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Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association Medi_20_167
Blue Shield of California
Promise Health Plan
Medi-Cal Drug Formulary
(Preferred Drug List)
December 2020
This formulary is for the following plans Blue Shield of California Promise Health Plan Medi-Cal
Los Angeles and Blue Shield of California Promise Health Plan Medi-Cal San Diego
We last updated it on 1212020 This formulary may change and all earlier versions of the formulary no longer apply For the most current information about the Medi-Cal Drug
Formulary visit wwwblueshieldcacompromisemedi-cal
You can find information about drug benefits in the Member HandbookEvidence of
Coverage For plan and coverage documents visit wwwblueshieldcacompromisemedi-
cal For additional information about your plan please call Customer Care at (800) 605-2556
(Los Angeles County) or (855) 699-5557 (San Diego County)
Blue Shield of California Promise Health Plan is contracted with LA Care Health Plan to
provide Medi-Cal managed care services in Los Angeles County
You can get this document for free in other formats such as large print braille andor audio
Call (800) 605-2556 (Los Angeles County) or (855) 699-5557 (San Diego County) (TTY 711) 800
am ndash 6 00 pm Monday through Friday The call is free
ii
Medi-Cal Formulary
The Blue Shield of California Promise Health Plan Medi-Cal Formulary is a list of covered drugs
(Formulary) This list includes drugs used to treat common health problems A team of doctors
and pharmacists meets four times a year to decide which drugs should be on the drug list
They review new and old drugs and choose the ones that are safe and work best
Definitions The following words and definitions will be used throughout the formulary drug list
Word
ldquoBrand name drugrdquo is a drug that is sold under a trademark name We will list the
brand name drug will in all CAPITAL letters
ldquoDrug Tierrdquo shows a group of drugs and how we cover them (see below)
ldquoEnrolleerdquo or ldquomemberrdquo is a person enrolled in a health plan and receives services
from the plan
ldquoException requestrdquo is when the member requests for the plan to cover a drug The
health plan must cover the drug if medically required to treat the members condition
ldquoExigent circumstancesrdquo are when a member suffers from a health condition that may
seriously risk their life health or daily life This is also when a member currently uses a
drug that is not covered
ldquoFormularyrdquo or ldquopreferred drug listrdquo is the list of drugs covered under the drug benefit
ldquoGeneric drugrdquo is the same drug as its brand name version in strength how it is taken
quality and safety A generic drug is listed in bold and italicized lowercase letters
ldquoNon-formulary drugrdquo is a drug not listed on the plans drug list
ldquoPrescribing providerrdquo may prescribe a drug to treat a medical condition for a
member
ldquoPrescriptionrdquo is an oral written or electronic order by a prescribing provider that
contains the name of the drug amount date providerrsquos name and contact
signature of the provider (if in writing) and the medical condition or purpose for
which the drug is being prescribed (if requested by the member)
ldquoPrescription drugrdquo is a drug that requires a prescription and prescribed by the
memberrsquos provider
ldquoPrior authorizationrdquo is a plans requirement that the member or provider get the
health plans approval for a drug before the plan will cover it The plan will approve
the drug when it is medically required
ldquoStep therapyrdquo is when the plan requires the member to try one or more drugs to treat
the medical condition before it will cover a certain drug If the memberrsquos provider
submits a request for approval the plan will approve the drug is medically required
iii
How do I use the Blue Shield of California Promise Health Plan Medi-Cal
Formulary
To look for a drug check the index at the end It lists all of the drugs on the Formulary Next to
your drug you will see the page number where you can find it The drugs are listed in
alphabetical order under the column ldquoPrescription Drug Namerdquo under its category and class
To look for a drug class check the Table of Contents
Even if the drug is on the list this does not guarantee that your doctor will prescribe it
The Formulary covers generics and certain brands when available If there is an approved
generic drug then we will cover the generic only
bull A generic name for a brand name drug is listed after the brand name of the drug in all
lowercase italics
o If both a generic and brand are covered we will list the generic separately from
the brand name in all lowercase italics
o When a drug is sold as a brand name we will list the brand name after the
generic name in parentheses in all CAPITALS
bull We will list a brand name drug in all CAPITALS followed by the name in parentheses in
lowercase italics
Example
Drug Type How the drug name will appear
in the formulary drug list
generic drug atorvastatin calcium
generic drug marketed with a
brand name
oxycodoneacetaminophen
(ENDOCET)
brand drug LIPITOR (atorvastatin calcium)
Some drugs are injections that are not listed but they may be covered for up to a 10-day
supply after you leave the hospital These include drugs for parenteral nutrition (TPN) lipids
and other unlisted drugs and antibiotics
iv
What are drug tiers
Drugs are placed into drug tiers
Drug Tier What Does it mean
Covered (Tier 1) These drugs are covered on the Drug
List (Formulary) at $0 co-payment
Medi-Cal Carve Out (Tier 2) These drugs are carved out by the
Department of Health Care Services
This means these drugs are covered by
the Medi-Cal Fee-for Service program
and can be billed to the State
Medical Benefit (Tier 3) These drugs may be available at the
doctorrsquos office or medical setting
How to read the formulary
The column titled ldquoCoverage Requirements and Limitationsrdquo shows how the drug is covered
and if there are limits
Coverage Requirements
and Limitations
What does it stand for What does it mean
AL1 Age Restrictions We cover some drugs only
for some ages
PA Prior Authorization
Required
Your doctor must ask for
approval from us before
we cover some drugs
QL Quantity Limit We only cover some drugs
for a certain amount
ST Step Therapy Required In some cases you must
first try certain drugs
before we cover another
drug for your condition
STAR Extended Day Supply You may fill this drug for a
90 day supply
MDD Max Daily Dose We limit the amount of this
drug covered per day
C Custom This drug has special limits
QLC Quantity Limit (Custom) We limit the amount of this
drug covered each fill or
within a time frame
SP Specialty Pharmacy A network specialty
pharmacy will fill this drug
v
How often will the formulary change
The formulary may change monthly Some changes that can happen without notice include
bull When we remove a brand name drug if a generic is available
bull When we remove a drug taken off the market because the Food and Drug
Administration (FDA) has found it unsafe or if the manufacturer has removed it
bull When we add a drug to the formulary or if we remove a limit (like prior authorization or
step therapy)
Changes to formulary that we will notify you of at least 30 days before include
bull When we remove a drug or dosage form
bull When we add or change limits on the drug
What is a medical benefit drug
A medical benefit drug is a drug that usually is given as an injection or infusion in a medical
setting
What if my drug requires a prior authorization or step therapy
A prior authorization means that your doctor asks for approval for the drug because it is
medically necessary A step therapy means that you need to try certain drugs before we
cover your drug
You may ask for an exception by calling Customer Care at (800) 605-2556 (Los Angeles
County) or (855) 699-5557 (San Diego County) Or your doctor can call us at (877) 792-2731 or
fax at (866) 712-2731 to request that drug be covered
What if my drug is not on the Blue Shield of California Promise Health Plan Medi-
Cal Formulary
If your doctor gives you a drug that is not on the drug list you can ask your doctor for another
drug that is on formulary or you may request for us to cover the drug (exception) by calling
Customer Care at (800) 605-2556 (Los Angeles County) or (855) 699-5557 (San Diego County)
Your doctor can call us at (877) 792-2731 or fax at (866) 712-2731 to request that drug be
covered
You might now take a drug and your doctor still prescribes it If the drug is safe and effective
for your condition we will continue to cover it if we covered it before
vi
Participating retail pharmacies
You can fill prescriptions at any participating pharmacy (network pharmacy) unless it is for a
specialty drug You may find a network pharmacy by visiting
httpspromiseblueshieldcacomcapharmacysearchversion=2020amplob=mcal
What are specialty drugs
Specialty drugs require extra training before you take them extra visits with your doctor need
special handling and transport and are usually high-cost These drugs may require prior
authorization or non-formulary exception If approved a network specialty pharmacy will
deliver them by mail Please visit wwwblueshieldcacompromisemedi-cal for more
information
What if I have additional questions
If you want a copy of the Blue Shield of California Promise Health Plan Medi-Cal Formulary or
have questions please call Customer Care at (800) 605-2556 (Los Angeles County) or (855)
699-5557 (San Diego County)
Blue Shield of California Promise Health Plan
601 Potrero Grande Drive Monterey Park CA 91755
vii
H5928_19_269A2_C 08302019
Blu
e S
hie
ld o
f C
alif
orn
ia P
rom
ise
He
alth
Pla
n is
an
ind
ep
en
de
nt
lice
nse
e o
f th
e B
lue
Sh
ield
Ass
oc
iatio
n
A512
47-C
MS (
91
8)
Discrimination is Against the Law
Blue Shield of California Promise Health Plan complies with applicable state laws and federal civil rights laws and does not discriminate on the basis of race color national origin ancestry religion sex marital status gender gender identity sexual orientation age or disability Blue Shield of California Promise Health Plan does not exclude people or treat them differently because of race color national origin ancestry religion sex marital status gender gender identity sexual orientation age or disability
Blue Shield of California Promise Health Plan provides bull Aids and services at no cost to people with disabilities to communicate effectively with us
such aso Qualified sign language interpreterso Written information in other formats (large print audio accessible electronic
formats other formats)bull Language services at no cost to people whose primary language is not English such as
o Qualified interpreterso Information written in other languages
If you need these services contact the Blue Shield of California Promise Health Plan Civil Rights Coordinator
If you believe that Blue Shield of California Promise Health Plan has failed to provide these
services or discriminated in another way on the basis of race color national origin
ancestry religion sex marital status gender gender identity sexual orientation age or
disability you can file a grievance with
Blue Shield of California Promise Health Plan
Civil Rights Coordinator
601 Potrero Grande Dr
Monterey Park CA 91755
Phone (844) 883-2233 (TTY 711)
Fax (323) 889-2228
Email BSCPHPCivilRightsblueshieldcacom
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 Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD)
Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language Assistance Notice for LA County
viii
English
ATTENTION Language assistance services free of charge are available to you Call 1-800-605-
2556 (TTY 711)
繁體中文 (Chinese)
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1-800-605-2556(TTY
711)
한국어 (Korean)
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-800-
605-2556 (TTY 711)번으로 전화해 주십시오
Русский (Russian)
ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги
перевода Звоните 1-800-605-2556 (телетайп 711)
Kreyogravel Ayisyen (Haitian-Creole)
ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele 1-
800-605-2556 (TTY 711)
Franccedilais (French)
ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes
gratuitement Appelez le 1-800-605-2556 (TTY 711)
Portuguecircs (Portuguese)
ATENCcedilAtildeO Se fala portuguecircs encontram-se disponiacuteveis serviccedilos linguiacutesticos graacutetis Ligue para 1-
800-605-2556 (TTY 711)
Italiano (Italian)
ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza
linguistica gratuiti Chiamare il numero 1-800-605-2556 (TTY 711)
(Farsi) فارسی
2556-605-800-1 با باشد می فراهم شما برای رایگان بصورت زبانی تسهیلات کنید می گفتگو فارسی زبان به اگر توجه
(TTY 771) بگیرید تماس
ह िदी (Hindi)
धयान द यदद आप द िदी बोलत तो आपक ललए मफत म भाषा स ायता सवाएि उपलबध 1-800-605-
2556 (TTY 711) पर कॉल करHmong (Hmong)
LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb rau koj Hu rau
1-800-605-2556 (TTY 711)
Espantildeol (Spanish)
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica
Llame al 1-800-605-2556 (TTY 711)
Language Assistance Notice for LA County (Continued)
ix
Tiếng Việt (Vietnamese)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-
800-605-2556 (TTY 711)
Tagalog (Tagalog - Filipino)
PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa
wika nang walang bayad Tumawag sa 1-800-605-2556 (TTY 711)
(Arabic) العربية
2556-605-800-1مجان اتصل برقم ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بال
(711YTT)
Polski (Polish)
UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń
pod numer 1-800-605-2556 (TTY 711)
ພາສາລາວ (Lao)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ ໂທຣ 1-800-605-2556 (TTY 711)
日本語 (Japanese)
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1-800-605-
2556(TTY711)までお電話にてご連絡ください
ภาษาไทย (Thai)
เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-800-605-2556 (TTY 711)
λληνικά (Greek)
ΠΡΟΣΟΧΗ Αν μιλάτε ελληνικά στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης
οι οποίες παρέχονται δωρεάν Καλέστε 1-800-605-2556 (TTY 711)
ਪਜਾਬੀ ਦ (Punjabi)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-800-605-
2556 (TTY 711) ਤ ਕਾਲ ਕਰ
ខមែរ (Cambodian)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល
គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-800-605-2556 (TTY 711)
Հայերեն (Armenian)
ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող են
տրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք 1-800-605-2556
(TTY (հեռատիպ)711)
Language Assistance Notice for San Diego County
x
English
ATTENTION Language assistance services free of charge are available to you
Call 1-855-699-5557 (TTY 711)
繁體中文 (Chinese)
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1-855-699-5557(TTY
711)
한국어 (Korean)
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-855-
699-5557 (TTY 711)번으로 전화해 주십시오
Русский (Russian)
ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные
услуги перевода Звоните 1-855-699-5557 (телетайп 711)
Italiano (Italian)
ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di
assistenza linguistica gratuiti Chiamare il numero 1-855-699-5557 (TTY 711)
(Farsi) فارسی
-699-855-1 با باشد می فراهم شما برای رایگان بصورت زبانی تسهیلات کنید می گفتگو فارسی زبان به اگر توجه
5557 (TTY 771) بگیرید تماس
ह िदी (Hindi)
धयान द यदद आप द िदी बोलत तो आपक ललए मफत म भाषा स ायता सवाएि उपलबध 1-855-699-
5557 (TTY 711) पर कॉल कर
Hmong (Hmong)
LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb
rau koj Hu rau 1-855-699-5557 (TTY 711)
Espantildeol (Spanish)
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia
linguumliacutestica Llame al 1-855-699-5557 (TTY 711)
Tiếng Việt (Vietnamese)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho
bạn Gọi số 1-855-699-5557 (TTY 711)
Tagalog (Tagalog - Filipino)
PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga
serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-855-699-5557 (TTY
711)
Language Assistance Notice for San Diego County (Continued)
xi
(Arabic) العربية
5557-699-855-1 برقم اتصل بالمجان لك تتوافر اللغویة المساعدة خدمات فإن اللغة اذكر تتحدث كنت إذا ملحوظة
(711YTT)
ພາສາລາວ (Lao)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ ໂທຣ 1-855-699-5557 (TTY 711)
日本語 (Japanese)
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1-855-699-
5557(TTY711)までお電話にてご連絡ください
ภาษาไทย (Thai)
เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-855-699-5557 (TTY 711)
ਪਜਾਬੀ ਦ (Punjabi)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-855-
699-5557 (TTY 711) ਤ ਕਾਲ ਕਰ
ខមែរ (Cambodian)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល
គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-855-699-5557 (TTY 711)
Հայերեն (Armenian)
ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող են
տրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք 1-855-699-
5557 (TTY (հեռատիպ)711)
Categorical List of Prescription DrugsANALGESICS (Drugs for Pain) 1
ANESTHETICS (Drugs for Numbing) 6
ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS (Drugs for AddictionSubstance Abuse) 6
ANTIBACTERIALS (Drugs for Bacterial Infections) 8
ANTICONVULSANTS (Drugs for Seizures) 14
ANTIDEMENTIA AGENTS (Drugs for Alzheimers Disease and Dementia) 17
ANTIDEPRESSANTS (Drugs for Depression) 17
ANTIEMETICS (Drugs for Nausea and Vomiting) 20
ANTIFUNGALS (Drugs for Fungal Infections) 21
ANTIGOUT AGENTS (Drugs for Gout) 24
ANTIMIGRAINE AGENTS (Drugs for Migraine) 25
ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis) 25
ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections) 26
ANTINEOPLASTICS (Drugs for Cancer) 26
ANTIPARASITICS (Drugs for Parasitic Infections) 28
ANTIPARKINSON AGENTS (Drugs for Parkinsons Disease) 29
ANTIPSYCHOTICS (Drugs for Mental Health) 30
ANTISPASTICITY AGENTS (Drugs for Muscle Spasm) 35
ANTIVIRALS (Drugs for Viral Infections) 35
ANXIOLYTICS (Drugs for Anxiety) 41
BIPOLAR AGENTS (Drugs for Bipolar Disorder) 42
BLOOD GLUCOSE REGULATORS (Drugs for Diabetes) 42
BLOOD PRODUCTSMODIFIERSVOLUME EXPANDERS (Drugs for Blood Disorders) 46
CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation) 51
CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions) 61
DENTAL AND ORAL AGENTS (Drugs for the Mouth) 66
DERMATOLOGICAL AGENTS (Drugs for the Skin) 66
ELECTROLYTESMINERALSMETALSVITAMINS 69
GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach) 77
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERS TREATMENT (Drugs for Genetic or
Enzyme Disorders) 85
GENITOURINARY AGENTS (Drugs for the Genital Bladder and Kidney) 86
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (ADRENAL) (Drugs for
ReplacingStimulating Adrenal Gland Hormones) 87
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (PITUITARY) (Drugs for
ReplacingStimulating Pituitary Gland Hormones) 90
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEX HORMONESMODIFIERS) (Drugs
for ReplacingStimulating Sex Hormones) 91
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (THYROID) (Drugs for the Thyroid) 102
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs for Suppressing Hormones from the Pituitary
Gland) 104
HORMONAL AGENTS SUPPRESSANT (THYROID) (Drugs for the Thyroid) 104
LAST UPDATED 12012020
IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing the Immune System) 104
INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for Inflammatory Bowel Disease) 109
METABOLIC BONE DISEASE AGENTS (Drugs for the Bone) 109
MISCELLANEOUS THERAPEUTIC AGENTS 110
OPHTHALMIC AGENTS (Drugs for the Eyes) 112
OTIC AGENTS (Drugs for the Ears) 116
RESPIRATORY TRACTPULMONARY AGENTS (Drugs for the Lungs) 116
SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles) 130
SLEEP DISORDER AGENTS (Drugs for Insomnia) 130
LAST UPDATED 12012020
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANALGESICS (Drugs for Pain)
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (Pain and ArthritisDrugs)
aspirin (ADULT ASPIRIN REGIMEN)81 mg tablet dr
1-Covered
aspirin (ADULT LOW DOSE ASPIRINEC) 81 mg tablet dr
1-Covered
aspirin (ASPIR 81) mg tablet dr ) 1-Covered
aspirin (ASPIR-TRIN) 325 mg tabletdr -
1-Covered
aspirin (ASPIRIN) 325 mg tablet 1-Covered
aspirin (ECOTRIN) 81 mg tablet dr 1-Covered
aspirin (ECPIRIN) 325 mg tablet dr 1-Covered
aspirin (ST JOSEPH ASPIRIN EC) 81mg tablet dr
1-Covered
aspirin (ST JOSEPH ASPIRIN) 81 mgtab chew
1-Covered
aspirin 325mg tablet 1-Covered
aspirin 81 mg tab chew 81 mgtablet dr 325 mg tablet
1-Covered
ASPIRIN 81MG TABLET ASPIRIN81MG TABLET ASPIRIN 81MGTABLET
1-Covered
aspirinacetaminophencaffeine(ADDED STRENGTH HEADACHE)250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(BAYER MIGRAINE) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(EXTRA PAIN RELIEF) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(EXTRAPRIN) 250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(HEADACHE RELIEF) 250-250-65tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
1
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
aspirinacetaminophencaffeine(MIGRAINE FORMULA) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(MIGRAINE RELIEF) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(PAIN RELIEVER PLUS) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(PAIN RELIEVER) 250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(PAIN-OFF) 250-250-65 tablet -
1-Covered
butalbitalaspirincaffeine 50-325-40 capsule
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
butalbitalaspirincaffeine 50-325-40 tablet
1-Covered
celecoxib 50 mg capsule 100 mgcapsule 200 mg capsule 400 mgcapsule
1-Covered ST
CELECOXIB 50 MG CAPSULE 100MG CAPSULE 200 MG CAPSULE400 MG CAPSULE
1-Covered ST
CHILDRENS IBUPROFEN CHILD 200MG10 ML CHILDREN 100 MG5 ML
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
diclofenac sodium 25 mg tablet dr50 mg tablet dr 75 mg tablet dr100 mg tab er 24h
1-Covered
diflunisal 500 mg tablet 1-Covered
etodolac 600 mg tab er 24h 1-Covered PA
EXCEDRIN EXTRA STRENGTH(aspirinacetaminophencaffeine)CAPLET
1-Covered
EXCEDRIN MIGRAINE(aspirinacetaminophencaffeine)CAPLET GELTAB
1-Covered
flurbiprofen 50 mg tablet 100 mgtablet
1-Covered
HEADACHE RELIEF HM 250-250-65MG CPLT
1-Covered
ibuprofen (ADDAPRIN) 200 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
2
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ibuprofen (I-PRIN) 200 mg tablet - 1-Covered
ibuprofen (IBU) 400 mg tablet 600mg tablet 800 mg tablet
1-Covered
ibuprofen (IBU-200) mg tablet -) 1-Covered
ibuprofen (PROVIL) 200 mg tablet 1-Covered
ibuprofen (WAL-PROFEN) 200 mgtablet -
1-Covered
ibuprofen 100 mg5ml oral susp 1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
IBUPROFEN 400 MG TABLET 600 MGTABLET 800 MG TABLET
1-Covered
ibuprofen 50 mg125 drops susp100 mg tab chew 200 mg tablet400 mg tablet 600 mg tablet 800mg tablet
1-Covered
indomethacin 25 mg capsule 50mg capsule 75 mg capsule er
1-Covered
ketoprofen 50 mg capsule 75 mgcapsule
1-Covered
meloxicam 75 mg tablet 15 mgtablet
1-Covered
naproxen 250 mg tablet 375 mgtablet 500 mg tablet
1-Covered
naproxen sodium 275 mg tablet550 mg tablet
1-Covered
piroxicam 10 mg capsule 20 mgcapsule
1-Covered
salsalate 500 mg tablet 750 mgtablet
1-Covered
sulindac 150 mg tablet 200 mgtablet
1-Covered
tolmetin sodium 200 mg tablet 400mg capsule 600 mg tablet
1-Covered
OPIOID ANALGESICS LONG-ACTING (Long-acting Narcotic PainRelievers)
BELBUCA (buprenorphine hcl) 75MCG FILM 150 MCG FILM 300MCG FILM 450 MCG FILM 600MCG FILM 750 MCG FILM 900MCG FILM
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
3
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
buprenorphine 5 mcghr patch75 mcghr patch 10 mcghrpatch 15 mcghr patch 20mcghr patch
2-MedicalCarve out
BUTRANS (buprenorphine) 5MCGHR PATCH 75 MCGHRPATCH 10 MCGHR PATCH 15MCGHR PATCH 20 MCGHRPATCH
2-MedicalCarve out
fentanyl 25 mcghr patch50mcghr patch 75mcghr patch100 mcghr patch
1-Covered PA QL (10 PER 30 DAY(S))
methadone hcl (METHADONEINTENSOL) 10 mgml oral conc
1-Covered PA
methadone hcl (METHADOSE) 40mg tablet sol
1-Covered PA
METHADONE HCL 10 MG TABLET 1-Covered QL (60 PER 30 DAYS)
METHADONE HCL 10 MGML ORALCONC
1-Covered PA
methadone hcl 5 mg tablet 10 mgtablet
1-Covered QL (60 PER 30 DAYS)
methadone hcl 5 mg5 ml solution10 mg5 ml solution 10 mgml oralconc
1-Covered PA
morphine sulfate 15 mg tablet er 1-Covered QL (90 PER 30 DAYS)
morphine sulfate 30 mg tablet er 1-Covered QL (60 PER 30 DAYS)
morphine sulfate 60 mg tablet er100 mg tablet er 200 mg tablet er
1-Covered PA
oxycodone hcl 10 mg tab er 20mg tab er 40 mg tab er 80 mgtab er
1-Covered PA QL (60 PER 30 DAYS)
SUBLOCADE (buprenorphine) 100MG05 ML SYRING 300 MG15 MLSYRING
2-MedicalCarve out
OPIOID ANALGESICS SHORT-ACTING (Short-acting Narcotic PainRelievers)
acetaminophen with codeinephosphate -15mg tablet -30mgtablet -60mg tablet
1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old) QLC (LIMIT 100TABS TOTAL APAPCODEINETABLETS PER MONTH)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
4
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acetaminophen with codeinephosphate 120-12mg5 solution
1-Covered QL (240 PER 30 DAYS) AL1 (Atleast 12 yrs old)
butorphanol tartrate 10 mgmlspray
1-Covered PA
codeinephosphatebutalbitalaspirincaffeine codeinebutalbitalasacaffein30-50-325 capsule
1-Covered QL (60 PER 30 DAYS) AL1 (At least12 yrs old)
codeine sulfate 15 mg tablet 30mg tablet 60 mg tablet
1-Covered PA AL1 (At least 12 yrs old)
hydrocodonebitartrateacetaminophen(LORCET HD)hydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAY(S))
hydrocodonebitartrateacetaminophen(LORTAB)hydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAY(S))
hydrocodonebitartrateacetaminophenhydrocodoneacetaminophen 5mg-325mg tablethydrocodoneacetaminophen75-325 mg tablethydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS OF HYDROCODONEPRODUCTS PER 30 DAYS)
hydromorphone hcl 1 mgml liquid3 mg supprect
1-Covered
hydromorphone hcl 2 mg tablet 4mg tablet 8 mg tablet
1-Covered QL (60 PER 30 DAYS)
meperidine hcl 50 mg tablet 100mg tablet
1-Covered QL (100 PER 30 DAYS)
morphine sulfate 10 mg5 ml 20mg5 ml 100 mg5ml
1-Covered PA
morphine sulfate 15 mg tablet 30mg tablet
1-Covered QL (90 PER 30 DAYS)
morphine sulfate 30 mg supprect 1-Covered QL (24 PER 30 DAY(S)) QLC (LIMIT24 SUPPOSITORIES IN 30 DAYS)
morphine sulfate 5 mg 10 mg 20mg
1-Covered QL (24 PER 30 DAY(S)) QLC (LIMIT24 SUPPOSITORIES IN 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
5
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
oxycodone hcl 5 mg capsule 5mg tablet 5 mg5 ml solution 15mg tablet 20 mgml oral conc 30mg tablet
1-Covered PA
oxycodone hclacetaminophen(ENDOCET) 5 mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS PER 30 DAYS OF TOTALOXYCODONE APAP ANDOXYCODONE ASA PER MONTH)
oxycodone hclacetaminophen 5mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS PER 30 DAYS OF TOTALOXYCODONE APAP ANDOXYCODONE ASA PER MONTH)
oxycodone hclacetaminophen 5-3255 ml solution
1-Covered PA
oxycodone hclaspirin 48355-325tablet
1-Covered QL (100 PER 30 DAY(S))
tramadol hcl 50 mg tablet 1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old)
TRAMADOL HCL 50 MG TABLET 1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old)
ANESTHETICS (Drugs for Numbing)
LOCAL ANESTHETICS (Skin Numbing Drugs)lidocaine hcl 10 mgml vial 1-Covered PA
lidocaine hcl 2 solution 1-Covered
LIDOCAINE HCL VISCOUS 2 SOLN 1-Covered
lidocaine hclpf 10 mgml vial 10mgml ampul
1-Covered PA
ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS (Drugs forAddictionSubstance Abuse)
ALCOHOL DETERRENTSANTI-CRAVING (Drugs for AlcoholDependence)
acamprosate calcium 333 mgtablet dr
2-MedicalCarve out
disulfiram 250 mg tablet 500 mgtablet
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
6
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
naltrexone hcl 50 mg tablet 2-MedicalCarve out
NALTREXONE HCL 50 MG TABLET 2-MedicalCarve out
VIVITROL (naltrexonemicrospheres) 380 MG VIAL +DILUENT
2-MedicalCarve out
OPIOID DEPENDENCE TREATMENTS (Drugs for Opioid Dependence)BUNAVAIL (buprenorphinehclnaloxone hcl) 21-03 MG FILM42-07 MG FILM 63-1 MG FILM
2-MedicalCarve out
BUPRENEX (buprenorphine hcl) 03MGML AMPUL
2-MedicalCarve out
buprenorphine hcl 03 mgml vial03 mgml cartridge 2 mg tab subl8 mg tab subl
2-MedicalCarve out
buprenorphine hclnaloxone hclnaloxone 2 mg-05mg filmnaloxone 2 mg-05mg tab sublnaloxone 4mg-1mg filmnaloxone 8 mg-2 mg filmnaloxone 8 mg-2 mg tab subl
2-MedicalCarve out
LUCEMYRA (lofexidine hcl) 018 MGTABLET
2-MedicalCarve out
PROBUPHINE (buprenorphine hcl)742 MG IMPLANT
2-MedicalCarve out
SUBOXONE (buprenorphinehclnaloxone hcl) 2 MG-05 MGFILM 4 MG-1 MG FILM 8 MG-2 MGFILM 12 MG-3 MG FILM
2-MedicalCarve out
ZUBSOLV (buprenorphinehclnaloxone hcl) 07-018 MGTABLET 14-036 MG TABLET 29-071 MG TABLET 57-14 MG TABLET86-21 MG TABLET 114-29 MGTABLET
2-MedicalCarve out
OPIOID REVERSAL AGENTS (Drugs for Opioid Overdose)EVZIO (naloxone hcl) 04 MGAUTO- 2 MG AUTO-
2-MedicalCarve out
naloxone hcl 04 mgml cartridge04 mgml vial 1 mgml syringe 2mg04ml auto injct
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
7
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NARCAN (naloxone hcl) 4 MGNASAL SPRAY
2-MedicalCarve out
SMOKING CESSATION AGENTS (Drugs to Help Quit Smoking)bupropion hcl (BUPROBAN) 150 mgtab er 12h
1-Covered QL (2 PER 1 DAY(S))
bupropion hcl 150 mg tab er 12h 1-Covered QL (2 PER 1 DAY(S))
CHANTIX (varenicline tartrate) 05MG TABLET 1 MG TABLET 1 MGCONT MONTH BOX STARTINGMONTH BOX
1-Covered PA
nicotine 14mg patch 1-Covered QL (1 PER 1 DAY(S))
nicotine 21mg patch 1-Covered QL (1 PER 1 DAY(S))
nicotine 2mg gum 1-Covered QL (24 PER 1 DAY(S))
nicotine 4mg gum 1-Covered QL (24 PER 1 DAY(S))
nicotine 7mg patch 1-Covered QL (1 PER 1 DAY(S))
NICOTINE LOZENGE 2 MGLOZENGE HM 2 MG LOZENGE 4MG LOZENGE HM 4 MG LOZENGE
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (QUIT 2) mglozenge )
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (QUIT 4) mglozenge )
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (STOP SMOKINGAID) 2 mg 4 mg
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex 2 mg 4 mg 1-Covered QL (24 PER 1 DAY(S))
NICOTROL (nicotine) CARTRIDGEINHALER
1-Covered PA
NICOTROL NS (nicotine) 10 MGMLSPRAY
1-Covered PA
ANTIBACTERIALS (Drugs for Bacterial Infections)
AMINOGLYCOSIDESgentamicin sulfate (GENTAK) 03 oint (g)
1-Covered
gentamicin sulfate 01 oint (g)01 cream (g) 03 oint (g) 03 drops
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
8
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GENTAMICIN SULFATE 01 CREAM 1-Covered
neomycin sulfate 500 mg tablet 1-Covered
paromomycin sulfate 250 mgcapsule
1-Covered
tobramycin 03 drops 1-Covered
TOBREX (tobramycin) 03 EYEOINTMENT
1-Covered
ANTIBACTERIALS OTHERbacitracin (BACITRAYCIN PLUS) 500unitg oint (g)
1-Covered
bacitracin 500 unitg packet 500unitg oint (g)
1-Covered
BACITRACIN 500 UNITGM OINTMNT 1-Covered
bacitracin zinc (ANTIBIOTIC) 500unitg oint (g)
1-Covered
bacitracin zinc 500 unitg ointpack 500 unitg oint (g)
1-Covered
BACITRACIN ZINC ZN 500 UNITGMOINT
1-Covered
CLEOCIN (clindamycin phosphate)100 MG VAGINAL OVULE
1-Covered
clindamycin hcl 75 mg capsule150 mg capsule 300 mg capsule
1-Covered
clindamycin palmitate hcl 75 mg5ml soln recon
1-Covered
clindamycin phosphate 1 gel(gram) 1 lotion 1 med swab1 solution 1 gel daily 2 creamappl
1-Covered
CLINDAMYCIN PHOSPHATE 1SOLUTION 1 GEL
1-Covered
erythromycin basebenzoylperoxide erythromycinbenzoyl 3-5 gel (gram)
1-Covered ST
methenaminemethylenebluesodphospsalicylatehyoscyamine(PHOSPHASAL) methmebluesodphospsalhyos 816-108 tablet
1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
9
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
methenaminemethylenebluesodphospsalicylatehyoscyamine(URIN DS) methmebluesodphospsalhyos 816-108 tablet
1-Covered PA
METRO IV (metronidazole in sodiumchloride) 500 MG100 ML
1-Covered
metronidazole 075 gel wappl250 mg tablet 375 mg capsule500 mg tablet
1-Covered
METRONIDAZOLE 250 MG TABLET500 MG TABLET
1-Covered
metronidazole in sodium chloridemetronidazolesodium 500mg01lpiggyback
1-Covered PA
mupirocin 2 oint (g) 1-Covered QL (22 PER 30 DAY(S))
mupirocin calcium 2 cream (g) 1-Covered PA
neomycin sulfatebacitracinzincpolymyxin b (ANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
neomycin sulfatebacitracinzincpolymyxin b (FIRST AIDANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
neomycin sulfatebacitracinzincpolymyxin b (TRIPLEANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
nitrofurantoin 25 mg5 ml oral susp 1-Covered
NITROFURANTOIN 50 MG CAP 100MG CAP
1-Covered
nitrofurantoin macrocrystal 50 mgcapsule 100 mg capsule
1-Covered
nitrofurantoinmonohydratemacrocrystalsmonohydm-100 mg capsule
1-Covered
trimethoprim 100 mg tablet 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
10
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRIPLE ANTIBIOTIC (neomycinsulfatebacitracin zincpolymyxinb) CURAD OINT MEDI-FIRSTMEDICHOICE OINTMENTOINTMENT PKT
1-Covered
TRIPLE ANTIBIOTIC HM PKT 1-Covered
URETRON D-S(methenaminemethylenebluesodphospsalicylatehyoscyamine) -TABLET
1-Covered PA
VANDAZOLE (metronidazole)VAGINAL 075 GEL
1-Covered
BETA-LACTAM CEPHALOSPORINScefaclor 125 mg5ml susp recon250 mg5ml susp recon 250 mgcapsule 375 mg5ml susp recon500 mg capsule
1-Covered
CEFDINIR 125 MG5 ML SUSP 250MG5 ML SUSP
1-Covered QL (200 PER 10 DAY(S))
cefdinir 125 mg5ml 250 mg5ml 1-Covered QL (200 PER 10 DAY(S))
cefdinir 300 mg capsule 1-Covered QL (20 PER 10 DAY(S))
cephalexin 125 mg5ml susprecon 250 mg capsule 250mg5ml susp recon 500 mgcapsule
1-Covered
BETA-LACTAM PENICILLINSamoxicillin 125 mg5ml susp recon125 mg tab chew 200 mg5mlsusp recon 250 mg tab chew 250mg5ml susp recon 250 mgcapsule 400 mg5ml susp recon500 mg tablet 500 mg capsule875 mg tablet
1-Covered
AMOXICILLIN-CLAVULANATEPOTASS -600-429 MG5 ML SUS
1-Covered QL (300 PER FILL) QLC (1 FILL IN 30DAYS)
AMOXICILLIN-CLAVULANATEPOTASS -875-125 MG TABLET
1-Covered
amoxicillinpotassium clavulanate1000-625 tab er 12h
1-Covered QL (40 PER FILL(S)) MFL (1 30day(s))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
11
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
amoxicillinpotassium clavulanate200-2855 susp recon 200-285mgtab chew 250-125 mg tablet 400-57mg5 susp recon 400-57mg tabchew 500-125 mg tablet 875-125mg tablet
1-Covered
amoxicillinpotassium clavulanate600-4295 susp recon
1-Covered QL (300 PER FILL) QLC (1 FILL IN 30DAYS)
ampicillin trihydrate 125 mg5mlsusp recon 250 mg capsule 250mg5ml susp recon 500 mgcapsule
1-Covered
dicloxacillin sodium 250 mgcapsule 500 mg capsule
1-Covered
penicillin v potassium 125 mg5mlsoln recon 250 mg5ml soln recon250 mg tablet 500 mg tablet
1-Covered
MACROLIDESazithromycin 1 g packet 1-Covered QL (1 PER 30 DAYS)
azithromycin 100 mg5ml 200mg5ml
1-Covered
AZITHROMYCIN 200 MG5 ML SUSP 1-Covered
azithromycin 250 mg tablet 1-Covered QL (6 PER FILL(S)) MFL (2 30day(s))
AZITHROMYCIN 250 MG TABLET 1-Covered QL (6 PER FILL(S)) MFL (2 30day(s))
azithromycin 500 mg tablet 1-Covered QL (3 PER FILL(S)) MFL (2 30day(s))
AZITHROMYCIN 500 MG TABLET 1-Covered QL (3 PER FILL(S)) MFL (2 30day(s))
azithromycin 600 mg tablet 1-Covered QL (2 PER 7 DAY(S)) MFL (8 28day(s))
clarithromycin 500 mg tablet 1-Covered ST
EES 200 (erythromycinethylsuccinate) MG5 MLSUSPENSION
1-Covered
EES 400 (erythromycinethylsuccinate) FILMTAB
1-Covered
ERYTHROCIN STEARATE(erythromycin stearate) 250 MGFILMTAB
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
12
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ERYTHROMYCIN 250 MG 500 MG 1-Covered
erythromycin base 5 mggramoint (g) 250 mg capsule dr 250mg tablet dr 250 mg tablet 333mg tablet dr 500 mg tablet 500mg tablet dr
1-Covered
erythromycin base in ethanol (ERY)2 med swab
1-Covered
erythromycin base in ethanol 2 solution 2 med swab
1-Covered
ERYTHROMYCIN ETHYLSUCCINATE200 MG5 ML SUSP
1-Covered
erythromycin ethylsuccinate 200mg5ml susp recon 400 mg tablet
1-Covered
QUINOLONESCILOXAN (ciprofloxacin hcl) 03OINTMENT
1-Covered
ciprofloxacin hcl 03 drops 1-Covered
ciprofloxacin hcl 100 mg tablet 1-Covered PA AL1 (At least 18 yrs old)
ciprofloxacin hcl 250 mg tablet500 mg tablet 750 mg tablet
1-Covered AL1 (At least 18 yrs old)
CIPROFLOXACIN HCL 500 MG TAB 1-Covered AL1 (At least 18 yrs old)
levofloxacin 250 mg tablet 500 mgtablet 750 mg tablet
1-Covered AL1 (At least 18 yrs old)
moxifloxacin hcl 400 mg tablet 1-Covered PA AL1 (At least 18 yrs old)
ofloxacin 03 drops 1-Covered QL (5 PER 30 DAY(S))
SULFONAMIDESBLEPH-10 (sulfacetamide sodium) - EYE DROPS
1-Covered
silver sulfadiazine 1 cream (g) 1-Covered
SSD (silver sulfadiazine) 1 CREAM 1-Covered
sulfacetamide sodium 10 oint(g) 10 drops
1-Covered
sulfamethoxazoletrimethoprim200-40mg5 oral susp 400mg-80mgtablet 800-16020 oral susp 800-160 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
13
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SULFATRIM(sulfamethoxazoletrimethoprim)PEDIATRIC SUSPENSION
1-Covered
TETRACYCLINESDOXYCYCLINE HYCLATE 100 MGCAP
1-Covered AL1 (At least 8 yrs old)
doxycycline hyclate 100 mgcapsule
1-Covered AL1 (At least 8 yrs old)
DOXYCYCLINE HYCLATE 20 MG TAB 1-Covered QL (60 PER 30 DAYS)
doxycycline hyclate 20 mg tablet 1-Covered QL (60 PER 30 DAYS)
doxycycline monohydrate 50 mgcapsule 100 mg capsule
1-Covered AL1 (At least 8 yrs old)
minocycline hcl 50 mg capsule100 mg capsule
1-Covered
ANTICONVULSANTS (Drugs for Seizures)
ANTICONVULSANTS OTHER (Other Seizure Control Drugs)LEVETIRACETAM 100 MGML SOLN250 MG TABLET 500 MG5 ML SOLN
1-Covered
levetiracetam 100 mgml solution250 mg tablet 500 mg tablet 500mg5ml solution 750 mg tablet1000 mg tablet
1-Covered
levetiracetam 500 mg tab er 24h 1-Covered MDD (6 Per Day)
levetiracetam 750 mg tab er 24h 1-Covered QL (120 PER 30 DAY(S))
LEVETIRACETAM ER 500 MG TABLET 1-Covered MDD (6 Per Day)
LEVETIRACETAM ER 750 MG TABLET 1-Covered QL (120 PER 30 DAY(S))
CALCIUM CHANNEL MODIFYING AGENTSCELONTIN (methsuximide) 300 MGKAPSEAL
1-Covered
ETHOSUXIMIDE 250 MG CAPSULE 1-Covered
ethosuximide 250 mg5ml solution250 mg capsule
1-Covered
zonisamide 25 mg capsule 50 mgcapsule 100 mg capsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
