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052165_2021 Last Updated 08-03-2021
Metallic M2 - List of Covered Drugs (Formulary)
Effective Date 08-01-2021
The Metallic M2 Formulary is used by these plans Essential Bronze HSA
What is the list of covered drugs (Formulary) This document contains a list of generic brand and specialty drugs covered under your plan
How is the list of covered drugs developed The drug list is developed with an independent committee of physicians pharmacists and other healthcare providers called the Pharmacy and Therapeutics Committee This independent committee reviews and selects drugs for coverage based on each drugs safety effectiveness and cost The committee meets at least quarterly to review new drugs to market to determine placement on this list and also reviews updated safety effectiveness and cost information for existing drugs to ensure the formulary remains up to date with current medical evidence
How do I use the Formulary Drugs are listed by categories depending on the type of medical conditions that they are used to treat If you know what your drug is used for look for the category name in the list that begins below Then look under the category name for your drug
If you are not sure what category to look under you can also search for the drug in the Index The Index provides an alphabetical list of all of the drugs included in this document Next to the name of the drug in the Index 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
How does this drug list help me understand my drug coverage Drug coverage is based on your coverage contract Coverage for a specific drug is subject to the rules outlined in your member booklet This document will tell you if a drug is included on the formulary attached to your plan
Will this drug list (Formulary) change This drug list (Formulary) is updated throughout the year If you are taking a drug and it will be removed from the formulary or moved to a higher cost sharing tier we will notify you of this change via letter We
also post information on upcoming formulary changes on our website on the ldquoUpcoming Formulary Changesrdquo page
Are there any restrictions on my coverage Some covered drugs may have additional requirements or limits on coverage These can be seen in the column next to the drug name on the list These requirements and limits may include
bull Prior Authorization some drugs require prior approval before they are coveredbull Quantity Limits for some drugs we limit the amount of the drug that we will cover For example
we will cover 18 per 30 day supply of zolmitriptan oral tabletsbull Step Therapy for some drugs we require that you 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 Bboth treat your medical condition we may not cover Drug B unless you try Drug A first If Drug Adoes not work for you then we will then cover Drug B
Drugs subject to these restrictions will generally mean that your physician or healthcare provider may need to provide additional information on your medical condition before the drug will be covered at the pharmacy Information on this process is on our website on the ldquoDrugs Requiring Approvalrdquo page
Metallic Formulary The first column of the chart lists the drug name Brand name drugs are capitalized (eg JANUVIA) and generic drugs are listed in lower-case italics (eg metformin oral tablet) The information in the RequirementsLimits column tells you if we have any special requirements for coverage of your drug
COVERAGE NOTES ABBREVIATIONS
ABBREVIATION DESCRIPTION EXPLANATION
Utilization Management Restrictions
PA Prior Authorization Restriction You (or your physician) are required to get prior authorization from us before you fill your prescription for this drug Without prior approval we may not cover this drug
QL Quantity Limit Restriction We limit the amount of this drug that is covered per prescription or within a specific time frame
ST Step Therapy Restriction Before we will provide coverage for this drug you must first try another drug to treat your medical condition This drug may only be covered if the other drug does not work for you
Other Special Requirements for Coverage
LA Limited Access Drug Some drugs under your plan may only be filled at an in-network specialty pharmacy These are drugs where the FDA has restricted distribution or are drugs that require special handling provider coordination or patient education that cannot be met by a network retail pharmacy
Vac Vaccines For more information on the coverage of vaccines administered at a Pharmacy please see your member booklet or contact Customer Service
OCh Oral Chemo Oral Chemotherapy Drug Certain oral chemotherapy drugs may be covered under your medical plan Please check your member booklet for more details
The amount you pay for a covered drug will depend on if you have met any applicable deductible for the plan year if you have met any applicable maximum out of pocket for the plan year and what tier the medication is on More information on applicable deductibles and maximum out of pockets can be found in your member booklet
Metallic M2 Formulary
Drug Tier Includes
Formulary Drugs (1) Formulary Drugs include Preferred Generic Preferred Brand and Non-Preferred Drugs Medical plan cost shares apply to formulary drugs Once you have satisfied your medical deductible you will pay your applicable coinsurance until you reach your out of pocket maximum limit
Specialty Drug (2) Tier 2 includes specialty drugs Specialty drugs are generally biologics and other targeted drugs usually used for complex medical conditions and often requiring special handling
ACA PV The ACA PV tier includes Affordable Care Act (ACA) Preventive medications The ACA makes certain preventive medications available to you at no cost Coverage of any medication as ACA PV (including over-the-counter (OTC) medications) requires a prescription from a licensed health care provider
MB (Medical Benefit) The MB tier includes medical benefit drugs normally administered in a clinic infusion center or provided by a home infusion service These drugs and their services are covered under the medical benefit not under the pharmacy benefit This drug may require prior authorization
1
Drug Name Drug Tier Requirements Limits
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG
MB
amphotericin b injection recon soln 50 mg MB
CANCIDAS INTRAVENOUS RECON SOLN 50 MG 70 MG
MB
clotrimazole mucous membrane troche 10 mg 1
CRESEMBA INTRAVENOUS RECON SOLN 372 MG
MB
CRESEMBA ORAL CAPSULE 186 MG 1 PA
ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG 50 MG
MB
fluconazole oral suspension for reconstitution 10 mgml 40 mgml
1
fluconazole oral tablet 100 mg 150 mg 200 mg 50 mg
1
flucytosine oral capsule 250 mg 500 mg 1
griseofulvin microsize oral suspension 125 mg5 ml
1
griseofulvin microsize oral tablet 500 mg 1
griseofulvin ultramicrosize oral tablet 125 mg 250 mg
1
itraconazole oral capsule 100 mg 1
itraconazole oral solution 10 mgml 1
ketoconazole oral tablet 200 mg 1
MYCAMINE INTRAVENOUS RECON SOLN 100 MG 50 MG
MB
NOXAFIL ORAL SUSPENSION 200 MG5 ML (40 MGML)
1
nystatin oral suspension 100000 unitml 1
nystatin oral tablet 500000 unit 1
ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET 50 MG
1
posaconazole oral tabletdelayed release (drec) 100 mg
1
terbinafine hcl oral tablet 250 mg 1
voriconazole intravenous recon soln 200 mg MB
2
Drug Name Drug Tier Requirements Limits
voriconazole oral suspension for reconstitution 200 mg5 ml (40 mgml)
1
voriconazole oral tablet 200 mg 50 mg 1
ANTIVIRALS
abacavir oral solution 20 mgml 1 QL (60 per 30 days)
abacavir oral tablet 300 mg 1 QL (60 per 30 days)
abacavir-lamivudine oral tablet 600-300 mg 1 QL (30 per 30 days)
abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg
1 QL (60 per 30 days)
acyclovir oral capsule 200 mg 1
acyclovir oral suspension 200 mg5 ml 1
acyclovir oral tablet 400 mg 800 mg 1
adefovir oral tablet 10 mg 1
amantadine hcl oral capsule 100 mg 1
amantadine hcl oral solution 50 mg5 ml 1
amantadine hcl oral tablet 100 mg 1
APTIVUS ORAL CAPSULE 250 MG 1 QL (120 per 30 days)
atazanavir oral capsule 150 mg 300 mg 1 QL (30 per 30 days)
atazanavir oral capsule 200 mg 1 QL (60 per 30 days)
BARACLUDE ORAL SOLUTION 005 MGML 1
BIKTARVY ORAL TABLET 50-200-25 MG 1 QL (30 per 30 days)
CABENUVA INTRAMUSCULAR SUSPENSIONEXTENDED RELEASE 400 MG2 ML- 600 MG2 ML 600 MG3 ML- 900 MG3 ML
2 PA
cidofovir intravenous solution 75 mgml MB
CIMDUO ORAL TABLET 300-300 MG 1 QL (30 per 30 days)
COMPLERA ORAL TABLET 200-25-300 MG 1 QL (30 per 30 days)
CYTOVENE INTRAVENOUS RECON SOLN 500 MG
MB
DESCOVY ORAL TABLET 200-25 MG 1 QL (30 per 30 days)
didanosine oral capsuledelayed release(drec) 250 mg 400 mg
1 QL (30 per 30 days)
DOVATO ORAL TABLET 50-300 MG 1 QL (30 per 30 days)
EDURANT ORAL TABLET 25 MG 1 QL (30 per 30 days)
efavirenz oral capsule 200 mg 50 mg 1 QL (30 per 30 days)
efavirenz oral tablet 600 mg 1 QL (30 per 30 days)
3
Drug Name Drug Tier Requirements Limits
efavirenz-emtricitabin-tenofov oral tablet 600-200-300 mg
1
efavirenz-lamivu-tenofov disop oral tablet 400-300-300 mg 600-300-300 mg
1
emtricitabine oral capsule 200 mg 1 QL (30 per 30 days)
emtricitabine-tenofovir (tdf) oral tablet 100-150 mg 133-200 mg 167-250 mg 200-300 mg
1
EMTRIVA ORAL SOLUTION 10 MGML 1 QL (720 per 30 days)
entecavir oral tablet 05 mg 1 mg 1
EPCLUSA ORAL TABLET 200-50 MG 400-100 MG
2 PA LA
EPIVIR HBV ORAL SOLUTION 25 MG5 ML (5 MGML)
1
etravirine oral tablet 100 mg 200 mg 1 QL (60 per 30 days)
EVOTAZ ORAL TABLET 300-150 MG 1 QL (30 per 30 days)
famciclovir oral tablet 125 mg 250 mg 500 mg 1
fosamprenavir oral tablet 700 mg 1 QL (60 per 30 days)
FUZEON SUBCUTANEOUS RECON SOLN 90 MG
2 QL (30 per 30 days)
GANCICLOVIR INTRAVENOUS SOLUTION 500 MG250 ML (2 MGML)
MB
ganciclovir sodium intravenous recon soln 500 mg MB
GENVOYA ORAL TABLET 150-150-200-10 MG
1 QL (30 per 30 days)
HARVONI ORAL PELLETS IN PACKET 3375-150 MG 45-200 MG
2 LA
HARVONI ORAL TABLET 45-200 MG 90-400 MG
2 PA LA
INTELENCE ORAL TABLET 100 MG 200 MG 25 MG
1 QL (60 per 30 days)
INVIRASE ORAL TABLET 500 MG 1 QL (120 per 30 days)
ISENTRESS HD ORAL TABLET 600 MG 1 QL (60 per 30 days)
ISENTRESS ORAL POWDER IN PACKET 100 MG
1 QL (60 per 30 days)
ISENTRESS ORAL TABLET 400 MG 1 QL (60 per 30 days)
ISENTRESS ORAL TABLETCHEWABLE 100 MG 25 MG
1 QL (60 per 30 days)
JULUCA ORAL TABLET 50-25 MG 1 QL (30 per 30 days)
KALETRA ORAL TABLET 100-25 MG 1 QL (60 per 30 days)
4
Drug Name Drug Tier Requirements Limits
KALETRA ORAL TABLET 200-50 MG 1 QL (120 per 30 days)
lamivudine oral solution 10 mgml 1 QL (900 per 30 days)
lamivudine oral tablet 100 mg 1
lamivudine oral tablet 150 mg 300 mg 1 QL (60 per 30 days)
lamivudine-zidovudine oral tablet 150-300 mg 1 QL (60 per 30 days)
LEXIVA ORAL SUSPENSION 50 MGML 1 QL (60 per 30 days)
lopinavir-ritonavir oral solution 400-100 mg5 ml 1 QL (320 per 30 days)
lopinavir-ritonavir oral tablet 100-25 mg 200-50 mg
1 QL (120 per 30 days)
MAVYRET ORAL TABLET 100-40 MG 2 PA LA
nevirapine oral suspension 50 mg5 ml 1 QL (60 per 30 days)
nevirapine oral tablet 200 mg 1 QL (60 per 30 days)
nevirapine oral tablet extended release 24 hr 100 mg 400 mg
1 QL (30 per 30 days)
NORVIR ORAL POWDER IN PACKET 100 MG 1 QL (360 per 30 days)
NORVIR ORAL SOLUTION 80 MGML 1 QL (480 per 30 days)
ODEFSEY ORAL TABLET 200-25-25 MG 1 QL (30 per 30 days)
oseltamivir oral capsule 30 mg 1 QL (40 per 365 days)
oseltamivir oral capsule 45 mg 75 mg 1 QL (20 per 365 days)
oseltamivir oral suspension for reconstitution 6 mgml
1 QL (180 per 30 days)
PREVYMIS INTRAVENOUS SOLUTION 240 MG12 ML 480 MG24 ML
MB PA
PREZCOBIX ORAL TABLET 800-150 MG-MG 1 QL (30 per 30 days)
PREZISTA ORAL SUSPENSION 100 MGML 1 QL (30 per 30 days)
PREZISTA ORAL TABLET 150 MG 600 MG 75 MG
1 QL (60 per 30 days)
PREZISTA ORAL TABLET 800 MG 1 QL (30 per 30 days)
RAPIVAB (PF) INTRAVENOUS SOLUTION 200 MG20 ML (10 MGML)
MB
RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MGACTUATION
1 QL (2 per 30 days)
REYATAZ ORAL POWDER IN PACKET 50 MG
1 QL (150 per 30 days)
ribavirin inhalation recon soln 6 gram MB
rimantadine oral tablet 100 mg 1
ritonavir oral tablet 100 mg 1 QL (360 per 30 days)
5
Drug Name Drug Tier Requirements Limits
SELZENTRY ORAL SOLUTION 20 MGML 1 QL (8 per 30 days)
SELZENTRY ORAL TABLET 150 MG 25 MG 300 MG 75 MG
1 QL (60 per 30 days)
SOVALDI ORAL PELLETS IN PACKET 150 MG 200 MG
2 LA
SOVALDI ORAL TABLET 200 MG 400 MG 2 PA LA
stavudine oral capsule 15 mg 20 mg 40 mg 1 QL (120 per 30 days)
STRIBILD ORAL TABLET 150-150-200-300 MG
1 QL (30 per 30 days)
SYNAGIS INTRAMUSCULAR SOLUTION 100 MGML 50 MG05 ML
MB LA
tenofovir disoproxil fumarate oral tablet 300 mg 1 QL (30 per 30 days)
TIVICAY ORAL TABLET 10 MG 25 MG 50 MG
1 QL (60 per 30 days)
TIVICAY PD ORAL TABLET FOR SUSPENSION 5 MG
1 QL (60 per 30 days)
TRIUMEQ ORAL TABLET 600-50-300 MG 1 QL (30 per 30 days)
TROGARZO INTRAVENOUS SOLUTION 200 MG133 ML (150 MGML)
MB PA
TYBOST ORAL TABLET 150 MG 1 QL (30 per 30 days)
valacyclovir oral tablet 1 gram 500 mg 1
valganciclovir oral recon soln 50 mgml 1
valganciclovir oral tablet 450 mg 1
VEMLIDY ORAL TABLET 25 MG 1
VIEKIRA PAK ORAL TABLETSDOSE PACK 125 MG-75 MG -50 MG250 MG
2 PA
VIRACEPT ORAL TABLET 250 MG 1 QL (90 per 30 days)
VIRACEPT ORAL TABLET 625 MG 1 QL (60 per 30 days)
VIREAD ORAL POWDER 40 MGSCOOP (40 MGGRAM)
1 QL (4 per 30 days)
VIREAD ORAL TABLET 150 MG 200 MG 250 MG
1 QL (30 per 30 days)
VOSEVI ORAL TABLET 400-100-100 MG 2 PA LA
ZEPATIER ORAL TABLET 50-100 MG 2 PA LA
zidovudine oral capsule 100 mg 1 QL (60 per 30 days)
zidovudine oral syrup 10 mgml 1 QL (960 per 30 days)
zidovudine oral tablet 300 mg 1 QL (60 per 30 days)
CEPHALOSPORINS
6
Drug Name Drug Tier Requirements Limits
AVYCAZ INTRAVENOUS RECON SOLN 25 GRAM
MB
cefaclor oral capsule 250 mg 500 mg 1
cefaclor oral suspension for reconstitution 125 mg5 ml 250 mg5 ml 375 mg5 ml
1
cefaclor oral tablet extended release 12 hr 500 mg 1
cefadroxil oral capsule 500 mg 1
cefadroxil oral suspension for reconstitution 250 mg5 ml 500 mg5 ml
1
cefadroxil oral tablet 1 gram 1
cefazolin in dextrose (iso-os) intravenous piggyback 1 gram50 ml
MB
cefazolin injection recon soln 1 gram 10 gram 100 gram 20 gram 300 g 500 mg
MB
cefazolin intravenous recon soln 1 gram MB
cefdinir oral capsule 300 mg 1
cefdinir oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cefditoren pivoxil oral tablet 200 mg 400 mg 1
CEFEPIME IN DEXTROSE 5 INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
cefepime in dextroseiso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml
MB
cefepime injection recon soln 1 gram 2 gram MB
cefixime oral capsule 400 mg 1
cefixime oral suspension for reconstitution 100 mg5 ml 200 mg5 ml
1
CEFOTAN INJECTION RECON SOLN 1 GRAM 2 GRAM
MB
cefotaxime injection recon soln 1 gram MB
CEFOTETAN IN DEXTROSE ISO-OSM INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
cefotetan injection recon soln 1 gram 2 gram MB
cefotetan intravenous recon soln 10 gram MB
cefoxitin intravenous recon soln 10 gram MB
cefpodoxime oral suspension for reconstitution 100 mg5 ml 50 mg5 ml
1
7
Drug Name Drug Tier Requirements Limits
cefpodoxime oral tablet 100 mg 200 mg 1
cefprozil oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cefprozil oral tablet 250 mg 500 mg 1
CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
ceftazidime injection recon soln 1 gram 2 gram 6 gram
MB
ceftriaxone in dextroseiso-os intravenous piggyback 1 gram50 ml 2 gram50 ml
MB
ceftriaxone injection recon soln 1 gram 10 gram 2 gram 250 mg 500 mg
MB
CEFTRIAXONE INJECTION RECON SOLN 100 GRAM
MB
ceftriaxone intravenous recon soln 1 gram 2 gram MB
cefuroxime axetil oral tablet 250 mg 500 mg 1
cephalexin oral capsule 250 mg 500 mg 750 mg 1
cephalexin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cephalexin oral tablet 250 mg 500 mg 1
SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG5 ML
1
SUPRAX ORAL TABLETCHEWABLE 100 MG 200 MG
1
tazicef injection recon soln 1 gram 2 gram 6 gram
MB
tazicef intravenous recon soln 1 gram 2 gram MB
TEFLARO INTRAVENOUS RECON SOLN 400 MG 600 MG
MB
ZERBAXA INTRAVENOUS RECON SOLN 15 GRAM
MB
ERYTHROMYCINS amp OTHER MACROLIDES
azithromycin oral packet 1 gram 1
azithromycin oral suspension for reconstitution 100 mg5 ml 200 mg5 ml
1
azithromycin oral tablet 250 mg 500 mg 600 mg 1
clarithromycin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
clarithromycin oral tablet 250 mg 500 mg 1
8
Drug Name Drug Tier Requirements Limits
clarithromycin oral tablet extended release 24 hr 500 mg
1
DIFICID ORAL TABLET 200 MG 1
ees 400 oral tablet 400 mg 1
ery-tab oral tabletdelayed release (drec) 250 mg 333 mg
1
erythrocin (as stearate) oral tablet 250 mg 1
erythromycin ethylsuccinate oral suspension for reconstitution 200 mg5 ml 400 mg5 ml
1
erythromycin ethylsuccinate oral tablet 400 mg 1
erythromycin oral capsuledelayed release(drec) 250 mg
1
erythromycin oral tablet 250 mg 500 mg 1
erythromycin oral tabletdelayed release (drec) 250 mg 333 mg 500 mg
1
MISCELLANEOUS ANTIINFECTIVES
albendazole oral tablet 200 mg 1
ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG5 ML
1 PA ST
amikacin injection solution 500 mg2 ml MB
atovaquone oral suspension 750 mg5 ml 1
atovaquone-proguanil oral tablet 250-100 mg 625-25 mg
1
bacitracin intramuscular recon soln 50000 unit 1
CAPASTAT INJECTION RECON SOLN 1 GRAM
1
CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MGML
2 PA LA QL (84 per 30 days)
chloramphenicol sod succinate intravenous recon soln 1 gram
MB
chloroquine phosphate oral tablet 250 mg 500 mg 1
clindamycin hcl oral capsule 150 mg 300 mg 75 mg
1
clindamycin pediatric oral recon soln 75 mg5 ml 1
clindamycin phosphate injection solution 150 mgml
MB
COARTEM ORAL TABLET 20-120 MG 1
CUBICIN INTRAVENOUS RECON SOLN 500 MG
MB
9
Drug Name Drug Tier Requirements Limits
CUBICIN RF INTRAVENOUS RECON SOLN 500 MG
MB
CYCLOSERINE ORAL CAPSULE 250 MG 1
dapsone oral tablet 100 mg 25 mg 1
EMVERM ORAL TABLETCHEWABLE 100 MG
1
ethambutol oral tablet 100 mg 400 mg 1
gentamicin injection solution 20 mg2 ml 40 mgml
MB
gentamicin sulfate (ped) (pf) injection solution 20 mg2 ml
MB
hydroxychloroquine oral tablet 200 mg 1
imipenem-cilastatin intravenous recon soln 250 mg 500 mg
MB
INVANZ INJECTION RECON SOLN 1 GRAM MB
isoniazid injection solution 100 mgml 1
isoniazid oral solution 50 mg5 ml 1
isoniazid oral tablet 100 mg 300 mg 1
ivermectin oral tablet 3 mg 1
LINCOCIN INJECTION SOLUTION 300 MGML
MB
linezolid in dextrose 5 intravenous piggyback 600 mg300 ml
MB
linezolid oral suspension for reconstitution 100 mg5 ml
1
linezolid oral tablet 600 mg 1
linezolid-09 sodium chloride intravenous parenteral solution 600 mg300 ml
MB
mefloquine oral tablet 250 mg 1
meropenem intravenous recon soln 1 gram 500 mg
MB
MEROPENEM-09 SODIUM CHLORIDE INTRAVENOUS PIGGYBACK 1 GRAM50 ML 500 MG50 ML
MB
metronidazole oral capsule 375 mg 1
metronidazole oral tablet 250 mg 500 mg 1
neomycin oral tablet 500 mg 1
nitazoxanide oral tablet 500 mg 1
10
Drug Name Drug Tier Requirements Limits
paromomycin oral capsule 250 mg 1
PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM
1
PENTAM INJECTION RECON SOLN 300 MG MB
pentamidine inhalation recon soln 300 mg 1
pentamidine injection recon soln 300 mg MB
polymyxin b sulfate injection recon soln 500000 unit
MB
praziquantel oral tablet 600 mg 1
PRIFTIN ORAL TABLET 150 MG 1
primaquine oral tablet 263 mg 1
pyrazinamide oral tablet 500 mg 1
pyrimethamine oral tablet 25 mg 2 PA
quinine sulfate oral capsule 324 mg 1
rifabutin oral capsule 150 mg 1
rifampin oral capsule 150 mg 300 mg 1
SIRTURO ORAL TABLET 100 MG 1 PA
SIRTURO ORAL TABLET 20 MG 1
SIVEXTRO ORAL TABLET 200 MG 1 QL (6 per 30 days)
STREPTOMYCIN INTRAMUSCULAR RECON SOLN 1 GRAM
1
tinidazole oral tablet 250 mg 500 mg 1
tobramycin in 0225 nacl inhalation solution for nebulization 300 mg5 ml
2
tobramycin inhalation solution for nebulization 300 mg4 ml
2
tobramycin sulfate injection recon soln 12 gram 1
tobramycin sulfate injection solution 10 mgml MB
tobramycin sulfate injection solution 40 mgml 1
TOBRAMYCIN WITH NEBULIZER INHALATION SOLUTION FOR NEBULIZATION 300 MG5 ML
2 PA ST
TRECATOR ORAL TABLET 250 MG 1
TYGACIL INTRAVENOUS RECON SOLN 50 MG
MB
XENLETA INTRAVENOUS SOLUTION 150 MG15 ML
MB
XIFAXAN ORAL TABLET 200 MG 550 MG 1 PA QL (60 per 30 days)
11
Drug Name Drug Tier Requirements Limits
PENICILLINS
amoxicillin oral capsule 250 mg 500 mg 1
amoxicillin oral suspension for reconstitution 125 mg5 ml 200 mg5 ml 250 mg5 ml 400 mg5 ml
1
amoxicillin oral tablet 500 mg 875 mg 1
amoxicillin oral tabletchewable 125 mg 250 mg 1
amoxicillin-pot clavulanate oral suspension for reconstitution 200-285 mg5 ml 250-625 mg5 ml 400-57 mg5 ml 600-429 mg5 ml
1
amoxicillin-pot clavulanate oral tablet 250-125 mg 500-125 mg 875-125 mg
1
amoxicillin-pot clavulanate oral tablet extended release 12 hr 1000-625 mg
1
amoxicillin-pot clavulanate oral tabletchewable 200-285 mg 400-57 mg
1
ampicillin oral capsule 500 mg 1
ampicillin-sulbactam injection recon soln 15 gram MB
BICILLIN C-R INTRAMUSCULAR SYRINGE 1200000 UNIT 2 ML(900K300K)
MB
dicloxacillin oral capsule 250 mg 500 mg 1
MOXATAG ORAL TABLET ER MULTIPHASE 24 HR 775 MG
1
nafcillin in dextrose iso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml
MB
nafcillin injection recon soln 1 gram 10 gram 2 gram
MB
nafcillin intravenous recon soln 1 gram 2 gram MB
oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram50 ml 2 gram50 ml
MB
oxacillin injection recon soln 1 gram 10 gram 2 gram
MB
penicillin g procaine intramuscular syringe 12 million unit2 ml 600000 unitml
MB
penicillin v potassium oral recon soln 125 mg5 ml 250 mg5 ml
1
penicillin v potassium oral tablet 250 mg 500 mg 1
piperacillin-tazobactam intravenous recon soln 135 gram 225 gram 3375 gram 45 gram 405 gram
MB
12
Drug Name Drug Tier Requirements Limits
QUINOLONES
BAXDELA INTRAVENOUS RECON SOLN 300 MG
MB
BAXDELA ORAL TABLET 450 MG 1
ciprofloxacin hcl oral tablet 100 mg 250 mg 500 mg 750 mg
1
ciprofloxacin oral suspensionmicrocapsule recon 250 mg5 ml 500 mg5 ml
1
FACTIVE ORAL TABLET 320 MG 1 ST
levofloxacin oral solution 250 mg10 ml 1
levofloxacin oral tablet 250 mg 500 mg 750 mg 1
moxifloxacin oral tablet 400 mg 1
ofloxacin oral tablet 300 mg 400 mg 1
SULFAS amp RELATED AGENTS
sulfadiazine oral tablet 500 mg 1
sulfamethoxazole-trimethoprim oral suspension 200-40 mg5 ml
1
sulfamethoxazole-trimethoprim oral tablet 400-80 mg 800-160 mg
1
sulfatrim oral suspension 200-40 mg5 ml 1
TETRACYCLINES
avidoxy oral tablet 100 mg 1 ST
demeclocycline oral tablet 150 mg 300 mg 1
doxycycline hyclate oral capsule 100 mg 50 mg 1
doxycycline hyclate oral tablet 100 mg 150 mg 20 mg 50 mg 75 mg
1
doxycycline hyclate oral tabletdelayed release (drec) 100 mg 150 mg 200 mg 50 mg 75 mg
1
doxycycline monohydrate oral capsule 100 mg 150 mg 50 mg 75 mg
1
doxycycline monohydrate oral suspension for reconstitution 25 mg5 ml
1
doxycycline monohydrate oral tablet 100 mg 150 mg 50 mg 75 mg
1
minocycline oral capsule 100 mg 50 mg 75 mg 1
minocycline oral tablet 100 mg 50 mg 75 mg 1
mondoxyne nl oral capsule 100 mg 75 mg 1
tetracycline oral capsule 250 mg 500 mg 1
13
Drug Name Drug Tier Requirements Limits
URINARY TRACT AGENTS
fosfomycin tromethamine oral packet 3 gram 1
methenamine hippurate oral tablet 1 gram 1
methenamine mandelate oral tablet 05 g 1 gram 1
nitrofurantoin macrocrystal oral capsule 100 mg 25 mg 50 mg
1
nitrofurantoin monohydm-cryst oral capsule 100 mg
1
nitrofurantoin oral suspension 25 mg5 ml 1
PRIMSOL ORAL SOLUTION 50 MG5 ML 1
trimethoprim oral tablet 100 mg 1
VANCOMYCIN
vancomycin oral capsule 125 mg 250 mg 1
vancomycin oral recon soln 50 mgml 1
VIBATIV INTRAVENOUS RECON SOLN 750 MG
MB
ANTINEOPLASTIC amp IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
KEPIVANCE INTRAVENOUS RECON SOLN 625 MG
MB
leucovorin calcium injection recon soln 100 mg 200 mg 350 mg 50 mg 500 mg
MB
leucovorin calcium injection solution 10 mgml MB
leucovorin calcium oral tablet 10 mg 15 mg 25 mg 5 mg
1
VISTOGARD ORAL GRANULES IN PACKET 10 GRAM
2
VORAXAZE INTRAVENOUS RECON SOLN 1000 UNIT
MB
XGEVA SUBCUTANEOUS SOLUTION 120 MG17 ML (70 MGML)
2 LA
ANTINEOPLASTIC amp IMMUNOSUPPRESSANT DRUGS
abiraterone oral tablet 250 mg 2 PA OCh LA
abiraterone oral tablet 500 mg 2 PA ST OCh LA
ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG
MB PA LA
ADAKVEO INTRAVENOUS SOLUTION 10 MGML
MB PA
14
Drug Name Drug Tier Requirements Limits
ADCETRIS INTRAVENOUS RECON SOLN 50 MG
MB PA LA
AFINITOR ORAL TABLET 10 MG 2 OCh LA
ALECENSA ORAL CAPSULE 150 MG 2 PA OCh LA
ALIMTA INTRAVENOUS RECON SOLN 100 MG 500 MG
MB PA
ALIQOPA INTRAVENOUS RECON SOLN 60 MG
MB PA
anastrozole oral tablet 1 mg ACA PV OCh QL (30 per 30 days)
ARRANON INTRAVENOUS SOLUTION 250 MG50 ML
MB LA
ARZERRA INTRAVENOUS SOLUTION 1000 MG50 ML 100 MG5 ML
MB PA LA
ASPARLAS INTRAVENOUS SOLUTION 750 UNITML
MB PA
AVASTIN INTRAVENOUS SOLUTION 25 MGML
MB PA LA
azathioprine oral tablet 50 mg 1
BALVERSA ORAL TABLET 3 MG 4 MG 5 MG
2 PA OCh
BAVENCIO INTRAVENOUS SOLUTION 20 MGML
MB PA
BELEODAQ INTRAVENOUS RECON SOLN 500 MG
MB PA
BELRAPZO INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BENDAMUSTINE INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BENDEKA INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BESPONSA INTRAVENOUS RECON SOLN 09 MG (025 MGML INITIAL)
MB PA LA
bexarotene oral capsule 75 mg 2 PA ST OCh
bicalutamide oral tablet 50 mg 2 OCh QL (30 per 30 days)
BLINCYTO INTRAVENOUS KIT 35 MCG MB PA
BORTEZOMIB INTRAVENOUS RECON SOLN 35 MG
MB
BOSULIF ORAL TABLET 100 MG 400 MG 500 MG
2 PA ST OCh LA
BRAFTOVI ORAL CAPSULE 50 MG 75 MG 2 PA OCh LA
15
Drug Name Drug Tier Requirements Limits
BUSULFEX INTRAVENOUS SOLUTION 60 MG10 ML
MB
CABOMETYX ORAL TABLET 20 MG 40 MG 60 MG
2 PA ST OCh LA
CALQUENCE ORAL CAPSULE 100 MG 2 PA ST OCh
capecitabine oral tablet 150 mg 2 OCh LA QL (210 per 30 days)
capecitabine oral tablet 500 mg 2 OCh LA QL (84 per 30 days)
CAPRELSA ORAL TABLET 100 MG 300 MG 2 PA OCh
CLOLAR INTRAVENOUS SOLUTION 20 MG20 ML
MB PA
COMETRIQ ORAL CAPSULE 100 MGDAY(80 MG X1-20 MG X1) 140 MGDAY(80 MG X1-20 MG X3) 60 MGDAY (20 MG X 3DAY)
2 PA OCh
COPIKTRA ORAL CAPSULE 15 MG 25 MG 2 PA OCh
COTELLIC ORAL TABLET 20 MG 2 PA OCh LA
cyclophosphamide intravenous recon soln 1 gram 2 gram 500 mg
MB
cyclophosphamide oral capsule 25 mg 50 mg 2 OCh
CYCLOPHOSPHAMIDE ORAL TABLET 25 MG 50 MG
2 OCh
cyclosporine modified oral capsule 100 mg 25 mg 50 mg
1
cyclosporine modified oral solution 100 mgml 1
cyclosporine oral capsule 100 mg 25 mg 1
CYRAMZA INTRAVENOUS SOLUTION 10 MGML
MB PA LA
DACOGEN INTRAVENOUS RECON SOLN 50 MG
MB PA LA
DARZALEX INTRAVENOUS SOLUTION 20 MGML
MB PA LA
DAURISMO ORAL TABLET 100 MG 25 MG 2 PA OCh LA
decitabine intravenous recon soln 50 mg MB LA
ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 225 MG
2
ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG
2
ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG
2
16
Drug Name Drug Tier Requirements Limits
ELIGARD SUBCUTANEOUS SYRINGE 75 MG (1 MONTH)
2
ELZONRIS INTRAVENOUS SOLUTION 1000 MCGML
MB PA
EMCYT ORAL CAPSULE 140 MG 2 OCh
EMPLICITI INTRAVENOUS RECON SOLN 300 MG 400 MG
MB PA LA
ENHERTU INTRAVENOUS RECON SOLN 100 MG
MB PA LA
ERBITUX INTRAVENOUS SOLUTION 100 MG50 ML 200 MG100 ML
MB PA LA
ERLEADA ORAL TABLET 60 MG 2 PA OCh LA
erlotinib oral tablet 100 mg 150 mg 25 mg 2 PA OCh LA
ERWINAZE INJECTION RECON SOLN 10000 UNIT
MB
etoposide intravenous solution 20 mgml MB
etoposide oral capsule 50 mg 2 OCh
everolimus (antineoplastic) oral tablet 25 mg 5 mg 75 mg
2 PA ST OCh LA
everolimus (immunosuppressive) oral tablet 025 mg 05 mg 075 mg
1 PA
exemestane oral tablet 25 mg ACA PV OCh QL (30 per 30 days)
FASLODEX INTRAMUSCULAR SYRINGE 250 MG5 ML
MB PA
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG 80 MG
2 LA
fludarabine intravenous recon soln 50 mg MB
fluorouracil intravenous solution 25 gram50 ml 5 gram100 ml 500 mg10 ml
MB PA
flutamide oral capsule 125 mg 2 OCh QL (180 per 30 days)
FOLOTYN INTRAVENOUS SOLUTION 20 MGML (1 ML) 40 MG2 ML (20 MGML)
MB PA LA
fulvestrant intramuscular syringe 250 mg5 ml MB
GAMIFANT INTRAVENOUS SOLUTION 5 MGML
MB PA
GAZYVA INTRAVENOUS SOLUTION 1000 MG40 ML
MB PA LA
gemcitabine intravenous recon soln 1 gram 2 gram 200 mg
MB
17
Drug Name Drug Tier Requirements Limits
gemcitabine intravenous solution 2 gram526 ml (38 mgml) 200 mg526 ml (38 mgml)
MB
gengraf oral capsule 100 mg 25 mg 1
gengraf oral solution 100 mgml 1
GILOTRIF ORAL TABLET 20 MG 30 MG 40 MG
2 PA OCh LA
GLEOSTINE ORAL CAPSULE 10 MG 100 MG 40 MG
2 PA OCh
HALAVEN INTRAVENOUS SOLUTION 1 MG2 ML (05 MGML)
MB PA LA
HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600 MG-10000 UNIT5 ML
MB LA
HERCEPTIN INTRAVENOUS RECON SOLN 150 MG
MB PA LA
HERZUMA INTRAVENOUS RECON SOLN 150 MG
MB PA LA
HYCAMTIN ORAL CAPSULE 025 MG 1 MG 2 OCh LA
hydroxyurea oral capsule 500 mg 2 OCh
IBRANCE ORAL CAPSULE 100 MG 125 MG 75 MG
2 PA OCh LA
IBRANCE ORAL TABLET 100 MG 125 MG 75 MG
2 OCh LA
ICLUSIG ORAL TABLET 10 MG 15 MG 30 MG 45 MG
2 PA ST OCh
IDHIFA ORAL TABLET 100 MG 50 MG 2 PA OCh LA
imatinib oral tablet 100 mg 2 OCh LA QL (90 per 30 days)
imatinib oral tablet 400 mg 2 OCh LA QL (60 per 30 days)
IMBRUVICA ORAL CAPSULE 140 MG 70 MG 2 PA ST OCh
IMBRUVICA ORAL TABLET 140 MG 280 MG 420 MG 560 MG
2 PA ST OCh
IMFINZI INTRAVENOUS SOLUTION 50 MGML
MB PA LA
IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFUML 10EXP8 (100 MILLION) PFUML
MB
18
Drug Name Drug Tier Requirements Limits
INFUGEM INTRAVENOUS PIGGYBACK 1200 MG120 ML (10 MGML) 1300 MG130 ML (10 MGML) 1400 MG140 ML (10 MGML) 1500 MG150 ML (10 MGML) 1600 MG160 ML (10 MGML) 1700 MG170 ML (10 MGML) 1800 MG180 ML (10 MGML) 1900 MG190 ML (10 MGML) 2000 MG200 ML (10 MGML) 2200 MG220 ML (10 MGML)
MB
INLYTA ORAL TABLET 1 MG 5 MG 2 PA OCh LA
IRESSA ORAL TABLET 250 MG 2 PA OCh LA
ISTODAX INTRAVENOUS RECON SOLN 10 MG2 ML
MB PA LA
IXEMPRA INTRAVENOUS RECON SOLN 15 MG 45 MG
MB PA LA
JAKAFI ORAL TABLET 10 MG 15 MG 20 MG 25 MG 5 MG
2 PA OCh LA
JEVTANA INTRAVENOUS SOLUTION 10 MGML (FIRST DILUTION)
MB PA LA
KADCYLA INTRAVENOUS RECON SOLN 100 MG 160 MG
MB PA LA
KANJINTI INTRAVENOUS RECON SOLN 150 MG 420 MG
MB PA LA
KEYTRUDA INTRAVENOUS SOLUTION 25 MGML
MB PA
KISQALI FEMARA CO-PACK ORAL TABLET 200 MGDAY(200 MG X 1)-25 MG 400 MGDAY(200 MG X 2)-25 MG 600 MGDAY(200 MG X 3)-25 MG
2 PA ST OCh LA
KISQALI ORAL TABLET 200 MGDAY (200 MG X 1) 400 MGDAY (200 MG X 2) 600 MGDAY (200 MG X 3)
2 PA ST OCh LA
KYMRIAH INTRAVENOUS SUSPENSION 02X10EXP6 TO 25X10EXP8 CELL 06 TO 6 X 10EXP8 CELL
MB PA
KYPROLIS INTRAVENOUS RECON SOLN 10 MG 30 MG 60 MG
MB PA
lapatinib oral tablet 250 mg 2 PA OCh LA QL (180 per 30 days)
LENVIMA ORAL CAPSULE 10 MGDAY (10 MG X 1) 12 MGDAY (4 MG X 3) 14 MGDAY(10 MG X 1-4 MG X 1) 18 MGDAY (10 MG X 1-4 MG X2) 20 MGDAY (10 MG X 2) 24 MGDAY(10 MG X 2-4 MG X 1) 4 MG 8 MGDAY (4 MG X 2)
2 PA ST OCh LA
19
Drug Name Drug Tier Requirements Limits
letrozole oral tablet 25 mg ACA PV OCh QL (30 per 30 days)
LEUKERAN ORAL TABLET 2 MG 2 OCh
leuprolide subcutaneous kit 1 mg02 ml 2
LIBTAYO INTRAVENOUS SOLUTION 50 MGML
MB PA
LONSURF ORAL TABLET 15-614 MG 20-819 MG
2 PA ST OCh LA
LUMOXITI INTRAVENOUS RECON SOLN 1 MG
MB
LUPKYNIS ORAL CAPSULE 79 MG 2 PA ST
LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 225 MG
2
LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG
2
LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG
2
LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 375 MG 75 MG
2
LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 30 MG
2
LUPRON DEPOT-PED INTRAMUSCULAR KIT 1125 MG 15 MG 75 MG (PED)
2
LYNPARZA ORAL TABLET 100 MG 150 MG 2 PA ST OCh LA
LYSODREN ORAL TABLET 500 MG 2 OCh
MARQIBO INTRAVENOUS KIT 5 MG31 ML(016 MGML) FINAL
MB PA
MATULANE ORAL CAPSULE 50 MG 2 OCh
megestrol oral suspension 400 mg10 ml (40 mgml)
1 QL (2 per 30 days)
megestrol oral suspension 625 mg5 ml (125 mgml)
1 QL (1 per 30 days)
megestrol oral tablet 20 mg 2 OCh QL (480 per 30 days)
megestrol oral tablet 40 mg 2 OCh QL (240 per 30 days)
MEKINIST ORAL TABLET 05 MG 2 MG 2 PA ST OCh LA
MEKTOVI ORAL TABLET 15 MG 2 PA OCh LA
melphalan hcl intravenous recon soln 50 mg MB
melphalan oral tablet 2 mg 2 OCh
20
Drug Name Drug Tier Requirements Limits
mercaptopurine oral tablet 50 mg 2 OCh QL (300 per 30 days)
methotrexate sodium (pf) injection recon soln 1 gram
1
methotrexate sodium (pf) injection solution 25 mgml
1
methotrexate sodium injection solution 25 mgml 1
methotrexate sodium oral tablet 25 mg 2 OCh
mitoxantrone intravenous concentrate 2 mgml MB PA LA
mycophenolate mofetil oral capsule 250 mg 1
mycophenolate mofetil oral tablet 500 mg 1
mycophenolate sodium oral tabletdelayed release (drec) 180 mg 360 mg
1
MYLOTARG INTRAVENOUS RECON SOLN 45 MG (1 MGML INITIAL CONC)
MB PA LA
NERLYNX ORAL TABLET 40 MG 2 PA OCh LA QL (180 per 30 days)
NEXAVAR ORAL TABLET 200 MG 2 PA ST OCh LA
nilutamide oral tablet 150 mg 2 OCh QL (60 per 30 days)
NINLARO ORAL CAPSULE 23 MG 3 MG 4 MG
2 PA ST OCh LA
NULOJIX INTRAVENOUS RECON SOLN 250 MG
MB PA
octreotide acetate injection solution 1000 mcgml 100 mcgml 200 mcgml 50 mcgml 500 mcgml
2
octreotide acetate injection syringe 100 mcgml (1 ml) 50 mcgml (1 ml) 500 mcgml (1 ml)
2
OGIVRI INTRAVENOUS RECON SOLN 150 MG 420 MG
MB PA LA
ONCASPAR INJECTION SOLUTION 750 UNITML
MB
ONIVYDE INTRAVENOUS DISPERSION 43 MGML
MB PA
OPDIVO INTRAVENOUS SOLUTION 100 MG10 ML 240 MG24 ML 40 MG4 ML
MB PA LA
PADCEV INTRAVENOUS RECON SOLN 20 MG 30 MG
MB PA LA
PEMAZYRE ORAL TABLET 135 MG 45 MG 9 MG
2 PA ST OCh
PERJETA INTRAVENOUS SOLUTION 420 MG14 ML (30 MGML)
MB PA LA
21
Drug Name Drug Tier Requirements Limits
PIQRAY ORAL TABLET 200 MGDAY (200 MG X 1) 250 MGDAY (200 MG X1-50 MG X1) 300 MGDAY (150 MG X 2)
2 PA OCh LA
POLIVY INTRAVENOUS RECON SOLN 140 MG
MB PA LA
PORTRAZZA INTRAVENOUS SOLUTION 800 MG50 ML (16 MGML)
MB PA LA
POTELIGEO INTRAVENOUS SOLUTION 4 MGML
MB PA
PROGRAF INTRAVENOUS SOLUTION 5 MGML
MB
QINLOCK ORAL TABLET 50 MG 2 OCh
RETEVMO ORAL CAPSULE 40 MG 2 PA OCh LA QL (240 per 30 days)
RETEVMO ORAL CAPSULE 80 MG 2 PA OCh LA QL (120 per 30 days)
RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG117 ML (120 MGML) 1600 MG134 ML (120 MGML)
MB LA
RITUXAN INTRAVENOUS CONCENTRATE 10 MGML
MB PA LA
RUBRACA ORAL TABLET 200 MG 250 MG 300 MG
2 PA ST OCh LA
RYDAPT ORAL CAPSULE 25 MG 2 PA ST OCh LA
SARCLISA INTRAVENOUS SOLUTION 20 MGML
MB
SIGNIFOR SUBCUTANEOUS SOLUTION 03 MGML (1 ML) 06 MGML (1 ML) 09 MGML (1 ML)
2 PA ST
SIMULECT INTRAVENOUS RECON SOLN 10 MG 20 MG
MB
sirolimus oral solution 1 mgml 1
sirolimus oral tablet 05 mg 1 mg 2 mg 1
SOLTAMOX ORAL SOLUTION 20 MG10 ML 2 OCh
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG05 ML 60 MG02 ML 90 MG03 ML
2 PA LA
SPRYCEL ORAL TABLET 100 MG 140 MG 20 MG 50 MG 70 MG 80 MG
2 PA ST OCh LA
STIVARGA ORAL TABLET 40 MG 2 PA ST OCh LA
SUPPRELIN LA IMPLANT KIT 50 MG (65 MCGDAY)
MB LA
22
Drug Name Drug Tier Requirements Limits
SUTENT ORAL CAPSULE 125 MG 25 MG 375 MG 50 MG
2 PA ST OCh LA
SYLVANT INTRAVENOUS RECON SOLN 100 MG 400 MG
MB PA LA
SYNRIBO SUBCUTANEOUS RECON SOLN 35 MG
2 PA ST
TABLOID ORAL TABLET 40 MG 2 OCh
tacrolimus oral capsule 05 mg 1 mg 5 mg 1
TAFINLAR ORAL CAPSULE 50 MG 75 MG 2 PA OCh LA
TAGRISSO ORAL TABLET 40 MG 80 MG 2 PA OCh LA
TALZENNA ORAL CAPSULE 025 MG 1 MG 2 PA OCh LA
tamoxifen oral tablet 10 mg 20 mg 2 OCh QL (60 per 30 days)
TARGRETIN TOPICAL GEL 1 1 PA ST
TASIGNA ORAL CAPSULE 150 MG 200 MG 50 MG
2 PA ST OCh LA
TECENTRIQ INTRAVENOUS SOLUTION 1200 MG20 ML (60 MGML) 840 MG14 ML (60 MGML)
MB PA LA
TEMODAR INTRAVENOUS RECON SOLN 100 MG
MB PA LA
temozolomide oral capsule 100 mg 140 mg 180 mg 20 mg 250 mg 5 mg
2 OCh LA
temsirolimus intravenous recon soln 30 mg3 ml (10 mgml) (first)
MB PA LA
THALOMID ORAL CAPSULE 100 MG 150 MG 200 MG 50 MG
2 OCh LA
TIBSOVO ORAL TABLET 250 MG 2 PA OCh
toremifene oral tablet 60 mg 2 OCh
TORISEL INTRAVENOUS RECON SOLN 30 MG3 ML (10 MGML) (FIRST)
MB PA LA
TREANDA INTRAVENOUS RECON SOLN 100 MG 25 MG
MB PA LA
TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 1125 MG 225 MG 375 MG
MB
tretinoin (antineoplastic) oral capsule 10 mg 2 OCh
TREXALL ORAL TABLET 10 MG 15 MG 5 MG 75 MG
2 PA ST OCh QL (15 per 30 days)
TRUXIMA INTRAVENOUS SOLUTION 10 MGML
MB PA LA
23
Drug Name Drug Tier Requirements Limits
TUKYSA ORAL TABLET 150 MG 50 MG 2 PA ST OCh QL (120 per 30 days)
UNITUXIN INTRAVENOUS SOLUTION 35 MGML
MB PA
VANTAS IMPLANT KIT 50 MG (50 MCGDAY)
MB LA
VECTIBIX INTRAVENOUS SOLUTION 100 MG5 ML (20 MGML) 400 MG20 ML (20 MGML)
MB PA LA
VELCADE INJECTION RECON SOLN 35 MG MB LA
VENCLEXTA ORAL TABLET 10 MG 100 MG 50 MG
2 PA ST OCh
VENCLEXTA STARTING PACK ORAL TABLETSDOSE PACK 10 MG-50 MG- 100 MG
2 PA OCh
VERZENIO ORAL TABLET 100 MG 150 MG 200 MG 50 MG
2 PA ST OCh LA
VIDAZA INJECTION RECON SOLN 100 MG MB PA LA
VITRAKVI ORAL CAPSULE 100 MG 2 PA OCh LA
VITRAKVI ORAL CAPSULE 25 MG 2 PA ST OCh LA
VITRAKVI ORAL SOLUTION 20 MGML 2 PA OCh LA
VOTRIENT ORAL TABLET 200 MG 2 PA ST OCh LA
VYXEOS INTRAVENOUS RECON SOLN 44-100 MG
MB PA
XALKORI ORAL CAPSULE 200 MG 250 MG 2 PA OCh LA
XERMELO ORAL TABLET 250 MG 2 PA ST
XOSPATA ORAL TABLET 40 MG 2 PA OCh
XTANDI ORAL CAPSULE 40 MG 2 PA OCh LA
XTANDI ORAL TABLET 40 MG 80 MG 2 PA OCh LA
YERVOY INTRAVENOUS SOLUTION 200 MG40 ML (5 MGML) 50 MG10 ML (5 MGML)
MB PA LA
YESCARTA INTRAVENOUS SUSPENSION MB PA
YONDELIS INTRAVENOUS RECON SOLN 1 MG
MB PA
YONSA ORAL TABLET 125 MG 2 PA OCh LA
ZALTRAP INTRAVENOUS SOLUTION 100 MG4 ML (25 MGML) 200 MG8 ML (25 MGML)
MB PA LA
ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM
MB
24
Drug Name Drug Tier Requirements Limits
ZEJULA ORAL CAPSULE 100 MG 2 OCh
ZELBORAF ORAL TABLET 240 MG 2 PA ST OCh LA
ZOLADEX SUBCUTANEOUS IMPLANT 108 MG 36 MG
MB LA
ZOLINZA ORAL CAPSULE 100 MG 2 PA ST OCh LA
ZYKADIA ORAL TABLET 150 MG 2 PA ST OCh LA
AUTONOMIC amp CNS DRUGS NEUROLOGY amp PSYCH
ANTICONVULSANTS
BANZEL ORAL TABLET 200 MG 400 MG 1 PA ST
BRIVIACT ORAL SOLUTION 10 MGML 1 ST QL (150 per 30 days)
BRIVIACT ORAL TABLET 10 MG 100 MG 25 MG 50 MG 75 MG
1 ST QL (60 per 30 days)
carbamazepine oral capsule er multiphase 12 hr 100 mg 200 mg 300 mg
1
carbamazepine oral suspension 100 mg5 ml 200 mg10 ml
1
carbamazepine oral tablet 200 mg 1
carbamazepine oral tablet extended release 12 hr 100 mg 200 mg 400 mg
1
carbamazepine oral tabletchewable 100 mg 1
CELONTIN ORAL CAPSULE 300 MG 1
clobazam oral suspension 25 mgml 1
clobazam oral tablet 10 mg 20 mg 1
clonazepam oral tablet 05 mg 1 mg 2 mg 1
clonazepam oral tabletdisintegrating 0125 mg 025 mg 05 mg 1 mg 2 mg
1
diazepam rectal kit 25 mg 1
DILANTIN EXTENDED ORAL CAPSULE 100 MG
1
DILANTIN INFATABS ORAL TABLETCHEWABLE 50 MG
1
DILANTIN ORAL CAPSULE 30 MG 1
DILANTIN-125 ORAL SUSPENSION 125 MG5 ML
1
divalproex oral capsule delayed rel sprinkle 125 mg
1
divalproex oral tablet extended release 24 hr 250 mg 500 mg
1
25
Drug Name Drug Tier Requirements Limits
divalproex oral tabletdelayed release (drec) 125 mg 250 mg 500 mg
1
EPIDIOLEX ORAL SOLUTION 100 MGML 2 PA LA QL (400 per 30 days)
epitol oral tablet 200 mg 1
ethosuximide oral capsule 250 mg 1
ethosuximide oral solution 250 mg5 ml 1
felbamate oral suspension 600 mg5 ml 1
felbamate oral tablet 400 mg 600 mg 1
FINTEPLA ORAL SOLUTION 22 MGML 2
gabapentin oral capsule 100 mg 300 mg 400 mg 1
gabapentin oral solution 250 mg5 ml 300 mg6 ml (6 ml)
1
gabapentin oral tablet 600 mg 800 mg 1
lamotrigine oral tablet 100 mg 150 mg 200 mg 25 mg
1
lamotrigine oral tablet disintegrating dose pk 25 mg (21) -50 mg (7) 25 mg(14)-50 mg (14)-100 mg (7) 50 mg (42) -100 mg (14)
1
lamotrigine oral tablet extended release 24hr 100 mg 200 mg 25 mg 250 mg 300 mg 50 mg
1
lamotrigine oral tablet chewable dispersible 25 mg 5 mg
1
lamotrigine oral tabletdisintegrating 100 mg 200 mg 25 mg 50 mg
1
lamotrigine oral tabletsdose pack 25 mg (35) 25 mg (42) -100 mg (7) 25 mg (84) -100 mg (14)
1
levetiracetam oral solution 100 mgml 500 mg5 ml (5 ml)
1
levetiracetam oral tablet 1000 mg 250 mg 500 mg 750 mg
1
levetiracetam oral tablet extended release 24 hr 500 mg 750 mg
1
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG 330 MG 825 MG
1 PA ST
oxcarbazepine oral suspension 300 mg5 ml (60 mgml)
1
oxcarbazepine oral tablet 150 mg 300 mg 600 mg 1
phenobarbital oral elixir 20 mg5 ml (4 mgml) 1
26
Drug Name Drug Tier Requirements Limits
phenobarbital oral tablet 100 mg 15 mg 162 mg 30 mg 324 mg 60 mg 648 mg 972 mg
1
phenytoin oral suspension 100 mg4 ml 125 mg5 ml
1
phenytoin oral tabletchewable 50 mg 1
phenytoin sodium extended oral capsule 100 mg 200 mg 300 mg
1
pregabalin oral capsule 100 mg 150 mg 200 mg 225 mg 25 mg 300 mg 50 mg 75 mg
1 PA ST
pregabalin oral solution 20 mgml 1 PA ST
pregabalin oral tablet extended release 24 hr 165 mg 330 mg 825 mg
1 PA ST
primidone oral tablet 250 mg 50 mg 1
roweepra oral tablet 1000 mg 500 mg 750 mg 1
rufinamide oral suspension 40 mgml 1 PA
rufinamide oral tablet 200 mg 400 mg 1 PA
subvenite oral tablet 100 mg 150 mg 200 mg 25 mg
1
subvenite starter (blue) kit oral tabletsdose pack 25 mg (35)
1
subvenite starter (green) kit oral tabletsdose pack 25 mg (84) -100 mg (14)
1
subvenite starter (orange) kit oral tabletsdose pack 25 mg (42) -100 mg (7)
1
SYMPAZAN ORAL FILM 10 MG 20 MG 5 MG 1 PA QL (30 per 30 days)
tiagabine oral tablet 12 mg 16 mg 2 mg 4 mg 1
topiramate oral capsule sprinkle 15 mg 25 mg 1
topiramate oral tablet 100 mg 200 mg 25 mg 50 mg
1
valproic acid (as sodium salt) oral solution 250 mg5 ml 500 mg10 ml (10 ml)
1
valproic acid oral capsule 250 mg 1
vigabatrin oral powder in packet 500 mg 2 PA LA
vigabatrin oral tablet 500 mg 2 PA LA
vigadrone oral powder in packet 500 mg 2 PA ST
VIMPAT ORAL SOLUTION 10 MGML 1 PA ST QL (6 per 30 days)
VIMPAT ORAL TABLET 100 MG 150 MG 200 MG 50 MG
1 ST QL (60 per 30 days)
27
Drug Name Drug Tier Requirements Limits
XCOPRI MAINTENANCE PACK ORAL TABLET 250 MGDAY (200 MG X1-50 MG X1) 350 MGDAY (200 MG X1-150MG X1)
2
XCOPRI MAINTENANCE PACK ORAL TABLET 250MGDAY(150 MG X1-100MG X1)
2 PA ST
XCOPRI ORAL TABLET 100 MG 150 MG 200 MG 50 MG
2
XCOPRI TITRATION PACK ORAL TABLETSDOSE PACK 125 MG (14)- 25 MG (14) 150 MG (14)- 200 MG (14) 50 MG (14)- 100 MG (14)
2
zonisamide oral capsule 100 mg 25 mg 50 mg 1
ANTIPARKINSONISM AGENTS
APOKYN SUBCUTANEOUS CARTRIDGE 10 MGML
2 PA LA QL (1 per 30 days)
benztropine injection solution 1 mgml 1
benztropine oral tablet 05 mg 1 mg 2 mg 1
bromocriptine oral capsule 5 mg 1
bromocriptine oral tablet 25 mg 1
carbidopa oral tablet 25 mg 1
carbidopa-levodopa oral tablet 10-100 mg 25-100 mg 25-250 mg
1
carbidopa-levodopa oral tablet extended release 25-100 mg 50-200 mg
1
carbidopa-levodopa oral tabletdisintegrating 10-100 mg 25-100 mg 25-250 mg
1
carbidopa-levodopa-entacapone oral tablet 125-50-200 mg 1875-75-200 mg 25-100-200 mg 3125-125-200 mg 375-150-200 mg 50-200-200 mg
1
entacapone oral tablet 200 mg 1
pramipexole oral tablet 0125 mg 025 mg 05 mg 075 mg 1 mg 15 mg
1
pramipexole oral tablet extended release 24 hr 0375 mg 075 mg 15 mg 225 mg 3 mg 375 mg 45 mg
1
rasagiline oral tablet 05 mg 1 mg 1
ropinirole oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg 5 mg
1
28
Drug Name Drug Tier Requirements Limits
ropinirole oral tablet extended release 24 hr 12 mg 2 mg 4 mg 6 mg 8 mg
1
selegiline hcl oral capsule 5 mg 1
selegiline hcl oral tablet 5 mg 1
tolcapone oral tablet 100 mg 1
trihexyphenidyl oral elixir 04 mgml 1
trihexyphenidyl oral tablet 2 mg 5 mg 1
MIGRAINE amp CLUSTER HEADACHE THERAPY
AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MGML 70 MGML
1 PA ST
AJOVY AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 225 MG15 ML
1 ST
AJOVY SYRINGE SUBCUTANEOUS SYRINGE 225 MG15 ML
1 PA ST
almotriptan malate oral tablet 125 mg 625 mg 1 QL (18 per 30 days)
dihydroergotamine injection solution 1 mgml 1
dihydroergotamine nasal spraynon-aerosol 05 mgpump act (4 mgml)
1 QL (8 per 30 days)
eletriptan oral tablet 20 mg 40 mg 1 QL (18 per 30 days)
EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MGML
1 PA ST
EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MGML 300 MG3 ML (100 MGML X 3)
1 PA ST
ergotamine-caffeine oral tablet 1-100 mg 1
frovatriptan oral tablet 25 mg 1 QL (18 per 30 days)
migergot rectal suppository 2-100 mg 1
naratriptan oral tablet 1 mg 25 mg 1 QL (18 per 30 days)
ONZETRA XSAIL NASAL AEROSOL POWDR BREATH ACTIVATED 11 MG
1 ST QL (16 per 30 days)
rizatriptan oral tablet 10 mg 5 mg 1 QL (18 per 30 days)
rizatriptan oral tabletdisintegrating 10 mg 5 mg 1 QL (18 per 30 days)
sumatriptan nasal spraynon-aerosol 20 mgactuation 5 mgactuation
1 QL (18 per 30 days)
sumatriptan succinate oral tablet 100 mg 25 mg 50 mg
1 QL (18 per 30 days)
sumatriptan succinate subcutaneous cartridge 4 mg05 ml 6 mg05 ml
1 QL (8 per 30 days)
29
Drug Name Drug Tier Requirements Limits
sumatriptan succinate subcutaneous pen injector 4 mg05 ml 6 mg05 ml
1 QL (8 per 30 days)
sumatriptan succinate subcutaneous solution 6 mg05 ml
1 QL (8 per 30 days)
sumatriptan succinate subcutaneous syringe 6 mg05 ml
1 QL (8 per 30 days)
UBRELVY ORAL TABLET 100 MG 50 MG 1 QL (16 per 30 days)
VYEPTI INTRAVENOUS SOLUTION 100 MGML
MB PA
zolmitriptan oral tablet 25 mg 5 mg 1 QL (18 per 30 days)
zolmitriptan oral tabletdisintegrating 25 mg 5 mg
1 QL (18 per 30 days)
ZOMIG NASAL SPRAYNON-AEROSOL 25 MG 5 MG
1 ST QL (18 per 30 days)
MISCELLANEOUS NEUROLOGICAL THERAPY
AUSTEDO ORAL TABLET 12 MG 6 MG 9 MG
2 PA LA
dalfampridine oral tablet extended release 12 hr 10 mg
2 PA LA QL (60 per 30 days)
donepezil oral tablet 10 mg 23 mg 5 mg 1
donepezil oral tabletdisintegrating 10 mg 5 mg 1
EXONDYS-51 INTRAVENOUS SOLUTION 50 MGML
MB PA
galantamine oral capsuleext rel pellets 24 hr 16 mg 24 mg 8 mg
1
galantamine oral solution 4 mgml 1
galantamine oral tablet 12 mg 4 mg 8 mg 1
memantine oral capsulesprinkleer 24hr 14 mg 21 mg 28 mg 7 mg
1
memantine oral solution 2 mgml 1
memantine oral tablet 10 mg 5 mg 1
NUEDEXTA ORAL CAPSULE 20-10 MG 1
ONPATTRO INTRAVENOUS SOLUTION 2 MGML
MB PA
RADICAVA INTRAVENOUS SOLUTION 30 MG100 ML
MB PA
rivastigmine tartrate oral capsule 15 mg 3 mg 45 mg 6 mg
1
30
Drug Name Drug Tier Requirements Limits
rivastigmine transdermal patch 24 hour 133 mg24 hour 46 mg24 hour 95 mg24 hour
1
tetrabenazine oral tablet 125 mg 25 mg 2 LA
TYSABRI INTRAVENOUS SOLUTION 300 MG15 ML
MB PA ST LA
VYONDYS-53 INTRAVENOUS SOLUTION 50 MGML
MB PA
ZOLGENSMA INTRAVENOUS KIT 2 X 10EXP13 VGML
MB LA
MUSCLE RELAXANTS amp ANTISPASMODIC THERAPY
baclofen oral tablet 10 mg 20 mg 5 mg 1
carisoprodol oral tablet 250 mg 350 mg 1
carisoprodol-aspirin oral tablet 200-325 mg 1
carisoprodol-aspirin-codeine oral tablet 200-325-16 mg
1 PA ST
chlorzoxazone oral tablet 250 mg 375 mg 750 mg 1 ST
chlorzoxazone oral tablet 500 mg 1
cyclobenzaprine oral tablet 10 mg 5 mg 75 mg 1
dantrolene oral capsule 100 mg 25 mg 50 mg 1
meprobamate oral tablet 200 mg 400 mg 1
metaxalone oral tablet 400 mg 800 mg 1
methocarbamol oral tablet 500 mg 750 mg 1
orphenadrine citrate injection solution 30 mgml 1
orphenadrine citrate oral tablet extended release 100 mg
1
pyridostigmine bromide oral syrup 60 mg5 ml 1
pyridostigmine bromide oral tablet 60 mg 1
pyridostigmine bromide oral tablet extended release 180 mg
1
tizanidine oral capsule 2 mg 4 mg 6 mg 1
tizanidine oral tablet 2 mg 4 mg 1
vanadom oral tablet 350 mg 1
NARCOTIC ANALGESICS
acetaminophen-caff-dihydrocod oral capsule 3205-30-16 mg
1 PA ST
acetaminophen-caff-dihydrocod oral tablet 325-30-16 mg
1 PA ST
31
Drug Name Drug Tier Requirements Limits
acetaminophen-codeine oral solution 120-12 mg5 ml 300 mg-30 mg 125 ml
1 PA ST
acetaminophen-codeine oral tablet 300-15 mg 300-30 mg 300-60 mg
1 PA ST
ascomp with codeine oral capsule 30-50-325-40 mg
1 PA ST
buprenorphine hcl injection solution 03 mgml 1 PA ST
buprenorphine hcl injection syringe 03 mgml 1 PA ST
buprenorphine hcl sublingual tablet 2 mg 8 mg 1
buprenorphine transdermal patch weekly 10 mcghour 15 mcghour 20 mcghour 5 mcghour 75 mcghour
1
butalbital compound wcodeine oral capsule 30-50-325-40 mg
1 PA ST
butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg 50-325-40-30 mg
1 PA ST
butalbital-acetaminophen-caff oral capsule 50-300-40 mg 50-325-40 mg
1
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
1
butalbital-aspirin-caffeine oral capsule 50-325-40 mg
1
butalbital-aspirin-caffeine oral tablet 50-325-40 mg
1
codeine sulfate oral tablet 15 mg 30 mg 60 mg 1 PA ST
codeine-butalbital-asa-caff oral capsule 30-50-325-40 mg
1 PA ST
diskets oral tabletsoluble 40 mg 1 PA ST
DSUVIA SUBLINGUAL TABLET IN APPLICATOR 30 MCG
MB
duramorph (pf) injection solution 05 mgml 1 mgml
MB PA ST
dvorah oral tablet 325-30-16 mg 1 PA ST
endocet oral tablet 10-325 mg 25-325 mg 5-325 mg 75-325 mg
1 PA ST
fentanyl citrate buccal lozenge on a handle 1200 mcg 1600 mcg 200 mcg 400 mcg 600 mcg 800 mcg
1 PA
32
Drug Name Drug Tier Requirements Limits
fentanyl transdermal patch 72 hour 100 mcghr 12 mcghr 25 mcghr 375 mcghour 50 mcghr 625 mcghour 75 mcghr 875 mcghour
1 PA ST
hydrocodone bitartrate oral capsule oral only er 12hr 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg
1 PA ST QL (60 per 30 days)
hydrocodone bitartrate oral tabletoral onlyextrel24 hr 100 mg 120 mg 20 mg 30 mg 40 mg 60 mg 80 mg
1 PA ST
hydrocodone-acetaminophen oral solution 10-325 mg15 ml(15 ml) 75-325 mg15 ml
1 PA ST
hydrocodone-acetaminophen oral tablet 10-300 mg 10-325 mg 5-300 mg 5-325 mg 75-300 mg 75-325 mg
1 PA ST
hydrocodone-ibuprofen oral tablet 10-200 mg 5-200 mg 75-200 mg
1 PA ST
HYDROMORPHONE INJECTION SYRINGE 05 MG05 ML
1 PA ST
hydromorphone oral liquid 1 mgml 1 PA ST
hydromorphone oral tablet 2 mg 4 mg 8 mg 1 PA ST
hydromorphone oral tablet extended release 24 hr 12 mg 16 mg 32 mg 8 mg
1 PA ST QL (60 per 30 days)
hydromorphone rectal suppository 3 mg 1 PA ST
levorphanol tartrate oral tablet 2 mg 3 mg 1 PA ST
meperidine oral solution 50 mg5 ml 1 PA ST
meperidine oral tablet 50 mg 1 PA ST
methadone injection solution 10 mgml 1 PA ST
methadone oral concentrate 10 mgml 1 PA ST
methadone oral solution 10 mg5 ml 5 mg5 ml 1 PA ST
methadone oral tablet 10 mg 5 mg 1 PA ST
methadone oral tabletsoluble 40 mg 1 PA ST
methadose oral concentrate 10 mgml 1 PA ST
methadose oral tabletsoluble 40 mg 1 PA ST
morphine (pf) injection solution 05 mgml MB PA ST
morphine concentrate oral solution 100 mg5 ml (20 mgml)
1 PA ST
morphine oral capsule er multiphase 24 hr 120 mg 30 mg 45 mg 60 mg 75 mg 90 mg
1 PA ST QL (60 per 30 days)
morphine oral capsuleextendrelease pellets 10 mg 100 mg 20 mg 50 mg 80 mg
1 PA ST QL (90 per 30 days)
33
Drug Name Drug Tier Requirements Limits
morphine oral capsuleextendrelease pellets 30 mg 60 mg
1 PA ST QL (60 per 30 days)
morphine oral capsuleextendrelease pellets 40 mg
1 PA QL (90 per 30 days)
morphine oral solution 10 mg5 ml 20 mg5 ml (4 mgml)
1 PA ST
morphine oral tablet 15 mg 30 mg 1 PA ST
morphine oral tablet extended release 100 mg 15 mg 200 mg 30 mg 60 mg
1 PA ST QL (120 per 30 days)
morphine rectal suppository 10 mg 20 mg 30 mg 5 mg
1 PA ST
oxycodone oral capsule 5 mg 1 PA ST
oxycodone oral concentrate 20 mgml 1 PA ST
oxycodone oral solution 5 mg5 ml 1 PA ST
oxycodone oral tablet 10 mg 15 mg 20 mg 30 mg 5 mg
1 PA ST
oxycodone-acetaminophen oral tablet 10-325 mg 25-300 mg 25-325 mg 5-325 mg 75-325 mg
1 PA ST
oxycodone-aspirin oral tablet 48355-325 mg 1 PA ST
OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 10 MG 15 MG 20 MG 30 MG 40 MG
1 PA ST QL (90 per 30 days)
OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 60 MG 80 MG
1 PA ST QL (120 per 30 days)
oxymorphone oral tablet 10 mg 5 mg 1 PA ST
oxymorphone oral tablet extended release 12 hr 10 mg 15 mg 20 mg 30 mg 40 mg 5 mg 75 mg
1 PA ST QL (90 per 30 days)
SUBLOCADE SUBCUTANEOUS SOLUTION EXTENDED REL SYRINGE 100 MG05 ML 300 MG15 ML
MB
tencon oral tablet 50-325 mg 1
NON-NARCOTIC ANALGESICS
adult aspirin regimen oral tabletdelayed release (drec) 81 mg
ACA PV
aspirin low dose oral tabletdelayed release (drec) 81 mg
ACA PV
aspirin oral tablet 325 mg ACA PV
aspirin oral tabletchewable 81 mg ACA PV
34
Drug Name Drug Tier Requirements Limits
aspirin oral tabletdelayed release (drec) 325 mg 81 mg
ACA PV
aspir-trin oral tabletdelayed release (drec) 325 mg
ACA PV
bayer aspirin oral tablet 325 mg ACA PV
BAYER CHEWABLE ASPIRIN ORAL TABLETCHEWABLE 81 MG
ACA PV
buprenorphine-naloxone sublingual film 12-3 mg 1 QL (60 per 30 days)
buprenorphine-naloxone sublingual film 2-05 mg 4-1 mg 8-2 mg
1 QL (90 per 30 days)
buprenorphine-naloxone sublingual tablet 2-05 mg 8-2 mg
1 QL (90 per 30 days)
butorphanol nasal spraynon-aerosol 10 mgml 1 PA ST QL (5 per 30 days)
cataflam oral tablet 50 mg 1
celecoxib oral capsule 100 mg 200 mg 400 mg 50 mg
1
childrens aspirin oral tabletchewable 81 mg ACA PV
cholinemagnesium salicylate oral liquid 500 mg5 ml
1
diclofenac potassium oral tablet 50 mg 1
diclofenac sodium oral tablet extended release 24 hr 100 mg
1
diclofenac sodium oral tabletdelayed release (drec) 25 mg 50 mg 75 mg
1
diclofenac sodium topical drops 15 1
diclofenac sodium topical gel 1 1
diclofenac-misoprostol oral tabletirdelayed relbiphasic 50-200 mg-mcg 75-200 mg-mcg
1
diflunisal oral tablet 500 mg 1
DUEXIS ORAL TABLET 800-266 MG 1 ST
ecotrin low strength oral tabletdelayed release (drec) 81 mg
ACA PV
ecotrin oral tabletdelayed release (drec) 325 mg ACA PV
etodolac oral capsule 200 mg 300 mg 1
etodolac oral tablet 400 mg 500 mg 1
etodolac oral tablet extended release 24 hr 400 mg 500 mg 600 mg
1
EUFLEXXA INTRA-ARTICULAR SYRINGE 10 MGML(MW 24 -36 MILLION)
MB
35
Drug Name Drug Tier Requirements Limits
fenoprofen oral tablet 600 mg 1
flurbiprofen oral tablet 100 mg 1
ibu oral tablet 400 mg 600 mg 800 mg 1
ibuprofen oral suspension 100 mg5 ml 1
ibuprofen oral tablet 400 mg 600 mg 800 mg 1
indomethacin oral capsule 25 mg 50 mg 1
indomethacin oral capsule extended release 75 mg
1
ketoprofen oral capsule 25 mg 50 mg 75 mg 1
ketoprofen oral capsuleext rel pellets 24 hr 200 mg
1
ketorolac injection cartridge 15 mgml 30 mgml 1
ketorolac injection solution 15 mgml 30 mgml MB
ketorolac injection solution 30 mgml (1 ml) 1
ketorolac intramuscular cartridge 60 mg2 ml 1
ketorolac intramuscular solution 60 mg2 ml 1
ketorolac intramuscular syringe 60 mg2 ml 1
ketorolac oral tablet 10 mg 1
meclofenamate oral capsule 100 mg 50 mg 1
mefenamic acid oral capsule 250 mg 1
meloxicam oral tablet 15 mg 75 mg 1
MONOVISC INTRA-ARTICULAR SYRINGE 88 MG4 ML
MB LA
nabumetone oral tablet 500 mg 750 mg 1
nalbuphine injection solution 10 mgml MB PA ST
naloxone injection solution 04 mgml 1
naloxone injection syringe 04 mgml 1 mgml 1
naltrexone oral tablet 50 mg 1
naproxen oral suspension 125 mg5 ml 1
naproxen oral tablet 250 mg 375 mg 500 mg 1
naproxen oral tabletdelayed release (drec) 375 mg 500 mg
1
naproxen sodium oral tablet 275 mg 550 mg 1
NARCAN NASAL SPRAYNON-AEROSOL 4 MGACTUATION
1
36
Drug Name Drug Tier Requirements Limits
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG 150 MG 200 MG 250 MG 50 MG
1 PA ST QL (60 per 30 days)
ORTHOVISC INTRA-ARTICULAR SYRINGE 30 MG2 ML
MB
oxaprozin oral tablet 600 mg 1
pentazocine-naloxone oral tablet 50-05 mg 1 PA ST
piroxicam oral capsule 10 mg 20 mg 1
salsalate oral tablet 500 mg 750 mg 1
st joseph aspirin oral tabletchewable 81 mg ACA PV
st joseph aspirin oral tabletdelayed release (drec) 81 mg
ACA PV
sulindac oral tablet 150 mg 200 mg 1
tolmetin oral capsule 400 mg 1
tolmetin oral tablet 200 mg 600 mg 1
tramadol oral tablet 50 mg 1 PA ST
tramadol oral tablet extended release 24 hr 100 mg 200 mg 300 mg
1 PA ST
tramadol oral tablet er multiphase 24 hr 100 mg 200 mg 300 mg
1 PA ST
tramadol-acetaminophen oral tablet 375-325 mg 1 PA ST
VIVITROL INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 380 MG
MB
PSYCHOTHERAPEUTIC DRUGS
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 300 MG 400 MG
1
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 300 MG 400 MG
1
ADHANSIA XR ORAL CAPSULE ER BIPHASIC 20-80 25 MG 35 MG 45 MG 55 MG 70 MG 85 MG
1 PA ST
ADZENYS ER ORAL SUSPEN IR - ER BIPHASIC 24HR 125 MGML
1 ST
ADZENYS XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 125 MG 157 MG 188 MG 31 MG 63 MG 94 MG
1 ST
37
Drug Name Drug Tier Requirements Limits
alprazolam intensol oral concentrate 1 mgml 1
alprazolam oral tablet 025 mg 05 mg 1 mg 2 mg
1
alprazolam oral tablet extended release 24 hr 05 mg 1 mg 2 mg 3 mg
1
alprazolam oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg
1
amitriptyline oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
amitriptyline-chlordiazepoxide oral tablet 125-5 mg 25-10 mg
1
amoxapine oral tablet 100 mg 150 mg 25 mg 50 mg
1
AMPHETAMINE ORAL SUSPEN IR - ER BIPHASIC 24HR 125 MGML
1 ST
amphetamine sulfate oral tablet 10 mg 5 mg 1
APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG 348 MG 522 MG
1 ST
aripiprazole oral solution 1 mgml 1
aripiprazole oral tablet 10 mg 15 mg 2 mg 20 mg 30 mg 5 mg
1
aripiprazole oral tabletdisintegrating 10 mg 15 mg
1
ARISTADA INITIO INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 675 MG24 ML
MB
ARISTADA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 1064 MG39 ML 441 MG16 ML 662 MG24 ML 882 MG32 ML
MB
armodafinil oral tablet 150 mg 200 mg 250 mg 50 mg
1
asenapine maleate sublingual tablet 10 mg 25 mg 5 mg
1
atomoxetine oral capsule 10 mg 100 mg 18 mg 25 mg 40 mg 60 mg 80 mg
1
BELSOMRA ORAL TABLET 10 MG 15 MG 20 MG 5 MG
1 ST
bupropion hcl oral tablet 100 mg 75 mg 1
bupropion hcl oral tablet extended release 24 hr 150 mg 300 mg
1
38
Drug Name Drug Tier Requirements Limits
bupropion hcl oral tablet sustained-release 12 hr 100 mg 150 mg 200 mg
1
buspirone oral tablet 10 mg 15 mg 30 mg 5 mg 75 mg
1
chlordiazepoxide hcl oral capsule 10 mg 25 mg 5 mg
1
chlorpromazine injection solution 25 mgml 1
chlorpromazine oral tablet 10 mg 100 mg 200 mg 25 mg 50 mg
1
citalopram oral solution 10 mg5 ml 1
citalopram oral tablet 10 mg 20 mg 40 mg 1
clomipramine oral capsule 25 mg 50 mg 75 mg 1
clonidine hcl oral tablet extended release 12 hr 01 mg
1
clorazepate dipotassium oral tablet 15 mg 375 mg 75 mg
1
clozapine oral tablet 100 mg 200 mg 25 mg 50 mg
1
clozapine oral tabletdisintegrating 100 mg 125 mg 150 mg 200 mg 25 mg
1
COTEMPLA XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 173 MG 259 MG 86 MG
1 ST
DAYTRANA TRANSDERMAL PATCH 24 HOUR 10 MG9 HR 15 MG9 HR 20 MG9 HR 30 MG9 HR
1 ST
desipramine oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG 50 MG
1 ST
desvenlafaxine succinate oral tablet extended release 24 hr 100 mg 25 mg 50 mg
1
dexmethylphenidate oral capsuleer biphasic 50-50 10 mg 15 mg 20 mg 25 mg 30 mg 35 mg 40 mg 5 mg
1
dexmethylphenidate oral tablet 10 mg 25 mg 5 mg
1
dextroamphetamine oral capsule extended release 10 mg 15 mg 5 mg
1
dextroamphetamine oral solution 5 mg5 ml 1
39
Drug Name Drug Tier Requirements Limits
dextroamphetamine oral tablet 10 mg 5 mg 1
dextroamphetamine-amphetamine oral capsuleextended release 24hr 10 mg 15 mg 20 mg 25 mg 30 mg 5 mg
1
dextroamphetamine-amphetamine oral tablet 10 mg 125 mg 15 mg 20 mg 30 mg 5 mg 75 mg
1
diazepam injection solution 5 mgml MB
diazepam injection syringe 5 mgml MB
diazepam intensol oral concentrate 5 mgml 1
diazepam oral solution 5 mg5 ml (1 mgml) 1
diazepam oral tablet 10 mg 2 mg 5 mg 1
doxepin oral capsule 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
doxepin oral concentrate 10 mgml 1
duloxetine oral capsuledelayed release(drec) 20 mg 30 mg 40 mg 60 mg
1
DYANAVEL XR ORAL SUSPEN IR - ER BIPHASIC 24HR 25 MGML
1 ST
EDLUAR SUBLINGUAL TABLET 10 MG 5 MG
1 ST
EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG24 HR 6 MG24 HR 9 MG24 HR
1 ST
ergoloid oral tablet 1 mg 1
escitalopram oxalate oral solution 5 mg5 ml 1
escitalopram oxalate oral tablet 10 mg 20 mg 5 mg
1
estazolam oral tablet 1 mg 2 mg 1
eszopiclone oral tablet 1 mg 2 mg 3 mg 1
FANAPT ORAL TABLET 1 MG 10 MG 12 MG 2 MG 4 MG 6 MG 8 MG
1 PA ST
FANAPT ORAL TABLETSDOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)
1 PA ST
FETZIMA ORAL CAPSULEEXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)
1 ST
FETZIMA ORAL CAPSULEEXTENDED RELEASE 24 HR 120 MG 20 MG 40 MG 80 MG
1 ST
fluoxetine oral capsule 10 mg 20 mg 40 mg 1
40
Drug Name Drug Tier Requirements Limits
fluoxetine oral capsuledelayed release(drec) 90 mg
1
fluoxetine oral solution 20 mg5 ml (4 mgml) 1
fluoxetine oral tablet 10 mg 20 mg 1
fluoxetine oral tablet 60 mg 1 PA
fluphenazine hcl injection solution 25 mgml 1
fluphenazine hcl oral concentrate 5 mgml 1
fluphenazine hcl oral elixir 25 mg5 ml 1
fluphenazine hcl oral tablet 1 mg 10 mg 25 mg 5 mg
1
flurazepam oral capsule 15 mg 30 mg 1
fluvoxamine oral capsuleextended release 24hr 100 mg 150 mg
1
fluvoxamine oral tablet 100 mg 25 mg 50 mg 1
guanfacine oral tablet extended release 24 hr 1 mg 2 mg 3 mg 4 mg
1
haloperidol decanoate intramuscular solution 100 mgml 50 mgml
1
haloperidol lactate injection solution 5 mgml 1
haloperidol lactate oral concentrate 2 mgml 1
haloperidol oral tablet 05 mg 1 mg 10 mg 2 mg 20 mg 5 mg
1
HETLIOZ LQ ORAL SUSPENSION 4 MGML 2 PA ST LA
HETLIOZ ORAL CAPSULE 20 MG 2 PA ST LA
imipramine hcl oral tablet 10 mg 25 mg 50 mg 1
imipramine pamoate oral capsule 100 mg 125 mg 150 mg 75 mg
1
INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG075 ML 156 MGML 234 MG15 ML 39 MG025 ML 78 MG05 ML
1
JORNAY PM ORAL CAPSULEDEL RELEXT REL SPRINK 100 MG 20 MG 40 MG 60 MG 80 MG
1 ST
LATUDA ORAL TABLET 120 MG 20 MG 40 MG 60 MG 80 MG
1 PA ST
lithium carbonate oral capsule 150 mg 300 mg 600 mg
1
lithium carbonate oral tablet 300 mg 1
41
Drug Name Drug Tier Requirements Limits
lithium carbonate oral tablet extended release 300 mg 450 mg
1
lorazepam intensol oral concentrate 2 mgml 1
lorazepam oral concentrate 2 mgml 1
lorazepam oral tablet 05 mg 1 mg 2 mg 1
loxapine succinate oral capsule 10 mg 25 mg 5 mg 50 mg
1
maprotiline oral tablet 25 mg 50 mg 75 mg 1
MARPLAN ORAL TABLET 10 MG 1
methamphetamine oral tablet 5 mg 1
METHYLIN ORAL SOLUTION 10 MG5 ML 5 MG5 ML
1
methylphenidate hcl oral caper sprinklebiphasic 40-60 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg 60 mg
1
methylphenidate hcl oral capsule er biphasic 30-70 10 mg 20 mg 30 mg 40 mg 50 mg 60 mg
1
methylphenidate hcl oral capsuleer biphasic 50-50 10 mg 20 mg 30 mg 40 mg 60 mg
1
methylphenidate hcl oral solution 10 mg5 ml 5 mg5 ml
1
methylphenidate hcl oral tablet 10 mg 20 mg 5 mg
1
methylphenidate hcl oral tablet extended release 10 mg 20 mg
1
methylphenidate hcl oral tablet extended release 24hr 18 mg 27 mg 36 mg 54 mg
1
methylphenidate hcl oral tabletchewable 10 mg 25 mg 5 mg
1
midazolam oral syrup 2 mgml 1
mirtazapine oral tablet 15 mg 30 mg 45 mg 75 mg
1
mirtazapine oral tabletdisintegrating 15 mg 30 mg 45 mg
1
modafinil oral tablet 100 mg 200 mg 1
molindone oral tablet 10 mg 25 mg 5 mg 1
MYDAYIS ORAL CAPSULE ER TRIPHASIC 24 HR 125 MG 25 MG 375 MG 50 MG
1 ST
nefazodone oral tablet 100 mg 150 mg 200 mg 250 mg 50 mg
1
42
Drug Name Drug Tier Requirements Limits
nortriptyline oral capsule 10 mg 25 mg 50 mg 75 mg
1
nortriptyline oral solution 10 mg5 ml 1
NUPLAZID ORAL CAPSULE 34 MG 2 PA LA
NUPLAZID ORAL TABLET 10 MG 2 PA LA
olanzapine intramuscular recon soln 10 mg 1
olanzapine oral tablet 10 mg 15 mg 25 mg 20 mg 5 mg 75 mg
1
olanzapine oral tabletdisintegrating 10 mg 15 mg 20 mg 5 mg
1
olanzapine-fluoxetine oral capsule 12-25 mg 12-50 mg 3-25 mg 6-25 mg 6-50 mg
1
oxazepam oral capsule 10 mg 15 mg 30 mg 1
paliperidone oral tablet extended release 24hr 15 mg 3 mg 6 mg 9 mg
1
paroxetine hcl oral tablet 10 mg 20 mg 30 mg 40 mg
1
paroxetine hcl oral tablet extended release 24 hr 125 mg 25 mg 375 mg
1
paroxetine mesylate(menopsym) oral capsule 75 mg
1
perphenazine oral tablet 16 mg 2 mg 4 mg 8 mg 1
perphenazine-amitriptyline oral tablet 2-10 mg 2-25 mg 4-10 mg 4-25 mg 4-50 mg
1
phenelzine oral tablet 15 mg 1
pimozide oral tablet 1 mg 2 mg 1
procentra oral solution 5 mg5 ml 1
protriptyline oral tablet 10 mg 5 mg 1
quetiapine oral tablet 100 mg 200 mg 25 mg 300 mg 400 mg 50 mg
1
quetiapine oral tablet extended release 24 hr 150 mg 200 mg 300 mg 400 mg 50 mg
1
QUILLICHEW ER ORAL TABLETCHEWIR-ERBIPHASIC24HR 20 MG 30 MG 40 MG
1 ST
QUILLIVANT XR ORAL SUSPENSIONEXT REL 24HRRECON 5 MGML (25 MG5 ML)
1 ST
ramelteon oral tablet 8 mg 1
RELEXXII ORAL TABLET EXTENDED RELEASE 24HR 72 MG
1 ST
43
Drug Name Drug Tier Requirements Limits
REXULTI ORAL TABLET 025 MG 05 MG 1 MG 2 MG 3 MG 4 MG
1 PA ST
RISPERDAL CONSTA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 125 MG2 ML 25 MG2 ML 375 MG2 ML 50 MG2 ML
1
risperidone oral solution 1 mgml 1
risperidone oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg
1
risperidone oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg
1
seconal sodium oral capsule 100 mg 1
sertraline oral concentrate 20 mgml 1
sertraline oral tablet 100 mg 25 mg 50 mg 1
SPRAVATO NASAL SPRAYNON-AEROSOL 56 MG (28 MG X 2) 84 MG (28 MG X 3)
MB PA
SUNOSI ORAL TABLET 150 MG 1 PA QL (30 per 30 days)
SUNOSI ORAL TABLET 75 MG 1 PA QL (60 per 30 days)
temazepam oral capsule 15 mg 225 mg 30 mg 75 mg
1
thioridazine oral tablet 10 mg 100 mg 25 mg 50 mg
1
thiothixene oral capsule 1 mg 10 mg 2 mg 5 mg 1
tranylcypromine oral tablet 10 mg 1
trazodone oral tablet 100 mg 150 mg 300 mg 50 mg
1
triazolam oral tablet 0125 mg 025 mg 1
trifluoperazine oral tablet 1 mg 10 mg 2 mg 5 mg
1
trimipramine oral capsule 100 mg 25 mg 50 mg 1
TRINTELLIX ORAL TABLET 10 MG 20 MG 5 MG
1 ST
venlafaxine oral capsuleextended release 24hr 150 mg 375 mg 75 mg
1
venlafaxine oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg
1
venlafaxine oral tablet extended release 24hr 150 mg 225 mg 375 mg 75 mg
1
VERSACLOZ ORAL SUSPENSION 50 MGML 1 PA ST
44
Drug Name Drug Tier Requirements Limits
VRAYLAR ORAL CAPSULE 15 MG 3 MG 45 MG 6 MG
1 PA ST
VRAYLAR ORAL CAPSULEDOSE PACK 15 MG (1)- 3 MG (6)
1 PA ST
VYVANSE ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG 70 MG
1 PA ST
VYVANSE ORAL TABLETCHEWABLE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG
1 PA ST
XYREM ORAL SOLUTION 500 MGML 1 PA QL (540 per 30 days)
zaleplon oral capsule 10 mg 5 mg 1
ZENZEDI ORAL TABLET 15 MG 25 MG 20 MG 30 MG 75 MG
1 ST
ziprasidone hcl oral capsule 20 mg 40 mg 60 mg 80 mg
1
zolpidem oral tablet 10 mg 5 mg 1
zolpidem oral tabletext release multiphase 125 mg 625 mg
1
zolpidem sublingual tablet 175 mg 35 mg 1
ZOLPIMIST ORAL SPRAYNON-AEROSOL 5 MGSPRAY (01 ML)
1 ST
ZULRESSO INTRAVENOUS SOLUTION 5 MGML
MB
CARDIOVASCULAR HYPERTENSION amp LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone oral tablet 100 mg 200 mg 400 mg 1
disopyramide phosphate oral capsule 100 mg 150 mg
1
dofetilide oral capsule 125 mcg 250 mcg 500 mcg 1
flecainide oral tablet 100 mg 150 mg 50 mg 1
mexiletine oral capsule 150 mg 200 mg 250 mg 1
MULTAQ ORAL TABLET 400 MG 1
NORPACE CR ORAL CAPSULE EXTENDED RELEASE 100 MG 150 MG
1
pacerone oral tablet 100 mg 200 mg 400 mg 1
procainamide injection solution 100 mgml 500 mgml
MB
propafenone oral capsuleextended release 12 hr 225 mg 325 mg 425 mg
1
45
Drug Name Drug Tier Requirements Limits
propafenone oral tablet 150 mg 225 mg 300 mg 1
quinidine gluconate oral tablet extended release 324 mg
1
quinidine sulfate oral tablet 200 mg 300 mg 1
sorine oral tablet 120 mg 160 mg 240 mg 80 mg 1
sotalol af oral tablet 120 mg 160 mg 80 mg 1
sotalol oral tablet 120 mg 160 mg 240 mg 80 mg 1
ANTIHYPERTENSIVE THERAPY
acebutolol oral capsule 200 mg 400 mg 1
aliskiren oral tablet 150 mg 300 mg 1
amiloride oral tablet 5 mg 1
amiloride-hydrochlorothiazide oral tablet 5-50 mg 1
amlodipine oral tablet 10 mg 25 mg 5 mg 1
amlodipine-benazepril oral capsule 10-20 mg 10-40 mg 25-10 mg 5-10 mg 5-20 mg 5-40 mg
1 ST
amlodipine-olmesartan oral tablet 10-20 mg 10-40 mg 5-20 mg 5-40 mg
1 ST
amlodipine-valsartan oral tablet 10-160 mg 10-320 mg 5-160 mg 5-320 mg
1 ST
amlodipine-valsartan-hcthiazid oral tablet 10-160-125 mg 10-160-25 mg 10-320-25 mg 5-160-125 mg 5-160-25 mg
1
atenolol oral tablet 100 mg 25 mg 50 mg 1
atenolol-chlorthalidone oral tablet 100-25 mg 50-25 mg
1
benazepril oral tablet 10 mg 20 mg 40 mg 5 mg 1
benazepril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg 5-625 mg
1
betaxolol oral tablet 10 mg 20 mg 1
bisoprolol fumarate oral tablet 10 mg 5 mg 1
bisoprolol-hydrochlorothiazide oral tablet 10-625 mg 25-625 mg 5-625 mg
1
bumetanide injection solution 025 mgml 1
bumetanide oral tablet 05 mg 1 mg 2 mg 1
BYSTOLIC ORAL TABLET 10 MG 25 MG 20 MG 5 MG
1 ST
candesartan oral tablet 16 mg 32 mg 4 mg 8 mg 1
46
Drug Name Drug Tier Requirements Limits
candesartan-hydrochlorothiazid oral tablet 16-125 mg 32-125 mg 32-25 mg
1
captopril oral tablet 100 mg 125 mg 25 mg 50 mg
1
captopril-hydrochlorothiazide oral tablet 25-15 mg 25-25 mg 50-15 mg 50-25 mg
1
cartia xt oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg
1
carvedilol oral tablet 125 mg 25 mg 3125 mg 625 mg
1
carvedilol phosphate oral capsule er multiphase 24 hr 10 mg 20 mg 40 mg 80 mg
1
chlorthalidone oral tablet 25 mg 50 mg 1
clonidine hcl oral tablet 01 mg 02 mg 03 mg 1
clonidine transdermal patch weekly 01 mg24 hr 02 mg24 hr 03 mg24 hr
1
diltiazem hcl oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg
1
diltiazem hcl oral capsuleextended release 12 hr 120 mg 60 mg 90 mg
1
diltiazem hcl oral capsuleextended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
diltiazem hcl oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg 360 mg
1
diltiazem hcl oral tablet 120 mg 30 mg 60 mg 90 mg
1
diltiazem hcl oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
dilt-xr oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg
1
doxazosin oral tablet 1 mg 2 mg 4 mg 8 mg 1
EDARBI ORAL TABLET 40 MG 80 MG 1 ST
EDARBYCLOR ORAL TABLET 40-125 MG 40-25 MG
1 ST
enalapril maleate oral tablet 10 mg 25 mg 20 mg 5 mg
1
enalaprilat intravenous solution 125 mgml MB
enalapril-hydrochlorothiazide oral tablet 10-25 mg 5-125 mg
1
EPANED ORAL SOLUTION 1 MGML 1
47
Drug Name Drug Tier Requirements Limits
eplerenone oral tablet 25 mg 50 mg 1
epoprostenol (glycine) intravenous recon soln 05 mg 15 mg
MB PA LA
eprosartan oral tablet 600 mg 1
ethacrynic acid oral tablet 25 mg 1
felodipine oral tablet extended release 24 hr 10 mg 25 mg 5 mg
1
FLOLAN INTRAVENOUS RECON SOLN 05 MG 15 MG
MB PA LA
fosinopril oral tablet 10 mg 20 mg 40 mg 1
fosinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg
1
furosemide oral solution 10 mgml 40 mg5 ml (8 mgml)
1
furosemide oral tablet 20 mg 40 mg 80 mg 1
guanfacine oral tablet 1 mg 2 mg 1
hydralazine oral tablet 10 mg 100 mg 25 mg 50 mg
1
hydrochlorothiazide oral capsule 125 mg 1
hydrochlorothiazide oral tablet 125 mg 25 mg 50 mg
1
indapamide oral tablet 125 mg 25 mg 1
irbesartan oral tablet 150 mg 300 mg 75 mg 1
irbesartan-hydrochlorothiazide oral tablet 150-125 mg 300-125 mg
1
isradipine oral capsule 25 mg 5 mg 1
labetalol oral tablet 100 mg 200 mg 300 mg 1
lisinopril oral tablet 10 mg 25 mg 20 mg 30 mg 40 mg 5 mg
1
lisinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg
1
losartan oral tablet 100 mg 25 mg 50 mg 1
losartan-hydrochlorothiazide oral tablet 100-125 mg 100-25 mg 50-125 mg
1
matzim la oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
methyldopa oral tablet 250 mg 500 mg 1
methyldopa-hydrochlorothiazide oral tablet 250-15 mg 250-25 mg
1
48
Drug Name Drug Tier Requirements Limits
methyldopate intravenous solution 250 mg5 ml MB
metolazone oral tablet 10 mg 25 mg 5 mg 1
metoprolol succinate oral tablet extended release 24 hr 100 mg 200 mg 25 mg 50 mg
1
metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg 100-50 mg 50-25 mg
1
metoprolol tartrate oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg
1
metyrosine oral capsule 250 mg 1
minoxidil oral tablet 10 mg 25 mg 1
moexipril oral tablet 15 mg 75 mg 1
nadolol oral tablet 20 mg 40 mg 80 mg 1
nadolol-bendroflumethiazide oral tablet 80-5 mg 1
nicardipine oral capsule 20 mg 30 mg 1
nifedipine oral capsule 10 mg 20 mg 1
nifedipine oral tablet extended release 24hr 30 mg 60 mg 90 mg
1
nifedipine oral tablet extended release 30 mg 60 mg 90 mg
1
nimodipine oral capsule 30 mg 1
nisoldipine oral tablet extended release 24 hr 17 mg 20 mg 255 mg 30 mg 34 mg 40 mg 85 mg
1
olmesartan oral tablet 20 mg 40 mg 5 mg 1
olmesartan-amlodipin-hcthiazid oral tablet 20-5-125 mg 40-10-125 mg 40-10-25 mg 40-5-125 mg 40-5-25 mg
1
olmesartan-hydrochlorothiazide oral tablet 20-125 mg 40-125 mg 40-25 mg
1 ST
ORENITRAM ORAL TABLET EXTENDED RELEASE 0125 MG 025 MG 1 MG 25 MG 5 MG
2 PA LA
perindopril erbumine oral tablet 2 mg 4 mg 8 mg 1
phenoxybenzamine oral capsule 10 mg 1
pindolol oral tablet 10 mg 5 mg 1
prazosin oral capsule 1 mg 2 mg 5 mg 1
propranolol oral capsuleextended release 24 hr 120 mg 160 mg 60 mg 80 mg
1
propranolol oral solution 20 mg5 ml (4 mgml) 40 mg5 ml (8 mgml)
1
49
Drug Name Drug Tier Requirements Limits
propranolol oral tablet 10 mg 20 mg 40 mg 60 mg 80 mg
1
propranolol-hydrochlorothiazid oral tablet 40-25 mg 80-25 mg
1
QBRELIS ORAL SOLUTION 1 MGML 1
quinapril oral tablet 10 mg 20 mg 40 mg 5 mg 1
quinapril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg
1
ramipril oral capsule 125 mg 10 mg 25 mg 5 mg
1
spironolactone oral tablet 100 mg 25 mg 50 mg 1
spironolacton-hydrochlorothiaz oral tablet 25-25 mg
1
taztia xt oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg
1
TEKTURNA HCT ORAL TABLET 150-125 MG 150-25 MG 300-125 MG 300-25 MG
1
telmisartan oral tablet 20 mg 40 mg 80 mg 1
telmisartan-amlodipine oral tablet 40-10 mg 40-5 mg 80-10 mg 80-5 mg
1 ST
telmisartan-hydrochlorothiazid oral tablet 40-125 mg 80-125 mg 80-25 mg
1
terazosin oral capsule 1 mg 10 mg 2 mg 5 mg 1
tiadylt er oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg 420 mg
1
timolol maleate oral tablet 10 mg 20 mg 5 mg 1
torsemide oral tablet 10 mg 100 mg 20 mg 5 mg 1
trandolapril oral tablet 1 mg 2 mg 4 mg 1
trandolapril-verapamil oral tablet ir - er biphasic 24hr 1-240 mg 2-180 mg 2-240 mg 4-240 mg
1 ST
triamterene oral capsule 100 mg 50 mg 1
triamterene-hydrochlorothiazid oral capsule 375-25 mg
1
triamterene-hydrochlorothiazid oral tablet 375-25 mg 75-50 mg
1
valsartan oral tablet 160 mg 320 mg 40 mg 80 mg
1
valsartan-hydrochlorothiazide oral tablet 160-125 mg 160-25 mg 320-125 mg 320-25 mg 80-125 mg
1
50
Drug Name Drug Tier Requirements Limits
veletri intravenous recon soln 05 mg 15 mg MB PA LA
verapamil oral capsule 24 hr er pellet ct 100 mg 200 mg 300 mg
1
verapamil oral capsuleext rel pellets 24 hr 120 mg 180 mg 240 mg 360 mg
1
verapamil oral tablet 120 mg 40 mg 80 mg 1
verapamil oral tablet extended release 120 mg 180 mg 240 mg
1
CARDIAC GLYCOSIDES
digitek oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
digox oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
digoxin oral solution 50 mcgml (005 mgml) 1
digoxin oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
COAGULATION THERAPY
ADVATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 4000 (+-) UNIT 500 (+-) UNIT
MB
ADYNOVATE INTRAVENOUS SOLUTION 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT 750 (+-) UNIT
MB LA
AFSTYLA INTRAVENOUS RECON SOLN 1000 (+-) UNIT RANGE 1500 (+-) UNIT RANGE 2000 (+-) UNIT RANGE 2500 (+-) UNIT RANGE 250 (+-) UNIT RANGE 3000 (+-) UNIT RANGE 500 (+-) UNIT RANGE
MB LA
ALPHANATE INTRAVENOUS RECON SOLN 1000 (400 VWF) UNIT10 ML 1500 (600 VWF) UNIT10 ML 2000 (800 VWF) UNIT10 ML 250 (100 VWF) UNIT5 ML 500 (200 VWF) UNIT5 ML
MB LA
ALPHANINE SD INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT
MB LA
ALPROLIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 500 UNIT
MB LA
aminocaproic acid oral solution 250 mgml (25 ) 1
51
Drug Name Drug Tier Requirements Limits
aminocaproic acid oral tablet 1000 mg 500 mg 1
ANDEXXA INTRAVENOUS RECON SOLN 200 MG
MB
aspirin-dipyridamole oral capsule er multiphase 12 hr 25-200 mg
1
BENEFIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
BRILINTA ORAL TABLET 60 MG 90 MG 1
CABLIVI INJECTION KIT 11 MG 2 PA
cilostazol oral tablet 100 mg 50 mg 1
clopidogrel oral tablet 300 mg 75 mg 1
COAGADEX INTRAVENOUS RECON SOLN 250 (+-) UNIT RANGE 500 (+-) UNIT RANGE
MB
CORIFACT INTRAVENOUS RECON SOLN 1000-1600 UNIT
MB LA
dipyridamole oral tablet 25 mg 50 mg 75 mg 1
DOPTELET (15 TAB PACK) ORAL TABLET 20 MG
2 PA LA
ELIQUIS DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 5 MG (74 TABS)
1
ELIQUIS ORAL TABLET 25 MG 5 MG 1
ELOCTATE INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 5000 UNIT 500 UNIT 6000 UNIT 750 UNIT
MB LA
enoxaparin subcutaneous solution 300 mg3 ml 2
enoxaparin subcutaneous syringe 100 mgml 120 mg08 ml 150 mgml 30 mg03 ml 40 mg04 ml 60 mg06 ml 80 mg08 ml
2
ESPEROCT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
FEIBA NF INTRAVENOUS RECON SOLN 1750-3250 UNIT 350-650 UNIT 700-1300 UNIT
MB LA
FIBRYGA INTRAVENOUS RECON SOLN 1 GRAM (700 MG- 1300 MG)
MB
fondaparinux subcutaneous syringe 10 mg08 ml 25 mg05 ml 5 mg04 ml 75 mg06 ml
2
52
Drug Name Drug Tier Requirements Limits
FRAGMIN SUBCUTANEOUS SOLUTION 25000 ANTI-XA UNITML
2
FRAGMIN SUBCUTANEOUS SYRINGE 10000 ANTI-XA UNITML 12500 ANTI-XA UNIT05 ML 15000 ANTI-XA UNIT06 ML 18000 ANTI-XA UNIT072 ML 2500 ANTI-XA UNIT02 ML 5000 ANTI-XA UNIT02 ML 7500 ANTI-XA UNIT03 ML
2
HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG07 ML 150 MGML 30 MGML 60 MG04 ML
2 PA LA
HEMOFIL M HIGH INTRAVENOUS RECON SOLN 801-1500 UNIT
MB
HEMOFIL M LOW INTRAVENOUS RECON SOLN 220-400 UNIT
MB
HEMOFIL M MID INTRAVENOUS RECON SOLN 401-800 UNIT
MB
HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 1501-2000 UNIT
MB
hep flush-10 (pf) intravenous solution 10 unitml MB
heparin (porcine) in 5 dex intravenous parenteral solution 25000 unit250 ml(100 unitml) 25000 unit500 ml (50 unitml)
MB
heparin (porcine) injection cartridge 5000 unitml (1 ml)
1
heparin (porcine) injection solution 1000 unitml 10000 unitml 20000 unitml 5000 unitml
1
heparin lock flush (porcine) intravenous solution 100 unitml
MB
heparin lockflush(porcine)(pf) intravenous syringe 100 unitml
MB
HEPARIN(PORCINE) IN 045 NACL INTRAVENOUS PARENTERAL SOLUTION 12500 UNIT250 ML
MB
heparin(porcine) in 045 nacl intravenous parenteral solution 25000 unit250 ml 25000 unit500 ml
MB
heparin porcine (pf) injection solution 1000 unitml 5000 unit05 ml
MB
heparin porcine (pf) injection syringe 5000 unit05 ml
1
53
Drug Name Drug Tier Requirements Limits
heparin porcine (pf) intravenous solution 100 unitml (1 ml)
MB
heparin porcine (pf) intravenous syringe 10 unitml 100 unitml
MB
HUMATE-P INTRAVENOUS RECON SOLN 1000-2400 UNIT 250-600 UNIT 500-1200 UNIT
MB LA
IDELVION INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3500 (+-) UNIT 500 (+-) UNIT
MB LA
IXINITY INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
jantoven oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg
1
JIVI INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
KOATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB
KOGENATE FS INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB
KOVALTRY INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB
MONONINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT
MB LA
MULPLETA ORAL TABLET 3 MG 2 PA LA
NOVOEIGHT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
NOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1000 MCG) 2 MG (2000 MCG) 5 MG (5000 MCG) 8 MG (8000 MCG)
MB LA
NPLATE SUBCUTANEOUS RECON SOLN 125 MCG 250 MCG 500 MCG
MB LA
NUWIQ INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 2500 UNIT 250 (+-) UNIT 3000 UNIT 4000 UNIT 500 (+-) UNIT
MB LA
54
Drug Name Drug Tier Requirements Limits
OBIZUR INTRAVENOUS RECON SOLN 500 (+-) UNIT RANGE
MB
pentoxifylline oral tablet extended release 400 mg 1
phytonadione (vitamin k1) oral tablet 5 mg 1
prasugrel oral tablet 10 mg 5 mg 1
PROFILNINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT
MB LA
PROMACTA ORAL POWDER IN PACKET 125 MG
2 PA ST LA
PROMACTA ORAL POWDER IN PACKET 25 MG
2 LA
PROMACTA ORAL TABLET 125 MG 25 MG 50 MG 75 MG
2 PA ST LA
REBINYN INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 500 (+-) UNIT
MB LA
RECOMBINATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB LA
RIASTAP INTRAVENOUS RECON SOLN 1 GRAM (900MG-1300MG)
MB LA
RIXUBIS INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
tranexamic acid intravenous solution 1000 mg10 ml (100 mgml)
MB
TRETTEN INTRAVENOUS RECON SOLN 2500 UNIT
MB LA
VONVENDI INTRAVENOUS RECON SOLN 1300 (+-) UNIT RANGE 650 (+-) UNIT RANGE
MB LA
warfarin oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg
1
WILATE INTRAVENOUS RECON SOLN 1000-1000 UNIT 500-500 UNIT
MB LA
XARELTO DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 15 MG (42)- 20 MG (9)
1
XARELTO ORAL TABLET 10 MG 15 MG 25 MG 20 MG
1
55
Drug Name Drug Tier Requirements Limits
XYNTHA INTRAVENOUS SOLUTION 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB LA
XYNTHA SOLOFUSE INTRAVENOUS SYRINGE 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
ZONTIVITY ORAL TABLET 208 MG 1
LIPIDCHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg 25-10 mg 25-20 mg 25-40 mg 5-10 mg 5-20 mg 5-40 mg 5-80 mg
1 ST
atorvastatin oral tablet 10 mg 20 mg ACA PV
atorvastatin oral tablet 40 mg 80 mg 1
cholestyramine (with sugar) oral powder 4 gram 1
cholestyramine (with sugar) oral powder in packet 4 gram
1
cholestyramine light oral powder 4 gram 1
cholestyramine light oral powder in packet 4 gram 1
colesevelam oral powder in packet 375 gram 1
colesevelam oral tablet 625 mg 1
colestipol oral granules 5 gram 1
colestipol oral packet 5 gram 1
colestipol oral tablet 1 gram 1
ezetimibe oral tablet 10 mg 1
ezetimibe-simvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg
1
fenofibrate micronized oral capsule 130 mg 134 mg 200 mg 43 mg 67 mg
1
fenofibrate nanocrystallized oral tablet 145 mg 48 mg
1
FENOFIBRATE ORAL CAPSULE 150 MG 50 MG
1
fenofibrate oral tablet 120 mg 160 mg 40 mg 54 mg
1
fenofibric acid (choline) oral capsuledelayed release(drec) 135 mg 45 mg
1
fenofibric acid oral tablet 105 mg 35 mg 1
fluvastatin oral capsule 20 mg 40 mg ACA PV
56
Drug Name Drug Tier Requirements Limits
fluvastatin oral tablet extended release 24 hr 80 mg
ACA PV
gemfibrozil oral tablet 600 mg 1
icosapent ethyl oral capsule 1 gram 1 PA ST QL (120 per 30 days)
JUXTAPID ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 5 MG 60 MG
2 PA LA QL (30 per 30 days)
LIPOFEN ORAL CAPSULE 150 MG 50 MG 1
lovastatin oral tablet 10 mg 20 mg 40 mg ACA PV
niacin oral tablet 500 mg 1
niacin oral tablet extended release 24 hr 1000 mg 500 mg 750 mg
1
NIACOR ORAL TABLET 500 MG 1
omega-3 acid ethyl esters oral capsule 1 gram 1
pravastatin oral tablet 10 mg 20 mg 40 mg 80 mg
ACA PV
prevalite oral powder 4 gram 1
prevalite oral powder in packet 4 gram 1
REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG35 ML
1 PA ST
REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MGML
1 PA ST
REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MGML
1 PA ST
rosuvastatin oral tablet 10 mg 5 mg ACA PV
rosuvastatin oral tablet 20 mg 40 mg 1
simvastatin oral tablet 10 mg 20 mg 40 mg 5 mg ACA PV
simvastatin oral tablet 80 mg 1
VASCEPA ORAL CAPSULE 05 GRAM 1 GRAM
1 PA ST QL (120 per 30 days)
ZYPITAMAG ORAL TABLET 2 MG 4 MG 1 PA ST
MISCELLANEOUS CARDIOVASCULAR AGENTS
CORLANOR ORAL SOLUTION 5 MG5 ML 1 PA
CORLANOR ORAL TABLET 5 MG 75 MG 1 PA
ENTRESTO ORAL TABLET 24-26 MG 49-51 MG 97-103 MG
1 PA ST
GIAPREZA INTRAVENOUS SOLUTION 25 MGML
MB
57
Drug Name Drug Tier Requirements Limits
ranolazine oral tablet extended release 12 hr 1000 mg 500 mg
1 ST
NITRATES
GONITRO SUBLINGUAL POWDER IN PACKET 400 MCG
1
isosorbide dinitrate oral tablet 10 mg 20 mg 30 mg 40 mg 5 mg
1
isosorbide mononitrate oral tablet 10 mg 20 mg 1
isosorbide mononitrate oral tablet extended release 24 hr 120 mg 30 mg 60 mg
1
MINITRAN TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 04 MGHR 06 MGHR
1 PA ST
nitro-bid transdermal ointment 2 1
NITRO-DUR TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 03 MGHR 04 MGHR 06 MGHR 08 MGHR
1 PA ST
nitroglycerin in 5 dextrose intravenous solution 25 mg250 ml (100 mcgml) 50 mg500 ml (100 mcgml)
MB
nitroglycerin sublingual tablet 03 mg 04 mg 06 mg
1
nitroglycerin transdermal patch 24 hour 01 mghr 02 mghr 04 mghr 06 mghr
1
nitroglycerin translingual spraynon-aerosol 400 mcgspray
1
nitro-time oral capsule extended release 25 mg 65 mg 9 mg
1
DERMATOLOGICALSTOPICAL THERAPY
ANTIPSORIATIC ANTISEBORRHEIC
acitretin oral capsule 10 mg 175 mg 25 mg 1
calcipotriene scalp solution 0005 1
calcipotriene topical cream 0005 1
calcipotriene topical ointment 0005 1
calcipotriene-betamethasone topical ointment 0005-0064
1
calcitriol topical ointment 3 mcggram 1
COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
58
Drug Name Drug Tier Requirements Limits
COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
COSENTYX SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
COSENTYX SUBCUTANEOUS SYRINGE 75 MG05 ML
2 PA LA
hydrocortisone-pramoxine topical cream 25-1 1
ILUMYA SUBCUTANEOUS SYRINGE 100 MGML
2 PA ST LA
selenium sulfide topical lotion 25 1
selenium sulfide topical shampoo 225 23 1
SILIQ SUBCUTANEOUS SYRINGE 210 MG15 ML
2 PA ST LA
SKYRIZI SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
SKYRIZI SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
SKYRIZI SUBCUTANEOUS SYRINGE KIT 150MG166ML(75 MG083 ML X2)
2 PA ST LA
STELARA INTRAVENOUS SOLUTION 130 MG26 ML
MB PA LA
STELARA SUBCUTANEOUS SOLUTION 45 MG05 ML
2 PA ST LA
STELARA SUBCUTANEOUS SYRINGE 45 MG05 ML 90 MGML
2 PA ST LA
sulfacetamide sodium topical cleanser 10 1
sulfacetamide sodium topical cleanser gel 10 1
sulfacetamide sodium topical shampoo 10 1
TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MGML
2 PA ST LA
59
Drug Name Drug Tier Requirements Limits
TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 MGML
2 PA ST LA
TREMFYA SUBCUTANEOUS SYRINGE 100 MGML
2 PA ST LA
BURN THERAPY
silver sulfadiazine topical cream 1 1
ssd topical cream 1 1
MISCELLANEOUS DERMATOLOGICALS
ammonium lactate topical cream 12 1
ammonium lactate topical lotion 12 1
diclofenac sodium topical gel 3 1
DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300 MG2 ML
2 LA
DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG114 ML 300 MG2 ML
2 PA ST LA
EUCRISA TOPICAL OINTMENT 2 1 PA ST
FLUOROURACIL TOPICAL CREAM 05 1 PA ST
fluorouracil topical cream 5 1 PA ST
fluorouracil topical solution 2 5 1
LEVULAN TOPICAL SOLUTION 20 1
methoxsalen oral capsuleliqd-filledrapid rel 10 mg
1
PANRETIN TOPICAL GEL 01 1
PICATO TOPICAL GEL 0015 005 1
pimecrolimus topical cream 1 1
podofilox topical solution 05 1
prudoxin topical cream 5 1
REGRANEX TOPICAL GEL 001 1
SCENESSE SUBCUTANEOUS IMPLANT 16 MG
MB PA
tacrolimus topical ointment 003 01 1
UVADEX INJECTION SOLUTION 20 MCGML 1
VALCHLOR TOPICAL GEL 0016 2 PA ST LA
THERAPY FOR ACNE
accutane oral capsule 20 mg 30 mg 40 mg 1
adapalene topical cream 01 1 ST
60
Drug Name Drug Tier Requirements Limits
adapalene topical gel 03 1 ST
adapalene topical gel with pump 03 1 ST
ADAPALENE TOPICAL LOTION 01 1 ST
adapalene topical solution 01 1 ST
adapalene topical swab 01 1 ST
adapalene-benzoyl peroxide topical gel with pump 01-25
1
amnesteem oral capsule 10 mg 20 mg 40 mg 1 PA ST
avita topical cream 0025 1
AVITA TOPICAL GEL 0025 1 ST
azelaic acid topical gel 15 1
AZELEX TOPICAL CREAM 20 1 ST
claravis oral capsule 10 mg 20 mg 30 mg 1 PA ST
claravis oral capsule 40 mg 1
clindacin p topical swab 1 1
clindamycin phosphate topical foam 1 1
clindamycin phosphate topical gel 1 1
clindamycin phosphate topical lotion 1 1
clindamycin phosphate topical solution 1 1
clindamycin phosphate topical swab 1 1
clindamycin-benzoyl peroxide topical gel 1-5 12 (1 base) -5
1
clindamycin-benzoyl peroxide topical gel with pump 1-5
1
clindamycin-tretinoin topical gel 12-0025 1
dapsone topical gel 5 1
ery pads topical swab 2 1
erygel topical gel 2 1
erythromycin with ethanol topical gel 2 1
erythromycin with ethanol topical solution 2 1
erythromycin-benzoyl peroxide topical gel 3-5 1
isotretinoin oral capsule 10 mg 20 mg 25 mg 30 mg 35 mg 40 mg
1
metronidazole topical cream 075 1
metronidazole topical gel 075 1 1
metronidazole topical gel with pump 1 1
61
Drug Name Drug Tier Requirements Limits
metronidazole topical lotion 075 1
myorisan oral capsule 10 mg 20 mg 30 mg 40 mg
1
rosadan topical cream 075 1
rosadan topical gel 075 1
tazarotene topical cream 01 1 ST
tretinoin microspheres topical gel 004 01 1
tretinoin microspheres topical gel with pump 004 01
1
tretinoin topical cream 0025 005 01 1
tretinoin topical gel 001 0025 005 1
zenatane oral capsule 10 mg 20 mg 30 mg 40 mg 1
TOPICAL ANESTHETICS
lidocaine hcl injection solution 10 mgml (1 ) 1
lidocaine hcl laryngotracheal solution 4 1
lidocaine hcl mucous membrane jelly 2 1
lidocaine hcl mucous membrane jelly in applicator 2
1
lidocaine hcl mucous membrane solution 4 (40 mgml)
1
lidocaine hcl-hydrocortison ac topical cream 3-05
1
lidocaine topical adhesive patchmedicated 5 1
lidocaine topical ointment 5 1
lidocaine viscous mucous membrane solution 2 1
lidocaine-prilocaine topical cream 25-25 1
lidocaine-prilocaine topical kit 25-25 1
LIDOCAINE-TETRACAINE TOPICAL CREAM 7-7
1 ST
SYNERA TOPICAL PATCH MEDICATED SELF-HEATING 70-70 MG
1 ST
TOPICAL ANTIBACTERIALS
ALCORTIN A TOPICAL GEL 2-1-1 1 ST
ALCORTIN A TOPICAL GEL IN PACKET 2-1-1
1 ST
ALTABAX TOPICAL OINTMENT 1 1
gentamicin topical cream 01 1
62
Drug Name Drug Tier Requirements Limits
gentamicin topical ointment 01 1
mafenide acetate topical packet 50 gram 1
mupirocin calcium topical cream 2 1
mupirocin topical ointment 2 1
sulfacetamide sodium (acne) topical suspension 10
1
SULFAMYLON TOPICAL CREAM 85 MGG 1
TOPICAL ANTIFUNGALS
ciclodan topical cream 077 1
ciclodan topical solution 8 1
ciclopirox topical cream 077 1
ciclopirox topical gel 077 1
ciclopirox topical shampoo 1 1
ciclopirox topical solution 8 1
ciclopirox topical suspension 077 1
ciclopirox-ure-camph-menth-euc topical solution 8
1
clotrimazole topical cream 1 1
clotrimazole topical solution 1 1
clotrimazole-betamethasone topical cream 1-005
1
clotrimazole-betamethasone topical lotion 1-005
1
econazole topical cream 1 1
EXELDERM TOPICAL CREAM 1 1
EXELDERM TOPICAL SOLUTION 1 1
JUBLIA TOPICAL SOLUTION WITH APPLICATOR 10
1 PA ST
ketoconazole topical cream 2 1
ketoconazole topical foam 2 1
ketoconazole topical shampoo 2 1
ketodan topical foam 2 1
LULICONAZOLE TOPICAL CREAM 1 1
LUZU TOPICAL CREAM 1 1
MENTAX TOPICAL CREAM 1 1
naftifine topical cream 1 2 1
63
Drug Name Drug Tier Requirements Limits
naftifine topical gel 1 1
nyamyc topical powder 100000 unitgram 1
nystatin topical cream 100000 unitgram 1
nystatin topical ointment 100000 unitgram 1
nystatin topical powder 100000 unitgram 1
nystatin-triamcinolone topical cream 100000-01 unitg-
1
nystatin-triamcinolone topical ointment 100000-01 unitgram-
1
nystop topical powder 100000 unitgram 1
oxiconazole topical cream 1 1
OXISTAT TOPICAL LOTION 1 1
tavaborole topical solution with applicator 5 1 PA ST
TOPICAL ANTIVIRALS
acyclovir topical cream 5 1
acyclovir topical ointment 5 1
DENAVIR TOPICAL CREAM 1 1
TOPICAL CORTICOSTEROIDS
ala-cort topical cream 1 1
alclometasone topical cream 005 1
alclometasone topical ointment 005 1
amcinonide topical cream 01 1
amcinonide topical lotion 01 1
apexicon e topical cream 005 1
beser topical lotion 005 1
betamethasone dipropionate topical cream 005 1
betamethasone dipropionate topical lotion 005 1
betamethasone dipropionate topical ointment 005
1
betamethasone valerate topical cream 01 1
betamethasone valerate topical foam 012 1
betamethasone valerate topical lotion 01 1
betamethasone valerate topical ointment 01 1
betamethasone augmented topical cream 005 1
betamethasone augmented topical gel 005 1
betamethasone augmented topical lotion 005 1
64
Drug Name Drug Tier Requirements Limits
betamethasone augmented topical ointment 005
1
clobetasol scalp solution 005 1
clobetasol topical cream 005 1
clobetasol topical foam 005 1
clobetasol topical gel 005 1
clobetasol topical lotion 005 1
clobetasol topical ointment 005 1
clobetasol topical shampoo 005 1
clobetasol topical spraynon-aerosol 005 1
clobetasol-emollient topical cream 005 1
clobetasol-emollient topical foam 005 1
CLOCORTOLONE PIVALATE TOPICAL CREAM 01
1 ST
CLODERM TOPICAL CREAM 01 1 ST
desonide topical cream 005 1
desonide topical lotion 005 1
desonide topical ointment 005 1
desoximetasone topical cream 005 025 1
desoximetasone topical gel 005 1
desoximetasone topical ointment 005 025 1
desoximetasone topical spraynon-aerosol 025 1
diflorasone topical cream 005 1
diflorasone topical ointment 005 1
fluocinolone and shower cap scalp oil 001 1
fluocinolone topical cream 001 0025 1
fluocinolone topical oil 001 1
fluocinolone topical ointment 0025 1
fluocinolone topical solution 001 1
fluocinonide topical cream 005 01 1
fluocinonide topical gel 005 1
fluocinonide topical ointment 005 1
fluocinonide topical solution 005 1
fluocinonide-e topical cream 005 1
flurandrenolide topical cream 005 1
65
Drug Name Drug Tier Requirements Limits
flurandrenolide topical lotion 005 1
flurandrenolide topical ointment 005 1
fluticasone propionate topical cream 005 1
fluticasone propionate topical lotion 005 1
fluticasone propionate topical ointment 0005 1
halcinonide topical cream 01 1
halobetasol propionate topical cream 005 1
halobetasol propionate topical ointment 005 1
hydrocortisone butyrate topical cream 01 1
hydrocortisone butyrate topical lotion 01 1
hydrocortisone butyrate topical ointment 01 1
hydrocortisone butyrate topical solution 01 1
hydrocortisone butyr-emollient topical cream 01
1
hydrocortisone topical cream 1 25 1
hydrocortisone topical lotion 25 1
hydrocortisone topical ointment 1 25 1
hydrocortisone valerate topical cream 02 1
hydrocortisone valerate topical ointment 02 1
mometasone topical cream 01 1
mometasone topical ointment 01 1
mometasone topical solution 01 1
prednicarbate topical cream 01 1
prednicarbate topical ointment 01 1
scalacort topical lotion 2 1
triamcinolone acetonide topical aerosol 0147 mggram
1
triamcinolone acetonide topical cream 0025 01 05
1
triamcinolone acetonide topical lotion 0025 01
1
triamcinolone acetonide topical ointment 0025 005 01 05
1
triderm topical cream 01 05 1
TOPICAL ENZYMES
SANTYL TOPICAL OINTMENT 250 UNITGRAM
1 QL (2 per 30 days)
66
Drug Name Drug Tier Requirements Limits
TOPICAL SCABICIDES PEDICULICIDES
crotan topical lotion 10 1
EURAX TOPICAL CREAM 10 1
EURAX TOPICAL LOTION 10 1
ivermectin topical lotion 05 1
lindane topical shampoo 1 1
malathion topical lotion 05 1
permethrin topical cream 5 1
spinosad topical suspension 09 1
ULESFIA TOPICAL LOTION 5 1
DIAGNOSTICS amp MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
PHYSIOLYTE IRRIGATION SOLUTION 140-5-3-98 MEQL
MB
PHYSIOSOL IRRIGATION IRRIGATION SOLUTION 140-5-3-98 MEQL
MB
MISCELLANEOUS AGENTS
acamprosate oral tabletdelayed release (drec) 333 mg
1
acetic acid irrigation solution 025 1
anagrelide oral capsule 05 mg 1 mg 1
ARALAST NP INTRAVENOUS RECON SOLN 1000 MG 500 MG
MB LA
CARBAGLU ORAL TABLET DISPERSIBLE 200 MG
2 PA LA
cevimeline oral capsule 30 mg 1
CHEMET ORAL CAPSULE 100 MG 1
clovique oral capsule 250 mg 1 PA QL (240 per 30 days)
deferasirox oral granules in packet 180 mg 360 mg 90 mg
2 PA LA
deferasirox oral tablet 180 mg 2 PA LA
deferasirox oral tablet 360 mg 90 mg 2 ST LA
deferasirox oral tablet dispersible 125 mg 250 mg 500 mg
2 ST LA
deferiprone oral tablet 500 mg 1 PA
disulfiram oral tablet 250 mg 500 mg 1
67
Drug Name Drug Tier Requirements Limits
EMPAVELI SUBCUTANEOUS SOLUTION 1080 MG20 ML
2 PA
FERRIPROX ORAL SOLUTION 100 MGML 1 PA
FERRIPROX ORAL TABLET 1000 MG 500 MG
1 PA
GIVLAARI SUBCUTANEOUS SOLUTION 189 MGML
MB PA LA
GLASSIA INTRAVENOUS SOLUTION 1 GRAM50 ML (2 )
MB LA
INCRELEX SUBCUTANEOUS SOLUTION 10 MGML
2 PA LA
levocarnitine (with sugar) oral solution 100 mgml 1
levocarnitine oral solution 100 mgml 1
levocarnitine oral tablet 330 mg 1
midodrine oral tablet 10 mg 25 mg 5 mg 1
nitisinone oral capsule 10 mg 2 mg 5 mg 2 PA LA
NITYR ORAL TABLET 10 MG 2 MG 5 MG 2 PA LA
pilocarpine hcl oral tablet 5 mg 1
PROLASTIN-C INTRAVENOUS SOLUTION 1000 MG (+-)20 ML
MB
RAVICTI ORAL LIQUID 11 GRAMML 2 PA ST LA QL (10 per 30 days)
RECLAST INTRAVENOUS PIGGYBACK 5 MG100 ML
MB
riluzole oral tablet 50 mg 1
risedronate oral tablet 30 mg 1
sodium chloride 09 injection solution MB
sodium chloride 09 intravenous parenteral solution
MB
sodium chloride 09 intravenous piggyback MB
sodium phenylbutyrate oral powder 094 gramgram
1 PA
sodium phenylbutyrate oral tablet 500 mg 1 PA
SOLIRIS INTRAVENOUS SOLUTION 300 MG30 ML
MB PA LA
trientine oral capsule 250 mg 1 PA QL (240 per 30 days)
XURIDEN ORAL GRANULES IN PACKET 2 GRAM
2 PA QL (120 per 30 days)
68
Drug Name Drug Tier Requirements Limits
ZEMAIRA INTRAVENOUS RECON SOLN 1000 MG
MB LA
ZOKINVY ORAL CAPSULE 50 MG 75 MG 2 PA ST
SMOKING DETERRENTS
bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg
ACA PV
CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG
ACA PV QL (180 per 365 days)
CHANTIX ORAL TABLET 05 MG 1 MG ACA PV QL (180 per 365 days)
CHANTIX STARTING MONTH BOX ORAL TABLETSDOSE PACK 05 MG (11)- 1 MG (42)
ACA PV QL (180 per 365 days)
nicorette buccal gum 4 mg ACA PV
nicotine (polacrilex) buccal gum 2 mg 4 mg ACA PV
nicotine (polacrilex) buccal lozenge 2 mg 4 mg ACA PV
nicotine (polacrilex) buccal mini lozenge 2 mg 4 mg
ACA PV
nicotine transdermal patch 24 hour 14 mg24 hr 21 mg24 hr 7 mg24 hr
ACA PV
nicotine transdermal patch td daily sequential 21-14-7 mg24 hr
ACA PV
NICOTROL INHALATION CARTRIDGE 10 MG
ACA PV
NICOTROL NS NASAL SPRAYNON-AEROSOL 10 MGML
ACA PV
quit 2 buccal gum 2 mg ACA PV
quit 2 buccal lozenge 2 mg ACA PV
quit 4 buccal gum 4 mg ACA PV
quit 4 buccal lozenge 4 mg ACA PV
stop smoking aid buccal lozenge 2 mg 4 mg ACA PV
EAR NOSE amp THROAT MEDICATIONS
MISCELLANEOUS AGENTS
ARESTIN DENTAL CARTRIDGE 1 MG MB
azelastine nasal aerosolspray 137 mcg (01 ) 1
azelastine nasal spraynon-aerosol 2055 mcg (015 )
1
chlorhexidine gluconate mucous membrane mouthwash 012
1
denta 5000 plus dental cream 11 1
69
Drug Name Drug Tier Requirements Limits
dentagel dental gel 11 1
fluoride (sodium) dental cream 11 1
fluoride (sodium) dental gel 11 1
fluoride (sodium) dental paste 11 1
ipratropium bromide nasal spraynon-aerosol 21 mcg (003 ) 42 mcg (006 )
1
olopatadine nasal spraynon-aerosol 06 1
oralone dental paste 01 1
paroex oral rinse mucous membrane mouthwash 012
1
periogard mucous membrane mouthwash 012 1
pilocarpine hcl oral tablet 75 mg 1
sf 5000 plus dental cream 11 1
sf dental gel 11 1
sodium fluoride 5000 dry mouth dental gel 11 1
sodium fluoride 5000 plus dental cream 11 1
sodium fluoride-pot nitrate dental paste 11-5 1
triamcinolone acetonide dental paste 01 1
MISCELLANEOUS OTIC PREPARATIONS
acetic acid otic (ear) solution 2 1
ciprofloxacin hcl otic (ear) dropperette 02 1
flac otic oil otic (ear) drops 001 1
fluocinolone acetonide oil otic (ear) drops 001 1
hydrocortisone-acetic acid otic (ear) drops 1-2 1
ofloxacin otic (ear) drops 03 1
OTIC STEROID ANTIBIOTIC
CIPRO HC OTIC (EAR) DROPSSUSPENSION 02-1
1
ciprofloxacin-dexamethasone otic (ear) dropssuspension 03-01
1
neomycin-polymyxin-hc otic (ear) dropssuspension 35-10000-1 mgml-unitml-
1
neomycin-polymyxin-hc otic (ear) solution 35-10000-1 mgml-unitml-
1
OTOVEL OTIC (EAR) SOLUTION 03-0025 (025 ML)
1
ENDOCRINEDIABETES
70
Drug Name Drug Tier Requirements Limits
ADRENAL HORMONES
ACTHAR INJECTION GEL 80 UNITML 2 PA LA
decadron oral tablet 05 mg 1
dexamethasone intensol oral drops 1 mgml 1
dexamethasone oral elixir 05 mg5 ml 1
dexamethasone oral solution 05 mg5 ml 1
dexamethasone oral tablet 05 mg 075 mg 1 mg 15 mg 2 mg 4 mg 6 mg
1
dexamethasone oral tabletsdose pack 15 mg (21 tabs) 15 mg (35 tabs) 15 mg (51 tabs)
1
dexamethasone sodium phos (pf) injection solution 10 mgml
1
dexamethasone sodium phosphate injection solution 10 mgml 4 mgml
1
dexamethasone sodium phosphate injection syringe 4 mgml
1
fludrocortisone oral tablet 01 mg 1
hydrocortisone oral tablet 10 mg 20 mg 5 mg 1
methylprednisolone acetate injection suspension 40 mgml 80 mgml
1
methylprednisolone oral tablet 16 mg 32 mg 4 mg 8 mg
1
methylprednisolone oral tabletsdose pack 4 mg 1
millipred dp oral tabletsdose pack 5 mg (21 tabs) 5 mg (48 tabs)
1
millipred oral tablet 5 mg 1
prednisolone oral solution 15 mg5 ml 1
prednisolone sodium phosphate oral solution 10 mg5 ml 15 mg5 ml (3 mgml) 20 mg5 ml (4 mgml) 25 mg5 ml (5 mgml) 5 mg base5 ml (67 mg5 ml)
1
prednisolone sodium phosphate oral tabletdisintegrating 10 mg 15 mg 30 mg
1
prednisone intensol oral concentrate 5 mgml 1
prednisone oral solution 5 mg5 ml 1
prednisone oral tablet 1 mg 10 mg 25 mg 20 mg 5 mg 50 mg
1
prednisone oral tabletsdose pack 10 mg 5 mg 1
71
Drug Name Drug Tier Requirements Limits
triamcinolone acetonide injection suspension 40 mgml
MB
ANTITHYROID AGENTS
methimazole oral tablet 10 mg 5 mg 1
propylthiouracil oral tablet 50 mg 1
SSKI ORAL SOLUTION 1 GRAMML 1
BLOOD GLUCOSE MONITORING DEVICES amp SUPPLIES
CONTOUR NEXT TEST STRIPS STRIP 1
CONTOUR TEST STRIPS STRIP 1
ONETOUCH ULTRA TEST STRIP 1
ONETOUCH VERIO TEST STRIPS STRIP 1
DIABETES SUPPLIES amp DURABLE MEDICAL EQUIPMENT
AEROCHAMBER MINI SPACER 1
AEROCHAMBER PLUS FLOW-VU SPACER 1
GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN 1 MGML
1
GLUCAGON HCL INJECTION RECON SOLN 1 MGML
1
INSULIN SYRINGE-NEEDLE U-100 SYRINGE 05 ML 29 GAUGE X 12
1
TRIJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-5-1000 MG 125-25-1000 MG 25-5-1000 MG 5-25-1000 MG
1 PA ST
GLUCOSE ELEVATING AGENTS
BAQSIMI NASAL SPRAYNON-AEROSOL 3 MGACTUATION
1
diazoxide oral suspension 50 mgml 1
GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG
1
GLUCAGON (HCL) EMERGENCY KIT INJECTION RECON SOLN 1 MG
1
glucagon emergency kit (human) injection recon soln 1 mg
1
INSULIN SYRINGESMISCELLANEOUS DURABLE MEDICAL EQU
FREESTYLE LIBRE 14 DAY SENSOR KIT 1
FREESTYLE LIBRE 2 SENSOR KIT 1
NOVOPEN ECHO SUBCUTANEOUS INSULIN PEN
1
72
Drug Name Drug Tier Requirements Limits
PEN NEEDLE DIABETIC NEEDLE 29 GAUGE X 12
1
INSULIN THERAPY
FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
FIASP PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML (3 ML)
1
FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN HALF-UNIT 100 UNITML
1
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML
1 ST
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 200 UNITML (3 ML)
1
HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNITML (50-50)
1 ST
HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (50-50)
1 ST
HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (75-25)
1 ST
HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNITML (75-25)
1 ST
HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML
1 ST
HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1 ST
HUMULIN 7030 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)
1 ST
HUMULIN 7030 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1 ST
73
Drug Name Drug Tier Requirements Limits
HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1 ST
HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML
1 ST
HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNITML
1 ST
HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNITML
1
HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNITML (3 ML)
1
INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML (70-30)
1
INSULIN ASPART U-100 SUBCUTANEOUS CARTRIDGE 100 UNITML
1
INSULIN ASPART U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
INSULIN ASPART U-100 SUBCUTANEOUS SOLUTION 100 UNITML
1
LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
NOVOLIN R FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
74
Drug Name Drug Tier Requirements Limits
NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNITML (70-30)
1
NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML
1
NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML
1
RELION NOVOLIN 7030 SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)
1
RELION NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNITML
1
RELION NOVOLIN R INJECTION SOLUTION 100 UNITML
1
SOLIQUA 10033 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCGML
1 PA ST
TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNITML (3 ML)
1
TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNITML (15 ML)
1
TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN 200 UNITML (3 ML)
1
TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
XULTOPHY 10036 SUBCUTANEOUS INSULIN PEN 100 UNIT-36 MG ML (3 ML)
1 PA ST
MISCELLANEOUS HORMONES
ALDURAZYME INTRAVENOUS SOLUTION 29 MG5 ML
MB PA LA
ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG24 HOUR 4 MG24 HR
1 ST QL (30 per 30 days)
75
Drug Name Drug Tier Requirements Limits
BRINEURA INTRAVENTRICULAR KIT 300 MG10 ML (150MG5ML X2)
MB
cabergoline oral tablet 05 mg 1
calcitonin (salmon) injection solution 200 unitml 1
calcitonin (salmon) nasal spraynon-aerosol 200 unitactuation
1
calcitriol oral capsule 025 mcg 05 mcg 1
calcitriol oral solution 1 mcgml 1
CERDELGA ORAL CAPSULE 84 MG 2 PA LA
CEREZYME INTRAVENOUS RECON SOLN 400 UNIT
MB PA LA
cinacalcet oral tablet 30 mg 60 mg 90 mg 2 PA
CRYSVITA SUBCUTANEOUS SOLUTION 10 MGML 20 MGML 30 MGML
MB PA LA
danazol oral capsule 100 mg 200 mg 50 mg 1
DEPO-TESTOSTERONE INTRAMUSCULAR OIL 100 MGML
1
desmopressin nasal spraynon-aerosol 10 mcgspray (01 ml)
1
desmopressin oral tablet 01 mg 02 mg 1
doxercalciferol oral capsule 05 mcg 1 mcg 25 mcg
1
ELAPRASE INTRAVENOUS SOLUTION 6 MG3 ML
MB PA LA
ELELYSO INTRAVENOUS RECON SOLN 200 UNIT
MB PA LA
FABRAZYME INTRAVENOUS RECON SOLN 35 MG 5 MG
MB PA LA
GALAFOLD ORAL CAPSULE 123 MG 2 PA LA
JYNARQUE ORAL TABLET 15 MG 30 MG 2 PA QL (60 per 30 days)
JYNARQUE ORAL TABLETS SEQUENTIAL 45 MG (AM) 15 MG (PM) 60 MG (AM) 30 MG (PM) 90 MG (AM) 30 MG (PM)
2 PA QL (60 per 30 days)
KANUMA INTRAVENOUS SOLUTION 2 MGML
MB PA LA
KORLYM ORAL TABLET 300 MG 2 PA ST
LUMIZYME INTRAVENOUS RECON SOLN 50 MG
MB PA LA
76
Drug Name Drug Tier Requirements Limits
MEPSEVII INTRAVENOUS SOLUTION 2 MGML
MB PA LA
methyltestosterone oral capsule 10 mg 1
MIACALCIN INJECTION SOLUTION 200 UNITML
1
miglustat oral capsule 100 mg 2 PA LA
MYALEPT SUBCUTANEOUS RECON SOLN 5 MGML (FINAL CONC)
2 LA
NAGLAZYME INTRAVENOUS SOLUTION 5 MG5 ML
MB PA LA
NATPARA SUBCUTANEOUS CARTRIDGE 100 MCGDOSE 25 MCGDOSE 50 MCGDOSE 75 MCGDOSE
2 PA ST LA
oxandrolone oral tablet 10 mg 25 mg 1
PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG05 ML 25 MG05 ML 20 MGML
2 PA LA
pamidronate intravenous solution 30 mg10 ml (3 mgml)
MB
PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCGML
MB
paricalcitol intravenous solution 5 mcgml MB
paricalcitol oral capsule 1 mcg 2 mcg 4 mcg 1
PARSABIV INTRAVENOUS SOLUTION 5 MGML
MB PA
SAMSCA ORAL TABLET 15 MG 2 PA LA QL (60 per 30 days)
sapropterin oral powder in packet 100 mg 500 mg 2 PA LA
sapropterin oral tabletsoluble 100 mg 2 PA LA
SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG 15 MG 20 MG 25 MG 30 MG
2 PA LA QL (30 per 30 days)
STRENSIQ SUBCUTANEOUS SOLUTION 18 MG045 ML 28 MG07 ML 40 MGML 80 MG08 ML
2 PA
SYNAREL NASAL SPRAYNON-AEROSOL 2 MGML
1
TEPEZZA INTRAVENOUS RECON SOLN 500 MG
MB PA LA
testosterone cypionate intramuscular oil 100 mgml 200 mgml
1
testosterone enanthate intramuscular oil 200 mgml
1
77
Drug Name Drug Tier Requirements Limits
testosterone transdermal gel 50 mg5 gram (1 ) 1 QL (60 per 30 days)
testosterone transdermal gel in metered-dose pump 10 mg05 gram actuation 2025 mg125 gram (162 )
1 QL (2 per 30 days)
testosterone transdermal gel in metered-dose pump 125 mg 125 gram (1 )
1 QL (4 per 30 days)
testosterone transdermal gel in packet 1 (25 mg25gram) 162 (2025 mg125 gram)
1 QL (30 per 30 days)
testosterone transdermal gel in packet 1 (50 mg5 gram) 162 (405 mg25 gram)
1 QL (60 per 30 days)
testosterone transdermal solution in metered pump wapp 30 mgactuation (15 ml)
1 QL (2 per 30 days)
VIMIZIM INTRAVENOUS SOLUTION 5 MG5 ML (1 MGML)
MB PA LA
VPRIV INTRAVENOUS RECON SOLN 400 UNIT
MB PA LA
NON-INSULIN HYPOGLYCEMIC AGENTS
acarbose oral tablet 100 mg 25 mg 50 mg 1
ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 125-15 MG 125-30 MG 125-45 MG 25-15 MG 25-30 MG 25-45 MG
1 PA ST
BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG085 ML
1 PA ST
BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCGDOSE(250 MCGML) 24 ML 5 MCGDOSE (250 MCGML) 12 ML
1 PA ST
CYCLOSET ORAL TABLET 08 MG 1
FARXIGA ORAL TABLET 10 MG 5 MG 1 PA ST
glimepiride oral tablet 1 mg 2 mg 4 mg 1
glipizide oral tablet 10 mg 5 mg 1
glipizide oral tablet extended release 24hr 10 mg 25 mg 5 mg
1
glipizide-metformin oral tablet 25-250 mg 25-500 mg 5-500 mg
1
glyburide micronized oral tablet 15 mg 3 mg 6 mg
1
glyburide oral tablet 125 mg 25 mg 5 mg 1
glyburide-metformin oral tablet 125-250 mg 25-500 mg 5-500 mg
1
78
Drug Name Drug Tier Requirements Limits
GLYXAMBI ORAL TABLET 10-5 MG 25-5 MG
1 PA ST
JANUMET ORAL TABLET 50-1000 MG 50-500 MG
1 PA ST
JANUMET XR ORAL TABLET ER MULTIPHASE 24 HR 100-1000 MG 50-1000 MG 50-500 MG
1 PA ST
JANUVIA ORAL TABLET 100 MG 25 MG 50 MG
1 PA ST
JARDIANCE ORAL TABLET 10 MG 25 MG 1 PA ST
JENTADUETO ORAL TABLET 25-1000 MG 25-500 MG 25-850 MG
1 PA ST
JENTADUETO XR ORAL TABLET IR - ER BIPHASIC 24HR 25-1000 MG 5-1000 MG
1 PA ST
metformin oral solution 500 mg5 ml 1 PA
metformin oral tablet 1000 mg 500 mg 850 mg 1
metformin oral tablet extended release 24 hr 500 mg 750 mg
1
metformin oral tablet extended release 24hr 1000 mg 500 mg
1 PA ST
metformin oral tableter gastretention 24 hr 1000 mg 500 mg
1 ST
miglitol oral tablet 100 mg 25 mg 50 mg 1
nateglinide oral tablet 120 mg 60 mg 1
OZEMPIC SUBCUTANEOUS PEN INJECTOR 025 MG OR 05 MG(2 MG15 ML) 1 MGDOSE (2 MG15 ML) 1 MGDOSE (4 MG3 ML)
1 PA ST
pioglitazone oral tablet 15 mg 30 mg 45 mg 1
pioglitazone-glimepiride oral tablet 30-2 mg 30-4 mg
1
pioglitazone-metformin oral tablet 15-500 mg 15-850 mg
1
QTERN ORAL TABLET 10-5 MG 5-5 MG 1 PA ST
repaglinide oral tablet 05 mg 1 mg 2 mg 1
repaglinide-metformin oral tablet 1-500 mg 2-500 mg
1
RIOMET ER ORAL SUSPENSIONEXTENDED REL RECON 500 MG5 ML
1 PA ST
79
Drug Name Drug Tier Requirements Limits
RYBELSUS ORAL TABLET 14 MG 3 MG 7 MG
1 PA ST
SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2700 MCG27 ML
1 PA ST
SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1500 MCG15 ML
1 PA ST
SYNJARDY ORAL TABLET 125-1000 MG 125-500 MG 5-1000 MG 5-500 MG
1 PA ST
SYNJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 125-1000 MG 25-1000 MG 5-1000 MG
1 PA ST
TRADJENTA ORAL TABLET 5 MG 1 PA ST
TRULICITY SUBCUTANEOUS PEN INJECTOR 075 MG05 ML 15 MG05 ML 3 MG05 ML 45 MG05 ML
1 PA ST
XIGDUO XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 10-500 MG 25-1000 MG 5-1000 MG 5-500 MG
1 PA ST
THYROID HORMONES
ARMOUR THYROID ORAL TABLET 120 MG 15 MG 180 MG 240 MG 30 MG 300 MG 60 MG 90 MG
1
levothyroxine oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 300 mcg 50 mcg 75 mcg 88 mcg
1
levoxyl oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 50 mcg 75 mcg 88 mcg
1
liothyronine oral tablet 25 mcg 5 mcg 50 mcg 1
np thyroid oral tablet 120 mg 15 mg 30 mg 60 mg 90 mg
1
SYNTHROID ORAL TABLET 100 MCG 112 MCG 125 MCG 137 MCG 150 MCG 175 MCG 200 MCG 25 MCG 300 MCG 50 MCG 75 MCG 88 MCG
1
THYROLAR-1 ORAL TABLET 125-50 MCG 1
THYROLAR-12 ORAL TABLET 625-25 MCG 1
THYROLAR-14 ORAL TABLET 31-125 MCG 1
THYROLAR-2 ORAL TABLET 25-100 MCG 1
THYROLAR-3 ORAL TABLET 375-150 MCG 1
80
Drug Name Drug Tier Requirements Limits
unithroid oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 300 mcg 50 mcg 75 mcg 88 mcg
1
westhroid oral tablet 130 mg 195 mg 325 mg 65 mg 975 mg
1
GASTROENTEROLOGY
ANTIDIARRHEALS amp ANTISPASMODICS
anaspaz oral tabletdisintegrating 0125 mg 1
atropine injection syringe 005 mgml 01 mgml 1
belladonna alkaloids-opium rectal suppository 162-30 mg 162-60 mg
1 PA ST
chlordiazepoxide-clidinium oral capsule 5-25 mg 1
dicyclomine intramuscular solution 10 mgml MB
dicyclomine oral capsule 10 mg 1
dicyclomine oral solution 10 mg5 ml 1
dicyclomine oral tablet 20 mg 1
diphenoxylate-atropine oral liquid 25-0025 mg5 ml
1
diphenoxylate-atropine oral tablet 25-0025 mg 1
DONNATAL ORAL TABLET 162-01037 -00194 MG
1
ed-spaz oral tabletdisintegrating 0125 mg 1
glycopyrrolate injection solution 02 mgml 1
glycopyrrolate oral tablet 1 mg 15 mg 2 mg 1
hyoscyamine sulfate oral drops 0125 mgml 1
hyoscyamine sulfate oral elixir 0125 mg5 ml 1
hyoscyamine sulfate oral tablet 0125 mg 1
hyoscyamine sulfate oral tablet extended release 12 hr 0375 mg
1
hyoscyamine sulfate oral tabletdisintegrating 0125 mg
1
hyoscyamine sulfate sublingual tablet 0125 mg 1
hyosyne oral drops 0125 mgml 1
hyosyne oral elixir 0125 mg5 ml 1
loperamide oral capsule 2 mg 1
methscopolamine oral tablet 25 mg 5 mg 1
MOTOFEN ORAL TABLET 1-0025 MG 1
81
Drug Name Drug Tier Requirements Limits
opium tincture oral tincture 10 mgml (morphine) 1
oscimin oral tablet 0125 mg 1
oscimin sl sublingual tablet 0125 mg 1
oscimin sr oral tablet extended release 12 hr 0375 mg
1
phenobarb-hyoscy-atropine-scop oral elixir 162-01037 -00194 mg5 ml
1
phenobarb-hyoscy-atropine-scop oral tablet 162-01037 -00194 mg
1
phenohytro oral elixir 162-01037 -00194 mg5 ml
1
phenohytro oral tablet 162-01037 -00194 mg 1
symax fastabs oral tabletdisintegrating 0125 mg 1
symax-sl sublingual tablet 0125 mg 1
symax-sr oral tablet extended release 12 hr 0375 mg
1
MISCELLANEOUS GASTROINTESTINAL AGENTS
AKYNZEO (NETUPITANT) ORAL CAPSULE 300-05 MG
1 QL (1 per 30 days)
alosetron oral tablet 05 mg 1 mg 1
ALOXI INTRAVENOUS SOLUTION 025 MG5 ML
MB
AMITIZA ORAL CAPSULE 24 MCG 8 MCG 1 PA
anucort-hc rectal suppository 25 mg 1
aprepitant oral capsule 125 mg 40 mg 1 QL (1 per 30 days)
aprepitant oral capsule 80 mg 1 QL (2 per 30 days)
aprepitant oral capsuledose pack 125 mg (1)- 80 mg (2)
1 QL (1 per 30 days)
balsalazide oral capsule 750 mg 1
budesonide oral capsuledelayedextendrelease 3 mg
1
calcium acetate(phosphat bind) oral capsule 667 mg
1
calcium acetate(phosphat bind) oral tablet 667 mg 1
CHOLBAM ORAL CAPSULE 250 MG 50 MG 2
CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)
2 PA ST LA
82
Drug Name Drug Tier Requirements Limits
CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG2 ML (200 MGML X 2)
2 PA ST LA
CLENPIQ ORAL SOLUTION 10 MG-35 GRAM -12 GRAM160 ML
ACA PV
compro rectal suppository 25 mg 1
constulose oral solution 10 gram15 ml 1
CORTIFOAM RECTAL FOAM 10 (80 MG) 1
CREON ORAL CAPSULEDELAYED RELEASE(DREC) 12000-38000 -60000 UNIT 24000-76000 -120000 UNIT 3000-9500- 15000 UNIT 36000-114000- 180000 UNIT 6000-19000 -30000 UNIT
1 PA
cromolyn oral concentrate 100 mg5 ml 1
DIPENTUM ORAL CAPSULE 250 MG 1 PA ST
doxylamine-pyridoxine (vit b6) oral tabletdelayed release (drec) 10-10 mg
1
dronabinol oral capsule 10 mg 25 mg 5 mg 1
EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG ML FINAL CONC)
1
ENTYVIO INTRAVENOUS RECON SOLN 300 MG
MB PA LA
enulose oral solution 10 gram15 ml 1
gavilyte-c oral recon soln 240-2272-672 -584 gram
ACA PV
gavilyte-g oral recon soln 236-2274-674 -586 gram
ACA PV
gavilyte-n oral recon soln 420 gram ACA PV
generlac oral solution 10 gram15 ml 1
granisetron hcl oral tablet 1 mg 1 QL (6 per 30 days)
hemmorex-hc rectal suppository 25 mg 1
hydrocortisone acetate rectal suppository 25 mg 30 mg
1
hydrocortisone rectal enema 100 mg60 ml 1
hydrocortisone topical cream with perineal applicator 1 25
1
hydrocortisone-pramoxine rectal cream 1-1 25-1 25-1 (4g)
1
INFLECTRA INTRAVENOUS RECON SOLN 100 MG
MB PA LA
83
Drug Name Drug Tier Requirements Limits
lactulose oral packet 10 gram 1
lactulose oral solution 10 gram15 ml 20 gram30 ml
1
lanthanum oral tabletchewable 1000 mg 500 mg 750 mg
1
lidocaine hcl-hydrocortison ac rectal cream 3-05
1
LIDOCAINE HCL-HYDROCORTISON AC RECTAL GEL 3 -25 (7 GRAM)
1
lidocaine hcl-hydrocortison ac rectal kit 2 -2 (7 gram)
1 ST
lidocaine hcl-hydrocortison ac rectal kit 3-05 3-1 (7 gram)
1 PA ST
lidocaine-hydrocortisone-aloe rectal gel 28-055
1
lidocaine-hydrocortisone-aloe rectal kit 3-25 (7 gram)
1 PA ST
LINZESS ORAL CAPSULE 145 MCG 290 MCG 72 MCG
1 PA
meclizine oral tablet 125 mg 25 mg 1
mesalamine oral capsuleextended release 24hr 0375 gram
1
mesalamine oral tabletdelayed release (drec) 12 gram 800 mg
1
mesalamine rectal enema 4 gram60 ml 1
mesalamine rectal suppository 1000 mg 1
mesalamine with cleansing wipe rectal enema kit 4 gram60 ml
1 ST
metoclopramide hcl injection solution 5 mgml MB
metoclopramide hcl injection syringe 5 mgml MB
metoclopramide hcl oral solution 5 mg5 ml 1
metoclopramide hcl oral tablet 10 mg 5 mg 1
metoclopramide hcl oral tabletdisintegrating 10 mg 5 mg
1
MOVANTIK ORAL TABLET 125 MG 25 MG 1 PA ST
NULYTELY LEMON-LIME ORAL RECON SOLN 420 GRAM
ACA PV
ondansetron hcl intravenous solution 2 mgml MB
ondansetron hcl oral solution 4 mg5 ml 1 QL (100 per 30 days)
84
Drug Name Drug Tier Requirements Limits
ondansetron hcl oral tablet 4 mg 8 mg 1 QL (9 per 30 days)
ondansetron oral tabletdisintegrating 4 mg 8 mg 1 QL (9 per 30 days)
OSMOPREP ORAL TABLET 15 GRAM ACA PV
peg 3350-electrolytes oral recon soln 236-2274-674 -586 gram
ACA PV
peg3350-sod sul-nacl-kcl-asb-c oral powder in packet 100-75-2691 gram
ACA PV
peg-electrolyte soln oral recon soln 420 gram ACA PV
peg-prep oral kit 5-210 mg-gram ACA PV
PLENVU ORAL POWDER IN PACKET SEQUENTIAL 140-9-52 GRAM
ACA PV
prochlorperazine edisylate injection solution 10 mg2 ml (5 mgml) 5 mgml
1
prochlorperazine maleate oral tablet 10 mg 5 mg 1
prochlorperazine rectal suppository 25 mg 1
procto-med hc topical cream with perineal applicator 25
1
procto-pak topical cream with perineal applicator 1
1
proctosol hc topical cream with perineal applicator 25
1
proctozone-hc topical cream with perineal applicator 25
1
RECTIV RECTAL OINTMENT 04 (WW) 1
RELISTOR ORAL TABLET 150 MG 1
RELISTOR SUBCUTANEOUS SOLUTION 12 MG06 ML
1
RELISTOR SUBCUTANEOUS SYRINGE 12 MG06 ML 8 MG04 ML
1
REMICADE INTRAVENOUS RECON SOLN 100 MG
MB PA LA
RENFLEXIS INTRAVENOUS RECON SOLN 100 MG
MB PA LA
scopolamine base transdermal patch 3 day 1 mg over 3 days
1
sevelamer carbonate oral powder in packet 08 gram 24 gram
1
sevelamer carbonate oral tablet 800 mg 1
sevelamer hcl oral tablet 400 mg 800 mg 1
85
Drug Name Drug Tier Requirements Limits
sodium polystyrene sulfonate oral powder 1
sps (with sorbitol) oral suspension 15-20 gram60 ml
1
sps (with sorbitol) rectal enema 30-40 gram120 ml
1
SUCRAID ORAL SOLUTION 8500 UNITML 2 PA ST QL (2 per 30 days)
sulfasalazine oral tablet 500 mg 1
sulfasalazine oral tabletdelayed release (drec) 500 mg
1
SUPREP BOWEL PREP KIT ORAL RECON SOLN 175-313-16 GRAM
ACA PV ST
trilyte with flavor packets oral recon soln 420 gram
ACA PV
trimethobenzamide oral capsule 300 mg 1
ursodiol oral capsule 300 mg 1
ursodiol oral tablet 250 mg 500 mg 1
VARUBI ORAL TABLET 90 MG 1
VELPHORO ORAL TABLETCHEWABLE 500 MG
1 ST
VIBERZI ORAL TABLET 100 MG 75 MG 1 PA ST
ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 10000-32000 -42000 UNIT 15000-47000 -63000 UNIT 20000-63000- 84000 UNIT 3000-10000 -14000-UNIT 40000-126000- 168000 UNIT 5000-17000- 24000 UNIT
1 PA
ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 25000-79000- 105000 UNIT
1
ULCER THERAPY
amoxicil-clarithromy-lansopraz oral combo pack 500-500-30 mg
1
cimetidine hcl oral solution 300 mg5 ml 1
cimetidine oral tablet 200 mg 300 mg 400 mg 800 mg
1
DEXILANT ORAL CAPSULEBIPHASE DELAYED RELEAS 30 MG 60 MG
1 ST
esomeprazole magnesium oral capsuledelayed release(drec) 20 mg 40 mg
1
famotidine (pf) intravenous solution 20 mg2 ml MB
86
Drug Name Drug Tier Requirements Limits
famotidine oral suspension 40 mg5 ml (8 mgml) 1
famotidine oral tablet 20 mg 40 mg 1
lansoprazole oral capsuledelayed release(drec) 15 mg 30 mg
1
lansoprazole oral tabletdisintegrat delay rel 15 mg 30 mg
1
misoprostol oral tablet 100 mcg 200 mcg 1
nizatidine oral capsule 150 mg 300 mg 1
nizatidine oral solution 150 mg10 ml 1
omeprazole oral capsuledelayed release(drec) 10 mg 20 mg 40 mg
1
pantoprazole oral tabletdelayed release (drec) 20 mg 40 mg
1
rabeprazole oral tabletdelayed release (drec) 20 mg
1
sucralfate oral suspension 100 mgml 1
sucralfate oral tablet 1 gram 1
IMMUNOLOGY VACCINES amp BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCGML 200 MCGML 25 MCGML 300 MCGML 40 MCGML 60 MCGML
2 LA
ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG04 ML 100 MCG05 ML 150 MCG03 ML 200 MCG04 ML 25 MCG042 ML 300 MCG06 ML 40 MCG04 ML 500 MCGML 60 MCG03 ML
2 LA
EPOGEN INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML
2 LA
GRANIX SUBCUTANEOUS SOLUTION 300 MCGML 480 MCG16 ML
2
GRANIX SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML
2
LEUKINE INJECTION RECON SOLN 250 MCG 2 PA ST
MIRCERA INJECTION SYRINGE 100 MCG03 ML 150 MCG03 ML 200 MCG03 ML 30 MCG03 ML 50 MCG03 ML 75 MCG03 ML
MB
87
Drug Name Drug Tier Requirements Limits
MOZOBIL SUBCUTANEOUS SOLUTION 24 MG12 ML (20 MGML)
MB LA
NEUPOGEN INJECTION SOLUTION 300 MCGML 480 MCG16 ML
2 PA ST
NEUPOGEN INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML
2 PA ST
NIVESTYM INJECTION SOLUTION 300 MCGML 480 MCG16 ML
2
NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML
2
PROCRIT INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML 40000 UNITML
2 LA
UDENYCA SUBCUTANEOUS SYRINGE 6 MG06 ML
2 PA ST
ZARXIO INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML
2 PA ST
ZIEXTENZO SUBCUTANEOUS SYRINGE 6 MG06 ML
2 PA ST
GROWTH HORMONES
GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 02 MG025 ML 04 MG025 ML 06 MG025 ML 08 MG025 ML 1 MG025 ML 12 MG025 ML 14 MG025 ML 16 MG025 ML 18 MG025 ML 2 MG025 ML
2 PA ST LA
GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MGML (36 UNITML) 5 MGML (15 UNITML)
2 PA ST LA
OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG15 ML (67 MGML) 5 MG15 ML (33 MGML)
2 PA ST LA
OMNITROPE SUBCUTANEOUS RECON SOLN 58 MG
2 PA ST LA
SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG 5 MG 6 MG
2 PA ST LA
ZORBTIVE SUBCUTANEOUS RECON SOLN 88 MG
2 PA ST LA
INTERFERONS
AUBAGIO ORAL TABLET 14 MG 7 MG 2 PA LA
88
Drug Name Drug Tier Requirements Limits
AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG05 ML
2 PA ST LA QL (4 per 30 days)
AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG05 ML
2 PA ST LA QL (4 per 30 days)
BETASERON SUBCUTANEOUS KIT 03 MG 2 PA LA QL (14 per 30 days)
dimethyl fumarate oral capsuledelayed release(drec) 120 mg
2 PA LA QL (14 per 365 days)
dimethyl fumarate oral capsuledelayed release(drec) 120 mg (14)- 240 mg (46)
2 PA LA QL (1 per 365 days)
dimethyl fumarate oral capsuledelayed release(drec) 240 mg
2 PA LA QL (60 per 30 days)
GILENYA ORAL CAPSULE 05 MG 2 PA LA QL (30 per 30 days)
glatiramer subcutaneous syringe 20 mgml 2 PA LA QL (30 per 30 days)
glatiramer subcutaneous syringe 40 mgml 2 PA LA QL (12 per 30 days)
glatopa subcutaneous syringe 20 mgml 2 PA LA QL (30 per 30 days)
glatopa subcutaneous syringe 40 mgml 2 PA LA QL (12 per 30 days)
LEMTRADA INTRAVENOUS SOLUTION 12 MG12 ML
MB PA ST LA
MAVENCLAD (10 TABLET PACK) ORAL TABLET 10 MG
2 LA
MAVENCLAD (4 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (5 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (6 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (7 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (8 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (9 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAYZENT ORAL TABLET 025 MG 2 MG 2 PA ST LA QL (30 per 30 days)
MAYZENT STARTER PACK ORAL TABLETSDOSE PACK 025 MG (12 TABS)
2 PA ST LA QL (1 per 365 days)
OCREVUS INTRAVENOUS SOLUTION 30 MGML
MB PA LA
PEGASYS SUBCUTANEOUS SOLUTION 180 MCGML
2 PA LA
89
Drug Name Drug Tier Requirements Limits
PEGASYS SUBCUTANEOUS SYRINGE 180 MCG05 ML
2 PA LA
PLEGRIDY INTRAMUSCULAR SYRINGE 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG05 ML- 94 MCG05 ML
2 PA LA QL (1 per 365 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG05 ML- 94 MCG05 ML
2 PA LA QL (1 per 365 days)
POMALYST ORAL CAPSULE 1 MG 2 MG 3 MG 4 MG
2 PA ST OCh LA
PONVORY 14-DAY STARTER PACK ORAL TABLETSDOSE PACK 2 MG (2) - 10 MG (3)
2 PA LA QL (1 per 365 days)
PONVORY ORAL TABLET 20 MG 2 PA LA QL (30 per 30 days)
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG05 ML 44 MCG05 ML
2 PA LA QL (6 per 30 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG05 ML 44 MCG05 ML
2 PA LA QL (6 per 30 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 88MCG02ML-22 MCG05ML (6)
2 PA LA QL (5 per 30 days)
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 88MCG02ML-22 MCG05ML (6)
2 PA LA QL (5 per 30 days)
REVLIMID ORAL CAPSULE 10 MG 15 MG 25 MG 20 MG 25 MG 5 MG
2 PA ST OCh LA
ribavirin oral capsule 200 mg 2 LA
ribavirin oral tablet 200 mg 2 LA
ZEPOSIA ORAL CAPSULE 092 MG 2 LA QL (30 per 30 days)
ZEPOSIA STARTER KIT ORAL CAPSULEDOSE PACK 023-046-092 MG
2 LA QL (30 per 30 days)
ZEPOSIA STARTER PACK ORAL CAPSULEDOSE PACK 023 MG (4)- 046 MG (3)
2 LA QL (30 per 30 days)
INTERLEUKINS
ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG05 ML
2 PA LA
ARCALYST SUBCUTANEOUS RECON SOLN 220 MG
2 LA
90
Drug Name Drug Tier Requirements Limits
ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MGML
MB PA LA
imiquimod topical cream in packet 5 1
INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) 18 MILLION UNIT (1 ML) 50 MILLION UNIT (1 ML)
2 PA LA
INTRON A INJECTION SOLUTION 10 MILLION UNITML 6 MILLION UNITML
2 PA LA
PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT
MB LA
VACCINES amp MISCELLANEOUS IMMUNOLOGICALS
ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(25-5-3-5 MCG)-5LF05 ML
1 Vac
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(25-5-3-5 MCG)-5LF05 ML
1 Vac
ASCENIV INTRAVENOUS SOLUTION 10 MB PA LA
ATGAM INTRAVENOUS SOLUTION 50 MGML
MB
BCG VACCINE LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG
1 Vac
BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG05 ML
1 Vac
BIOTHRAX INTRAMUSCULAR SUSPENSION 05 MLDOSE
1 Vac
BIVIGAM INTRAVENOUS SOLUTION 10 MB PA LA
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 25-8-5 LF-MCG-LF05ML
1 Vac
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 25-8-5 LF-MCG-LF05ML
1 Vac
BOTOX INJECTION RECON SOLN 100 UNIT 200 UNIT
MB
CUTAQUIG SUBCUTANEOUS SOLUTION 165
MB LA
CUVITRU SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 ) 8 GRAM40 ML (20 )
MB LA
91
Drug Name Drug Tier Requirements Limits
DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF05ML
1 Vac
DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT 500 UNIT
MB LA
ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCGML
1 Vac
ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCGML
1 Vac
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG05 ML
1 Vac
FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 5
MB PA
GAMASTAN INTRAMUSCULAR SOLUTION 15-18 RANGE
MB
GAMASTAN SD INTRAMUSCULAR SOLUTION 15-18 RANGE
MB
GAMMAGARD LIQUID INJECTION SOLUTION 10
MB LA
GAMMAGARD S-D (IGA lt 1 MCGML) INTRAVENOUS RECON SOLN 10 GRAM 5 GRAM
MB PA LA
GAMMAKED INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 20 GRAM200 ML (10 ) 5 GRAM50 ML (10 )
MB LA
GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5
MB PA LA
GAMMAPLEX INTRAVENOUS SOLUTION 10
MB PA LA
GAMUNEX-C INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 25 GRAM25 ML (10 ) 20 GRAM200 ML (10 ) 40 GRAM400 ML (10 ) 5 GRAM50 ML (10 )
MB LA
GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 05 ML
1 Vac
GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 05 ML
1 Vac
GRASTEK SUBLINGUAL TABLET 2800 BAU 1 PA
HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1440 ELISA UNITML
1 Vac
92
Drug Name Drug Tier Requirements Limits
HAVRIX (PF) INTRAMUSCULAR SYRINGE 1440 ELISA UNITML 720 ELISA UNIT05 ML
1 Vac
HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE 20 MCG05 ML
1 Vac
HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )
MB LA
HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM 100 ML (10 ) 25 GRAM 25 ML (10 ) 20 GRAM 200 ML (10 ) 30 GRAM 300 ML (10 ) 5 GRAM 50 ML (10 )
MB LA
IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 25 UNIT
1 Vac
INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF05ML
1 Vac
IPOL INJECTION SUSPENSION 40-8-32 UNIT05 ML
1 Vac
IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG05 ML
1 Vac
KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF05 ML
1 Vac
MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG05 ML
1 Vac
MENQUADFI (PF) INTRAMUSCULAR SOLUTION 10 MCG05 ML
1 Vac
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG05 ML
1 Vac
M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1000-12500 TCID5005 ML
1 Vac
MYOBLOC INTRAMUSCULAR SOLUTION 10000 UNIT2 ML 2500 UNIT05 ML 5000 UNITML
MB LA
OCTAGAM INTRAVENOUS SOLUTION 10 5
MB PA LA
ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY
2 PA
PANZYGA INTRAVENOUS SOLUTION 10 MB PA
PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF05 ML
1 Vac
93
Drug Name Drug Tier Requirements Limits
PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 75 MCG05 ML
1 Vac
PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF05 ML 15LF-48MCG-62DU -10 MCG05ML
1 Vac
PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
PNEUMOVAX-23 INJECTION SOLUTION 25 MCG05 ML
1 Vac
PNEUMOVAX-23 INJECTION SYRINGE 25 MCG05 ML
1 Vac
PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE 05 ML
1 Vac
PRIVIGEN INTRAVENOUS SOLUTION 10 MB PA LA
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-43-3- 399 TCID5005
1 Vac
PROVENGE INTRAVENOUS SUSPENSION 50 MILLION CELL250 ML
MB PA
QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT05ML
1 Vac
RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 25 UNIT
1 Vac
RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT
1 PA
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCGML 40 MCGML 5 MCG05 ML
1 Vac
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCGML 5 MCG05 ML
1 Vac
SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG05 ML
1 Vac
STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1000 UNIT05 ML
1 Vac
TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF UNIT05 ML
1 Vac
94
Drug Name Drug Tier Requirements Limits
TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT05ML
1 Vac
TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT05 ML
1 Vac
TETANUSDIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT05 ML
1 Vac
THYMOGLOBULIN INTRAVENOUS RECON SOLN 25 MG
MB
TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG05 ML
1 Vac
TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCGML
1 Vac
TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG05 ML
1 Vac
TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG05 ML
1 Vac
VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT05 ML 50 UNITML
1 Vac
VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT05 ML 50 UNITML
1 Vac
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1350 UNIT05 ML
1 Vac
VAXELIS (PF) INTRAMUSCULAR SUSPENSION 15 UNIT-5 UNIT- 10 MCG05 ML
1 Vac
VAXELIS (PF) INTRAMUSCULAR SYRINGE 15 UNIT-5 UNIT- 10 MCG05 ML
1 Vac
XEMBIFY SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )
MB LA
XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT 200 UNIT 50 UNIT
MB LA
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP474 UNIT05 ML
1 Vac
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19400 UNIT065 ML
1 Vac
MUSCULOSKELETAL amp RHEUMATOLOGY
95
Drug Name Drug Tier Requirements Limits
GOUT THERAPY
allopurinol oral tablet 100 mg 300 mg 1
COLCHICINE ORAL CAPSULE 06 MG 1
colchicine oral tablet 06 mg 1
febuxostat oral tablet 40 mg 80 mg 1
KRYSTEXXA INTRAVENOUS SOLUTION 8 MGML
MB PA LA
MITIGARE ORAL CAPSULE 06 MG 1
probenecid oral tablet 500 mg 1
probenecid-colchicine oral tablet 500-05 mg 1
OSTEOPOROSIS THERAPY
alendronate oral solution 70 mg75 ml 1
alendronate oral tablet 10 mg 35 mg 5 mg 70 mg 1
EVENITY SUBCUTANEOUS SYRINGE 105 MG117 ML 210MG234ML ( 105MG117MLX2)
2 PA ST LA
FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCGDOSE (620MCG248ML)
2 PA ST LA QL (1 per 30 days)
FOSAMAX PLUS D ORAL TABLET 70 MG- 2800 UNIT 70 MG- 5600 UNIT
1
ibandronate oral tablet 150 mg 1
PROLIA SUBCUTANEOUS SYRINGE 60 MGML
2 ST LA
raloxifene oral tablet 60 mg 2 OCh
risedronate oral tablet 150 mg 35 mg 5 mg 1
risedronate oral tabletdelayed release (drec) 35 mg
1
TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3120 MCG156 ML)
2 PA ST LA
OTHER RHEUMATOLOGICALS
ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG09 ML
2 PA ST LA
ACTEMRA INTRAVENOUS SOLUTION 200 MG10 ML (20 MGML) 400 MG20 ML (20 MGML) 80 MG4 ML (20 MGML)
MB PA LA
ACTEMRA SUBCUTANEOUS SYRINGE 162 MG09 ML
2 PA ST LA
96
Drug Name Drug Tier Requirements Limits
BENLYSTA INTRAVENOUS RECON SOLN 120 MG 400 MG
MB PA LA
BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MGML
2 PA LA
BENLYSTA SUBCUTANEOUS SYRINGE 200 MGML
2 PA LA
ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MGML (1 ML)
2 PA ST LA
ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)
2 PA ST LA
ENBREL SUBCUTANEOUS SOLUTION 25 MG05 ML
2 PA ST LA
ENBREL SUBCUTANEOUS SYRINGE 25 MG05 ML (05) 50 MGML (1 ML)
2 PA ST LA
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MGML (1 ML)
2 PA ST LA
HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG08 ML
2 PA ST LA
HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG08 ML 80 MG08 ML-40 MG04 ML
2 PA ST LA
HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
2 PA ST LA
HUMIRA(CF) PEN PEDIATRIC UC SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
2 PA ST LA
HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML-40 MG04 ML
2 PA ST LA
HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG04 ML
2 PA ST LA
97
Drug Name Drug Tier Requirements Limits
HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG01 ML 20 MG02 ML 40 MG04 ML
2 PA ST LA
KEVZARA SUBCUTANEOUS PEN INJECTOR 150 MG114 ML 200 MG114 ML
2 PA ST LA
KEVZARA SUBCUTANEOUS SYRINGE 150 MG114 ML 200 MG114 ML
2 PA ST LA
leflunomide oral tablet 10 mg 20 mg 1
OLUMIANT ORAL TABLET 1 MG 2 MG 2 PA ST LA
ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG
MB PA LA
ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MGML
2 PA ST LA
ORENCIA SUBCUTANEOUS SYRINGE 125 MGML 50 MG04 ML 875 MG07 ML
2 PA ST LA
OTEZLA ORAL TABLET 30 MG 2 PA ST LA
OTEZLA STARTER ORAL TABLETSDOSE PACK 10 MG (4)-20 MG (4)-30 MG (47)
2 PA ST LA
penicillamine oral capsule 250 mg 1 PA
penicillamine oral tablet 250 mg 1 PA
RIDAURA ORAL CAPSULE 3 MG 1
RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 MG
2 PA ST LA
SAVELLA ORAL TABLET 100 MG 125 MG 25 MG 50 MG
1 PA ST
SAVELLA ORAL TABLETSDOSE PACK 125 MG (5)-25 MG(8)-50 MG(42)
1 PA ST
SIMPONI ARIA INTRAVENOUS SOLUTION 125 MGML
MB PA LA
SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MGML 50 MG05 ML
2 PA ST LA
SIMPONI SUBCUTANEOUS SYRINGE 100 MGML 50 MG05 ML
2 PA ST LA
XELJANZ ORAL SOLUTION 1 MGML 2 PA ST LA
XELJANZ ORAL TABLET 10 MG 5 MG 2 PA ST LA
XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG 22 MG
2 PA ST LA
OBSTETRICS amp GYNECOLOGY
DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES
98
Drug Name Drug Tier Requirements Limits
CAYA CONTOURED VAGINAL DIAPHRAGM 65-80 MM
ACA PV
FC2 FEMALE CONDOM ACA PV
FEMCAP VAGINAL DEVICE 22 MM ACA PV
KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 175 MCG24 HRS (5 YRS) 195 MG
ACA PV
LILETTA INTRAUTERINE INTRAUTERINE DEVICE 201 MCG24 HRS (6 YRS) 52 MG
ACA PV ST
MIRENA INTRAUTERINE INTRAUTERINE DEVICE 20 MCG24 HOURS (6 YRS) 52 MG
ACA PV
PARAGARD T 380A INTRAUTERINE INTRAUTERINE DEVICE 380 SQUARE MM
ACA PV
SKYLA INTRAUTERINE INTRAUTERINE DEVICE 14 MCG24 HRS (3 YRS) 135 MG
ACA PV
WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 MM
ACA PV
ESTROGENS amp PROGESTINS
amabelz oral tablet 05-01 mg 1-05 mg 1
ANGELIQ ORAL TABLET 025-05 MG 05-1 MG
1
camila oral tablet 035 mg ACA PV
COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 005-014 MG24 HR 005-025 MG24 HR
1
covaryx hs oral tablet 0625-125 mg 1
covaryx oral tablet 125-25 mg 1
CRINONE VAGINAL GEL 4 1
deblitane oral tablet 035 mg ACA PV
DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MGML
1
DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MGML
MB
DEPO-PROVERA INTRAMUSCULAR SYRINGE 150 MGML
MB
DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE 104 MG065 ML
ACA PV
99
Drug Name Drug Tier Requirements Limits
DIVIGEL TRANSDERMAL GEL IN PACKET 025 MG025 GRAM (01 ) 05 MG05 GRAM (01 ) 075 MG075 GRAM (01) 1 MGGRAM (01 ) 125 MG125 GRAM (01 )
1 QL (30 per 30 days)
dotti transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
DUAVEE ORAL TABLET 045-20 MG 1
eemt hs oral tablet 0625-125 mg 1
eemt oral tablet 125-25 mg 1
errin oral tablet 035 mg ACA PV
estradiol oral tablet 05 mg 1 mg 2 mg 1
estradiol transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
estradiol transdermal patch weekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 006 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (4 per 30 days)
estradiol vaginal cream 001 (01 mggram) 1
estradiol vaginal tablet 10 mcg 1
estradiol valerate intramuscular oil 20 mgml 40 mgml
1
estradiol-norethindrone acet oral tablet 05-01 mg 1-05 mg
1
ESTRING VAGINAL RING 2 MG (75 MCG 24 HOUR)
1
estrogens-methyltestosterone oral tablet 0625-125 mg 125-25 mg
1
EVAMIST TRANSDERMAL SPRAYNON-AEROSOL 153 MGSPRAY (17)
1 QL (2 per 30 days)
FEMRING VAGINAL RING 005 MG24 HR 01 MG24 HR
1
fyavolv oral tablet 05-25 mg-mcg 1-5 mg-mcg 1
heather oral tablet 035 mg ACA PV
hydroxyprogest(pf)(preg presv) intramuscular oil 250 mgml (1 ml)
2
hydroxyprogesterone cap(ppres) intramuscular oil 250 mgml
2
100
Drug Name Drug Tier Requirements Limits
hydroxyprogesterone caproate intramuscular oil 250 mgml
2
incassia oral tablet 035 mg ACA PV
jencycla oral tablet 035 mg ACA PV
jinteli oral tablet 1-5 mg-mcg 1
lyleq oral tablet 035 mg ACA PV
lyllana transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
lyza oral tablet 035 mg ACA PV
medroxyprogesterone intramuscular suspension 150 mgml
ACA PV
medroxyprogesterone intramuscular syringe 150 mgml
ACA PV
medroxyprogesterone oral tablet 10 mg 25 mg 5 mg
1
MENEST ORAL TABLET 03 MG 0625 MG 125 MG 25 MG
1
MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG24 HR
1 QL (4 per 30 days)
mimvey oral tablet 1-05 mg 1
nora-be oral tablet 035 mg ACA PV
norethindrone (contraceptive) oral tablet 035 mg ACA PV
norethindrone acetate oral tablet 5 mg 1
norethindrone ac-eth estradiol oral tablet 05-25 mg-mcg 1-5 mg-mcg
1
norlyda oral tablet 035 mg ACA PV
PREMARIN INJECTION RECON SOLN 25 MG 1
PREMARIN ORAL TABLET 03 MG 045 MG 0625 MG 09 MG 125 MG
1
PREMARIN VAGINAL CREAM 0625 MGGRAM
1
PREMPHASE ORAL TABLET 0625 MG (14) 0625MG-5MG(14)
1
PREMPRO ORAL TABLET 03-15 MG 045-15 MG 0625-25 MG 0625-5 MG
1
progesterone intramuscular oil 50 mgml 1
progesterone micronized oral capsule 100 mg 200 mg
1
101
Drug Name Drug Tier Requirements Limits
sharobel oral tablet 035 mg ACA PV
tulana oral tablet 035 mg ACA PV
yuvafem vaginal tablet 10 mcg 1
MISCELLANEOUS OBGYN
ANNOVERA VAGINAL RING 015-0013 MG24 HOUR
ACA PV
clindamycin phosphate vaginal cream 2 1
eluryng vaginal ring 012-0015 mg24 hr ACA PV
etonogestrel-ethinyl estradiol vaginal ring 012-0015 mg24 hr
ACA PV
fem ph vaginal gel 09-0025 1
GYNAZOLE-1 VAGINAL CREAM 2 1
gynol ii vaginal gel 3 ACA PV
INTRAROSA VAGINAL INSERT 65 MG 1
isoxsuprine oral tablet 10 mg 20 mg 1
LUPANETA PACK (1 MONTH) KIT SYRINGE AND TABLET 375 MG -5 MG (30)
2 LA
LUPANETA PACK (3 MONTH) KIT SYRINGE AND TABLET 1125 MG -5 MG (90)
2 LA
metronidazole vaginal gel 075 1
NEXPLANON SUBDERMAL IMPLANT 68 MG ACA PV
OSPHENA ORAL TABLET 60 MG 1
PHEXXI VAGINAL GEL 18-1-04 ACA PV
terconazole vaginal cream 04 08 1
terconazole vaginal suppository 80 mg 1
TODAY CONTRACEPTIVE SPONGE VAGINAL CONTRACEPTIVE SPONGE 1000 MG
ACA PV
tranexamic acid oral tablet 650 mg 1
TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 MCG24 HR
ACA PV
vaginal contraceptive foam vaginal foam 125 ACA PV
vandazole vaginal gel 075 1
VCF CONTRACEPTIVE FILM VAGINAL FILM 28
ACA PV
VCF CONTRACEPTIVE GEL VAGINAL GEL 4
ACA PV
102
Drug Name Drug Tier Requirements Limits
xulane transdermal patch weekly 150-35 mcg24 hr
ACA PV
zafemy transdermal patch weekly 150-35 mcg24 hr
ACA PV
ORAL CONTRACEPTIVES amp RELATED AGENTS
afirmelle oral tablet 01-20 mg-mcg ACA PV
altavera (28) oral tablet 015-003 mg ACA PV
alyacen 135 (28) oral tablet 1-35 mg-mcg ACA PV
alyacen 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
amethia oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
amethyst (28) oral tablet 90-20 mcg (28) ACA PV
apri oral tablet 015-003 mg ACA PV
aranelle (28) oral tablet 05105-35 mg-mcg ACA PV
ashlyna oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
aubra eq oral tablet 01-20 mg-mcg ACA PV
aubra oral tablet 01-20 mg-mcg ACA PV
aurovela 1530 (21) oral tablet 15-30 mg-mcg ACA PV
aurovela 120 (21) oral tablet 1-20 mg-mcg ACA PV
aurovela 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
aurovela fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
aurovela fe 1-20 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
aviane oral tablet 01-20 mg-mcg ACA PV
ayuna oral tablet 015-003 mg ACA PV
azurette (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
BALCOLTRA ORAL TABLET 01 MG-002 MG (21)365 MG(7)
ACA PV
balziva (28) oral tablet 04-35 mg-mcg ACA PV
blisovi 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
blisovi fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
103
Drug Name Drug Tier Requirements Limits
blisovi fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
briellyn oral tablet 04-35 mg-mcg ACA PV
camrese lo oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)
ACA PV
camrese oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
caziant (28) oral tablet 0112515-25 mg-mcg ACA PV
charlotte 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
chateal (28) oral tablet 015-003 mg ACA PV
chateal eq (28) oral tablet 015-003 mg ACA PV
cryselle (28) oral tablet 03-30 mg-mcg ACA PV
cyclafem 135 (28) oral tablet 1-35 mg-mcg ACA PV
cyclafem 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
cyred eq oral tablet 015-003 mg ACA PV
cyred oral tablet 015-003 mg ACA PV
dasetta 135 (28) oral tablet 1-35 mg-mcg ACA PV
dasetta 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
daysee oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
desog-eestradioleestradiol oral tablet 015-002 mgx21 001 mg x 5
ACA PV
desogestrel-ethinyl estradiol oral tablet 015-003 mg
ACA PV
dolishale oral tablet 90-20 mcg (28) ACA PV
drospirenone-eestradiol-lmfa oral tablet 3-002-0451 mg (24) (4) 3-003-0451 mg (21) (7)
ACA PV
drospirenone-ethinyl estradiol oral tablet 3-002 mg 3-003 mg
ACA PV
econtra ez oral tablet 15 mg ACA PV
econtra one-step oral tablet 15 mg ACA PV
elinest oral tablet 03-30 mg-mcg ACA PV
ELLA ORAL TABLET 30 MG ACA PV
emoquette oral tablet 015-003 mg ACA PV
104
Drug Name Drug Tier Requirements Limits
enpresse oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
enskyce oral tablet 015-003 mg ACA PV
estarylla oral tablet 025-35 mg-mcg ACA PV
ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg 1-50 mg-mcg
ACA PV
falmina (28) oral tablet 01-20 mg-mcg ACA PV
fayosim oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg
ACA PV
femynor oral tablet 025-35 mg-mcg ACA PV
gemmily oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV
hailey 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
hailey fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
hailey fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
hailey oral tablet 15-30 mg-mcg ACA PV
iclevia oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
isibloom oral tablet 015-003 mg ACA PV
jaimiess oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
jasmiel (28) oral tablet 3-002 mg ACA PV
jolessa oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
juleber oral tablet 015-003 mg ACA PV
junel 1530 (21) oral tablet 15-30 mg-mcg ACA PV
junel 120 (21) oral tablet 1-20 mg-mcg ACA PV
junel fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
junel fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
junel fe 24 oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV
kaitlib fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)
ACA PV
kalliga oral tablet 015-003 mg ACA PV
kariva (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
105
Drug Name Drug Tier Requirements Limits
kelnor 135 (28) oral tablet 1-35 mg-mcg ACA PV
kelnor 1-50 (28) oral tablet 1-50 mg-mcg ACA PV
kurvelo (28) oral tablet 015-003 mg ACA PV
l norgesteestradiol-eestrad oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7) 015 mg-20 mcg 015 mg-25 mcg 015 mg-30 mcg (84)10 mcg (7)
ACA PV
larin 1530 (21) oral tablet 15-30 mg-mcg ACA PV
larin 120 (21) oral tablet 1-20 mg-mcg ACA PV
larin 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV
larin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
larin fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
larissia oral tablet 01-20 mg-mcg ACA PV
layolis fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)
ACA PV
leena 28 oral tablet 05105-35 mg-mcg ACA PV
lessina oral tablet 01-20 mg-mcg ACA PV
levonest (28) oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
levonorgestrel oral tablet 15 mg ACA PV
levonorgestrel-ethinyl estrad oral tablet 01-20 mg-mcg 015-003 mg 90-20 mcg (28)
ACA PV
levonorgestrel-ethinyl estrad oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
levonorg-eth estrad triphasic oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
levora-28 oral tablet 015-003 mg ACA PV
lillow (28) oral tablet 015-003 mg ACA PV
LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG (24)10 MCG (2)
ACA PV
lojaimiess oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)
ACA PV
loryna (28) oral tablet 3-002 mg ACA PV
low-ogestrel (28) oral tablet 03-30 mg-mcg ACA PV
lo-zumandimine (28) oral tablet 3-002 mg ACA PV
lutera (28) oral tablet 01-20 mg-mcg ACA PV
106
Drug Name Drug Tier Requirements Limits
marlissa (28) oral tablet 015-003 mg ACA PV
merzee oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV
mibelas 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
microgestin 1530 (21) oral tablet 15-30 mg-mcg ACA PV
microgestin 120 (21) oral tablet 1-20 mg-mcg ACA PV
microgestin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
microgestin fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
mili oral tablet 025-35 mg-mcg ACA PV
mono-linyah oral tablet 025-35 mg-mcg ACA PV
my choice oral tablet 15 mg ACA PV
my way oral tablet 15 mg ACA PV
NATAZIA ORAL TABLET 3 MG2 MG-2 MG 2 MG-3 MG1 MG
ACA PV
necon 0535 (28) oral tablet 05-35 mg-mcg ACA PV
new day oral tablet 15 mg ACA PV
NEXTSTELLIS ORAL TABLET 3 MG- 142 MG (28)
ACA PV
nikki (28) oral tablet 3-002 mg ACA PV
noreth-ethinyl estradiol-iron oral tabletchewable 04mg-35mcg(21) and 75 mg (7) 08mg-25mcg(24) and 75 mg (4)
ACA PV
norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg 15-30 mg-mcg
ACA PV
norethindrone-eestradiol-iron oral capsule 1 mg-20 mcg (24)75 mg (4)
ACA PV
norethindrone-eestradiol-iron oral tablet 1 mg-20 mcg (21)75 mg (7) 15 mg-30 mcg (21)75 mg (7)
ACA PV
norethindrone-eestradiol-iron oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
norgestimate-ethinyl estradiol oral tablet 0180215025 mg-25 mcg 0180215025 mg-35 mcg (28) 025-35 mg-mcg
ACA PV
nortrel 0535 (28) oral tablet 05-35 mg-mcg ACA PV
nortrel 135 (21) oral tablet 1-35 mg-mcg (21) ACA PV
nortrel 135 (28) oral tablet 1-35 mg-mcg ACA PV
107
Drug Name Drug Tier Requirements Limits
nortrel 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
nylia 777 (28) oral tablet 050751 mg- 35 mcg ACA PV
nymyo oral tablet 025-35 mg-mcg ACA PV
ocella oral tablet 3-003 mg ACA PV
opcicon one-step oral tablet 15 mg ACA PV
option-2 oral tablet 15 mg ACA PV
orsythia oral tablet 01-20 mg-mcg ACA PV
philith oral tablet 04-35 mg-mcg ACA PV
pimtrea (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
pirmella oral tablet 050751 mg- 35 mcg 1-35 mg-mcg
ACA PV
portia 28 oral tablet 015-003 mg ACA PV
previfem oral tablet 025-35 mg-mcg ACA PV
reclipsen (28) oral tablet 015-003 mg ACA PV
rivelsa oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg
ACA PV
setlakin oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
simliya (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
simpesse oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
SLYND ORAL TABLET 4 MG (28) ACA PV
sprintec (28) oral tablet 025-35 mg-mcg ACA PV
sronyx oral tablet 01-20 mg-mcg ACA PV
syeda oral tablet 3-003 mg ACA PV
tarina 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
tarina fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
tilia fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9) ACA PV
tri femynor oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-estarylla oral tablet 0180215025 mg-35 mcg (28)
ACA PV
108
Drug Name Drug Tier Requirements Limits
tri-legest fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9)
ACA PV
tri-linyah oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-lo-estarylla oral tablet 0180215025 mg-25 mcg
ACA PV
tri-lo-marzia oral tablet 0180215025 mg-25 mcg
ACA PV
tri-lo-mili oral tablet 0180215025 mg-25 mcg ACA PV
tri-lo-sprintec oral tablet 0180215025 mg-25 mcg
ACA PV
tri-mili oral tablet 0180215025 mg-35 mcg (28) ACA PV
tri-nymyo oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-previfem (28) oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-sprintec (28) oral tablet 0180215025 mg-35 mcg (28)
ACA PV
trivora (28) oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
tri-vylibra lo oral tablet 0180215025 mg-25 mcg
ACA PV
tri-vylibra oral tablet 0180215025 mg-35 mcg (28)
ACA PV
TYBLUME ORAL TABLETCHEWABLE 01 MG- 20 MCG
ACA PV
tydemy oral tablet 3-003-0451 mg (21) (7) ACA PV
velivet triphasic regimen (28) oral tablet 0112515-25 mg-mcg
ACA PV
vestura (28) oral tablet 3-002 mg ACA PV
vienva oral tablet 01-20 mg-mcg ACA PV
viorele (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
volnea (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
vyfemla (28) oral tablet 04-35 mg-mcg ACA PV
vylibra oral tablet 025-35 mg-mcg ACA PV
wera (28) oral tablet 05-35 mg-mcg ACA PV
wymzya fe oral tabletchewable 04mg-35mcg(21) and 75 mg (7)
ACA PV
109
Drug Name Drug Tier Requirements Limits
zarah oral tablet 3-003 mg ACA PV
zovia 135e (28) oral tablet 1-35 mg-mcg ACA PV
zumandimine (28) oral tablet 3-003 mg ACA PV
OXYTOCICS
methergine oral tablet 02 mg 1
methylergonovine oral tablet 02 mg 1
OPHTHALMOLOGY
ANTIBIOTICS
ak-poly-bac ophthalmic (eye) ointment 500-10000 unitgram
1
AZASITE OPHTHALMIC (EYE) DROPS 1 1
bacitracin ophthalmic (eye) ointment 500 unitgram
1
bacitracin-polymyxin b ophthalmic (eye) ointment 500-10000 unitgram
1
BESIVANCE OPHTHALMIC (EYE) DROPSSUSPENSION 06
1
ciprofloxacin hcl ophthalmic (eye) drops 03 1
erythromycin ophthalmic (eye) ointment 5 mggram (05 )
1
gatifloxacin ophthalmic (eye) drops 05 1
gentak ophthalmic (eye) ointment 03 (3 mggram)
1
gentamicin ophthalmic (eye) drops 03 1
levofloxacin ophthalmic (eye) drops 05 1
moxifloxacin ophthalmic (eye) drops 05 1
moxifloxacin ophthalmic (eye) drops viscous 05
1
NATACYN OPHTHALMIC (EYE) DROPSSUSPENSION 5
1
neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
1
neomycin-polymyxin-gramicidin ophthalmic (eye) drops 175 mg-10000 unit-0025mgml
1
neo-polycin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
1
ofloxacin ophthalmic (eye) drops 03 1
110
Drug Name Drug Tier Requirements Limits
polycin ophthalmic (eye) ointment 500-10000 unitgram
1
polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10000 unit- 1 mgml
1
tobramycin ophthalmic (eye) drops 03 1
TOBREX OPHTHALMIC (EYE) OINTMENT 03
1
ANTIVIRALS
trifluridine ophthalmic (eye) drops 1 1
ZIRGAN OPHTHALMIC (EYE) GEL 015 1
BETA-BLOCKERS
betaxolol ophthalmic (eye) drops 05 1
BETIMOL OPHTHALMIC (EYE) DROPS 025 05
1
BETOPTIC S OPHTHALMIC (EYE) DROPSSUSPENSION 025
1
carteolol ophthalmic (eye) drops 1 1
levobunolol ophthalmic (eye) drops 05 1
timolol maleate ophthalmic (eye) drops 025 05
1
timolol maleate ophthalmic (eye) drops once daily 05
1
timolol maleate ophthalmic (eye) gel forming solution 025 05
1
CYCLOPLEGIC MYDRIATICS
atropine ophthalmic (eye) drops 1 1
atropine ophthalmic (eye) ointment 1 1
cyclopentolate ophthalmic (eye) drops 05 1 2
1
homatropaire ophthalmic (eye) drops 5 1
tropicamide ophthalmic (eye) drops 05 1 1
DIRECT ACTING MIOTICS
pilocarpine hcl ophthalmic (eye) drops 1 2 4
1
MISCELLANEOUS OPHTHALMOLOGICS
ALOCRIL OPHTHALMIC (EYE) DROPS 2 1 ST
ALOMIDE OPHTHALMIC (EYE) DROPS 01 1 ST
111
Drug Name Drug Tier Requirements Limits
altacaine ophthalmic (eye) drops 05 1
azelastine ophthalmic (eye) drops 005 1
BEOVU INTRAVITREAL SOLUTION 6 MG005 ML
MB PA LA
bepotastine besilate ophthalmic (eye) drops 15 1 ST
BEPREVE OPHTHALMIC (EYE) DROPS 15 1 ST
cromolyn ophthalmic (eye) drops 4 1
CYSTARAN OPHTHALMIC (EYE) DROPS 044
2 PA
epinastine ophthalmic (eye) drops 005 1
EYLEA INTRAVITREAL SOLUTION 2 MG005 ML
MB PA LA
EYLEA INTRAVITREAL SYRINGE 2 MG005 ML
MB PA LA
LACRISERT OPHTHALMIC (EYE) INSERT 5 MG
1
LASTACAFT OPHTHALMIC (EYE) DROPS 025
1 ST
LUCENTIS INTRAVITREAL SOLUTION 03 MG005 ML 05 MG005 ML
MB PA LA
LUCENTIS INTRAVITREAL SYRINGE 03 MG005 ML 05 MG005 ML
MB PA LA
LUXTURNA SUBRETINAL SUSPENSION 15 X 10EXP11 VG03 ML (FNL)
MB LA
olopatadine ophthalmic (eye) drops 01 02 1
OMIDRIA INTRAOCULAR CONCENTRATE 1-03
MB
proparacaine ophthalmic (eye) drops 05 1
RESTASIS OPHTHALMIC (EYE) DROPPERETTE 005
1 QL (120 per 30 days)
TETRACAINE HCL (PF) OPHTHALMIC (EYE) DROPS 05
1
tetracaine hcl ophthalmic (eye) drops 05 1
VISUDYNE INTRAVENOUS RECON SOLN 15 MG
MB LA
XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5
1 PA ST QL (60 per 30 days)
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
112
Drug Name Drug Tier Requirements Limits
ACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE 045
1 ST
bromfenac ophthalmic (eye) drops 009 1
diclofenac sodium ophthalmic (eye) drops 01 1
flurbiprofen sodium ophthalmic (eye) drops 003
1
ketorolac ophthalmic (eye) drops 04 05 1
NEVANAC OPHTHALMIC (EYE) DROPSSUSPENSION 01
1
ORAL DRUGS FOR GLAUCOMA
acetazolamide oral capsule extended release 500 mg
1
acetazolamide oral tablet 125 mg 250 mg 1
methazolamide oral tablet 25 mg 50 mg 1
OTHER GLAUCOMA DRUGS
bimatoprost ophthalmic (eye) drops 003 1
brinzolamide ophthalmic (eye) dropssuspension 1
1
COMBIGAN OPHTHALMIC (EYE) DROPS 02-05
1
dorzolamide ophthalmic (eye) drops 2 1
dorzolamide-timolol (pf) ophthalmic (eye) dropperette 2-05
1
dorzolamide-timolol ophthalmic (eye) drops 223-68 mgml
1
latanoprost ophthalmic (eye) drops 0005 1
LUMIGAN OPHTHALMIC (EYE) DROPS 001
1 ST
RHOPRESSA OPHTHALMIC (EYE) DROPS 002
1 PA ST
SIMBRINZA OPHTHALMIC (EYE) DROPSSUSPENSION 1-02
1
travoprost ophthalmic (eye) drops 0004 1
STEROID-ANTIBIOTIC COMBINATIONS
neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
1
neomycin-polymyxin b-dexameth ophthalmic (eye) dropssuspension 35mgml-10000 unitml-01
1
113
Drug Name Drug Tier Requirements Limits
neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 35 mgg-10000 unitg-01
1
neomycin-polymyxin-hc ophthalmic (eye) dropssuspension 35-10000-10 mg-unit-mgml
1
neo-polycin hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
1
TOBRADEX OPHTHALMIC (EYE) OINTMENT 03-01
1
TOBRADEX ST OPHTHALMIC (EYE) DROPSSUSPENSION 03-005
1
tobramycin-dexamethasone ophthalmic (eye) dropssuspension 03-01
1
STEROIDS
ALREX OPHTHALMIC (EYE) DROPSSUSPENSION 02
1 ST
dexamethasone sodium phosphate ophthalmic (eye) drops 01
1
DUREZOL OPHTHALMIC (EYE) DROPS 005
1
fluorometholone ophthalmic (eye) dropssuspension 01
1
FML FORTE OPHTHALMIC (EYE) DROPSSUSPENSION 025
1
FML SOP OPHTHALMIC (EYE) OINTMENT 01
1
INVELTYS OPHTHALMIC (EYE) DROPSSUSPENSION 1
1 ST
LOTEMAX OPHTHALMIC (EYE) OINTMENT 05
1 ST
loteprednol etabonate ophthalmic (eye) dropsgel 05
1
loteprednol etabonate ophthalmic (eye) dropssuspension 05
1
MAXIDEX OPHTHALMIC (EYE) DROPSSUSPENSION 01
1
OZURDEX INTRAVITREAL IMPLANT 07 MG MB LA
PRED MILD OPHTHALMIC (EYE) DROPSSUSPENSION 012
1
prednisolone acetate ophthalmic (eye) dropssuspension 1
1
114
Drug Name Drug Tier Requirements Limits
prednisolone sodium phosphate ophthalmic (eye) drops 1
1
RETISERT INTRAVITREAL IMPLANT 059 MG
MB LA
YUTIQ INTRAVITREAL IMPLANT 018 MG MB
STEROID-SULFONAMIDE COMBINATIONS
BLEPHAMIDE OPHTHALMIC (EYE) DROPSSUSPENSION 10-02
1
BLEPHAMIDE SOP OPHTHALMIC (EYE) OINTMENT 10-02
1
sulfacetamide-prednisolone ophthalmic (eye) drops 10 -023 (025 )
1
SULFONAMIDES
sulfacetamide sodium ophthalmic (eye) drops 10
1
sulfacetamide sodium ophthalmic (eye) ointment 10
1
SYMPATHOMIMETICS
apraclonidine ophthalmic (eye) drops 05 1
brimonidine ophthalmic (eye) drops 015 02 1
IOPIDINE OPHTHALMIC (EYE) DROPPERETTE 1
1
VASOCONSTRICTOR DECONGESTANTS
phenylephrine hcl ophthalmic (eye) drops 10 25
1
RESPIRATORY ALLERGY COUGH amp COLD
ANTIHISTAMINE amp ANTIALLERGENIC AGENTS
adrenalin injection solution 1 mgml 1 mgml (1 ml)
1
carbinoxamine maleate oral liquid 4 mg5 ml 1 PA ST QL (2 per 30 days)
carbinoxamine maleate oral tablet 4 mg 1 PA ST QL (240 per 30 days)
carbinoxamine maleate oral tablet 6 mg 1 PA ST QL (120 per 30 days)
cetirizine oral solution 1 mgml 1
clemastine oral syrup 05 mg5 ml 1
clemastine oral tablet 268 mg 1
cyproheptadine oral syrup 2 mg5 ml 1
cyproheptadine oral tablet 4 mg 1
115
Drug Name Drug Tier Requirements Limits
desloratadine oral tablet 5 mg 1 PA ST QL (30 per 30 days)
desloratadine oral tabletdisintegrating 25 mg 5 mg
1 PA ST
diphenhydramine hcl injection solution 50 mgml 1
diphenhydramine hcl injection syringe 50 mgml MB
EPINEPHRINE INJECTION AUTO-INJECTOR 015 MG015 ML
1
epinephrine injection auto-injector 015 mg03 ml 03 mg03 ml
1
epinephrine injection solution 1 mgml 1 mgml (1 ml)
1
epinephrine injection syringe 01 mgml 1
hydroxyzine hcl intramuscular solution 25 mgml MB
hydroxyzine hcl oral solution 10 mg5 ml 1
hydroxyzine hcl oral tablet 10 mg 25 mg 50 mg 1
hydroxyzine pamoate oral capsule 100 mg 25 mg 50 mg
1
levocetirizine oral solution 25 mg5 ml 1
levocetirizine oral tablet 5 mg 1
promethazine injection solution 25 mgml MB
promethazine oral syrup 625 mg5 ml 1
promethazine oral tablet 125 mg 25 mg 50 mg 1
promethazine rectal suppository 125 mg 25 mg 1
promethegan rectal suppository 125 mg 25 mg 50 mg
1
COUGH amp COLD THERAPY
benzonatate oral capsule 100 mg 150 mg 200 mg 1
brompheniramine-pseudoeph-dm oral syrup 2-30-10 mg5 ml
1
codeine-guaifenesin oral liquid 10-100 mg5 ml 1
g tussin ac oral liquid 10-100 mg5 ml 1
guaiatussin ac oral liquid 10-100 mg5 ml 1
hydrocodone-chlorpheniramine oral suspensionextended rel 12 hr 10-8 mg5 ml
1
hydrocodone-homatropine oral syrup 5-15 mg5 ml
1
hydrocodone-homatropine oral tablet 5-15 mg 1
116
Drug Name Drug Tier Requirements Limits
hydromet oral syrup 5-15 mg5 ml 1
maxi-tuss ac oral liquid 10-100 mg5 ml 1
m-clear wc oral liquid 63-100 mg5 ml 1
promethazine-codeine oral syrup 625-10 mg5 ml 1
promethazine-dm oral syrup 625-15 mg5 ml 1
promethazine-phenyleph-codeine oral syrup 625-5-10 mg5 ml
1
promethazine-phenylephrine oral syrup 625-5 mg5 ml
1
virtussin ac oral liquid 10-100 mg5 ml 1
PULMONARY AGENTS
acetylcysteine solution 100 mgml (10 ) 200 mgml (20 )
1
ADEMPAS ORAL TABLET 05 MG 1 MG 15 MG 2 MG 25 MG
2 PA LA
ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCGACTUATION 230-21 MCGACTUATION 45-21 MCGACTUATION
1 QL (1 per 30 days)
ALBUTEROL HFA 90 MCG INHALER 90 MCGACTUATION
1 QL (2 per 30 days)
albuterol sulfate inhalation inhalation hfa aerosol inhaler 90 mcgactuation
1 QL (2 per 30 days)
albuterol sulfate inhalation inhalation solution for nebulization 063 mg3 ml 125 mg3 ml 25 mg 3 ml (0083 ) 25 mg05 ml 5 mgml
1
albuterol sulfate inhalation oral syrup 2 mg5 ml 1
albuterol sulfate inhalation oral tablet 2 mg 4 mg 1
albuterol sulfate inhalation oral tablet extended release 12 hr 4 mg 8 mg
1
ALVESCO INHALATION HFA AEROSOL INHALER 160 MCGACTUATION 80 MCGACTUATION
1 PA ST QL (1 per 30 days)
alyq oral tablet 20 mg 2 PA
ambrisentan oral tablet 10 mg 5 mg 2 PA LA
aminophylline intravenous solution 250 mg10 ml MB
ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 625-25 MCGACTUATION
1 QL (1 per 30 days)
arformoterol inhalation solution for nebulization 15 mcg2 ml
1
117
Drug Name Drug Tier Requirements Limits
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 200 MCGACTUATION
1 QL (1 per 30 days)
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 50 MCGACTUATION
1
ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCGACTUATION
1 QL (2 per 30 days)
BERINERT INTRAVENOUS KIT 500 UNIT (10 ML)
MB PA LA
BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-48 MCG
1
bosentan oral tablet 125 mg 625 mg 2 PA LA
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCGDOSE
1 QL (1 per 30 days)
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 200-25 MCGDOSE
1
BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG2 ML
1
budesonide inhalation suspension for nebulization 025 mg2 ml 05 mg2 ml
1 QL (120 per 30 days)
budesonide inhalation suspension for nebulization 1 mg2 ml
1 QL (60 per 30 days)
CINQAIR INTRAVENOUS SOLUTION 10 MGML
MB PA
CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)
MB PA LA
COMBIVENT RESPIMAT INHALATION MIST 20-100 MCGACTUATION
1 QL (2 per 30 days)
cromolyn inhalation solution for nebulization 20 mg2 ml
1
DALIRESP ORAL TABLET 250 MCG 500 MCG
1
DULERA INHALATION HFA AEROSOL INHALER 100-5 MCGACTUATION 200-5 MCGACTUATION 50-5 MCGACTUATION
1 QL (1 per 30 days)
ELIXOPHYLLIN ORAL ELIXIR 80 MG15 ML 1
ESBRIET ORAL CAPSULE 267 MG 2 PA LA QL (270 per 30 days)
ESBRIET ORAL TABLET 267 MG 801 MG 2 PA LA QL (90 per 30 days)
FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MGML
MB PA LA
118
Drug Name Drug Tier Requirements Limits
FASENRA SUBCUTANEOUS SYRINGE 30 MGML
MB PA LA
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 50 MCGACTUATION
1 QL (1 per 30 days)
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCGACTUATION
1 QL (4 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCGACTUATION 44 MCGACTUATION
1 QL (1 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCGACTUATION
1 QL (2 per 30 days)
fluticasone propionate nasal spraysuspension 50 mcgactuation
1
fluticasone propion-salmeterol inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose
1 QL (1 per 30 days)
formoterol fumarate inhalation solution for nebulization 20 mcg2 ml
1
HAEGARDA SUBCUTANEOUS RECON SOLN 2000 UNIT 3000 UNIT
2 PA LA
icatibant subcutaneous syringe 30 mg3 ml 2 PA
INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 625 MCGACTUATION
1 QL (1 per 30 days)
ipratropium bromide inhalation solution 002 1
ipratropium-albuterol inhalation solution for nebulization 05 mg-3 mg(25 mg base)3 ml
1 QL (180 per 30 days)
KALBITOR SUBCUTANEOUS SOLUTION 10 MGML (1 ML)
2 PA LA
KALYDECO ORAL GRANULES IN PACKET 25 MG 50 MG 75 MG
2 PA LA
KALYDECO ORAL TABLET 150 MG 2 PA LA
levalbuterol hcl inhalation solution for nebulization 031 mg3 ml 063 mg3 ml 125 mg05 ml 125 mg3 ml
1
LEVALBUTEROL TARTRATE INHALATION HFA AEROSOL INHALER 45 MCGACTUATION
1 QL (2 per 30 days)
metaproterenol oral syrup 10 mg5 ml 1
montelukast oral granules in packet 4 mg 1
montelukast oral tablet 10 mg 1
119
Drug Name Drug Tier Requirements Limits
montelukast oral tabletchewable 4 mg 5 mg 1
nebusal inhalation solution for nebulization 3 1
NUCALA SUBCUTANEOUS RECON SOLN 100 MG
MB PA LA
OFEV ORAL CAPSULE 100 MG 150 MG 2 PA LA QL (60 per 30 days)
OPSUMIT ORAL TABLET 10 MG 2 PA LA
ORLADEYO ORAL CAPSULE 110 MG 150 MG
2 PA ST QL (28 per 28 days)
PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG2 ML
1
pulmosal inhalation solution for nebulization 7 1
PULMOZYME INHALATION SOLUTION 1 MGML
2 PA LA
QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCGACTUATION 80 MCGACTUATION
1
REVATIO INTRAVENOUS SOLUTION 10 MG125 ML
MB LA
RUCONEST INTRAVENOUS RECON SOLN 2100 UNIT
MB PA LA
SEEBRI NEOHALER INHALATION CAPSULE WINHALATION DEVICE 156 MCG
1
SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCGDOSE
1
sildenafil (pulmhypertension) intravenous solution 10 mg125 ml
MB
sildenafil (pulmhypertension) oral suspension for reconstitution 10 mgml
2
sildenafil (pulmhypertension) oral tablet 20 mg 2 PA
SINUVA SINUS IMPLANT 1350 MCG MB
sodium chloride inhalation solution for nebulization 09 10 3 7
1
SPIRIVA RESPIMAT INHALATION MIST 125 MCGACTUATION
1
SPIRIVA RESPIMAT INHALATION MIST 25 MCGACTUATION
1 QL (1 per 30 days)
SPIRIVA WITH HANDIHALER INHALATION CAPSULE WINHALATION DEVICE 18 MCG
1 QL (30 per 30 days)
STIOLTO RESPIMAT INHALATION MIST 25-25 MCGACTUATION
1
120
Drug Name Drug Tier Requirements Limits
STRIVERDI RESPIMAT INHALATION MIST 25 MCGACTUATION
1
SYMBICORT INHALATION HFA AEROSOL INHALER 160-45 MCGACTUATION 80-45 MCGACTUATION
1 QL (1 per 30 days)
SYMDEKO ORAL TABLETS SEQUENTIAL 100-150 MG (D) 150 MG (N) 50-75 MG (D) 75 MG (N)
2 PA LA
tadalafil (pulm hypertension) oral tablet 20 mg 2 PA
TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG2 ML (150 MGML)
2 PA LA
terbutaline oral tablet 25 mg 5 mg 1
terbutaline subcutaneous solution 1 mgml 1
theophylline oral elixir 80 mg15 ml 1
theophylline oral solution 80 mg15 ml 1
theophylline oral tablet extended release 12 hr 300 mg 450 mg
1
theophylline oral tablet extended release 24 hr 400 mg 600 mg
1
TRACLEER ORAL TABLET FOR SUSPENSION 32 MG
2 PA LA
TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-625-25 MCG 200-625-25 MCG
1
TRIKAFTA ORAL TABLETS SEQUENTIAL 100-50-75 MG(D) 150 MG (N) 50-25-375 MG (D)75 MG (N)
2 PA LA
TYVASO INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)
2 PA LA
TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)
2 PA LA
TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML
2 PA LA
UTIBRON NEOHALER INHALATION CAPSULE WINHALATION DEVICE 275-156 MCG
1
VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCGML 20 MCGML
2 PA LA
121
Drug Name Drug Tier Requirements Limits
wixela inhub inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose
1 QL (1 per 30 days)
XOLAIR SUBCUTANEOUS RECON SOLN 150 MG
MB LA
XOLAIR SUBCUTANEOUS SYRINGE 150 MGML 75 MG05 ML
MB PA LA QL (7 per 30 days)
zafirlukast oral tablet 10 mg 20 mg 1
zileuton oral tablet er multiphase 12 hr 600 mg 1 ST
ZYFLO ORAL TABLET 600 MG 1 ST
UROLOGICALS
ANTICHOLINERGICS amp ANTISPASMODICS
darifenacin oral tablet extended release 24 hr 15 mg 75 mg
1
flavoxate oral tablet 100 mg 1
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG 50 MG
1 ST
oxybutynin chloride oral syrup 5 mg5 ml 1
oxybutynin chloride oral tablet 5 mg 1
oxybutynin chloride oral tablet extended release 24hr 10 mg 15 mg 5 mg
1
solifenacin oral tablet 10 mg 5 mg 1
tolterodine oral capsuleextended release 24hr 2 mg 4 mg
1
tolterodine oral tablet 1 mg 2 mg 1
trospium oral capsuleextended release 24hr 60 mg
1
trospium oral tablet 20 mg 1
BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY
alfuzosin oral tablet extended release 24 hr 10 mg 1
dutasteride oral capsule 05 mg 1
dutasteride-tamsulosin oral capsule er multiphase 24 hr 05-04 mg
1
finasteride oral tablet 5 mg 1
silodosin oral capsule 4 mg 8 mg 1
tadalafil oral tablet 25 mg 5 mg 1 PA ST
tamsulosin oral capsule 04 mg 1
CHOLINERGIC STIMULANTS
122
Drug Name Drug Tier Requirements Limits
bethanechol chloride oral tablet 10 mg 25 mg 5 mg 50 mg
1
MISCELLANEOUS UROLOGICALS
CYSTAGON ORAL CAPSULE 150 MG 50 MG 2 PA
ELMIRON ORAL CAPSULE 100 MG 1
hyophen oral tablet 816-012-108 mg 1
K-PHOS NO 2 ORAL TABLET 305-700 MG 1
K-PHOS ORIGINAL ORAL TABLETSOLUBLE 500 MG
1
methen-sod phos-meth blue-hyos oral tablet 816-408-012 mg
1
OXLUMO SUBCUTANEOUS SOLUTION 945 MG05 ML
2 PA
phosphasal oral tablet 816-108-408 mg 1
potassium citrate oral tablet extended release 10 meq (1080 mg) 15 meq 5 meq (540 mg)
1
RENACIDIN IRRIGATION SOLUTION 19806 MG-594 MG-9804MG30ML
1
URELLE ORAL TABLET 81-108-408 MG 1
uretron d-s oral tablet 816-108-408 mg 1
urimar-t oral tablet 120-012-108 mg 1
urogesic-blue oral tablet 816-408-012 mg 1
uryl oral tablet 816-408-012 mg 1
ustell oral capsule 120-012 mg 1
utira-c oral tablet 816-108-408 mg 1
URINARY ANESTHETICS
phenazopyridine oral tablet 100 mg 200 mg 1
VITAMINS HEMATINICS amp ELECTROLYTES
ELECTROLYTES
effer-k oral tablet effervescent 25 meq 1
klor-con 10 oral tablet extended release 10 meq 1
klor-con 8 oral tablet extended release 8 meq 1
klor-con m10 oral tableter particlescrystals 10 meq
1
klor-con m15 oral tableter particlescrystals 15 meq
1
123
Drug Name Drug Tier Requirements Limits
klor-con m20 oral tableter particlescrystals 20 meq
1
klor-con oral packet 20 meq 1
klor-conef oral tablet effervescent 25 meq 1
K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ
1
k-tab oral tablet extended release 8 meq 1
NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION
MB
potassium chloride oral capsule extended release 10 meq 8 meq
1
potassium chloride oral liquid 20 meq15 ml 40 meq15 ml
1
potassium chloride oral packet 20 meq 1
potassium chloride oral tablet extended release 10 meq 20 meq 8 meq
1
potassium chloride oral tableter particlescrystals 10 meq 20 meq
1
sodium chloride 045 intravenous parenteral solution 045
MB
MISCELLANEOUS VITAMINS HEMATINICS amp ELECTROLYTES
ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION
MB
PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION
MB
PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION
MB
VITAMINS amp HEMATINICS
cyanocobalamin (vitamin b-12) injection solution 1000 mcgml
1
ergocalciferol (vitamin d2) oral capsule 1250 mcg (50000 unit)
1
FA-8 ORAL CAPSULE 08 MG ACA PV
FER-IN-SOL ORAL DROPS 15 MG IRON (75 MG)ML
ACA PV
FLORIVA (FLUORIDE-VITAMIN D3) ORAL DROPS 025 MG (055 MG)-400 UNITML
ACA PV
fluoride (sodium) oral drops 05 mg (11 mg sodfluorid)ml
ACA PV
124
Drug Name Drug Tier Requirements Limits
fluoride (sodium) oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)
ACA PV
folic acid injection solution 5 mgml 1
folic acid oral tablet 1 mg 1
folic acid oral tablet 400 mcg 800 mcg ACA PV
hydroxocobalamin intramuscular solution 1000 mcgml
1
INFED INJECTION SOLUTION 50 MGML MB
ludent fluoride oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)
ACA PV
multi-vitamin with fluoride oral drops 025 mgml 05 mgml
ACA PV
multi-vitamin with fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
multivitamins with fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
mvc-fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
NOVAFERRUM ORAL DROPS 15 MG IRONML
ACA PV
tri-vitamin with fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml
ACA PV
vitamins acd and fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml
ACA PV
125
Index
A abacavir 2 abacavir-lamivudine 2 abacavir-lamivudine-
zidovudine 2 ABILIFY MAINTENA 36 abiraterone 13 ABRAXANE 13 acamprosate 66 acarbose 77 accutane 59 acebutolol 45 acetaminophen-caff-
dihydrocod 30 acetaminophen-codeine 31 acetazolamide 112 acetic acid 66 69 acetylcysteine 116 acitretin 57 ACTEMRA 95 ACTEMRA ACTPEN 95 ACTHAR 70 ACTHIB (PF) 90 ACTIMMUNE 89 ACUVAIL (PF) 112 acyclovir 2 63 ADACEL(TDAP
ADOLESNADULT)(PF) 90 ADAKVEO 13 adapalene 59 60 ADAPALENE 60 adapalene-benzoyl peroxide 60 ADCETRIS 14 adefovir 2 ADEMPAS 116 ADHANSIA XR 36 adrenalin 114 adult aspirin regimen 33 ADVAIR HFA 116 ADVATE 50 ADYNOVATE 50 ADZENYS ER 36 ADZENYS XR-ODT 36 AEROCHAMBER MINI 71 AEROCHAMBER PLUS
FLOW-VU 71 AFINITOR 14 afirmelle 102
AFSTYLA 50 AIMOVIG AUTOINJECTOR
28 AJOVY AUTOINJECTOR 28 AJOVY SYRINGE 28 ak-poly-bac 109 AKYNZEO (NETUPITANT)
81 ala-cort 63 albendazole 8 albuterol sulfate inhalation 116 ALBUTEROL SULFATE
INHALATION 116 alclometasone 63 ALCORTIN A 61 ALDURAZYME 74 ALECENSA 14 alendronate 95 alfuzosin 121 ALIMTA 14 ALINIA 8 ALIQOPA 14 aliskiren 45 allopurinol 95 almotriptan malate 28 ALOCRIL 110 ALOGLIPTIN-
PIOGLITAZONE 77 ALOMIDE 110 alosetron 81 ALOXI 81 ALPHANATE 50 ALPHANINE SD 50 alprazolam 37 alprazolam intensol 37 ALPROLIX 50 ALREX 113 ALTABAX 61 altacaine 111 altavera (28) 102 ALVESCO 116 alyacen 135 (28) 102 alyacen 777 (28) 102 alyq 116 amabelz 98 amantadine hcl 2 AMBISOME 1 ambrisentan 116
amcinonide 63 amethia 102 amethyst (28) 102 amikacin 8 amiloride 45 amiloride-hydrochlorothiazide
45 aminocaproic acid 50 51 aminophylline 116 amiodarone 44 AMITIZA 81 amitriptyline 37 amitriptyline-chlordiazepoxide
37 amlodipine 45 amlodipine-atorvastatin 55 amlodipine-benazepril 45 amlodipine-olmesartan 45 amlodipine-valsartan 45 amlodipine-valsartan-hcthiazid
45 ammonium lactate 59 amnesteem 60 amoxapine 37 amoxicil-clarithromy-lansopraz
85 amoxicillin 11 amoxicillin-pot clavulanate 11 AMPHETAMINE 37 amphetamine sulfate 37 amphotericin b 1 ampicillin 11 ampicillin-sulbactam 11 anagrelide 66 anaspaz 80 anastrozole 14 ANDEXXA 51 ANDRODERM 74 ANGELIQ 98 ANNOVERA 101 ANORO ELLIPTA 116 anucort-hc 81 apexicon e 63 APLENZIN 37 APOKYN 27 apraclonidine 114 aprepitant 81 apri 102
126
APTIVUS 2 ARALAST NP 66 aranelle (28) 102 ARANESP (IN
POLYSORBATE) 86 ARCALYST 89 ARESTIN 68 arformoterol 116 aripiprazole 37 ARISTADA 37 ARISTADA INITIO 37 armodafinil 37 ARMOUR THYROID 79 ARNUITY ELLIPTA 117 ARRANON 14 ARZERRA 14 ASCENIV 90 ascomp with codeine 31 asenapine maleate 37 ashlyna 102 ASPARLAS 14 aspirin 33 34 aspirin low dose 33 aspirin-dipyridamole 51 aspir-trin 34 atazanavir 2 atenolol 45 atenolol-chlorthalidone 45 ATGAM 90 atomoxetine 37 atorvastatin 55 atovaquone 8 atovaquone-proguanil 8 atropine 80 110 ATROVENT HFA 117 AUBAGIO 87 aubra 102 aubra eq 102 aurovela 1530 (21) 102 aurovela 120 (21) 102 aurovela 24 fe 102 aurovela fe 1530 (28) 102 aurovela fe 1-20 (28) 102 AUSTEDO 29 AVASTIN 14 aviane 102 avidoxy 12 avita 60 AVITA 60 AVONEX 88 AVYCAZ 6
ayuna 102 AZASITE 109 azathioprine 14 azelaic acid 60 azelastine 68 111 AZELEX 60 azithromycin 7 azurette (28) 102 B bacitracin 8 109 bacitracin-polymyxin b 109 baclofen 30 BALCOLTRA 102 balsalazide 81 BALVERSA 14 balziva (28) 102 BANZEL 24 BAQSIMI 71 BARACLUDE 2 BAVENCIO 14 BAXDELA 12 bayer aspirin 34 BAYER CHEWABLE
ASPIRIN 34 BCG VACCINE LIVE (PF) 90 BELEODAQ 14 belladonna alkaloids-opium 80 BELRAPZO 14 BELSOMRA 37 benazepril 45 benazepril-hydrochlorothiazide
45 BENDAMUSTINE 14 BENDEKA 14 BENEFIX 51 BENLYSTA 96 benzonatate 115 benztropine 27 BEOVU 111 bepotastine besilate 111 BEPREVE 111 BERINERT 117 beser 63 BESIVANCE 109 BESPONSA 14 betamethasone dipropionate 63 betamethasone valerate 63 betamethasone augmented 63
64 BETASERON 88 betaxolol 45 110
bethanechol chloride 122 BETIMOL 110 BETOPTIC S 110 BEVESPI AEROSPHERE 117 bexarotene 14 BEXSERO 90 bicalutamide 14 BICILLIN C-R 11 BIKTARVY 2 bimatoprost 112 BIOTHRAX 90 bisoprolol fumarate 45 bisoprolol-hydrochlorothiazide
45 BIVIGAM 90 BLEPHAMIDE 114 BLEPHAMIDE SOP 114 BLINCYTO 14 blisovi 24 fe 102 blisovi fe 1530 (28) 102 blisovi fe 120 (28) 103 BOOSTRIX TDAP 90 BORTEZOMIB 14 bosentan 117 BOSULIF 14 BOTOX 90 BRAFTOVI 14 BREO ELLIPTA 117 briellyn 103 BRILINTA 51 brimonidine 114 BRINEURA 75 brinzolamide 112 BRIVIACT 24 bromfenac 112 bromocriptine 27 brompheniramine-pseudoeph-
dm 115 BROVANA 117 budesonide 81 117 bumetanide 45 buprenorphine 31 buprenorphine hcl 31 buprenorphine-naloxone 34 bupropion hcl 37 38 bupropion hcl (smoking deter)
68 buspirone 38 BUSULFEX 15 butalbital compound wcodeine
31
127
butalbital-acetaminop-caf-cod 31
butalbital-acetaminophen-caff 31
butalbital-aspirin-caffeine 31 butorphanol 34 BYDUREON BCISE 77 BYETTA 77 BYSTOLIC 45 C CABENUVA 2 cabergoline 75 CABLIVI 51 CABOMETYX 15 calcipotriene 57 calcipotriene-betamethasone 57 calcitonin (salmon) 75 calcitriol 57 75 calcium acetate(phosphat bind)
81 CALQUENCE 15 camila 98 camrese 103 camrese lo 103 CANCIDAS 1 candesartan 45 candesartan-hydrochlorothiazid
46 CAPASTAT 8 capecitabine 15 CAPRELSA 15 captopril 46 captopril-hydrochlorothiazide
46 CARBAGLU 66 carbamazepine 24 carbidopa 27 carbidopa-levodopa 27 carbidopa-levodopa-
entacapone 27 carbinoxamine maleate 114 carisoprodol 30 carisoprodol-aspirin 30 carisoprodol-aspirin-codeine 30 carteolol 110 cartia xt 46 carvedilol 46 carvedilol phosphate 46 cataflam 34 CAYA CONTOURED 98 CAYSTON 8
caziant (28) 103 cefaclor 6 cefadroxil 6 cefazolin 6 cefazolin in dextrose (iso-os) 6 cefdinir 6 cefditoren pivoxil 6 cefepime 6 CEFEPIME IN DEXTROSE 5
6 cefepime in dextroseiso-osm 6 cefixime 6 CEFOTAN 6 cefotaxime 6 cefotetan 6 CEFOTETAN IN
DEXTROSE ISO-OSM 6 cefoxitin 6 cefpodoxime 6 7 cefprozil 7 ceftazidime 7 CEFTAZIDIME IN D5W 7 ceftriaxone 7 CEFTRIAXONE 7 ceftriaxone in dextroseiso-os 7 cefuroxime axetil 7 celecoxib 34 CELONTIN 24 cephalexin 7 CERDELGA 75 CEREZYME 75 cetirizine 114 cevimeline 66 CHANTIX 68 CHANTIX CONTINUING
MONTH BOX 68 CHANTIX STARTING
MONTH BOX 68 charlotte 24 fe 103 chateal (28) 103 chateal eq (28) 103 CHEMET 66 childrens aspirin 34 chloramphenicol sod succinate
8 chlordiazepoxide hcl 38 chlordiazepoxide-clidinium 80 chlorhexidine gluconate 68 chloroquine phosphate 8 chlorpromazine 38 chlorthalidone 46
chlorzoxazone 30 CHOLBAM 81 cholestyramine (with sugar) 55 cholestyramine light 55 cholinemagnesium salicylate
34 ciclodan 62 ciclopirox 62 ciclopirox-ure-camph-menth-
euc 62 cidofovir 2 cilostazol 51 CIMDUO 2 cimetidine 85 cimetidine hcl 85 CIMZIA 82 CIMZIA POWDER FOR
RECONST 81 cinacalcet 75 CINQAIR 117 CINRYZE 117 CIPRO HC 69 ciprofloxacin 12 ciprofloxacin hcl 12 69 109 ciprofloxacin-dexamethasone
69 citalopram 38 claravis 60 clarithromycin 7 8 clemastine 114 CLENPIQ 82 clindacin p 60 clindamycin hcl 8 clindamycin pediatric 8 clindamycin phosphate 8 60
101 clindamycin-benzoyl peroxide
60 clindamycin-tretinoin 60 clobazam 24 clobetasol 64 clobetasol-emollient 64 CLOCORTOLONE
PIVALATE 64 CLODERM 64 CLOLAR 15 clomipramine 38 clonazepam 24 clonidine 46 clonidine hcl 38 46 clopidogrel 51
128
clorazepate dipotassium 38 clotrimazole 1 62 clotrimazole-betamethasone 62 clovique 66 clozapine 38 COAGADEX 51 COARTEM 8 codeine sulfate 31 codeine-butalbital-asa-caff 31 codeine-guaifenesin 115 colchicine 95 COLCHICINE 95 colesevelam 55 colestipol 55 COMBIGAN 112 COMBIPATCH 98 COMBIVENT RESPIMAT 117 COMETRIQ 15 COMPLERA 2 compro 82 constulose 82 CONTOUR NEXT TEST
STRIPS 71 CONTOUR TEST STRIPS 71 COPIKTRA 15 CORIFACT 51 CORLANOR 56 CORTIFOAM 82 COSENTYX 58 COSENTYX (2 SYRINGES)
57 COSENTYX PEN 58 COSENTYX PEN (2 PENS) 58 COTELLIC 15 COTEMPLA XR-ODT 38 covaryx 98 covaryx hs 98 CREON 82 CRESEMBA 1 CRINONE 98 cromolyn 82 111 117 crotan 66 cryselle (28) 103 CRYSVITA 75 CUBICIN 8 CUBICIN RF 9 CUTAQUIG 90 CUVITRU 90 cyanocobalamin (vitamin b-12)
123 cyclafem 135 (28) 103
cyclafem 777 (28) 103 cyclobenzaprine 30 cyclopentolate 110 cyclophosphamide 15 CYCLOPHOSPHAMIDE 15 CYCLOSERINE 9 CYCLOSET 77 cyclosporine 15 cyclosporine modified 15 cyproheptadine 114 CYRAMZA 15 cyred 103 cyred eq 103 CYSTAGON 122 CYSTARAN 111 CYTOVENE 2 D DACOGEN 15 dalfampridine 29 DALIRESP 117 danazol 75 dantrolene 30 dapsone 9 60 DAPTACEL (DTAP
PEDIATRIC) (PF) 91 darifenacin 121 DARZALEX 15 dasetta 135 (28) 103 dasetta 777 (28) 103 DAURISMO 15 daysee 103 DAYTRANA 38 deblitane 98 decadron 70 decitabine 15 deferasirox 66 deferiprone 66 demeclocycline 12 DENAVIR 63 denta 5000 plus 68 dentagel 69 DEPO-ESTRADIOL 98 DEPO-PROVERA 98 DEPO-SUBQ PROVERA 104
98 DEPO-TESTOSTERONE 75 DESCOVY 2 desipramine 38 desloratadine 115 desmopressin 75
desog-eestradioleestradiol 103
desogestrel-ethinyl estradiol 103
desonide 64 desoximetasone 64 DESVENLAFAXINE 38 desvenlafaxine succinate 38 dexamethasone 70 dexamethasone intensol 70 dexamethasone sodium phos
(pf) 70 dexamethasone sodium
phosphate 70 113 DEXILANT 85 dexmethylphenidate 38 dextroamphetamine 38 39 dextroamphetamine-
amphetamine 39 diazepam 24 39 diazepam intensol 39 diazoxide 71 diclofenac potassium 34 diclofenac sodium 34 59 112 diclofenac-misoprostol 34 dicloxacillin 11 dicyclomine 80 didanosine 2 DIFICID 8 diflorasone 64 diflunisal 34 digitek 50 digox 50 digoxin 50 dihydroergotamine 28 DILANTIN 24 DILANTIN EXTENDED 24 DILANTIN INFATABS 24 DILANTIN-125 24 diltiazem 46 dilt-xr 46 dimethyl fumarate 88 DIPENTUM 82 diphenhydramine hcl 115 diphenoxylate-atropine 80 dipyridamole 51 diskets 31 disopyramide phosphate 44 disulfiram 66 divalproex 24 25 DIVIGEL 99
129
dofetilide 44 dolishale 103 donepezil 29 DONNATAL 80 DOPTELET (15 TAB PACK)
51 dorzolamide 112 dorzolamide-timolol 112 dorzolamide-timolol (pf) 112 dotti 99 DOVATO 2 doxazosin 46 doxepin 39 doxercalciferol 75 doxycycline hyclate 12 doxycycline monohydrate 12 doxylamine-pyridoxine (vit b6)
82 dronabinol 82 drospirenone-eestradiol-lmfa
103 drospirenone-ethinyl estradiol
103 DSUVIA 31 DUAVEE 99 DUEXIS 34 DULERA 117 duloxetine 39 DUPIXENT PEN 59 DUPIXENT SYRINGE 59 duramorph (pf) 31 DUREZOL 113 dutasteride 121 dutasteride-tamsulosin 121 dvorah 31 DYANAVEL XR 39 DYSPORT 91 E ees 400 8 econazole 62 econtra ez 103 econtra one-step 103 ecotrin 34 ecotrin low strength 34 EDARBI 46 EDARBYCLOR 46 EDLUAR 39 ed-spaz 80 EDURANT 2 eemt 99 eemt hs 99
efavirenz 2 efavirenz-emtricitabin-tenofov
3 efavirenz-lamivu-tenofov disop
3 effer-k 122 ELAPRASE 75 ELELYSO 75 eletriptan 28 ELIGARD 16 ELIGARD (3 MONTH) 15 ELIGARD (4 MONTH) 15 ELIGARD (6 MONTH) 15 elinest 103 ELIQUIS 51 ELIQUIS DVT-PE TREAT
30D START 51 ELIXOPHYLLIN 117 ELLA 103 ELMIRON 122 ELOCTATE 51 eluryng 101 ELZONRIS 16 EMCYT 16 EMEND 82 EMGALITY PEN 28 EMGALITY SYRINGE 28 emoquette 103 EMPAVELI 67 EMPLICITI 16 EMSAM 39 emtricitabine 3 emtricitabine-tenofovir (tdf) 3 EMTRIVA 3 EMVERM 9 enalapril maleate 46 enalaprilat 46 enalapril-hydrochlorothiazide
46 ENBREL 96 ENBREL MINI 96 ENBREL SURECLICK 96 endocet 31 ENGERIX-B (PF) 91 ENGERIX-B PEDIATRIC
(PF) 91 ENHERTU 16 enoxaparin 51 enpresse 104 enskyce 104 entacapone 27
entecavir 3 ENTRESTO 56 ENTYVIO 82 enulose 82 EPANED 46 EPCLUSA 3 EPIDIOLEX 25 epinastine 111 epinephrine 115 EPINEPHRINE 115 epitol 25 EPIVIR HBV 3 eplerenone 47 EPOGEN 86 epoprostenol (glycine) 47 eprosartan 47 ERAXIS(WATER DILUENT)
1 ERBITUX 16 ergocalciferol (vitamin d2) 123 ergoloid 39 ergotamine-caffeine 28 ERLEADA 16 erlotinib 16 errin 99 ERWINAZE 16 ery pads 60 erygel 60 ery-tab 8 erythrocin (as stearate) 8 erythromycin 8 109 erythromycin ethylsuccinate 8 erythromycin with ethanol 60 erythromycin-benzoyl peroxide
60 ESBRIET 117 escitalopram oxalate 39 esomeprazole magnesium 85 ESPEROCT 51 estarylla 104 estazolam 39 estradiol 99 estradiol valerate 99 estradiol-norethindrone acet 99 ESTRING 99 estrogens-methyltestosterone 99 eszopiclone 39 ethacrynic acid 47 ethambutol 9 ethosuximide 25
130
ethynodiol diac-eth estradiol 104
etodolac 34 etonogestrel-ethinyl estradiol
101 etoposide 16 etravirine 3 EUCRISA 59 EUFLEXXA 34 EURAX 66 EVAMIST 99 EVENITY 95 everolimus (antineoplastic) 16 everolimus
(immunosuppressive) 16 EVOTAZ 3 EXELDERM 62 exemestane 16 EXONDYS-51 29 EYLEA 111 ezetimibe 55 ezetimibe-simvastatin 55 F FA-8 123 FABRAZYME 75 FACTIVE 12 falmina (28) 104 famciclovir 3 famotidine 86 famotidine (pf) 85 FANAPT 39 FARXIGA 77 FASENRA 118 FASENRA PEN 117 FASLODEX 16 fayosim 104 FC2 FEMALE CONDOM 98 febuxostat 95 FEIBA NF 51 felbamate 25 felodipine 47 fem ph 101 FEMCAP 98 FEMRING 99 femynor 104 fenofibrate 55 FENOFIBRATE 55 fenofibrate micronized 55 fenofibrate nanocrystallized 55 fenofibric acid 55 fenofibric acid (choline) 55
fenoprofen 35 fentanyl 32 fentanyl citrate 31 FER-IN-SOL 123 FERRIPROX 67 FETZIMA 39 FIASP FLEXTOUCH U-100
INSULIN 72 FIASP PENFILL U-100
INSULIN 72 FIASP U-100 INSULIN 72 FIBRYGA 51 finasteride 121 FINTEPLA 25 FIRMAGON KIT W
DILUENT SYRINGE 16 flac otic oil 69 flavoxate 121 FLEBOGAMMA DIF 91 flecainide 44 FLOLAN 47 FLORIVA (FLUORIDE-
VITAMIN D3) 123 FLOVENT DISKUS 118 FLOVENT HFA 118 fluconazole 1 flucytosine 1 fludarabine 16 fludrocortisone 70 fluocinolone 64 fluocinolone acetonide oil 69 fluocinolone and shower cap 64 fluocinonide 64 fluocinonide-e 64 fluoride (sodium) 69 123 124 fluorometholone 113 fluorouracil 16 59 FLUOROURACIL 59 fluoxetine 39 40 fluphenazine hcl 40 flurandrenolide 64 65 flurazepam 40 flurbiprofen 35 flurbiprofen sodium 112 flutamide 16 fluticasone propionate 65 118 fluticasone propion-salmeterol
118 fluvastatin 55 56 fluvoxamine 40 FML FORTE 113
FML SOP 113 folic acid 124 FOLOTYN 16 fondaparinux 51 formoterol fumarate 118 FORTEO 95 FOSAMAX PLUS D 95 fosamprenavir 3 fosfomycin tromethamine 13 fosinopril 47 fosinopril-hydrochlorothiazide
47 FRAGMIN 52 FREESTYLE LIBRE 14 DAY
SENSOR 71 FREESTYLE LIBRE 2
SENSOR 71 frovatriptan 28 fulvestrant 16 furosemide 47 FUZEON 3 fyavolv 99 G g tussin ac 115 gabapentin 25 GALAFOLD 75 galantamine 29 GAMASTAN 91 GAMASTAN SD 91 GAMIFANT 16 GAMMAGARD LIQUID 91 GAMMAGARD S-D (IGA lt 1
MCGML) 91 GAMMAKED 91 GAMMAPLEX 91 GAMMAPLEX (WITH
SORBITOL) 91 GAMUNEX-C 91 GANCICLOVIR 3 ganciclovir sodium 3 GARDASIL 9 (PF) 91 gatifloxacin 109 gavilyte-c 82 gavilyte-g 82 gavilyte-n 82 GAZYVA 16 gemcitabine 16 17 gemfibrozil 56 gemmily 104 generlac 82 gengraf 17
131
GENOTROPIN 87 GENOTROPIN MINIQUICK
87 gentak 109 gentamicin 9 61 62 109 gentamicin sulfate (ped) (pf) 9 GENVOYA 3 GIAPREZA 56 GILENYA 88 GILOTRIF 17 GIVLAARI 67 GLASSIA 67 glatiramer 88 glatopa 88 GLEOSTINE 17 glimepiride 77 glipizide 77 glipizide-metformin 77 GLUCAGEN DIAGNOSTIC
KIT 71 GLUCAGEN HYPOKIT 71 GLUCAGON (HCL)
EMERGENCY KIT 71 glucagon emergency kit
(human) 71 GLUCAGON HCL 71 glyburide 77 glyburide micronized 77 glyburide-metformin 77 glycopyrrolate 80 GLYXAMBI 78 GONITRO 57 granisetron hcl 82 GRANIX 86 GRASTEK 91 griseofulvin microsize 1 griseofulvin ultramicrosize 1 guaiatussin ac 115 guanfacine 40 47 GYNAZOLE-1 101 gynol ii 101 H HAEGARDA 118 hailey 104 hailey 24 fe 104 hailey fe 1530 (28) 104 hailey fe 120 (28) 104 HALAVEN 17 halcinonide 65 halobetasol propionate 65 haloperidol 40
haloperidol decanoate 40 haloperidol lactate 40 HARVONI 3 HAVRIX (PF) 91 92 heather 99 HEMLIBRA 52 hemmorex-hc 82 HEMOFIL M HIGH 52 HEMOFIL M LOW 52 HEMOFIL M MID 52 HEMOFIL M SUPER HIGH52 hep flush-10 (pf) 52 heparin (porcine) 52 heparin (porcine) in 5 dex 52 heparin lock flush (porcine) 52 heparin lockflush(porcine)(pf)
52 heparin(porcine) in 045 nacl
52 HEPARIN(PORCINE) IN
045 NACL 52 heparin porcine (pf) 52 53 HEPLISAV-B (PF) 92 HERCEPTIN 17 HERCEPTIN HYLECTA 17 HERZUMA 17 HETLIOZ 40 HETLIOZ LQ 40 HIBERIX (PF) 92 HIZENTRA 92 homatropaire 110 HUMALOG JUNIOR
KWIKPEN U-100 72 HUMALOG KWIKPEN
INSULIN 72 HUMALOG MIX 50-50
INSULN U-100 72 HUMALOG MIX 50-50
KWIKPEN 72 HUMALOG MIX 75-25
KWIKPEN 72 HUMALOG MIX 75-25(U-
100)INSULN 72 HUMALOG U-100 INSULIN
72 HUMATE-P 53 HUMIRA 96 HUMIRA PEN 96 HUMIRA PEN CROHNS-UC-
HS START 96
HUMIRA PEN PSOR-UVEITS-ADOL HS 96
HUMIRA(CF) 97 HUMIRA(CF) PEDI
CROHNS STARTER 96 HUMIRA(CF) PEN 96 HUMIRA(CF) PEN
CROHNS-UC-HS 96 HUMIRA(CF) PEN
PEDIATRIC UC 96 HUMIRA(CF) PEN PSOR-
UV-ADOL HS 96 HUMULIN 7030 U-100
INSULIN 72 HUMULIN 7030 U-100
KWIKPEN 72 HUMULIN N NPH INSULIN
KWIKPEN 73 HUMULIN N NPH U-100
INSULIN 73 HUMULIN R REGULAR U-
100 INSULN 73 HUMULIN R U-500 (CONC)
INSULIN 73 HUMULIN R U-500 (CONC)
KWIKPEN 73 HYCAMTIN 17 hydralazine 47 hydrochlorothiazide 47 hydrocodone bitartrate 32 hydrocodone-acetaminophen 32 hydrocodone-chlorpheniramine
115 hydrocodone-homatropine 115 hydrocodone-ibuprofen 32 hydrocortisone 65 70 82 hydrocortisone acetate 82 hydrocortisone butyrate 65 hydrocortisone butyr-emollient
65 hydrocortisone valerate 65 hydrocortisone-acetic acid 69 hydrocortisone-pramoxine 58
82 hydromet 116 hydromorphone 32 HYDROMORPHONE 32 hydroxocobalamin 124 hydroxychloroquine 9 hydroxyprogest(pf)(preg presv)
99
132
hydroxyprogesterone cap(ppres) 99
hydroxyprogesterone caproate 100
hydroxyurea 17 hydroxyzine hcl 115 hydroxyzine pamoate 115 hyophen 122 hyoscyamine sulfate 80 hyosyne 80 HYQVIA 92 I ibandronate 95 IBRANCE 17 ibu 35 ibuprofen 35 icatibant 118 iclevia 104 ICLUSIG 17 icosapent ethyl 56 IDELVION 53 IDHIFA 17 ILARIS (PF) 90 ILUMYA 58 imatinib 17 IMBRUVICA 17 IMFINZI 17 imipenem-cilastatin 9 imipramine hcl 40 imipramine pamoate 40 imiquimod 90 IMLYGIC 17 IMOVAX RABIES VACCINE
(PF) 92 incassia 100 INCRELEX 67 INCRUSE ELLIPTA 118 indapamide 47 indomethacin 35 INFANRIX (DTAP) (PF) 92 INFED 124 INFLECTRA 82 INFUGEM 18 INLYTA 18 INSULIN ASP PRT-INSULIN
ASPART 73 INSULIN ASPART U-100 73 INSULIN SYRINGE-
NEEDLE U-100 71 INTELENCE 3 INTRAROSA 101
INTRON A 90 INVANZ 9 INVEGA SUSTENNA 40 INVELTYS 113 INVIRASE 3 IOPIDINE 114 IPOL 92 ipratropium bromide 69 118 ipratropium-albuterol 118 irbesartan 47 irbesartan-hydrochlorothiazide
47 IRESSA 18 ISENTRESS 3 ISENTRESS HD 3 isibloom 104 ISOLYTE-S 123 isoniazid 9 isosorbide dinitrate 57 isosorbide mononitrate 57 isotretinoin 60 isoxsuprine 101 isradipine 47 ISTODAX 18 itraconazole 1 ivermectin 9 66 IXEMPRA 18 IXIARO (PF) 92 IXINITY 53 J jaimiess 104 JAKAFI 18 jantoven 53 JANUMET 78 JANUMET XR 78 JANUVIA 78 JARDIANCE 78 jasmiel (28) 104 jencycla 100 JENTADUETO 78 JENTADUETO XR 78 JEVTANA 18 jinteli 100 JIVI 53 jolessa 104 JORNAY PM 40 JUBLIA 62 juleber 104 JULUCA 3 junel 1530 (21) 104 junel 120 (21) 104
junel fe 1530 (28) 104 junel fe 120 (28) 104 junel fe 24 104 JUXTAPID 56 JYNARQUE 75 K KADCYLA 18 kaitlib fe 104 KALBITOR 118 KALETRA 3 4 kalliga 104 KALYDECO 118 KANJINTI 18 KANUMA 75 kariva (28) 104 kelnor 135 (28) 105 kelnor 1-50 (28) 105 KEPIVANCE 13 ketoconazole 1 62 ketodan 62 ketoprofen 35 ketorolac 35 112 KEVZARA 97 KEYTRUDA 18 KINRIX (PF) 92 KISQALI 18 KISQALI FEMARA CO-
PACK 18 klor-con 123 klor-con 10 122 klor-con 8 122 klor-con m10 122 klor-con m15 122 klor-con m20 123 klor-conef 123 KOATE 53 KOGENATE FS 53 KORLYM 75 KOVALTRY 53 K-PHOS NO 2 122 K-PHOS ORIGINAL 122 KRYSTEXXA 95 k-tab 123 K-TAB 123 kurvelo (28) 105 KYLEENA 98 KYMRIAH 18 KYPROLIS 18 L l norgesteestradiol-eestrad
105
133
labetalol 47 LACRISERT 111 lactulose 83 lamivudine 4 lamivudine-zidovudine 4 lamotrigine 25 lansoprazole 86 lanthanum 83 LANTUS SOLOSTAR U-100
INSULIN 73 LANTUS U-100 INSULIN 73 lapatinib 18 larin 1530 (21) 105 larin 120 (21) 105 larin 24 fe 105 larin fe 1530 (28) 105 larin fe 120 (28) 105 larissia 105 LASTACAFT 111 latanoprost 112 LATUDA 40 layolis fe 105 leena 28 105 leflunomide 97 LEMTRADA 88 LENVIMA 18 lessina 105 letrozole 19 leucovorin calcium 13 LEUKERAN 19 LEUKINE 86 leuprolide 19 levalbuterol hcl 118 LEVALBUTEROL
TARTRATE 118 LEVEMIR FLEXTOUCH U-
100 INSULN 73 LEVEMIR U-100 INSULIN 73 levetiracetam 25 levobunolol 110 levocarnitine 67 levocarnitine (with sugar) 67 levocetirizine 115 levofloxacin 12 109 levonest (28) 105 levonorgestrel 105 levonorgestrel-ethinyl estrad
105 levonorg-eth estrad triphasic
105 levora-28 105
levorphanol tartrate 32 levothyroxine 79 levoxyl 79 LEVULAN 59 LEXIVA 4 LIBTAYO 19 lidocaine 61 lidocaine hcl 61 lidocaine hcl-hydrocortison ac
61 83 LIDOCAINE HCL-
HYDROCORTISON AC 83 lidocaine viscous 61 lidocaine-hydrocortisone-aloe
83 lidocaine-prilocaine 61 LIDOCAINE-TETRACAINE
61 LILETTA 98 lillow (28) 105 LINCOCIN 9 lindane 66 linezolid 9 linezolid in dextrose 5 9 linezolid-09 sodium chloride
9 LINZESS 83 liothyronine 79 LIPOFEN 56 lisinopril 47 lisinopril-hydrochlorothiazide
47 lithium carbonate 40 41 LO LOESTRIN FE 105 lojaimiess 105 LONSURF 19 loperamide 80 lopinavir-ritonavir 4 lorazepam 41 lorazepam intensol 41 loryna (28) 105 losartan 47 losartan-hydrochlorothiazide 47 LOTEMAX 113 loteprednol etabonate 113 lovastatin 56 low-ogestrel (28) 105 loxapine succinate 41 lo-zumandimine (28) 105 LUCENTIS 111 ludent fluoride 124
LULICONAZOLE 62 LUMIGAN 112 LUMIZYME 75 LUMOXITI 19 LUPANETA PACK (1
MONTH) 101 LUPANETA PACK (3
MONTH) 101 LUPKYNIS 19 LUPRON DEPOT 19 LUPRON DEPOT (3
MONTH) 19 LUPRON DEPOT (4
MONTH) 19 LUPRON DEPOT (6
MONTH) 19 LUPRON DEPOT-PED 19 LUPRON DEPOT-PED (3
MONTH) 19 lutera (28) 105 LUXTURNA 111 LUZU 62 lyleq 100 lyllana 100 LYNPARZA 19 LYRICA CR 25 LYSODREN 19 lyza 100 M mafenide acetate 62 malathion 66 maprotiline 41 marlissa (28) 106 MARPLAN 41 MARQIBO 19 MATULANE 19 matzim la 47 MAVENCLAD (10 TABLET
PACK) 88 MAVENCLAD (4 TABLET
PACK) 88 MAVENCLAD (5 TABLET
PACK) 88 MAVENCLAD (6 TABLET
PACK) 88 MAVENCLAD (7 TABLET
PACK) 88 MAVENCLAD (8 TABLET
PACK) 88 MAVENCLAD (9 TABLET
PACK) 88
134
MAVYRET 4 MAXIDEX 113 maxi-tuss ac 116 MAYZENT 88 MAYZENT STARTER PACK
88 m-clear wc 116 meclizine 83 meclofenamate 35 medroxyprogesterone 100 mefenamic acid 35 mefloquine 9 megestrol 19 MEKINIST 19 MEKTOVI 19 meloxicam 35 melphalan 19 melphalan hcl 19 memantine 29 MENACTRA (PF) 92 MENEST 100 MENOSTAR 100 MENQUADFI (PF) 92 MENTAX 62 MENVEO A-C-Y-W-135-DIP
(PF) 92 meperidine 32 meprobamate 30 MEPSEVII 76 mercaptopurine 20 meropenem 9 MEROPENEM-09
SODIUM CHLORIDE 9 merzee 106 mesalamine 83 mesalamine with cleansing
wipe 83 metaproterenol 118 metaxalone 30 metformin 78 methadone 32 methadose 32 methamphetamine 41 methazolamide 112 methenamine hippurate 13 methenamine mandelate 13 methen-sod phos-meth blue-
hyos 122 methergine 109 methimazole 71 methocarbamol 30
methotrexate sodium 20 methotrexate sodium (pf) 20 methoxsalen 59 methscopolamine 80 methyldopa 47 methyldopa-
hydrochlorothiazide 47 methyldopate 48 methylergonovine 109 METHYLIN 41 methylphenidate hcl 41 methylprednisolone 70 methylprednisolone acetate 70 methyltestosterone 76 metoclopramide hcl 83 metolazone 48 metoprolol succinate 48 metoprolol ta-hydrochlorothiaz
48 metoprolol tartrate 48 metronidazole 9 60 61 101 metyrosine 48 mexiletine 44 MIACALCIN 76 mibelas 24 fe 106 microgestin 1530 (21) 106 microgestin 120 (21) 106 microgestin fe 1530 (28) 106 microgestin fe 120 (28) 106 midazolam 41 midodrine 67 migergot 28 miglitol 78 miglustat 76 mili 106 millipred 70 millipred dp 70 mimvey 100 MINITRAN 57 minocycline 12 minoxidil 48 MIRCERA 86 MIRENA 98 mirtazapine 41 misoprostol 86 MITIGARE 95 mitoxantrone 20 M-M-R II (PF) 92 modafinil 41 moexipril 48 molindone 41
mometasone 65 mondoxyne nl 12 mono-linyah 106 MONONINE 53 MONOVISC 35 montelukast 118 119 morphine 32 33 morphine (pf) 32 morphine concentrate 32 MOTOFEN 80 MOVANTIK 83 MOXATAG 11 moxifloxacin 12 109 MOZOBIL 87 MULPLETA 53 MULTAQ 44 multi-vitamin with fluoride 124 multivitamins with fluoride 124 mupirocin 62 mupirocin calcium 62 mvc-fluoride 124 my choice 106 my way 106 MYALEPT 76 MYCAMINE 1 mycophenolate mofetil 20 mycophenolate sodium 20 MYDAYIS 41 MYLOTARG 20 MYOBLOC 92 myorisan 61 MYRBETRIQ 121 N nabumetone 35 nadolol 48 nadolol-bendroflumethiazide 48 nafcillin 11 nafcillin in dextrose iso-osm 11 naftifine 62 63 NAGLAZYME 76 nalbuphine 35 naloxone 35 naltrexone 35 naproxen 35 naproxen sodium 35 naratriptan 28 NARCAN 35 NATACYN 109 NATAZIA 106 nateglinide 78 NATPARA 76
135
nebusal 119 necon 0535 (28) 106 nefazodone 41 neomycin 9 neomycin-bacitracin-poly-hc
112 neomycin-bacitracin-
polymyxin 109 neomycin-polymyxin b-
dexameth 112 113 neomycin-polymyxin-
gramicidin 109 neomycin-polymyxin-hc 69
113 neo-polycin 109 neo-polycin hc 113 NERLYNX 20 NEUPOGEN 87 NEVANAC 112 nevirapine 4 new day 106 NEXAVAR 20 NEXPLANON 101 NEXTSTELLIS 106 niacin 56 NIACOR 56 nicardipine 48 nicorette 68 nicotine 68 nicotine (polacrilex) 68 NICOTROL 68 NICOTROL NS 68 nifedipine 48 nikki (28) 106 nilutamide 20 nimodipine 48 NINLARO 20 nisoldipine 48 nitazoxanide 9 nitisinone 67 nitro-bid 57 NITRO-DUR 57 nitrofurantoin 13 nitrofurantoin macrocrystal 13 nitrofurantoin monohydm-
cryst 13 nitroglycerin 57 nitroglycerin in 5 dextrose 57 nitro-time 57 NITYR 67 NIVESTYM 87
nizatidine 86 nora-be 100 noreth-ethinyl estradiol-iron
106 norethindrone (contraceptive)
100 norethindrone acetate 100 norethindrone ac-eth estradiol
100 106 norethindrone-eestradiol-iron
106 norgestimate-ethinyl estradiol
106 norlyda 100 NORMOSOL-R 123 NORPACE CR 44 nortrel 0535 (28) 106 nortrel 135 (21) 106 nortrel 135 (28) 106 nortrel 777 (28) 107 nortriptyline 42 NORVIR 4 NOVAFERRUM 124 NOVOEIGHT 53 NOVOLIN 70-30 FLEXPEN
U-100 73 NOVOLIN N FLEXPEN 73 NOVOLIN R FLEXPEN 73 NOVOLOG FLEXPEN U-100
INSULIN 74 NOVOLOG MIX 70-30 U-100
INSULN 74 NOVOLOG MIX 70-
30FLEXPEN U-100 74 NOVOLOG PENFILL U-100
INSULIN 74 NOVOLOG U-100 INSULIN
ASPART 74 NOVOPEN ECHO 71 NOVOSEVEN RT 53 NOXAFIL 1 np thyroid 79 NPLATE 53 NUCALA 119 NUCYNTA ER 36 NUEDEXTA 29 NULOJIX 20 NULYTELY LEMON-LIME
83 NUPLAZID 42 NUWIQ 53
nyamyc 63 nylia 777 (28) 107 nymyo 107 nystatin 1 63 nystatin-triamcinolone 63 nystop 63 O OBIZUR 54 ocella 107 OCREVUS 88 OCTAGAM 92 octreotide acetate 20 ODEFSEY 4 OFEV 119 ofloxacin 12 69 109 OGIVRI 20 olanzapine 42 olanzapine-fluoxetine 42 olmesartan 48 olmesartan-amlodipin-
hcthiazid 48 olmesartan-
hydrochlorothiazide 48 olopatadine 69 111 OLUMIANT 97 omega-3 acid ethyl esters 56 omeprazole 86 OMIDRIA 111 OMNITROPE 87 ONCASPAR 20 ondansetron 84 ondansetron hcl 83 84 ONETOUCH ULTRA TEST
71 ONETOUCH VERIO TEST
STRIPS 71 ONIVYDE 20 ONPATTRO 29 ONZETRA XSAIL 28 opcicon one-step 107 OPDIVO 20 opium tincture 81 OPSUMIT 119 option-2 107 ORALAIR 92 oralone 69 ORAVIG 1 ORENCIA 97 ORENCIA (WITH
MALTOSE) 97 ORENCIA CLICKJECT 97
136
ORENITRAM 48 ORLADEYO 119 orphenadrine citrate 30 orsythia 107 ORTHOVISC 36 oscimin 81 oscimin sl 81 oscimin sr 81 oseltamivir 4 OSMOPREP 84 OSPHENA 101 OTEZLA 97 OTEZLA STARTER 97 OTOVEL 69 oxacillin 11 oxacillin in dextrose(iso-osm)
11 oxandrolone 76 oxaprozin 36 oxazepam 42 oxcarbazepine 25 oxiconazole 63 OXISTAT 63 OXLUMO 122 oxybutynin chloride 121 oxycodone 33 oxycodone-acetaminophen 33 oxycodone-aspirin 33 OXYCONTIN 33 oxymorphone 33 OZEMPIC 78 OZURDEX 113 P pacerone 44 PADCEV 20 paliperidone 42 PALYNZIQ 76 pamidronate 76 PANRETIN 59 pantoprazole 86 PANZYGA 92 PARAGARD T 380A 98 paricalcitol 76 PARICALCITOL 76 paroex oral rinse 69 paromomycin 10 paroxetine hcl 42 paroxetine
mesylate(menopsym) 42 PARSABIV 76 PASER 10
PEDIARIX (PF) 92 PEDVAX HIB (PF) 93 peg 3350-electrolytes 84 peg3350-sod sul-nacl-kcl-asb-c
84 PEGASYS 88 89 peg-electrolyte soln 84 peg-prep 84 PEMAZYRE 20 PEN NEEDLE DIABETIC 72 penicillamine 97 penicillin g procaine 11 penicillin v potassium 11 PENTACEL (PF) 93 PENTACEL ACTHIB
COMPONENT (PF) 93 PENTAM 10 pentamidine 10 pentazocine-naloxone 36 pentoxifylline 54 PERFOROMIST 119 perindopril erbumine 48 periogard 69 PERJETA 20 permethrin 66 perphenazine 42 perphenazine-amitriptyline 42 phenazopyridine 122 phenelzine 42 phenobarb-hyoscy-atropine-
scop 81 phenobarbital 25 26 phenohytro 81 phenoxybenzamine 48 phenylephrine hcl 114 phenytoin 26 phenytoin sodium extended 26 PHEXXI 101 philith 107 phosphasal 122 PHYSIOLYTE 66 PHYSIOSOL IRRIGATION 66 phytonadione (vitamin k1) 54 PICATO 59 pilocarpine hcl 67 69 110 pimecrolimus 59 pimozide 42 pimtrea (28) 107 pindolol 48 pioglitazone 78 pioglitazone-glimepiride 78
pioglitazone-metformin 78 piperacillin-tazobactam 11 PIQRAY 21 pirmella 107 piroxicam 36 PLASMA-LYTE 148 123 PLASMA-LYTE A 123 PLEGRIDY 89 PLENVU 84 PNEUMOVAX-23 93 podofilox 59 POLIVY 21 polycin 110 polymyxin b sulfate 10 polymyxin b sulf-trimethoprim
110 POMALYST 89 PONVORY 89 PONVORY 14-DAY
STARTER PACK 89 portia 28 107 PORTRAZZA 21 posaconazole 1 potassium chloride 123 potassium citrate 122 POTELIGEO 21 pramipexole 27 prasugrel 54 pravastatin 56 praziquantel 10 prazosin 48 PRED MILD 113 prednicarbate 65 prednisolone 70 prednisolone acetate 113 prednisolone sodium phosphate
70 114 prednisone 70 prednisone intensol 70 pregabalin 26 PREMARIN 100 PREMPHASE 100 PREMPRO 100 prevalite 56 previfem 107 PREVNAR 13 (PF) 93 PREVYMIS 4 PREZCOBIX 4 PREZISTA 4 PRIFTIN 10 primaquine 10
137
primidone 26 PRIMSOL 13 PRIVIGEN 93 probenecid 95 probenecid-colchicine 95 procainamide 44 procentra 42 prochlorperazine 84 prochlorperazine edisylate 84 prochlorperazine maleate 84 PROCRIT 87 procto-med hc 84 procto-pak 84 proctosol hc 84 proctozone-hc 84 PROFILNINE 54 progesterone 100 progesterone micronized 100 PROGRAF 21 PROLASTIN-C 67 PROLEUKIN 90 PROLIA 95 PROMACTA 54 promethazine 115 promethazine-codeine 116 promethazine-dm 116 promethazine-phenyleph-
codeine 116 promethazine-phenylephrine
116 promethegan 115 propafenone 44 45 proparacaine 111 propranolol 48 49 propranolol-hydrochlorothiazid
49 propylthiouracil 71 PROQUAD (PF) 93 protriptyline 42 PROVENGE 93 prudoxin 59 pulmosal 119 PULMOZYME 119 pyrazinamide 10 pyridostigmine bromide 30 pyrimethamine 10 Q QBRELIS 49 QINLOCK 21 QTERN 78 QUADRACEL (PF) 93
quetiapine 42 QUILLICHEW ER 42 QUILLIVANT XR 42 quinapril 49 quinapril-hydrochlorothiazide
49 quinidine gluconate 45 quinidine sulfate 45 quinine sulfate 10 quit 2 68 quit 4 68 QVAR REDIHALER 119 R RABAVERT (PF) 93 rabeprazole 86 RADICAVA 29 RAGWITEK 93 raloxifene 95 ramelteon 42 ramipril 49 ranolazine 57 RAPIVAB (PF) 4 rasagiline 27 RAVICTI 67 REBIF (WITH ALBUMIN) 89 REBIF REBIDOSE 89 REBIF TITRATION PACK 89 REBINYN 54 RECLAST 67 reclipsen (28) 107 RECOMBINATE 54 RECOMBIVAX HB (PF) 93 RECTIV 84 REGRANEX 59 RELENZA DISKHALER 4 RELEXXII 42 RELION NOVOLIN 7030 74 RELION NOVOLIN N 74 RELION NOVOLIN R 74 RELISTOR 84 REMICADE 84 RENACIDIN 122 RENFLEXIS 84 repaglinide 78 repaglinide-metformin 78 REPATHA PUSHTRONEX 56 REPATHA SURECLICK 56 REPATHA SYRINGE 56 RESTASIS 111 RETEVMO 21 RETISERT 114
REVATIO 119 REVLIMID 89 REXULTI 43 REYATAZ 4 RHOPRESSA 112 RIASTAP 54 ribavirin 4 89 RIDAURA 97 rifabutin 10 rifampin 10 riluzole 67 rimantadine 4 RINVOQ 97 RIOMET ER 78 risedronate 67 95 RISPERDAL CONSTA 43 risperidone 43 ritonavir 4 RITUXAN 21 RITUXAN HYCELA 21 rivastigmine 30 rivastigmine tartrate 29 rivelsa 107 RIXUBIS 54 rizatriptan 28 ropinirole 27 28 rosadan 61 rosuvastatin 56 roweepra 26 RUBRACA 21 RUCONEST 119 rufinamide 26 RYBELSUS 79 RYDAPT 21 S salsalate 36 SAMSCA 76 SANTYL 65 sapropterin 76 SARCLISA 21 SAVELLA 97 scalacort 65 SCENESSE 59 scopolamine base 84 seconal sodium 43 SEEBRI NEOHALER 119 selegiline hcl 28 selenium sulfide 58 SELZENTRY 5 SEREVENT DISKUS 119 SEROSTIM 87
138
sertraline 43 setlakin 107 sevelamer carbonate 84 sevelamer hcl 84 sf 69 sf 5000 plus 69 sharobel 101 SHINGRIX (PF) 93 SIGNIFOR 21 sildenafil (pulmhypertension)
119 SILIQ 58 silodosin 121 silver sulfadiazine 59 SIMBRINZA 112 simliya (28) 107 simpesse 107 SIMPONI 97 SIMPONI ARIA 97 SIMULECT 21 simvastatin 56 SINUVA 119 sirolimus 21 SIRTURO 10 SIVEXTRO 10 SKYLA 98 SKYRIZI 58 SLYND 107 sodium chloride 119 sodium chloride 045 123 sodium chloride 09 67 sodium fluoride 5000 dry
mouth 69 sodium fluoride 5000 plus 69 sodium fluoride-pot nitrate 69 sodium phenylbutyrate 67 sodium polystyrene sulfonate
85 solifenacin 121 SOLIQUA 10033 74 SOLIRIS 67 SOLTAMOX 21 SOMATULINE DEPOT 21 SOMAVERT 76 sorine 45 sotalol 45 sotalol af 45 SOVALDI 5 spinosad 66 SPIRIVA RESPIMAT 119
SPIRIVA WITH HANDIHALER 119
spironolactone 49 spironolacton-hydrochlorothiaz
49 SPRAVATO 43 sprintec (28) 107 SPRYCEL 21 sps (with sorbitol) 85 sronyx 107 ssd 59 SSKI 71 st joseph aspirin 36 st joseph aspirin 36 STAMARIL (PF) 93 stavudine 5 STELARA 58 STIOLTO RESPIMAT 119 STIVARGA 21 stop smoking aid 68 STRENSIQ 76 STREPTOMYCIN 10 STRIBILD 5 STRIVERDI RESPIMAT 120 SUBLOCADE 33 subvenite 26 subvenite starter (blue) kit 26 subvenite starter (green) kit 26 subvenite starter (orange) kit 26 SUCRAID 85 sucralfate 86 sulfacetamide sodium 58 114 sulfacetamide sodium (acne) 62 sulfacetamide-prednisolone 114 sulfadiazine 12 sulfamethoxazole-trimethoprim
12 SULFAMYLON 62 sulfasalazine 85 sulfatrim 12 sulindac 36 sumatriptan 28 sumatriptan succinate 28 29 SUNOSI 43 SUPPRELIN LA 21 SUPRAX 7 SUPREP BOWEL PREP KIT
85 SUTENT 22 syeda 107 SYLVANT 22
symax fastabs 81 symax-sl 81 symax-sr 81 SYMBICORT 120 SYMDEKO 120 SYMLINPEN 120 79 SYMLINPEN 60 79 SYMPAZAN 26 SYNAGIS 5 SYNAREL 76 SYNERA 61 SYNJARDY 79 SYNJARDY XR 79 SYNRIBO 22 SYNTHROID 79 T TABLOID 22 tacrolimus 22 59 tadalafil 121 tadalafil (pulm hypertension)
120 TAFINLAR 22 TAGRISSO 22 TAKHZYRO 120 TALTZ AUTOINJECTOR 58 TALTZ AUTOINJECTOR (2
PACK) 58 TALTZ AUTOINJECTOR (3
PACK) 58 TALTZ SYRINGE 58 TALZENNA 22 tamoxifen 22 tamsulosin 121 TARGRETIN 22 tarina 24 fe 107 tarina fe 120 (28) 107 TASIGNA 22 tavaborole 63 tazarotene 61 tazicef 7 taztia xt 49 TDVAX 93 TECENTRIQ 22 TEFLARO 7 TEKTURNA HCT 49 telmisartan 49 telmisartan-amlodipine 49 telmisartan-hydrochlorothiazid
49 temazepam 43 TEMODAR 22
139
temozolomide 22 temsirolimus 22 tencon 33 TENIVAC (PF) 94 tenofovir disoproxil fumarate 5 TEPEZZA 76 terazosin 49 terbinafine hcl 1 terbutaline 120 terconazole 101 testosterone 77 testosterone cypionate 76 testosterone enanthate 76 TETANUSDIPHTHERIA
TOX PED(PF) 94 tetrabenazine 30 tetracaine hcl 111 TETRACAINE HCL (PF) 111 tetracycline 12 THALOMID 22 theophylline 120 thioridazine 43 thiothixene 43 THYMOGLOBULIN 94 THYROLAR-1 79 THYROLAR-12 79 THYROLAR-14 79 THYROLAR-2 79 THYROLAR-3 79 tiadylt er 49 tiagabine 26 TIBSOVO 22 tilia fe 107 timolol maleate 49 110 tinidazole 10 TIVICAY 5 TIVICAY PD 5 tizanidine 30 TOBRADEX 113 TOBRADEX ST 113 tobramycin 10 110 tobramycin in 0225 nacl 10 tobramycin sulfate 10 TOBRAMYCIN WITH
NEBULIZER 10 tobramycin-dexamethasone 113 TOBREX 110 TODAY CONTRACEPTIVE
SPONGE 101 tolcapone 28 tolmetin 36
tolterodine 121 topiramate 26 toremifene 22 TORISEL 22 torsemide 49 TOUJEO MAX U-300
SOLOSTAR 74 TOUJEO SOLOSTAR U-300
INSULIN 74 TRACLEER 120 TRADJENTA 79 tramadol 36 tramadol-acetaminophen 36 trandolapril 49 trandolapril-verapamil 49 tranexamic acid 54 101 tranylcypromine 43 travoprost 112 trazodone 43 TREANDA 22 TRECATOR 10 TRELEGY ELLIPTA 120 TRELSTAR 22 TREMFYA 59 TRESIBA FLEXTOUCH U-
100 74 TRESIBA FLEXTOUCH U-
200 74 TRESIBA U-100 INSULIN 74 tretinoin 61 tretinoin (antineoplastic) 22 tretinoin microspheres 61 TRETTEN 54 TREXALL 22 tri femynor 107 triamcinolone acetonide 65 69
71 triamterene 49 triamterene-hydrochlorothiazid
49 triazolam 43 triderm 65 trientine 67 tri-estarylla 107 trifluoperazine 43 trifluridine 110 trihexyphenidyl 28 TRIJARDY XR 71 TRIKAFTA 120 tri-legest fe 108 tri-linyah 108
tri-lo-estarylla 108 tri-lo-marzia 108 tri-lo-mili 108 tri-lo-sprintec 108 trilyte with flavor packets 85 trimethobenzamide 85 trimethoprim 13 tri-mili 108 trimipramine 43 TRINTELLIX 43 tri-nymyo 108 tri-previfem (28) 108 tri-sprintec (28) 108 TRIUMEQ 5 tri-vitamin with fluoride 124 trivora (28) 108 tri-vylibra 108 tri-vylibra lo 108 TROGARZO 5 tropicamide 110 trospium 121 TRULICITY 79 TRUMENBA 94 TRUXIMA 22 TUKYSA 23 tulana 101 TWINRIX (PF) 94 TWIRLA 101 TYBLUME 108 TYBOST 5 tydemy 108 TYGACIL 10 TYMLOS 95 TYPHIM VI 94 TYSABRI 30 TYVASO 120 TYVASO REFILL KIT 120 TYVASO STARTER KIT 120 U UBRELVY 29 UDENYCA 87 ULESFIA 66 unithroid 80 UNITUXIN 23 URELLE 122 uretron d-s 122 urimar-t 122 urogesic-blue 122 ursodiol 85 uryl 122 ustell 122
140
UTIBRON NEOHALER 120 utira-c 122 UVADEX 59 V vaginal contraceptive foam 101 valacyclovir 5 VALCHLOR 59 valganciclovir 5 valproic acid 26 valproic acid (as sodium salt)
26 valsartan 49 valsartan-hydrochlorothiazide
49 vanadom 30 vancomycin 13 vandazole 101 VANTAS 23 VAQTA (PF) 94 VARIVAX (PF) 94 VARUBI 85 VASCEPA 56 VAXELIS (PF) 94 VCF CONTRACEPTIVE
FILM 101 VCF CONTRACEPTIVE GEL
101 VECTIBIX 23 VELCADE 23 veletri 50 velivet triphasic regimen (28)
108 VELPHORO 85 VEMLIDY 5 VENCLEXTA 23 VENCLEXTA STARTING
PACK 23 venlafaxine 43 VENTAVIS 120 verapamil 50 VERSACLOZ 43 VERZENIO 23 vestura (28) 108 VIBATIV 13 VIBERZI 85 VIDAZA 23 VIEKIRA PAK 5 vienva 108 vigabatrin 26 vigadrone 26 VIMIZIM 77
VIMPAT 26 viorele (28) 108 VIRACEPT 5 VIREAD 5 virtussin ac 116 VISTOGARD 13 VISUDYNE 111 vitamins acd and fluoride 124 VITRAKVI 23 VIVITROL 36 volnea (28) 108 VONVENDI 54 VORAXAZE 13 voriconazole 1 2 VOSEVI 5 VOTRIENT 23 VPRIV 77 VRAYLAR 44 VYEPTI 29 vyfemla (28) 108 vylibra 108 VYONDYS-53 30 VYVANSE 44 VYXEOS 23 W warfarin 54 wera (28) 108 westhroid 80 WIDE-SEAL DIAPHRAGM
98 WILATE 54 wixela inhub 121 wymzya fe 108 X XALKORI 23 XARELTO 54 XARELTO DVT-PE TREAT
30D START 54 XCOPRI 27 XCOPRI MAINTENANCE
PACK 27 XCOPRI TITRATION PACK
27 XELJANZ 97 XELJANZ XR 97 XEMBIFY 94 XENLETA 10 XEOMIN 94 XERMELO 23 XGEVA 13 XIFAXAN 10
XIGDUO XR 79 XIIDRA 111 XOLAIR 121 XOSPATA 23 XTANDI 23 xulane 102 XULTOPHY 10036 74 XURIDEN 67 XYNTHA 55 XYNTHA SOLOFUSE 55 XYREM 44 Y YERVOY 23 YESCARTA 23 YF-VAX (PF) 94 YONDELIS 23 YONSA 23 YUTIQ 114 yuvafem 101 Z zafemy 102 zafirlukast 121 zaleplon 44 ZALTRAP 23 ZANOSAR 23 zarah 109 ZARXIO 87 ZEJULA 24 ZELBORAF 24 ZEMAIRA 68 zenatane 61 ZENPEP 85 ZENZEDI 44 ZEPATIER 5 ZEPOSIA 89 ZEPOSIA STARTER KIT 89 ZEPOSIA STARTER PACK
89 ZERBAXA 7 zidovudine 5 ZIEXTENZO 87 zileuton 121 ziprasidone hcl 44 ZIRGAN 110 ZOKINVY 68 ZOLADEX 24 ZOLGENSMA 30 ZOLINZA 24 zolmitriptan 29 zolpidem 44 ZOLPIMIST 44
141
ZOMIG 29 zonisamide 27 ZONTIVITY 55 ZORBTIVE 87
ZOSTAVAX (PF) 94 zovia 135e (28) 109 ZULRESSO 44 zumandimine (28) 109
ZYFLO 121 ZYKADIA 24 ZYPITAMAG 56
051267 (11-20-2019)
Discrimination is Against the Law
LifeWise Health Plan of Washington (LifeWise) complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex LifeWise does not exclude people or treat them differently because of race color national origin age disability sex gender identity or sexual orientation LifeWise provides free aids and services to people with disabilities to communicate effectively with us such as qualified sign language interpreters and written information in other formats (large print audio accessible electronic formats other formats) LifeWise provides free language services to people whose primary language is not English such as qualified interpreters and information written in other languages If you need these services contact the Civil Rights Coordinator If you believe that LifeWise 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 Civil Rights Coordinator Complaints and Appeals PO Box 91102 Seattle WA 98111 Toll free 855-332-6396 Fax 425-918-5592 TTY 711 Email AppealsDepartmentInquiriesLifeWiseHealthcom You can file a grievance in person or by mail fax or email If you need help filing a grievance the Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Ave SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language Assistance ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 800-817-3056 (TTY 711) 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 800-817-3056(TTY711) CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 800-817-3056 (TTY 711) 주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 800-817-3056
(TTY 711) 번으로 전화해 주십시오 ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните 800-817-3056
(телетайп 711) PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad
Tumawag sa 800-817-3056 (TTY 711) УВАГА Якщо ви розмовляєте українською мовою ви можете звернутися до безкоштовної служби
мовної підтримки Телефонуйте за номером 800-817-3056 (телетайп 711) របយត េបើសនអកនយ ែខរ េសជនយែផក េយមនគតឈ ល
គចនសបបេរ អក ចរ ទរសព 800-817-3056 (TTY 711) 注意事項日本語を話される場合無料の言語支援をご利用いただけます800-817-3056(TTY711)
までお電話にてご連絡ください ማስታወሻ የሚናገሩት ቋንቋ ኣማርኛ ከነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ
800-817-3056 (መስማት ለተሳናቸው 711) XIYYEEFFANNAA Afaan dubbattu Oroomiffa tajaajila gargaarsa afaanii kanfaltiidhaan ala ni argama Bilbilaa 800-817-3056 (TTY 711)
)711 والبكم الصم ھاتف رقم( 800-178-3056 برقم اتصل بالمجان لك تتوافر اللغویة المساعدة خدمات فإن اللغة اذكر تتحدث كنت إذا ملحوظةਿਧਆਨ ਿਦਓ ਜ ਤਸ ਪਜਾਬੀ ਬਲਦ ਹ ਤ ਭਾਸ਼ਾ ਿਵਚ ਸਹਾਇਤਾ ਸਵਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਧ ਹ 800-817-3056
(TTY 711) ਤ ਕਾਲ ਕਰ ACHTUNG Wenn Sie Deutsch sprechen stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfuumlgung
Rufnummer 800-817-3056 (TTY 711) ໂປດຊາບ ຖາວາ ທານເວາພາສາ ລາວ ການບລການຊວຍເຫອດານພາສາ ໂດຍບເສຽຄາ
ແມນມພອມໃຫທານ ໂທຣ 800-817-3056 (TTY 711) ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele 800-817-3056 (TTY 711) ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 800-817-3056 (ATS 711) UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń pod numer 800-817-3056 (TTY 711) ATENCcedilAtildeO Se fala portuguecircs encontram-se disponiacuteveis serviccedilos linguiacutesticos graacutetis Ligue para 800-817-3056 (TTY 711) ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza linguistica gratuiti Chiamare il numero
800-817-3056 (TTY 711) دیریبگ تماس 3056-817-800 (TTY 711) با باشد یم فراھم شما یبرا گانیرا بصورت یزبان لاتیتسھ دیکن یم گفتگو فارسی زبان بھ اگر توجھ
also post information on upcoming formulary changes on our website on the ldquoUpcoming Formulary Changesrdquo page
Are there any restrictions on my coverage Some covered drugs may have additional requirements or limits on coverage These can be seen in the column next to the drug name on the list These requirements and limits may include
bull Prior Authorization some drugs require prior approval before they are coveredbull Quantity Limits for some drugs we limit the amount of the drug that we will cover For example
we will cover 18 per 30 day supply of zolmitriptan oral tabletsbull Step Therapy for some drugs we require that you 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 Bboth treat your medical condition we may not cover Drug B unless you try Drug A first If Drug Adoes not work for you then we will then cover Drug B
Drugs subject to these restrictions will generally mean that your physician or healthcare provider may need to provide additional information on your medical condition before the drug will be covered at the pharmacy Information on this process is on our website on the ldquoDrugs Requiring Approvalrdquo page
Metallic Formulary The first column of the chart lists the drug name Brand name drugs are capitalized (eg JANUVIA) and generic drugs are listed in lower-case italics (eg metformin oral tablet) The information in the RequirementsLimits column tells you if we have any special requirements for coverage of your drug
COVERAGE NOTES ABBREVIATIONS
ABBREVIATION DESCRIPTION EXPLANATION
Utilization Management Restrictions
PA Prior Authorization Restriction You (or your physician) are required to get prior authorization from us before you fill your prescription for this drug Without prior approval we may not cover this drug
QL Quantity Limit Restriction We limit the amount of this drug that is covered per prescription or within a specific time frame
ST Step Therapy Restriction Before we will provide coverage for this drug you must first try another drug to treat your medical condition This drug may only be covered if the other drug does not work for you
Other Special Requirements for Coverage
LA Limited Access Drug Some drugs under your plan may only be filled at an in-network specialty pharmacy These are drugs where the FDA has restricted distribution or are drugs that require special handling provider coordination or patient education that cannot be met by a network retail pharmacy
Vac Vaccines For more information on the coverage of vaccines administered at a Pharmacy please see your member booklet or contact Customer Service
OCh Oral Chemo Oral Chemotherapy Drug Certain oral chemotherapy drugs may be covered under your medical plan Please check your member booklet for more details
The amount you pay for a covered drug will depend on if you have met any applicable deductible for the plan year if you have met any applicable maximum out of pocket for the plan year and what tier the medication is on More information on applicable deductibles and maximum out of pockets can be found in your member booklet
Metallic M2 Formulary
Drug Tier Includes
Formulary Drugs (1) Formulary Drugs include Preferred Generic Preferred Brand and Non-Preferred Drugs Medical plan cost shares apply to formulary drugs Once you have satisfied your medical deductible you will pay your applicable coinsurance until you reach your out of pocket maximum limit
Specialty Drug (2) Tier 2 includes specialty drugs Specialty drugs are generally biologics and other targeted drugs usually used for complex medical conditions and often requiring special handling
ACA PV The ACA PV tier includes Affordable Care Act (ACA) Preventive medications The ACA makes certain preventive medications available to you at no cost Coverage of any medication as ACA PV (including over-the-counter (OTC) medications) requires a prescription from a licensed health care provider
MB (Medical Benefit) The MB tier includes medical benefit drugs normally administered in a clinic infusion center or provided by a home infusion service These drugs and their services are covered under the medical benefit not under the pharmacy benefit This drug may require prior authorization
1
Drug Name Drug Tier Requirements Limits
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG
MB
amphotericin b injection recon soln 50 mg MB
CANCIDAS INTRAVENOUS RECON SOLN 50 MG 70 MG
MB
clotrimazole mucous membrane troche 10 mg 1
CRESEMBA INTRAVENOUS RECON SOLN 372 MG
MB
CRESEMBA ORAL CAPSULE 186 MG 1 PA
ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG 50 MG
MB
fluconazole oral suspension for reconstitution 10 mgml 40 mgml
1
fluconazole oral tablet 100 mg 150 mg 200 mg 50 mg
1
flucytosine oral capsule 250 mg 500 mg 1
griseofulvin microsize oral suspension 125 mg5 ml
1
griseofulvin microsize oral tablet 500 mg 1
griseofulvin ultramicrosize oral tablet 125 mg 250 mg
1
itraconazole oral capsule 100 mg 1
itraconazole oral solution 10 mgml 1
ketoconazole oral tablet 200 mg 1
MYCAMINE INTRAVENOUS RECON SOLN 100 MG 50 MG
MB
NOXAFIL ORAL SUSPENSION 200 MG5 ML (40 MGML)
1
nystatin oral suspension 100000 unitml 1
nystatin oral tablet 500000 unit 1
ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET 50 MG
1
posaconazole oral tabletdelayed release (drec) 100 mg
1
terbinafine hcl oral tablet 250 mg 1
voriconazole intravenous recon soln 200 mg MB
2
Drug Name Drug Tier Requirements Limits
voriconazole oral suspension for reconstitution 200 mg5 ml (40 mgml)
1
voriconazole oral tablet 200 mg 50 mg 1
ANTIVIRALS
abacavir oral solution 20 mgml 1 QL (60 per 30 days)
abacavir oral tablet 300 mg 1 QL (60 per 30 days)
abacavir-lamivudine oral tablet 600-300 mg 1 QL (30 per 30 days)
abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg
1 QL (60 per 30 days)
acyclovir oral capsule 200 mg 1
acyclovir oral suspension 200 mg5 ml 1
acyclovir oral tablet 400 mg 800 mg 1
adefovir oral tablet 10 mg 1
amantadine hcl oral capsule 100 mg 1
amantadine hcl oral solution 50 mg5 ml 1
amantadine hcl oral tablet 100 mg 1
APTIVUS ORAL CAPSULE 250 MG 1 QL (120 per 30 days)
atazanavir oral capsule 150 mg 300 mg 1 QL (30 per 30 days)
atazanavir oral capsule 200 mg 1 QL (60 per 30 days)
BARACLUDE ORAL SOLUTION 005 MGML 1
BIKTARVY ORAL TABLET 50-200-25 MG 1 QL (30 per 30 days)
CABENUVA INTRAMUSCULAR SUSPENSIONEXTENDED RELEASE 400 MG2 ML- 600 MG2 ML 600 MG3 ML- 900 MG3 ML
2 PA
cidofovir intravenous solution 75 mgml MB
CIMDUO ORAL TABLET 300-300 MG 1 QL (30 per 30 days)
COMPLERA ORAL TABLET 200-25-300 MG 1 QL (30 per 30 days)
CYTOVENE INTRAVENOUS RECON SOLN 500 MG
MB
DESCOVY ORAL TABLET 200-25 MG 1 QL (30 per 30 days)
didanosine oral capsuledelayed release(drec) 250 mg 400 mg
1 QL (30 per 30 days)
DOVATO ORAL TABLET 50-300 MG 1 QL (30 per 30 days)
EDURANT ORAL TABLET 25 MG 1 QL (30 per 30 days)
efavirenz oral capsule 200 mg 50 mg 1 QL (30 per 30 days)
efavirenz oral tablet 600 mg 1 QL (30 per 30 days)
3
Drug Name Drug Tier Requirements Limits
efavirenz-emtricitabin-tenofov oral tablet 600-200-300 mg
1
efavirenz-lamivu-tenofov disop oral tablet 400-300-300 mg 600-300-300 mg
1
emtricitabine oral capsule 200 mg 1 QL (30 per 30 days)
emtricitabine-tenofovir (tdf) oral tablet 100-150 mg 133-200 mg 167-250 mg 200-300 mg
1
EMTRIVA ORAL SOLUTION 10 MGML 1 QL (720 per 30 days)
entecavir oral tablet 05 mg 1 mg 1
EPCLUSA ORAL TABLET 200-50 MG 400-100 MG
2 PA LA
EPIVIR HBV ORAL SOLUTION 25 MG5 ML (5 MGML)
1
etravirine oral tablet 100 mg 200 mg 1 QL (60 per 30 days)
EVOTAZ ORAL TABLET 300-150 MG 1 QL (30 per 30 days)
famciclovir oral tablet 125 mg 250 mg 500 mg 1
fosamprenavir oral tablet 700 mg 1 QL (60 per 30 days)
FUZEON SUBCUTANEOUS RECON SOLN 90 MG
2 QL (30 per 30 days)
GANCICLOVIR INTRAVENOUS SOLUTION 500 MG250 ML (2 MGML)
MB
ganciclovir sodium intravenous recon soln 500 mg MB
GENVOYA ORAL TABLET 150-150-200-10 MG
1 QL (30 per 30 days)
HARVONI ORAL PELLETS IN PACKET 3375-150 MG 45-200 MG
2 LA
HARVONI ORAL TABLET 45-200 MG 90-400 MG
2 PA LA
INTELENCE ORAL TABLET 100 MG 200 MG 25 MG
1 QL (60 per 30 days)
INVIRASE ORAL TABLET 500 MG 1 QL (120 per 30 days)
ISENTRESS HD ORAL TABLET 600 MG 1 QL (60 per 30 days)
ISENTRESS ORAL POWDER IN PACKET 100 MG
1 QL (60 per 30 days)
ISENTRESS ORAL TABLET 400 MG 1 QL (60 per 30 days)
ISENTRESS ORAL TABLETCHEWABLE 100 MG 25 MG
1 QL (60 per 30 days)
JULUCA ORAL TABLET 50-25 MG 1 QL (30 per 30 days)
KALETRA ORAL TABLET 100-25 MG 1 QL (60 per 30 days)
4
Drug Name Drug Tier Requirements Limits
KALETRA ORAL TABLET 200-50 MG 1 QL (120 per 30 days)
lamivudine oral solution 10 mgml 1 QL (900 per 30 days)
lamivudine oral tablet 100 mg 1
lamivudine oral tablet 150 mg 300 mg 1 QL (60 per 30 days)
lamivudine-zidovudine oral tablet 150-300 mg 1 QL (60 per 30 days)
LEXIVA ORAL SUSPENSION 50 MGML 1 QL (60 per 30 days)
lopinavir-ritonavir oral solution 400-100 mg5 ml 1 QL (320 per 30 days)
lopinavir-ritonavir oral tablet 100-25 mg 200-50 mg
1 QL (120 per 30 days)
MAVYRET ORAL TABLET 100-40 MG 2 PA LA
nevirapine oral suspension 50 mg5 ml 1 QL (60 per 30 days)
nevirapine oral tablet 200 mg 1 QL (60 per 30 days)
nevirapine oral tablet extended release 24 hr 100 mg 400 mg
1 QL (30 per 30 days)
NORVIR ORAL POWDER IN PACKET 100 MG 1 QL (360 per 30 days)
NORVIR ORAL SOLUTION 80 MGML 1 QL (480 per 30 days)
ODEFSEY ORAL TABLET 200-25-25 MG 1 QL (30 per 30 days)
oseltamivir oral capsule 30 mg 1 QL (40 per 365 days)
oseltamivir oral capsule 45 mg 75 mg 1 QL (20 per 365 days)
oseltamivir oral suspension for reconstitution 6 mgml
1 QL (180 per 30 days)
PREVYMIS INTRAVENOUS SOLUTION 240 MG12 ML 480 MG24 ML
MB PA
PREZCOBIX ORAL TABLET 800-150 MG-MG 1 QL (30 per 30 days)
PREZISTA ORAL SUSPENSION 100 MGML 1 QL (30 per 30 days)
PREZISTA ORAL TABLET 150 MG 600 MG 75 MG
1 QL (60 per 30 days)
PREZISTA ORAL TABLET 800 MG 1 QL (30 per 30 days)
RAPIVAB (PF) INTRAVENOUS SOLUTION 200 MG20 ML (10 MGML)
MB
RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MGACTUATION
1 QL (2 per 30 days)
REYATAZ ORAL POWDER IN PACKET 50 MG
1 QL (150 per 30 days)
ribavirin inhalation recon soln 6 gram MB
rimantadine oral tablet 100 mg 1
ritonavir oral tablet 100 mg 1 QL (360 per 30 days)
5
Drug Name Drug Tier Requirements Limits
SELZENTRY ORAL SOLUTION 20 MGML 1 QL (8 per 30 days)
SELZENTRY ORAL TABLET 150 MG 25 MG 300 MG 75 MG
1 QL (60 per 30 days)
SOVALDI ORAL PELLETS IN PACKET 150 MG 200 MG
2 LA
SOVALDI ORAL TABLET 200 MG 400 MG 2 PA LA
stavudine oral capsule 15 mg 20 mg 40 mg 1 QL (120 per 30 days)
STRIBILD ORAL TABLET 150-150-200-300 MG
1 QL (30 per 30 days)
SYNAGIS INTRAMUSCULAR SOLUTION 100 MGML 50 MG05 ML
MB LA
tenofovir disoproxil fumarate oral tablet 300 mg 1 QL (30 per 30 days)
TIVICAY ORAL TABLET 10 MG 25 MG 50 MG
1 QL (60 per 30 days)
TIVICAY PD ORAL TABLET FOR SUSPENSION 5 MG
1 QL (60 per 30 days)
TRIUMEQ ORAL TABLET 600-50-300 MG 1 QL (30 per 30 days)
TROGARZO INTRAVENOUS SOLUTION 200 MG133 ML (150 MGML)
MB PA
TYBOST ORAL TABLET 150 MG 1 QL (30 per 30 days)
valacyclovir oral tablet 1 gram 500 mg 1
valganciclovir oral recon soln 50 mgml 1
valganciclovir oral tablet 450 mg 1
VEMLIDY ORAL TABLET 25 MG 1
VIEKIRA PAK ORAL TABLETSDOSE PACK 125 MG-75 MG -50 MG250 MG
2 PA
VIRACEPT ORAL TABLET 250 MG 1 QL (90 per 30 days)
VIRACEPT ORAL TABLET 625 MG 1 QL (60 per 30 days)
VIREAD ORAL POWDER 40 MGSCOOP (40 MGGRAM)
1 QL (4 per 30 days)
VIREAD ORAL TABLET 150 MG 200 MG 250 MG
1 QL (30 per 30 days)
VOSEVI ORAL TABLET 400-100-100 MG 2 PA LA
ZEPATIER ORAL TABLET 50-100 MG 2 PA LA
zidovudine oral capsule 100 mg 1 QL (60 per 30 days)
zidovudine oral syrup 10 mgml 1 QL (960 per 30 days)
zidovudine oral tablet 300 mg 1 QL (60 per 30 days)
CEPHALOSPORINS
6
Drug Name Drug Tier Requirements Limits
AVYCAZ INTRAVENOUS RECON SOLN 25 GRAM
MB
cefaclor oral capsule 250 mg 500 mg 1
cefaclor oral suspension for reconstitution 125 mg5 ml 250 mg5 ml 375 mg5 ml
1
cefaclor oral tablet extended release 12 hr 500 mg 1
cefadroxil oral capsule 500 mg 1
cefadroxil oral suspension for reconstitution 250 mg5 ml 500 mg5 ml
1
cefadroxil oral tablet 1 gram 1
cefazolin in dextrose (iso-os) intravenous piggyback 1 gram50 ml
MB
cefazolin injection recon soln 1 gram 10 gram 100 gram 20 gram 300 g 500 mg
MB
cefazolin intravenous recon soln 1 gram MB
cefdinir oral capsule 300 mg 1
cefdinir oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cefditoren pivoxil oral tablet 200 mg 400 mg 1
CEFEPIME IN DEXTROSE 5 INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
cefepime in dextroseiso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml
MB
cefepime injection recon soln 1 gram 2 gram MB
cefixime oral capsule 400 mg 1
cefixime oral suspension for reconstitution 100 mg5 ml 200 mg5 ml
1
CEFOTAN INJECTION RECON SOLN 1 GRAM 2 GRAM
MB
cefotaxime injection recon soln 1 gram MB
CEFOTETAN IN DEXTROSE ISO-OSM INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
cefotetan injection recon soln 1 gram 2 gram MB
cefotetan intravenous recon soln 10 gram MB
cefoxitin intravenous recon soln 10 gram MB
cefpodoxime oral suspension for reconstitution 100 mg5 ml 50 mg5 ml
1
7
Drug Name Drug Tier Requirements Limits
cefpodoxime oral tablet 100 mg 200 mg 1
cefprozil oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cefprozil oral tablet 250 mg 500 mg 1
CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
ceftazidime injection recon soln 1 gram 2 gram 6 gram
MB
ceftriaxone in dextroseiso-os intravenous piggyback 1 gram50 ml 2 gram50 ml
MB
ceftriaxone injection recon soln 1 gram 10 gram 2 gram 250 mg 500 mg
MB
CEFTRIAXONE INJECTION RECON SOLN 100 GRAM
MB
ceftriaxone intravenous recon soln 1 gram 2 gram MB
cefuroxime axetil oral tablet 250 mg 500 mg 1
cephalexin oral capsule 250 mg 500 mg 750 mg 1
cephalexin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cephalexin oral tablet 250 mg 500 mg 1
SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG5 ML
1
SUPRAX ORAL TABLETCHEWABLE 100 MG 200 MG
1
tazicef injection recon soln 1 gram 2 gram 6 gram
MB
tazicef intravenous recon soln 1 gram 2 gram MB
TEFLARO INTRAVENOUS RECON SOLN 400 MG 600 MG
MB
ZERBAXA INTRAVENOUS RECON SOLN 15 GRAM
MB
ERYTHROMYCINS amp OTHER MACROLIDES
azithromycin oral packet 1 gram 1
azithromycin oral suspension for reconstitution 100 mg5 ml 200 mg5 ml
1
azithromycin oral tablet 250 mg 500 mg 600 mg 1
clarithromycin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
clarithromycin oral tablet 250 mg 500 mg 1
8
Drug Name Drug Tier Requirements Limits
clarithromycin oral tablet extended release 24 hr 500 mg
1
DIFICID ORAL TABLET 200 MG 1
ees 400 oral tablet 400 mg 1
ery-tab oral tabletdelayed release (drec) 250 mg 333 mg
1
erythrocin (as stearate) oral tablet 250 mg 1
erythromycin ethylsuccinate oral suspension for reconstitution 200 mg5 ml 400 mg5 ml
1
erythromycin ethylsuccinate oral tablet 400 mg 1
erythromycin oral capsuledelayed release(drec) 250 mg
1
erythromycin oral tablet 250 mg 500 mg 1
erythromycin oral tabletdelayed release (drec) 250 mg 333 mg 500 mg
1
MISCELLANEOUS ANTIINFECTIVES
albendazole oral tablet 200 mg 1
ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG5 ML
1 PA ST
amikacin injection solution 500 mg2 ml MB
atovaquone oral suspension 750 mg5 ml 1
atovaquone-proguanil oral tablet 250-100 mg 625-25 mg
1
bacitracin intramuscular recon soln 50000 unit 1
CAPASTAT INJECTION RECON SOLN 1 GRAM
1
CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MGML
2 PA LA QL (84 per 30 days)
chloramphenicol sod succinate intravenous recon soln 1 gram
MB
chloroquine phosphate oral tablet 250 mg 500 mg 1
clindamycin hcl oral capsule 150 mg 300 mg 75 mg
1
clindamycin pediatric oral recon soln 75 mg5 ml 1
clindamycin phosphate injection solution 150 mgml
MB
COARTEM ORAL TABLET 20-120 MG 1
CUBICIN INTRAVENOUS RECON SOLN 500 MG
MB
9
Drug Name Drug Tier Requirements Limits
CUBICIN RF INTRAVENOUS RECON SOLN 500 MG
MB
CYCLOSERINE ORAL CAPSULE 250 MG 1
dapsone oral tablet 100 mg 25 mg 1
EMVERM ORAL TABLETCHEWABLE 100 MG
1
ethambutol oral tablet 100 mg 400 mg 1
gentamicin injection solution 20 mg2 ml 40 mgml
MB
gentamicin sulfate (ped) (pf) injection solution 20 mg2 ml
MB
hydroxychloroquine oral tablet 200 mg 1
imipenem-cilastatin intravenous recon soln 250 mg 500 mg
MB
INVANZ INJECTION RECON SOLN 1 GRAM MB
isoniazid injection solution 100 mgml 1
isoniazid oral solution 50 mg5 ml 1
isoniazid oral tablet 100 mg 300 mg 1
ivermectin oral tablet 3 mg 1
LINCOCIN INJECTION SOLUTION 300 MGML
MB
linezolid in dextrose 5 intravenous piggyback 600 mg300 ml
MB
linezolid oral suspension for reconstitution 100 mg5 ml
1
linezolid oral tablet 600 mg 1
linezolid-09 sodium chloride intravenous parenteral solution 600 mg300 ml
MB
mefloquine oral tablet 250 mg 1
meropenem intravenous recon soln 1 gram 500 mg
MB
MEROPENEM-09 SODIUM CHLORIDE INTRAVENOUS PIGGYBACK 1 GRAM50 ML 500 MG50 ML
MB
metronidazole oral capsule 375 mg 1
metronidazole oral tablet 250 mg 500 mg 1
neomycin oral tablet 500 mg 1
nitazoxanide oral tablet 500 mg 1
10
Drug Name Drug Tier Requirements Limits
paromomycin oral capsule 250 mg 1
PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM
1
PENTAM INJECTION RECON SOLN 300 MG MB
pentamidine inhalation recon soln 300 mg 1
pentamidine injection recon soln 300 mg MB
polymyxin b sulfate injection recon soln 500000 unit
MB
praziquantel oral tablet 600 mg 1
PRIFTIN ORAL TABLET 150 MG 1
primaquine oral tablet 263 mg 1
pyrazinamide oral tablet 500 mg 1
pyrimethamine oral tablet 25 mg 2 PA
quinine sulfate oral capsule 324 mg 1
rifabutin oral capsule 150 mg 1
rifampin oral capsule 150 mg 300 mg 1
SIRTURO ORAL TABLET 100 MG 1 PA
SIRTURO ORAL TABLET 20 MG 1
SIVEXTRO ORAL TABLET 200 MG 1 QL (6 per 30 days)
STREPTOMYCIN INTRAMUSCULAR RECON SOLN 1 GRAM
1
tinidazole oral tablet 250 mg 500 mg 1
tobramycin in 0225 nacl inhalation solution for nebulization 300 mg5 ml
2
tobramycin inhalation solution for nebulization 300 mg4 ml
2
tobramycin sulfate injection recon soln 12 gram 1
tobramycin sulfate injection solution 10 mgml MB
tobramycin sulfate injection solution 40 mgml 1
TOBRAMYCIN WITH NEBULIZER INHALATION SOLUTION FOR NEBULIZATION 300 MG5 ML
2 PA ST
