of Grievance and Appeals Department, Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence RI 02903, or by calling 1-800-267-0439 TTY: 711. You can file a grievance in person, by phone or by mail, fax at (401) 459-5668 or electronically through our member portal at bcbsri.com/Medicare. 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 800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

English:

Spanish:

Portuguese:

Chinese:

French Creole:

Cambodian-Mon-Khmer:

French:

Italian:

09/16 BMED-96729 .1370

Laotian: Blue Cross & Blue

Shield of Rhode Island,

. 1-800-267-0439.

Arabic:

Appendix B: Sample Translated Taglines - Languages Are Listed in Alphabetical Order

Language Translated Taglines 1. Albanian General Tagline:

Nëse ju, ose dikush që po ndihmoni, ka pyetje për [insert SBM program name], keni të drejtë të merrni ndihmë dhe informacion falas në gjuhën tuaj. Për të folur me një përkthyes, telefononi numrin [insert number here].

Tagline for Notices: Ky njoftim përmban informacion të rëndësishëm. Ky njoftim përmban informacion të rëndësishëm për aplikimin ose mbulimin tuaj nëpërmjet [insert SBM program name]. Kontrolloni për data të rëndësishme në këtë njoftim. Mund t'ju duhet të ndërmerrni veprim brenda afatave të caktuara për të mbajtur mbulimin tuaj shëndetësor ose për ndihmën me koston. Keni të drejtë ta merrni këtë informacion dhe ndihmë falas në gjuhën tuaj. Telefononi numrin [insert number here].

2. Amharic General Tagline: እርስዎ፣ ወይም እርስዎ የሚያግዙት ግለሰብ፣ ስለ [insert SBM program name] ጥያቄ ካላችሁ፣ ያለ ምንም ክፍያ በቋንቋዎ እርዳታና መረጃ የማግኘት መብት አላችሁ። ከአስተርጓሚ ጋር ለመነጋገር፣ [insert number here] ይደውሉ።

Tagline for Notices: ይህ ማስታወቂያ አስፈላጊ መረጃ ይዟል። ይህ ማስታወቂያ ስለ ማመልከቻዎ ወይም የ[insert SBM program name] ሽፋን አስፈላጊ መረጃ አለው። በዚሀ ማስታወቂያ ውስጥ ቁልፍ ቀኖችን ፈልጉ። የጤናን ሽፋንዎን ለመጠበቅና በአከፋፈል እርዳታ ለማግኘት በተውሰኑ የጊዜ ገደቦች እርምጃ መውሰድ ይገባዎት ይሆናል። ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት አለዎት። [insert number here] ይደውሉ።

3. Arabic General Tagline: (، فلديك الحق في الحصول على المساعدة والمعلومات insert SBM program nameإن كان لديك أو لدى شخص تساعده أسئلة بخصوص )

(. insert number hereالضرورية بلغتك من دون اية تكلفة. للتحدث مع مترجم اتصل بـ )

Tagline for Notices: insert SBM programيحوي هذا االشعار معلومات مهمة بخصوص طلبك للحصول على التغطية من خالل ) يحوي هذا االشعار معلومات هامة.

name here ابحث عن التواريخ الهامة في هذا االشعار. قد تحتاج التخاذ اجراء في تواريخ معينة للحفاظ على تغطيتك الصحية او للمساعدة في دفع .) (.insert number hereلمعلومات والمساعدة بلغتك من دون أي تكلفة. اتصل بـ )التكاليف. لك الحق في الحصور على ا

4. Armenian General Tagline: Եթե Դուք կամ Ձեր կողմից օգնություն ստացող անձը հարցեր ունի [insert SBM program name] մասին, Դուք իրավունք ունեք անվճար օգնություն և տեղեկություններ ստանալու Ձեր նախընտրած լեզվով։ Թարգմանչի հետ խոսելու համար զանգահարե՛ք [insert number here]։

Blue Cross & Blue Shield of Rhode Island


































.1-800-267-0439












Russian:

Rhode Island Language Assistance Taglines:

English If you, or someone you’re helping, has questions about Blue Cross & Blue Shield of Rhode Island, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1‐800‐267‐0439.

1. Spanish Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Blue Cross & Blue Shield of Rhode Island, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1‐800‐267‐0439.

2. Portuguese Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Blue Cross & Blue Shield of Rhode Island, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1‐800‐267‐0439.

3. Chinese 如果您，或是您正在協助的對象，有關於[插入SBM項目的名稱 Blue Cross & Blue Shield of Rhode Island 方面的問題，您有權利免費以您的母語得到幫助和訊息。洽詢一位翻譯員，請撥電話在

此插入數字1‐800‐267‐0439。 4. French

Creole Si oumenm oswa yon moun w ap ede gen kesyon konsènan Blue Cross & Blue Shield of Rhode Island, se dwa w pou resevwa asistans ak enfòmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avèk yon entèprèt, rele nan 1‐800‐267‐0439.

5. Cambodian‐Mon‐Khmer

របសិនបេរីអនក ឬនរណាមននក់ែដលអនកកំពុងែដជួយ មននសំណួរអ្◌ពីំ Blue Cross & Blue Shield of Rhode Island េប, អនកមននសិេ◌ធិេ◌េ◌◌ួលជំនួយនិងព័ែ◌◌ម៌នន េបៅកនុងភាសា ររស់អនក េបាយមិនអស់ប្◌ាក់ ។ ែបេ◌ើមបីនិយាយជាមួយអនករកដរប សូម 1‐800‐267‐0439 ។

6. French Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Blue Cross & Blue Shield of Rhode Island, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1‐800‐267‐0439.