14
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTSDEPAKENE (valproic acid (assodium salt) (valproate sodium))250 MG5 ML SOLUTION
1-Covered
DEPAKENE (valproic acid) 250 MGCAPSULE
1-Covered
diazepam 5-75-10mg kit 1-Covered
divalproex sodium 125 mg tabletdr 125 mg cap dr spr 250 mgtablet dr 500 mg tablet dr
1-Covered
DIVALPROEX SODIUM DR 125 MGCAP SPRNK
1-Covered
gabapentin 100 mg capsule 250mg5ml solution 300 mg capsule400 mg capsule 600 mg tablet800 mg tablet
1-Covered
GABAPENTIN 100 MG CAPSULE 300MG CAPSULE 400 MG CAPSULE
1-Covered
phenobarbital 15 mg tablet 20mg5 ml elixir 30 mg tablet 324mg tablet 60 mg tablet 648 mgtablet 972mg tablet 100 mgtablet
1-Covered
PHENOBARBITAL 20 MG5 ML SOLN324 MG TABLET 648 MG TABLET972 MG TABLET
1-Covered
primidone 50 mg tablet 250 mgtablet
1-Covered
valproic acid (as sodium salt)(valproate sodium) 250 mg5ml500mg10ml
1-Covered
valproic acid 250 mg capsule 1-Covered
VALPROIC ACID 250 MG CAPSULE 1-Covered
GLUTAMATE REDUCING AGENTSlamotrigine 25 mg tablet 100 mgtablet 150 mg tablet 200 mgtablet
1-Covered
lamotrigine 5 mg 25 mg 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
15
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
topiramate 15 mg cap sprink 25mg tablet 25 mg cap sprink 50mg tablet 100 mg tablet 200 mgtablet
1-Covered
TOPIRAMATE 25 MG TABLET 50 MGTABLET 100 MG TABLET 200 MGTABLET
1-Covered
SODIUM CHANNEL AGENTScarbamazepine (EPITOL) 200 mgtablet
1-Covered
carbamazepine 100 mg cpmp12hr 100 mg5ml oral susp 100 mgtab chew 100 mg tab er 12h 200mg cpmp 12hr 200 mg tab er 12h200 mg tablet 300 mg cpmp 12hr400 mg tab er 12h
1-Covered
CARBATROL (carbamazepine) ER100 MG CAPSULE ER 200 MGCAPSULE ER 300 MG CAPSULE
1-Covered
DILANTIN (phenytoin sodiumextended) 30 MG CAPSULE 100MG CAPSULE
1-Covered
DILANTIN (phenytoin) 50 MGINFATAB
1-Covered
DILANTIN-125 (phenytoin) MG5 MLSUSP
1-Covered
DILANTIN-125 MG5 ML SUSP 1-Covered
oxcarbazepine 150 mg tablet 300mg tablet 600 mg tablet
1-Covered
phenytoin 50 mg tab chew 100mg4ml oral susp 125 mg5ml oralsusp
1-Covered
phenytoin sodium extended 100mg capsule
1-Covered
TEGRETOL (carbamazepine) 100MG5 ML SUSP 200 MG TABLET
1-Covered
TEGRETOL XR (carbamazepine) 100MG TABLET 200 MG TABLET 400MG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
16
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIDEMENTIA AGENTS (Drugs for Alzheimers Disease andDementia)
CHOLINESTERASE INHIBITORSdonepezil hcl 5 mg tab rapdis 5mg tablet 10 mg tab rapdis 10mg tablet
1-Covered
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine hcl 5 mg tablet 10 mgtablet
1-Covered
MEMANTINE HCL 5 MG TABLET 10MG TABLET
1-Covered
ANTIDEPRESSANTS (Drugs for Depression)
ANTIDEPRESSANTS OTHERbupropion hcl 100 mg tab 150 mgtab 200 mg tab
1-Covered QL (60 PER 30 DAYS)
bupropion hcl 150 mg tab er 300mg tab er
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
bupropion hcl 75 mg tablet 100mg tablet
1-Covered
BUPROPION HCL SR SR 100 MGTABLET SR 150 MG TABLET SR 200MG TABLET
1-Covered QL (60 PER 30 DAYS)
BUPROPION XL 150 MG TABLET 300MG TABLET
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
mirtazapine 15 mg tab rapdis 1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old)
mirtazapine 15 mg tablet 30 mgtab rapdis 30 mg tablet 45 mgtab rapdis 45 mg tablet
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
olanzapinefluoxetine hcl 3 mg-25mg capsule 6mg-25mg capsule6mg-50mg capsule 12mg-50mgcapsule 12mg-25mg capsule
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
17
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SYMBYAX (olanzapinefluoxetinehcl) 3-25 MG CAPSULE 6-50 MGCAPSULE 6-25 MG CAPSULE 12-50MG CAPSULE 12-25 MG CAPSULE
2-MedicalCarve out
MONOAMINE OXIDASE INHIBITORSEMSAM (selegiline) 6 MG24PATCH 9 MG24 PATCH 12 MG24PATCH
2-MedicalCarve out
MARPLAN (isocarboxazid) 10 MGTABLET
2-MedicalCarve out
NARDIL (phenelzine sulfate) 15 MGTABLET
2-MedicalCarve out
PARNATE (tranylcypromine sulfate)10 MG TABLET
2-MedicalCarve out
phenelzine sulfate 15 mg tablet 2-MedicalCarve out
tranylcypromine sulfate 10 mgtablet
2-MedicalCarve out
SSRISSNRIS (SELECTIVE SEROTONIN REUPTAKEINHIBITORSEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)
citalopram hydrobromide 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
escitalopram oxalate 5 mg tablet10 mg tablet 20 mg tablet
1-Covered
ESCITALOPRAM OXALATE 5 MGTABLET 10 MG TABLET 20 MGTABLET
1-Covered
fluoxetine hcl 10 mg capsule 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
fluoxetine hcl 20 mg capsule 1-Covered QL (120 PER 30 DAY(S))
fluoxetine hcl 20 mg5 ml solution 1-Covered
FLUOXETINE HCL 20 MG5 MLSOLUTION
1-Covered
fluvoxamine maleate 25 mg tablet50 mg tablet 100 mg tablet
1-Covered AL1 (At least 8 yrs old)
paroxetine hcl 10 mg tablet 20 mgtablet 30 mg tablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
sertraline hcl 25 mg tablet 50 mgtablet 100 mg tablet
1-Covered QL (60 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
18
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRAZODONE HCL 50 MG TABLET100 MG TABLET
1-Covered
trazodone hcl 50 mg tablet 100mg tablet 150 mg tablet
1-Covered
venlafaxine hcl 25 mg tablet 375mg tablet 50 mg tablet 75 mgtablet 100 mg tablet
1-Covered QL (60 PER 30 DAYS)
venlafaxine hcl 375 mg cap er 75mg cap er 150 mg cap er
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
VENLAFAXINE HCL ER ER 375 MGCAP ER 75 MG CAP ER 150 MGCAP
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
TRICYCLICSamitriptyline hcl 10 mg tablet 25mg tablet 50 mg tablet 75 mgtablet 100 mg tablet 150 mgtablet
1-Covered
amoxapine 25 mg tablet 50 mgtablet 100 mg tablet 150 mgtablet
1-Covered
clomipramine hcl 25 mg capsule50 mg capsule 75 mg capsule
1-Covered PA
CLOMIPRAMINE HCL 25 MGCAPSULE 50 MG CAPSULE 75 MGCAPSULE
1-Covered PA
desipramine hcl 10 mg tablet 25mg tablet 50 mg tablet 75 mgtablet 100 mg tablet 150 mgtablet
1-Covered
DOXEPIN HCL 10 MG CAPSULE 25MG CAPSULE 50 MG CAPSULE 75MG CAPSULE 100 MG CAPSULE
1-Covered
doxepin hcl 10 mgml oral conc10 mg capsule 25 mg capsule 50mg capsule 75 mg capsule 100mg capsule 150 mg capsule
1-Covered
imipramine hcl 10 mg tablet 25mg tablet 50 mg tablet
1-Covered
IMIPRAMINE HCL 10 MG TABLET 25MG TABLET 50 MG TABLET
1-Covered
nortriptyline hcl 10 mg capsule 25mg capsule 50 mg capsule 75 mgcapsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
19
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIEMETICS (Drugs for Nausea and Vomiting)
ANTIEMETICS OTHER (Other Drugs for Nausea and Vomiting)meclizine hcl (DRAMAMINE LESSDROWSY) 25 mg tablet
1-Covered
meclizine hcl (MEDI-MECLIZINE) 25mg tablet -
1-Covered
meclizine hcl (MOTION RELIEF) 25mg tablet
1-Covered
meclizine hcl (MOTION SICKNESS II)25 mg tablet
1-Covered
meclizine hcl (MOTION SICKNESSRELIEF) 25 mg tablet 25 mg tabchew
1-Covered
meclizine hcl (MOTION SICKNESS)25 mg tablet
1-Covered
meclizine hcl (MOTION-TIME) 25 mgtab chew -
1-Covered
meclizine hcl (TRAVEL-EASE) 25 mgtablet -
1-Covered
meclizine hcl (VERTICALM) 25 mgtablet
1-Covered
meclizine hcl (WAL-DRAM 2) 25 mgtablet -
1-Covered
MECLIZINE HCL 125 MG CAPLET 25MG TABLET CHEW
1-Covered
meclizine hcl 125 mg tablet 25mg tab chew 25 mg tablet
1-Covered
metoclopramide hcl 5 mg tablet 5mg5 ml solution 10 mg tablet 10mg10ml solution
1-Covered
perphenazine 2 mg tablet 4 mgtablet 8 mg tablet 16 mg tablet
2-MedicalCarve out
prochlorperazine (COMPRO) 25mg supprect
1-Covered
prochlorperazine 25 mg supprect 1-Covered
prochlorperazine maleate 5 mgtablet 10 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
20
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
promethazine hcl (PHENADOZ)125 mg 25 mg
1-Covered
promethazine hcl (PROMETHEGAN)125 mg 25 mg 50 mg
1-Covered
promethazine hcl 125 mgsupprect 25 mg supprect 50 mgtablet 50 mg supprect
1-Covered
TRAVEL SICKNESS (meclizine hcl) 25MG TAB CHEW
1-Covered
trimethobenzamide hcl 300 mgcapsule
1-Covered
EMETOGENIC THERAPY ADJUNCTS (Drugs for Nausea and Vomiting)aprepitant 40 mg capsule 80 mgcapsule 125mg-80mg cap ds pk125 mg capsule
1-Covered PA
dronabinol 25 mg capsule 5 mgcapsule 10 mg capsule
1-Covered PA
granisetron hcl 1 mg tablet 1-Covered PA
ondansetron 4 mg tab rapdis 8mg tab rapdis
1-Covered QL (12 PER FILL(S)) MDD (3 PerDay) QLC (LIMIT TO 2 FILLS OF 12TABLETS IN 30 DAYS)
ondansetron hcl 4 mg tablet 8 mgtablet
1-Covered QL (12 PER FILL(S)) MDD (3 PerDay) QLC (LIMIT TO 2 FILLS OF 12TABLETS IN 30 DAYS)
ondansetron hcl 4 mg5 mlsolution 24 mg tablet
1-Covered PA
ANTIFUNGALS (Drugs for Fungal Infections)
ANTIFUNGALSANTIFUNGAL 1 TOPICAL CREAM 1-Covered
ATHLETES FOOT (terbinafine hcl) 1CREAM
1-Covered
ciclopirox 077 gel (gram) 1-Covered QLC (100 GRAMSMONTH)
ciclopirox 1 shampoo 1-Covered QLC (120 ozMONTH)
ciclopirox 8 solution 1-Covered
ciclopirox olamine 077 cream(g)
1-Covered QLC (90 GRAMSMONTH)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
21
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ciclopirox olamine 077 suspension
1-Covered QLC (60 MLMONTH)
clotrimazole (ANTIFUNGALRINGWORM) 1 cream (g)
1-Covered
clotrimazole (ANTIFUNGAL) 1 cream (g)
1-Covered
clotrimazole (ATHLETES FOOT) 1 cream (g)
1-Covered
clotrimazole (ATHLETIC FOOTCREAM) 1 cream (g)
1-Covered
clotrimazole (CLOTRIMAZOLE AF) 1 cream (g)
1-Covered
clotrimazole (ITCH RELIEF) 1 cream (g)
1-Covered
clotrimazole (JOCK ITCH RELIEF) 1 cream (g)
1-Covered
clotrimazole (JOCK ITCH) 1 cream (g)
1-Covered
clotrimazole (RINGWORM) 1 cream (g)
1-Covered
clotrimazole 1 cream (g) 1 solution 1 creamappl 10 mgtroche
1-Covered
CLOTRIMAZOLE 1 SOLUTION 1TOPICAL CREAM
1-Covered
fluconazole 10 mgml 40 mgml 1-Covered QL (70 PER 30 DAY(S))
fluconazole 150 mg tablet 1-Covered QL (2 PER 30 DAY(S))
FLUCONAZOLE 200 MG TABLET 1-Covered
fluconazole 50 mg tablet 100 mgtablet 200 mg tablet
1-Covered
fluconazole in dextrose iso-osmotic in dextreiso-200mg01l indextreiso-400mg02l
1-Covered PA
flucytosine 250 mg capsule 500mg capsule
1-Covered
FLUCYTOSINE 250 MG CAPSULE500 MG CAPSULE
1-Covered
griseofulvin ultramicrosize 125 mgtablet 250 mg tablet
1-Covered QL (60 PER 30 DAYS) AL1 (Up to18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
22
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
griseofulvin microsize 125 mg5mloral susp
1-Covered AL1 (Up to 12 yrs old) MDD (20Per Day)
griseofulvin microsize 500 mgtablet
1-Covered QL (60 PER 30 DAYS) AL1 (Up to18 yrs old)
itraconazole 100 mg capsule 1-Covered PA
ketoconazole 2 cream (g) 2 shampoo
1-Covered
ketoconazole 200 mg tablet 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
LAMISIL (terbinafine hcl)ANTIFUNGAL 1 SPRAY
1-Covered
LOTRIMIN AF (clotrimazole) 1CREAM
1-Covered
miconazole nitrate (ANTI-FUNGALCREAM) 2 cream (g) -
1-Covered
miconazole nitrate (ANTIFUNGALCREAM) 2 cream (g)
1-Covered
miconazole nitrate (BAZAANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate (INZOANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate (LOTRIMIN AF) 2 spray
1-Covered
miconazole nitrate (MICATIN) 2 cream (g)
1-Covered
miconazole nitrate (SECURAANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate 2 aero powd2 creamappl 2 cream (g)100 mg suppvag
1-Covered
MONISTAT 3 (miconazole nitrate)4 CREAM
1-Covered
MONISTAT 7 (miconazole nitrate)CREAM
1-Covered
NYSTATIN 100000 UNITGM CREAM100000 UNITGM OINT 100000UNITML SUSP 500000 UNIT5 MLSUS
1-Covered
nystatin 500k unit tablet 100000mloral susp 100000g cream (g)100000g oint (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
23
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terbinafine hcl (ANTIFUNGAL) 1 cream (g)
1-Covered
terbinafine hcl (ATHLETES FOOT AF)1 cream (g)
1-Covered
terbinafine hcl (ATHLETES FOOT) 1 cream (g)
1-Covered
terbinafine hcl (JOCK ITCH) 1 cream (g)
1-Covered
terbinafine hcl (LAMISIL AT) 1 cream (g)
1-Covered
terbinafine hcl 1 cream (g) 250mg tablet
1-Covered
tioconazole 65 oinpf app 1-Covered
tolnaftate (ANTIFUNGAL CREAM) 1 cream (g)
1-Covered
tolnaftate (ATHLETES FOOT) 1 cream (g)
1-Covered
tolnaftate (FUNGOID-D) 1 cream(g) -
1-Covered
tolnaftate 1 cream (g) 1-Covered
ANTIGOUT AGENTS (Drugs for Gout)
ANTIGOUT AGENTSallopurinol 100 mg tablet 300 mgtablet
1-Covered
ALLOPURINOL 100 MG TABLET 300MG TABLET
1-Covered
colchicine 06 mg tablet 1-Covered
COLCHICINE 06 MG TABLET 1-Covered
probenecid 500 mg tablet 1-Covered
probenecidcolchicine 500-05 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
24
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIMIGRAINE AGENTS (Drugs for Migraine)
ERGOT ALKALOIDSergotamine tartratecaffeine 1mg-100mg tablet
1-Covered
SEROTONIN (5-HT) 1B1D RECEPTOR AGONISTSrizatriptan benzoate 5 mg tablet10 mg tablet
1-Covered QL (12 PER 30 DAY(S)) AL1 (Atleast 6 yrs old)
SUMATRIPTAN 5 MG SPRAY 20 MGSPRAY
1-Covered QL (6 PER 30 DAY(S))
sumatriptan 5 mg 20 mg 1-Covered QL (6 PER 30 DAY(S))
sumatriptan succinate 25 mgtablet 50 mg tablet 100 mg tablet
1-Covered QL (9 PER 30 DAY(S))
SUMATRIPTAN SUCCINATE 25 MGTABLET 50 MG TABLET 100 MGTABLET
1-Covered QL (9 PER 30 DAY(S))
SUMATRIPTAN SUCCINATE 6 MG05ML CART
1-Covered QL (2 PER FILL(S)) MFL (1 30day(s))
SUMATRIPTAN SUCCINATE 6 MG05ML INJECT
1-Covered QL (2 PER 30 DAY(S)) MFL (1 30day(s))
sumatriptan succinate 6 mg05mlcartridge 6 mg05ml vial
1-Covered QL (2 PER FILL(S)) MFL (1 30day(s))
sumatriptan succinate 6 mg05mlpen injctr 6 mg05ml syringe
1-Covered QL (2 PER 30 DAY(S)) MFL (1 30day(s))
ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis)
PARASYMPATHOMIMETICSMESTINON (pyridostigminebromide) 60 MG5 ML SOLUTION
1-Covered
pyridostigmine bromide 60 mg5ml solution 60 mg tablet 180 mgtablet er
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
25
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections)
ANTIMYCOBACTERIALS OTHER (Other Drugs for MycobacterialInfection)
dapsone 25 mg tablet 100 mgtablet
1-Covered
rifabutin 150 mg capsule 1-Covered
ANTITUBERCULARS (Drugs for Tuberculosis)ethambutol hcl 100 mg tablet 400mg tablet
1-Covered
ETHAMBUTOL HCL 100 MG TABLET400 MG TABLET
1-Covered
isoniazid 50 mg5 ml solution 100mg tablet 300 mg tablet
1-Covered
PRIFTIN (rifapentine) 150 MG TABLET 1-Covered AL1 (At least 12 yrs old)
pyrazinamide 500 mg tablet 1-Covered
rifampin 150 mg capsule 300 mgcapsule
1-Covered
ANTINEOPLASTICS (Drugs for Cancer)
ALKYLATING AGENTScyclophosphamide 25 mgcapsule 50 mg capsule
1-Covered PA
CYCLOPHOSPHAMIDE 25 MGCAPSULE 50 MG CAPSULE
1-Covered PA
GLEOSTINE (lomustine) 10 MGCAPSULE 40 MG CAPSULE 100 MGCAPSULE
1-Covered PA
HEXALEN (altretamine) 50 MGCAPSULE
1-Covered
LEUKERAN (chlorambucil) 2 MGTABLET
1-Covered PA
MATULANE (procarbazine hcl) 50MG CAPSULE
1-Covered PA SP
melphalan 2 mg tablet 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
26
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
MYLERAN (busulfan) 2 MG TABLET 1-Covered
temozolomide 20 mg capsule 1-Covered PA SP
ANTIANDROGENSbicalutamide 50 mg tablet 1-Covered PA
flutamide 125 mg capsule 1-Covered PA
ANTIANGIOGENIC AGENTSTHALOMID (thalidomide) 50 MGCAPSULE
1-Covered PA SP
ANTIESTROGENSMODIFIERSEMCYT (estramustine phosphatesodium) 140 MG CAPSULE
1-Covered PA
TAMOXIFEN CITRATE 10 MG TABLET 1-Covered
tamoxifen citrate 10 mg tablet 20mg tablet
1-Covered
TOREMIFENE CITRATE 60 MG TAB 1-Covered PA
toremifene citrate 60 mg tablet 1-Covered PA
ANTIMETABOLITEScapecitabine 500 mg tablet 1-Covered PA SP
CAPECITABINE 500 MG TABLET 1-Covered PA SP
DROXIA (hydroxyurea) 200 MGCAPSULE 300 MG CAPSULE 400MG CAPSULE
1-Covered
fluorouracil (ADRUCIL) 25 g50mlvial 5 g100 ml vial
1-Covered PA
hydroxyurea 500 mg capsule 1-Covered PA
mercaptopurine 50 mg tablet 1-Covered PA
TABLOID (thioguanine) 40 MGTABLET
1-Covered PA
ANTINEOPLASTICS OTHERLEUCOVORIN CALCIUM 5 MG TAB25 MG TAB
1-Covered
leucovorin calcium 5 mg tablet 10mg tablet 15 mg tablet 25 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
27
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LYSODREN (mitotane) 500 MGTABLET
1-Covered PA
AROMATASE INHIBITORS 3RD GENERATIONanastrozole 1 mg tablet 1-Covered
ANASTROZOLE 1 MG TABLET 1-Covered
letrozole 25 mg tablet 1-Covered
ENZYME INHIBITORSetoposide 50 mg capsule 1-Covered PA
MOLECULAR TARGET INHIBITORSJAKAFI (ruxolitinib phosphate) 5MG TABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET 25 MGTABLET
1-Covered PA SP QL (2 PER 1 DAY(S))
RETINOIDStretinoin 10 mg capsule 1-Covered PA
ANTIPARASITICS (Drugs for Parasitic Infections)
ANTIHELMINTHICS (Drugs for Worm Infection)mebendazole (EMVERM) 100 mgtab chew
1-Covered
praziquantel 600 mg tablet 1-Covered
ANTIPROTOZOALS (Drugs for Protozoal Infection)chloroquine phosphate 250 mgtablet
1-Covered QL (25 PER 30 DAY(S))
chloroquine phosphate 500 mgtablet
1-Covered PA QL (25 PER 30 DAY(S))
HYDROXYCHLOROQUINE SULFATE200 MG TAB
1-Covered QL (3 PER 1 DAY(S))
hydroxychloroquine sulfate 200 mgtablet
1-Covered QL (3 PER 1 DAY(S))
mefloquine hcl 250 mg tablet 1-Covered
primaquine phosphate 263 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
28
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PEDICULICIDESSCABICIDES (Drugs for Scabies and Lice)permethrin (LICE TREATMENT) 1 liquid
1-Covered
permethrin 5 cream (g) 1-Covered
ANTIPARKINSON AGENTS (Drugs for Parkinsons Disease)
ANTICHOLINERGICSbenztropine mesylate 05 mgtablet 1 mg tablet 2 mg tablet 2mg2 ml ampul 2 mg2 ml vial
2-MedicalCarve out
COGENTIN (benztropine mesylate)2 MG2 ML AMPULE
2-MedicalCarve out
trihexyphenidyl hcl 2 mg5 ml elixir2 mg tablet 5 mg tablet
2-MedicalCarve out
ANTIPARKINSON AGENTS OTHERAMANTADINE 100 MG CAPSULE 2-Medical
Carve out
amantadine hcl 50 mg5 mlsolution 100 mg capsule 100 mgtablet
2-MedicalCarve out
entacapone 200 mg tablet 1-Covered ST
GOCOVRI (amantadine hcl) ER685 MG CAPSULE ER 137 MGCAPSULE
2-MedicalCarve out
OSMOLEX ER (amantadine hcl) ER129 MG TABLET ER 193 MG TABLETER 258 MG TABLET ER 322 MGDAILY DOSE
2-MedicalCarve out
DOPAMINE AGONISTSbromocriptine mesylate 25 mgtablet
1-Covered
pramipexole di-hcl -0125 mgtablet -025 mg tablet -05 mgtablet -075 mg tablet -1 mgtablet -15 mg tablet
1-Covered
ropinirole hcl 025 mg tablet 05mg tablet 1 mg tablet 2 mgtablet 3 mg tablet 4 mg tablet 5mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
29
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DOPAMINE PRECURSORSL-AMINO ACID DECARBOXYLASEINHIBITORS
carbidopalevodopa 10mg-100mgtablet 25mg-100mg tablet 25mg-100mg tablet er 25mg-250mgtablet 50mg-200mg tablet er
1-Covered
MONOAMINE OXIDASE B (MAO-B) INHIBITORSselegiline hcl 5 mg tablet 5 mgcapsule
1-Covered
ANTIPSYCHOTICS (Drugs for Mental Health)
1ST GENERATIONTYPICALADASUVE (loxapine) 10 MG POWD10 MG POWDR
2-MedicalCarve out
chlorpromazine hcl 10 mg tablet25 mg tablet 25 mgml ampul 50mg tablet 100 mg tablet 200 mgtablet
2-MedicalCarve out
CHLORPROMAZINE HCL 10 MGTABLET 25 MGML AMPULE 25 MGTABLET 50 MG TABLET 50 MG2 MLAMP 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
fluphenazine decanoate 25 mgmlvial
2-MedicalCarve out
fluphenazine hcl 1 mg tablet 25mg tablet 25 mg5ml elixir 25mgml vial 5 mgml oral conc 5mg tablet 10 mg tablet
2-MedicalCarve out
FLUPHENAZINE HCL 1 MG TABLET25 MG TABLET 5 MG TABLET 10MG TABLET
2-MedicalCarve out
HALDOL (haloperidol lactate) 5MGML AMPUL
2-MedicalCarve out
HALDOL DECANOATE 100(haloperidol decanoate) AMPUL
2-MedicalCarve out
HALDOL DECANOATE 50(haloperidol decanoate) AMPUL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
30
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
haloperidol 05 mg tablet 1 mgtablet 2 mg tablet 5 mg tablet 10mg tablet 20 mg tablet
2-MedicalCarve out
HALOPERIDOL 5 MG TABLET 2-MedicalCarve out
haloperidol decanoate 50 mgmlvial 50 mgml ampul 100 mgmlampul 100 mgml vial
2-MedicalCarve out
haloperidol lactate 2 mgml oralconc 5 mgml vial 5 mgmlampul 5 mgml syringe
2-MedicalCarve out
HALOPERIDOL LACTATE 5 MGMLSYRING
2-MedicalCarve out
loxapine succinate 5 mg capsule10 mg capsule 25 mg capsule 50mg capsule
2-MedicalCarve out
molindone hcl 5 mg tablet 10 mgtablet 25 mg tablet
2-MedicalCarve out
ORAP (pimozide) 1 MG TABLET 2MG TABLET
2-MedicalCarve out
pimozide 1 mg tablet 2 mg tablet 2-MedicalCarve out
thioridazine hcl 10 mg tablet 25mg tablet 50 mg tablet 100 mgtablet
2-MedicalCarve out
thiothixene 1 mg capsule 2 mgcapsule 5 mg capsule 10 mgcapsule
2-MedicalCarve out
trifluoperazine hcl 1 mg tablet 2mg tablet 5 mg tablet 10 mgtablet
2-MedicalCarve out
2ND GENERATIONATYPICALABILIFY (aripiprazole) 2 MG TABLET5 MG TABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET 30 MGTABLET
2-MedicalCarve out
ABILIFY MAINTENA (aripiprazole) ER300 MG VL ER 300 MG SYR ER 400MG SYR ER 400 MG VL
2-MedicalCarve out
ABILIFY MYCITE (aripiprazole) 2 MGKIT 5 MG KIT 10 MG KIT 15 MG KIT20 MG KIT 30 MG KIT
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
31
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
aripiprazole 1 mgml solution 2 mgtablet 5 mg tablet 10 mg tabrapdis 10 mg tablet 15 mg tablet15 mg tab rapdis 20 mg tablet 30mg tablet
2-MedicalCarve out
ARIPIPRAZOLE 1 MGML SOLUTION2 MG TABLET 5 MG TABLET 10 MGTABLET 15 MG TABLET 20 MGTABLET 30 MG TABLET
2-MedicalCarve out
ARISTADA (aripiprazole lauroxil) ER441 MG16 ML SYRN ER 662MG24 ML SYRN ER 882 MG32ML SYRN ER 1064 MG39 ML SYR
2-MedicalCarve out
ARISTADA INITIO (aripiprazolelauroxil submicronized) ER 675MG24
2-MedicalCarve out
CAPLYTA (lumateperone tosylate)42 MG CAPSULE
2-MedicalCarve out
FANAPT (iloperidone) 1 MG TABLET2 MG TABLET 4 MG TABLET 6 MGTABLET 8 MG TABLET 10 MGTABLET 12 MG TABLET TITRATIONPACK
2-MedicalCarve out
GEODON (ziprasidone hcl) 20 MGCAPSULE 40 MG CAPSULE 60 MGCAPSULE 80 MG CAPSULE
2-MedicalCarve out
GEODON (ziprasidone mesylate)20 MGML VIAL
2-MedicalCarve out
INVEGA (paliperidone) ER 15 MGTABLET ER 3 MG TABLET ER 6 MGTABLET ER 9 MG TABLET
2-MedicalCarve out
INVEGA SUSTENNA (paliperidonepalmitate) 39 MG025 ML 78MG05 ML 117 MG075 ML 156MGML SYRG 234 MG15 ML
2-MedicalCarve out
INVEGA TRINZA (paliperidonepalmitate) 273 MG0875 ML 410MG1315 ML 546 MG175 ML 819MG2625 ML
2-MedicalCarve out
LATUDA (lurasidone hcl) 20 MGTABLET 40 MG TABLET 60 MGTABLET 80 MG TABLET 120 MGTABLET
2-MedicalCarve out
NUPLAZID (pimavanserin tartrate)10 MG TABLET 17 MG TABLET 34MG CAPSULE
2-MedicalCarve out
SP
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
32
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
olanzapine 25 mg tablet 5 mgtab rapdis 5 mg tablet 75 mgtablet 10 mg tab rapdis 10 mgtablet 10 mg vial 15 mg tabrapdis 15 mg tablet 20 mg tablet20 mg tab rapdis
2-MedicalCarve out
paliperidone 15 mg tab er 24 3mg tab er 24 6 mg tab er 24 9 mgtab er 24
2-MedicalCarve out
PERSERIS (risperidone) ER 90 MGSYRINGE KIT ER 120 MG SYRINGEKIT
2-MedicalCarve out
quetiapine fumarate 25 mg tablet50 mg tab er 24h 50 mg tablet100 mg tablet 150 mg tab er 24h200 mg tab er 24h 200 mg tablet300 mg tablet 300 mg tab er 24h400 mg tab er 24h 400 mg tablet
2-MedicalCarve out
REXULTI (brexpiprazole) 025 MGTABLET 05 MG TABLET 1 MGTABLET 2 MG TABLET 3 MG TABLET4 MG TABLET
2-MedicalCarve out
RISPERDAL (risperidone) 025 MGTABLET 05 MG TABLET 1 MGMLSOLUTION 1 MG TABLET 2 MGTABLET 3 MG TABLET 4 MG TABLET
2-MedicalCarve out
RISPERDAL CONSTA (risperidonemicrospheres) 125 MG VIAL 25MG VIAL 375 MG VIAL 50 MGVIAL
2-MedicalCarve out
RISPERDAL M-TAB (risperidone) -TAB05 G ODT -TAB 1 G ODT -TAB 2 GODT -TAB 3 G ODT -TAB 4 G ODT
2-MedicalCarve out
risperidone 025 mg tab rapdis025 mg tablet 05 mg tab rapdis05 mg tablet 1 mg tablet 1mgml solution 1 mg tab rapdis 2mg tab rapdis 2 mg tablet 3 mgtablet 3 mg tab rapdis 4 mg tabrapdis 4 mg tablet
2-MedicalCarve out
SAPHRIS (asenapine maleate) 25MG TAB 5 MG TAB 10 MG TAB
2-MedicalCarve out
SECUADO (asenapine) 38 MG24HR PATCH 57 MG24 HR PATCH76 MG24 HR PATCH
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
33
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SEROQUEL (quetiapine fumarate)25 MG TABLET 50 MG TABLET 100MG TABLET 200 MG TABLET 300MG TABLET 400 MG TABLET
2-MedicalCarve out
SEROQUEL XR (quetiapinefumarate) 50 MG TABLET 150 MGTABLET 200 MG TABLET 300 MGTABLET 400 MG TABLET
2-MedicalCarve out
VRAYLAR (cariprazine hcl) 15 MG-3 MG PACK 15 MG CAPSULE 3MG CAPSULE 45 MG CAPSULE 6MG CAPSULE
2-MedicalCarve out
ziprasidone hcl 20 mg capsule 40mg capsule 60 mg capsule 80 mgcapsule
2-MedicalCarve out
ZIPRASIDONE HCL 20 MG CAPSULE40 MG CAPSULE 60 MG CAPSULE80 MG CAPSULE
2-MedicalCarve out
ZIPRASIDONE MESYLATE 20 MGMLVIAL
2-MedicalCarve out
ziprasidone mesylate fnl 20mg1vial
2-MedicalCarve out
ZYPREXA (olanzapine) 25 MGTABLET 5 MG TABLET 75 MGTABLET 10 MG VIAL 10 MG TABLET15 MG TABLET 20 MG TABLET
2-MedicalCarve out
ZYPREXA RELPREVV (olanzapinepamoate) 210 MG VL KIT 300 MGVL KIT 405 MG VL KIT
2-MedicalCarve out
ZYPREXA ZYDIS (olanzapine) 5 MGTABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET
2-MedicalCarve out
TREATMENT-RESISTANTclozapine 125 mg tab rapdis 25mg tab rapdis 25 mg tablet 50mg tablet 100 mg tablet 100 mgtab rapdis 150 mg tab rapdis 200mg tablet 200 mg tab rapdis
2-MedicalCarve out
CLOZAPINE 25 MG TABLET 50 MGTABLET 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
CLOZAPINE ODT ODT 150 MGTABLET ODT 200 MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
34
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CLOZARIL (clozapine) 25 MGTABLET 50 MG TABLET 100 MGTABLET 200 MG TABLET
2-MedicalCarve out
FAZACLO (clozapine) 125 MGODT 25 MG ODT 100 MG ODT 150MG ODT 200 MG ODT
2-MedicalCarve out
VERSACLOZ (clozapine) 50 MGMLSUSPENSION
2-MedicalCarve out
ANTISPASTICITY AGENTS (Drugs for Muscle Spasm)baclofen 10 mg tablet 20 mgtablet
1-Covered QL (90 PER 30 DAYS)
BACLOFEN 10 MG TABLET 20 MGTABLET
1-Covered QL (90 PER 30 DAYS)
tizanidine hcl 2 mg tablet 4 mgtablet
1-Covered QL (90 PER 30 DAY(S))
ANTIVIRALS (Drugs for Viral Infections)
ANTI-HEPATITIS B (HBV) AGENTSEPIVIR HBV (lamivudine) 100 MGTABLET
2-MedicalCarve out
EPIVIR HBV (lamivudine) 25 MG5ML SOLN
1-Covered PA
lamivudine 100 mg tablet 1-Covered PA
VEMLIDY (tenofovir alafenamide)25 MG TABLET
2-MedicalCarve out
ANTI-HEPATITIS C (HCV) AGENTS DIRECT ACTING AGENTSsofosbuvirvelpatasvir 400-100 mgtablet
1-Covered PA SP
ANTI-HEPATITIS C (HCV) AGENTS OTHERINTRON A (interferon alfa-2brecomb) 10 MILLION UNITS VIL -18 MILLION UNITS VIL - 18 MILLIONUNIT3 ML - 25 MILLION UNIT25ML- 50 MILLION UNITS VIL -
1-Covered PA SP
PEGINTRON REDIPEN(peginterferon alfa-2b) 50 MCG -
1-Covered PA SP
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
35
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ribavirin (RIBASPHERE) 200 mgtablet
1-Covered PA
ribavirin 200 mg tablet 1-Covered PA
ANTI-HIV AGENTSCIMDUO (lamivudinetenofovirdisoproxil fumarate) 300-300 MGTABLET
2-MedicalCarve out
EFAVIRENZ-LAMIVU-TENOFOVDISOP --600-300-300
2-MedicalCarve out
SYMFI(efavirenzlamivudinetenofovirdisoproxil fumarate) 600-300-300MG TABLET
2-MedicalCarve out
TEMIXYS (lamivudinetenofovirdisoproxil fumarate) 300-300 MGTABLET
2-MedicalCarve out
ANTI-HIV AGENTS INTEGRASE INHIBITORS (INSTI)BIKTARVY (bictegravirsodiumemtricitabinetenofoviralafenamide fumar) 50-200-25 MGTABLET
2-MedicalCarve out
GENVOYA(elvitegravircobicistatemtricitabinetenofovir alafenamide) TABLET
2-MedicalCarve out
ISENTRESS (raltegravir potassium) 25MG TABLET CHEW 100 MG TABLETCHEW 100 MG POWDER PACKET400 MG TABLET
2-MedicalCarve out
ISENTRESS HD (raltegravirpotassium) 600 MG TABLET
2-MedicalCarve out
STRIBILD(elvitegravircobicistatemtricitabinetenofovir disoproxil) TABLET
2-MedicalCarve out
TIVICAY (dolutegravir sodium) 10MG TABLET 25 MG TABLET 50 MGTABLET
2-MedicalCarve out
TIVICAY PD 5 MG TAB FOR SUSP 2-MedicalCarve out
VITEKTA (elvitegravir) 85 MGTABLET 150 MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
36
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTI-HIV AGENTS NON-NUCLEOSIDE REVERSE TRANSCRIPTASEINHIBITORS (NNRTI)
ATRIPLA(efavirenzemtricitabinetenofovirdisoproxil fumarate) TABLET
2-MedicalCarve out
COMPLERA(emtricitabinerilpivirinehcltenofovir disoproxil fumarate)TABLET
2-MedicalCarve out
DELSTRIGO(doravirinelamivudinetenofovirdisoproxil fumarate) 100-300-300MG TAB
2-MedicalCarve out
EDURANT (rilpivirine hcl) 25 MGTABLET
2-MedicalCarve out
efavirenz 50 mg capsule 200 mgcapsule 600 mg tablet
2-MedicalCarve out
EFAVIRENZ-EMTRIC-TENOFOVDISOP --600-200-300
2-MedicalCarve out
EFAVIRENZ-LAMIVU-TENOFOVDISOP --400-300-300
2-MedicalCarve out
INTELENCE (etravirine) 25 MGTABLET 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
nevirapine 50 mg5 ml oral susp100 mg tab er 24h 200 mg tablet400 mg tab er 24h
2-MedicalCarve out
ODEFSEY (emtricitabinerilpivirinehcltenofovir alafenamidefumarate) TABLET
2-MedicalCarve out
PIFELTRO (doravirine) 100 MGTABLET
2-MedicalCarve out
RESCRIPTOR (delavirdine mesylate)100 MG TABLET 200 MG TABLET
2-MedicalCarve out
SUSTIVA (efavirenz) 50 MGCAPSULE 200 MG CAPSULE 600MG TABLET
2-MedicalCarve out
SYMFI LO(efavirenzlamivudinetenofovirdisoproxil fumarate) 400-300-300MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
37
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
VIRAMUNE (nevirapine) 50 MG5ML SUSP 200 MG TABLET
2-MedicalCarve out
VIRAMUNE XR (nevirapine) 100 MGTABLET 400 MG TABLET
2-MedicalCarve out
ANTI-HIV AGENTS NUCLEOSIDE AND NUCLEOTIDE REVERSETRANSCRIPTASE INHIBITORS (NRTI)
abacavir sulfate 20 mgml solution300 mg tablet
2-MedicalCarve out
abacavir sulfatelamivudine 600-300mg tablet
2-MedicalCarve out
abacavirsulfatelamivudinezidovudineabacavirlamivudinezidovudine150-300 mg tablet
2-MedicalCarve out
ABACAVIR-LAMIVUDINE -600-300MG
2-MedicalCarve out
COMBIVIR (lamivudinezidovudine)TABLET
2-MedicalCarve out
EMTRICITABINE 200 MG CAPSULE 2-MedicalCarve out
EMTRICITABINE-TENOFOVIR DISOP -TENOFV 200-300MG
2-MedicalCarve out
EMTRIVA (emtricitabine) 10 MGMLSOLUTION 200 MG CAPSULE
2-MedicalCarve out
EPIVIR (lamivudine) 10 MGMLORAL SOLN 150 MG TABLET 300MG TABLET
2-MedicalCarve out
EPZICOM (abacavirsulfatelamivudine) TABLET
2-MedicalCarve out
lamivudine 10 mgml solution 150mg tablet 300 mg tablet
2-MedicalCarve out
lamivudinezidovudine 150-300mgtablet 150-300 mg tablet
2-MedicalCarve out
stavudine 1 mgml soln recon 15mg capsule 20 mg capsule 30 mgcapsule 40 mg capsule
2-MedicalCarve out
tenofovir disoproxil fumarate 300mg tablet
2-MedicalCarve out
TRIZIVIR (abacavirsulfatelamivudinezidovudine)TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
38
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRUVADA (emtricitabinetenofovirdisoproxil fumarate) 100 MG-150MG TABLET 133 MG-200 MGTABLET 167 MG-250 MG TABLET200 MG-300 MG TABLET
2-MedicalCarve out
VIREAD (tenofovir disoproxilfumarate) 150 MG TABLET 200 MGTABLET 250 MG TABLET 300 MGTABLET POWDER
2-MedicalCarve out
ZERIT (stavudine) 1 MGMLSOLUTION 15 MG CAPSULE 20 MGCAPSULE 30 MG CAPSULE 40 MGCAPSULE
2-MedicalCarve out
ZIAGEN (abacavir sulfate) 20MGML SOLUTION 300 MG TABLET
2-MedicalCarve out
ANTI-HIV AGENTS OTHERDESCOVY (emtricitabinetenofoviralafenamide fumarate) 200-25 MGTABLET
2-MedicalCarve out
DOVATO (dolutegravirsodiumlamivudine) 50-300 MGTABLET
2-MedicalCarve out
FUZEON (enfuvirtide) 90 MG VIAL 2-MedicalCarve out
SP
JULUCA (dolutegravirsodiumrilpivirine hcl) 50-25 MGTABLET
2-MedicalCarve out
RUKOBIA ER 600 MG TABLET 2-MedicalCarve out
SELZENTRY (maraviroc) 20 MGMLORAL SOLN 25 MG TABLET 75 MGTABLET 150 MG TABLET 300 MGTABLET
2-MedicalCarve out
TRIUMEQ (abacavirsulfatedolutegravirsodiumlamivudine) 600-50-300 MGTABLET
2-MedicalCarve out
TROGARZO (ibalizumab-uiyk) 200MG133 ML VIAL -
2-MedicalCarve out
TYBOST (cobicistat) 150 MG TABLET 2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
39
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTI-HIV AGENTS PROTEASE INHIBITORSAPTIVUS (tipranavir) 250 MGCAPSULE
2-MedicalCarve out
APTIVUS (tipranavirvitamin e tpgs)100 MGML SOLUTION
2-MedicalCarve out
ATAZANAVIR SULFATE 150 MG CAP200 MG CAP 300 MG CAP
2-MedicalCarve out
atazanavir sulfate 150 mg capsule200 mg capsule 300 mg capsule
2-MedicalCarve out
CRIXIVAN (indinavir sulfate) 200MG CAPSULE 400 MG CAPSULE
2-MedicalCarve out
EVOTAZ (atazanavirsulfatecobicistat) 300 MG-150 MGTABLET
2-MedicalCarve out
fosamprenavir calcium 700 mgtablet
2-MedicalCarve out
FOSAMPRENAVIR CALCIUM 700MG TABLET
2-MedicalCarve out
INVIRASE (saquinavir mesylate) 200MG CAPSULE 500 MG TABLET
2-MedicalCarve out
KALETRA (lopinavirritonavir) 80MG-20 MGML SOLN 100-25 MGTABLET 200-50 MG TABLET
2-MedicalCarve out
LEXIVA (fosamprenavir calcium) 50MGML SUSPENSION 700 MGTABLET
2-MedicalCarve out
lopinavirritonavir 400-1005solution
2-MedicalCarve out
NORVIR (ritonavir) 80 MGMLSOLUTION 100 MG TABLET 100 MGSOFTGEL CAP 100 MG POWDERPACKET
2-MedicalCarve out
PREZCOBIX (darunavirethanolatecobicistat) 800 MG-150MG TABLET
2-MedicalCarve out
PREZISTA (darunavir ethanolate) 75MG TABLET 100 MGMLSUSPENSION 150 MG TABLET 400MG TABLET 600 MG TABLET 800MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
40
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
REYATAZ (atazanavir sulfate) 50MG POWDER PACKET 150 MGCAPSULE 200 MG CAPSULE 300MG CAPSULE
2-MedicalCarve out
ritonavir 100 mg tablet 2-MedicalCarve out
SYMTUZA (darunavirethcobicistatemtricitabinetenofovir alafenamide) 800-150-200-10MG TAB
2-MedicalCarve out
VIRACEPT (nelfinavir mesylate) 250MG TABLET 625 MG TABLET
2-MedicalCarve out
ANTI-INFLUENZA AGENTSoseltamivir phosphate 30 mgcapsule 45 mg capsule 75 mgcapsule
1-Covered QL (10 PER 30 DAY(S)) MFL (1 180 day(s))
OSELTAMIVIR PHOSPHATE 30 MGCAPSULE 45 MG CAPSULE 75 MGCAPSULE
1-Covered QL (10 PER 30 DAY(S)) MFL (1 180 day(s))
oseltamivir phosphate 6 mgmlsusp recon
1-Covered QL (120 PER FILL(S)) MFL (120 180day(s))
OSELTAMIVIR PHOSPHATE 6 MGMLSUSPENSION
1-Covered QL (120 PER FILL(S)) MFL (120 180day(s))
RELENZA (zanamivir) 5 MGDISKHALER
1-Covered QL (20 PER 30 DAY(S))
ANTIHERPETIC AGENTSacyclovir 200 mg capsule 200mg5ml oral susp 400 mg tablet800 mg tablet
1-Covered
ACYCLOVIR 200 MG5 ML SUSP400 MG TABLET 800 MG TABLET
1-Covered
trifluridine 1 drops 1-Covered
valacyclovir hcl 500 mg tablet1000 mg tablet
1-Covered QL (60 PER 30 DAY(S))
ANXIOLYTICS (Drugs for Anxiety)
ANXIOLYTICS OTHER (Other Drugs for Anxiety)BUSPIRONE HCL 5 MG TABLET 10MG TABLET 15 MG TABLET 30 MGTABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
41
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
buspirone hcl 5 mg tablet 75 mgtablet 10 mg tablet 15 mg tablet30 mg tablet
1-Covered
BENZODIAZEPINESalprazolam (ALPRAZOLAMINTENSOL) 1 mgml oral conc
1-Covered
alprazolam 025 mg tablet 05 mgtablet 1 mg tablet 2 mg tablet
1-Covered QL (100 PER 30 DAYS)
clonazepam 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered QL (120 PER 30 DAY(S))
diazepam 2 mg tablet 5 mgtablet 10 mg tablet
1-Covered QL (100 PER 30 DAYS)
diazepam 5 mg5 ml solution 5mgml oral conc
1-Covered
lorazepam (LORAZEPAM INTENSOL)2 mgml oral conc
1-Covered
lorazepam 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered QL (100 PER 30 DAYS)
lorazepam 2 mgml oral conc 1-Covered
oxazepam 10 mg capsule 15 mgcapsule 30 mg capsule
1-Covered
BIPOLAR AGENTS (Drugs for Bipolar Disorder)
MOOD STABILIZERSlithium carbonate 150 mg capsule300 mg tablet er 300 mg capsule300 mg tablet 450 mg tablet er600 mg capsule
2-MedicalCarve out
lithium citrate 8 meq5 ml solution 2-MedicalCarve out
LITHOBID (lithium carbonate) ER300 MG TABLET
2-MedicalCarve out
BLOOD GLUCOSE REGULATORS (Drugs for Diabetes)
ANTIDIABETIC AGENTS (Drugs for High Blood Sugar)acarbose 100 mg tablet 1-Covered QL (3 PER 1 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
42
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acarbose 25 mg tablet 1-Covered QL (12 PER 1 DAYS)
acarbose 50 mg tablet 1-Covered QL (6 PER 1 DAYS)
ADLYXIN (lixisenatide) 10-20 MCGSTARTER PACK 20 MCGMAINTENANCE PK
1-Covered PA
alogliptin benzoate 625 mg tablet125 mg tablet 25 mg tablet
1-Covered ST
alogliptin benzoatemetformin hclbenzmetformin 125-1000 tabletbenzmetformin 125-500mg tablet
1-Covered ST
alogliptin benzoatepioglitazonehcl benzpioglitazone 125-15 mgtablet benzpioglitazone 125-45mg tablet benzpioglitazone 125-30 mg tablet benzpioglitazone 25mg-30mg tabletbenzpioglitazone 25 mg-45mgtablet benzpioglitazone 25 mg-15mg tablet
1-Covered ST
AVANDIA (rosiglitazone maleate) 2MG TABLET 4 MG TABLET
1-Covered QL (60 PER 30 DAYS)
glimepiride 1 mg tablet 2 mgtablet 4 mg tablet
1-Covered STAR (Preferred Drug)
glipizide 25 mg tab er 24 5 mgtablet 5 mg tab er 24 10 mg taber 24 10 mg tablet
1-Covered STAR (Preferred Drug)
glyburide 125 mg tablet 25 mgtablet 5 mg tablet
1-Covered STAR (Preferred Drug)
glyburidemetformin hcl 125-250mg tablet 25-500 mg tablet 5mg-500mg tablet
1-Covered STAR (Preferred Drug)
JARDIANCE (empagliflozin) 10 MGTABLET 25 MG TABLET
1-Covered PA QL (1 PER 1 DAYS)
metformin hcl 500 mg tablet 500mg tab er 24h 750 mg tab er 24h850 mg tablet 1000 mg tablet
1-Covered STAR (Preferred Drug)
METFORMIN HCL ER ER 500 MGTABLET ER 750 MG TABLET
1-Covered STAR (Preferred Drug)
nateglinide 60 mg tablet 120 mgtablet
1-Covered ST
pioglitazone hcl 15 mg tablet 30mg tablet 45 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
43
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PIOGLITAZONE HCL 15 MG TABLET30 MG TABLET 45 MG TABLET
1-Covered
SYNJARDY(empagliflozinmetformin hcl) 5-1000 MG TABLET
1-Covered PA QL (2 PER 1 DAY(S))
SYNJARDY(empagliflozinmetformin hcl) 5-500 MG TABLET 125-500 MGTABLET 125-1000 MG TABLET
1-Covered PA QL (2 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 10-MG TABLET 125-MG TAB
1-Covered PA QL (2 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 25-1000 MG TABLET
1-Covered PA QL (1 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 5-1000 MG TABLET
1-Covered PA QL (2 PER 1)
tolbutamide 500 mg tablet 1-Covered
TRULICITY (dulaglutide) 075MG05 ML PEN 15 MG05 ML PEN
1-Covered PA QLC (1 penweek)
TRULICITY 3 MG05 ML PEN 45MG05 ML PEN
1-Covered PA QL (05 PER 1 WEEK(S))
VICTOZA 2-PAK (liraglutide) -18MG3 ML PEN
1-Covered PA QLC (6 ml (2 pens)30 days)
VICTOZA 3-PAK (liraglutide) -18MGML PEN
1-Covered PA QLC (9 ml (3 pens)30 days)
GLYCEMIC AGENTS (Drugs for Low Blood Sugar)BAQSIMI (glucagon) 3 MG SPRAYTWO PACK 3 MG SPRAY ONEPACK
1-Covered QL (2 PER 30 DAY(S))
GLUCAGON EMERGENCY KIT(glucagon hcl) 1 MG
1-Covered
GLUCAGON EMERGENCY KIT(glucagonhuman recombinant) 1MG
1-Covered