TRECATOR ORAL TABLET 250 MG 1
TYGACIL INTRAVENOUS RECON SOLN 50 MG
MB
XENLETA INTRAVENOUS SOLUTION 150 MG15 ML
MB
XIFAXAN ORAL TABLET 200 MG 550 MG 1 PA QL (60 per 30 days)
11
Drug Name Drug Tier Requirements Limits
PENICILLINS
amoxicillin oral capsule 250 mg 500 mg 1
amoxicillin oral suspension for reconstitution 125 mg5 ml 200 mg5 ml 250 mg5 ml 400 mg5 ml
1
amoxicillin oral tablet 500 mg 875 mg 1
amoxicillin oral tabletchewable 125 mg 250 mg 1
amoxicillin-pot clavulanate oral suspension for reconstitution 200-285 mg5 ml 250-625 mg5 ml 400-57 mg5 ml 600-429 mg5 ml
1
amoxicillin-pot clavulanate oral tablet 250-125 mg 500-125 mg 875-125 mg
1
amoxicillin-pot clavulanate oral tablet extended release 12 hr 1000-625 mg
1
amoxicillin-pot clavulanate oral tabletchewable 200-285 mg 400-57 mg
1
ampicillin oral capsule 500 mg 1
ampicillin-sulbactam injection recon soln 15 gram MB
BICILLIN C-R INTRAMUSCULAR SYRINGE 1200000 UNIT 2 ML(900K300K)
MB
dicloxacillin oral capsule 250 mg 500 mg 1
MOXATAG ORAL TABLET ER MULTIPHASE 24 HR 775 MG
1
nafcillin in dextrose iso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml
MB
nafcillin injection recon soln 1 gram 10 gram 2 gram
MB
nafcillin intravenous recon soln 1 gram 2 gram MB
oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram50 ml 2 gram50 ml
MB
oxacillin injection recon soln 1 gram 10 gram 2 gram
MB
penicillin g procaine intramuscular syringe 12 million unit2 ml 600000 unitml
MB
penicillin v potassium oral recon soln 125 mg5 ml 250 mg5 ml
1
penicillin v potassium oral tablet 250 mg 500 mg 1
piperacillin-tazobactam intravenous recon soln 135 gram 225 gram 3375 gram 45 gram 405 gram
MB
12
Drug Name Drug Tier Requirements Limits
QUINOLONES
BAXDELA INTRAVENOUS RECON SOLN 300 MG
MB
BAXDELA ORAL TABLET 450 MG 1
ciprofloxacin hcl oral tablet 100 mg 250 mg 500 mg 750 mg
1
ciprofloxacin oral suspensionmicrocapsule recon 250 mg5 ml 500 mg5 ml
1
FACTIVE ORAL TABLET 320 MG 1 ST
levofloxacin oral solution 250 mg10 ml 1
levofloxacin oral tablet 250 mg 500 mg 750 mg 1
moxifloxacin oral tablet 400 mg 1
ofloxacin oral tablet 300 mg 400 mg 1
SULFAS amp RELATED AGENTS
sulfadiazine oral tablet 500 mg 1
sulfamethoxazole-trimethoprim oral suspension 200-40 mg5 ml
1
sulfamethoxazole-trimethoprim oral tablet 400-80 mg 800-160 mg
1
sulfatrim oral suspension 200-40 mg5 ml 1
TETRACYCLINES
avidoxy oral tablet 100 mg 1 ST
demeclocycline oral tablet 150 mg 300 mg 1
doxycycline hyclate oral capsule 100 mg 50 mg 1
doxycycline hyclate oral tablet 100 mg 150 mg 20 mg 50 mg 75 mg
1
doxycycline hyclate oral tabletdelayed release (drec) 100 mg 150 mg 200 mg 50 mg 75 mg
1
doxycycline monohydrate oral capsule 100 mg 150 mg 50 mg 75 mg
1
doxycycline monohydrate oral suspension for reconstitution 25 mg5 ml
1
doxycycline monohydrate oral tablet 100 mg 150 mg 50 mg 75 mg
1
minocycline oral capsule 100 mg 50 mg 75 mg 1
minocycline oral tablet 100 mg 50 mg 75 mg 1
mondoxyne nl oral capsule 100 mg 75 mg 1
tetracycline oral capsule 250 mg 500 mg 1
13
Drug Name Drug Tier Requirements Limits
URINARY TRACT AGENTS
fosfomycin tromethamine oral packet 3 gram 1
methenamine hippurate oral tablet 1 gram 1
methenamine mandelate oral tablet 05 g 1 gram 1
nitrofurantoin macrocrystal oral capsule 100 mg 25 mg 50 mg
1
nitrofurantoin monohydm-cryst oral capsule 100 mg
1
nitrofurantoin oral suspension 25 mg5 ml 1
PRIMSOL ORAL SOLUTION 50 MG5 ML 1
trimethoprim oral tablet 100 mg 1
VANCOMYCIN
vancomycin oral capsule 125 mg 250 mg 1
vancomycin oral recon soln 50 mgml 1
VIBATIV INTRAVENOUS RECON SOLN 750 MG
MB
ANTINEOPLASTIC amp IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
KEPIVANCE INTRAVENOUS RECON SOLN 625 MG
MB
leucovorin calcium injection recon soln 100 mg 200 mg 350 mg 50 mg 500 mg
MB
leucovorin calcium injection solution 10 mgml MB
leucovorin calcium oral tablet 10 mg 15 mg 25 mg 5 mg
1
VISTOGARD ORAL GRANULES IN PACKET 10 GRAM
2
VORAXAZE INTRAVENOUS RECON SOLN 1000 UNIT
MB
XGEVA SUBCUTANEOUS SOLUTION 120 MG17 ML (70 MGML)
2 LA
ANTINEOPLASTIC amp IMMUNOSUPPRESSANT DRUGS
abiraterone oral tablet 250 mg 2 PA OCh LA
abiraterone oral tablet 500 mg 2 PA ST OCh LA
ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG
MB PA LA
ADAKVEO INTRAVENOUS SOLUTION 10 MGML
MB PA
14
Drug Name Drug Tier Requirements Limits
ADCETRIS INTRAVENOUS RECON SOLN 50 MG
MB PA LA
AFINITOR ORAL TABLET 10 MG 2 OCh LA
ALECENSA ORAL CAPSULE 150 MG 2 PA OCh LA
ALIMTA INTRAVENOUS RECON SOLN 100 MG 500 MG
MB PA
ALIQOPA INTRAVENOUS RECON SOLN 60 MG
MB PA
anastrozole oral tablet 1 mg ACA PV OCh QL (30 per 30 days)
ARRANON INTRAVENOUS SOLUTION 250 MG50 ML
MB LA
ARZERRA INTRAVENOUS SOLUTION 1000 MG50 ML 100 MG5 ML
MB PA LA
ASPARLAS INTRAVENOUS SOLUTION 750 UNITML
MB PA
AVASTIN INTRAVENOUS SOLUTION 25 MGML
MB PA LA
azathioprine oral tablet 50 mg 1
BALVERSA ORAL TABLET 3 MG 4 MG 5 MG
2 PA OCh
BAVENCIO INTRAVENOUS SOLUTION 20 MGML
MB PA
BELEODAQ INTRAVENOUS RECON SOLN 500 MG
MB PA
BELRAPZO INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BENDAMUSTINE INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BENDEKA INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BESPONSA INTRAVENOUS RECON SOLN 09 MG (025 MGML INITIAL)
MB PA LA
bexarotene oral capsule 75 mg 2 PA ST OCh
bicalutamide oral tablet 50 mg 2 OCh QL (30 per 30 days)
BLINCYTO INTRAVENOUS KIT 35 MCG MB PA
BORTEZOMIB INTRAVENOUS RECON SOLN 35 MG
MB
BOSULIF ORAL TABLET 100 MG 400 MG 500 MG
2 PA ST OCh LA
BRAFTOVI ORAL CAPSULE 50 MG 75 MG 2 PA OCh LA
15
Drug Name Drug Tier Requirements Limits
BUSULFEX INTRAVENOUS SOLUTION 60 MG10 ML
MB
CABOMETYX ORAL TABLET 20 MG 40 MG 60 MG
2 PA ST OCh LA
CALQUENCE ORAL CAPSULE 100 MG 2 PA ST OCh
capecitabine oral tablet 150 mg 2 OCh LA QL (210 per 30 days)
capecitabine oral tablet 500 mg 2 OCh LA QL (84 per 30 days)
CAPRELSA ORAL TABLET 100 MG 300 MG 2 PA OCh
CLOLAR INTRAVENOUS SOLUTION 20 MG20 ML
MB PA
COMETRIQ ORAL CAPSULE 100 MGDAY(80 MG X1-20 MG X1) 140 MGDAY(80 MG X1-20 MG X3) 60 MGDAY (20 MG X 3DAY)
2 PA OCh
COPIKTRA ORAL CAPSULE 15 MG 25 MG 2 PA OCh
COTELLIC ORAL TABLET 20 MG 2 PA OCh LA
cyclophosphamide intravenous recon soln 1 gram 2 gram 500 mg
MB
cyclophosphamide oral capsule 25 mg 50 mg 2 OCh
CYCLOPHOSPHAMIDE ORAL TABLET 25 MG 50 MG
2 OCh
cyclosporine modified oral capsule 100 mg 25 mg 50 mg
1
cyclosporine modified oral solution 100 mgml 1
cyclosporine oral capsule 100 mg 25 mg 1
CYRAMZA INTRAVENOUS SOLUTION 10 MGML
MB PA LA
DACOGEN INTRAVENOUS RECON SOLN 50 MG
MB PA LA
DARZALEX INTRAVENOUS SOLUTION 20 MGML
MB PA LA
DAURISMO ORAL TABLET 100 MG 25 MG 2 PA OCh LA
decitabine intravenous recon soln 50 mg MB LA
ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 225 MG
2
ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG
2
ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG
2
16
Drug Name Drug Tier Requirements Limits
ELIGARD SUBCUTANEOUS SYRINGE 75 MG (1 MONTH)
2
ELZONRIS INTRAVENOUS SOLUTION 1000 MCGML
MB PA
EMCYT ORAL CAPSULE 140 MG 2 OCh
EMPLICITI INTRAVENOUS RECON SOLN 300 MG 400 MG
MB PA LA
ENHERTU INTRAVENOUS RECON SOLN 100 MG
MB PA LA
ERBITUX INTRAVENOUS SOLUTION 100 MG50 ML 200 MG100 ML
MB PA LA
ERLEADA ORAL TABLET 60 MG 2 PA OCh LA
erlotinib oral tablet 100 mg 150 mg 25 mg 2 PA OCh LA
ERWINAZE INJECTION RECON SOLN 10000 UNIT
MB
etoposide intravenous solution 20 mgml MB
etoposide oral capsule 50 mg 2 OCh
everolimus (antineoplastic) oral tablet 25 mg 5 mg 75 mg
2 PA ST OCh LA
everolimus (immunosuppressive) oral tablet 025 mg 05 mg 075 mg
1 PA
exemestane oral tablet 25 mg ACA PV OCh QL (30 per 30 days)
FASLODEX INTRAMUSCULAR SYRINGE 250 MG5 ML
MB PA
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG 80 MG
2 LA
fludarabine intravenous recon soln 50 mg MB
fluorouracil intravenous solution 25 gram50 ml 5 gram100 ml 500 mg10 ml
MB PA
flutamide oral capsule 125 mg 2 OCh QL (180 per 30 days)
FOLOTYN INTRAVENOUS SOLUTION 20 MGML (1 ML) 40 MG2 ML (20 MGML)
MB PA LA
fulvestrant intramuscular syringe 250 mg5 ml MB
GAMIFANT INTRAVENOUS SOLUTION 5 MGML
MB PA
GAZYVA INTRAVENOUS SOLUTION 1000 MG40 ML
MB PA LA
gemcitabine intravenous recon soln 1 gram 2 gram 200 mg
MB
17
Drug Name Drug Tier Requirements Limits
gemcitabine intravenous solution 2 gram526 ml (38 mgml) 200 mg526 ml (38 mgml)
MB
gengraf oral capsule 100 mg 25 mg 1
gengraf oral solution 100 mgml 1
GILOTRIF ORAL TABLET 20 MG 30 MG 40 MG
2 PA OCh LA
GLEOSTINE ORAL CAPSULE 10 MG 100 MG 40 MG
2 PA OCh
HALAVEN INTRAVENOUS SOLUTION 1 MG2 ML (05 MGML)
MB PA LA
HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600 MG-10000 UNIT5 ML
MB LA
HERCEPTIN INTRAVENOUS RECON SOLN 150 MG
MB PA LA
HERZUMA INTRAVENOUS RECON SOLN 150 MG
MB PA LA
HYCAMTIN ORAL CAPSULE 025 MG 1 MG 2 OCh LA
hydroxyurea oral capsule 500 mg 2 OCh
IBRANCE ORAL CAPSULE 100 MG 125 MG 75 MG
2 PA OCh LA
IBRANCE ORAL TABLET 100 MG 125 MG 75 MG
2 OCh LA
ICLUSIG ORAL TABLET 10 MG 15 MG 30 MG 45 MG
2 PA ST OCh
IDHIFA ORAL TABLET 100 MG 50 MG 2 PA OCh LA
imatinib oral tablet 100 mg 2 OCh LA QL (90 per 30 days)
imatinib oral tablet 400 mg 2 OCh LA QL (60 per 30 days)
IMBRUVICA ORAL CAPSULE 140 MG 70 MG 2 PA ST OCh
IMBRUVICA ORAL TABLET 140 MG 280 MG 420 MG 560 MG
2 PA ST OCh
IMFINZI INTRAVENOUS SOLUTION 50 MGML
MB PA LA
IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFUML 10EXP8 (100 MILLION) PFUML
MB
18
Drug Name Drug Tier Requirements Limits
INFUGEM INTRAVENOUS PIGGYBACK 1200 MG120 ML (10 MGML) 1300 MG130 ML (10 MGML) 1400 MG140 ML (10 MGML) 1500 MG150 ML (10 MGML) 1600 MG160 ML (10 MGML) 1700 MG170 ML (10 MGML) 1800 MG180 ML (10 MGML) 1900 MG190 ML (10 MGML) 2000 MG200 ML (10 MGML) 2200 MG220 ML (10 MGML)
MB
INLYTA ORAL TABLET 1 MG 5 MG 2 PA OCh LA
IRESSA ORAL TABLET 250 MG 2 PA OCh LA
ISTODAX INTRAVENOUS RECON SOLN 10 MG2 ML
MB PA LA
IXEMPRA INTRAVENOUS RECON SOLN 15 MG 45 MG
MB PA LA
JAKAFI ORAL TABLET 10 MG 15 MG 20 MG 25 MG 5 MG
2 PA OCh LA
JEVTANA INTRAVENOUS SOLUTION 10 MGML (FIRST DILUTION)
MB PA LA
KADCYLA INTRAVENOUS RECON SOLN 100 MG 160 MG
MB PA LA
KANJINTI INTRAVENOUS RECON SOLN 150 MG 420 MG
MB PA LA
KEYTRUDA INTRAVENOUS SOLUTION 25 MGML
MB PA
KISQALI FEMARA CO-PACK ORAL TABLET 200 MGDAY(200 MG X 1)-25 MG 400 MGDAY(200 MG X 2)-25 MG 600 MGDAY(200 MG X 3)-25 MG
2 PA ST OCh LA
KISQALI ORAL TABLET 200 MGDAY (200 MG X 1) 400 MGDAY (200 MG X 2) 600 MGDAY (200 MG X 3)
2 PA ST OCh LA
KYMRIAH INTRAVENOUS SUSPENSION 02X10EXP6 TO 25X10EXP8 CELL 06 TO 6 X 10EXP8 CELL
MB PA
KYPROLIS INTRAVENOUS RECON SOLN 10 MG 30 MG 60 MG
MB PA
lapatinib oral tablet 250 mg 2 PA OCh LA QL (180 per 30 days)
LENVIMA ORAL CAPSULE 10 MGDAY (10 MG X 1) 12 MGDAY (4 MG X 3) 14 MGDAY(10 MG X 1-4 MG X 1) 18 MGDAY (10 MG X 1-4 MG X2) 20 MGDAY (10 MG X 2) 24 MGDAY(10 MG X 2-4 MG X 1) 4 MG 8 MGDAY (4 MG X 2)
2 PA ST OCh LA
19
Drug Name Drug Tier Requirements Limits
letrozole oral tablet 25 mg ACA PV OCh QL (30 per 30 days)
LEUKERAN ORAL TABLET 2 MG 2 OCh
leuprolide subcutaneous kit 1 mg02 ml 2
LIBTAYO INTRAVENOUS SOLUTION 50 MGML
MB PA
LONSURF ORAL TABLET 15-614 MG 20-819 MG
2 PA ST OCh LA
LUMOXITI INTRAVENOUS RECON SOLN 1 MG
MB
LUPKYNIS ORAL CAPSULE 79 MG 2 PA ST
LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 225 MG
2
LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG
2
LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG
2
LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 375 MG 75 MG
2
LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 30 MG
2
LUPRON DEPOT-PED INTRAMUSCULAR KIT 1125 MG 15 MG 75 MG (PED)
2
LYNPARZA ORAL TABLET 100 MG 150 MG 2 PA ST OCh LA
LYSODREN ORAL TABLET 500 MG 2 OCh
MARQIBO INTRAVENOUS KIT 5 MG31 ML(016 MGML) FINAL
MB PA
MATULANE ORAL CAPSULE 50 MG 2 OCh
megestrol oral suspension 400 mg10 ml (40 mgml)
1 QL (2 per 30 days)
megestrol oral suspension 625 mg5 ml (125 mgml)
1 QL (1 per 30 days)
megestrol oral tablet 20 mg 2 OCh QL (480 per 30 days)
megestrol oral tablet 40 mg 2 OCh QL (240 per 30 days)
MEKINIST ORAL TABLET 05 MG 2 MG 2 PA ST OCh LA
MEKTOVI ORAL TABLET 15 MG 2 PA OCh LA
melphalan hcl intravenous recon soln 50 mg MB
melphalan oral tablet 2 mg 2 OCh
20
Drug Name Drug Tier Requirements Limits
mercaptopurine oral tablet 50 mg 2 OCh QL (300 per 30 days)
methotrexate sodium (pf) injection recon soln 1 gram
1
methotrexate sodium (pf) injection solution 25 mgml
1
methotrexate sodium injection solution 25 mgml 1
methotrexate sodium oral tablet 25 mg 2 OCh
mitoxantrone intravenous concentrate 2 mgml MB PA LA
mycophenolate mofetil oral capsule 250 mg 1
mycophenolate mofetil oral tablet 500 mg 1
mycophenolate sodium oral tabletdelayed release (drec) 180 mg 360 mg
1
MYLOTARG INTRAVENOUS RECON SOLN 45 MG (1 MGML INITIAL CONC)
MB PA LA
NERLYNX ORAL TABLET 40 MG 2 PA OCh LA QL (180 per 30 days)
NEXAVAR ORAL TABLET 200 MG 2 PA ST OCh LA
nilutamide oral tablet 150 mg 2 OCh QL (60 per 30 days)
NINLARO ORAL CAPSULE 23 MG 3 MG 4 MG
2 PA ST OCh LA
NULOJIX INTRAVENOUS RECON SOLN 250 MG
MB PA
octreotide acetate injection solution 1000 mcgml 100 mcgml 200 mcgml 50 mcgml 500 mcgml
2
octreotide acetate injection syringe 100 mcgml (1 ml) 50 mcgml (1 ml) 500 mcgml (1 ml)
2
OGIVRI INTRAVENOUS RECON SOLN 150 MG 420 MG
MB PA LA
ONCASPAR INJECTION SOLUTION 750 UNITML
MB
ONIVYDE INTRAVENOUS DISPERSION 43 MGML
MB PA
OPDIVO INTRAVENOUS SOLUTION 100 MG10 ML 240 MG24 ML 40 MG4 ML
MB PA LA
PADCEV INTRAVENOUS RECON SOLN 20 MG 30 MG
MB PA LA
PEMAZYRE ORAL TABLET 135 MG 45 MG 9 MG
2 PA ST OCh
PERJETA INTRAVENOUS SOLUTION 420 MG14 ML (30 MGML)
MB PA LA
21
Drug Name Drug Tier Requirements Limits
PIQRAY ORAL TABLET 200 MGDAY (200 MG X 1) 250 MGDAY (200 MG X1-50 MG X1) 300 MGDAY (150 MG X 2)
2 PA OCh LA
POLIVY INTRAVENOUS RECON SOLN 140 MG
MB PA LA
PORTRAZZA INTRAVENOUS SOLUTION 800 MG50 ML (16 MGML)
MB PA LA
POTELIGEO INTRAVENOUS SOLUTION 4 MGML
MB PA
PROGRAF INTRAVENOUS SOLUTION 5 MGML
MB
QINLOCK ORAL TABLET 50 MG 2 OCh
RETEVMO ORAL CAPSULE 40 MG 2 PA OCh LA QL (240 per 30 days)
RETEVMO ORAL CAPSULE 80 MG 2 PA OCh LA QL (120 per 30 days)
RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG117 ML (120 MGML) 1600 MG134 ML (120 MGML)
MB LA
RITUXAN INTRAVENOUS CONCENTRATE 10 MGML
MB PA LA
RUBRACA ORAL TABLET 200 MG 250 MG 300 MG
2 PA ST OCh LA
RYDAPT ORAL CAPSULE 25 MG 2 PA ST OCh LA
SARCLISA INTRAVENOUS SOLUTION 20 MGML
MB
SIGNIFOR SUBCUTANEOUS SOLUTION 03 MGML (1 ML) 06 MGML (1 ML) 09 MGML (1 ML)
2 PA ST
SIMULECT INTRAVENOUS RECON SOLN 10 MG 20 MG
MB
sirolimus oral solution 1 mgml 1
sirolimus oral tablet 05 mg 1 mg 2 mg 1
SOLTAMOX ORAL SOLUTION 20 MG10 ML 2 OCh
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG05 ML 60 MG02 ML 90 MG03 ML
2 PA LA
SPRYCEL ORAL TABLET 100 MG 140 MG 20 MG 50 MG 70 MG 80 MG
2 PA ST OCh LA
STIVARGA ORAL TABLET 40 MG 2 PA ST OCh LA
SUPPRELIN LA IMPLANT KIT 50 MG (65 MCGDAY)
MB LA
22
Drug Name Drug Tier Requirements Limits
SUTENT ORAL CAPSULE 125 MG 25 MG 375 MG 50 MG
2 PA ST OCh LA
SYLVANT INTRAVENOUS RECON SOLN 100 MG 400 MG
MB PA LA
SYNRIBO SUBCUTANEOUS RECON SOLN 35 MG
2 PA ST
TABLOID ORAL TABLET 40 MG 2 OCh
tacrolimus oral capsule 05 mg 1 mg 5 mg 1
TAFINLAR ORAL CAPSULE 50 MG 75 MG 2 PA OCh LA
TAGRISSO ORAL TABLET 40 MG 80 MG 2 PA OCh LA
TALZENNA ORAL CAPSULE 025 MG 1 MG 2 PA OCh LA
tamoxifen oral tablet 10 mg 20 mg 2 OCh QL (60 per 30 days)
TARGRETIN TOPICAL GEL 1 1 PA ST
TASIGNA ORAL CAPSULE 150 MG 200 MG 50 MG
2 PA ST OCh LA
TECENTRIQ INTRAVENOUS SOLUTION 1200 MG20 ML (60 MGML) 840 MG14 ML (60 MGML)
MB PA LA
TEMODAR INTRAVENOUS RECON SOLN 100 MG
MB PA LA
temozolomide oral capsule 100 mg 140 mg 180 mg 20 mg 250 mg 5 mg
2 OCh LA
temsirolimus intravenous recon soln 30 mg3 ml (10 mgml) (first)
MB PA LA
THALOMID ORAL CAPSULE 100 MG 150 MG 200 MG 50 MG
2 OCh LA
TIBSOVO ORAL TABLET 250 MG 2 PA OCh
toremifene oral tablet 60 mg 2 OCh
TORISEL INTRAVENOUS RECON SOLN 30 MG3 ML (10 MGML) (FIRST)
MB PA LA
TREANDA INTRAVENOUS RECON SOLN 100 MG 25 MG
MB PA LA
TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 1125 MG 225 MG 375 MG
MB
tretinoin (antineoplastic) oral capsule 10 mg 2 OCh
TREXALL ORAL TABLET 10 MG 15 MG 5 MG 75 MG
2 PA ST OCh QL (15 per 30 days)
TRUXIMA INTRAVENOUS SOLUTION 10 MGML
MB PA LA
23
Drug Name Drug Tier Requirements Limits
TUKYSA ORAL TABLET 150 MG 50 MG 2 PA ST OCh QL (120 per 30 days)
UNITUXIN INTRAVENOUS SOLUTION 35 MGML
MB PA
VANTAS IMPLANT KIT 50 MG (50 MCGDAY)
MB LA
VECTIBIX INTRAVENOUS SOLUTION 100 MG5 ML (20 MGML) 400 MG20 ML (20 MGML)
MB PA LA
VELCADE INJECTION RECON SOLN 35 MG MB LA
VENCLEXTA ORAL TABLET 10 MG 100 MG 50 MG
2 PA ST OCh
VENCLEXTA STARTING PACK ORAL TABLETSDOSE PACK 10 MG-50 MG- 100 MG
2 PA OCh
VERZENIO ORAL TABLET 100 MG 150 MG 200 MG 50 MG
2 PA ST OCh LA
VIDAZA INJECTION RECON SOLN 100 MG MB PA LA
VITRAKVI ORAL CAPSULE 100 MG 2 PA OCh LA
VITRAKVI ORAL CAPSULE 25 MG 2 PA ST OCh LA
VITRAKVI ORAL SOLUTION 20 MGML 2 PA OCh LA
VOTRIENT ORAL TABLET 200 MG 2 PA ST OCh LA
VYXEOS INTRAVENOUS RECON SOLN 44-100 MG
MB PA
XALKORI ORAL CAPSULE 200 MG 250 MG 2 PA OCh LA
XERMELO ORAL TABLET 250 MG 2 PA ST
XOSPATA ORAL TABLET 40 MG 2 PA OCh
XTANDI ORAL CAPSULE 40 MG 2 PA OCh LA
XTANDI ORAL TABLET 40 MG 80 MG 2 PA OCh LA
YERVOY INTRAVENOUS SOLUTION 200 MG40 ML (5 MGML) 50 MG10 ML (5 MGML)
MB PA LA
YESCARTA INTRAVENOUS SUSPENSION MB PA
YONDELIS INTRAVENOUS RECON SOLN 1 MG
MB PA
YONSA ORAL TABLET 125 MG 2 PA OCh LA
ZALTRAP INTRAVENOUS SOLUTION 100 MG4 ML (25 MGML) 200 MG8 ML (25 MGML)
MB PA LA
ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM
MB
24
Drug Name Drug Tier Requirements Limits
ZEJULA ORAL CAPSULE 100 MG 2 OCh
ZELBORAF ORAL TABLET 240 MG 2 PA ST OCh LA
ZOLADEX SUBCUTANEOUS IMPLANT 108 MG 36 MG
MB LA
ZOLINZA ORAL CAPSULE 100 MG 2 PA ST OCh LA
ZYKADIA ORAL TABLET 150 MG 2 PA ST OCh LA
AUTONOMIC amp CNS DRUGS NEUROLOGY amp PSYCH
ANTICONVULSANTS
BANZEL ORAL TABLET 200 MG 400 MG 1 PA ST
BRIVIACT ORAL SOLUTION 10 MGML 1 ST QL (150 per 30 days)
BRIVIACT ORAL TABLET 10 MG 100 MG 25 MG 50 MG 75 MG
1 ST QL (60 per 30 days)
carbamazepine oral capsule er multiphase 12 hr 100 mg 200 mg 300 mg
1
carbamazepine oral suspension 100 mg5 ml 200 mg10 ml
1
carbamazepine oral tablet 200 mg 1
carbamazepine oral tablet extended release 12 hr 100 mg 200 mg 400 mg
1
carbamazepine oral tabletchewable 100 mg 1
CELONTIN ORAL CAPSULE 300 MG 1
clobazam oral suspension 25 mgml 1
clobazam oral tablet 10 mg 20 mg 1
clonazepam oral tablet 05 mg 1 mg 2 mg 1
clonazepam oral tabletdisintegrating 0125 mg 025 mg 05 mg 1 mg 2 mg
1
diazepam rectal kit 25 mg 1
DILANTIN EXTENDED ORAL CAPSULE 100 MG
1
DILANTIN INFATABS ORAL TABLETCHEWABLE 50 MG
1
DILANTIN ORAL CAPSULE 30 MG 1
DILANTIN-125 ORAL SUSPENSION 125 MG5 ML
1
divalproex oral capsule delayed rel sprinkle 125 mg
1
divalproex oral tablet extended release 24 hr 250 mg 500 mg
1
25
Drug Name Drug Tier Requirements Limits
divalproex oral tabletdelayed release (drec) 125 mg 250 mg 500 mg
1
EPIDIOLEX ORAL SOLUTION 100 MGML 2 PA LA QL (400 per 30 days)
epitol oral tablet 200 mg 1
ethosuximide oral capsule 250 mg 1
ethosuximide oral solution 250 mg5 ml 1
felbamate oral suspension 600 mg5 ml 1
felbamate oral tablet 400 mg 600 mg 1
FINTEPLA ORAL SOLUTION 22 MGML 2
gabapentin oral capsule 100 mg 300 mg 400 mg 1
gabapentin oral solution 250 mg5 ml 300 mg6 ml (6 ml)
1
gabapentin oral tablet 600 mg 800 mg 1
lamotrigine oral tablet 100 mg 150 mg 200 mg 25 mg
1
lamotrigine oral tablet disintegrating dose pk 25 mg (21) -50 mg (7) 25 mg(14)-50 mg (14)-100 mg (7) 50 mg (42) -100 mg (14)
1
lamotrigine oral tablet extended release 24hr 100 mg 200 mg 25 mg 250 mg 300 mg 50 mg
1
lamotrigine oral tablet chewable dispersible 25 mg 5 mg
1
lamotrigine oral tabletdisintegrating 100 mg 200 mg 25 mg 50 mg
1
lamotrigine oral tabletsdose pack 25 mg (35) 25 mg (42) -100 mg (7) 25 mg (84) -100 mg (14)
1
levetiracetam oral solution 100 mgml 500 mg5 ml (5 ml)
1
levetiracetam oral tablet 1000 mg 250 mg 500 mg 750 mg
1
levetiracetam oral tablet extended release 24 hr 500 mg 750 mg
1
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG 330 MG 825 MG
1 PA ST
oxcarbazepine oral suspension 300 mg5 ml (60 mgml)
1
oxcarbazepine oral tablet 150 mg 300 mg 600 mg 1
phenobarbital oral elixir 20 mg5 ml (4 mgml) 1
26
Drug Name Drug Tier Requirements Limits
phenobarbital oral tablet 100 mg 15 mg 162 mg 30 mg 324 mg 60 mg 648 mg 972 mg
1
phenytoin oral suspension 100 mg4 ml 125 mg5 ml
1
phenytoin oral tabletchewable 50 mg 1
phenytoin sodium extended oral capsule 100 mg 200 mg 300 mg
1
pregabalin oral capsule 100 mg 150 mg 200 mg 225 mg 25 mg 300 mg 50 mg 75 mg
1 PA ST
pregabalin oral solution 20 mgml 1 PA ST
pregabalin oral tablet extended release 24 hr 165 mg 330 mg 825 mg
1 PA ST
primidone oral tablet 250 mg 50 mg 1
roweepra oral tablet 1000 mg 500 mg 750 mg 1
rufinamide oral suspension 40 mgml 1 PA
rufinamide oral tablet 200 mg 400 mg 1 PA
subvenite oral tablet 100 mg 150 mg 200 mg 25 mg
1
subvenite starter (blue) kit oral tabletsdose pack 25 mg (35)
1
subvenite starter (green) kit oral tabletsdose pack 25 mg (84) -100 mg (14)
1
subvenite starter (orange) kit oral tabletsdose pack 25 mg (42) -100 mg (7)
1
SYMPAZAN ORAL FILM 10 MG 20 MG 5 MG 1 PA QL (30 per 30 days)
tiagabine oral tablet 12 mg 16 mg 2 mg 4 mg 1
topiramate oral capsule sprinkle 15 mg 25 mg 1
topiramate oral tablet 100 mg 200 mg 25 mg 50 mg
1
valproic acid (as sodium salt) oral solution 250 mg5 ml 500 mg10 ml (10 ml)
1
valproic acid oral capsule 250 mg 1
vigabatrin oral powder in packet 500 mg 2 PA LA
vigabatrin oral tablet 500 mg 2 PA LA
vigadrone oral powder in packet 500 mg 2 PA ST
VIMPAT ORAL SOLUTION 10 MGML 1 PA ST QL (6 per 30 days)
VIMPAT ORAL TABLET 100 MG 150 MG 200 MG 50 MG
1 ST QL (60 per 30 days)
27
Drug Name Drug Tier Requirements Limits
XCOPRI MAINTENANCE PACK ORAL TABLET 250 MGDAY (200 MG X1-50 MG X1) 350 MGDAY (200 MG X1-150MG X1)
2
XCOPRI MAINTENANCE PACK ORAL TABLET 250MGDAY(150 MG X1-100MG X1)
2 PA ST
XCOPRI ORAL TABLET 100 MG 150 MG 200 MG 50 MG
2
XCOPRI TITRATION PACK ORAL TABLETSDOSE PACK 125 MG (14)- 25 MG (14) 150 MG (14)- 200 MG (14) 50 MG (14)- 100 MG (14)
2
zonisamide oral capsule 100 mg 25 mg 50 mg 1
ANTIPARKINSONISM AGENTS
APOKYN SUBCUTANEOUS CARTRIDGE 10 MGML
2 PA LA QL (1 per 30 days)
benztropine injection solution 1 mgml 1
benztropine oral tablet 05 mg 1 mg 2 mg 1
bromocriptine oral capsule 5 mg 1
bromocriptine oral tablet 25 mg 1
carbidopa oral tablet 25 mg 1
carbidopa-levodopa oral tablet 10-100 mg 25-100 mg 25-250 mg
1
carbidopa-levodopa oral tablet extended release 25-100 mg 50-200 mg
1
carbidopa-levodopa oral tabletdisintegrating 10-100 mg 25-100 mg 25-250 mg
1
carbidopa-levodopa-entacapone oral tablet 125-50-200 mg 1875-75-200 mg 25-100-200 mg 3125-125-200 mg 375-150-200 mg 50-200-200 mg
1
entacapone oral tablet 200 mg 1
pramipexole oral tablet 0125 mg 025 mg 05 mg 075 mg 1 mg 15 mg
1
pramipexole oral tablet extended release 24 hr 0375 mg 075 mg 15 mg 225 mg 3 mg 375 mg 45 mg
1
rasagiline oral tablet 05 mg 1 mg 1
ropinirole oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg 5 mg
1
28
Drug Name Drug Tier Requirements Limits
ropinirole oral tablet extended release 24 hr 12 mg 2 mg 4 mg 6 mg 8 mg
1
selegiline hcl oral capsule 5 mg 1
selegiline hcl oral tablet 5 mg 1
tolcapone oral tablet 100 mg 1
trihexyphenidyl oral elixir 04 mgml 1
trihexyphenidyl oral tablet 2 mg 5 mg 1
MIGRAINE amp CLUSTER HEADACHE THERAPY
AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MGML 70 MGML
1 PA ST
AJOVY AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 225 MG15 ML
1 ST
AJOVY SYRINGE SUBCUTANEOUS SYRINGE 225 MG15 ML
1 PA ST
almotriptan malate oral tablet 125 mg 625 mg 1 QL (18 per 30 days)
dihydroergotamine injection solution 1 mgml 1
dihydroergotamine nasal spraynon-aerosol 05 mgpump act (4 mgml)
1 QL (8 per 30 days)
eletriptan oral tablet 20 mg 40 mg 1 QL (18 per 30 days)
EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MGML
1 PA ST
EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MGML 300 MG3 ML (100 MGML X 3)
1 PA ST
ergotamine-caffeine oral tablet 1-100 mg 1
frovatriptan oral tablet 25 mg 1 QL (18 per 30 days)
migergot rectal suppository 2-100 mg 1
naratriptan oral tablet 1 mg 25 mg 1 QL (18 per 30 days)
ONZETRA XSAIL NASAL AEROSOL POWDR BREATH ACTIVATED 11 MG
1 ST QL (16 per 30 days)
rizatriptan oral tablet 10 mg 5 mg 1 QL (18 per 30 days)
rizatriptan oral tabletdisintegrating 10 mg 5 mg 1 QL (18 per 30 days)
sumatriptan nasal spraynon-aerosol 20 mgactuation 5 mgactuation
1 QL (18 per 30 days)
sumatriptan succinate oral tablet 100 mg 25 mg 50 mg
1 QL (18 per 30 days)
sumatriptan succinate subcutaneous cartridge 4 mg05 ml 6 mg05 ml
1 QL (8 per 30 days)
29
Drug Name Drug Tier Requirements Limits
sumatriptan succinate subcutaneous pen injector 4 mg05 ml 6 mg05 ml
1 QL (8 per 30 days)
sumatriptan succinate subcutaneous solution 6 mg05 ml
1 QL (8 per 30 days)
sumatriptan succinate subcutaneous syringe 6 mg05 ml
1 QL (8 per 30 days)
UBRELVY ORAL TABLET 100 MG 50 MG 1 QL (16 per 30 days)
VYEPTI INTRAVENOUS SOLUTION 100 MGML
MB PA
zolmitriptan oral tablet 25 mg 5 mg 1 QL (18 per 30 days)
zolmitriptan oral tabletdisintegrating 25 mg 5 mg
1 QL (18 per 30 days)
ZOMIG NASAL SPRAYNON-AEROSOL 25 MG 5 MG
1 ST QL (18 per 30 days)
MISCELLANEOUS NEUROLOGICAL THERAPY
AUSTEDO ORAL TABLET 12 MG 6 MG 9 MG
2 PA LA
dalfampridine oral tablet extended release 12 hr 10 mg
2 PA LA QL (60 per 30 days)
donepezil oral tablet 10 mg 23 mg 5 mg 1
donepezil oral tabletdisintegrating 10 mg 5 mg 1
EXONDYS-51 INTRAVENOUS SOLUTION 50 MGML
MB PA
galantamine oral capsuleext rel pellets 24 hr 16 mg 24 mg 8 mg
1
galantamine oral solution 4 mgml 1
galantamine oral tablet 12 mg 4 mg 8 mg 1
memantine oral capsulesprinkleer 24hr 14 mg 21 mg 28 mg 7 mg
1
memantine oral solution 2 mgml 1
memantine oral tablet 10 mg 5 mg 1
NUEDEXTA ORAL CAPSULE 20-10 MG 1
ONPATTRO INTRAVENOUS SOLUTION 2 MGML
MB PA
RADICAVA INTRAVENOUS SOLUTION 30 MG100 ML
MB PA
rivastigmine tartrate oral capsule 15 mg 3 mg 45 mg 6 mg
1
30
Drug Name Drug Tier Requirements Limits
rivastigmine transdermal patch 24 hour 133 mg24 hour 46 mg24 hour 95 mg24 hour
1
tetrabenazine oral tablet 125 mg 25 mg 2 LA
TYSABRI INTRAVENOUS SOLUTION 300 MG15 ML
MB PA ST LA
VYONDYS-53 INTRAVENOUS SOLUTION 50 MGML
MB PA
ZOLGENSMA INTRAVENOUS KIT 2 X 10EXP13 VGML
MB LA
MUSCLE RELAXANTS amp ANTISPASMODIC THERAPY
baclofen oral tablet 10 mg 20 mg 5 mg 1
carisoprodol oral tablet 250 mg 350 mg 1
carisoprodol-aspirin oral tablet 200-325 mg 1
carisoprodol-aspirin-codeine oral tablet 200-325-16 mg
1 PA ST
chlorzoxazone oral tablet 250 mg 375 mg 750 mg 1 ST
chlorzoxazone oral tablet 500 mg 1
cyclobenzaprine oral tablet 10 mg 5 mg 75 mg 1
dantrolene oral capsule 100 mg 25 mg 50 mg 1
meprobamate oral tablet 200 mg 400 mg 1
metaxalone oral tablet 400 mg 800 mg 1
methocarbamol oral tablet 500 mg 750 mg 1
orphenadrine citrate injection solution 30 mgml 1
orphenadrine citrate oral tablet extended release 100 mg
1
pyridostigmine bromide oral syrup 60 mg5 ml 1
pyridostigmine bromide oral tablet 60 mg 1
pyridostigmine bromide oral tablet extended release 180 mg
1
tizanidine oral capsule 2 mg 4 mg 6 mg 1
tizanidine oral tablet 2 mg 4 mg 1
vanadom oral tablet 350 mg 1
NARCOTIC ANALGESICS
acetaminophen-caff-dihydrocod oral capsule 3205-30-16 mg
1 PA ST
acetaminophen-caff-dihydrocod oral tablet 325-30-16 mg
1 PA ST
31
Drug Name Drug Tier Requirements Limits
acetaminophen-codeine oral solution 120-12 mg5 ml 300 mg-30 mg 125 ml
1 PA ST
acetaminophen-codeine oral tablet 300-15 mg 300-30 mg 300-60 mg
1 PA ST
ascomp with codeine oral capsule 30-50-325-40 mg
1 PA ST
buprenorphine hcl injection solution 03 mgml 1 PA ST
buprenorphine hcl injection syringe 03 mgml 1 PA ST
buprenorphine hcl sublingual tablet 2 mg 8 mg 1
buprenorphine transdermal patch weekly 10 mcghour 15 mcghour 20 mcghour 5 mcghour 75 mcghour
1
butalbital compound wcodeine oral capsule 30-50-325-40 mg
1 PA ST
butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg 50-325-40-30 mg
1 PA ST
butalbital-acetaminophen-caff oral capsule 50-300-40 mg 50-325-40 mg
1
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
1
butalbital-aspirin-caffeine oral capsule 50-325-40 mg
1
butalbital-aspirin-caffeine oral tablet 50-325-40 mg
1
codeine sulfate oral tablet 15 mg 30 mg 60 mg 1 PA ST
codeine-butalbital-asa-caff oral capsule 30-50-325-40 mg
1 PA ST
diskets oral tabletsoluble 40 mg 1 PA ST
DSUVIA SUBLINGUAL TABLET IN APPLICATOR 30 MCG
MB
duramorph (pf) injection solution 05 mgml 1 mgml
MB PA ST
dvorah oral tablet 325-30-16 mg 1 PA ST
endocet oral tablet 10-325 mg 25-325 mg 5-325 mg 75-325 mg
1 PA ST
fentanyl citrate buccal lozenge on a handle 1200 mcg 1600 mcg 200 mcg 400 mcg 600 mcg 800 mcg
1 PA
32
Drug Name Drug Tier Requirements Limits
fentanyl transdermal patch 72 hour 100 mcghr 12 mcghr 25 mcghr 375 mcghour 50 mcghr 625 mcghour 75 mcghr 875 mcghour
1 PA ST
hydrocodone bitartrate oral capsule oral only er 12hr 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg
1 PA ST QL (60 per 30 days)
hydrocodone bitartrate oral tabletoral onlyextrel24 hr 100 mg 120 mg 20 mg 30 mg 40 mg 60 mg 80 mg
1 PA ST
hydrocodone-acetaminophen oral solution 10-325 mg15 ml(15 ml) 75-325 mg15 ml
1 PA ST
hydrocodone-acetaminophen oral tablet 10-300 mg 10-325 mg 5-300 mg 5-325 mg 75-300 mg 75-325 mg
1 PA ST
hydrocodone-ibuprofen oral tablet 10-200 mg 5-200 mg 75-200 mg
1 PA ST
HYDROMORPHONE INJECTION SYRINGE 05 MG05 ML
1 PA ST
hydromorphone oral liquid 1 mgml 1 PA ST
hydromorphone oral tablet 2 mg 4 mg 8 mg 1 PA ST
hydromorphone oral tablet extended release 24 hr 12 mg 16 mg 32 mg 8 mg
1 PA ST QL (60 per 30 days)
hydromorphone rectal suppository 3 mg 1 PA ST
levorphanol tartrate oral tablet 2 mg 3 mg 1 PA ST
meperidine oral solution 50 mg5 ml 1 PA ST
meperidine oral tablet 50 mg 1 PA ST
methadone injection solution 10 mgml 1 PA ST
methadone oral concentrate 10 mgml 1 PA ST
methadone oral solution 10 mg5 ml 5 mg5 ml 1 PA ST
methadone oral tablet 10 mg 5 mg 1 PA ST
methadone oral tabletsoluble 40 mg 1 PA ST
methadose oral concentrate 10 mgml 1 PA ST
methadose oral tabletsoluble 40 mg 1 PA ST
morphine (pf) injection solution 05 mgml MB PA ST
morphine concentrate oral solution 100 mg5 ml (20 mgml)
1 PA ST
morphine oral capsule er multiphase 24 hr 120 mg 30 mg 45 mg 60 mg 75 mg 90 mg
1 PA ST QL (60 per 30 days)
morphine oral capsuleextendrelease pellets 10 mg 100 mg 20 mg 50 mg 80 mg
1 PA ST QL (90 per 30 days)
33
Drug Name Drug Tier Requirements Limits
morphine oral capsuleextendrelease pellets 30 mg 60 mg
1 PA ST QL (60 per 30 days)
morphine oral capsuleextendrelease pellets 40 mg
1 PA QL (90 per 30 days)
morphine oral solution 10 mg5 ml 20 mg5 ml (4 mgml)
1 PA ST
morphine oral tablet 15 mg 30 mg 1 PA ST
morphine oral tablet extended release 100 mg 15 mg 200 mg 30 mg 60 mg
1 PA ST QL (120 per 30 days)
morphine rectal suppository 10 mg 20 mg 30 mg 5 mg
1 PA ST
oxycodone oral capsule 5 mg 1 PA ST
oxycodone oral concentrate 20 mgml 1 PA ST
oxycodone oral solution 5 mg5 ml 1 PA ST
oxycodone oral tablet 10 mg 15 mg 20 mg 30 mg 5 mg
1 PA ST
oxycodone-acetaminophen oral tablet 10-325 mg 25-300 mg 25-325 mg 5-325 mg 75-325 mg
1 PA ST
oxycodone-aspirin oral tablet 48355-325 mg 1 PA ST
OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 10 MG 15 MG 20 MG 30 MG 40 MG
1 PA ST QL (90 per 30 days)
OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 60 MG 80 MG
1 PA ST QL (120 per 30 days)
oxymorphone oral tablet 10 mg 5 mg 1 PA ST
oxymorphone oral tablet extended release 12 hr 10 mg 15 mg 20 mg 30 mg 40 mg 5 mg 75 mg
1 PA ST QL (90 per 30 days)
SUBLOCADE SUBCUTANEOUS SOLUTION EXTENDED REL SYRINGE 100 MG05 ML 300 MG15 ML
MB
tencon oral tablet 50-325 mg 1
NON-NARCOTIC ANALGESICS
adult aspirin regimen oral tabletdelayed release (drec) 81 mg
ACA PV
aspirin low dose oral tabletdelayed release (drec) 81 mg
ACA PV
aspirin oral tablet 325 mg ACA PV
aspirin oral tabletchewable 81 mg ACA PV
34
Drug Name Drug Tier Requirements Limits
aspirin oral tabletdelayed release (drec) 325 mg 81 mg
ACA PV
aspir-trin oral tabletdelayed release (drec) 325 mg
ACA PV
bayer aspirin oral tablet 325 mg ACA PV
BAYER CHEWABLE ASPIRIN ORAL TABLETCHEWABLE 81 MG
ACA PV
buprenorphine-naloxone sublingual film 12-3 mg 1 QL (60 per 30 days)
buprenorphine-naloxone sublingual film 2-05 mg 4-1 mg 8-2 mg
1 QL (90 per 30 days)
buprenorphine-naloxone sublingual tablet 2-05 mg 8-2 mg
1 QL (90 per 30 days)
butorphanol nasal spraynon-aerosol 10 mgml 1 PA ST QL (5 per 30 days)
cataflam oral tablet 50 mg 1
celecoxib oral capsule 100 mg 200 mg 400 mg 50 mg
1
childrens aspirin oral tabletchewable 81 mg ACA PV
cholinemagnesium salicylate oral liquid 500 mg5 ml
1
diclofenac potassium oral tablet 50 mg 1
diclofenac sodium oral tablet extended release 24 hr 100 mg
1
diclofenac sodium oral tabletdelayed release (drec) 25 mg 50 mg 75 mg
1
diclofenac sodium topical drops 15 1
diclofenac sodium topical gel 1 1
diclofenac-misoprostol oral tabletirdelayed relbiphasic 50-200 mg-mcg 75-200 mg-mcg
1
diflunisal oral tablet 500 mg 1
DUEXIS ORAL TABLET 800-266 MG 1 ST
ecotrin low strength oral tabletdelayed release (drec) 81 mg
ACA PV
ecotrin oral tabletdelayed release (drec) 325 mg ACA PV
etodolac oral capsule 200 mg 300 mg 1
etodolac oral tablet 400 mg 500 mg 1
etodolac oral tablet extended release 24 hr 400 mg 500 mg 600 mg
1
EUFLEXXA INTRA-ARTICULAR SYRINGE 10 MGML(MW 24 -36 MILLION)
MB
35
Drug Name Drug Tier Requirements Limits
fenoprofen oral tablet 600 mg 1
flurbiprofen oral tablet 100 mg 1
ibu oral tablet 400 mg 600 mg 800 mg 1
ibuprofen oral suspension 100 mg5 ml 1
ibuprofen oral tablet 400 mg 600 mg 800 mg 1
indomethacin oral capsule 25 mg 50 mg 1
indomethacin oral capsule extended release 75 mg
1
ketoprofen oral capsule 25 mg 50 mg 75 mg 1
ketoprofen oral capsuleext rel pellets 24 hr 200 mg
1
ketorolac injection cartridge 15 mgml 30 mgml 1
ketorolac injection solution 15 mgml 30 mgml MB
ketorolac injection solution 30 mgml (1 ml) 1
ketorolac intramuscular cartridge 60 mg2 ml 1
ketorolac intramuscular solution 60 mg2 ml 1
ketorolac intramuscular syringe 60 mg2 ml 1
ketorolac oral tablet 10 mg 1
meclofenamate oral capsule 100 mg 50 mg 1
mefenamic acid oral capsule 250 mg 1
meloxicam oral tablet 15 mg 75 mg 1
MONOVISC INTRA-ARTICULAR SYRINGE 88 MG4 ML
MB LA
nabumetone oral tablet 500 mg 750 mg 1
nalbuphine injection solution 10 mgml MB PA ST
naloxone injection solution 04 mgml 1
naloxone injection syringe 04 mgml 1 mgml 1
naltrexone oral tablet 50 mg 1
naproxen oral suspension 125 mg5 ml 1
naproxen oral tablet 250 mg 375 mg 500 mg 1
naproxen oral tabletdelayed release (drec) 375 mg 500 mg
1
naproxen sodium oral tablet 275 mg 550 mg 1
NARCAN NASAL SPRAYNON-AEROSOL 4 MGACTUATION
1
36
Drug Name Drug Tier Requirements Limits
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG 150 MG 200 MG 250 MG 50 MG
1 PA ST QL (60 per 30 days)
ORTHOVISC INTRA-ARTICULAR SYRINGE 30 MG2 ML
MB
oxaprozin oral tablet 600 mg 1
pentazocine-naloxone oral tablet 50-05 mg 1 PA ST
piroxicam oral capsule 10 mg 20 mg 1
salsalate oral tablet 500 mg 750 mg 1
st joseph aspirin oral tabletchewable 81 mg ACA PV
st joseph aspirin oral tabletdelayed release (drec) 81 mg
ACA PV
sulindac oral tablet 150 mg 200 mg 1
tolmetin oral capsule 400 mg 1
tolmetin oral tablet 200 mg 600 mg 1
tramadol oral tablet 50 mg 1 PA ST
tramadol oral tablet extended release 24 hr 100 mg 200 mg 300 mg
1 PA ST
tramadol oral tablet er multiphase 24 hr 100 mg 200 mg 300 mg
1 PA ST
tramadol-acetaminophen oral tablet 375-325 mg 1 PA ST
VIVITROL INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 380 MG
MB
PSYCHOTHERAPEUTIC DRUGS
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 300 MG 400 MG
1
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 300 MG 400 MG
1
ADHANSIA XR ORAL CAPSULE ER BIPHASIC 20-80 25 MG 35 MG 45 MG 55 MG 70 MG 85 MG
1 PA ST
ADZENYS ER ORAL SUSPEN IR - ER BIPHASIC 24HR 125 MGML
1 ST
ADZENYS XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 125 MG 157 MG 188 MG 31 MG 63 MG 94 MG
1 ST
37
Drug Name Drug Tier Requirements Limits
alprazolam intensol oral concentrate 1 mgml 1
alprazolam oral tablet 025 mg 05 mg 1 mg 2 mg
1
alprazolam oral tablet extended release 24 hr 05 mg 1 mg 2 mg 3 mg
1
alprazolam oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg
1
amitriptyline oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
amitriptyline-chlordiazepoxide oral tablet 125-5 mg 25-10 mg
1
amoxapine oral tablet 100 mg 150 mg 25 mg 50 mg
1
AMPHETAMINE ORAL SUSPEN IR - ER BIPHASIC 24HR 125 MGML
1 ST
amphetamine sulfate oral tablet 10 mg 5 mg 1
APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG 348 MG 522 MG
1 ST
aripiprazole oral solution 1 mgml 1
aripiprazole oral tablet 10 mg 15 mg 2 mg 20 mg 30 mg 5 mg
1
aripiprazole oral tabletdisintegrating 10 mg 15 mg
1
ARISTADA INITIO INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 675 MG24 ML
MB
ARISTADA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 1064 MG39 ML 441 MG16 ML 662 MG24 ML 882 MG32 ML
MB
armodafinil oral tablet 150 mg 200 mg 250 mg 50 mg
1
asenapine maleate sublingual tablet 10 mg 25 mg 5 mg
1
atomoxetine oral capsule 10 mg 100 mg 18 mg 25 mg 40 mg 60 mg 80 mg
1
BELSOMRA ORAL TABLET 10 MG 15 MG 20 MG 5 MG
1 ST
bupropion hcl oral tablet 100 mg 75 mg 1
bupropion hcl oral tablet extended release 24 hr 150 mg 300 mg
1
38
Drug Name Drug Tier Requirements Limits
bupropion hcl oral tablet sustained-release 12 hr 100 mg 150 mg 200 mg
1
buspirone oral tablet 10 mg 15 mg 30 mg 5 mg 75 mg
1
chlordiazepoxide hcl oral capsule 10 mg 25 mg 5 mg
1
chlorpromazine injection solution 25 mgml 1
chlorpromazine oral tablet 10 mg 100 mg 200 mg 25 mg 50 mg
1
citalopram oral solution 10 mg5 ml 1
citalopram oral tablet 10 mg 20 mg 40 mg 1
clomipramine oral capsule 25 mg 50 mg 75 mg 1
clonidine hcl oral tablet extended release 12 hr 01 mg
1
clorazepate dipotassium oral tablet 15 mg 375 mg 75 mg
1
clozapine oral tablet 100 mg 200 mg 25 mg 50 mg
1
clozapine oral tabletdisintegrating 100 mg 125 mg 150 mg 200 mg 25 mg
1
COTEMPLA XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 173 MG 259 MG 86 MG
1 ST
DAYTRANA TRANSDERMAL PATCH 24 HOUR 10 MG9 HR 15 MG9 HR 20 MG9 HR 30 MG9 HR
1 ST
desipramine oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG 50 MG
1 ST
desvenlafaxine succinate oral tablet extended release 24 hr 100 mg 25 mg 50 mg
1
dexmethylphenidate oral capsuleer biphasic 50-50 10 mg 15 mg 20 mg 25 mg 30 mg 35 mg 40 mg 5 mg
1
dexmethylphenidate oral tablet 10 mg 25 mg 5 mg
1
dextroamphetamine oral capsule extended release 10 mg 15 mg 5 mg
1
dextroamphetamine oral solution 5 mg5 ml 1
39
Drug Name Drug Tier Requirements Limits
dextroamphetamine oral tablet 10 mg 5 mg 1
dextroamphetamine-amphetamine oral capsuleextended release 24hr 10 mg 15 mg 20 mg 25 mg 30 mg 5 mg
1
dextroamphetamine-amphetamine oral tablet 10 mg 125 mg 15 mg 20 mg 30 mg 5 mg 75 mg
1
diazepam injection solution 5 mgml MB
diazepam injection syringe 5 mgml MB
diazepam intensol oral concentrate 5 mgml 1
diazepam oral solution 5 mg5 ml (1 mgml) 1
diazepam oral tablet 10 mg 2 mg 5 mg 1
doxepin oral capsule 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
doxepin oral concentrate 10 mgml 1
duloxetine oral capsuledelayed release(drec) 20 mg 30 mg 40 mg 60 mg
1
DYANAVEL XR ORAL SUSPEN IR - ER BIPHASIC 24HR 25 MGML
1 ST
EDLUAR SUBLINGUAL TABLET 10 MG 5 MG
1 ST
EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG24 HR 6 MG24 HR 9 MG24 HR
1 ST
ergoloid oral tablet 1 mg 1
escitalopram oxalate oral solution 5 mg5 ml 1
escitalopram oxalate oral tablet 10 mg 20 mg 5 mg
1
estazolam oral tablet 1 mg 2 mg 1
eszopiclone oral tablet 1 mg 2 mg 3 mg 1
FANAPT ORAL TABLET 1 MG 10 MG 12 MG 2 MG 4 MG 6 MG 8 MG
1 PA ST
FANAPT ORAL TABLETSDOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)
1 PA ST
FETZIMA ORAL CAPSULEEXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)
1 ST
FETZIMA ORAL CAPSULEEXTENDED RELEASE 24 HR 120 MG 20 MG 40 MG 80 MG
1 ST
fluoxetine oral capsule 10 mg 20 mg 40 mg 1
40
Drug Name Drug Tier Requirements Limits
fluoxetine oral capsuledelayed release(drec) 90 mg
1
fluoxetine oral solution 20 mg5 ml (4 mgml) 1
fluoxetine oral tablet 10 mg 20 mg 1
fluoxetine oral tablet 60 mg 1 PA
fluphenazine hcl injection solution 25 mgml 1
fluphenazine hcl oral concentrate 5 mgml 1
fluphenazine hcl oral elixir 25 mg5 ml 1
fluphenazine hcl oral tablet 1 mg 10 mg 25 mg 5 mg
1
flurazepam oral capsule 15 mg 30 mg 1
fluvoxamine oral capsuleextended release 24hr 100 mg 150 mg
1
fluvoxamine oral tablet 100 mg 25 mg 50 mg 1
guanfacine oral tablet extended release 24 hr 1 mg 2 mg 3 mg 4 mg
1
haloperidol decanoate intramuscular solution 100 mgml 50 mgml
1
haloperidol lactate injection solution 5 mgml 1
haloperidol lactate oral concentrate 2 mgml 1
haloperidol oral tablet 05 mg 1 mg 10 mg 2 mg 20 mg 5 mg
1
HETLIOZ LQ ORAL SUSPENSION 4 MGML 2 PA ST LA
HETLIOZ ORAL CAPSULE 20 MG 2 PA ST LA
imipramine hcl oral tablet 10 mg 25 mg 50 mg 1
imipramine pamoate oral capsule 100 mg 125 mg 150 mg 75 mg
1
INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG075 ML 156 MGML 234 MG15 ML 39 MG025 ML 78 MG05 ML
1
JORNAY PM ORAL CAPSULEDEL RELEXT REL SPRINK 100 MG 20 MG 40 MG 60 MG 80 MG
1 ST
LATUDA ORAL TABLET 120 MG 20 MG 40 MG 60 MG 80 MG
1 PA ST
lithium carbonate oral capsule 150 mg 300 mg 600 mg
1
lithium carbonate oral tablet 300 mg 1
41
Drug Name Drug Tier Requirements Limits
lithium carbonate oral tablet extended release 300 mg 450 mg
1
lorazepam intensol oral concentrate 2 mgml 1
lorazepam oral concentrate 2 mgml 1
lorazepam oral tablet 05 mg 1 mg 2 mg 1
loxapine succinate oral capsule 10 mg 25 mg 5 mg 50 mg
1
maprotiline oral tablet 25 mg 50 mg 75 mg 1
MARPLAN ORAL TABLET 10 MG 1
methamphetamine oral tablet 5 mg 1
METHYLIN ORAL SOLUTION 10 MG5 ML 5 MG5 ML
1
methylphenidate hcl oral caper sprinklebiphasic 40-60 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg 60 mg
1
methylphenidate hcl oral capsule er biphasic 30-70 10 mg 20 mg 30 mg 40 mg 50 mg 60 mg
1
methylphenidate hcl oral capsuleer biphasic 50-50 10 mg 20 mg 30 mg 40 mg 60 mg
1
methylphenidate hcl oral solution 10 mg5 ml 5 mg5 ml
1
methylphenidate hcl oral tablet 10 mg 20 mg 5 mg
1
methylphenidate hcl oral tablet extended release 10 mg 20 mg
1
methylphenidate hcl oral tablet extended release 24hr 18 mg 27 mg 36 mg 54 mg
1
methylphenidate hcl oral tabletchewable 10 mg 25 mg 5 mg
1
midazolam oral syrup 2 mgml 1
mirtazapine oral tablet 15 mg 30 mg 45 mg 75 mg
1
mirtazapine oral tabletdisintegrating 15 mg 30 mg 45 mg
1
modafinil oral tablet 100 mg 200 mg 1
molindone oral tablet 10 mg 25 mg 5 mg 1
MYDAYIS ORAL CAPSULE ER TRIPHASIC 24 HR 125 MG 25 MG 375 MG 50 MG
1 ST
nefazodone oral tablet 100 mg 150 mg 200 mg 250 mg 50 mg
1
42
Drug Name Drug Tier Requirements Limits
nortriptyline oral capsule 10 mg 25 mg 50 mg 75 mg
1
nortriptyline oral solution 10 mg5 ml 1
NUPLAZID ORAL CAPSULE 34 MG 2 PA LA
NUPLAZID ORAL TABLET 10 MG 2 PA LA
olanzapine intramuscular recon soln 10 mg 1
olanzapine oral tablet 10 mg 15 mg 25 mg 20 mg 5 mg 75 mg
1
olanzapine oral tabletdisintegrating 10 mg 15 mg 20 mg 5 mg
1
olanzapine-fluoxetine oral capsule 12-25 mg 12-50 mg 3-25 mg 6-25 mg 6-50 mg
1
oxazepam oral capsule 10 mg 15 mg 30 mg 1
paliperidone oral tablet extended release 24hr 15 mg 3 mg 6 mg 9 mg
1
paroxetine hcl oral tablet 10 mg 20 mg 30 mg 40 mg
1
paroxetine hcl oral tablet extended release 24 hr 125 mg 25 mg 375 mg
1
paroxetine mesylate(menopsym) oral capsule 75 mg
1
perphenazine oral tablet 16 mg 2 mg 4 mg 8 mg 1
perphenazine-amitriptyline oral tablet 2-10 mg 2-25 mg 4-10 mg 4-25 mg 4-50 mg
1
phenelzine oral tablet 15 mg 1
pimozide oral tablet 1 mg 2 mg 1
procentra oral solution 5 mg5 ml 1
protriptyline oral tablet 10 mg 5 mg 1
quetiapine oral tablet 100 mg 200 mg 25 mg 300 mg 400 mg 50 mg
1
quetiapine oral tablet extended release 24 hr 150 mg 200 mg 300 mg 400 mg 50 mg
1
QUILLICHEW ER ORAL TABLETCHEWIR-ERBIPHASIC24HR 20 MG 30 MG 40 MG
1 ST
QUILLIVANT XR ORAL SUSPENSIONEXT REL 24HRRECON 5 MGML (25 MG5 ML)
1 ST
ramelteon oral tablet 8 mg 1
RELEXXII ORAL TABLET EXTENDED RELEASE 24HR 72 MG
1 ST
43
Drug Name Drug Tier Requirements Limits
REXULTI ORAL TABLET 025 MG 05 MG 1 MG 2 MG 3 MG 4 MG
1 PA ST
RISPERDAL CONSTA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 125 MG2 ML 25 MG2 ML 375 MG2 ML 50 MG2 ML
1
risperidone oral solution 1 mgml 1
risperidone oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg
1
risperidone oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg
1
seconal sodium oral capsule 100 mg 1
sertraline oral concentrate 20 mgml 1
sertraline oral tablet 100 mg 25 mg 50 mg 1
SPRAVATO NASAL SPRAYNON-AEROSOL 56 MG (28 MG X 2) 84 MG (28 MG X 3)
MB PA
SUNOSI ORAL TABLET 150 MG 1 PA QL (30 per 30 days)
SUNOSI ORAL TABLET 75 MG 1 PA QL (60 per 30 days)
temazepam oral capsule 15 mg 225 mg 30 mg 75 mg
1
thioridazine oral tablet 10 mg 100 mg 25 mg 50 mg
1
thiothixene oral capsule 1 mg 10 mg 2 mg 5 mg 1
tranylcypromine oral tablet 10 mg 1
trazodone oral tablet 100 mg 150 mg 300 mg 50 mg
1
triazolam oral tablet 0125 mg 025 mg 1
trifluoperazine oral tablet 1 mg 10 mg 2 mg 5 mg
1
trimipramine oral capsule 100 mg 25 mg 50 mg 1
TRINTELLIX ORAL TABLET 10 MG 20 MG 5 MG
1 ST
venlafaxine oral capsuleextended release 24hr 150 mg 375 mg 75 mg
1
venlafaxine oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg
1
venlafaxine oral tablet extended release 24hr 150 mg 225 mg 375 mg 75 mg
1
VERSACLOZ ORAL SUSPENSION 50 MGML 1 PA ST
44
Drug Name Drug Tier Requirements Limits
VRAYLAR ORAL CAPSULE 15 MG 3 MG 45 MG 6 MG
1 PA ST
VRAYLAR ORAL CAPSULEDOSE PACK 15 MG (1)- 3 MG (6)
1 PA ST
VYVANSE ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG 70 MG
1 PA ST
VYVANSE ORAL TABLETCHEWABLE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG
1 PA ST
XYREM ORAL SOLUTION 500 MGML 1 PA QL (540 per 30 days)
zaleplon oral capsule 10 mg 5 mg 1
ZENZEDI ORAL TABLET 15 MG 25 MG 20 MG 30 MG 75 MG
1 ST
ziprasidone hcl oral capsule 20 mg 40 mg 60 mg 80 mg
1
zolpidem oral tablet 10 mg 5 mg 1
zolpidem oral tabletext release multiphase 125 mg 625 mg
1
zolpidem sublingual tablet 175 mg 35 mg 1
ZOLPIMIST ORAL SPRAYNON-AEROSOL 5 MGSPRAY (01 ML)
1 ST
ZULRESSO INTRAVENOUS SOLUTION 5 MGML
MB
CARDIOVASCULAR HYPERTENSION amp LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone oral tablet 100 mg 200 mg 400 mg 1
disopyramide phosphate oral capsule 100 mg 150 mg
1
dofetilide oral capsule 125 mcg 250 mcg 500 mcg 1
flecainide oral tablet 100 mg 150 mg 50 mg 1
mexiletine oral capsule 150 mg 200 mg 250 mg 1
MULTAQ ORAL TABLET 400 MG 1
NORPACE CR ORAL CAPSULE EXTENDED RELEASE 100 MG 150 MG
1
pacerone oral tablet 100 mg 200 mg 400 mg 1
procainamide injection solution 100 mgml 500 mgml
MB
propafenone oral capsuleextended release 12 hr 225 mg 325 mg 425 mg
1
45
Drug Name Drug Tier Requirements Limits
propafenone oral tablet 150 mg 225 mg 300 mg 1
quinidine gluconate oral tablet extended release 324 mg
1
quinidine sulfate oral tablet 200 mg 300 mg 1
sorine oral tablet 120 mg 160 mg 240 mg 80 mg 1
sotalol af oral tablet 120 mg 160 mg 80 mg 1
sotalol oral tablet 120 mg 160 mg 240 mg 80 mg 1
ANTIHYPERTENSIVE THERAPY
acebutolol oral capsule 200 mg 400 mg 1
aliskiren oral tablet 150 mg 300 mg 1
amiloride oral tablet 5 mg 1
amiloride-hydrochlorothiazide oral tablet 5-50 mg 1
amlodipine oral tablet 10 mg 25 mg 5 mg 1
amlodipine-benazepril oral capsule 10-20 mg 10-40 mg 25-10 mg 5-10 mg 5-20 mg 5-40 mg
1 ST
amlodipine-olmesartan oral tablet 10-20 mg 10-40 mg 5-20 mg 5-40 mg
1 ST
amlodipine-valsartan oral tablet 10-160 mg 10-320 mg 5-160 mg 5-320 mg
1 ST
amlodipine-valsartan-hcthiazid oral tablet 10-160-125 mg 10-160-25 mg 10-320-25 mg 5-160-125 mg 5-160-25 mg
1
atenolol oral tablet 100 mg 25 mg 50 mg 1
atenolol-chlorthalidone oral tablet 100-25 mg 50-25 mg
1
benazepril oral tablet 10 mg 20 mg 40 mg 5 mg 1
benazepril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg 5-625 mg
1
betaxolol oral tablet 10 mg 20 mg 1
bisoprolol fumarate oral tablet 10 mg 5 mg 1
bisoprolol-hydrochlorothiazide oral tablet 10-625 mg 25-625 mg 5-625 mg
1
bumetanide injection solution 025 mgml 1
bumetanide oral tablet 05 mg 1 mg 2 mg 1
BYSTOLIC ORAL TABLET 10 MG 25 MG 20 MG 5 MG
1 ST
candesartan oral tablet 16 mg 32 mg 4 mg 8 mg 1
46
Drug Name Drug Tier Requirements Limits
candesartan-hydrochlorothiazid oral tablet 16-125 mg 32-125 mg 32-25 mg
1
captopril oral tablet 100 mg 125 mg 25 mg 50 mg
1
captopril-hydrochlorothiazide oral tablet 25-15 mg 25-25 mg 50-15 mg 50-25 mg
1
cartia xt oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg
1
carvedilol oral tablet 125 mg 25 mg 3125 mg 625 mg
1
carvedilol phosphate oral capsule er multiphase 24 hr 10 mg 20 mg 40 mg 80 mg
1
chlorthalidone oral tablet 25 mg 50 mg 1
clonidine hcl oral tablet 01 mg 02 mg 03 mg 1
clonidine transdermal patch weekly 01 mg24 hr 02 mg24 hr 03 mg24 hr
1
diltiazem hcl oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg
1
diltiazem hcl oral capsuleextended release 12 hr 120 mg 60 mg 90 mg
1
diltiazem hcl oral capsuleextended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
diltiazem hcl oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg 360 mg
1
diltiazem hcl oral tablet 120 mg 30 mg 60 mg 90 mg
1
diltiazem hcl oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
dilt-xr oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg
1
doxazosin oral tablet 1 mg 2 mg 4 mg 8 mg 1
EDARBI ORAL TABLET 40 MG 80 MG 1 ST
EDARBYCLOR ORAL TABLET 40-125 MG 40-25 MG
1 ST
enalapril maleate oral tablet 10 mg 25 mg 20 mg 5 mg
1
enalaprilat intravenous solution 125 mgml MB
enalapril-hydrochlorothiazide oral tablet 10-25 mg 5-125 mg
1
EPANED ORAL SOLUTION 1 MGML 1
47
Drug Name Drug Tier Requirements Limits
eplerenone oral tablet 25 mg 50 mg 1
epoprostenol (glycine) intravenous recon soln 05 mg 15 mg
MB PA LA
eprosartan oral tablet 600 mg 1
ethacrynic acid oral tablet 25 mg 1
felodipine oral tablet extended release 24 hr 10 mg 25 mg 5 mg
1
FLOLAN INTRAVENOUS RECON SOLN 05 MG 15 MG
MB PA LA
fosinopril oral tablet 10 mg 20 mg 40 mg 1
fosinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg
1
furosemide oral solution 10 mgml 40 mg5 ml (8 mgml)
1
furosemide oral tablet 20 mg 40 mg 80 mg 1
guanfacine oral tablet 1 mg 2 mg 1
hydralazine oral tablet 10 mg 100 mg 25 mg 50 mg
1
hydrochlorothiazide oral capsule 125 mg 1
hydrochlorothiazide oral tablet 125 mg 25 mg 50 mg
1
indapamide oral tablet 125 mg 25 mg 1
irbesartan oral tablet 150 mg 300 mg 75 mg 1
irbesartan-hydrochlorothiazide oral tablet 150-125 mg 300-125 mg
1
isradipine oral capsule 25 mg 5 mg 1
labetalol oral tablet 100 mg 200 mg 300 mg 1
lisinopril oral tablet 10 mg 25 mg 20 mg 30 mg 40 mg 5 mg
1
lisinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg
1
losartan oral tablet 100 mg 25 mg 50 mg 1
losartan-hydrochlorothiazide oral tablet 100-125 mg 100-25 mg 50-125 mg
1
matzim la oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
methyldopa oral tablet 250 mg 500 mg 1
methyldopa-hydrochlorothiazide oral tablet 250-15 mg 250-25 mg
1
48
Drug Name Drug Tier Requirements Limits
methyldopate intravenous solution 250 mg5 ml MB
metolazone oral tablet 10 mg 25 mg 5 mg 1
metoprolol succinate oral tablet extended release 24 hr 100 mg 200 mg 25 mg 50 mg
1
metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg 100-50 mg 50-25 mg
1
metoprolol tartrate oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg
1
metyrosine oral capsule 250 mg 1
minoxidil oral tablet 10 mg 25 mg 1
moexipril oral tablet 15 mg 75 mg 1
nadolol oral tablet 20 mg 40 mg 80 mg 1
nadolol-bendroflumethiazide oral tablet 80-5 mg 1
nicardipine oral capsule 20 mg 30 mg 1
nifedipine oral capsule 10 mg 20 mg 1
nifedipine oral tablet extended release 24hr 30 mg 60 mg 90 mg
1
nifedipine oral tablet extended release 30 mg 60 mg 90 mg
1
nimodipine oral capsule 30 mg 1
nisoldipine oral tablet extended release 24 hr 17 mg 20 mg 255 mg 30 mg 34 mg 40 mg 85 mg
1
olmesartan oral tablet 20 mg 40 mg 5 mg 1
olmesartan-amlodipin-hcthiazid oral tablet 20-5-125 mg 40-10-125 mg 40-10-25 mg 40-5-125 mg 40-5-25 mg
1
olmesartan-hydrochlorothiazide oral tablet 20-125 mg 40-125 mg 40-25 mg
1 ST
ORENITRAM ORAL TABLET EXTENDED RELEASE 0125 MG 025 MG 1 MG 25 MG 5 MG
2 PA LA
perindopril erbumine oral tablet 2 mg 4 mg 8 mg 1
phenoxybenzamine oral capsule 10 mg 1
pindolol oral tablet 10 mg 5 mg 1
prazosin oral capsule 1 mg 2 mg 5 mg 1
propranolol oral capsuleextended release 24 hr 120 mg 160 mg 60 mg 80 mg
1
propranolol oral solution 20 mg5 ml (4 mgml) 40 mg5 ml (8 mgml)
1
49
Drug Name Drug Tier Requirements Limits
propranolol oral tablet 10 mg 20 mg 40 mg 60 mg 80 mg
1
propranolol-hydrochlorothiazid oral tablet 40-25 mg 80-25 mg
1
QBRELIS ORAL SOLUTION 1 MGML 1
quinapril oral tablet 10 mg 20 mg 40 mg 5 mg 1
quinapril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg
1
ramipril oral capsule 125 mg 10 mg 25 mg 5 mg
1
spironolactone oral tablet 100 mg 25 mg 50 mg 1
spironolacton-hydrochlorothiaz oral tablet 25-25 mg
1
taztia xt oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg
1
TEKTURNA HCT ORAL TABLET 150-125 MG 150-25 MG 300-125 MG 300-25 MG
1
telmisartan oral tablet 20 mg 40 mg 80 mg 1
telmisartan-amlodipine oral tablet 40-10 mg 40-5 mg 80-10 mg 80-5 mg
1 ST
telmisartan-hydrochlorothiazid oral tablet 40-125 mg 80-125 mg 80-25 mg
1
terazosin oral capsule 1 mg 10 mg 2 mg 5 mg 1
tiadylt er oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg 420 mg
1
timolol maleate oral tablet 10 mg 20 mg 5 mg 1
torsemide oral tablet 10 mg 100 mg 20 mg 5 mg 1
trandolapril oral tablet 1 mg 2 mg 4 mg 1
trandolapril-verapamil oral tablet ir - er biphasic 24hr 1-240 mg 2-180 mg 2-240 mg 4-240 mg
1 ST
triamterene oral capsule 100 mg 50 mg 1
triamterene-hydrochlorothiazid oral capsule 375-25 mg
1
triamterene-hydrochlorothiazid oral tablet 375-25 mg 75-50 mg
1
valsartan oral tablet 160 mg 320 mg 40 mg 80 mg
1
valsartan-hydrochlorothiazide oral tablet 160-125 mg 160-25 mg 320-125 mg 320-25 mg 80-125 mg
1
50
Drug Name Drug Tier Requirements Limits
veletri intravenous recon soln 05 mg 15 mg MB PA LA
verapamil oral capsule 24 hr er pellet ct 100 mg 200 mg 300 mg
1
verapamil oral capsuleext rel pellets 24 hr 120 mg 180 mg 240 mg 360 mg
1
verapamil oral tablet 120 mg 40 mg 80 mg 1
verapamil oral tablet extended release 120 mg 180 mg 240 mg
1
CARDIAC GLYCOSIDES
digitek oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
digox oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
digoxin oral solution 50 mcgml (005 mgml) 1
digoxin oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
COAGULATION THERAPY
ADVATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 4000 (+-) UNIT 500 (+-) UNIT
MB
ADYNOVATE INTRAVENOUS SOLUTION 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT 750 (+-) UNIT
MB LA
AFSTYLA INTRAVENOUS RECON SOLN 1000 (+-) UNIT RANGE 1500 (+-) UNIT RANGE 2000 (+-) UNIT RANGE 2500 (+-) UNIT RANGE 250 (+-) UNIT RANGE 3000 (+-) UNIT RANGE 500 (+-) UNIT RANGE
MB LA
ALPHANATE INTRAVENOUS RECON SOLN 1000 (400 VWF) UNIT10 ML 1500 (600 VWF) UNIT10 ML 2000 (800 VWF) UNIT10 ML 250 (100 VWF) UNIT5 ML 500 (200 VWF) UNIT5 ML
MB LA
ALPHANINE SD INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT
MB LA
ALPROLIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 500 UNIT
MB LA
aminocaproic acid oral solution 250 mgml (25 ) 1
51
Drug Name Drug Tier Requirements Limits
aminocaproic acid oral tablet 1000 mg 500 mg 1
ANDEXXA INTRAVENOUS RECON SOLN 200 MG
MB
aspirin-dipyridamole oral capsule er multiphase 12 hr 25-200 mg
1
BENEFIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
BRILINTA ORAL TABLET 60 MG 90 MG 1
CABLIVI INJECTION KIT 11 MG 2 PA
cilostazol oral tablet 100 mg 50 mg 1
clopidogrel oral tablet 300 mg 75 mg 1
COAGADEX INTRAVENOUS RECON SOLN 250 (+-) UNIT RANGE 500 (+-) UNIT RANGE
MB
CORIFACT INTRAVENOUS RECON SOLN 1000-1600 UNIT
MB LA
dipyridamole oral tablet 25 mg 50 mg 75 mg 1
DOPTELET (15 TAB PACK) ORAL TABLET 20 MG
2 PA LA
ELIQUIS DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 5 MG (74 TABS)
1
ELIQUIS ORAL TABLET 25 MG 5 MG 1
ELOCTATE INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 5000 UNIT 500 UNIT 6000 UNIT 750 UNIT
MB LA
enoxaparin subcutaneous solution 300 mg3 ml 2
enoxaparin subcutaneous syringe 100 mgml 120 mg08 ml 150 mgml 30 mg03 ml 40 mg04 ml 60 mg06 ml 80 mg08 ml
2
ESPEROCT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
FEIBA NF INTRAVENOUS RECON SOLN 1750-3250 UNIT 350-650 UNIT 700-1300 UNIT
MB LA
FIBRYGA INTRAVENOUS RECON SOLN 1 GRAM (700 MG- 1300 MG)
MB
fondaparinux subcutaneous syringe 10 mg08 ml 25 mg05 ml 5 mg04 ml 75 mg06 ml
2
52
Drug Name Drug Tier Requirements Limits
FRAGMIN SUBCUTANEOUS SOLUTION 25000 ANTI-XA UNITML
2
FRAGMIN SUBCUTANEOUS SYRINGE 10000 ANTI-XA UNITML 12500 ANTI-XA UNIT05 ML 15000 ANTI-XA UNIT06 ML 18000 ANTI-XA UNIT072 ML 2500 ANTI-XA UNIT02 ML 5000 ANTI-XA UNIT02 ML 7500 ANTI-XA UNIT03 ML
2
HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG07 ML 150 MGML 30 MGML 60 MG04 ML
2 PA LA
HEMOFIL M HIGH INTRAVENOUS RECON SOLN 801-1500 UNIT
MB
HEMOFIL M LOW INTRAVENOUS RECON SOLN 220-400 UNIT
MB
HEMOFIL M MID INTRAVENOUS RECON SOLN 401-800 UNIT
MB
HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 1501-2000 UNIT
MB
hep flush-10 (pf) intravenous solution 10 unitml MB
heparin (porcine) in 5 dex intravenous parenteral solution 25000 unit250 ml(100 unitml) 25000 unit500 ml (50 unitml)
MB
heparin (porcine) injection cartridge 5000 unitml (1 ml)
1
heparin (porcine) injection solution 1000 unitml 10000 unitml 20000 unitml 5000 unitml
1
heparin lock flush (porcine) intravenous solution 100 unitml
MB
heparin lockflush(porcine)(pf) intravenous syringe 100 unitml
MB
HEPARIN(PORCINE) IN 045 NACL INTRAVENOUS PARENTERAL SOLUTION 12500 UNIT250 ML
MB
heparin(porcine) in 045 nacl intravenous parenteral solution 25000 unit250 ml 25000 unit500 ml
MB
heparin porcine (pf) injection solution 1000 unitml 5000 unit05 ml
MB
heparin porcine (pf) injection syringe 5000 unit05 ml
1
53
Drug Name Drug Tier Requirements Limits
heparin porcine (pf) intravenous solution 100 unitml (1 ml)
MB
heparin porcine (pf) intravenous syringe 10 unitml 100 unitml
MB
HUMATE-P INTRAVENOUS RECON SOLN 1000-2400 UNIT 250-600 UNIT 500-1200 UNIT
MB LA
IDELVION INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3500 (+-) UNIT 500 (+-) UNIT
MB LA
IXINITY INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
jantoven oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg
1
JIVI INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
KOATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB
KOGENATE FS INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB
KOVALTRY INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB
MONONINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT
MB LA
MULPLETA ORAL TABLET 3 MG 2 PA LA
NOVOEIGHT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
NOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1000 MCG) 2 MG (2000 MCG) 5 MG (5000 MCG) 8 MG (8000 MCG)
MB LA
NPLATE SUBCUTANEOUS RECON SOLN 125 MCG 250 MCG 500 MCG
MB LA
NUWIQ INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 2500 UNIT 250 (+-) UNIT 3000 UNIT 4000 UNIT 500 (+-) UNIT
MB LA
54
Drug Name Drug Tier Requirements Limits
OBIZUR INTRAVENOUS RECON SOLN 500 (+-) UNIT RANGE
MB
pentoxifylline oral tablet extended release 400 mg 1
phytonadione (vitamin k1) oral tablet 5 mg 1
prasugrel oral tablet 10 mg 5 mg 1
PROFILNINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT
MB LA
PROMACTA ORAL POWDER IN PACKET 125 MG
2 PA ST LA
PROMACTA ORAL POWDER IN PACKET 25 MG
2 LA
PROMACTA ORAL TABLET 125 MG 25 MG 50 MG 75 MG
2 PA ST LA
REBINYN INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 500 (+-) UNIT
MB LA
RECOMBINATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB LA
RIASTAP INTRAVENOUS RECON SOLN 1 GRAM (900MG-1300MG)
MB LA
RIXUBIS INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
tranexamic acid intravenous solution 1000 mg10 ml (100 mgml)
MB
TRETTEN INTRAVENOUS RECON SOLN 2500 UNIT
MB LA
VONVENDI INTRAVENOUS RECON SOLN 1300 (+-) UNIT RANGE 650 (+-) UNIT RANGE
MB LA
warfarin oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg
1
WILATE INTRAVENOUS RECON SOLN 1000-1000 UNIT 500-500 UNIT
MB LA
XARELTO DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 15 MG (42)- 20 MG (9)
1
XARELTO ORAL TABLET 10 MG 15 MG 25 MG 20 MG
1
55
Drug Name Drug Tier Requirements Limits
XYNTHA INTRAVENOUS SOLUTION 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB LA
XYNTHA SOLOFUSE INTRAVENOUS SYRINGE 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
ZONTIVITY ORAL TABLET 208 MG 1
LIPIDCHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg 25-10 mg 25-20 mg 25-40 mg 5-10 mg 5-20 mg 5-40 mg 5-80 mg
1 ST
atorvastatin oral tablet 10 mg 20 mg ACA PV
atorvastatin oral tablet 40 mg 80 mg 1
cholestyramine (with sugar) oral powder 4 gram 1
cholestyramine (with sugar) oral powder in packet 4 gram
1
cholestyramine light oral powder 4 gram 1
cholestyramine light oral powder in packet 4 gram 1
colesevelam oral powder in packet 375 gram 1
colesevelam oral tablet 625 mg 1
colestipol oral granules 5 gram 1
colestipol oral packet 5 gram 1
colestipol oral tablet 1 gram 1
ezetimibe oral tablet 10 mg 1
ezetimibe-simvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg
1
fenofibrate micronized oral capsule 130 mg 134 mg 200 mg 43 mg 67 mg
1
fenofibrate nanocrystallized oral tablet 145 mg 48 mg
1
FENOFIBRATE ORAL CAPSULE 150 MG 50 MG
1
fenofibrate oral tablet 120 mg 160 mg 40 mg 54 mg
1
fenofibric acid (choline) oral capsuledelayed release(drec) 135 mg 45 mg
1
fenofibric acid oral tablet 105 mg 35 mg 1
fluvastatin oral capsule 20 mg 40 mg ACA PV
56
Drug Name Drug Tier Requirements Limits
fluvastatin oral tablet extended release 24 hr 80 mg
ACA PV
gemfibrozil oral tablet 600 mg 1
icosapent ethyl oral capsule 1 gram 1 PA ST QL (120 per 30 days)
JUXTAPID ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 5 MG 60 MG
2 PA LA QL (30 per 30 days)
LIPOFEN ORAL CAPSULE 150 MG 50 MG 1
lovastatin oral tablet 10 mg 20 mg 40 mg ACA PV
niacin oral tablet 500 mg 1
niacin oral tablet extended release 24 hr 1000 mg 500 mg 750 mg
1
NIACOR ORAL TABLET 500 MG 1
omega-3 acid ethyl esters oral capsule 1 gram 1
pravastatin oral tablet 10 mg 20 mg 40 mg 80 mg
ACA PV
prevalite oral powder 4 gram 1
prevalite oral powder in packet 4 gram 1
REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG35 ML
1 PA ST
REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MGML
1 PA ST
REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MGML
1 PA ST
rosuvastatin oral tablet 10 mg 5 mg ACA PV
rosuvastatin oral tablet 20 mg 40 mg 1
simvastatin oral tablet 10 mg 20 mg 40 mg 5 mg ACA PV
simvastatin oral tablet 80 mg 1
VASCEPA ORAL CAPSULE 05 GRAM 1 GRAM
1 PA ST QL (120 per 30 days)
ZYPITAMAG ORAL TABLET 2 MG 4 MG 1 PA ST
MISCELLANEOUS CARDIOVASCULAR AGENTS
CORLANOR ORAL SOLUTION 5 MG5 ML 1 PA
CORLANOR ORAL TABLET 5 MG 75 MG 1 PA
ENTRESTO ORAL TABLET 24-26 MG 49-51 MG 97-103 MG
1 PA ST
GIAPREZA INTRAVENOUS SOLUTION 25 MGML
MB
57
Drug Name Drug Tier Requirements Limits
ranolazine oral tablet extended release 12 hr 1000 mg 500 mg
1 ST
NITRATES
GONITRO SUBLINGUAL POWDER IN PACKET 400 MCG
1
isosorbide dinitrate oral tablet 10 mg 20 mg 30 mg 40 mg 5 mg
1
isosorbide mononitrate oral tablet 10 mg 20 mg 1
isosorbide mononitrate oral tablet extended release 24 hr 120 mg 30 mg 60 mg
1
MINITRAN TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 04 MGHR 06 MGHR
1 PA ST
nitro-bid transdermal ointment 2 1
NITRO-DUR TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 03 MGHR 04 MGHR 06 MGHR 08 MGHR
1 PA ST
nitroglycerin in 5 dextrose intravenous solution 25 mg250 ml (100 mcgml) 50 mg500 ml (100 mcgml)
MB
nitroglycerin sublingual tablet 03 mg 04 mg 06 mg
1
nitroglycerin transdermal patch 24 hour 01 mghr 02 mghr 04 mghr 06 mghr
1
nitroglycerin translingual spraynon-aerosol 400 mcgspray
1
nitro-time oral capsule extended release 25 mg 65 mg 9 mg
1
DERMATOLOGICALSTOPICAL THERAPY
ANTIPSORIATIC ANTISEBORRHEIC
acitretin oral capsule 10 mg 175 mg 25 mg 1
calcipotriene scalp solution 0005 1
calcipotriene topical cream 0005 1
calcipotriene topical ointment 0005 1
calcipotriene-betamethasone topical ointment 0005-0064
1
calcitriol topical ointment 3 mcggram 1
COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
58
Drug Name Drug Tier Requirements Limits
COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
COSENTYX SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
COSENTYX SUBCUTANEOUS SYRINGE 75 MG05 ML
2 PA LA
hydrocortisone-pramoxine topical cream 25-1 1
ILUMYA SUBCUTANEOUS SYRINGE 100 MGML
2 PA ST LA
selenium sulfide topical lotion 25 1
selenium sulfide topical shampoo 225 23 1
SILIQ SUBCUTANEOUS SYRINGE 210 MG15 ML
2 PA ST LA
SKYRIZI SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
SKYRIZI SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
SKYRIZI SUBCUTANEOUS SYRINGE KIT 150MG166ML(75 MG083 ML X2)
2 PA ST LA
STELARA INTRAVENOUS SOLUTION 130 MG26 ML
MB PA LA
STELARA SUBCUTANEOUS SOLUTION 45 MG05 ML
2 PA ST LA
STELARA SUBCUTANEOUS SYRINGE 45 MG05 ML 90 MGML
2 PA ST LA
sulfacetamide sodium topical cleanser 10 1
sulfacetamide sodium topical cleanser gel 10 1
sulfacetamide sodium topical shampoo 10 1
TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MGML
2 PA ST LA
59
Drug Name Drug Tier Requirements Limits
TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 MGML
2 PA ST LA
TREMFYA SUBCUTANEOUS SYRINGE 100 MGML
2 PA ST LA
BURN THERAPY
silver sulfadiazine topical cream 1 1
ssd topical cream 1 1
MISCELLANEOUS DERMATOLOGICALS
ammonium lactate topical cream 12 1
ammonium lactate topical lotion 12 1
diclofenac sodium topical gel 3 1
DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300 MG2 ML
2 LA
DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG114 ML 300 MG2 ML
2 PA ST LA
EUCRISA TOPICAL OINTMENT 2 1 PA ST
FLUOROURACIL TOPICAL CREAM 05 1 PA ST
fluorouracil topical cream 5 1 PA ST
fluorouracil topical solution 2 5 1
LEVULAN TOPICAL SOLUTION 20 1
methoxsalen oral capsuleliqd-filledrapid rel 10 mg
1
PANRETIN TOPICAL GEL 01 1
PICATO TOPICAL GEL 0015 005 1
pimecrolimus topical cream 1 1
podofilox topical solution 05 1
prudoxin topical cream 5 1
REGRANEX TOPICAL GEL 001 1
SCENESSE SUBCUTANEOUS IMPLANT 16 MG
MB PA
tacrolimus topical ointment 003 01 1
UVADEX INJECTION SOLUTION 20 MCGML 1
VALCHLOR TOPICAL GEL 0016 2 PA ST LA
THERAPY FOR ACNE
accutane oral capsule 20 mg 30 mg 40 mg 1
adapalene topical cream 01 1 ST
60
Drug Name Drug Tier Requirements Limits
adapalene topical gel 03 1 ST
adapalene topical gel with pump 03 1 ST
ADAPALENE TOPICAL LOTION 01 1 ST
adapalene topical solution 01 1 ST
adapalene topical swab 01 1 ST
adapalene-benzoyl peroxide topical gel with pump 01-25
1
amnesteem oral capsule 10 mg 20 mg 40 mg 1 PA ST
avita topical cream 0025 1
AVITA TOPICAL GEL 0025 1 ST
azelaic acid topical gel 15 1
AZELEX TOPICAL CREAM 20 1 ST
claravis oral capsule 10 mg 20 mg 30 mg 1 PA ST
claravis oral capsule 40 mg 1
clindacin p topical swab 1 1
clindamycin phosphate topical foam 1 1
clindamycin phosphate topical gel 1 1
clindamycin phosphate topical lotion 1 1
clindamycin phosphate topical solution 1 1
clindamycin phosphate topical swab 1 1
clindamycin-benzoyl peroxide topical gel 1-5 12 (1 base) -5
1
clindamycin-benzoyl peroxide topical gel with pump 1-5
1
clindamycin-tretinoin topical gel 12-0025 1
dapsone topical gel 5 1
ery pads topical swab 2 1
erygel topical gel 2 1
erythromycin with ethanol topical gel 2 1
erythromycin with ethanol topical solution 2 1
erythromycin-benzoyl peroxide topical gel 3-5 1
isotretinoin oral capsule 10 mg 20 mg 25 mg 30 mg 35 mg 40 mg
1
metronidazole topical cream 075 1
metronidazole topical gel 075 1 1
metronidazole topical gel with pump 1 1
61
Drug Name Drug Tier Requirements Limits
metronidazole topical lotion 075 1
myorisan oral capsule 10 mg 20 mg 30 mg 40 mg
1
rosadan topical cream 075 1
rosadan topical gel 075 1
tazarotene topical cream 01 1 ST
tretinoin microspheres topical gel 004 01 1
tretinoin microspheres topical gel with pump 004 01
1
tretinoin topical cream 0025 005 01 1
tretinoin topical gel 001 0025 005 1
zenatane oral capsule 10 mg 20 mg 30 mg 40 mg 1
TOPICAL ANESTHETICS
lidocaine hcl injection solution 10 mgml (1 ) 1
lidocaine hcl laryngotracheal solution 4 1
lidocaine hcl mucous membrane jelly 2 1
lidocaine hcl mucous membrane jelly in applicator 2
1
lidocaine hcl mucous membrane solution 4 (40 mgml)
1
lidocaine hcl-hydrocortison ac topical cream 3-05
1
lidocaine topical adhesive patchmedicated 5 1
lidocaine topical ointment 5 1
lidocaine viscous mucous membrane solution 2 1
lidocaine-prilocaine topical cream 25-25 1
lidocaine-prilocaine topical kit 25-25 1
LIDOCAINE-TETRACAINE TOPICAL CREAM 7-7
1 ST
SYNERA TOPICAL PATCH MEDICATED SELF-HEATING 70-70 MG
1 ST
TOPICAL ANTIBACTERIALS
ALCORTIN A TOPICAL GEL 2-1-1 1 ST
ALCORTIN A TOPICAL GEL IN PACKET 2-1-1
1 ST
ALTABAX TOPICAL OINTMENT 1 1
gentamicin topical cream 01 1
62
Drug Name Drug Tier Requirements Limits
gentamicin topical ointment 01 1
mafenide acetate topical packet 50 gram 1
mupirocin calcium topical cream 2 1
mupirocin topical ointment 2 1
sulfacetamide sodium (acne) topical suspension 10
1
SULFAMYLON TOPICAL CREAM 85 MGG 1
TOPICAL ANTIFUNGALS
ciclodan topical cream 077 1
ciclodan topical solution 8 1
ciclopirox topical cream 077 1
ciclopirox topical gel 077 1
ciclopirox topical shampoo 1 1
ciclopirox topical solution 8 1
ciclopirox topical suspension 077 1
ciclopirox-ure-camph-menth-euc topical solution 8
1
clotrimazole topical cream 1 1
clotrimazole topical solution 1 1
clotrimazole-betamethasone topical cream 1-005
1
clotrimazole-betamethasone topical lotion 1-005
1
econazole topical cream 1 1
EXELDERM TOPICAL CREAM 1 1
EXELDERM TOPICAL SOLUTION 1 1
JUBLIA TOPICAL SOLUTION WITH APPLICATOR 10
1 PA ST
ketoconazole topical cream 2 1
ketoconazole topical foam 2 1
ketoconazole topical shampoo 2 1
ketodan topical foam 2 1
LULICONAZOLE TOPICAL CREAM 1 1
LUZU TOPICAL CREAM 1 1
MENTAX TOPICAL CREAM 1 1
naftifine topical cream 1 2 1
63
Drug Name Drug Tier Requirements Limits
naftifine topical gel 1 1
nyamyc topical powder 100000 unitgram 1
nystatin topical cream 100000 unitgram 1
nystatin topical ointment 100000 unitgram 1
nystatin topical powder 100000 unitgram 1
nystatin-triamcinolone topical cream 100000-01 unitg-
1
nystatin-triamcinolone topical ointment 100000-01 unitgram-
1
nystop topical powder 100000 unitgram 1
oxiconazole topical cream 1 1
OXISTAT TOPICAL LOTION 1 1
tavaborole topical solution with applicator 5 1 PA ST
TOPICAL ANTIVIRALS
acyclovir topical cream 5 1
acyclovir topical ointment 5 1
DENAVIR TOPICAL CREAM 1 1
TOPICAL CORTICOSTEROIDS
ala-cort topical cream 1 1
alclometasone topical cream 005 1
alclometasone topical ointment 005 1
amcinonide topical cream 01 1
amcinonide topical lotion 01 1
apexicon e topical cream 005 1
beser topical lotion 005 1
betamethasone dipropionate topical cream 005 1
betamethasone dipropionate topical lotion 005 1
betamethasone dipropionate topical ointment 005
1
betamethasone valerate topical cream 01 1
betamethasone valerate topical foam 012 1
betamethasone valerate topical lotion 01 1
betamethasone valerate topical ointment 01 1
betamethasone augmented topical cream 005 1
betamethasone augmented topical gel 005 1
betamethasone augmented topical lotion 005 1
64
Drug Name Drug Tier Requirements Limits
betamethasone augmented topical ointment 005
1
clobetasol scalp solution 005 1
clobetasol topical cream 005 1
clobetasol topical foam 005 1
clobetasol topical gel 005 1
clobetasol topical lotion 005 1
clobetasol topical ointment 005 1
clobetasol topical shampoo 005 1
clobetasol topical spraynon-aerosol 005 1
clobetasol-emollient topical cream 005 1
clobetasol-emollient topical foam 005 1
CLOCORTOLONE PIVALATE TOPICAL CREAM 01
1 ST
CLODERM TOPICAL CREAM 01 1 ST
desonide topical cream 005 1
desonide topical lotion 005 1
desonide topical ointment 005 1
desoximetasone topical cream 005 025 1
desoximetasone topical gel 005 1
desoximetasone topical ointment 005 025 1
desoximetasone topical spraynon-aerosol 025 1
diflorasone topical cream 005 1
diflorasone topical ointment 005 1
fluocinolone and shower cap scalp oil 001 1
fluocinolone topical cream 001 0025 1
fluocinolone topical oil 001 1
fluocinolone topical ointment 0025 1
fluocinolone topical solution 001 1
fluocinonide topical cream 005 01 1
fluocinonide topical gel 005 1
fluocinonide topical ointment 005 1
fluocinonide topical solution 005 1
fluocinonide-e topical cream 005 1
flurandrenolide topical cream 005 1
65
Drug Name Drug Tier Requirements Limits
flurandrenolide topical lotion 005 1
flurandrenolide topical ointment 005 1
fluticasone propionate topical cream 005 1
fluticasone propionate topical lotion 005 1
fluticasone propionate topical ointment 0005 1
halcinonide topical cream 01 1
halobetasol propionate topical cream 005 1
halobetasol propionate topical ointment 005 1
hydrocortisone butyrate topical cream 01 1
hydrocortisone butyrate topical lotion 01 1
hydrocortisone butyrate topical ointment 01 1
hydrocortisone butyrate topical solution 01 1
hydrocortisone butyr-emollient topical cream 01
1
hydrocortisone topical cream 1 25 1
hydrocortisone topical lotion 25 1
hydrocortisone topical ointment 1 25 1
hydrocortisone valerate topical cream 02 1
hydrocortisone valerate topical ointment 02 1
mometasone topical cream 01 1
mometasone topical ointment 01 1
mometasone topical solution 01 1
prednicarbate topical cream 01 1
prednicarbate topical ointment 01 1
scalacort topical lotion 2 1
triamcinolone acetonide topical aerosol 0147 mggram
1
triamcinolone acetonide topical cream 0025 01 05
1
triamcinolone acetonide topical lotion 0025 01
1
triamcinolone acetonide topical ointment 0025 005 01 05
1
triderm topical cream 01 05 1
TOPICAL ENZYMES
SANTYL TOPICAL OINTMENT 250 UNITGRAM
1 QL (2 per 30 days)
66
Drug Name Drug Tier Requirements Limits
TOPICAL SCABICIDES PEDICULICIDES
crotan topical lotion 10 1
EURAX TOPICAL CREAM 10 1
EURAX TOPICAL LOTION 10 1
ivermectin topical lotion 05 1
lindane topical shampoo 1 1
malathion topical lotion 05 1
permethrin topical cream 5 1
spinosad topical suspension 09 1
ULESFIA TOPICAL LOTION 5 1
DIAGNOSTICS amp MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
PHYSIOLYTE IRRIGATION SOLUTION 140-5-3-98 MEQL
MB
PHYSIOSOL IRRIGATION IRRIGATION SOLUTION 140-5-3-98 MEQL
MB
MISCELLANEOUS AGENTS
acamprosate oral tabletdelayed release (drec) 333 mg
1
acetic acid irrigation solution 025 1
anagrelide oral capsule 05 mg 1 mg 1
ARALAST NP INTRAVENOUS RECON SOLN 1000 MG 500 MG
MB LA
CARBAGLU ORAL TABLET DISPERSIBLE 200 MG
2 PA LA
cevimeline oral capsule 30 mg 1
CHEMET ORAL CAPSULE 100 MG 1
clovique oral capsule 250 mg 1 PA QL (240 per 30 days)
deferasirox oral granules in packet 180 mg 360 mg 90 mg
2 PA LA
deferasirox oral tablet 180 mg 2 PA LA
deferasirox oral tablet 360 mg 90 mg 2 ST LA
deferasirox oral tablet dispersible 125 mg 250 mg 500 mg
2 ST LA
deferiprone oral tablet 500 mg 1 PA
disulfiram oral tablet 250 mg 500 mg 1
67
Drug Name Drug Tier Requirements Limits
EMPAVELI SUBCUTANEOUS SOLUTION 1080 MG20 ML
2 PA
FERRIPROX ORAL SOLUTION 100 MGML 1 PA
FERRIPROX ORAL TABLET 1000 MG 500 MG
1 PA
GIVLAARI SUBCUTANEOUS SOLUTION 189 MGML
MB PA LA
GLASSIA INTRAVENOUS SOLUTION 1 GRAM50 ML (2 )
MB LA
INCRELEX SUBCUTANEOUS SOLUTION 10 MGML
2 PA LA
levocarnitine (with sugar) oral solution 100 mgml 1
levocarnitine oral solution 100 mgml 1
levocarnitine oral tablet 330 mg 1
midodrine oral tablet 10 mg 25 mg 5 mg 1
nitisinone oral capsule 10 mg 2 mg 5 mg 2 PA LA
NITYR ORAL TABLET 10 MG 2 MG 5 MG 2 PA LA
pilocarpine hcl oral tablet 5 mg 1
PROLASTIN-C INTRAVENOUS SOLUTION 1000 MG (+-)20 ML
MB
RAVICTI ORAL LIQUID 11 GRAMML 2 PA ST LA QL (10 per 30 days)
RECLAST INTRAVENOUS PIGGYBACK 5 MG100 ML
MB
riluzole oral tablet 50 mg 1
risedronate oral tablet 30 mg 1
sodium chloride 09 injection solution MB
sodium chloride 09 intravenous parenteral solution
MB
sodium chloride 09 intravenous piggyback MB
sodium phenylbutyrate oral powder 094 gramgram
1 PA
sodium phenylbutyrate oral tablet 500 mg 1 PA
SOLIRIS INTRAVENOUS SOLUTION 300 MG30 ML
MB PA LA
trientine oral capsule 250 mg 1 PA QL (240 per 30 days)
XURIDEN ORAL GRANULES IN PACKET 2 GRAM
2 PA QL (120 per 30 days)
68
Drug Name Drug Tier Requirements Limits
ZEMAIRA INTRAVENOUS RECON SOLN 1000 MG
MB LA
ZOKINVY ORAL CAPSULE 50 MG 75 MG 2 PA ST
SMOKING DETERRENTS
bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg
ACA PV
CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG
ACA PV QL (180 per 365 days)
CHANTIX ORAL TABLET 05 MG 1 MG ACA PV QL (180 per 365 days)
CHANTIX STARTING MONTH BOX ORAL TABLETSDOSE PACK 05 MG (11)- 1 MG (42)
ACA PV QL (180 per 365 days)
nicorette buccal gum 4 mg ACA PV
nicotine (polacrilex) buccal gum 2 mg 4 mg ACA PV
nicotine (polacrilex) buccal lozenge 2 mg 4 mg ACA PV
nicotine (polacrilex) buccal mini lozenge 2 mg 4 mg
ACA PV
nicotine transdermal patch 24 hour 14 mg24 hr 21 mg24 hr 7 mg24 hr
ACA PV
nicotine transdermal patch td daily sequential 21-14-7 mg24 hr
ACA PV
NICOTROL INHALATION CARTRIDGE 10 MG
ACA PV
NICOTROL NS NASAL SPRAYNON-AEROSOL 10 MGML
ACA PV
quit 2 buccal gum 2 mg ACA PV
quit 2 buccal lozenge 2 mg ACA PV
quit 4 buccal gum 4 mg ACA PV
quit 4 buccal lozenge 4 mg ACA PV
stop smoking aid buccal lozenge 2 mg 4 mg ACA PV
EAR NOSE amp THROAT MEDICATIONS
MISCELLANEOUS AGENTS
ARESTIN DENTAL CARTRIDGE 1 MG MB
azelastine nasal aerosolspray 137 mcg (01 ) 1
azelastine nasal spraynon-aerosol 2055 mcg (015 )
1
chlorhexidine gluconate mucous membrane mouthwash 012
1
denta 5000 plus dental cream 11 1
69
Drug Name Drug Tier Requirements Limits
dentagel dental gel 11 1
fluoride (sodium) dental cream 11 1
fluoride (sodium) dental gel 11 1
fluoride (sodium) dental paste 11 1
ipratropium bromide nasal spraynon-aerosol 21 mcg (003 ) 42 mcg (006 )
1
olopatadine nasal spraynon-aerosol 06 1
oralone dental paste 01 1
paroex oral rinse mucous membrane mouthwash 012
1
periogard mucous membrane mouthwash 012 1
pilocarpine hcl oral tablet 75 mg 1
sf 5000 plus dental cream 11 1
sf dental gel 11 1
sodium fluoride 5000 dry mouth dental gel 11 1
sodium fluoride 5000 plus dental cream 11 1
sodium fluoride-pot nitrate dental paste 11-5 1
triamcinolone acetonide dental paste 01 1
MISCELLANEOUS OTIC PREPARATIONS
acetic acid otic (ear) solution 2 1
ciprofloxacin hcl otic (ear) dropperette 02 1
flac otic oil otic (ear) drops 001 1
fluocinolone acetonide oil otic (ear) drops 001 1
hydrocortisone-acetic acid otic (ear) drops 1-2 1
ofloxacin otic (ear) drops 03 1
OTIC STEROID ANTIBIOTIC
CIPRO HC OTIC (EAR) DROPSSUSPENSION 02-1
1
ciprofloxacin-dexamethasone otic (ear) dropssuspension 03-01
1
neomycin-polymyxin-hc otic (ear) dropssuspension 35-10000-1 mgml-unitml-
1
neomycin-polymyxin-hc otic (ear) solution 35-10000-1 mgml-unitml-
1
OTOVEL OTIC (EAR) SOLUTION 03-0025 (025 ML)
1
ENDOCRINEDIABETES
70
Drug Name Drug Tier Requirements Limits
ADRENAL HORMONES
ACTHAR INJECTION GEL 80 UNITML 2 PA LA
decadron oral tablet 05 mg 1
dexamethasone intensol oral drops 1 mgml 1
dexamethasone oral elixir 05 mg5 ml 1
dexamethasone oral solution 05 mg5 ml 1
dexamethasone oral tablet 05 mg 075 mg 1 mg 15 mg 2 mg 4 mg 6 mg
1
dexamethasone oral tabletsdose pack 15 mg (21 tabs) 15 mg (35 tabs) 15 mg (51 tabs)
1
dexamethasone sodium phos (pf) injection solution 10 mgml
1
dexamethasone sodium phosphate injection solution 10 mgml 4 mgml
1
dexamethasone sodium phosphate injection syringe 4 mgml
1
fludrocortisone oral tablet 01 mg 1
hydrocortisone oral tablet 10 mg 20 mg 5 mg 1
methylprednisolone acetate injection suspension 40 mgml 80 mgml
1
methylprednisolone oral tablet 16 mg 32 mg 4 mg 8 mg
1
methylprednisolone oral tabletsdose pack 4 mg 1
millipred dp oral tabletsdose pack 5 mg (21 tabs) 5 mg (48 tabs)
1
millipred oral tablet 5 mg 1
prednisolone oral solution 15 mg5 ml 1
prednisolone sodium phosphate oral solution 10 mg5 ml 15 mg5 ml (3 mgml) 20 mg5 ml (4 mgml) 25 mg5 ml (5 mgml) 5 mg base5 ml (67 mg5 ml)
1
prednisolone sodium phosphate oral tabletdisintegrating 10 mg 15 mg 30 mg
1
prednisone intensol oral concentrate 5 mgml 1
prednisone oral solution 5 mg5 ml 1
prednisone oral tablet 1 mg 10 mg 25 mg 20 mg 5 mg 50 mg
1
prednisone oral tabletsdose pack 10 mg 5 mg 1
71
Drug Name Drug Tier Requirements Limits
triamcinolone acetonide injection suspension 40 mgml
MB
ANTITHYROID AGENTS
methimazole oral tablet 10 mg 5 mg 1
propylthiouracil oral tablet 50 mg 1
SSKI ORAL SOLUTION 1 GRAMML 1
BLOOD GLUCOSE MONITORING DEVICES amp SUPPLIES
CONTOUR NEXT TEST STRIPS STRIP 1
CONTOUR TEST STRIPS STRIP 1
ONETOUCH ULTRA TEST STRIP 1
ONETOUCH VERIO TEST STRIPS STRIP 1
DIABETES SUPPLIES amp DURABLE MEDICAL EQUIPMENT
AEROCHAMBER MINI SPACER 1
AEROCHAMBER PLUS FLOW-VU SPACER 1
GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN 1 MGML
1
GLUCAGON HCL INJECTION RECON SOLN 1 MGML
1
INSULIN SYRINGE-NEEDLE U-100 SYRINGE 05 ML 29 GAUGE X 12
1
TRIJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-5-1000 MG 125-25-1000 MG 25-5-1000 MG 5-25-1000 MG
1 PA ST
GLUCOSE ELEVATING AGENTS
BAQSIMI NASAL SPRAYNON-AEROSOL 3 MGACTUATION
1
diazoxide oral suspension 50 mgml 1
GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG
1
GLUCAGON (HCL) EMERGENCY KIT INJECTION RECON SOLN 1 MG
1
glucagon emergency kit (human) injection recon soln 1 mg
1
INSULIN SYRINGESMISCELLANEOUS DURABLE MEDICAL EQU
FREESTYLE LIBRE 14 DAY SENSOR KIT 1
FREESTYLE LIBRE 2 SENSOR KIT 1
NOVOPEN ECHO SUBCUTANEOUS INSULIN PEN
1
72
Drug Name Drug Tier Requirements Limits
PEN NEEDLE DIABETIC NEEDLE 29 GAUGE X 12
1
INSULIN THERAPY
FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
FIASP PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML (3 ML)
1
FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN HALF-UNIT 100 UNITML
1
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML
1 ST
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 200 UNITML (3 ML)
1
HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNITML (50-50)
1 ST
HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (50-50)
1 ST
HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (75-25)
1 ST
HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNITML (75-25)
1 ST
HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML
1 ST
HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1 ST
HUMULIN 7030 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)
1 ST
HUMULIN 7030 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1 ST
73
Drug Name Drug Tier Requirements Limits
HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1 ST
HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML
1 ST
HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNITML
1 ST
HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNITML
1
HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNITML (3 ML)
1
INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML (70-30)
1
INSULIN ASPART U-100 SUBCUTANEOUS CARTRIDGE 100 UNITML
1
INSULIN ASPART U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
INSULIN ASPART U-100 SUBCUTANEOUS SOLUTION 100 UNITML
1
LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
NOVOLIN R FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
74
Drug Name Drug Tier Requirements Limits
NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNITML (70-30)
1
NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML
1
NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML
1
RELION NOVOLIN 7030 SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)
1
RELION NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNITML
1
RELION NOVOLIN R INJECTION SOLUTION 100 UNITML
1
SOLIQUA 10033 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCGML
1 PA ST
TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNITML (3 ML)
1
TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNITML (15 ML)
1
TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN 200 UNITML (3 ML)
1
TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
XULTOPHY 10036 SUBCUTANEOUS INSULIN PEN 100 UNIT-36 MG ML (3 ML)
1 PA ST
MISCELLANEOUS HORMONES
ALDURAZYME INTRAVENOUS SOLUTION 29 MG5 ML
MB PA LA
ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG24 HOUR 4 MG24 HR
1 ST QL (30 per 30 days)
75
Drug Name Drug Tier Requirements Limits
BRINEURA INTRAVENTRICULAR KIT 300 MG10 ML (150MG5ML X2)
MB
cabergoline oral tablet 05 mg 1
calcitonin (salmon) injection solution 200 unitml 1
calcitonin (salmon) nasal spraynon-aerosol 200 unitactuation
1
calcitriol oral capsule 025 mcg 05 mcg 1
calcitriol oral solution 1 mcgml 1
CERDELGA ORAL CAPSULE 84 MG 2 PA LA
CEREZYME INTRAVENOUS RECON SOLN 400 UNIT
MB PA LA
cinacalcet oral tablet 30 mg 60 mg 90 mg 2 PA
CRYSVITA SUBCUTANEOUS SOLUTION 10 MGML 20 MGML 30 MGML
MB PA LA
danazol oral capsule 100 mg 200 mg 50 mg 1
DEPO-TESTOSTERONE INTRAMUSCULAR OIL 100 MGML
1
desmopressin nasal spraynon-aerosol 10 mcgspray (01 ml)
1
desmopressin oral tablet 01 mg 02 mg 1
doxercalciferol oral capsule 05 mcg 1 mcg 25 mcg
1
ELAPRASE INTRAVENOUS SOLUTION 6 MG3 ML
MB PA LA
ELELYSO INTRAVENOUS RECON SOLN 200 UNIT
MB PA LA
FABRAZYME INTRAVENOUS RECON SOLN 35 MG 5 MG
MB PA LA
GALAFOLD ORAL CAPSULE 123 MG 2 PA LA
JYNARQUE ORAL TABLET 15 MG 30 MG 2 PA QL (60 per 30 days)
JYNARQUE ORAL TABLETS SEQUENTIAL 45 MG (AM) 15 MG (PM) 60 MG (AM) 30 MG (PM) 90 MG (AM) 30 MG (PM)
2 PA QL (60 per 30 days)
KANUMA INTRAVENOUS SOLUTION 2 MGML
MB PA LA
KORLYM ORAL TABLET 300 MG 2 PA ST
LUMIZYME INTRAVENOUS RECON SOLN 50 MG
MB PA LA
76
Drug Name Drug Tier Requirements Limits
MEPSEVII INTRAVENOUS SOLUTION 2 MGML
MB PA LA
methyltestosterone oral capsule 10 mg 1
MIACALCIN INJECTION SOLUTION 200 UNITML
1
miglustat oral capsule 100 mg 2 PA LA
MYALEPT SUBCUTANEOUS RECON SOLN 5 MGML (FINAL CONC)
2 LA
NAGLAZYME INTRAVENOUS SOLUTION 5 MG5 ML
MB PA LA
NATPARA SUBCUTANEOUS CARTRIDGE 100 MCGDOSE 25 MCGDOSE 50 MCGDOSE 75 MCGDOSE
2 PA ST LA
oxandrolone oral tablet 10 mg 25 mg 1
PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG05 ML 25 MG05 ML 20 MGML
2 PA LA
pamidronate intravenous solution 30 mg10 ml (3 mgml)
MB
PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCGML
MB
paricalcitol intravenous solution 5 mcgml MB
paricalcitol oral capsule 1 mcg 2 mcg 4 mcg 1
PARSABIV INTRAVENOUS SOLUTION 5 MGML
MB PA
SAMSCA ORAL TABLET 15 MG 2 PA LA QL (60 per 30 days)
sapropterin oral powder in packet 100 mg 500 mg 2 PA LA
sapropterin oral tabletsoluble 100 mg 2 PA LA
SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG 15 MG 20 MG 25 MG 30 MG
2 PA LA QL (30 per 30 days)
STRENSIQ SUBCUTANEOUS SOLUTION 18 MG045 ML 28 MG07 ML 40 MGML 80 MG08 ML
2 PA
SYNAREL NASAL SPRAYNON-AEROSOL 2 MGML
1
TEPEZZA INTRAVENOUS RECON SOLN 500 MG
MB PA LA
testosterone cypionate intramuscular oil 100 mgml 200 mgml
1
testosterone enanthate intramuscular oil 200 mgml
1
77
Drug Name Drug Tier Requirements Limits
testosterone transdermal gel 50 mg5 gram (1 ) 1 QL (60 per 30 days)
testosterone transdermal gel in metered-dose pump 10 mg05 gram actuation 2025 mg125 gram (162 )
1 QL (2 per 30 days)
testosterone transdermal gel in metered-dose pump 125 mg 125 gram (1 )
1 QL (4 per 30 days)
testosterone transdermal gel in packet 1 (25 mg25gram) 162 (2025 mg125 gram)
1 QL (30 per 30 days)
testosterone transdermal gel in packet 1 (50 mg5 gram) 162 (405 mg25 gram)
1 QL (60 per 30 days)
testosterone transdermal solution in metered pump wapp 30 mgactuation (15 ml)
1 QL (2 per 30 days)
VIMIZIM INTRAVENOUS SOLUTION 5 MG5 ML (1 MGML)
MB PA LA
VPRIV INTRAVENOUS RECON SOLN 400 UNIT
MB PA LA
NON-INSULIN HYPOGLYCEMIC AGENTS
acarbose oral tablet 100 mg 25 mg 50 mg 1
ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 125-15 MG 125-30 MG 125-45 MG 25-15 MG 25-30 MG 25-45 MG
1 PA ST
BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG085 ML
1 PA ST
BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCGDOSE(250 MCGML) 24 ML 5 MCGDOSE (250 MCGML) 12 ML
1 PA ST
CYCLOSET ORAL TABLET 08 MG 1
FARXIGA ORAL TABLET 10 MG 5 MG 1 PA ST
glimepiride oral tablet 1 mg 2 mg 4 mg 1
glipizide oral tablet 10 mg 5 mg 1
glipizide oral tablet extended release 24hr 10 mg 25 mg 5 mg
1
glipizide-metformin oral tablet 25-250 mg 25-500 mg 5-500 mg
1
glyburide micronized oral tablet 15 mg 3 mg 6 mg
1
glyburide oral tablet 125 mg 25 mg 5 mg 1
glyburide-metformin oral tablet 125-250 mg 25-500 mg 5-500 mg
1
78
Drug Name Drug Tier Requirements Limits
GLYXAMBI ORAL TABLET 10-5 MG 25-5 MG
1 PA ST
JANUMET ORAL TABLET 50-1000 MG 50-500 MG
1 PA ST
JANUMET XR ORAL TABLET ER MULTIPHASE 24 HR 100-1000 MG 50-1000 MG 50-500 MG
1 PA ST
JANUVIA ORAL TABLET 100 MG 25 MG 50 MG
1 PA ST
JARDIANCE ORAL TABLET 10 MG 25 MG 1 PA ST
JENTADUETO ORAL TABLET 25-1000 MG 25-500 MG 25-850 MG
1 PA ST
JENTADUETO XR ORAL TABLET IR - ER BIPHASIC 24HR 25-1000 MG 5-1000 MG
1 PA ST
metformin oral solution 500 mg5 ml 1 PA
metformin oral tablet 1000 mg 500 mg 850 mg 1
metformin oral tablet extended release 24 hr 500 mg 750 mg
1
metformin oral tablet extended release 24hr 1000 mg 500 mg
1 PA ST
metformin oral tableter gastretention 24 hr 1000 mg 500 mg
1 ST
miglitol oral tablet 100 mg 25 mg 50 mg 1
nateglinide oral tablet 120 mg 60 mg 1
OZEMPIC SUBCUTANEOUS PEN INJECTOR 025 MG OR 05 MG(2 MG15 ML) 1 MGDOSE (2 MG15 ML) 1 MGDOSE (4 MG3 ML)
1 PA ST
pioglitazone oral tablet 15 mg 30 mg 45 mg 1
pioglitazone-glimepiride oral tablet 30-2 mg 30-4 mg
1
pioglitazone-metformin oral tablet 15-500 mg 15-850 mg
1
QTERN ORAL TABLET 10-5 MG 5-5 MG 1 PA ST
repaglinide oral tablet 05 mg 1 mg 2 mg 1
repaglinide-metformin oral tablet 1-500 mg 2-500 mg
1
RIOMET ER ORAL SUSPENSIONEXTENDED REL RECON 500 MG5 ML
1 PA ST
79
Drug Name Drug Tier Requirements Limits
RYBELSUS ORAL TABLET 14 MG 3 MG 7 MG
1 PA ST
SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2700 MCG27 ML
1 PA ST
SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1500 MCG15 ML
1 PA ST
SYNJARDY ORAL TABLET 125-1000 MG 125-500 MG 5-1000 MG 5-500 MG
1 PA ST
SYNJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 125-1000 MG 25-1000 MG 5-1000 MG
1 PA ST
TRADJENTA ORAL TABLET 5 MG 1 PA ST
TRULICITY SUBCUTANEOUS PEN INJECTOR 075 MG05 ML 15 MG05 ML 3 MG05 ML 45 MG05 ML
1 PA ST
XIGDUO XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 10-500 MG 25-1000 MG 5-1000 MG 5-500 MG
1 PA ST
THYROID HORMONES
ARMOUR THYROID ORAL TABLET 120 MG 15 MG 180 MG 240 MG 30 MG 300 MG 60 MG 90 MG
1
levothyroxine oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 300 mcg 50 mcg 75 mcg 88 mcg
1
levoxyl oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 50 mcg 75 mcg 88 mcg
1
liothyronine oral tablet 25 mcg 5 mcg 50 mcg 1
np thyroid oral tablet 120 mg 15 mg 30 mg 60 mg 90 mg
1
SYNTHROID ORAL TABLET 100 MCG 112 MCG 125 MCG 137 MCG 150 MCG 175 MCG 200 MCG 25 MCG 300 MCG 50 MCG 75 MCG 88 MCG
1
THYROLAR-1 ORAL TABLET 125-50 MCG 1
THYROLAR-12 ORAL TABLET 625-25 MCG 1
THYROLAR-14 ORAL TABLET 31-125 MCG 1
THYROLAR-2 ORAL TABLET 25-100 MCG 1
THYROLAR-3 ORAL TABLET 375-150 MCG 1
80
Drug Name Drug Tier Requirements Limits
unithroid oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 300 mcg 50 mcg 75 mcg 88 mcg
1
westhroid oral tablet 130 mg 195 mg 325 mg 65 mg 975 mg
1
GASTROENTEROLOGY
ANTIDIARRHEALS amp ANTISPASMODICS
anaspaz oral tabletdisintegrating 0125 mg 1
atropine injection syringe 005 mgml 01 mgml 1
belladonna alkaloids-opium rectal suppository 162-30 mg 162-60 mg
1 PA ST
chlordiazepoxide-clidinium oral capsule 5-25 mg 1
dicyclomine intramuscular solution 10 mgml MB
dicyclomine oral capsule 10 mg 1
dicyclomine oral solution 10 mg5 ml 1
dicyclomine oral tablet 20 mg 1
diphenoxylate-atropine oral liquid 25-0025 mg5 ml
1
diphenoxylate-atropine oral tablet 25-0025 mg 1
DONNATAL ORAL TABLET 162-01037 -00194 MG
1
ed-spaz oral tabletdisintegrating 0125 mg 1
glycopyrrolate injection solution 02 mgml 1
glycopyrrolate oral tablet 1 mg 15 mg 2 mg 1
hyoscyamine sulfate oral drops 0125 mgml 1
hyoscyamine sulfate oral elixir 0125 mg5 ml 1
hyoscyamine sulfate oral tablet 0125 mg 1
hyoscyamine sulfate oral tablet extended release 12 hr 0375 mg
1
hyoscyamine sulfate oral tabletdisintegrating 0125 mg
1
hyoscyamine sulfate sublingual tablet 0125 mg 1
hyosyne oral drops 0125 mgml 1
hyosyne oral elixir 0125 mg5 ml 1
loperamide oral capsule 2 mg 1
methscopolamine oral tablet 25 mg 5 mg 1
MOTOFEN ORAL TABLET 1-0025 MG 1
81
Drug Name Drug Tier Requirements Limits
opium tincture oral tincture 10 mgml (morphine) 1
oscimin oral tablet 0125 mg 1
oscimin sl sublingual tablet 0125 mg 1
oscimin sr oral tablet extended release 12 hr 0375 mg
1
phenobarb-hyoscy-atropine-scop oral elixir 162-01037 -00194 mg5 ml
1
phenobarb-hyoscy-atropine-scop oral tablet 162-01037 -00194 mg
1
phenohytro oral elixir 162-01037 -00194 mg5 ml
1
phenohytro oral tablet 162-01037 -00194 mg 1
symax fastabs oral tabletdisintegrating 0125 mg 1
symax-sl sublingual tablet 0125 mg 1
symax-sr oral tablet extended release 12 hr 0375 mg
1
MISCELLANEOUS GASTROINTESTINAL AGENTS
AKYNZEO (NETUPITANT) ORAL CAPSULE 300-05 MG
1 QL (1 per 30 days)
alosetron oral tablet 05 mg 1 mg 1
ALOXI INTRAVENOUS SOLUTION 025 MG5 ML
MB
AMITIZA ORAL CAPSULE 24 MCG 8 MCG 1 PA
anucort-hc rectal suppository 25 mg 1
aprepitant oral capsule 125 mg 40 mg 1 QL (1 per 30 days)
aprepitant oral capsule 80 mg 1 QL (2 per 30 days)
aprepitant oral capsuledose pack 125 mg (1)- 80 mg (2)
1 QL (1 per 30 days)
balsalazide oral capsule 750 mg 1
budesonide oral capsuledelayedextendrelease 3 mg
1
calcium acetate(phosphat bind) oral capsule 667 mg
1
calcium acetate(phosphat bind) oral tablet 667 mg 1
CHOLBAM ORAL CAPSULE 250 MG 50 MG 2
CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)
2 PA ST LA
82
Drug Name Drug Tier Requirements Limits
CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG2 ML (200 MGML X 2)
2 PA ST LA
CLENPIQ ORAL SOLUTION 10 MG-35 GRAM -12 GRAM160 ML
ACA PV
compro rectal suppository 25 mg 1
constulose oral solution 10 gram15 ml 1
CORTIFOAM RECTAL FOAM 10 (80 MG) 1
CREON ORAL CAPSULEDELAYED RELEASE(DREC) 12000-38000 -60000 UNIT 24000-76000 -120000 UNIT 3000-9500- 15000 UNIT 36000-114000- 180000 UNIT 6000-19000 -30000 UNIT
1 PA
cromolyn oral concentrate 100 mg5 ml 1
DIPENTUM ORAL CAPSULE 250 MG 1 PA ST
doxylamine-pyridoxine (vit b6) oral tabletdelayed release (drec) 10-10 mg
1
dronabinol oral capsule 10 mg 25 mg 5 mg 1
EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG ML FINAL CONC)
1
ENTYVIO INTRAVENOUS RECON SOLN 300 MG
MB PA LA
enulose oral solution 10 gram15 ml 1
gavilyte-c oral recon soln 240-2272-672 -584 gram
ACA PV
gavilyte-g oral recon soln 236-2274-674 -586 gram
ACA PV
gavilyte-n oral recon soln 420 gram ACA PV
generlac oral solution 10 gram15 ml 1
granisetron hcl oral tablet 1 mg 1 QL (6 per 30 days)
hemmorex-hc rectal suppository 25 mg 1
hydrocortisone acetate rectal suppository 25 mg 30 mg
1
hydrocortisone rectal enema 100 mg60 ml 1
hydrocortisone topical cream with perineal applicator 1 25
1
hydrocortisone-pramoxine rectal cream 1-1 25-1 25-1 (4g)
1
INFLECTRA INTRAVENOUS RECON SOLN 100 MG
MB PA LA
83
Drug Name Drug Tier Requirements Limits
lactulose oral packet 10 gram 1
lactulose oral solution 10 gram15 ml 20 gram30 ml
1
lanthanum oral tabletchewable 1000 mg 500 mg 750 mg
1
lidocaine hcl-hydrocortison ac rectal cream 3-05
1
LIDOCAINE HCL-HYDROCORTISON AC RECTAL GEL 3 -25 (7 GRAM)
1
lidocaine hcl-hydrocortison ac rectal kit 2 -2 (7 gram)
1 ST
lidocaine hcl-hydrocortison ac rectal kit 3-05 3-1 (7 gram)
1 PA ST
lidocaine-hydrocortisone-aloe rectal gel 28-055
1
lidocaine-hydrocortisone-aloe rectal kit 3-25 (7 gram)
1 PA ST
LINZESS ORAL CAPSULE 145 MCG 290 MCG 72 MCG
1 PA
meclizine oral tablet 125 mg 25 mg 1
mesalamine oral capsuleextended release 24hr 0375 gram
1
mesalamine oral tabletdelayed release (drec) 12 gram 800 mg
1
mesalamine rectal enema 4 gram60 ml 1
mesalamine rectal suppository 1000 mg 1
mesalamine with cleansing wipe rectal enema kit 4 gram60 ml
1 ST
metoclopramide hcl injection solution 5 mgml MB
metoclopramide hcl injection syringe 5 mgml MB
metoclopramide hcl oral solution 5 mg5 ml 1
metoclopramide hcl oral tablet 10 mg 5 mg 1
metoclopramide hcl oral tabletdisintegrating 10 mg 5 mg
1
MOVANTIK ORAL TABLET 125 MG 25 MG 1 PA ST
NULYTELY LEMON-LIME ORAL RECON SOLN 420 GRAM
ACA PV
ondansetron hcl intravenous solution 2 mgml MB
ondansetron hcl oral solution 4 mg5 ml 1 QL (100 per 30 days)
84
Drug Name Drug Tier Requirements Limits
ondansetron hcl oral tablet 4 mg 8 mg 1 QL (9 per 30 days)
ondansetron oral tabletdisintegrating 4 mg 8 mg 1 QL (9 per 30 days)
OSMOPREP ORAL TABLET 15 GRAM ACA PV
peg 3350-electrolytes oral recon soln 236-2274-674 -586 gram
ACA PV
peg3350-sod sul-nacl-kcl-asb-c oral powder in packet 100-75-2691 gram
ACA PV
peg-electrolyte soln oral recon soln 420 gram ACA PV
peg-prep oral kit 5-210 mg-gram ACA PV
PLENVU ORAL POWDER IN PACKET SEQUENTIAL 140-9-52 GRAM
ACA PV
prochlorperazine edisylate injection solution 10 mg2 ml (5 mgml) 5 mgml
1
prochlorperazine maleate oral tablet 10 mg 5 mg 1
prochlorperazine rectal suppository 25 mg 1
procto-med hc topical cream with perineal applicator 25
1
procto-pak topical cream with perineal applicator 1
1
proctosol hc topical cream with perineal applicator 25
1
proctozone-hc topical cream with perineal applicator 25
1
RECTIV RECTAL OINTMENT 04 (WW) 1
RELISTOR ORAL TABLET 150 MG 1
RELISTOR SUBCUTANEOUS SOLUTION 12 MG06 ML
1
RELISTOR SUBCUTANEOUS SYRINGE 12 MG06 ML 8 MG04 ML
1
REMICADE INTRAVENOUS RECON SOLN 100 MG
MB PA LA
RENFLEXIS INTRAVENOUS RECON SOLN 100 MG
MB PA LA
scopolamine base transdermal patch 3 day 1 mg over 3 days
1
sevelamer carbonate oral powder in packet 08 gram 24 gram
1
sevelamer carbonate oral tablet 800 mg 1
sevelamer hcl oral tablet 400 mg 800 mg 1
85
Drug Name Drug Tier Requirements Limits
sodium polystyrene sulfonate oral powder 1
sps (with sorbitol) oral suspension 15-20 gram60 ml
1
sps (with sorbitol) rectal enema 30-40 gram120 ml
1
SUCRAID ORAL SOLUTION 8500 UNITML 2 PA ST QL (2 per 30 days)
sulfasalazine oral tablet 500 mg 1
sulfasalazine oral tabletdelayed release (drec) 500 mg
1
SUPREP BOWEL PREP KIT ORAL RECON SOLN 175-313-16 GRAM
ACA PV ST
trilyte with flavor packets oral recon soln 420 gram
ACA PV
trimethobenzamide oral capsule 300 mg 1
ursodiol oral capsule 300 mg 1
ursodiol oral tablet 250 mg 500 mg 1
VARUBI ORAL TABLET 90 MG 1
VELPHORO ORAL TABLETCHEWABLE 500 MG
1 ST
VIBERZI ORAL TABLET 100 MG 75 MG 1 PA ST
ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 10000-32000 -42000 UNIT 15000-47000 -63000 UNIT 20000-63000- 84000 UNIT 3000-10000 -14000-UNIT 40000-126000- 168000 UNIT 5000-17000- 24000 UNIT
1 PA
ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 25000-79000- 105000 UNIT
1
ULCER THERAPY
amoxicil-clarithromy-lansopraz oral combo pack 500-500-30 mg
1
cimetidine hcl oral solution 300 mg5 ml 1
cimetidine oral tablet 200 mg 300 mg 400 mg 800 mg
1
DEXILANT ORAL CAPSULEBIPHASE DELAYED RELEAS 30 MG 60 MG
1 ST
esomeprazole magnesium oral capsuledelayed release(drec) 20 mg 40 mg
1
famotidine (pf) intravenous solution 20 mg2 ml MB
86
Drug Name Drug Tier Requirements Limits
famotidine oral suspension 40 mg5 ml (8 mgml) 1
famotidine oral tablet 20 mg 40 mg 1
lansoprazole oral capsuledelayed release(drec) 15 mg 30 mg
1
lansoprazole oral tabletdisintegrat delay rel 15 mg 30 mg
1
misoprostol oral tablet 100 mcg 200 mcg 1
nizatidine oral capsule 150 mg 300 mg 1
nizatidine oral solution 150 mg10 ml 1
omeprazole oral capsuledelayed release(drec) 10 mg 20 mg 40 mg
1
pantoprazole oral tabletdelayed release (drec) 20 mg 40 mg
1
rabeprazole oral tabletdelayed release (drec) 20 mg
1
sucralfate oral suspension 100 mgml 1
sucralfate oral tablet 1 gram 1
IMMUNOLOGY VACCINES amp BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCGML 200 MCGML 25 MCGML 300 MCGML 40 MCGML 60 MCGML
2 LA
ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG04 ML 100 MCG05 ML 150 MCG03 ML 200 MCG04 ML 25 MCG042 ML 300 MCG06 ML 40 MCG04 ML 500 MCGML 60 MCG03 ML
2 LA
EPOGEN INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML
2 LA
GRANIX SUBCUTANEOUS SOLUTION 300 MCGML 480 MCG16 ML
2
GRANIX SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML
2
LEUKINE INJECTION RECON SOLN 250 MCG 2 PA ST
MIRCERA INJECTION SYRINGE 100 MCG03 ML 150 MCG03 ML 200 MCG03 ML 30 MCG03 ML 50 MCG03 ML 75 MCG03 ML
MB
87
Drug Name Drug Tier Requirements Limits
MOZOBIL SUBCUTANEOUS SOLUTION 24 MG12 ML (20 MGML)
MB LA
NEUPOGEN INJECTION SOLUTION 300 MCGML 480 MCG16 ML
2 PA ST
NEUPOGEN INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML
2 PA ST
NIVESTYM INJECTION SOLUTION 300 MCGML 480 MCG16 ML
2
NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML
2
PROCRIT INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML 40000 UNITML
2 LA
UDENYCA SUBCUTANEOUS SYRINGE 6 MG06 ML
2 PA ST
ZARXIO INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML
2 PA ST
ZIEXTENZO SUBCUTANEOUS SYRINGE 6 MG06 ML
2 PA ST
GROWTH HORMONES
GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 02 MG025 ML 04 MG025 ML 06 MG025 ML 08 MG025 ML 1 MG025 ML 12 MG025 ML 14 MG025 ML 16 MG025 ML 18 MG025 ML 2 MG025 ML
2 PA ST LA
GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MGML (36 UNITML) 5 MGML (15 UNITML)
2 PA ST LA
OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG15 ML (67 MGML) 5 MG15 ML (33 MGML)
2 PA ST LA
OMNITROPE SUBCUTANEOUS RECON SOLN 58 MG
2 PA ST LA
SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG 5 MG 6 MG
2 PA ST LA
ZORBTIVE SUBCUTANEOUS RECON SOLN 88 MG
2 PA ST LA
INTERFERONS
AUBAGIO ORAL TABLET 14 MG 7 MG 2 PA LA
88
Drug Name Drug Tier Requirements Limits
AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG05 ML
2 PA ST LA QL (4 per 30 days)
AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG05 ML
2 PA ST LA QL (4 per 30 days)
BETASERON SUBCUTANEOUS KIT 03 MG 2 PA LA QL (14 per 30 days)
dimethyl fumarate oral capsuledelayed release(drec) 120 mg
2 PA LA QL (14 per 365 days)
dimethyl fumarate oral capsuledelayed release(drec) 120 mg (14)- 240 mg (46)
2 PA LA QL (1 per 365 days)
dimethyl fumarate oral capsuledelayed release(drec) 240 mg
2 PA LA QL (60 per 30 days)
GILENYA ORAL CAPSULE 05 MG 2 PA LA QL (30 per 30 days)
glatiramer subcutaneous syringe 20 mgml 2 PA LA QL (30 per 30 days)
glatiramer subcutaneous syringe 40 mgml 2 PA LA QL (12 per 30 days)
glatopa subcutaneous syringe 20 mgml 2 PA LA QL (30 per 30 days)
glatopa subcutaneous syringe 40 mgml 2 PA LA QL (12 per 30 days)
LEMTRADA INTRAVENOUS SOLUTION 12 MG12 ML
MB PA ST LA
MAVENCLAD (10 TABLET PACK) ORAL TABLET 10 MG
2 LA
MAVENCLAD (4 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (5 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (6 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (7 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (8 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (9 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAYZENT ORAL TABLET 025 MG 2 MG 2 PA ST LA QL (30 per 30 days)
MAYZENT STARTER PACK ORAL TABLETSDOSE PACK 025 MG (12 TABS)
2 PA ST LA QL (1 per 365 days)
OCREVUS INTRAVENOUS SOLUTION 30 MGML
MB PA LA
PEGASYS SUBCUTANEOUS SOLUTION 180 MCGML
2 PA LA
89
Drug Name Drug Tier Requirements Limits
PEGASYS SUBCUTANEOUS SYRINGE 180 MCG05 ML
2 PA LA
PLEGRIDY INTRAMUSCULAR SYRINGE 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG05 ML- 94 MCG05 ML
2 PA LA QL (1 per 365 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG05 ML- 94 MCG05 ML
2 PA LA QL (1 per 365 days)
POMALYST ORAL CAPSULE 1 MG 2 MG 3 MG 4 MG
2 PA ST OCh LA
PONVORY 14-DAY STARTER PACK ORAL TABLETSDOSE PACK 2 MG (2) - 10 MG (3)
2 PA LA QL (1 per 365 days)
PONVORY ORAL TABLET 20 MG 2 PA LA QL (30 per 30 days)
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG05 ML 44 MCG05 ML
2 PA LA QL (6 per 30 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG05 ML 44 MCG05 ML
2 PA LA QL (6 per 30 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 88MCG02ML-22 MCG05ML (6)
2 PA LA QL (5 per 30 days)
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 88MCG02ML-22 MCG05ML (6)
2 PA LA QL (5 per 30 days)
REVLIMID ORAL CAPSULE 10 MG 15 MG 25 MG 20 MG 25 MG 5 MG
2 PA ST OCh LA
ribavirin oral capsule 200 mg 2 LA
ribavirin oral tablet 200 mg 2 LA
ZEPOSIA ORAL CAPSULE 092 MG 2 LA QL (30 per 30 days)
ZEPOSIA STARTER KIT ORAL CAPSULEDOSE PACK 023-046-092 MG
2 LA QL (30 per 30 days)
ZEPOSIA STARTER PACK ORAL CAPSULEDOSE PACK 023 MG (4)- 046 MG (3)
2 LA QL (30 per 30 days)
INTERLEUKINS
ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG05 ML
2 PA LA
ARCALYST SUBCUTANEOUS RECON SOLN 220 MG
2 LA
90
Drug Name Drug Tier Requirements Limits
ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MGML
MB PA LA
imiquimod topical cream in packet 5 1
INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) 18 MILLION UNIT (1 ML) 50 MILLION UNIT (1 ML)
2 PA LA
INTRON A INJECTION SOLUTION 10 MILLION UNITML 6 MILLION UNITML
2 PA LA
PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT
MB LA
VACCINES amp MISCELLANEOUS IMMUNOLOGICALS
ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(25-5-3-5 MCG)-5LF05 ML
1 Vac
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(25-5-3-5 MCG)-5LF05 ML
1 Vac
ASCENIV INTRAVENOUS SOLUTION 10 MB PA LA
ATGAM INTRAVENOUS SOLUTION 50 MGML
MB
BCG VACCINE LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG
1 Vac
BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG05 ML
1 Vac
BIOTHRAX INTRAMUSCULAR SUSPENSION 05 MLDOSE
1 Vac
BIVIGAM INTRAVENOUS SOLUTION 10 MB PA LA
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 25-8-5 LF-MCG-LF05ML
1 Vac
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 25-8-5 LF-MCG-LF05ML
1 Vac
BOTOX INJECTION RECON SOLN 100 UNIT 200 UNIT
MB
CUTAQUIG SUBCUTANEOUS SOLUTION 165
MB LA
CUVITRU SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 ) 8 GRAM40 ML (20 )
MB LA
91
Drug Name Drug Tier Requirements Limits
DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF05ML
1 Vac
DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT 500 UNIT
MB LA
ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCGML
1 Vac
ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCGML
1 Vac
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG05 ML
1 Vac
FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 5
MB PA
GAMASTAN INTRAMUSCULAR SOLUTION 15-18 RANGE
MB
GAMASTAN SD INTRAMUSCULAR SOLUTION 15-18 RANGE
MB
GAMMAGARD LIQUID INJECTION SOLUTION 10
MB LA
GAMMAGARD S-D (IGA lt 1 MCGML) INTRAVENOUS RECON SOLN 10 GRAM 5 GRAM
MB PA LA
GAMMAKED INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 20 GRAM200 ML (10 ) 5 GRAM50 ML (10 )
MB LA
GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5
MB PA LA
GAMMAPLEX INTRAVENOUS SOLUTION 10
MB PA LA
GAMUNEX-C INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 25 GRAM25 ML (10 ) 20 GRAM200 ML (10 ) 40 GRAM400 ML (10 ) 5 GRAM50 ML (10 )
MB LA
GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 05 ML
1 Vac
GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 05 ML
1 Vac
GRASTEK SUBLINGUAL TABLET 2800 BAU 1 PA
HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1440 ELISA UNITML
1 Vac
92
Drug Name Drug Tier Requirements Limits
HAVRIX (PF) INTRAMUSCULAR SYRINGE 1440 ELISA UNITML 720 ELISA UNIT05 ML
1 Vac
HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE 20 MCG05 ML
1 Vac
HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )
MB LA
HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM 100 ML (10 ) 25 GRAM 25 ML (10 ) 20 GRAM 200 ML (10 ) 30 GRAM 300 ML (10 ) 5 GRAM 50 ML (10 )
MB LA
IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 25 UNIT
1 Vac
INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF05ML
1 Vac
IPOL INJECTION SUSPENSION 40-8-32 UNIT05 ML
1 Vac
IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG05 ML
1 Vac
KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF05 ML
1 Vac
MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG05 ML
1 Vac
MENQUADFI (PF) INTRAMUSCULAR SOLUTION 10 MCG05 ML
1 Vac
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG05 ML
1 Vac
M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1000-12500 TCID5005 ML
1 Vac
MYOBLOC INTRAMUSCULAR SOLUTION 10000 UNIT2 ML 2500 UNIT05 ML 5000 UNITML
MB LA
OCTAGAM INTRAVENOUS SOLUTION 10 5
MB PA LA
ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY
2 PA
PANZYGA INTRAVENOUS SOLUTION 10 MB PA
PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF05 ML
1 Vac
93
Drug Name Drug Tier Requirements Limits
PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 75 MCG05 ML
1 Vac
PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF05 ML 15LF-48MCG-62DU -10 MCG05ML
1 Vac
PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
PNEUMOVAX-23 INJECTION SOLUTION 25 MCG05 ML
1 Vac
PNEUMOVAX-23 INJECTION SYRINGE 25 MCG05 ML
1 Vac
PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE 05 ML
1 Vac
PRIVIGEN INTRAVENOUS SOLUTION 10 MB PA LA
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-43-3- 399 TCID5005
1 Vac
PROVENGE INTRAVENOUS SUSPENSION 50 MILLION CELL250 ML
MB PA
QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT05ML
1 Vac
RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 25 UNIT
1 Vac
RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT
1 PA
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCGML 40 MCGML 5 MCG05 ML
1 Vac
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCGML 5 MCG05 ML
1 Vac
SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG05 ML
1 Vac
STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1000 UNIT05 ML
1 Vac
TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF UNIT05 ML
1 Vac
94
Drug Name Drug Tier Requirements Limits
TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT05ML
1 Vac
TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT05 ML
1 Vac
TETANUSDIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT05 ML
1 Vac
THYMOGLOBULIN INTRAVENOUS RECON SOLN 25 MG
MB
TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG05 ML
1 Vac
TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCGML
1 Vac
TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG05 ML
1 Vac
TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG05 ML
1 Vac
VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT05 ML 50 UNITML
1 Vac
VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT05 ML 50 UNITML
1 Vac
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1350 UNIT05 ML
1 Vac
VAXELIS (PF) INTRAMUSCULAR SUSPENSION 15 UNIT-5 UNIT- 10 MCG05 ML
1 Vac
VAXELIS (PF) INTRAMUSCULAR SYRINGE 15 UNIT-5 UNIT- 10 MCG05 ML
1 Vac
XEMBIFY SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )
MB LA
XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT 200 UNIT 50 UNIT
MB LA
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP474 UNIT05 ML
1 Vac
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19400 UNIT065 ML
1 Vac
MUSCULOSKELETAL amp RHEUMATOLOGY
95
Drug Name Drug Tier Requirements Limits
GOUT THERAPY
allopurinol oral tablet 100 mg 300 mg 1
COLCHICINE ORAL CAPSULE 06 MG 1
colchicine oral tablet 06 mg 1
febuxostat oral tablet 40 mg 80 mg 1
KRYSTEXXA INTRAVENOUS SOLUTION 8 MGML
MB PA LA
MITIGARE ORAL CAPSULE 06 MG 1
probenecid oral tablet 500 mg 1
probenecid-colchicine oral tablet 500-05 mg 1
OSTEOPOROSIS THERAPY
alendronate oral solution 70 mg75 ml 1
alendronate oral tablet 10 mg 35 mg 5 mg 70 mg 1
EVENITY SUBCUTANEOUS SYRINGE 105 MG117 ML 210MG234ML ( 105MG117MLX2)
2 PA ST LA
FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCGDOSE (620MCG248ML)
2 PA ST LA QL (1 per 30 days)
FOSAMAX PLUS D ORAL TABLET 70 MG- 2800 UNIT 70 MG- 5600 UNIT
1
ibandronate oral tablet 150 mg 1
PROLIA SUBCUTANEOUS SYRINGE 60 MGML
2 ST LA
raloxifene oral tablet 60 mg 2 OCh
risedronate oral tablet 150 mg 35 mg 5 mg 1
risedronate oral tabletdelayed release (drec) 35 mg
1
TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3120 MCG156 ML)
2 PA ST LA
OTHER RHEUMATOLOGICALS
ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG09 ML
2 PA ST LA
ACTEMRA INTRAVENOUS SOLUTION 200 MG10 ML (20 MGML) 400 MG20 ML (20 MGML) 80 MG4 ML (20 MGML)
MB PA LA
ACTEMRA SUBCUTANEOUS SYRINGE 162 MG09 ML
2 PA ST LA
96
Drug Name Drug Tier Requirements Limits
BENLYSTA INTRAVENOUS RECON SOLN 120 MG 400 MG
MB PA LA
BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MGML
2 PA LA
BENLYSTA SUBCUTANEOUS SYRINGE 200 MGML
2 PA LA
ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MGML (1 ML)
2 PA ST LA
ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)
2 PA ST LA
ENBREL SUBCUTANEOUS SOLUTION 25 MG05 ML
2 PA ST LA
ENBREL SUBCUTANEOUS SYRINGE 25 MG05 ML (05) 50 MGML (1 ML)
2 PA ST LA
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MGML (1 ML)
2 PA ST LA
HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG08 ML
2 PA ST LA
HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG08 ML 80 MG08 ML-40 MG04 ML
2 PA ST LA
HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
2 PA ST LA
HUMIRA(CF) PEN PEDIATRIC UC SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
2 PA ST LA
HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML-40 MG04 ML
2 PA ST LA
HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG04 ML
2 PA ST LA
97
Drug Name Drug Tier Requirements Limits
HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG01 ML 20 MG02 ML 40 MG04 ML
2 PA ST LA
KEVZARA SUBCUTANEOUS PEN INJECTOR 150 MG114 ML 200 MG114 ML
2 PA ST LA
KEVZARA SUBCUTANEOUS SYRINGE 150 MG114 ML 200 MG114 ML
2 PA ST LA
leflunomide oral tablet 10 mg 20 mg 1
OLUMIANT ORAL TABLET 1 MG 2 MG 2 PA ST LA
ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG
MB PA LA
ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MGML
2 PA ST LA
ORENCIA SUBCUTANEOUS SYRINGE 125 MGML 50 MG04 ML 875 MG07 ML
2 PA ST LA
OTEZLA ORAL TABLET 30 MG 2 PA ST LA
OTEZLA STARTER ORAL TABLETSDOSE PACK 10 MG (4)-20 MG (4)-30 MG (47)
2 PA ST LA
penicillamine oral capsule 250 mg 1 PA
penicillamine oral tablet 250 mg 1 PA
RIDAURA ORAL CAPSULE 3 MG 1
RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 MG
2 PA ST LA
SAVELLA ORAL TABLET 100 MG 125 MG 25 MG 50 MG
1 PA ST
SAVELLA ORAL TABLETSDOSE PACK 125 MG (5)-25 MG(8)-50 MG(42)
1 PA ST
SIMPONI ARIA INTRAVENOUS SOLUTION 125 MGML
MB PA LA
SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MGML 50 MG05 ML
2 PA ST LA
SIMPONI SUBCUTANEOUS SYRINGE 100 MGML 50 MG05 ML
2 PA ST LA
XELJANZ ORAL SOLUTION 1 MGML 2 PA ST LA
XELJANZ ORAL TABLET 10 MG 5 MG 2 PA ST LA
XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG 22 MG
2 PA ST LA
OBSTETRICS amp GYNECOLOGY
DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES
98
Drug Name Drug Tier Requirements Limits
CAYA CONTOURED VAGINAL DIAPHRAGM 65-80 MM
ACA PV
FC2 FEMALE CONDOM ACA PV
FEMCAP VAGINAL DEVICE 22 MM ACA PV
KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 175 MCG24 HRS (5 YRS) 195 MG
ACA PV
LILETTA INTRAUTERINE INTRAUTERINE DEVICE 201 MCG24 HRS (6 YRS) 52 MG
ACA PV ST
MIRENA INTRAUTERINE INTRAUTERINE DEVICE 20 MCG24 HOURS (6 YRS) 52 MG
ACA PV
PARAGARD T 380A INTRAUTERINE INTRAUTERINE DEVICE 380 SQUARE MM
ACA PV
SKYLA INTRAUTERINE INTRAUTERINE DEVICE 14 MCG24 HRS (3 YRS) 135 MG
ACA PV
WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 MM
ACA PV
ESTROGENS amp PROGESTINS
amabelz oral tablet 05-01 mg 1-05 mg 1
ANGELIQ ORAL TABLET 025-05 MG 05-1 MG
1
camila oral tablet 035 mg ACA PV
COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 005-014 MG24 HR 005-025 MG24 HR
1
covaryx hs oral tablet 0625-125 mg 1
covaryx oral tablet 125-25 mg 1
CRINONE VAGINAL GEL 4 1
deblitane oral tablet 035 mg ACA PV
DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MGML
1
DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MGML
MB
DEPO-PROVERA INTRAMUSCULAR SYRINGE 150 MGML
MB
DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE 104 MG065 ML
ACA PV
99
Drug Name Drug Tier Requirements Limits
DIVIGEL TRANSDERMAL GEL IN PACKET 025 MG025 GRAM (01 ) 05 MG05 GRAM (01 ) 075 MG075 GRAM (01) 1 MGGRAM (01 ) 125 MG125 GRAM (01 )
1 QL (30 per 30 days)
dotti transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
DUAVEE ORAL TABLET 045-20 MG 1
eemt hs oral tablet 0625-125 mg 1
eemt oral tablet 125-25 mg 1
errin oral tablet 035 mg ACA PV
estradiol oral tablet 05 mg 1 mg 2 mg 1
estradiol transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
estradiol transdermal patch weekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 006 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (4 per 30 days)
estradiol vaginal cream 001 (01 mggram) 1
estradiol vaginal tablet 10 mcg 1
estradiol valerate intramuscular oil 20 mgml 40 mgml
1
estradiol-norethindrone acet oral tablet 05-01 mg 1-05 mg
1
ESTRING VAGINAL RING 2 MG (75 MCG 24 HOUR)
1
estrogens-methyltestosterone oral tablet 0625-125 mg 125-25 mg
1
EVAMIST TRANSDERMAL SPRAYNON-AEROSOL 153 MGSPRAY (17)
1 QL (2 per 30 days)
FEMRING VAGINAL RING 005 MG24 HR 01 MG24 HR
1
fyavolv oral tablet 05-25 mg-mcg 1-5 mg-mcg 1
heather oral tablet 035 mg ACA PV
hydroxyprogest(pf)(preg presv) intramuscular oil 250 mgml (1 ml)
2
hydroxyprogesterone cap(ppres) intramuscular oil 250 mgml
2
100
Drug Name Drug Tier Requirements Limits
hydroxyprogesterone caproate intramuscular oil 250 mgml
2
incassia oral tablet 035 mg ACA PV
jencycla oral tablet 035 mg ACA PV
jinteli oral tablet 1-5 mg-mcg 1
lyleq oral tablet 035 mg ACA PV
lyllana transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
lyza oral tablet 035 mg ACA PV
medroxyprogesterone intramuscular suspension 150 mgml
ACA PV
medroxyprogesterone intramuscular syringe 150 mgml
ACA PV
medroxyprogesterone oral tablet 10 mg 25 mg 5 mg
1
MENEST ORAL TABLET 03 MG 0625 MG 125 MG 25 MG
1
MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG24 HR
1 QL (4 per 30 days)
mimvey oral tablet 1-05 mg 1
nora-be oral tablet 035 mg ACA PV
norethindrone (contraceptive) oral tablet 035 mg ACA PV
norethindrone acetate oral tablet 5 mg 1
norethindrone ac-eth estradiol oral tablet 05-25 mg-mcg 1-5 mg-mcg
1
norlyda oral tablet 035 mg ACA PV
PREMARIN INJECTION RECON SOLN 25 MG 1
PREMARIN ORAL TABLET 03 MG 045 MG 0625 MG 09 MG 125 MG
1
PREMARIN VAGINAL CREAM 0625 MGGRAM
1
PREMPHASE ORAL TABLET 0625 MG (14) 0625MG-5MG(14)
1
PREMPRO ORAL TABLET 03-15 MG 045-15 MG 0625-25 MG 0625-5 MG
1
progesterone intramuscular oil 50 mgml 1
progesterone micronized oral capsule 100 mg 200 mg
1
101
Drug Name Drug Tier Requirements Limits
sharobel oral tablet 035 mg ACA PV
tulana oral tablet 035 mg ACA PV
yuvafem vaginal tablet 10 mcg 1
MISCELLANEOUS OBGYN
ANNOVERA VAGINAL RING 015-0013 MG24 HOUR
ACA PV
clindamycin phosphate vaginal cream 2 1
eluryng vaginal ring 012-0015 mg24 hr ACA PV
etonogestrel-ethinyl estradiol vaginal ring 012-0015 mg24 hr
ACA PV
fem ph vaginal gel 09-0025 1
GYNAZOLE-1 VAGINAL CREAM 2 1
gynol ii vaginal gel 3 ACA PV
INTRAROSA VAGINAL INSERT 65 MG 1
isoxsuprine oral tablet 10 mg 20 mg 1
LUPANETA PACK (1 MONTH) KIT SYRINGE AND TABLET 375 MG -5 MG (30)
2 LA
LUPANETA PACK (3 MONTH) KIT SYRINGE AND TABLET 1125 MG -5 MG (90)
2 LA
metronidazole vaginal gel 075 1
NEXPLANON SUBDERMAL IMPLANT 68 MG ACA PV
OSPHENA ORAL TABLET 60 MG 1
PHEXXI VAGINAL GEL 18-1-04 ACA PV
terconazole vaginal cream 04 08 1
terconazole vaginal suppository 80 mg 1
TODAY CONTRACEPTIVE SPONGE VAGINAL CONTRACEPTIVE SPONGE 1000 MG
ACA PV
tranexamic acid oral tablet 650 mg 1
TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 MCG24 HR
ACA PV
vaginal contraceptive foam vaginal foam 125 ACA PV
vandazole vaginal gel 075 1
VCF CONTRACEPTIVE FILM VAGINAL FILM 28
ACA PV
VCF CONTRACEPTIVE GEL VAGINAL GEL 4
ACA PV
102
Drug Name Drug Tier Requirements Limits
xulane transdermal patch weekly 150-35 mcg24 hr
ACA PV
zafemy transdermal patch weekly 150-35 mcg24 hr
ACA PV
ORAL CONTRACEPTIVES amp RELATED AGENTS
afirmelle oral tablet 01-20 mg-mcg ACA PV
altavera (28) oral tablet 015-003 mg ACA PV
alyacen 135 (28) oral tablet 1-35 mg-mcg ACA PV
alyacen 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
amethia oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
amethyst (28) oral tablet 90-20 mcg (28) ACA PV
apri oral tablet 015-003 mg ACA PV
aranelle (28) oral tablet 05105-35 mg-mcg ACA PV
ashlyna oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
aubra eq oral tablet 01-20 mg-mcg ACA PV
aubra oral tablet 01-20 mg-mcg ACA PV
aurovela 1530 (21) oral tablet 15-30 mg-mcg ACA PV
aurovela 120 (21) oral tablet 1-20 mg-mcg ACA PV
aurovela 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
aurovela fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
aurovela fe 1-20 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
aviane oral tablet 01-20 mg-mcg ACA PV
ayuna oral tablet 015-003 mg ACA PV
azurette (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
BALCOLTRA ORAL TABLET 01 MG-002 MG (21)365 MG(7)
ACA PV
balziva (28) oral tablet 04-35 mg-mcg ACA PV
blisovi 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
blisovi fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
103
Drug Name Drug Tier Requirements Limits
blisovi fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
briellyn oral tablet 04-35 mg-mcg ACA PV
camrese lo oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)
ACA PV
camrese oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
caziant (28) oral tablet 0112515-25 mg-mcg ACA PV
charlotte 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
chateal (28) oral tablet 015-003 mg ACA PV
chateal eq (28) oral tablet 015-003 mg ACA PV
cryselle (28) oral tablet 03-30 mg-mcg ACA PV
cyclafem 135 (28) oral tablet 1-35 mg-mcg ACA PV
cyclafem 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
cyred eq oral tablet 015-003 mg ACA PV
cyred oral tablet 015-003 mg ACA PV
dasetta 135 (28) oral tablet 1-35 mg-mcg ACA PV
dasetta 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
daysee oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
desog-eestradioleestradiol oral tablet 015-002 mgx21 001 mg x 5
ACA PV
desogestrel-ethinyl estradiol oral tablet 015-003 mg
ACA PV
dolishale oral tablet 90-20 mcg (28) ACA PV
drospirenone-eestradiol-lmfa oral tablet 3-002-0451 mg (24) (4) 3-003-0451 mg (21) (7)
ACA PV
drospirenone-ethinyl estradiol oral tablet 3-002 mg 3-003 mg
ACA PV
econtra ez oral tablet 15 mg ACA PV
econtra one-step oral tablet 15 mg ACA PV
elinest oral tablet 03-30 mg-mcg ACA PV
ELLA ORAL TABLET 30 MG ACA PV
emoquette oral tablet 015-003 mg ACA PV
104
Drug Name Drug Tier Requirements Limits
enpresse oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
enskyce oral tablet 015-003 mg ACA PV
estarylla oral tablet 025-35 mg-mcg ACA PV
ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg 1-50 mg-mcg
ACA PV
falmina (28) oral tablet 01-20 mg-mcg ACA PV
fayosim oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg
ACA PV
femynor oral tablet 025-35 mg-mcg ACA PV
gemmily oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV
hailey 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
hailey fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
hailey fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
hailey oral tablet 15-30 mg-mcg ACA PV
iclevia oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
isibloom oral tablet 015-003 mg ACA PV
jaimiess oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
jasmiel (28) oral tablet 3-002 mg ACA PV
jolessa oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
juleber oral tablet 015-003 mg ACA PV
junel 1530 (21) oral tablet 15-30 mg-mcg ACA PV
junel 120 (21) oral tablet 1-20 mg-mcg ACA PV
junel fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
junel fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
junel fe 24 oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV
kaitlib fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)
ACA PV
kalliga oral tablet 015-003 mg ACA PV
kariva (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
105
Drug Name Drug Tier Requirements Limits
kelnor 135 (28) oral tablet 1-35 mg-mcg ACA PV
kelnor 1-50 (28) oral tablet 1-50 mg-mcg ACA PV
kurvelo (28) oral tablet 015-003 mg ACA PV
l norgesteestradiol-eestrad oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7) 015 mg-20 mcg 015 mg-25 mcg 015 mg-30 mcg (84)10 mcg (7)
ACA PV
larin 1530 (21) oral tablet 15-30 mg-mcg ACA PV
larin 120 (21) oral tablet 1-20 mg-mcg ACA PV
larin 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV
larin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
larin fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
larissia oral tablet 01-20 mg-mcg ACA PV
layolis fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)
ACA PV
leena 28 oral tablet 05105-35 mg-mcg ACA PV
lessina oral tablet 01-20 mg-mcg ACA PV
levonest (28) oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
levonorgestrel oral tablet 15 mg ACA PV
levonorgestrel-ethinyl estrad oral tablet 01-20 mg-mcg 015-003 mg 90-20 mcg (28)
ACA PV
levonorgestrel-ethinyl estrad oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
levonorg-eth estrad triphasic oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
levora-28 oral tablet 015-003 mg ACA PV
lillow (28) oral tablet 015-003 mg ACA PV
LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG (24)10 MCG (2)
ACA PV
lojaimiess oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)
ACA PV
loryna (28) oral tablet 3-002 mg ACA PV
low-ogestrel (28) oral tablet 03-30 mg-mcg ACA PV
lo-zumandimine (28) oral tablet 3-002 mg ACA PV
lutera (28) oral tablet 01-20 mg-mcg ACA PV
106
Drug Name Drug Tier Requirements Limits
marlissa (28) oral tablet 015-003 mg ACA PV
merzee oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV
mibelas 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
microgestin 1530 (21) oral tablet 15-30 mg-mcg ACA PV
microgestin 120 (21) oral tablet 1-20 mg-mcg ACA PV
microgestin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
microgestin fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
mili oral tablet 025-35 mg-mcg ACA PV
mono-linyah oral tablet 025-35 mg-mcg ACA PV
my choice oral tablet 15 mg ACA PV
my way oral tablet 15 mg ACA PV
NATAZIA ORAL TABLET 3 MG2 MG-2 MG 2 MG-3 MG1 MG
ACA PV
necon 0535 (28) oral tablet 05-35 mg-mcg ACA PV
new day oral tablet 15 mg ACA PV
NEXTSTELLIS ORAL TABLET 3 MG- 142 MG (28)
ACA PV
nikki (28) oral tablet 3-002 mg ACA PV
noreth-ethinyl estradiol-iron oral tabletchewable 04mg-35mcg(21) and 75 mg (7) 08mg-25mcg(24) and 75 mg (4)
ACA PV
norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg 15-30 mg-mcg
ACA PV
norethindrone-eestradiol-iron oral capsule 1 mg-20 mcg (24)75 mg (4)
ACA PV
norethindrone-eestradiol-iron oral tablet 1 mg-20 mcg (21)75 mg (7) 15 mg-30 mcg (21)75 mg (7)
ACA PV
norethindrone-eestradiol-iron oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
norgestimate-ethinyl estradiol oral tablet 0180215025 mg-25 mcg 0180215025 mg-35 mcg (28) 025-35 mg-mcg
ACA PV
nortrel 0535 (28) oral tablet 05-35 mg-mcg ACA PV
nortrel 135 (21) oral tablet 1-35 mg-mcg (21) ACA PV
nortrel 135 (28) oral tablet 1-35 mg-mcg ACA PV
107
Drug Name Drug Tier Requirements Limits
nortrel 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
nylia 777 (28) oral tablet 050751 mg- 35 mcg ACA PV
nymyo oral tablet 025-35 mg-mcg ACA PV
ocella oral tablet 3-003 mg ACA PV
opcicon one-step oral tablet 15 mg ACA PV
option-2 oral tablet 15 mg ACA PV
orsythia oral tablet 01-20 mg-mcg ACA PV
philith oral tablet 04-35 mg-mcg ACA PV
pimtrea (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
pirmella oral tablet 050751 mg- 35 mcg 1-35 mg-mcg
ACA PV
portia 28 oral tablet 015-003 mg ACA PV
previfem oral tablet 025-35 mg-mcg ACA PV
reclipsen (28) oral tablet 015-003 mg ACA PV
rivelsa oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg
ACA PV
setlakin oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
simliya (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
simpesse oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
SLYND ORAL TABLET 4 MG (28) ACA PV
sprintec (28) oral tablet 025-35 mg-mcg ACA PV
sronyx oral tablet 01-20 mg-mcg ACA PV
syeda oral tablet 3-003 mg ACA PV
tarina 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
tarina fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
tilia fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9) ACA PV
tri femynor oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-estarylla oral tablet 0180215025 mg-35 mcg (28)
ACA PV
108
Drug Name Drug Tier Requirements Limits
tri-legest fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9)
ACA PV
tri-linyah oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-lo-estarylla oral tablet 0180215025 mg-25 mcg
ACA PV
tri-lo-marzia oral tablet 0180215025 mg-25 mcg
ACA PV
tri-lo-mili oral tablet 0180215025 mg-25 mcg ACA PV
tri-lo-sprintec oral tablet 0180215025 mg-25 mcg
ACA PV
tri-mili oral tablet 0180215025 mg-35 mcg (28) ACA PV
tri-nymyo oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-previfem (28) oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-sprintec (28) oral tablet 0180215025 mg-35 mcg (28)
ACA PV
trivora (28) oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
tri-vylibra lo oral tablet 0180215025 mg-25 mcg
ACA PV
tri-vylibra oral tablet 0180215025 mg-35 mcg (28)
ACA PV
TYBLUME ORAL TABLETCHEWABLE 01 MG- 20 MCG
ACA PV
tydemy oral tablet 3-003-0451 mg (21) (7) ACA PV
velivet triphasic regimen (28) oral tablet 0112515-25 mg-mcg
ACA PV
vestura (28) oral tablet 3-002 mg ACA PV
vienva oral tablet 01-20 mg-mcg ACA PV
viorele (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
volnea (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
vyfemla (28) oral tablet 04-35 mg-mcg ACA PV
vylibra oral tablet 025-35 mg-mcg ACA PV
wera (28) oral tablet 05-35 mg-mcg ACA PV
wymzya fe oral tabletchewable 04mg-35mcg(21) and 75 mg (7)
ACA PV
109
Drug Name Drug Tier Requirements Limits
zarah oral tablet 3-003 mg ACA PV
zovia 135e (28) oral tablet 1-35 mg-mcg ACA PV
zumandimine (28) oral tablet 3-003 mg ACA PV
OXYTOCICS
methergine oral tablet 02 mg 1
methylergonovine oral tablet 02 mg 1
OPHTHALMOLOGY
ANTIBIOTICS
ak-poly-bac ophthalmic (eye) ointment 500-10000 unitgram
1
AZASITE OPHTHALMIC (EYE) DROPS 1 1
bacitracin ophthalmic (eye) ointment 500 unitgram
1
bacitracin-polymyxin b ophthalmic (eye) ointment 500-10000 unitgram
1
BESIVANCE OPHTHALMIC (EYE) DROPSSUSPENSION 06
1
ciprofloxacin hcl ophthalmic (eye) drops 03 1
erythromycin ophthalmic (eye) ointment 5 mggram (05 )
1
gatifloxacin ophthalmic (eye) drops 05 1
gentak ophthalmic (eye) ointment 03 (3 mggram)
1
gentamicin ophthalmic (eye) drops 03 1
levofloxacin ophthalmic (eye) drops 05 1
moxifloxacin ophthalmic (eye) drops 05 1
moxifloxacin ophthalmic (eye) drops viscous 05
1
NATACYN OPHTHALMIC (EYE) DROPSSUSPENSION 5
1
neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
1
neomycin-polymyxin-gramicidin ophthalmic (eye) drops 175 mg-10000 unit-0025mgml
1
neo-polycin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
1
ofloxacin ophthalmic (eye) drops 03 1
110
Drug Name Drug Tier Requirements Limits
polycin ophthalmic (eye) ointment 500-10000 unitgram
1
polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10000 unit- 1 mgml
1
tobramycin ophthalmic (eye) drops 03 1
TOBREX OPHTHALMIC (EYE) OINTMENT 03
1
ANTIVIRALS
trifluridine ophthalmic (eye) drops 1 1
ZIRGAN OPHTHALMIC (EYE) GEL 015 1
BETA-BLOCKERS
betaxolol ophthalmic (eye) drops 05 1
BETIMOL OPHTHALMIC (EYE) DROPS 025 05
1
BETOPTIC S OPHTHALMIC (EYE) DROPSSUSPENSION 025
1
carteolol ophthalmic (eye) drops 1 1
levobunolol ophthalmic (eye) drops 05 1
timolol maleate ophthalmic (eye) drops 025 05
1
timolol maleate ophthalmic (eye) drops once daily 05
1
timolol maleate ophthalmic (eye) gel forming solution 025 05
1
CYCLOPLEGIC MYDRIATICS
atropine ophthalmic (eye) drops 1 1
atropine ophthalmic (eye) ointment 1 1
cyclopentolate ophthalmic (eye) drops 05 1 2
1
homatropaire ophthalmic (eye) drops 5 1
tropicamide ophthalmic (eye) drops 05 1 1
DIRECT ACTING MIOTICS
pilocarpine hcl ophthalmic (eye) drops 1 2 4
1
MISCELLANEOUS OPHTHALMOLOGICS
ALOCRIL OPHTHALMIC (EYE) DROPS 2 1 ST
ALOMIDE OPHTHALMIC (EYE) DROPS 01 1 ST
111
Drug Name Drug Tier Requirements Limits
altacaine ophthalmic (eye) drops 05 1
azelastine ophthalmic (eye) drops 005 1
BEOVU INTRAVITREAL SOLUTION 6 MG005 ML
MB PA LA
bepotastine besilate ophthalmic (eye) drops 15 1 ST
BEPREVE OPHTHALMIC (EYE) DROPS 15 1 ST
cromolyn ophthalmic (eye) drops 4 1
CYSTARAN OPHTHALMIC (EYE) DROPS 044
2 PA
epinastine ophthalmic (eye) drops 005 1
EYLEA INTRAVITREAL SOLUTION 2 MG005 ML
MB PA LA
EYLEA INTRAVITREAL SYRINGE 2 MG005 ML
MB PA LA
LACRISERT OPHTHALMIC (EYE) INSERT 5 MG
1
LASTACAFT OPHTHALMIC (EYE) DROPS 025
1 ST
LUCENTIS INTRAVITREAL SOLUTION 03 MG005 ML 05 MG005 ML
MB PA LA
LUCENTIS INTRAVITREAL SYRINGE 03 MG005 ML 05 MG005 ML
MB PA LA
LUXTURNA SUBRETINAL SUSPENSION 15 X 10EXP11 VG03 ML (FNL)
MB LA
olopatadine ophthalmic (eye) drops 01 02 1
OMIDRIA INTRAOCULAR CONCENTRATE 1-03
MB
proparacaine ophthalmic (eye) drops 05 1
RESTASIS OPHTHALMIC (EYE) DROPPERETTE 005
1 QL (120 per 30 days)
TETRACAINE HCL (PF) OPHTHALMIC (EYE) DROPS 05
1
tetracaine hcl ophthalmic (eye) drops 05 1
VISUDYNE INTRAVENOUS RECON SOLN 15 MG
MB LA
XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5
1 PA ST QL (60 per 30 days)
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
112
Drug Name Drug Tier Requirements Limits
ACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE 045
1 ST
bromfenac ophthalmic (eye) drops 009 1
diclofenac sodium ophthalmic (eye) drops 01 1
flurbiprofen sodium ophthalmic (eye) drops 003
1
ketorolac ophthalmic (eye) drops 04 05 1
NEVANAC OPHTHALMIC (EYE) DROPSSUSPENSION 01
1
ORAL DRUGS FOR GLAUCOMA
acetazolamide oral capsule extended release 500 mg
1
acetazolamide oral tablet 125 mg 250 mg 1
methazolamide oral tablet 25 mg 50 mg 1
OTHER GLAUCOMA DRUGS
bimatoprost ophthalmic (eye) drops 003 1
brinzolamide ophthalmic (eye) dropssuspension 1
1
COMBIGAN OPHTHALMIC (EYE) DROPS 02-05
1
dorzolamide ophthalmic (eye) drops 2 1
dorzolamide-timolol (pf) ophthalmic (eye) dropperette 2-05
1
dorzolamide-timolol ophthalmic (eye) drops 223-68 mgml
1
latanoprost ophthalmic (eye) drops 0005 1
LUMIGAN OPHTHALMIC (EYE) DROPS 001
1 ST
RHOPRESSA OPHTHALMIC (EYE) DROPS 002
1 PA ST
SIMBRINZA OPHTHALMIC (EYE) DROPSSUSPENSION 1-02
1
travoprost ophthalmic (eye) drops 0004 1
STEROID-ANTIBIOTIC COMBINATIONS
neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
1
neomycin-polymyxin b-dexameth ophthalmic (eye) dropssuspension 35mgml-10000 unitml-01
1
113
Drug Name Drug Tier Requirements Limits
neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 35 mgg-10000 unitg-01
1
neomycin-polymyxin-hc ophthalmic (eye) dropssuspension 35-10000-10 mg-unit-mgml
1
neo-polycin hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
1
TOBRADEX OPHTHALMIC (EYE) OINTMENT 03-01
1
TOBRADEX ST OPHTHALMIC (EYE) DROPSSUSPENSION 03-005
1
tobramycin-dexamethasone ophthalmic (eye) dropssuspension 03-01
1
STEROIDS
ALREX OPHTHALMIC (EYE) DROPSSUSPENSION 02
1 ST
dexamethasone sodium phosphate ophthalmic (eye) drops 01
1
DUREZOL OPHTHALMIC (EYE) DROPS 005
1
fluorometholone ophthalmic (eye) dropssuspension 01
1
FML FORTE OPHTHALMIC (EYE) DROPSSUSPENSION 025
1
FML SOP OPHTHALMIC (EYE) OINTMENT 01
1
INVELTYS OPHTHALMIC (EYE) DROPSSUSPENSION 1
1 ST
LOTEMAX OPHTHALMIC (EYE) OINTMENT 05
1 ST
loteprednol etabonate ophthalmic (eye) dropsgel 05
1
loteprednol etabonate ophthalmic (eye) dropssuspension 05
1
MAXIDEX OPHTHALMIC (EYE) DROPSSUSPENSION 01
1
OZURDEX INTRAVITREAL IMPLANT 07 MG MB LA
PRED MILD OPHTHALMIC (EYE) DROPSSUSPENSION 012
1
prednisolone acetate ophthalmic (eye) dropssuspension 1
1
114
Drug Name Drug Tier Requirements Limits
prednisolone sodium phosphate ophthalmic (eye) drops 1
1
RETISERT INTRAVITREAL IMPLANT 059 MG
MB LA
YUTIQ INTRAVITREAL IMPLANT 018 MG MB
STEROID-SULFONAMIDE COMBINATIONS
BLEPHAMIDE OPHTHALMIC (EYE) DROPSSUSPENSION 10-02
1
BLEPHAMIDE SOP OPHTHALMIC (EYE) OINTMENT 10-02
1
sulfacetamide-prednisolone ophthalmic (eye) drops 10 -023 (025 )
1
SULFONAMIDES
sulfacetamide sodium ophthalmic (eye) drops 10
1
sulfacetamide sodium ophthalmic (eye) ointment 10
1
SYMPATHOMIMETICS
apraclonidine ophthalmic (eye) drops 05 1
brimonidine ophthalmic (eye) drops 015 02 1
IOPIDINE OPHTHALMIC (EYE) DROPPERETTE 1
1
VASOCONSTRICTOR DECONGESTANTS
phenylephrine hcl ophthalmic (eye) drops 10 25
1
RESPIRATORY ALLERGY COUGH amp COLD
ANTIHISTAMINE amp ANTIALLERGENIC AGENTS
adrenalin injection solution 1 mgml 1 mgml (1 ml)
1
carbinoxamine maleate oral liquid 4 mg5 ml 1 PA ST QL (2 per 30 days)
carbinoxamine maleate oral tablet 4 mg 1 PA ST QL (240 per 30 days)
carbinoxamine maleate oral tablet 6 mg 1 PA ST QL (120 per 30 days)
cetirizine oral solution 1 mgml 1
clemastine oral syrup 05 mg5 ml 1
clemastine oral tablet 268 mg 1
cyproheptadine oral syrup 2 mg5 ml 1
cyproheptadine oral tablet 4 mg 1
115
Drug Name Drug Tier Requirements Limits
desloratadine oral tablet 5 mg 1 PA ST QL (30 per 30 days)
desloratadine oral tabletdisintegrating 25 mg 5 mg
1 PA ST
diphenhydramine hcl injection solution 50 mgml 1
diphenhydramine hcl injection syringe 50 mgml MB
EPINEPHRINE INJECTION AUTO-INJECTOR 015 MG015 ML
1
epinephrine injection auto-injector 015 mg03 ml 03 mg03 ml
1
epinephrine injection solution 1 mgml 1 mgml (1 ml)
1
epinephrine injection syringe 01 mgml 1
hydroxyzine hcl intramuscular solution 25 mgml MB
hydroxyzine hcl oral solution 10 mg5 ml 1
hydroxyzine hcl oral tablet 10 mg 25 mg 50 mg 1
hydroxyzine pamoate oral capsule 100 mg 25 mg 50 mg
1
levocetirizine oral solution 25 mg5 ml 1
levocetirizine oral tablet 5 mg 1
promethazine injection solution 25 mgml MB
promethazine oral syrup 625 mg5 ml 1
promethazine oral tablet 125 mg 25 mg 50 mg 1
promethazine rectal suppository 125 mg 25 mg 1
promethegan rectal suppository 125 mg 25 mg 50 mg
1
COUGH amp COLD THERAPY
benzonatate oral capsule 100 mg 150 mg 200 mg 1
brompheniramine-pseudoeph-dm oral syrup 2-30-10 mg5 ml
1
codeine-guaifenesin oral liquid 10-100 mg5 ml 1
g tussin ac oral liquid 10-100 mg5 ml 1
guaiatussin ac oral liquid 10-100 mg5 ml 1
hydrocodone-chlorpheniramine oral suspensionextended rel 12 hr 10-8 mg5 ml
1
hydrocodone-homatropine oral syrup 5-15 mg5 ml
1
hydrocodone-homatropine oral tablet 5-15 mg 1
116
Drug Name Drug Tier Requirements Limits
hydromet oral syrup 5-15 mg5 ml 1
maxi-tuss ac oral liquid 10-100 mg5 ml 1
m-clear wc oral liquid 63-100 mg5 ml 1
promethazine-codeine oral syrup 625-10 mg5 ml 1
promethazine-dm oral syrup 625-15 mg5 ml 1
promethazine-phenyleph-codeine oral syrup 625-5-10 mg5 ml
1
promethazine-phenylephrine oral syrup 625-5 mg5 ml
1
virtussin ac oral liquid 10-100 mg5 ml 1
PULMONARY AGENTS
acetylcysteine solution 100 mgml (10 ) 200 mgml (20 )
1
ADEMPAS ORAL TABLET 05 MG 1 MG 15 MG 2 MG 25 MG
2 PA LA
ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCGACTUATION 230-21 MCGACTUATION 45-21 MCGACTUATION
1 QL (1 per 30 days)
ALBUTEROL HFA 90 MCG INHALER 90 MCGACTUATION
1 QL (2 per 30 days)
albuterol sulfate inhalation inhalation hfa aerosol inhaler 90 mcgactuation
1 QL (2 per 30 days)
albuterol sulfate inhalation inhalation solution for nebulization 063 mg3 ml 125 mg3 ml 25 mg 3 ml (0083 ) 25 mg05 ml 5 mgml
1
albuterol sulfate inhalation oral syrup 2 mg5 ml 1
albuterol sulfate inhalation oral tablet 2 mg 4 mg 1
albuterol sulfate inhalation oral tablet extended release 12 hr 4 mg 8 mg
1
ALVESCO INHALATION HFA AEROSOL INHALER 160 MCGACTUATION 80 MCGACTUATION
1 PA ST QL (1 per 30 days)
alyq oral tablet 20 mg 2 PA
ambrisentan oral tablet 10 mg 5 mg 2 PA LA
aminophylline intravenous solution 250 mg10 ml MB
ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 625-25 MCGACTUATION
1 QL (1 per 30 days)
arformoterol inhalation solution for nebulization 15 mcg2 ml
1
117
Drug Name Drug Tier Requirements Limits
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 200 MCGACTUATION
1 QL (1 per 30 days)
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 50 MCGACTUATION
1
ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCGACTUATION
1 QL (2 per 30 days)
BERINERT INTRAVENOUS KIT 500 UNIT (10 ML)
MB PA LA
BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-48 MCG
1
bosentan oral tablet 125 mg 625 mg 2 PA LA
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCGDOSE
1 QL (1 per 30 days)
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 200-25 MCGDOSE
1
BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG2 ML
1
budesonide inhalation suspension for nebulization 025 mg2 ml 05 mg2 ml
1 QL (120 per 30 days)
budesonide inhalation suspension for nebulization 1 mg2 ml
1 QL (60 per 30 days)
CINQAIR INTRAVENOUS SOLUTION 10 MGML
MB PA
CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)
MB PA LA
COMBIVENT RESPIMAT INHALATION MIST 20-100 MCGACTUATION
1 QL (2 per 30 days)
cromolyn inhalation solution for nebulization 20 mg2 ml
1
DALIRESP ORAL TABLET 250 MCG 500 MCG
1
DULERA INHALATION HFA AEROSOL INHALER 100-5 MCGACTUATION 200-5 MCGACTUATION 50-5 MCGACTUATION
1 QL (1 per 30 days)
ELIXOPHYLLIN ORAL ELIXIR 80 MG15 ML 1
ESBRIET ORAL CAPSULE 267 MG 2 PA LA QL (270 per 30 days)
ESBRIET ORAL TABLET 267 MG 801 MG 2 PA LA QL (90 per 30 days)
FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MGML
MB PA LA
118
Drug Name Drug Tier Requirements Limits
FASENRA SUBCUTANEOUS SYRINGE 30 MGML
MB PA LA
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 50 MCGACTUATION
1 QL (1 per 30 days)
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCGACTUATION
1 QL (4 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCGACTUATION 44 MCGACTUATION
1 QL (1 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCGACTUATION
1 QL (2 per 30 days)
fluticasone propionate nasal spraysuspension 50 mcgactuation
1
fluticasone propion-salmeterol inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose
1 QL (1 per 30 days)
formoterol fumarate inhalation solution for nebulization 20 mcg2 ml
1
HAEGARDA SUBCUTANEOUS RECON SOLN 2000 UNIT 3000 UNIT
2 PA LA
icatibant subcutaneous syringe 30 mg3 ml 2 PA
INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 625 MCGACTUATION
1 QL (1 per 30 days)
ipratropium bromide inhalation solution 002 1
ipratropium-albuterol inhalation solution for nebulization 05 mg-3 mg(25 mg base)3 ml
1 QL (180 per 30 days)
KALBITOR SUBCUTANEOUS SOLUTION 10 MGML (1 ML)
2 PA LA
KALYDECO ORAL GRANULES IN PACKET 25 MG 50 MG 75 MG
2 PA LA
KALYDECO ORAL TABLET 150 MG 2 PA LA
levalbuterol hcl inhalation solution for nebulization 031 mg3 ml 063 mg3 ml 125 mg05 ml 125 mg3 ml
1
LEVALBUTEROL TARTRATE INHALATION HFA AEROSOL INHALER 45 MCGACTUATION
1 QL (2 per 30 days)
metaproterenol oral syrup 10 mg5 ml 1
montelukast oral granules in packet 4 mg 1
montelukast oral tablet 10 mg 1
119
Drug Name Drug Tier Requirements Limits
montelukast oral tabletchewable 4 mg 5 mg 1
nebusal inhalation solution for nebulization 3 1
NUCALA SUBCUTANEOUS RECON SOLN 100 MG
MB PA LA
OFEV ORAL CAPSULE 100 MG 150 MG 2 PA LA QL (60 per 30 days)
OPSUMIT ORAL TABLET 10 MG 2 PA LA
ORLADEYO ORAL CAPSULE 110 MG 150 MG
2 PA ST QL (28 per 28 days)
PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG2 ML
1
pulmosal inhalation solution for nebulization 7 1
PULMOZYME INHALATION SOLUTION 1 MGML
2 PA LA
QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCGACTUATION 80 MCGACTUATION
1
REVATIO INTRAVENOUS SOLUTION 10 MG125 ML
MB LA
RUCONEST INTRAVENOUS RECON SOLN 2100 UNIT
MB PA LA
SEEBRI NEOHALER INHALATION CAPSULE WINHALATION DEVICE 156 MCG
1
SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCGDOSE
1
sildenafil (pulmhypertension) intravenous solution 10 mg125 ml
MB
sildenafil (pulmhypertension) oral suspension for reconstitution 10 mgml
2
sildenafil (pulmhypertension) oral tablet 20 mg 2 PA
SINUVA SINUS IMPLANT 1350 MCG MB
sodium chloride inhalation solution for nebulization 09 10 3 7
1
SPIRIVA RESPIMAT INHALATION MIST 125 MCGACTUATION
1
SPIRIVA RESPIMAT INHALATION MIST 25 MCGACTUATION
1 QL (1 per 30 days)
SPIRIVA WITH HANDIHALER INHALATION CAPSULE WINHALATION DEVICE 18 MCG
1 QL (30 per 30 days)
STIOLTO RESPIMAT INHALATION MIST 25-25 MCGACTUATION
1
120
Drug Name Drug Tier Requirements Limits
STRIVERDI RESPIMAT INHALATION MIST 25 MCGACTUATION
1
SYMBICORT INHALATION HFA AEROSOL INHALER 160-45 MCGACTUATION 80-45 MCGACTUATION
1 QL (1 per 30 days)
SYMDEKO ORAL TABLETS SEQUENTIAL 100-150 MG (D) 150 MG (N) 50-75 MG (D) 75 MG (N)
2 PA LA
tadalafil (pulm hypertension) oral tablet 20 mg 2 PA
TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG2 ML (150 MGML)
2 PA LA
terbutaline oral tablet 25 mg 5 mg 1
terbutaline subcutaneous solution 1 mgml 1
theophylline oral elixir 80 mg15 ml 1
theophylline oral solution 80 mg15 ml 1
theophylline oral tablet extended release 12 hr 300 mg 450 mg
1
theophylline oral tablet extended release 24 hr 400 mg 600 mg
1
TRACLEER ORAL TABLET FOR SUSPENSION 32 MG
2 PA LA
TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-625-25 MCG 200-625-25 MCG
1
TRIKAFTA ORAL TABLETS SEQUENTIAL 100-50-75 MG(D) 150 MG (N) 50-25-375 MG (D)75 MG (N)
2 PA LA
TYVASO INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)
2 PA LA
TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)
2 PA LA
TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML
2 PA LA
UTIBRON NEOHALER INHALATION CAPSULE WINHALATION DEVICE 275-156 MCG
1
VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCGML 20 MCGML
2 PA LA
121
Drug Name Drug Tier Requirements Limits
wixela inhub inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose
1 QL (1 per 30 days)
XOLAIR SUBCUTANEOUS RECON SOLN 150 MG
MB LA
XOLAIR SUBCUTANEOUS SYRINGE 150 MGML 75 MG05 ML
MB PA LA QL (7 per 30 days)
zafirlukast oral tablet 10 mg 20 mg 1
zileuton oral tablet er multiphase 12 hr 600 mg 1 ST
ZYFLO ORAL TABLET 600 MG 1 ST
UROLOGICALS
ANTICHOLINERGICS amp ANTISPASMODICS
darifenacin oral tablet extended release 24 hr 15 mg 75 mg
1
flavoxate oral tablet 100 mg 1
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG 50 MG
1 ST
oxybutynin chloride oral syrup 5 mg5 ml 1
oxybutynin chloride oral tablet 5 mg 1
oxybutynin chloride oral tablet extended release 24hr 10 mg 15 mg 5 mg
1
solifenacin oral tablet 10 mg 5 mg 1
tolterodine oral capsuleextended release 24hr 2 mg 4 mg
1
tolterodine oral tablet 1 mg 2 mg 1
trospium oral capsuleextended release 24hr 60 mg
1
trospium oral tablet 20 mg 1
BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY
alfuzosin oral tablet extended release 24 hr 10 mg 1
dutasteride oral capsule 05 mg 1
dutasteride-tamsulosin oral capsule er multiphase 24 hr 05-04 mg
1
finasteride oral tablet 5 mg 1
silodosin oral capsule 4 mg 8 mg 1
tadalafil oral tablet 25 mg 5 mg 1 PA ST
tamsulosin oral capsule 04 mg 1
CHOLINERGIC STIMULANTS
122
Drug Name Drug Tier Requirements Limits
bethanechol chloride oral tablet 10 mg 25 mg 5 mg 50 mg
1
MISCELLANEOUS UROLOGICALS
CYSTAGON ORAL CAPSULE 150 MG 50 MG 2 PA
ELMIRON ORAL CAPSULE 100 MG 1
hyophen oral tablet 816-012-108 mg 1
K-PHOS NO 2 ORAL TABLET 305-700 MG 1
K-PHOS ORIGINAL ORAL TABLETSOLUBLE 500 MG
1
methen-sod phos-meth blue-hyos oral tablet 816-408-012 mg
1
OXLUMO SUBCUTANEOUS SOLUTION 945 MG05 ML
2 PA
phosphasal oral tablet 816-108-408 mg 1
potassium citrate oral tablet extended release 10 meq (1080 mg) 15 meq 5 meq (540 mg)
1
RENACIDIN IRRIGATION SOLUTION 19806 MG-594 MG-9804MG30ML
1
URELLE ORAL TABLET 81-108-408 MG 1
uretron d-s oral tablet 816-108-408 mg 1
urimar-t oral tablet 120-012-108 mg 1
urogesic-blue oral tablet 816-408-012 mg 1
uryl oral tablet 816-408-012 mg 1
ustell oral capsule 120-012 mg 1
utira-c oral tablet 816-108-408 mg 1
URINARY ANESTHETICS
phenazopyridine oral tablet 100 mg 200 mg 1
VITAMINS HEMATINICS amp ELECTROLYTES
ELECTROLYTES
effer-k oral tablet effervescent 25 meq 1
klor-con 10 oral tablet extended release 10 meq 1
klor-con 8 oral tablet extended release 8 meq 1
klor-con m10 oral tableter particlescrystals 10 meq
1
klor-con m15 oral tableter particlescrystals 15 meq
1
123
Drug Name Drug Tier Requirements Limits
klor-con m20 oral tableter particlescrystals 20 meq
1
klor-con oral packet 20 meq 1
klor-conef oral tablet effervescent 25 meq 1
K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ
1
k-tab oral tablet extended release 8 meq 1
NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION
MB
potassium chloride oral capsule extended release 10 meq 8 meq
1
potassium chloride oral liquid 20 meq15 ml 40 meq15 ml
1
potassium chloride oral packet 20 meq 1
potassium chloride oral tablet extended release 10 meq 20 meq 8 meq
1
potassium chloride oral tableter particlescrystals 10 meq 20 meq
1
sodium chloride 045 intravenous parenteral solution 045
MB
MISCELLANEOUS VITAMINS HEMATINICS amp ELECTROLYTES
ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION
MB
PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION
MB
PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION
MB
VITAMINS amp HEMATINICS
cyanocobalamin (vitamin b-12) injection solution 1000 mcgml
1
ergocalciferol (vitamin d2) oral capsule 1250 mcg (50000 unit)
1
FA-8 ORAL CAPSULE 08 MG ACA PV
FER-IN-SOL ORAL DROPS 15 MG IRON (75 MG)ML
ACA PV
FLORIVA (FLUORIDE-VITAMIN D3) ORAL DROPS 025 MG (055 MG)-400 UNITML
ACA PV
fluoride (sodium) oral drops 05 mg (11 mg sodfluorid)ml
ACA PV
124
Drug Name Drug Tier Requirements Limits
fluoride (sodium) oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)
ACA PV
folic acid injection solution 5 mgml 1
folic acid oral tablet 1 mg 1
folic acid oral tablet 400 mcg 800 mcg ACA PV
hydroxocobalamin intramuscular solution 1000 mcgml
1
INFED INJECTION SOLUTION 50 MGML MB
ludent fluoride oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)
ACA PV
multi-vitamin with fluoride oral drops 025 mgml 05 mgml
ACA PV
multi-vitamin with fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
multivitamins with fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
mvc-fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
NOVAFERRUM ORAL DROPS 15 MG IRONML
ACA PV
tri-vitamin with fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml
ACA PV
vitamins acd and fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml
ACA PV
125
Index
A abacavir 2 abacavir-lamivudine 2 abacavir-lamivudine-
zidovudine 2 ABILIFY MAINTENA 36 abiraterone 13 ABRAXANE 13 acamprosate 66 acarbose 77 accutane 59 acebutolol 45 acetaminophen-caff-
dihydrocod 30 acetaminophen-codeine 31 acetazolamide 112 acetic acid 66 69 acetylcysteine 116 acitretin 57 ACTEMRA 95 ACTEMRA ACTPEN 95 ACTHAR 70 ACTHIB (PF) 90 ACTIMMUNE 89 ACUVAIL (PF) 112 acyclovir 2 63 ADACEL(TDAP
ADOLESNADULT)(PF) 90 ADAKVEO 13 adapalene 59 60 ADAPALENE 60 adapalene-benzoyl peroxide 60 ADCETRIS 14 adefovir 2 ADEMPAS 116 ADHANSIA XR 36 adrenalin 114 adult aspirin regimen 33 ADVAIR HFA 116 ADVATE 50 ADYNOVATE 50 ADZENYS ER 36 ADZENYS XR-ODT 36 AEROCHAMBER MINI 71 AEROCHAMBER PLUS
FLOW-VU 71 AFINITOR 14 afirmelle 102
AFSTYLA 50 AIMOVIG AUTOINJECTOR
28 AJOVY AUTOINJECTOR 28 AJOVY SYRINGE 28 ak-poly-bac 109 AKYNZEO (NETUPITANT)
81 ala-cort 63 albendazole 8 albuterol sulfate inhalation 116 ALBUTEROL SULFATE
INHALATION 116 alclometasone 63 ALCORTIN A 61 ALDURAZYME 74 ALECENSA 14 alendronate 95 alfuzosin 121 ALIMTA 14 ALINIA 8 ALIQOPA 14 aliskiren 45 allopurinol 95 almotriptan malate 28 ALOCRIL 110 ALOGLIPTIN-
PIOGLITAZONE 77 ALOMIDE 110 alosetron 81 ALOXI 81 ALPHANATE 50 ALPHANINE SD 50 alprazolam 37 alprazolam intensol 37 ALPROLIX 50 ALREX 113 ALTABAX 61 altacaine 111 altavera (28) 102 ALVESCO 116 alyacen 135 (28) 102 alyacen 777 (28) 102 alyq 116 amabelz 98 amantadine hcl 2 AMBISOME 1 ambrisentan 116
amcinonide 63 amethia 102 amethyst (28) 102 amikacin 8 amiloride 45 amiloride-hydrochlorothiazide
45 aminocaproic acid 50 51 aminophylline 116 amiodarone 44 AMITIZA 81 amitriptyline 37 amitriptyline-chlordiazepoxide
37 amlodipine 45 amlodipine-atorvastatin 55 amlodipine-benazepril 45 amlodipine-olmesartan 45 amlodipine-valsartan 45 amlodipine-valsartan-hcthiazid
45 ammonium lactate 59 amnesteem 60 amoxapine 37 amoxicil-clarithromy-lansopraz
85 amoxicillin 11 amoxicillin-pot clavulanate 11 AMPHETAMINE 37 amphetamine sulfate 37 amphotericin b 1 ampicillin 11 ampicillin-sulbactam 11 anagrelide 66 anaspaz 80 anastrozole 14 ANDEXXA 51 ANDRODERM 74 ANGELIQ 98 ANNOVERA 101 ANORO ELLIPTA 116 anucort-hc 81 apexicon e 63 APLENZIN 37 APOKYN 27 apraclonidine 114 aprepitant 81 apri 102
126
APTIVUS 2 ARALAST NP 66 aranelle (28) 102 ARANESP (IN
POLYSORBATE) 86 ARCALYST 89 ARESTIN 68 arformoterol 116 aripiprazole 37 ARISTADA 37 ARISTADA INITIO 37 armodafinil 37 ARMOUR THYROID 79 ARNUITY ELLIPTA 117 ARRANON 14 ARZERRA 14 ASCENIV 90 ascomp with codeine 31 asenapine maleate 37 ashlyna 102 ASPARLAS 14 aspirin 33 34 aspirin low dose 33 aspirin-dipyridamole 51 aspir-trin 34 atazanavir 2 atenolol 45 atenolol-chlorthalidone 45 ATGAM 90 atomoxetine 37 atorvastatin 55 atovaquone 8 atovaquone-proguanil 8 atropine 80 110 ATROVENT HFA 117 AUBAGIO 87 aubra 102 aubra eq 102 aurovela 1530 (21) 102 aurovela 120 (21) 102 aurovela 24 fe 102 aurovela fe 1530 (28) 102 aurovela fe 1-20 (28) 102 AUSTEDO 29 AVASTIN 14 aviane 102 avidoxy 12 avita 60 AVITA 60 AVONEX 88 AVYCAZ 6
ayuna 102 AZASITE 109 azathioprine 14 azelaic acid 60 azelastine 68 111 AZELEX 60 azithromycin 7 azurette (28) 102 B bacitracin 8 109 bacitracin-polymyxin b 109 baclofen 30 BALCOLTRA 102 balsalazide 81 BALVERSA 14 balziva (28) 102 BANZEL 24 BAQSIMI 71 BARACLUDE 2 BAVENCIO 14 BAXDELA 12 bayer aspirin 34 BAYER CHEWABLE
ASPIRIN 34 BCG VACCINE LIVE (PF) 90 BELEODAQ 14 belladonna alkaloids-opium 80 BELRAPZO 14 BELSOMRA 37 benazepril 45 benazepril-hydrochlorothiazide
45 BENDAMUSTINE 14 BENDEKA 14 BENEFIX 51 BENLYSTA 96 benzonatate 115 benztropine 27 BEOVU 111 bepotastine besilate 111 BEPREVE 111 BERINERT 117 beser 63 BESIVANCE 109 BESPONSA 14 betamethasone dipropionate 63 betamethasone valerate 63 betamethasone augmented 63
64 BETASERON 88 betaxolol 45 110
bethanechol chloride 122 BETIMOL 110 BETOPTIC S 110 BEVESPI AEROSPHERE 117 bexarotene 14 BEXSERO 90 bicalutamide 14 BICILLIN C-R 11 BIKTARVY 2 bimatoprost 112 BIOTHRAX 90 bisoprolol fumarate 45 bisoprolol-hydrochlorothiazide
45 BIVIGAM 90 BLEPHAMIDE 114 BLEPHAMIDE SOP 114 BLINCYTO 14 blisovi 24 fe 102 blisovi fe 1530 (28) 102 blisovi fe 120 (28) 103 BOOSTRIX TDAP 90 BORTEZOMIB 14 bosentan 117 BOSULIF 14 BOTOX 90 BRAFTOVI 14 BREO ELLIPTA 117 briellyn 103 BRILINTA 51 brimonidine 114 BRINEURA 75 brinzolamide 112 BRIVIACT 24 bromfenac 112 bromocriptine 27 brompheniramine-pseudoeph-
dm 115 BROVANA 117 budesonide 81 117 bumetanide 45 buprenorphine 31 buprenorphine hcl 31 buprenorphine-naloxone 34 bupropion hcl 37 38 bupropion hcl (smoking deter)
68 buspirone 38 BUSULFEX 15 butalbital compound wcodeine
31
127
butalbital-acetaminop-caf-cod 31
butalbital-acetaminophen-caff 31
butalbital-aspirin-caffeine 31 butorphanol 34 BYDUREON BCISE 77 BYETTA 77 BYSTOLIC 45 C CABENUVA 2 cabergoline 75 CABLIVI 51 CABOMETYX 15 calcipotriene 57 calcipotriene-betamethasone 57 calcitonin (salmon) 75 calcitriol 57 75 calcium acetate(phosphat bind)
81 CALQUENCE 15 camila 98 camrese 103 camrese lo 103 CANCIDAS 1 candesartan 45 candesartan-hydrochlorothiazid
46 CAPASTAT 8 capecitabine 15 CAPRELSA 15 captopril 46 captopril-hydrochlorothiazide
46 CARBAGLU 66 carbamazepine 24 carbidopa 27 carbidopa-levodopa 27 carbidopa-levodopa-
entacapone 27 carbinoxamine maleate 114 carisoprodol 30 carisoprodol-aspirin 30 carisoprodol-aspirin-codeine 30 carteolol 110 cartia xt 46 carvedilol 46 carvedilol phosphate 46 cataflam 34 CAYA CONTOURED 98 CAYSTON 8
caziant (28) 103 cefaclor 6 cefadroxil 6 cefazolin 6 cefazolin in dextrose (iso-os) 6 cefdinir 6 cefditoren pivoxil 6 cefepime 6 CEFEPIME IN DEXTROSE 5
6 cefepime in dextroseiso-osm 6 cefixime 6 CEFOTAN 6 cefotaxime 6 cefotetan 6 CEFOTETAN IN
DEXTROSE ISO-OSM 6 cefoxitin 6 cefpodoxime 6 7 cefprozil 7 ceftazidime 7 CEFTAZIDIME IN D5W 7 ceftriaxone 7 CEFTRIAXONE 7 ceftriaxone in dextroseiso-os 7 cefuroxime axetil 7 celecoxib 34 CELONTIN 24 cephalexin 7 CERDELGA 75 CEREZYME 75 cetirizine 114 cevimeline 66 CHANTIX 68 CHANTIX CONTINUING
MONTH BOX 68 CHANTIX STARTING
MONTH BOX 68 charlotte 24 fe 103 chateal (28) 103 chateal eq (28) 103 CHEMET 66 childrens aspirin 34 chloramphenicol sod succinate
8 chlordiazepoxide hcl 38 chlordiazepoxide-clidinium 80 chlorhexidine gluconate 68 chloroquine phosphate 8 chlorpromazine 38 chlorthalidone 46
chlorzoxazone 30 CHOLBAM 81 cholestyramine (with sugar) 55 cholestyramine light 55 cholinemagnesium salicylate
34 ciclodan 62 ciclopirox 62 ciclopirox-ure-camph-menth-
euc 62 cidofovir 2 cilostazol 51 CIMDUO 2 cimetidine 85 cimetidine hcl 85 CIMZIA 82 CIMZIA POWDER FOR
RECONST 81 cinacalcet 75 CINQAIR 117 CINRYZE 117 CIPRO HC 69 ciprofloxacin 12 ciprofloxacin hcl 12 69 109 ciprofloxacin-dexamethasone
69 citalopram 38 claravis 60 clarithromycin 7 8 clemastine 114 CLENPIQ 82 clindacin p 60 clindamycin hcl 8 clindamycin pediatric 8 clindamycin phosphate 8 60
101 clindamycin-benzoyl peroxide
60 clindamycin-tretinoin 60 clobazam 24 clobetasol 64 clobetasol-emollient 64 CLOCORTOLONE
PIVALATE 64 CLODERM 64 CLOLAR 15 clomipramine 38 clonazepam 24 clonidine 46 clonidine hcl 38 46 clopidogrel 51
128
clorazepate dipotassium 38 clotrimazole 1 62 clotrimazole-betamethasone 62 clovique 66 clozapine 38 COAGADEX 51 COARTEM 8 codeine sulfate 31 codeine-butalbital-asa-caff 31 codeine-guaifenesin 115 colchicine 95 COLCHICINE 95 colesevelam 55 colestipol 55 COMBIGAN 112 COMBIPATCH 98 COMBIVENT RESPIMAT 117 COMETRIQ 15 COMPLERA 2 compro 82 constulose 82 CONTOUR NEXT TEST
STRIPS 71 CONTOUR TEST STRIPS 71 COPIKTRA 15 CORIFACT 51 CORLANOR 56 CORTIFOAM 82 COSENTYX 58 COSENTYX (2 SYRINGES)
57 COSENTYX PEN 58 COSENTYX PEN (2 PENS) 58 COTELLIC 15 COTEMPLA XR-ODT 38 covaryx 98 covaryx hs 98 CREON 82 CRESEMBA 1 CRINONE 98 cromolyn 82 111 117 crotan 66 cryselle (28) 103 CRYSVITA 75 CUBICIN 8 CUBICIN RF 9 CUTAQUIG 90 CUVITRU 90 cyanocobalamin (vitamin b-12)
123 cyclafem 135 (28) 103
cyclafem 777 (28) 103 cyclobenzaprine 30 cyclopentolate 110 cyclophosphamide 15 CYCLOPHOSPHAMIDE 15 CYCLOSERINE 9 CYCLOSET 77 cyclosporine 15 cyclosporine modified 15 cyproheptadine 114 CYRAMZA 15 cyred 103 cyred eq 103 CYSTAGON 122 CYSTARAN 111 CYTOVENE 2 D DACOGEN 15 dalfampridine 29 DALIRESP 117 danazol 75 dantrolene 30 dapsone 9 60 DAPTACEL (DTAP
PEDIATRIC) (PF) 91 darifenacin 121 DARZALEX 15 dasetta 135 (28) 103 dasetta 777 (28) 103 DAURISMO 15 daysee 103 DAYTRANA 38 deblitane 98 decadron 70 decitabine 15 deferasirox 66 deferiprone 66 demeclocycline 12 DENAVIR 63 denta 5000 plus 68 dentagel 69 DEPO-ESTRADIOL 98 DEPO-PROVERA 98 DEPO-SUBQ PROVERA 104
98 DEPO-TESTOSTERONE 75 DESCOVY 2 desipramine 38 desloratadine 115 desmopressin 75
desog-eestradioleestradiol 103
desogestrel-ethinyl estradiol 103
desonide 64 desoximetasone 64 DESVENLAFAXINE 38 desvenlafaxine succinate 38 dexamethasone 70 dexamethasone intensol 70 dexamethasone sodium phos
(pf) 70 dexamethasone sodium
phosphate 70 113 DEXILANT 85 dexmethylphenidate 38 dextroamphetamine 38 39 dextroamphetamine-
amphetamine 39 diazepam 24 39 diazepam intensol 39 diazoxide 71 diclofenac potassium 34 diclofenac sodium 34 59 112 diclofenac-misoprostol 34 dicloxacillin 11 dicyclomine 80 didanosine 2 DIFICID 8 diflorasone 64 diflunisal 34 digitek 50 digox 50 digoxin 50 dihydroergotamine 28 DILANTIN 24 DILANTIN EXTENDED 24 DILANTIN INFATABS 24 DILANTIN-125 24 diltiazem 46 dilt-xr 46 dimethyl fumarate 88 DIPENTUM 82 diphenhydramine hcl 115 diphenoxylate-atropine 80 dipyridamole 51 diskets 31 disopyramide phosphate 44 disulfiram 66 divalproex 24 25 DIVIGEL 99
129
dofetilide 44 dolishale 103 donepezil 29 DONNATAL 80 DOPTELET (15 TAB PACK)
51 dorzolamide 112 dorzolamide-timolol 112 dorzolamide-timolol (pf) 112 dotti 99 DOVATO 2 doxazosin 46 doxepin 39 doxercalciferol 75 doxycycline hyclate 12 doxycycline monohydrate 12 doxylamine-pyridoxine (vit b6)
82 dronabinol 82 drospirenone-eestradiol-lmfa
103 drospirenone-ethinyl estradiol
103 DSUVIA 31 DUAVEE 99 DUEXIS 34 DULERA 117 duloxetine 39 DUPIXENT PEN 59 DUPIXENT SYRINGE 59 duramorph (pf) 31 DUREZOL 113 dutasteride 121 dutasteride-tamsulosin 121 dvorah 31 DYANAVEL XR 39 DYSPORT 91 E ees 400 8 econazole 62 econtra ez 103 econtra one-step 103 ecotrin 34 ecotrin low strength 34 EDARBI 46 EDARBYCLOR 46 EDLUAR 39 ed-spaz 80 EDURANT 2 eemt 99 eemt hs 99
efavirenz 2 efavirenz-emtricitabin-tenofov
3 efavirenz-lamivu-tenofov disop
3 effer-k 122 ELAPRASE 75 ELELYSO 75 eletriptan 28 ELIGARD 16 ELIGARD (3 MONTH) 15 ELIGARD (4 MONTH) 15 ELIGARD (6 MONTH) 15 elinest 103 ELIQUIS 51 ELIQUIS DVT-PE TREAT
30D START 51 ELIXOPHYLLIN 117 ELLA 103 ELMIRON 122 ELOCTATE 51 eluryng 101 ELZONRIS 16 EMCYT 16 EMEND 82 EMGALITY PEN 28 EMGALITY SYRINGE 28 emoquette 103 EMPAVELI 67 EMPLICITI 16 EMSAM 39 emtricitabine 3 emtricitabine-tenofovir (tdf) 3 EMTRIVA 3 EMVERM 9 enalapril maleate 46 enalaprilat 46 enalapril-hydrochlorothiazide
46 ENBREL 96 ENBREL MINI 96 ENBREL SURECLICK 96 endocet 31 ENGERIX-B (PF) 91 ENGERIX-B PEDIATRIC
(PF) 91 ENHERTU 16 enoxaparin 51 enpresse 104 enskyce 104 entacapone 27
entecavir 3 ENTRESTO 56 ENTYVIO 82 enulose 82 EPANED 46 EPCLUSA 3 EPIDIOLEX 25 epinastine 111 epinephrine 115 EPINEPHRINE 115 epitol 25 EPIVIR HBV 3 eplerenone 47 EPOGEN 86 epoprostenol (glycine) 47 eprosartan 47 ERAXIS(WATER DILUENT)
1 ERBITUX 16 ergocalciferol (vitamin d2) 123 ergoloid 39 ergotamine-caffeine 28 ERLEADA 16 erlotinib 16 errin 99 ERWINAZE 16 ery pads 60 erygel 60 ery-tab 8 erythrocin (as stearate) 8 erythromycin 8 109 erythromycin ethylsuccinate 8 erythromycin with ethanol 60 erythromycin-benzoyl peroxide
60 ESBRIET 117 escitalopram oxalate 39 esomeprazole magnesium 85 ESPEROCT 51 estarylla 104 estazolam 39 estradiol 99 estradiol valerate 99 estradiol-norethindrone acet 99 ESTRING 99 estrogens-methyltestosterone 99 eszopiclone 39 ethacrynic acid 47 ethambutol 9 ethosuximide 25
130
ethynodiol diac-eth estradiol 104
etodolac 34 etonogestrel-ethinyl estradiol
101 etoposide 16 etravirine 3 EUCRISA 59 EUFLEXXA 34 EURAX 66 EVAMIST 99 EVENITY 95 everolimus (antineoplastic) 16 everolimus
(immunosuppressive) 16 EVOTAZ 3 EXELDERM 62 exemestane 16 EXONDYS-51 29 EYLEA 111 ezetimibe 55 ezetimibe-simvastatin 55 F FA-8 123 FABRAZYME 75 FACTIVE 12 falmina (28) 104 famciclovir 3 famotidine 86 famotidine (pf) 85 FANAPT 39 FARXIGA 77 FASENRA 118 FASENRA PEN 117 FASLODEX 16 fayosim 104 FC2 FEMALE CONDOM 98 febuxostat 95 FEIBA NF 51 felbamate 25 felodipine 47 fem ph 101 FEMCAP 98 FEMRING 99 femynor 104 fenofibrate 55 FENOFIBRATE 55 fenofibrate micronized 55 fenofibrate nanocrystallized 55 fenofibric acid 55 fenofibric acid (choline) 55
fenoprofen 35 fentanyl 32 fentanyl citrate 31 FER-IN-SOL 123 FERRIPROX 67 FETZIMA 39 FIASP FLEXTOUCH U-100
INSULIN 72 FIASP PENFILL U-100
INSULIN 72 FIASP U-100 INSULIN 72 FIBRYGA 51 finasteride 121 FINTEPLA 25 FIRMAGON KIT W
DILUENT SYRINGE 16 flac otic oil 69 flavoxate 121 FLEBOGAMMA DIF 91 flecainide 44 FLOLAN 47 FLORIVA (FLUORIDE-
VITAMIN D3) 123 FLOVENT DISKUS 118 FLOVENT HFA 118 fluconazole 1 flucytosine 1 fludarabine 16 fludrocortisone 70 fluocinolone 64 fluocinolone acetonide oil 69 fluocinolone and shower cap 64 fluocinonide 64 fluocinonide-e 64 fluoride (sodium) 69 123 124 fluorometholone 113 fluorouracil 16 59 FLUOROURACIL 59 fluoxetine 39 40 fluphenazine hcl 40 flurandrenolide 64 65 flurazepam 40 flurbiprofen 35 flurbiprofen sodium 112 flutamide 16 fluticasone propionate 65 118 fluticasone propion-salmeterol
118 fluvastatin 55 56 fluvoxamine 40 FML FORTE 113
FML SOP 113 folic acid 124 FOLOTYN 16 fondaparinux 51 formoterol fumarate 118 FORTEO 95 FOSAMAX PLUS D 95 fosamprenavir 3 fosfomycin tromethamine 13 fosinopril 47 fosinopril-hydrochlorothiazide
47 FRAGMIN 52 FREESTYLE LIBRE 14 DAY
SENSOR 71 FREESTYLE LIBRE 2
SENSOR 71 frovatriptan 28 fulvestrant 16 furosemide 47 FUZEON 3 fyavolv 99 G g tussin ac 115 gabapentin 25 GALAFOLD 75 galantamine 29 GAMASTAN 91 GAMASTAN SD 91 GAMIFANT 16 GAMMAGARD LIQUID 91 GAMMAGARD S-D (IGA lt 1
MCGML) 91 GAMMAKED 91 GAMMAPLEX 91 GAMMAPLEX (WITH
SORBITOL) 91 GAMUNEX-C 91 GANCICLOVIR 3 ganciclovir sodium 3 GARDASIL 9 (PF) 91 gatifloxacin 109 gavilyte-c 82 gavilyte-g 82 gavilyte-n 82 GAZYVA 16 gemcitabine 16 17 gemfibrozil 56 gemmily 104 generlac 82 gengraf 17
131
GENOTROPIN 87 GENOTROPIN MINIQUICK
87 gentak 109 gentamicin 9 61 62 109 gentamicin sulfate (ped) (pf) 9 GENVOYA 3 GIAPREZA 56 GILENYA 88 GILOTRIF 17 GIVLAARI 67 GLASSIA 67 glatiramer 88 glatopa 88 GLEOSTINE 17 glimepiride 77 glipizide 77 glipizide-metformin 77 GLUCAGEN DIAGNOSTIC
KIT 71 GLUCAGEN HYPOKIT 71 GLUCAGON (HCL)
EMERGENCY KIT 71 glucagon emergency kit
(human) 71 GLUCAGON HCL 71 glyburide 77 glyburide micronized 77 glyburide-metformin 77 glycopyrrolate 80 GLYXAMBI 78 GONITRO 57 granisetron hcl 82 GRANIX 86 GRASTEK 91 griseofulvin microsize 1 griseofulvin ultramicrosize 1 guaiatussin ac 115 guanfacine 40 47 GYNAZOLE-1 101 gynol ii 101 H HAEGARDA 118 hailey 104 hailey 24 fe 104 hailey fe 1530 (28) 104 hailey fe 120 (28) 104 HALAVEN 17 halcinonide 65 halobetasol propionate 65 haloperidol 40
haloperidol decanoate 40 haloperidol lactate 40 HARVONI 3 HAVRIX (PF) 91 92 heather 99 HEMLIBRA 52 hemmorex-hc 82 HEMOFIL M HIGH 52 HEMOFIL M LOW 52 HEMOFIL M MID 52 HEMOFIL M SUPER HIGH52 hep flush-10 (pf) 52 heparin (porcine) 52 heparin (porcine) in 5 dex 52 heparin lock flush (porcine) 52 heparin lockflush(porcine)(pf)
52 heparin(porcine) in 045 nacl
52 HEPARIN(PORCINE) IN
045 NACL 52 heparin porcine (pf) 52 53 HEPLISAV-B (PF) 92 HERCEPTIN 17 HERCEPTIN HYLECTA 17 HERZUMA 17 HETLIOZ 40 HETLIOZ LQ 40 HIBERIX (PF) 92 HIZENTRA 92 homatropaire 110 HUMALOG JUNIOR
KWIKPEN U-100 72 HUMALOG KWIKPEN
INSULIN 72 HUMALOG MIX 50-50
INSULN U-100 72 HUMALOG MIX 50-50
KWIKPEN 72 HUMALOG MIX 75-25
KWIKPEN 72 HUMALOG MIX 75-25(U-
100)INSULN 72 HUMALOG U-100 INSULIN
72 HUMATE-P 53 HUMIRA 96 HUMIRA PEN 96 HUMIRA PEN CROHNS-UC-
HS START 96
HUMIRA PEN PSOR-UVEITS-ADOL HS 96
HUMIRA(CF) 97 HUMIRA(CF) PEDI
CROHNS STARTER 96 HUMIRA(CF) PEN 96 HUMIRA(CF) PEN
CROHNS-UC-HS 96 HUMIRA(CF) PEN
PEDIATRIC UC 96 HUMIRA(CF) PEN PSOR-
UV-ADOL HS 96 HUMULIN 7030 U-100
INSULIN 72 HUMULIN 7030 U-100
KWIKPEN 72 HUMULIN N NPH INSULIN
KWIKPEN 73 HUMULIN N NPH U-100
INSULIN 73 HUMULIN R REGULAR U-
100 INSULN 73 HUMULIN R U-500 (CONC)
INSULIN 73 HUMULIN R U-500 (CONC)
KWIKPEN 73 HYCAMTIN 17 hydralazine 47 hydrochlorothiazide 47 hydrocodone bitartrate 32 hydrocodone-acetaminophen 32 hydrocodone-chlorpheniramine
115 hydrocodone-homatropine 115 hydrocodone-ibuprofen 32 hydrocortisone 65 70 82 hydrocortisone acetate 82 hydrocortisone butyrate 65 hydrocortisone butyr-emollient
65 hydrocortisone valerate 65 hydrocortisone-acetic acid 69 hydrocortisone-pramoxine 58
82 hydromet 116 hydromorphone 32 HYDROMORPHONE 32 hydroxocobalamin 124 hydroxychloroquine 9 hydroxyprogest(pf)(preg presv)
99
132
hydroxyprogesterone cap(ppres) 99
hydroxyprogesterone caproate 100
hydroxyurea 17 hydroxyzine hcl 115 hydroxyzine pamoate 115 hyophen 122 hyoscyamine sulfate 80 hyosyne 80 HYQVIA 92 I ibandronate 95 IBRANCE 17 ibu 35 ibuprofen 35 icatibant 118 iclevia 104 ICLUSIG 17 icosapent ethyl 56 IDELVION 53 IDHIFA 17 ILARIS (PF) 90 ILUMYA 58 imatinib 17 IMBRUVICA 17 IMFINZI 17 imipenem-cilastatin 9 imipramine hcl 40 imipramine pamoate 40 imiquimod 90 IMLYGIC 17 IMOVAX RABIES VACCINE
(PF) 92 incassia 100 INCRELEX 67 INCRUSE ELLIPTA 118 indapamide 47 indomethacin 35 INFANRIX (DTAP) (PF) 92 INFED 124 INFLECTRA 82 INFUGEM 18 INLYTA 18 INSULIN ASP PRT-INSULIN
ASPART 73 INSULIN ASPART U-100 73 INSULIN SYRINGE-
NEEDLE U-100 71 INTELENCE 3 INTRAROSA 101
INTRON A 90 INVANZ 9 INVEGA SUSTENNA 40 INVELTYS 113 INVIRASE 3 IOPIDINE 114 IPOL 92 ipratropium bromide 69 118 ipratropium-albuterol 118 irbesartan 47 irbesartan-hydrochlorothiazide
47 IRESSA 18 ISENTRESS 3 ISENTRESS HD 3 isibloom 104 ISOLYTE-S 123 isoniazid 9 isosorbide dinitrate 57 isosorbide mononitrate 57 isotretinoin 60 isoxsuprine 101 isradipine 47 ISTODAX 18 itraconazole 1 ivermectin 9 66 IXEMPRA 18 IXIARO (PF) 92 IXINITY 53 J jaimiess 104 JAKAFI 18 jantoven 53 JANUMET 78 JANUMET XR 78 JANUVIA 78 JARDIANCE 78 jasmiel (28) 104 jencycla 100 JENTADUETO 78 JENTADUETO XR 78 JEVTANA 18 jinteli 100 JIVI 53 jolessa 104 JORNAY PM 40 JUBLIA 62 juleber 104 JULUCA 3 junel 1530 (21) 104 junel 120 (21) 104
junel fe 1530 (28) 104 junel fe 120 (28) 104 junel fe 24 104 JUXTAPID 56 JYNARQUE 75 K KADCYLA 18 kaitlib fe 104 KALBITOR 118 KALETRA 3 4 kalliga 104 KALYDECO 118 KANJINTI 18 KANUMA 75 kariva (28) 104 kelnor 135 (28) 105 kelnor 1-50 (28) 105 KEPIVANCE 13 ketoconazole 1 62 ketodan 62 ketoprofen 35 ketorolac 35 112 KEVZARA 97 KEYTRUDA 18 KINRIX (PF) 92 KISQALI 18 KISQALI FEMARA CO-
PACK 18 klor-con 123 klor-con 10 122 klor-con 8 122 klor-con m10 122 klor-con m15 122 klor-con m20 123 klor-conef 123 KOATE 53 KOGENATE FS 53 KORLYM 75 KOVALTRY 53 K-PHOS NO 2 122 K-PHOS ORIGINAL 122 KRYSTEXXA 95 k-tab 123 K-TAB 123 kurvelo (28) 105 KYLEENA 98 KYMRIAH 18 KYPROLIS 18 L l norgesteestradiol-eestrad
105
133
labetalol 47 LACRISERT 111 lactulose 83 lamivudine 4 lamivudine-zidovudine 4 lamotrigine 25 lansoprazole 86 lanthanum 83 LANTUS SOLOSTAR U-100
INSULIN 73 LANTUS U-100 INSULIN 73 lapatinib 18 larin 1530 (21) 105 larin 120 (21) 105 larin 24 fe 105 larin fe 1530 (28) 105 larin fe 120 (28) 105 larissia 105 LASTACAFT 111 latanoprost 112 LATUDA 40 layolis fe 105 leena 28 105 leflunomide 97 LEMTRADA 88 LENVIMA 18 lessina 105 letrozole 19 leucovorin calcium 13 LEUKERAN 19 LEUKINE 86 leuprolide 19 levalbuterol hcl 118 LEVALBUTEROL
TARTRATE 118 LEVEMIR FLEXTOUCH U-
100 INSULN 73 LEVEMIR U-100 INSULIN 73 levetiracetam 25 levobunolol 110 levocarnitine 67 levocarnitine (with sugar) 67 levocetirizine 115 levofloxacin 12 109 levonest (28) 105 levonorgestrel 105 levonorgestrel-ethinyl estrad
105 levonorg-eth estrad triphasic
105 levora-28 105
levorphanol tartrate 32 levothyroxine 79 levoxyl 79 LEVULAN 59 LEXIVA 4 LIBTAYO 19 lidocaine 61 lidocaine hcl 61 lidocaine hcl-hydrocortison ac
61 83 LIDOCAINE HCL-
HYDROCORTISON AC 83 lidocaine viscous 61 lidocaine-hydrocortisone-aloe
83 lidocaine-prilocaine 61 LIDOCAINE-TETRACAINE
61 LILETTA 98 lillow (28) 105 LINCOCIN 9 lindane 66 linezolid 9 linezolid in dextrose 5 9 linezolid-09 sodium chloride
9 LINZESS 83 liothyronine 79 LIPOFEN 56 lisinopril 47 lisinopril-hydrochlorothiazide
47 lithium carbonate 40 41 LO LOESTRIN FE 105 lojaimiess 105 LONSURF 19 loperamide 80 lopinavir-ritonavir 4 lorazepam 41 lorazepam intensol 41 loryna (28) 105 losartan 47 losartan-hydrochlorothiazide 47 LOTEMAX 113 loteprednol etabonate 113 lovastatin 56 low-ogestrel (28) 105 loxapine succinate 41 lo-zumandimine (28) 105 LUCENTIS 111 ludent fluoride 124
LULICONAZOLE 62 LUMIGAN 112 LUMIZYME 75 LUMOXITI 19 LUPANETA PACK (1
MONTH) 101 LUPANETA PACK (3
MONTH) 101 LUPKYNIS 19 LUPRON DEPOT 19 LUPRON DEPOT (3
MONTH) 19 LUPRON DEPOT (4
MONTH) 19 LUPRON DEPOT (6
MONTH) 19 LUPRON DEPOT-PED 19 LUPRON DEPOT-PED (3
MONTH) 19 lutera (28) 105 LUXTURNA 111 LUZU 62 lyleq 100 lyllana 100 LYNPARZA 19 LYRICA CR 25 LYSODREN 19 lyza 100 M mafenide acetate 62 malathion 66 maprotiline 41 marlissa (28) 106 MARPLAN 41 MARQIBO 19 MATULANE 19 matzim la 47 MAVENCLAD (10 TABLET
PACK) 88 MAVENCLAD (4 TABLET
PACK) 88 MAVENCLAD (5 TABLET
PACK) 88 MAVENCLAD (6 TABLET
PACK) 88 MAVENCLAD (7 TABLET
PACK) 88 MAVENCLAD (8 TABLET
PACK) 88 MAVENCLAD (9 TABLET
PACK) 88
134
MAVYRET 4 MAXIDEX 113 maxi-tuss ac 116 MAYZENT 88 MAYZENT STARTER PACK
88 m-clear wc 116 meclizine 83 meclofenamate 35 medroxyprogesterone 100 mefenamic acid 35 mefloquine 9 megestrol 19 MEKINIST 19 MEKTOVI 19 meloxicam 35 melphalan 19 melphalan hcl 19 memantine 29 MENACTRA (PF) 92 MENEST 100 MENOSTAR 100 MENQUADFI (PF) 92 MENTAX 62 MENVEO A-C-Y-W-135-DIP
(PF) 92 meperidine 32 meprobamate 30 MEPSEVII 76 mercaptopurine 20 meropenem 9 MEROPENEM-09
SODIUM CHLORIDE 9 merzee 106 mesalamine 83 mesalamine with cleansing
wipe 83 metaproterenol 118 metaxalone 30 metformin 78 methadone 32 methadose 32 methamphetamine 41 methazolamide 112 methenamine hippurate 13 methenamine mandelate 13 methen-sod phos-meth blue-
hyos 122 methergine 109 methimazole 71 methocarbamol 30
methotrexate sodium 20 methotrexate sodium (pf) 20 methoxsalen 59 methscopolamine 80 methyldopa 47 methyldopa-
hydrochlorothiazide 47 methyldopate 48 methylergonovine 109 METHYLIN 41 methylphenidate hcl 41 methylprednisolone 70 methylprednisolone acetate 70 methyltestosterone 76 metoclopramide hcl 83 metolazone 48 metoprolol succinate 48 metoprolol ta-hydrochlorothiaz
48 metoprolol tartrate 48 metronidazole 9 60 61 101 metyrosine 48 mexiletine 44 MIACALCIN 76 mibelas 24 fe 106 microgestin 1530 (21) 106 microgestin 120 (21) 106 microgestin fe 1530 (28) 106 microgestin fe 120 (28) 106 midazolam 41 midodrine 67 migergot 28 miglitol 78 miglustat 76 mili 106 millipred 70 millipred dp 70 mimvey 100 MINITRAN 57 minocycline 12 minoxidil 48 MIRCERA 86 MIRENA 98 mirtazapine 41 misoprostol 86 MITIGARE 95 mitoxantrone 20 M-M-R II (PF) 92 modafinil 41 moexipril 48 molindone 41
mometasone 65 mondoxyne nl 12 mono-linyah 106 MONONINE 53 MONOVISC 35 montelukast 118 119 morphine 32 33 morphine (pf) 32 morphine concentrate 32 MOTOFEN 80 MOVANTIK 83 MOXATAG 11 moxifloxacin 12 109 MOZOBIL 87 MULPLETA 53 MULTAQ 44 multi-vitamin with fluoride 124 multivitamins with fluoride 124 mupirocin 62 mupirocin calcium 62 mvc-fluoride 124 my choice 106 my way 106 MYALEPT 76 MYCAMINE 1 mycophenolate mofetil 20 mycophenolate sodium 20 MYDAYIS 41 MYLOTARG 20 MYOBLOC 92 myorisan 61 MYRBETRIQ 121 N nabumetone 35 nadolol 48 nadolol-bendroflumethiazide 48 nafcillin 11 nafcillin in dextrose iso-osm 11 naftifine 62 63 NAGLAZYME 76 nalbuphine 35 naloxone 35 naltrexone 35 naproxen 35 naproxen sodium 35 naratriptan 28 NARCAN 35 NATACYN 109 NATAZIA 106 nateglinide 78 NATPARA 76
135
nebusal 119 necon 0535 (28) 106 nefazodone 41 neomycin 9 neomycin-bacitracin-poly-hc
112 neomycin-bacitracin-
polymyxin 109 neomycin-polymyxin b-
dexameth 112 113 neomycin-polymyxin-
gramicidin 109 neomycin-polymyxin-hc 69
113 neo-polycin 109 neo-polycin hc 113 NERLYNX 20 NEUPOGEN 87 NEVANAC 112 nevirapine 4 new day 106 NEXAVAR 20 NEXPLANON 101 NEXTSTELLIS 106 niacin 56 NIACOR 56 nicardipine 48 nicorette 68 nicotine 68 nicotine (polacrilex) 68 NICOTROL 68 NICOTROL NS 68 nifedipine 48 nikki (28) 106 nilutamide 20 nimodipine 48 NINLARO 20 nisoldipine 48 nitazoxanide 9 nitisinone 67 nitro-bid 57 NITRO-DUR 57 nitrofurantoin 13 nitrofurantoin macrocrystal 13 nitrofurantoin monohydm-
cryst 13 nitroglycerin 57 nitroglycerin in 5 dextrose 57 nitro-time 57 NITYR 67 NIVESTYM 87
nizatidine 86 nora-be 100 noreth-ethinyl estradiol-iron
106 norethindrone (contraceptive)
100 norethindrone acetate 100 norethindrone ac-eth estradiol
100 106 norethindrone-eestradiol-iron
106 norgestimate-ethinyl estradiol
106 norlyda 100 NORMOSOL-R 123 NORPACE CR 44 nortrel 0535 (28) 106 nortrel 135 (21) 106 nortrel 135 (28) 106 nortrel 777 (28) 107 nortriptyline 42 NORVIR 4 NOVAFERRUM 124 NOVOEIGHT 53 NOVOLIN 70-30 FLEXPEN
U-100 73 NOVOLIN N FLEXPEN 73 NOVOLIN R FLEXPEN 73 NOVOLOG FLEXPEN U-100
INSULIN 74 NOVOLOG MIX 70-30 U-100
INSULN 74 NOVOLOG MIX 70-
30FLEXPEN U-100 74 NOVOLOG PENFILL U-100
INSULIN 74 NOVOLOG U-100 INSULIN
ASPART 74 NOVOPEN ECHO 71 NOVOSEVEN RT 53 NOXAFIL 1 np thyroid 79 NPLATE 53 NUCALA 119 NUCYNTA ER 36 NUEDEXTA 29 NULOJIX 20 NULYTELY LEMON-LIME
83 NUPLAZID 42 NUWIQ 53
nyamyc 63 nylia 777 (28) 107 nymyo 107 nystatin 1 63 nystatin-triamcinolone 63 nystop 63 O OBIZUR 54 ocella 107 OCREVUS 88 OCTAGAM 92 octreotide acetate 20 ODEFSEY 4 OFEV 119 ofloxacin 12 69 109 OGIVRI 20 olanzapine 42 olanzapine-fluoxetine 42 olmesartan 48 olmesartan-amlodipin-
hcthiazid 48 olmesartan-
hydrochlorothiazide 48 olopatadine 69 111 OLUMIANT 97 omega-3 acid ethyl esters 56 omeprazole 86 OMIDRIA 111 OMNITROPE 87 ONCASPAR 20 ondansetron 84 ondansetron hcl 83 84 ONETOUCH ULTRA TEST
71 ONETOUCH VERIO TEST
STRIPS 71 ONIVYDE 20 ONPATTRO 29 ONZETRA XSAIL 28 opcicon one-step 107 OPDIVO 20 opium tincture 81 OPSUMIT 119 option-2 107 ORALAIR 92 oralone 69 ORAVIG 1 ORENCIA 97 ORENCIA (WITH
MALTOSE) 97 ORENCIA CLICKJECT 97
136
ORENITRAM 48 ORLADEYO 119 orphenadrine citrate 30 orsythia 107 ORTHOVISC 36 oscimin 81 oscimin sl 81 oscimin sr 81 oseltamivir 4 OSMOPREP 84 OSPHENA 101 OTEZLA 97 OTEZLA STARTER 97 OTOVEL 69 oxacillin 11 oxacillin in dextrose(iso-osm)
11 oxandrolone 76 oxaprozin 36 oxazepam 42 oxcarbazepine 25 oxiconazole 63 OXISTAT 63 OXLUMO 122 oxybutynin chloride 121 oxycodone 33 oxycodone-acetaminophen 33 oxycodone-aspirin 33 OXYCONTIN 33 oxymorphone 33 OZEMPIC 78 OZURDEX 113 P pacerone 44 PADCEV 20 paliperidone 42 PALYNZIQ 76 pamidronate 76 PANRETIN 59 pantoprazole 86 PANZYGA 92 PARAGARD T 380A 98 paricalcitol 76 PARICALCITOL 76 paroex oral rinse 69 paromomycin 10 paroxetine hcl 42 paroxetine
mesylate(menopsym) 42 PARSABIV 76 PASER 10
PEDIARIX (PF) 92 PEDVAX HIB (PF) 93 peg 3350-electrolytes 84 peg3350-sod sul-nacl-kcl-asb-c
84 PEGASYS 88 89 peg-electrolyte soln 84 peg-prep 84 PEMAZYRE 20 PEN NEEDLE DIABETIC 72 penicillamine 97 penicillin g procaine 11 penicillin v potassium 11 PENTACEL (PF) 93 PENTACEL ACTHIB
COMPONENT (PF) 93 PENTAM 10 pentamidine 10 pentazocine-naloxone 36 pentoxifylline 54 PERFOROMIST 119 perindopril erbumine 48 periogard 69 PERJETA 20 permethrin 66 perphenazine 42 perphenazine-amitriptyline 42 phenazopyridine 122 phenelzine 42 phenobarb-hyoscy-atropine-
scop 81 phenobarbital 25 26 phenohytro 81 phenoxybenzamine 48 phenylephrine hcl 114 phenytoin 26 phenytoin sodium extended 26 PHEXXI 101 philith 107 phosphasal 122 PHYSIOLYTE 66 PHYSIOSOL IRRIGATION 66 phytonadione (vitamin k1) 54 PICATO 59 pilocarpine hcl 67 69 110 pimecrolimus 59 pimozide 42 pimtrea (28) 107 pindolol 48 pioglitazone 78 pioglitazone-glimepiride 78
pioglitazone-metformin 78 piperacillin-tazobactam 11 PIQRAY 21 pirmella 107 piroxicam 36 PLASMA-LYTE 148 123 PLASMA-LYTE A 123 PLEGRIDY 89 PLENVU 84 PNEUMOVAX-23 93 podofilox 59 POLIVY 21 polycin 110 polymyxin b sulfate 10 polymyxin b sulf-trimethoprim
110 POMALYST 89 PONVORY 89 PONVORY 14-DAY
STARTER PACK 89 portia 28 107 PORTRAZZA 21 posaconazole 1 potassium chloride 123 potassium citrate 122 POTELIGEO 21 pramipexole 27 prasugrel 54 pravastatin 56 praziquantel 10 prazosin 48 PRED MILD 113 prednicarbate 65 prednisolone 70 prednisolone acetate 113 prednisolone sodium phosphate
70 114 prednisone 70 prednisone intensol 70 pregabalin 26 PREMARIN 100 PREMPHASE 100 PREMPRO 100 prevalite 56 previfem 107 PREVNAR 13 (PF) 93 PREVYMIS 4 PREZCOBIX 4 PREZISTA 4 PRIFTIN 10 primaquine 10
137
primidone 26 PRIMSOL 13 PRIVIGEN 93 probenecid 95 probenecid-colchicine 95 procainamide 44 procentra 42 prochlorperazine 84 prochlorperazine edisylate 84 prochlorperazine maleate 84 PROCRIT 87 procto-med hc 84 procto-pak 84 proctosol hc 84 proctozone-hc 84 PROFILNINE 54 progesterone 100 progesterone micronized 100 PROGRAF 21 PROLASTIN-C 67 PROLEUKIN 90 PROLIA 95 PROMACTA 54 promethazine 115 promethazine-codeine 116 promethazine-dm 116 promethazine-phenyleph-
codeine 116 promethazine-phenylephrine
116 promethegan 115 propafenone 44 45 proparacaine 111 propranolol 48 49 propranolol-hydrochlorothiazid
49 propylthiouracil 71 PROQUAD (PF) 93 protriptyline 42 PROVENGE 93 prudoxin 59 pulmosal 119 PULMOZYME 119 pyrazinamide 10 pyridostigmine bromide 30 pyrimethamine 10 Q QBRELIS 49 QINLOCK 21 QTERN 78 QUADRACEL (PF) 93
quetiapine 42 QUILLICHEW ER 42 QUILLIVANT XR 42 quinapril 49 quinapril-hydrochlorothiazide
49 quinidine gluconate 45 quinidine sulfate 45 quinine sulfate 10 quit 2 68 quit 4 68 QVAR REDIHALER 119 R RABAVERT (PF) 93 rabeprazole 86 RADICAVA 29 RAGWITEK 93 raloxifene 95 ramelteon 42 ramipril 49 ranolazine 57 RAPIVAB (PF) 4 rasagiline 27 RAVICTI 67 REBIF (WITH ALBUMIN) 89 REBIF REBIDOSE 89 REBIF TITRATION PACK 89 REBINYN 54 RECLAST 67 reclipsen (28) 107 RECOMBINATE 54 RECOMBIVAX HB (PF) 93 RECTIV 84 REGRANEX 59 RELENZA DISKHALER 4 RELEXXII 42 RELION NOVOLIN 7030 74 RELION NOVOLIN N 74 RELION NOVOLIN R 74 RELISTOR 84 REMICADE 84 RENACIDIN 122 RENFLEXIS 84 repaglinide 78 repaglinide-metformin 78 REPATHA PUSHTRONEX 56 REPATHA SURECLICK 56 REPATHA SYRINGE 56 RESTASIS 111 RETEVMO 21 RETISERT 114
REVATIO 119 REVLIMID 89 REXULTI 43 REYATAZ 4 RHOPRESSA 112 RIASTAP 54 ribavirin 4 89 RIDAURA 97 rifabutin 10 rifampin 10 riluzole 67 rimantadine 4 RINVOQ 97 RIOMET ER 78 risedronate 67 95 RISPERDAL CONSTA 43 risperidone 43 ritonavir 4 RITUXAN 21 RITUXAN HYCELA 21 rivastigmine 30 rivastigmine tartrate 29 rivelsa 107 RIXUBIS 54 rizatriptan 28 ropinirole 27 28 rosadan 61 rosuvastatin 56 roweepra 26 RUBRACA 21 RUCONEST 119 rufinamide 26 RYBELSUS 79 RYDAPT 21 S salsalate 36 SAMSCA 76 SANTYL 65 sapropterin 76 SARCLISA 21 SAVELLA 97 scalacort 65 SCENESSE 59 scopolamine base 84 seconal sodium 43 SEEBRI NEOHALER 119 selegiline hcl 28 selenium sulfide 58 SELZENTRY 5 SEREVENT DISKUS 119 SEROSTIM 87
138
sertraline 43 setlakin 107 sevelamer carbonate 84 sevelamer hcl 84 sf 69 sf 5000 plus 69 sharobel 101 SHINGRIX (PF) 93 SIGNIFOR 21 sildenafil (pulmhypertension)
119 SILIQ 58 silodosin 121 silver sulfadiazine 59 SIMBRINZA 112 simliya (28) 107 simpesse 107 SIMPONI 97 SIMPONI ARIA 97 SIMULECT 21 simvastatin 56 SINUVA 119 sirolimus 21 SIRTURO 10 SIVEXTRO 10 SKYLA 98 SKYRIZI 58 SLYND 107 sodium chloride 119 sodium chloride 045 123 sodium chloride 09 67 sodium fluoride 5000 dry
mouth 69 sodium fluoride 5000 plus 69 sodium fluoride-pot nitrate 69 sodium phenylbutyrate 67 sodium polystyrene sulfonate
85 solifenacin 121 SOLIQUA 10033 74 SOLIRIS 67 SOLTAMOX 21 SOMATULINE DEPOT 21 SOMAVERT 76 sorine 45 sotalol 45 sotalol af 45 SOVALDI 5 spinosad 66 SPIRIVA RESPIMAT 119
SPIRIVA WITH HANDIHALER 119
spironolactone 49 spironolacton-hydrochlorothiaz
49 SPRAVATO 43 sprintec (28) 107 SPRYCEL 21 sps (with sorbitol) 85 sronyx 107 ssd 59 SSKI 71 st joseph aspirin 36 st joseph aspirin 36 STAMARIL (PF) 93 stavudine 5 STELARA 58 STIOLTO RESPIMAT 119 STIVARGA 21 stop smoking aid 68 STRENSIQ 76 STREPTOMYCIN 10 STRIBILD 5 STRIVERDI RESPIMAT 120 SUBLOCADE 33 subvenite 26 subvenite starter (blue) kit 26 subvenite starter (green) kit 26 subvenite starter (orange) kit 26 SUCRAID 85 sucralfate 86 sulfacetamide sodium 58 114 sulfacetamide sodium (acne) 62 sulfacetamide-prednisolone 114 sulfadiazine 12 sulfamethoxazole-trimethoprim
12 SULFAMYLON 62 sulfasalazine 85 sulfatrim 12 sulindac 36 sumatriptan 28 sumatriptan succinate 28 29 SUNOSI 43 SUPPRELIN LA 21 SUPRAX 7 SUPREP BOWEL PREP KIT
85 SUTENT 22 syeda 107 SYLVANT 22
symax fastabs 81 symax-sl 81 symax-sr 81 SYMBICORT 120 SYMDEKO 120 SYMLINPEN 120 79 SYMLINPEN 60 79 SYMPAZAN 26 SYNAGIS 5 SYNAREL 76 SYNERA 61 SYNJARDY 79 SYNJARDY XR 79 SYNRIBO 22 SYNTHROID 79 T TABLOID 22 tacrolimus 22 59 tadalafil 121 tadalafil (pulm hypertension)
120 TAFINLAR 22 TAGRISSO 22 TAKHZYRO 120 TALTZ AUTOINJECTOR 58 TALTZ AUTOINJECTOR (2
PACK) 58 TALTZ AUTOINJECTOR (3
PACK) 58 TALTZ SYRINGE 58 TALZENNA 22 tamoxifen 22 tamsulosin 121 TARGRETIN 22 tarina 24 fe 107 tarina fe 120 (28) 107 TASIGNA 22 tavaborole 63 tazarotene 61 tazicef 7 taztia xt 49 TDVAX 93 TECENTRIQ 22 TEFLARO 7 TEKTURNA HCT 49 telmisartan 49 telmisartan-amlodipine 49 telmisartan-hydrochlorothiazid
49 temazepam 43 TEMODAR 22
139
temozolomide 22 temsirolimus 22 tencon 33 TENIVAC (PF) 94 tenofovir disoproxil fumarate 5 TEPEZZA 76 terazosin 49 terbinafine hcl 1 terbutaline 120 terconazole 101 testosterone 77 testosterone cypionate 76 testosterone enanthate 76 TETANUSDIPHTHERIA
TOX PED(PF) 94 tetrabenazine 30 tetracaine hcl 111 TETRACAINE HCL (PF) 111 tetracycline 12 THALOMID 22 theophylline 120 thioridazine 43 thiothixene 43 THYMOGLOBULIN 94 THYROLAR-1 79 THYROLAR-12 79 THYROLAR-14 79 THYROLAR-2 79 THYROLAR-3 79 tiadylt er 49 tiagabine 26 TIBSOVO 22 tilia fe 107 timolol maleate 49 110 tinidazole 10 TIVICAY 5 TIVICAY PD 5 tizanidine 30 TOBRADEX 113 TOBRADEX ST 113 tobramycin 10 110 tobramycin in 0225 nacl 10 tobramycin sulfate 10 TOBRAMYCIN WITH
NEBULIZER 10 tobramycin-dexamethasone 113 TOBREX 110 TODAY CONTRACEPTIVE
SPONGE 101 tolcapone 28 tolmetin 36
tolterodine 121 topiramate 26 toremifene 22 TORISEL 22 torsemide 49 TOUJEO MAX U-300
SOLOSTAR 74 TOUJEO SOLOSTAR U-300
INSULIN 74 TRACLEER 120 TRADJENTA 79 tramadol 36 tramadol-acetaminophen 36 trandolapril 49 trandolapril-verapamil 49 tranexamic acid 54 101 tranylcypromine 43 travoprost 112 trazodone 43 TREANDA 22 TRECATOR 10 TRELEGY ELLIPTA 120 TRELSTAR 22 TREMFYA 59 TRESIBA FLEXTOUCH U-
100 74 TRESIBA FLEXTOUCH U-
200 74 TRESIBA U-100 INSULIN 74 tretinoin 61 tretinoin (antineoplastic) 22 tretinoin microspheres 61 TRETTEN 54 TREXALL 22 tri femynor 107 triamcinolone acetonide 65 69
71 triamterene 49 triamterene-hydrochlorothiazid
49 triazolam 43 triderm 65 trientine 67 tri-estarylla 107 trifluoperazine 43 trifluridine 110 trihexyphenidyl 28 TRIJARDY XR 71 TRIKAFTA 120 tri-legest fe 108 tri-linyah 108
tri-lo-estarylla 108 tri-lo-marzia 108 tri-lo-mili 108 tri-lo-sprintec 108 trilyte with flavor packets 85 trimethobenzamide 85 trimethoprim 13 tri-mili 108 trimipramine 43 TRINTELLIX 43 tri-nymyo 108 tri-previfem (28) 108 tri-sprintec (28) 108 TRIUMEQ 5 tri-vitamin with fluoride 124 trivora (28) 108 tri-vylibra 108 tri-vylibra lo 108 TROGARZO 5 tropicamide 110 trospium 121 TRULICITY 79 TRUMENBA 94 TRUXIMA 22 TUKYSA 23 tulana 101 TWINRIX (PF) 94 TWIRLA 101 TYBLUME 108 TYBOST 5 tydemy 108 TYGACIL 10 TYMLOS 95 TYPHIM VI 94 TYSABRI 30 TYVASO 120 TYVASO REFILL KIT 120 TYVASO STARTER KIT 120 U UBRELVY 29 UDENYCA 87 ULESFIA 66 unithroid 80 UNITUXIN 23 URELLE 122 uretron d-s 122 urimar-t 122 urogesic-blue 122 ursodiol 85 uryl 122 ustell 122
140
UTIBRON NEOHALER 120 utira-c 122 UVADEX 59 V vaginal contraceptive foam 101 valacyclovir 5 VALCHLOR 59 valganciclovir 5 valproic acid 26 valproic acid (as sodium salt)
26 valsartan 49 valsartan-hydrochlorothiazide
49 vanadom 30 vancomycin 13 vandazole 101 VANTAS 23 VAQTA (PF) 94 VARIVAX (PF) 94 VARUBI 85 VASCEPA 56 VAXELIS (PF) 94 VCF CONTRACEPTIVE
FILM 101 VCF CONTRACEPTIVE GEL
101 VECTIBIX 23 VELCADE 23 veletri 50 velivet triphasic regimen (28)
108 VELPHORO 85 VEMLIDY 5 VENCLEXTA 23 VENCLEXTA STARTING
PACK 23 venlafaxine 43 VENTAVIS 120 verapamil 50 VERSACLOZ 43 VERZENIO 23 vestura (28) 108 VIBATIV 13 VIBERZI 85 VIDAZA 23 VIEKIRA PAK 5 vienva 108 vigabatrin 26 vigadrone 26 VIMIZIM 77
VIMPAT 26 viorele (28) 108 VIRACEPT 5 VIREAD 5 virtussin ac 116 VISTOGARD 13 VISUDYNE 111 vitamins acd and fluoride 124 VITRAKVI 23 VIVITROL 36 volnea (28) 108 VONVENDI 54 VORAXAZE 13 voriconazole 1 2 VOSEVI 5 VOTRIENT 23 VPRIV 77 VRAYLAR 44 VYEPTI 29 vyfemla (28) 108 vylibra 108 VYONDYS-53 30 VYVANSE 44 VYXEOS 23 W warfarin 54 wera (28) 108 westhroid 80 WIDE-SEAL DIAPHRAGM
98 WILATE 54 wixela inhub 121 wymzya fe 108 X XALKORI 23 XARELTO 54 XARELTO DVT-PE TREAT
30D START 54 XCOPRI 27 XCOPRI MAINTENANCE
PACK 27 XCOPRI TITRATION PACK
27 XELJANZ 97 XELJANZ XR 97 XEMBIFY 94 XENLETA 10 XEOMIN 94 XERMELO 23 XGEVA 13 XIFAXAN 10
XIGDUO XR 79 XIIDRA 111 XOLAIR 121 XOSPATA 23 XTANDI 23 xulane 102 XULTOPHY 10036 74 XURIDEN 67 XYNTHA 55 XYNTHA SOLOFUSE 55 XYREM 44 Y YERVOY 23 YESCARTA 23 YF-VAX (PF) 94 YONDELIS 23 YONSA 23 YUTIQ 114 yuvafem 101 Z zafemy 102 zafirlukast 121 zaleplon 44 ZALTRAP 23 ZANOSAR 23 zarah 109 ZARXIO 87 ZEJULA 24 ZELBORAF 24 ZEMAIRA 68 zenatane 61 ZENPEP 85 ZENZEDI 44 ZEPATIER 5 ZEPOSIA 89 ZEPOSIA STARTER KIT 89 ZEPOSIA STARTER PACK
89 ZERBAXA 7 zidovudine 5 ZIEXTENZO 87 zileuton 121 ziprasidone hcl 44 ZIRGAN 110 ZOKINVY 68 ZOLADEX 24 ZOLGENSMA 30 ZOLINZA 24 zolmitriptan 29 zolpidem 44 ZOLPIMIST 44
141
ZOMIG 29 zonisamide 27 ZONTIVITY 55 ZORBTIVE 87
ZOSTAVAX (PF) 94 zovia 135e (28) 109 ZULRESSO 44 zumandimine (28) 109
ZYFLO 121 ZYKADIA 24 ZYPITAMAG 56
051267 (11-20-2019)
Discrimination is Against the Law
LifeWise Health Plan of Washington (LifeWise) complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex LifeWise does not exclude people or treat them differently because of race color national origin age disability sex gender identity or sexual orientation LifeWise provides free aids and services to people with disabilities to communicate effectively with us such as qualified sign language interpreters and written information in other formats (large print audio accessible electronic formats other formats) LifeWise provides free language services to people whose primary language is not English such as qualified interpreters and information written in other languages If you need these services contact the Civil Rights Coordinator If you believe that LifeWise 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 Civil Rights Coordinator Complaints and Appeals PO Box 91102 Seattle WA 98111 Toll free 855-332-6396 Fax 425-918-5592 TTY 711 Email AppealsDepartmentInquiriesLifeWiseHealthcom You can file a grievance in person or by mail fax or email If you need help filing a grievance the Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Ave SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language Assistance ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 800-817-3056 (TTY 711) 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 800-817-3056(TTY711) CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 800-817-3056 (TTY 711) 주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 800-817-3056
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までお電話にてご連絡ください ማስታወሻ የሚናገሩት ቋንቋ ኣማርኛ ከነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ
800-817-3056 (መስማት ለተሳናቸው 711) XIYYEEFFANNAA Afaan dubbattu Oroomiffa tajaajila gargaarsa afaanii kanfaltiidhaan ala ni argama Bilbilaa 800-817-3056 (TTY 711)
)711 والبكم الصم ھاتف رقم( 800-178-3056 برقم اتصل بالمجان لك تتوافر اللغویة المساعدة خدمات فإن اللغة اذكر تتحدث كنت إذا ملحوظةਿਧਆਨ ਿਦਓ ਜ ਤਸ ਪਜਾਬੀ ਬਲਦ ਹ ਤ ਭਾਸ਼ਾ ਿਵਚ ਸਹਾਇਤਾ ਸਵਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਧ ਹ 800-817-3056
(TTY 711) ਤ ਕਾਲ ਕਰ ACHTUNG Wenn Sie Deutsch sprechen stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfuumlgung
Rufnummer 800-817-3056 (TTY 711) ໂປດຊາບ ຖາວາ ທານເວາພາສາ ລາວ ການບລການຊວຍເຫອດານພາສາ ໂດຍບເສຽຄາ
ແມນມພອມໃຫທານ ໂທຣ 800-817-3056 (TTY 711) ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele 800-817-3056 (TTY 711) ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 800-817-3056 (ATS 711) UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń pod numer 800-817-3056 (TTY 711) ATENCcedilAtildeO Se fala portuguecircs encontram-se disponiacuteveis serviccedilos linguiacutesticos graacutetis Ligue para 800-817-3056 (TTY 711) ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza linguistica gratuiti Chiamare il numero
800-817-3056 (TTY 711) دیریبگ تماس 3056-817-800 (TTY 711) با باشد یم فراھم شما یبرا گانیرا بصورت یزبان لاتیتسھ دیکن یم گفتگو فارسی زبان بھ اگر توجھ
COVERAGE NOTES ABBREVIATIONS
ABBREVIATION DESCRIPTION EXPLANATION
Utilization Management Restrictions
PA Prior Authorization Restriction You (or your physician) are required to get prior authorization from us before you fill your prescription for this drug Without prior approval we may not cover this drug
QL Quantity Limit Restriction We limit the amount of this drug that is covered per prescription or within a specific time frame
ST Step Therapy Restriction Before we will provide coverage for this drug you must first try another drug to treat your medical condition This drug may only be covered if the other drug does not work for you
Other Special Requirements for Coverage
LA Limited Access Drug Some drugs under your plan may only be filled at an in-network specialty pharmacy These are drugs where the FDA has restricted distribution or are drugs that require special handling provider coordination or patient education that cannot be met by a network retail pharmacy
Vac Vaccines For more information on the coverage of vaccines administered at a Pharmacy please see your member booklet or contact Customer Service
OCh Oral Chemo Oral Chemotherapy Drug Certain oral chemotherapy drugs may be covered under your medical plan Please check your member booklet for more details
The amount you pay for a covered drug will depend on if you have met any applicable deductible for the plan year if you have met any applicable maximum out of pocket for the plan year and what tier the medication is on More information on applicable deductibles and maximum out of pockets can be found in your member booklet
Metallic M2 Formulary
Drug Tier Includes
Formulary Drugs (1) Formulary Drugs include Preferred Generic Preferred Brand and Non-Preferred Drugs Medical plan cost shares apply to formulary drugs Once you have satisfied your medical deductible you will pay your applicable coinsurance until you reach your out of pocket maximum limit
Specialty Drug (2) Tier 2 includes specialty drugs Specialty drugs are generally biologics and other targeted drugs usually used for complex medical conditions and often requiring special handling
ACA PV The ACA PV tier includes Affordable Care Act (ACA) Preventive medications The ACA makes certain preventive medications available to you at no cost Coverage of any medication as ACA PV (including over-the-counter (OTC) medications) requires a prescription from a licensed health care provider
MB (Medical Benefit) The MB tier includes medical benefit drugs normally administered in a clinic infusion center or provided by a home infusion service These drugs and their services are covered under the medical benefit not under the pharmacy benefit This drug may require prior authorization
1
Drug Name Drug Tier Requirements Limits
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG
MB
amphotericin b injection recon soln 50 mg MB
CANCIDAS INTRAVENOUS RECON SOLN 50 MG 70 MG
MB
clotrimazole mucous membrane troche 10 mg 1
CRESEMBA INTRAVENOUS RECON SOLN 372 MG
MB
CRESEMBA ORAL CAPSULE 186 MG 1 PA
ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG 50 MG
MB
fluconazole oral suspension for reconstitution 10 mgml 40 mgml
1
fluconazole oral tablet 100 mg 150 mg 200 mg 50 mg
1
flucytosine oral capsule 250 mg 500 mg 1
griseofulvin microsize oral suspension 125 mg5 ml
1
griseofulvin microsize oral tablet 500 mg 1
griseofulvin ultramicrosize oral tablet 125 mg 250 mg
1
itraconazole oral capsule 100 mg 1
itraconazole oral solution 10 mgml 1
ketoconazole oral tablet 200 mg 1
MYCAMINE INTRAVENOUS RECON SOLN 100 MG 50 MG
MB
NOXAFIL ORAL SUSPENSION 200 MG5 ML (40 MGML)
1
nystatin oral suspension 100000 unitml 1
nystatin oral tablet 500000 unit 1
ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET 50 MG
1
posaconazole oral tabletdelayed release (drec) 100 mg
1
terbinafine hcl oral tablet 250 mg 1
voriconazole intravenous recon soln 200 mg MB
2
Drug Name Drug Tier Requirements Limits
voriconazole oral suspension for reconstitution 200 mg5 ml (40 mgml)
1
voriconazole oral tablet 200 mg 50 mg 1
ANTIVIRALS
abacavir oral solution 20 mgml 1 QL (60 per 30 days)
abacavir oral tablet 300 mg 1 QL (60 per 30 days)
abacavir-lamivudine oral tablet 600-300 mg 1 QL (30 per 30 days)
abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg
1 QL (60 per 30 days)
acyclovir oral capsule 200 mg 1
acyclovir oral suspension 200 mg5 ml 1
acyclovir oral tablet 400 mg 800 mg 1
adefovir oral tablet 10 mg 1
amantadine hcl oral capsule 100 mg 1
amantadine hcl oral solution 50 mg5 ml 1
amantadine hcl oral tablet 100 mg 1
APTIVUS ORAL CAPSULE 250 MG 1 QL (120 per 30 days)
atazanavir oral capsule 150 mg 300 mg 1 QL (30 per 30 days)
atazanavir oral capsule 200 mg 1 QL (60 per 30 days)
BARACLUDE ORAL SOLUTION 005 MGML 1
BIKTARVY ORAL TABLET 50-200-25 MG 1 QL (30 per 30 days)
CABENUVA INTRAMUSCULAR SUSPENSIONEXTENDED RELEASE 400 MG2 ML- 600 MG2 ML 600 MG3 ML- 900 MG3 ML
2 PA
cidofovir intravenous solution 75 mgml MB
CIMDUO ORAL TABLET 300-300 MG 1 QL (30 per 30 days)
COMPLERA ORAL TABLET 200-25-300 MG 1 QL (30 per 30 days)
CYTOVENE INTRAVENOUS RECON SOLN 500 MG
MB
DESCOVY ORAL TABLET 200-25 MG 1 QL (30 per 30 days)
didanosine oral capsuledelayed release(drec) 250 mg 400 mg
1 QL (30 per 30 days)
DOVATO ORAL TABLET 50-300 MG 1 QL (30 per 30 days)
EDURANT ORAL TABLET 25 MG 1 QL (30 per 30 days)
efavirenz oral capsule 200 mg 50 mg 1 QL (30 per 30 days)
efavirenz oral tablet 600 mg 1 QL (30 per 30 days)
3
Drug Name Drug Tier Requirements Limits
efavirenz-emtricitabin-tenofov oral tablet 600-200-300 mg
1
efavirenz-lamivu-tenofov disop oral tablet 400-300-300 mg 600-300-300 mg
1
emtricitabine oral capsule 200 mg 1 QL (30 per 30 days)
emtricitabine-tenofovir (tdf) oral tablet 100-150 mg 133-200 mg 167-250 mg 200-300 mg
1
EMTRIVA ORAL SOLUTION 10 MGML 1 QL (720 per 30 days)
entecavir oral tablet 05 mg 1 mg 1
EPCLUSA ORAL TABLET 200-50 MG 400-100 MG
2 PA LA
EPIVIR HBV ORAL SOLUTION 25 MG5 ML (5 MGML)
1
etravirine oral tablet 100 mg 200 mg 1 QL (60 per 30 days)
EVOTAZ ORAL TABLET 300-150 MG 1 QL (30 per 30 days)
famciclovir oral tablet 125 mg 250 mg 500 mg 1
fosamprenavir oral tablet 700 mg 1 QL (60 per 30 days)
FUZEON SUBCUTANEOUS RECON SOLN 90 MG
2 QL (30 per 30 days)
GANCICLOVIR INTRAVENOUS SOLUTION 500 MG250 ML (2 MGML)
MB
ganciclovir sodium intravenous recon soln 500 mg MB
GENVOYA ORAL TABLET 150-150-200-10 MG
1 QL (30 per 30 days)
HARVONI ORAL PELLETS IN PACKET 3375-150 MG 45-200 MG
2 LA
HARVONI ORAL TABLET 45-200 MG 90-400 MG
2 PA LA
INTELENCE ORAL TABLET 100 MG 200 MG 25 MG
1 QL (60 per 30 days)
INVIRASE ORAL TABLET 500 MG 1 QL (120 per 30 days)
ISENTRESS HD ORAL TABLET 600 MG 1 QL (60 per 30 days)
ISENTRESS ORAL POWDER IN PACKET 100 MG
1 QL (60 per 30 days)
ISENTRESS ORAL TABLET 400 MG 1 QL (60 per 30 days)
ISENTRESS ORAL TABLETCHEWABLE 100 MG 25 MG
1 QL (60 per 30 days)
JULUCA ORAL TABLET 50-25 MG 1 QL (30 per 30 days)
KALETRA ORAL TABLET 100-25 MG 1 QL (60 per 30 days)
4
Drug Name Drug Tier Requirements Limits
KALETRA ORAL TABLET 200-50 MG 1 QL (120 per 30 days)
lamivudine oral solution 10 mgml 1 QL (900 per 30 days)
lamivudine oral tablet 100 mg 1
lamivudine oral tablet 150 mg 300 mg 1 QL (60 per 30 days)
lamivudine-zidovudine oral tablet 150-300 mg 1 QL (60 per 30 days)
LEXIVA ORAL SUSPENSION 50 MGML 1 QL (60 per 30 days)
lopinavir-ritonavir oral solution 400-100 mg5 ml 1 QL (320 per 30 days)
lopinavir-ritonavir oral tablet 100-25 mg 200-50 mg
1 QL (120 per 30 days)
MAVYRET ORAL TABLET 100-40 MG 2 PA LA
nevirapine oral suspension 50 mg5 ml 1 QL (60 per 30 days)
nevirapine oral tablet 200 mg 1 QL (60 per 30 days)
nevirapine oral tablet extended release 24 hr 100 mg 400 mg
1 QL (30 per 30 days)
NORVIR ORAL POWDER IN PACKET 100 MG 1 QL (360 per 30 days)
NORVIR ORAL SOLUTION 80 MGML 1 QL (480 per 30 days)
ODEFSEY ORAL TABLET 200-25-25 MG 1 QL (30 per 30 days)
oseltamivir oral capsule 30 mg 1 QL (40 per 365 days)
oseltamivir oral capsule 45 mg 75 mg 1 QL (20 per 365 days)
oseltamivir oral suspension for reconstitution 6 mgml
1 QL (180 per 30 days)
PREVYMIS INTRAVENOUS SOLUTION 240 MG12 ML 480 MG24 ML
MB PA
PREZCOBIX ORAL TABLET 800-150 MG-MG 1 QL (30 per 30 days)
PREZISTA ORAL SUSPENSION 100 MGML 1 QL (30 per 30 days)
PREZISTA ORAL TABLET 150 MG 600 MG 75 MG
1 QL (60 per 30 days)
PREZISTA ORAL TABLET 800 MG 1 QL (30 per 30 days)
RAPIVAB (PF) INTRAVENOUS SOLUTION 200 MG20 ML (10 MGML)
MB
RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MGACTUATION
1 QL (2 per 30 days)
REYATAZ ORAL POWDER IN PACKET 50 MG
1 QL (150 per 30 days)
ribavirin inhalation recon soln 6 gram MB
rimantadine oral tablet 100 mg 1
ritonavir oral tablet 100 mg 1 QL (360 per 30 days)
5
Drug Name Drug Tier Requirements Limits
SELZENTRY ORAL SOLUTION 20 MGML 1 QL (8 per 30 days)
SELZENTRY ORAL TABLET 150 MG 25 MG 300 MG 75 MG
1 QL (60 per 30 days)
SOVALDI ORAL PELLETS IN PACKET 150 MG 200 MG
2 LA
SOVALDI ORAL TABLET 200 MG 400 MG 2 PA LA
stavudine oral capsule 15 mg 20 mg 40 mg 1 QL (120 per 30 days)
STRIBILD ORAL TABLET 150-150-200-300 MG
1 QL (30 per 30 days)
SYNAGIS INTRAMUSCULAR SOLUTION 100 MGML 50 MG05 ML
MB LA
tenofovir disoproxil fumarate oral tablet 300 mg 1 QL (30 per 30 days)
TIVICAY ORAL TABLET 10 MG 25 MG 50 MG
1 QL (60 per 30 days)
TIVICAY PD ORAL TABLET FOR SUSPENSION 5 MG
1 QL (60 per 30 days)
TRIUMEQ ORAL TABLET 600-50-300 MG 1 QL (30 per 30 days)
TROGARZO INTRAVENOUS SOLUTION 200 MG133 ML (150 MGML)
MB PA
TYBOST ORAL TABLET 150 MG 1 QL (30 per 30 days)
valacyclovir oral tablet 1 gram 500 mg 1
valganciclovir oral recon soln 50 mgml 1
valganciclovir oral tablet 450 mg 1
VEMLIDY ORAL TABLET 25 MG 1
VIEKIRA PAK ORAL TABLETSDOSE PACK 125 MG-75 MG -50 MG250 MG
2 PA
VIRACEPT ORAL TABLET 250 MG 1 QL (90 per 30 days)
VIRACEPT ORAL TABLET 625 MG 1 QL (60 per 30 days)
VIREAD ORAL POWDER 40 MGSCOOP (40 MGGRAM)
1 QL (4 per 30 days)
VIREAD ORAL TABLET 150 MG 200 MG 250 MG
1 QL (30 per 30 days)
VOSEVI ORAL TABLET 400-100-100 MG 2 PA LA
ZEPATIER ORAL TABLET 50-100 MG 2 PA LA
zidovudine oral capsule 100 mg 1 QL (60 per 30 days)
zidovudine oral syrup 10 mgml 1 QL (960 per 30 days)
zidovudine oral tablet 300 mg 1 QL (60 per 30 days)
CEPHALOSPORINS
6
Drug Name Drug Tier Requirements Limits
AVYCAZ INTRAVENOUS RECON SOLN 25 GRAM
MB
cefaclor oral capsule 250 mg 500 mg 1
cefaclor oral suspension for reconstitution 125 mg5 ml 250 mg5 ml 375 mg5 ml
1
cefaclor oral tablet extended release 12 hr 500 mg 1
cefadroxil oral capsule 500 mg 1
cefadroxil oral suspension for reconstitution 250 mg5 ml 500 mg5 ml
1
cefadroxil oral tablet 1 gram 1
cefazolin in dextrose (iso-os) intravenous piggyback 1 gram50 ml
MB
cefazolin injection recon soln 1 gram 10 gram 100 gram 20 gram 300 g 500 mg
MB
cefazolin intravenous recon soln 1 gram MB
cefdinir oral capsule 300 mg 1
cefdinir oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cefditoren pivoxil oral tablet 200 mg 400 mg 1
CEFEPIME IN DEXTROSE 5 INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
cefepime in dextroseiso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml
MB
cefepime injection recon soln 1 gram 2 gram MB
cefixime oral capsule 400 mg 1
cefixime oral suspension for reconstitution 100 mg5 ml 200 mg5 ml
1
CEFOTAN INJECTION RECON SOLN 1 GRAM 2 GRAM
MB
cefotaxime injection recon soln 1 gram MB
CEFOTETAN IN DEXTROSE ISO-OSM INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
cefotetan injection recon soln 1 gram 2 gram MB
cefotetan intravenous recon soln 10 gram MB
cefoxitin intravenous recon soln 10 gram MB
cefpodoxime oral suspension for reconstitution 100 mg5 ml 50 mg5 ml
1
7
Drug Name Drug Tier Requirements Limits
cefpodoxime oral tablet 100 mg 200 mg 1
cefprozil oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cefprozil oral tablet 250 mg 500 mg 1
CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
ceftazidime injection recon soln 1 gram 2 gram 6 gram
MB
ceftriaxone in dextroseiso-os intravenous piggyback 1 gram50 ml 2 gram50 ml
MB
ceftriaxone injection recon soln 1 gram 10 gram 2 gram 250 mg 500 mg
MB
CEFTRIAXONE INJECTION RECON SOLN 100 GRAM
MB
ceftriaxone intravenous recon soln 1 gram 2 gram MB
cefuroxime axetil oral tablet 250 mg 500 mg 1
cephalexin oral capsule 250 mg 500 mg 750 mg 1
cephalexin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cephalexin oral tablet 250 mg 500 mg 1
SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG5 ML
1
SUPRAX ORAL TABLETCHEWABLE 100 MG 200 MG
1
tazicef injection recon soln 1 gram 2 gram 6 gram
MB
tazicef intravenous recon soln 1 gram 2 gram MB
TEFLARO INTRAVENOUS RECON SOLN 400 MG 600 MG
MB
ZERBAXA INTRAVENOUS RECON SOLN 15 GRAM
MB
ERYTHROMYCINS amp OTHER MACROLIDES
azithromycin oral packet 1 gram 1
azithromycin oral suspension for reconstitution 100 mg5 ml 200 mg5 ml
1
azithromycin oral tablet 250 mg 500 mg 600 mg 1
clarithromycin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
clarithromycin oral tablet 250 mg 500 mg 1
8
Drug Name Drug Tier Requirements Limits
clarithromycin oral tablet extended release 24 hr 500 mg
1
DIFICID ORAL TABLET 200 MG 1
ees 400 oral tablet 400 mg 1
ery-tab oral tabletdelayed release (drec) 250 mg 333 mg
1
erythrocin (as stearate) oral tablet 250 mg 1
erythromycin ethylsuccinate oral suspension for reconstitution 200 mg5 ml 400 mg5 ml
1
erythromycin ethylsuccinate oral tablet 400 mg 1
erythromycin oral capsuledelayed release(drec) 250 mg
1
erythromycin oral tablet 250 mg 500 mg 1
erythromycin oral tabletdelayed release (drec) 250 mg 333 mg 500 mg
1
MISCELLANEOUS ANTIINFECTIVES
albendazole oral tablet 200 mg 1
ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG5 ML
1 PA ST
amikacin injection solution 500 mg2 ml MB
atovaquone oral suspension 750 mg5 ml 1
atovaquone-proguanil oral tablet 250-100 mg 625-25 mg
1
bacitracin intramuscular recon soln 50000 unit 1
CAPASTAT INJECTION RECON SOLN 1 GRAM
1
CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MGML
2 PA LA QL (84 per 30 days)
chloramphenicol sod succinate intravenous recon soln 1 gram
MB
chloroquine phosphate oral tablet 250 mg 500 mg 1
clindamycin hcl oral capsule 150 mg 300 mg 75 mg
1
clindamycin pediatric oral recon soln 75 mg5 ml 1
clindamycin phosphate injection solution 150 mgml
MB
COARTEM ORAL TABLET 20-120 MG 1
CUBICIN INTRAVENOUS RECON SOLN 500 MG
MB
9
Drug Name Drug Tier Requirements Limits
CUBICIN RF INTRAVENOUS RECON SOLN 500 MG
MB
CYCLOSERINE ORAL CAPSULE 250 MG 1
dapsone oral tablet 100 mg 25 mg 1
EMVERM ORAL TABLETCHEWABLE 100 MG
1
ethambutol oral tablet 100 mg 400 mg 1
gentamicin injection solution 20 mg2 ml 40 mgml
MB
gentamicin sulfate (ped) (pf) injection solution 20 mg2 ml
MB
hydroxychloroquine oral tablet 200 mg 1
imipenem-cilastatin intravenous recon soln 250 mg 500 mg
MB
INVANZ INJECTION RECON SOLN 1 GRAM MB
isoniazid injection solution 100 mgml 1
isoniazid oral solution 50 mg5 ml 1
isoniazid oral tablet 100 mg 300 mg 1
ivermectin oral tablet 3 mg 1
LINCOCIN INJECTION SOLUTION 300 MGML
MB
linezolid in dextrose 5 intravenous piggyback 600 mg300 ml
MB
linezolid oral suspension for reconstitution 100 mg5 ml
1
linezolid oral tablet 600 mg 1
linezolid-09 sodium chloride intravenous parenteral solution 600 mg300 ml
MB
mefloquine oral tablet 250 mg 1
meropenem intravenous recon soln 1 gram 500 mg
MB
MEROPENEM-09 SODIUM CHLORIDE INTRAVENOUS PIGGYBACK 1 GRAM50 ML 500 MG50 ML
MB
metronidazole oral capsule 375 mg 1
metronidazole oral tablet 250 mg 500 mg 1
neomycin oral tablet 500 mg 1
nitazoxanide oral tablet 500 mg 1
10
Drug Name Drug Tier Requirements Limits
paromomycin oral capsule 250 mg 1
PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM
1
PENTAM INJECTION RECON SOLN 300 MG MB
pentamidine inhalation recon soln 300 mg 1
pentamidine injection recon soln 300 mg MB
polymyxin b sulfate injection recon soln 500000 unit
MB
praziquantel oral tablet 600 mg 1
PRIFTIN ORAL TABLET 150 MG 1
primaquine oral tablet 263 mg 1
pyrazinamide oral tablet 500 mg 1
pyrimethamine oral tablet 25 mg 2 PA
quinine sulfate oral capsule 324 mg 1
rifabutin oral capsule 150 mg 1
rifampin oral capsule 150 mg 300 mg 1
SIRTURO ORAL TABLET 100 MG 1 PA
SIRTURO ORAL TABLET 20 MG 1
SIVEXTRO ORAL TABLET 200 MG 1 QL (6 per 30 days)
STREPTOMYCIN INTRAMUSCULAR RECON SOLN 1 GRAM
1
tinidazole oral tablet 250 mg 500 mg 1
tobramycin in 0225 nacl inhalation solution for nebulization 300 mg5 ml
2
tobramycin inhalation solution for nebulization 300 mg4 ml
2
tobramycin sulfate injection recon soln 12 gram 1
tobramycin sulfate injection solution 10 mgml MB
tobramycin sulfate injection solution 40 mgml 1
TOBRAMYCIN WITH NEBULIZER INHALATION SOLUTION FOR NEBULIZATION 300 MG5 ML
2 PA ST
TRECATOR ORAL TABLET 250 MG 1
TYGACIL INTRAVENOUS RECON SOLN 50 MG
MB
XENLETA INTRAVENOUS SOLUTION 150 MG15 ML
MB
XIFAXAN ORAL TABLET 200 MG 550 MG 1 PA QL (60 per 30 days)
11
Drug Name Drug Tier Requirements Limits
PENICILLINS
amoxicillin oral capsule 250 mg 500 mg 1
amoxicillin oral suspension for reconstitution 125 mg5 ml 200 mg5 ml 250 mg5 ml 400 mg5 ml
1
amoxicillin oral tablet 500 mg 875 mg 1
amoxicillin oral tabletchewable 125 mg 250 mg 1
amoxicillin-pot clavulanate oral suspension for reconstitution 200-285 mg5 ml 250-625 mg5 ml 400-57 mg5 ml 600-429 mg5 ml
1
amoxicillin-pot clavulanate oral tablet 250-125 mg 500-125 mg 875-125 mg
1
amoxicillin-pot clavulanate oral tablet extended release 12 hr 1000-625 mg
1
amoxicillin-pot clavulanate oral tabletchewable 200-285 mg 400-57 mg
1
ampicillin oral capsule 500 mg 1
ampicillin-sulbactam injection recon soln 15 gram MB
BICILLIN C-R INTRAMUSCULAR SYRINGE 1200000 UNIT 2 ML(900K300K)
MB
dicloxacillin oral capsule 250 mg 500 mg 1
MOXATAG ORAL TABLET ER MULTIPHASE 24 HR 775 MG
1
nafcillin in dextrose iso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml
MB
nafcillin injection recon soln 1 gram 10 gram 2 gram
MB
nafcillin intravenous recon soln 1 gram 2 gram MB
oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram50 ml 2 gram50 ml
MB
oxacillin injection recon soln 1 gram 10 gram 2 gram
MB
penicillin g procaine intramuscular syringe 12 million unit2 ml 600000 unitml
MB
penicillin v potassium oral recon soln 125 mg5 ml 250 mg5 ml
1
penicillin v potassium oral tablet 250 mg 500 mg 1
piperacillin-tazobactam intravenous recon soln 135 gram 225 gram 3375 gram 45 gram 405 gram
MB
12
Drug Name Drug Tier Requirements Limits
QUINOLONES
BAXDELA INTRAVENOUS RECON SOLN 300 MG
MB
BAXDELA ORAL TABLET 450 MG 1
ciprofloxacin hcl oral tablet 100 mg 250 mg 500 mg 750 mg
1
ciprofloxacin oral suspensionmicrocapsule recon 250 mg5 ml 500 mg5 ml
1
FACTIVE ORAL TABLET 320 MG 1 ST
levofloxacin oral solution 250 mg10 ml 1
levofloxacin oral tablet 250 mg 500 mg 750 mg 1
moxifloxacin oral tablet 400 mg 1
ofloxacin oral tablet 300 mg 400 mg 1
SULFAS amp RELATED AGENTS
sulfadiazine oral tablet 500 mg 1
sulfamethoxazole-trimethoprim oral suspension 200-40 mg5 ml
1
sulfamethoxazole-trimethoprim oral tablet 400-80 mg 800-160 mg
1
sulfatrim oral suspension 200-40 mg5 ml 1
TETRACYCLINES
avidoxy oral tablet 100 mg 1 ST
demeclocycline oral tablet 150 mg 300 mg 1
doxycycline hyclate oral capsule 100 mg 50 mg 1
doxycycline hyclate oral tablet 100 mg 150 mg 20 mg 50 mg 75 mg
1
doxycycline hyclate oral tabletdelayed release (drec) 100 mg 150 mg 200 mg 50 mg 75 mg
1
doxycycline monohydrate oral capsule 100 mg 150 mg 50 mg 75 mg
1
doxycycline monohydrate oral suspension for reconstitution 25 mg5 ml
1
doxycycline monohydrate oral tablet 100 mg 150 mg 50 mg 75 mg
1
minocycline oral capsule 100 mg 50 mg 75 mg 1
minocycline oral tablet 100 mg 50 mg 75 mg 1
mondoxyne nl oral capsule 100 mg 75 mg 1
tetracycline oral capsule 250 mg 500 mg 1
13
Drug Name Drug Tier Requirements Limits
URINARY TRACT AGENTS
fosfomycin tromethamine oral packet 3 gram 1
methenamine hippurate oral tablet 1 gram 1
methenamine mandelate oral tablet 05 g 1 gram 1
nitrofurantoin macrocrystal oral capsule 100 mg 25 mg 50 mg
1
nitrofurantoin monohydm-cryst oral capsule 100 mg
1
nitrofurantoin oral suspension 25 mg5 ml 1
PRIMSOL ORAL SOLUTION 50 MG5 ML 1
trimethoprim oral tablet 100 mg 1
VANCOMYCIN
vancomycin oral capsule 125 mg 250 mg 1
vancomycin oral recon soln 50 mgml 1
VIBATIV INTRAVENOUS RECON SOLN 750 MG
MB
ANTINEOPLASTIC amp IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
KEPIVANCE INTRAVENOUS RECON SOLN 625 MG
MB
leucovorin calcium injection recon soln 100 mg 200 mg 350 mg 50 mg 500 mg
MB
leucovorin calcium injection solution 10 mgml MB
leucovorin calcium oral tablet 10 mg 15 mg 25 mg 5 mg
1
VISTOGARD ORAL GRANULES IN PACKET 10 GRAM
2
VORAXAZE INTRAVENOUS RECON SOLN 1000 UNIT
MB
XGEVA SUBCUTANEOUS SOLUTION 120 MG17 ML (70 MGML)
2 LA
ANTINEOPLASTIC amp IMMUNOSUPPRESSANT DRUGS
abiraterone oral tablet 250 mg 2 PA OCh LA
abiraterone oral tablet 500 mg 2 PA ST OCh LA
ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG
MB PA LA
ADAKVEO INTRAVENOUS SOLUTION 10 MGML
MB PA
14
Drug Name Drug Tier Requirements Limits
ADCETRIS INTRAVENOUS RECON SOLN 50 MG
MB PA LA
AFINITOR ORAL TABLET 10 MG 2 OCh LA
ALECENSA ORAL CAPSULE 150 MG 2 PA OCh LA
ALIMTA INTRAVENOUS RECON SOLN 100 MG 500 MG
MB PA
ALIQOPA INTRAVENOUS RECON SOLN 60 MG
MB PA
anastrozole oral tablet 1 mg ACA PV OCh QL (30 per 30 days)
ARRANON INTRAVENOUS SOLUTION 250 MG50 ML
MB LA
ARZERRA INTRAVENOUS SOLUTION 1000 MG50 ML 100 MG5 ML
MB PA LA
ASPARLAS INTRAVENOUS SOLUTION 750 UNITML
MB PA
AVASTIN INTRAVENOUS SOLUTION 25 MGML
MB PA LA
azathioprine oral tablet 50 mg 1
BALVERSA ORAL TABLET 3 MG 4 MG 5 MG
2 PA OCh
BAVENCIO INTRAVENOUS SOLUTION 20 MGML
MB PA
BELEODAQ INTRAVENOUS RECON SOLN 500 MG
MB PA
BELRAPZO INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BENDAMUSTINE INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BENDEKA INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BESPONSA INTRAVENOUS RECON SOLN 09 MG (025 MGML INITIAL)
MB PA LA
bexarotene oral capsule 75 mg 2 PA ST OCh
bicalutamide oral tablet 50 mg 2 OCh QL (30 per 30 days)
BLINCYTO INTRAVENOUS KIT 35 MCG MB PA
BORTEZOMIB INTRAVENOUS RECON SOLN 35 MG
MB
BOSULIF ORAL TABLET 100 MG 400 MG 500 MG
2 PA ST OCh LA
BRAFTOVI ORAL CAPSULE 50 MG 75 MG 2 PA OCh LA
15
Drug Name Drug Tier Requirements Limits
BUSULFEX INTRAVENOUS SOLUTION 60 MG10 ML
MB
CABOMETYX ORAL TABLET 20 MG 40 MG 60 MG
2 PA ST OCh LA
CALQUENCE ORAL CAPSULE 100 MG 2 PA ST OCh
capecitabine oral tablet 150 mg 2 OCh LA QL (210 per 30 days)
capecitabine oral tablet 500 mg 2 OCh LA QL (84 per 30 days)
CAPRELSA ORAL TABLET 100 MG 300 MG 2 PA OCh
CLOLAR INTRAVENOUS SOLUTION 20 MG20 ML
MB PA
COMETRIQ ORAL CAPSULE 100 MGDAY(80 MG X1-20 MG X1) 140 MGDAY(80 MG X1-20 MG X3) 60 MGDAY (20 MG X 3DAY)
2 PA OCh
COPIKTRA ORAL CAPSULE 15 MG 25 MG 2 PA OCh
COTELLIC ORAL TABLET 20 MG 2 PA OCh LA
cyclophosphamide intravenous recon soln 1 gram 2 gram 500 mg
MB
cyclophosphamide oral capsule 25 mg 50 mg 2 OCh
CYCLOPHOSPHAMIDE ORAL TABLET 25 MG 50 MG
2 OCh
cyclosporine modified oral capsule 100 mg 25 mg 50 mg
1
cyclosporine modified oral solution 100 mgml 1
cyclosporine oral capsule 100 mg 25 mg 1
CYRAMZA INTRAVENOUS SOLUTION 10 MGML
MB PA LA
DACOGEN INTRAVENOUS RECON SOLN 50 MG
MB PA LA
DARZALEX INTRAVENOUS SOLUTION 20 MGML
MB PA LA
DAURISMO ORAL TABLET 100 MG 25 MG 2 PA OCh LA
decitabine intravenous recon soln 50 mg MB LA
ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 225 MG
2
ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG
2
ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG
2
16
Drug Name Drug Tier Requirements Limits
ELIGARD SUBCUTANEOUS SYRINGE 75 MG (1 MONTH)
2
ELZONRIS INTRAVENOUS SOLUTION 1000 MCGML
MB PA
EMCYT ORAL CAPSULE 140 MG 2 OCh
EMPLICITI INTRAVENOUS RECON SOLN 300 MG 400 MG
MB PA LA
ENHERTU INTRAVENOUS RECON SOLN 100 MG
MB PA LA
ERBITUX INTRAVENOUS SOLUTION 100 MG50 ML 200 MG100 ML
MB PA LA
ERLEADA ORAL TABLET 60 MG 2 PA OCh LA
erlotinib oral tablet 100 mg 150 mg 25 mg 2 PA OCh LA
ERWINAZE INJECTION RECON SOLN 10000 UNIT
MB
etoposide intravenous solution 20 mgml MB
etoposide oral capsule 50 mg 2 OCh
everolimus (antineoplastic) oral tablet 25 mg 5 mg 75 mg
2 PA ST OCh LA
everolimus (immunosuppressive) oral tablet 025 mg 05 mg 075 mg
1 PA
exemestane oral tablet 25 mg ACA PV OCh QL (30 per 30 days)
FASLODEX INTRAMUSCULAR SYRINGE 250 MG5 ML
MB PA
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG 80 MG
2 LA
fludarabine intravenous recon soln 50 mg MB
fluorouracil intravenous solution 25 gram50 ml 5 gram100 ml 500 mg10 ml
MB PA
flutamide oral capsule 125 mg 2 OCh QL (180 per 30 days)
FOLOTYN INTRAVENOUS SOLUTION 20 MGML (1 ML) 40 MG2 ML (20 MGML)
MB PA LA
fulvestrant intramuscular syringe 250 mg5 ml MB
GAMIFANT INTRAVENOUS SOLUTION 5 MGML
MB PA
GAZYVA INTRAVENOUS SOLUTION 1000 MG40 ML
MB PA LA
gemcitabine intravenous recon soln 1 gram 2 gram 200 mg
MB
17
Drug Name Drug Tier Requirements Limits
gemcitabine intravenous solution 2 gram526 ml (38 mgml) 200 mg526 ml (38 mgml)
MB
gengraf oral capsule 100 mg 25 mg 1
gengraf oral solution 100 mgml 1
GILOTRIF ORAL TABLET 20 MG 30 MG 40 MG
2 PA OCh LA
GLEOSTINE ORAL CAPSULE 10 MG 100 MG 40 MG
2 PA OCh
HALAVEN INTRAVENOUS SOLUTION 1 MG2 ML (05 MGML)
MB PA LA
HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600 MG-10000 UNIT5 ML
MB LA
HERCEPTIN INTRAVENOUS RECON SOLN 150 MG
MB PA LA
HERZUMA INTRAVENOUS RECON SOLN 150 MG
MB PA LA
HYCAMTIN ORAL CAPSULE 025 MG 1 MG 2 OCh LA
hydroxyurea oral capsule 500 mg 2 OCh
IBRANCE ORAL CAPSULE 100 MG 125 MG 75 MG
2 PA OCh LA
IBRANCE ORAL TABLET 100 MG 125 MG 75 MG
2 OCh LA
ICLUSIG ORAL TABLET 10 MG 15 MG 30 MG 45 MG
2 PA ST OCh
IDHIFA ORAL TABLET 100 MG 50 MG 2 PA OCh LA
imatinib oral tablet 100 mg 2 OCh LA QL (90 per 30 days)
imatinib oral tablet 400 mg 2 OCh LA QL (60 per 30 days)
IMBRUVICA ORAL CAPSULE 140 MG 70 MG 2 PA ST OCh
IMBRUVICA ORAL TABLET 140 MG 280 MG 420 MG 560 MG
2 PA ST OCh
IMFINZI INTRAVENOUS SOLUTION 50 MGML
MB PA LA
IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFUML 10EXP8 (100 MILLION) PFUML
MB
18
Drug Name Drug Tier Requirements Limits
INFUGEM INTRAVENOUS PIGGYBACK 1200 MG120 ML (10 MGML) 1300 MG130 ML (10 MGML) 1400 MG140 ML (10 MGML) 1500 MG150 ML (10 MGML) 1600 MG160 ML (10 MGML) 1700 MG170 ML (10 MGML) 1800 MG180 ML (10 MGML) 1900 MG190 ML (10 MGML) 2000 MG200 ML (10 MGML) 2200 MG220 ML (10 MGML)
MB
INLYTA ORAL TABLET 1 MG 5 MG 2 PA OCh LA
IRESSA ORAL TABLET 250 MG 2 PA OCh LA
ISTODAX INTRAVENOUS RECON SOLN 10 MG2 ML
MB PA LA
IXEMPRA INTRAVENOUS RECON SOLN 15 MG 45 MG
MB PA LA
JAKAFI ORAL TABLET 10 MG 15 MG 20 MG 25 MG 5 MG
2 PA OCh LA
JEVTANA INTRAVENOUS SOLUTION 10 MGML (FIRST DILUTION)
MB PA LA
KADCYLA INTRAVENOUS RECON SOLN 100 MG 160 MG
MB PA LA
KANJINTI INTRAVENOUS RECON SOLN 150 MG 420 MG
MB PA LA
KEYTRUDA INTRAVENOUS SOLUTION 25 MGML
MB PA
KISQALI FEMARA CO-PACK ORAL TABLET 200 MGDAY(200 MG X 1)-25 MG 400 MGDAY(200 MG X 2)-25 MG 600 MGDAY(200 MG X 3)-25 MG
2 PA ST OCh LA
KISQALI ORAL TABLET 200 MGDAY (200 MG X 1) 400 MGDAY (200 MG X 2) 600 MGDAY (200 MG X 3)
2 PA ST OCh LA
KYMRIAH INTRAVENOUS SUSPENSION 02X10EXP6 TO 25X10EXP8 CELL 06 TO 6 X 10EXP8 CELL
MB PA
KYPROLIS INTRAVENOUS RECON SOLN 10 MG 30 MG 60 MG
MB PA
lapatinib oral tablet 250 mg 2 PA OCh LA QL (180 per 30 days)
LENVIMA ORAL CAPSULE 10 MGDAY (10 MG X 1) 12 MGDAY (4 MG X 3) 14 MGDAY(10 MG X 1-4 MG X 1) 18 MGDAY (10 MG X 1-4 MG X2) 20 MGDAY (10 MG X 2) 24 MGDAY(10 MG X 2-4 MG X 1) 4 MG 8 MGDAY (4 MG X 2)
2 PA ST OCh LA
19
Drug Name Drug Tier Requirements Limits
letrozole oral tablet 25 mg ACA PV OCh QL (30 per 30 days)
LEUKERAN ORAL TABLET 2 MG 2 OCh
leuprolide subcutaneous kit 1 mg02 ml 2
LIBTAYO INTRAVENOUS SOLUTION 50 MGML
MB PA
LONSURF ORAL TABLET 15-614 MG 20-819 MG
2 PA ST OCh LA
LUMOXITI INTRAVENOUS RECON SOLN 1 MG
MB
LUPKYNIS ORAL CAPSULE 79 MG 2 PA ST
LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 225 MG
2
LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG
2
LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG
2
LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 375 MG 75 MG
2
LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 30 MG
2
LUPRON DEPOT-PED INTRAMUSCULAR KIT 1125 MG 15 MG 75 MG (PED)
2
LYNPARZA ORAL TABLET 100 MG 150 MG 2 PA ST OCh LA
LYSODREN ORAL TABLET 500 MG 2 OCh
MARQIBO INTRAVENOUS KIT 5 MG31 ML(016 MGML) FINAL
MB PA
MATULANE ORAL CAPSULE 50 MG 2 OCh
megestrol oral suspension 400 mg10 ml (40 mgml)
1 QL (2 per 30 days)
megestrol oral suspension 625 mg5 ml (125 mgml)
1 QL (1 per 30 days)
megestrol oral tablet 20 mg 2 OCh QL (480 per 30 days)
megestrol oral tablet 40 mg 2 OCh QL (240 per 30 days)
MEKINIST ORAL TABLET 05 MG 2 MG 2 PA ST OCh LA
MEKTOVI ORAL TABLET 15 MG 2 PA OCh LA
melphalan hcl intravenous recon soln 50 mg MB
melphalan oral tablet 2 mg 2 OCh
20
Drug Name Drug Tier Requirements Limits
mercaptopurine oral tablet 50 mg 2 OCh QL (300 per 30 days)
methotrexate sodium (pf) injection recon soln 1 gram
1
methotrexate sodium (pf) injection solution 25 mgml
1
methotrexate sodium injection solution 25 mgml 1
methotrexate sodium oral tablet 25 mg 2 OCh
mitoxantrone intravenous concentrate 2 mgml MB PA LA
mycophenolate mofetil oral capsule 250 mg 1
mycophenolate mofetil oral tablet 500 mg 1
mycophenolate sodium oral tabletdelayed release (drec) 180 mg 360 mg
1
MYLOTARG INTRAVENOUS RECON SOLN 45 MG (1 MGML INITIAL CONC)
MB PA LA
NERLYNX ORAL TABLET 40 MG 2 PA OCh LA QL (180 per 30 days)
NEXAVAR ORAL TABLET 200 MG 2 PA ST OCh LA
nilutamide oral tablet 150 mg 2 OCh QL (60 per 30 days)
NINLARO ORAL CAPSULE 23 MG 3 MG 4 MG
2 PA ST OCh LA
NULOJIX INTRAVENOUS RECON SOLN 250 MG
MB PA
octreotide acetate injection solution 1000 mcgml 100 mcgml 200 mcgml 50 mcgml 500 mcgml
2
octreotide acetate injection syringe 100 mcgml (1 ml) 50 mcgml (1 ml) 500 mcgml (1 ml)
2
OGIVRI INTRAVENOUS RECON SOLN 150 MG 420 MG
MB PA LA
ONCASPAR INJECTION SOLUTION 750 UNITML
MB
ONIVYDE INTRAVENOUS DISPERSION 43 MGML
MB PA
OPDIVO INTRAVENOUS SOLUTION 100 MG10 ML 240 MG24 ML 40 MG4 ML
MB PA LA
PADCEV INTRAVENOUS RECON SOLN 20 MG 30 MG
MB PA LA
PEMAZYRE ORAL TABLET 135 MG 45 MG 9 MG
2 PA ST OCh
PERJETA INTRAVENOUS SOLUTION 420 MG14 ML (30 MGML)
MB PA LA
21
Drug Name Drug Tier Requirements Limits
PIQRAY ORAL TABLET 200 MGDAY (200 MG X 1) 250 MGDAY (200 MG X1-50 MG X1) 300 MGDAY (150 MG X 2)
2 PA OCh LA
POLIVY INTRAVENOUS RECON SOLN 140 MG
MB PA LA
PORTRAZZA INTRAVENOUS SOLUTION 800 MG50 ML (16 MGML)
MB PA LA
POTELIGEO INTRAVENOUS SOLUTION 4 MGML
MB PA
PROGRAF INTRAVENOUS SOLUTION 5 MGML
MB
QINLOCK ORAL TABLET 50 MG 2 OCh
RETEVMO ORAL CAPSULE 40 MG 2 PA OCh LA QL (240 per 30 days)
RETEVMO ORAL CAPSULE 80 MG 2 PA OCh LA QL (120 per 30 days)
RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG117 ML (120 MGML) 1600 MG134 ML (120 MGML)
MB LA
RITUXAN INTRAVENOUS CONCENTRATE 10 MGML
MB PA LA
RUBRACA ORAL TABLET 200 MG 250 MG 300 MG
2 PA ST OCh LA
RYDAPT ORAL CAPSULE 25 MG 2 PA ST OCh LA
SARCLISA INTRAVENOUS SOLUTION 20 MGML
MB
SIGNIFOR SUBCUTANEOUS SOLUTION 03 MGML (1 ML) 06 MGML (1 ML) 09 MGML (1 ML)
2 PA ST
SIMULECT INTRAVENOUS RECON SOLN 10 MG 20 MG
MB
sirolimus oral solution 1 mgml 1
sirolimus oral tablet 05 mg 1 mg 2 mg 1
SOLTAMOX ORAL SOLUTION 20 MG10 ML 2 OCh
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG05 ML 60 MG02 ML 90 MG03 ML
2 PA LA
SPRYCEL ORAL TABLET 100 MG 140 MG 20 MG 50 MG 70 MG 80 MG
2 PA ST OCh LA
STIVARGA ORAL TABLET 40 MG 2 PA ST OCh LA
SUPPRELIN LA IMPLANT KIT 50 MG (65 MCGDAY)
MB LA
22
Drug Name Drug Tier Requirements Limits
SUTENT ORAL CAPSULE 125 MG 25 MG 375 MG 50 MG
2 PA ST OCh LA
SYLVANT INTRAVENOUS RECON SOLN 100 MG 400 MG
MB PA LA
SYNRIBO SUBCUTANEOUS RECON SOLN 35 MG
2 PA ST
TABLOID ORAL TABLET 40 MG 2 OCh
tacrolimus oral capsule 05 mg 1 mg 5 mg 1
TAFINLAR ORAL CAPSULE 50 MG 75 MG 2 PA OCh LA
TAGRISSO ORAL TABLET 40 MG 80 MG 2 PA OCh LA
TALZENNA ORAL CAPSULE 025 MG 1 MG 2 PA OCh LA
tamoxifen oral tablet 10 mg 20 mg 2 OCh QL (60 per 30 days)
TARGRETIN TOPICAL GEL 1 1 PA ST
TASIGNA ORAL CAPSULE 150 MG 200 MG 50 MG
2 PA ST OCh LA
TECENTRIQ INTRAVENOUS SOLUTION 1200 MG20 ML (60 MGML) 840 MG14 ML (60 MGML)
MB PA LA
TEMODAR INTRAVENOUS RECON SOLN 100 MG
MB PA LA
temozolomide oral capsule 100 mg 140 mg 180 mg 20 mg 250 mg 5 mg
2 OCh LA
temsirolimus intravenous recon soln 30 mg3 ml (10 mgml) (first)
MB PA LA
THALOMID ORAL CAPSULE 100 MG 150 MG 200 MG 50 MG
2 OCh LA
TIBSOVO ORAL TABLET 250 MG 2 PA OCh
toremifene oral tablet 60 mg 2 OCh
TORISEL INTRAVENOUS RECON SOLN 30 MG3 ML (10 MGML) (FIRST)
MB PA LA
TREANDA INTRAVENOUS RECON SOLN 100 MG 25 MG
MB PA LA
TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 1125 MG 225 MG 375 MG
MB
tretinoin (antineoplastic) oral capsule 10 mg 2 OCh
TREXALL ORAL TABLET 10 MG 15 MG 5 MG 75 MG
2 PA ST OCh QL (15 per 30 days)
TRUXIMA INTRAVENOUS SOLUTION 10 MGML
MB PA LA
23
Drug Name Drug Tier Requirements Limits
TUKYSA ORAL TABLET 150 MG 50 MG 2 PA ST OCh QL (120 per 30 days)
UNITUXIN INTRAVENOUS SOLUTION 35 MGML
MB PA
VANTAS IMPLANT KIT 50 MG (50 MCGDAY)
MB LA
VECTIBIX INTRAVENOUS SOLUTION 100 MG5 ML (20 MGML) 400 MG20 ML (20 MGML)
MB PA LA
VELCADE INJECTION RECON SOLN 35 MG MB LA
VENCLEXTA ORAL TABLET 10 MG 100 MG 50 MG
2 PA ST OCh
VENCLEXTA STARTING PACK ORAL TABLETSDOSE PACK 10 MG-50 MG- 100 MG
2 PA OCh
VERZENIO ORAL TABLET 100 MG 150 MG 200 MG 50 MG
2 PA ST OCh LA
VIDAZA INJECTION RECON SOLN 100 MG MB PA LA
VITRAKVI ORAL CAPSULE 100 MG 2 PA OCh LA
VITRAKVI ORAL CAPSULE 25 MG 2 PA ST OCh LA
VITRAKVI ORAL SOLUTION 20 MGML 2 PA OCh LA
VOTRIENT ORAL TABLET 200 MG 2 PA ST OCh LA
VYXEOS INTRAVENOUS RECON SOLN 44-100 MG
MB PA
XALKORI ORAL CAPSULE 200 MG 250 MG 2 PA OCh LA
XERMELO ORAL TABLET 250 MG 2 PA ST
XOSPATA ORAL TABLET 40 MG 2 PA OCh
XTANDI ORAL CAPSULE 40 MG 2 PA OCh LA
XTANDI ORAL TABLET 40 MG 80 MG 2 PA OCh LA
YERVOY INTRAVENOUS SOLUTION 200 MG40 ML (5 MGML) 50 MG10 ML (5 MGML)
MB PA LA
YESCARTA INTRAVENOUS SUSPENSION MB PA
YONDELIS INTRAVENOUS RECON SOLN 1 MG
MB PA
YONSA ORAL TABLET 125 MG 2 PA OCh LA
ZALTRAP INTRAVENOUS SOLUTION 100 MG4 ML (25 MGML) 200 MG8 ML (25 MGML)
MB PA LA
ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM
MB
24
Drug Name Drug Tier Requirements Limits
ZEJULA ORAL CAPSULE 100 MG 2 OCh
ZELBORAF ORAL TABLET 240 MG 2 PA ST OCh LA
ZOLADEX SUBCUTANEOUS IMPLANT 108 MG 36 MG
MB LA
ZOLINZA ORAL CAPSULE 100 MG 2 PA ST OCh LA
ZYKADIA ORAL TABLET 150 MG 2 PA ST OCh LA
AUTONOMIC amp CNS DRUGS NEUROLOGY amp PSYCH
ANTICONVULSANTS
BANZEL ORAL TABLET 200 MG 400 MG 1 PA ST
BRIVIACT ORAL SOLUTION 10 MGML 1 ST QL (150 per 30 days)
BRIVIACT ORAL TABLET 10 MG 100 MG 25 MG 50 MG 75 MG
1 ST QL (60 per 30 days)
carbamazepine oral capsule er multiphase 12 hr 100 mg 200 mg 300 mg
1
carbamazepine oral suspension 100 mg5 ml 200 mg10 ml
1
carbamazepine oral tablet 200 mg 1
carbamazepine oral tablet extended release 12 hr 100 mg 200 mg 400 mg
1
carbamazepine oral tabletchewable 100 mg 1
CELONTIN ORAL CAPSULE 300 MG 1
clobazam oral suspension 25 mgml 1
clobazam oral tablet 10 mg 20 mg 1
clonazepam oral tablet 05 mg 1 mg 2 mg 1
clonazepam oral tabletdisintegrating 0125 mg 025 mg 05 mg 1 mg 2 mg
1
diazepam rectal kit 25 mg 1
DILANTIN EXTENDED ORAL CAPSULE 100 MG
1
DILANTIN INFATABS ORAL TABLETCHEWABLE 50 MG
1
DILANTIN ORAL CAPSULE 30 MG 1
DILANTIN-125 ORAL SUSPENSION 125 MG5 ML
1
divalproex oral capsule delayed rel sprinkle 125 mg
1
divalproex oral tablet extended release 24 hr 250 mg 500 mg
1
25
Drug Name Drug Tier Requirements Limits
divalproex oral tabletdelayed release (drec) 125 mg 250 mg 500 mg
1
EPIDIOLEX ORAL SOLUTION 100 MGML 2 PA LA QL (400 per 30 days)
epitol oral tablet 200 mg 1
ethosuximide oral capsule 250 mg 1
ethosuximide oral solution 250 mg5 ml 1
felbamate oral suspension 600 mg5 ml 1
felbamate oral tablet 400 mg 600 mg 1
FINTEPLA ORAL SOLUTION 22 MGML 2
gabapentin oral capsule 100 mg 300 mg 400 mg 1
gabapentin oral solution 250 mg5 ml 300 mg6 ml (6 ml)
1
gabapentin oral tablet 600 mg 800 mg 1
lamotrigine oral tablet 100 mg 150 mg 200 mg 25 mg
1
lamotrigine oral tablet disintegrating dose pk 25 mg (21) -50 mg (7) 25 mg(14)-50 mg (14)-100 mg (7) 50 mg (42) -100 mg (14)
1
lamotrigine oral tablet extended release 24hr 100 mg 200 mg 25 mg 250 mg 300 mg 50 mg
1
lamotrigine oral tablet chewable dispersible 25 mg 5 mg
1
lamotrigine oral tabletdisintegrating 100 mg 200 mg 25 mg 50 mg
1
lamotrigine oral tabletsdose pack 25 mg (35) 25 mg (42) -100 mg (7) 25 mg (84) -100 mg (14)
1
levetiracetam oral solution 100 mgml 500 mg5 ml (5 ml)
1
levetiracetam oral tablet 1000 mg 250 mg 500 mg 750 mg
1
levetiracetam oral tablet extended release 24 hr 500 mg 750 mg
1
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG 330 MG 825 MG
1 PA ST
oxcarbazepine oral suspension 300 mg5 ml (60 mgml)
1
oxcarbazepine oral tablet 150 mg 300 mg 600 mg 1
phenobarbital oral elixir 20 mg5 ml (4 mgml) 1
26
Drug Name Drug Tier Requirements Limits
phenobarbital oral tablet 100 mg 15 mg 162 mg 30 mg 324 mg 60 mg 648 mg 972 mg
1
phenytoin oral suspension 100 mg4 ml 125 mg5 ml
1
phenytoin oral tabletchewable 50 mg 1
phenytoin sodium extended oral capsule 100 mg 200 mg 300 mg
1
pregabalin oral capsule 100 mg 150 mg 200 mg 225 mg 25 mg 300 mg 50 mg 75 mg
1 PA ST
pregabalin oral solution 20 mgml 1 PA ST
pregabalin oral tablet extended release 24 hr 165 mg 330 mg 825 mg
1 PA ST
primidone oral tablet 250 mg 50 mg 1
roweepra oral tablet 1000 mg 500 mg 750 mg 1
rufinamide oral suspension 40 mgml 1 PA
rufinamide oral tablet 200 mg 400 mg 1 PA
subvenite oral tablet 100 mg 150 mg 200 mg 25 mg
1
subvenite starter (blue) kit oral tabletsdose pack 25 mg (35)
1
subvenite starter (green) kit oral tabletsdose pack 25 mg (84) -100 mg (14)
1
subvenite starter (orange) kit oral tabletsdose pack 25 mg (42) -100 mg (7)
1
SYMPAZAN ORAL FILM 10 MG 20 MG 5 MG 1 PA QL (30 per 30 days)
tiagabine oral tablet 12 mg 16 mg 2 mg 4 mg 1
topiramate oral capsule sprinkle 15 mg 25 mg 1
topiramate oral tablet 100 mg 200 mg 25 mg 50 mg
1
valproic acid (as sodium salt) oral solution 250 mg5 ml 500 mg10 ml (10 ml)
1
valproic acid oral capsule 250 mg 1
vigabatrin oral powder in packet 500 mg 2 PA LA
vigabatrin oral tablet 500 mg 2 PA LA
vigadrone oral powder in packet 500 mg 2 PA ST
VIMPAT ORAL SOLUTION 10 MGML 1 PA ST QL (6 per 30 days)
VIMPAT ORAL TABLET 100 MG 150 MG 200 MG 50 MG
1 ST QL (60 per 30 days)
27
Drug Name Drug Tier Requirements Limits
XCOPRI MAINTENANCE PACK ORAL TABLET 250 MGDAY (200 MG X1-50 MG X1) 350 MGDAY (200 MG X1-150MG X1)
2
XCOPRI MAINTENANCE PACK ORAL TABLET 250MGDAY(150 MG X1-100MG X1)
2 PA ST
XCOPRI ORAL TABLET 100 MG 150 MG 200 MG 50 MG
2
XCOPRI TITRATION PACK ORAL TABLETSDOSE PACK 125 MG (14)- 25 MG (14) 150 MG (14)- 200 MG (14) 50 MG (14)- 100 MG (14)
2
zonisamide oral capsule 100 mg 25 mg 50 mg 1
ANTIPARKINSONISM AGENTS
APOKYN SUBCUTANEOUS CARTRIDGE 10 MGML
2 PA LA QL (1 per 30 days)