7. Italian Se tu o qualcuno che stai aiutando avete domande su Blue Cross & Blue Shield of Rhode Island, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un interprete, puoi chiamare 1‐800‐267‐0439.

8. Laotian ຖ້າທ່ານ, ຫ ◌ຼ ◌ື ຄົນທ ◌່ ທ່ານກໍາລັງຊ່ວຍເຫ ◌ຼ ◌ື ອ, ມ ຄໍ າຖາມກ່ຽວກັບ Blue Cross & Blue Shield of Rhode Island, ທ່ານມ ສິ ດທ ◌່ ຈະໄດ້ຮັບການຊ່ວຍເຫ ◌ຼ ◌ື ອແລະຂໍ ້ ມູນຂ່າວສານທ ◌່ ເປັນພາສາຂອງທ່ານບໍ່ ມ ຄ່າໃຊ້ຈ່າຍ. ການໂອ້ລົມກັບນາຍພາສາ, ໃຫ້ໂທຫາ 1‐800‐267‐0439.

9. Arabic ��د�� ، Blue Cross & Blue Shield of Rhode Island ��و� أ�� د� �� د� أو ��د�� ن إنو��م��وم�� م��د� �� و� ��

.0439‐267‐800‐1 ب �� م�� مع ��د� .�� دون من �� و��10. Russian Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Blue Cross & Blue

Shield of Rhode Island, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону 1‐800‐267‐0439.

11. Vietnamese Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Blue Cross & Blue Shield of Rhode Island, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1‐800‐267‐0439.

12. Kru I bale we, tole mut u ye hola, a gwee mbarga inyu [insert SBM program name], U gwee Kunde I kosna mahola ni biniiguene I hop wong nni nsaa wogui wo. I Nyu ipot ni mut a nla koblene we hop, sebel [insert number here].

13. Ibo Ọ bụrụ gị, ma o bụ onye I na eyere‐aka, nwere ajụjụ gbasara Blue Cross & Blue Shield of Rhode Island, I nwere ohere iwenta nye maka na ọmụma na asụsụ gị na akwu gị ụgwọ. I chọrọ I kwụrụ onye‐ntapịa okwu, kpọ 1‐800‐267‐0439.

14. Yoruba Bí ìwọ, tàbí ẹnikẹni tí o n ranlọwọ, bá ní ibeere nípa Blue Cross & Blue Shield of Rhode Island, o ní ẹtọlati rí iranwọ àti ìfitónilétí gbà ní èdè rẹ láìsanwó. Láti bá ongbufọ kan sọrọ, pè sórí 1‐800‐267‐0439

15. Polish Jeśli Ty lub osoba, której pomagasz ,macie pytania odnośnie (insert SBM program), masz prawo do uzyskania bezpłatnej informacji i pomocy we własnym języku .Aby porozmawiać z tłumaczem, zadzwoń pod numer 1‐800‐267‐0439

16. Korean 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이Blue Cross & Blue Shield of Rhode Island 에 관해서

질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는

권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1‐800‐267‐0439 로 전화하십시오. 17. Tagalog Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Blue Cross & Blue Shield of

Rhode Island, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1‐800‐267‐0439.






此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French



















Vietnamese: Blue Cross & Blue Shield of Rhode Island,

1-800-267-0439.

Kru: I bale we, tole mut u ye hola, a gwee mbarga inyu Blue Cross & Blue Shield of Rhode Island, U gwee Kunde I kosna mahola ni biniiguene I hop wong nni nsaa wogui wo. I Nyu ipot ni mut a nla koblene we hop, sebel 1-800-267-0439.

Ibo:






此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French



















Yoruba: Blue Cross & Blue Shield of Rhode Island,

1-800-267-0439.

Polish: Blue Cross & Blue Shield of Rhode Island, .

1-800-267-0439.

Korean:






此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French



















Tagalog: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Blue Cross & Blue Shield of Rhode Island, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1-800-267-0439.

This notice is being provided to you in compliance with federal law.

Laotian:

Arabic:

Russian:

Vietnamese:

Kru:

Ibo:

Yoruba:

Polish:

Korean:

Tagalog:

This notice is being provided to you in compliance with federal law.

This formulary was updated on . For more recent information or other questions, please call our Medicare Concierge Team at (401) 277-2958 or 1-800-267-0439 (TTY users should call 711) from October 1 - March 31, seven days a week, 8:00 a.m. to 8:00 p.m. April 1 - September 30, Monday through Friday, 8:00 a.m. to 8:00 p.m.; Saturday & Sunday, 8:00 a.m. to noon. You can use our automated answering system outside of these hours.

Blue Cross & Blue Shield of Rhode Island is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross & Blue Shield of Rhode Island depends on contract renewal. An independent licensee of the Blue Cross and Blue Shield Association.

500 Exchange Street • Providence, RI 02903-2699 • bcbsri.com/medicare

BMED-332875•1305

November 2019

11/19

2020 formulary - blue cross blue shield of ri · i you must generally use network pharmacies to use...

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