terbinafine hcl (JOCK ITCH) 1 cream (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
44
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
INSULINSADMELOG (insulin lispro) 100UNITML VIAL
1-Covered
ADMELOG SOLOSTAR (insulin lispro)100 UNITML
1-Covered PA
BASAGLAR KWIKPEN U-100 (insulinglarginehuman recombinantanalog) UNITML
1-Covered
HUMALOG (insulin lispro) 100UNITML CARTRIDGE
1-Covered PA
HUMALOG MIX 75-25 (insulin lisproprotamine and insulin lispro) -VIAL (
1-Covered
HUMALOG MIX 75-25 KWIKPEN(insulin lispro protamine and insulinlispro) -(
1-Covered PA
HUMULIN 70-30 (insulin nph humanisophaneinsulin regular human) -VIAL
1-Covered
HUMULIN 7030 KWIKPEN (insulinnph human isophaneinsulinregular human)
1-Covered PA
HUMULIN N (insulin nph humanisophane) 100 UITML VIAL
1-Covered
HUMULIN R (insulin regular human)100 UNITML VIAL
1-Covered
HUMULIN R U-500 (insulin regularhuman) UNITML VIAL
1-Covered
insulin lispro 100ml insuln pen 1-Covered PA
insulin lispro 100ml vial 1-Covered
INSULIN LISPRO PROTAMINE MIX(insulin lispro protamine and insulinlispro) 75-25 KWKPN (
1-Covered PA
NOVOLIN 70-30 (insulin nph humanisophaneinsulin regular human)70-30 100 UNITML VIAL RELION 70-30 VIAL
1-Covered
NOVOLIN N (insulin nph humanisophane) N 100 UNITML VIALRELION N 100 UNITML
1-Covered
NOVOLIN R (insulin regular human)R 100 UNITML VIAL RELION R 100UNITML
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
45
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
BLOOD PRODUCTSMODIFIERSVOLUME EXPANDERS (Drugs forBlood Disorders)
ANTICOAGULANTS (Blood Thinners)COUMADIN (warfarin sodium) 1MG TABLET 2 MG TABLET 25 MGTABLET 3 MG TABLET 4 MG TABLET5 MG TABLET 6 MG TABLET 75 MGTABLET 10 MG TABLET
1-Covered
ELIQUIS (apixaban) 25 MG TABLET5 MG TABLET
1-Covered QL (2 PER 1 DAY(S))
ELIQUIS (apixaban) DVT-PE TREATSTART 5MG
1-Covered QLC (1 PACK6 MONTHS)
ENOXAPARIN SODIUM 120 MG08ML SYR
1-Covered
ENOXAPARIN SODIUM 30 MG03ML SYR 40 MG04 ML SYR 60MG06 ML SYR 80 MG08 ML SYR100 MGML SYRINGE 150 MGMLSYRINGE
1-Covered PA
enoxaparin sodium 30mg03ml40mg04ml 60mg06ml80mg08ml 100 mgml120mg8ml 150 mgml
1-Covered PA
HEPARIN SODIUM SOD 5000UNITML VIAL SOD 10000 UNITMLVL SOD 20000 UNITML VL 50000UNIT5 ML VIAL
1-Covered
heparin sodiumporcine 5000mlvial 10000ml vial 20000ml vial
1-Covered
heparin sodiumporcinepf 1000mlvial
1-Covered
warfarin sodium (JANTOVEN) 1 mgtablet 2 mg tablet 25 mg tablet3 mg tablet 4 mg tablet 5 mgtablet 6 mg tablet 75 mg tablet10 mg tablet
1-Covered
warfarin sodium 1 mg tablet 2 mgtablet 25 mg tablet 3 mg tablet4 mg tablet 5 mg tablet 6 mgtablet 75 mg tablet 10 mg tablet
1-Covered
XARELTO (rivaroxaban) 10 MGTABLET 15 MG TABLET 20 MGTABLET
1-Covered QL (1 PER 1 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
46
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
XARELTO (rivaroxaban) DVT-PETREAT START 30D
1-Covered QLC (1 PACK6 MONTHS)
BLOOD FORMATION MODIFIERS (Blood Formation Drugs)anagrelide hcl 05 mg capsule 1mg capsule
1-Covered
EPOGEN (epoetin alfa) 2000UNITSML VIAL 3000 UNITSMLVIAL 4000 UNITSML VIAL 10000UNITSML VIAL 20000 UNITSMLVIAL
1-Covered PA SP
PROCRIT (epoetin alfa) 2000UNITSML VIAL 3000 UNITSMLVIAL 4000 UNITSML VIAL 10000UNITSML VIAL 20000 UNITSMLVIAL 40000 UNITSML VIAL
1-Covered PA SP
HEMOSTASIS AGENTS (Drugs to Stop Bleeding)ADVATE (antihemophilic factor(fviii) recombinantfull length) 200-400 VIAL 401-800 VIAL 801-1200VIAL 1201-1800 VIAL 1801-2400VIAL 2401-3600 VIAL 3601-4800VIAL
2-MedicalCarve out
ADYNOVATE (antihemophilicfactor (fviii) recombinant fulllength peg) 200-400 VIAL 401-800VIAL 750 VIAL 801-1250 VIAL1251-2500 VL 1500 VIAL 3000VIAL
2-MedicalCarve out
AFSTYLA (antihemophilic factor viiirecombsingle-chnb-domtruncated) 250 VIAL -- 500 VIAL --1000 VIAL -- 1500 RANGE VIAL --2000 VIAL -- 2500 RANGE VIAL --3000 VIAL --
2-MedicalCarve out
ALPHANATE (antihemophilic factorhumanvon willebrandfactorhuman) 250-100 VIALhuman) 500-200 VIAL human)1000-400 VIAL human) 1500-600VIAL human) 2000-800 VIALhuman)
2-MedicalCarve out
ALPHANINE SD (factor ix) SD 500VIAL SD 1000 VIAL SD 1500 VIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
47
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALPROLIX (factor ix recombinantfc fusion protein) 250 500 10002000 3000 4000
2-MedicalCarve out
BENEFIX (factor ix humanrecombinant) 250 500 10002000 3000
2-MedicalCarve out
COAGADEX (coagulation factor x)250 VIAL 500 VIAL
2-MedicalCarve out
CORIFACT (factor xiii) KIT 2-MedicalCarve out
ELOCTATE (antihemophilic factor(fviii) recombinant fc fusionprotein) 250 500 750 1000 15002000 3000 4000 5000 6000
2-MedicalCarve out
ESPEROCT (antihemophilic factor(fviii) rec b-dom truncated peg-exei) 500 VIAL -- 1000 VIAL --1500 VIAL -- 2000 VIAL -- 3000VIAL --
2-MedicalCarve out
FEIBA NF (anti-inhibitor coagulantcomplex) 500 (NOMINAL) - 1000(NOMINAL) - 2500 (NOMINAL) -
2-MedicalCarve out
FIBRYGA (fibrinogen) 1 GRAMRANGE VIAL
2-MedicalCarve out
HELIXATE FS (antihemophilic factor(fviii) recombinantfull length) 250UNIT VIAL 500 UNIT VIAL 1000 UNITVIAL 2000 UNIT VIAL 3000 UNITSVIAL
2-MedicalCarve out
HEMLIBRA (emicizumab-kxwh) 30MGML VIAL - 60 MG04 ML VIAL - 105 MG07 ML VIAL - 150 MGMLVIAL -
2-MedicalCarve out
HEMOFIL M (antihemophilic factorhuman) 250 500 1000 1700
2-MedicalCarve out
HUMATE-P (antihemophilic factorhumanvon willebrandfactorhuman) -600 human) -1200human) -2400 human)
2-MedicalCarve out
IDELVION (factor ixrecombinantalbumin fusionprotein) 250 VIAL 500 VIAL 1000VIAL 2000 VIAL 3500 VIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
48
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
IXINITY (factor ix humanrecombinant threonine 148) 500RANGE 500 VIAL 1000 VIAL 1000RANGE 1000 VIAL -2 VLS 1000RANGE-2 VLS 1500 RANGE-2 VLS1500 VIAL -2 VLS 1500 VIAL 1500RANGE
2-MedicalCarve out
JIVI (antihemophilic factor (fviii)rec b-domain deleted peg-aucl)500 VIAL -- 1000 VIAL -- 2000 VIAL-- 3000 VIAL --
2-MedicalCarve out
KCENTRA (human prothrombincomplex concentrate (pcc) 4-factor) 500 VIAL 4- 1000 VIAL 4-
2-MedicalCarve out
KOGENATE FS (antihemophilicfactor (fviii) recombinantfulllength) 250 UNIT VIAL 500 UNITVIAL 1000 UNITS VIAL 2000 UNITVIAL 3000 UNITS VIAL
2-MedicalCarve out
KOVALTRY (antihemophilic factor(fviii) recombinantfull length) 250KIT 500 KIT 1000 KIT 2000 KIT3000 KIT
2-MedicalCarve out
MONONINE (factor ix) 1000 UNITVIAL
2-MedicalCarve out
NOVOEIGHT (antihemophilic factorviii recombinant b-domaintruncated) 250 VIAL RECOMINANT- 500 VIAL RECOMINANT - 1000VIAL RECOMINANT - 1500 VIALRECOMINANT - 2000 VIALRECOMINANT - 3000 VIALRECOMINANT -
2-MedicalCarve out
NOVOSEVEN RT (coagulationfactor viia (recombinant)) 1 MGVIAL 2 MG VIAL 5 MG VIAL 8 MGVIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
49
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NUWIQ (antihemophilic factor viiirec hek cell b-domain deleted)250 VIAL - 250 VIAL PACK - 500VIAL - 500 VIAL PACK - 1000 VIAL - 1000 VIAL PACK - 2000 VIALPACK - 2000 VIAL - 2500 VIALPACK - 2500 VIAL - 3000 VIAL -3000 VIAL PACK - 4000 VIAL PACK- 4000 VIAL -
2-MedicalCarve out
OBIZUR (antihemophilic factor viiirecombinant porcine sequence)500 VIAL 500 VIAL - 5 VIALS 500VIAL -10 VIALS
2-MedicalCarve out
phytonadione (vit k1) 5 mg tablet 1-Covered
PROFILNINE (factor ix complexprothrombin cplx conc(pcc) no43-factor) 500 VIAL 3- 1000 VIAL 3-1500 VIAL 3-
2-MedicalCarve out
REBINYN (factor ix (human)recombinant pegylated) 500 VIAL1000 VIAL 2000 VIAL
2-MedicalCarve out
RECOMBINATE (antihemophilicfactor viii human recombinant)220-400 VIAL 401-800 VIAL 801-1240 VL 1241-1800 V 1801-2400V
2-MedicalCarve out
RIASTAP (fibrinogen) VIAL 2-MedicalCarve out
RIXUBIS (factor ix humanrecombinant) 250 500 10002000 3000
2-MedicalCarve out
SEVENFACT 1 MG VIAL 5 MG VIAL 2-MedicalCarve out
TRETTEN (factor xiii a-subunitrecombinant) 2500 UNIT VIAL(fctor -recombinnt)
2-MedicalCarve out
VONVENDI (von willebrand factor(recombinant)) 650 VIAL 1300VIAL
2-MedicalCarve out
WILATE (antihemophilic factorhumanvon willebrandfactorhuman) 450-450 VIALhuman) 500-500 VIAL human)900-900 VIAL human) 1000-1000VIAL human)
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
50
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
XYNTHA (antihemophilic factor(factor viii) recombb-domaindeleted) 250 KIT - 500 KIT - 1000KIT - 2000 KIT -
2-MedicalCarve out
XYNTHA SOLOFUSE (antihemophilicfactor (factor viii) recombb-domain deleted) 250 KIT - 500 KIT -1000 KIT - 2000 KIT - 3000 KIT -
2-MedicalCarve out
PLATELET MODIFYING AGENTScilostazol 50 mg tablet 100 mgtablet
1-Covered
clopidogrel bisulfate 75 mg tablet 1-Covered AL1 (At least 18 yrs old)
dipyridamole 25 mg tablet 50 mgtablet 75 mg tablet
1-Covered
CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation)
ALPHA-ADRENERGIC AGONISTSclonidine hcl 01 mg tablet 02 mgtablet 03 mg tablet
1-Covered
CLONIDINE HCL 01 MG TABLET 02MG TABLET 03 MG TABLET
1-Covered
guanfacine hcl 1 mg tablet 2 mgtablet
1-Covered
methyldopa 250 mg tablet 500mg tablet
1-Covered
ALPHA-ADRENERGIC BLOCKING AGENTSdoxazosin mesylate 1 mg tablet 2mg tablet 4 mg tablet 8 mgtablet
1-Covered
PHENOXYBENZAMINE HCL 10 MGCAP
1-Covered
phenoxybenzamine hcl 10 mgcapsule
1-Covered
prazosin hcl 1 mg capsule 2 mgcapsule 5 mg capsule
1-Covered
PRAZOSIN HCL 1 MG CAPSULE 2MG CAPSULE 5 MG CAPSULE
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
51
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terazosin hcl 1 mg capsule 2 mgcapsule 5 mg capsule 10 mgcapsule
1-Covered
TERAZOSIN HCL 1 MG CAPSULE 2MG CAPSULE 5 MG CAPSULE 10MG CAPSULE
1-Covered
ANGIOTENSIN II RECEPTOR ANTAGONISTSirbesartan 75 mg tablet 150 mgtablet 300 mg tablet
1-Covered ST
LOSARTAN POTASSIUM 25 MG TAB50 MG TAB 100 MG TAB
1-Covered STAR (Preferred Drug)
losartan potassium 25 mg tablet50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
valsartan 40 mg tablet 80 mgtablet 160 mg tablet 320 mgtablet
1-Covered ST
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORSbenazepril hcl 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered STAR (Preferred Drug)
captopril 125 mg tablet 25 mgtablet 50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
CAPTOPRIL 125 MG TABLET 25 MGTABLET 50 MG TABLET 100 MGTABLET
1-Covered STAR (Preferred Drug)
ENALAPRIL MALEATE 25 MG TAB 5MG TABLET 10 MG TAB 20 MG TAB
1-Covered STAR (Preferred Drug)
enalapril maleate 25 mg tablet 5mg tablet 10 mg tablet 20 mgtablet
1-Covered STAR (Preferred Drug)
fosinopril sodium 10 mg tablet 20mg tablet 40 mg tablet
1-Covered
lisinopril 25 mg tablet 5 mg tablet10 mg tablet 20 mg tablet 30 mgtablet 40 mg tablet
1-Covered STAR (Preferred Drug)
moexipril hcl 75 mg tablet 15 mgtablet
1-Covered
quinapril hcl 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered
ramipril 125 mg capsule 25 mgcapsule 5 mg capsule 10 mgcapsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
52
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
RAMIPRIL 125 MG CAPSULE 25MG CAPSULE 5 MG CAPSULE 10MG CAPSULE
1-Covered
trandolapril 1 mg tablet 2 mgtablet 4 mg tablet
1-Covered
ANTIARRHYTHMICS (Drugs for Irregular Heart Rhythm)amiodarone hcl (PACERONE) 200mg tablet
1-Covered
amiodarone hcl 200 mg tablet 1-Covered
disopyramide phosphate 100 mgcapsule
1-Covered
flecainide acetate 50 mg tablet100 mg tablet 150 mg tablet
1-Covered
mexiletine hcl 150 mg capsule 200mg capsule 250 mg capsule
1-Covered
MEXILETINE HCL 150 MG CAPSULE200 MG CAPSULE 250 MGCAPSULE
1-Covered
propafenone hcl 150 mg tablet225 mg tablet 300 mg tablet
1-Covered
quinidine gluconate 324 mg tableter
1-Covered
quinidine sulfate 200 mg tablet300 mg tablet
1-Covered
SOTALOL 80 MG TABLET 120 MGTABLET 160 MG TABLET 240 MGTABLET
1-Covered
SOTALOL AF 80 MG TABLET 120 MGTABLET
1-Covered
sotalol hcl (SORINE) 80 mg tablet120 mg tablet 160 mg tablet 240mg tablet
1-Covered
sotalol hcl 80 mg tablet 120 mgtablet 160 mg tablet 240 mgtablet
1-Covered
BETA-ADRENERGIC BLOCKING AGENTSatenolol 25 mg tablet 50 mgtablet 100 mg tablet
1-Covered STAR (Preferred Drug)
ATENOLOL 25 MG TABLET 50 MGTABLET 100 MG TABLET
1-Covered STAR (Preferred Drug)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
53
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
bisoprolol fumarate 5 mg tablet 10mg tablet
1-Covered
carvedilol 3125 mg tablet 625 mgtablet 125 mg tablet 25 mgtablet
1-Covered STAR (Preferred Drug)
labetalol hcl 100 mg tablet 200mg tablet 300 mg tablet
1-Covered
LABETALOL HCL 100 MG TABLET200 MG TABLET 300 MG TABLET
1-Covered
metoprolol succinate 200 mg taber 24h
1-Covered QL (60 PER 30 DAYS) MDD (2 PerDay) STAR (Preferred Drug)
metoprolol succinate 25 mg taber 50 mg tab er 100 mg tab er
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
METOPROLOL SUCCINATE ER 200MG TAB
1-Covered QL (60 PER 30 DAYS) MDD (2 PerDay) STAR (Preferred Drug)
METOPROLOL SUCCINATE ER 25MG TAB ER 50 MG TAB ER 100 MGTAB
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
metoprolol tartrate 25 mg tablet50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
nadolol 20 mg tablet 40 mgtablet 80 mg tablet
1-Covered STAR (Preferred Drug)
NADOLOL 20 MG TABLET 40 MGTABLET 80 MG TABLET
1-Covered STAR (Preferred Drug)
pindolol 5 mg tablet 10 mg tablet 1-Covered STAR (Preferred Drug)
propranolol hcl 10 mg tablet 20mg5 ml solution 20 mg tablet 40mg tablet 40mg5ml solution 60mg tablet 60 mg cap sa 24h 80mg tablet 80 mg cap sa 24h 120mg cap sa 24h 160 mg cap sa 24h
1-Covered
CALCIUM CHANNEL BLOCKING AGENTSAMLODIPINE BESYLATE 25 MG TAB5 MG TAB 10 MG TAB
1-Covered STAR (Preferred Drug)
amlodipine besylate 25 mg tablet5 mg tablet 10 mg tablet
1-Covered STAR (Preferred Drug)
DILTIAZEM 24HR ER (CD) 24HER(CD) 120 MG CP 24H ER(CD)240 MG CP 24H ER(CD) 180 MGCP 24H ER(CD) 360 MG CP 24HER(CD) 300 MG CP
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
54
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DILTIAZEM 24HR ER (XR) 24H ER(XR)240 MG CP 24H ER(XR) 180 MG CP
1-Covered
diltiazem hcl (CARTIA XT) 120 mgcap er 180 mg cap er 240 mgcap er 300 mg cap er
1-Covered
diltiazem hcl (DILT-XR) 120 mg caper - 180 mg cap er - 240 mg caper -
1-Covered
diltiazem hcl (TAZTIA XT) 120 mgcap 180 mg cap 240 mg cap 300mg cap 360 mg cap
1-Covered
diltiazem hcl 30 mg tablet 60 mgcap er 12h 60 mg tablet 90 mgtablet 90 mg cap er 12h 120 mgcap sa 24h 120 mg tablet 120 mgcap er 24h 120 mg cap er deg120 mg cap er 12h 180 mg cap sa24h 180 mg cap er deg 180 mgcap er 24h 240 mg cap er 24h 240mg cap er deg 240 mg cap sa24h 300 mg cap er 24h 300 mgcap sa 24h 360 mg cap sa 24h360 mg cap er 24h
1-Covered
felodipine 25 mg tab er 5 mg taber 10 mg tab er
1-Covered
FELODIPINE ER ER 25 MG TABLETER 5 MG TABLET ER 10 MG TABLET
1-Covered
nicardipine hcl 20 mg capsule 30mg capsule
1-Covered
nifedipine (AFEDITAB CR) 30 mgtablet er 60 mg tablet er
1-Covered
nifedipine (NIFEDICAL XL) 30 mgtab er 24 60 mg tab er 24
1-Covered
NIFEDIPINE 10 MG CAPSULE 1-Covered
nifedipine 10 mg capsule 20 mgcapsule 30 mg tablet er 30 mgtab er 24 60 mg tablet er 60 mgtab er 24 90 mg tablet er 90 mgtab er 24
1-Covered
nisoldipine 20 mg tab er 30 mgtab er 40 mg tab er
1-Covered
verapamil hcl 40 mg tablet 80 mgtablet 120 mg tablet 120 mgtablet er 180 mg tablet er 240 mgtablet er
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
55
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CARDIOVASCULAR AGENTS OTHERamiloride hclhydrochlorothiazideamiloridehydrochlorothiazide 5mg-50 mg tablet
1-Covered
amlodipine besylatebenazeprilhcl 25mg-10mg capsule 5 mg-20mg capsule 5 mg-10 mg capsule5 mg-40 mg capsule 10 mg-20mgcapsule 10 mg-40mg capsule
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day) STAR(Preferred Drug)
atenololchlorthalidone 50 mg-tablet 100mg-tablet
1-Covered STAR (Preferred Drug)
benazepril hclhydrochlorothiazidebenazeprilhydrochlorothiazide 5-625mg tabletbenazeprilhydrochlorothiazide 10-125mg tabletbenazeprilhydrochlorothiazide 20mg-25mg tabletbenazeprilhydrochlorothiazide 20-125 mg tablet
1-Covered STAR (Preferred Drug)
bisoprololfumaratehydrochlorothiazidebisoprololhydrochlorothiazide 25-tabletbisoprololhydrochlorothiazide 5-tabletbisoprololhydrochlorothiazide 10-tablet
1-Covered
BISOPROLOL-HYDROCHLOROTHIAZIDE -10-625MG TAB -25-625 MG TB -5-625MG TAB
1-Covered
captoprilhydrochlorothiazide 25mg-25mg tablet 25 mg-15mgtablet 50 mg-25mg tablet 50 mg-15mg tablet
1-Covered STAR (Preferred Drug)
digoxin (DIGITEK) 125 mcg tablet250 mcg tablet
1-Covered STAR (Preferred Drug)
digoxin (DIGOX) 125 mcg tablet250 mcg tablet
1-Covered STAR (Preferred Drug)
digoxin 125 mcg tablet 250 mcgtablet
1-Covered STAR (Preferred Drug)
digoxin 50 mcgml solution 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
56
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fosinoprilsodiumhydrochlorothiazidefosinoprilhydrochlorothiazide 10-125mg tabletfosinoprilhydrochlorothiazide 20-125 mg tablet
1-Covered
FOSINOPRIL-HYDROCHLOROTHIAZIDE -10-125MG TAB -20-125 MG TAB
1-Covered
irbesartanhydrochlorothiazide150-tablet 300-tablet
1-Covered ST
LANOXIN (digoxin) 125 MCGTABLET 250 MCG TABLET
1-Covered STAR (Preferred Drug)
lisinoprilhydrochlorothiazide 10-125mg tablet 20-125 mg tablet20 mg-25mg tablet
1-Covered STAR (Preferred Drug)
losartanpotassiumhydrochlorothiazidelosartanhydrochlorothiazide 50-125 mg tabletlosartanhydrochlorothiazide100mg-25mg tabletlosartanhydrochlorothiazide 100-125mg tablet
1-Covered STAR (Preferred Drug)
LOSARTAN-HYDROCHLOROTHIAZIDE -50-125MG TAB -100-125 MG TAB -100-25MG TAB
1-Covered STAR (Preferred Drug)
pentoxifylline 400 mg tablet er 1-Covered
spironolactonehydrochlorothiazide spironolacthydrochlorothiazid25 mg-25mg tablet
1-Covered
triamterenehydrochlorothiazide375-25 mg capsule 375-25 mgtablet 50 mg-25mg capsule 75mg-50mg tablet
1-Covered
valsartanhydrochlorothiazide 80-125mg tablet 160-125mg tablet160mg-25mg tablet 320-125mgtablet 320mg-25mg tablet
1-Covered ST
DIURETICS CARBONIC ANHYDRASE INHIBITORSacetazolamide 125 mg tablet 250mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
57
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ACETAZOLAMIDE 125 MG TABLET250 MG TABLET
1-Covered
DIURETICS LOOPbumetanide 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered
furosemide 10 mgml solution 20mg tablet 40mg5ml solution 40mg tablet 80 mg tablet
1-Covered STAR (Preferred Drug)
DIURETICS POTASSIUM-SPARINGamiloride hcl 5 mg tablet 1-Covered
spironolactone 25 mg tablet 50mg tablet 100 mg tablet
1-Covered
SPIRONOLACTONE 25 MG TABLET50 MG TABLET 100 MG TABLET
1-Covered
DIURETICS THIAZIDEchlorothiazide 250 mg tablet 500mg tablet
1-Covered
chlorthalidone 25 mg tablet 50 mgtablet
1-Covered
CHLORTHALIDONE 25 MG TABLET50 MG TABLET
1-Covered
DIURIL (chlorothiazide) 250 MG5ML ORAL SUSP
1-Covered
hydrochlorothiazide 125 mgcapsule 25 mg tablet 50 mgtablet
1-Covered STAR (Preferred Drug)
indapamide 125 mg tablet 25mg tablet
1-Covered
methyclothiazide 5 mg tablet 1-Covered
metolazone 25 mg tablet 5 mgtablet 10 mg tablet
1-Covered
DYSLIPIDEMICS FIBRIC ACID DERIVATIVES (Drugs for HighCholesterol)
fenofibrate 54 mg tablet 160 mgtablet
1-Covered ST
FENOFIBRATE 54 MG TABLET 160MG TABLET
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
58
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fenofibratemicronized 67 mgcapsule 134 mg capsule 200 mgcapsule
1-Covered ST
gemfibrozil 600 mg tablet 1-Covered
GEMFIBROZIL 600 MG TABLET 1-Covered
TRIGLIDE (fenofibratenanocrystallized) 160 MG TABLET
1-Covered ST
DYSLIPIDEMICS HMG COA REDUCTASE INHIBITORS (Drugs for HighCholesterol)
atorvastatin calcium 10 mg tablet20 mg tablet 40 mg tablet 80 mgtablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
ATORVASTATIN CALCIUM 10 MGTABLET 20 MG TABLET 40 MGTABLET 80 MG TABLET
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
lovastatin 10 mg tablet 20 mgtablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
rosuvastatin calcium 5 mg tablet10 mg tablet 20 mg tablet 40 mgtablet
1-Covered ST QL (30 PER 30 DAY(S))
simvastatin 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered STAR (Preferred Drug)
DYSLIPIDEMICS OTHER (Other Drugs for High Cholesterol)cholestyramine (with sugar) suar) 4powder
1-Covered
cholestyramineaspartame(PREVALITE) 4 g powder
1-Covered
cholestyramineaspartame 4 gpowder
1-Covered
COLESTID (colestipol hcl)FLAVORED GRANULES
1-Covered
colestipol hcl 1 tablet 5 ranules 5packet
1-Covered
ezetimibe 10 mg tablet 1-Covered
niacin (ENDUR-ACIN) 250 mgtablet er - 500 mg tablet er - 750mg tablet er -
1-Covered
niacin (SLO-NIACIN) 500 mg tableter -
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
59
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NIACIN 100 MG TABLET TR 500 MGTABLET
1-Covered
niacin 50 mg tablet 100 mg tablet250 mg capsule er 250 mg tablet250 mg tablet er 500 mg tablet500 mg tablet er 500 mg tab er24h 500 mg capsule er 750 mgtablet er 1000 mg tablet er
1-Covered
OMEGA-3 ACID ETHYL ESTERS -1GM CAP
1-Covered QL (4 PER 1 DAY(S))
omega-3 acid ethyl esters omea-1capsule
1-Covered QL (4 PER 1 DAY(S))
VASODILATORS DIRECT-ACTING ARTERIAL (Drugs for RelaxingArteries)
hydralazine hcl 10 mg tablet 25mg tablet 50 mg tablet 100 mgtablet
1-Covered
minoxidil 25 mg tablet 10 mgtablet
1-Covered
VASODILATORS DIRECT-ACTING ARTERIALVENOUS (Drugs forRelaxing Arteries and Veins)
ISOSORBIDE DINITRATE 5 MG TAB10 MG TAB 20 MG TAB 30 MG TAB
1-Covered STAR (Preferred Drug)
isosorbide dinitrate 5 mg tablet 10mg tablet 20 mg tablet 30 mgtablet 40 mg tablet er
1-Covered STAR (Preferred Drug)
isosorbide mononitrate 10 mgtablet 20 mg tablet 30 mg tab er24h 60 mg tab er 24h 120 mg taber 24h
1-Covered STAR (Preferred Drug)
NITRO-BID (nitroglycerin) -2OINTMENT
1-Covered
nitroglycerin (MINITRAN) 01mghrpatch 02mghr patch 04mghrpatch 06mghr patch
1-Covered
nitroglycerin (NITRO-TIME) 25 mgcapsule er - 65 mg capsule er - 9mg capsule er -
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
60
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
nitroglycerin 01mghr patch td2402mghr patch td24 03 mg tabsubl 04mghr patch td24 04 mgtab subl 06 mg tab subl 06mghrpatch td24 25 mg capsule er 65mg capsule er 9 mg capsule er400mcgspr spray
1-Covered
NITROGLYCERIN 400 MCG SPRAY 1-Covered
CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions)
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTSAMPHETAMINES
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 15 mg cap er 24h
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old) MDD (1 Per Day)
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 5 mg cap erdextroamphetamineamphetamine 10 mg cap erdextroamphetamineamphetamine 20 mg cap erdextroamphetamineamphetamine 25 mg cap erdextroamphetamineamphetamine 30 mg cap er
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old)
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 5 mg tabletdextroamphetamineamphetamine 75 mg tabletdextroamphetamineamphetamine 10 mg tabletdextroamphetamineamphetamine 125 mg tabletdextroamphetamineamphetamine 15 mg tabletdextroamphetamineamphetamine 20 mg tabletdextroamphetamineamphetamine 30 mg tablet
1-Covered AL1 (3 to 18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
61
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
dextroamphetamine sulfate(ZENZEDI) 5 mg tablet 10 mgtablet
1-Covered AL1 (3 to 18 yrs old)
dextroamphetamine sulfate 5 mgcapsule er 5 mg tablet 10 mgcapsule er 10 mg tablet 15 mgcapsule er
1-Covered AL1 (3 to 18 yrs old)
DEXTROAMPHETAMINE SULFATE 5MG TAB 10 MG TAB
1-Covered AL1 (3 to 18 yrs old)
DEXTROAMPHETAMINE-AMPHET ER-15 MG CAP
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old) MDD (1 Per Day)
DEXTROAMPHETAMINE-AMPHET ER-ER 5 MG CAP -ER 10 MG CAP -ER20 MG CAP -ER 25 MG CAP -ER 30MG CAP
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old)
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS NON-AMPHETAMINES
atomoxetine hcl 10 mg capsule 18mg capsule 25 mg capsule 40 mgcapsule 60 mg capsule 80 mgcapsule 100 mg capsule
1-Covered PA
guanfacine hcl 1 mg tab er 2 mgtab er 3 mg tab er 4 mg tab er
1-Covered QL (1 PER 1 DAY(S))
METHYLPHENIDATE ER ER 18 MGTAB ER 27 MG TAB ER 36 MG TABER 54 MG TAB
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl (METADATEER) 20 mg tablet er
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl 10 mg tableter 18 mg tab er 24 20 mg tableter 27 mg tab er 24 36 mg tab er24 54 mg tab er 24
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl 5 mg tablet10 mg cpbp 30-70 10 mg tablet20 mg tablet 20 mg cpbp 30-7030 mg cpbp 30-70 40 mg cpbp 30-70 50 mg cpbp 30-70 60 mg cpbp30-70
1-Covered AL1 (6 to 18 yrs old)
METHYLPHENIDATE HCL 5 MGTABLET 10 MG TABLET 20 MGTABLET
1-Covered AL1 (6 to 18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
62
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CENTRAL NERVOUS SYSTEM OTHERacetaminophen (ATHENOL) 325mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (CHILD FEVERREDUCER) 120 mg supprect
1-Covered
acetaminophen (CHILD PAIN REL-FEVER REDUCER) 120 mg supprect-
1-Covered
acetaminophen (CHILDRENSFEVER REDUCER) 120 mg supprect
1-Covered
acetaminophen (CHILDRENSFEVER REDUCING) 120 mgsupprect
1-Covered
acetaminophen (CHILDRENS PAINAND FEVER) 160 mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (CHILDRENSSILAPAP) 160 mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (ED-APAP) 160mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (LITTLE REMEDIESFEVER-PAIN) 160 mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (M-PAP) 160mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (MAPAP) 160mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (MAPAP) 325 mgtablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (MASOPHEN) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRINEXTRA STRENGTH) 500 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRINPAIN RELIEF) 500 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRIN)160 mg5ml elixir -
1-Covered QLC (LIMIT TO 2 FILLS OF 120ML IN30 DAYS)
acetaminophen (NON-ASPIRIN)325 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN amp FEVER)500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
63
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acetaminophen (PAIN RELIEFEXTRA STRENGTH) 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN RELIEF) 160mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (PAIN RELIEF) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN RELIEVER)325 mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PHARBETOL) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (SHAKE THATACHE) 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (TACTINAL) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen 120 mg 650 mg 1-Covered
acetaminophen 160 mg5ml elixir 1-Covered QLC (LIMIT TO 2 FILLS OF 120ML IN30 DAYS)
acetaminophen 160 mg5ml liquid 1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 160 mg5ml oralsusp
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 160 mg5mlsolution
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 325 mg tablet500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
ACETAMINOPHEN CVS 325 MGGELCP 325 MG TABLET 500 MGTABLET 500 MG GELCAP
1-Covered QL (60 PER 30 DAY(S))
butalbitalacetaminophen(TENCON) 50mg-325mg tablet
1-Covered QL (48 PER 30 DAY(S))
butalbitalacetaminophen 50mg-325mg tablet
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
butalbitalacetaminophencaffeine butalbacetaminophencaffeine50-325-40 tablet
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
PAIN amp FEVER (acetaminophen)500 MG TABLET
1-Covered QL (60 PER 30 DAY(S))
PAIN RELIEF 325 MG TABLET 500MG GELCAP 500 MG TABLET
1-Covered QL (60 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
64
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
riluzole 50 mg tablet 1-Covered PA
RILUZOLE 50 MG TABLET 1-Covered PA
FIBROMYALGIA AGENTSduloxetine hcl 20 mg capsule dr30 mg capsule dr 60 mg capsuledr
1-Covered
pregabalin 20 mgml solution 1-Covered PA QLC (30 MLDAY)
pregabalin 225 mg capsule 300mg capsule
1-Covered PA QL (2 PER 1 DAY(S))
PREGABALIN 225 MG CAPSULE 300MG CAPSULE
1-Covered PA QL (2 PER 1 DAY(S))
pregabalin 25 mg capsule 50 mgcapsule 75 mg capsule 100 mgcapsule 150 mg capsule 200 mgcapsule
1-Covered PA QL (3 PER 1 DAY(S))
PREGABALIN 25 MG CAPSULE 50MG CAPSULE 75 MG CAPSULE 100MG CAPSULE 150 MG CAPSULE200 MG CAPSULE
1-Covered PA QL (3 PER 1 DAY(S))
SAVELLA (milnacipran hcl) 125 MGTABLET 25 MG TABLET 50 MGTABLET 100 MG TABLET TITRATIONPACK
1-Covered PA
MULTIPLE SCLEROSIS AGENTSAVONEX (interferon beta-1a)PREFILLED SYR 30 MCG KT -
1-Covered PA SP
AVONEX (interferon beta-1aalbumin human) 30 MCG VIALKIT -
1-Covered PA SP
AVONEX PEN (interferon beta-1a)30 MCG05 ML KIT -
1-Covered PA SP
DIMETHYL FUMARATE 30D START PK 1-Covered PA SP
DIMETHYL FUMARATE DR 120 MGCP DR 240 MG CP
1-Covered PA SP QL (2 PER 1 DAY(S))
glatiramer acetate (GLATOPA) 20mgml syringe
1-Covered PA SP QLC (1 SYRINGEDAY)
glatiramer acetate (GLATOPA) 40mgml syringe
1-Covered PA SP QLC (12SYRINGESMONTH)
glatiramer acetate 20 mgmlsyringe
1-Covered PA SP QLC (1 SYRINGEDAY)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
65
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
glatiramer acetate 40 mgmlsyringe
1-Covered PA SP QLC (12SYRINGESMONTH)
PLEGRIDY (peginterferon beta-1a)125 MCG05 ML SYRING - SYRINGESTARTER PACK -
1-Covered PA SP
PLEGRIDY PEN (peginterferon beta-1a) 125 MCG05 ML PEN - PEN INJSTARTER PACK -
1-Covered PA SP
TECFIDERA (dimethyl fumarate) DR120 MG CAPSULE DR 240 MGCAPSULE STARTER PACK
1-Covered PA SP
DENTAL AND ORAL AGENTS (Drugs for the Mouth)
DENTAL AND ORAL AGENTSchlorhexidine gluconate (PAROEX)012 mouthwash
1-Covered
chlorhexidine gluconate 012 mouthwash
1-Covered
PHOS-FLUR (fluoride (sodium)) -ORAL RINSE
1-Covered
triamcinolone acetonide(ORALONE) 01 paste (g)
1-Covered
triamcinolone acetonide 01 paste (g)
1-Covered
TRIAMCINOLONE ACETONIDE 01PASTE
1-Covered
DERMATOLOGICAL AGENTS (Drugs for the Skin)ACNE MEDICATION (benzoylperoxide) 5 GEL
1-Covered
ACNE MEDICATION 25 GEL 1-Covered
ammonium lactate (SKINTREATMENT) 12 lotion
1-Covered
ammonium lactate 12 cream(g) 12 lotion
1-Covered
benzoyl peroxide (ACNE CONTROLCLEANSER) 10 cleanser
1-Covered
benzoyl peroxide (ACNE FOAMINGWASH) 10 cleanser
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
66
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
benzoyl peroxide (ACNETREATMENT) 10 gel (gram)
1-Covered
benzoyl peroxide (ACNECLEAR) 10 gel (gram)
1-Covered
benzoyl peroxide (ADVANCEDEXFOLIATING CLEANSER) 5 cleanser
1-Covered
benzoyl peroxide (BP WASH) 5 10
1-Covered
benzoyl peroxide (BP) 5 gel(gram) 10 gel (gram)
1-Covered
benzoyl peroxide (BPO-10) cleanser -
1-Covered
benzoyl peroxide (BPO-5) cleanser -)
1-Covered
benzoyl peroxide (CLEAN-CLEARCONTINUOUS CONTROL) 10 cleanser -
1-Covered
benzoyl peroxide (DAYLOGICACNE FOAMING WASH) 10 cleanser
1-Covered
benzoyl peroxide (DAYLOGICACNE TREATMENT) 10 gel (gram)
1-Covered
benzoyl peroxide (FOAMING ACNEFACE WASH) 10 cleanser
1-Covered
benzoyl peroxide (PANOXYL) 10 cleanser
1-Covered
benzoyl peroxide 25 gel (gram)5 cleanser 5 gel (gram) 10 gel (gram) 10 cleanser
1-Covered
CALADRYL (pramoxinehclcalamine) 1-8 LOTION
1-Covered
calcipotriene 0005 cream (g)0005 oint (g) 0005 solution
1-Covered PA
chlorhexidine gluconate 4 liquid 1-Covered
CORTISPORIN(neomycinbacitracinpolymyxinbhydrocortisone) OINTMENT
1-Covered
DIFFERIN (adapalene) 01 GEL 1-Covered AL1 (Up to 25 yrs old)
DRITHOCREME HP (anthralin) 1CREAM
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
67
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DRYSOL (aluminum chloride) DAB--MATIC SLUTIN
1-Covered
EPIFOAM (hydrocortisoneacetatepramoxine hcl)
1-Covered
hydrocortisoneacetatepramoxine hclhydrocortisonepramoxine 1 -1 creamapplhydrocortisonepramoxine 25 -1 cream (g)hydrocortisonepramoxine 25 -1 creamapplhydrocortisonepramoxine 25-1(4g) creamappl
1-Covered
isotretinoin (AMNESTEEM) 10 mgcapsule 20 mg capsule 40 mgcapsule
1-Covered PA
isotretinoin (CLARAVIS) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin (MYORISAN) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin (ZENATANE) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin 10 mg capsule 20 mgcapsule 30 mg capsule 40 mgcapsule
1-Covered PA
LICE KILLING SHAMPOO 1-Covered
metronidazole 075 cream (g)075 gel (gram) 1 gel (gram)
1-Covered
pimecrolimus 1 cream (g) 1-Covered PA
piperonyl butoxidepyrethrins (LICEKILLING) 4-033 shampoo
1-Covered
piperonyl butoxidepyrethrins (LICEPYRINYL SHAMPOO) 4-033shampoo
1-Covered
piperonyl butoxidepyrethrins (LICETREATMENT) 4-033 shampoo
1-Covered
piperonyl butoxidepyrethrins (RID)4-033 shampoo
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
68
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
piperonylbutoxidepyrethrinspermethrin(COMPLETE LICE TREATMENT)butoxpyrethrpermet 4-33-5 kit
1-Covered
piperonylbutoxidepyrethrinspermethrin(LICE SOLUTION)butoxpyrethrpermet 4-33-5 kit
1-Covered
podofilox 05 solution 1-Covered
pramoxine hclcalamine(CALAHIST) 1 -8 lotion
1-Covered
pramoxine hclcalamine(CALAMINE MEDICATED) 1 -8 lotion
1-Covered
PROCTOFOAM-HC (hydrocortisoneacetatepramoxine hcl) PROCTO-1-1
1-Covered
RID (piperonylbutoxidepyrethrinspermethrin) 1-2-3 KIT KIT
1-Covered
SANTYL (collagenase clostridiumhistolyticum) OINTMENT
1-Covered QL (60 PER 30 DAYS)
selenium sulfide (ANTI-DANDRUFF)1 shampoo -
1-Covered
selenium sulfide (MEDICATEDDANDRUFF SHAMPOO) 1 shampoo
1-Covered
selenium sulfide (SELSUN BLUE) 1 shampoo
1-Covered
selenium sulfide 25 lotion 1-Covered
selenium sulfidealoe vera (SELSUNBLUE MOISTURIZING) 1 shampoo
1-Covered
tacrolimus 003 (g) 01 (g) 1-Covered PA
ELECTROLYTESMINERALSMETALSVITAMINS
ELECTROLYTEMINERAL REPLACEMENT09 sodium chloride iv soln 1-Covered PA
calcium carbonate 600 mg tablet 1-Covered
dextrose 5 in water in iv soln 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
69
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levocarnitine 330 mg tablet 1-Covered
potassium chloride in 09 sodiumchloride 09nacl 10 meql iv soln
1-Covered PA
ringers solution iv soln 1-Covered
sodium chloride irrigating solution09 soln
1-Covered
ELECTROLYTEMINERALMETAL MODIFIERSCHEMET (succimer) 100 MGCAPSULE
1-Covered PA
09 sodium chloride iv soln 1-Covered PA
CLINIMIX (amino acids 425 indextrose 5 in water) -SOLUTION
1-Covered PA
dextrose 10 and 045 sodiumchloride nacl -iv soln
1-Covered PA
dextrose 10 in water 10 10 dehp fr bg 10 10 iv soln
1-Covered PA
dextrose 5 and 045 sodiumchloride -04chlord -04iv soln
1-Covered PA
dextrose 5 in water 5 5 ivsoln 5 5 vial
1-Covered PA
levocarnitine (with sugar) 100mgml solution
1-Covered
levocarnitine 100 mgml solution330 mg tablet
1-Covered
MYNATAL (prenatal vitamins withcalciumferrous fumaratefolicacid) CAPSULE
1-Covered
O-CAL PRENATAL (prenatal vit withcalcium no127ferrousfumaratefolic acid) -TABLET
1-Covered
potassium chloride (KLOR-CONM10) meq tab er prt -
1-Covered
potassium chloride (KLOR-CONM20) meq tab er prt -
1-Covered
potassium chloride 8 meq tableter 10 meq tablet er 10 meqcapsule er 10 meq tab er prt 20meq tablet er 20 meq tab er prt20meq15ml liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
70
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
POTASSIUM CHLORIDE ER 8 MEQTABLET 10 (20 MEQ15ML) 10(40 MEQ30ML) ER 10 MEQ TABLETER 20 MEQ TABLET
1-Covered
potassium chloride in 09 sodiumchloride 20 meql soln 40 meqlsoln
1-Covered PA
PRENATABS FA (prenatal vits withcalcium no78ferrousfumaratefolic acid) TABLET
1-Covered
PRENATABS RX (prenatal vitaminwith calciumno76ironcarbonylfolic acid)TABLET
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid (MYNATAL PLUS) vitironfumfolic 65 mg-1 mg tablet
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid (MYNATAL-Z) vitiron fumfolic65 mg-1 mg tablet -
1-Covered
prenatal vits with calcium118ferrous fumaratefolic acid (SE-NATAL 19) pnv no8ironfumaratefa 29 mg-mg tab chew -9)
1-Covered
prenatal vits with calcium136ferrous fumaratefolic acid(VINATE-M) vit36ironfolic acd 27mg-mg tablet -
1-Covered
prenatal vits with calciumno115iron fumaratefolic acidno5ironfolic 29 mg-mg tab chew
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acid(M-NATAL PLUS) pnvcalcium72ironfolic 27 mg-1 mg tablet -
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acid(PREPLUS) pnvcalcium 72ironfolic27 mg-1 mg tablet
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acidpnvcalcium 72ironfolic 27 mg-1mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
71
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
prenatal vits with calciumno72ironcarbonylfolic acidpnvcalcium 72ironcarbfolic 29mg-1 mg tablet
1-Covered
prenatal vits with calciumno74ferrous fumaratefolic acidvitcal 74ironfolic 27 mg-1 mgtablet
1-Covered
SE-NATAL-19 (prenatal vitaminsno119iron fumaratefolic acid) --TABLET
1-Covered
sodium chloride irrigating solution09 soln
1-Covered
sodium polystyrene sulfonate 15g60 ml oral susp
1-Covered
sodium polystyrenesulfonatesorbitol solution (KIONEX)sulfonsorb 15 g60 ml oral susp
1-Covered
SPS (sodium polystyrenesulfonatesorbitol solution) 15GM60 ML SUSPENSION
1-Covered
TRINATE (prenatal vits with calciumno73ferrous fumaratefolic acid)TABLET
1-Covered
VITAMINS09 sodium chloride iv soln 1-Covered PA
ascorbate calcium 500 mg tablet 1-Covered
ascorbic acid (SOOTHINGPUREWAY-C) 500 mg tablet -
1-Covered
ascorbic acid 250 mg tablet 500mg5ml syrup 500 mg tablet 1000mg tablet
1-Covered
CALCIUM 500-VIT D3 MG-MCG TB 1-Covered
CALCIUM 600 MG TABLET 1-Covered
CALCIUM 600-VIT D3 MG-10MCGTB
1-Covered
calcium carbonate (OYSCO-500)500(1250) tablet -
1-Covered
calcium carbonate (SUPERCALCIUM) 600 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
72
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcium carbonate 500(1250)tablet 600 mg tablet
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (HI-CAL)carbonatevitamin 500 mg-200tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OS-CAL 500-VIT D3)carbonatevitamin mg-200 tablet --
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OYSCO 500-VIT D3)carbonatevitamin mg-200 tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OYSTERCAL-D)carbonatevitamin 500 mg-400tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) carbonatevitamin250 mg-125 tabletcarbonatevitamin 500 mg-600tablet carbonatevitamin 500 mg-400 tablet carbonatevitamin 500mg-200 tablet carbonatevitamin600 mg-400 tablet