benztropine injection solution 1 mgml 1
benztropine oral tablet 05 mg 1 mg 2 mg 1
bromocriptine oral capsule 5 mg 1
bromocriptine oral tablet 25 mg 1
carbidopa oral tablet 25 mg 1
carbidopa-levodopa oral tablet 10-100 mg 25-100 mg 25-250 mg
1
carbidopa-levodopa oral tablet extended release 25-100 mg 50-200 mg
1
carbidopa-levodopa oral tabletdisintegrating 10-100 mg 25-100 mg 25-250 mg
1
carbidopa-levodopa-entacapone oral tablet 125-50-200 mg 1875-75-200 mg 25-100-200 mg 3125-125-200 mg 375-150-200 mg 50-200-200 mg
1
entacapone oral tablet 200 mg 1
pramipexole oral tablet 0125 mg 025 mg 05 mg 075 mg 1 mg 15 mg
1
pramipexole oral tablet extended release 24 hr 0375 mg 075 mg 15 mg 225 mg 3 mg 375 mg 45 mg
1
rasagiline oral tablet 05 mg 1 mg 1
ropinirole oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg 5 mg
1
28
Drug Name Drug Tier Requirements Limits
ropinirole oral tablet extended release 24 hr 12 mg 2 mg 4 mg 6 mg 8 mg
1
selegiline hcl oral capsule 5 mg 1
selegiline hcl oral tablet 5 mg 1
tolcapone oral tablet 100 mg 1
trihexyphenidyl oral elixir 04 mgml 1
trihexyphenidyl oral tablet 2 mg 5 mg 1
MIGRAINE amp CLUSTER HEADACHE THERAPY
AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MGML 70 MGML
1 PA ST
AJOVY AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 225 MG15 ML
1 ST
AJOVY SYRINGE SUBCUTANEOUS SYRINGE 225 MG15 ML
1 PA ST
almotriptan malate oral tablet 125 mg 625 mg 1 QL (18 per 30 days)
dihydroergotamine injection solution 1 mgml 1
dihydroergotamine nasal spraynon-aerosol 05 mgpump act (4 mgml)
1 QL (8 per 30 days)
eletriptan oral tablet 20 mg 40 mg 1 QL (18 per 30 days)
EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MGML
1 PA ST
EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MGML 300 MG3 ML (100 MGML X 3)
1 PA ST
ergotamine-caffeine oral tablet 1-100 mg 1
frovatriptan oral tablet 25 mg 1 QL (18 per 30 days)
migergot rectal suppository 2-100 mg 1
naratriptan oral tablet 1 mg 25 mg 1 QL (18 per 30 days)
ONZETRA XSAIL NASAL AEROSOL POWDR BREATH ACTIVATED 11 MG
1 ST QL (16 per 30 days)
rizatriptan oral tablet 10 mg 5 mg 1 QL (18 per 30 days)
rizatriptan oral tabletdisintegrating 10 mg 5 mg 1 QL (18 per 30 days)
sumatriptan nasal spraynon-aerosol 20 mgactuation 5 mgactuation
1 QL (18 per 30 days)
sumatriptan succinate oral tablet 100 mg 25 mg 50 mg
1 QL (18 per 30 days)
sumatriptan succinate subcutaneous cartridge 4 mg05 ml 6 mg05 ml
1 QL (8 per 30 days)
29
Drug Name Drug Tier Requirements Limits
sumatriptan succinate subcutaneous pen injector 4 mg05 ml 6 mg05 ml
1 QL (8 per 30 days)
sumatriptan succinate subcutaneous solution 6 mg05 ml
1 QL (8 per 30 days)
sumatriptan succinate subcutaneous syringe 6 mg05 ml
1 QL (8 per 30 days)
UBRELVY ORAL TABLET 100 MG 50 MG 1 QL (16 per 30 days)
VYEPTI INTRAVENOUS SOLUTION 100 MGML
MB PA
zolmitriptan oral tablet 25 mg 5 mg 1 QL (18 per 30 days)
zolmitriptan oral tabletdisintegrating 25 mg 5 mg
1 QL (18 per 30 days)
ZOMIG NASAL SPRAYNON-AEROSOL 25 MG 5 MG
1 ST QL (18 per 30 days)
MISCELLANEOUS NEUROLOGICAL THERAPY
AUSTEDO ORAL TABLET 12 MG 6 MG 9 MG
2 PA LA
dalfampridine oral tablet extended release 12 hr 10 mg
2 PA LA QL (60 per 30 days)
donepezil oral tablet 10 mg 23 mg 5 mg 1
donepezil oral tabletdisintegrating 10 mg 5 mg 1
EXONDYS-51 INTRAVENOUS SOLUTION 50 MGML
MB PA
galantamine oral capsuleext rel pellets 24 hr 16 mg 24 mg 8 mg
1
galantamine oral solution 4 mgml 1
galantamine oral tablet 12 mg 4 mg 8 mg 1
memantine oral capsulesprinkleer 24hr 14 mg 21 mg 28 mg 7 mg
1
memantine oral solution 2 mgml 1
memantine oral tablet 10 mg 5 mg 1
NUEDEXTA ORAL CAPSULE 20-10 MG 1
ONPATTRO INTRAVENOUS SOLUTION 2 MGML
MB PA
RADICAVA INTRAVENOUS SOLUTION 30 MG100 ML
MB PA
rivastigmine tartrate oral capsule 15 mg 3 mg 45 mg 6 mg
1
30
Drug Name Drug Tier Requirements Limits
rivastigmine transdermal patch 24 hour 133 mg24 hour 46 mg24 hour 95 mg24 hour
1
tetrabenazine oral tablet 125 mg 25 mg 2 LA
TYSABRI INTRAVENOUS SOLUTION 300 MG15 ML
MB PA ST LA
VYONDYS-53 INTRAVENOUS SOLUTION 50 MGML
MB PA
ZOLGENSMA INTRAVENOUS KIT 2 X 10EXP13 VGML
MB LA
MUSCLE RELAXANTS amp ANTISPASMODIC THERAPY
baclofen oral tablet 10 mg 20 mg 5 mg 1
carisoprodol oral tablet 250 mg 350 mg 1
carisoprodol-aspirin oral tablet 200-325 mg 1
carisoprodol-aspirin-codeine oral tablet 200-325-16 mg
1 PA ST
chlorzoxazone oral tablet 250 mg 375 mg 750 mg 1 ST
chlorzoxazone oral tablet 500 mg 1
cyclobenzaprine oral tablet 10 mg 5 mg 75 mg 1
dantrolene oral capsule 100 mg 25 mg 50 mg 1
meprobamate oral tablet 200 mg 400 mg 1
metaxalone oral tablet 400 mg 800 mg 1
methocarbamol oral tablet 500 mg 750 mg 1
orphenadrine citrate injection solution 30 mgml 1
orphenadrine citrate oral tablet extended release 100 mg
1
pyridostigmine bromide oral syrup 60 mg5 ml 1
pyridostigmine bromide oral tablet 60 mg 1
pyridostigmine bromide oral tablet extended release 180 mg
1
tizanidine oral capsule 2 mg 4 mg 6 mg 1
tizanidine oral tablet 2 mg 4 mg 1
vanadom oral tablet 350 mg 1
NARCOTIC ANALGESICS
acetaminophen-caff-dihydrocod oral capsule 3205-30-16 mg
1 PA ST
acetaminophen-caff-dihydrocod oral tablet 325-30-16 mg
1 PA ST
31
Drug Name Drug Tier Requirements Limits
acetaminophen-codeine oral solution 120-12 mg5 ml 300 mg-30 mg 125 ml
1 PA ST
acetaminophen-codeine oral tablet 300-15 mg 300-30 mg 300-60 mg
1 PA ST
ascomp with codeine oral capsule 30-50-325-40 mg
1 PA ST
buprenorphine hcl injection solution 03 mgml 1 PA ST
buprenorphine hcl injection syringe 03 mgml 1 PA ST
buprenorphine hcl sublingual tablet 2 mg 8 mg 1
buprenorphine transdermal patch weekly 10 mcghour 15 mcghour 20 mcghour 5 mcghour 75 mcghour
1
butalbital compound wcodeine oral capsule 30-50-325-40 mg
1 PA ST
butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg 50-325-40-30 mg
1 PA ST
butalbital-acetaminophen-caff oral capsule 50-300-40 mg 50-325-40 mg
1
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
1
butalbital-aspirin-caffeine oral capsule 50-325-40 mg
1
butalbital-aspirin-caffeine oral tablet 50-325-40 mg
1
codeine sulfate oral tablet 15 mg 30 mg 60 mg 1 PA ST
codeine-butalbital-asa-caff oral capsule 30-50-325-40 mg
1 PA ST
diskets oral tabletsoluble 40 mg 1 PA ST
DSUVIA SUBLINGUAL TABLET IN APPLICATOR 30 MCG
MB
duramorph (pf) injection solution 05 mgml 1 mgml
MB PA ST
dvorah oral tablet 325-30-16 mg 1 PA ST
endocet oral tablet 10-325 mg 25-325 mg 5-325 mg 75-325 mg
1 PA ST
fentanyl citrate buccal lozenge on a handle 1200 mcg 1600 mcg 200 mcg 400 mcg 600 mcg 800 mcg
1 PA
32
Drug Name Drug Tier Requirements Limits
fentanyl transdermal patch 72 hour 100 mcghr 12 mcghr 25 mcghr 375 mcghour 50 mcghr 625 mcghour 75 mcghr 875 mcghour
1 PA ST
hydrocodone bitartrate oral capsule oral only er 12hr 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg
1 PA ST QL (60 per 30 days)
hydrocodone bitartrate oral tabletoral onlyextrel24 hr 100 mg 120 mg 20 mg 30 mg 40 mg 60 mg 80 mg
1 PA ST
hydrocodone-acetaminophen oral solution 10-325 mg15 ml(15 ml) 75-325 mg15 ml
1 PA ST
hydrocodone-acetaminophen oral tablet 10-300 mg 10-325 mg 5-300 mg 5-325 mg 75-300 mg 75-325 mg
1 PA ST
hydrocodone-ibuprofen oral tablet 10-200 mg 5-200 mg 75-200 mg
1 PA ST
HYDROMORPHONE INJECTION SYRINGE 05 MG05 ML
1 PA ST
hydromorphone oral liquid 1 mgml 1 PA ST
hydromorphone oral tablet 2 mg 4 mg 8 mg 1 PA ST
hydromorphone oral tablet extended release 24 hr 12 mg 16 mg 32 mg 8 mg
1 PA ST QL (60 per 30 days)
hydromorphone rectal suppository 3 mg 1 PA ST
levorphanol tartrate oral tablet 2 mg 3 mg 1 PA ST
meperidine oral solution 50 mg5 ml 1 PA ST
meperidine oral tablet 50 mg 1 PA ST
methadone injection solution 10 mgml 1 PA ST
methadone oral concentrate 10 mgml 1 PA ST
methadone oral solution 10 mg5 ml 5 mg5 ml 1 PA ST
methadone oral tablet 10 mg 5 mg 1 PA ST
methadone oral tabletsoluble 40 mg 1 PA ST
methadose oral concentrate 10 mgml 1 PA ST
methadose oral tabletsoluble 40 mg 1 PA ST
morphine (pf) injection solution 05 mgml MB PA ST
morphine concentrate oral solution 100 mg5 ml (20 mgml)
1 PA ST
morphine oral capsule er multiphase 24 hr 120 mg 30 mg 45 mg 60 mg 75 mg 90 mg
1 PA ST QL (60 per 30 days)
morphine oral capsuleextendrelease pellets 10 mg 100 mg 20 mg 50 mg 80 mg
1 PA ST QL (90 per 30 days)
33
Drug Name Drug Tier Requirements Limits
morphine oral capsuleextendrelease pellets 30 mg 60 mg
1 PA ST QL (60 per 30 days)
morphine oral capsuleextendrelease pellets 40 mg
1 PA QL (90 per 30 days)
morphine oral solution 10 mg5 ml 20 mg5 ml (4 mgml)
1 PA ST
morphine oral tablet 15 mg 30 mg 1 PA ST
morphine oral tablet extended release 100 mg 15 mg 200 mg 30 mg 60 mg
1 PA ST QL (120 per 30 days)
morphine rectal suppository 10 mg 20 mg 30 mg 5 mg
1 PA ST
oxycodone oral capsule 5 mg 1 PA ST
oxycodone oral concentrate 20 mgml 1 PA ST
oxycodone oral solution 5 mg5 ml 1 PA ST
oxycodone oral tablet 10 mg 15 mg 20 mg 30 mg 5 mg
1 PA ST
oxycodone-acetaminophen oral tablet 10-325 mg 25-300 mg 25-325 mg 5-325 mg 75-325 mg
1 PA ST
oxycodone-aspirin oral tablet 48355-325 mg 1 PA ST
OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 10 MG 15 MG 20 MG 30 MG 40 MG
1 PA ST QL (90 per 30 days)
OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 60 MG 80 MG
1 PA ST QL (120 per 30 days)
oxymorphone oral tablet 10 mg 5 mg 1 PA ST
oxymorphone oral tablet extended release 12 hr 10 mg 15 mg 20 mg 30 mg 40 mg 5 mg 75 mg
1 PA ST QL (90 per 30 days)
SUBLOCADE SUBCUTANEOUS SOLUTION EXTENDED REL SYRINGE 100 MG05 ML 300 MG15 ML
MB
tencon oral tablet 50-325 mg 1
NON-NARCOTIC ANALGESICS
adult aspirin regimen oral tabletdelayed release (drec) 81 mg
ACA PV
aspirin low dose oral tabletdelayed release (drec) 81 mg
ACA PV
aspirin oral tablet 325 mg ACA PV
aspirin oral tabletchewable 81 mg ACA PV
34
Drug Name Drug Tier Requirements Limits
aspirin oral tabletdelayed release (drec) 325 mg 81 mg
ACA PV
aspir-trin oral tabletdelayed release (drec) 325 mg
ACA PV
bayer aspirin oral tablet 325 mg ACA PV
BAYER CHEWABLE ASPIRIN ORAL TABLETCHEWABLE 81 MG
ACA PV
buprenorphine-naloxone sublingual film 12-3 mg 1 QL (60 per 30 days)
buprenorphine-naloxone sublingual film 2-05 mg 4-1 mg 8-2 mg
1 QL (90 per 30 days)
buprenorphine-naloxone sublingual tablet 2-05 mg 8-2 mg
1 QL (90 per 30 days)
butorphanol nasal spraynon-aerosol 10 mgml 1 PA ST QL (5 per 30 days)
cataflam oral tablet 50 mg 1
celecoxib oral capsule 100 mg 200 mg 400 mg 50 mg
1
childrens aspirin oral tabletchewable 81 mg ACA PV
cholinemagnesium salicylate oral liquid 500 mg5 ml
1
diclofenac potassium oral tablet 50 mg 1
diclofenac sodium oral tablet extended release 24 hr 100 mg
1
diclofenac sodium oral tabletdelayed release (drec) 25 mg 50 mg 75 mg
1
diclofenac sodium topical drops 15 1
diclofenac sodium topical gel 1 1
diclofenac-misoprostol oral tabletirdelayed relbiphasic 50-200 mg-mcg 75-200 mg-mcg
1
diflunisal oral tablet 500 mg 1
DUEXIS ORAL TABLET 800-266 MG 1 ST
ecotrin low strength oral tabletdelayed release (drec) 81 mg
ACA PV
ecotrin oral tabletdelayed release (drec) 325 mg ACA PV
etodolac oral capsule 200 mg 300 mg 1
etodolac oral tablet 400 mg 500 mg 1
etodolac oral tablet extended release 24 hr 400 mg 500 mg 600 mg
1
EUFLEXXA INTRA-ARTICULAR SYRINGE 10 MGML(MW 24 -36 MILLION)
MB
35
Drug Name Drug Tier Requirements Limits
fenoprofen oral tablet 600 mg 1
flurbiprofen oral tablet 100 mg 1
ibu oral tablet 400 mg 600 mg 800 mg 1
ibuprofen oral suspension 100 mg5 ml 1
ibuprofen oral tablet 400 mg 600 mg 800 mg 1
indomethacin oral capsule 25 mg 50 mg 1
indomethacin oral capsule extended release 75 mg
1
ketoprofen oral capsule 25 mg 50 mg 75 mg 1
ketoprofen oral capsuleext rel pellets 24 hr 200 mg
1
ketorolac injection cartridge 15 mgml 30 mgml 1
ketorolac injection solution 15 mgml 30 mgml MB
ketorolac injection solution 30 mgml (1 ml) 1
ketorolac intramuscular cartridge 60 mg2 ml 1
ketorolac intramuscular solution 60 mg2 ml 1
ketorolac intramuscular syringe 60 mg2 ml 1
ketorolac oral tablet 10 mg 1
meclofenamate oral capsule 100 mg 50 mg 1
mefenamic acid oral capsule 250 mg 1
meloxicam oral tablet 15 mg 75 mg 1
MONOVISC INTRA-ARTICULAR SYRINGE 88 MG4 ML
MB LA
nabumetone oral tablet 500 mg 750 mg 1
nalbuphine injection solution 10 mgml MB PA ST
naloxone injection solution 04 mgml 1
naloxone injection syringe 04 mgml 1 mgml 1
naltrexone oral tablet 50 mg 1
naproxen oral suspension 125 mg5 ml 1
naproxen oral tablet 250 mg 375 mg 500 mg 1
naproxen oral tabletdelayed release (drec) 375 mg 500 mg
1
naproxen sodium oral tablet 275 mg 550 mg 1
NARCAN NASAL SPRAYNON-AEROSOL 4 MGACTUATION
1
36
Drug Name Drug Tier Requirements Limits
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG 150 MG 200 MG 250 MG 50 MG
1 PA ST QL (60 per 30 days)
ORTHOVISC INTRA-ARTICULAR SYRINGE 30 MG2 ML
MB
oxaprozin oral tablet 600 mg 1
pentazocine-naloxone oral tablet 50-05 mg 1 PA ST
piroxicam oral capsule 10 mg 20 mg 1
salsalate oral tablet 500 mg 750 mg 1
st joseph aspirin oral tabletchewable 81 mg ACA PV
st joseph aspirin oral tabletdelayed release (drec) 81 mg
ACA PV
sulindac oral tablet 150 mg 200 mg 1
tolmetin oral capsule 400 mg 1
tolmetin oral tablet 200 mg 600 mg 1
tramadol oral tablet 50 mg 1 PA ST
tramadol oral tablet extended release 24 hr 100 mg 200 mg 300 mg
1 PA ST
tramadol oral tablet er multiphase 24 hr 100 mg 200 mg 300 mg
1 PA ST
tramadol-acetaminophen oral tablet 375-325 mg 1 PA ST
VIVITROL INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 380 MG
MB
PSYCHOTHERAPEUTIC DRUGS
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 300 MG 400 MG
1
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 300 MG 400 MG
1
ADHANSIA XR ORAL CAPSULE ER BIPHASIC 20-80 25 MG 35 MG 45 MG 55 MG 70 MG 85 MG
1 PA ST
ADZENYS ER ORAL SUSPEN IR - ER BIPHASIC 24HR 125 MGML
1 ST
ADZENYS XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 125 MG 157 MG 188 MG 31 MG 63 MG 94 MG
1 ST
37
Drug Name Drug Tier Requirements Limits
alprazolam intensol oral concentrate 1 mgml 1
alprazolam oral tablet 025 mg 05 mg 1 mg 2 mg
1
alprazolam oral tablet extended release 24 hr 05 mg 1 mg 2 mg 3 mg
1
alprazolam oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg
1
amitriptyline oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
amitriptyline-chlordiazepoxide oral tablet 125-5 mg 25-10 mg
1
amoxapine oral tablet 100 mg 150 mg 25 mg 50 mg
1
AMPHETAMINE ORAL SUSPEN IR - ER BIPHASIC 24HR 125 MGML
1 ST
amphetamine sulfate oral tablet 10 mg 5 mg 1
APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG 348 MG 522 MG
1 ST
aripiprazole oral solution 1 mgml 1
aripiprazole oral tablet 10 mg 15 mg 2 mg 20 mg 30 mg 5 mg
1
aripiprazole oral tabletdisintegrating 10 mg 15 mg
1
ARISTADA INITIO INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 675 MG24 ML
MB
ARISTADA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 1064 MG39 ML 441 MG16 ML 662 MG24 ML 882 MG32 ML
MB
armodafinil oral tablet 150 mg 200 mg 250 mg 50 mg
1
asenapine maleate sublingual tablet 10 mg 25 mg 5 mg
1
atomoxetine oral capsule 10 mg 100 mg 18 mg 25 mg 40 mg 60 mg 80 mg
1
BELSOMRA ORAL TABLET 10 MG 15 MG 20 MG 5 MG
1 ST
bupropion hcl oral tablet 100 mg 75 mg 1
bupropion hcl oral tablet extended release 24 hr 150 mg 300 mg
1
38
Drug Name Drug Tier Requirements Limits
bupropion hcl oral tablet sustained-release 12 hr 100 mg 150 mg 200 mg
1
buspirone oral tablet 10 mg 15 mg 30 mg 5 mg 75 mg
1
chlordiazepoxide hcl oral capsule 10 mg 25 mg 5 mg
1
chlorpromazine injection solution 25 mgml 1
chlorpromazine oral tablet 10 mg 100 mg 200 mg 25 mg 50 mg
1
citalopram oral solution 10 mg5 ml 1
citalopram oral tablet 10 mg 20 mg 40 mg 1
clomipramine oral capsule 25 mg 50 mg 75 mg 1
clonidine hcl oral tablet extended release 12 hr 01 mg
1
clorazepate dipotassium oral tablet 15 mg 375 mg 75 mg
1
clozapine oral tablet 100 mg 200 mg 25 mg 50 mg
1
clozapine oral tabletdisintegrating 100 mg 125 mg 150 mg 200 mg 25 mg
1
COTEMPLA XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 173 MG 259 MG 86 MG
1 ST
DAYTRANA TRANSDERMAL PATCH 24 HOUR 10 MG9 HR 15 MG9 HR 20 MG9 HR 30 MG9 HR
1 ST
desipramine oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG 50 MG
1 ST
desvenlafaxine succinate oral tablet extended release 24 hr 100 mg 25 mg 50 mg
1
dexmethylphenidate oral capsuleer biphasic 50-50 10 mg 15 mg 20 mg 25 mg 30 mg 35 mg 40 mg 5 mg
1
dexmethylphenidate oral tablet 10 mg 25 mg 5 mg
1
dextroamphetamine oral capsule extended release 10 mg 15 mg 5 mg
1
dextroamphetamine oral solution 5 mg5 ml 1
39
Drug Name Drug Tier Requirements Limits
dextroamphetamine oral tablet 10 mg 5 mg 1
dextroamphetamine-amphetamine oral capsuleextended release 24hr 10 mg 15 mg 20 mg 25 mg 30 mg 5 mg
1
dextroamphetamine-amphetamine oral tablet 10 mg 125 mg 15 mg 20 mg 30 mg 5 mg 75 mg
1
diazepam injection solution 5 mgml MB
diazepam injection syringe 5 mgml MB
diazepam intensol oral concentrate 5 mgml 1
diazepam oral solution 5 mg5 ml (1 mgml) 1
diazepam oral tablet 10 mg 2 mg 5 mg 1
doxepin oral capsule 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
doxepin oral concentrate 10 mgml 1
duloxetine oral capsuledelayed release(drec) 20 mg 30 mg 40 mg 60 mg
1
DYANAVEL XR ORAL SUSPEN IR - ER BIPHASIC 24HR 25 MGML
1 ST
EDLUAR SUBLINGUAL TABLET 10 MG 5 MG
1 ST
EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG24 HR 6 MG24 HR 9 MG24 HR
1 ST
ergoloid oral tablet 1 mg 1
escitalopram oxalate oral solution 5 mg5 ml 1
escitalopram oxalate oral tablet 10 mg 20 mg 5 mg
1
estazolam oral tablet 1 mg 2 mg 1
eszopiclone oral tablet 1 mg 2 mg 3 mg 1
FANAPT ORAL TABLET 1 MG 10 MG 12 MG 2 MG 4 MG 6 MG 8 MG
1 PA ST
FANAPT ORAL TABLETSDOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)
1 PA ST
FETZIMA ORAL CAPSULEEXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)
1 ST
FETZIMA ORAL CAPSULEEXTENDED RELEASE 24 HR 120 MG 20 MG 40 MG 80 MG
1 ST
fluoxetine oral capsule 10 mg 20 mg 40 mg 1
40
Drug Name Drug Tier Requirements Limits
fluoxetine oral capsuledelayed release(drec) 90 mg
1
fluoxetine oral solution 20 mg5 ml (4 mgml) 1
fluoxetine oral tablet 10 mg 20 mg 1
fluoxetine oral tablet 60 mg 1 PA
fluphenazine hcl injection solution 25 mgml 1
fluphenazine hcl oral concentrate 5 mgml 1
fluphenazine hcl oral elixir 25 mg5 ml 1
fluphenazine hcl oral tablet 1 mg 10 mg 25 mg 5 mg
1
flurazepam oral capsule 15 mg 30 mg 1
fluvoxamine oral capsuleextended release 24hr 100 mg 150 mg
1
fluvoxamine oral tablet 100 mg 25 mg 50 mg 1
guanfacine oral tablet extended release 24 hr 1 mg 2 mg 3 mg 4 mg
1
haloperidol decanoate intramuscular solution 100 mgml 50 mgml
1
haloperidol lactate injection solution 5 mgml 1
haloperidol lactate oral concentrate 2 mgml 1
haloperidol oral tablet 05 mg 1 mg 10 mg 2 mg 20 mg 5 mg
1
HETLIOZ LQ ORAL SUSPENSION 4 MGML 2 PA ST LA
HETLIOZ ORAL CAPSULE 20 MG 2 PA ST LA
imipramine hcl oral tablet 10 mg 25 mg 50 mg 1
imipramine pamoate oral capsule 100 mg 125 mg 150 mg 75 mg
1
INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG075 ML 156 MGML 234 MG15 ML 39 MG025 ML 78 MG05 ML
1
JORNAY PM ORAL CAPSULEDEL RELEXT REL SPRINK 100 MG 20 MG 40 MG 60 MG 80 MG
1 ST
LATUDA ORAL TABLET 120 MG 20 MG 40 MG 60 MG 80 MG
1 PA ST
lithium carbonate oral capsule 150 mg 300 mg 600 mg
1
lithium carbonate oral tablet 300 mg 1
41
Drug Name Drug Tier Requirements Limits
lithium carbonate oral tablet extended release 300 mg 450 mg
1
lorazepam intensol oral concentrate 2 mgml 1
lorazepam oral concentrate 2 mgml 1
lorazepam oral tablet 05 mg 1 mg 2 mg 1
loxapine succinate oral capsule 10 mg 25 mg 5 mg 50 mg
1
maprotiline oral tablet 25 mg 50 mg 75 mg 1
MARPLAN ORAL TABLET 10 MG 1
methamphetamine oral tablet 5 mg 1
METHYLIN ORAL SOLUTION 10 MG5 ML 5 MG5 ML
1
methylphenidate hcl oral caper sprinklebiphasic 40-60 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg 60 mg
1
methylphenidate hcl oral capsule er biphasic 30-70 10 mg 20 mg 30 mg 40 mg 50 mg 60 mg
1
methylphenidate hcl oral capsuleer biphasic 50-50 10 mg 20 mg 30 mg 40 mg 60 mg
1
methylphenidate hcl oral solution 10 mg5 ml 5 mg5 ml
1
methylphenidate hcl oral tablet 10 mg 20 mg 5 mg
1
methylphenidate hcl oral tablet extended release 10 mg 20 mg
1
methylphenidate hcl oral tablet extended release 24hr 18 mg 27 mg 36 mg 54 mg
1
methylphenidate hcl oral tabletchewable 10 mg 25 mg 5 mg
1
midazolam oral syrup 2 mgml 1
mirtazapine oral tablet 15 mg 30 mg 45 mg 75 mg
1
mirtazapine oral tabletdisintegrating 15 mg 30 mg 45 mg
1
modafinil oral tablet 100 mg 200 mg 1
molindone oral tablet 10 mg 25 mg 5 mg 1
MYDAYIS ORAL CAPSULE ER TRIPHASIC 24 HR 125 MG 25 MG 375 MG 50 MG
1 ST
nefazodone oral tablet 100 mg 150 mg 200 mg 250 mg 50 mg
1
42
Drug Name Drug Tier Requirements Limits
nortriptyline oral capsule 10 mg 25 mg 50 mg 75 mg
1
nortriptyline oral solution 10 mg5 ml 1
NUPLAZID ORAL CAPSULE 34 MG 2 PA LA
NUPLAZID ORAL TABLET 10 MG 2 PA LA
olanzapine intramuscular recon soln 10 mg 1
olanzapine oral tablet 10 mg 15 mg 25 mg 20 mg 5 mg 75 mg
1
olanzapine oral tabletdisintegrating 10 mg 15 mg 20 mg 5 mg
1
olanzapine-fluoxetine oral capsule 12-25 mg 12-50 mg 3-25 mg 6-25 mg 6-50 mg
1
oxazepam oral capsule 10 mg 15 mg 30 mg 1
paliperidone oral tablet extended release 24hr 15 mg 3 mg 6 mg 9 mg
1
paroxetine hcl oral tablet 10 mg 20 mg 30 mg 40 mg
1
paroxetine hcl oral tablet extended release 24 hr 125 mg 25 mg 375 mg
1
paroxetine mesylate(menopsym) oral capsule 75 mg
1
perphenazine oral tablet 16 mg 2 mg 4 mg 8 mg 1
perphenazine-amitriptyline oral tablet 2-10 mg 2-25 mg 4-10 mg 4-25 mg 4-50 mg
1
phenelzine oral tablet 15 mg 1
pimozide oral tablet 1 mg 2 mg 1
procentra oral solution 5 mg5 ml 1
protriptyline oral tablet 10 mg 5 mg 1
quetiapine oral tablet 100 mg 200 mg 25 mg 300 mg 400 mg 50 mg
1
quetiapine oral tablet extended release 24 hr 150 mg 200 mg 300 mg 400 mg 50 mg
1
QUILLICHEW ER ORAL TABLETCHEWIR-ERBIPHASIC24HR 20 MG 30 MG 40 MG
1 ST
QUILLIVANT XR ORAL SUSPENSIONEXT REL 24HRRECON 5 MGML (25 MG5 ML)
1 ST
ramelteon oral tablet 8 mg 1
RELEXXII ORAL TABLET EXTENDED RELEASE 24HR 72 MG
1 ST
43
Drug Name Drug Tier Requirements Limits
REXULTI ORAL TABLET 025 MG 05 MG 1 MG 2 MG 3 MG 4 MG
1 PA ST
RISPERDAL CONSTA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 125 MG2 ML 25 MG2 ML 375 MG2 ML 50 MG2 ML
1
risperidone oral solution 1 mgml 1
risperidone oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg
1
risperidone oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg
1
seconal sodium oral capsule 100 mg 1
sertraline oral concentrate 20 mgml 1
sertraline oral tablet 100 mg 25 mg 50 mg 1
SPRAVATO NASAL SPRAYNON-AEROSOL 56 MG (28 MG X 2) 84 MG (28 MG X 3)
MB PA
SUNOSI ORAL TABLET 150 MG 1 PA QL (30 per 30 days)
SUNOSI ORAL TABLET 75 MG 1 PA QL (60 per 30 days)
temazepam oral capsule 15 mg 225 mg 30 mg 75 mg
1
thioridazine oral tablet 10 mg 100 mg 25 mg 50 mg
1
thiothixene oral capsule 1 mg 10 mg 2 mg 5 mg 1
tranylcypromine oral tablet 10 mg 1
trazodone oral tablet 100 mg 150 mg 300 mg 50 mg
1
triazolam oral tablet 0125 mg 025 mg 1
trifluoperazine oral tablet 1 mg 10 mg 2 mg 5 mg
1
trimipramine oral capsule 100 mg 25 mg 50 mg 1
TRINTELLIX ORAL TABLET 10 MG 20 MG 5 MG
1 ST
venlafaxine oral capsuleextended release 24hr 150 mg 375 mg 75 mg
1
venlafaxine oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg
1
venlafaxine oral tablet extended release 24hr 150 mg 225 mg 375 mg 75 mg
1
VERSACLOZ ORAL SUSPENSION 50 MGML 1 PA ST
44
Drug Name Drug Tier Requirements Limits
VRAYLAR ORAL CAPSULE 15 MG 3 MG 45 MG 6 MG
1 PA ST
VRAYLAR ORAL CAPSULEDOSE PACK 15 MG (1)- 3 MG (6)
1 PA ST
VYVANSE ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG 70 MG
1 PA ST
VYVANSE ORAL TABLETCHEWABLE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG
1 PA ST
XYREM ORAL SOLUTION 500 MGML 1 PA QL (540 per 30 days)
zaleplon oral capsule 10 mg 5 mg 1
ZENZEDI ORAL TABLET 15 MG 25 MG 20 MG 30 MG 75 MG
1 ST
ziprasidone hcl oral capsule 20 mg 40 mg 60 mg 80 mg
1
zolpidem oral tablet 10 mg 5 mg 1
zolpidem oral tabletext release multiphase 125 mg 625 mg
1
zolpidem sublingual tablet 175 mg 35 mg 1
ZOLPIMIST ORAL SPRAYNON-AEROSOL 5 MGSPRAY (01 ML)
1 ST
ZULRESSO INTRAVENOUS SOLUTION 5 MGML
MB
CARDIOVASCULAR HYPERTENSION amp LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone oral tablet 100 mg 200 mg 400 mg 1
disopyramide phosphate oral capsule 100 mg 150 mg
1
dofetilide oral capsule 125 mcg 250 mcg 500 mcg 1
flecainide oral tablet 100 mg 150 mg 50 mg 1
mexiletine oral capsule 150 mg 200 mg 250 mg 1
MULTAQ ORAL TABLET 400 MG 1
NORPACE CR ORAL CAPSULE EXTENDED RELEASE 100 MG 150 MG
1
pacerone oral tablet 100 mg 200 mg 400 mg 1
procainamide injection solution 100 mgml 500 mgml
MB
propafenone oral capsuleextended release 12 hr 225 mg 325 mg 425 mg
1
45
Drug Name Drug Tier Requirements Limits
propafenone oral tablet 150 mg 225 mg 300 mg 1
quinidine gluconate oral tablet extended release 324 mg
1
quinidine sulfate oral tablet 200 mg 300 mg 1
sorine oral tablet 120 mg 160 mg 240 mg 80 mg 1
sotalol af oral tablet 120 mg 160 mg 80 mg 1
sotalol oral tablet 120 mg 160 mg 240 mg 80 mg 1
ANTIHYPERTENSIVE THERAPY
acebutolol oral capsule 200 mg 400 mg 1
aliskiren oral tablet 150 mg 300 mg 1
amiloride oral tablet 5 mg 1
amiloride-hydrochlorothiazide oral tablet 5-50 mg 1
amlodipine oral tablet 10 mg 25 mg 5 mg 1
amlodipine-benazepril oral capsule 10-20 mg 10-40 mg 25-10 mg 5-10 mg 5-20 mg 5-40 mg
1 ST
amlodipine-olmesartan oral tablet 10-20 mg 10-40 mg 5-20 mg 5-40 mg
1 ST
amlodipine-valsartan oral tablet 10-160 mg 10-320 mg 5-160 mg 5-320 mg
1 ST
amlodipine-valsartan-hcthiazid oral tablet 10-160-125 mg 10-160-25 mg 10-320-25 mg 5-160-125 mg 5-160-25 mg
1
atenolol oral tablet 100 mg 25 mg 50 mg 1
atenolol-chlorthalidone oral tablet 100-25 mg 50-25 mg
1
benazepril oral tablet 10 mg 20 mg 40 mg 5 mg 1
benazepril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg 5-625 mg
1
betaxolol oral tablet 10 mg 20 mg 1
bisoprolol fumarate oral tablet 10 mg 5 mg 1
bisoprolol-hydrochlorothiazide oral tablet 10-625 mg 25-625 mg 5-625 mg
1
bumetanide injection solution 025 mgml 1
bumetanide oral tablet 05 mg 1 mg 2 mg 1
BYSTOLIC ORAL TABLET 10 MG 25 MG 20 MG 5 MG
1 ST
candesartan oral tablet 16 mg 32 mg 4 mg 8 mg 1
46
Drug Name Drug Tier Requirements Limits
candesartan-hydrochlorothiazid oral tablet 16-125 mg 32-125 mg 32-25 mg
1
captopril oral tablet 100 mg 125 mg 25 mg 50 mg
1
captopril-hydrochlorothiazide oral tablet 25-15 mg 25-25 mg 50-15 mg 50-25 mg
1
cartia xt oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg
1
carvedilol oral tablet 125 mg 25 mg 3125 mg 625 mg
1
carvedilol phosphate oral capsule er multiphase 24 hr 10 mg 20 mg 40 mg 80 mg
1
chlorthalidone oral tablet 25 mg 50 mg 1
clonidine hcl oral tablet 01 mg 02 mg 03 mg 1
clonidine transdermal patch weekly 01 mg24 hr 02 mg24 hr 03 mg24 hr
1
diltiazem hcl oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg
1
diltiazem hcl oral capsuleextended release 12 hr 120 mg 60 mg 90 mg
1
diltiazem hcl oral capsuleextended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
diltiazem hcl oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg 360 mg
1
diltiazem hcl oral tablet 120 mg 30 mg 60 mg 90 mg
1
diltiazem hcl oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
dilt-xr oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg
1
doxazosin oral tablet 1 mg 2 mg 4 mg 8 mg 1
EDARBI ORAL TABLET 40 MG 80 MG 1 ST
EDARBYCLOR ORAL TABLET 40-125 MG 40-25 MG
1 ST
enalapril maleate oral tablet 10 mg 25 mg 20 mg 5 mg
1
enalaprilat intravenous solution 125 mgml MB
enalapril-hydrochlorothiazide oral tablet 10-25 mg 5-125 mg
1
EPANED ORAL SOLUTION 1 MGML 1
47
Drug Name Drug Tier Requirements Limits
eplerenone oral tablet 25 mg 50 mg 1
epoprostenol (glycine) intravenous recon soln 05 mg 15 mg
MB PA LA
eprosartan oral tablet 600 mg 1
ethacrynic acid oral tablet 25 mg 1
felodipine oral tablet extended release 24 hr 10 mg 25 mg 5 mg
1
FLOLAN INTRAVENOUS RECON SOLN 05 MG 15 MG
MB PA LA
fosinopril oral tablet 10 mg 20 mg 40 mg 1
fosinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg
1
furosemide oral solution 10 mgml 40 mg5 ml (8 mgml)
1
furosemide oral tablet 20 mg 40 mg 80 mg 1
guanfacine oral tablet 1 mg 2 mg 1
hydralazine oral tablet 10 mg 100 mg 25 mg 50 mg
1
hydrochlorothiazide oral capsule 125 mg 1
hydrochlorothiazide oral tablet 125 mg 25 mg 50 mg
1
indapamide oral tablet 125 mg 25 mg 1
irbesartan oral tablet 150 mg 300 mg 75 mg 1
irbesartan-hydrochlorothiazide oral tablet 150-125 mg 300-125 mg
1
isradipine oral capsule 25 mg 5 mg 1
labetalol oral tablet 100 mg 200 mg 300 mg 1
lisinopril oral tablet 10 mg 25 mg 20 mg 30 mg 40 mg 5 mg
1
lisinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg
1
losartan oral tablet 100 mg 25 mg 50 mg 1
losartan-hydrochlorothiazide oral tablet 100-125 mg 100-25 mg 50-125 mg
1
matzim la oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
methyldopa oral tablet 250 mg 500 mg 1
methyldopa-hydrochlorothiazide oral tablet 250-15 mg 250-25 mg
1
48
Drug Name Drug Tier Requirements Limits
methyldopate intravenous solution 250 mg5 ml MB
metolazone oral tablet 10 mg 25 mg 5 mg 1
metoprolol succinate oral tablet extended release 24 hr 100 mg 200 mg 25 mg 50 mg
1
metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg 100-50 mg 50-25 mg
1
metoprolol tartrate oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg
1
metyrosine oral capsule 250 mg 1
minoxidil oral tablet 10 mg 25 mg 1
moexipril oral tablet 15 mg 75 mg 1
nadolol oral tablet 20 mg 40 mg 80 mg 1
nadolol-bendroflumethiazide oral tablet 80-5 mg 1
nicardipine oral capsule 20 mg 30 mg 1
nifedipine oral capsule 10 mg 20 mg 1
nifedipine oral tablet extended release 24hr 30 mg 60 mg 90 mg
1
nifedipine oral tablet extended release 30 mg 60 mg 90 mg
1
nimodipine oral capsule 30 mg 1
nisoldipine oral tablet extended release 24 hr 17 mg 20 mg 255 mg 30 mg 34 mg 40 mg 85 mg
1
olmesartan oral tablet 20 mg 40 mg 5 mg 1
olmesartan-amlodipin-hcthiazid oral tablet 20-5-125 mg 40-10-125 mg 40-10-25 mg 40-5-125 mg 40-5-25 mg
1
olmesartan-hydrochlorothiazide oral tablet 20-125 mg 40-125 mg 40-25 mg
1 ST
ORENITRAM ORAL TABLET EXTENDED RELEASE 0125 MG 025 MG 1 MG 25 MG 5 MG
2 PA LA
perindopril erbumine oral tablet 2 mg 4 mg 8 mg 1
phenoxybenzamine oral capsule 10 mg 1
pindolol oral tablet 10 mg 5 mg 1
prazosin oral capsule 1 mg 2 mg 5 mg 1
propranolol oral capsuleextended release 24 hr 120 mg 160 mg 60 mg 80 mg
1
propranolol oral solution 20 mg5 ml (4 mgml) 40 mg5 ml (8 mgml)
1
49
Drug Name Drug Tier Requirements Limits
propranolol oral tablet 10 mg 20 mg 40 mg 60 mg 80 mg
1
propranolol-hydrochlorothiazid oral tablet 40-25 mg 80-25 mg
1
QBRELIS ORAL SOLUTION 1 MGML 1
quinapril oral tablet 10 mg 20 mg 40 mg 5 mg 1
quinapril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg
1
ramipril oral capsule 125 mg 10 mg 25 mg 5 mg
1
spironolactone oral tablet 100 mg 25 mg 50 mg 1
spironolacton-hydrochlorothiaz oral tablet 25-25 mg
1
taztia xt oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg
1
TEKTURNA HCT ORAL TABLET 150-125 MG 150-25 MG 300-125 MG 300-25 MG
1
telmisartan oral tablet 20 mg 40 mg 80 mg 1
telmisartan-amlodipine oral tablet 40-10 mg 40-5 mg 80-10 mg 80-5 mg
1 ST
telmisartan-hydrochlorothiazid oral tablet 40-125 mg 80-125 mg 80-25 mg
1
terazosin oral capsule 1 mg 10 mg 2 mg 5 mg 1
tiadylt er oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg 420 mg
1
timolol maleate oral tablet 10 mg 20 mg 5 mg 1
torsemide oral tablet 10 mg 100 mg 20 mg 5 mg 1
trandolapril oral tablet 1 mg 2 mg 4 mg 1
trandolapril-verapamil oral tablet ir - er biphasic 24hr 1-240 mg 2-180 mg 2-240 mg 4-240 mg
1 ST
triamterene oral capsule 100 mg 50 mg 1
triamterene-hydrochlorothiazid oral capsule 375-25 mg
1
triamterene-hydrochlorothiazid oral tablet 375-25 mg 75-50 mg
1
valsartan oral tablet 160 mg 320 mg 40 mg 80 mg
1
valsartan-hydrochlorothiazide oral tablet 160-125 mg 160-25 mg 320-125 mg 320-25 mg 80-125 mg
1
50
Drug Name Drug Tier Requirements Limits
veletri intravenous recon soln 05 mg 15 mg MB PA LA
verapamil oral capsule 24 hr er pellet ct 100 mg 200 mg 300 mg
1
verapamil oral capsuleext rel pellets 24 hr 120 mg 180 mg 240 mg 360 mg
1
verapamil oral tablet 120 mg 40 mg 80 mg 1
verapamil oral tablet extended release 120 mg 180 mg 240 mg
1
CARDIAC GLYCOSIDES
digitek oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
digox oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
digoxin oral solution 50 mcgml (005 mgml) 1
digoxin oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
COAGULATION THERAPY
ADVATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 4000 (+-) UNIT 500 (+-) UNIT
MB
ADYNOVATE INTRAVENOUS SOLUTION 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT 750 (+-) UNIT
MB LA
AFSTYLA INTRAVENOUS RECON SOLN 1000 (+-) UNIT RANGE 1500 (+-) UNIT RANGE 2000 (+-) UNIT RANGE 2500 (+-) UNIT RANGE 250 (+-) UNIT RANGE 3000 (+-) UNIT RANGE 500 (+-) UNIT RANGE
MB LA
ALPHANATE INTRAVENOUS RECON SOLN 1000 (400 VWF) UNIT10 ML 1500 (600 VWF) UNIT10 ML 2000 (800 VWF) UNIT10 ML 250 (100 VWF) UNIT5 ML 500 (200 VWF) UNIT5 ML
MB LA
ALPHANINE SD INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT
MB LA
ALPROLIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 500 UNIT
MB LA
aminocaproic acid oral solution 250 mgml (25 ) 1
51
Drug Name Drug Tier Requirements Limits
aminocaproic acid oral tablet 1000 mg 500 mg 1
ANDEXXA INTRAVENOUS RECON SOLN 200 MG
MB
aspirin-dipyridamole oral capsule er multiphase 12 hr 25-200 mg
1
BENEFIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
BRILINTA ORAL TABLET 60 MG 90 MG 1
CABLIVI INJECTION KIT 11 MG 2 PA
cilostazol oral tablet 100 mg 50 mg 1
clopidogrel oral tablet 300 mg 75 mg 1
COAGADEX INTRAVENOUS RECON SOLN 250 (+-) UNIT RANGE 500 (+-) UNIT RANGE
MB
CORIFACT INTRAVENOUS RECON SOLN 1000-1600 UNIT
MB LA
dipyridamole oral tablet 25 mg 50 mg 75 mg 1
DOPTELET (15 TAB PACK) ORAL TABLET 20 MG
2 PA LA
ELIQUIS DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 5 MG (74 TABS)
1
ELIQUIS ORAL TABLET 25 MG 5 MG 1
ELOCTATE INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 5000 UNIT 500 UNIT 6000 UNIT 750 UNIT
MB LA
enoxaparin subcutaneous solution 300 mg3 ml 2
enoxaparin subcutaneous syringe 100 mgml 120 mg08 ml 150 mgml 30 mg03 ml 40 mg04 ml 60 mg06 ml 80 mg08 ml
2
ESPEROCT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
FEIBA NF INTRAVENOUS RECON SOLN 1750-3250 UNIT 350-650 UNIT 700-1300 UNIT
MB LA
FIBRYGA INTRAVENOUS RECON SOLN 1 GRAM (700 MG- 1300 MG)
MB
fondaparinux subcutaneous syringe 10 mg08 ml 25 mg05 ml 5 mg04 ml 75 mg06 ml
2
52
Drug Name Drug Tier Requirements Limits
FRAGMIN SUBCUTANEOUS SOLUTION 25000 ANTI-XA UNITML
2
FRAGMIN SUBCUTANEOUS SYRINGE 10000 ANTI-XA UNITML 12500 ANTI-XA UNIT05 ML 15000 ANTI-XA UNIT06 ML 18000 ANTI-XA UNIT072 ML 2500 ANTI-XA UNIT02 ML 5000 ANTI-XA UNIT02 ML 7500 ANTI-XA UNIT03 ML
2
HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG07 ML 150 MGML 30 MGML 60 MG04 ML
2 PA LA
HEMOFIL M HIGH INTRAVENOUS RECON SOLN 801-1500 UNIT
MB
HEMOFIL M LOW INTRAVENOUS RECON SOLN 220-400 UNIT
MB
HEMOFIL M MID INTRAVENOUS RECON SOLN 401-800 UNIT
MB
HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 1501-2000 UNIT
MB
hep flush-10 (pf) intravenous solution 10 unitml MB
heparin (porcine) in 5 dex intravenous parenteral solution 25000 unit250 ml(100 unitml) 25000 unit500 ml (50 unitml)
MB
heparin (porcine) injection cartridge 5000 unitml (1 ml)
1
heparin (porcine) injection solution 1000 unitml 10000 unitml 20000 unitml 5000 unitml
1
heparin lock flush (porcine) intravenous solution 100 unitml
MB
heparin lockflush(porcine)(pf) intravenous syringe 100 unitml
MB
HEPARIN(PORCINE) IN 045 NACL INTRAVENOUS PARENTERAL SOLUTION 12500 UNIT250 ML
MB
heparin(porcine) in 045 nacl intravenous parenteral solution 25000 unit250 ml 25000 unit500 ml
MB
heparin porcine (pf) injection solution 1000 unitml 5000 unit05 ml
MB
heparin porcine (pf) injection syringe 5000 unit05 ml
1
53
Drug Name Drug Tier Requirements Limits
heparin porcine (pf) intravenous solution 100 unitml (1 ml)
MB
heparin porcine (pf) intravenous syringe 10 unitml 100 unitml
MB
HUMATE-P INTRAVENOUS RECON SOLN 1000-2400 UNIT 250-600 UNIT 500-1200 UNIT
MB LA
IDELVION INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3500 (+-) UNIT 500 (+-) UNIT
MB LA
IXINITY INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
jantoven oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg
1
JIVI INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
KOATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB
KOGENATE FS INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB
KOVALTRY INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB
MONONINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT
MB LA
MULPLETA ORAL TABLET 3 MG 2 PA LA
NOVOEIGHT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
NOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1000 MCG) 2 MG (2000 MCG) 5 MG (5000 MCG) 8 MG (8000 MCG)
MB LA
NPLATE SUBCUTANEOUS RECON SOLN 125 MCG 250 MCG 500 MCG
MB LA
NUWIQ INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 2500 UNIT 250 (+-) UNIT 3000 UNIT 4000 UNIT 500 (+-) UNIT
MB LA
54
Drug Name Drug Tier Requirements Limits
OBIZUR INTRAVENOUS RECON SOLN 500 (+-) UNIT RANGE
MB
pentoxifylline oral tablet extended release 400 mg 1
phytonadione (vitamin k1) oral tablet 5 mg 1
prasugrel oral tablet 10 mg 5 mg 1
PROFILNINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT
MB LA
PROMACTA ORAL POWDER IN PACKET 125 MG
2 PA ST LA
PROMACTA ORAL POWDER IN PACKET 25 MG
2 LA
PROMACTA ORAL TABLET 125 MG 25 MG 50 MG 75 MG
2 PA ST LA
REBINYN INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 500 (+-) UNIT
MB LA
RECOMBINATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB LA
RIASTAP INTRAVENOUS RECON SOLN 1 GRAM (900MG-1300MG)
MB LA
RIXUBIS INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
tranexamic acid intravenous solution 1000 mg10 ml (100 mgml)
MB
TRETTEN INTRAVENOUS RECON SOLN 2500 UNIT
MB LA
VONVENDI INTRAVENOUS RECON SOLN 1300 (+-) UNIT RANGE 650 (+-) UNIT RANGE
MB LA
warfarin oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg
1
WILATE INTRAVENOUS RECON SOLN 1000-1000 UNIT 500-500 UNIT
MB LA
XARELTO DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 15 MG (42)- 20 MG (9)
1
XARELTO ORAL TABLET 10 MG 15 MG 25 MG 20 MG
1
55
Drug Name Drug Tier Requirements Limits
XYNTHA INTRAVENOUS SOLUTION 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB LA
XYNTHA SOLOFUSE INTRAVENOUS SYRINGE 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
ZONTIVITY ORAL TABLET 208 MG 1
LIPIDCHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg 25-10 mg 25-20 mg 25-40 mg 5-10 mg 5-20 mg 5-40 mg 5-80 mg
1 ST
atorvastatin oral tablet 10 mg 20 mg ACA PV
atorvastatin oral tablet 40 mg 80 mg 1
cholestyramine (with sugar) oral powder 4 gram 1
cholestyramine (with sugar) oral powder in packet 4 gram
1
cholestyramine light oral powder 4 gram 1
cholestyramine light oral powder in packet 4 gram 1
colesevelam oral powder in packet 375 gram 1
colesevelam oral tablet 625 mg 1
colestipol oral granules 5 gram 1
colestipol oral packet 5 gram 1
colestipol oral tablet 1 gram 1
ezetimibe oral tablet 10 mg 1
ezetimibe-simvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg
1
fenofibrate micronized oral capsule 130 mg 134 mg 200 mg 43 mg 67 mg
1
fenofibrate nanocrystallized oral tablet 145 mg 48 mg
1
FENOFIBRATE ORAL CAPSULE 150 MG 50 MG
1
fenofibrate oral tablet 120 mg 160 mg 40 mg 54 mg
1
fenofibric acid (choline) oral capsuledelayed release(drec) 135 mg 45 mg
1
fenofibric acid oral tablet 105 mg 35 mg 1
fluvastatin oral capsule 20 mg 40 mg ACA PV
56
Drug Name Drug Tier Requirements Limits
fluvastatin oral tablet extended release 24 hr 80 mg
ACA PV
gemfibrozil oral tablet 600 mg 1
icosapent ethyl oral capsule 1 gram 1 PA ST QL (120 per 30 days)
JUXTAPID ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 5 MG 60 MG
2 PA LA QL (30 per 30 days)
LIPOFEN ORAL CAPSULE 150 MG 50 MG 1
lovastatin oral tablet 10 mg 20 mg 40 mg ACA PV
niacin oral tablet 500 mg 1
niacin oral tablet extended release 24 hr 1000 mg 500 mg 750 mg
1
NIACOR ORAL TABLET 500 MG 1
omega-3 acid ethyl esters oral capsule 1 gram 1
pravastatin oral tablet 10 mg 20 mg 40 mg 80 mg
ACA PV
prevalite oral powder 4 gram 1
prevalite oral powder in packet 4 gram 1
REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG35 ML
1 PA ST
REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MGML
1 PA ST
REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MGML
1 PA ST
rosuvastatin oral tablet 10 mg 5 mg ACA PV
rosuvastatin oral tablet 20 mg 40 mg 1
simvastatin oral tablet 10 mg 20 mg 40 mg 5 mg ACA PV
simvastatin oral tablet 80 mg 1
VASCEPA ORAL CAPSULE 05 GRAM 1 GRAM
1 PA ST QL (120 per 30 days)
ZYPITAMAG ORAL TABLET 2 MG 4 MG 1 PA ST
MISCELLANEOUS CARDIOVASCULAR AGENTS
CORLANOR ORAL SOLUTION 5 MG5 ML 1 PA
CORLANOR ORAL TABLET 5 MG 75 MG 1 PA
ENTRESTO ORAL TABLET 24-26 MG 49-51 MG 97-103 MG
1 PA ST
GIAPREZA INTRAVENOUS SOLUTION 25 MGML
MB
57
Drug Name Drug Tier Requirements Limits
ranolazine oral tablet extended release 12 hr 1000 mg 500 mg
1 ST
NITRATES
GONITRO SUBLINGUAL POWDER IN PACKET 400 MCG
1
isosorbide dinitrate oral tablet 10 mg 20 mg 30 mg 40 mg 5 mg
1
isosorbide mononitrate oral tablet 10 mg 20 mg 1
isosorbide mononitrate oral tablet extended release 24 hr 120 mg 30 mg 60 mg
1
MINITRAN TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 04 MGHR 06 MGHR
1 PA ST
nitro-bid transdermal ointment 2 1
NITRO-DUR TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 03 MGHR 04 MGHR 06 MGHR 08 MGHR
1 PA ST
nitroglycerin in 5 dextrose intravenous solution 25 mg250 ml (100 mcgml) 50 mg500 ml (100 mcgml)
MB
nitroglycerin sublingual tablet 03 mg 04 mg 06 mg
1
nitroglycerin transdermal patch 24 hour 01 mghr 02 mghr 04 mghr 06 mghr
1
nitroglycerin translingual spraynon-aerosol 400 mcgspray
1
nitro-time oral capsule extended release 25 mg 65 mg 9 mg
1
DERMATOLOGICALSTOPICAL THERAPY
ANTIPSORIATIC ANTISEBORRHEIC
acitretin oral capsule 10 mg 175 mg 25 mg 1
calcipotriene scalp solution 0005 1
calcipotriene topical cream 0005 1
calcipotriene topical ointment 0005 1
calcipotriene-betamethasone topical ointment 0005-0064
1
calcitriol topical ointment 3 mcggram 1
COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
58
Drug Name Drug Tier Requirements Limits
COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
COSENTYX SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
COSENTYX SUBCUTANEOUS SYRINGE 75 MG05 ML
2 PA LA
hydrocortisone-pramoxine topical cream 25-1 1
ILUMYA SUBCUTANEOUS SYRINGE 100 MGML
2 PA ST LA
selenium sulfide topical lotion 25 1
selenium sulfide topical shampoo 225 23 1
SILIQ SUBCUTANEOUS SYRINGE 210 MG15 ML
2 PA ST LA
SKYRIZI SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
SKYRIZI SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
SKYRIZI SUBCUTANEOUS SYRINGE KIT 150MG166ML(75 MG083 ML X2)
2 PA ST LA
STELARA INTRAVENOUS SOLUTION 130 MG26 ML
MB PA LA
STELARA SUBCUTANEOUS SOLUTION 45 MG05 ML
2 PA ST LA
STELARA SUBCUTANEOUS SYRINGE 45 MG05 ML 90 MGML
2 PA ST LA
sulfacetamide sodium topical cleanser 10 1
sulfacetamide sodium topical cleanser gel 10 1
sulfacetamide sodium topical shampoo 10 1
TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MGML
2 PA ST LA
59
Drug Name Drug Tier Requirements Limits
TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 MGML
2 PA ST LA
TREMFYA SUBCUTANEOUS SYRINGE 100 MGML
2 PA ST LA
BURN THERAPY
silver sulfadiazine topical cream 1 1
ssd topical cream 1 1
MISCELLANEOUS DERMATOLOGICALS
ammonium lactate topical cream 12 1
ammonium lactate topical lotion 12 1
diclofenac sodium topical gel 3 1
DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300 MG2 ML
2 LA
DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG114 ML 300 MG2 ML
2 PA ST LA
EUCRISA TOPICAL OINTMENT 2 1 PA ST
FLUOROURACIL TOPICAL CREAM 05 1 PA ST
fluorouracil topical cream 5 1 PA ST
fluorouracil topical solution 2 5 1
LEVULAN TOPICAL SOLUTION 20 1
methoxsalen oral capsuleliqd-filledrapid rel 10 mg
1
PANRETIN TOPICAL GEL 01 1
PICATO TOPICAL GEL 0015 005 1
pimecrolimus topical cream 1 1
podofilox topical solution 05 1
prudoxin topical cream 5 1
REGRANEX TOPICAL GEL 001 1
SCENESSE SUBCUTANEOUS IMPLANT 16 MG
MB PA
tacrolimus topical ointment 003 01 1
UVADEX INJECTION SOLUTION 20 MCGML 1
VALCHLOR TOPICAL GEL 0016 2 PA ST LA
THERAPY FOR ACNE
accutane oral capsule 20 mg 30 mg 40 mg 1
adapalene topical cream 01 1 ST
60
Drug Name Drug Tier Requirements Limits
adapalene topical gel 03 1 ST
adapalene topical gel with pump 03 1 ST
ADAPALENE TOPICAL LOTION 01 1 ST
adapalene topical solution 01 1 ST
adapalene topical swab 01 1 ST
adapalene-benzoyl peroxide topical gel with pump 01-25
1
amnesteem oral capsule 10 mg 20 mg 40 mg 1 PA ST
avita topical cream 0025 1
AVITA TOPICAL GEL 0025 1 ST
azelaic acid topical gel 15 1
AZELEX TOPICAL CREAM 20 1 ST
claravis oral capsule 10 mg 20 mg 30 mg 1 PA ST
claravis oral capsule 40 mg 1
clindacin p topical swab 1 1
clindamycin phosphate topical foam 1 1
clindamycin phosphate topical gel 1 1
clindamycin phosphate topical lotion 1 1
clindamycin phosphate topical solution 1 1
clindamycin phosphate topical swab 1 1
clindamycin-benzoyl peroxide topical gel 1-5 12 (1 base) -5
1
clindamycin-benzoyl peroxide topical gel with pump 1-5
1
clindamycin-tretinoin topical gel 12-0025 1
dapsone topical gel 5 1
ery pads topical swab 2 1
erygel topical gel 2 1
erythromycin with ethanol topical gel 2 1
erythromycin with ethanol topical solution 2 1
erythromycin-benzoyl peroxide topical gel 3-5 1
isotretinoin oral capsule 10 mg 20 mg 25 mg 30 mg 35 mg 40 mg
1
metronidazole topical cream 075 1
metronidazole topical gel 075 1 1
metronidazole topical gel with pump 1 1
61
Drug Name Drug Tier Requirements Limits
metronidazole topical lotion 075 1
myorisan oral capsule 10 mg 20 mg 30 mg 40 mg
1
rosadan topical cream 075 1
rosadan topical gel 075 1
tazarotene topical cream 01 1 ST
tretinoin microspheres topical gel 004 01 1
tretinoin microspheres topical gel with pump 004 01
1
tretinoin topical cream 0025 005 01 1
tretinoin topical gel 001 0025 005 1
zenatane oral capsule 10 mg 20 mg 30 mg 40 mg 1
TOPICAL ANESTHETICS
lidocaine hcl injection solution 10 mgml (1 ) 1
lidocaine hcl laryngotracheal solution 4 1
lidocaine hcl mucous membrane jelly 2 1
lidocaine hcl mucous membrane jelly in applicator 2
1
lidocaine hcl mucous membrane solution 4 (40 mgml)
1
lidocaine hcl-hydrocortison ac topical cream 3-05
1
lidocaine topical adhesive patchmedicated 5 1
lidocaine topical ointment 5 1
lidocaine viscous mucous membrane solution 2 1
lidocaine-prilocaine topical cream 25-25 1
lidocaine-prilocaine topical kit 25-25 1
LIDOCAINE-TETRACAINE TOPICAL CREAM 7-7
1 ST
SYNERA TOPICAL PATCH MEDICATED SELF-HEATING 70-70 MG
1 ST
TOPICAL ANTIBACTERIALS
ALCORTIN A TOPICAL GEL 2-1-1 1 ST
ALCORTIN A TOPICAL GEL IN PACKET 2-1-1
1 ST
ALTABAX TOPICAL OINTMENT 1 1
gentamicin topical cream 01 1
62
Drug Name Drug Tier Requirements Limits
gentamicin topical ointment 01 1
mafenide acetate topical packet 50 gram 1
mupirocin calcium topical cream 2 1
mupirocin topical ointment 2 1
sulfacetamide sodium (acne) topical suspension 10
1
SULFAMYLON TOPICAL CREAM 85 MGG 1
TOPICAL ANTIFUNGALS
ciclodan topical cream 077 1
ciclodan topical solution 8 1
ciclopirox topical cream 077 1
ciclopirox topical gel 077 1
ciclopirox topical shampoo 1 1
ciclopirox topical solution 8 1
ciclopirox topical suspension 077 1
ciclopirox-ure-camph-menth-euc topical solution 8
1
clotrimazole topical cream 1 1
clotrimazole topical solution 1 1
clotrimazole-betamethasone topical cream 1-005
1
clotrimazole-betamethasone topical lotion 1-005
1
econazole topical cream 1 1
EXELDERM TOPICAL CREAM 1 1
EXELDERM TOPICAL SOLUTION 1 1
JUBLIA TOPICAL SOLUTION WITH APPLICATOR 10
1 PA ST
ketoconazole topical cream 2 1
ketoconazole topical foam 2 1
ketoconazole topical shampoo 2 1
ketodan topical foam 2 1
LULICONAZOLE TOPICAL CREAM 1 1
LUZU TOPICAL CREAM 1 1
MENTAX TOPICAL CREAM 1 1
naftifine topical cream 1 2 1
63
Drug Name Drug Tier Requirements Limits
naftifine topical gel 1 1
nyamyc topical powder 100000 unitgram 1
nystatin topical cream 100000 unitgram 1
nystatin topical ointment 100000 unitgram 1
nystatin topical powder 100000 unitgram 1
nystatin-triamcinolone topical cream 100000-01 unitg-
1
nystatin-triamcinolone topical ointment 100000-01 unitgram-
1
nystop topical powder 100000 unitgram 1
oxiconazole topical cream 1 1
OXISTAT TOPICAL LOTION 1 1
tavaborole topical solution with applicator 5 1 PA ST
TOPICAL ANTIVIRALS
acyclovir topical cream 5 1
acyclovir topical ointment 5 1
DENAVIR TOPICAL CREAM 1 1
TOPICAL CORTICOSTEROIDS
ala-cort topical cream 1 1
alclometasone topical cream 005 1
alclometasone topical ointment 005 1
amcinonide topical cream 01 1
amcinonide topical lotion 01 1
apexicon e topical cream 005 1
beser topical lotion 005 1
betamethasone dipropionate topical cream 005 1
betamethasone dipropionate topical lotion 005 1
betamethasone dipropionate topical ointment 005
1
betamethasone valerate topical cream 01 1
betamethasone valerate topical foam 012 1
betamethasone valerate topical lotion 01 1
betamethasone valerate topical ointment 01 1
betamethasone augmented topical cream 005 1
betamethasone augmented topical gel 005 1
betamethasone augmented topical lotion 005 1
64
Drug Name Drug Tier Requirements Limits
betamethasone augmented topical ointment 005
1
clobetasol scalp solution 005 1
clobetasol topical cream 005 1
clobetasol topical foam 005 1
clobetasol topical gel 005 1
clobetasol topical lotion 005 1
clobetasol topical ointment 005 1
clobetasol topical shampoo 005 1
clobetasol topical spraynon-aerosol 005 1
clobetasol-emollient topical cream 005 1
clobetasol-emollient topical foam 005 1
CLOCORTOLONE PIVALATE TOPICAL CREAM 01
1 ST
CLODERM TOPICAL CREAM 01 1 ST
desonide topical cream 005 1
desonide topical lotion 005 1
desonide topical ointment 005 1
desoximetasone topical cream 005 025 1
desoximetasone topical gel 005 1
desoximetasone topical ointment 005 025 1
desoximetasone topical spraynon-aerosol 025 1
diflorasone topical cream 005 1
diflorasone topical ointment 005 1
fluocinolone and shower cap scalp oil 001 1
fluocinolone topical cream 001 0025 1
fluocinolone topical oil 001 1
fluocinolone topical ointment 0025 1
fluocinolone topical solution 001 1
fluocinonide topical cream 005 01 1
fluocinonide topical gel 005 1
fluocinonide topical ointment 005 1
fluocinonide topical solution 005 1
fluocinonide-e topical cream 005 1
flurandrenolide topical cream 005 1
65
Drug Name Drug Tier Requirements Limits
flurandrenolide topical lotion 005 1
flurandrenolide topical ointment 005 1
fluticasone propionate topical cream 005 1
fluticasone propionate topical lotion 005 1
fluticasone propionate topical ointment 0005 1
halcinonide topical cream 01 1
halobetasol propionate topical cream 005 1
halobetasol propionate topical ointment 005 1
hydrocortisone butyrate topical cream 01 1
hydrocortisone butyrate topical lotion 01 1
hydrocortisone butyrate topical ointment 01 1
hydrocortisone butyrate topical solution 01 1
hydrocortisone butyr-emollient topical cream 01
1
hydrocortisone topical cream 1 25 1
hydrocortisone topical lotion 25 1
hydrocortisone topical ointment 1 25 1
hydrocortisone valerate topical cream 02 1
hydrocortisone valerate topical ointment 02 1
mometasone topical cream 01 1
mometasone topical ointment 01 1
mometasone topical solution 01 1
prednicarbate topical cream 01 1
prednicarbate topical ointment 01 1
scalacort topical lotion 2 1
triamcinolone acetonide topical aerosol 0147 mggram
1
triamcinolone acetonide topical cream 0025 01 05
1
triamcinolone acetonide topical lotion 0025 01
1
triamcinolone acetonide topical ointment 0025 005 01 05
1
triderm topical cream 01 05 1
TOPICAL ENZYMES
SANTYL TOPICAL OINTMENT 250 UNITGRAM
1 QL (2 per 30 days)
66
Drug Name Drug Tier Requirements Limits
TOPICAL SCABICIDES PEDICULICIDES
crotan topical lotion 10 1
EURAX TOPICAL CREAM 10 1
EURAX TOPICAL LOTION 10 1
ivermectin topical lotion 05 1
lindane topical shampoo 1 1
malathion topical lotion 05 1
permethrin topical cream 5 1
spinosad topical suspension 09 1
ULESFIA TOPICAL LOTION 5 1
DIAGNOSTICS amp MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
PHYSIOLYTE IRRIGATION SOLUTION 140-5-3-98 MEQL
MB
PHYSIOSOL IRRIGATION IRRIGATION SOLUTION 140-5-3-98 MEQL
MB
MISCELLANEOUS AGENTS
acamprosate oral tabletdelayed release (drec) 333 mg
1
acetic acid irrigation solution 025 1
anagrelide oral capsule 05 mg 1 mg 1
ARALAST NP INTRAVENOUS RECON SOLN 1000 MG 500 MG
MB LA
CARBAGLU ORAL TABLET DISPERSIBLE 200 MG
2 PA LA
cevimeline oral capsule 30 mg 1
CHEMET ORAL CAPSULE 100 MG 1
clovique oral capsule 250 mg 1 PA QL (240 per 30 days)
deferasirox oral granules in packet 180 mg 360 mg 90 mg
2 PA LA
deferasirox oral tablet 180 mg 2 PA LA
deferasirox oral tablet 360 mg 90 mg 2 ST LA
deferasirox oral tablet dispersible 125 mg 250 mg 500 mg
2 ST LA
deferiprone oral tablet 500 mg 1 PA
disulfiram oral tablet 250 mg 500 mg 1
67
Drug Name Drug Tier Requirements Limits
EMPAVELI SUBCUTANEOUS SOLUTION 1080 MG20 ML
2 PA
FERRIPROX ORAL SOLUTION 100 MGML 1 PA
FERRIPROX ORAL TABLET 1000 MG 500 MG
1 PA
GIVLAARI SUBCUTANEOUS SOLUTION 189 MGML
MB PA LA
GLASSIA INTRAVENOUS SOLUTION 1 GRAM50 ML (2 )
MB LA
INCRELEX SUBCUTANEOUS SOLUTION 10 MGML
2 PA LA
levocarnitine (with sugar) oral solution 100 mgml 1
levocarnitine oral solution 100 mgml 1
levocarnitine oral tablet 330 mg 1
midodrine oral tablet 10 mg 25 mg 5 mg 1
nitisinone oral capsule 10 mg 2 mg 5 mg 2 PA LA
NITYR ORAL TABLET 10 MG 2 MG 5 MG 2 PA LA
pilocarpine hcl oral tablet 5 mg 1
PROLASTIN-C INTRAVENOUS SOLUTION 1000 MG (+-)20 ML
MB
RAVICTI ORAL LIQUID 11 GRAMML 2 PA ST LA QL (10 per 30 days)
RECLAST INTRAVENOUS PIGGYBACK 5 MG100 ML
MB
riluzole oral tablet 50 mg 1
risedronate oral tablet 30 mg 1
sodium chloride 09 injection solution MB
sodium chloride 09 intravenous parenteral solution
MB
sodium chloride 09 intravenous piggyback MB
sodium phenylbutyrate oral powder 094 gramgram
1 PA
sodium phenylbutyrate oral tablet 500 mg 1 PA
SOLIRIS INTRAVENOUS SOLUTION 300 MG30 ML
MB PA LA
trientine oral capsule 250 mg 1 PA QL (240 per 30 days)
XURIDEN ORAL GRANULES IN PACKET 2 GRAM
2 PA QL (120 per 30 days)
68
Drug Name Drug Tier Requirements Limits
ZEMAIRA INTRAVENOUS RECON SOLN 1000 MG
MB LA
ZOKINVY ORAL CAPSULE 50 MG 75 MG 2 PA ST
SMOKING DETERRENTS
bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg
ACA PV
CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG
ACA PV QL (180 per 365 days)
CHANTIX ORAL TABLET 05 MG 1 MG ACA PV QL (180 per 365 days)
CHANTIX STARTING MONTH BOX ORAL TABLETSDOSE PACK 05 MG (11)- 1 MG (42)
ACA PV QL (180 per 365 days)
nicorette buccal gum 4 mg ACA PV
nicotine (polacrilex) buccal gum 2 mg 4 mg ACA PV
nicotine (polacrilex) buccal lozenge 2 mg 4 mg ACA PV
nicotine (polacrilex) buccal mini lozenge 2 mg 4 mg
ACA PV
nicotine transdermal patch 24 hour 14 mg24 hr 21 mg24 hr 7 mg24 hr
ACA PV
nicotine transdermal patch td daily sequential 21-14-7 mg24 hr
ACA PV
NICOTROL INHALATION CARTRIDGE 10 MG
ACA PV
NICOTROL NS NASAL SPRAYNON-AEROSOL 10 MGML
ACA PV
quit 2 buccal gum 2 mg ACA PV
quit 2 buccal lozenge 2 mg ACA PV
quit 4 buccal gum 4 mg ACA PV
quit 4 buccal lozenge 4 mg ACA PV
stop smoking aid buccal lozenge 2 mg 4 mg ACA PV
EAR NOSE amp THROAT MEDICATIONS
MISCELLANEOUS AGENTS
ARESTIN DENTAL CARTRIDGE 1 MG MB
azelastine nasal aerosolspray 137 mcg (01 ) 1
azelastine nasal spraynon-aerosol 2055 mcg (015 )
1
chlorhexidine gluconate mucous membrane mouthwash 012
1
denta 5000 plus dental cream 11 1
69
Drug Name Drug Tier Requirements Limits
dentagel dental gel 11 1
fluoride (sodium) dental cream 11 1
fluoride (sodium) dental gel 11 1
fluoride (sodium) dental paste 11 1
ipratropium bromide nasal spraynon-aerosol 21 mcg (003 ) 42 mcg (006 )
1
olopatadine nasal spraynon-aerosol 06 1
oralone dental paste 01 1
paroex oral rinse mucous membrane mouthwash 012
1
periogard mucous membrane mouthwash 012 1
pilocarpine hcl oral tablet 75 mg 1
sf 5000 plus dental cream 11 1
sf dental gel 11 1
sodium fluoride 5000 dry mouth dental gel 11 1
sodium fluoride 5000 plus dental cream 11 1
sodium fluoride-pot nitrate dental paste 11-5 1
triamcinolone acetonide dental paste 01 1
MISCELLANEOUS OTIC PREPARATIONS
acetic acid otic (ear) solution 2 1
ciprofloxacin hcl otic (ear) dropperette 02 1
flac otic oil otic (ear) drops 001 1
fluocinolone acetonide oil otic (ear) drops 001 1
hydrocortisone-acetic acid otic (ear) drops 1-2 1
ofloxacin otic (ear) drops 03 1
OTIC STEROID ANTIBIOTIC
CIPRO HC OTIC (EAR) DROPSSUSPENSION 02-1
1
ciprofloxacin-dexamethasone otic (ear) dropssuspension 03-01
1
neomycin-polymyxin-hc otic (ear) dropssuspension 35-10000-1 mgml-unitml-
1
neomycin-polymyxin-hc otic (ear) solution 35-10000-1 mgml-unitml-
1
OTOVEL OTIC (EAR) SOLUTION 03-0025 (025 ML)
1
ENDOCRINEDIABETES
70
Drug Name Drug Tier Requirements Limits
ADRENAL HORMONES
ACTHAR INJECTION GEL 80 UNITML 2 PA LA
decadron oral tablet 05 mg 1
dexamethasone intensol oral drops 1 mgml 1
dexamethasone oral elixir 05 mg5 ml 1
dexamethasone oral solution 05 mg5 ml 1
dexamethasone oral tablet 05 mg 075 mg 1 mg 15 mg 2 mg 4 mg 6 mg
1
dexamethasone oral tabletsdose pack 15 mg (21 tabs) 15 mg (35 tabs) 15 mg (51 tabs)
1
dexamethasone sodium phos (pf) injection solution 10 mgml
1
dexamethasone sodium phosphate injection solution 10 mgml 4 mgml
1
dexamethasone sodium phosphate injection syringe 4 mgml
1
fludrocortisone oral tablet 01 mg 1
hydrocortisone oral tablet 10 mg 20 mg 5 mg 1
methylprednisolone acetate injection suspension 40 mgml 80 mgml
1
methylprednisolone oral tablet 16 mg 32 mg 4 mg 8 mg
1
methylprednisolone oral tabletsdose pack 4 mg 1
millipred dp oral tabletsdose pack 5 mg (21 tabs) 5 mg (48 tabs)
1
millipred oral tablet 5 mg 1
prednisolone oral solution 15 mg5 ml 1
prednisolone sodium phosphate oral solution 10 mg5 ml 15 mg5 ml (3 mgml) 20 mg5 ml (4 mgml) 25 mg5 ml (5 mgml) 5 mg base5 ml (67 mg5 ml)
1
prednisolone sodium phosphate oral tabletdisintegrating 10 mg 15 mg 30 mg
1
prednisone intensol oral concentrate 5 mgml 1
prednisone oral solution 5 mg5 ml 1
prednisone oral tablet 1 mg 10 mg 25 mg 20 mg 5 mg 50 mg
1
prednisone oral tabletsdose pack 10 mg 5 mg 1
71
Drug Name Drug Tier Requirements Limits
triamcinolone acetonide injection suspension 40 mgml
MB
ANTITHYROID AGENTS
methimazole oral tablet 10 mg 5 mg 1
propylthiouracil oral tablet 50 mg 1
SSKI ORAL SOLUTION 1 GRAMML 1
BLOOD GLUCOSE MONITORING DEVICES amp SUPPLIES
CONTOUR NEXT TEST STRIPS STRIP 1
CONTOUR TEST STRIPS STRIP 1
ONETOUCH ULTRA TEST STRIP 1
ONETOUCH VERIO TEST STRIPS STRIP 1
DIABETES SUPPLIES amp DURABLE MEDICAL EQUIPMENT
AEROCHAMBER MINI SPACER 1
AEROCHAMBER PLUS FLOW-VU SPACER 1
GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN 1 MGML
1
GLUCAGON HCL INJECTION RECON SOLN 1 MGML
1
INSULIN SYRINGE-NEEDLE U-100 SYRINGE 05 ML 29 GAUGE X 12
1
TRIJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-5-1000 MG 125-25-1000 MG 25-5-1000 MG 5-25-1000 MG
1 PA ST
GLUCOSE ELEVATING AGENTS
BAQSIMI NASAL SPRAYNON-AEROSOL 3 MGACTUATION
1
diazoxide oral suspension 50 mgml 1
GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG
1
GLUCAGON (HCL) EMERGENCY KIT INJECTION RECON SOLN 1 MG
1
glucagon emergency kit (human) injection recon soln 1 mg
1
INSULIN SYRINGESMISCELLANEOUS DURABLE MEDICAL EQU
FREESTYLE LIBRE 14 DAY SENSOR KIT 1
FREESTYLE LIBRE 2 SENSOR KIT 1
NOVOPEN ECHO SUBCUTANEOUS INSULIN PEN
1
72
Drug Name Drug Tier Requirements Limits
PEN NEEDLE DIABETIC NEEDLE 29 GAUGE X 12
1
INSULIN THERAPY
FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
FIASP PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML (3 ML)
1
FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN HALF-UNIT 100 UNITML
1
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML
1 ST
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 200 UNITML (3 ML)
1
HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNITML (50-50)
1 ST
HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (50-50)
1 ST
HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (75-25)
1 ST
HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNITML (75-25)
1 ST
HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML
1 ST
HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1 ST
HUMULIN 7030 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)
1 ST
HUMULIN 7030 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1 ST
73
Drug Name Drug Tier Requirements Limits
HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1 ST
HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML
1 ST
HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNITML
1 ST
HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNITML
1
HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNITML (3 ML)
1
INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML (70-30)
1
INSULIN ASPART U-100 SUBCUTANEOUS CARTRIDGE 100 UNITML
1
INSULIN ASPART U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
INSULIN ASPART U-100 SUBCUTANEOUS SOLUTION 100 UNITML
1
LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
NOVOLIN R FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
74
Drug Name Drug Tier Requirements Limits
NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNITML (70-30)
1
NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML
1
NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML
1
RELION NOVOLIN 7030 SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)
1
RELION NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNITML
1
RELION NOVOLIN R INJECTION SOLUTION 100 UNITML
1
SOLIQUA 10033 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCGML
1 PA ST
TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNITML (3 ML)
1
TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNITML (15 ML)
1
TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN 200 UNITML (3 ML)
1
TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
XULTOPHY 10036 SUBCUTANEOUS INSULIN PEN 100 UNIT-36 MG ML (3 ML)
1 PA ST
MISCELLANEOUS HORMONES
ALDURAZYME INTRAVENOUS SOLUTION 29 MG5 ML
MB PA LA
ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG24 HOUR 4 MG24 HR
1 ST QL (30 per 30 days)
75
Drug Name Drug Tier Requirements Limits
BRINEURA INTRAVENTRICULAR KIT 300 MG10 ML (150MG5ML X2)
MB
cabergoline oral tablet 05 mg 1
calcitonin (salmon) injection solution 200 unitml 1
calcitonin (salmon) nasal spraynon-aerosol 200 unitactuation
1
calcitriol oral capsule 025 mcg 05 mcg 1
calcitriol oral solution 1 mcgml 1
CERDELGA ORAL CAPSULE 84 MG 2 PA LA
CEREZYME INTRAVENOUS RECON SOLN 400 UNIT
MB PA LA
cinacalcet oral tablet 30 mg 60 mg 90 mg 2 PA
CRYSVITA SUBCUTANEOUS SOLUTION 10 MGML 20 MGML 30 MGML
MB PA LA
danazol oral capsule 100 mg 200 mg 50 mg 1
DEPO-TESTOSTERONE INTRAMUSCULAR OIL 100 MGML
1
desmopressin nasal spraynon-aerosol 10 mcgspray (01 ml)
1
desmopressin oral tablet 01 mg 02 mg 1
doxercalciferol oral capsule 05 mcg 1 mcg 25 mcg
1
ELAPRASE INTRAVENOUS SOLUTION 6 MG3 ML
MB PA LA
ELELYSO INTRAVENOUS RECON SOLN 200 UNIT
MB PA LA
FABRAZYME INTRAVENOUS RECON SOLN 35 MG 5 MG
MB PA LA
GALAFOLD ORAL CAPSULE 123 MG 2 PA LA
JYNARQUE ORAL TABLET 15 MG 30 MG 2 PA QL (60 per 30 days)
JYNARQUE ORAL TABLETS SEQUENTIAL 45 MG (AM) 15 MG (PM) 60 MG (AM) 30 MG (PM) 90 MG (AM) 30 MG (PM)
2 PA QL (60 per 30 days)
KANUMA INTRAVENOUS SOLUTION 2 MGML
MB PA LA
KORLYM ORAL TABLET 300 MG 2 PA ST
LUMIZYME INTRAVENOUS RECON SOLN 50 MG
MB PA LA
76
Drug Name Drug Tier Requirements Limits
MEPSEVII INTRAVENOUS SOLUTION 2 MGML
MB PA LA
methyltestosterone oral capsule 10 mg 1
MIACALCIN INJECTION SOLUTION 200 UNITML
1
miglustat oral capsule 100 mg 2 PA LA
MYALEPT SUBCUTANEOUS RECON SOLN 5 MGML (FINAL CONC)
2 LA
NAGLAZYME INTRAVENOUS SOLUTION 5 MG5 ML
MB PA LA
NATPARA SUBCUTANEOUS CARTRIDGE 100 MCGDOSE 25 MCGDOSE 50 MCGDOSE 75 MCGDOSE
2 PA ST LA
oxandrolone oral tablet 10 mg 25 mg 1
PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG05 ML 25 MG05 ML 20 MGML
2 PA LA
pamidronate intravenous solution 30 mg10 ml (3 mgml)
MB
PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCGML
MB
paricalcitol intravenous solution 5 mcgml MB
paricalcitol oral capsule 1 mcg 2 mcg 4 mcg 1
PARSABIV INTRAVENOUS SOLUTION 5 MGML
MB PA
SAMSCA ORAL TABLET 15 MG 2 PA LA QL (60 per 30 days)
sapropterin oral powder in packet 100 mg 500 mg 2 PA LA
sapropterin oral tabletsoluble 100 mg 2 PA LA
SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG 15 MG 20 MG 25 MG 30 MG
2 PA LA QL (30 per 30 days)
STRENSIQ SUBCUTANEOUS SOLUTION 18 MG045 ML 28 MG07 ML 40 MGML 80 MG08 ML
2 PA
SYNAREL NASAL SPRAYNON-AEROSOL 2 MGML
1
TEPEZZA INTRAVENOUS RECON SOLN 500 MG
MB PA LA
testosterone cypionate intramuscular oil 100 mgml 200 mgml
1
testosterone enanthate intramuscular oil 200 mgml
1
77
Drug Name Drug Tier Requirements Limits
testosterone transdermal gel 50 mg5 gram (1 ) 1 QL (60 per 30 days)
testosterone transdermal gel in metered-dose pump 10 mg05 gram actuation 2025 mg125 gram (162 )
1 QL (2 per 30 days)
testosterone transdermal gel in metered-dose pump 125 mg 125 gram (1 )
1 QL (4 per 30 days)
testosterone transdermal gel in packet 1 (25 mg25gram) 162 (2025 mg125 gram)
1 QL (30 per 30 days)
testosterone transdermal gel in packet 1 (50 mg5 gram) 162 (405 mg25 gram)
1 QL (60 per 30 days)
testosterone transdermal solution in metered pump wapp 30 mgactuation (15 ml)
1 QL (2 per 30 days)
VIMIZIM INTRAVENOUS SOLUTION 5 MG5 ML (1 MGML)
MB PA LA
VPRIV INTRAVENOUS RECON SOLN 400 UNIT
MB PA LA
NON-INSULIN HYPOGLYCEMIC AGENTS
acarbose oral tablet 100 mg 25 mg 50 mg 1
ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 125-15 MG 125-30 MG 125-45 MG 25-15 MG 25-30 MG 25-45 MG
1 PA ST
BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG085 ML
1 PA ST
BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCGDOSE(250 MCGML) 24 ML 5 MCGDOSE (250 MCGML) 12 ML
1 PA ST
CYCLOSET ORAL TABLET 08 MG 1
FARXIGA ORAL TABLET 10 MG 5 MG 1 PA ST
glimepiride oral tablet 1 mg 2 mg 4 mg 1
glipizide oral tablet 10 mg 5 mg 1
glipizide oral tablet extended release 24hr 10 mg 25 mg 5 mg
1
glipizide-metformin oral tablet 25-250 mg 25-500 mg 5-500 mg
1
glyburide micronized oral tablet 15 mg 3 mg 6 mg
1
glyburide oral tablet 125 mg 25 mg 5 mg 1
glyburide-metformin oral tablet 125-250 mg 25-500 mg 5-500 mg
1
78
Drug Name Drug Tier Requirements Limits
GLYXAMBI ORAL TABLET 10-5 MG 25-5 MG
1 PA ST
JANUMET ORAL TABLET 50-1000 MG 50-500 MG
1 PA ST
JANUMET XR ORAL TABLET ER MULTIPHASE 24 HR 100-1000 MG 50-1000 MG 50-500 MG
1 PA ST
JANUVIA ORAL TABLET 100 MG 25 MG 50 MG
1 PA ST
JARDIANCE ORAL TABLET 10 MG 25 MG 1 PA ST
JENTADUETO ORAL TABLET 25-1000 MG 25-500 MG 25-850 MG
1 PA ST
JENTADUETO XR ORAL TABLET IR - ER BIPHASIC 24HR 25-1000 MG 5-1000 MG
1 PA ST
metformin oral solution 500 mg5 ml 1 PA
metformin oral tablet 1000 mg 500 mg 850 mg 1
metformin oral tablet extended release 24 hr 500 mg 750 mg
1
metformin oral tablet extended release 24hr 1000 mg 500 mg
1 PA ST
metformin oral tableter gastretention 24 hr 1000 mg 500 mg
1 ST
miglitol oral tablet 100 mg 25 mg 50 mg 1
nateglinide oral tablet 120 mg 60 mg 1
OZEMPIC SUBCUTANEOUS PEN INJECTOR 025 MG OR 05 MG(2 MG15 ML) 1 MGDOSE (2 MG15 ML) 1 MGDOSE (4 MG3 ML)
1 PA ST
pioglitazone oral tablet 15 mg 30 mg 45 mg 1
pioglitazone-glimepiride oral tablet 30-2 mg 30-4 mg
1
pioglitazone-metformin oral tablet 15-500 mg 15-850 mg
1
QTERN ORAL TABLET 10-5 MG 5-5 MG 1 PA ST
repaglinide oral tablet 05 mg 1 mg 2 mg 1
repaglinide-metformin oral tablet 1-500 mg 2-500 mg
1
RIOMET ER ORAL SUSPENSIONEXTENDED REL RECON 500 MG5 ML
1 PA ST
79
Drug Name Drug Tier Requirements Limits
RYBELSUS ORAL TABLET 14 MG 3 MG 7 MG
1 PA ST
SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2700 MCG27 ML
1 PA ST
SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1500 MCG15 ML
1 PA ST
SYNJARDY ORAL TABLET 125-1000 MG 125-500 MG 5-1000 MG 5-500 MG
1 PA ST
SYNJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 125-1000 MG 25-1000 MG 5-1000 MG
1 PA ST
TRADJENTA ORAL TABLET 5 MG 1 PA ST
TRULICITY SUBCUTANEOUS PEN INJECTOR 075 MG05 ML 15 MG05 ML 3 MG05 ML 45 MG05 ML
1 PA ST
XIGDUO XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 10-500 MG 25-1000 MG 5-1000 MG 5-500 MG
1 PA ST
THYROID HORMONES
ARMOUR THYROID ORAL TABLET 120 MG 15 MG 180 MG 240 MG 30 MG 300 MG 60 MG 90 MG
1
levothyroxine oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 300 mcg 50 mcg 75 mcg 88 mcg
1
levoxyl oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 50 mcg 75 mcg 88 mcg
1
liothyronine oral tablet 25 mcg 5 mcg 50 mcg 1
np thyroid oral tablet 120 mg 15 mg 30 mg 60 mg 90 mg
1
SYNTHROID ORAL TABLET 100 MCG 112 MCG 125 MCG 137 MCG 150 MCG 175 MCG 200 MCG 25 MCG 300 MCG 50 MCG 75 MCG 88 MCG
1
THYROLAR-1 ORAL TABLET 125-50 MCG 1
THYROLAR-12 ORAL TABLET 625-25 MCG 1
THYROLAR-14 ORAL TABLET 31-125 MCG 1
THYROLAR-2 ORAL TABLET 25-100 MCG 1
THYROLAR-3 ORAL TABLET 375-150 MCG 1
80
Drug Name Drug Tier Requirements Limits
unithroid oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 300 mcg 50 mcg 75 mcg 88 mcg
1
westhroid oral tablet 130 mg 195 mg 325 mg 65 mg 975 mg
1
GASTROENTEROLOGY
ANTIDIARRHEALS amp ANTISPASMODICS
anaspaz oral tabletdisintegrating 0125 mg 1
atropine injection syringe 005 mgml 01 mgml 1
belladonna alkaloids-opium rectal suppository 162-30 mg 162-60 mg
1 PA ST
chlordiazepoxide-clidinium oral capsule 5-25 mg 1
dicyclomine intramuscular solution 10 mgml MB
dicyclomine oral capsule 10 mg 1
dicyclomine oral solution 10 mg5 ml 1
dicyclomine oral tablet 20 mg 1
diphenoxylate-atropine oral liquid 25-0025 mg5 ml
1
diphenoxylate-atropine oral tablet 25-0025 mg 1
DONNATAL ORAL TABLET 162-01037 -00194 MG
1
ed-spaz oral tabletdisintegrating 0125 mg 1
glycopyrrolate injection solution 02 mgml 1
glycopyrrolate oral tablet 1 mg 15 mg 2 mg 1
hyoscyamine sulfate oral drops 0125 mgml 1
hyoscyamine sulfate oral elixir 0125 mg5 ml 1
hyoscyamine sulfate oral tablet 0125 mg 1
hyoscyamine sulfate oral tablet extended release 12 hr 0375 mg
1
hyoscyamine sulfate oral tabletdisintegrating 0125 mg
1
hyoscyamine sulfate sublingual tablet 0125 mg 1
hyosyne oral drops 0125 mgml 1
hyosyne oral elixir 0125 mg5 ml 1
loperamide oral capsule 2 mg 1
methscopolamine oral tablet 25 mg 5 mg 1
MOTOFEN ORAL TABLET 1-0025 MG 1
81
Drug Name Drug Tier Requirements Limits
opium tincture oral tincture 10 mgml (morphine) 1
oscimin oral tablet 0125 mg 1
oscimin sl sublingual tablet 0125 mg 1
oscimin sr oral tablet extended release 12 hr 0375 mg
1
phenobarb-hyoscy-atropine-scop oral elixir 162-01037 -00194 mg5 ml
1
phenobarb-hyoscy-atropine-scop oral tablet 162-01037 -00194 mg
1
phenohytro oral elixir 162-01037 -00194 mg5 ml
1
phenohytro oral tablet 162-01037 -00194 mg 1
symax fastabs oral tabletdisintegrating 0125 mg 1
symax-sl sublingual tablet 0125 mg 1
symax-sr oral tablet extended release 12 hr 0375 mg
1
MISCELLANEOUS GASTROINTESTINAL AGENTS
AKYNZEO (NETUPITANT) ORAL CAPSULE 300-05 MG
1 QL (1 per 30 days)
alosetron oral tablet 05 mg 1 mg 1
ALOXI INTRAVENOUS SOLUTION 025 MG5 ML
MB
AMITIZA ORAL CAPSULE 24 MCG 8 MCG 1 PA
anucort-hc rectal suppository 25 mg 1
aprepitant oral capsule 125 mg 40 mg 1 QL (1 per 30 days)
aprepitant oral capsule 80 mg 1 QL (2 per 30 days)
aprepitant oral capsuledose pack 125 mg (1)- 80 mg (2)
1 QL (1 per 30 days)
balsalazide oral capsule 750 mg 1
budesonide oral capsuledelayedextendrelease 3 mg
1
calcium acetate(phosphat bind) oral capsule 667 mg
1
calcium acetate(phosphat bind) oral tablet 667 mg 1
CHOLBAM ORAL CAPSULE 250 MG 50 MG 2
CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)
2 PA ST LA
82
Drug Name Drug Tier Requirements Limits
CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG2 ML (200 MGML X 2)
2 PA ST LA
CLENPIQ ORAL SOLUTION 10 MG-35 GRAM -12 GRAM160 ML
ACA PV
compro rectal suppository 25 mg 1
constulose oral solution 10 gram15 ml 1
CORTIFOAM RECTAL FOAM 10 (80 MG) 1
CREON ORAL CAPSULEDELAYED RELEASE(DREC) 12000-38000 -60000 UNIT 24000-76000 -120000 UNIT 3000-9500- 15000 UNIT 36000-114000- 180000 UNIT 6000-19000 -30000 UNIT
1 PA
cromolyn oral concentrate 100 mg5 ml 1
DIPENTUM ORAL CAPSULE 250 MG 1 PA ST
doxylamine-pyridoxine (vit b6) oral tabletdelayed release (drec) 10-10 mg
1
dronabinol oral capsule 10 mg 25 mg 5 mg 1
EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG ML FINAL CONC)
1
ENTYVIO INTRAVENOUS RECON SOLN 300 MG
MB PA LA
enulose oral solution 10 gram15 ml 1
gavilyte-c oral recon soln 240-2272-672 -584 gram
ACA PV
gavilyte-g oral recon soln 236-2274-674 -586 gram
ACA PV
gavilyte-n oral recon soln 420 gram ACA PV
generlac oral solution 10 gram15 ml 1
granisetron hcl oral tablet 1 mg 1 QL (6 per 30 days)
hemmorex-hc rectal suppository 25 mg 1
hydrocortisone acetate rectal suppository 25 mg 30 mg
1
hydrocortisone rectal enema 100 mg60 ml 1
hydrocortisone topical cream with perineal applicator 1 25
1
hydrocortisone-pramoxine rectal cream 1-1 25-1 25-1 (4g)
1
INFLECTRA INTRAVENOUS RECON SOLN 100 MG
MB PA LA
83
Drug Name Drug Tier Requirements Limits
lactulose oral packet 10 gram 1
lactulose oral solution 10 gram15 ml 20 gram30 ml
1
lanthanum oral tabletchewable 1000 mg 500 mg 750 mg
1
lidocaine hcl-hydrocortison ac rectal cream 3-05
1
LIDOCAINE HCL-HYDROCORTISON AC RECTAL GEL 3 -25 (7 GRAM)
1
lidocaine hcl-hydrocortison ac rectal kit 2 -2 (7 gram)
1 ST
lidocaine hcl-hydrocortison ac rectal kit 3-05 3-1 (7 gram)
1 PA ST
lidocaine-hydrocortisone-aloe rectal gel 28-055
1
lidocaine-hydrocortisone-aloe rectal kit 3-25 (7 gram)
1 PA ST
LINZESS ORAL CAPSULE 145 MCG 290 MCG 72 MCG
1 PA
meclizine oral tablet 125 mg 25 mg 1
mesalamine oral capsuleextended release 24hr 0375 gram
1
mesalamine oral tabletdelayed release (drec) 12 gram 800 mg
1
mesalamine rectal enema 4 gram60 ml 1
mesalamine rectal suppository 1000 mg 1
mesalamine with cleansing wipe rectal enema kit 4 gram60 ml
1 ST
metoclopramide hcl injection solution 5 mgml MB
metoclopramide hcl injection syringe 5 mgml MB
metoclopramide hcl oral solution 5 mg5 ml 1
metoclopramide hcl oral tablet 10 mg 5 mg 1
metoclopramide hcl oral tabletdisintegrating 10 mg 5 mg
1
MOVANTIK ORAL TABLET 125 MG 25 MG 1 PA ST
NULYTELY LEMON-LIME ORAL RECON SOLN 420 GRAM
ACA PV
ondansetron hcl intravenous solution 2 mgml MB
ondansetron hcl oral solution 4 mg5 ml 1 QL (100 per 30 days)
84
Drug Name Drug Tier Requirements Limits
ondansetron hcl oral tablet 4 mg 8 mg 1 QL (9 per 30 days)
ondansetron oral tabletdisintegrating 4 mg 8 mg 1 QL (9 per 30 days)
OSMOPREP ORAL TABLET 15 GRAM ACA PV
peg 3350-electrolytes oral recon soln 236-2274-674 -586 gram
ACA PV
peg3350-sod sul-nacl-kcl-asb-c oral powder in packet 100-75-2691 gram
ACA PV
peg-electrolyte soln oral recon soln 420 gram ACA PV
peg-prep oral kit 5-210 mg-gram ACA PV
PLENVU ORAL POWDER IN PACKET SEQUENTIAL 140-9-52 GRAM
ACA PV
prochlorperazine edisylate injection solution 10 mg2 ml (5 mgml) 5 mgml
1
prochlorperazine maleate oral tablet 10 mg 5 mg 1
prochlorperazine rectal suppository 25 mg 1
procto-med hc topical cream with perineal applicator 25
1
procto-pak topical cream with perineal applicator 1
1
proctosol hc topical cream with perineal applicator 25
1
proctozone-hc topical cream with perineal applicator 25
1
RECTIV RECTAL OINTMENT 04 (WW) 1
RELISTOR ORAL TABLET 150 MG 1
RELISTOR SUBCUTANEOUS SOLUTION 12 MG06 ML
1
RELISTOR SUBCUTANEOUS SYRINGE 12 MG06 ML 8 MG04 ML
1
REMICADE INTRAVENOUS RECON SOLN 100 MG
MB PA LA
RENFLEXIS INTRAVENOUS RECON SOLN 100 MG
MB PA LA
scopolamine base transdermal patch 3 day 1 mg over 3 days
1
sevelamer carbonate oral powder in packet 08 gram 24 gram
1
sevelamer carbonate oral tablet 800 mg 1
sevelamer hcl oral tablet 400 mg 800 mg 1
85
Drug Name Drug Tier Requirements Limits
sodium polystyrene sulfonate oral powder 1
sps (with sorbitol) oral suspension 15-20 gram60 ml
1
sps (with sorbitol) rectal enema 30-40 gram120 ml
1
SUCRAID ORAL SOLUTION 8500 UNITML 2 PA ST QL (2 per 30 days)
sulfasalazine oral tablet 500 mg 1
sulfasalazine oral tabletdelayed release (drec) 500 mg
1
SUPREP BOWEL PREP KIT ORAL RECON SOLN 175-313-16 GRAM
ACA PV ST
trilyte with flavor packets oral recon soln 420 gram
ACA PV
trimethobenzamide oral capsule 300 mg 1
ursodiol oral capsule 300 mg 1
ursodiol oral tablet 250 mg 500 mg 1
VARUBI ORAL TABLET 90 MG 1
VELPHORO ORAL TABLETCHEWABLE 500 MG
1 ST
VIBERZI ORAL TABLET 100 MG 75 MG 1 PA ST
ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 10000-32000 -42000 UNIT 15000-47000 -63000 UNIT 20000-63000- 84000 UNIT 3000-10000 -14000-UNIT 40000-126000- 168000 UNIT 5000-17000- 24000 UNIT
1 PA
ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 25000-79000- 105000 UNIT
1
ULCER THERAPY
amoxicil-clarithromy-lansopraz oral combo pack 500-500-30 mg
1
cimetidine hcl oral solution 300 mg5 ml 1
cimetidine oral tablet 200 mg 300 mg 400 mg 800 mg
1
DEXILANT ORAL CAPSULEBIPHASE DELAYED RELEAS 30 MG 60 MG
1 ST
esomeprazole magnesium oral capsuledelayed release(drec) 20 mg 40 mg
1
famotidine (pf) intravenous solution 20 mg2 ml MB
86
Drug Name Drug Tier Requirements Limits
famotidine oral suspension 40 mg5 ml (8 mgml) 1
famotidine oral tablet 20 mg 40 mg 1
lansoprazole oral capsuledelayed release(drec) 15 mg 30 mg
1
lansoprazole oral tabletdisintegrat delay rel 15 mg 30 mg
1
misoprostol oral tablet 100 mcg 200 mcg 1
nizatidine oral capsule 150 mg 300 mg 1
nizatidine oral solution 150 mg10 ml 1
omeprazole oral capsuledelayed release(drec) 10 mg 20 mg 40 mg
1
pantoprazole oral tabletdelayed release (drec) 20 mg 40 mg
1
rabeprazole oral tabletdelayed release (drec) 20 mg
1
sucralfate oral suspension 100 mgml 1
sucralfate oral tablet 1 gram 1
IMMUNOLOGY VACCINES amp BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCGML 200 MCGML 25 MCGML 300 MCGML 40 MCGML 60 MCGML
2 LA
ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG04 ML 100 MCG05 ML 150 MCG03 ML 200 MCG04 ML 25 MCG042 ML 300 MCG06 ML 40 MCG04 ML 500 MCGML 60 MCG03 ML
2 LA
EPOGEN INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML
2 LA
GRANIX SUBCUTANEOUS SOLUTION 300 MCGML 480 MCG16 ML
2
GRANIX SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML
2
LEUKINE INJECTION RECON SOLN 250 MCG 2 PA ST
MIRCERA INJECTION SYRINGE 100 MCG03 ML 150 MCG03 ML 200 MCG03 ML 30 MCG03 ML 50 MCG03 ML 75 MCG03 ML
MB
87
Drug Name Drug Tier Requirements Limits
MOZOBIL SUBCUTANEOUS SOLUTION 24 MG12 ML (20 MGML)
MB LA
NEUPOGEN INJECTION SOLUTION 300 MCGML 480 MCG16 ML
2 PA ST
NEUPOGEN INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML
2 PA ST
NIVESTYM INJECTION SOLUTION 300 MCGML 480 MCG16 ML
2
NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML
2
PROCRIT INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML 40000 UNITML
2 LA
UDENYCA SUBCUTANEOUS SYRINGE 6 MG06 ML
2 PA ST
ZARXIO INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML
2 PA ST
ZIEXTENZO SUBCUTANEOUS SYRINGE 6 MG06 ML
2 PA ST
GROWTH HORMONES
GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 02 MG025 ML 04 MG025 ML 06 MG025 ML 08 MG025 ML 1 MG025 ML 12 MG025 ML 14 MG025 ML 16 MG025 ML 18 MG025 ML 2 MG025 ML
2 PA ST LA
GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MGML (36 UNITML) 5 MGML (15 UNITML)
2 PA ST LA
OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG15 ML (67 MGML) 5 MG15 ML (33 MGML)
2 PA ST LA
OMNITROPE SUBCUTANEOUS RECON SOLN 58 MG
2 PA ST LA
SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG 5 MG 6 MG
2 PA ST LA
ZORBTIVE SUBCUTANEOUS RECON SOLN 88 MG
2 PA ST LA
INTERFERONS
AUBAGIO ORAL TABLET 14 MG 7 MG 2 PA LA
88
Drug Name Drug Tier Requirements Limits
AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG05 ML
2 PA ST LA QL (4 per 30 days)
AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG05 ML
2 PA ST LA QL (4 per 30 days)
BETASERON SUBCUTANEOUS KIT 03 MG 2 PA LA QL (14 per 30 days)
dimethyl fumarate oral capsuledelayed release(drec) 120 mg
2 PA LA QL (14 per 365 days)
dimethyl fumarate oral capsuledelayed release(drec) 120 mg (14)- 240 mg (46)
2 PA LA QL (1 per 365 days)
dimethyl fumarate oral capsuledelayed release(drec) 240 mg
2 PA LA QL (60 per 30 days)
GILENYA ORAL CAPSULE 05 MG 2 PA LA QL (30 per 30 days)
glatiramer subcutaneous syringe 20 mgml 2 PA LA QL (30 per 30 days)
glatiramer subcutaneous syringe 40 mgml 2 PA LA QL (12 per 30 days)
glatopa subcutaneous syringe 20 mgml 2 PA LA QL (30 per 30 days)
glatopa subcutaneous syringe 40 mgml 2 PA LA QL (12 per 30 days)
LEMTRADA INTRAVENOUS SOLUTION 12 MG12 ML
MB PA ST LA
MAVENCLAD (10 TABLET PACK) ORAL TABLET 10 MG
2 LA
MAVENCLAD (4 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (5 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (6 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (7 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (8 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (9 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAYZENT ORAL TABLET 025 MG 2 MG 2 PA ST LA QL (30 per 30 days)
MAYZENT STARTER PACK ORAL TABLETSDOSE PACK 025 MG (12 TABS)
2 PA ST LA QL (1 per 365 days)
OCREVUS INTRAVENOUS SOLUTION 30 MGML
MB PA LA
PEGASYS SUBCUTANEOUS SOLUTION 180 MCGML
2 PA LA
89
Drug Name Drug Tier Requirements Limits
PEGASYS SUBCUTANEOUS SYRINGE 180 MCG05 ML
2 PA LA
PLEGRIDY INTRAMUSCULAR SYRINGE 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG05 ML- 94 MCG05 ML
2 PA LA QL (1 per 365 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG05 ML- 94 MCG05 ML
2 PA LA QL (1 per 365 days)
POMALYST ORAL CAPSULE 1 MG 2 MG 3 MG 4 MG
2 PA ST OCh LA
PONVORY 14-DAY STARTER PACK ORAL TABLETSDOSE PACK 2 MG (2) - 10 MG (3)
2 PA LA QL (1 per 365 days)
PONVORY ORAL TABLET 20 MG 2 PA LA QL (30 per 30 days)
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG05 ML 44 MCG05 ML
2 PA LA QL (6 per 30 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG05 ML 44 MCG05 ML
2 PA LA QL (6 per 30 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 88MCG02ML-22 MCG05ML (6)
2 PA LA QL (5 per 30 days)
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 88MCG02ML-22 MCG05ML (6)
2 PA LA QL (5 per 30 days)
REVLIMID ORAL CAPSULE 10 MG 15 MG 25 MG 20 MG 25 MG 5 MG
2 PA ST OCh LA
ribavirin oral capsule 200 mg 2 LA
ribavirin oral tablet 200 mg 2 LA
ZEPOSIA ORAL CAPSULE 092 MG 2 LA QL (30 per 30 days)
ZEPOSIA STARTER KIT ORAL CAPSULEDOSE PACK 023-046-092 MG
2 LA QL (30 per 30 days)
ZEPOSIA STARTER PACK ORAL CAPSULEDOSE PACK 023 MG (4)- 046 MG (3)
2 LA QL (30 per 30 days)
INTERLEUKINS
ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG05 ML
2 PA LA
ARCALYST SUBCUTANEOUS RECON SOLN 220 MG
2 LA
90
Drug Name Drug Tier Requirements Limits
ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MGML
MB PA LA
imiquimod topical cream in packet 5 1
INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) 18 MILLION UNIT (1 ML) 50 MILLION UNIT (1 ML)
2 PA LA
INTRON A INJECTION SOLUTION 10 MILLION UNITML 6 MILLION UNITML
2 PA LA
PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT
MB LA
VACCINES amp MISCELLANEOUS IMMUNOLOGICALS
ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(25-5-3-5 MCG)-5LF05 ML
1 Vac
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(25-5-3-5 MCG)-5LF05 ML
1 Vac
ASCENIV INTRAVENOUS SOLUTION 10 MB PA LA
ATGAM INTRAVENOUS SOLUTION 50 MGML
MB
BCG VACCINE LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG
1 Vac
BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG05 ML
1 Vac
BIOTHRAX INTRAMUSCULAR SUSPENSION 05 MLDOSE
1 Vac
BIVIGAM INTRAVENOUS SOLUTION 10 MB PA LA
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 25-8-5 LF-MCG-LF05ML
1 Vac
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 25-8-5 LF-MCG-LF05ML
1 Vac
BOTOX INJECTION RECON SOLN 100 UNIT 200 UNIT
MB
CUTAQUIG SUBCUTANEOUS SOLUTION 165
MB LA
CUVITRU SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 ) 8 GRAM40 ML (20 )
MB LA
91
Drug Name Drug Tier Requirements Limits
DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF05ML
1 Vac
DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT 500 UNIT
MB LA
ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCGML
1 Vac
ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCGML
1 Vac
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG05 ML
1 Vac
FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 5
MB PA
GAMASTAN INTRAMUSCULAR SOLUTION 15-18 RANGE
MB
GAMASTAN SD INTRAMUSCULAR SOLUTION 15-18 RANGE
MB
GAMMAGARD LIQUID INJECTION SOLUTION 10
MB LA
GAMMAGARD S-D (IGA lt 1 MCGML) INTRAVENOUS RECON SOLN 10 GRAM 5 GRAM
MB PA LA
GAMMAKED INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 20 GRAM200 ML (10 ) 5 GRAM50 ML (10 )
MB LA
GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5
MB PA LA
GAMMAPLEX INTRAVENOUS SOLUTION 10
MB PA LA
GAMUNEX-C INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 25 GRAM25 ML (10 ) 20 GRAM200 ML (10 ) 40 GRAM400 ML (10 ) 5 GRAM50 ML (10 )
MB LA
GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 05 ML
1 Vac
GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 05 ML
1 Vac
GRASTEK SUBLINGUAL TABLET 2800 BAU 1 PA
HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1440 ELISA UNITML
1 Vac
92
Drug Name Drug Tier Requirements Limits
HAVRIX (PF) INTRAMUSCULAR SYRINGE 1440 ELISA UNITML 720 ELISA UNIT05 ML
1 Vac
HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE 20 MCG05 ML
1 Vac
HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )
MB LA
HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM 100 ML (10 ) 25 GRAM 25 ML (10 ) 20 GRAM 200 ML (10 ) 30 GRAM 300 ML (10 ) 5 GRAM 50 ML (10 )
MB LA
IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 25 UNIT
1 Vac
INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF05ML
1 Vac
IPOL INJECTION SUSPENSION 40-8-32 UNIT05 ML
1 Vac
IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG05 ML
1 Vac
KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF05 ML
1 Vac
MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG05 ML
1 Vac
MENQUADFI (PF) INTRAMUSCULAR SOLUTION 10 MCG05 ML
1 Vac
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG05 ML
1 Vac
M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1000-12500 TCID5005 ML
1 Vac
MYOBLOC INTRAMUSCULAR SOLUTION 10000 UNIT2 ML 2500 UNIT05 ML 5000 UNITML
MB LA
OCTAGAM INTRAVENOUS SOLUTION 10 5
MB PA LA
ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY
2 PA
PANZYGA INTRAVENOUS SOLUTION 10 MB PA
PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF05 ML
1 Vac
93
Drug Name Drug Tier Requirements Limits
PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 75 MCG05 ML
1 Vac
PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF05 ML 15LF-48MCG-62DU -10 MCG05ML
1 Vac
PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
PNEUMOVAX-23 INJECTION SOLUTION 25 MCG05 ML
1 Vac
PNEUMOVAX-23 INJECTION SYRINGE 25 MCG05 ML
1 Vac
PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE 05 ML
1 Vac
PRIVIGEN INTRAVENOUS SOLUTION 10 MB PA LA
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-43-3- 399 TCID5005
1 Vac
PROVENGE INTRAVENOUS SUSPENSION 50 MILLION CELL250 ML
MB PA
QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT05ML
1 Vac
RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 25 UNIT
1 Vac
RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT
1 PA
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCGML 40 MCGML 5 MCG05 ML
1 Vac
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCGML 5 MCG05 ML
1 Vac
SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG05 ML
1 Vac
STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1000 UNIT05 ML
1 Vac
TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF UNIT05 ML
1 Vac
94
Drug Name Drug Tier Requirements Limits
TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT05ML
1 Vac
TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT05 ML
1 Vac
TETANUSDIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT05 ML
1 Vac
THYMOGLOBULIN INTRAVENOUS RECON SOLN 25 MG
MB
TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG05 ML
1 Vac
TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCGML
1 Vac
TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG05 ML
1 Vac
TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG05 ML
1 Vac
VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT05 ML 50 UNITML
1 Vac
VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT05 ML 50 UNITML
1 Vac
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1350 UNIT05 ML
1 Vac
VAXELIS (PF) INTRAMUSCULAR SUSPENSION 15 UNIT-5 UNIT- 10 MCG05 ML
1 Vac
VAXELIS (PF) INTRAMUSCULAR SYRINGE 15 UNIT-5 UNIT- 10 MCG05 ML
1 Vac
XEMBIFY SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )
MB LA
XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT 200 UNIT 50 UNIT
MB LA
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP474 UNIT05 ML
1 Vac
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19400 UNIT065 ML
1 Vac
MUSCULOSKELETAL amp RHEUMATOLOGY
95
Drug Name Drug Tier Requirements Limits
GOUT THERAPY
allopurinol oral tablet 100 mg 300 mg 1
COLCHICINE ORAL CAPSULE 06 MG 1
colchicine oral tablet 06 mg 1
febuxostat oral tablet 40 mg 80 mg 1
KRYSTEXXA INTRAVENOUS SOLUTION 8 MGML
MB PA LA
MITIGARE ORAL CAPSULE 06 MG 1
probenecid oral tablet 500 mg 1
probenecid-colchicine oral tablet 500-05 mg 1
OSTEOPOROSIS THERAPY
alendronate oral solution 70 mg75 ml 1
alendronate oral tablet 10 mg 35 mg 5 mg 70 mg 1
EVENITY SUBCUTANEOUS SYRINGE 105 MG117 ML 210MG234ML ( 105MG117MLX2)
2 PA ST LA
FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCGDOSE (620MCG248ML)
2 PA ST LA QL (1 per 30 days)
FOSAMAX PLUS D ORAL TABLET 70 MG- 2800 UNIT 70 MG- 5600 UNIT
1
ibandronate oral tablet 150 mg 1
PROLIA SUBCUTANEOUS SYRINGE 60 MGML
2 ST LA
raloxifene oral tablet 60 mg 2 OCh
risedronate oral tablet 150 mg 35 mg 5 mg 1
risedronate oral tabletdelayed release (drec) 35 mg
1
TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3120 MCG156 ML)
2 PA ST LA
OTHER RHEUMATOLOGICALS
ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG09 ML
2 PA ST LA
ACTEMRA INTRAVENOUS SOLUTION 200 MG10 ML (20 MGML) 400 MG20 ML (20 MGML) 80 MG4 ML (20 MGML)
MB PA LA
ACTEMRA SUBCUTANEOUS SYRINGE 162 MG09 ML
2 PA ST LA
96
Drug Name Drug Tier Requirements Limits
BENLYSTA INTRAVENOUS RECON SOLN 120 MG 400 MG
MB PA LA
BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MGML
2 PA LA
BENLYSTA SUBCUTANEOUS SYRINGE 200 MGML
2 PA LA
ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MGML (1 ML)
2 PA ST LA
ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)
2 PA ST LA
ENBREL SUBCUTANEOUS SOLUTION 25 MG05 ML
2 PA ST LA
ENBREL SUBCUTANEOUS SYRINGE 25 MG05 ML (05) 50 MGML (1 ML)
2 PA ST LA
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MGML (1 ML)
2 PA ST LA
HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG08 ML
2 PA ST LA
HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG08 ML 80 MG08 ML-40 MG04 ML
2 PA ST LA
HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
2 PA ST LA
HUMIRA(CF) PEN PEDIATRIC UC SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
2 PA ST LA
HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML-40 MG04 ML
2 PA ST LA
HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG04 ML
2 PA ST LA
97
Drug Name Drug Tier Requirements Limits
HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG01 ML 20 MG02 ML 40 MG04 ML
2 PA ST LA
KEVZARA SUBCUTANEOUS PEN INJECTOR 150 MG114 ML 200 MG114 ML
2 PA ST LA
KEVZARA SUBCUTANEOUS SYRINGE 150 MG114 ML 200 MG114 ML
2 PA ST LA
leflunomide oral tablet 10 mg 20 mg 1
OLUMIANT ORAL TABLET 1 MG 2 MG 2 PA ST LA
ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG
MB PA LA
ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MGML
2 PA ST LA
ORENCIA SUBCUTANEOUS SYRINGE 125 MGML 50 MG04 ML 875 MG07 ML
2 PA ST LA
OTEZLA ORAL TABLET 30 MG 2 PA ST LA
OTEZLA STARTER ORAL TABLETSDOSE PACK 10 MG (4)-20 MG (4)-30 MG (47)
2 PA ST LA
penicillamine oral capsule 250 mg 1 PA
penicillamine oral tablet 250 mg 1 PA
RIDAURA ORAL CAPSULE 3 MG 1
RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 MG
2 PA ST LA
SAVELLA ORAL TABLET 100 MG 125 MG 25 MG 50 MG
1 PA ST
SAVELLA ORAL TABLETSDOSE PACK 125 MG (5)-25 MG(8)-50 MG(42)
1 PA ST
SIMPONI ARIA INTRAVENOUS SOLUTION 125 MGML
MB PA LA
SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MGML 50 MG05 ML
2 PA ST LA
SIMPONI SUBCUTANEOUS SYRINGE 100 MGML 50 MG05 ML
2 PA ST LA
XELJANZ ORAL SOLUTION 1 MGML 2 PA ST LA
XELJANZ ORAL TABLET 10 MG 5 MG 2 PA ST LA
XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG 22 MG
2 PA ST LA
OBSTETRICS amp GYNECOLOGY
DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES
98
Drug Name Drug Tier Requirements Limits
CAYA CONTOURED VAGINAL DIAPHRAGM 65-80 MM
ACA PV
FC2 FEMALE CONDOM ACA PV
FEMCAP VAGINAL DEVICE 22 MM ACA PV
KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 175 MCG24 HRS (5 YRS) 195 MG
ACA PV
LILETTA INTRAUTERINE INTRAUTERINE DEVICE 201 MCG24 HRS (6 YRS) 52 MG
ACA PV ST
MIRENA INTRAUTERINE INTRAUTERINE DEVICE 20 MCG24 HOURS (6 YRS) 52 MG
ACA PV
PARAGARD T 380A INTRAUTERINE INTRAUTERINE DEVICE 380 SQUARE MM
ACA PV
SKYLA INTRAUTERINE INTRAUTERINE DEVICE 14 MCG24 HRS (3 YRS) 135 MG
ACA PV
WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 MM
ACA PV
ESTROGENS amp PROGESTINS
amabelz oral tablet 05-01 mg 1-05 mg 1
ANGELIQ ORAL TABLET 025-05 MG 05-1 MG
1
camila oral tablet 035 mg ACA PV
COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 005-014 MG24 HR 005-025 MG24 HR
1
covaryx hs oral tablet 0625-125 mg 1
covaryx oral tablet 125-25 mg 1
CRINONE VAGINAL GEL 4 1
deblitane oral tablet 035 mg ACA PV
DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MGML
1
DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MGML
MB
DEPO-PROVERA INTRAMUSCULAR SYRINGE 150 MGML
MB
DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE 104 MG065 ML
ACA PV
99
Drug Name Drug Tier Requirements Limits
DIVIGEL TRANSDERMAL GEL IN PACKET 025 MG025 GRAM (01 ) 05 MG05 GRAM (01 ) 075 MG075 GRAM (01) 1 MGGRAM (01 ) 125 MG125 GRAM (01 )
1 QL (30 per 30 days)
dotti transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
DUAVEE ORAL TABLET 045-20 MG 1
eemt hs oral tablet 0625-125 mg 1
eemt oral tablet 125-25 mg 1
errin oral tablet 035 mg ACA PV
estradiol oral tablet 05 mg 1 mg 2 mg 1
estradiol transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
estradiol transdermal patch weekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 006 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (4 per 30 days)
estradiol vaginal cream 001 (01 mggram) 1
estradiol vaginal tablet 10 mcg 1
estradiol valerate intramuscular oil 20 mgml 40 mgml
1
estradiol-norethindrone acet oral tablet 05-01 mg 1-05 mg
1
ESTRING VAGINAL RING 2 MG (75 MCG 24 HOUR)
1
estrogens-methyltestosterone oral tablet 0625-125 mg 125-25 mg
1
EVAMIST TRANSDERMAL SPRAYNON-AEROSOL 153 MGSPRAY (17)
1 QL (2 per 30 days)
FEMRING VAGINAL RING 005 MG24 HR 01 MG24 HR
1
fyavolv oral tablet 05-25 mg-mcg 1-5 mg-mcg 1
heather oral tablet 035 mg ACA PV
hydroxyprogest(pf)(preg presv) intramuscular oil 250 mgml (1 ml)
2
hydroxyprogesterone cap(ppres) intramuscular oil 250 mgml
2
100
Drug Name Drug Tier Requirements Limits
hydroxyprogesterone caproate intramuscular oil 250 mgml
2
incassia oral tablet 035 mg ACA PV
jencycla oral tablet 035 mg ACA PV
jinteli oral tablet 1-5 mg-mcg 1
lyleq oral tablet 035 mg ACA PV
lyllana transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
lyza oral tablet 035 mg ACA PV
medroxyprogesterone intramuscular suspension 150 mgml
ACA PV
medroxyprogesterone intramuscular syringe 150 mgml
ACA PV
medroxyprogesterone oral tablet 10 mg 25 mg 5 mg
1
MENEST ORAL TABLET 03 MG 0625 MG 125 MG 25 MG
1
MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG24 HR
1 QL (4 per 30 days)
mimvey oral tablet 1-05 mg 1
nora-be oral tablet 035 mg ACA PV
norethindrone (contraceptive) oral tablet 035 mg ACA PV
norethindrone acetate oral tablet 5 mg 1
norethindrone ac-eth estradiol oral tablet 05-25 mg-mcg 1-5 mg-mcg
1
norlyda oral tablet 035 mg ACA PV
PREMARIN INJECTION RECON SOLN 25 MG 1
PREMARIN ORAL TABLET 03 MG 045 MG 0625 MG 09 MG 125 MG
1
PREMARIN VAGINAL CREAM 0625 MGGRAM
1
PREMPHASE ORAL TABLET 0625 MG (14) 0625MG-5MG(14)
1
PREMPRO ORAL TABLET 03-15 MG 045-15 MG 0625-25 MG 0625-5 MG
1
progesterone intramuscular oil 50 mgml 1
progesterone micronized oral capsule 100 mg 200 mg
1
101
Drug Name Drug Tier Requirements Limits
sharobel oral tablet 035 mg ACA PV
tulana oral tablet 035 mg ACA PV
yuvafem vaginal tablet 10 mcg 1
MISCELLANEOUS OBGYN
ANNOVERA VAGINAL RING 015-0013 MG24 HOUR
ACA PV
clindamycin phosphate vaginal cream 2 1
eluryng vaginal ring 012-0015 mg24 hr ACA PV
etonogestrel-ethinyl estradiol vaginal ring 012-0015 mg24 hr
ACA PV
fem ph vaginal gel 09-0025 1
GYNAZOLE-1 VAGINAL CREAM 2 1
gynol ii vaginal gel 3 ACA PV
INTRAROSA VAGINAL INSERT 65 MG 1
isoxsuprine oral tablet 10 mg 20 mg 1
LUPANETA PACK (1 MONTH) KIT SYRINGE AND TABLET 375 MG -5 MG (30)
2 LA
LUPANETA PACK (3 MONTH) KIT SYRINGE AND TABLET 1125 MG -5 MG (90)
2 LA
metronidazole vaginal gel 075 1
NEXPLANON SUBDERMAL IMPLANT 68 MG ACA PV
OSPHENA ORAL TABLET 60 MG 1
PHEXXI VAGINAL GEL 18-1-04 ACA PV
terconazole vaginal cream 04 08 1
terconazole vaginal suppository 80 mg 1
TODAY CONTRACEPTIVE SPONGE VAGINAL CONTRACEPTIVE SPONGE 1000 MG
ACA PV
tranexamic acid oral tablet 650 mg 1
TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 MCG24 HR
ACA PV
vaginal contraceptive foam vaginal foam 125 ACA PV
vandazole vaginal gel 075 1
VCF CONTRACEPTIVE FILM VAGINAL FILM 28
ACA PV
VCF CONTRACEPTIVE GEL VAGINAL GEL 4
ACA PV
102
Drug Name Drug Tier Requirements Limits
xulane transdermal patch weekly 150-35 mcg24 hr
ACA PV
zafemy transdermal patch weekly 150-35 mcg24 hr
ACA PV
ORAL CONTRACEPTIVES amp RELATED AGENTS
afirmelle oral tablet 01-20 mg-mcg ACA PV
altavera (28) oral tablet 015-003 mg ACA PV
alyacen 135 (28) oral tablet 1-35 mg-mcg ACA PV
alyacen 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
amethia oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
amethyst (28) oral tablet 90-20 mcg (28) ACA PV
apri oral tablet 015-003 mg ACA PV
aranelle (28) oral tablet 05105-35 mg-mcg ACA PV
ashlyna oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
aubra eq oral tablet 01-20 mg-mcg ACA PV
aubra oral tablet 01-20 mg-mcg ACA PV
aurovela 1530 (21) oral tablet 15-30 mg-mcg ACA PV
aurovela 120 (21) oral tablet 1-20 mg-mcg ACA PV
aurovela 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
aurovela fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
aurovela fe 1-20 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
aviane oral tablet 01-20 mg-mcg ACA PV
ayuna oral tablet 015-003 mg ACA PV
azurette (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
BALCOLTRA ORAL TABLET 01 MG-002 MG (21)365 MG(7)
ACA PV
balziva (28) oral tablet 04-35 mg-mcg ACA PV
blisovi 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
blisovi fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
103
Drug Name Drug Tier Requirements Limits
blisovi fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
briellyn oral tablet 04-35 mg-mcg ACA PV
camrese lo oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)
ACA PV
camrese oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
caziant (28) oral tablet 0112515-25 mg-mcg ACA PV
charlotte 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
chateal (28) oral tablet 015-003 mg ACA PV
chateal eq (28) oral tablet 015-003 mg ACA PV
cryselle (28) oral tablet 03-30 mg-mcg ACA PV
cyclafem 135 (28) oral tablet 1-35 mg-mcg ACA PV
cyclafem 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
cyred eq oral tablet 015-003 mg ACA PV
cyred oral tablet 015-003 mg ACA PV
dasetta 135 (28) oral tablet 1-35 mg-mcg ACA PV
dasetta 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
daysee oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
desog-eestradioleestradiol oral tablet 015-002 mgx21 001 mg x 5
ACA PV
desogestrel-ethinyl estradiol oral tablet 015-003 mg
ACA PV
dolishale oral tablet 90-20 mcg (28) ACA PV
drospirenone-eestradiol-lmfa oral tablet 3-002-0451 mg (24) (4) 3-003-0451 mg (21) (7)
ACA PV
drospirenone-ethinyl estradiol oral tablet 3-002 mg 3-003 mg
ACA PV
econtra ez oral tablet 15 mg ACA PV
econtra one-step oral tablet 15 mg ACA PV
elinest oral tablet 03-30 mg-mcg ACA PV
ELLA ORAL TABLET 30 MG ACA PV
emoquette oral tablet 015-003 mg ACA PV
104
Drug Name Drug Tier Requirements Limits
enpresse oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
enskyce oral tablet 015-003 mg ACA PV
estarylla oral tablet 025-35 mg-mcg ACA PV
ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg 1-50 mg-mcg
ACA PV
falmina (28) oral tablet 01-20 mg-mcg ACA PV
fayosim oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg
ACA PV
femynor oral tablet 025-35 mg-mcg ACA PV
gemmily oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV
hailey 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
hailey fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
hailey fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
hailey oral tablet 15-30 mg-mcg ACA PV
iclevia oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
isibloom oral tablet 015-003 mg ACA PV
jaimiess oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
jasmiel (28) oral tablet 3-002 mg ACA PV
jolessa oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
juleber oral tablet 015-003 mg ACA PV
junel 1530 (21) oral tablet 15-30 mg-mcg ACA PV
junel 120 (21) oral tablet 1-20 mg-mcg ACA PV
junel fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
junel fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
junel fe 24 oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV
kaitlib fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)
ACA PV
kalliga oral tablet 015-003 mg ACA PV
kariva (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
105
Drug Name Drug Tier Requirements Limits
kelnor 135 (28) oral tablet 1-35 mg-mcg ACA PV
kelnor 1-50 (28) oral tablet 1-50 mg-mcg ACA PV
kurvelo (28) oral tablet 015-003 mg ACA PV
l norgesteestradiol-eestrad oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7) 015 mg-20 mcg 015 mg-25 mcg 015 mg-30 mcg (84)10 mcg (7)
ACA PV
larin 1530 (21) oral tablet 15-30 mg-mcg ACA PV
larin 120 (21) oral tablet 1-20 mg-mcg ACA PV
larin 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV
larin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
larin fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
larissia oral tablet 01-20 mg-mcg ACA PV
layolis fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)
ACA PV
leena 28 oral tablet 05105-35 mg-mcg ACA PV
lessina oral tablet 01-20 mg-mcg ACA PV
levonest (28) oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
levonorgestrel oral tablet 15 mg ACA PV
levonorgestrel-ethinyl estrad oral tablet 01-20 mg-mcg 015-003 mg 90-20 mcg (28)
ACA PV
levonorgestrel-ethinyl estrad oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
levonorg-eth estrad triphasic oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
levora-28 oral tablet 015-003 mg ACA PV
lillow (28) oral tablet 015-003 mg ACA PV
LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG (24)10 MCG (2)
ACA PV
lojaimiess oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)
ACA PV
loryna (28) oral tablet 3-002 mg ACA PV
low-ogestrel (28) oral tablet 03-30 mg-mcg ACA PV
lo-zumandimine (28) oral tablet 3-002 mg ACA PV
lutera (28) oral tablet 01-20 mg-mcg ACA PV
106
Drug Name Drug Tier Requirements Limits
marlissa (28) oral tablet 015-003 mg ACA PV
merzee oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV
mibelas 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
microgestin 1530 (21) oral tablet 15-30 mg-mcg ACA PV
microgestin 120 (21) oral tablet 1-20 mg-mcg ACA PV
microgestin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
microgestin fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
mili oral tablet 025-35 mg-mcg ACA PV
mono-linyah oral tablet 025-35 mg-mcg ACA PV
my choice oral tablet 15 mg ACA PV
my way oral tablet 15 mg ACA PV
NATAZIA ORAL TABLET 3 MG2 MG-2 MG 2 MG-3 MG1 MG
ACA PV
necon 0535 (28) oral tablet 05-35 mg-mcg ACA PV
new day oral tablet 15 mg ACA PV
NEXTSTELLIS ORAL TABLET 3 MG- 142 MG (28)
ACA PV
nikki (28) oral tablet 3-002 mg ACA PV
noreth-ethinyl estradiol-iron oral tabletchewable 04mg-35mcg(21) and 75 mg (7) 08mg-25mcg(24) and 75 mg (4)
ACA PV
norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg 15-30 mg-mcg
ACA PV
norethindrone-eestradiol-iron oral capsule 1 mg-20 mcg (24)75 mg (4)
ACA PV
norethindrone-eestradiol-iron oral tablet 1 mg-20 mcg (21)75 mg (7) 15 mg-30 mcg (21)75 mg (7)
ACA PV
norethindrone-eestradiol-iron oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
norgestimate-ethinyl estradiol oral tablet 0180215025 mg-25 mcg 0180215025 mg-35 mcg (28) 025-35 mg-mcg
ACA PV
nortrel 0535 (28) oral tablet 05-35 mg-mcg ACA PV
nortrel 135 (21) oral tablet 1-35 mg-mcg (21) ACA PV
nortrel 135 (28) oral tablet 1-35 mg-mcg ACA PV
107
Drug Name Drug Tier Requirements Limits
nortrel 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
nylia 777 (28) oral tablet 050751 mg- 35 mcg ACA PV
nymyo oral tablet 025-35 mg-mcg ACA PV
ocella oral tablet 3-003 mg ACA PV
opcicon one-step oral tablet 15 mg ACA PV
option-2 oral tablet 15 mg ACA PV
orsythia oral tablet 01-20 mg-mcg ACA PV
philith oral tablet 04-35 mg-mcg ACA PV
pimtrea (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
pirmella oral tablet 050751 mg- 35 mcg 1-35 mg-mcg
ACA PV
portia 28 oral tablet 015-003 mg ACA PV
previfem oral tablet 025-35 mg-mcg ACA PV
reclipsen (28) oral tablet 015-003 mg ACA PV
rivelsa oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg
ACA PV
setlakin oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
simliya (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
simpesse oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
SLYND ORAL TABLET 4 MG (28) ACA PV
sprintec (28) oral tablet 025-35 mg-mcg ACA PV
sronyx oral tablet 01-20 mg-mcg ACA PV
syeda oral tablet 3-003 mg ACA PV
tarina 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
tarina fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
tilia fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9) ACA PV
tri femynor oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-estarylla oral tablet 0180215025 mg-35 mcg (28)
ACA PV
108
Drug Name Drug Tier Requirements Limits
tri-legest fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9)
ACA PV
tri-linyah oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-lo-estarylla oral tablet 0180215025 mg-25 mcg
ACA PV
tri-lo-marzia oral tablet 0180215025 mg-25 mcg
ACA PV
tri-lo-mili oral tablet 0180215025 mg-25 mcg ACA PV
tri-lo-sprintec oral tablet 0180215025 mg-25 mcg
ACA PV
tri-mili oral tablet 0180215025 mg-35 mcg (28) ACA PV
tri-nymyo oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-previfem (28) oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-sprintec (28) oral tablet 0180215025 mg-35 mcg (28)
ACA PV
trivora (28) oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
tri-vylibra lo oral tablet 0180215025 mg-25 mcg
ACA PV
tri-vylibra oral tablet 0180215025 mg-35 mcg (28)
ACA PV
TYBLUME ORAL TABLETCHEWABLE 01 MG- 20 MCG
ACA PV
tydemy oral tablet 3-003-0451 mg (21) (7) ACA PV
velivet triphasic regimen (28) oral tablet 0112515-25 mg-mcg
ACA PV
vestura (28) oral tablet 3-002 mg ACA PV
vienva oral tablet 01-20 mg-mcg ACA PV
viorele (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
volnea (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
vyfemla (28) oral tablet 04-35 mg-mcg ACA PV
vylibra oral tablet 025-35 mg-mcg ACA PV
wera (28) oral tablet 05-35 mg-mcg ACA PV
wymzya fe oral tabletchewable 04mg-35mcg(21) and 75 mg (7)
ACA PV
109
Drug Name Drug Tier Requirements Limits
zarah oral tablet 3-003 mg ACA PV
zovia 135e (28) oral tablet 1-35 mg-mcg ACA PV
zumandimine (28) oral tablet 3-003 mg ACA PV
OXYTOCICS
methergine oral tablet 02 mg 1
methylergonovine oral tablet 02 mg 1
OPHTHALMOLOGY
ANTIBIOTICS
ak-poly-bac ophthalmic (eye) ointment 500-10000 unitgram
1
AZASITE OPHTHALMIC (EYE) DROPS 1 1
bacitracin ophthalmic (eye) ointment 500 unitgram
1
bacitracin-polymyxin b ophthalmic (eye) ointment 500-10000 unitgram
1
BESIVANCE OPHTHALMIC (EYE) DROPSSUSPENSION 06
1
ciprofloxacin hcl ophthalmic (eye) drops 03 1
erythromycin ophthalmic (eye) ointment 5 mggram (05 )
1
gatifloxacin ophthalmic (eye) drops 05 1
gentak ophthalmic (eye) ointment 03 (3 mggram)
1
gentamicin ophthalmic (eye) drops 03 1
levofloxacin ophthalmic (eye) drops 05 1
moxifloxacin ophthalmic (eye) drops 05 1
moxifloxacin ophthalmic (eye) drops viscous 05
1
NATACYN OPHTHALMIC (EYE) DROPSSUSPENSION 5
1
neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
1
neomycin-polymyxin-gramicidin ophthalmic (eye) drops 175 mg-10000 unit-0025mgml
1
neo-polycin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
1
ofloxacin ophthalmic (eye) drops 03 1
110
Drug Name Drug Tier Requirements Limits
polycin ophthalmic (eye) ointment 500-10000 unitgram
1
polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10000 unit- 1 mgml
1
tobramycin ophthalmic (eye) drops 03 1
TOBREX OPHTHALMIC (EYE) OINTMENT 03
1
ANTIVIRALS
trifluridine ophthalmic (eye) drops 1 1
ZIRGAN OPHTHALMIC (EYE) GEL 015 1
BETA-BLOCKERS
betaxolol ophthalmic (eye) drops 05 1
BETIMOL OPHTHALMIC (EYE) DROPS 025 05
1
BETOPTIC S OPHTHALMIC (EYE) DROPSSUSPENSION 025
1
carteolol ophthalmic (eye) drops 1 1
levobunolol ophthalmic (eye) drops 05 1
timolol maleate ophthalmic (eye) drops 025 05
1
timolol maleate ophthalmic (eye) drops once daily 05
1
timolol maleate ophthalmic (eye) gel forming solution 025 05
1
CYCLOPLEGIC MYDRIATICS
atropine ophthalmic (eye) drops 1 1
atropine ophthalmic (eye) ointment 1 1
cyclopentolate ophthalmic (eye) drops 05 1 2
1
homatropaire ophthalmic (eye) drops 5 1
tropicamide ophthalmic (eye) drops 05 1 1
DIRECT ACTING MIOTICS
pilocarpine hcl ophthalmic (eye) drops 1 2 4
1
MISCELLANEOUS OPHTHALMOLOGICS
ALOCRIL OPHTHALMIC (EYE) DROPS 2 1 ST
ALOMIDE OPHTHALMIC (EYE) DROPS 01 1 ST
111
Drug Name Drug Tier Requirements Limits
altacaine ophthalmic (eye) drops 05 1
azelastine ophthalmic (eye) drops 005 1
BEOVU INTRAVITREAL SOLUTION 6 MG005 ML
MB PA LA
bepotastine besilate ophthalmic (eye) drops 15 1 ST
BEPREVE OPHTHALMIC (EYE) DROPS 15 1 ST
cromolyn ophthalmic (eye) drops 4 1
CYSTARAN OPHTHALMIC (EYE) DROPS 044
2 PA
epinastine ophthalmic (eye) drops 005 1
EYLEA INTRAVITREAL SOLUTION 2 MG005 ML
MB PA LA
EYLEA INTRAVITREAL SYRINGE 2 MG005 ML
MB PA LA
LACRISERT OPHTHALMIC (EYE) INSERT 5 MG
1
LASTACAFT OPHTHALMIC (EYE) DROPS 025
1 ST
LUCENTIS INTRAVITREAL SOLUTION 03 MG005 ML 05 MG005 ML
MB PA LA
LUCENTIS INTRAVITREAL SYRINGE 03 MG005 ML 05 MG005 ML
MB PA LA
LUXTURNA SUBRETINAL SUSPENSION 15 X 10EXP11 VG03 ML (FNL)
MB LA
olopatadine ophthalmic (eye) drops 01 02 1
OMIDRIA INTRAOCULAR CONCENTRATE 1-03
MB
proparacaine ophthalmic (eye) drops 05 1
RESTASIS OPHTHALMIC (EYE) DROPPERETTE 005
1 QL (120 per 30 days)
TETRACAINE HCL (PF) OPHTHALMIC (EYE) DROPS 05
1
tetracaine hcl ophthalmic (eye) drops 05 1
VISUDYNE INTRAVENOUS RECON SOLN 15 MG
MB LA
XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5
1 PA ST QL (60 per 30 days)
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
112
Drug Name Drug Tier Requirements Limits
ACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE 045
1 ST
bromfenac ophthalmic (eye) drops 009 1
diclofenac sodium ophthalmic (eye) drops 01 1
flurbiprofen sodium ophthalmic (eye) drops 003
1
ketorolac ophthalmic (eye) drops 04 05 1
NEVANAC OPHTHALMIC (EYE) DROPSSUSPENSION 01
1
ORAL DRUGS FOR GLAUCOMA
acetazolamide oral capsule extended release 500 mg
1
acetazolamide oral tablet 125 mg 250 mg 1
methazolamide oral tablet 25 mg 50 mg 1
OTHER GLAUCOMA DRUGS
bimatoprost ophthalmic (eye) drops 003 1
brinzolamide ophthalmic (eye) dropssuspension 1
1
COMBIGAN OPHTHALMIC (EYE) DROPS 02-05
1
dorzolamide ophthalmic (eye) drops 2 1
dorzolamide-timolol (pf) ophthalmic (eye) dropperette 2-05
1
dorzolamide-timolol ophthalmic (eye) drops 223-68 mgml
1
latanoprost ophthalmic (eye) drops 0005 1
LUMIGAN OPHTHALMIC (EYE) DROPS 001
1 ST
RHOPRESSA OPHTHALMIC (EYE) DROPS 002
1 PA ST
SIMBRINZA OPHTHALMIC (EYE) DROPSSUSPENSION 1-02
1
travoprost ophthalmic (eye) drops 0004 1
STEROID-ANTIBIOTIC COMBINATIONS
neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
1
neomycin-polymyxin b-dexameth ophthalmic (eye) dropssuspension 35mgml-10000 unitml-01
1
113
Drug Name Drug Tier Requirements Limits
neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 35 mgg-10000 unitg-01
1
neomycin-polymyxin-hc ophthalmic (eye) dropssuspension 35-10000-10 mg-unit-mgml
1
neo-polycin hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
1
TOBRADEX OPHTHALMIC (EYE) OINTMENT 03-01
1
TOBRADEX ST OPHTHALMIC (EYE) DROPSSUSPENSION 03-005
1
tobramycin-dexamethasone ophthalmic (eye) dropssuspension 03-01
1
STEROIDS
ALREX OPHTHALMIC (EYE) DROPSSUSPENSION 02
1 ST
dexamethasone sodium phosphate ophthalmic (eye) drops 01
1
DUREZOL OPHTHALMIC (EYE) DROPS 005
1
fluorometholone ophthalmic (eye) dropssuspension 01
1
FML FORTE OPHTHALMIC (EYE) DROPSSUSPENSION 025
1
FML SOP OPHTHALMIC (EYE) OINTMENT 01
1
INVELTYS OPHTHALMIC (EYE) DROPSSUSPENSION 1
1 ST
LOTEMAX OPHTHALMIC (EYE) OINTMENT 05
1 ST
loteprednol etabonate ophthalmic (eye) dropsgel 05
1
loteprednol etabonate ophthalmic (eye) dropssuspension 05
1
MAXIDEX OPHTHALMIC (EYE) DROPSSUSPENSION 01
1
OZURDEX INTRAVITREAL IMPLANT 07 MG MB LA
PRED MILD OPHTHALMIC (EYE) DROPSSUSPENSION 012
1
prednisolone acetate ophthalmic (eye) dropssuspension 1
1
114
Drug Name Drug Tier Requirements Limits
prednisolone sodium phosphate ophthalmic (eye) drops 1
1
RETISERT INTRAVITREAL IMPLANT 059 MG
MB LA
YUTIQ INTRAVITREAL IMPLANT 018 MG MB
STEROID-SULFONAMIDE COMBINATIONS
BLEPHAMIDE OPHTHALMIC (EYE) DROPSSUSPENSION 10-02
1
BLEPHAMIDE SOP OPHTHALMIC (EYE) OINTMENT 10-02
1
sulfacetamide-prednisolone ophthalmic (eye) drops 10 -023 (025 )
1
SULFONAMIDES
sulfacetamide sodium ophthalmic (eye) drops 10
1
sulfacetamide sodium ophthalmic (eye) ointment 10
1
SYMPATHOMIMETICS
apraclonidine ophthalmic (eye) drops 05 1
brimonidine ophthalmic (eye) drops 015 02 1
IOPIDINE OPHTHALMIC (EYE) DROPPERETTE 1
1
VASOCONSTRICTOR DECONGESTANTS
phenylephrine hcl ophthalmic (eye) drops 10 25
1
RESPIRATORY ALLERGY COUGH amp COLD
ANTIHISTAMINE amp ANTIALLERGENIC AGENTS
adrenalin injection solution 1 mgml 1 mgml (1 ml)
1
carbinoxamine maleate oral liquid 4 mg5 ml 1 PA ST QL (2 per 30 days)
carbinoxamine maleate oral tablet 4 mg 1 PA ST QL (240 per 30 days)
carbinoxamine maleate oral tablet 6 mg 1 PA ST QL (120 per 30 days)
cetirizine oral solution 1 mgml 1
clemastine oral syrup 05 mg5 ml 1
clemastine oral tablet 268 mg 1
cyproheptadine oral syrup 2 mg5 ml 1
cyproheptadine oral tablet 4 mg 1
115
Drug Name Drug Tier Requirements Limits
desloratadine oral tablet 5 mg 1 PA ST QL (30 per 30 days)
desloratadine oral tabletdisintegrating 25 mg 5 mg
1 PA ST
diphenhydramine hcl injection solution 50 mgml 1
diphenhydramine hcl injection syringe 50 mgml MB
EPINEPHRINE INJECTION AUTO-INJECTOR 015 MG015 ML
1
epinephrine injection auto-injector 015 mg03 ml 03 mg03 ml
1
epinephrine injection solution 1 mgml 1 mgml (1 ml)
1
epinephrine injection syringe 01 mgml 1
hydroxyzine hcl intramuscular solution 25 mgml MB
hydroxyzine hcl oral solution 10 mg5 ml 1
hydroxyzine hcl oral tablet 10 mg 25 mg 50 mg 1
hydroxyzine pamoate oral capsule 100 mg 25 mg 50 mg
1
levocetirizine oral solution 25 mg5 ml 1
levocetirizine oral tablet 5 mg 1
promethazine injection solution 25 mgml MB
promethazine oral syrup 625 mg5 ml 1
promethazine oral tablet 125 mg 25 mg 50 mg 1
promethazine rectal suppository 125 mg 25 mg 1
promethegan rectal suppository 125 mg 25 mg 50 mg
1
COUGH amp COLD THERAPY
benzonatate oral capsule 100 mg 150 mg 200 mg 1
brompheniramine-pseudoeph-dm oral syrup 2-30-10 mg5 ml
1
codeine-guaifenesin oral liquid 10-100 mg5 ml 1
g tussin ac oral liquid 10-100 mg5 ml 1
guaiatussin ac oral liquid 10-100 mg5 ml 1
hydrocodone-chlorpheniramine oral suspensionextended rel 12 hr 10-8 mg5 ml
1
hydrocodone-homatropine oral syrup 5-15 mg5 ml
1
hydrocodone-homatropine oral tablet 5-15 mg 1
116
Drug Name Drug Tier Requirements Limits
hydromet oral syrup 5-15 mg5 ml 1
maxi-tuss ac oral liquid 10-100 mg5 ml 1
m-clear wc oral liquid 63-100 mg5 ml 1
promethazine-codeine oral syrup 625-10 mg5 ml 1
promethazine-dm oral syrup 625-15 mg5 ml 1
promethazine-phenyleph-codeine oral syrup 625-5-10 mg5 ml
1
promethazine-phenylephrine oral syrup 625-5 mg5 ml
1
virtussin ac oral liquid 10-100 mg5 ml 1
PULMONARY AGENTS
acetylcysteine solution 100 mgml (10 ) 200 mgml (20 )
1
ADEMPAS ORAL TABLET 05 MG 1 MG 15 MG 2 MG 25 MG
2 PA LA
ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCGACTUATION 230-21 MCGACTUATION 45-21 MCGACTUATION
1 QL (1 per 30 days)
ALBUTEROL HFA 90 MCG INHALER 90 MCGACTUATION
1 QL (2 per 30 days)
albuterol sulfate inhalation inhalation hfa aerosol inhaler 90 mcgactuation
1 QL (2 per 30 days)
albuterol sulfate inhalation inhalation solution for nebulization 063 mg3 ml 125 mg3 ml 25 mg 3 ml (0083 ) 25 mg05 ml 5 mgml
1
albuterol sulfate inhalation oral syrup 2 mg5 ml 1
albuterol sulfate inhalation oral tablet 2 mg 4 mg 1
albuterol sulfate inhalation oral tablet extended release 12 hr 4 mg 8 mg
1
ALVESCO INHALATION HFA AEROSOL INHALER 160 MCGACTUATION 80 MCGACTUATION
1 PA ST QL (1 per 30 days)
alyq oral tablet 20 mg 2 PA
ambrisentan oral tablet 10 mg 5 mg 2 PA LA
aminophylline intravenous solution 250 mg10 ml MB
ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 625-25 MCGACTUATION
1 QL (1 per 30 days)
arformoterol inhalation solution for nebulization 15 mcg2 ml
1
117
Drug Name Drug Tier Requirements Limits
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 200 MCGACTUATION
1 QL (1 per 30 days)
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 50 MCGACTUATION
1
ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCGACTUATION
1 QL (2 per 30 days)
BERINERT INTRAVENOUS KIT 500 UNIT (10 ML)
MB PA LA
BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-48 MCG
1
bosentan oral tablet 125 mg 625 mg 2 PA LA
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCGDOSE
1 QL (1 per 30 days)
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 200-25 MCGDOSE
1
BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG2 ML
1
budesonide inhalation suspension for nebulization 025 mg2 ml 05 mg2 ml
1 QL (120 per 30 days)
budesonide inhalation suspension for nebulization 1 mg2 ml
1 QL (60 per 30 days)
CINQAIR INTRAVENOUS SOLUTION 10 MGML
MB PA
CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)
MB PA LA
COMBIVENT RESPIMAT INHALATION MIST 20-100 MCGACTUATION
1 QL (2 per 30 days)
cromolyn inhalation solution for nebulization 20 mg2 ml
1
DALIRESP ORAL TABLET 250 MCG 500 MCG
1
DULERA INHALATION HFA AEROSOL INHALER 100-5 MCGACTUATION 200-5 MCGACTUATION 50-5 MCGACTUATION
1 QL (1 per 30 days)
ELIXOPHYLLIN ORAL ELIXIR 80 MG15 ML 1
ESBRIET ORAL CAPSULE 267 MG 2 PA LA QL (270 per 30 days)
ESBRIET ORAL TABLET 267 MG 801 MG 2 PA LA QL (90 per 30 days)
FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MGML
MB PA LA
118
Drug Name Drug Tier Requirements Limits
FASENRA SUBCUTANEOUS SYRINGE 30 MGML
MB PA LA
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 50 MCGACTUATION
1 QL (1 per 30 days)
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCGACTUATION
1 QL (4 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCGACTUATION 44 MCGACTUATION
1 QL (1 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCGACTUATION
1 QL (2 per 30 days)
fluticasone propionate nasal spraysuspension 50 mcgactuation
1
fluticasone propion-salmeterol inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose
1 QL (1 per 30 days)
formoterol fumarate inhalation solution for nebulization 20 mcg2 ml
1
HAEGARDA SUBCUTANEOUS RECON SOLN 2000 UNIT 3000 UNIT
2 PA LA
icatibant subcutaneous syringe 30 mg3 ml 2 PA
INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 625 MCGACTUATION
1 QL (1 per 30 days)
ipratropium bromide inhalation solution 002 1
ipratropium-albuterol inhalation solution for nebulization 05 mg-3 mg(25 mg base)3 ml
1 QL (180 per 30 days)
KALBITOR SUBCUTANEOUS SOLUTION 10 MGML (1 ML)
2 PA LA
KALYDECO ORAL GRANULES IN PACKET 25 MG 50 MG 75 MG
2 PA LA
KALYDECO ORAL TABLET 150 MG 2 PA LA
levalbuterol hcl inhalation solution for nebulization 031 mg3 ml 063 mg3 ml 125 mg05 ml 125 mg3 ml
1
LEVALBUTEROL TARTRATE INHALATION HFA AEROSOL INHALER 45 MCGACTUATION
1 QL (2 per 30 days)
metaproterenol oral syrup 10 mg5 ml 1
montelukast oral granules in packet 4 mg 1
montelukast oral tablet 10 mg 1
119
Drug Name Drug Tier Requirements Limits
montelukast oral tabletchewable 4 mg 5 mg 1
nebusal inhalation solution for nebulization 3 1
NUCALA SUBCUTANEOUS RECON SOLN 100 MG
MB PA LA
OFEV ORAL CAPSULE 100 MG 150 MG 2 PA LA QL (60 per 30 days)
OPSUMIT ORAL TABLET 10 MG 2 PA LA
ORLADEYO ORAL CAPSULE 110 MG 150 MG
2 PA ST QL (28 per 28 days)
PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG2 ML
1
pulmosal inhalation solution for nebulization 7 1
PULMOZYME INHALATION SOLUTION 1 MGML
2 PA LA
QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCGACTUATION 80 MCGACTUATION
1
REVATIO INTRAVENOUS SOLUTION 10 MG125 ML
MB LA
RUCONEST INTRAVENOUS RECON SOLN 2100 UNIT
MB PA LA
SEEBRI NEOHALER INHALATION CAPSULE WINHALATION DEVICE 156 MCG
1
SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCGDOSE
1
sildenafil (pulmhypertension) intravenous solution 10 mg125 ml
MB
sildenafil (pulmhypertension) oral suspension for reconstitution 10 mgml
2
sildenafil (pulmhypertension) oral tablet 20 mg 2 PA
SINUVA SINUS IMPLANT 1350 MCG MB
sodium chloride inhalation solution for nebulization 09 10 3 7
1
SPIRIVA RESPIMAT INHALATION MIST 125 MCGACTUATION
1
SPIRIVA RESPIMAT INHALATION MIST 25 MCGACTUATION
1 QL (1 per 30 days)
SPIRIVA WITH HANDIHALER INHALATION CAPSULE WINHALATION DEVICE 18 MCG
1 QL (30 per 30 days)
STIOLTO RESPIMAT INHALATION MIST 25-25 MCGACTUATION
1
120
Drug Name Drug Tier Requirements Limits
STRIVERDI RESPIMAT INHALATION MIST 25 MCGACTUATION
1
SYMBICORT INHALATION HFA AEROSOL INHALER 160-45 MCGACTUATION 80-45 MCGACTUATION
1 QL (1 per 30 days)
SYMDEKO ORAL TABLETS SEQUENTIAL 100-150 MG (D) 150 MG (N) 50-75 MG (D) 75 MG (N)
2 PA LA
tadalafil (pulm hypertension) oral tablet 20 mg 2 PA
TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG2 ML (150 MGML)
2 PA LA
terbutaline oral tablet 25 mg 5 mg 1
terbutaline subcutaneous solution 1 mgml 1
theophylline oral elixir 80 mg15 ml 1
theophylline oral solution 80 mg15 ml 1
theophylline oral tablet extended release 12 hr 300 mg 450 mg
1
theophylline oral tablet extended release 24 hr 400 mg 600 mg
1
TRACLEER ORAL TABLET FOR SUSPENSION 32 MG
2 PA LA
TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-625-25 MCG 200-625-25 MCG
1
TRIKAFTA ORAL TABLETS SEQUENTIAL 100-50-75 MG(D) 150 MG (N) 50-25-375 MG (D)75 MG (N)
2 PA LA
TYVASO INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)
2 PA LA
TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)
2 PA LA
TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML
2 PA LA
UTIBRON NEOHALER INHALATION CAPSULE WINHALATION DEVICE 275-156 MCG
1
VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCGML 20 MCGML
2 PA LA
121
Drug Name Drug Tier Requirements Limits
wixela inhub inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose
1 QL (1 per 30 days)
XOLAIR SUBCUTANEOUS RECON SOLN 150 MG
MB LA
XOLAIR SUBCUTANEOUS SYRINGE 150 MGML 75 MG05 ML
MB PA LA QL (7 per 30 days)
zafirlukast oral tablet 10 mg 20 mg 1
zileuton oral tablet er multiphase 12 hr 600 mg 1 ST
ZYFLO ORAL TABLET 600 MG 1 ST
UROLOGICALS
ANTICHOLINERGICS amp ANTISPASMODICS
darifenacin oral tablet extended release 24 hr 15 mg 75 mg
1
flavoxate oral tablet 100 mg 1
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG 50 MG
1 ST
oxybutynin chloride oral syrup 5 mg5 ml 1
oxybutynin chloride oral tablet 5 mg 1
oxybutynin chloride oral tablet extended release 24hr 10 mg 15 mg 5 mg
1
solifenacin oral tablet 10 mg 5 mg 1
tolterodine oral capsuleextended release 24hr 2 mg 4 mg
1
tolterodine oral tablet 1 mg 2 mg 1
trospium oral capsuleextended release 24hr 60 mg
1
trospium oral tablet 20 mg 1
BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY
alfuzosin oral tablet extended release 24 hr 10 mg 1
dutasteride oral capsule 05 mg 1
dutasteride-tamsulosin oral capsule er multiphase 24 hr 05-04 mg
1
finasteride oral tablet 5 mg 1
silodosin oral capsule 4 mg 8 mg 1
tadalafil oral tablet 25 mg 5 mg 1 PA ST
tamsulosin oral capsule 04 mg 1
CHOLINERGIC STIMULANTS
122
Drug Name Drug Tier Requirements Limits
bethanechol chloride oral tablet 10 mg 25 mg 5 mg 50 mg
1
MISCELLANEOUS UROLOGICALS
CYSTAGON ORAL CAPSULE 150 MG 50 MG 2 PA
ELMIRON ORAL CAPSULE 100 MG 1
hyophen oral tablet 816-012-108 mg 1
K-PHOS NO 2 ORAL TABLET 305-700 MG 1
K-PHOS ORIGINAL ORAL TABLETSOLUBLE 500 MG
1
methen-sod phos-meth blue-hyos oral tablet 816-408-012 mg
1
OXLUMO SUBCUTANEOUS SOLUTION 945 MG05 ML
2 PA
phosphasal oral tablet 816-108-408 mg 1
potassium citrate oral tablet extended release 10 meq (1080 mg) 15 meq 5 meq (540 mg)
1
RENACIDIN IRRIGATION SOLUTION 19806 MG-594 MG-9804MG30ML
1
URELLE ORAL TABLET 81-108-408 MG 1
uretron d-s oral tablet 816-108-408 mg 1
urimar-t oral tablet 120-012-108 mg 1
urogesic-blue oral tablet 816-408-012 mg 1
uryl oral tablet 816-408-012 mg 1
ustell oral capsule 120-012 mg 1
utira-c oral tablet 816-108-408 mg 1
URINARY ANESTHETICS
phenazopyridine oral tablet 100 mg 200 mg 1
VITAMINS HEMATINICS amp ELECTROLYTES
ELECTROLYTES
effer-k oral tablet effervescent 25 meq 1
klor-con 10 oral tablet extended release 10 meq 1
klor-con 8 oral tablet extended release 8 meq 1
klor-con m10 oral tableter particlescrystals 10 meq
1
klor-con m15 oral tableter particlescrystals 15 meq
1
123
Drug Name Drug Tier Requirements Limits
klor-con m20 oral tableter particlescrystals 20 meq
1
klor-con oral packet 20 meq 1
klor-conef oral tablet effervescent 25 meq 1
K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ
1
k-tab oral tablet extended release 8 meq 1
NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION
MB
potassium chloride oral capsule extended release 10 meq 8 meq
1
potassium chloride oral liquid 20 meq15 ml 40 meq15 ml
1
potassium chloride oral packet 20 meq 1
potassium chloride oral tablet extended release 10 meq 20 meq 8 meq
1
potassium chloride oral tableter particlescrystals 10 meq 20 meq
1
sodium chloride 045 intravenous parenteral solution 045
MB
MISCELLANEOUS VITAMINS HEMATINICS amp ELECTROLYTES
ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION
MB
PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION
MB
PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION
MB
VITAMINS amp HEMATINICS
cyanocobalamin (vitamin b-12) injection solution 1000 mcgml
1
ergocalciferol (vitamin d2) oral capsule 1250 mcg (50000 unit)
1
FA-8 ORAL CAPSULE 08 MG ACA PV
FER-IN-SOL ORAL DROPS 15 MG IRON (75 MG)ML
ACA PV
FLORIVA (FLUORIDE-VITAMIN D3) ORAL DROPS 025 MG (055 MG)-400 UNITML
ACA PV
fluoride (sodium) oral drops 05 mg (11 mg sodfluorid)ml
ACA PV
124
Drug Name Drug Tier Requirements Limits
fluoride (sodium) oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)
ACA PV
folic acid injection solution 5 mgml 1
folic acid oral tablet 1 mg 1
folic acid oral tablet 400 mcg 800 mcg ACA PV
hydroxocobalamin intramuscular solution 1000 mcgml
1
INFED INJECTION SOLUTION 50 MGML MB
ludent fluoride oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)
ACA PV
multi-vitamin with fluoride oral drops 025 mgml 05 mgml
ACA PV
multi-vitamin with fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
multivitamins with fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
mvc-fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
NOVAFERRUM ORAL DROPS 15 MG IRONML
ACA PV
tri-vitamin with fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml
ACA PV
vitamins acd and fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml
ACA PV
125
Index
A abacavir 2 abacavir-lamivudine 2 abacavir-lamivudine-
zidovudine 2 ABILIFY MAINTENA 36 abiraterone 13 ABRAXANE 13 acamprosate 66 acarbose 77 accutane 59 acebutolol 45 acetaminophen-caff-
dihydrocod 30 acetaminophen-codeine 31 acetazolamide 112 acetic acid 66 69 acetylcysteine 116 acitretin 57 ACTEMRA 95 ACTEMRA ACTPEN 95 ACTHAR 70 ACTHIB (PF) 90 ACTIMMUNE 89 ACUVAIL (PF) 112 acyclovir 2 63 ADACEL(TDAP
ADOLESNADULT)(PF) 90 ADAKVEO 13 adapalene 59 60 ADAPALENE 60 adapalene-benzoyl peroxide 60 ADCETRIS 14 adefovir 2 ADEMPAS 116 ADHANSIA XR 36 adrenalin 114 adult aspirin regimen 33 ADVAIR HFA 116 ADVATE 50 ADYNOVATE 50 ADZENYS ER 36 ADZENYS XR-ODT 36 AEROCHAMBER MINI 71 AEROCHAMBER PLUS
FLOW-VU 71 AFINITOR 14 afirmelle 102
AFSTYLA 50 AIMOVIG AUTOINJECTOR
28 AJOVY AUTOINJECTOR 28 AJOVY SYRINGE 28 ak-poly-bac 109 AKYNZEO (NETUPITANT)
81 ala-cort 63 albendazole 8 albuterol sulfate inhalation 116 ALBUTEROL SULFATE
INHALATION 116 alclometasone 63 ALCORTIN A 61 ALDURAZYME 74 ALECENSA 14 alendronate 95 alfuzosin 121 ALIMTA 14 ALINIA 8 ALIQOPA 14 aliskiren 45 allopurinol 95 almotriptan malate 28 ALOCRIL 110 ALOGLIPTIN-
PIOGLITAZONE 77 ALOMIDE 110 alosetron 81 ALOXI 81 ALPHANATE 50 ALPHANINE SD 50 alprazolam 37 alprazolam intensol 37 ALPROLIX 50 ALREX 113 ALTABAX 61 altacaine 111 altavera (28) 102 ALVESCO 116 alyacen 135 (28) 102 alyacen 777 (28) 102 alyq 116 amabelz 98 amantadine hcl 2 AMBISOME 1 ambrisentan 116
amcinonide 63 amethia 102 amethyst (28) 102 amikacin 8 amiloride 45 amiloride-hydrochlorothiazide
45 aminocaproic acid 50 51 aminophylline 116 amiodarone 44 AMITIZA 81 amitriptyline 37 amitriptyline-chlordiazepoxide
37 amlodipine 45 amlodipine-atorvastatin 55 amlodipine-benazepril 45 amlodipine-olmesartan 45 amlodipine-valsartan 45 amlodipine-valsartan-hcthiazid
45 ammonium lactate 59 amnesteem 60 amoxapine 37 amoxicil-clarithromy-lansopraz
85 amoxicillin 11 amoxicillin-pot clavulanate 11 AMPHETAMINE 37 amphetamine sulfate 37 amphotericin b 1 ampicillin 11 ampicillin-sulbactam 11 anagrelide 66 anaspaz 80 anastrozole 14 ANDEXXA 51 ANDRODERM 74 ANGELIQ 98 ANNOVERA 101 ANORO ELLIPTA 116 anucort-hc 81 apexicon e 63 APLENZIN 37 APOKYN 27 apraclonidine 114 aprepitant 81 apri 102
126
APTIVUS 2 ARALAST NP 66 aranelle (28) 102 ARANESP (IN
POLYSORBATE) 86 ARCALYST 89 ARESTIN 68 arformoterol 116 aripiprazole 37 ARISTADA 37 ARISTADA INITIO 37 armodafinil 37 ARMOUR THYROID 79 ARNUITY ELLIPTA 117 ARRANON 14 ARZERRA 14 ASCENIV 90 ascomp with codeine 31 asenapine maleate 37 ashlyna 102 ASPARLAS 14 aspirin 33 34 aspirin low dose 33 aspirin-dipyridamole 51 aspir-trin 34 atazanavir 2 atenolol 45 atenolol-chlorthalidone 45 ATGAM 90 atomoxetine 37 atorvastatin 55 atovaquone 8 atovaquone-proguanil 8 atropine 80 110 ATROVENT HFA 117 AUBAGIO 87 aubra 102 aubra eq 102 aurovela 1530 (21) 102 aurovela 120 (21) 102 aurovela 24 fe 102 aurovela fe 1530 (28) 102 aurovela fe 1-20 (28) 102 AUSTEDO 29 AVASTIN 14 aviane 102 avidoxy 12 avita 60 AVITA 60 AVONEX 88 AVYCAZ 6
ayuna 102 AZASITE 109 azathioprine 14 azelaic acid 60 azelastine 68 111 AZELEX 60 azithromycin 7 azurette (28) 102 B bacitracin 8 109 bacitracin-polymyxin b 109 baclofen 30 BALCOLTRA 102 balsalazide 81 BALVERSA 14 balziva (28) 102 BANZEL 24 BAQSIMI 71 BARACLUDE 2 BAVENCIO 14 BAXDELA 12 bayer aspirin 34 BAYER CHEWABLE
ASPIRIN 34 BCG VACCINE LIVE (PF) 90 BELEODAQ 14 belladonna alkaloids-opium 80 BELRAPZO 14 BELSOMRA 37 benazepril 45 benazepril-hydrochlorothiazide
45 BENDAMUSTINE 14 BENDEKA 14 BENEFIX 51 BENLYSTA 96 benzonatate 115 benztropine 27 BEOVU 111 bepotastine besilate 111 BEPREVE 111 BERINERT 117 beser 63 BESIVANCE 109 BESPONSA 14 betamethasone dipropionate 63 betamethasone valerate 63 betamethasone augmented 63
64 BETASERON 88 betaxolol 45 110
bethanechol chloride 122 BETIMOL 110 BETOPTIC S 110 BEVESPI AEROSPHERE 117 bexarotene 14 BEXSERO 90 bicalutamide 14 BICILLIN C-R 11 BIKTARVY 2 bimatoprost 112 BIOTHRAX 90 bisoprolol fumarate 45 bisoprolol-hydrochlorothiazide
45 BIVIGAM 90 BLEPHAMIDE 114 BLEPHAMIDE SOP 114 BLINCYTO 14 blisovi 24 fe 102 blisovi fe 1530 (28) 102 blisovi fe 120 (28) 103 BOOSTRIX TDAP 90 BORTEZOMIB 14 bosentan 117 BOSULIF 14 BOTOX 90 BRAFTOVI 14 BREO ELLIPTA 117 briellyn 103 BRILINTA 51 brimonidine 114 BRINEURA 75 brinzolamide 112 BRIVIACT 24 bromfenac 112 bromocriptine 27 brompheniramine-pseudoeph-
dm 115 BROVANA 117 budesonide 81 117 bumetanide 45 buprenorphine 31 buprenorphine hcl 31 buprenorphine-naloxone 34 bupropion hcl 37 38 bupropion hcl (smoking deter)
68 buspirone 38 BUSULFEX 15 butalbital compound wcodeine
31
127
butalbital-acetaminop-caf-cod 31
butalbital-acetaminophen-caff 31
butalbital-aspirin-caffeine 31 butorphanol 34 BYDUREON BCISE 77 BYETTA 77 BYSTOLIC 45 C CABENUVA 2 cabergoline 75 CABLIVI 51 CABOMETYX 15 calcipotriene 57 calcipotriene-betamethasone 57 calcitonin (salmon) 75 calcitriol 57 75 calcium acetate(phosphat bind)
81 CALQUENCE 15 camila 98 camrese 103 camrese lo 103 CANCIDAS 1 candesartan 45 candesartan-hydrochlorothiazid
46 CAPASTAT 8 capecitabine 15 CAPRELSA 15 captopril 46 captopril-hydrochlorothiazide
46 CARBAGLU 66 carbamazepine 24 carbidopa 27 carbidopa-levodopa 27 carbidopa-levodopa-
entacapone 27 carbinoxamine maleate 114 carisoprodol 30 carisoprodol-aspirin 30 carisoprodol-aspirin-codeine 30 carteolol 110 cartia xt 46 carvedilol 46 carvedilol phosphate 46 cataflam 34 CAYA CONTOURED 98 CAYSTON 8
caziant (28) 103 cefaclor 6 cefadroxil 6 cefazolin 6 cefazolin in dextrose (iso-os) 6 cefdinir 6 cefditoren pivoxil 6 cefepime 6 CEFEPIME IN DEXTROSE 5
6 cefepime in dextroseiso-osm 6 cefixime 6 CEFOTAN 6 cefotaxime 6 cefotetan 6 CEFOTETAN IN
DEXTROSE ISO-OSM 6 cefoxitin 6 cefpodoxime 6 7 cefprozil 7 ceftazidime 7 CEFTAZIDIME IN D5W 7 ceftriaxone 7 CEFTRIAXONE 7 ceftriaxone in dextroseiso-os 7 cefuroxime axetil 7 celecoxib 34 CELONTIN 24 cephalexin 7 CERDELGA 75 CEREZYME 75 cetirizine 114 cevimeline 66 CHANTIX 68 CHANTIX CONTINUING
MONTH BOX 68 CHANTIX STARTING
MONTH BOX 68 charlotte 24 fe 103 chateal (28) 103 chateal eq (28) 103 CHEMET 66 childrens aspirin 34 chloramphenicol sod succinate
8 chlordiazepoxide hcl 38 chlordiazepoxide-clidinium 80 chlorhexidine gluconate 68 chloroquine phosphate 8 chlorpromazine 38 chlorthalidone 46
chlorzoxazone 30 CHOLBAM 81 cholestyramine (with sugar) 55 cholestyramine light 55 cholinemagnesium salicylate
34 ciclodan 62 ciclopirox 62 ciclopirox-ure-camph-menth-
euc 62 cidofovir 2 cilostazol 51 CIMDUO 2 cimetidine 85 cimetidine hcl 85 CIMZIA 82 CIMZIA POWDER FOR
RECONST 81 cinacalcet 75 CINQAIR 117 CINRYZE 117 CIPRO HC 69 ciprofloxacin 12 ciprofloxacin hcl 12 69 109 ciprofloxacin-dexamethasone
69 citalopram 38 claravis 60 clarithromycin 7 8 clemastine 114 CLENPIQ 82 clindacin p 60 clindamycin hcl 8 clindamycin pediatric 8 clindamycin phosphate 8 60
101 clindamycin-benzoyl peroxide
60 clindamycin-tretinoin 60 clobazam 24 clobetasol 64 clobetasol-emollient 64 CLOCORTOLONE
PIVALATE 64 CLODERM 64 CLOLAR 15 clomipramine 38 clonazepam 24 clonidine 46 clonidine hcl 38 46 clopidogrel 51
128
clorazepate dipotassium 38 clotrimazole 1 62 clotrimazole-betamethasone 62 clovique 66 clozapine 38 COAGADEX 51 COARTEM 8 codeine sulfate 31 codeine-butalbital-asa-caff 31 codeine-guaifenesin 115 colchicine 95 COLCHICINE 95 colesevelam 55 colestipol 55 COMBIGAN 112 COMBIPATCH 98 COMBIVENT RESPIMAT 117 COMETRIQ 15 COMPLERA 2 compro 82 constulose 82 CONTOUR NEXT TEST
STRIPS 71 CONTOUR TEST STRIPS 71 COPIKTRA 15 CORIFACT 51 CORLANOR 56 CORTIFOAM 82 COSENTYX 58 COSENTYX (2 SYRINGES)
57 COSENTYX PEN 58 COSENTYX PEN (2 PENS) 58 COTELLIC 15 COTEMPLA XR-ODT 38 covaryx 98 covaryx hs 98 CREON 82 CRESEMBA 1 CRINONE 98 cromolyn 82 111 117 crotan 66 cryselle (28) 103 CRYSVITA 75 CUBICIN 8 CUBICIN RF 9 CUTAQUIG 90 CUVITRU 90 cyanocobalamin (vitamin b-12)
123 cyclafem 135 (28) 103
cyclafem 777 (28) 103 cyclobenzaprine 30 cyclopentolate 110 cyclophosphamide 15 CYCLOPHOSPHAMIDE 15 CYCLOSERINE 9 CYCLOSET 77 cyclosporine 15 cyclosporine modified 15 cyproheptadine 114 CYRAMZA 15 cyred 103 cyred eq 103 CYSTAGON 122 CYSTARAN 111 CYTOVENE 2 D DACOGEN 15 dalfampridine 29 DALIRESP 117 danazol 75 dantrolene 30 dapsone 9 60 DAPTACEL (DTAP
PEDIATRIC) (PF) 91 darifenacin 121 DARZALEX 15 dasetta 135 (28) 103 dasetta 777 (28) 103 DAURISMO 15 daysee 103 DAYTRANA 38 deblitane 98 decadron 70 decitabine 15 deferasirox 66 deferiprone 66 demeclocycline 12 DENAVIR 63 denta 5000 plus 68 dentagel 69 DEPO-ESTRADIOL 98 DEPO-PROVERA 98 DEPO-SUBQ PROVERA 104
98 DEPO-TESTOSTERONE 75 DESCOVY 2 desipramine 38 desloratadine 115 desmopressin 75
desog-eestradioleestradiol 103
desogestrel-ethinyl estradiol 103
desonide 64 desoximetasone 64 DESVENLAFAXINE 38 desvenlafaxine succinate 38 dexamethasone 70 dexamethasone intensol 70 dexamethasone sodium phos
(pf) 70 dexamethasone sodium
phosphate 70 113 DEXILANT 85 dexmethylphenidate 38 dextroamphetamine 38 39 dextroamphetamine-
amphetamine 39 diazepam 24 39 diazepam intensol 39 diazoxide 71 diclofenac potassium 34 diclofenac sodium 34 59 112 diclofenac-misoprostol 34 dicloxacillin 11 dicyclomine 80 didanosine 2 DIFICID 8 diflorasone 64 diflunisal 34 digitek 50 digox 50 digoxin 50 dihydroergotamine 28 DILANTIN 24 DILANTIN EXTENDED 24 DILANTIN INFATABS 24 DILANTIN-125 24 diltiazem 46 dilt-xr 46 dimethyl fumarate 88 DIPENTUM 82 diphenhydramine hcl 115 diphenoxylate-atropine 80 dipyridamole 51 diskets 31 disopyramide phosphate 44 disulfiram 66 divalproex 24 25 DIVIGEL 99
129
dofetilide 44 dolishale 103 donepezil 29 DONNATAL 80 DOPTELET (15 TAB PACK)
51 dorzolamide 112 dorzolamide-timolol 112 dorzolamide-timolol (pf) 112 dotti 99 DOVATO 2 doxazosin 46 doxepin 39 doxercalciferol 75 doxycycline hyclate 12 doxycycline monohydrate 12 doxylamine-pyridoxine (vit b6)
82 dronabinol 82 drospirenone-eestradiol-lmfa
103 drospirenone-ethinyl estradiol
103 DSUVIA 31 DUAVEE 99 DUEXIS 34 DULERA 117 duloxetine 39 DUPIXENT PEN 59 DUPIXENT SYRINGE 59 duramorph (pf) 31 DUREZOL 113 dutasteride 121 dutasteride-tamsulosin 121 dvorah 31 DYANAVEL XR 39 DYSPORT 91 E ees 400 8 econazole 62 econtra ez 103 econtra one-step 103 ecotrin 34 ecotrin low strength 34 EDARBI 46 EDARBYCLOR 46 EDLUAR 39 ed-spaz 80 EDURANT 2 eemt 99 eemt hs 99
efavirenz 2 efavirenz-emtricitabin-tenofov
3 efavirenz-lamivu-tenofov disop
3 effer-k 122 ELAPRASE 75 ELELYSO 75 eletriptan 28 ELIGARD 16 ELIGARD (3 MONTH) 15 ELIGARD (4 MONTH) 15 ELIGARD (6 MONTH) 15 elinest 103 ELIQUIS 51 ELIQUIS DVT-PE TREAT
30D START 51 ELIXOPHYLLIN 117 ELLA 103 ELMIRON 122 ELOCTATE 51 eluryng 101 ELZONRIS 16 EMCYT 16 EMEND 82 EMGALITY PEN 28 EMGALITY SYRINGE 28 emoquette 103 EMPAVELI 67 EMPLICITI 16 EMSAM 39 emtricitabine 3 emtricitabine-tenofovir (tdf) 3 EMTRIVA 3 EMVERM 9 enalapril maleate 46 enalaprilat 46 enalapril-hydrochlorothiazide
46 ENBREL 96 ENBREL MINI 96 ENBREL SURECLICK 96 endocet 31 ENGERIX-B (PF) 91 ENGERIX-B PEDIATRIC
(PF) 91 ENHERTU 16 enoxaparin 51 enpresse 104 enskyce 104 entacapone 27
entecavir 3 ENTRESTO 56 ENTYVIO 82 enulose 82 EPANED 46 EPCLUSA 3 EPIDIOLEX 25 epinastine 111 epinephrine 115 EPINEPHRINE 115 epitol 25 EPIVIR HBV 3 eplerenone 47 EPOGEN 86 epoprostenol (glycine) 47 eprosartan 47 ERAXIS(WATER DILUENT)
1 ERBITUX 16 ergocalciferol (vitamin d2) 123 ergoloid 39 ergotamine-caffeine 28 ERLEADA 16 erlotinib 16 errin 99 ERWINAZE 16 ery pads 60 erygel 60 ery-tab 8 erythrocin (as stearate) 8 erythromycin 8 109 erythromycin ethylsuccinate 8 erythromycin with ethanol 60 erythromycin-benzoyl peroxide
60 ESBRIET 117 escitalopram oxalate 39 esomeprazole magnesium 85 ESPEROCT 51 estarylla 104 estazolam 39 estradiol 99 estradiol valerate 99 estradiol-norethindrone acet 99 ESTRING 99 estrogens-methyltestosterone 99 eszopiclone 39 ethacrynic acid 47 ethambutol 9 ethosuximide 25
130
ethynodiol diac-eth estradiol 104
etodolac 34 etonogestrel-ethinyl estradiol
101 etoposide 16 etravirine 3 EUCRISA 59 EUFLEXXA 34 EURAX 66 EVAMIST 99 EVENITY 95 everolimus (antineoplastic) 16 everolimus
(immunosuppressive) 16 EVOTAZ 3 EXELDERM 62 exemestane 16 EXONDYS-51 29 EYLEA 111 ezetimibe 55 ezetimibe-simvastatin 55 F FA-8 123 FABRAZYME 75 FACTIVE 12 falmina (28) 104 famciclovir 3 famotidine 86 famotidine (pf) 85 FANAPT 39 FARXIGA 77 FASENRA 118 FASENRA PEN 117 FASLODEX 16 fayosim 104 FC2 FEMALE CONDOM 98 febuxostat 95 FEIBA NF 51 felbamate 25 felodipine 47 fem ph 101 FEMCAP 98 FEMRING 99 femynor 104 fenofibrate 55 FENOFIBRATE 55 fenofibrate micronized 55 fenofibrate nanocrystallized 55 fenofibric acid 55 fenofibric acid (choline) 55
fenoprofen 35 fentanyl 32 fentanyl citrate 31 FER-IN-SOL 123 FERRIPROX 67 FETZIMA 39 FIASP FLEXTOUCH U-100
INSULIN 72 FIASP PENFILL U-100
INSULIN 72 FIASP U-100 INSULIN 72 FIBRYGA 51 finasteride 121 FINTEPLA 25 FIRMAGON KIT W
DILUENT SYRINGE 16 flac otic oil 69 flavoxate 121 FLEBOGAMMA DIF 91 flecainide 44 FLOLAN 47 FLORIVA (FLUORIDE-
VITAMIN D3) 123 FLOVENT DISKUS 118 FLOVENT HFA 118 fluconazole 1 flucytosine 1 fludarabine 16 fludrocortisone 70 fluocinolone 64 fluocinolone acetonide oil 69 fluocinolone and shower cap 64 fluocinonide 64 fluocinonide-e 64 fluoride (sodium) 69 123 124 fluorometholone 113 fluorouracil 16 59 FLUOROURACIL 59 fluoxetine 39 40 fluphenazine hcl 40 flurandrenolide 64 65 flurazepam 40 flurbiprofen 35 flurbiprofen sodium 112 flutamide 16 fluticasone propionate 65 118 fluticasone propion-salmeterol
118 fluvastatin 55 56 fluvoxamine 40 FML FORTE 113
FML SOP 113 folic acid 124 FOLOTYN 16 fondaparinux 51 formoterol fumarate 118 FORTEO 95 FOSAMAX PLUS D 95 fosamprenavir 3 fosfomycin tromethamine 13 fosinopril 47 fosinopril-hydrochlorothiazide
47 FRAGMIN 52 FREESTYLE LIBRE 14 DAY
SENSOR 71 FREESTYLE LIBRE 2
SENSOR 71 frovatriptan 28 fulvestrant 16 furosemide 47 FUZEON 3 fyavolv 99 G g tussin ac 115 gabapentin 25 GALAFOLD 75 galantamine 29 GAMASTAN 91 GAMASTAN SD 91 GAMIFANT 16 GAMMAGARD LIQUID 91 GAMMAGARD S-D (IGA lt 1
MCGML) 91 GAMMAKED 91 GAMMAPLEX 91 GAMMAPLEX (WITH
SORBITOL) 91 GAMUNEX-C 91 GANCICLOVIR 3 ganciclovir sodium 3 GARDASIL 9 (PF) 91 gatifloxacin 109 gavilyte-c 82 gavilyte-g 82 gavilyte-n 82 GAZYVA 16 gemcitabine 16 17 gemfibrozil 56 gemmily 104 generlac 82 gengraf 17
131
GENOTROPIN 87 GENOTROPIN MINIQUICK
87 gentak 109 gentamicin 9 61 62 109 gentamicin sulfate (ped) (pf) 9 GENVOYA 3 GIAPREZA 56 GILENYA 88 GILOTRIF 17 GIVLAARI 67 GLASSIA 67 glatiramer 88 glatopa 88 GLEOSTINE 17 glimepiride 77 glipizide 77 glipizide-metformin 77 GLUCAGEN DIAGNOSTIC
KIT 71 GLUCAGEN HYPOKIT 71 GLUCAGON (HCL)
EMERGENCY KIT 71 glucagon emergency kit
(human) 71 GLUCAGON HCL 71 glyburide 77 glyburide micronized 77 glyburide-metformin 77 glycopyrrolate 80 GLYXAMBI 78 GONITRO 57 granisetron hcl 82 GRANIX 86 GRASTEK 91 griseofulvin microsize 1 griseofulvin ultramicrosize 1 guaiatussin ac 115 guanfacine 40 47 GYNAZOLE-1 101 gynol ii 101 H HAEGARDA 118 hailey 104 hailey 24 fe 104 hailey fe 1530 (28) 104 hailey fe 120 (28) 104 HALAVEN 17 halcinonide 65 halobetasol propionate 65 haloperidol 40
haloperidol decanoate 40 haloperidol lactate 40 HARVONI 3 HAVRIX (PF) 91 92 heather 99 HEMLIBRA 52 hemmorex-hc 82 HEMOFIL M HIGH 52 HEMOFIL M LOW 52 HEMOFIL M MID 52 HEMOFIL M SUPER HIGH52 hep flush-10 (pf) 52 heparin (porcine) 52 heparin (porcine) in 5 dex 52 heparin lock flush (porcine) 52 heparin lockflush(porcine)(pf)
52 heparin(porcine) in 045 nacl
52 HEPARIN(PORCINE) IN
045 NACL 52 heparin porcine (pf) 52 53 HEPLISAV-B (PF) 92 HERCEPTIN 17 HERCEPTIN HYLECTA 17 HERZUMA 17 HETLIOZ 40 HETLIOZ LQ 40 HIBERIX (PF) 92 HIZENTRA 92 homatropaire 110 HUMALOG JUNIOR
KWIKPEN U-100 72 HUMALOG KWIKPEN
INSULIN 72 HUMALOG MIX 50-50
INSULN U-100 72 HUMALOG MIX 50-50
KWIKPEN 72 HUMALOG MIX 75-25
KWIKPEN 72 HUMALOG MIX 75-25(U-
100)INSULN 72 HUMALOG U-100 INSULIN
72 HUMATE-P 53 HUMIRA 96 HUMIRA PEN 96 HUMIRA PEN CROHNS-UC-
HS START 96
HUMIRA PEN PSOR-UVEITS-ADOL HS 96
HUMIRA(CF) 97 HUMIRA(CF) PEDI
CROHNS STARTER 96 HUMIRA(CF) PEN 96 HUMIRA(CF) PEN
CROHNS-UC-HS 96 HUMIRA(CF) PEN
PEDIATRIC UC 96 HUMIRA(CF) PEN PSOR-
UV-ADOL HS 96 HUMULIN 7030 U-100
INSULIN 72 HUMULIN 7030 U-100
KWIKPEN 72 HUMULIN N NPH INSULIN
KWIKPEN 73 HUMULIN N NPH U-100
INSULIN 73 HUMULIN R REGULAR U-
100 INSULN 73 HUMULIN R U-500 (CONC)
INSULIN 73 HUMULIN R U-500 (CONC)
KWIKPEN 73 HYCAMTIN 17 hydralazine 47 hydrochlorothiazide 47 hydrocodone bitartrate 32 hydrocodone-acetaminophen 32 hydrocodone-chlorpheniramine
115 hydrocodone-homatropine 115 hydrocodone-ibuprofen 32 hydrocortisone 65 70 82 hydrocortisone acetate 82 hydrocortisone butyrate 65 hydrocortisone butyr-emollient
65 hydrocortisone valerate 65 hydrocortisone-acetic acid 69 hydrocortisone-pramoxine 58
82 hydromet 116 hydromorphone 32 HYDROMORPHONE 32 hydroxocobalamin 124 hydroxychloroquine 9 hydroxyprogest(pf)(preg presv)
99
132
hydroxyprogesterone cap(ppres) 99
hydroxyprogesterone caproate 100
hydroxyurea 17 hydroxyzine hcl 115 hydroxyzine pamoate 115 hyophen 122 hyoscyamine sulfate 80 hyosyne 80 HYQVIA 92 I ibandronate 95 IBRANCE 17 ibu 35 ibuprofen 35 icatibant 118 iclevia 104 ICLUSIG 17 icosapent ethyl 56 IDELVION 53 IDHIFA 17 ILARIS (PF) 90 ILUMYA 58 imatinib 17 IMBRUVICA 17 IMFINZI 17 imipenem-cilastatin 9 imipramine hcl 40 imipramine pamoate 40 imiquimod 90 IMLYGIC 17 IMOVAX RABIES VACCINE
(PF) 92 incassia 100 INCRELEX 67 INCRUSE ELLIPTA 118 indapamide 47 indomethacin 35 INFANRIX (DTAP) (PF) 92 INFED 124 INFLECTRA 82 INFUGEM 18 INLYTA 18 INSULIN ASP PRT-INSULIN
ASPART 73 INSULIN ASPART U-100 73 INSULIN SYRINGE-
NEEDLE U-100 71 INTELENCE 3 INTRAROSA 101
INTRON A 90 INVANZ 9 INVEGA SUSTENNA 40 INVELTYS 113 INVIRASE 3 IOPIDINE 114 IPOL 92 ipratropium bromide 69 118 ipratropium-albuterol 118 irbesartan 47 irbesartan-hydrochlorothiazide
47 IRESSA 18 ISENTRESS 3 ISENTRESS HD 3 isibloom 104 ISOLYTE-S 123 isoniazid 9 isosorbide dinitrate 57 isosorbide mononitrate 57 isotretinoin 60 isoxsuprine 101 isradipine 47 ISTODAX 18 itraconazole 1 ivermectin 9 66 IXEMPRA 18 IXIARO (PF) 92 IXINITY 53 J jaimiess 104 JAKAFI 18 jantoven 53 JANUMET 78 JANUMET XR 78 JANUVIA 78 JARDIANCE 78 jasmiel (28) 104 jencycla 100 JENTADUETO 78 JENTADUETO XR 78 JEVTANA 18 jinteli 100 JIVI 53 jolessa 104 JORNAY PM 40 JUBLIA 62 juleber 104 JULUCA 3 junel 1530 (21) 104 junel 120 (21) 104
junel fe 1530 (28) 104 junel fe 120 (28) 104 junel fe 24 104 JUXTAPID 56 JYNARQUE 75 K KADCYLA 18 kaitlib fe 104 KALBITOR 118 KALETRA 3 4 kalliga 104 KALYDECO 118 KANJINTI 18 KANUMA 75 kariva (28) 104 kelnor 135 (28) 105 kelnor 1-50 (28) 105 KEPIVANCE 13 ketoconazole 1 62 ketodan 62 ketoprofen 35 ketorolac 35 112 KEVZARA 97 KEYTRUDA 18 KINRIX (PF) 92 KISQALI 18 KISQALI FEMARA CO-
PACK 18 klor-con 123 klor-con 10 122 klor-con 8 122 klor-con m10 122 klor-con m15 122 klor-con m20 123 klor-conef 123 KOATE 53 KOGENATE FS 53 KORLYM 75 KOVALTRY 53 K-PHOS NO 2 122 K-PHOS ORIGINAL 122 KRYSTEXXA 95 k-tab 123 K-TAB 123 kurvelo (28) 105 KYLEENA 98 KYMRIAH 18 KYPROLIS 18 L l norgesteestradiol-eestrad
105
133
labetalol 47 LACRISERT 111 lactulose 83 lamivudine 4 lamivudine-zidovudine 4 lamotrigine 25 lansoprazole 86 lanthanum 83 LANTUS SOLOSTAR U-100
INSULIN 73 LANTUS U-100 INSULIN 73 lapatinib 18 larin 1530 (21) 105 larin 120 (21) 105 larin 24 fe 105 larin fe 1530 (28) 105 larin fe 120 (28) 105 larissia 105 LASTACAFT 111 latanoprost 112 LATUDA 40 layolis fe 105 leena 28 105 leflunomide 97 LEMTRADA 88 LENVIMA 18 lessina 105 letrozole 19 leucovorin calcium 13 LEUKERAN 19 LEUKINE 86 leuprolide 19 levalbuterol hcl 118 LEVALBUTEROL
TARTRATE 118 LEVEMIR FLEXTOUCH U-
100 INSULN 73 LEVEMIR U-100 INSULIN 73 levetiracetam 25 levobunolol 110 levocarnitine 67 levocarnitine (with sugar) 67 levocetirizine 115 levofloxacin 12 109 levonest (28) 105 levonorgestrel 105 levonorgestrel-ethinyl estrad
105 levonorg-eth estrad triphasic
105 levora-28 105
levorphanol tartrate 32 levothyroxine 79 levoxyl 79 LEVULAN 59 LEXIVA 4 LIBTAYO 19 lidocaine 61 lidocaine hcl 61 lidocaine hcl-hydrocortison ac
61 83 LIDOCAINE HCL-
HYDROCORTISON AC 83 lidocaine viscous 61 lidocaine-hydrocortisone-aloe
83 lidocaine-prilocaine 61 LIDOCAINE-TETRACAINE
61 LILETTA 98 lillow (28) 105 LINCOCIN 9 lindane 66 linezolid 9 linezolid in dextrose 5 9 linezolid-09 sodium chloride
9 LINZESS 83 liothyronine 79 LIPOFEN 56 lisinopril 47 lisinopril-hydrochlorothiazide
47 lithium carbonate 40 41 LO LOESTRIN FE 105 lojaimiess 105 LONSURF 19 loperamide 80 lopinavir-ritonavir 4 lorazepam 41 lorazepam intensol 41 loryna (28) 105 losartan 47 losartan-hydrochlorothiazide 47 LOTEMAX 113 loteprednol etabonate 113 lovastatin 56 low-ogestrel (28) 105 loxapine succinate 41 lo-zumandimine (28) 105 LUCENTIS 111 ludent fluoride 124
LULICONAZOLE 62 LUMIGAN 112 LUMIZYME 75 LUMOXITI 19 LUPANETA PACK (1
MONTH) 101 LUPANETA PACK (3
MONTH) 101 LUPKYNIS 19 LUPRON DEPOT 19 LUPRON DEPOT (3
MONTH) 19 LUPRON DEPOT (4
MONTH) 19 LUPRON DEPOT (6
MONTH) 19 LUPRON DEPOT-PED 19 LUPRON DEPOT-PED (3
MONTH) 19 lutera (28) 105 LUXTURNA 111 LUZU 62 lyleq 100 lyllana 100 LYNPARZA 19 LYRICA CR 25 LYSODREN 19 lyza 100 M mafenide acetate 62 malathion 66 maprotiline 41 marlissa (28) 106 MARPLAN 41 MARQIBO 19 MATULANE 19 matzim la 47 MAVENCLAD (10 TABLET
PACK) 88 MAVENCLAD (4 TABLET
PACK) 88 MAVENCLAD (5 TABLET
PACK) 88 MAVENCLAD (6 TABLET
PACK) 88 MAVENCLAD (7 TABLET
PACK) 88 MAVENCLAD (8 TABLET
PACK) 88 MAVENCLAD (9 TABLET
PACK) 88
134
MAVYRET 4 MAXIDEX 113 maxi-tuss ac 116 MAYZENT 88 MAYZENT STARTER PACK
88 m-clear wc 116 meclizine 83 meclofenamate 35 medroxyprogesterone 100 mefenamic acid 35 mefloquine 9 megestrol 19 MEKINIST 19 MEKTOVI 19 meloxicam 35 melphalan 19 melphalan hcl 19 memantine 29 MENACTRA (PF) 92 MENEST 100 MENOSTAR 100 MENQUADFI (PF) 92 MENTAX 62 MENVEO A-C-Y-W-135-DIP
(PF) 92 meperidine 32 meprobamate 30 MEPSEVII 76 mercaptopurine 20 meropenem 9 MEROPENEM-09
SODIUM CHLORIDE 9 merzee 106 mesalamine 83 mesalamine with cleansing
wipe 83 metaproterenol 118 metaxalone 30 metformin 78 methadone 32 methadose 32 methamphetamine 41 methazolamide 112 methenamine hippurate 13 methenamine mandelate 13 methen-sod phos-meth blue-
hyos 122 methergine 109 methimazole 71 methocarbamol 30
methotrexate sodium 20 methotrexate sodium (pf) 20 methoxsalen 59 methscopolamine 80 methyldopa 47 methyldopa-
hydrochlorothiazide 47 methyldopate 48 methylergonovine 109 METHYLIN 41 methylphenidate hcl 41 methylprednisolone 70 methylprednisolone acetate 70 methyltestosterone 76 metoclopramide hcl 83 metolazone 48 metoprolol succinate 48 metoprolol ta-hydrochlorothiaz
48 metoprolol tartrate 48 metronidazole 9 60 61 101 metyrosine 48 mexiletine 44 MIACALCIN 76 mibelas 24 fe 106 microgestin 1530 (21) 106 microgestin 120 (21) 106 microgestin fe 1530 (28) 106 microgestin fe 120 (28) 106 midazolam 41 midodrine 67 migergot 28 miglitol 78 miglustat 76 mili 106 millipred 70 millipred dp 70 mimvey 100 MINITRAN 57 minocycline 12 minoxidil 48 MIRCERA 86 MIRENA 98 mirtazapine 41 misoprostol 86 MITIGARE 95 mitoxantrone 20 M-M-R II (PF) 92 modafinil 41 moexipril 48 molindone 41
mometasone 65 mondoxyne nl 12 mono-linyah 106 MONONINE 53 MONOVISC 35 montelukast 118 119 morphine 32 33 morphine (pf) 32 morphine concentrate 32 MOTOFEN 80 MOVANTIK 83 MOXATAG 11 moxifloxacin 12 109 MOZOBIL 87 MULPLETA 53 MULTAQ 44 multi-vitamin with fluoride 124 multivitamins with fluoride 124 mupirocin 62 mupirocin calcium 62 mvc-fluoride 124 my choice 106 my way 106 MYALEPT 76 MYCAMINE 1 mycophenolate mofetil 20 mycophenolate sodium 20 MYDAYIS 41 MYLOTARG 20 MYOBLOC 92 myorisan 61 MYRBETRIQ 121 N nabumetone 35 nadolol 48 nadolol-bendroflumethiazide 48 nafcillin 11 nafcillin in dextrose iso-osm 11 naftifine 62 63 NAGLAZYME 76 nalbuphine 35 naloxone 35 naltrexone 35 naproxen 35 naproxen sodium 35 naratriptan 28 NARCAN 35 NATACYN 109 NATAZIA 106 nateglinide 78 NATPARA 76
135
nebusal 119 necon 0535 (28) 106 nefazodone 41 neomycin 9 neomycin-bacitracin-poly-hc
112 neomycin-bacitracin-
polymyxin 109 neomycin-polymyxin b-
dexameth 112 113 neomycin-polymyxin-
gramicidin 109 neomycin-polymyxin-hc 69
113 neo-polycin 109 neo-polycin hc 113 NERLYNX 20 NEUPOGEN 87 NEVANAC 112 nevirapine 4 new day 106 NEXAVAR 20 NEXPLANON 101 NEXTSTELLIS 106 niacin 56 NIACOR 56 nicardipine 48 nicorette 68 nicotine 68 nicotine (polacrilex) 68 NICOTROL 68 NICOTROL NS 68 nifedipine 48 nikki (28) 106 nilutamide 20 nimodipine 48 NINLARO 20 nisoldipine 48 nitazoxanide 9 nitisinone 67 nitro-bid 57 NITRO-DUR 57 nitrofurantoin 13 nitrofurantoin macrocrystal 13 nitrofurantoin monohydm-
cryst 13 nitroglycerin 57 nitroglycerin in 5 dextrose 57 nitro-time 57 NITYR 67 NIVESTYM 87
nizatidine 86 nora-be 100 noreth-ethinyl estradiol-iron
106 norethindrone (contraceptive)
100 norethindrone acetate 100 norethindrone ac-eth estradiol
100 106 norethindrone-eestradiol-iron
106 norgestimate-ethinyl estradiol
106 norlyda 100 NORMOSOL-R 123 NORPACE CR 44 nortrel 0535 (28) 106 nortrel 135 (21) 106 nortrel 135 (28) 106 nortrel 777 (28) 107 nortriptyline 42 NORVIR 4 NOVAFERRUM 124 NOVOEIGHT 53 NOVOLIN 70-30 FLEXPEN
U-100 73 NOVOLIN N FLEXPEN 73 NOVOLIN R FLEXPEN 73 NOVOLOG FLEXPEN U-100
INSULIN 74 NOVOLOG MIX 70-30 U-100
INSULN 74 NOVOLOG MIX 70-
30FLEXPEN U-100 74 NOVOLOG PENFILL U-100
INSULIN 74 NOVOLOG U-100 INSULIN
ASPART 74 NOVOPEN ECHO 71 NOVOSEVEN RT 53 NOXAFIL 1 np thyroid 79 NPLATE 53 NUCALA 119 NUCYNTA ER 36 NUEDEXTA 29 NULOJIX 20 NULYTELY LEMON-LIME
83 NUPLAZID 42 NUWIQ 53
nyamyc 63 nylia 777 (28) 107 nymyo 107 nystatin 1 63 nystatin-triamcinolone 63 nystop 63 O OBIZUR 54 ocella 107 OCREVUS 88 OCTAGAM 92 octreotide acetate 20 ODEFSEY 4 OFEV 119 ofloxacin 12 69 109 OGIVRI 20 olanzapine 42 olanzapine-fluoxetine 42 olmesartan 48 olmesartan-amlodipin-
hcthiazid 48 olmesartan-
hydrochlorothiazide 48 olopatadine 69 111 OLUMIANT 97 omega-3 acid ethyl esters 56 omeprazole 86 OMIDRIA 111 OMNITROPE 87 ONCASPAR 20 ondansetron 84 ondansetron hcl 83 84 ONETOUCH ULTRA TEST
71 ONETOUCH VERIO TEST
STRIPS 71 ONIVYDE 20 ONPATTRO 29 ONZETRA XSAIL 28 opcicon one-step 107 OPDIVO 20 opium tincture 81 OPSUMIT 119 option-2 107 ORALAIR 92 oralone 69 ORAVIG 1 ORENCIA 97 ORENCIA (WITH
MALTOSE) 97 ORENCIA CLICKJECT 97
136
ORENITRAM 48 ORLADEYO 119 orphenadrine citrate 30 orsythia 107 ORTHOVISC 36 oscimin 81 oscimin sl 81 oscimin sr 81 oseltamivir 4 OSMOPREP 84 OSPHENA 101 OTEZLA 97 OTEZLA STARTER 97 OTOVEL 69 oxacillin 11 oxacillin in dextrose(iso-osm)
11 oxandrolone 76 oxaprozin 36 oxazepam 42 oxcarbazepine 25 oxiconazole 63 OXISTAT 63 OXLUMO 122 oxybutynin chloride 121 oxycodone 33 oxycodone-acetaminophen 33 oxycodone-aspirin 33 OXYCONTIN 33 oxymorphone 33 OZEMPIC 78 OZURDEX 113 P pacerone 44 PADCEV 20 paliperidone 42 PALYNZIQ 76 pamidronate 76 PANRETIN 59 pantoprazole 86 PANZYGA 92 PARAGARD T 380A 98 paricalcitol 76 PARICALCITOL 76 paroex oral rinse 69 paromomycin 10 paroxetine hcl 42 paroxetine
mesylate(menopsym) 42 PARSABIV 76 PASER 10
PEDIARIX (PF) 92 PEDVAX HIB (PF) 93 peg 3350-electrolytes 84 peg3350-sod sul-nacl-kcl-asb-c
84 PEGASYS 88 89 peg-electrolyte soln 84 peg-prep 84 PEMAZYRE 20 PEN NEEDLE DIABETIC 72 penicillamine 97 penicillin g procaine 11 penicillin v potassium 11 PENTACEL (PF) 93 PENTACEL ACTHIB
COMPONENT (PF) 93 PENTAM 10 pentamidine 10 pentazocine-naloxone 36 pentoxifylline 54 PERFOROMIST 119 perindopril erbumine 48 periogard 69 PERJETA 20 permethrin 66 perphenazine 42 perphenazine-amitriptyline 42 phenazopyridine 122 phenelzine 42 phenobarb-hyoscy-atropine-
scop 81 phenobarbital 25 26 phenohytro 81 phenoxybenzamine 48 phenylephrine hcl 114 phenytoin 26 phenytoin sodium extended 26 PHEXXI 101 philith 107 phosphasal 122 PHYSIOLYTE 66 PHYSIOSOL IRRIGATION 66 phytonadione (vitamin k1) 54 PICATO 59 pilocarpine hcl 67 69 110 pimecrolimus 59 pimozide 42 pimtrea (28) 107 pindolol 48 pioglitazone 78 pioglitazone-glimepiride 78
pioglitazone-metformin 78 piperacillin-tazobactam 11 PIQRAY 21 pirmella 107 piroxicam 36 PLASMA-LYTE 148 123 PLASMA-LYTE A 123 PLEGRIDY 89 PLENVU 84 PNEUMOVAX-23 93 podofilox 59 POLIVY 21 polycin 110 polymyxin b sulfate 10 polymyxin b sulf-trimethoprim
110 POMALYST 89 PONVORY 89 PONVORY 14-DAY
STARTER PACK 89 portia 28 107 PORTRAZZA 21 posaconazole 1 potassium chloride 123 potassium citrate 122 POTELIGEO 21 pramipexole 27 prasugrel 54 pravastatin 56 praziquantel 10 prazosin 48 PRED MILD 113 prednicarbate 65 prednisolone 70 prednisolone acetate 113 prednisolone sodium phosphate
70 114 prednisone 70 prednisone intensol 70 pregabalin 26 PREMARIN 100 PREMPHASE 100 PREMPRO 100 prevalite 56 previfem 107 PREVNAR 13 (PF) 93 PREVYMIS 4 PREZCOBIX 4 PREZISTA 4 PRIFTIN 10 primaquine 10
137
primidone 26 PRIMSOL 13 PRIVIGEN 93 probenecid 95 probenecid-colchicine 95 procainamide 44 procentra 42 prochlorperazine 84 prochlorperazine edisylate 84 prochlorperazine maleate 84 PROCRIT 87 procto-med hc 84 procto-pak 84 proctosol hc 84 proctozone-hc 84 PROFILNINE 54 progesterone 100 progesterone micronized 100 PROGRAF 21 PROLASTIN-C 67 PROLEUKIN 90 PROLIA 95 PROMACTA 54 promethazine 115 promethazine-codeine 116 promethazine-dm 116 promethazine-phenyleph-
codeine 116 promethazine-phenylephrine
116 promethegan 115 propafenone 44 45 proparacaine 111 propranolol 48 49 propranolol-hydrochlorothiazid
49 propylthiouracil 71 PROQUAD (PF) 93 protriptyline 42 PROVENGE 93 prudoxin 59 pulmosal 119 PULMOZYME 119 pyrazinamide 10 pyridostigmine bromide 30 pyrimethamine 10 Q QBRELIS 49 QINLOCK 21 QTERN 78 QUADRACEL (PF) 93
quetiapine 42 QUILLICHEW ER 42 QUILLIVANT XR 42 quinapril 49 quinapril-hydrochlorothiazide
49 quinidine gluconate 45 quinidine sulfate 45 quinine sulfate 10 quit 2 68 quit 4 68 QVAR REDIHALER 119 R RABAVERT (PF) 93 rabeprazole 86 RADICAVA 29 RAGWITEK 93 raloxifene 95 ramelteon 42 ramipril 49 ranolazine 57 RAPIVAB (PF) 4 rasagiline 27 RAVICTI 67 REBIF (WITH ALBUMIN) 89 REBIF REBIDOSE 89 REBIF TITRATION PACK 89 REBINYN 54 RECLAST 67 reclipsen (28) 107 RECOMBINATE 54 RECOMBIVAX HB (PF) 93 RECTIV 84 REGRANEX 59 RELENZA DISKHALER 4 RELEXXII 42 RELION NOVOLIN 7030 74 RELION NOVOLIN N 74 RELION NOVOLIN R 74 RELISTOR 84 REMICADE 84 RENACIDIN 122 RENFLEXIS 84 repaglinide 78 repaglinide-metformin 78 REPATHA PUSHTRONEX 56 REPATHA SURECLICK 56 REPATHA SYRINGE 56 RESTASIS 111 RETEVMO 21 RETISERT 114
REVATIO 119 REVLIMID 89 REXULTI 43 REYATAZ 4 RHOPRESSA 112 RIASTAP 54 ribavirin 4 89 RIDAURA 97 rifabutin 10 rifampin 10 riluzole 67 rimantadine 4 RINVOQ 97 RIOMET ER 78 risedronate 67 95 RISPERDAL CONSTA 43 risperidone 43 ritonavir 4 RITUXAN 21 RITUXAN HYCELA 21 rivastigmine 30 rivastigmine tartrate 29 rivelsa 107 RIXUBIS 54 rizatriptan 28 ropinirole 27 28 rosadan 61 rosuvastatin 56 roweepra 26 RUBRACA 21 RUCONEST 119 rufinamide 26 RYBELSUS 79 RYDAPT 21 S salsalate 36 SAMSCA 76 SANTYL 65 sapropterin 76 SARCLISA 21 SAVELLA 97 scalacort 65 SCENESSE 59 scopolamine base 84 seconal sodium 43 SEEBRI NEOHALER 119 selegiline hcl 28 selenium sulfide 58 SELZENTRY 5 SEREVENT DISKUS 119 SEROSTIM 87
138
sertraline 43 setlakin 107 sevelamer carbonate 84 sevelamer hcl 84 sf 69 sf 5000 plus 69 sharobel 101 SHINGRIX (PF) 93 SIGNIFOR 21 sildenafil (pulmhypertension)
119 SILIQ 58 silodosin 121 silver sulfadiazine 59 SIMBRINZA 112 simliya (28) 107 simpesse 107 SIMPONI 97 SIMPONI ARIA 97 SIMULECT 21 simvastatin 56 SINUVA 119 sirolimus 21 SIRTURO 10 SIVEXTRO 10 SKYLA 98 SKYRIZI 58 SLYND 107 sodium chloride 119 sodium chloride 045 123 sodium chloride 09 67 sodium fluoride 5000 dry
mouth 69 sodium fluoride 5000 plus 69 sodium fluoride-pot nitrate 69 sodium phenylbutyrate 67 sodium polystyrene sulfonate
85 solifenacin 121 SOLIQUA 10033 74 SOLIRIS 67 SOLTAMOX 21 SOMATULINE DEPOT 21 SOMAVERT 76 sorine 45 sotalol 45 sotalol af 45 SOVALDI 5 spinosad 66 SPIRIVA RESPIMAT 119
SPIRIVA WITH HANDIHALER 119
spironolactone 49 spironolacton-hydrochlorothiaz
49 SPRAVATO 43 sprintec (28) 107 SPRYCEL 21 sps (with sorbitol) 85 sronyx 107 ssd 59 SSKI 71 st joseph aspirin 36 st joseph aspirin 36 STAMARIL (PF) 93 stavudine 5 STELARA 58 STIOLTO RESPIMAT 119 STIVARGA 21 stop smoking aid 68 STRENSIQ 76 STREPTOMYCIN 10 STRIBILD 5 STRIVERDI RESPIMAT 120 SUBLOCADE 33 subvenite 26 subvenite starter (blue) kit 26 subvenite starter (green) kit 26 subvenite starter (orange) kit 26 SUCRAID 85 sucralfate 86 sulfacetamide sodium 58 114 sulfacetamide sodium (acne) 62 sulfacetamide-prednisolone 114 sulfadiazine 12 sulfamethoxazole-trimethoprim
12 SULFAMYLON 62 sulfasalazine 85 sulfatrim 12 sulindac 36 sumatriptan 28 sumatriptan succinate 28 29 SUNOSI 43 SUPPRELIN LA 21 SUPRAX 7 SUPREP BOWEL PREP KIT
85 SUTENT 22 syeda 107 SYLVANT 22
symax fastabs 81 symax-sl 81 symax-sr 81 SYMBICORT 120 SYMDEKO 120 SYMLINPEN 120 79 SYMLINPEN 60 79 SYMPAZAN 26 SYNAGIS 5 SYNAREL 76 SYNERA 61 SYNJARDY 79 SYNJARDY XR 79 SYNRIBO 22 SYNTHROID 79 T TABLOID 22 tacrolimus 22 59 tadalafil 121 tadalafil (pulm hypertension)
120 TAFINLAR 22 TAGRISSO 22 TAKHZYRO 120 TALTZ AUTOINJECTOR 58 TALTZ AUTOINJECTOR (2
PACK) 58 TALTZ AUTOINJECTOR (3
PACK) 58 TALTZ SYRINGE 58 TALZENNA 22 tamoxifen 22 tamsulosin 121 TARGRETIN 22 tarina 24 fe 107 tarina fe 120 (28) 107 TASIGNA 22 tavaborole 63 tazarotene 61 tazicef 7 taztia xt 49 TDVAX 93 TECENTRIQ 22 TEFLARO 7 TEKTURNA HCT 49 telmisartan 49 telmisartan-amlodipine 49 telmisartan-hydrochlorothiazid
49 temazepam 43 TEMODAR 22
139
temozolomide 22 temsirolimus 22 tencon 33 TENIVAC (PF) 94 tenofovir disoproxil fumarate 5 TEPEZZA 76 terazosin 49 terbinafine hcl 1 terbutaline 120 terconazole 101 testosterone 77 testosterone cypionate 76 testosterone enanthate 76 TETANUSDIPHTHERIA
TOX PED(PF) 94 tetrabenazine 30 tetracaine hcl 111 TETRACAINE HCL (PF) 111 tetracycline 12 THALOMID 22 theophylline 120 thioridazine 43 thiothixene 43 THYMOGLOBULIN 94 THYROLAR-1 79 THYROLAR-12 79 THYROLAR-14 79 THYROLAR-2 79 THYROLAR-3 79 tiadylt er 49 tiagabine 26 TIBSOVO 22 tilia fe 107 timolol maleate 49 110 tinidazole 10 TIVICAY 5 TIVICAY PD 5 tizanidine 30 TOBRADEX 113 TOBRADEX ST 113 tobramycin 10 110 tobramycin in 0225 nacl 10 tobramycin sulfate 10 TOBRAMYCIN WITH
NEBULIZER 10 tobramycin-dexamethasone 113 TOBREX 110 TODAY CONTRACEPTIVE
SPONGE 101 tolcapone 28 tolmetin 36
tolterodine 121 topiramate 26 toremifene 22 TORISEL 22 torsemide 49 TOUJEO MAX U-300
SOLOSTAR 74 TOUJEO SOLOSTAR U-300
INSULIN 74 TRACLEER 120 TRADJENTA 79 tramadol 36 tramadol-acetaminophen 36 trandolapril 49 trandolapril-verapamil 49 tranexamic acid 54 101 tranylcypromine 43 travoprost 112 trazodone 43 TREANDA 22 TRECATOR 10 TRELEGY ELLIPTA 120 TRELSTAR 22 TREMFYA 59 TRESIBA FLEXTOUCH U-
100 74 TRESIBA FLEXTOUCH U-
200 74 TRESIBA U-100 INSULIN 74 tretinoin 61 tretinoin (antineoplastic) 22 tretinoin microspheres 61 TRETTEN 54 TREXALL 22 tri femynor 107 triamcinolone acetonide 65 69
71 triamterene 49 triamterene-hydrochlorothiazid
49 triazolam 43 triderm 65 trientine 67 tri-estarylla 107 trifluoperazine 43 trifluridine 110 trihexyphenidyl 28 TRIJARDY XR 71 TRIKAFTA 120 tri-legest fe 108 tri-linyah 108
tri-lo-estarylla 108 tri-lo-marzia 108 tri-lo-mili 108 tri-lo-sprintec 108 trilyte with flavor packets 85 trimethobenzamide 85 trimethoprim 13 tri-mili 108 trimipramine 43 TRINTELLIX 43 tri-nymyo 108 tri-previfem (28) 108 tri-sprintec (28) 108 TRIUMEQ 5 tri-vitamin with fluoride 124 trivora (28) 108 tri-vylibra 108 tri-vylibra lo 108 TROGARZO 5 tropicamide 110 trospium 121 TRULICITY 79 TRUMENBA 94 TRUXIMA 22 TUKYSA 23 tulana 101 TWINRIX (PF) 94 TWIRLA 101 TYBLUME 108 TYBOST 5 tydemy 108 TYGACIL 10 TYMLOS 95 TYPHIM VI 94 TYSABRI 30 TYVASO 120 TYVASO REFILL KIT 120 TYVASO STARTER KIT 120 U UBRELVY 29 UDENYCA 87 ULESFIA 66 unithroid 80 UNITUXIN 23 URELLE 122 uretron d-s 122 urimar-t 122 urogesic-blue 122 ursodiol 85 uryl 122 ustell 122
140
UTIBRON NEOHALER 120 utira-c 122 UVADEX 59 V vaginal contraceptive foam 101 valacyclovir 5 VALCHLOR 59 valganciclovir 5 valproic acid 26 valproic acid (as sodium salt)
26 valsartan 49 valsartan-hydrochlorothiazide
49 vanadom 30 vancomycin 13 vandazole 101 VANTAS 23 VAQTA (PF) 94 VARIVAX (PF) 94 VARUBI 85 VASCEPA 56 VAXELIS (PF) 94 VCF CONTRACEPTIVE
FILM 101 VCF CONTRACEPTIVE GEL
101 VECTIBIX 23 VELCADE 23 veletri 50 velivet triphasic regimen (28)
108 VELPHORO 85 VEMLIDY 5 VENCLEXTA 23 VENCLEXTA STARTING
PACK 23 venlafaxine 43 VENTAVIS 120 verapamil 50 VERSACLOZ 43 VERZENIO 23 vestura (28) 108 VIBATIV 13 VIBERZI 85 VIDAZA 23 VIEKIRA PAK 5 vienva 108 vigabatrin 26 vigadrone 26 VIMIZIM 77
VIMPAT 26 viorele (28) 108 VIRACEPT 5 VIREAD 5 virtussin ac 116 VISTOGARD 13 VISUDYNE 111 vitamins acd and fluoride 124 VITRAKVI 23 VIVITROL 36 volnea (28) 108 VONVENDI 54 VORAXAZE 13 voriconazole 1 2 VOSEVI 5 VOTRIENT 23 VPRIV 77 VRAYLAR 44 VYEPTI 29 vyfemla (28) 108 vylibra 108 VYONDYS-53 30 VYVANSE 44 VYXEOS 23 W warfarin 54 wera (28) 108 westhroid 80 WIDE-SEAL DIAPHRAGM
98 WILATE 54 wixela inhub 121 wymzya fe 108 X XALKORI 23 XARELTO 54 XARELTO DVT-PE TREAT
30D START 54 XCOPRI 27 XCOPRI MAINTENANCE
PACK 27 XCOPRI TITRATION PACK
27 XELJANZ 97 XELJANZ XR 97 XEMBIFY 94 XENLETA 10 XEOMIN 94 XERMELO 23 XGEVA 13 XIFAXAN 10
XIGDUO XR 79 XIIDRA 111 XOLAIR 121 XOSPATA 23 XTANDI 23 xulane 102 XULTOPHY 10036 74 XURIDEN 67 XYNTHA 55 XYNTHA SOLOFUSE 55 XYREM 44 Y YERVOY 23 YESCARTA 23 YF-VAX (PF) 94 YONDELIS 23 YONSA 23 YUTIQ 114 yuvafem 101 Z zafemy 102 zafirlukast 121 zaleplon 44 ZALTRAP 23 ZANOSAR 23 zarah 109 ZARXIO 87 ZEJULA 24 ZELBORAF 24 ZEMAIRA 68 zenatane 61 ZENPEP 85 ZENZEDI 44 ZEPATIER 5 ZEPOSIA 89 ZEPOSIA STARTER KIT 89 ZEPOSIA STARTER PACK
89 ZERBAXA 7 zidovudine 5 ZIEXTENZO 87 zileuton 121 ziprasidone hcl 44 ZIRGAN 110 ZOKINVY 68 ZOLADEX 24 ZOLGENSMA 30 ZOLINZA 24 zolmitriptan 29 zolpidem 44 ZOLPIMIST 44
141
ZOMIG 29 zonisamide 27 ZONTIVITY 55 ZORBTIVE 87
ZOSTAVAX (PF) 94 zovia 135e (28) 109 ZULRESSO 44 zumandimine (28) 109
ZYFLO 121 ZYKADIA 24 ZYPITAMAG 56
051267 (11-20-2019)
Discrimination is Against the Law
LifeWise Health Plan of Washington (LifeWise) complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex LifeWise does not exclude people or treat them differently because of race color national origin age disability sex gender identity or sexual orientation LifeWise provides free aids and services to people with disabilities to communicate effectively with us such as qualified sign language interpreters and written information in other formats (large print audio accessible electronic formats other formats) LifeWise provides free language services to people whose primary language is not English such as qualified interpreters and information written in other languages If you need these services contact the Civil Rights Coordinator If you believe that LifeWise 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 Civil Rights Coordinator Complaints and Appeals PO Box 91102 Seattle WA 98111 Toll free 855-332-6396 Fax 425-918-5592 TTY 711 Email AppealsDepartmentInquiriesLifeWiseHealthcom You can file a grievance in person or by mail fax or email If you need help filing a grievance the Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Ave SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
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Metallic M2 Formulary
Drug Tier Includes
Formulary Drugs (1) Formulary Drugs include Preferred Generic Preferred Brand and Non-Preferred Drugs Medical plan cost shares apply to formulary drugs Once you have satisfied your medical deductible you will pay your applicable coinsurance until you reach your out of pocket maximum limit
Specialty Drug (2) Tier 2 includes specialty drugs Specialty drugs are generally biologics and other targeted drugs usually used for complex medical conditions and often requiring special handling
ACA PV The ACA PV tier includes Affordable Care Act (ACA) Preventive medications The ACA makes certain preventive medications available to you at no cost Coverage of any medication as ACA PV (including over-the-counter (OTC) medications) requires a prescription from a licensed health care provider
MB (Medical Benefit) The MB tier includes medical benefit drugs normally administered in a clinic infusion center or provided by a home infusion service These drugs and their services are covered under the medical benefit not under the pharmacy benefit This drug may require prior authorization
1
Drug Name Drug Tier Requirements Limits
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG
MB
amphotericin b injection recon soln 50 mg MB
CANCIDAS INTRAVENOUS RECON SOLN 50 MG 70 MG
MB
clotrimazole mucous membrane troche 10 mg 1
CRESEMBA INTRAVENOUS RECON SOLN 372 MG
MB
CRESEMBA ORAL CAPSULE 186 MG 1 PA
ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG 50 MG
MB
fluconazole oral suspension for reconstitution 10 mgml 40 mgml
1
fluconazole oral tablet 100 mg 150 mg 200 mg 50 mg
1
flucytosine oral capsule 250 mg 500 mg 1
griseofulvin microsize oral suspension 125 mg5 ml
1
griseofulvin microsize oral tablet 500 mg 1
griseofulvin ultramicrosize oral tablet 125 mg 250 mg
1
itraconazole oral capsule 100 mg 1
itraconazole oral solution 10 mgml 1
ketoconazole oral tablet 200 mg 1
MYCAMINE INTRAVENOUS RECON SOLN 100 MG 50 MG
MB
NOXAFIL ORAL SUSPENSION 200 MG5 ML (40 MGML)
1
nystatin oral suspension 100000 unitml 1
nystatin oral tablet 500000 unit 1
ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET 50 MG
1
posaconazole oral tabletdelayed release (drec) 100 mg
1
terbinafine hcl oral tablet 250 mg 1
voriconazole intravenous recon soln 200 mg MB
2
Drug Name Drug Tier Requirements Limits
voriconazole oral suspension for reconstitution 200 mg5 ml (40 mgml)
1
voriconazole oral tablet 200 mg 50 mg 1
ANTIVIRALS
abacavir oral solution 20 mgml 1 QL (60 per 30 days)
abacavir oral tablet 300 mg 1 QL (60 per 30 days)
abacavir-lamivudine oral tablet 600-300 mg 1 QL (30 per 30 days)
abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg
1 QL (60 per 30 days)
acyclovir oral capsule 200 mg 1
acyclovir oral suspension 200 mg5 ml 1
acyclovir oral tablet 400 mg 800 mg 1
adefovir oral tablet 10 mg 1
amantadine hcl oral capsule 100 mg 1
amantadine hcl oral solution 50 mg5 ml 1
amantadine hcl oral tablet 100 mg 1
APTIVUS ORAL CAPSULE 250 MG 1 QL (120 per 30 days)
atazanavir oral capsule 150 mg 300 mg 1 QL (30 per 30 days)
atazanavir oral capsule 200 mg 1 QL (60 per 30 days)
BARACLUDE ORAL SOLUTION 005 MGML 1
BIKTARVY ORAL TABLET 50-200-25 MG 1 QL (30 per 30 days)
CABENUVA INTRAMUSCULAR SUSPENSIONEXTENDED RELEASE 400 MG2 ML- 600 MG2 ML 600 MG3 ML- 900 MG3 ML
2 PA
cidofovir intravenous solution 75 mgml MB
CIMDUO ORAL TABLET 300-300 MG 1 QL (30 per 30 days)
COMPLERA ORAL TABLET 200-25-300 MG 1 QL (30 per 30 days)
CYTOVENE INTRAVENOUS RECON SOLN 500 MG
MB
DESCOVY ORAL TABLET 200-25 MG 1 QL (30 per 30 days)
didanosine oral capsuledelayed release(drec) 250 mg 400 mg
1 QL (30 per 30 days)
DOVATO ORAL TABLET 50-300 MG 1 QL (30 per 30 days)
EDURANT ORAL TABLET 25 MG 1 QL (30 per 30 days)
efavirenz oral capsule 200 mg 50 mg 1 QL (30 per 30 days)
efavirenz oral tablet 600 mg 1 QL (30 per 30 days)
3
Drug Name Drug Tier Requirements Limits
efavirenz-emtricitabin-tenofov oral tablet 600-200-300 mg
1
efavirenz-lamivu-tenofov disop oral tablet 400-300-300 mg 600-300-300 mg
1
emtricitabine oral capsule 200 mg 1 QL (30 per 30 days)
emtricitabine-tenofovir (tdf) oral tablet 100-150 mg 133-200 mg 167-250 mg 200-300 mg
1
EMTRIVA ORAL SOLUTION 10 MGML 1 QL (720 per 30 days)
entecavir oral tablet 05 mg 1 mg 1
EPCLUSA ORAL TABLET 200-50 MG 400-100 MG
2 PA LA
EPIVIR HBV ORAL SOLUTION 25 MG5 ML (5 MGML)
1
etravirine oral tablet 100 mg 200 mg 1 QL (60 per 30 days)
EVOTAZ ORAL TABLET 300-150 MG 1 QL (30 per 30 days)
famciclovir oral tablet 125 mg 250 mg 500 mg 1
fosamprenavir oral tablet 700 mg 1 QL (60 per 30 days)
FUZEON SUBCUTANEOUS RECON SOLN 90 MG
2 QL (30 per 30 days)
GANCICLOVIR INTRAVENOUS SOLUTION 500 MG250 ML (2 MGML)
MB
ganciclovir sodium intravenous recon soln 500 mg MB
GENVOYA ORAL TABLET 150-150-200-10 MG
1 QL (30 per 30 days)
HARVONI ORAL PELLETS IN PACKET 3375-150 MG 45-200 MG
2 LA
HARVONI ORAL TABLET 45-200 MG 90-400 MG
2 PA LA
INTELENCE ORAL TABLET 100 MG 200 MG 25 MG
1 QL (60 per 30 days)
INVIRASE ORAL TABLET 500 MG 1 QL (120 per 30 days)
ISENTRESS HD ORAL TABLET 600 MG 1 QL (60 per 30 days)
ISENTRESS ORAL POWDER IN PACKET 100 MG
1 QL (60 per 30 days)
ISENTRESS ORAL TABLET 400 MG 1 QL (60 per 30 days)
ISENTRESS ORAL TABLETCHEWABLE 100 MG 25 MG
1 QL (60 per 30 days)
JULUCA ORAL TABLET 50-25 MG 1 QL (30 per 30 days)
KALETRA ORAL TABLET 100-25 MG 1 QL (60 per 30 days)
4
Drug Name Drug Tier Requirements Limits
KALETRA ORAL TABLET 200-50 MG 1 QL (120 per 30 days)
lamivudine oral solution 10 mgml 1 QL (900 per 30 days)
lamivudine oral tablet 100 mg 1
lamivudine oral tablet 150 mg 300 mg 1 QL (60 per 30 days)
lamivudine-zidovudine oral tablet 150-300 mg 1 QL (60 per 30 days)
LEXIVA ORAL SUSPENSION 50 MGML 1 QL (60 per 30 days)
lopinavir-ritonavir oral solution 400-100 mg5 ml 1 QL (320 per 30 days)
lopinavir-ritonavir oral tablet 100-25 mg 200-50 mg
1 QL (120 per 30 days)
MAVYRET ORAL TABLET 100-40 MG 2 PA LA
nevirapine oral suspension 50 mg5 ml 1 QL (60 per 30 days)
nevirapine oral tablet 200 mg 1 QL (60 per 30 days)
nevirapine oral tablet extended release 24 hr 100 mg 400 mg
1 QL (30 per 30 days)
NORVIR ORAL POWDER IN PACKET 100 MG 1 QL (360 per 30 days)
NORVIR ORAL SOLUTION 80 MGML 1 QL (480 per 30 days)
ODEFSEY ORAL TABLET 200-25-25 MG 1 QL (30 per 30 days)
oseltamivir oral capsule 30 mg 1 QL (40 per 365 days)
oseltamivir oral capsule 45 mg 75 mg 1 QL (20 per 365 days)
oseltamivir oral suspension for reconstitution 6 mgml
1 QL (180 per 30 days)
PREVYMIS INTRAVENOUS SOLUTION 240 MG12 ML 480 MG24 ML
MB PA
PREZCOBIX ORAL TABLET 800-150 MG-MG 1 QL (30 per 30 days)
PREZISTA ORAL SUSPENSION 100 MGML 1 QL (30 per 30 days)
PREZISTA ORAL TABLET 150 MG 600 MG 75 MG
1 QL (60 per 30 days)
PREZISTA ORAL TABLET 800 MG 1 QL (30 per 30 days)
RAPIVAB (PF) INTRAVENOUS SOLUTION 200 MG20 ML (10 MGML)
MB
RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MGACTUATION
1 QL (2 per 30 days)
REYATAZ ORAL POWDER IN PACKET 50 MG
1 QL (150 per 30 days)
ribavirin inhalation recon soln 6 gram MB
rimantadine oral tablet 100 mg 1
ritonavir oral tablet 100 mg 1 QL (360 per 30 days)
5
Drug Name Drug Tier Requirements Limits
SELZENTRY ORAL SOLUTION 20 MGML 1 QL (8 per 30 days)
SELZENTRY ORAL TABLET 150 MG 25 MG 300 MG 75 MG
1 QL (60 per 30 days)
SOVALDI ORAL PELLETS IN PACKET 150 MG 200 MG
2 LA
SOVALDI ORAL TABLET 200 MG 400 MG 2 PA LA
stavudine oral capsule 15 mg 20 mg 40 mg 1 QL (120 per 30 days)
STRIBILD ORAL TABLET 150-150-200-300 MG
1 QL (30 per 30 days)
SYNAGIS INTRAMUSCULAR SOLUTION 100 MGML 50 MG05 ML
MB LA
tenofovir disoproxil fumarate oral tablet 300 mg 1 QL (30 per 30 days)
TIVICAY ORAL TABLET 10 MG 25 MG 50 MG
1 QL (60 per 30 days)
TIVICAY PD ORAL TABLET FOR SUSPENSION 5 MG
1 QL (60 per 30 days)
TRIUMEQ ORAL TABLET 600-50-300 MG 1 QL (30 per 30 days)
TROGARZO INTRAVENOUS SOLUTION 200 MG133 ML (150 MGML)
MB PA
TYBOST ORAL TABLET 150 MG 1 QL (30 per 30 days)
valacyclovir oral tablet 1 gram 500 mg 1
valganciclovir oral recon soln 50 mgml 1
valganciclovir oral tablet 450 mg 1
VEMLIDY ORAL TABLET 25 MG 1
VIEKIRA PAK ORAL TABLETSDOSE PACK 125 MG-75 MG -50 MG250 MG
2 PA
VIRACEPT ORAL TABLET 250 MG 1 QL (90 per 30 days)
VIRACEPT ORAL TABLET 625 MG 1 QL (60 per 30 days)
VIREAD ORAL POWDER 40 MGSCOOP (40 MGGRAM)
1 QL (4 per 30 days)
VIREAD ORAL TABLET 150 MG 200 MG 250 MG
1 QL (30 per 30 days)
VOSEVI ORAL TABLET 400-100-100 MG 2 PA LA
ZEPATIER ORAL TABLET 50-100 MG 2 PA LA
zidovudine oral capsule 100 mg 1 QL (60 per 30 days)
zidovudine oral syrup 10 mgml 1 QL (960 per 30 days)
zidovudine oral tablet 300 mg 1 QL (60 per 30 days)
CEPHALOSPORINS
6
Drug Name Drug Tier Requirements Limits
AVYCAZ INTRAVENOUS RECON SOLN 25 GRAM
MB
cefaclor oral capsule 250 mg 500 mg 1
cefaclor oral suspension for reconstitution 125 mg5 ml 250 mg5 ml 375 mg5 ml
1
cefaclor oral tablet extended release 12 hr 500 mg 1
cefadroxil oral capsule 500 mg 1
cefadroxil oral suspension for reconstitution 250 mg5 ml 500 mg5 ml
1
cefadroxil oral tablet 1 gram 1
cefazolin in dextrose (iso-os) intravenous piggyback 1 gram50 ml
MB
cefazolin injection recon soln 1 gram 10 gram 100 gram 20 gram 300 g 500 mg
MB
cefazolin intravenous recon soln 1 gram MB
cefdinir oral capsule 300 mg 1
cefdinir oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cefditoren pivoxil oral tablet 200 mg 400 mg 1
CEFEPIME IN DEXTROSE 5 INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
cefepime in dextroseiso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml
MB
cefepime injection recon soln 1 gram 2 gram MB
cefixime oral capsule 400 mg 1
cefixime oral suspension for reconstitution 100 mg5 ml 200 mg5 ml
1
CEFOTAN INJECTION RECON SOLN 1 GRAM 2 GRAM
MB
cefotaxime injection recon soln 1 gram MB
CEFOTETAN IN DEXTROSE ISO-OSM INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
cefotetan injection recon soln 1 gram 2 gram MB
cefotetan intravenous recon soln 10 gram MB
cefoxitin intravenous recon soln 10 gram MB
cefpodoxime oral suspension for reconstitution 100 mg5 ml 50 mg5 ml
1
7
Drug Name Drug Tier Requirements Limits
cefpodoxime oral tablet 100 mg 200 mg 1
cefprozil oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cefprozil oral tablet 250 mg 500 mg 1
CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
ceftazidime injection recon soln 1 gram 2 gram 6 gram
MB
ceftriaxone in dextroseiso-os intravenous piggyback 1 gram50 ml 2 gram50 ml
MB
ceftriaxone injection recon soln 1 gram 10 gram 2 gram 250 mg 500 mg
MB
CEFTRIAXONE INJECTION RECON SOLN 100 GRAM
MB
ceftriaxone intravenous recon soln 1 gram 2 gram MB
cefuroxime axetil oral tablet 250 mg 500 mg 1
cephalexin oral capsule 250 mg 500 mg 750 mg 1
cephalexin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cephalexin oral tablet 250 mg 500 mg 1
SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG5 ML
1
SUPRAX ORAL TABLETCHEWABLE 100 MG 200 MG
1
tazicef injection recon soln 1 gram 2 gram 6 gram
MB
tazicef intravenous recon soln 1 gram 2 gram MB
TEFLARO INTRAVENOUS RECON SOLN 400 MG 600 MG
MB
ZERBAXA INTRAVENOUS RECON SOLN 15 GRAM
MB
ERYTHROMYCINS amp OTHER MACROLIDES
azithromycin oral packet 1 gram 1
azithromycin oral suspension for reconstitution 100 mg5 ml 200 mg5 ml
1
azithromycin oral tablet 250 mg 500 mg 600 mg 1
clarithromycin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
clarithromycin oral tablet 250 mg 500 mg 1
8
Drug Name Drug Tier Requirements Limits
clarithromycin oral tablet extended release 24 hr 500 mg
1
DIFICID ORAL TABLET 200 MG 1
ees 400 oral tablet 400 mg 1
ery-tab oral tabletdelayed release (drec) 250 mg 333 mg
1
erythrocin (as stearate) oral tablet 250 mg 1
erythromycin ethylsuccinate oral suspension for reconstitution 200 mg5 ml 400 mg5 ml
1
erythromycin ethylsuccinate oral tablet 400 mg 1
erythromycin oral capsuledelayed release(drec) 250 mg
1
erythromycin oral tablet 250 mg 500 mg 1
erythromycin oral tabletdelayed release (drec) 250 mg 333 mg 500 mg
1
MISCELLANEOUS ANTIINFECTIVES
albendazole oral tablet 200 mg 1
ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG5 ML
1 PA ST
amikacin injection solution 500 mg2 ml MB
atovaquone oral suspension 750 mg5 ml 1
atovaquone-proguanil oral tablet 250-100 mg 625-25 mg
1
bacitracin intramuscular recon soln 50000 unit 1
CAPASTAT INJECTION RECON SOLN 1 GRAM
1
CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MGML
2 PA LA QL (84 per 30 days)
chloramphenicol sod succinate intravenous recon soln 1 gram
MB
chloroquine phosphate oral tablet 250 mg 500 mg 1
clindamycin hcl oral capsule 150 mg 300 mg 75 mg
1
clindamycin pediatric oral recon soln 75 mg5 ml 1
clindamycin phosphate injection solution 150 mgml
MB
COARTEM ORAL TABLET 20-120 MG 1
CUBICIN INTRAVENOUS RECON SOLN 500 MG
MB
9
Drug Name Drug Tier Requirements Limits
CUBICIN RF INTRAVENOUS RECON SOLN 500 MG
MB
CYCLOSERINE ORAL CAPSULE 250 MG 1
dapsone oral tablet 100 mg 25 mg 1
EMVERM ORAL TABLETCHEWABLE 100 MG
1
ethambutol oral tablet 100 mg 400 mg 1
gentamicin injection solution 20 mg2 ml 40 mgml
MB
gentamicin sulfate (ped) (pf) injection solution 20 mg2 ml
MB
hydroxychloroquine oral tablet 200 mg 1
imipenem-cilastatin intravenous recon soln 250 mg 500 mg
MB
INVANZ INJECTION RECON SOLN 1 GRAM MB
isoniazid injection solution 100 mgml 1
isoniazid oral solution 50 mg5 ml 1
isoniazid oral tablet 100 mg 300 mg 1
ivermectin oral tablet 3 mg 1
LINCOCIN INJECTION SOLUTION 300 MGML
MB
linezolid in dextrose 5 intravenous piggyback 600 mg300 ml
MB
linezolid oral suspension for reconstitution 100 mg5 ml
1
linezolid oral tablet 600 mg 1
linezolid-09 sodium chloride intravenous parenteral solution 600 mg300 ml
MB
mefloquine oral tablet 250 mg 1
meropenem intravenous recon soln 1 gram 500 mg
MB
MEROPENEM-09 SODIUM CHLORIDE INTRAVENOUS PIGGYBACK 1 GRAM50 ML 500 MG50 ML
MB
metronidazole oral capsule 375 mg 1
metronidazole oral tablet 250 mg 500 mg 1
neomycin oral tablet 500 mg 1
nitazoxanide oral tablet 500 mg 1
10
Drug Name Drug Tier Requirements Limits
paromomycin oral capsule 250 mg 1
PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM
1
PENTAM INJECTION RECON SOLN 300 MG MB
pentamidine inhalation recon soln 300 mg 1
pentamidine injection recon soln 300 mg MB
polymyxin b sulfate injection recon soln 500000 unit
MB
praziquantel oral tablet 600 mg 1
PRIFTIN ORAL TABLET 150 MG 1
primaquine oral tablet 263 mg 1
pyrazinamide oral tablet 500 mg 1
pyrimethamine oral tablet 25 mg 2 PA
quinine sulfate oral capsule 324 mg 1
rifabutin oral capsule 150 mg 1
rifampin oral capsule 150 mg 300 mg 1
SIRTURO ORAL TABLET 100 MG 1 PA
SIRTURO ORAL TABLET 20 MG 1
SIVEXTRO ORAL TABLET 200 MG 1 QL (6 per 30 days)
STREPTOMYCIN INTRAMUSCULAR RECON SOLN 1 GRAM
1
tinidazole oral tablet 250 mg 500 mg 1
tobramycin in 0225 nacl inhalation solution for nebulization 300 mg5 ml
2
tobramycin inhalation solution for nebulization 300 mg4 ml
2
tobramycin sulfate injection recon soln 12 gram 1
tobramycin sulfate injection solution 10 mgml MB
tobramycin sulfate injection solution 40 mgml 1
TOBRAMYCIN WITH NEBULIZER INHALATION SOLUTION FOR NEBULIZATION 300 MG5 ML
2 PA ST
TRECATOR ORAL TABLET 250 MG 1
TYGACIL INTRAVENOUS RECON SOLN 50 MG
MB
XENLETA INTRAVENOUS SOLUTION 150 MG15 ML
MB
XIFAXAN ORAL TABLET 200 MG 550 MG 1 PA QL (60 per 30 days)
11
Drug Name Drug Tier Requirements Limits
PENICILLINS
amoxicillin oral capsule 250 mg 500 mg 1
amoxicillin oral suspension for reconstitution 125 mg5 ml 200 mg5 ml 250 mg5 ml 400 mg5 ml
1
amoxicillin oral tablet 500 mg 875 mg 1
amoxicillin oral tabletchewable 125 mg 250 mg 1
amoxicillin-pot clavulanate oral suspension for reconstitution 200-285 mg5 ml 250-625 mg5 ml 400-57 mg5 ml 600-429 mg5 ml
1
amoxicillin-pot clavulanate oral tablet 250-125 mg 500-125 mg 875-125 mg
1
amoxicillin-pot clavulanate oral tablet extended release 12 hr 1000-625 mg
1
amoxicillin-pot clavulanate oral tabletchewable 200-285 mg 400-57 mg
1
ampicillin oral capsule 500 mg 1
ampicillin-sulbactam injection recon soln 15 gram MB
BICILLIN C-R INTRAMUSCULAR SYRINGE 1200000 UNIT 2 ML(900K300K)
MB
dicloxacillin oral capsule 250 mg 500 mg 1
MOXATAG ORAL TABLET ER MULTIPHASE 24 HR 775 MG
1
nafcillin in dextrose iso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml
MB
nafcillin injection recon soln 1 gram 10 gram 2 gram
MB
nafcillin intravenous recon soln 1 gram 2 gram MB
oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram50 ml 2 gram50 ml
MB
oxacillin injection recon soln 1 gram 10 gram 2 gram
MB
penicillin g procaine intramuscular syringe 12 million unit2 ml 600000 unitml
MB
penicillin v potassium oral recon soln 125 mg5 ml 250 mg5 ml
1
penicillin v potassium oral tablet 250 mg 500 mg 1
piperacillin-tazobactam intravenous recon soln 135 gram 225 gram 3375 gram 45 gram 405 gram
MB
12
Drug Name Drug Tier Requirements Limits
QUINOLONES
BAXDELA INTRAVENOUS RECON SOLN 300 MG
MB
BAXDELA ORAL TABLET 450 MG 1
ciprofloxacin hcl oral tablet 100 mg 250 mg 500 mg 750 mg
1
ciprofloxacin oral suspensionmicrocapsule recon 250 mg5 ml 500 mg5 ml
1
FACTIVE ORAL TABLET 320 MG 1 ST
levofloxacin oral solution 250 mg10 ml 1
levofloxacin oral tablet 250 mg 500 mg 750 mg 1
moxifloxacin oral tablet 400 mg 1
ofloxacin oral tablet 300 mg 400 mg 1
SULFAS amp RELATED AGENTS
sulfadiazine oral tablet 500 mg 1
sulfamethoxazole-trimethoprim oral suspension 200-40 mg5 ml
1
sulfamethoxazole-trimethoprim oral tablet 400-80 mg 800-160 mg
1
sulfatrim oral suspension 200-40 mg5 ml 1
TETRACYCLINES
avidoxy oral tablet 100 mg 1 ST
demeclocycline oral tablet 150 mg 300 mg 1
doxycycline hyclate oral capsule 100 mg 50 mg 1
doxycycline hyclate oral tablet 100 mg 150 mg 20 mg 50 mg 75 mg
1
doxycycline hyclate oral tabletdelayed release (drec) 100 mg 150 mg 200 mg 50 mg 75 mg
1
doxycycline monohydrate oral capsule 100 mg 150 mg 50 mg 75 mg
1
doxycycline monohydrate oral suspension for reconstitution 25 mg5 ml
1
doxycycline monohydrate oral tablet 100 mg 150 mg 50 mg 75 mg
1
minocycline oral capsule 100 mg 50 mg 75 mg 1
minocycline oral tablet 100 mg 50 mg 75 mg 1
mondoxyne nl oral capsule 100 mg 75 mg 1
tetracycline oral capsule 250 mg 500 mg 1
13
Drug Name Drug Tier Requirements Limits
URINARY TRACT AGENTS
fosfomycin tromethamine oral packet 3 gram 1
methenamine hippurate oral tablet 1 gram 1
methenamine mandelate oral tablet 05 g 1 gram 1
nitrofurantoin macrocrystal oral capsule 100 mg 25 mg 50 mg
1
nitrofurantoin monohydm-cryst oral capsule 100 mg
1
nitrofurantoin oral suspension 25 mg5 ml 1
PRIMSOL ORAL SOLUTION 50 MG5 ML 1
trimethoprim oral tablet 100 mg 1
VANCOMYCIN
vancomycin oral capsule 125 mg 250 mg 1
vancomycin oral recon soln 50 mgml 1
VIBATIV INTRAVENOUS RECON SOLN 750 MG
MB
ANTINEOPLASTIC amp IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
KEPIVANCE INTRAVENOUS RECON SOLN 625 MG
MB
leucovorin calcium injection recon soln 100 mg 200 mg 350 mg 50 mg 500 mg
MB
leucovorin calcium injection solution 10 mgml MB
leucovorin calcium oral tablet 10 mg 15 mg 25 mg 5 mg
1
VISTOGARD ORAL GRANULES IN PACKET 10 GRAM
2
VORAXAZE INTRAVENOUS RECON SOLN 1000 UNIT
MB
XGEVA SUBCUTANEOUS SOLUTION 120 MG17 ML (70 MGML)
2 LA
ANTINEOPLASTIC amp IMMUNOSUPPRESSANT DRUGS
abiraterone oral tablet 250 mg 2 PA OCh LA
abiraterone oral tablet 500 mg 2 PA ST OCh LA
ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG
MB PA LA
ADAKVEO INTRAVENOUS SOLUTION 10 MGML
MB PA
14
Drug Name Drug Tier Requirements Limits
ADCETRIS INTRAVENOUS RECON SOLN 50 MG
MB PA LA
AFINITOR ORAL TABLET 10 MG 2 OCh LA
ALECENSA ORAL CAPSULE 150 MG 2 PA OCh LA
ALIMTA INTRAVENOUS RECON SOLN 100 MG 500 MG
MB PA
ALIQOPA INTRAVENOUS RECON SOLN 60 MG
MB PA
anastrozole oral tablet 1 mg ACA PV OCh QL (30 per 30 days)
ARRANON INTRAVENOUS SOLUTION 250 MG50 ML
MB LA
ARZERRA INTRAVENOUS SOLUTION 1000 MG50 ML 100 MG5 ML
MB PA LA
ASPARLAS INTRAVENOUS SOLUTION 750 UNITML
MB PA
AVASTIN INTRAVENOUS SOLUTION 25 MGML
MB PA LA
azathioprine oral tablet 50 mg 1
BALVERSA ORAL TABLET 3 MG 4 MG 5 MG
2 PA OCh
BAVENCIO INTRAVENOUS SOLUTION 20 MGML
MB PA
BELEODAQ INTRAVENOUS RECON SOLN 500 MG
MB PA
BELRAPZO INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BENDAMUSTINE INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BENDEKA INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BESPONSA INTRAVENOUS RECON SOLN 09 MG (025 MGML INITIAL)
MB PA LA
bexarotene oral capsule 75 mg 2 PA ST OCh
bicalutamide oral tablet 50 mg 2 OCh QL (30 per 30 days)
BLINCYTO INTRAVENOUS KIT 35 MCG MB PA
BORTEZOMIB INTRAVENOUS RECON SOLN 35 MG
MB
BOSULIF ORAL TABLET 100 MG 400 MG 500 MG
2 PA ST OCh LA
BRAFTOVI ORAL CAPSULE 50 MG 75 MG 2 PA OCh LA
15
Drug Name Drug Tier Requirements Limits
BUSULFEX INTRAVENOUS SOLUTION 60 MG10 ML
MB
CABOMETYX ORAL TABLET 20 MG 40 MG 60 MG
2 PA ST OCh LA
CALQUENCE ORAL CAPSULE 100 MG 2 PA ST OCh
capecitabine oral tablet 150 mg 2 OCh LA QL (210 per 30 days)
capecitabine oral tablet 500 mg 2 OCh LA QL (84 per 30 days)
CAPRELSA ORAL TABLET 100 MG 300 MG 2 PA OCh
CLOLAR INTRAVENOUS SOLUTION 20 MG20 ML
MB PA
COMETRIQ ORAL CAPSULE 100 MGDAY(80 MG X1-20 MG X1) 140 MGDAY(80 MG X1-20 MG X3) 60 MGDAY (20 MG X 3DAY)
2 PA OCh
COPIKTRA ORAL CAPSULE 15 MG 25 MG 2 PA OCh
COTELLIC ORAL TABLET 20 MG 2 PA OCh LA
cyclophosphamide intravenous recon soln 1 gram 2 gram 500 mg
MB
cyclophosphamide oral capsule 25 mg 50 mg 2 OCh
CYCLOPHOSPHAMIDE ORAL TABLET 25 MG 50 MG
2 OCh
cyclosporine modified oral capsule 100 mg 25 mg 50 mg
1
cyclosporine modified oral solution 100 mgml 1
cyclosporine oral capsule 100 mg 25 mg 1
CYRAMZA INTRAVENOUS SOLUTION 10 MGML
MB PA LA
DACOGEN INTRAVENOUS RECON SOLN 50 MG
MB PA LA
DARZALEX INTRAVENOUS SOLUTION 20 MGML
MB PA LA
DAURISMO ORAL TABLET 100 MG 25 MG 2 PA OCh LA
decitabine intravenous recon soln 50 mg MB LA
ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 225 MG
2
ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG
2
ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG
2
16
Drug Name Drug Tier Requirements Limits
ELIGARD SUBCUTANEOUS SYRINGE 75 MG (1 MONTH)
2
ELZONRIS INTRAVENOUS SOLUTION 1000 MCGML
MB PA
EMCYT ORAL CAPSULE 140 MG 2 OCh
EMPLICITI INTRAVENOUS RECON SOLN 300 MG 400 MG
MB PA LA
ENHERTU INTRAVENOUS RECON SOLN 100 MG
MB PA LA
ERBITUX INTRAVENOUS SOLUTION 100 MG50 ML 200 MG100 ML
MB PA LA
ERLEADA ORAL TABLET 60 MG 2 PA OCh LA
erlotinib oral tablet 100 mg 150 mg 25 mg 2 PA OCh LA
ERWINAZE INJECTION RECON SOLN 10000 UNIT
MB
etoposide intravenous solution 20 mgml MB
etoposide oral capsule 50 mg 2 OCh
everolimus (antineoplastic) oral tablet 25 mg 5 mg 75 mg
2 PA ST OCh LA
everolimus (immunosuppressive) oral tablet 025 mg 05 mg 075 mg
1 PA
exemestane oral tablet 25 mg ACA PV OCh QL (30 per 30 days)
FASLODEX INTRAMUSCULAR SYRINGE 250 MG5 ML
MB PA
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG 80 MG
2 LA
fludarabine intravenous recon soln 50 mg MB
fluorouracil intravenous solution 25 gram50 ml 5 gram100 ml 500 mg10 ml
MB PA
flutamide oral capsule 125 mg 2 OCh QL (180 per 30 days)
FOLOTYN INTRAVENOUS SOLUTION 20 MGML (1 ML) 40 MG2 ML (20 MGML)
MB PA LA
fulvestrant intramuscular syringe 250 mg5 ml MB
GAMIFANT INTRAVENOUS SOLUTION 5 MGML
MB PA
GAZYVA INTRAVENOUS SOLUTION 1000 MG40 ML
MB PA LA
gemcitabine intravenous recon soln 1 gram 2 gram 200 mg
MB
17
Drug Name Drug Tier Requirements Limits
gemcitabine intravenous solution 2 gram526 ml (38 mgml) 200 mg526 ml (38 mgml)
MB
gengraf oral capsule 100 mg 25 mg 1
gengraf oral solution 100 mgml 1
GILOTRIF ORAL TABLET 20 MG 30 MG 40 MG
2 PA OCh LA
GLEOSTINE ORAL CAPSULE 10 MG 100 MG 40 MG
2 PA OCh
HALAVEN INTRAVENOUS SOLUTION 1 MG2 ML (05 MGML)
MB PA LA
HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600 MG-10000 UNIT5 ML
MB LA
HERCEPTIN INTRAVENOUS RECON SOLN 150 MG
MB PA LA
HERZUMA INTRAVENOUS RECON SOLN 150 MG
MB PA LA
HYCAMTIN ORAL CAPSULE 025 MG 1 MG 2 OCh LA
hydroxyurea oral capsule 500 mg 2 OCh
IBRANCE ORAL CAPSULE 100 MG 125 MG 75 MG
2 PA OCh LA
IBRANCE ORAL TABLET 100 MG 125 MG 75 MG
2 OCh LA
ICLUSIG ORAL TABLET 10 MG 15 MG 30 MG 45 MG
2 PA ST OCh
IDHIFA ORAL TABLET 100 MG 50 MG 2 PA OCh LA
imatinib oral tablet 100 mg 2 OCh LA QL (90 per 30 days)
imatinib oral tablet 400 mg 2 OCh LA QL (60 per 30 days)
IMBRUVICA ORAL CAPSULE 140 MG 70 MG 2 PA ST OCh
IMBRUVICA ORAL TABLET 140 MG 280 MG 420 MG 560 MG
2 PA ST OCh
IMFINZI INTRAVENOUS SOLUTION 50 MGML
MB PA LA
IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFUML 10EXP8 (100 MILLION) PFUML
MB
18
Drug Name Drug Tier Requirements Limits
INFUGEM INTRAVENOUS PIGGYBACK 1200 MG120 ML (10 MGML) 1300 MG130 ML (10 MGML) 1400 MG140 ML (10 MGML) 1500 MG150 ML (10 MGML) 1600 MG160 ML (10 MGML) 1700 MG170 ML (10 MGML) 1800 MG180 ML (10 MGML) 1900 MG190 ML (10 MGML) 2000 MG200 ML (10 MGML) 2200 MG220 ML (10 MGML)
MB
INLYTA ORAL TABLET 1 MG 5 MG 2 PA OCh LA
IRESSA ORAL TABLET 250 MG 2 PA OCh LA
ISTODAX INTRAVENOUS RECON SOLN 10 MG2 ML
MB PA LA
IXEMPRA INTRAVENOUS RECON SOLN 15 MG 45 MG
MB PA LA
JAKAFI ORAL TABLET 10 MG 15 MG 20 MG 25 MG 5 MG
2 PA OCh LA
JEVTANA INTRAVENOUS SOLUTION 10 MGML (FIRST DILUTION)
MB PA LA
KADCYLA INTRAVENOUS RECON SOLN 100 MG 160 MG
MB PA LA
KANJINTI INTRAVENOUS RECON SOLN 150 MG 420 MG
MB PA LA
KEYTRUDA INTRAVENOUS SOLUTION 25 MGML
MB PA
KISQALI FEMARA CO-PACK ORAL TABLET 200 MGDAY(200 MG X 1)-25 MG 400 MGDAY(200 MG X 2)-25 MG 600 MGDAY(200 MG X 3)-25 MG
2 PA ST OCh LA
KISQALI ORAL TABLET 200 MGDAY (200 MG X 1) 400 MGDAY (200 MG X 2) 600 MGDAY (200 MG X 3)
2 PA ST OCh LA
KYMRIAH INTRAVENOUS SUSPENSION 02X10EXP6 TO 25X10EXP8 CELL 06 TO 6 X 10EXP8 CELL
MB PA
KYPROLIS INTRAVENOUS RECON SOLN 10 MG 30 MG 60 MG
MB PA
lapatinib oral tablet 250 mg 2 PA OCh LA QL (180 per 30 days)
LENVIMA ORAL CAPSULE 10 MGDAY (10 MG X 1) 12 MGDAY (4 MG X 3) 14 MGDAY(10 MG X 1-4 MG X 1) 18 MGDAY (10 MG X 1-4 MG X2) 20 MGDAY (10 MG X 2) 24 MGDAY(10 MG X 2-4 MG X 1) 4 MG 8 MGDAY (4 MG X 2)
2 PA ST OCh LA
19
Drug Name Drug Tier Requirements Limits
letrozole oral tablet 25 mg ACA PV OCh QL (30 per 30 days)
LEUKERAN ORAL TABLET 2 MG 2 OCh
leuprolide subcutaneous kit 1 mg02 ml 2
LIBTAYO INTRAVENOUS SOLUTION 50 MGML
MB PA
LONSURF ORAL TABLET 15-614 MG 20-819 MG
2 PA ST OCh LA
LUMOXITI INTRAVENOUS RECON SOLN 1 MG
MB
LUPKYNIS ORAL CAPSULE 79 MG 2 PA ST
LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 225 MG
2
LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG
2
LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG
2
LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 375 MG 75 MG
2
LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 30 MG
2
LUPRON DEPOT-PED INTRAMUSCULAR KIT 1125 MG 15 MG 75 MG (PED)
2
LYNPARZA ORAL TABLET 100 MG 150 MG 2 PA ST OCh LA
LYSODREN ORAL TABLET 500 MG 2 OCh
MARQIBO INTRAVENOUS KIT 5 MG31 ML(016 MGML) FINAL
MB PA
MATULANE ORAL CAPSULE 50 MG 2 OCh
megestrol oral suspension 400 mg10 ml (40 mgml)
1 QL (2 per 30 days)
megestrol oral suspension 625 mg5 ml (125 mgml)
1 QL (1 per 30 days)
megestrol oral tablet 20 mg 2 OCh QL (480 per 30 days)
megestrol oral tablet 40 mg 2 OCh QL (240 per 30 days)
MEKINIST ORAL TABLET 05 MG 2 MG 2 PA ST OCh LA
MEKTOVI ORAL TABLET 15 MG 2 PA OCh LA
melphalan hcl intravenous recon soln 50 mg MB
melphalan oral tablet 2 mg 2 OCh
20
Drug Name Drug Tier Requirements Limits
mercaptopurine oral tablet 50 mg 2 OCh QL (300 per 30 days)
methotrexate sodium (pf) injection recon soln 1 gram
1
methotrexate sodium (pf) injection solution 25 mgml
1
methotrexate sodium injection solution 25 mgml 1
methotrexate sodium oral tablet 25 mg 2 OCh
mitoxantrone intravenous concentrate 2 mgml MB PA LA
mycophenolate mofetil oral capsule 250 mg 1
mycophenolate mofetil oral tablet 500 mg 1
mycophenolate sodium oral tabletdelayed release (drec) 180 mg 360 mg
1
MYLOTARG INTRAVENOUS RECON SOLN 45 MG (1 MGML INITIAL CONC)
MB PA LA
NERLYNX ORAL TABLET 40 MG 2 PA OCh LA QL (180 per 30 days)
NEXAVAR ORAL TABLET 200 MG 2 PA ST OCh LA
nilutamide oral tablet 150 mg 2 OCh QL (60 per 30 days)
NINLARO ORAL CAPSULE 23 MG 3 MG 4 MG
2 PA ST OCh LA
NULOJIX INTRAVENOUS RECON SOLN 250 MG
MB PA
octreotide acetate injection solution 1000 mcgml 100 mcgml 200 mcgml 50 mcgml 500 mcgml
2
octreotide acetate injection syringe 100 mcgml (1 ml) 50 mcgml (1 ml) 500 mcgml (1 ml)
2
OGIVRI INTRAVENOUS RECON SOLN 150 MG 420 MG
MB PA LA
ONCASPAR INJECTION SOLUTION 750 UNITML
MB
ONIVYDE INTRAVENOUS DISPERSION 43 MGML
MB PA
OPDIVO INTRAVENOUS SOLUTION 100 MG10 ML 240 MG24 ML 40 MG4 ML
MB PA LA
PADCEV INTRAVENOUS RECON SOLN 20 MG 30 MG
MB PA LA
PEMAZYRE ORAL TABLET 135 MG 45 MG 9 MG
2 PA ST OCh
PERJETA INTRAVENOUS SOLUTION 420 MG14 ML (30 MGML)
MB PA LA
21
Drug Name Drug Tier Requirements Limits
PIQRAY ORAL TABLET 200 MGDAY (200 MG X 1) 250 MGDAY (200 MG X1-50 MG X1) 300 MGDAY (150 MG X 2)
2 PA OCh LA
POLIVY INTRAVENOUS RECON SOLN 140 MG
MB PA LA
PORTRAZZA INTRAVENOUS SOLUTION 800 MG50 ML (16 MGML)
MB PA LA
POTELIGEO INTRAVENOUS SOLUTION 4 MGML
MB PA
PROGRAF INTRAVENOUS SOLUTION 5 MGML
MB
QINLOCK ORAL TABLET 50 MG 2 OCh
RETEVMO ORAL CAPSULE 40 MG 2 PA OCh LA QL (240 per 30 days)
RETEVMO ORAL CAPSULE 80 MG 2 PA OCh LA QL (120 per 30 days)
RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG117 ML (120 MGML) 1600 MG134 ML (120 MGML)
MB LA
RITUXAN INTRAVENOUS CONCENTRATE 10 MGML
MB PA LA
RUBRACA ORAL TABLET 200 MG 250 MG 300 MG
2 PA ST OCh LA
RYDAPT ORAL CAPSULE 25 MG 2 PA ST OCh LA
SARCLISA INTRAVENOUS SOLUTION 20 MGML
MB
SIGNIFOR SUBCUTANEOUS SOLUTION 03 MGML (1 ML) 06 MGML (1 ML) 09 MGML (1 ML)
2 PA ST
SIMULECT INTRAVENOUS RECON SOLN 10 MG 20 MG
MB
sirolimus oral solution 1 mgml 1
sirolimus oral tablet 05 mg 1 mg 2 mg 1
SOLTAMOX ORAL SOLUTION 20 MG10 ML 2 OCh
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG05 ML 60 MG02 ML 90 MG03 ML
2 PA LA
SPRYCEL ORAL TABLET 100 MG 140 MG 20 MG 50 MG 70 MG 80 MG
2 PA ST OCh LA
STIVARGA ORAL TABLET 40 MG 2 PA ST OCh LA
SUPPRELIN LA IMPLANT KIT 50 MG (65 MCGDAY)
MB LA
22
Drug Name Drug Tier Requirements Limits
SUTENT ORAL CAPSULE 125 MG 25 MG 375 MG 50 MG
2 PA ST OCh LA
SYLVANT INTRAVENOUS RECON SOLN 100 MG 400 MG
MB PA LA
SYNRIBO SUBCUTANEOUS RECON SOLN 35 MG
2 PA ST
TABLOID ORAL TABLET 40 MG 2 OCh
tacrolimus oral capsule 05 mg 1 mg 5 mg 1
TAFINLAR ORAL CAPSULE 50 MG 75 MG 2 PA OCh LA
TAGRISSO ORAL TABLET 40 MG 80 MG 2 PA OCh LA
TALZENNA ORAL CAPSULE 025 MG 1 MG 2 PA OCh LA
tamoxifen oral tablet 10 mg 20 mg 2 OCh QL (60 per 30 days)
TARGRETIN TOPICAL GEL 1 1 PA ST
TASIGNA ORAL CAPSULE 150 MG 200 MG 50 MG
2 PA ST OCh LA
TECENTRIQ INTRAVENOUS SOLUTION 1200 MG20 ML (60 MGML) 840 MG14 ML (60 MGML)
MB PA LA
TEMODAR INTRAVENOUS RECON SOLN 100 MG
MB PA LA
temozolomide oral capsule 100 mg 140 mg 180 mg 20 mg 250 mg 5 mg
2 OCh LA
temsirolimus intravenous recon soln 30 mg3 ml (10 mgml) (first)
MB PA LA
THALOMID ORAL CAPSULE 100 MG 150 MG 200 MG 50 MG
2 OCh LA
TIBSOVO ORAL TABLET 250 MG 2 PA OCh
toremifene oral tablet 60 mg 2 OCh
TORISEL INTRAVENOUS RECON SOLN 30 MG3 ML (10 MGML) (FIRST)
MB PA LA
TREANDA INTRAVENOUS RECON SOLN 100 MG 25 MG
MB PA LA
TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 1125 MG 225 MG 375 MG
MB
tretinoin (antineoplastic) oral capsule 10 mg 2 OCh
TREXALL ORAL TABLET 10 MG 15 MG 5 MG 75 MG
2 PA ST OCh QL (15 per 30 days)
TRUXIMA INTRAVENOUS SOLUTION 10 MGML
MB PA LA
23
Drug Name Drug Tier Requirements Limits
TUKYSA ORAL TABLET 150 MG 50 MG 2 PA ST OCh QL (120 per 30 days)
UNITUXIN INTRAVENOUS SOLUTION 35 MGML
MB PA
VANTAS IMPLANT KIT 50 MG (50 MCGDAY)
MB LA
VECTIBIX INTRAVENOUS SOLUTION 100 MG5 ML (20 MGML) 400 MG20 ML (20 MGML)
MB PA LA
VELCADE INJECTION RECON SOLN 35 MG MB LA
VENCLEXTA ORAL TABLET 10 MG 100 MG 50 MG
2 PA ST OCh
VENCLEXTA STARTING PACK ORAL TABLETSDOSE PACK 10 MG-50 MG- 100 MG
2 PA OCh
VERZENIO ORAL TABLET 100 MG 150 MG 200 MG 50 MG
2 PA ST OCh LA
VIDAZA INJECTION RECON SOLN 100 MG MB PA LA
VITRAKVI ORAL CAPSULE 100 MG 2 PA OCh LA
VITRAKVI ORAL CAPSULE 25 MG 2 PA ST OCh LA
VITRAKVI ORAL SOLUTION 20 MGML 2 PA OCh LA
VOTRIENT ORAL TABLET 200 MG 2 PA ST OCh LA
VYXEOS INTRAVENOUS RECON SOLN 44-100 MG
MB PA
XALKORI ORAL CAPSULE 200 MG 250 MG 2 PA OCh LA
XERMELO ORAL TABLET 250 MG 2 PA ST
XOSPATA ORAL TABLET 40 MG 2 PA OCh
XTANDI ORAL CAPSULE 40 MG 2 PA OCh LA
XTANDI ORAL TABLET 40 MG 80 MG 2 PA OCh LA
YERVOY INTRAVENOUS SOLUTION 200 MG40 ML (5 MGML) 50 MG10 ML (5 MGML)
MB PA LA
YESCARTA INTRAVENOUS SUSPENSION MB PA
YONDELIS INTRAVENOUS RECON SOLN 1 MG
MB PA
YONSA ORAL TABLET 125 MG 2 PA OCh LA
ZALTRAP INTRAVENOUS SOLUTION 100 MG4 ML (25 MGML) 200 MG8 ML (25 MGML)
MB PA LA
ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM
MB
24
Drug Name Drug Tier Requirements Limits
ZEJULA ORAL CAPSULE 100 MG 2 OCh
ZELBORAF ORAL TABLET 240 MG 2 PA ST OCh LA
ZOLADEX SUBCUTANEOUS IMPLANT 108 MG 36 MG
MB LA
ZOLINZA ORAL CAPSULE 100 MG 2 PA ST OCh LA
ZYKADIA ORAL TABLET 150 MG 2 PA ST OCh LA
AUTONOMIC amp CNS DRUGS NEUROLOGY amp PSYCH
ANTICONVULSANTS
BANZEL ORAL TABLET 200 MG 400 MG 1 PA ST
BRIVIACT ORAL SOLUTION 10 MGML 1 ST QL (150 per 30 days)
BRIVIACT ORAL TABLET 10 MG 100 MG 25 MG 50 MG 75 MG
1 ST QL (60 per 30 days)
carbamazepine oral capsule er multiphase 12 hr 100 mg 200 mg 300 mg
1
carbamazepine oral suspension 100 mg5 ml 200 mg10 ml
1
carbamazepine oral tablet 200 mg 1
carbamazepine oral tablet extended release 12 hr 100 mg 200 mg 400 mg
1
carbamazepine oral tabletchewable 100 mg 1
CELONTIN ORAL CAPSULE 300 MG 1
clobazam oral suspension 25 mgml 1
clobazam oral tablet 10 mg 20 mg 1
clonazepam oral tablet 05 mg 1 mg 2 mg 1
clonazepam oral tabletdisintegrating 0125 mg 025 mg 05 mg 1 mg 2 mg
1
diazepam rectal kit 25 mg 1
DILANTIN EXTENDED ORAL CAPSULE 100 MG
1
DILANTIN INFATABS ORAL TABLETCHEWABLE 50 MG
1
DILANTIN ORAL CAPSULE 30 MG 1
DILANTIN-125 ORAL SUSPENSION 125 MG5 ML
1
divalproex oral capsule delayed rel sprinkle 125 mg
1
divalproex oral tablet extended release 24 hr 250 mg 500 mg
1
25
Drug Name Drug Tier Requirements Limits
divalproex oral tabletdelayed release (drec) 125 mg 250 mg 500 mg
1
EPIDIOLEX ORAL SOLUTION 100 MGML 2 PA LA QL (400 per 30 days)
epitol oral tablet 200 mg 1
ethosuximide oral capsule 250 mg 1
ethosuximide oral solution 250 mg5 ml 1
felbamate oral suspension 600 mg5 ml 1
felbamate oral tablet 400 mg 600 mg 1
FINTEPLA ORAL SOLUTION 22 MGML 2
gabapentin oral capsule 100 mg 300 mg 400 mg 1
gabapentin oral solution 250 mg5 ml 300 mg6 ml (6 ml)
1
gabapentin oral tablet 600 mg 800 mg 1
lamotrigine oral tablet 100 mg 150 mg 200 mg 25 mg
1
lamotrigine oral tablet disintegrating dose pk 25 mg (21) -50 mg (7) 25 mg(14)-50 mg (14)-100 mg (7) 50 mg (42) -100 mg (14)
1
lamotrigine oral tablet extended release 24hr 100 mg 200 mg 25 mg 250 mg 300 mg 50 mg
1
lamotrigine oral tablet chewable dispersible 25 mg 5 mg
1
lamotrigine oral tabletdisintegrating 100 mg 200 mg 25 mg 50 mg
1
lamotrigine oral tabletsdose pack 25 mg (35) 25 mg (42) -100 mg (7) 25 mg (84) -100 mg (14)
1
levetiracetam oral solution 100 mgml 500 mg5 ml (5 ml)
1
levetiracetam oral tablet 1000 mg 250 mg 500 mg 750 mg
1
levetiracetam oral tablet extended release 24 hr 500 mg 750 mg
1
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG 330 MG 825 MG
1 PA ST
oxcarbazepine oral suspension 300 mg5 ml (60 mgml)
1
oxcarbazepine oral tablet 150 mg 300 mg 600 mg 1
phenobarbital oral elixir 20 mg5 ml (4 mgml) 1
26
Drug Name Drug Tier Requirements Limits
phenobarbital oral tablet 100 mg 15 mg 162 mg 30 mg 324 mg 60 mg 648 mg 972 mg
1
phenytoin oral suspension 100 mg4 ml 125 mg5 ml
1
phenytoin oral tabletchewable 50 mg 1
phenytoin sodium extended oral capsule 100 mg 200 mg 300 mg
1
pregabalin oral capsule 100 mg 150 mg 200 mg 225 mg 25 mg 300 mg 50 mg 75 mg
1 PA ST
pregabalin oral solution 20 mgml 1 PA ST
pregabalin oral tablet extended release 24 hr 165 mg 330 mg 825 mg
1 PA ST
primidone oral tablet 250 mg 50 mg 1
roweepra oral tablet 1000 mg 500 mg 750 mg 1
rufinamide oral suspension 40 mgml 1 PA
rufinamide oral tablet 200 mg 400 mg 1 PA
subvenite oral tablet 100 mg 150 mg 200 mg 25 mg
1
subvenite starter (blue) kit oral tabletsdose pack 25 mg (35)
1
subvenite starter (green) kit oral tabletsdose pack 25 mg (84) -100 mg (14)
1
subvenite starter (orange) kit oral tabletsdose pack 25 mg (42) -100 mg (7)
1
SYMPAZAN ORAL FILM 10 MG 20 MG 5 MG 1 PA QL (30 per 30 days)
tiagabine oral tablet 12 mg 16 mg 2 mg 4 mg 1
topiramate oral capsule sprinkle 15 mg 25 mg 1
topiramate oral tablet 100 mg 200 mg 25 mg 50 mg
1
valproic acid (as sodium salt) oral solution 250 mg5 ml 500 mg10 ml (10 ml)
1
valproic acid oral capsule 250 mg 1
vigabatrin oral powder in packet 500 mg 2 PA LA
vigabatrin oral tablet 500 mg 2 PA LA
vigadrone oral powder in packet 500 mg 2 PA ST
VIMPAT ORAL SOLUTION 10 MGML 1 PA ST QL (6 per 30 days)
VIMPAT ORAL TABLET 100 MG 150 MG 200 MG 50 MG
1 ST QL (60 per 30 days)
27
Drug Name Drug Tier Requirements Limits
XCOPRI MAINTENANCE PACK ORAL TABLET 250 MGDAY (200 MG X1-50 MG X1) 350 MGDAY (200 MG X1-150MG X1)
2
XCOPRI MAINTENANCE PACK ORAL TABLET 250MGDAY(150 MG X1-100MG X1)
2 PA ST
XCOPRI ORAL TABLET 100 MG 150 MG 200 MG 50 MG
2
XCOPRI TITRATION PACK ORAL TABLETSDOSE PACK 125 MG (14)- 25 MG (14) 150 MG (14)- 200 MG (14) 50 MG (14)- 100 MG (14)
2
zonisamide oral capsule 100 mg 25 mg 50 mg 1
ANTIPARKINSONISM AGENTS
APOKYN SUBCUTANEOUS CARTRIDGE 10 MGML
2 PA LA QL (1 per 30 days)
benztropine injection solution 1 mgml 1
benztropine oral tablet 05 mg 1 mg 2 mg 1
bromocriptine oral capsule 5 mg 1
bromocriptine oral tablet 25 mg 1
carbidopa oral tablet 25 mg 1
carbidopa-levodopa oral tablet 10-100 mg 25-100 mg 25-250 mg
1
carbidopa-levodopa oral tablet extended release 25-100 mg 50-200 mg
1
carbidopa-levodopa oral tabletdisintegrating 10-100 mg 25-100 mg 25-250 mg
1
carbidopa-levodopa-entacapone oral tablet 125-50-200 mg 1875-75-200 mg 25-100-200 mg 3125-125-200 mg 375-150-200 mg 50-200-200 mg
1
entacapone oral tablet 200 mg 1
pramipexole oral tablet 0125 mg 025 mg 05 mg 075 mg 1 mg 15 mg
1
pramipexole oral tablet extended release 24 hr 0375 mg 075 mg 15 mg 225 mg 3 mg 375 mg 45 mg
1
rasagiline oral tablet 05 mg 1 mg 1
ropinirole oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg 5 mg
1
28
Drug Name Drug Tier Requirements Limits
ropinirole oral tablet extended release 24 hr 12 mg 2 mg 4 mg 6 mg 8 mg
1
selegiline hcl oral capsule 5 mg 1
selegiline hcl oral tablet 5 mg 1
tolcapone oral tablet 100 mg 1
trihexyphenidyl oral elixir 04 mgml 1
trihexyphenidyl oral tablet 2 mg 5 mg 1
MIGRAINE amp CLUSTER HEADACHE THERAPY
AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MGML 70 MGML
1 PA ST
AJOVY AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 225 MG15 ML
1 ST
AJOVY SYRINGE SUBCUTANEOUS SYRINGE 225 MG15 ML
1 PA ST
almotriptan malate oral tablet 125 mg 625 mg 1 QL (18 per 30 days)
dihydroergotamine injection solution 1 mgml 1
dihydroergotamine nasal spraynon-aerosol 05 mgpump act (4 mgml)
1 QL (8 per 30 days)
eletriptan oral tablet 20 mg 40 mg 1 QL (18 per 30 days)
EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MGML
1 PA ST
EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MGML 300 MG3 ML (100 MGML X 3)
1 PA ST
ergotamine-caffeine oral tablet 1-100 mg 1
frovatriptan oral tablet 25 mg 1 QL (18 per 30 days)
migergot rectal suppository 2-100 mg 1
naratriptan oral tablet 1 mg 25 mg 1 QL (18 per 30 days)
ONZETRA XSAIL NASAL AEROSOL POWDR BREATH ACTIVATED 11 MG
1 ST QL (16 per 30 days)
rizatriptan oral tablet 10 mg 5 mg 1 QL (18 per 30 days)
rizatriptan oral tabletdisintegrating 10 mg 5 mg 1 QL (18 per 30 days)
sumatriptan nasal spraynon-aerosol 20 mgactuation 5 mgactuation
1 QL (18 per 30 days)
sumatriptan succinate oral tablet 100 mg 25 mg 50 mg
1 QL (18 per 30 days)
sumatriptan succinate subcutaneous cartridge 4 mg05 ml 6 mg05 ml
1 QL (8 per 30 days)
29
Drug Name Drug Tier Requirements Limits
sumatriptan succinate subcutaneous pen injector 4 mg05 ml 6 mg05 ml
1 QL (8 per 30 days)
sumatriptan succinate subcutaneous solution 6 mg05 ml
1 QL (8 per 30 days)
sumatriptan succinate subcutaneous syringe 6 mg05 ml
1 QL (8 per 30 days)
UBRELVY ORAL TABLET 100 MG 50 MG 1 QL (16 per 30 days)
VYEPTI INTRAVENOUS SOLUTION 100 MGML
MB PA
zolmitriptan oral tablet 25 mg 5 mg 1 QL (18 per 30 days)
zolmitriptan oral tabletdisintegrating 25 mg 5 mg
1 QL (18 per 30 days)
ZOMIG NASAL SPRAYNON-AEROSOL 25 MG 5 MG
1 ST QL (18 per 30 days)
MISCELLANEOUS NEUROLOGICAL THERAPY
AUSTEDO ORAL TABLET 12 MG 6 MG 9 MG
2 PA LA
dalfampridine oral tablet extended release 12 hr 10 mg
2 PA LA QL (60 per 30 days)
donepezil oral tablet 10 mg 23 mg 5 mg 1
donepezil oral tabletdisintegrating 10 mg 5 mg 1
EXONDYS-51 INTRAVENOUS SOLUTION 50 MGML
MB PA
galantamine oral capsuleext rel pellets 24 hr 16 mg 24 mg 8 mg
1
galantamine oral solution 4 mgml 1
galantamine oral tablet 12 mg 4 mg 8 mg 1
memantine oral capsulesprinkleer 24hr 14 mg 21 mg 28 mg 7 mg
1
memantine oral solution 2 mgml 1
memantine oral tablet 10 mg 5 mg 1
NUEDEXTA ORAL CAPSULE 20-10 MG 1
ONPATTRO INTRAVENOUS SOLUTION 2 MGML
MB PA
RADICAVA INTRAVENOUS SOLUTION 30 MG100 ML
MB PA
rivastigmine tartrate oral capsule 15 mg 3 mg 45 mg 6 mg
1
30
Drug Name Drug Tier Requirements Limits
rivastigmine transdermal patch 24 hour 133 mg24 hour 46 mg24 hour 95 mg24 hour
1
tetrabenazine oral tablet 125 mg 25 mg 2 LA
TYSABRI INTRAVENOUS SOLUTION 300 MG15 ML
MB PA ST LA
VYONDYS-53 INTRAVENOUS SOLUTION 50 MGML
MB PA
ZOLGENSMA INTRAVENOUS KIT 2 X 10EXP13 VGML
MB LA
MUSCLE RELAXANTS amp ANTISPASMODIC THERAPY
baclofen oral tablet 10 mg 20 mg 5 mg 1
carisoprodol oral tablet 250 mg 350 mg 1
carisoprodol-aspirin oral tablet 200-325 mg 1
carisoprodol-aspirin-codeine oral tablet 200-325-16 mg
1 PA ST
chlorzoxazone oral tablet 250 mg 375 mg 750 mg 1 ST
chlorzoxazone oral tablet 500 mg 1
cyclobenzaprine oral tablet 10 mg 5 mg 75 mg 1
dantrolene oral capsule 100 mg 25 mg 50 mg 1
meprobamate oral tablet 200 mg 400 mg 1
metaxalone oral tablet 400 mg 800 mg 1
methocarbamol oral tablet 500 mg 750 mg 1
orphenadrine citrate injection solution 30 mgml 1
orphenadrine citrate oral tablet extended release 100 mg
1
pyridostigmine bromide oral syrup 60 mg5 ml 1
pyridostigmine bromide oral tablet 60 mg 1
pyridostigmine bromide oral tablet extended release 180 mg
1
tizanidine oral capsule 2 mg 4 mg 6 mg 1
tizanidine oral tablet 2 mg 4 mg 1
vanadom oral tablet 350 mg 1
NARCOTIC ANALGESICS
acetaminophen-caff-dihydrocod oral capsule 3205-30-16 mg
1 PA ST
acetaminophen-caff-dihydrocod oral tablet 325-30-16 mg
1 PA ST
31
Drug Name Drug Tier Requirements Limits
acetaminophen-codeine oral solution 120-12 mg5 ml 300 mg-30 mg 125 ml
1 PA ST
acetaminophen-codeine oral tablet 300-15 mg 300-30 mg 300-60 mg
1 PA ST
ascomp with codeine oral capsule 30-50-325-40 mg
1 PA ST
buprenorphine hcl injection solution 03 mgml 1 PA ST
buprenorphine hcl injection syringe 03 mgml 1 PA ST
buprenorphine hcl sublingual tablet 2 mg 8 mg 1
buprenorphine transdermal patch weekly 10 mcghour 15 mcghour 20 mcghour 5 mcghour 75 mcghour
1
butalbital compound wcodeine oral capsule 30-50-325-40 mg
1 PA ST
butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg 50-325-40-30 mg
1 PA ST
butalbital-acetaminophen-caff oral capsule 50-300-40 mg 50-325-40 mg
1
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
1
butalbital-aspirin-caffeine oral capsule 50-325-40 mg
1
butalbital-aspirin-caffeine oral tablet 50-325-40 mg
1
codeine sulfate oral tablet 15 mg 30 mg 60 mg 1 PA ST
codeine-butalbital-asa-caff oral capsule 30-50-325-40 mg
1 PA ST
diskets oral tabletsoluble 40 mg 1 PA ST
DSUVIA SUBLINGUAL TABLET IN APPLICATOR 30 MCG
MB
duramorph (pf) injection solution 05 mgml 1 mgml
MB PA ST
dvorah oral tablet 325-30-16 mg 1 PA ST
endocet oral tablet 10-325 mg 25-325 mg 5-325 mg 75-325 mg
1 PA ST
fentanyl citrate buccal lozenge on a handle 1200 mcg 1600 mcg 200 mcg 400 mcg 600 mcg 800 mcg
1 PA
32
Drug Name Drug Tier Requirements Limits
fentanyl transdermal patch 72 hour 100 mcghr 12 mcghr 25 mcghr 375 mcghour 50 mcghr 625 mcghour 75 mcghr 875 mcghour
1 PA ST
hydrocodone bitartrate oral capsule oral only er 12hr 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg
1 PA ST QL (60 per 30 days)
hydrocodone bitartrate oral tabletoral onlyextrel24 hr 100 mg 120 mg 20 mg 30 mg 40 mg 60 mg 80 mg
1 PA ST
hydrocodone-acetaminophen oral solution 10-325 mg15 ml(15 ml) 75-325 mg15 ml
1 PA ST
hydrocodone-acetaminophen oral tablet 10-300 mg 10-325 mg 5-300 mg 5-325 mg 75-300 mg 75-325 mg
1 PA ST
hydrocodone-ibuprofen oral tablet 10-200 mg 5-200 mg 75-200 mg
1 PA ST
HYDROMORPHONE INJECTION SYRINGE 05 MG05 ML
1 PA ST
hydromorphone oral liquid 1 mgml 1 PA ST
hydromorphone oral tablet 2 mg 4 mg 8 mg 1 PA ST
hydromorphone oral tablet extended release 24 hr 12 mg 16 mg 32 mg 8 mg
1 PA ST QL (60 per 30 days)
hydromorphone rectal suppository 3 mg 1 PA ST
levorphanol tartrate oral tablet 2 mg 3 mg 1 PA ST
meperidine oral solution 50 mg5 ml 1 PA ST
meperidine oral tablet 50 mg 1 PA ST
methadone injection solution 10 mgml 1 PA ST
methadone oral concentrate 10 mgml 1 PA ST
methadone oral solution 10 mg5 ml 5 mg5 ml 1 PA ST
methadone oral tablet 10 mg 5 mg 1 PA ST
methadone oral tabletsoluble 40 mg 1 PA ST
methadose oral concentrate 10 mgml 1 PA ST
methadose oral tabletsoluble 40 mg 1 PA ST
morphine (pf) injection solution 05 mgml MB PA ST
morphine concentrate oral solution 100 mg5 ml (20 mgml)
1 PA ST
morphine oral capsule er multiphase 24 hr 120 mg 30 mg 45 mg 60 mg 75 mg 90 mg
1 PA ST QL (60 per 30 days)
morphine oral capsuleextendrelease pellets 10 mg 100 mg 20 mg 50 mg 80 mg
1 PA ST QL (90 per 30 days)
33
Drug Name Drug Tier Requirements Limits
morphine oral capsuleextendrelease pellets 30 mg 60 mg
1 PA ST QL (60 per 30 days)
morphine oral capsuleextendrelease pellets 40 mg
1 PA QL (90 per 30 days)
morphine oral solution 10 mg5 ml 20 mg5 ml (4 mgml)
1 PA ST
morphine oral tablet 15 mg 30 mg 1 PA ST
morphine oral tablet extended release 100 mg 15 mg 200 mg 30 mg 60 mg
1 PA ST QL (120 per 30 days)
morphine rectal suppository 10 mg 20 mg 30 mg 5 mg
1 PA ST
oxycodone oral capsule 5 mg 1 PA ST
oxycodone oral concentrate 20 mgml 1 PA ST
oxycodone oral solution 5 mg5 ml 1 PA ST
oxycodone oral tablet 10 mg 15 mg 20 mg 30 mg 5 mg
1 PA ST
oxycodone-acetaminophen oral tablet 10-325 mg 25-300 mg 25-325 mg 5-325 mg 75-325 mg
1 PA ST
oxycodone-aspirin oral tablet 48355-325 mg 1 PA ST
OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 10 MG 15 MG 20 MG 30 MG 40 MG
1 PA ST QL (90 per 30 days)
OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 60 MG 80 MG
1 PA ST QL (120 per 30 days)
oxymorphone oral tablet 10 mg 5 mg 1 PA ST
oxymorphone oral tablet extended release 12 hr 10 mg 15 mg 20 mg 30 mg 40 mg 5 mg 75 mg
1 PA ST QL (90 per 30 days)
SUBLOCADE SUBCUTANEOUS SOLUTION EXTENDED REL SYRINGE 100 MG05 ML 300 MG15 ML
MB
tencon oral tablet 50-325 mg 1
NON-NARCOTIC ANALGESICS
adult aspirin regimen oral tabletdelayed release (drec) 81 mg
ACA PV
aspirin low dose oral tabletdelayed release (drec) 81 mg
ACA PV
aspirin oral tablet 325 mg ACA PV
aspirin oral tabletchewable 81 mg ACA PV
34
Drug Name Drug Tier Requirements Limits
aspirin oral tabletdelayed release (drec) 325 mg 81 mg
ACA PV
aspir-trin oral tabletdelayed release (drec) 325 mg
ACA PV
bayer aspirin oral tablet 325 mg ACA PV
BAYER CHEWABLE ASPIRIN ORAL TABLETCHEWABLE 81 MG
ACA PV
buprenorphine-naloxone sublingual film 12-3 mg 1 QL (60 per 30 days)
buprenorphine-naloxone sublingual film 2-05 mg 4-1 mg 8-2 mg
1 QL (90 per 30 days)
buprenorphine-naloxone sublingual tablet 2-05 mg 8-2 mg
1 QL (90 per 30 days)
butorphanol nasal spraynon-aerosol 10 mgml 1 PA ST QL (5 per 30 days)
cataflam oral tablet 50 mg 1
celecoxib oral capsule 100 mg 200 mg 400 mg 50 mg
1
childrens aspirin oral tabletchewable 81 mg ACA PV
cholinemagnesium salicylate oral liquid 500 mg5 ml
1
diclofenac potassium oral tablet 50 mg 1
diclofenac sodium oral tablet extended release 24 hr 100 mg
1
diclofenac sodium oral tabletdelayed release (drec) 25 mg 50 mg 75 mg
1
diclofenac sodium topical drops 15 1
diclofenac sodium topical gel 1 1
diclofenac-misoprostol oral tabletirdelayed relbiphasic 50-200 mg-mcg 75-200 mg-mcg
1
diflunisal oral tablet 500 mg 1
DUEXIS ORAL TABLET 800-266 MG 1 ST
ecotrin low strength oral tabletdelayed release (drec) 81 mg
ACA PV
ecotrin oral tabletdelayed release (drec) 325 mg ACA PV
etodolac oral capsule 200 mg 300 mg 1
etodolac oral tablet 400 mg 500 mg 1
etodolac oral tablet extended release 24 hr 400 mg 500 mg 600 mg
1
EUFLEXXA INTRA-ARTICULAR SYRINGE 10 MGML(MW 24 -36 MILLION)
MB
35
Drug Name Drug Tier Requirements Limits
fenoprofen oral tablet 600 mg 1
flurbiprofen oral tablet 100 mg 1
ibu oral tablet 400 mg 600 mg 800 mg 1
ibuprofen oral suspension 100 mg5 ml 1
ibuprofen oral tablet 400 mg 600 mg 800 mg 1
indomethacin oral capsule 25 mg 50 mg 1
indomethacin oral capsule extended release 75 mg
1
ketoprofen oral capsule 25 mg 50 mg 75 mg 1
ketoprofen oral capsuleext rel pellets 24 hr 200 mg
1
ketorolac injection cartridge 15 mgml 30 mgml 1
ketorolac injection solution 15 mgml 30 mgml MB
ketorolac injection solution 30 mgml (1 ml) 1
ketorolac intramuscular cartridge 60 mg2 ml 1
ketorolac intramuscular solution 60 mg2 ml 1
ketorolac intramuscular syringe 60 mg2 ml 1
ketorolac oral tablet 10 mg 1
meclofenamate oral capsule 100 mg 50 mg 1
mefenamic acid oral capsule 250 mg 1
meloxicam oral tablet 15 mg 75 mg 1
MONOVISC INTRA-ARTICULAR SYRINGE 88 MG4 ML
MB LA
nabumetone oral tablet 500 mg 750 mg 1
nalbuphine injection solution 10 mgml MB PA ST
naloxone injection solution 04 mgml 1
naloxone injection syringe 04 mgml 1 mgml 1
naltrexone oral tablet 50 mg 1
naproxen oral suspension 125 mg5 ml 1
naproxen oral tablet 250 mg 375 mg 500 mg 1
naproxen oral tabletdelayed release (drec) 375 mg 500 mg
1
naproxen sodium oral tablet 275 mg 550 mg 1
NARCAN NASAL SPRAYNON-AEROSOL 4 MGACTUATION
1
36
Drug Name Drug Tier Requirements Limits
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG 150 MG 200 MG 250 MG 50 MG
1 PA ST QL (60 per 30 days)
ORTHOVISC INTRA-ARTICULAR SYRINGE 30 MG2 ML
MB
oxaprozin oral tablet 600 mg 1
pentazocine-naloxone oral tablet 50-05 mg 1 PA ST
piroxicam oral capsule 10 mg 20 mg 1
salsalate oral tablet 500 mg 750 mg 1
st joseph aspirin oral tabletchewable 81 mg ACA PV
st joseph aspirin oral tabletdelayed release (drec) 81 mg
ACA PV
sulindac oral tablet 150 mg 200 mg 1
tolmetin oral capsule 400 mg 1
tolmetin oral tablet 200 mg 600 mg 1
tramadol oral tablet 50 mg 1 PA ST
tramadol oral tablet extended release 24 hr 100 mg 200 mg 300 mg
1 PA ST
tramadol oral tablet er multiphase 24 hr 100 mg 200 mg 300 mg
1 PA ST
tramadol-acetaminophen oral tablet 375-325 mg 1 PA ST
VIVITROL INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 380 MG
MB
PSYCHOTHERAPEUTIC DRUGS
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 300 MG 400 MG
1
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 300 MG 400 MG
1
ADHANSIA XR ORAL CAPSULE ER BIPHASIC 20-80 25 MG 35 MG 45 MG 55 MG 70 MG 85 MG
1 PA ST
ADZENYS ER ORAL SUSPEN IR - ER BIPHASIC 24HR 125 MGML
1 ST
ADZENYS XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 125 MG 157 MG 188 MG 31 MG 63 MG 94 MG
1 ST
37
Drug Name Drug Tier Requirements Limits
alprazolam intensol oral concentrate 1 mgml 1
alprazolam oral tablet 025 mg 05 mg 1 mg 2 mg
1
alprazolam oral tablet extended release 24 hr 05 mg 1 mg 2 mg 3 mg
1
alprazolam oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg
1
amitriptyline oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
amitriptyline-chlordiazepoxide oral tablet 125-5 mg 25-10 mg
1
amoxapine oral tablet 100 mg 150 mg 25 mg 50 mg
1
AMPHETAMINE ORAL SUSPEN IR - ER BIPHASIC 24HR 125 MGML
1 ST
amphetamine sulfate oral tablet 10 mg 5 mg 1
APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG 348 MG 522 MG
1 ST
aripiprazole oral solution 1 mgml 1
aripiprazole oral tablet 10 mg 15 mg 2 mg 20 mg 30 mg 5 mg
1
aripiprazole oral tabletdisintegrating 10 mg 15 mg
1
ARISTADA INITIO INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 675 MG24 ML
MB
ARISTADA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 1064 MG39 ML 441 MG16 ML 662 MG24 ML 882 MG32 ML
MB
armodafinil oral tablet 150 mg 200 mg 250 mg 50 mg
1
asenapine maleate sublingual tablet 10 mg 25 mg 5 mg
1
atomoxetine oral capsule 10 mg 100 mg 18 mg 25 mg 40 mg 60 mg 80 mg
1
BELSOMRA ORAL TABLET 10 MG 15 MG 20 MG 5 MG
1 ST
bupropion hcl oral tablet 100 mg 75 mg 1
bupropion hcl oral tablet extended release 24 hr 150 mg 300 mg
1
38
Drug Name Drug Tier Requirements Limits
bupropion hcl oral tablet sustained-release 12 hr 100 mg 150 mg 200 mg
1
buspirone oral tablet 10 mg 15 mg 30 mg 5 mg 75 mg
1
chlordiazepoxide hcl oral capsule 10 mg 25 mg 5 mg
1
chlorpromazine injection solution 25 mgml 1
chlorpromazine oral tablet 10 mg 100 mg 200 mg 25 mg 50 mg
1
citalopram oral solution 10 mg5 ml 1
citalopram oral tablet 10 mg 20 mg 40 mg 1
clomipramine oral capsule 25 mg 50 mg 75 mg 1
clonidine hcl oral tablet extended release 12 hr 01 mg
1
clorazepate dipotassium oral tablet 15 mg 375 mg 75 mg
1
clozapine oral tablet 100 mg 200 mg 25 mg 50 mg
1
clozapine oral tabletdisintegrating 100 mg 125 mg 150 mg 200 mg 25 mg
1
COTEMPLA XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 173 MG 259 MG 86 MG
1 ST
DAYTRANA TRANSDERMAL PATCH 24 HOUR 10 MG9 HR 15 MG9 HR 20 MG9 HR 30 MG9 HR
1 ST
desipramine oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG 50 MG
1 ST
desvenlafaxine succinate oral tablet extended release 24 hr 100 mg 25 mg 50 mg
1
dexmethylphenidate oral capsuleer biphasic 50-50 10 mg 15 mg 20 mg 25 mg 30 mg 35 mg 40 mg 5 mg
1
dexmethylphenidate oral tablet 10 mg 25 mg 5 mg
1
dextroamphetamine oral capsule extended release 10 mg 15 mg 5 mg
1
dextroamphetamine oral solution 5 mg5 ml 1
39
Drug Name Drug Tier Requirements Limits
dextroamphetamine oral tablet 10 mg 5 mg 1
dextroamphetamine-amphetamine oral capsuleextended release 24hr 10 mg 15 mg 20 mg 25 mg 30 mg 5 mg
1
dextroamphetamine-amphetamine oral tablet 10 mg 125 mg 15 mg 20 mg 30 mg 5 mg 75 mg
1
diazepam injection solution 5 mgml MB
diazepam injection syringe 5 mgml MB
diazepam intensol oral concentrate 5 mgml 1
diazepam oral solution 5 mg5 ml (1 mgml) 1
diazepam oral tablet 10 mg 2 mg 5 mg 1
doxepin oral capsule 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
doxepin oral concentrate 10 mgml 1
duloxetine oral capsuledelayed release(drec) 20 mg 30 mg 40 mg 60 mg
1
DYANAVEL XR ORAL SUSPEN IR - ER BIPHASIC 24HR 25 MGML
1 ST
EDLUAR SUBLINGUAL TABLET 10 MG 5 MG
1 ST
EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG24 HR 6 MG24 HR 9 MG24 HR
1 ST
ergoloid oral tablet 1 mg 1
escitalopram oxalate oral solution 5 mg5 ml 1
escitalopram oxalate oral tablet 10 mg 20 mg 5 mg
1
estazolam oral tablet 1 mg 2 mg 1
eszopiclone oral tablet 1 mg 2 mg 3 mg 1
FANAPT ORAL TABLET 1 MG 10 MG 12 MG 2 MG 4 MG 6 MG 8 MG
1 PA ST
FANAPT ORAL TABLETSDOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)
1 PA ST
FETZIMA ORAL CAPSULEEXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)
1 ST
FETZIMA ORAL CAPSULEEXTENDED RELEASE 24 HR 120 MG 20 MG 40 MG 80 MG
1 ST
fluoxetine oral capsule 10 mg 20 mg 40 mg 1
40
Drug Name Drug Tier Requirements Limits
fluoxetine oral capsuledelayed release(drec) 90 mg
1
fluoxetine oral solution 20 mg5 ml (4 mgml) 1
fluoxetine oral tablet 10 mg 20 mg 1
fluoxetine oral tablet 60 mg 1 PA
fluphenazine hcl injection solution 25 mgml 1
fluphenazine hcl oral concentrate 5 mgml 1
fluphenazine hcl oral elixir 25 mg5 ml 1
fluphenazine hcl oral tablet 1 mg 10 mg 25 mg 5 mg
1
flurazepam oral capsule 15 mg 30 mg 1
fluvoxamine oral capsuleextended release 24hr 100 mg 150 mg
1
fluvoxamine oral tablet 100 mg 25 mg 50 mg 1
guanfacine oral tablet extended release 24 hr 1 mg 2 mg 3 mg 4 mg
1
haloperidol decanoate intramuscular solution 100 mgml 50 mgml
1
haloperidol lactate injection solution 5 mgml 1
haloperidol lactate oral concentrate 2 mgml 1
haloperidol oral tablet 05 mg 1 mg 10 mg 2 mg 20 mg 5 mg
1
HETLIOZ LQ ORAL SUSPENSION 4 MGML 2 PA ST LA
HETLIOZ ORAL CAPSULE 20 MG 2 PA ST LA
imipramine hcl oral tablet 10 mg 25 mg 50 mg 1
imipramine pamoate oral capsule 100 mg 125 mg 150 mg 75 mg
1
INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG075 ML 156 MGML 234 MG15 ML 39 MG025 ML 78 MG05 ML
1
JORNAY PM ORAL CAPSULEDEL RELEXT REL SPRINK 100 MG 20 MG 40 MG 60 MG 80 MG
1 ST
LATUDA ORAL TABLET 120 MG 20 MG 40 MG 60 MG 80 MG
1 PA ST
lithium carbonate oral capsule 150 mg 300 mg 600 mg
1
lithium carbonate oral tablet 300 mg 1
41
Drug Name Drug Tier Requirements Limits
lithium carbonate oral tablet extended release 300 mg 450 mg
1
lorazepam intensol oral concentrate 2 mgml 1
lorazepam oral concentrate 2 mgml 1
lorazepam oral tablet 05 mg 1 mg 2 mg 1
loxapine succinate oral capsule 10 mg 25 mg 5 mg 50 mg
1
maprotiline oral tablet 25 mg 50 mg 75 mg 1
MARPLAN ORAL TABLET 10 MG 1
methamphetamine oral tablet 5 mg 1
METHYLIN ORAL SOLUTION 10 MG5 ML 5 MG5 ML
1
methylphenidate hcl oral caper sprinklebiphasic 40-60 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg 60 mg
1
methylphenidate hcl oral capsule er biphasic 30-70 10 mg 20 mg 30 mg 40 mg 50 mg 60 mg
1
methylphenidate hcl oral capsuleer biphasic 50-50 10 mg 20 mg 30 mg 40 mg 60 mg
1
methylphenidate hcl oral solution 10 mg5 ml 5 mg5 ml
1
methylphenidate hcl oral tablet 10 mg 20 mg 5 mg
1
methylphenidate hcl oral tablet extended release 10 mg 20 mg
1
methylphenidate hcl oral tablet extended release 24hr 18 mg 27 mg 36 mg 54 mg
1
methylphenidate hcl oral tabletchewable 10 mg 25 mg 5 mg
1
midazolam oral syrup 2 mgml 1
mirtazapine oral tablet 15 mg 30 mg 45 mg 75 mg
1
mirtazapine oral tabletdisintegrating 15 mg 30 mg 45 mg
1
modafinil oral tablet 100 mg 200 mg 1
molindone oral tablet 10 mg 25 mg 5 mg 1
MYDAYIS ORAL CAPSULE ER TRIPHASIC 24 HR 125 MG 25 MG 375 MG 50 MG
1 ST
nefazodone oral tablet 100 mg 150 mg 200 mg 250 mg 50 mg
1
42
Drug Name Drug Tier Requirements Limits
nortriptyline oral capsule 10 mg 25 mg 50 mg 75 mg
1
nortriptyline oral solution 10 mg5 ml 1
NUPLAZID ORAL CAPSULE 34 MG 2 PA LA
NUPLAZID ORAL TABLET 10 MG 2 PA LA
olanzapine intramuscular recon soln 10 mg 1
olanzapine oral tablet 10 mg 15 mg 25 mg 20 mg 5 mg 75 mg
1
olanzapine oral tabletdisintegrating 10 mg 15 mg 20 mg 5 mg
1
olanzapine-fluoxetine oral capsule 12-25 mg 12-50 mg 3-25 mg 6-25 mg 6-50 mg
1
oxazepam oral capsule 10 mg 15 mg 30 mg 1
paliperidone oral tablet extended release 24hr 15 mg 3 mg 6 mg 9 mg
1
paroxetine hcl oral tablet 10 mg 20 mg 30 mg 40 mg
1
paroxetine hcl oral tablet extended release 24 hr 125 mg 25 mg 375 mg
1
paroxetine mesylate(menopsym) oral capsule 75 mg
1
perphenazine oral tablet 16 mg 2 mg 4 mg 8 mg 1
perphenazine-amitriptyline oral tablet 2-10 mg 2-25 mg 4-10 mg 4-25 mg 4-50 mg
1
phenelzine oral tablet 15 mg 1
pimozide oral tablet 1 mg 2 mg 1
procentra oral solution 5 mg5 ml 1
protriptyline oral tablet 10 mg 5 mg 1
quetiapine oral tablet 100 mg 200 mg 25 mg 300 mg 400 mg 50 mg
1
quetiapine oral tablet extended release 24 hr 150 mg 200 mg 300 mg 400 mg 50 mg
1
QUILLICHEW ER ORAL TABLETCHEWIR-ERBIPHASIC24HR 20 MG 30 MG 40 MG
1 ST
QUILLIVANT XR ORAL SUSPENSIONEXT REL 24HRRECON 5 MGML (25 MG5 ML)
1 ST
ramelteon oral tablet 8 mg 1
RELEXXII ORAL TABLET EXTENDED RELEASE 24HR 72 MG
1 ST
43
Drug Name Drug Tier Requirements Limits
REXULTI ORAL TABLET 025 MG 05 MG 1 MG 2 MG 3 MG 4 MG
1 PA ST
RISPERDAL CONSTA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 125 MG2 ML 25 MG2 ML 375 MG2 ML 50 MG2 ML
1
risperidone oral solution 1 mgml 1
risperidone oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg
1
risperidone oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg
1
seconal sodium oral capsule 100 mg 1
sertraline oral concentrate 20 mgml 1
sertraline oral tablet 100 mg 25 mg 50 mg 1
SPRAVATO NASAL SPRAYNON-AEROSOL 56 MG (28 MG X 2) 84 MG (28 MG X 3)
MB PA
SUNOSI ORAL TABLET 150 MG 1 PA QL (30 per 30 days)
SUNOSI ORAL TABLET 75 MG 1 PA QL (60 per 30 days)
temazepam oral capsule 15 mg 225 mg 30 mg 75 mg
1
thioridazine oral tablet 10 mg 100 mg 25 mg 50 mg
1
thiothixene oral capsule 1 mg 10 mg 2 mg 5 mg 1
tranylcypromine oral tablet 10 mg 1
trazodone oral tablet 100 mg 150 mg 300 mg 50 mg
1
triazolam oral tablet 0125 mg 025 mg 1
trifluoperazine oral tablet 1 mg 10 mg 2 mg 5 mg
1
trimipramine oral capsule 100 mg 25 mg 50 mg 1
TRINTELLIX ORAL TABLET 10 MG 20 MG 5 MG
1 ST
venlafaxine oral capsuleextended release 24hr 150 mg 375 mg 75 mg
1
venlafaxine oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg
1
venlafaxine oral tablet extended release 24hr 150 mg 225 mg 375 mg 75 mg
1
VERSACLOZ ORAL SUSPENSION 50 MGML 1 PA ST
44
Drug Name Drug Tier Requirements Limits
VRAYLAR ORAL CAPSULE 15 MG 3 MG 45 MG 6 MG
1 PA ST
VRAYLAR ORAL CAPSULEDOSE PACK 15 MG (1)- 3 MG (6)
1 PA ST
VYVANSE ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG 70 MG
1 PA ST
VYVANSE ORAL TABLETCHEWABLE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG
1 PA ST
XYREM ORAL SOLUTION 500 MGML 1 PA QL (540 per 30 days)
zaleplon oral capsule 10 mg 5 mg 1
ZENZEDI ORAL TABLET 15 MG 25 MG 20 MG 30 MG 75 MG
1 ST
ziprasidone hcl oral capsule 20 mg 40 mg 60 mg 80 mg
1
zolpidem oral tablet 10 mg 5 mg 1
zolpidem oral tabletext release multiphase 125 mg 625 mg
1
zolpidem sublingual tablet 175 mg 35 mg 1
ZOLPIMIST ORAL SPRAYNON-AEROSOL 5 MGSPRAY (01 ML)
1 ST
ZULRESSO INTRAVENOUS SOLUTION 5 MGML
MB
CARDIOVASCULAR HYPERTENSION amp LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone oral tablet 100 mg 200 mg 400 mg 1
disopyramide phosphate oral capsule 100 mg 150 mg
1
dofetilide oral capsule 125 mcg 250 mcg 500 mcg 1
flecainide oral tablet 100 mg 150 mg 50 mg 1
mexiletine oral capsule 150 mg 200 mg 250 mg 1
MULTAQ ORAL TABLET 400 MG 1
NORPACE CR ORAL CAPSULE EXTENDED RELEASE 100 MG 150 MG
1
pacerone oral tablet 100 mg 200 mg 400 mg 1
procainamide injection solution 100 mgml 500 mgml
MB
propafenone oral capsuleextended release 12 hr 225 mg 325 mg 425 mg
1
45
Drug Name Drug Tier Requirements Limits
propafenone oral tablet 150 mg 225 mg 300 mg 1
quinidine gluconate oral tablet extended release 324 mg
1
quinidine sulfate oral tablet 200 mg 300 mg 1
sorine oral tablet 120 mg 160 mg 240 mg 80 mg 1
sotalol af oral tablet 120 mg 160 mg 80 mg 1
sotalol oral tablet 120 mg 160 mg 240 mg 80 mg 1
ANTIHYPERTENSIVE THERAPY
acebutolol oral capsule 200 mg 400 mg 1
aliskiren oral tablet 150 mg 300 mg 1
amiloride oral tablet 5 mg 1
amiloride-hydrochlorothiazide oral tablet 5-50 mg 1
amlodipine oral tablet 10 mg 25 mg 5 mg 1
amlodipine-benazepril oral capsule 10-20 mg 10-40 mg 25-10 mg 5-10 mg 5-20 mg 5-40 mg
1 ST
amlodipine-olmesartan oral tablet 10-20 mg 10-40 mg 5-20 mg 5-40 mg
1 ST
amlodipine-valsartan oral tablet 10-160 mg 10-320 mg 5-160 mg 5-320 mg
1 ST
amlodipine-valsartan-hcthiazid oral tablet 10-160-125 mg 10-160-25 mg 10-320-25 mg 5-160-125 mg 5-160-25 mg
1
atenolol oral tablet 100 mg 25 mg 50 mg 1
atenolol-chlorthalidone oral tablet 100-25 mg 50-25 mg
1
benazepril oral tablet 10 mg 20 mg 40 mg 5 mg 1
benazepril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg 5-625 mg
1
betaxolol oral tablet 10 mg 20 mg 1
bisoprolol fumarate oral tablet 10 mg 5 mg 1
bisoprolol-hydrochlorothiazide oral tablet 10-625 mg 25-625 mg 5-625 mg
1
bumetanide injection solution 025 mgml 1
bumetanide oral tablet 05 mg 1 mg 2 mg 1
BYSTOLIC ORAL TABLET 10 MG 25 MG 20 MG 5 MG
1 ST
candesartan oral tablet 16 mg 32 mg 4 mg 8 mg 1
46
Drug Name Drug Tier Requirements Limits
candesartan-hydrochlorothiazid oral tablet 16-125 mg 32-125 mg 32-25 mg
1
captopril oral tablet 100 mg 125 mg 25 mg 50 mg
1
captopril-hydrochlorothiazide oral tablet 25-15 mg 25-25 mg 50-15 mg 50-25 mg
1
cartia xt oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg
1
carvedilol oral tablet 125 mg 25 mg 3125 mg 625 mg
1
carvedilol phosphate oral capsule er multiphase 24 hr 10 mg 20 mg 40 mg 80 mg
1
chlorthalidone oral tablet 25 mg 50 mg 1
clonidine hcl oral tablet 01 mg 02 mg 03 mg 1
clonidine transdermal patch weekly 01 mg24 hr 02 mg24 hr 03 mg24 hr
1
diltiazem hcl oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg
1
diltiazem hcl oral capsuleextended release 12 hr 120 mg 60 mg 90 mg
1
diltiazem hcl oral capsuleextended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
diltiazem hcl oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg 360 mg
1
diltiazem hcl oral tablet 120 mg 30 mg 60 mg 90 mg
1
diltiazem hcl oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
dilt-xr oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg
1
doxazosin oral tablet 1 mg 2 mg 4 mg 8 mg 1
EDARBI ORAL TABLET 40 MG 80 MG 1 ST
EDARBYCLOR ORAL TABLET 40-125 MG 40-25 MG
1 ST
enalapril maleate oral tablet 10 mg 25 mg 20 mg 5 mg
1
enalaprilat intravenous solution 125 mgml MB
enalapril-hydrochlorothiazide oral tablet 10-25 mg 5-125 mg
1
EPANED ORAL SOLUTION 1 MGML 1
47
Drug Name Drug Tier Requirements Limits
eplerenone oral tablet 25 mg 50 mg 1
epoprostenol (glycine) intravenous recon soln 05 mg 15 mg
MB PA LA
eprosartan oral tablet 600 mg 1
ethacrynic acid oral tablet 25 mg 1
felodipine oral tablet extended release 24 hr 10 mg 25 mg 5 mg
1
FLOLAN INTRAVENOUS RECON SOLN 05 MG 15 MG
MB PA LA
fosinopril oral tablet 10 mg 20 mg 40 mg 1
fosinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg
1
furosemide oral solution 10 mgml 40 mg5 ml (8 mgml)
1
furosemide oral tablet 20 mg 40 mg 80 mg 1
guanfacine oral tablet 1 mg 2 mg 1
hydralazine oral tablet 10 mg 100 mg 25 mg 50 mg
1
hydrochlorothiazide oral capsule 125 mg 1
hydrochlorothiazide oral tablet 125 mg 25 mg 50 mg
1
indapamide oral tablet 125 mg 25 mg 1
irbesartan oral tablet 150 mg 300 mg 75 mg 1
irbesartan-hydrochlorothiazide oral tablet 150-125 mg 300-125 mg
1
isradipine oral capsule 25 mg 5 mg 1
labetalol oral tablet 100 mg 200 mg 300 mg 1
lisinopril oral tablet 10 mg 25 mg 20 mg 30 mg 40 mg 5 mg
1
lisinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg
1
losartan oral tablet 100 mg 25 mg 50 mg 1
losartan-hydrochlorothiazide oral tablet 100-125 mg 100-25 mg 50-125 mg
1
matzim la oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
methyldopa oral tablet 250 mg 500 mg 1
methyldopa-hydrochlorothiazide oral tablet 250-15 mg 250-25 mg
1
48
Drug Name Drug Tier Requirements Limits
methyldopate intravenous solution 250 mg5 ml MB
metolazone oral tablet 10 mg 25 mg 5 mg 1
metoprolol succinate oral tablet extended release 24 hr 100 mg 200 mg 25 mg 50 mg
1
metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg 100-50 mg 50-25 mg
1
metoprolol tartrate oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg
1
metyrosine oral capsule 250 mg 1
minoxidil oral tablet 10 mg 25 mg 1
moexipril oral tablet 15 mg 75 mg 1
nadolol oral tablet 20 mg 40 mg 80 mg 1
nadolol-bendroflumethiazide oral tablet 80-5 mg 1
nicardipine oral capsule 20 mg 30 mg 1
nifedipine oral capsule 10 mg 20 mg 1
nifedipine oral tablet extended release 24hr 30 mg 60 mg 90 mg
1
nifedipine oral tablet extended release 30 mg 60 mg 90 mg
1
nimodipine oral capsule 30 mg 1
nisoldipine oral tablet extended release 24 hr 17 mg 20 mg 255 mg 30 mg 34 mg 40 mg 85 mg
1
olmesartan oral tablet 20 mg 40 mg 5 mg 1
olmesartan-amlodipin-hcthiazid oral tablet 20-5-125 mg 40-10-125 mg 40-10-25 mg 40-5-125 mg 40-5-25 mg
1
olmesartan-hydrochlorothiazide oral tablet 20-125 mg 40-125 mg 40-25 mg
1 ST
ORENITRAM ORAL TABLET EXTENDED RELEASE 0125 MG 025 MG 1 MG 25 MG 5 MG
2 PA LA
perindopril erbumine oral tablet 2 mg 4 mg 8 mg 1
phenoxybenzamine oral capsule 10 mg 1
pindolol oral tablet 10 mg 5 mg 1
prazosin oral capsule 1 mg 2 mg 5 mg 1
propranolol oral capsuleextended release 24 hr 120 mg 160 mg 60 mg 80 mg
1
propranolol oral solution 20 mg5 ml (4 mgml) 40 mg5 ml (8 mgml)
1
49
Drug Name Drug Tier Requirements Limits
propranolol oral tablet 10 mg 20 mg 40 mg 60 mg 80 mg
1
propranolol-hydrochlorothiazid oral tablet 40-25 mg 80-25 mg
1
QBRELIS ORAL SOLUTION 1 MGML 1
quinapril oral tablet 10 mg 20 mg 40 mg 5 mg 1
quinapril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg
1
ramipril oral capsule 125 mg 10 mg 25 mg 5 mg
1
spironolactone oral tablet 100 mg 25 mg 50 mg 1
spironolacton-hydrochlorothiaz oral tablet 25-25 mg
1
taztia xt oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg
1
TEKTURNA HCT ORAL TABLET 150-125 MG 150-25 MG 300-125 MG 300-25 MG
1
telmisartan oral tablet 20 mg 40 mg 80 mg 1
telmisartan-amlodipine oral tablet 40-10 mg 40-5 mg 80-10 mg 80-5 mg
1 ST
telmisartan-hydrochlorothiazid oral tablet 40-125 mg 80-125 mg 80-25 mg
1
terazosin oral capsule 1 mg 10 mg 2 mg 5 mg 1
tiadylt er oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg 420 mg
1
timolol maleate oral tablet 10 mg 20 mg 5 mg 1
torsemide oral tablet 10 mg 100 mg 20 mg 5 mg 1
trandolapril oral tablet 1 mg 2 mg 4 mg 1
trandolapril-verapamil oral tablet ir - er biphasic 24hr 1-240 mg 2-180 mg 2-240 mg 4-240 mg
1 ST
triamterene oral capsule 100 mg 50 mg 1
triamterene-hydrochlorothiazid oral capsule 375-25 mg
1
triamterene-hydrochlorothiazid oral tablet 375-25 mg 75-50 mg
1
valsartan oral tablet 160 mg 320 mg 40 mg 80 mg
1
valsartan-hydrochlorothiazide oral tablet 160-125 mg 160-25 mg 320-125 mg 320-25 mg 80-125 mg
1
50
Drug Name Drug Tier Requirements Limits
veletri intravenous recon soln 05 mg 15 mg MB PA LA
verapamil oral capsule 24 hr er pellet ct 100 mg 200 mg 300 mg
1
verapamil oral capsuleext rel pellets 24 hr 120 mg 180 mg 240 mg 360 mg
1
verapamil oral tablet 120 mg 40 mg 80 mg 1
verapamil oral tablet extended release 120 mg 180 mg 240 mg
1
CARDIAC GLYCOSIDES
digitek oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
digox oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
digoxin oral solution 50 mcgml (005 mgml) 1
digoxin oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
COAGULATION THERAPY
ADVATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 4000 (+-) UNIT 500 (+-) UNIT
MB
ADYNOVATE INTRAVENOUS SOLUTION 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT 750 (+-) UNIT
MB LA
AFSTYLA INTRAVENOUS RECON SOLN 1000 (+-) UNIT RANGE 1500 (+-) UNIT RANGE 2000 (+-) UNIT RANGE 2500 (+-) UNIT RANGE 250 (+-) UNIT RANGE 3000 (+-) UNIT RANGE 500 (+-) UNIT RANGE
MB LA
ALPHANATE INTRAVENOUS RECON SOLN 1000 (400 VWF) UNIT10 ML 1500 (600 VWF) UNIT10 ML 2000 (800 VWF) UNIT10 ML 250 (100 VWF) UNIT5 ML 500 (200 VWF) UNIT5 ML
MB LA
ALPHANINE SD INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT
MB LA
ALPROLIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 500 UNIT
MB LA
aminocaproic acid oral solution 250 mgml (25 ) 1
51
Drug Name Drug Tier Requirements Limits
aminocaproic acid oral tablet 1000 mg 500 mg 1
ANDEXXA INTRAVENOUS RECON SOLN 200 MG
MB
aspirin-dipyridamole oral capsule er multiphase 12 hr 25-200 mg
1
BENEFIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
BRILINTA ORAL TABLET 60 MG 90 MG 1
CABLIVI INJECTION KIT 11 MG 2 PA
cilostazol oral tablet 100 mg 50 mg 1
clopidogrel oral tablet 300 mg 75 mg 1
COAGADEX INTRAVENOUS RECON SOLN 250 (+-) UNIT RANGE 500 (+-) UNIT RANGE
MB
CORIFACT INTRAVENOUS RECON SOLN 1000-1600 UNIT
MB LA
dipyridamole oral tablet 25 mg 50 mg 75 mg 1
DOPTELET (15 TAB PACK) ORAL TABLET 20 MG
2 PA LA
ELIQUIS DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 5 MG (74 TABS)
1
ELIQUIS ORAL TABLET 25 MG 5 MG 1
ELOCTATE INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 5000 UNIT 500 UNIT 6000 UNIT 750 UNIT
MB LA
enoxaparin subcutaneous solution 300 mg3 ml 2
enoxaparin subcutaneous syringe 100 mgml 120 mg08 ml 150 mgml 30 mg03 ml 40 mg04 ml 60 mg06 ml 80 mg08 ml
2
ESPEROCT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
FEIBA NF INTRAVENOUS RECON SOLN 1750-3250 UNIT 350-650 UNIT 700-1300 UNIT
MB LA
FIBRYGA INTRAVENOUS RECON SOLN 1 GRAM (700 MG- 1300 MG)
MB
fondaparinux subcutaneous syringe 10 mg08 ml 25 mg05 ml 5 mg04 ml 75 mg06 ml
2
52
Drug Name Drug Tier Requirements Limits
FRAGMIN SUBCUTANEOUS SOLUTION 25000 ANTI-XA UNITML
2
FRAGMIN SUBCUTANEOUS SYRINGE 10000 ANTI-XA UNITML 12500 ANTI-XA UNIT05 ML 15000 ANTI-XA UNIT06 ML 18000 ANTI-XA UNIT072 ML 2500 ANTI-XA UNIT02 ML 5000 ANTI-XA UNIT02 ML 7500 ANTI-XA UNIT03 ML
2
HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG07 ML 150 MGML 30 MGML 60 MG04 ML
2 PA LA
HEMOFIL M HIGH INTRAVENOUS RECON SOLN 801-1500 UNIT
MB
HEMOFIL M LOW INTRAVENOUS RECON SOLN 220-400 UNIT
MB
HEMOFIL M MID INTRAVENOUS RECON SOLN 401-800 UNIT
MB
HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 1501-2000 UNIT
MB
hep flush-10 (pf) intravenous solution 10 unitml MB
heparin (porcine) in 5 dex intravenous parenteral solution 25000 unit250 ml(100 unitml) 25000 unit500 ml (50 unitml)
MB
heparin (porcine) injection cartridge 5000 unitml (1 ml)
1
heparin (porcine) injection solution 1000 unitml 10000 unitml 20000 unitml 5000 unitml
1
heparin lock flush (porcine) intravenous solution 100 unitml
MB
heparin lockflush(porcine)(pf) intravenous syringe 100 unitml
MB
HEPARIN(PORCINE) IN 045 NACL INTRAVENOUS PARENTERAL SOLUTION 12500 UNIT250 ML
MB
heparin(porcine) in 045 nacl intravenous parenteral solution 25000 unit250 ml 25000 unit500 ml
MB
heparin porcine (pf) injection solution 1000 unitml 5000 unit05 ml
MB
heparin porcine (pf) injection syringe 5000 unit05 ml
1
53
Drug Name Drug Tier Requirements Limits
heparin porcine (pf) intravenous solution 100 unitml (1 ml)
MB
heparin porcine (pf) intravenous syringe 10 unitml 100 unitml
MB
HUMATE-P INTRAVENOUS RECON SOLN 1000-2400 UNIT 250-600 UNIT 500-1200 UNIT
MB LA
IDELVION INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3500 (+-) UNIT 500 (+-) UNIT
MB LA
IXINITY INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
jantoven oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg
1
JIVI INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
KOATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB
KOGENATE FS INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB
KOVALTRY INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB
MONONINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT
MB LA
MULPLETA ORAL TABLET 3 MG 2 PA LA
NOVOEIGHT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
NOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1000 MCG) 2 MG (2000 MCG) 5 MG (5000 MCG) 8 MG (8000 MCG)
MB LA
NPLATE SUBCUTANEOUS RECON SOLN 125 MCG 250 MCG 500 MCG
MB LA
NUWIQ INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 2500 UNIT 250 (+-) UNIT 3000 UNIT 4000 UNIT 500 (+-) UNIT
MB LA
54
Drug Name Drug Tier Requirements Limits
OBIZUR INTRAVENOUS RECON SOLN 500 (+-) UNIT RANGE
MB
pentoxifylline oral tablet extended release 400 mg 1
phytonadione (vitamin k1) oral tablet 5 mg 1
prasugrel oral tablet 10 mg 5 mg 1
PROFILNINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT
MB LA
PROMACTA ORAL POWDER IN PACKET 125 MG
2 PA ST LA
PROMACTA ORAL POWDER IN PACKET 25 MG
2 LA
PROMACTA ORAL TABLET 125 MG 25 MG 50 MG 75 MG
2 PA ST LA
REBINYN INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 500 (+-) UNIT
MB LA
RECOMBINATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB LA
RIASTAP INTRAVENOUS RECON SOLN 1 GRAM (900MG-1300MG)
MB LA
RIXUBIS INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
tranexamic acid intravenous solution 1000 mg10 ml (100 mgml)
MB
TRETTEN INTRAVENOUS RECON SOLN 2500 UNIT
MB LA
VONVENDI INTRAVENOUS RECON SOLN 1300 (+-) UNIT RANGE 650 (+-) UNIT RANGE
MB LA
warfarin oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg
1
WILATE INTRAVENOUS RECON SOLN 1000-1000 UNIT 500-500 UNIT
MB LA
XARELTO DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 15 MG (42)- 20 MG (9)
1
XARELTO ORAL TABLET 10 MG 15 MG 25 MG 20 MG
1
55
Drug Name Drug Tier Requirements Limits
XYNTHA INTRAVENOUS SOLUTION 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB LA
XYNTHA SOLOFUSE INTRAVENOUS SYRINGE 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
ZONTIVITY ORAL TABLET 208 MG 1
LIPIDCHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg 25-10 mg 25-20 mg 25-40 mg 5-10 mg 5-20 mg 5-40 mg 5-80 mg
1 ST
atorvastatin oral tablet 10 mg 20 mg ACA PV
atorvastatin oral tablet 40 mg 80 mg 1
cholestyramine (with sugar) oral powder 4 gram 1
cholestyramine (with sugar) oral powder in packet 4 gram
1
cholestyramine light oral powder 4 gram 1
cholestyramine light oral powder in packet 4 gram 1
colesevelam oral powder in packet 375 gram 1
colesevelam oral tablet 625 mg 1
colestipol oral granules 5 gram 1
colestipol oral packet 5 gram 1
colestipol oral tablet 1 gram 1
ezetimibe oral tablet 10 mg 1
ezetimibe-simvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg
1
fenofibrate micronized oral capsule 130 mg 134 mg 200 mg 43 mg 67 mg
1
fenofibrate nanocrystallized oral tablet 145 mg 48 mg
1
FENOFIBRATE ORAL CAPSULE 150 MG 50 MG
1
fenofibrate oral tablet 120 mg 160 mg 40 mg 54 mg
1
fenofibric acid (choline) oral capsuledelayed release(drec) 135 mg 45 mg
1
fenofibric acid oral tablet 105 mg 35 mg 1
fluvastatin oral capsule 20 mg 40 mg ACA PV
56
Drug Name Drug Tier Requirements Limits
fluvastatin oral tablet extended release 24 hr 80 mg
ACA PV
gemfibrozil oral tablet 600 mg 1
icosapent ethyl oral capsule 1 gram 1 PA ST QL (120 per 30 days)
JUXTAPID ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 5 MG 60 MG
2 PA LA QL (30 per 30 days)
LIPOFEN ORAL CAPSULE 150 MG 50 MG 1
lovastatin oral tablet 10 mg 20 mg 40 mg ACA PV
niacin oral tablet 500 mg 1
niacin oral tablet extended release 24 hr 1000 mg 500 mg 750 mg
1
NIACOR ORAL TABLET 500 MG 1
omega-3 acid ethyl esters oral capsule 1 gram 1
pravastatin oral tablet 10 mg 20 mg 40 mg 80 mg
ACA PV
prevalite oral powder 4 gram 1
prevalite oral powder in packet 4 gram 1
REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG35 ML
1 PA ST
REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MGML
1 PA ST
REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MGML
1 PA ST
rosuvastatin oral tablet 10 mg 5 mg ACA PV
rosuvastatin oral tablet 20 mg 40 mg 1
simvastatin oral tablet 10 mg 20 mg 40 mg 5 mg ACA PV
simvastatin oral tablet 80 mg 1
VASCEPA ORAL CAPSULE 05 GRAM 1 GRAM
1 PA ST QL (120 per 30 days)
ZYPITAMAG ORAL TABLET 2 MG 4 MG 1 PA ST
MISCELLANEOUS CARDIOVASCULAR AGENTS
CORLANOR ORAL SOLUTION 5 MG5 ML 1 PA
CORLANOR ORAL TABLET 5 MG 75 MG 1 PA
ENTRESTO ORAL TABLET 24-26 MG 49-51 MG 97-103 MG
1 PA ST
GIAPREZA INTRAVENOUS SOLUTION 25 MGML
MB
57
Drug Name Drug Tier Requirements Limits
ranolazine oral tablet extended release 12 hr 1000 mg 500 mg
1 ST
NITRATES
GONITRO SUBLINGUAL POWDER IN PACKET 400 MCG
1
isosorbide dinitrate oral tablet 10 mg 20 mg 30 mg 40 mg 5 mg
1
isosorbide mononitrate oral tablet 10 mg 20 mg 1
isosorbide mononitrate oral tablet extended release 24 hr 120 mg 30 mg 60 mg
1
MINITRAN TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 04 MGHR 06 MGHR
1 PA ST
nitro-bid transdermal ointment 2 1
NITRO-DUR TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 03 MGHR 04 MGHR 06 MGHR 08 MGHR
1 PA ST
nitroglycerin in 5 dextrose intravenous solution 25 mg250 ml (100 mcgml) 50 mg500 ml (100 mcgml)
MB
nitroglycerin sublingual tablet 03 mg 04 mg 06 mg
1
nitroglycerin transdermal patch 24 hour 01 mghr 02 mghr 04 mghr 06 mghr
1
nitroglycerin translingual spraynon-aerosol 400 mcgspray
1
nitro-time oral capsule extended release 25 mg 65 mg 9 mg
1
DERMATOLOGICALSTOPICAL THERAPY
ANTIPSORIATIC ANTISEBORRHEIC
acitretin oral capsule 10 mg 175 mg 25 mg 1
calcipotriene scalp solution 0005 1
calcipotriene topical cream 0005 1
calcipotriene topical ointment 0005 1
calcipotriene-betamethasone topical ointment 0005-0064
1
calcitriol topical ointment 3 mcggram 1
COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
58
Drug Name Drug Tier Requirements Limits
COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
COSENTYX SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
COSENTYX SUBCUTANEOUS SYRINGE 75 MG05 ML
2 PA LA
hydrocortisone-pramoxine topical cream 25-1 1
ILUMYA SUBCUTANEOUS SYRINGE 100 MGML
2 PA ST LA
selenium sulfide topical lotion 25 1
selenium sulfide topical shampoo 225 23 1
SILIQ SUBCUTANEOUS SYRINGE 210 MG15 ML
2 PA ST LA
SKYRIZI SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
SKYRIZI SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
SKYRIZI SUBCUTANEOUS SYRINGE KIT 150MG166ML(75 MG083 ML X2)
2 PA ST LA
STELARA INTRAVENOUS SOLUTION 130 MG26 ML
MB PA LA
STELARA SUBCUTANEOUS SOLUTION 45 MG05 ML
2 PA ST LA
STELARA SUBCUTANEOUS SYRINGE 45 MG05 ML 90 MGML
2 PA ST LA
sulfacetamide sodium topical cleanser 10 1
sulfacetamide sodium topical cleanser gel 10 1
sulfacetamide sodium topical shampoo 10 1
TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MGML
2 PA ST LA
59
Drug Name Drug Tier Requirements Limits
TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 MGML
2 PA ST LA
TREMFYA SUBCUTANEOUS SYRINGE 100 MGML
2 PA ST LA
BURN THERAPY
silver sulfadiazine topical cream 1 1
ssd topical cream 1 1
MISCELLANEOUS DERMATOLOGICALS
ammonium lactate topical cream 12 1
ammonium lactate topical lotion 12 1
diclofenac sodium topical gel 3 1
DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300 MG2 ML
2 LA
DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG114 ML 300 MG2 ML
2 PA ST LA
EUCRISA TOPICAL OINTMENT 2 1 PA ST
FLUOROURACIL TOPICAL CREAM 05 1 PA ST
fluorouracil topical cream 5 1 PA ST
fluorouracil topical solution 2 5 1
LEVULAN TOPICAL SOLUTION 20 1
methoxsalen oral capsuleliqd-filledrapid rel 10 mg
1
PANRETIN TOPICAL GEL 01 1
PICATO TOPICAL GEL 0015 005 1
pimecrolimus topical cream 1 1
podofilox topical solution 05 1
prudoxin topical cream 5 1
REGRANEX TOPICAL GEL 001 1
SCENESSE SUBCUTANEOUS IMPLANT 16 MG
MB PA
tacrolimus topical ointment 003 01 1
UVADEX INJECTION SOLUTION 20 MCGML 1
VALCHLOR TOPICAL GEL 0016 2 PA ST LA
THERAPY FOR ACNE
accutane oral capsule 20 mg 30 mg 40 mg 1
adapalene topical cream 01 1 ST
60
Drug Name Drug Tier Requirements Limits
adapalene topical gel 03 1 ST
adapalene topical gel with pump 03 1 ST
ADAPALENE TOPICAL LOTION 01 1 ST
adapalene topical solution 01 1 ST
adapalene topical swab 01 1 ST
adapalene-benzoyl peroxide topical gel with pump 01-25
1
amnesteem oral capsule 10 mg 20 mg 40 mg 1 PA ST
avita topical cream 0025 1
AVITA TOPICAL GEL 0025 1 ST
azelaic acid topical gel 15 1
AZELEX TOPICAL CREAM 20 1 ST
claravis oral capsule 10 mg 20 mg 30 mg 1 PA ST
claravis oral capsule 40 mg 1
clindacin p topical swab 1 1
clindamycin phosphate topical foam 1 1
clindamycin phosphate topical gel 1 1
clindamycin phosphate topical lotion 1 1
clindamycin phosphate topical solution 1 1
clindamycin phosphate topical swab 1 1
clindamycin-benzoyl peroxide topical gel 1-5 12 (1 base) -5
1
clindamycin-benzoyl peroxide topical gel with pump 1-5
1
clindamycin-tretinoin topical gel 12-0025 1
dapsone topical gel 5 1
ery pads topical swab 2 1
erygel topical gel 2 1
erythromycin with ethanol topical gel 2 1
erythromycin with ethanol topical solution 2 1
erythromycin-benzoyl peroxide topical gel 3-5 1
isotretinoin oral capsule 10 mg 20 mg 25 mg 30 mg 35 mg 40 mg
1
metronidazole topical cream 075 1
metronidazole topical gel 075 1 1
metronidazole topical gel with pump 1 1
61
Drug Name Drug Tier Requirements Limits
metronidazole topical lotion 075 1
myorisan oral capsule 10 mg 20 mg 30 mg 40 mg
1
rosadan topical cream 075 1
rosadan topical gel 075 1
tazarotene topical cream 01 1 ST
tretinoin microspheres topical gel 004 01 1
tretinoin microspheres topical gel with pump 004 01
1
tretinoin topical cream 0025 005 01 1
tretinoin topical gel 001 0025 005 1
zenatane oral capsule 10 mg 20 mg 30 mg 40 mg 1
TOPICAL ANESTHETICS
lidocaine hcl injection solution 10 mgml (1 ) 1
lidocaine hcl laryngotracheal solution 4 1
lidocaine hcl mucous membrane jelly 2 1
lidocaine hcl mucous membrane jelly in applicator 2
1
lidocaine hcl mucous membrane solution 4 (40 mgml)
1
lidocaine hcl-hydrocortison ac topical cream 3-05
1
lidocaine topical adhesive patchmedicated 5 1
lidocaine topical ointment 5 1
lidocaine viscous mucous membrane solution 2 1
lidocaine-prilocaine topical cream 25-25 1
lidocaine-prilocaine topical kit 25-25 1
LIDOCAINE-TETRACAINE TOPICAL CREAM 7-7
1 ST
SYNERA TOPICAL PATCH MEDICATED SELF-HEATING 70-70 MG
1 ST
TOPICAL ANTIBACTERIALS
ALCORTIN A TOPICAL GEL 2-1-1 1 ST
ALCORTIN A TOPICAL GEL IN PACKET 2-1-1
1 ST
ALTABAX TOPICAL OINTMENT 1 1
gentamicin topical cream 01 1
62
Drug Name Drug Tier Requirements Limits
gentamicin topical ointment 01 1
mafenide acetate topical packet 50 gram 1
mupirocin calcium topical cream 2 1
mupirocin topical ointment 2 1
sulfacetamide sodium (acne) topical suspension 10
1
SULFAMYLON TOPICAL CREAM 85 MGG 1
TOPICAL ANTIFUNGALS
ciclodan topical cream 077 1
ciclodan topical solution 8 1
ciclopirox topical cream 077 1
ciclopirox topical gel 077 1
ciclopirox topical shampoo 1 1
ciclopirox topical solution 8 1
ciclopirox topical suspension 077 1
ciclopirox-ure-camph-menth-euc topical solution 8
1
clotrimazole topical cream 1 1
clotrimazole topical solution 1 1
clotrimazole-betamethasone topical cream 1-005
1
clotrimazole-betamethasone topical lotion 1-005
1
econazole topical cream 1 1
EXELDERM TOPICAL CREAM 1 1
EXELDERM TOPICAL SOLUTION 1 1
JUBLIA TOPICAL SOLUTION WITH APPLICATOR 10
1 PA ST
ketoconazole topical cream 2 1
ketoconazole topical foam 2 1
ketoconazole topical shampoo 2 1
ketodan topical foam 2 1
LULICONAZOLE TOPICAL CREAM 1 1
LUZU TOPICAL CREAM 1 1
MENTAX TOPICAL CREAM 1 1
naftifine topical cream 1 2 1
63
Drug Name Drug Tier Requirements Limits
naftifine topical gel 1 1
nyamyc topical powder 100000 unitgram 1
nystatin topical cream 100000 unitgram 1
nystatin topical ointment 100000 unitgram 1
nystatin topical powder 100000 unitgram 1
nystatin-triamcinolone topical cream 100000-01 unitg-
1
nystatin-triamcinolone topical ointment 100000-01 unitgram-
1
nystop topical powder 100000 unitgram 1
oxiconazole topical cream 1 1
OXISTAT TOPICAL LOTION 1 1
tavaborole topical solution with applicator 5 1 PA ST
TOPICAL ANTIVIRALS
acyclovir topical cream 5 1
acyclovir topical ointment 5 1
DENAVIR TOPICAL CREAM 1 1
TOPICAL CORTICOSTEROIDS
ala-cort topical cream 1 1
alclometasone topical cream 005 1
alclometasone topical ointment 005 1
amcinonide topical cream 01 1
amcinonide topical lotion 01 1
apexicon e topical cream 005 1
beser topical lotion 005 1
betamethasone dipropionate topical cream 005 1
betamethasone dipropionate topical lotion 005 1
betamethasone dipropionate topical ointment 005
1
betamethasone valerate topical cream 01 1
betamethasone valerate topical foam 012 1
betamethasone valerate topical lotion 01 1
betamethasone valerate topical ointment 01 1
betamethasone augmented topical cream 005 1
betamethasone augmented topical gel 005 1
betamethasone augmented topical lotion 005 1
64
Drug Name Drug Tier Requirements Limits
betamethasone augmented topical ointment 005
1
clobetasol scalp solution 005 1
clobetasol topical cream 005 1
clobetasol topical foam 005 1
clobetasol topical gel 005 1
clobetasol topical lotion 005 1
clobetasol topical ointment 005 1
clobetasol topical shampoo 005 1
clobetasol topical spraynon-aerosol 005 1
clobetasol-emollient topical cream 005 1
clobetasol-emollient topical foam 005 1
CLOCORTOLONE PIVALATE TOPICAL CREAM 01
1 ST
CLODERM TOPICAL CREAM 01 1 ST
desonide topical cream 005 1
desonide topical lotion 005 1
desonide topical ointment 005 1
desoximetasone topical cream 005 025 1
desoximetasone topical gel 005 1
desoximetasone topical ointment 005 025 1
desoximetasone topical spraynon-aerosol 025 1
diflorasone topical cream 005 1
diflorasone topical ointment 005 1
fluocinolone and shower cap scalp oil 001 1
fluocinolone topical cream 001 0025 1
fluocinolone topical oil 001 1
fluocinolone topical ointment 0025 1
fluocinolone topical solution 001 1
fluocinonide topical cream 005 01 1
fluocinonide topical gel 005 1
fluocinonide topical ointment 005 1
fluocinonide topical solution 005 1
fluocinonide-e topical cream 005 1
flurandrenolide topical cream 005 1
65
Drug Name Drug Tier Requirements Limits
flurandrenolide topical lotion 005 1
flurandrenolide topical ointment 005 1
fluticasone propionate topical cream 005 1
fluticasone propionate topical lotion 005 1
fluticasone propionate topical ointment 0005 1
halcinonide topical cream 01 1
halobetasol propionate topical cream 005 1
halobetasol propionate topical ointment 005 1
hydrocortisone butyrate topical cream 01 1
hydrocortisone butyrate topical lotion 01 1
hydrocortisone butyrate topical ointment 01 1
hydrocortisone butyrate topical solution 01 1
hydrocortisone butyr-emollient topical cream 01
1
hydrocortisone topical cream 1 25 1
hydrocortisone topical lotion 25 1
hydrocortisone topical ointment 1 25 1
hydrocortisone valerate topical cream 02 1
hydrocortisone valerate topical ointment 02 1
mometasone topical cream 01 1
mometasone topical ointment 01 1
mometasone topical solution 01 1
prednicarbate topical cream 01 1
prednicarbate topical ointment 01 1
scalacort topical lotion 2 1
triamcinolone acetonide topical aerosol 0147 mggram
1
triamcinolone acetonide topical cream 0025 01 05
1
triamcinolone acetonide topical lotion 0025 01
1
triamcinolone acetonide topical ointment 0025 005 01 05
1
triderm topical cream 01 05 1
TOPICAL ENZYMES
SANTYL TOPICAL OINTMENT 250 UNITGRAM
1 QL (2 per 30 days)
66
Drug Name Drug Tier Requirements Limits
TOPICAL SCABICIDES PEDICULICIDES
crotan topical lotion 10 1
EURAX TOPICAL CREAM 10 1
EURAX TOPICAL LOTION 10 1
ivermectin topical lotion 05 1
lindane topical shampoo 1 1
malathion topical lotion 05 1
permethrin topical cream 5 1
spinosad topical suspension 09 1
ULESFIA TOPICAL LOTION 5 1
DIAGNOSTICS amp MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
PHYSIOLYTE IRRIGATION SOLUTION 140-5-3-98 MEQL
MB
PHYSIOSOL IRRIGATION IRRIGATION SOLUTION 140-5-3-98 MEQL
MB
MISCELLANEOUS AGENTS
acamprosate oral tabletdelayed release (drec) 333 mg
1
acetic acid irrigation solution 025 1
anagrelide oral capsule 05 mg 1 mg 1
ARALAST NP INTRAVENOUS RECON SOLN 1000 MG 500 MG
MB LA
CARBAGLU ORAL TABLET DISPERSIBLE 200 MG
2 PA LA
cevimeline oral capsule 30 mg 1
CHEMET ORAL CAPSULE 100 MG 1
clovique oral capsule 250 mg 1 PA QL (240 per 30 days)
deferasirox oral granules in packet 180 mg 360 mg 90 mg
2 PA LA
deferasirox oral tablet 180 mg 2 PA LA
deferasirox oral tablet 360 mg 90 mg 2 ST LA
deferasirox oral tablet dispersible 125 mg 250 mg 500 mg
2 ST LA
deferiprone oral tablet 500 mg 1 PA
disulfiram oral tablet 250 mg 500 mg 1
67
Drug Name Drug Tier Requirements Limits
EMPAVELI SUBCUTANEOUS SOLUTION 1080 MG20 ML
2 PA
FERRIPROX ORAL SOLUTION 100 MGML 1 PA
FERRIPROX ORAL TABLET 1000 MG 500 MG
1 PA
GIVLAARI SUBCUTANEOUS SOLUTION 189 MGML
MB PA LA
GLASSIA INTRAVENOUS SOLUTION 1 GRAM50 ML (2 )
MB LA
INCRELEX SUBCUTANEOUS SOLUTION 10 MGML
2 PA LA
levocarnitine (with sugar) oral solution 100 mgml 1
levocarnitine oral solution 100 mgml 1
levocarnitine oral tablet 330 mg 1
midodrine oral tablet 10 mg 25 mg 5 mg 1
nitisinone oral capsule 10 mg 2 mg 5 mg 2 PA LA
NITYR ORAL TABLET 10 MG 2 MG 5 MG 2 PA LA
pilocarpine hcl oral tablet 5 mg 1
PROLASTIN-C INTRAVENOUS SOLUTION 1000 MG (+-)20 ML
MB
RAVICTI ORAL LIQUID 11 GRAMML 2 PA ST LA QL (10 per 30 days)
RECLAST INTRAVENOUS PIGGYBACK 5 MG100 ML
MB
riluzole oral tablet 50 mg 1
risedronate oral tablet 30 mg 1
sodium chloride 09 injection solution MB
sodium chloride 09 intravenous parenteral solution
MB
sodium chloride 09 intravenous piggyback MB
sodium phenylbutyrate oral powder 094 gramgram
1 PA
sodium phenylbutyrate oral tablet 500 mg 1 PA
SOLIRIS INTRAVENOUS SOLUTION 300 MG30 ML
MB PA LA
trientine oral capsule 250 mg 1 PA QL (240 per 30 days)
XURIDEN ORAL GRANULES IN PACKET 2 GRAM
2 PA QL (120 per 30 days)
68
Drug Name Drug Tier Requirements Limits
ZEMAIRA INTRAVENOUS RECON SOLN 1000 MG
MB LA
ZOKINVY ORAL CAPSULE 50 MG 75 MG 2 PA ST
SMOKING DETERRENTS
bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg
ACA PV
CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG
ACA PV QL (180 per 365 days)
CHANTIX ORAL TABLET 05 MG 1 MG ACA PV QL (180 per 365 days)
CHANTIX STARTING MONTH BOX ORAL TABLETSDOSE PACK 05 MG (11)- 1 MG (42)
ACA PV QL (180 per 365 days)
nicorette buccal gum 4 mg ACA PV
nicotine (polacrilex) buccal gum 2 mg 4 mg ACA PV
nicotine (polacrilex) buccal lozenge 2 mg 4 mg ACA PV
nicotine (polacrilex) buccal mini lozenge 2 mg 4 mg
ACA PV
nicotine transdermal patch 24 hour 14 mg24 hr 21 mg24 hr 7 mg24 hr
ACA PV
nicotine transdermal patch td daily sequential 21-14-7 mg24 hr
ACA PV
NICOTROL INHALATION CARTRIDGE 10 MG
ACA PV
NICOTROL NS NASAL SPRAYNON-AEROSOL 10 MGML
ACA PV
quit 2 buccal gum 2 mg ACA PV
quit 2 buccal lozenge 2 mg ACA PV
quit 4 buccal gum 4 mg ACA PV
quit 4 buccal lozenge 4 mg ACA PV
stop smoking aid buccal lozenge 2 mg 4 mg ACA PV
EAR NOSE amp THROAT MEDICATIONS
MISCELLANEOUS AGENTS
ARESTIN DENTAL CARTRIDGE 1 MG MB
azelastine nasal aerosolspray 137 mcg (01 ) 1
azelastine nasal spraynon-aerosol 2055 mcg (015 )
1
chlorhexidine gluconate mucous membrane mouthwash 012
1
denta 5000 plus dental cream 11 1
69
Drug Name Drug Tier Requirements Limits
dentagel dental gel 11 1
fluoride (sodium) dental cream 11 1
fluoride (sodium) dental gel 11 1
fluoride (sodium) dental paste 11 1
ipratropium bromide nasal spraynon-aerosol 21 mcg (003 ) 42 mcg (006 )
1
olopatadine nasal spraynon-aerosol 06 1
oralone dental paste 01 1
paroex oral rinse mucous membrane mouthwash 012
1
periogard mucous membrane mouthwash 012 1
pilocarpine hcl oral tablet 75 mg 1
sf 5000 plus dental cream 11 1
sf dental gel 11 1
sodium fluoride 5000 dry mouth dental gel 11 1
sodium fluoride 5000 plus dental cream 11 1
sodium fluoride-pot nitrate dental paste 11-5 1
triamcinolone acetonide dental paste 01 1
MISCELLANEOUS OTIC PREPARATIONS
acetic acid otic (ear) solution 2 1
ciprofloxacin hcl otic (ear) dropperette 02 1
flac otic oil otic (ear) drops 001 1
fluocinolone acetonide oil otic (ear) drops 001 1
hydrocortisone-acetic acid otic (ear) drops 1-2 1
ofloxacin otic (ear) drops 03 1
OTIC STEROID ANTIBIOTIC
CIPRO HC OTIC (EAR) DROPSSUSPENSION 02-1
1
ciprofloxacin-dexamethasone otic (ear) dropssuspension 03-01
1
neomycin-polymyxin-hc otic (ear) dropssuspension 35-10000-1 mgml-unitml-
1
neomycin-polymyxin-hc otic (ear) solution 35-10000-1 mgml-unitml-
1
OTOVEL OTIC (EAR) SOLUTION 03-0025 (025 ML)
1
ENDOCRINEDIABETES
70
Drug Name Drug Tier Requirements Limits
ADRENAL HORMONES
ACTHAR INJECTION GEL 80 UNITML 2 PA LA
decadron oral tablet 05 mg 1
dexamethasone intensol oral drops 1 mgml 1
dexamethasone oral elixir 05 mg5 ml 1
dexamethasone oral solution 05 mg5 ml 1
dexamethasone oral tablet 05 mg 075 mg 1 mg 15 mg 2 mg 4 mg 6 mg
1
dexamethasone oral tabletsdose pack 15 mg (21 tabs) 15 mg (35 tabs) 15 mg (51 tabs)
1
dexamethasone sodium phos (pf) injection solution 10 mgml
1
dexamethasone sodium phosphate injection solution 10 mgml 4 mgml
1
dexamethasone sodium phosphate injection syringe 4 mgml
1
fludrocortisone oral tablet 01 mg 1
hydrocortisone oral tablet 10 mg 20 mg 5 mg 1
methylprednisolone acetate injection suspension 40 mgml 80 mgml
1
methylprednisolone oral tablet 16 mg 32 mg 4 mg 8 mg
1
methylprednisolone oral tabletsdose pack 4 mg 1
millipred dp oral tabletsdose pack 5 mg (21 tabs) 5 mg (48 tabs)
1
millipred oral tablet 5 mg 1
prednisolone oral solution 15 mg5 ml 1
prednisolone sodium phosphate oral solution 10 mg5 ml 15 mg5 ml (3 mgml) 20 mg5 ml (4 mgml) 25 mg5 ml (5 mgml) 5 mg base5 ml (67 mg5 ml)
1
prednisolone sodium phosphate oral tabletdisintegrating 10 mg 15 mg 30 mg
1
prednisone intensol oral concentrate 5 mgml 1
prednisone oral solution 5 mg5 ml 1
prednisone oral tablet 1 mg 10 mg 25 mg 20 mg 5 mg 50 mg
1
prednisone oral tabletsdose pack 10 mg 5 mg 1
71
Drug Name Drug Tier Requirements Limits
triamcinolone acetonide injection suspension 40 mgml
MB
ANTITHYROID AGENTS
methimazole oral tablet 10 mg 5 mg 1
propylthiouracil oral tablet 50 mg 1
SSKI ORAL SOLUTION 1 GRAMML 1
BLOOD GLUCOSE MONITORING DEVICES amp SUPPLIES
CONTOUR NEXT TEST STRIPS STRIP 1
CONTOUR TEST STRIPS STRIP 1
ONETOUCH ULTRA TEST STRIP 1
ONETOUCH VERIO TEST STRIPS STRIP 1
DIABETES SUPPLIES amp DURABLE MEDICAL EQUIPMENT
AEROCHAMBER MINI SPACER 1
AEROCHAMBER PLUS FLOW-VU SPACER 1
GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN 1 MGML
1
GLUCAGON HCL INJECTION RECON SOLN 1 MGML
1
INSULIN SYRINGE-NEEDLE U-100 SYRINGE 05 ML 29 GAUGE X 12
1
TRIJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-5-1000 MG 125-25-1000 MG 25-5-1000 MG 5-25-1000 MG
1 PA ST
GLUCOSE ELEVATING AGENTS
BAQSIMI NASAL SPRAYNON-AEROSOL 3 MGACTUATION
1
diazoxide oral suspension 50 mgml 1
GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG
1
GLUCAGON (HCL) EMERGENCY KIT INJECTION RECON SOLN 1 MG
1
glucagon emergency kit (human) injection recon soln 1 mg
1
INSULIN SYRINGESMISCELLANEOUS DURABLE MEDICAL EQU
FREESTYLE LIBRE 14 DAY SENSOR KIT 1
FREESTYLE LIBRE 2 SENSOR KIT 1
NOVOPEN ECHO SUBCUTANEOUS INSULIN PEN
1
72
Drug Name Drug Tier Requirements Limits
PEN NEEDLE DIABETIC NEEDLE 29 GAUGE X 12
1
INSULIN THERAPY
FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
FIASP PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML (3 ML)
1
FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN HALF-UNIT 100 UNITML
1
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML
1 ST
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 200 UNITML (3 ML)
1
HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNITML (50-50)
1 ST
HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (50-50)
1 ST
HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (75-25)
1 ST
HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNITML (75-25)
1 ST
HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML
1 ST
HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1 ST
HUMULIN 7030 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)
1 ST
HUMULIN 7030 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1 ST
73
Drug Name Drug Tier Requirements Limits
HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1 ST
HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML
1 ST
HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNITML
1 ST
HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNITML
1
HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNITML (3 ML)
1
INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML (70-30)
1
INSULIN ASPART U-100 SUBCUTANEOUS CARTRIDGE 100 UNITML
1
INSULIN ASPART U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
INSULIN ASPART U-100 SUBCUTANEOUS SOLUTION 100 UNITML
1
LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
NOVOLIN R FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
74
Drug Name Drug Tier Requirements Limits
NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNITML (70-30)
1
NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML
1
NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML
1
RELION NOVOLIN 7030 SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)
1
RELION NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNITML
1
RELION NOVOLIN R INJECTION SOLUTION 100 UNITML
1
SOLIQUA 10033 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCGML
1 PA ST
TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNITML (3 ML)
1
TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNITML (15 ML)
1
TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN 200 UNITML (3 ML)
1
TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
XULTOPHY 10036 SUBCUTANEOUS INSULIN PEN 100 UNIT-36 MG ML (3 ML)
1 PA ST
MISCELLANEOUS HORMONES
ALDURAZYME INTRAVENOUS SOLUTION 29 MG5 ML
MB PA LA
ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG24 HOUR 4 MG24 HR
1 ST QL (30 per 30 days)
75
Drug Name Drug Tier Requirements Limits
BRINEURA INTRAVENTRICULAR KIT 300 MG10 ML (150MG5ML X2)
MB
cabergoline oral tablet 05 mg 1
calcitonin (salmon) injection solution 200 unitml 1
calcitonin (salmon) nasal spraynon-aerosol 200 unitactuation
1
calcitriol oral capsule 025 mcg 05 mcg 1
calcitriol oral solution 1 mcgml 1
CERDELGA ORAL CAPSULE 84 MG 2 PA LA
CEREZYME INTRAVENOUS RECON SOLN 400 UNIT
MB PA LA
cinacalcet oral tablet 30 mg 60 mg 90 mg 2 PA
CRYSVITA SUBCUTANEOUS SOLUTION 10 MGML 20 MGML 30 MGML
MB PA LA
danazol oral capsule 100 mg 200 mg 50 mg 1
DEPO-TESTOSTERONE INTRAMUSCULAR OIL 100 MGML
1
desmopressin nasal spraynon-aerosol 10 mcgspray (01 ml)
1
desmopressin oral tablet 01 mg 02 mg 1
doxercalciferol oral capsule 05 mcg 1 mcg 25 mcg
1
ELAPRASE INTRAVENOUS SOLUTION 6 MG3 ML
MB PA LA
ELELYSO INTRAVENOUS RECON SOLN 200 UNIT
MB PA LA
FABRAZYME INTRAVENOUS RECON SOLN 35 MG 5 MG
MB PA LA
GALAFOLD ORAL CAPSULE 123 MG 2 PA LA
JYNARQUE ORAL TABLET 15 MG 30 MG 2 PA QL (60 per 30 days)
JYNARQUE ORAL TABLETS SEQUENTIAL 45 MG (AM) 15 MG (PM) 60 MG (AM) 30 MG (PM) 90 MG (AM) 30 MG (PM)
2 PA QL (60 per 30 days)
KANUMA INTRAVENOUS SOLUTION 2 MGML
MB PA LA
KORLYM ORAL TABLET 300 MG 2 PA ST
LUMIZYME INTRAVENOUS RECON SOLN 50 MG
MB PA LA
76
Drug Name Drug Tier Requirements Limits
MEPSEVII INTRAVENOUS SOLUTION 2 MGML
MB PA LA
methyltestosterone oral capsule 10 mg 1
MIACALCIN INJECTION SOLUTION 200 UNITML
1
miglustat oral capsule 100 mg 2 PA LA
MYALEPT SUBCUTANEOUS RECON SOLN 5 MGML (FINAL CONC)
2 LA
NAGLAZYME INTRAVENOUS SOLUTION 5 MG5 ML
MB PA LA
NATPARA SUBCUTANEOUS CARTRIDGE 100 MCGDOSE 25 MCGDOSE 50 MCGDOSE 75 MCGDOSE
2 PA ST LA
oxandrolone oral tablet 10 mg 25 mg 1
PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG05 ML 25 MG05 ML 20 MGML
2 PA LA
pamidronate intravenous solution 30 mg10 ml (3 mgml)
MB
PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCGML
MB
paricalcitol intravenous solution 5 mcgml MB
paricalcitol oral capsule 1 mcg 2 mcg 4 mcg 1
PARSABIV INTRAVENOUS SOLUTION 5 MGML
MB PA
SAMSCA ORAL TABLET 15 MG 2 PA LA QL (60 per 30 days)
sapropterin oral powder in packet 100 mg 500 mg 2 PA LA
sapropterin oral tabletsoluble 100 mg 2 PA LA
SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG 15 MG 20 MG 25 MG 30 MG
2 PA LA QL (30 per 30 days)
STRENSIQ SUBCUTANEOUS SOLUTION 18 MG045 ML 28 MG07 ML 40 MGML 80 MG08 ML
2 PA
SYNAREL NASAL SPRAYNON-AEROSOL 2 MGML
1
TEPEZZA INTRAVENOUS RECON SOLN 500 MG
MB PA LA
testosterone cypionate intramuscular oil 100 mgml 200 mgml
1
testosterone enanthate intramuscular oil 200 mgml
1
77
Drug Name Drug Tier Requirements Limits
testosterone transdermal gel 50 mg5 gram (1 ) 1 QL (60 per 30 days)
testosterone transdermal gel in metered-dose pump 10 mg05 gram actuation 2025 mg125 gram (162 )
1 QL (2 per 30 days)
testosterone transdermal gel in metered-dose pump 125 mg 125 gram (1 )
1 QL (4 per 30 days)
testosterone transdermal gel in packet 1 (25 mg25gram) 162 (2025 mg125 gram)
1 QL (30 per 30 days)
testosterone transdermal gel in packet 1 (50 mg5 gram) 162 (405 mg25 gram)
1 QL (60 per 30 days)
testosterone transdermal solution in metered pump wapp 30 mgactuation (15 ml)
1 QL (2 per 30 days)
VIMIZIM INTRAVENOUS SOLUTION 5 MG5 ML (1 MGML)
MB PA LA
VPRIV INTRAVENOUS RECON SOLN 400 UNIT
MB PA LA
NON-INSULIN HYPOGLYCEMIC AGENTS
acarbose oral tablet 100 mg 25 mg 50 mg 1
ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 125-15 MG 125-30 MG 125-45 MG 25-15 MG 25-30 MG 25-45 MG
1 PA ST
BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG085 ML
1 PA ST
BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCGDOSE(250 MCGML) 24 ML 5 MCGDOSE (250 MCGML) 12 ML
1 PA ST
CYCLOSET ORAL TABLET 08 MG 1
FARXIGA ORAL TABLET 10 MG 5 MG 1 PA ST
glimepiride oral tablet 1 mg 2 mg 4 mg 1
glipizide oral tablet 10 mg 5 mg 1
glipizide oral tablet extended release 24hr 10 mg 25 mg 5 mg
1
glipizide-metformin oral tablet 25-250 mg 25-500 mg 5-500 mg
1
glyburide micronized oral tablet 15 mg 3 mg 6 mg
1
glyburide oral tablet 125 mg 25 mg 5 mg 1
glyburide-metformin oral tablet 125-250 mg 25-500 mg 5-500 mg
1
78
Drug Name Drug Tier Requirements Limits
GLYXAMBI ORAL TABLET 10-5 MG 25-5 MG
1 PA ST
JANUMET ORAL TABLET 50-1000 MG 50-500 MG
1 PA ST
JANUMET XR ORAL TABLET ER MULTIPHASE 24 HR 100-1000 MG 50-1000 MG 50-500 MG
1 PA ST
JANUVIA ORAL TABLET 100 MG 25 MG 50 MG
1 PA ST
JARDIANCE ORAL TABLET 10 MG 25 MG 1 PA ST
JENTADUETO ORAL TABLET 25-1000 MG 25-500 MG 25-850 MG
1 PA ST
JENTADUETO XR ORAL TABLET IR - ER BIPHASIC 24HR 25-1000 MG 5-1000 MG
1 PA ST
metformin oral solution 500 mg5 ml 1 PA
metformin oral tablet 1000 mg 500 mg 850 mg 1
metformin oral tablet extended release 24 hr 500 mg 750 mg
1
metformin oral tablet extended release 24hr 1000 mg 500 mg
1 PA ST
metformin oral tableter gastretention 24 hr 1000 mg 500 mg
1 ST
miglitol oral tablet 100 mg 25 mg 50 mg 1
nateglinide oral tablet 120 mg 60 mg 1
OZEMPIC SUBCUTANEOUS PEN INJECTOR 025 MG OR 05 MG(2 MG15 ML) 1 MGDOSE (2 MG15 ML) 1 MGDOSE (4 MG3 ML)
1 PA ST
pioglitazone oral tablet 15 mg 30 mg 45 mg 1
pioglitazone-glimepiride oral tablet 30-2 mg 30-4 mg
1
pioglitazone-metformin oral tablet 15-500 mg 15-850 mg
1
QTERN ORAL TABLET 10-5 MG 5-5 MG 1 PA ST
repaglinide oral tablet 05 mg 1 mg 2 mg 1
repaglinide-metformin oral tablet 1-500 mg 2-500 mg
1
RIOMET ER ORAL SUSPENSIONEXTENDED REL RECON 500 MG5 ML
1 PA ST
79
Drug Name Drug Tier Requirements Limits
RYBELSUS ORAL TABLET 14 MG 3 MG 7 MG
1 PA ST
SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2700 MCG27 ML
1 PA ST
SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1500 MCG15 ML
1 PA ST
SYNJARDY ORAL TABLET 125-1000 MG 125-500 MG 5-1000 MG 5-500 MG
1 PA ST
SYNJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 125-1000 MG 25-1000 MG 5-1000 MG
1 PA ST
TRADJENTA ORAL TABLET 5 MG 1 PA ST
TRULICITY SUBCUTANEOUS PEN INJECTOR 075 MG05 ML 15 MG05 ML 3 MG05 ML 45 MG05 ML
1 PA ST
XIGDUO XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 10-500 MG 25-1000 MG 5-1000 MG 5-500 MG
1 PA ST
THYROID HORMONES
ARMOUR THYROID ORAL TABLET 120 MG 15 MG 180 MG 240 MG 30 MG 300 MG 60 MG 90 MG
1
levothyroxine oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 300 mcg 50 mcg 75 mcg 88 mcg
1
levoxyl oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 50 mcg 75 mcg 88 mcg
1
liothyronine oral tablet 25 mcg 5 mcg 50 mcg 1
np thyroid oral tablet 120 mg 15 mg 30 mg 60 mg 90 mg
1
SYNTHROID ORAL TABLET 100 MCG 112 MCG 125 MCG 137 MCG 150 MCG 175 MCG 200 MCG 25 MCG 300 MCG 50 MCG 75 MCG 88 MCG
1
THYROLAR-1 ORAL TABLET 125-50 MCG 1
THYROLAR-12 ORAL TABLET 625-25 MCG 1
THYROLAR-14 ORAL TABLET 31-125 MCG 1
THYROLAR-2 ORAL TABLET 25-100 MCG 1
THYROLAR-3 ORAL TABLET 375-150 MCG 1
80
Drug Name Drug Tier Requirements Limits
unithroid oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 300 mcg 50 mcg 75 mcg 88 mcg
1
westhroid oral tablet 130 mg 195 mg 325 mg 65 mg 975 mg
1
GASTROENTEROLOGY
ANTIDIARRHEALS amp ANTISPASMODICS
anaspaz oral tabletdisintegrating 0125 mg 1
atropine injection syringe 005 mgml 01 mgml 1
belladonna alkaloids-opium rectal suppository 162-30 mg 162-60 mg
1 PA ST
chlordiazepoxide-clidinium oral capsule 5-25 mg 1
dicyclomine intramuscular solution 10 mgml MB
dicyclomine oral capsule 10 mg 1
dicyclomine oral solution 10 mg5 ml 1
dicyclomine oral tablet 20 mg 1
diphenoxylate-atropine oral liquid 25-0025 mg5 ml
1
diphenoxylate-atropine oral tablet 25-0025 mg 1
DONNATAL ORAL TABLET 162-01037 -00194 MG
1
ed-spaz oral tabletdisintegrating 0125 mg 1
glycopyrrolate injection solution 02 mgml 1
glycopyrrolate oral tablet 1 mg 15 mg 2 mg 1
hyoscyamine sulfate oral drops 0125 mgml 1
hyoscyamine sulfate oral elixir 0125 mg5 ml 1
hyoscyamine sulfate oral tablet 0125 mg 1
hyoscyamine sulfate oral tablet extended release 12 hr 0375 mg
1
hyoscyamine sulfate oral tabletdisintegrating 0125 mg
1
hyoscyamine sulfate sublingual tablet 0125 mg 1
hyosyne oral drops 0125 mgml 1
hyosyne oral elixir 0125 mg5 ml 1
loperamide oral capsule 2 mg 1
methscopolamine oral tablet 25 mg 5 mg 1
MOTOFEN ORAL TABLET 1-0025 MG 1
81
Drug Name Drug Tier Requirements Limits
opium tincture oral tincture 10 mgml (morphine) 1
oscimin oral tablet 0125 mg 1
oscimin sl sublingual tablet 0125 mg 1
oscimin sr oral tablet extended release 12 hr 0375 mg
1
phenobarb-hyoscy-atropine-scop oral elixir 162-01037 -00194 mg5 ml
1
phenobarb-hyoscy-atropine-scop oral tablet 162-01037 -00194 mg
1
phenohytro oral elixir 162-01037 -00194 mg5 ml
1
phenohytro oral tablet 162-01037 -00194 mg 1
symax fastabs oral tabletdisintegrating 0125 mg 1
symax-sl sublingual tablet 0125 mg 1
symax-sr oral tablet extended release 12 hr 0375 mg
1
MISCELLANEOUS GASTROINTESTINAL AGENTS
AKYNZEO (NETUPITANT) ORAL CAPSULE 300-05 MG
1 QL (1 per 30 days)
alosetron oral tablet 05 mg 1 mg 1
ALOXI INTRAVENOUS SOLUTION 025 MG5 ML
MB
AMITIZA ORAL CAPSULE 24 MCG 8 MCG 1 PA
anucort-hc rectal suppository 25 mg 1
aprepitant oral capsule 125 mg 40 mg 1 QL (1 per 30 days)
aprepitant oral capsule 80 mg 1 QL (2 per 30 days)
aprepitant oral capsuledose pack 125 mg (1)- 80 mg (2)
1 QL (1 per 30 days)
balsalazide oral capsule 750 mg 1
budesonide oral capsuledelayedextendrelease 3 mg
1
calcium acetate(phosphat bind) oral capsule 667 mg
1
calcium acetate(phosphat bind) oral tablet 667 mg 1
CHOLBAM ORAL CAPSULE 250 MG 50 MG 2
CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)
2 PA ST LA
82
Drug Name Drug Tier Requirements Limits
CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG2 ML (200 MGML X 2)
2 PA ST LA
CLENPIQ ORAL SOLUTION 10 MG-35 GRAM -12 GRAM160 ML
ACA PV
compro rectal suppository 25 mg 1
constulose oral solution 10 gram15 ml 1
CORTIFOAM RECTAL FOAM 10 (80 MG) 1
CREON ORAL CAPSULEDELAYED RELEASE(DREC) 12000-38000 -60000 UNIT 24000-76000 -120000 UNIT 3000-9500- 15000 UNIT 36000-114000- 180000 UNIT 6000-19000 -30000 UNIT
1 PA
cromolyn oral concentrate 100 mg5 ml 1
DIPENTUM ORAL CAPSULE 250 MG 1 PA ST
doxylamine-pyridoxine (vit b6) oral tabletdelayed release (drec) 10-10 mg
1
dronabinol oral capsule 10 mg 25 mg 5 mg 1
EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG ML FINAL CONC)
1
ENTYVIO INTRAVENOUS RECON SOLN 300 MG
MB PA LA
enulose oral solution 10 gram15 ml 1
gavilyte-c oral recon soln 240-2272-672 -584 gram
ACA PV
gavilyte-g oral recon soln 236-2274-674 -586 gram
ACA PV
gavilyte-n oral recon soln 420 gram ACA PV
generlac oral solution 10 gram15 ml 1
granisetron hcl oral tablet 1 mg 1 QL (6 per 30 days)
hemmorex-hc rectal suppository 25 mg 1
hydrocortisone acetate rectal suppository 25 mg 30 mg
1
hydrocortisone rectal enema 100 mg60 ml 1
hydrocortisone topical cream with perineal applicator 1 25
1
hydrocortisone-pramoxine rectal cream 1-1 25-1 25-1 (4g)
1
INFLECTRA INTRAVENOUS RECON SOLN 100 MG
MB PA LA
83
Drug Name Drug Tier Requirements Limits
lactulose oral packet 10 gram 1
lactulose oral solution 10 gram15 ml 20 gram30 ml
1
lanthanum oral tabletchewable 1000 mg 500 mg 750 mg
1
lidocaine hcl-hydrocortison ac rectal cream 3-05
1
LIDOCAINE HCL-HYDROCORTISON AC RECTAL GEL 3 -25 (7 GRAM)
1
lidocaine hcl-hydrocortison ac rectal kit 2 -2 (7 gram)
1 ST
lidocaine hcl-hydrocortison ac rectal kit 3-05 3-1 (7 gram)
1 PA ST
lidocaine-hydrocortisone-aloe rectal gel 28-055
1
lidocaine-hydrocortisone-aloe rectal kit 3-25 (7 gram)
1 PA ST
LINZESS ORAL CAPSULE 145 MCG 290 MCG 72 MCG
1 PA
meclizine oral tablet 125 mg 25 mg 1
mesalamine oral capsuleextended release 24hr 0375 gram
1
mesalamine oral tabletdelayed release (drec) 12 gram 800 mg
1
mesalamine rectal enema 4 gram60 ml 1
mesalamine rectal suppository 1000 mg 1
mesalamine with cleansing wipe rectal enema kit 4 gram60 ml
1 ST
metoclopramide hcl injection solution 5 mgml MB
metoclopramide hcl injection syringe 5 mgml MB
metoclopramide hcl oral solution 5 mg5 ml 1
metoclopramide hcl oral tablet 10 mg 5 mg 1
metoclopramide hcl oral tabletdisintegrating 10 mg 5 mg
1
MOVANTIK ORAL TABLET 125 MG 25 MG 1 PA ST
NULYTELY LEMON-LIME ORAL RECON SOLN 420 GRAM
ACA PV
ondansetron hcl intravenous solution 2 mgml MB
ondansetron hcl oral solution 4 mg5 ml 1 QL (100 per 30 days)
84
Drug Name Drug Tier Requirements Limits
ondansetron hcl oral tablet 4 mg 8 mg 1 QL (9 per 30 days)
ondansetron oral tabletdisintegrating 4 mg 8 mg 1 QL (9 per 30 days)
OSMOPREP ORAL TABLET 15 GRAM ACA PV
peg 3350-electrolytes oral recon soln 236-2274-674 -586 gram
ACA PV
peg3350-sod sul-nacl-kcl-asb-c oral powder in packet 100-75-2691 gram
ACA PV
peg-electrolyte soln oral recon soln 420 gram ACA PV
peg-prep oral kit 5-210 mg-gram ACA PV
PLENVU ORAL POWDER IN PACKET SEQUENTIAL 140-9-52 GRAM
ACA PV
prochlorperazine edisylate injection solution 10 mg2 ml (5 mgml) 5 mgml
1
prochlorperazine maleate oral tablet 10 mg 5 mg 1
prochlorperazine rectal suppository 25 mg 1
procto-med hc topical cream with perineal applicator 25
1
procto-pak topical cream with perineal applicator 1
1
proctosol hc topical cream with perineal applicator 25
1
proctozone-hc topical cream with perineal applicator 25
1
RECTIV RECTAL OINTMENT 04 (WW) 1
RELISTOR ORAL TABLET 150 MG 1
RELISTOR SUBCUTANEOUS SOLUTION 12 MG06 ML
1
RELISTOR SUBCUTANEOUS SYRINGE 12 MG06 ML 8 MG04 ML
1
REMICADE INTRAVENOUS RECON SOLN 100 MG
MB PA LA
RENFLEXIS INTRAVENOUS RECON SOLN 100 MG
MB PA LA
scopolamine base transdermal patch 3 day 1 mg over 3 days
1
sevelamer carbonate oral powder in packet 08 gram 24 gram
1
sevelamer carbonate oral tablet 800 mg 1
sevelamer hcl oral tablet 400 mg 800 mg 1
85
Drug Name Drug Tier Requirements Limits
sodium polystyrene sulfonate oral powder 1
sps (with sorbitol) oral suspension 15-20 gram60 ml
1
sps (with sorbitol) rectal enema 30-40 gram120 ml
1
SUCRAID ORAL SOLUTION 8500 UNITML 2 PA ST QL (2 per 30 days)
sulfasalazine oral tablet 500 mg 1
sulfasalazine oral tabletdelayed release (drec) 500 mg
1
SUPREP BOWEL PREP KIT ORAL RECON SOLN 175-313-16 GRAM
ACA PV ST
trilyte with flavor packets oral recon soln 420 gram
ACA PV
trimethobenzamide oral capsule 300 mg 1
ursodiol oral capsule 300 mg 1
ursodiol oral tablet 250 mg 500 mg 1
VARUBI ORAL TABLET 90 MG 1
VELPHORO ORAL TABLETCHEWABLE 500 MG
1 ST
VIBERZI ORAL TABLET 100 MG 75 MG 1 PA ST
ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 10000-32000 -42000 UNIT 15000-47000 -63000 UNIT 20000-63000- 84000 UNIT 3000-10000 -14000-UNIT 40000-126000- 168000 UNIT 5000-17000- 24000 UNIT
1 PA
ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 25000-79000- 105000 UNIT
1
ULCER THERAPY
amoxicil-clarithromy-lansopraz oral combo pack 500-500-30 mg
1
cimetidine hcl oral solution 300 mg5 ml 1
cimetidine oral tablet 200 mg 300 mg 400 mg 800 mg
1
DEXILANT ORAL CAPSULEBIPHASE DELAYED RELEAS 30 MG 60 MG
1 ST
esomeprazole magnesium oral capsuledelayed release(drec) 20 mg 40 mg
1
famotidine (pf) intravenous solution 20 mg2 ml MB
86
Drug Name Drug Tier Requirements Limits
famotidine oral suspension 40 mg5 ml (8 mgml) 1
famotidine oral tablet 20 mg 40 mg 1
lansoprazole oral capsuledelayed release(drec) 15 mg 30 mg
1
lansoprazole oral tabletdisintegrat delay rel 15 mg 30 mg
1
misoprostol oral tablet 100 mcg 200 mcg 1
nizatidine oral capsule 150 mg 300 mg 1
nizatidine oral solution 150 mg10 ml 1
omeprazole oral capsuledelayed release(drec) 10 mg 20 mg 40 mg
1
pantoprazole oral tabletdelayed release (drec) 20 mg 40 mg
1
rabeprazole oral tabletdelayed release (drec) 20 mg
1
sucralfate oral suspension 100 mgml 1
sucralfate oral tablet 1 gram 1
IMMUNOLOGY VACCINES amp BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCGML 200 MCGML 25 MCGML 300 MCGML 40 MCGML 60 MCGML
2 LA
ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG04 ML 100 MCG05 ML 150 MCG03 ML 200 MCG04 ML 25 MCG042 ML 300 MCG06 ML 40 MCG04 ML 500 MCGML 60 MCG03 ML
2 LA
EPOGEN INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML
2 LA
GRANIX SUBCUTANEOUS SOLUTION 300 MCGML 480 MCG16 ML
2
GRANIX SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML
2
LEUKINE INJECTION RECON SOLN 250 MCG 2 PA ST
MIRCERA INJECTION SYRINGE 100 MCG03 ML 150 MCG03 ML 200 MCG03 ML 30 MCG03 ML 50 MCG03 ML 75 MCG03 ML
MB
87
Drug Name Drug Tier Requirements Limits
MOZOBIL SUBCUTANEOUS SOLUTION 24 MG12 ML (20 MGML)
MB LA
NEUPOGEN INJECTION SOLUTION 300 MCGML 480 MCG16 ML
2 PA ST
NEUPOGEN INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML
2 PA ST
NIVESTYM INJECTION SOLUTION 300 MCGML 480 MCG16 ML
2
NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML
2
PROCRIT INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML 40000 UNITML
2 LA
UDENYCA SUBCUTANEOUS SYRINGE 6 MG06 ML
2 PA ST
ZARXIO INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML
2 PA ST
ZIEXTENZO SUBCUTANEOUS SYRINGE 6 MG06 ML
2 PA ST
GROWTH HORMONES
GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 02 MG025 ML 04 MG025 ML 06 MG025 ML 08 MG025 ML 1 MG025 ML 12 MG025 ML 14 MG025 ML 16 MG025 ML 18 MG025 ML 2 MG025 ML
2 PA ST LA
GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MGML (36 UNITML) 5 MGML (15 UNITML)
2 PA ST LA
OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG15 ML (67 MGML) 5 MG15 ML (33 MGML)
2 PA ST LA
OMNITROPE SUBCUTANEOUS RECON SOLN 58 MG
2 PA ST LA
SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG 5 MG 6 MG
2 PA ST LA
ZORBTIVE SUBCUTANEOUS RECON SOLN 88 MG
2 PA ST LA
INTERFERONS
AUBAGIO ORAL TABLET 14 MG 7 MG 2 PA LA
88
Drug Name Drug Tier Requirements Limits
AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG05 ML
2 PA ST LA QL (4 per 30 days)
AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG05 ML
2 PA ST LA QL (4 per 30 days)
BETASERON SUBCUTANEOUS KIT 03 MG 2 PA LA QL (14 per 30 days)
dimethyl fumarate oral capsuledelayed release(drec) 120 mg
2 PA LA QL (14 per 365 days)
dimethyl fumarate oral capsuledelayed release(drec) 120 mg (14)- 240 mg (46)
2 PA LA QL (1 per 365 days)
dimethyl fumarate oral capsuledelayed release(drec) 240 mg
2 PA LA QL (60 per 30 days)
GILENYA ORAL CAPSULE 05 MG 2 PA LA QL (30 per 30 days)
glatiramer subcutaneous syringe 20 mgml 2 PA LA QL (30 per 30 days)
glatiramer subcutaneous syringe 40 mgml 2 PA LA QL (12 per 30 days)
glatopa subcutaneous syringe 20 mgml 2 PA LA QL (30 per 30 days)
glatopa subcutaneous syringe 40 mgml 2 PA LA QL (12 per 30 days)
LEMTRADA INTRAVENOUS SOLUTION 12 MG12 ML
MB PA ST LA
MAVENCLAD (10 TABLET PACK) ORAL TABLET 10 MG
2 LA
MAVENCLAD (4 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (5 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (6 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (7 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (8 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (9 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAYZENT ORAL TABLET 025 MG 2 MG 2 PA ST LA QL (30 per 30 days)
MAYZENT STARTER PACK ORAL TABLETSDOSE PACK 025 MG (12 TABS)
2 PA ST LA QL (1 per 365 days)
OCREVUS INTRAVENOUS SOLUTION 30 MGML
MB PA LA
PEGASYS SUBCUTANEOUS SOLUTION 180 MCGML
2 PA LA
89
Drug Name Drug Tier Requirements Limits
PEGASYS SUBCUTANEOUS SYRINGE 180 MCG05 ML
2 PA LA
PLEGRIDY INTRAMUSCULAR SYRINGE 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG05 ML- 94 MCG05 ML
2 PA LA QL (1 per 365 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG05 ML- 94 MCG05 ML
2 PA LA QL (1 per 365 days)
POMALYST ORAL CAPSULE 1 MG 2 MG 3 MG 4 MG
2 PA ST OCh LA
PONVORY 14-DAY STARTER PACK ORAL TABLETSDOSE PACK 2 MG (2) - 10 MG (3)
2 PA LA QL (1 per 365 days)
PONVORY ORAL TABLET 20 MG 2 PA LA QL (30 per 30 days)
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG05 ML 44 MCG05 ML
2 PA LA QL (6 per 30 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG05 ML 44 MCG05 ML
2 PA LA QL (6 per 30 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 88MCG02ML-22 MCG05ML (6)
2 PA LA QL (5 per 30 days)
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 88MCG02ML-22 MCG05ML (6)
2 PA LA QL (5 per 30 days)
REVLIMID ORAL CAPSULE 10 MG 15 MG 25 MG 20 MG 25 MG 5 MG
2 PA ST OCh LA
ribavirin oral capsule 200 mg 2 LA
ribavirin oral tablet 200 mg 2 LA
ZEPOSIA ORAL CAPSULE 092 MG 2 LA QL (30 per 30 days)
ZEPOSIA STARTER KIT ORAL CAPSULEDOSE PACK 023-046-092 MG
2 LA QL (30 per 30 days)
ZEPOSIA STARTER PACK ORAL CAPSULEDOSE PACK 023 MG (4)- 046 MG (3)
2 LA QL (30 per 30 days)
INTERLEUKINS
ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG05 ML
2 PA LA
ARCALYST SUBCUTANEOUS RECON SOLN 220 MG
2 LA
90
Drug Name Drug Tier Requirements Limits
ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MGML
MB PA LA
imiquimod topical cream in packet 5 1
INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) 18 MILLION UNIT (1 ML) 50 MILLION UNIT (1 ML)
2 PA LA
INTRON A INJECTION SOLUTION 10 MILLION UNITML 6 MILLION UNITML
2 PA LA
PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT
MB LA
VACCINES amp MISCELLANEOUS IMMUNOLOGICALS
ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(25-5-3-5 MCG)-5LF05 ML
1 Vac
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(25-5-3-5 MCG)-5LF05 ML
1 Vac
ASCENIV INTRAVENOUS SOLUTION 10 MB PA LA
ATGAM INTRAVENOUS SOLUTION 50 MGML
MB
BCG VACCINE LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG
1 Vac
BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG05 ML
1 Vac
BIOTHRAX INTRAMUSCULAR SUSPENSION 05 MLDOSE
1 Vac
BIVIGAM INTRAVENOUS SOLUTION 10 MB PA LA
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 25-8-5 LF-MCG-LF05ML
1 Vac
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 25-8-5 LF-MCG-LF05ML
1 Vac
BOTOX INJECTION RECON SOLN 100 UNIT 200 UNIT
MB
CUTAQUIG SUBCUTANEOUS SOLUTION 165
MB LA
CUVITRU SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 ) 8 GRAM40 ML (20 )
MB LA
91
Drug Name Drug Tier Requirements Limits
DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF05ML
1 Vac
DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT 500 UNIT
MB LA
ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCGML
1 Vac
ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCGML
1 Vac
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG05 ML
1 Vac
FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 5
MB PA
GAMASTAN INTRAMUSCULAR SOLUTION 15-18 RANGE
MB
GAMASTAN SD INTRAMUSCULAR SOLUTION 15-18 RANGE
MB
GAMMAGARD LIQUID INJECTION SOLUTION 10
MB LA
GAMMAGARD S-D (IGA lt 1 MCGML) INTRAVENOUS RECON SOLN 10 GRAM 5 GRAM
MB PA LA
GAMMAKED INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 20 GRAM200 ML (10 ) 5 GRAM50 ML (10 )
MB LA
GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5
MB PA LA
GAMMAPLEX INTRAVENOUS SOLUTION 10
MB PA LA
GAMUNEX-C INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 25 GRAM25 ML (10 ) 20 GRAM200 ML (10 ) 40 GRAM400 ML (10 ) 5 GRAM50 ML (10 )
MB LA
GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 05 ML
1 Vac
GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 05 ML
1 Vac
GRASTEK SUBLINGUAL TABLET 2800 BAU 1 PA
HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1440 ELISA UNITML
1 Vac
92
Drug Name Drug Tier Requirements Limits
HAVRIX (PF) INTRAMUSCULAR SYRINGE 1440 ELISA UNITML 720 ELISA UNIT05 ML
1 Vac
HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE 20 MCG05 ML
1 Vac
HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )
MB LA
HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM 100 ML (10 ) 25 GRAM 25 ML (10 ) 20 GRAM 200 ML (10 ) 30 GRAM 300 ML (10 ) 5 GRAM 50 ML (10 )
MB LA
IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 25 UNIT
1 Vac
INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF05ML
1 Vac
IPOL INJECTION SUSPENSION 40-8-32 UNIT05 ML
1 Vac
IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG05 ML
1 Vac
KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF05 ML
1 Vac
MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG05 ML
1 Vac
MENQUADFI (PF) INTRAMUSCULAR SOLUTION 10 MCG05 ML
1 Vac
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG05 ML
1 Vac
M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1000-12500 TCID5005 ML
1 Vac
MYOBLOC INTRAMUSCULAR SOLUTION 10000 UNIT2 ML 2500 UNIT05 ML 5000 UNITML
MB LA
OCTAGAM INTRAVENOUS SOLUTION 10 5
MB PA LA
ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY
2 PA
PANZYGA INTRAVENOUS SOLUTION 10 MB PA
PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF05 ML
1 Vac
93
Drug Name Drug Tier Requirements Limits
PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 75 MCG05 ML
1 Vac
PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF05 ML 15LF-48MCG-62DU -10 MCG05ML
1 Vac
PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
PNEUMOVAX-23 INJECTION SOLUTION 25 MCG05 ML
1 Vac
PNEUMOVAX-23 INJECTION SYRINGE 25 MCG05 ML
1 Vac
PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE 05 ML
1 Vac
PRIVIGEN INTRAVENOUS SOLUTION 10 MB PA LA
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-43-3- 399 TCID5005
1 Vac
PROVENGE INTRAVENOUS SUSPENSION 50 MILLION CELL250 ML
MB PA
QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT05ML
1 Vac
RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 25 UNIT
1 Vac
RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT
1 PA
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCGML 40 MCGML 5 MCG05 ML
1 Vac
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCGML 5 MCG05 ML
1 Vac
SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG05 ML
1 Vac
STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1000 UNIT05 ML
1 Vac
TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF UNIT05 ML
1 Vac
94
Drug Name Drug Tier Requirements Limits
TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT05ML
1 Vac
TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT05 ML
1 Vac
TETANUSDIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT05 ML
1 Vac
THYMOGLOBULIN INTRAVENOUS RECON SOLN 25 MG
MB
TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG05 ML
1 Vac
TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCGML
1 Vac
TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG05 ML
1 Vac
TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG05 ML
1 Vac
VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT05 ML 50 UNITML
1 Vac
VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT05 ML 50 UNITML
1 Vac
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1350 UNIT05 ML
1 Vac
VAXELIS (PF) INTRAMUSCULAR SUSPENSION 15 UNIT-5 UNIT- 10 MCG05 ML
1 Vac
VAXELIS (PF) INTRAMUSCULAR SYRINGE 15 UNIT-5 UNIT- 10 MCG05 ML
1 Vac
XEMBIFY SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )
MB LA
XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT 200 UNIT 50 UNIT
MB LA
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP474 UNIT05 ML
1 Vac
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19400 UNIT065 ML
1 Vac
MUSCULOSKELETAL amp RHEUMATOLOGY
95
Drug Name Drug Tier Requirements Limits
GOUT THERAPY
allopurinol oral tablet 100 mg 300 mg 1
COLCHICINE ORAL CAPSULE 06 MG 1
colchicine oral tablet 06 mg 1
febuxostat oral tablet 40 mg 80 mg 1
KRYSTEXXA INTRAVENOUS SOLUTION 8 MGML
MB PA LA
MITIGARE ORAL CAPSULE 06 MG 1
probenecid oral tablet 500 mg 1
probenecid-colchicine oral tablet 500-05 mg 1
OSTEOPOROSIS THERAPY
alendronate oral solution 70 mg75 ml 1
alendronate oral tablet 10 mg 35 mg 5 mg 70 mg 1
EVENITY SUBCUTANEOUS SYRINGE 105 MG117 ML 210MG234ML ( 105MG117MLX2)
2 PA ST LA
FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCGDOSE (620MCG248ML)
2 PA ST LA QL (1 per 30 days)
FOSAMAX PLUS D ORAL TABLET 70 MG- 2800 UNIT 70 MG- 5600 UNIT
1
ibandronate oral tablet 150 mg 1
PROLIA SUBCUTANEOUS SYRINGE 60 MGML
2 ST LA
raloxifene oral tablet 60 mg 2 OCh
risedronate oral tablet 150 mg 35 mg 5 mg 1
risedronate oral tabletdelayed release (drec) 35 mg
1
TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3120 MCG156 ML)
2 PA ST LA
OTHER RHEUMATOLOGICALS
ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG09 ML
2 PA ST LA
ACTEMRA INTRAVENOUS SOLUTION 200 MG10 ML (20 MGML) 400 MG20 ML (20 MGML) 80 MG4 ML (20 MGML)
MB PA LA
ACTEMRA SUBCUTANEOUS SYRINGE 162 MG09 ML
2 PA ST LA
96
Drug Name Drug Tier Requirements Limits
BENLYSTA INTRAVENOUS RECON SOLN 120 MG 400 MG
MB PA LA
BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MGML
2 PA LA
BENLYSTA SUBCUTANEOUS SYRINGE 200 MGML
2 PA LA
ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MGML (1 ML)
2 PA ST LA
ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)
2 PA ST LA
ENBREL SUBCUTANEOUS SOLUTION 25 MG05 ML
2 PA ST LA
ENBREL SUBCUTANEOUS SYRINGE 25 MG05 ML (05) 50 MGML (1 ML)
2 PA ST LA
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MGML (1 ML)
2 PA ST LA
HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG08 ML
2 PA ST LA
HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG08 ML 80 MG08 ML-40 MG04 ML
2 PA ST LA
HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
2 PA ST LA
HUMIRA(CF) PEN PEDIATRIC UC SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
2 PA ST LA
HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML-40 MG04 ML
2 PA ST LA
HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG04 ML
2 PA ST LA
97
Drug Name Drug Tier Requirements Limits
HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG01 ML 20 MG02 ML 40 MG04 ML
2 PA ST LA
KEVZARA SUBCUTANEOUS PEN INJECTOR 150 MG114 ML 200 MG114 ML
2 PA ST LA
KEVZARA SUBCUTANEOUS SYRINGE 150 MG114 ML 200 MG114 ML
2 PA ST LA
leflunomide oral tablet 10 mg 20 mg 1
OLUMIANT ORAL TABLET 1 MG 2 MG 2 PA ST LA
ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG
MB PA LA
ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MGML
2 PA ST LA
ORENCIA SUBCUTANEOUS SYRINGE 125 MGML 50 MG04 ML 875 MG07 ML
2 PA ST LA
OTEZLA ORAL TABLET 30 MG 2 PA ST LA
OTEZLA STARTER ORAL TABLETSDOSE PACK 10 MG (4)-20 MG (4)-30 MG (47)
2 PA ST LA
penicillamine oral capsule 250 mg 1 PA
penicillamine oral tablet 250 mg 1 PA
RIDAURA ORAL CAPSULE 3 MG 1
RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 MG
2 PA ST LA
SAVELLA ORAL TABLET 100 MG 125 MG 25 MG 50 MG
1 PA ST
SAVELLA ORAL TABLETSDOSE PACK 125 MG (5)-25 MG(8)-50 MG(42)
1 PA ST
SIMPONI ARIA INTRAVENOUS SOLUTION 125 MGML
MB PA LA
SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MGML 50 MG05 ML
2 PA ST LA
SIMPONI SUBCUTANEOUS SYRINGE 100 MGML 50 MG05 ML
2 PA ST LA
XELJANZ ORAL SOLUTION 1 MGML 2 PA ST LA
XELJANZ ORAL TABLET 10 MG 5 MG 2 PA ST LA
XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG 22 MG
2 PA ST LA
OBSTETRICS amp GYNECOLOGY
DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES
98
Drug Name Drug Tier Requirements Limits
CAYA CONTOURED VAGINAL DIAPHRAGM 65-80 MM
ACA PV
FC2 FEMALE CONDOM ACA PV
FEMCAP VAGINAL DEVICE 22 MM ACA PV
KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 175 MCG24 HRS (5 YRS) 195 MG
ACA PV
LILETTA INTRAUTERINE INTRAUTERINE DEVICE 201 MCG24 HRS (6 YRS) 52 MG
ACA PV ST
MIRENA INTRAUTERINE INTRAUTERINE DEVICE 20 MCG24 HOURS (6 YRS) 52 MG
ACA PV
PARAGARD T 380A INTRAUTERINE INTRAUTERINE DEVICE 380 SQUARE MM
ACA PV
SKYLA INTRAUTERINE INTRAUTERINE DEVICE 14 MCG24 HRS (3 YRS) 135 MG
ACA PV
WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 MM
ACA PV
ESTROGENS amp PROGESTINS
amabelz oral tablet 05-01 mg 1-05 mg 1
ANGELIQ ORAL TABLET 025-05 MG 05-1 MG
1
camila oral tablet 035 mg ACA PV
COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 005-014 MG24 HR 005-025 MG24 HR
1
covaryx hs oral tablet 0625-125 mg 1
covaryx oral tablet 125-25 mg 1
CRINONE VAGINAL GEL 4 1
deblitane oral tablet 035 mg ACA PV
DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MGML
1
DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MGML
MB
DEPO-PROVERA INTRAMUSCULAR SYRINGE 150 MGML
MB
DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE 104 MG065 ML
ACA PV
99
Drug Name Drug Tier Requirements Limits
DIVIGEL TRANSDERMAL GEL IN PACKET 025 MG025 GRAM (01 ) 05 MG05 GRAM (01 ) 075 MG075 GRAM (01) 1 MGGRAM (01 ) 125 MG125 GRAM (01 )
1 QL (30 per 30 days)
dotti transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
DUAVEE ORAL TABLET 045-20 MG 1
eemt hs oral tablet 0625-125 mg 1
eemt oral tablet 125-25 mg 1
errin oral tablet 035 mg ACA PV
estradiol oral tablet 05 mg 1 mg 2 mg 1
estradiol transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
estradiol transdermal patch weekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 006 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (4 per 30 days)
estradiol vaginal cream 001 (01 mggram) 1
estradiol vaginal tablet 10 mcg 1
estradiol valerate intramuscular oil 20 mgml 40 mgml
1
estradiol-norethindrone acet oral tablet 05-01 mg 1-05 mg
1
ESTRING VAGINAL RING 2 MG (75 MCG 24 HOUR)
1
estrogens-methyltestosterone oral tablet 0625-125 mg 125-25 mg
1
EVAMIST TRANSDERMAL SPRAYNON-AEROSOL 153 MGSPRAY (17)
1 QL (2 per 30 days)
FEMRING VAGINAL RING 005 MG24 HR 01 MG24 HR
1
fyavolv oral tablet 05-25 mg-mcg 1-5 mg-mcg 1
heather oral tablet 035 mg ACA PV
hydroxyprogest(pf)(preg presv) intramuscular oil 250 mgml (1 ml)
2
hydroxyprogesterone cap(ppres) intramuscular oil 250 mgml
2
100
Drug Name Drug Tier Requirements Limits
hydroxyprogesterone caproate intramuscular oil 250 mgml
2
incassia oral tablet 035 mg ACA PV
jencycla oral tablet 035 mg ACA PV
jinteli oral tablet 1-5 mg-mcg 1
lyleq oral tablet 035 mg ACA PV
lyllana transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
lyza oral tablet 035 mg ACA PV
medroxyprogesterone intramuscular suspension 150 mgml
ACA PV
medroxyprogesterone intramuscular syringe 150 mgml
ACA PV
medroxyprogesterone oral tablet 10 mg 25 mg 5 mg
1
MENEST ORAL TABLET 03 MG 0625 MG 125 MG 25 MG
1
MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG24 HR
1 QL (4 per 30 days)
mimvey oral tablet 1-05 mg 1
nora-be oral tablet 035 mg ACA PV
norethindrone (contraceptive) oral tablet 035 mg ACA PV
norethindrone acetate oral tablet 5 mg 1
norethindrone ac-eth estradiol oral tablet 05-25 mg-mcg 1-5 mg-mcg
1
norlyda oral tablet 035 mg ACA PV
PREMARIN INJECTION RECON SOLN 25 MG 1
PREMARIN ORAL TABLET 03 MG 045 MG 0625 MG 09 MG 125 MG
1
PREMARIN VAGINAL CREAM 0625 MGGRAM
1
PREMPHASE ORAL TABLET 0625 MG (14) 0625MG-5MG(14)
1
PREMPRO ORAL TABLET 03-15 MG 045-15 MG 0625-25 MG 0625-5 MG
1
progesterone intramuscular oil 50 mgml 1
progesterone micronized oral capsule 100 mg 200 mg
1
101
Drug Name Drug Tier Requirements Limits
sharobel oral tablet 035 mg ACA PV
tulana oral tablet 035 mg ACA PV
yuvafem vaginal tablet 10 mcg 1
MISCELLANEOUS OBGYN
ANNOVERA VAGINAL RING 015-0013 MG24 HOUR
ACA PV
clindamycin phosphate vaginal cream 2 1
eluryng vaginal ring 012-0015 mg24 hr ACA PV
etonogestrel-ethinyl estradiol vaginal ring 012-0015 mg24 hr
ACA PV
fem ph vaginal gel 09-0025 1
GYNAZOLE-1 VAGINAL CREAM 2 1
gynol ii vaginal gel 3 ACA PV
INTRAROSA VAGINAL INSERT 65 MG 1
isoxsuprine oral tablet 10 mg 20 mg 1
LUPANETA PACK (1 MONTH) KIT SYRINGE AND TABLET 375 MG -5 MG (30)
2 LA
LUPANETA PACK (3 MONTH) KIT SYRINGE AND TABLET 1125 MG -5 MG (90)
2 LA
metronidazole vaginal gel 075 1
NEXPLANON SUBDERMAL IMPLANT 68 MG ACA PV
OSPHENA ORAL TABLET 60 MG 1
PHEXXI VAGINAL GEL 18-1-04 ACA PV
terconazole vaginal cream 04 08 1
terconazole vaginal suppository 80 mg 1
TODAY CONTRACEPTIVE SPONGE VAGINAL CONTRACEPTIVE SPONGE 1000 MG
ACA PV
tranexamic acid oral tablet 650 mg 1
TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 MCG24 HR
ACA PV
vaginal contraceptive foam vaginal foam 125 ACA PV
vandazole vaginal gel 075 1
VCF CONTRACEPTIVE FILM VAGINAL FILM 28
ACA PV
VCF CONTRACEPTIVE GEL VAGINAL GEL 4
ACA PV
102
Drug Name Drug Tier Requirements Limits
xulane transdermal patch weekly 150-35 mcg24 hr
ACA PV
zafemy transdermal patch weekly 150-35 mcg24 hr
ACA PV
ORAL CONTRACEPTIVES amp RELATED AGENTS
afirmelle oral tablet 01-20 mg-mcg ACA PV
altavera (28) oral tablet 015-003 mg ACA PV
alyacen 135 (28) oral tablet 1-35 mg-mcg ACA PV
alyacen 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
amethia oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
amethyst (28) oral tablet 90-20 mcg (28) ACA PV
apri oral tablet 015-003 mg ACA PV
aranelle (28) oral tablet 05105-35 mg-mcg ACA PV
ashlyna oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
aubra eq oral tablet 01-20 mg-mcg ACA PV
aubra oral tablet 01-20 mg-mcg ACA PV
aurovela 1530 (21) oral tablet 15-30 mg-mcg ACA PV
aurovela 120 (21) oral tablet 1-20 mg-mcg ACA PV
aurovela 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
aurovela fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
aurovela fe 1-20 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
aviane oral tablet 01-20 mg-mcg ACA PV
ayuna oral tablet 015-003 mg ACA PV
azurette (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
BALCOLTRA ORAL TABLET 01 MG-002 MG (21)365 MG(7)
ACA PV
balziva (28) oral tablet 04-35 mg-mcg ACA PV
blisovi 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
blisovi fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
103
Drug Name Drug Tier Requirements Limits
blisovi fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
briellyn oral tablet 04-35 mg-mcg ACA PV
camrese lo oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)
ACA PV
camrese oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
caziant (28) oral tablet 0112515-25 mg-mcg ACA PV
charlotte 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
chateal (28) oral tablet 015-003 mg ACA PV
chateal eq (28) oral tablet 015-003 mg ACA PV
cryselle (28) oral tablet 03-30 mg-mcg ACA PV
cyclafem 135 (28) oral tablet 1-35 mg-mcg ACA PV
cyclafem 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
cyred eq oral tablet 015-003 mg ACA PV
cyred oral tablet 015-003 mg ACA PV
dasetta 135 (28) oral tablet 1-35 mg-mcg ACA PV
dasetta 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
daysee oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
desog-eestradioleestradiol oral tablet 015-002 mgx21 001 mg x 5
ACA PV
desogestrel-ethinyl estradiol oral tablet 015-003 mg
ACA PV
dolishale oral tablet 90-20 mcg (28) ACA PV
drospirenone-eestradiol-lmfa oral tablet 3-002-0451 mg (24) (4) 3-003-0451 mg (21) (7)
ACA PV
drospirenone-ethinyl estradiol oral tablet 3-002 mg 3-003 mg
ACA PV
econtra ez oral tablet 15 mg ACA PV
econtra one-step oral tablet 15 mg ACA PV
elinest oral tablet 03-30 mg-mcg ACA PV
ELLA ORAL TABLET 30 MG ACA PV
emoquette oral tablet 015-003 mg ACA PV
104
Drug Name Drug Tier Requirements Limits
enpresse oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
enskyce oral tablet 015-003 mg ACA PV
estarylla oral tablet 025-35 mg-mcg ACA PV
ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg 1-50 mg-mcg
ACA PV
falmina (28) oral tablet 01-20 mg-mcg ACA PV
fayosim oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg
ACA PV
femynor oral tablet 025-35 mg-mcg ACA PV
gemmily oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV
hailey 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
hailey fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
hailey fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
hailey oral tablet 15-30 mg-mcg ACA PV
iclevia oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
isibloom oral tablet 015-003 mg ACA PV
jaimiess oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
jasmiel (28) oral tablet 3-002 mg ACA PV
jolessa oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
juleber oral tablet 015-003 mg ACA PV
junel 1530 (21) oral tablet 15-30 mg-mcg ACA PV
junel 120 (21) oral tablet 1-20 mg-mcg ACA PV
junel fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
junel fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
junel fe 24 oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV
kaitlib fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)
ACA PV
kalliga oral tablet 015-003 mg ACA PV
kariva (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
105
Drug Name Drug Tier Requirements Limits
kelnor 135 (28) oral tablet 1-35 mg-mcg ACA PV
kelnor 1-50 (28) oral tablet 1-50 mg-mcg ACA PV
kurvelo (28) oral tablet 015-003 mg ACA PV
l norgesteestradiol-eestrad oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7) 015 mg-20 mcg 015 mg-25 mcg 015 mg-30 mcg (84)10 mcg (7)
ACA PV
larin 1530 (21) oral tablet 15-30 mg-mcg ACA PV
larin 120 (21) oral tablet 1-20 mg-mcg ACA PV
larin 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV
larin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
larin fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
larissia oral tablet 01-20 mg-mcg ACA PV
layolis fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)
ACA PV
leena 28 oral tablet 05105-35 mg-mcg ACA PV
lessina oral tablet 01-20 mg-mcg ACA PV
levonest (28) oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
levonorgestrel oral tablet 15 mg ACA PV
levonorgestrel-ethinyl estrad oral tablet 01-20 mg-mcg 015-003 mg 90-20 mcg (28)
ACA PV
levonorgestrel-ethinyl estrad oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
levonorg-eth estrad triphasic oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
levora-28 oral tablet 015-003 mg ACA PV
lillow (28) oral tablet 015-003 mg ACA PV
LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG (24)10 MCG (2)
ACA PV
lojaimiess oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)
ACA PV
loryna (28) oral tablet 3-002 mg ACA PV
low-ogestrel (28) oral tablet 03-30 mg-mcg ACA PV
lo-zumandimine (28) oral tablet 3-002 mg ACA PV
lutera (28) oral tablet 01-20 mg-mcg ACA PV
106
Drug Name Drug Tier Requirements Limits
marlissa (28) oral tablet 015-003 mg ACA PV
merzee oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV
mibelas 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
microgestin 1530 (21) oral tablet 15-30 mg-mcg ACA PV
microgestin 120 (21) oral tablet 1-20 mg-mcg ACA PV
microgestin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
microgestin fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
mili oral tablet 025-35 mg-mcg ACA PV
mono-linyah oral tablet 025-35 mg-mcg ACA PV
my choice oral tablet 15 mg ACA PV
my way oral tablet 15 mg ACA PV
NATAZIA ORAL TABLET 3 MG2 MG-2 MG 2 MG-3 MG1 MG
ACA PV
necon 0535 (28) oral tablet 05-35 mg-mcg ACA PV
new day oral tablet 15 mg ACA PV
NEXTSTELLIS ORAL TABLET 3 MG- 142 MG (28)
ACA PV
nikki (28) oral tablet 3-002 mg ACA PV
noreth-ethinyl estradiol-iron oral tabletchewable 04mg-35mcg(21) and 75 mg (7) 08mg-25mcg(24) and 75 mg (4)
ACA PV
norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg 15-30 mg-mcg
ACA PV
norethindrone-eestradiol-iron oral capsule 1 mg-20 mcg (24)75 mg (4)
ACA PV
norethindrone-eestradiol-iron oral tablet 1 mg-20 mcg (21)75 mg (7) 15 mg-30 mcg (21)75 mg (7)
ACA PV
norethindrone-eestradiol-iron oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
norgestimate-ethinyl estradiol oral tablet 0180215025 mg-25 mcg 0180215025 mg-35 mcg (28) 025-35 mg-mcg
ACA PV
nortrel 0535 (28) oral tablet 05-35 mg-mcg ACA PV
nortrel 135 (21) oral tablet 1-35 mg-mcg (21) ACA PV
nortrel 135 (28) oral tablet 1-35 mg-mcg ACA PV
107
Drug Name Drug Tier Requirements Limits
nortrel 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
nylia 777 (28) oral tablet 050751 mg- 35 mcg ACA PV
nymyo oral tablet 025-35 mg-mcg ACA PV
ocella oral tablet 3-003 mg ACA PV
opcicon one-step oral tablet 15 mg ACA PV
option-2 oral tablet 15 mg ACA PV
orsythia oral tablet 01-20 mg-mcg ACA PV
philith oral tablet 04-35 mg-mcg ACA PV
pimtrea (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
pirmella oral tablet 050751 mg- 35 mcg 1-35 mg-mcg
ACA PV
portia 28 oral tablet 015-003 mg ACA PV
previfem oral tablet 025-35 mg-mcg ACA PV
reclipsen (28) oral tablet 015-003 mg ACA PV
rivelsa oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg
ACA PV
setlakin oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
simliya (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
simpesse oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
SLYND ORAL TABLET 4 MG (28) ACA PV
sprintec (28) oral tablet 025-35 mg-mcg ACA PV
sronyx oral tablet 01-20 mg-mcg ACA PV
syeda oral tablet 3-003 mg ACA PV
tarina 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
tarina fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
tilia fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9) ACA PV
tri femynor oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-estarylla oral tablet 0180215025 mg-35 mcg (28)
ACA PV
108
Drug Name Drug Tier Requirements Limits
tri-legest fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9)
ACA PV
tri-linyah oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-lo-estarylla oral tablet 0180215025 mg-25 mcg
ACA PV
tri-lo-marzia oral tablet 0180215025 mg-25 mcg
ACA PV
tri-lo-mili oral tablet 0180215025 mg-25 mcg ACA PV
tri-lo-sprintec oral tablet 0180215025 mg-25 mcg
ACA PV
tri-mili oral tablet 0180215025 mg-35 mcg (28) ACA PV
tri-nymyo oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-previfem (28) oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-sprintec (28) oral tablet 0180215025 mg-35 mcg (28)
ACA PV
trivora (28) oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
tri-vylibra lo oral tablet 0180215025 mg-25 mcg
ACA PV
tri-vylibra oral tablet 0180215025 mg-35 mcg (28)
ACA PV
TYBLUME ORAL TABLETCHEWABLE 01 MG- 20 MCG
ACA PV
tydemy oral tablet 3-003-0451 mg (21) (7) ACA PV
velivet triphasic regimen (28) oral tablet 0112515-25 mg-mcg
ACA PV
vestura (28) oral tablet 3-002 mg ACA PV
vienva oral tablet 01-20 mg-mcg ACA PV
viorele (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
volnea (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
vyfemla (28) oral tablet 04-35 mg-mcg ACA PV
vylibra oral tablet 025-35 mg-mcg ACA PV
wera (28) oral tablet 05-35 mg-mcg ACA PV
wymzya fe oral tabletchewable 04mg-35mcg(21) and 75 mg (7)
ACA PV
109
Drug Name Drug Tier Requirements Limits
zarah oral tablet 3-003 mg ACA PV
zovia 135e (28) oral tablet 1-35 mg-mcg ACA PV
zumandimine (28) oral tablet 3-003 mg ACA PV
OXYTOCICS
methergine oral tablet 02 mg 1
methylergonovine oral tablet 02 mg 1
OPHTHALMOLOGY
ANTIBIOTICS
ak-poly-bac ophthalmic (eye) ointment 500-10000 unitgram
1
AZASITE OPHTHALMIC (EYE) DROPS 1 1
bacitracin ophthalmic (eye) ointment 500 unitgram
1
bacitracin-polymyxin b ophthalmic (eye) ointment 500-10000 unitgram
1
BESIVANCE OPHTHALMIC (EYE) DROPSSUSPENSION 06
1
ciprofloxacin hcl ophthalmic (eye) drops 03 1
erythromycin ophthalmic (eye) ointment 5 mggram (05 )
1
gatifloxacin ophthalmic (eye) drops 05 1
gentak ophthalmic (eye) ointment 03 (3 mggram)
1
gentamicin ophthalmic (eye) drops 03 1
levofloxacin ophthalmic (eye) drops 05 1
moxifloxacin ophthalmic (eye) drops 05 1
moxifloxacin ophthalmic (eye) drops viscous 05
1
NATACYN OPHTHALMIC (EYE) DROPSSUSPENSION 5
1
neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
1
neomycin-polymyxin-gramicidin ophthalmic (eye) drops 175 mg-10000 unit-0025mgml
1
neo-polycin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
1
ofloxacin ophthalmic (eye) drops 03 1
110
Drug Name Drug Tier Requirements Limits
polycin ophthalmic (eye) ointment 500-10000 unitgram
1
polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10000 unit- 1 mgml
1
tobramycin ophthalmic (eye) drops 03 1
TOBREX OPHTHALMIC (EYE) OINTMENT 03
1
ANTIVIRALS
trifluridine ophthalmic (eye) drops 1 1
ZIRGAN OPHTHALMIC (EYE) GEL 015 1
BETA-BLOCKERS
betaxolol ophthalmic (eye) drops 05 1
BETIMOL OPHTHALMIC (EYE) DROPS 025 05
1
BETOPTIC S OPHTHALMIC (EYE) DROPSSUSPENSION 025
1
carteolol ophthalmic (eye) drops 1 1
levobunolol ophthalmic (eye) drops 05 1
timolol maleate ophthalmic (eye) drops 025 05
1
timolol maleate ophthalmic (eye) drops once daily 05
1
timolol maleate ophthalmic (eye) gel forming solution 025 05
1
CYCLOPLEGIC MYDRIATICS
atropine ophthalmic (eye) drops 1 1
atropine ophthalmic (eye) ointment 1 1
cyclopentolate ophthalmic (eye) drops 05 1 2
1
homatropaire ophthalmic (eye) drops 5 1
tropicamide ophthalmic (eye) drops 05 1 1
DIRECT ACTING MIOTICS
pilocarpine hcl ophthalmic (eye) drops 1 2 4
1
MISCELLANEOUS OPHTHALMOLOGICS
ALOCRIL OPHTHALMIC (EYE) DROPS 2 1 ST
ALOMIDE OPHTHALMIC (EYE) DROPS 01 1 ST
111
Drug Name Drug Tier Requirements Limits
altacaine ophthalmic (eye) drops 05 1
azelastine ophthalmic (eye) drops 005 1
BEOVU INTRAVITREAL SOLUTION 6 MG005 ML
MB PA LA
bepotastine besilate ophthalmic (eye) drops 15 1 ST
BEPREVE OPHTHALMIC (EYE) DROPS 15 1 ST
cromolyn ophthalmic (eye) drops 4 1
CYSTARAN OPHTHALMIC (EYE) DROPS 044
2 PA
epinastine ophthalmic (eye) drops 005 1
EYLEA INTRAVITREAL SOLUTION 2 MG005 ML
MB PA LA
EYLEA INTRAVITREAL SYRINGE 2 MG005 ML
MB PA LA
LACRISERT OPHTHALMIC (EYE) INSERT 5 MG
1
LASTACAFT OPHTHALMIC (EYE) DROPS 025
1 ST
LUCENTIS INTRAVITREAL SOLUTION 03 MG005 ML 05 MG005 ML
MB PA LA
LUCENTIS INTRAVITREAL SYRINGE 03 MG005 ML 05 MG005 ML
MB PA LA
LUXTURNA SUBRETINAL SUSPENSION 15 X 10EXP11 VG03 ML (FNL)
MB LA
olopatadine ophthalmic (eye) drops 01 02 1
OMIDRIA INTRAOCULAR CONCENTRATE 1-03
MB
proparacaine ophthalmic (eye) drops 05 1
RESTASIS OPHTHALMIC (EYE) DROPPERETTE 005
1 QL (120 per 30 days)
TETRACAINE HCL (PF) OPHTHALMIC (EYE) DROPS 05
1
tetracaine hcl ophthalmic (eye) drops 05 1
VISUDYNE INTRAVENOUS RECON SOLN 15 MG
MB LA
XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5
1 PA ST QL (60 per 30 days)
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
112
Drug Name Drug Tier Requirements Limits
ACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE 045
1 ST
bromfenac ophthalmic (eye) drops 009 1
diclofenac sodium ophthalmic (eye) drops 01 1
flurbiprofen sodium ophthalmic (eye) drops 003
1
ketorolac ophthalmic (eye) drops 04 05 1
NEVANAC OPHTHALMIC (EYE) DROPSSUSPENSION 01
1
ORAL DRUGS FOR GLAUCOMA
acetazolamide oral capsule extended release 500 mg
1
acetazolamide oral tablet 125 mg 250 mg 1
methazolamide oral tablet 25 mg 50 mg 1
OTHER GLAUCOMA DRUGS
bimatoprost ophthalmic (eye) drops 003 1
brinzolamide ophthalmic (eye) dropssuspension 1
1
COMBIGAN OPHTHALMIC (EYE) DROPS 02-05
1
dorzolamide ophthalmic (eye) drops 2 1
dorzolamide-timolol (pf) ophthalmic (eye) dropperette 2-05
1
dorzolamide-timolol ophthalmic (eye) drops 223-68 mgml
1
latanoprost ophthalmic (eye) drops 0005 1
LUMIGAN OPHTHALMIC (EYE) DROPS 001
1 ST
RHOPRESSA OPHTHALMIC (EYE) DROPS 002
1 PA ST
SIMBRINZA OPHTHALMIC (EYE) DROPSSUSPENSION 1-02
1
travoprost ophthalmic (eye) drops 0004 1
STEROID-ANTIBIOTIC COMBINATIONS
neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
1
neomycin-polymyxin b-dexameth ophthalmic (eye) dropssuspension 35mgml-10000 unitml-01
1
113
Drug Name Drug Tier Requirements Limits
neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 35 mgg-10000 unitg-01
1
neomycin-polymyxin-hc ophthalmic (eye) dropssuspension 35-10000-10 mg-unit-mgml
1
neo-polycin hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
1
TOBRADEX OPHTHALMIC (EYE) OINTMENT 03-01
1
TOBRADEX ST OPHTHALMIC (EYE) DROPSSUSPENSION 03-005
1
tobramycin-dexamethasone ophthalmic (eye) dropssuspension 03-01
1
STEROIDS
ALREX OPHTHALMIC (EYE) DROPSSUSPENSION 02
1 ST
dexamethasone sodium phosphate ophthalmic (eye) drops 01
1
DUREZOL OPHTHALMIC (EYE) DROPS 005
1
fluorometholone ophthalmic (eye) dropssuspension 01
1
FML FORTE OPHTHALMIC (EYE) DROPSSUSPENSION 025
1
FML SOP OPHTHALMIC (EYE) OINTMENT 01
1
INVELTYS OPHTHALMIC (EYE) DROPSSUSPENSION 1
1 ST
LOTEMAX OPHTHALMIC (EYE) OINTMENT 05
1 ST
loteprednol etabonate ophthalmic (eye) dropsgel 05
1
loteprednol etabonate ophthalmic (eye) dropssuspension 05
1
MAXIDEX OPHTHALMIC (EYE) DROPSSUSPENSION 01
1
OZURDEX INTRAVITREAL IMPLANT 07 MG MB LA
PRED MILD OPHTHALMIC (EYE) DROPSSUSPENSION 012
1
prednisolone acetate ophthalmic (eye) dropssuspension 1
1
114
Drug Name Drug Tier Requirements Limits
prednisolone sodium phosphate ophthalmic (eye) drops 1
1
RETISERT INTRAVITREAL IMPLANT 059 MG
MB LA
YUTIQ INTRAVITREAL IMPLANT 018 MG MB
STEROID-SULFONAMIDE COMBINATIONS
BLEPHAMIDE OPHTHALMIC (EYE) DROPSSUSPENSION 10-02
1
BLEPHAMIDE SOP OPHTHALMIC (EYE) OINTMENT 10-02
1
sulfacetamide-prednisolone ophthalmic (eye) drops 10 -023 (025 )
1
SULFONAMIDES
sulfacetamide sodium ophthalmic (eye) drops 10
1
sulfacetamide sodium ophthalmic (eye) ointment 10
1
SYMPATHOMIMETICS
apraclonidine ophthalmic (eye) drops 05 1
brimonidine ophthalmic (eye) drops 015 02 1
IOPIDINE OPHTHALMIC (EYE) DROPPERETTE 1
1
VASOCONSTRICTOR DECONGESTANTS
phenylephrine hcl ophthalmic (eye) drops 10 25
1
RESPIRATORY ALLERGY COUGH amp COLD
ANTIHISTAMINE amp ANTIALLERGENIC AGENTS
adrenalin injection solution 1 mgml 1 mgml (1 ml)
1
carbinoxamine maleate oral liquid 4 mg5 ml 1 PA ST QL (2 per 30 days)
carbinoxamine maleate oral tablet 4 mg 1 PA ST QL (240 per 30 days)
carbinoxamine maleate oral tablet 6 mg 1 PA ST QL (120 per 30 days)
cetirizine oral solution 1 mgml 1
clemastine oral syrup 05 mg5 ml 1
clemastine oral tablet 268 mg 1
cyproheptadine oral syrup 2 mg5 ml 1
cyproheptadine oral tablet 4 mg 1
115
Drug Name Drug Tier Requirements Limits
desloratadine oral tablet 5 mg 1 PA ST QL (30 per 30 days)
desloratadine oral tabletdisintegrating 25 mg 5 mg
1 PA ST
diphenhydramine hcl injection solution 50 mgml 1
diphenhydramine hcl injection syringe 50 mgml MB
EPINEPHRINE INJECTION AUTO-INJECTOR 015 MG015 ML
1
epinephrine injection auto-injector 015 mg03 ml 03 mg03 ml
1
epinephrine injection solution 1 mgml 1 mgml (1 ml)
1
epinephrine injection syringe 01 mgml 1
hydroxyzine hcl intramuscular solution 25 mgml MB
hydroxyzine hcl oral solution 10 mg5 ml 1
hydroxyzine hcl oral tablet 10 mg 25 mg 50 mg 1
hydroxyzine pamoate oral capsule 100 mg 25 mg 50 mg
1
levocetirizine oral solution 25 mg5 ml 1
levocetirizine oral tablet 5 mg 1
promethazine injection solution 25 mgml MB
promethazine oral syrup 625 mg5 ml 1
promethazine oral tablet 125 mg 25 mg 50 mg 1
promethazine rectal suppository 125 mg 25 mg 1
promethegan rectal suppository 125 mg 25 mg 50 mg
1
COUGH amp COLD THERAPY
benzonatate oral capsule 100 mg 150 mg 200 mg 1
brompheniramine-pseudoeph-dm oral syrup 2-30-10 mg5 ml
1
codeine-guaifenesin oral liquid 10-100 mg5 ml 1
g tussin ac oral liquid 10-100 mg5 ml 1
guaiatussin ac oral liquid 10-100 mg5 ml 1
hydrocodone-chlorpheniramine oral suspensionextended rel 12 hr 10-8 mg5 ml
1
hydrocodone-homatropine oral syrup 5-15 mg5 ml
1
hydrocodone-homatropine oral tablet 5-15 mg 1
116
Drug Name Drug Tier Requirements Limits
hydromet oral syrup 5-15 mg5 ml 1
maxi-tuss ac oral liquid 10-100 mg5 ml 1
m-clear wc oral liquid 63-100 mg5 ml 1
promethazine-codeine oral syrup 625-10 mg5 ml 1
promethazine-dm oral syrup 625-15 mg5 ml 1
promethazine-phenyleph-codeine oral syrup 625-5-10 mg5 ml
1
promethazine-phenylephrine oral syrup 625-5 mg5 ml
1
virtussin ac oral liquid 10-100 mg5 ml 1
PULMONARY AGENTS
acetylcysteine solution 100 mgml (10 ) 200 mgml (20 )
1
ADEMPAS ORAL TABLET 05 MG 1 MG 15 MG 2 MG 25 MG
2 PA LA
ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCGACTUATION 230-21 MCGACTUATION 45-21 MCGACTUATION
1 QL (1 per 30 days)
ALBUTEROL HFA 90 MCG INHALER 90 MCGACTUATION
1 QL (2 per 30 days)
albuterol sulfate inhalation inhalation hfa aerosol inhaler 90 mcgactuation
1 QL (2 per 30 days)
albuterol sulfate inhalation inhalation solution for nebulization 063 mg3 ml 125 mg3 ml 25 mg 3 ml (0083 ) 25 mg05 ml 5 mgml
1
albuterol sulfate inhalation oral syrup 2 mg5 ml 1
albuterol sulfate inhalation oral tablet 2 mg 4 mg 1
albuterol sulfate inhalation oral tablet extended release 12 hr 4 mg 8 mg
1
ALVESCO INHALATION HFA AEROSOL INHALER 160 MCGACTUATION 80 MCGACTUATION
1 PA ST QL (1 per 30 days)
alyq oral tablet 20 mg 2 PA
ambrisentan oral tablet 10 mg 5 mg 2 PA LA
aminophylline intravenous solution 250 mg10 ml MB
ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 625-25 MCGACTUATION
1 QL (1 per 30 days)
arformoterol inhalation solution for nebulization 15 mcg2 ml
1
117
Drug Name Drug Tier Requirements Limits
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 200 MCGACTUATION
1 QL (1 per 30 days)
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 50 MCGACTUATION
1
ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCGACTUATION
1 QL (2 per 30 days)
BERINERT INTRAVENOUS KIT 500 UNIT (10 ML)
MB PA LA
BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-48 MCG
1
bosentan oral tablet 125 mg 625 mg 2 PA LA
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCGDOSE
1 QL (1 per 30 days)
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 200-25 MCGDOSE
1
BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG2 ML
1
budesonide inhalation suspension for nebulization 025 mg2 ml 05 mg2 ml
1 QL (120 per 30 days)
budesonide inhalation suspension for nebulization 1 mg2 ml
1 QL (60 per 30 days)
CINQAIR INTRAVENOUS SOLUTION 10 MGML
MB PA
CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)
MB PA LA
COMBIVENT RESPIMAT INHALATION MIST 20-100 MCGACTUATION
1 QL (2 per 30 days)
cromolyn inhalation solution for nebulization 20 mg2 ml
1
DALIRESP ORAL TABLET 250 MCG 500 MCG
1
DULERA INHALATION HFA AEROSOL INHALER 100-5 MCGACTUATION 200-5 MCGACTUATION 50-5 MCGACTUATION
1 QL (1 per 30 days)
ELIXOPHYLLIN ORAL ELIXIR 80 MG15 ML 1
ESBRIET ORAL CAPSULE 267 MG 2 PA LA QL (270 per 30 days)
ESBRIET ORAL TABLET 267 MG 801 MG 2 PA LA QL (90 per 30 days)
FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MGML
MB PA LA
118
Drug Name Drug Tier Requirements Limits
FASENRA SUBCUTANEOUS SYRINGE 30 MGML
MB PA LA
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 50 MCGACTUATION
1 QL (1 per 30 days)
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCGACTUATION
1 QL (4 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCGACTUATION 44 MCGACTUATION
1 QL (1 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCGACTUATION
1 QL (2 per 30 days)
fluticasone propionate nasal spraysuspension 50 mcgactuation
1
fluticasone propion-salmeterol inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose
1 QL (1 per 30 days)
formoterol fumarate inhalation solution for nebulization 20 mcg2 ml
1
HAEGARDA SUBCUTANEOUS RECON SOLN 2000 UNIT 3000 UNIT
2 PA LA
icatibant subcutaneous syringe 30 mg3 ml 2 PA
INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 625 MCGACTUATION
1 QL (1 per 30 days)
ipratropium bromide inhalation solution 002 1
ipratropium-albuterol inhalation solution for nebulization 05 mg-3 mg(25 mg base)3 ml
1 QL (180 per 30 days)
KALBITOR SUBCUTANEOUS SOLUTION 10 MGML (1 ML)
2 PA LA
KALYDECO ORAL GRANULES IN PACKET 25 MG 50 MG 75 MG
2 PA LA
KALYDECO ORAL TABLET 150 MG 2 PA LA
levalbuterol hcl inhalation solution for nebulization 031 mg3 ml 063 mg3 ml 125 mg05 ml 125 mg3 ml
1
LEVALBUTEROL TARTRATE INHALATION HFA AEROSOL INHALER 45 MCGACTUATION
1 QL (2 per 30 days)
metaproterenol oral syrup 10 mg5 ml 1
montelukast oral granules in packet 4 mg 1
montelukast oral tablet 10 mg 1
119
Drug Name Drug Tier Requirements Limits
montelukast oral tabletchewable 4 mg 5 mg 1
nebusal inhalation solution for nebulization 3 1
NUCALA SUBCUTANEOUS RECON SOLN 100 MG
MB PA LA
OFEV ORAL CAPSULE 100 MG 150 MG 2 PA LA QL (60 per 30 days)
OPSUMIT ORAL TABLET 10 MG 2 PA LA
ORLADEYO ORAL CAPSULE 110 MG 150 MG
2 PA ST QL (28 per 28 days)
PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG2 ML
1
pulmosal inhalation solution for nebulization 7 1
PULMOZYME INHALATION SOLUTION 1 MGML
2 PA LA
QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCGACTUATION 80 MCGACTUATION
1
REVATIO INTRAVENOUS SOLUTION 10 MG125 ML
MB LA
RUCONEST INTRAVENOUS RECON SOLN 2100 UNIT
MB PA LA
SEEBRI NEOHALER INHALATION CAPSULE WINHALATION DEVICE 156 MCG
1
SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCGDOSE
1
sildenafil (pulmhypertension) intravenous solution 10 mg125 ml
MB
sildenafil (pulmhypertension) oral suspension for reconstitution 10 mgml
2
sildenafil (pulmhypertension) oral tablet 20 mg 2 PA
SINUVA SINUS IMPLANT 1350 MCG MB
sodium chloride inhalation solution for nebulization 09 10 3 7
1
SPIRIVA RESPIMAT INHALATION MIST 125 MCGACTUATION
1
SPIRIVA RESPIMAT INHALATION MIST 25 MCGACTUATION
1 QL (1 per 30 days)
SPIRIVA WITH HANDIHALER INHALATION CAPSULE WINHALATION DEVICE 18 MCG
1 QL (30 per 30 days)
STIOLTO RESPIMAT INHALATION MIST 25-25 MCGACTUATION
1
120
Drug Name Drug Tier Requirements Limits
STRIVERDI RESPIMAT INHALATION MIST 25 MCGACTUATION
1
SYMBICORT INHALATION HFA AEROSOL INHALER 160-45 MCGACTUATION 80-45 MCGACTUATION
1 QL (1 per 30 days)
SYMDEKO ORAL TABLETS SEQUENTIAL 100-150 MG (D) 150 MG (N) 50-75 MG (D) 75 MG (N)
2 PA LA
tadalafil (pulm hypertension) oral tablet 20 mg 2 PA
TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG2 ML (150 MGML)
2 PA LA
terbutaline oral tablet 25 mg 5 mg 1
terbutaline subcutaneous solution 1 mgml 1
theophylline oral elixir 80 mg15 ml 1
theophylline oral solution 80 mg15 ml 1
theophylline oral tablet extended release 12 hr 300 mg 450 mg
1
theophylline oral tablet extended release 24 hr 400 mg 600 mg
1
TRACLEER ORAL TABLET FOR SUSPENSION 32 MG
2 PA LA
TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-625-25 MCG 200-625-25 MCG
1
TRIKAFTA ORAL TABLETS SEQUENTIAL 100-50-75 MG(D) 150 MG (N) 50-25-375 MG (D)75 MG (N)
2 PA LA
TYVASO INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)
2 PA LA
TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)
2 PA LA
TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML
2 PA LA
UTIBRON NEOHALER INHALATION CAPSULE WINHALATION DEVICE 275-156 MCG
1
VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCGML 20 MCGML
2 PA LA
121
Drug Name Drug Tier Requirements Limits
wixela inhub inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose
1 QL (1 per 30 days)
XOLAIR SUBCUTANEOUS RECON SOLN 150 MG
MB LA
XOLAIR SUBCUTANEOUS SYRINGE 150 MGML 75 MG05 ML
MB PA LA QL (7 per 30 days)
zafirlukast oral tablet 10 mg 20 mg 1
zileuton oral tablet er multiphase 12 hr 600 mg 1 ST
ZYFLO ORAL TABLET 600 MG 1 ST
UROLOGICALS
ANTICHOLINERGICS amp ANTISPASMODICS
darifenacin oral tablet extended release 24 hr 15 mg 75 mg
1
flavoxate oral tablet 100 mg 1
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG 50 MG
1 ST
oxybutynin chloride oral syrup 5 mg5 ml 1
oxybutynin chloride oral tablet 5 mg 1
oxybutynin chloride oral tablet extended release 24hr 10 mg 15 mg 5 mg
1
solifenacin oral tablet 10 mg 5 mg 1
tolterodine oral capsuleextended release 24hr 2 mg 4 mg
1
tolterodine oral tablet 1 mg 2 mg 1
trospium oral capsuleextended release 24hr 60 mg
1
trospium oral tablet 20 mg 1
BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY
alfuzosin oral tablet extended release 24 hr 10 mg 1
dutasteride oral capsule 05 mg 1
dutasteride-tamsulosin oral capsule er multiphase 24 hr 05-04 mg
1
finasteride oral tablet 5 mg 1
silodosin oral capsule 4 mg 8 mg 1
tadalafil oral tablet 25 mg 5 mg 1 PA ST
tamsulosin oral capsule 04 mg 1
CHOLINERGIC STIMULANTS
122
Drug Name Drug Tier Requirements Limits
bethanechol chloride oral tablet 10 mg 25 mg 5 mg 50 mg
1
MISCELLANEOUS UROLOGICALS
CYSTAGON ORAL CAPSULE 150 MG 50 MG 2 PA
ELMIRON ORAL CAPSULE 100 MG 1
hyophen oral tablet 816-012-108 mg 1
K-PHOS NO 2 ORAL TABLET 305-700 MG 1
K-PHOS ORIGINAL ORAL TABLETSOLUBLE 500 MG
1
methen-sod phos-meth blue-hyos oral tablet 816-408-012 mg
1
OXLUMO SUBCUTANEOUS SOLUTION 945 MG05 ML
2 PA
phosphasal oral tablet 816-108-408 mg 1
potassium citrate oral tablet extended release 10 meq (1080 mg) 15 meq 5 meq (540 mg)
1
RENACIDIN IRRIGATION SOLUTION 19806 MG-594 MG-9804MG30ML
1
URELLE ORAL TABLET 81-108-408 MG 1
uretron d-s oral tablet 816-108-408 mg 1
urimar-t oral tablet 120-012-108 mg 1
urogesic-blue oral tablet 816-408-012 mg 1
uryl oral tablet 816-408-012 mg 1
ustell oral capsule 120-012 mg 1
utira-c oral tablet 816-108-408 mg 1
URINARY ANESTHETICS
phenazopyridine oral tablet 100 mg 200 mg 1
VITAMINS HEMATINICS amp ELECTROLYTES
ELECTROLYTES
effer-k oral tablet effervescent 25 meq 1
klor-con 10 oral tablet extended release 10 meq 1
klor-con 8 oral tablet extended release 8 meq 1
klor-con m10 oral tableter particlescrystals 10 meq
1
klor-con m15 oral tableter particlescrystals 15 meq
1
123
Drug Name Drug Tier Requirements Limits
klor-con m20 oral tableter particlescrystals 20 meq
1
klor-con oral packet 20 meq 1
klor-conef oral tablet effervescent 25 meq 1
K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ
1
k-tab oral tablet extended release 8 meq 1
NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION
MB
potassium chloride oral capsule extended release 10 meq 8 meq
1
potassium chloride oral liquid 20 meq15 ml 40 meq15 ml
1
potassium chloride oral packet 20 meq 1
potassium chloride oral tablet extended release 10 meq 20 meq 8 meq
1
potassium chloride oral tableter particlescrystals 10 meq 20 meq
1
sodium chloride 045 intravenous parenteral solution 045
MB
MISCELLANEOUS VITAMINS HEMATINICS amp ELECTROLYTES
ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION
MB
PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION
MB
PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION
MB
VITAMINS amp HEMATINICS
cyanocobalamin (vitamin b-12) injection solution 1000 mcgml
1
ergocalciferol (vitamin d2) oral capsule 1250 mcg (50000 unit)
1
FA-8 ORAL CAPSULE 08 MG ACA PV
FER-IN-SOL ORAL DROPS 15 MG IRON (75 MG)ML
ACA PV
FLORIVA (FLUORIDE-VITAMIN D3) ORAL DROPS 025 MG (055 MG)-400 UNITML
ACA PV
fluoride (sodium) oral drops 05 mg (11 mg sodfluorid)ml
ACA PV
124
Drug Name Drug Tier Requirements Limits
fluoride (sodium) oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)
ACA PV
folic acid injection solution 5 mgml 1
folic acid oral tablet 1 mg 1
folic acid oral tablet 400 mcg 800 mcg ACA PV
hydroxocobalamin intramuscular solution 1000 mcgml
1
INFED INJECTION SOLUTION 50 MGML MB
ludent fluoride oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)
ACA PV
multi-vitamin with fluoride oral drops 025 mgml 05 mgml
ACA PV
multi-vitamin with fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
multivitamins with fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
mvc-fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
NOVAFERRUM ORAL DROPS 15 MG IRONML
ACA PV
tri-vitamin with fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml
ACA PV
vitamins acd and fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml
ACA PV
125
Index
A abacavir 2 abacavir-lamivudine 2 abacavir-lamivudine-
zidovudine 2 ABILIFY MAINTENA 36 abiraterone 13 ABRAXANE 13 acamprosate 66 acarbose 77 accutane 59 acebutolol 45 acetaminophen-caff-
dihydrocod 30 acetaminophen-codeine 31 acetazolamide 112 acetic acid 66 69 acetylcysteine 116 acitretin 57 ACTEMRA 95 ACTEMRA ACTPEN 95 ACTHAR 70 ACTHIB (PF) 90 ACTIMMUNE 89 ACUVAIL (PF) 112 acyclovir 2 63 ADACEL(TDAP
ADOLESNADULT)(PF) 90 ADAKVEO 13 adapalene 59 60 ADAPALENE 60 adapalene-benzoyl peroxide 60 ADCETRIS 14 adefovir 2 ADEMPAS 116 ADHANSIA XR 36 adrenalin 114 adult aspirin regimen 33 ADVAIR HFA 116 ADVATE 50 ADYNOVATE 50 ADZENYS ER 36 ADZENYS XR-ODT 36 AEROCHAMBER MINI 71 AEROCHAMBER PLUS
FLOW-VU 71 AFINITOR 14 afirmelle 102
AFSTYLA 50 AIMOVIG AUTOINJECTOR
28 AJOVY AUTOINJECTOR 28 AJOVY SYRINGE 28 ak-poly-bac 109 AKYNZEO (NETUPITANT)
81 ala-cort 63 albendazole 8 albuterol sulfate inhalation 116 ALBUTEROL SULFATE
INHALATION 116 alclometasone 63 ALCORTIN A 61 ALDURAZYME 74 ALECENSA 14 alendronate 95 alfuzosin 121 ALIMTA 14 ALINIA 8 ALIQOPA 14 aliskiren 45 allopurinol 95 almotriptan malate 28 ALOCRIL 110 ALOGLIPTIN-
PIOGLITAZONE 77 ALOMIDE 110 alosetron 81 ALOXI 81 ALPHANATE 50 ALPHANINE SD 50 alprazolam 37 alprazolam intensol 37 ALPROLIX 50 ALREX 113 ALTABAX 61 altacaine 111 altavera (28) 102 ALVESCO 116 alyacen 135 (28) 102 alyacen 777 (28) 102 alyq 116 amabelz 98 amantadine hcl 2 AMBISOME 1 ambrisentan 116
amcinonide 63 amethia 102 amethyst (28) 102 amikacin 8 amiloride 45 amiloride-hydrochlorothiazide
45 aminocaproic acid 50 51 aminophylline 116 amiodarone 44 AMITIZA 81 amitriptyline 37 amitriptyline-chlordiazepoxide
37 amlodipine 45 amlodipine-atorvastatin 55 amlodipine-benazepril 45 amlodipine-olmesartan 45 amlodipine-valsartan 45 amlodipine-valsartan-hcthiazid
45 ammonium lactate 59 amnesteem 60 amoxapine 37 amoxicil-clarithromy-lansopraz
85 amoxicillin 11 amoxicillin-pot clavulanate 11 AMPHETAMINE 37 amphetamine sulfate 37 amphotericin b 1 ampicillin 11 ampicillin-sulbactam 11 anagrelide 66 anaspaz 80 anastrozole 14 ANDEXXA 51 ANDRODERM 74 ANGELIQ 98 ANNOVERA 101 ANORO ELLIPTA 116 anucort-hc 81 apexicon e 63 APLENZIN 37 APOKYN 27 apraclonidine 114 aprepitant 81 apri 102
126
APTIVUS 2 ARALAST NP 66 aranelle (28) 102 ARANESP (IN
POLYSORBATE) 86 ARCALYST 89 ARESTIN 68 arformoterol 116 aripiprazole 37 ARISTADA 37 ARISTADA INITIO 37 armodafinil 37 ARMOUR THYROID 79 ARNUITY ELLIPTA 117 ARRANON 14 ARZERRA 14 ASCENIV 90 ascomp with codeine 31 asenapine maleate 37 ashlyna 102 ASPARLAS 14 aspirin 33 34 aspirin low dose 33 aspirin-dipyridamole 51 aspir-trin 34 atazanavir 2 atenolol 45 atenolol-chlorthalidone 45 ATGAM 90 atomoxetine 37 atorvastatin 55 atovaquone 8 atovaquone-proguanil 8 atropine 80 110 ATROVENT HFA 117 AUBAGIO 87 aubra 102 aubra eq 102 aurovela 1530 (21) 102 aurovela 120 (21) 102 aurovela 24 fe 102 aurovela fe 1530 (28) 102 aurovela fe 1-20 (28) 102 AUSTEDO 29 AVASTIN 14 aviane 102 avidoxy 12 avita 60 AVITA 60 AVONEX 88 AVYCAZ 6
ayuna 102 AZASITE 109 azathioprine 14 azelaic acid 60 azelastine 68 111 AZELEX 60 azithromycin 7 azurette (28) 102 B bacitracin 8 109 bacitracin-polymyxin b 109 baclofen 30 BALCOLTRA 102 balsalazide 81 BALVERSA 14 balziva (28) 102 BANZEL 24 BAQSIMI 71 BARACLUDE 2 BAVENCIO 14 BAXDELA 12 bayer aspirin 34 BAYER CHEWABLE
ASPIRIN 34 BCG VACCINE LIVE (PF) 90 BELEODAQ 14 belladonna alkaloids-opium 80 BELRAPZO 14 BELSOMRA 37 benazepril 45 benazepril-hydrochlorothiazide
45 BENDAMUSTINE 14 BENDEKA 14 BENEFIX 51 BENLYSTA 96 benzonatate 115 benztropine 27 BEOVU 111 bepotastine besilate 111 BEPREVE 111 BERINERT 117 beser 63 BESIVANCE 109 BESPONSA 14 betamethasone dipropionate 63 betamethasone valerate 63 betamethasone augmented 63
64 BETASERON 88 betaxolol 45 110
bethanechol chloride 122 BETIMOL 110 BETOPTIC S 110 BEVESPI AEROSPHERE 117 bexarotene 14 BEXSERO 90 bicalutamide 14 BICILLIN C-R 11 BIKTARVY 2 bimatoprost 112 BIOTHRAX 90 bisoprolol fumarate 45 bisoprolol-hydrochlorothiazide
45 BIVIGAM 90 BLEPHAMIDE 114 BLEPHAMIDE SOP 114 BLINCYTO 14 blisovi 24 fe 102 blisovi fe 1530 (28) 102 blisovi fe 120 (28) 103 BOOSTRIX TDAP 90 BORTEZOMIB 14 bosentan 117 BOSULIF 14 BOTOX 90 BRAFTOVI 14 BREO ELLIPTA 117 briellyn 103 BRILINTA 51 brimonidine 114 BRINEURA 75 brinzolamide 112 BRIVIACT 24 bromfenac 112 bromocriptine 27 brompheniramine-pseudoeph-
dm 115 BROVANA 117 budesonide 81 117 bumetanide 45 buprenorphine 31 buprenorphine hcl 31 buprenorphine-naloxone 34 bupropion hcl 37 38 bupropion hcl (smoking deter)
68 buspirone 38 BUSULFEX 15 butalbital compound wcodeine
31
127
butalbital-acetaminop-caf-cod 31
butalbital-acetaminophen-caff 31
butalbital-aspirin-caffeine 31 butorphanol 34 BYDUREON BCISE 77 BYETTA 77 BYSTOLIC 45 C CABENUVA 2 cabergoline 75 CABLIVI 51 CABOMETYX 15 calcipotriene 57 calcipotriene-betamethasone 57 calcitonin (salmon) 75 calcitriol 57 75 calcium acetate(phosphat bind)
81 CALQUENCE 15 camila 98 camrese 103 camrese lo 103 CANCIDAS 1 candesartan 45 candesartan-hydrochlorothiazid
46 CAPASTAT 8 capecitabine 15 CAPRELSA 15 captopril 46 captopril-hydrochlorothiazide
46 CARBAGLU 66 carbamazepine 24 carbidopa 27 carbidopa-levodopa 27 carbidopa-levodopa-
entacapone 27 carbinoxamine maleate 114 carisoprodol 30 carisoprodol-aspirin 30 carisoprodol-aspirin-codeine 30 carteolol 110 cartia xt 46 carvedilol 46 carvedilol phosphate 46 cataflam 34 CAYA CONTOURED 98 CAYSTON 8
caziant (28) 103 cefaclor 6 cefadroxil 6 cefazolin 6 cefazolin in dextrose (iso-os) 6 cefdinir 6 cefditoren pivoxil 6 cefepime 6 CEFEPIME IN DEXTROSE 5
6 cefepime in dextroseiso-osm 6 cefixime 6 CEFOTAN 6 cefotaxime 6 cefotetan 6 CEFOTETAN IN
DEXTROSE ISO-OSM 6 cefoxitin 6 cefpodoxime 6 7 cefprozil 7 ceftazidime 7 CEFTAZIDIME IN D5W 7 ceftriaxone 7 CEFTRIAXONE 7 ceftriaxone in dextroseiso-os 7 cefuroxime axetil 7 celecoxib 34 CELONTIN 24 cephalexin 7 CERDELGA 75 CEREZYME 75 cetirizine 114 cevimeline 66 CHANTIX 68 CHANTIX CONTINUING
MONTH BOX 68 CHANTIX STARTING
MONTH BOX 68 charlotte 24 fe 103 chateal (28) 103 chateal eq (28) 103 CHEMET 66 childrens aspirin 34 chloramphenicol sod succinate
8 chlordiazepoxide hcl 38 chlordiazepoxide-clidinium 80 chlorhexidine gluconate 68 chloroquine phosphate 8 chlorpromazine 38 chlorthalidone 46
chlorzoxazone 30 CHOLBAM 81 cholestyramine (with sugar) 55 cholestyramine light 55 cholinemagnesium salicylate
34 ciclodan 62 ciclopirox 62 ciclopirox-ure-camph-menth-
euc 62 cidofovir 2 cilostazol 51 CIMDUO 2 cimetidine 85 cimetidine hcl 85 CIMZIA 82 CIMZIA POWDER FOR
RECONST 81 cinacalcet 75 CINQAIR 117 CINRYZE 117 CIPRO HC 69 ciprofloxacin 12 ciprofloxacin hcl 12 69 109 ciprofloxacin-dexamethasone
69 citalopram 38 claravis 60 clarithromycin 7 8 clemastine 114 CLENPIQ 82 clindacin p 60 clindamycin hcl 8 clindamycin pediatric 8 clindamycin phosphate 8 60
101 clindamycin-benzoyl peroxide
60 clindamycin-tretinoin 60 clobazam 24 clobetasol 64 clobetasol-emollient 64 CLOCORTOLONE
PIVALATE 64 CLODERM 64 CLOLAR 15 clomipramine 38 clonazepam 24 clonidine 46 clonidine hcl 38 46 clopidogrel 51
128
clorazepate dipotassium 38 clotrimazole 1 62 clotrimazole-betamethasone 62 clovique 66 clozapine 38 COAGADEX 51 COARTEM 8 codeine sulfate 31 codeine-butalbital-asa-caff 31 codeine-guaifenesin 115 colchicine 95 COLCHICINE 95 colesevelam 55 colestipol 55 COMBIGAN 112 COMBIPATCH 98 COMBIVENT RESPIMAT 117 COMETRIQ 15 COMPLERA 2 compro 82 constulose 82 CONTOUR NEXT TEST
STRIPS 71 CONTOUR TEST STRIPS 71 COPIKTRA 15 CORIFACT 51 CORLANOR 56 CORTIFOAM 82 COSENTYX 58 COSENTYX (2 SYRINGES)
57 COSENTYX PEN 58 COSENTYX PEN (2 PENS) 58 COTELLIC 15 COTEMPLA XR-ODT 38 covaryx 98 covaryx hs 98 CREON 82 CRESEMBA 1 CRINONE 98 cromolyn 82 111 117 crotan 66 cryselle (28) 103 CRYSVITA 75 CUBICIN 8 CUBICIN RF 9 CUTAQUIG 90 CUVITRU 90 cyanocobalamin (vitamin b-12)
123 cyclafem 135 (28) 103
cyclafem 777 (28) 103 cyclobenzaprine 30 cyclopentolate 110 cyclophosphamide 15 CYCLOPHOSPHAMIDE 15 CYCLOSERINE 9 CYCLOSET 77 cyclosporine 15 cyclosporine modified 15 cyproheptadine 114 CYRAMZA 15 cyred 103 cyred eq 103 CYSTAGON 122 CYSTARAN 111 CYTOVENE 2 D DACOGEN 15 dalfampridine 29 DALIRESP 117 danazol 75 dantrolene 30 dapsone 9 60 DAPTACEL (DTAP
PEDIATRIC) (PF) 91 darifenacin 121 DARZALEX 15 dasetta 135 (28) 103 dasetta 777 (28) 103 DAURISMO 15 daysee 103 DAYTRANA 38 deblitane 98 decadron 70 decitabine 15 deferasirox 66 deferiprone 66 demeclocycline 12 DENAVIR 63 denta 5000 plus 68 dentagel 69 DEPO-ESTRADIOL 98 DEPO-PROVERA 98 DEPO-SUBQ PROVERA 104
98 DEPO-TESTOSTERONE 75 DESCOVY 2 desipramine 38 desloratadine 115 desmopressin 75
desog-eestradioleestradiol 103
desogestrel-ethinyl estradiol 103
desonide 64 desoximetasone 64 DESVENLAFAXINE 38 desvenlafaxine succinate 38 dexamethasone 70 dexamethasone intensol 70 dexamethasone sodium phos
(pf) 70 dexamethasone sodium
phosphate 70 113 DEXILANT 85 dexmethylphenidate 38 dextroamphetamine 38 39 dextroamphetamine-
amphetamine 39 diazepam 24 39 diazepam intensol 39 diazoxide 71 diclofenac potassium 34 diclofenac sodium 34 59 112 diclofenac-misoprostol 34 dicloxacillin 11 dicyclomine 80 didanosine 2 DIFICID 8 diflorasone 64 diflunisal 34 digitek 50 digox 50 digoxin 50 dihydroergotamine 28 DILANTIN 24 DILANTIN EXTENDED 24 DILANTIN INFATABS 24 DILANTIN-125 24 diltiazem 46 dilt-xr 46 dimethyl fumarate 88 DIPENTUM 82 diphenhydramine hcl 115 diphenoxylate-atropine 80 dipyridamole 51 diskets 31 disopyramide phosphate 44 disulfiram 66 divalproex 24 25 DIVIGEL 99
129
dofetilide 44 dolishale 103 donepezil 29 DONNATAL 80 DOPTELET (15 TAB PACK)
51 dorzolamide 112 dorzolamide-timolol 112 dorzolamide-timolol (pf) 112 dotti 99 DOVATO 2 doxazosin 46 doxepin 39 doxercalciferol 75 doxycycline hyclate 12 doxycycline monohydrate 12 doxylamine-pyridoxine (vit b6)
82 dronabinol 82 drospirenone-eestradiol-lmfa
103 drospirenone-ethinyl estradiol
103 DSUVIA 31 DUAVEE 99 DUEXIS 34 DULERA 117 duloxetine 39 DUPIXENT PEN 59 DUPIXENT SYRINGE 59 duramorph (pf) 31 DUREZOL 113 dutasteride 121 dutasteride-tamsulosin 121 dvorah 31 DYANAVEL XR 39 DYSPORT 91 E ees 400 8 econazole 62 econtra ez 103 econtra one-step 103 ecotrin 34 ecotrin low strength 34 EDARBI 46 EDARBYCLOR 46 EDLUAR 39 ed-spaz 80 EDURANT 2 eemt 99 eemt hs 99
efavirenz 2 efavirenz-emtricitabin-tenofov
3 efavirenz-lamivu-tenofov disop
3 effer-k 122 ELAPRASE 75 ELELYSO 75 eletriptan 28 ELIGARD 16 ELIGARD (3 MONTH) 15 ELIGARD (4 MONTH) 15 ELIGARD (6 MONTH) 15 elinest 103 ELIQUIS 51 ELIQUIS DVT-PE TREAT
30D START 51 ELIXOPHYLLIN 117 ELLA 103 ELMIRON 122 ELOCTATE 51 eluryng 101 ELZONRIS 16 EMCYT 16 EMEND 82 EMGALITY PEN 28 EMGALITY SYRINGE 28 emoquette 103 EMPAVELI 67 EMPLICITI 16 EMSAM 39 emtricitabine 3 emtricitabine-tenofovir (tdf) 3 EMTRIVA 3 EMVERM 9 enalapril maleate 46 enalaprilat 46 enalapril-hydrochlorothiazide
46 ENBREL 96 ENBREL MINI 96 ENBREL SURECLICK 96 endocet 31 ENGERIX-B (PF) 91 ENGERIX-B PEDIATRIC
(PF) 91 ENHERTU 16 enoxaparin 51 enpresse 104 enskyce 104 entacapone 27
entecavir 3 ENTRESTO 56 ENTYVIO 82 enulose 82 EPANED 46 EPCLUSA 3 EPIDIOLEX 25 epinastine 111 epinephrine 115 EPINEPHRINE 115 epitol 25 EPIVIR HBV 3 eplerenone 47 EPOGEN 86 epoprostenol (glycine) 47 eprosartan 47 ERAXIS(WATER DILUENT)
1 ERBITUX 16 ergocalciferol (vitamin d2) 123 ergoloid 39 ergotamine-caffeine 28 ERLEADA 16 erlotinib 16 errin 99 ERWINAZE 16 ery pads 60 erygel 60 ery-tab 8 erythrocin (as stearate) 8 erythromycin 8 109 erythromycin ethylsuccinate 8 erythromycin with ethanol 60 erythromycin-benzoyl peroxide
60 ESBRIET 117 escitalopram oxalate 39 esomeprazole magnesium 85 ESPEROCT 51 estarylla 104 estazolam 39 estradiol 99 estradiol valerate 99 estradiol-norethindrone acet 99 ESTRING 99 estrogens-methyltestosterone 99 eszopiclone 39 ethacrynic acid 47 ethambutol 9 ethosuximide 25
130
ethynodiol diac-eth estradiol 104
etodolac 34 etonogestrel-ethinyl estradiol
101 etoposide 16 etravirine 3 EUCRISA 59 EUFLEXXA 34 EURAX 66 EVAMIST 99 EVENITY 95 everolimus (antineoplastic) 16 everolimus
(immunosuppressive) 16 EVOTAZ 3 EXELDERM 62 exemestane 16 EXONDYS-51 29 EYLEA 111 ezetimibe 55 ezetimibe-simvastatin 55 F FA-8 123 FABRAZYME 75 FACTIVE 12 falmina (28) 104 famciclovir 3 famotidine 86 famotidine (pf) 85 FANAPT 39 FARXIGA 77 FASENRA 118 FASENRA PEN 117 FASLODEX 16 fayosim 104 FC2 FEMALE CONDOM 98 febuxostat 95 FEIBA NF 51 felbamate 25 felodipine 47 fem ph 101 FEMCAP 98 FEMRING 99 femynor 104 fenofibrate 55 FENOFIBRATE 55 fenofibrate micronized 55 fenofibrate nanocrystallized 55 fenofibric acid 55 fenofibric acid (choline) 55
fenoprofen 35 fentanyl 32 fentanyl citrate 31 FER-IN-SOL 123 FERRIPROX 67 FETZIMA 39 FIASP FLEXTOUCH U-100
INSULIN 72 FIASP PENFILL U-100
INSULIN 72 FIASP U-100 INSULIN 72 FIBRYGA 51 finasteride 121 FINTEPLA 25 FIRMAGON KIT W
DILUENT SYRINGE 16 flac otic oil 69 flavoxate 121 FLEBOGAMMA DIF 91 flecainide 44 FLOLAN 47 FLORIVA (FLUORIDE-
VITAMIN D3) 123 FLOVENT DISKUS 118 FLOVENT HFA 118 fluconazole 1 flucytosine 1 fludarabine 16 fludrocortisone 70 fluocinolone 64 fluocinolone acetonide oil 69 fluocinolone and shower cap 64 fluocinonide 64 fluocinonide-e 64 fluoride (sodium) 69 123 124 fluorometholone 113 fluorouracil 16 59 FLUOROURACIL 59 fluoxetine 39 40 fluphenazine hcl 40 flurandrenolide 64 65 flurazepam 40 flurbiprofen 35 flurbiprofen sodium 112 flutamide 16 fluticasone propionate 65 118 fluticasone propion-salmeterol
118 fluvastatin 55 56 fluvoxamine 40 FML FORTE 113
FML SOP 113 folic acid 124 FOLOTYN 16 fondaparinux 51 formoterol fumarate 118 FORTEO 95 FOSAMAX PLUS D 95 fosamprenavir 3 fosfomycin tromethamine 13 fosinopril 47 fosinopril-hydrochlorothiazide
47 FRAGMIN 52 FREESTYLE LIBRE 14 DAY
SENSOR 71 FREESTYLE LIBRE 2
SENSOR 71 frovatriptan 28 fulvestrant 16 furosemide 47 FUZEON 3 fyavolv 99 G g tussin ac 115 gabapentin 25 GALAFOLD 75 galantamine 29 GAMASTAN 91 GAMASTAN SD 91 GAMIFANT 16 GAMMAGARD LIQUID 91 GAMMAGARD S-D (IGA lt 1
MCGML) 91 GAMMAKED 91 GAMMAPLEX 91 GAMMAPLEX (WITH
SORBITOL) 91 GAMUNEX-C 91 GANCICLOVIR 3 ganciclovir sodium 3 GARDASIL 9 (PF) 91 gatifloxacin 109 gavilyte-c 82 gavilyte-g 82 gavilyte-n 82 GAZYVA 16 gemcitabine 16 17 gemfibrozil 56 gemmily 104 generlac 82 gengraf 17
131
GENOTROPIN 87 GENOTROPIN MINIQUICK
87 gentak 109 gentamicin 9 61 62 109 gentamicin sulfate (ped) (pf) 9 GENVOYA 3 GIAPREZA 56 GILENYA 88 GILOTRIF 17 GIVLAARI 67 GLASSIA 67 glatiramer 88 glatopa 88 GLEOSTINE 17 glimepiride 77 glipizide 77 glipizide-metformin 77 GLUCAGEN DIAGNOSTIC
KIT 71 GLUCAGEN HYPOKIT 71 GLUCAGON (HCL)
EMERGENCY KIT 71 glucagon emergency kit
(human) 71 GLUCAGON HCL 71 glyburide 77 glyburide micronized 77 glyburide-metformin 77 glycopyrrolate 80 GLYXAMBI 78 GONITRO 57 granisetron hcl 82 GRANIX 86 GRASTEK 91 griseofulvin microsize 1 griseofulvin ultramicrosize 1 guaiatussin ac 115 guanfacine 40 47 GYNAZOLE-1 101 gynol ii 101 H HAEGARDA 118 hailey 104 hailey 24 fe 104 hailey fe 1530 (28) 104 hailey fe 120 (28) 104 HALAVEN 17 halcinonide 65 halobetasol propionate 65 haloperidol 40
haloperidol decanoate 40 haloperidol lactate 40 HARVONI 3 HAVRIX (PF) 91 92 heather 99 HEMLIBRA 52 hemmorex-hc 82 HEMOFIL M HIGH 52 HEMOFIL M LOW 52 HEMOFIL M MID 52 HEMOFIL M SUPER HIGH52 hep flush-10 (pf) 52 heparin (porcine) 52 heparin (porcine) in 5 dex 52 heparin lock flush (porcine) 52 heparin lockflush(porcine)(pf)
52 heparin(porcine) in 045 nacl
52 HEPARIN(PORCINE) IN
045 NACL 52 heparin porcine (pf) 52 53 HEPLISAV-B (PF) 92 HERCEPTIN 17 HERCEPTIN HYLECTA 17 HERZUMA 17 HETLIOZ 40 HETLIOZ LQ 40 HIBERIX (PF) 92 HIZENTRA 92 homatropaire 110 HUMALOG JUNIOR
KWIKPEN U-100 72 HUMALOG KWIKPEN
INSULIN 72 HUMALOG MIX 50-50
INSULN U-100 72 HUMALOG MIX 50-50
KWIKPEN 72 HUMALOG MIX 75-25
KWIKPEN 72 HUMALOG MIX 75-25(U-
100)INSULN 72 HUMALOG U-100 INSULIN
72 HUMATE-P 53 HUMIRA 96 HUMIRA PEN 96 HUMIRA PEN CROHNS-UC-
HS START 96
HUMIRA PEN PSOR-UVEITS-ADOL HS 96
HUMIRA(CF) 97 HUMIRA(CF) PEDI
CROHNS STARTER 96 HUMIRA(CF) PEN 96 HUMIRA(CF) PEN
CROHNS-UC-HS 96 HUMIRA(CF) PEN
PEDIATRIC UC 96 HUMIRA(CF) PEN PSOR-
UV-ADOL HS 96 HUMULIN 7030 U-100
INSULIN 72 HUMULIN 7030 U-100
KWIKPEN 72 HUMULIN N NPH INSULIN
KWIKPEN 73 HUMULIN N NPH U-100
INSULIN 73 HUMULIN R REGULAR U-
100 INSULN 73 HUMULIN R U-500 (CONC)
INSULIN 73 HUMULIN R U-500 (CONC)
KWIKPEN 73 HYCAMTIN 17 hydralazine 47 hydrochlorothiazide 47 hydrocodone bitartrate 32 hydrocodone-acetaminophen 32 hydrocodone-chlorpheniramine
115 hydrocodone-homatropine 115 hydrocodone-ibuprofen 32 hydrocortisone 65 70 82 hydrocortisone acetate 82 hydrocortisone butyrate 65 hydrocortisone butyr-emollient
65 hydrocortisone valerate 65 hydrocortisone-acetic acid 69 hydrocortisone-pramoxine 58
82 hydromet 116 hydromorphone 32 HYDROMORPHONE 32 hydroxocobalamin 124 hydroxychloroquine 9 hydroxyprogest(pf)(preg presv)
99
132
hydroxyprogesterone cap(ppres) 99
hydroxyprogesterone caproate 100
hydroxyurea 17 hydroxyzine hcl 115 hydroxyzine pamoate 115 hyophen 122 hyoscyamine sulfate 80 hyosyne 80 HYQVIA 92 I ibandronate 95 IBRANCE 17 ibu 35 ibuprofen 35 icatibant 118 iclevia 104 ICLUSIG 17 icosapent ethyl 56 IDELVION 53 IDHIFA 17 ILARIS (PF) 90 ILUMYA 58 imatinib 17 IMBRUVICA 17 IMFINZI 17 imipenem-cilastatin 9 imipramine hcl 40 imipramine pamoate 40 imiquimod 90 IMLYGIC 17 IMOVAX RABIES VACCINE
(PF) 92 incassia 100 INCRELEX 67 INCRUSE ELLIPTA 118 indapamide 47 indomethacin 35 INFANRIX (DTAP) (PF) 92 INFED 124 INFLECTRA 82 INFUGEM 18 INLYTA 18 INSULIN ASP PRT-INSULIN
ASPART 73 INSULIN ASPART U-100 73 INSULIN SYRINGE-
NEEDLE U-100 71 INTELENCE 3 INTRAROSA 101
INTRON A 90 INVANZ 9 INVEGA SUSTENNA 40 INVELTYS 113 INVIRASE 3 IOPIDINE 114 IPOL 92 ipratropium bromide 69 118 ipratropium-albuterol 118 irbesartan 47 irbesartan-hydrochlorothiazide
47 IRESSA 18 ISENTRESS 3 ISENTRESS HD 3 isibloom 104 ISOLYTE-S 123 isoniazid 9 isosorbide dinitrate 57 isosorbide mononitrate 57 isotretinoin 60 isoxsuprine 101 isradipine 47 ISTODAX 18 itraconazole 1 ivermectin 9 66 IXEMPRA 18 IXIARO (PF) 92 IXINITY 53 J jaimiess 104 JAKAFI 18 jantoven 53 JANUMET 78 JANUMET XR 78 JANUVIA 78 JARDIANCE 78 jasmiel (28) 104 jencycla 100 JENTADUETO 78 JENTADUETO XR 78 JEVTANA 18 jinteli 100 JIVI 53 jolessa 104 JORNAY PM 40 JUBLIA 62 juleber 104 JULUCA 3 junel 1530 (21) 104 junel 120 (21) 104
junel fe 1530 (28) 104 junel fe 120 (28) 104 junel fe 24 104 JUXTAPID 56 JYNARQUE 75 K KADCYLA 18 kaitlib fe 104 KALBITOR 118 KALETRA 3 4 kalliga 104 KALYDECO 118 KANJINTI 18 KANUMA 75 kariva (28) 104 kelnor 135 (28) 105 kelnor 1-50 (28) 105 KEPIVANCE 13 ketoconazole 1 62 ketodan 62 ketoprofen 35 ketorolac 35 112 KEVZARA 97 KEYTRUDA 18 KINRIX (PF) 92 KISQALI 18 KISQALI FEMARA CO-
PACK 18 klor-con 123 klor-con 10 122 klor-con 8 122 klor-con m10 122 klor-con m15 122 klor-con m20 123 klor-conef 123 KOATE 53 KOGENATE FS 53 KORLYM 75 KOVALTRY 53 K-PHOS NO 2 122 K-PHOS ORIGINAL 122 KRYSTEXXA 95 k-tab 123 K-TAB 123 kurvelo (28) 105 KYLEENA 98 KYMRIAH 18 KYPROLIS 18 L l norgesteestradiol-eestrad
105
133
labetalol 47 LACRISERT 111 lactulose 83 lamivudine 4 lamivudine-zidovudine 4 lamotrigine 25 lansoprazole 86 lanthanum 83 LANTUS SOLOSTAR U-100
INSULIN 73 LANTUS U-100 INSULIN 73 lapatinib 18 larin 1530 (21) 105 larin 120 (21) 105 larin 24 fe 105 larin fe 1530 (28) 105 larin fe 120 (28) 105 larissia 105 LASTACAFT 111 latanoprost 112 LATUDA 40 layolis fe 105 leena 28 105 leflunomide 97 LEMTRADA 88 LENVIMA 18 lessina 105 letrozole 19 leucovorin calcium 13 LEUKERAN 19 LEUKINE 86 leuprolide 19 levalbuterol hcl 118 LEVALBUTEROL
TARTRATE 118 LEVEMIR FLEXTOUCH U-
100 INSULN 73 LEVEMIR U-100 INSULIN 73 levetiracetam 25 levobunolol 110 levocarnitine 67 levocarnitine (with sugar) 67 levocetirizine 115 levofloxacin 12 109 levonest (28) 105 levonorgestrel 105 levonorgestrel-ethinyl estrad
105 levonorg-eth estrad triphasic
105 levora-28 105
levorphanol tartrate 32 levothyroxine 79 levoxyl 79 LEVULAN 59 LEXIVA 4 LIBTAYO 19 lidocaine 61 lidocaine hcl 61 lidocaine hcl-hydrocortison ac
61 83 LIDOCAINE HCL-
HYDROCORTISON AC 83 lidocaine viscous 61 lidocaine-hydrocortisone-aloe
83 lidocaine-prilocaine 61 LIDOCAINE-TETRACAINE
61 LILETTA 98 lillow (28) 105 LINCOCIN 9 lindane 66 linezolid 9 linezolid in dextrose 5 9 linezolid-09 sodium chloride
9 LINZESS 83 liothyronine 79 LIPOFEN 56 lisinopril 47 lisinopril-hydrochlorothiazide
47 lithium carbonate 40 41 LO LOESTRIN FE 105 lojaimiess 105 LONSURF 19 loperamide 80 lopinavir-ritonavir 4 lorazepam 41 lorazepam intensol 41 loryna (28) 105 losartan 47 losartan-hydrochlorothiazide 47 LOTEMAX 113 loteprednol etabonate 113 lovastatin 56 low-ogestrel (28) 105 loxapine succinate 41 lo-zumandimine (28) 105 LUCENTIS 111 ludent fluoride 124
LULICONAZOLE 62 LUMIGAN 112 LUMIZYME 75 LUMOXITI 19 LUPANETA PACK (1
MONTH) 101 LUPANETA PACK (3
MONTH) 101 LUPKYNIS 19 LUPRON DEPOT 19 LUPRON DEPOT (3
MONTH) 19 LUPRON DEPOT (4
MONTH) 19 LUPRON DEPOT (6
MONTH) 19 LUPRON DEPOT-PED 19 LUPRON DEPOT-PED (3
MONTH) 19 lutera (28) 105 LUXTURNA 111 LUZU 62 lyleq 100 lyllana 100 LYNPARZA 19 LYRICA CR 25 LYSODREN 19 lyza 100 M mafenide acetate 62 malathion 66 maprotiline 41 marlissa (28) 106 MARPLAN 41 MARQIBO 19 MATULANE 19 matzim la 47 MAVENCLAD (10 TABLET
PACK) 88 MAVENCLAD (4 TABLET
PACK) 88 MAVENCLAD (5 TABLET
PACK) 88 MAVENCLAD (6 TABLET
PACK) 88 MAVENCLAD (7 TABLET
PACK) 88 MAVENCLAD (8 TABLET
PACK) 88 MAVENCLAD (9 TABLET
PACK) 88
134
MAVYRET 4 MAXIDEX 113 maxi-tuss ac 116 MAYZENT 88 MAYZENT STARTER PACK
88 m-clear wc 116 meclizine 83 meclofenamate 35 medroxyprogesterone 100 mefenamic acid 35 mefloquine 9 megestrol 19 MEKINIST 19 MEKTOVI 19 meloxicam 35 melphalan 19 melphalan hcl 19 memantine 29 MENACTRA (PF) 92 MENEST 100 MENOSTAR 100 MENQUADFI (PF) 92 MENTAX 62 MENVEO A-C-Y-W-135-DIP
(PF) 92 meperidine 32 meprobamate 30 MEPSEVII 76 mercaptopurine 20 meropenem 9 MEROPENEM-09
SODIUM CHLORIDE 9 merzee 106 mesalamine 83 mesalamine with cleansing
wipe 83 metaproterenol 118 metaxalone 30 metformin 78 methadone 32 methadose 32 methamphetamine 41 methazolamide 112 methenamine hippurate 13 methenamine mandelate 13 methen-sod phos-meth blue-
hyos 122 methergine 109 methimazole 71 methocarbamol 30
methotrexate sodium 20 methotrexate sodium (pf) 20 methoxsalen 59 methscopolamine 80 methyldopa 47 methyldopa-
hydrochlorothiazide 47 methyldopate 48 methylergonovine 109 METHYLIN 41 methylphenidate hcl 41 methylprednisolone 70 methylprednisolone acetate 70 methyltestosterone 76 metoclopramide hcl 83 metolazone 48 metoprolol succinate 48 metoprolol ta-hydrochlorothiaz
48 metoprolol tartrate 48 metronidazole 9 60 61 101 metyrosine 48 mexiletine 44 MIACALCIN 76 mibelas 24 fe 106 microgestin 1530 (21) 106 microgestin 120 (21) 106 microgestin fe 1530 (28) 106 microgestin fe 120 (28) 106 midazolam 41 midodrine 67 migergot 28 miglitol 78 miglustat 76 mili 106 millipred 70 millipred dp 70 mimvey 100 MINITRAN 57 minocycline 12 minoxidil 48 MIRCERA 86 MIRENA 98 mirtazapine 41 misoprostol 86 MITIGARE 95 mitoxantrone 20 M-M-R II (PF) 92 modafinil 41 moexipril 48 molindone 41
mometasone 65 mondoxyne nl 12 mono-linyah 106 MONONINE 53 MONOVISC 35 montelukast 118 119 morphine 32 33 morphine (pf) 32 morphine concentrate 32 MOTOFEN 80 MOVANTIK 83 MOXATAG 11 moxifloxacin 12 109 MOZOBIL 87 MULPLETA 53 MULTAQ 44 multi-vitamin with fluoride 124 multivitamins with fluoride 124 mupirocin 62 mupirocin calcium 62 mvc-fluoride 124 my choice 106 my way 106 MYALEPT 76 MYCAMINE 1 mycophenolate mofetil 20 mycophenolate sodium 20 MYDAYIS 41 MYLOTARG 20 MYOBLOC 92 myorisan 61 MYRBETRIQ 121 N nabumetone 35 nadolol 48 nadolol-bendroflumethiazide 48 nafcillin 11 nafcillin in dextrose iso-osm 11 naftifine 62 63 NAGLAZYME 76 nalbuphine 35 naloxone 35 naltrexone 35 naproxen 35 naproxen sodium 35 naratriptan 28 NARCAN 35 NATACYN 109 NATAZIA 106 nateglinide 78 NATPARA 76
135
nebusal 119 necon 0535 (28) 106 nefazodone 41 neomycin 9 neomycin-bacitracin-poly-hc
112 neomycin-bacitracin-
polymyxin 109 neomycin-polymyxin b-
dexameth 112 113 neomycin-polymyxin-
gramicidin 109 neomycin-polymyxin-hc 69
113 neo-polycin 109 neo-polycin hc 113 NERLYNX 20 NEUPOGEN 87 NEVANAC 112 nevirapine 4 new day 106 NEXAVAR 20 NEXPLANON 101 NEXTSTELLIS 106 niacin 56 NIACOR 56 nicardipine 48 nicorette 68 nicotine 68 nicotine (polacrilex) 68 NICOTROL 68 NICOTROL NS 68 nifedipine 48 nikki (28) 106 nilutamide 20 nimodipine 48 NINLARO 20 nisoldipine 48 nitazoxanide 9 nitisinone 67 nitro-bid 57 NITRO-DUR 57 nitrofurantoin 13 nitrofurantoin macrocrystal 13 nitrofurantoin monohydm-
cryst 13 nitroglycerin 57 nitroglycerin in 5 dextrose 57 nitro-time 57 NITYR 67 NIVESTYM 87
nizatidine 86 nora-be 100 noreth-ethinyl estradiol-iron
106 norethindrone (contraceptive)
100 norethindrone acetate 100 norethindrone ac-eth estradiol
100 106 norethindrone-eestradiol-iron
106 norgestimate-ethinyl estradiol
106 norlyda 100 NORMOSOL-R 123 NORPACE CR 44 nortrel 0535 (28) 106 nortrel 135 (21) 106 nortrel 135 (28) 106 nortrel 777 (28) 107 nortriptyline 42 NORVIR 4 NOVAFERRUM 124 NOVOEIGHT 53 NOVOLIN 70-30 FLEXPEN
U-100 73 NOVOLIN N FLEXPEN 73 NOVOLIN R FLEXPEN 73 NOVOLOG FLEXPEN U-100
INSULIN 74 NOVOLOG MIX 70-30 U-100
INSULN 74 NOVOLOG MIX 70-
30FLEXPEN U-100 74 NOVOLOG PENFILL U-100
INSULIN 74 NOVOLOG U-100 INSULIN
ASPART 74 NOVOPEN ECHO 71 NOVOSEVEN RT 53 NOXAFIL 1 np thyroid 79 NPLATE 53 NUCALA 119 NUCYNTA ER 36 NUEDEXTA 29 NULOJIX 20 NULYTELY LEMON-LIME
83 NUPLAZID 42 NUWIQ 53
nyamyc 63 nylia 777 (28) 107 nymyo 107 nystatin 1 63 nystatin-triamcinolone 63 nystop 63 O OBIZUR 54 ocella 107 OCREVUS 88 OCTAGAM 92 octreotide acetate 20 ODEFSEY 4 OFEV 119 ofloxacin 12 69 109 OGIVRI 20 olanzapine 42 olanzapine-fluoxetine 42 olmesartan 48 olmesartan-amlodipin-
hcthiazid 48 olmesartan-
hydrochlorothiazide 48 olopatadine 69 111 OLUMIANT 97 omega-3 acid ethyl esters 56 omeprazole 86 OMIDRIA 111 OMNITROPE 87 ONCASPAR 20 ondansetron 84 ondansetron hcl 83 84 ONETOUCH ULTRA TEST
71 ONETOUCH VERIO TEST
STRIPS 71 ONIVYDE 20 ONPATTRO 29 ONZETRA XSAIL 28 opcicon one-step 107 OPDIVO 20 opium tincture 81 OPSUMIT 119 option-2 107 ORALAIR 92 oralone 69 ORAVIG 1 ORENCIA 97 ORENCIA (WITH
MALTOSE) 97 ORENCIA CLICKJECT 97
136
ORENITRAM 48 ORLADEYO 119 orphenadrine citrate 30 orsythia 107 ORTHOVISC 36 oscimin 81 oscimin sl 81 oscimin sr 81 oseltamivir 4 OSMOPREP 84 OSPHENA 101 OTEZLA 97 OTEZLA STARTER 97 OTOVEL 69 oxacillin 11 oxacillin in dextrose(iso-osm)
11 oxandrolone 76 oxaprozin 36 oxazepam 42 oxcarbazepine 25 oxiconazole 63 OXISTAT 63 OXLUMO 122 oxybutynin chloride 121 oxycodone 33 oxycodone-acetaminophen 33 oxycodone-aspirin 33 OXYCONTIN 33 oxymorphone 33 OZEMPIC 78 OZURDEX 113 P pacerone 44 PADCEV 20 paliperidone 42 PALYNZIQ 76 pamidronate 76 PANRETIN 59 pantoprazole 86 PANZYGA 92 PARAGARD T 380A 98 paricalcitol 76 PARICALCITOL 76 paroex oral rinse 69 paromomycin 10 paroxetine hcl 42 paroxetine
mesylate(menopsym) 42 PARSABIV 76 PASER 10
PEDIARIX (PF) 92 PEDVAX HIB (PF) 93 peg 3350-electrolytes 84 peg3350-sod sul-nacl-kcl-asb-c
84 PEGASYS 88 89 peg-electrolyte soln 84 peg-prep 84 PEMAZYRE 20 PEN NEEDLE DIABETIC 72 penicillamine 97 penicillin g procaine 11 penicillin v potassium 11 PENTACEL (PF) 93 PENTACEL ACTHIB
COMPONENT (PF) 93 PENTAM 10 pentamidine 10 pentazocine-naloxone 36 pentoxifylline 54 PERFOROMIST 119 perindopril erbumine 48 periogard 69 PERJETA 20 permethrin 66 perphenazine 42 perphenazine-amitriptyline 42 phenazopyridine 122 phenelzine 42 phenobarb-hyoscy-atropine-
scop 81 phenobarbital 25 26 phenohytro 81 phenoxybenzamine 48 phenylephrine hcl 114 phenytoin 26 phenytoin sodium extended 26 PHEXXI 101 philith 107 phosphasal 122 PHYSIOLYTE 66 PHYSIOSOL IRRIGATION 66 phytonadione (vitamin k1) 54 PICATO 59 pilocarpine hcl 67 69 110 pimecrolimus 59 pimozide 42 pimtrea (28) 107 pindolol 48 pioglitazone 78 pioglitazone-glimepiride 78
pioglitazone-metformin 78 piperacillin-tazobactam 11 PIQRAY 21 pirmella 107 piroxicam 36 PLASMA-LYTE 148 123 PLASMA-LYTE A 123 PLEGRIDY 89 PLENVU 84 PNEUMOVAX-23 93 podofilox 59 POLIVY 21 polycin 110 polymyxin b sulfate 10 polymyxin b sulf-trimethoprim
110 POMALYST 89 PONVORY 89 PONVORY 14-DAY
STARTER PACK 89 portia 28 107 PORTRAZZA 21 posaconazole 1 potassium chloride 123 potassium citrate 122 POTELIGEO 21 pramipexole 27 prasugrel 54 pravastatin 56 praziquantel 10 prazosin 48 PRED MILD 113 prednicarbate 65 prednisolone 70 prednisolone acetate 113 prednisolone sodium phosphate
70 114 prednisone 70 prednisone intensol 70 pregabalin 26 PREMARIN 100 PREMPHASE 100 PREMPRO 100 prevalite 56 previfem 107 PREVNAR 13 (PF) 93 PREVYMIS 4 PREZCOBIX 4 PREZISTA 4 PRIFTIN 10 primaquine 10
137
primidone 26 PRIMSOL 13 PRIVIGEN 93 probenecid 95 probenecid-colchicine 95 procainamide 44 procentra 42 prochlorperazine 84 prochlorperazine edisylate 84 prochlorperazine maleate 84 PROCRIT 87 procto-med hc 84 procto-pak 84 proctosol hc 84 proctozone-hc 84 PROFILNINE 54 progesterone 100 progesterone micronized 100 PROGRAF 21 PROLASTIN-C 67 PROLEUKIN 90 PROLIA 95 PROMACTA 54 promethazine 115 promethazine-codeine 116 promethazine-dm 116 promethazine-phenyleph-
codeine 116 promethazine-phenylephrine
116 promethegan 115 propafenone 44 45 proparacaine 111 propranolol 48 49 propranolol-hydrochlorothiazid
49 propylthiouracil 71 PROQUAD (PF) 93 protriptyline 42 PROVENGE 93 prudoxin 59 pulmosal 119 PULMOZYME 119 pyrazinamide 10 pyridostigmine bromide 30 pyrimethamine 10 Q QBRELIS 49 QINLOCK 21 QTERN 78 QUADRACEL (PF) 93
quetiapine 42 QUILLICHEW ER 42 QUILLIVANT XR 42 quinapril 49 quinapril-hydrochlorothiazide
49 quinidine gluconate 45 quinidine sulfate 45 quinine sulfate 10 quit 2 68 quit 4 68 QVAR REDIHALER 119 R RABAVERT (PF) 93 rabeprazole 86 RADICAVA 29 RAGWITEK 93 raloxifene 95 ramelteon 42 ramipril 49 ranolazine 57 RAPIVAB (PF) 4 rasagiline 27 RAVICTI 67 REBIF (WITH ALBUMIN) 89 REBIF REBIDOSE 89 REBIF TITRATION PACK 89 REBINYN 54 RECLAST 67 reclipsen (28) 107 RECOMBINATE 54 RECOMBIVAX HB (PF) 93 RECTIV 84 REGRANEX 59 RELENZA DISKHALER 4 RELEXXII 42 RELION NOVOLIN 7030 74 RELION NOVOLIN N 74 RELION NOVOLIN R 74 RELISTOR 84 REMICADE 84 RENACIDIN 122 RENFLEXIS 84 repaglinide 78 repaglinide-metformin 78 REPATHA PUSHTRONEX 56 REPATHA SURECLICK 56 REPATHA SYRINGE 56 RESTASIS 111 RETEVMO 21 RETISERT 114
REVATIO 119 REVLIMID 89 REXULTI 43 REYATAZ 4 RHOPRESSA 112 RIASTAP 54 ribavirin 4 89 RIDAURA 97 rifabutin 10 rifampin 10 riluzole 67 rimantadine 4 RINVOQ 97 RIOMET ER 78 risedronate 67 95 RISPERDAL CONSTA 43 risperidone 43 ritonavir 4 RITUXAN 21 RITUXAN HYCELA 21 rivastigmine 30 rivastigmine tartrate 29 rivelsa 107 RIXUBIS 54 rizatriptan 28 ropinirole 27 28 rosadan 61 rosuvastatin 56 roweepra 26 RUBRACA 21 RUCONEST 119 rufinamide 26 RYBELSUS 79 RYDAPT 21 S salsalate 36 SAMSCA 76 SANTYL 65 sapropterin 76 SARCLISA 21 SAVELLA 97 scalacort 65 SCENESSE 59 scopolamine base 84 seconal sodium 43 SEEBRI NEOHALER 119 selegiline hcl 28 selenium sulfide 58 SELZENTRY 5 SEREVENT DISKUS 119 SEROSTIM 87
138
sertraline 43 setlakin 107 sevelamer carbonate 84 sevelamer hcl 84 sf 69 sf 5000 plus 69 sharobel 101 SHINGRIX (PF) 93 SIGNIFOR 21 sildenafil (pulmhypertension)
119 SILIQ 58 silodosin 121 silver sulfadiazine 59 SIMBRINZA 112 simliya (28) 107 simpesse 107 SIMPONI 97 SIMPONI ARIA 97 SIMULECT 21 simvastatin 56 SINUVA 119 sirolimus 21 SIRTURO 10 SIVEXTRO 10 SKYLA 98 SKYRIZI 58 SLYND 107 sodium chloride 119 sodium chloride 045 123 sodium chloride 09 67 sodium fluoride 5000 dry
mouth 69 sodium fluoride 5000 plus 69 sodium fluoride-pot nitrate 69 sodium phenylbutyrate 67 sodium polystyrene sulfonate
85 solifenacin 121 SOLIQUA 10033 74 SOLIRIS 67 SOLTAMOX 21 SOMATULINE DEPOT 21 SOMAVERT 76 sorine 45 sotalol 45 sotalol af 45 SOVALDI 5 spinosad 66 SPIRIVA RESPIMAT 119
SPIRIVA WITH HANDIHALER 119
spironolactone 49 spironolacton-hydrochlorothiaz
49 SPRAVATO 43 sprintec (28) 107 SPRYCEL 21 sps (with sorbitol) 85 sronyx 107 ssd 59 SSKI 71 st joseph aspirin 36 st joseph aspirin 36 STAMARIL (PF) 93 stavudine 5 STELARA 58 STIOLTO RESPIMAT 119 STIVARGA 21 stop smoking aid 68 STRENSIQ 76 STREPTOMYCIN 10 STRIBILD 5 STRIVERDI RESPIMAT 120 SUBLOCADE 33 subvenite 26 subvenite starter (blue) kit 26 subvenite starter (green) kit 26 subvenite starter (orange) kit 26 SUCRAID 85 sucralfate 86 sulfacetamide sodium 58 114 sulfacetamide sodium (acne) 62 sulfacetamide-prednisolone 114 sulfadiazine 12 sulfamethoxazole-trimethoprim
12 SULFAMYLON 62 sulfasalazine 85 sulfatrim 12 sulindac 36 sumatriptan 28 sumatriptan succinate 28 29 SUNOSI 43 SUPPRELIN LA 21 SUPRAX 7 SUPREP BOWEL PREP KIT
85 SUTENT 22 syeda 107 SYLVANT 22
symax fastabs 81 symax-sl 81 symax-sr 81 SYMBICORT 120 SYMDEKO 120 SYMLINPEN 120 79 SYMLINPEN 60 79 SYMPAZAN 26 SYNAGIS 5 SYNAREL 76 SYNERA 61 SYNJARDY 79 SYNJARDY XR 79 SYNRIBO 22 SYNTHROID 79 T TABLOID 22 tacrolimus 22 59 tadalafil 121 tadalafil (pulm hypertension)
120 TAFINLAR 22 TAGRISSO 22 TAKHZYRO 120 TALTZ AUTOINJECTOR 58 TALTZ AUTOINJECTOR (2
PACK) 58 TALTZ AUTOINJECTOR (3
PACK) 58 TALTZ SYRINGE 58 TALZENNA 22 tamoxifen 22 tamsulosin 121 TARGRETIN 22 tarina 24 fe 107 tarina fe 120 (28) 107 TASIGNA 22 tavaborole 63 tazarotene 61 tazicef 7 taztia xt 49 TDVAX 93 TECENTRIQ 22 TEFLARO 7 TEKTURNA HCT 49 telmisartan 49 telmisartan-amlodipine 49 telmisartan-hydrochlorothiazid
49 temazepam 43 TEMODAR 22
139
temozolomide 22 temsirolimus 22 tencon 33 TENIVAC (PF) 94 tenofovir disoproxil fumarate 5 TEPEZZA 76 terazosin 49 terbinafine hcl 1 terbutaline 120 terconazole 101 testosterone 77 testosterone cypionate 76 testosterone enanthate 76 TETANUSDIPHTHERIA
TOX PED(PF) 94 tetrabenazine 30 tetracaine hcl 111 TETRACAINE HCL (PF) 111 tetracycline 12 THALOMID 22 theophylline 120 thioridazine 43 thiothixene 43 THYMOGLOBULIN 94 THYROLAR-1 79 THYROLAR-12 79 THYROLAR-14 79 THYROLAR-2 79 THYROLAR-3 79 tiadylt er 49 tiagabine 26 TIBSOVO 22 tilia fe 107 timolol maleate 49 110 tinidazole 10 TIVICAY 5 TIVICAY PD 5 tizanidine 30 TOBRADEX 113 TOBRADEX ST 113 tobramycin 10 110 tobramycin in 0225 nacl 10 tobramycin sulfate 10 TOBRAMYCIN WITH
NEBULIZER 10 tobramycin-dexamethasone 113 TOBREX 110 TODAY CONTRACEPTIVE
SPONGE 101 tolcapone 28 tolmetin 36
tolterodine 121 topiramate 26 toremifene 22 TORISEL 22 torsemide 49 TOUJEO MAX U-300
SOLOSTAR 74 TOUJEO SOLOSTAR U-300
INSULIN 74 TRACLEER 120 TRADJENTA 79 tramadol 36 tramadol-acetaminophen 36 trandolapril 49 trandolapril-verapamil 49 tranexamic acid 54 101 tranylcypromine 43 travoprost 112 trazodone 43 TREANDA 22 TRECATOR 10 TRELEGY ELLIPTA 120 TRELSTAR 22 TREMFYA 59 TRESIBA FLEXTOUCH U-
100 74 TRESIBA FLEXTOUCH U-
200 74 TRESIBA U-100 INSULIN 74 tretinoin 61 tretinoin (antineoplastic) 22 tretinoin microspheres 61 TRETTEN 54 TREXALL 22 tri femynor 107 triamcinolone acetonide 65 69
71 triamterene 49 triamterene-hydrochlorothiazid
49 triazolam 43 triderm 65 trientine 67 tri-estarylla 107 trifluoperazine 43 trifluridine 110 trihexyphenidyl 28 TRIJARDY XR 71 TRIKAFTA 120 tri-legest fe 108 tri-linyah 108
tri-lo-estarylla 108 tri-lo-marzia 108 tri-lo-mili 108 tri-lo-sprintec 108 trilyte with flavor packets 85 trimethobenzamide 85 trimethoprim 13 tri-mili 108 trimipramine 43 TRINTELLIX 43 tri-nymyo 108 tri-previfem (28) 108 tri-sprintec (28) 108 TRIUMEQ 5 tri-vitamin with fluoride 124 trivora (28) 108 tri-vylibra 108 tri-vylibra lo 108 TROGARZO 5 tropicamide 110 trospium 121 TRULICITY 79 TRUMENBA 94 TRUXIMA 22 TUKYSA 23 tulana 101 TWINRIX (PF) 94 TWIRLA 101 TYBLUME 108 TYBOST 5 tydemy 108 TYGACIL 10 TYMLOS 95 TYPHIM VI 94 TYSABRI 30 TYVASO 120 TYVASO REFILL KIT 120 TYVASO STARTER KIT 120 U UBRELVY 29 UDENYCA 87 ULESFIA 66 unithroid 80 UNITUXIN 23 URELLE 122 uretron d-s 122 urimar-t 122 urogesic-blue 122 ursodiol 85 uryl 122 ustell 122
140
UTIBRON NEOHALER 120 utira-c 122 UVADEX 59 V vaginal contraceptive foam 101 valacyclovir 5 VALCHLOR 59 valganciclovir 5 valproic acid 26 valproic acid (as sodium salt)
26 valsartan 49 valsartan-hydrochlorothiazide
49 vanadom 30 vancomycin 13 vandazole 101 VANTAS 23 VAQTA (PF) 94 VARIVAX (PF) 94 VARUBI 85 VASCEPA 56 VAXELIS (PF) 94 VCF CONTRACEPTIVE
FILM 101 VCF CONTRACEPTIVE GEL
101 VECTIBIX 23 VELCADE 23 veletri 50 velivet triphasic regimen (28)
108 VELPHORO 85 VEMLIDY 5 VENCLEXTA 23 VENCLEXTA STARTING
PACK 23 venlafaxine 43 VENTAVIS 120 verapamil 50 VERSACLOZ 43 VERZENIO 23 vestura (28) 108 VIBATIV 13 VIBERZI 85 VIDAZA 23 VIEKIRA PAK 5 vienva 108 vigabatrin 26 vigadrone 26 VIMIZIM 77
VIMPAT 26 viorele (28) 108 VIRACEPT 5 VIREAD 5 virtussin ac 116 VISTOGARD 13 VISUDYNE 111 vitamins acd and fluoride 124 VITRAKVI 23 VIVITROL 36 volnea (28) 108 VONVENDI 54 VORAXAZE 13 voriconazole 1 2 VOSEVI 5 VOTRIENT 23 VPRIV 77 VRAYLAR 44 VYEPTI 29 vyfemla (28) 108 vylibra 108 VYONDYS-53 30 VYVANSE 44 VYXEOS 23 W warfarin 54 wera (28) 108 westhroid 80 WIDE-SEAL DIAPHRAGM
98 WILATE 54 wixela inhub 121 wymzya fe 108 X XALKORI 23 XARELTO 54 XARELTO DVT-PE TREAT
30D START 54 XCOPRI 27 XCOPRI MAINTENANCE
PACK 27 XCOPRI TITRATION PACK
27 XELJANZ 97 XELJANZ XR 97 XEMBIFY 94 XENLETA 10 XEOMIN 94 XERMELO 23 XGEVA 13 XIFAXAN 10
XIGDUO XR 79 XIIDRA 111 XOLAIR 121 XOSPATA 23 XTANDI 23 xulane 102 XULTOPHY 10036 74 XURIDEN 67 XYNTHA 55 XYNTHA SOLOFUSE 55 XYREM 44 Y YERVOY 23 YESCARTA 23 YF-VAX (PF) 94 YONDELIS 23 YONSA 23 YUTIQ 114 yuvafem 101 Z zafemy 102 zafirlukast 121 zaleplon 44 ZALTRAP 23 ZANOSAR 23 zarah 109 ZARXIO 87 ZEJULA 24 ZELBORAF 24 ZEMAIRA 68 zenatane 61 ZENPEP 85 ZENZEDI 44 ZEPATIER 5 ZEPOSIA 89 ZEPOSIA STARTER KIT 89 ZEPOSIA STARTER PACK
89 ZERBAXA 7 zidovudine 5 ZIEXTENZO 87 zileuton 121 ziprasidone hcl 44 ZIRGAN 110 ZOKINVY 68 ZOLADEX 24 ZOLGENSMA 30 ZOLINZA 24 zolmitriptan 29 zolpidem 44 ZOLPIMIST 44
141
ZOMIG 29 zonisamide 27 ZONTIVITY 55 ZORBTIVE 87
ZOSTAVAX (PF) 94 zovia 135e (28) 109 ZULRESSO 44 zumandimine (28) 109
ZYFLO 121 ZYKADIA 24 ZYPITAMAG 56
051267 (11-20-2019)
Discrimination is Against the Law
LifeWise Health Plan of Washington (LifeWise) complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex LifeWise does not exclude people or treat them differently because of race color national origin age disability sex gender identity or sexual orientation LifeWise provides free aids and services to people with disabilities to communicate effectively with us such as qualified sign language interpreters and written information in other formats (large print audio accessible electronic formats other formats) LifeWise provides free language services to people whose primary language is not English such as qualified interpreters and information written in other languages If you need these services contact the Civil Rights Coordinator If you believe that LifeWise 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 Civil Rights Coordinator Complaints and Appeals PO Box 91102 Seattle WA 98111 Toll free 855-332-6396 Fax 425-918-5592 TTY 711 Email AppealsDepartmentInquiriesLifeWiseHealthcom You can file a grievance in person or by mail fax or email If you need help filing a grievance the Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Ave SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
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)711 والبكم الصم ھاتف رقم( 800-178-3056 برقم اتصل بالمجان لك تتوافر اللغویة المساعدة خدمات فإن اللغة اذكر تتحدث كنت إذا ملحوظةਿਧਆਨ ਿਦਓ ਜ ਤਸ ਪਜਾਬੀ ਬਲਦ ਹ ਤ ਭਾਸ਼ਾ ਿਵਚ ਸਹਾਇਤਾ ਸਵਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਧ ਹ 800-817-3056
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ແມນມພອມໃຫທານ ໂທຣ 800-817-3056 (TTY 711) ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele 800-817-3056 (TTY 711) ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 800-817-3056 (ATS 711) UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń pod numer 800-817-3056 (TTY 711) ATENCcedilAtildeO Se fala portuguecircs encontram-se disponiacuteveis serviccedilos linguiacutesticos graacutetis Ligue para 800-817-3056 (TTY 711) ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza linguistica gratuiti Chiamare il numero
800-817-3056 (TTY 711) دیریبگ تماس 3056-817-800 (TTY 711) با باشد یم فراھم شما یبرا گانیرا بصورت یزبان لاتیتسھ دیکن یم گفتگو فارسی زبان بھ اگر توجھ
1
Drug Name Drug Tier Requirements Limits
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG
MB
amphotericin b injection recon soln 50 mg MB
CANCIDAS INTRAVENOUS RECON SOLN 50 MG 70 MG
MB
clotrimazole mucous membrane troche 10 mg 1
CRESEMBA INTRAVENOUS RECON SOLN 372 MG
MB
CRESEMBA ORAL CAPSULE 186 MG 1 PA
ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG 50 MG
MB
fluconazole oral suspension for reconstitution 10 mgml 40 mgml
1
fluconazole oral tablet 100 mg 150 mg 200 mg 50 mg
1
flucytosine oral capsule 250 mg 500 mg 1
griseofulvin microsize oral suspension 125 mg5 ml
1
griseofulvin microsize oral tablet 500 mg 1
griseofulvin ultramicrosize oral tablet 125 mg 250 mg
1
itraconazole oral capsule 100 mg 1
itraconazole oral solution 10 mgml 1
ketoconazole oral tablet 200 mg 1
MYCAMINE INTRAVENOUS RECON SOLN 100 MG 50 MG
MB
NOXAFIL ORAL SUSPENSION 200 MG5 ML (40 MGML)
1
nystatin oral suspension 100000 unitml 1
nystatin oral tablet 500000 unit 1
ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET 50 MG
1
posaconazole oral tabletdelayed release (drec) 100 mg
1
terbinafine hcl oral tablet 250 mg 1
voriconazole intravenous recon soln 200 mg MB
2
Drug Name Drug Tier Requirements Limits
voriconazole oral suspension for reconstitution 200 mg5 ml (40 mgml)
1
voriconazole oral tablet 200 mg 50 mg 1
ANTIVIRALS
abacavir oral solution 20 mgml 1 QL (60 per 30 days)
abacavir oral tablet 300 mg 1 QL (60 per 30 days)
abacavir-lamivudine oral tablet 600-300 mg 1 QL (30 per 30 days)
abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg
1 QL (60 per 30 days)
acyclovir oral capsule 200 mg 1
acyclovir oral suspension 200 mg5 ml 1
acyclovir oral tablet 400 mg 800 mg 1
adefovir oral tablet 10 mg 1
amantadine hcl oral capsule 100 mg 1
amantadine hcl oral solution 50 mg5 ml 1
amantadine hcl oral tablet 100 mg 1
APTIVUS ORAL CAPSULE 250 MG 1 QL (120 per 30 days)
atazanavir oral capsule 150 mg 300 mg 1 QL (30 per 30 days)
atazanavir oral capsule 200 mg 1 QL (60 per 30 days)
BARACLUDE ORAL SOLUTION 005 MGML 1
BIKTARVY ORAL TABLET 50-200-25 MG 1 QL (30 per 30 days)
CABENUVA INTRAMUSCULAR SUSPENSIONEXTENDED RELEASE 400 MG2 ML- 600 MG2 ML 600 MG3 ML- 900 MG3 ML
2 PA
cidofovir intravenous solution 75 mgml MB
CIMDUO ORAL TABLET 300-300 MG 1 QL (30 per 30 days)
COMPLERA ORAL TABLET 200-25-300 MG 1 QL (30 per 30 days)
CYTOVENE INTRAVENOUS RECON SOLN 500 MG
MB
DESCOVY ORAL TABLET 200-25 MG 1 QL (30 per 30 days)
didanosine oral capsuledelayed release(drec) 250 mg 400 mg
1 QL (30 per 30 days)
DOVATO ORAL TABLET 50-300 MG 1 QL (30 per 30 days)
EDURANT ORAL TABLET 25 MG 1 QL (30 per 30 days)
efavirenz oral capsule 200 mg 50 mg 1 QL (30 per 30 days)
efavirenz oral tablet 600 mg 1 QL (30 per 30 days)
3
Drug Name Drug Tier Requirements Limits
efavirenz-emtricitabin-tenofov oral tablet 600-200-300 mg
1
efavirenz-lamivu-tenofov disop oral tablet 400-300-300 mg 600-300-300 mg
1
emtricitabine oral capsule 200 mg 1 QL (30 per 30 days)
emtricitabine-tenofovir (tdf) oral tablet 100-150 mg 133-200 mg 167-250 mg 200-300 mg
1
EMTRIVA ORAL SOLUTION 10 MGML 1 QL (720 per 30 days)
entecavir oral tablet 05 mg 1 mg 1
EPCLUSA ORAL TABLET 200-50 MG 400-100 MG
2 PA LA
EPIVIR HBV ORAL SOLUTION 25 MG5 ML (5 MGML)
1
etravirine oral tablet 100 mg 200 mg 1 QL (60 per 30 days)
EVOTAZ ORAL TABLET 300-150 MG 1 QL (30 per 30 days)
famciclovir oral tablet 125 mg 250 mg 500 mg 1
fosamprenavir oral tablet 700 mg 1 QL (60 per 30 days)
FUZEON SUBCUTANEOUS RECON SOLN 90 MG
2 QL (30 per 30 days)
GANCICLOVIR INTRAVENOUS SOLUTION 500 MG250 ML (2 MGML)
MB
ganciclovir sodium intravenous recon soln 500 mg MB
GENVOYA ORAL TABLET 150-150-200-10 MG
1 QL (30 per 30 days)
HARVONI ORAL PELLETS IN PACKET 3375-150 MG 45-200 MG
2 LA
HARVONI ORAL TABLET 45-200 MG 90-400 MG
2 PA LA
INTELENCE ORAL TABLET 100 MG 200 MG 25 MG
1 QL (60 per 30 days)
INVIRASE ORAL TABLET 500 MG 1 QL (120 per 30 days)
ISENTRESS HD ORAL TABLET 600 MG 1 QL (60 per 30 days)
ISENTRESS ORAL POWDER IN PACKET 100 MG
1 QL (60 per 30 days)
ISENTRESS ORAL TABLET 400 MG 1 QL (60 per 30 days)
ISENTRESS ORAL TABLETCHEWABLE 100 MG 25 MG
1 QL (60 per 30 days)
JULUCA ORAL TABLET 50-25 MG 1 QL (30 per 30 days)
KALETRA ORAL TABLET 100-25 MG 1 QL (60 per 30 days)
4
Drug Name Drug Tier Requirements Limits
KALETRA ORAL TABLET 200-50 MG 1 QL (120 per 30 days)
lamivudine oral solution 10 mgml 1 QL (900 per 30 days)
lamivudine oral tablet 100 mg 1
lamivudine oral tablet 150 mg 300 mg 1 QL (60 per 30 days)
lamivudine-zidovudine oral tablet 150-300 mg 1 QL (60 per 30 days)
LEXIVA ORAL SUSPENSION 50 MGML 1 QL (60 per 30 days)
lopinavir-ritonavir oral solution 400-100 mg5 ml 1 QL (320 per 30 days)
lopinavir-ritonavir oral tablet 100-25 mg 200-50 mg
1 QL (120 per 30 days)
MAVYRET ORAL TABLET 100-40 MG 2 PA LA
nevirapine oral suspension 50 mg5 ml 1 QL (60 per 30 days)
nevirapine oral tablet 200 mg 1 QL (60 per 30 days)
nevirapine oral tablet extended release 24 hr 100 mg 400 mg
1 QL (30 per 30 days)
NORVIR ORAL POWDER IN PACKET 100 MG 1 QL (360 per 30 days)
NORVIR ORAL SOLUTION 80 MGML 1 QL (480 per 30 days)
ODEFSEY ORAL TABLET 200-25-25 MG 1 QL (30 per 30 days)
oseltamivir oral capsule 30 mg 1 QL (40 per 365 days)
oseltamivir oral capsule 45 mg 75 mg 1 QL (20 per 365 days)
oseltamivir oral suspension for reconstitution 6 mgml
1 QL (180 per 30 days)
PREVYMIS INTRAVENOUS SOLUTION 240 MG12 ML 480 MG24 ML
MB PA
PREZCOBIX ORAL TABLET 800-150 MG-MG 1 QL (30 per 30 days)
PREZISTA ORAL SUSPENSION 100 MGML 1 QL (30 per 30 days)
PREZISTA ORAL TABLET 150 MG 600 MG 75 MG
1 QL (60 per 30 days)
PREZISTA ORAL TABLET 800 MG 1 QL (30 per 30 days)
RAPIVAB (PF) INTRAVENOUS SOLUTION 200 MG20 ML (10 MGML)
MB
RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MGACTUATION
1 QL (2 per 30 days)
REYATAZ ORAL POWDER IN PACKET 50 MG
1 QL (150 per 30 days)
ribavirin inhalation recon soln 6 gram MB
rimantadine oral tablet 100 mg 1
ritonavir oral tablet 100 mg 1 QL (360 per 30 days)
5
Drug Name Drug Tier Requirements Limits
SELZENTRY ORAL SOLUTION 20 MGML 1 QL (8 per 30 days)
SELZENTRY ORAL TABLET 150 MG 25 MG 300 MG 75 MG
1 QL (60 per 30 days)
SOVALDI ORAL PELLETS IN PACKET 150 MG 200 MG
2 LA
SOVALDI ORAL TABLET 200 MG 400 MG 2 PA LA
stavudine oral capsule 15 mg 20 mg 40 mg 1 QL (120 per 30 days)
STRIBILD ORAL TABLET 150-150-200-300 MG
1 QL (30 per 30 days)
SYNAGIS INTRAMUSCULAR SOLUTION 100 MGML 50 MG05 ML
MB LA
tenofovir disoproxil fumarate oral tablet 300 mg 1 QL (30 per 30 days)
TIVICAY ORAL TABLET 10 MG 25 MG 50 MG
1 QL (60 per 30 days)
TIVICAY PD ORAL TABLET FOR SUSPENSION 5 MG
1 QL (60 per 30 days)
TRIUMEQ ORAL TABLET 600-50-300 MG 1 QL (30 per 30 days)
TROGARZO INTRAVENOUS SOLUTION 200 MG133 ML (150 MGML)
MB PA
TYBOST ORAL TABLET 150 MG 1 QL (30 per 30 days)
valacyclovir oral tablet 1 gram 500 mg 1
valganciclovir oral recon soln 50 mgml 1
valganciclovir oral tablet 450 mg 1
VEMLIDY ORAL TABLET 25 MG 1
VIEKIRA PAK ORAL TABLETSDOSE PACK 125 MG-75 MG -50 MG250 MG
2 PA
VIRACEPT ORAL TABLET 250 MG 1 QL (90 per 30 days)
VIRACEPT ORAL TABLET 625 MG 1 QL (60 per 30 days)
VIREAD ORAL POWDER 40 MGSCOOP (40 MGGRAM)
1 QL (4 per 30 days)
VIREAD ORAL TABLET 150 MG 200 MG 250 MG
1 QL (30 per 30 days)
VOSEVI ORAL TABLET 400-100-100 MG 2 PA LA
ZEPATIER ORAL TABLET 50-100 MG 2 PA LA
zidovudine oral capsule 100 mg 1 QL (60 per 30 days)
zidovudine oral syrup 10 mgml 1 QL (960 per 30 days)
zidovudine oral tablet 300 mg 1 QL (60 per 30 days)
CEPHALOSPORINS
6
Drug Name Drug Tier Requirements Limits
AVYCAZ INTRAVENOUS RECON SOLN 25 GRAM
MB
cefaclor oral capsule 250 mg 500 mg 1
cefaclor oral suspension for reconstitution 125 mg5 ml 250 mg5 ml 375 mg5 ml
1
cefaclor oral tablet extended release 12 hr 500 mg 1
cefadroxil oral capsule 500 mg 1
cefadroxil oral suspension for reconstitution 250 mg5 ml 500 mg5 ml
1
cefadroxil oral tablet 1 gram 1
cefazolin in dextrose (iso-os) intravenous piggyback 1 gram50 ml
MB
cefazolin injection recon soln 1 gram 10 gram 100 gram 20 gram 300 g 500 mg
MB
cefazolin intravenous recon soln 1 gram MB
cefdinir oral capsule 300 mg 1
cefdinir oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cefditoren pivoxil oral tablet 200 mg 400 mg 1
CEFEPIME IN DEXTROSE 5 INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
cefepime in dextroseiso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml
MB
cefepime injection recon soln 1 gram 2 gram MB
cefixime oral capsule 400 mg 1
cefixime oral suspension for reconstitution 100 mg5 ml 200 mg5 ml
1
CEFOTAN INJECTION RECON SOLN 1 GRAM 2 GRAM
MB
cefotaxime injection recon soln 1 gram MB
CEFOTETAN IN DEXTROSE ISO-OSM INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
cefotetan injection recon soln 1 gram 2 gram MB
cefotetan intravenous recon soln 10 gram MB
cefoxitin intravenous recon soln 10 gram MB
cefpodoxime oral suspension for reconstitution 100 mg5 ml 50 mg5 ml
1
7
Drug Name Drug Tier Requirements Limits
cefpodoxime oral tablet 100 mg 200 mg 1
cefprozil oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cefprozil oral tablet 250 mg 500 mg 1
CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
ceftazidime injection recon soln 1 gram 2 gram 6 gram
MB
ceftriaxone in dextroseiso-os intravenous piggyback 1 gram50 ml 2 gram50 ml
MB
ceftriaxone injection recon soln 1 gram 10 gram 2 gram 250 mg 500 mg
MB
CEFTRIAXONE INJECTION RECON SOLN 100 GRAM
MB
ceftriaxone intravenous recon soln 1 gram 2 gram MB
cefuroxime axetil oral tablet 250 mg 500 mg 1
cephalexin oral capsule 250 mg 500 mg 750 mg 1
cephalexin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cephalexin oral tablet 250 mg 500 mg 1
SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG5 ML
1
SUPRAX ORAL TABLETCHEWABLE 100 MG 200 MG
1
tazicef injection recon soln 1 gram 2 gram 6 gram
MB
tazicef intravenous recon soln 1 gram 2 gram MB
TEFLARO INTRAVENOUS RECON SOLN 400 MG 600 MG
MB
ZERBAXA INTRAVENOUS RECON SOLN 15 GRAM
MB
ERYTHROMYCINS amp OTHER MACROLIDES
azithromycin oral packet 1 gram 1
azithromycin oral suspension for reconstitution 100 mg5 ml 200 mg5 ml
1
azithromycin oral tablet 250 mg 500 mg 600 mg 1
clarithromycin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
clarithromycin oral tablet 250 mg 500 mg 1
8
Drug Name Drug Tier Requirements Limits
clarithromycin oral tablet extended release 24 hr 500 mg
1
DIFICID ORAL TABLET 200 MG 1
ees 400 oral tablet 400 mg 1
ery-tab oral tabletdelayed release (drec) 250 mg 333 mg
1
erythrocin (as stearate) oral tablet 250 mg 1
erythromycin ethylsuccinate oral suspension for reconstitution 200 mg5 ml 400 mg5 ml
1
erythromycin ethylsuccinate oral tablet 400 mg 1
erythromycin oral capsuledelayed release(drec) 250 mg
1
erythromycin oral tablet 250 mg 500 mg 1
erythromycin oral tabletdelayed release (drec) 250 mg 333 mg 500 mg
1
MISCELLANEOUS ANTIINFECTIVES
albendazole oral tablet 200 mg 1
ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG5 ML
1 PA ST
amikacin injection solution 500 mg2 ml MB
atovaquone oral suspension 750 mg5 ml 1
atovaquone-proguanil oral tablet 250-100 mg 625-25 mg
1
bacitracin intramuscular recon soln 50000 unit 1
CAPASTAT INJECTION RECON SOLN 1 GRAM
1
CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MGML
2 PA LA QL (84 per 30 days)
chloramphenicol sod succinate intravenous recon soln 1 gram
MB
chloroquine phosphate oral tablet 250 mg 500 mg 1
clindamycin hcl oral capsule 150 mg 300 mg 75 mg
1
clindamycin pediatric oral recon soln 75 mg5 ml 1
clindamycin phosphate injection solution 150 mgml
MB
COARTEM ORAL TABLET 20-120 MG 1
CUBICIN INTRAVENOUS RECON SOLN 500 MG
MB
9
Drug Name Drug Tier Requirements Limits
CUBICIN RF INTRAVENOUS RECON SOLN 500 MG
MB
CYCLOSERINE ORAL CAPSULE 250 MG 1
dapsone oral tablet 100 mg 25 mg 1
EMVERM ORAL TABLETCHEWABLE 100 MG
1
ethambutol oral tablet 100 mg 400 mg 1
gentamicin injection solution 20 mg2 ml 40 mgml
MB
gentamicin sulfate (ped) (pf) injection solution 20 mg2 ml
MB
hydroxychloroquine oral tablet 200 mg 1
imipenem-cilastatin intravenous recon soln 250 mg 500 mg
MB
INVANZ INJECTION RECON SOLN 1 GRAM MB
isoniazid injection solution 100 mgml 1
isoniazid oral solution 50 mg5 ml 1
isoniazid oral tablet 100 mg 300 mg 1
ivermectin oral tablet 3 mg 1
LINCOCIN INJECTION SOLUTION 300 MGML
MB
linezolid in dextrose 5 intravenous piggyback 600 mg300 ml
MB
linezolid oral suspension for reconstitution 100 mg5 ml
1
linezolid oral tablet 600 mg 1
linezolid-09 sodium chloride intravenous parenteral solution 600 mg300 ml
MB
mefloquine oral tablet 250 mg 1
meropenem intravenous recon soln 1 gram 500 mg
MB
MEROPENEM-09 SODIUM CHLORIDE INTRAVENOUS PIGGYBACK 1 GRAM50 ML 500 MG50 ML
MB
metronidazole oral capsule 375 mg 1
metronidazole oral tablet 250 mg 500 mg 1
neomycin oral tablet 500 mg 1
nitazoxanide oral tablet 500 mg 1
10
Drug Name Drug Tier Requirements Limits
paromomycin oral capsule 250 mg 1
PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM
1
PENTAM INJECTION RECON SOLN 300 MG MB
pentamidine inhalation recon soln 300 mg 1
pentamidine injection recon soln 300 mg MB
polymyxin b sulfate injection recon soln 500000 unit
MB
praziquantel oral tablet 600 mg 1
PRIFTIN ORAL TABLET 150 MG 1
primaquine oral tablet 263 mg 1
pyrazinamide oral tablet 500 mg 1
pyrimethamine oral tablet 25 mg 2 PA
quinine sulfate oral capsule 324 mg 1
rifabutin oral capsule 150 mg 1
rifampin oral capsule 150 mg 300 mg 1
SIRTURO ORAL TABLET 100 MG 1 PA
SIRTURO ORAL TABLET 20 MG 1
SIVEXTRO ORAL TABLET 200 MG 1 QL (6 per 30 days)
STREPTOMYCIN INTRAMUSCULAR RECON SOLN 1 GRAM
1
tinidazole oral tablet 250 mg 500 mg 1
tobramycin in 0225 nacl inhalation solution for nebulization 300 mg5 ml
2
tobramycin inhalation solution for nebulization 300 mg4 ml
2
tobramycin sulfate injection recon soln 12 gram 1
tobramycin sulfate injection solution 10 mgml MB
tobramycin sulfate injection solution 40 mgml 1
TOBRAMYCIN WITH NEBULIZER INHALATION SOLUTION FOR NEBULIZATION 300 MG5 ML
2 PA ST
TRECATOR ORAL TABLET 250 MG 1
TYGACIL INTRAVENOUS RECON SOLN 50 MG
MB
XENLETA INTRAVENOUS SOLUTION 150 MG15 ML
MB
XIFAXAN ORAL TABLET 200 MG 550 MG 1 PA QL (60 per 30 days)
11
Drug Name Drug Tier Requirements Limits
PENICILLINS
amoxicillin oral capsule 250 mg 500 mg 1
amoxicillin oral suspension for reconstitution 125 mg5 ml 200 mg5 ml 250 mg5 ml 400 mg5 ml
1
amoxicillin oral tablet 500 mg 875 mg 1
amoxicillin oral tabletchewable 125 mg 250 mg 1
amoxicillin-pot clavulanate oral suspension for reconstitution 200-285 mg5 ml 250-625 mg5 ml 400-57 mg5 ml 600-429 mg5 ml
1
amoxicillin-pot clavulanate oral tablet 250-125 mg 500-125 mg 875-125 mg
1
amoxicillin-pot clavulanate oral tablet extended release 12 hr 1000-625 mg
1
amoxicillin-pot clavulanate oral tabletchewable 200-285 mg 400-57 mg
1
ampicillin oral capsule 500 mg 1
ampicillin-sulbactam injection recon soln 15 gram MB
BICILLIN C-R INTRAMUSCULAR SYRINGE 1200000 UNIT 2 ML(900K300K)
MB
dicloxacillin oral capsule 250 mg 500 mg 1
MOXATAG ORAL TABLET ER MULTIPHASE 24 HR 775 MG
1
nafcillin in dextrose iso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml
MB
nafcillin injection recon soln 1 gram 10 gram 2 gram
MB
nafcillin intravenous recon soln 1 gram 2 gram MB
oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram50 ml 2 gram50 ml
MB
oxacillin injection recon soln 1 gram 10 gram 2 gram
MB
penicillin g procaine intramuscular syringe 12 million unit2 ml 600000 unitml
MB
penicillin v potassium oral recon soln 125 mg5 ml 250 mg5 ml
1
penicillin v potassium oral tablet 250 mg 500 mg 1
piperacillin-tazobactam intravenous recon soln 135 gram 225 gram 3375 gram 45 gram 405 gram
MB
12
Drug Name Drug Tier Requirements Limits
QUINOLONES
BAXDELA INTRAVENOUS RECON SOLN 300 MG
MB
BAXDELA ORAL TABLET 450 MG 1
ciprofloxacin hcl oral tablet 100 mg 250 mg 500 mg 750 mg
1
ciprofloxacin oral suspensionmicrocapsule recon 250 mg5 ml 500 mg5 ml
1
FACTIVE ORAL TABLET 320 MG 1 ST
levofloxacin oral solution 250 mg10 ml 1
levofloxacin oral tablet 250 mg 500 mg 750 mg 1
moxifloxacin oral tablet 400 mg 1
ofloxacin oral tablet 300 mg 400 mg 1
SULFAS amp RELATED AGENTS
sulfadiazine oral tablet 500 mg 1
sulfamethoxazole-trimethoprim oral suspension 200-40 mg5 ml
1
sulfamethoxazole-trimethoprim oral tablet 400-80 mg 800-160 mg
1
sulfatrim oral suspension 200-40 mg5 ml 1
TETRACYCLINES
avidoxy oral tablet 100 mg 1 ST
demeclocycline oral tablet 150 mg 300 mg 1
doxycycline hyclate oral capsule 100 mg 50 mg 1
doxycycline hyclate oral tablet 100 mg 150 mg 20 mg 50 mg 75 mg
1
doxycycline hyclate oral tabletdelayed release (drec) 100 mg 150 mg 200 mg 50 mg 75 mg
1
doxycycline monohydrate oral capsule 100 mg 150 mg 50 mg 75 mg
1
doxycycline monohydrate oral suspension for reconstitution 25 mg5 ml
1
doxycycline monohydrate oral tablet 100 mg 150 mg 50 mg 75 mg
1
minocycline oral capsule 100 mg 50 mg 75 mg 1
minocycline oral tablet 100 mg 50 mg 75 mg 1
mondoxyne nl oral capsule 100 mg 75 mg 1
tetracycline oral capsule 250 mg 500 mg 1
13
Drug Name Drug Tier Requirements Limits
URINARY TRACT AGENTS
fosfomycin tromethamine oral packet 3 gram 1
methenamine hippurate oral tablet 1 gram 1
methenamine mandelate oral tablet 05 g 1 gram 1
nitrofurantoin macrocrystal oral capsule 100 mg 25 mg 50 mg
1
nitrofurantoin monohydm-cryst oral capsule 100 mg
1
nitrofurantoin oral suspension 25 mg5 ml 1
PRIMSOL ORAL SOLUTION 50 MG5 ML 1
trimethoprim oral tablet 100 mg 1
VANCOMYCIN
vancomycin oral capsule 125 mg 250 mg 1
vancomycin oral recon soln 50 mgml 1
VIBATIV INTRAVENOUS RECON SOLN 750 MG
MB
ANTINEOPLASTIC amp IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
KEPIVANCE INTRAVENOUS RECON SOLN 625 MG
MB
leucovorin calcium injection recon soln 100 mg 200 mg 350 mg 50 mg 500 mg
MB
leucovorin calcium injection solution 10 mgml MB
leucovorin calcium oral tablet 10 mg 15 mg 25 mg 5 mg
1
VISTOGARD ORAL GRANULES IN PACKET 10 GRAM
2
VORAXAZE INTRAVENOUS RECON SOLN 1000 UNIT
MB
XGEVA SUBCUTANEOUS SOLUTION 120 MG17 ML (70 MGML)
2 LA
ANTINEOPLASTIC amp IMMUNOSUPPRESSANT DRUGS
abiraterone oral tablet 250 mg 2 PA OCh LA
abiraterone oral tablet 500 mg 2 PA ST OCh LA
ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG
MB PA LA
ADAKVEO INTRAVENOUS SOLUTION 10 MGML
MB PA
14
Drug Name Drug Tier Requirements Limits
ADCETRIS INTRAVENOUS RECON SOLN 50 MG
MB PA LA
AFINITOR ORAL TABLET 10 MG 2 OCh LA
ALECENSA ORAL CAPSULE 150 MG 2 PA OCh LA
ALIMTA INTRAVENOUS RECON SOLN 100 MG 500 MG
MB PA
ALIQOPA INTRAVENOUS RECON SOLN 60 MG
MB PA
anastrozole oral tablet 1 mg ACA PV OCh QL (30 per 30 days)
ARRANON INTRAVENOUS SOLUTION 250 MG50 ML
MB LA
ARZERRA INTRAVENOUS SOLUTION 1000 MG50 ML 100 MG5 ML
MB PA LA
ASPARLAS INTRAVENOUS SOLUTION 750 UNITML
MB PA
AVASTIN INTRAVENOUS SOLUTION 25 MGML
MB PA LA
azathioprine oral tablet 50 mg 1
BALVERSA ORAL TABLET 3 MG 4 MG 5 MG
2 PA OCh
BAVENCIO INTRAVENOUS SOLUTION 20 MGML
MB PA
BELEODAQ INTRAVENOUS RECON SOLN 500 MG
MB PA
BELRAPZO INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BENDAMUSTINE INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BENDEKA INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BESPONSA INTRAVENOUS RECON SOLN 09 MG (025 MGML INITIAL)
MB PA LA
bexarotene oral capsule 75 mg 2 PA ST OCh
bicalutamide oral tablet 50 mg 2 OCh QL (30 per 30 days)
BLINCYTO INTRAVENOUS KIT 35 MCG MB PA
BORTEZOMIB INTRAVENOUS RECON SOLN 35 MG
MB
BOSULIF ORAL TABLET 100 MG 400 MG 500 MG
2 PA ST OCh LA
BRAFTOVI ORAL CAPSULE 50 MG 75 MG 2 PA OCh LA
15
Drug Name Drug Tier Requirements Limits
BUSULFEX INTRAVENOUS SOLUTION 60 MG10 ML
MB
CABOMETYX ORAL TABLET 20 MG 40 MG 60 MG
2 PA ST OCh LA
CALQUENCE ORAL CAPSULE 100 MG 2 PA ST OCh
capecitabine oral tablet 150 mg 2 OCh LA QL (210 per 30 days)
capecitabine oral tablet 500 mg 2 OCh LA QL (84 per 30 days)
CAPRELSA ORAL TABLET 100 MG 300 MG 2 PA OCh
CLOLAR INTRAVENOUS SOLUTION 20 MG20 ML
MB PA
COMETRIQ ORAL CAPSULE 100 MGDAY(80 MG X1-20 MG X1) 140 MGDAY(80 MG X1-20 MG X3) 60 MGDAY (20 MG X 3DAY)
2 PA OCh
COPIKTRA ORAL CAPSULE 15 MG 25 MG 2 PA OCh
COTELLIC ORAL TABLET 20 MG 2 PA OCh LA
cyclophosphamide intravenous recon soln 1 gram 2 gram 500 mg
MB
cyclophosphamide oral capsule 25 mg 50 mg 2 OCh
CYCLOPHOSPHAMIDE ORAL TABLET 25 MG 50 MG
2 OCh
cyclosporine modified oral capsule 100 mg 25 mg 50 mg
1
cyclosporine modified oral solution 100 mgml 1
cyclosporine oral capsule 100 mg 25 mg 1
CYRAMZA INTRAVENOUS SOLUTION 10 MGML
MB PA LA
DACOGEN INTRAVENOUS RECON SOLN 50 MG
MB PA LA
DARZALEX INTRAVENOUS SOLUTION 20 MGML
MB PA LA
DAURISMO ORAL TABLET 100 MG 25 MG 2 PA OCh LA
decitabine intravenous recon soln 50 mg MB LA
ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 225 MG
2
ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG
2
ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG
2
16
Drug Name Drug Tier Requirements Limits
ELIGARD SUBCUTANEOUS SYRINGE 75 MG (1 MONTH)
2
ELZONRIS INTRAVENOUS SOLUTION 1000 MCGML
MB PA
EMCYT ORAL CAPSULE 140 MG 2 OCh
EMPLICITI INTRAVENOUS RECON SOLN 300 MG 400 MG
MB PA LA
ENHERTU INTRAVENOUS RECON SOLN 100 MG
MB PA LA
ERBITUX INTRAVENOUS SOLUTION 100 MG50 ML 200 MG100 ML
MB PA LA
ERLEADA ORAL TABLET 60 MG 2 PA OCh LA
erlotinib oral tablet 100 mg 150 mg 25 mg 2 PA OCh LA
ERWINAZE INJECTION RECON SOLN 10000 UNIT
MB
etoposide intravenous solution 20 mgml MB
etoposide oral capsule 50 mg 2 OCh
everolimus (antineoplastic) oral tablet 25 mg 5 mg 75 mg
2 PA ST OCh LA
everolimus (immunosuppressive) oral tablet 025 mg 05 mg 075 mg
1 PA
exemestane oral tablet 25 mg ACA PV OCh QL (30 per 30 days)
FASLODEX INTRAMUSCULAR SYRINGE 250 MG5 ML
MB PA
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG 80 MG
2 LA
fludarabine intravenous recon soln 50 mg MB
fluorouracil intravenous solution 25 gram50 ml 5 gram100 ml 500 mg10 ml
MB PA
flutamide oral capsule 125 mg 2 OCh QL (180 per 30 days)
FOLOTYN INTRAVENOUS SOLUTION 20 MGML (1 ML) 40 MG2 ML (20 MGML)
MB PA LA
fulvestrant intramuscular syringe 250 mg5 ml MB
GAMIFANT INTRAVENOUS SOLUTION 5 MGML
MB PA
GAZYVA INTRAVENOUS SOLUTION 1000 MG40 ML
MB PA LA
gemcitabine intravenous recon soln 1 gram 2 gram 200 mg
MB
17
Drug Name Drug Tier Requirements Limits
gemcitabine intravenous solution 2 gram526 ml (38 mgml) 200 mg526 ml (38 mgml)
MB
gengraf oral capsule 100 mg 25 mg 1
gengraf oral solution 100 mgml 1
GILOTRIF ORAL TABLET 20 MG 30 MG 40 MG
2 PA OCh LA
GLEOSTINE ORAL CAPSULE 10 MG 100 MG 40 MG
2 PA OCh
HALAVEN INTRAVENOUS SOLUTION 1 MG2 ML (05 MGML)
MB PA LA
HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600 MG-10000 UNIT5 ML
MB LA
HERCEPTIN INTRAVENOUS RECON SOLN 150 MG
MB PA LA
HERZUMA INTRAVENOUS RECON SOLN 150 MG
MB PA LA
HYCAMTIN ORAL CAPSULE 025 MG 1 MG 2 OCh LA
hydroxyurea oral capsule 500 mg 2 OCh
IBRANCE ORAL CAPSULE 100 MG 125 MG 75 MG
2 PA OCh LA
IBRANCE ORAL TABLET 100 MG 125 MG 75 MG
2 OCh LA
ICLUSIG ORAL TABLET 10 MG 15 MG 30 MG 45 MG
2 PA ST OCh
IDHIFA ORAL TABLET 100 MG 50 MG 2 PA OCh LA
imatinib oral tablet 100 mg 2 OCh LA QL (90 per 30 days)
imatinib oral tablet 400 mg 2 OCh LA QL (60 per 30 days)
IMBRUVICA ORAL CAPSULE 140 MG 70 MG 2 PA ST OCh
IMBRUVICA ORAL TABLET 140 MG 280 MG 420 MG 560 MG
2 PA ST OCh
IMFINZI INTRAVENOUS SOLUTION 50 MGML
MB PA LA
IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFUML 10EXP8 (100 MILLION) PFUML
MB
18
Drug Name Drug Tier Requirements Limits
INFUGEM INTRAVENOUS PIGGYBACK 1200 MG120 ML (10 MGML) 1300 MG130 ML (10 MGML) 1400 MG140 ML (10 MGML) 1500 MG150 ML (10 MGML) 1600 MG160 ML (10 MGML) 1700 MG170 ML (10 MGML) 1800 MG180 ML (10 MGML) 1900 MG190 ML (10 MGML) 2000 MG200 ML (10 MGML) 2200 MG220 ML (10 MGML)
MB
INLYTA ORAL TABLET 1 MG 5 MG 2 PA OCh LA
IRESSA ORAL TABLET 250 MG 2 PA OCh LA
ISTODAX INTRAVENOUS RECON SOLN 10 MG2 ML
MB PA LA
IXEMPRA INTRAVENOUS RECON SOLN 15 MG 45 MG
MB PA LA
JAKAFI ORAL TABLET 10 MG 15 MG 20 MG 25 MG 5 MG
2 PA OCh LA
JEVTANA INTRAVENOUS SOLUTION 10 MGML (FIRST DILUTION)
MB PA LA
KADCYLA INTRAVENOUS RECON SOLN 100 MG 160 MG
MB PA LA
KANJINTI INTRAVENOUS RECON SOLN 150 MG 420 MG
MB PA LA
KEYTRUDA INTRAVENOUS SOLUTION 25 MGML
MB PA
KISQALI FEMARA CO-PACK ORAL TABLET 200 MGDAY(200 MG X 1)-25 MG 400 MGDAY(200 MG X 2)-25 MG 600 MGDAY(200 MG X 3)-25 MG
2 PA ST OCh LA
KISQALI ORAL TABLET 200 MGDAY (200 MG X 1) 400 MGDAY (200 MG X 2) 600 MGDAY (200 MG X 3)
2 PA ST OCh LA
KYMRIAH INTRAVENOUS SUSPENSION 02X10EXP6 TO 25X10EXP8 CELL 06 TO 6 X 10EXP8 CELL
MB PA
KYPROLIS INTRAVENOUS RECON SOLN 10 MG 30 MG 60 MG
MB PA
lapatinib oral tablet 250 mg 2 PA OCh LA QL (180 per 30 days)
LENVIMA ORAL CAPSULE 10 MGDAY (10 MG X 1) 12 MGDAY (4 MG X 3) 14 MGDAY(10 MG X 1-4 MG X 1) 18 MGDAY (10 MG X 1-4 MG X2) 20 MGDAY (10 MG X 2) 24 MGDAY(10 MG X 2-4 MG X 1) 4 MG 8 MGDAY (4 MG X 2)
2 PA ST OCh LA
19
Drug Name Drug Tier Requirements Limits
letrozole oral tablet 25 mg ACA PV OCh QL (30 per 30 days)
LEUKERAN ORAL TABLET 2 MG 2 OCh
leuprolide subcutaneous kit 1 mg02 ml 2
LIBTAYO INTRAVENOUS SOLUTION 50 MGML
MB PA
LONSURF ORAL TABLET 15-614 MG 20-819 MG
2 PA ST OCh LA
LUMOXITI INTRAVENOUS RECON SOLN 1 MG
MB
LUPKYNIS ORAL CAPSULE 79 MG 2 PA ST
LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 225 MG
2
LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG
2
LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG
2
LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 375 MG 75 MG
2
LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 30 MG
2
LUPRON DEPOT-PED INTRAMUSCULAR KIT 1125 MG 15 MG 75 MG (PED)
2
LYNPARZA ORAL TABLET 100 MG 150 MG 2 PA ST OCh LA
LYSODREN ORAL TABLET 500 MG 2 OCh
MARQIBO INTRAVENOUS KIT 5 MG31 ML(016 MGML) FINAL
MB PA
MATULANE ORAL CAPSULE 50 MG 2 OCh
megestrol oral suspension 400 mg10 ml (40 mgml)
1 QL (2 per 30 days)
megestrol oral suspension 625 mg5 ml (125 mgml)
1 QL (1 per 30 days)
megestrol oral tablet 20 mg 2 OCh QL (480 per 30 days)
megestrol oral tablet 40 mg 2 OCh QL (240 per 30 days)
MEKINIST ORAL TABLET 05 MG 2 MG 2 PA ST OCh LA
MEKTOVI ORAL TABLET 15 MG 2 PA OCh LA
melphalan hcl intravenous recon soln 50 mg MB
melphalan oral tablet 2 mg 2 OCh
20
Drug Name Drug Tier Requirements Limits
mercaptopurine oral tablet 50 mg 2 OCh QL (300 per 30 days)
methotrexate sodium (pf) injection recon soln 1 gram
1
methotrexate sodium (pf) injection solution 25 mgml
1
methotrexate sodium injection solution 25 mgml 1
methotrexate sodium oral tablet 25 mg 2 OCh
mitoxantrone intravenous concentrate 2 mgml MB PA LA
mycophenolate mofetil oral capsule 250 mg 1
mycophenolate mofetil oral tablet 500 mg 1
mycophenolate sodium oral tabletdelayed release (drec) 180 mg 360 mg
1
MYLOTARG INTRAVENOUS RECON SOLN 45 MG (1 MGML INITIAL CONC)
MB PA LA
NERLYNX ORAL TABLET 40 MG 2 PA OCh LA QL (180 per 30 days)
NEXAVAR ORAL TABLET 200 MG 2 PA ST OCh LA
nilutamide oral tablet 150 mg 2 OCh QL (60 per 30 days)
NINLARO ORAL CAPSULE 23 MG 3 MG 4 MG
2 PA ST OCh LA
NULOJIX INTRAVENOUS RECON SOLN 250 MG
MB PA
octreotide acetate injection solution 1000 mcgml 100 mcgml 200 mcgml 50 mcgml 500 mcgml
2
octreotide acetate injection syringe 100 mcgml (1 ml) 50 mcgml (1 ml) 500 mcgml (1 ml)
2
OGIVRI INTRAVENOUS RECON SOLN 150 MG 420 MG
MB PA LA
ONCASPAR INJECTION SOLUTION 750 UNITML
MB
ONIVYDE INTRAVENOUS DISPERSION 43 MGML
MB PA
OPDIVO INTRAVENOUS SOLUTION 100 MG10 ML 240 MG24 ML 40 MG4 ML
MB PA LA
PADCEV INTRAVENOUS RECON SOLN 20 MG 30 MG
MB PA LA
PEMAZYRE ORAL TABLET 135 MG 45 MG 9 MG
2 PA ST OCh
PERJETA INTRAVENOUS SOLUTION 420 MG14 ML (30 MGML)
MB PA LA
21
Drug Name Drug Tier Requirements Limits
PIQRAY ORAL TABLET 200 MGDAY (200 MG X 1) 250 MGDAY (200 MG X1-50 MG X1) 300 MGDAY (150 MG X 2)
2 PA OCh LA
POLIVY INTRAVENOUS RECON SOLN 140 MG
MB PA LA
PORTRAZZA INTRAVENOUS SOLUTION 800 MG50 ML (16 MGML)
MB PA LA
POTELIGEO INTRAVENOUS SOLUTION 4 MGML
MB PA
PROGRAF INTRAVENOUS SOLUTION 5 MGML
MB
QINLOCK ORAL TABLET 50 MG 2 OCh
RETEVMO ORAL CAPSULE 40 MG 2 PA OCh LA QL (240 per 30 days)
RETEVMO ORAL CAPSULE 80 MG 2 PA OCh LA QL (120 per 30 days)
RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG117 ML (120 MGML) 1600 MG134 ML (120 MGML)
MB LA
RITUXAN INTRAVENOUS CONCENTRATE 10 MGML
MB PA LA
RUBRACA ORAL TABLET 200 MG 250 MG 300 MG
2 PA ST OCh LA
RYDAPT ORAL CAPSULE 25 MG 2 PA ST OCh LA
SARCLISA INTRAVENOUS SOLUTION 20 MGML
MB
SIGNIFOR SUBCUTANEOUS SOLUTION 03 MGML (1 ML) 06 MGML (1 ML) 09 MGML (1 ML)
2 PA ST
SIMULECT INTRAVENOUS RECON SOLN 10 MG 20 MG
MB
sirolimus oral solution 1 mgml 1
sirolimus oral tablet 05 mg 1 mg 2 mg 1
SOLTAMOX ORAL SOLUTION 20 MG10 ML 2 OCh
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG05 ML 60 MG02 ML 90 MG03 ML
2 PA LA
SPRYCEL ORAL TABLET 100 MG 140 MG 20 MG 50 MG 70 MG 80 MG
2 PA ST OCh LA
STIVARGA ORAL TABLET 40 MG 2 PA ST OCh LA
SUPPRELIN LA IMPLANT KIT 50 MG (65 MCGDAY)
MB LA
22
Drug Name Drug Tier Requirements Limits
SUTENT ORAL CAPSULE 125 MG 25 MG 375 MG 50 MG
2 PA ST OCh LA
SYLVANT INTRAVENOUS RECON SOLN 100 MG 400 MG
MB PA LA
SYNRIBO SUBCUTANEOUS RECON SOLN 35 MG
2 PA ST
TABLOID ORAL TABLET 40 MG 2 OCh
tacrolimus oral capsule 05 mg 1 mg 5 mg 1
TAFINLAR ORAL CAPSULE 50 MG 75 MG 2 PA OCh LA
TAGRISSO ORAL TABLET 40 MG 80 MG 2 PA OCh LA
TALZENNA ORAL CAPSULE 025 MG 1 MG 2 PA OCh LA
tamoxifen oral tablet 10 mg 20 mg 2 OCh QL (60 per 30 days)
TARGRETIN TOPICAL GEL 1 1 PA ST
TASIGNA ORAL CAPSULE 150 MG 200 MG 50 MG
2 PA ST OCh LA
TECENTRIQ INTRAVENOUS SOLUTION 1200 MG20 ML (60 MGML) 840 MG14 ML (60 MGML)
MB PA LA
TEMODAR INTRAVENOUS RECON SOLN 100 MG
MB PA LA
temozolomide oral capsule 100 mg 140 mg 180 mg 20 mg 250 mg 5 mg
2 OCh LA
temsirolimus intravenous recon soln 30 mg3 ml (10 mgml) (first)
MB PA LA
THALOMID ORAL CAPSULE 100 MG 150 MG 200 MG 50 MG
2 OCh LA
TIBSOVO ORAL TABLET 250 MG 2 PA OCh
toremifene oral tablet 60 mg 2 OCh
TORISEL INTRAVENOUS RECON SOLN 30 MG3 ML (10 MGML) (FIRST)
MB PA LA
TREANDA INTRAVENOUS RECON SOLN 100 MG 25 MG
MB PA LA
TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 1125 MG 225 MG 375 MG
MB
tretinoin (antineoplastic) oral capsule 10 mg 2 OCh
TREXALL ORAL TABLET 10 MG 15 MG 5 MG 75 MG
2 PA ST OCh QL (15 per 30 days)
TRUXIMA INTRAVENOUS SOLUTION 10 MGML
MB PA LA
23
Drug Name Drug Tier Requirements Limits
TUKYSA ORAL TABLET 150 MG 50 MG 2 PA ST OCh QL (120 per 30 days)
UNITUXIN INTRAVENOUS SOLUTION 35 MGML
MB PA
VANTAS IMPLANT KIT 50 MG (50 MCGDAY)
MB LA
VECTIBIX INTRAVENOUS SOLUTION 100 MG5 ML (20 MGML) 400 MG20 ML (20 MGML)
MB PA LA
VELCADE INJECTION RECON SOLN 35 MG MB LA
VENCLEXTA ORAL TABLET 10 MG 100 MG 50 MG
2 PA ST OCh
VENCLEXTA STARTING PACK ORAL TABLETSDOSE PACK 10 MG-50 MG- 100 MG
2 PA OCh
VERZENIO ORAL TABLET 100 MG 150 MG 200 MG 50 MG
2 PA ST OCh LA
VIDAZA INJECTION RECON SOLN 100 MG MB PA LA
VITRAKVI ORAL CAPSULE 100 MG 2 PA OCh LA
VITRAKVI ORAL CAPSULE 25 MG 2 PA ST OCh LA
VITRAKVI ORAL SOLUTION 20 MGML 2 PA OCh LA
VOTRIENT ORAL TABLET 200 MG 2 PA ST OCh LA
VYXEOS INTRAVENOUS RECON SOLN 44-100 MG
MB PA
XALKORI ORAL CAPSULE 200 MG 250 MG 2 PA OCh LA
XERMELO ORAL TABLET 250 MG 2 PA ST
XOSPATA ORAL TABLET 40 MG 2 PA OCh
XTANDI ORAL CAPSULE 40 MG 2 PA OCh LA
XTANDI ORAL TABLET 40 MG 80 MG 2 PA OCh LA
YERVOY INTRAVENOUS SOLUTION 200 MG40 ML (5 MGML) 50 MG10 ML (5 MGML)
MB PA LA
YESCARTA INTRAVENOUS SUSPENSION MB PA
YONDELIS INTRAVENOUS RECON SOLN 1 MG
MB PA
YONSA ORAL TABLET 125 MG 2 PA OCh LA
ZALTRAP INTRAVENOUS SOLUTION 100 MG4 ML (25 MGML) 200 MG8 ML (25 MGML)
MB PA LA
ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM
MB
24
Drug Name Drug Tier Requirements Limits
ZEJULA ORAL CAPSULE 100 MG 2 OCh
ZELBORAF ORAL TABLET 240 MG 2 PA ST OCh LA
ZOLADEX SUBCUTANEOUS IMPLANT 108 MG 36 MG
MB LA
ZOLINZA ORAL CAPSULE 100 MG 2 PA ST OCh LA
ZYKADIA ORAL TABLET 150 MG 2 PA ST OCh LA
AUTONOMIC amp CNS DRUGS NEUROLOGY amp PSYCH
ANTICONVULSANTS
BANZEL ORAL TABLET 200 MG 400 MG 1 PA ST
BRIVIACT ORAL SOLUTION 10 MGML 1 ST QL (150 per 30 days)
BRIVIACT ORAL TABLET 10 MG 100 MG 25 MG 50 MG 75 MG
1 ST QL (60 per 30 days)
carbamazepine oral capsule er multiphase 12 hr 100 mg 200 mg 300 mg
1
carbamazepine oral suspension 100 mg5 ml 200 mg10 ml
1
carbamazepine oral tablet 200 mg 1
carbamazepine oral tablet extended release 12 hr 100 mg 200 mg 400 mg
1
carbamazepine oral tabletchewable 100 mg 1
CELONTIN ORAL CAPSULE 300 MG 1
clobazam oral suspension 25 mgml 1
clobazam oral tablet 10 mg 20 mg 1
clonazepam oral tablet 05 mg 1 mg 2 mg 1
clonazepam oral tabletdisintegrating 0125 mg 025 mg 05 mg 1 mg 2 mg
1
diazepam rectal kit 25 mg 1
DILANTIN EXTENDED ORAL CAPSULE 100 MG
1
DILANTIN INFATABS ORAL TABLETCHEWABLE 50 MG
1
DILANTIN ORAL CAPSULE 30 MG 1
DILANTIN-125 ORAL SUSPENSION 125 MG5 ML
1
divalproex oral capsule delayed rel sprinkle 125 mg
1
divalproex oral tablet extended release 24 hr 250 mg 500 mg
1
25
Drug Name Drug Tier Requirements Limits
divalproex oral tabletdelayed release (drec) 125 mg 250 mg 500 mg
1
EPIDIOLEX ORAL SOLUTION 100 MGML 2 PA LA QL (400 per 30 days)
epitol oral tablet 200 mg 1
ethosuximide oral capsule 250 mg 1
ethosuximide oral solution 250 mg5 ml 1
felbamate oral suspension 600 mg5 ml 1
felbamate oral tablet 400 mg 600 mg 1
FINTEPLA ORAL SOLUTION 22 MGML 2
gabapentin oral capsule 100 mg 300 mg 400 mg 1
gabapentin oral solution 250 mg5 ml 300 mg6 ml (6 ml)
1
gabapentin oral tablet 600 mg 800 mg 1
lamotrigine oral tablet 100 mg 150 mg 200 mg 25 mg
1
lamotrigine oral tablet disintegrating dose pk 25 mg (21) -50 mg (7) 25 mg(14)-50 mg (14)-100 mg (7) 50 mg (42) -100 mg (14)
1
lamotrigine oral tablet extended release 24hr 100 mg 200 mg 25 mg 250 mg 300 mg 50 mg
1
lamotrigine oral tablet chewable dispersible 25 mg 5 mg
1
lamotrigine oral tabletdisintegrating 100 mg 200 mg 25 mg 50 mg
1
lamotrigine oral tabletsdose pack 25 mg (35) 25 mg (42) -100 mg (7) 25 mg (84) -100 mg (14)
1
levetiracetam oral solution 100 mgml 500 mg5 ml (5 ml)
1
levetiracetam oral tablet 1000 mg 250 mg 500 mg 750 mg
1
levetiracetam oral tablet extended release 24 hr 500 mg 750 mg
1
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG 330 MG 825 MG
1 PA ST
oxcarbazepine oral suspension 300 mg5 ml (60 mgml)
1
oxcarbazepine oral tablet 150 mg 300 mg 600 mg 1
phenobarbital oral elixir 20 mg5 ml (4 mgml) 1
26
Drug Name Drug Tier Requirements Limits
phenobarbital oral tablet 100 mg 15 mg 162 mg 30 mg 324 mg 60 mg 648 mg 972 mg
1
phenytoin oral suspension 100 mg4 ml 125 mg5 ml
1
phenytoin oral tabletchewable 50 mg 1
phenytoin sodium extended oral capsule 100 mg 200 mg 300 mg
1
pregabalin oral capsule 100 mg 150 mg 200 mg 225 mg 25 mg 300 mg 50 mg 75 mg
1 PA ST
pregabalin oral solution 20 mgml 1 PA ST
pregabalin oral tablet extended release 24 hr 165 mg 330 mg 825 mg
1 PA ST
primidone oral tablet 250 mg 50 mg 1
roweepra oral tablet 1000 mg 500 mg 750 mg 1
rufinamide oral suspension 40 mgml 1 PA
rufinamide oral tablet 200 mg 400 mg 1 PA
subvenite oral tablet 100 mg 150 mg 200 mg 25 mg
1
subvenite starter (blue) kit oral tabletsdose pack 25 mg (35)
1
subvenite starter (green) kit oral tabletsdose pack 25 mg (84) -100 mg (14)
1
subvenite starter (orange) kit oral tabletsdose pack 25 mg (42) -100 mg (7)
1
SYMPAZAN ORAL FILM 10 MG 20 MG 5 MG 1 PA QL (30 per 30 days)
tiagabine oral tablet 12 mg 16 mg 2 mg 4 mg 1
topiramate oral capsule sprinkle 15 mg 25 mg 1
topiramate oral tablet 100 mg 200 mg 25 mg 50 mg
1
valproic acid (as sodium salt) oral solution 250 mg5 ml 500 mg10 ml (10 ml)
1
valproic acid oral capsule 250 mg 1
vigabatrin oral powder in packet 500 mg 2 PA LA
vigabatrin oral tablet 500 mg 2 PA LA
vigadrone oral powder in packet 500 mg 2 PA ST
VIMPAT ORAL SOLUTION 10 MGML 1 PA ST QL (6 per 30 days)
VIMPAT ORAL TABLET 100 MG 150 MG 200 MG 50 MG
1 ST QL (60 per 30 days)
27
Drug Name Drug Tier Requirements Limits
XCOPRI MAINTENANCE PACK ORAL TABLET 250 MGDAY (200 MG X1-50 MG X1) 350 MGDAY (200 MG X1-150MG X1)
2
XCOPRI MAINTENANCE PACK ORAL TABLET 250MGDAY(150 MG X1-100MG X1)
2 PA ST
XCOPRI ORAL TABLET 100 MG 150 MG 200 MG 50 MG
2
XCOPRI TITRATION PACK ORAL TABLETSDOSE PACK 125 MG (14)- 25 MG (14) 150 MG (14)- 200 MG (14) 50 MG (14)- 100 MG (14)
2
zonisamide oral capsule 100 mg 25 mg 50 mg 1
ANTIPARKINSONISM AGENTS
APOKYN SUBCUTANEOUS CARTRIDGE 10 MGML
2 PA LA QL (1 per 30 days)
benztropine injection solution 1 mgml 1
benztropine oral tablet 05 mg 1 mg 2 mg 1
bromocriptine oral capsule 5 mg 1
bromocriptine oral tablet 25 mg 1
carbidopa oral tablet 25 mg 1
carbidopa-levodopa oral tablet 10-100 mg 25-100 mg 25-250 mg
1
carbidopa-levodopa oral tablet extended release 25-100 mg 50-200 mg
1
carbidopa-levodopa oral tabletdisintegrating 10-100 mg 25-100 mg 25-250 mg
1
carbidopa-levodopa-entacapone oral tablet 125-50-200 mg 1875-75-200 mg 25-100-200 mg 3125-125-200 mg 375-150-200 mg 50-200-200 mg
1
entacapone oral tablet 200 mg 1
pramipexole oral tablet 0125 mg 025 mg 05 mg 075 mg 1 mg 15 mg
1
pramipexole oral tablet extended release 24 hr 0375 mg 075 mg 15 mg 225 mg 3 mg 375 mg 45 mg
1
rasagiline oral tablet 05 mg 1 mg 1
ropinirole oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg 5 mg
1
28
Drug Name Drug Tier Requirements Limits
ropinirole oral tablet extended release 24 hr 12 mg 2 mg 4 mg 6 mg 8 mg
1
selegiline hcl oral capsule 5 mg 1
selegiline hcl oral tablet 5 mg 1
tolcapone oral tablet 100 mg 1
trihexyphenidyl oral elixir 04 mgml 1
trihexyphenidyl oral tablet 2 mg 5 mg 1
MIGRAINE amp CLUSTER HEADACHE THERAPY
AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MGML 70 MGML
1 PA ST
AJOVY AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 225 MG15 ML
1 ST
AJOVY SYRINGE SUBCUTANEOUS SYRINGE 225 MG15 ML
1 PA ST
almotriptan malate oral tablet 125 mg 625 mg 1 QL (18 per 30 days)
dihydroergotamine injection solution 1 mgml 1
dihydroergotamine nasal spraynon-aerosol 05 mgpump act (4 mgml)
1 QL (8 per 30 days)
eletriptan oral tablet 20 mg 40 mg 1 QL (18 per 30 days)
EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MGML
1 PA ST
EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MGML 300 MG3 ML (100 MGML X 3)
1 PA ST
ergotamine-caffeine oral tablet 1-100 mg 1
frovatriptan oral tablet 25 mg 1 QL (18 per 30 days)
migergot rectal suppository 2-100 mg 1
naratriptan oral tablet 1 mg 25 mg 1 QL (18 per 30 days)
ONZETRA XSAIL NASAL AEROSOL POWDR BREATH ACTIVATED 11 MG
1 ST QL (16 per 30 days)
rizatriptan oral tablet 10 mg 5 mg 1 QL (18 per 30 days)
rizatriptan oral tabletdisintegrating 10 mg 5 mg 1 QL (18 per 30 days)
sumatriptan nasal spraynon-aerosol 20 mgactuation 5 mgactuation
1 QL (18 per 30 days)
sumatriptan succinate oral tablet 100 mg 25 mg 50 mg
1 QL (18 per 30 days)
sumatriptan succinate subcutaneous cartridge 4 mg05 ml 6 mg05 ml
1 QL (8 per 30 days)
29
Drug Name Drug Tier Requirements Limits
sumatriptan succinate subcutaneous pen injector 4 mg05 ml 6 mg05 ml
1 QL (8 per 30 days)
sumatriptan succinate subcutaneous solution 6 mg05 ml
1 QL (8 per 30 days)
sumatriptan succinate subcutaneous syringe 6 mg05 ml
1 QL (8 per 30 days)
UBRELVY ORAL TABLET 100 MG 50 MG 1 QL (16 per 30 days)
VYEPTI INTRAVENOUS SOLUTION 100 MGML
MB PA
zolmitriptan oral tablet 25 mg 5 mg 1 QL (18 per 30 days)
zolmitriptan oral tabletdisintegrating 25 mg 5 mg
1 QL (18 per 30 days)
ZOMIG NASAL SPRAYNON-AEROSOL 25 MG 5 MG
1 ST QL (18 per 30 days)
MISCELLANEOUS NEUROLOGICAL THERAPY
AUSTEDO ORAL TABLET 12 MG 6 MG 9 MG
2 PA LA
dalfampridine oral tablet extended release 12 hr 10 mg
2 PA LA QL (60 per 30 days)
donepezil oral tablet 10 mg 23 mg 5 mg 1
donepezil oral tabletdisintegrating 10 mg 5 mg 1
EXONDYS-51 INTRAVENOUS SOLUTION 50 MGML
MB PA
galantamine oral capsuleext rel pellets 24 hr 16 mg 24 mg 8 mg
1
galantamine oral solution 4 mgml 1
galantamine oral tablet 12 mg 4 mg 8 mg 1
memantine oral capsulesprinkleer 24hr 14 mg 21 mg 28 mg 7 mg
1
memantine oral solution 2 mgml 1
memantine oral tablet 10 mg 5 mg 1
NUEDEXTA ORAL CAPSULE 20-10 MG 1
ONPATTRO INTRAVENOUS SOLUTION 2 MGML
MB PA
RADICAVA INTRAVENOUS SOLUTION 30 MG100 ML
MB PA
rivastigmine tartrate oral capsule 15 mg 3 mg 45 mg 6 mg
1
30
Drug Name Drug Tier Requirements Limits
rivastigmine transdermal patch 24 hour 133 mg24 hour 46 mg24 hour 95 mg24 hour
1
tetrabenazine oral tablet 125 mg 25 mg 2 LA
TYSABRI INTRAVENOUS SOLUTION 300 MG15 ML
MB PA ST LA
VYONDYS-53 INTRAVENOUS SOLUTION 50 MGML
MB PA
ZOLGENSMA INTRAVENOUS KIT 2 X 10EXP13 VGML
MB LA
MUSCLE RELAXANTS amp ANTISPASMODIC THERAPY
baclofen oral tablet 10 mg 20 mg 5 mg 1
carisoprodol oral tablet 250 mg 350 mg 1
carisoprodol-aspirin oral tablet 200-325 mg 1
carisoprodol-aspirin-codeine oral tablet 200-325-16 mg
1 PA ST
chlorzoxazone oral tablet 250 mg 375 mg 750 mg 1 ST
chlorzoxazone oral tablet 500 mg 1
cyclobenzaprine oral tablet 10 mg 5 mg 75 mg 1
dantrolene oral capsule 100 mg 25 mg 50 mg 1
meprobamate oral tablet 200 mg 400 mg 1
metaxalone oral tablet 400 mg 800 mg 1
methocarbamol oral tablet 500 mg 750 mg 1
orphenadrine citrate injection solution 30 mgml 1
orphenadrine citrate oral tablet extended release 100 mg
1
pyridostigmine bromide oral syrup 60 mg5 ml 1
pyridostigmine bromide oral tablet 60 mg 1
pyridostigmine bromide oral tablet extended release 180 mg
1
tizanidine oral capsule 2 mg 4 mg 6 mg 1
tizanidine oral tablet 2 mg 4 mg 1
vanadom oral tablet 350 mg 1
NARCOTIC ANALGESICS
acetaminophen-caff-dihydrocod oral capsule 3205-30-16 mg
1 PA ST
acetaminophen-caff-dihydrocod oral tablet 325-30-16 mg
1 PA ST
31
Drug Name Drug Tier Requirements Limits
acetaminophen-codeine oral solution 120-12 mg5 ml 300 mg-30 mg 125 ml
1 PA ST
acetaminophen-codeine oral tablet 300-15 mg 300-30 mg 300-60 mg
1 PA ST
ascomp with codeine oral capsule 30-50-325-40 mg
1 PA ST
buprenorphine hcl injection solution 03 mgml 1 PA ST
buprenorphine hcl injection syringe 03 mgml 1 PA ST
buprenorphine hcl sublingual tablet 2 mg 8 mg 1
buprenorphine transdermal patch weekly 10 mcghour 15 mcghour 20 mcghour 5 mcghour 75 mcghour
1
butalbital compound wcodeine oral capsule 30-50-325-40 mg
1 PA ST
butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg 50-325-40-30 mg
1 PA ST
butalbital-acetaminophen-caff oral capsule 50-300-40 mg 50-325-40 mg
1
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
1
butalbital-aspirin-caffeine oral capsule 50-325-40 mg
1
butalbital-aspirin-caffeine oral tablet 50-325-40 mg
1
codeine sulfate oral tablet 15 mg 30 mg 60 mg 1 PA ST
codeine-butalbital-asa-caff oral capsule 30-50-325-40 mg
1 PA ST
diskets oral tabletsoluble 40 mg 1 PA ST
DSUVIA SUBLINGUAL TABLET IN APPLICATOR 30 MCG
MB
duramorph (pf) injection solution 05 mgml 1 mgml
MB PA ST
dvorah oral tablet 325-30-16 mg 1 PA ST
endocet oral tablet 10-325 mg 25-325 mg 5-325 mg 75-325 mg
1 PA ST
fentanyl citrate buccal lozenge on a handle 1200 mcg 1600 mcg 200 mcg 400 mcg 600 mcg 800 mcg
1 PA
32
Drug Name Drug Tier Requirements Limits
fentanyl transdermal patch 72 hour 100 mcghr 12 mcghr 25 mcghr 375 mcghour 50 mcghr 625 mcghour 75 mcghr 875 mcghour
1 PA ST
hydrocodone bitartrate oral capsule oral only er 12hr 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg
1 PA ST QL (60 per 30 days)
hydrocodone bitartrate oral tabletoral onlyextrel24 hr 100 mg 120 mg 20 mg 30 mg 40 mg 60 mg 80 mg
1 PA ST
hydrocodone-acetaminophen oral solution 10-325 mg15 ml(15 ml) 75-325 mg15 ml
1 PA ST
hydrocodone-acetaminophen oral tablet 10-300 mg 10-325 mg 5-300 mg 5-325 mg 75-300 mg 75-325 mg
1 PA ST
hydrocodone-ibuprofen oral tablet 10-200 mg 5-200 mg 75-200 mg
1 PA ST
HYDROMORPHONE INJECTION SYRINGE 05 MG05 ML
1 PA ST
hydromorphone oral liquid 1 mgml 1 PA ST
hydromorphone oral tablet 2 mg 4 mg 8 mg 1 PA ST
hydromorphone oral tablet extended release 24 hr 12 mg 16 mg 32 mg 8 mg
1 PA ST QL (60 per 30 days)
hydromorphone rectal suppository 3 mg 1 PA ST
levorphanol tartrate oral tablet 2 mg 3 mg 1 PA ST
meperidine oral solution 50 mg5 ml 1 PA ST
meperidine oral tablet 50 mg 1 PA ST
methadone injection solution 10 mgml 1 PA ST
methadone oral concentrate 10 mgml 1 PA ST
methadone oral solution 10 mg5 ml 5 mg5 ml 1 PA ST
methadone oral tablet 10 mg 5 mg 1 PA ST
methadone oral tabletsoluble 40 mg 1 PA ST
methadose oral concentrate 10 mgml 1 PA ST
methadose oral tabletsoluble 40 mg 1 PA ST
morphine (pf) injection solution 05 mgml MB PA ST
morphine concentrate oral solution 100 mg5 ml (20 mgml)
1 PA ST
morphine oral capsule er multiphase 24 hr 120 mg 30 mg 45 mg 60 mg 75 mg 90 mg
1 PA ST QL (60 per 30 days)
morphine oral capsuleextendrelease pellets 10 mg 100 mg 20 mg 50 mg 80 mg
1 PA ST QL (90 per 30 days)
33
Drug Name Drug Tier Requirements Limits
morphine oral capsuleextendrelease pellets 30 mg 60 mg
1 PA ST QL (60 per 30 days)
morphine oral capsuleextendrelease pellets 40 mg
1 PA QL (90 per 30 days)
morphine oral solution 10 mg5 ml 20 mg5 ml (4 mgml)
1 PA ST
morphine oral tablet 15 mg 30 mg 1 PA ST
morphine oral tablet extended release 100 mg 15 mg 200 mg 30 mg 60 mg
1 PA ST QL (120 per 30 days)
morphine rectal suppository 10 mg 20 mg 30 mg 5 mg
1 PA ST
oxycodone oral capsule 5 mg 1 PA ST
oxycodone oral concentrate 20 mgml 1 PA ST
oxycodone oral solution 5 mg5 ml 1 PA ST
oxycodone oral tablet 10 mg 15 mg 20 mg 30 mg 5 mg
1 PA ST
oxycodone-acetaminophen oral tablet 10-325 mg 25-300 mg 25-325 mg 5-325 mg 75-325 mg
1 PA ST
oxycodone-aspirin oral tablet 48355-325 mg 1 PA ST
OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 10 MG 15 MG 20 MG 30 MG 40 MG
1 PA ST QL (90 per 30 days)
OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 60 MG 80 MG
1 PA ST QL (120 per 30 days)
oxymorphone oral tablet 10 mg 5 mg 1 PA ST
oxymorphone oral tablet extended release 12 hr 10 mg 15 mg 20 mg 30 mg 40 mg 5 mg 75 mg
1 PA ST QL (90 per 30 days)
SUBLOCADE SUBCUTANEOUS SOLUTION EXTENDED REL SYRINGE 100 MG05 ML 300 MG15 ML
MB
tencon oral tablet 50-325 mg 1
NON-NARCOTIC ANALGESICS
adult aspirin regimen oral tabletdelayed release (drec) 81 mg
ACA PV
aspirin low dose oral tabletdelayed release (drec) 81 mg
ACA PV
aspirin oral tablet 325 mg ACA PV
aspirin oral tabletchewable 81 mg ACA PV
34
Drug Name Drug Tier Requirements Limits
aspirin oral tabletdelayed release (drec) 325 mg 81 mg
ACA PV
aspir-trin oral tabletdelayed release (drec) 325 mg
ACA PV
bayer aspirin oral tablet 325 mg ACA PV
BAYER CHEWABLE ASPIRIN ORAL TABLETCHEWABLE 81 MG
ACA PV
buprenorphine-naloxone sublingual film 12-3 mg 1 QL (60 per 30 days)
buprenorphine-naloxone sublingual film 2-05 mg 4-1 mg 8-2 mg
1 QL (90 per 30 days)
buprenorphine-naloxone sublingual tablet 2-05 mg 8-2 mg
1 QL (90 per 30 days)
butorphanol nasal spraynon-aerosol 10 mgml 1 PA ST QL (5 per 30 days)
cataflam oral tablet 50 mg 1
celecoxib oral capsule 100 mg 200 mg 400 mg 50 mg
1
childrens aspirin oral tabletchewable 81 mg ACA PV
cholinemagnesium salicylate oral liquid 500 mg5 ml
1
diclofenac potassium oral tablet 50 mg 1
diclofenac sodium oral tablet extended release 24 hr 100 mg
1
diclofenac sodium oral tabletdelayed release (drec) 25 mg 50 mg 75 mg
1
diclofenac sodium topical drops 15 1
diclofenac sodium topical gel 1 1
diclofenac-misoprostol oral tabletirdelayed relbiphasic 50-200 mg-mcg 75-200 mg-mcg
1
diflunisal oral tablet 500 mg 1
DUEXIS ORAL TABLET 800-266 MG 1 ST
ecotrin low strength oral tabletdelayed release (drec) 81 mg
ACA PV
ecotrin oral tabletdelayed release (drec) 325 mg ACA PV
etodolac oral capsule 200 mg 300 mg 1
etodolac oral tablet 400 mg 500 mg 1
etodolac oral tablet extended release 24 hr 400 mg 500 mg 600 mg
1
EUFLEXXA INTRA-ARTICULAR SYRINGE 10 MGML(MW 24 -36 MILLION)
MB
35
Drug Name Drug Tier Requirements Limits
fenoprofen oral tablet 600 mg 1
flurbiprofen oral tablet 100 mg 1
ibu oral tablet 400 mg 600 mg 800 mg 1
ibuprofen oral suspension 100 mg5 ml 1
ibuprofen oral tablet 400 mg 600 mg 800 mg 1
indomethacin oral capsule 25 mg 50 mg 1
indomethacin oral capsule extended release 75 mg
1
ketoprofen oral capsule 25 mg 50 mg 75 mg 1
ketoprofen oral capsuleext rel pellets 24 hr 200 mg
1
ketorolac injection cartridge 15 mgml 30 mgml 1
ketorolac injection solution 15 mgml 30 mgml MB
ketorolac injection solution 30 mgml (1 ml) 1
ketorolac intramuscular cartridge 60 mg2 ml 1
ketorolac intramuscular solution 60 mg2 ml 1
ketorolac intramuscular syringe 60 mg2 ml 1
ketorolac oral tablet 10 mg 1
meclofenamate oral capsule 100 mg 50 mg 1
mefenamic acid oral capsule 250 mg 1
meloxicam oral tablet 15 mg 75 mg 1
MONOVISC INTRA-ARTICULAR SYRINGE 88 MG4 ML
MB LA
nabumetone oral tablet 500 mg 750 mg 1
nalbuphine injection solution 10 mgml MB PA ST
naloxone injection solution 04 mgml 1
naloxone injection syringe 04 mgml 1 mgml 1
naltrexone oral tablet 50 mg 1
naproxen oral suspension 125 mg5 ml 1
naproxen oral tablet 250 mg 375 mg 500 mg 1
naproxen oral tabletdelayed release (drec) 375 mg 500 mg
1
naproxen sodium oral tablet 275 mg 550 mg 1
NARCAN NASAL SPRAYNON-AEROSOL 4 MGACTUATION
1
36
Drug Name Drug Tier Requirements Limits
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG 150 MG 200 MG 250 MG 50 MG
1 PA ST QL (60 per 30 days)
ORTHOVISC INTRA-ARTICULAR SYRINGE 30 MG2 ML
MB
oxaprozin oral tablet 600 mg 1
pentazocine-naloxone oral tablet 50-05 mg 1 PA ST
piroxicam oral capsule 10 mg 20 mg 1
salsalate oral tablet 500 mg 750 mg 1
st joseph aspirin oral tabletchewable 81 mg ACA PV
st joseph aspirin oral tabletdelayed release (drec) 81 mg
ACA PV
sulindac oral tablet 150 mg 200 mg 1
tolmetin oral capsule 400 mg 1
tolmetin oral tablet 200 mg 600 mg 1
tramadol oral tablet 50 mg 1 PA ST
tramadol oral tablet extended release 24 hr 100 mg 200 mg 300 mg
1 PA ST
tramadol oral tablet er multiphase 24 hr 100 mg 200 mg 300 mg
1 PA ST
tramadol-acetaminophen oral tablet 375-325 mg 1 PA ST
VIVITROL INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 380 MG
MB
PSYCHOTHERAPEUTIC DRUGS
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 300 MG 400 MG
1
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 300 MG 400 MG
1
ADHANSIA XR ORAL CAPSULE ER BIPHASIC 20-80 25 MG 35 MG 45 MG 55 MG 70 MG 85 MG
1 PA ST
ADZENYS ER ORAL SUSPEN IR - ER BIPHASIC 24HR 125 MGML
1 ST
ADZENYS XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 125 MG 157 MG 188 MG 31 MG 63 MG 94 MG
1 ST
37
Drug Name Drug Tier Requirements Limits
alprazolam intensol oral concentrate 1 mgml 1
alprazolam oral tablet 025 mg 05 mg 1 mg 2 mg
1
alprazolam oral tablet extended release 24 hr 05 mg 1 mg 2 mg 3 mg
1
alprazolam oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg
1
amitriptyline oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
amitriptyline-chlordiazepoxide oral tablet 125-5 mg 25-10 mg
1
amoxapine oral tablet 100 mg 150 mg 25 mg 50 mg
1
AMPHETAMINE ORAL SUSPEN IR - ER BIPHASIC 24HR 125 MGML
1 ST
amphetamine sulfate oral tablet 10 mg 5 mg 1
APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG 348 MG 522 MG
1 ST
aripiprazole oral solution 1 mgml 1
aripiprazole oral tablet 10 mg 15 mg 2 mg 20 mg 30 mg 5 mg
1
aripiprazole oral tabletdisintegrating 10 mg 15 mg
1
ARISTADA INITIO INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 675 MG24 ML
MB
ARISTADA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 1064 MG39 ML 441 MG16 ML 662 MG24 ML 882 MG32 ML
MB
armodafinil oral tablet 150 mg 200 mg 250 mg 50 mg
1
asenapine maleate sublingual tablet 10 mg 25 mg 5 mg
1
atomoxetine oral capsule 10 mg 100 mg 18 mg 25 mg 40 mg 60 mg 80 mg
1
BELSOMRA ORAL TABLET 10 MG 15 MG 20 MG 5 MG
1 ST
bupropion hcl oral tablet 100 mg 75 mg 1
bupropion hcl oral tablet extended release 24 hr 150 mg 300 mg
1
38
Drug Name Drug Tier Requirements Limits
bupropion hcl oral tablet sustained-release 12 hr 100 mg 150 mg 200 mg
1
buspirone oral tablet 10 mg 15 mg 30 mg 5 mg 75 mg
1
chlordiazepoxide hcl oral capsule 10 mg 25 mg 5 mg
1
chlorpromazine injection solution 25 mgml 1
chlorpromazine oral tablet 10 mg 100 mg 200 mg 25 mg 50 mg
1
citalopram oral solution 10 mg5 ml 1
citalopram oral tablet 10 mg 20 mg 40 mg 1
clomipramine oral capsule 25 mg 50 mg 75 mg 1
clonidine hcl oral tablet extended release 12 hr 01 mg
1
clorazepate dipotassium oral tablet 15 mg 375 mg 75 mg
1
clozapine oral tablet 100 mg 200 mg 25 mg 50 mg
1
clozapine oral tabletdisintegrating 100 mg 125 mg 150 mg 200 mg 25 mg
1
COTEMPLA XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 173 MG 259 MG 86 MG
1 ST
DAYTRANA TRANSDERMAL PATCH 24 HOUR 10 MG9 HR 15 MG9 HR 20 MG9 HR 30 MG9 HR
1 ST
desipramine oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG 50 MG
1 ST
desvenlafaxine succinate oral tablet extended release 24 hr 100 mg 25 mg 50 mg
1
dexmethylphenidate oral capsuleer biphasic 50-50 10 mg 15 mg 20 mg 25 mg 30 mg 35 mg 40 mg 5 mg
1
dexmethylphenidate oral tablet 10 mg 25 mg 5 mg
1
dextroamphetamine oral capsule extended release 10 mg 15 mg 5 mg
1
dextroamphetamine oral solution 5 mg5 ml 1
39
Drug Name Drug Tier Requirements Limits
dextroamphetamine oral tablet 10 mg 5 mg 1
dextroamphetamine-amphetamine oral capsuleextended release 24hr 10 mg 15 mg 20 mg 25 mg 30 mg 5 mg
1
dextroamphetamine-amphetamine oral tablet 10 mg 125 mg 15 mg 20 mg 30 mg 5 mg 75 mg
1
diazepam injection solution 5 mgml MB
diazepam injection syringe 5 mgml MB
diazepam intensol oral concentrate 5 mgml 1
diazepam oral solution 5 mg5 ml (1 mgml) 1
diazepam oral tablet 10 mg 2 mg 5 mg 1
doxepin oral capsule 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
doxepin oral concentrate 10 mgml 1
duloxetine oral capsuledelayed release(drec) 20 mg 30 mg 40 mg 60 mg
1
DYANAVEL XR ORAL SUSPEN IR - ER BIPHASIC 24HR 25 MGML
1 ST
EDLUAR SUBLINGUAL TABLET 10 MG 5 MG
1 ST
EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG24 HR 6 MG24 HR 9 MG24 HR
1 ST
ergoloid oral tablet 1 mg 1
escitalopram oxalate oral solution 5 mg5 ml 1
escitalopram oxalate oral tablet 10 mg 20 mg 5 mg
1
estazolam oral tablet 1 mg 2 mg 1
eszopiclone oral tablet 1 mg 2 mg 3 mg 1
FANAPT ORAL TABLET 1 MG 10 MG 12 MG 2 MG 4 MG 6 MG 8 MG
1 PA ST
FANAPT ORAL TABLETSDOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)
1 PA ST
FETZIMA ORAL CAPSULEEXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)
1 ST
FETZIMA ORAL CAPSULEEXTENDED RELEASE 24 HR 120 MG 20 MG 40 MG 80 MG
1 ST
fluoxetine oral capsule 10 mg 20 mg 40 mg 1
40
Drug Name Drug Tier Requirements Limits
fluoxetine oral capsuledelayed release(drec) 90 mg
1
fluoxetine oral solution 20 mg5 ml (4 mgml) 1
fluoxetine oral tablet 10 mg 20 mg 1
fluoxetine oral tablet 60 mg 1 PA
fluphenazine hcl injection solution 25 mgml 1
fluphenazine hcl oral concentrate 5 mgml 1
fluphenazine hcl oral elixir 25 mg5 ml 1
fluphenazine hcl oral tablet 1 mg 10 mg 25 mg 5 mg
1
flurazepam oral capsule 15 mg 30 mg 1
fluvoxamine oral capsuleextended release 24hr 100 mg 150 mg
1
fluvoxamine oral tablet 100 mg 25 mg 50 mg 1
guanfacine oral tablet extended release 24 hr 1 mg 2 mg 3 mg 4 mg
1
haloperidol decanoate intramuscular solution 100 mgml 50 mgml
1
haloperidol lactate injection solution 5 mgml 1
haloperidol lactate oral concentrate 2 mgml 1
haloperidol oral tablet 05 mg 1 mg 10 mg 2 mg 20 mg 5 mg
1
HETLIOZ LQ ORAL SUSPENSION 4 MGML 2 PA ST LA
HETLIOZ ORAL CAPSULE 20 MG 2 PA ST LA
imipramine hcl oral tablet 10 mg 25 mg 50 mg 1
imipramine pamoate oral capsule 100 mg 125 mg 150 mg 75 mg
1
INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG075 ML 156 MGML 234 MG15 ML 39 MG025 ML 78 MG05 ML
1
JORNAY PM ORAL CAPSULEDEL RELEXT REL SPRINK 100 MG 20 MG 40 MG 60 MG 80 MG
1 ST
LATUDA ORAL TABLET 120 MG 20 MG 40 MG 60 MG 80 MG
1 PA ST
lithium carbonate oral capsule 150 mg 300 mg 600 mg
1
lithium carbonate oral tablet 300 mg 1
41
Drug Name Drug Tier Requirements Limits
lithium carbonate oral tablet extended release 300 mg 450 mg
1
lorazepam intensol oral concentrate 2 mgml 1
lorazepam oral concentrate 2 mgml 1
lorazepam oral tablet 05 mg 1 mg 2 mg 1
loxapine succinate oral capsule 10 mg 25 mg 5 mg 50 mg
1
maprotiline oral tablet 25 mg 50 mg 75 mg 1
MARPLAN ORAL TABLET 10 MG 1
methamphetamine oral tablet 5 mg 1
METHYLIN ORAL SOLUTION 10 MG5 ML 5 MG5 ML
1
methylphenidate hcl oral caper sprinklebiphasic 40-60 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg 60 mg
1
methylphenidate hcl oral capsule er biphasic 30-70 10 mg 20 mg 30 mg 40 mg 50 mg 60 mg
1
methylphenidate hcl oral capsuleer biphasic 50-50 10 mg 20 mg 30 mg 40 mg 60 mg
1
methylphenidate hcl oral solution 10 mg5 ml 5 mg5 ml
1
methylphenidate hcl oral tablet 10 mg 20 mg 5 mg
1
methylphenidate hcl oral tablet extended release 10 mg 20 mg
1
methylphenidate hcl oral tablet extended release 24hr 18 mg 27 mg 36 mg 54 mg
1
methylphenidate hcl oral tabletchewable 10 mg 25 mg 5 mg
1
midazolam oral syrup 2 mgml 1
mirtazapine oral tablet 15 mg 30 mg 45 mg 75 mg
1
mirtazapine oral tabletdisintegrating 15 mg 30 mg 45 mg
1
modafinil oral tablet 100 mg 200 mg 1
molindone oral tablet 10 mg 25 mg 5 mg 1
MYDAYIS ORAL CAPSULE ER TRIPHASIC 24 HR 125 MG 25 MG 375 MG 50 MG
1 ST
nefazodone oral tablet 100 mg 150 mg 200 mg 250 mg 50 mg
1
42
Drug Name Drug Tier Requirements Limits
nortriptyline oral capsule 10 mg 25 mg 50 mg 75 mg
1
nortriptyline oral solution 10 mg5 ml 1
NUPLAZID ORAL CAPSULE 34 MG 2 PA LA
NUPLAZID ORAL TABLET 10 MG 2 PA LA
olanzapine intramuscular recon soln 10 mg 1
olanzapine oral tablet 10 mg 15 mg 25 mg 20 mg 5 mg 75 mg
1
olanzapine oral tabletdisintegrating 10 mg 15 mg 20 mg 5 mg
1
olanzapine-fluoxetine oral capsule 12-25 mg 12-50 mg 3-25 mg 6-25 mg 6-50 mg
1
oxazepam oral capsule 10 mg 15 mg 30 mg 1
paliperidone oral tablet extended release 24hr 15 mg 3 mg 6 mg 9 mg
1
paroxetine hcl oral tablet 10 mg 20 mg 30 mg 40 mg
1
paroxetine hcl oral tablet extended release 24 hr 125 mg 25 mg 375 mg
1
paroxetine mesylate(menopsym) oral capsule 75 mg
1
perphenazine oral tablet 16 mg 2 mg 4 mg 8 mg 1
perphenazine-amitriptyline oral tablet 2-10 mg 2-25 mg 4-10 mg 4-25 mg 4-50 mg
1
phenelzine oral tablet 15 mg 1
pimozide oral tablet 1 mg 2 mg 1
procentra oral solution 5 mg5 ml 1
protriptyline oral tablet 10 mg 5 mg 1
quetiapine oral tablet 100 mg 200 mg 25 mg 300 mg 400 mg 50 mg
1
quetiapine oral tablet extended release 24 hr 150 mg 200 mg 300 mg 400 mg 50 mg
1
QUILLICHEW ER ORAL TABLETCHEWIR-ERBIPHASIC24HR 20 MG 30 MG 40 MG
1 ST
QUILLIVANT XR ORAL SUSPENSIONEXT REL 24HRRECON 5 MGML (25 MG5 ML)
1 ST
ramelteon oral tablet 8 mg 1
RELEXXII ORAL TABLET EXTENDED RELEASE 24HR 72 MG
1 ST
43
Drug Name Drug Tier Requirements Limits
REXULTI ORAL TABLET 025 MG 05 MG 1 MG 2 MG 3 MG 4 MG
1 PA ST
RISPERDAL CONSTA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 125 MG2 ML 25 MG2 ML 375 MG2 ML 50 MG2 ML
1
risperidone oral solution 1 mgml 1
risperidone oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg
1
risperidone oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg
1
seconal sodium oral capsule 100 mg 1
sertraline oral concentrate 20 mgml 1
sertraline oral tablet 100 mg 25 mg 50 mg 1
SPRAVATO NASAL SPRAYNON-AEROSOL 56 MG (28 MG X 2) 84 MG (28 MG X 3)
MB PA
SUNOSI ORAL TABLET 150 MG 1 PA QL (30 per 30 days)
SUNOSI ORAL TABLET 75 MG 1 PA QL (60 per 30 days)
temazepam oral capsule 15 mg 225 mg 30 mg 75 mg
1
thioridazine oral tablet 10 mg 100 mg 25 mg 50 mg
1
thiothixene oral capsule 1 mg 10 mg 2 mg 5 mg 1
tranylcypromine oral tablet 10 mg 1
trazodone oral tablet 100 mg 150 mg 300 mg 50 mg
1
triazolam oral tablet 0125 mg 025 mg 1
trifluoperazine oral tablet 1 mg 10 mg 2 mg 5 mg
1
trimipramine oral capsule 100 mg 25 mg 50 mg 1
TRINTELLIX ORAL TABLET 10 MG 20 MG 5 MG
1 ST
venlafaxine oral capsuleextended release 24hr 150 mg 375 mg 75 mg
1
venlafaxine oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg
1
venlafaxine oral tablet extended release 24hr 150 mg 225 mg 375 mg 75 mg
1
VERSACLOZ ORAL SUSPENSION 50 MGML 1 PA ST
44
Drug Name Drug Tier Requirements Limits
VRAYLAR ORAL CAPSULE 15 MG 3 MG 45 MG 6 MG
1 PA ST
VRAYLAR ORAL CAPSULEDOSE PACK 15 MG (1)- 3 MG (6)
1 PA ST
VYVANSE ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG 70 MG
1 PA ST
VYVANSE ORAL TABLETCHEWABLE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG
1 PA ST
XYREM ORAL SOLUTION 500 MGML 1 PA QL (540 per 30 days)
zaleplon oral capsule 10 mg 5 mg 1
ZENZEDI ORAL TABLET 15 MG 25 MG 20 MG 30 MG 75 MG
1 ST
ziprasidone hcl oral capsule 20 mg 40 mg 60 mg 80 mg
1
zolpidem oral tablet 10 mg 5 mg 1
zolpidem oral tabletext release multiphase 125 mg 625 mg
1
zolpidem sublingual tablet 175 mg 35 mg 1
ZOLPIMIST ORAL SPRAYNON-AEROSOL 5 MGSPRAY (01 ML)
1 ST
ZULRESSO INTRAVENOUS SOLUTION 5 MGML
MB
CARDIOVASCULAR HYPERTENSION amp LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone oral tablet 100 mg 200 mg 400 mg 1
disopyramide phosphate oral capsule 100 mg 150 mg
1
dofetilide oral capsule 125 mcg 250 mcg 500 mcg 1
flecainide oral tablet 100 mg 150 mg 50 mg 1
mexiletine oral capsule 150 mg 200 mg 250 mg 1
MULTAQ ORAL TABLET 400 MG 1
NORPACE CR ORAL CAPSULE EXTENDED RELEASE 100 MG 150 MG
1
pacerone oral tablet 100 mg 200 mg 400 mg 1
procainamide injection solution 100 mgml 500 mgml
MB
propafenone oral capsuleextended release 12 hr 225 mg 325 mg 425 mg
1
45
Drug Name Drug Tier Requirements Limits
propafenone oral tablet 150 mg 225 mg 300 mg 1
quinidine gluconate oral tablet extended release 324 mg
1
quinidine sulfate oral tablet 200 mg 300 mg 1
sorine oral tablet 120 mg 160 mg 240 mg 80 mg 1
sotalol af oral tablet 120 mg 160 mg 80 mg 1
sotalol oral tablet 120 mg 160 mg 240 mg 80 mg 1
ANTIHYPERTENSIVE THERAPY
acebutolol oral capsule 200 mg 400 mg 1
aliskiren oral tablet 150 mg 300 mg 1
amiloride oral tablet 5 mg 1
amiloride-hydrochlorothiazide oral tablet 5-50 mg 1
amlodipine oral tablet 10 mg 25 mg 5 mg 1
amlodipine-benazepril oral capsule 10-20 mg 10-40 mg 25-10 mg 5-10 mg 5-20 mg 5-40 mg
1 ST
amlodipine-olmesartan oral tablet 10-20 mg 10-40 mg 5-20 mg 5-40 mg
1 ST
amlodipine-valsartan oral tablet 10-160 mg 10-320 mg 5-160 mg 5-320 mg
1 ST
amlodipine-valsartan-hcthiazid oral tablet 10-160-125 mg 10-160-25 mg 10-320-25 mg 5-160-125 mg 5-160-25 mg
1
atenolol oral tablet 100 mg 25 mg 50 mg 1
atenolol-chlorthalidone oral tablet 100-25 mg 50-25 mg
1
benazepril oral tablet 10 mg 20 mg 40 mg 5 mg 1
benazepril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg 5-625 mg
1
betaxolol oral tablet 10 mg 20 mg 1
bisoprolol fumarate oral tablet 10 mg 5 mg 1
bisoprolol-hydrochlorothiazide oral tablet 10-625 mg 25-625 mg 5-625 mg
1
bumetanide injection solution 025 mgml 1
bumetanide oral tablet 05 mg 1 mg 2 mg 1
BYSTOLIC ORAL TABLET 10 MG 25 MG 20 MG 5 MG
1 ST
candesartan oral tablet 16 mg 32 mg 4 mg 8 mg 1
46
Drug Name Drug Tier Requirements Limits
candesartan-hydrochlorothiazid oral tablet 16-125 mg 32-125 mg 32-25 mg
1
captopril oral tablet 100 mg 125 mg 25 mg 50 mg
1
captopril-hydrochlorothiazide oral tablet 25-15 mg 25-25 mg 50-15 mg 50-25 mg
1
cartia xt oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg
1
carvedilol oral tablet 125 mg 25 mg 3125 mg 625 mg
1
carvedilol phosphate oral capsule er multiphase 24 hr 10 mg 20 mg 40 mg 80 mg
1
chlorthalidone oral tablet 25 mg 50 mg 1
clonidine hcl oral tablet 01 mg 02 mg 03 mg 1
clonidine transdermal patch weekly 01 mg24 hr 02 mg24 hr 03 mg24 hr
1
diltiazem hcl oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg
1
diltiazem hcl oral capsuleextended release 12 hr 120 mg 60 mg 90 mg
1
diltiazem hcl oral capsuleextended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
diltiazem hcl oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg 360 mg
1
diltiazem hcl oral tablet 120 mg 30 mg 60 mg 90 mg
1
diltiazem hcl oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
dilt-xr oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg
1
doxazosin oral tablet 1 mg 2 mg 4 mg 8 mg 1
EDARBI ORAL TABLET 40 MG 80 MG 1 ST
EDARBYCLOR ORAL TABLET 40-125 MG 40-25 MG
1 ST
enalapril maleate oral tablet 10 mg 25 mg 20 mg 5 mg
1
enalaprilat intravenous solution 125 mgml MB
enalapril-hydrochlorothiazide oral tablet 10-25 mg 5-125 mg
1
EPANED ORAL SOLUTION 1 MGML 1
47
Drug Name Drug Tier Requirements Limits
eplerenone oral tablet 25 mg 50 mg 1
epoprostenol (glycine) intravenous recon soln 05 mg 15 mg
MB PA LA
eprosartan oral tablet 600 mg 1
ethacrynic acid oral tablet 25 mg 1
felodipine oral tablet extended release 24 hr 10 mg 25 mg 5 mg
1
FLOLAN INTRAVENOUS RECON SOLN 05 MG 15 MG
MB PA LA
fosinopril oral tablet 10 mg 20 mg 40 mg 1
fosinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg
1
furosemide oral solution 10 mgml 40 mg5 ml (8 mgml)
1
furosemide oral tablet 20 mg 40 mg 80 mg 1
guanfacine oral tablet 1 mg 2 mg 1
hydralazine oral tablet 10 mg 100 mg 25 mg 50 mg
1
hydrochlorothiazide oral capsule 125 mg 1
hydrochlorothiazide oral tablet 125 mg 25 mg 50 mg
1
indapamide oral tablet 125 mg 25 mg 1
irbesartan oral tablet 150 mg 300 mg 75 mg 1
irbesartan-hydrochlorothiazide oral tablet 150-125 mg 300-125 mg
1
isradipine oral capsule 25 mg 5 mg 1
labetalol oral tablet 100 mg 200 mg 300 mg 1
lisinopril oral tablet 10 mg 25 mg 20 mg 30 mg 40 mg 5 mg
1
lisinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg
1
losartan oral tablet 100 mg 25 mg 50 mg 1
losartan-hydrochlorothiazide oral tablet 100-125 mg 100-25 mg 50-125 mg
1
matzim la oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
methyldopa oral tablet 250 mg 500 mg 1
methyldopa-hydrochlorothiazide oral tablet 250-15 mg 250-25 mg
1
48
Drug Name Drug Tier Requirements Limits
methyldopate intravenous solution 250 mg5 ml MB
metolazone oral tablet 10 mg 25 mg 5 mg 1
metoprolol succinate oral tablet extended release 24 hr 100 mg 200 mg 25 mg 50 mg
1
metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg 100-50 mg 50-25 mg
1
metoprolol tartrate oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg
1
metyrosine oral capsule 250 mg 1
minoxidil oral tablet 10 mg 25 mg 1
moexipril oral tablet 15 mg 75 mg 1
nadolol oral tablet 20 mg 40 mg 80 mg 1
nadolol-bendroflumethiazide oral tablet 80-5 mg 1
nicardipine oral capsule 20 mg 30 mg 1
nifedipine oral capsule 10 mg 20 mg 1
nifedipine oral tablet extended release 24hr 30 mg 60 mg 90 mg
1
nifedipine oral tablet extended release 30 mg 60 mg 90 mg
1
nimodipine oral capsule 30 mg 1
nisoldipine oral tablet extended release 24 hr 17 mg 20 mg 255 mg 30 mg 34 mg 40 mg 85 mg
1
olmesartan oral tablet 20 mg 40 mg 5 mg 1
olmesartan-amlodipin-hcthiazid oral tablet 20-5-125 mg 40-10-125 mg 40-10-25 mg 40-5-125 mg 40-5-25 mg
1
olmesartan-hydrochlorothiazide oral tablet 20-125 mg 40-125 mg 40-25 mg
1 ST
ORENITRAM ORAL TABLET EXTENDED RELEASE 0125 MG 025 MG 1 MG 25 MG 5 MG
2 PA LA
perindopril erbumine oral tablet 2 mg 4 mg 8 mg 1
phenoxybenzamine oral capsule 10 mg 1
pindolol oral tablet 10 mg 5 mg 1
prazosin oral capsule 1 mg 2 mg 5 mg 1
propranolol oral capsuleextended release 24 hr 120 mg 160 mg 60 mg 80 mg
1
propranolol oral solution 20 mg5 ml (4 mgml) 40 mg5 ml (8 mgml)
1
49
Drug Name Drug Tier Requirements Limits
propranolol oral tablet 10 mg 20 mg 40 mg 60 mg 80 mg
1
propranolol-hydrochlorothiazid oral tablet 40-25 mg 80-25 mg
1
QBRELIS ORAL SOLUTION 1 MGML 1
quinapril oral tablet 10 mg 20 mg 40 mg 5 mg 1
quinapril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg
1
ramipril oral capsule 125 mg 10 mg 25 mg 5 mg
1
spironolactone oral tablet 100 mg 25 mg 50 mg 1
spironolacton-hydrochlorothiaz oral tablet 25-25 mg
1
taztia xt oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg
1
TEKTURNA HCT ORAL TABLET 150-125 MG 150-25 MG 300-125 MG 300-25 MG
1
telmisartan oral tablet 20 mg 40 mg 80 mg 1
telmisartan-amlodipine oral tablet 40-10 mg 40-5 mg 80-10 mg 80-5 mg
1 ST
telmisartan-hydrochlorothiazid oral tablet 40-125 mg 80-125 mg 80-25 mg
1
terazosin oral capsule 1 mg 10 mg 2 mg 5 mg 1
tiadylt er oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg 420 mg
1
timolol maleate oral tablet 10 mg 20 mg 5 mg 1
torsemide oral tablet 10 mg 100 mg 20 mg 5 mg 1
trandolapril oral tablet 1 mg 2 mg 4 mg 1
trandolapril-verapamil oral tablet ir - er biphasic 24hr 1-240 mg 2-180 mg 2-240 mg 4-240 mg
1 ST
triamterene oral capsule 100 mg 50 mg 1
triamterene-hydrochlorothiazid oral capsule 375-25 mg
1
triamterene-hydrochlorothiazid oral tablet 375-25 mg 75-50 mg
1
valsartan oral tablet 160 mg 320 mg 40 mg 80 mg
1
valsartan-hydrochlorothiazide oral tablet 160-125 mg 160-25 mg 320-125 mg 320-25 mg 80-125 mg
1
50
Drug Name Drug Tier Requirements Limits
veletri intravenous recon soln 05 mg 15 mg MB PA LA
verapamil oral capsule 24 hr er pellet ct 100 mg 200 mg 300 mg
1
verapamil oral capsuleext rel pellets 24 hr 120 mg 180 mg 240 mg 360 mg
1
verapamil oral tablet 120 mg 40 mg 80 mg 1
verapamil oral tablet extended release 120 mg 180 mg 240 mg
1
CARDIAC GLYCOSIDES
digitek oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
digox oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
digoxin oral solution 50 mcgml (005 mgml) 1
digoxin oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
COAGULATION THERAPY
ADVATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 4000 (+-) UNIT 500 (+-) UNIT
MB
ADYNOVATE INTRAVENOUS SOLUTION 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT 750 (+-) UNIT
MB LA
AFSTYLA INTRAVENOUS RECON SOLN 1000 (+-) UNIT RANGE 1500 (+-) UNIT RANGE 2000 (+-) UNIT RANGE 2500 (+-) UNIT RANGE 250 (+-) UNIT RANGE 3000 (+-) UNIT RANGE 500 (+-) UNIT RANGE
MB LA
ALPHANATE INTRAVENOUS RECON SOLN 1000 (400 VWF) UNIT10 ML 1500 (600 VWF) UNIT10 ML 2000 (800 VWF) UNIT10 ML 250 (100 VWF) UNIT5 ML 500 (200 VWF) UNIT5 ML
MB LA
ALPHANINE SD INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT
MB LA
ALPROLIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 500 UNIT
MB LA
aminocaproic acid oral solution 250 mgml (25 ) 1
51
Drug Name Drug Tier Requirements Limits
aminocaproic acid oral tablet 1000 mg 500 mg 1
ANDEXXA INTRAVENOUS RECON SOLN 200 MG
MB
aspirin-dipyridamole oral capsule er multiphase 12 hr 25-200 mg
1
BENEFIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
BRILINTA ORAL TABLET 60 MG 90 MG 1
CABLIVI INJECTION KIT 11 MG 2 PA
cilostazol oral tablet 100 mg 50 mg 1
clopidogrel oral tablet 300 mg 75 mg 1
COAGADEX INTRAVENOUS RECON SOLN 250 (+-) UNIT RANGE 500 (+-) UNIT RANGE
MB
CORIFACT INTRAVENOUS RECON SOLN 1000-1600 UNIT
MB LA
dipyridamole oral tablet 25 mg 50 mg 75 mg 1
DOPTELET (15 TAB PACK) ORAL TABLET 20 MG
2 PA LA
ELIQUIS DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 5 MG (74 TABS)
1
ELIQUIS ORAL TABLET 25 MG 5 MG 1
ELOCTATE INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 5000 UNIT 500 UNIT 6000 UNIT 750 UNIT
MB LA
enoxaparin subcutaneous solution 300 mg3 ml 2
enoxaparin subcutaneous syringe 100 mgml 120 mg08 ml 150 mgml 30 mg03 ml 40 mg04 ml 60 mg06 ml 80 mg08 ml
2
ESPEROCT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
FEIBA NF INTRAVENOUS RECON SOLN 1750-3250 UNIT 350-650 UNIT 700-1300 UNIT
MB LA
FIBRYGA INTRAVENOUS RECON SOLN 1 GRAM (700 MG- 1300 MG)
MB
fondaparinux subcutaneous syringe 10 mg08 ml 25 mg05 ml 5 mg04 ml 75 mg06 ml
2
52
Drug Name Drug Tier Requirements Limits
FRAGMIN SUBCUTANEOUS SOLUTION 25000 ANTI-XA UNITML
2
FRAGMIN SUBCUTANEOUS SYRINGE 10000 ANTI-XA UNITML 12500 ANTI-XA UNIT05 ML 15000 ANTI-XA UNIT06 ML 18000 ANTI-XA UNIT072 ML 2500 ANTI-XA UNIT02 ML 5000 ANTI-XA UNIT02 ML 7500 ANTI-XA UNIT03 ML
2
HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG07 ML 150 MGML 30 MGML 60 MG04 ML
2 PA LA
HEMOFIL M HIGH INTRAVENOUS RECON SOLN 801-1500 UNIT
MB
HEMOFIL M LOW INTRAVENOUS RECON SOLN 220-400 UNIT
MB
HEMOFIL M MID INTRAVENOUS RECON SOLN 401-800 UNIT
MB
HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 1501-2000 UNIT
MB
hep flush-10 (pf) intravenous solution 10 unitml MB
heparin (porcine) in 5 dex intravenous parenteral solution 25000 unit250 ml(100 unitml) 25000 unit500 ml (50 unitml)
MB
heparin (porcine) injection cartridge 5000 unitml (1 ml)
1
heparin (porcine) injection solution 1000 unitml 10000 unitml 20000 unitml 5000 unitml
1
heparin lock flush (porcine) intravenous solution 100 unitml
MB
heparin lockflush(porcine)(pf) intravenous syringe 100 unitml
MB
HEPARIN(PORCINE) IN 045 NACL INTRAVENOUS PARENTERAL SOLUTION 12500 UNIT250 ML
MB
heparin(porcine) in 045 nacl intravenous parenteral solution 25000 unit250 ml 25000 unit500 ml
MB
heparin porcine (pf) injection solution 1000 unitml 5000 unit05 ml
MB
heparin porcine (pf) injection syringe 5000 unit05 ml
1
53
Drug Name Drug Tier Requirements Limits
heparin porcine (pf) intravenous solution 100 unitml (1 ml)
MB
heparin porcine (pf) intravenous syringe 10 unitml 100 unitml
MB
HUMATE-P INTRAVENOUS RECON SOLN 1000-2400 UNIT 250-600 UNIT 500-1200 UNIT
MB LA
IDELVION INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3500 (+-) UNIT 500 (+-) UNIT
MB LA
IXINITY INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
jantoven oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg
1
JIVI INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
KOATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB
KOGENATE FS INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB
KOVALTRY INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB
MONONINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT
MB LA
MULPLETA ORAL TABLET 3 MG 2 PA LA
NOVOEIGHT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
NOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1000 MCG) 2 MG (2000 MCG) 5 MG (5000 MCG) 8 MG (8000 MCG)
MB LA
NPLATE SUBCUTANEOUS RECON SOLN 125 MCG 250 MCG 500 MCG
MB LA
NUWIQ INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 2500 UNIT 250 (+-) UNIT 3000 UNIT 4000 UNIT 500 (+-) UNIT
MB LA
54
Drug Name Drug Tier Requirements Limits
OBIZUR INTRAVENOUS RECON SOLN 500 (+-) UNIT RANGE
MB
pentoxifylline oral tablet extended release 400 mg 1
phytonadione (vitamin k1) oral tablet 5 mg 1
prasugrel oral tablet 10 mg 5 mg 1
PROFILNINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT
MB LA
PROMACTA ORAL POWDER IN PACKET 125 MG
2 PA ST LA
PROMACTA ORAL POWDER IN PACKET 25 MG
2 LA
PROMACTA ORAL TABLET 125 MG 25 MG 50 MG 75 MG
2 PA ST LA
REBINYN INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 500 (+-) UNIT
MB LA
RECOMBINATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB LA
RIASTAP INTRAVENOUS RECON SOLN 1 GRAM (900MG-1300MG)
MB LA
RIXUBIS INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
tranexamic acid intravenous solution 1000 mg10 ml (100 mgml)
MB
TRETTEN INTRAVENOUS RECON SOLN 2500 UNIT
MB LA
VONVENDI INTRAVENOUS RECON SOLN 1300 (+-) UNIT RANGE 650 (+-) UNIT RANGE
MB LA
warfarin oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg
1
WILATE INTRAVENOUS RECON SOLN 1000-1000 UNIT 500-500 UNIT
MB LA
XARELTO DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 15 MG (42)- 20 MG (9)
1
XARELTO ORAL TABLET 10 MG 15 MG 25 MG 20 MG
1
55
Drug Name Drug Tier Requirements Limits
XYNTHA INTRAVENOUS SOLUTION 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB LA
XYNTHA SOLOFUSE INTRAVENOUS SYRINGE 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
ZONTIVITY ORAL TABLET 208 MG 1
LIPIDCHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg 25-10 mg 25-20 mg 25-40 mg 5-10 mg 5-20 mg 5-40 mg 5-80 mg
1 ST
atorvastatin oral tablet 10 mg 20 mg ACA PV
atorvastatin oral tablet 40 mg 80 mg 1
cholestyramine (with sugar) oral powder 4 gram 1
cholestyramine (with sugar) oral powder in packet 4 gram
1
cholestyramine light oral powder 4 gram 1
cholestyramine light oral powder in packet 4 gram 1
colesevelam oral powder in packet 375 gram 1
colesevelam oral tablet 625 mg 1
colestipol oral granules 5 gram 1
colestipol oral packet 5 gram 1
colestipol oral tablet 1 gram 1
ezetimibe oral tablet 10 mg 1
ezetimibe-simvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg
1
fenofibrate micronized oral capsule 130 mg 134 mg 200 mg 43 mg 67 mg
1
fenofibrate nanocrystallized oral tablet 145 mg 48 mg
1
FENOFIBRATE ORAL CAPSULE 150 MG 50 MG
1
fenofibrate oral tablet 120 mg 160 mg 40 mg 54 mg
1
fenofibric acid (choline) oral capsuledelayed release(drec) 135 mg 45 mg
1
fenofibric acid oral tablet 105 mg 35 mg 1
fluvastatin oral capsule 20 mg 40 mg ACA PV
56
Drug Name Drug Tier Requirements Limits
fluvastatin oral tablet extended release 24 hr 80 mg
ACA PV
gemfibrozil oral tablet 600 mg 1
icosapent ethyl oral capsule 1 gram 1 PA ST QL (120 per 30 days)
JUXTAPID ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 5 MG 60 MG
2 PA LA QL (30 per 30 days)
LIPOFEN ORAL CAPSULE 150 MG 50 MG 1
lovastatin oral tablet 10 mg 20 mg 40 mg ACA PV
niacin oral tablet 500 mg 1
niacin oral tablet extended release 24 hr 1000 mg 500 mg 750 mg
1
NIACOR ORAL TABLET 500 MG 1
omega-3 acid ethyl esters oral capsule 1 gram 1
pravastatin oral tablet 10 mg 20 mg 40 mg 80 mg
ACA PV
prevalite oral powder 4 gram 1
prevalite oral powder in packet 4 gram 1
REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG35 ML
1 PA ST
REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MGML
1 PA ST
REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MGML
1 PA ST
rosuvastatin oral tablet 10 mg 5 mg ACA PV
rosuvastatin oral tablet 20 mg 40 mg 1
simvastatin oral tablet 10 mg 20 mg 40 mg 5 mg ACA PV
simvastatin oral tablet 80 mg 1
VASCEPA ORAL CAPSULE 05 GRAM 1 GRAM
1 PA ST QL (120 per 30 days)
ZYPITAMAG ORAL TABLET 2 MG 4 MG 1 PA ST
MISCELLANEOUS CARDIOVASCULAR AGENTS
CORLANOR ORAL SOLUTION 5 MG5 ML 1 PA
CORLANOR ORAL TABLET 5 MG 75 MG 1 PA
ENTRESTO ORAL TABLET 24-26 MG 49-51 MG 97-103 MG
1 PA ST
GIAPREZA INTRAVENOUS SOLUTION 25 MGML
MB
57
Drug Name Drug Tier Requirements Limits
ranolazine oral tablet extended release 12 hr 1000 mg 500 mg
1 ST
NITRATES
GONITRO SUBLINGUAL POWDER IN PACKET 400 MCG
1
isosorbide dinitrate oral tablet 10 mg 20 mg 30 mg 40 mg 5 mg
1
isosorbide mononitrate oral tablet 10 mg 20 mg 1
isosorbide mononitrate oral tablet extended release 24 hr 120 mg 30 mg 60 mg
1
MINITRAN TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 04 MGHR 06 MGHR
1 PA ST
nitro-bid transdermal ointment 2 1
NITRO-DUR TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 03 MGHR 04 MGHR 06 MGHR 08 MGHR
1 PA ST
nitroglycerin in 5 dextrose intravenous solution 25 mg250 ml (100 mcgml) 50 mg500 ml (100 mcgml)
MB
nitroglycerin sublingual tablet 03 mg 04 mg 06 mg
1
nitroglycerin transdermal patch 24 hour 01 mghr 02 mghr 04 mghr 06 mghr
1
nitroglycerin translingual spraynon-aerosol 400 mcgspray
1
nitro-time oral capsule extended release 25 mg 65 mg 9 mg
1
DERMATOLOGICALSTOPICAL THERAPY
ANTIPSORIATIC ANTISEBORRHEIC
acitretin oral capsule 10 mg 175 mg 25 mg 1
calcipotriene scalp solution 0005 1
calcipotriene topical cream 0005 1
calcipotriene topical ointment 0005 1
calcipotriene-betamethasone topical ointment 0005-0064
1
calcitriol topical ointment 3 mcggram 1
COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
58
Drug Name Drug Tier Requirements Limits
COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
COSENTYX SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
COSENTYX SUBCUTANEOUS SYRINGE 75 MG05 ML
2 PA LA
hydrocortisone-pramoxine topical cream 25-1 1
ILUMYA SUBCUTANEOUS SYRINGE 100 MGML
2 PA ST LA
selenium sulfide topical lotion 25 1
selenium sulfide topical shampoo 225 23 1
SILIQ SUBCUTANEOUS SYRINGE 210 MG15 ML
2 PA ST LA
SKYRIZI SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
SKYRIZI SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
SKYRIZI SUBCUTANEOUS SYRINGE KIT 150MG166ML(75 MG083 ML X2)
2 PA ST LA
STELARA INTRAVENOUS SOLUTION 130 MG26 ML
MB PA LA
STELARA SUBCUTANEOUS SOLUTION 45 MG05 ML
2 PA ST LA
STELARA SUBCUTANEOUS SYRINGE 45 MG05 ML 90 MGML
2 PA ST LA
sulfacetamide sodium topical cleanser 10 1
sulfacetamide sodium topical cleanser gel 10 1
sulfacetamide sodium topical shampoo 10 1
TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MGML
2 PA ST LA
59
Drug Name Drug Tier Requirements Limits
TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 MGML
2 PA ST LA
TREMFYA SUBCUTANEOUS SYRINGE 100 MGML
2 PA ST LA
BURN THERAPY
silver sulfadiazine topical cream 1 1
ssd topical cream 1 1
MISCELLANEOUS DERMATOLOGICALS
ammonium lactate topical cream 12 1
ammonium lactate topical lotion 12 1
diclofenac sodium topical gel 3 1
DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300 MG2 ML
2 LA
DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG114 ML 300 MG2 ML
2 PA ST LA
EUCRISA TOPICAL OINTMENT 2 1 PA ST
FLUOROURACIL TOPICAL CREAM 05 1 PA ST
fluorouracil topical cream 5 1 PA ST
fluorouracil topical solution 2 5 1
LEVULAN TOPICAL SOLUTION 20 1
methoxsalen oral capsuleliqd-filledrapid rel 10 mg
1
PANRETIN TOPICAL GEL 01 1
PICATO TOPICAL GEL 0015 005 1
pimecrolimus topical cream 1 1
podofilox topical solution 05 1
prudoxin topical cream 5 1
REGRANEX TOPICAL GEL 001 1
SCENESSE SUBCUTANEOUS IMPLANT 16 MG
MB PA
tacrolimus topical ointment 003 01 1
UVADEX INJECTION SOLUTION 20 MCGML 1
VALCHLOR TOPICAL GEL 0016 2 PA ST LA
THERAPY FOR ACNE
accutane oral capsule 20 mg 30 mg 40 mg 1
adapalene topical cream 01 1 ST
60
Drug Name Drug Tier Requirements Limits
adapalene topical gel 03 1 ST
adapalene topical gel with pump 03 1 ST
ADAPALENE TOPICAL LOTION 01 1 ST
adapalene topical solution 01 1 ST
adapalene topical swab 01 1 ST
adapalene-benzoyl peroxide topical gel with pump 01-25
1
amnesteem oral capsule 10 mg 20 mg 40 mg 1 PA ST
avita topical cream 0025 1
AVITA TOPICAL GEL 0025 1 ST
azelaic acid topical gel 15 1
AZELEX TOPICAL CREAM 20 1 ST
claravis oral capsule 10 mg 20 mg 30 mg 1 PA ST
claravis oral capsule 40 mg 1
clindacin p topical swab 1 1
clindamycin phosphate topical foam 1 1
clindamycin phosphate topical gel 1 1
clindamycin phosphate topical lotion 1 1
clindamycin phosphate topical solution 1 1
clindamycin phosphate topical swab 1 1
clindamycin-benzoyl peroxide topical gel 1-5 12 (1 base) -5
1
clindamycin-benzoyl peroxide topical gel with pump 1-5
1
clindamycin-tretinoin topical gel 12-0025 1
dapsone topical gel 5 1
ery pads topical swab 2 1
erygel topical gel 2 1
erythromycin with ethanol topical gel 2 1
erythromycin with ethanol topical solution 2 1
erythromycin-benzoyl peroxide topical gel 3-5 1
isotretinoin oral capsule 10 mg 20 mg 25 mg 30 mg 35 mg 40 mg
1
metronidazole topical cream 075 1
metronidazole topical gel 075 1 1
metronidazole topical gel with pump 1 1
61
Drug Name Drug Tier Requirements Limits
metronidazole topical lotion 075 1
myorisan oral capsule 10 mg 20 mg 30 mg 40 mg
1
rosadan topical cream 075 1
rosadan topical gel 075 1
tazarotene topical cream 01 1 ST
tretinoin microspheres topical gel 004 01 1
tretinoin microspheres topical gel with pump 004 01
1
tretinoin topical cream 0025 005 01 1
tretinoin topical gel 001 0025 005 1
zenatane oral capsule 10 mg 20 mg 30 mg 40 mg 1
TOPICAL ANESTHETICS
lidocaine hcl injection solution 10 mgml (1 ) 1
lidocaine hcl laryngotracheal solution 4 1
lidocaine hcl mucous membrane jelly 2 1
lidocaine hcl mucous membrane jelly in applicator 2
1
lidocaine hcl mucous membrane solution 4 (40 mgml)
1
lidocaine hcl-hydrocortison ac topical cream 3-05
1
lidocaine topical adhesive patchmedicated 5 1
lidocaine topical ointment 5 1
lidocaine viscous mucous membrane solution 2 1
lidocaine-prilocaine topical cream 25-25 1
lidocaine-prilocaine topical kit 25-25 1
LIDOCAINE-TETRACAINE TOPICAL CREAM 7-7
1 ST
SYNERA TOPICAL PATCH MEDICATED SELF-HEATING 70-70 MG
1 ST
TOPICAL ANTIBACTERIALS
ALCORTIN A TOPICAL GEL 2-1-1 1 ST
ALCORTIN A TOPICAL GEL IN PACKET 2-1-1
1 ST
ALTABAX TOPICAL OINTMENT 1 1
gentamicin topical cream 01 1
62
Drug Name Drug Tier Requirements Limits
gentamicin topical ointment 01 1
mafenide acetate topical packet 50 gram 1
mupirocin calcium topical cream 2 1
mupirocin topical ointment 2 1
sulfacetamide sodium (acne) topical suspension 10
1
SULFAMYLON TOPICAL CREAM 85 MGG 1
TOPICAL ANTIFUNGALS
ciclodan topical cream 077 1
ciclodan topical solution 8 1
ciclopirox topical cream 077 1
ciclopirox topical gel 077 1
ciclopirox topical shampoo 1 1
ciclopirox topical solution 8 1
ciclopirox topical suspension 077 1
ciclopirox-ure-camph-menth-euc topical solution 8
1
clotrimazole topical cream 1 1
clotrimazole topical solution 1 1
clotrimazole-betamethasone topical cream 1-005
1
clotrimazole-betamethasone topical lotion 1-005
1
econazole topical cream 1 1
EXELDERM TOPICAL CREAM 1 1
EXELDERM TOPICAL SOLUTION 1 1
JUBLIA TOPICAL SOLUTION WITH APPLICATOR 10
1 PA ST
ketoconazole topical cream 2 1
ketoconazole topical foam 2 1
ketoconazole topical shampoo 2 1
ketodan topical foam 2 1
LULICONAZOLE TOPICAL CREAM 1 1
LUZU TOPICAL CREAM 1 1
MENTAX TOPICAL CREAM 1 1
naftifine topical cream 1 2 1
63
Drug Name Drug Tier Requirements Limits
naftifine topical gel 1 1
nyamyc topical powder 100000 unitgram 1
nystatin topical cream 100000 unitgram 1
nystatin topical ointment 100000 unitgram 1
nystatin topical powder 100000 unitgram 1
nystatin-triamcinolone topical cream 100000-01 unitg-
1
nystatin-triamcinolone topical ointment 100000-01 unitgram-
1
nystop topical powder 100000 unitgram 1
oxiconazole topical cream 1 1
OXISTAT TOPICAL LOTION 1 1
tavaborole topical solution with applicator 5 1 PA ST
TOPICAL ANTIVIRALS
acyclovir topical cream 5 1
acyclovir topical ointment 5 1
DENAVIR TOPICAL CREAM 1 1
TOPICAL CORTICOSTEROIDS
ala-cort topical cream 1 1
alclometasone topical cream 005 1
alclometasone topical ointment 005 1
amcinonide topical cream 01 1
amcinonide topical lotion 01 1
apexicon e topical cream 005 1
beser topical lotion 005 1
betamethasone dipropionate topical cream 005 1
betamethasone dipropionate topical lotion 005 1
betamethasone dipropionate topical ointment 005
1
betamethasone valerate topical cream 01 1
betamethasone valerate topical foam 012 1
betamethasone valerate topical lotion 01 1
betamethasone valerate topical ointment 01 1
betamethasone augmented topical cream 005 1
betamethasone augmented topical gel 005 1
betamethasone augmented topical lotion 005 1
64
Drug Name Drug Tier Requirements Limits
betamethasone augmented topical ointment 005
1
clobetasol scalp solution 005 1
clobetasol topical cream 005 1
clobetasol topical foam 005 1
clobetasol topical gel 005 1
clobetasol topical lotion 005 1
clobetasol topical ointment 005 1
clobetasol topical shampoo 005 1
clobetasol topical spraynon-aerosol 005 1
clobetasol-emollient topical cream 005 1
clobetasol-emollient topical foam 005 1
CLOCORTOLONE PIVALATE TOPICAL CREAM 01
1 ST
CLODERM TOPICAL CREAM 01 1 ST
desonide topical cream 005 1
desonide topical lotion 005 1
desonide topical ointment 005 1
desoximetasone topical cream 005 025 1
desoximetasone topical gel 005 1
desoximetasone topical ointment 005 025 1
desoximetasone topical spraynon-aerosol 025 1
diflorasone topical cream 005 1
diflorasone topical ointment 005 1
fluocinolone and shower cap scalp oil 001 1
fluocinolone topical cream 001 0025 1
fluocinolone topical oil 001 1
fluocinolone topical ointment 0025 1
fluocinolone topical solution 001 1
fluocinonide topical cream 005 01 1
fluocinonide topical gel 005 1
fluocinonide topical ointment 005 1
fluocinonide topical solution 005 1
fluocinonide-e topical cream 005 1
flurandrenolide topical cream 005 1
65
Drug Name Drug Tier Requirements Limits
flurandrenolide topical lotion 005 1
flurandrenolide topical ointment 005 1
fluticasone propionate topical cream 005 1
fluticasone propionate topical lotion 005 1
fluticasone propionate topical ointment 0005 1
halcinonide topical cream 01 1
halobetasol propionate topical cream 005 1
halobetasol propionate topical ointment 005 1