1-Covered
calcium gluconate 60(650) mgtablet
1-Covered
calcium lactate 84 mg(648) tablet 1-Covered
cyanocobalamin (vitamin b-12) (B-12 DOTS) cyanocoalamin -) 500mcg talet -
1-Covered
cyanocobalamin (vitamin b-12)cyanocoalamin -500 mcg talet
1-Covered
dextrose 10 in water iv soln 1-Covered PA
dextrose 5 and 045 sodiumchloride -04chlord -04iv soln
1-Covered PA
dextrose 5 in lactated ringers -ivsoln
1-Covered PA
dextrose 5 in water in iv soln 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
73
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DEXTROSE IN WATER 5-IV SOLN10-IV SOLUTION
1-Covered PA
electrolytesdextrose(ELECTROLYTE) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (ORALYTE)solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (PEDIATRICELECTROLYTE) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (PEDIATRICFREEZER POPS) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
ferrous sulfate (CHILDRENS IRON)15 mgml drops
1-Covered
ferrous sulfate (FEOSOL) 325(65)mg tablet
1-Covered
ferrous sulfate (FEROSUL) 325(65)mg tablet
1-Covered
ferrous sulfate (FERRO-TIME) 325(65)mg tablet -
1-Covered
ferrous sulfate (FERROUSUL) 325(65)mg tablet
1-Covered
ferrous sulfate (PEDIA IRON) 15mgml drops
1-Covered
ferrous sulfate 15 mgml drops 220(44)5 solution 220 (44)5 elixir324(65)mg tablet dr 325(65) mgtablet dr 325(65) mg tablet
1-Covered
FERROUS SULFATE SULF 220 MG5ML LIQ SULF EC 325 MG TABLETSULFATE 325 MG TABLET
1-Covered
fluoride (sodium) 025(055) tabchew 05(11)mg tab chew 05mgml drops 1mg(22mg) tabchew
1-Covered STAR (Preferred Drug)
folic acid 04 mg tablet 08 mgtablet 1 mg tablet 20 mg capsule
1-Covered
FOLIC ACID 400 MCG TABLET 800MCG TABLET
1-Covered
IRON 65 MG TABLET 1-Covered
OYSTER SHELL CALCIUM 500 MG TB 1-Covered
OYSTER SHELL CALCIUM-VIT D3 250MG-312MCG
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
74
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PEDIATRIC IRON PHARM CHC15MGML DRP
1-Covered
pediatric multivit with acd3no21sodium fluorideno21fluoride 025 mgml dropsno21fluoride 05 mgml drops
1-Covered STAR (Preferred Drug)
pediatric multivitaminno16sodium fluoride -025 mg tabche -05 mg tab che -1 mg tabche
1-Covered
pediatric multivitamin no2sodiumfluoride w-025 mgml drops
1-Covered
pediatric multivitamin no2sodiumfluoride w-05 mgml drops
1-Covered STAR (Preferred Drug)
pediatric multivitaminno45sodium fluorideferroussulfate 45fluorideiron 025-10mldrops
1-Covered STAR (Preferred Drug)
pediatric multivitamins no17 withsodium fluoride -025 mg tab che -05 mg tab che -1 mg tab che
1-Covered STAR (Preferred Drug)
POLY-VITAMIN (multivitamin) -TABCHEW
1-Covered STAR (Preferred Drug)
POTASSIUM 99 MG TABLET 1-Covered
potassium bicarbonatecitric acid(EFFER-K) 25 meq tablet eff -
1-Covered
potassium bicarbonatecitric acid(K EFFERVESCENT) 25 meq tableteff
1-Covered
potassium bicarbonatecitric acid(KLOR-CON-EF) 25 meq tablet eff --
1-Covered
potassium bicarbonatecitric acid25 meq tablet eff
1-Covered
POTASSIUM CHL-NORMAL SALINE20 -ML IV SOLN 40 -ML IV SOLN
1-Covered
potassium chloride (KLOR-CONSPRINKLE) 10 meq capsule er -
1-Covered
potassium chloride 20meq15mlliquid
1-Covered
potassium chloridepotassiumbicarbonatecitric acidchloridebicarbcit 25 meq tableteff
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
75
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
potassium gluconate 595(99)mgtablet
1-Covered
PRENATAL MULTIVITAMIN TABLET 1-Covered
prenatal vit with calciumno129ferrous fumaratefolic acidno129ironfolic 27mg-08mgtablet
1-Covered
prenatal vit with calciumno130ferrous fumaratefolic acidno130ironfolic 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vitamins no121ferrousfumaratefolic acid pnvno121ironfolic 28mg-08mgtablet
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid vitiron fumfolic 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vitamins withcalciumferrous fumaratefolicacid vitiron fumfolic 28mg-08mgtablet
1-Covered
prenatal vits with calcium118ferrous fumaratefolic acidpnv no8iron fumaratefa 29 mg-mg tab chew
1-Covered
prenatal vits with calcium137ferrous fumaratefolic acidno137ironfolic acd 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vits with calcium95ferrous fumaratefolic acid pnvno95ferrous fumfolic 28mg-08mg tablet
1-Covered
prenatal vits with calciumno96ferrous fumaratefolic acidvits96iron fumfolic 27mg-08mgtablet
1-Covered
pyridoxine hcl (vitamin b6) 25 mgtablet 50 mg tablet 100 mgtablet 250 mg tablet
1-Covered
ringers solution iv soln 1-Covered PA
SODIUM CHLORIDE 09 IRRIG 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
76
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SODIUM CHLORIDE 09 SOLUTION 1-Covered PA
sodium chloride irrigating solution(AQUA CARE SODIUM CHLORIDE)09 soln
1-Covered
sodium chloride irrigating solution(CURITY) 09 soln
1-Covered
sodium chloride irrigating solution09 soln
1-Covered
TRI-VI-SOL (vitamin apalmitateascorbicacidcholecalciferol (vit d3)) --DROPS (vitmin plmittescorbiccidcholeclciferol
1-Covered STAR (Preferred Drug)
VITAMIN B-12 -500 MCG TALET 1-Covered
VITAMIN C 1000 MG TABLET 1-Covered
GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach)
ANTISPASMODICS GASTROINTESTINAL (Drugs to Prevent Bowel andStomach Spasam)
CHLORDIAZEPOXIDE-CLIDINIUM -CAP
1-Covered MDD (8 Per Day)
chlordiazepoxideclidiniumbromide 5 mg-25mg capsule
1-Covered MDD (8 Per Day)
DICYCLOMINE HCL 10 MG5 MLSOLN
1-Covered
dicyclomine hcl 10 mg5 mlsolution 10 mg capsule 20 mgtablet
1-Covered
hyoscyamine sulfate (HYOSYNE)0125mgml drops 125mcg5mlelixir
1-Covered
hyoscyamine sulfate 0125 mg tabsubl 0125 mg tablet 0125mgmldrops 0375 mg tab er 12h125mcg5ml elixir
1-Covered
propantheline bromide 15 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
77
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GASTROINTESTINAL AGENTS OTHER (Other Drugs for the Bowel andStomach)
ALLI (orlistat) 60 MG CAPSULE 1-Covered PA
ANTACID 500 MG CHEW TABLET 1-Covered
ANTACID EXTRA STRENGTH -750 MGTAB CHEW CVS -750 MG CHEW
1-Covered
ANTI-DIARRHEAL HM -2 MGSOFTGEL
1-Covered
bismuth subsalicylate (BISMATROL)262 mg tab chew
1-Covered
bismuth subsalicylate (DIOTAME)262 mg tab chew
1-Covered
bismuth subsalicylate (PEP-T-MED)262 mg tab chew --
1-Covered
bismuth subsalicylate (PEPTICRELIEF) 262 mg tab chew
1-Covered
bismuth subsalicylate (PINKBISMUTH) 262 mg tab chew
1-Covered
bismuth subsalicylate (SOOTHE)262 mg tab chew
1-Covered
bismuth subsalicylate (STOMACHRELIEF) 262 mg tab chew
1-Covered
bismuth subsalicylate 262 mg tabchew
1-Covered
calcium carbonate (ANTACIDCALCIUM) 215(500)mg tab chew
1-Covered
calcium carbonate (ANTACIDEXTRA STRENGTH) 300mg(750) tabchew
1-Covered
calcium carbonate (ANTACID)200(500)mg tab chew 215(500)mgtab chew 300mg(750) tab chew
1-Covered
calcium carbonate (BAN-ACID)300mg(750) tab chew -
1-Covered
calcium carbonate (CAL-GEST)200(500)mg tab chew -
1-Covered
calcium carbonate (CALCIUMANTACID) 200(500)mg tab chew215(500)mg tab chew 300mg(750)tab chew
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
78
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcium carbonate (CHILDRENSPEPTO) 400 mg tab chew
1-Covered
calcium carbonate (CHILDRENSSOOTHE) 400 mg tab chew
1-Covered
calcium carbonate (FLAVORCHEWS ANTACID) 300mg(750) tabchew
1-Covered
calcium carbonate (SMOOTHANTACID) 300mg(750) tab chew
1-Covered
calcium carbonate (SMOOTHDISSOLVING ANTACID) 300mg(750)tab chew
1-Covered
calcium carbonate 200(500)mgtab chew 300mg(750) tab chew
1-Covered
diphenoxylate hclatropine sulfate25-0255 liquid 25-025mg tablet
1-Covered
DIPHENOXYLATE-ATROPINE -25-0025
1-Covered
GAS RELIEF (simethicone) (SIMETH)80 MG CHEW
1-Covered
GAS RELIEF GAS 125 MG CHEWTABLET GAS (SIMETH) 80 MGCHEW HM GAS 125 MG SOFTGELHM GAS 125 MG CHEW TAB
1-Covered
GAS-X (simethicone) -E-STR 125 MGTAB CHEW
1-Covered
INFANTS GAS RELIEF RLF 20 MG03ML
1-Covered
loperamide hcl (ANTI-DIARRHEAL) 2mg capsule - 2 mg tablet -
1-Covered
loperamide hcl (DIAMODE) 2 mgtablet
1-Covered
loperamide hcl (ULTRA A-D) 2 mgtablet -
1-Covered
loperamide hcl 1 mg5 ml liquid 2mg capsule 2 mg tablet
1-Covered
PEPTO-BISMOL (bismuthsubsalicylate) -TABLET CHEW
1-Covered
PEPTO-BISMOL TO-GO (bismuthsubsalicylate) --262 MG CHEW
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
79
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
simethicone (GAS RELIEF)40mg06ml drops susp 80 mg tabchew 125 mg tab chew 125 mgcapsule
1-Covered
simethicone (GAS-X) 125 mgcapsule -
1-Covered
simethicone (INFANT GAS RELIEF)40mg06ml drops susp
1-Covered
simethicone (INFANTS GAS RELIEF)40mg06ml drops susp
1-Covered
simethicone (MI-ACID) 80 mg tabchew -
1-Covered
simethicone 40mg06ml dropssusp 80 mg tab chew 125 mgcapsule 125 mg tab chew
1-Covered
STOMACH RELIEF 262 MG CHEWTAB
1-Covered
ursodiol 300 mg capsule 1-Covered
HISTAMINE2 (H2) RECEPTOR ANTAGONISTSACID CONTROLLER 20 MG TABLET 1-Covered
ACID REDUCER 10 MG TABLET 1-Covered PA
ACID REDUCER 20 MG TABLET 1-Covered
cimetidine (ACID REDUCER) 200mg tablet
1-Covered
cimetidine (HEARTBURN RELIEF) 200mg tablet
1-Covered
cimetidine 200 mg tablet 300 mgtablet 400 mg tablet 800 mgtablet
1-Covered
CIMETIDINE 300 MG5 ML SOLN 1-Covered
cimetidine hcl 300 mg5ml solution 1-Covered
famotidine (ACID CONTROLLER) 10mg tablet
1-Covered PA
famotidine (ACID CONTROLLER) 20mg tablet
1-Covered
famotidine (ACID REDUCER) 10 mgtablet
1-Covered PA
famotidine (ACID REDUCER) 20 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
80
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
famotidine (HEARTBURNPREVENTION) 10 mg tablet
1-Covered PA
famotidine (HEARTBURNPREVENTION) 20 mg tablet
1-Covered
famotidine (HEARTBURN RELIEF) 10mg tablet
1-Covered PA
famotidine (HEARTBURN RELIEF) 20mg tablet
1-Covered
famotidine (PEPCID) 20 mg tablet 1-Covered
famotidine 10 mg tablet 1-Covered PA
FAMOTIDINE 10 MG TABLET 1-Covered PA
famotidine 20 mg tablet 40 mgtablet
1-Covered
FAMOTIDINE 20 MG TABLET EQ 20MG TABLET 40 MG TABLET
1-Covered
IRRITABLE BOWEL SYNDROME AGENTSAMITIZA (lubiprostone) 8 MCGCAPSULE 24 MCG CAPSULES
1-Covered PA
LAXATIVES (Drugs for Bowel Cleansing and Constipation)bisacodyl (ALOPHEN PILLS) 5 mgtablet dr
1-Covered
bisacodyl (BISA-LAX) 5 mg tablet dr-
1-Covered
bisacodyl (BISACODYL) 5 mgtablet dr
1-Covered
bisacodyl (BISCOLAX) 10 mgsupprect
1-Covered
bisacodyl (C-LAX LAXATIVE) 5 mgtablet dr -ATIVE)
1-Covered
bisacodyl (DUCODYL) 5 mg tabletdr
1-Covered
bisacodyl (FAST RELIEF LAXATIVE)10 mg supprect
1-Covered
bisacodyl (GENTLE LAXATIVE) 5 mgtablet dr 10 mg supprect
1-Covered
bisacodyl (LAXATIVE SUPPOSITORY)10 mg supprect
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
81
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
bisacodyl (LAXATIVE) 5 mg tabletdr
1-Covered
bisacodyl (MAGIC BULLET) 10 mgsupprect
1-Covered
bisacodyl (WOMENS GENTLELAXATIVE) 5 mg tablet dr
1-Covered
bisacodyl (WOMENS LAXATIVE) 5mg tablet dr
1-Covered
bisacodyl 5 mg tablet dr 10 mgsupprect
1-Covered
BISACODYL EC 5 MG TABLET 10MG SUPPOSITORY
1-Covered
docusate sodium (COL-RITE) 100mg capsule - 250 mg capsule -
1-Covered
docusate sodium (DIOCTYL) 60mg15ml syrup
1-Covered
docusate sodium (DOCU LIQUID)50 mg5 ml liquid
1-Covered
docusate sodium (DOCUSIL) 100mg capsule
1-Covered
docusate sodium (DSS) 250 mgcapsule
1-Covered
docusate sodium (DULCOEASE)100 mg capsule
1-Covered
docusate sodium (DULCOLAXSTOOL SOFTENER) 100 mg capsule
1-Covered
docusate sodium (LAXA BASIC 100)mg capsule )
1-Covered
docusate sodium (PHILLIPSLAXATIVE) 100 mg capsule
1-Covered
docusate sodium (SOF-LAX) 100mg capsule -
1-Covered
docusate sodium (STOOLSOFTENER) 50 mg capsule 50 mg5ml liquid 60 mg15ml syrup 100mg capsule 250 mg capsule
1-Covered
DOCUSATE SODIUM 50 MG5 MLLIQ 100 MG SOFTGEL
1-Covered
docusate sodium 50 mg5 mlliquid 60 mg15ml syrup 100 mgcapsule 250 mg capsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
82
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DOK (docusate sodium) 100 MG250 MG
1-Covered
GENTLE LAXATIVE 10 MG SUPPOSIT 1-Covered
glycerin (ADULT GLYCERIN) adultsupprect
1-Covered
glycerin (LAXATIVE SUPPOSITORY)pediatric supprect
1-Covered
glycerin (PEDIA-LAX) pediatricsupprect -
1-Covered
glycerin (SUPPOSITORY) adultsupprect
1-Covered
glycerin adult pediatric 1-Covered
lactulose (CONSTULOSE) 10 g15 mlsolution
1-Covered
lactulose (ENULOSE) 10 g15 mlsolution
1-Covered
lactulose (GENERLAC) 10 g15 mlsolution
1-Covered
lactulose 10 g15 ml 20 g30 ml 1-Covered
MAGNESIUM CITRATE HM SOLUTION 1-Covered
magnesium citrate solution 1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloride(GAVILYTE-C) peg3350sodsulfbicarbclkcl 240-2272g solnrecon -
1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloride(GAVILYTE-G) peg3350sodsulfbicarbclkcl 236-2274g solnrecon -
1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloridepeg3350sod sulfbicarbclkcl 236-2274g soln peg3350sodsulfbicarbclkcl 240-2272g soln
1-Covered
PEG-3350 AND ELECTROLYTES -SOLN
1-Covered
polyethylene glycol 3350(CLEARLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
83
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
polyethylene glycol 3350(GAVILAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(GENTLELAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(GLYCOLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(LAXACLEAR) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350 (NATURA-LAX) 17gdose powder -
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(POWDERLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(PURELAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(SMOOTHLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350 17gdosepowder
1-Covered QL (527 PER 30 DAY(S))
SILACE (docusate sodium) 50MG5 ML LIQUID
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepeg (GAVILYTE-N)chloridenahco3kclpeg 420gsoln recon -
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepeg (TRILYTE WITH FLAVORPACKETS)chloridenahco3kclpeg 420gsoln recon
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepegchloridenahco3kclpeg 420gsoln recon
1-Covered
STOOL SOFTENER (docusatesodium) 100 MG SOFTGEL 100 MGCAPSULE 250 MG SOFTGEL
1-Covered
STOOL SOFTENER HM 100 MGSFTGL 100 MG SOFTGEL HM 250MG SFTGL
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
84
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PROTECTANTSmisoprostol 100 mcg tablet 200mcg tablet
1-Covered PA
sucralfate 1 g tablet 1-Covered
PROTON PUMP INHIBITORSlansoprazole 15 mg capsule dr 1-Covered ST
lansoprazole 30 mg capsule dr 1-Covered
LANSOPRAZOLE DR 15 MGCAPSULE
1-Covered ST
LANSOPRAZOLE DR 30 MGCAPSULE
1-Covered
omeprazole 10 mg capsule dr 20mg tablet dr
1-Covered
omeprazole 20 mg capsule dr 1-Covered QL (60 PER 30 DAYS)
omeprazole 40 mg capsule dr 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
OMEPRAZOLE DR 20 MG CAPSULE 1-Covered QL (60 PER 30 DAYS)
OMEPRAZOLE DR 20 MG TABLET 1-Covered
pantoprazole sodium 20 mg tabletdr 40 mg tablet dr
1-Covered
PANTOPRAZOLE SODIUM DR 20 MGTAB DR 40 MG TAB
1-Covered
PREVACID (lansoprazole) DR 15MG CAPSULE
1-Covered
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERSTREATMENT (Drugs for Genetic or Enzyme Disorders)
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERSTREATMENT
CREON (lipaseproteaseamylase)DR 6000 UNITS CAPSULE
1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
85
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GENITOURINARY AGENTS (Drugs for the Genital Bladder andKidney)
ANTISPASMODICS URINARY (Drugs for Bladder Spasms)oxybutynin chloride 5 mg5 mlsyrup 5 mg tab er 24 5 mg tablet10 mg tab er 24 15 mg tab er 24
1-Covered
OXYBUTYNIN CHLORIDE ER ER 5 MGTABLET ER 10 MG TABLET ER 15 MGTABLET
1-Covered
OXYTROL FOR WOMEN(oxybutynin) 39 MG24HR
1-Covered ST
trospium chloride 20 mg tablet 1-Covered ST
TROSPIUM CHLORIDE 20 MG TABLET 1-Covered ST
BENIGN PROSTATIC HYPERTROPHY AGENTSalfuzosin hcl 10 mg tab er 24h 1-Covered PA
finasteride 5 mg tablet 1-Covered
tamsulosin hcl 04 mg capsule 1-Covered
GENITOURINARY AGENTS OTHER (Other Drugs for the GenitalBladder and Kidney)
bethanechol chloride 5 mg tablet10 mg tablet 25 mg tablet 50 mgtablet
1-Covered
citric acidsodium citrate (CYTRA-2) 334-500mg solution -
1-Covered
citric acidsodium citrate(VIRTRATE-2) 334-500mg solution -
1-Covered
citric acidsodium citrate 334-500mg solution
1-Covered
nonoxynol 9 (VCF) 125 foamappl
1-Covered
penicillamine 250 mg capsule 1-Covered PA QL (16 PER 1 DAY(S))
PENICILLAMINE 250 MG CAPSULE 1-Covered PA QL (16 PER 1 DAY(S))
phenazopyridine hcl (URINARYPAIN RELIEF) 95 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
86
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PHENAZOPYRIDINE HCL 100 MGTAB 200 MG TAB
1-Covered
phenazopyridine hcl 100 mgtablet 200 mg tablet
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit ac(CYTRA-3) sodpotk citsod citcitacid 500-5505 solution -
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit ac(TRICITRATES) sodpotk citsodcitcit acid 500-5505 solution
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit acsodpotk citsod citcit acid 500-5505 solution
1-Covered
URINARY PAIN RELIEF HM RLF 95 MGTAB
1-Covered
PHOSPHATE BINDERScalcium acetate (ELIPHOS) 667 mgtablet
1-Covered QL (270 PER 30 DAYS) AL1 (Atleast 21 yrs old)
calcium acetate 667 mg capsule667 mg tablet
1-Covered QL (270 PER 30 DAYS) AL1 (Atleast 21 yrs old)
lanthanum carbonate 500 mg tabchew 750 mg tab chew 1000 mgtab chew
1-Covered PA
sevelamer carbonate 800 mgtablet
1-Covered PA
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(ADRENAL) (Drugs for ReplacingStimulating Adrenal GlandHormones)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(ADRENAL) (Glucocorticoids)
betamethasone dipropionate 005 lotion
1-Covered
betamethasone dipropionate 005 oint (g) 005 cream (g)
1-Covered ST
BETAMETHASONE DIPROPIONATEDP 005 OINT
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
87
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
betamethasonedipropionatepropylene glycolbetamethasonepropylene 005 cream (g)
1-Covered ST
betamethasone valerate 01 lotion 01 cream (g) 01 oint(g)
1-Covered
clobetasol propionate 005 gel(gram) 005 solution 005 cream (g) 005 oint (g)
1-Covered ST
CLOBETASOL PROPIONATE 005CREAM
1-Covered ST
DELTASONE (prednisone) 20 MGTABLET
1-Covered
desonide 005 lotion 005 oint(g) 005 cream (g)
1-Covered ST
DESONIDE 005 LOTION 005CREAM
1-Covered ST
dexamethasone(DEXAMETHASONE INTENSOL) 1mgml drops
1-Covered
dexamethasone 05 mg5mlsolution 05 mg tablet 05 mg5mlelixir 075 mg tablet 1 mg tablet15 mg tablet 2 mg tablet 4 mgtablet 6 mg tablet
1-Covered
DEXAMETHASONE 4 MG TABLET 1-Covered
fludrocortisone acetate 01 mgtablet
1-Covered
fluocinolone acetonide 001 cream (g) 001 solution 0025 cream (g) 0025 oint (g)
1-Covered ST
fluocinonide 005 cream (g) 005 gel (gram) 005 oint (g) 005 solution
1-Covered
FLUOCINONIDE 005 OINTMENT 1-Covered
hydrocortisone (ANTI-ITCH) 1 cream (g) -
1-Covered
hydrocortisone (ANUSOL-HC) 25 crmpe app -
1-Covered
hydrocortisone (CORTISONE) 1 cream (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
88
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
hydrocortisone (CORTIZONE-10PLUS) cream (g) -0
1-Covered
hydrocortisone (CORTIZONE-10) cream (g) -
1-Covered
hydrocortisone (HYDROCREAM) 1 cream (g)
1-Covered
hydrocortisone (NOBLE FORMULAHC) 1 cream (g)
1-Covered
hydrocortisone (PREPARATION H) 1 cream (g)
1-Covered
hydrocortisone (PROCTO-MED HC)25 crmpe app -
1-Covered
hydrocortisone (PROCTO-PAK) 1 crmpe app -
1-Covered
hydrocortisone (PROCTOSOL-HC)25 crmpe app -
1-Covered
hydrocortisone (PROCTOZONE-HC)25 crmpe app -
1-Covered
hydrocortisone (SOOTHING CARE)1 cream (g)
1-Covered
hydrocortisone 05 oint (g) 1 cream (g) 1 oint (g) 1 crmpe app 25 cream (g) 25 crmpe app 25 oint (g) 25 lotion 5 mg tablet 10 mg tablet20 mg tablet
1-Covered
HYDROCORTISONE 5 MG TABLET10 MG TABLET
1-Covered
hydrocortisone acetate(ANUCORT-HC) 25 mg supprect -
1-Covered
hydrocortisone acetate (ANUSOL-HC) 25 mg supprect -
1-Covered
hydrocortisone acetate(HEMMOREX-HC) 25 mg supprect -
1-Covered
HYDROCORTISONE ACETATE 25 MGSUPP
1-Covered
hydrocortisone acetate 25 mgsupprect
1-Covered
methylprednisolone 4 mg tablet 4mg tab ds pk 8 mg tablet 16 mgtablet 32 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
89
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
mometasone furoate 01 cream(g) 01 oint (g)
1-Covered
prednisolone (MILLIPRED DP) 5 mg(48) tab 5 mg (21) tab
1-Covered
prednisolone (MILLIPRED) 5 mgtablet
1-Covered
prednisolone 15 mg5 ml solution 1-Covered
prednisolone sodium phosphate 5mg5 ml 15 mg5 ml
1-Covered
prednisone (PREDNISONEINTENSOL) 5 mgml oral conc
1-Covered
prednisone 1 mg tablet 25 mgtablet 5 mg tab ds pk 5 mgtablet 5 mg5 ml solution 10 mgtablet 10 mg tab ds pk 20 mgtablet 50 mg tablet
1-Covered
triamcinolone acetonide 0025 oint (g) 0025 cream (g) 0025 lotion 01 cream (g) 01 lotion 01 oint (g) 0147mggaerosol 05 cream (g) 05 oint(g)
1-Covered
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(PITUITARY) (Drugs for ReplacingStimulating Pituitary GlandHormones)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(PITUITARY) (Drugs to ReplaceStimulate Pituitary Gland Hormones)
desmopressin acetate (non-refrigerated) (nonrefrigerated)10spray spraypump
1-Covered PA AL1 (8 to 14 yrs old)
desmopressin acetate 01 mgmlsolution 01 mg tablet 02 mgtablet
1-Covered AL1 (8 to 14 yrs old)
desmopressin acetate 4 mcgmlvial 4 mcgml ampul 10sprayspraypump
1-Covered PA AL1 (8 to 14 yrs old)
DESMOPRESSIN ACETATE 40MCG10 ML VIAL
1-Covered PA AL1 (8 to 14 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
90
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEXHORMONESMODIFIERS) (Drugs for ReplacingStimulating SexHormones)
ANDROGENSdanazol 50 mg capsule 100 mgcapsule 200 mg capsule
1-Covered
fluoxymesterone (ANDROXY) 10mg tablet
1-Covered
testosterone 125125g gel mdpmp 50 mg (1) gel packet
1-Covered PA
testosterone cypionate 100 mgmlvial 200 mgml vial
1-Covered PA
ESTROGENS (Contraceptives and Drugs for Menopause)desogestrel-ethinyl estradiol (APRI)-015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(CYRED EQ) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(CYRED) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(EMOQUETTE) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(ENSKYCE) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(ISIBLOOM) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(JULEBER) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(KALLIGA) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(RECLIPSEN) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol -015-003 tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (AZURETTE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
91
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
desogestrel-ethinyl estradiolethinylestradiol (BEKYREE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (KARIVA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (KIMIDESS) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (PIMTREA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (SIMLIYA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (VIORELE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (VOLNEA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol -eestradioleestradiol 21-5 (28) tablet
1-Covered
DROSPIRENONE-ETHINYL ESTRADIOL-EE 3-002 MG TAB
1-Covered
estradiol (DOTTI) 025mg24hpatch 0375mg24 patch005mg24h patch 075mg24hpatch 01mg24hr patch
1-Covered QL (16 PER 28 DAY(S))
estradiol 025mg24h patch0375mg24 patch 005mg24hpatch 075mg24h patch01mg24hr patch
1-Covered QL (16 PER 28 DAY(S))
estradiol 001 creamappl025mg24h patch tdwk005mg24h patch tdwk075mg24h patch tdwk01mg24hr patch tdwk 05 mgtablet 1 mg tablet 2 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
92
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ESTRADIOL 1 MG TABLET 2 MGTABLET
1-Covered
estrogensesterifiedmethyltestosterone (COVARYX HS)estrogenesterme-0625-125tablet
1-Covered PA
estrogensesterifiedmethyltestosterone (EEMT HS) estrogenesterme-0625-125 tablet
1-Covered PA
estrogensesterifiedmethyltestosterone estrogenesterme-0625-125tablet
1-Covered PA
ethinyl estradioldrospirenone(GIANVI) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(JASMIEL) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone (LO-ZUMANDIMINE) 002-3(28) tablet -
1-Covered
ethinyl estradioldrospirenone(LORYNA) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(NIKKI) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(VESTURA) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone 002-3(28) tablet
1-Covered
ethynodiol diacetate-ethinylestradiol (KELNOR 1-35) ethynoiol -estraiol mg-35mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol (KELNOR 1-50) ethynoiol -estraiol mg-50mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol (ZOVIA 1-35E) ethynoiol -estraiol mg-35mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol ethynoiol -estraiol 1 mg-50mcg tablet ethynoiol -estraiol 1mg-35mcg tablet
1-Covered
etonogestrelethinyl estradiol(ELURYNG) 12-015mg vag ring
1-Covered QL (1 PER 28 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
93
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
etonogestrelethinyl estradiol 12-015mg vag ring
1-Covered QL (1 PER 28 DAY(S))
HAILEY FE 1-20 TABLET 15-30 TABLET 1-Covered
LEVONORGESTREL-ETH ESTRADIOL -TRIPHASIC
1-Covered
levonorgestrelethinyl estradiol(AFIRMELLE)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(ALTAVERA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(AUBRA EQ)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AUBRA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AVIANE)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AYUNA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(CHATEAL EQ)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(CHATEAL)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(DELYLA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(ENPRESSE)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
94
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrelethinyl estradiol(FALMINA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(KURVELO)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(LARISSIA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(LESSINA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(LEVONEST)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
levonorgestrelethinyl estradiol(LEVORA-28)levonorgestrelethinestradiol 015-003 tablet -
1-Covered
levonorgestrelethinyl estradiol(LILLOW)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(LUTERA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(MARLISSA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(MYZILRA)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
levonorgestrelethinyl estradiol(ORSYTHIA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
95
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrelethinyl estradiol(PORTIA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(SRONYX)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(TRIVORA-28)levonorgestrelethinestradiol 6-5-10 tablet -
1-Covered
levonorgestrelethinyl estradiol(VIENVA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiollevonorgestrelethinestradiol 01-002mg tabletlevonorgestrelethinestradiol 015-003 tabletlevonorgestrelethinestradiol 6-5-10 tablet
1-Covered
LYLLANA 0025 MG PATCH 00375MG PATCH 005 MG PATCH 0075MG PATCH 01 MG PATCH
1-Covered QL (16 PER 28 DAY(S))
MENEST (estrogensesterified) 03MG TABLET 0625 MG TABLET 125MG TABLET 25 MG TABLET
1-Covered
MICROGESTIN 21 1-20 TABLET 1-Covered
MICROGESTIN FE 1-20 TABLET 1-Covered
norelgestrominethinyl estradiol(XULANE)norelgestrominethinestradiol 150-3524h patch tdwk
1-Covered QL (3 PER 28 DAY(S))
norethindrone acetate-ethinylestradiol (AUROVELA) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (GILDESS) -15-003mgtablet
1-Covered
norethindrone acetate-ethinylestradiol (HAILEY) -15-003mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
96
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone acetate-ethinylestradiol (JUNEL) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (LARIN) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (MICROGESTIN) -1mg-20mcg tablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol -1mg-20mcg tablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate(AUROVELA FE) -eestradiol-iron15-30(21) tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (BLISOVIFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (JUNELFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (LARINFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate(MICROGESTIN FE) --1mg-20(21)tablet --15-30(21) tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TARINAFE 1-20 EQ) -eestradiol-iron mg-(2)tablet -
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TARINAFE) -eestradiol-iron 1mg-20(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TILIA FE)-eestradiol-iron 5-7-9-7 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
97
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone acetate-ethinylestradiolferrous fumarate (TRI-LEGEST FE) -eestradiol-iron 5-7-9-7tablet -
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate --1mg-20(21) tablet --15-30(21) tablet
1-Covered
norethindrone-ethinyl estradiol(ALYACEN) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(ARANELLE) -ethin 7-9-5 tablet
1-Covered
norethindrone-ethinyl estradiol(BALZIVA) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(BRIELLYN) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(CYCLAFEM) -1 mg-35mcg tablet -7 days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(DASETTA) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(LEENA) -ethin 7-9-5 tablet
1-Covered
norethindrone-ethinyl estradiol(NECON) -ethin 05-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(NORTREL) -05-0035 tablet -1 mg-35mcg tablet -7 days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(PHILITH) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(PIRMELLA) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(VYFEMLA) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(WERA) -ethin 05-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(ZENCHENT) -ethin 04-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(ESTARYLLA) -025-0035 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
98
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norgestimate-ethinyl estradiol(FEMYNOR) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(MILI) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(MONO-LINYAH) -025-0035 tablet -
1-Covered
norgestimate-ethinyl estradiol(MONONESSA) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(PREVIFEM) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(SPRINTEC) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol (TRIFEMYNOR) -7daysx3 28 tablet
1-Covered
norgestimate-ethinyl estradiol (TRI-ESTARYLLA) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-LINYAH) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-ESTARYLLA) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-MARZIA) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-MILI) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-SPRINTEC) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-PREVIFEM) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-SPRINTEC) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-VYLIBRA LO) -7daysx3 lo tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-VYLIBRA) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol(TRINESSA LO) -7daysx3 lo tablet
1-Covered
norgestimate-ethinyl estradiol(TRINESSA) -7daysx3 28 tablet
1-Covered
norgestimate-ethinyl estradiol(VYLIBRA) -025-0035 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
99
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NORGESTIMATE-ETHINYL ESTRADIOL-025-0035 MG
1-Covered
norgestimate-ethinyl estradiol -025-0035 tablet -7daysx3 28tablet -7daysx3 lo tablet
1-Covered
norgestrel-ethinyl estradiol(CRYSELLE) -03-003mg tablet
1-Covered
norgestrel-ethinyl estradiol (ELINEST)-03-003mg tablet
1-Covered
norgestrel-ethinyl estradiol (LOW-OGESTREL) -03-003mg tablet -
1-Covered
norgestrel-ethinyl estradiol(OGESTREL) -05 mg-50 tablet
1-Covered
PREMARIN (estrogens conjugated)03 MG TABLET 045 MG TABLET0625 MG TABLET 09 MG TABLET125 MG TABLET
1-Covered
PREMARIN (estrogens conjugated)VAGINAL CREAM-APPL
1-Covered QL (43 PER 30 DAY(S))
PREMPHASE (estrogensconjugatedmedroxyprogesteroneacetate) 0625-5 MG TABLET
1-Covered
PREMPRO (estrogensconjugatedmedroxyprogesteroneacetate) 03 MG-15 MG TABLET045-15 MG TABLET 0625-5 MGTABLET 0625-25 MG TABLET
1-Covered
ZOVIA 1-35 -TABLET 1-Covered
PROGESTINSDEPO-PROVERA(medroxyprogesterone acetate) -400 MGML VIAL
1-Covered
DEPO-SUBQ PROVERA 104(medroxyprogesterone acetate) -SYRINGE
1-Covered
hydroxyprogesterone caproate250 mgml vial
1-Covered PA SP
hydroxyprogesterone caproatepfcaproatpf 250 mgml vial
1-Covered PA SP
JENCYCLA 035 MG TABLET 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
100
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrel (AFTERA) 15 mgtablet
1-Covered
levonorgestrel (ECONTRA EZ) 15mg tablet
1-Covered
levonorgestrel (ECONTRA ONE-STEP) 15 mg tablet -
1-Covered
levonorgestrel (FALLBACK SOLO)15 mg tablet
1-Covered
levonorgestrel (MY CHOICE) 15mg tablet
1-Covered
levonorgestrel (MY WAY) 15 mgtablet
1-Covered
levonorgestrel (NEW DAY) 15 mgtablet
1-Covered
levonorgestrel (OPCICON ONE-STEP) 15 mg tablet -
1-Covered
levonorgestrel (OPTION 2) 15 mgtablet
1-Covered
levonorgestrel (TAKE ACTION) 15mg tablet
1-Covered
levonorgestrel 15 mg tablet 1-Covered QL (1 PER 1 DAYS)
MEDROXYPROGESTERONE ACETATE150 MGML
1-Covered QL (1 PER 84 DAYS)
medroxyprogesterone acetate 150mgml vial 150 mgml syringe
1-Covered QL (1 PER 84 DAYS)
MEDROXYPROGESTERONE ACETATE25 MG TAB
1-Covered
medroxyprogesterone acetate 25mg tablet 5 mg tablet 10 mgtablet
1-Covered
megestrol acetate 20 mg tablet40 mg tablet
1-Covered
megestrol acetate 400mg10mloral susp
1-Covered PA
norethindrone (CAMILA) 035 mgtablet
1-Covered
norethindrone (DEBLITANE) 035 mgtablet
1-Covered
norethindrone (ERRIN) 035 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
101
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone (HEATHER) 035 mgtablet
1-Covered
norethindrone (INCASSIA) 035 mgtablet
1-Covered
norethindrone (JENCYCLA) 035mg tablet
1-Covered
norethindrone (JOLIVETTE) 035 mgtablet
1-Covered
norethindrone (LYZA) 035 mgtablet
1-Covered
norethindrone (NORA-BE) 035 mgtablet -
1-Covered
norethindrone (NORLYDA) 035 mgtablet
1-Covered
norethindrone (NORLYROC) 035mg tablet
1-Covered
norethindrone (SHAROBEL) 035 mgtablet
1-Covered
norethindrone (TULANA) 035 mgtablet
1-Covered
norethindrone 035 mg tablet 1-Covered
norethindrone acetate 5 mg tablet 1-Covered
PLAN B ONE-STEP (levonorgestrel) -15 MG TALET
1-Covered
TAKE ACTION (levonorgestrel) 15MG TABLET
1-Covered
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(THYROID) (Drugs for the Thyroid)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(THYROID) (Drugs to Replace Thyroid Hormone)
ARMOUR THYROID (thyroidpork) 15MG TABLET 30 MG TABLET 60 MGTABLET 90 MG TABLET 120 MGTABLET 180 MG TABLET 240 MGTABLET 300 MG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
102
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LEVO-T (levothyroxine sodium) -25MCG ABLE -50 MCG ABLE -75MCG ABLE -88 MCG ABLE -100MCG ABLE -112 MCG ABLE -125MCG ABLE -137 MCG ABLE -150MCG ABLE -175 MCG ABLE -200MCG ABLE -300 MCG ABLE
1-Covered
levothyroxine sodium 25 mcgtablet 50 mcg tablet 75 mcgtablet 88 mcg tablet 100 mcgtablet 112 mcg tablet 125 mcgtablet 137 mcg tablet 150 mcgtablet 175 mcg tablet 200 mcgtablet 300 mcg tablet
1-Covered STAR (Preferred Drug)
LEVOTHYROXINE SODIUM 25 MCGTABLET 50 MCG TABLET 75 MCGTABLET 88 MCG TABLET 100 MCGTABLET 112 MCG TABLET 125 MCGTABLET 137 MCG TABLET 150 MCGTABLET 175 MCG TABLET 200 MCGTABLET 300 MCG TABLET
1-Covered STAR (Preferred Drug)
LEVOXYL (levothyroxine sodium) 25MCG TABLET 50 MCG TABLET 75MCG TABLET 88 MCG TABLET 100MCG TABLET 112 MCG TABLET 125MCG TABLET 137 MCG TABLET 150MCG TABLET 175 MCG TABLET 200MCG TABLET
1-Covered
SYNTHROID (levothyroxine sodium)25 MCG TABLET 50 MCG TABLET75 MCG TABLET 88 MCG TABLET100 MCG TABLET 112 MCG TABLET125 MCG TABLET 137 MCG TABLET150 MCG TABLET 175 MCG TABLET200 MCG TABLET 300 MCG TABLET
1-Covered
thyroidpork (NP THYROID) 15 mgtablet 30 mg tablet 60 mg tablet90 mg tablet 120 mg tablet
1-Covered STAR (Preferred Drug)
UNITHROID (levothyroxine sodium)25 MCG TABLET 50 MCG TABLET75 MCG TABLET 88 MCG TABLET100 MCG TABLET 112 MCG TABLET125 MCG TABLET 137 MCG TABLET150 MCG TABLET 175 MCG TABLET200 MCG TABLET 300 MCG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
103
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs forSuppressing Hormones from the Pituitary Gland)
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs to SuppressPituitary Hormones)
leuprolide acetate 1 mg02ml kit 1-Covered PA SP
LUPRON DEPOT-PED (leuprolideacetate) -15 MG KIT
1-Covered PA
SYNAREL (nafarelin acetate) 2MGML NASAL SPRAY
1-Covered PA
HORMONAL AGENTS SUPPRESSANT (THYROID) (Drugs for theThyroid)
ANTITHYROID AGENTS (Drugs to Suppress Thyroid Hormone)methimazole 5 mg tablet 10 mgtablet
1-Covered
propylthiouracil 50 mg tablet 1-Covered
IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing theImmune System)
IMMUNE SUPPRESSANTS (Drugs to Suppress the Immune System)azathioprine 50 mg tablet 1-Covered
AZATHIOPRINE 50 MG TABLET 1-Covered
cyclosporine 25 mg capsule 100mg capsule
1-Covered
cyclosporine modified (GENGRAF)25 mg capsule 100 mgml solution100 mg capsule
1-Covered
cyclosporine modified 25 mgcapsule 100 mgml solution 100mg capsule
1-Covered
ENBREL (etanercept) 25 MG KIT 1-Covered PA SP QLC (8 vials28 days)
ENBREL (etanercept) 25 MG05 MLSYRINGE 50 MGML SYRINGE
1-Covered PA SP QLC (4 syringes [1 kit]28days)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
104
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ENBREL 25 MG05 ML VIAL 1-Covered PA QL (4 PER 28 DAY(S))