hydrocortisone butyrate topical cream 01 1
hydrocortisone butyrate topical lotion 01 1
hydrocortisone butyrate topical ointment 01 1
hydrocortisone butyrate topical solution 01 1
hydrocortisone butyr-emollient topical cream 01
1
hydrocortisone topical cream 1 25 1
hydrocortisone topical lotion 25 1
hydrocortisone topical ointment 1 25 1
hydrocortisone valerate topical cream 02 1
hydrocortisone valerate topical ointment 02 1
mometasone topical cream 01 1
mometasone topical ointment 01 1
mometasone topical solution 01 1
prednicarbate topical cream 01 1
prednicarbate topical ointment 01 1
scalacort topical lotion 2 1
triamcinolone acetonide topical aerosol 0147 mggram
1
triamcinolone acetonide topical cream 0025 01 05
1
triamcinolone acetonide topical lotion 0025 01
1
triamcinolone acetonide topical ointment 0025 005 01 05
1
triderm topical cream 01 05 1
TOPICAL ENZYMES
SANTYL TOPICAL OINTMENT 250 UNITGRAM
1 QL (2 per 30 days)
66
Drug Name Drug Tier Requirements Limits
TOPICAL SCABICIDES PEDICULICIDES
crotan topical lotion 10 1
EURAX TOPICAL CREAM 10 1
EURAX TOPICAL LOTION 10 1
ivermectin topical lotion 05 1
lindane topical shampoo 1 1
malathion topical lotion 05 1
permethrin topical cream 5 1
spinosad topical suspension 09 1
ULESFIA TOPICAL LOTION 5 1
DIAGNOSTICS amp MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
PHYSIOLYTE IRRIGATION SOLUTION 140-5-3-98 MEQL
MB
PHYSIOSOL IRRIGATION IRRIGATION SOLUTION 140-5-3-98 MEQL
MB
MISCELLANEOUS AGENTS
acamprosate oral tabletdelayed release (drec) 333 mg
1
acetic acid irrigation solution 025 1
anagrelide oral capsule 05 mg 1 mg 1
ARALAST NP INTRAVENOUS RECON SOLN 1000 MG 500 MG
MB LA
CARBAGLU ORAL TABLET DISPERSIBLE 200 MG
2 PA LA
cevimeline oral capsule 30 mg 1
CHEMET ORAL CAPSULE 100 MG 1
clovique oral capsule 250 mg 1 PA QL (240 per 30 days)
deferasirox oral granules in packet 180 mg 360 mg 90 mg
2 PA LA
deferasirox oral tablet 180 mg 2 PA LA
deferasirox oral tablet 360 mg 90 mg 2 ST LA
deferasirox oral tablet dispersible 125 mg 250 mg 500 mg
2 ST LA
deferiprone oral tablet 500 mg 1 PA
disulfiram oral tablet 250 mg 500 mg 1
67
Drug Name Drug Tier Requirements Limits
EMPAVELI SUBCUTANEOUS SOLUTION 1080 MG20 ML
2 PA
FERRIPROX ORAL SOLUTION 100 MGML 1 PA
FERRIPROX ORAL TABLET 1000 MG 500 MG
1 PA
GIVLAARI SUBCUTANEOUS SOLUTION 189 MGML
MB PA LA
GLASSIA INTRAVENOUS SOLUTION 1 GRAM50 ML (2 )
MB LA
INCRELEX SUBCUTANEOUS SOLUTION 10 MGML
2 PA LA
levocarnitine (with sugar) oral solution 100 mgml 1
levocarnitine oral solution 100 mgml 1
levocarnitine oral tablet 330 mg 1
midodrine oral tablet 10 mg 25 mg 5 mg 1
nitisinone oral capsule 10 mg 2 mg 5 mg 2 PA LA
NITYR ORAL TABLET 10 MG 2 MG 5 MG 2 PA LA
pilocarpine hcl oral tablet 5 mg 1
PROLASTIN-C INTRAVENOUS SOLUTION 1000 MG (+-)20 ML
MB
RAVICTI ORAL LIQUID 11 GRAMML 2 PA ST LA QL (10 per 30 days)
RECLAST INTRAVENOUS PIGGYBACK 5 MG100 ML
MB
riluzole oral tablet 50 mg 1
risedronate oral tablet 30 mg 1
sodium chloride 09 injection solution MB
sodium chloride 09 intravenous parenteral solution
MB
sodium chloride 09 intravenous piggyback MB
sodium phenylbutyrate oral powder 094 gramgram
1 PA
sodium phenylbutyrate oral tablet 500 mg 1 PA
SOLIRIS INTRAVENOUS SOLUTION 300 MG30 ML
MB PA LA
trientine oral capsule 250 mg 1 PA QL (240 per 30 days)
XURIDEN ORAL GRANULES IN PACKET 2 GRAM
2 PA QL (120 per 30 days)
68
Drug Name Drug Tier Requirements Limits
ZEMAIRA INTRAVENOUS RECON SOLN 1000 MG
MB LA
ZOKINVY ORAL CAPSULE 50 MG 75 MG 2 PA ST
SMOKING DETERRENTS
bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg
ACA PV
CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG
ACA PV QL (180 per 365 days)
CHANTIX ORAL TABLET 05 MG 1 MG ACA PV QL (180 per 365 days)
CHANTIX STARTING MONTH BOX ORAL TABLETSDOSE PACK 05 MG (11)- 1 MG (42)
ACA PV QL (180 per 365 days)
nicorette buccal gum 4 mg ACA PV
nicotine (polacrilex) buccal gum 2 mg 4 mg ACA PV
nicotine (polacrilex) buccal lozenge 2 mg 4 mg ACA PV
nicotine (polacrilex) buccal mini lozenge 2 mg 4 mg
ACA PV
nicotine transdermal patch 24 hour 14 mg24 hr 21 mg24 hr 7 mg24 hr
ACA PV
nicotine transdermal patch td daily sequential 21-14-7 mg24 hr
ACA PV
NICOTROL INHALATION CARTRIDGE 10 MG
ACA PV
NICOTROL NS NASAL SPRAYNON-AEROSOL 10 MGML
ACA PV
quit 2 buccal gum 2 mg ACA PV
quit 2 buccal lozenge 2 mg ACA PV
quit 4 buccal gum 4 mg ACA PV
quit 4 buccal lozenge 4 mg ACA PV
stop smoking aid buccal lozenge 2 mg 4 mg ACA PV
EAR NOSE amp THROAT MEDICATIONS
MISCELLANEOUS AGENTS
ARESTIN DENTAL CARTRIDGE 1 MG MB
azelastine nasal aerosolspray 137 mcg (01 ) 1
azelastine nasal spraynon-aerosol 2055 mcg (015 )
1
chlorhexidine gluconate mucous membrane mouthwash 012
1
denta 5000 plus dental cream 11 1
69
Drug Name Drug Tier Requirements Limits
dentagel dental gel 11 1
fluoride (sodium) dental cream 11 1
fluoride (sodium) dental gel 11 1
fluoride (sodium) dental paste 11 1
ipratropium bromide nasal spraynon-aerosol 21 mcg (003 ) 42 mcg (006 )
1
olopatadine nasal spraynon-aerosol 06 1
oralone dental paste 01 1
paroex oral rinse mucous membrane mouthwash 012
1
periogard mucous membrane mouthwash 012 1
pilocarpine hcl oral tablet 75 mg 1
sf 5000 plus dental cream 11 1
sf dental gel 11 1
sodium fluoride 5000 dry mouth dental gel 11 1
sodium fluoride 5000 plus dental cream 11 1
sodium fluoride-pot nitrate dental paste 11-5 1
triamcinolone acetonide dental paste 01 1
MISCELLANEOUS OTIC PREPARATIONS
acetic acid otic (ear) solution 2 1
ciprofloxacin hcl otic (ear) dropperette 02 1
flac otic oil otic (ear) drops 001 1
fluocinolone acetonide oil otic (ear) drops 001 1
hydrocortisone-acetic acid otic (ear) drops 1-2 1
ofloxacin otic (ear) drops 03 1
OTIC STEROID ANTIBIOTIC
CIPRO HC OTIC (EAR) DROPSSUSPENSION 02-1
1
ciprofloxacin-dexamethasone otic (ear) dropssuspension 03-01
1
neomycin-polymyxin-hc otic (ear) dropssuspension 35-10000-1 mgml-unitml-
1
neomycin-polymyxin-hc otic (ear) solution 35-10000-1 mgml-unitml-
1
OTOVEL OTIC (EAR) SOLUTION 03-0025 (025 ML)
1
ENDOCRINEDIABETES
70
Drug Name Drug Tier Requirements Limits
ADRENAL HORMONES
ACTHAR INJECTION GEL 80 UNITML 2 PA LA
decadron oral tablet 05 mg 1
dexamethasone intensol oral drops 1 mgml 1
dexamethasone oral elixir 05 mg5 ml 1
dexamethasone oral solution 05 mg5 ml 1
dexamethasone oral tablet 05 mg 075 mg 1 mg 15 mg 2 mg 4 mg 6 mg
1
dexamethasone oral tabletsdose pack 15 mg (21 tabs) 15 mg (35 tabs) 15 mg (51 tabs)
1
dexamethasone sodium phos (pf) injection solution 10 mgml
1
dexamethasone sodium phosphate injection solution 10 mgml 4 mgml
1
dexamethasone sodium phosphate injection syringe 4 mgml
1
fludrocortisone oral tablet 01 mg 1
hydrocortisone oral tablet 10 mg 20 mg 5 mg 1
methylprednisolone acetate injection suspension 40 mgml 80 mgml
1
methylprednisolone oral tablet 16 mg 32 mg 4 mg 8 mg
1
methylprednisolone oral tabletsdose pack 4 mg 1
millipred dp oral tabletsdose pack 5 mg (21 tabs) 5 mg (48 tabs)
1
millipred oral tablet 5 mg 1
prednisolone oral solution 15 mg5 ml 1
prednisolone sodium phosphate oral solution 10 mg5 ml 15 mg5 ml (3 mgml) 20 mg5 ml (4 mgml) 25 mg5 ml (5 mgml) 5 mg base5 ml (67 mg5 ml)
1
prednisolone sodium phosphate oral tabletdisintegrating 10 mg 15 mg 30 mg
1
prednisone intensol oral concentrate 5 mgml 1
prednisone oral solution 5 mg5 ml 1
prednisone oral tablet 1 mg 10 mg 25 mg 20 mg 5 mg 50 mg
1
prednisone oral tabletsdose pack 10 mg 5 mg 1
71
Drug Name Drug Tier Requirements Limits
triamcinolone acetonide injection suspension 40 mgml
MB
ANTITHYROID AGENTS
methimazole oral tablet 10 mg 5 mg 1
propylthiouracil oral tablet 50 mg 1
SSKI ORAL SOLUTION 1 GRAMML 1
BLOOD GLUCOSE MONITORING DEVICES amp SUPPLIES
CONTOUR NEXT TEST STRIPS STRIP 1
CONTOUR TEST STRIPS STRIP 1
ONETOUCH ULTRA TEST STRIP 1
ONETOUCH VERIO TEST STRIPS STRIP 1
DIABETES SUPPLIES amp DURABLE MEDICAL EQUIPMENT
AEROCHAMBER MINI SPACER 1
AEROCHAMBER PLUS FLOW-VU SPACER 1
GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN 1 MGML
1
GLUCAGON HCL INJECTION RECON SOLN 1 MGML
1
INSULIN SYRINGE-NEEDLE U-100 SYRINGE 05 ML 29 GAUGE X 12
1
TRIJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-5-1000 MG 125-25-1000 MG 25-5-1000 MG 5-25-1000 MG
1 PA ST
GLUCOSE ELEVATING AGENTS
BAQSIMI NASAL SPRAYNON-AEROSOL 3 MGACTUATION
1
diazoxide oral suspension 50 mgml 1
GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG
1
GLUCAGON (HCL) EMERGENCY KIT INJECTION RECON SOLN 1 MG
1
glucagon emergency kit (human) injection recon soln 1 mg
1
INSULIN SYRINGESMISCELLANEOUS DURABLE MEDICAL EQU
FREESTYLE LIBRE 14 DAY SENSOR KIT 1
FREESTYLE LIBRE 2 SENSOR KIT 1
NOVOPEN ECHO SUBCUTANEOUS INSULIN PEN
1
72
Drug Name Drug Tier Requirements Limits
PEN NEEDLE DIABETIC NEEDLE 29 GAUGE X 12
1
INSULIN THERAPY
FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
FIASP PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML (3 ML)
1
FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN HALF-UNIT 100 UNITML
1
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML
1 ST
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 200 UNITML (3 ML)
1
HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNITML (50-50)
1 ST
HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (50-50)
1 ST
HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (75-25)
1 ST
HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNITML (75-25)
1 ST
HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML
1 ST
HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1 ST
HUMULIN 7030 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)
1 ST
HUMULIN 7030 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1 ST
73
Drug Name Drug Tier Requirements Limits
HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1 ST
HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML
1 ST
HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNITML
1 ST
HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNITML
1
HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNITML (3 ML)
1
INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML (70-30)
1
INSULIN ASPART U-100 SUBCUTANEOUS CARTRIDGE 100 UNITML
1
INSULIN ASPART U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
INSULIN ASPART U-100 SUBCUTANEOUS SOLUTION 100 UNITML
1
LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
NOVOLIN R FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
74
Drug Name Drug Tier Requirements Limits
NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNITML (70-30)
1
NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML
1
NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML
1
RELION NOVOLIN 7030 SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)
1
RELION NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNITML
1
RELION NOVOLIN R INJECTION SOLUTION 100 UNITML
1
SOLIQUA 10033 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCGML
1 PA ST
TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNITML (3 ML)
1
TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNITML (15 ML)
1
TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN 200 UNITML (3 ML)
1
TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
XULTOPHY 10036 SUBCUTANEOUS INSULIN PEN 100 UNIT-36 MG ML (3 ML)
1 PA ST
MISCELLANEOUS HORMONES
ALDURAZYME INTRAVENOUS SOLUTION 29 MG5 ML
MB PA LA
ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG24 HOUR 4 MG24 HR
1 ST QL (30 per 30 days)
75
Drug Name Drug Tier Requirements Limits
BRINEURA INTRAVENTRICULAR KIT 300 MG10 ML (150MG5ML X2)
MB
cabergoline oral tablet 05 mg 1
calcitonin (salmon) injection solution 200 unitml 1
calcitonin (salmon) nasal spraynon-aerosol 200 unitactuation
1
calcitriol oral capsule 025 mcg 05 mcg 1
calcitriol oral solution 1 mcgml 1
CERDELGA ORAL CAPSULE 84 MG 2 PA LA
CEREZYME INTRAVENOUS RECON SOLN 400 UNIT
MB PA LA
cinacalcet oral tablet 30 mg 60 mg 90 mg 2 PA
CRYSVITA SUBCUTANEOUS SOLUTION 10 MGML 20 MGML 30 MGML
MB PA LA
danazol oral capsule 100 mg 200 mg 50 mg 1
DEPO-TESTOSTERONE INTRAMUSCULAR OIL 100 MGML
1
desmopressin nasal spraynon-aerosol 10 mcgspray (01 ml)
1
desmopressin oral tablet 01 mg 02 mg 1
doxercalciferol oral capsule 05 mcg 1 mcg 25 mcg
1
ELAPRASE INTRAVENOUS SOLUTION 6 MG3 ML
MB PA LA
ELELYSO INTRAVENOUS RECON SOLN 200 UNIT
MB PA LA
FABRAZYME INTRAVENOUS RECON SOLN 35 MG 5 MG
MB PA LA
GALAFOLD ORAL CAPSULE 123 MG 2 PA LA
JYNARQUE ORAL TABLET 15 MG 30 MG 2 PA QL (60 per 30 days)
JYNARQUE ORAL TABLETS SEQUENTIAL 45 MG (AM) 15 MG (PM) 60 MG (AM) 30 MG (PM) 90 MG (AM) 30 MG (PM)
2 PA QL (60 per 30 days)
KANUMA INTRAVENOUS SOLUTION 2 MGML
MB PA LA
KORLYM ORAL TABLET 300 MG 2 PA ST
LUMIZYME INTRAVENOUS RECON SOLN 50 MG
MB PA LA
76
Drug Name Drug Tier Requirements Limits
MEPSEVII INTRAVENOUS SOLUTION 2 MGML
MB PA LA
methyltestosterone oral capsule 10 mg 1
MIACALCIN INJECTION SOLUTION 200 UNITML
1
miglustat oral capsule 100 mg 2 PA LA
MYALEPT SUBCUTANEOUS RECON SOLN 5 MGML (FINAL CONC)
2 LA
NAGLAZYME INTRAVENOUS SOLUTION 5 MG5 ML
MB PA LA
NATPARA SUBCUTANEOUS CARTRIDGE 100 MCGDOSE 25 MCGDOSE 50 MCGDOSE 75 MCGDOSE
2 PA ST LA
oxandrolone oral tablet 10 mg 25 mg 1
PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG05 ML 25 MG05 ML 20 MGML
2 PA LA
pamidronate intravenous solution 30 mg10 ml (3 mgml)
MB
PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCGML
MB
paricalcitol intravenous solution 5 mcgml MB
paricalcitol oral capsule 1 mcg 2 mcg 4 mcg 1
PARSABIV INTRAVENOUS SOLUTION 5 MGML
MB PA
SAMSCA ORAL TABLET 15 MG 2 PA LA QL (60 per 30 days)
sapropterin oral powder in packet 100 mg 500 mg 2 PA LA
sapropterin oral tabletsoluble 100 mg 2 PA LA
SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG 15 MG 20 MG 25 MG 30 MG
2 PA LA QL (30 per 30 days)
STRENSIQ SUBCUTANEOUS SOLUTION 18 MG045 ML 28 MG07 ML 40 MGML 80 MG08 ML
2 PA
SYNAREL NASAL SPRAYNON-AEROSOL 2 MGML
1
TEPEZZA INTRAVENOUS RECON SOLN 500 MG
MB PA LA
testosterone cypionate intramuscular oil 100 mgml 200 mgml
1
testosterone enanthate intramuscular oil 200 mgml
1
77
Drug Name Drug Tier Requirements Limits
testosterone transdermal gel 50 mg5 gram (1 ) 1 QL (60 per 30 days)
testosterone transdermal gel in metered-dose pump 10 mg05 gram actuation 2025 mg125 gram (162 )
1 QL (2 per 30 days)
testosterone transdermal gel in metered-dose pump 125 mg 125 gram (1 )
1 QL (4 per 30 days)
testosterone transdermal gel in packet 1 (25 mg25gram) 162 (2025 mg125 gram)
1 QL (30 per 30 days)
testosterone transdermal gel in packet 1 (50 mg5 gram) 162 (405 mg25 gram)
1 QL (60 per 30 days)
testosterone transdermal solution in metered pump wapp 30 mgactuation (15 ml)
1 QL (2 per 30 days)
VIMIZIM INTRAVENOUS SOLUTION 5 MG5 ML (1 MGML)
MB PA LA
VPRIV INTRAVENOUS RECON SOLN 400 UNIT
MB PA LA
NON-INSULIN HYPOGLYCEMIC AGENTS
acarbose oral tablet 100 mg 25 mg 50 mg 1
ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 125-15 MG 125-30 MG 125-45 MG 25-15 MG 25-30 MG 25-45 MG
1 PA ST
BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG085 ML
1 PA ST
BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCGDOSE(250 MCGML) 24 ML 5 MCGDOSE (250 MCGML) 12 ML
1 PA ST
CYCLOSET ORAL TABLET 08 MG 1
FARXIGA ORAL TABLET 10 MG 5 MG 1 PA ST
glimepiride oral tablet 1 mg 2 mg 4 mg 1
glipizide oral tablet 10 mg 5 mg 1
glipizide oral tablet extended release 24hr 10 mg 25 mg 5 mg
1
glipizide-metformin oral tablet 25-250 mg 25-500 mg 5-500 mg
1
glyburide micronized oral tablet 15 mg 3 mg 6 mg
1
glyburide oral tablet 125 mg 25 mg 5 mg 1
glyburide-metformin oral tablet 125-250 mg 25-500 mg 5-500 mg
1
78
Drug Name Drug Tier Requirements Limits
GLYXAMBI ORAL TABLET 10-5 MG 25-5 MG
1 PA ST
JANUMET ORAL TABLET 50-1000 MG 50-500 MG
1 PA ST
JANUMET XR ORAL TABLET ER MULTIPHASE 24 HR 100-1000 MG 50-1000 MG 50-500 MG
1 PA ST
JANUVIA ORAL TABLET 100 MG 25 MG 50 MG
1 PA ST
JARDIANCE ORAL TABLET 10 MG 25 MG 1 PA ST
JENTADUETO ORAL TABLET 25-1000 MG 25-500 MG 25-850 MG
1 PA ST
JENTADUETO XR ORAL TABLET IR - ER BIPHASIC 24HR 25-1000 MG 5-1000 MG
1 PA ST
metformin oral solution 500 mg5 ml 1 PA
metformin oral tablet 1000 mg 500 mg 850 mg 1
metformin oral tablet extended release 24 hr 500 mg 750 mg
1
metformin oral tablet extended release 24hr 1000 mg 500 mg
1 PA ST
metformin oral tableter gastretention 24 hr 1000 mg 500 mg
1 ST
miglitol oral tablet 100 mg 25 mg 50 mg 1
nateglinide oral tablet 120 mg 60 mg 1
OZEMPIC SUBCUTANEOUS PEN INJECTOR 025 MG OR 05 MG(2 MG15 ML) 1 MGDOSE (2 MG15 ML) 1 MGDOSE (4 MG3 ML)
1 PA ST
pioglitazone oral tablet 15 mg 30 mg 45 mg 1
pioglitazone-glimepiride oral tablet 30-2 mg 30-4 mg
1
pioglitazone-metformin oral tablet 15-500 mg 15-850 mg
1
QTERN ORAL TABLET 10-5 MG 5-5 MG 1 PA ST
repaglinide oral tablet 05 mg 1 mg 2 mg 1
repaglinide-metformin oral tablet 1-500 mg 2-500 mg
1
RIOMET ER ORAL SUSPENSIONEXTENDED REL RECON 500 MG5 ML
1 PA ST
79
Drug Name Drug Tier Requirements Limits
RYBELSUS ORAL TABLET 14 MG 3 MG 7 MG
1 PA ST
SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2700 MCG27 ML
1 PA ST
SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1500 MCG15 ML
1 PA ST
SYNJARDY ORAL TABLET 125-1000 MG 125-500 MG 5-1000 MG 5-500 MG
1 PA ST
SYNJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 125-1000 MG 25-1000 MG 5-1000 MG
1 PA ST
TRADJENTA ORAL TABLET 5 MG 1 PA ST
TRULICITY SUBCUTANEOUS PEN INJECTOR 075 MG05 ML 15 MG05 ML 3 MG05 ML 45 MG05 ML
1 PA ST
XIGDUO XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 10-500 MG 25-1000 MG 5-1000 MG 5-500 MG
1 PA ST
THYROID HORMONES
ARMOUR THYROID ORAL TABLET 120 MG 15 MG 180 MG 240 MG 30 MG 300 MG 60 MG 90 MG
1
levothyroxine oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 300 mcg 50 mcg 75 mcg 88 mcg
1
levoxyl oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 50 mcg 75 mcg 88 mcg
1
liothyronine oral tablet 25 mcg 5 mcg 50 mcg 1
np thyroid oral tablet 120 mg 15 mg 30 mg 60 mg 90 mg
1
SYNTHROID ORAL TABLET 100 MCG 112 MCG 125 MCG 137 MCG 150 MCG 175 MCG 200 MCG 25 MCG 300 MCG 50 MCG 75 MCG 88 MCG
1
THYROLAR-1 ORAL TABLET 125-50 MCG 1
THYROLAR-12 ORAL TABLET 625-25 MCG 1
THYROLAR-14 ORAL TABLET 31-125 MCG 1
THYROLAR-2 ORAL TABLET 25-100 MCG 1
THYROLAR-3 ORAL TABLET 375-150 MCG 1
80
Drug Name Drug Tier Requirements Limits
unithroid oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 300 mcg 50 mcg 75 mcg 88 mcg
1
westhroid oral tablet 130 mg 195 mg 325 mg 65 mg 975 mg
1
GASTROENTEROLOGY
ANTIDIARRHEALS amp ANTISPASMODICS
anaspaz oral tabletdisintegrating 0125 mg 1
atropine injection syringe 005 mgml 01 mgml 1
belladonna alkaloids-opium rectal suppository 162-30 mg 162-60 mg
1 PA ST
chlordiazepoxide-clidinium oral capsule 5-25 mg 1
dicyclomine intramuscular solution 10 mgml MB
dicyclomine oral capsule 10 mg 1
dicyclomine oral solution 10 mg5 ml 1
dicyclomine oral tablet 20 mg 1
diphenoxylate-atropine oral liquid 25-0025 mg5 ml
1
diphenoxylate-atropine oral tablet 25-0025 mg 1
DONNATAL ORAL TABLET 162-01037 -00194 MG
1
ed-spaz oral tabletdisintegrating 0125 mg 1
glycopyrrolate injection solution 02 mgml 1
glycopyrrolate oral tablet 1 mg 15 mg 2 mg 1
hyoscyamine sulfate oral drops 0125 mgml 1
hyoscyamine sulfate oral elixir 0125 mg5 ml 1
hyoscyamine sulfate oral tablet 0125 mg 1
hyoscyamine sulfate oral tablet extended release 12 hr 0375 mg
1
hyoscyamine sulfate oral tabletdisintegrating 0125 mg
1
hyoscyamine sulfate sublingual tablet 0125 mg 1
hyosyne oral drops 0125 mgml 1
hyosyne oral elixir 0125 mg5 ml 1
loperamide oral capsule 2 mg 1
methscopolamine oral tablet 25 mg 5 mg 1
MOTOFEN ORAL TABLET 1-0025 MG 1
81
Drug Name Drug Tier Requirements Limits
opium tincture oral tincture 10 mgml (morphine) 1
oscimin oral tablet 0125 mg 1
oscimin sl sublingual tablet 0125 mg 1
oscimin sr oral tablet extended release 12 hr 0375 mg
1
phenobarb-hyoscy-atropine-scop oral elixir 162-01037 -00194 mg5 ml
1
phenobarb-hyoscy-atropine-scop oral tablet 162-01037 -00194 mg
1
phenohytro oral elixir 162-01037 -00194 mg5 ml
1
phenohytro oral tablet 162-01037 -00194 mg 1
symax fastabs oral tabletdisintegrating 0125 mg 1
symax-sl sublingual tablet 0125 mg 1
symax-sr oral tablet extended release 12 hr 0375 mg
1
MISCELLANEOUS GASTROINTESTINAL AGENTS
AKYNZEO (NETUPITANT) ORAL CAPSULE 300-05 MG
1 QL (1 per 30 days)
alosetron oral tablet 05 mg 1 mg 1
ALOXI INTRAVENOUS SOLUTION 025 MG5 ML
MB
AMITIZA ORAL CAPSULE 24 MCG 8 MCG 1 PA
anucort-hc rectal suppository 25 mg 1
aprepitant oral capsule 125 mg 40 mg 1 QL (1 per 30 days)
aprepitant oral capsule 80 mg 1 QL (2 per 30 days)
aprepitant oral capsuledose pack 125 mg (1)- 80 mg (2)
1 QL (1 per 30 days)
balsalazide oral capsule 750 mg 1
budesonide oral capsuledelayedextendrelease 3 mg
1
calcium acetate(phosphat bind) oral capsule 667 mg
1
calcium acetate(phosphat bind) oral tablet 667 mg 1
CHOLBAM ORAL CAPSULE 250 MG 50 MG 2
CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)
2 PA ST LA
82
Drug Name Drug Tier Requirements Limits
CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG2 ML (200 MGML X 2)
2 PA ST LA
CLENPIQ ORAL SOLUTION 10 MG-35 GRAM -12 GRAM160 ML
ACA PV
compro rectal suppository 25 mg 1
constulose oral solution 10 gram15 ml 1
CORTIFOAM RECTAL FOAM 10 (80 MG) 1
CREON ORAL CAPSULEDELAYED RELEASE(DREC) 12000-38000 -60000 UNIT 24000-76000 -120000 UNIT 3000-9500- 15000 UNIT 36000-114000- 180000 UNIT 6000-19000 -30000 UNIT
1 PA
cromolyn oral concentrate 100 mg5 ml 1
DIPENTUM ORAL CAPSULE 250 MG 1 PA ST
doxylamine-pyridoxine (vit b6) oral tabletdelayed release (drec) 10-10 mg
1
dronabinol oral capsule 10 mg 25 mg 5 mg 1
EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG ML FINAL CONC)
1
ENTYVIO INTRAVENOUS RECON SOLN 300 MG
MB PA LA
enulose oral solution 10 gram15 ml 1
gavilyte-c oral recon soln 240-2272-672 -584 gram
ACA PV
gavilyte-g oral recon soln 236-2274-674 -586 gram
ACA PV
gavilyte-n oral recon soln 420 gram ACA PV
generlac oral solution 10 gram15 ml 1
granisetron hcl oral tablet 1 mg 1 QL (6 per 30 days)
hemmorex-hc rectal suppository 25 mg 1
hydrocortisone acetate rectal suppository 25 mg 30 mg
1
hydrocortisone rectal enema 100 mg60 ml 1
hydrocortisone topical cream with perineal applicator 1 25
1
hydrocortisone-pramoxine rectal cream 1-1 25-1 25-1 (4g)
1
INFLECTRA INTRAVENOUS RECON SOLN 100 MG
MB PA LA
83
Drug Name Drug Tier Requirements Limits
lactulose oral packet 10 gram 1
lactulose oral solution 10 gram15 ml 20 gram30 ml
1
lanthanum oral tabletchewable 1000 mg 500 mg 750 mg
1
lidocaine hcl-hydrocortison ac rectal cream 3-05
1
LIDOCAINE HCL-HYDROCORTISON AC RECTAL GEL 3 -25 (7 GRAM)
1
lidocaine hcl-hydrocortison ac rectal kit 2 -2 (7 gram)
1 ST
lidocaine hcl-hydrocortison ac rectal kit 3-05 3-1 (7 gram)
1 PA ST
lidocaine-hydrocortisone-aloe rectal gel 28-055
1
lidocaine-hydrocortisone-aloe rectal kit 3-25 (7 gram)
1 PA ST
LINZESS ORAL CAPSULE 145 MCG 290 MCG 72 MCG
1 PA
meclizine oral tablet 125 mg 25 mg 1
mesalamine oral capsuleextended release 24hr 0375 gram
1
mesalamine oral tabletdelayed release (drec) 12 gram 800 mg
1
mesalamine rectal enema 4 gram60 ml 1
mesalamine rectal suppository 1000 mg 1
mesalamine with cleansing wipe rectal enema kit 4 gram60 ml
1 ST
metoclopramide hcl injection solution 5 mgml MB
metoclopramide hcl injection syringe 5 mgml MB
metoclopramide hcl oral solution 5 mg5 ml 1
metoclopramide hcl oral tablet 10 mg 5 mg 1
metoclopramide hcl oral tabletdisintegrating 10 mg 5 mg
1
MOVANTIK ORAL TABLET 125 MG 25 MG 1 PA ST
NULYTELY LEMON-LIME ORAL RECON SOLN 420 GRAM
ACA PV
ondansetron hcl intravenous solution 2 mgml MB
ondansetron hcl oral solution 4 mg5 ml 1 QL (100 per 30 days)
84
Drug Name Drug Tier Requirements Limits
ondansetron hcl oral tablet 4 mg 8 mg 1 QL (9 per 30 days)
ondansetron oral tabletdisintegrating 4 mg 8 mg 1 QL (9 per 30 days)
OSMOPREP ORAL TABLET 15 GRAM ACA PV
peg 3350-electrolytes oral recon soln 236-2274-674 -586 gram
ACA PV
peg3350-sod sul-nacl-kcl-asb-c oral powder in packet 100-75-2691 gram
ACA PV
peg-electrolyte soln oral recon soln 420 gram ACA PV
peg-prep oral kit 5-210 mg-gram ACA PV
PLENVU ORAL POWDER IN PACKET SEQUENTIAL 140-9-52 GRAM
ACA PV
prochlorperazine edisylate injection solution 10 mg2 ml (5 mgml) 5 mgml
1
prochlorperazine maleate oral tablet 10 mg 5 mg 1
prochlorperazine rectal suppository 25 mg 1
procto-med hc topical cream with perineal applicator 25
1
procto-pak topical cream with perineal applicator 1
1
proctosol hc topical cream with perineal applicator 25
1
proctozone-hc topical cream with perineal applicator 25
1
RECTIV RECTAL OINTMENT 04 (WW) 1
RELISTOR ORAL TABLET 150 MG 1
RELISTOR SUBCUTANEOUS SOLUTION 12 MG06 ML
1
RELISTOR SUBCUTANEOUS SYRINGE 12 MG06 ML 8 MG04 ML
1
REMICADE INTRAVENOUS RECON SOLN 100 MG
MB PA LA
RENFLEXIS INTRAVENOUS RECON SOLN 100 MG
MB PA LA
scopolamine base transdermal patch 3 day 1 mg over 3 days
1
sevelamer carbonate oral powder in packet 08 gram 24 gram
1
sevelamer carbonate oral tablet 800 mg 1
sevelamer hcl oral tablet 400 mg 800 mg 1
85
Drug Name Drug Tier Requirements Limits
sodium polystyrene sulfonate oral powder 1
sps (with sorbitol) oral suspension 15-20 gram60 ml
1
sps (with sorbitol) rectal enema 30-40 gram120 ml
1
SUCRAID ORAL SOLUTION 8500 UNITML 2 PA ST QL (2 per 30 days)
sulfasalazine oral tablet 500 mg 1
sulfasalazine oral tabletdelayed release (drec) 500 mg
1
SUPREP BOWEL PREP KIT ORAL RECON SOLN 175-313-16 GRAM
ACA PV ST
trilyte with flavor packets oral recon soln 420 gram
ACA PV
trimethobenzamide oral capsule 300 mg 1
ursodiol oral capsule 300 mg 1
ursodiol oral tablet 250 mg 500 mg 1
VARUBI ORAL TABLET 90 MG 1
VELPHORO ORAL TABLETCHEWABLE 500 MG
1 ST
VIBERZI ORAL TABLET 100 MG 75 MG 1 PA ST
ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 10000-32000 -42000 UNIT 15000-47000 -63000 UNIT 20000-63000- 84000 UNIT 3000-10000 -14000-UNIT 40000-126000- 168000 UNIT 5000-17000- 24000 UNIT
1 PA
ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 25000-79000- 105000 UNIT
1
ULCER THERAPY
amoxicil-clarithromy-lansopraz oral combo pack 500-500-30 mg
1
cimetidine hcl oral solution 300 mg5 ml 1
cimetidine oral tablet 200 mg 300 mg 400 mg 800 mg
1
DEXILANT ORAL CAPSULEBIPHASE DELAYED RELEAS 30 MG 60 MG
1 ST
esomeprazole magnesium oral capsuledelayed release(drec) 20 mg 40 mg
1
famotidine (pf) intravenous solution 20 mg2 ml MB
86
Drug Name Drug Tier Requirements Limits
famotidine oral suspension 40 mg5 ml (8 mgml) 1
famotidine oral tablet 20 mg 40 mg 1
lansoprazole oral capsuledelayed release(drec) 15 mg 30 mg
1
lansoprazole oral tabletdisintegrat delay rel 15 mg 30 mg
1
misoprostol oral tablet 100 mcg 200 mcg 1
nizatidine oral capsule 150 mg 300 mg 1
nizatidine oral solution 150 mg10 ml 1
omeprazole oral capsuledelayed release(drec) 10 mg 20 mg 40 mg
1
pantoprazole oral tabletdelayed release (drec) 20 mg 40 mg
1
rabeprazole oral tabletdelayed release (drec) 20 mg
1
sucralfate oral suspension 100 mgml 1
sucralfate oral tablet 1 gram 1
IMMUNOLOGY VACCINES amp BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCGML 200 MCGML 25 MCGML 300 MCGML 40 MCGML 60 MCGML
2 LA
ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG04 ML 100 MCG05 ML 150 MCG03 ML 200 MCG04 ML 25 MCG042 ML 300 MCG06 ML 40 MCG04 ML 500 MCGML 60 MCG03 ML
2 LA
EPOGEN INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML
2 LA
GRANIX SUBCUTANEOUS SOLUTION 300 MCGML 480 MCG16 ML
2
GRANIX SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML
2
LEUKINE INJECTION RECON SOLN 250 MCG 2 PA ST
MIRCERA INJECTION SYRINGE 100 MCG03 ML 150 MCG03 ML 200 MCG03 ML 30 MCG03 ML 50 MCG03 ML 75 MCG03 ML
MB
87
Drug Name Drug Tier Requirements Limits
MOZOBIL SUBCUTANEOUS SOLUTION 24 MG12 ML (20 MGML)
MB LA
NEUPOGEN INJECTION SOLUTION 300 MCGML 480 MCG16 ML
2 PA ST
NEUPOGEN INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML
2 PA ST
NIVESTYM INJECTION SOLUTION 300 MCGML 480 MCG16 ML
2
NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML
2
PROCRIT INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML 40000 UNITML
2 LA
UDENYCA SUBCUTANEOUS SYRINGE 6 MG06 ML
2 PA ST
ZARXIO INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML
2 PA ST
ZIEXTENZO SUBCUTANEOUS SYRINGE 6 MG06 ML
2 PA ST
GROWTH HORMONES
GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 02 MG025 ML 04 MG025 ML 06 MG025 ML 08 MG025 ML 1 MG025 ML 12 MG025 ML 14 MG025 ML 16 MG025 ML 18 MG025 ML 2 MG025 ML
2 PA ST LA
GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MGML (36 UNITML) 5 MGML (15 UNITML)
2 PA ST LA
OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG15 ML (67 MGML) 5 MG15 ML (33 MGML)
2 PA ST LA
OMNITROPE SUBCUTANEOUS RECON SOLN 58 MG
2 PA ST LA
SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG 5 MG 6 MG
2 PA ST LA
ZORBTIVE SUBCUTANEOUS RECON SOLN 88 MG
2 PA ST LA
INTERFERONS
AUBAGIO ORAL TABLET 14 MG 7 MG 2 PA LA
88
Drug Name Drug Tier Requirements Limits
AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG05 ML
2 PA ST LA QL (4 per 30 days)
AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG05 ML
2 PA ST LA QL (4 per 30 days)
BETASERON SUBCUTANEOUS KIT 03 MG 2 PA LA QL (14 per 30 days)
dimethyl fumarate oral capsuledelayed release(drec) 120 mg
2 PA LA QL (14 per 365 days)
dimethyl fumarate oral capsuledelayed release(drec) 120 mg (14)- 240 mg (46)
2 PA LA QL (1 per 365 days)
dimethyl fumarate oral capsuledelayed release(drec) 240 mg
2 PA LA QL (60 per 30 days)
GILENYA ORAL CAPSULE 05 MG 2 PA LA QL (30 per 30 days)
glatiramer subcutaneous syringe 20 mgml 2 PA LA QL (30 per 30 days)
glatiramer subcutaneous syringe 40 mgml 2 PA LA QL (12 per 30 days)
glatopa subcutaneous syringe 20 mgml 2 PA LA QL (30 per 30 days)
glatopa subcutaneous syringe 40 mgml 2 PA LA QL (12 per 30 days)
LEMTRADA INTRAVENOUS SOLUTION 12 MG12 ML
MB PA ST LA
MAVENCLAD (10 TABLET PACK) ORAL TABLET 10 MG
2 LA
MAVENCLAD (4 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (5 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (6 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (7 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (8 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (9 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAYZENT ORAL TABLET 025 MG 2 MG 2 PA ST LA QL (30 per 30 days)
MAYZENT STARTER PACK ORAL TABLETSDOSE PACK 025 MG (12 TABS)
2 PA ST LA QL (1 per 365 days)
OCREVUS INTRAVENOUS SOLUTION 30 MGML
MB PA LA
PEGASYS SUBCUTANEOUS SOLUTION 180 MCGML
2 PA LA
89
Drug Name Drug Tier Requirements Limits
PEGASYS SUBCUTANEOUS SYRINGE 180 MCG05 ML
2 PA LA
PLEGRIDY INTRAMUSCULAR SYRINGE 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG05 ML- 94 MCG05 ML
2 PA LA QL (1 per 365 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG05 ML- 94 MCG05 ML
2 PA LA QL (1 per 365 days)
POMALYST ORAL CAPSULE 1 MG 2 MG 3 MG 4 MG
2 PA ST OCh LA
PONVORY 14-DAY STARTER PACK ORAL TABLETSDOSE PACK 2 MG (2) - 10 MG (3)
2 PA LA QL (1 per 365 days)
PONVORY ORAL TABLET 20 MG 2 PA LA QL (30 per 30 days)
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG05 ML 44 MCG05 ML
2 PA LA QL (6 per 30 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG05 ML 44 MCG05 ML
2 PA LA QL (6 per 30 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 88MCG02ML-22 MCG05ML (6)
2 PA LA QL (5 per 30 days)
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 88MCG02ML-22 MCG05ML (6)
2 PA LA QL (5 per 30 days)
REVLIMID ORAL CAPSULE 10 MG 15 MG 25 MG 20 MG 25 MG 5 MG
2 PA ST OCh LA
ribavirin oral capsule 200 mg 2 LA
ribavirin oral tablet 200 mg 2 LA
ZEPOSIA ORAL CAPSULE 092 MG 2 LA QL (30 per 30 days)
ZEPOSIA STARTER KIT ORAL CAPSULEDOSE PACK 023-046-092 MG
2 LA QL (30 per 30 days)
ZEPOSIA STARTER PACK ORAL CAPSULEDOSE PACK 023 MG (4)- 046 MG (3)
2 LA QL (30 per 30 days)
INTERLEUKINS
ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG05 ML
2 PA LA
ARCALYST SUBCUTANEOUS RECON SOLN 220 MG
2 LA
90
Drug Name Drug Tier Requirements Limits
ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MGML
MB PA LA
imiquimod topical cream in packet 5 1
INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) 18 MILLION UNIT (1 ML) 50 MILLION UNIT (1 ML)
2 PA LA
INTRON A INJECTION SOLUTION 10 MILLION UNITML 6 MILLION UNITML
2 PA LA
PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT
MB LA
VACCINES amp MISCELLANEOUS IMMUNOLOGICALS
ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(25-5-3-5 MCG)-5LF05 ML
1 Vac
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(25-5-3-5 MCG)-5LF05 ML
1 Vac
ASCENIV INTRAVENOUS SOLUTION 10 MB PA LA
ATGAM INTRAVENOUS SOLUTION 50 MGML
MB
BCG VACCINE LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG
1 Vac
BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG05 ML
1 Vac
BIOTHRAX INTRAMUSCULAR SUSPENSION 05 MLDOSE
1 Vac
BIVIGAM INTRAVENOUS SOLUTION 10 MB PA LA
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 25-8-5 LF-MCG-LF05ML
1 Vac
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 25-8-5 LF-MCG-LF05ML
1 Vac
BOTOX INJECTION RECON SOLN 100 UNIT 200 UNIT
MB
CUTAQUIG SUBCUTANEOUS SOLUTION 165
MB LA
CUVITRU SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 ) 8 GRAM40 ML (20 )
MB LA
91
Drug Name Drug Tier Requirements Limits
DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF05ML
1 Vac
DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT 500 UNIT
MB LA
ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCGML
1 Vac
ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCGML
1 Vac
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG05 ML
1 Vac
FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 5
MB PA
GAMASTAN INTRAMUSCULAR SOLUTION 15-18 RANGE
MB
GAMASTAN SD INTRAMUSCULAR SOLUTION 15-18 RANGE
MB
GAMMAGARD LIQUID INJECTION SOLUTION 10
MB LA
GAMMAGARD S-D (IGA lt 1 MCGML) INTRAVENOUS RECON SOLN 10 GRAM 5 GRAM
MB PA LA
GAMMAKED INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 20 GRAM200 ML (10 ) 5 GRAM50 ML (10 )
MB LA
GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5
MB PA LA
GAMMAPLEX INTRAVENOUS SOLUTION 10
MB PA LA
GAMUNEX-C INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 25 GRAM25 ML (10 ) 20 GRAM200 ML (10 ) 40 GRAM400 ML (10 ) 5 GRAM50 ML (10 )
MB LA
GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 05 ML
1 Vac
GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 05 ML
1 Vac
GRASTEK SUBLINGUAL TABLET 2800 BAU 1 PA
HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1440 ELISA UNITML
1 Vac
92
Drug Name Drug Tier Requirements Limits
HAVRIX (PF) INTRAMUSCULAR SYRINGE 1440 ELISA UNITML 720 ELISA UNIT05 ML
1 Vac
HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE 20 MCG05 ML
1 Vac
HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )
MB LA
HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM 100 ML (10 ) 25 GRAM 25 ML (10 ) 20 GRAM 200 ML (10 ) 30 GRAM 300 ML (10 ) 5 GRAM 50 ML (10 )
MB LA
IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 25 UNIT
1 Vac
INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF05ML
1 Vac
IPOL INJECTION SUSPENSION 40-8-32 UNIT05 ML
1 Vac
IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG05 ML
1 Vac
KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF05 ML
1 Vac
MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG05 ML
1 Vac
MENQUADFI (PF) INTRAMUSCULAR SOLUTION 10 MCG05 ML
1 Vac
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG05 ML
1 Vac
M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1000-12500 TCID5005 ML
1 Vac
MYOBLOC INTRAMUSCULAR SOLUTION 10000 UNIT2 ML 2500 UNIT05 ML 5000 UNITML
MB LA
OCTAGAM INTRAVENOUS SOLUTION 10 5
MB PA LA
ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY
2 PA
PANZYGA INTRAVENOUS SOLUTION 10 MB PA
PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF05 ML
1 Vac
93
Drug Name Drug Tier Requirements Limits
PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 75 MCG05 ML
1 Vac
PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF05 ML 15LF-48MCG-62DU -10 MCG05ML
1 Vac
PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
PNEUMOVAX-23 INJECTION SOLUTION 25 MCG05 ML
1 Vac
PNEUMOVAX-23 INJECTION SYRINGE 25 MCG05 ML
1 Vac
PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE 05 ML
1 Vac
PRIVIGEN INTRAVENOUS SOLUTION 10 MB PA LA
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-43-3- 399 TCID5005
1 Vac
PROVENGE INTRAVENOUS SUSPENSION 50 MILLION CELL250 ML
MB PA
QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT05ML
1 Vac
RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 25 UNIT
1 Vac
RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT
1 PA
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCGML 40 MCGML 5 MCG05 ML
1 Vac
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCGML 5 MCG05 ML
1 Vac
SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG05 ML
1 Vac
STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1000 UNIT05 ML
1 Vac
TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF UNIT05 ML
1 Vac
94
Drug Name Drug Tier Requirements Limits
TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT05ML
1 Vac
TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT05 ML
1 Vac
TETANUSDIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT05 ML
1 Vac
THYMOGLOBULIN INTRAVENOUS RECON SOLN 25 MG
MB
TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG05 ML
1 Vac
TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCGML
1 Vac
TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG05 ML
1 Vac
TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG05 ML
1 Vac
VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT05 ML 50 UNITML
1 Vac
VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT05 ML 50 UNITML
1 Vac
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1350 UNIT05 ML
1 Vac
VAXELIS (PF) INTRAMUSCULAR SUSPENSION 15 UNIT-5 UNIT- 10 MCG05 ML
1 Vac
VAXELIS (PF) INTRAMUSCULAR SYRINGE 15 UNIT-5 UNIT- 10 MCG05 ML
1 Vac
XEMBIFY SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )
MB LA
XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT 200 UNIT 50 UNIT
MB LA
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP474 UNIT05 ML
1 Vac
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19400 UNIT065 ML
1 Vac
MUSCULOSKELETAL amp RHEUMATOLOGY
95
Drug Name Drug Tier Requirements Limits
GOUT THERAPY
allopurinol oral tablet 100 mg 300 mg 1
COLCHICINE ORAL CAPSULE 06 MG 1
colchicine oral tablet 06 mg 1
febuxostat oral tablet 40 mg 80 mg 1
KRYSTEXXA INTRAVENOUS SOLUTION 8 MGML
MB PA LA
MITIGARE ORAL CAPSULE 06 MG 1
probenecid oral tablet 500 mg 1
probenecid-colchicine oral tablet 500-05 mg 1
OSTEOPOROSIS THERAPY
alendronate oral solution 70 mg75 ml 1
alendronate oral tablet 10 mg 35 mg 5 mg 70 mg 1
EVENITY SUBCUTANEOUS SYRINGE 105 MG117 ML 210MG234ML ( 105MG117MLX2)
2 PA ST LA
FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCGDOSE (620MCG248ML)
2 PA ST LA QL (1 per 30 days)
FOSAMAX PLUS D ORAL TABLET 70 MG- 2800 UNIT 70 MG- 5600 UNIT
1
ibandronate oral tablet 150 mg 1
PROLIA SUBCUTANEOUS SYRINGE 60 MGML
2 ST LA
raloxifene oral tablet 60 mg 2 OCh
risedronate oral tablet 150 mg 35 mg 5 mg 1
risedronate oral tabletdelayed release (drec) 35 mg
1
TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3120 MCG156 ML)
2 PA ST LA
OTHER RHEUMATOLOGICALS
ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG09 ML
2 PA ST LA
ACTEMRA INTRAVENOUS SOLUTION 200 MG10 ML (20 MGML) 400 MG20 ML (20 MGML) 80 MG4 ML (20 MGML)
MB PA LA
ACTEMRA SUBCUTANEOUS SYRINGE 162 MG09 ML
2 PA ST LA
96
Drug Name Drug Tier Requirements Limits
BENLYSTA INTRAVENOUS RECON SOLN 120 MG 400 MG
MB PA LA
BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MGML
2 PA LA
BENLYSTA SUBCUTANEOUS SYRINGE 200 MGML
2 PA LA
ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MGML (1 ML)
2 PA ST LA
ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)
2 PA ST LA
ENBREL SUBCUTANEOUS SOLUTION 25 MG05 ML
2 PA ST LA
ENBREL SUBCUTANEOUS SYRINGE 25 MG05 ML (05) 50 MGML (1 ML)
2 PA ST LA
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MGML (1 ML)
2 PA ST LA
HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG08 ML
2 PA ST LA
HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG08 ML 80 MG08 ML-40 MG04 ML
2 PA ST LA
HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
2 PA ST LA
HUMIRA(CF) PEN PEDIATRIC UC SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
2 PA ST LA
HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML-40 MG04 ML
2 PA ST LA
HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG04 ML
2 PA ST LA
97
Drug Name Drug Tier Requirements Limits
HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG01 ML 20 MG02 ML 40 MG04 ML
2 PA ST LA
KEVZARA SUBCUTANEOUS PEN INJECTOR 150 MG114 ML 200 MG114 ML
2 PA ST LA
KEVZARA SUBCUTANEOUS SYRINGE 150 MG114 ML 200 MG114 ML
2 PA ST LA
leflunomide oral tablet 10 mg 20 mg 1
OLUMIANT ORAL TABLET 1 MG 2 MG 2 PA ST LA
ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG
MB PA LA
ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MGML
2 PA ST LA
ORENCIA SUBCUTANEOUS SYRINGE 125 MGML 50 MG04 ML 875 MG07 ML
2 PA ST LA
OTEZLA ORAL TABLET 30 MG 2 PA ST LA
OTEZLA STARTER ORAL TABLETSDOSE PACK 10 MG (4)-20 MG (4)-30 MG (47)
2 PA ST LA
penicillamine oral capsule 250 mg 1 PA
penicillamine oral tablet 250 mg 1 PA
RIDAURA ORAL CAPSULE 3 MG 1
RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 MG
2 PA ST LA
SAVELLA ORAL TABLET 100 MG 125 MG 25 MG 50 MG
1 PA ST
SAVELLA ORAL TABLETSDOSE PACK 125 MG (5)-25 MG(8)-50 MG(42)
1 PA ST
SIMPONI ARIA INTRAVENOUS SOLUTION 125 MGML
MB PA LA
SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MGML 50 MG05 ML
2 PA ST LA
SIMPONI SUBCUTANEOUS SYRINGE 100 MGML 50 MG05 ML
2 PA ST LA
XELJANZ ORAL SOLUTION 1 MGML 2 PA ST LA
XELJANZ ORAL TABLET 10 MG 5 MG 2 PA ST LA
XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG 22 MG
2 PA ST LA
OBSTETRICS amp GYNECOLOGY
DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES
98
Drug Name Drug Tier Requirements Limits
CAYA CONTOURED VAGINAL DIAPHRAGM 65-80 MM
ACA PV
FC2 FEMALE CONDOM ACA PV
FEMCAP VAGINAL DEVICE 22 MM ACA PV
KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 175 MCG24 HRS (5 YRS) 195 MG
ACA PV
LILETTA INTRAUTERINE INTRAUTERINE DEVICE 201 MCG24 HRS (6 YRS) 52 MG
ACA PV ST
MIRENA INTRAUTERINE INTRAUTERINE DEVICE 20 MCG24 HOURS (6 YRS) 52 MG
ACA PV
PARAGARD T 380A INTRAUTERINE INTRAUTERINE DEVICE 380 SQUARE MM
ACA PV
SKYLA INTRAUTERINE INTRAUTERINE DEVICE 14 MCG24 HRS (3 YRS) 135 MG
ACA PV
WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 MM
ACA PV
ESTROGENS amp PROGESTINS
amabelz oral tablet 05-01 mg 1-05 mg 1
ANGELIQ ORAL TABLET 025-05 MG 05-1 MG
1
camila oral tablet 035 mg ACA PV
COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 005-014 MG24 HR 005-025 MG24 HR
1
covaryx hs oral tablet 0625-125 mg 1
covaryx oral tablet 125-25 mg 1
CRINONE VAGINAL GEL 4 1
deblitane oral tablet 035 mg ACA PV
DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MGML
1
DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MGML
MB
DEPO-PROVERA INTRAMUSCULAR SYRINGE 150 MGML
MB
DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE 104 MG065 ML
ACA PV
99
Drug Name Drug Tier Requirements Limits
DIVIGEL TRANSDERMAL GEL IN PACKET 025 MG025 GRAM (01 ) 05 MG05 GRAM (01 ) 075 MG075 GRAM (01) 1 MGGRAM (01 ) 125 MG125 GRAM (01 )
1 QL (30 per 30 days)
dotti transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
DUAVEE ORAL TABLET 045-20 MG 1
eemt hs oral tablet 0625-125 mg 1
eemt oral tablet 125-25 mg 1
errin oral tablet 035 mg ACA PV
estradiol oral tablet 05 mg 1 mg 2 mg 1
estradiol transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
estradiol transdermal patch weekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 006 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (4 per 30 days)
estradiol vaginal cream 001 (01 mggram) 1
estradiol vaginal tablet 10 mcg 1
estradiol valerate intramuscular oil 20 mgml 40 mgml
1
estradiol-norethindrone acet oral tablet 05-01 mg 1-05 mg
1
ESTRING VAGINAL RING 2 MG (75 MCG 24 HOUR)
1
estrogens-methyltestosterone oral tablet 0625-125 mg 125-25 mg
1
EVAMIST TRANSDERMAL SPRAYNON-AEROSOL 153 MGSPRAY (17)
1 QL (2 per 30 days)
FEMRING VAGINAL RING 005 MG24 HR 01 MG24 HR
1
fyavolv oral tablet 05-25 mg-mcg 1-5 mg-mcg 1
heather oral tablet 035 mg ACA PV
hydroxyprogest(pf)(preg presv) intramuscular oil 250 mgml (1 ml)
2
hydroxyprogesterone cap(ppres) intramuscular oil 250 mgml
2
100
Drug Name Drug Tier Requirements Limits
hydroxyprogesterone caproate intramuscular oil 250 mgml
2
incassia oral tablet 035 mg ACA PV
jencycla oral tablet 035 mg ACA PV
jinteli oral tablet 1-5 mg-mcg 1
lyleq oral tablet 035 mg ACA PV
lyllana transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
lyza oral tablet 035 mg ACA PV
medroxyprogesterone intramuscular suspension 150 mgml
ACA PV
medroxyprogesterone intramuscular syringe 150 mgml
ACA PV
medroxyprogesterone oral tablet 10 mg 25 mg 5 mg
1
MENEST ORAL TABLET 03 MG 0625 MG 125 MG 25 MG
1
MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG24 HR
1 QL (4 per 30 days)
mimvey oral tablet 1-05 mg 1
nora-be oral tablet 035 mg ACA PV
norethindrone (contraceptive) oral tablet 035 mg ACA PV
norethindrone acetate oral tablet 5 mg 1
norethindrone ac-eth estradiol oral tablet 05-25 mg-mcg 1-5 mg-mcg
1
norlyda oral tablet 035 mg ACA PV
PREMARIN INJECTION RECON SOLN 25 MG 1
PREMARIN ORAL TABLET 03 MG 045 MG 0625 MG 09 MG 125 MG
1
PREMARIN VAGINAL CREAM 0625 MGGRAM
1
PREMPHASE ORAL TABLET 0625 MG (14) 0625MG-5MG(14)
1
PREMPRO ORAL TABLET 03-15 MG 045-15 MG 0625-25 MG 0625-5 MG
1
progesterone intramuscular oil 50 mgml 1
progesterone micronized oral capsule 100 mg 200 mg
1
101
Drug Name Drug Tier Requirements Limits
sharobel oral tablet 035 mg ACA PV
tulana oral tablet 035 mg ACA PV
yuvafem vaginal tablet 10 mcg 1
MISCELLANEOUS OBGYN
ANNOVERA VAGINAL RING 015-0013 MG24 HOUR
ACA PV
clindamycin phosphate vaginal cream 2 1
eluryng vaginal ring 012-0015 mg24 hr ACA PV
etonogestrel-ethinyl estradiol vaginal ring 012-0015 mg24 hr
ACA PV
fem ph vaginal gel 09-0025 1
GYNAZOLE-1 VAGINAL CREAM 2 1
gynol ii vaginal gel 3 ACA PV
INTRAROSA VAGINAL INSERT 65 MG 1
isoxsuprine oral tablet 10 mg 20 mg 1
LUPANETA PACK (1 MONTH) KIT SYRINGE AND TABLET 375 MG -5 MG (30)
2 LA
LUPANETA PACK (3 MONTH) KIT SYRINGE AND TABLET 1125 MG -5 MG (90)
2 LA
metronidazole vaginal gel 075 1
NEXPLANON SUBDERMAL IMPLANT 68 MG ACA PV
OSPHENA ORAL TABLET 60 MG 1
PHEXXI VAGINAL GEL 18-1-04 ACA PV
terconazole vaginal cream 04 08 1
terconazole vaginal suppository 80 mg 1
TODAY CONTRACEPTIVE SPONGE VAGINAL CONTRACEPTIVE SPONGE 1000 MG
ACA PV
tranexamic acid oral tablet 650 mg 1
TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 MCG24 HR
ACA PV
vaginal contraceptive foam vaginal foam 125 ACA PV
vandazole vaginal gel 075 1
VCF CONTRACEPTIVE FILM VAGINAL FILM 28
ACA PV
VCF CONTRACEPTIVE GEL VAGINAL GEL 4
ACA PV
102
Drug Name Drug Tier Requirements Limits
xulane transdermal patch weekly 150-35 mcg24 hr
ACA PV
zafemy transdermal patch weekly 150-35 mcg24 hr
ACA PV
ORAL CONTRACEPTIVES amp RELATED AGENTS
afirmelle oral tablet 01-20 mg-mcg ACA PV
altavera (28) oral tablet 015-003 mg ACA PV
alyacen 135 (28) oral tablet 1-35 mg-mcg ACA PV
alyacen 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
amethia oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
amethyst (28) oral tablet 90-20 mcg (28) ACA PV
apri oral tablet 015-003 mg ACA PV
aranelle (28) oral tablet 05105-35 mg-mcg ACA PV
ashlyna oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
aubra eq oral tablet 01-20 mg-mcg ACA PV
aubra oral tablet 01-20 mg-mcg ACA PV
aurovela 1530 (21) oral tablet 15-30 mg-mcg ACA PV
aurovela 120 (21) oral tablet 1-20 mg-mcg ACA PV
aurovela 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
aurovela fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
aurovela fe 1-20 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
aviane oral tablet 01-20 mg-mcg ACA PV
ayuna oral tablet 015-003 mg ACA PV
azurette (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
BALCOLTRA ORAL TABLET 01 MG-002 MG (21)365 MG(7)
ACA PV
balziva (28) oral tablet 04-35 mg-mcg ACA PV
blisovi 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
blisovi fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
103
Drug Name Drug Tier Requirements Limits
blisovi fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
briellyn oral tablet 04-35 mg-mcg ACA PV
camrese lo oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)
ACA PV
camrese oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
caziant (28) oral tablet 0112515-25 mg-mcg ACA PV
charlotte 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
chateal (28) oral tablet 015-003 mg ACA PV
chateal eq (28) oral tablet 015-003 mg ACA PV
cryselle (28) oral tablet 03-30 mg-mcg ACA PV
cyclafem 135 (28) oral tablet 1-35 mg-mcg ACA PV
cyclafem 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
cyred eq oral tablet 015-003 mg ACA PV
cyred oral tablet 015-003 mg ACA PV
dasetta 135 (28) oral tablet 1-35 mg-mcg ACA PV
dasetta 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
daysee oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
desog-eestradioleestradiol oral tablet 015-002 mgx21 001 mg x 5
ACA PV
desogestrel-ethinyl estradiol oral tablet 015-003 mg
ACA PV
dolishale oral tablet 90-20 mcg (28) ACA PV
drospirenone-eestradiol-lmfa oral tablet 3-002-0451 mg (24) (4) 3-003-0451 mg (21) (7)
ACA PV
drospirenone-ethinyl estradiol oral tablet 3-002 mg 3-003 mg
ACA PV
econtra ez oral tablet 15 mg ACA PV
econtra one-step oral tablet 15 mg ACA PV
elinest oral tablet 03-30 mg-mcg ACA PV
ELLA ORAL TABLET 30 MG ACA PV
emoquette oral tablet 015-003 mg ACA PV
104
Drug Name Drug Tier Requirements Limits
enpresse oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
enskyce oral tablet 015-003 mg ACA PV
estarylla oral tablet 025-35 mg-mcg ACA PV
ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg 1-50 mg-mcg
ACA PV
falmina (28) oral tablet 01-20 mg-mcg ACA PV
fayosim oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg
ACA PV
femynor oral tablet 025-35 mg-mcg ACA PV
gemmily oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV
hailey 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
hailey fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
hailey fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
hailey oral tablet 15-30 mg-mcg ACA PV
iclevia oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
isibloom oral tablet 015-003 mg ACA PV
jaimiess oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
jasmiel (28) oral tablet 3-002 mg ACA PV
jolessa oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
juleber oral tablet 015-003 mg ACA PV
junel 1530 (21) oral tablet 15-30 mg-mcg ACA PV
junel 120 (21) oral tablet 1-20 mg-mcg ACA PV
junel fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
junel fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
junel fe 24 oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV
kaitlib fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)
ACA PV
kalliga oral tablet 015-003 mg ACA PV
kariva (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
105
Drug Name Drug Tier Requirements Limits
kelnor 135 (28) oral tablet 1-35 mg-mcg ACA PV
kelnor 1-50 (28) oral tablet 1-50 mg-mcg ACA PV
kurvelo (28) oral tablet 015-003 mg ACA PV
l norgesteestradiol-eestrad oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7) 015 mg-20 mcg 015 mg-25 mcg 015 mg-30 mcg (84)10 mcg (7)
ACA PV
larin 1530 (21) oral tablet 15-30 mg-mcg ACA PV
larin 120 (21) oral tablet 1-20 mg-mcg ACA PV
larin 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV
larin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
larin fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
larissia oral tablet 01-20 mg-mcg ACA PV
layolis fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)
ACA PV
leena 28 oral tablet 05105-35 mg-mcg ACA PV
lessina oral tablet 01-20 mg-mcg ACA PV
levonest (28) oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
levonorgestrel oral tablet 15 mg ACA PV
levonorgestrel-ethinyl estrad oral tablet 01-20 mg-mcg 015-003 mg 90-20 mcg (28)
ACA PV
levonorgestrel-ethinyl estrad oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
levonorg-eth estrad triphasic oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
levora-28 oral tablet 015-003 mg ACA PV
lillow (28) oral tablet 015-003 mg ACA PV
LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG (24)10 MCG (2)
ACA PV
lojaimiess oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)
ACA PV
loryna (28) oral tablet 3-002 mg ACA PV
low-ogestrel (28) oral tablet 03-30 mg-mcg ACA PV
lo-zumandimine (28) oral tablet 3-002 mg ACA PV
lutera (28) oral tablet 01-20 mg-mcg ACA PV
106
Drug Name Drug Tier Requirements Limits
marlissa (28) oral tablet 015-003 mg ACA PV
merzee oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV
mibelas 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
microgestin 1530 (21) oral tablet 15-30 mg-mcg ACA PV
microgestin 120 (21) oral tablet 1-20 mg-mcg ACA PV
microgestin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
microgestin fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
mili oral tablet 025-35 mg-mcg ACA PV
mono-linyah oral tablet 025-35 mg-mcg ACA PV
my choice oral tablet 15 mg ACA PV
my way oral tablet 15 mg ACA PV
NATAZIA ORAL TABLET 3 MG2 MG-2 MG 2 MG-3 MG1 MG
ACA PV
necon 0535 (28) oral tablet 05-35 mg-mcg ACA PV
new day oral tablet 15 mg ACA PV
NEXTSTELLIS ORAL TABLET 3 MG- 142 MG (28)
ACA PV
nikki (28) oral tablet 3-002 mg ACA PV
noreth-ethinyl estradiol-iron oral tabletchewable 04mg-35mcg(21) and 75 mg (7) 08mg-25mcg(24) and 75 mg (4)
ACA PV
norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg 15-30 mg-mcg
ACA PV
norethindrone-eestradiol-iron oral capsule 1 mg-20 mcg (24)75 mg (4)
ACA PV
norethindrone-eestradiol-iron oral tablet 1 mg-20 mcg (21)75 mg (7) 15 mg-30 mcg (21)75 mg (7)
ACA PV
norethindrone-eestradiol-iron oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
norgestimate-ethinyl estradiol oral tablet 0180215025 mg-25 mcg 0180215025 mg-35 mcg (28) 025-35 mg-mcg
ACA PV
nortrel 0535 (28) oral tablet 05-35 mg-mcg ACA PV
nortrel 135 (21) oral tablet 1-35 mg-mcg (21) ACA PV
nortrel 135 (28) oral tablet 1-35 mg-mcg ACA PV
107
Drug Name Drug Tier Requirements Limits
nortrel 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
nylia 777 (28) oral tablet 050751 mg- 35 mcg ACA PV
nymyo oral tablet 025-35 mg-mcg ACA PV
ocella oral tablet 3-003 mg ACA PV
opcicon one-step oral tablet 15 mg ACA PV
option-2 oral tablet 15 mg ACA PV
orsythia oral tablet 01-20 mg-mcg ACA PV
philith oral tablet 04-35 mg-mcg ACA PV
pimtrea (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
pirmella oral tablet 050751 mg- 35 mcg 1-35 mg-mcg
ACA PV
portia 28 oral tablet 015-003 mg ACA PV
previfem oral tablet 025-35 mg-mcg ACA PV
reclipsen (28) oral tablet 015-003 mg ACA PV
rivelsa oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg
ACA PV
setlakin oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
simliya (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
simpesse oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
SLYND ORAL TABLET 4 MG (28) ACA PV
sprintec (28) oral tablet 025-35 mg-mcg ACA PV
sronyx oral tablet 01-20 mg-mcg ACA PV
syeda oral tablet 3-003 mg ACA PV
tarina 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
tarina fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
tilia fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9) ACA PV
tri femynor oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-estarylla oral tablet 0180215025 mg-35 mcg (28)
ACA PV
108
Drug Name Drug Tier Requirements Limits
tri-legest fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9)
ACA PV
tri-linyah oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-lo-estarylla oral tablet 0180215025 mg-25 mcg
ACA PV
tri-lo-marzia oral tablet 0180215025 mg-25 mcg
ACA PV
tri-lo-mili oral tablet 0180215025 mg-25 mcg ACA PV
tri-lo-sprintec oral tablet 0180215025 mg-25 mcg
ACA PV
tri-mili oral tablet 0180215025 mg-35 mcg (28) ACA PV
tri-nymyo oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-previfem (28) oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-sprintec (28) oral tablet 0180215025 mg-35 mcg (28)
ACA PV
trivora (28) oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
tri-vylibra lo oral tablet 0180215025 mg-25 mcg
ACA PV
tri-vylibra oral tablet 0180215025 mg-35 mcg (28)
ACA PV
TYBLUME ORAL TABLETCHEWABLE 01 MG- 20 MCG
ACA PV
tydemy oral tablet 3-003-0451 mg (21) (7) ACA PV
velivet triphasic regimen (28) oral tablet 0112515-25 mg-mcg
ACA PV
vestura (28) oral tablet 3-002 mg ACA PV
vienva oral tablet 01-20 mg-mcg ACA PV
viorele (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
volnea (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
vyfemla (28) oral tablet 04-35 mg-mcg ACA PV
vylibra oral tablet 025-35 mg-mcg ACA PV
wera (28) oral tablet 05-35 mg-mcg ACA PV
wymzya fe oral tabletchewable 04mg-35mcg(21) and 75 mg (7)
ACA PV
109
Drug Name Drug Tier Requirements Limits
zarah oral tablet 3-003 mg ACA PV
zovia 135e (28) oral tablet 1-35 mg-mcg ACA PV
zumandimine (28) oral tablet 3-003 mg ACA PV
OXYTOCICS
methergine oral tablet 02 mg 1
methylergonovine oral tablet 02 mg 1
OPHTHALMOLOGY
ANTIBIOTICS
ak-poly-bac ophthalmic (eye) ointment 500-10000 unitgram
1
AZASITE OPHTHALMIC (EYE) DROPS 1 1
bacitracin ophthalmic (eye) ointment 500 unitgram
1
bacitracin-polymyxin b ophthalmic (eye) ointment 500-10000 unitgram
1
BESIVANCE OPHTHALMIC (EYE) DROPSSUSPENSION 06
1
ciprofloxacin hcl ophthalmic (eye) drops 03 1
erythromycin ophthalmic (eye) ointment 5 mggram (05 )
1
gatifloxacin ophthalmic (eye) drops 05 1
gentak ophthalmic (eye) ointment 03 (3 mggram)
1
gentamicin ophthalmic (eye) drops 03 1
levofloxacin ophthalmic (eye) drops 05 1
moxifloxacin ophthalmic (eye) drops 05 1
moxifloxacin ophthalmic (eye) drops viscous 05
1
NATACYN OPHTHALMIC (EYE) DROPSSUSPENSION 5
1
neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
1
neomycin-polymyxin-gramicidin ophthalmic (eye) drops 175 mg-10000 unit-0025mgml
1
neo-polycin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
1
ofloxacin ophthalmic (eye) drops 03 1
110
Drug Name Drug Tier Requirements Limits
polycin ophthalmic (eye) ointment 500-10000 unitgram
1
polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10000 unit- 1 mgml
1
tobramycin ophthalmic (eye) drops 03 1
TOBREX OPHTHALMIC (EYE) OINTMENT 03
1
ANTIVIRALS
trifluridine ophthalmic (eye) drops 1 1
ZIRGAN OPHTHALMIC (EYE) GEL 015 1
BETA-BLOCKERS
betaxolol ophthalmic (eye) drops 05 1
BETIMOL OPHTHALMIC (EYE) DROPS 025 05
1
BETOPTIC S OPHTHALMIC (EYE) DROPSSUSPENSION 025
1
carteolol ophthalmic (eye) drops 1 1
levobunolol ophthalmic (eye) drops 05 1
timolol maleate ophthalmic (eye) drops 025 05
1
timolol maleate ophthalmic (eye) drops once daily 05
1
timolol maleate ophthalmic (eye) gel forming solution 025 05
1
CYCLOPLEGIC MYDRIATICS
atropine ophthalmic (eye) drops 1 1
atropine ophthalmic (eye) ointment 1 1
cyclopentolate ophthalmic (eye) drops 05 1 2
1
homatropaire ophthalmic (eye) drops 5 1
tropicamide ophthalmic (eye) drops 05 1 1
DIRECT ACTING MIOTICS
pilocarpine hcl ophthalmic (eye) drops 1 2 4
1
MISCELLANEOUS OPHTHALMOLOGICS
ALOCRIL OPHTHALMIC (EYE) DROPS 2 1 ST
ALOMIDE OPHTHALMIC (EYE) DROPS 01 1 ST
111
Drug Name Drug Tier Requirements Limits
altacaine ophthalmic (eye) drops 05 1
azelastine ophthalmic (eye) drops 005 1
BEOVU INTRAVITREAL SOLUTION 6 MG005 ML
MB PA LA
bepotastine besilate ophthalmic (eye) drops 15 1 ST
BEPREVE OPHTHALMIC (EYE) DROPS 15 1 ST
cromolyn ophthalmic (eye) drops 4 1
CYSTARAN OPHTHALMIC (EYE) DROPS 044
2 PA
epinastine ophthalmic (eye) drops 005 1
EYLEA INTRAVITREAL SOLUTION 2 MG005 ML
MB PA LA
EYLEA INTRAVITREAL SYRINGE 2 MG005 ML
MB PA LA
LACRISERT OPHTHALMIC (EYE) INSERT 5 MG
1
LASTACAFT OPHTHALMIC (EYE) DROPS 025
1 ST
LUCENTIS INTRAVITREAL SOLUTION 03 MG005 ML 05 MG005 ML
MB PA LA
LUCENTIS INTRAVITREAL SYRINGE 03 MG005 ML 05 MG005 ML
MB PA LA
LUXTURNA SUBRETINAL SUSPENSION 15 X 10EXP11 VG03 ML (FNL)
MB LA
olopatadine ophthalmic (eye) drops 01 02 1
OMIDRIA INTRAOCULAR CONCENTRATE 1-03
MB
proparacaine ophthalmic (eye) drops 05 1
RESTASIS OPHTHALMIC (EYE) DROPPERETTE 005
1 QL (120 per 30 days)
TETRACAINE HCL (PF) OPHTHALMIC (EYE) DROPS 05
1
tetracaine hcl ophthalmic (eye) drops 05 1
VISUDYNE INTRAVENOUS RECON SOLN 15 MG
MB LA
XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5
1 PA ST QL (60 per 30 days)
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
112
Drug Name Drug Tier Requirements Limits
ACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE 045
1 ST
bromfenac ophthalmic (eye) drops 009 1
diclofenac sodium ophthalmic (eye) drops 01 1
flurbiprofen sodium ophthalmic (eye) drops 003
1
ketorolac ophthalmic (eye) drops 04 05 1
NEVANAC OPHTHALMIC (EYE) DROPSSUSPENSION 01
1
ORAL DRUGS FOR GLAUCOMA
acetazolamide oral capsule extended release 500 mg
1
acetazolamide oral tablet 125 mg 250 mg 1
methazolamide oral tablet 25 mg 50 mg 1
OTHER GLAUCOMA DRUGS
bimatoprost ophthalmic (eye) drops 003 1
brinzolamide ophthalmic (eye) dropssuspension 1
1
COMBIGAN OPHTHALMIC (EYE) DROPS 02-05
1
dorzolamide ophthalmic (eye) drops 2 1
dorzolamide-timolol (pf) ophthalmic (eye) dropperette 2-05
1
dorzolamide-timolol ophthalmic (eye) drops 223-68 mgml
1
latanoprost ophthalmic (eye) drops 0005 1
LUMIGAN OPHTHALMIC (EYE) DROPS 001
1 ST
RHOPRESSA OPHTHALMIC (EYE) DROPS 002
1 PA ST
SIMBRINZA OPHTHALMIC (EYE) DROPSSUSPENSION 1-02
1
travoprost ophthalmic (eye) drops 0004 1
STEROID-ANTIBIOTIC COMBINATIONS
neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
1
neomycin-polymyxin b-dexameth ophthalmic (eye) dropssuspension 35mgml-10000 unitml-01
1
113
Drug Name Drug Tier Requirements Limits
neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 35 mgg-10000 unitg-01
1
neomycin-polymyxin-hc ophthalmic (eye) dropssuspension 35-10000-10 mg-unit-mgml
1
neo-polycin hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
1
TOBRADEX OPHTHALMIC (EYE) OINTMENT 03-01
1
TOBRADEX ST OPHTHALMIC (EYE) DROPSSUSPENSION 03-005
1
tobramycin-dexamethasone ophthalmic (eye) dropssuspension 03-01
1
STEROIDS
ALREX OPHTHALMIC (EYE) DROPSSUSPENSION 02
1 ST
dexamethasone sodium phosphate ophthalmic (eye) drops 01
1
DUREZOL OPHTHALMIC (EYE) DROPS 005
1
fluorometholone ophthalmic (eye) dropssuspension 01
1
FML FORTE OPHTHALMIC (EYE) DROPSSUSPENSION 025
1
FML SOP OPHTHALMIC (EYE) OINTMENT 01
1
INVELTYS OPHTHALMIC (EYE) DROPSSUSPENSION 1
1 ST
LOTEMAX OPHTHALMIC (EYE) OINTMENT 05
1 ST
loteprednol etabonate ophthalmic (eye) dropsgel 05
1
loteprednol etabonate ophthalmic (eye) dropssuspension 05
1
MAXIDEX OPHTHALMIC (EYE) DROPSSUSPENSION 01
1
OZURDEX INTRAVITREAL IMPLANT 07 MG MB LA
PRED MILD OPHTHALMIC (EYE) DROPSSUSPENSION 012
1
prednisolone acetate ophthalmic (eye) dropssuspension 1
1
114
Drug Name Drug Tier Requirements Limits
prednisolone sodium phosphate ophthalmic (eye) drops 1
1
RETISERT INTRAVITREAL IMPLANT 059 MG
MB LA
YUTIQ INTRAVITREAL IMPLANT 018 MG MB
STEROID-SULFONAMIDE COMBINATIONS
BLEPHAMIDE OPHTHALMIC (EYE) DROPSSUSPENSION 10-02
1
BLEPHAMIDE SOP OPHTHALMIC (EYE) OINTMENT 10-02
1
sulfacetamide-prednisolone ophthalmic (eye) drops 10 -023 (025 )
1
SULFONAMIDES
sulfacetamide sodium ophthalmic (eye) drops 10
1
sulfacetamide sodium ophthalmic (eye) ointment 10
1
SYMPATHOMIMETICS
apraclonidine ophthalmic (eye) drops 05 1
brimonidine ophthalmic (eye) drops 015 02 1
IOPIDINE OPHTHALMIC (EYE) DROPPERETTE 1
1
VASOCONSTRICTOR DECONGESTANTS
phenylephrine hcl ophthalmic (eye) drops 10 25
1
RESPIRATORY ALLERGY COUGH amp COLD
ANTIHISTAMINE amp ANTIALLERGENIC AGENTS
adrenalin injection solution 1 mgml 1 mgml (1 ml)
1
carbinoxamine maleate oral liquid 4 mg5 ml 1 PA ST QL (2 per 30 days)
carbinoxamine maleate oral tablet 4 mg 1 PA ST QL (240 per 30 days)
carbinoxamine maleate oral tablet 6 mg 1 PA ST QL (120 per 30 days)
cetirizine oral solution 1 mgml 1
clemastine oral syrup 05 mg5 ml 1
clemastine oral tablet 268 mg 1
cyproheptadine oral syrup 2 mg5 ml 1
cyproheptadine oral tablet 4 mg 1
115
Drug Name Drug Tier Requirements Limits
desloratadine oral tablet 5 mg 1 PA ST QL (30 per 30 days)
desloratadine oral tabletdisintegrating 25 mg 5 mg
1 PA ST
diphenhydramine hcl injection solution 50 mgml 1
diphenhydramine hcl injection syringe 50 mgml MB
EPINEPHRINE INJECTION AUTO-INJECTOR 015 MG015 ML
1
epinephrine injection auto-injector 015 mg03 ml 03 mg03 ml
1
epinephrine injection solution 1 mgml 1 mgml (1 ml)
1
epinephrine injection syringe 01 mgml 1
hydroxyzine hcl intramuscular solution 25 mgml MB
hydroxyzine hcl oral solution 10 mg5 ml 1
hydroxyzine hcl oral tablet 10 mg 25 mg 50 mg 1
hydroxyzine pamoate oral capsule 100 mg 25 mg 50 mg
1
levocetirizine oral solution 25 mg5 ml 1
levocetirizine oral tablet 5 mg 1
promethazine injection solution 25 mgml MB
promethazine oral syrup 625 mg5 ml 1
promethazine oral tablet 125 mg 25 mg 50 mg 1
promethazine rectal suppository 125 mg 25 mg 1
promethegan rectal suppository 125 mg 25 mg 50 mg
1
COUGH amp COLD THERAPY
benzonatate oral capsule 100 mg 150 mg 200 mg 1
brompheniramine-pseudoeph-dm oral syrup 2-30-10 mg5 ml
1
codeine-guaifenesin oral liquid 10-100 mg5 ml 1
g tussin ac oral liquid 10-100 mg5 ml 1
guaiatussin ac oral liquid 10-100 mg5 ml 1
hydrocodone-chlorpheniramine oral suspensionextended rel 12 hr 10-8 mg5 ml
1
hydrocodone-homatropine oral syrup 5-15 mg5 ml
1
hydrocodone-homatropine oral tablet 5-15 mg 1
116
Drug Name Drug Tier Requirements Limits
hydromet oral syrup 5-15 mg5 ml 1
maxi-tuss ac oral liquid 10-100 mg5 ml 1
m-clear wc oral liquid 63-100 mg5 ml 1
promethazine-codeine oral syrup 625-10 mg5 ml 1
promethazine-dm oral syrup 625-15 mg5 ml 1
promethazine-phenyleph-codeine oral syrup 625-5-10 mg5 ml
1
promethazine-phenylephrine oral syrup 625-5 mg5 ml
1
virtussin ac oral liquid 10-100 mg5 ml 1
PULMONARY AGENTS
acetylcysteine solution 100 mgml (10 ) 200 mgml (20 )
1
ADEMPAS ORAL TABLET 05 MG 1 MG 15 MG 2 MG 25 MG
2 PA LA
ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCGACTUATION 230-21 MCGACTUATION 45-21 MCGACTUATION
1 QL (1 per 30 days)
ALBUTEROL HFA 90 MCG INHALER 90 MCGACTUATION
1 QL (2 per 30 days)
albuterol sulfate inhalation inhalation hfa aerosol inhaler 90 mcgactuation
1 QL (2 per 30 days)
albuterol sulfate inhalation inhalation solution for nebulization 063 mg3 ml 125 mg3 ml 25 mg 3 ml (0083 ) 25 mg05 ml 5 mgml
1
albuterol sulfate inhalation oral syrup 2 mg5 ml 1
albuterol sulfate inhalation oral tablet 2 mg 4 mg 1
albuterol sulfate inhalation oral tablet extended release 12 hr 4 mg 8 mg
1
ALVESCO INHALATION HFA AEROSOL INHALER 160 MCGACTUATION 80 MCGACTUATION
1 PA ST QL (1 per 30 days)
alyq oral tablet 20 mg 2 PA
ambrisentan oral tablet 10 mg 5 mg 2 PA LA
aminophylline intravenous solution 250 mg10 ml MB
ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 625-25 MCGACTUATION
1 QL (1 per 30 days)
arformoterol inhalation solution for nebulization 15 mcg2 ml
1
117
Drug Name Drug Tier Requirements Limits
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 200 MCGACTUATION
1 QL (1 per 30 days)
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 50 MCGACTUATION
1
ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCGACTUATION
1 QL (2 per 30 days)
BERINERT INTRAVENOUS KIT 500 UNIT (10 ML)
MB PA LA
BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-48 MCG
1
bosentan oral tablet 125 mg 625 mg 2 PA LA
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCGDOSE
1 QL (1 per 30 days)
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 200-25 MCGDOSE
1
BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG2 ML
1
budesonide inhalation suspension for nebulization 025 mg2 ml 05 mg2 ml
1 QL (120 per 30 days)
budesonide inhalation suspension for nebulization 1 mg2 ml
1 QL (60 per 30 days)
CINQAIR INTRAVENOUS SOLUTION 10 MGML
MB PA
CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)
MB PA LA
COMBIVENT RESPIMAT INHALATION MIST 20-100 MCGACTUATION
1 QL (2 per 30 days)
cromolyn inhalation solution for nebulization 20 mg2 ml
1
DALIRESP ORAL TABLET 250 MCG 500 MCG
1
DULERA INHALATION HFA AEROSOL INHALER 100-5 MCGACTUATION 200-5 MCGACTUATION 50-5 MCGACTUATION
1 QL (1 per 30 days)
ELIXOPHYLLIN ORAL ELIXIR 80 MG15 ML 1
ESBRIET ORAL CAPSULE 267 MG 2 PA LA QL (270 per 30 days)
ESBRIET ORAL TABLET 267 MG 801 MG 2 PA LA QL (90 per 30 days)
FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MGML
MB PA LA
118
Drug Name Drug Tier Requirements Limits
FASENRA SUBCUTANEOUS SYRINGE 30 MGML
MB PA LA
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 50 MCGACTUATION
1 QL (1 per 30 days)
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCGACTUATION
1 QL (4 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCGACTUATION 44 MCGACTUATION
1 QL (1 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCGACTUATION
1 QL (2 per 30 days)
fluticasone propionate nasal spraysuspension 50 mcgactuation
1
fluticasone propion-salmeterol inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose
1 QL (1 per 30 days)
formoterol fumarate inhalation solution for nebulization 20 mcg2 ml
1
HAEGARDA SUBCUTANEOUS RECON SOLN 2000 UNIT 3000 UNIT
2 PA LA
icatibant subcutaneous syringe 30 mg3 ml 2 PA
INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 625 MCGACTUATION
1 QL (1 per 30 days)
ipratropium bromide inhalation solution 002 1
ipratropium-albuterol inhalation solution for nebulization 05 mg-3 mg(25 mg base)3 ml
1 QL (180 per 30 days)
KALBITOR SUBCUTANEOUS SOLUTION 10 MGML (1 ML)
2 PA LA
KALYDECO ORAL GRANULES IN PACKET 25 MG 50 MG 75 MG
2 PA LA
KALYDECO ORAL TABLET 150 MG 2 PA LA
levalbuterol hcl inhalation solution for nebulization 031 mg3 ml 063 mg3 ml 125 mg05 ml 125 mg3 ml
1
LEVALBUTEROL TARTRATE INHALATION HFA AEROSOL INHALER 45 MCGACTUATION
1 QL (2 per 30 days)
metaproterenol oral syrup 10 mg5 ml 1
montelukast oral granules in packet 4 mg 1
montelukast oral tablet 10 mg 1
119
Drug Name Drug Tier Requirements Limits
montelukast oral tabletchewable 4 mg 5 mg 1
nebusal inhalation solution for nebulization 3 1
NUCALA SUBCUTANEOUS RECON SOLN 100 MG
MB PA LA
OFEV ORAL CAPSULE 100 MG 150 MG 2 PA LA QL (60 per 30 days)
OPSUMIT ORAL TABLET 10 MG 2 PA LA
ORLADEYO ORAL CAPSULE 110 MG 150 MG
2 PA ST QL (28 per 28 days)
PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG2 ML
1
pulmosal inhalation solution for nebulization 7 1
PULMOZYME INHALATION SOLUTION 1 MGML
2 PA LA
QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCGACTUATION 80 MCGACTUATION
1
REVATIO INTRAVENOUS SOLUTION 10 MG125 ML
MB LA
RUCONEST INTRAVENOUS RECON SOLN 2100 UNIT
MB PA LA
SEEBRI NEOHALER INHALATION CAPSULE WINHALATION DEVICE 156 MCG
1
SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCGDOSE
1
sildenafil (pulmhypertension) intravenous solution 10 mg125 ml
MB
sildenafil (pulmhypertension) oral suspension for reconstitution 10 mgml
2
sildenafil (pulmhypertension) oral tablet 20 mg 2 PA
SINUVA SINUS IMPLANT 1350 MCG MB
sodium chloride inhalation solution for nebulization 09 10 3 7
1
SPIRIVA RESPIMAT INHALATION MIST 125 MCGACTUATION
1
SPIRIVA RESPIMAT INHALATION MIST 25 MCGACTUATION
1 QL (1 per 30 days)
SPIRIVA WITH HANDIHALER INHALATION CAPSULE WINHALATION DEVICE 18 MCG
1 QL (30 per 30 days)
STIOLTO RESPIMAT INHALATION MIST 25-25 MCGACTUATION
1
120
Drug Name Drug Tier Requirements Limits
STRIVERDI RESPIMAT INHALATION MIST 25 MCGACTUATION
1
SYMBICORT INHALATION HFA AEROSOL INHALER 160-45 MCGACTUATION 80-45 MCGACTUATION
1 QL (1 per 30 days)
SYMDEKO ORAL TABLETS SEQUENTIAL 100-150 MG (D) 150 MG (N) 50-75 MG (D) 75 MG (N)
2 PA LA
tadalafil (pulm hypertension) oral tablet 20 mg 2 PA
TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG2 ML (150 MGML)
2 PA LA
terbutaline oral tablet 25 mg 5 mg 1
terbutaline subcutaneous solution 1 mgml 1
theophylline oral elixir 80 mg15 ml 1
theophylline oral solution 80 mg15 ml 1
theophylline oral tablet extended release 12 hr 300 mg 450 mg
1
theophylline oral tablet extended release 24 hr 400 mg 600 mg
1
TRACLEER ORAL TABLET FOR SUSPENSION 32 MG
2 PA LA
TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-625-25 MCG 200-625-25 MCG
1
TRIKAFTA ORAL TABLETS SEQUENTIAL 100-50-75 MG(D) 150 MG (N) 50-25-375 MG (D)75 MG (N)
2 PA LA
TYVASO INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)
2 PA LA
TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)
2 PA LA
TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML
2 PA LA
UTIBRON NEOHALER INHALATION CAPSULE WINHALATION DEVICE 275-156 MCG
1
VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCGML 20 MCGML
2 PA LA
121
Drug Name Drug Tier Requirements Limits
wixela inhub inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose
1 QL (1 per 30 days)
XOLAIR SUBCUTANEOUS RECON SOLN 150 MG
MB LA
XOLAIR SUBCUTANEOUS SYRINGE 150 MGML 75 MG05 ML
MB PA LA QL (7 per 30 days)
zafirlukast oral tablet 10 mg 20 mg 1
zileuton oral tablet er multiphase 12 hr 600 mg 1 ST
ZYFLO ORAL TABLET 600 MG 1 ST
UROLOGICALS
ANTICHOLINERGICS amp ANTISPASMODICS
darifenacin oral tablet extended release 24 hr 15 mg 75 mg
1
flavoxate oral tablet 100 mg 1
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG 50 MG
1 ST
oxybutynin chloride oral syrup 5 mg5 ml 1
oxybutynin chloride oral tablet 5 mg 1
oxybutynin chloride oral tablet extended release 24hr 10 mg 15 mg 5 mg
1
solifenacin oral tablet 10 mg 5 mg 1
tolterodine oral capsuleextended release 24hr 2 mg 4 mg
1
tolterodine oral tablet 1 mg 2 mg 1
trospium oral capsuleextended release 24hr 60 mg
1
trospium oral tablet 20 mg 1
BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY
alfuzosin oral tablet extended release 24 hr 10 mg 1
dutasteride oral capsule 05 mg 1
dutasteride-tamsulosin oral capsule er multiphase 24 hr 05-04 mg
1
finasteride oral tablet 5 mg 1
silodosin oral capsule 4 mg 8 mg 1
tadalafil oral tablet 25 mg 5 mg 1 PA ST
tamsulosin oral capsule 04 mg 1
CHOLINERGIC STIMULANTS
122
Drug Name Drug Tier Requirements Limits
bethanechol chloride oral tablet 10 mg 25 mg 5 mg 50 mg
1
MISCELLANEOUS UROLOGICALS
CYSTAGON ORAL CAPSULE 150 MG 50 MG 2 PA
ELMIRON ORAL CAPSULE 100 MG 1
hyophen oral tablet 816-012-108 mg 1
K-PHOS NO 2 ORAL TABLET 305-700 MG 1
K-PHOS ORIGINAL ORAL TABLETSOLUBLE 500 MG
1
methen-sod phos-meth blue-hyos oral tablet 816-408-012 mg
1
OXLUMO SUBCUTANEOUS SOLUTION 945 MG05 ML
2 PA
phosphasal oral tablet 816-108-408 mg 1
potassium citrate oral tablet extended release 10 meq (1080 mg) 15 meq 5 meq (540 mg)
1
RENACIDIN IRRIGATION SOLUTION 19806 MG-594 MG-9804MG30ML
1
URELLE ORAL TABLET 81-108-408 MG 1
uretron d-s oral tablet 816-108-408 mg 1
urimar-t oral tablet 120-012-108 mg 1
urogesic-blue oral tablet 816-408-012 mg 1
uryl oral tablet 816-408-012 mg 1
ustell oral capsule 120-012 mg 1
utira-c oral tablet 816-108-408 mg 1
URINARY ANESTHETICS
phenazopyridine oral tablet 100 mg 200 mg 1
VITAMINS HEMATINICS amp ELECTROLYTES
ELECTROLYTES
effer-k oral tablet effervescent 25 meq 1
klor-con 10 oral tablet extended release 10 meq 1
klor-con 8 oral tablet extended release 8 meq 1
klor-con m10 oral tableter particlescrystals 10 meq
1
klor-con m15 oral tableter particlescrystals 15 meq
1
123
Drug Name Drug Tier Requirements Limits
klor-con m20 oral tableter particlescrystals 20 meq
1
klor-con oral packet 20 meq 1
klor-conef oral tablet effervescent 25 meq 1
K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ
1
k-tab oral tablet extended release 8 meq 1
NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION
MB
potassium chloride oral capsule extended release 10 meq 8 meq
1
potassium chloride oral liquid 20 meq15 ml 40 meq15 ml
1
potassium chloride oral packet 20 meq 1
potassium chloride oral tablet extended release 10 meq 20 meq 8 meq
1
potassium chloride oral tableter particlescrystals 10 meq 20 meq
1
sodium chloride 045 intravenous parenteral solution 045
MB
MISCELLANEOUS VITAMINS HEMATINICS amp ELECTROLYTES
ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION
MB
PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION
MB
PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION
MB
VITAMINS amp HEMATINICS
cyanocobalamin (vitamin b-12) injection solution 1000 mcgml
1
ergocalciferol (vitamin d2) oral capsule 1250 mcg (50000 unit)
1
FA-8 ORAL CAPSULE 08 MG ACA PV
FER-IN-SOL ORAL DROPS 15 MG IRON (75 MG)ML
ACA PV
FLORIVA (FLUORIDE-VITAMIN D3) ORAL DROPS 025 MG (055 MG)-400 UNITML
ACA PV
fluoride (sodium) oral drops 05 mg (11 mg sodfluorid)ml
ACA PV
124
Drug Name Drug Tier Requirements Limits
fluoride (sodium) oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)
ACA PV
folic acid injection solution 5 mgml 1
folic acid oral tablet 1 mg 1
folic acid oral tablet 400 mcg 800 mcg ACA PV
hydroxocobalamin intramuscular solution 1000 mcgml
1
INFED INJECTION SOLUTION 50 MGML MB
ludent fluoride oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)
ACA PV
multi-vitamin with fluoride oral drops 025 mgml 05 mgml
ACA PV
multi-vitamin with fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
multivitamins with fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
mvc-fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
NOVAFERRUM ORAL DROPS 15 MG IRONML
ACA PV
tri-vitamin with fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml
ACA PV
vitamins acd and fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml
ACA PV
125
Index
A abacavir 2 abacavir-lamivudine 2 abacavir-lamivudine-
zidovudine 2 ABILIFY MAINTENA 36 abiraterone 13 ABRAXANE 13 acamprosate 66 acarbose 77 accutane 59 acebutolol 45 acetaminophen-caff-
dihydrocod 30 acetaminophen-codeine 31 acetazolamide 112 acetic acid 66 69 acetylcysteine 116 acitretin 57 ACTEMRA 95 ACTEMRA ACTPEN 95 ACTHAR 70 ACTHIB (PF) 90 ACTIMMUNE 89 ACUVAIL (PF) 112 acyclovir 2 63 ADACEL(TDAP
ADOLESNADULT)(PF) 90 ADAKVEO 13 adapalene 59 60 ADAPALENE 60 adapalene-benzoyl peroxide 60 ADCETRIS 14 adefovir 2 ADEMPAS 116 ADHANSIA XR 36 adrenalin 114 adult aspirin regimen 33 ADVAIR HFA 116 ADVATE 50 ADYNOVATE 50 ADZENYS ER 36 ADZENYS XR-ODT 36 AEROCHAMBER MINI 71 AEROCHAMBER PLUS
FLOW-VU 71 AFINITOR 14 afirmelle 102
AFSTYLA 50 AIMOVIG AUTOINJECTOR
28 AJOVY AUTOINJECTOR 28 AJOVY SYRINGE 28 ak-poly-bac 109 AKYNZEO (NETUPITANT)
81 ala-cort 63 albendazole 8 albuterol sulfate inhalation 116 ALBUTEROL SULFATE
INHALATION 116 alclometasone 63 ALCORTIN A 61 ALDURAZYME 74 ALECENSA 14 alendronate 95 alfuzosin 121 ALIMTA 14 ALINIA 8 ALIQOPA 14 aliskiren 45 allopurinol 95 almotriptan malate 28 ALOCRIL 110 ALOGLIPTIN-
PIOGLITAZONE 77 ALOMIDE 110 alosetron 81 ALOXI 81 ALPHANATE 50 ALPHANINE SD 50 alprazolam 37 alprazolam intensol 37 ALPROLIX 50 ALREX 113 ALTABAX 61 altacaine 111 altavera (28) 102 ALVESCO 116 alyacen 135 (28) 102 alyacen 777 (28) 102 alyq 116 amabelz 98 amantadine hcl 2 AMBISOME 1 ambrisentan 116
amcinonide 63 amethia 102 amethyst (28) 102 amikacin 8 amiloride 45 amiloride-hydrochlorothiazide
45 aminocaproic acid 50 51 aminophylline 116 amiodarone 44 AMITIZA 81 amitriptyline 37 amitriptyline-chlordiazepoxide
37 amlodipine 45 amlodipine-atorvastatin 55 amlodipine-benazepril 45 amlodipine-olmesartan 45 amlodipine-valsartan 45 amlodipine-valsartan-hcthiazid
45 ammonium lactate 59 amnesteem 60 amoxapine 37 amoxicil-clarithromy-lansopraz
85 amoxicillin 11 amoxicillin-pot clavulanate 11 AMPHETAMINE 37 amphetamine sulfate 37 amphotericin b 1 ampicillin 11 ampicillin-sulbactam 11 anagrelide 66 anaspaz 80 anastrozole 14 ANDEXXA 51 ANDRODERM 74 ANGELIQ 98 ANNOVERA 101 ANORO ELLIPTA 116 anucort-hc 81 apexicon e 63 APLENZIN 37 APOKYN 27 apraclonidine 114 aprepitant 81 apri 102
126
APTIVUS 2 ARALAST NP 66 aranelle (28) 102 ARANESP (IN
POLYSORBATE) 86 ARCALYST 89 ARESTIN 68 arformoterol 116 aripiprazole 37 ARISTADA 37 ARISTADA INITIO 37 armodafinil 37 ARMOUR THYROID 79 ARNUITY ELLIPTA 117 ARRANON 14 ARZERRA 14 ASCENIV 90 ascomp with codeine 31 asenapine maleate 37 ashlyna 102 ASPARLAS 14 aspirin 33 34 aspirin low dose 33 aspirin-dipyridamole 51 aspir-trin 34 atazanavir 2 atenolol 45 atenolol-chlorthalidone 45 ATGAM 90 atomoxetine 37 atorvastatin 55 atovaquone 8 atovaquone-proguanil 8 atropine 80 110 ATROVENT HFA 117 AUBAGIO 87 aubra 102 aubra eq 102 aurovela 1530 (21) 102 aurovela 120 (21) 102 aurovela 24 fe 102 aurovela fe 1530 (28) 102 aurovela fe 1-20 (28) 102 AUSTEDO 29 AVASTIN 14 aviane 102 avidoxy 12 avita 60 AVITA 60 AVONEX 88 AVYCAZ 6
ayuna 102 AZASITE 109 azathioprine 14 azelaic acid 60 azelastine 68 111 AZELEX 60 azithromycin 7 azurette (28) 102 B bacitracin 8 109 bacitracin-polymyxin b 109 baclofen 30 BALCOLTRA 102 balsalazide 81 BALVERSA 14 balziva (28) 102 BANZEL 24 BAQSIMI 71 BARACLUDE 2 BAVENCIO 14 BAXDELA 12 bayer aspirin 34 BAYER CHEWABLE
ASPIRIN 34 BCG VACCINE LIVE (PF) 90 BELEODAQ 14 belladonna alkaloids-opium 80 BELRAPZO 14 BELSOMRA 37 benazepril 45 benazepril-hydrochlorothiazide
45 BENDAMUSTINE 14 BENDEKA 14 BENEFIX 51 BENLYSTA 96 benzonatate 115 benztropine 27 BEOVU 111 bepotastine besilate 111 BEPREVE 111 BERINERT 117 beser 63 BESIVANCE 109 BESPONSA 14 betamethasone dipropionate 63 betamethasone valerate 63 betamethasone augmented 63
64 BETASERON 88 betaxolol 45 110
bethanechol chloride 122 BETIMOL 110 BETOPTIC S 110 BEVESPI AEROSPHERE 117 bexarotene 14 BEXSERO 90 bicalutamide 14 BICILLIN C-R 11 BIKTARVY 2 bimatoprost 112 BIOTHRAX 90 bisoprolol fumarate 45 bisoprolol-hydrochlorothiazide
45 BIVIGAM 90 BLEPHAMIDE 114 BLEPHAMIDE SOP 114 BLINCYTO 14 blisovi 24 fe 102 blisovi fe 1530 (28) 102 blisovi fe 120 (28) 103 BOOSTRIX TDAP 90 BORTEZOMIB 14 bosentan 117 BOSULIF 14 BOTOX 90 BRAFTOVI 14 BREO ELLIPTA 117 briellyn 103 BRILINTA 51 brimonidine 114 BRINEURA 75 brinzolamide 112 BRIVIACT 24 bromfenac 112 bromocriptine 27 brompheniramine-pseudoeph-
dm 115 BROVANA 117 budesonide 81 117 bumetanide 45 buprenorphine 31 buprenorphine hcl 31 buprenorphine-naloxone 34 bupropion hcl 37 38 bupropion hcl (smoking deter)
68 buspirone 38 BUSULFEX 15 butalbital compound wcodeine
31
127
butalbital-acetaminop-caf-cod 31
butalbital-acetaminophen-caff 31
butalbital-aspirin-caffeine 31 butorphanol 34 BYDUREON BCISE 77 BYETTA 77 BYSTOLIC 45 C CABENUVA 2 cabergoline 75 CABLIVI 51 CABOMETYX 15 calcipotriene 57 calcipotriene-betamethasone 57 calcitonin (salmon) 75 calcitriol 57 75 calcium acetate(phosphat bind)
81 CALQUENCE 15 camila 98 camrese 103 camrese lo 103 CANCIDAS 1 candesartan 45 candesartan-hydrochlorothiazid
46 CAPASTAT 8 capecitabine 15 CAPRELSA 15 captopril 46 captopril-hydrochlorothiazide
46 CARBAGLU 66 carbamazepine 24 carbidopa 27 carbidopa-levodopa 27 carbidopa-levodopa-
entacapone 27 carbinoxamine maleate 114 carisoprodol 30 carisoprodol-aspirin 30 carisoprodol-aspirin-codeine 30 carteolol 110 cartia xt 46 carvedilol 46 carvedilol phosphate 46 cataflam 34 CAYA CONTOURED 98 CAYSTON 8
caziant (28) 103 cefaclor 6 cefadroxil 6 cefazolin 6 cefazolin in dextrose (iso-os) 6 cefdinir 6 cefditoren pivoxil 6 cefepime 6 CEFEPIME IN DEXTROSE 5
6 cefepime in dextroseiso-osm 6 cefixime 6 CEFOTAN 6 cefotaxime 6 cefotetan 6 CEFOTETAN IN
DEXTROSE ISO-OSM 6 cefoxitin 6 cefpodoxime 6 7 cefprozil 7 ceftazidime 7 CEFTAZIDIME IN D5W 7 ceftriaxone 7 CEFTRIAXONE 7 ceftriaxone in dextroseiso-os 7 cefuroxime axetil 7 celecoxib 34 CELONTIN 24 cephalexin 7 CERDELGA 75 CEREZYME 75 cetirizine 114 cevimeline 66 CHANTIX 68 CHANTIX CONTINUING
MONTH BOX 68 CHANTIX STARTING
MONTH BOX 68 charlotte 24 fe 103 chateal (28) 103 chateal eq (28) 103 CHEMET 66 childrens aspirin 34 chloramphenicol sod succinate
8 chlordiazepoxide hcl 38 chlordiazepoxide-clidinium 80 chlorhexidine gluconate 68 chloroquine phosphate 8 chlorpromazine 38 chlorthalidone 46
chlorzoxazone 30 CHOLBAM 81 cholestyramine (with sugar) 55 cholestyramine light 55 cholinemagnesium salicylate
34 ciclodan 62 ciclopirox 62 ciclopirox-ure-camph-menth-
euc 62 cidofovir 2 cilostazol 51 CIMDUO 2 cimetidine 85 cimetidine hcl 85 CIMZIA 82 CIMZIA POWDER FOR
RECONST 81 cinacalcet 75 CINQAIR 117 CINRYZE 117 CIPRO HC 69 ciprofloxacin 12 ciprofloxacin hcl 12 69 109 ciprofloxacin-dexamethasone
69 citalopram 38 claravis 60 clarithromycin 7 8 clemastine 114 CLENPIQ 82 clindacin p 60 clindamycin hcl 8 clindamycin pediatric 8 clindamycin phosphate 8 60
101 clindamycin-benzoyl peroxide
60 clindamycin-tretinoin 60 clobazam 24 clobetasol 64 clobetasol-emollient 64 CLOCORTOLONE
PIVALATE 64 CLODERM 64 CLOLAR 15 clomipramine 38 clonazepam 24 clonidine 46 clonidine hcl 38 46 clopidogrel 51
128
clorazepate dipotassium 38 clotrimazole 1 62 clotrimazole-betamethasone 62 clovique 66 clozapine 38 COAGADEX 51 COARTEM 8 codeine sulfate 31 codeine-butalbital-asa-caff 31 codeine-guaifenesin 115 colchicine 95 COLCHICINE 95 colesevelam 55 colestipol 55 COMBIGAN 112 COMBIPATCH 98 COMBIVENT RESPIMAT 117 COMETRIQ 15 COMPLERA 2 compro 82 constulose 82 CONTOUR NEXT TEST
STRIPS 71 CONTOUR TEST STRIPS 71 COPIKTRA 15 CORIFACT 51 CORLANOR 56 CORTIFOAM 82 COSENTYX 58 COSENTYX (2 SYRINGES)
57 COSENTYX PEN 58 COSENTYX PEN (2 PENS) 58 COTELLIC 15 COTEMPLA XR-ODT 38 covaryx 98 covaryx hs 98 CREON 82 CRESEMBA 1 CRINONE 98 cromolyn 82 111 117 crotan 66 cryselle (28) 103 CRYSVITA 75 CUBICIN 8 CUBICIN RF 9 CUTAQUIG 90 CUVITRU 90 cyanocobalamin (vitamin b-12)
123 cyclafem 135 (28) 103
cyclafem 777 (28) 103 cyclobenzaprine 30 cyclopentolate 110 cyclophosphamide 15 CYCLOPHOSPHAMIDE 15 CYCLOSERINE 9 CYCLOSET 77 cyclosporine 15 cyclosporine modified 15 cyproheptadine 114 CYRAMZA 15 cyred 103 cyred eq 103 CYSTAGON 122 CYSTARAN 111 CYTOVENE 2 D DACOGEN 15 dalfampridine 29 DALIRESP 117 danazol 75 dantrolene 30 dapsone 9 60 DAPTACEL (DTAP
PEDIATRIC) (PF) 91 darifenacin 121 DARZALEX 15 dasetta 135 (28) 103 dasetta 777 (28) 103 DAURISMO 15 daysee 103 DAYTRANA 38 deblitane 98 decadron 70 decitabine 15 deferasirox 66 deferiprone 66 demeclocycline 12 DENAVIR 63 denta 5000 plus 68 dentagel 69 DEPO-ESTRADIOL 98 DEPO-PROVERA 98 DEPO-SUBQ PROVERA 104
98 DEPO-TESTOSTERONE 75 DESCOVY 2 desipramine 38 desloratadine 115 desmopressin 75
desog-eestradioleestradiol 103
desogestrel-ethinyl estradiol 103
desonide 64 desoximetasone 64 DESVENLAFAXINE 38 desvenlafaxine succinate 38 dexamethasone 70 dexamethasone intensol 70 dexamethasone sodium phos
(pf) 70 dexamethasone sodium
phosphate 70 113 DEXILANT 85 dexmethylphenidate 38 dextroamphetamine 38 39 dextroamphetamine-
amphetamine 39 diazepam 24 39 diazepam intensol 39 diazoxide 71 diclofenac potassium 34 diclofenac sodium 34 59 112 diclofenac-misoprostol 34 dicloxacillin 11 dicyclomine 80 didanosine 2 DIFICID 8 diflorasone 64 diflunisal 34 digitek 50 digox 50 digoxin 50 dihydroergotamine 28 DILANTIN 24 DILANTIN EXTENDED 24 DILANTIN INFATABS 24 DILANTIN-125 24 diltiazem 46 dilt-xr 46 dimethyl fumarate 88 DIPENTUM 82 diphenhydramine hcl 115 diphenoxylate-atropine 80 dipyridamole 51 diskets 31 disopyramide phosphate 44 disulfiram 66 divalproex 24 25 DIVIGEL 99
129
dofetilide 44 dolishale 103 donepezil 29 DONNATAL 80 DOPTELET (15 TAB PACK)
51 dorzolamide 112 dorzolamide-timolol 112 dorzolamide-timolol (pf) 112 dotti 99 DOVATO 2 doxazosin 46 doxepin 39 doxercalciferol 75 doxycycline hyclate 12 doxycycline monohydrate 12 doxylamine-pyridoxine (vit b6)
82 dronabinol 82 drospirenone-eestradiol-lmfa
103 drospirenone-ethinyl estradiol
103 DSUVIA 31 DUAVEE 99 DUEXIS 34 DULERA 117 duloxetine 39 DUPIXENT PEN 59 DUPIXENT SYRINGE 59 duramorph (pf) 31 DUREZOL 113 dutasteride 121 dutasteride-tamsulosin 121 dvorah 31 DYANAVEL XR 39 DYSPORT 91 E ees 400 8 econazole 62 econtra ez 103 econtra one-step 103 ecotrin 34 ecotrin low strength 34 EDARBI 46 EDARBYCLOR 46 EDLUAR 39 ed-spaz 80 EDURANT 2 eemt 99 eemt hs 99
efavirenz 2 efavirenz-emtricitabin-tenofov
3 efavirenz-lamivu-tenofov disop
3 effer-k 122 ELAPRASE 75 ELELYSO 75 eletriptan 28 ELIGARD 16 ELIGARD (3 MONTH) 15 ELIGARD (4 MONTH) 15 ELIGARD (6 MONTH) 15 elinest 103 ELIQUIS 51 ELIQUIS DVT-PE TREAT
30D START 51 ELIXOPHYLLIN 117 ELLA 103 ELMIRON 122 ELOCTATE 51 eluryng 101 ELZONRIS 16 EMCYT 16 EMEND 82 EMGALITY PEN 28 EMGALITY SYRINGE 28 emoquette 103 EMPAVELI 67 EMPLICITI 16 EMSAM 39 emtricitabine 3 emtricitabine-tenofovir (tdf) 3 EMTRIVA 3 EMVERM 9 enalapril maleate 46 enalaprilat 46 enalapril-hydrochlorothiazide
46 ENBREL 96 ENBREL MINI 96 ENBREL SURECLICK 96 endocet 31 ENGERIX-B (PF) 91 ENGERIX-B PEDIATRIC
(PF) 91 ENHERTU 16 enoxaparin 51 enpresse 104 enskyce 104 entacapone 27
entecavir 3 ENTRESTO 56 ENTYVIO 82 enulose 82 EPANED 46 EPCLUSA 3 EPIDIOLEX 25 epinastine 111 epinephrine 115 EPINEPHRINE 115 epitol 25 EPIVIR HBV 3 eplerenone 47 EPOGEN 86 epoprostenol (glycine) 47 eprosartan 47 ERAXIS(WATER DILUENT)
1 ERBITUX 16 ergocalciferol (vitamin d2) 123 ergoloid 39 ergotamine-caffeine 28 ERLEADA 16 erlotinib 16 errin 99 ERWINAZE 16 ery pads 60 erygel 60 ery-tab 8 erythrocin (as stearate) 8 erythromycin 8 109 erythromycin ethylsuccinate 8 erythromycin with ethanol 60 erythromycin-benzoyl peroxide
60 ESBRIET 117 escitalopram oxalate 39 esomeprazole magnesium 85 ESPEROCT 51 estarylla 104 estazolam 39 estradiol 99 estradiol valerate 99 estradiol-norethindrone acet 99 ESTRING 99 estrogens-methyltestosterone 99 eszopiclone 39 ethacrynic acid 47 ethambutol 9 ethosuximide 25
130
ethynodiol diac-eth estradiol 104
etodolac 34 etonogestrel-ethinyl estradiol
101 etoposide 16 etravirine 3 EUCRISA 59 EUFLEXXA 34 EURAX 66 EVAMIST 99 EVENITY 95 everolimus (antineoplastic) 16 everolimus
(immunosuppressive) 16 EVOTAZ 3 EXELDERM 62 exemestane 16 EXONDYS-51 29 EYLEA 111 ezetimibe 55 ezetimibe-simvastatin 55 F FA-8 123 FABRAZYME 75 FACTIVE 12 falmina (28) 104 famciclovir 3 famotidine 86 famotidine (pf) 85 FANAPT 39 FARXIGA 77 FASENRA 118 FASENRA PEN 117 FASLODEX 16 fayosim 104 FC2 FEMALE CONDOM 98 febuxostat 95 FEIBA NF 51 felbamate 25 felodipine 47 fem ph 101 FEMCAP 98 FEMRING 99 femynor 104 fenofibrate 55 FENOFIBRATE 55 fenofibrate micronized 55 fenofibrate nanocrystallized 55 fenofibric acid 55 fenofibric acid (choline) 55
fenoprofen 35 fentanyl 32 fentanyl citrate 31 FER-IN-SOL 123 FERRIPROX 67 FETZIMA 39 FIASP FLEXTOUCH U-100
INSULIN 72 FIASP PENFILL U-100
INSULIN 72 FIASP U-100 INSULIN 72 FIBRYGA 51 finasteride 121 FINTEPLA 25 FIRMAGON KIT W
DILUENT SYRINGE 16 flac otic oil 69 flavoxate 121 FLEBOGAMMA DIF 91 flecainide 44 FLOLAN 47 FLORIVA (FLUORIDE-
VITAMIN D3) 123 FLOVENT DISKUS 118 FLOVENT HFA 118 fluconazole 1 flucytosine 1 fludarabine 16 fludrocortisone 70 fluocinolone 64 fluocinolone acetonide oil 69 fluocinolone and shower cap 64 fluocinonide 64 fluocinonide-e 64 fluoride (sodium) 69 123 124 fluorometholone 113 fluorouracil 16 59 FLUOROURACIL 59 fluoxetine 39 40 fluphenazine hcl 40 flurandrenolide 64 65 flurazepam 40 flurbiprofen 35 flurbiprofen sodium 112 flutamide 16 fluticasone propionate 65 118 fluticasone propion-salmeterol
118 fluvastatin 55 56 fluvoxamine 40 FML FORTE 113
FML SOP 113 folic acid 124 FOLOTYN 16 fondaparinux 51 formoterol fumarate 118 FORTEO 95 FOSAMAX PLUS D 95 fosamprenavir 3 fosfomycin tromethamine 13 fosinopril 47 fosinopril-hydrochlorothiazide
47 FRAGMIN 52 FREESTYLE LIBRE 14 DAY
SENSOR 71 FREESTYLE LIBRE 2
SENSOR 71 frovatriptan 28 fulvestrant 16 furosemide 47 FUZEON 3 fyavolv 99 G g tussin ac 115 gabapentin 25 GALAFOLD 75 galantamine 29 GAMASTAN 91 GAMASTAN SD 91 GAMIFANT 16 GAMMAGARD LIQUID 91 GAMMAGARD S-D (IGA lt 1
MCGML) 91 GAMMAKED 91 GAMMAPLEX 91 GAMMAPLEX (WITH
SORBITOL) 91 GAMUNEX-C 91 GANCICLOVIR 3 ganciclovir sodium 3 GARDASIL 9 (PF) 91 gatifloxacin 109 gavilyte-c 82 gavilyte-g 82 gavilyte-n 82 GAZYVA 16 gemcitabine 16 17 gemfibrozil 56 gemmily 104 generlac 82 gengraf 17
131
GENOTROPIN 87 GENOTROPIN MINIQUICK
87 gentak 109 gentamicin 9 61 62 109 gentamicin sulfate (ped) (pf) 9 GENVOYA 3 GIAPREZA 56 GILENYA 88 GILOTRIF 17 GIVLAARI 67 GLASSIA 67 glatiramer 88 glatopa 88 GLEOSTINE 17 glimepiride 77 glipizide 77 glipizide-metformin 77 GLUCAGEN DIAGNOSTIC
KIT 71 GLUCAGEN HYPOKIT 71 GLUCAGON (HCL)
EMERGENCY KIT 71 glucagon emergency kit
(human) 71 GLUCAGON HCL 71 glyburide 77 glyburide micronized 77 glyburide-metformin 77 glycopyrrolate 80 GLYXAMBI 78 GONITRO 57 granisetron hcl 82 GRANIX 86 GRASTEK 91 griseofulvin microsize 1 griseofulvin ultramicrosize 1 guaiatussin ac 115 guanfacine 40 47 GYNAZOLE-1 101 gynol ii 101 H HAEGARDA 118 hailey 104 hailey 24 fe 104 hailey fe 1530 (28) 104 hailey fe 120 (28) 104 HALAVEN 17 halcinonide 65 halobetasol propionate 65 haloperidol 40
haloperidol decanoate 40 haloperidol lactate 40 HARVONI 3 HAVRIX (PF) 91 92 heather 99 HEMLIBRA 52 hemmorex-hc 82 HEMOFIL M HIGH 52 HEMOFIL M LOW 52 HEMOFIL M MID 52 HEMOFIL M SUPER HIGH52 hep flush-10 (pf) 52 heparin (porcine) 52 heparin (porcine) in 5 dex 52 heparin lock flush (porcine) 52 heparin lockflush(porcine)(pf)
52 heparin(porcine) in 045 nacl
52 HEPARIN(PORCINE) IN
045 NACL 52 heparin porcine (pf) 52 53 HEPLISAV-B (PF) 92 HERCEPTIN 17 HERCEPTIN HYLECTA 17 HERZUMA 17 HETLIOZ 40 HETLIOZ LQ 40 HIBERIX (PF) 92 HIZENTRA 92 homatropaire 110 HUMALOG JUNIOR
KWIKPEN U-100 72 HUMALOG KWIKPEN
INSULIN 72 HUMALOG MIX 50-50
INSULN U-100 72 HUMALOG MIX 50-50
KWIKPEN 72 HUMALOG MIX 75-25
KWIKPEN 72 HUMALOG MIX 75-25(U-
100)INSULN 72 HUMALOG U-100 INSULIN
72 HUMATE-P 53 HUMIRA 96 HUMIRA PEN 96 HUMIRA PEN CROHNS-UC-
HS START 96
HUMIRA PEN PSOR-UVEITS-ADOL HS 96
HUMIRA(CF) 97 HUMIRA(CF) PEDI
CROHNS STARTER 96 HUMIRA(CF) PEN 96 HUMIRA(CF) PEN
CROHNS-UC-HS 96 HUMIRA(CF) PEN
PEDIATRIC UC 96 HUMIRA(CF) PEN PSOR-
UV-ADOL HS 96 HUMULIN 7030 U-100
INSULIN 72 HUMULIN 7030 U-100
KWIKPEN 72 HUMULIN N NPH INSULIN
KWIKPEN 73 HUMULIN N NPH U-100
INSULIN 73 HUMULIN R REGULAR U-
100 INSULN 73 HUMULIN R U-500 (CONC)
INSULIN 73 HUMULIN R U-500 (CONC)
KWIKPEN 73 HYCAMTIN 17 hydralazine 47 hydrochlorothiazide 47 hydrocodone bitartrate 32 hydrocodone-acetaminophen 32 hydrocodone-chlorpheniramine
115 hydrocodone-homatropine 115 hydrocodone-ibuprofen 32 hydrocortisone 65 70 82 hydrocortisone acetate 82 hydrocortisone butyrate 65 hydrocortisone butyr-emollient
65 hydrocortisone valerate 65 hydrocortisone-acetic acid 69 hydrocortisone-pramoxine 58
82 hydromet 116 hydromorphone 32 HYDROMORPHONE 32 hydroxocobalamin 124 hydroxychloroquine 9 hydroxyprogest(pf)(preg presv)
99
132
hydroxyprogesterone cap(ppres) 99
hydroxyprogesterone caproate 100
hydroxyurea 17 hydroxyzine hcl 115 hydroxyzine pamoate 115 hyophen 122 hyoscyamine sulfate 80 hyosyne 80 HYQVIA 92 I ibandronate 95 IBRANCE 17 ibu 35 ibuprofen 35 icatibant 118 iclevia 104 ICLUSIG 17 icosapent ethyl 56 IDELVION 53 IDHIFA 17 ILARIS (PF) 90 ILUMYA 58 imatinib 17 IMBRUVICA 17 IMFINZI 17 imipenem-cilastatin 9 imipramine hcl 40 imipramine pamoate 40 imiquimod 90 IMLYGIC 17 IMOVAX RABIES VACCINE
(PF) 92 incassia 100 INCRELEX 67 INCRUSE ELLIPTA 118 indapamide 47 indomethacin 35 INFANRIX (DTAP) (PF) 92 INFED 124 INFLECTRA 82 INFUGEM 18 INLYTA 18 INSULIN ASP PRT-INSULIN
ASPART 73 INSULIN ASPART U-100 73 INSULIN SYRINGE-
NEEDLE U-100 71 INTELENCE 3 INTRAROSA 101
INTRON A 90 INVANZ 9 INVEGA SUSTENNA 40 INVELTYS 113 INVIRASE 3 IOPIDINE 114 IPOL 92 ipratropium bromide 69 118 ipratropium-albuterol 118 irbesartan 47 irbesartan-hydrochlorothiazide
47 IRESSA 18 ISENTRESS 3 ISENTRESS HD 3 isibloom 104 ISOLYTE-S 123 isoniazid 9 isosorbide dinitrate 57 isosorbide mononitrate 57 isotretinoin 60 isoxsuprine 101 isradipine 47 ISTODAX 18 itraconazole 1 ivermectin 9 66 IXEMPRA 18 IXIARO (PF) 92 IXINITY 53 J jaimiess 104 JAKAFI 18 jantoven 53 JANUMET 78 JANUMET XR 78 JANUVIA 78 JARDIANCE 78 jasmiel (28) 104 jencycla 100 JENTADUETO 78 JENTADUETO XR 78 JEVTANA 18 jinteli 100 JIVI 53 jolessa 104 JORNAY PM 40 JUBLIA 62 juleber 104 JULUCA 3 junel 1530 (21) 104 junel 120 (21) 104
junel fe 1530 (28) 104 junel fe 120 (28) 104 junel fe 24 104 JUXTAPID 56 JYNARQUE 75 K KADCYLA 18 kaitlib fe 104 KALBITOR 118 KALETRA 3 4 kalliga 104 KALYDECO 118 KANJINTI 18 KANUMA 75 kariva (28) 104 kelnor 135 (28) 105 kelnor 1-50 (28) 105 KEPIVANCE 13 ketoconazole 1 62 ketodan 62 ketoprofen 35 ketorolac 35 112 KEVZARA 97 KEYTRUDA 18 KINRIX (PF) 92 KISQALI 18 KISQALI FEMARA CO-
PACK 18 klor-con 123 klor-con 10 122 klor-con 8 122 klor-con m10 122 klor-con m15 122 klor-con m20 123 klor-conef 123 KOATE 53 KOGENATE FS 53 KORLYM 75 KOVALTRY 53 K-PHOS NO 2 122 K-PHOS ORIGINAL 122 KRYSTEXXA 95 k-tab 123 K-TAB 123 kurvelo (28) 105 KYLEENA 98 KYMRIAH 18 KYPROLIS 18 L l norgesteestradiol-eestrad
105
133
labetalol 47 LACRISERT 111 lactulose 83 lamivudine 4 lamivudine-zidovudine 4 lamotrigine 25 lansoprazole 86 lanthanum 83 LANTUS SOLOSTAR U-100
INSULIN 73 LANTUS U-100 INSULIN 73 lapatinib 18 larin 1530 (21) 105 larin 120 (21) 105 larin 24 fe 105 larin fe 1530 (28) 105 larin fe 120 (28) 105 larissia 105 LASTACAFT 111 latanoprost 112 LATUDA 40 layolis fe 105 leena 28 105 leflunomide 97 LEMTRADA 88 LENVIMA 18 lessina 105 letrozole 19 leucovorin calcium 13 LEUKERAN 19 LEUKINE 86 leuprolide 19 levalbuterol hcl 118 LEVALBUTEROL
TARTRATE 118 LEVEMIR FLEXTOUCH U-
100 INSULN 73 LEVEMIR U-100 INSULIN 73 levetiracetam 25 levobunolol 110 levocarnitine 67 levocarnitine (with sugar) 67 levocetirizine 115 levofloxacin 12 109 levonest (28) 105 levonorgestrel 105 levonorgestrel-ethinyl estrad
105 levonorg-eth estrad triphasic
105 levora-28 105
levorphanol tartrate 32 levothyroxine 79 levoxyl 79 LEVULAN 59 LEXIVA 4 LIBTAYO 19 lidocaine 61 lidocaine hcl 61 lidocaine hcl-hydrocortison ac
61 83 LIDOCAINE HCL-
HYDROCORTISON AC 83 lidocaine viscous 61 lidocaine-hydrocortisone-aloe
83 lidocaine-prilocaine 61 LIDOCAINE-TETRACAINE
61 LILETTA 98 lillow (28) 105 LINCOCIN 9 lindane 66 linezolid 9 linezolid in dextrose 5 9 linezolid-09 sodium chloride
9 LINZESS 83 liothyronine 79 LIPOFEN 56 lisinopril 47 lisinopril-hydrochlorothiazide
47 lithium carbonate 40 41 LO LOESTRIN FE 105 lojaimiess 105 LONSURF 19 loperamide 80 lopinavir-ritonavir 4 lorazepam 41 lorazepam intensol 41 loryna (28) 105 losartan 47 losartan-hydrochlorothiazide 47 LOTEMAX 113 loteprednol etabonate 113 lovastatin 56 low-ogestrel (28) 105 loxapine succinate 41 lo-zumandimine (28) 105 LUCENTIS 111 ludent fluoride 124
LULICONAZOLE 62 LUMIGAN 112 LUMIZYME 75 LUMOXITI 19 LUPANETA PACK (1
MONTH) 101 LUPANETA PACK (3
MONTH) 101 LUPKYNIS 19 LUPRON DEPOT 19 LUPRON DEPOT (3
MONTH) 19 LUPRON DEPOT (4
MONTH) 19 LUPRON DEPOT (6
MONTH) 19 LUPRON DEPOT-PED 19 LUPRON DEPOT-PED (3
MONTH) 19 lutera (28) 105 LUXTURNA 111 LUZU 62 lyleq 100 lyllana 100 LYNPARZA 19 LYRICA CR 25 LYSODREN 19 lyza 100 M mafenide acetate 62 malathion 66 maprotiline 41 marlissa (28) 106 MARPLAN 41 MARQIBO 19 MATULANE 19 matzim la 47 MAVENCLAD (10 TABLET
PACK) 88 MAVENCLAD (4 TABLET
PACK) 88 MAVENCLAD (5 TABLET
PACK) 88 MAVENCLAD (6 TABLET
PACK) 88 MAVENCLAD (7 TABLET
PACK) 88 MAVENCLAD (8 TABLET
PACK) 88 MAVENCLAD (9 TABLET
PACK) 88
134
MAVYRET 4 MAXIDEX 113 maxi-tuss ac 116 MAYZENT 88 MAYZENT STARTER PACK
88 m-clear wc 116 meclizine 83 meclofenamate 35 medroxyprogesterone 100 mefenamic acid 35 mefloquine 9 megestrol 19 MEKINIST 19 MEKTOVI 19 meloxicam 35 melphalan 19 melphalan hcl 19 memantine 29 MENACTRA (PF) 92 MENEST 100 MENOSTAR 100 MENQUADFI (PF) 92 MENTAX 62 MENVEO A-C-Y-W-135-DIP
(PF) 92 meperidine 32 meprobamate 30 MEPSEVII 76 mercaptopurine 20 meropenem 9 MEROPENEM-09
SODIUM CHLORIDE 9 merzee 106 mesalamine 83 mesalamine with cleansing
wipe 83 metaproterenol 118 metaxalone 30 metformin 78 methadone 32 methadose 32 methamphetamine 41 methazolamide 112 methenamine hippurate 13 methenamine mandelate 13 methen-sod phos-meth blue-
hyos 122 methergine 109 methimazole 71 methocarbamol 30
methotrexate sodium 20 methotrexate sodium (pf) 20 methoxsalen 59 methscopolamine 80 methyldopa 47 methyldopa-
hydrochlorothiazide 47 methyldopate 48 methylergonovine 109 METHYLIN 41 methylphenidate hcl 41 methylprednisolone 70 methylprednisolone acetate 70 methyltestosterone 76 metoclopramide hcl 83 metolazone 48 metoprolol succinate 48 metoprolol ta-hydrochlorothiaz
48 metoprolol tartrate 48 metronidazole 9 60 61 101 metyrosine 48 mexiletine 44 MIACALCIN 76 mibelas 24 fe 106 microgestin 1530 (21) 106 microgestin 120 (21) 106 microgestin fe 1530 (28) 106 microgestin fe 120 (28) 106 midazolam 41 midodrine 67 migergot 28 miglitol 78 miglustat 76 mili 106 millipred 70 millipred dp 70 mimvey 100 MINITRAN 57 minocycline 12 minoxidil 48 MIRCERA 86 MIRENA 98 mirtazapine 41 misoprostol 86 MITIGARE 95 mitoxantrone 20 M-M-R II (PF) 92 modafinil 41 moexipril 48 molindone 41
mometasone 65 mondoxyne nl 12 mono-linyah 106 MONONINE 53 MONOVISC 35 montelukast 118 119 morphine 32 33 morphine (pf) 32 morphine concentrate 32 MOTOFEN 80 MOVANTIK 83 MOXATAG 11 moxifloxacin 12 109 MOZOBIL 87 MULPLETA 53 MULTAQ 44 multi-vitamin with fluoride 124 multivitamins with fluoride 124 mupirocin 62 mupirocin calcium 62 mvc-fluoride 124 my choice 106 my way 106 MYALEPT 76 MYCAMINE 1 mycophenolate mofetil 20 mycophenolate sodium 20 MYDAYIS 41 MYLOTARG 20 MYOBLOC 92 myorisan 61 MYRBETRIQ 121 N nabumetone 35 nadolol 48 nadolol-bendroflumethiazide 48 nafcillin 11 nafcillin in dextrose iso-osm 11 naftifine 62 63 NAGLAZYME 76 nalbuphine 35 naloxone 35 naltrexone 35 naproxen 35 naproxen sodium 35 naratriptan 28 NARCAN 35 NATACYN 109 NATAZIA 106 nateglinide 78 NATPARA 76
135
nebusal 119 necon 0535 (28) 106 nefazodone 41 neomycin 9 neomycin-bacitracin-poly-hc
112 neomycin-bacitracin-
polymyxin 109 neomycin-polymyxin b-
dexameth 112 113 neomycin-polymyxin-
gramicidin 109 neomycin-polymyxin-hc 69
113 neo-polycin 109 neo-polycin hc 113 NERLYNX 20 NEUPOGEN 87 NEVANAC 112 nevirapine 4 new day 106 NEXAVAR 20 NEXPLANON 101 NEXTSTELLIS 106 niacin 56 NIACOR 56 nicardipine 48 nicorette 68 nicotine 68 nicotine (polacrilex) 68 NICOTROL 68 NICOTROL NS 68 nifedipine 48 nikki (28) 106 nilutamide 20 nimodipine 48 NINLARO 20 nisoldipine 48 nitazoxanide 9 nitisinone 67 nitro-bid 57 NITRO-DUR 57 nitrofurantoin 13 nitrofurantoin macrocrystal 13 nitrofurantoin monohydm-
cryst 13 nitroglycerin 57 nitroglycerin in 5 dextrose 57 nitro-time 57 NITYR 67 NIVESTYM 87
nizatidine 86 nora-be 100 noreth-ethinyl estradiol-iron
106 norethindrone (contraceptive)
100 norethindrone acetate 100 norethindrone ac-eth estradiol
100 106 norethindrone-eestradiol-iron
106 norgestimate-ethinyl estradiol
106 norlyda 100 NORMOSOL-R 123 NORPACE CR 44 nortrel 0535 (28) 106 nortrel 135 (21) 106 nortrel 135 (28) 106 nortrel 777 (28) 107 nortriptyline 42 NORVIR 4 NOVAFERRUM 124 NOVOEIGHT 53 NOVOLIN 70-30 FLEXPEN
U-100 73 NOVOLIN N FLEXPEN 73 NOVOLIN R FLEXPEN 73 NOVOLOG FLEXPEN U-100
INSULIN 74 NOVOLOG MIX 70-30 U-100
INSULN 74 NOVOLOG MIX 70-
30FLEXPEN U-100 74 NOVOLOG PENFILL U-100
INSULIN 74 NOVOLOG U-100 INSULIN
ASPART 74 NOVOPEN ECHO 71 NOVOSEVEN RT 53 NOXAFIL 1 np thyroid 79 NPLATE 53 NUCALA 119 NUCYNTA ER 36 NUEDEXTA 29 NULOJIX 20 NULYTELY LEMON-LIME
83 NUPLAZID 42 NUWIQ 53
nyamyc 63 nylia 777 (28) 107 nymyo 107 nystatin 1 63 nystatin-triamcinolone 63 nystop 63 O OBIZUR 54 ocella 107 OCREVUS 88 OCTAGAM 92 octreotide acetate 20 ODEFSEY 4 OFEV 119 ofloxacin 12 69 109 OGIVRI 20 olanzapine 42 olanzapine-fluoxetine 42 olmesartan 48 olmesartan-amlodipin-
hcthiazid 48 olmesartan-
hydrochlorothiazide 48 olopatadine 69 111 OLUMIANT 97 omega-3 acid ethyl esters 56 omeprazole 86 OMIDRIA 111 OMNITROPE 87 ONCASPAR 20 ondansetron 84 ondansetron hcl 83 84 ONETOUCH ULTRA TEST
71 ONETOUCH VERIO TEST
STRIPS 71 ONIVYDE 20 ONPATTRO 29 ONZETRA XSAIL 28 opcicon one-step 107 OPDIVO 20 opium tincture 81 OPSUMIT 119 option-2 107 ORALAIR 92 oralone 69 ORAVIG 1 ORENCIA 97 ORENCIA (WITH
MALTOSE) 97 ORENCIA CLICKJECT 97
136
ORENITRAM 48 ORLADEYO 119 orphenadrine citrate 30 orsythia 107 ORTHOVISC 36 oscimin 81 oscimin sl 81 oscimin sr 81 oseltamivir 4 OSMOPREP 84 OSPHENA 101 OTEZLA 97 OTEZLA STARTER 97 OTOVEL 69 oxacillin 11 oxacillin in dextrose(iso-osm)
11 oxandrolone 76 oxaprozin 36 oxazepam 42 oxcarbazepine 25 oxiconazole 63 OXISTAT 63 OXLUMO 122 oxybutynin chloride 121 oxycodone 33 oxycodone-acetaminophen 33 oxycodone-aspirin 33 OXYCONTIN 33 oxymorphone 33 OZEMPIC 78 OZURDEX 113 P pacerone 44 PADCEV 20 paliperidone 42 PALYNZIQ 76 pamidronate 76 PANRETIN 59 pantoprazole 86 PANZYGA 92 PARAGARD T 380A 98 paricalcitol 76 PARICALCITOL 76 paroex oral rinse 69 paromomycin 10 paroxetine hcl 42 paroxetine
mesylate(menopsym) 42 PARSABIV 76 PASER 10
PEDIARIX (PF) 92 PEDVAX HIB (PF) 93 peg 3350-electrolytes 84 peg3350-sod sul-nacl-kcl-asb-c
84 PEGASYS 88 89 peg-electrolyte soln 84 peg-prep 84 PEMAZYRE 20 PEN NEEDLE DIABETIC 72 penicillamine 97 penicillin g procaine 11 penicillin v potassium 11 PENTACEL (PF) 93 PENTACEL ACTHIB
COMPONENT (PF) 93 PENTAM 10 pentamidine 10 pentazocine-naloxone 36 pentoxifylline 54 PERFOROMIST 119 perindopril erbumine 48 periogard 69 PERJETA 20 permethrin 66 perphenazine 42 perphenazine-amitriptyline 42 phenazopyridine 122 phenelzine 42 phenobarb-hyoscy-atropine-
scop 81 phenobarbital 25 26 phenohytro 81 phenoxybenzamine 48 phenylephrine hcl 114 phenytoin 26 phenytoin sodium extended 26 PHEXXI 101 philith 107 phosphasal 122 PHYSIOLYTE 66 PHYSIOSOL IRRIGATION 66 phytonadione (vitamin k1) 54 PICATO 59 pilocarpine hcl 67 69 110 pimecrolimus 59 pimozide 42 pimtrea (28) 107 pindolol 48 pioglitazone 78 pioglitazone-glimepiride 78
pioglitazone-metformin 78 piperacillin-tazobactam 11 PIQRAY 21 pirmella 107 piroxicam 36 PLASMA-LYTE 148 123 PLASMA-LYTE A 123 PLEGRIDY 89 PLENVU 84 PNEUMOVAX-23 93 podofilox 59 POLIVY 21 polycin 110 polymyxin b sulfate 10 polymyxin b sulf-trimethoprim
110 POMALYST 89 PONVORY 89 PONVORY 14-DAY
STARTER PACK 89 portia 28 107 PORTRAZZA 21 posaconazole 1 potassium chloride 123 potassium citrate 122 POTELIGEO 21 pramipexole 27 prasugrel 54 pravastatin 56 praziquantel 10 prazosin 48 PRED MILD 113 prednicarbate 65 prednisolone 70 prednisolone acetate 113 prednisolone sodium phosphate
70 114 prednisone 70 prednisone intensol 70 pregabalin 26 PREMARIN 100 PREMPHASE 100 PREMPRO 100 prevalite 56 previfem 107 PREVNAR 13 (PF) 93 PREVYMIS 4 PREZCOBIX 4 PREZISTA 4 PRIFTIN 10 primaquine 10
137
primidone 26 PRIMSOL 13 PRIVIGEN 93 probenecid 95 probenecid-colchicine 95 procainamide 44 procentra 42 prochlorperazine 84 prochlorperazine edisylate 84 prochlorperazine maleate 84 PROCRIT 87 procto-med hc 84 procto-pak 84 proctosol hc 84 proctozone-hc 84 PROFILNINE 54 progesterone 100 progesterone micronized 100 PROGRAF 21 PROLASTIN-C 67 PROLEUKIN 90 PROLIA 95 PROMACTA 54 promethazine 115 promethazine-codeine 116 promethazine-dm 116 promethazine-phenyleph-
codeine 116 promethazine-phenylephrine
116 promethegan 115 propafenone 44 45 proparacaine 111 propranolol 48 49 propranolol-hydrochlorothiazid
49 propylthiouracil 71 PROQUAD (PF) 93 protriptyline 42 PROVENGE 93 prudoxin 59 pulmosal 119 PULMOZYME 119 pyrazinamide 10 pyridostigmine bromide 30 pyrimethamine 10 Q QBRELIS 49 QINLOCK 21 QTERN 78 QUADRACEL (PF) 93
quetiapine 42 QUILLICHEW ER 42 QUILLIVANT XR 42 quinapril 49 quinapril-hydrochlorothiazide
49 quinidine gluconate 45 quinidine sulfate 45 quinine sulfate 10 quit 2 68 quit 4 68 QVAR REDIHALER 119 R RABAVERT (PF) 93 rabeprazole 86 RADICAVA 29 RAGWITEK 93 raloxifene 95 ramelteon 42 ramipril 49 ranolazine 57 RAPIVAB (PF) 4 rasagiline 27 RAVICTI 67 REBIF (WITH ALBUMIN) 89 REBIF REBIDOSE 89 REBIF TITRATION PACK 89 REBINYN 54 RECLAST 67 reclipsen (28) 107 RECOMBINATE 54 RECOMBIVAX HB (PF) 93 RECTIV 84 REGRANEX 59 RELENZA DISKHALER 4 RELEXXII 42 RELION NOVOLIN 7030 74 RELION NOVOLIN N 74 RELION NOVOLIN R 74 RELISTOR 84 REMICADE 84 RENACIDIN 122 RENFLEXIS 84 repaglinide 78 repaglinide-metformin 78 REPATHA PUSHTRONEX 56 REPATHA SURECLICK 56 REPATHA SYRINGE 56 RESTASIS 111 RETEVMO 21 RETISERT 114
REVATIO 119 REVLIMID 89 REXULTI 43 REYATAZ 4 RHOPRESSA 112 RIASTAP 54 ribavirin 4 89 RIDAURA 97 rifabutin 10 rifampin 10 riluzole 67 rimantadine 4 RINVOQ 97 RIOMET ER 78 risedronate 67 95 RISPERDAL CONSTA 43 risperidone 43 ritonavir 4 RITUXAN 21 RITUXAN HYCELA 21 rivastigmine 30 rivastigmine tartrate 29 rivelsa 107 RIXUBIS 54 rizatriptan 28 ropinirole 27 28 rosadan 61 rosuvastatin 56 roweepra 26 RUBRACA 21 RUCONEST 119 rufinamide 26 RYBELSUS 79 RYDAPT 21 S salsalate 36 SAMSCA 76 SANTYL 65 sapropterin 76 SARCLISA 21 SAVELLA 97 scalacort 65 SCENESSE 59 scopolamine base 84 seconal sodium 43 SEEBRI NEOHALER 119 selegiline hcl 28 selenium sulfide 58 SELZENTRY 5 SEREVENT DISKUS 119 SEROSTIM 87
138
sertraline 43 setlakin 107 sevelamer carbonate 84 sevelamer hcl 84 sf 69 sf 5000 plus 69 sharobel 101 SHINGRIX (PF) 93 SIGNIFOR 21 sildenafil (pulmhypertension)
119 SILIQ 58 silodosin 121 silver sulfadiazine 59 SIMBRINZA 112 simliya (28) 107 simpesse 107 SIMPONI 97 SIMPONI ARIA 97 SIMULECT 21 simvastatin 56 SINUVA 119 sirolimus 21 SIRTURO 10 SIVEXTRO 10 SKYLA 98 SKYRIZI 58 SLYND 107 sodium chloride 119 sodium chloride 045 123 sodium chloride 09 67 sodium fluoride 5000 dry
mouth 69 sodium fluoride 5000 plus 69 sodium fluoride-pot nitrate 69 sodium phenylbutyrate 67 sodium polystyrene sulfonate
85 solifenacin 121 SOLIQUA 10033 74 SOLIRIS 67 SOLTAMOX 21 SOMATULINE DEPOT 21 SOMAVERT 76 sorine 45 sotalol 45 sotalol af 45 SOVALDI 5 spinosad 66 SPIRIVA RESPIMAT 119
SPIRIVA WITH HANDIHALER 119
spironolactone 49 spironolacton-hydrochlorothiaz
49 SPRAVATO 43 sprintec (28) 107 SPRYCEL 21 sps (with sorbitol) 85 sronyx 107 ssd 59 SSKI 71 st joseph aspirin 36 st joseph aspirin 36 STAMARIL (PF) 93 stavudine 5 STELARA 58 STIOLTO RESPIMAT 119 STIVARGA 21 stop smoking aid 68 STRENSIQ 76 STREPTOMYCIN 10 STRIBILD 5 STRIVERDI RESPIMAT 120 SUBLOCADE 33 subvenite 26 subvenite starter (blue) kit 26 subvenite starter (green) kit 26 subvenite starter (orange) kit 26 SUCRAID 85 sucralfate 86 sulfacetamide sodium 58 114 sulfacetamide sodium (acne) 62 sulfacetamide-prednisolone 114 sulfadiazine 12 sulfamethoxazole-trimethoprim
12 SULFAMYLON 62 sulfasalazine 85 sulfatrim 12 sulindac 36 sumatriptan 28 sumatriptan succinate 28 29 SUNOSI 43 SUPPRELIN LA 21 SUPRAX 7 SUPREP BOWEL PREP KIT
85 SUTENT 22 syeda 107 SYLVANT 22
symax fastabs 81 symax-sl 81 symax-sr 81 SYMBICORT 120 SYMDEKO 120 SYMLINPEN 120 79 SYMLINPEN 60 79 SYMPAZAN 26 SYNAGIS 5 SYNAREL 76 SYNERA 61 SYNJARDY 79 SYNJARDY XR 79 SYNRIBO 22 SYNTHROID 79 T TABLOID 22 tacrolimus 22 59 tadalafil 121 tadalafil (pulm hypertension)
120 TAFINLAR 22 TAGRISSO 22 TAKHZYRO 120 TALTZ AUTOINJECTOR 58 TALTZ AUTOINJECTOR (2
PACK) 58 TALTZ AUTOINJECTOR (3
PACK) 58 TALTZ SYRINGE 58 TALZENNA 22 tamoxifen 22 tamsulosin 121 TARGRETIN 22 tarina 24 fe 107 tarina fe 120 (28) 107 TASIGNA 22 tavaborole 63 tazarotene 61 tazicef 7 taztia xt 49 TDVAX 93 TECENTRIQ 22 TEFLARO 7 TEKTURNA HCT 49 telmisartan 49 telmisartan-amlodipine 49 telmisartan-hydrochlorothiazid
49 temazepam 43 TEMODAR 22
139
temozolomide 22 temsirolimus 22 tencon 33 TENIVAC (PF) 94 tenofovir disoproxil fumarate 5 TEPEZZA 76 terazosin 49 terbinafine hcl 1 terbutaline 120 terconazole 101 testosterone 77 testosterone cypionate 76 testosterone enanthate 76 TETANUSDIPHTHERIA
TOX PED(PF) 94 tetrabenazine 30 tetracaine hcl 111 TETRACAINE HCL (PF) 111 tetracycline 12 THALOMID 22 theophylline 120 thioridazine 43 thiothixene 43 THYMOGLOBULIN 94 THYROLAR-1 79 THYROLAR-12 79 THYROLAR-14 79 THYROLAR-2 79 THYROLAR-3 79 tiadylt er 49 tiagabine 26 TIBSOVO 22 tilia fe 107 timolol maleate 49 110 tinidazole 10 TIVICAY 5 TIVICAY PD 5 tizanidine 30 TOBRADEX 113 TOBRADEX ST 113 tobramycin 10 110 tobramycin in 0225 nacl 10 tobramycin sulfate 10 TOBRAMYCIN WITH
NEBULIZER 10 tobramycin-dexamethasone 113 TOBREX 110 TODAY CONTRACEPTIVE
SPONGE 101 tolcapone 28 tolmetin 36
tolterodine 121 topiramate 26 toremifene 22 TORISEL 22 torsemide 49 TOUJEO MAX U-300
SOLOSTAR 74 TOUJEO SOLOSTAR U-300
INSULIN 74 TRACLEER 120 TRADJENTA 79 tramadol 36 tramadol-acetaminophen 36 trandolapril 49 trandolapril-verapamil 49 tranexamic acid 54 101 tranylcypromine 43 travoprost 112 trazodone 43 TREANDA 22 TRECATOR 10 TRELEGY ELLIPTA 120 TRELSTAR 22 TREMFYA 59 TRESIBA FLEXTOUCH U-
100 74 TRESIBA FLEXTOUCH U-
200 74 TRESIBA U-100 INSULIN 74 tretinoin 61 tretinoin (antineoplastic) 22 tretinoin microspheres 61 TRETTEN 54 TREXALL 22 tri femynor 107 triamcinolone acetonide 65 69
71 triamterene 49 triamterene-hydrochlorothiazid
49 triazolam 43 triderm 65 trientine 67 tri-estarylla 107 trifluoperazine 43 trifluridine 110 trihexyphenidyl 28 TRIJARDY XR 71 TRIKAFTA 120 tri-legest fe 108 tri-linyah 108
tri-lo-estarylla 108 tri-lo-marzia 108 tri-lo-mili 108 tri-lo-sprintec 108 trilyte with flavor packets 85 trimethobenzamide 85 trimethoprim 13 tri-mili 108 trimipramine 43 TRINTELLIX 43 tri-nymyo 108 tri-previfem (28) 108 tri-sprintec (28) 108 TRIUMEQ 5 tri-vitamin with fluoride 124 trivora (28) 108 tri-vylibra 108 tri-vylibra lo 108 TROGARZO 5 tropicamide 110 trospium 121 TRULICITY 79 TRUMENBA 94 TRUXIMA 22 TUKYSA 23 tulana 101 TWINRIX (PF) 94 TWIRLA 101 TYBLUME 108 TYBOST 5 tydemy 108 TYGACIL 10 TYMLOS 95 TYPHIM VI 94 TYSABRI 30 TYVASO 120 TYVASO REFILL KIT 120 TYVASO STARTER KIT 120 U UBRELVY 29 UDENYCA 87 ULESFIA 66 unithroid 80 UNITUXIN 23 URELLE 122 uretron d-s 122 urimar-t 122 urogesic-blue 122 ursodiol 85 uryl 122 ustell 122
140
UTIBRON NEOHALER 120 utira-c 122 UVADEX 59 V vaginal contraceptive foam 101 valacyclovir 5 VALCHLOR 59 valganciclovir 5 valproic acid 26 valproic acid (as sodium salt)
26 valsartan 49 valsartan-hydrochlorothiazide
49 vanadom 30 vancomycin 13 vandazole 101 VANTAS 23 VAQTA (PF) 94 VARIVAX (PF) 94 VARUBI 85 VASCEPA 56 VAXELIS (PF) 94 VCF CONTRACEPTIVE
FILM 101 VCF CONTRACEPTIVE GEL
101 VECTIBIX 23 VELCADE 23 veletri 50 velivet triphasic regimen (28)
108 VELPHORO 85 VEMLIDY 5 VENCLEXTA 23 VENCLEXTA STARTING
PACK 23 venlafaxine 43 VENTAVIS 120 verapamil 50 VERSACLOZ 43 VERZENIO 23 vestura (28) 108 VIBATIV 13 VIBERZI 85 VIDAZA 23 VIEKIRA PAK 5 vienva 108 vigabatrin 26 vigadrone 26 VIMIZIM 77
VIMPAT 26 viorele (28) 108 VIRACEPT 5 VIREAD 5 virtussin ac 116 VISTOGARD 13 VISUDYNE 111 vitamins acd and fluoride 124 VITRAKVI 23 VIVITROL 36 volnea (28) 108 VONVENDI 54 VORAXAZE 13 voriconazole 1 2 VOSEVI 5 VOTRIENT 23 VPRIV 77 VRAYLAR 44 VYEPTI 29 vyfemla (28) 108 vylibra 108 VYONDYS-53 30 VYVANSE 44 VYXEOS 23 W warfarin 54 wera (28) 108 westhroid 80 WIDE-SEAL DIAPHRAGM
98 WILATE 54 wixela inhub 121 wymzya fe 108 X XALKORI 23 XARELTO 54 XARELTO DVT-PE TREAT
30D START 54 XCOPRI 27 XCOPRI MAINTENANCE
PACK 27 XCOPRI TITRATION PACK
27 XELJANZ 97 XELJANZ XR 97 XEMBIFY 94 XENLETA 10 XEOMIN 94 XERMELO 23 XGEVA 13 XIFAXAN 10
XIGDUO XR 79 XIIDRA 111 XOLAIR 121 XOSPATA 23 XTANDI 23 xulane 102 XULTOPHY 10036 74 XURIDEN 67 XYNTHA 55 XYNTHA SOLOFUSE 55 XYREM 44 Y YERVOY 23 YESCARTA 23 YF-VAX (PF) 94 YONDELIS 23 YONSA 23 YUTIQ 114 yuvafem 101 Z zafemy 102 zafirlukast 121 zaleplon 44 ZALTRAP 23 ZANOSAR 23 zarah 109 ZARXIO 87 ZEJULA 24 ZELBORAF 24 ZEMAIRA 68 zenatane 61 ZENPEP 85 ZENZEDI 44 ZEPATIER 5 ZEPOSIA 89 ZEPOSIA STARTER KIT 89 ZEPOSIA STARTER PACK
89 ZERBAXA 7 zidovudine 5 ZIEXTENZO 87 zileuton 121 ziprasidone hcl 44 ZIRGAN 110 ZOKINVY 68 ZOLADEX 24 ZOLGENSMA 30 ZOLINZA 24 zolmitriptan 29 zolpidem 44 ZOLPIMIST 44
141
ZOMIG 29 zonisamide 27 ZONTIVITY 55 ZORBTIVE 87
ZOSTAVAX (PF) 94 zovia 135e (28) 109 ZULRESSO 44 zumandimine (28) 109
ZYFLO 121 ZYKADIA 24 ZYPITAMAG 56
051267 (11-20-2019)
Discrimination is Against the Law
LifeWise Health Plan of Washington (LifeWise) complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex LifeWise does not exclude people or treat them differently because of race color national origin age disability sex gender identity or sexual orientation LifeWise provides free aids and services to people with disabilities to communicate effectively with us such as qualified sign language interpreters and written information in other formats (large print audio accessible electronic formats other formats) LifeWise provides free language services to people whose primary language is not English such as qualified interpreters and information written in other languages If you need these services contact the Civil Rights Coordinator If you believe that LifeWise 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 Civil Rights Coordinator Complaints and Appeals PO Box 91102 Seattle WA 98111 Toll free 855-332-6396 Fax 425-918-5592 TTY 711 Email AppealsDepartmentInquiriesLifeWiseHealthcom You can file a grievance in person or by mail fax or email If you need help filing a grievance the Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Ave SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
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までお電話にてご連絡ください ማስታወሻ የሚናገሩት ቋንቋ ኣማርኛ ከነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ
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)711 والبكم الصم ھاتف رقم( 800-178-3056 برقم اتصل بالمجان لك تتوافر اللغویة المساعدة خدمات فإن اللغة اذكر تتحدث كنت إذا ملحوظةਿਧਆਨ ਿਦਓ ਜ ਤਸ ਪਜਾਬੀ ਬਲਦ ਹ ਤ ਭਾਸ਼ਾ ਿਵਚ ਸਹਾਇਤਾ ਸਵਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਧ ਹ 800-817-3056
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Rufnummer 800-817-3056 (TTY 711) ໂປດຊາບ ຖາວາ ທານເວາພາສາ ລາວ ການບລການຊວຍເຫອດານພາສາ ໂດຍບເສຽຄາ
ແມນມພອມໃຫທານ ໂທຣ 800-817-3056 (TTY 711) ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele 800-817-3056 (TTY 711) ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 800-817-3056 (ATS 711) UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń pod numer 800-817-3056 (TTY 711) ATENCcedilAtildeO Se fala portuguecircs encontram-se disponiacuteveis serviccedilos linguiacutesticos graacutetis Ligue para 800-817-3056 (TTY 711) ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza linguistica gratuiti Chiamare il numero
800-817-3056 (TTY 711) دیریبگ تماس 3056-817-800 (TTY 711) با باشد یم فراھم شما یبرا گانیرا بصورت یزبان لاتیتسھ دیکن یم گفتگو فارسی زبان بھ اگر توجھ
2
Drug Name Drug Tier Requirements Limits
voriconazole oral suspension for reconstitution 200 mg5 ml (40 mgml)
1
voriconazole oral tablet 200 mg 50 mg 1
ANTIVIRALS
abacavir oral solution 20 mgml 1 QL (60 per 30 days)
abacavir oral tablet 300 mg 1 QL (60 per 30 days)
abacavir-lamivudine oral tablet 600-300 mg 1 QL (30 per 30 days)
abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg
1 QL (60 per 30 days)
acyclovir oral capsule 200 mg 1
acyclovir oral suspension 200 mg5 ml 1
acyclovir oral tablet 400 mg 800 mg 1
adefovir oral tablet 10 mg 1
amantadine hcl oral capsule 100 mg 1
amantadine hcl oral solution 50 mg5 ml 1
amantadine hcl oral tablet 100 mg 1
APTIVUS ORAL CAPSULE 250 MG 1 QL (120 per 30 days)
atazanavir oral capsule 150 mg 300 mg 1 QL (30 per 30 days)
atazanavir oral capsule 200 mg 1 QL (60 per 30 days)
BARACLUDE ORAL SOLUTION 005 MGML 1
BIKTARVY ORAL TABLET 50-200-25 MG 1 QL (30 per 30 days)
CABENUVA INTRAMUSCULAR SUSPENSIONEXTENDED RELEASE 400 MG2 ML- 600 MG2 ML 600 MG3 ML- 900 MG3 ML
2 PA
cidofovir intravenous solution 75 mgml MB
CIMDUO ORAL TABLET 300-300 MG 1 QL (30 per 30 days)
COMPLERA ORAL TABLET 200-25-300 MG 1 QL (30 per 30 days)
CYTOVENE INTRAVENOUS RECON SOLN 500 MG
MB
DESCOVY ORAL TABLET 200-25 MG 1 QL (30 per 30 days)
didanosine oral capsuledelayed release(drec) 250 mg 400 mg
1 QL (30 per 30 days)
DOVATO ORAL TABLET 50-300 MG 1 QL (30 per 30 days)
EDURANT ORAL TABLET 25 MG 1 QL (30 per 30 days)
efavirenz oral capsule 200 mg 50 mg 1 QL (30 per 30 days)
efavirenz oral tablet 600 mg 1 QL (30 per 30 days)
3
Drug Name Drug Tier Requirements Limits
efavirenz-emtricitabin-tenofov oral tablet 600-200-300 mg
1
efavirenz-lamivu-tenofov disop oral tablet 400-300-300 mg 600-300-300 mg
1
emtricitabine oral capsule 200 mg 1 QL (30 per 30 days)
emtricitabine-tenofovir (tdf) oral tablet 100-150 mg 133-200 mg 167-250 mg 200-300 mg
1
EMTRIVA ORAL SOLUTION 10 MGML 1 QL (720 per 30 days)
entecavir oral tablet 05 mg 1 mg 1
EPCLUSA ORAL TABLET 200-50 MG 400-100 MG
2 PA LA
EPIVIR HBV ORAL SOLUTION 25 MG5 ML (5 MGML)
1
etravirine oral tablet 100 mg 200 mg 1 QL (60 per 30 days)
EVOTAZ ORAL TABLET 300-150 MG 1 QL (30 per 30 days)
famciclovir oral tablet 125 mg 250 mg 500 mg 1
fosamprenavir oral tablet 700 mg 1 QL (60 per 30 days)
FUZEON SUBCUTANEOUS RECON SOLN 90 MG
2 QL (30 per 30 days)
GANCICLOVIR INTRAVENOUS SOLUTION 500 MG250 ML (2 MGML)
MB
ganciclovir sodium intravenous recon soln 500 mg MB
GENVOYA ORAL TABLET 150-150-200-10 MG
1 QL (30 per 30 days)
HARVONI ORAL PELLETS IN PACKET 3375-150 MG 45-200 MG
2 LA
HARVONI ORAL TABLET 45-200 MG 90-400 MG
2 PA LA
INTELENCE ORAL TABLET 100 MG 200 MG 25 MG
1 QL (60 per 30 days)
INVIRASE ORAL TABLET 500 MG 1 QL (120 per 30 days)
ISENTRESS HD ORAL TABLET 600 MG 1 QL (60 per 30 days)
ISENTRESS ORAL POWDER IN PACKET 100 MG
1 QL (60 per 30 days)
ISENTRESS ORAL TABLET 400 MG 1 QL (60 per 30 days)
ISENTRESS ORAL TABLETCHEWABLE 100 MG 25 MG
1 QL (60 per 30 days)
JULUCA ORAL TABLET 50-25 MG 1 QL (30 per 30 days)
KALETRA ORAL TABLET 100-25 MG 1 QL (60 per 30 days)
4
Drug Name Drug Tier Requirements Limits
KALETRA ORAL TABLET 200-50 MG 1 QL (120 per 30 days)
lamivudine oral solution 10 mgml 1 QL (900 per 30 days)
lamivudine oral tablet 100 mg 1
lamivudine oral tablet 150 mg 300 mg 1 QL (60 per 30 days)
lamivudine-zidovudine oral tablet 150-300 mg 1 QL (60 per 30 days)
LEXIVA ORAL SUSPENSION 50 MGML 1 QL (60 per 30 days)
lopinavir-ritonavir oral solution 400-100 mg5 ml 1 QL (320 per 30 days)
lopinavir-ritonavir oral tablet 100-25 mg 200-50 mg
1 QL (120 per 30 days)
MAVYRET ORAL TABLET 100-40 MG 2 PA LA
nevirapine oral suspension 50 mg5 ml 1 QL (60 per 30 days)
nevirapine oral tablet 200 mg 1 QL (60 per 30 days)
nevirapine oral tablet extended release 24 hr 100 mg 400 mg
1 QL (30 per 30 days)
NORVIR ORAL POWDER IN PACKET 100 MG 1 QL (360 per 30 days)
NORVIR ORAL SOLUTION 80 MGML 1 QL (480 per 30 days)
ODEFSEY ORAL TABLET 200-25-25 MG 1 QL (30 per 30 days)
oseltamivir oral capsule 30 mg 1 QL (40 per 365 days)
oseltamivir oral capsule 45 mg 75 mg 1 QL (20 per 365 days)
oseltamivir oral suspension for reconstitution 6 mgml
1 QL (180 per 30 days)
PREVYMIS INTRAVENOUS SOLUTION 240 MG12 ML 480 MG24 ML
MB PA
PREZCOBIX ORAL TABLET 800-150 MG-MG 1 QL (30 per 30 days)
PREZISTA ORAL SUSPENSION 100 MGML 1 QL (30 per 30 days)
PREZISTA ORAL TABLET 150 MG 600 MG 75 MG
1 QL (60 per 30 days)
PREZISTA ORAL TABLET 800 MG 1 QL (30 per 30 days)
RAPIVAB (PF) INTRAVENOUS SOLUTION 200 MG20 ML (10 MGML)
MB
RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MGACTUATION
1 QL (2 per 30 days)
REYATAZ ORAL POWDER IN PACKET 50 MG
1 QL (150 per 30 days)
ribavirin inhalation recon soln 6 gram MB
rimantadine oral tablet 100 mg 1
ritonavir oral tablet 100 mg 1 QL (360 per 30 days)
5
Drug Name Drug Tier Requirements Limits
SELZENTRY ORAL SOLUTION 20 MGML 1 QL (8 per 30 days)
SELZENTRY ORAL TABLET 150 MG 25 MG 300 MG 75 MG
1 QL (60 per 30 days)
SOVALDI ORAL PELLETS IN PACKET 150 MG 200 MG
2 LA
SOVALDI ORAL TABLET 200 MG 400 MG 2 PA LA
stavudine oral capsule 15 mg 20 mg 40 mg 1 QL (120 per 30 days)
STRIBILD ORAL TABLET 150-150-200-300 MG
1 QL (30 per 30 days)
SYNAGIS INTRAMUSCULAR SOLUTION 100 MGML 50 MG05 ML
MB LA
tenofovir disoproxil fumarate oral tablet 300 mg 1 QL (30 per 30 days)
TIVICAY ORAL TABLET 10 MG 25 MG 50 MG
1 QL (60 per 30 days)
TIVICAY PD ORAL TABLET FOR SUSPENSION 5 MG
1 QL (60 per 30 days)
TRIUMEQ ORAL TABLET 600-50-300 MG 1 QL (30 per 30 days)
TROGARZO INTRAVENOUS SOLUTION 200 MG133 ML (150 MGML)
MB PA
TYBOST ORAL TABLET 150 MG 1 QL (30 per 30 days)
valacyclovir oral tablet 1 gram 500 mg 1
valganciclovir oral recon soln 50 mgml 1
valganciclovir oral tablet 450 mg 1
VEMLIDY ORAL TABLET 25 MG 1
VIEKIRA PAK ORAL TABLETSDOSE PACK 125 MG-75 MG -50 MG250 MG
2 PA
VIRACEPT ORAL TABLET 250 MG 1 QL (90 per 30 days)
VIRACEPT ORAL TABLET 625 MG 1 QL (60 per 30 days)
VIREAD ORAL POWDER 40 MGSCOOP (40 MGGRAM)
1 QL (4 per 30 days)
VIREAD ORAL TABLET 150 MG 200 MG 250 MG
1 QL (30 per 30 days)
VOSEVI ORAL TABLET 400-100-100 MG 2 PA LA
ZEPATIER ORAL TABLET 50-100 MG 2 PA LA
zidovudine oral capsule 100 mg 1 QL (60 per 30 days)
zidovudine oral syrup 10 mgml 1 QL (960 per 30 days)
zidovudine oral tablet 300 mg 1 QL (60 per 30 days)
CEPHALOSPORINS
6
Drug Name Drug Tier Requirements Limits
AVYCAZ INTRAVENOUS RECON SOLN 25 GRAM
MB
cefaclor oral capsule 250 mg 500 mg 1
cefaclor oral suspension for reconstitution 125 mg5 ml 250 mg5 ml 375 mg5 ml
1
cefaclor oral tablet extended release 12 hr 500 mg 1
cefadroxil oral capsule 500 mg 1
cefadroxil oral suspension for reconstitution 250 mg5 ml 500 mg5 ml
1
cefadroxil oral tablet 1 gram 1
cefazolin in dextrose (iso-os) intravenous piggyback 1 gram50 ml
MB
cefazolin injection recon soln 1 gram 10 gram 100 gram 20 gram 300 g 500 mg
MB
cefazolin intravenous recon soln 1 gram MB
cefdinir oral capsule 300 mg 1
cefdinir oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cefditoren pivoxil oral tablet 200 mg 400 mg 1
CEFEPIME IN DEXTROSE 5 INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
cefepime in dextroseiso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml
MB
cefepime injection recon soln 1 gram 2 gram MB
cefixime oral capsule 400 mg 1
cefixime oral suspension for reconstitution 100 mg5 ml 200 mg5 ml
1
CEFOTAN INJECTION RECON SOLN 1 GRAM 2 GRAM
MB
cefotaxime injection recon soln 1 gram MB
CEFOTETAN IN DEXTROSE ISO-OSM INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
cefotetan injection recon soln 1 gram 2 gram MB
cefotetan intravenous recon soln 10 gram MB
cefoxitin intravenous recon soln 10 gram MB
cefpodoxime oral suspension for reconstitution 100 mg5 ml 50 mg5 ml
1
7
Drug Name Drug Tier Requirements Limits
cefpodoxime oral tablet 100 mg 200 mg 1
cefprozil oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cefprozil oral tablet 250 mg 500 mg 1
CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
ceftazidime injection recon soln 1 gram 2 gram 6 gram
MB
ceftriaxone in dextroseiso-os intravenous piggyback 1 gram50 ml 2 gram50 ml
MB
ceftriaxone injection recon soln 1 gram 10 gram 2 gram 250 mg 500 mg
MB
CEFTRIAXONE INJECTION RECON SOLN 100 GRAM
MB
ceftriaxone intravenous recon soln 1 gram 2 gram MB
cefuroxime axetil oral tablet 250 mg 500 mg 1
cephalexin oral capsule 250 mg 500 mg 750 mg 1
cephalexin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cephalexin oral tablet 250 mg 500 mg 1
SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG5 ML
1
SUPRAX ORAL TABLETCHEWABLE 100 MG 200 MG
1
tazicef injection recon soln 1 gram 2 gram 6 gram
MB
tazicef intravenous recon soln 1 gram 2 gram MB
TEFLARO INTRAVENOUS RECON SOLN 400 MG 600 MG
MB
ZERBAXA INTRAVENOUS RECON SOLN 15 GRAM
MB
ERYTHROMYCINS amp OTHER MACROLIDES
azithromycin oral packet 1 gram 1
azithromycin oral suspension for reconstitution 100 mg5 ml 200 mg5 ml
1
azithromycin oral tablet 250 mg 500 mg 600 mg 1
clarithromycin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
clarithromycin oral tablet 250 mg 500 mg 1
8
Drug Name Drug Tier Requirements Limits
clarithromycin oral tablet extended release 24 hr 500 mg
1
DIFICID ORAL TABLET 200 MG 1
ees 400 oral tablet 400 mg 1
ery-tab oral tabletdelayed release (drec) 250 mg 333 mg
1
erythrocin (as stearate) oral tablet 250 mg 1
erythromycin ethylsuccinate oral suspension for reconstitution 200 mg5 ml 400 mg5 ml
1
erythromycin ethylsuccinate oral tablet 400 mg 1
erythromycin oral capsuledelayed release(drec) 250 mg
1
erythromycin oral tablet 250 mg 500 mg 1
erythromycin oral tabletdelayed release (drec) 250 mg 333 mg 500 mg
1
MISCELLANEOUS ANTIINFECTIVES
albendazole oral tablet 200 mg 1
ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG5 ML
1 PA ST
amikacin injection solution 500 mg2 ml MB
atovaquone oral suspension 750 mg5 ml 1
atovaquone-proguanil oral tablet 250-100 mg 625-25 mg
1
bacitracin intramuscular recon soln 50000 unit 1
CAPASTAT INJECTION RECON SOLN 1 GRAM
1
CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MGML
2 PA LA QL (84 per 30 days)
chloramphenicol sod succinate intravenous recon soln 1 gram
MB
chloroquine phosphate oral tablet 250 mg 500 mg 1
clindamycin hcl oral capsule 150 mg 300 mg 75 mg
1
clindamycin pediatric oral recon soln 75 mg5 ml 1
clindamycin phosphate injection solution 150 mgml
MB
COARTEM ORAL TABLET 20-120 MG 1
CUBICIN INTRAVENOUS RECON SOLN 500 MG
MB
9
Drug Name Drug Tier Requirements Limits
CUBICIN RF INTRAVENOUS RECON SOLN 500 MG
MB
CYCLOSERINE ORAL CAPSULE 250 MG 1
dapsone oral tablet 100 mg 25 mg 1
EMVERM ORAL TABLETCHEWABLE 100 MG
1
ethambutol oral tablet 100 mg 400 mg 1
gentamicin injection solution 20 mg2 ml 40 mgml
MB
gentamicin sulfate (ped) (pf) injection solution 20 mg2 ml
MB
hydroxychloroquine oral tablet 200 mg 1
imipenem-cilastatin intravenous recon soln 250 mg 500 mg
MB
INVANZ INJECTION RECON SOLN 1 GRAM MB
isoniazid injection solution 100 mgml 1
isoniazid oral solution 50 mg5 ml 1
isoniazid oral tablet 100 mg 300 mg 1
ivermectin oral tablet 3 mg 1
LINCOCIN INJECTION SOLUTION 300 MGML
MB
linezolid in dextrose 5 intravenous piggyback 600 mg300 ml
MB
linezolid oral suspension for reconstitution 100 mg5 ml
1
linezolid oral tablet 600 mg 1
linezolid-09 sodium chloride intravenous parenteral solution 600 mg300 ml
MB
mefloquine oral tablet 250 mg 1
meropenem intravenous recon soln 1 gram 500 mg
MB
MEROPENEM-09 SODIUM CHLORIDE INTRAVENOUS PIGGYBACK 1 GRAM50 ML 500 MG50 ML
MB
metronidazole oral capsule 375 mg 1
metronidazole oral tablet 250 mg 500 mg 1
neomycin oral tablet 500 mg 1
nitazoxanide oral tablet 500 mg 1
10
Drug Name Drug Tier Requirements Limits
paromomycin oral capsule 250 mg 1
PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM
1
PENTAM INJECTION RECON SOLN 300 MG MB
pentamidine inhalation recon soln 300 mg 1
pentamidine injection recon soln 300 mg MB
polymyxin b sulfate injection recon soln 500000 unit
MB
praziquantel oral tablet 600 mg 1
PRIFTIN ORAL TABLET 150 MG 1
primaquine oral tablet 263 mg 1
pyrazinamide oral tablet 500 mg 1
pyrimethamine oral tablet 25 mg 2 PA
quinine sulfate oral capsule 324 mg 1
rifabutin oral capsule 150 mg 1
rifampin oral capsule 150 mg 300 mg 1
SIRTURO ORAL TABLET 100 MG 1 PA
SIRTURO ORAL TABLET 20 MG 1
SIVEXTRO ORAL TABLET 200 MG 1 QL (6 per 30 days)
STREPTOMYCIN INTRAMUSCULAR RECON SOLN 1 GRAM
1
tinidazole oral tablet 250 mg 500 mg 1
tobramycin in 0225 nacl inhalation solution for nebulization 300 mg5 ml
2
tobramycin inhalation solution for nebulization 300 mg4 ml
2
tobramycin sulfate injection recon soln 12 gram 1
tobramycin sulfate injection solution 10 mgml MB
tobramycin sulfate injection solution 40 mgml 1
TOBRAMYCIN WITH NEBULIZER INHALATION SOLUTION FOR NEBULIZATION 300 MG5 ML
2 PA ST
TRECATOR ORAL TABLET 250 MG 1
TYGACIL INTRAVENOUS RECON SOLN 50 MG
MB
XENLETA INTRAVENOUS SOLUTION 150 MG15 ML
MB
XIFAXAN ORAL TABLET 200 MG 550 MG 1 PA QL (60 per 30 days)
11
Drug Name Drug Tier Requirements Limits
PENICILLINS
amoxicillin oral capsule 250 mg 500 mg 1
amoxicillin oral suspension for reconstitution 125 mg5 ml 200 mg5 ml 250 mg5 ml 400 mg5 ml
1
amoxicillin oral tablet 500 mg 875 mg 1
amoxicillin oral tabletchewable 125 mg 250 mg 1
amoxicillin-pot clavulanate oral suspension for reconstitution 200-285 mg5 ml 250-625 mg5 ml 400-57 mg5 ml 600-429 mg5 ml
1
amoxicillin-pot clavulanate oral tablet 250-125 mg 500-125 mg 875-125 mg
1
amoxicillin-pot clavulanate oral tablet extended release 12 hr 1000-625 mg
1
amoxicillin-pot clavulanate oral tabletchewable 200-285 mg 400-57 mg
1
ampicillin oral capsule 500 mg 1
ampicillin-sulbactam injection recon soln 15 gram MB
BICILLIN C-R INTRAMUSCULAR SYRINGE 1200000 UNIT 2 ML(900K300K)
MB
dicloxacillin oral capsule 250 mg 500 mg 1
MOXATAG ORAL TABLET ER MULTIPHASE 24 HR 775 MG
1
nafcillin in dextrose iso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml
MB
nafcillin injection recon soln 1 gram 10 gram 2 gram
MB
nafcillin intravenous recon soln 1 gram 2 gram MB
oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram50 ml 2 gram50 ml
MB
oxacillin injection recon soln 1 gram 10 gram 2 gram
MB
penicillin g procaine intramuscular syringe 12 million unit2 ml 600000 unitml
MB
penicillin v potassium oral recon soln 125 mg5 ml 250 mg5 ml
1
penicillin v potassium oral tablet 250 mg 500 mg 1
piperacillin-tazobactam intravenous recon soln 135 gram 225 gram 3375 gram 45 gram 405 gram
MB
12
Drug Name Drug Tier Requirements Limits
QUINOLONES
BAXDELA INTRAVENOUS RECON SOLN 300 MG
MB
BAXDELA ORAL TABLET 450 MG 1
ciprofloxacin hcl oral tablet 100 mg 250 mg 500 mg 750 mg
1
ciprofloxacin oral suspensionmicrocapsule recon 250 mg5 ml 500 mg5 ml
1
FACTIVE ORAL TABLET 320 MG 1 ST
levofloxacin oral solution 250 mg10 ml 1
levofloxacin oral tablet 250 mg 500 mg 750 mg 1
moxifloxacin oral tablet 400 mg 1
ofloxacin oral tablet 300 mg 400 mg 1
SULFAS amp RELATED AGENTS
sulfadiazine oral tablet 500 mg 1
sulfamethoxazole-trimethoprim oral suspension 200-40 mg5 ml
1
sulfamethoxazole-trimethoprim oral tablet 400-80 mg 800-160 mg
1
sulfatrim oral suspension 200-40 mg5 ml 1
TETRACYCLINES
avidoxy oral tablet 100 mg 1 ST
demeclocycline oral tablet 150 mg 300 mg 1
doxycycline hyclate oral capsule 100 mg 50 mg 1
doxycycline hyclate oral tablet 100 mg 150 mg 20 mg 50 mg 75 mg
1
doxycycline hyclate oral tabletdelayed release (drec) 100 mg 150 mg 200 mg 50 mg 75 mg
1
doxycycline monohydrate oral capsule 100 mg 150 mg 50 mg 75 mg
1
doxycycline monohydrate oral suspension for reconstitution 25 mg5 ml
1
doxycycline monohydrate oral tablet 100 mg 150 mg 50 mg 75 mg
1
minocycline oral capsule 100 mg 50 mg 75 mg 1
minocycline oral tablet 100 mg 50 mg 75 mg 1
mondoxyne nl oral capsule 100 mg 75 mg 1
tetracycline oral capsule 250 mg 500 mg 1
13
Drug Name Drug Tier Requirements Limits
URINARY TRACT AGENTS
fosfomycin tromethamine oral packet 3 gram 1
methenamine hippurate oral tablet 1 gram 1
methenamine mandelate oral tablet 05 g 1 gram 1
nitrofurantoin macrocrystal oral capsule 100 mg 25 mg 50 mg
1
nitrofurantoin monohydm-cryst oral capsule 100 mg
1
nitrofurantoin oral suspension 25 mg5 ml 1
PRIMSOL ORAL SOLUTION 50 MG5 ML 1
trimethoprim oral tablet 100 mg 1
VANCOMYCIN
vancomycin oral capsule 125 mg 250 mg 1
vancomycin oral recon soln 50 mgml 1
VIBATIV INTRAVENOUS RECON SOLN 750 MG
MB
ANTINEOPLASTIC amp IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
KEPIVANCE INTRAVENOUS RECON SOLN 625 MG
MB
leucovorin calcium injection recon soln 100 mg 200 mg 350 mg 50 mg 500 mg
MB
leucovorin calcium injection solution 10 mgml MB
leucovorin calcium oral tablet 10 mg 15 mg 25 mg 5 mg
1
VISTOGARD ORAL GRANULES IN PACKET 10 GRAM
2
VORAXAZE INTRAVENOUS RECON SOLN 1000 UNIT
MB
XGEVA SUBCUTANEOUS SOLUTION 120 MG17 ML (70 MGML)
2 LA
ANTINEOPLASTIC amp IMMUNOSUPPRESSANT DRUGS
abiraterone oral tablet 250 mg 2 PA OCh LA
abiraterone oral tablet 500 mg 2 PA ST OCh LA
ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG
MB PA LA
ADAKVEO INTRAVENOUS SOLUTION 10 MGML
MB PA
14
Drug Name Drug Tier Requirements Limits
ADCETRIS INTRAVENOUS RECON SOLN 50 MG
MB PA LA
AFINITOR ORAL TABLET 10 MG 2 OCh LA
ALECENSA ORAL CAPSULE 150 MG 2 PA OCh LA
ALIMTA INTRAVENOUS RECON SOLN 100 MG 500 MG
MB PA
ALIQOPA INTRAVENOUS RECON SOLN 60 MG
MB PA
anastrozole oral tablet 1 mg ACA PV OCh QL (30 per 30 days)
ARRANON INTRAVENOUS SOLUTION 250 MG50 ML
MB LA
ARZERRA INTRAVENOUS SOLUTION 1000 MG50 ML 100 MG5 ML
MB PA LA
ASPARLAS INTRAVENOUS SOLUTION 750 UNITML
MB PA
AVASTIN INTRAVENOUS SOLUTION 25 MGML
MB PA LA
azathioprine oral tablet 50 mg 1
BALVERSA ORAL TABLET 3 MG 4 MG 5 MG
2 PA OCh
BAVENCIO INTRAVENOUS SOLUTION 20 MGML
MB PA
BELEODAQ INTRAVENOUS RECON SOLN 500 MG
MB PA
BELRAPZO INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BENDAMUSTINE INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BENDEKA INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BESPONSA INTRAVENOUS RECON SOLN 09 MG (025 MGML INITIAL)
MB PA LA
bexarotene oral capsule 75 mg 2 PA ST OCh
bicalutamide oral tablet 50 mg 2 OCh QL (30 per 30 days)
BLINCYTO INTRAVENOUS KIT 35 MCG MB PA
BORTEZOMIB INTRAVENOUS RECON SOLN 35 MG
MB
BOSULIF ORAL TABLET 100 MG 400 MG 500 MG
2 PA ST OCh LA
BRAFTOVI ORAL CAPSULE 50 MG 75 MG 2 PA OCh LA
15
Drug Name Drug Tier Requirements Limits
BUSULFEX INTRAVENOUS SOLUTION 60 MG10 ML
MB
CABOMETYX ORAL TABLET 20 MG 40 MG 60 MG
2 PA ST OCh LA
CALQUENCE ORAL CAPSULE 100 MG 2 PA ST OCh
capecitabine oral tablet 150 mg 2 OCh LA QL (210 per 30 days)
capecitabine oral tablet 500 mg 2 OCh LA QL (84 per 30 days)
CAPRELSA ORAL TABLET 100 MG 300 MG 2 PA OCh
CLOLAR INTRAVENOUS SOLUTION 20 MG20 ML
MB PA
COMETRIQ ORAL CAPSULE 100 MGDAY(80 MG X1-20 MG X1) 140 MGDAY(80 MG X1-20 MG X3) 60 MGDAY (20 MG X 3DAY)
2 PA OCh
COPIKTRA ORAL CAPSULE 15 MG 25 MG 2 PA OCh
COTELLIC ORAL TABLET 20 MG 2 PA OCh LA
cyclophosphamide intravenous recon soln 1 gram 2 gram 500 mg
MB
cyclophosphamide oral capsule 25 mg 50 mg 2 OCh
CYCLOPHOSPHAMIDE ORAL TABLET 25 MG 50 MG
2 OCh
cyclosporine modified oral capsule 100 mg 25 mg 50 mg
1
cyclosporine modified oral solution 100 mgml 1
cyclosporine oral capsule 100 mg 25 mg 1
CYRAMZA INTRAVENOUS SOLUTION 10 MGML
MB PA LA
DACOGEN INTRAVENOUS RECON SOLN 50 MG
MB PA LA
DARZALEX INTRAVENOUS SOLUTION 20 MGML
MB PA LA
DAURISMO ORAL TABLET 100 MG 25 MG 2 PA OCh LA
decitabine intravenous recon soln 50 mg MB LA
ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 225 MG
2
ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG
2
ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG
2
16
Drug Name Drug Tier Requirements Limits
ELIGARD SUBCUTANEOUS SYRINGE 75 MG (1 MONTH)
2
ELZONRIS INTRAVENOUS SOLUTION 1000 MCGML
MB PA
EMCYT ORAL CAPSULE 140 MG 2 OCh
EMPLICITI INTRAVENOUS RECON SOLN 300 MG 400 MG
MB PA LA
ENHERTU INTRAVENOUS RECON SOLN 100 MG
MB PA LA
ERBITUX INTRAVENOUS SOLUTION 100 MG50 ML 200 MG100 ML
MB PA LA
ERLEADA ORAL TABLET 60 MG 2 PA OCh LA
erlotinib oral tablet 100 mg 150 mg 25 mg 2 PA OCh LA
ERWINAZE INJECTION RECON SOLN 10000 UNIT
MB
etoposide intravenous solution 20 mgml MB
etoposide oral capsule 50 mg 2 OCh
everolimus (antineoplastic) oral tablet 25 mg 5 mg 75 mg
2 PA ST OCh LA
everolimus (immunosuppressive) oral tablet 025 mg 05 mg 075 mg
1 PA
exemestane oral tablet 25 mg ACA PV OCh QL (30 per 30 days)
FASLODEX INTRAMUSCULAR SYRINGE 250 MG5 ML
MB PA
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG 80 MG
2 LA
fludarabine intravenous recon soln 50 mg MB
fluorouracil intravenous solution 25 gram50 ml 5 gram100 ml 500 mg10 ml
MB PA
flutamide oral capsule 125 mg 2 OCh QL (180 per 30 days)
FOLOTYN INTRAVENOUS SOLUTION 20 MGML (1 ML) 40 MG2 ML (20 MGML)
MB PA LA
fulvestrant intramuscular syringe 250 mg5 ml MB
GAMIFANT INTRAVENOUS SOLUTION 5 MGML
MB PA
GAZYVA INTRAVENOUS SOLUTION 1000 MG40 ML
MB PA LA
gemcitabine intravenous recon soln 1 gram 2 gram 200 mg
MB
17
Drug Name Drug Tier Requirements Limits
gemcitabine intravenous solution 2 gram526 ml (38 mgml) 200 mg526 ml (38 mgml)
MB
gengraf oral capsule 100 mg 25 mg 1
gengraf oral solution 100 mgml 1
GILOTRIF ORAL TABLET 20 MG 30 MG 40 MG
2 PA OCh LA
GLEOSTINE ORAL CAPSULE 10 MG 100 MG 40 MG
2 PA OCh
HALAVEN INTRAVENOUS SOLUTION 1 MG2 ML (05 MGML)
MB PA LA
HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600 MG-10000 UNIT5 ML
MB LA
HERCEPTIN INTRAVENOUS RECON SOLN 150 MG
MB PA LA
HERZUMA INTRAVENOUS RECON SOLN 150 MG
MB PA LA
HYCAMTIN ORAL CAPSULE 025 MG 1 MG 2 OCh LA
hydroxyurea oral capsule 500 mg 2 OCh
IBRANCE ORAL CAPSULE 100 MG 125 MG 75 MG
2 PA OCh LA
IBRANCE ORAL TABLET 100 MG 125 MG 75 MG
2 OCh LA
ICLUSIG ORAL TABLET 10 MG 15 MG 30 MG 45 MG
2 PA ST OCh
IDHIFA ORAL TABLET 100 MG 50 MG 2 PA OCh LA
imatinib oral tablet 100 mg 2 OCh LA QL (90 per 30 days)
imatinib oral tablet 400 mg 2 OCh LA QL (60 per 30 days)
IMBRUVICA ORAL CAPSULE 140 MG 70 MG 2 PA ST OCh
IMBRUVICA ORAL TABLET 140 MG 280 MG 420 MG 560 MG
2 PA ST OCh
IMFINZI INTRAVENOUS SOLUTION 50 MGML
MB PA LA
IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFUML 10EXP8 (100 MILLION) PFUML
MB
18
Drug Name Drug Tier Requirements Limits
INFUGEM INTRAVENOUS PIGGYBACK 1200 MG120 ML (10 MGML) 1300 MG130 ML (10 MGML) 1400 MG140 ML (10 MGML) 1500 MG150 ML (10 MGML) 1600 MG160 ML (10 MGML) 1700 MG170 ML (10 MGML) 1800 MG180 ML (10 MGML) 1900 MG190 ML (10 MGML) 2000 MG200 ML (10 MGML) 2200 MG220 ML (10 MGML)
MB
INLYTA ORAL TABLET 1 MG 5 MG 2 PA OCh LA
IRESSA ORAL TABLET 250 MG 2 PA OCh LA
ISTODAX INTRAVENOUS RECON SOLN 10 MG2 ML
MB PA LA
IXEMPRA INTRAVENOUS RECON SOLN 15 MG 45 MG
MB PA LA
JAKAFI ORAL TABLET 10 MG 15 MG 20 MG 25 MG 5 MG
2 PA OCh LA
JEVTANA INTRAVENOUS SOLUTION 10 MGML (FIRST DILUTION)
MB PA LA
KADCYLA INTRAVENOUS RECON SOLN 100 MG 160 MG
MB PA LA
KANJINTI INTRAVENOUS RECON SOLN 150 MG 420 MG
MB PA LA
KEYTRUDA INTRAVENOUS SOLUTION 25 MGML
MB PA
KISQALI FEMARA CO-PACK ORAL TABLET 200 MGDAY(200 MG X 1)-25 MG 400 MGDAY(200 MG X 2)-25 MG 600 MGDAY(200 MG X 3)-25 MG
2 PA ST OCh LA
KISQALI ORAL TABLET 200 MGDAY (200 MG X 1) 400 MGDAY (200 MG X 2) 600 MGDAY (200 MG X 3)
2 PA ST OCh LA
KYMRIAH INTRAVENOUS SUSPENSION 02X10EXP6 TO 25X10EXP8 CELL 06 TO 6 X 10EXP8 CELL
MB PA
KYPROLIS INTRAVENOUS RECON SOLN 10 MG 30 MG 60 MG
MB PA
lapatinib oral tablet 250 mg 2 PA OCh LA QL (180 per 30 days)
LENVIMA ORAL CAPSULE 10 MGDAY (10 MG X 1) 12 MGDAY (4 MG X 3) 14 MGDAY(10 MG X 1-4 MG X 1) 18 MGDAY (10 MG X 1-4 MG X2) 20 MGDAY (10 MG X 2) 24 MGDAY(10 MG X 2-4 MG X 1) 4 MG 8 MGDAY (4 MG X 2)
2 PA ST OCh LA
19
Drug Name Drug Tier Requirements Limits
letrozole oral tablet 25 mg ACA PV OCh QL (30 per 30 days)
LEUKERAN ORAL TABLET 2 MG 2 OCh
leuprolide subcutaneous kit 1 mg02 ml 2
LIBTAYO INTRAVENOUS SOLUTION 50 MGML
MB PA
LONSURF ORAL TABLET 15-614 MG 20-819 MG
2 PA ST OCh LA
LUMOXITI INTRAVENOUS RECON SOLN 1 MG
MB
LUPKYNIS ORAL CAPSULE 79 MG 2 PA ST
LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 225 MG
2
LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG
2
LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG
2
LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 375 MG 75 MG
2
LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 30 MG
2
LUPRON DEPOT-PED INTRAMUSCULAR KIT 1125 MG 15 MG 75 MG (PED)
2
LYNPARZA ORAL TABLET 100 MG 150 MG 2 PA ST OCh LA
LYSODREN ORAL TABLET 500 MG 2 OCh
MARQIBO INTRAVENOUS KIT 5 MG31 ML(016 MGML) FINAL
MB PA
MATULANE ORAL CAPSULE 50 MG 2 OCh
megestrol oral suspension 400 mg10 ml (40 mgml)
1 QL (2 per 30 days)
megestrol oral suspension 625 mg5 ml (125 mgml)
1 QL (1 per 30 days)
megestrol oral tablet 20 mg 2 OCh QL (480 per 30 days)
megestrol oral tablet 40 mg 2 OCh QL (240 per 30 days)
MEKINIST ORAL TABLET 05 MG 2 MG 2 PA ST OCh LA
MEKTOVI ORAL TABLET 15 MG 2 PA OCh LA
melphalan hcl intravenous recon soln 50 mg MB
melphalan oral tablet 2 mg 2 OCh
20
Drug Name Drug Tier Requirements Limits
mercaptopurine oral tablet 50 mg 2 OCh QL (300 per 30 days)
methotrexate sodium (pf) injection recon soln 1 gram
1
methotrexate sodium (pf) injection solution 25 mgml
1
methotrexate sodium injection solution 25 mgml 1
methotrexate sodium oral tablet 25 mg 2 OCh
mitoxantrone intravenous concentrate 2 mgml MB PA LA
mycophenolate mofetil oral capsule 250 mg 1
mycophenolate mofetil oral tablet 500 mg 1
mycophenolate sodium oral tabletdelayed release (drec) 180 mg 360 mg
1
MYLOTARG INTRAVENOUS RECON SOLN 45 MG (1 MGML INITIAL CONC)
MB PA LA
NERLYNX ORAL TABLET 40 MG 2 PA OCh LA QL (180 per 30 days)
NEXAVAR ORAL TABLET 200 MG 2 PA ST OCh LA
nilutamide oral tablet 150 mg 2 OCh QL (60 per 30 days)
NINLARO ORAL CAPSULE 23 MG 3 MG 4 MG
2 PA ST OCh LA
NULOJIX INTRAVENOUS RECON SOLN 250 MG
MB PA
octreotide acetate injection solution 1000 mcgml 100 mcgml 200 mcgml 50 mcgml 500 mcgml
2
octreotide acetate injection syringe 100 mcgml (1 ml) 50 mcgml (1 ml) 500 mcgml (1 ml)
2
OGIVRI INTRAVENOUS RECON SOLN 150 MG 420 MG
MB PA LA
ONCASPAR INJECTION SOLUTION 750 UNITML
MB
ONIVYDE INTRAVENOUS DISPERSION 43 MGML
MB PA
OPDIVO INTRAVENOUS SOLUTION 100 MG10 ML 240 MG24 ML 40 MG4 ML
MB PA LA
PADCEV INTRAVENOUS RECON SOLN 20 MG 30 MG
MB PA LA
PEMAZYRE ORAL TABLET 135 MG 45 MG 9 MG
2 PA ST OCh
PERJETA INTRAVENOUS SOLUTION 420 MG14 ML (30 MGML)
MB PA LA
21
Drug Name Drug Tier Requirements Limits
PIQRAY ORAL TABLET 200 MGDAY (200 MG X 1) 250 MGDAY (200 MG X1-50 MG X1) 300 MGDAY (150 MG X 2)
2 PA OCh LA
POLIVY INTRAVENOUS RECON SOLN 140 MG
MB PA LA
PORTRAZZA INTRAVENOUS SOLUTION 800 MG50 ML (16 MGML)
MB PA LA
POTELIGEO INTRAVENOUS SOLUTION 4 MGML
MB PA
PROGRAF INTRAVENOUS SOLUTION 5 MGML
MB
QINLOCK ORAL TABLET 50 MG 2 OCh
RETEVMO ORAL CAPSULE 40 MG 2 PA OCh LA QL (240 per 30 days)
RETEVMO ORAL CAPSULE 80 MG 2 PA OCh LA QL (120 per 30 days)
RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG117 ML (120 MGML) 1600 MG134 ML (120 MGML)
MB LA
RITUXAN INTRAVENOUS CONCENTRATE 10 MGML
MB PA LA
RUBRACA ORAL TABLET 200 MG 250 MG 300 MG
2 PA ST OCh LA
RYDAPT ORAL CAPSULE 25 MG 2 PA ST OCh LA
SARCLISA INTRAVENOUS SOLUTION 20 MGML
MB
SIGNIFOR SUBCUTANEOUS SOLUTION 03 MGML (1 ML) 06 MGML (1 ML) 09 MGML (1 ML)
2 PA ST
SIMULECT INTRAVENOUS RECON SOLN 10 MG 20 MG
MB
sirolimus oral solution 1 mgml 1
sirolimus oral tablet 05 mg 1 mg 2 mg 1
SOLTAMOX ORAL SOLUTION 20 MG10 ML 2 OCh
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG05 ML 60 MG02 ML 90 MG03 ML
2 PA LA
SPRYCEL ORAL TABLET 100 MG 140 MG 20 MG 50 MG 70 MG 80 MG
2 PA ST OCh LA
STIVARGA ORAL TABLET 40 MG 2 PA ST OCh LA
SUPPRELIN LA IMPLANT KIT 50 MG (65 MCGDAY)
MB LA
22
Drug Name Drug Tier Requirements Limits
SUTENT ORAL CAPSULE 125 MG 25 MG 375 MG 50 MG
2 PA ST OCh LA
SYLVANT INTRAVENOUS RECON SOLN 100 MG 400 MG
MB PA LA
SYNRIBO SUBCUTANEOUS RECON SOLN 35 MG
2 PA ST
TABLOID ORAL TABLET 40 MG 2 OCh
tacrolimus oral capsule 05 mg 1 mg 5 mg 1
TAFINLAR ORAL CAPSULE 50 MG 75 MG 2 PA OCh LA
TAGRISSO ORAL TABLET 40 MG 80 MG 2 PA OCh LA
TALZENNA ORAL CAPSULE 025 MG 1 MG 2 PA OCh LA
tamoxifen oral tablet 10 mg 20 mg 2 OCh QL (60 per 30 days)
TARGRETIN TOPICAL GEL 1 1 PA ST
TASIGNA ORAL CAPSULE 150 MG 200 MG 50 MG
2 PA ST OCh LA
TECENTRIQ INTRAVENOUS SOLUTION 1200 MG20 ML (60 MGML) 840 MG14 ML (60 MGML)
MB PA LA
TEMODAR INTRAVENOUS RECON SOLN 100 MG
MB PA LA
temozolomide oral capsule 100 mg 140 mg 180 mg 20 mg 250 mg 5 mg
2 OCh LA
temsirolimus intravenous recon soln 30 mg3 ml (10 mgml) (first)
MB PA LA
THALOMID ORAL CAPSULE 100 MG 150 MG 200 MG 50 MG
2 OCh LA
TIBSOVO ORAL TABLET 250 MG 2 PA OCh
toremifene oral tablet 60 mg 2 OCh
TORISEL INTRAVENOUS RECON SOLN 30 MG3 ML (10 MGML) (FIRST)
MB PA LA
TREANDA INTRAVENOUS RECON SOLN 100 MG 25 MG
MB PA LA
TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 1125 MG 225 MG 375 MG
MB
tretinoin (antineoplastic) oral capsule 10 mg 2 OCh
TREXALL ORAL TABLET 10 MG 15 MG 5 MG 75 MG
2 PA ST OCh QL (15 per 30 days)
TRUXIMA INTRAVENOUS SOLUTION 10 MGML
MB PA LA
23
Drug Name Drug Tier Requirements Limits
TUKYSA ORAL TABLET 150 MG 50 MG 2 PA ST OCh QL (120 per 30 days)
UNITUXIN INTRAVENOUS SOLUTION 35 MGML
MB PA
VANTAS IMPLANT KIT 50 MG (50 MCGDAY)
MB LA
VECTIBIX INTRAVENOUS SOLUTION 100 MG5 ML (20 MGML) 400 MG20 ML (20 MGML)
MB PA LA
VELCADE INJECTION RECON SOLN 35 MG MB LA
VENCLEXTA ORAL TABLET 10 MG 100 MG 50 MG
2 PA ST OCh
VENCLEXTA STARTING PACK ORAL TABLETSDOSE PACK 10 MG-50 MG- 100 MG
2 PA OCh
VERZENIO ORAL TABLET 100 MG 150 MG 200 MG 50 MG
2 PA ST OCh LA
VIDAZA INJECTION RECON SOLN 100 MG MB PA LA
VITRAKVI ORAL CAPSULE 100 MG 2 PA OCh LA
VITRAKVI ORAL CAPSULE 25 MG 2 PA ST OCh LA
VITRAKVI ORAL SOLUTION 20 MGML 2 PA OCh LA
VOTRIENT ORAL TABLET 200 MG 2 PA ST OCh LA
VYXEOS INTRAVENOUS RECON SOLN 44-100 MG
MB PA
XALKORI ORAL CAPSULE 200 MG 250 MG 2 PA OCh LA
XERMELO ORAL TABLET 250 MG 2 PA ST
XOSPATA ORAL TABLET 40 MG 2 PA OCh
XTANDI ORAL CAPSULE 40 MG 2 PA OCh LA
XTANDI ORAL TABLET 40 MG 80 MG 2 PA OCh LA
YERVOY INTRAVENOUS SOLUTION 200 MG40 ML (5 MGML) 50 MG10 ML (5 MGML)
MB PA LA
YESCARTA INTRAVENOUS SUSPENSION MB PA
YONDELIS INTRAVENOUS RECON SOLN 1 MG
MB PA
YONSA ORAL TABLET 125 MG 2 PA OCh LA
ZALTRAP INTRAVENOUS SOLUTION 100 MG4 ML (25 MGML) 200 MG8 ML (25 MGML)
MB PA LA
ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM
MB
24
Drug Name Drug Tier Requirements Limits
ZEJULA ORAL CAPSULE 100 MG 2 OCh
ZELBORAF ORAL TABLET 240 MG 2 PA ST OCh LA
ZOLADEX SUBCUTANEOUS IMPLANT 108 MG 36 MG
MB LA
ZOLINZA ORAL CAPSULE 100 MG 2 PA ST OCh LA
ZYKADIA ORAL TABLET 150 MG 2 PA ST OCh LA
AUTONOMIC amp CNS DRUGS NEUROLOGY amp PSYCH
ANTICONVULSANTS
BANZEL ORAL TABLET 200 MG 400 MG 1 PA ST
BRIVIACT ORAL SOLUTION 10 MGML 1 ST QL (150 per 30 days)
BRIVIACT ORAL TABLET 10 MG 100 MG 25 MG 50 MG 75 MG
1 ST QL (60 per 30 days)
carbamazepine oral capsule er multiphase 12 hr 100 mg 200 mg 300 mg
1
carbamazepine oral suspension 100 mg5 ml 200 mg10 ml
1
carbamazepine oral tablet 200 mg 1
carbamazepine oral tablet extended release 12 hr 100 mg 200 mg 400 mg
1
carbamazepine oral tabletchewable 100 mg 1
CELONTIN ORAL CAPSULE 300 MG 1
clobazam oral suspension 25 mgml 1
clobazam oral tablet 10 mg 20 mg 1
clonazepam oral tablet 05 mg 1 mg 2 mg 1
clonazepam oral tabletdisintegrating 0125 mg 025 mg 05 mg 1 mg 2 mg
1
diazepam rectal kit 25 mg 1
DILANTIN EXTENDED ORAL CAPSULE 100 MG
1
DILANTIN INFATABS ORAL TABLETCHEWABLE 50 MG
1
DILANTIN ORAL CAPSULE 30 MG 1
DILANTIN-125 ORAL SUSPENSION 125 MG5 ML
1
divalproex oral capsule delayed rel sprinkle 125 mg
1
divalproex oral tablet extended release 24 hr 250 mg 500 mg
1
25
Drug Name Drug Tier Requirements Limits
divalproex oral tabletdelayed release (drec) 125 mg 250 mg 500 mg
1
EPIDIOLEX ORAL SOLUTION 100 MGML 2 PA LA QL (400 per 30 days)
epitol oral tablet 200 mg 1
ethosuximide oral capsule 250 mg 1
ethosuximide oral solution 250 mg5 ml 1
felbamate oral suspension 600 mg5 ml 1
felbamate oral tablet 400 mg 600 mg 1
FINTEPLA ORAL SOLUTION 22 MGML 2
gabapentin oral capsule 100 mg 300 mg 400 mg 1
gabapentin oral solution 250 mg5 ml 300 mg6 ml (6 ml)
1
gabapentin oral tablet 600 mg 800 mg 1
lamotrigine oral tablet 100 mg 150 mg 200 mg 25 mg
1
lamotrigine oral tablet disintegrating dose pk 25 mg (21) -50 mg (7) 25 mg(14)-50 mg (14)-100 mg (7) 50 mg (42) -100 mg (14)
1
lamotrigine oral tablet extended release 24hr 100 mg 200 mg 25 mg 250 mg 300 mg 50 mg
1
lamotrigine oral tablet chewable dispersible 25 mg 5 mg
1
lamotrigine oral tabletdisintegrating 100 mg 200 mg 25 mg 50 mg
1
lamotrigine oral tabletsdose pack 25 mg (35) 25 mg (42) -100 mg (7) 25 mg (84) -100 mg (14)
1
levetiracetam oral solution 100 mgml 500 mg5 ml (5 ml)
1
levetiracetam oral tablet 1000 mg 250 mg 500 mg 750 mg
1
levetiracetam oral tablet extended release 24 hr 500 mg 750 mg
1
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG 330 MG 825 MG
1 PA ST
oxcarbazepine oral suspension 300 mg5 ml (60 mgml)
1
oxcarbazepine oral tablet 150 mg 300 mg 600 mg 1
phenobarbital oral elixir 20 mg5 ml (4 mgml) 1
26
Drug Name Drug Tier Requirements Limits
phenobarbital oral tablet 100 mg 15 mg 162 mg 30 mg 324 mg 60 mg 648 mg 972 mg
1
phenytoin oral suspension 100 mg4 ml 125 mg5 ml
1
phenytoin oral tabletchewable 50 mg 1
phenytoin sodium extended oral capsule 100 mg 200 mg 300 mg
1
pregabalin oral capsule 100 mg 150 mg 200 mg 225 mg 25 mg 300 mg 50 mg 75 mg
1 PA ST
pregabalin oral solution 20 mgml 1 PA ST
pregabalin oral tablet extended release 24 hr 165 mg 330 mg 825 mg
1 PA ST
primidone oral tablet 250 mg 50 mg 1
roweepra oral tablet 1000 mg 500 mg 750 mg 1
rufinamide oral suspension 40 mgml 1 PA
rufinamide oral tablet 200 mg 400 mg 1 PA
subvenite oral tablet 100 mg 150 mg 200 mg 25 mg
1
subvenite starter (blue) kit oral tabletsdose pack 25 mg (35)
1
subvenite starter (green) kit oral tabletsdose pack 25 mg (84) -100 mg (14)
1
subvenite starter (orange) kit oral tabletsdose pack 25 mg (42) -100 mg (7)
1
SYMPAZAN ORAL FILM 10 MG 20 MG 5 MG 1 PA QL (30 per 30 days)
tiagabine oral tablet 12 mg 16 mg 2 mg 4 mg 1
topiramate oral capsule sprinkle 15 mg 25 mg 1
topiramate oral tablet 100 mg 200 mg 25 mg 50 mg
1
valproic acid (as sodium salt) oral solution 250 mg5 ml 500 mg10 ml (10 ml)
1
valproic acid oral capsule 250 mg 1
vigabatrin oral powder in packet 500 mg 2 PA LA
vigabatrin oral tablet 500 mg 2 PA LA
vigadrone oral powder in packet 500 mg 2 PA ST
VIMPAT ORAL SOLUTION 10 MGML 1 PA ST QL (6 per 30 days)
VIMPAT ORAL TABLET 100 MG 150 MG 200 MG 50 MG
1 ST QL (60 per 30 days)
27
Drug Name Drug Tier Requirements Limits
XCOPRI MAINTENANCE PACK ORAL TABLET 250 MGDAY (200 MG X1-50 MG X1) 350 MGDAY (200 MG X1-150MG X1)
2
XCOPRI MAINTENANCE PACK ORAL TABLET 250MGDAY(150 MG X1-100MG X1)
2 PA ST
XCOPRI ORAL TABLET 100 MG 150 MG 200 MG 50 MG
2
XCOPRI TITRATION PACK ORAL TABLETSDOSE PACK 125 MG (14)- 25 MG (14) 150 MG (14)- 200 MG (14) 50 MG (14)- 100 MG (14)
2
zonisamide oral capsule 100 mg 25 mg 50 mg 1
ANTIPARKINSONISM AGENTS
APOKYN SUBCUTANEOUS CARTRIDGE 10 MGML
2 PA LA QL (1 per 30 days)
benztropine injection solution 1 mgml 1
benztropine oral tablet 05 mg 1 mg 2 mg 1
bromocriptine oral capsule 5 mg 1
bromocriptine oral tablet 25 mg 1
carbidopa oral tablet 25 mg 1
carbidopa-levodopa oral tablet 10-100 mg 25-100 mg 25-250 mg
1
carbidopa-levodopa oral tablet extended release 25-100 mg 50-200 mg
1
carbidopa-levodopa oral tabletdisintegrating 10-100 mg 25-100 mg 25-250 mg
1
carbidopa-levodopa-entacapone oral tablet 125-50-200 mg 1875-75-200 mg 25-100-200 mg 3125-125-200 mg 375-150-200 mg 50-200-200 mg
1
entacapone oral tablet 200 mg 1
pramipexole oral tablet 0125 mg 025 mg 05 mg 075 mg 1 mg 15 mg
1
pramipexole oral tablet extended release 24 hr 0375 mg 075 mg 15 mg 225 mg 3 mg 375 mg 45 mg
1
rasagiline oral tablet 05 mg 1 mg 1
ropinirole oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg 5 mg
1
28
Drug Name Drug Tier Requirements Limits
ropinirole oral tablet extended release 24 hr 12 mg 2 mg 4 mg 6 mg 8 mg
1
selegiline hcl oral capsule 5 mg 1
selegiline hcl oral tablet 5 mg 1
tolcapone oral tablet 100 mg 1
trihexyphenidyl oral elixir 04 mgml 1
trihexyphenidyl oral tablet 2 mg 5 mg 1
MIGRAINE amp CLUSTER HEADACHE THERAPY
AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MGML 70 MGML
1 PA ST
AJOVY AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 225 MG15 ML
1 ST
AJOVY SYRINGE SUBCUTANEOUS SYRINGE 225 MG15 ML
1 PA ST
almotriptan malate oral tablet 125 mg 625 mg 1 QL (18 per 30 days)
dihydroergotamine injection solution 1 mgml 1
dihydroergotamine nasal spraynon-aerosol 05 mgpump act (4 mgml)
1 QL (8 per 30 days)
eletriptan oral tablet 20 mg 40 mg 1 QL (18 per 30 days)
EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MGML
1 PA ST
EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MGML 300 MG3 ML (100 MGML X 3)
1 PA ST
ergotamine-caffeine oral tablet 1-100 mg 1
frovatriptan oral tablet 25 mg 1 QL (18 per 30 days)
migergot rectal suppository 2-100 mg 1
naratriptan oral tablet 1 mg 25 mg 1 QL (18 per 30 days)
ONZETRA XSAIL NASAL AEROSOL POWDR BREATH ACTIVATED 11 MG
1 ST QL (16 per 30 days)
rizatriptan oral tablet 10 mg 5 mg 1 QL (18 per 30 days)
rizatriptan oral tabletdisintegrating 10 mg 5 mg 1 QL (18 per 30 days)
sumatriptan nasal spraynon-aerosol 20 mgactuation 5 mgactuation
1 QL (18 per 30 days)
sumatriptan succinate oral tablet 100 mg 25 mg 50 mg
1 QL (18 per 30 days)
sumatriptan succinate subcutaneous cartridge 4 mg05 ml 6 mg05 ml
1 QL (8 per 30 days)
29
Drug Name Drug Tier Requirements Limits
sumatriptan succinate subcutaneous pen injector 4 mg05 ml 6 mg05 ml
1 QL (8 per 30 days)
sumatriptan succinate subcutaneous solution 6 mg05 ml
1 QL (8 per 30 days)
sumatriptan succinate subcutaneous syringe 6 mg05 ml
1 QL (8 per 30 days)
UBRELVY ORAL TABLET 100 MG 50 MG 1 QL (16 per 30 days)
VYEPTI INTRAVENOUS SOLUTION 100 MGML
MB PA
zolmitriptan oral tablet 25 mg 5 mg 1 QL (18 per 30 days)
zolmitriptan oral tabletdisintegrating 25 mg 5 mg
1 QL (18 per 30 days)
ZOMIG NASAL SPRAYNON-AEROSOL 25 MG 5 MG
1 ST QL (18 per 30 days)
MISCELLANEOUS NEUROLOGICAL THERAPY
AUSTEDO ORAL TABLET 12 MG 6 MG 9 MG
2 PA LA
dalfampridine oral tablet extended release 12 hr 10 mg
2 PA LA QL (60 per 30 days)
donepezil oral tablet 10 mg 23 mg 5 mg 1
donepezil oral tabletdisintegrating 10 mg 5 mg 1
EXONDYS-51 INTRAVENOUS SOLUTION 50 MGML
MB PA
galantamine oral capsuleext rel pellets 24 hr 16 mg 24 mg 8 mg
1
galantamine oral solution 4 mgml 1
galantamine oral tablet 12 mg 4 mg 8 mg 1
memantine oral capsulesprinkleer 24hr 14 mg 21 mg 28 mg 7 mg
1
memantine oral solution 2 mgml 1
memantine oral tablet 10 mg 5 mg 1
NUEDEXTA ORAL CAPSULE 20-10 MG 1
ONPATTRO INTRAVENOUS SOLUTION 2 MGML
MB PA
RADICAVA INTRAVENOUS SOLUTION 30 MG100 ML
MB PA
rivastigmine tartrate oral capsule 15 mg 3 mg 45 mg 6 mg
1
30
Drug Name Drug Tier Requirements Limits
rivastigmine transdermal patch 24 hour 133 mg24 hour 46 mg24 hour 95 mg24 hour
1
tetrabenazine oral tablet 125 mg 25 mg 2 LA
TYSABRI INTRAVENOUS SOLUTION 300 MG15 ML
MB PA ST LA
VYONDYS-53 INTRAVENOUS SOLUTION 50 MGML
MB PA
ZOLGENSMA INTRAVENOUS KIT 2 X 10EXP13 VGML
MB LA
MUSCLE RELAXANTS amp ANTISPASMODIC THERAPY
baclofen oral tablet 10 mg 20 mg 5 mg 1
carisoprodol oral tablet 250 mg 350 mg 1
carisoprodol-aspirin oral tablet 200-325 mg 1
carisoprodol-aspirin-codeine oral tablet 200-325-16 mg
1 PA ST
chlorzoxazone oral tablet 250 mg 375 mg 750 mg 1 ST
chlorzoxazone oral tablet 500 mg 1
cyclobenzaprine oral tablet 10 mg 5 mg 75 mg 1
dantrolene oral capsule 100 mg 25 mg 50 mg 1
meprobamate oral tablet 200 mg 400 mg 1
metaxalone oral tablet 400 mg 800 mg 1
methocarbamol oral tablet 500 mg 750 mg 1
orphenadrine citrate injection solution 30 mgml 1
orphenadrine citrate oral tablet extended release 100 mg
1
pyridostigmine bromide oral syrup 60 mg5 ml 1
pyridostigmine bromide oral tablet 60 mg 1
pyridostigmine bromide oral tablet extended release 180 mg
1
tizanidine oral capsule 2 mg 4 mg 6 mg 1
tizanidine oral tablet 2 mg 4 mg 1
vanadom oral tablet 350 mg 1
NARCOTIC ANALGESICS
acetaminophen-caff-dihydrocod oral capsule 3205-30-16 mg
1 PA ST
acetaminophen-caff-dihydrocod oral tablet 325-30-16 mg
1 PA ST
31
Drug Name Drug Tier Requirements Limits
acetaminophen-codeine oral solution 120-12 mg5 ml 300 mg-30 mg 125 ml
1 PA ST
acetaminophen-codeine oral tablet 300-15 mg 300-30 mg 300-60 mg
1 PA ST
ascomp with codeine oral capsule 30-50-325-40 mg
1 PA ST
buprenorphine hcl injection solution 03 mgml 1 PA ST
buprenorphine hcl injection syringe 03 mgml 1 PA ST
buprenorphine hcl sublingual tablet 2 mg 8 mg 1
buprenorphine transdermal patch weekly 10 mcghour 15 mcghour 20 mcghour 5 mcghour 75 mcghour
1
butalbital compound wcodeine oral capsule 30-50-325-40 mg
1 PA ST
butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg 50-325-40-30 mg
1 PA ST
butalbital-acetaminophen-caff oral capsule 50-300-40 mg 50-325-40 mg
1
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
1
butalbital-aspirin-caffeine oral capsule 50-325-40 mg
1
butalbital-aspirin-caffeine oral tablet 50-325-40 mg
1
codeine sulfate oral tablet 15 mg 30 mg 60 mg 1 PA ST
codeine-butalbital-asa-caff oral capsule 30-50-325-40 mg
1 PA ST
diskets oral tabletsoluble 40 mg 1 PA ST
DSUVIA SUBLINGUAL TABLET IN APPLICATOR 30 MCG
MB
duramorph (pf) injection solution 05 mgml 1 mgml
MB PA ST
dvorah oral tablet 325-30-16 mg 1 PA ST
endocet oral tablet 10-325 mg 25-325 mg 5-325 mg 75-325 mg
1 PA ST
fentanyl citrate buccal lozenge on a handle 1200 mcg 1600 mcg 200 mcg 400 mcg 600 mcg 800 mcg
1 PA
32
Drug Name Drug Tier Requirements Limits
fentanyl transdermal patch 72 hour 100 mcghr 12 mcghr 25 mcghr 375 mcghour 50 mcghr 625 mcghour 75 mcghr 875 mcghour
1 PA ST
hydrocodone bitartrate oral capsule oral only er 12hr 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg
1 PA ST QL (60 per 30 days)
hydrocodone bitartrate oral tabletoral onlyextrel24 hr 100 mg 120 mg 20 mg 30 mg 40 mg 60 mg 80 mg
1 PA ST
hydrocodone-acetaminophen oral solution 10-325 mg15 ml(15 ml) 75-325 mg15 ml
1 PA ST
hydrocodone-acetaminophen oral tablet 10-300 mg 10-325 mg 5-300 mg 5-325 mg 75-300 mg 75-325 mg
1 PA ST
hydrocodone-ibuprofen oral tablet 10-200 mg 5-200 mg 75-200 mg
1 PA ST
HYDROMORPHONE INJECTION SYRINGE 05 MG05 ML
1 PA ST
hydromorphone oral liquid 1 mgml 1 PA ST
hydromorphone oral tablet 2 mg 4 mg 8 mg 1 PA ST
hydromorphone oral tablet extended release 24 hr 12 mg 16 mg 32 mg 8 mg
1 PA ST QL (60 per 30 days)
hydromorphone rectal suppository 3 mg 1 PA ST
levorphanol tartrate oral tablet 2 mg 3 mg 1 PA ST
meperidine oral solution 50 mg5 ml 1 PA ST
meperidine oral tablet 50 mg 1 PA ST
methadone injection solution 10 mgml 1 PA ST
methadone oral concentrate 10 mgml 1 PA ST
methadone oral solution 10 mg5 ml 5 mg5 ml 1 PA ST
methadone oral tablet 10 mg 5 mg 1 PA ST
methadone oral tabletsoluble 40 mg 1 PA ST
methadose oral concentrate 10 mgml 1 PA ST
methadose oral tabletsoluble 40 mg 1 PA ST
morphine (pf) injection solution 05 mgml MB PA ST
morphine concentrate oral solution 100 mg5 ml (20 mgml)
1 PA ST
morphine oral capsule er multiphase 24 hr 120 mg 30 mg 45 mg 60 mg 75 mg 90 mg
1 PA ST QL (60 per 30 days)
morphine oral capsuleextendrelease pellets 10 mg 100 mg 20 mg 50 mg 80 mg
1 PA ST QL (90 per 30 days)
33
Drug Name Drug Tier Requirements Limits
morphine oral capsuleextendrelease pellets 30 mg 60 mg
1 PA ST QL (60 per 30 days)
morphine oral capsuleextendrelease pellets 40 mg
1 PA QL (90 per 30 days)
morphine oral solution 10 mg5 ml 20 mg5 ml (4 mgml)
1 PA ST
morphine oral tablet 15 mg 30 mg 1 PA ST
morphine oral tablet extended release 100 mg 15 mg 200 mg 30 mg 60 mg
1 PA ST QL (120 per 30 days)
morphine rectal suppository 10 mg 20 mg 30 mg 5 mg
1 PA ST
oxycodone oral capsule 5 mg 1 PA ST
oxycodone oral concentrate 20 mgml 1 PA ST
oxycodone oral solution 5 mg5 ml 1 PA ST
oxycodone oral tablet 10 mg 15 mg 20 mg 30 mg 5 mg
1 PA ST
oxycodone-acetaminophen oral tablet 10-325 mg 25-300 mg 25-325 mg 5-325 mg 75-325 mg
1 PA ST
oxycodone-aspirin oral tablet 48355-325 mg 1 PA ST
OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 10 MG 15 MG 20 MG 30 MG 40 MG
1 PA ST QL (90 per 30 days)
OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 60 MG 80 MG
1 PA ST QL (120 per 30 days)
oxymorphone oral tablet 10 mg 5 mg 1 PA ST
oxymorphone oral tablet extended release 12 hr 10 mg 15 mg 20 mg 30 mg 40 mg 5 mg 75 mg
1 PA ST QL (90 per 30 days)
SUBLOCADE SUBCUTANEOUS SOLUTION EXTENDED REL SYRINGE 100 MG05 ML 300 MG15 ML
MB
tencon oral tablet 50-325 mg 1
NON-NARCOTIC ANALGESICS
adult aspirin regimen oral tabletdelayed release (drec) 81 mg
ACA PV
aspirin low dose oral tabletdelayed release (drec) 81 mg
ACA PV
aspirin oral tablet 325 mg ACA PV
aspirin oral tabletchewable 81 mg ACA PV
34
Drug Name Drug Tier Requirements Limits
aspirin oral tabletdelayed release (drec) 325 mg 81 mg
ACA PV
aspir-trin oral tabletdelayed release (drec) 325 mg
ACA PV
bayer aspirin oral tablet 325 mg ACA PV
BAYER CHEWABLE ASPIRIN ORAL TABLETCHEWABLE 81 MG
ACA PV
buprenorphine-naloxone sublingual film 12-3 mg 1 QL (60 per 30 days)
buprenorphine-naloxone sublingual film 2-05 mg 4-1 mg 8-2 mg
1 QL (90 per 30 days)
buprenorphine-naloxone sublingual tablet 2-05 mg 8-2 mg
1 QL (90 per 30 days)
butorphanol nasal spraynon-aerosol 10 mgml 1 PA ST QL (5 per 30 days)
cataflam oral tablet 50 mg 1
celecoxib oral capsule 100 mg 200 mg 400 mg 50 mg
1
childrens aspirin oral tabletchewable 81 mg ACA PV
cholinemagnesium salicylate oral liquid 500 mg5 ml
1
diclofenac potassium oral tablet 50 mg 1
diclofenac sodium oral tablet extended release 24 hr 100 mg
1
diclofenac sodium oral tabletdelayed release (drec) 25 mg 50 mg 75 mg
1
diclofenac sodium topical drops 15 1
diclofenac sodium topical gel 1 1
diclofenac-misoprostol oral tabletirdelayed relbiphasic 50-200 mg-mcg 75-200 mg-mcg
1
diflunisal oral tablet 500 mg 1
DUEXIS ORAL TABLET 800-266 MG 1 ST
ecotrin low strength oral tabletdelayed release (drec) 81 mg
ACA PV
ecotrin oral tabletdelayed release (drec) 325 mg ACA PV
etodolac oral capsule 200 mg 300 mg 1
etodolac oral tablet 400 mg 500 mg 1
etodolac oral tablet extended release 24 hr 400 mg 500 mg 600 mg
1
EUFLEXXA INTRA-ARTICULAR SYRINGE 10 MGML(MW 24 -36 MILLION)
MB
35
Drug Name Drug Tier Requirements Limits
fenoprofen oral tablet 600 mg 1
flurbiprofen oral tablet 100 mg 1
ibu oral tablet 400 mg 600 mg 800 mg 1
ibuprofen oral suspension 100 mg5 ml 1
ibuprofen oral tablet 400 mg 600 mg 800 mg 1
indomethacin oral capsule 25 mg 50 mg 1
indomethacin oral capsule extended release 75 mg
1
ketoprofen oral capsule 25 mg 50 mg 75 mg 1
ketoprofen oral capsuleext rel pellets 24 hr 200 mg
1
ketorolac injection cartridge 15 mgml 30 mgml 1
ketorolac injection solution 15 mgml 30 mgml MB
ketorolac injection solution 30 mgml (1 ml) 1
ketorolac intramuscular cartridge 60 mg2 ml 1
ketorolac intramuscular solution 60 mg2 ml 1
ketorolac intramuscular syringe 60 mg2 ml 1
ketorolac oral tablet 10 mg 1
meclofenamate oral capsule 100 mg 50 mg 1
mefenamic acid oral capsule 250 mg 1
meloxicam oral tablet 15 mg 75 mg 1
MONOVISC INTRA-ARTICULAR SYRINGE 88 MG4 ML
MB LA
nabumetone oral tablet 500 mg 750 mg 1
nalbuphine injection solution 10 mgml MB PA ST
naloxone injection solution 04 mgml 1
naloxone injection syringe 04 mgml 1 mgml 1
naltrexone oral tablet 50 mg 1
naproxen oral suspension 125 mg5 ml 1
naproxen oral tablet 250 mg 375 mg 500 mg 1
naproxen oral tabletdelayed release (drec) 375 mg 500 mg
1
naproxen sodium oral tablet 275 mg 550 mg 1
NARCAN NASAL SPRAYNON-AEROSOL 4 MGACTUATION
1
36
Drug Name Drug Tier Requirements Limits
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG 150 MG 200 MG 250 MG 50 MG
1 PA ST QL (60 per 30 days)
ORTHOVISC INTRA-ARTICULAR SYRINGE 30 MG2 ML
MB
oxaprozin oral tablet 600 mg 1
pentazocine-naloxone oral tablet 50-05 mg 1 PA ST
piroxicam oral capsule 10 mg 20 mg 1
salsalate oral tablet 500 mg 750 mg 1
st joseph aspirin oral tabletchewable 81 mg ACA PV
st joseph aspirin oral tabletdelayed release (drec) 81 mg
ACA PV
sulindac oral tablet 150 mg 200 mg 1
tolmetin oral capsule 400 mg 1
tolmetin oral tablet 200 mg 600 mg 1
tramadol oral tablet 50 mg 1 PA ST
tramadol oral tablet extended release 24 hr 100 mg 200 mg 300 mg
1 PA ST
tramadol oral tablet er multiphase 24 hr 100 mg 200 mg 300 mg
1 PA ST
tramadol-acetaminophen oral tablet 375-325 mg 1 PA ST
VIVITROL INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 380 MG
MB
PSYCHOTHERAPEUTIC DRUGS
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 300 MG 400 MG
1
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 300 MG 400 MG
1
ADHANSIA XR ORAL CAPSULE ER BIPHASIC 20-80 25 MG 35 MG 45 MG 55 MG 70 MG 85 MG
1 PA ST
ADZENYS ER ORAL SUSPEN IR - ER BIPHASIC 24HR 125 MGML
1 ST
ADZENYS XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 125 MG 157 MG 188 MG 31 MG 63 MG 94 MG
1 ST
37
Drug Name Drug Tier Requirements Limits
alprazolam intensol oral concentrate 1 mgml 1
alprazolam oral tablet 025 mg 05 mg 1 mg 2 mg
1
alprazolam oral tablet extended release 24 hr 05 mg 1 mg 2 mg 3 mg
1
alprazolam oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg
1
amitriptyline oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
amitriptyline-chlordiazepoxide oral tablet 125-5 mg 25-10 mg
1
amoxapine oral tablet 100 mg 150 mg 25 mg 50 mg
1
AMPHETAMINE ORAL SUSPEN IR - ER BIPHASIC 24HR 125 MGML
1 ST
amphetamine sulfate oral tablet 10 mg 5 mg 1
APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG 348 MG 522 MG
1 ST
aripiprazole oral solution 1 mgml 1
aripiprazole oral tablet 10 mg 15 mg 2 mg 20 mg 30 mg 5 mg
1
aripiprazole oral tabletdisintegrating 10 mg 15 mg
1
ARISTADA INITIO INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 675 MG24 ML
MB
ARISTADA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 1064 MG39 ML 441 MG16 ML 662 MG24 ML 882 MG32 ML
MB
armodafinil oral tablet 150 mg 200 mg 250 mg 50 mg
1
asenapine maleate sublingual tablet 10 mg 25 mg 5 mg
1
atomoxetine oral capsule 10 mg 100 mg 18 mg 25 mg 40 mg 60 mg 80 mg
1
BELSOMRA ORAL TABLET 10 MG 15 MG 20 MG 5 MG
1 ST
bupropion hcl oral tablet 100 mg 75 mg 1
bupropion hcl oral tablet extended release 24 hr 150 mg 300 mg
1
38
Drug Name Drug Tier Requirements Limits
bupropion hcl oral tablet sustained-release 12 hr 100 mg 150 mg 200 mg
1
buspirone oral tablet 10 mg 15 mg 30 mg 5 mg 75 mg
1
chlordiazepoxide hcl oral capsule 10 mg 25 mg 5 mg
1
chlorpromazine injection solution 25 mgml 1
chlorpromazine oral tablet 10 mg 100 mg 200 mg 25 mg 50 mg
1
citalopram oral solution 10 mg5 ml 1
citalopram oral tablet 10 mg 20 mg 40 mg 1
clomipramine oral capsule 25 mg 50 mg 75 mg 1
clonidine hcl oral tablet extended release 12 hr 01 mg
1
clorazepate dipotassium oral tablet 15 mg 375 mg 75 mg
1
clozapine oral tablet 100 mg 200 mg 25 mg 50 mg
1
clozapine oral tabletdisintegrating 100 mg 125 mg 150 mg 200 mg 25 mg
1
COTEMPLA XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 173 MG 259 MG 86 MG
1 ST
DAYTRANA TRANSDERMAL PATCH 24 HOUR 10 MG9 HR 15 MG9 HR 20 MG9 HR 30 MG9 HR
1 ST
desipramine oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG 50 MG
1 ST
desvenlafaxine succinate oral tablet extended release 24 hr 100 mg 25 mg 50 mg
1
dexmethylphenidate oral capsuleer biphasic 50-50 10 mg 15 mg 20 mg 25 mg 30 mg 35 mg 40 mg 5 mg
1
dexmethylphenidate oral tablet 10 mg 25 mg 5 mg
1
dextroamphetamine oral capsule extended release 10 mg 15 mg 5 mg
1
dextroamphetamine oral solution 5 mg5 ml 1
39
Drug Name Drug Tier Requirements Limits
dextroamphetamine oral tablet 10 mg 5 mg 1
dextroamphetamine-amphetamine oral capsuleextended release 24hr 10 mg 15 mg 20 mg 25 mg 30 mg 5 mg
1
dextroamphetamine-amphetamine oral tablet 10 mg 125 mg 15 mg 20 mg 30 mg 5 mg 75 mg
1
diazepam injection solution 5 mgml MB
diazepam injection syringe 5 mgml MB
diazepam intensol oral concentrate 5 mgml 1
diazepam oral solution 5 mg5 ml (1 mgml) 1
diazepam oral tablet 10 mg 2 mg 5 mg 1
doxepin oral capsule 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
doxepin oral concentrate 10 mgml 1
duloxetine oral capsuledelayed release(drec) 20 mg 30 mg 40 mg 60 mg
1
DYANAVEL XR ORAL SUSPEN IR - ER BIPHASIC 24HR 25 MGML
1 ST
EDLUAR SUBLINGUAL TABLET 10 MG 5 MG
1 ST
EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG24 HR 6 MG24 HR 9 MG24 HR
1 ST
ergoloid oral tablet 1 mg 1
escitalopram oxalate oral solution 5 mg5 ml 1
escitalopram oxalate oral tablet 10 mg 20 mg 5 mg
1
estazolam oral tablet 1 mg 2 mg 1
eszopiclone oral tablet 1 mg 2 mg 3 mg 1
FANAPT ORAL TABLET 1 MG 10 MG 12 MG 2 MG 4 MG 6 MG 8 MG
1 PA ST
FANAPT ORAL TABLETSDOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)
1 PA ST
FETZIMA ORAL CAPSULEEXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)
1 ST
FETZIMA ORAL CAPSULEEXTENDED RELEASE 24 HR 120 MG 20 MG 40 MG 80 MG
1 ST
fluoxetine oral capsule 10 mg 20 mg 40 mg 1
40
Drug Name Drug Tier Requirements Limits
fluoxetine oral capsuledelayed release(drec) 90 mg
1
fluoxetine oral solution 20 mg5 ml (4 mgml) 1
fluoxetine oral tablet 10 mg 20 mg 1
fluoxetine oral tablet 60 mg 1 PA
fluphenazine hcl injection solution 25 mgml 1
fluphenazine hcl oral concentrate 5 mgml 1
fluphenazine hcl oral elixir 25 mg5 ml 1
fluphenazine hcl oral tablet 1 mg 10 mg 25 mg 5 mg
1
flurazepam oral capsule 15 mg 30 mg 1
fluvoxamine oral capsuleextended release 24hr 100 mg 150 mg
1
fluvoxamine oral tablet 100 mg 25 mg 50 mg 1
guanfacine oral tablet extended release 24 hr 1 mg 2 mg 3 mg 4 mg
1
haloperidol decanoate intramuscular solution 100 mgml 50 mgml
1
haloperidol lactate injection solution 5 mgml 1
haloperidol lactate oral concentrate 2 mgml 1
haloperidol oral tablet 05 mg 1 mg 10 mg 2 mg 20 mg 5 mg
1
HETLIOZ LQ ORAL SUSPENSION 4 MGML 2 PA ST LA
HETLIOZ ORAL CAPSULE 20 MG 2 PA ST LA
imipramine hcl oral tablet 10 mg 25 mg 50 mg 1
imipramine pamoate oral capsule 100 mg 125 mg 150 mg 75 mg
1
INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG075 ML 156 MGML 234 MG15 ML 39 MG025 ML 78 MG05 ML
1
JORNAY PM ORAL CAPSULEDEL RELEXT REL SPRINK 100 MG 20 MG 40 MG 60 MG 80 MG
1 ST
LATUDA ORAL TABLET 120 MG 20 MG 40 MG 60 MG 80 MG
1 PA ST
lithium carbonate oral capsule 150 mg 300 mg 600 mg
1
lithium carbonate oral tablet 300 mg 1
41
Drug Name Drug Tier Requirements Limits
lithium carbonate oral tablet extended release 300 mg 450 mg
1
lorazepam intensol oral concentrate 2 mgml 1
lorazepam oral concentrate 2 mgml 1
lorazepam oral tablet 05 mg 1 mg 2 mg 1
loxapine succinate oral capsule 10 mg 25 mg 5 mg 50 mg
1
maprotiline oral tablet 25 mg 50 mg 75 mg 1
MARPLAN ORAL TABLET 10 MG 1
methamphetamine oral tablet 5 mg 1
METHYLIN ORAL SOLUTION 10 MG5 ML 5 MG5 ML
1
methylphenidate hcl oral caper sprinklebiphasic 40-60 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg 60 mg
1
methylphenidate hcl oral capsule er biphasic 30-70 10 mg 20 mg 30 mg 40 mg 50 mg 60 mg
1
methylphenidate hcl oral capsuleer biphasic 50-50 10 mg 20 mg 30 mg 40 mg 60 mg
1
methylphenidate hcl oral solution 10 mg5 ml 5 mg5 ml
1
methylphenidate hcl oral tablet 10 mg 20 mg 5 mg
1
methylphenidate hcl oral tablet extended release 10 mg 20 mg
1
methylphenidate hcl oral tablet extended release 24hr 18 mg 27 mg 36 mg 54 mg
1
methylphenidate hcl oral tabletchewable 10 mg 25 mg 5 mg
1
midazolam oral syrup 2 mgml 1
mirtazapine oral tablet 15 mg 30 mg 45 mg 75 mg
1
mirtazapine oral tabletdisintegrating 15 mg 30 mg 45 mg
1
modafinil oral tablet 100 mg 200 mg 1
molindone oral tablet 10 mg 25 mg 5 mg 1
MYDAYIS ORAL CAPSULE ER TRIPHASIC 24 HR 125 MG 25 MG 375 MG 50 MG
1 ST
nefazodone oral tablet 100 mg 150 mg 200 mg 250 mg 50 mg
1
42
Drug Name Drug Tier Requirements Limits
nortriptyline oral capsule 10 mg 25 mg 50 mg 75 mg
1
nortriptyline oral solution 10 mg5 ml 1
NUPLAZID ORAL CAPSULE 34 MG 2 PA LA
NUPLAZID ORAL TABLET 10 MG 2 PA LA
olanzapine intramuscular recon soln 10 mg 1
olanzapine oral tablet 10 mg 15 mg 25 mg 20 mg 5 mg 75 mg
1
olanzapine oral tabletdisintegrating 10 mg 15 mg 20 mg 5 mg
1
olanzapine-fluoxetine oral capsule 12-25 mg 12-50 mg 3-25 mg 6-25 mg 6-50 mg
1
oxazepam oral capsule 10 mg 15 mg 30 mg 1
paliperidone oral tablet extended release 24hr 15 mg 3 mg 6 mg 9 mg
1
paroxetine hcl oral tablet 10 mg 20 mg 30 mg 40 mg
1
paroxetine hcl oral tablet extended release 24 hr 125 mg 25 mg 375 mg
1
paroxetine mesylate(menopsym) oral capsule 75 mg
1
perphenazine oral tablet 16 mg 2 mg 4 mg 8 mg 1
perphenazine-amitriptyline oral tablet 2-10 mg 2-25 mg 4-10 mg 4-25 mg 4-50 mg
1
phenelzine oral tablet 15 mg 1
pimozide oral tablet 1 mg 2 mg 1
procentra oral solution 5 mg5 ml 1
protriptyline oral tablet 10 mg 5 mg 1
quetiapine oral tablet 100 mg 200 mg 25 mg 300 mg 400 mg 50 mg
1
quetiapine oral tablet extended release 24 hr 150 mg 200 mg 300 mg 400 mg 50 mg
1
QUILLICHEW ER ORAL TABLETCHEWIR-ERBIPHASIC24HR 20 MG 30 MG 40 MG
1 ST
QUILLIVANT XR ORAL SUSPENSIONEXT REL 24HRRECON 5 MGML (25 MG5 ML)
1 ST
ramelteon oral tablet 8 mg 1
RELEXXII ORAL TABLET EXTENDED RELEASE 24HR 72 MG
1 ST
43
Drug Name Drug Tier Requirements Limits
REXULTI ORAL TABLET 025 MG 05 MG 1 MG 2 MG 3 MG 4 MG
1 PA ST
RISPERDAL CONSTA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 125 MG2 ML 25 MG2 ML 375 MG2 ML 50 MG2 ML
1
risperidone oral solution 1 mgml 1
risperidone oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg
1
risperidone oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg
1
seconal sodium oral capsule 100 mg 1
sertraline oral concentrate 20 mgml 1
sertraline oral tablet 100 mg 25 mg 50 mg 1
SPRAVATO NASAL SPRAYNON-AEROSOL 56 MG (28 MG X 2) 84 MG (28 MG X 3)
MB PA
SUNOSI ORAL TABLET 150 MG 1 PA QL (30 per 30 days)
SUNOSI ORAL TABLET 75 MG 1 PA QL (60 per 30 days)
temazepam oral capsule 15 mg 225 mg 30 mg 75 mg
1
thioridazine oral tablet 10 mg 100 mg 25 mg 50 mg
1
thiothixene oral capsule 1 mg 10 mg 2 mg 5 mg 1
tranylcypromine oral tablet 10 mg 1
trazodone oral tablet 100 mg 150 mg 300 mg 50 mg
1
triazolam oral tablet 0125 mg 025 mg 1
trifluoperazine oral tablet 1 mg 10 mg 2 mg 5 mg
1
trimipramine oral capsule 100 mg 25 mg 50 mg 1
TRINTELLIX ORAL TABLET 10 MG 20 MG 5 MG
1 ST
venlafaxine oral capsuleextended release 24hr 150 mg 375 mg 75 mg
1
venlafaxine oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg
1
venlafaxine oral tablet extended release 24hr 150 mg 225 mg 375 mg 75 mg
1
VERSACLOZ ORAL SUSPENSION 50 MGML 1 PA ST
44
Drug Name Drug Tier Requirements Limits
VRAYLAR ORAL CAPSULE 15 MG 3 MG 45 MG 6 MG
1 PA ST
VRAYLAR ORAL CAPSULEDOSE PACK 15 MG (1)- 3 MG (6)
1 PA ST
VYVANSE ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG 70 MG
1 PA ST
VYVANSE ORAL TABLETCHEWABLE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG
1 PA ST
XYREM ORAL SOLUTION 500 MGML 1 PA QL (540 per 30 days)
zaleplon oral capsule 10 mg 5 mg 1
ZENZEDI ORAL TABLET 15 MG 25 MG 20 MG 30 MG 75 MG
1 ST
ziprasidone hcl oral capsule 20 mg 40 mg 60 mg 80 mg
1
zolpidem oral tablet 10 mg 5 mg 1
zolpidem oral tabletext release multiphase 125 mg 625 mg
1
zolpidem sublingual tablet 175 mg 35 mg 1
ZOLPIMIST ORAL SPRAYNON-AEROSOL 5 MGSPRAY (01 ML)
1 ST
ZULRESSO INTRAVENOUS SOLUTION 5 MGML
MB
CARDIOVASCULAR HYPERTENSION amp LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone oral tablet 100 mg 200 mg 400 mg 1
disopyramide phosphate oral capsule 100 mg 150 mg
1
dofetilide oral capsule 125 mcg 250 mcg 500 mcg 1
flecainide oral tablet 100 mg 150 mg 50 mg 1
mexiletine oral capsule 150 mg 200 mg 250 mg 1
MULTAQ ORAL TABLET 400 MG 1
NORPACE CR ORAL CAPSULE EXTENDED RELEASE 100 MG 150 MG
1
pacerone oral tablet 100 mg 200 mg 400 mg 1
procainamide injection solution 100 mgml 500 mgml
MB
propafenone oral capsuleextended release 12 hr 225 mg 325 mg 425 mg
1
45
Drug Name Drug Tier Requirements Limits
propafenone oral tablet 150 mg 225 mg 300 mg 1
quinidine gluconate oral tablet extended release 324 mg
1
quinidine sulfate oral tablet 200 mg 300 mg 1
sorine oral tablet 120 mg 160 mg 240 mg 80 mg 1
sotalol af oral tablet 120 mg 160 mg 80 mg 1
sotalol oral tablet 120 mg 160 mg 240 mg 80 mg 1
ANTIHYPERTENSIVE THERAPY
acebutolol oral capsule 200 mg 400 mg 1
aliskiren oral tablet 150 mg 300 mg 1
amiloride oral tablet 5 mg 1
amiloride-hydrochlorothiazide oral tablet 5-50 mg 1
amlodipine oral tablet 10 mg 25 mg 5 mg 1
amlodipine-benazepril oral capsule 10-20 mg 10-40 mg 25-10 mg 5-10 mg 5-20 mg 5-40 mg
1 ST
amlodipine-olmesartan oral tablet 10-20 mg 10-40 mg 5-20 mg 5-40 mg
1 ST
amlodipine-valsartan oral tablet 10-160 mg 10-320 mg 5-160 mg 5-320 mg
1 ST
amlodipine-valsartan-hcthiazid oral tablet 10-160-125 mg 10-160-25 mg 10-320-25 mg 5-160-125 mg 5-160-25 mg
1
atenolol oral tablet 100 mg 25 mg 50 mg 1
atenolol-chlorthalidone oral tablet 100-25 mg 50-25 mg
1
benazepril oral tablet 10 mg 20 mg 40 mg 5 mg 1
benazepril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg 5-625 mg
1
betaxolol oral tablet 10 mg 20 mg 1
bisoprolol fumarate oral tablet 10 mg 5 mg 1
bisoprolol-hydrochlorothiazide oral tablet 10-625 mg 25-625 mg 5-625 mg
1
bumetanide injection solution 025 mgml 1
bumetanide oral tablet 05 mg 1 mg 2 mg 1
BYSTOLIC ORAL TABLET 10 MG 25 MG 20 MG 5 MG
1 ST
candesartan oral tablet 16 mg 32 mg 4 mg 8 mg 1
46
Drug Name Drug Tier Requirements Limits
candesartan-hydrochlorothiazid oral tablet 16-125 mg 32-125 mg 32-25 mg
1
captopril oral tablet 100 mg 125 mg 25 mg 50 mg
1
captopril-hydrochlorothiazide oral tablet 25-15 mg 25-25 mg 50-15 mg 50-25 mg
1
cartia xt oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg
1
carvedilol oral tablet 125 mg 25 mg 3125 mg 625 mg
1
carvedilol phosphate oral capsule er multiphase 24 hr 10 mg 20 mg 40 mg 80 mg
1
chlorthalidone oral tablet 25 mg 50 mg 1
clonidine hcl oral tablet 01 mg 02 mg 03 mg 1
clonidine transdermal patch weekly 01 mg24 hr 02 mg24 hr 03 mg24 hr
1
diltiazem hcl oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg
1
diltiazem hcl oral capsuleextended release 12 hr 120 mg 60 mg 90 mg
1
diltiazem hcl oral capsuleextended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
diltiazem hcl oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg 360 mg
1
diltiazem hcl oral tablet 120 mg 30 mg 60 mg 90 mg
1
diltiazem hcl oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
dilt-xr oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg
1
doxazosin oral tablet 1 mg 2 mg 4 mg 8 mg 1
EDARBI ORAL TABLET 40 MG 80 MG 1 ST
EDARBYCLOR ORAL TABLET 40-125 MG 40-25 MG
1 ST
enalapril maleate oral tablet 10 mg 25 mg 20 mg 5 mg
1
enalaprilat intravenous solution 125 mgml MB
enalapril-hydrochlorothiazide oral tablet 10-25 mg 5-125 mg
1
EPANED ORAL SOLUTION 1 MGML 1
47
Drug Name Drug Tier Requirements Limits
eplerenone oral tablet 25 mg 50 mg 1
epoprostenol (glycine) intravenous recon soln 05 mg 15 mg
MB PA LA
eprosartan oral tablet 600 mg 1
ethacrynic acid oral tablet 25 mg 1
felodipine oral tablet extended release 24 hr 10 mg 25 mg 5 mg
1
FLOLAN INTRAVENOUS RECON SOLN 05 MG 15 MG
MB PA LA
fosinopril oral tablet 10 mg 20 mg 40 mg 1
fosinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg
1
furosemide oral solution 10 mgml 40 mg5 ml (8 mgml)
1
furosemide oral tablet 20 mg 40 mg 80 mg 1
guanfacine oral tablet 1 mg 2 mg 1
hydralazine oral tablet 10 mg 100 mg 25 mg 50 mg
1
hydrochlorothiazide oral capsule 125 mg 1
hydrochlorothiazide oral tablet 125 mg 25 mg 50 mg
1
indapamide oral tablet 125 mg 25 mg 1
irbesartan oral tablet 150 mg 300 mg 75 mg 1
irbesartan-hydrochlorothiazide oral tablet 150-125 mg 300-125 mg
1
isradipine oral capsule 25 mg 5 mg 1
labetalol oral tablet 100 mg 200 mg 300 mg 1
lisinopril oral tablet 10 mg 25 mg 20 mg 30 mg 40 mg 5 mg
1
lisinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg
1
losartan oral tablet 100 mg 25 mg 50 mg 1
losartan-hydrochlorothiazide oral tablet 100-125 mg 100-25 mg 50-125 mg
1
matzim la oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
methyldopa oral tablet 250 mg 500 mg 1
methyldopa-hydrochlorothiazide oral tablet 250-15 mg 250-25 mg
1
48
Drug Name Drug Tier Requirements Limits
methyldopate intravenous solution 250 mg5 ml MB
metolazone oral tablet 10 mg 25 mg 5 mg 1
metoprolol succinate oral tablet extended release 24 hr 100 mg 200 mg 25 mg 50 mg
1
metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg 100-50 mg 50-25 mg
1
metoprolol tartrate oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg
1
metyrosine oral capsule 250 mg 1
minoxidil oral tablet 10 mg 25 mg 1
moexipril oral tablet 15 mg 75 mg 1
nadolol oral tablet 20 mg 40 mg 80 mg 1
nadolol-bendroflumethiazide oral tablet 80-5 mg 1
nicardipine oral capsule 20 mg 30 mg 1
nifedipine oral capsule 10 mg 20 mg 1
nifedipine oral tablet extended release 24hr 30 mg 60 mg 90 mg
1
nifedipine oral tablet extended release 30 mg 60 mg 90 mg
1
nimodipine oral capsule 30 mg 1
nisoldipine oral tablet extended release 24 hr 17 mg 20 mg 255 mg 30 mg 34 mg 40 mg 85 mg
1
olmesartan oral tablet 20 mg 40 mg 5 mg 1
olmesartan-amlodipin-hcthiazid oral tablet 20-5-125 mg 40-10-125 mg 40-10-25 mg 40-5-125 mg 40-5-25 mg
1
olmesartan-hydrochlorothiazide oral tablet 20-125 mg 40-125 mg 40-25 mg
1 ST
ORENITRAM ORAL TABLET EXTENDED RELEASE 0125 MG 025 MG 1 MG 25 MG 5 MG
2 PA LA
perindopril erbumine oral tablet 2 mg 4 mg 8 mg 1
phenoxybenzamine oral capsule 10 mg 1
pindolol oral tablet 10 mg 5 mg 1
prazosin oral capsule 1 mg 2 mg 5 mg 1
propranolol oral capsuleextended release 24 hr 120 mg 160 mg 60 mg 80 mg
1
propranolol oral solution 20 mg5 ml (4 mgml) 40 mg5 ml (8 mgml)
1
49
Drug Name Drug Tier Requirements Limits
propranolol oral tablet 10 mg 20 mg 40 mg 60 mg 80 mg
1
propranolol-hydrochlorothiazid oral tablet 40-25 mg 80-25 mg
1
QBRELIS ORAL SOLUTION 1 MGML 1
quinapril oral tablet 10 mg 20 mg 40 mg 5 mg 1
quinapril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg
1
ramipril oral capsule 125 mg 10 mg 25 mg 5 mg
1
spironolactone oral tablet 100 mg 25 mg 50 mg 1
spironolacton-hydrochlorothiaz oral tablet 25-25 mg
1
taztia xt oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg
1
TEKTURNA HCT ORAL TABLET 150-125 MG 150-25 MG 300-125 MG 300-25 MG
1
telmisartan oral tablet 20 mg 40 mg 80 mg 1
telmisartan-amlodipine oral tablet 40-10 mg 40-5 mg 80-10 mg 80-5 mg
1 ST
telmisartan-hydrochlorothiazid oral tablet 40-125 mg 80-125 mg 80-25 mg
1
terazosin oral capsule 1 mg 10 mg 2 mg 5 mg 1
tiadylt er oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg 420 mg
1
timolol maleate oral tablet 10 mg 20 mg 5 mg 1
torsemide oral tablet 10 mg 100 mg 20 mg 5 mg 1
trandolapril oral tablet 1 mg 2 mg 4 mg 1
trandolapril-verapamil oral tablet ir - er biphasic 24hr 1-240 mg 2-180 mg 2-240 mg 4-240 mg
1 ST
triamterene oral capsule 100 mg 50 mg 1
triamterene-hydrochlorothiazid oral capsule 375-25 mg
1
triamterene-hydrochlorothiazid oral tablet 375-25 mg 75-50 mg
1
valsartan oral tablet 160 mg 320 mg 40 mg 80 mg
1
valsartan-hydrochlorothiazide oral tablet 160-125 mg 160-25 mg 320-125 mg 320-25 mg 80-125 mg
1
50
Drug Name Drug Tier Requirements Limits
veletri intravenous recon soln 05 mg 15 mg MB PA LA
verapamil oral capsule 24 hr er pellet ct 100 mg 200 mg 300 mg
1
verapamil oral capsuleext rel pellets 24 hr 120 mg 180 mg 240 mg 360 mg
1
verapamil oral tablet 120 mg 40 mg 80 mg 1
verapamil oral tablet extended release 120 mg 180 mg 240 mg
1
CARDIAC GLYCOSIDES
digitek oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
digox oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
digoxin oral solution 50 mcgml (005 mgml) 1
digoxin oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
COAGULATION THERAPY
ADVATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 4000 (+-) UNIT 500 (+-) UNIT
MB
ADYNOVATE INTRAVENOUS SOLUTION 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT 750 (+-) UNIT
MB LA
AFSTYLA INTRAVENOUS RECON SOLN 1000 (+-) UNIT RANGE 1500 (+-) UNIT RANGE 2000 (+-) UNIT RANGE 2500 (+-) UNIT RANGE 250 (+-) UNIT RANGE 3000 (+-) UNIT RANGE 500 (+-) UNIT RANGE
MB LA
ALPHANATE INTRAVENOUS RECON SOLN 1000 (400 VWF) UNIT10 ML 1500 (600 VWF) UNIT10 ML 2000 (800 VWF) UNIT10 ML 250 (100 VWF) UNIT5 ML 500 (200 VWF) UNIT5 ML
MB LA
ALPHANINE SD INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT
MB LA
ALPROLIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 500 UNIT
MB LA
aminocaproic acid oral solution 250 mgml (25 ) 1
51
Drug Name Drug Tier Requirements Limits
aminocaproic acid oral tablet 1000 mg 500 mg 1
ANDEXXA INTRAVENOUS RECON SOLN 200 MG
MB
aspirin-dipyridamole oral capsule er multiphase 12 hr 25-200 mg
1
BENEFIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
BRILINTA ORAL TABLET 60 MG 90 MG 1
CABLIVI INJECTION KIT 11 MG 2 PA
cilostazol oral tablet 100 mg 50 mg 1
clopidogrel oral tablet 300 mg 75 mg 1
COAGADEX INTRAVENOUS RECON SOLN 250 (+-) UNIT RANGE 500 (+-) UNIT RANGE
MB
CORIFACT INTRAVENOUS RECON SOLN 1000-1600 UNIT
MB LA
dipyridamole oral tablet 25 mg 50 mg 75 mg 1
DOPTELET (15 TAB PACK) ORAL TABLET 20 MG
2 PA LA
ELIQUIS DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 5 MG (74 TABS)
1
ELIQUIS ORAL TABLET 25 MG 5 MG 1
ELOCTATE INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 5000 UNIT 500 UNIT 6000 UNIT 750 UNIT
MB LA
enoxaparin subcutaneous solution 300 mg3 ml 2
enoxaparin subcutaneous syringe 100 mgml 120 mg08 ml 150 mgml 30 mg03 ml 40 mg04 ml 60 mg06 ml 80 mg08 ml
2
ESPEROCT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
FEIBA NF INTRAVENOUS RECON SOLN 1750-3250 UNIT 350-650 UNIT 700-1300 UNIT
MB LA
FIBRYGA INTRAVENOUS RECON SOLN 1 GRAM (700 MG- 1300 MG)
MB
fondaparinux subcutaneous syringe 10 mg08 ml 25 mg05 ml 5 mg04 ml 75 mg06 ml
2
52
Drug Name Drug Tier Requirements Limits
FRAGMIN SUBCUTANEOUS SOLUTION 25000 ANTI-XA UNITML
2
FRAGMIN SUBCUTANEOUS SYRINGE 10000 ANTI-XA UNITML 12500 ANTI-XA UNIT05 ML 15000 ANTI-XA UNIT06 ML 18000 ANTI-XA UNIT072 ML 2500 ANTI-XA UNIT02 ML 5000 ANTI-XA UNIT02 ML 7500 ANTI-XA UNIT03 ML
2
HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG07 ML 150 MGML 30 MGML 60 MG04 ML
2 PA LA
HEMOFIL M HIGH INTRAVENOUS RECON SOLN 801-1500 UNIT
MB
HEMOFIL M LOW INTRAVENOUS RECON SOLN 220-400 UNIT
MB
HEMOFIL M MID INTRAVENOUS RECON SOLN 401-800 UNIT
MB
HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 1501-2000 UNIT
MB
hep flush-10 (pf) intravenous solution 10 unitml MB
heparin (porcine) in 5 dex intravenous parenteral solution 25000 unit250 ml(100 unitml) 25000 unit500 ml (50 unitml)
MB
heparin (porcine) injection cartridge 5000 unitml (1 ml)
1
heparin (porcine) injection solution 1000 unitml 10000 unitml 20000 unitml 5000 unitml
1
heparin lock flush (porcine) intravenous solution 100 unitml
MB
heparin lockflush(porcine)(pf) intravenous syringe 100 unitml
MB
HEPARIN(PORCINE) IN 045 NACL INTRAVENOUS PARENTERAL SOLUTION 12500 UNIT250 ML
MB
heparin(porcine) in 045 nacl intravenous parenteral solution 25000 unit250 ml 25000 unit500 ml
MB
heparin porcine (pf) injection solution 1000 unitml 5000 unit05 ml
MB
heparin porcine (pf) injection syringe 5000 unit05 ml
1
53
Drug Name Drug Tier Requirements Limits
heparin porcine (pf) intravenous solution 100 unitml (1 ml)
MB
heparin porcine (pf) intravenous syringe 10 unitml 100 unitml
MB
HUMATE-P INTRAVENOUS RECON SOLN 1000-2400 UNIT 250-600 UNIT 500-1200 UNIT
MB LA
IDELVION INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3500 (+-) UNIT 500 (+-) UNIT
MB LA
IXINITY INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
jantoven oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg
1
JIVI INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
KOATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB
KOGENATE FS INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB
KOVALTRY INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB
MONONINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT
MB LA
MULPLETA ORAL TABLET 3 MG 2 PA LA
NOVOEIGHT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
NOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1000 MCG) 2 MG (2000 MCG) 5 MG (5000 MCG) 8 MG (8000 MCG)
MB LA
NPLATE SUBCUTANEOUS RECON SOLN 125 MCG 250 MCG 500 MCG
MB LA
NUWIQ INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 2500 UNIT 250 (+-) UNIT 3000 UNIT 4000 UNIT 500 (+-) UNIT
MB LA
54
Drug Name Drug Tier Requirements Limits
OBIZUR INTRAVENOUS RECON SOLN 500 (+-) UNIT RANGE
MB
pentoxifylline oral tablet extended release 400 mg 1
phytonadione (vitamin k1) oral tablet 5 mg 1
prasugrel oral tablet 10 mg 5 mg 1
PROFILNINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT
MB LA
PROMACTA ORAL POWDER IN PACKET 125 MG
2 PA ST LA
PROMACTA ORAL POWDER IN PACKET 25 MG
2 LA
PROMACTA ORAL TABLET 125 MG 25 MG 50 MG 75 MG
2 PA ST LA
REBINYN INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 500 (+-) UNIT
MB LA
RECOMBINATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB LA
RIASTAP INTRAVENOUS RECON SOLN 1 GRAM (900MG-1300MG)
MB LA
RIXUBIS INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
tranexamic acid intravenous solution 1000 mg10 ml (100 mgml)
MB
TRETTEN INTRAVENOUS RECON SOLN 2500 UNIT
MB LA
VONVENDI INTRAVENOUS RECON SOLN 1300 (+-) UNIT RANGE 650 (+-) UNIT RANGE
MB LA
warfarin oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg
1
WILATE INTRAVENOUS RECON SOLN 1000-1000 UNIT 500-500 UNIT
MB LA
XARELTO DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 15 MG (42)- 20 MG (9)
1
XARELTO ORAL TABLET 10 MG 15 MG 25 MG 20 MG
1
55
Drug Name Drug Tier Requirements Limits
XYNTHA INTRAVENOUS SOLUTION 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB LA
XYNTHA SOLOFUSE INTRAVENOUS SYRINGE 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
ZONTIVITY ORAL TABLET 208 MG 1
LIPIDCHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg 25-10 mg 25-20 mg 25-40 mg 5-10 mg 5-20 mg 5-40 mg 5-80 mg
1 ST
atorvastatin oral tablet 10 mg 20 mg ACA PV
atorvastatin oral tablet 40 mg 80 mg 1
cholestyramine (with sugar) oral powder 4 gram 1
cholestyramine (with sugar) oral powder in packet 4 gram
1
cholestyramine light oral powder 4 gram 1
cholestyramine light oral powder in packet 4 gram 1
colesevelam oral powder in packet 375 gram 1
colesevelam oral tablet 625 mg 1
colestipol oral granules 5 gram 1
colestipol oral packet 5 gram 1
colestipol oral tablet 1 gram 1
ezetimibe oral tablet 10 mg 1
ezetimibe-simvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg
1
fenofibrate micronized oral capsule 130 mg 134 mg 200 mg 43 mg 67 mg
1
fenofibrate nanocrystallized oral tablet 145 mg 48 mg
1
FENOFIBRATE ORAL CAPSULE 150 MG 50 MG
1
fenofibrate oral tablet 120 mg 160 mg 40 mg 54 mg
1
fenofibric acid (choline) oral capsuledelayed release(drec) 135 mg 45 mg
1
fenofibric acid oral tablet 105 mg 35 mg 1
fluvastatin oral capsule 20 mg 40 mg ACA PV
56
Drug Name Drug Tier Requirements Limits
fluvastatin oral tablet extended release 24 hr 80 mg
ACA PV
gemfibrozil oral tablet 600 mg 1
icosapent ethyl oral capsule 1 gram 1 PA ST QL (120 per 30 days)
JUXTAPID ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 5 MG 60 MG
2 PA LA QL (30 per 30 days)
LIPOFEN ORAL CAPSULE 150 MG 50 MG 1
lovastatin oral tablet 10 mg 20 mg 40 mg ACA PV
niacin oral tablet 500 mg 1
niacin oral tablet extended release 24 hr 1000 mg 500 mg 750 mg
1
NIACOR ORAL TABLET 500 MG 1
omega-3 acid ethyl esters oral capsule 1 gram 1
pravastatin oral tablet 10 mg 20 mg 40 mg 80 mg
ACA PV
prevalite oral powder 4 gram 1
prevalite oral powder in packet 4 gram 1
REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG35 ML
1 PA ST
REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MGML
1 PA ST
REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MGML
1 PA ST
rosuvastatin oral tablet 10 mg 5 mg ACA PV
rosuvastatin oral tablet 20 mg 40 mg 1
simvastatin oral tablet 10 mg 20 mg 40 mg 5 mg ACA PV
simvastatin oral tablet 80 mg 1
VASCEPA ORAL CAPSULE 05 GRAM 1 GRAM
1 PA ST QL (120 per 30 days)
ZYPITAMAG ORAL TABLET 2 MG 4 MG 1 PA ST
MISCELLANEOUS CARDIOVASCULAR AGENTS
CORLANOR ORAL SOLUTION 5 MG5 ML 1 PA
CORLANOR ORAL TABLET 5 MG 75 MG 1 PA
ENTRESTO ORAL TABLET 24-26 MG 49-51 MG 97-103 MG
1 PA ST
GIAPREZA INTRAVENOUS SOLUTION 25 MGML
MB
57
Drug Name Drug Tier Requirements Limits
ranolazine oral tablet extended release 12 hr 1000 mg 500 mg
1 ST
NITRATES
GONITRO SUBLINGUAL POWDER IN PACKET 400 MCG
1
isosorbide dinitrate oral tablet 10 mg 20 mg 30 mg 40 mg 5 mg
1
isosorbide mononitrate oral tablet 10 mg 20 mg 1
isosorbide mononitrate oral tablet extended release 24 hr 120 mg 30 mg 60 mg
1
MINITRAN TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 04 MGHR 06 MGHR
1 PA ST
nitro-bid transdermal ointment 2 1
NITRO-DUR TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 03 MGHR 04 MGHR 06 MGHR 08 MGHR
1 PA ST
nitroglycerin in 5 dextrose intravenous solution 25 mg250 ml (100 mcgml) 50 mg500 ml (100 mcgml)
MB
nitroglycerin sublingual tablet 03 mg 04 mg 06 mg
1
nitroglycerin transdermal patch 24 hour 01 mghr 02 mghr 04 mghr 06 mghr
1
nitroglycerin translingual spraynon-aerosol 400 mcgspray
1
nitro-time oral capsule extended release 25 mg 65 mg 9 mg
1
DERMATOLOGICALSTOPICAL THERAPY
ANTIPSORIATIC ANTISEBORRHEIC
acitretin oral capsule 10 mg 175 mg 25 mg 1
calcipotriene scalp solution 0005 1
calcipotriene topical cream 0005 1
calcipotriene topical ointment 0005 1
calcipotriene-betamethasone topical ointment 0005-0064
1
calcitriol topical ointment 3 mcggram 1
COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
58
Drug Name Drug Tier Requirements Limits
COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
COSENTYX SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
COSENTYX SUBCUTANEOUS SYRINGE 75 MG05 ML
2 PA LA
hydrocortisone-pramoxine topical cream 25-1 1
ILUMYA SUBCUTANEOUS SYRINGE 100 MGML
2 PA ST LA
selenium sulfide topical lotion 25 1
selenium sulfide topical shampoo 225 23 1
SILIQ SUBCUTANEOUS SYRINGE 210 MG15 ML
2 PA ST LA
SKYRIZI SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
SKYRIZI SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
SKYRIZI SUBCUTANEOUS SYRINGE KIT 150MG166ML(75 MG083 ML X2)
2 PA ST LA
STELARA INTRAVENOUS SOLUTION 130 MG26 ML
MB PA LA
STELARA SUBCUTANEOUS SOLUTION 45 MG05 ML
2 PA ST LA
STELARA SUBCUTANEOUS SYRINGE 45 MG05 ML 90 MGML
2 PA ST LA
sulfacetamide sodium topical cleanser 10 1
sulfacetamide sodium topical cleanser gel 10 1
sulfacetamide sodium topical shampoo 10 1
TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MGML
2 PA ST LA
59
Drug Name Drug Tier Requirements Limits
TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 MGML
2 PA ST LA
TREMFYA SUBCUTANEOUS SYRINGE 100 MGML
2 PA ST LA
BURN THERAPY
silver sulfadiazine topical cream 1 1
ssd topical cream 1 1
MISCELLANEOUS DERMATOLOGICALS
ammonium lactate topical cream 12 1
ammonium lactate topical lotion 12 1
diclofenac sodium topical gel 3 1
DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300 MG2 ML
2 LA
DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG114 ML 300 MG2 ML
2 PA ST LA
EUCRISA TOPICAL OINTMENT 2 1 PA ST
FLUOROURACIL TOPICAL CREAM 05 1 PA ST
fluorouracil topical cream 5 1 PA ST
fluorouracil topical solution 2 5 1
LEVULAN TOPICAL SOLUTION 20 1
methoxsalen oral capsuleliqd-filledrapid rel 10 mg
1
PANRETIN TOPICAL GEL 01 1
PICATO TOPICAL GEL 0015 005 1
pimecrolimus topical cream 1 1
podofilox topical solution 05 1
prudoxin topical cream 5 1
REGRANEX TOPICAL GEL 001 1
SCENESSE SUBCUTANEOUS IMPLANT 16 MG
MB PA
tacrolimus topical ointment 003 01 1
UVADEX INJECTION SOLUTION 20 MCGML 1
VALCHLOR TOPICAL GEL 0016 2 PA ST LA
THERAPY FOR ACNE
accutane oral capsule 20 mg 30 mg 40 mg 1
adapalene topical cream 01 1 ST
60
Drug Name Drug Tier Requirements Limits
adapalene topical gel 03 1 ST
adapalene topical gel with pump 03 1 ST
ADAPALENE TOPICAL LOTION 01 1 ST
adapalene topical solution 01 1 ST
adapalene topical swab 01 1 ST
adapalene-benzoyl peroxide topical gel with pump 01-25
1
amnesteem oral capsule 10 mg 20 mg 40 mg 1 PA ST
avita topical cream 0025 1
AVITA TOPICAL GEL 0025 1 ST
azelaic acid topical gel 15 1
AZELEX TOPICAL CREAM 20 1 ST
claravis oral capsule 10 mg 20 mg 30 mg 1 PA ST
claravis oral capsule 40 mg 1
clindacin p topical swab 1 1
clindamycin phosphate topical foam 1 1
clindamycin phosphate topical gel 1 1
clindamycin phosphate topical lotion 1 1
clindamycin phosphate topical solution 1 1
clindamycin phosphate topical swab 1 1
clindamycin-benzoyl peroxide topical gel 1-5 12 (1 base) -5
1
clindamycin-benzoyl peroxide topical gel with pump 1-5
1
clindamycin-tretinoin topical gel 12-0025 1
dapsone topical gel 5 1
ery pads topical swab 2 1
erygel topical gel 2 1
erythromycin with ethanol topical gel 2 1
erythromycin with ethanol topical solution 2 1
erythromycin-benzoyl peroxide topical gel 3-5 1
isotretinoin oral capsule 10 mg 20 mg 25 mg 30 mg 35 mg 40 mg
1
metronidazole topical cream 075 1
metronidazole topical gel 075 1 1
metronidazole topical gel with pump 1 1
61
Drug Name Drug Tier Requirements Limits
metronidazole topical lotion 075 1
myorisan oral capsule 10 mg 20 mg 30 mg 40 mg
1
rosadan topical cream 075 1
rosadan topical gel 075 1
tazarotene topical cream 01 1 ST
tretinoin microspheres topical gel 004 01 1
tretinoin microspheres topical gel with pump 004 01
1
tretinoin topical cream 0025 005 01 1
tretinoin topical gel 001 0025 005 1
zenatane oral capsule 10 mg 20 mg 30 mg 40 mg 1
TOPICAL ANESTHETICS
lidocaine hcl injection solution 10 mgml (1 ) 1
lidocaine hcl laryngotracheal solution 4 1
lidocaine hcl mucous membrane jelly 2 1
lidocaine hcl mucous membrane jelly in applicator 2
1
lidocaine hcl mucous membrane solution 4 (40 mgml)
1
lidocaine hcl-hydrocortison ac topical cream 3-05
1
lidocaine topical adhesive patchmedicated 5 1
lidocaine topical ointment 5 1
lidocaine viscous mucous membrane solution 2 1
lidocaine-prilocaine topical cream 25-25 1
lidocaine-prilocaine topical kit 25-25 1
LIDOCAINE-TETRACAINE TOPICAL CREAM 7-7
1 ST
SYNERA TOPICAL PATCH MEDICATED SELF-HEATING 70-70 MG
1 ST
TOPICAL ANTIBACTERIALS
ALCORTIN A TOPICAL GEL 2-1-1 1 ST
ALCORTIN A TOPICAL GEL IN PACKET 2-1-1
1 ST
ALTABAX TOPICAL OINTMENT 1 1
gentamicin topical cream 01 1
62
Drug Name Drug Tier Requirements Limits
gentamicin topical ointment 01 1
mafenide acetate topical packet 50 gram 1
mupirocin calcium topical cream 2 1
mupirocin topical ointment 2 1
sulfacetamide sodium (acne) topical suspension 10
1
SULFAMYLON TOPICAL CREAM 85 MGG 1
TOPICAL ANTIFUNGALS
ciclodan topical cream 077 1
ciclodan topical solution 8 1
ciclopirox topical cream 077 1
ciclopirox topical gel 077 1
ciclopirox topical shampoo 1 1
ciclopirox topical solution 8 1
ciclopirox topical suspension 077 1
ciclopirox-ure-camph-menth-euc topical solution 8
1
clotrimazole topical cream 1 1
clotrimazole topical solution 1 1
clotrimazole-betamethasone topical cream 1-005
1
clotrimazole-betamethasone topical lotion 1-005
1
econazole topical cream 1 1
EXELDERM TOPICAL CREAM 1 1
EXELDERM TOPICAL SOLUTION 1 1
JUBLIA TOPICAL SOLUTION WITH APPLICATOR 10
1 PA ST
ketoconazole topical cream 2 1
ketoconazole topical foam 2 1
ketoconazole topical shampoo 2 1
ketodan topical foam 2 1
LULICONAZOLE TOPICAL CREAM 1 1
LUZU TOPICAL CREAM 1 1
MENTAX TOPICAL CREAM 1 1
naftifine topical cream 1 2 1
63
Drug Name Drug Tier Requirements Limits
naftifine topical gel 1 1
nyamyc topical powder 100000 unitgram 1
nystatin topical cream 100000 unitgram 1
nystatin topical ointment 100000 unitgram 1
nystatin topical powder 100000 unitgram 1
nystatin-triamcinolone topical cream 100000-01 unitg-
1
nystatin-triamcinolone topical ointment 100000-01 unitgram-
1
nystop topical powder 100000 unitgram 1
oxiconazole topical cream 1 1
OXISTAT TOPICAL LOTION 1 1
tavaborole topical solution with applicator 5 1 PA ST
TOPICAL ANTIVIRALS
acyclovir topical cream 5 1
acyclovir topical ointment 5 1
DENAVIR TOPICAL CREAM 1 1
TOPICAL CORTICOSTEROIDS
ala-cort topical cream 1 1
alclometasone topical cream 005 1
alclometasone topical ointment 005 1
amcinonide topical cream 01 1
amcinonide topical lotion 01 1
apexicon e topical cream 005 1
beser topical lotion 005 1
betamethasone dipropionate topical cream 005 1
betamethasone dipropionate topical lotion 005 1
betamethasone dipropionate topical ointment 005
1
betamethasone valerate topical cream 01 1
betamethasone valerate topical foam 012 1
betamethasone valerate topical lotion 01 1
betamethasone valerate topical ointment 01 1
betamethasone augmented topical cream 005 1
betamethasone augmented topical gel 005 1
betamethasone augmented topical lotion 005 1
64
Drug Name Drug Tier Requirements Limits
betamethasone augmented topical ointment 005
1
clobetasol scalp solution 005 1
clobetasol topical cream 005 1
clobetasol topical foam 005 1
clobetasol topical gel 005 1
clobetasol topical lotion 005 1
clobetasol topical ointment 005 1
clobetasol topical shampoo 005 1
clobetasol topical spraynon-aerosol 005 1
clobetasol-emollient topical cream 005 1
clobetasol-emollient topical foam 005 1
CLOCORTOLONE PIVALATE TOPICAL CREAM 01
1 ST
CLODERM TOPICAL CREAM 01 1 ST
desonide topical cream 005 1
desonide topical lotion 005 1
desonide topical ointment 005 1
desoximetasone topical cream 005 025 1
desoximetasone topical gel 005 1
desoximetasone topical ointment 005 025 1
desoximetasone topical spraynon-aerosol 025 1
diflorasone topical cream 005 1
diflorasone topical ointment 005 1
fluocinolone and shower cap scalp oil 001 1
fluocinolone topical cream 001 0025 1
fluocinolone topical oil 001 1
fluocinolone topical ointment 0025 1
fluocinolone topical solution 001 1
fluocinonide topical cream 005 01 1
fluocinonide topical gel 005 1
fluocinonide topical ointment 005 1
fluocinonide topical solution 005 1
fluocinonide-e topical cream 005 1
flurandrenolide topical cream 005 1
65
Drug Name Drug Tier Requirements Limits
flurandrenolide topical lotion 005 1
flurandrenolide topical ointment 005 1
fluticasone propionate topical cream 005 1
fluticasone propionate topical lotion 005 1
fluticasone propionate topical ointment 0005 1
halcinonide topical cream 01 1
halobetasol propionate topical cream 005 1
halobetasol propionate topical ointment 005 1
hydrocortisone butyrate topical cream 01 1
hydrocortisone butyrate topical lotion 01 1
hydrocortisone butyrate topical ointment 01 1
hydrocortisone butyrate topical solution 01 1
hydrocortisone butyr-emollient topical cream 01
1
hydrocortisone topical cream 1 25 1
hydrocortisone topical lotion 25 1
hydrocortisone topical ointment 1 25 1
hydrocortisone valerate topical cream 02 1
hydrocortisone valerate topical ointment 02 1
mometasone topical cream 01 1
mometasone topical ointment 01 1
mometasone topical solution 01 1
prednicarbate topical cream 01 1
prednicarbate topical ointment 01 1
scalacort topical lotion 2 1
triamcinolone acetonide topical aerosol 0147 mggram
1
triamcinolone acetonide topical cream 0025 01 05
1
triamcinolone acetonide topical lotion 0025 01
1
triamcinolone acetonide topical ointment 0025 005 01 05
1
triderm topical cream 01 05 1
TOPICAL ENZYMES
SANTYL TOPICAL OINTMENT 250 UNITGRAM
1 QL (2 per 30 days)
66
Drug Name Drug Tier Requirements Limits
TOPICAL SCABICIDES PEDICULICIDES
crotan topical lotion 10 1
EURAX TOPICAL CREAM 10 1
EURAX TOPICAL LOTION 10 1
ivermectin topical lotion 05 1
lindane topical shampoo 1 1
malathion topical lotion 05 1
permethrin topical cream 5 1
spinosad topical suspension 09 1
ULESFIA TOPICAL LOTION 5 1
DIAGNOSTICS amp MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
PHYSIOLYTE IRRIGATION SOLUTION 140-5-3-98 MEQL
MB
PHYSIOSOL IRRIGATION IRRIGATION SOLUTION 140-5-3-98 MEQL
MB
MISCELLANEOUS AGENTS
acamprosate oral tabletdelayed release (drec) 333 mg
1
acetic acid irrigation solution 025 1
anagrelide oral capsule 05 mg 1 mg 1
ARALAST NP INTRAVENOUS RECON SOLN 1000 MG 500 MG
MB LA
CARBAGLU ORAL TABLET DISPERSIBLE 200 MG
2 PA LA
cevimeline oral capsule 30 mg 1
CHEMET ORAL CAPSULE 100 MG 1
clovique oral capsule 250 mg 1 PA QL (240 per 30 days)
deferasirox oral granules in packet 180 mg 360 mg 90 mg
2 PA LA
deferasirox oral tablet 180 mg 2 PA LA
deferasirox oral tablet 360 mg 90 mg 2 ST LA
deferasirox oral tablet dispersible 125 mg 250 mg 500 mg
2 ST LA
deferiprone oral tablet 500 mg 1 PA
disulfiram oral tablet 250 mg 500 mg 1
67
Drug Name Drug Tier Requirements Limits
EMPAVELI SUBCUTANEOUS SOLUTION 1080 MG20 ML
2 PA
FERRIPROX ORAL SOLUTION 100 MGML 1 PA
FERRIPROX ORAL TABLET 1000 MG 500 MG
1 PA
GIVLAARI SUBCUTANEOUS SOLUTION 189 MGML
MB PA LA
GLASSIA INTRAVENOUS SOLUTION 1 GRAM50 ML (2 )
MB LA
INCRELEX SUBCUTANEOUS SOLUTION 10 MGML
2 PA LA
levocarnitine (with sugar) oral solution 100 mgml 1
levocarnitine oral solution 100 mgml 1
levocarnitine oral tablet 330 mg 1
midodrine oral tablet 10 mg 25 mg 5 mg 1
nitisinone oral capsule 10 mg 2 mg 5 mg 2 PA LA
NITYR ORAL TABLET 10 MG 2 MG 5 MG 2 PA LA
pilocarpine hcl oral tablet 5 mg 1
PROLASTIN-C INTRAVENOUS SOLUTION 1000 MG (+-)20 ML
MB
RAVICTI ORAL LIQUID 11 GRAMML 2 PA ST LA QL (10 per 30 days)
RECLAST INTRAVENOUS PIGGYBACK 5 MG100 ML
MB
riluzole oral tablet 50 mg 1
risedronate oral tablet 30 mg 1
sodium chloride 09 injection solution MB
sodium chloride 09 intravenous parenteral solution
MB
sodium chloride 09 intravenous piggyback MB
sodium phenylbutyrate oral powder 094 gramgram
1 PA
sodium phenylbutyrate oral tablet 500 mg 1 PA
SOLIRIS INTRAVENOUS SOLUTION 300 MG30 ML
MB PA LA
trientine oral capsule 250 mg 1 PA QL (240 per 30 days)
XURIDEN ORAL GRANULES IN PACKET 2 GRAM
2 PA QL (120 per 30 days)
68
Drug Name Drug Tier Requirements Limits
ZEMAIRA INTRAVENOUS RECON SOLN 1000 MG
MB LA
ZOKINVY ORAL CAPSULE 50 MG 75 MG 2 PA ST
SMOKING DETERRENTS
bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg
ACA PV
CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG
ACA PV QL (180 per 365 days)
CHANTIX ORAL TABLET 05 MG 1 MG ACA PV QL (180 per 365 days)
CHANTIX STARTING MONTH BOX ORAL TABLETSDOSE PACK 05 MG (11)- 1 MG (42)
ACA PV QL (180 per 365 days)
nicorette buccal gum 4 mg ACA PV
nicotine (polacrilex) buccal gum 2 mg 4 mg ACA PV
nicotine (polacrilex) buccal lozenge 2 mg 4 mg ACA PV
nicotine (polacrilex) buccal mini lozenge 2 mg 4 mg
ACA PV
nicotine transdermal patch 24 hour 14 mg24 hr 21 mg24 hr 7 mg24 hr
ACA PV
nicotine transdermal patch td daily sequential 21-14-7 mg24 hr
ACA PV
NICOTROL INHALATION CARTRIDGE 10 MG
ACA PV
NICOTROL NS NASAL SPRAYNON-AEROSOL 10 MGML
ACA PV
quit 2 buccal gum 2 mg ACA PV
quit 2 buccal lozenge 2 mg ACA PV
quit 4 buccal gum 4 mg ACA PV
quit 4 buccal lozenge 4 mg ACA PV
stop smoking aid buccal lozenge 2 mg 4 mg ACA PV
EAR NOSE amp THROAT MEDICATIONS
MISCELLANEOUS AGENTS
ARESTIN DENTAL CARTRIDGE 1 MG MB
azelastine nasal aerosolspray 137 mcg (01 ) 1
azelastine nasal spraynon-aerosol 2055 mcg (015 )
1
chlorhexidine gluconate mucous membrane mouthwash 012
1
denta 5000 plus dental cream 11 1
69
Drug Name Drug Tier Requirements Limits
dentagel dental gel 11 1
fluoride (sodium) dental cream 11 1
fluoride (sodium) dental gel 11 1
fluoride (sodium) dental paste 11 1
ipratropium bromide nasal spraynon-aerosol 21 mcg (003 ) 42 mcg (006 )
1
olopatadine nasal spraynon-aerosol 06 1
oralone dental paste 01 1
paroex oral rinse mucous membrane mouthwash 012
1
periogard mucous membrane mouthwash 012 1
pilocarpine hcl oral tablet 75 mg 1
sf 5000 plus dental cream 11 1
sf dental gel 11 1
sodium fluoride 5000 dry mouth dental gel 11 1
sodium fluoride 5000 plus dental cream 11 1
sodium fluoride-pot nitrate dental paste 11-5 1
triamcinolone acetonide dental paste 01 1
MISCELLANEOUS OTIC PREPARATIONS
acetic acid otic (ear) solution 2 1
ciprofloxacin hcl otic (ear) dropperette 02 1
flac otic oil otic (ear) drops 001 1
fluocinolone acetonide oil otic (ear) drops 001 1
hydrocortisone-acetic acid otic (ear) drops 1-2 1
ofloxacin otic (ear) drops 03 1
OTIC STEROID ANTIBIOTIC
CIPRO HC OTIC (EAR) DROPSSUSPENSION 02-1
1
ciprofloxacin-dexamethasone otic (ear) dropssuspension 03-01
1
neomycin-polymyxin-hc otic (ear) dropssuspension 35-10000-1 mgml-unitml-
1
neomycin-polymyxin-hc otic (ear) solution 35-10000-1 mgml-unitml-
1
OTOVEL OTIC (EAR) SOLUTION 03-0025 (025 ML)
1
ENDOCRINEDIABETES
70
Drug Name Drug Tier Requirements Limits
ADRENAL HORMONES
ACTHAR INJECTION GEL 80 UNITML 2 PA LA
decadron oral tablet 05 mg 1
dexamethasone intensol oral drops 1 mgml 1
dexamethasone oral elixir 05 mg5 ml 1
dexamethasone oral solution 05 mg5 ml 1
dexamethasone oral tablet 05 mg 075 mg 1 mg 15 mg 2 mg 4 mg 6 mg
1
dexamethasone oral tabletsdose pack 15 mg (21 tabs) 15 mg (35 tabs) 15 mg (51 tabs)
1
dexamethasone sodium phos (pf) injection solution 10 mgml
1
dexamethasone sodium phosphate injection solution 10 mgml 4 mgml
1
dexamethasone sodium phosphate injection syringe 4 mgml
1
fludrocortisone oral tablet 01 mg 1
hydrocortisone oral tablet 10 mg 20 mg 5 mg 1
methylprednisolone acetate injection suspension 40 mgml 80 mgml
1
methylprednisolone oral tablet 16 mg 32 mg 4 mg 8 mg
1
methylprednisolone oral tabletsdose pack 4 mg 1
millipred dp oral tabletsdose pack 5 mg (21 tabs) 5 mg (48 tabs)
1
millipred oral tablet 5 mg 1
prednisolone oral solution 15 mg5 ml 1
prednisolone sodium phosphate oral solution 10 mg5 ml 15 mg5 ml (3 mgml) 20 mg5 ml (4 mgml) 25 mg5 ml (5 mgml) 5 mg base5 ml (67 mg5 ml)
1
prednisolone sodium phosphate oral tabletdisintegrating 10 mg 15 mg 30 mg
1
prednisone intensol oral concentrate 5 mgml 1
prednisone oral solution 5 mg5 ml 1
prednisone oral tablet 1 mg 10 mg 25 mg 20 mg 5 mg 50 mg
1
prednisone oral tabletsdose pack 10 mg 5 mg 1
71
Drug Name Drug Tier Requirements Limits
triamcinolone acetonide injection suspension 40 mgml
MB
ANTITHYROID AGENTS
methimazole oral tablet 10 mg 5 mg 1
propylthiouracil oral tablet 50 mg 1
SSKI ORAL SOLUTION 1 GRAMML 1
BLOOD GLUCOSE MONITORING DEVICES amp SUPPLIES
CONTOUR NEXT TEST STRIPS STRIP 1
CONTOUR TEST STRIPS STRIP 1
ONETOUCH ULTRA TEST STRIP 1
ONETOUCH VERIO TEST STRIPS STRIP 1
DIABETES SUPPLIES amp DURABLE MEDICAL EQUIPMENT
AEROCHAMBER MINI SPACER 1
AEROCHAMBER PLUS FLOW-VU SPACER 1
GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN 1 MGML
1
GLUCAGON HCL INJECTION RECON SOLN 1 MGML
1
INSULIN SYRINGE-NEEDLE U-100 SYRINGE 05 ML 29 GAUGE X 12
1
TRIJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-5-1000 MG 125-25-1000 MG 25-5-1000 MG 5-25-1000 MG
1 PA ST
GLUCOSE ELEVATING AGENTS
BAQSIMI NASAL SPRAYNON-AEROSOL 3 MGACTUATION
1
diazoxide oral suspension 50 mgml 1
GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG
1
GLUCAGON (HCL) EMERGENCY KIT INJECTION RECON SOLN 1 MG
1
glucagon emergency kit (human) injection recon soln 1 mg
1
INSULIN SYRINGESMISCELLANEOUS DURABLE MEDICAL EQU
FREESTYLE LIBRE 14 DAY SENSOR KIT 1
FREESTYLE LIBRE 2 SENSOR KIT 1
NOVOPEN ECHO SUBCUTANEOUS INSULIN PEN
1
72
Drug Name Drug Tier Requirements Limits
PEN NEEDLE DIABETIC NEEDLE 29 GAUGE X 12
1
INSULIN THERAPY
FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
FIASP PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML (3 ML)
1
FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN HALF-UNIT 100 UNITML
1
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML
1 ST
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 200 UNITML (3 ML)
1
HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNITML (50-50)
1 ST
HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (50-50)
1 ST
HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (75-25)
1 ST
HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNITML (75-25)
1 ST
HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML
1 ST
HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1 ST
HUMULIN 7030 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)
1 ST
HUMULIN 7030 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1 ST
73
Drug Name Drug Tier Requirements Limits
HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1 ST
HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML
1 ST
HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNITML
1 ST
HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNITML
1
HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNITML (3 ML)
1
INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML (70-30)
1
INSULIN ASPART U-100 SUBCUTANEOUS CARTRIDGE 100 UNITML
1
INSULIN ASPART U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
INSULIN ASPART U-100 SUBCUTANEOUS SOLUTION 100 UNITML
1
LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
NOVOLIN R FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
74
Drug Name Drug Tier Requirements Limits
NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNITML (70-30)
1
NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML
1
NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML
1
RELION NOVOLIN 7030 SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)
1
RELION NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNITML
1
RELION NOVOLIN R INJECTION SOLUTION 100 UNITML
1
SOLIQUA 10033 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCGML
1 PA ST
TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNITML (3 ML)
1
TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNITML (15 ML)
1
TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN 200 UNITML (3 ML)
1
TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
XULTOPHY 10036 SUBCUTANEOUS INSULIN PEN 100 UNIT-36 MG ML (3 ML)
1 PA ST
MISCELLANEOUS HORMONES
ALDURAZYME INTRAVENOUS SOLUTION 29 MG5 ML
MB PA LA
ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG24 HOUR 4 MG24 HR
1 ST QL (30 per 30 days)
75
Drug Name Drug Tier Requirements Limits
BRINEURA INTRAVENTRICULAR KIT 300 MG10 ML (150MG5ML X2)
MB
cabergoline oral tablet 05 mg 1
calcitonin (salmon) injection solution 200 unitml 1
calcitonin (salmon) nasal spraynon-aerosol 200 unitactuation
1
calcitriol oral capsule 025 mcg 05 mcg 1
calcitriol oral solution 1 mcgml 1
CERDELGA ORAL CAPSULE 84 MG 2 PA LA
CEREZYME INTRAVENOUS RECON SOLN 400 UNIT
MB PA LA
cinacalcet oral tablet 30 mg 60 mg 90 mg 2 PA
CRYSVITA SUBCUTANEOUS SOLUTION 10 MGML 20 MGML 30 MGML
MB PA LA
danazol oral capsule 100 mg 200 mg 50 mg 1
DEPO-TESTOSTERONE INTRAMUSCULAR OIL 100 MGML
1
desmopressin nasal spraynon-aerosol 10 mcgspray (01 ml)
1
desmopressin oral tablet 01 mg 02 mg 1
doxercalciferol oral capsule 05 mcg 1 mcg 25 mcg
1
ELAPRASE INTRAVENOUS SOLUTION 6 MG3 ML
MB PA LA
ELELYSO INTRAVENOUS RECON SOLN 200 UNIT
MB PA LA
FABRAZYME INTRAVENOUS RECON SOLN 35 MG 5 MG
MB PA LA
GALAFOLD ORAL CAPSULE 123 MG 2 PA LA
JYNARQUE ORAL TABLET 15 MG 30 MG 2 PA QL (60 per 30 days)
JYNARQUE ORAL TABLETS SEQUENTIAL 45 MG (AM) 15 MG (PM) 60 MG (AM) 30 MG (PM) 90 MG (AM) 30 MG (PM)
2 PA QL (60 per 30 days)
KANUMA INTRAVENOUS SOLUTION 2 MGML
MB PA LA
KORLYM ORAL TABLET 300 MG 2 PA ST
LUMIZYME INTRAVENOUS RECON SOLN 50 MG
MB PA LA
76
Drug Name Drug Tier Requirements Limits
MEPSEVII INTRAVENOUS SOLUTION 2 MGML
MB PA LA
methyltestosterone oral capsule 10 mg 1
MIACALCIN INJECTION SOLUTION 200 UNITML
1
miglustat oral capsule 100 mg 2 PA LA
MYALEPT SUBCUTANEOUS RECON SOLN 5 MGML (FINAL CONC)
2 LA
NAGLAZYME INTRAVENOUS SOLUTION 5 MG5 ML
MB PA LA
NATPARA SUBCUTANEOUS CARTRIDGE 100 MCGDOSE 25 MCGDOSE 50 MCGDOSE 75 MCGDOSE
2 PA ST LA
oxandrolone oral tablet 10 mg 25 mg 1
PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG05 ML 25 MG05 ML 20 MGML
2 PA LA
pamidronate intravenous solution 30 mg10 ml (3 mgml)
MB
PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCGML
MB
paricalcitol intravenous solution 5 mcgml MB
paricalcitol oral capsule 1 mcg 2 mcg 4 mcg 1
PARSABIV INTRAVENOUS SOLUTION 5 MGML
MB PA
SAMSCA ORAL TABLET 15 MG 2 PA LA QL (60 per 30 days)
sapropterin oral powder in packet 100 mg 500 mg 2 PA LA
sapropterin oral tabletsoluble 100 mg 2 PA LA
SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG 15 MG 20 MG 25 MG 30 MG
2 PA LA QL (30 per 30 days)
STRENSIQ SUBCUTANEOUS SOLUTION 18 MG045 ML 28 MG07 ML 40 MGML 80 MG08 ML
2 PA
SYNAREL NASAL SPRAYNON-AEROSOL 2 MGML
1
TEPEZZA INTRAVENOUS RECON SOLN 500 MG
MB PA LA
testosterone cypionate intramuscular oil 100 mgml 200 mgml
1
testosterone enanthate intramuscular oil 200 mgml
1
77
Drug Name Drug Tier Requirements Limits
testosterone transdermal gel 50 mg5 gram (1 ) 1 QL (60 per 30 days)
testosterone transdermal gel in metered-dose pump 10 mg05 gram actuation 2025 mg125 gram (162 )
1 QL (2 per 30 days)
testosterone transdermal gel in metered-dose pump 125 mg 125 gram (1 )
1 QL (4 per 30 days)
testosterone transdermal gel in packet 1 (25 mg25gram) 162 (2025 mg125 gram)
1 QL (30 per 30 days)
testosterone transdermal gel in packet 1 (50 mg5 gram) 162 (405 mg25 gram)
1 QL (60 per 30 days)
testosterone transdermal solution in metered pump wapp 30 mgactuation (15 ml)
1 QL (2 per 30 days)
VIMIZIM INTRAVENOUS SOLUTION 5 MG5 ML (1 MGML)
MB PA LA
VPRIV INTRAVENOUS RECON SOLN 400 UNIT
MB PA LA
NON-INSULIN HYPOGLYCEMIC AGENTS
acarbose oral tablet 100 mg 25 mg 50 mg 1
ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 125-15 MG 125-30 MG 125-45 MG 25-15 MG 25-30 MG 25-45 MG
1 PA ST
BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG085 ML
1 PA ST
BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCGDOSE(250 MCGML) 24 ML 5 MCGDOSE (250 MCGML) 12 ML
1 PA ST
CYCLOSET ORAL TABLET 08 MG 1
FARXIGA ORAL TABLET 10 MG 5 MG 1 PA ST
glimepiride oral tablet 1 mg 2 mg 4 mg 1
glipizide oral tablet 10 mg 5 mg 1
glipizide oral tablet extended release 24hr 10 mg 25 mg 5 mg
1
glipizide-metformin oral tablet 25-250 mg 25-500 mg 5-500 mg
1
glyburide micronized oral tablet 15 mg 3 mg 6 mg
1
glyburide oral tablet 125 mg 25 mg 5 mg 1
glyburide-metformin oral tablet 125-250 mg 25-500 mg 5-500 mg
1
78
Drug Name Drug Tier Requirements Limits
GLYXAMBI ORAL TABLET 10-5 MG 25-5 MG
1 PA ST
JANUMET ORAL TABLET 50-1000 MG 50-500 MG
1 PA ST
JANUMET XR ORAL TABLET ER MULTIPHASE 24 HR 100-1000 MG 50-1000 MG 50-500 MG
1 PA ST
JANUVIA ORAL TABLET 100 MG 25 MG 50 MG
1 PA ST
JARDIANCE ORAL TABLET 10 MG 25 MG 1 PA ST
JENTADUETO ORAL TABLET 25-1000 MG 25-500 MG 25-850 MG
1 PA ST
JENTADUETO XR ORAL TABLET IR - ER BIPHASIC 24HR 25-1000 MG 5-1000 MG
1 PA ST
metformin oral solution 500 mg5 ml 1 PA
metformin oral tablet 1000 mg 500 mg 850 mg 1
metformin oral tablet extended release 24 hr 500 mg 750 mg
1
metformin oral tablet extended release 24hr 1000 mg 500 mg
1 PA ST
metformin oral tableter gastretention 24 hr 1000 mg 500 mg
1 ST
miglitol oral tablet 100 mg 25 mg 50 mg 1
nateglinide oral tablet 120 mg 60 mg 1
OZEMPIC SUBCUTANEOUS PEN INJECTOR 025 MG OR 05 MG(2 MG15 ML) 1 MGDOSE (2 MG15 ML) 1 MGDOSE (4 MG3 ML)
1 PA ST
pioglitazone oral tablet 15 mg 30 mg 45 mg 1
pioglitazone-glimepiride oral tablet 30-2 mg 30-4 mg
1
pioglitazone-metformin oral tablet 15-500 mg 15-850 mg
1
QTERN ORAL TABLET 10-5 MG 5-5 MG 1 PA ST
repaglinide oral tablet 05 mg 1 mg 2 mg 1
repaglinide-metformin oral tablet 1-500 mg 2-500 mg
1
RIOMET ER ORAL SUSPENSIONEXTENDED REL RECON 500 MG5 ML
1 PA ST
79
Drug Name Drug Tier Requirements Limits
RYBELSUS ORAL TABLET 14 MG 3 MG 7 MG
1 PA ST
SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2700 MCG27 ML
1 PA ST
SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1500 MCG15 ML
1 PA ST
SYNJARDY ORAL TABLET 125-1000 MG 125-500 MG 5-1000 MG 5-500 MG
1 PA ST
SYNJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 125-1000 MG 25-1000 MG 5-1000 MG
1 PA ST
TRADJENTA ORAL TABLET 5 MG 1 PA ST
TRULICITY SUBCUTANEOUS PEN INJECTOR 075 MG05 ML 15 MG05 ML 3 MG05 ML 45 MG05 ML
1 PA ST
XIGDUO XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 10-500 MG 25-1000 MG 5-1000 MG 5-500 MG
1 PA ST
THYROID HORMONES
ARMOUR THYROID ORAL TABLET 120 MG 15 MG 180 MG 240 MG 30 MG 300 MG 60 MG 90 MG
1
levothyroxine oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 300 mcg 50 mcg 75 mcg 88 mcg
1
levoxyl oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 50 mcg 75 mcg 88 mcg
1
liothyronine oral tablet 25 mcg 5 mcg 50 mcg 1
np thyroid oral tablet 120 mg 15 mg 30 mg 60 mg 90 mg
1
SYNTHROID ORAL TABLET 100 MCG 112 MCG 125 MCG 137 MCG 150 MCG 175 MCG 200 MCG 25 MCG 300 MCG 50 MCG 75 MCG 88 MCG
1
THYROLAR-1 ORAL TABLET 125-50 MCG 1
THYROLAR-12 ORAL TABLET 625-25 MCG 1
THYROLAR-14 ORAL TABLET 31-125 MCG 1
THYROLAR-2 ORAL TABLET 25-100 MCG 1
THYROLAR-3 ORAL TABLET 375-150 MCG 1
80
Drug Name Drug Tier Requirements Limits
unithroid oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 300 mcg 50 mcg 75 mcg 88 mcg
1
westhroid oral tablet 130 mg 195 mg 325 mg 65 mg 975 mg
1
GASTROENTEROLOGY
ANTIDIARRHEALS amp ANTISPASMODICS
anaspaz oral tabletdisintegrating 0125 mg 1
atropine injection syringe 005 mgml 01 mgml 1
belladonna alkaloids-opium rectal suppository 162-30 mg 162-60 mg
1 PA ST
chlordiazepoxide-clidinium oral capsule 5-25 mg 1
dicyclomine intramuscular solution 10 mgml MB
dicyclomine oral capsule 10 mg 1
dicyclomine oral solution 10 mg5 ml 1
dicyclomine oral tablet 20 mg 1
diphenoxylate-atropine oral liquid 25-0025 mg5 ml
1
diphenoxylate-atropine oral tablet 25-0025 mg 1
DONNATAL ORAL TABLET 162-01037 -00194 MG
1
ed-spaz oral tabletdisintegrating 0125 mg 1
glycopyrrolate injection solution 02 mgml 1
glycopyrrolate oral tablet 1 mg 15 mg 2 mg 1
hyoscyamine sulfate oral drops 0125 mgml 1
hyoscyamine sulfate oral elixir 0125 mg5 ml 1
hyoscyamine sulfate oral tablet 0125 mg 1
hyoscyamine sulfate oral tablet extended release 12 hr 0375 mg
1
hyoscyamine sulfate oral tabletdisintegrating 0125 mg
1
hyoscyamine sulfate sublingual tablet 0125 mg 1
hyosyne oral drops 0125 mgml 1
hyosyne oral elixir 0125 mg5 ml 1
loperamide oral capsule 2 mg 1
methscopolamine oral tablet 25 mg 5 mg 1
MOTOFEN ORAL TABLET 1-0025 MG 1
81
Drug Name Drug Tier Requirements Limits
opium tincture oral tincture 10 mgml (morphine) 1
oscimin oral tablet 0125 mg 1
oscimin sl sublingual tablet 0125 mg 1
oscimin sr oral tablet extended release 12 hr 0375 mg
1
phenobarb-hyoscy-atropine-scop oral elixir 162-01037 -00194 mg5 ml
1
phenobarb-hyoscy-atropine-scop oral tablet 162-01037 -00194 mg
1
phenohytro oral elixir 162-01037 -00194 mg5 ml
1
phenohytro oral tablet 162-01037 -00194 mg 1
symax fastabs oral tabletdisintegrating 0125 mg 1
symax-sl sublingual tablet 0125 mg 1
symax-sr oral tablet extended release 12 hr 0375 mg
1
MISCELLANEOUS GASTROINTESTINAL AGENTS
AKYNZEO (NETUPITANT) ORAL CAPSULE 300-05 MG
1 QL (1 per 30 days)
alosetron oral tablet 05 mg 1 mg 1
ALOXI INTRAVENOUS SOLUTION 025 MG5 ML
MB
AMITIZA ORAL CAPSULE 24 MCG 8 MCG 1 PA
anucort-hc rectal suppository 25 mg 1
aprepitant oral capsule 125 mg 40 mg 1 QL (1 per 30 days)
aprepitant oral capsule 80 mg 1 QL (2 per 30 days)
aprepitant oral capsuledose pack 125 mg (1)- 80 mg (2)
1 QL (1 per 30 days)
balsalazide oral capsule 750 mg 1
budesonide oral capsuledelayedextendrelease 3 mg
1
calcium acetate(phosphat bind) oral capsule 667 mg
1
calcium acetate(phosphat bind) oral tablet 667 mg 1
CHOLBAM ORAL CAPSULE 250 MG 50 MG 2
CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)
2 PA ST LA
82
Drug Name Drug Tier Requirements Limits
CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG2 ML (200 MGML X 2)
2 PA ST LA
CLENPIQ ORAL SOLUTION 10 MG-35 GRAM -12 GRAM160 ML
ACA PV
compro rectal suppository 25 mg 1
constulose oral solution 10 gram15 ml 1
CORTIFOAM RECTAL FOAM 10 (80 MG) 1
CREON ORAL CAPSULEDELAYED RELEASE(DREC) 12000-38000 -60000 UNIT 24000-76000 -120000 UNIT 3000-9500- 15000 UNIT 36000-114000- 180000 UNIT 6000-19000 -30000 UNIT
1 PA
cromolyn oral concentrate 100 mg5 ml 1
DIPENTUM ORAL CAPSULE 250 MG 1 PA ST
doxylamine-pyridoxine (vit b6) oral tabletdelayed release (drec) 10-10 mg
1
dronabinol oral capsule 10 mg 25 mg 5 mg 1
EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG ML FINAL CONC)
1
ENTYVIO INTRAVENOUS RECON SOLN 300 MG
MB PA LA
enulose oral solution 10 gram15 ml 1
gavilyte-c oral recon soln 240-2272-672 -584 gram
ACA PV
gavilyte-g oral recon soln 236-2274-674 -586 gram
ACA PV
gavilyte-n oral recon soln 420 gram ACA PV
generlac oral solution 10 gram15 ml 1
granisetron hcl oral tablet 1 mg 1 QL (6 per 30 days)
hemmorex-hc rectal suppository 25 mg 1
hydrocortisone acetate rectal suppository 25 mg 30 mg
1
hydrocortisone rectal enema 100 mg60 ml 1
hydrocortisone topical cream with perineal applicator 1 25
1
hydrocortisone-pramoxine rectal cream 1-1 25-1 25-1 (4g)
1
INFLECTRA INTRAVENOUS RECON SOLN 100 MG
MB PA LA
83
Drug Name Drug Tier Requirements Limits
lactulose oral packet 10 gram 1
lactulose oral solution 10 gram15 ml 20 gram30 ml
1
lanthanum oral tabletchewable 1000 mg 500 mg 750 mg
1
lidocaine hcl-hydrocortison ac rectal cream 3-05
1
LIDOCAINE HCL-HYDROCORTISON AC RECTAL GEL 3 -25 (7 GRAM)
1
lidocaine hcl-hydrocortison ac rectal kit 2 -2 (7 gram)
1 ST
lidocaine hcl-hydrocortison ac rectal kit 3-05 3-1 (7 gram)
1 PA ST
lidocaine-hydrocortisone-aloe rectal gel 28-055
1
lidocaine-hydrocortisone-aloe rectal kit 3-25 (7 gram)
1 PA ST
LINZESS ORAL CAPSULE 145 MCG 290 MCG 72 MCG
1 PA
meclizine oral tablet 125 mg 25 mg 1
mesalamine oral capsuleextended release 24hr 0375 gram
1
mesalamine oral tabletdelayed release (drec) 12 gram 800 mg
1
mesalamine rectal enema 4 gram60 ml 1
mesalamine rectal suppository 1000 mg 1
mesalamine with cleansing wipe rectal enema kit 4 gram60 ml
1 ST
metoclopramide hcl injection solution 5 mgml MB
metoclopramide hcl injection syringe 5 mgml MB
metoclopramide hcl oral solution 5 mg5 ml 1
metoclopramide hcl oral tablet 10 mg 5 mg 1
metoclopramide hcl oral tabletdisintegrating 10 mg 5 mg
1
MOVANTIK ORAL TABLET 125 MG 25 MG 1 PA ST
NULYTELY LEMON-LIME ORAL RECON SOLN 420 GRAM
ACA PV
ondansetron hcl intravenous solution 2 mgml MB
ondansetron hcl oral solution 4 mg5 ml 1 QL (100 per 30 days)
84
Drug Name Drug Tier Requirements Limits
ondansetron hcl oral tablet 4 mg 8 mg 1 QL (9 per 30 days)
ondansetron oral tabletdisintegrating 4 mg 8 mg 1 QL (9 per 30 days)
OSMOPREP ORAL TABLET 15 GRAM ACA PV
peg 3350-electrolytes oral recon soln 236-2274-674 -586 gram
ACA PV
peg3350-sod sul-nacl-kcl-asb-c oral powder in packet 100-75-2691 gram
ACA PV
peg-electrolyte soln oral recon soln 420 gram ACA PV
peg-prep oral kit 5-210 mg-gram ACA PV
PLENVU ORAL POWDER IN PACKET SEQUENTIAL 140-9-52 GRAM
ACA PV
prochlorperazine edisylate injection solution 10 mg2 ml (5 mgml) 5 mgml
1
prochlorperazine maleate oral tablet 10 mg 5 mg 1
prochlorperazine rectal suppository 25 mg 1
procto-med hc topical cream with perineal applicator 25
1
procto-pak topical cream with perineal applicator 1
1
proctosol hc topical cream with perineal applicator 25
1
proctozone-hc topical cream with perineal applicator 25
1
RECTIV RECTAL OINTMENT 04 (WW) 1
RELISTOR ORAL TABLET 150 MG 1
RELISTOR SUBCUTANEOUS SOLUTION 12 MG06 ML
1
RELISTOR SUBCUTANEOUS SYRINGE 12 MG06 ML 8 MG04 ML
1
REMICADE INTRAVENOUS RECON SOLN 100 MG
MB PA LA
RENFLEXIS INTRAVENOUS RECON SOLN 100 MG
MB PA LA
scopolamine base transdermal patch 3 day 1 mg over 3 days
1
sevelamer carbonate oral powder in packet 08 gram 24 gram
1
sevelamer carbonate oral tablet 800 mg 1
sevelamer hcl oral tablet 400 mg 800 mg 1
85
Drug Name Drug Tier Requirements Limits
sodium polystyrene sulfonate oral powder 1
sps (with sorbitol) oral suspension 15-20 gram60 ml
1
sps (with sorbitol) rectal enema 30-40 gram120 ml
1
SUCRAID ORAL SOLUTION 8500 UNITML 2 PA ST QL (2 per 30 days)
sulfasalazine oral tablet 500 mg 1
sulfasalazine oral tabletdelayed release (drec) 500 mg
1
SUPREP BOWEL PREP KIT ORAL RECON SOLN 175-313-16 GRAM
ACA PV ST
trilyte with flavor packets oral recon soln 420 gram
ACA PV
trimethobenzamide oral capsule 300 mg 1
ursodiol oral capsule 300 mg 1
ursodiol oral tablet 250 mg 500 mg 1
VARUBI ORAL TABLET 90 MG 1
VELPHORO ORAL TABLETCHEWABLE 500 MG
1 ST
VIBERZI ORAL TABLET 100 MG 75 MG 1 PA ST
ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 10000-32000 -42000 UNIT 15000-47000 -63000 UNIT 20000-63000- 84000 UNIT 3000-10000 -14000-UNIT 40000-126000- 168000 UNIT 5000-17000- 24000 UNIT
1 PA
ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 25000-79000- 105000 UNIT
1
ULCER THERAPY
amoxicil-clarithromy-lansopraz oral combo pack 500-500-30 mg
1
cimetidine hcl oral solution 300 mg5 ml 1
cimetidine oral tablet 200 mg 300 mg 400 mg 800 mg
1
DEXILANT ORAL CAPSULEBIPHASE DELAYED RELEAS 30 MG 60 MG
1 ST
esomeprazole magnesium oral capsuledelayed release(drec) 20 mg 40 mg
1
famotidine (pf) intravenous solution 20 mg2 ml MB
86
Drug Name Drug Tier Requirements Limits
famotidine oral suspension 40 mg5 ml (8 mgml) 1
famotidine oral tablet 20 mg 40 mg 1
lansoprazole oral capsuledelayed release(drec) 15 mg 30 mg
1
lansoprazole oral tabletdisintegrat delay rel 15 mg 30 mg
1
misoprostol oral tablet 100 mcg 200 mcg 1
nizatidine oral capsule 150 mg 300 mg 1
nizatidine oral solution 150 mg10 ml 1
omeprazole oral capsuledelayed release(drec) 10 mg 20 mg 40 mg
1
pantoprazole oral tabletdelayed release (drec) 20 mg 40 mg
1
rabeprazole oral tabletdelayed release (drec) 20 mg
1
sucralfate oral suspension 100 mgml 1
sucralfate oral tablet 1 gram 1
IMMUNOLOGY VACCINES amp BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCGML 200 MCGML 25 MCGML 300 MCGML 40 MCGML 60 MCGML
2 LA
ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG04 ML 100 MCG05 ML 150 MCG03 ML 200 MCG04 ML 25 MCG042 ML 300 MCG06 ML 40 MCG04 ML 500 MCGML 60 MCG03 ML
2 LA
EPOGEN INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML
2 LA
GRANIX SUBCUTANEOUS SOLUTION 300 MCGML 480 MCG16 ML
2
GRANIX SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML
2
LEUKINE INJECTION RECON SOLN 250 MCG 2 PA ST
MIRCERA INJECTION SYRINGE 100 MCG03 ML 150 MCG03 ML 200 MCG03 ML 30 MCG03 ML 50 MCG03 ML 75 MCG03 ML
MB
87
Drug Name Drug Tier Requirements Limits
MOZOBIL SUBCUTANEOUS SOLUTION 24 MG12 ML (20 MGML)
MB LA
NEUPOGEN INJECTION SOLUTION 300 MCGML 480 MCG16 ML
2 PA ST
NEUPOGEN INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML
2 PA ST
NIVESTYM INJECTION SOLUTION 300 MCGML 480 MCG16 ML
2
NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML
2
PROCRIT INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML 40000 UNITML
2 LA
UDENYCA SUBCUTANEOUS SYRINGE 6 MG06 ML
2 PA ST
ZARXIO INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML
2 PA ST
ZIEXTENZO SUBCUTANEOUS SYRINGE 6 MG06 ML
2 PA ST
GROWTH HORMONES
GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 02 MG025 ML 04 MG025 ML 06 MG025 ML 08 MG025 ML 1 MG025 ML 12 MG025 ML 14 MG025 ML 16 MG025 ML 18 MG025 ML 2 MG025 ML
2 PA ST LA
GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MGML (36 UNITML) 5 MGML (15 UNITML)
2 PA ST LA
OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG15 ML (67 MGML) 5 MG15 ML (33 MGML)
2 PA ST LA
OMNITROPE SUBCUTANEOUS RECON SOLN 58 MG
2 PA ST LA
SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG 5 MG 6 MG
2 PA ST LA
ZORBTIVE SUBCUTANEOUS RECON SOLN 88 MG
2 PA ST LA
INTERFERONS
AUBAGIO ORAL TABLET 14 MG 7 MG 2 PA LA
88
Drug Name Drug Tier Requirements Limits
AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG05 ML
2 PA ST LA QL (4 per 30 days)
AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG05 ML
2 PA ST LA QL (4 per 30 days)
BETASERON SUBCUTANEOUS KIT 03 MG 2 PA LA QL (14 per 30 days)
dimethyl fumarate oral capsuledelayed release(drec) 120 mg
2 PA LA QL (14 per 365 days)
dimethyl fumarate oral capsuledelayed release(drec) 120 mg (14)- 240 mg (46)
2 PA LA QL (1 per 365 days)
dimethyl fumarate oral capsuledelayed release(drec) 240 mg
2 PA LA QL (60 per 30 days)
GILENYA ORAL CAPSULE 05 MG 2 PA LA QL (30 per 30 days)
glatiramer subcutaneous syringe 20 mgml 2 PA LA QL (30 per 30 days)
glatiramer subcutaneous syringe 40 mgml 2 PA LA QL (12 per 30 days)
glatopa subcutaneous syringe 20 mgml 2 PA LA QL (30 per 30 days)
glatopa subcutaneous syringe 40 mgml 2 PA LA QL (12 per 30 days)
LEMTRADA INTRAVENOUS SOLUTION 12 MG12 ML
MB PA ST LA
MAVENCLAD (10 TABLET PACK) ORAL TABLET 10 MG
2 LA
MAVENCLAD (4 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (5 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (6 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (7 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (8 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (9 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAYZENT ORAL TABLET 025 MG 2 MG 2 PA ST LA QL (30 per 30 days)
MAYZENT STARTER PACK ORAL TABLETSDOSE PACK 025 MG (12 TABS)
2 PA ST LA QL (1 per 365 days)
OCREVUS INTRAVENOUS SOLUTION 30 MGML
MB PA LA
PEGASYS SUBCUTANEOUS SOLUTION 180 MCGML
2 PA LA
89
Drug Name Drug Tier Requirements Limits
PEGASYS SUBCUTANEOUS SYRINGE 180 MCG05 ML
2 PA LA
PLEGRIDY INTRAMUSCULAR SYRINGE 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG05 ML- 94 MCG05 ML
2 PA LA QL (1 per 365 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG05 ML- 94 MCG05 ML
2 PA LA QL (1 per 365 days)
POMALYST ORAL CAPSULE 1 MG 2 MG 3 MG 4 MG
2 PA ST OCh LA
PONVORY 14-DAY STARTER PACK ORAL TABLETSDOSE PACK 2 MG (2) - 10 MG (3)
2 PA LA QL (1 per 365 days)
PONVORY ORAL TABLET 20 MG 2 PA LA QL (30 per 30 days)
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG05 ML 44 MCG05 ML
2 PA LA QL (6 per 30 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG05 ML 44 MCG05 ML
2 PA LA QL (6 per 30 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 88MCG02ML-22 MCG05ML (6)
2 PA LA QL (5 per 30 days)
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 88MCG02ML-22 MCG05ML (6)
2 PA LA QL (5 per 30 days)
REVLIMID ORAL CAPSULE 10 MG 15 MG 25 MG 20 MG 25 MG 5 MG
2 PA ST OCh LA
ribavirin oral capsule 200 mg 2 LA
ribavirin oral tablet 200 mg 2 LA
ZEPOSIA ORAL CAPSULE 092 MG 2 LA QL (30 per 30 days)
ZEPOSIA STARTER KIT ORAL CAPSULEDOSE PACK 023-046-092 MG
2 LA QL (30 per 30 days)
ZEPOSIA STARTER PACK ORAL CAPSULEDOSE PACK 023 MG (4)- 046 MG (3)
2 LA QL (30 per 30 days)
INTERLEUKINS
ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG05 ML
2 PA LA
ARCALYST SUBCUTANEOUS RECON SOLN 220 MG
2 LA
90
Drug Name Drug Tier Requirements Limits
ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MGML
MB PA LA
imiquimod topical cream in packet 5 1
INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) 18 MILLION UNIT (1 ML) 50 MILLION UNIT (1 ML)
2 PA LA
INTRON A INJECTION SOLUTION 10 MILLION UNITML 6 MILLION UNITML
2 PA LA
PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT
MB LA
VACCINES amp MISCELLANEOUS IMMUNOLOGICALS
ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(25-5-3-5 MCG)-5LF05 ML
1 Vac
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(25-5-3-5 MCG)-5LF05 ML
1 Vac
ASCENIV INTRAVENOUS SOLUTION 10 MB PA LA
ATGAM INTRAVENOUS SOLUTION 50 MGML
MB
BCG VACCINE LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG
1 Vac
BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG05 ML
1 Vac
BIOTHRAX INTRAMUSCULAR SUSPENSION 05 MLDOSE
1 Vac
BIVIGAM INTRAVENOUS SOLUTION 10 MB PA LA
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 25-8-5 LF-MCG-LF05ML
1 Vac
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 25-8-5 LF-MCG-LF05ML
1 Vac
BOTOX INJECTION RECON SOLN 100 UNIT 200 UNIT
MB
CUTAQUIG SUBCUTANEOUS SOLUTION 165
MB LA
CUVITRU SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 ) 8 GRAM40 ML (20 )
MB LA
91
Drug Name Drug Tier Requirements Limits
DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF05ML
1 Vac
DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT 500 UNIT
MB LA
ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCGML
1 Vac
ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCGML
1 Vac
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG05 ML
1 Vac
FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 5
MB PA
GAMASTAN INTRAMUSCULAR SOLUTION 15-18 RANGE
MB
GAMASTAN SD INTRAMUSCULAR SOLUTION 15-18 RANGE
MB
GAMMAGARD LIQUID INJECTION SOLUTION 10
MB LA
GAMMAGARD S-D (IGA lt 1 MCGML) INTRAVENOUS RECON SOLN 10 GRAM 5 GRAM
MB PA LA
GAMMAKED INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 20 GRAM200 ML (10 ) 5 GRAM50 ML (10 )
MB LA
GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5
MB PA LA
GAMMAPLEX INTRAVENOUS SOLUTION 10
MB PA LA
GAMUNEX-C INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 25 GRAM25 ML (10 ) 20 GRAM200 ML (10 ) 40 GRAM400 ML (10 ) 5 GRAM50 ML (10 )
MB LA
GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 05 ML
1 Vac
GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 05 ML
1 Vac
GRASTEK SUBLINGUAL TABLET 2800 BAU 1 PA
HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1440 ELISA UNITML
1 Vac
92
Drug Name Drug Tier Requirements Limits
HAVRIX (PF) INTRAMUSCULAR SYRINGE 1440 ELISA UNITML 720 ELISA UNIT05 ML
1 Vac
HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE 20 MCG05 ML
1 Vac
HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )
MB LA
HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM 100 ML (10 ) 25 GRAM 25 ML (10 ) 20 GRAM 200 ML (10 ) 30 GRAM 300 ML (10 ) 5 GRAM 50 ML (10 )
MB LA
IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 25 UNIT
1 Vac
INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF05ML
1 Vac
IPOL INJECTION SUSPENSION 40-8-32 UNIT05 ML
1 Vac
IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG05 ML
1 Vac
KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF05 ML
1 Vac
MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG05 ML
1 Vac
MENQUADFI (PF) INTRAMUSCULAR SOLUTION 10 MCG05 ML
1 Vac
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG05 ML
1 Vac
M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1000-12500 TCID5005 ML
1 Vac
MYOBLOC INTRAMUSCULAR SOLUTION 10000 UNIT2 ML 2500 UNIT05 ML 5000 UNITML
MB LA
OCTAGAM INTRAVENOUS SOLUTION 10 5
MB PA LA
ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY
2 PA
PANZYGA INTRAVENOUS SOLUTION 10 MB PA
PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF05 ML
1 Vac
93
Drug Name Drug Tier Requirements Limits
PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 75 MCG05 ML
1 Vac
PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF05 ML 15LF-48MCG-62DU -10 MCG05ML
1 Vac
PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
PNEUMOVAX-23 INJECTION SOLUTION 25 MCG05 ML
1 Vac
PNEUMOVAX-23 INJECTION SYRINGE 25 MCG05 ML
1 Vac
PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE 05 ML
1 Vac
PRIVIGEN INTRAVENOUS SOLUTION 10 MB PA LA
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-43-3- 399 TCID5005
1 Vac
PROVENGE INTRAVENOUS SUSPENSION 50 MILLION CELL250 ML
MB PA
QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT05ML
1 Vac
RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 25 UNIT
1 Vac
RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT
1 PA
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCGML 40 MCGML 5 MCG05 ML
1 Vac
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCGML 5 MCG05 ML
1 Vac
SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG05 ML
1 Vac
STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1000 UNIT05 ML
1 Vac
TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF UNIT05 ML
1 Vac
94
Drug Name Drug Tier Requirements Limits
TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT05ML
1 Vac
TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT05 ML
1 Vac
TETANUSDIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT05 ML
1 Vac
THYMOGLOBULIN INTRAVENOUS RECON SOLN 25 MG
MB
TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG05 ML
1 Vac
TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCGML
1 Vac
TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG05 ML
1 Vac
TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG05 ML
1 Vac
VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT05 ML 50 UNITML
1 Vac
VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT05 ML 50 UNITML
1 Vac
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1350 UNIT05 ML
1 Vac
VAXELIS (PF) INTRAMUSCULAR SUSPENSION 15 UNIT-5 UNIT- 10 MCG05 ML
1 Vac
VAXELIS (PF) INTRAMUSCULAR SYRINGE 15 UNIT-5 UNIT- 10 MCG05 ML
1 Vac
XEMBIFY SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )
MB LA
XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT 200 UNIT 50 UNIT
MB LA
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP474 UNIT05 ML
1 Vac
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19400 UNIT065 ML
1 Vac
MUSCULOSKELETAL amp RHEUMATOLOGY
95
Drug Name Drug Tier Requirements Limits
GOUT THERAPY
allopurinol oral tablet 100 mg 300 mg 1
COLCHICINE ORAL CAPSULE 06 MG 1
colchicine oral tablet 06 mg 1
febuxostat oral tablet 40 mg 80 mg 1
KRYSTEXXA INTRAVENOUS SOLUTION 8 MGML
MB PA LA
MITIGARE ORAL CAPSULE 06 MG 1
probenecid oral tablet 500 mg 1
probenecid-colchicine oral tablet 500-05 mg 1
OSTEOPOROSIS THERAPY
alendronate oral solution 70 mg75 ml 1
alendronate oral tablet 10 mg 35 mg 5 mg 70 mg 1
EVENITY SUBCUTANEOUS SYRINGE 105 MG117 ML 210MG234ML ( 105MG117MLX2)
2 PA ST LA
FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCGDOSE (620MCG248ML)
2 PA ST LA QL (1 per 30 days)
FOSAMAX PLUS D ORAL TABLET 70 MG- 2800 UNIT 70 MG- 5600 UNIT
1
ibandronate oral tablet 150 mg 1
PROLIA SUBCUTANEOUS SYRINGE 60 MGML
2 ST LA
raloxifene oral tablet 60 mg 2 OCh
risedronate oral tablet 150 mg 35 mg 5 mg 1
risedronate oral tabletdelayed release (drec) 35 mg
1
TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3120 MCG156 ML)
2 PA ST LA
OTHER RHEUMATOLOGICALS
ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG09 ML
2 PA ST LA
ACTEMRA INTRAVENOUS SOLUTION 200 MG10 ML (20 MGML) 400 MG20 ML (20 MGML) 80 MG4 ML (20 MGML)
MB PA LA
ACTEMRA SUBCUTANEOUS SYRINGE 162 MG09 ML
2 PA ST LA
96
Drug Name Drug Tier Requirements Limits
BENLYSTA INTRAVENOUS RECON SOLN 120 MG 400 MG
MB PA LA
BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MGML
2 PA LA
BENLYSTA SUBCUTANEOUS SYRINGE 200 MGML
2 PA LA
ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MGML (1 ML)
2 PA ST LA
ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)
2 PA ST LA
ENBREL SUBCUTANEOUS SOLUTION 25 MG05 ML
2 PA ST LA
ENBREL SUBCUTANEOUS SYRINGE 25 MG05 ML (05) 50 MGML (1 ML)
2 PA ST LA
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MGML (1 ML)
2 PA ST LA
HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG08 ML
2 PA ST LA
HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG08 ML 80 MG08 ML-40 MG04 ML
2 PA ST LA
HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
2 PA ST LA
HUMIRA(CF) PEN PEDIATRIC UC SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
2 PA ST LA
HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML-40 MG04 ML
2 PA ST LA
HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG04 ML
2 PA ST LA
97
Drug Name Drug Tier Requirements Limits
HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG01 ML 20 MG02 ML 40 MG04 ML
2 PA ST LA
KEVZARA SUBCUTANEOUS PEN INJECTOR 150 MG114 ML 200 MG114 ML
2 PA ST LA
KEVZARA SUBCUTANEOUS SYRINGE 150 MG114 ML 200 MG114 ML
2 PA ST LA
leflunomide oral tablet 10 mg 20 mg 1
OLUMIANT ORAL TABLET 1 MG 2 MG 2 PA ST LA
ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG
MB PA LA
ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MGML
2 PA ST LA
ORENCIA SUBCUTANEOUS SYRINGE 125 MGML 50 MG04 ML 875 MG07 ML
2 PA ST LA
OTEZLA ORAL TABLET 30 MG 2 PA ST LA
OTEZLA STARTER ORAL TABLETSDOSE PACK 10 MG (4)-20 MG (4)-30 MG (47)
2 PA ST LA
penicillamine oral capsule 250 mg 1 PA
penicillamine oral tablet 250 mg 1 PA
RIDAURA ORAL CAPSULE 3 MG 1
RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 MG
2 PA ST LA
SAVELLA ORAL TABLET 100 MG 125 MG 25 MG 50 MG
1 PA ST
SAVELLA ORAL TABLETSDOSE PACK 125 MG (5)-25 MG(8)-50 MG(42)
1 PA ST
SIMPONI ARIA INTRAVENOUS SOLUTION 125 MGML
MB PA LA
SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MGML 50 MG05 ML
2 PA ST LA
SIMPONI SUBCUTANEOUS SYRINGE 100 MGML 50 MG05 ML
2 PA ST LA
XELJANZ ORAL SOLUTION 1 MGML 2 PA ST LA
XELJANZ ORAL TABLET 10 MG 5 MG 2 PA ST LA
XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG 22 MG
2 PA ST LA
OBSTETRICS amp GYNECOLOGY
DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES
98
Drug Name Drug Tier Requirements Limits
CAYA CONTOURED VAGINAL DIAPHRAGM 65-80 MM
ACA PV
FC2 FEMALE CONDOM ACA PV
FEMCAP VAGINAL DEVICE 22 MM ACA PV
KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 175 MCG24 HRS (5 YRS) 195 MG
ACA PV
LILETTA INTRAUTERINE INTRAUTERINE DEVICE 201 MCG24 HRS (6 YRS) 52 MG
ACA PV ST
MIRENA INTRAUTERINE INTRAUTERINE DEVICE 20 MCG24 HOURS (6 YRS) 52 MG
ACA PV
PARAGARD T 380A INTRAUTERINE INTRAUTERINE DEVICE 380 SQUARE MM
ACA PV
SKYLA INTRAUTERINE INTRAUTERINE DEVICE 14 MCG24 HRS (3 YRS) 135 MG
ACA PV
WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 MM
ACA PV
ESTROGENS amp PROGESTINS
amabelz oral tablet 05-01 mg 1-05 mg 1
ANGELIQ ORAL TABLET 025-05 MG 05-1 MG
1
camila oral tablet 035 mg ACA PV
COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 005-014 MG24 HR 005-025 MG24 HR
1
covaryx hs oral tablet 0625-125 mg 1
covaryx oral tablet 125-25 mg 1
CRINONE VAGINAL GEL 4 1
deblitane oral tablet 035 mg ACA PV
DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MGML
1
DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MGML
MB
DEPO-PROVERA INTRAMUSCULAR SYRINGE 150 MGML
MB
DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE 104 MG065 ML
ACA PV
99
Drug Name Drug Tier Requirements Limits
DIVIGEL TRANSDERMAL GEL IN PACKET 025 MG025 GRAM (01 ) 05 MG05 GRAM (01 ) 075 MG075 GRAM (01) 1 MGGRAM (01 ) 125 MG125 GRAM (01 )
1 QL (30 per 30 days)
dotti transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
DUAVEE ORAL TABLET 045-20 MG 1
eemt hs oral tablet 0625-125 mg 1
eemt oral tablet 125-25 mg 1
errin oral tablet 035 mg ACA PV
estradiol oral tablet 05 mg 1 mg 2 mg 1
estradiol transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
estradiol transdermal patch weekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 006 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (4 per 30 days)
estradiol vaginal cream 001 (01 mggram) 1
estradiol vaginal tablet 10 mcg 1
estradiol valerate intramuscular oil 20 mgml 40 mgml
1
estradiol-norethindrone acet oral tablet 05-01 mg 1-05 mg
1
ESTRING VAGINAL RING 2 MG (75 MCG 24 HOUR)
1
estrogens-methyltestosterone oral tablet 0625-125 mg 125-25 mg
1
EVAMIST TRANSDERMAL SPRAYNON-AEROSOL 153 MGSPRAY (17)
1 QL (2 per 30 days)
FEMRING VAGINAL RING 005 MG24 HR 01 MG24 HR
1
fyavolv oral tablet 05-25 mg-mcg 1-5 mg-mcg 1
heather oral tablet 035 mg ACA PV
hydroxyprogest(pf)(preg presv) intramuscular oil 250 mgml (1 ml)
2
hydroxyprogesterone cap(ppres) intramuscular oil 250 mgml
2
100
Drug Name Drug Tier Requirements Limits
hydroxyprogesterone caproate intramuscular oil 250 mgml
2
incassia oral tablet 035 mg ACA PV
jencycla oral tablet 035 mg ACA PV
jinteli oral tablet 1-5 mg-mcg 1
lyleq oral tablet 035 mg ACA PV
lyllana transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
lyza oral tablet 035 mg ACA PV
medroxyprogesterone intramuscular suspension 150 mgml
ACA PV
medroxyprogesterone intramuscular syringe 150 mgml
ACA PV
medroxyprogesterone oral tablet 10 mg 25 mg 5 mg
1
MENEST ORAL TABLET 03 MG 0625 MG 125 MG 25 MG
1
MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG24 HR
1 QL (4 per 30 days)
mimvey oral tablet 1-05 mg 1
nora-be oral tablet 035 mg ACA PV
norethindrone (contraceptive) oral tablet 035 mg ACA PV
norethindrone acetate oral tablet 5 mg 1
norethindrone ac-eth estradiol oral tablet 05-25 mg-mcg 1-5 mg-mcg
1
norlyda oral tablet 035 mg ACA PV
PREMARIN INJECTION RECON SOLN 25 MG 1
PREMARIN ORAL TABLET 03 MG 045 MG 0625 MG 09 MG 125 MG
1
PREMARIN VAGINAL CREAM 0625 MGGRAM
1
PREMPHASE ORAL TABLET 0625 MG (14) 0625MG-5MG(14)
1
PREMPRO ORAL TABLET 03-15 MG 045-15 MG 0625-25 MG 0625-5 MG
1
progesterone intramuscular oil 50 mgml 1
progesterone micronized oral capsule 100 mg 200 mg
1
101
Drug Name Drug Tier Requirements Limits
sharobel oral tablet 035 mg ACA PV
tulana oral tablet 035 mg ACA PV
yuvafem vaginal tablet 10 mcg 1
MISCELLANEOUS OBGYN
ANNOVERA VAGINAL RING 015-0013 MG24 HOUR
ACA PV
clindamycin phosphate vaginal cream 2 1
eluryng vaginal ring 012-0015 mg24 hr ACA PV
etonogestrel-ethinyl estradiol vaginal ring 012-0015 mg24 hr
ACA PV
fem ph vaginal gel 09-0025 1
GYNAZOLE-1 VAGINAL CREAM 2 1
gynol ii vaginal gel 3 ACA PV
INTRAROSA VAGINAL INSERT 65 MG 1
isoxsuprine oral tablet 10 mg 20 mg 1
LUPANETA PACK (1 MONTH) KIT SYRINGE AND TABLET 375 MG -5 MG (30)
2 LA
LUPANETA PACK (3 MONTH) KIT SYRINGE AND TABLET 1125 MG -5 MG (90)
2 LA
metronidazole vaginal gel 075 1
NEXPLANON SUBDERMAL IMPLANT 68 MG ACA PV
OSPHENA ORAL TABLET 60 MG 1
PHEXXI VAGINAL GEL 18-1-04 ACA PV
terconazole vaginal cream 04 08 1
terconazole vaginal suppository 80 mg 1
TODAY CONTRACEPTIVE SPONGE VAGINAL CONTRACEPTIVE SPONGE 1000 MG
ACA PV
tranexamic acid oral tablet 650 mg 1
TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 MCG24 HR
ACA PV
vaginal contraceptive foam vaginal foam 125 ACA PV
vandazole vaginal gel 075 1
VCF CONTRACEPTIVE FILM VAGINAL FILM 28
ACA PV
VCF CONTRACEPTIVE GEL VAGINAL GEL 4
ACA PV
102
Drug Name Drug Tier Requirements Limits
xulane transdermal patch weekly 150-35 mcg24 hr
ACA PV
zafemy transdermal patch weekly 150-35 mcg24 hr
ACA PV
ORAL CONTRACEPTIVES amp RELATED AGENTS
afirmelle oral tablet 01-20 mg-mcg ACA PV
altavera (28) oral tablet 015-003 mg ACA PV
alyacen 135 (28) oral tablet 1-35 mg-mcg ACA PV
alyacen 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
amethia oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
amethyst (28) oral tablet 90-20 mcg (28) ACA PV
apri oral tablet 015-003 mg ACA PV
aranelle (28) oral tablet 05105-35 mg-mcg ACA PV
ashlyna oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
aubra eq oral tablet 01-20 mg-mcg ACA PV
aubra oral tablet 01-20 mg-mcg ACA PV
aurovela 1530 (21) oral tablet 15-30 mg-mcg ACA PV
aurovela 120 (21) oral tablet 1-20 mg-mcg ACA PV
aurovela 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
aurovela fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
aurovela fe 1-20 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
aviane oral tablet 01-20 mg-mcg ACA PV
ayuna oral tablet 015-003 mg ACA PV
azurette (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
BALCOLTRA ORAL TABLET 01 MG-002 MG (21)365 MG(7)
ACA PV
balziva (28) oral tablet 04-35 mg-mcg ACA PV
blisovi 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
blisovi fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
103
Drug Name Drug Tier Requirements Limits
blisovi fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
briellyn oral tablet 04-35 mg-mcg ACA PV
camrese lo oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)
ACA PV
camrese oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
caziant (28) oral tablet 0112515-25 mg-mcg ACA PV
charlotte 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
chateal (28) oral tablet 015-003 mg ACA PV
chateal eq (28) oral tablet 015-003 mg ACA PV
cryselle (28) oral tablet 03-30 mg-mcg ACA PV
cyclafem 135 (28) oral tablet 1-35 mg-mcg ACA PV
cyclafem 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
cyred eq oral tablet 015-003 mg ACA PV
cyred oral tablet 015-003 mg ACA PV
dasetta 135 (28) oral tablet 1-35 mg-mcg ACA PV
dasetta 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
daysee oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
desog-eestradioleestradiol oral tablet 015-002 mgx21 001 mg x 5
ACA PV
desogestrel-ethinyl estradiol oral tablet 015-003 mg
ACA PV
dolishale oral tablet 90-20 mcg (28) ACA PV
drospirenone-eestradiol-lmfa oral tablet 3-002-0451 mg (24) (4) 3-003-0451 mg (21) (7)
ACA PV
drospirenone-ethinyl estradiol oral tablet 3-002 mg 3-003 mg
ACA PV
econtra ez oral tablet 15 mg ACA PV
econtra one-step oral tablet 15 mg ACA PV
elinest oral tablet 03-30 mg-mcg ACA PV
ELLA ORAL TABLET 30 MG ACA PV
emoquette oral tablet 015-003 mg ACA PV
104
Drug Name Drug Tier Requirements Limits
enpresse oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
enskyce oral tablet 015-003 mg ACA PV
estarylla oral tablet 025-35 mg-mcg ACA PV
ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg 1-50 mg-mcg
ACA PV
falmina (28) oral tablet 01-20 mg-mcg ACA PV
fayosim oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg
ACA PV
femynor oral tablet 025-35 mg-mcg ACA PV
gemmily oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV
hailey 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
hailey fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
hailey fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
hailey oral tablet 15-30 mg-mcg ACA PV
iclevia oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
isibloom oral tablet 015-003 mg ACA PV
jaimiess oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
jasmiel (28) oral tablet 3-002 mg ACA PV
jolessa oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
juleber oral tablet 015-003 mg ACA PV
junel 1530 (21) oral tablet 15-30 mg-mcg ACA PV
junel 120 (21) oral tablet 1-20 mg-mcg ACA PV
junel fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
junel fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
junel fe 24 oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV
kaitlib fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)
ACA PV
kalliga oral tablet 015-003 mg ACA PV
kariva (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
105
Drug Name Drug Tier Requirements Limits
kelnor 135 (28) oral tablet 1-35 mg-mcg ACA PV
kelnor 1-50 (28) oral tablet 1-50 mg-mcg ACA PV
kurvelo (28) oral tablet 015-003 mg ACA PV
l norgesteestradiol-eestrad oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7) 015 mg-20 mcg 015 mg-25 mcg 015 mg-30 mcg (84)10 mcg (7)
ACA PV
larin 1530 (21) oral tablet 15-30 mg-mcg ACA PV
larin 120 (21) oral tablet 1-20 mg-mcg ACA PV
larin 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV
larin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
larin fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
larissia oral tablet 01-20 mg-mcg ACA PV
layolis fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)
ACA PV
leena 28 oral tablet 05105-35 mg-mcg ACA PV
lessina oral tablet 01-20 mg-mcg ACA PV
levonest (28) oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
levonorgestrel oral tablet 15 mg ACA PV
levonorgestrel-ethinyl estrad oral tablet 01-20 mg-mcg 015-003 mg 90-20 mcg (28)
ACA PV
levonorgestrel-ethinyl estrad oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
levonorg-eth estrad triphasic oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
levora-28 oral tablet 015-003 mg ACA PV
lillow (28) oral tablet 015-003 mg ACA PV
LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG (24)10 MCG (2)
ACA PV
lojaimiess oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)
ACA PV
loryna (28) oral tablet 3-002 mg ACA PV
low-ogestrel (28) oral tablet 03-30 mg-mcg ACA PV
lo-zumandimine (28) oral tablet 3-002 mg ACA PV
lutera (28) oral tablet 01-20 mg-mcg ACA PV
106
Drug Name Drug Tier Requirements Limits
marlissa (28) oral tablet 015-003 mg ACA PV
merzee oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV
mibelas 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
microgestin 1530 (21) oral tablet 15-30 mg-mcg ACA PV
microgestin 120 (21) oral tablet 1-20 mg-mcg ACA PV
microgestin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
microgestin fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
mili oral tablet 025-35 mg-mcg ACA PV
mono-linyah oral tablet 025-35 mg-mcg ACA PV
my choice oral tablet 15 mg ACA PV
my way oral tablet 15 mg ACA PV
NATAZIA ORAL TABLET 3 MG2 MG-2 MG 2 MG-3 MG1 MG
ACA PV
necon 0535 (28) oral tablet 05-35 mg-mcg ACA PV
new day oral tablet 15 mg ACA PV
NEXTSTELLIS ORAL TABLET 3 MG- 142 MG (28)
ACA PV
nikki (28) oral tablet 3-002 mg ACA PV
noreth-ethinyl estradiol-iron oral tabletchewable 04mg-35mcg(21) and 75 mg (7) 08mg-25mcg(24) and 75 mg (4)
ACA PV
norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg 15-30 mg-mcg
ACA PV
norethindrone-eestradiol-iron oral capsule 1 mg-20 mcg (24)75 mg (4)
ACA PV
norethindrone-eestradiol-iron oral tablet 1 mg-20 mcg (21)75 mg (7) 15 mg-30 mcg (21)75 mg (7)
ACA PV
norethindrone-eestradiol-iron oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
norgestimate-ethinyl estradiol oral tablet 0180215025 mg-25 mcg 0180215025 mg-35 mcg (28) 025-35 mg-mcg
ACA PV
nortrel 0535 (28) oral tablet 05-35 mg-mcg ACA PV
nortrel 135 (21) oral tablet 1-35 mg-mcg (21) ACA PV
nortrel 135 (28) oral tablet 1-35 mg-mcg ACA PV
107
Drug Name Drug Tier Requirements Limits
nortrel 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
nylia 777 (28) oral tablet 050751 mg- 35 mcg ACA PV
nymyo oral tablet 025-35 mg-mcg ACA PV
ocella oral tablet 3-003 mg ACA PV
opcicon one-step oral tablet 15 mg ACA PV
option-2 oral tablet 15 mg ACA PV
orsythia oral tablet 01-20 mg-mcg ACA PV
philith oral tablet 04-35 mg-mcg ACA PV
pimtrea (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
pirmella oral tablet 050751 mg- 35 mcg 1-35 mg-mcg
ACA PV
portia 28 oral tablet 015-003 mg ACA PV
previfem oral tablet 025-35 mg-mcg ACA PV
reclipsen (28) oral tablet 015-003 mg ACA PV
rivelsa oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg
ACA PV
setlakin oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
simliya (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
simpesse oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
SLYND ORAL TABLET 4 MG (28) ACA PV
sprintec (28) oral tablet 025-35 mg-mcg ACA PV
sronyx oral tablet 01-20 mg-mcg ACA PV
syeda oral tablet 3-003 mg ACA PV
tarina 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
tarina fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
tilia fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9) ACA PV
tri femynor oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-estarylla oral tablet 0180215025 mg-35 mcg (28)
ACA PV
108
Drug Name Drug Tier Requirements Limits
tri-legest fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9)
ACA PV
tri-linyah oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-lo-estarylla oral tablet 0180215025 mg-25 mcg
ACA PV
tri-lo-marzia oral tablet 0180215025 mg-25 mcg
ACA PV
tri-lo-mili oral tablet 0180215025 mg-25 mcg ACA PV
tri-lo-sprintec oral tablet 0180215025 mg-25 mcg
ACA PV
tri-mili oral tablet 0180215025 mg-35 mcg (28) ACA PV
tri-nymyo oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-previfem (28) oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-sprintec (28) oral tablet 0180215025 mg-35 mcg (28)
ACA PV
trivora (28) oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
tri-vylibra lo oral tablet 0180215025 mg-25 mcg
ACA PV
tri-vylibra oral tablet 0180215025 mg-35 mcg (28)
ACA PV
TYBLUME ORAL TABLETCHEWABLE 01 MG- 20 MCG
ACA PV
tydemy oral tablet 3-003-0451 mg (21) (7) ACA PV
velivet triphasic regimen (28) oral tablet 0112515-25 mg-mcg
ACA PV
vestura (28) oral tablet 3-002 mg ACA PV
vienva oral tablet 01-20 mg-mcg ACA PV
viorele (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
volnea (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
vyfemla (28) oral tablet 04-35 mg-mcg ACA PV
vylibra oral tablet 025-35 mg-mcg ACA PV
wera (28) oral tablet 05-35 mg-mcg ACA PV
wymzya fe oral tabletchewable 04mg-35mcg(21) and 75 mg (7)
ACA PV
109
Drug Name Drug Tier Requirements Limits
zarah oral tablet 3-003 mg ACA PV
zovia 135e (28) oral tablet 1-35 mg-mcg ACA PV
zumandimine (28) oral tablet 3-003 mg ACA PV
OXYTOCICS
methergine oral tablet 02 mg 1
methylergonovine oral tablet 02 mg 1
OPHTHALMOLOGY
ANTIBIOTICS
ak-poly-bac ophthalmic (eye) ointment 500-10000 unitgram
1
AZASITE OPHTHALMIC (EYE) DROPS 1 1
bacitracin ophthalmic (eye) ointment 500 unitgram
1
bacitracin-polymyxin b ophthalmic (eye) ointment 500-10000 unitgram
1
BESIVANCE OPHTHALMIC (EYE) DROPSSUSPENSION 06
1
ciprofloxacin hcl ophthalmic (eye) drops 03 1
erythromycin ophthalmic (eye) ointment 5 mggram (05 )
1
gatifloxacin ophthalmic (eye) drops 05 1
gentak ophthalmic (eye) ointment 03 (3 mggram)
1
gentamicin ophthalmic (eye) drops 03 1
levofloxacin ophthalmic (eye) drops 05 1
moxifloxacin ophthalmic (eye) drops 05 1
moxifloxacin ophthalmic (eye) drops viscous 05
1
NATACYN OPHTHALMIC (EYE) DROPSSUSPENSION 5
1
neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
1
neomycin-polymyxin-gramicidin ophthalmic (eye) drops 175 mg-10000 unit-0025mgml
1
neo-polycin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
1
ofloxacin ophthalmic (eye) drops 03 1
110
Drug Name Drug Tier Requirements Limits
polycin ophthalmic (eye) ointment 500-10000 unitgram
1
polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10000 unit- 1 mgml
1
tobramycin ophthalmic (eye) drops 03 1
TOBREX OPHTHALMIC (EYE) OINTMENT 03
1
ANTIVIRALS
trifluridine ophthalmic (eye) drops 1 1
ZIRGAN OPHTHALMIC (EYE) GEL 015 1
BETA-BLOCKERS
betaxolol ophthalmic (eye) drops 05 1
BETIMOL OPHTHALMIC (EYE) DROPS 025 05
1
BETOPTIC S OPHTHALMIC (EYE) DROPSSUSPENSION 025
1
carteolol ophthalmic (eye) drops 1 1
levobunolol ophthalmic (eye) drops 05 1
timolol maleate ophthalmic (eye) drops 025 05
1
timolol maleate ophthalmic (eye) drops once daily 05
1
timolol maleate ophthalmic (eye) gel forming solution 025 05
1
CYCLOPLEGIC MYDRIATICS
atropine ophthalmic (eye) drops 1 1
atropine ophthalmic (eye) ointment 1 1
cyclopentolate ophthalmic (eye) drops 05 1 2
1
homatropaire ophthalmic (eye) drops 5 1
tropicamide ophthalmic (eye) drops 05 1 1
DIRECT ACTING MIOTICS
pilocarpine hcl ophthalmic (eye) drops 1 2 4
1
MISCELLANEOUS OPHTHALMOLOGICS
ALOCRIL OPHTHALMIC (EYE) DROPS 2 1 ST
ALOMIDE OPHTHALMIC (EYE) DROPS 01 1 ST
111
Drug Name Drug Tier Requirements Limits
altacaine ophthalmic (eye) drops 05 1
azelastine ophthalmic (eye) drops 005 1
BEOVU INTRAVITREAL SOLUTION 6 MG005 ML
MB PA LA
bepotastine besilate ophthalmic (eye) drops 15 1 ST
BEPREVE OPHTHALMIC (EYE) DROPS 15 1 ST
cromolyn ophthalmic (eye) drops 4 1
CYSTARAN OPHTHALMIC (EYE) DROPS 044
2 PA
epinastine ophthalmic (eye) drops 005 1
EYLEA INTRAVITREAL SOLUTION 2 MG005 ML
MB PA LA
EYLEA INTRAVITREAL SYRINGE 2 MG005 ML
MB PA LA
LACRISERT OPHTHALMIC (EYE) INSERT 5 MG
1
LASTACAFT OPHTHALMIC (EYE) DROPS 025
1 ST
LUCENTIS INTRAVITREAL SOLUTION 03 MG005 ML 05 MG005 ML
MB PA LA
LUCENTIS INTRAVITREAL SYRINGE 03 MG005 ML 05 MG005 ML
MB PA LA
LUXTURNA SUBRETINAL SUSPENSION 15 X 10EXP11 VG03 ML (FNL)
MB LA
olopatadine ophthalmic (eye) drops 01 02 1
OMIDRIA INTRAOCULAR CONCENTRATE 1-03
MB
proparacaine ophthalmic (eye) drops 05 1
RESTASIS OPHTHALMIC (EYE) DROPPERETTE 005
1 QL (120 per 30 days)
TETRACAINE HCL (PF) OPHTHALMIC (EYE) DROPS 05
1
tetracaine hcl ophthalmic (eye) drops 05 1
VISUDYNE INTRAVENOUS RECON SOLN 15 MG
MB LA
XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5
1 PA ST QL (60 per 30 days)
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
112
Drug Name Drug Tier Requirements Limits
ACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE 045
1 ST
bromfenac ophthalmic (eye) drops 009 1
diclofenac sodium ophthalmic (eye) drops 01 1
flurbiprofen sodium ophthalmic (eye) drops 003
1
ketorolac ophthalmic (eye) drops 04 05 1
NEVANAC OPHTHALMIC (EYE) DROPSSUSPENSION 01
1
ORAL DRUGS FOR GLAUCOMA
acetazolamide oral capsule extended release 500 mg
1
acetazolamide oral tablet 125 mg 250 mg 1
methazolamide oral tablet 25 mg 50 mg 1
OTHER GLAUCOMA DRUGS
bimatoprost ophthalmic (eye) drops 003 1
brinzolamide ophthalmic (eye) dropssuspension 1
1
COMBIGAN OPHTHALMIC (EYE) DROPS 02-05
1
dorzolamide ophthalmic (eye) drops 2 1
dorzolamide-timolol (pf) ophthalmic (eye) dropperette 2-05
1
dorzolamide-timolol ophthalmic (eye) drops 223-68 mgml
1
latanoprost ophthalmic (eye) drops 0005 1
LUMIGAN OPHTHALMIC (EYE) DROPS 001
1 ST
RHOPRESSA OPHTHALMIC (EYE) DROPS 002
1 PA ST
SIMBRINZA OPHTHALMIC (EYE) DROPSSUSPENSION 1-02
1
travoprost ophthalmic (eye) drops 0004 1
STEROID-ANTIBIOTIC COMBINATIONS
neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
1
neomycin-polymyxin b-dexameth ophthalmic (eye) dropssuspension 35mgml-10000 unitml-01
1
113
Drug Name Drug Tier Requirements Limits
neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 35 mgg-10000 unitg-01
1
neomycin-polymyxin-hc ophthalmic (eye) dropssuspension 35-10000-10 mg-unit-mgml
1
neo-polycin hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
1
TOBRADEX OPHTHALMIC (EYE) OINTMENT 03-01
1
TOBRADEX ST OPHTHALMIC (EYE) DROPSSUSPENSION 03-005
1
tobramycin-dexamethasone ophthalmic (eye) dropssuspension 03-01
1
STEROIDS
ALREX OPHTHALMIC (EYE) DROPSSUSPENSION 02
1 ST
dexamethasone sodium phosphate ophthalmic (eye) drops 01
1
DUREZOL OPHTHALMIC (EYE) DROPS 005
1
fluorometholone ophthalmic (eye) dropssuspension 01
1
FML FORTE OPHTHALMIC (EYE) DROPSSUSPENSION 025
1
FML SOP OPHTHALMIC (EYE) OINTMENT 01
1
INVELTYS OPHTHALMIC (EYE) DROPSSUSPENSION 1
1 ST
LOTEMAX OPHTHALMIC (EYE) OINTMENT 05
1 ST
loteprednol etabonate ophthalmic (eye) dropsgel 05
1
loteprednol etabonate ophthalmic (eye) dropssuspension 05
1
MAXIDEX OPHTHALMIC (EYE) DROPSSUSPENSION 01
1
OZURDEX INTRAVITREAL IMPLANT 07 MG MB LA
PRED MILD OPHTHALMIC (EYE) DROPSSUSPENSION 012
1
prednisolone acetate ophthalmic (eye) dropssuspension 1
1
114
Drug Name Drug Tier Requirements Limits
prednisolone sodium phosphate ophthalmic (eye) drops 1
1
RETISERT INTRAVITREAL IMPLANT 059 MG
MB LA
YUTIQ INTRAVITREAL IMPLANT 018 MG MB
STEROID-SULFONAMIDE COMBINATIONS
BLEPHAMIDE OPHTHALMIC (EYE) DROPSSUSPENSION 10-02
1
BLEPHAMIDE SOP OPHTHALMIC (EYE) OINTMENT 10-02
1
sulfacetamide-prednisolone ophthalmic (eye) drops 10 -023 (025 )
1
SULFONAMIDES
sulfacetamide sodium ophthalmic (eye) drops 10
1
sulfacetamide sodium ophthalmic (eye) ointment 10
1
SYMPATHOMIMETICS
apraclonidine ophthalmic (eye) drops 05 1
brimonidine ophthalmic (eye) drops 015 02 1
IOPIDINE OPHTHALMIC (EYE) DROPPERETTE 1
1
VASOCONSTRICTOR DECONGESTANTS
phenylephrine hcl ophthalmic (eye) drops 10 25
1
RESPIRATORY ALLERGY COUGH amp COLD
ANTIHISTAMINE amp ANTIALLERGENIC AGENTS
adrenalin injection solution 1 mgml 1 mgml (1 ml)
1
carbinoxamine maleate oral liquid 4 mg5 ml 1 PA ST QL (2 per 30 days)
carbinoxamine maleate oral tablet 4 mg 1 PA ST QL (240 per 30 days)
carbinoxamine maleate oral tablet 6 mg 1 PA ST QL (120 per 30 days)
cetirizine oral solution 1 mgml 1
clemastine oral syrup 05 mg5 ml 1
clemastine oral tablet 268 mg 1
cyproheptadine oral syrup 2 mg5 ml 1
cyproheptadine oral tablet 4 mg 1
115
Drug Name Drug Tier Requirements Limits
desloratadine oral tablet 5 mg 1 PA ST QL (30 per 30 days)
desloratadine oral tabletdisintegrating 25 mg 5 mg
1 PA ST
diphenhydramine hcl injection solution 50 mgml 1
diphenhydramine hcl injection syringe 50 mgml MB
EPINEPHRINE INJECTION AUTO-INJECTOR 015 MG015 ML
1
epinephrine injection auto-injector 015 mg03 ml 03 mg03 ml
1
epinephrine injection solution 1 mgml 1 mgml (1 ml)
1
epinephrine injection syringe 01 mgml 1
hydroxyzine hcl intramuscular solution 25 mgml MB
hydroxyzine hcl oral solution 10 mg5 ml 1
hydroxyzine hcl oral tablet 10 mg 25 mg 50 mg 1
hydroxyzine pamoate oral capsule 100 mg 25 mg 50 mg
1
levocetirizine oral solution 25 mg5 ml 1
levocetirizine oral tablet 5 mg 1
promethazine injection solution 25 mgml MB
promethazine oral syrup 625 mg5 ml 1
promethazine oral tablet 125 mg 25 mg 50 mg 1
promethazine rectal suppository 125 mg 25 mg 1
promethegan rectal suppository 125 mg 25 mg 50 mg
1
COUGH amp COLD THERAPY
benzonatate oral capsule 100 mg 150 mg 200 mg 1
brompheniramine-pseudoeph-dm oral syrup 2-30-10 mg5 ml
1
codeine-guaifenesin oral liquid 10-100 mg5 ml 1
g tussin ac oral liquid 10-100 mg5 ml 1
guaiatussin ac oral liquid 10-100 mg5 ml 1
hydrocodone-chlorpheniramine oral suspensionextended rel 12 hr 10-8 mg5 ml
1
hydrocodone-homatropine oral syrup 5-15 mg5 ml
1
hydrocodone-homatropine oral tablet 5-15 mg 1
116
Drug Name Drug Tier Requirements Limits
hydromet oral syrup 5-15 mg5 ml 1
maxi-tuss ac oral liquid 10-100 mg5 ml 1
m-clear wc oral liquid 63-100 mg5 ml 1
promethazine-codeine oral syrup 625-10 mg5 ml 1
promethazine-dm oral syrup 625-15 mg5 ml 1
promethazine-phenyleph-codeine oral syrup 625-5-10 mg5 ml
1
promethazine-phenylephrine oral syrup 625-5 mg5 ml
1
virtussin ac oral liquid 10-100 mg5 ml 1
PULMONARY AGENTS
acetylcysteine solution 100 mgml (10 ) 200 mgml (20 )
1
ADEMPAS ORAL TABLET 05 MG 1 MG 15 MG 2 MG 25 MG
2 PA LA
ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCGACTUATION 230-21 MCGACTUATION 45-21 MCGACTUATION
1 QL (1 per 30 days)
ALBUTEROL HFA 90 MCG INHALER 90 MCGACTUATION
1 QL (2 per 30 days)
albuterol sulfate inhalation inhalation hfa aerosol inhaler 90 mcgactuation
1 QL (2 per 30 days)
albuterol sulfate inhalation inhalation solution for nebulization 063 mg3 ml 125 mg3 ml 25 mg 3 ml (0083 ) 25 mg05 ml 5 mgml
1
albuterol sulfate inhalation oral syrup 2 mg5 ml 1
albuterol sulfate inhalation oral tablet 2 mg 4 mg 1
albuterol sulfate inhalation oral tablet extended release 12 hr 4 mg 8 mg
1
ALVESCO INHALATION HFA AEROSOL INHALER 160 MCGACTUATION 80 MCGACTUATION
1 PA ST QL (1 per 30 days)
alyq oral tablet 20 mg 2 PA
ambrisentan oral tablet 10 mg 5 mg 2 PA LA
aminophylline intravenous solution 250 mg10 ml MB
ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 625-25 MCGACTUATION
1 QL (1 per 30 days)
arformoterol inhalation solution for nebulization 15 mcg2 ml
1
117
Drug Name Drug Tier Requirements Limits
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 200 MCGACTUATION
1 QL (1 per 30 days)
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 50 MCGACTUATION
1
ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCGACTUATION
1 QL (2 per 30 days)
BERINERT INTRAVENOUS KIT 500 UNIT (10 ML)
MB PA LA
BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-48 MCG
1
bosentan oral tablet 125 mg 625 mg 2 PA LA
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCGDOSE
1 QL (1 per 30 days)
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 200-25 MCGDOSE
1
BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG2 ML
1
budesonide inhalation suspension for nebulization 025 mg2 ml 05 mg2 ml
1 QL (120 per 30 days)
budesonide inhalation suspension for nebulization 1 mg2 ml
1 QL (60 per 30 days)
CINQAIR INTRAVENOUS SOLUTION 10 MGML
MB PA
CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)
MB PA LA
COMBIVENT RESPIMAT INHALATION MIST 20-100 MCGACTUATION
1 QL (2 per 30 days)
cromolyn inhalation solution for nebulization 20 mg2 ml
1
DALIRESP ORAL TABLET 250 MCG 500 MCG
1
DULERA INHALATION HFA AEROSOL INHALER 100-5 MCGACTUATION 200-5 MCGACTUATION 50-5 MCGACTUATION
1 QL (1 per 30 days)
ELIXOPHYLLIN ORAL ELIXIR 80 MG15 ML 1
ESBRIET ORAL CAPSULE 267 MG 2 PA LA QL (270 per 30 days)
ESBRIET ORAL TABLET 267 MG 801 MG 2 PA LA QL (90 per 30 days)
FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MGML
MB PA LA
118
Drug Name Drug Tier Requirements Limits
FASENRA SUBCUTANEOUS SYRINGE 30 MGML
MB PA LA
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 50 MCGACTUATION
1 QL (1 per 30 days)
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCGACTUATION
1 QL (4 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCGACTUATION 44 MCGACTUATION
1 QL (1 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCGACTUATION
1 QL (2 per 30 days)
fluticasone propionate nasal spraysuspension 50 mcgactuation
1
fluticasone propion-salmeterol inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose
1 QL (1 per 30 days)
formoterol fumarate inhalation solution for nebulization 20 mcg2 ml
1
HAEGARDA SUBCUTANEOUS RECON SOLN 2000 UNIT 3000 UNIT
2 PA LA
icatibant subcutaneous syringe 30 mg3 ml 2 PA
INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 625 MCGACTUATION
1 QL (1 per 30 days)
ipratropium bromide inhalation solution 002 1
ipratropium-albuterol inhalation solution for nebulization 05 mg-3 mg(25 mg base)3 ml
1 QL (180 per 30 days)
KALBITOR SUBCUTANEOUS SOLUTION 10 MGML (1 ML)
2 PA LA
KALYDECO ORAL GRANULES IN PACKET 25 MG 50 MG 75 MG
2 PA LA
KALYDECO ORAL TABLET 150 MG 2 PA LA
levalbuterol hcl inhalation solution for nebulization 031 mg3 ml 063 mg3 ml 125 mg05 ml 125 mg3 ml
1
LEVALBUTEROL TARTRATE INHALATION HFA AEROSOL INHALER 45 MCGACTUATION
1 QL (2 per 30 days)
metaproterenol oral syrup 10 mg5 ml 1
montelukast oral granules in packet 4 mg 1
montelukast oral tablet 10 mg 1
119
Drug Name Drug Tier Requirements Limits
montelukast oral tabletchewable 4 mg 5 mg 1
nebusal inhalation solution for nebulization 3 1
NUCALA SUBCUTANEOUS RECON SOLN 100 MG
MB PA LA
OFEV ORAL CAPSULE 100 MG 150 MG 2 PA LA QL (60 per 30 days)
OPSUMIT ORAL TABLET 10 MG 2 PA LA
ORLADEYO ORAL CAPSULE 110 MG 150 MG
2 PA ST QL (28 per 28 days)
PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG2 ML
1
pulmosal inhalation solution for nebulization 7 1
PULMOZYME INHALATION SOLUTION 1 MGML
2 PA LA
QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCGACTUATION 80 MCGACTUATION
1
REVATIO INTRAVENOUS SOLUTION 10 MG125 ML
MB LA
RUCONEST INTRAVENOUS RECON SOLN 2100 UNIT
MB PA LA
SEEBRI NEOHALER INHALATION CAPSULE WINHALATION DEVICE 156 MCG
1
SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCGDOSE
1
sildenafil (pulmhypertension) intravenous solution 10 mg125 ml
MB
sildenafil (pulmhypertension) oral suspension for reconstitution 10 mgml
2
sildenafil (pulmhypertension) oral tablet 20 mg 2 PA
SINUVA SINUS IMPLANT 1350 MCG MB
sodium chloride inhalation solution for nebulization 09 10 3 7
1
SPIRIVA RESPIMAT INHALATION MIST 125 MCGACTUATION
1
SPIRIVA RESPIMAT INHALATION MIST 25 MCGACTUATION
1 QL (1 per 30 days)
SPIRIVA WITH HANDIHALER INHALATION CAPSULE WINHALATION DEVICE 18 MCG
1 QL (30 per 30 days)
STIOLTO RESPIMAT INHALATION MIST 25-25 MCGACTUATION
1
120
Drug Name Drug Tier Requirements Limits
STRIVERDI RESPIMAT INHALATION MIST 25 MCGACTUATION
1
SYMBICORT INHALATION HFA AEROSOL INHALER 160-45 MCGACTUATION 80-45 MCGACTUATION
1 QL (1 per 30 days)
SYMDEKO ORAL TABLETS SEQUENTIAL 100-150 MG (D) 150 MG (N) 50-75 MG (D) 75 MG (N)
2 PA LA
tadalafil (pulm hypertension) oral tablet 20 mg 2 PA
TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG2 ML (150 MGML)
2 PA LA
terbutaline oral tablet 25 mg 5 mg 1
terbutaline subcutaneous solution 1 mgml 1
theophylline oral elixir 80 mg15 ml 1
theophylline oral solution 80 mg15 ml 1
theophylline oral tablet extended release 12 hr 300 mg 450 mg
1
theophylline oral tablet extended release 24 hr 400 mg 600 mg
1
TRACLEER ORAL TABLET FOR SUSPENSION 32 MG
2 PA LA
TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-625-25 MCG 200-625-25 MCG
1
TRIKAFTA ORAL TABLETS SEQUENTIAL 100-50-75 MG(D) 150 MG (N) 50-25-375 MG (D)75 MG (N)
2 PA LA
TYVASO INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)
2 PA LA
TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)
2 PA LA
TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML
2 PA LA
UTIBRON NEOHALER INHALATION CAPSULE WINHALATION DEVICE 275-156 MCG
1
VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCGML 20 MCGML
2 PA LA
121
Drug Name Drug Tier Requirements Limits
wixela inhub inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose
1 QL (1 per 30 days)
XOLAIR SUBCUTANEOUS RECON SOLN 150 MG
MB LA
XOLAIR SUBCUTANEOUS SYRINGE 150 MGML 75 MG05 ML
MB PA LA QL (7 per 30 days)
zafirlukast oral tablet 10 mg 20 mg 1
zileuton oral tablet er multiphase 12 hr 600 mg 1 ST
ZYFLO ORAL TABLET 600 MG 1 ST
UROLOGICALS
ANTICHOLINERGICS amp ANTISPASMODICS
darifenacin oral tablet extended release 24 hr 15 mg 75 mg
1
flavoxate oral tablet 100 mg 1
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG 50 MG
1 ST
oxybutynin chloride oral syrup 5 mg5 ml 1
oxybutynin chloride oral tablet 5 mg 1
oxybutynin chloride oral tablet extended release 24hr 10 mg 15 mg 5 mg
1
solifenacin oral tablet 10 mg 5 mg 1
tolterodine oral capsuleextended release 24hr 2 mg 4 mg
1
tolterodine oral tablet 1 mg 2 mg 1
trospium oral capsuleextended release 24hr 60 mg
1
trospium oral tablet 20 mg 1
BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY
alfuzosin oral tablet extended release 24 hr 10 mg 1
dutasteride oral capsule 05 mg 1
dutasteride-tamsulosin oral capsule er multiphase 24 hr 05-04 mg
1
finasteride oral tablet 5 mg 1
silodosin oral capsule 4 mg 8 mg 1
tadalafil oral tablet 25 mg 5 mg 1 PA ST
tamsulosin oral capsule 04 mg 1
CHOLINERGIC STIMULANTS
122
Drug Name Drug Tier Requirements Limits
bethanechol chloride oral tablet 10 mg 25 mg 5 mg 50 mg
1
MISCELLANEOUS UROLOGICALS
CYSTAGON ORAL CAPSULE 150 MG 50 MG 2 PA
ELMIRON ORAL CAPSULE 100 MG 1
hyophen oral tablet 816-012-108 mg 1
K-PHOS NO 2 ORAL TABLET 305-700 MG 1
K-PHOS ORIGINAL ORAL TABLETSOLUBLE 500 MG
1
methen-sod phos-meth blue-hyos oral tablet 816-408-012 mg
1
OXLUMO SUBCUTANEOUS SOLUTION 945 MG05 ML
2 PA
phosphasal oral tablet 816-108-408 mg 1
potassium citrate oral tablet extended release 10 meq (1080 mg) 15 meq 5 meq (540 mg)
1
RENACIDIN IRRIGATION SOLUTION 19806 MG-594 MG-9804MG30ML
1
URELLE ORAL TABLET 81-108-408 MG 1
uretron d-s oral tablet 816-108-408 mg 1
urimar-t oral tablet 120-012-108 mg 1
urogesic-blue oral tablet 816-408-012 mg 1
uryl oral tablet 816-408-012 mg 1
ustell oral capsule 120-012 mg 1
utira-c oral tablet 816-108-408 mg 1
URINARY ANESTHETICS
phenazopyridine oral tablet 100 mg 200 mg 1
VITAMINS HEMATINICS amp ELECTROLYTES
ELECTROLYTES
effer-k oral tablet effervescent 25 meq 1
klor-con 10 oral tablet extended release 10 meq 1
klor-con 8 oral tablet extended release 8 meq 1
klor-con m10 oral tableter particlescrystals 10 meq
1
klor-con m15 oral tableter particlescrystals 15 meq
1
123
Drug Name Drug Tier Requirements Limits
klor-con m20 oral tableter particlescrystals 20 meq
1
klor-con oral packet 20 meq 1
klor-conef oral tablet effervescent 25 meq 1
K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ
1
k-tab oral tablet extended release 8 meq 1
NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION
MB
potassium chloride oral capsule extended release 10 meq 8 meq
1
potassium chloride oral liquid 20 meq15 ml 40 meq15 ml
1
potassium chloride oral packet 20 meq 1
potassium chloride oral tablet extended release 10 meq 20 meq 8 meq
1
potassium chloride oral tableter particlescrystals 10 meq 20 meq
1
sodium chloride 045 intravenous parenteral solution 045
MB
MISCELLANEOUS VITAMINS HEMATINICS amp ELECTROLYTES
ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION
MB
PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION
MB
PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION
MB
VITAMINS amp HEMATINICS
cyanocobalamin (vitamin b-12) injection solution 1000 mcgml
1
ergocalciferol (vitamin d2) oral capsule 1250 mcg (50000 unit)
1
FA-8 ORAL CAPSULE 08 MG ACA PV
FER-IN-SOL ORAL DROPS 15 MG IRON (75 MG)ML
ACA PV
FLORIVA (FLUORIDE-VITAMIN D3) ORAL DROPS 025 MG (055 MG)-400 UNITML
ACA PV
fluoride (sodium) oral drops 05 mg (11 mg sodfluorid)ml
ACA PV
124
Drug Name Drug Tier Requirements Limits
fluoride (sodium) oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)
ACA PV
folic acid injection solution 5 mgml 1
folic acid oral tablet 1 mg 1
folic acid oral tablet 400 mcg 800 mcg ACA PV
hydroxocobalamin intramuscular solution 1000 mcgml
1
INFED INJECTION SOLUTION 50 MGML MB
ludent fluoride oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)
ACA PV
multi-vitamin with fluoride oral drops 025 mgml 05 mgml
ACA PV
multi-vitamin with fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
multivitamins with fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
mvc-fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
NOVAFERRUM ORAL DROPS 15 MG IRONML
ACA PV
tri-vitamin with fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml
ACA PV
vitamins acd and fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml
ACA PV
125
Index
A abacavir 2 abacavir-lamivudine 2 abacavir-lamivudine-
zidovudine 2 ABILIFY MAINTENA 36 abiraterone 13 ABRAXANE 13 acamprosate 66 acarbose 77 accutane 59 acebutolol 45 acetaminophen-caff-
dihydrocod 30 acetaminophen-codeine 31 acetazolamide 112 acetic acid 66 69 acetylcysteine 116 acitretin 57 ACTEMRA 95 ACTEMRA ACTPEN 95 ACTHAR 70 ACTHIB (PF) 90 ACTIMMUNE 89 ACUVAIL (PF) 112 acyclovir 2 63 ADACEL(TDAP
ADOLESNADULT)(PF) 90 ADAKVEO 13 adapalene 59 60 ADAPALENE 60 adapalene-benzoyl peroxide 60 ADCETRIS 14 adefovir 2 ADEMPAS 116 ADHANSIA XR 36 adrenalin 114 adult aspirin regimen 33 ADVAIR HFA 116 ADVATE 50 ADYNOVATE 50 ADZENYS ER 36 ADZENYS XR-ODT 36 AEROCHAMBER MINI 71 AEROCHAMBER PLUS
FLOW-VU 71 AFINITOR 14 afirmelle 102
AFSTYLA 50 AIMOVIG AUTOINJECTOR
28 AJOVY AUTOINJECTOR 28 AJOVY SYRINGE 28 ak-poly-bac 109 AKYNZEO (NETUPITANT)
81 ala-cort 63 albendazole 8 albuterol sulfate inhalation 116 ALBUTEROL SULFATE
INHALATION 116 alclometasone 63 ALCORTIN A 61 ALDURAZYME 74 ALECENSA 14 alendronate 95 alfuzosin 121 ALIMTA 14 ALINIA 8 ALIQOPA 14 aliskiren 45 allopurinol 95 almotriptan malate 28 ALOCRIL 110 ALOGLIPTIN-
PIOGLITAZONE 77 ALOMIDE 110 alosetron 81 ALOXI 81 ALPHANATE 50 ALPHANINE SD 50 alprazolam 37 alprazolam intensol 37 ALPROLIX 50 ALREX 113 ALTABAX 61 altacaine 111 altavera (28) 102 ALVESCO 116 alyacen 135 (28) 102 alyacen 777 (28) 102 alyq 116 amabelz 98 amantadine hcl 2 AMBISOME 1 ambrisentan 116
amcinonide 63 amethia 102 amethyst (28) 102 amikacin 8 amiloride 45 amiloride-hydrochlorothiazide
45 aminocaproic acid 50 51 aminophylline 116 amiodarone 44 AMITIZA 81 amitriptyline 37 amitriptyline-chlordiazepoxide
37 amlodipine 45 amlodipine-atorvastatin 55 amlodipine-benazepril 45 amlodipine-olmesartan 45 amlodipine-valsartan 45 amlodipine-valsartan-hcthiazid
45 ammonium lactate 59 amnesteem 60 amoxapine 37 amoxicil-clarithromy-lansopraz
85 amoxicillin 11 amoxicillin-pot clavulanate 11 AMPHETAMINE 37 amphetamine sulfate 37 amphotericin b 1 ampicillin 11 ampicillin-sulbactam 11 anagrelide 66 anaspaz 80 anastrozole 14 ANDEXXA 51 ANDRODERM 74 ANGELIQ 98 ANNOVERA 101 ANORO ELLIPTA 116 anucort-hc 81 apexicon e 63 APLENZIN 37 APOKYN 27 apraclonidine 114 aprepitant 81 apri 102
126
APTIVUS 2 ARALAST NP 66 aranelle (28) 102 ARANESP (IN
POLYSORBATE) 86 ARCALYST 89 ARESTIN 68 arformoterol 116 aripiprazole 37 ARISTADA 37 ARISTADA INITIO 37 armodafinil 37 ARMOUR THYROID 79 ARNUITY ELLIPTA 117 ARRANON 14 ARZERRA 14 ASCENIV 90 ascomp with codeine 31 asenapine maleate 37 ashlyna 102 ASPARLAS 14 aspirin 33 34 aspirin low dose 33 aspirin-dipyridamole 51 aspir-trin 34 atazanavir 2 atenolol 45 atenolol-chlorthalidone 45 ATGAM 90 atomoxetine 37 atorvastatin 55 atovaquone 8 atovaquone-proguanil 8 atropine 80 110 ATROVENT HFA 117 AUBAGIO 87 aubra 102 aubra eq 102 aurovela 1530 (21) 102 aurovela 120 (21) 102 aurovela 24 fe 102 aurovela fe 1530 (28) 102 aurovela fe 1-20 (28) 102 AUSTEDO 29 AVASTIN 14 aviane 102 avidoxy 12 avita 60 AVITA 60 AVONEX 88 AVYCAZ 6
ayuna 102 AZASITE 109 azathioprine 14 azelaic acid 60 azelastine 68 111 AZELEX 60 azithromycin 7 azurette (28) 102 B bacitracin 8 109 bacitracin-polymyxin b 109 baclofen 30 BALCOLTRA 102 balsalazide 81 BALVERSA 14 balziva (28) 102 BANZEL 24 BAQSIMI 71 BARACLUDE 2 BAVENCIO 14 BAXDELA 12 bayer aspirin 34 BAYER CHEWABLE
ASPIRIN 34 BCG VACCINE LIVE (PF) 90 BELEODAQ 14 belladonna alkaloids-opium 80 BELRAPZO 14 BELSOMRA 37 benazepril 45 benazepril-hydrochlorothiazide
45 BENDAMUSTINE 14 BENDEKA 14 BENEFIX 51 BENLYSTA 96 benzonatate 115 benztropine 27 BEOVU 111 bepotastine besilate 111 BEPREVE 111 BERINERT 117 beser 63 BESIVANCE 109 BESPONSA 14 betamethasone dipropionate 63 betamethasone valerate 63 betamethasone augmented 63
64 BETASERON 88 betaxolol 45 110
bethanechol chloride 122 BETIMOL 110 BETOPTIC S 110 BEVESPI AEROSPHERE 117 bexarotene 14 BEXSERO 90 bicalutamide 14 BICILLIN C-R 11 BIKTARVY 2 bimatoprost 112 BIOTHRAX 90 bisoprolol fumarate 45 bisoprolol-hydrochlorothiazide
45 BIVIGAM 90 BLEPHAMIDE 114 BLEPHAMIDE SOP 114 BLINCYTO 14 blisovi 24 fe 102 blisovi fe 1530 (28) 102 blisovi fe 120 (28) 103 BOOSTRIX TDAP 90 BORTEZOMIB 14 bosentan 117 BOSULIF 14 BOTOX 90 BRAFTOVI 14 BREO ELLIPTA 117 briellyn 103 BRILINTA 51 brimonidine 114 BRINEURA 75 brinzolamide 112 BRIVIACT 24 bromfenac 112 bromocriptine 27 brompheniramine-pseudoeph-
dm 115 BROVANA 117 budesonide 81 117 bumetanide 45 buprenorphine 31 buprenorphine hcl 31 buprenorphine-naloxone 34 bupropion hcl 37 38 bupropion hcl (smoking deter)
68 buspirone 38 BUSULFEX 15 butalbital compound wcodeine
31
127
butalbital-acetaminop-caf-cod 31
butalbital-acetaminophen-caff 31
butalbital-aspirin-caffeine 31 butorphanol 34 BYDUREON BCISE 77 BYETTA 77 BYSTOLIC 45 C CABENUVA 2 cabergoline 75 CABLIVI 51 CABOMETYX 15 calcipotriene 57 calcipotriene-betamethasone 57 calcitonin (salmon) 75 calcitriol 57 75 calcium acetate(phosphat bind)
81 CALQUENCE 15 camila 98 camrese 103 camrese lo 103 CANCIDAS 1 candesartan 45 candesartan-hydrochlorothiazid
46 CAPASTAT 8 capecitabine 15 CAPRELSA 15 captopril 46 captopril-hydrochlorothiazide
46 CARBAGLU 66 carbamazepine 24 carbidopa 27 carbidopa-levodopa 27 carbidopa-levodopa-
entacapone 27 carbinoxamine maleate 114 carisoprodol 30 carisoprodol-aspirin 30 carisoprodol-aspirin-codeine 30 carteolol 110 cartia xt 46 carvedilol 46 carvedilol phosphate 46 cataflam 34 CAYA CONTOURED 98 CAYSTON 8
caziant (28) 103 cefaclor 6 cefadroxil 6 cefazolin 6 cefazolin in dextrose (iso-os) 6 cefdinir 6 cefditoren pivoxil 6 cefepime 6 CEFEPIME IN DEXTROSE 5
6 cefepime in dextroseiso-osm 6 cefixime 6 CEFOTAN 6 cefotaxime 6 cefotetan 6 CEFOTETAN IN
DEXTROSE ISO-OSM 6 cefoxitin 6 cefpodoxime 6 7 cefprozil 7 ceftazidime 7 CEFTAZIDIME IN D5W 7 ceftriaxone 7 CEFTRIAXONE 7 ceftriaxone in dextroseiso-os 7 cefuroxime axetil 7 celecoxib 34 CELONTIN 24 cephalexin 7 CERDELGA 75 CEREZYME 75 cetirizine 114 cevimeline 66 CHANTIX 68 CHANTIX CONTINUING
MONTH BOX 68 CHANTIX STARTING
MONTH BOX 68 charlotte 24 fe 103 chateal (28) 103 chateal eq (28) 103 CHEMET 66 childrens aspirin 34 chloramphenicol sod succinate
8 chlordiazepoxide hcl 38 chlordiazepoxide-clidinium 80 chlorhexidine gluconate 68 chloroquine phosphate 8 chlorpromazine 38 chlorthalidone 46
chlorzoxazone 30 CHOLBAM 81 cholestyramine (with sugar) 55 cholestyramine light 55 cholinemagnesium salicylate
34 ciclodan 62 ciclopirox 62 ciclopirox-ure-camph-menth-
euc 62 cidofovir 2 cilostazol 51 CIMDUO 2 cimetidine 85 cimetidine hcl 85 CIMZIA 82 CIMZIA POWDER FOR
RECONST 81 cinacalcet 75 CINQAIR 117 CINRYZE 117 CIPRO HC 69 ciprofloxacin 12 ciprofloxacin hcl 12 69 109 ciprofloxacin-dexamethasone
69 citalopram 38 claravis 60 clarithromycin 7 8 clemastine 114 CLENPIQ 82 clindacin p 60 clindamycin hcl 8 clindamycin pediatric 8 clindamycin phosphate 8 60
101 clindamycin-benzoyl peroxide
60 clindamycin-tretinoin 60 clobazam 24 clobetasol 64 clobetasol-emollient 64 CLOCORTOLONE
PIVALATE 64 CLODERM 64 CLOLAR 15 clomipramine 38 clonazepam 24 clonidine 46 clonidine hcl 38 46 clopidogrel 51
128
clorazepate dipotassium 38 clotrimazole 1 62 clotrimazole-betamethasone 62 clovique 66 clozapine 38 COAGADEX 51 COARTEM 8 codeine sulfate 31 codeine-butalbital-asa-caff 31 codeine-guaifenesin 115 colchicine 95 COLCHICINE 95 colesevelam 55 colestipol 55 COMBIGAN 112 COMBIPATCH 98 COMBIVENT RESPIMAT 117 COMETRIQ 15 COMPLERA 2 compro 82 constulose 82 CONTOUR NEXT TEST
STRIPS 71 CONTOUR TEST STRIPS 71 COPIKTRA 15 CORIFACT 51 CORLANOR 56 CORTIFOAM 82 COSENTYX 58 COSENTYX (2 SYRINGES)
57 COSENTYX PEN 58 COSENTYX PEN (2 PENS) 58 COTELLIC 15 COTEMPLA XR-ODT 38 covaryx 98 covaryx hs 98 CREON 82 CRESEMBA 1 CRINONE 98 cromolyn 82 111 117 crotan 66 cryselle (28) 103 CRYSVITA 75 CUBICIN 8 CUBICIN RF 9 CUTAQUIG 90 CUVITRU 90 cyanocobalamin (vitamin b-12)
123 cyclafem 135 (28) 103
cyclafem 777 (28) 103 cyclobenzaprine 30 cyclopentolate 110 cyclophosphamide 15 CYCLOPHOSPHAMIDE 15 CYCLOSERINE 9 CYCLOSET 77 cyclosporine 15 cyclosporine modified 15 cyproheptadine 114 CYRAMZA 15 cyred 103 cyred eq 103 CYSTAGON 122 CYSTARAN 111 CYTOVENE 2 D DACOGEN 15 dalfampridine 29 DALIRESP 117 danazol 75 dantrolene 30 dapsone 9 60 DAPTACEL (DTAP
PEDIATRIC) (PF) 91 darifenacin 121 DARZALEX 15 dasetta 135 (28) 103 dasetta 777 (28) 103 DAURISMO 15 daysee 103 DAYTRANA 38 deblitane 98 decadron 70 decitabine 15 deferasirox 66 deferiprone 66 demeclocycline 12 DENAVIR 63 denta 5000 plus 68 dentagel 69 DEPO-ESTRADIOL 98 DEPO-PROVERA 98 DEPO-SUBQ PROVERA 104
98 DEPO-TESTOSTERONE 75 DESCOVY 2 desipramine 38 desloratadine 115 desmopressin 75
desog-eestradioleestradiol 103
desogestrel-ethinyl estradiol 103
desonide 64 desoximetasone 64 DESVENLAFAXINE 38 desvenlafaxine succinate 38 dexamethasone 70 dexamethasone intensol 70 dexamethasone sodium phos
(pf) 70 dexamethasone sodium
phosphate 70 113 DEXILANT 85 dexmethylphenidate 38 dextroamphetamine 38 39 dextroamphetamine-
amphetamine 39 diazepam 24 39 diazepam intensol 39 diazoxide 71 diclofenac potassium 34 diclofenac sodium 34 59 112 diclofenac-misoprostol 34 dicloxacillin 11 dicyclomine 80 didanosine 2 DIFICID 8 diflorasone 64 diflunisal 34 digitek 50 digox 50 digoxin 50 dihydroergotamine 28 DILANTIN 24 DILANTIN EXTENDED 24 DILANTIN INFATABS 24 DILANTIN-125 24 diltiazem 46 dilt-xr 46 dimethyl fumarate 88 DIPENTUM 82 diphenhydramine hcl 115 diphenoxylate-atropine 80 dipyridamole 51 diskets 31 disopyramide phosphate 44 disulfiram 66 divalproex 24 25 DIVIGEL 99
129
dofetilide 44 dolishale 103 donepezil 29 DONNATAL 80 DOPTELET (15 TAB PACK)
51 dorzolamide 112 dorzolamide-timolol 112 dorzolamide-timolol (pf) 112 dotti 99 DOVATO 2 doxazosin 46 doxepin 39 doxercalciferol 75 doxycycline hyclate 12 doxycycline monohydrate 12 doxylamine-pyridoxine (vit b6)
82 dronabinol 82 drospirenone-eestradiol-lmfa
103 drospirenone-ethinyl estradiol
103 DSUVIA 31 DUAVEE 99 DUEXIS 34 DULERA 117 duloxetine 39 DUPIXENT PEN 59 DUPIXENT SYRINGE 59 duramorph (pf) 31 DUREZOL 113 dutasteride 121 dutasteride-tamsulosin 121 dvorah 31 DYANAVEL XR 39 DYSPORT 91 E ees 400 8 econazole 62 econtra ez 103 econtra one-step 103 ecotrin 34 ecotrin low strength 34 EDARBI 46 EDARBYCLOR 46 EDLUAR 39 ed-spaz 80 EDURANT 2 eemt 99 eemt hs 99
efavirenz 2 efavirenz-emtricitabin-tenofov
3 efavirenz-lamivu-tenofov disop
3 effer-k 122 ELAPRASE 75 ELELYSO 75 eletriptan 28 ELIGARD 16 ELIGARD (3 MONTH) 15 ELIGARD (4 MONTH) 15 ELIGARD (6 MONTH) 15 elinest 103 ELIQUIS 51 ELIQUIS DVT-PE TREAT
30D START 51 ELIXOPHYLLIN 117 ELLA 103 ELMIRON 122 ELOCTATE 51 eluryng 101 ELZONRIS 16 EMCYT 16 EMEND 82 EMGALITY PEN 28 EMGALITY SYRINGE 28 emoquette 103 EMPAVELI 67 EMPLICITI 16 EMSAM 39 emtricitabine 3 emtricitabine-tenofovir (tdf) 3 EMTRIVA 3 EMVERM 9 enalapril maleate 46 enalaprilat 46 enalapril-hydrochlorothiazide
46 ENBREL 96 ENBREL MINI 96 ENBREL SURECLICK 96 endocet 31 ENGERIX-B (PF) 91 ENGERIX-B PEDIATRIC
(PF) 91 ENHERTU 16 enoxaparin 51 enpresse 104 enskyce 104 entacapone 27
entecavir 3 ENTRESTO 56 ENTYVIO 82 enulose 82 EPANED 46 EPCLUSA 3 EPIDIOLEX 25 epinastine 111 epinephrine 115 EPINEPHRINE 115 epitol 25 EPIVIR HBV 3 eplerenone 47 EPOGEN 86 epoprostenol (glycine) 47 eprosartan 47 ERAXIS(WATER DILUENT)
1 ERBITUX 16 ergocalciferol (vitamin d2) 123 ergoloid 39 ergotamine-caffeine 28 ERLEADA 16 erlotinib 16 errin 99 ERWINAZE 16 ery pads 60 erygel 60 ery-tab 8 erythrocin (as stearate) 8 erythromycin 8 109 erythromycin ethylsuccinate 8 erythromycin with ethanol 60 erythromycin-benzoyl peroxide
60 ESBRIET 117 escitalopram oxalate 39 esomeprazole magnesium 85 ESPEROCT 51 estarylla 104 estazolam 39 estradiol 99 estradiol valerate 99 estradiol-norethindrone acet 99 ESTRING 99 estrogens-methyltestosterone 99 eszopiclone 39 ethacrynic acid 47 ethambutol 9 ethosuximide 25
130
ethynodiol diac-eth estradiol 104
etodolac 34 etonogestrel-ethinyl estradiol
101 etoposide 16 etravirine 3 EUCRISA 59 EUFLEXXA 34 EURAX 66 EVAMIST 99 EVENITY 95 everolimus (antineoplastic) 16 everolimus
(immunosuppressive) 16 EVOTAZ 3 EXELDERM 62 exemestane 16 EXONDYS-51 29 EYLEA 111 ezetimibe 55 ezetimibe-simvastatin 55 F FA-8 123 FABRAZYME 75 FACTIVE 12 falmina (28) 104 famciclovir 3 famotidine 86 famotidine (pf) 85 FANAPT 39 FARXIGA 77 FASENRA 118 FASENRA PEN 117 FASLODEX 16 fayosim 104 FC2 FEMALE CONDOM 98 febuxostat 95 FEIBA NF 51 felbamate 25 felodipine 47 fem ph 101 FEMCAP 98 FEMRING 99 femynor 104 fenofibrate 55 FENOFIBRATE 55 fenofibrate micronized 55 fenofibrate nanocrystallized 55 fenofibric acid 55 fenofibric acid (choline) 55
fenoprofen 35 fentanyl 32 fentanyl citrate 31 FER-IN-SOL 123 FERRIPROX 67 FETZIMA 39 FIASP FLEXTOUCH U-100
INSULIN 72 FIASP PENFILL U-100
INSULIN 72 FIASP U-100 INSULIN 72 FIBRYGA 51 finasteride 121 FINTEPLA 25 FIRMAGON KIT W
DILUENT SYRINGE 16 flac otic oil 69 flavoxate 121 FLEBOGAMMA DIF 91 flecainide 44 FLOLAN 47 FLORIVA (FLUORIDE-
VITAMIN D3) 123 FLOVENT DISKUS 118 FLOVENT HFA 118 fluconazole 1 flucytosine 1 fludarabine 16 fludrocortisone 70 fluocinolone 64 fluocinolone acetonide oil 69 fluocinolone and shower cap 64 fluocinonide 64 fluocinonide-e 64 fluoride (sodium) 69 123 124 fluorometholone 113 fluorouracil 16 59 FLUOROURACIL 59 fluoxetine 39 40 fluphenazine hcl 40 flurandrenolide 64 65 flurazepam 40 flurbiprofen 35 flurbiprofen sodium 112 flutamide 16 fluticasone propionate 65 118 fluticasone propion-salmeterol
118 fluvastatin 55 56 fluvoxamine 40 FML FORTE 113
FML SOP 113 folic acid 124 FOLOTYN 16 fondaparinux 51 formoterol fumarate 118 FORTEO 95 FOSAMAX PLUS D 95 fosamprenavir 3 fosfomycin tromethamine 13 fosinopril 47 fosinopril-hydrochlorothiazide
47 FRAGMIN 52 FREESTYLE LIBRE 14 DAY
SENSOR 71 FREESTYLE LIBRE 2
SENSOR 71 frovatriptan 28 fulvestrant 16 furosemide 47 FUZEON 3 fyavolv 99 G g tussin ac 115 gabapentin 25 GALAFOLD 75 galantamine 29 GAMASTAN 91 GAMASTAN SD 91 GAMIFANT 16 GAMMAGARD LIQUID 91 GAMMAGARD S-D (IGA lt 1
MCGML) 91 GAMMAKED 91 GAMMAPLEX 91 GAMMAPLEX (WITH
SORBITOL) 91 GAMUNEX-C 91 GANCICLOVIR 3 ganciclovir sodium 3 GARDASIL 9 (PF) 91 gatifloxacin 109 gavilyte-c 82 gavilyte-g 82 gavilyte-n 82 GAZYVA 16 gemcitabine 16 17 gemfibrozil 56 gemmily 104 generlac 82 gengraf 17
131
GENOTROPIN 87 GENOTROPIN MINIQUICK
87 gentak 109 gentamicin 9 61 62 109 gentamicin sulfate (ped) (pf) 9 GENVOYA 3 GIAPREZA 56 GILENYA 88 GILOTRIF 17 GIVLAARI 67 GLASSIA 67 glatiramer 88 glatopa 88 GLEOSTINE 17 glimepiride 77 glipizide 77 glipizide-metformin 77 GLUCAGEN DIAGNOSTIC
KIT 71 GLUCAGEN HYPOKIT 71 GLUCAGON (HCL)
EMERGENCY KIT 71 glucagon emergency kit
(human) 71 GLUCAGON HCL 71 glyburide 77 glyburide micronized 77 glyburide-metformin 77 glycopyrrolate 80 GLYXAMBI 78 GONITRO 57 granisetron hcl 82 GRANIX 86 GRASTEK 91 griseofulvin microsize 1 griseofulvin ultramicrosize 1 guaiatussin ac 115 guanfacine 40 47 GYNAZOLE-1 101 gynol ii 101 H HAEGARDA 118 hailey 104 hailey 24 fe 104 hailey fe 1530 (28) 104 hailey fe 120 (28) 104 HALAVEN 17 halcinonide 65 halobetasol propionate 65 haloperidol 40
haloperidol decanoate 40 haloperidol lactate 40 HARVONI 3 HAVRIX (PF) 91 92 heather 99 HEMLIBRA 52 hemmorex-hc 82 HEMOFIL M HIGH 52 HEMOFIL M LOW 52 HEMOFIL M MID 52 HEMOFIL M SUPER HIGH52 hep flush-10 (pf) 52 heparin (porcine) 52 heparin (porcine) in 5 dex 52 heparin lock flush (porcine) 52 heparin lockflush(porcine)(pf)
52 heparin(porcine) in 045 nacl
52 HEPARIN(PORCINE) IN
045 NACL 52 heparin porcine (pf) 52 53 HEPLISAV-B (PF) 92 HERCEPTIN 17 HERCEPTIN HYLECTA 17 HERZUMA 17 HETLIOZ 40 HETLIOZ LQ 40 HIBERIX (PF) 92 HIZENTRA 92 homatropaire 110 HUMALOG JUNIOR
KWIKPEN U-100 72 HUMALOG KWIKPEN
INSULIN 72 HUMALOG MIX 50-50
INSULN U-100 72 HUMALOG MIX 50-50
KWIKPEN 72 HUMALOG MIX 75-25
KWIKPEN 72 HUMALOG MIX 75-25(U-
100)INSULN 72 HUMALOG U-100 INSULIN
72 HUMATE-P 53 HUMIRA 96 HUMIRA PEN 96 HUMIRA PEN CROHNS-UC-
HS START 96
HUMIRA PEN PSOR-UVEITS-ADOL HS 96
HUMIRA(CF) 97 HUMIRA(CF) PEDI
CROHNS STARTER 96 HUMIRA(CF) PEN 96 HUMIRA(CF) PEN
CROHNS-UC-HS 96 HUMIRA(CF) PEN
PEDIATRIC UC 96 HUMIRA(CF) PEN PSOR-
UV-ADOL HS 96 HUMULIN 7030 U-100
INSULIN 72 HUMULIN 7030 U-100
KWIKPEN 72 HUMULIN N NPH INSULIN
KWIKPEN 73 HUMULIN N NPH U-100
INSULIN 73 HUMULIN R REGULAR U-
100 INSULN 73 HUMULIN R U-500 (CONC)
INSULIN 73 HUMULIN R U-500 (CONC)
KWIKPEN 73 HYCAMTIN 17 hydralazine 47 hydrochlorothiazide 47 hydrocodone bitartrate 32 hydrocodone-acetaminophen 32 hydrocodone-chlorpheniramine
115 hydrocodone-homatropine 115 hydrocodone-ibuprofen 32 hydrocortisone 65 70 82 hydrocortisone acetate 82 hydrocortisone butyrate 65 hydrocortisone butyr-emollient
65 hydrocortisone valerate 65 hydrocortisone-acetic acid 69 hydrocortisone-pramoxine 58
82 hydromet 116 hydromorphone 32 HYDROMORPHONE 32 hydroxocobalamin 124 hydroxychloroquine 9 hydroxyprogest(pf)(preg presv)
99
132
hydroxyprogesterone cap(ppres) 99
hydroxyprogesterone caproate 100
hydroxyurea 17 hydroxyzine hcl 115 hydroxyzine pamoate 115 hyophen 122 hyoscyamine sulfate 80 hyosyne 80 HYQVIA 92 I ibandronate 95 IBRANCE 17 ibu 35 ibuprofen 35 icatibant 118 iclevia 104 ICLUSIG 17 icosapent ethyl 56 IDELVION 53 IDHIFA 17 ILARIS (PF) 90 ILUMYA 58 imatinib 17 IMBRUVICA 17 IMFINZI 17 imipenem-cilastatin 9 imipramine hcl 40 imipramine pamoate 40 imiquimod 90 IMLYGIC 17 IMOVAX RABIES VACCINE
(PF) 92 incassia 100 INCRELEX 67 INCRUSE ELLIPTA 118 indapamide 47 indomethacin 35 INFANRIX (DTAP) (PF) 92 INFED 124 INFLECTRA 82 INFUGEM 18 INLYTA 18 INSULIN ASP PRT-INSULIN
ASPART 73 INSULIN ASPART U-100 73 INSULIN SYRINGE-
NEEDLE U-100 71 INTELENCE 3 INTRAROSA 101
INTRON A 90 INVANZ 9 INVEGA SUSTENNA 40 INVELTYS 113 INVIRASE 3 IOPIDINE 114 IPOL 92 ipratropium bromide 69 118 ipratropium-albuterol 118 irbesartan 47 irbesartan-hydrochlorothiazide
47 IRESSA 18 ISENTRESS 3 ISENTRESS HD 3 isibloom 104 ISOLYTE-S 123 isoniazid 9 isosorbide dinitrate 57 isosorbide mononitrate 57 isotretinoin 60 isoxsuprine 101 isradipine 47 ISTODAX 18 itraconazole 1 ivermectin 9 66 IXEMPRA 18 IXIARO (PF) 92 IXINITY 53 J jaimiess 104 JAKAFI 18 jantoven 53 JANUMET 78 JANUMET XR 78 JANUVIA 78 JARDIANCE 78 jasmiel (28) 104 jencycla 100 JENTADUETO 78 JENTADUETO XR 78 JEVTANA 18 jinteli 100 JIVI 53 jolessa 104 JORNAY PM 40 JUBLIA 62 juleber 104 JULUCA 3 junel 1530 (21) 104 junel 120 (21) 104
junel fe 1530 (28) 104 junel fe 120 (28) 104 junel fe 24 104 JUXTAPID 56 JYNARQUE 75 K KADCYLA 18 kaitlib fe 104 KALBITOR 118 KALETRA 3 4 kalliga 104 KALYDECO 118 KANJINTI 18 KANUMA 75 kariva (28) 104 kelnor 135 (28) 105 kelnor 1-50 (28) 105 KEPIVANCE 13 ketoconazole 1 62 ketodan 62 ketoprofen 35 ketorolac 35 112 KEVZARA 97 KEYTRUDA 18 KINRIX (PF) 92 KISQALI 18 KISQALI FEMARA CO-
PACK 18 klor-con 123 klor-con 10 122 klor-con 8 122 klor-con m10 122 klor-con m15 122 klor-con m20 123 klor-conef 123 KOATE 53 KOGENATE FS 53 KORLYM 75 KOVALTRY 53 K-PHOS NO 2 122 K-PHOS ORIGINAL 122 KRYSTEXXA 95 k-tab 123 K-TAB 123 kurvelo (28) 105 KYLEENA 98 KYMRIAH 18 KYPROLIS 18 L l norgesteestradiol-eestrad
105
133
labetalol 47 LACRISERT 111 lactulose 83 lamivudine 4 lamivudine-zidovudine 4 lamotrigine 25 lansoprazole 86 lanthanum 83 LANTUS SOLOSTAR U-100
INSULIN 73 LANTUS U-100 INSULIN 73 lapatinib 18 larin 1530 (21) 105 larin 120 (21) 105 larin 24 fe 105 larin fe 1530 (28) 105 larin fe 120 (28) 105 larissia 105 LASTACAFT 111 latanoprost 112 LATUDA 40 layolis fe 105 leena 28 105 leflunomide 97 LEMTRADA 88 LENVIMA 18 lessina 105 letrozole 19 leucovorin calcium 13 LEUKERAN 19 LEUKINE 86 leuprolide 19 levalbuterol hcl 118 LEVALBUTEROL
TARTRATE 118 LEVEMIR FLEXTOUCH U-
100 INSULN 73 LEVEMIR U-100 INSULIN 73 levetiracetam 25 levobunolol 110 levocarnitine 67 levocarnitine (with sugar) 67 levocetirizine 115 levofloxacin 12 109 levonest (28) 105 levonorgestrel 105 levonorgestrel-ethinyl estrad
105 levonorg-eth estrad triphasic
105 levora-28 105
levorphanol tartrate 32 levothyroxine 79 levoxyl 79 LEVULAN 59 LEXIVA 4 LIBTAYO 19 lidocaine 61 lidocaine hcl 61 lidocaine hcl-hydrocortison ac
61 83 LIDOCAINE HCL-
HYDROCORTISON AC 83 lidocaine viscous 61 lidocaine-hydrocortisone-aloe
83 lidocaine-prilocaine 61 LIDOCAINE-TETRACAINE
61 LILETTA 98 lillow (28) 105 LINCOCIN 9 lindane 66 linezolid 9 linezolid in dextrose 5 9 linezolid-09 sodium chloride
9 LINZESS 83 liothyronine 79 LIPOFEN 56 lisinopril 47 lisinopril-hydrochlorothiazide
47 lithium carbonate 40 41 LO LOESTRIN FE 105 lojaimiess 105 LONSURF 19 loperamide 80 lopinavir-ritonavir 4 lorazepam 41 lorazepam intensol 41 loryna (28) 105 losartan 47 losartan-hydrochlorothiazide 47 LOTEMAX 113 loteprednol etabonate 113 lovastatin 56 low-ogestrel (28) 105 loxapine succinate 41 lo-zumandimine (28) 105 LUCENTIS 111 ludent fluoride 124
LULICONAZOLE 62 LUMIGAN 112 LUMIZYME 75 LUMOXITI 19 LUPANETA PACK (1
MONTH) 101 LUPANETA PACK (3
MONTH) 101 LUPKYNIS 19 LUPRON DEPOT 19 LUPRON DEPOT (3
MONTH) 19 LUPRON DEPOT (4
MONTH) 19 LUPRON DEPOT (6
MONTH) 19 LUPRON DEPOT-PED 19 LUPRON DEPOT-PED (3
MONTH) 19 lutera (28) 105 LUXTURNA 111 LUZU 62 lyleq 100 lyllana 100 LYNPARZA 19 LYRICA CR 25 LYSODREN 19 lyza 100 M mafenide acetate 62 malathion 66 maprotiline 41 marlissa (28) 106 MARPLAN 41 MARQIBO 19 MATULANE 19 matzim la 47 MAVENCLAD (10 TABLET
PACK) 88 MAVENCLAD (4 TABLET
PACK) 88 MAVENCLAD (5 TABLET
PACK) 88 MAVENCLAD (6 TABLET
PACK) 88 MAVENCLAD (7 TABLET
PACK) 88 MAVENCLAD (8 TABLET
PACK) 88 MAVENCLAD (9 TABLET
PACK) 88
134
MAVYRET 4 MAXIDEX 113 maxi-tuss ac 116 MAYZENT 88 MAYZENT STARTER PACK
88 m-clear wc 116 meclizine 83 meclofenamate 35 medroxyprogesterone 100 mefenamic acid 35 mefloquine 9 megestrol 19 MEKINIST 19 MEKTOVI 19 meloxicam 35 melphalan 19 melphalan hcl 19 memantine 29 MENACTRA (PF) 92 MENEST 100 MENOSTAR 100 MENQUADFI (PF) 92 MENTAX 62 MENVEO A-C-Y-W-135-DIP
(PF) 92 meperidine 32 meprobamate 30 MEPSEVII 76 mercaptopurine 20 meropenem 9 MEROPENEM-09
SODIUM CHLORIDE 9 merzee 106 mesalamine 83 mesalamine with cleansing
wipe 83 metaproterenol 118 metaxalone 30 metformin 78 methadone 32 methadose 32 methamphetamine 41 methazolamide 112 methenamine hippurate 13 methenamine mandelate 13 methen-sod phos-meth blue-
hyos 122 methergine 109 methimazole 71 methocarbamol 30
methotrexate sodium 20 methotrexate sodium (pf) 20 methoxsalen 59 methscopolamine 80 methyldopa 47 methyldopa-
hydrochlorothiazide 47 methyldopate 48 methylergonovine 109 METHYLIN 41 methylphenidate hcl 41 methylprednisolone 70 methylprednisolone acetate 70 methyltestosterone 76 metoclopramide hcl 83 metolazone 48 metoprolol succinate 48 metoprolol ta-hydrochlorothiaz
48 metoprolol tartrate 48 metronidazole 9 60 61 101 metyrosine 48 mexiletine 44 MIACALCIN 76 mibelas 24 fe 106 microgestin 1530 (21) 106 microgestin 120 (21) 106 microgestin fe 1530 (28) 106 microgestin fe 120 (28) 106 midazolam 41 midodrine 67 migergot 28 miglitol 78 miglustat 76 mili 106 millipred 70 millipred dp 70 mimvey 100 MINITRAN 57 minocycline 12 minoxidil 48 MIRCERA 86 MIRENA 98 mirtazapine 41 misoprostol 86 MITIGARE 95 mitoxantrone 20 M-M-R II (PF) 92 modafinil 41 moexipril 48 molindone 41
mometasone 65 mondoxyne nl 12 mono-linyah 106 MONONINE 53 MONOVISC 35 montelukast 118 119 morphine 32 33 morphine (pf) 32 morphine concentrate 32 MOTOFEN 80 MOVANTIK 83 MOXATAG 11 moxifloxacin 12 109 MOZOBIL 87 MULPLETA 53 MULTAQ 44 multi-vitamin with fluoride 124 multivitamins with fluoride 124 mupirocin 62 mupirocin calcium 62 mvc-fluoride 124 my choice 106 my way 106 MYALEPT 76 MYCAMINE 1 mycophenolate mofetil 20 mycophenolate sodium 20 MYDAYIS 41 MYLOTARG 20 MYOBLOC 92 myorisan 61 MYRBETRIQ 121 N nabumetone 35 nadolol 48 nadolol-bendroflumethiazide 48 nafcillin 11 nafcillin in dextrose iso-osm 11 naftifine 62 63 NAGLAZYME 76 nalbuphine 35 naloxone 35 naltrexone 35 naproxen 35 naproxen sodium 35 naratriptan 28 NARCAN 35 NATACYN 109 NATAZIA 106 nateglinide 78 NATPARA 76
135
nebusal 119 necon 0535 (28) 106 nefazodone 41 neomycin 9 neomycin-bacitracin-poly-hc
112 neomycin-bacitracin-
polymyxin 109 neomycin-polymyxin b-
dexameth 112 113 neomycin-polymyxin-
gramicidin 109 neomycin-polymyxin-hc 69
113 neo-polycin 109 neo-polycin hc 113 NERLYNX 20 NEUPOGEN 87 NEVANAC 112 nevirapine 4 new day 106 NEXAVAR 20 NEXPLANON 101 NEXTSTELLIS 106 niacin 56 NIACOR 56 nicardipine 48 nicorette 68 nicotine 68 nicotine (polacrilex) 68 NICOTROL 68 NICOTROL NS 68 nifedipine 48 nikki (28) 106 nilutamide 20 nimodipine 48 NINLARO 20 nisoldipine 48 nitazoxanide 9 nitisinone 67 nitro-bid 57 NITRO-DUR 57 nitrofurantoin 13 nitrofurantoin macrocrystal 13 nitrofurantoin monohydm-
cryst 13 nitroglycerin 57 nitroglycerin in 5 dextrose 57 nitro-time 57 NITYR 67 NIVESTYM 87
nizatidine 86 nora-be 100 noreth-ethinyl estradiol-iron
106 norethindrone (contraceptive)
100 norethindrone acetate 100 norethindrone ac-eth estradiol
100 106 norethindrone-eestradiol-iron
106 norgestimate-ethinyl estradiol
106 norlyda 100 NORMOSOL-R 123 NORPACE CR 44 nortrel 0535 (28) 106 nortrel 135 (21) 106 nortrel 135 (28) 106 nortrel 777 (28) 107 nortriptyline 42 NORVIR 4 NOVAFERRUM 124 NOVOEIGHT 53 NOVOLIN 70-30 FLEXPEN
U-100 73 NOVOLIN N FLEXPEN 73 NOVOLIN R FLEXPEN 73 NOVOLOG FLEXPEN U-100
INSULIN 74 NOVOLOG MIX 70-30 U-100
INSULN 74 NOVOLOG MIX 70-
30FLEXPEN U-100 74 NOVOLOG PENFILL U-100
INSULIN 74 NOVOLOG U-100 INSULIN
ASPART 74 NOVOPEN ECHO 71 NOVOSEVEN RT 53 NOXAFIL 1 np thyroid 79 NPLATE 53 NUCALA 119 NUCYNTA ER 36 NUEDEXTA 29 NULOJIX 20 NULYTELY LEMON-LIME
83 NUPLAZID 42 NUWIQ 53
nyamyc 63 nylia 777 (28) 107 nymyo 107 nystatin 1 63 nystatin-triamcinolone 63 nystop 63 O OBIZUR 54 ocella 107 OCREVUS 88 OCTAGAM 92 octreotide acetate 20 ODEFSEY 4 OFEV 119 ofloxacin 12 69 109 OGIVRI 20 olanzapine 42 olanzapine-fluoxetine 42 olmesartan 48 olmesartan-amlodipin-
hcthiazid 48 olmesartan-
hydrochlorothiazide 48 olopatadine 69 111 OLUMIANT 97 omega-3 acid ethyl esters 56 omeprazole 86 OMIDRIA 111 OMNITROPE 87 ONCASPAR 20 ondansetron 84 ondansetron hcl 83 84 ONETOUCH ULTRA TEST
71 ONETOUCH VERIO TEST
STRIPS 71 ONIVYDE 20 ONPATTRO 29 ONZETRA XSAIL 28 opcicon one-step 107 OPDIVO 20 opium tincture 81 OPSUMIT 119 option-2 107 ORALAIR 92 oralone 69 ORAVIG 1 ORENCIA 97 ORENCIA (WITH
MALTOSE) 97 ORENCIA CLICKJECT 97
136
ORENITRAM 48 ORLADEYO 119 orphenadrine citrate 30 orsythia 107 ORTHOVISC 36 oscimin 81 oscimin sl 81 oscimin sr 81 oseltamivir 4 OSMOPREP 84 OSPHENA 101 OTEZLA 97 OTEZLA STARTER 97 OTOVEL 69 oxacillin 11 oxacillin in dextrose(iso-osm)
11 oxandrolone 76 oxaprozin 36 oxazepam 42 oxcarbazepine 25 oxiconazole 63 OXISTAT 63 OXLUMO 122 oxybutynin chloride 121 oxycodone 33 oxycodone-acetaminophen 33 oxycodone-aspirin 33 OXYCONTIN 33 oxymorphone 33 OZEMPIC 78 OZURDEX 113 P pacerone 44 PADCEV 20 paliperidone 42 PALYNZIQ 76 pamidronate 76 PANRETIN 59 pantoprazole 86 PANZYGA 92 PARAGARD T 380A 98 paricalcitol 76 PARICALCITOL 76 paroex oral rinse 69 paromomycin 10 paroxetine hcl 42 paroxetine
mesylate(menopsym) 42 PARSABIV 76 PASER 10
PEDIARIX (PF) 92 PEDVAX HIB (PF) 93 peg 3350-electrolytes 84 peg3350-sod sul-nacl-kcl-asb-c
84 PEGASYS 88 89 peg-electrolyte soln 84 peg-prep 84 PEMAZYRE 20 PEN NEEDLE DIABETIC 72 penicillamine 97 penicillin g procaine 11 penicillin v potassium 11 PENTACEL (PF) 93 PENTACEL ACTHIB
COMPONENT (PF) 93 PENTAM 10 pentamidine 10 pentazocine-naloxone 36 pentoxifylline 54 PERFOROMIST 119 perindopril erbumine 48 periogard 69 PERJETA 20 permethrin 66 perphenazine 42 perphenazine-amitriptyline 42 phenazopyridine 122 phenelzine 42 phenobarb-hyoscy-atropine-
scop 81 phenobarbital 25 26 phenohytro 81 phenoxybenzamine 48 phenylephrine hcl 114 phenytoin 26 phenytoin sodium extended 26 PHEXXI 101 philith 107 phosphasal 122 PHYSIOLYTE 66 PHYSIOSOL IRRIGATION 66 phytonadione (vitamin k1) 54 PICATO 59 pilocarpine hcl 67 69 110 pimecrolimus 59 pimozide 42 pimtrea (28) 107 pindolol 48 pioglitazone 78 pioglitazone-glimepiride 78
pioglitazone-metformin 78 piperacillin-tazobactam 11 PIQRAY 21 pirmella 107 piroxicam 36 PLASMA-LYTE 148 123 PLASMA-LYTE A 123 PLEGRIDY 89 PLENVU 84 PNEUMOVAX-23 93 podofilox 59 POLIVY 21 polycin 110 polymyxin b sulfate 10 polymyxin b sulf-trimethoprim
110 POMALYST 89 PONVORY 89 PONVORY 14-DAY
STARTER PACK 89 portia 28 107 PORTRAZZA 21 posaconazole 1 potassium chloride 123 potassium citrate 122 POTELIGEO 21 pramipexole 27 prasugrel 54 pravastatin 56 praziquantel 10 prazosin 48 PRED MILD 113 prednicarbate 65 prednisolone 70 prednisolone acetate 113 prednisolone sodium phosphate
70 114 prednisone 70 prednisone intensol 70 pregabalin 26 PREMARIN 100 PREMPHASE 100 PREMPRO 100 prevalite 56 previfem 107 PREVNAR 13 (PF) 93 PREVYMIS 4 PREZCOBIX 4 PREZISTA 4 PRIFTIN 10 primaquine 10
137
primidone 26 PRIMSOL 13 PRIVIGEN 93 probenecid 95 probenecid-colchicine 95 procainamide 44 procentra 42 prochlorperazine 84 prochlorperazine edisylate 84 prochlorperazine maleate 84 PROCRIT 87 procto-med hc 84 procto-pak 84 proctosol hc 84 proctozone-hc 84 PROFILNINE 54 progesterone 100 progesterone micronized 100 PROGRAF 21 PROLASTIN-C 67 PROLEUKIN 90 PROLIA 95 PROMACTA 54 promethazine 115 promethazine-codeine 116 promethazine-dm 116 promethazine-phenyleph-
codeine 116 promethazine-phenylephrine
116 promethegan 115 propafenone 44 45 proparacaine 111 propranolol 48 49 propranolol-hydrochlorothiazid
49 propylthiouracil 71 PROQUAD (PF) 93 protriptyline 42 PROVENGE 93 prudoxin 59 pulmosal 119 PULMOZYME 119 pyrazinamide 10 pyridostigmine bromide 30 pyrimethamine 10 Q QBRELIS 49 QINLOCK 21 QTERN 78 QUADRACEL (PF) 93
quetiapine 42 QUILLICHEW ER 42 QUILLIVANT XR 42 quinapril 49 quinapril-hydrochlorothiazide
49 quinidine gluconate 45 quinidine sulfate 45 quinine sulfate 10 quit 2 68 quit 4 68 QVAR REDIHALER 119 R RABAVERT (PF) 93 rabeprazole 86 RADICAVA 29 RAGWITEK 93 raloxifene 95 ramelteon 42 ramipril 49 ranolazine 57 RAPIVAB (PF) 4 rasagiline 27 RAVICTI 67 REBIF (WITH ALBUMIN) 89 REBIF REBIDOSE 89 REBIF TITRATION PACK 89 REBINYN 54 RECLAST 67 reclipsen (28) 107 RECOMBINATE 54 RECOMBIVAX HB (PF) 93 RECTIV 84 REGRANEX 59 RELENZA DISKHALER 4 RELEXXII 42 RELION NOVOLIN 7030 74 RELION NOVOLIN N 74 RELION NOVOLIN R 74 RELISTOR 84 REMICADE 84 RENACIDIN 122 RENFLEXIS 84 repaglinide 78 repaglinide-metformin 78 REPATHA PUSHTRONEX 56 REPATHA SURECLICK 56 REPATHA SYRINGE 56 RESTASIS 111 RETEVMO 21 RETISERT 114
REVATIO 119 REVLIMID 89 REXULTI 43 REYATAZ 4 RHOPRESSA 112 RIASTAP 54 ribavirin 4 89 RIDAURA 97 rifabutin 10 rifampin 10 riluzole 67 rimantadine 4 RINVOQ 97 RIOMET ER 78 risedronate 67 95 RISPERDAL CONSTA 43 risperidone 43 ritonavir 4 RITUXAN 21 RITUXAN HYCELA 21 rivastigmine 30 rivastigmine tartrate 29 rivelsa 107 RIXUBIS 54 rizatriptan 28 ropinirole 27 28 rosadan 61 rosuvastatin 56 roweepra 26 RUBRACA 21 RUCONEST 119 rufinamide 26 RYBELSUS 79 RYDAPT 21 S salsalate 36 SAMSCA 76 SANTYL 65 sapropterin 76 SARCLISA 21 SAVELLA 97 scalacort 65 SCENESSE 59 scopolamine base 84 seconal sodium 43 SEEBRI NEOHALER 119 selegiline hcl 28 selenium sulfide 58 SELZENTRY 5 SEREVENT DISKUS 119 SEROSTIM 87
138
sertraline 43 setlakin 107 sevelamer carbonate 84 sevelamer hcl 84 sf 69 sf 5000 plus 69 sharobel 101 SHINGRIX (PF) 93 SIGNIFOR 21 sildenafil (pulmhypertension)
119 SILIQ 58 silodosin 121 silver sulfadiazine 59 SIMBRINZA 112 simliya (28) 107 simpesse 107 SIMPONI 97 SIMPONI ARIA 97 SIMULECT 21 simvastatin 56 SINUVA 119 sirolimus 21 SIRTURO 10 SIVEXTRO 10 SKYLA 98 SKYRIZI 58 SLYND 107 sodium chloride 119 sodium chloride 045 123 sodium chloride 09 67 sodium fluoride 5000 dry
mouth 69 sodium fluoride 5000 plus 69 sodium fluoride-pot nitrate 69 sodium phenylbutyrate 67 sodium polystyrene sulfonate
85 solifenacin 121 SOLIQUA 10033 74 SOLIRIS 67 SOLTAMOX 21 SOMATULINE DEPOT 21 SOMAVERT 76 sorine 45 sotalol 45 sotalol af 45 SOVALDI 5 spinosad 66 SPIRIVA RESPIMAT 119
SPIRIVA WITH HANDIHALER 119
spironolactone 49 spironolacton-hydrochlorothiaz
49 SPRAVATO 43 sprintec (28) 107 SPRYCEL 21 sps (with sorbitol) 85 sronyx 107 ssd 59 SSKI 71 st joseph aspirin 36 st joseph aspirin 36 STAMARIL (PF) 93 stavudine 5 STELARA 58 STIOLTO RESPIMAT 119 STIVARGA 21 stop smoking aid 68 STRENSIQ 76 STREPTOMYCIN 10 STRIBILD 5 STRIVERDI RESPIMAT 120 SUBLOCADE 33 subvenite 26 subvenite starter (blue) kit 26 subvenite starter (green) kit 26 subvenite starter (orange) kit 26 SUCRAID 85 sucralfate 86 sulfacetamide sodium 58 114 sulfacetamide sodium (acne) 62 sulfacetamide-prednisolone 114 sulfadiazine 12 sulfamethoxazole-trimethoprim
12 SULFAMYLON 62 sulfasalazine 85 sulfatrim 12 sulindac 36 sumatriptan 28 sumatriptan succinate 28 29 SUNOSI 43 SUPPRELIN LA 21 SUPRAX 7 SUPREP BOWEL PREP KIT
85 SUTENT 22 syeda 107 SYLVANT 22
symax fastabs 81 symax-sl 81 symax-sr 81 SYMBICORT 120 SYMDEKO 120 SYMLINPEN 120 79 SYMLINPEN 60 79 SYMPAZAN 26 SYNAGIS 5 SYNAREL 76 SYNERA 61 SYNJARDY 79 SYNJARDY XR 79 SYNRIBO 22 SYNTHROID 79 T TABLOID 22 tacrolimus 22 59 tadalafil 121 tadalafil (pulm hypertension)
120 TAFINLAR 22 TAGRISSO 22 TAKHZYRO 120 TALTZ AUTOINJECTOR 58 TALTZ AUTOINJECTOR (2
PACK) 58 TALTZ AUTOINJECTOR (3
PACK) 58 TALTZ SYRINGE 58 TALZENNA 22 tamoxifen 22 tamsulosin 121 TARGRETIN 22 tarina 24 fe 107 tarina fe 120 (28) 107 TASIGNA 22 tavaborole 63 tazarotene 61 tazicef 7 taztia xt 49 TDVAX 93 TECENTRIQ 22 TEFLARO 7 TEKTURNA HCT 49 telmisartan 49 telmisartan-amlodipine 49 telmisartan-hydrochlorothiazid
49 temazepam 43 TEMODAR 22
139
temozolomide 22 temsirolimus 22 tencon 33 TENIVAC (PF) 94 tenofovir disoproxil fumarate 5 TEPEZZA 76 terazosin 49 terbinafine hcl 1 terbutaline 120 terconazole 101 testosterone 77 testosterone cypionate 76 testosterone enanthate 76 TETANUSDIPHTHERIA
TOX PED(PF) 94 tetrabenazine 30 tetracaine hcl 111 TETRACAINE HCL (PF) 111 tetracycline 12 THALOMID 22 theophylline 120 thioridazine 43 thiothixene 43 THYMOGLOBULIN 94 THYROLAR-1 79 THYROLAR-12 79 THYROLAR-14 79 THYROLAR-2 79 THYROLAR-3 79 tiadylt er 49 tiagabine 26 TIBSOVO 22 tilia fe 107 timolol maleate 49 110 tinidazole 10 TIVICAY 5 TIVICAY PD 5 tizanidine 30 TOBRADEX 113 TOBRADEX ST 113 tobramycin 10 110 tobramycin in 0225 nacl 10 tobramycin sulfate 10 TOBRAMYCIN WITH
NEBULIZER 10 tobramycin-dexamethasone 113 TOBREX 110 TODAY CONTRACEPTIVE
SPONGE 101 tolcapone 28 tolmetin 36
tolterodine 121 topiramate 26 toremifene 22 TORISEL 22 torsemide 49 TOUJEO MAX U-300
SOLOSTAR 74 TOUJEO SOLOSTAR U-300
INSULIN 74 TRACLEER 120 TRADJENTA 79 tramadol 36 tramadol-acetaminophen 36 trandolapril 49 trandolapril-verapamil 49 tranexamic acid 54 101 tranylcypromine 43 travoprost 112 trazodone 43 TREANDA 22 TRECATOR 10 TRELEGY ELLIPTA 120 TRELSTAR 22 TREMFYA 59 TRESIBA FLEXTOUCH U-
100 74 TRESIBA FLEXTOUCH U-
200 74 TRESIBA U-100 INSULIN 74 tretinoin 61 tretinoin (antineoplastic) 22 tretinoin microspheres 61 TRETTEN 54 TREXALL 22 tri femynor 107 triamcinolone acetonide 65 69
71 triamterene 49 triamterene-hydrochlorothiazid
49 triazolam 43 triderm 65 trientine 67 tri-estarylla 107 trifluoperazine 43 trifluridine 110 trihexyphenidyl 28 TRIJARDY XR 71 TRIKAFTA 120 tri-legest fe 108 tri-linyah 108
tri-lo-estarylla 108 tri-lo-marzia 108 tri-lo-mili 108 tri-lo-sprintec 108 trilyte with flavor packets 85 trimethobenzamide 85 trimethoprim 13 tri-mili 108 trimipramine 43 TRINTELLIX 43 tri-nymyo 108 tri-previfem (28) 108 tri-sprintec (28) 108 TRIUMEQ 5 tri-vitamin with fluoride 124 trivora (28) 108 tri-vylibra 108 tri-vylibra lo 108 TROGARZO 5 tropicamide 110 trospium 121 TRULICITY 79 TRUMENBA 94 TRUXIMA 22 TUKYSA 23 tulana 101 TWINRIX (PF) 94 TWIRLA 101 TYBLUME 108 TYBOST 5 tydemy 108 TYGACIL 10 TYMLOS 95 TYPHIM VI 94 TYSABRI 30 TYVASO 120 TYVASO REFILL KIT 120 TYVASO STARTER KIT 120 U UBRELVY 29 UDENYCA 87 ULESFIA 66 unithroid 80 UNITUXIN 23 URELLE 122 uretron d-s 122 urimar-t 122 urogesic-blue 122 ursodiol 85 uryl 122 ustell 122
140
UTIBRON NEOHALER 120 utira-c 122 UVADEX 59 V vaginal contraceptive foam 101 valacyclovir 5 VALCHLOR 59 valganciclovir 5 valproic acid 26 valproic acid (as sodium salt)
26 valsartan 49 valsartan-hydrochlorothiazide
49 vanadom 30 vancomycin 13 vandazole 101 VANTAS 23 VAQTA (PF) 94 VARIVAX (PF) 94 VARUBI 85 VASCEPA 56 VAXELIS (PF) 94 VCF CONTRACEPTIVE
FILM 101 VCF CONTRACEPTIVE GEL
101 VECTIBIX 23 VELCADE 23 veletri 50 velivet triphasic regimen (28)
108 VELPHORO 85 VEMLIDY 5 VENCLEXTA 23 VENCLEXTA STARTING
PACK 23 venlafaxine 43 VENTAVIS 120 verapamil 50 VERSACLOZ 43 VERZENIO 23 vestura (28) 108 VIBATIV 13 VIBERZI 85 VIDAZA 23 VIEKIRA PAK 5 vienva 108 vigabatrin 26 vigadrone 26 VIMIZIM 77
VIMPAT 26 viorele (28) 108 VIRACEPT 5 VIREAD 5 virtussin ac 116 VISTOGARD 13 VISUDYNE 111 vitamins acd and fluoride 124 VITRAKVI 23 VIVITROL 36 volnea (28) 108 VONVENDI 54 VORAXAZE 13 voriconazole 1 2 VOSEVI 5 VOTRIENT 23 VPRIV 77 VRAYLAR 44 VYEPTI 29 vyfemla (28) 108 vylibra 108 VYONDYS-53 30 VYVANSE 44 VYXEOS 23 W warfarin 54 wera (28) 108 westhroid 80 WIDE-SEAL DIAPHRAGM
98 WILATE 54 wixela inhub 121 wymzya fe 108 X XALKORI 23 XARELTO 54 XARELTO DVT-PE TREAT
30D START 54 XCOPRI 27 XCOPRI MAINTENANCE
PACK 27 XCOPRI TITRATION PACK
27 XELJANZ 97 XELJANZ XR 97 XEMBIFY 94 XENLETA 10 XEOMIN 94 XERMELO 23 XGEVA 13 XIFAXAN 10
XIGDUO XR 79 XIIDRA 111 XOLAIR 121 XOSPATA 23 XTANDI 23 xulane 102 XULTOPHY 10036 74 XURIDEN 67 XYNTHA 55 XYNTHA SOLOFUSE 55 XYREM 44 Y YERVOY 23 YESCARTA 23 YF-VAX (PF) 94 YONDELIS 23 YONSA 23 YUTIQ 114 yuvafem 101 Z zafemy 102 zafirlukast 121 zaleplon 44 ZALTRAP 23 ZANOSAR 23 zarah 109 ZARXIO 87 ZEJULA 24 ZELBORAF 24 ZEMAIRA 68 zenatane 61 ZENPEP 85 ZENZEDI 44 ZEPATIER 5 ZEPOSIA 89 ZEPOSIA STARTER KIT 89 ZEPOSIA STARTER PACK
89 ZERBAXA 7 zidovudine 5 ZIEXTENZO 87 zileuton 121 ziprasidone hcl 44 ZIRGAN 110 ZOKINVY 68 ZOLADEX 24 ZOLGENSMA 30 ZOLINZA 24 zolmitriptan 29 zolpidem 44 ZOLPIMIST 44
141
ZOMIG 29 zonisamide 27 ZONTIVITY 55 ZORBTIVE 87
ZOSTAVAX (PF) 94 zovia 135e (28) 109 ZULRESSO 44 zumandimine (28) 109
ZYFLO 121 ZYKADIA 24 ZYPITAMAG 56
051267 (11-20-2019)
Discrimination is Against the Law
LifeWise Health Plan of Washington (LifeWise) complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex LifeWise does not exclude people or treat them differently because of race color national origin age disability sex gender identity or sexual orientation LifeWise provides free aids and services to people with disabilities to communicate effectively with us such as qualified sign language interpreters and written information in other formats (large print audio accessible electronic formats other formats) LifeWise provides free language services to people whose primary language is not English such as qualified interpreters and information written in other languages If you need these services contact the Civil Rights Coordinator If you believe that LifeWise 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 Civil Rights Coordinator Complaints and Appeals PO Box 91102 Seattle WA 98111 Toll free 855-332-6396 Fax 425-918-5592 TTY 711 Email AppealsDepartmentInquiriesLifeWiseHealthcom You can file a grievance in person or by mail fax or email If you need help filing a grievance the Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Ave SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
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までお電話にてご連絡ください ማስታወሻ የሚናገሩት ቋንቋ ኣማርኛ ከነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ
800-817-3056 (መስማት ለተሳናቸው 711) XIYYEEFFANNAA Afaan dubbattu Oroomiffa tajaajila gargaarsa afaanii kanfaltiidhaan ala ni argama Bilbilaa 800-817-3056 (TTY 711)
)711 والبكم الصم ھاتف رقم( 800-178-3056 برقم اتصل بالمجان لك تتوافر اللغویة المساعدة خدمات فإن اللغة اذكر تتحدث كنت إذا ملحوظةਿਧਆਨ ਿਦਓ ਜ ਤਸ ਪਜਾਬੀ ਬਲਦ ਹ ਤ ਭਾਸ਼ਾ ਿਵਚ ਸਹਾਇਤਾ ਸਵਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਧ ਹ 800-817-3056
(TTY 711) ਤ ਕਾਲ ਕਰ ACHTUNG Wenn Sie Deutsch sprechen stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfuumlgung
Rufnummer 800-817-3056 (TTY 711) ໂປດຊາບ ຖາວາ ທານເວາພາສາ ລາວ ການບລການຊວຍເຫອດານພາສາ ໂດຍບເສຽຄາ
ແມນມພອມໃຫທານ ໂທຣ 800-817-3056 (TTY 711) ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele 800-817-3056 (TTY 711) ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 800-817-3056 (ATS 711) UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń pod numer 800-817-3056 (TTY 711) ATENCcedilAtildeO Se fala portuguecircs encontram-se disponiacuteveis serviccedilos linguiacutesticos graacutetis Ligue para 800-817-3056 (TTY 711) ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza linguistica gratuiti Chiamare il numero
800-817-3056 (TTY 711) دیریبگ تماس 3056-817-800 (TTY 711) با باشد یم فراھم شما یبرا گانیرا بصورت یزبان لاتیتسھ دیکن یم گفتگو فارسی زبان بھ اگر توجھ
3
Drug Name Drug Tier Requirements Limits
efavirenz-emtricitabin-tenofov oral tablet 600-200-300 mg
1
efavirenz-lamivu-tenofov disop oral tablet 400-300-300 mg 600-300-300 mg
1
emtricitabine oral capsule 200 mg 1 QL (30 per 30 days)
emtricitabine-tenofovir (tdf) oral tablet 100-150 mg 133-200 mg 167-250 mg 200-300 mg
1
EMTRIVA ORAL SOLUTION 10 MGML 1 QL (720 per 30 days)
entecavir oral tablet 05 mg 1 mg 1
EPCLUSA ORAL TABLET 200-50 MG 400-100 MG
2 PA LA
EPIVIR HBV ORAL SOLUTION 25 MG5 ML (5 MGML)
1
etravirine oral tablet 100 mg 200 mg 1 QL (60 per 30 days)
EVOTAZ ORAL TABLET 300-150 MG 1 QL (30 per 30 days)
famciclovir oral tablet 125 mg 250 mg 500 mg 1
fosamprenavir oral tablet 700 mg 1 QL (60 per 30 days)
FUZEON SUBCUTANEOUS RECON SOLN 90 MG
2 QL (30 per 30 days)
GANCICLOVIR INTRAVENOUS SOLUTION 500 MG250 ML (2 MGML)
MB
ganciclovir sodium intravenous recon soln 500 mg MB
GENVOYA ORAL TABLET 150-150-200-10 MG
1 QL (30 per 30 days)
HARVONI ORAL PELLETS IN PACKET 3375-150 MG 45-200 MG
2 LA
HARVONI ORAL TABLET 45-200 MG 90-400 MG
2 PA LA
INTELENCE ORAL TABLET 100 MG 200 MG 25 MG
1 QL (60 per 30 days)
INVIRASE ORAL TABLET 500 MG 1 QL (120 per 30 days)
ISENTRESS HD ORAL TABLET 600 MG 1 QL (60 per 30 days)
ISENTRESS ORAL POWDER IN PACKET 100 MG
1 QL (60 per 30 days)
ISENTRESS ORAL TABLET 400 MG 1 QL (60 per 30 days)
ISENTRESS ORAL TABLETCHEWABLE 100 MG 25 MG
1 QL (60 per 30 days)
JULUCA ORAL TABLET 50-25 MG 1 QL (30 per 30 days)
KALETRA ORAL TABLET 100-25 MG 1 QL (60 per 30 days)
4
Drug Name Drug Tier Requirements Limits
KALETRA ORAL TABLET 200-50 MG 1 QL (120 per 30 days)
lamivudine oral solution 10 mgml 1 QL (900 per 30 days)
lamivudine oral tablet 100 mg 1
lamivudine oral tablet 150 mg 300 mg 1 QL (60 per 30 days)
lamivudine-zidovudine oral tablet 150-300 mg 1 QL (60 per 30 days)
LEXIVA ORAL SUSPENSION 50 MGML 1 QL (60 per 30 days)
lopinavir-ritonavir oral solution 400-100 mg5 ml 1 QL (320 per 30 days)
lopinavir-ritonavir oral tablet 100-25 mg 200-50 mg
1 QL (120 per 30 days)
MAVYRET ORAL TABLET 100-40 MG 2 PA LA
nevirapine oral suspension 50 mg5 ml 1 QL (60 per 30 days)
nevirapine oral tablet 200 mg 1 QL (60 per 30 days)
nevirapine oral tablet extended release 24 hr 100 mg 400 mg
1 QL (30 per 30 days)
NORVIR ORAL POWDER IN PACKET 100 MG 1 QL (360 per 30 days)
NORVIR ORAL SOLUTION 80 MGML 1 QL (480 per 30 days)
ODEFSEY ORAL TABLET 200-25-25 MG 1 QL (30 per 30 days)
oseltamivir oral capsule 30 mg 1 QL (40 per 365 days)
oseltamivir oral capsule 45 mg 75 mg 1 QL (20 per 365 days)
oseltamivir oral suspension for reconstitution 6 mgml
1 QL (180 per 30 days)
PREVYMIS INTRAVENOUS SOLUTION 240 MG12 ML 480 MG24 ML
MB PA
PREZCOBIX ORAL TABLET 800-150 MG-MG 1 QL (30 per 30 days)
PREZISTA ORAL SUSPENSION 100 MGML 1 QL (30 per 30 days)
PREZISTA ORAL TABLET 150 MG 600 MG 75 MG
1 QL (60 per 30 days)
PREZISTA ORAL TABLET 800 MG 1 QL (30 per 30 days)
RAPIVAB (PF) INTRAVENOUS SOLUTION 200 MG20 ML (10 MGML)
MB
RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MGACTUATION
1 QL (2 per 30 days)
REYATAZ ORAL POWDER IN PACKET 50 MG
1 QL (150 per 30 days)
ribavirin inhalation recon soln 6 gram MB
rimantadine oral tablet 100 mg 1
ritonavir oral tablet 100 mg 1 QL (360 per 30 days)
5
Drug Name Drug Tier Requirements Limits
SELZENTRY ORAL SOLUTION 20 MGML 1 QL (8 per 30 days)
SELZENTRY ORAL TABLET 150 MG 25 MG 300 MG 75 MG
1 QL (60 per 30 days)
SOVALDI ORAL PELLETS IN PACKET 150 MG 200 MG
2 LA
SOVALDI ORAL TABLET 200 MG 400 MG 2 PA LA
stavudine oral capsule 15 mg 20 mg 40 mg 1 QL (120 per 30 days)
STRIBILD ORAL TABLET 150-150-200-300 MG
1 QL (30 per 30 days)
SYNAGIS INTRAMUSCULAR SOLUTION 100 MGML 50 MG05 ML
MB LA
tenofovir disoproxil fumarate oral tablet 300 mg 1 QL (30 per 30 days)
TIVICAY ORAL TABLET 10 MG 25 MG 50 MG
1 QL (60 per 30 days)
TIVICAY PD ORAL TABLET FOR SUSPENSION 5 MG
1 QL (60 per 30 days)
TRIUMEQ ORAL TABLET 600-50-300 MG 1 QL (30 per 30 days)
TROGARZO INTRAVENOUS SOLUTION 200 MG133 ML (150 MGML)
MB PA
TYBOST ORAL TABLET 150 MG 1 QL (30 per 30 days)
valacyclovir oral tablet 1 gram 500 mg 1
valganciclovir oral recon soln 50 mgml 1
valganciclovir oral tablet 450 mg 1
VEMLIDY ORAL TABLET 25 MG 1
VIEKIRA PAK ORAL TABLETSDOSE PACK 125 MG-75 MG -50 MG250 MG
2 PA
VIRACEPT ORAL TABLET 250 MG 1 QL (90 per 30 days)
VIRACEPT ORAL TABLET 625 MG 1 QL (60 per 30 days)
VIREAD ORAL POWDER 40 MGSCOOP (40 MGGRAM)
1 QL (4 per 30 days)
VIREAD ORAL TABLET 150 MG 200 MG 250 MG
1 QL (30 per 30 days)
VOSEVI ORAL TABLET 400-100-100 MG 2 PA LA
ZEPATIER ORAL TABLET 50-100 MG 2 PA LA
zidovudine oral capsule 100 mg 1 QL (60 per 30 days)
zidovudine oral syrup 10 mgml 1 QL (960 per 30 days)
zidovudine oral tablet 300 mg 1 QL (60 per 30 days)
CEPHALOSPORINS
6
Drug Name Drug Tier Requirements Limits
AVYCAZ INTRAVENOUS RECON SOLN 25 GRAM
MB
cefaclor oral capsule 250 mg 500 mg 1
cefaclor oral suspension for reconstitution 125 mg5 ml 250 mg5 ml 375 mg5 ml
1
cefaclor oral tablet extended release 12 hr 500 mg 1
cefadroxil oral capsule 500 mg 1
cefadroxil oral suspension for reconstitution 250 mg5 ml 500 mg5 ml
1
cefadroxil oral tablet 1 gram 1
cefazolin in dextrose (iso-os) intravenous piggyback 1 gram50 ml
MB
cefazolin injection recon soln 1 gram 10 gram 100 gram 20 gram 300 g 500 mg
MB
cefazolin intravenous recon soln 1 gram MB
cefdinir oral capsule 300 mg 1
cefdinir oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cefditoren pivoxil oral tablet 200 mg 400 mg 1
CEFEPIME IN DEXTROSE 5 INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
cefepime in dextroseiso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml
MB
cefepime injection recon soln 1 gram 2 gram MB
cefixime oral capsule 400 mg 1
cefixime oral suspension for reconstitution 100 mg5 ml 200 mg5 ml
1
CEFOTAN INJECTION RECON SOLN 1 GRAM 2 GRAM
MB
cefotaxime injection recon soln 1 gram MB
CEFOTETAN IN DEXTROSE ISO-OSM INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
cefotetan injection recon soln 1 gram 2 gram MB
cefotetan intravenous recon soln 10 gram MB
cefoxitin intravenous recon soln 10 gram MB
cefpodoxime oral suspension for reconstitution 100 mg5 ml 50 mg5 ml
1
7
Drug Name Drug Tier Requirements Limits
cefpodoxime oral tablet 100 mg 200 mg 1
cefprozil oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cefprozil oral tablet 250 mg 500 mg 1
CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
ceftazidime injection recon soln 1 gram 2 gram 6 gram
MB
ceftriaxone in dextroseiso-os intravenous piggyback 1 gram50 ml 2 gram50 ml
MB
ceftriaxone injection recon soln 1 gram 10 gram 2 gram 250 mg 500 mg
MB
CEFTRIAXONE INJECTION RECON SOLN 100 GRAM
MB
ceftriaxone intravenous recon soln 1 gram 2 gram MB
cefuroxime axetil oral tablet 250 mg 500 mg 1
cephalexin oral capsule 250 mg 500 mg 750 mg 1
cephalexin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cephalexin oral tablet 250 mg 500 mg 1
SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG5 ML
1
SUPRAX ORAL TABLETCHEWABLE 100 MG 200 MG
1
tazicef injection recon soln 1 gram 2 gram 6 gram
MB
tazicef intravenous recon soln 1 gram 2 gram MB
TEFLARO INTRAVENOUS RECON SOLN 400 MG 600 MG
MB
ZERBAXA INTRAVENOUS RECON SOLN 15 GRAM
MB
ERYTHROMYCINS amp OTHER MACROLIDES
azithromycin oral packet 1 gram 1
azithromycin oral suspension for reconstitution 100 mg5 ml 200 mg5 ml
1
azithromycin oral tablet 250 mg 500 mg 600 mg 1
clarithromycin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
clarithromycin oral tablet 250 mg 500 mg 1
8
Drug Name Drug Tier Requirements Limits
clarithromycin oral tablet extended release 24 hr 500 mg
1
DIFICID ORAL TABLET 200 MG 1
ees 400 oral tablet 400 mg 1
ery-tab oral tabletdelayed release (drec) 250 mg 333 mg
1
erythrocin (as stearate) oral tablet 250 mg 1
erythromycin ethylsuccinate oral suspension for reconstitution 200 mg5 ml 400 mg5 ml
1
erythromycin ethylsuccinate oral tablet 400 mg 1
erythromycin oral capsuledelayed release(drec) 250 mg
1
erythromycin oral tablet 250 mg 500 mg 1
erythromycin oral tabletdelayed release (drec) 250 mg 333 mg 500 mg
1
MISCELLANEOUS ANTIINFECTIVES
albendazole oral tablet 200 mg 1
ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG5 ML
1 PA ST
amikacin injection solution 500 mg2 ml MB
atovaquone oral suspension 750 mg5 ml 1
atovaquone-proguanil oral tablet 250-100 mg 625-25 mg
1
bacitracin intramuscular recon soln 50000 unit 1
CAPASTAT INJECTION RECON SOLN 1 GRAM
1
CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MGML
2 PA LA QL (84 per 30 days)
chloramphenicol sod succinate intravenous recon soln 1 gram
MB
chloroquine phosphate oral tablet 250 mg 500 mg 1
clindamycin hcl oral capsule 150 mg 300 mg 75 mg
1
clindamycin pediatric oral recon soln 75 mg5 ml 1
clindamycin phosphate injection solution 150 mgml
MB
COARTEM ORAL TABLET 20-120 MG 1
CUBICIN INTRAVENOUS RECON SOLN 500 MG
MB
9
Drug Name Drug Tier Requirements Limits
CUBICIN RF INTRAVENOUS RECON SOLN 500 MG
MB
CYCLOSERINE ORAL CAPSULE 250 MG 1
dapsone oral tablet 100 mg 25 mg 1
EMVERM ORAL TABLETCHEWABLE 100 MG
1
ethambutol oral tablet 100 mg 400 mg 1
gentamicin injection solution 20 mg2 ml 40 mgml
MB
gentamicin sulfate (ped) (pf) injection solution 20 mg2 ml
MB
hydroxychloroquine oral tablet 200 mg 1
imipenem-cilastatin intravenous recon soln 250 mg 500 mg
MB
INVANZ INJECTION RECON SOLN 1 GRAM MB
isoniazid injection solution 100 mgml 1
isoniazid oral solution 50 mg5 ml 1
isoniazid oral tablet 100 mg 300 mg 1
ivermectin oral tablet 3 mg 1
LINCOCIN INJECTION SOLUTION 300 MGML
MB
linezolid in dextrose 5 intravenous piggyback 600 mg300 ml
MB
linezolid oral suspension for reconstitution 100 mg5 ml
1
linezolid oral tablet 600 mg 1
linezolid-09 sodium chloride intravenous parenteral solution 600 mg300 ml
MB
mefloquine oral tablet 250 mg 1
meropenem intravenous recon soln 1 gram 500 mg
MB
MEROPENEM-09 SODIUM CHLORIDE INTRAVENOUS PIGGYBACK 1 GRAM50 ML 500 MG50 ML
MB
metronidazole oral capsule 375 mg 1
metronidazole oral tablet 250 mg 500 mg 1
neomycin oral tablet 500 mg 1
nitazoxanide oral tablet 500 mg 1
10
Drug Name Drug Tier Requirements Limits
paromomycin oral capsule 250 mg 1
PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM
1
PENTAM INJECTION RECON SOLN 300 MG MB
pentamidine inhalation recon soln 300 mg 1
pentamidine injection recon soln 300 mg MB
polymyxin b sulfate injection recon soln 500000 unit
MB
praziquantel oral tablet 600 mg 1
PRIFTIN ORAL TABLET 150 MG 1
primaquine oral tablet 263 mg 1
pyrazinamide oral tablet 500 mg 1
pyrimethamine oral tablet 25 mg 2 PA
quinine sulfate oral capsule 324 mg 1
rifabutin oral capsule 150 mg 1
rifampin oral capsule 150 mg 300 mg 1
SIRTURO ORAL TABLET 100 MG 1 PA
SIRTURO ORAL TABLET 20 MG 1
SIVEXTRO ORAL TABLET 200 MG 1 QL (6 per 30 days)
STREPTOMYCIN INTRAMUSCULAR RECON SOLN 1 GRAM
1
tinidazole oral tablet 250 mg 500 mg 1
tobramycin in 0225 nacl inhalation solution for nebulization 300 mg5 ml
2
tobramycin inhalation solution for nebulization 300 mg4 ml
2
tobramycin sulfate injection recon soln 12 gram 1
tobramycin sulfate injection solution 10 mgml MB
tobramycin sulfate injection solution 40 mgml 1
TOBRAMYCIN WITH NEBULIZER INHALATION SOLUTION FOR NEBULIZATION 300 MG5 ML
2 PA ST
TRECATOR ORAL TABLET 250 MG 1
TYGACIL INTRAVENOUS RECON SOLN 50 MG
MB
XENLETA INTRAVENOUS SOLUTION 150 MG15 ML
MB
XIFAXAN ORAL TABLET 200 MG 550 MG 1 PA QL (60 per 30 days)
11
Drug Name Drug Tier Requirements Limits
PENICILLINS
amoxicillin oral capsule 250 mg 500 mg 1
amoxicillin oral suspension for reconstitution 125 mg5 ml 200 mg5 ml 250 mg5 ml 400 mg5 ml
1
amoxicillin oral tablet 500 mg 875 mg 1
amoxicillin oral tabletchewable 125 mg 250 mg 1
amoxicillin-pot clavulanate oral suspension for reconstitution 200-285 mg5 ml 250-625 mg5 ml 400-57 mg5 ml 600-429 mg5 ml
1
amoxicillin-pot clavulanate oral tablet 250-125 mg 500-125 mg 875-125 mg
1
amoxicillin-pot clavulanate oral tablet extended release 12 hr 1000-625 mg
1
amoxicillin-pot clavulanate oral tabletchewable 200-285 mg 400-57 mg
1
ampicillin oral capsule 500 mg 1
ampicillin-sulbactam injection recon soln 15 gram MB
BICILLIN C-R INTRAMUSCULAR SYRINGE 1200000 UNIT 2 ML(900K300K)
MB
dicloxacillin oral capsule 250 mg 500 mg 1
MOXATAG ORAL TABLET ER MULTIPHASE 24 HR 775 MG
1
nafcillin in dextrose iso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml
MB
nafcillin injection recon soln 1 gram 10 gram 2 gram
MB
nafcillin intravenous recon soln 1 gram 2 gram MB
oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram50 ml 2 gram50 ml
MB
oxacillin injection recon soln 1 gram 10 gram 2 gram
MB
penicillin g procaine intramuscular syringe 12 million unit2 ml 600000 unitml
MB
penicillin v potassium oral recon soln 125 mg5 ml 250 mg5 ml
1
penicillin v potassium oral tablet 250 mg 500 mg 1
piperacillin-tazobactam intravenous recon soln 135 gram 225 gram 3375 gram 45 gram 405 gram
MB
12
Drug Name Drug Tier Requirements Limits
QUINOLONES
BAXDELA INTRAVENOUS RECON SOLN 300 MG
MB
BAXDELA ORAL TABLET 450 MG 1
ciprofloxacin hcl oral tablet 100 mg 250 mg 500 mg 750 mg
1
ciprofloxacin oral suspensionmicrocapsule recon 250 mg5 ml 500 mg5 ml
1
FACTIVE ORAL TABLET 320 MG 1 ST
levofloxacin oral solution 250 mg10 ml 1
levofloxacin oral tablet 250 mg 500 mg 750 mg 1
moxifloxacin oral tablet 400 mg 1
ofloxacin oral tablet 300 mg 400 mg 1
SULFAS amp RELATED AGENTS
sulfadiazine oral tablet 500 mg 1
sulfamethoxazole-trimethoprim oral suspension 200-40 mg5 ml
1
sulfamethoxazole-trimethoprim oral tablet 400-80 mg 800-160 mg
1
sulfatrim oral suspension 200-40 mg5 ml 1
TETRACYCLINES
avidoxy oral tablet 100 mg 1 ST
demeclocycline oral tablet 150 mg 300 mg 1
doxycycline hyclate oral capsule 100 mg 50 mg 1
doxycycline hyclate oral tablet 100 mg 150 mg 20 mg 50 mg 75 mg
1
doxycycline hyclate oral tabletdelayed release (drec) 100 mg 150 mg 200 mg 50 mg 75 mg
1
doxycycline monohydrate oral capsule 100 mg 150 mg 50 mg 75 mg
1
doxycycline monohydrate oral suspension for reconstitution 25 mg5 ml
1
doxycycline monohydrate oral tablet 100 mg 150 mg 50 mg 75 mg
1
minocycline oral capsule 100 mg 50 mg 75 mg 1
minocycline oral tablet 100 mg 50 mg 75 mg 1
mondoxyne nl oral capsule 100 mg 75 mg 1
tetracycline oral capsule 250 mg 500 mg 1
13
Drug Name Drug Tier Requirements Limits
URINARY TRACT AGENTS
fosfomycin tromethamine oral packet 3 gram 1
methenamine hippurate oral tablet 1 gram 1
methenamine mandelate oral tablet 05 g 1 gram 1
nitrofurantoin macrocrystal oral capsule 100 mg 25 mg 50 mg
1
nitrofurantoin monohydm-cryst oral capsule 100 mg
1
nitrofurantoin oral suspension 25 mg5 ml 1
PRIMSOL ORAL SOLUTION 50 MG5 ML 1
trimethoprim oral tablet 100 mg 1
VANCOMYCIN
vancomycin oral capsule 125 mg 250 mg 1
vancomycin oral recon soln 50 mgml 1
VIBATIV INTRAVENOUS RECON SOLN 750 MG
MB
ANTINEOPLASTIC amp IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
KEPIVANCE INTRAVENOUS RECON SOLN 625 MG
MB
leucovorin calcium injection recon soln 100 mg 200 mg 350 mg 50 mg 500 mg
MB
leucovorin calcium injection solution 10 mgml MB
leucovorin calcium oral tablet 10 mg 15 mg 25 mg 5 mg
1
VISTOGARD ORAL GRANULES IN PACKET 10 GRAM
2
VORAXAZE INTRAVENOUS RECON SOLN 1000 UNIT
MB
XGEVA SUBCUTANEOUS SOLUTION 120 MG17 ML (70 MGML)
2 LA
ANTINEOPLASTIC amp IMMUNOSUPPRESSANT DRUGS
abiraterone oral tablet 250 mg 2 PA OCh LA
abiraterone oral tablet 500 mg 2 PA ST OCh LA
ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG
MB PA LA
ADAKVEO INTRAVENOUS SOLUTION 10 MGML
MB PA
14
Drug Name Drug Tier Requirements Limits
ADCETRIS INTRAVENOUS RECON SOLN 50 MG
MB PA LA
AFINITOR ORAL TABLET 10 MG 2 OCh LA
ALECENSA ORAL CAPSULE 150 MG 2 PA OCh LA
ALIMTA INTRAVENOUS RECON SOLN 100 MG 500 MG
MB PA
ALIQOPA INTRAVENOUS RECON SOLN 60 MG
MB PA
anastrozole oral tablet 1 mg ACA PV OCh QL (30 per 30 days)
ARRANON INTRAVENOUS SOLUTION 250 MG50 ML
MB LA
ARZERRA INTRAVENOUS SOLUTION 1000 MG50 ML 100 MG5 ML
MB PA LA
ASPARLAS INTRAVENOUS SOLUTION 750 UNITML
MB PA
AVASTIN INTRAVENOUS SOLUTION 25 MGML
MB PA LA
azathioprine oral tablet 50 mg 1
BALVERSA ORAL TABLET 3 MG 4 MG 5 MG
2 PA OCh
BAVENCIO INTRAVENOUS SOLUTION 20 MGML
MB PA
BELEODAQ INTRAVENOUS RECON SOLN 500 MG
MB PA
BELRAPZO INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BENDAMUSTINE INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BENDEKA INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BESPONSA INTRAVENOUS RECON SOLN 09 MG (025 MGML INITIAL)
MB PA LA
bexarotene oral capsule 75 mg 2 PA ST OCh
bicalutamide oral tablet 50 mg 2 OCh QL (30 per 30 days)
BLINCYTO INTRAVENOUS KIT 35 MCG MB PA
BORTEZOMIB INTRAVENOUS RECON SOLN 35 MG
MB
BOSULIF ORAL TABLET 100 MG 400 MG 500 MG
2 PA ST OCh LA
BRAFTOVI ORAL CAPSULE 50 MG 75 MG 2 PA OCh LA
15
Drug Name Drug Tier Requirements Limits
BUSULFEX INTRAVENOUS SOLUTION 60 MG10 ML
MB
CABOMETYX ORAL TABLET 20 MG 40 MG 60 MG
2 PA ST OCh LA
CALQUENCE ORAL CAPSULE 100 MG 2 PA ST OCh
capecitabine oral tablet 150 mg 2 OCh LA QL (210 per 30 days)
capecitabine oral tablet 500 mg 2 OCh LA QL (84 per 30 days)
CAPRELSA ORAL TABLET 100 MG 300 MG 2 PA OCh
CLOLAR INTRAVENOUS SOLUTION 20 MG20 ML
MB PA
COMETRIQ ORAL CAPSULE 100 MGDAY(80 MG X1-20 MG X1) 140 MGDAY(80 MG X1-20 MG X3) 60 MGDAY (20 MG X 3DAY)
2 PA OCh
COPIKTRA ORAL CAPSULE 15 MG 25 MG 2 PA OCh
COTELLIC ORAL TABLET 20 MG 2 PA OCh LA
cyclophosphamide intravenous recon soln 1 gram 2 gram 500 mg
MB
cyclophosphamide oral capsule 25 mg 50 mg 2 OCh
CYCLOPHOSPHAMIDE ORAL TABLET 25 MG 50 MG
2 OCh
cyclosporine modified oral capsule 100 mg 25 mg 50 mg
1
cyclosporine modified oral solution 100 mgml 1
cyclosporine oral capsule 100 mg 25 mg 1
CYRAMZA INTRAVENOUS SOLUTION 10 MGML
MB PA LA
DACOGEN INTRAVENOUS RECON SOLN 50 MG
MB PA LA
DARZALEX INTRAVENOUS SOLUTION 20 MGML
MB PA LA
DAURISMO ORAL TABLET 100 MG 25 MG 2 PA OCh LA
decitabine intravenous recon soln 50 mg MB LA
ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 225 MG
2
ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG
2
ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG
2
16
Drug Name Drug Tier Requirements Limits
ELIGARD SUBCUTANEOUS SYRINGE 75 MG (1 MONTH)
2
ELZONRIS INTRAVENOUS SOLUTION 1000 MCGML
MB PA
EMCYT ORAL CAPSULE 140 MG 2 OCh
EMPLICITI INTRAVENOUS RECON SOLN 300 MG 400 MG
MB PA LA
ENHERTU INTRAVENOUS RECON SOLN 100 MG
MB PA LA
ERBITUX INTRAVENOUS SOLUTION 100 MG50 ML 200 MG100 ML
MB PA LA
ERLEADA ORAL TABLET 60 MG 2 PA OCh LA
erlotinib oral tablet 100 mg 150 mg 25 mg 2 PA OCh LA
ERWINAZE INJECTION RECON SOLN 10000 UNIT
MB
etoposide intravenous solution 20 mgml MB
etoposide oral capsule 50 mg 2 OCh
everolimus (antineoplastic) oral tablet 25 mg 5 mg 75 mg
2 PA ST OCh LA
everolimus (immunosuppressive) oral tablet 025 mg 05 mg 075 mg
1 PA
exemestane oral tablet 25 mg ACA PV OCh QL (30 per 30 days)
FASLODEX INTRAMUSCULAR SYRINGE 250 MG5 ML
MB PA
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG 80 MG
2 LA
fludarabine intravenous recon soln 50 mg MB
fluorouracil intravenous solution 25 gram50 ml 5 gram100 ml 500 mg10 ml
MB PA
flutamide oral capsule 125 mg 2 OCh QL (180 per 30 days)
FOLOTYN INTRAVENOUS SOLUTION 20 MGML (1 ML) 40 MG2 ML (20 MGML)
MB PA LA
fulvestrant intramuscular syringe 250 mg5 ml MB
GAMIFANT INTRAVENOUS SOLUTION 5 MGML
MB PA
GAZYVA INTRAVENOUS SOLUTION 1000 MG40 ML
MB PA LA
gemcitabine intravenous recon soln 1 gram 2 gram 200 mg
MB
17
Drug Name Drug Tier Requirements Limits
gemcitabine intravenous solution 2 gram526 ml (38 mgml) 200 mg526 ml (38 mgml)
MB
gengraf oral capsule 100 mg 25 mg 1
gengraf oral solution 100 mgml 1
GILOTRIF ORAL TABLET 20 MG 30 MG 40 MG
2 PA OCh LA
GLEOSTINE ORAL CAPSULE 10 MG 100 MG 40 MG
2 PA OCh
HALAVEN INTRAVENOUS SOLUTION 1 MG2 ML (05 MGML)
MB PA LA
HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600 MG-10000 UNIT5 ML
MB LA
HERCEPTIN INTRAVENOUS RECON SOLN 150 MG
MB PA LA
HERZUMA INTRAVENOUS RECON SOLN 150 MG
MB PA LA
HYCAMTIN ORAL CAPSULE 025 MG 1 MG 2 OCh LA
hydroxyurea oral capsule 500 mg 2 OCh
IBRANCE ORAL CAPSULE 100 MG 125 MG 75 MG
2 PA OCh LA
IBRANCE ORAL TABLET 100 MG 125 MG 75 MG
2 OCh LA
ICLUSIG ORAL TABLET 10 MG 15 MG 30 MG 45 MG
2 PA ST OCh
IDHIFA ORAL TABLET 100 MG 50 MG 2 PA OCh LA
imatinib oral tablet 100 mg 2 OCh LA QL (90 per 30 days)
imatinib oral tablet 400 mg 2 OCh LA QL (60 per 30 days)
IMBRUVICA ORAL CAPSULE 140 MG 70 MG 2 PA ST OCh
IMBRUVICA ORAL TABLET 140 MG 280 MG 420 MG 560 MG
2 PA ST OCh
IMFINZI INTRAVENOUS SOLUTION 50 MGML
MB PA LA
IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFUML 10EXP8 (100 MILLION) PFUML
MB
18
Drug Name Drug Tier Requirements Limits
INFUGEM INTRAVENOUS PIGGYBACK 1200 MG120 ML (10 MGML) 1300 MG130 ML (10 MGML) 1400 MG140 ML (10 MGML) 1500 MG150 ML (10 MGML) 1600 MG160 ML (10 MGML) 1700 MG170 ML (10 MGML) 1800 MG180 ML (10 MGML) 1900 MG190 ML (10 MGML) 2000 MG200 ML (10 MGML) 2200 MG220 ML (10 MGML)
MB
INLYTA ORAL TABLET 1 MG 5 MG 2 PA OCh LA
IRESSA ORAL TABLET 250 MG 2 PA OCh LA
ISTODAX INTRAVENOUS RECON SOLN 10 MG2 ML
MB PA LA
IXEMPRA INTRAVENOUS RECON SOLN 15 MG 45 MG
MB PA LA
JAKAFI ORAL TABLET 10 MG 15 MG 20 MG 25 MG 5 MG
2 PA OCh LA
JEVTANA INTRAVENOUS SOLUTION 10 MGML (FIRST DILUTION)
MB PA LA
KADCYLA INTRAVENOUS RECON SOLN 100 MG 160 MG
MB PA LA
KANJINTI INTRAVENOUS RECON SOLN 150 MG 420 MG
MB PA LA
KEYTRUDA INTRAVENOUS SOLUTION 25 MGML
MB PA
KISQALI FEMARA CO-PACK ORAL TABLET 200 MGDAY(200 MG X 1)-25 MG 400 MGDAY(200 MG X 2)-25 MG 600 MGDAY(200 MG X 3)-25 MG
2 PA ST OCh LA
KISQALI ORAL TABLET 200 MGDAY (200 MG X 1) 400 MGDAY (200 MG X 2) 600 MGDAY (200 MG X 3)
2 PA ST OCh LA
KYMRIAH INTRAVENOUS SUSPENSION 02X10EXP6 TO 25X10EXP8 CELL 06 TO 6 X 10EXP8 CELL
MB PA
KYPROLIS INTRAVENOUS RECON SOLN 10 MG 30 MG 60 MG
MB PA
lapatinib oral tablet 250 mg 2 PA OCh LA QL (180 per 30 days)
LENVIMA ORAL CAPSULE 10 MGDAY (10 MG X 1) 12 MGDAY (4 MG X 3) 14 MGDAY(10 MG X 1-4 MG X 1) 18 MGDAY (10 MG X 1-4 MG X2) 20 MGDAY (10 MG X 2) 24 MGDAY(10 MG X 2-4 MG X 1) 4 MG 8 MGDAY (4 MG X 2)
2 PA ST OCh LA
19
Drug Name Drug Tier Requirements Limits
letrozole oral tablet 25 mg ACA PV OCh QL (30 per 30 days)
LEUKERAN ORAL TABLET 2 MG 2 OCh
leuprolide subcutaneous kit 1 mg02 ml 2
LIBTAYO INTRAVENOUS SOLUTION 50 MGML
MB PA
LONSURF ORAL TABLET 15-614 MG 20-819 MG
2 PA ST OCh LA
LUMOXITI INTRAVENOUS RECON SOLN 1 MG
MB
LUPKYNIS ORAL CAPSULE 79 MG 2 PA ST
LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 225 MG
2
LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG
2
LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG
2
LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 375 MG 75 MG
2
LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 30 MG
2
LUPRON DEPOT-PED INTRAMUSCULAR KIT 1125 MG 15 MG 75 MG (PED)
2
LYNPARZA ORAL TABLET 100 MG 150 MG 2 PA ST OCh LA
LYSODREN ORAL TABLET 500 MG 2 OCh
MARQIBO INTRAVENOUS KIT 5 MG31 ML(016 MGML) FINAL
MB PA
MATULANE ORAL CAPSULE 50 MG 2 OCh
megestrol oral suspension 400 mg10 ml (40 mgml)
1 QL (2 per 30 days)
megestrol oral suspension 625 mg5 ml (125 mgml)
1 QL (1 per 30 days)
megestrol oral tablet 20 mg 2 OCh QL (480 per 30 days)
megestrol oral tablet 40 mg 2 OCh QL (240 per 30 days)
MEKINIST ORAL TABLET 05 MG 2 MG 2 PA ST OCh LA
MEKTOVI ORAL TABLET 15 MG 2 PA OCh LA
melphalan hcl intravenous recon soln 50 mg MB
melphalan oral tablet 2 mg 2 OCh
20
Drug Name Drug Tier Requirements Limits
mercaptopurine oral tablet 50 mg 2 OCh QL (300 per 30 days)
methotrexate sodium (pf) injection recon soln 1 gram
1
methotrexate sodium (pf) injection solution 25 mgml
1
methotrexate sodium injection solution 25 mgml 1
methotrexate sodium oral tablet 25 mg 2 OCh
mitoxantrone intravenous concentrate 2 mgml MB PA LA
mycophenolate mofetil oral capsule 250 mg 1
mycophenolate mofetil oral tablet 500 mg 1
mycophenolate sodium oral tabletdelayed release (drec) 180 mg 360 mg
1
MYLOTARG INTRAVENOUS RECON SOLN 45 MG (1 MGML INITIAL CONC)
MB PA LA
NERLYNX ORAL TABLET 40 MG 2 PA OCh LA QL (180 per 30 days)
NEXAVAR ORAL TABLET 200 MG 2 PA ST OCh LA
nilutamide oral tablet 150 mg 2 OCh QL (60 per 30 days)
NINLARO ORAL CAPSULE 23 MG 3 MG 4 MG
2 PA ST OCh LA
NULOJIX INTRAVENOUS RECON SOLN 250 MG
MB PA
octreotide acetate injection solution 1000 mcgml 100 mcgml 200 mcgml 50 mcgml 500 mcgml
2
octreotide acetate injection syringe 100 mcgml (1 ml) 50 mcgml (1 ml) 500 mcgml (1 ml)
2
OGIVRI INTRAVENOUS RECON SOLN 150 MG 420 MG
MB PA LA
ONCASPAR INJECTION SOLUTION 750 UNITML
MB
ONIVYDE INTRAVENOUS DISPERSION 43 MGML
MB PA
OPDIVO INTRAVENOUS SOLUTION 100 MG10 ML 240 MG24 ML 40 MG4 ML
MB PA LA
PADCEV INTRAVENOUS RECON SOLN 20 MG 30 MG
MB PA LA
PEMAZYRE ORAL TABLET 135 MG 45 MG 9 MG
2 PA ST OCh
PERJETA INTRAVENOUS SOLUTION 420 MG14 ML (30 MGML)
MB PA LA
21
Drug Name Drug Tier Requirements Limits
PIQRAY ORAL TABLET 200 MGDAY (200 MG X 1) 250 MGDAY (200 MG X1-50 MG X1) 300 MGDAY (150 MG X 2)
2 PA OCh LA
POLIVY INTRAVENOUS RECON SOLN 140 MG
MB PA LA
PORTRAZZA INTRAVENOUS SOLUTION 800 MG50 ML (16 MGML)
MB PA LA
POTELIGEO INTRAVENOUS SOLUTION 4 MGML
MB PA
PROGRAF INTRAVENOUS SOLUTION 5 MGML
MB
QINLOCK ORAL TABLET 50 MG 2 OCh
RETEVMO ORAL CAPSULE 40 MG 2 PA OCh LA QL (240 per 30 days)
RETEVMO ORAL CAPSULE 80 MG 2 PA OCh LA QL (120 per 30 days)
RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG117 ML (120 MGML) 1600 MG134 ML (120 MGML)
MB LA
RITUXAN INTRAVENOUS CONCENTRATE 10 MGML
MB PA LA
RUBRACA ORAL TABLET 200 MG 250 MG 300 MG
2 PA ST OCh LA
RYDAPT ORAL CAPSULE 25 MG 2 PA ST OCh LA
SARCLISA INTRAVENOUS SOLUTION 20 MGML
MB
SIGNIFOR SUBCUTANEOUS SOLUTION 03 MGML (1 ML) 06 MGML (1 ML) 09 MGML (1 ML)
2 PA ST
SIMULECT INTRAVENOUS RECON SOLN 10 MG 20 MG
MB
sirolimus oral solution 1 mgml 1
sirolimus oral tablet 05 mg 1 mg 2 mg 1
SOLTAMOX ORAL SOLUTION 20 MG10 ML 2 OCh
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG05 ML 60 MG02 ML 90 MG03 ML
2 PA LA
SPRYCEL ORAL TABLET 100 MG 140 MG 20 MG 50 MG 70 MG 80 MG
2 PA ST OCh LA
STIVARGA ORAL TABLET 40 MG 2 PA ST OCh LA
SUPPRELIN LA IMPLANT KIT 50 MG (65 MCGDAY)
MB LA
22
Drug Name Drug Tier Requirements Limits
SUTENT ORAL CAPSULE 125 MG 25 MG 375 MG 50 MG
2 PA ST OCh LA
SYLVANT INTRAVENOUS RECON SOLN 100 MG 400 MG
MB PA LA
SYNRIBO SUBCUTANEOUS RECON SOLN 35 MG
2 PA ST
TABLOID ORAL TABLET 40 MG 2 OCh
tacrolimus oral capsule 05 mg 1 mg 5 mg 1
TAFINLAR ORAL CAPSULE 50 MG 75 MG 2 PA OCh LA
TAGRISSO ORAL TABLET 40 MG 80 MG 2 PA OCh LA
TALZENNA ORAL CAPSULE 025 MG 1 MG 2 PA OCh LA
tamoxifen oral tablet 10 mg 20 mg 2 OCh QL (60 per 30 days)
TARGRETIN TOPICAL GEL 1 1 PA ST
TASIGNA ORAL CAPSULE 150 MG 200 MG 50 MG
2 PA ST OCh LA
TECENTRIQ INTRAVENOUS SOLUTION 1200 MG20 ML (60 MGML) 840 MG14 ML (60 MGML)
MB PA LA
TEMODAR INTRAVENOUS RECON SOLN 100 MG
MB PA LA
temozolomide oral capsule 100 mg 140 mg 180 mg 20 mg 250 mg 5 mg
2 OCh LA
temsirolimus intravenous recon soln 30 mg3 ml (10 mgml) (first)
MB PA LA
THALOMID ORAL CAPSULE 100 MG 150 MG 200 MG 50 MG
2 OCh LA
TIBSOVO ORAL TABLET 250 MG 2 PA OCh
toremifene oral tablet 60 mg 2 OCh
TORISEL INTRAVENOUS RECON SOLN 30 MG3 ML (10 MGML) (FIRST)
MB PA LA
TREANDA INTRAVENOUS RECON SOLN 100 MG 25 MG
MB PA LA
TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 1125 MG 225 MG 375 MG
MB
tretinoin (antineoplastic) oral capsule 10 mg 2 OCh
TREXALL ORAL TABLET 10 MG 15 MG 5 MG 75 MG
2 PA ST OCh QL (15 per 30 days)
TRUXIMA INTRAVENOUS SOLUTION 10 MGML
MB PA LA
23
Drug Name Drug Tier Requirements Limits
TUKYSA ORAL TABLET 150 MG 50 MG 2 PA ST OCh QL (120 per 30 days)
UNITUXIN INTRAVENOUS SOLUTION 35 MGML
MB PA
VANTAS IMPLANT KIT 50 MG (50 MCGDAY)
MB LA
VECTIBIX INTRAVENOUS SOLUTION 100 MG5 ML (20 MGML) 400 MG20 ML (20 MGML)
MB PA LA
VELCADE INJECTION RECON SOLN 35 MG MB LA
VENCLEXTA ORAL TABLET 10 MG 100 MG 50 MG
2 PA ST OCh
VENCLEXTA STARTING PACK ORAL TABLETSDOSE PACK 10 MG-50 MG- 100 MG
2 PA OCh
VERZENIO ORAL TABLET 100 MG 150 MG 200 MG 50 MG
2 PA ST OCh LA
VIDAZA INJECTION RECON SOLN 100 MG MB PA LA
VITRAKVI ORAL CAPSULE 100 MG 2 PA OCh LA
VITRAKVI ORAL CAPSULE 25 MG 2 PA ST OCh LA
VITRAKVI ORAL SOLUTION 20 MGML 2 PA OCh LA
VOTRIENT ORAL TABLET 200 MG 2 PA ST OCh LA
VYXEOS INTRAVENOUS RECON SOLN 44-100 MG
MB PA
XALKORI ORAL CAPSULE 200 MG 250 MG 2 PA OCh LA
XERMELO ORAL TABLET 250 MG 2 PA ST
XOSPATA ORAL TABLET 40 MG 2 PA OCh
XTANDI ORAL CAPSULE 40 MG 2 PA OCh LA
XTANDI ORAL TABLET 40 MG 80 MG 2 PA OCh LA
YERVOY INTRAVENOUS SOLUTION 200 MG40 ML (5 MGML) 50 MG10 ML (5 MGML)
MB PA LA
YESCARTA INTRAVENOUS SUSPENSION MB PA
YONDELIS INTRAVENOUS RECON SOLN 1 MG
MB PA
YONSA ORAL TABLET 125 MG 2 PA OCh LA
ZALTRAP INTRAVENOUS SOLUTION 100 MG4 ML (25 MGML) 200 MG8 ML (25 MGML)
MB PA LA
ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM
MB
24
Drug Name Drug Tier Requirements Limits
ZEJULA ORAL CAPSULE 100 MG 2 OCh
ZELBORAF ORAL TABLET 240 MG 2 PA ST OCh LA
ZOLADEX SUBCUTANEOUS IMPLANT 108 MG 36 MG
MB LA
ZOLINZA ORAL CAPSULE 100 MG 2 PA ST OCh LA
ZYKADIA ORAL TABLET 150 MG 2 PA ST OCh LA
AUTONOMIC amp CNS DRUGS NEUROLOGY amp PSYCH
ANTICONVULSANTS
BANZEL ORAL TABLET 200 MG 400 MG 1 PA ST
BRIVIACT ORAL SOLUTION 10 MGML 1 ST QL (150 per 30 days)
BRIVIACT ORAL TABLET 10 MG 100 MG 25 MG 50 MG 75 MG
1 ST QL (60 per 30 days)
carbamazepine oral capsule er multiphase 12 hr 100 mg 200 mg 300 mg
1
carbamazepine oral suspension 100 mg5 ml 200 mg10 ml
1
carbamazepine oral tablet 200 mg 1
carbamazepine oral tablet extended release 12 hr 100 mg 200 mg 400 mg
1
carbamazepine oral tabletchewable 100 mg 1
CELONTIN ORAL CAPSULE 300 MG 1
clobazam oral suspension 25 mgml 1
clobazam oral tablet 10 mg 20 mg 1
clonazepam oral tablet 05 mg 1 mg 2 mg 1
clonazepam oral tabletdisintegrating 0125 mg 025 mg 05 mg 1 mg 2 mg
1
diazepam rectal kit 25 mg 1
DILANTIN EXTENDED ORAL CAPSULE 100 MG
1
DILANTIN INFATABS ORAL TABLETCHEWABLE 50 MG
1
DILANTIN ORAL CAPSULE 30 MG 1
DILANTIN-125 ORAL SUSPENSION 125 MG5 ML
1
divalproex oral capsule delayed rel sprinkle 125 mg
1
divalproex oral tablet extended release 24 hr 250 mg 500 mg
1
25
Drug Name Drug Tier Requirements Limits
divalproex oral tabletdelayed release (drec) 125 mg 250 mg 500 mg
1
EPIDIOLEX ORAL SOLUTION 100 MGML 2 PA LA QL (400 per 30 days)
epitol oral tablet 200 mg 1
ethosuximide oral capsule 250 mg 1
ethosuximide oral solution 250 mg5 ml 1
felbamate oral suspension 600 mg5 ml 1
felbamate oral tablet 400 mg 600 mg 1
FINTEPLA ORAL SOLUTION 22 MGML 2
gabapentin oral capsule 100 mg 300 mg 400 mg 1
gabapentin oral solution 250 mg5 ml 300 mg6 ml (6 ml)
1
gabapentin oral tablet 600 mg 800 mg 1
lamotrigine oral tablet 100 mg 150 mg 200 mg 25 mg
1
lamotrigine oral tablet disintegrating dose pk 25 mg (21) -50 mg (7) 25 mg(14)-50 mg (14)-100 mg (7) 50 mg (42) -100 mg (14)
1
lamotrigine oral tablet extended release 24hr 100 mg 200 mg 25 mg 250 mg 300 mg 50 mg
1
lamotrigine oral tablet chewable dispersible 25 mg 5 mg
1
lamotrigine oral tabletdisintegrating 100 mg 200 mg 25 mg 50 mg
1
lamotrigine oral tabletsdose pack 25 mg (35) 25 mg (42) -100 mg (7) 25 mg (84) -100 mg (14)
1
levetiracetam oral solution 100 mgml 500 mg5 ml (5 ml)
1
levetiracetam oral tablet 1000 mg 250 mg 500 mg 750 mg
1
levetiracetam oral tablet extended release 24 hr 500 mg 750 mg
1
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG 330 MG 825 MG
1 PA ST
oxcarbazepine oral suspension 300 mg5 ml (60 mgml)
1
oxcarbazepine oral tablet 150 mg 300 mg 600 mg 1
phenobarbital oral elixir 20 mg5 ml (4 mgml) 1
26
Drug Name Drug Tier Requirements Limits
phenobarbital oral tablet 100 mg 15 mg 162 mg 30 mg 324 mg 60 mg 648 mg 972 mg
1
phenytoin oral suspension 100 mg4 ml 125 mg5 ml
1
phenytoin oral tabletchewable 50 mg 1
phenytoin sodium extended oral capsule 100 mg 200 mg 300 mg
1
pregabalin oral capsule 100 mg 150 mg 200 mg 225 mg 25 mg 300 mg 50 mg 75 mg
1 PA ST
pregabalin oral solution 20 mgml 1 PA ST
pregabalin oral tablet extended release 24 hr 165 mg 330 mg 825 mg
1 PA ST
primidone oral tablet 250 mg 50 mg 1
roweepra oral tablet 1000 mg 500 mg 750 mg 1
rufinamide oral suspension 40 mgml 1 PA
rufinamide oral tablet 200 mg 400 mg 1 PA
subvenite oral tablet 100 mg 150 mg 200 mg 25 mg
1
subvenite starter (blue) kit oral tabletsdose pack 25 mg (35)
1
subvenite starter (green) kit oral tabletsdose pack 25 mg (84) -100 mg (14)
1
subvenite starter (orange) kit oral tabletsdose pack 25 mg (42) -100 mg (7)
1
SYMPAZAN ORAL FILM 10 MG 20 MG 5 MG 1 PA QL (30 per 30 days)
tiagabine oral tablet 12 mg 16 mg 2 mg 4 mg 1
topiramate oral capsule sprinkle 15 mg 25 mg 1
topiramate oral tablet 100 mg 200 mg 25 mg 50 mg
1
valproic acid (as sodium salt) oral solution 250 mg5 ml 500 mg10 ml (10 ml)
1
valproic acid oral capsule 250 mg 1
vigabatrin oral powder in packet 500 mg 2 PA LA
vigabatrin oral tablet 500 mg 2 PA LA
vigadrone oral powder in packet 500 mg 2 PA ST
VIMPAT ORAL SOLUTION 10 MGML 1 PA ST QL (6 per 30 days)
VIMPAT ORAL TABLET 100 MG 150 MG 200 MG 50 MG
1 ST QL (60 per 30 days)
27
Drug Name Drug Tier Requirements Limits
XCOPRI MAINTENANCE PACK ORAL TABLET 250 MGDAY (200 MG X1-50 MG X1) 350 MGDAY (200 MG X1-150MG X1)
2
XCOPRI MAINTENANCE PACK ORAL TABLET 250MGDAY(150 MG X1-100MG X1)
2 PA ST
XCOPRI ORAL TABLET 100 MG 150 MG 200 MG 50 MG
2
XCOPRI TITRATION PACK ORAL TABLETSDOSE PACK 125 MG (14)- 25 MG (14) 150 MG (14)- 200 MG (14) 50 MG (14)- 100 MG (14)
2
zonisamide oral capsule 100 mg 25 mg 50 mg 1
ANTIPARKINSONISM AGENTS
APOKYN SUBCUTANEOUS CARTRIDGE 10 MGML
2 PA LA QL (1 per 30 days)
benztropine injection solution 1 mgml 1
benztropine oral tablet 05 mg 1 mg 2 mg 1
bromocriptine oral capsule 5 mg 1
bromocriptine oral tablet 25 mg 1
carbidopa oral tablet 25 mg 1
carbidopa-levodopa oral tablet 10-100 mg 25-100 mg 25-250 mg
1
carbidopa-levodopa oral tablet extended release 25-100 mg 50-200 mg
1
carbidopa-levodopa oral tabletdisintegrating 10-100 mg 25-100 mg 25-250 mg
1
carbidopa-levodopa-entacapone oral tablet 125-50-200 mg 1875-75-200 mg 25-100-200 mg 3125-125-200 mg 375-150-200 mg 50-200-200 mg
1
entacapone oral tablet 200 mg 1
pramipexole oral tablet 0125 mg 025 mg 05 mg 075 mg 1 mg 15 mg
1
pramipexole oral tablet extended release 24 hr 0375 mg 075 mg 15 mg 225 mg 3 mg 375 mg 45 mg
1
rasagiline oral tablet 05 mg 1 mg 1
ropinirole oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg 5 mg
1
28
Drug Name Drug Tier Requirements Limits
ropinirole oral tablet extended release 24 hr 12 mg 2 mg 4 mg 6 mg 8 mg
1
selegiline hcl oral capsule 5 mg 1
selegiline hcl oral tablet 5 mg 1
tolcapone oral tablet 100 mg 1
trihexyphenidyl oral elixir 04 mgml 1
trihexyphenidyl oral tablet 2 mg 5 mg 1
MIGRAINE amp CLUSTER HEADACHE THERAPY
AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MGML 70 MGML
1 PA ST
AJOVY AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 225 MG15 ML
1 ST
AJOVY SYRINGE SUBCUTANEOUS SYRINGE 225 MG15 ML
1 PA ST
almotriptan malate oral tablet 125 mg 625 mg 1 QL (18 per 30 days)
dihydroergotamine injection solution 1 mgml 1
dihydroergotamine nasal spraynon-aerosol 05 mgpump act (4 mgml)
1 QL (8 per 30 days)
eletriptan oral tablet 20 mg 40 mg 1 QL (18 per 30 days)
EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MGML
1 PA ST
EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MGML 300 MG3 ML (100 MGML X 3)
1 PA ST
ergotamine-caffeine oral tablet 1-100 mg 1
frovatriptan oral tablet 25 mg 1 QL (18 per 30 days)
migergot rectal suppository 2-100 mg 1
naratriptan oral tablet 1 mg 25 mg 1 QL (18 per 30 days)
ONZETRA XSAIL NASAL AEROSOL POWDR BREATH ACTIVATED 11 MG
1 ST QL (16 per 30 days)
rizatriptan oral tablet 10 mg 5 mg 1 QL (18 per 30 days)
rizatriptan oral tabletdisintegrating 10 mg 5 mg 1 QL (18 per 30 days)
sumatriptan nasal spraynon-aerosol 20 mgactuation 5 mgactuation
1 QL (18 per 30 days)
sumatriptan succinate oral tablet 100 mg 25 mg 50 mg
1 QL (18 per 30 days)
sumatriptan succinate subcutaneous cartridge 4 mg05 ml 6 mg05 ml
1 QL (8 per 30 days)
29
Drug Name Drug Tier Requirements Limits
sumatriptan succinate subcutaneous pen injector 4 mg05 ml 6 mg05 ml
1 QL (8 per 30 days)
sumatriptan succinate subcutaneous solution 6 mg05 ml
1 QL (8 per 30 days)
sumatriptan succinate subcutaneous syringe 6 mg05 ml
1 QL (8 per 30 days)
UBRELVY ORAL TABLET 100 MG 50 MG 1 QL (16 per 30 days)
VYEPTI INTRAVENOUS SOLUTION 100 MGML
MB PA
zolmitriptan oral tablet 25 mg 5 mg 1 QL (18 per 30 days)
zolmitriptan oral tabletdisintegrating 25 mg 5 mg
1 QL (18 per 30 days)
ZOMIG NASAL SPRAYNON-AEROSOL 25 MG 5 MG
1 ST QL (18 per 30 days)
MISCELLANEOUS NEUROLOGICAL THERAPY
AUSTEDO ORAL TABLET 12 MG 6 MG 9 MG
2 PA LA
dalfampridine oral tablet extended release 12 hr 10 mg
2 PA LA QL (60 per 30 days)
donepezil oral tablet 10 mg 23 mg 5 mg 1
donepezil oral tabletdisintegrating 10 mg 5 mg 1
EXONDYS-51 INTRAVENOUS SOLUTION 50 MGML
MB PA
galantamine oral capsuleext rel pellets 24 hr 16 mg 24 mg 8 mg
1
galantamine oral solution 4 mgml 1
galantamine oral tablet 12 mg 4 mg 8 mg 1
memantine oral capsulesprinkleer 24hr 14 mg 21 mg 28 mg 7 mg
1
memantine oral solution 2 mgml 1
memantine oral tablet 10 mg 5 mg 1
NUEDEXTA ORAL CAPSULE 20-10 MG 1
ONPATTRO INTRAVENOUS SOLUTION 2 MGML
MB PA
RADICAVA INTRAVENOUS SOLUTION 30 MG100 ML
MB PA
rivastigmine tartrate oral capsule 15 mg 3 mg 45 mg 6 mg
1
30
Drug Name Drug Tier Requirements Limits
rivastigmine transdermal patch 24 hour 133 mg24 hour 46 mg24 hour 95 mg24 hour
1
tetrabenazine oral tablet 125 mg 25 mg 2 LA
TYSABRI INTRAVENOUS SOLUTION 300 MG15 ML
MB PA ST LA
VYONDYS-53 INTRAVENOUS SOLUTION 50 MGML
MB PA
ZOLGENSMA INTRAVENOUS KIT 2 X 10EXP13 VGML
MB LA
MUSCLE RELAXANTS amp ANTISPASMODIC THERAPY
baclofen oral tablet 10 mg 20 mg 5 mg 1
carisoprodol oral tablet 250 mg 350 mg 1
carisoprodol-aspirin oral tablet 200-325 mg 1
carisoprodol-aspirin-codeine oral tablet 200-325-16 mg
1 PA ST
chlorzoxazone oral tablet 250 mg 375 mg 750 mg 1 ST
chlorzoxazone oral tablet 500 mg 1
cyclobenzaprine oral tablet 10 mg 5 mg 75 mg 1
dantrolene oral capsule 100 mg 25 mg 50 mg 1
meprobamate oral tablet 200 mg 400 mg 1
metaxalone oral tablet 400 mg 800 mg 1
methocarbamol oral tablet 500 mg 750 mg 1
orphenadrine citrate injection solution 30 mgml 1
orphenadrine citrate oral tablet extended release 100 mg
1
pyridostigmine bromide oral syrup 60 mg5 ml 1
pyridostigmine bromide oral tablet 60 mg 1
pyridostigmine bromide oral tablet extended release 180 mg
1
tizanidine oral capsule 2 mg 4 mg 6 mg 1
tizanidine oral tablet 2 mg 4 mg 1
vanadom oral tablet 350 mg 1
NARCOTIC ANALGESICS
acetaminophen-caff-dihydrocod oral capsule 3205-30-16 mg
1 PA ST
acetaminophen-caff-dihydrocod oral tablet 325-30-16 mg
1 PA ST
31
Drug Name Drug Tier Requirements Limits
acetaminophen-codeine oral solution 120-12 mg5 ml 300 mg-30 mg 125 ml
1 PA ST
acetaminophen-codeine oral tablet 300-15 mg 300-30 mg 300-60 mg
1 PA ST
ascomp with codeine oral capsule 30-50-325-40 mg
1 PA ST
buprenorphine hcl injection solution 03 mgml 1 PA ST
buprenorphine hcl injection syringe 03 mgml 1 PA ST
buprenorphine hcl sublingual tablet 2 mg 8 mg 1
buprenorphine transdermal patch weekly 10 mcghour 15 mcghour 20 mcghour 5 mcghour 75 mcghour
1
butalbital compound wcodeine oral capsule 30-50-325-40 mg
1 PA ST
butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg 50-325-40-30 mg
1 PA ST
butalbital-acetaminophen-caff oral capsule 50-300-40 mg 50-325-40 mg
1
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
1
butalbital-aspirin-caffeine oral capsule 50-325-40 mg
1
butalbital-aspirin-caffeine oral tablet 50-325-40 mg
1
codeine sulfate oral tablet 15 mg 30 mg 60 mg 1 PA ST
codeine-butalbital-asa-caff oral capsule 30-50-325-40 mg
1 PA ST
diskets oral tabletsoluble 40 mg 1 PA ST
DSUVIA SUBLINGUAL TABLET IN APPLICATOR 30 MCG
MB
duramorph (pf) injection solution 05 mgml 1 mgml
MB PA ST
dvorah oral tablet 325-30-16 mg 1 PA ST
endocet oral tablet 10-325 mg 25-325 mg 5-325 mg 75-325 mg
1 PA ST
fentanyl citrate buccal lozenge on a handle 1200 mcg 1600 mcg 200 mcg 400 mcg 600 mcg 800 mcg
1 PA
32
Drug Name Drug Tier Requirements Limits
fentanyl transdermal patch 72 hour 100 mcghr 12 mcghr 25 mcghr 375 mcghour 50 mcghr 625 mcghour 75 mcghr 875 mcghour
1 PA ST
hydrocodone bitartrate oral capsule oral only er 12hr 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg
1 PA ST QL (60 per 30 days)
hydrocodone bitartrate oral tabletoral onlyextrel24 hr 100 mg 120 mg 20 mg 30 mg 40 mg 60 mg 80 mg
1 PA ST
hydrocodone-acetaminophen oral solution 10-325 mg15 ml(15 ml) 75-325 mg15 ml
1 PA ST
hydrocodone-acetaminophen oral tablet 10-300 mg 10-325 mg 5-300 mg 5-325 mg 75-300 mg 75-325 mg
1 PA ST
hydrocodone-ibuprofen oral tablet 10-200 mg 5-200 mg 75-200 mg
1 PA ST
HYDROMORPHONE INJECTION SYRINGE 05 MG05 ML
1 PA ST
hydromorphone oral liquid 1 mgml 1 PA ST
hydromorphone oral tablet 2 mg 4 mg 8 mg 1 PA ST
hydromorphone oral tablet extended release 24 hr 12 mg 16 mg 32 mg 8 mg
1 PA ST QL (60 per 30 days)
hydromorphone rectal suppository 3 mg 1 PA ST
levorphanol tartrate oral tablet 2 mg 3 mg 1 PA ST
meperidine oral solution 50 mg5 ml 1 PA ST
meperidine oral tablet 50 mg 1 PA ST
methadone injection solution 10 mgml 1 PA ST
methadone oral concentrate 10 mgml 1 PA ST
methadone oral solution 10 mg5 ml 5 mg5 ml 1 PA ST
methadone oral tablet 10 mg 5 mg 1 PA ST
methadone oral tabletsoluble 40 mg 1 PA ST
methadose oral concentrate 10 mgml 1 PA ST
methadose oral tabletsoluble 40 mg 1 PA ST
morphine (pf) injection solution 05 mgml MB PA ST
morphine concentrate oral solution 100 mg5 ml (20 mgml)
1 PA ST
morphine oral capsule er multiphase 24 hr 120 mg 30 mg 45 mg 60 mg 75 mg 90 mg
1 PA ST QL (60 per 30 days)
morphine oral capsuleextendrelease pellets 10 mg 100 mg 20 mg 50 mg 80 mg
1 PA ST QL (90 per 30 days)
33
Drug Name Drug Tier Requirements Limits
morphine oral capsuleextendrelease pellets 30 mg 60 mg
1 PA ST QL (60 per 30 days)
morphine oral capsuleextendrelease pellets 40 mg
1 PA QL (90 per 30 days)
morphine oral solution 10 mg5 ml 20 mg5 ml (4 mgml)
1 PA ST
morphine oral tablet 15 mg 30 mg 1 PA ST
morphine oral tablet extended release 100 mg 15 mg 200 mg 30 mg 60 mg
1 PA ST QL (120 per 30 days)
morphine rectal suppository 10 mg 20 mg 30 mg 5 mg
1 PA ST
oxycodone oral capsule 5 mg 1 PA ST
oxycodone oral concentrate 20 mgml 1 PA ST
oxycodone oral solution 5 mg5 ml 1 PA ST
oxycodone oral tablet 10 mg 15 mg 20 mg 30 mg 5 mg
1 PA ST
oxycodone-acetaminophen oral tablet 10-325 mg 25-300 mg 25-325 mg 5-325 mg 75-325 mg
1 PA ST
oxycodone-aspirin oral tablet 48355-325 mg 1 PA ST
OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 10 MG 15 MG 20 MG 30 MG 40 MG
1 PA ST QL (90 per 30 days)
OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 60 MG 80 MG
1 PA ST QL (120 per 30 days)
oxymorphone oral tablet 10 mg 5 mg 1 PA ST
oxymorphone oral tablet extended release 12 hr 10 mg 15 mg 20 mg 30 mg 40 mg 5 mg 75 mg
1 PA ST QL (90 per 30 days)
SUBLOCADE SUBCUTANEOUS SOLUTION EXTENDED REL SYRINGE 100 MG05 ML 300 MG15 ML
MB
tencon oral tablet 50-325 mg 1
NON-NARCOTIC ANALGESICS
adult aspirin regimen oral tabletdelayed release (drec) 81 mg
ACA PV
aspirin low dose oral tabletdelayed release (drec) 81 mg
ACA PV
aspirin oral tablet 325 mg ACA PV
aspirin oral tabletchewable 81 mg ACA PV
34
Drug Name Drug Tier Requirements Limits
aspirin oral tabletdelayed release (drec) 325 mg 81 mg
ACA PV
aspir-trin oral tabletdelayed release (drec) 325 mg
ACA PV
bayer aspirin oral tablet 325 mg ACA PV
BAYER CHEWABLE ASPIRIN ORAL TABLETCHEWABLE 81 MG
ACA PV
buprenorphine-naloxone sublingual film 12-3 mg 1 QL (60 per 30 days)
buprenorphine-naloxone sublingual film 2-05 mg 4-1 mg 8-2 mg
1 QL (90 per 30 days)
buprenorphine-naloxone sublingual tablet 2-05 mg 8-2 mg
1 QL (90 per 30 days)
butorphanol nasal spraynon-aerosol 10 mgml 1 PA ST QL (5 per 30 days)
cataflam oral tablet 50 mg 1
celecoxib oral capsule 100 mg 200 mg 400 mg 50 mg
1
childrens aspirin oral tabletchewable 81 mg ACA PV
cholinemagnesium salicylate oral liquid 500 mg5 ml
1
diclofenac potassium oral tablet 50 mg 1
diclofenac sodium oral tablet extended release 24 hr 100 mg
1
diclofenac sodium oral tabletdelayed release (drec) 25 mg 50 mg 75 mg
1
diclofenac sodium topical drops 15 1
diclofenac sodium topical gel 1 1
diclofenac-misoprostol oral tabletirdelayed relbiphasic 50-200 mg-mcg 75-200 mg-mcg
1
diflunisal oral tablet 500 mg 1
DUEXIS ORAL TABLET 800-266 MG 1 ST
ecotrin low strength oral tabletdelayed release (drec) 81 mg
ACA PV
ecotrin oral tabletdelayed release (drec) 325 mg ACA PV
etodolac oral capsule 200 mg 300 mg 1
etodolac oral tablet 400 mg 500 mg 1
etodolac oral tablet extended release 24 hr 400 mg 500 mg 600 mg
1
EUFLEXXA INTRA-ARTICULAR SYRINGE 10 MGML(MW 24 -36 MILLION)
MB
35
Drug Name Drug Tier Requirements Limits
fenoprofen oral tablet 600 mg 1
flurbiprofen oral tablet 100 mg 1
ibu oral tablet 400 mg 600 mg 800 mg 1
ibuprofen oral suspension 100 mg5 ml 1
ibuprofen oral tablet 400 mg 600 mg 800 mg 1
indomethacin oral capsule 25 mg 50 mg 1
indomethacin oral capsule extended release 75 mg
1
ketoprofen oral capsule 25 mg 50 mg 75 mg 1
ketoprofen oral capsuleext rel pellets 24 hr 200 mg
1
ketorolac injection cartridge 15 mgml 30 mgml 1
ketorolac injection solution 15 mgml 30 mgml MB
ketorolac injection solution 30 mgml (1 ml) 1
ketorolac intramuscular cartridge 60 mg2 ml 1
ketorolac intramuscular solution 60 mg2 ml 1
ketorolac intramuscular syringe 60 mg2 ml 1
ketorolac oral tablet 10 mg 1
meclofenamate oral capsule 100 mg 50 mg 1
mefenamic acid oral capsule 250 mg 1
meloxicam oral tablet 15 mg 75 mg 1
MONOVISC INTRA-ARTICULAR SYRINGE 88 MG4 ML
MB LA
nabumetone oral tablet 500 mg 750 mg 1
nalbuphine injection solution 10 mgml MB PA ST
naloxone injection solution 04 mgml 1
naloxone injection syringe 04 mgml 1 mgml 1
naltrexone oral tablet 50 mg 1
naproxen oral suspension 125 mg5 ml 1
naproxen oral tablet 250 mg 375 mg 500 mg 1
naproxen oral tabletdelayed release (drec) 375 mg 500 mg
1
naproxen sodium oral tablet 275 mg 550 mg 1
NARCAN NASAL SPRAYNON-AEROSOL 4 MGACTUATION
1
36
Drug Name Drug Tier Requirements Limits
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG 150 MG 200 MG 250 MG 50 MG
1 PA ST QL (60 per 30 days)
ORTHOVISC INTRA-ARTICULAR SYRINGE 30 MG2 ML
MB
oxaprozin oral tablet 600 mg 1
pentazocine-naloxone oral tablet 50-05 mg 1 PA ST
piroxicam oral capsule 10 mg 20 mg 1
salsalate oral tablet 500 mg 750 mg 1
st joseph aspirin oral tabletchewable 81 mg ACA PV
st joseph aspirin oral tabletdelayed release (drec) 81 mg
ACA PV
sulindac oral tablet 150 mg 200 mg 1
tolmetin oral capsule 400 mg 1
tolmetin oral tablet 200 mg 600 mg 1
tramadol oral tablet 50 mg 1 PA ST
tramadol oral tablet extended release 24 hr 100 mg 200 mg 300 mg
1 PA ST
tramadol oral tablet er multiphase 24 hr 100 mg 200 mg 300 mg
1 PA ST
tramadol-acetaminophen oral tablet 375-325 mg 1 PA ST
VIVITROL INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 380 MG
MB
PSYCHOTHERAPEUTIC DRUGS
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 300 MG 400 MG
1
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 300 MG 400 MG
1
ADHANSIA XR ORAL CAPSULE ER BIPHASIC 20-80 25 MG 35 MG 45 MG 55 MG 70 MG 85 MG
1 PA ST
ADZENYS ER ORAL SUSPEN IR - ER BIPHASIC 24HR 125 MGML
1 ST
ADZENYS XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 125 MG 157 MG 188 MG 31 MG 63 MG 94 MG
1 ST
37
Drug Name Drug Tier Requirements Limits
alprazolam intensol oral concentrate 1 mgml 1
alprazolam oral tablet 025 mg 05 mg 1 mg 2 mg
1
alprazolam oral tablet extended release 24 hr 05 mg 1 mg 2 mg 3 mg
1
alprazolam oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg
1
amitriptyline oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
amitriptyline-chlordiazepoxide oral tablet 125-5 mg 25-10 mg
1
amoxapine oral tablet 100 mg 150 mg 25 mg 50 mg
1
AMPHETAMINE ORAL SUSPEN IR - ER BIPHASIC 24HR 125 MGML
1 ST
amphetamine sulfate oral tablet 10 mg 5 mg 1
APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG 348 MG 522 MG
1 ST
aripiprazole oral solution 1 mgml 1
aripiprazole oral tablet 10 mg 15 mg 2 mg 20 mg 30 mg 5 mg
1
aripiprazole oral tabletdisintegrating 10 mg 15 mg
1
ARISTADA INITIO INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 675 MG24 ML
MB
ARISTADA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 1064 MG39 ML 441 MG16 ML 662 MG24 ML 882 MG32 ML
MB
armodafinil oral tablet 150 mg 200 mg 250 mg 50 mg
1
asenapine maleate sublingual tablet 10 mg 25 mg 5 mg
1
atomoxetine oral capsule 10 mg 100 mg 18 mg 25 mg 40 mg 60 mg 80 mg
1
BELSOMRA ORAL TABLET 10 MG 15 MG 20 MG 5 MG
1 ST
bupropion hcl oral tablet 100 mg 75 mg 1
bupropion hcl oral tablet extended release 24 hr 150 mg 300 mg
1
38
Drug Name Drug Tier Requirements Limits
bupropion hcl oral tablet sustained-release 12 hr 100 mg 150 mg 200 mg
1
buspirone oral tablet 10 mg 15 mg 30 mg 5 mg 75 mg
1
chlordiazepoxide hcl oral capsule 10 mg 25 mg 5 mg
1
chlorpromazine injection solution 25 mgml 1
chlorpromazine oral tablet 10 mg 100 mg 200 mg 25 mg 50 mg
1
citalopram oral solution 10 mg5 ml 1
citalopram oral tablet 10 mg 20 mg 40 mg 1
clomipramine oral capsule 25 mg 50 mg 75 mg 1
clonidine hcl oral tablet extended release 12 hr 01 mg
1
clorazepate dipotassium oral tablet 15 mg 375 mg 75 mg
1
clozapine oral tablet 100 mg 200 mg 25 mg 50 mg
1
clozapine oral tabletdisintegrating 100 mg 125 mg 150 mg 200 mg 25 mg
1
COTEMPLA XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 173 MG 259 MG 86 MG
1 ST
DAYTRANA TRANSDERMAL PATCH 24 HOUR 10 MG9 HR 15 MG9 HR 20 MG9 HR 30 MG9 HR
1 ST
desipramine oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG 50 MG
1 ST
desvenlafaxine succinate oral tablet extended release 24 hr 100 mg 25 mg 50 mg
1
dexmethylphenidate oral capsuleer biphasic 50-50 10 mg 15 mg 20 mg 25 mg 30 mg 35 mg 40 mg 5 mg
1
dexmethylphenidate oral tablet 10 mg 25 mg 5 mg
1
dextroamphetamine oral capsule extended release 10 mg 15 mg 5 mg
1
dextroamphetamine oral solution 5 mg5 ml 1
39
Drug Name Drug Tier Requirements Limits
dextroamphetamine oral tablet 10 mg 5 mg 1
dextroamphetamine-amphetamine oral capsuleextended release 24hr 10 mg 15 mg 20 mg 25 mg 30 mg 5 mg
1
dextroamphetamine-amphetamine oral tablet 10 mg 125 mg 15 mg 20 mg 30 mg 5 mg 75 mg
1
diazepam injection solution 5 mgml MB
diazepam injection syringe 5 mgml MB
diazepam intensol oral concentrate 5 mgml 1
diazepam oral solution 5 mg5 ml (1 mgml) 1
diazepam oral tablet 10 mg 2 mg 5 mg 1
doxepin oral capsule 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
doxepin oral concentrate 10 mgml 1
duloxetine oral capsuledelayed release(drec) 20 mg 30 mg 40 mg 60 mg
1
DYANAVEL XR ORAL SUSPEN IR - ER BIPHASIC 24HR 25 MGML
1 ST
EDLUAR SUBLINGUAL TABLET 10 MG 5 MG
1 ST
EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG24 HR 6 MG24 HR 9 MG24 HR
1 ST
ergoloid oral tablet 1 mg 1
escitalopram oxalate oral solution 5 mg5 ml 1
escitalopram oxalate oral tablet 10 mg 20 mg 5 mg
1
estazolam oral tablet 1 mg 2 mg 1
eszopiclone oral tablet 1 mg 2 mg 3 mg 1
FANAPT ORAL TABLET 1 MG 10 MG 12 MG 2 MG 4 MG 6 MG 8 MG
1 PA ST
FANAPT ORAL TABLETSDOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)
1 PA ST
FETZIMA ORAL CAPSULEEXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)
1 ST
FETZIMA ORAL CAPSULEEXTENDED RELEASE 24 HR 120 MG 20 MG 40 MG 80 MG
1 ST
fluoxetine oral capsule 10 mg 20 mg 40 mg 1
40
Drug Name Drug Tier Requirements Limits
fluoxetine oral capsuledelayed release(drec) 90 mg
1
fluoxetine oral solution 20 mg5 ml (4 mgml) 1
fluoxetine oral tablet 10 mg 20 mg 1
fluoxetine oral tablet 60 mg 1 PA
fluphenazine hcl injection solution 25 mgml 1
fluphenazine hcl oral concentrate 5 mgml 1
fluphenazine hcl oral elixir 25 mg5 ml 1
fluphenazine hcl oral tablet 1 mg 10 mg 25 mg 5 mg
1
flurazepam oral capsule 15 mg 30 mg 1
fluvoxamine oral capsuleextended release 24hr 100 mg 150 mg
1
fluvoxamine oral tablet 100 mg 25 mg 50 mg 1
guanfacine oral tablet extended release 24 hr 1 mg 2 mg 3 mg 4 mg
1
haloperidol decanoate intramuscular solution 100 mgml 50 mgml
1
haloperidol lactate injection solution 5 mgml 1
haloperidol lactate oral concentrate 2 mgml 1
haloperidol oral tablet 05 mg 1 mg 10 mg 2 mg 20 mg 5 mg
1
HETLIOZ LQ ORAL SUSPENSION 4 MGML 2 PA ST LA
HETLIOZ ORAL CAPSULE 20 MG 2 PA ST LA
imipramine hcl oral tablet 10 mg 25 mg 50 mg 1
imipramine pamoate oral capsule 100 mg 125 mg 150 mg 75 mg
1
INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG075 ML 156 MGML 234 MG15 ML 39 MG025 ML 78 MG05 ML
1
JORNAY PM ORAL CAPSULEDEL RELEXT REL SPRINK 100 MG 20 MG 40 MG 60 MG 80 MG
1 ST
LATUDA ORAL TABLET 120 MG 20 MG 40 MG 60 MG 80 MG
1 PA ST
lithium carbonate oral capsule 150 mg 300 mg 600 mg
1
lithium carbonate oral tablet 300 mg 1
41
Drug Name Drug Tier Requirements Limits
lithium carbonate oral tablet extended release 300 mg 450 mg
1
lorazepam intensol oral concentrate 2 mgml 1
lorazepam oral concentrate 2 mgml 1
lorazepam oral tablet 05 mg 1 mg 2 mg 1
loxapine succinate oral capsule 10 mg 25 mg 5 mg 50 mg
1
maprotiline oral tablet 25 mg 50 mg 75 mg 1
MARPLAN ORAL TABLET 10 MG 1
methamphetamine oral tablet 5 mg 1
METHYLIN ORAL SOLUTION 10 MG5 ML 5 MG5 ML
1
methylphenidate hcl oral caper sprinklebiphasic 40-60 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg 60 mg
1
methylphenidate hcl oral capsule er biphasic 30-70 10 mg 20 mg 30 mg 40 mg 50 mg 60 mg
1
methylphenidate hcl oral capsuleer biphasic 50-50 10 mg 20 mg 30 mg 40 mg 60 mg
1
methylphenidate hcl oral solution 10 mg5 ml 5 mg5 ml
1
methylphenidate hcl oral tablet 10 mg 20 mg 5 mg
1
methylphenidate hcl oral tablet extended release 10 mg 20 mg
1
methylphenidate hcl oral tablet extended release 24hr 18 mg 27 mg 36 mg 54 mg
1
methylphenidate hcl oral tabletchewable 10 mg 25 mg 5 mg
1
midazolam oral syrup 2 mgml 1
mirtazapine oral tablet 15 mg 30 mg 45 mg 75 mg
1
mirtazapine oral tabletdisintegrating 15 mg 30 mg 45 mg
1
modafinil oral tablet 100 mg 200 mg 1
molindone oral tablet 10 mg 25 mg 5 mg 1
MYDAYIS ORAL CAPSULE ER TRIPHASIC 24 HR 125 MG 25 MG 375 MG 50 MG
1 ST
nefazodone oral tablet 100 mg 150 mg 200 mg 250 mg 50 mg
1
42
Drug Name Drug Tier Requirements Limits
nortriptyline oral capsule 10 mg 25 mg 50 mg 75 mg
1
nortriptyline oral solution 10 mg5 ml 1
NUPLAZID ORAL CAPSULE 34 MG 2 PA LA
NUPLAZID ORAL TABLET 10 MG 2 PA LA
olanzapine intramuscular recon soln 10 mg 1
olanzapine oral tablet 10 mg 15 mg 25 mg 20 mg 5 mg 75 mg
1
olanzapine oral tabletdisintegrating 10 mg 15 mg 20 mg 5 mg
1
olanzapine-fluoxetine oral capsule 12-25 mg 12-50 mg 3-25 mg 6-25 mg 6-50 mg
1
oxazepam oral capsule 10 mg 15 mg 30 mg 1
paliperidone oral tablet extended release 24hr 15 mg 3 mg 6 mg 9 mg
1
paroxetine hcl oral tablet 10 mg 20 mg 30 mg 40 mg
1
paroxetine hcl oral tablet extended release 24 hr 125 mg 25 mg 375 mg
1
paroxetine mesylate(menopsym) oral capsule 75 mg
1
perphenazine oral tablet 16 mg 2 mg 4 mg 8 mg 1
perphenazine-amitriptyline oral tablet 2-10 mg 2-25 mg 4-10 mg 4-25 mg 4-50 mg
1
phenelzine oral tablet 15 mg 1
pimozide oral tablet 1 mg 2 mg 1
procentra oral solution 5 mg5 ml 1
protriptyline oral tablet 10 mg 5 mg 1
quetiapine oral tablet 100 mg 200 mg 25 mg 300 mg 400 mg 50 mg
1
quetiapine oral tablet extended release 24 hr 150 mg 200 mg 300 mg 400 mg 50 mg
1
QUILLICHEW ER ORAL TABLETCHEWIR-ERBIPHASIC24HR 20 MG 30 MG 40 MG
1 ST
QUILLIVANT XR ORAL SUSPENSIONEXT REL 24HRRECON 5 MGML (25 MG5 ML)
1 ST
ramelteon oral tablet 8 mg 1
RELEXXII ORAL TABLET EXTENDED RELEASE 24HR 72 MG
1 ST
43
Drug Name Drug Tier Requirements Limits
REXULTI ORAL TABLET 025 MG 05 MG 1 MG 2 MG 3 MG 4 MG
1 PA ST
RISPERDAL CONSTA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 125 MG2 ML 25 MG2 ML 375 MG2 ML 50 MG2 ML
1
risperidone oral solution 1 mgml 1
risperidone oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg
1
risperidone oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg
1
seconal sodium oral capsule 100 mg 1
sertraline oral concentrate 20 mgml 1
sertraline oral tablet 100 mg 25 mg 50 mg 1
SPRAVATO NASAL SPRAYNON-AEROSOL 56 MG (28 MG X 2) 84 MG (28 MG X 3)
MB PA
SUNOSI ORAL TABLET 150 MG 1 PA QL (30 per 30 days)
SUNOSI ORAL TABLET 75 MG 1 PA QL (60 per 30 days)
temazepam oral capsule 15 mg 225 mg 30 mg 75 mg
1
thioridazine oral tablet 10 mg 100 mg 25 mg 50 mg
1
thiothixene oral capsule 1 mg 10 mg 2 mg 5 mg 1
tranylcypromine oral tablet 10 mg 1
trazodone oral tablet 100 mg 150 mg 300 mg 50 mg
1
triazolam oral tablet 0125 mg 025 mg 1
trifluoperazine oral tablet 1 mg 10 mg 2 mg 5 mg
1
trimipramine oral capsule 100 mg 25 mg 50 mg 1
TRINTELLIX ORAL TABLET 10 MG 20 MG 5 MG
1 ST
venlafaxine oral capsuleextended release 24hr 150 mg 375 mg 75 mg
1
venlafaxine oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg
1
venlafaxine oral tablet extended release 24hr 150 mg 225 mg 375 mg 75 mg
1
VERSACLOZ ORAL SUSPENSION 50 MGML 1 PA ST
44
Drug Name Drug Tier Requirements Limits
VRAYLAR ORAL CAPSULE 15 MG 3 MG 45 MG 6 MG
1 PA ST
VRAYLAR ORAL CAPSULEDOSE PACK 15 MG (1)- 3 MG (6)
1 PA ST
VYVANSE ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG 70 MG
1 PA ST
VYVANSE ORAL TABLETCHEWABLE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG
1 PA ST
XYREM ORAL SOLUTION 500 MGML 1 PA QL (540 per 30 days)
zaleplon oral capsule 10 mg 5 mg 1
ZENZEDI ORAL TABLET 15 MG 25 MG 20 MG 30 MG 75 MG
1 ST
ziprasidone hcl oral capsule 20 mg 40 mg 60 mg 80 mg
1
zolpidem oral tablet 10 mg 5 mg 1
zolpidem oral tabletext release multiphase 125 mg 625 mg
1
zolpidem sublingual tablet 175 mg 35 mg 1
ZOLPIMIST ORAL SPRAYNON-AEROSOL 5 MGSPRAY (01 ML)
1 ST
ZULRESSO INTRAVENOUS SOLUTION 5 MGML
MB
CARDIOVASCULAR HYPERTENSION amp LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone oral tablet 100 mg 200 mg 400 mg 1
disopyramide phosphate oral capsule 100 mg 150 mg
1
dofetilide oral capsule 125 mcg 250 mcg 500 mcg 1
flecainide oral tablet 100 mg 150 mg 50 mg 1
mexiletine oral capsule 150 mg 200 mg 250 mg 1
MULTAQ ORAL TABLET 400 MG 1
NORPACE CR ORAL CAPSULE EXTENDED RELEASE 100 MG 150 MG
1
pacerone oral tablet 100 mg 200 mg 400 mg 1
procainamide injection solution 100 mgml 500 mgml
MB
propafenone oral capsuleextended release 12 hr 225 mg 325 mg 425 mg
1
45
Drug Name Drug Tier Requirements Limits
propafenone oral tablet 150 mg 225 mg 300 mg 1
quinidine gluconate oral tablet extended release 324 mg
1
quinidine sulfate oral tablet 200 mg 300 mg 1
sorine oral tablet 120 mg 160 mg 240 mg 80 mg 1
sotalol af oral tablet 120 mg 160 mg 80 mg 1
sotalol oral tablet 120 mg 160 mg 240 mg 80 mg 1
ANTIHYPERTENSIVE THERAPY
acebutolol oral capsule 200 mg 400 mg 1
aliskiren oral tablet 150 mg 300 mg 1
amiloride oral tablet 5 mg 1
amiloride-hydrochlorothiazide oral tablet 5-50 mg 1
amlodipine oral tablet 10 mg 25 mg 5 mg 1
amlodipine-benazepril oral capsule 10-20 mg 10-40 mg 25-10 mg 5-10 mg 5-20 mg 5-40 mg
1 ST
amlodipine-olmesartan oral tablet 10-20 mg 10-40 mg 5-20 mg 5-40 mg
1 ST
amlodipine-valsartan oral tablet 10-160 mg 10-320 mg 5-160 mg 5-320 mg
1 ST
amlodipine-valsartan-hcthiazid oral tablet 10-160-125 mg 10-160-25 mg 10-320-25 mg 5-160-125 mg 5-160-25 mg
1
atenolol oral tablet 100 mg 25 mg 50 mg 1
atenolol-chlorthalidone oral tablet 100-25 mg 50-25 mg
1
benazepril oral tablet 10 mg 20 mg 40 mg 5 mg 1
benazepril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg 5-625 mg
1
betaxolol oral tablet 10 mg 20 mg 1
bisoprolol fumarate oral tablet 10 mg 5 mg 1
bisoprolol-hydrochlorothiazide oral tablet 10-625 mg 25-625 mg 5-625 mg
1
bumetanide injection solution 025 mgml 1
bumetanide oral tablet 05 mg 1 mg 2 mg 1
BYSTOLIC ORAL TABLET 10 MG 25 MG 20 MG 5 MG
1 ST
candesartan oral tablet 16 mg 32 mg 4 mg 8 mg 1
46
Drug Name Drug Tier Requirements Limits
candesartan-hydrochlorothiazid oral tablet 16-125 mg 32-125 mg 32-25 mg
1
captopril oral tablet 100 mg 125 mg 25 mg 50 mg
1
captopril-hydrochlorothiazide oral tablet 25-15 mg 25-25 mg 50-15 mg 50-25 mg
1
cartia xt oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg
1
carvedilol oral tablet 125 mg 25 mg 3125 mg 625 mg
1
carvedilol phosphate oral capsule er multiphase 24 hr 10 mg 20 mg 40 mg 80 mg
1
chlorthalidone oral tablet 25 mg 50 mg 1
clonidine hcl oral tablet 01 mg 02 mg 03 mg 1
clonidine transdermal patch weekly 01 mg24 hr 02 mg24 hr 03 mg24 hr
1
diltiazem hcl oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg
1
diltiazem hcl oral capsuleextended release 12 hr 120 mg 60 mg 90 mg
1
diltiazem hcl oral capsuleextended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
diltiazem hcl oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg 360 mg
1
diltiazem hcl oral tablet 120 mg 30 mg 60 mg 90 mg
1
diltiazem hcl oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
dilt-xr oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg
1
doxazosin oral tablet 1 mg 2 mg 4 mg 8 mg 1
EDARBI ORAL TABLET 40 MG 80 MG 1 ST
EDARBYCLOR ORAL TABLET 40-125 MG 40-25 MG
1 ST
enalapril maleate oral tablet 10 mg 25 mg 20 mg 5 mg
1
enalaprilat intravenous solution 125 mgml MB
enalapril-hydrochlorothiazide oral tablet 10-25 mg 5-125 mg
1
EPANED ORAL SOLUTION 1 MGML 1
47
Drug Name Drug Tier Requirements Limits
eplerenone oral tablet 25 mg 50 mg 1
epoprostenol (glycine) intravenous recon soln 05 mg 15 mg
MB PA LA
eprosartan oral tablet 600 mg 1
ethacrynic acid oral tablet 25 mg 1
felodipine oral tablet extended release 24 hr 10 mg 25 mg 5 mg
1
FLOLAN INTRAVENOUS RECON SOLN 05 MG 15 MG
MB PA LA
fosinopril oral tablet 10 mg 20 mg 40 mg 1
fosinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg
1
furosemide oral solution 10 mgml 40 mg5 ml (8 mgml)
1
furosemide oral tablet 20 mg 40 mg 80 mg 1
guanfacine oral tablet 1 mg 2 mg 1
hydralazine oral tablet 10 mg 100 mg 25 mg 50 mg
1
hydrochlorothiazide oral capsule 125 mg 1
hydrochlorothiazide oral tablet 125 mg 25 mg 50 mg
1
indapamide oral tablet 125 mg 25 mg 1
irbesartan oral tablet 150 mg 300 mg 75 mg 1
irbesartan-hydrochlorothiazide oral tablet 150-125 mg 300-125 mg
1
isradipine oral capsule 25 mg 5 mg 1
labetalol oral tablet 100 mg 200 mg 300 mg 1
lisinopril oral tablet 10 mg 25 mg 20 mg 30 mg 40 mg 5 mg
1
lisinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg
1
losartan oral tablet 100 mg 25 mg 50 mg 1
losartan-hydrochlorothiazide oral tablet 100-125 mg 100-25 mg 50-125 mg
1
matzim la oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
methyldopa oral tablet 250 mg 500 mg 1
methyldopa-hydrochlorothiazide oral tablet 250-15 mg 250-25 mg
1
48
Drug Name Drug Tier Requirements Limits
methyldopate intravenous solution 250 mg5 ml MB
metolazone oral tablet 10 mg 25 mg 5 mg 1
metoprolol succinate oral tablet extended release 24 hr 100 mg 200 mg 25 mg 50 mg
1
metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg 100-50 mg 50-25 mg
1
metoprolol tartrate oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg
1
metyrosine oral capsule 250 mg 1
minoxidil oral tablet 10 mg 25 mg 1
moexipril oral tablet 15 mg 75 mg 1
nadolol oral tablet 20 mg 40 mg 80 mg 1
nadolol-bendroflumethiazide oral tablet 80-5 mg 1
nicardipine oral capsule 20 mg 30 mg 1
nifedipine oral capsule 10 mg 20 mg 1
nifedipine oral tablet extended release 24hr 30 mg 60 mg 90 mg
1
nifedipine oral tablet extended release 30 mg 60 mg 90 mg
1
nimodipine oral capsule 30 mg 1
nisoldipine oral tablet extended release 24 hr 17 mg 20 mg 255 mg 30 mg 34 mg 40 mg 85 mg
1
olmesartan oral tablet 20 mg 40 mg 5 mg 1
olmesartan-amlodipin-hcthiazid oral tablet 20-5-125 mg 40-10-125 mg 40-10-25 mg 40-5-125 mg 40-5-25 mg
1
olmesartan-hydrochlorothiazide oral tablet 20-125 mg 40-125 mg 40-25 mg
1 ST
ORENITRAM ORAL TABLET EXTENDED RELEASE 0125 MG 025 MG 1 MG 25 MG 5 MG
2 PA LA
perindopril erbumine oral tablet 2 mg 4 mg 8 mg 1
phenoxybenzamine oral capsule 10 mg 1
pindolol oral tablet 10 mg 5 mg 1
prazosin oral capsule 1 mg 2 mg 5 mg 1
propranolol oral capsuleextended release 24 hr 120 mg 160 mg 60 mg 80 mg
1
propranolol oral solution 20 mg5 ml (4 mgml) 40 mg5 ml (8 mgml)
1
49
Drug Name Drug Tier Requirements Limits
propranolol oral tablet 10 mg 20 mg 40 mg 60 mg 80 mg
1
propranolol-hydrochlorothiazid oral tablet 40-25 mg 80-25 mg
1
QBRELIS ORAL SOLUTION 1 MGML 1
quinapril oral tablet 10 mg 20 mg 40 mg 5 mg 1
quinapril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg
1
ramipril oral capsule 125 mg 10 mg 25 mg 5 mg
1
spironolactone oral tablet 100 mg 25 mg 50 mg 1
spironolacton-hydrochlorothiaz oral tablet 25-25 mg
1
taztia xt oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg
1
TEKTURNA HCT ORAL TABLET 150-125 MG 150-25 MG 300-125 MG 300-25 MG
1
telmisartan oral tablet 20 mg 40 mg 80 mg 1
telmisartan-amlodipine oral tablet 40-10 mg 40-5 mg 80-10 mg 80-5 mg
1 ST
telmisartan-hydrochlorothiazid oral tablet 40-125 mg 80-125 mg 80-25 mg
1
terazosin oral capsule 1 mg 10 mg 2 mg 5 mg 1
tiadylt er oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg 420 mg
1
timolol maleate oral tablet 10 mg 20 mg 5 mg 1
torsemide oral tablet 10 mg 100 mg 20 mg 5 mg 1
trandolapril oral tablet 1 mg 2 mg 4 mg 1
trandolapril-verapamil oral tablet ir - er biphasic 24hr 1-240 mg 2-180 mg 2-240 mg 4-240 mg
1 ST
triamterene oral capsule 100 mg 50 mg 1
triamterene-hydrochlorothiazid oral capsule 375-25 mg
1
triamterene-hydrochlorothiazid oral tablet 375-25 mg 75-50 mg
1
valsartan oral tablet 160 mg 320 mg 40 mg 80 mg
1
valsartan-hydrochlorothiazide oral tablet 160-125 mg 160-25 mg 320-125 mg 320-25 mg 80-125 mg
1
50
Drug Name Drug Tier Requirements Limits
veletri intravenous recon soln 05 mg 15 mg MB PA LA
verapamil oral capsule 24 hr er pellet ct 100 mg 200 mg 300 mg
1
verapamil oral capsuleext rel pellets 24 hr 120 mg 180 mg 240 mg 360 mg
1
verapamil oral tablet 120 mg 40 mg 80 mg 1
verapamil oral tablet extended release 120 mg 180 mg 240 mg
1
CARDIAC GLYCOSIDES
digitek oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
digox oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
digoxin oral solution 50 mcgml (005 mgml) 1
digoxin oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
COAGULATION THERAPY
ADVATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 4000 (+-) UNIT 500 (+-) UNIT
MB
ADYNOVATE INTRAVENOUS SOLUTION 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT 750 (+-) UNIT
MB LA
AFSTYLA INTRAVENOUS RECON SOLN 1000 (+-) UNIT RANGE 1500 (+-) UNIT RANGE 2000 (+-) UNIT RANGE 2500 (+-) UNIT RANGE 250 (+-) UNIT RANGE 3000 (+-) UNIT RANGE 500 (+-) UNIT RANGE
MB LA
ALPHANATE INTRAVENOUS RECON SOLN 1000 (400 VWF) UNIT10 ML 1500 (600 VWF) UNIT10 ML 2000 (800 VWF) UNIT10 ML 250 (100 VWF) UNIT5 ML 500 (200 VWF) UNIT5 ML
MB LA
ALPHANINE SD INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT
MB LA
ALPROLIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 500 UNIT
MB LA
aminocaproic acid oral solution 250 mgml (25 ) 1
51
Drug Name Drug Tier Requirements Limits
aminocaproic acid oral tablet 1000 mg 500 mg 1
ANDEXXA INTRAVENOUS RECON SOLN 200 MG
MB
aspirin-dipyridamole oral capsule er multiphase 12 hr 25-200 mg
1
BENEFIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
BRILINTA ORAL TABLET 60 MG 90 MG 1
CABLIVI INJECTION KIT 11 MG 2 PA
cilostazol oral tablet 100 mg 50 mg 1
clopidogrel oral tablet 300 mg 75 mg 1
COAGADEX INTRAVENOUS RECON SOLN 250 (+-) UNIT RANGE 500 (+-) UNIT RANGE
MB
CORIFACT INTRAVENOUS RECON SOLN 1000-1600 UNIT
MB LA
dipyridamole oral tablet 25 mg 50 mg 75 mg 1
DOPTELET (15 TAB PACK) ORAL TABLET 20 MG
2 PA LA
ELIQUIS DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 5 MG (74 TABS)
1
ELIQUIS ORAL TABLET 25 MG 5 MG 1
ELOCTATE INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 5000 UNIT 500 UNIT 6000 UNIT 750 UNIT
MB LA
enoxaparin subcutaneous solution 300 mg3 ml 2
enoxaparin subcutaneous syringe 100 mgml 120 mg08 ml 150 mgml 30 mg03 ml 40 mg04 ml 60 mg06 ml 80 mg08 ml
2
ESPEROCT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
FEIBA NF INTRAVENOUS RECON SOLN 1750-3250 UNIT 350-650 UNIT 700-1300 UNIT
MB LA
FIBRYGA INTRAVENOUS RECON SOLN 1 GRAM (700 MG- 1300 MG)
MB
fondaparinux subcutaneous syringe 10 mg08 ml 25 mg05 ml 5 mg04 ml 75 mg06 ml
2
52
Drug Name Drug Tier Requirements Limits
FRAGMIN SUBCUTANEOUS SOLUTION 25000 ANTI-XA UNITML
2
FRAGMIN SUBCUTANEOUS SYRINGE 10000 ANTI-XA UNITML 12500 ANTI-XA UNIT05 ML 15000 ANTI-XA UNIT06 ML 18000 ANTI-XA UNIT072 ML 2500 ANTI-XA UNIT02 ML 5000 ANTI-XA UNIT02 ML 7500 ANTI-XA UNIT03 ML
2
HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG07 ML 150 MGML 30 MGML 60 MG04 ML
2 PA LA
HEMOFIL M HIGH INTRAVENOUS RECON SOLN 801-1500 UNIT
MB
HEMOFIL M LOW INTRAVENOUS RECON SOLN 220-400 UNIT
MB
HEMOFIL M MID INTRAVENOUS RECON SOLN 401-800 UNIT
MB
HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 1501-2000 UNIT
MB
hep flush-10 (pf) intravenous solution 10 unitml MB
heparin (porcine) in 5 dex intravenous parenteral solution 25000 unit250 ml(100 unitml) 25000 unit500 ml (50 unitml)
MB
heparin (porcine) injection cartridge 5000 unitml (1 ml)
1
heparin (porcine) injection solution 1000 unitml 10000 unitml 20000 unitml 5000 unitml
1
heparin lock flush (porcine) intravenous solution 100 unitml
MB
heparin lockflush(porcine)(pf) intravenous syringe 100 unitml
MB
HEPARIN(PORCINE) IN 045 NACL INTRAVENOUS PARENTERAL SOLUTION 12500 UNIT250 ML
MB
heparin(porcine) in 045 nacl intravenous parenteral solution 25000 unit250 ml 25000 unit500 ml
MB
heparin porcine (pf) injection solution 1000 unitml 5000 unit05 ml
MB
heparin porcine (pf) injection syringe 5000 unit05 ml
1
53
Drug Name Drug Tier Requirements Limits
heparin porcine (pf) intravenous solution 100 unitml (1 ml)
MB
heparin porcine (pf) intravenous syringe 10 unitml 100 unitml
MB
HUMATE-P INTRAVENOUS RECON SOLN 1000-2400 UNIT 250-600 UNIT 500-1200 UNIT
MB LA
IDELVION INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3500 (+-) UNIT 500 (+-) UNIT
MB LA
IXINITY INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
jantoven oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg
1
JIVI INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
KOATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB
KOGENATE FS INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB
KOVALTRY INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB
MONONINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT
MB LA
MULPLETA ORAL TABLET 3 MG 2 PA LA
NOVOEIGHT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
NOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1000 MCG) 2 MG (2000 MCG) 5 MG (5000 MCG) 8 MG (8000 MCG)
MB LA
NPLATE SUBCUTANEOUS RECON SOLN 125 MCG 250 MCG 500 MCG
MB LA
NUWIQ INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 2500 UNIT 250 (+-) UNIT 3000 UNIT 4000 UNIT 500 (+-) UNIT
MB LA
54
Drug Name Drug Tier Requirements Limits
OBIZUR INTRAVENOUS RECON SOLN 500 (+-) UNIT RANGE
MB
pentoxifylline oral tablet extended release 400 mg 1
phytonadione (vitamin k1) oral tablet 5 mg 1
prasugrel oral tablet 10 mg 5 mg 1
PROFILNINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT
MB LA
PROMACTA ORAL POWDER IN PACKET 125 MG
2 PA ST LA
PROMACTA ORAL POWDER IN PACKET 25 MG
2 LA
PROMACTA ORAL TABLET 125 MG 25 MG 50 MG 75 MG
2 PA ST LA
REBINYN INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 500 (+-) UNIT
MB LA
RECOMBINATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB LA
RIASTAP INTRAVENOUS RECON SOLN 1 GRAM (900MG-1300MG)
MB LA
RIXUBIS INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
tranexamic acid intravenous solution 1000 mg10 ml (100 mgml)
MB
TRETTEN INTRAVENOUS RECON SOLN 2500 UNIT
MB LA
VONVENDI INTRAVENOUS RECON SOLN 1300 (+-) UNIT RANGE 650 (+-) UNIT RANGE
MB LA
warfarin oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg
1
WILATE INTRAVENOUS RECON SOLN 1000-1000 UNIT 500-500 UNIT
MB LA
XARELTO DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 15 MG (42)- 20 MG (9)
1
XARELTO ORAL TABLET 10 MG 15 MG 25 MG 20 MG
1
55
Drug Name Drug Tier Requirements Limits
XYNTHA INTRAVENOUS SOLUTION 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB LA
XYNTHA SOLOFUSE INTRAVENOUS SYRINGE 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
ZONTIVITY ORAL TABLET 208 MG 1
LIPIDCHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg 25-10 mg 25-20 mg 25-40 mg 5-10 mg 5-20 mg 5-40 mg 5-80 mg
1 ST
atorvastatin oral tablet 10 mg 20 mg ACA PV
atorvastatin oral tablet 40 mg 80 mg 1
cholestyramine (with sugar) oral powder 4 gram 1
cholestyramine (with sugar) oral powder in packet 4 gram
1
cholestyramine light oral powder 4 gram 1
cholestyramine light oral powder in packet 4 gram 1
colesevelam oral powder in packet 375 gram 1
colesevelam oral tablet 625 mg 1
colestipol oral granules 5 gram 1
colestipol oral packet 5 gram 1
colestipol oral tablet 1 gram 1
ezetimibe oral tablet 10 mg 1
ezetimibe-simvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg
1
fenofibrate micronized oral capsule 130 mg 134 mg 200 mg 43 mg 67 mg
1
fenofibrate nanocrystallized oral tablet 145 mg 48 mg
1
FENOFIBRATE ORAL CAPSULE 150 MG 50 MG
1
fenofibrate oral tablet 120 mg 160 mg 40 mg 54 mg
1
fenofibric acid (choline) oral capsuledelayed release(drec) 135 mg 45 mg
1
fenofibric acid oral tablet 105 mg 35 mg 1
fluvastatin oral capsule 20 mg 40 mg ACA PV
56
Drug Name Drug Tier Requirements Limits
fluvastatin oral tablet extended release 24 hr 80 mg
ACA PV
gemfibrozil oral tablet 600 mg 1
icosapent ethyl oral capsule 1 gram 1 PA ST QL (120 per 30 days)
JUXTAPID ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 5 MG 60 MG
2 PA LA QL (30 per 30 days)
LIPOFEN ORAL CAPSULE 150 MG 50 MG 1
lovastatin oral tablet 10 mg 20 mg 40 mg ACA PV
niacin oral tablet 500 mg 1
niacin oral tablet extended release 24 hr 1000 mg 500 mg 750 mg
1
NIACOR ORAL TABLET 500 MG 1
omega-3 acid ethyl esters oral capsule 1 gram 1
pravastatin oral tablet 10 mg 20 mg 40 mg 80 mg
ACA PV
prevalite oral powder 4 gram 1
prevalite oral powder in packet 4 gram 1
REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG35 ML
1 PA ST
REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MGML
1 PA ST
REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MGML
1 PA ST
rosuvastatin oral tablet 10 mg 5 mg ACA PV
rosuvastatin oral tablet 20 mg 40 mg 1
simvastatin oral tablet 10 mg 20 mg 40 mg 5 mg ACA PV
simvastatin oral tablet 80 mg 1
VASCEPA ORAL CAPSULE 05 GRAM 1 GRAM
1 PA ST QL (120 per 30 days)
ZYPITAMAG ORAL TABLET 2 MG 4 MG 1 PA ST
MISCELLANEOUS CARDIOVASCULAR AGENTS
CORLANOR ORAL SOLUTION 5 MG5 ML 1 PA
CORLANOR ORAL TABLET 5 MG 75 MG 1 PA
ENTRESTO ORAL TABLET 24-26 MG 49-51 MG 97-103 MG
1 PA ST
GIAPREZA INTRAVENOUS SOLUTION 25 MGML
MB
57
Drug Name Drug Tier Requirements Limits
ranolazine oral tablet extended release 12 hr 1000 mg 500 mg
1 ST
NITRATES
GONITRO SUBLINGUAL POWDER IN PACKET 400 MCG
1
isosorbide dinitrate oral tablet 10 mg 20 mg 30 mg 40 mg 5 mg
1
isosorbide mononitrate oral tablet 10 mg 20 mg 1
isosorbide mononitrate oral tablet extended release 24 hr 120 mg 30 mg 60 mg
1
MINITRAN TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 04 MGHR 06 MGHR
1 PA ST
nitro-bid transdermal ointment 2 1
NITRO-DUR TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 03 MGHR 04 MGHR 06 MGHR 08 MGHR
1 PA ST
nitroglycerin in 5 dextrose intravenous solution 25 mg250 ml (100 mcgml) 50 mg500 ml (100 mcgml)
MB
nitroglycerin sublingual tablet 03 mg 04 mg 06 mg
1
nitroglycerin transdermal patch 24 hour 01 mghr 02 mghr 04 mghr 06 mghr
1
nitroglycerin translingual spraynon-aerosol 400 mcgspray
1
nitro-time oral capsule extended release 25 mg 65 mg 9 mg
1
DERMATOLOGICALSTOPICAL THERAPY
ANTIPSORIATIC ANTISEBORRHEIC
acitretin oral capsule 10 mg 175 mg 25 mg 1
calcipotriene scalp solution 0005 1
calcipotriene topical cream 0005 1
calcipotriene topical ointment 0005 1
calcipotriene-betamethasone topical ointment 0005-0064
1
calcitriol topical ointment 3 mcggram 1
COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
58
Drug Name Drug Tier Requirements Limits
COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
COSENTYX SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
COSENTYX SUBCUTANEOUS SYRINGE 75 MG05 ML
2 PA LA
hydrocortisone-pramoxine topical cream 25-1 1
ILUMYA SUBCUTANEOUS SYRINGE 100 MGML
2 PA ST LA
selenium sulfide topical lotion 25 1
selenium sulfide topical shampoo 225 23 1
SILIQ SUBCUTANEOUS SYRINGE 210 MG15 ML
2 PA ST LA
SKYRIZI SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
SKYRIZI SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
SKYRIZI SUBCUTANEOUS SYRINGE KIT 150MG166ML(75 MG083 ML X2)
2 PA ST LA
STELARA INTRAVENOUS SOLUTION 130 MG26 ML
MB PA LA
STELARA SUBCUTANEOUS SOLUTION 45 MG05 ML
2 PA ST LA
STELARA SUBCUTANEOUS SYRINGE 45 MG05 ML 90 MGML
2 PA ST LA
sulfacetamide sodium topical cleanser 10 1
sulfacetamide sodium topical cleanser gel 10 1
sulfacetamide sodium topical shampoo 10 1
TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MGML
2 PA ST LA
59
Drug Name Drug Tier Requirements Limits
TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 MGML
2 PA ST LA
TREMFYA SUBCUTANEOUS SYRINGE 100 MGML
2 PA ST LA
BURN THERAPY
silver sulfadiazine topical cream 1 1
ssd topical cream 1 1
MISCELLANEOUS DERMATOLOGICALS
ammonium lactate topical cream 12 1
ammonium lactate topical lotion 12 1
diclofenac sodium topical gel 3 1
DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300 MG2 ML
2 LA
DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG114 ML 300 MG2 ML
2 PA ST LA
EUCRISA TOPICAL OINTMENT 2 1 PA ST
FLUOROURACIL TOPICAL CREAM 05 1 PA ST
fluorouracil topical cream 5 1 PA ST
fluorouracil topical solution 2 5 1
LEVULAN TOPICAL SOLUTION 20 1
methoxsalen oral capsuleliqd-filledrapid rel 10 mg
1
PANRETIN TOPICAL GEL 01 1
PICATO TOPICAL GEL 0015 005 1
pimecrolimus topical cream 1 1
podofilox topical solution 05 1
prudoxin topical cream 5 1
REGRANEX TOPICAL GEL 001 1
SCENESSE SUBCUTANEOUS IMPLANT 16 MG
MB PA
tacrolimus topical ointment 003 01 1
UVADEX INJECTION SOLUTION 20 MCGML 1
VALCHLOR TOPICAL GEL 0016 2 PA ST LA
THERAPY FOR ACNE
accutane oral capsule 20 mg 30 mg 40 mg 1
adapalene topical cream 01 1 ST
60
Drug Name Drug Tier Requirements Limits
adapalene topical gel 03 1 ST
adapalene topical gel with pump 03 1 ST
ADAPALENE TOPICAL LOTION 01 1 ST
adapalene topical solution 01 1 ST
adapalene topical swab 01 1 ST
adapalene-benzoyl peroxide topical gel with pump 01-25
1
amnesteem oral capsule 10 mg 20 mg 40 mg 1 PA ST
avita topical cream 0025 1
AVITA TOPICAL GEL 0025 1 ST
azelaic acid topical gel 15 1
AZELEX TOPICAL CREAM 20 1 ST
claravis oral capsule 10 mg 20 mg 30 mg 1 PA ST
claravis oral capsule 40 mg 1
clindacin p topical swab 1 1
clindamycin phosphate topical foam 1 1
clindamycin phosphate topical gel 1 1
clindamycin phosphate topical lotion 1 1
clindamycin phosphate topical solution 1 1
clindamycin phosphate topical swab 1 1
clindamycin-benzoyl peroxide topical gel 1-5 12 (1 base) -5
1
clindamycin-benzoyl peroxide topical gel with pump 1-5
1
clindamycin-tretinoin topical gel 12-0025 1
dapsone topical gel 5 1
ery pads topical swab 2 1
erygel topical gel 2 1
erythromycin with ethanol topical gel 2 1
erythromycin with ethanol topical solution 2 1
erythromycin-benzoyl peroxide topical gel 3-5 1
isotretinoin oral capsule 10 mg 20 mg 25 mg 30 mg 35 mg 40 mg
1
metronidazole topical cream 075 1
metronidazole topical gel 075 1 1
metronidazole topical gel with pump 1 1
61
Drug Name Drug Tier Requirements Limits
metronidazole topical lotion 075 1
myorisan oral capsule 10 mg 20 mg 30 mg 40 mg
1
rosadan topical cream 075 1
rosadan topical gel 075 1
tazarotene topical cream 01 1 ST
tretinoin microspheres topical gel 004 01 1
tretinoin microspheres topical gel with pump 004 01
1
tretinoin topical cream 0025 005 01 1
tretinoin topical gel 001 0025 005 1
zenatane oral capsule 10 mg 20 mg 30 mg 40 mg 1
TOPICAL ANESTHETICS
lidocaine hcl injection solution 10 mgml (1 ) 1
lidocaine hcl laryngotracheal solution 4 1
lidocaine hcl mucous membrane jelly 2 1
lidocaine hcl mucous membrane jelly in applicator 2
1
lidocaine hcl mucous membrane solution 4 (40 mgml)
1
lidocaine hcl-hydrocortison ac topical cream 3-05
1
lidocaine topical adhesive patchmedicated 5 1
lidocaine topical ointment 5 1
lidocaine viscous mucous membrane solution 2 1
lidocaine-prilocaine topical cream 25-25 1
lidocaine-prilocaine topical kit 25-25 1
LIDOCAINE-TETRACAINE TOPICAL CREAM 7-7
1 ST
SYNERA TOPICAL PATCH MEDICATED SELF-HEATING 70-70 MG
1 ST
TOPICAL ANTIBACTERIALS
ALCORTIN A TOPICAL GEL 2-1-1 1 ST
ALCORTIN A TOPICAL GEL IN PACKET 2-1-1
1 ST
ALTABAX TOPICAL OINTMENT 1 1
gentamicin topical cream 01 1
62
Drug Name Drug Tier Requirements Limits
gentamicin topical ointment 01 1
mafenide acetate topical packet 50 gram 1
mupirocin calcium topical cream 2 1
mupirocin topical ointment 2 1
sulfacetamide sodium (acne) topical suspension 10
1
SULFAMYLON TOPICAL CREAM 85 MGG 1
TOPICAL ANTIFUNGALS
ciclodan topical cream 077 1
ciclodan topical solution 8 1
ciclopirox topical cream 077 1
ciclopirox topical gel 077 1
ciclopirox topical shampoo 1 1
ciclopirox topical solution 8 1
ciclopirox topical suspension 077 1
ciclopirox-ure-camph-menth-euc topical solution 8
1
clotrimazole topical cream 1 1
clotrimazole topical solution 1 1
clotrimazole-betamethasone topical cream 1-005
1
clotrimazole-betamethasone topical lotion 1-005
1
econazole topical cream 1 1
EXELDERM TOPICAL CREAM 1 1
EXELDERM TOPICAL SOLUTION 1 1
JUBLIA TOPICAL SOLUTION WITH APPLICATOR 10
1 PA ST
ketoconazole topical cream 2 1
ketoconazole topical foam 2 1
ketoconazole topical shampoo 2 1
ketodan topical foam 2 1
LULICONAZOLE TOPICAL CREAM 1 1
LUZU TOPICAL CREAM 1 1
MENTAX TOPICAL CREAM 1 1
naftifine topical cream 1 2 1
63
Drug Name Drug Tier Requirements Limits
naftifine topical gel 1 1
nyamyc topical powder 100000 unitgram 1
nystatin topical cream 100000 unitgram 1
nystatin topical ointment 100000 unitgram 1
nystatin topical powder 100000 unitgram 1
nystatin-triamcinolone topical cream 100000-01 unitg-
1
nystatin-triamcinolone topical ointment 100000-01 unitgram-
1
nystop topical powder 100000 unitgram 1
oxiconazole topical cream 1 1
OXISTAT TOPICAL LOTION 1 1
tavaborole topical solution with applicator 5 1 PA ST
TOPICAL ANTIVIRALS
acyclovir topical cream 5 1
acyclovir topical ointment 5 1
DENAVIR TOPICAL CREAM 1 1
TOPICAL CORTICOSTEROIDS
ala-cort topical cream 1 1
alclometasone topical cream 005 1
alclometasone topical ointment 005 1
amcinonide topical cream 01 1
amcinonide topical lotion 01 1
apexicon e topical cream 005 1
beser topical lotion 005 1
betamethasone dipropionate topical cream 005 1
betamethasone dipropionate topical lotion 005 1
betamethasone dipropionate topical ointment 005
1
betamethasone valerate topical cream 01 1
betamethasone valerate topical foam 012 1
betamethasone valerate topical lotion 01 1
betamethasone valerate topical ointment 01 1
betamethasone augmented topical cream 005 1
betamethasone augmented topical gel 005 1
betamethasone augmented topical lotion 005 1
64
Drug Name Drug Tier Requirements Limits
betamethasone augmented topical ointment 005
1
clobetasol scalp solution 005 1
clobetasol topical cream 005 1
clobetasol topical foam 005 1
clobetasol topical gel 005 1
clobetasol topical lotion 005 1
clobetasol topical ointment 005 1
clobetasol topical shampoo 005 1
clobetasol topical spraynon-aerosol 005 1
clobetasol-emollient topical cream 005 1
clobetasol-emollient topical foam 005 1
CLOCORTOLONE PIVALATE TOPICAL CREAM 01
1 ST
CLODERM TOPICAL CREAM 01 1 ST
desonide topical cream 005 1
desonide topical lotion 005 1
desonide topical ointment 005 1
desoximetasone topical cream 005 025 1
desoximetasone topical gel 005 1
desoximetasone topical ointment 005 025 1
desoximetasone topical spraynon-aerosol 025 1
diflorasone topical cream 005 1
diflorasone topical ointment 005 1
fluocinolone and shower cap scalp oil 001 1
fluocinolone topical cream 001 0025 1
fluocinolone topical oil 001 1
fluocinolone topical ointment 0025 1
fluocinolone topical solution 001 1
fluocinonide topical cream 005 01 1
fluocinonide topical gel 005 1
fluocinonide topical ointment 005 1
fluocinonide topical solution 005 1
fluocinonide-e topical cream 005 1
flurandrenolide topical cream 005 1
65
Drug Name Drug Tier Requirements Limits
flurandrenolide topical lotion 005 1
flurandrenolide topical ointment 005 1
fluticasone propionate topical cream 005 1
fluticasone propionate topical lotion 005 1
fluticasone propionate topical ointment 0005 1
halcinonide topical cream 01 1
halobetasol propionate topical cream 005 1
halobetasol propionate topical ointment 005 1
hydrocortisone butyrate topical cream 01 1
hydrocortisone butyrate topical lotion 01 1
hydrocortisone butyrate topical ointment 01 1
hydrocortisone butyrate topical solution 01 1
hydrocortisone butyr-emollient topical cream 01
1
hydrocortisone topical cream 1 25 1
hydrocortisone topical lotion 25 1
hydrocortisone topical ointment 1 25 1
hydrocortisone valerate topical cream 02 1
hydrocortisone valerate topical ointment 02 1
mometasone topical cream 01 1
mometasone topical ointment 01 1
mometasone topical solution 01 1
prednicarbate topical cream 01 1
prednicarbate topical ointment 01 1
scalacort topical lotion 2 1
triamcinolone acetonide topical aerosol 0147 mggram
1
triamcinolone acetonide topical cream 0025 01 05
1
triamcinolone acetonide topical lotion 0025 01
1
triamcinolone acetonide topical ointment 0025 005 01 05
1
triderm topical cream 01 05 1
TOPICAL ENZYMES
SANTYL TOPICAL OINTMENT 250 UNITGRAM
1 QL (2 per 30 days)
66
Drug Name Drug Tier Requirements Limits
TOPICAL SCABICIDES PEDICULICIDES
crotan topical lotion 10 1
EURAX TOPICAL CREAM 10 1
EURAX TOPICAL LOTION 10 1
ivermectin topical lotion 05 1
lindane topical shampoo 1 1
malathion topical lotion 05 1
permethrin topical cream 5 1
spinosad topical suspension 09 1
ULESFIA TOPICAL LOTION 5 1
DIAGNOSTICS amp MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
PHYSIOLYTE IRRIGATION SOLUTION 140-5-3-98 MEQL
MB
PHYSIOSOL IRRIGATION IRRIGATION SOLUTION 140-5-3-98 MEQL
MB
MISCELLANEOUS AGENTS
acamprosate oral tabletdelayed release (drec) 333 mg
1
acetic acid irrigation solution 025 1
anagrelide oral capsule 05 mg 1 mg 1
ARALAST NP INTRAVENOUS RECON SOLN 1000 MG 500 MG
MB LA
CARBAGLU ORAL TABLET DISPERSIBLE 200 MG
2 PA LA
cevimeline oral capsule 30 mg 1
CHEMET ORAL CAPSULE 100 MG 1
clovique oral capsule 250 mg 1 PA QL (240 per 30 days)
deferasirox oral granules in packet 180 mg 360 mg 90 mg
2 PA LA
deferasirox oral tablet 180 mg 2 PA LA
deferasirox oral tablet 360 mg 90 mg 2 ST LA
deferasirox oral tablet dispersible 125 mg 250 mg 500 mg
2 ST LA
deferiprone oral tablet 500 mg 1 PA
disulfiram oral tablet 250 mg 500 mg 1
67
Drug Name Drug Tier Requirements Limits
EMPAVELI SUBCUTANEOUS SOLUTION 1080 MG20 ML
2 PA
FERRIPROX ORAL SOLUTION 100 MGML 1 PA
FERRIPROX ORAL TABLET 1000 MG 500 MG
1 PA
GIVLAARI SUBCUTANEOUS SOLUTION 189 MGML
MB PA LA
GLASSIA INTRAVENOUS SOLUTION 1 GRAM50 ML (2 )
MB LA
INCRELEX SUBCUTANEOUS SOLUTION 10 MGML
2 PA LA
levocarnitine (with sugar) oral solution 100 mgml 1
levocarnitine oral solution 100 mgml 1
levocarnitine oral tablet 330 mg 1
midodrine oral tablet 10 mg 25 mg 5 mg 1
nitisinone oral capsule 10 mg 2 mg 5 mg 2 PA LA
NITYR ORAL TABLET 10 MG 2 MG 5 MG 2 PA LA
pilocarpine hcl oral tablet 5 mg 1
PROLASTIN-C INTRAVENOUS SOLUTION 1000 MG (+-)20 ML
MB
RAVICTI ORAL LIQUID 11 GRAMML 2 PA ST LA QL (10 per 30 days)
RECLAST INTRAVENOUS PIGGYBACK 5 MG100 ML
MB
riluzole oral tablet 50 mg 1
risedronate oral tablet 30 mg 1
sodium chloride 09 injection solution MB
sodium chloride 09 intravenous parenteral solution
MB
sodium chloride 09 intravenous piggyback MB
sodium phenylbutyrate oral powder 094 gramgram
1 PA
sodium phenylbutyrate oral tablet 500 mg 1 PA
SOLIRIS INTRAVENOUS SOLUTION 300 MG30 ML
MB PA LA
trientine oral capsule 250 mg 1 PA QL (240 per 30 days)
XURIDEN ORAL GRANULES IN PACKET 2 GRAM
2 PA QL (120 per 30 days)
68
Drug Name Drug Tier Requirements Limits
ZEMAIRA INTRAVENOUS RECON SOLN 1000 MG
MB LA
ZOKINVY ORAL CAPSULE 50 MG 75 MG 2 PA ST
SMOKING DETERRENTS
bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg
ACA PV
CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG
ACA PV QL (180 per 365 days)
CHANTIX ORAL TABLET 05 MG 1 MG ACA PV QL (180 per 365 days)
CHANTIX STARTING MONTH BOX ORAL TABLETSDOSE PACK 05 MG (11)- 1 MG (42)
ACA PV QL (180 per 365 days)
nicorette buccal gum 4 mg ACA PV
nicotine (polacrilex) buccal gum 2 mg 4 mg ACA PV
nicotine (polacrilex) buccal lozenge 2 mg 4 mg ACA PV
nicotine (polacrilex) buccal mini lozenge 2 mg 4 mg
ACA PV
nicotine transdermal patch 24 hour 14 mg24 hr 21 mg24 hr 7 mg24 hr
ACA PV
nicotine transdermal patch td daily sequential 21-14-7 mg24 hr
ACA PV
NICOTROL INHALATION CARTRIDGE 10 MG
ACA PV
NICOTROL NS NASAL SPRAYNON-AEROSOL 10 MGML
ACA PV
quit 2 buccal gum 2 mg ACA PV
quit 2 buccal lozenge 2 mg ACA PV
quit 4 buccal gum 4 mg ACA PV
quit 4 buccal lozenge 4 mg ACA PV
stop smoking aid buccal lozenge 2 mg 4 mg ACA PV
EAR NOSE amp THROAT MEDICATIONS
MISCELLANEOUS AGENTS
ARESTIN DENTAL CARTRIDGE 1 MG MB
azelastine nasal aerosolspray 137 mcg (01 ) 1
azelastine nasal spraynon-aerosol 2055 mcg (015 )
1
chlorhexidine gluconate mucous membrane mouthwash 012
1
denta 5000 plus dental cream 11 1
69
Drug Name Drug Tier Requirements Limits
dentagel dental gel 11 1
fluoride (sodium) dental cream 11 1
fluoride (sodium) dental gel 11 1
fluoride (sodium) dental paste 11 1
ipratropium bromide nasal spraynon-aerosol 21 mcg (003 ) 42 mcg (006 )
1
olopatadine nasal spraynon-aerosol 06 1
oralone dental paste 01 1
paroex oral rinse mucous membrane mouthwash 012
1
periogard mucous membrane mouthwash 012 1
pilocarpine hcl oral tablet 75 mg 1
sf 5000 plus dental cream 11 1
sf dental gel 11 1
sodium fluoride 5000 dry mouth dental gel 11 1
sodium fluoride 5000 plus dental cream 11 1
sodium fluoride-pot nitrate dental paste 11-5 1
triamcinolone acetonide dental paste 01 1
MISCELLANEOUS OTIC PREPARATIONS
acetic acid otic (ear) solution 2 1
ciprofloxacin hcl otic (ear) dropperette 02 1
flac otic oil otic (ear) drops 001 1
fluocinolone acetonide oil otic (ear) drops 001 1
hydrocortisone-acetic acid otic (ear) drops 1-2 1
ofloxacin otic (ear) drops 03 1
OTIC STEROID ANTIBIOTIC
CIPRO HC OTIC (EAR) DROPSSUSPENSION 02-1
1
ciprofloxacin-dexamethasone otic (ear) dropssuspension 03-01
1
neomycin-polymyxin-hc otic (ear) dropssuspension 35-10000-1 mgml-unitml-
1
neomycin-polymyxin-hc otic (ear) solution 35-10000-1 mgml-unitml-
1
OTOVEL OTIC (EAR) SOLUTION 03-0025 (025 ML)
1
ENDOCRINEDIABETES
70
Drug Name Drug Tier Requirements Limits
ADRENAL HORMONES
ACTHAR INJECTION GEL 80 UNITML 2 PA LA
decadron oral tablet 05 mg 1
dexamethasone intensol oral drops 1 mgml 1
dexamethasone oral elixir 05 mg5 ml 1
dexamethasone oral solution 05 mg5 ml 1
dexamethasone oral tablet 05 mg 075 mg 1 mg 15 mg 2 mg 4 mg 6 mg
1
dexamethasone oral tabletsdose pack 15 mg (21 tabs) 15 mg (35 tabs) 15 mg (51 tabs)
1
dexamethasone sodium phos (pf) injection solution 10 mgml
1
dexamethasone sodium phosphate injection solution 10 mgml 4 mgml
1
dexamethasone sodium phosphate injection syringe 4 mgml
1
fludrocortisone oral tablet 01 mg 1
hydrocortisone oral tablet 10 mg 20 mg 5 mg 1
methylprednisolone acetate injection suspension 40 mgml 80 mgml
1
methylprednisolone oral tablet 16 mg 32 mg 4 mg 8 mg
1
methylprednisolone oral tabletsdose pack 4 mg 1
millipred dp oral tabletsdose pack 5 mg (21 tabs) 5 mg (48 tabs)
1
millipred oral tablet 5 mg 1
prednisolone oral solution 15 mg5 ml 1
prednisolone sodium phosphate oral solution 10 mg5 ml 15 mg5 ml (3 mgml) 20 mg5 ml (4 mgml) 25 mg5 ml (5 mgml) 5 mg base5 ml (67 mg5 ml)
1
prednisolone sodium phosphate oral tabletdisintegrating 10 mg 15 mg 30 mg
1
prednisone intensol oral concentrate 5 mgml 1
prednisone oral solution 5 mg5 ml 1
prednisone oral tablet 1 mg 10 mg 25 mg 20 mg 5 mg 50 mg
1
prednisone oral tabletsdose pack 10 mg 5 mg 1
71
Drug Name Drug Tier Requirements Limits
triamcinolone acetonide injection suspension 40 mgml
MB
ANTITHYROID AGENTS
methimazole oral tablet 10 mg 5 mg 1
propylthiouracil oral tablet 50 mg 1
SSKI ORAL SOLUTION 1 GRAMML 1
BLOOD GLUCOSE MONITORING DEVICES amp SUPPLIES
CONTOUR NEXT TEST STRIPS STRIP 1
CONTOUR TEST STRIPS STRIP 1
ONETOUCH ULTRA TEST STRIP 1
ONETOUCH VERIO TEST STRIPS STRIP 1
DIABETES SUPPLIES amp DURABLE MEDICAL EQUIPMENT
AEROCHAMBER MINI SPACER 1
AEROCHAMBER PLUS FLOW-VU SPACER 1
GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN 1 MGML
1
GLUCAGON HCL INJECTION RECON SOLN 1 MGML
1
INSULIN SYRINGE-NEEDLE U-100 SYRINGE 05 ML 29 GAUGE X 12
1
TRIJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-5-1000 MG 125-25-1000 MG 25-5-1000 MG 5-25-1000 MG
1 PA ST
GLUCOSE ELEVATING AGENTS
BAQSIMI NASAL SPRAYNON-AEROSOL 3 MGACTUATION
1
diazoxide oral suspension 50 mgml 1
GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG
1
GLUCAGON (HCL) EMERGENCY KIT INJECTION RECON SOLN 1 MG
1
glucagon emergency kit (human) injection recon soln 1 mg
1
INSULIN SYRINGESMISCELLANEOUS DURABLE MEDICAL EQU
FREESTYLE LIBRE 14 DAY SENSOR KIT 1
FREESTYLE LIBRE 2 SENSOR KIT 1
NOVOPEN ECHO SUBCUTANEOUS INSULIN PEN
1
72
Drug Name Drug Tier Requirements Limits
PEN NEEDLE DIABETIC NEEDLE 29 GAUGE X 12
1
INSULIN THERAPY
FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
FIASP PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML (3 ML)
1
FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN HALF-UNIT 100 UNITML
1
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML
1 ST
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 200 UNITML (3 ML)
1
HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNITML (50-50)
1 ST
HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (50-50)
1 ST
HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (75-25)
1 ST
HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNITML (75-25)
1 ST
HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML
1 ST
HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1 ST
HUMULIN 7030 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)
1 ST
HUMULIN 7030 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1 ST
73
Drug Name Drug Tier Requirements Limits
HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1 ST
HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML
1 ST
HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNITML
1 ST
HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNITML
1
HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNITML (3 ML)
1
INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML (70-30)
1
INSULIN ASPART U-100 SUBCUTANEOUS CARTRIDGE 100 UNITML
1
INSULIN ASPART U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
INSULIN ASPART U-100 SUBCUTANEOUS SOLUTION 100 UNITML
1
LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
NOVOLIN R FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
74
Drug Name Drug Tier Requirements Limits
NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNITML (70-30)
1
NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML
1
NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML
1
RELION NOVOLIN 7030 SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)
1
RELION NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNITML
1
RELION NOVOLIN R INJECTION SOLUTION 100 UNITML
1
SOLIQUA 10033 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCGML
1 PA ST
TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNITML (3 ML)
1
TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNITML (15 ML)
1
TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN 200 UNITML (3 ML)
1
TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
XULTOPHY 10036 SUBCUTANEOUS INSULIN PEN 100 UNIT-36 MG ML (3 ML)
1 PA ST
MISCELLANEOUS HORMONES
ALDURAZYME INTRAVENOUS SOLUTION 29 MG5 ML
MB PA LA
ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG24 HOUR 4 MG24 HR
1 ST QL (30 per 30 days)
75
Drug Name Drug Tier Requirements Limits
BRINEURA INTRAVENTRICULAR KIT 300 MG10 ML (150MG5ML X2)
MB
cabergoline oral tablet 05 mg 1
calcitonin (salmon) injection solution 200 unitml 1
calcitonin (salmon) nasal spraynon-aerosol 200 unitactuation
1
calcitriol oral capsule 025 mcg 05 mcg 1
calcitriol oral solution 1 mcgml 1
CERDELGA ORAL CAPSULE 84 MG 2 PA LA
CEREZYME INTRAVENOUS RECON SOLN 400 UNIT
MB PA LA
cinacalcet oral tablet 30 mg 60 mg 90 mg 2 PA
CRYSVITA SUBCUTANEOUS SOLUTION 10 MGML 20 MGML 30 MGML
MB PA LA
danazol oral capsule 100 mg 200 mg 50 mg 1
DEPO-TESTOSTERONE INTRAMUSCULAR OIL 100 MGML
1
desmopressin nasal spraynon-aerosol 10 mcgspray (01 ml)
1
desmopressin oral tablet 01 mg 02 mg 1
doxercalciferol oral capsule 05 mcg 1 mcg 25 mcg
1
ELAPRASE INTRAVENOUS SOLUTION 6 MG3 ML
MB PA LA
ELELYSO INTRAVENOUS RECON SOLN 200 UNIT
MB PA LA
FABRAZYME INTRAVENOUS RECON SOLN 35 MG 5 MG
MB PA LA
GALAFOLD ORAL CAPSULE 123 MG 2 PA LA
JYNARQUE ORAL TABLET 15 MG 30 MG 2 PA QL (60 per 30 days)
JYNARQUE ORAL TABLETS SEQUENTIAL 45 MG (AM) 15 MG (PM) 60 MG (AM) 30 MG (PM) 90 MG (AM) 30 MG (PM)
2 PA QL (60 per 30 days)
KANUMA INTRAVENOUS SOLUTION 2 MGML
MB PA LA
KORLYM ORAL TABLET 300 MG 2 PA ST
LUMIZYME INTRAVENOUS RECON SOLN 50 MG
MB PA LA
76
Drug Name Drug Tier Requirements Limits
MEPSEVII INTRAVENOUS SOLUTION 2 MGML
MB PA LA
methyltestosterone oral capsule 10 mg 1
MIACALCIN INJECTION SOLUTION 200 UNITML
1
miglustat oral capsule 100 mg 2 PA LA
MYALEPT SUBCUTANEOUS RECON SOLN 5 MGML (FINAL CONC)
2 LA
NAGLAZYME INTRAVENOUS SOLUTION 5 MG5 ML
MB PA LA
NATPARA SUBCUTANEOUS CARTRIDGE 100 MCGDOSE 25 MCGDOSE 50 MCGDOSE 75 MCGDOSE
2 PA ST LA
oxandrolone oral tablet 10 mg 25 mg 1
PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG05 ML 25 MG05 ML 20 MGML
2 PA LA
pamidronate intravenous solution 30 mg10 ml (3 mgml)
MB
PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCGML
MB
paricalcitol intravenous solution 5 mcgml MB
paricalcitol oral capsule 1 mcg 2 mcg 4 mcg 1
PARSABIV INTRAVENOUS SOLUTION 5 MGML
MB PA
SAMSCA ORAL TABLET 15 MG 2 PA LA QL (60 per 30 days)
sapropterin oral powder in packet 100 mg 500 mg 2 PA LA
sapropterin oral tabletsoluble 100 mg 2 PA LA
SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG 15 MG 20 MG 25 MG 30 MG
2 PA LA QL (30 per 30 days)
STRENSIQ SUBCUTANEOUS SOLUTION 18 MG045 ML 28 MG07 ML 40 MGML 80 MG08 ML
2 PA
SYNAREL NASAL SPRAYNON-AEROSOL 2 MGML
1
TEPEZZA INTRAVENOUS RECON SOLN 500 MG
MB PA LA
testosterone cypionate intramuscular oil 100 mgml 200 mgml
1
testosterone enanthate intramuscular oil 200 mgml
1
77
Drug Name Drug Tier Requirements Limits
testosterone transdermal gel 50 mg5 gram (1 ) 1 QL (60 per 30 days)
testosterone transdermal gel in metered-dose pump 10 mg05 gram actuation 2025 mg125 gram (162 )
1 QL (2 per 30 days)
testosterone transdermal gel in metered-dose pump 125 mg 125 gram (1 )
1 QL (4 per 30 days)
testosterone transdermal gel in packet 1 (25 mg25gram) 162 (2025 mg125 gram)
1 QL (30 per 30 days)
testosterone transdermal gel in packet 1 (50 mg5 gram) 162 (405 mg25 gram)
1 QL (60 per 30 days)
testosterone transdermal solution in metered pump wapp 30 mgactuation (15 ml)
1 QL (2 per 30 days)
VIMIZIM INTRAVENOUS SOLUTION 5 MG5 ML (1 MGML)
MB PA LA
VPRIV INTRAVENOUS RECON SOLN 400 UNIT
MB PA LA
NON-INSULIN HYPOGLYCEMIC AGENTS
acarbose oral tablet 100 mg 25 mg 50 mg 1
ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 125-15 MG 125-30 MG 125-45 MG 25-15 MG 25-30 MG 25-45 MG
1 PA ST
BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG085 ML
1 PA ST
BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCGDOSE(250 MCGML) 24 ML 5 MCGDOSE (250 MCGML) 12 ML
1 PA ST
CYCLOSET ORAL TABLET 08 MG 1
FARXIGA ORAL TABLET 10 MG 5 MG 1 PA ST
glimepiride oral tablet 1 mg 2 mg 4 mg 1
glipizide oral tablet 10 mg 5 mg 1
glipizide oral tablet extended release 24hr 10 mg 25 mg 5 mg
1
glipizide-metformin oral tablet 25-250 mg 25-500 mg 5-500 mg
1
glyburide micronized oral tablet 15 mg 3 mg 6 mg
1
glyburide oral tablet 125 mg 25 mg 5 mg 1
glyburide-metformin oral tablet 125-250 mg 25-500 mg 5-500 mg
1
78
Drug Name Drug Tier Requirements Limits
GLYXAMBI ORAL TABLET 10-5 MG 25-5 MG
1 PA ST
JANUMET ORAL TABLET 50-1000 MG 50-500 MG
1 PA ST
JANUMET XR ORAL TABLET ER MULTIPHASE 24 HR 100-1000 MG 50-1000 MG 50-500 MG
1 PA ST
JANUVIA ORAL TABLET 100 MG 25 MG 50 MG
1 PA ST
JARDIANCE ORAL TABLET 10 MG 25 MG 1 PA ST
JENTADUETO ORAL TABLET 25-1000 MG 25-500 MG 25-850 MG
1 PA ST
JENTADUETO XR ORAL TABLET IR - ER BIPHASIC 24HR 25-1000 MG 5-1000 MG
1 PA ST
metformin oral solution 500 mg5 ml 1 PA
metformin oral tablet 1000 mg 500 mg 850 mg 1
metformin oral tablet extended release 24 hr 500 mg 750 mg
1
metformin oral tablet extended release 24hr 1000 mg 500 mg
1 PA ST
metformin oral tableter gastretention 24 hr 1000 mg 500 mg
1 ST
miglitol oral tablet 100 mg 25 mg 50 mg 1
nateglinide oral tablet 120 mg 60 mg 1
OZEMPIC SUBCUTANEOUS PEN INJECTOR 025 MG OR 05 MG(2 MG15 ML) 1 MGDOSE (2 MG15 ML) 1 MGDOSE (4 MG3 ML)
1 PA ST
pioglitazone oral tablet 15 mg 30 mg 45 mg 1
pioglitazone-glimepiride oral tablet 30-2 mg 30-4 mg
1
pioglitazone-metformin oral tablet 15-500 mg 15-850 mg
1
QTERN ORAL TABLET 10-5 MG 5-5 MG 1 PA ST
repaglinide oral tablet 05 mg 1 mg 2 mg 1
repaglinide-metformin oral tablet 1-500 mg 2-500 mg
1
RIOMET ER ORAL SUSPENSIONEXTENDED REL RECON 500 MG5 ML
1 PA ST
79
Drug Name Drug Tier Requirements Limits
RYBELSUS ORAL TABLET 14 MG 3 MG 7 MG
1 PA ST
SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2700 MCG27 ML
1 PA ST
SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1500 MCG15 ML
1 PA ST
SYNJARDY ORAL TABLET 125-1000 MG 125-500 MG 5-1000 MG 5-500 MG
1 PA ST
SYNJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 125-1000 MG 25-1000 MG 5-1000 MG
1 PA ST
TRADJENTA ORAL TABLET 5 MG 1 PA ST
TRULICITY SUBCUTANEOUS PEN INJECTOR 075 MG05 ML 15 MG05 ML 3 MG05 ML 45 MG05 ML
1 PA ST
XIGDUO XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 10-500 MG 25-1000 MG 5-1000 MG 5-500 MG
1 PA ST
THYROID HORMONES
ARMOUR THYROID ORAL TABLET 120 MG 15 MG 180 MG 240 MG 30 MG 300 MG 60 MG 90 MG
1
levothyroxine oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 300 mcg 50 mcg 75 mcg 88 mcg
1
levoxyl oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 50 mcg 75 mcg 88 mcg
1
liothyronine oral tablet 25 mcg 5 mcg 50 mcg 1
np thyroid oral tablet 120 mg 15 mg 30 mg 60 mg 90 mg
1
SYNTHROID ORAL TABLET 100 MCG 112 MCG 125 MCG 137 MCG 150 MCG 175 MCG 200 MCG 25 MCG 300 MCG 50 MCG 75 MCG 88 MCG
1
THYROLAR-1 ORAL TABLET 125-50 MCG 1
THYROLAR-12 ORAL TABLET 625-25 MCG 1
THYROLAR-14 ORAL TABLET 31-125 MCG 1
THYROLAR-2 ORAL TABLET 25-100 MCG 1
THYROLAR-3 ORAL TABLET 375-150 MCG 1
80
Drug Name Drug Tier Requirements Limits
unithroid oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 300 mcg 50 mcg 75 mcg 88 mcg
1
westhroid oral tablet 130 mg 195 mg 325 mg 65 mg 975 mg
1
GASTROENTEROLOGY
ANTIDIARRHEALS amp ANTISPASMODICS
anaspaz oral tabletdisintegrating 0125 mg 1
atropine injection syringe 005 mgml 01 mgml 1
belladonna alkaloids-opium rectal suppository 162-30 mg 162-60 mg
1 PA ST
chlordiazepoxide-clidinium oral capsule 5-25 mg 1
dicyclomine intramuscular solution 10 mgml MB
dicyclomine oral capsule 10 mg 1
dicyclomine oral solution 10 mg5 ml 1
dicyclomine oral tablet 20 mg 1
diphenoxylate-atropine oral liquid 25-0025 mg5 ml
1
diphenoxylate-atropine oral tablet 25-0025 mg 1
DONNATAL ORAL TABLET 162-01037 -00194 MG
1
ed-spaz oral tabletdisintegrating 0125 mg 1
glycopyrrolate injection solution 02 mgml 1
glycopyrrolate oral tablet 1 mg 15 mg 2 mg 1
hyoscyamine sulfate oral drops 0125 mgml 1
hyoscyamine sulfate oral elixir 0125 mg5 ml 1
hyoscyamine sulfate oral tablet 0125 mg 1
hyoscyamine sulfate oral tablet extended release 12 hr 0375 mg
1
hyoscyamine sulfate oral tabletdisintegrating 0125 mg
1
hyoscyamine sulfate sublingual tablet 0125 mg 1
hyosyne oral drops 0125 mgml 1
hyosyne oral elixir 0125 mg5 ml 1
loperamide oral capsule 2 mg 1
methscopolamine oral tablet 25 mg 5 mg 1
MOTOFEN ORAL TABLET 1-0025 MG 1
81
Drug Name Drug Tier Requirements Limits
opium tincture oral tincture 10 mgml (morphine) 1
oscimin oral tablet 0125 mg 1
oscimin sl sublingual tablet 0125 mg 1
oscimin sr oral tablet extended release 12 hr 0375 mg
1
phenobarb-hyoscy-atropine-scop oral elixir 162-01037 -00194 mg5 ml
1
phenobarb-hyoscy-atropine-scop oral tablet 162-01037 -00194 mg
1
phenohytro oral elixir 162-01037 -00194 mg5 ml
1
phenohytro oral tablet 162-01037 -00194 mg 1
symax fastabs oral tabletdisintegrating 0125 mg 1
symax-sl sublingual tablet 0125 mg 1
symax-sr oral tablet extended release 12 hr 0375 mg
1
MISCELLANEOUS GASTROINTESTINAL AGENTS
AKYNZEO (NETUPITANT) ORAL CAPSULE 300-05 MG
1 QL (1 per 30 days)
alosetron oral tablet 05 mg 1 mg 1
ALOXI INTRAVENOUS SOLUTION 025 MG5 ML
MB
AMITIZA ORAL CAPSULE 24 MCG 8 MCG 1 PA
anucort-hc rectal suppository 25 mg 1
aprepitant oral capsule 125 mg 40 mg 1 QL (1 per 30 days)
aprepitant oral capsule 80 mg 1 QL (2 per 30 days)
aprepitant oral capsuledose pack 125 mg (1)- 80 mg (2)
1 QL (1 per 30 days)
balsalazide oral capsule 750 mg 1
budesonide oral capsuledelayedextendrelease 3 mg
1
calcium acetate(phosphat bind) oral capsule 667 mg
1
calcium acetate(phosphat bind) oral tablet 667 mg 1
CHOLBAM ORAL CAPSULE 250 MG 50 MG 2
CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)
2 PA ST LA
82
Drug Name Drug Tier Requirements Limits
CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG2 ML (200 MGML X 2)
2 PA ST LA
CLENPIQ ORAL SOLUTION 10 MG-35 GRAM -12 GRAM160 ML
ACA PV
compro rectal suppository 25 mg 1
constulose oral solution 10 gram15 ml 1
CORTIFOAM RECTAL FOAM 10 (80 MG) 1
CREON ORAL CAPSULEDELAYED RELEASE(DREC) 12000-38000 -60000 UNIT 24000-76000 -120000 UNIT 3000-9500- 15000 UNIT 36000-114000- 180000 UNIT 6000-19000 -30000 UNIT
1 PA
cromolyn oral concentrate 100 mg5 ml 1
DIPENTUM ORAL CAPSULE 250 MG 1 PA ST
doxylamine-pyridoxine (vit b6) oral tabletdelayed release (drec) 10-10 mg
1
dronabinol oral capsule 10 mg 25 mg 5 mg 1
EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG ML FINAL CONC)
1
ENTYVIO INTRAVENOUS RECON SOLN 300 MG
MB PA LA
enulose oral solution 10 gram15 ml 1
gavilyte-c oral recon soln 240-2272-672 -584 gram
ACA PV
gavilyte-g oral recon soln 236-2274-674 -586 gram
ACA PV
gavilyte-n oral recon soln 420 gram ACA PV
generlac oral solution 10 gram15 ml 1
granisetron hcl oral tablet 1 mg 1 QL (6 per 30 days)
hemmorex-hc rectal suppository 25 mg 1
hydrocortisone acetate rectal suppository 25 mg 30 mg
1
hydrocortisone rectal enema 100 mg60 ml 1
hydrocortisone topical cream with perineal applicator 1 25
1
hydrocortisone-pramoxine rectal cream 1-1 25-1 25-1 (4g)
1
INFLECTRA INTRAVENOUS RECON SOLN 100 MG
MB PA LA
83
Drug Name Drug Tier Requirements Limits
lactulose oral packet 10 gram 1
lactulose oral solution 10 gram15 ml 20 gram30 ml
1
lanthanum oral tabletchewable 1000 mg 500 mg 750 mg
1
lidocaine hcl-hydrocortison ac rectal cream 3-05
1
LIDOCAINE HCL-HYDROCORTISON AC RECTAL GEL 3 -25 (7 GRAM)
1
lidocaine hcl-hydrocortison ac rectal kit 2 -2 (7 gram)
1 ST
lidocaine hcl-hydrocortison ac rectal kit 3-05 3-1 (7 gram)
1 PA ST
lidocaine-hydrocortisone-aloe rectal gel 28-055
1
lidocaine-hydrocortisone-aloe rectal kit 3-25 (7 gram)
1 PA ST
LINZESS ORAL CAPSULE 145 MCG 290 MCG 72 MCG
1 PA
meclizine oral tablet 125 mg 25 mg 1
mesalamine oral capsuleextended release 24hr 0375 gram
1
mesalamine oral tabletdelayed release (drec) 12 gram 800 mg
1
mesalamine rectal enema 4 gram60 ml 1
mesalamine rectal suppository 1000 mg 1
mesalamine with cleansing wipe rectal enema kit 4 gram60 ml
1 ST
metoclopramide hcl injection solution 5 mgml MB
metoclopramide hcl injection syringe 5 mgml MB
metoclopramide hcl oral solution 5 mg5 ml 1
metoclopramide hcl oral tablet 10 mg 5 mg 1
metoclopramide hcl oral tabletdisintegrating 10 mg 5 mg
1
MOVANTIK ORAL TABLET 125 MG 25 MG 1 PA ST
NULYTELY LEMON-LIME ORAL RECON SOLN 420 GRAM
ACA PV
ondansetron hcl intravenous solution 2 mgml MB
ondansetron hcl oral solution 4 mg5 ml 1 QL (100 per 30 days)
84
Drug Name Drug Tier Requirements Limits
ondansetron hcl oral tablet 4 mg 8 mg 1 QL (9 per 30 days)
ondansetron oral tabletdisintegrating 4 mg 8 mg 1 QL (9 per 30 days)
OSMOPREP ORAL TABLET 15 GRAM ACA PV
peg 3350-electrolytes oral recon soln 236-2274-674 -586 gram
ACA PV
peg3350-sod sul-nacl-kcl-asb-c oral powder in packet 100-75-2691 gram
ACA PV
peg-electrolyte soln oral recon soln 420 gram ACA PV
peg-prep oral kit 5-210 mg-gram ACA PV
PLENVU ORAL POWDER IN PACKET SEQUENTIAL 140-9-52 GRAM
ACA PV
prochlorperazine edisylate injection solution 10 mg2 ml (5 mgml) 5 mgml
1
prochlorperazine maleate oral tablet 10 mg 5 mg 1
prochlorperazine rectal suppository 25 mg 1
procto-med hc topical cream with perineal applicator 25
1
procto-pak topical cream with perineal applicator 1
1
proctosol hc topical cream with perineal applicator 25
1
proctozone-hc topical cream with perineal applicator 25
1
RECTIV RECTAL OINTMENT 04 (WW) 1
RELISTOR ORAL TABLET 150 MG 1
RELISTOR SUBCUTANEOUS SOLUTION 12 MG06 ML
1
RELISTOR SUBCUTANEOUS SYRINGE 12 MG06 ML 8 MG04 ML
1
REMICADE INTRAVENOUS RECON SOLN 100 MG
MB PA LA
RENFLEXIS INTRAVENOUS RECON SOLN 100 MG
MB PA LA
scopolamine base transdermal patch 3 day 1 mg over 3 days
1
sevelamer carbonate oral powder in packet 08 gram 24 gram
1
sevelamer carbonate oral tablet 800 mg 1
sevelamer hcl oral tablet 400 mg 800 mg 1
85
Drug Name Drug Tier Requirements Limits
sodium polystyrene sulfonate oral powder 1
sps (with sorbitol) oral suspension 15-20 gram60 ml
1
sps (with sorbitol) rectal enema 30-40 gram120 ml
1
SUCRAID ORAL SOLUTION 8500 UNITML 2 PA ST QL (2 per 30 days)
sulfasalazine oral tablet 500 mg 1
sulfasalazine oral tabletdelayed release (drec) 500 mg
1
SUPREP BOWEL PREP KIT ORAL RECON SOLN 175-313-16 GRAM
ACA PV ST
trilyte with flavor packets oral recon soln 420 gram
ACA PV
trimethobenzamide oral capsule 300 mg 1
ursodiol oral capsule 300 mg 1
ursodiol oral tablet 250 mg 500 mg 1
VARUBI ORAL TABLET 90 MG 1
VELPHORO ORAL TABLETCHEWABLE 500 MG
1 ST
VIBERZI ORAL TABLET 100 MG 75 MG 1 PA ST
ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 10000-32000 -42000 UNIT 15000-47000 -63000 UNIT 20000-63000- 84000 UNIT 3000-10000 -14000-UNIT 40000-126000- 168000 UNIT 5000-17000- 24000 UNIT
1 PA
ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 25000-79000- 105000 UNIT
1
ULCER THERAPY
amoxicil-clarithromy-lansopraz oral combo pack 500-500-30 mg
1
cimetidine hcl oral solution 300 mg5 ml 1
cimetidine oral tablet 200 mg 300 mg 400 mg 800 mg
1
DEXILANT ORAL CAPSULEBIPHASE DELAYED RELEAS 30 MG 60 MG
1 ST
esomeprazole magnesium oral capsuledelayed release(drec) 20 mg 40 mg
1
famotidine (pf) intravenous solution 20 mg2 ml MB
86
Drug Name Drug Tier Requirements Limits
famotidine oral suspension 40 mg5 ml (8 mgml) 1
famotidine oral tablet 20 mg 40 mg 1
lansoprazole oral capsuledelayed release(drec) 15 mg 30 mg
1
lansoprazole oral tabletdisintegrat delay rel 15 mg 30 mg
1
misoprostol oral tablet 100 mcg 200 mcg 1
nizatidine oral capsule 150 mg 300 mg 1
nizatidine oral solution 150 mg10 ml 1
omeprazole oral capsuledelayed release(drec) 10 mg 20 mg 40 mg
1
pantoprazole oral tabletdelayed release (drec) 20 mg 40 mg
1
rabeprazole oral tabletdelayed release (drec) 20 mg
1
sucralfate oral suspension 100 mgml 1
sucralfate oral tablet 1 gram 1
IMMUNOLOGY VACCINES amp BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCGML 200 MCGML 25 MCGML 300 MCGML 40 MCGML 60 MCGML
2 LA
ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG04 ML 100 MCG05 ML 150 MCG03 ML 200 MCG04 ML 25 MCG042 ML 300 MCG06 ML 40 MCG04 ML 500 MCGML 60 MCG03 ML
2 LA
EPOGEN INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML
2 LA
GRANIX SUBCUTANEOUS SOLUTION 300 MCGML 480 MCG16 ML
2
GRANIX SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML
2
LEUKINE INJECTION RECON SOLN 250 MCG 2 PA ST
MIRCERA INJECTION SYRINGE 100 MCG03 ML 150 MCG03 ML 200 MCG03 ML 30 MCG03 ML 50 MCG03 ML 75 MCG03 ML
MB
87
Drug Name Drug Tier Requirements Limits
MOZOBIL SUBCUTANEOUS SOLUTION 24 MG12 ML (20 MGML)
MB LA
NEUPOGEN INJECTION SOLUTION 300 MCGML 480 MCG16 ML
2 PA ST
NEUPOGEN INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML
2 PA ST
NIVESTYM INJECTION SOLUTION 300 MCGML 480 MCG16 ML
2
NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML
2
PROCRIT INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML 40000 UNITML
2 LA
UDENYCA SUBCUTANEOUS SYRINGE 6 MG06 ML
2 PA ST
ZARXIO INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML
2 PA ST
ZIEXTENZO SUBCUTANEOUS SYRINGE 6 MG06 ML
2 PA ST
GROWTH HORMONES
GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 02 MG025 ML 04 MG025 ML 06 MG025 ML 08 MG025 ML 1 MG025 ML 12 MG025 ML 14 MG025 ML 16 MG025 ML 18 MG025 ML 2 MG025 ML
2 PA ST LA
GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MGML (36 UNITML) 5 MGML (15 UNITML)
2 PA ST LA
OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG15 ML (67 MGML) 5 MG15 ML (33 MGML)
2 PA ST LA
OMNITROPE SUBCUTANEOUS RECON SOLN 58 MG
2 PA ST LA
SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG 5 MG 6 MG
2 PA ST LA
ZORBTIVE SUBCUTANEOUS RECON SOLN 88 MG
2 PA ST LA
INTERFERONS
AUBAGIO ORAL TABLET 14 MG 7 MG 2 PA LA
88
Drug Name Drug Tier Requirements Limits
AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG05 ML
2 PA ST LA QL (4 per 30 days)
AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG05 ML
2 PA ST LA QL (4 per 30 days)
BETASERON SUBCUTANEOUS KIT 03 MG 2 PA LA QL (14 per 30 days)
dimethyl fumarate oral capsuledelayed release(drec) 120 mg
2 PA LA QL (14 per 365 days)
dimethyl fumarate oral capsuledelayed release(drec) 120 mg (14)- 240 mg (46)
2 PA LA QL (1 per 365 days)
dimethyl fumarate oral capsuledelayed release(drec) 240 mg
2 PA LA QL (60 per 30 days)
GILENYA ORAL CAPSULE 05 MG 2 PA LA QL (30 per 30 days)
glatiramer subcutaneous syringe 20 mgml 2 PA LA QL (30 per 30 days)
glatiramer subcutaneous syringe 40 mgml 2 PA LA QL (12 per 30 days)
glatopa subcutaneous syringe 20 mgml 2 PA LA QL (30 per 30 days)
glatopa subcutaneous syringe 40 mgml 2 PA LA QL (12 per 30 days)
LEMTRADA INTRAVENOUS SOLUTION 12 MG12 ML
MB PA ST LA
MAVENCLAD (10 TABLET PACK) ORAL TABLET 10 MG
2 LA
MAVENCLAD (4 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (5 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (6 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (7 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (8 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (9 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAYZENT ORAL TABLET 025 MG 2 MG 2 PA ST LA QL (30 per 30 days)
MAYZENT STARTER PACK ORAL TABLETSDOSE PACK 025 MG (12 TABS)
2 PA ST LA QL (1 per 365 days)
OCREVUS INTRAVENOUS SOLUTION 30 MGML
MB PA LA
PEGASYS SUBCUTANEOUS SOLUTION 180 MCGML
2 PA LA
89
Drug Name Drug Tier Requirements Limits
PEGASYS SUBCUTANEOUS SYRINGE 180 MCG05 ML
2 PA LA
PLEGRIDY INTRAMUSCULAR SYRINGE 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG05 ML- 94 MCG05 ML
2 PA LA QL (1 per 365 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG05 ML- 94 MCG05 ML
2 PA LA QL (1 per 365 days)
POMALYST ORAL CAPSULE 1 MG 2 MG 3 MG 4 MG
2 PA ST OCh LA
PONVORY 14-DAY STARTER PACK ORAL TABLETSDOSE PACK 2 MG (2) - 10 MG (3)
2 PA LA QL (1 per 365 days)
PONVORY ORAL TABLET 20 MG 2 PA LA QL (30 per 30 days)
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG05 ML 44 MCG05 ML
2 PA LA QL (6 per 30 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG05 ML 44 MCG05 ML
2 PA LA QL (6 per 30 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 88MCG02ML-22 MCG05ML (6)
2 PA LA QL (5 per 30 days)
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 88MCG02ML-22 MCG05ML (6)
2 PA LA QL (5 per 30 days)
REVLIMID ORAL CAPSULE 10 MG 15 MG 25 MG 20 MG 25 MG 5 MG
2 PA ST OCh LA
ribavirin oral capsule 200 mg 2 LA
ribavirin oral tablet 200 mg 2 LA
ZEPOSIA ORAL CAPSULE 092 MG 2 LA QL (30 per 30 days)
ZEPOSIA STARTER KIT ORAL CAPSULEDOSE PACK 023-046-092 MG
2 LA QL (30 per 30 days)
ZEPOSIA STARTER PACK ORAL CAPSULEDOSE PACK 023 MG (4)- 046 MG (3)
2 LA QL (30 per 30 days)
INTERLEUKINS
ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG05 ML
2 PA LA
ARCALYST SUBCUTANEOUS RECON SOLN 220 MG
2 LA
90
Drug Name Drug Tier Requirements Limits
ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MGML
MB PA LA
imiquimod topical cream in packet 5 1
INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) 18 MILLION UNIT (1 ML) 50 MILLION UNIT (1 ML)
2 PA LA
INTRON A INJECTION SOLUTION 10 MILLION UNITML 6 MILLION UNITML
2 PA LA
PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT
MB LA
VACCINES amp MISCELLANEOUS IMMUNOLOGICALS
ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(25-5-3-5 MCG)-5LF05 ML
1 Vac
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(25-5-3-5 MCG)-5LF05 ML
1 Vac
ASCENIV INTRAVENOUS SOLUTION 10 MB PA LA
ATGAM INTRAVENOUS SOLUTION 50 MGML
MB
BCG VACCINE LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG
1 Vac
BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG05 ML
1 Vac
BIOTHRAX INTRAMUSCULAR SUSPENSION 05 MLDOSE
1 Vac
BIVIGAM INTRAVENOUS SOLUTION 10 MB PA LA
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 25-8-5 LF-MCG-LF05ML
1 Vac
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 25-8-5 LF-MCG-LF05ML
1 Vac
BOTOX INJECTION RECON SOLN 100 UNIT 200 UNIT
MB
CUTAQUIG SUBCUTANEOUS SOLUTION 165
MB LA
CUVITRU SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 ) 8 GRAM40 ML (20 )
MB LA
91
Drug Name Drug Tier Requirements Limits
DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF05ML
1 Vac
DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT 500 UNIT
MB LA
ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCGML
1 Vac
ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCGML
1 Vac
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG05 ML
1 Vac
FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 5
MB PA
GAMASTAN INTRAMUSCULAR SOLUTION 15-18 RANGE
MB
GAMASTAN SD INTRAMUSCULAR SOLUTION 15-18 RANGE
MB
GAMMAGARD LIQUID INJECTION SOLUTION 10
MB LA
GAMMAGARD S-D (IGA lt 1 MCGML) INTRAVENOUS RECON SOLN 10 GRAM 5 GRAM
MB PA LA
GAMMAKED INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 20 GRAM200 ML (10 ) 5 GRAM50 ML (10 )
MB LA
GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5
MB PA LA
GAMMAPLEX INTRAVENOUS SOLUTION 10
MB PA LA
GAMUNEX-C INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 25 GRAM25 ML (10 ) 20 GRAM200 ML (10 ) 40 GRAM400 ML (10 ) 5 GRAM50 ML (10 )
MB LA
GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 05 ML
1 Vac
GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 05 ML
1 Vac
GRASTEK SUBLINGUAL TABLET 2800 BAU 1 PA
HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1440 ELISA UNITML
1 Vac
92
Drug Name Drug Tier Requirements Limits
HAVRIX (PF) INTRAMUSCULAR SYRINGE 1440 ELISA UNITML 720 ELISA UNIT05 ML
1 Vac
HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE 20 MCG05 ML
1 Vac
HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )
MB LA
HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM 100 ML (10 ) 25 GRAM 25 ML (10 ) 20 GRAM 200 ML (10 ) 30 GRAM 300 ML (10 ) 5 GRAM 50 ML (10 )
MB LA
IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 25 UNIT
1 Vac
INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF05ML
1 Vac
IPOL INJECTION SUSPENSION 40-8-32 UNIT05 ML
1 Vac
IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG05 ML
1 Vac
KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF05 ML
1 Vac
MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG05 ML
1 Vac
MENQUADFI (PF) INTRAMUSCULAR SOLUTION 10 MCG05 ML
1 Vac
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG05 ML
1 Vac
M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1000-12500 TCID5005 ML
1 Vac
MYOBLOC INTRAMUSCULAR SOLUTION 10000 UNIT2 ML 2500 UNIT05 ML 5000 UNITML
MB LA
OCTAGAM INTRAVENOUS SOLUTION 10 5
MB PA LA
ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY
2 PA
PANZYGA INTRAVENOUS SOLUTION 10 MB PA
PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF05 ML
1 Vac
93
Drug Name Drug Tier Requirements Limits
PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 75 MCG05 ML
1 Vac
PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF05 ML 15LF-48MCG-62DU -10 MCG05ML
1 Vac
PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
PNEUMOVAX-23 INJECTION SOLUTION 25 MCG05 ML
1 Vac
PNEUMOVAX-23 INJECTION SYRINGE 25 MCG05 ML
1 Vac
PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE 05 ML
1 Vac
PRIVIGEN INTRAVENOUS SOLUTION 10 MB PA LA
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-43-3- 399 TCID5005
1 Vac
PROVENGE INTRAVENOUS SUSPENSION 50 MILLION CELL250 ML
MB PA
QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT05ML
1 Vac
RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 25 UNIT
1 Vac
RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT
1 PA
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCGML 40 MCGML 5 MCG05 ML
1 Vac
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCGML 5 MCG05 ML
1 Vac
SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG05 ML
1 Vac
STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1000 UNIT05 ML
1 Vac
TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF UNIT05 ML
1 Vac
94
Drug Name Drug Tier Requirements Limits
TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT05ML
1 Vac
TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT05 ML
1 Vac
TETANUSDIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT05 ML
1 Vac
THYMOGLOBULIN INTRAVENOUS RECON SOLN 25 MG
MB
TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG05 ML
1 Vac
TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCGML
1 Vac
TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG05 ML
1 Vac
TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG05 ML
1 Vac
VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT05 ML 50 UNITML
1 Vac
VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT05 ML 50 UNITML
1 Vac
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1350 UNIT05 ML
1 Vac
VAXELIS (PF) INTRAMUSCULAR SUSPENSION 15 UNIT-5 UNIT- 10 MCG05 ML
1 Vac
VAXELIS (PF) INTRAMUSCULAR SYRINGE 15 UNIT-5 UNIT- 10 MCG05 ML
1 Vac
XEMBIFY SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )
MB LA
XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT 200 UNIT 50 UNIT
MB LA
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP474 UNIT05 ML
1 Vac
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19400 UNIT065 ML
1 Vac
MUSCULOSKELETAL amp RHEUMATOLOGY
95
Drug Name Drug Tier Requirements Limits
GOUT THERAPY
allopurinol oral tablet 100 mg 300 mg 1
COLCHICINE ORAL CAPSULE 06 MG 1
colchicine oral tablet 06 mg 1
febuxostat oral tablet 40 mg 80 mg 1
KRYSTEXXA INTRAVENOUS SOLUTION 8 MGML
MB PA LA
MITIGARE ORAL CAPSULE 06 MG 1
probenecid oral tablet 500 mg 1
probenecid-colchicine oral tablet 500-05 mg 1
OSTEOPOROSIS THERAPY
alendronate oral solution 70 mg75 ml 1
alendronate oral tablet 10 mg 35 mg 5 mg 70 mg 1
EVENITY SUBCUTANEOUS SYRINGE 105 MG117 ML 210MG234ML ( 105MG117MLX2)
2 PA ST LA
FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCGDOSE (620MCG248ML)
2 PA ST LA QL (1 per 30 days)
FOSAMAX PLUS D ORAL TABLET 70 MG- 2800 UNIT 70 MG- 5600 UNIT
1
ibandronate oral tablet 150 mg 1
PROLIA SUBCUTANEOUS SYRINGE 60 MGML
2 ST LA
raloxifene oral tablet 60 mg 2 OCh
risedronate oral tablet 150 mg 35 mg 5 mg 1
risedronate oral tabletdelayed release (drec) 35 mg
1
TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3120 MCG156 ML)
2 PA ST LA
OTHER RHEUMATOLOGICALS
ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG09 ML
2 PA ST LA
ACTEMRA INTRAVENOUS SOLUTION 200 MG10 ML (20 MGML) 400 MG20 ML (20 MGML) 80 MG4 ML (20 MGML)
MB PA LA
ACTEMRA SUBCUTANEOUS SYRINGE 162 MG09 ML
2 PA ST LA
96
Drug Name Drug Tier Requirements Limits
BENLYSTA INTRAVENOUS RECON SOLN 120 MG 400 MG
MB PA LA
BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MGML
2 PA LA
BENLYSTA SUBCUTANEOUS SYRINGE 200 MGML
2 PA LA
ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MGML (1 ML)
2 PA ST LA
ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)
2 PA ST LA
ENBREL SUBCUTANEOUS SOLUTION 25 MG05 ML
2 PA ST LA
ENBREL SUBCUTANEOUS SYRINGE 25 MG05 ML (05) 50 MGML (1 ML)
2 PA ST LA
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MGML (1 ML)
2 PA ST LA
HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG08 ML
2 PA ST LA
HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG08 ML 80 MG08 ML-40 MG04 ML
2 PA ST LA
HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
2 PA ST LA
HUMIRA(CF) PEN PEDIATRIC UC SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
2 PA ST LA
HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML-40 MG04 ML
2 PA ST LA
HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG04 ML
2 PA ST LA
97
Drug Name Drug Tier Requirements Limits
HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG01 ML 20 MG02 ML 40 MG04 ML
2 PA ST LA
KEVZARA SUBCUTANEOUS PEN INJECTOR 150 MG114 ML 200 MG114 ML
2 PA ST LA
KEVZARA SUBCUTANEOUS SYRINGE 150 MG114 ML 200 MG114 ML
2 PA ST LA
leflunomide oral tablet 10 mg 20 mg 1
OLUMIANT ORAL TABLET 1 MG 2 MG 2 PA ST LA
ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG
MB PA LA
ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MGML
2 PA ST LA
ORENCIA SUBCUTANEOUS SYRINGE 125 MGML 50 MG04 ML 875 MG07 ML
2 PA ST LA
OTEZLA ORAL TABLET 30 MG 2 PA ST LA
OTEZLA STARTER ORAL TABLETSDOSE PACK 10 MG (4)-20 MG (4)-30 MG (47)
2 PA ST LA
penicillamine oral capsule 250 mg 1 PA
penicillamine oral tablet 250 mg 1 PA
RIDAURA ORAL CAPSULE 3 MG 1
RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 MG
2 PA ST LA
SAVELLA ORAL TABLET 100 MG 125 MG 25 MG 50 MG
1 PA ST
SAVELLA ORAL TABLETSDOSE PACK 125 MG (5)-25 MG(8)-50 MG(42)
1 PA ST
SIMPONI ARIA INTRAVENOUS SOLUTION 125 MGML
MB PA LA
SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MGML 50 MG05 ML
2 PA ST LA
SIMPONI SUBCUTANEOUS SYRINGE 100 MGML 50 MG05 ML
2 PA ST LA
XELJANZ ORAL SOLUTION 1 MGML 2 PA ST LA
XELJANZ ORAL TABLET 10 MG 5 MG 2 PA ST LA
XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG 22 MG
2 PA ST LA
OBSTETRICS amp GYNECOLOGY
DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES
98
Drug Name Drug Tier Requirements Limits
CAYA CONTOURED VAGINAL DIAPHRAGM 65-80 MM
ACA PV
FC2 FEMALE CONDOM ACA PV
FEMCAP VAGINAL DEVICE 22 MM ACA PV
KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 175 MCG24 HRS (5 YRS) 195 MG
ACA PV
LILETTA INTRAUTERINE INTRAUTERINE DEVICE 201 MCG24 HRS (6 YRS) 52 MG
ACA PV ST
MIRENA INTRAUTERINE INTRAUTERINE DEVICE 20 MCG24 HOURS (6 YRS) 52 MG
ACA PV
PARAGARD T 380A INTRAUTERINE INTRAUTERINE DEVICE 380 SQUARE MM
ACA PV
SKYLA INTRAUTERINE INTRAUTERINE DEVICE 14 MCG24 HRS (3 YRS) 135 MG
ACA PV
WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 MM
ACA PV
ESTROGENS amp PROGESTINS
amabelz oral tablet 05-01 mg 1-05 mg 1
ANGELIQ ORAL TABLET 025-05 MG 05-1 MG
1
camila oral tablet 035 mg ACA PV
COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 005-014 MG24 HR 005-025 MG24 HR
1
covaryx hs oral tablet 0625-125 mg 1
covaryx oral tablet 125-25 mg 1
CRINONE VAGINAL GEL 4 1
deblitane oral tablet 035 mg ACA PV
DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MGML
1
DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MGML
MB
DEPO-PROVERA INTRAMUSCULAR SYRINGE 150 MGML
MB
DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE 104 MG065 ML
ACA PV
99
Drug Name Drug Tier Requirements Limits
DIVIGEL TRANSDERMAL GEL IN PACKET 025 MG025 GRAM (01 ) 05 MG05 GRAM (01 ) 075 MG075 GRAM (01) 1 MGGRAM (01 ) 125 MG125 GRAM (01 )
1 QL (30 per 30 days)
dotti transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
DUAVEE ORAL TABLET 045-20 MG 1
eemt hs oral tablet 0625-125 mg 1
eemt oral tablet 125-25 mg 1
errin oral tablet 035 mg ACA PV
estradiol oral tablet 05 mg 1 mg 2 mg 1
estradiol transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
estradiol transdermal patch weekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 006 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (4 per 30 days)
estradiol vaginal cream 001 (01 mggram) 1
estradiol vaginal tablet 10 mcg 1
estradiol valerate intramuscular oil 20 mgml 40 mgml
1
estradiol-norethindrone acet oral tablet 05-01 mg 1-05 mg
1
ESTRING VAGINAL RING 2 MG (75 MCG 24 HOUR)
1
estrogens-methyltestosterone oral tablet 0625-125 mg 125-25 mg
1
EVAMIST TRANSDERMAL SPRAYNON-AEROSOL 153 MGSPRAY (17)
1 QL (2 per 30 days)
FEMRING VAGINAL RING 005 MG24 HR 01 MG24 HR
1
fyavolv oral tablet 05-25 mg-mcg 1-5 mg-mcg 1
heather oral tablet 035 mg ACA PV
hydroxyprogest(pf)(preg presv) intramuscular oil 250 mgml (1 ml)
2
hydroxyprogesterone cap(ppres) intramuscular oil 250 mgml
2
100
Drug Name Drug Tier Requirements Limits
hydroxyprogesterone caproate intramuscular oil 250 mgml
2
incassia oral tablet 035 mg ACA PV
jencycla oral tablet 035 mg ACA PV
jinteli oral tablet 1-5 mg-mcg 1
lyleq oral tablet 035 mg ACA PV
lyllana transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
lyza oral tablet 035 mg ACA PV
medroxyprogesterone intramuscular suspension 150 mgml
ACA PV
medroxyprogesterone intramuscular syringe 150 mgml
ACA PV
medroxyprogesterone oral tablet 10 mg 25 mg 5 mg
1
MENEST ORAL TABLET 03 MG 0625 MG 125 MG 25 MG
1
MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG24 HR
1 QL (4 per 30 days)
mimvey oral tablet 1-05 mg 1
nora-be oral tablet 035 mg ACA PV
norethindrone (contraceptive) oral tablet 035 mg ACA PV
norethindrone acetate oral tablet 5 mg 1
norethindrone ac-eth estradiol oral tablet 05-25 mg-mcg 1-5 mg-mcg
1
norlyda oral tablet 035 mg ACA PV
PREMARIN INJECTION RECON SOLN 25 MG 1
PREMARIN ORAL TABLET 03 MG 045 MG 0625 MG 09 MG 125 MG
1
PREMARIN VAGINAL CREAM 0625 MGGRAM
1
PREMPHASE ORAL TABLET 0625 MG (14) 0625MG-5MG(14)
1
PREMPRO ORAL TABLET 03-15 MG 045-15 MG 0625-25 MG 0625-5 MG
1
progesterone intramuscular oil 50 mgml 1
progesterone micronized oral capsule 100 mg 200 mg
1
101
Drug Name Drug Tier Requirements Limits
sharobel oral tablet 035 mg ACA PV
tulana oral tablet 035 mg ACA PV
yuvafem vaginal tablet 10 mcg 1
MISCELLANEOUS OBGYN
ANNOVERA VAGINAL RING 015-0013 MG24 HOUR
ACA PV
clindamycin phosphate vaginal cream 2 1
eluryng vaginal ring 012-0015 mg24 hr ACA PV
etonogestrel-ethinyl estradiol vaginal ring 012-0015 mg24 hr
ACA PV
fem ph vaginal gel 09-0025 1
GYNAZOLE-1 VAGINAL CREAM 2 1
gynol ii vaginal gel 3 ACA PV
INTRAROSA VAGINAL INSERT 65 MG 1
isoxsuprine oral tablet 10 mg 20 mg 1
LUPANETA PACK (1 MONTH) KIT SYRINGE AND TABLET 375 MG -5 MG (30)
2 LA
LUPANETA PACK (3 MONTH) KIT SYRINGE AND TABLET 1125 MG -5 MG (90)
2 LA
metronidazole vaginal gel 075 1
NEXPLANON SUBDERMAL IMPLANT 68 MG ACA PV
OSPHENA ORAL TABLET 60 MG 1
PHEXXI VAGINAL GEL 18-1-04 ACA PV
terconazole vaginal cream 04 08 1
terconazole vaginal suppository 80 mg 1
TODAY CONTRACEPTIVE SPONGE VAGINAL CONTRACEPTIVE SPONGE 1000 MG
ACA PV
tranexamic acid oral tablet 650 mg 1
TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 MCG24 HR
ACA PV
vaginal contraceptive foam vaginal foam 125 ACA PV
vandazole vaginal gel 075 1
VCF CONTRACEPTIVE FILM VAGINAL FILM 28
ACA PV
VCF CONTRACEPTIVE GEL VAGINAL GEL 4
ACA PV
102
Drug Name Drug Tier Requirements Limits
xulane transdermal patch weekly 150-35 mcg24 hr
ACA PV
zafemy transdermal patch weekly 150-35 mcg24 hr
ACA PV
ORAL CONTRACEPTIVES amp RELATED AGENTS
afirmelle oral tablet 01-20 mg-mcg ACA PV
altavera (28) oral tablet 015-003 mg ACA PV
alyacen 135 (28) oral tablet 1-35 mg-mcg ACA PV
alyacen 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
amethia oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
amethyst (28) oral tablet 90-20 mcg (28) ACA PV
apri oral tablet 015-003 mg ACA PV
aranelle (28) oral tablet 05105-35 mg-mcg ACA PV
ashlyna oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
aubra eq oral tablet 01-20 mg-mcg ACA PV
aubra oral tablet 01-20 mg-mcg ACA PV
aurovela 1530 (21) oral tablet 15-30 mg-mcg ACA PV
aurovela 120 (21) oral tablet 1-20 mg-mcg ACA PV
aurovela 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
aurovela fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
aurovela fe 1-20 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
aviane oral tablet 01-20 mg-mcg ACA PV
ayuna oral tablet 015-003 mg ACA PV
azurette (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
BALCOLTRA ORAL TABLET 01 MG-002 MG (21)365 MG(7)
ACA PV
balziva (28) oral tablet 04-35 mg-mcg ACA PV
blisovi 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
blisovi fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
103
Drug Name Drug Tier Requirements Limits
blisovi fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
briellyn oral tablet 04-35 mg-mcg ACA PV
camrese lo oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)
ACA PV
camrese oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
caziant (28) oral tablet 0112515-25 mg-mcg ACA PV
charlotte 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
chateal (28) oral tablet 015-003 mg ACA PV
chateal eq (28) oral tablet 015-003 mg ACA PV
cryselle (28) oral tablet 03-30 mg-mcg ACA PV
cyclafem 135 (28) oral tablet 1-35 mg-mcg ACA PV
cyclafem 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
cyred eq oral tablet 015-003 mg ACA PV
cyred oral tablet 015-003 mg ACA PV
dasetta 135 (28) oral tablet 1-35 mg-mcg ACA PV
dasetta 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
daysee oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
desog-eestradioleestradiol oral tablet 015-002 mgx21 001 mg x 5
ACA PV
desogestrel-ethinyl estradiol oral tablet 015-003 mg
ACA PV
dolishale oral tablet 90-20 mcg (28) ACA PV
drospirenone-eestradiol-lmfa oral tablet 3-002-0451 mg (24) (4) 3-003-0451 mg (21) (7)
ACA PV
drospirenone-ethinyl estradiol oral tablet 3-002 mg 3-003 mg
ACA PV
econtra ez oral tablet 15 mg ACA PV
econtra one-step oral tablet 15 mg ACA PV
elinest oral tablet 03-30 mg-mcg ACA PV
ELLA ORAL TABLET 30 MG ACA PV
emoquette oral tablet 015-003 mg ACA PV
104
Drug Name Drug Tier Requirements Limits
enpresse oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
enskyce oral tablet 015-003 mg ACA PV
estarylla oral tablet 025-35 mg-mcg ACA PV
ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg 1-50 mg-mcg
ACA PV
falmina (28) oral tablet 01-20 mg-mcg ACA PV
fayosim oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg
ACA PV
femynor oral tablet 025-35 mg-mcg ACA PV
gemmily oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV
hailey 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
hailey fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
hailey fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
hailey oral tablet 15-30 mg-mcg ACA PV
iclevia oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
isibloom oral tablet 015-003 mg ACA PV
jaimiess oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
jasmiel (28) oral tablet 3-002 mg ACA PV
jolessa oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
juleber oral tablet 015-003 mg ACA PV
junel 1530 (21) oral tablet 15-30 mg-mcg ACA PV
junel 120 (21) oral tablet 1-20 mg-mcg ACA PV
junel fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
junel fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
junel fe 24 oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV
kaitlib fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)
ACA PV
kalliga oral tablet 015-003 mg ACA PV
kariva (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
105
Drug Name Drug Tier Requirements Limits
kelnor 135 (28) oral tablet 1-35 mg-mcg ACA PV
kelnor 1-50 (28) oral tablet 1-50 mg-mcg ACA PV
kurvelo (28) oral tablet 015-003 mg ACA PV
l norgesteestradiol-eestrad oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7) 015 mg-20 mcg 015 mg-25 mcg 015 mg-30 mcg (84)10 mcg (7)
ACA PV
larin 1530 (21) oral tablet 15-30 mg-mcg ACA PV
larin 120 (21) oral tablet 1-20 mg-mcg ACA PV
larin 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV
larin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
larin fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
larissia oral tablet 01-20 mg-mcg ACA PV
layolis fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)
ACA PV
leena 28 oral tablet 05105-35 mg-mcg ACA PV
lessina oral tablet 01-20 mg-mcg ACA PV
levonest (28) oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
levonorgestrel oral tablet 15 mg ACA PV
levonorgestrel-ethinyl estrad oral tablet 01-20 mg-mcg 015-003 mg 90-20 mcg (28)
ACA PV
levonorgestrel-ethinyl estrad oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
levonorg-eth estrad triphasic oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
levora-28 oral tablet 015-003 mg ACA PV
lillow (28) oral tablet 015-003 mg ACA PV
LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG (24)10 MCG (2)
ACA PV
lojaimiess oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)
ACA PV
loryna (28) oral tablet 3-002 mg ACA PV
low-ogestrel (28) oral tablet 03-30 mg-mcg ACA PV
lo-zumandimine (28) oral tablet 3-002 mg ACA PV
lutera (28) oral tablet 01-20 mg-mcg ACA PV
106
Drug Name Drug Tier Requirements Limits
marlissa (28) oral tablet 015-003 mg ACA PV
merzee oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV
mibelas 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
microgestin 1530 (21) oral tablet 15-30 mg-mcg ACA PV
microgestin 120 (21) oral tablet 1-20 mg-mcg ACA PV
microgestin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
microgestin fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
mili oral tablet 025-35 mg-mcg ACA PV
mono-linyah oral tablet 025-35 mg-mcg ACA PV
my choice oral tablet 15 mg ACA PV
my way oral tablet 15 mg ACA PV
NATAZIA ORAL TABLET 3 MG2 MG-2 MG 2 MG-3 MG1 MG
ACA PV
necon 0535 (28) oral tablet 05-35 mg-mcg ACA PV
new day oral tablet 15 mg ACA PV
NEXTSTELLIS ORAL TABLET 3 MG- 142 MG (28)
ACA PV
nikki (28) oral tablet 3-002 mg ACA PV
noreth-ethinyl estradiol-iron oral tabletchewable 04mg-35mcg(21) and 75 mg (7) 08mg-25mcg(24) and 75 mg (4)
ACA PV
norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg 15-30 mg-mcg
ACA PV
norethindrone-eestradiol-iron oral capsule 1 mg-20 mcg (24)75 mg (4)
ACA PV
norethindrone-eestradiol-iron oral tablet 1 mg-20 mcg (21)75 mg (7) 15 mg-30 mcg (21)75 mg (7)
ACA PV
norethindrone-eestradiol-iron oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
norgestimate-ethinyl estradiol oral tablet 0180215025 mg-25 mcg 0180215025 mg-35 mcg (28) 025-35 mg-mcg
ACA PV
nortrel 0535 (28) oral tablet 05-35 mg-mcg ACA PV
nortrel 135 (21) oral tablet 1-35 mg-mcg (21) ACA PV
nortrel 135 (28) oral tablet 1-35 mg-mcg ACA PV
107
Drug Name Drug Tier Requirements Limits
nortrel 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
nylia 777 (28) oral tablet 050751 mg- 35 mcg ACA PV
nymyo oral tablet 025-35 mg-mcg ACA PV
ocella oral tablet 3-003 mg ACA PV
opcicon one-step oral tablet 15 mg ACA PV