ENBREL SURECLICK (etanercept) 50MGML
1-Covered PA SP QLC (4 pens [1 kit]28days)
HUMIRA (adalimumab) 10 MG02ML SYRINGE 20 MG04 MLSYRINGE 40 MG08 ML SYRINGE
1-Covered PA SP QLC (2 syringes [1 kit]28days)
HUMIRA PEDIATRIC CROHNS(adalimumab) 40 MG08 ML
1-Covered PA SP QLC (3 or 6 syringesyeardepending upon package size)
HUMIRA PEN (adalimumab) 40MG08 ML
1-Covered PA SP QLC (2 pens [1 kit]28days)
HUMIRA PEN CROHNS-UC-HS(adalimumab) --40 MG
1-Covered PA SP QLC (6 pens [1 kit]year)
HUMIRA PEN PSOR-UVEITS-ADOL HS(adalimumab) --40 MG
1-Covered PA SP QLC (4 pens [1 kit]year)
HUMIRA(CF) (adalimumab) 10MG01 ML SYRING 20 MG02 MLSYRING 40 MG04 ML SYRING
1-Covered PA SP QLC (2 syringes [1 kit]28days)
HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 80-40 MG
1-Covered PA SP QLC (2 syringes [1kit]year)
HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 80MG08
1-Covered PA SP QLC (3 syringes [1kit]year)
HUMIRA(CF) PEN (adalimumab) 40MG04 ML
1-Covered PA SP QLC (2 pens [1 kit]28days)
HUMIRA(CF) PEN CROHNS-UC-HS(adalimumab) CRHN--80MG
1-Covered PA SP QLC (3 pens [1 kit]year)
HUMIRA(CF) PEN PSOR-UV-ADOLHS (adalimumab) --AHS 80-40
1-Covered PA SP QLC (3 pens [1 kit]year)
METHOTREXATE 25 MG TABLET 1-Covered
methotrexate sodium 25 mgtablet
1-Covered
mycophenolate mofetil 200 mgmlsusp recon
1-Covered PA
mycophenolate mofetil 250 mgcapsule 500 mg tablet
1-Covered AL1 (At least 21 yrs old)
RHEUMATREX (methotrexatesodium) 25 MG TABLET
1-Covered
SANDIMMUNE (cyclosporine) 25MG CAPSULE 100 MGML SOLN
1-Covered
sirolimus 1 mgml solution 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
105
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
tacrolimus 05 mg capsule 1 mgcapsule 5 mg capsule
1-Covered AL1 (At least 21 yrs old)
TACROLIMUS 05 MG CAPSULE 1MG CAPSULE 5 MG CAPSULE
1-Covered AL1 (At least 21 yrs old)
IMMUNIZING AGENTS PASSIVE (Vaccines)HYPERTET S-D (tetanus immuneglobulinpf) -250 UNIT YRINGE
3-MedicalBenefit
NABI-HB (hepatitis b immuneglobulin) -VIAL gloulin)
3-MedicalBenefit
IMMUNOMODULATORSleflunomide 10 mg tablet 20 mgtablet
1-Covered
LEFLUNOMIDE 10 MG TABLET 20MG TABLET
1-Covered
RIDAURA (auranofin) 3 MGCAPSULE
1-Covered PA
VACCINESADACEL TDAP(diphtheriapertussis(acellular)tetanus vaccinepf) VIAL
1-Covered AL1 (At least 19 yrs old)
AFLURIA QUAD 2020-2021 -VIAL 1-Covered AL1 (At least 19 yrs old)
AFLURIA QUAD 2020-21 (3YR UP) - 1-Covered AL1 (At least 19 yrs old)
BEXSERO (meningococcal group bvaccine 4-component) PREFILLEDSYRINGE -
1-Covered QL (2 PER LIFETIME) AL1 (19 to 25yrs old)
BOOSTRIX TDAP(diphtheriapertussis(acellular)tetanus vaccine) SYRINGE VIAL
1-Covered AL1 (At least 19 yrs old)
ENGERIX-B ADULT (hepatitis b virusvaccine recombinantpf) -20MCGML VIAL recominantpf) -20MCGML SYRN recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
FLUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 65 yrs old)
FLUAD QUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 19 yrs old)
FLUARIX QUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 19 yrs old)
FLUBLOK QUAD 2018-2019(influenza virus vaccine qv 2018-19(18 yrs and older)rcmbpf) -SYRINGE -
1-Covered AL1 (19 to 999 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
106
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
FLUBLOK QUAD 2020-2021 -SYRINGE
1-Covered AL1 (At least 19 yrs old)
FLUCELVAX QUAD 2020-2021 2020-2021 SYR 2020-2021 VIAL
1-Covered AL1 (At least 19 yrs old)
FLULAVAL QUAD 2019-2020(influenza virus vaccinequadrivalent 2019-20 (6 mos andup)) -VIAL -
1-Covered AL1 (At least 19 yrs old)
FLULAVAL QUAD 2020-2021 -SYR 1-Covered AL1 (At least 19 yrs old)
FLUZONE HIGH-DOSE QUAD 2020-21 --
1-Covered AL1 (At least 65 yrs old)
FLUZONE QUAD 2019-2020(influenza virus vaccine quadrival2019-2020(6 mos and up)pf) -VIAL-
1-Covered AL1 (At least 19 yrs old)
FLUZONE QUAD 2020-2021 2020-2021 VIAL 2020-2021 SYRINGE
1-Covered AL1 (At least 19 yrs old)
GARDASIL 9 (human papillomavirusvaccine 9-valentpf) 9 SYRINGE 9-9 VIAL 9-
1-Covered QL (3 PER LIFETIME) AL1 (19 to 27yrs old)
HAVRIX (hepatitis a virusvaccinepf) 720 UNIT05 MLSYRINGE (heptitis vccinepf) 720UNITS05 ML VIAL (heptitisvccinepf) 1440 UNITSMLSYRINGE (heptitis vccinepf) 1440UNITSML VIAL (heptitis vccinepf)
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
HEPLISAV-B (hepatitis b vaccinerecombinantvaccine adjuvantcpg 1018pf) -20 MCG05 MLSYRNG RECOMINANT -20MCG05 ML VIAL RECOMINANT
1-Covered AL1 (At least 19 yrs old) QLC (2perlifetime)
IMOVAX RABIES VACCINE (rabiesvaccine human diploid cellpf)VIAL
3-MedicalBenefit
M-M-R II VACCINE (measlesmumps and rubella vaccinelivepf) --VIAL
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
MENACTRA(meningococcalvaccine acyw-135diphtheria toxoid conjpf) VIAL-
1-Covered AL1 (At least 19 yrs old)
MENQUADFI VIAL 1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
107
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
MENVEO A-C-Y-W-135-DIP(meningococcalvaccine acyw-135diphtheria toxoid conjpf) -----VIL KT -DIPHTHERIA
1-Covered QL (1 PER LIFETIME) AL1 (19 to 55yrs old)
PNEUMOVAX 23 (pneumococcal23-valent polysaccharide vaccine)23 VIAL 23- 23 SYRINGE 23-
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
PREVNAR 13 (pneumococcal 13-valent conjugate vaccine(diphtheria crm)pf) SYRINGE -
1-Covered QL (1 PER LIFETIME) AL1 (At least19 yrs old)
RABAVERT (rabies vaccine purifiedchicken embryo cell (pcec)pf)RABIES VACC W-DILUENT
1-Covered AL1 (At least 19 yrs old)
RECOMBIVAX HB (hepatitis b virusvaccine recombinantpf) 5MCG05 ML SYR recominantpf)10 MCGML SYR recominantpf)40 MCGML VIAL recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
RECOMBIVAX HB (hepatitis b virusvaccine recombinantpf) 5MCG05 ML VL recominantpf) 10MCGML VIAL recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
SHINGRIX (varicella-zoster virusglycoprotein erecas01badjuvantpf) VIAL KIT -
1-Covered QL (2 PER LIFETIME) AL1 (At least50 yrs old)
TDVAX (tetanus and diphtheriatoxoids adult) VIAL
1-Covered AL1 (At least 19 yrs old)
TENIVAC (tetanus and diphtheriatoxoids adsorbed adultpf) VIAL
1-Covered AL1 (At least 19 yrs old)
tetanus and diphtheria toxoidsadult tetanus toxadult 2-2 lf05vial
1-Covered AL1 (At least 19 yrs old)
TRUMENBA (neisseria meningitidisgroup b lipidated fhbprecombinant) 120 MCG05 MLVACCIN
1-Covered QL (2 PER LIFETIME) AL1 (19 to 25yrs old)
TWINRIX (hepatitis a virus andhepatitis b virus vaccinepf)VACCINE SYRINGE (heptitis ndheptitis vccinepf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
108
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
VAQTA (hepatitis a virusvaccinepf) 25 UNITS05 ML VIAL(heptitis vccinepf) 25 UNITS05ML SYRINGE (heptitis vccinepf) 50UNITSML VIAL (heptitis vccinepf)50 UNITSML SYRINGE (heptitisvccinepf)
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
VARIVAX VACCINE (varicella virusvaccine livepf) WITH DILUENT
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
ZOSTAVAX (zoster vaccine livepf)VIAL
1-Covered QL (1 PER LIFETIME) AL1 (At least60 yrs old)
INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for InflammatoryBowel Disease)
AMINOSALICYLATESbalsalazide disodium 750 mgcapsule
1-Covered
mesalamine 4 g60 ml enema 1-Covered
mesalamine 400 mg cap(drtab) 1-Covered QL (6 PER 1 DAY(S))
GLUCOCORTICOIDShydrocortisone (COLOCORT)100mg60ml enema
1-Covered
hydrocortisone 100mg60mlenema
1-Covered
SULFONAMIDESsulfasalazine 500 mg tablet dr 500mg tablet
1-Covered
METABOLIC BONE DISEASE AGENTS (Drugs for the Bone)
METABOLIC BONE DISEASE AGENTSalendronate sodium 10 mg tablet40 mg tablet
1-Covered PA STAR (Preferred Drug)
alendronate sodium 35 mg tablet70 mg tablet
1-Covered STAR (Preferred Drug)
alendronate sodium 5 mg tablet 1-Covered AL1 (At least 65 yrs old) STAR(Preferred Drug)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
109
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcitoninsalmonsynthetic200spray spraypump
1-Covered PA
CALCITRIOL 025 MCG CAPSULE05 MCG CAPSULE
1-Covered
calcitriol 025 mcg capsule 05mcg capsule 1 mcgml solution
1-Covered
cholecalciferol (vitamin d3) 10mcg capsule 10 mcg tablet
1-Covered
cinacalcet hcl 30 mg tablet 60 mgtablet 90 mg tablet
1-Covered PA
CINACALCET HCL 30 MG TABLET60 MG TABLET 90 MG TABLET
1-Covered PA
ergocalciferol (vitamin d2)(CALCIDOL) 200 mcgml drops
1-Covered
ergocalciferol (vitamin d2) 10 mcgtablet 200 mcgml drops 1250mcg capsule
1-Covered
ERGOCALCIFEROL 200 MCGMLDROP
1-Covered
FOSAMAX PLUS D (alendronatesodiumcholecalciferol (vitamind3)) 70 MG-2800 IU
1-Covered PA
MISCELLANEOUS THERAPEUTIC AGENTSalcohol antiseptic pads s med 1-Covered
ALCOHOL WIPES 70 1-Covered
ASSURE ID DUO-SHIELD -30GX316-30GX516
1-Covered
ASSURE ID INSULIN SAFETY SYR05ML 31GX1564 SYR 1 ML31GX1564
1-Covered
condoms female each 1-Covered
condoms latex lubricated each 1-Covered
cromolyn sodium 52 mgspraypump
1-Covered
DROPLET MICRON PEN NEEDLE 34GX 964
1-Covered
freestyle insulix test strips 1-Covered QL (100 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
110
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
freestyle lite test strips 1-Covered QL (100 PER 30 DAYS)
freestyle test strips 1-Covered QL (100 PER 30 DAYS)
inhalerassist device with largemask devicelg spacer
1-Covered
inhalerassist device with mediummask devicemed spacer
1-Covered
inhalerassist device with smallmask devsmall spacer
1-Covered
INSULIN PEN NEEDLES INSULIN PENNEEDLES INSULIN PEN NEEDLES
1-Covered
insulin syringe 03 ml 1-Covered
insulin syringe 05 ml 1-Covered
insulin syringe 1 ml 1-Covered
lancets 28 gauge 30 gauge 33gauge
1-Covered
methylergonovine maleate 02 mgtablet
1-Covered
PEN NEEDLE 29G 12MM 1-Covered
pen needle diabetic 29 g x12 30gx516 31 g x14 31 gx316 31gx516 32gx 532 32 gx 14 32gx316 32 gx516 33 gx532
1-Covered
pen needle diabetic disposablesafety 30 gx516 30 gx316
1-Covered
pen needle diabetic removerand disposal unit 31 gx316 32gx532
1-Covered
pen needle diabetic safety 30gx316 dis
1-Covered
RID (permethrin) PEDICULICIDESSPRAY
1-Covered
syringe with needle insulin safety1 ml geneedleinsulnsafe1ml 30gx316 disp
1-Covered
syringe withneedledisposableinsulin 1 ml30gx12 disp 31 gx516 disp31gx1564 disp
1-Covered
syringe with needleinsulin03 ml -needldispinsul03 29 x12 disp
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
111
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
syringe with needleinsulin05 ml -ml 30gx12 disp -ml 31 gx516disp -ml 31gx1564 disp
1-Covered
UNIFINE PENTIPS MAXFLOW30GX316
1-Covered
OPHTHALMIC AGENTS (Drugs for the Eyes)
OPHTHALMIC AGENTS OTHER (Other Drugs for the Eyes)atropine sulfate 1 drops 1-Covered
bacitracinpolymyxin b sulfate (AK-POLY-BAC) 500-10kg oint (g) --
1-Covered
bacitracinpolymyxin b sulfate(POLYCIN) 500-10kg oint (g)
1-Covered
bacitracinpolymyxin b sulfate 500-10kg oint (g)
1-Covered
BEOVU (brolucizumab-dbll) 6MG005 ML VIAL -
3-MedicalBenefit
BLEPHAMIDE (sulfacetamidesodiumprednisolone acetate) EYEDROPS
1-Covered
CORTISPORIN (neomycinsulfatepolymyxin bsulfatehydrocortisone) CREAM
1-Covered
cyclopentolate hcl 05 drops 1 drops 2 drops
1-Covered
homatropine hbr (HOMATROPAIRE)5 drops
1-Covered
homatropine hbr 5 drops 1-Covered
MURO-128 (sodium chloride) -5EYE DROPS
1-Covered
neomycin sulfatebacitracinzincpolymyxin bhydrocortisone(NEO-POLYCIN HC)neomycinbacitp-myxhydrocort35-10k-1 oint (g) -
1-Covered
neomycin sulfatebacitracinzincpolymyxin bhydrocortisoneneomycinbacitp-myxhydrocort35-10k-1 oint (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
112
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
neomycinsulfatebacitracinpolymyxin b(NEO-POLYCIN)sulfbacitracinpoly 35mg-400oint (g) -
1-Covered
neomycinsulfatebacitracinpolymyxin bsulfbacitracinpoly 35mg-400oint (g)
1-Covered
neomycin sulfatepolymyxin bsulfategramicidin dneomycinpolymyxn bgramicidin175mg-10k drops
1-Covered
neomycin sulfatepolymyxin bsulfatehydrocortisoneneomycinpolymyxin bhydrocort35-10k-10 drops susp
1-Covered
neomycinpolymyxin bsulfatedexamethasonebdexametha 01 drops suspbdexametha 35-10k-1 oint (g)
1-Covered
phenylephrine hcl 25 drops 10 drops
1-Covered
polymyxin b sulfatetrimethoprimsulftrimethoprim 10000-1ml drops
1-Covered
proparacaine hcl 05 drops 1-Covered PA
sodium chloride (MURO-128) drops -18)
1-Covered
sodium chloride 5 drops 1-Covered
sulfacetamidesodiumprednisolone sodiumphosphatesulfacetamideprednisolone 10 -023 drops
1-Covered
TOBRADEX(tobramycindexamethasone) EYEOINTMENT
1-Covered
tobramycindexamethasone 03-01 drops susp
1-Covered
OPHTHALMIC ANTI-ALLERGY AGENTS (Drugs for Eye Allergies)ALAWAY (ketotifen fumarate)0025 EYE DROPS
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
113
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALOMIDE (lodoxamidetromethamine) 01 EYE DROPS
1-Covered
cromolyn sodium 4 drops 1-Covered
EYE ITCH RELIEF 0025 DROPS HM0025 DROP
1-Covered
ketotifen fumarate (ALLERGY EYEDROPS) 0025 drops
1-Covered
ketotifen fumarate (EYE ITCHRELIEF) 0025 drops
1-Covered
ketotifen fumarate (ITCHY EYE)0025 drops
1-Covered
ketotifen fumarate (WAL-ZYR) 0025 drops -
1-Covered
ketotifen fumarate (ZADITOR) 0025 drops
1-Covered
ketotifen fumarate 0025 drops 1-Covered
OPHTHALMIC ANTI-INFLAMMATORIES (Drugs to Reduce EyeSwelling)
dexamethasone sodiumphosphate 01 drops
1-Covered
diclofenac sodium 01 drops 1-Covered
fluorometholone 01 drops susp 1-Covered
flurbiprofen sodium 003 drops 1-Covered
FML FORTE (fluorometholone)025 EYE DROPS
1-Covered
FML SOP (fluorometholone) 01OINTMENT
1-Covered
ketorolac tromethamine 05 drops
1-Covered
PRED MILD (prednisolone acetate)012 EYE DROPS
1-Covered
prednisolone acetate 1 dropssusp
1-Covered
prednisolone sodium phosphate 1 drops
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
114
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
OPHTHALMIC ANTIGLAUCOMA AGENTS (Drugs for Glaucoma)ALPHAGAN P (brimonidinetartrate) ALHAGAN 01 DROS
1-Covered QL (1 PER 30 DAYS)
apraclonidine hcl 05 drops 1-Covered
betaxolol hcl 05 drops 1-Covered
BETIMOL (timolol) 025 DROPS05 DROPS
1-Covered
BETOPTIC S (betaxolol hcl) 025EYE DROP
1-Covered
brimonidine tartrate 02 drops 1-Covered
dorzolamide hcl 2 drops 1-Covered
dorzolamide hcltimolol maleate223-681 drops
1-Covered QL (10 PER 30 DAY(S))
DORZOLAMIDE-TIMOLOL -EYEDROPS
1-Covered QL (10 PER 30 DAY(S))
IOPIDINE (apraclonidine hcl) 1EYE DROPS
1-Covered
levobunolol hcl 05 drops 1-Covered
methazolamide 25 mg tablet 50mg tablet
1-Covered
METHAZOLAMIDE 25 MG TABLET 50MG TABLET
1-Covered
PHOSPHOLINE IODIDE(echothiophate iodide) 0125
1-Covered
pilocarpine hcl 1 drops 2 drops 4 drops
1-Covered
PILOCARPINE HCL 1 DROPS 2DROPS
1-Covered
timolol maleate 025 sol-gel 025 drops 05 drops 05 sol-gel
1-Covered
TIMOLOL MALEATE 05 EYE DROPS 1-Covered
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS (Drugsfor Glaucoma)
latanoprost 0005 drops 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
115
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
OTIC AGENTS (Drugs for the Ears)
OTIC AGENTS (Drugs for Ear Infection)acetic acid 2 solution 1-Covered
ACETIC ACID 2 EAR SOLUTION 1-Covered
carbamide peroxide(CARBAMOXIDE) 65 drops
1-Covered
carbamide peroxide (EAR DROPS)65 drops
1-Covered
carbamide peroxide (EAR SYSTEM)65 drops
1-Covered
carbamide peroxide (EAR WAXREMOVAL) 65 drops
1-Covered
carbamide peroxide (MURINE EARWAX REMOVAL SYSTEM) 65 drops
1-Covered
DEBROX (carbamide peroxide)65 EAR DROPS
1-Covered
EAR DROPS (carbamide peroxide)65
1-Covered
hydrocortisoneacetic acid(ACETASOL HC) 1 -2 drops
1-Covered
hydrocortisoneacetic acid 1 -2 drops
1-Covered
MURINE EAR DROPS (carbamideperoxide) 65
1-Covered
neomycin sulfatepolymyxin bsulfatehydrocortisoneneomycinpolymyxin bhydrocort35--1 solutionneomycinpolymyxin bhydrocort35--1 drops susp
1-Covered
NEOMYCIN-POLYMYXIN-HC --EARSUSP
1-Covered
RESPIRATORY TRACTPULMONARY AGENTS (Drugs for the Lungs)
ANTI-INFLAMMATORIES INHALED CORTICOSTEROIDS (Inhaled Drugsto Prevent Swelling of the Airways)
BUDESONIDE 025 MG2 ML SUSP 1-Covered AL1 (Up to 6 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
116
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
budesonide 025mg2ml - 05mg2ml -
1-Covered AL1 (Up to 6 yrs old)
CHILDRENS NASACORT(triamcinolone acetonide)ALLERGY 24 HR
1-Covered QL (17 PER 30 DAY(S))
FLOVENT DISKUS (fluticasonepropionate) 50 MCG 100 MCG250 MCG
1-Covered
FLOVENT HFA (fluticasonepropionate) HFA 44 MCG INHALERHFA 110 MCG INHALER HFA 220MCG INHALER
1-Covered
fluticasone propionate (ALLERGYRELIEF) 50 mcg spray susp
1-Covered QL (16 PER 30 DAY(S))
fluticasone propionate 50 mcgspray susp
1-Covered QL (16 PER 30 DAY(S))
NASACORT (triamcinoloneacetonide) ALLERGY 24HR SPRAY
1-Covered
PULMICORT FLEXHALER(budesonide) 180 MCG
1-Covered
QVAR REDIHALER(beclomethasone dipropionate)40 MCG 80 MCG
1-Covered
triamcinolone acetonide 55 mcgspray
1-Covered QL (17 PER 30 DAY(S))
ANTIHISTAMINESALAVERT (loratadine) 10 MG ODT 1-Covered AL1 (Up to 12 yrs old)
ALL DAY ALLERGY ERGY 10 MGTABLET SM ERGY 10 MG TAB
1-Covered
ALLERGY RELIEF (LORATADINE) 10MG TAB RELIEF 10 MG TABLET
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
ALLERGY RELIEF 4 MG TABLET HM 4MG TABLET HM 25 MG CAP 25 MGSOFTGEL GS 25 MG TABLET
1-Covered
ALLERGY RELIEF HM 180 MG TAB180 MG TABLET
1-Covered ST
AZELASTINE HCL 01 (137 MCG)SPRY
1-Covered QL (1 PER 30 DAYS)
azelastine hcl 137 mcgspraypump
1-Covered QL (1 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
117
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
cetirizine hcl (24HOUR ALLERGY) 10mg tablet
1-Covered
cetirizine hcl (ALL DAY ALLERGYRELIEF) 10 mg tablet
1-Covered
cetirizine hcl (ALL DAY ALLERGY) 10mg tablet
1-Covered
cetirizine hcl (ALLER-TEC) 10 mgtablet -
1-Covered
cetirizine hcl (ALLERGY RELIEF) 10mg tablet
1-Covered
cetirizine hcl (WAL-ZYR) 10 mgtablet -
1-Covered
cetirizine hcl 1 mgml 5 mg5 ml 1-Covered ST AL1 (Up to 5 yrs old)
CETIRIZINE HCL 10 MG TABLET 1-Covered
cetirizine hcl 5 mg tablet 10 mgtablet
1-Covered
CHILDRENS ALLERGY RELIEF 5MG5 ML
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
CHILDRENS ALLERGY RELIEF RLF125 MG5 ML
1-Covered
chlorpheniramine maleate(ALLERGY 4-HOUR) mg tablet -
1-Covered
chlorpheniramine maleate(ALLERGY RELIEF) 4 mg tablet
1-Covered
chlorpheniramine maleate(ALLERGY) 4 mg tablet
1-Covered
chlorpheniramine maleate(ALLERGY-TIME) 4 mg tablet -
1-Covered
chlorpheniramine maleate(CHLORHIST) 4 mg tablet
1-Covered
chlorpheniramine maleate(CHLORTABS) 4 mg tablet
1-Covered
chlorpheniramine maleate (EDCHLORPED JR) 2 mg5 ml syrup
1-Covered
chlorpheniramine maleate(PHARBECHLOR) 4 mg tablet
1-Covered
chlorpheniramine maleate (WAL-FINATE) 4 mg tablet -
1-Covered
chlorpheniramine maleate 4 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
118
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
clemastine fumarate 268 mgtablet
1-Covered
cyproheptadine hcl 2 mg5 mlsyrup 4 mg tablet 4 mg10 mlsyrup
1-Covered
diphenhydramine hcl (ALER-CAPS)25 mg capsule -
1-Covered
diphenhydramine hcl (ALLER-G-TIME) 25 mg tablet --
1-Covered
diphenhydramine hcl (ALLERGYMEDICATION) 25 mg capsule 25mg tablet
1-Covered
diphenhydramine hcl (ALLERGYMEDICINE) 25 mg tablet
1-Covered
diphenhydramine hcl (ALLERGYRELIEF) 125mg5ml liquid 25 mgcapsule 25 mg tablet
1-Covered
diphenhydramine hcl (ALLERGY)125mg5ml liquid 25 mg capsule25 mg tablet
1-Covered
diphenhydramine hcl (BANOPHEN)125mg5ml liquid 25 mg tablet 25mg capsule 50 mg capsule
1-Covered
diphenhydramine hcl (BENADRYLALLERGY) 25 mg tablet
1-Covered
diphenhydramine hcl (CHILDRENSALLERGY RELIEF) 125mg5ml liquid
1-Covered
diphenhydramine hcl (CHILDRENSALLERGY) 125mg5ml elixir125mg5ml liquid
1-Covered
diphenhydramine hcl (CHILDRENSBENADRYL ALLERGY) 125mg5mlliquid
1-Covered
diphenhydramine hcl (CHILDRENSWAL-DRYL ALLERGY) 125mg5mlliquid -
1-Covered
diphenhydramine hcl (COMPLETEALLERGY) 25 mg capsule 25 mgtablet
1-Covered
diphenhydramine hcl (DIPHEDRYLALLERGY) 125mg5ml liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
119
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
diphenhydramine hcl (DIPHEDRYL)125mg5ml liquid 25 mg capsule
1-Covered
diphenhydramine hcl (DIPHEN)125mg5ml elixir 25 mg tablet
1-Covered
diphenhydramine hcl (DIPHENHIST)125mg5ml liquid 25 mg tablet
1-Covered
diphenhydramine hcl (GERI-DRYL)125mg5ml liquid - 25 mg tablet -
1-Covered
diphenhydramine hcl (M-DRYL)125mg5ml liquid -
1-Covered
diphenhydramine hcl (NIGHTTIMEALLERGY RELIEF) 25 mg tablet
1-Covered
diphenhydramine hcl (NIGHTTIMESLEEP AID) 25 mg tablet
1-Covered
diphenhydramine hcl(PHARBEDRYL) 25 mg capsule 50mg capsule
1-Covered
diphenhydramine hcl (SILADRYL)125mg5ml liquid
1-Covered
diphenhydramine hcl (SIMPLYSLEEP) 25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP AID)25 mg tablet
1-Covered
diphenhydramine hcl (TOTALALLERGY) 25 mg tablet
1-Covered
diphenhydramine hcl (WAL-DRYLALLERGY) 125mg5ml liquid - 25mg tablet -
1-Covered
diphenhydramine hcl (WAL-DRYL)25 mg capsule -
1-Covered
DIPHENHYDRAMINE HCL 125 MG5ML 25 MG10 ML
1-Covered
diphenhydramine hcl 125mg5mlelixir 125mg5ml syrup125mg5ml liquid 25 mg tablet 25mg capsule 50 mg capsule
1-Covered
fexofenadine hcl (ALLER-EASE) 60mg tablet - 180 mg tablet -
1-Covered ST
fexofenadine hcl (ALLER-FEX) 180mg tablet -
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
120
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fexofenadine hcl (ALLERGY RELIEF)60 mg tablet 180 mg tablet
1-Covered ST
fexofenadine hcl (WAL-FEXALLERGY) 60 mg tablet - 180 mgtablet -
1-Covered ST
fexofenadine hcl 60 mg tablet 180mg tablet
1-Covered ST
FEXOFENADINE HCL HM 60 MGTAB 60 MG TABLET 180 MG TABLET
1-Covered ST
GERI-DRYL -125 MG5 ML LIQUID 1-Covered
hydroxyzine hcl 10 mg tablet 10mg5 ml solution 25 mg tablet 50mg tablet 50 mg25ml solution
1-Covered
HYDROXYZINE PAMOATE 25 MGCAP 50 MG CAP
1-Covered
hydroxyzine pamoate 25 mgcapsule 50 mg capsule 100 mgcapsule
1-Covered
loratadine (ALLERCLEAR) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (ALLERGY RELIEF) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (ALLERGY RELIEF) 5mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (ALLERGY) 10 mg tablet 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (CHILDRENS ALLERGYRELIEF) 5 mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (CHILDRENS ALLERGY) 5mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (LORADAMED) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (NON-DROWSYALLERGY) 10 mg tablet -
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (WAL-ITIN) 10 mg tablet-
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (WAL-ITIN) 5 mg5 mlsolution -
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine 10 mg tablet 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
121
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LORATADINE 10 MG TABLET 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine 5 mg5 ml solution 1-Covered QL (150 PER 30 DAYS) AL1 (Up to6 yrs old)
NIGHTTIME SLEEP AID HM 25 MGCPLT
1-Covered
promethazine hcl 125 mg tablet25 mg tablet
1-Covered
PROMETHAZINE HCL 625 MG5 MLSOLN
1-Covered AL1 (At least 2 yrs old)
promethazine hcl 625mg5mlsyrup
1-Covered AL1 (At least 2 yrs old)
ANTILEUKOTRIENESmontelukast sodium 4 mg granpack
1-Covered ST
MONTELUKAST SODIUM 4 MGGRANULES
1-Covered ST
montelukast sodium 4 mg tabchew 5 mg tab chew 10 mgtablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
BRONCHODILATORS ANTICHOLINERGIC (Anticholinergic Drugs toOpen the Airway)
ATROVENT HFA (ipratropiumbromide) 17 MCG INHALER
1-Covered
INCRUSE ELLIPTA (umeclidiniumbromide) 625 MCG INH
1-Covered C (RESTRICTED TO THE DIAGNOSISOF CHRONIC OBSTRUCTIVEPULMONARY DISEASE (COPD))
ipratropium bromide 02 mgmlsolution 21 mcg spray 42 mcgspray
1-Covered
BRONCHODILATORS SYMPATHOMIMETIC (Sympathomimetic Drugsto Open the Airway)
albuterol 90mcg hfa inhaler(generic proair)
1-Covered QL (2 PER 30 [DAYS])
albuterol 90mcg hfa inhaler(generic proventil)
1-Covered QL (2 PER 30 [DAYS])
albuterol 90mcg hfa inhaler(generic ventolin)
1-Covered QL (2 PER 30 [DAYS])
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
122
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALBUTEROL SULFATE 100 MG20 MLSOLN
1-Covered
albuterol sulfate 2 mg tablet 2mg5 ml syrup 25 mg3ml vial-neb 25 mg05 vial-neb 4 mg taber 12h 4 mg tablet 5 mgmlsolution 8 mg tab er 12h
1-Covered
albuterol sulfate 90 mcg hfa aerad
1-Covered QL (2 PER 30 [DAYS])
ALBUTEROL SULFATE HFA 90 MCGINHALER
1-Covered QL (2 PER 30 [DAYS])
epinephrine 015mg03 03mg03 1-Covered QL (2 PER FILL(S))
FORADIL (formoterol fumarate)AEROLIZER 12 MCG CAP
1-Covered ST
levalbuterol tartrate 45 mcg hfaaer ad
1-Covered QL (30 PER 30 DAY(S))
metaproterenol sulfate 10 mg5 mlsyrup 10 mg tablet 20 mg tablet
1-Covered
NASAL DECONGESTANT(pseudoephedrine hcl) 30 MG TAB
1-Covered
pseudoephedrine hcl (NASALDECONGESTANT) 30 mg tablet
1-Covered
pseudoephedrine hcl (SUDOGEST)30 mg tablet 60 mg tablet
1-Covered
pseudoephedrine hcl (SUPHEDRIN)30 mg tablet
1-Covered
pseudoephedrine hcl (SUPHEDRINESINUS CONGESTION) 30 mg tablet
1-Covered
pseudoephedrine hcl(SUPHEDRINE) 30 mg tablet
1-Covered
pseudoephedrine hcl (WAL-PHED)30 mg tablet -
1-Covered
pseudoephedrine hcl 30 mgtablet 60 mg tablet
1-Covered
SEREVENT DISKUS (salmeterolxinafoate) 50 MCG
1-Covered QL (60 PER 30 DAYS)
SUDAFED (pseudoephedrine hcl)30 MG TABLET
1-Covered
TERBUTALINE SULFATE 25 MG TAB 5MG TAB
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
123
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terbutaline sulfate 25 mg tablet 5mg tablet
1-Covered
PHOSPHODIESTERASE INHIBITORS AIRWAYS DISEASE (Drugs thatBlock Phosphodiesterase)
ELIXOPHYLLIN (theophyllineanhydrous) OPHYLLIN 80 MG15 ML
1-Covered
THEO-24 (theophylline anhydrous) -24 ER 200 MG CAPSULE -24 ER 300MG CAPSULE -24 ER 100 MGCAPSULE -24 ER 400 MG CAPSULE
1-Covered
theophylline anhydrous(THEOCHRON) 100 mg tab er 200mg tab er 300 mg tab er
1-Covered
theophylline anhydrous 80mg15ml solution 80 mg15ml elixir100 mg tab er 12h 200 mg tab er12h 300 mg tab er 12h 400 mgtab er 24h 450 mg tab er 12h 600mg tab er 24h
1-Covered
PULMONARY ANTIHYPERTENSIVES (Drugs for PulmonaryHypertension)
ambrisentan 5 mg tablet 10 mgtablet
1-Covered PA QL (1 PER 1 DAY(S)) SP
bosentan 625 mg tablet 125 mgtablet
1-Covered PA QL (2 PER 1 DAY(S)) SP
sildenafil citrate 20 mg tablet 1-Covered PA QL (3 PER 1 DAY(S)) SP
SILDENAFIL CITRATE 20 MG TABLET 1-Covered PA QL (3 PER 1 DAY(S)) SP
tadalafil (ALYQ) 20 mg tablet 1-Covered PA QL (2 PER 1 DAY(S)) SP
tadalafil 20 mg tablet 1-Covered PA QL (2 PER 1 DAY(S)) SP
RESPIRATORY TRACT AGENTS OTHER (Other Drugs for BreathingConditions)
acetylcysteine 100 mgml vial 200mgml vial
1-Covered
benzonatate 100 mg capsule 1-Covered
BEVESPI AEROSPHERE(glycopyrrolateformoterolfumarate) INHALER
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
124
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
brompheniraminemaleatepseudoephedrine hcl(RYNEX PSE)brompheniraminpseudoephedrine 1-15mg5ml liquid
1-Covered
BROTAPP DM (brompheniraminemaleatepseudoephedrinehcldextromethorphan) 1-15-5MG5 ML LIQ
1-Covered
chlorpheniraminemaleatepseudoephedrinedextromethorphan (KIDKARE)chlorpheniraminpseudoepheddm 1-15-5mg5 liquid
1-Covered
codeine phosphateguaifenesin(CHERATUSSIN AC) 10-100mg5liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(G TUSSIN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(GUAIATUSSIN AC) 10-100mg5 20-20010
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(GUAIFENESIN AC) 10-100mg5liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(ROBAFEN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(VIRTUSSIN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin10-100mg5 20-20010
1-Covered AL1 (At least 12 yrs old)
CODEINE-GUAIFENESIN -10-100MG5 ML
1-Covered AL1 (At least 12 yrs old)
COMBIVENT RESPIMAT (ipratropiumbromidealbuterol sulfate) 20-100MCG
1-Covered
COUGH FORMULA DM(guaifenesindextromethorphanhbr) SYRUP
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
125
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fluticasone propionatesalmeterolxinafoate (WIXELA INHUB)propionsalmeterol 100-50 mcgwdev propionsalmeterol 250-50mcg wdev propionsalmeterol500-50 mcg wdev
1-Covered QL (60 PER 30 DAY(S))
fluticasone propionatesalmeterolxinafoate propionsalmeterol 100-50 mcg wdev propionsalmeterol250-50 mcg wdevpropionsalmeterol 500-50 mcgwdev
1-Covered QL (60 PER 30 DAY(S))
fluticasone propionatesalmeterolxinafoate propionsalmeterol 55-14mcg propionsalmeterol 113-14mcg propionsalmeterol 232-14mcg
1-Covered QL (1 PER 30 DAYS)
GUAIASORB DM LIQUID 1-Covered
guaifenesin (MUCUS ER) 600 mgtab er 12h
1-Covered
guaifenesin (MUCUS RELIEF ER) 600mg tab er 12h
1-Covered
GUAIFENESIN-DEXTROMETHORPHAN DM SYRUP
1-Covered
guaifenesindextromethorphanhbr (ADULT ROBITUSSIN PEAK COLDDM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ADULT TUSSIN COUGHCONGEST DM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ADULT TUSSIN DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (ADULT WAL-TUSSIN DM) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (ANTITUSSIVE DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (BIOCOTRON) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (COUGH DM) 100-10mg5syrup
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
126
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesindextromethorphanhbr (DIABETIC SILTUSSIN-DM) 100-10mg5 liquid -
1-Covered
guaifenesindextromethorphanhbr (DIABETIC TUSSIN DM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (EXPECTORANT DM) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (EXTRA ACTION COUGH) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (GERI-TUSSIN DM) 100-10mg5liquid - 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (GILTUSS DIABETIC) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (GILTUSS HBP) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (GUAIASORB DM) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (RI-TUSSIN DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM COUGH) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM COUGH-CHESTCONGEST) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM PEAK COLD)100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN-DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr (SAFETUSSIN DM) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (SILTUSSIN DM DAS) 100-10mg5liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
127
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesindextromethorphanhbr (SILTUSSIN DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (SORBUGEN NR) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSNEL DIABETIC) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSSIN COUGH) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM CLEAR) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM COUGH) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM COUGH-CHESTCONGEST) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM) 100-10mg5 liquid100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (ULTRA DM FREE amp CLEAR) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ULTRA TUSS) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (WAL-TUSSIN DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr 100-10mg5 syrup 100-10mg5liquid
1-Covered
guaifenesinpseudoephedrine hcl(MUCUS D)guaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
guaifenesinpseudoephedrine hcl(MUCUS RELIEF D)guaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
128
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesinpseudoephedrine hclguaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
ipratropium bromidealbuterolsulfate ipratropiumalbuterol 05-3mg3 ampul-neb
1-Covered QL (540 PER 30 DAY(S))
IPRATROPIUM-ALBUTEROL -05-3(25) MG3 ML
1-Covered QL (540 PER 30 DAY(S))
MAXI-TUSS G -LIQUID 1-Covered
MUCUS ER CVS 600 MG TABLET 1-Covered
MUCUS RELIEF ER HM 600 MG TAB 1-Covered
phenylephrine hclpromethazinehcl prometh 5-625mg5 syrup
1-Covered AL1 (At least 2 yrs old)
promethazine hclcodeine 625-105 syrup
1-Covered QL (240 PER 30 DAYS) AL1 (Atleast 12 yrs old) QLC (LIMIT 240ML(8OZ) PER 30 DAYS)
promethazinehcldextromethorphan hbrpromethazinedextromethorphan625-155 syrup
1-Covered AL1 (At least 2 yrs old)
PROMETHAZINE-DM -625-15MG5ML
1-Covered AL1 (At least 2 yrs old)
promethazinephenylephrinehclcodeinepromethazinephenylephcodeine625-5-10 syrup
1-Covered AL1 (At least 12 yrs old)
sodium chloride for inhalation 09 vial- 3 vial- 10 vial-
1-Covered
triprolidine hclpseudoephedrinehcl (APRODINE)triprolidinepseudoephedrine25mg-60mg tablet
1-Covered
triprolidine hclpseudoephedrinehcl (ED A-HIST PSE)triprolidinepseudoephedrine25mg-60mg tablet -
1-Covered
triprolidine hclpseudoephedrinehcl (RITIFED)triprolidinepseudoephedrine 125-305 syrup
1-Covered
triprolidine hclpseudoephedrinehcl (WAL-ACT D COLD amp ALLERGY)triprolidinepseudoephedrine25mg-60mg tablet -col
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
129
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles)
SKELETAL MUSCLE RELAXANTS (Drugs to Relax the Muscles)carisoprodol 350 mg tablet 1-Covered QL (90 PER 30 DAYS)
CARISOPRODOL 350 MG TABLET 1-Covered QL (90 PER 30 DAYS)
cyclobenzaprine hcl 10 mg tablet 1-Covered QL (90 PER 30 DAYS)
cyclobenzaprine hcl 5 mg tablet 1-Covered QL (90 PER 30 DAY(S))
methocarbamol 500 mg tablet750 mg tablet
1-Covered QL (90 PER 30 DAYS)
METHOCARBAMOL 500 MG TABLET750 MG TABLET
1-Covered QL (90 PER 30 DAYS)
VANADOM 350 MG TABLET 1-Covered QL (90 PER 30 DAY(S))
SLEEP DISORDER AGENTS (Drugs for Insomnia)
GABA RECEPTOR MODULATORSflurazepam hcl 15 mg capsule 30mg capsule
1-Covered AL1 (Up to 65 yrs old)
temazepam 75 mg capsule 15mg capsule 30 mg capsule
1-Covered
triazolam 0125 mg tablet 025 mgtablet
1-Covered QL (14 PER 30 DAY(S))
zaleplon 5 mg capsule 10 mgcapsule
1-Covered ST
zolpidem tartrate 5 mg tablet 10mg tablet
1-Covered
SLEEP DISORDERS OTHERdiphenhydramine hcl (ALKA-SELTZER PLUS ALLERGY) 25 mgtablet -
1-Covered
diphenhydramine hcl (COMPOZ)25 mg tablet
1-Covered
diphenhydramine hcl (NIGHTTIMESLEEP AID) 25 mg tablet
1-Covered
diphenhydramine hcl (NYTOLQUICKCAPS) 25 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
130
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
diphenhydramine hcl (SIMPLYSLEEP) 25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP AID)25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP II) 25mg tablet
1-Covered
diphenhydramine hcl (SLEEPTABLET) 25 mg tablet
1-Covered
modafinil 100 mg tablet 200 mgtablet
1-Covered PA QL (3 PER 1 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
131
Alphabetical Index of Prescription Drugs
009 sodium chloride 697072
Aabacavir sulfate 38abacavir sulfatelamivudine 38abacavir sulfatelamivudinezidovudine 38ABACAVIR-LAMIVUDINE 38ABILIFY (aripiprazole) 31ABILIFY MAINTENA (aripiprazole) 31ABILIFY MYCITE (aripiprazole) 31acamprosate calcium 6acarbose 4243acetaminophen 64ACETAMINOPHEN 64acetaminophen (ATHENOL) 63acetaminophen (CHILD FEVER REDUCER) 63acetaminophen (CHILD PAIN REL-FEVERREDUCER) 63acetaminophen (CHILDRENS FEVERREDUCER) 63acetaminophen (CHILDRENS FEVERREDUCING) 63acetaminophen (CHILDRENS PAIN ANDFEVER) 63acetaminophen (CHILDRENS SILAPAP) 63acetaminophen (ED-APAP) 63acetaminophen (LITTLE REMEDIES FEVER-PAIN) 63acetaminophen (M-PAP) 63acetaminophen (MAPAP) 63acetaminophen (MASOPHEN) 63acetaminophen (NON-ASPIRIN EXTRASTRENGTH) 63acetaminophen (NON-ASPIRIN PAIN RELIEF) 63acetaminophen (NON-ASPIRIN) 63acetaminophen (PAIN amp FEVER) 63acetaminophen (PAIN RELIEF EXTRASTRENGTH) 64acetaminophen (PAIN RELIEF) 64
acetaminophen (PAIN RELIEVER) 64acetaminophen (PHARBETOL) 64acetaminophen (SHAKE THAT ACHE) 64acetaminophen (TACTINAL) 64ACETAMINOPHEN 160 MG5ML ORAL SUSP 64ACETAMINOPHEN 160 MG5ML SOLUTION 64acetaminophen with codeine phosphate 45acetazolamide 57ACETAZOLAMIDE 58acetic acid 116ACETIC ACID 116acetylcysteine 124ACID CONTROLLER 80ACID REDUCER 80ACNE MEDICATION 66ACNE MEDICATION (benzoyl peroxide) 66acyclovir 41ACYCLOVIR 41ADACEL TDAP(diphtheriapertussis(acellular)tetanusvaccinepf) 106ADASUVE (loxapine) 30ADLYXIN (lixisenatide) 43ADMELOG (insulin lispro) 45ADMELOG SOLOSTAR (insulin lispro) 45ADVATE (antihemophilic factor (fviii)recombinantfull length) 47ADYNOVATE (antihemophilic factor (fviii)recombinant full length peg) 47AFLURIA QUAD 2020-2021 106AFLURIA QUAD 2020-21 (3YR UP) 106AFSTYLA (antihemophilic factor viiirecombsingle-chnb-dom truncated) 47ALAVERT (loratadine) 117ALAWAY (ketotifen fumarate) 113Albuterol 90mcg HFA inhaler (GenericProair) 122Albuterol 90mcg HFA inhaler (GenericProventil) 122Albuterol 90mcg HFA inhaler (GenericVentolin) 122
LAST UPDATED 12012020132
ALBUTEROL SULFATE 123albuterol sulfate 123ALBUTEROL SULFATE HFA 123alcohol antiseptic pads 110ALCOHOL WIPES 110alendronate sodium 109alfuzosin hcl 86ALL DAY ALLERGY 117ALLERGY RELIEF 117ALLI (orlistat) 78allopurinol 24ALLOPURINOL 24alogliptin benzoate 43alogliptin benzoatemetformin hcl 43alogliptin benzoatepioglitazone hcl 43ALOMIDE (lodoxamide tromethamine) 114ALPHAGAN P (brimonidine tartrate) 115ALPHANATE (antihemophilic factorhumanvon willebrand factorhuman) 47ALPHANINE SD (factor ix) 47alprazolam 42alprazolam (ALPRAZOLAM INTENSOL) 42ALPROLIX (factor ix recombinant fc fusionprotein) 48AMANTADINE 29amantadine hcl 29ambrisentan 124amiloride hcl 58amiloride hclhydrochlorothiazide 56amiodarone hcl 53amiodarone hcl (PACERONE) 53AMITIZA (lubiprostone) 81amitriptyline hcl 19AMLODIPINE BESYLATE 54amlodipine besylate 54amlodipine besylatebenazepril hcl 56ammonium lactate 66ammonium lactate (SKIN TREATMENT) 66amoxapine 19amoxicillin 11AMOXICILLIN-CLAVULANATE POTASS 11
amoxicillinpotassium clavulanate 1112ampicillin trihydrate 12anagrelide hcl 47anastrozole 28ANASTROZOLE 28ANTACID 78ANTACID EXTRA STRENGTH 78ANTI-DIARRHEAL 78ANTIFUNGAL 21apraclonidine hcl 115aprepitant 21APTIVUS (tipranavir) 40APTIVUS (tipranavirvitamin e tpgs) 40aripiprazole 32ARIPIPRAZOLE 32ARISTADA (aripiprazole lauroxil) 32ARISTADA INITIO (aripiprazole lauroxilsubmicronized) 32ARMOUR THYROID (thyroidpork) 102ascorbate calcium 72ascorbic acid 72ascorbic acid (SOOTHING PUREWAY-C) 72aspirin 1aspirin (ADULT ASPIRIN REGIMEN) 1aspirin (ADULT LOW DOSE ASPIRIN EC) 1aspirin (ASPIR 81) 1aspirin (ASPIR-TRIN) 1aspirin (ASPIRIN) 1aspirin (ECOTRIN) 1aspirin (ECPIRIN) 1aspirin (ST JOSEPH ASPIRIN EC) 1aspirin (ST JOSEPH ASPIRIN) 1ASPIRIN 325MG TABLET 1ASPIRIN 81MG TABLET 1aspirinacetaminophencaffeine (ADDEDSTRENGTH HEADACHE) 1aspirinacetaminophencaffeine (BAYERMIGRAINE) 1aspirinacetaminophencaffeine (EXTRA PAINRELIEF) 1