option-2 oral tablet 15 mg ACA PV
orsythia oral tablet 01-20 mg-mcg ACA PV
philith oral tablet 04-35 mg-mcg ACA PV
pimtrea (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
pirmella oral tablet 050751 mg- 35 mcg 1-35 mg-mcg
ACA PV
portia 28 oral tablet 015-003 mg ACA PV
previfem oral tablet 025-35 mg-mcg ACA PV
reclipsen (28) oral tablet 015-003 mg ACA PV
rivelsa oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg
ACA PV
setlakin oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
simliya (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
simpesse oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
SLYND ORAL TABLET 4 MG (28) ACA PV
sprintec (28) oral tablet 025-35 mg-mcg ACA PV
sronyx oral tablet 01-20 mg-mcg ACA PV
syeda oral tablet 3-003 mg ACA PV
tarina 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
tarina fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
tilia fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9) ACA PV
tri femynor oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-estarylla oral tablet 0180215025 mg-35 mcg (28)
ACA PV
108
Drug Name Drug Tier Requirements Limits
tri-legest fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9)
ACA PV
tri-linyah oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-lo-estarylla oral tablet 0180215025 mg-25 mcg
ACA PV
tri-lo-marzia oral tablet 0180215025 mg-25 mcg
ACA PV
tri-lo-mili oral tablet 0180215025 mg-25 mcg ACA PV
tri-lo-sprintec oral tablet 0180215025 mg-25 mcg
ACA PV
tri-mili oral tablet 0180215025 mg-35 mcg (28) ACA PV
tri-nymyo oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-previfem (28) oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-sprintec (28) oral tablet 0180215025 mg-35 mcg (28)
ACA PV
trivora (28) oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
tri-vylibra lo oral tablet 0180215025 mg-25 mcg
ACA PV
tri-vylibra oral tablet 0180215025 mg-35 mcg (28)
ACA PV
TYBLUME ORAL TABLETCHEWABLE 01 MG- 20 MCG
ACA PV
tydemy oral tablet 3-003-0451 mg (21) (7) ACA PV
velivet triphasic regimen (28) oral tablet 0112515-25 mg-mcg
ACA PV
vestura (28) oral tablet 3-002 mg ACA PV
vienva oral tablet 01-20 mg-mcg ACA PV
viorele (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
volnea (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
vyfemla (28) oral tablet 04-35 mg-mcg ACA PV
vylibra oral tablet 025-35 mg-mcg ACA PV
wera (28) oral tablet 05-35 mg-mcg ACA PV
wymzya fe oral tabletchewable 04mg-35mcg(21) and 75 mg (7)
ACA PV
109
Drug Name Drug Tier Requirements Limits
zarah oral tablet 3-003 mg ACA PV
zovia 135e (28) oral tablet 1-35 mg-mcg ACA PV
zumandimine (28) oral tablet 3-003 mg ACA PV
OXYTOCICS
methergine oral tablet 02 mg 1
methylergonovine oral tablet 02 mg 1
OPHTHALMOLOGY
ANTIBIOTICS
ak-poly-bac ophthalmic (eye) ointment 500-10000 unitgram
1
AZASITE OPHTHALMIC (EYE) DROPS 1 1
bacitracin ophthalmic (eye) ointment 500 unitgram
1
bacitracin-polymyxin b ophthalmic (eye) ointment 500-10000 unitgram
1
BESIVANCE OPHTHALMIC (EYE) DROPSSUSPENSION 06
1
ciprofloxacin hcl ophthalmic (eye) drops 03 1
erythromycin ophthalmic (eye) ointment 5 mggram (05 )
1
gatifloxacin ophthalmic (eye) drops 05 1
gentak ophthalmic (eye) ointment 03 (3 mggram)
1
gentamicin ophthalmic (eye) drops 03 1
levofloxacin ophthalmic (eye) drops 05 1
moxifloxacin ophthalmic (eye) drops 05 1
moxifloxacin ophthalmic (eye) drops viscous 05
1
NATACYN OPHTHALMIC (EYE) DROPSSUSPENSION 5
1
neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
1
neomycin-polymyxin-gramicidin ophthalmic (eye) drops 175 mg-10000 unit-0025mgml
1
neo-polycin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
1
ofloxacin ophthalmic (eye) drops 03 1
110
Drug Name Drug Tier Requirements Limits
polycin ophthalmic (eye) ointment 500-10000 unitgram
1
polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10000 unit- 1 mgml
1
tobramycin ophthalmic (eye) drops 03 1
TOBREX OPHTHALMIC (EYE) OINTMENT 03
1
ANTIVIRALS
trifluridine ophthalmic (eye) drops 1 1
ZIRGAN OPHTHALMIC (EYE) GEL 015 1
BETA-BLOCKERS
betaxolol ophthalmic (eye) drops 05 1
BETIMOL OPHTHALMIC (EYE) DROPS 025 05
1
BETOPTIC S OPHTHALMIC (EYE) DROPSSUSPENSION 025
1
carteolol ophthalmic (eye) drops 1 1
levobunolol ophthalmic (eye) drops 05 1
timolol maleate ophthalmic (eye) drops 025 05
1
timolol maleate ophthalmic (eye) drops once daily 05
1
timolol maleate ophthalmic (eye) gel forming solution 025 05
1
CYCLOPLEGIC MYDRIATICS
atropine ophthalmic (eye) drops 1 1
atropine ophthalmic (eye) ointment 1 1
cyclopentolate ophthalmic (eye) drops 05 1 2
1
homatropaire ophthalmic (eye) drops 5 1
tropicamide ophthalmic (eye) drops 05 1 1
DIRECT ACTING MIOTICS
pilocarpine hcl ophthalmic (eye) drops 1 2 4
1
MISCELLANEOUS OPHTHALMOLOGICS
ALOCRIL OPHTHALMIC (EYE) DROPS 2 1 ST
ALOMIDE OPHTHALMIC (EYE) DROPS 01 1 ST
111
Drug Name Drug Tier Requirements Limits
altacaine ophthalmic (eye) drops 05 1
azelastine ophthalmic (eye) drops 005 1
BEOVU INTRAVITREAL SOLUTION 6 MG005 ML
MB PA LA
bepotastine besilate ophthalmic (eye) drops 15 1 ST
BEPREVE OPHTHALMIC (EYE) DROPS 15 1 ST
cromolyn ophthalmic (eye) drops 4 1
CYSTARAN OPHTHALMIC (EYE) DROPS 044
2 PA
epinastine ophthalmic (eye) drops 005 1
EYLEA INTRAVITREAL SOLUTION 2 MG005 ML
MB PA LA
EYLEA INTRAVITREAL SYRINGE 2 MG005 ML
MB PA LA
LACRISERT OPHTHALMIC (EYE) INSERT 5 MG
1
LASTACAFT OPHTHALMIC (EYE) DROPS 025
1 ST
LUCENTIS INTRAVITREAL SOLUTION 03 MG005 ML 05 MG005 ML
MB PA LA
LUCENTIS INTRAVITREAL SYRINGE 03 MG005 ML 05 MG005 ML
MB PA LA
LUXTURNA SUBRETINAL SUSPENSION 15 X 10EXP11 VG03 ML (FNL)
MB LA
olopatadine ophthalmic (eye) drops 01 02 1
OMIDRIA INTRAOCULAR CONCENTRATE 1-03
MB
proparacaine ophthalmic (eye) drops 05 1
RESTASIS OPHTHALMIC (EYE) DROPPERETTE 005
1 QL (120 per 30 days)
TETRACAINE HCL (PF) OPHTHALMIC (EYE) DROPS 05
1
tetracaine hcl ophthalmic (eye) drops 05 1
VISUDYNE INTRAVENOUS RECON SOLN 15 MG
MB LA
XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5
1 PA ST QL (60 per 30 days)
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
112
Drug Name Drug Tier Requirements Limits
ACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE 045
1 ST
bromfenac ophthalmic (eye) drops 009 1
diclofenac sodium ophthalmic (eye) drops 01 1
flurbiprofen sodium ophthalmic (eye) drops 003
1
ketorolac ophthalmic (eye) drops 04 05 1
NEVANAC OPHTHALMIC (EYE) DROPSSUSPENSION 01
1
ORAL DRUGS FOR GLAUCOMA
acetazolamide oral capsule extended release 500 mg
1
acetazolamide oral tablet 125 mg 250 mg 1
methazolamide oral tablet 25 mg 50 mg 1
OTHER GLAUCOMA DRUGS
bimatoprost ophthalmic (eye) drops 003 1
brinzolamide ophthalmic (eye) dropssuspension 1
1
COMBIGAN OPHTHALMIC (EYE) DROPS 02-05
1
dorzolamide ophthalmic (eye) drops 2 1
dorzolamide-timolol (pf) ophthalmic (eye) dropperette 2-05
1
dorzolamide-timolol ophthalmic (eye) drops 223-68 mgml
1
latanoprost ophthalmic (eye) drops 0005 1
LUMIGAN OPHTHALMIC (EYE) DROPS 001
1 ST
RHOPRESSA OPHTHALMIC (EYE) DROPS 002
1 PA ST
SIMBRINZA OPHTHALMIC (EYE) DROPSSUSPENSION 1-02
1
travoprost ophthalmic (eye) drops 0004 1
STEROID-ANTIBIOTIC COMBINATIONS
neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
1
neomycin-polymyxin b-dexameth ophthalmic (eye) dropssuspension 35mgml-10000 unitml-01
1
113
Drug Name Drug Tier Requirements Limits
neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 35 mgg-10000 unitg-01
1
neomycin-polymyxin-hc ophthalmic (eye) dropssuspension 35-10000-10 mg-unit-mgml
1
neo-polycin hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
1
TOBRADEX OPHTHALMIC (EYE) OINTMENT 03-01
1
TOBRADEX ST OPHTHALMIC (EYE) DROPSSUSPENSION 03-005
1
tobramycin-dexamethasone ophthalmic (eye) dropssuspension 03-01
1
STEROIDS
ALREX OPHTHALMIC (EYE) DROPSSUSPENSION 02
1 ST
dexamethasone sodium phosphate ophthalmic (eye) drops 01
1
DUREZOL OPHTHALMIC (EYE) DROPS 005
1
fluorometholone ophthalmic (eye) dropssuspension 01
1
FML FORTE OPHTHALMIC (EYE) DROPSSUSPENSION 025
1
FML SOP OPHTHALMIC (EYE) OINTMENT 01
1
INVELTYS OPHTHALMIC (EYE) DROPSSUSPENSION 1
1 ST
LOTEMAX OPHTHALMIC (EYE) OINTMENT 05
1 ST
loteprednol etabonate ophthalmic (eye) dropsgel 05
1
loteprednol etabonate ophthalmic (eye) dropssuspension 05
1
MAXIDEX OPHTHALMIC (EYE) DROPSSUSPENSION 01
1
OZURDEX INTRAVITREAL IMPLANT 07 MG MB LA
PRED MILD OPHTHALMIC (EYE) DROPSSUSPENSION 012
1
prednisolone acetate ophthalmic (eye) dropssuspension 1
1
114
Drug Name Drug Tier Requirements Limits
prednisolone sodium phosphate ophthalmic (eye) drops 1
1
RETISERT INTRAVITREAL IMPLANT 059 MG
MB LA
YUTIQ INTRAVITREAL IMPLANT 018 MG MB
STEROID-SULFONAMIDE COMBINATIONS
BLEPHAMIDE OPHTHALMIC (EYE) DROPSSUSPENSION 10-02
1
BLEPHAMIDE SOP OPHTHALMIC (EYE) OINTMENT 10-02
1
sulfacetamide-prednisolone ophthalmic (eye) drops 10 -023 (025 )
1
SULFONAMIDES
sulfacetamide sodium ophthalmic (eye) drops 10
1
sulfacetamide sodium ophthalmic (eye) ointment 10
1
SYMPATHOMIMETICS
apraclonidine ophthalmic (eye) drops 05 1
brimonidine ophthalmic (eye) drops 015 02 1
IOPIDINE OPHTHALMIC (EYE) DROPPERETTE 1
1
VASOCONSTRICTOR DECONGESTANTS
phenylephrine hcl ophthalmic (eye) drops 10 25
1
RESPIRATORY ALLERGY COUGH amp COLD
ANTIHISTAMINE amp ANTIALLERGENIC AGENTS
adrenalin injection solution 1 mgml 1 mgml (1 ml)
1
carbinoxamine maleate oral liquid 4 mg5 ml 1 PA ST QL (2 per 30 days)
carbinoxamine maleate oral tablet 4 mg 1 PA ST QL (240 per 30 days)
carbinoxamine maleate oral tablet 6 mg 1 PA ST QL (120 per 30 days)
cetirizine oral solution 1 mgml 1
clemastine oral syrup 05 mg5 ml 1
clemastine oral tablet 268 mg 1
cyproheptadine oral syrup 2 mg5 ml 1
cyproheptadine oral tablet 4 mg 1
115
Drug Name Drug Tier Requirements Limits
desloratadine oral tablet 5 mg 1 PA ST QL (30 per 30 days)
desloratadine oral tabletdisintegrating 25 mg 5 mg
1 PA ST
diphenhydramine hcl injection solution 50 mgml 1
diphenhydramine hcl injection syringe 50 mgml MB
EPINEPHRINE INJECTION AUTO-INJECTOR 015 MG015 ML
1
epinephrine injection auto-injector 015 mg03 ml 03 mg03 ml
1
epinephrine injection solution 1 mgml 1 mgml (1 ml)
1
epinephrine injection syringe 01 mgml 1
hydroxyzine hcl intramuscular solution 25 mgml MB
hydroxyzine hcl oral solution 10 mg5 ml 1
hydroxyzine hcl oral tablet 10 mg 25 mg 50 mg 1
hydroxyzine pamoate oral capsule 100 mg 25 mg 50 mg
1
levocetirizine oral solution 25 mg5 ml 1
levocetirizine oral tablet 5 mg 1
promethazine injection solution 25 mgml MB
promethazine oral syrup 625 mg5 ml 1
promethazine oral tablet 125 mg 25 mg 50 mg 1
promethazine rectal suppository 125 mg 25 mg 1
promethegan rectal suppository 125 mg 25 mg 50 mg
1
COUGH amp COLD THERAPY
benzonatate oral capsule 100 mg 150 mg 200 mg 1
brompheniramine-pseudoeph-dm oral syrup 2-30-10 mg5 ml
1
codeine-guaifenesin oral liquid 10-100 mg5 ml 1
g tussin ac oral liquid 10-100 mg5 ml 1
guaiatussin ac oral liquid 10-100 mg5 ml 1
hydrocodone-chlorpheniramine oral suspensionextended rel 12 hr 10-8 mg5 ml
1
hydrocodone-homatropine oral syrup 5-15 mg5 ml
1
hydrocodone-homatropine oral tablet 5-15 mg 1
116
Drug Name Drug Tier Requirements Limits
hydromet oral syrup 5-15 mg5 ml 1
maxi-tuss ac oral liquid 10-100 mg5 ml 1
m-clear wc oral liquid 63-100 mg5 ml 1
promethazine-codeine oral syrup 625-10 mg5 ml 1
promethazine-dm oral syrup 625-15 mg5 ml 1
promethazine-phenyleph-codeine oral syrup 625-5-10 mg5 ml
1
promethazine-phenylephrine oral syrup 625-5 mg5 ml
1
virtussin ac oral liquid 10-100 mg5 ml 1
PULMONARY AGENTS
acetylcysteine solution 100 mgml (10 ) 200 mgml (20 )
1
ADEMPAS ORAL TABLET 05 MG 1 MG 15 MG 2 MG 25 MG
2 PA LA
ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCGACTUATION 230-21 MCGACTUATION 45-21 MCGACTUATION
1 QL (1 per 30 days)
ALBUTEROL HFA 90 MCG INHALER 90 MCGACTUATION
1 QL (2 per 30 days)
albuterol sulfate inhalation inhalation hfa aerosol inhaler 90 mcgactuation
1 QL (2 per 30 days)
albuterol sulfate inhalation inhalation solution for nebulization 063 mg3 ml 125 mg3 ml 25 mg 3 ml (0083 ) 25 mg05 ml 5 mgml
1
albuterol sulfate inhalation oral syrup 2 mg5 ml 1
albuterol sulfate inhalation oral tablet 2 mg 4 mg 1
albuterol sulfate inhalation oral tablet extended release 12 hr 4 mg 8 mg
1
ALVESCO INHALATION HFA AEROSOL INHALER 160 MCGACTUATION 80 MCGACTUATION
1 PA ST QL (1 per 30 days)
alyq oral tablet 20 mg 2 PA
ambrisentan oral tablet 10 mg 5 mg 2 PA LA
aminophylline intravenous solution 250 mg10 ml MB
ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 625-25 MCGACTUATION
1 QL (1 per 30 days)
arformoterol inhalation solution for nebulization 15 mcg2 ml
1
117
Drug Name Drug Tier Requirements Limits
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 200 MCGACTUATION
1 QL (1 per 30 days)
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 50 MCGACTUATION
1
ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCGACTUATION
1 QL (2 per 30 days)
BERINERT INTRAVENOUS KIT 500 UNIT (10 ML)
MB PA LA
BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-48 MCG
1
bosentan oral tablet 125 mg 625 mg 2 PA LA
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCGDOSE
1 QL (1 per 30 days)
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 200-25 MCGDOSE
1
BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG2 ML
1
budesonide inhalation suspension for nebulization 025 mg2 ml 05 mg2 ml
1 QL (120 per 30 days)
budesonide inhalation suspension for nebulization 1 mg2 ml
1 QL (60 per 30 days)
CINQAIR INTRAVENOUS SOLUTION 10 MGML
MB PA
CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)
MB PA LA
COMBIVENT RESPIMAT INHALATION MIST 20-100 MCGACTUATION
1 QL (2 per 30 days)
cromolyn inhalation solution for nebulization 20 mg2 ml
1
DALIRESP ORAL TABLET 250 MCG 500 MCG
1
DULERA INHALATION HFA AEROSOL INHALER 100-5 MCGACTUATION 200-5 MCGACTUATION 50-5 MCGACTUATION
1 QL (1 per 30 days)
ELIXOPHYLLIN ORAL ELIXIR 80 MG15 ML 1
ESBRIET ORAL CAPSULE 267 MG 2 PA LA QL (270 per 30 days)
ESBRIET ORAL TABLET 267 MG 801 MG 2 PA LA QL (90 per 30 days)
FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MGML
MB PA LA
118
Drug Name Drug Tier Requirements Limits
FASENRA SUBCUTANEOUS SYRINGE 30 MGML
MB PA LA
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 50 MCGACTUATION
1 QL (1 per 30 days)
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCGACTUATION
1 QL (4 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCGACTUATION 44 MCGACTUATION
1 QL (1 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCGACTUATION
1 QL (2 per 30 days)
fluticasone propionate nasal spraysuspension 50 mcgactuation
1
fluticasone propion-salmeterol inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose
1 QL (1 per 30 days)
formoterol fumarate inhalation solution for nebulization 20 mcg2 ml
1
HAEGARDA SUBCUTANEOUS RECON SOLN 2000 UNIT 3000 UNIT
2 PA LA
icatibant subcutaneous syringe 30 mg3 ml 2 PA
INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 625 MCGACTUATION
1 QL (1 per 30 days)
ipratropium bromide inhalation solution 002 1
ipratropium-albuterol inhalation solution for nebulization 05 mg-3 mg(25 mg base)3 ml
1 QL (180 per 30 days)
KALBITOR SUBCUTANEOUS SOLUTION 10 MGML (1 ML)
2 PA LA
KALYDECO ORAL GRANULES IN PACKET 25 MG 50 MG 75 MG
2 PA LA
KALYDECO ORAL TABLET 150 MG 2 PA LA
levalbuterol hcl inhalation solution for nebulization 031 mg3 ml 063 mg3 ml 125 mg05 ml 125 mg3 ml
1
LEVALBUTEROL TARTRATE INHALATION HFA AEROSOL INHALER 45 MCGACTUATION
1 QL (2 per 30 days)
metaproterenol oral syrup 10 mg5 ml 1
montelukast oral granules in packet 4 mg 1
montelukast oral tablet 10 mg 1
119
Drug Name Drug Tier Requirements Limits
montelukast oral tabletchewable 4 mg 5 mg 1
nebusal inhalation solution for nebulization 3 1
NUCALA SUBCUTANEOUS RECON SOLN 100 MG
MB PA LA
OFEV ORAL CAPSULE 100 MG 150 MG 2 PA LA QL (60 per 30 days)
OPSUMIT ORAL TABLET 10 MG 2 PA LA
ORLADEYO ORAL CAPSULE 110 MG 150 MG
2 PA ST QL (28 per 28 days)
PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG2 ML
1
pulmosal inhalation solution for nebulization 7 1
PULMOZYME INHALATION SOLUTION 1 MGML
2 PA LA
QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCGACTUATION 80 MCGACTUATION
1
REVATIO INTRAVENOUS SOLUTION 10 MG125 ML
MB LA
RUCONEST INTRAVENOUS RECON SOLN 2100 UNIT
MB PA LA
SEEBRI NEOHALER INHALATION CAPSULE WINHALATION DEVICE 156 MCG
1
SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCGDOSE
1
sildenafil (pulmhypertension) intravenous solution 10 mg125 ml
MB
sildenafil (pulmhypertension) oral suspension for reconstitution 10 mgml
2
sildenafil (pulmhypertension) oral tablet 20 mg 2 PA
SINUVA SINUS IMPLANT 1350 MCG MB
sodium chloride inhalation solution for nebulization 09 10 3 7
1
SPIRIVA RESPIMAT INHALATION MIST 125 MCGACTUATION
1
SPIRIVA RESPIMAT INHALATION MIST 25 MCGACTUATION
1 QL (1 per 30 days)
SPIRIVA WITH HANDIHALER INHALATION CAPSULE WINHALATION DEVICE 18 MCG
1 QL (30 per 30 days)
STIOLTO RESPIMAT INHALATION MIST 25-25 MCGACTUATION
1
120
Drug Name Drug Tier Requirements Limits
STRIVERDI RESPIMAT INHALATION MIST 25 MCGACTUATION
1
SYMBICORT INHALATION HFA AEROSOL INHALER 160-45 MCGACTUATION 80-45 MCGACTUATION
1 QL (1 per 30 days)
SYMDEKO ORAL TABLETS SEQUENTIAL 100-150 MG (D) 150 MG (N) 50-75 MG (D) 75 MG (N)
2 PA LA
tadalafil (pulm hypertension) oral tablet 20 mg 2 PA
TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG2 ML (150 MGML)
2 PA LA
terbutaline oral tablet 25 mg 5 mg 1
terbutaline subcutaneous solution 1 mgml 1
theophylline oral elixir 80 mg15 ml 1
theophylline oral solution 80 mg15 ml 1
theophylline oral tablet extended release 12 hr 300 mg 450 mg
1
theophylline oral tablet extended release 24 hr 400 mg 600 mg
1
TRACLEER ORAL TABLET FOR SUSPENSION 32 MG
2 PA LA
TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-625-25 MCG 200-625-25 MCG
1
TRIKAFTA ORAL TABLETS SEQUENTIAL 100-50-75 MG(D) 150 MG (N) 50-25-375 MG (D)75 MG (N)
2 PA LA
TYVASO INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)
2 PA LA
TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)
2 PA LA
TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML
2 PA LA
UTIBRON NEOHALER INHALATION CAPSULE WINHALATION DEVICE 275-156 MCG
1
VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCGML 20 MCGML
2 PA LA
121
Drug Name Drug Tier Requirements Limits
wixela inhub inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose
1 QL (1 per 30 days)
XOLAIR SUBCUTANEOUS RECON SOLN 150 MG
MB LA
XOLAIR SUBCUTANEOUS SYRINGE 150 MGML 75 MG05 ML
MB PA LA QL (7 per 30 days)
zafirlukast oral tablet 10 mg 20 mg 1
zileuton oral tablet er multiphase 12 hr 600 mg 1 ST
ZYFLO ORAL TABLET 600 MG 1 ST
UROLOGICALS
ANTICHOLINERGICS amp ANTISPASMODICS
darifenacin oral tablet extended release 24 hr 15 mg 75 mg
1
flavoxate oral tablet 100 mg 1
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG 50 MG
1 ST
oxybutynin chloride oral syrup 5 mg5 ml 1
oxybutynin chloride oral tablet 5 mg 1
oxybutynin chloride oral tablet extended release 24hr 10 mg 15 mg 5 mg
1
solifenacin oral tablet 10 mg 5 mg 1
tolterodine oral capsuleextended release 24hr 2 mg 4 mg
1
tolterodine oral tablet 1 mg 2 mg 1
trospium oral capsuleextended release 24hr 60 mg
1
trospium oral tablet 20 mg 1
BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY
alfuzosin oral tablet extended release 24 hr 10 mg 1
dutasteride oral capsule 05 mg 1
dutasteride-tamsulosin oral capsule er multiphase 24 hr 05-04 mg
1
finasteride oral tablet 5 mg 1
silodosin oral capsule 4 mg 8 mg 1
tadalafil oral tablet 25 mg 5 mg 1 PA ST
tamsulosin oral capsule 04 mg 1
CHOLINERGIC STIMULANTS
122
Drug Name Drug Tier Requirements Limits
bethanechol chloride oral tablet 10 mg 25 mg 5 mg 50 mg
1
MISCELLANEOUS UROLOGICALS
CYSTAGON ORAL CAPSULE 150 MG 50 MG 2 PA
ELMIRON ORAL CAPSULE 100 MG 1
hyophen oral tablet 816-012-108 mg 1
K-PHOS NO 2 ORAL TABLET 305-700 MG 1
K-PHOS ORIGINAL ORAL TABLETSOLUBLE 500 MG
1
methen-sod phos-meth blue-hyos oral tablet 816-408-012 mg
1
OXLUMO SUBCUTANEOUS SOLUTION 945 MG05 ML
2 PA
phosphasal oral tablet 816-108-408 mg 1
potassium citrate oral tablet extended release 10 meq (1080 mg) 15 meq 5 meq (540 mg)
1
RENACIDIN IRRIGATION SOLUTION 19806 MG-594 MG-9804MG30ML
1
URELLE ORAL TABLET 81-108-408 MG 1
uretron d-s oral tablet 816-108-408 mg 1
urimar-t oral tablet 120-012-108 mg 1
urogesic-blue oral tablet 816-408-012 mg 1
uryl oral tablet 816-408-012 mg 1
ustell oral capsule 120-012 mg 1
utira-c oral tablet 816-108-408 mg 1
URINARY ANESTHETICS
phenazopyridine oral tablet 100 mg 200 mg 1
VITAMINS HEMATINICS amp ELECTROLYTES
ELECTROLYTES
effer-k oral tablet effervescent 25 meq 1
klor-con 10 oral tablet extended release 10 meq 1
klor-con 8 oral tablet extended release 8 meq 1
klor-con m10 oral tableter particlescrystals 10 meq
1
klor-con m15 oral tableter particlescrystals 15 meq
1
123
Drug Name Drug Tier Requirements Limits
klor-con m20 oral tableter particlescrystals 20 meq
1
klor-con oral packet 20 meq 1
klor-conef oral tablet effervescent 25 meq 1
K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ
1
k-tab oral tablet extended release 8 meq 1
NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION
MB
potassium chloride oral capsule extended release 10 meq 8 meq
1
potassium chloride oral liquid 20 meq15 ml 40 meq15 ml
1
potassium chloride oral packet 20 meq 1
potassium chloride oral tablet extended release 10 meq 20 meq 8 meq
1
potassium chloride oral tableter particlescrystals 10 meq 20 meq
1
sodium chloride 045 intravenous parenteral solution 045
MB
MISCELLANEOUS VITAMINS HEMATINICS amp ELECTROLYTES
ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION
MB
PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION
MB
PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION
MB
VITAMINS amp HEMATINICS
cyanocobalamin (vitamin b-12) injection solution 1000 mcgml
1
ergocalciferol (vitamin d2) oral capsule 1250 mcg (50000 unit)
1
FA-8 ORAL CAPSULE 08 MG ACA PV
FER-IN-SOL ORAL DROPS 15 MG IRON (75 MG)ML
ACA PV
FLORIVA (FLUORIDE-VITAMIN D3) ORAL DROPS 025 MG (055 MG)-400 UNITML
ACA PV
fluoride (sodium) oral drops 05 mg (11 mg sodfluorid)ml
ACA PV
124
Drug Name Drug Tier Requirements Limits
fluoride (sodium) oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)
ACA PV
folic acid injection solution 5 mgml 1
folic acid oral tablet 1 mg 1
folic acid oral tablet 400 mcg 800 mcg ACA PV
hydroxocobalamin intramuscular solution 1000 mcgml
1
INFED INJECTION SOLUTION 50 MGML MB
ludent fluoride oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)
ACA PV
multi-vitamin with fluoride oral drops 025 mgml 05 mgml
ACA PV
multi-vitamin with fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
multivitamins with fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
mvc-fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
NOVAFERRUM ORAL DROPS 15 MG IRONML
ACA PV
tri-vitamin with fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml
ACA PV
vitamins acd and fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml
ACA PV
125
Index
A abacavir 2 abacavir-lamivudine 2 abacavir-lamivudine-
zidovudine 2 ABILIFY MAINTENA 36 abiraterone 13 ABRAXANE 13 acamprosate 66 acarbose 77 accutane 59 acebutolol 45 acetaminophen-caff-
dihydrocod 30 acetaminophen-codeine 31 acetazolamide 112 acetic acid 66 69 acetylcysteine 116 acitretin 57 ACTEMRA 95 ACTEMRA ACTPEN 95 ACTHAR 70 ACTHIB (PF) 90 ACTIMMUNE 89 ACUVAIL (PF) 112 acyclovir 2 63 ADACEL(TDAP
ADOLESNADULT)(PF) 90 ADAKVEO 13 adapalene 59 60 ADAPALENE 60 adapalene-benzoyl peroxide 60 ADCETRIS 14 adefovir 2 ADEMPAS 116 ADHANSIA XR 36 adrenalin 114 adult aspirin regimen 33 ADVAIR HFA 116 ADVATE 50 ADYNOVATE 50 ADZENYS ER 36 ADZENYS XR-ODT 36 AEROCHAMBER MINI 71 AEROCHAMBER PLUS
FLOW-VU 71 AFINITOR 14 afirmelle 102
AFSTYLA 50 AIMOVIG AUTOINJECTOR
28 AJOVY AUTOINJECTOR 28 AJOVY SYRINGE 28 ak-poly-bac 109 AKYNZEO (NETUPITANT)
81 ala-cort 63 albendazole 8 albuterol sulfate inhalation 116 ALBUTEROL SULFATE
INHALATION 116 alclometasone 63 ALCORTIN A 61 ALDURAZYME 74 ALECENSA 14 alendronate 95 alfuzosin 121 ALIMTA 14 ALINIA 8 ALIQOPA 14 aliskiren 45 allopurinol 95 almotriptan malate 28 ALOCRIL 110 ALOGLIPTIN-
PIOGLITAZONE 77 ALOMIDE 110 alosetron 81 ALOXI 81 ALPHANATE 50 ALPHANINE SD 50 alprazolam 37 alprazolam intensol 37 ALPROLIX 50 ALREX 113 ALTABAX 61 altacaine 111 altavera (28) 102 ALVESCO 116 alyacen 135 (28) 102 alyacen 777 (28) 102 alyq 116 amabelz 98 amantadine hcl 2 AMBISOME 1 ambrisentan 116
amcinonide 63 amethia 102 amethyst (28) 102 amikacin 8 amiloride 45 amiloride-hydrochlorothiazide
45 aminocaproic acid 50 51 aminophylline 116 amiodarone 44 AMITIZA 81 amitriptyline 37 amitriptyline-chlordiazepoxide
37 amlodipine 45 amlodipine-atorvastatin 55 amlodipine-benazepril 45 amlodipine-olmesartan 45 amlodipine-valsartan 45 amlodipine-valsartan-hcthiazid
45 ammonium lactate 59 amnesteem 60 amoxapine 37 amoxicil-clarithromy-lansopraz
85 amoxicillin 11 amoxicillin-pot clavulanate 11 AMPHETAMINE 37 amphetamine sulfate 37 amphotericin b 1 ampicillin 11 ampicillin-sulbactam 11 anagrelide 66 anaspaz 80 anastrozole 14 ANDEXXA 51 ANDRODERM 74 ANGELIQ 98 ANNOVERA 101 ANORO ELLIPTA 116 anucort-hc 81 apexicon e 63 APLENZIN 37 APOKYN 27 apraclonidine 114 aprepitant 81 apri 102
126
APTIVUS 2 ARALAST NP 66 aranelle (28) 102 ARANESP (IN
POLYSORBATE) 86 ARCALYST 89 ARESTIN 68 arformoterol 116 aripiprazole 37 ARISTADA 37 ARISTADA INITIO 37 armodafinil 37 ARMOUR THYROID 79 ARNUITY ELLIPTA 117 ARRANON 14 ARZERRA 14 ASCENIV 90 ascomp with codeine 31 asenapine maleate 37 ashlyna 102 ASPARLAS 14 aspirin 33 34 aspirin low dose 33 aspirin-dipyridamole 51 aspir-trin 34 atazanavir 2 atenolol 45 atenolol-chlorthalidone 45 ATGAM 90 atomoxetine 37 atorvastatin 55 atovaquone 8 atovaquone-proguanil 8 atropine 80 110 ATROVENT HFA 117 AUBAGIO 87 aubra 102 aubra eq 102 aurovela 1530 (21) 102 aurovela 120 (21) 102 aurovela 24 fe 102 aurovela fe 1530 (28) 102 aurovela fe 1-20 (28) 102 AUSTEDO 29 AVASTIN 14 aviane 102 avidoxy 12 avita 60 AVITA 60 AVONEX 88 AVYCAZ 6
ayuna 102 AZASITE 109 azathioprine 14 azelaic acid 60 azelastine 68 111 AZELEX 60 azithromycin 7 azurette (28) 102 B bacitracin 8 109 bacitracin-polymyxin b 109 baclofen 30 BALCOLTRA 102 balsalazide 81 BALVERSA 14 balziva (28) 102 BANZEL 24 BAQSIMI 71 BARACLUDE 2 BAVENCIO 14 BAXDELA 12 bayer aspirin 34 BAYER CHEWABLE
ASPIRIN 34 BCG VACCINE LIVE (PF) 90 BELEODAQ 14 belladonna alkaloids-opium 80 BELRAPZO 14 BELSOMRA 37 benazepril 45 benazepril-hydrochlorothiazide
45 BENDAMUSTINE 14 BENDEKA 14 BENEFIX 51 BENLYSTA 96 benzonatate 115 benztropine 27 BEOVU 111 bepotastine besilate 111 BEPREVE 111 BERINERT 117 beser 63 BESIVANCE 109 BESPONSA 14 betamethasone dipropionate 63 betamethasone valerate 63 betamethasone augmented 63
64 BETASERON 88 betaxolol 45 110
bethanechol chloride 122 BETIMOL 110 BETOPTIC S 110 BEVESPI AEROSPHERE 117 bexarotene 14 BEXSERO 90 bicalutamide 14 BICILLIN C-R 11 BIKTARVY 2 bimatoprost 112 BIOTHRAX 90 bisoprolol fumarate 45 bisoprolol-hydrochlorothiazide
45 BIVIGAM 90 BLEPHAMIDE 114 BLEPHAMIDE SOP 114 BLINCYTO 14 blisovi 24 fe 102 blisovi fe 1530 (28) 102 blisovi fe 120 (28) 103 BOOSTRIX TDAP 90 BORTEZOMIB 14 bosentan 117 BOSULIF 14 BOTOX 90 BRAFTOVI 14 BREO ELLIPTA 117 briellyn 103 BRILINTA 51 brimonidine 114 BRINEURA 75 brinzolamide 112 BRIVIACT 24 bromfenac 112 bromocriptine 27 brompheniramine-pseudoeph-
dm 115 BROVANA 117 budesonide 81 117 bumetanide 45 buprenorphine 31 buprenorphine hcl 31 buprenorphine-naloxone 34 bupropion hcl 37 38 bupropion hcl (smoking deter)
68 buspirone 38 BUSULFEX 15 butalbital compound wcodeine
31
127
butalbital-acetaminop-caf-cod 31
butalbital-acetaminophen-caff 31
butalbital-aspirin-caffeine 31 butorphanol 34 BYDUREON BCISE 77 BYETTA 77 BYSTOLIC 45 C CABENUVA 2 cabergoline 75 CABLIVI 51 CABOMETYX 15 calcipotriene 57 calcipotriene-betamethasone 57 calcitonin (salmon) 75 calcitriol 57 75 calcium acetate(phosphat bind)
81 CALQUENCE 15 camila 98 camrese 103 camrese lo 103 CANCIDAS 1 candesartan 45 candesartan-hydrochlorothiazid
46 CAPASTAT 8 capecitabine 15 CAPRELSA 15 captopril 46 captopril-hydrochlorothiazide
46 CARBAGLU 66 carbamazepine 24 carbidopa 27 carbidopa-levodopa 27 carbidopa-levodopa-
entacapone 27 carbinoxamine maleate 114 carisoprodol 30 carisoprodol-aspirin 30 carisoprodol-aspirin-codeine 30 carteolol 110 cartia xt 46 carvedilol 46 carvedilol phosphate 46 cataflam 34 CAYA CONTOURED 98 CAYSTON 8
caziant (28) 103 cefaclor 6 cefadroxil 6 cefazolin 6 cefazolin in dextrose (iso-os) 6 cefdinir 6 cefditoren pivoxil 6 cefepime 6 CEFEPIME IN DEXTROSE 5
6 cefepime in dextroseiso-osm 6 cefixime 6 CEFOTAN 6 cefotaxime 6 cefotetan 6 CEFOTETAN IN
DEXTROSE ISO-OSM 6 cefoxitin 6 cefpodoxime 6 7 cefprozil 7 ceftazidime 7 CEFTAZIDIME IN D5W 7 ceftriaxone 7 CEFTRIAXONE 7 ceftriaxone in dextroseiso-os 7 cefuroxime axetil 7 celecoxib 34 CELONTIN 24 cephalexin 7 CERDELGA 75 CEREZYME 75 cetirizine 114 cevimeline 66 CHANTIX 68 CHANTIX CONTINUING
MONTH BOX 68 CHANTIX STARTING
MONTH BOX 68 charlotte 24 fe 103 chateal (28) 103 chateal eq (28) 103 CHEMET 66 childrens aspirin 34 chloramphenicol sod succinate
8 chlordiazepoxide hcl 38 chlordiazepoxide-clidinium 80 chlorhexidine gluconate 68 chloroquine phosphate 8 chlorpromazine 38 chlorthalidone 46
chlorzoxazone 30 CHOLBAM 81 cholestyramine (with sugar) 55 cholestyramine light 55 cholinemagnesium salicylate
34 ciclodan 62 ciclopirox 62 ciclopirox-ure-camph-menth-
euc 62 cidofovir 2 cilostazol 51 CIMDUO 2 cimetidine 85 cimetidine hcl 85 CIMZIA 82 CIMZIA POWDER FOR
RECONST 81 cinacalcet 75 CINQAIR 117 CINRYZE 117 CIPRO HC 69 ciprofloxacin 12 ciprofloxacin hcl 12 69 109 ciprofloxacin-dexamethasone
69 citalopram 38 claravis 60 clarithromycin 7 8 clemastine 114 CLENPIQ 82 clindacin p 60 clindamycin hcl 8 clindamycin pediatric 8 clindamycin phosphate 8 60
101 clindamycin-benzoyl peroxide
60 clindamycin-tretinoin 60 clobazam 24 clobetasol 64 clobetasol-emollient 64 CLOCORTOLONE
PIVALATE 64 CLODERM 64 CLOLAR 15 clomipramine 38 clonazepam 24 clonidine 46 clonidine hcl 38 46 clopidogrel 51
128
clorazepate dipotassium 38 clotrimazole 1 62 clotrimazole-betamethasone 62 clovique 66 clozapine 38 COAGADEX 51 COARTEM 8 codeine sulfate 31 codeine-butalbital-asa-caff 31 codeine-guaifenesin 115 colchicine 95 COLCHICINE 95 colesevelam 55 colestipol 55 COMBIGAN 112 COMBIPATCH 98 COMBIVENT RESPIMAT 117 COMETRIQ 15 COMPLERA 2 compro 82 constulose 82 CONTOUR NEXT TEST
STRIPS 71 CONTOUR TEST STRIPS 71 COPIKTRA 15 CORIFACT 51 CORLANOR 56 CORTIFOAM 82 COSENTYX 58 COSENTYX (2 SYRINGES)
57 COSENTYX PEN 58 COSENTYX PEN (2 PENS) 58 COTELLIC 15 COTEMPLA XR-ODT 38 covaryx 98 covaryx hs 98 CREON 82 CRESEMBA 1 CRINONE 98 cromolyn 82 111 117 crotan 66 cryselle (28) 103 CRYSVITA 75 CUBICIN 8 CUBICIN RF 9 CUTAQUIG 90 CUVITRU 90 cyanocobalamin (vitamin b-12)
123 cyclafem 135 (28) 103
cyclafem 777 (28) 103 cyclobenzaprine 30 cyclopentolate 110 cyclophosphamide 15 CYCLOPHOSPHAMIDE 15 CYCLOSERINE 9 CYCLOSET 77 cyclosporine 15 cyclosporine modified 15 cyproheptadine 114 CYRAMZA 15 cyred 103 cyred eq 103 CYSTAGON 122 CYSTARAN 111 CYTOVENE 2 D DACOGEN 15 dalfampridine 29 DALIRESP 117 danazol 75 dantrolene 30 dapsone 9 60 DAPTACEL (DTAP
PEDIATRIC) (PF) 91 darifenacin 121 DARZALEX 15 dasetta 135 (28) 103 dasetta 777 (28) 103 DAURISMO 15 daysee 103 DAYTRANA 38 deblitane 98 decadron 70 decitabine 15 deferasirox 66 deferiprone 66 demeclocycline 12 DENAVIR 63 denta 5000 plus 68 dentagel 69 DEPO-ESTRADIOL 98 DEPO-PROVERA 98 DEPO-SUBQ PROVERA 104
98 DEPO-TESTOSTERONE 75 DESCOVY 2 desipramine 38 desloratadine 115 desmopressin 75
desog-eestradioleestradiol 103
desogestrel-ethinyl estradiol 103
desonide 64 desoximetasone 64 DESVENLAFAXINE 38 desvenlafaxine succinate 38 dexamethasone 70 dexamethasone intensol 70 dexamethasone sodium phos
(pf) 70 dexamethasone sodium
phosphate 70 113 DEXILANT 85 dexmethylphenidate 38 dextroamphetamine 38 39 dextroamphetamine-
amphetamine 39 diazepam 24 39 diazepam intensol 39 diazoxide 71 diclofenac potassium 34 diclofenac sodium 34 59 112 diclofenac-misoprostol 34 dicloxacillin 11 dicyclomine 80 didanosine 2 DIFICID 8 diflorasone 64 diflunisal 34 digitek 50 digox 50 digoxin 50 dihydroergotamine 28 DILANTIN 24 DILANTIN EXTENDED 24 DILANTIN INFATABS 24 DILANTIN-125 24 diltiazem 46 dilt-xr 46 dimethyl fumarate 88 DIPENTUM 82 diphenhydramine hcl 115 diphenoxylate-atropine 80 dipyridamole 51 diskets 31 disopyramide phosphate 44 disulfiram 66 divalproex 24 25 DIVIGEL 99
129
dofetilide 44 dolishale 103 donepezil 29 DONNATAL 80 DOPTELET (15 TAB PACK)
51 dorzolamide 112 dorzolamide-timolol 112 dorzolamide-timolol (pf) 112 dotti 99 DOVATO 2 doxazosin 46 doxepin 39 doxercalciferol 75 doxycycline hyclate 12 doxycycline monohydrate 12 doxylamine-pyridoxine (vit b6)
82 dronabinol 82 drospirenone-eestradiol-lmfa
103 drospirenone-ethinyl estradiol
103 DSUVIA 31 DUAVEE 99 DUEXIS 34 DULERA 117 duloxetine 39 DUPIXENT PEN 59 DUPIXENT SYRINGE 59 duramorph (pf) 31 DUREZOL 113 dutasteride 121 dutasteride-tamsulosin 121 dvorah 31 DYANAVEL XR 39 DYSPORT 91 E ees 400 8 econazole 62 econtra ez 103 econtra one-step 103 ecotrin 34 ecotrin low strength 34 EDARBI 46 EDARBYCLOR 46 EDLUAR 39 ed-spaz 80 EDURANT 2 eemt 99 eemt hs 99
efavirenz 2 efavirenz-emtricitabin-tenofov
3 efavirenz-lamivu-tenofov disop
3 effer-k 122 ELAPRASE 75 ELELYSO 75 eletriptan 28 ELIGARD 16 ELIGARD (3 MONTH) 15 ELIGARD (4 MONTH) 15 ELIGARD (6 MONTH) 15 elinest 103 ELIQUIS 51 ELIQUIS DVT-PE TREAT
30D START 51 ELIXOPHYLLIN 117 ELLA 103 ELMIRON 122 ELOCTATE 51 eluryng 101 ELZONRIS 16 EMCYT 16 EMEND 82 EMGALITY PEN 28 EMGALITY SYRINGE 28 emoquette 103 EMPAVELI 67 EMPLICITI 16 EMSAM 39 emtricitabine 3 emtricitabine-tenofovir (tdf) 3 EMTRIVA 3 EMVERM 9 enalapril maleate 46 enalaprilat 46 enalapril-hydrochlorothiazide
46 ENBREL 96 ENBREL MINI 96 ENBREL SURECLICK 96 endocet 31 ENGERIX-B (PF) 91 ENGERIX-B PEDIATRIC
(PF) 91 ENHERTU 16 enoxaparin 51 enpresse 104 enskyce 104 entacapone 27
entecavir 3 ENTRESTO 56 ENTYVIO 82 enulose 82 EPANED 46 EPCLUSA 3 EPIDIOLEX 25 epinastine 111 epinephrine 115 EPINEPHRINE 115 epitol 25 EPIVIR HBV 3 eplerenone 47 EPOGEN 86 epoprostenol (glycine) 47 eprosartan 47 ERAXIS(WATER DILUENT)
1 ERBITUX 16 ergocalciferol (vitamin d2) 123 ergoloid 39 ergotamine-caffeine 28 ERLEADA 16 erlotinib 16 errin 99 ERWINAZE 16 ery pads 60 erygel 60 ery-tab 8 erythrocin (as stearate) 8 erythromycin 8 109 erythromycin ethylsuccinate 8 erythromycin with ethanol 60 erythromycin-benzoyl peroxide
60 ESBRIET 117 escitalopram oxalate 39 esomeprazole magnesium 85 ESPEROCT 51 estarylla 104 estazolam 39 estradiol 99 estradiol valerate 99 estradiol-norethindrone acet 99 ESTRING 99 estrogens-methyltestosterone 99 eszopiclone 39 ethacrynic acid 47 ethambutol 9 ethosuximide 25
130
ethynodiol diac-eth estradiol 104
etodolac 34 etonogestrel-ethinyl estradiol
101 etoposide 16 etravirine 3 EUCRISA 59 EUFLEXXA 34 EURAX 66 EVAMIST 99 EVENITY 95 everolimus (antineoplastic) 16 everolimus
(immunosuppressive) 16 EVOTAZ 3 EXELDERM 62 exemestane 16 EXONDYS-51 29 EYLEA 111 ezetimibe 55 ezetimibe-simvastatin 55 F FA-8 123 FABRAZYME 75 FACTIVE 12 falmina (28) 104 famciclovir 3 famotidine 86 famotidine (pf) 85 FANAPT 39 FARXIGA 77 FASENRA 118 FASENRA PEN 117 FASLODEX 16 fayosim 104 FC2 FEMALE CONDOM 98 febuxostat 95 FEIBA NF 51 felbamate 25 felodipine 47 fem ph 101 FEMCAP 98 FEMRING 99 femynor 104 fenofibrate 55 FENOFIBRATE 55 fenofibrate micronized 55 fenofibrate nanocrystallized 55 fenofibric acid 55 fenofibric acid (choline) 55
fenoprofen 35 fentanyl 32 fentanyl citrate 31 FER-IN-SOL 123 FERRIPROX 67 FETZIMA 39 FIASP FLEXTOUCH U-100
INSULIN 72 FIASP PENFILL U-100
INSULIN 72 FIASP U-100 INSULIN 72 FIBRYGA 51 finasteride 121 FINTEPLA 25 FIRMAGON KIT W
DILUENT SYRINGE 16 flac otic oil 69 flavoxate 121 FLEBOGAMMA DIF 91 flecainide 44 FLOLAN 47 FLORIVA (FLUORIDE-
VITAMIN D3) 123 FLOVENT DISKUS 118 FLOVENT HFA 118 fluconazole 1 flucytosine 1 fludarabine 16 fludrocortisone 70 fluocinolone 64 fluocinolone acetonide oil 69 fluocinolone and shower cap 64 fluocinonide 64 fluocinonide-e 64 fluoride (sodium) 69 123 124 fluorometholone 113 fluorouracil 16 59 FLUOROURACIL 59 fluoxetine 39 40 fluphenazine hcl 40 flurandrenolide 64 65 flurazepam 40 flurbiprofen 35 flurbiprofen sodium 112 flutamide 16 fluticasone propionate 65 118 fluticasone propion-salmeterol
118 fluvastatin 55 56 fluvoxamine 40 FML FORTE 113
FML SOP 113 folic acid 124 FOLOTYN 16 fondaparinux 51 formoterol fumarate 118 FORTEO 95 FOSAMAX PLUS D 95 fosamprenavir 3 fosfomycin tromethamine 13 fosinopril 47 fosinopril-hydrochlorothiazide
47 FRAGMIN 52 FREESTYLE LIBRE 14 DAY
SENSOR 71 FREESTYLE LIBRE 2
SENSOR 71 frovatriptan 28 fulvestrant 16 furosemide 47 FUZEON 3 fyavolv 99 G g tussin ac 115 gabapentin 25 GALAFOLD 75 galantamine 29 GAMASTAN 91 GAMASTAN SD 91 GAMIFANT 16 GAMMAGARD LIQUID 91 GAMMAGARD S-D (IGA lt 1
MCGML) 91 GAMMAKED 91 GAMMAPLEX 91 GAMMAPLEX (WITH
SORBITOL) 91 GAMUNEX-C 91 GANCICLOVIR 3 ganciclovir sodium 3 GARDASIL 9 (PF) 91 gatifloxacin 109 gavilyte-c 82 gavilyte-g 82 gavilyte-n 82 GAZYVA 16 gemcitabine 16 17 gemfibrozil 56 gemmily 104 generlac 82 gengraf 17
131
GENOTROPIN 87 GENOTROPIN MINIQUICK
87 gentak 109 gentamicin 9 61 62 109 gentamicin sulfate (ped) (pf) 9 GENVOYA 3 GIAPREZA 56 GILENYA 88 GILOTRIF 17 GIVLAARI 67 GLASSIA 67 glatiramer 88 glatopa 88 GLEOSTINE 17 glimepiride 77 glipizide 77 glipizide-metformin 77 GLUCAGEN DIAGNOSTIC
KIT 71 GLUCAGEN HYPOKIT 71 GLUCAGON (HCL)
EMERGENCY KIT 71 glucagon emergency kit
(human) 71 GLUCAGON HCL 71 glyburide 77 glyburide micronized 77 glyburide-metformin 77 glycopyrrolate 80 GLYXAMBI 78 GONITRO 57 granisetron hcl 82 GRANIX 86 GRASTEK 91 griseofulvin microsize 1 griseofulvin ultramicrosize 1 guaiatussin ac 115 guanfacine 40 47 GYNAZOLE-1 101 gynol ii 101 H HAEGARDA 118 hailey 104 hailey 24 fe 104 hailey fe 1530 (28) 104 hailey fe 120 (28) 104 HALAVEN 17 halcinonide 65 halobetasol propionate 65 haloperidol 40
haloperidol decanoate 40 haloperidol lactate 40 HARVONI 3 HAVRIX (PF) 91 92 heather 99 HEMLIBRA 52 hemmorex-hc 82 HEMOFIL M HIGH 52 HEMOFIL M LOW 52 HEMOFIL M MID 52 HEMOFIL M SUPER HIGH52 hep flush-10 (pf) 52 heparin (porcine) 52 heparin (porcine) in 5 dex 52 heparin lock flush (porcine) 52 heparin lockflush(porcine)(pf)
52 heparin(porcine) in 045 nacl
52 HEPARIN(PORCINE) IN
045 NACL 52 heparin porcine (pf) 52 53 HEPLISAV-B (PF) 92 HERCEPTIN 17 HERCEPTIN HYLECTA 17 HERZUMA 17 HETLIOZ 40 HETLIOZ LQ 40 HIBERIX (PF) 92 HIZENTRA 92 homatropaire 110 HUMALOG JUNIOR
KWIKPEN U-100 72 HUMALOG KWIKPEN
INSULIN 72 HUMALOG MIX 50-50
INSULN U-100 72 HUMALOG MIX 50-50
KWIKPEN 72 HUMALOG MIX 75-25
KWIKPEN 72 HUMALOG MIX 75-25(U-
100)INSULN 72 HUMALOG U-100 INSULIN
72 HUMATE-P 53 HUMIRA 96 HUMIRA PEN 96 HUMIRA PEN CROHNS-UC-
HS START 96
HUMIRA PEN PSOR-UVEITS-ADOL HS 96
HUMIRA(CF) 97 HUMIRA(CF) PEDI
CROHNS STARTER 96 HUMIRA(CF) PEN 96 HUMIRA(CF) PEN
CROHNS-UC-HS 96 HUMIRA(CF) PEN
PEDIATRIC UC 96 HUMIRA(CF) PEN PSOR-
UV-ADOL HS 96 HUMULIN 7030 U-100
INSULIN 72 HUMULIN 7030 U-100
KWIKPEN 72 HUMULIN N NPH INSULIN
KWIKPEN 73 HUMULIN N NPH U-100
INSULIN 73 HUMULIN R REGULAR U-
100 INSULN 73 HUMULIN R U-500 (CONC)
INSULIN 73 HUMULIN R U-500 (CONC)
KWIKPEN 73 HYCAMTIN 17 hydralazine 47 hydrochlorothiazide 47 hydrocodone bitartrate 32 hydrocodone-acetaminophen 32 hydrocodone-chlorpheniramine
115 hydrocodone-homatropine 115 hydrocodone-ibuprofen 32 hydrocortisone 65 70 82 hydrocortisone acetate 82 hydrocortisone butyrate 65 hydrocortisone butyr-emollient
65 hydrocortisone valerate 65 hydrocortisone-acetic acid 69 hydrocortisone-pramoxine 58
82 hydromet 116 hydromorphone 32 HYDROMORPHONE 32 hydroxocobalamin 124 hydroxychloroquine 9 hydroxyprogest(pf)(preg presv)
99
132
hydroxyprogesterone cap(ppres) 99
hydroxyprogesterone caproate 100
hydroxyurea 17 hydroxyzine hcl 115 hydroxyzine pamoate 115 hyophen 122 hyoscyamine sulfate 80 hyosyne 80 HYQVIA 92 I ibandronate 95 IBRANCE 17 ibu 35 ibuprofen 35 icatibant 118 iclevia 104 ICLUSIG 17 icosapent ethyl 56 IDELVION 53 IDHIFA 17 ILARIS (PF) 90 ILUMYA 58 imatinib 17 IMBRUVICA 17 IMFINZI 17 imipenem-cilastatin 9 imipramine hcl 40 imipramine pamoate 40 imiquimod 90 IMLYGIC 17 IMOVAX RABIES VACCINE
(PF) 92 incassia 100 INCRELEX 67 INCRUSE ELLIPTA 118 indapamide 47 indomethacin 35 INFANRIX (DTAP) (PF) 92 INFED 124 INFLECTRA 82 INFUGEM 18 INLYTA 18 INSULIN ASP PRT-INSULIN
ASPART 73 INSULIN ASPART U-100 73 INSULIN SYRINGE-
NEEDLE U-100 71 INTELENCE 3 INTRAROSA 101
INTRON A 90 INVANZ 9 INVEGA SUSTENNA 40 INVELTYS 113 INVIRASE 3 IOPIDINE 114 IPOL 92 ipratropium bromide 69 118 ipratropium-albuterol 118 irbesartan 47 irbesartan-hydrochlorothiazide
47 IRESSA 18 ISENTRESS 3 ISENTRESS HD 3 isibloom 104 ISOLYTE-S 123 isoniazid 9 isosorbide dinitrate 57 isosorbide mononitrate 57 isotretinoin 60 isoxsuprine 101 isradipine 47 ISTODAX 18 itraconazole 1 ivermectin 9 66 IXEMPRA 18 IXIARO (PF) 92 IXINITY 53 J jaimiess 104 JAKAFI 18 jantoven 53 JANUMET 78 JANUMET XR 78 JANUVIA 78 JARDIANCE 78 jasmiel (28) 104 jencycla 100 JENTADUETO 78 JENTADUETO XR 78 JEVTANA 18 jinteli 100 JIVI 53 jolessa 104 JORNAY PM 40 JUBLIA 62 juleber 104 JULUCA 3 junel 1530 (21) 104 junel 120 (21) 104
junel fe 1530 (28) 104 junel fe 120 (28) 104 junel fe 24 104 JUXTAPID 56 JYNARQUE 75 K KADCYLA 18 kaitlib fe 104 KALBITOR 118 KALETRA 3 4 kalliga 104 KALYDECO 118 KANJINTI 18 KANUMA 75 kariva (28) 104 kelnor 135 (28) 105 kelnor 1-50 (28) 105 KEPIVANCE 13 ketoconazole 1 62 ketodan 62 ketoprofen 35 ketorolac 35 112 KEVZARA 97 KEYTRUDA 18 KINRIX (PF) 92 KISQALI 18 KISQALI FEMARA CO-
PACK 18 klor-con 123 klor-con 10 122 klor-con 8 122 klor-con m10 122 klor-con m15 122 klor-con m20 123 klor-conef 123 KOATE 53 KOGENATE FS 53 KORLYM 75 KOVALTRY 53 K-PHOS NO 2 122 K-PHOS ORIGINAL 122 KRYSTEXXA 95 k-tab 123 K-TAB 123 kurvelo (28) 105 KYLEENA 98 KYMRIAH 18 KYPROLIS 18 L l norgesteestradiol-eestrad
105
133
labetalol 47 LACRISERT 111 lactulose 83 lamivudine 4 lamivudine-zidovudine 4 lamotrigine 25 lansoprazole 86 lanthanum 83 LANTUS SOLOSTAR U-100
INSULIN 73 LANTUS U-100 INSULIN 73 lapatinib 18 larin 1530 (21) 105 larin 120 (21) 105 larin 24 fe 105 larin fe 1530 (28) 105 larin fe 120 (28) 105 larissia 105 LASTACAFT 111 latanoprost 112 LATUDA 40 layolis fe 105 leena 28 105 leflunomide 97 LEMTRADA 88 LENVIMA 18 lessina 105 letrozole 19 leucovorin calcium 13 LEUKERAN 19 LEUKINE 86 leuprolide 19 levalbuterol hcl 118 LEVALBUTEROL
TARTRATE 118 LEVEMIR FLEXTOUCH U-
100 INSULN 73 LEVEMIR U-100 INSULIN 73 levetiracetam 25 levobunolol 110 levocarnitine 67 levocarnitine (with sugar) 67 levocetirizine 115 levofloxacin 12 109 levonest (28) 105 levonorgestrel 105 levonorgestrel-ethinyl estrad
105 levonorg-eth estrad triphasic
105 levora-28 105
levorphanol tartrate 32 levothyroxine 79 levoxyl 79 LEVULAN 59 LEXIVA 4 LIBTAYO 19 lidocaine 61 lidocaine hcl 61 lidocaine hcl-hydrocortison ac
61 83 LIDOCAINE HCL-
HYDROCORTISON AC 83 lidocaine viscous 61 lidocaine-hydrocortisone-aloe
83 lidocaine-prilocaine 61 LIDOCAINE-TETRACAINE
61 LILETTA 98 lillow (28) 105 LINCOCIN 9 lindane 66 linezolid 9 linezolid in dextrose 5 9 linezolid-09 sodium chloride
9 LINZESS 83 liothyronine 79 LIPOFEN 56 lisinopril 47 lisinopril-hydrochlorothiazide
47 lithium carbonate 40 41 LO LOESTRIN FE 105 lojaimiess 105 LONSURF 19 loperamide 80 lopinavir-ritonavir 4 lorazepam 41 lorazepam intensol 41 loryna (28) 105 losartan 47 losartan-hydrochlorothiazide 47 LOTEMAX 113 loteprednol etabonate 113 lovastatin 56 low-ogestrel (28) 105 loxapine succinate 41 lo-zumandimine (28) 105 LUCENTIS 111 ludent fluoride 124
LULICONAZOLE 62 LUMIGAN 112 LUMIZYME 75 LUMOXITI 19 LUPANETA PACK (1
MONTH) 101 LUPANETA PACK (3
MONTH) 101 LUPKYNIS 19 LUPRON DEPOT 19 LUPRON DEPOT (3
MONTH) 19 LUPRON DEPOT (4
MONTH) 19 LUPRON DEPOT (6
MONTH) 19 LUPRON DEPOT-PED 19 LUPRON DEPOT-PED (3
MONTH) 19 lutera (28) 105 LUXTURNA 111 LUZU 62 lyleq 100 lyllana 100 LYNPARZA 19 LYRICA CR 25 LYSODREN 19 lyza 100 M mafenide acetate 62 malathion 66 maprotiline 41 marlissa (28) 106 MARPLAN 41 MARQIBO 19 MATULANE 19 matzim la 47 MAVENCLAD (10 TABLET
PACK) 88 MAVENCLAD (4 TABLET
PACK) 88 MAVENCLAD (5 TABLET
PACK) 88 MAVENCLAD (6 TABLET
PACK) 88 MAVENCLAD (7 TABLET
PACK) 88 MAVENCLAD (8 TABLET
PACK) 88 MAVENCLAD (9 TABLET
PACK) 88
134
MAVYRET 4 MAXIDEX 113 maxi-tuss ac 116 MAYZENT 88 MAYZENT STARTER PACK
88 m-clear wc 116 meclizine 83 meclofenamate 35 medroxyprogesterone 100 mefenamic acid 35 mefloquine 9 megestrol 19 MEKINIST 19 MEKTOVI 19 meloxicam 35 melphalan 19 melphalan hcl 19 memantine 29 MENACTRA (PF) 92 MENEST 100 MENOSTAR 100 MENQUADFI (PF) 92 MENTAX 62 MENVEO A-C-Y-W-135-DIP
(PF) 92 meperidine 32 meprobamate 30 MEPSEVII 76 mercaptopurine 20 meropenem 9 MEROPENEM-09
SODIUM CHLORIDE 9 merzee 106 mesalamine 83 mesalamine with cleansing
wipe 83 metaproterenol 118 metaxalone 30 metformin 78 methadone 32 methadose 32 methamphetamine 41 methazolamide 112 methenamine hippurate 13 methenamine mandelate 13 methen-sod phos-meth blue-
hyos 122 methergine 109 methimazole 71 methocarbamol 30
methotrexate sodium 20 methotrexate sodium (pf) 20 methoxsalen 59 methscopolamine 80 methyldopa 47 methyldopa-
hydrochlorothiazide 47 methyldopate 48 methylergonovine 109 METHYLIN 41 methylphenidate hcl 41 methylprednisolone 70 methylprednisolone acetate 70 methyltestosterone 76 metoclopramide hcl 83 metolazone 48 metoprolol succinate 48 metoprolol ta-hydrochlorothiaz
48 metoprolol tartrate 48 metronidazole 9 60 61 101 metyrosine 48 mexiletine 44 MIACALCIN 76 mibelas 24 fe 106 microgestin 1530 (21) 106 microgestin 120 (21) 106 microgestin fe 1530 (28) 106 microgestin fe 120 (28) 106 midazolam 41 midodrine 67 migergot 28 miglitol 78 miglustat 76 mili 106 millipred 70 millipred dp 70 mimvey 100 MINITRAN 57 minocycline 12 minoxidil 48 MIRCERA 86 MIRENA 98 mirtazapine 41 misoprostol 86 MITIGARE 95 mitoxantrone 20 M-M-R II (PF) 92 modafinil 41 moexipril 48 molindone 41
mometasone 65 mondoxyne nl 12 mono-linyah 106 MONONINE 53 MONOVISC 35 montelukast 118 119 morphine 32 33 morphine (pf) 32 morphine concentrate 32 MOTOFEN 80 MOVANTIK 83 MOXATAG 11 moxifloxacin 12 109 MOZOBIL 87 MULPLETA 53 MULTAQ 44 multi-vitamin with fluoride 124 multivitamins with fluoride 124 mupirocin 62 mupirocin calcium 62 mvc-fluoride 124 my choice 106 my way 106 MYALEPT 76 MYCAMINE 1 mycophenolate mofetil 20 mycophenolate sodium 20 MYDAYIS 41 MYLOTARG 20 MYOBLOC 92 myorisan 61 MYRBETRIQ 121 N nabumetone 35 nadolol 48 nadolol-bendroflumethiazide 48 nafcillin 11 nafcillin in dextrose iso-osm 11 naftifine 62 63 NAGLAZYME 76 nalbuphine 35 naloxone 35 naltrexone 35 naproxen 35 naproxen sodium 35 naratriptan 28 NARCAN 35 NATACYN 109 NATAZIA 106 nateglinide 78 NATPARA 76
135
nebusal 119 necon 0535 (28) 106 nefazodone 41 neomycin 9 neomycin-bacitracin-poly-hc
112 neomycin-bacitracin-
polymyxin 109 neomycin-polymyxin b-
dexameth 112 113 neomycin-polymyxin-
gramicidin 109 neomycin-polymyxin-hc 69
113 neo-polycin 109 neo-polycin hc 113 NERLYNX 20 NEUPOGEN 87 NEVANAC 112 nevirapine 4 new day 106 NEXAVAR 20 NEXPLANON 101 NEXTSTELLIS 106 niacin 56 NIACOR 56 nicardipine 48 nicorette 68 nicotine 68 nicotine (polacrilex) 68 NICOTROL 68 NICOTROL NS 68 nifedipine 48 nikki (28) 106 nilutamide 20 nimodipine 48 NINLARO 20 nisoldipine 48 nitazoxanide 9 nitisinone 67 nitro-bid 57 NITRO-DUR 57 nitrofurantoin 13 nitrofurantoin macrocrystal 13 nitrofurantoin monohydm-
cryst 13 nitroglycerin 57 nitroglycerin in 5 dextrose 57 nitro-time 57 NITYR 67 NIVESTYM 87
nizatidine 86 nora-be 100 noreth-ethinyl estradiol-iron
106 norethindrone (contraceptive)
100 norethindrone acetate 100 norethindrone ac-eth estradiol
100 106 norethindrone-eestradiol-iron
106 norgestimate-ethinyl estradiol
106 norlyda 100 NORMOSOL-R 123 NORPACE CR 44 nortrel 0535 (28) 106 nortrel 135 (21) 106 nortrel 135 (28) 106 nortrel 777 (28) 107 nortriptyline 42 NORVIR 4 NOVAFERRUM 124 NOVOEIGHT 53 NOVOLIN 70-30 FLEXPEN
U-100 73 NOVOLIN N FLEXPEN 73 NOVOLIN R FLEXPEN 73 NOVOLOG FLEXPEN U-100
INSULIN 74 NOVOLOG MIX 70-30 U-100
INSULN 74 NOVOLOG MIX 70-
30FLEXPEN U-100 74 NOVOLOG PENFILL U-100
INSULIN 74 NOVOLOG U-100 INSULIN
ASPART 74 NOVOPEN ECHO 71 NOVOSEVEN RT 53 NOXAFIL 1 np thyroid 79 NPLATE 53 NUCALA 119 NUCYNTA ER 36 NUEDEXTA 29 NULOJIX 20 NULYTELY LEMON-LIME
83 NUPLAZID 42 NUWIQ 53
nyamyc 63 nylia 777 (28) 107 nymyo 107 nystatin 1 63 nystatin-triamcinolone 63 nystop 63 O OBIZUR 54 ocella 107 OCREVUS 88 OCTAGAM 92 octreotide acetate 20 ODEFSEY 4 OFEV 119 ofloxacin 12 69 109 OGIVRI 20 olanzapine 42 olanzapine-fluoxetine 42 olmesartan 48 olmesartan-amlodipin-
hcthiazid 48 olmesartan-
hydrochlorothiazide 48 olopatadine 69 111 OLUMIANT 97 omega-3 acid ethyl esters 56 omeprazole 86 OMIDRIA 111 OMNITROPE 87 ONCASPAR 20 ondansetron 84 ondansetron hcl 83 84 ONETOUCH ULTRA TEST
71 ONETOUCH VERIO TEST
STRIPS 71 ONIVYDE 20 ONPATTRO 29 ONZETRA XSAIL 28 opcicon one-step 107 OPDIVO 20 opium tincture 81 OPSUMIT 119 option-2 107 ORALAIR 92 oralone 69 ORAVIG 1 ORENCIA 97 ORENCIA (WITH
MALTOSE) 97 ORENCIA CLICKJECT 97
136
ORENITRAM 48 ORLADEYO 119 orphenadrine citrate 30 orsythia 107 ORTHOVISC 36 oscimin 81 oscimin sl 81 oscimin sr 81 oseltamivir 4 OSMOPREP 84 OSPHENA 101 OTEZLA 97 OTEZLA STARTER 97 OTOVEL 69 oxacillin 11 oxacillin in dextrose(iso-osm)
11 oxandrolone 76 oxaprozin 36 oxazepam 42 oxcarbazepine 25 oxiconazole 63 OXISTAT 63 OXLUMO 122 oxybutynin chloride 121 oxycodone 33 oxycodone-acetaminophen 33 oxycodone-aspirin 33 OXYCONTIN 33 oxymorphone 33 OZEMPIC 78 OZURDEX 113 P pacerone 44 PADCEV 20 paliperidone 42 PALYNZIQ 76 pamidronate 76 PANRETIN 59 pantoprazole 86 PANZYGA 92 PARAGARD T 380A 98 paricalcitol 76 PARICALCITOL 76 paroex oral rinse 69 paromomycin 10 paroxetine hcl 42 paroxetine
mesylate(menopsym) 42 PARSABIV 76 PASER 10
PEDIARIX (PF) 92 PEDVAX HIB (PF) 93 peg 3350-electrolytes 84 peg3350-sod sul-nacl-kcl-asb-c
84 PEGASYS 88 89 peg-electrolyte soln 84 peg-prep 84 PEMAZYRE 20 PEN NEEDLE DIABETIC 72 penicillamine 97 penicillin g procaine 11 penicillin v potassium 11 PENTACEL (PF) 93 PENTACEL ACTHIB
COMPONENT (PF) 93 PENTAM 10 pentamidine 10 pentazocine-naloxone 36 pentoxifylline 54 PERFOROMIST 119 perindopril erbumine 48 periogard 69 PERJETA 20 permethrin 66 perphenazine 42 perphenazine-amitriptyline 42 phenazopyridine 122 phenelzine 42 phenobarb-hyoscy-atropine-
scop 81 phenobarbital 25 26 phenohytro 81 phenoxybenzamine 48 phenylephrine hcl 114 phenytoin 26 phenytoin sodium extended 26 PHEXXI 101 philith 107 phosphasal 122 PHYSIOLYTE 66 PHYSIOSOL IRRIGATION 66 phytonadione (vitamin k1) 54 PICATO 59 pilocarpine hcl 67 69 110 pimecrolimus 59 pimozide 42 pimtrea (28) 107 pindolol 48 pioglitazone 78 pioglitazone-glimepiride 78
pioglitazone-metformin 78 piperacillin-tazobactam 11 PIQRAY 21 pirmella 107 piroxicam 36 PLASMA-LYTE 148 123 PLASMA-LYTE A 123 PLEGRIDY 89 PLENVU 84 PNEUMOVAX-23 93 podofilox 59 POLIVY 21 polycin 110 polymyxin b sulfate 10 polymyxin b sulf-trimethoprim
110 POMALYST 89 PONVORY 89 PONVORY 14-DAY
STARTER PACK 89 portia 28 107 PORTRAZZA 21 posaconazole 1 potassium chloride 123 potassium citrate 122 POTELIGEO 21 pramipexole 27 prasugrel 54 pravastatin 56 praziquantel 10 prazosin 48 PRED MILD 113 prednicarbate 65 prednisolone 70 prednisolone acetate 113 prednisolone sodium phosphate
70 114 prednisone 70 prednisone intensol 70 pregabalin 26 PREMARIN 100 PREMPHASE 100 PREMPRO 100 prevalite 56 previfem 107 PREVNAR 13 (PF) 93 PREVYMIS 4 PREZCOBIX 4 PREZISTA 4 PRIFTIN 10 primaquine 10
137
primidone 26 PRIMSOL 13 PRIVIGEN 93 probenecid 95 probenecid-colchicine 95 procainamide 44 procentra 42 prochlorperazine 84 prochlorperazine edisylate 84 prochlorperazine maleate 84 PROCRIT 87 procto-med hc 84 procto-pak 84 proctosol hc 84 proctozone-hc 84 PROFILNINE 54 progesterone 100 progesterone micronized 100 PROGRAF 21 PROLASTIN-C 67 PROLEUKIN 90 PROLIA 95 PROMACTA 54 promethazine 115 promethazine-codeine 116 promethazine-dm 116 promethazine-phenyleph-
codeine 116 promethazine-phenylephrine
116 promethegan 115 propafenone 44 45 proparacaine 111 propranolol 48 49 propranolol-hydrochlorothiazid
49 propylthiouracil 71 PROQUAD (PF) 93 protriptyline 42 PROVENGE 93 prudoxin 59 pulmosal 119 PULMOZYME 119 pyrazinamide 10 pyridostigmine bromide 30 pyrimethamine 10 Q QBRELIS 49 QINLOCK 21 QTERN 78 QUADRACEL (PF) 93
quetiapine 42 QUILLICHEW ER 42 QUILLIVANT XR 42 quinapril 49 quinapril-hydrochlorothiazide
49 quinidine gluconate 45 quinidine sulfate 45 quinine sulfate 10 quit 2 68 quit 4 68 QVAR REDIHALER 119 R RABAVERT (PF) 93 rabeprazole 86 RADICAVA 29 RAGWITEK 93 raloxifene 95 ramelteon 42 ramipril 49 ranolazine 57 RAPIVAB (PF) 4 rasagiline 27 RAVICTI 67 REBIF (WITH ALBUMIN) 89 REBIF REBIDOSE 89 REBIF TITRATION PACK 89 REBINYN 54 RECLAST 67 reclipsen (28) 107 RECOMBINATE 54 RECOMBIVAX HB (PF) 93 RECTIV 84 REGRANEX 59 RELENZA DISKHALER 4 RELEXXII 42 RELION NOVOLIN 7030 74 RELION NOVOLIN N 74 RELION NOVOLIN R 74 RELISTOR 84 REMICADE 84 RENACIDIN 122 RENFLEXIS 84 repaglinide 78 repaglinide-metformin 78 REPATHA PUSHTRONEX 56 REPATHA SURECLICK 56 REPATHA SYRINGE 56 RESTASIS 111 RETEVMO 21 RETISERT 114
REVATIO 119 REVLIMID 89 REXULTI 43 REYATAZ 4 RHOPRESSA 112 RIASTAP 54 ribavirin 4 89 RIDAURA 97 rifabutin 10 rifampin 10 riluzole 67 rimantadine 4 RINVOQ 97 RIOMET ER 78 risedronate 67 95 RISPERDAL CONSTA 43 risperidone 43 ritonavir 4 RITUXAN 21 RITUXAN HYCELA 21 rivastigmine 30 rivastigmine tartrate 29 rivelsa 107 RIXUBIS 54 rizatriptan 28 ropinirole 27 28 rosadan 61 rosuvastatin 56 roweepra 26 RUBRACA 21 RUCONEST 119 rufinamide 26 RYBELSUS 79 RYDAPT 21 S salsalate 36 SAMSCA 76 SANTYL 65 sapropterin 76 SARCLISA 21 SAVELLA 97 scalacort 65 SCENESSE 59 scopolamine base 84 seconal sodium 43 SEEBRI NEOHALER 119 selegiline hcl 28 selenium sulfide 58 SELZENTRY 5 SEREVENT DISKUS 119 SEROSTIM 87
138
sertraline 43 setlakin 107 sevelamer carbonate 84 sevelamer hcl 84 sf 69 sf 5000 plus 69 sharobel 101 SHINGRIX (PF) 93 SIGNIFOR 21 sildenafil (pulmhypertension)
119 SILIQ 58 silodosin 121 silver sulfadiazine 59 SIMBRINZA 112 simliya (28) 107 simpesse 107 SIMPONI 97 SIMPONI ARIA 97 SIMULECT 21 simvastatin 56 SINUVA 119 sirolimus 21 SIRTURO 10 SIVEXTRO 10 SKYLA 98 SKYRIZI 58 SLYND 107 sodium chloride 119 sodium chloride 045 123 sodium chloride 09 67 sodium fluoride 5000 dry
mouth 69 sodium fluoride 5000 plus 69 sodium fluoride-pot nitrate 69 sodium phenylbutyrate 67 sodium polystyrene sulfonate
85 solifenacin 121 SOLIQUA 10033 74 SOLIRIS 67 SOLTAMOX 21 SOMATULINE DEPOT 21 SOMAVERT 76 sorine 45 sotalol 45 sotalol af 45 SOVALDI 5 spinosad 66 SPIRIVA RESPIMAT 119
SPIRIVA WITH HANDIHALER 119
spironolactone 49 spironolacton-hydrochlorothiaz
49 SPRAVATO 43 sprintec (28) 107 SPRYCEL 21 sps (with sorbitol) 85 sronyx 107 ssd 59 SSKI 71 st joseph aspirin 36 st joseph aspirin 36 STAMARIL (PF) 93 stavudine 5 STELARA 58 STIOLTO RESPIMAT 119 STIVARGA 21 stop smoking aid 68 STRENSIQ 76 STREPTOMYCIN 10 STRIBILD 5 STRIVERDI RESPIMAT 120 SUBLOCADE 33 subvenite 26 subvenite starter (blue) kit 26 subvenite starter (green) kit 26 subvenite starter (orange) kit 26 SUCRAID 85 sucralfate 86 sulfacetamide sodium 58 114 sulfacetamide sodium (acne) 62 sulfacetamide-prednisolone 114 sulfadiazine 12 sulfamethoxazole-trimethoprim
12 SULFAMYLON 62 sulfasalazine 85 sulfatrim 12 sulindac 36 sumatriptan 28 sumatriptan succinate 28 29 SUNOSI 43 SUPPRELIN LA 21 SUPRAX 7 SUPREP BOWEL PREP KIT
85 SUTENT 22 syeda 107 SYLVANT 22
symax fastabs 81 symax-sl 81 symax-sr 81 SYMBICORT 120 SYMDEKO 120 SYMLINPEN 120 79 SYMLINPEN 60 79 SYMPAZAN 26 SYNAGIS 5 SYNAREL 76 SYNERA 61 SYNJARDY 79 SYNJARDY XR 79 SYNRIBO 22 SYNTHROID 79 T TABLOID 22 tacrolimus 22 59 tadalafil 121 tadalafil (pulm hypertension)
120 TAFINLAR 22 TAGRISSO 22 TAKHZYRO 120 TALTZ AUTOINJECTOR 58 TALTZ AUTOINJECTOR (2
PACK) 58 TALTZ AUTOINJECTOR (3
PACK) 58 TALTZ SYRINGE 58 TALZENNA 22 tamoxifen 22 tamsulosin 121 TARGRETIN 22 tarina 24 fe 107 tarina fe 120 (28) 107 TASIGNA 22 tavaborole 63 tazarotene 61 tazicef 7 taztia xt 49 TDVAX 93 TECENTRIQ 22 TEFLARO 7 TEKTURNA HCT 49 telmisartan 49 telmisartan-amlodipine 49 telmisartan-hydrochlorothiazid
49 temazepam 43 TEMODAR 22
139
temozolomide 22 temsirolimus 22 tencon 33 TENIVAC (PF) 94 tenofovir disoproxil fumarate 5 TEPEZZA 76 terazosin 49 terbinafine hcl 1 terbutaline 120 terconazole 101 testosterone 77 testosterone cypionate 76 testosterone enanthate 76 TETANUSDIPHTHERIA
TOX PED(PF) 94 tetrabenazine 30 tetracaine hcl 111 TETRACAINE HCL (PF) 111 tetracycline 12 THALOMID 22 theophylline 120 thioridazine 43 thiothixene 43 THYMOGLOBULIN 94 THYROLAR-1 79 THYROLAR-12 79 THYROLAR-14 79 THYROLAR-2 79 THYROLAR-3 79 tiadylt er 49 tiagabine 26 TIBSOVO 22 tilia fe 107 timolol maleate 49 110 tinidazole 10 TIVICAY 5 TIVICAY PD 5 tizanidine 30 TOBRADEX 113 TOBRADEX ST 113 tobramycin 10 110 tobramycin in 0225 nacl 10 tobramycin sulfate 10 TOBRAMYCIN WITH
NEBULIZER 10 tobramycin-dexamethasone 113 TOBREX 110 TODAY CONTRACEPTIVE
SPONGE 101 tolcapone 28 tolmetin 36
tolterodine 121 topiramate 26 toremifene 22 TORISEL 22 torsemide 49 TOUJEO MAX U-300
SOLOSTAR 74 TOUJEO SOLOSTAR U-300
INSULIN 74 TRACLEER 120 TRADJENTA 79 tramadol 36 tramadol-acetaminophen 36 trandolapril 49 trandolapril-verapamil 49 tranexamic acid 54 101 tranylcypromine 43 travoprost 112 trazodone 43 TREANDA 22 TRECATOR 10 TRELEGY ELLIPTA 120 TRELSTAR 22 TREMFYA 59 TRESIBA FLEXTOUCH U-
100 74 TRESIBA FLEXTOUCH U-
200 74 TRESIBA U-100 INSULIN 74 tretinoin 61 tretinoin (antineoplastic) 22 tretinoin microspheres 61 TRETTEN 54 TREXALL 22 tri femynor 107 triamcinolone acetonide 65 69
71 triamterene 49 triamterene-hydrochlorothiazid
49 triazolam 43 triderm 65 trientine 67 tri-estarylla 107 trifluoperazine 43 trifluridine 110 trihexyphenidyl 28 TRIJARDY XR 71 TRIKAFTA 120 tri-legest fe 108 tri-linyah 108
tri-lo-estarylla 108 tri-lo-marzia 108 tri-lo-mili 108 tri-lo-sprintec 108 trilyte with flavor packets 85 trimethobenzamide 85 trimethoprim 13 tri-mili 108 trimipramine 43 TRINTELLIX 43 tri-nymyo 108 tri-previfem (28) 108 tri-sprintec (28) 108 TRIUMEQ 5 tri-vitamin with fluoride 124 trivora (28) 108 tri-vylibra 108 tri-vylibra lo 108 TROGARZO 5 tropicamide 110 trospium 121 TRULICITY 79 TRUMENBA 94 TRUXIMA 22 TUKYSA 23 tulana 101 TWINRIX (PF) 94 TWIRLA 101 TYBLUME 108 TYBOST 5 tydemy 108 TYGACIL 10 TYMLOS 95 TYPHIM VI 94 TYSABRI 30 TYVASO 120 TYVASO REFILL KIT 120 TYVASO STARTER KIT 120 U UBRELVY 29 UDENYCA 87 ULESFIA 66 unithroid 80 UNITUXIN 23 URELLE 122 uretron d-s 122 urimar-t 122 urogesic-blue 122 ursodiol 85 uryl 122 ustell 122
140
UTIBRON NEOHALER 120 utira-c 122 UVADEX 59 V vaginal contraceptive foam 101 valacyclovir 5 VALCHLOR 59 valganciclovir 5 valproic acid 26 valproic acid (as sodium salt)
26 valsartan 49 valsartan-hydrochlorothiazide
49 vanadom 30 vancomycin 13 vandazole 101 VANTAS 23 VAQTA (PF) 94 VARIVAX (PF) 94 VARUBI 85 VASCEPA 56 VAXELIS (PF) 94 VCF CONTRACEPTIVE
FILM 101 VCF CONTRACEPTIVE GEL
101 VECTIBIX 23 VELCADE 23 veletri 50 velivet triphasic regimen (28)
108 VELPHORO 85 VEMLIDY 5 VENCLEXTA 23 VENCLEXTA STARTING
PACK 23 venlafaxine 43 VENTAVIS 120 verapamil 50 VERSACLOZ 43 VERZENIO 23 vestura (28) 108 VIBATIV 13 VIBERZI 85 VIDAZA 23 VIEKIRA PAK 5 vienva 108 vigabatrin 26 vigadrone 26 VIMIZIM 77
VIMPAT 26 viorele (28) 108 VIRACEPT 5 VIREAD 5 virtussin ac 116 VISTOGARD 13 VISUDYNE 111 vitamins acd and fluoride 124 VITRAKVI 23 VIVITROL 36 volnea (28) 108 VONVENDI 54 VORAXAZE 13 voriconazole 1 2 VOSEVI 5 VOTRIENT 23 VPRIV 77 VRAYLAR 44 VYEPTI 29 vyfemla (28) 108 vylibra 108 VYONDYS-53 30 VYVANSE 44 VYXEOS 23 W warfarin 54 wera (28) 108 westhroid 80 WIDE-SEAL DIAPHRAGM
98 WILATE 54 wixela inhub 121 wymzya fe 108 X XALKORI 23 XARELTO 54 XARELTO DVT-PE TREAT
30D START 54 XCOPRI 27 XCOPRI MAINTENANCE
PACK 27 XCOPRI TITRATION PACK
27 XELJANZ 97 XELJANZ XR 97 XEMBIFY 94 XENLETA 10 XEOMIN 94 XERMELO 23 XGEVA 13 XIFAXAN 10
XIGDUO XR 79 XIIDRA 111 XOLAIR 121 XOSPATA 23 XTANDI 23 xulane 102 XULTOPHY 10036 74 XURIDEN 67 XYNTHA 55 XYNTHA SOLOFUSE 55 XYREM 44 Y YERVOY 23 YESCARTA 23 YF-VAX (PF) 94 YONDELIS 23 YONSA 23 YUTIQ 114 yuvafem 101 Z zafemy 102 zafirlukast 121 zaleplon 44 ZALTRAP 23 ZANOSAR 23 zarah 109 ZARXIO 87 ZEJULA 24 ZELBORAF 24 ZEMAIRA 68 zenatane 61 ZENPEP 85 ZENZEDI 44 ZEPATIER 5 ZEPOSIA 89 ZEPOSIA STARTER KIT 89 ZEPOSIA STARTER PACK
89 ZERBAXA 7 zidovudine 5 ZIEXTENZO 87 zileuton 121 ziprasidone hcl 44 ZIRGAN 110 ZOKINVY 68 ZOLADEX 24 ZOLGENSMA 30 ZOLINZA 24 zolmitriptan 29 zolpidem 44 ZOLPIMIST 44
141
ZOMIG 29 zonisamide 27 ZONTIVITY 55 ZORBTIVE 87
ZOSTAVAX (PF) 94 zovia 135e (28) 109 ZULRESSO 44 zumandimine (28) 109
ZYFLO 121 ZYKADIA 24 ZYPITAMAG 56
051267 (11-20-2019)
Discrimination is Against the Law
LifeWise Health Plan of Washington (LifeWise) complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex LifeWise does not exclude people or treat them differently because of race color national origin age disability sex gender identity or sexual orientation LifeWise provides free aids and services to people with disabilities to communicate effectively with us such as qualified sign language interpreters and written information in other formats (large print audio accessible electronic formats other formats) LifeWise provides free language services to people whose primary language is not English such as qualified interpreters and information written in other languages If you need these services contact the Civil Rights Coordinator If you believe that LifeWise 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 Civil Rights Coordinator Complaints and Appeals PO Box 91102 Seattle WA 98111 Toll free 855-332-6396 Fax 425-918-5592 TTY 711 Email AppealsDepartmentInquiriesLifeWiseHealthcom You can file a grievance in person or by mail fax or email If you need help filing a grievance the Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Ave SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language Assistance ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 800-817-3056 (TTY 711) 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 800-817-3056(TTY711) CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 800-817-3056 (TTY 711) 주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 800-817-3056
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Tumawag sa 800-817-3056 (TTY 711) УВАГА Якщо ви розмовляєте українською мовою ви можете звернутися до безкоштовної служби
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គចនសបបេរ អក ចរ ទរសព 800-817-3056 (TTY 711) 注意事項日本語を話される場合無料の言語支援をご利用いただけます800-817-3056(TTY711)
までお電話にてご連絡ください ማስታወሻ የሚናገሩት ቋንቋ ኣማርኛ ከነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ
800-817-3056 (መስማት ለተሳናቸው 711) XIYYEEFFANNAA Afaan dubbattu Oroomiffa tajaajila gargaarsa afaanii kanfaltiidhaan ala ni argama Bilbilaa 800-817-3056 (TTY 711)
)711 والبكم الصم ھاتف رقم( 800-178-3056 برقم اتصل بالمجان لك تتوافر اللغویة المساعدة خدمات فإن اللغة اذكر تتحدث كنت إذا ملحوظةਿਧਆਨ ਿਦਓ ਜ ਤਸ ਪਜਾਬੀ ਬਲਦ ਹ ਤ ਭਾਸ਼ਾ ਿਵਚ ਸਹਾਇਤਾ ਸਵਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਧ ਹ 800-817-3056
(TTY 711) ਤ ਕਾਲ ਕਰ ACHTUNG Wenn Sie Deutsch sprechen stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfuumlgung
Rufnummer 800-817-3056 (TTY 711) ໂປດຊາບ ຖາວາ ທານເວາພາສາ ລາວ ການບລການຊວຍເຫອດານພາສາ ໂດຍບເສຽຄາ
ແມນມພອມໃຫທານ ໂທຣ 800-817-3056 (TTY 711) ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele 800-817-3056 (TTY 711) ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 800-817-3056 (ATS 711) UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń pod numer 800-817-3056 (TTY 711) ATENCcedilAtildeO Se fala portuguecircs encontram-se disponiacuteveis serviccedilos linguiacutesticos graacutetis Ligue para 800-817-3056 (TTY 711) ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza linguistica gratuiti Chiamare il numero
800-817-3056 (TTY 711) دیریبگ تماس 3056-817-800 (TTY 711) با باشد یم فراھم شما یبرا گانیرا بصورت یزبان لاتیتسھ دیکن یم گفتگو فارسی زبان بھ اگر توجھ
4
Drug Name Drug Tier Requirements Limits
KALETRA ORAL TABLET 200-50 MG 1 QL (120 per 30 days)
lamivudine oral solution 10 mgml 1 QL (900 per 30 days)
lamivudine oral tablet 100 mg 1
lamivudine oral tablet 150 mg 300 mg 1 QL (60 per 30 days)
lamivudine-zidovudine oral tablet 150-300 mg 1 QL (60 per 30 days)
LEXIVA ORAL SUSPENSION 50 MGML 1 QL (60 per 30 days)
lopinavir-ritonavir oral solution 400-100 mg5 ml 1 QL (320 per 30 days)
lopinavir-ritonavir oral tablet 100-25 mg 200-50 mg
1 QL (120 per 30 days)
MAVYRET ORAL TABLET 100-40 MG 2 PA LA
nevirapine oral suspension 50 mg5 ml 1 QL (60 per 30 days)
nevirapine oral tablet 200 mg 1 QL (60 per 30 days)
nevirapine oral tablet extended release 24 hr 100 mg 400 mg
1 QL (30 per 30 days)
NORVIR ORAL POWDER IN PACKET 100 MG 1 QL (360 per 30 days)
NORVIR ORAL SOLUTION 80 MGML 1 QL (480 per 30 days)
ODEFSEY ORAL TABLET 200-25-25 MG 1 QL (30 per 30 days)
oseltamivir oral capsule 30 mg 1 QL (40 per 365 days)
oseltamivir oral capsule 45 mg 75 mg 1 QL (20 per 365 days)
oseltamivir oral suspension for reconstitution 6 mgml
1 QL (180 per 30 days)
PREVYMIS INTRAVENOUS SOLUTION 240 MG12 ML 480 MG24 ML
MB PA
PREZCOBIX ORAL TABLET 800-150 MG-MG 1 QL (30 per 30 days)
PREZISTA ORAL SUSPENSION 100 MGML 1 QL (30 per 30 days)
PREZISTA ORAL TABLET 150 MG 600 MG 75 MG
1 QL (60 per 30 days)
PREZISTA ORAL TABLET 800 MG 1 QL (30 per 30 days)
RAPIVAB (PF) INTRAVENOUS SOLUTION 200 MG20 ML (10 MGML)
MB
RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MGACTUATION
1 QL (2 per 30 days)
REYATAZ ORAL POWDER IN PACKET 50 MG
1 QL (150 per 30 days)
ribavirin inhalation recon soln 6 gram MB
rimantadine oral tablet 100 mg 1
ritonavir oral tablet 100 mg 1 QL (360 per 30 days)
5
Drug Name Drug Tier Requirements Limits
SELZENTRY ORAL SOLUTION 20 MGML 1 QL (8 per 30 days)
SELZENTRY ORAL TABLET 150 MG 25 MG 300 MG 75 MG
1 QL (60 per 30 days)
SOVALDI ORAL PELLETS IN PACKET 150 MG 200 MG
2 LA
SOVALDI ORAL TABLET 200 MG 400 MG 2 PA LA
stavudine oral capsule 15 mg 20 mg 40 mg 1 QL (120 per 30 days)
STRIBILD ORAL TABLET 150-150-200-300 MG
1 QL (30 per 30 days)
SYNAGIS INTRAMUSCULAR SOLUTION 100 MGML 50 MG05 ML
MB LA
tenofovir disoproxil fumarate oral tablet 300 mg 1 QL (30 per 30 days)
TIVICAY ORAL TABLET 10 MG 25 MG 50 MG
1 QL (60 per 30 days)
TIVICAY PD ORAL TABLET FOR SUSPENSION 5 MG
1 QL (60 per 30 days)
TRIUMEQ ORAL TABLET 600-50-300 MG 1 QL (30 per 30 days)
TROGARZO INTRAVENOUS SOLUTION 200 MG133 ML (150 MGML)
MB PA
TYBOST ORAL TABLET 150 MG 1 QL (30 per 30 days)
valacyclovir oral tablet 1 gram 500 mg 1
valganciclovir oral recon soln 50 mgml 1
valganciclovir oral tablet 450 mg 1
VEMLIDY ORAL TABLET 25 MG 1
VIEKIRA PAK ORAL TABLETSDOSE PACK 125 MG-75 MG -50 MG250 MG
2 PA
VIRACEPT ORAL TABLET 250 MG 1 QL (90 per 30 days)
VIRACEPT ORAL TABLET 625 MG 1 QL (60 per 30 days)
VIREAD ORAL POWDER 40 MGSCOOP (40 MGGRAM)
1 QL (4 per 30 days)
VIREAD ORAL TABLET 150 MG 200 MG 250 MG
1 QL (30 per 30 days)
VOSEVI ORAL TABLET 400-100-100 MG 2 PA LA
ZEPATIER ORAL TABLET 50-100 MG 2 PA LA
zidovudine oral capsule 100 mg 1 QL (60 per 30 days)
zidovudine oral syrup 10 mgml 1 QL (960 per 30 days)
zidovudine oral tablet 300 mg 1 QL (60 per 30 days)
CEPHALOSPORINS
6
Drug Name Drug Tier Requirements Limits
AVYCAZ INTRAVENOUS RECON SOLN 25 GRAM
MB
cefaclor oral capsule 250 mg 500 mg 1
cefaclor oral suspension for reconstitution 125 mg5 ml 250 mg5 ml 375 mg5 ml
1
cefaclor oral tablet extended release 12 hr 500 mg 1
cefadroxil oral capsule 500 mg 1
cefadroxil oral suspension for reconstitution 250 mg5 ml 500 mg5 ml
1
cefadroxil oral tablet 1 gram 1
cefazolin in dextrose (iso-os) intravenous piggyback 1 gram50 ml
MB
cefazolin injection recon soln 1 gram 10 gram 100 gram 20 gram 300 g 500 mg
MB
cefazolin intravenous recon soln 1 gram MB
cefdinir oral capsule 300 mg 1
cefdinir oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cefditoren pivoxil oral tablet 200 mg 400 mg 1
CEFEPIME IN DEXTROSE 5 INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
cefepime in dextroseiso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml
MB
cefepime injection recon soln 1 gram 2 gram MB
cefixime oral capsule 400 mg 1
cefixime oral suspension for reconstitution 100 mg5 ml 200 mg5 ml
1
CEFOTAN INJECTION RECON SOLN 1 GRAM 2 GRAM
MB
cefotaxime injection recon soln 1 gram MB
CEFOTETAN IN DEXTROSE ISO-OSM INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
cefotetan injection recon soln 1 gram 2 gram MB
cefotetan intravenous recon soln 10 gram MB
cefoxitin intravenous recon soln 10 gram MB
cefpodoxime oral suspension for reconstitution 100 mg5 ml 50 mg5 ml
1
7
Drug Name Drug Tier Requirements Limits
cefpodoxime oral tablet 100 mg 200 mg 1
cefprozil oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cefprozil oral tablet 250 mg 500 mg 1
CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
ceftazidime injection recon soln 1 gram 2 gram 6 gram
MB
ceftriaxone in dextroseiso-os intravenous piggyback 1 gram50 ml 2 gram50 ml
MB
ceftriaxone injection recon soln 1 gram 10 gram 2 gram 250 mg 500 mg
MB
CEFTRIAXONE INJECTION RECON SOLN 100 GRAM
MB
ceftriaxone intravenous recon soln 1 gram 2 gram MB
cefuroxime axetil oral tablet 250 mg 500 mg 1
cephalexin oral capsule 250 mg 500 mg 750 mg 1
cephalexin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cephalexin oral tablet 250 mg 500 mg 1
SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG5 ML
1
SUPRAX ORAL TABLETCHEWABLE 100 MG 200 MG
1
tazicef injection recon soln 1 gram 2 gram 6 gram
MB
tazicef intravenous recon soln 1 gram 2 gram MB
TEFLARO INTRAVENOUS RECON SOLN 400 MG 600 MG
MB
ZERBAXA INTRAVENOUS RECON SOLN 15 GRAM
MB
ERYTHROMYCINS amp OTHER MACROLIDES
azithromycin oral packet 1 gram 1
azithromycin oral suspension for reconstitution 100 mg5 ml 200 mg5 ml
1
azithromycin oral tablet 250 mg 500 mg 600 mg 1
clarithromycin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
clarithromycin oral tablet 250 mg 500 mg 1
8
Drug Name Drug Tier Requirements Limits
clarithromycin oral tablet extended release 24 hr 500 mg
1
DIFICID ORAL TABLET 200 MG 1
ees 400 oral tablet 400 mg 1
ery-tab oral tabletdelayed release (drec) 250 mg 333 mg
1
erythrocin (as stearate) oral tablet 250 mg 1
erythromycin ethylsuccinate oral suspension for reconstitution 200 mg5 ml 400 mg5 ml
1
erythromycin ethylsuccinate oral tablet 400 mg 1
erythromycin oral capsuledelayed release(drec) 250 mg
1
erythromycin oral tablet 250 mg 500 mg 1
erythromycin oral tabletdelayed release (drec) 250 mg 333 mg 500 mg
1
MISCELLANEOUS ANTIINFECTIVES
albendazole oral tablet 200 mg 1
ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG5 ML
1 PA ST
amikacin injection solution 500 mg2 ml MB
atovaquone oral suspension 750 mg5 ml 1
atovaquone-proguanil oral tablet 250-100 mg 625-25 mg
1
bacitracin intramuscular recon soln 50000 unit 1
CAPASTAT INJECTION RECON SOLN 1 GRAM
1
CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MGML
2 PA LA QL (84 per 30 days)
chloramphenicol sod succinate intravenous recon soln 1 gram
MB
chloroquine phosphate oral tablet 250 mg 500 mg 1
clindamycin hcl oral capsule 150 mg 300 mg 75 mg
1
clindamycin pediatric oral recon soln 75 mg5 ml 1
clindamycin phosphate injection solution 150 mgml
MB
COARTEM ORAL TABLET 20-120 MG 1
CUBICIN INTRAVENOUS RECON SOLN 500 MG
MB
9
Drug Name Drug Tier Requirements Limits
CUBICIN RF INTRAVENOUS RECON SOLN 500 MG
MB
CYCLOSERINE ORAL CAPSULE 250 MG 1
dapsone oral tablet 100 mg 25 mg 1
EMVERM ORAL TABLETCHEWABLE 100 MG
1
ethambutol oral tablet 100 mg 400 mg 1
gentamicin injection solution 20 mg2 ml 40 mgml
MB
gentamicin sulfate (ped) (pf) injection solution 20 mg2 ml
MB
hydroxychloroquine oral tablet 200 mg 1
imipenem-cilastatin intravenous recon soln 250 mg 500 mg
MB
INVANZ INJECTION RECON SOLN 1 GRAM MB
isoniazid injection solution 100 mgml 1
isoniazid oral solution 50 mg5 ml 1
isoniazid oral tablet 100 mg 300 mg 1
ivermectin oral tablet 3 mg 1
LINCOCIN INJECTION SOLUTION 300 MGML
MB
linezolid in dextrose 5 intravenous piggyback 600 mg300 ml
MB
linezolid oral suspension for reconstitution 100 mg5 ml
1
linezolid oral tablet 600 mg 1
linezolid-09 sodium chloride intravenous parenteral solution 600 mg300 ml
MB
mefloquine oral tablet 250 mg 1
meropenem intravenous recon soln 1 gram 500 mg
MB
MEROPENEM-09 SODIUM CHLORIDE INTRAVENOUS PIGGYBACK 1 GRAM50 ML 500 MG50 ML
MB
metronidazole oral capsule 375 mg 1
metronidazole oral tablet 250 mg 500 mg 1
neomycin oral tablet 500 mg 1
nitazoxanide oral tablet 500 mg 1
10
Drug Name Drug Tier Requirements Limits
paromomycin oral capsule 250 mg 1
PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM
1
PENTAM INJECTION RECON SOLN 300 MG MB
pentamidine inhalation recon soln 300 mg 1
pentamidine injection recon soln 300 mg MB
polymyxin b sulfate injection recon soln 500000 unit
MB
praziquantel oral tablet 600 mg 1
PRIFTIN ORAL TABLET 150 MG 1
primaquine oral tablet 263 mg 1
pyrazinamide oral tablet 500 mg 1
pyrimethamine oral tablet 25 mg 2 PA
quinine sulfate oral capsule 324 mg 1
rifabutin oral capsule 150 mg 1
rifampin oral capsule 150 mg 300 mg 1
SIRTURO ORAL TABLET 100 MG 1 PA
SIRTURO ORAL TABLET 20 MG 1
SIVEXTRO ORAL TABLET 200 MG 1 QL (6 per 30 days)
STREPTOMYCIN INTRAMUSCULAR RECON SOLN 1 GRAM
1
tinidazole oral tablet 250 mg 500 mg 1
tobramycin in 0225 nacl inhalation solution for nebulization 300 mg5 ml
2
tobramycin inhalation solution for nebulization 300 mg4 ml
2
tobramycin sulfate injection recon soln 12 gram 1
tobramycin sulfate injection solution 10 mgml MB
tobramycin sulfate injection solution 40 mgml 1
TOBRAMYCIN WITH NEBULIZER INHALATION SOLUTION FOR NEBULIZATION 300 MG5 ML
2 PA ST
TRECATOR ORAL TABLET 250 MG 1
TYGACIL INTRAVENOUS RECON SOLN 50 MG
MB
XENLETA INTRAVENOUS SOLUTION 150 MG15 ML
MB
XIFAXAN ORAL TABLET 200 MG 550 MG 1 PA QL (60 per 30 days)
11
Drug Name Drug Tier Requirements Limits
PENICILLINS
amoxicillin oral capsule 250 mg 500 mg 1
amoxicillin oral suspension for reconstitution 125 mg5 ml 200 mg5 ml 250 mg5 ml 400 mg5 ml
1
amoxicillin oral tablet 500 mg 875 mg 1
amoxicillin oral tabletchewable 125 mg 250 mg 1
amoxicillin-pot clavulanate oral suspension for reconstitution 200-285 mg5 ml 250-625 mg5 ml 400-57 mg5 ml 600-429 mg5 ml
1
amoxicillin-pot clavulanate oral tablet 250-125 mg 500-125 mg 875-125 mg
1
amoxicillin-pot clavulanate oral tablet extended release 12 hr 1000-625 mg
1
amoxicillin-pot clavulanate oral tabletchewable 200-285 mg 400-57 mg
1
ampicillin oral capsule 500 mg 1
ampicillin-sulbactam injection recon soln 15 gram MB
BICILLIN C-R INTRAMUSCULAR SYRINGE 1200000 UNIT 2 ML(900K300K)
MB
dicloxacillin oral capsule 250 mg 500 mg 1
MOXATAG ORAL TABLET ER MULTIPHASE 24 HR 775 MG
1
nafcillin in dextrose iso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml
MB
nafcillin injection recon soln 1 gram 10 gram 2 gram
MB
nafcillin intravenous recon soln 1 gram 2 gram MB
oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram50 ml 2 gram50 ml
MB
oxacillin injection recon soln 1 gram 10 gram 2 gram
MB
penicillin g procaine intramuscular syringe 12 million unit2 ml 600000 unitml
MB
penicillin v potassium oral recon soln 125 mg5 ml 250 mg5 ml
1
penicillin v potassium oral tablet 250 mg 500 mg 1
piperacillin-tazobactam intravenous recon soln 135 gram 225 gram 3375 gram 45 gram 405 gram
MB
12
Drug Name Drug Tier Requirements Limits
QUINOLONES
BAXDELA INTRAVENOUS RECON SOLN 300 MG
MB
BAXDELA ORAL TABLET 450 MG 1
ciprofloxacin hcl oral tablet 100 mg 250 mg 500 mg 750 mg
1
ciprofloxacin oral suspensionmicrocapsule recon 250 mg5 ml 500 mg5 ml
1
FACTIVE ORAL TABLET 320 MG 1 ST
levofloxacin oral solution 250 mg10 ml 1
levofloxacin oral tablet 250 mg 500 mg 750 mg 1
moxifloxacin oral tablet 400 mg 1
ofloxacin oral tablet 300 mg 400 mg 1
SULFAS amp RELATED AGENTS
sulfadiazine oral tablet 500 mg 1
sulfamethoxazole-trimethoprim oral suspension 200-40 mg5 ml
1
sulfamethoxazole-trimethoprim oral tablet 400-80 mg 800-160 mg
1
sulfatrim oral suspension 200-40 mg5 ml 1
TETRACYCLINES
avidoxy oral tablet 100 mg 1 ST
demeclocycline oral tablet 150 mg 300 mg 1
doxycycline hyclate oral capsule 100 mg 50 mg 1
doxycycline hyclate oral tablet 100 mg 150 mg 20 mg 50 mg 75 mg
1
doxycycline hyclate oral tabletdelayed release (drec) 100 mg 150 mg 200 mg 50 mg 75 mg
1
doxycycline monohydrate oral capsule 100 mg 150 mg 50 mg 75 mg
1
doxycycline monohydrate oral suspension for reconstitution 25 mg5 ml
1
doxycycline monohydrate oral tablet 100 mg 150 mg 50 mg 75 mg
1
minocycline oral capsule 100 mg 50 mg 75 mg 1
minocycline oral tablet 100 mg 50 mg 75 mg 1
mondoxyne nl oral capsule 100 mg 75 mg 1
tetracycline oral capsule 250 mg 500 mg 1
13
Drug Name Drug Tier Requirements Limits
URINARY TRACT AGENTS
fosfomycin tromethamine oral packet 3 gram 1
methenamine hippurate oral tablet 1 gram 1
methenamine mandelate oral tablet 05 g 1 gram 1
nitrofurantoin macrocrystal oral capsule 100 mg 25 mg 50 mg
1
nitrofurantoin monohydm-cryst oral capsule 100 mg
1
nitrofurantoin oral suspension 25 mg5 ml 1
PRIMSOL ORAL SOLUTION 50 MG5 ML 1
trimethoprim oral tablet 100 mg 1
VANCOMYCIN
vancomycin oral capsule 125 mg 250 mg 1
vancomycin oral recon soln 50 mgml 1
VIBATIV INTRAVENOUS RECON SOLN 750 MG
MB
ANTINEOPLASTIC amp IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
KEPIVANCE INTRAVENOUS RECON SOLN 625 MG
MB
leucovorin calcium injection recon soln 100 mg 200 mg 350 mg 50 mg 500 mg
MB
leucovorin calcium injection solution 10 mgml MB
leucovorin calcium oral tablet 10 mg 15 mg 25 mg 5 mg
1
VISTOGARD ORAL GRANULES IN PACKET 10 GRAM
2
VORAXAZE INTRAVENOUS RECON SOLN 1000 UNIT
MB
XGEVA SUBCUTANEOUS SOLUTION 120 MG17 ML (70 MGML)
2 LA
ANTINEOPLASTIC amp IMMUNOSUPPRESSANT DRUGS
abiraterone oral tablet 250 mg 2 PA OCh LA
abiraterone oral tablet 500 mg 2 PA ST OCh LA
ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG
MB PA LA
ADAKVEO INTRAVENOUS SOLUTION 10 MGML
MB PA
14
Drug Name Drug Tier Requirements Limits
ADCETRIS INTRAVENOUS RECON SOLN 50 MG
MB PA LA
AFINITOR ORAL TABLET 10 MG 2 OCh LA
ALECENSA ORAL CAPSULE 150 MG 2 PA OCh LA
ALIMTA INTRAVENOUS RECON SOLN 100 MG 500 MG
MB PA
ALIQOPA INTRAVENOUS RECON SOLN 60 MG
MB PA
anastrozole oral tablet 1 mg ACA PV OCh QL (30 per 30 days)
ARRANON INTRAVENOUS SOLUTION 250 MG50 ML
MB LA
ARZERRA INTRAVENOUS SOLUTION 1000 MG50 ML 100 MG5 ML
MB PA LA
ASPARLAS INTRAVENOUS SOLUTION 750 UNITML
MB PA
AVASTIN INTRAVENOUS SOLUTION 25 MGML
MB PA LA
azathioprine oral tablet 50 mg 1
BALVERSA ORAL TABLET 3 MG 4 MG 5 MG
2 PA OCh
BAVENCIO INTRAVENOUS SOLUTION 20 MGML
MB PA
BELEODAQ INTRAVENOUS RECON SOLN 500 MG
MB PA
BELRAPZO INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BENDAMUSTINE INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BENDEKA INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BESPONSA INTRAVENOUS RECON SOLN 09 MG (025 MGML INITIAL)
MB PA LA
bexarotene oral capsule 75 mg 2 PA ST OCh
bicalutamide oral tablet 50 mg 2 OCh QL (30 per 30 days)
BLINCYTO INTRAVENOUS KIT 35 MCG MB PA
BORTEZOMIB INTRAVENOUS RECON SOLN 35 MG
MB
BOSULIF ORAL TABLET 100 MG 400 MG 500 MG
2 PA ST OCh LA
BRAFTOVI ORAL CAPSULE 50 MG 75 MG 2 PA OCh LA
15
Drug Name Drug Tier Requirements Limits
BUSULFEX INTRAVENOUS SOLUTION 60 MG10 ML
MB
CABOMETYX ORAL TABLET 20 MG 40 MG 60 MG
2 PA ST OCh LA
CALQUENCE ORAL CAPSULE 100 MG 2 PA ST OCh
capecitabine oral tablet 150 mg 2 OCh LA QL (210 per 30 days)
capecitabine oral tablet 500 mg 2 OCh LA QL (84 per 30 days)
CAPRELSA ORAL TABLET 100 MG 300 MG 2 PA OCh
CLOLAR INTRAVENOUS SOLUTION 20 MG20 ML
MB PA
COMETRIQ ORAL CAPSULE 100 MGDAY(80 MG X1-20 MG X1) 140 MGDAY(80 MG X1-20 MG X3) 60 MGDAY (20 MG X 3DAY)
2 PA OCh
COPIKTRA ORAL CAPSULE 15 MG 25 MG 2 PA OCh
COTELLIC ORAL TABLET 20 MG 2 PA OCh LA
cyclophosphamide intravenous recon soln 1 gram 2 gram 500 mg
MB
cyclophosphamide oral capsule 25 mg 50 mg 2 OCh
CYCLOPHOSPHAMIDE ORAL TABLET 25 MG 50 MG
2 OCh
cyclosporine modified oral capsule 100 mg 25 mg 50 mg
1
cyclosporine modified oral solution 100 mgml 1
cyclosporine oral capsule 100 mg 25 mg 1
CYRAMZA INTRAVENOUS SOLUTION 10 MGML
MB PA LA
DACOGEN INTRAVENOUS RECON SOLN 50 MG
MB PA LA
DARZALEX INTRAVENOUS SOLUTION 20 MGML
MB PA LA
DAURISMO ORAL TABLET 100 MG 25 MG 2 PA OCh LA
decitabine intravenous recon soln 50 mg MB LA
ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 225 MG
2
ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG
2
ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG
2
16
Drug Name Drug Tier Requirements Limits
ELIGARD SUBCUTANEOUS SYRINGE 75 MG (1 MONTH)
2
ELZONRIS INTRAVENOUS SOLUTION 1000 MCGML
MB PA
EMCYT ORAL CAPSULE 140 MG 2 OCh
EMPLICITI INTRAVENOUS RECON SOLN 300 MG 400 MG
MB PA LA
ENHERTU INTRAVENOUS RECON SOLN 100 MG
MB PA LA
ERBITUX INTRAVENOUS SOLUTION 100 MG50 ML 200 MG100 ML
MB PA LA
ERLEADA ORAL TABLET 60 MG 2 PA OCh LA
erlotinib oral tablet 100 mg 150 mg 25 mg 2 PA OCh LA
ERWINAZE INJECTION RECON SOLN 10000 UNIT
MB
etoposide intravenous solution 20 mgml MB
etoposide oral capsule 50 mg 2 OCh
everolimus (antineoplastic) oral tablet 25 mg 5 mg 75 mg
2 PA ST OCh LA
everolimus (immunosuppressive) oral tablet 025 mg 05 mg 075 mg
1 PA
exemestane oral tablet 25 mg ACA PV OCh QL (30 per 30 days)
FASLODEX INTRAMUSCULAR SYRINGE 250 MG5 ML
MB PA
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG 80 MG
2 LA
fludarabine intravenous recon soln 50 mg MB
fluorouracil intravenous solution 25 gram50 ml 5 gram100 ml 500 mg10 ml
MB PA
flutamide oral capsule 125 mg 2 OCh QL (180 per 30 days)
FOLOTYN INTRAVENOUS SOLUTION 20 MGML (1 ML) 40 MG2 ML (20 MGML)
MB PA LA
fulvestrant intramuscular syringe 250 mg5 ml MB
GAMIFANT INTRAVENOUS SOLUTION 5 MGML
MB PA
GAZYVA INTRAVENOUS SOLUTION 1000 MG40 ML
MB PA LA
gemcitabine intravenous recon soln 1 gram 2 gram 200 mg
MB
17
Drug Name Drug Tier Requirements Limits
gemcitabine intravenous solution 2 gram526 ml (38 mgml) 200 mg526 ml (38 mgml)
MB
gengraf oral capsule 100 mg 25 mg 1
gengraf oral solution 100 mgml 1
GILOTRIF ORAL TABLET 20 MG 30 MG 40 MG
2 PA OCh LA
GLEOSTINE ORAL CAPSULE 10 MG 100 MG 40 MG
2 PA OCh
HALAVEN INTRAVENOUS SOLUTION 1 MG2 ML (05 MGML)
MB PA LA
HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600 MG-10000 UNIT5 ML
MB LA
HERCEPTIN INTRAVENOUS RECON SOLN 150 MG
MB PA LA
HERZUMA INTRAVENOUS RECON SOLN 150 MG
MB PA LA
HYCAMTIN ORAL CAPSULE 025 MG 1 MG 2 OCh LA
hydroxyurea oral capsule 500 mg 2 OCh
IBRANCE ORAL CAPSULE 100 MG 125 MG 75 MG
2 PA OCh LA
IBRANCE ORAL TABLET 100 MG 125 MG 75 MG
2 OCh LA
ICLUSIG ORAL TABLET 10 MG 15 MG 30 MG 45 MG
2 PA ST OCh
IDHIFA ORAL TABLET 100 MG 50 MG 2 PA OCh LA
imatinib oral tablet 100 mg 2 OCh LA QL (90 per 30 days)
imatinib oral tablet 400 mg 2 OCh LA QL (60 per 30 days)
IMBRUVICA ORAL CAPSULE 140 MG 70 MG 2 PA ST OCh
IMBRUVICA ORAL TABLET 140 MG 280 MG 420 MG 560 MG
2 PA ST OCh
IMFINZI INTRAVENOUS SOLUTION 50 MGML
MB PA LA
IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFUML 10EXP8 (100 MILLION) PFUML
MB
18
Drug Name Drug Tier Requirements Limits
INFUGEM INTRAVENOUS PIGGYBACK 1200 MG120 ML (10 MGML) 1300 MG130 ML (10 MGML) 1400 MG140 ML (10 MGML) 1500 MG150 ML (10 MGML) 1600 MG160 ML (10 MGML) 1700 MG170 ML (10 MGML) 1800 MG180 ML (10 MGML) 1900 MG190 ML (10 MGML) 2000 MG200 ML (10 MGML) 2200 MG220 ML (10 MGML)
MB
INLYTA ORAL TABLET 1 MG 5 MG 2 PA OCh LA
IRESSA ORAL TABLET 250 MG 2 PA OCh LA
ISTODAX INTRAVENOUS RECON SOLN 10 MG2 ML
MB PA LA
IXEMPRA INTRAVENOUS RECON SOLN 15 MG 45 MG
MB PA LA
JAKAFI ORAL TABLET 10 MG 15 MG 20 MG 25 MG 5 MG
2 PA OCh LA
JEVTANA INTRAVENOUS SOLUTION 10 MGML (FIRST DILUTION)
MB PA LA
KADCYLA INTRAVENOUS RECON SOLN 100 MG 160 MG
MB PA LA
KANJINTI INTRAVENOUS RECON SOLN 150 MG 420 MG
MB PA LA
KEYTRUDA INTRAVENOUS SOLUTION 25 MGML
MB PA
KISQALI FEMARA CO-PACK ORAL TABLET 200 MGDAY(200 MG X 1)-25 MG 400 MGDAY(200 MG X 2)-25 MG 600 MGDAY(200 MG X 3)-25 MG
2 PA ST OCh LA
KISQALI ORAL TABLET 200 MGDAY (200 MG X 1) 400 MGDAY (200 MG X 2) 600 MGDAY (200 MG X 3)
2 PA ST OCh LA
KYMRIAH INTRAVENOUS SUSPENSION 02X10EXP6 TO 25X10EXP8 CELL 06 TO 6 X 10EXP8 CELL
MB PA
KYPROLIS INTRAVENOUS RECON SOLN 10 MG 30 MG 60 MG
MB PA
lapatinib oral tablet 250 mg 2 PA OCh LA QL (180 per 30 days)
LENVIMA ORAL CAPSULE 10 MGDAY (10 MG X 1) 12 MGDAY (4 MG X 3) 14 MGDAY(10 MG X 1-4 MG X 1) 18 MGDAY (10 MG X 1-4 MG X2) 20 MGDAY (10 MG X 2) 24 MGDAY(10 MG X 2-4 MG X 1) 4 MG 8 MGDAY (4 MG X 2)
2 PA ST OCh LA
19
Drug Name Drug Tier Requirements Limits
letrozole oral tablet 25 mg ACA PV OCh QL (30 per 30 days)
LEUKERAN ORAL TABLET 2 MG 2 OCh
leuprolide subcutaneous kit 1 mg02 ml 2
LIBTAYO INTRAVENOUS SOLUTION 50 MGML
MB PA
LONSURF ORAL TABLET 15-614 MG 20-819 MG
2 PA ST OCh LA
LUMOXITI INTRAVENOUS RECON SOLN 1 MG
MB
LUPKYNIS ORAL CAPSULE 79 MG 2 PA ST
LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 225 MG
2
LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG
2
LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG
2
LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 375 MG 75 MG
2
LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 30 MG
2
LUPRON DEPOT-PED INTRAMUSCULAR KIT 1125 MG 15 MG 75 MG (PED)
2
LYNPARZA ORAL TABLET 100 MG 150 MG 2 PA ST OCh LA
LYSODREN ORAL TABLET 500 MG 2 OCh
MARQIBO INTRAVENOUS KIT 5 MG31 ML(016 MGML) FINAL
MB PA
MATULANE ORAL CAPSULE 50 MG 2 OCh
megestrol oral suspension 400 mg10 ml (40 mgml)
1 QL (2 per 30 days)
megestrol oral suspension 625 mg5 ml (125 mgml)
1 QL (1 per 30 days)
megestrol oral tablet 20 mg 2 OCh QL (480 per 30 days)
megestrol oral tablet 40 mg 2 OCh QL (240 per 30 days)
MEKINIST ORAL TABLET 05 MG 2 MG 2 PA ST OCh LA
MEKTOVI ORAL TABLET 15 MG 2 PA OCh LA
melphalan hcl intravenous recon soln 50 mg MB
melphalan oral tablet 2 mg 2 OCh
20
Drug Name Drug Tier Requirements Limits
mercaptopurine oral tablet 50 mg 2 OCh QL (300 per 30 days)
methotrexate sodium (pf) injection recon soln 1 gram
1
methotrexate sodium (pf) injection solution 25 mgml
1
methotrexate sodium injection solution 25 mgml 1
methotrexate sodium oral tablet 25 mg 2 OCh
mitoxantrone intravenous concentrate 2 mgml MB PA LA
mycophenolate mofetil oral capsule 250 mg 1
mycophenolate mofetil oral tablet 500 mg 1
mycophenolate sodium oral tabletdelayed release (drec) 180 mg 360 mg
1
MYLOTARG INTRAVENOUS RECON SOLN 45 MG (1 MGML INITIAL CONC)
MB PA LA
NERLYNX ORAL TABLET 40 MG 2 PA OCh LA QL (180 per 30 days)
NEXAVAR ORAL TABLET 200 MG 2 PA ST OCh LA
nilutamide oral tablet 150 mg 2 OCh QL (60 per 30 days)
NINLARO ORAL CAPSULE 23 MG 3 MG 4 MG
2 PA ST OCh LA
NULOJIX INTRAVENOUS RECON SOLN 250 MG
MB PA
octreotide acetate injection solution 1000 mcgml 100 mcgml 200 mcgml 50 mcgml 500 mcgml
2
octreotide acetate injection syringe 100 mcgml (1 ml) 50 mcgml (1 ml) 500 mcgml (1 ml)
2
OGIVRI INTRAVENOUS RECON SOLN 150 MG 420 MG
MB PA LA
ONCASPAR INJECTION SOLUTION 750 UNITML
MB
ONIVYDE INTRAVENOUS DISPERSION 43 MGML
MB PA
OPDIVO INTRAVENOUS SOLUTION 100 MG10 ML 240 MG24 ML 40 MG4 ML
MB PA LA
PADCEV INTRAVENOUS RECON SOLN 20 MG 30 MG
MB PA LA
PEMAZYRE ORAL TABLET 135 MG 45 MG 9 MG
2 PA ST OCh
PERJETA INTRAVENOUS SOLUTION 420 MG14 ML (30 MGML)
MB PA LA
21
Drug Name Drug Tier Requirements Limits
PIQRAY ORAL TABLET 200 MGDAY (200 MG X 1) 250 MGDAY (200 MG X1-50 MG X1) 300 MGDAY (150 MG X 2)
2 PA OCh LA
POLIVY INTRAVENOUS RECON SOLN 140 MG
MB PA LA
PORTRAZZA INTRAVENOUS SOLUTION 800 MG50 ML (16 MGML)
MB PA LA
POTELIGEO INTRAVENOUS SOLUTION 4 MGML
MB PA
PROGRAF INTRAVENOUS SOLUTION 5 MGML
MB
QINLOCK ORAL TABLET 50 MG 2 OCh
RETEVMO ORAL CAPSULE 40 MG 2 PA OCh LA QL (240 per 30 days)
RETEVMO ORAL CAPSULE 80 MG 2 PA OCh LA QL (120 per 30 days)
RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG117 ML (120 MGML) 1600 MG134 ML (120 MGML)
MB LA
RITUXAN INTRAVENOUS CONCENTRATE 10 MGML
MB PA LA
RUBRACA ORAL TABLET 200 MG 250 MG 300 MG
2 PA ST OCh LA
RYDAPT ORAL CAPSULE 25 MG 2 PA ST OCh LA
SARCLISA INTRAVENOUS SOLUTION 20 MGML
MB
SIGNIFOR SUBCUTANEOUS SOLUTION 03 MGML (1 ML) 06 MGML (1 ML) 09 MGML (1 ML)
2 PA ST
SIMULECT INTRAVENOUS RECON SOLN 10 MG 20 MG
MB
sirolimus oral solution 1 mgml 1
sirolimus oral tablet 05 mg 1 mg 2 mg 1
SOLTAMOX ORAL SOLUTION 20 MG10 ML 2 OCh
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG05 ML 60 MG02 ML 90 MG03 ML
2 PA LA
SPRYCEL ORAL TABLET 100 MG 140 MG 20 MG 50 MG 70 MG 80 MG
2 PA ST OCh LA
STIVARGA ORAL TABLET 40 MG 2 PA ST OCh LA
SUPPRELIN LA IMPLANT KIT 50 MG (65 MCGDAY)
MB LA
22
Drug Name Drug Tier Requirements Limits
SUTENT ORAL CAPSULE 125 MG 25 MG 375 MG 50 MG
2 PA ST OCh LA
SYLVANT INTRAVENOUS RECON SOLN 100 MG 400 MG
MB PA LA
SYNRIBO SUBCUTANEOUS RECON SOLN 35 MG
2 PA ST
TABLOID ORAL TABLET 40 MG 2 OCh
tacrolimus oral capsule 05 mg 1 mg 5 mg 1
TAFINLAR ORAL CAPSULE 50 MG 75 MG 2 PA OCh LA
TAGRISSO ORAL TABLET 40 MG 80 MG 2 PA OCh LA
TALZENNA ORAL CAPSULE 025 MG 1 MG 2 PA OCh LA
tamoxifen oral tablet 10 mg 20 mg 2 OCh QL (60 per 30 days)
TARGRETIN TOPICAL GEL 1 1 PA ST
TASIGNA ORAL CAPSULE 150 MG 200 MG 50 MG
2 PA ST OCh LA
TECENTRIQ INTRAVENOUS SOLUTION 1200 MG20 ML (60 MGML) 840 MG14 ML (60 MGML)
MB PA LA
TEMODAR INTRAVENOUS RECON SOLN 100 MG
MB PA LA
temozolomide oral capsule 100 mg 140 mg 180 mg 20 mg 250 mg 5 mg
2 OCh LA
temsirolimus intravenous recon soln 30 mg3 ml (10 mgml) (first)
MB PA LA
THALOMID ORAL CAPSULE 100 MG 150 MG 200 MG 50 MG
2 OCh LA
TIBSOVO ORAL TABLET 250 MG 2 PA OCh
toremifene oral tablet 60 mg 2 OCh
TORISEL INTRAVENOUS RECON SOLN 30 MG3 ML (10 MGML) (FIRST)
MB PA LA
TREANDA INTRAVENOUS RECON SOLN 100 MG 25 MG
MB PA LA
TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 1125 MG 225 MG 375 MG
MB
tretinoin (antineoplastic) oral capsule 10 mg 2 OCh
TREXALL ORAL TABLET 10 MG 15 MG 5 MG 75 MG
2 PA ST OCh QL (15 per 30 days)
TRUXIMA INTRAVENOUS SOLUTION 10 MGML
MB PA LA
23
Drug Name Drug Tier Requirements Limits
TUKYSA ORAL TABLET 150 MG 50 MG 2 PA ST OCh QL (120 per 30 days)
UNITUXIN INTRAVENOUS SOLUTION 35 MGML
MB PA
VANTAS IMPLANT KIT 50 MG (50 MCGDAY)
MB LA
VECTIBIX INTRAVENOUS SOLUTION 100 MG5 ML (20 MGML) 400 MG20 ML (20 MGML)
MB PA LA
VELCADE INJECTION RECON SOLN 35 MG MB LA
VENCLEXTA ORAL TABLET 10 MG 100 MG 50 MG
2 PA ST OCh
VENCLEXTA STARTING PACK ORAL TABLETSDOSE PACK 10 MG-50 MG- 100 MG
2 PA OCh
VERZENIO ORAL TABLET 100 MG 150 MG 200 MG 50 MG
2 PA ST OCh LA
VIDAZA INJECTION RECON SOLN 100 MG MB PA LA
VITRAKVI ORAL CAPSULE 100 MG 2 PA OCh LA
VITRAKVI ORAL CAPSULE 25 MG 2 PA ST OCh LA
VITRAKVI ORAL SOLUTION 20 MGML 2 PA OCh LA
VOTRIENT ORAL TABLET 200 MG 2 PA ST OCh LA
VYXEOS INTRAVENOUS RECON SOLN 44-100 MG
MB PA
XALKORI ORAL CAPSULE 200 MG 250 MG 2 PA OCh LA
XERMELO ORAL TABLET 250 MG 2 PA ST
XOSPATA ORAL TABLET 40 MG 2 PA OCh
XTANDI ORAL CAPSULE 40 MG 2 PA OCh LA
XTANDI ORAL TABLET 40 MG 80 MG 2 PA OCh LA
YERVOY INTRAVENOUS SOLUTION 200 MG40 ML (5 MGML) 50 MG10 ML (5 MGML)
MB PA LA
YESCARTA INTRAVENOUS SUSPENSION MB PA
YONDELIS INTRAVENOUS RECON SOLN 1 MG
MB PA
YONSA ORAL TABLET 125 MG 2 PA OCh LA
ZALTRAP INTRAVENOUS SOLUTION 100 MG4 ML (25 MGML) 200 MG8 ML (25 MGML)
MB PA LA
ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM
MB
24
Drug Name Drug Tier Requirements Limits
ZEJULA ORAL CAPSULE 100 MG 2 OCh
ZELBORAF ORAL TABLET 240 MG 2 PA ST OCh LA
ZOLADEX SUBCUTANEOUS IMPLANT 108 MG 36 MG
MB LA
ZOLINZA ORAL CAPSULE 100 MG 2 PA ST OCh LA
ZYKADIA ORAL TABLET 150 MG 2 PA ST OCh LA
AUTONOMIC amp CNS DRUGS NEUROLOGY amp PSYCH
ANTICONVULSANTS
BANZEL ORAL TABLET 200 MG 400 MG 1 PA ST
BRIVIACT ORAL SOLUTION 10 MGML 1 ST QL (150 per 30 days)
BRIVIACT ORAL TABLET 10 MG 100 MG 25 MG 50 MG 75 MG
1 ST QL (60 per 30 days)
carbamazepine oral capsule er multiphase 12 hr 100 mg 200 mg 300 mg
1
carbamazepine oral suspension 100 mg5 ml 200 mg10 ml
1
carbamazepine oral tablet 200 mg 1
carbamazepine oral tablet extended release 12 hr 100 mg 200 mg 400 mg
1
carbamazepine oral tabletchewable 100 mg 1
CELONTIN ORAL CAPSULE 300 MG 1
clobazam oral suspension 25 mgml 1
clobazam oral tablet 10 mg 20 mg 1
clonazepam oral tablet 05 mg 1 mg 2 mg 1
clonazepam oral tabletdisintegrating 0125 mg 025 mg 05 mg 1 mg 2 mg
1
diazepam rectal kit 25 mg 1
DILANTIN EXTENDED ORAL CAPSULE 100 MG
1
DILANTIN INFATABS ORAL TABLETCHEWABLE 50 MG
1
DILANTIN ORAL CAPSULE 30 MG 1
DILANTIN-125 ORAL SUSPENSION 125 MG5 ML
1
divalproex oral capsule delayed rel sprinkle 125 mg
1
divalproex oral tablet extended release 24 hr 250 mg 500 mg
1
25
Drug Name Drug Tier Requirements Limits
divalproex oral tabletdelayed release (drec) 125 mg 250 mg 500 mg
1
EPIDIOLEX ORAL SOLUTION 100 MGML 2 PA LA QL (400 per 30 days)
epitol oral tablet 200 mg 1
ethosuximide oral capsule 250 mg 1
ethosuximide oral solution 250 mg5 ml 1
felbamate oral suspension 600 mg5 ml 1
felbamate oral tablet 400 mg 600 mg 1
FINTEPLA ORAL SOLUTION 22 MGML 2
gabapentin oral capsule 100 mg 300 mg 400 mg 1
gabapentin oral solution 250 mg5 ml 300 mg6 ml (6 ml)
1
gabapentin oral tablet 600 mg 800 mg 1
lamotrigine oral tablet 100 mg 150 mg 200 mg 25 mg
1
lamotrigine oral tablet disintegrating dose pk 25 mg (21) -50 mg (7) 25 mg(14)-50 mg (14)-100 mg (7) 50 mg (42) -100 mg (14)
1
lamotrigine oral tablet extended release 24hr 100 mg 200 mg 25 mg 250 mg 300 mg 50 mg
1
lamotrigine oral tablet chewable dispersible 25 mg 5 mg
1
lamotrigine oral tabletdisintegrating 100 mg 200 mg 25 mg 50 mg
1
lamotrigine oral tabletsdose pack 25 mg (35) 25 mg (42) -100 mg (7) 25 mg (84) -100 mg (14)
1
levetiracetam oral solution 100 mgml 500 mg5 ml (5 ml)
1
levetiracetam oral tablet 1000 mg 250 mg 500 mg 750 mg
1
levetiracetam oral tablet extended release 24 hr 500 mg 750 mg
1
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG 330 MG 825 MG
1 PA ST
oxcarbazepine oral suspension 300 mg5 ml (60 mgml)
1
oxcarbazepine oral tablet 150 mg 300 mg 600 mg 1
phenobarbital oral elixir 20 mg5 ml (4 mgml) 1
26
Drug Name Drug Tier Requirements Limits
phenobarbital oral tablet 100 mg 15 mg 162 mg 30 mg 324 mg 60 mg 648 mg 972 mg
1
phenytoin oral suspension 100 mg4 ml 125 mg5 ml
1
phenytoin oral tabletchewable 50 mg 1
phenytoin sodium extended oral capsule 100 mg 200 mg 300 mg
1
pregabalin oral capsule 100 mg 150 mg 200 mg 225 mg 25 mg 300 mg 50 mg 75 mg
1 PA ST
pregabalin oral solution 20 mgml 1 PA ST
pregabalin oral tablet extended release 24 hr 165 mg 330 mg 825 mg
1 PA ST
primidone oral tablet 250 mg 50 mg 1
roweepra oral tablet 1000 mg 500 mg 750 mg 1
rufinamide oral suspension 40 mgml 1 PA
rufinamide oral tablet 200 mg 400 mg 1 PA
subvenite oral tablet 100 mg 150 mg 200 mg 25 mg
1
subvenite starter (blue) kit oral tabletsdose pack 25 mg (35)
1
subvenite starter (green) kit oral tabletsdose pack 25 mg (84) -100 mg (14)
1
subvenite starter (orange) kit oral tabletsdose pack 25 mg (42) -100 mg (7)
1
SYMPAZAN ORAL FILM 10 MG 20 MG 5 MG 1 PA QL (30 per 30 days)
tiagabine oral tablet 12 mg 16 mg 2 mg 4 mg 1
topiramate oral capsule sprinkle 15 mg 25 mg 1
topiramate oral tablet 100 mg 200 mg 25 mg 50 mg
1
valproic acid (as sodium salt) oral solution 250 mg5 ml 500 mg10 ml (10 ml)
1
valproic acid oral capsule 250 mg 1
vigabatrin oral powder in packet 500 mg 2 PA LA
vigabatrin oral tablet 500 mg 2 PA LA
vigadrone oral powder in packet 500 mg 2 PA ST
VIMPAT ORAL SOLUTION 10 MGML 1 PA ST QL (6 per 30 days)
VIMPAT ORAL TABLET 100 MG 150 MG 200 MG 50 MG
1 ST QL (60 per 30 days)
27
Drug Name Drug Tier Requirements Limits
XCOPRI MAINTENANCE PACK ORAL TABLET 250 MGDAY (200 MG X1-50 MG X1) 350 MGDAY (200 MG X1-150MG X1)
2
XCOPRI MAINTENANCE PACK ORAL TABLET 250MGDAY(150 MG X1-100MG X1)
2 PA ST
XCOPRI ORAL TABLET 100 MG 150 MG 200 MG 50 MG
2
XCOPRI TITRATION PACK ORAL TABLETSDOSE PACK 125 MG (14)- 25 MG (14) 150 MG (14)- 200 MG (14) 50 MG (14)- 100 MG (14)
2
zonisamide oral capsule 100 mg 25 mg 50 mg 1
ANTIPARKINSONISM AGENTS
APOKYN SUBCUTANEOUS CARTRIDGE 10 MGML
2 PA LA QL (1 per 30 days)
benztropine injection solution 1 mgml 1
benztropine oral tablet 05 mg 1 mg 2 mg 1
bromocriptine oral capsule 5 mg 1
bromocriptine oral tablet 25 mg 1
carbidopa oral tablet 25 mg 1
carbidopa-levodopa oral tablet 10-100 mg 25-100 mg 25-250 mg
1
carbidopa-levodopa oral tablet extended release 25-100 mg 50-200 mg
1
carbidopa-levodopa oral tabletdisintegrating 10-100 mg 25-100 mg 25-250 mg
1
carbidopa-levodopa-entacapone oral tablet 125-50-200 mg 1875-75-200 mg 25-100-200 mg 3125-125-200 mg 375-150-200 mg 50-200-200 mg
1
entacapone oral tablet 200 mg 1
pramipexole oral tablet 0125 mg 025 mg 05 mg 075 mg 1 mg 15 mg
1
pramipexole oral tablet extended release 24 hr 0375 mg 075 mg 15 mg 225 mg 3 mg 375 mg 45 mg
1
rasagiline oral tablet 05 mg 1 mg 1
ropinirole oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg 5 mg
1
28
Drug Name Drug Tier Requirements Limits
ropinirole oral tablet extended release 24 hr 12 mg 2 mg 4 mg 6 mg 8 mg
1
selegiline hcl oral capsule 5 mg 1
selegiline hcl oral tablet 5 mg 1
tolcapone oral tablet 100 mg 1
trihexyphenidyl oral elixir 04 mgml 1
trihexyphenidyl oral tablet 2 mg 5 mg 1
MIGRAINE amp CLUSTER HEADACHE THERAPY
AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MGML 70 MGML
1 PA ST
AJOVY AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 225 MG15 ML
1 ST
AJOVY SYRINGE SUBCUTANEOUS SYRINGE 225 MG15 ML
1 PA ST
almotriptan malate oral tablet 125 mg 625 mg 1 QL (18 per 30 days)
dihydroergotamine injection solution 1 mgml 1
dihydroergotamine nasal spraynon-aerosol 05 mgpump act (4 mgml)
1 QL (8 per 30 days)
eletriptan oral tablet 20 mg 40 mg 1 QL (18 per 30 days)
EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MGML
1 PA ST
EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MGML 300 MG3 ML (100 MGML X 3)
1 PA ST
ergotamine-caffeine oral tablet 1-100 mg 1
frovatriptan oral tablet 25 mg 1 QL (18 per 30 days)
migergot rectal suppository 2-100 mg 1
naratriptan oral tablet 1 mg 25 mg 1 QL (18 per 30 days)
ONZETRA XSAIL NASAL AEROSOL POWDR BREATH ACTIVATED 11 MG
1 ST QL (16 per 30 days)
rizatriptan oral tablet 10 mg 5 mg 1 QL (18 per 30 days)
rizatriptan oral tabletdisintegrating 10 mg 5 mg 1 QL (18 per 30 days)
sumatriptan nasal spraynon-aerosol 20 mgactuation 5 mgactuation
1 QL (18 per 30 days)
sumatriptan succinate oral tablet 100 mg 25 mg 50 mg
1 QL (18 per 30 days)
sumatriptan succinate subcutaneous cartridge 4 mg05 ml 6 mg05 ml
1 QL (8 per 30 days)
29
Drug Name Drug Tier Requirements Limits
sumatriptan succinate subcutaneous pen injector 4 mg05 ml 6 mg05 ml
1 QL (8 per 30 days)
sumatriptan succinate subcutaneous solution 6 mg05 ml
1 QL (8 per 30 days)
sumatriptan succinate subcutaneous syringe 6 mg05 ml
1 QL (8 per 30 days)
UBRELVY ORAL TABLET 100 MG 50 MG 1 QL (16 per 30 days)
VYEPTI INTRAVENOUS SOLUTION 100 MGML
MB PA
zolmitriptan oral tablet 25 mg 5 mg 1 QL (18 per 30 days)
zolmitriptan oral tabletdisintegrating 25 mg 5 mg
1 QL (18 per 30 days)
ZOMIG NASAL SPRAYNON-AEROSOL 25 MG 5 MG
1 ST QL (18 per 30 days)
MISCELLANEOUS NEUROLOGICAL THERAPY
AUSTEDO ORAL TABLET 12 MG 6 MG 9 MG
2 PA LA
dalfampridine oral tablet extended release 12 hr 10 mg
2 PA LA QL (60 per 30 days)
donepezil oral tablet 10 mg 23 mg 5 mg 1
donepezil oral tabletdisintegrating 10 mg 5 mg 1
EXONDYS-51 INTRAVENOUS SOLUTION 50 MGML
MB PA
galantamine oral capsuleext rel pellets 24 hr 16 mg 24 mg 8 mg
1
galantamine oral solution 4 mgml 1
galantamine oral tablet 12 mg 4 mg 8 mg 1
memantine oral capsulesprinkleer 24hr 14 mg 21 mg 28 mg 7 mg
1
memantine oral solution 2 mgml 1
memantine oral tablet 10 mg 5 mg 1
NUEDEXTA ORAL CAPSULE 20-10 MG 1
ONPATTRO INTRAVENOUS SOLUTION 2 MGML
MB PA
RADICAVA INTRAVENOUS SOLUTION 30 MG100 ML
MB PA
rivastigmine tartrate oral capsule 15 mg 3 mg 45 mg 6 mg
1
30
Drug Name Drug Tier Requirements Limits
rivastigmine transdermal patch 24 hour 133 mg24 hour 46 mg24 hour 95 mg24 hour
1
tetrabenazine oral tablet 125 mg 25 mg 2 LA
TYSABRI INTRAVENOUS SOLUTION 300 MG15 ML
MB PA ST LA
VYONDYS-53 INTRAVENOUS SOLUTION 50 MGML
MB PA
ZOLGENSMA INTRAVENOUS KIT 2 X 10EXP13 VGML
MB LA
MUSCLE RELAXANTS amp ANTISPASMODIC THERAPY
baclofen oral tablet 10 mg 20 mg 5 mg 1
carisoprodol oral tablet 250 mg 350 mg 1
carisoprodol-aspirin oral tablet 200-325 mg 1
carisoprodol-aspirin-codeine oral tablet 200-325-16 mg
1 PA ST
chlorzoxazone oral tablet 250 mg 375 mg 750 mg 1 ST
chlorzoxazone oral tablet 500 mg 1
cyclobenzaprine oral tablet 10 mg 5 mg 75 mg 1
dantrolene oral capsule 100 mg 25 mg 50 mg 1
meprobamate oral tablet 200 mg 400 mg 1
metaxalone oral tablet 400 mg 800 mg 1
methocarbamol oral tablet 500 mg 750 mg 1
orphenadrine citrate injection solution 30 mgml 1
orphenadrine citrate oral tablet extended release 100 mg
1
pyridostigmine bromide oral syrup 60 mg5 ml 1
pyridostigmine bromide oral tablet 60 mg 1
pyridostigmine bromide oral tablet extended release 180 mg
1
tizanidine oral capsule 2 mg 4 mg 6 mg 1
tizanidine oral tablet 2 mg 4 mg 1
vanadom oral tablet 350 mg 1
NARCOTIC ANALGESICS
acetaminophen-caff-dihydrocod oral capsule 3205-30-16 mg
1 PA ST
acetaminophen-caff-dihydrocod oral tablet 325-30-16 mg
1 PA ST
31
Drug Name Drug Tier Requirements Limits
acetaminophen-codeine oral solution 120-12 mg5 ml 300 mg-30 mg 125 ml
1 PA ST
acetaminophen-codeine oral tablet 300-15 mg 300-30 mg 300-60 mg
1 PA ST
ascomp with codeine oral capsule 30-50-325-40 mg
1 PA ST
buprenorphine hcl injection solution 03 mgml 1 PA ST
buprenorphine hcl injection syringe 03 mgml 1 PA ST
buprenorphine hcl sublingual tablet 2 mg 8 mg 1
buprenorphine transdermal patch weekly 10 mcghour 15 mcghour 20 mcghour 5 mcghour 75 mcghour
1
butalbital compound wcodeine oral capsule 30-50-325-40 mg
1 PA ST
butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg 50-325-40-30 mg
1 PA ST
butalbital-acetaminophen-caff oral capsule 50-300-40 mg 50-325-40 mg
1
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
1
butalbital-aspirin-caffeine oral capsule 50-325-40 mg
1
butalbital-aspirin-caffeine oral tablet 50-325-40 mg
1
codeine sulfate oral tablet 15 mg 30 mg 60 mg 1 PA ST
codeine-butalbital-asa-caff oral capsule 30-50-325-40 mg
1 PA ST
diskets oral tabletsoluble 40 mg 1 PA ST
DSUVIA SUBLINGUAL TABLET IN APPLICATOR 30 MCG
MB
duramorph (pf) injection solution 05 mgml 1 mgml
MB PA ST
dvorah oral tablet 325-30-16 mg 1 PA ST
endocet oral tablet 10-325 mg 25-325 mg 5-325 mg 75-325 mg
1 PA ST
fentanyl citrate buccal lozenge on a handle 1200 mcg 1600 mcg 200 mcg 400 mcg 600 mcg 800 mcg
1 PA
32
Drug Name Drug Tier Requirements Limits
fentanyl transdermal patch 72 hour 100 mcghr 12 mcghr 25 mcghr 375 mcghour 50 mcghr 625 mcghour 75 mcghr 875 mcghour
1 PA ST
hydrocodone bitartrate oral capsule oral only er 12hr 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg
1 PA ST QL (60 per 30 days)
hydrocodone bitartrate oral tabletoral onlyextrel24 hr 100 mg 120 mg 20 mg 30 mg 40 mg 60 mg 80 mg
1 PA ST
hydrocodone-acetaminophen oral solution 10-325 mg15 ml(15 ml) 75-325 mg15 ml
1 PA ST
hydrocodone-acetaminophen oral tablet 10-300 mg 10-325 mg 5-300 mg 5-325 mg 75-300 mg 75-325 mg
1 PA ST
hydrocodone-ibuprofen oral tablet 10-200 mg 5-200 mg 75-200 mg
1 PA ST
HYDROMORPHONE INJECTION SYRINGE 05 MG05 ML
1 PA ST
hydromorphone oral liquid 1 mgml 1 PA ST
hydromorphone oral tablet 2 mg 4 mg 8 mg 1 PA ST
hydromorphone oral tablet extended release 24 hr 12 mg 16 mg 32 mg 8 mg
1 PA ST QL (60 per 30 days)
hydromorphone rectal suppository 3 mg 1 PA ST
levorphanol tartrate oral tablet 2 mg 3 mg 1 PA ST
meperidine oral solution 50 mg5 ml 1 PA ST
meperidine oral tablet 50 mg 1 PA ST
methadone injection solution 10 mgml 1 PA ST
methadone oral concentrate 10 mgml 1 PA ST
methadone oral solution 10 mg5 ml 5 mg5 ml 1 PA ST
methadone oral tablet 10 mg 5 mg 1 PA ST
methadone oral tabletsoluble 40 mg 1 PA ST
methadose oral concentrate 10 mgml 1 PA ST
methadose oral tabletsoluble 40 mg 1 PA ST
morphine (pf) injection solution 05 mgml MB PA ST
morphine concentrate oral solution 100 mg5 ml (20 mgml)
1 PA ST
morphine oral capsule er multiphase 24 hr 120 mg 30 mg 45 mg 60 mg 75 mg 90 mg
1 PA ST QL (60 per 30 days)
morphine oral capsuleextendrelease pellets 10 mg 100 mg 20 mg 50 mg 80 mg
1 PA ST QL (90 per 30 days)
33
Drug Name Drug Tier Requirements Limits
morphine oral capsuleextendrelease pellets 30 mg 60 mg
1 PA ST QL (60 per 30 days)
morphine oral capsuleextendrelease pellets 40 mg
1 PA QL (90 per 30 days)
morphine oral solution 10 mg5 ml 20 mg5 ml (4 mgml)
1 PA ST
morphine oral tablet 15 mg 30 mg 1 PA ST
morphine oral tablet extended release 100 mg 15 mg 200 mg 30 mg 60 mg
1 PA ST QL (120 per 30 days)
morphine rectal suppository 10 mg 20 mg 30 mg 5 mg
1 PA ST
oxycodone oral capsule 5 mg 1 PA ST
oxycodone oral concentrate 20 mgml 1 PA ST
oxycodone oral solution 5 mg5 ml 1 PA ST
oxycodone oral tablet 10 mg 15 mg 20 mg 30 mg 5 mg
1 PA ST
oxycodone-acetaminophen oral tablet 10-325 mg 25-300 mg 25-325 mg 5-325 mg 75-325 mg
1 PA ST
oxycodone-aspirin oral tablet 48355-325 mg 1 PA ST
OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 10 MG 15 MG 20 MG 30 MG 40 MG
1 PA ST QL (90 per 30 days)
OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 60 MG 80 MG
1 PA ST QL (120 per 30 days)
oxymorphone oral tablet 10 mg 5 mg 1 PA ST
oxymorphone oral tablet extended release 12 hr 10 mg 15 mg 20 mg 30 mg 40 mg 5 mg 75 mg
1 PA ST QL (90 per 30 days)
SUBLOCADE SUBCUTANEOUS SOLUTION EXTENDED REL SYRINGE 100 MG05 ML 300 MG15 ML
MB
tencon oral tablet 50-325 mg 1
NON-NARCOTIC ANALGESICS
adult aspirin regimen oral tabletdelayed release (drec) 81 mg
ACA PV
aspirin low dose oral tabletdelayed release (drec) 81 mg
ACA PV
aspirin oral tablet 325 mg ACA PV
aspirin oral tabletchewable 81 mg ACA PV
34
Drug Name Drug Tier Requirements Limits
aspirin oral tabletdelayed release (drec) 325 mg 81 mg
ACA PV
aspir-trin oral tabletdelayed release (drec) 325 mg
ACA PV
bayer aspirin oral tablet 325 mg ACA PV
BAYER CHEWABLE ASPIRIN ORAL TABLETCHEWABLE 81 MG
ACA PV
buprenorphine-naloxone sublingual film 12-3 mg 1 QL (60 per 30 days)
buprenorphine-naloxone sublingual film 2-05 mg 4-1 mg 8-2 mg
1 QL (90 per 30 days)
buprenorphine-naloxone sublingual tablet 2-05 mg 8-2 mg
1 QL (90 per 30 days)
butorphanol nasal spraynon-aerosol 10 mgml 1 PA ST QL (5 per 30 days)
cataflam oral tablet 50 mg 1
celecoxib oral capsule 100 mg 200 mg 400 mg 50 mg
1
childrens aspirin oral tabletchewable 81 mg ACA PV
cholinemagnesium salicylate oral liquid 500 mg5 ml
1
diclofenac potassium oral tablet 50 mg 1
diclofenac sodium oral tablet extended release 24 hr 100 mg
1
diclofenac sodium oral tabletdelayed release (drec) 25 mg 50 mg 75 mg
1
diclofenac sodium topical drops 15 1
diclofenac sodium topical gel 1 1
diclofenac-misoprostol oral tabletirdelayed relbiphasic 50-200 mg-mcg 75-200 mg-mcg
1
diflunisal oral tablet 500 mg 1
DUEXIS ORAL TABLET 800-266 MG 1 ST
ecotrin low strength oral tabletdelayed release (drec) 81 mg
ACA PV
ecotrin oral tabletdelayed release (drec) 325 mg ACA PV
etodolac oral capsule 200 mg 300 mg 1
etodolac oral tablet 400 mg 500 mg 1
etodolac oral tablet extended release 24 hr 400 mg 500 mg 600 mg
1
EUFLEXXA INTRA-ARTICULAR SYRINGE 10 MGML(MW 24 -36 MILLION)
MB
35
Drug Name Drug Tier Requirements Limits
fenoprofen oral tablet 600 mg 1
flurbiprofen oral tablet 100 mg 1
ibu oral tablet 400 mg 600 mg 800 mg 1
ibuprofen oral suspension 100 mg5 ml 1
ibuprofen oral tablet 400 mg 600 mg 800 mg 1
indomethacin oral capsule 25 mg 50 mg 1
indomethacin oral capsule extended release 75 mg
1
ketoprofen oral capsule 25 mg 50 mg 75 mg 1
ketoprofen oral capsuleext rel pellets 24 hr 200 mg
1
ketorolac injection cartridge 15 mgml 30 mgml 1
ketorolac injection solution 15 mgml 30 mgml MB
ketorolac injection solution 30 mgml (1 ml) 1
ketorolac intramuscular cartridge 60 mg2 ml 1
ketorolac intramuscular solution 60 mg2 ml 1
ketorolac intramuscular syringe 60 mg2 ml 1
ketorolac oral tablet 10 mg 1
meclofenamate oral capsule 100 mg 50 mg 1
mefenamic acid oral capsule 250 mg 1
meloxicam oral tablet 15 mg 75 mg 1
MONOVISC INTRA-ARTICULAR SYRINGE 88 MG4 ML
MB LA
nabumetone oral tablet 500 mg 750 mg 1
nalbuphine injection solution 10 mgml MB PA ST
naloxone injection solution 04 mgml 1
naloxone injection syringe 04 mgml 1 mgml 1
naltrexone oral tablet 50 mg 1
naproxen oral suspension 125 mg5 ml 1
naproxen oral tablet 250 mg 375 mg 500 mg 1
naproxen oral tabletdelayed release (drec) 375 mg 500 mg
1
naproxen sodium oral tablet 275 mg 550 mg 1
NARCAN NASAL SPRAYNON-AEROSOL 4 MGACTUATION
1
36
Drug Name Drug Tier Requirements Limits
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG 150 MG 200 MG 250 MG 50 MG
1 PA ST QL (60 per 30 days)
ORTHOVISC INTRA-ARTICULAR SYRINGE 30 MG2 ML
MB
oxaprozin oral tablet 600 mg 1
pentazocine-naloxone oral tablet 50-05 mg 1 PA ST
piroxicam oral capsule 10 mg 20 mg 1
salsalate oral tablet 500 mg 750 mg 1
st joseph aspirin oral tabletchewable 81 mg ACA PV
st joseph aspirin oral tabletdelayed release (drec) 81 mg
ACA PV
sulindac oral tablet 150 mg 200 mg 1
tolmetin oral capsule 400 mg 1
tolmetin oral tablet 200 mg 600 mg 1
tramadol oral tablet 50 mg 1 PA ST
tramadol oral tablet extended release 24 hr 100 mg 200 mg 300 mg
1 PA ST
tramadol oral tablet er multiphase 24 hr 100 mg 200 mg 300 mg
1 PA ST
tramadol-acetaminophen oral tablet 375-325 mg 1 PA ST
VIVITROL INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 380 MG
MB
PSYCHOTHERAPEUTIC DRUGS
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 300 MG 400 MG
1
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 300 MG 400 MG
1
ADHANSIA XR ORAL CAPSULE ER BIPHASIC 20-80 25 MG 35 MG 45 MG 55 MG 70 MG 85 MG
1 PA ST
ADZENYS ER ORAL SUSPEN IR - ER BIPHASIC 24HR 125 MGML
1 ST
ADZENYS XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 125 MG 157 MG 188 MG 31 MG 63 MG 94 MG
1 ST
37
Drug Name Drug Tier Requirements Limits
alprazolam intensol oral concentrate 1 mgml 1
alprazolam oral tablet 025 mg 05 mg 1 mg 2 mg
1
alprazolam oral tablet extended release 24 hr 05 mg 1 mg 2 mg 3 mg
1
alprazolam oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg
1
amitriptyline oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
amitriptyline-chlordiazepoxide oral tablet 125-5 mg 25-10 mg
1
amoxapine oral tablet 100 mg 150 mg 25 mg 50 mg
1
AMPHETAMINE ORAL SUSPEN IR - ER BIPHASIC 24HR 125 MGML
1 ST
amphetamine sulfate oral tablet 10 mg 5 mg 1
APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG 348 MG 522 MG
1 ST
aripiprazole oral solution 1 mgml 1
aripiprazole oral tablet 10 mg 15 mg 2 mg 20 mg 30 mg 5 mg
1
aripiprazole oral tabletdisintegrating 10 mg 15 mg
1
ARISTADA INITIO INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 675 MG24 ML
MB
ARISTADA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 1064 MG39 ML 441 MG16 ML 662 MG24 ML 882 MG32 ML
MB
armodafinil oral tablet 150 mg 200 mg 250 mg 50 mg
1
asenapine maleate sublingual tablet 10 mg 25 mg 5 mg
1
atomoxetine oral capsule 10 mg 100 mg 18 mg 25 mg 40 mg 60 mg 80 mg
1
BELSOMRA ORAL TABLET 10 MG 15 MG 20 MG 5 MG
1 ST
bupropion hcl oral tablet 100 mg 75 mg 1
bupropion hcl oral tablet extended release 24 hr 150 mg 300 mg
1
38
Drug Name Drug Tier Requirements Limits
bupropion hcl oral tablet sustained-release 12 hr 100 mg 150 mg 200 mg
1
buspirone oral tablet 10 mg 15 mg 30 mg 5 mg 75 mg
1
chlordiazepoxide hcl oral capsule 10 mg 25 mg 5 mg
1
chlorpromazine injection solution 25 mgml 1
chlorpromazine oral tablet 10 mg 100 mg 200 mg 25 mg 50 mg
1
citalopram oral solution 10 mg5 ml 1
citalopram oral tablet 10 mg 20 mg 40 mg 1
clomipramine oral capsule 25 mg 50 mg 75 mg 1
clonidine hcl oral tablet extended release 12 hr 01 mg
1
clorazepate dipotassium oral tablet 15 mg 375 mg 75 mg
1
clozapine oral tablet 100 mg 200 mg 25 mg 50 mg
1
clozapine oral tabletdisintegrating 100 mg 125 mg 150 mg 200 mg 25 mg
1
COTEMPLA XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 173 MG 259 MG 86 MG
1 ST
DAYTRANA TRANSDERMAL PATCH 24 HOUR 10 MG9 HR 15 MG9 HR 20 MG9 HR 30 MG9 HR
1 ST
desipramine oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG 50 MG
1 ST
desvenlafaxine succinate oral tablet extended release 24 hr 100 mg 25 mg 50 mg
1
dexmethylphenidate oral capsuleer biphasic 50-50 10 mg 15 mg 20 mg 25 mg 30 mg 35 mg 40 mg 5 mg
1
dexmethylphenidate oral tablet 10 mg 25 mg 5 mg
1
dextroamphetamine oral capsule extended release 10 mg 15 mg 5 mg
1
dextroamphetamine oral solution 5 mg5 ml 1
39
Drug Name Drug Tier Requirements Limits
dextroamphetamine oral tablet 10 mg 5 mg 1
dextroamphetamine-amphetamine oral capsuleextended release 24hr 10 mg 15 mg 20 mg 25 mg 30 mg 5 mg
1
dextroamphetamine-amphetamine oral tablet 10 mg 125 mg 15 mg 20 mg 30 mg 5 mg 75 mg
1
diazepam injection solution 5 mgml MB
diazepam injection syringe 5 mgml MB
diazepam intensol oral concentrate 5 mgml 1
diazepam oral solution 5 mg5 ml (1 mgml) 1
diazepam oral tablet 10 mg 2 mg 5 mg 1
doxepin oral capsule 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
doxepin oral concentrate 10 mgml 1
duloxetine oral capsuledelayed release(drec) 20 mg 30 mg 40 mg 60 mg
1
DYANAVEL XR ORAL SUSPEN IR - ER BIPHASIC 24HR 25 MGML
1 ST
EDLUAR SUBLINGUAL TABLET 10 MG 5 MG
1 ST
EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG24 HR 6 MG24 HR 9 MG24 HR
1 ST
ergoloid oral tablet 1 mg 1
escitalopram oxalate oral solution 5 mg5 ml 1
escitalopram oxalate oral tablet 10 mg 20 mg 5 mg
1
estazolam oral tablet 1 mg 2 mg 1
eszopiclone oral tablet 1 mg 2 mg 3 mg 1
FANAPT ORAL TABLET 1 MG 10 MG 12 MG 2 MG 4 MG 6 MG 8 MG
1 PA ST
FANAPT ORAL TABLETSDOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)
1 PA ST
FETZIMA ORAL CAPSULEEXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)
1 ST
FETZIMA ORAL CAPSULEEXTENDED RELEASE 24 HR 120 MG 20 MG 40 MG 80 MG
1 ST
fluoxetine oral capsule 10 mg 20 mg 40 mg 1
40
Drug Name Drug Tier Requirements Limits
fluoxetine oral capsuledelayed release(drec) 90 mg
1
fluoxetine oral solution 20 mg5 ml (4 mgml) 1
fluoxetine oral tablet 10 mg 20 mg 1
fluoxetine oral tablet 60 mg 1 PA
fluphenazine hcl injection solution 25 mgml 1
fluphenazine hcl oral concentrate 5 mgml 1
fluphenazine hcl oral elixir 25 mg5 ml 1
fluphenazine hcl oral tablet 1 mg 10 mg 25 mg 5 mg
1
flurazepam oral capsule 15 mg 30 mg 1
fluvoxamine oral capsuleextended release 24hr 100 mg 150 mg
1
fluvoxamine oral tablet 100 mg 25 mg 50 mg 1
guanfacine oral tablet extended release 24 hr 1 mg 2 mg 3 mg 4 mg
1
haloperidol decanoate intramuscular solution 100 mgml 50 mgml
1
haloperidol lactate injection solution 5 mgml 1
haloperidol lactate oral concentrate 2 mgml 1
haloperidol oral tablet 05 mg 1 mg 10 mg 2 mg 20 mg 5 mg
1
HETLIOZ LQ ORAL SUSPENSION 4 MGML 2 PA ST LA
HETLIOZ ORAL CAPSULE 20 MG 2 PA ST LA
imipramine hcl oral tablet 10 mg 25 mg 50 mg 1
imipramine pamoate oral capsule 100 mg 125 mg 150 mg 75 mg
1
INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG075 ML 156 MGML 234 MG15 ML 39 MG025 ML 78 MG05 ML
1
JORNAY PM ORAL CAPSULEDEL RELEXT REL SPRINK 100 MG 20 MG 40 MG 60 MG 80 MG
1 ST
LATUDA ORAL TABLET 120 MG 20 MG 40 MG 60 MG 80 MG
1 PA ST
lithium carbonate oral capsule 150 mg 300 mg 600 mg
1
lithium carbonate oral tablet 300 mg 1
41
Drug Name Drug Tier Requirements Limits
lithium carbonate oral tablet extended release 300 mg 450 mg
1
lorazepam intensol oral concentrate 2 mgml 1
lorazepam oral concentrate 2 mgml 1
lorazepam oral tablet 05 mg 1 mg 2 mg 1
loxapine succinate oral capsule 10 mg 25 mg 5 mg 50 mg
1
maprotiline oral tablet 25 mg 50 mg 75 mg 1
MARPLAN ORAL TABLET 10 MG 1
methamphetamine oral tablet 5 mg 1
METHYLIN ORAL SOLUTION 10 MG5 ML 5 MG5 ML
1
methylphenidate hcl oral caper sprinklebiphasic 40-60 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg 60 mg
1
methylphenidate hcl oral capsule er biphasic 30-70 10 mg 20 mg 30 mg 40 mg 50 mg 60 mg
1
methylphenidate hcl oral capsuleer biphasic 50-50 10 mg 20 mg 30 mg 40 mg 60 mg
1
methylphenidate hcl oral solution 10 mg5 ml 5 mg5 ml
1
methylphenidate hcl oral tablet 10 mg 20 mg 5 mg
1
methylphenidate hcl oral tablet extended release 10 mg 20 mg
1
methylphenidate hcl oral tablet extended release 24hr 18 mg 27 mg 36 mg 54 mg
1
methylphenidate hcl oral tabletchewable 10 mg 25 mg 5 mg
1
midazolam oral syrup 2 mgml 1
mirtazapine oral tablet 15 mg 30 mg 45 mg 75 mg
1
mirtazapine oral tabletdisintegrating 15 mg 30 mg 45 mg
1
modafinil oral tablet 100 mg 200 mg 1
molindone oral tablet 10 mg 25 mg 5 mg 1
MYDAYIS ORAL CAPSULE ER TRIPHASIC 24 HR 125 MG 25 MG 375 MG 50 MG
1 ST
nefazodone oral tablet 100 mg 150 mg 200 mg 250 mg 50 mg
1
42
Drug Name Drug Tier Requirements Limits
nortriptyline oral capsule 10 mg 25 mg 50 mg 75 mg
1
nortriptyline oral solution 10 mg5 ml 1
NUPLAZID ORAL CAPSULE 34 MG 2 PA LA
NUPLAZID ORAL TABLET 10 MG 2 PA LA
olanzapine intramuscular recon soln 10 mg 1
olanzapine oral tablet 10 mg 15 mg 25 mg 20 mg 5 mg 75 mg
1
olanzapine oral tabletdisintegrating 10 mg 15 mg 20 mg 5 mg
1
olanzapine-fluoxetine oral capsule 12-25 mg 12-50 mg 3-25 mg 6-25 mg 6-50 mg
1
oxazepam oral capsule 10 mg 15 mg 30 mg 1
paliperidone oral tablet extended release 24hr 15 mg 3 mg 6 mg 9 mg
1
paroxetine hcl oral tablet 10 mg 20 mg 30 mg 40 mg
1
paroxetine hcl oral tablet extended release 24 hr 125 mg 25 mg 375 mg
1
paroxetine mesylate(menopsym) oral capsule 75 mg
1
perphenazine oral tablet 16 mg 2 mg 4 mg 8 mg 1
perphenazine-amitriptyline oral tablet 2-10 mg 2-25 mg 4-10 mg 4-25 mg 4-50 mg
1
phenelzine oral tablet 15 mg 1
pimozide oral tablet 1 mg 2 mg 1
procentra oral solution 5 mg5 ml 1
protriptyline oral tablet 10 mg 5 mg 1
quetiapine oral tablet 100 mg 200 mg 25 mg 300 mg 400 mg 50 mg
1
quetiapine oral tablet extended release 24 hr 150 mg 200 mg 300 mg 400 mg 50 mg
1
QUILLICHEW ER ORAL TABLETCHEWIR-ERBIPHASIC24HR 20 MG 30 MG 40 MG
1 ST
QUILLIVANT XR ORAL SUSPENSIONEXT REL 24HRRECON 5 MGML (25 MG5 ML)
1 ST
ramelteon oral tablet 8 mg 1
RELEXXII ORAL TABLET EXTENDED RELEASE 24HR 72 MG
1 ST
43
Drug Name Drug Tier Requirements Limits
REXULTI ORAL TABLET 025 MG 05 MG 1 MG 2 MG 3 MG 4 MG
1 PA ST
RISPERDAL CONSTA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 125 MG2 ML 25 MG2 ML 375 MG2 ML 50 MG2 ML
1
risperidone oral solution 1 mgml 1
risperidone oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg
1
risperidone oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg
1
seconal sodium oral capsule 100 mg 1
sertraline oral concentrate 20 mgml 1
sertraline oral tablet 100 mg 25 mg 50 mg 1
SPRAVATO NASAL SPRAYNON-AEROSOL 56 MG (28 MG X 2) 84 MG (28 MG X 3)
MB PA
SUNOSI ORAL TABLET 150 MG 1 PA QL (30 per 30 days)
SUNOSI ORAL TABLET 75 MG 1 PA QL (60 per 30 days)
temazepam oral capsule 15 mg 225 mg 30 mg 75 mg
1
thioridazine oral tablet 10 mg 100 mg 25 mg 50 mg
1
thiothixene oral capsule 1 mg 10 mg 2 mg 5 mg 1
tranylcypromine oral tablet 10 mg 1
trazodone oral tablet 100 mg 150 mg 300 mg 50 mg
1
triazolam oral tablet 0125 mg 025 mg 1
trifluoperazine oral tablet 1 mg 10 mg 2 mg 5 mg
1
trimipramine oral capsule 100 mg 25 mg 50 mg 1
TRINTELLIX ORAL TABLET 10 MG 20 MG 5 MG
1 ST
venlafaxine oral capsuleextended release 24hr 150 mg 375 mg 75 mg
1
venlafaxine oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg
1
venlafaxine oral tablet extended release 24hr 150 mg 225 mg 375 mg 75 mg
1
VERSACLOZ ORAL SUSPENSION 50 MGML 1 PA ST
44
Drug Name Drug Tier Requirements Limits
VRAYLAR ORAL CAPSULE 15 MG 3 MG 45 MG 6 MG
1 PA ST
VRAYLAR ORAL CAPSULEDOSE PACK 15 MG (1)- 3 MG (6)
1 PA ST
VYVANSE ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG 70 MG
1 PA ST
VYVANSE ORAL TABLETCHEWABLE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG
1 PA ST
XYREM ORAL SOLUTION 500 MGML 1 PA QL (540 per 30 days)
zaleplon oral capsule 10 mg 5 mg 1
ZENZEDI ORAL TABLET 15 MG 25 MG 20 MG 30 MG 75 MG
1 ST
ziprasidone hcl oral capsule 20 mg 40 mg 60 mg 80 mg
1
zolpidem oral tablet 10 mg 5 mg 1
zolpidem oral tabletext release multiphase 125 mg 625 mg
1
zolpidem sublingual tablet 175 mg 35 mg 1
ZOLPIMIST ORAL SPRAYNON-AEROSOL 5 MGSPRAY (01 ML)
1 ST
ZULRESSO INTRAVENOUS SOLUTION 5 MGML
MB
CARDIOVASCULAR HYPERTENSION amp LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone oral tablet 100 mg 200 mg 400 mg 1
disopyramide phosphate oral capsule 100 mg 150 mg
1
dofetilide oral capsule 125 mcg 250 mcg 500 mcg 1
flecainide oral tablet 100 mg 150 mg 50 mg 1
mexiletine oral capsule 150 mg 200 mg 250 mg 1
MULTAQ ORAL TABLET 400 MG 1
NORPACE CR ORAL CAPSULE EXTENDED RELEASE 100 MG 150 MG
1
pacerone oral tablet 100 mg 200 mg 400 mg 1
procainamide injection solution 100 mgml 500 mgml
MB
propafenone oral capsuleextended release 12 hr 225 mg 325 mg 425 mg
1
45
Drug Name Drug Tier Requirements Limits
propafenone oral tablet 150 mg 225 mg 300 mg 1
quinidine gluconate oral tablet extended release 324 mg
1
quinidine sulfate oral tablet 200 mg 300 mg 1
sorine oral tablet 120 mg 160 mg 240 mg 80 mg 1
sotalol af oral tablet 120 mg 160 mg 80 mg 1
sotalol oral tablet 120 mg 160 mg 240 mg 80 mg 1
ANTIHYPERTENSIVE THERAPY
acebutolol oral capsule 200 mg 400 mg 1
aliskiren oral tablet 150 mg 300 mg 1
amiloride oral tablet 5 mg 1
amiloride-hydrochlorothiazide oral tablet 5-50 mg 1
amlodipine oral tablet 10 mg 25 mg 5 mg 1
amlodipine-benazepril oral capsule 10-20 mg 10-40 mg 25-10 mg 5-10 mg 5-20 mg 5-40 mg
1 ST
amlodipine-olmesartan oral tablet 10-20 mg 10-40 mg 5-20 mg 5-40 mg
1 ST
amlodipine-valsartan oral tablet 10-160 mg 10-320 mg 5-160 mg 5-320 mg
1 ST
amlodipine-valsartan-hcthiazid oral tablet 10-160-125 mg 10-160-25 mg 10-320-25 mg 5-160-125 mg 5-160-25 mg
1
atenolol oral tablet 100 mg 25 mg 50 mg 1
atenolol-chlorthalidone oral tablet 100-25 mg 50-25 mg
1
benazepril oral tablet 10 mg 20 mg 40 mg 5 mg 1
benazepril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg 5-625 mg
1
betaxolol oral tablet 10 mg 20 mg 1
bisoprolol fumarate oral tablet 10 mg 5 mg 1
bisoprolol-hydrochlorothiazide oral tablet 10-625 mg 25-625 mg 5-625 mg
1
bumetanide injection solution 025 mgml 1
bumetanide oral tablet 05 mg 1 mg 2 mg 1
BYSTOLIC ORAL TABLET 10 MG 25 MG 20 MG 5 MG
1 ST
candesartan oral tablet 16 mg 32 mg 4 mg 8 mg 1
46
Drug Name Drug Tier Requirements Limits
candesartan-hydrochlorothiazid oral tablet 16-125 mg 32-125 mg 32-25 mg
1
captopril oral tablet 100 mg 125 mg 25 mg 50 mg
1
captopril-hydrochlorothiazide oral tablet 25-15 mg 25-25 mg 50-15 mg 50-25 mg
1
cartia xt oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg
1
carvedilol oral tablet 125 mg 25 mg 3125 mg 625 mg
1
carvedilol phosphate oral capsule er multiphase 24 hr 10 mg 20 mg 40 mg 80 mg
1
chlorthalidone oral tablet 25 mg 50 mg 1
clonidine hcl oral tablet 01 mg 02 mg 03 mg 1
clonidine transdermal patch weekly 01 mg24 hr 02 mg24 hr 03 mg24 hr
1
diltiazem hcl oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg
1
diltiazem hcl oral capsuleextended release 12 hr 120 mg 60 mg 90 mg
1
diltiazem hcl oral capsuleextended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
diltiazem hcl oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg 360 mg
1
diltiazem hcl oral tablet 120 mg 30 mg 60 mg 90 mg
1
diltiazem hcl oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
dilt-xr oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg
1
doxazosin oral tablet 1 mg 2 mg 4 mg 8 mg 1
EDARBI ORAL TABLET 40 MG 80 MG 1 ST
EDARBYCLOR ORAL TABLET 40-125 MG 40-25 MG
1 ST
enalapril maleate oral tablet 10 mg 25 mg 20 mg 5 mg
1
enalaprilat intravenous solution 125 mgml MB
enalapril-hydrochlorothiazide oral tablet 10-25 mg 5-125 mg
1
EPANED ORAL SOLUTION 1 MGML 1
47
Drug Name Drug Tier Requirements Limits
eplerenone oral tablet 25 mg 50 mg 1
epoprostenol (glycine) intravenous recon soln 05 mg 15 mg
MB PA LA
eprosartan oral tablet 600 mg 1
ethacrynic acid oral tablet 25 mg 1
felodipine oral tablet extended release 24 hr 10 mg 25 mg 5 mg
1
FLOLAN INTRAVENOUS RECON SOLN 05 MG 15 MG
MB PA LA
fosinopril oral tablet 10 mg 20 mg 40 mg 1
fosinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg
1
furosemide oral solution 10 mgml 40 mg5 ml (8 mgml)
1
furosemide oral tablet 20 mg 40 mg 80 mg 1
guanfacine oral tablet 1 mg 2 mg 1
hydralazine oral tablet 10 mg 100 mg 25 mg 50 mg
1
hydrochlorothiazide oral capsule 125 mg 1
hydrochlorothiazide oral tablet 125 mg 25 mg 50 mg
1
indapamide oral tablet 125 mg 25 mg 1
irbesartan oral tablet 150 mg 300 mg 75 mg 1
irbesartan-hydrochlorothiazide oral tablet 150-125 mg 300-125 mg
1
isradipine oral capsule 25 mg 5 mg 1
labetalol oral tablet 100 mg 200 mg 300 mg 1
lisinopril oral tablet 10 mg 25 mg 20 mg 30 mg 40 mg 5 mg
1
lisinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg
1
losartan oral tablet 100 mg 25 mg 50 mg 1
losartan-hydrochlorothiazide oral tablet 100-125 mg 100-25 mg 50-125 mg
1
matzim la oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
methyldopa oral tablet 250 mg 500 mg 1
methyldopa-hydrochlorothiazide oral tablet 250-15 mg 250-25 mg
1
48
Drug Name Drug Tier Requirements Limits
methyldopate intravenous solution 250 mg5 ml MB
metolazone oral tablet 10 mg 25 mg 5 mg 1
metoprolol succinate oral tablet extended release 24 hr 100 mg 200 mg 25 mg 50 mg
1
metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg 100-50 mg 50-25 mg
1
metoprolol tartrate oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg
1
metyrosine oral capsule 250 mg 1
minoxidil oral tablet 10 mg 25 mg 1
moexipril oral tablet 15 mg 75 mg 1
nadolol oral tablet 20 mg 40 mg 80 mg 1
nadolol-bendroflumethiazide oral tablet 80-5 mg 1
nicardipine oral capsule 20 mg 30 mg 1
nifedipine oral capsule 10 mg 20 mg 1
nifedipine oral tablet extended release 24hr 30 mg 60 mg 90 mg
1
nifedipine oral tablet extended release 30 mg 60 mg 90 mg
1
nimodipine oral capsule 30 mg 1
nisoldipine oral tablet extended release 24 hr 17 mg 20 mg 255 mg 30 mg 34 mg 40 mg 85 mg
1
olmesartan oral tablet 20 mg 40 mg 5 mg 1
olmesartan-amlodipin-hcthiazid oral tablet 20-5-125 mg 40-10-125 mg 40-10-25 mg 40-5-125 mg 40-5-25 mg
1
olmesartan-hydrochlorothiazide oral tablet 20-125 mg 40-125 mg 40-25 mg
1 ST
ORENITRAM ORAL TABLET EXTENDED RELEASE 0125 MG 025 MG 1 MG 25 MG 5 MG
2 PA LA
perindopril erbumine oral tablet 2 mg 4 mg 8 mg 1
phenoxybenzamine oral capsule 10 mg 1
pindolol oral tablet 10 mg 5 mg 1
prazosin oral capsule 1 mg 2 mg 5 mg 1
propranolol oral capsuleextended release 24 hr 120 mg 160 mg 60 mg 80 mg
1
propranolol oral solution 20 mg5 ml (4 mgml) 40 mg5 ml (8 mgml)
1
49
Drug Name Drug Tier Requirements Limits
propranolol oral tablet 10 mg 20 mg 40 mg 60 mg 80 mg
1
propranolol-hydrochlorothiazid oral tablet 40-25 mg 80-25 mg
1
QBRELIS ORAL SOLUTION 1 MGML 1
quinapril oral tablet 10 mg 20 mg 40 mg 5 mg 1
quinapril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg
1
ramipril oral capsule 125 mg 10 mg 25 mg 5 mg
1
spironolactone oral tablet 100 mg 25 mg 50 mg 1
spironolacton-hydrochlorothiaz oral tablet 25-25 mg
1
taztia xt oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg
1
TEKTURNA HCT ORAL TABLET 150-125 MG 150-25 MG 300-125 MG 300-25 MG
1
telmisartan oral tablet 20 mg 40 mg 80 mg 1
telmisartan-amlodipine oral tablet 40-10 mg 40-5 mg 80-10 mg 80-5 mg
1 ST
telmisartan-hydrochlorothiazid oral tablet 40-125 mg 80-125 mg 80-25 mg
1
terazosin oral capsule 1 mg 10 mg 2 mg 5 mg 1
tiadylt er oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg 420 mg
1
timolol maleate oral tablet 10 mg 20 mg 5 mg 1
torsemide oral tablet 10 mg 100 mg 20 mg 5 mg 1
trandolapril oral tablet 1 mg 2 mg 4 mg 1
trandolapril-verapamil oral tablet ir - er biphasic 24hr 1-240 mg 2-180 mg 2-240 mg 4-240 mg
1 ST
triamterene oral capsule 100 mg 50 mg 1
triamterene-hydrochlorothiazid oral capsule 375-25 mg
1
triamterene-hydrochlorothiazid oral tablet 375-25 mg 75-50 mg
1
valsartan oral tablet 160 mg 320 mg 40 mg 80 mg
1
valsartan-hydrochlorothiazide oral tablet 160-125 mg 160-25 mg 320-125 mg 320-25 mg 80-125 mg
1
50
Drug Name Drug Tier Requirements Limits
veletri intravenous recon soln 05 mg 15 mg MB PA LA
verapamil oral capsule 24 hr er pellet ct 100 mg 200 mg 300 mg
1
verapamil oral capsuleext rel pellets 24 hr 120 mg 180 mg 240 mg 360 mg
1
verapamil oral tablet 120 mg 40 mg 80 mg 1
verapamil oral tablet extended release 120 mg 180 mg 240 mg
1
CARDIAC GLYCOSIDES
digitek oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
digox oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
digoxin oral solution 50 mcgml (005 mgml) 1
digoxin oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
COAGULATION THERAPY
ADVATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 4000 (+-) UNIT 500 (+-) UNIT
MB
ADYNOVATE INTRAVENOUS SOLUTION 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT 750 (+-) UNIT
MB LA
AFSTYLA INTRAVENOUS RECON SOLN 1000 (+-) UNIT RANGE 1500 (+-) UNIT RANGE 2000 (+-) UNIT RANGE 2500 (+-) UNIT RANGE 250 (+-) UNIT RANGE 3000 (+-) UNIT RANGE 500 (+-) UNIT RANGE
MB LA
ALPHANATE INTRAVENOUS RECON SOLN 1000 (400 VWF) UNIT10 ML 1500 (600 VWF) UNIT10 ML 2000 (800 VWF) UNIT10 ML 250 (100 VWF) UNIT5 ML 500 (200 VWF) UNIT5 ML
MB LA
ALPHANINE SD INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT
MB LA
ALPROLIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 500 UNIT
MB LA
aminocaproic acid oral solution 250 mgml (25 ) 1
51
Drug Name Drug Tier Requirements Limits
aminocaproic acid oral tablet 1000 mg 500 mg 1
ANDEXXA INTRAVENOUS RECON SOLN 200 MG
MB
aspirin-dipyridamole oral capsule er multiphase 12 hr 25-200 mg
1
BENEFIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
BRILINTA ORAL TABLET 60 MG 90 MG 1
CABLIVI INJECTION KIT 11 MG 2 PA
cilostazol oral tablet 100 mg 50 mg 1
clopidogrel oral tablet 300 mg 75 mg 1
COAGADEX INTRAVENOUS RECON SOLN 250 (+-) UNIT RANGE 500 (+-) UNIT RANGE
MB
CORIFACT INTRAVENOUS RECON SOLN 1000-1600 UNIT
MB LA
dipyridamole oral tablet 25 mg 50 mg 75 mg 1
DOPTELET (15 TAB PACK) ORAL TABLET 20 MG
2 PA LA
ELIQUIS DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 5 MG (74 TABS)
1
ELIQUIS ORAL TABLET 25 MG 5 MG 1
ELOCTATE INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 5000 UNIT 500 UNIT 6000 UNIT 750 UNIT
MB LA
enoxaparin subcutaneous solution 300 mg3 ml 2
enoxaparin subcutaneous syringe 100 mgml 120 mg08 ml 150 mgml 30 mg03 ml 40 mg04 ml 60 mg06 ml 80 mg08 ml
2
ESPEROCT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
FEIBA NF INTRAVENOUS RECON SOLN 1750-3250 UNIT 350-650 UNIT 700-1300 UNIT
MB LA
FIBRYGA INTRAVENOUS RECON SOLN 1 GRAM (700 MG- 1300 MG)
MB
fondaparinux subcutaneous syringe 10 mg08 ml 25 mg05 ml 5 mg04 ml 75 mg06 ml
2
52
Drug Name Drug Tier Requirements Limits
FRAGMIN SUBCUTANEOUS SOLUTION 25000 ANTI-XA UNITML
2
FRAGMIN SUBCUTANEOUS SYRINGE 10000 ANTI-XA UNITML 12500 ANTI-XA UNIT05 ML 15000 ANTI-XA UNIT06 ML 18000 ANTI-XA UNIT072 ML 2500 ANTI-XA UNIT02 ML 5000 ANTI-XA UNIT02 ML 7500 ANTI-XA UNIT03 ML
2
HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG07 ML 150 MGML 30 MGML 60 MG04 ML
2 PA LA
HEMOFIL M HIGH INTRAVENOUS RECON SOLN 801-1500 UNIT
MB
HEMOFIL M LOW INTRAVENOUS RECON SOLN 220-400 UNIT
MB
HEMOFIL M MID INTRAVENOUS RECON SOLN 401-800 UNIT
MB
HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 1501-2000 UNIT
MB
hep flush-10 (pf) intravenous solution 10 unitml MB
heparin (porcine) in 5 dex intravenous parenteral solution 25000 unit250 ml(100 unitml) 25000 unit500 ml (50 unitml)
MB
heparin (porcine) injection cartridge 5000 unitml (1 ml)
1
heparin (porcine) injection solution 1000 unitml 10000 unitml 20000 unitml 5000 unitml
1
heparin lock flush (porcine) intravenous solution 100 unitml
MB
heparin lockflush(porcine)(pf) intravenous syringe 100 unitml
MB
HEPARIN(PORCINE) IN 045 NACL INTRAVENOUS PARENTERAL SOLUTION 12500 UNIT250 ML
MB
heparin(porcine) in 045 nacl intravenous parenteral solution 25000 unit250 ml 25000 unit500 ml
MB
heparin porcine (pf) injection solution 1000 unitml 5000 unit05 ml
MB
heparin porcine (pf) injection syringe 5000 unit05 ml
1
53
Drug Name Drug Tier Requirements Limits
heparin porcine (pf) intravenous solution 100 unitml (1 ml)
MB
heparin porcine (pf) intravenous syringe 10 unitml 100 unitml
MB
HUMATE-P INTRAVENOUS RECON SOLN 1000-2400 UNIT 250-600 UNIT 500-1200 UNIT
MB LA
IDELVION INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3500 (+-) UNIT 500 (+-) UNIT
MB LA
IXINITY INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
jantoven oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg
1
JIVI INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
KOATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB
KOGENATE FS INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB
KOVALTRY INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB
MONONINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT
MB LA
MULPLETA ORAL TABLET 3 MG 2 PA LA
NOVOEIGHT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
NOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1000 MCG) 2 MG (2000 MCG) 5 MG (5000 MCG) 8 MG (8000 MCG)
MB LA
NPLATE SUBCUTANEOUS RECON SOLN 125 MCG 250 MCG 500 MCG
MB LA
NUWIQ INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 2500 UNIT 250 (+-) UNIT 3000 UNIT 4000 UNIT 500 (+-) UNIT
MB LA
54
Drug Name Drug Tier Requirements Limits
OBIZUR INTRAVENOUS RECON SOLN 500 (+-) UNIT RANGE
MB
pentoxifylline oral tablet extended release 400 mg 1
phytonadione (vitamin k1) oral tablet 5 mg 1
prasugrel oral tablet 10 mg 5 mg 1
PROFILNINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT
MB LA
PROMACTA ORAL POWDER IN PACKET 125 MG
2 PA ST LA
PROMACTA ORAL POWDER IN PACKET 25 MG
2 LA
PROMACTA ORAL TABLET 125 MG 25 MG 50 MG 75 MG
2 PA ST LA
REBINYN INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 500 (+-) UNIT
MB LA
RECOMBINATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB LA
RIASTAP INTRAVENOUS RECON SOLN 1 GRAM (900MG-1300MG)
MB LA
RIXUBIS INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
tranexamic acid intravenous solution 1000 mg10 ml (100 mgml)
MB
TRETTEN INTRAVENOUS RECON SOLN 2500 UNIT
MB LA
VONVENDI INTRAVENOUS RECON SOLN 1300 (+-) UNIT RANGE 650 (+-) UNIT RANGE
MB LA
warfarin oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg
1
WILATE INTRAVENOUS RECON SOLN 1000-1000 UNIT 500-500 UNIT
MB LA
XARELTO DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 15 MG (42)- 20 MG (9)
1
XARELTO ORAL TABLET 10 MG 15 MG 25 MG 20 MG
1
55
Drug Name Drug Tier Requirements Limits
XYNTHA INTRAVENOUS SOLUTION 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB LA
XYNTHA SOLOFUSE INTRAVENOUS SYRINGE 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
ZONTIVITY ORAL TABLET 208 MG 1
LIPIDCHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg 25-10 mg 25-20 mg 25-40 mg 5-10 mg 5-20 mg 5-40 mg 5-80 mg
1 ST
atorvastatin oral tablet 10 mg 20 mg ACA PV
atorvastatin oral tablet 40 mg 80 mg 1
cholestyramine (with sugar) oral powder 4 gram 1
cholestyramine (with sugar) oral powder in packet 4 gram
1
cholestyramine light oral powder 4 gram 1
cholestyramine light oral powder in packet 4 gram 1
colesevelam oral powder in packet 375 gram 1
colesevelam oral tablet 625 mg 1
colestipol oral granules 5 gram 1
colestipol oral packet 5 gram 1
colestipol oral tablet 1 gram 1
ezetimibe oral tablet 10 mg 1
ezetimibe-simvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg
1
fenofibrate micronized oral capsule 130 mg 134 mg 200 mg 43 mg 67 mg
1
fenofibrate nanocrystallized oral tablet 145 mg 48 mg
1
FENOFIBRATE ORAL CAPSULE 150 MG 50 MG
1
fenofibrate oral tablet 120 mg 160 mg 40 mg 54 mg
1
fenofibric acid (choline) oral capsuledelayed release(drec) 135 mg 45 mg
1
fenofibric acid oral tablet 105 mg 35 mg 1
fluvastatin oral capsule 20 mg 40 mg ACA PV
56
Drug Name Drug Tier Requirements Limits
fluvastatin oral tablet extended release 24 hr 80 mg
ACA PV
gemfibrozil oral tablet 600 mg 1
icosapent ethyl oral capsule 1 gram 1 PA ST QL (120 per 30 days)
JUXTAPID ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 5 MG 60 MG
2 PA LA QL (30 per 30 days)
LIPOFEN ORAL CAPSULE 150 MG 50 MG 1
lovastatin oral tablet 10 mg 20 mg 40 mg ACA PV
niacin oral tablet 500 mg 1
niacin oral tablet extended release 24 hr 1000 mg 500 mg 750 mg
1
NIACOR ORAL TABLET 500 MG 1
omega-3 acid ethyl esters oral capsule 1 gram 1
pravastatin oral tablet 10 mg 20 mg 40 mg 80 mg
ACA PV
prevalite oral powder 4 gram 1
prevalite oral powder in packet 4 gram 1
REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG35 ML
1 PA ST
REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MGML
1 PA ST
REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MGML
1 PA ST
rosuvastatin oral tablet 10 mg 5 mg ACA PV
rosuvastatin oral tablet 20 mg 40 mg 1
simvastatin oral tablet 10 mg 20 mg 40 mg 5 mg ACA PV
simvastatin oral tablet 80 mg 1
VASCEPA ORAL CAPSULE 05 GRAM 1 GRAM
1 PA ST QL (120 per 30 days)
ZYPITAMAG ORAL TABLET 2 MG 4 MG 1 PA ST
MISCELLANEOUS CARDIOVASCULAR AGENTS
CORLANOR ORAL SOLUTION 5 MG5 ML 1 PA
CORLANOR ORAL TABLET 5 MG 75 MG 1 PA
ENTRESTO ORAL TABLET 24-26 MG 49-51 MG 97-103 MG
1 PA ST
GIAPREZA INTRAVENOUS SOLUTION 25 MGML
MB
57
Drug Name Drug Tier Requirements Limits
ranolazine oral tablet extended release 12 hr 1000 mg 500 mg
1 ST
NITRATES
GONITRO SUBLINGUAL POWDER IN PACKET 400 MCG
1
isosorbide dinitrate oral tablet 10 mg 20 mg 30 mg 40 mg 5 mg
1
isosorbide mononitrate oral tablet 10 mg 20 mg 1
isosorbide mononitrate oral tablet extended release 24 hr 120 mg 30 mg 60 mg
1
MINITRAN TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 04 MGHR 06 MGHR
1 PA ST
nitro-bid transdermal ointment 2 1
NITRO-DUR TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 03 MGHR 04 MGHR 06 MGHR 08 MGHR
1 PA ST
nitroglycerin in 5 dextrose intravenous solution 25 mg250 ml (100 mcgml) 50 mg500 ml (100 mcgml)
MB
nitroglycerin sublingual tablet 03 mg 04 mg 06 mg
1
nitroglycerin transdermal patch 24 hour 01 mghr 02 mghr 04 mghr 06 mghr
1
nitroglycerin translingual spraynon-aerosol 400 mcgspray
1
nitro-time oral capsule extended release 25 mg 65 mg 9 mg
1
DERMATOLOGICALSTOPICAL THERAPY
ANTIPSORIATIC ANTISEBORRHEIC
acitretin oral capsule 10 mg 175 mg 25 mg 1
calcipotriene scalp solution 0005 1
calcipotriene topical cream 0005 1
calcipotriene topical ointment 0005 1
calcipotriene-betamethasone topical ointment 0005-0064
1
calcitriol topical ointment 3 mcggram 1
COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
58
Drug Name Drug Tier Requirements Limits
COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
COSENTYX SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
COSENTYX SUBCUTANEOUS SYRINGE 75 MG05 ML
2 PA LA
hydrocortisone-pramoxine topical cream 25-1 1
ILUMYA SUBCUTANEOUS SYRINGE 100 MGML
2 PA ST LA
selenium sulfide topical lotion 25 1
selenium sulfide topical shampoo 225 23 1
SILIQ SUBCUTANEOUS SYRINGE 210 MG15 ML
2 PA ST LA
SKYRIZI SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
SKYRIZI SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
SKYRIZI SUBCUTANEOUS SYRINGE KIT 150MG166ML(75 MG083 ML X2)
2 PA ST LA
STELARA INTRAVENOUS SOLUTION 130 MG26 ML
MB PA LA
STELARA SUBCUTANEOUS SOLUTION 45 MG05 ML
2 PA ST LA
STELARA SUBCUTANEOUS SYRINGE 45 MG05 ML 90 MGML
2 PA ST LA
sulfacetamide sodium topical cleanser 10 1
sulfacetamide sodium topical cleanser gel 10 1
sulfacetamide sodium topical shampoo 10 1
TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MGML
2 PA ST LA
59
Drug Name Drug Tier Requirements Limits
TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 MGML
2 PA ST LA
TREMFYA SUBCUTANEOUS SYRINGE 100 MGML
2 PA ST LA
BURN THERAPY
silver sulfadiazine topical cream 1 1
ssd topical cream 1 1
MISCELLANEOUS DERMATOLOGICALS
ammonium lactate topical cream 12 1
ammonium lactate topical lotion 12 1
diclofenac sodium topical gel 3 1
DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300 MG2 ML
2 LA
DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG114 ML 300 MG2 ML
2 PA ST LA
EUCRISA TOPICAL OINTMENT 2 1 PA ST
FLUOROURACIL TOPICAL CREAM 05 1 PA ST
fluorouracil topical cream 5 1 PA ST
fluorouracil topical solution 2 5 1
LEVULAN TOPICAL SOLUTION 20 1
methoxsalen oral capsuleliqd-filledrapid rel 10 mg
1
PANRETIN TOPICAL GEL 01 1
PICATO TOPICAL GEL 0015 005 1
pimecrolimus topical cream 1 1
podofilox topical solution 05 1
prudoxin topical cream 5 1
REGRANEX TOPICAL GEL 001 1
SCENESSE SUBCUTANEOUS IMPLANT 16 MG
MB PA
tacrolimus topical ointment 003 01 1
UVADEX INJECTION SOLUTION 20 MCGML 1
VALCHLOR TOPICAL GEL 0016 2 PA ST LA
THERAPY FOR ACNE
accutane oral capsule 20 mg 30 mg 40 mg 1
adapalene topical cream 01 1 ST
60
Drug Name Drug Tier Requirements Limits
adapalene topical gel 03 1 ST
adapalene topical gel with pump 03 1 ST
ADAPALENE TOPICAL LOTION 01 1 ST
adapalene topical solution 01 1 ST
adapalene topical swab 01 1 ST
adapalene-benzoyl peroxide topical gel with pump 01-25
1
amnesteem oral capsule 10 mg 20 mg 40 mg 1 PA ST
avita topical cream 0025 1
AVITA TOPICAL GEL 0025 1 ST
azelaic acid topical gel 15 1
AZELEX TOPICAL CREAM 20 1 ST
claravis oral capsule 10 mg 20 mg 30 mg 1 PA ST
claravis oral capsule 40 mg 1
clindacin p topical swab 1 1
clindamycin phosphate topical foam 1 1
clindamycin phosphate topical gel 1 1
clindamycin phosphate topical lotion 1 1
clindamycin phosphate topical solution 1 1
clindamycin phosphate topical swab 1 1
clindamycin-benzoyl peroxide topical gel 1-5 12 (1 base) -5
1
clindamycin-benzoyl peroxide topical gel with pump 1-5
1
clindamycin-tretinoin topical gel 12-0025 1
dapsone topical gel 5 1
ery pads topical swab 2 1
erygel topical gel 2 1
erythromycin with ethanol topical gel 2 1
erythromycin with ethanol topical solution 2 1
erythromycin-benzoyl peroxide topical gel 3-5 1
isotretinoin oral capsule 10 mg 20 mg 25 mg 30 mg 35 mg 40 mg
1
metronidazole topical cream 075 1
metronidazole topical gel 075 1 1
metronidazole topical gel with pump 1 1
61
Drug Name Drug Tier Requirements Limits
metronidazole topical lotion 075 1
myorisan oral capsule 10 mg 20 mg 30 mg 40 mg
1
rosadan topical cream 075 1
rosadan topical gel 075 1
tazarotene topical cream 01 1 ST
tretinoin microspheres topical gel 004 01 1
tretinoin microspheres topical gel with pump 004 01
1
tretinoin topical cream 0025 005 01 1
tretinoin topical gel 001 0025 005 1
zenatane oral capsule 10 mg 20 mg 30 mg 40 mg 1
TOPICAL ANESTHETICS
lidocaine hcl injection solution 10 mgml (1 ) 1
lidocaine hcl laryngotracheal solution 4 1
lidocaine hcl mucous membrane jelly 2 1
lidocaine hcl mucous membrane jelly in applicator 2
1
lidocaine hcl mucous membrane solution 4 (40 mgml)
1
lidocaine hcl-hydrocortison ac topical cream 3-05
1
lidocaine topical adhesive patchmedicated 5 1
lidocaine topical ointment 5 1
lidocaine viscous mucous membrane solution 2 1
lidocaine-prilocaine topical cream 25-25 1
lidocaine-prilocaine topical kit 25-25 1
LIDOCAINE-TETRACAINE TOPICAL CREAM 7-7
1 ST
SYNERA TOPICAL PATCH MEDICATED SELF-HEATING 70-70 MG
1 ST
TOPICAL ANTIBACTERIALS
ALCORTIN A TOPICAL GEL 2-1-1 1 ST
ALCORTIN A TOPICAL GEL IN PACKET 2-1-1
1 ST
ALTABAX TOPICAL OINTMENT 1 1
gentamicin topical cream 01 1
62
Drug Name Drug Tier Requirements Limits
gentamicin topical ointment 01 1
mafenide acetate topical packet 50 gram 1
mupirocin calcium topical cream 2 1
mupirocin topical ointment 2 1
sulfacetamide sodium (acne) topical suspension 10
1
SULFAMYLON TOPICAL CREAM 85 MGG 1
TOPICAL ANTIFUNGALS
ciclodan topical cream 077 1
ciclodan topical solution 8 1
ciclopirox topical cream 077 1
ciclopirox topical gel 077 1
ciclopirox topical shampoo 1 1
ciclopirox topical solution 8 1
ciclopirox topical suspension 077 1
ciclopirox-ure-camph-menth-euc topical solution 8
1
clotrimazole topical cream 1 1
clotrimazole topical solution 1 1
clotrimazole-betamethasone topical cream 1-005
1
clotrimazole-betamethasone topical lotion 1-005
1
econazole topical cream 1 1
EXELDERM TOPICAL CREAM 1 1
EXELDERM TOPICAL SOLUTION 1 1
JUBLIA TOPICAL SOLUTION WITH APPLICATOR 10
1 PA ST
ketoconazole topical cream 2 1
ketoconazole topical foam 2 1
ketoconazole topical shampoo 2 1
ketodan topical foam 2 1
LULICONAZOLE TOPICAL CREAM 1 1
LUZU TOPICAL CREAM 1 1
MENTAX TOPICAL CREAM 1 1
naftifine topical cream 1 2 1
63
Drug Name Drug Tier Requirements Limits
naftifine topical gel 1 1
nyamyc topical powder 100000 unitgram 1
nystatin topical cream 100000 unitgram 1
nystatin topical ointment 100000 unitgram 1
nystatin topical powder 100000 unitgram 1
nystatin-triamcinolone topical cream 100000-01 unitg-
1
nystatin-triamcinolone topical ointment 100000-01 unitgram-
1
nystop topical powder 100000 unitgram 1
oxiconazole topical cream 1 1
OXISTAT TOPICAL LOTION 1 1
tavaborole topical solution with applicator 5 1 PA ST
TOPICAL ANTIVIRALS
acyclovir topical cream 5 1
acyclovir topical ointment 5 1
DENAVIR TOPICAL CREAM 1 1
TOPICAL CORTICOSTEROIDS
ala-cort topical cream 1 1
alclometasone topical cream 005 1
alclometasone topical ointment 005 1
amcinonide topical cream 01 1
amcinonide topical lotion 01 1
apexicon e topical cream 005 1
beser topical lotion 005 1
betamethasone dipropionate topical cream 005 1
betamethasone dipropionate topical lotion 005 1
betamethasone dipropionate topical ointment 005
1
betamethasone valerate topical cream 01 1
betamethasone valerate topical foam 012 1
betamethasone valerate topical lotion 01 1
betamethasone valerate topical ointment 01 1
betamethasone augmented topical cream 005 1
betamethasone augmented topical gel 005 1
betamethasone augmented topical lotion 005 1
64
Drug Name Drug Tier Requirements Limits
betamethasone augmented topical ointment 005
1
clobetasol scalp solution 005 1
clobetasol topical cream 005 1
clobetasol topical foam 005 1
clobetasol topical gel 005 1
clobetasol topical lotion 005 1
clobetasol topical ointment 005 1
clobetasol topical shampoo 005 1
clobetasol topical spraynon-aerosol 005 1
clobetasol-emollient topical cream 005 1
clobetasol-emollient topical foam 005 1
CLOCORTOLONE PIVALATE TOPICAL CREAM 01
1 ST
CLODERM TOPICAL CREAM 01 1 ST
desonide topical cream 005 1
desonide topical lotion 005 1
desonide topical ointment 005 1
desoximetasone topical cream 005 025 1
desoximetasone topical gel 005 1
desoximetasone topical ointment 005 025 1
desoximetasone topical spraynon-aerosol 025 1
diflorasone topical cream 005 1
diflorasone topical ointment 005 1
fluocinolone and shower cap scalp oil 001 1
fluocinolone topical cream 001 0025 1
fluocinolone topical oil 001 1
fluocinolone topical ointment 0025 1
fluocinolone topical solution 001 1
fluocinonide topical cream 005 01 1
fluocinonide topical gel 005 1
fluocinonide topical ointment 005 1
fluocinonide topical solution 005 1
fluocinonide-e topical cream 005 1
flurandrenolide topical cream 005 1
65
Drug Name Drug Tier Requirements Limits
flurandrenolide topical lotion 005 1
flurandrenolide topical ointment 005 1
fluticasone propionate topical cream 005 1
fluticasone propionate topical lotion 005 1
fluticasone propionate topical ointment 0005 1
halcinonide topical cream 01 1
halobetasol propionate topical cream 005 1
halobetasol propionate topical ointment 005 1
hydrocortisone butyrate topical cream 01 1
hydrocortisone butyrate topical lotion 01 1
hydrocortisone butyrate topical ointment 01 1
hydrocortisone butyrate topical solution 01 1
hydrocortisone butyr-emollient topical cream 01
1
hydrocortisone topical cream 1 25 1
hydrocortisone topical lotion 25 1
hydrocortisone topical ointment 1 25 1
hydrocortisone valerate topical cream 02 1
hydrocortisone valerate topical ointment 02 1
mometasone topical cream 01 1
mometasone topical ointment 01 1
mometasone topical solution 01 1
prednicarbate topical cream 01 1
prednicarbate topical ointment 01 1
scalacort topical lotion 2 1
triamcinolone acetonide topical aerosol 0147 mggram
1
triamcinolone acetonide topical cream 0025 01 05
1
triamcinolone acetonide topical lotion 0025 01
1
triamcinolone acetonide topical ointment 0025 005 01 05
1
triderm topical cream 01 05 1
TOPICAL ENZYMES
SANTYL TOPICAL OINTMENT 250 UNITGRAM
1 QL (2 per 30 days)
66
Drug Name Drug Tier Requirements Limits
TOPICAL SCABICIDES PEDICULICIDES
crotan topical lotion 10 1
EURAX TOPICAL CREAM 10 1
EURAX TOPICAL LOTION 10 1
ivermectin topical lotion 05 1
lindane topical shampoo 1 1
malathion topical lotion 05 1
permethrin topical cream 5 1
spinosad topical suspension 09 1
ULESFIA TOPICAL LOTION 5 1
DIAGNOSTICS amp MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
PHYSIOLYTE IRRIGATION SOLUTION 140-5-3-98 MEQL
MB
PHYSIOSOL IRRIGATION IRRIGATION SOLUTION 140-5-3-98 MEQL
MB
MISCELLANEOUS AGENTS
acamprosate oral tabletdelayed release (drec) 333 mg
1
acetic acid irrigation solution 025 1
anagrelide oral capsule 05 mg 1 mg 1
ARALAST NP INTRAVENOUS RECON SOLN 1000 MG 500 MG
MB LA
CARBAGLU ORAL TABLET DISPERSIBLE 200 MG
2 PA LA
cevimeline oral capsule 30 mg 1
CHEMET ORAL CAPSULE 100 MG 1
clovique oral capsule 250 mg 1 PA QL (240 per 30 days)
deferasirox oral granules in packet 180 mg 360 mg 90 mg
2 PA LA
deferasirox oral tablet 180 mg 2 PA LA
deferasirox oral tablet 360 mg 90 mg 2 ST LA
deferasirox oral tablet dispersible 125 mg 250 mg 500 mg
2 ST LA
deferiprone oral tablet 500 mg 1 PA
disulfiram oral tablet 250 mg 500 mg 1
67
Drug Name Drug Tier Requirements Limits
EMPAVELI SUBCUTANEOUS SOLUTION 1080 MG20 ML
2 PA
FERRIPROX ORAL SOLUTION 100 MGML 1 PA
FERRIPROX ORAL TABLET 1000 MG 500 MG
1 PA
GIVLAARI SUBCUTANEOUS SOLUTION 189 MGML
MB PA LA
GLASSIA INTRAVENOUS SOLUTION 1 GRAM50 ML (2 )
MB LA
INCRELEX SUBCUTANEOUS SOLUTION 10 MGML
2 PA LA
levocarnitine (with sugar) oral solution 100 mgml 1
levocarnitine oral solution 100 mgml 1
levocarnitine oral tablet 330 mg 1
midodrine oral tablet 10 mg 25 mg 5 mg 1
nitisinone oral capsule 10 mg 2 mg 5 mg 2 PA LA
NITYR ORAL TABLET 10 MG 2 MG 5 MG 2 PA LA
pilocarpine hcl oral tablet 5 mg 1
PROLASTIN-C INTRAVENOUS SOLUTION 1000 MG (+-)20 ML
MB
RAVICTI ORAL LIQUID 11 GRAMML 2 PA ST LA QL (10 per 30 days)
RECLAST INTRAVENOUS PIGGYBACK 5 MG100 ML
MB
riluzole oral tablet 50 mg 1
risedronate oral tablet 30 mg 1
sodium chloride 09 injection solution MB
sodium chloride 09 intravenous parenteral solution
MB
sodium chloride 09 intravenous piggyback MB
sodium phenylbutyrate oral powder 094 gramgram
1 PA
sodium phenylbutyrate oral tablet 500 mg 1 PA
SOLIRIS INTRAVENOUS SOLUTION 300 MG30 ML
MB PA LA
trientine oral capsule 250 mg 1 PA QL (240 per 30 days)
XURIDEN ORAL GRANULES IN PACKET 2 GRAM
2 PA QL (120 per 30 days)
68
Drug Name Drug Tier Requirements Limits
ZEMAIRA INTRAVENOUS RECON SOLN 1000 MG
MB LA
ZOKINVY ORAL CAPSULE 50 MG 75 MG 2 PA ST
SMOKING DETERRENTS
bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg
ACA PV
CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG
ACA PV QL (180 per 365 days)
CHANTIX ORAL TABLET 05 MG 1 MG ACA PV QL (180 per 365 days)
CHANTIX STARTING MONTH BOX ORAL TABLETSDOSE PACK 05 MG (11)- 1 MG (42)
ACA PV QL (180 per 365 days)
nicorette buccal gum 4 mg ACA PV
nicotine (polacrilex) buccal gum 2 mg 4 mg ACA PV
nicotine (polacrilex) buccal lozenge 2 mg 4 mg ACA PV
nicotine (polacrilex) buccal mini lozenge 2 mg 4 mg
ACA PV
nicotine transdermal patch 24 hour 14 mg24 hr 21 mg24 hr 7 mg24 hr
ACA PV
nicotine transdermal patch td daily sequential 21-14-7 mg24 hr
ACA PV
NICOTROL INHALATION CARTRIDGE 10 MG
ACA PV
NICOTROL NS NASAL SPRAYNON-AEROSOL 10 MGML
ACA PV
quit 2 buccal gum 2 mg ACA PV
quit 2 buccal lozenge 2 mg ACA PV
quit 4 buccal gum 4 mg ACA PV
quit 4 buccal lozenge 4 mg ACA PV
stop smoking aid buccal lozenge 2 mg 4 mg ACA PV
EAR NOSE amp THROAT MEDICATIONS
MISCELLANEOUS AGENTS
ARESTIN DENTAL CARTRIDGE 1 MG MB
azelastine nasal aerosolspray 137 mcg (01 ) 1
azelastine nasal spraynon-aerosol 2055 mcg (015 )
1
chlorhexidine gluconate mucous membrane mouthwash 012
1
denta 5000 plus dental cream 11 1
69
Drug Name Drug Tier Requirements Limits
dentagel dental gel 11 1
fluoride (sodium) dental cream 11 1
fluoride (sodium) dental gel 11 1
fluoride (sodium) dental paste 11 1
ipratropium bromide nasal spraynon-aerosol 21 mcg (003 ) 42 mcg (006 )
1
olopatadine nasal spraynon-aerosol 06 1
oralone dental paste 01 1
paroex oral rinse mucous membrane mouthwash 012
1
periogard mucous membrane mouthwash 012 1
pilocarpine hcl oral tablet 75 mg 1
sf 5000 plus dental cream 11 1
sf dental gel 11 1
sodium fluoride 5000 dry mouth dental gel 11 1
sodium fluoride 5000 plus dental cream 11 1
sodium fluoride-pot nitrate dental paste 11-5 1
triamcinolone acetonide dental paste 01 1
MISCELLANEOUS OTIC PREPARATIONS
acetic acid otic (ear) solution 2 1
ciprofloxacin hcl otic (ear) dropperette 02 1
flac otic oil otic (ear) drops 001 1
fluocinolone acetonide oil otic (ear) drops 001 1
hydrocortisone-acetic acid otic (ear) drops 1-2 1
ofloxacin otic (ear) drops 03 1
OTIC STEROID ANTIBIOTIC
CIPRO HC OTIC (EAR) DROPSSUSPENSION 02-1
1
ciprofloxacin-dexamethasone otic (ear) dropssuspension 03-01
1
neomycin-polymyxin-hc otic (ear) dropssuspension 35-10000-1 mgml-unitml-
1
neomycin-polymyxin-hc otic (ear) solution 35-10000-1 mgml-unitml-
1
OTOVEL OTIC (EAR) SOLUTION 03-0025 (025 ML)
1
ENDOCRINEDIABETES
70
Drug Name Drug Tier Requirements Limits
ADRENAL HORMONES
ACTHAR INJECTION GEL 80 UNITML 2 PA LA
decadron oral tablet 05 mg 1
dexamethasone intensol oral drops 1 mgml 1
dexamethasone oral elixir 05 mg5 ml 1
dexamethasone oral solution 05 mg5 ml 1
dexamethasone oral tablet 05 mg 075 mg 1 mg 15 mg 2 mg 4 mg 6 mg
1
dexamethasone oral tabletsdose pack 15 mg (21 tabs) 15 mg (35 tabs) 15 mg (51 tabs)
1
dexamethasone sodium phos (pf) injection solution 10 mgml
1
dexamethasone sodium phosphate injection solution 10 mgml 4 mgml
1
dexamethasone sodium phosphate injection syringe 4 mgml
1
fludrocortisone oral tablet 01 mg 1
hydrocortisone oral tablet 10 mg 20 mg 5 mg 1
methylprednisolone acetate injection suspension 40 mgml 80 mgml
1
methylprednisolone oral tablet 16 mg 32 mg 4 mg 8 mg
1
methylprednisolone oral tabletsdose pack 4 mg 1
millipred dp oral tabletsdose pack 5 mg (21 tabs) 5 mg (48 tabs)
1
millipred oral tablet 5 mg 1
prednisolone oral solution 15 mg5 ml 1
prednisolone sodium phosphate oral solution 10 mg5 ml 15 mg5 ml (3 mgml) 20 mg5 ml (4 mgml) 25 mg5 ml (5 mgml) 5 mg base5 ml (67 mg5 ml)
1
prednisolone sodium phosphate oral tabletdisintegrating 10 mg 15 mg 30 mg
1
prednisone intensol oral concentrate 5 mgml 1
prednisone oral solution 5 mg5 ml 1
prednisone oral tablet 1 mg 10 mg 25 mg 20 mg 5 mg 50 mg
1
prednisone oral tabletsdose pack 10 mg 5 mg 1
71
Drug Name Drug Tier Requirements Limits
triamcinolone acetonide injection suspension 40 mgml
MB
ANTITHYROID AGENTS
methimazole oral tablet 10 mg 5 mg 1
propylthiouracil oral tablet 50 mg 1
SSKI ORAL SOLUTION 1 GRAMML 1
BLOOD GLUCOSE MONITORING DEVICES amp SUPPLIES
CONTOUR NEXT TEST STRIPS STRIP 1
CONTOUR TEST STRIPS STRIP 1
ONETOUCH ULTRA TEST STRIP 1
ONETOUCH VERIO TEST STRIPS STRIP 1
DIABETES SUPPLIES amp DURABLE MEDICAL EQUIPMENT
AEROCHAMBER MINI SPACER 1
AEROCHAMBER PLUS FLOW-VU SPACER 1
GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN 1 MGML
1
GLUCAGON HCL INJECTION RECON SOLN 1 MGML
1
INSULIN SYRINGE-NEEDLE U-100 SYRINGE 05 ML 29 GAUGE X 12
1
TRIJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-5-1000 MG 125-25-1000 MG 25-5-1000 MG 5-25-1000 MG
1 PA ST
GLUCOSE ELEVATING AGENTS
BAQSIMI NASAL SPRAYNON-AEROSOL 3 MGACTUATION
1
diazoxide oral suspension 50 mgml 1
GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG
1
GLUCAGON (HCL) EMERGENCY KIT INJECTION RECON SOLN 1 MG
1
glucagon emergency kit (human) injection recon soln 1 mg
1
INSULIN SYRINGESMISCELLANEOUS DURABLE MEDICAL EQU
FREESTYLE LIBRE 14 DAY SENSOR KIT 1
FREESTYLE LIBRE 2 SENSOR KIT 1
NOVOPEN ECHO SUBCUTANEOUS INSULIN PEN
1
72
Drug Name Drug Tier Requirements Limits
PEN NEEDLE DIABETIC NEEDLE 29 GAUGE X 12
1
INSULIN THERAPY
FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
FIASP PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML (3 ML)
1
FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN HALF-UNIT 100 UNITML
1
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML
1 ST
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 200 UNITML (3 ML)
1
HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNITML (50-50)
1 ST
HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (50-50)
1 ST
HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (75-25)
1 ST
HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNITML (75-25)
1 ST
HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML
1 ST
HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1 ST
HUMULIN 7030 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)
1 ST
HUMULIN 7030 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1 ST
73
Drug Name Drug Tier Requirements Limits
HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1 ST
HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML
1 ST
HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNITML
1 ST
HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNITML
1
HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNITML (3 ML)
1
INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML (70-30)
1
INSULIN ASPART U-100 SUBCUTANEOUS CARTRIDGE 100 UNITML
1
INSULIN ASPART U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
INSULIN ASPART U-100 SUBCUTANEOUS SOLUTION 100 UNITML
1
LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
NOVOLIN R FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
74
Drug Name Drug Tier Requirements Limits
NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNITML (70-30)
1
NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML
1
NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML
1
RELION NOVOLIN 7030 SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)
1
RELION NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNITML
1
RELION NOVOLIN R INJECTION SOLUTION 100 UNITML
1
SOLIQUA 10033 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCGML
1 PA ST
TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNITML (3 ML)
1
TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNITML (15 ML)
1
TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN 200 UNITML (3 ML)
1
TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
XULTOPHY 10036 SUBCUTANEOUS INSULIN PEN 100 UNIT-36 MG ML (3 ML)
1 PA ST
MISCELLANEOUS HORMONES
ALDURAZYME INTRAVENOUS SOLUTION 29 MG5 ML
MB PA LA
ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG24 HOUR 4 MG24 HR
1 ST QL (30 per 30 days)
75
Drug Name Drug Tier Requirements Limits
BRINEURA INTRAVENTRICULAR KIT 300 MG10 ML (150MG5ML X2)
MB
cabergoline oral tablet 05 mg 1
calcitonin (salmon) injection solution 200 unitml 1
calcitonin (salmon) nasal spraynon-aerosol 200 unitactuation
1
calcitriol oral capsule 025 mcg 05 mcg 1
calcitriol oral solution 1 mcgml 1
CERDELGA ORAL CAPSULE 84 MG 2 PA LA
CEREZYME INTRAVENOUS RECON SOLN 400 UNIT
MB PA LA
cinacalcet oral tablet 30 mg 60 mg 90 mg 2 PA
CRYSVITA SUBCUTANEOUS SOLUTION 10 MGML 20 MGML 30 MGML
MB PA LA
danazol oral capsule 100 mg 200 mg 50 mg 1
DEPO-TESTOSTERONE INTRAMUSCULAR OIL 100 MGML
1
desmopressin nasal spraynon-aerosol 10 mcgspray (01 ml)
1
desmopressin oral tablet 01 mg 02 mg 1
doxercalciferol oral capsule 05 mcg 1 mcg 25 mcg
1
ELAPRASE INTRAVENOUS SOLUTION 6 MG3 ML
MB PA LA
ELELYSO INTRAVENOUS RECON SOLN 200 UNIT
MB PA LA
FABRAZYME INTRAVENOUS RECON SOLN 35 MG 5 MG
MB PA LA
GALAFOLD ORAL CAPSULE 123 MG 2 PA LA
JYNARQUE ORAL TABLET 15 MG 30 MG 2 PA QL (60 per 30 days)
JYNARQUE ORAL TABLETS SEQUENTIAL 45 MG (AM) 15 MG (PM) 60 MG (AM) 30 MG (PM) 90 MG (AM) 30 MG (PM)
2 PA QL (60 per 30 days)
KANUMA INTRAVENOUS SOLUTION 2 MGML
MB PA LA
KORLYM ORAL TABLET 300 MG 2 PA ST
LUMIZYME INTRAVENOUS RECON SOLN 50 MG
MB PA LA
76
Drug Name Drug Tier Requirements Limits
MEPSEVII INTRAVENOUS SOLUTION 2 MGML
MB PA LA
methyltestosterone oral capsule 10 mg 1
MIACALCIN INJECTION SOLUTION 200 UNITML
1
miglustat oral capsule 100 mg 2 PA LA
MYALEPT SUBCUTANEOUS RECON SOLN 5 MGML (FINAL CONC)
2 LA
NAGLAZYME INTRAVENOUS SOLUTION 5 MG5 ML
MB PA LA
NATPARA SUBCUTANEOUS CARTRIDGE 100 MCGDOSE 25 MCGDOSE 50 MCGDOSE 75 MCGDOSE
2 PA ST LA
oxandrolone oral tablet 10 mg 25 mg 1
PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG05 ML 25 MG05 ML 20 MGML
2 PA LA
pamidronate intravenous solution 30 mg10 ml (3 mgml)
MB
PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCGML
MB
paricalcitol intravenous solution 5 mcgml MB
paricalcitol oral capsule 1 mcg 2 mcg 4 mcg 1
PARSABIV INTRAVENOUS SOLUTION 5 MGML
MB PA
SAMSCA ORAL TABLET 15 MG 2 PA LA QL (60 per 30 days)
sapropterin oral powder in packet 100 mg 500 mg 2 PA LA
sapropterin oral tabletsoluble 100 mg 2 PA LA
SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG 15 MG 20 MG 25 MG 30 MG
2 PA LA QL (30 per 30 days)
STRENSIQ SUBCUTANEOUS SOLUTION 18 MG045 ML 28 MG07 ML 40 MGML 80 MG08 ML
2 PA
SYNAREL NASAL SPRAYNON-AEROSOL 2 MGML
1
TEPEZZA INTRAVENOUS RECON SOLN 500 MG
MB PA LA
testosterone cypionate intramuscular oil 100 mgml 200 mgml
1
testosterone enanthate intramuscular oil 200 mgml
1
77
Drug Name Drug Tier Requirements Limits
testosterone transdermal gel 50 mg5 gram (1 ) 1 QL (60 per 30 days)
testosterone transdermal gel in metered-dose pump 10 mg05 gram actuation 2025 mg125 gram (162 )
1 QL (2 per 30 days)
testosterone transdermal gel in metered-dose pump 125 mg 125 gram (1 )
1 QL (4 per 30 days)
testosterone transdermal gel in packet 1 (25 mg25gram) 162 (2025 mg125 gram)
1 QL (30 per 30 days)
testosterone transdermal gel in packet 1 (50 mg5 gram) 162 (405 mg25 gram)
1 QL (60 per 30 days)
testosterone transdermal solution in metered pump wapp 30 mgactuation (15 ml)
1 QL (2 per 30 days)
VIMIZIM INTRAVENOUS SOLUTION 5 MG5 ML (1 MGML)
MB PA LA
VPRIV INTRAVENOUS RECON SOLN 400 UNIT
MB PA LA
NON-INSULIN HYPOGLYCEMIC AGENTS
acarbose oral tablet 100 mg 25 mg 50 mg 1
ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 125-15 MG 125-30 MG 125-45 MG 25-15 MG 25-30 MG 25-45 MG
1 PA ST
BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG085 ML
1 PA ST
BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCGDOSE(250 MCGML) 24 ML 5 MCGDOSE (250 MCGML) 12 ML
1 PA ST
CYCLOSET ORAL TABLET 08 MG 1
FARXIGA ORAL TABLET 10 MG 5 MG 1 PA ST
glimepiride oral tablet 1 mg 2 mg 4 mg 1
glipizide oral tablet 10 mg 5 mg 1
glipizide oral tablet extended release 24hr 10 mg 25 mg 5 mg
1
glipizide-metformin oral tablet 25-250 mg 25-500 mg 5-500 mg
1
glyburide micronized oral tablet 15 mg 3 mg 6 mg
1
glyburide oral tablet 125 mg 25 mg 5 mg 1
glyburide-metformin oral tablet 125-250 mg 25-500 mg 5-500 mg
1
78
Drug Name Drug Tier Requirements Limits
GLYXAMBI ORAL TABLET 10-5 MG 25-5 MG
1 PA ST
JANUMET ORAL TABLET 50-1000 MG 50-500 MG
1 PA ST
JANUMET XR ORAL TABLET ER MULTIPHASE 24 HR 100-1000 MG 50-1000 MG 50-500 MG
1 PA ST
JANUVIA ORAL TABLET 100 MG 25 MG 50 MG
1 PA ST
JARDIANCE ORAL TABLET 10 MG 25 MG 1 PA ST
JENTADUETO ORAL TABLET 25-1000 MG 25-500 MG 25-850 MG
1 PA ST
JENTADUETO XR ORAL TABLET IR - ER BIPHASIC 24HR 25-1000 MG 5-1000 MG
1 PA ST
metformin oral solution 500 mg5 ml 1 PA
metformin oral tablet 1000 mg 500 mg 850 mg 1
metformin oral tablet extended release 24 hr 500 mg 750 mg
1
metformin oral tablet extended release 24hr 1000 mg 500 mg
1 PA ST
metformin oral tableter gastretention 24 hr 1000 mg 500 mg
1 ST
miglitol oral tablet 100 mg 25 mg 50 mg 1
nateglinide oral tablet 120 mg 60 mg 1
OZEMPIC SUBCUTANEOUS PEN INJECTOR 025 MG OR 05 MG(2 MG15 ML) 1 MGDOSE (2 MG15 ML) 1 MGDOSE (4 MG3 ML)
1 PA ST
pioglitazone oral tablet 15 mg 30 mg 45 mg 1
pioglitazone-glimepiride oral tablet 30-2 mg 30-4 mg
1
pioglitazone-metformin oral tablet 15-500 mg 15-850 mg
1
QTERN ORAL TABLET 10-5 MG 5-5 MG 1 PA ST
repaglinide oral tablet 05 mg 1 mg 2 mg 1
repaglinide-metformin oral tablet 1-500 mg 2-500 mg
1
RIOMET ER ORAL SUSPENSIONEXTENDED REL RECON 500 MG5 ML
1 PA ST
79
Drug Name Drug Tier Requirements Limits
RYBELSUS ORAL TABLET 14 MG 3 MG 7 MG
1 PA ST
SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2700 MCG27 ML
1 PA ST
SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1500 MCG15 ML
1 PA ST
SYNJARDY ORAL TABLET 125-1000 MG 125-500 MG 5-1000 MG 5-500 MG
1 PA ST
SYNJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 125-1000 MG 25-1000 MG 5-1000 MG
1 PA ST
TRADJENTA ORAL TABLET 5 MG 1 PA ST
TRULICITY SUBCUTANEOUS PEN INJECTOR 075 MG05 ML 15 MG05 ML 3 MG05 ML 45 MG05 ML
1 PA ST
XIGDUO XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 10-500 MG 25-1000 MG 5-1000 MG 5-500 MG
1 PA ST
THYROID HORMONES
ARMOUR THYROID ORAL TABLET 120 MG 15 MG 180 MG 240 MG 30 MG 300 MG 60 MG 90 MG
1
levothyroxine oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 300 mcg 50 mcg 75 mcg 88 mcg
1
levoxyl oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 50 mcg 75 mcg 88 mcg
1
liothyronine oral tablet 25 mcg 5 mcg 50 mcg 1
np thyroid oral tablet 120 mg 15 mg 30 mg 60 mg 90 mg
1
SYNTHROID ORAL TABLET 100 MCG 112 MCG 125 MCG 137 MCG 150 MCG 175 MCG 200 MCG 25 MCG 300 MCG 50 MCG 75 MCG 88 MCG
1
THYROLAR-1 ORAL TABLET 125-50 MCG 1
THYROLAR-12 ORAL TABLET 625-25 MCG 1
THYROLAR-14 ORAL TABLET 31-125 MCG 1
THYROLAR-2 ORAL TABLET 25-100 MCG 1
THYROLAR-3 ORAL TABLET 375-150 MCG 1
80
Drug Name Drug Tier Requirements Limits
unithroid oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 300 mcg 50 mcg 75 mcg 88 mcg
1
westhroid oral tablet 130 mg 195 mg 325 mg 65 mg 975 mg
1
GASTROENTEROLOGY
ANTIDIARRHEALS amp ANTISPASMODICS
anaspaz oral tabletdisintegrating 0125 mg 1
atropine injection syringe 005 mgml 01 mgml 1
belladonna alkaloids-opium rectal suppository 162-30 mg 162-60 mg
1 PA ST
chlordiazepoxide-clidinium oral capsule 5-25 mg 1
dicyclomine intramuscular solution 10 mgml MB
dicyclomine oral capsule 10 mg 1
dicyclomine oral solution 10 mg5 ml 1
dicyclomine oral tablet 20 mg 1
diphenoxylate-atropine oral liquid 25-0025 mg5 ml
1
diphenoxylate-atropine oral tablet 25-0025 mg 1
DONNATAL ORAL TABLET 162-01037 -00194 MG
1
ed-spaz oral tabletdisintegrating 0125 mg 1
glycopyrrolate injection solution 02 mgml 1
glycopyrrolate oral tablet 1 mg 15 mg 2 mg 1
hyoscyamine sulfate oral drops 0125 mgml 1
hyoscyamine sulfate oral elixir 0125 mg5 ml 1
hyoscyamine sulfate oral tablet 0125 mg 1
hyoscyamine sulfate oral tablet extended release 12 hr 0375 mg
1
hyoscyamine sulfate oral tabletdisintegrating 0125 mg
1
hyoscyamine sulfate sublingual tablet 0125 mg 1
hyosyne oral drops 0125 mgml 1
hyosyne oral elixir 0125 mg5 ml 1
loperamide oral capsule 2 mg 1
methscopolamine oral tablet 25 mg 5 mg 1
MOTOFEN ORAL TABLET 1-0025 MG 1
81
Drug Name Drug Tier Requirements Limits
opium tincture oral tincture 10 mgml (morphine) 1
oscimin oral tablet 0125 mg 1
oscimin sl sublingual tablet 0125 mg 1
oscimin sr oral tablet extended release 12 hr 0375 mg
1
phenobarb-hyoscy-atropine-scop oral elixir 162-01037 -00194 mg5 ml
1
phenobarb-hyoscy-atropine-scop oral tablet 162-01037 -00194 mg
1
phenohytro oral elixir 162-01037 -00194 mg5 ml
1
phenohytro oral tablet 162-01037 -00194 mg 1
symax fastabs oral tabletdisintegrating 0125 mg 1
symax-sl sublingual tablet 0125 mg 1
symax-sr oral tablet extended release 12 hr 0375 mg
1
MISCELLANEOUS GASTROINTESTINAL AGENTS
AKYNZEO (NETUPITANT) ORAL CAPSULE 300-05 MG
1 QL (1 per 30 days)
alosetron oral tablet 05 mg 1 mg 1
ALOXI INTRAVENOUS SOLUTION 025 MG5 ML
MB
AMITIZA ORAL CAPSULE 24 MCG 8 MCG 1 PA
anucort-hc rectal suppository 25 mg 1
aprepitant oral capsule 125 mg 40 mg 1 QL (1 per 30 days)
aprepitant oral capsule 80 mg 1 QL (2 per 30 days)
aprepitant oral capsuledose pack 125 mg (1)- 80 mg (2)
1 QL (1 per 30 days)
balsalazide oral capsule 750 mg 1
budesonide oral capsuledelayedextendrelease 3 mg
1
calcium acetate(phosphat bind) oral capsule 667 mg
1
calcium acetate(phosphat bind) oral tablet 667 mg 1
CHOLBAM ORAL CAPSULE 250 MG 50 MG 2
CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)
2 PA ST LA
82
Drug Name Drug Tier Requirements Limits
CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG2 ML (200 MGML X 2)
2 PA ST LA
CLENPIQ ORAL SOLUTION 10 MG-35 GRAM -12 GRAM160 ML
ACA PV
compro rectal suppository 25 mg 1
constulose oral solution 10 gram15 ml 1
CORTIFOAM RECTAL FOAM 10 (80 MG) 1
CREON ORAL CAPSULEDELAYED RELEASE(DREC) 12000-38000 -60000 UNIT 24000-76000 -120000 UNIT 3000-9500- 15000 UNIT 36000-114000- 180000 UNIT 6000-19000 -30000 UNIT
1 PA
cromolyn oral concentrate 100 mg5 ml 1
DIPENTUM ORAL CAPSULE 250 MG 1 PA ST
doxylamine-pyridoxine (vit b6) oral tabletdelayed release (drec) 10-10 mg
1
dronabinol oral capsule 10 mg 25 mg 5 mg 1
EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG ML FINAL CONC)
1
ENTYVIO INTRAVENOUS RECON SOLN 300 MG
MB PA LA
enulose oral solution 10 gram15 ml 1
gavilyte-c oral recon soln 240-2272-672 -584 gram
ACA PV
gavilyte-g oral recon soln 236-2274-674 -586 gram
ACA PV
gavilyte-n oral recon soln 420 gram ACA PV
generlac oral solution 10 gram15 ml 1
granisetron hcl oral tablet 1 mg 1 QL (6 per 30 days)
hemmorex-hc rectal suppository 25 mg 1
hydrocortisone acetate rectal suppository 25 mg 30 mg
1
hydrocortisone rectal enema 100 mg60 ml 1
hydrocortisone topical cream with perineal applicator 1 25
1
hydrocortisone-pramoxine rectal cream 1-1 25-1 25-1 (4g)
1
INFLECTRA INTRAVENOUS RECON SOLN 100 MG
MB PA LA
83
Drug Name Drug Tier Requirements Limits
lactulose oral packet 10 gram 1
lactulose oral solution 10 gram15 ml 20 gram30 ml
1
lanthanum oral tabletchewable 1000 mg 500 mg 750 mg
1
lidocaine hcl-hydrocortison ac rectal cream 3-05
1
LIDOCAINE HCL-HYDROCORTISON AC RECTAL GEL 3 -25 (7 GRAM)
1
lidocaine hcl-hydrocortison ac rectal kit 2 -2 (7 gram)
1 ST
lidocaine hcl-hydrocortison ac rectal kit 3-05 3-1 (7 gram)
1 PA ST
lidocaine-hydrocortisone-aloe rectal gel 28-055
1
lidocaine-hydrocortisone-aloe rectal kit 3-25 (7 gram)
1 PA ST
LINZESS ORAL CAPSULE 145 MCG 290 MCG 72 MCG
1 PA
meclizine oral tablet 125 mg 25 mg 1
mesalamine oral capsuleextended release 24hr 0375 gram
1
mesalamine oral tabletdelayed release (drec) 12 gram 800 mg
1
mesalamine rectal enema 4 gram60 ml 1
mesalamine rectal suppository 1000 mg 1
mesalamine with cleansing wipe rectal enema kit 4 gram60 ml
1 ST
metoclopramide hcl injection solution 5 mgml MB
metoclopramide hcl injection syringe 5 mgml MB
metoclopramide hcl oral solution 5 mg5 ml 1
metoclopramide hcl oral tablet 10 mg 5 mg 1
metoclopramide hcl oral tabletdisintegrating 10 mg 5 mg
1
MOVANTIK ORAL TABLET 125 MG 25 MG 1 PA ST
NULYTELY LEMON-LIME ORAL RECON SOLN 420 GRAM
ACA PV
ondansetron hcl intravenous solution 2 mgml MB
ondansetron hcl oral solution 4 mg5 ml 1 QL (100 per 30 days)
84
Drug Name Drug Tier Requirements Limits
ondansetron hcl oral tablet 4 mg 8 mg 1 QL (9 per 30 days)
ondansetron oral tabletdisintegrating 4 mg 8 mg 1 QL (9 per 30 days)
OSMOPREP ORAL TABLET 15 GRAM ACA PV
peg 3350-electrolytes oral recon soln 236-2274-674 -586 gram
ACA PV
peg3350-sod sul-nacl-kcl-asb-c oral powder in packet 100-75-2691 gram
ACA PV
peg-electrolyte soln oral recon soln 420 gram ACA PV
peg-prep oral kit 5-210 mg-gram ACA PV
PLENVU ORAL POWDER IN PACKET SEQUENTIAL 140-9-52 GRAM
ACA PV
prochlorperazine edisylate injection solution 10 mg2 ml (5 mgml) 5 mgml
1
prochlorperazine maleate oral tablet 10 mg 5 mg 1
prochlorperazine rectal suppository 25 mg 1
procto-med hc topical cream with perineal applicator 25
1
procto-pak topical cream with perineal applicator 1
1
proctosol hc topical cream with perineal applicator 25
1
proctozone-hc topical cream with perineal applicator 25
1
RECTIV RECTAL OINTMENT 04 (WW) 1
RELISTOR ORAL TABLET 150 MG 1
RELISTOR SUBCUTANEOUS SOLUTION 12 MG06 ML
1
RELISTOR SUBCUTANEOUS SYRINGE 12 MG06 ML 8 MG04 ML
1
REMICADE INTRAVENOUS RECON SOLN 100 MG
MB PA LA
RENFLEXIS INTRAVENOUS RECON SOLN 100 MG
MB PA LA
scopolamine base transdermal patch 3 day 1 mg over 3 days
1
sevelamer carbonate oral powder in packet 08 gram 24 gram
1
sevelamer carbonate oral tablet 800 mg 1
sevelamer hcl oral tablet 400 mg 800 mg 1
85
Drug Name Drug Tier Requirements Limits
sodium polystyrene sulfonate oral powder 1
sps (with sorbitol) oral suspension 15-20 gram60 ml
1
sps (with sorbitol) rectal enema 30-40 gram120 ml
1
SUCRAID ORAL SOLUTION 8500 UNITML 2 PA ST QL (2 per 30 days)
sulfasalazine oral tablet 500 mg 1
sulfasalazine oral tabletdelayed release (drec) 500 mg
1
SUPREP BOWEL PREP KIT ORAL RECON SOLN 175-313-16 GRAM
ACA PV ST
trilyte with flavor packets oral recon soln 420 gram
ACA PV
trimethobenzamide oral capsule 300 mg 1
ursodiol oral capsule 300 mg 1
ursodiol oral tablet 250 mg 500 mg 1
VARUBI ORAL TABLET 90 MG 1
VELPHORO ORAL TABLETCHEWABLE 500 MG
1 ST
VIBERZI ORAL TABLET 100 MG 75 MG 1 PA ST
ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 10000-32000 -42000 UNIT 15000-47000 -63000 UNIT 20000-63000- 84000 UNIT 3000-10000 -14000-UNIT 40000-126000- 168000 UNIT 5000-17000- 24000 UNIT
1 PA
ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 25000-79000- 105000 UNIT
1
ULCER THERAPY
amoxicil-clarithromy-lansopraz oral combo pack 500-500-30 mg
1
cimetidine hcl oral solution 300 mg5 ml 1
cimetidine oral tablet 200 mg 300 mg 400 mg 800 mg
1
DEXILANT ORAL CAPSULEBIPHASE DELAYED RELEAS 30 MG 60 MG
1 ST
esomeprazole magnesium oral capsuledelayed release(drec) 20 mg 40 mg
1
famotidine (pf) intravenous solution 20 mg2 ml MB
86
Drug Name Drug Tier Requirements Limits
famotidine oral suspension 40 mg5 ml (8 mgml) 1
famotidine oral tablet 20 mg 40 mg 1
lansoprazole oral capsuledelayed release(drec) 15 mg 30 mg
1
lansoprazole oral tabletdisintegrat delay rel 15 mg 30 mg
1
misoprostol oral tablet 100 mcg 200 mcg 1
nizatidine oral capsule 150 mg 300 mg 1
nizatidine oral solution 150 mg10 ml 1
omeprazole oral capsuledelayed release(drec) 10 mg 20 mg 40 mg
1
pantoprazole oral tabletdelayed release (drec) 20 mg 40 mg
1
rabeprazole oral tabletdelayed release (drec) 20 mg
1
sucralfate oral suspension 100 mgml 1
sucralfate oral tablet 1 gram 1
IMMUNOLOGY VACCINES amp BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCGML 200 MCGML 25 MCGML 300 MCGML 40 MCGML 60 MCGML
2 LA
ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG04 ML 100 MCG05 ML 150 MCG03 ML 200 MCG04 ML 25 MCG042 ML 300 MCG06 ML 40 MCG04 ML 500 MCGML 60 MCG03 ML
2 LA
EPOGEN INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML
2 LA
GRANIX SUBCUTANEOUS SOLUTION 300 MCGML 480 MCG16 ML
2
GRANIX SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML
2
LEUKINE INJECTION RECON SOLN 250 MCG 2 PA ST
MIRCERA INJECTION SYRINGE 100 MCG03 ML 150 MCG03 ML 200 MCG03 ML 30 MCG03 ML 50 MCG03 ML 75 MCG03 ML
MB
87
Drug Name Drug Tier Requirements Limits
MOZOBIL SUBCUTANEOUS SOLUTION 24 MG12 ML (20 MGML)
MB LA
NEUPOGEN INJECTION SOLUTION 300 MCGML 480 MCG16 ML
2 PA ST
NEUPOGEN INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML
2 PA ST
NIVESTYM INJECTION SOLUTION 300 MCGML 480 MCG16 ML
2
NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML
2
PROCRIT INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML 40000 UNITML
2 LA
UDENYCA SUBCUTANEOUS SYRINGE 6 MG06 ML
2 PA ST
ZARXIO INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML
2 PA ST
ZIEXTENZO SUBCUTANEOUS SYRINGE 6 MG06 ML
2 PA ST
GROWTH HORMONES
GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 02 MG025 ML 04 MG025 ML 06 MG025 ML 08 MG025 ML 1 MG025 ML 12 MG025 ML 14 MG025 ML 16 MG025 ML 18 MG025 ML 2 MG025 ML
2 PA ST LA
GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MGML (36 UNITML) 5 MGML (15 UNITML)
2 PA ST LA
OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG15 ML (67 MGML) 5 MG15 ML (33 MGML)
2 PA ST LA
OMNITROPE SUBCUTANEOUS RECON SOLN 58 MG
2 PA ST LA
SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG 5 MG 6 MG
2 PA ST LA
ZORBTIVE SUBCUTANEOUS RECON SOLN 88 MG
2 PA ST LA
INTERFERONS
AUBAGIO ORAL TABLET 14 MG 7 MG 2 PA LA
88
Drug Name Drug Tier Requirements Limits
AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG05 ML
2 PA ST LA QL (4 per 30 days)
AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG05 ML
2 PA ST LA QL (4 per 30 days)
BETASERON SUBCUTANEOUS KIT 03 MG 2 PA LA QL (14 per 30 days)
dimethyl fumarate oral capsuledelayed release(drec) 120 mg
2 PA LA QL (14 per 365 days)
dimethyl fumarate oral capsuledelayed release(drec) 120 mg (14)- 240 mg (46)
2 PA LA QL (1 per 365 days)
dimethyl fumarate oral capsuledelayed release(drec) 240 mg
2 PA LA QL (60 per 30 days)
GILENYA ORAL CAPSULE 05 MG 2 PA LA QL (30 per 30 days)
glatiramer subcutaneous syringe 20 mgml 2 PA LA QL (30 per 30 days)
glatiramer subcutaneous syringe 40 mgml 2 PA LA QL (12 per 30 days)
glatopa subcutaneous syringe 20 mgml 2 PA LA QL (30 per 30 days)
glatopa subcutaneous syringe 40 mgml 2 PA LA QL (12 per 30 days)
LEMTRADA INTRAVENOUS SOLUTION 12 MG12 ML
MB PA ST LA
MAVENCLAD (10 TABLET PACK) ORAL TABLET 10 MG
2 LA
MAVENCLAD (4 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (5 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (6 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (7 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (8 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (9 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAYZENT ORAL TABLET 025 MG 2 MG 2 PA ST LA QL (30 per 30 days)
MAYZENT STARTER PACK ORAL TABLETSDOSE PACK 025 MG (12 TABS)
2 PA ST LA QL (1 per 365 days)
OCREVUS INTRAVENOUS SOLUTION 30 MGML
MB PA LA
PEGASYS SUBCUTANEOUS SOLUTION 180 MCGML
2 PA LA
89
Drug Name Drug Tier Requirements Limits
PEGASYS SUBCUTANEOUS SYRINGE 180 MCG05 ML
2 PA LA
PLEGRIDY INTRAMUSCULAR SYRINGE 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG05 ML- 94 MCG05 ML
2 PA LA QL (1 per 365 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG05 ML- 94 MCG05 ML
2 PA LA QL (1 per 365 days)
POMALYST ORAL CAPSULE 1 MG 2 MG 3 MG 4 MG
2 PA ST OCh LA
PONVORY 14-DAY STARTER PACK ORAL TABLETSDOSE PACK 2 MG (2) - 10 MG (3)
2 PA LA QL (1 per 365 days)
PONVORY ORAL TABLET 20 MG 2 PA LA QL (30 per 30 days)
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG05 ML 44 MCG05 ML
2 PA LA QL (6 per 30 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG05 ML 44 MCG05 ML
2 PA LA QL (6 per 30 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 88MCG02ML-22 MCG05ML (6)
2 PA LA QL (5 per 30 days)
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 88MCG02ML-22 MCG05ML (6)
2 PA LA QL (5 per 30 days)
REVLIMID ORAL CAPSULE 10 MG 15 MG 25 MG 20 MG 25 MG 5 MG
2 PA ST OCh LA
ribavirin oral capsule 200 mg 2 LA
ribavirin oral tablet 200 mg 2 LA
ZEPOSIA ORAL CAPSULE 092 MG 2 LA QL (30 per 30 days)
ZEPOSIA STARTER KIT ORAL CAPSULEDOSE PACK 023-046-092 MG
2 LA QL (30 per 30 days)
ZEPOSIA STARTER PACK ORAL CAPSULEDOSE PACK 023 MG (4)- 046 MG (3)
2 LA QL (30 per 30 days)
INTERLEUKINS
ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG05 ML
2 PA LA
ARCALYST SUBCUTANEOUS RECON SOLN 220 MG
2 LA
90
Drug Name Drug Tier Requirements Limits
ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MGML
MB PA LA
imiquimod topical cream in packet 5 1
INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) 18 MILLION UNIT (1 ML) 50 MILLION UNIT (1 ML)
2 PA LA
INTRON A INJECTION SOLUTION 10 MILLION UNITML 6 MILLION UNITML
2 PA LA
PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT
MB LA
VACCINES amp MISCELLANEOUS IMMUNOLOGICALS
ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(25-5-3-5 MCG)-5LF05 ML
1 Vac
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(25-5-3-5 MCG)-5LF05 ML
1 Vac
ASCENIV INTRAVENOUS SOLUTION 10 MB PA LA
ATGAM INTRAVENOUS SOLUTION 50 MGML
MB
BCG VACCINE LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG
1 Vac
BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG05 ML
1 Vac
BIOTHRAX INTRAMUSCULAR SUSPENSION 05 MLDOSE
1 Vac
BIVIGAM INTRAVENOUS SOLUTION 10 MB PA LA
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 25-8-5 LF-MCG-LF05ML
1 Vac
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 25-8-5 LF-MCG-LF05ML
1 Vac
BOTOX INJECTION RECON SOLN 100 UNIT 200 UNIT
MB
CUTAQUIG SUBCUTANEOUS SOLUTION 165
MB LA
CUVITRU SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 ) 8 GRAM40 ML (20 )
MB LA
91
Drug Name Drug Tier Requirements Limits
DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF05ML
1 Vac
DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT 500 UNIT
MB LA
ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCGML
1 Vac
ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCGML
1 Vac
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG05 ML
1 Vac
FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 5
MB PA
GAMASTAN INTRAMUSCULAR SOLUTION 15-18 RANGE
MB
GAMASTAN SD INTRAMUSCULAR SOLUTION 15-18 RANGE
MB
GAMMAGARD LIQUID INJECTION SOLUTION 10
MB LA
GAMMAGARD S-D (IGA lt 1 MCGML) INTRAVENOUS RECON SOLN 10 GRAM 5 GRAM
MB PA LA
GAMMAKED INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 20 GRAM200 ML (10 ) 5 GRAM50 ML (10 )
MB LA
GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5
MB PA LA
GAMMAPLEX INTRAVENOUS SOLUTION 10
MB PA LA
GAMUNEX-C INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 25 GRAM25 ML (10 ) 20 GRAM200 ML (10 ) 40 GRAM400 ML (10 ) 5 GRAM50 ML (10 )
MB LA
GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 05 ML
1 Vac
GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 05 ML
1 Vac
GRASTEK SUBLINGUAL TABLET 2800 BAU 1 PA
HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1440 ELISA UNITML
1 Vac
92
Drug Name Drug Tier Requirements Limits
HAVRIX (PF) INTRAMUSCULAR SYRINGE 1440 ELISA UNITML 720 ELISA UNIT05 ML
1 Vac
HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE 20 MCG05 ML
1 Vac
HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )
MB LA
HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM 100 ML (10 ) 25 GRAM 25 ML (10 ) 20 GRAM 200 ML (10 ) 30 GRAM 300 ML (10 ) 5 GRAM 50 ML (10 )
MB LA
IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 25 UNIT
1 Vac
INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF05ML
1 Vac
IPOL INJECTION SUSPENSION 40-8-32 UNIT05 ML
1 Vac
IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG05 ML
1 Vac
KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF05 ML
1 Vac
MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG05 ML
1 Vac
MENQUADFI (PF) INTRAMUSCULAR SOLUTION 10 MCG05 ML
1 Vac
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG05 ML
1 Vac
M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1000-12500 TCID5005 ML
1 Vac
MYOBLOC INTRAMUSCULAR SOLUTION 10000 UNIT2 ML 2500 UNIT05 ML 5000 UNITML
MB LA
OCTAGAM INTRAVENOUS SOLUTION 10 5
MB PA LA
ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY
2 PA
PANZYGA INTRAVENOUS SOLUTION 10 MB PA
PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF05 ML
1 Vac
93
Drug Name Drug Tier Requirements Limits
PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 75 MCG05 ML
1 Vac
PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF05 ML 15LF-48MCG-62DU -10 MCG05ML
1 Vac
PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
PNEUMOVAX-23 INJECTION SOLUTION 25 MCG05 ML
1 Vac
PNEUMOVAX-23 INJECTION SYRINGE 25 MCG05 ML
1 Vac
PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE 05 ML
1 Vac
PRIVIGEN INTRAVENOUS SOLUTION 10 MB PA LA
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-43-3- 399 TCID5005
1 Vac
PROVENGE INTRAVENOUS SUSPENSION 50 MILLION CELL250 ML
MB PA
QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT05ML
1 Vac
RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 25 UNIT
1 Vac
RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT
1 PA
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCGML 40 MCGML 5 MCG05 ML
1 Vac
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCGML 5 MCG05 ML
1 Vac
SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG05 ML
1 Vac
STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1000 UNIT05 ML
1 Vac
TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF UNIT05 ML
1 Vac
94
Drug Name Drug Tier Requirements Limits
TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT05ML
1 Vac
TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT05 ML
1 Vac
TETANUSDIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT05 ML
1 Vac
THYMOGLOBULIN INTRAVENOUS RECON SOLN 25 MG
MB
TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG05 ML
1 Vac
TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCGML
1 Vac
TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG05 ML
1 Vac
TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG05 ML
1 Vac
VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT05 ML 50 UNITML
1 Vac
VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT05 ML 50 UNITML
1 Vac
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1350 UNIT05 ML
1 Vac
VAXELIS (PF) INTRAMUSCULAR SUSPENSION 15 UNIT-5 UNIT- 10 MCG05 ML
1 Vac
VAXELIS (PF) INTRAMUSCULAR SYRINGE 15 UNIT-5 UNIT- 10 MCG05 ML
1 Vac
XEMBIFY SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )
MB LA
XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT 200 UNIT 50 UNIT
MB LA
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP474 UNIT05 ML
1 Vac
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19400 UNIT065 ML
1 Vac
MUSCULOSKELETAL amp RHEUMATOLOGY
95
Drug Name Drug Tier Requirements Limits
GOUT THERAPY
allopurinol oral tablet 100 mg 300 mg 1
COLCHICINE ORAL CAPSULE 06 MG 1
colchicine oral tablet 06 mg 1
febuxostat oral tablet 40 mg 80 mg 1
KRYSTEXXA INTRAVENOUS SOLUTION 8 MGML
MB PA LA
MITIGARE ORAL CAPSULE 06 MG 1
probenecid oral tablet 500 mg 1
probenecid-colchicine oral tablet 500-05 mg 1
OSTEOPOROSIS THERAPY
alendronate oral solution 70 mg75 ml 1
alendronate oral tablet 10 mg 35 mg 5 mg 70 mg 1
EVENITY SUBCUTANEOUS SYRINGE 105 MG117 ML 210MG234ML ( 105MG117MLX2)
2 PA ST LA
FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCGDOSE (620MCG248ML)
2 PA ST LA QL (1 per 30 days)
FOSAMAX PLUS D ORAL TABLET 70 MG- 2800 UNIT 70 MG- 5600 UNIT
1
ibandronate oral tablet 150 mg 1
PROLIA SUBCUTANEOUS SYRINGE 60 MGML
2 ST LA
raloxifene oral tablet 60 mg 2 OCh
risedronate oral tablet 150 mg 35 mg 5 mg 1
risedronate oral tabletdelayed release (drec) 35 mg
1
TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3120 MCG156 ML)
2 PA ST LA
OTHER RHEUMATOLOGICALS
ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG09 ML
2 PA ST LA
ACTEMRA INTRAVENOUS SOLUTION 200 MG10 ML (20 MGML) 400 MG20 ML (20 MGML) 80 MG4 ML (20 MGML)
MB PA LA
ACTEMRA SUBCUTANEOUS SYRINGE 162 MG09 ML
2 PA ST LA
96
Drug Name Drug Tier Requirements Limits
BENLYSTA INTRAVENOUS RECON SOLN 120 MG 400 MG
MB PA LA
BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MGML
2 PA LA
BENLYSTA SUBCUTANEOUS SYRINGE 200 MGML
2 PA LA
ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MGML (1 ML)
2 PA ST LA
ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)
2 PA ST LA
ENBREL SUBCUTANEOUS SOLUTION 25 MG05 ML
2 PA ST LA
ENBREL SUBCUTANEOUS SYRINGE 25 MG05 ML (05) 50 MGML (1 ML)
2 PA ST LA
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MGML (1 ML)
2 PA ST LA
HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG08 ML
2 PA ST LA
HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG08 ML 80 MG08 ML-40 MG04 ML
2 PA ST LA
HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
2 PA ST LA
HUMIRA(CF) PEN PEDIATRIC UC SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
2 PA ST LA
HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML-40 MG04 ML
2 PA ST LA
HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG04 ML
2 PA ST LA
97
Drug Name Drug Tier Requirements Limits
HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG01 ML 20 MG02 ML 40 MG04 ML
2 PA ST LA
KEVZARA SUBCUTANEOUS PEN INJECTOR 150 MG114 ML 200 MG114 ML
2 PA ST LA
KEVZARA SUBCUTANEOUS SYRINGE 150 MG114 ML 200 MG114 ML
2 PA ST LA
leflunomide oral tablet 10 mg 20 mg 1
OLUMIANT ORAL TABLET 1 MG 2 MG 2 PA ST LA
ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG
MB PA LA
ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MGML
2 PA ST LA
ORENCIA SUBCUTANEOUS SYRINGE 125 MGML 50 MG04 ML 875 MG07 ML
2 PA ST LA
OTEZLA ORAL TABLET 30 MG 2 PA ST LA
OTEZLA STARTER ORAL TABLETSDOSE PACK 10 MG (4)-20 MG (4)-30 MG (47)
2 PA ST LA
penicillamine oral capsule 250 mg 1 PA
penicillamine oral tablet 250 mg 1 PA
RIDAURA ORAL CAPSULE 3 MG 1
RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 MG
2 PA ST LA
SAVELLA ORAL TABLET 100 MG 125 MG 25 MG 50 MG
1 PA ST
SAVELLA ORAL TABLETSDOSE PACK 125 MG (5)-25 MG(8)-50 MG(42)
1 PA ST
SIMPONI ARIA INTRAVENOUS SOLUTION 125 MGML
MB PA LA
SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MGML 50 MG05 ML
2 PA ST LA
SIMPONI SUBCUTANEOUS SYRINGE 100 MGML 50 MG05 ML
2 PA ST LA
XELJANZ ORAL SOLUTION 1 MGML 2 PA ST LA
XELJANZ ORAL TABLET 10 MG 5 MG 2 PA ST LA
XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG 22 MG
2 PA ST LA
OBSTETRICS amp GYNECOLOGY
DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES
98
Drug Name Drug Tier Requirements Limits
CAYA CONTOURED VAGINAL DIAPHRAGM 65-80 MM
ACA PV
FC2 FEMALE CONDOM ACA PV
FEMCAP VAGINAL DEVICE 22 MM ACA PV
KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 175 MCG24 HRS (5 YRS) 195 MG
ACA PV
LILETTA INTRAUTERINE INTRAUTERINE DEVICE 201 MCG24 HRS (6 YRS) 52 MG
ACA PV ST
MIRENA INTRAUTERINE INTRAUTERINE DEVICE 20 MCG24 HOURS (6 YRS) 52 MG
ACA PV
PARAGARD T 380A INTRAUTERINE INTRAUTERINE DEVICE 380 SQUARE MM
ACA PV
SKYLA INTRAUTERINE INTRAUTERINE DEVICE 14 MCG24 HRS (3 YRS) 135 MG
ACA PV
WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 MM
ACA PV
ESTROGENS amp PROGESTINS
amabelz oral tablet 05-01 mg 1-05 mg 1
ANGELIQ ORAL TABLET 025-05 MG 05-1 MG
1
camila oral tablet 035 mg ACA PV
COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 005-014 MG24 HR 005-025 MG24 HR
1
covaryx hs oral tablet 0625-125 mg 1
covaryx oral tablet 125-25 mg 1
CRINONE VAGINAL GEL 4 1
deblitane oral tablet 035 mg ACA PV
DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MGML
1
DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MGML
MB
DEPO-PROVERA INTRAMUSCULAR SYRINGE 150 MGML
MB
DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE 104 MG065 ML
ACA PV
99
Drug Name Drug Tier Requirements Limits
DIVIGEL TRANSDERMAL GEL IN PACKET 025 MG025 GRAM (01 ) 05 MG05 GRAM (01 ) 075 MG075 GRAM (01) 1 MGGRAM (01 ) 125 MG125 GRAM (01 )
1 QL (30 per 30 days)
dotti transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
DUAVEE ORAL TABLET 045-20 MG 1
eemt hs oral tablet 0625-125 mg 1
eemt oral tablet 125-25 mg 1
errin oral tablet 035 mg ACA PV
estradiol oral tablet 05 mg 1 mg 2 mg 1
estradiol transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
estradiol transdermal patch weekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 006 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (4 per 30 days)
estradiol vaginal cream 001 (01 mggram) 1
estradiol vaginal tablet 10 mcg 1
estradiol valerate intramuscular oil 20 mgml 40 mgml
1
estradiol-norethindrone acet oral tablet 05-01 mg 1-05 mg
1
ESTRING VAGINAL RING 2 MG (75 MCG 24 HOUR)
1
estrogens-methyltestosterone oral tablet 0625-125 mg 125-25 mg
1
EVAMIST TRANSDERMAL SPRAYNON-AEROSOL 153 MGSPRAY (17)
1 QL (2 per 30 days)
FEMRING VAGINAL RING 005 MG24 HR 01 MG24 HR
1
fyavolv oral tablet 05-25 mg-mcg 1-5 mg-mcg 1
heather oral tablet 035 mg ACA PV
hydroxyprogest(pf)(preg presv) intramuscular oil 250 mgml (1 ml)
2
hydroxyprogesterone cap(ppres) intramuscular oil 250 mgml
2
100
Drug Name Drug Tier Requirements Limits
hydroxyprogesterone caproate intramuscular oil 250 mgml
2
incassia oral tablet 035 mg ACA PV
jencycla oral tablet 035 mg ACA PV
jinteli oral tablet 1-5 mg-mcg 1
lyleq oral tablet 035 mg ACA PV
lyllana transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
lyza oral tablet 035 mg ACA PV
medroxyprogesterone intramuscular suspension 150 mgml
ACA PV
medroxyprogesterone intramuscular syringe 150 mgml
ACA PV
medroxyprogesterone oral tablet 10 mg 25 mg 5 mg
1
MENEST ORAL TABLET 03 MG 0625 MG 125 MG 25 MG
1
MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG24 HR
1 QL (4 per 30 days)
mimvey oral tablet 1-05 mg 1
nora-be oral tablet 035 mg ACA PV
norethindrone (contraceptive) oral tablet 035 mg ACA PV
norethindrone acetate oral tablet 5 mg 1
norethindrone ac-eth estradiol oral tablet 05-25 mg-mcg 1-5 mg-mcg
1
norlyda oral tablet 035 mg ACA PV
PREMARIN INJECTION RECON SOLN 25 MG 1
PREMARIN ORAL TABLET 03 MG 045 MG 0625 MG 09 MG 125 MG
1
PREMARIN VAGINAL CREAM 0625 MGGRAM
1
PREMPHASE ORAL TABLET 0625 MG (14) 0625MG-5MG(14)
1
PREMPRO ORAL TABLET 03-15 MG 045-15 MG 0625-25 MG 0625-5 MG
1
progesterone intramuscular oil 50 mgml 1
progesterone micronized oral capsule 100 mg 200 mg
1
101
Drug Name Drug Tier Requirements Limits
sharobel oral tablet 035 mg ACA PV
tulana oral tablet 035 mg ACA PV
yuvafem vaginal tablet 10 mcg 1
MISCELLANEOUS OBGYN
ANNOVERA VAGINAL RING 015-0013 MG24 HOUR
ACA PV
clindamycin phosphate vaginal cream 2 1
eluryng vaginal ring 012-0015 mg24 hr ACA PV
etonogestrel-ethinyl estradiol vaginal ring 012-0015 mg24 hr
ACA PV
fem ph vaginal gel 09-0025 1
GYNAZOLE-1 VAGINAL CREAM 2 1
gynol ii vaginal gel 3 ACA PV
INTRAROSA VAGINAL INSERT 65 MG 1
isoxsuprine oral tablet 10 mg 20 mg 1
LUPANETA PACK (1 MONTH) KIT SYRINGE AND TABLET 375 MG -5 MG (30)
2 LA
LUPANETA PACK (3 MONTH) KIT SYRINGE AND TABLET 1125 MG -5 MG (90)
2 LA
metronidazole vaginal gel 075 1
NEXPLANON SUBDERMAL IMPLANT 68 MG ACA PV
OSPHENA ORAL TABLET 60 MG 1
PHEXXI VAGINAL GEL 18-1-04 ACA PV
terconazole vaginal cream 04 08 1
terconazole vaginal suppository 80 mg 1
TODAY CONTRACEPTIVE SPONGE VAGINAL CONTRACEPTIVE SPONGE 1000 MG
ACA PV
tranexamic acid oral tablet 650 mg 1
TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 MCG24 HR
ACA PV
vaginal contraceptive foam vaginal foam 125 ACA PV
vandazole vaginal gel 075 1
VCF CONTRACEPTIVE FILM VAGINAL FILM 28
ACA PV
VCF CONTRACEPTIVE GEL VAGINAL GEL 4
ACA PV
102
Drug Name Drug Tier Requirements Limits
xulane transdermal patch weekly 150-35 mcg24 hr
ACA PV
zafemy transdermal patch weekly 150-35 mcg24 hr
ACA PV
ORAL CONTRACEPTIVES amp RELATED AGENTS
afirmelle oral tablet 01-20 mg-mcg ACA PV
altavera (28) oral tablet 015-003 mg ACA PV
alyacen 135 (28) oral tablet 1-35 mg-mcg ACA PV
alyacen 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
amethia oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
amethyst (28) oral tablet 90-20 mcg (28) ACA PV
apri oral tablet 015-003 mg ACA PV
aranelle (28) oral tablet 05105-35 mg-mcg ACA PV
ashlyna oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
aubra eq oral tablet 01-20 mg-mcg ACA PV
aubra oral tablet 01-20 mg-mcg ACA PV
aurovela 1530 (21) oral tablet 15-30 mg-mcg ACA PV
aurovela 120 (21) oral tablet 1-20 mg-mcg ACA PV
aurovela 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
aurovela fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
aurovela fe 1-20 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
aviane oral tablet 01-20 mg-mcg ACA PV
ayuna oral tablet 015-003 mg ACA PV
azurette (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
BALCOLTRA ORAL TABLET 01 MG-002 MG (21)365 MG(7)
ACA PV
balziva (28) oral tablet 04-35 mg-mcg ACA PV
blisovi 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
blisovi fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
103
Drug Name Drug Tier Requirements Limits
blisovi fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
briellyn oral tablet 04-35 mg-mcg ACA PV
camrese lo oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)
ACA PV
camrese oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
caziant (28) oral tablet 0112515-25 mg-mcg ACA PV
charlotte 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
chateal (28) oral tablet 015-003 mg ACA PV
chateal eq (28) oral tablet 015-003 mg ACA PV
cryselle (28) oral tablet 03-30 mg-mcg ACA PV
cyclafem 135 (28) oral tablet 1-35 mg-mcg ACA PV
cyclafem 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
cyred eq oral tablet 015-003 mg ACA PV
cyred oral tablet 015-003 mg ACA PV
dasetta 135 (28) oral tablet 1-35 mg-mcg ACA PV
dasetta 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
daysee oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
desog-eestradioleestradiol oral tablet 015-002 mgx21 001 mg x 5
ACA PV
desogestrel-ethinyl estradiol oral tablet 015-003 mg
ACA PV
dolishale oral tablet 90-20 mcg (28) ACA PV
drospirenone-eestradiol-lmfa oral tablet 3-002-0451 mg (24) (4) 3-003-0451 mg (21) (7)
ACA PV
drospirenone-ethinyl estradiol oral tablet 3-002 mg 3-003 mg
ACA PV
econtra ez oral tablet 15 mg ACA PV
econtra one-step oral tablet 15 mg ACA PV
elinest oral tablet 03-30 mg-mcg ACA PV
ELLA ORAL TABLET 30 MG ACA PV
emoquette oral tablet 015-003 mg ACA PV
104
Drug Name Drug Tier Requirements Limits
enpresse oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
enskyce oral tablet 015-003 mg ACA PV
estarylla oral tablet 025-35 mg-mcg ACA PV
ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg 1-50 mg-mcg
ACA PV
falmina (28) oral tablet 01-20 mg-mcg ACA PV
fayosim oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg
ACA PV
femynor oral tablet 025-35 mg-mcg ACA PV
gemmily oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV
hailey 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
hailey fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
hailey fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
hailey oral tablet 15-30 mg-mcg ACA PV
iclevia oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
isibloom oral tablet 015-003 mg ACA PV
jaimiess oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
jasmiel (28) oral tablet 3-002 mg ACA PV
jolessa oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
juleber oral tablet 015-003 mg ACA PV
junel 1530 (21) oral tablet 15-30 mg-mcg ACA PV
junel 120 (21) oral tablet 1-20 mg-mcg ACA PV
junel fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
junel fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
junel fe 24 oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV
kaitlib fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)
ACA PV
kalliga oral tablet 015-003 mg ACA PV
kariva (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
105
Drug Name Drug Tier Requirements Limits
kelnor 135 (28) oral tablet 1-35 mg-mcg ACA PV
kelnor 1-50 (28) oral tablet 1-50 mg-mcg ACA PV
kurvelo (28) oral tablet 015-003 mg ACA PV
l norgesteestradiol-eestrad oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7) 015 mg-20 mcg 015 mg-25 mcg 015 mg-30 mcg (84)10 mcg (7)
ACA PV
larin 1530 (21) oral tablet 15-30 mg-mcg ACA PV
larin 120 (21) oral tablet 1-20 mg-mcg ACA PV
larin 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV
larin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
larin fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
larissia oral tablet 01-20 mg-mcg ACA PV
layolis fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)
ACA PV
leena 28 oral tablet 05105-35 mg-mcg ACA PV
lessina oral tablet 01-20 mg-mcg ACA PV
levonest (28) oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
levonorgestrel oral tablet 15 mg ACA PV
levonorgestrel-ethinyl estrad oral tablet 01-20 mg-mcg 015-003 mg 90-20 mcg (28)
ACA PV
levonorgestrel-ethinyl estrad oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
levonorg-eth estrad triphasic oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
levora-28 oral tablet 015-003 mg ACA PV
lillow (28) oral tablet 015-003 mg ACA PV
LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG (24)10 MCG (2)
ACA PV
lojaimiess oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)
ACA PV
loryna (28) oral tablet 3-002 mg ACA PV
low-ogestrel (28) oral tablet 03-30 mg-mcg ACA PV
lo-zumandimine (28) oral tablet 3-002 mg ACA PV
lutera (28) oral tablet 01-20 mg-mcg ACA PV
106
Drug Name Drug Tier Requirements Limits
marlissa (28) oral tablet 015-003 mg ACA PV
merzee oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV
mibelas 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
microgestin 1530 (21) oral tablet 15-30 mg-mcg ACA PV
microgestin 120 (21) oral tablet 1-20 mg-mcg ACA PV
microgestin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
microgestin fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
mili oral tablet 025-35 mg-mcg ACA PV
mono-linyah oral tablet 025-35 mg-mcg ACA PV
my choice oral tablet 15 mg ACA PV
my way oral tablet 15 mg ACA PV
NATAZIA ORAL TABLET 3 MG2 MG-2 MG 2 MG-3 MG1 MG
ACA PV
necon 0535 (28) oral tablet 05-35 mg-mcg ACA PV
new day oral tablet 15 mg ACA PV
NEXTSTELLIS ORAL TABLET 3 MG- 142 MG (28)
ACA PV
nikki (28) oral tablet 3-002 mg ACA PV
noreth-ethinyl estradiol-iron oral tabletchewable 04mg-35mcg(21) and 75 mg (7) 08mg-25mcg(24) and 75 mg (4)
ACA PV
norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg 15-30 mg-mcg
ACA PV
norethindrone-eestradiol-iron oral capsule 1 mg-20 mcg (24)75 mg (4)
ACA PV
norethindrone-eestradiol-iron oral tablet 1 mg-20 mcg (21)75 mg (7) 15 mg-30 mcg (21)75 mg (7)
ACA PV
norethindrone-eestradiol-iron oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
norgestimate-ethinyl estradiol oral tablet 0180215025 mg-25 mcg 0180215025 mg-35 mcg (28) 025-35 mg-mcg
ACA PV
nortrel 0535 (28) oral tablet 05-35 mg-mcg ACA PV
nortrel 135 (21) oral tablet 1-35 mg-mcg (21) ACA PV
nortrel 135 (28) oral tablet 1-35 mg-mcg ACA PV
107
Drug Name Drug Tier Requirements Limits
nortrel 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
nylia 777 (28) oral tablet 050751 mg- 35 mcg ACA PV
nymyo oral tablet 025-35 mg-mcg ACA PV
ocella oral tablet 3-003 mg ACA PV
opcicon one-step oral tablet 15 mg ACA PV
option-2 oral tablet 15 mg ACA PV
orsythia oral tablet 01-20 mg-mcg ACA PV
philith oral tablet 04-35 mg-mcg ACA PV
pimtrea (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
pirmella oral tablet 050751 mg- 35 mcg 1-35 mg-mcg
ACA PV
portia 28 oral tablet 015-003 mg ACA PV
previfem oral tablet 025-35 mg-mcg ACA PV
reclipsen (28) oral tablet 015-003 mg ACA PV
rivelsa oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg
ACA PV
setlakin oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
simliya (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
simpesse oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
SLYND ORAL TABLET 4 MG (28) ACA PV
sprintec (28) oral tablet 025-35 mg-mcg ACA PV
sronyx oral tablet 01-20 mg-mcg ACA PV
syeda oral tablet 3-003 mg ACA PV
tarina 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
tarina fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
tilia fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9) ACA PV
tri femynor oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-estarylla oral tablet 0180215025 mg-35 mcg (28)
ACA PV
108
Drug Name Drug Tier Requirements Limits
tri-legest fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9)
ACA PV
tri-linyah oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-lo-estarylla oral tablet 0180215025 mg-25 mcg
ACA PV
tri-lo-marzia oral tablet 0180215025 mg-25 mcg
ACA PV
tri-lo-mili oral tablet 0180215025 mg-25 mcg ACA PV
tri-lo-sprintec oral tablet 0180215025 mg-25 mcg
ACA PV
tri-mili oral tablet 0180215025 mg-35 mcg (28) ACA PV
tri-nymyo oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-previfem (28) oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-sprintec (28) oral tablet 0180215025 mg-35 mcg (28)
ACA PV
trivora (28) oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
tri-vylibra lo oral tablet 0180215025 mg-25 mcg
ACA PV
tri-vylibra oral tablet 0180215025 mg-35 mcg (28)
ACA PV
TYBLUME ORAL TABLETCHEWABLE 01 MG- 20 MCG
ACA PV
tydemy oral tablet 3-003-0451 mg (21) (7) ACA PV
velivet triphasic regimen (28) oral tablet 0112515-25 mg-mcg
ACA PV
vestura (28) oral tablet 3-002 mg ACA PV
vienva oral tablet 01-20 mg-mcg ACA PV
viorele (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
volnea (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
vyfemla (28) oral tablet 04-35 mg-mcg ACA PV
vylibra oral tablet 025-35 mg-mcg ACA PV
wera (28) oral tablet 05-35 mg-mcg ACA PV
wymzya fe oral tabletchewable 04mg-35mcg(21) and 75 mg (7)
ACA PV
109
Drug Name Drug Tier Requirements Limits
zarah oral tablet 3-003 mg ACA PV
zovia 135e (28) oral tablet 1-35 mg-mcg ACA PV
zumandimine (28) oral tablet 3-003 mg ACA PV
OXYTOCICS
methergine oral tablet 02 mg 1
methylergonovine oral tablet 02 mg 1
OPHTHALMOLOGY
ANTIBIOTICS
ak-poly-bac ophthalmic (eye) ointment 500-10000 unitgram
1
AZASITE OPHTHALMIC (EYE) DROPS 1 1
bacitracin ophthalmic (eye) ointment 500 unitgram
1
bacitracin-polymyxin b ophthalmic (eye) ointment 500-10000 unitgram
1
BESIVANCE OPHTHALMIC (EYE) DROPSSUSPENSION 06
1
ciprofloxacin hcl ophthalmic (eye) drops 03 1
erythromycin ophthalmic (eye) ointment 5 mggram (05 )
1
gatifloxacin ophthalmic (eye) drops 05 1
gentak ophthalmic (eye) ointment 03 (3 mggram)
1
gentamicin ophthalmic (eye) drops 03 1
levofloxacin ophthalmic (eye) drops 05 1
moxifloxacin ophthalmic (eye) drops 05 1
moxifloxacin ophthalmic (eye) drops viscous 05
1
NATACYN OPHTHALMIC (EYE) DROPSSUSPENSION 5
1
neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
1
neomycin-polymyxin-gramicidin ophthalmic (eye) drops 175 mg-10000 unit-0025mgml
1
neo-polycin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
1
ofloxacin ophthalmic (eye) drops 03 1
110
Drug Name Drug Tier Requirements Limits
polycin ophthalmic (eye) ointment 500-10000 unitgram
1
polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10000 unit- 1 mgml
1
tobramycin ophthalmic (eye) drops 03 1
TOBREX OPHTHALMIC (EYE) OINTMENT 03
1
ANTIVIRALS
trifluridine ophthalmic (eye) drops 1 1
ZIRGAN OPHTHALMIC (EYE) GEL 015 1
BETA-BLOCKERS
betaxolol ophthalmic (eye) drops 05 1
BETIMOL OPHTHALMIC (EYE) DROPS 025 05
1
BETOPTIC S OPHTHALMIC (EYE) DROPSSUSPENSION 025
1
carteolol ophthalmic (eye) drops 1 1
levobunolol ophthalmic (eye) drops 05 1
timolol maleate ophthalmic (eye) drops 025 05
1
timolol maleate ophthalmic (eye) drops once daily 05
1
timolol maleate ophthalmic (eye) gel forming solution 025 05
1
CYCLOPLEGIC MYDRIATICS
atropine ophthalmic (eye) drops 1 1
atropine ophthalmic (eye) ointment 1 1
cyclopentolate ophthalmic (eye) drops 05 1 2
1
homatropaire ophthalmic (eye) drops 5 1
tropicamide ophthalmic (eye) drops 05 1 1
DIRECT ACTING MIOTICS
pilocarpine hcl ophthalmic (eye) drops 1 2 4
1
MISCELLANEOUS OPHTHALMOLOGICS
ALOCRIL OPHTHALMIC (EYE) DROPS 2 1 ST
ALOMIDE OPHTHALMIC (EYE) DROPS 01 1 ST
111
Drug Name Drug Tier Requirements Limits
altacaine ophthalmic (eye) drops 05 1
azelastine ophthalmic (eye) drops 005 1
BEOVU INTRAVITREAL SOLUTION 6 MG005 ML
MB PA LA
bepotastine besilate ophthalmic (eye) drops 15 1 ST
BEPREVE OPHTHALMIC (EYE) DROPS 15 1 ST
cromolyn ophthalmic (eye) drops 4 1
CYSTARAN OPHTHALMIC (EYE) DROPS 044
2 PA
epinastine ophthalmic (eye) drops 005 1
EYLEA INTRAVITREAL SOLUTION 2 MG005 ML
MB PA LA
EYLEA INTRAVITREAL SYRINGE 2 MG005 ML
MB PA LA
LACRISERT OPHTHALMIC (EYE) INSERT 5 MG
1
LASTACAFT OPHTHALMIC (EYE) DROPS 025
1 ST
LUCENTIS INTRAVITREAL SOLUTION 03 MG005 ML 05 MG005 ML
MB PA LA
LUCENTIS INTRAVITREAL SYRINGE 03 MG005 ML 05 MG005 ML
MB PA LA
LUXTURNA SUBRETINAL SUSPENSION 15 X 10EXP11 VG03 ML (FNL)
MB LA
olopatadine ophthalmic (eye) drops 01 02 1
OMIDRIA INTRAOCULAR CONCENTRATE 1-03
MB
proparacaine ophthalmic (eye) drops 05 1
RESTASIS OPHTHALMIC (EYE) DROPPERETTE 005
1 QL (120 per 30 days)
TETRACAINE HCL (PF) OPHTHALMIC (EYE) DROPS 05
1
tetracaine hcl ophthalmic (eye) drops 05 1
VISUDYNE INTRAVENOUS RECON SOLN 15 MG
MB LA
XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5
1 PA ST QL (60 per 30 days)
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
112
Drug Name Drug Tier Requirements Limits
ACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE 045
1 ST
bromfenac ophthalmic (eye) drops 009 1
diclofenac sodium ophthalmic (eye) drops 01 1
flurbiprofen sodium ophthalmic (eye) drops 003
1
ketorolac ophthalmic (eye) drops 04 05 1
NEVANAC OPHTHALMIC (EYE) DROPSSUSPENSION 01
1
ORAL DRUGS FOR GLAUCOMA
acetazolamide oral capsule extended release 500 mg
1
acetazolamide oral tablet 125 mg 250 mg 1
methazolamide oral tablet 25 mg 50 mg 1
OTHER GLAUCOMA DRUGS
bimatoprost ophthalmic (eye) drops 003 1
brinzolamide ophthalmic (eye) dropssuspension 1
1
COMBIGAN OPHTHALMIC (EYE) DROPS 02-05
1
dorzolamide ophthalmic (eye) drops 2 1
dorzolamide-timolol (pf) ophthalmic (eye) dropperette 2-05
1
dorzolamide-timolol ophthalmic (eye) drops 223-68 mgml
1
latanoprost ophthalmic (eye) drops 0005 1
LUMIGAN OPHTHALMIC (EYE) DROPS 001
1 ST
RHOPRESSA OPHTHALMIC (EYE) DROPS 002
1 PA ST
SIMBRINZA OPHTHALMIC (EYE) DROPSSUSPENSION 1-02
1
travoprost ophthalmic (eye) drops 0004 1
STEROID-ANTIBIOTIC COMBINATIONS
neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
1
neomycin-polymyxin b-dexameth ophthalmic (eye) dropssuspension 35mgml-10000 unitml-01
1
113
Drug Name Drug Tier Requirements Limits
neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 35 mgg-10000 unitg-01
1
neomycin-polymyxin-hc ophthalmic (eye) dropssuspension 35-10000-10 mg-unit-mgml
1
neo-polycin hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
1
TOBRADEX OPHTHALMIC (EYE) OINTMENT 03-01
1
TOBRADEX ST OPHTHALMIC (EYE) DROPSSUSPENSION 03-005
1
tobramycin-dexamethasone ophthalmic (eye) dropssuspension 03-01
1
STEROIDS
ALREX OPHTHALMIC (EYE) DROPSSUSPENSION 02
1 ST
dexamethasone sodium phosphate ophthalmic (eye) drops 01
1
DUREZOL OPHTHALMIC (EYE) DROPS 005
1
fluorometholone ophthalmic (eye) dropssuspension 01
1
FML FORTE OPHTHALMIC (EYE) DROPSSUSPENSION 025
1
FML SOP OPHTHALMIC (EYE) OINTMENT 01
1
INVELTYS OPHTHALMIC (EYE) DROPSSUSPENSION 1
1 ST
LOTEMAX OPHTHALMIC (EYE) OINTMENT 05
1 ST
loteprednol etabonate ophthalmic (eye) dropsgel 05
1
loteprednol etabonate ophthalmic (eye) dropssuspension 05
1
MAXIDEX OPHTHALMIC (EYE) DROPSSUSPENSION 01
1
OZURDEX INTRAVITREAL IMPLANT 07 MG MB LA
PRED MILD OPHTHALMIC (EYE) DROPSSUSPENSION 012
1
prednisolone acetate ophthalmic (eye) dropssuspension 1
1
114
Drug Name Drug Tier Requirements Limits
prednisolone sodium phosphate ophthalmic (eye) drops 1
1
RETISERT INTRAVITREAL IMPLANT 059 MG
MB LA
YUTIQ INTRAVITREAL IMPLANT 018 MG MB
STEROID-SULFONAMIDE COMBINATIONS
BLEPHAMIDE OPHTHALMIC (EYE) DROPSSUSPENSION 10-02
1
BLEPHAMIDE SOP OPHTHALMIC (EYE) OINTMENT 10-02
1
sulfacetamide-prednisolone ophthalmic (eye) drops 10 -023 (025 )
1
SULFONAMIDES
sulfacetamide sodium ophthalmic (eye) drops 10
1
sulfacetamide sodium ophthalmic (eye) ointment 10
1
SYMPATHOMIMETICS
apraclonidine ophthalmic (eye) drops 05 1
brimonidine ophthalmic (eye) drops 015 02 1
IOPIDINE OPHTHALMIC (EYE) DROPPERETTE 1
1
VASOCONSTRICTOR DECONGESTANTS
phenylephrine hcl ophthalmic (eye) drops 10 25
1
RESPIRATORY ALLERGY COUGH amp COLD
ANTIHISTAMINE amp ANTIALLERGENIC AGENTS
adrenalin injection solution 1 mgml 1 mgml (1 ml)
1
carbinoxamine maleate oral liquid 4 mg5 ml 1 PA ST QL (2 per 30 days)
carbinoxamine maleate oral tablet 4 mg 1 PA ST QL (240 per 30 days)
carbinoxamine maleate oral tablet 6 mg 1 PA ST QL (120 per 30 days)
cetirizine oral solution 1 mgml 1
clemastine oral syrup 05 mg5 ml 1
clemastine oral tablet 268 mg 1
cyproheptadine oral syrup 2 mg5 ml 1
cyproheptadine oral tablet 4 mg 1
115
Drug Name Drug Tier Requirements Limits
desloratadine oral tablet 5 mg 1 PA ST QL (30 per 30 days)
desloratadine oral tabletdisintegrating 25 mg 5 mg
1 PA ST
diphenhydramine hcl injection solution 50 mgml 1
diphenhydramine hcl injection syringe 50 mgml MB
EPINEPHRINE INJECTION AUTO-INJECTOR 015 MG015 ML
1
epinephrine injection auto-injector 015 mg03 ml 03 mg03 ml
1
epinephrine injection solution 1 mgml 1 mgml (1 ml)
1
epinephrine injection syringe 01 mgml 1
hydroxyzine hcl intramuscular solution 25 mgml MB
hydroxyzine hcl oral solution 10 mg5 ml 1
hydroxyzine hcl oral tablet 10 mg 25 mg 50 mg 1
hydroxyzine pamoate oral capsule 100 mg 25 mg 50 mg
1
levocetirizine oral solution 25 mg5 ml 1
levocetirizine oral tablet 5 mg 1
promethazine injection solution 25 mgml MB
promethazine oral syrup 625 mg5 ml 1
promethazine oral tablet 125 mg 25 mg 50 mg 1
promethazine rectal suppository 125 mg 25 mg 1
promethegan rectal suppository 125 mg 25 mg 50 mg
1
COUGH amp COLD THERAPY
benzonatate oral capsule 100 mg 150 mg 200 mg 1
brompheniramine-pseudoeph-dm oral syrup 2-30-10 mg5 ml
1
codeine-guaifenesin oral liquid 10-100 mg5 ml 1
g tussin ac oral liquid 10-100 mg5 ml 1
guaiatussin ac oral liquid 10-100 mg5 ml 1
hydrocodone-chlorpheniramine oral suspensionextended rel 12 hr 10-8 mg5 ml
1
hydrocodone-homatropine oral syrup 5-15 mg5 ml
1
hydrocodone-homatropine oral tablet 5-15 mg 1
116
Drug Name Drug Tier Requirements Limits
hydromet oral syrup 5-15 mg5 ml 1
maxi-tuss ac oral liquid 10-100 mg5 ml 1
m-clear wc oral liquid 63-100 mg5 ml 1
promethazine-codeine oral syrup 625-10 mg5 ml 1
promethazine-dm oral syrup 625-15 mg5 ml 1
promethazine-phenyleph-codeine oral syrup 625-5-10 mg5 ml
1
promethazine-phenylephrine oral syrup 625-5 mg5 ml
1
virtussin ac oral liquid 10-100 mg5 ml 1
PULMONARY AGENTS
acetylcysteine solution 100 mgml (10 ) 200 mgml (20 )
1
ADEMPAS ORAL TABLET 05 MG 1 MG 15 MG 2 MG 25 MG
2 PA LA
ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCGACTUATION 230-21 MCGACTUATION 45-21 MCGACTUATION
1 QL (1 per 30 days)
ALBUTEROL HFA 90 MCG INHALER 90 MCGACTUATION
1 QL (2 per 30 days)
albuterol sulfate inhalation inhalation hfa aerosol inhaler 90 mcgactuation
1 QL (2 per 30 days)
albuterol sulfate inhalation inhalation solution for nebulization 063 mg3 ml 125 mg3 ml 25 mg 3 ml (0083 ) 25 mg05 ml 5 mgml
1
albuterol sulfate inhalation oral syrup 2 mg5 ml 1
albuterol sulfate inhalation oral tablet 2 mg 4 mg 1
albuterol sulfate inhalation oral tablet extended release 12 hr 4 mg 8 mg
1
ALVESCO INHALATION HFA AEROSOL INHALER 160 MCGACTUATION 80 MCGACTUATION
1 PA ST QL (1 per 30 days)
alyq oral tablet 20 mg 2 PA
ambrisentan oral tablet 10 mg 5 mg 2 PA LA
aminophylline intravenous solution 250 mg10 ml MB
ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 625-25 MCGACTUATION
1 QL (1 per 30 days)
arformoterol inhalation solution for nebulization 15 mcg2 ml
1
117
Drug Name Drug Tier Requirements Limits
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 200 MCGACTUATION
1 QL (1 per 30 days)
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 50 MCGACTUATION
1
ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCGACTUATION
1 QL (2 per 30 days)
BERINERT INTRAVENOUS KIT 500 UNIT (10 ML)
MB PA LA
BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-48 MCG
1
bosentan oral tablet 125 mg 625 mg 2 PA LA
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCGDOSE
1 QL (1 per 30 days)
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 200-25 MCGDOSE
1
BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG2 ML
1
budesonide inhalation suspension for nebulization 025 mg2 ml 05 mg2 ml
1 QL (120 per 30 days)
budesonide inhalation suspension for nebulization 1 mg2 ml
1 QL (60 per 30 days)
CINQAIR INTRAVENOUS SOLUTION 10 MGML
MB PA
CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)
MB PA LA
COMBIVENT RESPIMAT INHALATION MIST 20-100 MCGACTUATION
1 QL (2 per 30 days)
cromolyn inhalation solution for nebulization 20 mg2 ml
1
DALIRESP ORAL TABLET 250 MCG 500 MCG
1
DULERA INHALATION HFA AEROSOL INHALER 100-5 MCGACTUATION 200-5 MCGACTUATION 50-5 MCGACTUATION
1 QL (1 per 30 days)
ELIXOPHYLLIN ORAL ELIXIR 80 MG15 ML 1
ESBRIET ORAL CAPSULE 267 MG 2 PA LA QL (270 per 30 days)
ESBRIET ORAL TABLET 267 MG 801 MG 2 PA LA QL (90 per 30 days)
FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MGML
MB PA LA
118
Drug Name Drug Tier Requirements Limits
FASENRA SUBCUTANEOUS SYRINGE 30 MGML
MB PA LA
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 50 MCGACTUATION
1 QL (1 per 30 days)
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCGACTUATION
1 QL (4 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCGACTUATION 44 MCGACTUATION
1 QL (1 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCGACTUATION
1 QL (2 per 30 days)
fluticasone propionate nasal spraysuspension 50 mcgactuation
1
fluticasone propion-salmeterol inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose
1 QL (1 per 30 days)
formoterol fumarate inhalation solution for nebulization 20 mcg2 ml
1
HAEGARDA SUBCUTANEOUS RECON SOLN 2000 UNIT 3000 UNIT
2 PA LA
icatibant subcutaneous syringe 30 mg3 ml 2 PA
INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 625 MCGACTUATION
1 QL (1 per 30 days)
ipratropium bromide inhalation solution 002 1
ipratropium-albuterol inhalation solution for nebulization 05 mg-3 mg(25 mg base)3 ml
1 QL (180 per 30 days)
KALBITOR SUBCUTANEOUS SOLUTION 10 MGML (1 ML)
2 PA LA
KALYDECO ORAL GRANULES IN PACKET 25 MG 50 MG 75 MG
2 PA LA
KALYDECO ORAL TABLET 150 MG 2 PA LA
levalbuterol hcl inhalation solution for nebulization 031 mg3 ml 063 mg3 ml 125 mg05 ml 125 mg3 ml
1
LEVALBUTEROL TARTRATE INHALATION HFA AEROSOL INHALER 45 MCGACTUATION
1 QL (2 per 30 days)
metaproterenol oral syrup 10 mg5 ml 1
montelukast oral granules in packet 4 mg 1
montelukast oral tablet 10 mg 1
119
Drug Name Drug Tier Requirements Limits
montelukast oral tabletchewable 4 mg 5 mg 1
nebusal inhalation solution for nebulization 3 1
NUCALA SUBCUTANEOUS RECON SOLN 100 MG
MB PA LA
OFEV ORAL CAPSULE 100 MG 150 MG 2 PA LA QL (60 per 30 days)
OPSUMIT ORAL TABLET 10 MG 2 PA LA
ORLADEYO ORAL CAPSULE 110 MG 150 MG
2 PA ST QL (28 per 28 days)
PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG2 ML
1
pulmosal inhalation solution for nebulization 7 1
PULMOZYME INHALATION SOLUTION 1 MGML
2 PA LA
QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCGACTUATION 80 MCGACTUATION
1
REVATIO INTRAVENOUS SOLUTION 10 MG125 ML
MB LA
RUCONEST INTRAVENOUS RECON SOLN 2100 UNIT
MB PA LA
SEEBRI NEOHALER INHALATION CAPSULE WINHALATION DEVICE 156 MCG
1
SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCGDOSE
1
sildenafil (pulmhypertension) intravenous solution 10 mg125 ml
MB
sildenafil (pulmhypertension) oral suspension for reconstitution 10 mgml
2
sildenafil (pulmhypertension) oral tablet 20 mg 2 PA
SINUVA SINUS IMPLANT 1350 MCG MB
sodium chloride inhalation solution for nebulization 09 10 3 7
1
SPIRIVA RESPIMAT INHALATION MIST 125 MCGACTUATION
1
SPIRIVA RESPIMAT INHALATION MIST 25 MCGACTUATION
1 QL (1 per 30 days)
SPIRIVA WITH HANDIHALER INHALATION CAPSULE WINHALATION DEVICE 18 MCG
1 QL (30 per 30 days)
STIOLTO RESPIMAT INHALATION MIST 25-25 MCGACTUATION
1
120
Drug Name Drug Tier Requirements Limits
STRIVERDI RESPIMAT INHALATION MIST 25 MCGACTUATION
1
SYMBICORT INHALATION HFA AEROSOL INHALER 160-45 MCGACTUATION 80-45 MCGACTUATION
1 QL (1 per 30 days)
SYMDEKO ORAL TABLETS SEQUENTIAL 100-150 MG (D) 150 MG (N) 50-75 MG (D) 75 MG (N)
2 PA LA
tadalafil (pulm hypertension) oral tablet 20 mg 2 PA
TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG2 ML (150 MGML)
2 PA LA
terbutaline oral tablet 25 mg 5 mg 1
terbutaline subcutaneous solution 1 mgml 1
theophylline oral elixir 80 mg15 ml 1
theophylline oral solution 80 mg15 ml 1
theophylline oral tablet extended release 12 hr 300 mg 450 mg
1
theophylline oral tablet extended release 24 hr 400 mg 600 mg
1
TRACLEER ORAL TABLET FOR SUSPENSION 32 MG
2 PA LA
TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-625-25 MCG 200-625-25 MCG
1
TRIKAFTA ORAL TABLETS SEQUENTIAL 100-50-75 MG(D) 150 MG (N) 50-25-375 MG (D)75 MG (N)
2 PA LA
TYVASO INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)
2 PA LA
TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)
2 PA LA
TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML
2 PA LA
UTIBRON NEOHALER INHALATION CAPSULE WINHALATION DEVICE 275-156 MCG
1
VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCGML 20 MCGML
2 PA LA
121
Drug Name Drug Tier Requirements Limits
wixela inhub inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose
1 QL (1 per 30 days)
XOLAIR SUBCUTANEOUS RECON SOLN 150 MG
MB LA
XOLAIR SUBCUTANEOUS SYRINGE 150 MGML 75 MG05 ML
MB PA LA QL (7 per 30 days)
zafirlukast oral tablet 10 mg 20 mg 1
zileuton oral tablet er multiphase 12 hr 600 mg 1 ST
ZYFLO ORAL TABLET 600 MG 1 ST
UROLOGICALS
ANTICHOLINERGICS amp ANTISPASMODICS
darifenacin oral tablet extended release 24 hr 15 mg 75 mg
1
flavoxate oral tablet 100 mg 1
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG 50 MG
1 ST
oxybutynin chloride oral syrup 5 mg5 ml 1
oxybutynin chloride oral tablet 5 mg 1
oxybutynin chloride oral tablet extended release 24hr 10 mg 15 mg 5 mg
1
solifenacin oral tablet 10 mg 5 mg 1
tolterodine oral capsuleextended release 24hr 2 mg 4 mg
1
tolterodine oral tablet 1 mg 2 mg 1
trospium oral capsuleextended release 24hr 60 mg
1
trospium oral tablet 20 mg 1
BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY
alfuzosin oral tablet extended release 24 hr 10 mg 1
dutasteride oral capsule 05 mg 1
dutasteride-tamsulosin oral capsule er multiphase 24 hr 05-04 mg
1
finasteride oral tablet 5 mg 1
silodosin oral capsule 4 mg 8 mg 1
tadalafil oral tablet 25 mg 5 mg 1 PA ST
tamsulosin oral capsule 04 mg 1
CHOLINERGIC STIMULANTS
122
Drug Name Drug Tier Requirements Limits
bethanechol chloride oral tablet 10 mg 25 mg 5 mg 50 mg
1
MISCELLANEOUS UROLOGICALS
CYSTAGON ORAL CAPSULE 150 MG 50 MG 2 PA
ELMIRON ORAL CAPSULE 100 MG 1
hyophen oral tablet 816-012-108 mg 1
K-PHOS NO 2 ORAL TABLET 305-700 MG 1
K-PHOS ORIGINAL ORAL TABLETSOLUBLE 500 MG
1
methen-sod phos-meth blue-hyos oral tablet 816-408-012 mg
1
OXLUMO SUBCUTANEOUS SOLUTION 945 MG05 ML
2 PA
phosphasal oral tablet 816-108-408 mg 1
potassium citrate oral tablet extended release 10 meq (1080 mg) 15 meq 5 meq (540 mg)
1
RENACIDIN IRRIGATION SOLUTION 19806 MG-594 MG-9804MG30ML
1
URELLE ORAL TABLET 81-108-408 MG 1
uretron d-s oral tablet 816-108-408 mg 1
urimar-t oral tablet 120-012-108 mg 1
urogesic-blue oral tablet 816-408-012 mg 1
uryl oral tablet 816-408-012 mg 1
ustell oral capsule 120-012 mg 1
utira-c oral tablet 816-108-408 mg 1
URINARY ANESTHETICS
phenazopyridine oral tablet 100 mg 200 mg 1
VITAMINS HEMATINICS amp ELECTROLYTES
ELECTROLYTES
effer-k oral tablet effervescent 25 meq 1
klor-con 10 oral tablet extended release 10 meq 1
klor-con 8 oral tablet extended release 8 meq 1
klor-con m10 oral tableter particlescrystals 10 meq
1
klor-con m15 oral tableter particlescrystals 15 meq
1
123
Drug Name Drug Tier Requirements Limits
klor-con m20 oral tableter particlescrystals 20 meq
1
klor-con oral packet 20 meq 1
klor-conef oral tablet effervescent 25 meq 1
K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ
1
k-tab oral tablet extended release 8 meq 1
NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION
MB
potassium chloride oral capsule extended release 10 meq 8 meq
1
potassium chloride oral liquid 20 meq15 ml 40 meq15 ml
1
potassium chloride oral packet 20 meq 1
potassium chloride oral tablet extended release 10 meq 20 meq 8 meq
1
potassium chloride oral tableter particlescrystals 10 meq 20 meq
1
sodium chloride 045 intravenous parenteral solution 045
MB
MISCELLANEOUS VITAMINS HEMATINICS amp ELECTROLYTES
ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION
MB
PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION
MB
PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION
MB
VITAMINS amp HEMATINICS
cyanocobalamin (vitamin b-12) injection solution 1000 mcgml
1
ergocalciferol (vitamin d2) oral capsule 1250 mcg (50000 unit)
1
FA-8 ORAL CAPSULE 08 MG ACA PV
FER-IN-SOL ORAL DROPS 15 MG IRON (75 MG)ML
ACA PV
FLORIVA (FLUORIDE-VITAMIN D3) ORAL DROPS 025 MG (055 MG)-400 UNITML
ACA PV
fluoride (sodium) oral drops 05 mg (11 mg sodfluorid)ml
ACA PV
124
Drug Name Drug Tier Requirements Limits
fluoride (sodium) oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)
ACA PV
folic acid injection solution 5 mgml 1
folic acid oral tablet 1 mg 1
folic acid oral tablet 400 mcg 800 mcg ACA PV
hydroxocobalamin intramuscular solution 1000 mcgml
1
INFED INJECTION SOLUTION 50 MGML MB
ludent fluoride oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)
ACA PV
multi-vitamin with fluoride oral drops 025 mgml 05 mgml
ACA PV
multi-vitamin with fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
multivitamins with fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
mvc-fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
NOVAFERRUM ORAL DROPS 15 MG IRONML
ACA PV
tri-vitamin with fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml
ACA PV
vitamins acd and fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml
ACA PV
125
Index
A abacavir 2 abacavir-lamivudine 2 abacavir-lamivudine-
zidovudine 2 ABILIFY MAINTENA 36 abiraterone 13 ABRAXANE 13 acamprosate 66 acarbose 77 accutane 59 acebutolol 45 acetaminophen-caff-
dihydrocod 30 acetaminophen-codeine 31 acetazolamide 112 acetic acid 66 69 acetylcysteine 116 acitretin 57 ACTEMRA 95 ACTEMRA ACTPEN 95 ACTHAR 70 ACTHIB (PF) 90 ACTIMMUNE 89 ACUVAIL (PF) 112 acyclovir 2 63 ADACEL(TDAP
ADOLESNADULT)(PF) 90 ADAKVEO 13 adapalene 59 60 ADAPALENE 60 adapalene-benzoyl peroxide 60 ADCETRIS 14 adefovir 2 ADEMPAS 116 ADHANSIA XR 36 adrenalin 114 adult aspirin regimen 33 ADVAIR HFA 116 ADVATE 50 ADYNOVATE 50 ADZENYS ER 36 ADZENYS XR-ODT 36 AEROCHAMBER MINI 71 AEROCHAMBER PLUS
FLOW-VU 71 AFINITOR 14 afirmelle 102
AFSTYLA 50 AIMOVIG AUTOINJECTOR
28 AJOVY AUTOINJECTOR 28 AJOVY SYRINGE 28 ak-poly-bac 109 AKYNZEO (NETUPITANT)
81 ala-cort 63 albendazole 8 albuterol sulfate inhalation 116 ALBUTEROL SULFATE
INHALATION 116 alclometasone 63 ALCORTIN A 61 ALDURAZYME 74 ALECENSA 14 alendronate 95 alfuzosin 121 ALIMTA 14 ALINIA 8 ALIQOPA 14 aliskiren 45 allopurinol 95 almotriptan malate 28 ALOCRIL 110 ALOGLIPTIN-
PIOGLITAZONE 77 ALOMIDE 110 alosetron 81 ALOXI 81 ALPHANATE 50 ALPHANINE SD 50 alprazolam 37 alprazolam intensol 37 ALPROLIX 50 ALREX 113 ALTABAX 61 altacaine 111 altavera (28) 102 ALVESCO 116 alyacen 135 (28) 102 alyacen 777 (28) 102 alyq 116 amabelz 98 amantadine hcl 2 AMBISOME 1 ambrisentan 116
amcinonide 63 amethia 102 amethyst (28) 102 amikacin 8 amiloride 45 amiloride-hydrochlorothiazide
45 aminocaproic acid 50 51 aminophylline 116 amiodarone 44 AMITIZA 81 amitriptyline 37 amitriptyline-chlordiazepoxide
37 amlodipine 45 amlodipine-atorvastatin 55 amlodipine-benazepril 45 amlodipine-olmesartan 45 amlodipine-valsartan 45 amlodipine-valsartan-hcthiazid
45 ammonium lactate 59 amnesteem 60 amoxapine 37 amoxicil-clarithromy-lansopraz
85 amoxicillin 11 amoxicillin-pot clavulanate 11 AMPHETAMINE 37 amphetamine sulfate 37 amphotericin b 1 ampicillin 11 ampicillin-sulbactam 11 anagrelide 66 anaspaz 80 anastrozole 14 ANDEXXA 51 ANDRODERM 74 ANGELIQ 98 ANNOVERA 101 ANORO ELLIPTA 116 anucort-hc 81 apexicon e 63 APLENZIN 37 APOKYN 27 apraclonidine 114 aprepitant 81 apri 102
126
APTIVUS 2 ARALAST NP 66 aranelle (28) 102 ARANESP (IN
POLYSORBATE) 86 ARCALYST 89 ARESTIN 68 arformoterol 116 aripiprazole 37 ARISTADA 37 ARISTADA INITIO 37 armodafinil 37 ARMOUR THYROID 79 ARNUITY ELLIPTA 117 ARRANON 14 ARZERRA 14 ASCENIV 90 ascomp with codeine 31 asenapine maleate 37 ashlyna 102 ASPARLAS 14 aspirin 33 34 aspirin low dose 33 aspirin-dipyridamole 51 aspir-trin 34 atazanavir 2 atenolol 45 atenolol-chlorthalidone 45 ATGAM 90 atomoxetine 37 atorvastatin 55 atovaquone 8 atovaquone-proguanil 8 atropine 80 110 ATROVENT HFA 117 AUBAGIO 87 aubra 102 aubra eq 102 aurovela 1530 (21) 102 aurovela 120 (21) 102 aurovela 24 fe 102 aurovela fe 1530 (28) 102 aurovela fe 1-20 (28) 102 AUSTEDO 29 AVASTIN 14 aviane 102 avidoxy 12 avita 60 AVITA 60 AVONEX 88 AVYCAZ 6
ayuna 102 AZASITE 109 azathioprine 14 azelaic acid 60 azelastine 68 111 AZELEX 60 azithromycin 7 azurette (28) 102 B bacitracin 8 109 bacitracin-polymyxin b 109 baclofen 30 BALCOLTRA 102 balsalazide 81 BALVERSA 14 balziva (28) 102 BANZEL 24 BAQSIMI 71 BARACLUDE 2 BAVENCIO 14 BAXDELA 12 bayer aspirin 34 BAYER CHEWABLE
ASPIRIN 34 BCG VACCINE LIVE (PF) 90 BELEODAQ 14 belladonna alkaloids-opium 80 BELRAPZO 14 BELSOMRA 37 benazepril 45 benazepril-hydrochlorothiazide
45 BENDAMUSTINE 14 BENDEKA 14 BENEFIX 51 BENLYSTA 96 benzonatate 115 benztropine 27 BEOVU 111 bepotastine besilate 111 BEPREVE 111 BERINERT 117 beser 63 BESIVANCE 109 BESPONSA 14 betamethasone dipropionate 63 betamethasone valerate 63 betamethasone augmented 63
64 BETASERON 88 betaxolol 45 110
bethanechol chloride 122 BETIMOL 110 BETOPTIC S 110 BEVESPI AEROSPHERE 117 bexarotene 14 BEXSERO 90 bicalutamide 14 BICILLIN C-R 11 BIKTARVY 2 bimatoprost 112 BIOTHRAX 90 bisoprolol fumarate 45 bisoprolol-hydrochlorothiazide
45 BIVIGAM 90 BLEPHAMIDE 114 BLEPHAMIDE SOP 114 BLINCYTO 14 blisovi 24 fe 102 blisovi fe 1530 (28) 102 blisovi fe 120 (28) 103 BOOSTRIX TDAP 90 BORTEZOMIB 14 bosentan 117 BOSULIF 14 BOTOX 90 BRAFTOVI 14 BREO ELLIPTA 117 briellyn 103 BRILINTA 51 brimonidine 114 BRINEURA 75 brinzolamide 112 BRIVIACT 24 bromfenac 112 bromocriptine 27 brompheniramine-pseudoeph-
dm 115 BROVANA 117 budesonide 81 117 bumetanide 45 buprenorphine 31 buprenorphine hcl 31 buprenorphine-naloxone 34 bupropion hcl 37 38 bupropion hcl (smoking deter)
68 buspirone 38 BUSULFEX 15 butalbital compound wcodeine
31
127
butalbital-acetaminop-caf-cod 31
butalbital-acetaminophen-caff 31
butalbital-aspirin-caffeine 31 butorphanol 34 BYDUREON BCISE 77 BYETTA 77 BYSTOLIC 45 C CABENUVA 2 cabergoline 75 CABLIVI 51 CABOMETYX 15 calcipotriene 57 calcipotriene-betamethasone 57 calcitonin (salmon) 75 calcitriol 57 75 calcium acetate(phosphat bind)
81 CALQUENCE 15 camila 98 camrese 103 camrese lo 103 CANCIDAS 1 candesartan 45 candesartan-hydrochlorothiazid
46 CAPASTAT 8 capecitabine 15 CAPRELSA 15 captopril 46 captopril-hydrochlorothiazide
46 CARBAGLU 66 carbamazepine 24 carbidopa 27 carbidopa-levodopa 27 carbidopa-levodopa-
entacapone 27 carbinoxamine maleate 114 carisoprodol 30 carisoprodol-aspirin 30 carisoprodol-aspirin-codeine 30 carteolol 110 cartia xt 46 carvedilol 46 carvedilol phosphate 46 cataflam 34 CAYA CONTOURED 98 CAYSTON 8
caziant (28) 103 cefaclor 6 cefadroxil 6 cefazolin 6 cefazolin in dextrose (iso-os) 6 cefdinir 6 cefditoren pivoxil 6 cefepime 6 CEFEPIME IN DEXTROSE 5
6 cefepime in dextroseiso-osm 6 cefixime 6 CEFOTAN 6 cefotaxime 6 cefotetan 6 CEFOTETAN IN
DEXTROSE ISO-OSM 6 cefoxitin 6 cefpodoxime 6 7 cefprozil 7 ceftazidime 7 CEFTAZIDIME IN D5W 7 ceftriaxone 7 CEFTRIAXONE 7 ceftriaxone in dextroseiso-os 7 cefuroxime axetil 7 celecoxib 34 CELONTIN 24 cephalexin 7 CERDELGA 75 CEREZYME 75 cetirizine 114 cevimeline 66 CHANTIX 68 CHANTIX CONTINUING