LAST UPDATED 12012020133
aspirinacetaminophencaffeine(EXTRAPRIN) 1aspirinacetaminophencaffeine (HEADACHERELIEF) 1aspirinacetaminophencaffeine (MIGRAINEFORMULA) 2aspirinacetaminophencaffeine (MIGRAINERELIEF) 2aspirinacetaminophencaffeine (PAINRELIEVER PLUS) 2aspirinacetaminophencaffeine (PAINRELIEVER) 2aspirinacetaminophencaffeine (PAIN-OFF) 2ASSURE ID DUO-SHIELD 110ASSURE ID INSULIN SAFETY 110ATAZANAVIR SULFATE 40atazanavir sulfate 40atenolol 53ATENOLOL 53atenololchlorthalidone 56ATHLETES FOOT (terbinafine hcl) 21atomoxetine hcl 62atorvastatin calcium 59ATORVASTATIN CALCIUM 59ATRIPLA (efavirenzemtricitabinetenofovirdisoproxil fumarate) 37atropine sulfate 112ATROVENT HFA (ipratropium bromide) 122AVANDIA (rosiglitazone maleate) 43AVONEX (interferon beta-1a) 65AVONEX (interferon beta-1aalbuminhuman) 65AVONEX PEN (interferon beta-1a) 65azathioprine 104AZATHIOPRINE 104AZELASTINE HCL 117azelastine hcl 117azithromycin 12AZITHROMYCIN 12
Bbacitracin 9BACITRACIN 9bacitracin (BACITRAYCIN PLUS) 9bacitracin zinc 9BACITRACIN ZINC 9bacitracin zinc (ANTIBIOTIC) 9bacitracinpolymyxin b sulfate 112bacitracinpolymyxin b sulfate (AK-POLY-BAC) 112bacitracinpolymyxin b sulfate (POLYCIN) 112baclofen 35BACLOFEN 35balsalazide disodium 109BAQSIMI (glucagon) 44BASAGLAR KWIKPEN U-100 (insulinglarginehuman recombinant analog) 45BELBUCA (buprenorphine hcl) 3benazepril hcl 52benazepril hclhydrochlorothiazide 56BENEFIX (factor ix human recombinant) 48benzonatate 124benzoyl peroxide 67benzoyl peroxide (ACNE CONTROLCLEANSER) 66benzoyl peroxide (ACNE FOAMING WASH) 66benzoyl peroxide (ACNE TREATMENT) 67benzoyl peroxide (ACNECLEAR) 67benzoyl peroxide (ADVANCED EXFOLIATINGCLEANSER) 67benzoyl peroxide (BP WASH) 67benzoyl peroxide (BP) 67benzoyl peroxide (BPO-10) 67benzoyl peroxide (BPO-5) 67benzoyl peroxide (CLEAN-CLEARCONTINUOUS CONTROL) 67benzoyl peroxide (DAYLOGIC ACNEFOAMING WASH) 67benzoyl peroxide (DAYLOGIC ACNETREATMENT) 67
LAST UPDATED 12012020134
benzoyl peroxide (FOAMING ACNE FACEWASH) 67benzoyl peroxide (PANOXYL) 67benztropine mesylate 29BEOVU (brolucizumab-dbll) 112betamethasone dipropionate 87BETAMETHASONE DIPROPIONATE 87betamethasone dipropionatepropyleneglycol 88betamethasone valerate 88betaxolol hcl 115bethanechol chloride 86BETIMOL (timolol) 115BETOPTIC S (betaxolol hcl) 115BEVESPI AEROSPHERE(glycopyrrolateformoterol fumarate) 124BEXSERO (meningococcal group b vaccine4-component) 106bicalutamide 27BIKTARVY (bictegravirsodiumemtricitabinetenofovir alafenamidefumar) 36bisacodyl 82BISACODYL 82bisacodyl (ALOPHEN PILLS) 81bisacodyl (BISA-LAX) 81bisacodyl (BISACODYL) 81bisacodyl (BISCOLAX) 81bisacodyl (C-LAX LAXATIVE) 81bisacodyl (DUCODYL) 81bisacodyl (FAST RELIEF LAXATIVE) 81bisacodyl (GENTLE LAXATIVE) 81bisacodyl (LAXATIVE SUPPOSITORY) 81bisacodyl (LAXATIVE) 82bisacodyl (MAGIC BULLET) 82bisacodyl (WOMENS GENTLE LAXATIVE) 82bisacodyl (WOMENS LAXATIVE) 82bismuth subsalicylate 78bismuth subsalicylate (BISMATROL) 78bismuth subsalicylate (DIOTAME) 78bismuth subsalicylate (PEP-T-MED) 78
bismuth subsalicylate (PEPTIC RELIEF) 78bismuth subsalicylate (PINK BISMUTH) 78bismuth subsalicylate (SOOTHE) 78bismuth subsalicylate (STOMACH RELIEF) 78bisoprolol fumarate 54bisoprolol fumaratehydrochlorothiazide 56BISOPROLOL-HYDROCHLOROTHIAZIDE 56BLEPH-10 (sulfacetamide sodium) 13BLEPHAMIDE (sulfacetamidesodiumprednisolone acetate) 112BOOSTRIX TDAP(diphtheriapertussis(acellular)tetanusvaccine) 106bosentan 124brimonidine tartrate 115bromocriptine mesylate 29brompheniramine maleatepseudoephedrinehcl (RYNEX PSE) 125BROTAPP DM (brompheniraminemaleatepseudoephedrinehcldextromethorphan) 125BUDESONIDE 116budesonide 117bumetanide 58BUNAVAIL (buprenorphine hclnaloxone hcl) 7BUPRENEX (buprenorphine hcl) 7buprenorphine 4buprenorphine hcl 7buprenorphine hclnaloxone hcl 7bupropion hcl 817bupropion hcl (BUPROBAN) 8BUPROPION HCL SR 17BUPROPION XL 17BUSPIRONE HCL 41buspirone hcl 42butalbitalacetaminophen 64butalbitalacetaminophen (TENCON) 64butalbitalacetaminophencaffeine 64butalbitalaspirincaffeine 2butorphanol tartrate 5BUTRANS (buprenorphine) 4
LAST UPDATED 12012020135
CCALADRYL (pramoxine hclcalamine) 67calcipotriene 67calcitoninsalmonsynthetic 110CALCITRIOL 110calcitriol 110CALCIUM 72CALCIUM 500-VIT D3 72CALCIUM 600-VIT D3 72calcium acetate 87calcium acetate (ELIPHOS) 87calcium carbonate 697379calcium carbonate (ANTACID CALCIUM) 78calcium carbonate (ANTACID EXTRASTRENGTH) 78calcium carbonate (ANTACID) 78calcium carbonate (BAN-ACID) 78calcium carbonate (CAL-GEST) 78calcium carbonate (CALCIUM ANTACID) 78calcium carbonate (CHILDRENS PEPTO) 79calcium carbonate (CHILDRENS SOOTHE) 79calcium carbonate (FLAVOR CHEWSANTACID) 79calcium carbonate (OYSCO-500) 72calcium carbonate (SMOOTH ANTACID) 79calcium carbonate (SMOOTH DISSOLVINGANTACID) 79calcium carbonate (SUPER CALCIUM) 72calcium carbonatecholecalciferol (vitamind3) 73calcium carbonatecholecalciferol (vitamind3) (HI-CAL) 73calcium carbonatecholecalciferol (vitamind3) (OS-CAL 500-VIT D3) 73calcium carbonatecholecalciferol (vitamind3) (OYSCO 500-VIT D3) 73calcium carbonatecholecalciferol (vitamind3) (OYSTERCAL-D) 73calcium gluconate 73calcium lactate 73
capecitabine 27CAPECITABINE 27CAPLYTA (lumateperone tosylate) 32captopril 52CAPTOPRIL 52captoprilhydrochlorothiazide 56carbamazepine 16carbamazepine (EPITOL) 16carbamide peroxide (CARBAMOXIDE) 116carbamide peroxide (EAR DROPS) 116carbamide peroxide (EAR SYSTEM) 116carbamide peroxide (EAR WAXREMOVAL) 116carbamide peroxide (MURINE EAR WAXREMOVAL SYSTEM) 116CARBATROL (carbamazepine) 16carbidopalevodopa 30carisoprodol 130CARISOPRODOL 130carvedilol 54cefaclor 11CEFDINIR 11cefdinir 11celecoxib 2CELECOXIB 2CELONTIN (methsuximide) 14cephalexin 11cetirizine hcl 118CETIRIZINE HCL 118cetirizine hcl (24HOUR ALLERGY) 118cetirizine hcl (ALL DAY ALLERGY RELIEF) 118cetirizine hcl (ALL DAY ALLERGY) 118cetirizine hcl (ALLER-TEC) 118cetirizine hcl (ALLERGY RELIEF) 118cetirizine hcl (WAL-ZYR) 118CHANTIX (varenicline tartrate) 8CHEMET (succimer) 70CHILDRENS ALLERGY RELIEF 118CHILDRENS IBUPROFEN 2CHILDRENS NASACORT (triamcinoloneacetonide) 117
LAST UPDATED 12012020136
CHLORDIAZEPOXIDE-CLIDINIUM 77chlordiazepoxideclidinium bromide 77chlorhexidine gluconate 6667chlorhexidine gluconate (PAROEX) 66chloroquine phosphate 28chlorothiazide 58chlorpheniramine maleate 118chlorpheniramine maleate (ALLERGY 4-HOUR) 118chlorpheniramine maleate (ALLERGYRELIEF) 118chlorpheniramine maleate (ALLERGY) 118chlorpheniramine maleate (ALLERGY-TIME) 118chlorpheniramine maleate (CHLORHIST) 118chlorpheniramine maleate (CHLORTABS) 118chlorpheniramine maleate (ED CHLORPEDJR) 118chlorpheniramine maleate(PHARBECHLOR) 118chlorpheniramine maleate (WAL-FINATE) 118chlorpheniraminemaleatepseudoephedrinedextromethorphan (KIDKARE) 125chlorpromazine hcl 30CHLORPROMAZINE HCL 30chlorthalidone 58CHLORTHALIDONE 58cholecalciferol (vitamin d3) 110cholestyramine (with sugar) 59cholestyramineaspartame 59cholestyramineaspartame (PREVALITE) 59ciclopirox 21ciclopirox olamine 2122cilostazol 51CILOXAN (ciprofloxacin hcl) 13CIMDUO (lamivudinetenofovir disoproxilfumarate) 36cimetidine 80CIMETIDINE 80cimetidine (ACID REDUCER) 80
cimetidine (HEARTBURN RELIEF) 80cimetidine hcl 80cinacalcet hcl 110CINACALCET HCL 110ciprofloxacin hcl 13CIPROFLOXACIN HCL 13citalopram hydrobromide 18citric acidsodium citrate 86citric acidsodium citrate (CYTRA-2) 86citric acidsodium citrate (VIRTRATE-2) 86clarithromycin 12clemastine fumarate 119CLEOCIN (clindamycin phosphate) 9clindamycin hcl 9clindamycin palmitate hcl 9clindamycin phosphate 9CLINDAMYCIN PHOSPHATE 9CLINIMIX (amino acids 425 in dextrose 5 in water) 70clobetasol propionate 88CLOBETASOL PROPIONATE 88clomipramine hcl 19CLOMIPRAMINE HCL 19clonazepam 42clonidine hcl 51CLONIDINE HCL 51clopidogrel bisulfate 51clotrimazole 22CLOTRIMAZOLE 22clotrimazole (ANTIFUNGAL RINGWORM) 22clotrimazole (ANTIFUNGAL) 22clotrimazole (ATHLETES FOOT) 22clotrimazole (ATHLETIC FOOT CREAM) 22clotrimazole (CLOTRIMAZOLE AF) 22clotrimazole (ITCH RELIEF) 22clotrimazole (JOCK ITCH RELIEF) 22clotrimazole (JOCK ITCH) 22clotrimazole (RINGWORM) 22clozapine 34CLOZAPINE 34CLOZAPINE ODT 34
LAST UPDATED 12012020137
CLOZARIL (clozapine) 35COAGADEX (coagulation factor x) 48codeinephosphatebutalbitalaspirincaffeine 5codeine phosphateguaifenesin 125codeine phosphateguaifenesin(CHERATUSSIN AC) 125codeine phosphateguaifenesin (G TUSSINAC) 125codeine phosphateguaifenesin(GUAIATUSSIN AC) 125codeine phosphateguaifenesin(GUAIFENESIN AC) 125codeine phosphateguaifenesin (ROBAFENAC) 125codeine phosphateguaifenesin (VIRTUSSINAC) 125codeine sulfate 5CODEINE-GUAIFENESIN 125COGENTIN (benztropine mesylate) 29colchicine 24COLCHICINE 24COLESTID (colestipol hcl) 59colestipol hcl 59COMBIVENT RESPIMAT (ipratropiumbromidealbuterol sulfate) 125COMBIVIR (lamivudinezidovudine) 38COMPLERA (emtricitabinerilpivirinehcltenofovir disoproxil fumarate) 37condoms female 110condoms latex lubricated 110CORIFACT (factor xiii) 48CORTISPORIN (neomycin sulfatepolymyxin bsulfatehydrocortisone) 112CORTISPORIN(neomycinbacitracinpolymyxinbhydrocortisone) 67COUGH FORMULA DM(guaifenesindextromethorphan hbr) 125COUMADIN (warfarin sodium) 46CREON (lipaseproteaseamylase) 85
CRIXIVAN (indinavir sulfate) 40cromolyn sodium 110114cyanocobalamin (vitamin b-12) 73cyanocobalamin (vitamin b-12) (B-12DOTS) 73cyclobenzaprine hcl 130cyclopentolate hcl 112cyclophosphamide 26CYCLOPHOSPHAMIDE 26cyclosporine 104cyclosporine modified 104cyclosporine modified (GENGRAF) 104cyproheptadine hcl 119
Ddanazol 91dapsone 26DEBROX (carbamide peroxide) 116DELSTRIGO (doravirinelamivudinetenofovirdisoproxil fumarate) 37DELTASONE (prednisone) 88DEPAKENE (valproic acid (as sodium salt)(valproate sodium)) 15DEPAKENE (valproic acid) 15DEPO-PROVERA (medroxyprogesteroneacetate) 100DEPO-SUBQ PROVERA 104(medroxyprogesterone acetate) 100DESCOVY (emtricitabinetenofoviralafenamide fumarate) 39desipramine hcl 19desmopressin acetate 90DESMOPRESSIN ACETATE 90desmopressin acetate (non-refrigerated) 90desogestrel-ethinyl estradiol 91desogestrel-ethinyl estradiol (APRI) 91desogestrel-ethinyl estradiol (CYRED EQ) 91desogestrel-ethinyl estradiol (CYRED) 91desogestrel-ethinyl estradiol (EMOQUETTE) 91desogestrel-ethinyl estradiol (ENSKYCE) 91desogestrel-ethinyl estradiol (ISIBLOOM) 91
LAST UPDATED 12012020138
desogestrel-ethinyl estradiol (JULEBER) 91desogestrel-ethinyl estradiol (KALLIGA) 91desogestrel-ethinyl estradiol (RECLIPSEN) 91desogestrel-ethinyl estradiolethinylestradiol 92desogestrel-ethinyl estradiolethinyl estradiol(AZURETTE) 91desogestrel-ethinyl estradiolethinyl estradiol(BEKYREE) 92desogestrel-ethinyl estradiolethinyl estradiol(KARIVA) 92desogestrel-ethinyl estradiolethinyl estradiol(KIMIDESS) 92desogestrel-ethinyl estradiolethinyl estradiol(PIMTREA) 92desogestrel-ethinyl estradiolethinyl estradiol(SIMLIYA) 92desogestrel-ethinyl estradiolethinyl estradiol(VIORELE) 92desogestrel-ethinyl estradiolethinyl estradiol(VOLNEA) 92desonide 88DESONIDE 88dexamethasone 88DEXAMETHASONE 88dexamethasone (DEXAMETHASONEINTENSOL) 88dexamethasone sodium phosphate 114dextroamphetamine sulf-saccharateamphetamine sulf-aspartate 61dextroamphetamine sulfate 62DEXTROAMPHETAMINE SULFATE 62dextroamphetamine sulfate (ZENZEDI) 62DEXTROAMPHETAMINE-AMPHET ER 62dextrose 10 and 045 sodium chloride 70dextrose 10 in water 7073dextrose 5 and 045 sodium chloride 7073dextrose 5 in lactated ringers 73dextrose 5 in water 697073DEXTROSE IN WATER 74diazepam 1542
diclofenac sodium 2114dicloxacillin sodium 12DICYCLOMINE HCL 77dicyclomine hcl 77DIFFERIN (adapalene) 67diflunisal 2digoxin 56digoxin (DIGITEK) 56digoxin (DIGOX) 56DILANTIN (phenytoin sodium extended) 16DILANTIN (phenytoin) 16DILANTIN-125 16DILANTIN-125 (phenytoin) 16DILTIAZEM 24HR ER (CD) 54DILTIAZEM 24HR ER (XR) 55diltiazem hcl 55diltiazem hcl (CARTIA XT) 55diltiazem hcl (DILT-XR) 55diltiazem hcl (TAZTIA XT) 55DIMETHYL FUMARATE 65DIPHENHYDRAMINE HCL 120diphenhydramine hcl 120diphenhydramine hcl (ALER-CAPS) 119diphenhydramine hcl (ALKA-SELTZER PLUSALLERGY) 130diphenhydramine hcl (ALLER-G-TIME) 119diphenhydramine hcl (ALLERGYMEDICATION) 119diphenhydramine hcl (ALLERGYMEDICINE) 119diphenhydramine hcl (ALLERGY RELIEF) 119diphenhydramine hcl (ALLERGY) 119diphenhydramine hcl (BANOPHEN) 119diphenhydramine hcl (BENADRYLALLERGY) 119diphenhydramine hcl (CHILDRENS ALLERGYRELIEF) 119diphenhydramine hcl (CHILDRENSALLERGY) 119diphenhydramine hcl (CHILDRENS BENADRYLALLERGY) 119
LAST UPDATED 12012020139
diphenhydramine hcl (CHILDRENS WAL-DRYLALLERGY) 119diphenhydramine hcl (COMPLETEALLERGY) 119diphenhydramine hcl (COMPOZ) 130diphenhydramine hcl (DIPHEDRYLALLERGY) 119diphenhydramine hcl (DIPHEDRYL) 120diphenhydramine hcl (DIPHEN) 120diphenhydramine hcl (DIPHENHIST) 120diphenhydramine hcl (GERI-DRYL) 120diphenhydramine hcl (M-DRYL) 120diphenhydramine hcl (NIGHTTIME ALLERGYRELIEF) 120diphenhydramine hcl (NIGHTTIME SLEEPAID) 120130diphenhydramine hcl (NYTOL QUICKCAPS)130diphenhydramine hcl (PHARBEDRYL) 120diphenhydramine hcl (SILADRYL) 120diphenhydramine hcl (SIMPLY SLEEP) 120131diphenhydramine hcl (SLEEP AID) 120131diphenhydramine hcl (SLEEP II) 131diphenhydramine hcl (SLEEP TABLET) 131diphenhydramine hcl (TOTAL ALLERGY) 120diphenhydramine hcl (WAL-DRYLALLERGY) 120diphenhydramine hcl (WAL-DRYL) 120diphenoxylate hclatropine sulfate 79DIPHENOXYLATE-ATROPINE 79dipyridamole 51disopyramide phosphate 53disulfiram 6DIURIL (chlorothiazide) 58divalproex sodium 15DIVALPROEX SODIUM 15DOCUSATE SODIUM 82docusate sodium 82docusate sodium (COL-RITE) 82docusate sodium (DIOCTYL) 82docusate sodium (DOCU LIQUID) 82docusate sodium (DOCUSIL) 82
docusate sodium (DSS) 82docusate sodium (DULCOEASE) 82docusate sodium (DULCOLAX STOOLSOFTENER) 82docusate sodium (LAXA BASIC 100) 82docusate sodium (PHILLIPS LAXATIVE) 82docusate sodium (SOF-LAX) 82docusate sodium (STOOL SOFTENER) 82DOK (docusate sodium) 83donepezil hcl 17dorzolamide hcl 115dorzolamide hcltimolol maleate 115DORZOLAMIDE-TIMOLOL 115DOVATO (dolutegravir sodiumlamivudine) 39doxazosin mesylate 51DOXEPIN HCL 19doxepin hcl 19DOXYCYCLINE HYCLATE 14doxycycline hyclate 14doxycycline monohydrate 14DRITHOCREME HP (anthralin) 67dronabinol 21DROPLET MICRON PEN NEEDLE 110DROSPIRENONE-ETHINYL ESTRADIOL 92DROXIA (hydroxyurea) 27DRYSOL (aluminum chloride) 68duloxetine hcl 65
EEES 200 (erythromycin ethylsuccinate) 12EES 400 (erythromycin ethylsuccinate) 12EAR DROPS (carbamide peroxide) 116EDURANT (rilpivirine hcl) 37efavirenz 37EFAVIRENZ-EMTRIC-TENOFOV DISOP 37EFAVIRENZ-LAMIVU-TENOFOV DISOP 3637electrolytesdextrose (ELECTROLYTE) 74electrolytesdextrose (ORALYTE) 74electrolytesdextrose (PEDIATRICELECTROLYTE) 74
LAST UPDATED 12012020140
electrolytesdextrose (PEDIATRIC FREEZERPOPS) 74ELIQUIS (apixaban) 46ELIXOPHYLLIN (theophylline anhydrous) 124ELOCTATE (antihemophilic factor (fviii)recombinant fc fusion protein) 48EMCYT (estramustine phosphate sodium) 27EMSAM (selegiline) 18EMTRICITABINE 38EMTRICITABINE-TENOFOVIR DISOP 38EMTRIVA (emtricitabine) 38ENALAPRIL MALEATE 52enalapril maleate 52ENBREL 105ENBREL (etanercept) 104ENBREL SURECLICK (etanercept) 105ENGERIX-B ADULT (hepatitis b virus vaccinerecombinantpf) 106ENOXAPARIN SODIUM 46enoxaparin sodium 46entacapone 29EPIFOAM (hydrocortisone acetatepramoxinehcl) 68epinephrine 123EPIVIR (lamivudine) 38EPIVIR HBV (lamivudine) 35EPOGEN (epoetin alfa) 47EPZICOM (abacavir sulfatelamivudine) 38ERGOCALCIFEROL 110ergocalciferol (vitamin d2) 110ergocalciferol (vitamin d2) (CALCIDOL) 110ergotamine tartratecaffeine 25ERYTHROCIN STEARATE (erythromycinstearate) 12ERYTHROMYCIN 13erythromycin base 13erythromycin base in ethanol 13erythromycin base in ethanol (ERY) 13erythromycin basebenzoyl peroxide 9ERYTHROMYCIN ETHYLSUCCINATE 13erythromycin ethylsuccinate 13
escitalopram oxalate 18ESCITALOPRAM OXALATE 18ESPEROCT (antihemophilic factor (fviii) rec b-dom truncated peg-exei) 48estradiol 92ESTRADIOL 93estradiol (DOTTI) 92estrogensesterifiedmethyltestosterone 93estrogensesterifiedmethyltestosterone(COVARYX HS) 93estrogensesterifiedmethyltestosterone (EEMTHS) 93ethambutol hcl 26ETHAMBUTOL HCL 26ethinyl estradioldrospirenone 93ethinyl estradioldrospirenone (GIANVI) 93ethinyl estradioldrospirenone (JASMIEL) 93ethinyl estradioldrospirenone (LO-ZUMANDIMINE) 93ethinyl estradioldrospirenone (LORYNA) 93ethinyl estradioldrospirenone (NIKKI) 93ethinyl estradioldrospirenone (VESTURA) 93ETHOSUXIMIDE 14ethosuximide 14ethynodiol diacetate-ethinyl estradiol 93ethynodiol diacetate-ethinyl estradiol(KELNOR 1-35) 93ethynodiol diacetate-ethinyl estradiol(KELNOR 1-50) 93ethynodiol diacetate-ethinyl estradiol (ZOVIA1-35E) 93etodolac 2etonogestrelethinyl estradiol 94etonogestrelethinyl estradiol (ELURYNG) 93etoposide 28EVOTAZ (atazanavir sulfatecobicistat) 40EVZIO (naloxone hcl) 7EXCEDRIN EXTRA STRENGTH(aspirinacetaminophencaffeine) 2EXCEDRIN MIGRAINE(aspirinacetaminophencaffeine) 2
LAST UPDATED 12012020141
EYE ITCH RELIEF 114ezetimibe 59
Ffamotidine 81FAMOTIDINE 81famotidine (ACID CONTROLLER) 80famotidine (ACID REDUCER) 80famotidine (HEARTBURN PREVENTION) 81famotidine (HEARTBURN RELIEF) 81famotidine (PEPCID) 81FANAPT (iloperidone) 32FAZACLO (clozapine) 35FEIBA NF (anti-inhibitor coagulant complex) 48felodipine 55FELODIPINE ER 55fenofibrate 58FENOFIBRATE 58fenofibratemicronized 59fentanyl 4ferrous sulfate 74FERROUS SULFATE 74ferrous sulfate (CHILDRENS IRON) 74ferrous sulfate (FEOSOL) 74ferrous sulfate (FEROSUL) 74ferrous sulfate (FERRO-TIME) 74ferrous sulfate (FERROUSUL) 74ferrous sulfate (PEDIA IRON) 74fexofenadine hcl 121FEXOFENADINE HCL 121fexofenadine hcl (ALLER-EASE) 120fexofenadine hcl (ALLER-FEX) 120fexofenadine hcl (ALLERGY RELIEF) 121fexofenadine hcl (WAL-FEX ALLERGY) 121FIBRYGA (fibrinogen) 48finasteride 86flecainide acetate 53FLOVENT DISKUS (fluticasone propionate) 117FLOVENT HFA (fluticasone propionate) 117FLUAD 2020-2021 106FLUAD QUAD 2020-2021 106
FLUARIX QUAD 2020-2021 106FLUBLOK QUAD 2018-2019 (influenza virusvaccine qv 2018-19(18 yrs andolder)rcmbpf) 106FLUBLOK QUAD 2020-2021 107FLUCELVAX QUAD 2020-2021 107fluconazole 22FLUCONAZOLE 22fluconazole in dextrose iso-osmotic 22flucytosine 22FLUCYTOSINE 22fludrocortisone acetate 88FLULAVAL QUAD 2019-2020 (influenza virusvaccine quadrivalent 2019-20 (6 mos andup)) 107FLULAVAL QUAD 2020-2021 107fluocinolone acetonide 88fluocinonide 88FLUOCINONIDE 88fluoride (sodium) 74fluorometholone 114fluorouracil (ADRUCIL) 27fluoxetine hcl 18FLUOXETINE HCL 18fluoxymesterone (ANDROXY) 91fluphenazine decanoate 30fluphenazine hcl 30FLUPHENAZINE HCL 30flurazepam hcl 130flurbiprofen 2flurbiprofen sodium 114flutamide 27fluticasone propionate 117fluticasone propionate (ALLERGY RELIEF) 117fluticasone propionatesalmeterolxinafoate 126fluticasone propionatesalmeterol xinafoate(WIXELA INHUB) 126fluvoxamine maleate 18FLUZONE HIGH-DOSE QUAD 2020-21 107
LAST UPDATED 12012020142
FLUZONE QUAD 2019-2020 (influenza virusvaccine quadrival 2019-2020(6 mos andup)pf) 107FLUZONE QUAD 2020-2021 107FML FORTE (fluorometholone) 114FML SOP (fluorometholone) 114folic acid 74FOLIC ACID 74FORADIL (formoterol fumarate) 123FOSAMAX PLUS D (alendronatesodiumcholecalciferol (vitamin d3)) 110fosamprenavir calcium 40FOSAMPRENAVIR CALCIUM 40fosinopril sodium 52fosinopril sodiumhydrochlorothiazide 57FOSINOPRIL-HYDROCHLOROTHIAZIDE 57Freestyle Insulix Test Strips 110Freestyle Lite Test Strips 111Freestyle Test Strips 111furosemide 58FUZEON (enfuvirtide) 39
Ggabapentin 15GABAPENTIN 15GARDASIL 9 (human papillomavirus vaccine9-valentpf) 107GAS RELIEF 79GAS RELIEF (simethicone) 79GAS-X (simethicone) 79gemfibrozil 59GEMFIBROZIL 59gentamicin sulfate 8GENTAMICIN SULFATE 9gentamicin sulfate (GENTAK) 8GENTLE LAXATIVE 83GENVOYA(elvitegravircobicistatemtricitabinetenofovir alafenamide) 36GEODON (ziprasidone hcl) 32GEODON (ziprasidone mesylate) 32
GERI-DRYL 121glatiramer acetate 6566glatiramer acetate (GLATOPA) 65GLEOSTINE (lomustine) 26glimepiride 43glipizide 43GLUCAGON EMERGENCY KIT (glucagonhcl) 44GLUCAGON EMERGENCY KIT(glucagonhuman recombinant) 44glyburide 43glyburidemetformin hcl 43glycerin 83glycerin (ADULT GLYCERIN) 83glycerin (LAXATIVE SUPPOSITORY) 83glycerin (PEDIA-LAX) 83glycerin (SUPPOSITORY) 83GOCOVRI (amantadine hcl) 29granisetron hcl 21griseofulvin ultramicrosize 22griseofulvin microsize 23GUAIASORB DM 126guaifenesin (MUCUS ER) 126guaifenesin (MUCUS RELIEF ER) 126GUAIFENESIN-DEXTROMETHORPHAN 126guaifenesindextromethorphan hbr 128guaifenesindextromethorphan hbr (ADULTROBITUSSIN PEAK COLD DM) 126guaifenesindextromethorphan hbr (ADULTTUSSIN COUGH CONGEST DM) 126guaifenesindextromethorphan hbr (ADULTTUSSIN DM) 126guaifenesindextromethorphan hbr (ADULTWAL-TUSSIN DM) 126guaifenesindextromethorphan hbr(ANTITUSSIVE DM) 126guaifenesindextromethorphan hbr(BIOCOTRON) 126guaifenesindextromethorphan hbr (COUGHDM) 126
LAST UPDATED 12012020143
guaifenesindextromethorphan hbr (DIABETICSILTUSSIN-DM) 127guaifenesindextromethorphan hbr (DIABETICTUSSIN DM) 127guaifenesindextromethorphan hbr(EXPECTORANT DM) 127guaifenesindextromethorphan hbr (EXTRAACTION COUGH) 127guaifenesindextromethorphan hbr (GERI-TUSSIN DM) 127guaifenesindextromethorphan hbr (GILTUSSDIABETIC) 127guaifenesindextromethorphan hbr (GILTUSSHBP) 127guaifenesindextromethorphan hbr(GUAIASORB DM) 127guaifenesindextromethorphan hbr (RI-TUSSINDM) 127guaifenesindextromethorphan hbr (ROBAFENDM COUGH) 127guaifenesindextromethorphan hbr (ROBAFENDM COUGH-CHEST CONGEST) 127guaifenesindextromethorphan hbr (ROBAFENDM PEAK COLD) 127guaifenesindextromethorphan hbr(ROBAFEN-DM) 127guaifenesindextromethorphan hbr(SAFETUSSIN DM) 127guaifenesindextromethorphan hbr (SILTUSSINDM DAS) 127guaifenesindextromethorphan hbr (SILTUSSINDM) 128guaifenesindextromethorphan hbr(SORBUGEN NR) 128guaifenesindextromethorphan hbr (TUSNELDIABETIC) 128guaifenesindextromethorphan hbr (TUSSINCOUGH) 128guaifenesindextromethorphan hbr (TUSSINDM CLEAR) 128
guaifenesindextromethorphan hbr (TUSSINDM COUGH) 128guaifenesindextromethorphan hbr (TUSSINDM COUGH-CHEST CONGEST) 128guaifenesindextromethorphan hbr (TUSSINDM) 128guaifenesindextromethorphan hbr (ULTRADM FREE amp CLEAR) 128guaifenesindextromethorphan hbr (ULTRATUSS) 128guaifenesindextromethorphan hbr (WAL-TUSSIN DM) 128guaifenesinpseudoephedrine hcl 129guaifenesinpseudoephedrine hcl (MUCUSD) 128guaifenesinpseudoephedrine hcl (MUCUSRELIEF D) 128guanfacine hcl 5162
HHAILEY FE 94HALDOL (haloperidol lactate) 30HALDOL DECANOATE 100 (haloperidoldecanoate) 30HALDOL DECANOATE 50 (haloperidoldecanoate) 30haloperidol 31HALOPERIDOL 31haloperidol decanoate 31haloperidol lactate 31HALOPERIDOL LACTATE 31HAVRIX (hepatitis a virus vaccinepf) 107HEADACHE RELIEF 2HELIXATE FS (antihemophilic factor (fviii)recombinantfull length) 48HEMLIBRA (emicizumab-kxwh) 48HEMOFIL M (antihemophilic factor human) 48HEPARIN SODIUM 46heparin sodiumporcine 46heparin sodiumporcinepf 46
LAST UPDATED 12012020144
HEPLISAV-B (hepatitis b vaccinerecombinantvaccine adjuvant cpg1018pf) 107HEXALEN (altretamine) 26homatropine hbr 112homatropine hbr (HOMATROPAIRE) 112HUMALOG (insulin lispro) 45HUMALOG MIX 75-25 (insulin lispro protamineand insulin lispro) 45HUMALOG MIX 75-25 KWIKPEN (insulin lisproprotamine and insulin lispro) 45HUMATE-P (antihemophilic factor humanvonwillebrand factorhuman) 48HUMIRA (adalimumab) 105HUMIRA PEDIATRIC CROHNS(adalimumab) 105HUMIRA PEN (adalimumab) 105HUMIRA PEN CROHNS-UC-HS(adalimumab) 105HUMIRA PEN PSOR-UVEITS-ADOL HS(adalimumab) 105HUMIRA(CF) (adalimumab) 105HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 105HUMIRA(CF) PEN (adalimumab) 105HUMIRA(CF) PEN CROHNS-UC-HS(adalimumab) 105HUMIRA(CF) PEN PSOR-UV-ADOL HS(adalimumab) 105HUMULIN 70-30 (insulin nph humanisophaneinsulin regular human) 45HUMULIN 7030 KWIKPEN (insulin nph humanisophaneinsulin regular human) 45HUMULIN N (insulin nph human isophane) 45HUMULIN R (insulin regular human) 45HUMULIN R U-500 (insulin regular human) 45hydralazine hcl 60hydrochlorothiazide 58hydrocodone bitartrateacetaminophen 5hydrocodone bitartrateacetaminophen(LORCET HD) 5
hydrocodone bitartrateacetaminophen(LORTAB) 5hydrocortisone 89109HYDROCORTISONE 89hydrocortisone (ANTI-ITCH) 88hydrocortisone (ANUSOL-HC) 88hydrocortisone (COLOCORT) 109hydrocortisone (CORTISONE) 88hydrocortisone (CORTIZONE-10 PLUS) 89hydrocortisone (CORTIZONE-10) 89hydrocortisone (HYDROCREAM) 89hydrocortisone (NOBLE FORMULA HC) 89hydrocortisone (PREPARATION H) 89hydrocortisone (PROCTO-MED HC) 89hydrocortisone (PROCTO-PAK) 89hydrocortisone (PROCTOSOL-HC) 89hydrocortisone (PROCTOZONE-HC) 89hydrocortisone (SOOTHING CARE) 89HYDROCORTISONE ACETATE 89hydrocortisone acetate 89hydrocortisone acetate (ANUCORT-HC) 89hydrocortisone acetate (ANUSOL-HC) 89hydrocortisone acetate (HEMMOREX-HC) 89hydrocortisone acetatepramoxine hcl 68hydrocortisoneacetic acid 116hydrocortisoneacetic acid (ACETASOLHC) 116hydromorphone hcl 5HYDROXYCHLOROQUINE SULFATE 28hydroxychloroquine sulfate 28hydroxyprogesterone caproate 100hydroxyprogesterone caproatepf 100hydroxyurea 27hydroxyzine hcl 121HYDROXYZINE PAMOATE 121hydroxyzine pamoate 121hyoscyamine sulfate 77hyoscyamine sulfate (HYOSYNE) 77HYPERTET S-D (tetanus immuneglobulinpf) 106
LAST UPDATED 12012020145
Iibuprofen 3IBUPROFEN 3ibuprofen (ADDAPRIN) 2ibuprofen (I-PRIN) 3ibuprofen (IBU) 3ibuprofen (IBU-200) 3ibuprofen (PROVIL) 3ibuprofen (WAL-PROFEN) 3IDELVION (factor ix recombinantalbuminfusion protein) 48imipramine hcl 19IMIPRAMINE HCL 19IMOVAX RABIES VACCINE (rabies vaccinehuman diploid cellpf) 107INCRUSE ELLIPTA (umeclidinium bromide) 122indapamide 58indomethacin 3INFANTS GAS RELIEF 79inhalerassist device with large mask 111inhalerassist device with medium mask 111inhalerassist device with small mask 111insulin lispro 45INSULIN LISPRO PROTAMINE MIX (insulin lisproprotamine and insulin lispro) 45Insulin pen needles 111INSULIN SYRINGE 03 ML 111INSULIN SYRINGE 05 ML 111INSULIN SYRINGE 1 ML 111INTELENCE (etravirine) 37INTRON A (interferon alfa-2brecomb) 35INVEGA (paliperidone) 32INVEGA SUSTENNA (paliperidone palmitate)32INVEGA TRINZA (paliperidone palmitate) 32INVIRASE (saquinavir mesylate) 40IOPIDINE (apraclonidine hcl) 115ipratropium bromide 122ipratropium bromidealbuterol sulfate 129IPRATROPIUM-ALBUTEROL 129irbesartan 52
irbesartanhydrochlorothiazide 57IRON 74ISENTRESS (raltegravir potassium) 36ISENTRESS HD (raltegravir potassium) 36isoniazid 26ISOSORBIDE DINITRATE 60isosorbide dinitrate 60isosorbide mononitrate 60isotretinoin 68isotretinoin (AMNESTEEM) 68isotretinoin (CLARAVIS) 68isotretinoin (MYORISAN) 68isotretinoin (ZENATANE) 68itraconazole 23IXINITY (factor ix human recombinantthreonine 148) 49
JJAKAFI (ruxolitinib phosphate) 28JARDIANCE (empagliflozin) 43JENCYCLA 100JIVI (antihemophilic factor (fviii) rec b-domain deleted peg-aucl) 49JULUCA (dolutegravir sodiumrilpivirine hcl) 39
KKALETRA (lopinavirritonavir) 40KCENTRA (human prothrombin complexconcentrate (pcc) 4-factor) 49ketoconazole 23ketoprofen 3ketorolac tromethamine 114ketotifen fumarate 114ketotifen fumarate (ALLERGY EYE DROPS) 114ketotifen fumarate (EYE ITCH RELIEF) 114ketotifen fumarate (ITCHY EYE) 114ketotifen fumarate (WAL-ZYR) 114ketotifen fumarate (ZADITOR) 114KOGENATE FS (antihemophilic factor (fviii)recombinantfull length) 49
LAST UPDATED 12012020146
KOVALTRY (antihemophilic factor (fviii)recombinantfull length) 49
Llabetalol hcl 54LABETALOL HCL 54lactulose 83lactulose (CONSTULOSE) 83lactulose (ENULOSE) 83lactulose (GENERLAC) 83LAMISIL (terbinafine hcl) 23lamivudine 3538lamivudinezidovudine 38lamotrigine 15lancets 111LANOXIN (digoxin) 57lansoprazole 85LANSOPRAZOLE 85lanthanum carbonate 87latanoprost 115LATUDA (lurasidone hcl) 32leflunomide 106LEFLUNOMIDE 106letrozole 28LEUCOVORIN CALCIUM 27leucovorin calcium 27LEUKERAN (chlorambucil) 26leuprolide acetate 104levalbuterol tartrate 123LEVETIRACETAM 14levetiracetam 14LEVETIRACETAM ER 14LEVO-T (levothyroxine sodium) 103levobunolol hcl 115levocarnitine 70levocarnitine (with sugar) 70levofloxacin 13levonorgestrel 101levonorgestrel (AFTERA) 101levonorgestrel (ECONTRA EZ) 101levonorgestrel (ECONTRA ONE-STEP) 101
levonorgestrel (FALLBACK SOLO) 101levonorgestrel (MY CHOICE) 101levonorgestrel (MY WAY) 101levonorgestrel (NEW DAY) 101levonorgestrel (OPCICON ONE-STEP) 101levonorgestrel (OPTION 2) 101levonorgestrel (TAKE ACTION) 101LEVONORGESTREL-ETH ESTRADIOL 94levonorgestrelethinyl estradiol 96levonorgestrelethinyl estradiol (AFIRMELLE) 94levonorgestrelethinyl estradiol (ALTAVERA) 94levonorgestrelethinyl estradiol (AUBRA EQ) 94levonorgestrelethinyl estradiol (AUBRA) 94levonorgestrelethinyl estradiol (AVIANE) 94levonorgestrelethinyl estradiol (AYUNA) 94levonorgestrelethinyl estradiol (CHATEALEQ) 94levonorgestrelethinyl estradiol (CHATEAL) 94levonorgestrelethinyl estradiol (DELYLA) 94levonorgestrelethinyl estradiol (ENPRESSE) 94levonorgestrelethinyl estradiol (FALMINA) 95levonorgestrelethinyl estradiol (KURVELO) 95levonorgestrelethinyl estradiol (LARISSIA) 95levonorgestrelethinyl estradiol (LESSINA) 95levonorgestrelethinyl estradiol (LEVONEST) 95levonorgestrelethinyl estradiol (LEVORA-28)95levonorgestrelethinyl estradiol (LILLOW) 95levonorgestrelethinyl estradiol (LUTERA) 95levonorgestrelethinyl estradiol (MARLISSA) 95levonorgestrelethinyl estradiol (MYZILRA) 95levonorgestrelethinyl estradiol (ORSYTHIA) 95levonorgestrelethinyl estradiol (PORTIA) 96levonorgestrelethinyl estradiol (SRONYX) 96levonorgestrelethinyl estradiol (TRIVORA-28) 96levonorgestrelethinyl estradiol (VIENVA) 96levothyroxine sodium 103LEVOTHYROXINE SODIUM 103LEVOXYL (levothyroxine sodium) 103LEXIVA (fosamprenavir calcium) 40LICE KILLING 68
LAST UPDATED 12012020147
lidocaine hcl 6LIDOCAINE HCL VISCOUS 6lidocaine hclpf 6lisinopril 52lisinoprilhydrochlorothiazide 57lithium carbonate 42lithium citrate 42LITHOBID (lithium carbonate) 42loperamide hcl 79loperamide hcl (ANTI-DIARRHEAL) 79loperamide hcl (DIAMODE) 79loperamide hcl (ULTRA A-D) 79lopinavirritonavir 40loratadine 121122LORATADINE 122loratadine (ALLERCLEAR) 121loratadine (ALLERGY RELIEF) 121loratadine (ALLERGY) 121loratadine (CHILDRENS ALLERGY RELIEF) 121loratadine (CHILDRENS ALLERGY) 121loratadine (LORADAMED) 121loratadine (NON-DROWSY ALLERGY) 121loratadine (WAL-ITIN) 121lorazepam 42lorazepam (LORAZEPAM INTENSOL) 42LOSARTAN POTASSIUM 52losartan potassium 52losartan potassiumhydrochlorothiazide 57LOSARTAN-HYDROCHLOROTHIAZIDE 57LOTRIMIN AF (clotrimazole) 23lovastatin 59loxapine succinate 31LUCEMYRA (lofexidine hcl) 7LUPRON DEPOT-PED (leuprolide acetate) 104LYLLANA 96LYSODREN (mitotane) 28
MM-M-R II VACCINE (measles mumps andrubella vaccine livepf) 107MAGNESIUM CITRATE 83
magnesium citrate 83MARPLAN (isocarboxazid) 18MATULANE (procarbazine hcl) 26MAXI-TUSS G 129mebendazole (EMVERM) 28MECLIZINE HCL 20meclizine hcl 20meclizine hcl (DRAMAMINE LESS DROWSY) 20meclizine hcl (MEDI-MECLIZINE) 20meclizine hcl (MOTION RELIEF) 20meclizine hcl (MOTION SICKNESS II) 20meclizine hcl (MOTION SICKNESS RELIEF) 20meclizine hcl (MOTION SICKNESS) 20meclizine hcl (MOTION-TIME) 20meclizine hcl (TRAVEL-EASE) 20meclizine hcl (VERTICALM) 20meclizine hcl (WAL-DRAM 2) 20MEDROXYPROGESTERONE ACETATE 101medroxyprogesterone acetate 101mefloquine hcl 28megestrol acetate 101meloxicam 3melphalan 26memantine hcl 17MEMANTINE HCL 17MENACTRA (meningococcalvaccine acyw-135diphtheria toxoid conjpf) 107MENEST (estrogensesterified) 96MENQUADFI 107MENVEO A-C-Y-W-135-DIP(meningococcalvaccine acyw-135diphtheria toxoid conjpf) 108meperidine hcl 5mercaptopurine 27mesalamine 109MESTINON (pyridostigmine bromide) 25metaproterenol sulfate 123metformin hcl 43METFORMIN HCL ER 43METHADONE HCL 4methadone hcl 4
LAST UPDATED 12012020148
methadone hcl (METHADONE INTENSOL) 4methadone hcl (METHADOSE) 4methazolamide 115METHAZOLAMIDE 115methenaminemethylene bluesodphospsalicylatehyoscyamine(PHOSPHASAL) 9methenaminemethylene bluesodphospsalicylatehyoscyamine (URIN DS) 10methimazole 104methocarbamol 130METHOCARBAMOL 130METHOTREXATE 105methotrexate sodium 105methyclothiazide 58methyldopa 51methylergonovine maleate 111METHYLPHENIDATE ER 62methylphenidate hcl 62METHYLPHENIDATE HCL 62methylphenidate hcl (METADATE ER) 62methylprednisolone 89metoclopramide hcl 20metolazone 58metoprolol succinate 54METOPROLOL SUCCINATE 54metoprolol tartrate 54METRO IV (metronidazole in sodiumchloride) 10metronidazole 1068METRONIDAZOLE 10metronidazole in sodium chloride 10mexiletine hcl 53MEXILETINE HCL 53miconazole nitrate 23miconazole nitrate (ANTI-FUNGAL CREAM) 23miconazole nitrate (ANTIFUNGAL CREAM) 23miconazole nitrate (BAZA ANTIFUNGAL) 23miconazole nitrate (INZO ANTIFUNGAL) 23miconazole nitrate (LOTRIMIN AF) 23miconazole nitrate (MICATIN) 23
miconazole nitrate (SECURA ANTIFUNGAL) 23MICROGESTIN 96MICROGESTIN FE 96minocycline hcl 14minoxidil 60mirtazapine 17misoprostol 85modafinil 131moexipril hcl 52molindone hcl 31mometasone furoate 90MONISTAT 3 (miconazole nitrate) 23MONISTAT 7 (miconazole nitrate) 23MONONINE (factor ix) 49montelukast sodium 122MONTELUKAST SODIUM 122morphine sulfate 45moxifloxacin hcl 13MUCUS ER 129MUCUS RELIEF ER 129mupirocin 10mupirocin calcium 10MURINE EAR DROPS (carbamide peroxide) 116MURO-128 (sodium chloride) 112mycophenolate mofetil 105MYLERAN (busulfan) 27MYNATAL (prenatal vitamins withcalciumferrous fumaratefolic acid) 70
NNABI-HB (hepatitis b immune globulin) 106nadolol 54NADOLOL 54naloxone hcl 7naltrexone hcl 7NALTREXONE HCL 7naproxen 3naproxen sodium 3NARCAN (naloxone hcl) 8NARDIL (phenelzine sulfate) 18NASACORT (triamcinolone acetonide) 117
LAST UPDATED 12012020149
NASAL DECONGESTANT (pseudoephedrinehcl) 123nateglinide 43neomycin sulfate 9neomycin sulfatebacitracin zincpolymyxin b(ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxin b(FIRST AID ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxin b(TRIPLE ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxinbhydrocortisone 112neomycin sulfatebacitracin zincpolymyxinbhydrocortisone (NEO-POLYCIN HC) 112neomycin sulfatebacitracinpolymyxin b 113neomycin sulfatebacitracinpolymyxin b(NEO-POLYCIN) 113neomycin sulfatepolymyxin bsulfategramicidin d 113neomycin sulfatepolymyxin bsulfatehydrocortisone 113116NEOMYCIN-POLYMYXIN-HC 116neomycinpolymyxin bsulfatedexamethasone 113nevirapine 37NIACIN 60niacin 60niacin (ENDUR-ACIN) 59niacin (SLO-NIACIN) 59nicardipine hcl 55NICOTINE 14MG PATCH 8NICOTINE 21MG PATCH 8NICOTINE 2MG GUM 8NICOTINE 4MG GUM 8NICOTINE 7MG PATCH 8NICOTINE LOZENGE 8nicotine polacrilex 8nicotine polacrilex (QUIT 2) 8nicotine polacrilex (QUIT 4) 8nicotine polacrilex (STOP SMOKING AID) 8NICOTROL (nicotine) 8
NICOTROL NS (nicotine) 8NIFEDIPINE 55nifedipine 55nifedipine (AFEDITAB CR) 55nifedipine (NIFEDICAL XL) 55NIGHTTIME SLEEP AID 122nisoldipine 55NITRO-BID (nitroglycerin) 60nitrofurantoin 10NITROFURANTOIN 10nitrofurantoin macrocrystal 10nitrofurantoin monohydratemacrocrystals 10nitroglycerin 61NITROGLYCERIN 61nitroglycerin (MINITRAN) 60nitroglycerin (NITRO-TIME) 60nonoxynol 9 (VCF) 86norelgestrominethinyl estradiol (XULANE) 96norethindrone 102norethindrone (CAMILA) 101norethindrone (DEBLITANE) 101norethindrone (ERRIN) 101norethindrone (HEATHER) 102norethindrone (INCASSIA) 102norethindrone (JENCYCLA) 102norethindrone (JOLIVETTE) 102norethindrone (LYZA) 102norethindrone (NORA-BE) 102norethindrone (NORLYDA) 102norethindrone (NORLYROC) 102norethindrone (SHAROBEL) 102norethindrone (TULANA) 102norethindrone acetate 102norethindrone acetate-ethinyl estradiol 97norethindrone acetate-ethinyl estradiol(AUROVELA) 96norethindrone acetate-ethinyl estradiol(GILDESS) 96norethindrone acetate-ethinyl estradiol(HAILEY) 96
LAST UPDATED 12012020150
norethindrone acetate-ethinyl estradiol(JUNEL) 97norethindrone acetate-ethinyl estradiol(LARIN) 97norethindrone acetate-ethinyl estradiol(MICROGESTIN) 97norethindrone acetate-ethinylestradiolferrous fumarate 98norethindrone acetate-ethinylestradiolferrous fumarate (AUROVELA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (BLISOVI FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (JUNEL FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (LARIN FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (MICROGESTINFE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TARINA FE 1-20EQ) 97norethindrone acetate-ethinylestradiolferrous fumarate (TARINA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TILIA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TRI-LEGEST FE) 98norethindrone-ethinyl estradiol (ALYACEN) 98norethindrone-ethinyl estradiol (ARANELLE) 98norethindrone-ethinyl estradiol (BALZIVA) 98norethindrone-ethinyl estradiol (BRIELLYN) 98norethindrone-ethinyl estradiol (CYCLAFEM)98norethindrone-ethinyl estradiol (DASETTA) 98norethindrone-ethinyl estradiol (LEENA) 98norethindrone-ethinyl estradiol (NECON) 98norethindrone-ethinyl estradiol (NORTREL) 98norethindrone-ethinyl estradiol (PHILITH) 98norethindrone-ethinyl estradiol (PIRMELLA) 98norethindrone-ethinyl estradiol (VYFEMLA) 98norethindrone-ethinyl estradiol (WERA) 98
norethindrone-ethinyl estradiol (ZENCHENT) 98NORGESTIMATE-ETHINYL ESTRADIOL 100norgestimate-ethinyl estradiol 100norgestimate-ethinyl estradiol (ESTARYLLA) 98norgestimate-ethinyl estradiol (FEMYNOR) 99norgestimate-ethinyl estradiol (MILI) 99norgestimate-ethinyl estradiol (MONO-LINYAH) 99norgestimate-ethinyl estradiol(MONONESSA) 99norgestimate-ethinyl estradiol (PREVIFEM) 99norgestimate-ethinyl estradiol (SPRINTEC) 99norgestimate-ethinyl estradiol (TRIFEMYNOR) 99norgestimate-ethinyl estradiol (TRI-ESTARYLLA) 99norgestimate-ethinyl estradiol (TRI-LINYAH) 99norgestimate-ethinyl estradiol (TRI-LO-ESTARYLLA) 99norgestimate-ethinyl estradiol (TRI-LO-MARZIA) 99norgestimate-ethinyl estradiol (TRI-LO-MILI) 99norgestimate-ethinyl estradiol (TRI-LO-SPRINTEC) 99norgestimate-ethinyl estradiol (TRI-PREVIFEM) 99norgestimate-ethinyl estradiol (TRI-SPRINTEC) 99norgestimate-ethinyl estradiol (TRI-VYLIBRALO) 99norgestimate-ethinyl estradiol (TRI-VYLIBRA) 99norgestimate-ethinyl estradiol (TRINESSA LO)99norgestimate-ethinyl estradiol (TRINESSA) 99norgestimate-ethinyl estradiol (VYLIBRA) 99norgestrel-ethinyl estradiol (CRYSELLE) 100norgestrel-ethinyl estradiol (ELINEST) 100norgestrel-ethinyl estradiol (LOW-OGESTREL) 100norgestrel-ethinyl estradiol (OGESTREL) 100nortriptyline hcl 19NORVIR (ritonavir) 40
LAST UPDATED 12012020151
NOVOEIGHT (antihemophilic factor viiirecombinant b-domain truncated) 49NOVOLIN 70-30 (insulin nph humanisophaneinsulin regular human) 45NOVOLIN N (insulin nph human isophane) 45NOVOLIN R (insulin regular human) 45NOVOSEVEN RT (coagulation factor viia(recombinant)) 49NUPLAZID (pimavanserin tartrate) 32NUWIQ (antihemophilic factor viii rec hek cellb-domain deleted) 50NYSTATIN 23nystatin 23
OO-CAL PRENATAL (prenatal vit with calciumno127ferrous fumaratefolic acid) 70OBIZUR (antihemophilic factor viiirecombinant porcine sequence) 50ODEFSEY (emtricitabinerilpivirinehcltenofovir alafenamide fumarate) 37ofloxacin 13olanzapine 33olanzapinefluoxetine hcl 17OMEGA-3 ACID ETHYL ESTERS 60omega-3 acid ethyl esters 60omeprazole 85OMEPRAZOLE 85ondansetron 21ondansetron hcl 21ORAP (pimozide) 31oseltamivir phosphate 41OSELTAMIVIR PHOSPHATE 41OSMOLEX ER (amantadine hcl) 29oxazepam 42oxcarbazepine 16oxybutynin chloride 86OXYBUTYNIN CHLORIDE ER 86oxycodone hcl 46oxycodone hclacetaminophen 6oxycodone hclacetaminophen (ENDOCET) 6
oxycodone hclaspirin 6OXYTROL FOR WOMEN (oxybutynin) 86OYSTER SHELL CALCIUM 74OYSTER SHELL CALCIUM-VIT D3 74
PPAIN amp FEVER (acetaminophen) 64PAIN RELIEF 64paliperidone 33pantoprazole sodium 85PANTOPRAZOLE SODIUM 85PARNATE (tranylcypromine sulfate) 18paromomycin sulfate 9paroxetine hcl 18PEDIATRIC IRON 75pediatric multivit with acd3 no21sodiumfluoride 75pediatric multivitamin no16sodiumfluoride 75pediatric multivitamin no2sodium fluoride 75pediatric multivitamin no45sodiumfluorideferrous sulfate 75pediatric multivitamins no17 with sodiumfluoride 75peg 3350sod sulfsod bicarbsodchloridepotassium chloride 83peg 3350sod sulfsod bicarbsodchloridepotassium chloride (GAVILYTE-C) 83peg 3350sod sulfsod bicarbsodchloridepotassium chloride (GAVILYTE-G) 83PEG-3350 AND ELECTROLYTES 83PEGINTRON REDIPEN (peginterferon alfa-2b) 35PEN NEEDLE 111pen needle diabetic 111pen needle diabetic disposable safety 111pen needle diabetic remover and disposalunit 111pen needle diabetic safety 111penicillamine 86PENICILLAMINE 86
LAST UPDATED 12012020152
penicillin v potassium 12pentoxifylline 57PEPTO-BISMOL (bismuth subsalicylate) 79PEPTO-BISMOL TO-GO (bismuthsubsalicylate) 79permethrin 29permethrin (LICE TREATMENT) 29perphenazine 20PERSERIS (risperidone) 33PHENAZOPYRIDINE HCL 87phenazopyridine hcl 87phenazopyridine hcl (URINARY PAIN RELIEF) 86phenelzine sulfate 18phenobarbital 15PHENOBARBITAL 15PHENOXYBENZAMINE HCL 51phenoxybenzamine hcl 51phenylephrine hcl 113phenylephrine hclpromethazine hcl 129phenytoin 16phenytoin sodium extended 16PHOS-FLUR (fluoride (sodium)) 66PHOSPHOLINE IODIDE (echothiophateiodide) 115phytonadione (vit k1) 50PIFELTRO (doravirine) 37pilocarpine hcl 115PILOCARPINE HCL 115pimecrolimus 68pimozide 31pindolol 54pioglitazone hcl 43PIOGLITAZONE HCL 44piperonyl butoxidepyrethrins (LICE KILLING)68piperonyl butoxidepyrethrins (LICE PYRINYLSHAMPOO) 68piperonyl butoxidepyrethrins (LICETREATMENT) 68piperonyl butoxidepyrethrins (RID) 68piperonyl butoxidepyrethrinspermethrin(COMPLETE LICE TREATMENT) 69
piperonyl butoxidepyrethrinspermethrin(LICE SOLUTION) 69piroxicam 3PLAN B ONE-STEP (levonorgestrel) 102PLEGRIDY (peginterferon beta-1a) 66PLEGRIDY PEN (peginterferon beta-1a) 66PNEUMOVAX 23 (pneumococcal 23-valentpolysaccharide vaccine) 108podofilox 69POLY-VITAMIN (multivitamin) 75polyethylene glycol 3350 84polyethylene glycol 3350 (CLEARLAX) 83polyethylene glycol 3350 (GAVILAX) 84polyethylene glycol 3350 (GENTLELAX) 84polyethylene glycol 3350 (GLYCOLAX) 84polyethylene glycol 3350 (LAXACLEAR) 84polyethylene glycol 3350 (NATURA-LAX) 84polyethylene glycol 3350 (POWDERLAX) 84polyethylene glycol 3350 (PURELAX) 84polyethylene glycol 3350 (SMOOTHLAX) 84polymyxin b sulfatetrimethoprim 113POTASSIUM 75potassium bicarbonatecitric acid 75potassium bicarbonatecitric acid (EFFER-K)75potassium bicarbonatecitric acid (KEFFERVESCENT) 75potassium bicarbonatecitric acid (KLOR-CON-EF) 75POTASSIUM CHL-NORMAL SALINE 75potassium chloride 7075POTASSIUM CHLORIDE 71potassium chloride (KLOR-CON M10) 70potassium chloride (KLOR-CON M20) 70potassium chloride (KLOR-CON SPRINKLE) 75potassium chloride in 09 sodiumchloride 7071potassium chloridepotassiumbicarbonatecitric acid 75potassium gluconate 76pramipexole di-hcl 29pramoxine hclcalamine (CALAHIST) 69
LAST UPDATED 12012020153
pramoxine hclcalamine (CALAMINEMEDICATED) 69praziquantel 28prazosin hcl 51PRAZOSIN HCL 51PRED MILD (prednisolone acetate) 114prednisolone 90prednisolone (MILLIPRED DP) 90prednisolone (MILLIPRED) 90prednisolone acetate 114prednisolone sodium phosphate 90114prednisone 90prednisone (PREDNISONE INTENSOL) 90pregabalin 65PREGABALIN 65PREMARIN (estrogens conjugated) 100PREMPHASE (estrogensconjugatedmedroxyprogesteroneacetate) 100PREMPRO (estrogensconjugatedmedroxyprogesteroneacetate) 100PRENATABS FA (prenatal vits with calciumno78ferrous fumaratefolic acid) 71PRENATABS RX (prenatal vitamin with calciumno76ironcarbonylfolic acid) 71PRENATAL MULTIVITAMIN 76prenatal vit with calcium no129ferrousfumaratefolic acid 76prenatal vit with calcium no130ferrousfumaratefolic acid 76prenatal vitamins no121ferrousfumaratefolic acid 76prenatal vitamins with calciumferrousfumaratefolic acid 76prenatal vitamins with calciumferrousfumaratefolic acid (MYNATAL PLUS) 71prenatal vitamins with calciumferrousfumaratefolic acid (MYNATAL-Z) 71prenatal vits with calcium 118ferrousfumaratefolic acid 76
prenatal vits with calcium 118ferrousfumaratefolic acid (SE-NATAL 19) 71prenatal vits with calcium 136ferrousfumaratefolic acid (VINATE-M) 71prenatal vits with calcium 137ferrousfumaratefolic acid 76prenatal vits with calcium 95ferrousfumaratefolic acid 76prenatal vits with calcium no115ironfumaratefolic acid 71prenatal vits with calcium no72ferrousfumaratefolic acid 71prenatal vits with calcium no72ferrousfumaratefolic acid (M-NATAL PLUS) 71prenatal vits with calcium no72ferrousfumaratefolic acid (PREPLUS) 71prenatal vits with calciumno72ironcarbonylfolic acid 72prenatal vits with calcium no74ferrousfumaratefolic acid 72prenatal vits with calcium no96ferrousfumaratefolic acid 76PREVACID (lansoprazole) 85PREVNAR 13 (pneumococcal 13-valentconjugate vaccine (diphtheria crm)pf) 108PREZCOBIX (darunavirethanolatecobicistat) 40PREZISTA (darunavir ethanolate) 40PRIFTIN (rifapentine) 26primaquine phosphate 28primidone 15probenecid 24probenecidcolchicine 24PROBUPHINE (buprenorphine hcl) 7prochlorperazine 20prochlorperazine (COMPRO) 20prochlorperazine maleate 20PROCRIT (epoetin alfa) 47PROCTOFOAM-HC (hydrocortisoneacetatepramoxine hcl) 69
LAST UPDATED 12012020154
PROFILNINE (factor ix complex prothrombincplx conc(pcc) no4 3-factor) 50promethazine hcl 21122PROMETHAZINE HCL 122promethazine hcl (PHENADOZ) 21promethazine hcl (PROMETHEGAN) 21promethazine hclcodeine 129promethazine hcldextromethorphan hbr 129PROMETHAZINE-DM 129promethazinephenylephrine hclcodeine 129propafenone hcl 53propantheline bromide 77proparacaine hcl 113propranolol hcl 54propylthiouracil 104pseudoephedrine hcl 123pseudoephedrine hcl (NASALDECONGESTANT) 123pseudoephedrine hcl (SUDOGEST) 123pseudoephedrine hcl (SUPHEDRIN) 123pseudoephedrine hcl (SUPHEDRINE SINUSCONGESTION) 123pseudoephedrine hcl (SUPHEDRINE) 123pseudoephedrine hcl (WAL-PHED) 123PULMICORT FLEXHALER (budesonide) 117pyrazinamide 26pyridostigmine bromide 25pyridoxine hcl (vitamin b6) 76
Qquetiapine fumarate 33quinapril hcl 52quinidine gluconate 53quinidine sulfate 53QVAR REDIHALER (beclomethasonedipropionate) 117
RRABAVERT (rabies vaccine purified chickenembryo cell (pcec)pf) 108ramipril 52
RAMIPRIL 53REBINYN (factor ix (human) recombinantpegylated) 50RECOMBINATE (antihemophilic factor viiihuman recombinant) 50RECOMBIVAX HB (hepatitis b virus vaccinerecombinantpf) 108RELENZA (zanamivir) 41RESCRIPTOR (delavirdine mesylate) 37REXULTI (brexpiprazole) 33REYATAZ (atazanavir sulfate) 41RHEUMATREX (methotrexate sodium) 105RIASTAP (fibrinogen) 50ribavirin 36ribavirin (RIBASPHERE) 36RID (permethrin) 111RID (piperonylbutoxidepyrethrinspermethrin) 69RIDAURA (auranofin) 106rifabutin 26rifampin 26riluzole 65RILUZOLE 65ringers solution 7076RISPERDAL (risperidone) 33RISPERDAL CONSTA (risperidonemicrospheres) 33RISPERDAL M-TAB (risperidone) 33risperidone 33ritonavir 41RIXUBIS (factor ix human recombinant) 50rizatriptan benzoate 25ropinirole hcl 29rosuvastatin calcium 59RUKOBIA 39
Ssalsalate 3SANDIMMUNE (cyclosporine) 105SANTYL (collagenase clostridiumhistolyticum) 69
LAST UPDATED 12012020155
SAPHRIS (asenapine maleate) 33SAVELLA (milnacipran hcl) 65SE-NATAL-19 (prenatal vitamins no119ironfumaratefolic acid) 72SECUADO (asenapine) 33selegiline hcl 30selenium sulfide 69selenium sulfide (ANTI-DANDRUFF) 69selenium sulfide (MEDICATED DANDRUFFSHAMPOO) 69selenium sulfide (SELSUN BLUE) 69selenium sulfidealoe vera (SELSUN BLUEMOISTURIZING) 69SELZENTRY (maraviroc) 39SEREVENT DISKUS (salmeterol xinafoate) 123SEROQUEL (quetiapine fumarate) 34SEROQUEL XR (quetiapine fumarate) 34sertraline hcl 18sevelamer carbonate 87SEVENFACT 50SHINGRIX (varicella-zoster virus glycoproteinerecas01b adjuvantpf) 108SILACE (docusate sodium) 84sildenafil citrate 124SILDENAFIL CITRATE 124silver sulfadiazine 13simethicone 80simethicone (GAS RELIEF) 80simethicone (GAS-X) 80simethicone (INFANT GAS RELIEF) 80simethicone (INFANTS GAS RELIEF) 80simethicone (MI-ACID) 80simvastatin 59sirolimus 105SODIUM CHLORIDE 7677sodium chloride 113sodium chloride (MURO-128) 113sodium chloride for inhalation 129sodium chloride irrigating solution 707277sodium chloride irrigating solution (AQUACARE SODIUM CHLORIDE) 77
sodium chloride irrigating solution (CURITY) 77sodium chloridesodiumbicarbonatepotassium chloridepeg 84sodium chloridesodiumbicarbonatepotassium chloridepeg(GAVILYTE-N) 84sodium chloridesodiumbicarbonatepotassium chloridepeg (TRILYTEWITH FLAVOR PACKETS) 84sodium polystyrene sulfonate 72sodium polystyrene sulfonatesorbitol solution(KIONEX) 72sodiumpotassiumpotassium citratesodiumcitratecit ac 87sodiumpotassiumpotassium citratesodiumcitratecit ac (CYTRA-3) 87sodiumpotassiumpotassium citratesodiumcitratecit ac (TRICITRATES) 87sofosbuvirvelpatasvir 35SOTALOL 53SOTALOL AF 53sotalol hcl 53sotalol hcl (SORINE) 53spironolactone 58SPIRONOLACTONE 58spironolactonehydrochlorothiazide 57SPS (sodium polystyrene sulfonatesorbitolsolution) 72SSD (silver sulfadiazine) 13stavudine 38STOMACH RELIEF 80STOOL SOFTENER 84STOOL SOFTENER (docusate sodium) 84STRIBILD(elvitegravircobicistatemtricitabinetenofovir disoproxil) 36SUBLOCADE (buprenorphine) 4SUBOXONE (buprenorphine hclnaloxonehcl) 7sucralfate 85SUDAFED (pseudoephedrine hcl) 123
LAST UPDATED 12012020156
sulfacetamide sodium 13sulfacetamide sodiumprednisolone sodiumphosphate 113sulfamethoxazoletrimethoprim 13sulfasalazine 109SULFATRIM (sulfamethoxazoletrimethoprim)14sulindac 3SUMATRIPTAN 25sumatriptan 25sumatriptan succinate 25SUMATRIPTAN SUCCINATE 25SUSTIVA (efavirenz) 37SYMBYAX (olanzapinefluoxetine hcl) 18SYMFI (efavirenzlamivudinetenofovirdisoproxil fumarate) 36SYMFI LO (efavirenzlamivudinetenofovirdisoproxil fumarate) 37SYMTUZA (darunavirethcobicistatemtricitabinetenofoviralafenamide) 41SYNAREL (nafarelin acetate) 104SYNJARDY (empagliflozinmetformin hcl) 44SYNJARDY XR (empagliflozinmetformin hcl) 44SYNTHROID (levothyroxine sodium) 103syringe with needle insulin safety 1 ml 111syringe with needledisposableinsulin 1 ml 111syringe with needleinsulin03 ml 111syringe with needleinsulin05 ml 112
TTABLOID (thioguanine) 27tacrolimus 69106TACROLIMUS 106tadalafil 124tadalafil (ALYQ) 124TAKE ACTION (levonorgestrel) 102TAMOXIFEN CITRATE 27tamoxifen citrate 27tamsulosin hcl 86TDVAX (tetanus and diphtheria toxoidsadult) 108
TECFIDERA (dimethyl fumarate) 66TEGRETOL (carbamazepine) 16TEGRETOL XR (carbamazepine) 16temazepam 130TEMIXYS (lamivudinetenofovir disoproxilfumarate) 36temozolomide 27TENIVAC (tetanus and diphtheria toxoidsadsorbed adultpf) 108tenofovir disoproxil fumarate 38terazosin hcl 52TERAZOSIN HCL 52terbinafine hcl 24terbinafine hcl (ANTIFUNGAL) 24terbinafine hcl (ATHLETES FOOT AF) 24terbinafine hcl (ATHLETES FOOT) 24terbinafine hcl (JOCK ITCH) 2444terbinafine hcl (LAMISIL AT) 24TERBUTALINE SULFATE 123terbutaline sulfate 124testosterone 91testosterone cypionate 91tetanus and diphtheria toxoids adult 108THALOMID (thalidomide) 27THEO-24 (theophylline anhydrous) 124theophylline anhydrous 124theophylline anhydrous (THEOCHRON) 124thioridazine hcl 31thiothixene 31thyroidpork (NP THYROID) 103timolol maleate 115TIMOLOL MALEATE 115tioconazole 24TIVICAY (dolutegravir sodium) 36TIVICAY PD 36tizanidine hcl 35TOBRADEX (tobramycindexamethasone) 113tobramycin 9tobramycindexamethasone 113TOBREX (tobramycin) 9tolbutamide 44
LAST UPDATED 12012020157
tolmetin sodium 3tolnaftate 24tolnaftate (ANTIFUNGAL CREAM) 24tolnaftate (ATHLETES FOOT) 24tolnaftate (FUNGOID-D) 24topiramate 16TOPIRAMATE 16TOREMIFENE CITRATE 27toremifene citrate 27tramadol hcl 6TRAMADOL HCL 6trandolapril 53tranylcypromine sulfate 18TRAVEL SICKNESS (meclizine hcl) 21TRAZODONE HCL 19trazodone hcl 19tretinoin 28TRETTEN (factor xiii a-subunit recombinant) 50TRI-VI-SOL (vitamin a palmitateascorbicacidcholecalciferol (vit d3)) 77triamcinolone acetonide 6690117TRIAMCINOLONE ACETONIDE 66triamcinolone acetonide (ORALONE) 66triamterenehydrochlorothiazide 57triazolam 130trifluoperazine hcl 31trifluridine 41TRIGLIDE (fenofibrate nanocrystallized) 59trihexyphenidyl hcl 29trimethobenzamide hcl 21trimethoprim 10TRINATE (prenatal vits with calciumno73ferrous fumaratefolic acid) 72TRIPLE ANTIBIOTIC 11TRIPLE ANTIBIOTIC (neomycinsulfatebacitracin zincpolymyxin b) 11triprolidine hclpseudoephedrine hcl(APRODINE) 129triprolidine hclpseudoephedrine hcl (ED A-HIST PSE) 129
triprolidine hclpseudoephedrine hcl(RITIFED) 129triprolidine hclpseudoephedrine hcl (WAL-ACT D COLD amp ALLERGY) 129TRIUMEQ (abacavir sulfatedolutegravirsodiumlamivudine) 39TRIZIVIR (abacavirsulfatelamivudinezidovudine) 38TROGARZO (ibalizumab-uiyk) 39trospium chloride 86TROSPIUM CHLORIDE 86TRULICITY 44TRULICITY (dulaglutide) 44TRUMENBA (neisseria meningitidis group blipidated fhbp recombinant) 108TRUVADA (emtricitabinetenofovir disoproxilfumarate) 39TWINRIX (hepatitis a virus and hepatitis b virusvaccinepf) 108TYBOST (cobicistat) 39
UUNIFINE PENTIPS MAXFLOW 112UNITHROID (levothyroxine sodium) 103URETRON D-S (methenaminemethylenebluesod phospsalicylatehyoscyamine) 11URINARY PAIN RELIEF 87ursodiol 80
Vvalacyclovir hcl 41valproic acid 15VALPROIC ACID 15valproic acid (as sodium salt) (valproatesodium) 15valsartan 52valsartanhydrochlorothiazide 57VANADOM 130VANDAZOLE (metronidazole) 11VAQTA (hepatitis a virus vaccinepf) 109
LAST UPDATED 12012020158
VARIVAX VACCINE (varicella virus vaccinelivepf) 109VEMLIDY (tenofovir alafenamide) 35venlafaxine hcl 19VENLAFAXINE HCL ER 19verapamil hcl 55VERSACLOZ (clozapine) 35VICTOZA 2-PAK (liraglutide) 44VICTOZA 3-PAK (liraglutide) 44VIRACEPT (nelfinavir mesylate) 41VIRAMUNE (nevirapine) 38VIRAMUNE XR (nevirapine) 38VIREAD (tenofovir disoproxil fumarate) 39VITAMIN B-12 77VITAMIN C 77VITEKTA (elvitegravir) 36VIVITROL (naltrexone microspheres) 7VONVENDI (von willebrand factor(recombinant)) 50VRAYLAR (cariprazine hcl) 34
Wwarfarin sodium 46warfarin sodium (JANTOVEN) 46WILATE (antihemophilic factor humanvonwillebrand factorhuman) 50
XXARELTO (rivaroxaban) 4647XYNTHA (antihemophilic factor (factor viii)recombb-domain deleted) 51XYNTHA SOLOFUSE (antihemophilic factor(factor viii) recombb-domain deleted) 51
Zzaleplon 130ZERIT (stavudine) 39ZIAGEN (abacavir sulfate) 39ziprasidone hcl 34ZIPRASIDONE HCL 34ZIPRASIDONE MESYLATE 34
ziprasidone mesylate 34zolpidem tartrate 130zonisamide 14ZOSTAVAX (zoster vaccine livepf) 109ZOVIA 1-35 100ZUBSOLV (buprenorphine hclnaloxone hcl) 7ZYPREXA (olanzapine) 34ZYPREXA RELPREVV (olanzapine pamoate) 34ZYPREXA ZYDIS (olanzapine) 34
LAST UPDATED 12012020159
ii
Medi-Cal Formulary
The Blue Shield of California Promise Health Plan Medi-Cal Formulary is a list of covered drugs
(Formulary) This list includes drugs used to treat common health problems A team of doctors
and pharmacists meets four times a year to decide which drugs should be on the drug list
They review new and old drugs and choose the ones that are safe and work best
Definitions The following words and definitions will be used throughout the formulary drug list
Word
ldquoBrand name drugrdquo is a drug that is sold under a trademark name We will list the
brand name drug will in all CAPITAL letters
ldquoDrug Tierrdquo shows a group of drugs and how we cover them (see below)
ldquoEnrolleerdquo or ldquomemberrdquo is a person enrolled in a health plan and receives services
from the plan
ldquoException requestrdquo is when the member requests for the plan to cover a drug The
health plan must cover the drug if medically required to treat the members condition
ldquoExigent circumstancesrdquo are when a member suffers from a health condition that may
seriously risk their life health or daily life This is also when a member currently uses a
drug that is not covered
ldquoFormularyrdquo or ldquopreferred drug listrdquo is the list of drugs covered under the drug benefit
ldquoGeneric drugrdquo is the same drug as its brand name version in strength how it is taken
quality and safety A generic drug is listed in bold and italicized lowercase letters
ldquoNon-formulary drugrdquo is a drug not listed on the plans drug list
ldquoPrescribing providerrdquo may prescribe a drug to treat a medical condition for a
member
ldquoPrescriptionrdquo is an oral written or electronic order by a prescribing provider that
contains the name of the drug amount date providerrsquos name and contact
signature of the provider (if in writing) and the medical condition or purpose for
which the drug is being prescribed (if requested by the member)
ldquoPrescription drugrdquo is a drug that requires a prescription and prescribed by the
memberrsquos provider
ldquoPrior authorizationrdquo is a plans requirement that the member or provider get the
health plans approval for a drug before the plan will cover it The plan will approve
the drug when it is medically required
ldquoStep therapyrdquo is when the plan requires the member to try one or more drugs to treat
the medical condition before it will cover a certain drug If the memberrsquos provider
submits a request for approval the plan will approve the drug is medically required
iii
How do I use the Blue Shield of California Promise Health Plan Medi-Cal
Formulary
To look for a drug check the index at the end It lists all of the drugs on the Formulary Next to
your drug you will see the page number where you can find it The drugs are listed in
alphabetical order under the column ldquoPrescription Drug Namerdquo under its category and class
To look for a drug class check the Table of Contents
Even if the drug is on the list this does not guarantee that your doctor will prescribe it
The Formulary covers generics and certain brands when available If there is an approved
generic drug then we will cover the generic only
bull A generic name for a brand name drug is listed after the brand name of the drug in all
lowercase italics
o If both a generic and brand are covered we will list the generic separately from
the brand name in all lowercase italics
o When a drug is sold as a brand name we will list the brand name after the
generic name in parentheses in all CAPITALS
bull We will list a brand name drug in all CAPITALS followed by the name in parentheses in
lowercase italics
Example
Drug Type How the drug name will appear
in the formulary drug list
generic drug atorvastatin calcium
generic drug marketed with a
brand name
oxycodoneacetaminophen
(ENDOCET)
brand drug LIPITOR (atorvastatin calcium)
Some drugs are injections that are not listed but they may be covered for up to a 10-day
supply after you leave the hospital These include drugs for parenteral nutrition (TPN) lipids
and other unlisted drugs and antibiotics
iv
What are drug tiers
Drugs are placed into drug tiers
Drug Tier What Does it mean
Covered (Tier 1) These drugs are covered on the Drug
List (Formulary) at $0 co-payment
Medi-Cal Carve Out (Tier 2) These drugs are carved out by the
Department of Health Care Services
This means these drugs are covered by
the Medi-Cal Fee-for Service program
and can be billed to the State
Medical Benefit (Tier 3) These drugs may be available at the
doctorrsquos office or medical setting
How to read the formulary
The column titled ldquoCoverage Requirements and Limitationsrdquo shows how the drug is covered
and if there are limits
Coverage Requirements
and Limitations
What does it stand for What does it mean
AL1 Age Restrictions We cover some drugs only
for some ages
PA Prior Authorization
Required
Your doctor must ask for
approval from us before
we cover some drugs
QL Quantity Limit We only cover some drugs
for a certain amount
ST Step Therapy Required In some cases you must
first try certain drugs
before we cover another
drug for your condition
STAR Extended Day Supply You may fill this drug for a
90 day supply
MDD Max Daily Dose We limit the amount of this
drug covered per day
C Custom This drug has special limits
QLC Quantity Limit (Custom) We limit the amount of this
drug covered each fill or
within a time frame
SP Specialty Pharmacy A network specialty
pharmacy will fill this drug
v
How often will the formulary change
The formulary may change monthly Some changes that can happen without notice include
bull When we remove a brand name drug if a generic is available
bull When we remove a drug taken off the market because the Food and Drug
Administration (FDA) has found it unsafe or if the manufacturer has removed it
bull When we add a drug to the formulary or if we remove a limit (like prior authorization or
step therapy)
Changes to formulary that we will notify you of at least 30 days before include
bull When we remove a drug or dosage form
bull When we add or change limits on the drug
What is a medical benefit drug
A medical benefit drug is a drug that usually is given as an injection or infusion in a medical
setting
What if my drug requires a prior authorization or step therapy
A prior authorization means that your doctor asks for approval for the drug because it is
medically necessary A step therapy means that you need to try certain drugs before we
cover your drug
You may ask for an exception by calling Customer Care at (800) 605-2556 (Los Angeles
County) or (855) 699-5557 (San Diego County) Or your doctor can call us at (877) 792-2731 or
fax at (866) 712-2731 to request that drug be covered
What if my drug is not on the Blue Shield of California Promise Health Plan Medi-
Cal Formulary
If your doctor gives you a drug that is not on the drug list you can ask your doctor for another
drug that is on formulary or you may request for us to cover the drug (exception) by calling
Customer Care at (800) 605-2556 (Los Angeles County) or (855) 699-5557 (San Diego County)
Your doctor can call us at (877) 792-2731 or fax at (866) 712-2731 to request that drug be
covered
You might now take a drug and your doctor still prescribes it If the drug is safe and effective
for your condition we will continue to cover it if we covered it before
vi
Participating retail pharmacies
You can fill prescriptions at any participating pharmacy (network pharmacy) unless it is for a
specialty drug You may find a network pharmacy by visiting
httpspromiseblueshieldcacomcapharmacysearchversion=2020amplob=mcal
What are specialty drugs
Specialty drugs require extra training before you take them extra visits with your doctor need
special handling and transport and are usually high-cost These drugs may require prior
authorization or non-formulary exception If approved a network specialty pharmacy will
deliver them by mail Please visit wwwblueshieldcacompromisemedi-cal for more
information
What if I have additional questions
If you want a copy of the Blue Shield of California Promise Health Plan Medi-Cal Formulary or
have questions please call Customer Care at (800) 605-2556 (Los Angeles County) or (855)
699-5557 (San Diego County)
Blue Shield of California Promise Health Plan
601 Potrero Grande Drive Monterey Park CA 91755
vii
H5928_19_269A2_C 08302019
Blu
e S
hie
ld o
f C
alif
orn
ia P
rom
ise
He
alth
Pla
n is
an
ind
ep
en
de
nt
lice
nse
e o
f th
e B
lue
Sh
ield
Ass
oc
iatio
n
A512
47-C
MS (
91
8)
Discrimination is Against the Law
Blue Shield of California Promise Health Plan complies with applicable state laws and federal civil rights laws and does not discriminate on the basis of race color national origin ancestry religion sex marital status gender gender identity sexual orientation age or disability Blue Shield of California Promise Health Plan does not exclude people or treat them differently because of race color national origin ancestry religion sex marital status gender gender identity sexual orientation age or disability
Blue Shield of California Promise Health Plan provides bull Aids and services at no cost to people with disabilities to communicate effectively with us
such aso Qualified sign language interpreterso Written information in other formats (large print audio accessible electronic
formats other formats)bull Language services at no cost to people whose primary language is not English such as
o Qualified interpreterso Information written in other languages
If you need these services contact the Blue Shield of California Promise Health Plan Civil Rights Coordinator
If you believe that Blue Shield of California Promise Health Plan has failed to provide these
services or discriminated in another way on the basis of race color national origin
ancestry religion sex marital status gender gender identity sexual orientation age or
disability you can file a grievance with
Blue Shield of California Promise Health Plan
Civil Rights Coordinator
601 Potrero Grande Dr
Monterey Park CA 91755
Phone (844) 883-2233 (TTY 711)
Fax (323) 889-2228
Email BSCPHPCivilRightsblueshieldcacom
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 Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD)
Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language Assistance Notice for LA County
viii
English
ATTENTION Language assistance services free of charge are available to you Call 1-800-605-
2556 (TTY 711)
繁體中文 (Chinese)
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1-800-605-2556(TTY
711)
한국어 (Korean)
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-800-
605-2556 (TTY 711)번으로 전화해 주십시오
Русский (Russian)
ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги
перевода Звоните 1-800-605-2556 (телетайп 711)
Kreyogravel Ayisyen (Haitian-Creole)
ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele 1-
800-605-2556 (TTY 711)
Franccedilais (French)
ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes
gratuitement Appelez le 1-800-605-2556 (TTY 711)
Portuguecircs (Portuguese)
ATENCcedilAtildeO Se fala portuguecircs encontram-se disponiacuteveis serviccedilos linguiacutesticos graacutetis Ligue para 1-
800-605-2556 (TTY 711)
Italiano (Italian)
ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza
linguistica gratuiti Chiamare il numero 1-800-605-2556 (TTY 711)
(Farsi) فارسی
2556-605-800-1 با باشد می فراهم شما برای رایگان بصورت زبانی تسهیلات کنید می گفتگو فارسی زبان به اگر توجه
(TTY 771) بگیرید تماس
ह िदी (Hindi)
धयान द यदद आप द िदी बोलत तो आपक ललए मफत म भाषा स ायता सवाएि उपलबध 1-800-605-
2556 (TTY 711) पर कॉल करHmong (Hmong)
LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb rau koj Hu rau
1-800-605-2556 (TTY 711)
Espantildeol (Spanish)
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica
Llame al 1-800-605-2556 (TTY 711)
Language Assistance Notice for LA County (Continued)
ix
Tiếng Việt (Vietnamese)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-
800-605-2556 (TTY 711)
Tagalog (Tagalog - Filipino)
PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa
wika nang walang bayad Tumawag sa 1-800-605-2556 (TTY 711)
(Arabic) العربية
2556-605-800-1مجان اتصل برقم ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بال
(711YTT)
Polski (Polish)
UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń
pod numer 1-800-605-2556 (TTY 711)
ພາສາລາວ (Lao)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ ໂທຣ 1-800-605-2556 (TTY 711)
日本語 (Japanese)
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1-800-605-
2556(TTY711)までお電話にてご連絡ください
ภาษาไทย (Thai)
เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-800-605-2556 (TTY 711)
λληνικά (Greek)
ΠΡΟΣΟΧΗ Αν μιλάτε ελληνικά στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης
οι οποίες παρέχονται δωρεάν Καλέστε 1-800-605-2556 (TTY 711)
ਪਜਾਬੀ ਦ (Punjabi)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-800-605-
2556 (TTY 711) ਤ ਕਾਲ ਕਰ
ខមែរ (Cambodian)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល
គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-800-605-2556 (TTY 711)
Հայերեն (Armenian)
ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող են
տրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք 1-800-605-2556
(TTY (հեռատիպ)711)
Language Assistance Notice for San Diego County
x
English
ATTENTION Language assistance services free of charge are available to you
Call 1-855-699-5557 (TTY 711)
繁體中文 (Chinese)
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1-855-699-5557(TTY
711)
한국어 (Korean)
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-855-
699-5557 (TTY 711)번으로 전화해 주십시오
Русский (Russian)
ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные
услуги перевода Звоните 1-855-699-5557 (телетайп 711)
Italiano (Italian)
ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di
assistenza linguistica gratuiti Chiamare il numero 1-855-699-5557 (TTY 711)
(Farsi) فارسی
-699-855-1 با باشد می فراهم شما برای رایگان بصورت زبانی تسهیلات کنید می گفتگو فارسی زبان به اگر توجه
5557 (TTY 771) بگیرید تماس
ह िदी (Hindi)
धयान द यदद आप द िदी बोलत तो आपक ललए मफत म भाषा स ायता सवाएि उपलबध 1-855-699-
5557 (TTY 711) पर कॉल कर
Hmong (Hmong)
LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb
rau koj Hu rau 1-855-699-5557 (TTY 711)
Espantildeol (Spanish)
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia
linguumliacutestica Llame al 1-855-699-5557 (TTY 711)
Tiếng Việt (Vietnamese)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho
bạn Gọi số 1-855-699-5557 (TTY 711)
Tagalog (Tagalog - Filipino)
PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga
serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-855-699-5557 (TTY
711)
Language Assistance Notice for San Diego County (Continued)
xi
(Arabic) العربية
5557-699-855-1 برقم اتصل بالمجان لك تتوافر اللغویة المساعدة خدمات فإن اللغة اذكر تتحدث كنت إذا ملحوظة
(711YTT)
ພາສາລາວ (Lao)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ ໂທຣ 1-855-699-5557 (TTY 711)
日本語 (Japanese)
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1-855-699-
5557(TTY711)までお電話にてご連絡ください
ภาษาไทย (Thai)
เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-855-699-5557 (TTY 711)
ਪਜਾਬੀ ਦ (Punjabi)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-855-
699-5557 (TTY 711) ਤ ਕਾਲ ਕਰ
ខមែរ (Cambodian)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល
គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-855-699-5557 (TTY 711)
Հայերեն (Armenian)
ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող են
տրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք 1-855-699-
5557 (TTY (հեռատիպ)711)
Categorical List of Prescription DrugsANALGESICS (Drugs for Pain) 1
ANESTHETICS (Drugs for Numbing) 6
ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS (Drugs for AddictionSubstance Abuse) 6
ANTIBACTERIALS (Drugs for Bacterial Infections) 8
ANTICONVULSANTS (Drugs for Seizures) 14
ANTIDEMENTIA AGENTS (Drugs for Alzheimers Disease and Dementia) 17
ANTIDEPRESSANTS (Drugs for Depression) 17
ANTIEMETICS (Drugs for Nausea and Vomiting) 20
ANTIFUNGALS (Drugs for Fungal Infections) 21
ANTIGOUT AGENTS (Drugs for Gout) 24
ANTIMIGRAINE AGENTS (Drugs for Migraine) 25
ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis) 25
ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections) 26
ANTINEOPLASTICS (Drugs for Cancer) 26
ANTIPARASITICS (Drugs for Parasitic Infections) 28
ANTIPARKINSON AGENTS (Drugs for Parkinsons Disease) 29
ANTIPSYCHOTICS (Drugs for Mental Health) 30
ANTISPASTICITY AGENTS (Drugs for Muscle Spasm) 35
ANTIVIRALS (Drugs for Viral Infections) 35
ANXIOLYTICS (Drugs for Anxiety) 41
BIPOLAR AGENTS (Drugs for Bipolar Disorder) 42
BLOOD GLUCOSE REGULATORS (Drugs for Diabetes) 42
BLOOD PRODUCTSMODIFIERSVOLUME EXPANDERS (Drugs for Blood Disorders) 46
CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation) 51
CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions) 61
DENTAL AND ORAL AGENTS (Drugs for the Mouth) 66
DERMATOLOGICAL AGENTS (Drugs for the Skin) 66
ELECTROLYTESMINERALSMETALSVITAMINS 69
GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach) 77
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERS TREATMENT (Drugs for Genetic or
Enzyme Disorders) 85
GENITOURINARY AGENTS (Drugs for the Genital Bladder and Kidney) 86
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (ADRENAL) (Drugs for
ReplacingStimulating Adrenal Gland Hormones) 87
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (PITUITARY) (Drugs for
ReplacingStimulating Pituitary Gland Hormones) 90
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEX HORMONESMODIFIERS) (Drugs
for ReplacingStimulating Sex Hormones) 91
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (THYROID) (Drugs for the Thyroid) 102
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs for Suppressing Hormones from the Pituitary
Gland) 104
HORMONAL AGENTS SUPPRESSANT (THYROID) (Drugs for the Thyroid) 104
LAST UPDATED 12012020
IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing the Immune System) 104
INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for Inflammatory Bowel Disease) 109
METABOLIC BONE DISEASE AGENTS (Drugs for the Bone) 109
MISCELLANEOUS THERAPEUTIC AGENTS 110
OPHTHALMIC AGENTS (Drugs for the Eyes) 112
OTIC AGENTS (Drugs for the Ears) 116
RESPIRATORY TRACTPULMONARY AGENTS (Drugs for the Lungs) 116
SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles) 130
SLEEP DISORDER AGENTS (Drugs for Insomnia) 130
LAST UPDATED 12012020
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANALGESICS (Drugs for Pain)
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (Pain and ArthritisDrugs)
aspirin (ADULT ASPIRIN REGIMEN)81 mg tablet dr
1-Covered
aspirin (ADULT LOW DOSE ASPIRINEC) 81 mg tablet dr
1-Covered
aspirin (ASPIR 81) mg tablet dr ) 1-Covered
aspirin (ASPIR-TRIN) 325 mg tabletdr -
1-Covered
aspirin (ASPIRIN) 325 mg tablet 1-Covered
aspirin (ECOTRIN) 81 mg tablet dr 1-Covered
aspirin (ECPIRIN) 325 mg tablet dr 1-Covered
aspirin (ST JOSEPH ASPIRIN EC) 81mg tablet dr
1-Covered
aspirin (ST JOSEPH ASPIRIN) 81 mgtab chew
1-Covered
aspirin 325mg tablet 1-Covered
aspirin 81 mg tab chew 81 mgtablet dr 325 mg tablet
1-Covered
ASPIRIN 81MG TABLET ASPIRIN81MG TABLET ASPIRIN 81MGTABLET
1-Covered
aspirinacetaminophencaffeine(ADDED STRENGTH HEADACHE)250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(BAYER MIGRAINE) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(EXTRA PAIN RELIEF) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(EXTRAPRIN) 250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(HEADACHE RELIEF) 250-250-65tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
1
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
aspirinacetaminophencaffeine(MIGRAINE FORMULA) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(MIGRAINE RELIEF) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(PAIN RELIEVER PLUS) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(PAIN RELIEVER) 250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(PAIN-OFF) 250-250-65 tablet -
1-Covered
butalbitalaspirincaffeine 50-325-40 capsule
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
butalbitalaspirincaffeine 50-325-40 tablet
1-Covered
celecoxib 50 mg capsule 100 mgcapsule 200 mg capsule 400 mgcapsule
1-Covered ST
CELECOXIB 50 MG CAPSULE 100MG CAPSULE 200 MG CAPSULE400 MG CAPSULE
1-Covered ST
CHILDRENS IBUPROFEN CHILD 200MG10 ML CHILDREN 100 MG5 ML
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
diclofenac sodium 25 mg tablet dr50 mg tablet dr 75 mg tablet dr100 mg tab er 24h
1-Covered
diflunisal 500 mg tablet 1-Covered
etodolac 600 mg tab er 24h 1-Covered PA
EXCEDRIN EXTRA STRENGTH(aspirinacetaminophencaffeine)CAPLET
1-Covered
EXCEDRIN MIGRAINE(aspirinacetaminophencaffeine)CAPLET GELTAB
1-Covered
flurbiprofen 50 mg tablet 100 mgtablet
1-Covered
HEADACHE RELIEF HM 250-250-65MG CPLT
1-Covered
ibuprofen (ADDAPRIN) 200 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
2
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ibuprofen (I-PRIN) 200 mg tablet - 1-Covered
ibuprofen (IBU) 400 mg tablet 600mg tablet 800 mg tablet
1-Covered
ibuprofen (IBU-200) mg tablet -) 1-Covered
ibuprofen (PROVIL) 200 mg tablet 1-Covered
ibuprofen (WAL-PROFEN) 200 mgtablet -
1-Covered
ibuprofen 100 mg5ml oral susp 1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
IBUPROFEN 400 MG TABLET 600 MGTABLET 800 MG TABLET
1-Covered
ibuprofen 50 mg125 drops susp100 mg tab chew 200 mg tablet400 mg tablet 600 mg tablet 800mg tablet
1-Covered
indomethacin 25 mg capsule 50mg capsule 75 mg capsule er
1-Covered
ketoprofen 50 mg capsule 75 mgcapsule
1-Covered
meloxicam 75 mg tablet 15 mgtablet
1-Covered
naproxen 250 mg tablet 375 mgtablet 500 mg tablet
1-Covered
naproxen sodium 275 mg tablet550 mg tablet
1-Covered
piroxicam 10 mg capsule 20 mgcapsule
1-Covered
salsalate 500 mg tablet 750 mgtablet
1-Covered
sulindac 150 mg tablet 200 mgtablet
1-Covered
tolmetin sodium 200 mg tablet 400mg capsule 600 mg tablet
1-Covered
OPIOID ANALGESICS LONG-ACTING (Long-acting Narcotic PainRelievers)