MONTH BOX 68 CHANTIX STARTING
MONTH BOX 68 charlotte 24 fe 103 chateal (28) 103 chateal eq (28) 103 CHEMET 66 childrens aspirin 34 chloramphenicol sod succinate
8 chlordiazepoxide hcl 38 chlordiazepoxide-clidinium 80 chlorhexidine gluconate 68 chloroquine phosphate 8 chlorpromazine 38 chlorthalidone 46
chlorzoxazone 30 CHOLBAM 81 cholestyramine (with sugar) 55 cholestyramine light 55 cholinemagnesium salicylate
34 ciclodan 62 ciclopirox 62 ciclopirox-ure-camph-menth-
euc 62 cidofovir 2 cilostazol 51 CIMDUO 2 cimetidine 85 cimetidine hcl 85 CIMZIA 82 CIMZIA POWDER FOR
RECONST 81 cinacalcet 75 CINQAIR 117 CINRYZE 117 CIPRO HC 69 ciprofloxacin 12 ciprofloxacin hcl 12 69 109 ciprofloxacin-dexamethasone
69 citalopram 38 claravis 60 clarithromycin 7 8 clemastine 114 CLENPIQ 82 clindacin p 60 clindamycin hcl 8 clindamycin pediatric 8 clindamycin phosphate 8 60
101 clindamycin-benzoyl peroxide
60 clindamycin-tretinoin 60 clobazam 24 clobetasol 64 clobetasol-emollient 64 CLOCORTOLONE
PIVALATE 64 CLODERM 64 CLOLAR 15 clomipramine 38 clonazepam 24 clonidine 46 clonidine hcl 38 46 clopidogrel 51
128
clorazepate dipotassium 38 clotrimazole 1 62 clotrimazole-betamethasone 62 clovique 66 clozapine 38 COAGADEX 51 COARTEM 8 codeine sulfate 31 codeine-butalbital-asa-caff 31 codeine-guaifenesin 115 colchicine 95 COLCHICINE 95 colesevelam 55 colestipol 55 COMBIGAN 112 COMBIPATCH 98 COMBIVENT RESPIMAT 117 COMETRIQ 15 COMPLERA 2 compro 82 constulose 82 CONTOUR NEXT TEST
STRIPS 71 CONTOUR TEST STRIPS 71 COPIKTRA 15 CORIFACT 51 CORLANOR 56 CORTIFOAM 82 COSENTYX 58 COSENTYX (2 SYRINGES)
57 COSENTYX PEN 58 COSENTYX PEN (2 PENS) 58 COTELLIC 15 COTEMPLA XR-ODT 38 covaryx 98 covaryx hs 98 CREON 82 CRESEMBA 1 CRINONE 98 cromolyn 82 111 117 crotan 66 cryselle (28) 103 CRYSVITA 75 CUBICIN 8 CUBICIN RF 9 CUTAQUIG 90 CUVITRU 90 cyanocobalamin (vitamin b-12)
123 cyclafem 135 (28) 103
cyclafem 777 (28) 103 cyclobenzaprine 30 cyclopentolate 110 cyclophosphamide 15 CYCLOPHOSPHAMIDE 15 CYCLOSERINE 9 CYCLOSET 77 cyclosporine 15 cyclosporine modified 15 cyproheptadine 114 CYRAMZA 15 cyred 103 cyred eq 103 CYSTAGON 122 CYSTARAN 111 CYTOVENE 2 D DACOGEN 15 dalfampridine 29 DALIRESP 117 danazol 75 dantrolene 30 dapsone 9 60 DAPTACEL (DTAP
PEDIATRIC) (PF) 91 darifenacin 121 DARZALEX 15 dasetta 135 (28) 103 dasetta 777 (28) 103 DAURISMO 15 daysee 103 DAYTRANA 38 deblitane 98 decadron 70 decitabine 15 deferasirox 66 deferiprone 66 demeclocycline 12 DENAVIR 63 denta 5000 plus 68 dentagel 69 DEPO-ESTRADIOL 98 DEPO-PROVERA 98 DEPO-SUBQ PROVERA 104
98 DEPO-TESTOSTERONE 75 DESCOVY 2 desipramine 38 desloratadine 115 desmopressin 75
desog-eestradioleestradiol 103
desogestrel-ethinyl estradiol 103
desonide 64 desoximetasone 64 DESVENLAFAXINE 38 desvenlafaxine succinate 38 dexamethasone 70 dexamethasone intensol 70 dexamethasone sodium phos
(pf) 70 dexamethasone sodium
phosphate 70 113 DEXILANT 85 dexmethylphenidate 38 dextroamphetamine 38 39 dextroamphetamine-
amphetamine 39 diazepam 24 39 diazepam intensol 39 diazoxide 71 diclofenac potassium 34 diclofenac sodium 34 59 112 diclofenac-misoprostol 34 dicloxacillin 11 dicyclomine 80 didanosine 2 DIFICID 8 diflorasone 64 diflunisal 34 digitek 50 digox 50 digoxin 50 dihydroergotamine 28 DILANTIN 24 DILANTIN EXTENDED 24 DILANTIN INFATABS 24 DILANTIN-125 24 diltiazem 46 dilt-xr 46 dimethyl fumarate 88 DIPENTUM 82 diphenhydramine hcl 115 diphenoxylate-atropine 80 dipyridamole 51 diskets 31 disopyramide phosphate 44 disulfiram 66 divalproex 24 25 DIVIGEL 99
129
dofetilide 44 dolishale 103 donepezil 29 DONNATAL 80 DOPTELET (15 TAB PACK)
51 dorzolamide 112 dorzolamide-timolol 112 dorzolamide-timolol (pf) 112 dotti 99 DOVATO 2 doxazosin 46 doxepin 39 doxercalciferol 75 doxycycline hyclate 12 doxycycline monohydrate 12 doxylamine-pyridoxine (vit b6)
82 dronabinol 82 drospirenone-eestradiol-lmfa
103 drospirenone-ethinyl estradiol
103 DSUVIA 31 DUAVEE 99 DUEXIS 34 DULERA 117 duloxetine 39 DUPIXENT PEN 59 DUPIXENT SYRINGE 59 duramorph (pf) 31 DUREZOL 113 dutasteride 121 dutasteride-tamsulosin 121 dvorah 31 DYANAVEL XR 39 DYSPORT 91 E ees 400 8 econazole 62 econtra ez 103 econtra one-step 103 ecotrin 34 ecotrin low strength 34 EDARBI 46 EDARBYCLOR 46 EDLUAR 39 ed-spaz 80 EDURANT 2 eemt 99 eemt hs 99
efavirenz 2 efavirenz-emtricitabin-tenofov
3 efavirenz-lamivu-tenofov disop
3 effer-k 122 ELAPRASE 75 ELELYSO 75 eletriptan 28 ELIGARD 16 ELIGARD (3 MONTH) 15 ELIGARD (4 MONTH) 15 ELIGARD (6 MONTH) 15 elinest 103 ELIQUIS 51 ELIQUIS DVT-PE TREAT
30D START 51 ELIXOPHYLLIN 117 ELLA 103 ELMIRON 122 ELOCTATE 51 eluryng 101 ELZONRIS 16 EMCYT 16 EMEND 82 EMGALITY PEN 28 EMGALITY SYRINGE 28 emoquette 103 EMPAVELI 67 EMPLICITI 16 EMSAM 39 emtricitabine 3 emtricitabine-tenofovir (tdf) 3 EMTRIVA 3 EMVERM 9 enalapril maleate 46 enalaprilat 46 enalapril-hydrochlorothiazide
46 ENBREL 96 ENBREL MINI 96 ENBREL SURECLICK 96 endocet 31 ENGERIX-B (PF) 91 ENGERIX-B PEDIATRIC
(PF) 91 ENHERTU 16 enoxaparin 51 enpresse 104 enskyce 104 entacapone 27
entecavir 3 ENTRESTO 56 ENTYVIO 82 enulose 82 EPANED 46 EPCLUSA 3 EPIDIOLEX 25 epinastine 111 epinephrine 115 EPINEPHRINE 115 epitol 25 EPIVIR HBV 3 eplerenone 47 EPOGEN 86 epoprostenol (glycine) 47 eprosartan 47 ERAXIS(WATER DILUENT)
1 ERBITUX 16 ergocalciferol (vitamin d2) 123 ergoloid 39 ergotamine-caffeine 28 ERLEADA 16 erlotinib 16 errin 99 ERWINAZE 16 ery pads 60 erygel 60 ery-tab 8 erythrocin (as stearate) 8 erythromycin 8 109 erythromycin ethylsuccinate 8 erythromycin with ethanol 60 erythromycin-benzoyl peroxide
60 ESBRIET 117 escitalopram oxalate 39 esomeprazole magnesium 85 ESPEROCT 51 estarylla 104 estazolam 39 estradiol 99 estradiol valerate 99 estradiol-norethindrone acet 99 ESTRING 99 estrogens-methyltestosterone 99 eszopiclone 39 ethacrynic acid 47 ethambutol 9 ethosuximide 25
130
ethynodiol diac-eth estradiol 104
etodolac 34 etonogestrel-ethinyl estradiol
101 etoposide 16 etravirine 3 EUCRISA 59 EUFLEXXA 34 EURAX 66 EVAMIST 99 EVENITY 95 everolimus (antineoplastic) 16 everolimus
(immunosuppressive) 16 EVOTAZ 3 EXELDERM 62 exemestane 16 EXONDYS-51 29 EYLEA 111 ezetimibe 55 ezetimibe-simvastatin 55 F FA-8 123 FABRAZYME 75 FACTIVE 12 falmina (28) 104 famciclovir 3 famotidine 86 famotidine (pf) 85 FANAPT 39 FARXIGA 77 FASENRA 118 FASENRA PEN 117 FASLODEX 16 fayosim 104 FC2 FEMALE CONDOM 98 febuxostat 95 FEIBA NF 51 felbamate 25 felodipine 47 fem ph 101 FEMCAP 98 FEMRING 99 femynor 104 fenofibrate 55 FENOFIBRATE 55 fenofibrate micronized 55 fenofibrate nanocrystallized 55 fenofibric acid 55 fenofibric acid (choline) 55
fenoprofen 35 fentanyl 32 fentanyl citrate 31 FER-IN-SOL 123 FERRIPROX 67 FETZIMA 39 FIASP FLEXTOUCH U-100
INSULIN 72 FIASP PENFILL U-100
INSULIN 72 FIASP U-100 INSULIN 72 FIBRYGA 51 finasteride 121 FINTEPLA 25 FIRMAGON KIT W
DILUENT SYRINGE 16 flac otic oil 69 flavoxate 121 FLEBOGAMMA DIF 91 flecainide 44 FLOLAN 47 FLORIVA (FLUORIDE-
VITAMIN D3) 123 FLOVENT DISKUS 118 FLOVENT HFA 118 fluconazole 1 flucytosine 1 fludarabine 16 fludrocortisone 70 fluocinolone 64 fluocinolone acetonide oil 69 fluocinolone and shower cap 64 fluocinonide 64 fluocinonide-e 64 fluoride (sodium) 69 123 124 fluorometholone 113 fluorouracil 16 59 FLUOROURACIL 59 fluoxetine 39 40 fluphenazine hcl 40 flurandrenolide 64 65 flurazepam 40 flurbiprofen 35 flurbiprofen sodium 112 flutamide 16 fluticasone propionate 65 118 fluticasone propion-salmeterol
118 fluvastatin 55 56 fluvoxamine 40 FML FORTE 113
FML SOP 113 folic acid 124 FOLOTYN 16 fondaparinux 51 formoterol fumarate 118 FORTEO 95 FOSAMAX PLUS D 95 fosamprenavir 3 fosfomycin tromethamine 13 fosinopril 47 fosinopril-hydrochlorothiazide
47 FRAGMIN 52 FREESTYLE LIBRE 14 DAY
SENSOR 71 FREESTYLE LIBRE 2
SENSOR 71 frovatriptan 28 fulvestrant 16 furosemide 47 FUZEON 3 fyavolv 99 G g tussin ac 115 gabapentin 25 GALAFOLD 75 galantamine 29 GAMASTAN 91 GAMASTAN SD 91 GAMIFANT 16 GAMMAGARD LIQUID 91 GAMMAGARD S-D (IGA lt 1
MCGML) 91 GAMMAKED 91 GAMMAPLEX 91 GAMMAPLEX (WITH
SORBITOL) 91 GAMUNEX-C 91 GANCICLOVIR 3 ganciclovir sodium 3 GARDASIL 9 (PF) 91 gatifloxacin 109 gavilyte-c 82 gavilyte-g 82 gavilyte-n 82 GAZYVA 16 gemcitabine 16 17 gemfibrozil 56 gemmily 104 generlac 82 gengraf 17
131
GENOTROPIN 87 GENOTROPIN MINIQUICK
87 gentak 109 gentamicin 9 61 62 109 gentamicin sulfate (ped) (pf) 9 GENVOYA 3 GIAPREZA 56 GILENYA 88 GILOTRIF 17 GIVLAARI 67 GLASSIA 67 glatiramer 88 glatopa 88 GLEOSTINE 17 glimepiride 77 glipizide 77 glipizide-metformin 77 GLUCAGEN DIAGNOSTIC
KIT 71 GLUCAGEN HYPOKIT 71 GLUCAGON (HCL)
EMERGENCY KIT 71 glucagon emergency kit
(human) 71 GLUCAGON HCL 71 glyburide 77 glyburide micronized 77 glyburide-metformin 77 glycopyrrolate 80 GLYXAMBI 78 GONITRO 57 granisetron hcl 82 GRANIX 86 GRASTEK 91 griseofulvin microsize 1 griseofulvin ultramicrosize 1 guaiatussin ac 115 guanfacine 40 47 GYNAZOLE-1 101 gynol ii 101 H HAEGARDA 118 hailey 104 hailey 24 fe 104 hailey fe 1530 (28) 104 hailey fe 120 (28) 104 HALAVEN 17 halcinonide 65 halobetasol propionate 65 haloperidol 40
haloperidol decanoate 40 haloperidol lactate 40 HARVONI 3 HAVRIX (PF) 91 92 heather 99 HEMLIBRA 52 hemmorex-hc 82 HEMOFIL M HIGH 52 HEMOFIL M LOW 52 HEMOFIL M MID 52 HEMOFIL M SUPER HIGH52 hep flush-10 (pf) 52 heparin (porcine) 52 heparin (porcine) in 5 dex 52 heparin lock flush (porcine) 52 heparin lockflush(porcine)(pf)
52 heparin(porcine) in 045 nacl
52 HEPARIN(PORCINE) IN
045 NACL 52 heparin porcine (pf) 52 53 HEPLISAV-B (PF) 92 HERCEPTIN 17 HERCEPTIN HYLECTA 17 HERZUMA 17 HETLIOZ 40 HETLIOZ LQ 40 HIBERIX (PF) 92 HIZENTRA 92 homatropaire 110 HUMALOG JUNIOR
KWIKPEN U-100 72 HUMALOG KWIKPEN
INSULIN 72 HUMALOG MIX 50-50
INSULN U-100 72 HUMALOG MIX 50-50
KWIKPEN 72 HUMALOG MIX 75-25
KWIKPEN 72 HUMALOG MIX 75-25(U-
100)INSULN 72 HUMALOG U-100 INSULIN
72 HUMATE-P 53 HUMIRA 96 HUMIRA PEN 96 HUMIRA PEN CROHNS-UC-
HS START 96
HUMIRA PEN PSOR-UVEITS-ADOL HS 96
HUMIRA(CF) 97 HUMIRA(CF) PEDI
CROHNS STARTER 96 HUMIRA(CF) PEN 96 HUMIRA(CF) PEN
CROHNS-UC-HS 96 HUMIRA(CF) PEN
PEDIATRIC UC 96 HUMIRA(CF) PEN PSOR-
UV-ADOL HS 96 HUMULIN 7030 U-100
INSULIN 72 HUMULIN 7030 U-100
KWIKPEN 72 HUMULIN N NPH INSULIN
KWIKPEN 73 HUMULIN N NPH U-100
INSULIN 73 HUMULIN R REGULAR U-
100 INSULN 73 HUMULIN R U-500 (CONC)
INSULIN 73 HUMULIN R U-500 (CONC)
KWIKPEN 73 HYCAMTIN 17 hydralazine 47 hydrochlorothiazide 47 hydrocodone bitartrate 32 hydrocodone-acetaminophen 32 hydrocodone-chlorpheniramine
115 hydrocodone-homatropine 115 hydrocodone-ibuprofen 32 hydrocortisone 65 70 82 hydrocortisone acetate 82 hydrocortisone butyrate 65 hydrocortisone butyr-emollient
65 hydrocortisone valerate 65 hydrocortisone-acetic acid 69 hydrocortisone-pramoxine 58
82 hydromet 116 hydromorphone 32 HYDROMORPHONE 32 hydroxocobalamin 124 hydroxychloroquine 9 hydroxyprogest(pf)(preg presv)
99
132
hydroxyprogesterone cap(ppres) 99
hydroxyprogesterone caproate 100
hydroxyurea 17 hydroxyzine hcl 115 hydroxyzine pamoate 115 hyophen 122 hyoscyamine sulfate 80 hyosyne 80 HYQVIA 92 I ibandronate 95 IBRANCE 17 ibu 35 ibuprofen 35 icatibant 118 iclevia 104 ICLUSIG 17 icosapent ethyl 56 IDELVION 53 IDHIFA 17 ILARIS (PF) 90 ILUMYA 58 imatinib 17 IMBRUVICA 17 IMFINZI 17 imipenem-cilastatin 9 imipramine hcl 40 imipramine pamoate 40 imiquimod 90 IMLYGIC 17 IMOVAX RABIES VACCINE
(PF) 92 incassia 100 INCRELEX 67 INCRUSE ELLIPTA 118 indapamide 47 indomethacin 35 INFANRIX (DTAP) (PF) 92 INFED 124 INFLECTRA 82 INFUGEM 18 INLYTA 18 INSULIN ASP PRT-INSULIN
ASPART 73 INSULIN ASPART U-100 73 INSULIN SYRINGE-
NEEDLE U-100 71 INTELENCE 3 INTRAROSA 101
INTRON A 90 INVANZ 9 INVEGA SUSTENNA 40 INVELTYS 113 INVIRASE 3 IOPIDINE 114 IPOL 92 ipratropium bromide 69 118 ipratropium-albuterol 118 irbesartan 47 irbesartan-hydrochlorothiazide
47 IRESSA 18 ISENTRESS 3 ISENTRESS HD 3 isibloom 104 ISOLYTE-S 123 isoniazid 9 isosorbide dinitrate 57 isosorbide mononitrate 57 isotretinoin 60 isoxsuprine 101 isradipine 47 ISTODAX 18 itraconazole 1 ivermectin 9 66 IXEMPRA 18 IXIARO (PF) 92 IXINITY 53 J jaimiess 104 JAKAFI 18 jantoven 53 JANUMET 78 JANUMET XR 78 JANUVIA 78 JARDIANCE 78 jasmiel (28) 104 jencycla 100 JENTADUETO 78 JENTADUETO XR 78 JEVTANA 18 jinteli 100 JIVI 53 jolessa 104 JORNAY PM 40 JUBLIA 62 juleber 104 JULUCA 3 junel 1530 (21) 104 junel 120 (21) 104
junel fe 1530 (28) 104 junel fe 120 (28) 104 junel fe 24 104 JUXTAPID 56 JYNARQUE 75 K KADCYLA 18 kaitlib fe 104 KALBITOR 118 KALETRA 3 4 kalliga 104 KALYDECO 118 KANJINTI 18 KANUMA 75 kariva (28) 104 kelnor 135 (28) 105 kelnor 1-50 (28) 105 KEPIVANCE 13 ketoconazole 1 62 ketodan 62 ketoprofen 35 ketorolac 35 112 KEVZARA 97 KEYTRUDA 18 KINRIX (PF) 92 KISQALI 18 KISQALI FEMARA CO-
PACK 18 klor-con 123 klor-con 10 122 klor-con 8 122 klor-con m10 122 klor-con m15 122 klor-con m20 123 klor-conef 123 KOATE 53 KOGENATE FS 53 KORLYM 75 KOVALTRY 53 K-PHOS NO 2 122 K-PHOS ORIGINAL 122 KRYSTEXXA 95 k-tab 123 K-TAB 123 kurvelo (28) 105 KYLEENA 98 KYMRIAH 18 KYPROLIS 18 L l norgesteestradiol-eestrad
105
133
labetalol 47 LACRISERT 111 lactulose 83 lamivudine 4 lamivudine-zidovudine 4 lamotrigine 25 lansoprazole 86 lanthanum 83 LANTUS SOLOSTAR U-100
INSULIN 73 LANTUS U-100 INSULIN 73 lapatinib 18 larin 1530 (21) 105 larin 120 (21) 105 larin 24 fe 105 larin fe 1530 (28) 105 larin fe 120 (28) 105 larissia 105 LASTACAFT 111 latanoprost 112 LATUDA 40 layolis fe 105 leena 28 105 leflunomide 97 LEMTRADA 88 LENVIMA 18 lessina 105 letrozole 19 leucovorin calcium 13 LEUKERAN 19 LEUKINE 86 leuprolide 19 levalbuterol hcl 118 LEVALBUTEROL
TARTRATE 118 LEVEMIR FLEXTOUCH U-
100 INSULN 73 LEVEMIR U-100 INSULIN 73 levetiracetam 25 levobunolol 110 levocarnitine 67 levocarnitine (with sugar) 67 levocetirizine 115 levofloxacin 12 109 levonest (28) 105 levonorgestrel 105 levonorgestrel-ethinyl estrad
105 levonorg-eth estrad triphasic
105 levora-28 105
levorphanol tartrate 32 levothyroxine 79 levoxyl 79 LEVULAN 59 LEXIVA 4 LIBTAYO 19 lidocaine 61 lidocaine hcl 61 lidocaine hcl-hydrocortison ac
61 83 LIDOCAINE HCL-
HYDROCORTISON AC 83 lidocaine viscous 61 lidocaine-hydrocortisone-aloe
83 lidocaine-prilocaine 61 LIDOCAINE-TETRACAINE
61 LILETTA 98 lillow (28) 105 LINCOCIN 9 lindane 66 linezolid 9 linezolid in dextrose 5 9 linezolid-09 sodium chloride
9 LINZESS 83 liothyronine 79 LIPOFEN 56 lisinopril 47 lisinopril-hydrochlorothiazide
47 lithium carbonate 40 41 LO LOESTRIN FE 105 lojaimiess 105 LONSURF 19 loperamide 80 lopinavir-ritonavir 4 lorazepam 41 lorazepam intensol 41 loryna (28) 105 losartan 47 losartan-hydrochlorothiazide 47 LOTEMAX 113 loteprednol etabonate 113 lovastatin 56 low-ogestrel (28) 105 loxapine succinate 41 lo-zumandimine (28) 105 LUCENTIS 111 ludent fluoride 124
LULICONAZOLE 62 LUMIGAN 112 LUMIZYME 75 LUMOXITI 19 LUPANETA PACK (1
MONTH) 101 LUPANETA PACK (3
MONTH) 101 LUPKYNIS 19 LUPRON DEPOT 19 LUPRON DEPOT (3
MONTH) 19 LUPRON DEPOT (4
MONTH) 19 LUPRON DEPOT (6
MONTH) 19 LUPRON DEPOT-PED 19 LUPRON DEPOT-PED (3
MONTH) 19 lutera (28) 105 LUXTURNA 111 LUZU 62 lyleq 100 lyllana 100 LYNPARZA 19 LYRICA CR 25 LYSODREN 19 lyza 100 M mafenide acetate 62 malathion 66 maprotiline 41 marlissa (28) 106 MARPLAN 41 MARQIBO 19 MATULANE 19 matzim la 47 MAVENCLAD (10 TABLET
PACK) 88 MAVENCLAD (4 TABLET
PACK) 88 MAVENCLAD (5 TABLET
PACK) 88 MAVENCLAD (6 TABLET
PACK) 88 MAVENCLAD (7 TABLET
PACK) 88 MAVENCLAD (8 TABLET
PACK) 88 MAVENCLAD (9 TABLET
PACK) 88
134
MAVYRET 4 MAXIDEX 113 maxi-tuss ac 116 MAYZENT 88 MAYZENT STARTER PACK
88 m-clear wc 116 meclizine 83 meclofenamate 35 medroxyprogesterone 100 mefenamic acid 35 mefloquine 9 megestrol 19 MEKINIST 19 MEKTOVI 19 meloxicam 35 melphalan 19 melphalan hcl 19 memantine 29 MENACTRA (PF) 92 MENEST 100 MENOSTAR 100 MENQUADFI (PF) 92 MENTAX 62 MENVEO A-C-Y-W-135-DIP
(PF) 92 meperidine 32 meprobamate 30 MEPSEVII 76 mercaptopurine 20 meropenem 9 MEROPENEM-09
SODIUM CHLORIDE 9 merzee 106 mesalamine 83 mesalamine with cleansing
wipe 83 metaproterenol 118 metaxalone 30 metformin 78 methadone 32 methadose 32 methamphetamine 41 methazolamide 112 methenamine hippurate 13 methenamine mandelate 13 methen-sod phos-meth blue-
hyos 122 methergine 109 methimazole 71 methocarbamol 30
methotrexate sodium 20 methotrexate sodium (pf) 20 methoxsalen 59 methscopolamine 80 methyldopa 47 methyldopa-
hydrochlorothiazide 47 methyldopate 48 methylergonovine 109 METHYLIN 41 methylphenidate hcl 41 methylprednisolone 70 methylprednisolone acetate 70 methyltestosterone 76 metoclopramide hcl 83 metolazone 48 metoprolol succinate 48 metoprolol ta-hydrochlorothiaz
48 metoprolol tartrate 48 metronidazole 9 60 61 101 metyrosine 48 mexiletine 44 MIACALCIN 76 mibelas 24 fe 106 microgestin 1530 (21) 106 microgestin 120 (21) 106 microgestin fe 1530 (28) 106 microgestin fe 120 (28) 106 midazolam 41 midodrine 67 migergot 28 miglitol 78 miglustat 76 mili 106 millipred 70 millipred dp 70 mimvey 100 MINITRAN 57 minocycline 12 minoxidil 48 MIRCERA 86 MIRENA 98 mirtazapine 41 misoprostol 86 MITIGARE 95 mitoxantrone 20 M-M-R II (PF) 92 modafinil 41 moexipril 48 molindone 41
mometasone 65 mondoxyne nl 12 mono-linyah 106 MONONINE 53 MONOVISC 35 montelukast 118 119 morphine 32 33 morphine (pf) 32 morphine concentrate 32 MOTOFEN 80 MOVANTIK 83 MOXATAG 11 moxifloxacin 12 109 MOZOBIL 87 MULPLETA 53 MULTAQ 44 multi-vitamin with fluoride 124 multivitamins with fluoride 124 mupirocin 62 mupirocin calcium 62 mvc-fluoride 124 my choice 106 my way 106 MYALEPT 76 MYCAMINE 1 mycophenolate mofetil 20 mycophenolate sodium 20 MYDAYIS 41 MYLOTARG 20 MYOBLOC 92 myorisan 61 MYRBETRIQ 121 N nabumetone 35 nadolol 48 nadolol-bendroflumethiazide 48 nafcillin 11 nafcillin in dextrose iso-osm 11 naftifine 62 63 NAGLAZYME 76 nalbuphine 35 naloxone 35 naltrexone 35 naproxen 35 naproxen sodium 35 naratriptan 28 NARCAN 35 NATACYN 109 NATAZIA 106 nateglinide 78 NATPARA 76
135
nebusal 119 necon 0535 (28) 106 nefazodone 41 neomycin 9 neomycin-bacitracin-poly-hc
112 neomycin-bacitracin-
polymyxin 109 neomycin-polymyxin b-
dexameth 112 113 neomycin-polymyxin-
gramicidin 109 neomycin-polymyxin-hc 69
113 neo-polycin 109 neo-polycin hc 113 NERLYNX 20 NEUPOGEN 87 NEVANAC 112 nevirapine 4 new day 106 NEXAVAR 20 NEXPLANON 101 NEXTSTELLIS 106 niacin 56 NIACOR 56 nicardipine 48 nicorette 68 nicotine 68 nicotine (polacrilex) 68 NICOTROL 68 NICOTROL NS 68 nifedipine 48 nikki (28) 106 nilutamide 20 nimodipine 48 NINLARO 20 nisoldipine 48 nitazoxanide 9 nitisinone 67 nitro-bid 57 NITRO-DUR 57 nitrofurantoin 13 nitrofurantoin macrocrystal 13 nitrofurantoin monohydm-
cryst 13 nitroglycerin 57 nitroglycerin in 5 dextrose 57 nitro-time 57 NITYR 67 NIVESTYM 87
nizatidine 86 nora-be 100 noreth-ethinyl estradiol-iron
106 norethindrone (contraceptive)
100 norethindrone acetate 100 norethindrone ac-eth estradiol
100 106 norethindrone-eestradiol-iron
106 norgestimate-ethinyl estradiol
106 norlyda 100 NORMOSOL-R 123 NORPACE CR 44 nortrel 0535 (28) 106 nortrel 135 (21) 106 nortrel 135 (28) 106 nortrel 777 (28) 107 nortriptyline 42 NORVIR 4 NOVAFERRUM 124 NOVOEIGHT 53 NOVOLIN 70-30 FLEXPEN
U-100 73 NOVOLIN N FLEXPEN 73 NOVOLIN R FLEXPEN 73 NOVOLOG FLEXPEN U-100
INSULIN 74 NOVOLOG MIX 70-30 U-100
INSULN 74 NOVOLOG MIX 70-
30FLEXPEN U-100 74 NOVOLOG PENFILL U-100
INSULIN 74 NOVOLOG U-100 INSULIN
ASPART 74 NOVOPEN ECHO 71 NOVOSEVEN RT 53 NOXAFIL 1 np thyroid 79 NPLATE 53 NUCALA 119 NUCYNTA ER 36 NUEDEXTA 29 NULOJIX 20 NULYTELY LEMON-LIME
83 NUPLAZID 42 NUWIQ 53
nyamyc 63 nylia 777 (28) 107 nymyo 107 nystatin 1 63 nystatin-triamcinolone 63 nystop 63 O OBIZUR 54 ocella 107 OCREVUS 88 OCTAGAM 92 octreotide acetate 20 ODEFSEY 4 OFEV 119 ofloxacin 12 69 109 OGIVRI 20 olanzapine 42 olanzapine-fluoxetine 42 olmesartan 48 olmesartan-amlodipin-
hcthiazid 48 olmesartan-
hydrochlorothiazide 48 olopatadine 69 111 OLUMIANT 97 omega-3 acid ethyl esters 56 omeprazole 86 OMIDRIA 111 OMNITROPE 87 ONCASPAR 20 ondansetron 84 ondansetron hcl 83 84 ONETOUCH ULTRA TEST
71 ONETOUCH VERIO TEST
STRIPS 71 ONIVYDE 20 ONPATTRO 29 ONZETRA XSAIL 28 opcicon one-step 107 OPDIVO 20 opium tincture 81 OPSUMIT 119 option-2 107 ORALAIR 92 oralone 69 ORAVIG 1 ORENCIA 97 ORENCIA (WITH
MALTOSE) 97 ORENCIA CLICKJECT 97
136
ORENITRAM 48 ORLADEYO 119 orphenadrine citrate 30 orsythia 107 ORTHOVISC 36 oscimin 81 oscimin sl 81 oscimin sr 81 oseltamivir 4 OSMOPREP 84 OSPHENA 101 OTEZLA 97 OTEZLA STARTER 97 OTOVEL 69 oxacillin 11 oxacillin in dextrose(iso-osm)
11 oxandrolone 76 oxaprozin 36 oxazepam 42 oxcarbazepine 25 oxiconazole 63 OXISTAT 63 OXLUMO 122 oxybutynin chloride 121 oxycodone 33 oxycodone-acetaminophen 33 oxycodone-aspirin 33 OXYCONTIN 33 oxymorphone 33 OZEMPIC 78 OZURDEX 113 P pacerone 44 PADCEV 20 paliperidone 42 PALYNZIQ 76 pamidronate 76 PANRETIN 59 pantoprazole 86 PANZYGA 92 PARAGARD T 380A 98 paricalcitol 76 PARICALCITOL 76 paroex oral rinse 69 paromomycin 10 paroxetine hcl 42 paroxetine
mesylate(menopsym) 42 PARSABIV 76 PASER 10
PEDIARIX (PF) 92 PEDVAX HIB (PF) 93 peg 3350-electrolytes 84 peg3350-sod sul-nacl-kcl-asb-c
84 PEGASYS 88 89 peg-electrolyte soln 84 peg-prep 84 PEMAZYRE 20 PEN NEEDLE DIABETIC 72 penicillamine 97 penicillin g procaine 11 penicillin v potassium 11 PENTACEL (PF) 93 PENTACEL ACTHIB
COMPONENT (PF) 93 PENTAM 10 pentamidine 10 pentazocine-naloxone 36 pentoxifylline 54 PERFOROMIST 119 perindopril erbumine 48 periogard 69 PERJETA 20 permethrin 66 perphenazine 42 perphenazine-amitriptyline 42 phenazopyridine 122 phenelzine 42 phenobarb-hyoscy-atropine-
scop 81 phenobarbital 25 26 phenohytro 81 phenoxybenzamine 48 phenylephrine hcl 114 phenytoin 26 phenytoin sodium extended 26 PHEXXI 101 philith 107 phosphasal 122 PHYSIOLYTE 66 PHYSIOSOL IRRIGATION 66 phytonadione (vitamin k1) 54 PICATO 59 pilocarpine hcl 67 69 110 pimecrolimus 59 pimozide 42 pimtrea (28) 107 pindolol 48 pioglitazone 78 pioglitazone-glimepiride 78
pioglitazone-metformin 78 piperacillin-tazobactam 11 PIQRAY 21 pirmella 107 piroxicam 36 PLASMA-LYTE 148 123 PLASMA-LYTE A 123 PLEGRIDY 89 PLENVU 84 PNEUMOVAX-23 93 podofilox 59 POLIVY 21 polycin 110 polymyxin b sulfate 10 polymyxin b sulf-trimethoprim
110 POMALYST 89 PONVORY 89 PONVORY 14-DAY
STARTER PACK 89 portia 28 107 PORTRAZZA 21 posaconazole 1 potassium chloride 123 potassium citrate 122 POTELIGEO 21 pramipexole 27 prasugrel 54 pravastatin 56 praziquantel 10 prazosin 48 PRED MILD 113 prednicarbate 65 prednisolone 70 prednisolone acetate 113 prednisolone sodium phosphate
70 114 prednisone 70 prednisone intensol 70 pregabalin 26 PREMARIN 100 PREMPHASE 100 PREMPRO 100 prevalite 56 previfem 107 PREVNAR 13 (PF) 93 PREVYMIS 4 PREZCOBIX 4 PREZISTA 4 PRIFTIN 10 primaquine 10
137
primidone 26 PRIMSOL 13 PRIVIGEN 93 probenecid 95 probenecid-colchicine 95 procainamide 44 procentra 42 prochlorperazine 84 prochlorperazine edisylate 84 prochlorperazine maleate 84 PROCRIT 87 procto-med hc 84 procto-pak 84 proctosol hc 84 proctozone-hc 84 PROFILNINE 54 progesterone 100 progesterone micronized 100 PROGRAF 21 PROLASTIN-C 67 PROLEUKIN 90 PROLIA 95 PROMACTA 54 promethazine 115 promethazine-codeine 116 promethazine-dm 116 promethazine-phenyleph-
codeine 116 promethazine-phenylephrine
116 promethegan 115 propafenone 44 45 proparacaine 111 propranolol 48 49 propranolol-hydrochlorothiazid
49 propylthiouracil 71 PROQUAD (PF) 93 protriptyline 42 PROVENGE 93 prudoxin 59 pulmosal 119 PULMOZYME 119 pyrazinamide 10 pyridostigmine bromide 30 pyrimethamine 10 Q QBRELIS 49 QINLOCK 21 QTERN 78 QUADRACEL (PF) 93
quetiapine 42 QUILLICHEW ER 42 QUILLIVANT XR 42 quinapril 49 quinapril-hydrochlorothiazide
49 quinidine gluconate 45 quinidine sulfate 45 quinine sulfate 10 quit 2 68 quit 4 68 QVAR REDIHALER 119 R RABAVERT (PF) 93 rabeprazole 86 RADICAVA 29 RAGWITEK 93 raloxifene 95 ramelteon 42 ramipril 49 ranolazine 57 RAPIVAB (PF) 4 rasagiline 27 RAVICTI 67 REBIF (WITH ALBUMIN) 89 REBIF REBIDOSE 89 REBIF TITRATION PACK 89 REBINYN 54 RECLAST 67 reclipsen (28) 107 RECOMBINATE 54 RECOMBIVAX HB (PF) 93 RECTIV 84 REGRANEX 59 RELENZA DISKHALER 4 RELEXXII 42 RELION NOVOLIN 7030 74 RELION NOVOLIN N 74 RELION NOVOLIN R 74 RELISTOR 84 REMICADE 84 RENACIDIN 122 RENFLEXIS 84 repaglinide 78 repaglinide-metformin 78 REPATHA PUSHTRONEX 56 REPATHA SURECLICK 56 REPATHA SYRINGE 56 RESTASIS 111 RETEVMO 21 RETISERT 114
REVATIO 119 REVLIMID 89 REXULTI 43 REYATAZ 4 RHOPRESSA 112 RIASTAP 54 ribavirin 4 89 RIDAURA 97 rifabutin 10 rifampin 10 riluzole 67 rimantadine 4 RINVOQ 97 RIOMET ER 78 risedronate 67 95 RISPERDAL CONSTA 43 risperidone 43 ritonavir 4 RITUXAN 21 RITUXAN HYCELA 21 rivastigmine 30 rivastigmine tartrate 29 rivelsa 107 RIXUBIS 54 rizatriptan 28 ropinirole 27 28 rosadan 61 rosuvastatin 56 roweepra 26 RUBRACA 21 RUCONEST 119 rufinamide 26 RYBELSUS 79 RYDAPT 21 S salsalate 36 SAMSCA 76 SANTYL 65 sapropterin 76 SARCLISA 21 SAVELLA 97 scalacort 65 SCENESSE 59 scopolamine base 84 seconal sodium 43 SEEBRI NEOHALER 119 selegiline hcl 28 selenium sulfide 58 SELZENTRY 5 SEREVENT DISKUS 119 SEROSTIM 87
138
sertraline 43 setlakin 107 sevelamer carbonate 84 sevelamer hcl 84 sf 69 sf 5000 plus 69 sharobel 101 SHINGRIX (PF) 93 SIGNIFOR 21 sildenafil (pulmhypertension)
119 SILIQ 58 silodosin 121 silver sulfadiazine 59 SIMBRINZA 112 simliya (28) 107 simpesse 107 SIMPONI 97 SIMPONI ARIA 97 SIMULECT 21 simvastatin 56 SINUVA 119 sirolimus 21 SIRTURO 10 SIVEXTRO 10 SKYLA 98 SKYRIZI 58 SLYND 107 sodium chloride 119 sodium chloride 045 123 sodium chloride 09 67 sodium fluoride 5000 dry
mouth 69 sodium fluoride 5000 plus 69 sodium fluoride-pot nitrate 69 sodium phenylbutyrate 67 sodium polystyrene sulfonate
85 solifenacin 121 SOLIQUA 10033 74 SOLIRIS 67 SOLTAMOX 21 SOMATULINE DEPOT 21 SOMAVERT 76 sorine 45 sotalol 45 sotalol af 45 SOVALDI 5 spinosad 66 SPIRIVA RESPIMAT 119
SPIRIVA WITH HANDIHALER 119
spironolactone 49 spironolacton-hydrochlorothiaz
49 SPRAVATO 43 sprintec (28) 107 SPRYCEL 21 sps (with sorbitol) 85 sronyx 107 ssd 59 SSKI 71 st joseph aspirin 36 st joseph aspirin 36 STAMARIL (PF) 93 stavudine 5 STELARA 58 STIOLTO RESPIMAT 119 STIVARGA 21 stop smoking aid 68 STRENSIQ 76 STREPTOMYCIN 10 STRIBILD 5 STRIVERDI RESPIMAT 120 SUBLOCADE 33 subvenite 26 subvenite starter (blue) kit 26 subvenite starter (green) kit 26 subvenite starter (orange) kit 26 SUCRAID 85 sucralfate 86 sulfacetamide sodium 58 114 sulfacetamide sodium (acne) 62 sulfacetamide-prednisolone 114 sulfadiazine 12 sulfamethoxazole-trimethoprim
12 SULFAMYLON 62 sulfasalazine 85 sulfatrim 12 sulindac 36 sumatriptan 28 sumatriptan succinate 28 29 SUNOSI 43 SUPPRELIN LA 21 SUPRAX 7 SUPREP BOWEL PREP KIT
85 SUTENT 22 syeda 107 SYLVANT 22
symax fastabs 81 symax-sl 81 symax-sr 81 SYMBICORT 120 SYMDEKO 120 SYMLINPEN 120 79 SYMLINPEN 60 79 SYMPAZAN 26 SYNAGIS 5 SYNAREL 76 SYNERA 61 SYNJARDY 79 SYNJARDY XR 79 SYNRIBO 22 SYNTHROID 79 T TABLOID 22 tacrolimus 22 59 tadalafil 121 tadalafil (pulm hypertension)
120 TAFINLAR 22 TAGRISSO 22 TAKHZYRO 120 TALTZ AUTOINJECTOR 58 TALTZ AUTOINJECTOR (2
PACK) 58 TALTZ AUTOINJECTOR (3
PACK) 58 TALTZ SYRINGE 58 TALZENNA 22 tamoxifen 22 tamsulosin 121 TARGRETIN 22 tarina 24 fe 107 tarina fe 120 (28) 107 TASIGNA 22 tavaborole 63 tazarotene 61 tazicef 7 taztia xt 49 TDVAX 93 TECENTRIQ 22 TEFLARO 7 TEKTURNA HCT 49 telmisartan 49 telmisartan-amlodipine 49 telmisartan-hydrochlorothiazid
49 temazepam 43 TEMODAR 22
139
temozolomide 22 temsirolimus 22 tencon 33 TENIVAC (PF) 94 tenofovir disoproxil fumarate 5 TEPEZZA 76 terazosin 49 terbinafine hcl 1 terbutaline 120 terconazole 101 testosterone 77 testosterone cypionate 76 testosterone enanthate 76 TETANUSDIPHTHERIA
TOX PED(PF) 94 tetrabenazine 30 tetracaine hcl 111 TETRACAINE HCL (PF) 111 tetracycline 12 THALOMID 22 theophylline 120 thioridazine 43 thiothixene 43 THYMOGLOBULIN 94 THYROLAR-1 79 THYROLAR-12 79 THYROLAR-14 79 THYROLAR-2 79 THYROLAR-3 79 tiadylt er 49 tiagabine 26 TIBSOVO 22 tilia fe 107 timolol maleate 49 110 tinidazole 10 TIVICAY 5 TIVICAY PD 5 tizanidine 30 TOBRADEX 113 TOBRADEX ST 113 tobramycin 10 110 tobramycin in 0225 nacl 10 tobramycin sulfate 10 TOBRAMYCIN WITH
NEBULIZER 10 tobramycin-dexamethasone 113 TOBREX 110 TODAY CONTRACEPTIVE
SPONGE 101 tolcapone 28 tolmetin 36
tolterodine 121 topiramate 26 toremifene 22 TORISEL 22 torsemide 49 TOUJEO MAX U-300
SOLOSTAR 74 TOUJEO SOLOSTAR U-300
INSULIN 74 TRACLEER 120 TRADJENTA 79 tramadol 36 tramadol-acetaminophen 36 trandolapril 49 trandolapril-verapamil 49 tranexamic acid 54 101 tranylcypromine 43 travoprost 112 trazodone 43 TREANDA 22 TRECATOR 10 TRELEGY ELLIPTA 120 TRELSTAR 22 TREMFYA 59 TRESIBA FLEXTOUCH U-
100 74 TRESIBA FLEXTOUCH U-
200 74 TRESIBA U-100 INSULIN 74 tretinoin 61 tretinoin (antineoplastic) 22 tretinoin microspheres 61 TRETTEN 54 TREXALL 22 tri femynor 107 triamcinolone acetonide 65 69
71 triamterene 49 triamterene-hydrochlorothiazid
49 triazolam 43 triderm 65 trientine 67 tri-estarylla 107 trifluoperazine 43 trifluridine 110 trihexyphenidyl 28 TRIJARDY XR 71 TRIKAFTA 120 tri-legest fe 108 tri-linyah 108
tri-lo-estarylla 108 tri-lo-marzia 108 tri-lo-mili 108 tri-lo-sprintec 108 trilyte with flavor packets 85 trimethobenzamide 85 trimethoprim 13 tri-mili 108 trimipramine 43 TRINTELLIX 43 tri-nymyo 108 tri-previfem (28) 108 tri-sprintec (28) 108 TRIUMEQ 5 tri-vitamin with fluoride 124 trivora (28) 108 tri-vylibra 108 tri-vylibra lo 108 TROGARZO 5 tropicamide 110 trospium 121 TRULICITY 79 TRUMENBA 94 TRUXIMA 22 TUKYSA 23 tulana 101 TWINRIX (PF) 94 TWIRLA 101 TYBLUME 108 TYBOST 5 tydemy 108 TYGACIL 10 TYMLOS 95 TYPHIM VI 94 TYSABRI 30 TYVASO 120 TYVASO REFILL KIT 120 TYVASO STARTER KIT 120 U UBRELVY 29 UDENYCA 87 ULESFIA 66 unithroid 80 UNITUXIN 23 URELLE 122 uretron d-s 122 urimar-t 122 urogesic-blue 122 ursodiol 85 uryl 122 ustell 122
140
UTIBRON NEOHALER 120 utira-c 122 UVADEX 59 V vaginal contraceptive foam 101 valacyclovir 5 VALCHLOR 59 valganciclovir 5 valproic acid 26 valproic acid (as sodium salt)
26 valsartan 49 valsartan-hydrochlorothiazide
49 vanadom 30 vancomycin 13 vandazole 101 VANTAS 23 VAQTA (PF) 94 VARIVAX (PF) 94 VARUBI 85 VASCEPA 56 VAXELIS (PF) 94 VCF CONTRACEPTIVE
FILM 101 VCF CONTRACEPTIVE GEL
101 VECTIBIX 23 VELCADE 23 veletri 50 velivet triphasic regimen (28)
108 VELPHORO 85 VEMLIDY 5 VENCLEXTA 23 VENCLEXTA STARTING
PACK 23 venlafaxine 43 VENTAVIS 120 verapamil 50 VERSACLOZ 43 VERZENIO 23 vestura (28) 108 VIBATIV 13 VIBERZI 85 VIDAZA 23 VIEKIRA PAK 5 vienva 108 vigabatrin 26 vigadrone 26 VIMIZIM 77
VIMPAT 26 viorele (28) 108 VIRACEPT 5 VIREAD 5 virtussin ac 116 VISTOGARD 13 VISUDYNE 111 vitamins acd and fluoride 124 VITRAKVI 23 VIVITROL 36 volnea (28) 108 VONVENDI 54 VORAXAZE 13 voriconazole 1 2 VOSEVI 5 VOTRIENT 23 VPRIV 77 VRAYLAR 44 VYEPTI 29 vyfemla (28) 108 vylibra 108 VYONDYS-53 30 VYVANSE 44 VYXEOS 23 W warfarin 54 wera (28) 108 westhroid 80 WIDE-SEAL DIAPHRAGM
98 WILATE 54 wixela inhub 121 wymzya fe 108 X XALKORI 23 XARELTO 54 XARELTO DVT-PE TREAT
30D START 54 XCOPRI 27 XCOPRI MAINTENANCE
PACK 27 XCOPRI TITRATION PACK
27 XELJANZ 97 XELJANZ XR 97 XEMBIFY 94 XENLETA 10 XEOMIN 94 XERMELO 23 XGEVA 13 XIFAXAN 10
XIGDUO XR 79 XIIDRA 111 XOLAIR 121 XOSPATA 23 XTANDI 23 xulane 102 XULTOPHY 10036 74 XURIDEN 67 XYNTHA 55 XYNTHA SOLOFUSE 55 XYREM 44 Y YERVOY 23 YESCARTA 23 YF-VAX (PF) 94 YONDELIS 23 YONSA 23 YUTIQ 114 yuvafem 101 Z zafemy 102 zafirlukast 121 zaleplon 44 ZALTRAP 23 ZANOSAR 23 zarah 109 ZARXIO 87 ZEJULA 24 ZELBORAF 24 ZEMAIRA 68 zenatane 61 ZENPEP 85 ZENZEDI 44 ZEPATIER 5 ZEPOSIA 89 ZEPOSIA STARTER KIT 89 ZEPOSIA STARTER PACK
89 ZERBAXA 7 zidovudine 5 ZIEXTENZO 87 zileuton 121 ziprasidone hcl 44 ZIRGAN 110 ZOKINVY 68 ZOLADEX 24 ZOLGENSMA 30 ZOLINZA 24 zolmitriptan 29 zolpidem 44 ZOLPIMIST 44
141
ZOMIG 29 zonisamide 27 ZONTIVITY 55 ZORBTIVE 87
ZOSTAVAX (PF) 94 zovia 135e (28) 109 ZULRESSO 44 zumandimine (28) 109
ZYFLO 121 ZYKADIA 24 ZYPITAMAG 56
051267 (11-20-2019)
Discrimination is Against the Law
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)711 والبكم الصم ھاتف رقم( 800-178-3056 برقم اتصل بالمجان لك تتوافر اللغویة المساعدة خدمات فإن اللغة اذكر تتحدث كنت إذا ملحوظةਿਧਆਨ ਿਦਓ ਜ ਤਸ ਪਜਾਬੀ ਬਲਦ ਹ ਤ ਭਾਸ਼ਾ ਿਵਚ ਸਹਾਇਤਾ ਸਵਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਧ ਹ 800-817-3056
(TTY 711) ਤ ਕਾਲ ਕਰ ACHTUNG Wenn Sie Deutsch sprechen stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfuumlgung
Rufnummer 800-817-3056 (TTY 711) ໂປດຊາບ ຖາວາ ທານເວາພາສາ ລາວ ການບລການຊວຍເຫອດານພາສາ ໂດຍບເສຽຄາ
ແມນມພອມໃຫທານ ໂທຣ 800-817-3056 (TTY 711) ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele 800-817-3056 (TTY 711) ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 800-817-3056 (ATS 711) UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń pod numer 800-817-3056 (TTY 711) ATENCcedilAtildeO Se fala portuguecircs encontram-se disponiacuteveis serviccedilos linguiacutesticos graacutetis Ligue para 800-817-3056 (TTY 711) ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza linguistica gratuiti Chiamare il numero
800-817-3056 (TTY 711) دیریبگ تماس 3056-817-800 (TTY 711) با باشد یم فراھم شما یبرا گانیرا بصورت یزبان لاتیتسھ دیکن یم گفتگو فارسی زبان بھ اگر توجھ
5
Drug Name Drug Tier Requirements Limits
SELZENTRY ORAL SOLUTION 20 MGML 1 QL (8 per 30 days)
SELZENTRY ORAL TABLET 150 MG 25 MG 300 MG 75 MG
1 QL (60 per 30 days)
SOVALDI ORAL PELLETS IN PACKET 150 MG 200 MG
2 LA
SOVALDI ORAL TABLET 200 MG 400 MG 2 PA LA
stavudine oral capsule 15 mg 20 mg 40 mg 1 QL (120 per 30 days)
STRIBILD ORAL TABLET 150-150-200-300 MG
1 QL (30 per 30 days)
SYNAGIS INTRAMUSCULAR SOLUTION 100 MGML 50 MG05 ML
MB LA
tenofovir disoproxil fumarate oral tablet 300 mg 1 QL (30 per 30 days)
TIVICAY ORAL TABLET 10 MG 25 MG 50 MG
1 QL (60 per 30 days)
TIVICAY PD ORAL TABLET FOR SUSPENSION 5 MG
1 QL (60 per 30 days)
TRIUMEQ ORAL TABLET 600-50-300 MG 1 QL (30 per 30 days)
TROGARZO INTRAVENOUS SOLUTION 200 MG133 ML (150 MGML)
MB PA
TYBOST ORAL TABLET 150 MG 1 QL (30 per 30 days)
valacyclovir oral tablet 1 gram 500 mg 1
valganciclovir oral recon soln 50 mgml 1
valganciclovir oral tablet 450 mg 1
VEMLIDY ORAL TABLET 25 MG 1
VIEKIRA PAK ORAL TABLETSDOSE PACK 125 MG-75 MG -50 MG250 MG
2 PA
VIRACEPT ORAL TABLET 250 MG 1 QL (90 per 30 days)
VIRACEPT ORAL TABLET 625 MG 1 QL (60 per 30 days)
VIREAD ORAL POWDER 40 MGSCOOP (40 MGGRAM)
1 QL (4 per 30 days)
VIREAD ORAL TABLET 150 MG 200 MG 250 MG
1 QL (30 per 30 days)
VOSEVI ORAL TABLET 400-100-100 MG 2 PA LA
ZEPATIER ORAL TABLET 50-100 MG 2 PA LA
zidovudine oral capsule 100 mg 1 QL (60 per 30 days)
zidovudine oral syrup 10 mgml 1 QL (960 per 30 days)
zidovudine oral tablet 300 mg 1 QL (60 per 30 days)
CEPHALOSPORINS
6
Drug Name Drug Tier Requirements Limits
AVYCAZ INTRAVENOUS RECON SOLN 25 GRAM
MB
cefaclor oral capsule 250 mg 500 mg 1
cefaclor oral suspension for reconstitution 125 mg5 ml 250 mg5 ml 375 mg5 ml
1
cefaclor oral tablet extended release 12 hr 500 mg 1
cefadroxil oral capsule 500 mg 1
cefadroxil oral suspension for reconstitution 250 mg5 ml 500 mg5 ml
1
cefadroxil oral tablet 1 gram 1
cefazolin in dextrose (iso-os) intravenous piggyback 1 gram50 ml
MB
cefazolin injection recon soln 1 gram 10 gram 100 gram 20 gram 300 g 500 mg
MB
cefazolin intravenous recon soln 1 gram MB
cefdinir oral capsule 300 mg 1
cefdinir oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cefditoren pivoxil oral tablet 200 mg 400 mg 1
CEFEPIME IN DEXTROSE 5 INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
cefepime in dextroseiso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml
MB
cefepime injection recon soln 1 gram 2 gram MB
cefixime oral capsule 400 mg 1
cefixime oral suspension for reconstitution 100 mg5 ml 200 mg5 ml
1
CEFOTAN INJECTION RECON SOLN 1 GRAM 2 GRAM
MB
cefotaxime injection recon soln 1 gram MB
CEFOTETAN IN DEXTROSE ISO-OSM INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
cefotetan injection recon soln 1 gram 2 gram MB
cefotetan intravenous recon soln 10 gram MB
cefoxitin intravenous recon soln 10 gram MB
cefpodoxime oral suspension for reconstitution 100 mg5 ml 50 mg5 ml
1
7
Drug Name Drug Tier Requirements Limits
cefpodoxime oral tablet 100 mg 200 mg 1
cefprozil oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cefprozil oral tablet 250 mg 500 mg 1
CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK 1 GRAM50 ML 2 GRAM50 ML
MB
ceftazidime injection recon soln 1 gram 2 gram 6 gram
MB
ceftriaxone in dextroseiso-os intravenous piggyback 1 gram50 ml 2 gram50 ml
MB
ceftriaxone injection recon soln 1 gram 10 gram 2 gram 250 mg 500 mg
MB
CEFTRIAXONE INJECTION RECON SOLN 100 GRAM
MB
ceftriaxone intravenous recon soln 1 gram 2 gram MB
cefuroxime axetil oral tablet 250 mg 500 mg 1
cephalexin oral capsule 250 mg 500 mg 750 mg 1
cephalexin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
cephalexin oral tablet 250 mg 500 mg 1
SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG5 ML
1
SUPRAX ORAL TABLETCHEWABLE 100 MG 200 MG
1
tazicef injection recon soln 1 gram 2 gram 6 gram
MB
tazicef intravenous recon soln 1 gram 2 gram MB
TEFLARO INTRAVENOUS RECON SOLN 400 MG 600 MG
MB
ZERBAXA INTRAVENOUS RECON SOLN 15 GRAM
MB
ERYTHROMYCINS amp OTHER MACROLIDES
azithromycin oral packet 1 gram 1
azithromycin oral suspension for reconstitution 100 mg5 ml 200 mg5 ml
1
azithromycin oral tablet 250 mg 500 mg 600 mg 1
clarithromycin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml
1
clarithromycin oral tablet 250 mg 500 mg 1
8
Drug Name Drug Tier Requirements Limits
clarithromycin oral tablet extended release 24 hr 500 mg
1
DIFICID ORAL TABLET 200 MG 1
ees 400 oral tablet 400 mg 1
ery-tab oral tabletdelayed release (drec) 250 mg 333 mg
1
erythrocin (as stearate) oral tablet 250 mg 1
erythromycin ethylsuccinate oral suspension for reconstitution 200 mg5 ml 400 mg5 ml
1
erythromycin ethylsuccinate oral tablet 400 mg 1
erythromycin oral capsuledelayed release(drec) 250 mg
1
erythromycin oral tablet 250 mg 500 mg 1
erythromycin oral tabletdelayed release (drec) 250 mg 333 mg 500 mg
1
MISCELLANEOUS ANTIINFECTIVES
albendazole oral tablet 200 mg 1
ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG5 ML
1 PA ST
amikacin injection solution 500 mg2 ml MB
atovaquone oral suspension 750 mg5 ml 1
atovaquone-proguanil oral tablet 250-100 mg 625-25 mg
1
bacitracin intramuscular recon soln 50000 unit 1
CAPASTAT INJECTION RECON SOLN 1 GRAM
1
CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MGML
2 PA LA QL (84 per 30 days)
chloramphenicol sod succinate intravenous recon soln 1 gram
MB
chloroquine phosphate oral tablet 250 mg 500 mg 1
clindamycin hcl oral capsule 150 mg 300 mg 75 mg
1
clindamycin pediatric oral recon soln 75 mg5 ml 1
clindamycin phosphate injection solution 150 mgml
MB
COARTEM ORAL TABLET 20-120 MG 1
CUBICIN INTRAVENOUS RECON SOLN 500 MG
MB
9
Drug Name Drug Tier Requirements Limits
CUBICIN RF INTRAVENOUS RECON SOLN 500 MG
MB
CYCLOSERINE ORAL CAPSULE 250 MG 1
dapsone oral tablet 100 mg 25 mg 1
EMVERM ORAL TABLETCHEWABLE 100 MG
1
ethambutol oral tablet 100 mg 400 mg 1
gentamicin injection solution 20 mg2 ml 40 mgml
MB
gentamicin sulfate (ped) (pf) injection solution 20 mg2 ml
MB
hydroxychloroquine oral tablet 200 mg 1
imipenem-cilastatin intravenous recon soln 250 mg 500 mg
MB
INVANZ INJECTION RECON SOLN 1 GRAM MB
isoniazid injection solution 100 mgml 1
isoniazid oral solution 50 mg5 ml 1
isoniazid oral tablet 100 mg 300 mg 1
ivermectin oral tablet 3 mg 1
LINCOCIN INJECTION SOLUTION 300 MGML
MB
linezolid in dextrose 5 intravenous piggyback 600 mg300 ml
MB
linezolid oral suspension for reconstitution 100 mg5 ml
1
linezolid oral tablet 600 mg 1
linezolid-09 sodium chloride intravenous parenteral solution 600 mg300 ml
MB
mefloquine oral tablet 250 mg 1
meropenem intravenous recon soln 1 gram 500 mg
MB
MEROPENEM-09 SODIUM CHLORIDE INTRAVENOUS PIGGYBACK 1 GRAM50 ML 500 MG50 ML
MB
metronidazole oral capsule 375 mg 1
metronidazole oral tablet 250 mg 500 mg 1
neomycin oral tablet 500 mg 1
nitazoxanide oral tablet 500 mg 1
10
Drug Name Drug Tier Requirements Limits
paromomycin oral capsule 250 mg 1
PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM
1
PENTAM INJECTION RECON SOLN 300 MG MB
pentamidine inhalation recon soln 300 mg 1
pentamidine injection recon soln 300 mg MB
polymyxin b sulfate injection recon soln 500000 unit
MB
praziquantel oral tablet 600 mg 1
PRIFTIN ORAL TABLET 150 MG 1
primaquine oral tablet 263 mg 1
pyrazinamide oral tablet 500 mg 1
pyrimethamine oral tablet 25 mg 2 PA
quinine sulfate oral capsule 324 mg 1
rifabutin oral capsule 150 mg 1
rifampin oral capsule 150 mg 300 mg 1
SIRTURO ORAL TABLET 100 MG 1 PA
SIRTURO ORAL TABLET 20 MG 1
SIVEXTRO ORAL TABLET 200 MG 1 QL (6 per 30 days)
STREPTOMYCIN INTRAMUSCULAR RECON SOLN 1 GRAM
1
tinidazole oral tablet 250 mg 500 mg 1
tobramycin in 0225 nacl inhalation solution for nebulization 300 mg5 ml
2
tobramycin inhalation solution for nebulization 300 mg4 ml
2
tobramycin sulfate injection recon soln 12 gram 1
tobramycin sulfate injection solution 10 mgml MB
tobramycin sulfate injection solution 40 mgml 1
TOBRAMYCIN WITH NEBULIZER INHALATION SOLUTION FOR NEBULIZATION 300 MG5 ML
2 PA ST
TRECATOR ORAL TABLET 250 MG 1
TYGACIL INTRAVENOUS RECON SOLN 50 MG
MB
XENLETA INTRAVENOUS SOLUTION 150 MG15 ML
MB
XIFAXAN ORAL TABLET 200 MG 550 MG 1 PA QL (60 per 30 days)
11
Drug Name Drug Tier Requirements Limits
PENICILLINS
amoxicillin oral capsule 250 mg 500 mg 1
amoxicillin oral suspension for reconstitution 125 mg5 ml 200 mg5 ml 250 mg5 ml 400 mg5 ml
1
amoxicillin oral tablet 500 mg 875 mg 1
amoxicillin oral tabletchewable 125 mg 250 mg 1
amoxicillin-pot clavulanate oral suspension for reconstitution 200-285 mg5 ml 250-625 mg5 ml 400-57 mg5 ml 600-429 mg5 ml
1
amoxicillin-pot clavulanate oral tablet 250-125 mg 500-125 mg 875-125 mg
1
amoxicillin-pot clavulanate oral tablet extended release 12 hr 1000-625 mg
1
amoxicillin-pot clavulanate oral tabletchewable 200-285 mg 400-57 mg
1
ampicillin oral capsule 500 mg 1
ampicillin-sulbactam injection recon soln 15 gram MB
BICILLIN C-R INTRAMUSCULAR SYRINGE 1200000 UNIT 2 ML(900K300K)
MB
dicloxacillin oral capsule 250 mg 500 mg 1
MOXATAG ORAL TABLET ER MULTIPHASE 24 HR 775 MG
1
nafcillin in dextrose iso-osm intravenous piggyback 1 gram50 ml 2 gram100 ml
MB
nafcillin injection recon soln 1 gram 10 gram 2 gram
MB
nafcillin intravenous recon soln 1 gram 2 gram MB
oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram50 ml 2 gram50 ml
MB
oxacillin injection recon soln 1 gram 10 gram 2 gram
MB
penicillin g procaine intramuscular syringe 12 million unit2 ml 600000 unitml
MB
penicillin v potassium oral recon soln 125 mg5 ml 250 mg5 ml
1
penicillin v potassium oral tablet 250 mg 500 mg 1
piperacillin-tazobactam intravenous recon soln 135 gram 225 gram 3375 gram 45 gram 405 gram
MB
12
Drug Name Drug Tier Requirements Limits
QUINOLONES
BAXDELA INTRAVENOUS RECON SOLN 300 MG
MB
BAXDELA ORAL TABLET 450 MG 1
ciprofloxacin hcl oral tablet 100 mg 250 mg 500 mg 750 mg
1
ciprofloxacin oral suspensionmicrocapsule recon 250 mg5 ml 500 mg5 ml
1
FACTIVE ORAL TABLET 320 MG 1 ST
levofloxacin oral solution 250 mg10 ml 1
levofloxacin oral tablet 250 mg 500 mg 750 mg 1
moxifloxacin oral tablet 400 mg 1
ofloxacin oral tablet 300 mg 400 mg 1
SULFAS amp RELATED AGENTS
sulfadiazine oral tablet 500 mg 1
sulfamethoxazole-trimethoprim oral suspension 200-40 mg5 ml
1
sulfamethoxazole-trimethoprim oral tablet 400-80 mg 800-160 mg
1
sulfatrim oral suspension 200-40 mg5 ml 1
TETRACYCLINES
avidoxy oral tablet 100 mg 1 ST
demeclocycline oral tablet 150 mg 300 mg 1
doxycycline hyclate oral capsule 100 mg 50 mg 1
doxycycline hyclate oral tablet 100 mg 150 mg 20 mg 50 mg 75 mg
1
doxycycline hyclate oral tabletdelayed release (drec) 100 mg 150 mg 200 mg 50 mg 75 mg
1
doxycycline monohydrate oral capsule 100 mg 150 mg 50 mg 75 mg
1
doxycycline monohydrate oral suspension for reconstitution 25 mg5 ml
1
doxycycline monohydrate oral tablet 100 mg 150 mg 50 mg 75 mg
1
minocycline oral capsule 100 mg 50 mg 75 mg 1
minocycline oral tablet 100 mg 50 mg 75 mg 1
mondoxyne nl oral capsule 100 mg 75 mg 1
tetracycline oral capsule 250 mg 500 mg 1
13
Drug Name Drug Tier Requirements Limits
URINARY TRACT AGENTS
fosfomycin tromethamine oral packet 3 gram 1
methenamine hippurate oral tablet 1 gram 1
methenamine mandelate oral tablet 05 g 1 gram 1
nitrofurantoin macrocrystal oral capsule 100 mg 25 mg 50 mg
1
nitrofurantoin monohydm-cryst oral capsule 100 mg
1
nitrofurantoin oral suspension 25 mg5 ml 1
PRIMSOL ORAL SOLUTION 50 MG5 ML 1
trimethoprim oral tablet 100 mg 1
VANCOMYCIN
vancomycin oral capsule 125 mg 250 mg 1
vancomycin oral recon soln 50 mgml 1
VIBATIV INTRAVENOUS RECON SOLN 750 MG
MB
ANTINEOPLASTIC amp IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
KEPIVANCE INTRAVENOUS RECON SOLN 625 MG
MB
leucovorin calcium injection recon soln 100 mg 200 mg 350 mg 50 mg 500 mg
MB
leucovorin calcium injection solution 10 mgml MB
leucovorin calcium oral tablet 10 mg 15 mg 25 mg 5 mg
1
VISTOGARD ORAL GRANULES IN PACKET 10 GRAM
2
VORAXAZE INTRAVENOUS RECON SOLN 1000 UNIT
MB
XGEVA SUBCUTANEOUS SOLUTION 120 MG17 ML (70 MGML)
2 LA
ANTINEOPLASTIC amp IMMUNOSUPPRESSANT DRUGS
abiraterone oral tablet 250 mg 2 PA OCh LA
abiraterone oral tablet 500 mg 2 PA ST OCh LA
ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG
MB PA LA
ADAKVEO INTRAVENOUS SOLUTION 10 MGML
MB PA
14
Drug Name Drug Tier Requirements Limits
ADCETRIS INTRAVENOUS RECON SOLN 50 MG
MB PA LA
AFINITOR ORAL TABLET 10 MG 2 OCh LA
ALECENSA ORAL CAPSULE 150 MG 2 PA OCh LA
ALIMTA INTRAVENOUS RECON SOLN 100 MG 500 MG
MB PA
ALIQOPA INTRAVENOUS RECON SOLN 60 MG
MB PA
anastrozole oral tablet 1 mg ACA PV OCh QL (30 per 30 days)
ARRANON INTRAVENOUS SOLUTION 250 MG50 ML
MB LA
ARZERRA INTRAVENOUS SOLUTION 1000 MG50 ML 100 MG5 ML
MB PA LA
ASPARLAS INTRAVENOUS SOLUTION 750 UNITML
MB PA
AVASTIN INTRAVENOUS SOLUTION 25 MGML
MB PA LA
azathioprine oral tablet 50 mg 1
BALVERSA ORAL TABLET 3 MG 4 MG 5 MG
2 PA OCh
BAVENCIO INTRAVENOUS SOLUTION 20 MGML
MB PA
BELEODAQ INTRAVENOUS RECON SOLN 500 MG
MB PA
BELRAPZO INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BENDAMUSTINE INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BENDEKA INTRAVENOUS SOLUTION 25 MGML
MB PA LA
BESPONSA INTRAVENOUS RECON SOLN 09 MG (025 MGML INITIAL)
MB PA LA
bexarotene oral capsule 75 mg 2 PA ST OCh
bicalutamide oral tablet 50 mg 2 OCh QL (30 per 30 days)
BLINCYTO INTRAVENOUS KIT 35 MCG MB PA
BORTEZOMIB INTRAVENOUS RECON SOLN 35 MG
MB
BOSULIF ORAL TABLET 100 MG 400 MG 500 MG
2 PA ST OCh LA
BRAFTOVI ORAL CAPSULE 50 MG 75 MG 2 PA OCh LA
15
Drug Name Drug Tier Requirements Limits
BUSULFEX INTRAVENOUS SOLUTION 60 MG10 ML
MB
CABOMETYX ORAL TABLET 20 MG 40 MG 60 MG
2 PA ST OCh LA
CALQUENCE ORAL CAPSULE 100 MG 2 PA ST OCh
capecitabine oral tablet 150 mg 2 OCh LA QL (210 per 30 days)
capecitabine oral tablet 500 mg 2 OCh LA QL (84 per 30 days)
CAPRELSA ORAL TABLET 100 MG 300 MG 2 PA OCh
CLOLAR INTRAVENOUS SOLUTION 20 MG20 ML
MB PA
COMETRIQ ORAL CAPSULE 100 MGDAY(80 MG X1-20 MG X1) 140 MGDAY(80 MG X1-20 MG X3) 60 MGDAY (20 MG X 3DAY)
2 PA OCh
COPIKTRA ORAL CAPSULE 15 MG 25 MG 2 PA OCh
COTELLIC ORAL TABLET 20 MG 2 PA OCh LA
cyclophosphamide intravenous recon soln 1 gram 2 gram 500 mg
MB
cyclophosphamide oral capsule 25 mg 50 mg 2 OCh
CYCLOPHOSPHAMIDE ORAL TABLET 25 MG 50 MG
2 OCh
cyclosporine modified oral capsule 100 mg 25 mg 50 mg
1
cyclosporine modified oral solution 100 mgml 1
cyclosporine oral capsule 100 mg 25 mg 1
CYRAMZA INTRAVENOUS SOLUTION 10 MGML
MB PA LA
DACOGEN INTRAVENOUS RECON SOLN 50 MG
MB PA LA
DARZALEX INTRAVENOUS SOLUTION 20 MGML
MB PA LA
DAURISMO ORAL TABLET 100 MG 25 MG 2 PA OCh LA
decitabine intravenous recon soln 50 mg MB LA
ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 225 MG
2
ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG
2
ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG
2
16
Drug Name Drug Tier Requirements Limits
ELIGARD SUBCUTANEOUS SYRINGE 75 MG (1 MONTH)
2
ELZONRIS INTRAVENOUS SOLUTION 1000 MCGML
MB PA
EMCYT ORAL CAPSULE 140 MG 2 OCh
EMPLICITI INTRAVENOUS RECON SOLN 300 MG 400 MG
MB PA LA
ENHERTU INTRAVENOUS RECON SOLN 100 MG
MB PA LA
ERBITUX INTRAVENOUS SOLUTION 100 MG50 ML 200 MG100 ML
MB PA LA
ERLEADA ORAL TABLET 60 MG 2 PA OCh LA
erlotinib oral tablet 100 mg 150 mg 25 mg 2 PA OCh LA
ERWINAZE INJECTION RECON SOLN 10000 UNIT
MB
etoposide intravenous solution 20 mgml MB
etoposide oral capsule 50 mg 2 OCh
everolimus (antineoplastic) oral tablet 25 mg 5 mg 75 mg
2 PA ST OCh LA
everolimus (immunosuppressive) oral tablet 025 mg 05 mg 075 mg
1 PA
exemestane oral tablet 25 mg ACA PV OCh QL (30 per 30 days)
FASLODEX INTRAMUSCULAR SYRINGE 250 MG5 ML
MB PA
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG 80 MG
2 LA
fludarabine intravenous recon soln 50 mg MB
fluorouracil intravenous solution 25 gram50 ml 5 gram100 ml 500 mg10 ml
MB PA
flutamide oral capsule 125 mg 2 OCh QL (180 per 30 days)
FOLOTYN INTRAVENOUS SOLUTION 20 MGML (1 ML) 40 MG2 ML (20 MGML)
MB PA LA
fulvestrant intramuscular syringe 250 mg5 ml MB
GAMIFANT INTRAVENOUS SOLUTION 5 MGML
MB PA
GAZYVA INTRAVENOUS SOLUTION 1000 MG40 ML
MB PA LA
gemcitabine intravenous recon soln 1 gram 2 gram 200 mg
MB
17
Drug Name Drug Tier Requirements Limits
gemcitabine intravenous solution 2 gram526 ml (38 mgml) 200 mg526 ml (38 mgml)
MB
gengraf oral capsule 100 mg 25 mg 1
gengraf oral solution 100 mgml 1
GILOTRIF ORAL TABLET 20 MG 30 MG 40 MG
2 PA OCh LA
GLEOSTINE ORAL CAPSULE 10 MG 100 MG 40 MG
2 PA OCh
HALAVEN INTRAVENOUS SOLUTION 1 MG2 ML (05 MGML)
MB PA LA
HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600 MG-10000 UNIT5 ML
MB LA
HERCEPTIN INTRAVENOUS RECON SOLN 150 MG
MB PA LA
HERZUMA INTRAVENOUS RECON SOLN 150 MG
MB PA LA
HYCAMTIN ORAL CAPSULE 025 MG 1 MG 2 OCh LA
hydroxyurea oral capsule 500 mg 2 OCh
IBRANCE ORAL CAPSULE 100 MG 125 MG 75 MG
2 PA OCh LA
IBRANCE ORAL TABLET 100 MG 125 MG 75 MG
2 OCh LA
ICLUSIG ORAL TABLET 10 MG 15 MG 30 MG 45 MG
2 PA ST OCh
IDHIFA ORAL TABLET 100 MG 50 MG 2 PA OCh LA
imatinib oral tablet 100 mg 2 OCh LA QL (90 per 30 days)
imatinib oral tablet 400 mg 2 OCh LA QL (60 per 30 days)
IMBRUVICA ORAL CAPSULE 140 MG 70 MG 2 PA ST OCh
IMBRUVICA ORAL TABLET 140 MG 280 MG 420 MG 560 MG
2 PA ST OCh
IMFINZI INTRAVENOUS SOLUTION 50 MGML
MB PA LA
IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFUML 10EXP8 (100 MILLION) PFUML
MB
18
Drug Name Drug Tier Requirements Limits
INFUGEM INTRAVENOUS PIGGYBACK 1200 MG120 ML (10 MGML) 1300 MG130 ML (10 MGML) 1400 MG140 ML (10 MGML) 1500 MG150 ML (10 MGML) 1600 MG160 ML (10 MGML) 1700 MG170 ML (10 MGML) 1800 MG180 ML (10 MGML) 1900 MG190 ML (10 MGML) 2000 MG200 ML (10 MGML) 2200 MG220 ML (10 MGML)
MB
INLYTA ORAL TABLET 1 MG 5 MG 2 PA OCh LA
IRESSA ORAL TABLET 250 MG 2 PA OCh LA
ISTODAX INTRAVENOUS RECON SOLN 10 MG2 ML
MB PA LA
IXEMPRA INTRAVENOUS RECON SOLN 15 MG 45 MG
MB PA LA
JAKAFI ORAL TABLET 10 MG 15 MG 20 MG 25 MG 5 MG
2 PA OCh LA
JEVTANA INTRAVENOUS SOLUTION 10 MGML (FIRST DILUTION)
MB PA LA
KADCYLA INTRAVENOUS RECON SOLN 100 MG 160 MG
MB PA LA
KANJINTI INTRAVENOUS RECON SOLN 150 MG 420 MG
MB PA LA
KEYTRUDA INTRAVENOUS SOLUTION 25 MGML
MB PA
KISQALI FEMARA CO-PACK ORAL TABLET 200 MGDAY(200 MG X 1)-25 MG 400 MGDAY(200 MG X 2)-25 MG 600 MGDAY(200 MG X 3)-25 MG
2 PA ST OCh LA
KISQALI ORAL TABLET 200 MGDAY (200 MG X 1) 400 MGDAY (200 MG X 2) 600 MGDAY (200 MG X 3)
2 PA ST OCh LA
KYMRIAH INTRAVENOUS SUSPENSION 02X10EXP6 TO 25X10EXP8 CELL 06 TO 6 X 10EXP8 CELL
MB PA
KYPROLIS INTRAVENOUS RECON SOLN 10 MG 30 MG 60 MG
MB PA
lapatinib oral tablet 250 mg 2 PA OCh LA QL (180 per 30 days)
LENVIMA ORAL CAPSULE 10 MGDAY (10 MG X 1) 12 MGDAY (4 MG X 3) 14 MGDAY(10 MG X 1-4 MG X 1) 18 MGDAY (10 MG X 1-4 MG X2) 20 MGDAY (10 MG X 2) 24 MGDAY(10 MG X 2-4 MG X 1) 4 MG 8 MGDAY (4 MG X 2)
2 PA ST OCh LA
19
Drug Name Drug Tier Requirements Limits
letrozole oral tablet 25 mg ACA PV OCh QL (30 per 30 days)
LEUKERAN ORAL TABLET 2 MG 2 OCh
leuprolide subcutaneous kit 1 mg02 ml 2
LIBTAYO INTRAVENOUS SOLUTION 50 MGML
MB PA
LONSURF ORAL TABLET 15-614 MG 20-819 MG
2 PA ST OCh LA
LUMOXITI INTRAVENOUS RECON SOLN 1 MG
MB
LUPKYNIS ORAL CAPSULE 79 MG 2 PA ST
LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 225 MG
2
LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG
2
LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG
2
LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 375 MG 75 MG
2
LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG 30 MG
2
LUPRON DEPOT-PED INTRAMUSCULAR KIT 1125 MG 15 MG 75 MG (PED)
2
LYNPARZA ORAL TABLET 100 MG 150 MG 2 PA ST OCh LA
LYSODREN ORAL TABLET 500 MG 2 OCh
MARQIBO INTRAVENOUS KIT 5 MG31 ML(016 MGML) FINAL
MB PA
MATULANE ORAL CAPSULE 50 MG 2 OCh
megestrol oral suspension 400 mg10 ml (40 mgml)
1 QL (2 per 30 days)
megestrol oral suspension 625 mg5 ml (125 mgml)
1 QL (1 per 30 days)
megestrol oral tablet 20 mg 2 OCh QL (480 per 30 days)
megestrol oral tablet 40 mg 2 OCh QL (240 per 30 days)
MEKINIST ORAL TABLET 05 MG 2 MG 2 PA ST OCh LA
MEKTOVI ORAL TABLET 15 MG 2 PA OCh LA
melphalan hcl intravenous recon soln 50 mg MB
melphalan oral tablet 2 mg 2 OCh
20
Drug Name Drug Tier Requirements Limits
mercaptopurine oral tablet 50 mg 2 OCh QL (300 per 30 days)
methotrexate sodium (pf) injection recon soln 1 gram
1
methotrexate sodium (pf) injection solution 25 mgml
1
methotrexate sodium injection solution 25 mgml 1
methotrexate sodium oral tablet 25 mg 2 OCh
mitoxantrone intravenous concentrate 2 mgml MB PA LA
mycophenolate mofetil oral capsule 250 mg 1
mycophenolate mofetil oral tablet 500 mg 1
mycophenolate sodium oral tabletdelayed release (drec) 180 mg 360 mg
1
MYLOTARG INTRAVENOUS RECON SOLN 45 MG (1 MGML INITIAL CONC)
MB PA LA
NERLYNX ORAL TABLET 40 MG 2 PA OCh LA QL (180 per 30 days)
NEXAVAR ORAL TABLET 200 MG 2 PA ST OCh LA
nilutamide oral tablet 150 mg 2 OCh QL (60 per 30 days)
NINLARO ORAL CAPSULE 23 MG 3 MG 4 MG
2 PA ST OCh LA
NULOJIX INTRAVENOUS RECON SOLN 250 MG
MB PA
octreotide acetate injection solution 1000 mcgml 100 mcgml 200 mcgml 50 mcgml 500 mcgml
2
octreotide acetate injection syringe 100 mcgml (1 ml) 50 mcgml (1 ml) 500 mcgml (1 ml)
2
OGIVRI INTRAVENOUS RECON SOLN 150 MG 420 MG
MB PA LA
ONCASPAR INJECTION SOLUTION 750 UNITML
MB
ONIVYDE INTRAVENOUS DISPERSION 43 MGML
MB PA
OPDIVO INTRAVENOUS SOLUTION 100 MG10 ML 240 MG24 ML 40 MG4 ML
MB PA LA
PADCEV INTRAVENOUS RECON SOLN 20 MG 30 MG
MB PA LA
PEMAZYRE ORAL TABLET 135 MG 45 MG 9 MG
2 PA ST OCh
PERJETA INTRAVENOUS SOLUTION 420 MG14 ML (30 MGML)
MB PA LA
21
Drug Name Drug Tier Requirements Limits
PIQRAY ORAL TABLET 200 MGDAY (200 MG X 1) 250 MGDAY (200 MG X1-50 MG X1) 300 MGDAY (150 MG X 2)
2 PA OCh LA
POLIVY INTRAVENOUS RECON SOLN 140 MG
MB PA LA
PORTRAZZA INTRAVENOUS SOLUTION 800 MG50 ML (16 MGML)
MB PA LA
POTELIGEO INTRAVENOUS SOLUTION 4 MGML
MB PA
PROGRAF INTRAVENOUS SOLUTION 5 MGML
MB
QINLOCK ORAL TABLET 50 MG 2 OCh
RETEVMO ORAL CAPSULE 40 MG 2 PA OCh LA QL (240 per 30 days)
RETEVMO ORAL CAPSULE 80 MG 2 PA OCh LA QL (120 per 30 days)
RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG117 ML (120 MGML) 1600 MG134 ML (120 MGML)
MB LA
RITUXAN INTRAVENOUS CONCENTRATE 10 MGML
MB PA LA
RUBRACA ORAL TABLET 200 MG 250 MG 300 MG
2 PA ST OCh LA
RYDAPT ORAL CAPSULE 25 MG 2 PA ST OCh LA
SARCLISA INTRAVENOUS SOLUTION 20 MGML
MB
SIGNIFOR SUBCUTANEOUS SOLUTION 03 MGML (1 ML) 06 MGML (1 ML) 09 MGML (1 ML)
2 PA ST
SIMULECT INTRAVENOUS RECON SOLN 10 MG 20 MG
MB
sirolimus oral solution 1 mgml 1
sirolimus oral tablet 05 mg 1 mg 2 mg 1
SOLTAMOX ORAL SOLUTION 20 MG10 ML 2 OCh
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG05 ML 60 MG02 ML 90 MG03 ML
2 PA LA
SPRYCEL ORAL TABLET 100 MG 140 MG 20 MG 50 MG 70 MG 80 MG
2 PA ST OCh LA
STIVARGA ORAL TABLET 40 MG 2 PA ST OCh LA
SUPPRELIN LA IMPLANT KIT 50 MG (65 MCGDAY)
MB LA
22
Drug Name Drug Tier Requirements Limits
SUTENT ORAL CAPSULE 125 MG 25 MG 375 MG 50 MG
2 PA ST OCh LA
SYLVANT INTRAVENOUS RECON SOLN 100 MG 400 MG
MB PA LA
SYNRIBO SUBCUTANEOUS RECON SOLN 35 MG
2 PA ST
TABLOID ORAL TABLET 40 MG 2 OCh
tacrolimus oral capsule 05 mg 1 mg 5 mg 1
TAFINLAR ORAL CAPSULE 50 MG 75 MG 2 PA OCh LA
TAGRISSO ORAL TABLET 40 MG 80 MG 2 PA OCh LA
TALZENNA ORAL CAPSULE 025 MG 1 MG 2 PA OCh LA
tamoxifen oral tablet 10 mg 20 mg 2 OCh QL (60 per 30 days)
TARGRETIN TOPICAL GEL 1 1 PA ST
TASIGNA ORAL CAPSULE 150 MG 200 MG 50 MG
2 PA ST OCh LA
TECENTRIQ INTRAVENOUS SOLUTION 1200 MG20 ML (60 MGML) 840 MG14 ML (60 MGML)
MB PA LA
TEMODAR INTRAVENOUS RECON SOLN 100 MG
MB PA LA
temozolomide oral capsule 100 mg 140 mg 180 mg 20 mg 250 mg 5 mg
2 OCh LA
temsirolimus intravenous recon soln 30 mg3 ml (10 mgml) (first)
MB PA LA
THALOMID ORAL CAPSULE 100 MG 150 MG 200 MG 50 MG
2 OCh LA
TIBSOVO ORAL TABLET 250 MG 2 PA OCh
toremifene oral tablet 60 mg 2 OCh
TORISEL INTRAVENOUS RECON SOLN 30 MG3 ML (10 MGML) (FIRST)
MB PA LA
TREANDA INTRAVENOUS RECON SOLN 100 MG 25 MG
MB PA LA
TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 1125 MG 225 MG 375 MG
MB
tretinoin (antineoplastic) oral capsule 10 mg 2 OCh
TREXALL ORAL TABLET 10 MG 15 MG 5 MG 75 MG
2 PA ST OCh QL (15 per 30 days)
TRUXIMA INTRAVENOUS SOLUTION 10 MGML
MB PA LA
23
Drug Name Drug Tier Requirements Limits
TUKYSA ORAL TABLET 150 MG 50 MG 2 PA ST OCh QL (120 per 30 days)
UNITUXIN INTRAVENOUS SOLUTION 35 MGML
MB PA
VANTAS IMPLANT KIT 50 MG (50 MCGDAY)
MB LA
VECTIBIX INTRAVENOUS SOLUTION 100 MG5 ML (20 MGML) 400 MG20 ML (20 MGML)
MB PA LA
VELCADE INJECTION RECON SOLN 35 MG MB LA
VENCLEXTA ORAL TABLET 10 MG 100 MG 50 MG
2 PA ST OCh
VENCLEXTA STARTING PACK ORAL TABLETSDOSE PACK 10 MG-50 MG- 100 MG
2 PA OCh
VERZENIO ORAL TABLET 100 MG 150 MG 200 MG 50 MG
2 PA ST OCh LA
VIDAZA INJECTION RECON SOLN 100 MG MB PA LA
VITRAKVI ORAL CAPSULE 100 MG 2 PA OCh LA
VITRAKVI ORAL CAPSULE 25 MG 2 PA ST OCh LA
VITRAKVI ORAL SOLUTION 20 MGML 2 PA OCh LA
VOTRIENT ORAL TABLET 200 MG 2 PA ST OCh LA
VYXEOS INTRAVENOUS RECON SOLN 44-100 MG
MB PA
XALKORI ORAL CAPSULE 200 MG 250 MG 2 PA OCh LA
XERMELO ORAL TABLET 250 MG 2 PA ST
XOSPATA ORAL TABLET 40 MG 2 PA OCh
XTANDI ORAL CAPSULE 40 MG 2 PA OCh LA
XTANDI ORAL TABLET 40 MG 80 MG 2 PA OCh LA
YERVOY INTRAVENOUS SOLUTION 200 MG40 ML (5 MGML) 50 MG10 ML (5 MGML)
MB PA LA
YESCARTA INTRAVENOUS SUSPENSION MB PA
YONDELIS INTRAVENOUS RECON SOLN 1 MG
MB PA
YONSA ORAL TABLET 125 MG 2 PA OCh LA
ZALTRAP INTRAVENOUS SOLUTION 100 MG4 ML (25 MGML) 200 MG8 ML (25 MGML)
MB PA LA
ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM
MB
24
Drug Name Drug Tier Requirements Limits
ZEJULA ORAL CAPSULE 100 MG 2 OCh
ZELBORAF ORAL TABLET 240 MG 2 PA ST OCh LA
ZOLADEX SUBCUTANEOUS IMPLANT 108 MG 36 MG
MB LA
ZOLINZA ORAL CAPSULE 100 MG 2 PA ST OCh LA
ZYKADIA ORAL TABLET 150 MG 2 PA ST OCh LA
AUTONOMIC amp CNS DRUGS NEUROLOGY amp PSYCH
ANTICONVULSANTS
BANZEL ORAL TABLET 200 MG 400 MG 1 PA ST
BRIVIACT ORAL SOLUTION 10 MGML 1 ST QL (150 per 30 days)
BRIVIACT ORAL TABLET 10 MG 100 MG 25 MG 50 MG 75 MG
1 ST QL (60 per 30 days)
carbamazepine oral capsule er multiphase 12 hr 100 mg 200 mg 300 mg
1
carbamazepine oral suspension 100 mg5 ml 200 mg10 ml
1
carbamazepine oral tablet 200 mg 1
carbamazepine oral tablet extended release 12 hr 100 mg 200 mg 400 mg
1
carbamazepine oral tabletchewable 100 mg 1
CELONTIN ORAL CAPSULE 300 MG 1
clobazam oral suspension 25 mgml 1
clobazam oral tablet 10 mg 20 mg 1
clonazepam oral tablet 05 mg 1 mg 2 mg 1
clonazepam oral tabletdisintegrating 0125 mg 025 mg 05 mg 1 mg 2 mg
1
diazepam rectal kit 25 mg 1
DILANTIN EXTENDED ORAL CAPSULE 100 MG
1
DILANTIN INFATABS ORAL TABLETCHEWABLE 50 MG
1
DILANTIN ORAL CAPSULE 30 MG 1
DILANTIN-125 ORAL SUSPENSION 125 MG5 ML
1
divalproex oral capsule delayed rel sprinkle 125 mg
1
divalproex oral tablet extended release 24 hr 250 mg 500 mg
1
25
Drug Name Drug Tier Requirements Limits
divalproex oral tabletdelayed release (drec) 125 mg 250 mg 500 mg
1
EPIDIOLEX ORAL SOLUTION 100 MGML 2 PA LA QL (400 per 30 days)
epitol oral tablet 200 mg 1
ethosuximide oral capsule 250 mg 1
ethosuximide oral solution 250 mg5 ml 1
felbamate oral suspension 600 mg5 ml 1
felbamate oral tablet 400 mg 600 mg 1
FINTEPLA ORAL SOLUTION 22 MGML 2
gabapentin oral capsule 100 mg 300 mg 400 mg 1
gabapentin oral solution 250 mg5 ml 300 mg6 ml (6 ml)
1
gabapentin oral tablet 600 mg 800 mg 1
lamotrigine oral tablet 100 mg 150 mg 200 mg 25 mg
1
lamotrigine oral tablet disintegrating dose pk 25 mg (21) -50 mg (7) 25 mg(14)-50 mg (14)-100 mg (7) 50 mg (42) -100 mg (14)
1
lamotrigine oral tablet extended release 24hr 100 mg 200 mg 25 mg 250 mg 300 mg 50 mg
1
lamotrigine oral tablet chewable dispersible 25 mg 5 mg
1
lamotrigine oral tabletdisintegrating 100 mg 200 mg 25 mg 50 mg
1
lamotrigine oral tabletsdose pack 25 mg (35) 25 mg (42) -100 mg (7) 25 mg (84) -100 mg (14)
1
levetiracetam oral solution 100 mgml 500 mg5 ml (5 ml)
1
levetiracetam oral tablet 1000 mg 250 mg 500 mg 750 mg
1
levetiracetam oral tablet extended release 24 hr 500 mg 750 mg
1
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG 330 MG 825 MG
1 PA ST
oxcarbazepine oral suspension 300 mg5 ml (60 mgml)
1
oxcarbazepine oral tablet 150 mg 300 mg 600 mg 1
phenobarbital oral elixir 20 mg5 ml (4 mgml) 1
26
Drug Name Drug Tier Requirements Limits
phenobarbital oral tablet 100 mg 15 mg 162 mg 30 mg 324 mg 60 mg 648 mg 972 mg
1
phenytoin oral suspension 100 mg4 ml 125 mg5 ml
1
phenytoin oral tabletchewable 50 mg 1
phenytoin sodium extended oral capsule 100 mg 200 mg 300 mg
1
pregabalin oral capsule 100 mg 150 mg 200 mg 225 mg 25 mg 300 mg 50 mg 75 mg
1 PA ST
pregabalin oral solution 20 mgml 1 PA ST
pregabalin oral tablet extended release 24 hr 165 mg 330 mg 825 mg
1 PA ST
primidone oral tablet 250 mg 50 mg 1
roweepra oral tablet 1000 mg 500 mg 750 mg 1
rufinamide oral suspension 40 mgml 1 PA
rufinamide oral tablet 200 mg 400 mg 1 PA
subvenite oral tablet 100 mg 150 mg 200 mg 25 mg
1
subvenite starter (blue) kit oral tabletsdose pack 25 mg (35)
1
subvenite starter (green) kit oral tabletsdose pack 25 mg (84) -100 mg (14)
1
subvenite starter (orange) kit oral tabletsdose pack 25 mg (42) -100 mg (7)
1
SYMPAZAN ORAL FILM 10 MG 20 MG 5 MG 1 PA QL (30 per 30 days)
tiagabine oral tablet 12 mg 16 mg 2 mg 4 mg 1
topiramate oral capsule sprinkle 15 mg 25 mg 1
topiramate oral tablet 100 mg 200 mg 25 mg 50 mg
1
valproic acid (as sodium salt) oral solution 250 mg5 ml 500 mg10 ml (10 ml)
1
valproic acid oral capsule 250 mg 1
vigabatrin oral powder in packet 500 mg 2 PA LA
vigabatrin oral tablet 500 mg 2 PA LA
vigadrone oral powder in packet 500 mg 2 PA ST
VIMPAT ORAL SOLUTION 10 MGML 1 PA ST QL (6 per 30 days)
VIMPAT ORAL TABLET 100 MG 150 MG 200 MG 50 MG
1 ST QL (60 per 30 days)
27
Drug Name Drug Tier Requirements Limits
XCOPRI MAINTENANCE PACK ORAL TABLET 250 MGDAY (200 MG X1-50 MG X1) 350 MGDAY (200 MG X1-150MG X1)
2
XCOPRI MAINTENANCE PACK ORAL TABLET 250MGDAY(150 MG X1-100MG X1)
2 PA ST
XCOPRI ORAL TABLET 100 MG 150 MG 200 MG 50 MG
2
XCOPRI TITRATION PACK ORAL TABLETSDOSE PACK 125 MG (14)- 25 MG (14) 150 MG (14)- 200 MG (14) 50 MG (14)- 100 MG (14)
2
zonisamide oral capsule 100 mg 25 mg 50 mg 1
ANTIPARKINSONISM AGENTS
APOKYN SUBCUTANEOUS CARTRIDGE 10 MGML
2 PA LA QL (1 per 30 days)
benztropine injection solution 1 mgml 1
benztropine oral tablet 05 mg 1 mg 2 mg 1
bromocriptine oral capsule 5 mg 1
bromocriptine oral tablet 25 mg 1
carbidopa oral tablet 25 mg 1
carbidopa-levodopa oral tablet 10-100 mg 25-100 mg 25-250 mg
1
carbidopa-levodopa oral tablet extended release 25-100 mg 50-200 mg
1
carbidopa-levodopa oral tabletdisintegrating 10-100 mg 25-100 mg 25-250 mg
1
carbidopa-levodopa-entacapone oral tablet 125-50-200 mg 1875-75-200 mg 25-100-200 mg 3125-125-200 mg 375-150-200 mg 50-200-200 mg
1
entacapone oral tablet 200 mg 1
pramipexole oral tablet 0125 mg 025 mg 05 mg 075 mg 1 mg 15 mg
1
pramipexole oral tablet extended release 24 hr 0375 mg 075 mg 15 mg 225 mg 3 mg 375 mg 45 mg
1
rasagiline oral tablet 05 mg 1 mg 1
ropinirole oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg 5 mg
1
28
Drug Name Drug Tier Requirements Limits
ropinirole oral tablet extended release 24 hr 12 mg 2 mg 4 mg 6 mg 8 mg
1
selegiline hcl oral capsule 5 mg 1
selegiline hcl oral tablet 5 mg 1
tolcapone oral tablet 100 mg 1
trihexyphenidyl oral elixir 04 mgml 1
trihexyphenidyl oral tablet 2 mg 5 mg 1
MIGRAINE amp CLUSTER HEADACHE THERAPY
AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MGML 70 MGML
1 PA ST
AJOVY AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 225 MG15 ML
1 ST
AJOVY SYRINGE SUBCUTANEOUS SYRINGE 225 MG15 ML
1 PA ST
almotriptan malate oral tablet 125 mg 625 mg 1 QL (18 per 30 days)
dihydroergotamine injection solution 1 mgml 1
dihydroergotamine nasal spraynon-aerosol 05 mgpump act (4 mgml)
1 QL (8 per 30 days)
eletriptan oral tablet 20 mg 40 mg 1 QL (18 per 30 days)
EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MGML
1 PA ST
EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MGML 300 MG3 ML (100 MGML X 3)
1 PA ST
ergotamine-caffeine oral tablet 1-100 mg 1
frovatriptan oral tablet 25 mg 1 QL (18 per 30 days)
migergot rectal suppository 2-100 mg 1
naratriptan oral tablet 1 mg 25 mg 1 QL (18 per 30 days)
ONZETRA XSAIL NASAL AEROSOL POWDR BREATH ACTIVATED 11 MG
1 ST QL (16 per 30 days)
rizatriptan oral tablet 10 mg 5 mg 1 QL (18 per 30 days)
rizatriptan oral tabletdisintegrating 10 mg 5 mg 1 QL (18 per 30 days)
sumatriptan nasal spraynon-aerosol 20 mgactuation 5 mgactuation
1 QL (18 per 30 days)
sumatriptan succinate oral tablet 100 mg 25 mg 50 mg
1 QL (18 per 30 days)
sumatriptan succinate subcutaneous cartridge 4 mg05 ml 6 mg05 ml
1 QL (8 per 30 days)
29
Drug Name Drug Tier Requirements Limits
sumatriptan succinate subcutaneous pen injector 4 mg05 ml 6 mg05 ml
1 QL (8 per 30 days)
sumatriptan succinate subcutaneous solution 6 mg05 ml
1 QL (8 per 30 days)
sumatriptan succinate subcutaneous syringe 6 mg05 ml
1 QL (8 per 30 days)
UBRELVY ORAL TABLET 100 MG 50 MG 1 QL (16 per 30 days)
VYEPTI INTRAVENOUS SOLUTION 100 MGML
MB PA
zolmitriptan oral tablet 25 mg 5 mg 1 QL (18 per 30 days)
zolmitriptan oral tabletdisintegrating 25 mg 5 mg
1 QL (18 per 30 days)
ZOMIG NASAL SPRAYNON-AEROSOL 25 MG 5 MG
1 ST QL (18 per 30 days)
MISCELLANEOUS NEUROLOGICAL THERAPY
AUSTEDO ORAL TABLET 12 MG 6 MG 9 MG
2 PA LA
dalfampridine oral tablet extended release 12 hr 10 mg
2 PA LA QL (60 per 30 days)
donepezil oral tablet 10 mg 23 mg 5 mg 1
donepezil oral tabletdisintegrating 10 mg 5 mg 1
EXONDYS-51 INTRAVENOUS SOLUTION 50 MGML
MB PA
galantamine oral capsuleext rel pellets 24 hr 16 mg 24 mg 8 mg
1
galantamine oral solution 4 mgml 1
galantamine oral tablet 12 mg 4 mg 8 mg 1
memantine oral capsulesprinkleer 24hr 14 mg 21 mg 28 mg 7 mg
1
memantine oral solution 2 mgml 1
memantine oral tablet 10 mg 5 mg 1
NUEDEXTA ORAL CAPSULE 20-10 MG 1
ONPATTRO INTRAVENOUS SOLUTION 2 MGML
MB PA
RADICAVA INTRAVENOUS SOLUTION 30 MG100 ML
MB PA
rivastigmine tartrate oral capsule 15 mg 3 mg 45 mg 6 mg
1
30
Drug Name Drug Tier Requirements Limits
rivastigmine transdermal patch 24 hour 133 mg24 hour 46 mg24 hour 95 mg24 hour
1
tetrabenazine oral tablet 125 mg 25 mg 2 LA
TYSABRI INTRAVENOUS SOLUTION 300 MG15 ML
MB PA ST LA
VYONDYS-53 INTRAVENOUS SOLUTION 50 MGML
MB PA
ZOLGENSMA INTRAVENOUS KIT 2 X 10EXP13 VGML
MB LA
MUSCLE RELAXANTS amp ANTISPASMODIC THERAPY
baclofen oral tablet 10 mg 20 mg 5 mg 1
carisoprodol oral tablet 250 mg 350 mg 1
carisoprodol-aspirin oral tablet 200-325 mg 1
carisoprodol-aspirin-codeine oral tablet 200-325-16 mg
1 PA ST
chlorzoxazone oral tablet 250 mg 375 mg 750 mg 1 ST
chlorzoxazone oral tablet 500 mg 1
cyclobenzaprine oral tablet 10 mg 5 mg 75 mg 1
dantrolene oral capsule 100 mg 25 mg 50 mg 1
meprobamate oral tablet 200 mg 400 mg 1
metaxalone oral tablet 400 mg 800 mg 1
methocarbamol oral tablet 500 mg 750 mg 1
orphenadrine citrate injection solution 30 mgml 1
orphenadrine citrate oral tablet extended release 100 mg
1
pyridostigmine bromide oral syrup 60 mg5 ml 1
pyridostigmine bromide oral tablet 60 mg 1
pyridostigmine bromide oral tablet extended release 180 mg
1
tizanidine oral capsule 2 mg 4 mg 6 mg 1
tizanidine oral tablet 2 mg 4 mg 1
vanadom oral tablet 350 mg 1
NARCOTIC ANALGESICS
acetaminophen-caff-dihydrocod oral capsule 3205-30-16 mg
1 PA ST
acetaminophen-caff-dihydrocod oral tablet 325-30-16 mg
1 PA ST
31
Drug Name Drug Tier Requirements Limits
acetaminophen-codeine oral solution 120-12 mg5 ml 300 mg-30 mg 125 ml
1 PA ST
acetaminophen-codeine oral tablet 300-15 mg 300-30 mg 300-60 mg
1 PA ST
ascomp with codeine oral capsule 30-50-325-40 mg
1 PA ST
buprenorphine hcl injection solution 03 mgml 1 PA ST
buprenorphine hcl injection syringe 03 mgml 1 PA ST
buprenorphine hcl sublingual tablet 2 mg 8 mg 1
buprenorphine transdermal patch weekly 10 mcghour 15 mcghour 20 mcghour 5 mcghour 75 mcghour
1
butalbital compound wcodeine oral capsule 30-50-325-40 mg
1 PA ST
butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg 50-325-40-30 mg
1 PA ST
butalbital-acetaminophen-caff oral capsule 50-300-40 mg 50-325-40 mg
1
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
1
butalbital-aspirin-caffeine oral capsule 50-325-40 mg
1
butalbital-aspirin-caffeine oral tablet 50-325-40 mg
1
codeine sulfate oral tablet 15 mg 30 mg 60 mg 1 PA ST
codeine-butalbital-asa-caff oral capsule 30-50-325-40 mg
1 PA ST
diskets oral tabletsoluble 40 mg 1 PA ST
DSUVIA SUBLINGUAL TABLET IN APPLICATOR 30 MCG
MB
duramorph (pf) injection solution 05 mgml 1 mgml
MB PA ST
dvorah oral tablet 325-30-16 mg 1 PA ST
endocet oral tablet 10-325 mg 25-325 mg 5-325 mg 75-325 mg
1 PA ST
fentanyl citrate buccal lozenge on a handle 1200 mcg 1600 mcg 200 mcg 400 mcg 600 mcg 800 mcg
1 PA
32
Drug Name Drug Tier Requirements Limits
fentanyl transdermal patch 72 hour 100 mcghr 12 mcghr 25 mcghr 375 mcghour 50 mcghr 625 mcghour 75 mcghr 875 mcghour
1 PA ST
hydrocodone bitartrate oral capsule oral only er 12hr 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg
1 PA ST QL (60 per 30 days)
hydrocodone bitartrate oral tabletoral onlyextrel24 hr 100 mg 120 mg 20 mg 30 mg 40 mg 60 mg 80 mg
1 PA ST
hydrocodone-acetaminophen oral solution 10-325 mg15 ml(15 ml) 75-325 mg15 ml
1 PA ST
hydrocodone-acetaminophen oral tablet 10-300 mg 10-325 mg 5-300 mg 5-325 mg 75-300 mg 75-325 mg
1 PA ST
hydrocodone-ibuprofen oral tablet 10-200 mg 5-200 mg 75-200 mg
1 PA ST
HYDROMORPHONE INJECTION SYRINGE 05 MG05 ML
1 PA ST
hydromorphone oral liquid 1 mgml 1 PA ST
hydromorphone oral tablet 2 mg 4 mg 8 mg 1 PA ST
hydromorphone oral tablet extended release 24 hr 12 mg 16 mg 32 mg 8 mg
1 PA ST QL (60 per 30 days)
hydromorphone rectal suppository 3 mg 1 PA ST
levorphanol tartrate oral tablet 2 mg 3 mg 1 PA ST
meperidine oral solution 50 mg5 ml 1 PA ST
meperidine oral tablet 50 mg 1 PA ST
methadone injection solution 10 mgml 1 PA ST
methadone oral concentrate 10 mgml 1 PA ST
methadone oral solution 10 mg5 ml 5 mg5 ml 1 PA ST
methadone oral tablet 10 mg 5 mg 1 PA ST
methadone oral tabletsoluble 40 mg 1 PA ST
methadose oral concentrate 10 mgml 1 PA ST
methadose oral tabletsoluble 40 mg 1 PA ST
morphine (pf) injection solution 05 mgml MB PA ST
morphine concentrate oral solution 100 mg5 ml (20 mgml)
1 PA ST
morphine oral capsule er multiphase 24 hr 120 mg 30 mg 45 mg 60 mg 75 mg 90 mg
1 PA ST QL (60 per 30 days)
morphine oral capsuleextendrelease pellets 10 mg 100 mg 20 mg 50 mg 80 mg
1 PA ST QL (90 per 30 days)
33
Drug Name Drug Tier Requirements Limits
morphine oral capsuleextendrelease pellets 30 mg 60 mg
1 PA ST QL (60 per 30 days)
morphine oral capsuleextendrelease pellets 40 mg
1 PA QL (90 per 30 days)
morphine oral solution 10 mg5 ml 20 mg5 ml (4 mgml)
1 PA ST
morphine oral tablet 15 mg 30 mg 1 PA ST
morphine oral tablet extended release 100 mg 15 mg 200 mg 30 mg 60 mg
1 PA ST QL (120 per 30 days)
morphine rectal suppository 10 mg 20 mg 30 mg 5 mg
1 PA ST
oxycodone oral capsule 5 mg 1 PA ST
oxycodone oral concentrate 20 mgml 1 PA ST
oxycodone oral solution 5 mg5 ml 1 PA ST
oxycodone oral tablet 10 mg 15 mg 20 mg 30 mg 5 mg
1 PA ST
oxycodone-acetaminophen oral tablet 10-325 mg 25-300 mg 25-325 mg 5-325 mg 75-325 mg
1 PA ST
oxycodone-aspirin oral tablet 48355-325 mg 1 PA ST
OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 10 MG 15 MG 20 MG 30 MG 40 MG
1 PA ST QL (90 per 30 days)
OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 60 MG 80 MG
1 PA ST QL (120 per 30 days)
oxymorphone oral tablet 10 mg 5 mg 1 PA ST
oxymorphone oral tablet extended release 12 hr 10 mg 15 mg 20 mg 30 mg 40 mg 5 mg 75 mg
1 PA ST QL (90 per 30 days)
SUBLOCADE SUBCUTANEOUS SOLUTION EXTENDED REL SYRINGE 100 MG05 ML 300 MG15 ML
MB
tencon oral tablet 50-325 mg 1
NON-NARCOTIC ANALGESICS
adult aspirin regimen oral tabletdelayed release (drec) 81 mg
ACA PV
aspirin low dose oral tabletdelayed release (drec) 81 mg
ACA PV
aspirin oral tablet 325 mg ACA PV
aspirin oral tabletchewable 81 mg ACA PV
34
Drug Name Drug Tier Requirements Limits
aspirin oral tabletdelayed release (drec) 325 mg 81 mg
ACA PV
aspir-trin oral tabletdelayed release (drec) 325 mg
ACA PV
bayer aspirin oral tablet 325 mg ACA PV
BAYER CHEWABLE ASPIRIN ORAL TABLETCHEWABLE 81 MG
ACA PV
buprenorphine-naloxone sublingual film 12-3 mg 1 QL (60 per 30 days)
buprenorphine-naloxone sublingual film 2-05 mg 4-1 mg 8-2 mg
1 QL (90 per 30 days)
buprenorphine-naloxone sublingual tablet 2-05 mg 8-2 mg
1 QL (90 per 30 days)
butorphanol nasal spraynon-aerosol 10 mgml 1 PA ST QL (5 per 30 days)
cataflam oral tablet 50 mg 1
celecoxib oral capsule 100 mg 200 mg 400 mg 50 mg
1
childrens aspirin oral tabletchewable 81 mg ACA PV
cholinemagnesium salicylate oral liquid 500 mg5 ml
1
diclofenac potassium oral tablet 50 mg 1
diclofenac sodium oral tablet extended release 24 hr 100 mg
1
diclofenac sodium oral tabletdelayed release (drec) 25 mg 50 mg 75 mg
1
diclofenac sodium topical drops 15 1
diclofenac sodium topical gel 1 1
diclofenac-misoprostol oral tabletirdelayed relbiphasic 50-200 mg-mcg 75-200 mg-mcg
1
diflunisal oral tablet 500 mg 1
DUEXIS ORAL TABLET 800-266 MG 1 ST
ecotrin low strength oral tabletdelayed release (drec) 81 mg
ACA PV
ecotrin oral tabletdelayed release (drec) 325 mg ACA PV
etodolac oral capsule 200 mg 300 mg 1
etodolac oral tablet 400 mg 500 mg 1
etodolac oral tablet extended release 24 hr 400 mg 500 mg 600 mg
1
EUFLEXXA INTRA-ARTICULAR SYRINGE 10 MGML(MW 24 -36 MILLION)
MB
35
Drug Name Drug Tier Requirements Limits
fenoprofen oral tablet 600 mg 1
flurbiprofen oral tablet 100 mg 1
ibu oral tablet 400 mg 600 mg 800 mg 1
ibuprofen oral suspension 100 mg5 ml 1
ibuprofen oral tablet 400 mg 600 mg 800 mg 1
indomethacin oral capsule 25 mg 50 mg 1
indomethacin oral capsule extended release 75 mg
1
ketoprofen oral capsule 25 mg 50 mg 75 mg 1
ketoprofen oral capsuleext rel pellets 24 hr 200 mg
1
ketorolac injection cartridge 15 mgml 30 mgml 1
ketorolac injection solution 15 mgml 30 mgml MB
ketorolac injection solution 30 mgml (1 ml) 1
ketorolac intramuscular cartridge 60 mg2 ml 1
ketorolac intramuscular solution 60 mg2 ml 1
ketorolac intramuscular syringe 60 mg2 ml 1
ketorolac oral tablet 10 mg 1
meclofenamate oral capsule 100 mg 50 mg 1
mefenamic acid oral capsule 250 mg 1
meloxicam oral tablet 15 mg 75 mg 1
MONOVISC INTRA-ARTICULAR SYRINGE 88 MG4 ML
MB LA
nabumetone oral tablet 500 mg 750 mg 1
nalbuphine injection solution 10 mgml MB PA ST
naloxone injection solution 04 mgml 1
naloxone injection syringe 04 mgml 1 mgml 1
naltrexone oral tablet 50 mg 1
naproxen oral suspension 125 mg5 ml 1
naproxen oral tablet 250 mg 375 mg 500 mg 1
naproxen oral tabletdelayed release (drec) 375 mg 500 mg
1
naproxen sodium oral tablet 275 mg 550 mg 1
NARCAN NASAL SPRAYNON-AEROSOL 4 MGACTUATION
1
36
Drug Name Drug Tier Requirements Limits
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG 150 MG 200 MG 250 MG 50 MG
1 PA ST QL (60 per 30 days)
ORTHOVISC INTRA-ARTICULAR SYRINGE 30 MG2 ML
MB
oxaprozin oral tablet 600 mg 1
pentazocine-naloxone oral tablet 50-05 mg 1 PA ST
piroxicam oral capsule 10 mg 20 mg 1
salsalate oral tablet 500 mg 750 mg 1
st joseph aspirin oral tabletchewable 81 mg ACA PV
st joseph aspirin oral tabletdelayed release (drec) 81 mg
ACA PV
sulindac oral tablet 150 mg 200 mg 1
tolmetin oral capsule 400 mg 1
tolmetin oral tablet 200 mg 600 mg 1
tramadol oral tablet 50 mg 1 PA ST
tramadol oral tablet extended release 24 hr 100 mg 200 mg 300 mg
1 PA ST
tramadol oral tablet er multiphase 24 hr 100 mg 200 mg 300 mg
1 PA ST
tramadol-acetaminophen oral tablet 375-325 mg 1 PA ST
VIVITROL INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 380 MG
MB
PSYCHOTHERAPEUTIC DRUGS
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 300 MG 400 MG
1
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 300 MG 400 MG
1
ADHANSIA XR ORAL CAPSULE ER BIPHASIC 20-80 25 MG 35 MG 45 MG 55 MG 70 MG 85 MG
1 PA ST
ADZENYS ER ORAL SUSPEN IR - ER BIPHASIC 24HR 125 MGML
1 ST
ADZENYS XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 125 MG 157 MG 188 MG 31 MG 63 MG 94 MG
1 ST
37
Drug Name Drug Tier Requirements Limits
alprazolam intensol oral concentrate 1 mgml 1
alprazolam oral tablet 025 mg 05 mg 1 mg 2 mg
1
alprazolam oral tablet extended release 24 hr 05 mg 1 mg 2 mg 3 mg
1
alprazolam oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg
1
amitriptyline oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
amitriptyline-chlordiazepoxide oral tablet 125-5 mg 25-10 mg
1
amoxapine oral tablet 100 mg 150 mg 25 mg 50 mg
1
AMPHETAMINE ORAL SUSPEN IR - ER BIPHASIC 24HR 125 MGML
1 ST
amphetamine sulfate oral tablet 10 mg 5 mg 1
APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG 348 MG 522 MG
1 ST
aripiprazole oral solution 1 mgml 1
aripiprazole oral tablet 10 mg 15 mg 2 mg 20 mg 30 mg 5 mg
1
aripiprazole oral tabletdisintegrating 10 mg 15 mg
1
ARISTADA INITIO INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 675 MG24 ML
MB
ARISTADA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 1064 MG39 ML 441 MG16 ML 662 MG24 ML 882 MG32 ML
MB
armodafinil oral tablet 150 mg 200 mg 250 mg 50 mg
1
asenapine maleate sublingual tablet 10 mg 25 mg 5 mg
1
atomoxetine oral capsule 10 mg 100 mg 18 mg 25 mg 40 mg 60 mg 80 mg
1
BELSOMRA ORAL TABLET 10 MG 15 MG 20 MG 5 MG
1 ST
bupropion hcl oral tablet 100 mg 75 mg 1
bupropion hcl oral tablet extended release 24 hr 150 mg 300 mg
1
38
Drug Name Drug Tier Requirements Limits
bupropion hcl oral tablet sustained-release 12 hr 100 mg 150 mg 200 mg
1
buspirone oral tablet 10 mg 15 mg 30 mg 5 mg 75 mg
1
chlordiazepoxide hcl oral capsule 10 mg 25 mg 5 mg
1
chlorpromazine injection solution 25 mgml 1
chlorpromazine oral tablet 10 mg 100 mg 200 mg 25 mg 50 mg
1
citalopram oral solution 10 mg5 ml 1
citalopram oral tablet 10 mg 20 mg 40 mg 1
clomipramine oral capsule 25 mg 50 mg 75 mg 1
clonidine hcl oral tablet extended release 12 hr 01 mg
1
clorazepate dipotassium oral tablet 15 mg 375 mg 75 mg
1
clozapine oral tablet 100 mg 200 mg 25 mg 50 mg
1
clozapine oral tabletdisintegrating 100 mg 125 mg 150 mg 200 mg 25 mg
1
COTEMPLA XR-ODT ORAL TABLETDISINTEG ER BIPHASE 24H 173 MG 259 MG 86 MG
1 ST
DAYTRANA TRANSDERMAL PATCH 24 HOUR 10 MG9 HR 15 MG9 HR 20 MG9 HR 30 MG9 HR
1 ST
desipramine oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG 50 MG
1 ST
desvenlafaxine succinate oral tablet extended release 24 hr 100 mg 25 mg 50 mg
1
dexmethylphenidate oral capsuleer biphasic 50-50 10 mg 15 mg 20 mg 25 mg 30 mg 35 mg 40 mg 5 mg
1
dexmethylphenidate oral tablet 10 mg 25 mg 5 mg
1
dextroamphetamine oral capsule extended release 10 mg 15 mg 5 mg
1
dextroamphetamine oral solution 5 mg5 ml 1
39
Drug Name Drug Tier Requirements Limits
dextroamphetamine oral tablet 10 mg 5 mg 1
dextroamphetamine-amphetamine oral capsuleextended release 24hr 10 mg 15 mg 20 mg 25 mg 30 mg 5 mg
1
dextroamphetamine-amphetamine oral tablet 10 mg 125 mg 15 mg 20 mg 30 mg 5 mg 75 mg
1
diazepam injection solution 5 mgml MB
diazepam injection syringe 5 mgml MB
diazepam intensol oral concentrate 5 mgml 1
diazepam oral solution 5 mg5 ml (1 mgml) 1
diazepam oral tablet 10 mg 2 mg 5 mg 1
doxepin oral capsule 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg
1
doxepin oral concentrate 10 mgml 1
duloxetine oral capsuledelayed release(drec) 20 mg 30 mg 40 mg 60 mg
1
DYANAVEL XR ORAL SUSPEN IR - ER BIPHASIC 24HR 25 MGML
1 ST
EDLUAR SUBLINGUAL TABLET 10 MG 5 MG
1 ST
EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG24 HR 6 MG24 HR 9 MG24 HR
1 ST
ergoloid oral tablet 1 mg 1
escitalopram oxalate oral solution 5 mg5 ml 1
escitalopram oxalate oral tablet 10 mg 20 mg 5 mg
1
estazolam oral tablet 1 mg 2 mg 1
eszopiclone oral tablet 1 mg 2 mg 3 mg 1
FANAPT ORAL TABLET 1 MG 10 MG 12 MG 2 MG 4 MG 6 MG 8 MG
1 PA ST
FANAPT ORAL TABLETSDOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)
1 PA ST
FETZIMA ORAL CAPSULEEXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)
1 ST
FETZIMA ORAL CAPSULEEXTENDED RELEASE 24 HR 120 MG 20 MG 40 MG 80 MG
1 ST
fluoxetine oral capsule 10 mg 20 mg 40 mg 1
40
Drug Name Drug Tier Requirements Limits
fluoxetine oral capsuledelayed release(drec) 90 mg
1
fluoxetine oral solution 20 mg5 ml (4 mgml) 1
fluoxetine oral tablet 10 mg 20 mg 1
fluoxetine oral tablet 60 mg 1 PA
fluphenazine hcl injection solution 25 mgml 1
fluphenazine hcl oral concentrate 5 mgml 1
fluphenazine hcl oral elixir 25 mg5 ml 1
fluphenazine hcl oral tablet 1 mg 10 mg 25 mg 5 mg
1
flurazepam oral capsule 15 mg 30 mg 1
fluvoxamine oral capsuleextended release 24hr 100 mg 150 mg
1
fluvoxamine oral tablet 100 mg 25 mg 50 mg 1
guanfacine oral tablet extended release 24 hr 1 mg 2 mg 3 mg 4 mg
1
haloperidol decanoate intramuscular solution 100 mgml 50 mgml
1
haloperidol lactate injection solution 5 mgml 1
haloperidol lactate oral concentrate 2 mgml 1
haloperidol oral tablet 05 mg 1 mg 10 mg 2 mg 20 mg 5 mg
1
HETLIOZ LQ ORAL SUSPENSION 4 MGML 2 PA ST LA
HETLIOZ ORAL CAPSULE 20 MG 2 PA ST LA
imipramine hcl oral tablet 10 mg 25 mg 50 mg 1
imipramine pamoate oral capsule 100 mg 125 mg 150 mg 75 mg
1
INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG075 ML 156 MGML 234 MG15 ML 39 MG025 ML 78 MG05 ML
1
JORNAY PM ORAL CAPSULEDEL RELEXT REL SPRINK 100 MG 20 MG 40 MG 60 MG 80 MG
1 ST
LATUDA ORAL TABLET 120 MG 20 MG 40 MG 60 MG 80 MG
1 PA ST
lithium carbonate oral capsule 150 mg 300 mg 600 mg
1
lithium carbonate oral tablet 300 mg 1
41
Drug Name Drug Tier Requirements Limits
lithium carbonate oral tablet extended release 300 mg 450 mg
1
lorazepam intensol oral concentrate 2 mgml 1
lorazepam oral concentrate 2 mgml 1
lorazepam oral tablet 05 mg 1 mg 2 mg 1
loxapine succinate oral capsule 10 mg 25 mg 5 mg 50 mg
1
maprotiline oral tablet 25 mg 50 mg 75 mg 1
MARPLAN ORAL TABLET 10 MG 1
methamphetamine oral tablet 5 mg 1
METHYLIN ORAL SOLUTION 10 MG5 ML 5 MG5 ML
1
methylphenidate hcl oral caper sprinklebiphasic 40-60 10 mg 15 mg 20 mg 30 mg 40 mg 50 mg 60 mg
1
methylphenidate hcl oral capsule er biphasic 30-70 10 mg 20 mg 30 mg 40 mg 50 mg 60 mg
1
methylphenidate hcl oral capsuleer biphasic 50-50 10 mg 20 mg 30 mg 40 mg 60 mg
1
methylphenidate hcl oral solution 10 mg5 ml 5 mg5 ml
1
methylphenidate hcl oral tablet 10 mg 20 mg 5 mg
1
methylphenidate hcl oral tablet extended release 10 mg 20 mg
1
methylphenidate hcl oral tablet extended release 24hr 18 mg 27 mg 36 mg 54 mg
1
methylphenidate hcl oral tabletchewable 10 mg 25 mg 5 mg
1
midazolam oral syrup 2 mgml 1
mirtazapine oral tablet 15 mg 30 mg 45 mg 75 mg
1
mirtazapine oral tabletdisintegrating 15 mg 30 mg 45 mg
1
modafinil oral tablet 100 mg 200 mg 1
molindone oral tablet 10 mg 25 mg 5 mg 1
MYDAYIS ORAL CAPSULE ER TRIPHASIC 24 HR 125 MG 25 MG 375 MG 50 MG
1 ST
nefazodone oral tablet 100 mg 150 mg 200 mg 250 mg 50 mg
1
42
Drug Name Drug Tier Requirements Limits
nortriptyline oral capsule 10 mg 25 mg 50 mg 75 mg
1
nortriptyline oral solution 10 mg5 ml 1
NUPLAZID ORAL CAPSULE 34 MG 2 PA LA
NUPLAZID ORAL TABLET 10 MG 2 PA LA
olanzapine intramuscular recon soln 10 mg 1
olanzapine oral tablet 10 mg 15 mg 25 mg 20 mg 5 mg 75 mg
1
olanzapine oral tabletdisintegrating 10 mg 15 mg 20 mg 5 mg
1
olanzapine-fluoxetine oral capsule 12-25 mg 12-50 mg 3-25 mg 6-25 mg 6-50 mg
1
oxazepam oral capsule 10 mg 15 mg 30 mg 1
paliperidone oral tablet extended release 24hr 15 mg 3 mg 6 mg 9 mg
1
paroxetine hcl oral tablet 10 mg 20 mg 30 mg 40 mg
1
paroxetine hcl oral tablet extended release 24 hr 125 mg 25 mg 375 mg
1
paroxetine mesylate(menopsym) oral capsule 75 mg
1
perphenazine oral tablet 16 mg 2 mg 4 mg 8 mg 1
perphenazine-amitriptyline oral tablet 2-10 mg 2-25 mg 4-10 mg 4-25 mg 4-50 mg
1
phenelzine oral tablet 15 mg 1
pimozide oral tablet 1 mg 2 mg 1
procentra oral solution 5 mg5 ml 1
protriptyline oral tablet 10 mg 5 mg 1
quetiapine oral tablet 100 mg 200 mg 25 mg 300 mg 400 mg 50 mg
1
quetiapine oral tablet extended release 24 hr 150 mg 200 mg 300 mg 400 mg 50 mg
1
QUILLICHEW ER ORAL TABLETCHEWIR-ERBIPHASIC24HR 20 MG 30 MG 40 MG
1 ST
QUILLIVANT XR ORAL SUSPENSIONEXT REL 24HRRECON 5 MGML (25 MG5 ML)
1 ST
ramelteon oral tablet 8 mg 1
RELEXXII ORAL TABLET EXTENDED RELEASE 24HR 72 MG
1 ST
43
Drug Name Drug Tier Requirements Limits
REXULTI ORAL TABLET 025 MG 05 MG 1 MG 2 MG 3 MG 4 MG
1 PA ST
RISPERDAL CONSTA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 125 MG2 ML 25 MG2 ML 375 MG2 ML 50 MG2 ML
1
risperidone oral solution 1 mgml 1
risperidone oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg
1
risperidone oral tabletdisintegrating 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg
1
seconal sodium oral capsule 100 mg 1
sertraline oral concentrate 20 mgml 1
sertraline oral tablet 100 mg 25 mg 50 mg 1
SPRAVATO NASAL SPRAYNON-AEROSOL 56 MG (28 MG X 2) 84 MG (28 MG X 3)
MB PA
SUNOSI ORAL TABLET 150 MG 1 PA QL (30 per 30 days)
SUNOSI ORAL TABLET 75 MG 1 PA QL (60 per 30 days)
temazepam oral capsule 15 mg 225 mg 30 mg 75 mg
1
thioridazine oral tablet 10 mg 100 mg 25 mg 50 mg
1
thiothixene oral capsule 1 mg 10 mg 2 mg 5 mg 1
tranylcypromine oral tablet 10 mg 1
trazodone oral tablet 100 mg 150 mg 300 mg 50 mg
1
triazolam oral tablet 0125 mg 025 mg 1
trifluoperazine oral tablet 1 mg 10 mg 2 mg 5 mg
1
trimipramine oral capsule 100 mg 25 mg 50 mg 1
TRINTELLIX ORAL TABLET 10 MG 20 MG 5 MG
1 ST
venlafaxine oral capsuleextended release 24hr 150 mg 375 mg 75 mg
1
venlafaxine oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg
1
venlafaxine oral tablet extended release 24hr 150 mg 225 mg 375 mg 75 mg
1
VERSACLOZ ORAL SUSPENSION 50 MGML 1 PA ST
44
Drug Name Drug Tier Requirements Limits
VRAYLAR ORAL CAPSULE 15 MG 3 MG 45 MG 6 MG
1 PA ST
VRAYLAR ORAL CAPSULEDOSE PACK 15 MG (1)- 3 MG (6)
1 PA ST
VYVANSE ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG 70 MG
1 PA ST
VYVANSE ORAL TABLETCHEWABLE 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG
1 PA ST
XYREM ORAL SOLUTION 500 MGML 1 PA QL (540 per 30 days)
zaleplon oral capsule 10 mg 5 mg 1
ZENZEDI ORAL TABLET 15 MG 25 MG 20 MG 30 MG 75 MG
1 ST
ziprasidone hcl oral capsule 20 mg 40 mg 60 mg 80 mg
1
zolpidem oral tablet 10 mg 5 mg 1
zolpidem oral tabletext release multiphase 125 mg 625 mg
1
zolpidem sublingual tablet 175 mg 35 mg 1
ZOLPIMIST ORAL SPRAYNON-AEROSOL 5 MGSPRAY (01 ML)
1 ST
ZULRESSO INTRAVENOUS SOLUTION 5 MGML
MB
CARDIOVASCULAR HYPERTENSION amp LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone oral tablet 100 mg 200 mg 400 mg 1
disopyramide phosphate oral capsule 100 mg 150 mg
1
dofetilide oral capsule 125 mcg 250 mcg 500 mcg 1
flecainide oral tablet 100 mg 150 mg 50 mg 1
mexiletine oral capsule 150 mg 200 mg 250 mg 1
MULTAQ ORAL TABLET 400 MG 1
NORPACE CR ORAL CAPSULE EXTENDED RELEASE 100 MG 150 MG
1
pacerone oral tablet 100 mg 200 mg 400 mg 1
procainamide injection solution 100 mgml 500 mgml
MB
propafenone oral capsuleextended release 12 hr 225 mg 325 mg 425 mg
1
45
Drug Name Drug Tier Requirements Limits
propafenone oral tablet 150 mg 225 mg 300 mg 1
quinidine gluconate oral tablet extended release 324 mg
1
quinidine sulfate oral tablet 200 mg 300 mg 1
sorine oral tablet 120 mg 160 mg 240 mg 80 mg 1
sotalol af oral tablet 120 mg 160 mg 80 mg 1
sotalol oral tablet 120 mg 160 mg 240 mg 80 mg 1
ANTIHYPERTENSIVE THERAPY
acebutolol oral capsule 200 mg 400 mg 1
aliskiren oral tablet 150 mg 300 mg 1
amiloride oral tablet 5 mg 1
amiloride-hydrochlorothiazide oral tablet 5-50 mg 1
amlodipine oral tablet 10 mg 25 mg 5 mg 1
amlodipine-benazepril oral capsule 10-20 mg 10-40 mg 25-10 mg 5-10 mg 5-20 mg 5-40 mg
1 ST
amlodipine-olmesartan oral tablet 10-20 mg 10-40 mg 5-20 mg 5-40 mg
1 ST
amlodipine-valsartan oral tablet 10-160 mg 10-320 mg 5-160 mg 5-320 mg
1 ST
amlodipine-valsartan-hcthiazid oral tablet 10-160-125 mg 10-160-25 mg 10-320-25 mg 5-160-125 mg 5-160-25 mg
1
atenolol oral tablet 100 mg 25 mg 50 mg 1
atenolol-chlorthalidone oral tablet 100-25 mg 50-25 mg
1
benazepril oral tablet 10 mg 20 mg 40 mg 5 mg 1
benazepril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg 5-625 mg
1
betaxolol oral tablet 10 mg 20 mg 1
bisoprolol fumarate oral tablet 10 mg 5 mg 1
bisoprolol-hydrochlorothiazide oral tablet 10-625 mg 25-625 mg 5-625 mg
1
bumetanide injection solution 025 mgml 1
bumetanide oral tablet 05 mg 1 mg 2 mg 1
BYSTOLIC ORAL TABLET 10 MG 25 MG 20 MG 5 MG
1 ST
candesartan oral tablet 16 mg 32 mg 4 mg 8 mg 1
46
Drug Name Drug Tier Requirements Limits
candesartan-hydrochlorothiazid oral tablet 16-125 mg 32-125 mg 32-25 mg
1
captopril oral tablet 100 mg 125 mg 25 mg 50 mg
1
captopril-hydrochlorothiazide oral tablet 25-15 mg 25-25 mg 50-15 mg 50-25 mg
1
cartia xt oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg
1
carvedilol oral tablet 125 mg 25 mg 3125 mg 625 mg
1
carvedilol phosphate oral capsule er multiphase 24 hr 10 mg 20 mg 40 mg 80 mg
1
chlorthalidone oral tablet 25 mg 50 mg 1
clonidine hcl oral tablet 01 mg 02 mg 03 mg 1
clonidine transdermal patch weekly 01 mg24 hr 02 mg24 hr 03 mg24 hr
1
diltiazem hcl oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg
1
diltiazem hcl oral capsuleextended release 12 hr 120 mg 60 mg 90 mg
1
diltiazem hcl oral capsuleextended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
diltiazem hcl oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg 360 mg
1
diltiazem hcl oral tablet 120 mg 30 mg 60 mg 90 mg
1
diltiazem hcl oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
dilt-xr oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg
1
doxazosin oral tablet 1 mg 2 mg 4 mg 8 mg 1
EDARBI ORAL TABLET 40 MG 80 MG 1 ST
EDARBYCLOR ORAL TABLET 40-125 MG 40-25 MG
1 ST
enalapril maleate oral tablet 10 mg 25 mg 20 mg 5 mg
1
enalaprilat intravenous solution 125 mgml MB
enalapril-hydrochlorothiazide oral tablet 10-25 mg 5-125 mg
1
EPANED ORAL SOLUTION 1 MGML 1
47
Drug Name Drug Tier Requirements Limits
eplerenone oral tablet 25 mg 50 mg 1
epoprostenol (glycine) intravenous recon soln 05 mg 15 mg
MB PA LA
eprosartan oral tablet 600 mg 1
ethacrynic acid oral tablet 25 mg 1
felodipine oral tablet extended release 24 hr 10 mg 25 mg 5 mg
1
FLOLAN INTRAVENOUS RECON SOLN 05 MG 15 MG
MB PA LA
fosinopril oral tablet 10 mg 20 mg 40 mg 1
fosinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg
1
furosemide oral solution 10 mgml 40 mg5 ml (8 mgml)
1
furosemide oral tablet 20 mg 40 mg 80 mg 1
guanfacine oral tablet 1 mg 2 mg 1
hydralazine oral tablet 10 mg 100 mg 25 mg 50 mg
1
hydrochlorothiazide oral capsule 125 mg 1
hydrochlorothiazide oral tablet 125 mg 25 mg 50 mg
1
indapamide oral tablet 125 mg 25 mg 1
irbesartan oral tablet 150 mg 300 mg 75 mg 1
irbesartan-hydrochlorothiazide oral tablet 150-125 mg 300-125 mg
1
isradipine oral capsule 25 mg 5 mg 1
labetalol oral tablet 100 mg 200 mg 300 mg 1
lisinopril oral tablet 10 mg 25 mg 20 mg 30 mg 40 mg 5 mg
1
lisinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg
1
losartan oral tablet 100 mg 25 mg 50 mg 1
losartan-hydrochlorothiazide oral tablet 100-125 mg 100-25 mg 50-125 mg
1
matzim la oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg
1
methyldopa oral tablet 250 mg 500 mg 1
methyldopa-hydrochlorothiazide oral tablet 250-15 mg 250-25 mg
1
48
Drug Name Drug Tier Requirements Limits
methyldopate intravenous solution 250 mg5 ml MB
metolazone oral tablet 10 mg 25 mg 5 mg 1
metoprolol succinate oral tablet extended release 24 hr 100 mg 200 mg 25 mg 50 mg
1
metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg 100-50 mg 50-25 mg
1
metoprolol tartrate oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg
1
metyrosine oral capsule 250 mg 1
minoxidil oral tablet 10 mg 25 mg 1
moexipril oral tablet 15 mg 75 mg 1
nadolol oral tablet 20 mg 40 mg 80 mg 1
nadolol-bendroflumethiazide oral tablet 80-5 mg 1
nicardipine oral capsule 20 mg 30 mg 1
nifedipine oral capsule 10 mg 20 mg 1
nifedipine oral tablet extended release 24hr 30 mg 60 mg 90 mg
1
nifedipine oral tablet extended release 30 mg 60 mg 90 mg
1
nimodipine oral capsule 30 mg 1
nisoldipine oral tablet extended release 24 hr 17 mg 20 mg 255 mg 30 mg 34 mg 40 mg 85 mg
1
olmesartan oral tablet 20 mg 40 mg 5 mg 1
olmesartan-amlodipin-hcthiazid oral tablet 20-5-125 mg 40-10-125 mg 40-10-25 mg 40-5-125 mg 40-5-25 mg
1
olmesartan-hydrochlorothiazide oral tablet 20-125 mg 40-125 mg 40-25 mg
1 ST
ORENITRAM ORAL TABLET EXTENDED RELEASE 0125 MG 025 MG 1 MG 25 MG 5 MG
2 PA LA
perindopril erbumine oral tablet 2 mg 4 mg 8 mg 1
phenoxybenzamine oral capsule 10 mg 1
pindolol oral tablet 10 mg 5 mg 1
prazosin oral capsule 1 mg 2 mg 5 mg 1
propranolol oral capsuleextended release 24 hr 120 mg 160 mg 60 mg 80 mg
1
propranolol oral solution 20 mg5 ml (4 mgml) 40 mg5 ml (8 mgml)
1
49
Drug Name Drug Tier Requirements Limits
propranolol oral tablet 10 mg 20 mg 40 mg 60 mg 80 mg
1
propranolol-hydrochlorothiazid oral tablet 40-25 mg 80-25 mg
1
QBRELIS ORAL SOLUTION 1 MGML 1
quinapril oral tablet 10 mg 20 mg 40 mg 5 mg 1
quinapril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg
1
ramipril oral capsule 125 mg 10 mg 25 mg 5 mg
1
spironolactone oral tablet 100 mg 25 mg 50 mg 1
spironolacton-hydrochlorothiaz oral tablet 25-25 mg
1
taztia xt oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg
1
TEKTURNA HCT ORAL TABLET 150-125 MG 150-25 MG 300-125 MG 300-25 MG
1
telmisartan oral tablet 20 mg 40 mg 80 mg 1
telmisartan-amlodipine oral tablet 40-10 mg 40-5 mg 80-10 mg 80-5 mg
1 ST
telmisartan-hydrochlorothiazid oral tablet 40-125 mg 80-125 mg 80-25 mg
1
terazosin oral capsule 1 mg 10 mg 2 mg 5 mg 1
tiadylt er oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg 420 mg
1
timolol maleate oral tablet 10 mg 20 mg 5 mg 1
torsemide oral tablet 10 mg 100 mg 20 mg 5 mg 1
trandolapril oral tablet 1 mg 2 mg 4 mg 1
trandolapril-verapamil oral tablet ir - er biphasic 24hr 1-240 mg 2-180 mg 2-240 mg 4-240 mg
1 ST
triamterene oral capsule 100 mg 50 mg 1
triamterene-hydrochlorothiazid oral capsule 375-25 mg
1
triamterene-hydrochlorothiazid oral tablet 375-25 mg 75-50 mg
1
valsartan oral tablet 160 mg 320 mg 40 mg 80 mg
1
valsartan-hydrochlorothiazide oral tablet 160-125 mg 160-25 mg 320-125 mg 320-25 mg 80-125 mg
1
50
Drug Name Drug Tier Requirements Limits
veletri intravenous recon soln 05 mg 15 mg MB PA LA
verapamil oral capsule 24 hr er pellet ct 100 mg 200 mg 300 mg
1
verapamil oral capsuleext rel pellets 24 hr 120 mg 180 mg 240 mg 360 mg
1
verapamil oral tablet 120 mg 40 mg 80 mg 1
verapamil oral tablet extended release 120 mg 180 mg 240 mg
1
CARDIAC GLYCOSIDES
digitek oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
digox oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
digoxin oral solution 50 mcgml (005 mgml) 1
digoxin oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)
1
COAGULATION THERAPY
ADVATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 4000 (+-) UNIT 500 (+-) UNIT
MB
ADYNOVATE INTRAVENOUS SOLUTION 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT 750 (+-) UNIT
MB LA
AFSTYLA INTRAVENOUS RECON SOLN 1000 (+-) UNIT RANGE 1500 (+-) UNIT RANGE 2000 (+-) UNIT RANGE 2500 (+-) UNIT RANGE 250 (+-) UNIT RANGE 3000 (+-) UNIT RANGE 500 (+-) UNIT RANGE
MB LA
ALPHANATE INTRAVENOUS RECON SOLN 1000 (400 VWF) UNIT10 ML 1500 (600 VWF) UNIT10 ML 2000 (800 VWF) UNIT10 ML 250 (100 VWF) UNIT5 ML 500 (200 VWF) UNIT5 ML
MB LA
ALPHANINE SD INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT
MB LA
ALPROLIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 500 UNIT
MB LA
aminocaproic acid oral solution 250 mgml (25 ) 1
51
Drug Name Drug Tier Requirements Limits
aminocaproic acid oral tablet 1000 mg 500 mg 1
ANDEXXA INTRAVENOUS RECON SOLN 200 MG
MB
aspirin-dipyridamole oral capsule er multiphase 12 hr 25-200 mg
1
BENEFIX INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
BRILINTA ORAL TABLET 60 MG 90 MG 1
CABLIVI INJECTION KIT 11 MG 2 PA
cilostazol oral tablet 100 mg 50 mg 1
clopidogrel oral tablet 300 mg 75 mg 1
COAGADEX INTRAVENOUS RECON SOLN 250 (+-) UNIT RANGE 500 (+-) UNIT RANGE
MB
CORIFACT INTRAVENOUS RECON SOLN 1000-1600 UNIT
MB LA
dipyridamole oral tablet 25 mg 50 mg 75 mg 1
DOPTELET (15 TAB PACK) ORAL TABLET 20 MG
2 PA LA
ELIQUIS DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 5 MG (74 TABS)
1
ELIQUIS ORAL TABLET 25 MG 5 MG 1
ELOCTATE INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 4000 UNIT 5000 UNIT 500 UNIT 6000 UNIT 750 UNIT
MB LA
enoxaparin subcutaneous solution 300 mg3 ml 2
enoxaparin subcutaneous syringe 100 mgml 120 mg08 ml 150 mgml 30 mg03 ml 40 mg04 ml 60 mg06 ml 80 mg08 ml
2
ESPEROCT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
FEIBA NF INTRAVENOUS RECON SOLN 1750-3250 UNIT 350-650 UNIT 700-1300 UNIT
MB LA
FIBRYGA INTRAVENOUS RECON SOLN 1 GRAM (700 MG- 1300 MG)
MB
fondaparinux subcutaneous syringe 10 mg08 ml 25 mg05 ml 5 mg04 ml 75 mg06 ml
2
52
Drug Name Drug Tier Requirements Limits
FRAGMIN SUBCUTANEOUS SOLUTION 25000 ANTI-XA UNITML
2
FRAGMIN SUBCUTANEOUS SYRINGE 10000 ANTI-XA UNITML 12500 ANTI-XA UNIT05 ML 15000 ANTI-XA UNIT06 ML 18000 ANTI-XA UNIT072 ML 2500 ANTI-XA UNIT02 ML 5000 ANTI-XA UNIT02 ML 7500 ANTI-XA UNIT03 ML
2
HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG07 ML 150 MGML 30 MGML 60 MG04 ML
2 PA LA
HEMOFIL M HIGH INTRAVENOUS RECON SOLN 801-1500 UNIT
MB
HEMOFIL M LOW INTRAVENOUS RECON SOLN 220-400 UNIT
MB
HEMOFIL M MID INTRAVENOUS RECON SOLN 401-800 UNIT
MB
HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 1501-2000 UNIT
MB
hep flush-10 (pf) intravenous solution 10 unitml MB
heparin (porcine) in 5 dex intravenous parenteral solution 25000 unit250 ml(100 unitml) 25000 unit500 ml (50 unitml)
MB
heparin (porcine) injection cartridge 5000 unitml (1 ml)
1
heparin (porcine) injection solution 1000 unitml 10000 unitml 20000 unitml 5000 unitml
1
heparin lock flush (porcine) intravenous solution 100 unitml
MB
heparin lockflush(porcine)(pf) intravenous syringe 100 unitml
MB
HEPARIN(PORCINE) IN 045 NACL INTRAVENOUS PARENTERAL SOLUTION 12500 UNIT250 ML
MB
heparin(porcine) in 045 nacl intravenous parenteral solution 25000 unit250 ml 25000 unit500 ml
MB
heparin porcine (pf) injection solution 1000 unitml 5000 unit05 ml
MB
heparin porcine (pf) injection syringe 5000 unit05 ml
1
53
Drug Name Drug Tier Requirements Limits
heparin porcine (pf) intravenous solution 100 unitml (1 ml)
MB
heparin porcine (pf) intravenous syringe 10 unitml 100 unitml
MB
HUMATE-P INTRAVENOUS RECON SOLN 1000-2400 UNIT 250-600 UNIT 500-1200 UNIT
MB LA
IDELVION INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3500 (+-) UNIT 500 (+-) UNIT
MB LA
IXINITY INTRAVENOUS RECON SOLN 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
jantoven oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg
1
JIVI INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
KOATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB
KOGENATE FS INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB
KOVALTRY INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB
MONONINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT
MB LA
MULPLETA ORAL TABLET 3 MG 2 PA LA
NOVOEIGHT INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
NOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1000 MCG) 2 MG (2000 MCG) 5 MG (5000 MCG) 8 MG (8000 MCG)
MB LA
NPLATE SUBCUTANEOUS RECON SOLN 125 MCG 250 MCG 500 MCG
MB LA
NUWIQ INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 2500 UNIT 250 (+-) UNIT 3000 UNIT 4000 UNIT 500 (+-) UNIT
MB LA
54
Drug Name Drug Tier Requirements Limits
OBIZUR INTRAVENOUS RECON SOLN 500 (+-) UNIT RANGE
MB
pentoxifylline oral tablet extended release 400 mg 1
phytonadione (vitamin k1) oral tablet 5 mg 1
prasugrel oral tablet 10 mg 5 mg 1
PROFILNINE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 500 (+-) UNIT
MB LA
PROMACTA ORAL POWDER IN PACKET 125 MG
2 PA ST LA
PROMACTA ORAL POWDER IN PACKET 25 MG
2 LA
PROMACTA ORAL TABLET 125 MG 25 MG 50 MG 75 MG
2 PA ST LA
REBINYN INTRAVENOUS RECON SOLN 1000 (+-) UNIT 2000 (+-) UNIT 500 (+-) UNIT
MB LA
RECOMBINATE INTRAVENOUS RECON SOLN 1000 (+-) UNIT 1500 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB LA
RIASTAP INTRAVENOUS RECON SOLN 1 GRAM (900MG-1300MG)
MB LA
RIXUBIS INTRAVENOUS RECON SOLN 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT
MB LA
tranexamic acid intravenous solution 1000 mg10 ml (100 mgml)
MB
TRETTEN INTRAVENOUS RECON SOLN 2500 UNIT
MB LA
VONVENDI INTRAVENOUS RECON SOLN 1300 (+-) UNIT RANGE 650 (+-) UNIT RANGE
MB LA
warfarin oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg
1
WILATE INTRAVENOUS RECON SOLN 1000-1000 UNIT 500-500 UNIT
MB LA
XARELTO DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 15 MG (42)- 20 MG (9)
1
XARELTO ORAL TABLET 10 MG 15 MG 25 MG 20 MG
1
55
Drug Name Drug Tier Requirements Limits
XYNTHA INTRAVENOUS SOLUTION 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 500 (+-) UNIT
MB LA
XYNTHA SOLOFUSE INTRAVENOUS SYRINGE 1000 (+-) UNIT 2000 (+-) UNIT 250 (+-) UNIT 3000 (+-) UNIT 500 (+-) UNIT
MB LA
ZONTIVITY ORAL TABLET 208 MG 1
LIPIDCHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg 25-10 mg 25-20 mg 25-40 mg 5-10 mg 5-20 mg 5-40 mg 5-80 mg
1 ST
atorvastatin oral tablet 10 mg 20 mg ACA PV
atorvastatin oral tablet 40 mg 80 mg 1
cholestyramine (with sugar) oral powder 4 gram 1
cholestyramine (with sugar) oral powder in packet 4 gram
1
cholestyramine light oral powder 4 gram 1
cholestyramine light oral powder in packet 4 gram 1
colesevelam oral powder in packet 375 gram 1
colesevelam oral tablet 625 mg 1
colestipol oral granules 5 gram 1
colestipol oral packet 5 gram 1
colestipol oral tablet 1 gram 1
ezetimibe oral tablet 10 mg 1
ezetimibe-simvastatin oral tablet 10-10 mg 10-20 mg 10-40 mg 10-80 mg
1
fenofibrate micronized oral capsule 130 mg 134 mg 200 mg 43 mg 67 mg
1
fenofibrate nanocrystallized oral tablet 145 mg 48 mg
1
FENOFIBRATE ORAL CAPSULE 150 MG 50 MG
1
fenofibrate oral tablet 120 mg 160 mg 40 mg 54 mg
1
fenofibric acid (choline) oral capsuledelayed release(drec) 135 mg 45 mg
1
fenofibric acid oral tablet 105 mg 35 mg 1
fluvastatin oral capsule 20 mg 40 mg ACA PV
56
Drug Name Drug Tier Requirements Limits
fluvastatin oral tablet extended release 24 hr 80 mg
ACA PV
gemfibrozil oral tablet 600 mg 1
icosapent ethyl oral capsule 1 gram 1 PA ST QL (120 per 30 days)
JUXTAPID ORAL CAPSULE 10 MG 20 MG 30 MG 40 MG 5 MG 60 MG
2 PA LA QL (30 per 30 days)
LIPOFEN ORAL CAPSULE 150 MG 50 MG 1
lovastatin oral tablet 10 mg 20 mg 40 mg ACA PV
niacin oral tablet 500 mg 1
niacin oral tablet extended release 24 hr 1000 mg 500 mg 750 mg
1
NIACOR ORAL TABLET 500 MG 1
omega-3 acid ethyl esters oral capsule 1 gram 1
pravastatin oral tablet 10 mg 20 mg 40 mg 80 mg
ACA PV
prevalite oral powder 4 gram 1
prevalite oral powder in packet 4 gram 1
REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG35 ML
1 PA ST
REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MGML
1 PA ST
REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MGML
1 PA ST
rosuvastatin oral tablet 10 mg 5 mg ACA PV
rosuvastatin oral tablet 20 mg 40 mg 1
simvastatin oral tablet 10 mg 20 mg 40 mg 5 mg ACA PV
simvastatin oral tablet 80 mg 1
VASCEPA ORAL CAPSULE 05 GRAM 1 GRAM
1 PA ST QL (120 per 30 days)
ZYPITAMAG ORAL TABLET 2 MG 4 MG 1 PA ST
MISCELLANEOUS CARDIOVASCULAR AGENTS
CORLANOR ORAL SOLUTION 5 MG5 ML 1 PA
CORLANOR ORAL TABLET 5 MG 75 MG 1 PA
ENTRESTO ORAL TABLET 24-26 MG 49-51 MG 97-103 MG
1 PA ST
GIAPREZA INTRAVENOUS SOLUTION 25 MGML
MB
57
Drug Name Drug Tier Requirements Limits
ranolazine oral tablet extended release 12 hr 1000 mg 500 mg
1 ST
NITRATES
GONITRO SUBLINGUAL POWDER IN PACKET 400 MCG
1
isosorbide dinitrate oral tablet 10 mg 20 mg 30 mg 40 mg 5 mg
1
isosorbide mononitrate oral tablet 10 mg 20 mg 1
isosorbide mononitrate oral tablet extended release 24 hr 120 mg 30 mg 60 mg
1
MINITRAN TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 04 MGHR 06 MGHR
1 PA ST
nitro-bid transdermal ointment 2 1
NITRO-DUR TRANSDERMAL PATCH 24 HOUR 01 MGHR 02 MGHR 03 MGHR 04 MGHR 06 MGHR 08 MGHR
1 PA ST
nitroglycerin in 5 dextrose intravenous solution 25 mg250 ml (100 mcgml) 50 mg500 ml (100 mcgml)
MB
nitroglycerin sublingual tablet 03 mg 04 mg 06 mg
1
nitroglycerin transdermal patch 24 hour 01 mghr 02 mghr 04 mghr 06 mghr
1
nitroglycerin translingual spraynon-aerosol 400 mcgspray
1
nitro-time oral capsule extended release 25 mg 65 mg 9 mg
1
DERMATOLOGICALSTOPICAL THERAPY
ANTIPSORIATIC ANTISEBORRHEIC
acitretin oral capsule 10 mg 175 mg 25 mg 1
calcipotriene scalp solution 0005 1
calcipotriene topical cream 0005 1
calcipotriene topical ointment 0005 1
calcipotriene-betamethasone topical ointment 0005-0064
1
calcitriol topical ointment 3 mcggram 1
COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
58
Drug Name Drug Tier Requirements Limits
COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
COSENTYX SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
COSENTYX SUBCUTANEOUS SYRINGE 75 MG05 ML
2 PA LA
hydrocortisone-pramoxine topical cream 25-1 1
ILUMYA SUBCUTANEOUS SYRINGE 100 MGML
2 PA ST LA
selenium sulfide topical lotion 25 1
selenium sulfide topical shampoo 225 23 1
SILIQ SUBCUTANEOUS SYRINGE 210 MG15 ML
2 PA ST LA
SKYRIZI SUBCUTANEOUS PEN INJECTOR 150 MGML
2 PA ST LA
SKYRIZI SUBCUTANEOUS SYRINGE 150 MGML
2 PA ST LA
SKYRIZI SUBCUTANEOUS SYRINGE KIT 150MG166ML(75 MG083 ML X2)
2 PA ST LA
STELARA INTRAVENOUS SOLUTION 130 MG26 ML
MB PA LA
STELARA SUBCUTANEOUS SOLUTION 45 MG05 ML
2 PA ST LA
STELARA SUBCUTANEOUS SYRINGE 45 MG05 ML 90 MGML
2 PA ST LA
sulfacetamide sodium topical cleanser 10 1
sulfacetamide sodium topical cleanser gel 10 1
sulfacetamide sodium topical shampoo 10 1
TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MGML
2 PA ST LA
TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MGML
2 PA ST LA
59
Drug Name Drug Tier Requirements Limits
TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 MGML
2 PA ST LA
TREMFYA SUBCUTANEOUS SYRINGE 100 MGML
2 PA ST LA
BURN THERAPY
silver sulfadiazine topical cream 1 1
ssd topical cream 1 1
MISCELLANEOUS DERMATOLOGICALS
ammonium lactate topical cream 12 1
ammonium lactate topical lotion 12 1
diclofenac sodium topical gel 3 1
DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300 MG2 ML
2 LA
DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG114 ML 300 MG2 ML
2 PA ST LA
EUCRISA TOPICAL OINTMENT 2 1 PA ST
FLUOROURACIL TOPICAL CREAM 05 1 PA ST
fluorouracil topical cream 5 1 PA ST
fluorouracil topical solution 2 5 1
LEVULAN TOPICAL SOLUTION 20 1
methoxsalen oral capsuleliqd-filledrapid rel 10 mg
1
PANRETIN TOPICAL GEL 01 1
PICATO TOPICAL GEL 0015 005 1
pimecrolimus topical cream 1 1
podofilox topical solution 05 1
prudoxin topical cream 5 1
REGRANEX TOPICAL GEL 001 1
SCENESSE SUBCUTANEOUS IMPLANT 16 MG
MB PA
tacrolimus topical ointment 003 01 1
UVADEX INJECTION SOLUTION 20 MCGML 1
VALCHLOR TOPICAL GEL 0016 2 PA ST LA
THERAPY FOR ACNE
accutane oral capsule 20 mg 30 mg 40 mg 1
adapalene topical cream 01 1 ST
60
Drug Name Drug Tier Requirements Limits
adapalene topical gel 03 1 ST
adapalene topical gel with pump 03 1 ST
ADAPALENE TOPICAL LOTION 01 1 ST
adapalene topical solution 01 1 ST
adapalene topical swab 01 1 ST
adapalene-benzoyl peroxide topical gel with pump 01-25
1
amnesteem oral capsule 10 mg 20 mg 40 mg 1 PA ST
avita topical cream 0025 1
AVITA TOPICAL GEL 0025 1 ST
azelaic acid topical gel 15 1
AZELEX TOPICAL CREAM 20 1 ST
claravis oral capsule 10 mg 20 mg 30 mg 1 PA ST
claravis oral capsule 40 mg 1
clindacin p topical swab 1 1
clindamycin phosphate topical foam 1 1
clindamycin phosphate topical gel 1 1
clindamycin phosphate topical lotion 1 1
clindamycin phosphate topical solution 1 1
clindamycin phosphate topical swab 1 1
clindamycin-benzoyl peroxide topical gel 1-5 12 (1 base) -5
1
clindamycin-benzoyl peroxide topical gel with pump 1-5
1
clindamycin-tretinoin topical gel 12-0025 1
dapsone topical gel 5 1
ery pads topical swab 2 1
erygel topical gel 2 1
erythromycin with ethanol topical gel 2 1
erythromycin with ethanol topical solution 2 1
erythromycin-benzoyl peroxide topical gel 3-5 1
isotretinoin oral capsule 10 mg 20 mg 25 mg 30 mg 35 mg 40 mg
1
metronidazole topical cream 075 1
metronidazole topical gel 075 1 1
metronidazole topical gel with pump 1 1
61
Drug Name Drug Tier Requirements Limits
metronidazole topical lotion 075 1
myorisan oral capsule 10 mg 20 mg 30 mg 40 mg
1
rosadan topical cream 075 1
rosadan topical gel 075 1
tazarotene topical cream 01 1 ST
tretinoin microspheres topical gel 004 01 1
tretinoin microspheres topical gel with pump 004 01
1
tretinoin topical cream 0025 005 01 1
tretinoin topical gel 001 0025 005 1
zenatane oral capsule 10 mg 20 mg 30 mg 40 mg 1
TOPICAL ANESTHETICS
lidocaine hcl injection solution 10 mgml (1 ) 1
lidocaine hcl laryngotracheal solution 4 1
lidocaine hcl mucous membrane jelly 2 1
lidocaine hcl mucous membrane jelly in applicator 2
1
lidocaine hcl mucous membrane solution 4 (40 mgml)
1
lidocaine hcl-hydrocortison ac topical cream 3-05
1
lidocaine topical adhesive patchmedicated 5 1
lidocaine topical ointment 5 1
lidocaine viscous mucous membrane solution 2 1
lidocaine-prilocaine topical cream 25-25 1
lidocaine-prilocaine topical kit 25-25 1
LIDOCAINE-TETRACAINE TOPICAL CREAM 7-7
1 ST
SYNERA TOPICAL PATCH MEDICATED SELF-HEATING 70-70 MG
1 ST
TOPICAL ANTIBACTERIALS
ALCORTIN A TOPICAL GEL 2-1-1 1 ST
ALCORTIN A TOPICAL GEL IN PACKET 2-1-1
1 ST
ALTABAX TOPICAL OINTMENT 1 1
gentamicin topical cream 01 1
62
Drug Name Drug Tier Requirements Limits
gentamicin topical ointment 01 1
mafenide acetate topical packet 50 gram 1
mupirocin calcium topical cream 2 1
mupirocin topical ointment 2 1
sulfacetamide sodium (acne) topical suspension 10
1
SULFAMYLON TOPICAL CREAM 85 MGG 1
TOPICAL ANTIFUNGALS
ciclodan topical cream 077 1
ciclodan topical solution 8 1
ciclopirox topical cream 077 1
ciclopirox topical gel 077 1
ciclopirox topical shampoo 1 1
ciclopirox topical solution 8 1
ciclopirox topical suspension 077 1
ciclopirox-ure-camph-menth-euc topical solution 8
1
clotrimazole topical cream 1 1
clotrimazole topical solution 1 1
clotrimazole-betamethasone topical cream 1-005
1
clotrimazole-betamethasone topical lotion 1-005
1
econazole topical cream 1 1
EXELDERM TOPICAL CREAM 1 1
EXELDERM TOPICAL SOLUTION 1 1
JUBLIA TOPICAL SOLUTION WITH APPLICATOR 10
1 PA ST
ketoconazole topical cream 2 1
ketoconazole topical foam 2 1
ketoconazole topical shampoo 2 1
ketodan topical foam 2 1
LULICONAZOLE TOPICAL CREAM 1 1
LUZU TOPICAL CREAM 1 1
MENTAX TOPICAL CREAM 1 1
naftifine topical cream 1 2 1
63
Drug Name Drug Tier Requirements Limits
naftifine topical gel 1 1
nyamyc topical powder 100000 unitgram 1
nystatin topical cream 100000 unitgram 1
nystatin topical ointment 100000 unitgram 1
nystatin topical powder 100000 unitgram 1
nystatin-triamcinolone topical cream 100000-01 unitg-
1
nystatin-triamcinolone topical ointment 100000-01 unitgram-
1
nystop topical powder 100000 unitgram 1
oxiconazole topical cream 1 1
OXISTAT TOPICAL LOTION 1 1
tavaborole topical solution with applicator 5 1 PA ST
TOPICAL ANTIVIRALS
acyclovir topical cream 5 1
acyclovir topical ointment 5 1
DENAVIR TOPICAL CREAM 1 1
TOPICAL CORTICOSTEROIDS
ala-cort topical cream 1 1
alclometasone topical cream 005 1
alclometasone topical ointment 005 1
amcinonide topical cream 01 1
amcinonide topical lotion 01 1
apexicon e topical cream 005 1
beser topical lotion 005 1
betamethasone dipropionate topical cream 005 1
betamethasone dipropionate topical lotion 005 1
betamethasone dipropionate topical ointment 005
1
betamethasone valerate topical cream 01 1
betamethasone valerate topical foam 012 1
betamethasone valerate topical lotion 01 1
betamethasone valerate topical ointment 01 1
betamethasone augmented topical cream 005 1
betamethasone augmented topical gel 005 1
betamethasone augmented topical lotion 005 1
64
Drug Name Drug Tier Requirements Limits
betamethasone augmented topical ointment 005
1
clobetasol scalp solution 005 1
clobetasol topical cream 005 1
clobetasol topical foam 005 1
clobetasol topical gel 005 1
clobetasol topical lotion 005 1
clobetasol topical ointment 005 1
clobetasol topical shampoo 005 1
clobetasol topical spraynon-aerosol 005 1
clobetasol-emollient topical cream 005 1
clobetasol-emollient topical foam 005 1
CLOCORTOLONE PIVALATE TOPICAL CREAM 01
1 ST
CLODERM TOPICAL CREAM 01 1 ST
desonide topical cream 005 1
desonide topical lotion 005 1
desonide topical ointment 005 1
desoximetasone topical cream 005 025 1
desoximetasone topical gel 005 1
desoximetasone topical ointment 005 025 1
desoximetasone topical spraynon-aerosol 025 1
diflorasone topical cream 005 1
diflorasone topical ointment 005 1
fluocinolone and shower cap scalp oil 001 1
fluocinolone topical cream 001 0025 1
fluocinolone topical oil 001 1
fluocinolone topical ointment 0025 1
fluocinolone topical solution 001 1
fluocinonide topical cream 005 01 1
fluocinonide topical gel 005 1
fluocinonide topical ointment 005 1
fluocinonide topical solution 005 1
fluocinonide-e topical cream 005 1
flurandrenolide topical cream 005 1
65
Drug Name Drug Tier Requirements Limits
flurandrenolide topical lotion 005 1
flurandrenolide topical ointment 005 1
fluticasone propionate topical cream 005 1
fluticasone propionate topical lotion 005 1
fluticasone propionate topical ointment 0005 1
halcinonide topical cream 01 1
halobetasol propionate topical cream 005 1
halobetasol propionate topical ointment 005 1
hydrocortisone butyrate topical cream 01 1
hydrocortisone butyrate topical lotion 01 1
hydrocortisone butyrate topical ointment 01 1
hydrocortisone butyrate topical solution 01 1
hydrocortisone butyr-emollient topical cream 01
1
hydrocortisone topical cream 1 25 1
hydrocortisone topical lotion 25 1
hydrocortisone topical ointment 1 25 1
hydrocortisone valerate topical cream 02 1
hydrocortisone valerate topical ointment 02 1
mometasone topical cream 01 1
mometasone topical ointment 01 1
mometasone topical solution 01 1
prednicarbate topical cream 01 1
prednicarbate topical ointment 01 1
scalacort topical lotion 2 1
triamcinolone acetonide topical aerosol 0147 mggram
1
triamcinolone acetonide topical cream 0025 01 05
1
triamcinolone acetonide topical lotion 0025 01
1
triamcinolone acetonide topical ointment 0025 005 01 05
1
triderm topical cream 01 05 1
TOPICAL ENZYMES
SANTYL TOPICAL OINTMENT 250 UNITGRAM
1 QL (2 per 30 days)
66
Drug Name Drug Tier Requirements Limits
TOPICAL SCABICIDES PEDICULICIDES
crotan topical lotion 10 1
EURAX TOPICAL CREAM 10 1
EURAX TOPICAL LOTION 10 1
ivermectin topical lotion 05 1
lindane topical shampoo 1 1
malathion topical lotion 05 1
permethrin topical cream 5 1
spinosad topical suspension 09 1
ULESFIA TOPICAL LOTION 5 1
DIAGNOSTICS amp MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
PHYSIOLYTE IRRIGATION SOLUTION 140-5-3-98 MEQL
MB
PHYSIOSOL IRRIGATION IRRIGATION SOLUTION 140-5-3-98 MEQL
MB
MISCELLANEOUS AGENTS
acamprosate oral tabletdelayed release (drec) 333 mg
1
acetic acid irrigation solution 025 1
anagrelide oral capsule 05 mg 1 mg 1
ARALAST NP INTRAVENOUS RECON SOLN 1000 MG 500 MG
MB LA
CARBAGLU ORAL TABLET DISPERSIBLE 200 MG
2 PA LA
cevimeline oral capsule 30 mg 1
CHEMET ORAL CAPSULE 100 MG 1
clovique oral capsule 250 mg 1 PA QL (240 per 30 days)
deferasirox oral granules in packet 180 mg 360 mg 90 mg
2 PA LA
deferasirox oral tablet 180 mg 2 PA LA
deferasirox oral tablet 360 mg 90 mg 2 ST LA
deferasirox oral tablet dispersible 125 mg 250 mg 500 mg
2 ST LA
deferiprone oral tablet 500 mg 1 PA
disulfiram oral tablet 250 mg 500 mg 1
67
Drug Name Drug Tier Requirements Limits
EMPAVELI SUBCUTANEOUS SOLUTION 1080 MG20 ML
2 PA
FERRIPROX ORAL SOLUTION 100 MGML 1 PA
FERRIPROX ORAL TABLET 1000 MG 500 MG
1 PA
GIVLAARI SUBCUTANEOUS SOLUTION 189 MGML
MB PA LA
GLASSIA INTRAVENOUS SOLUTION 1 GRAM50 ML (2 )
MB LA
INCRELEX SUBCUTANEOUS SOLUTION 10 MGML
2 PA LA
levocarnitine (with sugar) oral solution 100 mgml 1
levocarnitine oral solution 100 mgml 1
levocarnitine oral tablet 330 mg 1
midodrine oral tablet 10 mg 25 mg 5 mg 1
nitisinone oral capsule 10 mg 2 mg 5 mg 2 PA LA
NITYR ORAL TABLET 10 MG 2 MG 5 MG 2 PA LA
pilocarpine hcl oral tablet 5 mg 1
PROLASTIN-C INTRAVENOUS SOLUTION 1000 MG (+-)20 ML
MB
RAVICTI ORAL LIQUID 11 GRAMML 2 PA ST LA QL (10 per 30 days)
RECLAST INTRAVENOUS PIGGYBACK 5 MG100 ML
MB
riluzole oral tablet 50 mg 1
risedronate oral tablet 30 mg 1
sodium chloride 09 injection solution MB
sodium chloride 09 intravenous parenteral solution
MB
sodium chloride 09 intravenous piggyback MB
sodium phenylbutyrate oral powder 094 gramgram
1 PA
sodium phenylbutyrate oral tablet 500 mg 1 PA
SOLIRIS INTRAVENOUS SOLUTION 300 MG30 ML
MB PA LA
trientine oral capsule 250 mg 1 PA QL (240 per 30 days)
XURIDEN ORAL GRANULES IN PACKET 2 GRAM
2 PA QL (120 per 30 days)
68
Drug Name Drug Tier Requirements Limits
ZEMAIRA INTRAVENOUS RECON SOLN 1000 MG
MB LA
ZOKINVY ORAL CAPSULE 50 MG 75 MG 2 PA ST
SMOKING DETERRENTS
bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg
ACA PV
CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG
ACA PV QL (180 per 365 days)
CHANTIX ORAL TABLET 05 MG 1 MG ACA PV QL (180 per 365 days)
CHANTIX STARTING MONTH BOX ORAL TABLETSDOSE PACK 05 MG (11)- 1 MG (42)
ACA PV QL (180 per 365 days)
nicorette buccal gum 4 mg ACA PV
nicotine (polacrilex) buccal gum 2 mg 4 mg ACA PV
nicotine (polacrilex) buccal lozenge 2 mg 4 mg ACA PV
nicotine (polacrilex) buccal mini lozenge 2 mg 4 mg
ACA PV
nicotine transdermal patch 24 hour 14 mg24 hr 21 mg24 hr 7 mg24 hr
ACA PV
nicotine transdermal patch td daily sequential 21-14-7 mg24 hr
ACA PV
NICOTROL INHALATION CARTRIDGE 10 MG
ACA PV
NICOTROL NS NASAL SPRAYNON-AEROSOL 10 MGML
ACA PV
quit 2 buccal gum 2 mg ACA PV
quit 2 buccal lozenge 2 mg ACA PV
quit 4 buccal gum 4 mg ACA PV
quit 4 buccal lozenge 4 mg ACA PV
stop smoking aid buccal lozenge 2 mg 4 mg ACA PV
EAR NOSE amp THROAT MEDICATIONS
MISCELLANEOUS AGENTS
ARESTIN DENTAL CARTRIDGE 1 MG MB
azelastine nasal aerosolspray 137 mcg (01 ) 1
azelastine nasal spraynon-aerosol 2055 mcg (015 )
1
chlorhexidine gluconate mucous membrane mouthwash 012
1
denta 5000 plus dental cream 11 1
69
Drug Name Drug Tier Requirements Limits
dentagel dental gel 11 1
fluoride (sodium) dental cream 11 1
fluoride (sodium) dental gel 11 1
fluoride (sodium) dental paste 11 1
ipratropium bromide nasal spraynon-aerosol 21 mcg (003 ) 42 mcg (006 )
1
olopatadine nasal spraynon-aerosol 06 1
oralone dental paste 01 1
paroex oral rinse mucous membrane mouthwash 012
1
periogard mucous membrane mouthwash 012 1
pilocarpine hcl oral tablet 75 mg 1
sf 5000 plus dental cream 11 1
sf dental gel 11 1
sodium fluoride 5000 dry mouth dental gel 11 1
sodium fluoride 5000 plus dental cream 11 1
sodium fluoride-pot nitrate dental paste 11-5 1
triamcinolone acetonide dental paste 01 1
MISCELLANEOUS OTIC PREPARATIONS
acetic acid otic (ear) solution 2 1
ciprofloxacin hcl otic (ear) dropperette 02 1
flac otic oil otic (ear) drops 001 1
fluocinolone acetonide oil otic (ear) drops 001 1
hydrocortisone-acetic acid otic (ear) drops 1-2 1
ofloxacin otic (ear) drops 03 1
OTIC STEROID ANTIBIOTIC
CIPRO HC OTIC (EAR) DROPSSUSPENSION 02-1
1
ciprofloxacin-dexamethasone otic (ear) dropssuspension 03-01
1
neomycin-polymyxin-hc otic (ear) dropssuspension 35-10000-1 mgml-unitml-
1
neomycin-polymyxin-hc otic (ear) solution 35-10000-1 mgml-unitml-
1
OTOVEL OTIC (EAR) SOLUTION 03-0025 (025 ML)
1
ENDOCRINEDIABETES
70
Drug Name Drug Tier Requirements Limits
ADRENAL HORMONES
ACTHAR INJECTION GEL 80 UNITML 2 PA LA
decadron oral tablet 05 mg 1
dexamethasone intensol oral drops 1 mgml 1
dexamethasone oral elixir 05 mg5 ml 1
dexamethasone oral solution 05 mg5 ml 1
dexamethasone oral tablet 05 mg 075 mg 1 mg 15 mg 2 mg 4 mg 6 mg
1
dexamethasone oral tabletsdose pack 15 mg (21 tabs) 15 mg (35 tabs) 15 mg (51 tabs)
1
dexamethasone sodium phos (pf) injection solution 10 mgml
1
dexamethasone sodium phosphate injection solution 10 mgml 4 mgml
1
dexamethasone sodium phosphate injection syringe 4 mgml
1
fludrocortisone oral tablet 01 mg 1
hydrocortisone oral tablet 10 mg 20 mg 5 mg 1
methylprednisolone acetate injection suspension 40 mgml 80 mgml
1
methylprednisolone oral tablet 16 mg 32 mg 4 mg 8 mg
1
methylprednisolone oral tabletsdose pack 4 mg 1
millipred dp oral tabletsdose pack 5 mg (21 tabs) 5 mg (48 tabs)
1
millipred oral tablet 5 mg 1
prednisolone oral solution 15 mg5 ml 1
prednisolone sodium phosphate oral solution 10 mg5 ml 15 mg5 ml (3 mgml) 20 mg5 ml (4 mgml) 25 mg5 ml (5 mgml) 5 mg base5 ml (67 mg5 ml)
1
prednisolone sodium phosphate oral tabletdisintegrating 10 mg 15 mg 30 mg
1
prednisone intensol oral concentrate 5 mgml 1
prednisone oral solution 5 mg5 ml 1
prednisone oral tablet 1 mg 10 mg 25 mg 20 mg 5 mg 50 mg
1
prednisone oral tabletsdose pack 10 mg 5 mg 1
71
Drug Name Drug Tier Requirements Limits
triamcinolone acetonide injection suspension 40 mgml
MB
ANTITHYROID AGENTS
methimazole oral tablet 10 mg 5 mg 1
propylthiouracil oral tablet 50 mg 1
SSKI ORAL SOLUTION 1 GRAMML 1
BLOOD GLUCOSE MONITORING DEVICES amp SUPPLIES
CONTOUR NEXT TEST STRIPS STRIP 1
CONTOUR TEST STRIPS STRIP 1
ONETOUCH ULTRA TEST STRIP 1
ONETOUCH VERIO TEST STRIPS STRIP 1
DIABETES SUPPLIES amp DURABLE MEDICAL EQUIPMENT
AEROCHAMBER MINI SPACER 1
AEROCHAMBER PLUS FLOW-VU SPACER 1
GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN 1 MGML
1
GLUCAGON HCL INJECTION RECON SOLN 1 MGML
1
INSULIN SYRINGE-NEEDLE U-100 SYRINGE 05 ML 29 GAUGE X 12
1
TRIJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-5-1000 MG 125-25-1000 MG 25-5-1000 MG 5-25-1000 MG
1 PA ST
GLUCOSE ELEVATING AGENTS
BAQSIMI NASAL SPRAYNON-AEROSOL 3 MGACTUATION
1
diazoxide oral suspension 50 mgml 1
GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG
1
GLUCAGON (HCL) EMERGENCY KIT INJECTION RECON SOLN 1 MG
1
glucagon emergency kit (human) injection recon soln 1 mg
1
INSULIN SYRINGESMISCELLANEOUS DURABLE MEDICAL EQU
FREESTYLE LIBRE 14 DAY SENSOR KIT 1
FREESTYLE LIBRE 2 SENSOR KIT 1
NOVOPEN ECHO SUBCUTANEOUS INSULIN PEN
1
72
Drug Name Drug Tier Requirements Limits
PEN NEEDLE DIABETIC NEEDLE 29 GAUGE X 12
1
INSULIN THERAPY
FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
FIASP PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML (3 ML)
1
FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN HALF-UNIT 100 UNITML
1
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML
1 ST
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 200 UNITML (3 ML)
1
HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNITML (50-50)
1 ST
HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (50-50)
1 ST
HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (75-25)
1 ST
HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNITML (75-25)
1 ST
HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML
1 ST
HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1 ST
HUMULIN 7030 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)
1 ST
HUMULIN 7030 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1 ST
73
Drug Name Drug Tier Requirements Limits
HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1 ST
HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML
1 ST
HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNITML
1 ST
HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNITML
1
HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNITML (3 ML)
1
INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
INSULIN ASP PRT-INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML (70-30)
1
INSULIN ASPART U-100 SUBCUTANEOUS CARTRIDGE 100 UNITML
1
INSULIN ASPART U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
INSULIN ASPART U-100 SUBCUTANEOUS SOLUTION 100 UNITML
1
LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
NOVOLIN R FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
74
Drug Name Drug Tier Requirements Limits
NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNITML (70-30)
1
NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)
1
NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML
1
NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML
1
RELION NOVOLIN 7030 SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)
1
RELION NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNITML
1
RELION NOVOLIN R INJECTION SOLUTION 100 UNITML
1
SOLIQUA 10033 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCGML
1 PA ST
TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNITML (3 ML)
1
TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNITML (15 ML)
1
TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)
1
TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN 200 UNITML (3 ML)
1
TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML
1
XULTOPHY 10036 SUBCUTANEOUS INSULIN PEN 100 UNIT-36 MG ML (3 ML)
1 PA ST
MISCELLANEOUS HORMONES
ALDURAZYME INTRAVENOUS SOLUTION 29 MG5 ML
MB PA LA
ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG24 HOUR 4 MG24 HR
1 ST QL (30 per 30 days)
75
Drug Name Drug Tier Requirements Limits
BRINEURA INTRAVENTRICULAR KIT 300 MG10 ML (150MG5ML X2)
MB
cabergoline oral tablet 05 mg 1
calcitonin (salmon) injection solution 200 unitml 1
calcitonin (salmon) nasal spraynon-aerosol 200 unitactuation
1
calcitriol oral capsule 025 mcg 05 mcg 1
calcitriol oral solution 1 mcgml 1
CERDELGA ORAL CAPSULE 84 MG 2 PA LA
CEREZYME INTRAVENOUS RECON SOLN 400 UNIT
MB PA LA
cinacalcet oral tablet 30 mg 60 mg 90 mg 2 PA
CRYSVITA SUBCUTANEOUS SOLUTION 10 MGML 20 MGML 30 MGML
MB PA LA
danazol oral capsule 100 mg 200 mg 50 mg 1
DEPO-TESTOSTERONE INTRAMUSCULAR OIL 100 MGML
1
desmopressin nasal spraynon-aerosol 10 mcgspray (01 ml)
1
desmopressin oral tablet 01 mg 02 mg 1
doxercalciferol oral capsule 05 mcg 1 mcg 25 mcg
1
ELAPRASE INTRAVENOUS SOLUTION 6 MG3 ML
MB PA LA
ELELYSO INTRAVENOUS RECON SOLN 200 UNIT
MB PA LA
FABRAZYME INTRAVENOUS RECON SOLN 35 MG 5 MG
MB PA LA
GALAFOLD ORAL CAPSULE 123 MG 2 PA LA
JYNARQUE ORAL TABLET 15 MG 30 MG 2 PA QL (60 per 30 days)
JYNARQUE ORAL TABLETS SEQUENTIAL 45 MG (AM) 15 MG (PM) 60 MG (AM) 30 MG (PM) 90 MG (AM) 30 MG (PM)
2 PA QL (60 per 30 days)
KANUMA INTRAVENOUS SOLUTION 2 MGML
MB PA LA
KORLYM ORAL TABLET 300 MG 2 PA ST
LUMIZYME INTRAVENOUS RECON SOLN 50 MG
MB PA LA
76
Drug Name Drug Tier Requirements Limits
MEPSEVII INTRAVENOUS SOLUTION 2 MGML
MB PA LA
methyltestosterone oral capsule 10 mg 1
MIACALCIN INJECTION SOLUTION 200 UNITML
1
miglustat oral capsule 100 mg 2 PA LA
MYALEPT SUBCUTANEOUS RECON SOLN 5 MGML (FINAL CONC)
2 LA
NAGLAZYME INTRAVENOUS SOLUTION 5 MG5 ML
MB PA LA
NATPARA SUBCUTANEOUS CARTRIDGE 100 MCGDOSE 25 MCGDOSE 50 MCGDOSE 75 MCGDOSE
2 PA ST LA
oxandrolone oral tablet 10 mg 25 mg 1
PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG05 ML 25 MG05 ML 20 MGML
2 PA LA
pamidronate intravenous solution 30 mg10 ml (3 mgml)
MB
PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCGML
MB
paricalcitol intravenous solution 5 mcgml MB
paricalcitol oral capsule 1 mcg 2 mcg 4 mcg 1
PARSABIV INTRAVENOUS SOLUTION 5 MGML
MB PA
SAMSCA ORAL TABLET 15 MG 2 PA LA QL (60 per 30 days)
sapropterin oral powder in packet 100 mg 500 mg 2 PA LA
sapropterin oral tabletsoluble 100 mg 2 PA LA
SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG 15 MG 20 MG 25 MG 30 MG
2 PA LA QL (30 per 30 days)
STRENSIQ SUBCUTANEOUS SOLUTION 18 MG045 ML 28 MG07 ML 40 MGML 80 MG08 ML
2 PA
SYNAREL NASAL SPRAYNON-AEROSOL 2 MGML
1
TEPEZZA INTRAVENOUS RECON SOLN 500 MG
MB PA LA
testosterone cypionate intramuscular oil 100 mgml 200 mgml
1
testosterone enanthate intramuscular oil 200 mgml
1
77
Drug Name Drug Tier Requirements Limits
testosterone transdermal gel 50 mg5 gram (1 ) 1 QL (60 per 30 days)
testosterone transdermal gel in metered-dose pump 10 mg05 gram actuation 2025 mg125 gram (162 )
1 QL (2 per 30 days)
testosterone transdermal gel in metered-dose pump 125 mg 125 gram (1 )
1 QL (4 per 30 days)
testosterone transdermal gel in packet 1 (25 mg25gram) 162 (2025 mg125 gram)
1 QL (30 per 30 days)
testosterone transdermal gel in packet 1 (50 mg5 gram) 162 (405 mg25 gram)
1 QL (60 per 30 days)
testosterone transdermal solution in metered pump wapp 30 mgactuation (15 ml)
1 QL (2 per 30 days)
VIMIZIM INTRAVENOUS SOLUTION 5 MG5 ML (1 MGML)
MB PA LA
VPRIV INTRAVENOUS RECON SOLN 400 UNIT
MB PA LA
NON-INSULIN HYPOGLYCEMIC AGENTS
acarbose oral tablet 100 mg 25 mg 50 mg 1
ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 125-15 MG 125-30 MG 125-45 MG 25-15 MG 25-30 MG 25-45 MG
1 PA ST
BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG085 ML
1 PA ST
BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCGDOSE(250 MCGML) 24 ML 5 MCGDOSE (250 MCGML) 12 ML
1 PA ST
CYCLOSET ORAL TABLET 08 MG 1
FARXIGA ORAL TABLET 10 MG 5 MG 1 PA ST
glimepiride oral tablet 1 mg 2 mg 4 mg 1
glipizide oral tablet 10 mg 5 mg 1
glipizide oral tablet extended release 24hr 10 mg 25 mg 5 mg
1
glipizide-metformin oral tablet 25-250 mg 25-500 mg 5-500 mg
1
glyburide micronized oral tablet 15 mg 3 mg 6 mg
1
glyburide oral tablet 125 mg 25 mg 5 mg 1
glyburide-metformin oral tablet 125-250 mg 25-500 mg 5-500 mg
1
78
Drug Name Drug Tier Requirements Limits
GLYXAMBI ORAL TABLET 10-5 MG 25-5 MG
1 PA ST
JANUMET ORAL TABLET 50-1000 MG 50-500 MG
1 PA ST
JANUMET XR ORAL TABLET ER MULTIPHASE 24 HR 100-1000 MG 50-1000 MG 50-500 MG
1 PA ST
JANUVIA ORAL TABLET 100 MG 25 MG 50 MG
1 PA ST
JARDIANCE ORAL TABLET 10 MG 25 MG 1 PA ST
JENTADUETO ORAL TABLET 25-1000 MG 25-500 MG 25-850 MG
1 PA ST
JENTADUETO XR ORAL TABLET IR - ER BIPHASIC 24HR 25-1000 MG 5-1000 MG
1 PA ST
metformin oral solution 500 mg5 ml 1 PA
metformin oral tablet 1000 mg 500 mg 850 mg 1
metformin oral tablet extended release 24 hr 500 mg 750 mg
1
metformin oral tablet extended release 24hr 1000 mg 500 mg
1 PA ST
metformin oral tableter gastretention 24 hr 1000 mg 500 mg
1 ST
miglitol oral tablet 100 mg 25 mg 50 mg 1
nateglinide oral tablet 120 mg 60 mg 1
OZEMPIC SUBCUTANEOUS PEN INJECTOR 025 MG OR 05 MG(2 MG15 ML) 1 MGDOSE (2 MG15 ML) 1 MGDOSE (4 MG3 ML)
1 PA ST
pioglitazone oral tablet 15 mg 30 mg 45 mg 1
pioglitazone-glimepiride oral tablet 30-2 mg 30-4 mg
1
pioglitazone-metformin oral tablet 15-500 mg 15-850 mg
1
QTERN ORAL TABLET 10-5 MG 5-5 MG 1 PA ST
repaglinide oral tablet 05 mg 1 mg 2 mg 1
repaglinide-metformin oral tablet 1-500 mg 2-500 mg
1
RIOMET ER ORAL SUSPENSIONEXTENDED REL RECON 500 MG5 ML
1 PA ST
79
Drug Name Drug Tier Requirements Limits
RYBELSUS ORAL TABLET 14 MG 3 MG 7 MG
1 PA ST
SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2700 MCG27 ML
1 PA ST
SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1500 MCG15 ML
1 PA ST
SYNJARDY ORAL TABLET 125-1000 MG 125-500 MG 5-1000 MG 5-500 MG
1 PA ST
SYNJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 125-1000 MG 25-1000 MG 5-1000 MG
1 PA ST
TRADJENTA ORAL TABLET 5 MG 1 PA ST
TRULICITY SUBCUTANEOUS PEN INJECTOR 075 MG05 ML 15 MG05 ML 3 MG05 ML 45 MG05 ML
1 PA ST
XIGDUO XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 10-500 MG 25-1000 MG 5-1000 MG 5-500 MG
1 PA ST
THYROID HORMONES
ARMOUR THYROID ORAL TABLET 120 MG 15 MG 180 MG 240 MG 30 MG 300 MG 60 MG 90 MG
1
levothyroxine oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 300 mcg 50 mcg 75 mcg 88 mcg
1
levoxyl oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 50 mcg 75 mcg 88 mcg
1
liothyronine oral tablet 25 mcg 5 mcg 50 mcg 1
np thyroid oral tablet 120 mg 15 mg 30 mg 60 mg 90 mg
1
SYNTHROID ORAL TABLET 100 MCG 112 MCG 125 MCG 137 MCG 150 MCG 175 MCG 200 MCG 25 MCG 300 MCG 50 MCG 75 MCG 88 MCG
1
THYROLAR-1 ORAL TABLET 125-50 MCG 1
THYROLAR-12 ORAL TABLET 625-25 MCG 1
THYROLAR-14 ORAL TABLET 31-125 MCG 1
THYROLAR-2 ORAL TABLET 25-100 MCG 1
THYROLAR-3 ORAL TABLET 375-150 MCG 1
80
Drug Name Drug Tier Requirements Limits
unithroid oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 300 mcg 50 mcg 75 mcg 88 mcg
1
westhroid oral tablet 130 mg 195 mg 325 mg 65 mg 975 mg
1
GASTROENTEROLOGY
ANTIDIARRHEALS amp ANTISPASMODICS
anaspaz oral tabletdisintegrating 0125 mg 1
atropine injection syringe 005 mgml 01 mgml 1
belladonna alkaloids-opium rectal suppository 162-30 mg 162-60 mg
1 PA ST
chlordiazepoxide-clidinium oral capsule 5-25 mg 1
dicyclomine intramuscular solution 10 mgml MB
dicyclomine oral capsule 10 mg 1
dicyclomine oral solution 10 mg5 ml 1
dicyclomine oral tablet 20 mg 1
diphenoxylate-atropine oral liquid 25-0025 mg5 ml
1
diphenoxylate-atropine oral tablet 25-0025 mg 1
DONNATAL ORAL TABLET 162-01037 -00194 MG
1
ed-spaz oral tabletdisintegrating 0125 mg 1
glycopyrrolate injection solution 02 mgml 1
glycopyrrolate oral tablet 1 mg 15 mg 2 mg 1
hyoscyamine sulfate oral drops 0125 mgml 1
hyoscyamine sulfate oral elixir 0125 mg5 ml 1
hyoscyamine sulfate oral tablet 0125 mg 1
hyoscyamine sulfate oral tablet extended release 12 hr 0375 mg
1
hyoscyamine sulfate oral tabletdisintegrating 0125 mg
1
hyoscyamine sulfate sublingual tablet 0125 mg 1
hyosyne oral drops 0125 mgml 1
hyosyne oral elixir 0125 mg5 ml 1
loperamide oral capsule 2 mg 1
methscopolamine oral tablet 25 mg 5 mg 1
MOTOFEN ORAL TABLET 1-0025 MG 1
81
Drug Name Drug Tier Requirements Limits
opium tincture oral tincture 10 mgml (morphine) 1
oscimin oral tablet 0125 mg 1
oscimin sl sublingual tablet 0125 mg 1
oscimin sr oral tablet extended release 12 hr 0375 mg
1
phenobarb-hyoscy-atropine-scop oral elixir 162-01037 -00194 mg5 ml
1
phenobarb-hyoscy-atropine-scop oral tablet 162-01037 -00194 mg
1
phenohytro oral elixir 162-01037 -00194 mg5 ml
1
phenohytro oral tablet 162-01037 -00194 mg 1
symax fastabs oral tabletdisintegrating 0125 mg 1
symax-sl sublingual tablet 0125 mg 1
symax-sr oral tablet extended release 12 hr 0375 mg
1
MISCELLANEOUS GASTROINTESTINAL AGENTS
AKYNZEO (NETUPITANT) ORAL CAPSULE 300-05 MG
1 QL (1 per 30 days)
alosetron oral tablet 05 mg 1 mg 1
ALOXI INTRAVENOUS SOLUTION 025 MG5 ML
MB
AMITIZA ORAL CAPSULE 24 MCG 8 MCG 1 PA
anucort-hc rectal suppository 25 mg 1
aprepitant oral capsule 125 mg 40 mg 1 QL (1 per 30 days)
aprepitant oral capsule 80 mg 1 QL (2 per 30 days)
aprepitant oral capsuledose pack 125 mg (1)- 80 mg (2)
1 QL (1 per 30 days)
balsalazide oral capsule 750 mg 1
budesonide oral capsuledelayedextendrelease 3 mg
1
calcium acetate(phosphat bind) oral capsule 667 mg
1
calcium acetate(phosphat bind) oral tablet 667 mg 1
CHOLBAM ORAL CAPSULE 250 MG 50 MG 2
CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)
2 PA ST LA
82
Drug Name Drug Tier Requirements Limits
CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG2 ML (200 MGML X 2)
2 PA ST LA
CLENPIQ ORAL SOLUTION 10 MG-35 GRAM -12 GRAM160 ML
ACA PV
compro rectal suppository 25 mg 1
constulose oral solution 10 gram15 ml 1
CORTIFOAM RECTAL FOAM 10 (80 MG) 1
CREON ORAL CAPSULEDELAYED RELEASE(DREC) 12000-38000 -60000 UNIT 24000-76000 -120000 UNIT 3000-9500- 15000 UNIT 36000-114000- 180000 UNIT 6000-19000 -30000 UNIT
1 PA
cromolyn oral concentrate 100 mg5 ml 1
DIPENTUM ORAL CAPSULE 250 MG 1 PA ST
doxylamine-pyridoxine (vit b6) oral tabletdelayed release (drec) 10-10 mg
1
dronabinol oral capsule 10 mg 25 mg 5 mg 1
EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG ML FINAL CONC)
1
ENTYVIO INTRAVENOUS RECON SOLN 300 MG
MB PA LA
enulose oral solution 10 gram15 ml 1
gavilyte-c oral recon soln 240-2272-672 -584 gram
ACA PV
gavilyte-g oral recon soln 236-2274-674 -586 gram
ACA PV
gavilyte-n oral recon soln 420 gram ACA PV
generlac oral solution 10 gram15 ml 1
granisetron hcl oral tablet 1 mg 1 QL (6 per 30 days)
hemmorex-hc rectal suppository 25 mg 1
hydrocortisone acetate rectal suppository 25 mg 30 mg
1
hydrocortisone rectal enema 100 mg60 ml 1
hydrocortisone topical cream with perineal applicator 1 25
1
hydrocortisone-pramoxine rectal cream 1-1 25-1 25-1 (4g)
1
INFLECTRA INTRAVENOUS RECON SOLN 100 MG
MB PA LA
83
Drug Name Drug Tier Requirements Limits
lactulose oral packet 10 gram 1
lactulose oral solution 10 gram15 ml 20 gram30 ml
1
lanthanum oral tabletchewable 1000 mg 500 mg 750 mg
1
lidocaine hcl-hydrocortison ac rectal cream 3-05
1
LIDOCAINE HCL-HYDROCORTISON AC RECTAL GEL 3 -25 (7 GRAM)
1
lidocaine hcl-hydrocortison ac rectal kit 2 -2 (7 gram)
1 ST
lidocaine hcl-hydrocortison ac rectal kit 3-05 3-1 (7 gram)
1 PA ST
lidocaine-hydrocortisone-aloe rectal gel 28-055
1
lidocaine-hydrocortisone-aloe rectal kit 3-25 (7 gram)
1 PA ST
LINZESS ORAL CAPSULE 145 MCG 290 MCG 72 MCG
1 PA
meclizine oral tablet 125 mg 25 mg 1
mesalamine oral capsuleextended release 24hr 0375 gram
1
mesalamine oral tabletdelayed release (drec) 12 gram 800 mg
1
mesalamine rectal enema 4 gram60 ml 1
mesalamine rectal suppository 1000 mg 1
mesalamine with cleansing wipe rectal enema kit 4 gram60 ml
1 ST
metoclopramide hcl injection solution 5 mgml MB
metoclopramide hcl injection syringe 5 mgml MB
metoclopramide hcl oral solution 5 mg5 ml 1
metoclopramide hcl oral tablet 10 mg 5 mg 1
metoclopramide hcl oral tabletdisintegrating 10 mg 5 mg
1
MOVANTIK ORAL TABLET 125 MG 25 MG 1 PA ST
NULYTELY LEMON-LIME ORAL RECON SOLN 420 GRAM
ACA PV
ondansetron hcl intravenous solution 2 mgml MB
ondansetron hcl oral solution 4 mg5 ml 1 QL (100 per 30 days)
84
Drug Name Drug Tier Requirements Limits
ondansetron hcl oral tablet 4 mg 8 mg 1 QL (9 per 30 days)
ondansetron oral tabletdisintegrating 4 mg 8 mg 1 QL (9 per 30 days)
OSMOPREP ORAL TABLET 15 GRAM ACA PV
peg 3350-electrolytes oral recon soln 236-2274-674 -586 gram
ACA PV
peg3350-sod sul-nacl-kcl-asb-c oral powder in packet 100-75-2691 gram
ACA PV
peg-electrolyte soln oral recon soln 420 gram ACA PV
peg-prep oral kit 5-210 mg-gram ACA PV
PLENVU ORAL POWDER IN PACKET SEQUENTIAL 140-9-52 GRAM
ACA PV
prochlorperazine edisylate injection solution 10 mg2 ml (5 mgml) 5 mgml
1
prochlorperazine maleate oral tablet 10 mg 5 mg 1
prochlorperazine rectal suppository 25 mg 1
procto-med hc topical cream with perineal applicator 25
1
procto-pak topical cream with perineal applicator 1
1
proctosol hc topical cream with perineal applicator 25
1
proctozone-hc topical cream with perineal applicator 25
1
RECTIV RECTAL OINTMENT 04 (WW) 1
RELISTOR ORAL TABLET 150 MG 1
RELISTOR SUBCUTANEOUS SOLUTION 12 MG06 ML
1
RELISTOR SUBCUTANEOUS SYRINGE 12 MG06 ML 8 MG04 ML
1
REMICADE INTRAVENOUS RECON SOLN 100 MG
MB PA LA
RENFLEXIS INTRAVENOUS RECON SOLN 100 MG
MB PA LA
scopolamine base transdermal patch 3 day 1 mg over 3 days
1
sevelamer carbonate oral powder in packet 08 gram 24 gram
1
sevelamer carbonate oral tablet 800 mg 1
sevelamer hcl oral tablet 400 mg 800 mg 1
85
Drug Name Drug Tier Requirements Limits
sodium polystyrene sulfonate oral powder 1
sps (with sorbitol) oral suspension 15-20 gram60 ml
1
sps (with sorbitol) rectal enema 30-40 gram120 ml
1
SUCRAID ORAL SOLUTION 8500 UNITML 2 PA ST QL (2 per 30 days)
sulfasalazine oral tablet 500 mg 1
sulfasalazine oral tabletdelayed release (drec) 500 mg
1
SUPREP BOWEL PREP KIT ORAL RECON SOLN 175-313-16 GRAM
ACA PV ST
trilyte with flavor packets oral recon soln 420 gram
ACA PV
trimethobenzamide oral capsule 300 mg 1
ursodiol oral capsule 300 mg 1
ursodiol oral tablet 250 mg 500 mg 1
VARUBI ORAL TABLET 90 MG 1
VELPHORO ORAL TABLETCHEWABLE 500 MG
1 ST
VIBERZI ORAL TABLET 100 MG 75 MG 1 PA ST
ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 10000-32000 -42000 UNIT 15000-47000 -63000 UNIT 20000-63000- 84000 UNIT 3000-10000 -14000-UNIT 40000-126000- 168000 UNIT 5000-17000- 24000 UNIT
1 PA
ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 25000-79000- 105000 UNIT
1
ULCER THERAPY
amoxicil-clarithromy-lansopraz oral combo pack 500-500-30 mg
1
cimetidine hcl oral solution 300 mg5 ml 1
cimetidine oral tablet 200 mg 300 mg 400 mg 800 mg
1
DEXILANT ORAL CAPSULEBIPHASE DELAYED RELEAS 30 MG 60 MG
1 ST
esomeprazole magnesium oral capsuledelayed release(drec) 20 mg 40 mg
1
famotidine (pf) intravenous solution 20 mg2 ml MB
86
Drug Name Drug Tier Requirements Limits
famotidine oral suspension 40 mg5 ml (8 mgml) 1
famotidine oral tablet 20 mg 40 mg 1
lansoprazole oral capsuledelayed release(drec) 15 mg 30 mg
1
lansoprazole oral tabletdisintegrat delay rel 15 mg 30 mg
1
misoprostol oral tablet 100 mcg 200 mcg 1
nizatidine oral capsule 150 mg 300 mg 1
nizatidine oral solution 150 mg10 ml 1
omeprazole oral capsuledelayed release(drec) 10 mg 20 mg 40 mg
1
pantoprazole oral tabletdelayed release (drec) 20 mg 40 mg
1
rabeprazole oral tabletdelayed release (drec) 20 mg
1
sucralfate oral suspension 100 mgml 1
sucralfate oral tablet 1 gram 1
IMMUNOLOGY VACCINES amp BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCGML 200 MCGML 25 MCGML 300 MCGML 40 MCGML 60 MCGML
2 LA
ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG04 ML 100 MCG05 ML 150 MCG03 ML 200 MCG04 ML 25 MCG042 ML 300 MCG06 ML 40 MCG04 ML 500 MCGML 60 MCG03 ML
2 LA
EPOGEN INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML
2 LA
GRANIX SUBCUTANEOUS SOLUTION 300 MCGML 480 MCG16 ML
2
GRANIX SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML
2
LEUKINE INJECTION RECON SOLN 250 MCG 2 PA ST
MIRCERA INJECTION SYRINGE 100 MCG03 ML 150 MCG03 ML 200 MCG03 ML 30 MCG03 ML 50 MCG03 ML 75 MCG03 ML
MB
87
Drug Name Drug Tier Requirements Limits
MOZOBIL SUBCUTANEOUS SOLUTION 24 MG12 ML (20 MGML)
MB LA
NEUPOGEN INJECTION SOLUTION 300 MCGML 480 MCG16 ML
2 PA ST
NEUPOGEN INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML
2 PA ST
NIVESTYM INJECTION SOLUTION 300 MCGML 480 MCG16 ML
2
NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML
2
PROCRIT INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML 40000 UNITML
2 LA
UDENYCA SUBCUTANEOUS SYRINGE 6 MG06 ML
2 PA ST
ZARXIO INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML
2 PA ST
ZIEXTENZO SUBCUTANEOUS SYRINGE 6 MG06 ML
2 PA ST
GROWTH HORMONES
GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 02 MG025 ML 04 MG025 ML 06 MG025 ML 08 MG025 ML 1 MG025 ML 12 MG025 ML 14 MG025 ML 16 MG025 ML 18 MG025 ML 2 MG025 ML
2 PA ST LA
GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MGML (36 UNITML) 5 MGML (15 UNITML)
2 PA ST LA
OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG15 ML (67 MGML) 5 MG15 ML (33 MGML)
2 PA ST LA
OMNITROPE SUBCUTANEOUS RECON SOLN 58 MG
2 PA ST LA
SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG 5 MG 6 MG
2 PA ST LA
ZORBTIVE SUBCUTANEOUS RECON SOLN 88 MG
2 PA ST LA
INTERFERONS
AUBAGIO ORAL TABLET 14 MG 7 MG 2 PA LA
88
Drug Name Drug Tier Requirements Limits
AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG05 ML
2 PA ST LA QL (4 per 30 days)
AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG05 ML
2 PA ST LA QL (4 per 30 days)
BETASERON SUBCUTANEOUS KIT 03 MG 2 PA LA QL (14 per 30 days)
dimethyl fumarate oral capsuledelayed release(drec) 120 mg
2 PA LA QL (14 per 365 days)
dimethyl fumarate oral capsuledelayed release(drec) 120 mg (14)- 240 mg (46)
2 PA LA QL (1 per 365 days)
dimethyl fumarate oral capsuledelayed release(drec) 240 mg
2 PA LA QL (60 per 30 days)
GILENYA ORAL CAPSULE 05 MG 2 PA LA QL (30 per 30 days)
glatiramer subcutaneous syringe 20 mgml 2 PA LA QL (30 per 30 days)
glatiramer subcutaneous syringe 40 mgml 2 PA LA QL (12 per 30 days)
glatopa subcutaneous syringe 20 mgml 2 PA LA QL (30 per 30 days)
glatopa subcutaneous syringe 40 mgml 2 PA LA QL (12 per 30 days)
LEMTRADA INTRAVENOUS SOLUTION 12 MG12 ML
MB PA ST LA
MAVENCLAD (10 TABLET PACK) ORAL TABLET 10 MG
2 LA
MAVENCLAD (4 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (5 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (6 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (7 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (8 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAVENCLAD (9 TABLET PACK) ORAL TABLET 10 MG
2 PA ST LA QL (1 per 30 days)
MAYZENT ORAL TABLET 025 MG 2 MG 2 PA ST LA QL (30 per 30 days)
MAYZENT STARTER PACK ORAL TABLETSDOSE PACK 025 MG (12 TABS)
2 PA ST LA QL (1 per 365 days)
OCREVUS INTRAVENOUS SOLUTION 30 MGML
MB PA LA
PEGASYS SUBCUTANEOUS SOLUTION 180 MCGML
2 PA LA
89
Drug Name Drug Tier Requirements Limits
PEGASYS SUBCUTANEOUS SYRINGE 180 MCG05 ML
2 PA LA
PLEGRIDY INTRAMUSCULAR SYRINGE 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG05 ML- 94 MCG05 ML
2 PA LA QL (1 per 365 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG05 ML
2 PA LA QL (1 per 30 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG05 ML- 94 MCG05 ML
2 PA LA QL (1 per 365 days)
POMALYST ORAL CAPSULE 1 MG 2 MG 3 MG 4 MG
2 PA ST OCh LA
PONVORY 14-DAY STARTER PACK ORAL TABLETSDOSE PACK 2 MG (2) - 10 MG (3)
2 PA LA QL (1 per 365 days)
PONVORY ORAL TABLET 20 MG 2 PA LA QL (30 per 30 days)
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG05 ML 44 MCG05 ML
2 PA LA QL (6 per 30 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG05 ML 44 MCG05 ML
2 PA LA QL (6 per 30 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 88MCG02ML-22 MCG05ML (6)
2 PA LA QL (5 per 30 days)
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 88MCG02ML-22 MCG05ML (6)
2 PA LA QL (5 per 30 days)
REVLIMID ORAL CAPSULE 10 MG 15 MG 25 MG 20 MG 25 MG 5 MG
2 PA ST OCh LA
ribavirin oral capsule 200 mg 2 LA
ribavirin oral tablet 200 mg 2 LA
ZEPOSIA ORAL CAPSULE 092 MG 2 LA QL (30 per 30 days)
ZEPOSIA STARTER KIT ORAL CAPSULEDOSE PACK 023-046-092 MG
2 LA QL (30 per 30 days)
ZEPOSIA STARTER PACK ORAL CAPSULEDOSE PACK 023 MG (4)- 046 MG (3)
2 LA QL (30 per 30 days)
INTERLEUKINS
ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG05 ML
2 PA LA
ARCALYST SUBCUTANEOUS RECON SOLN 220 MG
2 LA
90
Drug Name Drug Tier Requirements Limits
ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MGML
MB PA LA
imiquimod topical cream in packet 5 1
INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) 18 MILLION UNIT (1 ML) 50 MILLION UNIT (1 ML)
2 PA LA
INTRON A INJECTION SOLUTION 10 MILLION UNITML 6 MILLION UNITML
2 PA LA
PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT
MB LA
VACCINES amp MISCELLANEOUS IMMUNOLOGICALS
ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(25-5-3-5 MCG)-5LF05 ML
1 Vac
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(25-5-3-5 MCG)-5LF05 ML
1 Vac
ASCENIV INTRAVENOUS SOLUTION 10 MB PA LA
ATGAM INTRAVENOUS SOLUTION 50 MGML
MB
BCG VACCINE LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG
1 Vac
BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG05 ML
1 Vac
BIOTHRAX INTRAMUSCULAR SUSPENSION 05 MLDOSE
1 Vac
BIVIGAM INTRAVENOUS SOLUTION 10 MB PA LA
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 25-8-5 LF-MCG-LF05ML
1 Vac
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 25-8-5 LF-MCG-LF05ML
1 Vac
BOTOX INJECTION RECON SOLN 100 UNIT 200 UNIT
MB
CUTAQUIG SUBCUTANEOUS SOLUTION 165
MB LA
CUVITRU SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 ) 8 GRAM40 ML (20 )
MB LA
91
Drug Name Drug Tier Requirements Limits
DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF05ML
1 Vac
DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT 500 UNIT
MB LA
ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCGML
1 Vac
ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCGML
1 Vac
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG05 ML
1 Vac
FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 5
MB PA
GAMASTAN INTRAMUSCULAR SOLUTION 15-18 RANGE
MB
GAMASTAN SD INTRAMUSCULAR SOLUTION 15-18 RANGE
MB
GAMMAGARD LIQUID INJECTION SOLUTION 10
MB LA
GAMMAGARD S-D (IGA lt 1 MCGML) INTRAVENOUS RECON SOLN 10 GRAM 5 GRAM
MB PA LA
GAMMAKED INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 20 GRAM200 ML (10 ) 5 GRAM50 ML (10 )
MB LA
GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5
MB PA LA
GAMMAPLEX INTRAVENOUS SOLUTION 10
MB PA LA
GAMUNEX-C INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 25 GRAM25 ML (10 ) 20 GRAM200 ML (10 ) 40 GRAM400 ML (10 ) 5 GRAM50 ML (10 )
MB LA
GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 05 ML
1 Vac
GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 05 ML
1 Vac
GRASTEK SUBLINGUAL TABLET 2800 BAU 1 PA
HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1440 ELISA UNITML
1 Vac
92
Drug Name Drug Tier Requirements Limits
HAVRIX (PF) INTRAMUSCULAR SYRINGE 1440 ELISA UNITML 720 ELISA UNIT05 ML
1 Vac
HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE 20 MCG05 ML
1 Vac
HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )
MB LA
HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM 100 ML (10 ) 25 GRAM 25 ML (10 ) 20 GRAM 200 ML (10 ) 30 GRAM 300 ML (10 ) 5 GRAM 50 ML (10 )
MB LA
IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 25 UNIT
1 Vac
INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF05ML
1 Vac
IPOL INJECTION SUSPENSION 40-8-32 UNIT05 ML
1 Vac
IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG05 ML
1 Vac
KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF05 ML
1 Vac
MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG05 ML
1 Vac
MENQUADFI (PF) INTRAMUSCULAR SOLUTION 10 MCG05 ML
1 Vac
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG05 ML
1 Vac
M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1000-12500 TCID5005 ML
1 Vac
MYOBLOC INTRAMUSCULAR SOLUTION 10000 UNIT2 ML 2500 UNIT05 ML 5000 UNITML
MB LA
OCTAGAM INTRAVENOUS SOLUTION 10 5
MB PA LA
ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY
2 PA
PANZYGA INTRAVENOUS SOLUTION 10 MB PA
PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF05 ML
1 Vac
93
Drug Name Drug Tier Requirements Limits
PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 75 MCG05 ML
1 Vac
PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF05 ML 15LF-48MCG-62DU -10 MCG05ML
1 Vac
PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
1 Vac
PNEUMOVAX-23 INJECTION SOLUTION 25 MCG05 ML
1 Vac
PNEUMOVAX-23 INJECTION SYRINGE 25 MCG05 ML
1 Vac
PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE 05 ML
1 Vac
PRIVIGEN INTRAVENOUS SOLUTION 10 MB PA LA
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-43-3- 399 TCID5005
1 Vac
PROVENGE INTRAVENOUS SUSPENSION 50 MILLION CELL250 ML
MB PA
QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT05ML
1 Vac
RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 25 UNIT
1 Vac
RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT
1 PA
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCGML 40 MCGML 5 MCG05 ML
1 Vac
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCGML 5 MCG05 ML
1 Vac
SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG05 ML
1 Vac
STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1000 UNIT05 ML
1 Vac
TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF UNIT05 ML
1 Vac
94
Drug Name Drug Tier Requirements Limits
TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT05ML
1 Vac
TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT05 ML
1 Vac
TETANUSDIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT05 ML
1 Vac
THYMOGLOBULIN INTRAVENOUS RECON SOLN 25 MG
MB
TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG05 ML
1 Vac
TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCGML
1 Vac
TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG05 ML
1 Vac
TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG05 ML
1 Vac
VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT05 ML 50 UNITML
1 Vac
VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT05 ML 50 UNITML
1 Vac
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1350 UNIT05 ML
1 Vac
VAXELIS (PF) INTRAMUSCULAR SUSPENSION 15 UNIT-5 UNIT- 10 MCG05 ML
1 Vac
VAXELIS (PF) INTRAMUSCULAR SYRINGE 15 UNIT-5 UNIT- 10 MCG05 ML
1 Vac
XEMBIFY SUBCUTANEOUS SOLUTION 1 GRAM5 ML (20 ) 10 GRAM50 ML (20 ) 2 GRAM10 ML (20 ) 4 GRAM20 ML (20 )
MB LA
XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT 200 UNIT 50 UNIT
MB LA
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP474 UNIT05 ML
1 Vac
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19400 UNIT065 ML
1 Vac
MUSCULOSKELETAL amp RHEUMATOLOGY
95
Drug Name Drug Tier Requirements Limits
GOUT THERAPY
allopurinol oral tablet 100 mg 300 mg 1
COLCHICINE ORAL CAPSULE 06 MG 1
colchicine oral tablet 06 mg 1
febuxostat oral tablet 40 mg 80 mg 1
KRYSTEXXA INTRAVENOUS SOLUTION 8 MGML
MB PA LA
MITIGARE ORAL CAPSULE 06 MG 1
probenecid oral tablet 500 mg 1
probenecid-colchicine oral tablet 500-05 mg 1
OSTEOPOROSIS THERAPY
alendronate oral solution 70 mg75 ml 1
alendronate oral tablet 10 mg 35 mg 5 mg 70 mg 1
EVENITY SUBCUTANEOUS SYRINGE 105 MG117 ML 210MG234ML ( 105MG117MLX2)
2 PA ST LA
FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCGDOSE (620MCG248ML)
2 PA ST LA QL (1 per 30 days)
FOSAMAX PLUS D ORAL TABLET 70 MG- 2800 UNIT 70 MG- 5600 UNIT
1
ibandronate oral tablet 150 mg 1
PROLIA SUBCUTANEOUS SYRINGE 60 MGML
2 ST LA
raloxifene oral tablet 60 mg 2 OCh
risedronate oral tablet 150 mg 35 mg 5 mg 1
risedronate oral tabletdelayed release (drec) 35 mg
1
TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3120 MCG156 ML)
2 PA ST LA
OTHER RHEUMATOLOGICALS
ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG09 ML
2 PA ST LA
ACTEMRA INTRAVENOUS SOLUTION 200 MG10 ML (20 MGML) 400 MG20 ML (20 MGML) 80 MG4 ML (20 MGML)
MB PA LA
ACTEMRA SUBCUTANEOUS SYRINGE 162 MG09 ML
2 PA ST LA
96
Drug Name Drug Tier Requirements Limits
BENLYSTA INTRAVENOUS RECON SOLN 120 MG 400 MG
MB PA LA
BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MGML
2 PA LA
BENLYSTA SUBCUTANEOUS SYRINGE 200 MGML
2 PA LA
ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MGML (1 ML)
2 PA ST LA
ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)
2 PA ST LA
ENBREL SUBCUTANEOUS SOLUTION 25 MG05 ML
2 PA ST LA
ENBREL SUBCUTANEOUS SYRINGE 25 MG05 ML (05) 50 MGML (1 ML)
2 PA ST LA
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MGML (1 ML)
2 PA ST LA
HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
2 PA ST LA
HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG08 ML
2 PA ST LA
HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG08 ML 80 MG08 ML-40 MG04 ML
2 PA ST LA
HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
2 PA ST LA
HUMIRA(CF) PEN PEDIATRIC UC SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
2 PA ST LA
HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML-40 MG04 ML
2 PA ST LA
HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG04 ML
2 PA ST LA
97
Drug Name Drug Tier Requirements Limits
HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG01 ML 20 MG02 ML 40 MG04 ML
2 PA ST LA
KEVZARA SUBCUTANEOUS PEN INJECTOR 150 MG114 ML 200 MG114 ML
2 PA ST LA
KEVZARA SUBCUTANEOUS SYRINGE 150 MG114 ML 200 MG114 ML
2 PA ST LA
leflunomide oral tablet 10 mg 20 mg 1
OLUMIANT ORAL TABLET 1 MG 2 MG 2 PA ST LA
ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG
MB PA LA
ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MGML
2 PA ST LA
ORENCIA SUBCUTANEOUS SYRINGE 125 MGML 50 MG04 ML 875 MG07 ML
2 PA ST LA
OTEZLA ORAL TABLET 30 MG 2 PA ST LA
OTEZLA STARTER ORAL TABLETSDOSE PACK 10 MG (4)-20 MG (4)-30 MG (47)
2 PA ST LA
penicillamine oral capsule 250 mg 1 PA
penicillamine oral tablet 250 mg 1 PA
RIDAURA ORAL CAPSULE 3 MG 1
RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 MG
2 PA ST LA
SAVELLA ORAL TABLET 100 MG 125 MG 25 MG 50 MG
1 PA ST
SAVELLA ORAL TABLETSDOSE PACK 125 MG (5)-25 MG(8)-50 MG(42)
1 PA ST
SIMPONI ARIA INTRAVENOUS SOLUTION 125 MGML
MB PA LA
SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MGML 50 MG05 ML
2 PA ST LA
SIMPONI SUBCUTANEOUS SYRINGE 100 MGML 50 MG05 ML
2 PA ST LA
XELJANZ ORAL SOLUTION 1 MGML 2 PA ST LA
XELJANZ ORAL TABLET 10 MG 5 MG 2 PA ST LA
XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG 22 MG
2 PA ST LA
OBSTETRICS amp GYNECOLOGY
DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES
98
Drug Name Drug Tier Requirements Limits
CAYA CONTOURED VAGINAL DIAPHRAGM 65-80 MM
ACA PV
FC2 FEMALE CONDOM ACA PV
FEMCAP VAGINAL DEVICE 22 MM ACA PV
KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 175 MCG24 HRS (5 YRS) 195 MG
ACA PV
LILETTA INTRAUTERINE INTRAUTERINE DEVICE 201 MCG24 HRS (6 YRS) 52 MG
ACA PV ST
MIRENA INTRAUTERINE INTRAUTERINE DEVICE 20 MCG24 HOURS (6 YRS) 52 MG
ACA PV
PARAGARD T 380A INTRAUTERINE INTRAUTERINE DEVICE 380 SQUARE MM
ACA PV
SKYLA INTRAUTERINE INTRAUTERINE DEVICE 14 MCG24 HRS (3 YRS) 135 MG
ACA PV
WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 MM
ACA PV
ESTROGENS amp PROGESTINS
amabelz oral tablet 05-01 mg 1-05 mg 1
ANGELIQ ORAL TABLET 025-05 MG 05-1 MG
1
camila oral tablet 035 mg ACA PV
COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 005-014 MG24 HR 005-025 MG24 HR
1
covaryx hs oral tablet 0625-125 mg 1
covaryx oral tablet 125-25 mg 1
CRINONE VAGINAL GEL 4 1
deblitane oral tablet 035 mg ACA PV
DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MGML
1
DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MGML
MB
DEPO-PROVERA INTRAMUSCULAR SYRINGE 150 MGML
MB
DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE 104 MG065 ML
ACA PV
99
Drug Name Drug Tier Requirements Limits
DIVIGEL TRANSDERMAL GEL IN PACKET 025 MG025 GRAM (01 ) 05 MG05 GRAM (01 ) 075 MG075 GRAM (01) 1 MGGRAM (01 ) 125 MG125 GRAM (01 )
1 QL (30 per 30 days)
dotti transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
DUAVEE ORAL TABLET 045-20 MG 1
eemt hs oral tablet 0625-125 mg 1
eemt oral tablet 125-25 mg 1
errin oral tablet 035 mg ACA PV
estradiol oral tablet 05 mg 1 mg 2 mg 1
estradiol transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
estradiol transdermal patch weekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 006 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (4 per 30 days)
estradiol vaginal cream 001 (01 mggram) 1
estradiol vaginal tablet 10 mcg 1
estradiol valerate intramuscular oil 20 mgml 40 mgml
1
estradiol-norethindrone acet oral tablet 05-01 mg 1-05 mg
1
ESTRING VAGINAL RING 2 MG (75 MCG 24 HOUR)
1
estrogens-methyltestosterone oral tablet 0625-125 mg 125-25 mg
1
EVAMIST TRANSDERMAL SPRAYNON-AEROSOL 153 MGSPRAY (17)
1 QL (2 per 30 days)
FEMRING VAGINAL RING 005 MG24 HR 01 MG24 HR
1
fyavolv oral tablet 05-25 mg-mcg 1-5 mg-mcg 1
heather oral tablet 035 mg ACA PV
hydroxyprogest(pf)(preg presv) intramuscular oil 250 mgml (1 ml)
2
hydroxyprogesterone cap(ppres) intramuscular oil 250 mgml
2
100
Drug Name Drug Tier Requirements Limits
hydroxyprogesterone caproate intramuscular oil 250 mgml
2
incassia oral tablet 035 mg ACA PV
jencycla oral tablet 035 mg ACA PV
jinteli oral tablet 1-5 mg-mcg 1
lyleq oral tablet 035 mg ACA PV
lyllana transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
1 QL (8 per 30 days)
lyza oral tablet 035 mg ACA PV
medroxyprogesterone intramuscular suspension 150 mgml
ACA PV
medroxyprogesterone intramuscular syringe 150 mgml
ACA PV
medroxyprogesterone oral tablet 10 mg 25 mg 5 mg
1
MENEST ORAL TABLET 03 MG 0625 MG 125 MG 25 MG
1
MENOSTAR TRANSDERMAL PATCH WEEKLY 14 MCG24 HR
1 QL (4 per 30 days)
mimvey oral tablet 1-05 mg 1
nora-be oral tablet 035 mg ACA PV
norethindrone (contraceptive) oral tablet 035 mg ACA PV
norethindrone acetate oral tablet 5 mg 1
norethindrone ac-eth estradiol oral tablet 05-25 mg-mcg 1-5 mg-mcg
1
norlyda oral tablet 035 mg ACA PV
PREMARIN INJECTION RECON SOLN 25 MG 1
PREMARIN ORAL TABLET 03 MG 045 MG 0625 MG 09 MG 125 MG
1
PREMARIN VAGINAL CREAM 0625 MGGRAM
1
PREMPHASE ORAL TABLET 0625 MG (14) 0625MG-5MG(14)
1
PREMPRO ORAL TABLET 03-15 MG 045-15 MG 0625-25 MG 0625-5 MG
1
progesterone intramuscular oil 50 mgml 1
progesterone micronized oral capsule 100 mg 200 mg
1
101
Drug Name Drug Tier Requirements Limits
sharobel oral tablet 035 mg ACA PV
tulana oral tablet 035 mg ACA PV
yuvafem vaginal tablet 10 mcg 1
MISCELLANEOUS OBGYN
ANNOVERA VAGINAL RING 015-0013 MG24 HOUR
ACA PV
clindamycin phosphate vaginal cream 2 1
eluryng vaginal ring 012-0015 mg24 hr ACA PV
etonogestrel-ethinyl estradiol vaginal ring 012-0015 mg24 hr
ACA PV
fem ph vaginal gel 09-0025 1
GYNAZOLE-1 VAGINAL CREAM 2 1
gynol ii vaginal gel 3 ACA PV
INTRAROSA VAGINAL INSERT 65 MG 1
isoxsuprine oral tablet 10 mg 20 mg 1
LUPANETA PACK (1 MONTH) KIT SYRINGE AND TABLET 375 MG -5 MG (30)
2 LA
LUPANETA PACK (3 MONTH) KIT SYRINGE AND TABLET 1125 MG -5 MG (90)
2 LA
metronidazole vaginal gel 075 1
NEXPLANON SUBDERMAL IMPLANT 68 MG ACA PV
OSPHENA ORAL TABLET 60 MG 1
PHEXXI VAGINAL GEL 18-1-04 ACA PV
terconazole vaginal cream 04 08 1
terconazole vaginal suppository 80 mg 1
TODAY CONTRACEPTIVE SPONGE VAGINAL CONTRACEPTIVE SPONGE 1000 MG
ACA PV
tranexamic acid oral tablet 650 mg 1
TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 MCG24 HR
ACA PV
vaginal contraceptive foam vaginal foam 125 ACA PV
vandazole vaginal gel 075 1
VCF CONTRACEPTIVE FILM VAGINAL FILM 28
ACA PV
VCF CONTRACEPTIVE GEL VAGINAL GEL 4
ACA PV
102
Drug Name Drug Tier Requirements Limits
xulane transdermal patch weekly 150-35 mcg24 hr
ACA PV
zafemy transdermal patch weekly 150-35 mcg24 hr
ACA PV
ORAL CONTRACEPTIVES amp RELATED AGENTS
afirmelle oral tablet 01-20 mg-mcg ACA PV
altavera (28) oral tablet 015-003 mg ACA PV
alyacen 135 (28) oral tablet 1-35 mg-mcg ACA PV
alyacen 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
amethia oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
amethyst (28) oral tablet 90-20 mcg (28) ACA PV
apri oral tablet 015-003 mg ACA PV
aranelle (28) oral tablet 05105-35 mg-mcg ACA PV
ashlyna oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
aubra eq oral tablet 01-20 mg-mcg ACA PV
aubra oral tablet 01-20 mg-mcg ACA PV
aurovela 1530 (21) oral tablet 15-30 mg-mcg ACA PV
aurovela 120 (21) oral tablet 1-20 mg-mcg ACA PV
aurovela 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
aurovela fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
aurovela fe 1-20 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
aviane oral tablet 01-20 mg-mcg ACA PV
ayuna oral tablet 015-003 mg ACA PV
azurette (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
BALCOLTRA ORAL TABLET 01 MG-002 MG (21)365 MG(7)
ACA PV
balziva (28) oral tablet 04-35 mg-mcg ACA PV
blisovi 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
blisovi fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
103
Drug Name Drug Tier Requirements Limits
blisovi fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
briellyn oral tablet 04-35 mg-mcg ACA PV
camrese lo oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)
ACA PV
camrese oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
caziant (28) oral tablet 0112515-25 mg-mcg ACA PV
charlotte 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
chateal (28) oral tablet 015-003 mg ACA PV
chateal eq (28) oral tablet 015-003 mg ACA PV
cryselle (28) oral tablet 03-30 mg-mcg ACA PV
cyclafem 135 (28) oral tablet 1-35 mg-mcg ACA PV
cyclafem 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
cyred eq oral tablet 015-003 mg ACA PV
cyred oral tablet 015-003 mg ACA PV
dasetta 135 (28) oral tablet 1-35 mg-mcg ACA PV
dasetta 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
daysee oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
desog-eestradioleestradiol oral tablet 015-002 mgx21 001 mg x 5
ACA PV
desogestrel-ethinyl estradiol oral tablet 015-003 mg
ACA PV
dolishale oral tablet 90-20 mcg (28) ACA PV
drospirenone-eestradiol-lmfa oral tablet 3-002-0451 mg (24) (4) 3-003-0451 mg (21) (7)
ACA PV
drospirenone-ethinyl estradiol oral tablet 3-002 mg 3-003 mg
ACA PV
econtra ez oral tablet 15 mg ACA PV
econtra one-step oral tablet 15 mg ACA PV
elinest oral tablet 03-30 mg-mcg ACA PV
ELLA ORAL TABLET 30 MG ACA PV
emoquette oral tablet 015-003 mg ACA PV
104
Drug Name Drug Tier Requirements Limits
enpresse oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
enskyce oral tablet 015-003 mg ACA PV
estarylla oral tablet 025-35 mg-mcg ACA PV
ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg 1-50 mg-mcg
ACA PV
falmina (28) oral tablet 01-20 mg-mcg ACA PV
fayosim oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg
ACA PV
femynor oral tablet 025-35 mg-mcg ACA PV
gemmily oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV
hailey 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
hailey fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
hailey fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
hailey oral tablet 15-30 mg-mcg ACA PV
iclevia oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
isibloom oral tablet 015-003 mg ACA PV
jaimiess oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
jasmiel (28) oral tablet 3-002 mg ACA PV
jolessa oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
juleber oral tablet 015-003 mg ACA PV
junel 1530 (21) oral tablet 15-30 mg-mcg ACA PV
junel 120 (21) oral tablet 1-20 mg-mcg ACA PV
junel fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
junel fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
junel fe 24 oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV
kaitlib fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)
ACA PV
kalliga oral tablet 015-003 mg ACA PV
kariva (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
105
Drug Name Drug Tier Requirements Limits
kelnor 135 (28) oral tablet 1-35 mg-mcg ACA PV
kelnor 1-50 (28) oral tablet 1-50 mg-mcg ACA PV
kurvelo (28) oral tablet 015-003 mg ACA PV
l norgesteestradiol-eestrad oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7) 015 mg-20 mcg 015 mg-25 mcg 015 mg-30 mcg (84)10 mcg (7)
ACA PV
larin 1530 (21) oral tablet 15-30 mg-mcg ACA PV
larin 120 (21) oral tablet 1-20 mg-mcg ACA PV
larin 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4) ACA PV
larin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
larin fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
larissia oral tablet 01-20 mg-mcg ACA PV
layolis fe oral tabletchewable 08mg-25mcg(24) and 75 mg (4)
ACA PV
leena 28 oral tablet 05105-35 mg-mcg ACA PV
lessina oral tablet 01-20 mg-mcg ACA PV
levonest (28) oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
levonorgestrel oral tablet 15 mg ACA PV
levonorgestrel-ethinyl estrad oral tablet 01-20 mg-mcg 015-003 mg 90-20 mcg (28)
ACA PV
levonorgestrel-ethinyl estrad oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
levonorg-eth estrad triphasic oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
levora-28 oral tablet 015-003 mg ACA PV
lillow (28) oral tablet 015-003 mg ACA PV
LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG (24)10 MCG (2)
ACA PV
lojaimiess oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)
ACA PV
loryna (28) oral tablet 3-002 mg ACA PV
low-ogestrel (28) oral tablet 03-30 mg-mcg ACA PV
lo-zumandimine (28) oral tablet 3-002 mg ACA PV
lutera (28) oral tablet 01-20 mg-mcg ACA PV
106
Drug Name Drug Tier Requirements Limits
marlissa (28) oral tablet 015-003 mg ACA PV
merzee oral capsule 1 mg-20 mcg (24)75 mg (4) ACA PV
mibelas 24 fe oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
microgestin 1530 (21) oral tablet 15-30 mg-mcg ACA PV
microgestin 120 (21) oral tablet 1-20 mg-mcg ACA PV
microgestin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)
ACA PV
microgestin fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
mili oral tablet 025-35 mg-mcg ACA PV
mono-linyah oral tablet 025-35 mg-mcg ACA PV
my choice oral tablet 15 mg ACA PV
my way oral tablet 15 mg ACA PV
NATAZIA ORAL TABLET 3 MG2 MG-2 MG 2 MG-3 MG1 MG
ACA PV
necon 0535 (28) oral tablet 05-35 mg-mcg ACA PV
new day oral tablet 15 mg ACA PV
NEXTSTELLIS ORAL TABLET 3 MG- 142 MG (28)
ACA PV
nikki (28) oral tablet 3-002 mg ACA PV
noreth-ethinyl estradiol-iron oral tabletchewable 04mg-35mcg(21) and 75 mg (7) 08mg-25mcg(24) and 75 mg (4)
ACA PV
norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg 15-30 mg-mcg
ACA PV
norethindrone-eestradiol-iron oral capsule 1 mg-20 mcg (24)75 mg (4)
ACA PV
norethindrone-eestradiol-iron oral tablet 1 mg-20 mcg (21)75 mg (7) 15 mg-30 mcg (21)75 mg (7)
ACA PV
norethindrone-eestradiol-iron oral tabletchewable 1 mg-20 mcg(24) 75 mg (4)
ACA PV
norgestimate-ethinyl estradiol oral tablet 0180215025 mg-25 mcg 0180215025 mg-35 mcg (28) 025-35 mg-mcg
ACA PV
nortrel 0535 (28) oral tablet 05-35 mg-mcg ACA PV
nortrel 135 (21) oral tablet 1-35 mg-mcg (21) ACA PV
nortrel 135 (28) oral tablet 1-35 mg-mcg ACA PV
107
Drug Name Drug Tier Requirements Limits
nortrel 777 (28) oral tablet 050751 mg- 35 mcg
ACA PV
nylia 777 (28) oral tablet 050751 mg- 35 mcg ACA PV
nymyo oral tablet 025-35 mg-mcg ACA PV
ocella oral tablet 3-003 mg ACA PV
opcicon one-step oral tablet 15 mg ACA PV
option-2 oral tablet 15 mg ACA PV
orsythia oral tablet 01-20 mg-mcg ACA PV
philith oral tablet 04-35 mg-mcg ACA PV
pimtrea (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
pirmella oral tablet 050751 mg- 35 mcg 1-35 mg-mcg
ACA PV
portia 28 oral tablet 015-003 mg ACA PV
previfem oral tablet 025-35 mg-mcg ACA PV
reclipsen (28) oral tablet 015-003 mg ACA PV
rivelsa oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg
ACA PV
setlakin oral tabletsdose pack3 month 015 mg-30 mcg (91)
ACA PV
simliya (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
simpesse oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)
ACA PV
SLYND ORAL TABLET 4 MG (28) ACA PV
sprintec (28) oral tablet 025-35 mg-mcg ACA PV
sronyx oral tablet 01-20 mg-mcg ACA PV
syeda oral tablet 3-003 mg ACA PV
tarina 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
ACA PV
tarina fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
ACA PV
tilia fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9) ACA PV
tri femynor oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-estarylla oral tablet 0180215025 mg-35 mcg (28)
ACA PV
108
Drug Name Drug Tier Requirements Limits
tri-legest fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9)
ACA PV
tri-linyah oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-lo-estarylla oral tablet 0180215025 mg-25 mcg
ACA PV
tri-lo-marzia oral tablet 0180215025 mg-25 mcg
ACA PV
tri-lo-mili oral tablet 0180215025 mg-25 mcg ACA PV
tri-lo-sprintec oral tablet 0180215025 mg-25 mcg
ACA PV
tri-mili oral tablet 0180215025 mg-35 mcg (28) ACA PV
tri-nymyo oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-previfem (28) oral tablet 0180215025 mg-35 mcg (28)
ACA PV
tri-sprintec (28) oral tablet 0180215025 mg-35 mcg (28)
ACA PV
trivora (28) oral tablet 50-30 (6)75-40 (5)125-30(10)
ACA PV
tri-vylibra lo oral tablet 0180215025 mg-25 mcg
ACA PV
tri-vylibra oral tablet 0180215025 mg-35 mcg (28)
ACA PV
TYBLUME ORAL TABLETCHEWABLE 01 MG- 20 MCG
ACA PV
tydemy oral tablet 3-003-0451 mg (21) (7) ACA PV
velivet triphasic regimen (28) oral tablet 0112515-25 mg-mcg
ACA PV
vestura (28) oral tablet 3-002 mg ACA PV
vienva oral tablet 01-20 mg-mcg ACA PV
viorele (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
volnea (28) oral tablet 015-002 mgx21 001 mg x 5
ACA PV
vyfemla (28) oral tablet 04-35 mg-mcg ACA PV
vylibra oral tablet 025-35 mg-mcg ACA PV
wera (28) oral tablet 05-35 mg-mcg ACA PV
wymzya fe oral tabletchewable 04mg-35mcg(21) and 75 mg (7)
ACA PV
109
Drug Name Drug Tier Requirements Limits
zarah oral tablet 3-003 mg ACA PV
zovia 135e (28) oral tablet 1-35 mg-mcg ACA PV
zumandimine (28) oral tablet 3-003 mg ACA PV
OXYTOCICS
methergine oral tablet 02 mg 1
methylergonovine oral tablet 02 mg 1
OPHTHALMOLOGY
ANTIBIOTICS
ak-poly-bac ophthalmic (eye) ointment 500-10000 unitgram
1
AZASITE OPHTHALMIC (EYE) DROPS 1 1
bacitracin ophthalmic (eye) ointment 500 unitgram
1
bacitracin-polymyxin b ophthalmic (eye) ointment 500-10000 unitgram
1
BESIVANCE OPHTHALMIC (EYE) DROPSSUSPENSION 06
1
ciprofloxacin hcl ophthalmic (eye) drops 03 1
erythromycin ophthalmic (eye) ointment 5 mggram (05 )
1
gatifloxacin ophthalmic (eye) drops 05 1
gentak ophthalmic (eye) ointment 03 (3 mggram)
1
gentamicin ophthalmic (eye) drops 03 1
levofloxacin ophthalmic (eye) drops 05 1
moxifloxacin ophthalmic (eye) drops 05 1
moxifloxacin ophthalmic (eye) drops viscous 05
1
NATACYN OPHTHALMIC (EYE) DROPSSUSPENSION 5
1
neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
1
neomycin-polymyxin-gramicidin ophthalmic (eye) drops 175 mg-10000 unit-0025mgml
1
neo-polycin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
1
ofloxacin ophthalmic (eye) drops 03 1
110
Drug Name Drug Tier Requirements Limits
polycin ophthalmic (eye) ointment 500-10000 unitgram
1
polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10000 unit- 1 mgml
1
tobramycin ophthalmic (eye) drops 03 1
TOBREX OPHTHALMIC (EYE) OINTMENT 03
1
ANTIVIRALS
trifluridine ophthalmic (eye) drops 1 1
ZIRGAN OPHTHALMIC (EYE) GEL 015 1
BETA-BLOCKERS
betaxolol ophthalmic (eye) drops 05 1
BETIMOL OPHTHALMIC (EYE) DROPS 025 05
1
BETOPTIC S OPHTHALMIC (EYE) DROPSSUSPENSION 025
1
carteolol ophthalmic (eye) drops 1 1
levobunolol ophthalmic (eye) drops 05 1
timolol maleate ophthalmic (eye) drops 025 05
1
timolol maleate ophthalmic (eye) drops once daily 05
1
timolol maleate ophthalmic (eye) gel forming solution 025 05
1
CYCLOPLEGIC MYDRIATICS
atropine ophthalmic (eye) drops 1 1
atropine ophthalmic (eye) ointment 1 1
cyclopentolate ophthalmic (eye) drops 05 1 2
1
homatropaire ophthalmic (eye) drops 5 1
tropicamide ophthalmic (eye) drops 05 1 1
DIRECT ACTING MIOTICS
pilocarpine hcl ophthalmic (eye) drops 1 2 4
1
MISCELLANEOUS OPHTHALMOLOGICS
ALOCRIL OPHTHALMIC (EYE) DROPS 2 1 ST
ALOMIDE OPHTHALMIC (EYE) DROPS 01 1 ST
111
Drug Name Drug Tier Requirements Limits
altacaine ophthalmic (eye) drops 05 1
azelastine ophthalmic (eye) drops 005 1
BEOVU INTRAVITREAL SOLUTION 6 MG005 ML
MB PA LA
bepotastine besilate ophthalmic (eye) drops 15 1 ST
BEPREVE OPHTHALMIC (EYE) DROPS 15 1 ST
cromolyn ophthalmic (eye) drops 4 1
CYSTARAN OPHTHALMIC (EYE) DROPS 044
2 PA
epinastine ophthalmic (eye) drops 005 1
EYLEA INTRAVITREAL SOLUTION 2 MG005 ML
MB PA LA
EYLEA INTRAVITREAL SYRINGE 2 MG005 ML
MB PA LA
LACRISERT OPHTHALMIC (EYE) INSERT 5 MG
1
LASTACAFT OPHTHALMIC (EYE) DROPS 025
1 ST
LUCENTIS INTRAVITREAL SOLUTION 03 MG005 ML 05 MG005 ML
MB PA LA
LUCENTIS INTRAVITREAL SYRINGE 03 MG005 ML 05 MG005 ML
MB PA LA
LUXTURNA SUBRETINAL SUSPENSION 15 X 10EXP11 VG03 ML (FNL)
MB LA
olopatadine ophthalmic (eye) drops 01 02 1
OMIDRIA INTRAOCULAR CONCENTRATE 1-03
MB
proparacaine ophthalmic (eye) drops 05 1
RESTASIS OPHTHALMIC (EYE) DROPPERETTE 005
1 QL (120 per 30 days)
TETRACAINE HCL (PF) OPHTHALMIC (EYE) DROPS 05
1
tetracaine hcl ophthalmic (eye) drops 05 1
VISUDYNE INTRAVENOUS RECON SOLN 15 MG
MB LA
XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5
1 PA ST QL (60 per 30 days)
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
112
Drug Name Drug Tier Requirements Limits
ACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE 045
1 ST
bromfenac ophthalmic (eye) drops 009 1
diclofenac sodium ophthalmic (eye) drops 01 1
flurbiprofen sodium ophthalmic (eye) drops 003
1
ketorolac ophthalmic (eye) drops 04 05 1
NEVANAC OPHTHALMIC (EYE) DROPSSUSPENSION 01
1
ORAL DRUGS FOR GLAUCOMA
acetazolamide oral capsule extended release 500 mg
1
acetazolamide oral tablet 125 mg 250 mg 1
methazolamide oral tablet 25 mg 50 mg 1
OTHER GLAUCOMA DRUGS
bimatoprost ophthalmic (eye) drops 003 1
brinzolamide ophthalmic (eye) dropssuspension 1
1
COMBIGAN OPHTHALMIC (EYE) DROPS 02-05
1
dorzolamide ophthalmic (eye) drops 2 1
dorzolamide-timolol (pf) ophthalmic (eye) dropperette 2-05
1
dorzolamide-timolol ophthalmic (eye) drops 223-68 mgml
1
latanoprost ophthalmic (eye) drops 0005 1
LUMIGAN OPHTHALMIC (EYE) DROPS 001
1 ST
RHOPRESSA OPHTHALMIC (EYE) DROPS 002
1 PA ST
SIMBRINZA OPHTHALMIC (EYE) DROPSSUSPENSION 1-02
1
travoprost ophthalmic (eye) drops 0004 1
STEROID-ANTIBIOTIC COMBINATIONS
neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
1
neomycin-polymyxin b-dexameth ophthalmic (eye) dropssuspension 35mgml-10000 unitml-01
1
113
Drug Name Drug Tier Requirements Limits
neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 35 mgg-10000 unitg-01
1
neomycin-polymyxin-hc ophthalmic (eye) dropssuspension 35-10000-10 mg-unit-mgml
1
neo-polycin hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
1
TOBRADEX OPHTHALMIC (EYE) OINTMENT 03-01
1
TOBRADEX ST OPHTHALMIC (EYE) DROPSSUSPENSION 03-005
1
tobramycin-dexamethasone ophthalmic (eye) dropssuspension 03-01
1
STEROIDS
ALREX OPHTHALMIC (EYE) DROPSSUSPENSION 02
1 ST
dexamethasone sodium phosphate ophthalmic (eye) drops 01
1
DUREZOL OPHTHALMIC (EYE) DROPS 005
1
fluorometholone ophthalmic (eye) dropssuspension 01
1
FML FORTE OPHTHALMIC (EYE) DROPSSUSPENSION 025
1
FML SOP OPHTHALMIC (EYE) OINTMENT 01
1
INVELTYS OPHTHALMIC (EYE) DROPSSUSPENSION 1
1 ST
LOTEMAX OPHTHALMIC (EYE) OINTMENT 05
1 ST
loteprednol etabonate ophthalmic (eye) dropsgel 05
1
loteprednol etabonate ophthalmic (eye) dropssuspension 05
1
MAXIDEX OPHTHALMIC (EYE) DROPSSUSPENSION 01
1
OZURDEX INTRAVITREAL IMPLANT 07 MG MB LA
PRED MILD OPHTHALMIC (EYE) DROPSSUSPENSION 012
1
prednisolone acetate ophthalmic (eye) dropssuspension 1
1
114
Drug Name Drug Tier Requirements Limits
prednisolone sodium phosphate ophthalmic (eye) drops 1
1
RETISERT INTRAVITREAL IMPLANT 059 MG
MB LA
YUTIQ INTRAVITREAL IMPLANT 018 MG MB
STEROID-SULFONAMIDE COMBINATIONS
BLEPHAMIDE OPHTHALMIC (EYE) DROPSSUSPENSION 10-02
1
BLEPHAMIDE SOP OPHTHALMIC (EYE) OINTMENT 10-02
1
sulfacetamide-prednisolone ophthalmic (eye) drops 10 -023 (025 )
1
SULFONAMIDES
sulfacetamide sodium ophthalmic (eye) drops 10
1
sulfacetamide sodium ophthalmic (eye) ointment 10
1
SYMPATHOMIMETICS
apraclonidine ophthalmic (eye) drops 05 1
brimonidine ophthalmic (eye) drops 015 02 1
IOPIDINE OPHTHALMIC (EYE) DROPPERETTE 1
1
VASOCONSTRICTOR DECONGESTANTS
phenylephrine hcl ophthalmic (eye) drops 10 25
1
RESPIRATORY ALLERGY COUGH amp COLD
ANTIHISTAMINE amp ANTIALLERGENIC AGENTS
adrenalin injection solution 1 mgml 1 mgml (1 ml)
1
carbinoxamine maleate oral liquid 4 mg5 ml 1 PA ST QL (2 per 30 days)
carbinoxamine maleate oral tablet 4 mg 1 PA ST QL (240 per 30 days)
carbinoxamine maleate oral tablet 6 mg 1 PA ST QL (120 per 30 days)
cetirizine oral solution 1 mgml 1
clemastine oral syrup 05 mg5 ml 1
clemastine oral tablet 268 mg 1
cyproheptadine oral syrup 2 mg5 ml 1
cyproheptadine oral tablet 4 mg 1
115
Drug Name Drug Tier Requirements Limits
desloratadine oral tablet 5 mg 1 PA ST QL (30 per 30 days)
desloratadine oral tabletdisintegrating 25 mg 5 mg
1 PA ST
diphenhydramine hcl injection solution 50 mgml 1
diphenhydramine hcl injection syringe 50 mgml MB
EPINEPHRINE INJECTION AUTO-INJECTOR 015 MG015 ML
1
epinephrine injection auto-injector 015 mg03 ml 03 mg03 ml
1
epinephrine injection solution 1 mgml 1 mgml (1 ml)
1
epinephrine injection syringe 01 mgml 1
hydroxyzine hcl intramuscular solution 25 mgml MB
hydroxyzine hcl oral solution 10 mg5 ml 1
hydroxyzine hcl oral tablet 10 mg 25 mg 50 mg 1
hydroxyzine pamoate oral capsule 100 mg 25 mg 50 mg
1
levocetirizine oral solution 25 mg5 ml 1
levocetirizine oral tablet 5 mg 1
promethazine injection solution 25 mgml MB
promethazine oral syrup 625 mg5 ml 1
promethazine oral tablet 125 mg 25 mg 50 mg 1
promethazine rectal suppository 125 mg 25 mg 1
promethegan rectal suppository 125 mg 25 mg 50 mg
1
COUGH amp COLD THERAPY
benzonatate oral capsule 100 mg 150 mg 200 mg 1
brompheniramine-pseudoeph-dm oral syrup 2-30-10 mg5 ml
1
codeine-guaifenesin oral liquid 10-100 mg5 ml 1
g tussin ac oral liquid 10-100 mg5 ml 1
guaiatussin ac oral liquid 10-100 mg5 ml 1
hydrocodone-chlorpheniramine oral suspensionextended rel 12 hr 10-8 mg5 ml
1
hydrocodone-homatropine oral syrup 5-15 mg5 ml
1
hydrocodone-homatropine oral tablet 5-15 mg 1
116
Drug Name Drug Tier Requirements Limits
hydromet oral syrup 5-15 mg5 ml 1
maxi-tuss ac oral liquid 10-100 mg5 ml 1
m-clear wc oral liquid 63-100 mg5 ml 1
promethazine-codeine oral syrup 625-10 mg5 ml 1
promethazine-dm oral syrup 625-15 mg5 ml 1
promethazine-phenyleph-codeine oral syrup 625-5-10 mg5 ml
1
promethazine-phenylephrine oral syrup 625-5 mg5 ml
1
virtussin ac oral liquid 10-100 mg5 ml 1
PULMONARY AGENTS
acetylcysteine solution 100 mgml (10 ) 200 mgml (20 )
1
ADEMPAS ORAL TABLET 05 MG 1 MG 15 MG 2 MG 25 MG
2 PA LA
ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCGACTUATION 230-21 MCGACTUATION 45-21 MCGACTUATION
1 QL (1 per 30 days)
ALBUTEROL HFA 90 MCG INHALER 90 MCGACTUATION
1 QL (2 per 30 days)
albuterol sulfate inhalation inhalation hfa aerosol inhaler 90 mcgactuation
1 QL (2 per 30 days)
albuterol sulfate inhalation inhalation solution for nebulization 063 mg3 ml 125 mg3 ml 25 mg 3 ml (0083 ) 25 mg05 ml 5 mgml
1
albuterol sulfate inhalation oral syrup 2 mg5 ml 1
albuterol sulfate inhalation oral tablet 2 mg 4 mg 1
albuterol sulfate inhalation oral tablet extended release 12 hr 4 mg 8 mg
1
ALVESCO INHALATION HFA AEROSOL INHALER 160 MCGACTUATION 80 MCGACTUATION
1 PA ST QL (1 per 30 days)
alyq oral tablet 20 mg 2 PA
ambrisentan oral tablet 10 mg 5 mg 2 PA LA
aminophylline intravenous solution 250 mg10 ml MB
ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 625-25 MCGACTUATION
1 QL (1 per 30 days)
arformoterol inhalation solution for nebulization 15 mcg2 ml
1
117
Drug Name Drug Tier Requirements Limits
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 200 MCGACTUATION
1 QL (1 per 30 days)
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 50 MCGACTUATION
1
ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCGACTUATION
1 QL (2 per 30 days)
BERINERT INTRAVENOUS KIT 500 UNIT (10 ML)
MB PA LA
BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-48 MCG
1
bosentan oral tablet 125 mg 625 mg 2 PA LA
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCGDOSE
1 QL (1 per 30 days)
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 200-25 MCGDOSE
1
BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG2 ML
1
budesonide inhalation suspension for nebulization 025 mg2 ml 05 mg2 ml
1 QL (120 per 30 days)
budesonide inhalation suspension for nebulization 1 mg2 ml
1 QL (60 per 30 days)
CINQAIR INTRAVENOUS SOLUTION 10 MGML
MB PA
CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)
MB PA LA
COMBIVENT RESPIMAT INHALATION MIST 20-100 MCGACTUATION
1 QL (2 per 30 days)
cromolyn inhalation solution for nebulization 20 mg2 ml
1
DALIRESP ORAL TABLET 250 MCG 500 MCG
1
DULERA INHALATION HFA AEROSOL INHALER 100-5 MCGACTUATION 200-5 MCGACTUATION 50-5 MCGACTUATION
1 QL (1 per 30 days)
ELIXOPHYLLIN ORAL ELIXIR 80 MG15 ML 1
ESBRIET ORAL CAPSULE 267 MG 2 PA LA QL (270 per 30 days)
ESBRIET ORAL TABLET 267 MG 801 MG 2 PA LA QL (90 per 30 days)
FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MGML
MB PA LA
118
Drug Name Drug Tier Requirements Limits
FASENRA SUBCUTANEOUS SYRINGE 30 MGML
MB PA LA
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 50 MCGACTUATION
1 QL (1 per 30 days)
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCGACTUATION
1 QL (4 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCGACTUATION 44 MCGACTUATION
1 QL (1 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCGACTUATION
1 QL (2 per 30 days)
fluticasone propionate nasal spraysuspension 50 mcgactuation
1
fluticasone propion-salmeterol inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose
1 QL (1 per 30 days)
formoterol fumarate inhalation solution for nebulization 20 mcg2 ml
1
HAEGARDA SUBCUTANEOUS RECON SOLN 2000 UNIT 3000 UNIT
2 PA LA
icatibant subcutaneous syringe 30 mg3 ml 2 PA
INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 625 MCGACTUATION
1 QL (1 per 30 days)
ipratropium bromide inhalation solution 002 1
ipratropium-albuterol inhalation solution for nebulization 05 mg-3 mg(25 mg base)3 ml
1 QL (180 per 30 days)
KALBITOR SUBCUTANEOUS SOLUTION 10 MGML (1 ML)
2 PA LA
KALYDECO ORAL GRANULES IN PACKET 25 MG 50 MG 75 MG
2 PA LA
KALYDECO ORAL TABLET 150 MG 2 PA LA
levalbuterol hcl inhalation solution for nebulization 031 mg3 ml 063 mg3 ml 125 mg05 ml 125 mg3 ml
1
LEVALBUTEROL TARTRATE INHALATION HFA AEROSOL INHALER 45 MCGACTUATION
1 QL (2 per 30 days)
metaproterenol oral syrup 10 mg5 ml 1
montelukast oral granules in packet 4 mg 1
montelukast oral tablet 10 mg 1
119
Drug Name Drug Tier Requirements Limits
montelukast oral tabletchewable 4 mg 5 mg 1
nebusal inhalation solution for nebulization 3 1
NUCALA SUBCUTANEOUS RECON SOLN 100 MG
MB PA LA
OFEV ORAL CAPSULE 100 MG 150 MG 2 PA LA QL (60 per 30 days)
OPSUMIT ORAL TABLET 10 MG 2 PA LA
ORLADEYO ORAL CAPSULE 110 MG 150 MG
2 PA ST QL (28 per 28 days)
PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG2 ML
1
pulmosal inhalation solution for nebulization 7 1
PULMOZYME INHALATION SOLUTION 1 MGML
2 PA LA
QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCGACTUATION 80 MCGACTUATION
1
REVATIO INTRAVENOUS SOLUTION 10 MG125 ML
MB LA
RUCONEST INTRAVENOUS RECON SOLN 2100 UNIT
MB PA LA
SEEBRI NEOHALER INHALATION CAPSULE WINHALATION DEVICE 156 MCG
1
SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCGDOSE
1
sildenafil (pulmhypertension) intravenous solution 10 mg125 ml
MB
sildenafil (pulmhypertension) oral suspension for reconstitution 10 mgml
2
sildenafil (pulmhypertension) oral tablet 20 mg 2 PA
SINUVA SINUS IMPLANT 1350 MCG MB
sodium chloride inhalation solution for nebulization 09 10 3 7
1
SPIRIVA RESPIMAT INHALATION MIST 125 MCGACTUATION
1
SPIRIVA RESPIMAT INHALATION MIST 25 MCGACTUATION
1 QL (1 per 30 days)
SPIRIVA WITH HANDIHALER INHALATION CAPSULE WINHALATION DEVICE 18 MCG
1 QL (30 per 30 days)
STIOLTO RESPIMAT INHALATION MIST 25-25 MCGACTUATION
1
120
Drug Name Drug Tier Requirements Limits
STRIVERDI RESPIMAT INHALATION MIST 25 MCGACTUATION
1
SYMBICORT INHALATION HFA AEROSOL INHALER 160-45 MCGACTUATION 80-45 MCGACTUATION
1 QL (1 per 30 days)
SYMDEKO ORAL TABLETS SEQUENTIAL 100-150 MG (D) 150 MG (N) 50-75 MG (D) 75 MG (N)
2 PA LA
tadalafil (pulm hypertension) oral tablet 20 mg 2 PA
TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG2 ML (150 MGML)
2 PA LA
terbutaline oral tablet 25 mg 5 mg 1
terbutaline subcutaneous solution 1 mgml 1
theophylline oral elixir 80 mg15 ml 1
theophylline oral solution 80 mg15 ml 1
theophylline oral tablet extended release 12 hr 300 mg 450 mg
1
theophylline oral tablet extended release 24 hr 400 mg 600 mg
1
TRACLEER ORAL TABLET FOR SUSPENSION 32 MG
2 PA LA
TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-625-25 MCG 200-625-25 MCG
1
TRIKAFTA ORAL TABLETS SEQUENTIAL 100-50-75 MG(D) 150 MG (N) 50-25-375 MG (D)75 MG (N)
2 PA LA
TYVASO INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)
2 PA LA
TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)
2 PA LA
TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML
2 PA LA
UTIBRON NEOHALER INHALATION CAPSULE WINHALATION DEVICE 275-156 MCG
1
VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCGML 20 MCGML
2 PA LA
121
Drug Name Drug Tier Requirements Limits
wixela inhub inhalation blister with device 100-50 mcgdose 250-50 mcgdose 500-50 mcgdose
1 QL (1 per 30 days)
XOLAIR SUBCUTANEOUS RECON SOLN 150 MG
MB LA
XOLAIR SUBCUTANEOUS SYRINGE 150 MGML 75 MG05 ML
MB PA LA QL (7 per 30 days)
zafirlukast oral tablet 10 mg 20 mg 1
zileuton oral tablet er multiphase 12 hr 600 mg 1 ST
ZYFLO ORAL TABLET 600 MG 1 ST
UROLOGICALS
ANTICHOLINERGICS amp ANTISPASMODICS
darifenacin oral tablet extended release 24 hr 15 mg 75 mg
1
flavoxate oral tablet 100 mg 1
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG 50 MG
1 ST
oxybutynin chloride oral syrup 5 mg5 ml 1
oxybutynin chloride oral tablet 5 mg 1
oxybutynin chloride oral tablet extended release 24hr 10 mg 15 mg 5 mg
1
solifenacin oral tablet 10 mg 5 mg 1
tolterodine oral capsuleextended release 24hr 2 mg 4 mg
1
tolterodine oral tablet 1 mg 2 mg 1
trospium oral capsuleextended release 24hr 60 mg
1
trospium oral tablet 20 mg 1
BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY
alfuzosin oral tablet extended release 24 hr 10 mg 1
dutasteride oral capsule 05 mg 1
dutasteride-tamsulosin oral capsule er multiphase 24 hr 05-04 mg
1
finasteride oral tablet 5 mg 1
silodosin oral capsule 4 mg 8 mg 1
tadalafil oral tablet 25 mg 5 mg 1 PA ST
tamsulosin oral capsule 04 mg 1
CHOLINERGIC STIMULANTS
122
Drug Name Drug Tier Requirements Limits
bethanechol chloride oral tablet 10 mg 25 mg 5 mg 50 mg
1
MISCELLANEOUS UROLOGICALS
CYSTAGON ORAL CAPSULE 150 MG 50 MG 2 PA
ELMIRON ORAL CAPSULE 100 MG 1
hyophen oral tablet 816-012-108 mg 1
K-PHOS NO 2 ORAL TABLET 305-700 MG 1
K-PHOS ORIGINAL ORAL TABLETSOLUBLE 500 MG
1
methen-sod phos-meth blue-hyos oral tablet 816-408-012 mg
1
OXLUMO SUBCUTANEOUS SOLUTION 945 MG05 ML
2 PA
phosphasal oral tablet 816-108-408 mg 1
potassium citrate oral tablet extended release 10 meq (1080 mg) 15 meq 5 meq (540 mg)
1
RENACIDIN IRRIGATION SOLUTION 19806 MG-594 MG-9804MG30ML
1
URELLE ORAL TABLET 81-108-408 MG 1
uretron d-s oral tablet 816-108-408 mg 1
urimar-t oral tablet 120-012-108 mg 1
urogesic-blue oral tablet 816-408-012 mg 1
uryl oral tablet 816-408-012 mg 1
ustell oral capsule 120-012 mg 1
utira-c oral tablet 816-108-408 mg 1
URINARY ANESTHETICS
phenazopyridine oral tablet 100 mg 200 mg 1
VITAMINS HEMATINICS amp ELECTROLYTES
ELECTROLYTES
effer-k oral tablet effervescent 25 meq 1
klor-con 10 oral tablet extended release 10 meq 1
klor-con 8 oral tablet extended release 8 meq 1
klor-con m10 oral tableter particlescrystals 10 meq
1
klor-con m15 oral tableter particlescrystals 15 meq
1
123
Drug Name Drug Tier Requirements Limits
klor-con m20 oral tableter particlescrystals 20 meq
1
klor-con oral packet 20 meq 1
klor-conef oral tablet effervescent 25 meq 1
K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ
1
k-tab oral tablet extended release 8 meq 1
NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION
MB
potassium chloride oral capsule extended release 10 meq 8 meq
1
potassium chloride oral liquid 20 meq15 ml 40 meq15 ml
1
potassium chloride oral packet 20 meq 1
potassium chloride oral tablet extended release 10 meq 20 meq 8 meq
1
potassium chloride oral tableter particlescrystals 10 meq 20 meq
1
sodium chloride 045 intravenous parenteral solution 045
MB
MISCELLANEOUS VITAMINS HEMATINICS amp ELECTROLYTES
ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION
MB
PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION
MB
PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION
MB
VITAMINS amp HEMATINICS
cyanocobalamin (vitamin b-12) injection solution 1000 mcgml
1
ergocalciferol (vitamin d2) oral capsule 1250 mcg (50000 unit)
1
FA-8 ORAL CAPSULE 08 MG ACA PV
FER-IN-SOL ORAL DROPS 15 MG IRON (75 MG)ML
ACA PV
FLORIVA (FLUORIDE-VITAMIN D3) ORAL DROPS 025 MG (055 MG)-400 UNITML
ACA PV
fluoride (sodium) oral drops 05 mg (11 mg sodfluorid)ml
ACA PV
124
Drug Name Drug Tier Requirements Limits
fluoride (sodium) oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)
ACA PV
folic acid injection solution 5 mgml 1
folic acid oral tablet 1 mg 1
folic acid oral tablet 400 mcg 800 mcg ACA PV
hydroxocobalamin intramuscular solution 1000 mcgml
1
INFED INJECTION SOLUTION 50 MGML MB
ludent fluoride oral tabletchewable 025 mg(055 mg sod fluoride) 05 mg (11 mg sodium fluorid) 1 mg (22 mg sod fluoride)
ACA PV
multi-vitamin with fluoride oral drops 025 mgml 05 mgml
ACA PV
multi-vitamin with fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
multivitamins with fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
mvc-fluoride oral tabletchewable 025 mg 05 mg 1 mg
ACA PV
NOVAFERRUM ORAL DROPS 15 MG IRONML
ACA PV
tri-vitamin with fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml
ACA PV
vitamins acd and fluoride oral drops 025 mg fluor (055 mg)ml 05 mg fluoride (11 mg)ml
ACA PV
125
Index
A abacavir 2 abacavir-lamivudine 2 abacavir-lamivudine-
zidovudine 2 ABILIFY MAINTENA 36 abiraterone 13 ABRAXANE 13 acamprosate 66 acarbose 77 accutane 59 acebutolol 45 acetaminophen-caff-
dihydrocod 30 acetaminophen-codeine 31 acetazolamide 112 acetic acid 66 69 acetylcysteine 116 acitretin 57 ACTEMRA 95 ACTEMRA ACTPEN 95 ACTHAR 70 ACTHIB (PF) 90 ACTIMMUNE 89 ACUVAIL (PF) 112 acyclovir 2 63 ADACEL(TDAP
ADOLESNADULT)(PF) 90 ADAKVEO 13 adapalene 59 60 ADAPALENE 60 adapalene-benzoyl peroxide 60 ADCETRIS 14 adefovir 2 ADEMPAS 116 ADHANSIA XR 36 adrenalin 114 adult aspirin regimen 33 ADVAIR HFA 116 ADVATE 50 ADYNOVATE 50 ADZENYS ER 36 ADZENYS XR-ODT 36 AEROCHAMBER MINI 71 AEROCHAMBER PLUS
FLOW-VU 71 AFINITOR 14 afirmelle 102
AFSTYLA 50 AIMOVIG AUTOINJECTOR
28 AJOVY AUTOINJECTOR 28 AJOVY SYRINGE 28 ak-poly-bac 109 AKYNZEO (NETUPITANT)
81 ala-cort 63 albendazole 8 albuterol sulfate inhalation 116 ALBUTEROL SULFATE
INHALATION 116 alclometasone 63 ALCORTIN A 61 ALDURAZYME 74 ALECENSA 14 alendronate 95 alfuzosin 121 ALIMTA 14 ALINIA 8 ALIQOPA 14 aliskiren 45 allopurinol 95 almotriptan malate 28 ALOCRIL 110 ALOGLIPTIN-
PIOGLITAZONE 77 ALOMIDE 110 alosetron 81 ALOXI 81 ALPHANATE 50 ALPHANINE SD 50 alprazolam 37 alprazolam intensol 37 ALPROLIX 50 ALREX 113 ALTABAX 61 altacaine 111 altavera (28) 102 ALVESCO 116 alyacen 135 (28) 102 alyacen 777 (28) 102 alyq 116 amabelz 98 amantadine hcl 2 AMBISOME 1 ambrisentan 116
amcinonide 63 amethia 102 amethyst (28) 102 amikacin 8 amiloride 45 amiloride-hydrochlorothiazide
45 aminocaproic acid 50 51 aminophylline 116 amiodarone 44 AMITIZA 81 amitriptyline 37 amitriptyline-chlordiazepoxide
37 amlodipine 45 amlodipine-atorvastatin 55 amlodipine-benazepril 45 amlodipine-olmesartan 45 amlodipine-valsartan 45 amlodipine-valsartan-hcthiazid
45 ammonium lactate 59 amnesteem 60 amoxapine 37 amoxicil-clarithromy-lansopraz
85 amoxicillin 11 amoxicillin-pot clavulanate 11 AMPHETAMINE 37 amphetamine sulfate 37 amphotericin b 1 ampicillin 11 ampicillin-sulbactam 11 anagrelide 66 anaspaz 80 anastrozole 14 ANDEXXA 51 ANDRODERM 74 ANGELIQ 98 ANNOVERA 101 ANORO ELLIPTA 116 anucort-hc 81 apexicon e 63 APLENZIN 37 APOKYN 27 apraclonidine 114 aprepitant 81 apri 102
126
APTIVUS 2 ARALAST NP 66 aranelle (28) 102 ARANESP (IN
POLYSORBATE) 86 ARCALYST 89 ARESTIN 68 arformoterol 116 aripiprazole 37 ARISTADA 37 ARISTADA INITIO 37 armodafinil 37 ARMOUR THYROID 79 ARNUITY ELLIPTA 117 ARRANON 14 ARZERRA 14 ASCENIV 90 ascomp with codeine 31 asenapine maleate 37 ashlyna 102 ASPARLAS 14 aspirin 33 34 aspirin low dose 33 aspirin-dipyridamole 51 aspir-trin 34 atazanavir 2 atenolol 45 atenolol-chlorthalidone 45 ATGAM 90 atomoxetine 37 atorvastatin 55 atovaquone 8 atovaquone-proguanil 8 atropine 80 110 ATROVENT HFA 117 AUBAGIO 87 aubra 102 aubra eq 102 aurovela 1530 (21) 102 aurovela 120 (21) 102 aurovela 24 fe 102 aurovela fe 1530 (28) 102 aurovela fe 1-20 (28) 102 AUSTEDO 29 AVASTIN 14 aviane 102 avidoxy 12 avita 60 AVITA 60 AVONEX 88 AVYCAZ 6
ayuna 102 AZASITE 109 azathioprine 14 azelaic acid 60 azelastine 68 111 AZELEX 60 azithromycin 7 azurette (28) 102 B bacitracin 8 109 bacitracin-polymyxin b 109 baclofen 30 BALCOLTRA 102 balsalazide 81 BALVERSA 14 balziva (28) 102 BANZEL 24 BAQSIMI 71 BARACLUDE 2 BAVENCIO 14 BAXDELA 12 bayer aspirin 34 BAYER CHEWABLE
ASPIRIN 34 BCG VACCINE LIVE (PF) 90 BELEODAQ 14 belladonna alkaloids-opium 80 BELRAPZO 14 BELSOMRA 37 benazepril 45 benazepril-hydrochlorothiazide
45 BENDAMUSTINE 14 BENDEKA 14 BENEFIX 51 BENLYSTA 96 benzonatate 115 benztropine 27 BEOVU 111 bepotastine besilate 111 BEPREVE 111 BERINERT 117 beser 63 BESIVANCE 109 BESPONSA 14 betamethasone dipropionate 63 betamethasone valerate 63 betamethasone augmented 63
64 BETASERON 88 betaxolol 45 110
bethanechol chloride 122 BETIMOL 110 BETOPTIC S 110 BEVESPI AEROSPHERE 117 bexarotene 14 BEXSERO 90 bicalutamide 14 BICILLIN C-R 11 BIKTARVY 2 bimatoprost 112 BIOTHRAX 90 bisoprolol fumarate 45 bisoprolol-hydrochlorothiazide
45 BIVIGAM 90 BLEPHAMIDE 114 BLEPHAMIDE SOP 114 BLINCYTO 14 blisovi 24 fe 102 blisovi fe 1530 (28) 102 blisovi fe 120 (28) 103 BOOSTRIX TDAP 90 BORTEZOMIB 14 bosentan 117 BOSULIF 14 BOTOX 90 BRAFTOVI 14 BREO ELLIPTA 117 briellyn 103 BRILINTA 51 brimonidine 114 BRINEURA 75 brinzolamide 112 BRIVIACT 24 bromfenac 112 bromocriptine 27 brompheniramine-pseudoeph-
dm 115 BROVANA 117 budesonide 81 117 bumetanide 45 buprenorphine 31 buprenorphine hcl 31 buprenorphine-naloxone 34 bupropion hcl 37 38 bupropion hcl (smoking deter)
68 buspirone 38 BUSULFEX 15 butalbital compound wcodeine
31
127
butalbital-acetaminop-caf-cod 31
butalbital-acetaminophen-caff 31
butalbital-aspirin-caffeine 31 butorphanol 34 BYDUREON BCISE 77 BYETTA 77 BYSTOLIC 45 C CABENUVA 2 cabergoline 75 CABLIVI 51 CABOMETYX 15 calcipotriene 57 calcipotriene-betamethasone 57 calcitonin (salmon) 75 calcitriol 57 75 calcium acetate(phosphat bind)
81 CALQUENCE 15 camila 98 camrese 103 camrese lo 103 CANCIDAS 1 candesartan 45 candesartan-hydrochlorothiazid
46 CAPASTAT 8 capecitabine 15 CAPRELSA 15 captopril 46 captopril-hydrochlorothiazide
46 CARBAGLU 66 carbamazepine 24 carbidopa 27 carbidopa-levodopa 27 carbidopa-levodopa-
entacapone 27 carbinoxamine maleate 114 carisoprodol 30 carisoprodol-aspirin 30 carisoprodol-aspirin-codeine 30 carteolol 110 cartia xt 46 carvedilol 46 carvedilol phosphate 46 cataflam 34 CAYA CONTOURED 98 CAYSTON 8
caziant (28) 103 cefaclor 6 cefadroxil 6 cefazolin 6 cefazolin in dextrose (iso-os) 6 cefdinir 6 cefditoren pivoxil 6 cefepime 6 CEFEPIME IN DEXTROSE 5
6 cefepime in dextroseiso-osm 6 cefixime 6 CEFOTAN 6 cefotaxime 6 cefotetan 6 CEFOTETAN IN
DEXTROSE ISO-OSM 6 cefoxitin 6 cefpodoxime 6 7 cefprozil 7 ceftazidime 7 CEFTAZIDIME IN D5W 7 ceftriaxone 7 CEFTRIAXONE 7 ceftriaxone in dextroseiso-os 7 cefuroxime axetil 7 celecoxib 34 CELONTIN 24 cephalexin 7 CERDELGA 75 CEREZYME 75 cetirizine 114 cevimeline 66 CHANTIX 68 CHANTIX CONTINUING
MONTH BOX 68 CHANTIX STARTING
MONTH BOX 68 charlotte 24 fe 103 chateal (28) 103 chateal eq (28) 103 CHEMET 66 childrens aspirin 34 chloramphenicol sod succinate
8 chlordiazepoxide hcl 38 chlordiazepoxide-clidinium 80 chlorhexidine gluconate 68 chloroquine phosphate 8 chlorpromazine 38 chlorthalidone 46
chlorzoxazone 30 CHOLBAM 81 cholestyramine (with sugar) 55 cholestyramine light 55 cholinemagnesium salicylate
34 ciclodan 62 ciclopirox 62 ciclopirox-ure-camph-menth-
euc 62 cidofovir 2 cilostazol 51 CIMDUO 2 cimetidine 85 cimetidine hcl 85 CIMZIA 82 CIMZIA POWDER FOR
RECONST 81 cinacalcet 75 CINQAIR 117 CINRYZE 117 CIPRO HC 69 ciprofloxacin 12 ciprofloxacin hcl 12 69 109 ciprofloxacin-dexamethasone
69 citalopram 38 claravis 60 clarithromycin 7 8 clemastine 114 CLENPIQ 82 clindacin p 60 clindamycin hcl 8 clindamycin pediatric 8 clindamycin phosphate 8 60
101 clindamycin-benzoyl peroxide
60 clindamycin-tretinoin 60 clobazam 24 clobetasol 64 clobetasol-emollient 64 CLOCORTOLONE
PIVALATE 64 CLODERM 64 CLOLAR 15 clomipramine 38 clonazepam 24 clonidine 46 clonidine hcl 38 46 clopidogrel 51
128
clorazepate dipotassium 38 clotrimazole 1 62 clotrimazole-betamethasone 62 clovique 66 clozapine 38 COAGADEX 51 COARTEM 8 codeine sulfate 31 codeine-butalbital-asa-caff 31 codeine-guaifenesin 115 colchicine 95 COLCHICINE 95 colesevelam 55 colestipol 55 COMBIGAN 112 COMBIPATCH 98 COMBIVENT RESPIMAT 117 COMETRIQ 15 COMPLERA 2 compro 82 constulose 82 CONTOUR NEXT TEST
STRIPS 71 CONTOUR TEST STRIPS 71 COPIKTRA 15 CORIFACT 51 CORLANOR 56 CORTIFOAM 82 COSENTYX 58 COSENTYX (2 SYRINGES)
57 COSENTYX PEN 58 COSENTYX PEN (2 PENS) 58 COTELLIC 15 COTEMPLA XR-ODT 38 covaryx 98 covaryx hs 98 CREON 82 CRESEMBA 1 CRINONE 98 cromolyn 82 111 117 crotan 66 cryselle (28) 103 CRYSVITA 75 CUBICIN 8 CUBICIN RF 9 CUTAQUIG 90 CUVITRU 90 cyanocobalamin (vitamin b-12)
123 cyclafem 135 (28) 103
cyclafem 777 (28) 103 cyclobenzaprine 30 cyclopentolate 110 cyclophosphamide 15 CYCLOPHOSPHAMIDE 15 CYCLOSERINE 9 CYCLOSET 77 cyclosporine 15 cyclosporine modified 15 cyproheptadine 114 CYRAMZA 15 cyred 103 cyred eq 103 CYSTAGON 122 CYSTARAN 111 CYTOVENE 2 D DACOGEN 15 dalfampridine 29 DALIRESP 117 danazol 75 dantrolene 30 dapsone 9 60 DAPTACEL (DTAP
PEDIATRIC) (PF) 91 darifenacin 121 DARZALEX 15 dasetta 135 (28) 103 dasetta 777 (28) 103 DAURISMO 15 daysee 103 DAYTRANA 38 deblitane 98 decadron 70 decitabine 15 deferasirox 66 deferiprone 66 demeclocycline 12 DENAVIR 63 denta 5000 plus 68 dentagel 69 DEPO-ESTRADIOL 98 DEPO-PROVERA 98 DEPO-SUBQ PROVERA 104
98 DEPO-TESTOSTERONE 75 DESCOVY 2 desipramine 38 desloratadine 115 desmopressin 75
desog-eestradioleestradiol 103
desogestrel-ethinyl estradiol 103
desonide 64 desoximetasone 64 DESVENLAFAXINE 38 desvenlafaxine succinate 38 dexamethasone 70 dexamethasone intensol 70 dexamethasone sodium phos
(pf) 70 dexamethasone sodium
phosphate 70 113 DEXILANT 85 dexmethylphenidate 38 dextroamphetamine 38 39 dextroamphetamine-
amphetamine 39 diazepam 24 39 diazepam intensol 39 diazoxide 71 diclofenac potassium 34 diclofenac sodium 34 59 112 diclofenac-misoprostol 34 dicloxacillin 11 dicyclomine 80 didanosine 2 DIFICID 8 diflorasone 64 diflunisal 34 digitek 50 digox 50 digoxin 50 dihydroergotamine 28 DILANTIN 24 DILANTIN EXTENDED 24 DILANTIN INFATABS 24 DILANTIN-125 24 diltiazem 46 dilt-xr 46 dimethyl fumarate 88 DIPENTUM 82 diphenhydramine hcl 115 diphenoxylate-atropine 80 dipyridamole 51 diskets 31 disopyramide phosphate 44 disulfiram 66 divalproex 24 25 DIVIGEL 99
129
dofetilide 44 dolishale 103 donepezil 29 DONNATAL 80 DOPTELET (15 TAB PACK)
51 dorzolamide 112 dorzolamide-timolol 112 dorzolamide-timolol (pf) 112 dotti 99 DOVATO 2 doxazosin 46 doxepin 39 doxercalciferol 75 doxycycline hyclate 12 doxycycline monohydrate 12 doxylamine-pyridoxine (vit b6)
82 dronabinol 82 drospirenone-eestradiol-lmfa
103 drospirenone-ethinyl estradiol
103 DSUVIA 31 DUAVEE 99 DUEXIS 34 DULERA 117 duloxetine 39 DUPIXENT PEN 59 DUPIXENT SYRINGE 59 duramorph (pf) 31 DUREZOL 113 dutasteride 121 dutasteride-tamsulosin 121 dvorah 31 DYANAVEL XR 39 DYSPORT 91 E ees 400 8 econazole 62 econtra ez 103 econtra one-step 103 ecotrin 34 ecotrin low strength 34 EDARBI 46 EDARBYCLOR 46 EDLUAR 39 ed-spaz 80 EDURANT 2 eemt 99 eemt hs 99
efavirenz 2 efavirenz-emtricitabin-tenofov
3 efavirenz-lamivu-tenofov disop
3 effer-k 122 ELAPRASE 75 ELELYSO 75 eletriptan 28 ELIGARD 16 ELIGARD (3 MONTH) 15 ELIGARD (4 MONTH) 15 ELIGARD (6 MONTH) 15 elinest 103 ELIQUIS 51 ELIQUIS DVT-PE TREAT
30D START 51 ELIXOPHYLLIN 117 ELLA 103 ELMIRON 122 ELOCTATE 51 eluryng 101 ELZONRIS 16 EMCYT 16 EMEND 82 EMGALITY PEN 28 EMGALITY SYRINGE 28 emoquette 103 EMPAVELI 67 EMPLICITI 16 EMSAM 39 emtricitabine 3 emtricitabine-tenofovir (tdf) 3 EMTRIVA 3 EMVERM 9 enalapril maleate 46 enalaprilat 46 enalapril-hydrochlorothiazide
46 ENBREL 96 ENBREL MINI 96 ENBREL SURECLICK 96 endocet 31 ENGERIX-B (PF) 91 ENGERIX-B PEDIATRIC
(PF) 91 ENHERTU 16 enoxaparin 51 enpresse 104 enskyce 104 entacapone 27
entecavir 3 ENTRESTO 56 ENTYVIO 82 enulose 82 EPANED 46 EPCLUSA 3 EPIDIOLEX 25 epinastine 111 epinephrine 115 EPINEPHRINE 115 epitol 25 EPIVIR HBV 3 eplerenone 47 EPOGEN 86 epoprostenol (glycine) 47 eprosartan 47 ERAXIS(WATER DILUENT)
1 ERBITUX 16 ergocalciferol (vitamin d2) 123 ergoloid 39 ergotamine-caffeine 28 ERLEADA 16 erlotinib 16 errin 99 ERWINAZE 16 ery pads 60 erygel 60 ery-tab 8 erythrocin (as stearate) 8 erythromycin 8 109 erythromycin ethylsuccinate 8 erythromycin with ethanol 60 erythromycin-benzoyl peroxide
60 ESBRIET 117 escitalopram oxalate 39 esomeprazole magnesium 85 ESPEROCT 51 estarylla 104 estazolam 39 estradiol 99 estradiol valerate 99 estradiol-norethindrone acet 99 ESTRING 99 estrogens-methyltestosterone 99 eszopiclone 39 ethacrynic acid 47 ethambutol 9 ethosuximide 25
130
ethynodiol diac-eth estradiol 104
etodolac 34 etonogestrel-ethinyl estradiol
101 etoposide 16 etravirine 3 EUCRISA 59 EUFLEXXA 34 EURAX 66 EVAMIST 99 EVENITY 95 everolimus (antineoplastic) 16 everolimus
(immunosuppressive) 16 EVOTAZ 3 EXELDERM 62 exemestane 16 EXONDYS-51 29 EYLEA 111 ezetimibe 55 ezetimibe-simvastatin 55 F FA-8 123 FABRAZYME 75 FACTIVE 12 falmina (28) 104 famciclovir 3 famotidine 86 famotidine (pf) 85 FANAPT 39 FARXIGA 77 FASENRA 118 FASENRA PEN 117 FASLODEX 16 fayosim 104 FC2 FEMALE CONDOM 98 febuxostat 95 FEIBA NF 51 felbamate 25 felodipine 47 fem ph 101 FEMCAP 98 FEMRING 99 femynor 104 fenofibrate 55 FENOFIBRATE 55 fenofibrate micronized 55 fenofibrate nanocrystallized 55 fenofibric acid 55 fenofibric acid (choline) 55
fenoprofen 35 fentanyl 32 fentanyl citrate 31 FER-IN-SOL 123 FERRIPROX 67 FETZIMA 39 FIASP FLEXTOUCH U-100
INSULIN 72 FIASP PENFILL U-100
INSULIN 72 FIASP U-100 INSULIN 72 FIBRYGA 51 finasteride 121 FINTEPLA 25 FIRMAGON KIT W
DILUENT SYRINGE 16 flac otic oil 69 flavoxate 121 FLEBOGAMMA DIF 91 flecainide 44 FLOLAN 47 FLORIVA (FLUORIDE-
VITAMIN D3) 123 FLOVENT DISKUS 118 FLOVENT HFA 118 fluconazole 1 flucytosine 1 fludarabine 16 fludrocortisone 70 fluocinolone 64 fluocinolone acetonide oil 69 fluocinolone and shower cap 64 fluocinonide 64 fluocinonide-e 64 fluoride (sodium) 69 123 124 fluorometholone 113 fluorouracil 16 59 FLUOROURACIL 59 fluoxetine 39 40 fluphenazine hcl 40 flurandrenolide 64 65 flurazepam 40 flurbiprofen 35 flurbiprofen sodium 112 flutamide 16 fluticasone propionate 65 118 fluticasone propion-salmeterol
118 fluvastatin 55 56 fluvoxamine 40 FML FORTE 113
FML SOP 113 folic acid 124 FOLOTYN 16 fondaparinux 51 formoterol fumarate 118 FORTEO 95 FOSAMAX PLUS D 95 fosamprenavir 3 fosfomycin tromethamine 13 fosinopril 47 fosinopril-hydrochlorothiazide
47 FRAGMIN 52 FREESTYLE LIBRE 14 DAY
SENSOR 71 FREESTYLE LIBRE 2
SENSOR 71 frovatriptan 28 fulvestrant 16 furosemide 47 FUZEON 3 fyavolv 99 G g tussin ac 115 gabapentin 25 GALAFOLD 75 galantamine 29 GAMASTAN 91 GAMASTAN SD 91 GAMIFANT 16 GAMMAGARD LIQUID 91 GAMMAGARD S-D (IGA lt 1
MCGML) 91 GAMMAKED 91 GAMMAPLEX 91 GAMMAPLEX (WITH
SORBITOL) 91 GAMUNEX-C 91 GANCICLOVIR 3 ganciclovir sodium 3 GARDASIL 9 (PF) 91 gatifloxacin 109 gavilyte-c 82 gavilyte-g 82 gavilyte-n 82 GAZYVA 16 gemcitabine 16 17 gemfibrozil 56 gemmily 104 generlac 82 gengraf 17
131
GENOTROPIN 87 GENOTROPIN MINIQUICK
87 gentak 109 gentamicin 9 61 62 109 gentamicin sulfate (ped) (pf) 9 GENVOYA 3 GIAPREZA 56 GILENYA 88 GILOTRIF 17 GIVLAARI 67 GLASSIA 67 glatiramer 88 glatopa 88 GLEOSTINE 17 glimepiride 77 glipizide 77 glipizide-metformin 77 GLUCAGEN DIAGNOSTIC
KIT 71 GLUCAGEN HYPOKIT 71 GLUCAGON (HCL)
EMERGENCY KIT 71 glucagon emergency kit
(human) 71 GLUCAGON HCL 71 glyburide 77 glyburide micronized 77 glyburide-metformin 77 glycopyrrolate 80 GLYXAMBI 78 GONITRO 57 granisetron hcl 82 GRANIX 86 GRASTEK 91 griseofulvin microsize 1 griseofulvin ultramicrosize 1 guaiatussin ac 115 guanfacine 40 47 GYNAZOLE-1 101 gynol ii 101 H HAEGARDA 118 hailey 104 hailey 24 fe 104 hailey fe 1530 (28) 104 hailey fe 120 (28) 104 HALAVEN 17 halcinonide 65 halobetasol propionate 65 haloperidol 40
haloperidol decanoate 40 haloperidol lactate 40 HARVONI 3 HAVRIX (PF) 91 92 heather 99 HEMLIBRA 52 hemmorex-hc 82 HEMOFIL M HIGH 52 HEMOFIL M LOW 52 HEMOFIL M MID 52 HEMOFIL M SUPER HIGH52 hep flush-10 (pf) 52 heparin (porcine) 52 heparin (porcine) in 5 dex 52 heparin lock flush (porcine) 52 heparin lockflush(porcine)(pf)
52 heparin(porcine) in 045 nacl
52 HEPARIN(PORCINE) IN
045 NACL 52 heparin porcine (pf) 52 53 HEPLISAV-B (PF) 92 HERCEPTIN 17 HERCEPTIN HYLECTA 17 HERZUMA 17 HETLIOZ 40 HETLIOZ LQ 40 HIBERIX (PF) 92 HIZENTRA 92 homatropaire 110 HUMALOG JUNIOR
KWIKPEN U-100 72 HUMALOG KWIKPEN
INSULIN 72 HUMALOG MIX 50-50
INSULN U-100 72 HUMALOG MIX 50-50
KWIKPEN 72 HUMALOG MIX 75-25
KWIKPEN 72 HUMALOG MIX 75-25(U-
100)INSULN 72 HUMALOG U-100 INSULIN
72 HUMATE-P 53 HUMIRA 96 HUMIRA PEN 96 HUMIRA PEN CROHNS-UC-
HS START 96
HUMIRA PEN PSOR-UVEITS-ADOL HS 96
HUMIRA(CF) 97 HUMIRA(CF) PEDI
CROHNS STARTER 96 HUMIRA(CF) PEN 96 HUMIRA(CF) PEN
CROHNS-UC-HS 96 HUMIRA(CF) PEN
PEDIATRIC UC 96 HUMIRA(CF) PEN PSOR-
UV-ADOL HS 96 HUMULIN 7030 U-100
INSULIN 72 HUMULIN 7030 U-100
KWIKPEN 72 HUMULIN N NPH INSULIN
KWIKPEN 73 HUMULIN N NPH U-100
INSULIN 73 HUMULIN R REGULAR U-
100 INSULN 73 HUMULIN R U-500 (CONC)
INSULIN 73 HUMULIN R U-500 (CONC)
KWIKPEN 73 HYCAMTIN 17 hydralazine 47 hydrochlorothiazide 47 hydrocodone bitartrate 32 hydrocodone-acetaminophen 32 hydrocodone-chlorpheniramine
115 hydrocodone-homatropine 115 hydrocodone-ibuprofen 32 hydrocortisone 65 70 82 hydrocortisone acetate 82 hydrocortisone butyrate 65 hydrocortisone butyr-emollient
65 hydrocortisone valerate 65 hydrocortisone-acetic acid 69 hydrocortisone-pramoxine 58
82 hydromet 116 hydromorphone 32 HYDROMORPHONE 32 hydroxocobalamin 124 hydroxychloroquine 9 hydroxyprogest(pf)(preg presv)
99
132
hydroxyprogesterone cap(ppres) 99
hydroxyprogesterone caproate 100
hydroxyurea 17 hydroxyzine hcl 115 hydroxyzine pamoate 115 hyophen 122 hyoscyamine sulfate 80 hyosyne 80 HYQVIA 92 I ibandronate 95 IBRANCE 17 ibu 35 ibuprofen 35 icatibant 118 iclevia 104 ICLUSIG 17 icosapent ethyl 56 IDELVION 53 IDHIFA 17 ILARIS (PF) 90 ILUMYA 58 imatinib 17 IMBRUVICA 17 IMFINZI 17 imipenem-cilastatin 9 imipramine hcl 40 imipramine pamoate 40 imiquimod 90 IMLYGIC 17 IMOVAX RABIES VACCINE
(PF) 92 incassia 100 INCRELEX 67 INCRUSE ELLIPTA 118 indapamide 47 indomethacin 35 INFANRIX (DTAP) (PF) 92 INFED 124 INFLECTRA 82 INFUGEM 18 INLYTA 18 INSULIN ASP PRT-INSULIN
ASPART 73 INSULIN ASPART U-100 73 INSULIN SYRINGE-
NEEDLE U-100 71 INTELENCE 3 INTRAROSA 101
INTRON A 90 INVANZ 9 INVEGA SUSTENNA 40 INVELTYS 113 INVIRASE 3 IOPIDINE 114 IPOL 92 ipratropium bromide 69 118 ipratropium-albuterol 118 irbesartan 47 irbesartan-hydrochlorothiazide
47 IRESSA 18 ISENTRESS 3 ISENTRESS HD 3 isibloom 104 ISOLYTE-S 123 isoniazid 9 isosorbide dinitrate 57 isosorbide mononitrate 57 isotretinoin 60 isoxsuprine 101 isradipine 47 ISTODAX 18 itraconazole 1 ivermectin 9 66 IXEMPRA 18 IXIARO (PF) 92 IXINITY 53 J jaimiess 104 JAKAFI 18 jantoven 53 JANUMET 78 JANUMET XR 78 JANUVIA 78 JARDIANCE 78 jasmiel (28) 104 jencycla 100 JENTADUETO 78 JENTADUETO XR 78 JEVTANA 18 jinteli 100 JIVI 53 jolessa 104 JORNAY PM 40 JUBLIA 62 juleber 104 JULUCA 3 junel 1530 (21) 104 junel 120 (21) 104
junel fe 1530 (28) 104 junel fe 120 (28) 104 junel fe 24 104 JUXTAPID 56 JYNARQUE 75 K KADCYLA 18 kaitlib fe 104 KALBITOR 118 KALETRA 3 4 kalliga 104 KALYDECO 118 KANJINTI 18 KANUMA 75 kariva (28) 104 kelnor 135 (28) 105 kelnor 1-50 (28) 105 KEPIVANCE 13 ketoconazole 1 62 ketodan 62 ketoprofen 35 ketorolac 35 112 KEVZARA 97 KEYTRUDA 18 KINRIX (PF) 92 KISQALI 18 KISQALI FEMARA CO-
PACK 18 klor-con 123 klor-con 10 122 klor-con 8 122 klor-con m10 122 klor-con m15 122 klor-con m20 123 klor-conef 123 KOATE 53 KOGENATE FS 53 KORLYM 75 KOVALTRY 53 K-PHOS NO 2 122 K-PHOS ORIGINAL 122 KRYSTEXXA 95 k-tab 123 K-TAB 123 kurvelo (28) 105 KYLEENA 98 KYMRIAH 18 KYPROLIS 18 L l norgesteestradiol-eestrad
105
133
labetalol 47 LACRISERT 111 lactulose 83 lamivudine 4 lamivudine-zidovudine 4 lamotrigine 25 lansoprazole 86 lanthanum 83 LANTUS SOLOSTAR U-100
INSULIN 73 LANTUS U-100 INSULIN 73 lapatinib 18 larin 1530 (21) 105 larin 120 (21) 105 larin 24 fe 105 larin fe 1530 (28) 105 larin fe 120 (28) 105 larissia 105 LASTACAFT 111 latanoprost 112 LATUDA 40 layolis fe 105 leena 28 105 leflunomide 97 LEMTRADA 88 LENVIMA 18 lessina 105 letrozole 19 leucovorin calcium 13 LEUKERAN 19 LEUKINE 86 leuprolide 19 levalbuterol hcl 118 LEVALBUTEROL
TARTRATE 118 LEVEMIR FLEXTOUCH U-
100 INSULN 73 LEVEMIR U-100 INSULIN 73 levetiracetam 25 levobunolol 110 levocarnitine 67 levocarnitine (with sugar) 67 levocetirizine 115 levofloxacin 12 109 levonest (28) 105 levonorgestrel 105 levonorgestrel-ethinyl estrad
105 levonorg-eth estrad triphasic
105 levora-28 105
levorphanol tartrate 32 levothyroxine 79 levoxyl 79 LEVULAN 59 LEXIVA 4 LIBTAYO 19 lidocaine 61 lidocaine hcl 61 lidocaine hcl-hydrocortison ac
61 83 LIDOCAINE HCL-
HYDROCORTISON AC 83 lidocaine viscous 61 lidocaine-hydrocortisone-aloe
83 lidocaine-prilocaine 61 LIDOCAINE-TETRACAINE
61 LILETTA 98 lillow (28) 105 LINCOCIN 9 lindane 66 linezolid 9 linezolid in dextrose 5 9 linezolid-09 sodium chloride
9 LINZESS 83 liothyronine 79 LIPOFEN 56 lisinopril 47 lisinopril-hydrochlorothiazide
47 lithium carbonate 40 41 LO LOESTRIN FE 105 lojaimiess 105 LONSURF 19 loperamide 80 lopinavir-ritonavir 4 lorazepam 41 lorazepam intensol 41 loryna (28) 105 losartan 47 losartan-hydrochlorothiazide 47 LOTEMAX 113 loteprednol etabonate 113 lovastatin 56 low-ogestrel (28) 105 loxapine succinate 41 lo-zumandimine (28) 105 LUCENTIS 111 ludent fluoride 124
LULICONAZOLE 62 LUMIGAN 112 LUMIZYME 75 LUMOXITI 19 LUPANETA PACK (1
MONTH) 101 LUPANETA PACK (3
MONTH) 101 LUPKYNIS 19 LUPRON DEPOT 19 LUPRON DEPOT (3
MONTH) 19 LUPRON DEPOT (4
MONTH) 19 LUPRON DEPOT (6
MONTH) 19 LUPRON DEPOT-PED 19 LUPRON DEPOT-PED (3
MONTH) 19 lutera (28) 105 LUXTURNA 111 LUZU 62 lyleq 100 lyllana 100 LYNPARZA 19 LYRICA CR 25 LYSODREN 19 lyza 100 M mafenide acetate 62 malathion 66 maprotiline 41 marlissa (28) 106 MARPLAN 41 MARQIBO 19 MATULANE 19 matzim la 47 MAVENCLAD (10 TABLET
PACK) 88 MAVENCLAD (4 TABLET
PACK) 88 MAVENCLAD (5 TABLET
PACK) 88 MAVENCLAD (6 TABLET
PACK) 88 MAVENCLAD (7 TABLET
PACK) 88 MAVENCLAD (8 TABLET
PACK) 88 MAVENCLAD (9 TABLET
PACK) 88
134
MAVYRET 4 MAXIDEX 113 maxi-tuss ac 116 MAYZENT 88 MAYZENT STARTER PACK
88 m-clear wc 116 meclizine 83 meclofenamate 35 medroxyprogesterone 100 mefenamic acid 35 mefloquine 9 megestrol 19 MEKINIST 19 MEKTOVI 19 meloxicam 35 melphalan 19 melphalan hcl 19 memantine 29 MENACTRA (PF) 92 MENEST 100 MENOSTAR 100 MENQUADFI (PF) 92 MENTAX 62 MENVEO A-C-Y-W-135-DIP
(PF) 92 meperidine 32 meprobamate 30 MEPSEVII 76 mercaptopurine 20 meropenem 9 MEROPENEM-09
SODIUM CHLORIDE 9 merzee 106 mesalamine 83 mesalamine with cleansing
wipe 83 metaproterenol 118 metaxalone 30 metformin 78 methadone 32 methadose 32 methamphetamine 41 methazolamide 112 methenamine hippurate 13 methenamine mandelate 13 methen-sod phos-meth blue-
hyos 122 methergine 109 methimazole 71 methocarbamol 30
methotrexate sodium 20 methotrexate sodium (pf) 20 methoxsalen 59 methscopolamine 80 methyldopa 47 methyldopa-
hydrochlorothiazide 47 methyldopate 48 methylergonovine 109 METHYLIN 41 methylphenidate hcl 41 methylprednisolone 70 methylprednisolone acetate 70 methyltestosterone 76 metoclopramide hcl 83 metolazone 48 metoprolol succinate 48 metoprolol ta-hydrochlorothiaz
48 metoprolol tartrate 48 metronidazole 9 60 61 101 metyrosine 48 mexiletine 44 MIACALCIN 76 mibelas 24 fe 106 microgestin 1530 (21) 106 microgestin 120 (21) 106 microgestin fe 1530 (28) 106 microgestin fe 120 (28) 106 midazolam 41 midodrine 67 migergot 28 miglitol 78 miglustat 76 mili 106 millipred 70 millipred dp 70 mimvey 100 MINITRAN 57 minocycline 12 minoxidil 48 MIRCERA 86 MIRENA 98 mirtazapine 41 misoprostol 86 MITIGARE 95 mitoxantrone 20 M-M-R II (PF) 92 modafinil 41 moexipril 48 molindone 41
mometasone 65 mondoxyne nl 12 mono-linyah 106 MONONINE 53 MONOVISC 35 montelukast 118 119 morphine 32 33 morphine (pf) 32 morphine concentrate 32 MOTOFEN 80 MOVANTIK 83 MOXATAG 11 moxifloxacin 12 109 MOZOBIL 87 MULPLETA 53 MULTAQ 44 multi-vitamin with fluoride 124 multivitamins with fluoride 124 mupirocin 62 mupirocin calcium 62 mvc-fluoride 124 my choice 106 my way 106 MYALEPT 76 MYCAMINE 1 mycophenolate mofetil 20 mycophenolate sodium 20 MYDAYIS 41 MYLOTARG 20 MYOBLOC 92 myorisan 61 MYRBETRIQ 121 N nabumetone 35 nadolol 48 nadolol-bendroflumethiazide 48 nafcillin 11 nafcillin in dextrose iso-osm 11 naftifine 62 63 NAGLAZYME 76 nalbuphine 35 naloxone 35 naltrexone 35 naproxen 35 naproxen sodium 35 naratriptan 28 NARCAN 35 NATACYN 109 NATAZIA 106 nateglinide 78 NATPARA 76
135
nebusal 119 necon 0535 (28) 106 nefazodone 41 neomycin 9 neomycin-bacitracin-poly-hc
112 neomycin-bacitracin-
polymyxin 109 neomycin-polymyxin b-
dexameth 112 113 neomycin-polymyxin-
gramicidin 109 neomycin-polymyxin-hc 69
113 neo-polycin 109 neo-polycin hc 113 NERLYNX 20 NEUPOGEN 87 NEVANAC 112 nevirapine 4 new day 106 NEXAVAR 20 NEXPLANON 101 NEXTSTELLIS 106 niacin 56 NIACOR 56 nicardipine 48 nicorette 68 nicotine 68 nicotine (polacrilex) 68 NICOTROL 68 NICOTROL NS 68 nifedipine 48 nikki (28) 106 nilutamide 20 nimodipine 48 NINLARO 20 nisoldipine 48 nitazoxanide 9 nitisinone 67 nitro-bid 57 NITRO-DUR 57 nitrofurantoin 13 nitrofurantoin macrocrystal 13 nitrofurantoin monohydm-
cryst 13 nitroglycerin 57 nitroglycerin in 5 dextrose 57 nitro-time 57 NITYR 67 NIVESTYM 87
nizatidine 86 nora-be 100 noreth-ethinyl estradiol-iron
106 norethindrone (contraceptive)
100 norethindrone acetate 100 norethindrone ac-eth estradiol
100 106 norethindrone-eestradiol-iron
106 norgestimate-ethinyl estradiol
106 norlyda 100 NORMOSOL-R 123 NORPACE CR 44 nortrel 0535 (28) 106 nortrel 135 (21) 106 nortrel 135 (28) 106 nortrel 777 (28) 107 nortriptyline 42 NORVIR 4 NOVAFERRUM 124 NOVOEIGHT 53 NOVOLIN 70-30 FLEXPEN
U-100 73 NOVOLIN N FLEXPEN 73 NOVOLIN R FLEXPEN 73 NOVOLOG FLEXPEN U-100
INSULIN 74 NOVOLOG MIX 70-30 U-100
INSULN 74 NOVOLOG MIX 70-
30FLEXPEN U-100 74 NOVOLOG PENFILL U-100
INSULIN 74 NOVOLOG U-100 INSULIN
ASPART 74 NOVOPEN ECHO 71 NOVOSEVEN RT 53 NOXAFIL 1 np thyroid 79 NPLATE 53 NUCALA 119 NUCYNTA ER 36 NUEDEXTA 29 NULOJIX 20 NULYTELY LEMON-LIME
83 NUPLAZID 42 NUWIQ 53
nyamyc 63 nylia 777 (28) 107 nymyo 107 nystatin 1 63 nystatin-triamcinolone 63 nystop 63 O OBIZUR 54 ocella 107 OCREVUS 88 OCTAGAM 92 octreotide acetate 20 ODEFSEY 4 OFEV 119 ofloxacin 12 69 109 OGIVRI 20 olanzapine 42 olanzapine-fluoxetine 42 olmesartan 48 olmesartan-amlodipin-
hcthiazid 48 olmesartan-
hydrochlorothiazide 48 olopatadine 69 111 OLUMIANT 97 omega-3 acid ethyl esters 56 omeprazole 86 OMIDRIA 111 OMNITROPE 87 ONCASPAR 20 ondansetron 84 ondansetron hcl 83 84 ONETOUCH ULTRA TEST
71 ONETOUCH VERIO TEST
STRIPS 71 ONIVYDE 20 ONPATTRO 29 ONZETRA XSAIL 28 opcicon one-step 107 OPDIVO 20 opium tincture 81 OPSUMIT 119 option-2 107 ORALAIR 92 oralone 69 ORAVIG 1 ORENCIA 97 ORENCIA (WITH
MALTOSE) 97 ORENCIA CLICKJECT 97
136
ORENITRAM 48 ORLADEYO 119 orphenadrine citrate 30 orsythia 107 ORTHOVISC 36 oscimin 81 oscimin sl 81 oscimin sr 81 oseltamivir 4 OSMOPREP 84 OSPHENA 101 OTEZLA 97 OTEZLA STARTER 97 OTOVEL 69 oxacillin 11 oxacillin in dextrose(iso-osm)
11 oxandrolone 76 oxaprozin 36 oxazepam 42 oxcarbazepine 25 oxiconazole 63 OXISTAT 63 OXLUMO 122 oxybutynin chloride 121 oxycodone 33 oxycodone-acetaminophen 33 oxycodone-aspirin 33 OXYCONTIN 33 oxymorphone 33 OZEMPIC 78 OZURDEX 113 P pacerone 44 PADCEV 20 paliperidone 42 PALYNZIQ 76 pamidronate 76 PANRETIN 59 pantoprazole 86 PANZYGA 92 PARAGARD T 380A 98 paricalcitol 76 PARICALCITOL 76 paroex oral rinse 69 paromomycin 10 paroxetine hcl 42 paroxetine
mesylate(menopsym) 42 PARSABIV 76 PASER 10
PEDIARIX (PF) 92 PEDVAX HIB (PF) 93 peg 3350-electrolytes 84 peg3350-sod sul-nacl-kcl-asb-c
84 PEGASYS 88 89 peg-electrolyte soln 84 peg-prep 84 PEMAZYRE 20 PEN NEEDLE DIABETIC 72 penicillamine 97 penicillin g procaine 11 penicillin v potassium 11 PENTACEL (PF) 93 PENTACEL ACTHIB
COMPONENT (PF) 93 PENTAM 10 pentamidine 10 pentazocine-naloxone 36 pentoxifylline 54 PERFOROMIST 119 perindopril erbumine 48 periogard 69 PERJETA 20 permethrin 66 perphenazine 42 perphenazine-amitriptyline 42 phenazopyridine 122 phenelzine 42 phenobarb-hyoscy-atropine-
scop 81 phenobarbital 25 26 phenohytro 81 phenoxybenzamine 48 phenylephrine hcl 114 phenytoin 26 phenytoin sodium extended 26 PHEXXI 101 philith 107 phosphasal 122 PHYSIOLYTE 66 PHYSIOSOL IRRIGATION 66 phytonadione (vitamin k1) 54 PICATO 59 pilocarpine hcl 67 69 110 pimecrolimus 59 pimozide 42 pimtrea (28) 107 pindolol 48 pioglitazone 78 pioglitazone-glimepiride 78
pioglitazone-metformin 78 piperacillin-tazobactam 11 PIQRAY 21 pirmella 107 piroxicam 36 PLASMA-LYTE 148 123 PLASMA-LYTE A 123 PLEGRIDY 89 PLENVU 84 PNEUMOVAX-23 93 podofilox 59 POLIVY 21 polycin 110 polymyxin b sulfate 10 polymyxin b sulf-trimethoprim
110 POMALYST 89 PONVORY 89 PONVORY 14-DAY
STARTER PACK 89 portia 28 107 PORTRAZZA 21 posaconazole 1 potassium chloride 123 potassium citrate 122 POTELIGEO 21 pramipexole 27 prasugrel 54 pravastatin 56 praziquantel 10 prazosin 48 PRED MILD 113 prednicarbate 65 prednisolone 70 prednisolone acetate 113 prednisolone sodium phosphate
70 114 prednisone 70 prednisone intensol 70 pregabalin 26 PREMARIN 100 PREMPHASE 100 PREMPRO 100 prevalite 56 previfem 107 PREVNAR 13 (PF) 93 PREVYMIS 4 PREZCOBIX 4 PREZISTA 4 PRIFTIN 10 primaquine 10
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primidone 26 PRIMSOL 13 PRIVIGEN 93 probenecid 95 probenecid-colchicine 95 procainamide 44 procentra 42 prochlorperazine 84 prochlorperazine edisylate 84 prochlorperazine maleate 84 PROCRIT 87 procto-med hc 84 procto-pak 84 proctosol hc 84 proctozone-hc 84 PROFILNINE 54 progesterone 100 progesterone micronized 100 PROGRAF 21 PROLASTIN-C 67 PROLEUKIN 90 PROLIA 95 PROMACTA 54 promethazine 115 promethazine-codeine 116 promethazine-dm 116 promethazine-phenyleph-
codeine 116 promethazine-phenylephrine
116 promethegan 115 propafenone 44 45 proparacaine 111 propranolol 48 49 propranolol-hydrochlorothiazid
49 propylthiouracil 71 PROQUAD (PF) 93 protriptyline 42 PROVENGE 93 prudoxin 59 pulmosal 119 PULMOZYME 119 pyrazinamide 10 pyridostigmine bromide 30 pyrimethamine 10 Q QBRELIS 49 QINLOCK 21 QTERN 78 QUADRACEL (PF) 93
quetiapine 42 QUILLICHEW ER 42 QUILLIVANT XR 42 quinapril 49 quinapril-hydrochlorothiazide
49 quinidine gluconate 45 quinidine sulfate 45 quinine sulfate 10 quit 2 68 quit 4 68 QVAR REDIHALER 119 R RABAVERT (PF) 93 rabeprazole 86 RADICAVA 29 RAGWITEK 93 raloxifene 95 ramelteon 42 ramipril 49 ranolazine 57 RAPIVAB (PF) 4 rasagiline 27 RAVICTI 67 REBIF (WITH ALBUMIN) 89 REBIF REBIDOSE 89 REBIF TITRATION PACK 89 REBINYN 54 RECLAST 67 reclipsen (28) 107 RECOMBINATE 54 RECOMBIVAX HB (PF) 93 RECTIV 84 REGRANEX 59 RELENZA DISKHALER 4 RELEXXII 42 RELION NOVOLIN 7030 74 RELION NOVOLIN N 74 RELION NOVOLIN R 74 RELISTOR 84 REMICADE 84 RENACIDIN 122 RENFLEXIS 84 repaglinide 78 repaglinide-metformin 78 REPATHA PUSHTRONEX 56 REPATHA SURECLICK 56 REPATHA SYRINGE 56 RESTASIS 111 RETEVMO 21 RETISERT 114
REVATIO 119 REVLIMID 89 REXULTI 43 REYATAZ 4 RHOPRESSA 112 RIASTAP 54 ribavirin 4 89 RIDAURA 97 rifabutin 10 rifampin 10 riluzole 67 rimantadine 4 RINVOQ 97 RIOMET ER 78 risedronate 67 95 RISPERDAL CONSTA 43 risperidone 43 ritonavir 4 RITUXAN 21 RITUXAN HYCELA 21 rivastigmine 30 rivastigmine tartrate 29 rivelsa 107 RIXUBIS 54 rizatriptan 28 ropinirole 27 28 rosadan 61 rosuvastatin 56 roweepra 26 RUBRACA 21 RUCONEST 119 rufinamide 26 RYBELSUS 79 RYDAPT 21 S salsalate 36 SAMSCA 76 SANTYL 65 sapropterin 76 SARCLISA 21 SAVELLA 97 scalacort 65 SCENESSE 59 scopolamine base 84 seconal sodium 43 SEEBRI NEOHALER 119 selegiline hcl 28 selenium sulfide 58 SELZENTRY 5 SEREVENT DISKUS 119 SEROSTIM 87
138
sertraline 43 setlakin 107 sevelamer carbonate 84 sevelamer hcl 84 sf 69 sf 5000 plus 69 sharobel 101 SHINGRIX (PF) 93 SIGNIFOR 21 sildenafil (pulmhypertension)
119 SILIQ 58 silodosin 121 silver sulfadiazine 59 SIMBRINZA 112 simliya (28) 107 simpesse 107 SIMPONI 97 SIMPONI ARIA 97 SIMULECT 21 simvastatin 56 SINUVA 119 sirolimus 21 SIRTURO 10 SIVEXTRO 10 SKYLA 98 SKYRIZI 58 SLYND 107 sodium chloride 119 sodium chloride 045 123 sodium chloride 09 67 sodium fluoride 5000 dry
mouth 69 sodium fluoride 5000 plus 69 sodium fluoride-pot nitrate 69 sodium phenylbutyrate 67 sodium polystyrene sulfonate
85 solifenacin 121 SOLIQUA 10033 74 SOLIRIS 67 SOLTAMOX 21 SOMATULINE DEPOT 21 SOMAVERT 76 sorine 45 sotalol 45 sotalol af 45 SOVALDI 5 spinosad 66 SPIRIVA RESPIMAT 119
SPIRIVA WITH HANDIHALER 119
spironolactone 49 spironolacton-hydrochlorothiaz
49 SPRAVATO 43 sprintec (28) 107 SPRYCEL 21 sps (with sorbitol) 85 sronyx 107 ssd 59 SSKI 71 st joseph aspirin 36 st joseph aspirin 36 STAMARIL (PF) 93 stavudine 5 STELARA 58 STIOLTO RESPIMAT 119 STIVARGA 21 stop smoking aid 68 STRENSIQ 76 STREPTOMYCIN 10 STRIBILD 5 STRIVERDI RESPIMAT 120 SUBLOCADE 33 subvenite 26 subvenite starter (blue) kit 26 subvenite starter (green) kit 26 subvenite starter (orange) kit 26 SUCRAID 85 sucralfate 86 sulfacetamide sodium 58 114 sulfacetamide sodium (acne) 62 sulfacetamide-prednisolone 114 sulfadiazine 12 sulfamethoxazole-trimethoprim
12 SULFAMYLON 62 sulfasalazine 85 sulfatrim 12 sulindac 36 sumatriptan 28 sumatriptan succinate 28 29 SUNOSI 43 SUPPRELIN LA 21 SUPRAX 7 SUPREP BOWEL PREP KIT
85 SUTENT 22 syeda 107 SYLVANT 22
symax fastabs 81 symax-sl 81 symax-sr 81 SYMBICORT 120 SYMDEKO 120 SYMLINPEN 120 79 SYMLINPEN 60 79 SYMPAZAN 26 SYNAGIS 5 SYNAREL 76 SYNERA 61 SYNJARDY 79 SYNJARDY XR 79 SYNRIBO 22 SYNTHROID 79 T TABLOID 22 tacrolimus 22 59 tadalafil 121 tadalafil (pulm hypertension)
120 TAFINLAR 22 TAGRISSO 22 TAKHZYRO 120 TALTZ AUTOINJECTOR 58 TALTZ AUTOINJECTOR (2
PACK) 58 TALTZ AUTOINJECTOR (3
PACK) 58 TALTZ SYRINGE 58 TALZENNA 22 tamoxifen 22 tamsulosin 121 TARGRETIN 22 tarina 24 fe 107 tarina fe 120 (28) 107 TASIGNA 22 tavaborole 63 tazarotene 61 tazicef 7 taztia xt 49 TDVAX 93 TECENTRIQ 22 TEFLARO 7 TEKTURNA HCT 49 telmisartan 49 telmisartan-amlodipine 49 telmisartan-hydrochlorothiazid
49 temazepam 43 TEMODAR 22
139
temozolomide 22 temsirolimus 22 tencon 33 TENIVAC (PF) 94 tenofovir disoproxil fumarate 5 TEPEZZA 76 terazosin 49 terbinafine hcl 1 terbutaline 120 terconazole 101 testosterone 77 testosterone cypionate 76 testosterone enanthate 76 TETANUSDIPHTHERIA
TOX PED(PF) 94 tetrabenazine 30 tetracaine hcl 111 TETRACAINE HCL (PF) 111 tetracycline 12 THALOMID 22 theophylline 120 thioridazine 43 thiothixene 43 THYMOGLOBULIN 94 THYROLAR-1 79 THYROLAR-12 79 THYROLAR-14 79 THYROLAR-2 79 THYROLAR-3 79 tiadylt er 49 tiagabine 26 TIBSOVO 22 tilia fe 107 timolol maleate 49 110 tinidazole 10 TIVICAY 5 TIVICAY PD 5 tizanidine 30 TOBRADEX 113 TOBRADEX ST 113 tobramycin 10 110 tobramycin in 0225 nacl 10 tobramycin sulfate 10 TOBRAMYCIN WITH
NEBULIZER 10 tobramycin-dexamethasone 113 TOBREX 110 TODAY CONTRACEPTIVE
SPONGE 101 tolcapone 28 tolmetin 36
tolterodine 121 topiramate 26 toremifene 22 TORISEL 22 torsemide 49 TOUJEO MAX U-300
SOLOSTAR 74 TOUJEO SOLOSTAR U-300
INSULIN 74 TRACLEER 120 TRADJENTA 79 tramadol 36 tramadol-acetaminophen 36 trandolapril 49 trandolapril-verapamil 49 tranexamic acid 54 101 tranylcypromine 43 travoprost 112 trazodone 43 TREANDA 22 TRECATOR 10 TRELEGY ELLIPTA 120 TRELSTAR 22 TREMFYA 59 TRESIBA FLEXTOUCH U-
100 74 TRESIBA FLEXTOUCH U-
200 74 TRESIBA U-100 INSULIN 74 tretinoin 61 tretinoin (antineoplastic) 22 tretinoin microspheres 61 TRETTEN 54 TREXALL 22 tri femynor 107 triamcinolone acetonide 65 69
71 triamterene 49 triamterene-hydrochlorothiazid
49 triazolam 43 triderm 65 trientine 67 tri-estarylla 107 trifluoperazine 43 trifluridine 110 trihexyphenidyl 28 TRIJARDY XR 71 TRIKAFTA 120 tri-legest fe 108 tri-linyah 108
tri-lo-estarylla 108 tri-lo-marzia 108 tri-lo-mili 108 tri-lo-sprintec 108 trilyte with flavor packets 85 trimethobenzamide 85 trimethoprim 13 tri-mili 108 trimipramine 43 TRINTELLIX 43 tri-nymyo 108 tri-previfem (28) 108 tri-sprintec (28) 108 TRIUMEQ 5 tri-vitamin with fluoride 124 trivora (28) 108 tri-vylibra 108 tri-vylibra lo 108 TROGARZO 5 tropicamide 110 trospium 121 TRULICITY 79 TRUMENBA 94 TRUXIMA 22 TUKYSA 23 tulana 101 TWINRIX (PF) 94 TWIRLA 101 TYBLUME 108 TYBOST 5 tydemy 108 TYGACIL 10 TYMLOS 95 TYPHIM VI 94 TYSABRI 30 TYVASO 120 TYVASO REFILL KIT 120 TYVASO STARTER KIT 120 U UBRELVY 29 UDENYCA 87 ULESFIA 66 unithroid 80 UNITUXIN 23 URELLE 122 uretron d-s 122 urimar-t 122 urogesic-blue 122 ursodiol 85 uryl 122 ustell 122
140
UTIBRON NEOHALER 120 utira-c 122 UVADEX 59 V vaginal contraceptive foam 101 valacyclovir 5 VALCHLOR 59 valganciclovir 5 valproic acid 26 valproic acid (as sodium salt)
26 valsartan 49 valsartan-hydrochlorothiazide
49 vanadom 30 vancomycin 13 vandazole 101 VANTAS 23 VAQTA (PF) 94 VARIVAX (PF) 94 VARUBI 85 VASCEPA 56 VAXELIS (PF) 94 VCF CONTRACEPTIVE
FILM 101 VCF CONTRACEPTIVE GEL
101 VECTIBIX 23 VELCADE 23 veletri 50 velivet triphasic regimen (28)
108 VELPHORO 85 VEMLIDY 5 VENCLEXTA 23 VENCLEXTA STARTING
PACK 23 venlafaxine 43 VENTAVIS 120 verapamil 50 VERSACLOZ 43 VERZENIO 23 vestura (28) 108 VIBATIV 13 VIBERZI 85 VIDAZA 23 VIEKIRA PAK 5 vienva 108 vigabatrin 26 vigadrone 26 VIMIZIM 77
VIMPAT 26 viorele (28) 108 VIRACEPT 5 VIREAD 5 virtussin ac 116 VISTOGARD 13 VISUDYNE 111 vitamins acd and fluoride 124 VITRAKVI 23 VIVITROL 36 volnea (28) 108 VONVENDI 54 VORAXAZE 13 voriconazole 1 2 VOSEVI 5 VOTRIENT 23 VPRIV 77 VRAYLAR 44 VYEPTI 29 vyfemla (28) 108 vylibra 108 VYONDYS-53 30 VYVANSE 44 VYXEOS 23 W warfarin 54 wera (28) 108 westhroid 80 WIDE-SEAL DIAPHRAGM
98 WILATE 54 wixela inhub 121 wymzya fe 108 X XALKORI 23 XARELTO 54 XARELTO DVT-PE TREAT
30D START 54 XCOPRI 27 XCOPRI MAINTENANCE
PACK 27 XCOPRI TITRATION PACK
27 XELJANZ 97 XELJANZ XR 97 XEMBIFY 94 XENLETA 10 XEOMIN 94 XERMELO 23 XGEVA 13 XIFAXAN 10
XIGDUO XR 79 XIIDRA 111 XOLAIR 121 XOSPATA 23 XTANDI 23 xulane 102 XULTOPHY 10036 74 XURIDEN 67 XYNTHA 55 XYNTHA SOLOFUSE 55 XYREM 44 Y YERVOY 23 YESCARTA 23 YF-VAX (PF) 94 YONDELIS 23 YONSA 23 YUTIQ 114 yuvafem 101 Z zafemy 102 zafirlukast 121 zaleplon 44 ZALTRAP 23 ZANOSAR 23 zarah 109 ZARXIO 87 ZEJULA 24 ZELBORAF 24 ZEMAIRA 68 zenatane 61 ZENPEP 85 ZENZEDI 44 ZEPATIER 5 ZEPOSIA 89 ZEPOSIA STARTER KIT 89 ZEPOSIA STARTER PACK
89 ZERBAXA 7 zidovudine 5 ZIEXTENZO 87 zileuton 121 ziprasidone hcl 44 ZIRGAN 110 ZOKINVY 68 ZOLADEX 24 ZOLGENSMA 30 ZOLINZA 24 zolmitriptan 29 zolpidem 44 ZOLPIMIST 44
141
ZOMIG 29 zonisamide 27 ZONTIVITY 55 ZORBTIVE 87
ZOSTAVAX (PF) 94 zovia 135e (28) 109 ZULRESSO 44 zumandimine (28) 109
ZYFLO 121 ZYKADIA 24 ZYPITAMAG 56
051267 (11-20-2019)
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