BELBUCA (buprenorphine hcl) 75MCG FILM 150 MCG FILM 300MCG FILM 450 MCG FILM 600MCG FILM 750 MCG FILM 900MCG FILM
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
3
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
buprenorphine 5 mcghr patch75 mcghr patch 10 mcghrpatch 15 mcghr patch 20mcghr patch
2-MedicalCarve out
BUTRANS (buprenorphine) 5MCGHR PATCH 75 MCGHRPATCH 10 MCGHR PATCH 15MCGHR PATCH 20 MCGHRPATCH
2-MedicalCarve out
fentanyl 25 mcghr patch50mcghr patch 75mcghr patch100 mcghr patch
1-Covered PA QL (10 PER 30 DAY(S))
methadone hcl (METHADONEINTENSOL) 10 mgml oral conc
1-Covered PA
methadone hcl (METHADOSE) 40mg tablet sol
1-Covered PA
METHADONE HCL 10 MG TABLET 1-Covered QL (60 PER 30 DAYS)
METHADONE HCL 10 MGML ORALCONC
1-Covered PA
methadone hcl 5 mg tablet 10 mgtablet
1-Covered QL (60 PER 30 DAYS)
methadone hcl 5 mg5 ml solution10 mg5 ml solution 10 mgml oralconc
1-Covered PA
morphine sulfate 15 mg tablet er 1-Covered QL (90 PER 30 DAYS)
morphine sulfate 30 mg tablet er 1-Covered QL (60 PER 30 DAYS)
morphine sulfate 60 mg tablet er100 mg tablet er 200 mg tablet er
1-Covered PA
oxycodone hcl 10 mg tab er 20mg tab er 40 mg tab er 80 mgtab er
1-Covered PA QL (60 PER 30 DAYS)
SUBLOCADE (buprenorphine) 100MG05 ML SYRING 300 MG15 MLSYRING
2-MedicalCarve out
OPIOID ANALGESICS SHORT-ACTING (Short-acting Narcotic PainRelievers)
acetaminophen with codeinephosphate -15mg tablet -30mgtablet -60mg tablet
1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old) QLC (LIMIT 100TABS TOTAL APAPCODEINETABLETS PER MONTH)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
4
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acetaminophen with codeinephosphate 120-12mg5 solution
1-Covered QL (240 PER 30 DAYS) AL1 (Atleast 12 yrs old)
butorphanol tartrate 10 mgmlspray
1-Covered PA
codeinephosphatebutalbitalaspirincaffeine codeinebutalbitalasacaffein30-50-325 capsule
1-Covered QL (60 PER 30 DAYS) AL1 (At least12 yrs old)
codeine sulfate 15 mg tablet 30mg tablet 60 mg tablet
1-Covered PA AL1 (At least 12 yrs old)
hydrocodonebitartrateacetaminophen(LORCET HD)hydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAY(S))
hydrocodonebitartrateacetaminophen(LORTAB)hydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAY(S))
hydrocodonebitartrateacetaminophenhydrocodoneacetaminophen 5mg-325mg tablethydrocodoneacetaminophen75-325 mg tablethydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS OF HYDROCODONEPRODUCTS PER 30 DAYS)
hydromorphone hcl 1 mgml liquid3 mg supprect
1-Covered
hydromorphone hcl 2 mg tablet 4mg tablet 8 mg tablet
1-Covered QL (60 PER 30 DAYS)
meperidine hcl 50 mg tablet 100mg tablet
1-Covered QL (100 PER 30 DAYS)
morphine sulfate 10 mg5 ml 20mg5 ml 100 mg5ml
1-Covered PA
morphine sulfate 15 mg tablet 30mg tablet
1-Covered QL (90 PER 30 DAYS)
morphine sulfate 30 mg supprect 1-Covered QL (24 PER 30 DAY(S)) QLC (LIMIT24 SUPPOSITORIES IN 30 DAYS)
morphine sulfate 5 mg 10 mg 20mg
1-Covered QL (24 PER 30 DAY(S)) QLC (LIMIT24 SUPPOSITORIES IN 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
5
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
oxycodone hcl 5 mg capsule 5mg tablet 5 mg5 ml solution 15mg tablet 20 mgml oral conc 30mg tablet
1-Covered PA
oxycodone hclacetaminophen(ENDOCET) 5 mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS PER 30 DAYS OF TOTALOXYCODONE APAP ANDOXYCODONE ASA PER MONTH)
oxycodone hclacetaminophen 5mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS PER 30 DAYS OF TOTALOXYCODONE APAP ANDOXYCODONE ASA PER MONTH)
oxycodone hclacetaminophen 5-3255 ml solution
1-Covered PA
oxycodone hclaspirin 48355-325tablet
1-Covered QL (100 PER 30 DAY(S))
tramadol hcl 50 mg tablet 1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old)
TRAMADOL HCL 50 MG TABLET 1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old)
ANESTHETICS (Drugs for Numbing)
LOCAL ANESTHETICS (Skin Numbing Drugs)lidocaine hcl 10 mgml vial 1-Covered PA
lidocaine hcl 2 solution 1-Covered
LIDOCAINE HCL VISCOUS 2 SOLN 1-Covered
lidocaine hclpf 10 mgml vial 10mgml ampul
1-Covered PA
ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS (Drugs forAddictionSubstance Abuse)
ALCOHOL DETERRENTSANTI-CRAVING (Drugs for AlcoholDependence)
acamprosate calcium 333 mgtablet dr
2-MedicalCarve out
disulfiram 250 mg tablet 500 mgtablet
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
6
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
naltrexone hcl 50 mg tablet 2-MedicalCarve out
NALTREXONE HCL 50 MG TABLET 2-MedicalCarve out
VIVITROL (naltrexonemicrospheres) 380 MG VIAL +DILUENT
2-MedicalCarve out
OPIOID DEPENDENCE TREATMENTS (Drugs for Opioid Dependence)BUNAVAIL (buprenorphinehclnaloxone hcl) 21-03 MG FILM42-07 MG FILM 63-1 MG FILM
2-MedicalCarve out
BUPRENEX (buprenorphine hcl) 03MGML AMPUL
2-MedicalCarve out
buprenorphine hcl 03 mgml vial03 mgml cartridge 2 mg tab subl8 mg tab subl
2-MedicalCarve out
buprenorphine hclnaloxone hclnaloxone 2 mg-05mg filmnaloxone 2 mg-05mg tab sublnaloxone 4mg-1mg filmnaloxone 8 mg-2 mg filmnaloxone 8 mg-2 mg tab subl
2-MedicalCarve out
LUCEMYRA (lofexidine hcl) 018 MGTABLET
2-MedicalCarve out
PROBUPHINE (buprenorphine hcl)742 MG IMPLANT
2-MedicalCarve out
SUBOXONE (buprenorphinehclnaloxone hcl) 2 MG-05 MGFILM 4 MG-1 MG FILM 8 MG-2 MGFILM 12 MG-3 MG FILM
2-MedicalCarve out
ZUBSOLV (buprenorphinehclnaloxone hcl) 07-018 MGTABLET 14-036 MG TABLET 29-071 MG TABLET 57-14 MG TABLET86-21 MG TABLET 114-29 MGTABLET
2-MedicalCarve out
OPIOID REVERSAL AGENTS (Drugs for Opioid Overdose)EVZIO (naloxone hcl) 04 MGAUTO- 2 MG AUTO-
2-MedicalCarve out
naloxone hcl 04 mgml cartridge04 mgml vial 1 mgml syringe 2mg04ml auto injct
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
7
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NARCAN (naloxone hcl) 4 MGNASAL SPRAY
2-MedicalCarve out
SMOKING CESSATION AGENTS (Drugs to Help Quit Smoking)bupropion hcl (BUPROBAN) 150 mgtab er 12h
1-Covered QL (2 PER 1 DAY(S))
bupropion hcl 150 mg tab er 12h 1-Covered QL (2 PER 1 DAY(S))
CHANTIX (varenicline tartrate) 05MG TABLET 1 MG TABLET 1 MGCONT MONTH BOX STARTINGMONTH BOX
1-Covered PA
nicotine 14mg patch 1-Covered QL (1 PER 1 DAY(S))
nicotine 21mg patch 1-Covered QL (1 PER 1 DAY(S))
nicotine 2mg gum 1-Covered QL (24 PER 1 DAY(S))
nicotine 4mg gum 1-Covered QL (24 PER 1 DAY(S))
nicotine 7mg patch 1-Covered QL (1 PER 1 DAY(S))
NICOTINE LOZENGE 2 MGLOZENGE HM 2 MG LOZENGE 4MG LOZENGE HM 4 MG LOZENGE
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (QUIT 2) mglozenge )
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (QUIT 4) mglozenge )
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (STOP SMOKINGAID) 2 mg 4 mg
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex 2 mg 4 mg 1-Covered QL (24 PER 1 DAY(S))
NICOTROL (nicotine) CARTRIDGEINHALER
1-Covered PA
NICOTROL NS (nicotine) 10 MGMLSPRAY
1-Covered PA
ANTIBACTERIALS (Drugs for Bacterial Infections)
AMINOGLYCOSIDESgentamicin sulfate (GENTAK) 03 oint (g)
1-Covered
gentamicin sulfate 01 oint (g)01 cream (g) 03 oint (g) 03 drops
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
8
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GENTAMICIN SULFATE 01 CREAM 1-Covered
neomycin sulfate 500 mg tablet 1-Covered
paromomycin sulfate 250 mgcapsule
1-Covered
tobramycin 03 drops 1-Covered
TOBREX (tobramycin) 03 EYEOINTMENT
1-Covered
ANTIBACTERIALS OTHERbacitracin (BACITRAYCIN PLUS) 500unitg oint (g)
1-Covered
bacitracin 500 unitg packet 500unitg oint (g)
1-Covered
BACITRACIN 500 UNITGM OINTMNT 1-Covered
bacitracin zinc (ANTIBIOTIC) 500unitg oint (g)
1-Covered
bacitracin zinc 500 unitg ointpack 500 unitg oint (g)
1-Covered
BACITRACIN ZINC ZN 500 UNITGMOINT
1-Covered
CLEOCIN (clindamycin phosphate)100 MG VAGINAL OVULE
1-Covered
clindamycin hcl 75 mg capsule150 mg capsule 300 mg capsule
1-Covered
clindamycin palmitate hcl 75 mg5ml soln recon
1-Covered
clindamycin phosphate 1 gel(gram) 1 lotion 1 med swab1 solution 1 gel daily 2 creamappl
1-Covered
CLINDAMYCIN PHOSPHATE 1SOLUTION 1 GEL
1-Covered
erythromycin basebenzoylperoxide erythromycinbenzoyl 3-5 gel (gram)
1-Covered ST
methenaminemethylenebluesodphospsalicylatehyoscyamine(PHOSPHASAL) methmebluesodphospsalhyos 816-108 tablet
1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
9
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
methenaminemethylenebluesodphospsalicylatehyoscyamine(URIN DS) methmebluesodphospsalhyos 816-108 tablet
1-Covered PA
METRO IV (metronidazole in sodiumchloride) 500 MG100 ML
1-Covered
metronidazole 075 gel wappl250 mg tablet 375 mg capsule500 mg tablet
1-Covered
METRONIDAZOLE 250 MG TABLET500 MG TABLET
1-Covered
metronidazole in sodium chloridemetronidazolesodium 500mg01lpiggyback
1-Covered PA
mupirocin 2 oint (g) 1-Covered QL (22 PER 30 DAY(S))
mupirocin calcium 2 cream (g) 1-Covered PA
neomycin sulfatebacitracinzincpolymyxin b (ANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
neomycin sulfatebacitracinzincpolymyxin b (FIRST AIDANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
neomycin sulfatebacitracinzincpolymyxin b (TRIPLEANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
nitrofurantoin 25 mg5 ml oral susp 1-Covered
NITROFURANTOIN 50 MG CAP 100MG CAP
1-Covered
nitrofurantoin macrocrystal 50 mgcapsule 100 mg capsule
1-Covered
nitrofurantoinmonohydratemacrocrystalsmonohydm-100 mg capsule
1-Covered
trimethoprim 100 mg tablet 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
10
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRIPLE ANTIBIOTIC (neomycinsulfatebacitracin zincpolymyxinb) CURAD OINT MEDI-FIRSTMEDICHOICE OINTMENTOINTMENT PKT
1-Covered
TRIPLE ANTIBIOTIC HM PKT 1-Covered
URETRON D-S(methenaminemethylenebluesodphospsalicylatehyoscyamine) -TABLET
1-Covered PA
VANDAZOLE (metronidazole)VAGINAL 075 GEL
1-Covered
BETA-LACTAM CEPHALOSPORINScefaclor 125 mg5ml susp recon250 mg5ml susp recon 250 mgcapsule 375 mg5ml susp recon500 mg capsule
1-Covered
CEFDINIR 125 MG5 ML SUSP 250MG5 ML SUSP
1-Covered QL (200 PER 10 DAY(S))
cefdinir 125 mg5ml 250 mg5ml 1-Covered QL (200 PER 10 DAY(S))
cefdinir 300 mg capsule 1-Covered QL (20 PER 10 DAY(S))
cephalexin 125 mg5ml susprecon 250 mg capsule 250mg5ml susp recon 500 mgcapsule
1-Covered
BETA-LACTAM PENICILLINSamoxicillin 125 mg5ml susp recon125 mg tab chew 200 mg5mlsusp recon 250 mg tab chew 250mg5ml susp recon 250 mgcapsule 400 mg5ml susp recon500 mg tablet 500 mg capsule875 mg tablet
1-Covered
AMOXICILLIN-CLAVULANATEPOTASS -600-429 MG5 ML SUS
1-Covered QL (300 PER FILL) QLC (1 FILL IN 30DAYS)
AMOXICILLIN-CLAVULANATEPOTASS -875-125 MG TABLET
1-Covered
amoxicillinpotassium clavulanate1000-625 tab er 12h
1-Covered QL (40 PER FILL(S)) MFL (1 30day(s))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
11
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
amoxicillinpotassium clavulanate200-2855 susp recon 200-285mgtab chew 250-125 mg tablet 400-57mg5 susp recon 400-57mg tabchew 500-125 mg tablet 875-125mg tablet
1-Covered
amoxicillinpotassium clavulanate600-4295 susp recon
1-Covered QL (300 PER FILL) QLC (1 FILL IN 30DAYS)
ampicillin trihydrate 125 mg5mlsusp recon 250 mg capsule 250mg5ml susp recon 500 mgcapsule
1-Covered
dicloxacillin sodium 250 mgcapsule 500 mg capsule
1-Covered
penicillin v potassium 125 mg5mlsoln recon 250 mg5ml soln recon250 mg tablet 500 mg tablet
1-Covered
MACROLIDESazithromycin 1 g packet 1-Covered QL (1 PER 30 DAYS)
azithromycin 100 mg5ml 200mg5ml
1-Covered
AZITHROMYCIN 200 MG5 ML SUSP 1-Covered
azithromycin 250 mg tablet 1-Covered QL (6 PER FILL(S)) MFL (2 30day(s))
AZITHROMYCIN 250 MG TABLET 1-Covered QL (6 PER FILL(S)) MFL (2 30day(s))
azithromycin 500 mg tablet 1-Covered QL (3 PER FILL(S)) MFL (2 30day(s))
AZITHROMYCIN 500 MG TABLET 1-Covered QL (3 PER FILL(S)) MFL (2 30day(s))
azithromycin 600 mg tablet 1-Covered QL (2 PER 7 DAY(S)) MFL (8 28day(s))
clarithromycin 500 mg tablet 1-Covered ST
EES 200 (erythromycinethylsuccinate) MG5 MLSUSPENSION
1-Covered
EES 400 (erythromycinethylsuccinate) FILMTAB
1-Covered
ERYTHROCIN STEARATE(erythromycin stearate) 250 MGFILMTAB
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
12
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ERYTHROMYCIN 250 MG 500 MG 1-Covered
erythromycin base 5 mggramoint (g) 250 mg capsule dr 250mg tablet dr 250 mg tablet 333mg tablet dr 500 mg tablet 500mg tablet dr
1-Covered
erythromycin base in ethanol (ERY)2 med swab
1-Covered
erythromycin base in ethanol 2 solution 2 med swab
1-Covered
ERYTHROMYCIN ETHYLSUCCINATE200 MG5 ML SUSP
1-Covered
erythromycin ethylsuccinate 200mg5ml susp recon 400 mg tablet
1-Covered
QUINOLONESCILOXAN (ciprofloxacin hcl) 03OINTMENT
1-Covered
ciprofloxacin hcl 03 drops 1-Covered
ciprofloxacin hcl 100 mg tablet 1-Covered PA AL1 (At least 18 yrs old)
ciprofloxacin hcl 250 mg tablet500 mg tablet 750 mg tablet
1-Covered AL1 (At least 18 yrs old)
CIPROFLOXACIN HCL 500 MG TAB 1-Covered AL1 (At least 18 yrs old)
levofloxacin 250 mg tablet 500 mgtablet 750 mg tablet
1-Covered AL1 (At least 18 yrs old)
moxifloxacin hcl 400 mg tablet 1-Covered PA AL1 (At least 18 yrs old)
ofloxacin 03 drops 1-Covered QL (5 PER 30 DAY(S))
SULFONAMIDESBLEPH-10 (sulfacetamide sodium) - EYE DROPS
1-Covered
silver sulfadiazine 1 cream (g) 1-Covered
SSD (silver sulfadiazine) 1 CREAM 1-Covered
sulfacetamide sodium 10 oint(g) 10 drops
1-Covered
sulfamethoxazoletrimethoprim200-40mg5 oral susp 400mg-80mgtablet 800-16020 oral susp 800-160 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
13
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SULFATRIM(sulfamethoxazoletrimethoprim)PEDIATRIC SUSPENSION
1-Covered
TETRACYCLINESDOXYCYCLINE HYCLATE 100 MGCAP
1-Covered AL1 (At least 8 yrs old)
doxycycline hyclate 100 mgcapsule
1-Covered AL1 (At least 8 yrs old)
DOXYCYCLINE HYCLATE 20 MG TAB 1-Covered QL (60 PER 30 DAYS)
doxycycline hyclate 20 mg tablet 1-Covered QL (60 PER 30 DAYS)
doxycycline monohydrate 50 mgcapsule 100 mg capsule
1-Covered AL1 (At least 8 yrs old)
minocycline hcl 50 mg capsule100 mg capsule
1-Covered
ANTICONVULSANTS (Drugs for Seizures)
ANTICONVULSANTS OTHER (Other Seizure Control Drugs)LEVETIRACETAM 100 MGML SOLN250 MG TABLET 500 MG5 ML SOLN
1-Covered
levetiracetam 100 mgml solution250 mg tablet 500 mg tablet 500mg5ml solution 750 mg tablet1000 mg tablet
1-Covered
levetiracetam 500 mg tab er 24h 1-Covered MDD (6 Per Day)
levetiracetam 750 mg tab er 24h 1-Covered QL (120 PER 30 DAY(S))
LEVETIRACETAM ER 500 MG TABLET 1-Covered MDD (6 Per Day)
LEVETIRACETAM ER 750 MG TABLET 1-Covered QL (120 PER 30 DAY(S))
CALCIUM CHANNEL MODIFYING AGENTSCELONTIN (methsuximide) 300 MGKAPSEAL
1-Covered
ETHOSUXIMIDE 250 MG CAPSULE 1-Covered
ethosuximide 250 mg5ml solution250 mg capsule
1-Covered
zonisamide 25 mg capsule 50 mgcapsule 100 mg capsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
14
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTSDEPAKENE (valproic acid (assodium salt) (valproate sodium))250 MG5 ML SOLUTION
1-Covered
DEPAKENE (valproic acid) 250 MGCAPSULE
1-Covered
diazepam 5-75-10mg kit 1-Covered
divalproex sodium 125 mg tabletdr 125 mg cap dr spr 250 mgtablet dr 500 mg tablet dr
1-Covered
DIVALPROEX SODIUM DR 125 MGCAP SPRNK
1-Covered
gabapentin 100 mg capsule 250mg5ml solution 300 mg capsule400 mg capsule 600 mg tablet800 mg tablet
1-Covered
GABAPENTIN 100 MG CAPSULE 300MG CAPSULE 400 MG CAPSULE
1-Covered
phenobarbital 15 mg tablet 20mg5 ml elixir 30 mg tablet 324mg tablet 60 mg tablet 648 mgtablet 972mg tablet 100 mgtablet
1-Covered
PHENOBARBITAL 20 MG5 ML SOLN324 MG TABLET 648 MG TABLET972 MG TABLET
1-Covered
primidone 50 mg tablet 250 mgtablet
1-Covered
valproic acid (as sodium salt)(valproate sodium) 250 mg5ml500mg10ml
1-Covered
valproic acid 250 mg capsule 1-Covered
VALPROIC ACID 250 MG CAPSULE 1-Covered
GLUTAMATE REDUCING AGENTSlamotrigine 25 mg tablet 100 mgtablet 150 mg tablet 200 mgtablet
1-Covered
lamotrigine 5 mg 25 mg 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
15
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
topiramate 15 mg cap sprink 25mg tablet 25 mg cap sprink 50mg tablet 100 mg tablet 200 mgtablet
1-Covered
TOPIRAMATE 25 MG TABLET 50 MGTABLET 100 MG TABLET 200 MGTABLET
1-Covered
SODIUM CHANNEL AGENTScarbamazepine (EPITOL) 200 mgtablet
1-Covered
carbamazepine 100 mg cpmp12hr 100 mg5ml oral susp 100 mgtab chew 100 mg tab er 12h 200mg cpmp 12hr 200 mg tab er 12h200 mg tablet 300 mg cpmp 12hr400 mg tab er 12h
1-Covered
CARBATROL (carbamazepine) ER100 MG CAPSULE ER 200 MGCAPSULE ER 300 MG CAPSULE
1-Covered
DILANTIN (phenytoin sodiumextended) 30 MG CAPSULE 100MG CAPSULE
1-Covered
DILANTIN (phenytoin) 50 MGINFATAB
1-Covered
DILANTIN-125 (phenytoin) MG5 MLSUSP
1-Covered
DILANTIN-125 MG5 ML SUSP 1-Covered
oxcarbazepine 150 mg tablet 300mg tablet 600 mg tablet
1-Covered
phenytoin 50 mg tab chew 100mg4ml oral susp 125 mg5ml oralsusp
1-Covered
phenytoin sodium extended 100mg capsule
1-Covered
TEGRETOL (carbamazepine) 100MG5 ML SUSP 200 MG TABLET
1-Covered
TEGRETOL XR (carbamazepine) 100MG TABLET 200 MG TABLET 400MG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
16
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIDEMENTIA AGENTS (Drugs for Alzheimers Disease andDementia)
CHOLINESTERASE INHIBITORSdonepezil hcl 5 mg tab rapdis 5mg tablet 10 mg tab rapdis 10mg tablet
1-Covered
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine hcl 5 mg tablet 10 mgtablet
1-Covered
MEMANTINE HCL 5 MG TABLET 10MG TABLET
1-Covered
ANTIDEPRESSANTS (Drugs for Depression)
ANTIDEPRESSANTS OTHERbupropion hcl 100 mg tab 150 mgtab 200 mg tab
1-Covered QL (60 PER 30 DAYS)
bupropion hcl 150 mg tab er 300mg tab er
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
bupropion hcl 75 mg tablet 100mg tablet
1-Covered
BUPROPION HCL SR SR 100 MGTABLET SR 150 MG TABLET SR 200MG TABLET
1-Covered QL (60 PER 30 DAYS)
BUPROPION XL 150 MG TABLET 300MG TABLET
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
mirtazapine 15 mg tab rapdis 1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old)
mirtazapine 15 mg tablet 30 mgtab rapdis 30 mg tablet 45 mgtab rapdis 45 mg tablet
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
olanzapinefluoxetine hcl 3 mg-25mg capsule 6mg-25mg capsule6mg-50mg capsule 12mg-50mgcapsule 12mg-25mg capsule
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
17
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SYMBYAX (olanzapinefluoxetinehcl) 3-25 MG CAPSULE 6-50 MGCAPSULE 6-25 MG CAPSULE 12-50MG CAPSULE 12-25 MG CAPSULE
2-MedicalCarve out
MONOAMINE OXIDASE INHIBITORSEMSAM (selegiline) 6 MG24PATCH 9 MG24 PATCH 12 MG24PATCH
2-MedicalCarve out
MARPLAN (isocarboxazid) 10 MGTABLET
2-MedicalCarve out
NARDIL (phenelzine sulfate) 15 MGTABLET
2-MedicalCarve out
PARNATE (tranylcypromine sulfate)10 MG TABLET
2-MedicalCarve out
phenelzine sulfate 15 mg tablet 2-MedicalCarve out
tranylcypromine sulfate 10 mgtablet
2-MedicalCarve out
SSRISSNRIS (SELECTIVE SEROTONIN REUPTAKEINHIBITORSEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)
citalopram hydrobromide 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
escitalopram oxalate 5 mg tablet10 mg tablet 20 mg tablet
1-Covered
ESCITALOPRAM OXALATE 5 MGTABLET 10 MG TABLET 20 MGTABLET
1-Covered
fluoxetine hcl 10 mg capsule 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
fluoxetine hcl 20 mg capsule 1-Covered QL (120 PER 30 DAY(S))
fluoxetine hcl 20 mg5 ml solution 1-Covered
FLUOXETINE HCL 20 MG5 MLSOLUTION
1-Covered
fluvoxamine maleate 25 mg tablet50 mg tablet 100 mg tablet
1-Covered AL1 (At least 8 yrs old)
paroxetine hcl 10 mg tablet 20 mgtablet 30 mg tablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
sertraline hcl 25 mg tablet 50 mgtablet 100 mg tablet
1-Covered QL (60 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
18
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRAZODONE HCL 50 MG TABLET100 MG TABLET
1-Covered
trazodone hcl 50 mg tablet 100mg tablet 150 mg tablet
1-Covered
venlafaxine hcl 25 mg tablet 375mg tablet 50 mg tablet 75 mgtablet 100 mg tablet
1-Covered QL (60 PER 30 DAYS)
venlafaxine hcl 375 mg cap er 75mg cap er 150 mg cap er
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
VENLAFAXINE HCL ER ER 375 MGCAP ER 75 MG CAP ER 150 MGCAP
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
TRICYCLICSamitriptyline hcl 10 mg tablet 25mg tablet 50 mg tablet 75 mgtablet 100 mg tablet 150 mgtablet
1-Covered
amoxapine 25 mg tablet 50 mgtablet 100 mg tablet 150 mgtablet
1-Covered
clomipramine hcl 25 mg capsule50 mg capsule 75 mg capsule
1-Covered PA
CLOMIPRAMINE HCL 25 MGCAPSULE 50 MG CAPSULE 75 MGCAPSULE
1-Covered PA
desipramine hcl 10 mg tablet 25mg tablet 50 mg tablet 75 mgtablet 100 mg tablet 150 mgtablet
1-Covered
DOXEPIN HCL 10 MG CAPSULE 25MG CAPSULE 50 MG CAPSULE 75MG CAPSULE 100 MG CAPSULE
1-Covered
doxepin hcl 10 mgml oral conc10 mg capsule 25 mg capsule 50mg capsule 75 mg capsule 100mg capsule 150 mg capsule
1-Covered
imipramine hcl 10 mg tablet 25mg tablet 50 mg tablet
1-Covered
IMIPRAMINE HCL 10 MG TABLET 25MG TABLET 50 MG TABLET
1-Covered
nortriptyline hcl 10 mg capsule 25mg capsule 50 mg capsule 75 mgcapsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
19
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIEMETICS (Drugs for Nausea and Vomiting)
ANTIEMETICS OTHER (Other Drugs for Nausea and Vomiting)meclizine hcl (DRAMAMINE LESSDROWSY) 25 mg tablet
1-Covered
meclizine hcl (MEDI-MECLIZINE) 25mg tablet -
1-Covered
meclizine hcl (MOTION RELIEF) 25mg tablet
1-Covered
meclizine hcl (MOTION SICKNESS II)25 mg tablet
1-Covered
meclizine hcl (MOTION SICKNESSRELIEF) 25 mg tablet 25 mg tabchew
1-Covered
meclizine hcl (MOTION SICKNESS)25 mg tablet
1-Covered
meclizine hcl (MOTION-TIME) 25 mgtab chew -
1-Covered
meclizine hcl (TRAVEL-EASE) 25 mgtablet -
1-Covered
meclizine hcl (VERTICALM) 25 mgtablet
1-Covered
meclizine hcl (WAL-DRAM 2) 25 mgtablet -
1-Covered
MECLIZINE HCL 125 MG CAPLET 25MG TABLET CHEW
1-Covered
meclizine hcl 125 mg tablet 25mg tab chew 25 mg tablet
1-Covered
metoclopramide hcl 5 mg tablet 5mg5 ml solution 10 mg tablet 10mg10ml solution
1-Covered
perphenazine 2 mg tablet 4 mgtablet 8 mg tablet 16 mg tablet
2-MedicalCarve out
prochlorperazine (COMPRO) 25mg supprect
1-Covered
prochlorperazine 25 mg supprect 1-Covered
prochlorperazine maleate 5 mgtablet 10 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
20
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
promethazine hcl (PHENADOZ)125 mg 25 mg
1-Covered
promethazine hcl (PROMETHEGAN)125 mg 25 mg 50 mg
1-Covered
promethazine hcl 125 mgsupprect 25 mg supprect 50 mgtablet 50 mg supprect
1-Covered
TRAVEL SICKNESS (meclizine hcl) 25MG TAB CHEW
1-Covered
trimethobenzamide hcl 300 mgcapsule
1-Covered
EMETOGENIC THERAPY ADJUNCTS (Drugs for Nausea and Vomiting)aprepitant 40 mg capsule 80 mgcapsule 125mg-80mg cap ds pk125 mg capsule
1-Covered PA
dronabinol 25 mg capsule 5 mgcapsule 10 mg capsule
1-Covered PA
granisetron hcl 1 mg tablet 1-Covered PA
ondansetron 4 mg tab rapdis 8mg tab rapdis
1-Covered QL (12 PER FILL(S)) MDD (3 PerDay) QLC (LIMIT TO 2 FILLS OF 12TABLETS IN 30 DAYS)
ondansetron hcl 4 mg tablet 8 mgtablet
1-Covered QL (12 PER FILL(S)) MDD (3 PerDay) QLC (LIMIT TO 2 FILLS OF 12TABLETS IN 30 DAYS)
ondansetron hcl 4 mg5 mlsolution 24 mg tablet
1-Covered PA
ANTIFUNGALS (Drugs for Fungal Infections)
ANTIFUNGALSANTIFUNGAL 1 TOPICAL CREAM 1-Covered
ATHLETES FOOT (terbinafine hcl) 1CREAM
1-Covered
ciclopirox 077 gel (gram) 1-Covered QLC (100 GRAMSMONTH)
ciclopirox 1 shampoo 1-Covered QLC (120 ozMONTH)
ciclopirox 8 solution 1-Covered
ciclopirox olamine 077 cream(g)
1-Covered QLC (90 GRAMSMONTH)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
21
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ciclopirox olamine 077 suspension
1-Covered QLC (60 MLMONTH)
clotrimazole (ANTIFUNGALRINGWORM) 1 cream (g)
1-Covered
clotrimazole (ANTIFUNGAL) 1 cream (g)
1-Covered
clotrimazole (ATHLETES FOOT) 1 cream (g)
1-Covered
clotrimazole (ATHLETIC FOOTCREAM) 1 cream (g)
1-Covered
clotrimazole (CLOTRIMAZOLE AF) 1 cream (g)
1-Covered
clotrimazole (ITCH RELIEF) 1 cream (g)
1-Covered
clotrimazole (JOCK ITCH RELIEF) 1 cream (g)
1-Covered
clotrimazole (JOCK ITCH) 1 cream (g)
1-Covered
clotrimazole (RINGWORM) 1 cream (g)
1-Covered
clotrimazole 1 cream (g) 1 solution 1 creamappl 10 mgtroche
1-Covered
CLOTRIMAZOLE 1 SOLUTION 1TOPICAL CREAM
1-Covered
fluconazole 10 mgml 40 mgml 1-Covered QL (70 PER 30 DAY(S))
fluconazole 150 mg tablet 1-Covered QL (2 PER 30 DAY(S))
FLUCONAZOLE 200 MG TABLET 1-Covered
fluconazole 50 mg tablet 100 mgtablet 200 mg tablet
1-Covered
fluconazole in dextrose iso-osmotic in dextreiso-200mg01l indextreiso-400mg02l
1-Covered PA
flucytosine 250 mg capsule 500mg capsule
1-Covered
FLUCYTOSINE 250 MG CAPSULE500 MG CAPSULE
1-Covered
griseofulvin ultramicrosize 125 mgtablet 250 mg tablet
1-Covered QL (60 PER 30 DAYS) AL1 (Up to18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
22
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
griseofulvin microsize 125 mg5mloral susp
1-Covered AL1 (Up to 12 yrs old) MDD (20Per Day)
griseofulvin microsize 500 mgtablet
1-Covered QL (60 PER 30 DAYS) AL1 (Up to18 yrs old)
itraconazole 100 mg capsule 1-Covered PA
ketoconazole 2 cream (g) 2 shampoo
1-Covered
ketoconazole 200 mg tablet 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
LAMISIL (terbinafine hcl)ANTIFUNGAL 1 SPRAY
1-Covered
LOTRIMIN AF (clotrimazole) 1CREAM
1-Covered
miconazole nitrate (ANTI-FUNGALCREAM) 2 cream (g) -
1-Covered
miconazole nitrate (ANTIFUNGALCREAM) 2 cream (g)
1-Covered
miconazole nitrate (BAZAANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate (INZOANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate (LOTRIMIN AF) 2 spray
1-Covered
miconazole nitrate (MICATIN) 2 cream (g)
1-Covered
miconazole nitrate (SECURAANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate 2 aero powd2 creamappl 2 cream (g)100 mg suppvag
1-Covered
MONISTAT 3 (miconazole nitrate)4 CREAM
1-Covered
MONISTAT 7 (miconazole nitrate)CREAM
1-Covered
NYSTATIN 100000 UNITGM CREAM100000 UNITGM OINT 100000UNITML SUSP 500000 UNIT5 MLSUS
1-Covered
nystatin 500k unit tablet 100000mloral susp 100000g cream (g)100000g oint (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
23
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terbinafine hcl (ANTIFUNGAL) 1 cream (g)
1-Covered
terbinafine hcl (ATHLETES FOOT AF)1 cream (g)
1-Covered
terbinafine hcl (ATHLETES FOOT) 1 cream (g)
1-Covered
terbinafine hcl (JOCK ITCH) 1 cream (g)
1-Covered
terbinafine hcl (LAMISIL AT) 1 cream (g)
1-Covered
terbinafine hcl 1 cream (g) 250mg tablet
1-Covered
tioconazole 65 oinpf app 1-Covered
tolnaftate (ANTIFUNGAL CREAM) 1 cream (g)
1-Covered
tolnaftate (ATHLETES FOOT) 1 cream (g)
1-Covered
tolnaftate (FUNGOID-D) 1 cream(g) -
1-Covered
tolnaftate 1 cream (g) 1-Covered
ANTIGOUT AGENTS (Drugs for Gout)
ANTIGOUT AGENTSallopurinol 100 mg tablet 300 mgtablet
1-Covered
ALLOPURINOL 100 MG TABLET 300MG TABLET
1-Covered
colchicine 06 mg tablet 1-Covered
COLCHICINE 06 MG TABLET 1-Covered
probenecid 500 mg tablet 1-Covered
probenecidcolchicine 500-05 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
24
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIMIGRAINE AGENTS (Drugs for Migraine)
ERGOT ALKALOIDSergotamine tartratecaffeine 1mg-100mg tablet
1-Covered
SEROTONIN (5-HT) 1B1D RECEPTOR AGONISTSrizatriptan benzoate 5 mg tablet10 mg tablet
1-Covered QL (12 PER 30 DAY(S)) AL1 (Atleast 6 yrs old)
SUMATRIPTAN 5 MG SPRAY 20 MGSPRAY
1-Covered QL (6 PER 30 DAY(S))
sumatriptan 5 mg 20 mg 1-Covered QL (6 PER 30 DAY(S))
sumatriptan succinate 25 mgtablet 50 mg tablet 100 mg tablet
1-Covered QL (9 PER 30 DAY(S))
SUMATRIPTAN SUCCINATE 25 MGTABLET 50 MG TABLET 100 MGTABLET
1-Covered QL (9 PER 30 DAY(S))
SUMATRIPTAN SUCCINATE 6 MG05ML CART
1-Covered QL (2 PER FILL(S)) MFL (1 30day(s))
SUMATRIPTAN SUCCINATE 6 MG05ML INJECT
1-Covered QL (2 PER 30 DAY(S)) MFL (1 30day(s))
sumatriptan succinate 6 mg05mlcartridge 6 mg05ml vial
1-Covered QL (2 PER FILL(S)) MFL (1 30day(s))
sumatriptan succinate 6 mg05mlpen injctr 6 mg05ml syringe
1-Covered QL (2 PER 30 DAY(S)) MFL (1 30day(s))
ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis)
PARASYMPATHOMIMETICSMESTINON (pyridostigminebromide) 60 MG5 ML SOLUTION
1-Covered
pyridostigmine bromide 60 mg5ml solution 60 mg tablet 180 mgtablet er
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
25
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections)
ANTIMYCOBACTERIALS OTHER (Other Drugs for MycobacterialInfection)
dapsone 25 mg tablet 100 mgtablet
1-Covered
rifabutin 150 mg capsule 1-Covered
ANTITUBERCULARS (Drugs for Tuberculosis)ethambutol hcl 100 mg tablet 400mg tablet
1-Covered
ETHAMBUTOL HCL 100 MG TABLET400 MG TABLET
1-Covered
isoniazid 50 mg5 ml solution 100mg tablet 300 mg tablet
1-Covered
PRIFTIN (rifapentine) 150 MG TABLET 1-Covered AL1 (At least 12 yrs old)
pyrazinamide 500 mg tablet 1-Covered
rifampin 150 mg capsule 300 mgcapsule
1-Covered
ANTINEOPLASTICS (Drugs for Cancer)
ALKYLATING AGENTScyclophosphamide 25 mgcapsule 50 mg capsule
1-Covered PA
CYCLOPHOSPHAMIDE 25 MGCAPSULE 50 MG CAPSULE
1-Covered PA
GLEOSTINE (lomustine) 10 MGCAPSULE 40 MG CAPSULE 100 MGCAPSULE
1-Covered PA
HEXALEN (altretamine) 50 MGCAPSULE
1-Covered
LEUKERAN (chlorambucil) 2 MGTABLET
1-Covered PA
MATULANE (procarbazine hcl) 50MG CAPSULE
1-Covered PA SP
melphalan 2 mg tablet 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
26
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
MYLERAN (busulfan) 2 MG TABLET 1-Covered
temozolomide 20 mg capsule 1-Covered PA SP
ANTIANDROGENSbicalutamide 50 mg tablet 1-Covered PA
flutamide 125 mg capsule 1-Covered PA
ANTIANGIOGENIC AGENTSTHALOMID (thalidomide) 50 MGCAPSULE
1-Covered PA SP
ANTIESTROGENSMODIFIERSEMCYT (estramustine phosphatesodium) 140 MG CAPSULE
1-Covered PA
TAMOXIFEN CITRATE 10 MG TABLET 1-Covered
tamoxifen citrate 10 mg tablet 20mg tablet
1-Covered
TOREMIFENE CITRATE 60 MG TAB 1-Covered PA
toremifene citrate 60 mg tablet 1-Covered PA
ANTIMETABOLITEScapecitabine 500 mg tablet 1-Covered PA SP
CAPECITABINE 500 MG TABLET 1-Covered PA SP
DROXIA (hydroxyurea) 200 MGCAPSULE 300 MG CAPSULE 400MG CAPSULE
1-Covered
fluorouracil (ADRUCIL) 25 g50mlvial 5 g100 ml vial
1-Covered PA
hydroxyurea 500 mg capsule 1-Covered PA
mercaptopurine 50 mg tablet 1-Covered PA
TABLOID (thioguanine) 40 MGTABLET
1-Covered PA
ANTINEOPLASTICS OTHERLEUCOVORIN CALCIUM 5 MG TAB25 MG TAB
1-Covered
leucovorin calcium 5 mg tablet 10mg tablet 15 mg tablet 25 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
27
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LYSODREN (mitotane) 500 MGTABLET
1-Covered PA
AROMATASE INHIBITORS 3RD GENERATIONanastrozole 1 mg tablet 1-Covered
ANASTROZOLE 1 MG TABLET 1-Covered
letrozole 25 mg tablet 1-Covered
ENZYME INHIBITORSetoposide 50 mg capsule 1-Covered PA
MOLECULAR TARGET INHIBITORSJAKAFI (ruxolitinib phosphate) 5MG TABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET 25 MGTABLET
1-Covered PA SP QL (2 PER 1 DAY(S))
RETINOIDStretinoin 10 mg capsule 1-Covered PA
ANTIPARASITICS (Drugs for Parasitic Infections)
ANTIHELMINTHICS (Drugs for Worm Infection)mebendazole (EMVERM) 100 mgtab chew
1-Covered
praziquantel 600 mg tablet 1-Covered
ANTIPROTOZOALS (Drugs for Protozoal Infection)chloroquine phosphate 250 mgtablet
1-Covered QL (25 PER 30 DAY(S))
chloroquine phosphate 500 mgtablet
1-Covered PA QL (25 PER 30 DAY(S))
HYDROXYCHLOROQUINE SULFATE200 MG TAB
1-Covered QL (3 PER 1 DAY(S))
hydroxychloroquine sulfate 200 mgtablet
1-Covered QL (3 PER 1 DAY(S))
mefloquine hcl 250 mg tablet 1-Covered
primaquine phosphate 263 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
28
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PEDICULICIDESSCABICIDES (Drugs for Scabies and Lice)permethrin (LICE TREATMENT) 1 liquid
1-Covered
permethrin 5 cream (g) 1-Covered
ANTIPARKINSON AGENTS (Drugs for Parkinsons Disease)
ANTICHOLINERGICSbenztropine mesylate 05 mgtablet 1 mg tablet 2 mg tablet 2mg2 ml ampul 2 mg2 ml vial
2-MedicalCarve out
COGENTIN (benztropine mesylate)2 MG2 ML AMPULE
2-MedicalCarve out
trihexyphenidyl hcl 2 mg5 ml elixir2 mg tablet 5 mg tablet
2-MedicalCarve out
ANTIPARKINSON AGENTS OTHERAMANTADINE 100 MG CAPSULE 2-Medical
Carve out
amantadine hcl 50 mg5 mlsolution 100 mg capsule 100 mgtablet
2-MedicalCarve out
entacapone 200 mg tablet 1-Covered ST
GOCOVRI (amantadine hcl) ER685 MG CAPSULE ER 137 MGCAPSULE
2-MedicalCarve out
OSMOLEX ER (amantadine hcl) ER129 MG TABLET ER 193 MG TABLETER 258 MG TABLET ER 322 MGDAILY DOSE
2-MedicalCarve out
DOPAMINE AGONISTSbromocriptine mesylate 25 mgtablet
1-Covered
pramipexole di-hcl -0125 mgtablet -025 mg tablet -05 mgtablet -075 mg tablet -1 mgtablet -15 mg tablet
1-Covered
ropinirole hcl 025 mg tablet 05mg tablet 1 mg tablet 2 mgtablet 3 mg tablet 4 mg tablet 5mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
29
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DOPAMINE PRECURSORSL-AMINO ACID DECARBOXYLASEINHIBITORS
carbidopalevodopa 10mg-100mgtablet 25mg-100mg tablet 25mg-100mg tablet er 25mg-250mgtablet 50mg-200mg tablet er
1-Covered
MONOAMINE OXIDASE B (MAO-B) INHIBITORSselegiline hcl 5 mg tablet 5 mgcapsule
1-Covered
ANTIPSYCHOTICS (Drugs for Mental Health)
1ST GENERATIONTYPICALADASUVE (loxapine) 10 MG POWD10 MG POWDR
2-MedicalCarve out
chlorpromazine hcl 10 mg tablet25 mg tablet 25 mgml ampul 50mg tablet 100 mg tablet 200 mgtablet
2-MedicalCarve out
CHLORPROMAZINE HCL 10 MGTABLET 25 MGML AMPULE 25 MGTABLET 50 MG TABLET 50 MG2 MLAMP 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
fluphenazine decanoate 25 mgmlvial
2-MedicalCarve out
fluphenazine hcl 1 mg tablet 25mg tablet 25 mg5ml elixir 25mgml vial 5 mgml oral conc 5mg tablet 10 mg tablet
2-MedicalCarve out
FLUPHENAZINE HCL 1 MG TABLET25 MG TABLET 5 MG TABLET 10MG TABLET
2-MedicalCarve out
HALDOL (haloperidol lactate) 5MGML AMPUL
2-MedicalCarve out
HALDOL DECANOATE 100(haloperidol decanoate) AMPUL
2-MedicalCarve out
HALDOL DECANOATE 50(haloperidol decanoate) AMPUL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
30
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
haloperidol 05 mg tablet 1 mgtablet 2 mg tablet 5 mg tablet 10mg tablet 20 mg tablet
2-MedicalCarve out
HALOPERIDOL 5 MG TABLET 2-MedicalCarve out
haloperidol decanoate 50 mgmlvial 50 mgml ampul 100 mgmlampul 100 mgml vial
2-MedicalCarve out
haloperidol lactate 2 mgml oralconc 5 mgml vial 5 mgmlampul 5 mgml syringe
2-MedicalCarve out
HALOPERIDOL LACTATE 5 MGMLSYRING
2-MedicalCarve out
loxapine succinate 5 mg capsule10 mg capsule 25 mg capsule 50mg capsule
2-MedicalCarve out
molindone hcl 5 mg tablet 10 mgtablet 25 mg tablet
2-MedicalCarve out
ORAP (pimozide) 1 MG TABLET 2MG TABLET
2-MedicalCarve out
pimozide 1 mg tablet 2 mg tablet 2-MedicalCarve out
thioridazine hcl 10 mg tablet 25mg tablet 50 mg tablet 100 mgtablet
2-MedicalCarve out
thiothixene 1 mg capsule 2 mgcapsule 5 mg capsule 10 mgcapsule
2-MedicalCarve out
trifluoperazine hcl 1 mg tablet 2mg tablet 5 mg tablet 10 mgtablet
2-MedicalCarve out
2ND GENERATIONATYPICALABILIFY (aripiprazole) 2 MG TABLET5 MG TABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET 30 MGTABLET
2-MedicalCarve out
ABILIFY MAINTENA (aripiprazole) ER300 MG VL ER 300 MG SYR ER 400MG SYR ER 400 MG VL
2-MedicalCarve out
ABILIFY MYCITE (aripiprazole) 2 MGKIT 5 MG KIT 10 MG KIT 15 MG KIT20 MG KIT 30 MG KIT
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
31
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
aripiprazole 1 mgml solution 2 mgtablet 5 mg tablet 10 mg tabrapdis 10 mg tablet 15 mg tablet15 mg tab rapdis 20 mg tablet 30mg tablet
2-MedicalCarve out
ARIPIPRAZOLE 1 MGML SOLUTION2 MG TABLET 5 MG TABLET 10 MGTABLET 15 MG TABLET 20 MGTABLET 30 MG TABLET
2-MedicalCarve out
ARISTADA (aripiprazole lauroxil) ER441 MG16 ML SYRN ER 662MG24 ML SYRN ER 882 MG32ML SYRN ER 1064 MG39 ML SYR
2-MedicalCarve out
ARISTADA INITIO (aripiprazolelauroxil submicronized) ER 675MG24
2-MedicalCarve out
CAPLYTA (lumateperone tosylate)42 MG CAPSULE
2-MedicalCarve out
FANAPT (iloperidone) 1 MG TABLET2 MG TABLET 4 MG TABLET 6 MGTABLET 8 MG TABLET 10 MGTABLET 12 MG TABLET TITRATIONPACK
2-MedicalCarve out
GEODON (ziprasidone hcl) 20 MGCAPSULE 40 MG CAPSULE 60 MGCAPSULE 80 MG CAPSULE
2-MedicalCarve out
GEODON (ziprasidone mesylate)20 MGML VIAL
2-MedicalCarve out
INVEGA (paliperidone) ER 15 MGTABLET ER 3 MG TABLET ER 6 MGTABLET ER 9 MG TABLET
2-MedicalCarve out
INVEGA SUSTENNA (paliperidonepalmitate) 39 MG025 ML 78MG05 ML 117 MG075 ML 156MGML SYRG 234 MG15 ML
2-MedicalCarve out
INVEGA TRINZA (paliperidonepalmitate) 273 MG0875 ML 410MG1315 ML 546 MG175 ML 819MG2625 ML
2-MedicalCarve out
LATUDA (lurasidone hcl) 20 MGTABLET 40 MG TABLET 60 MGTABLET 80 MG TABLET 120 MGTABLET
2-MedicalCarve out
NUPLAZID (pimavanserin tartrate)10 MG TABLET 17 MG TABLET 34MG CAPSULE
2-MedicalCarve out
SP
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
32
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
olanzapine 25 mg tablet 5 mgtab rapdis 5 mg tablet 75 mgtablet 10 mg tab rapdis 10 mgtablet 10 mg vial 15 mg tabrapdis 15 mg tablet 20 mg tablet20 mg tab rapdis
2-MedicalCarve out
paliperidone 15 mg tab er 24 3mg tab er 24 6 mg tab er 24 9 mgtab er 24
2-MedicalCarve out
PERSERIS (risperidone) ER 90 MGSYRINGE KIT ER 120 MG SYRINGEKIT
2-MedicalCarve out
quetiapine fumarate 25 mg tablet50 mg tab er 24h 50 mg tablet100 mg tablet 150 mg tab er 24h200 mg tab er 24h 200 mg tablet300 mg tablet 300 mg tab er 24h400 mg tab er 24h 400 mg tablet
2-MedicalCarve out
REXULTI (brexpiprazole) 025 MGTABLET 05 MG TABLET 1 MGTABLET 2 MG TABLET 3 MG TABLET4 MG TABLET
2-MedicalCarve out
RISPERDAL (risperidone) 025 MGTABLET 05 MG TABLET 1 MGMLSOLUTION 1 MG TABLET 2 MGTABLET 3 MG TABLET 4 MG TABLET
2-MedicalCarve out
RISPERDAL CONSTA (risperidonemicrospheres) 125 MG VIAL 25MG VIAL 375 MG VIAL 50 MGVIAL
2-MedicalCarve out
RISPERDAL M-TAB (risperidone) -TAB05 G ODT -TAB 1 G ODT -TAB 2 GODT -TAB 3 G ODT -TAB 4 G ODT
2-MedicalCarve out
risperidone 025 mg tab rapdis025 mg tablet 05 mg tab rapdis05 mg tablet 1 mg tablet 1mgml solution 1 mg tab rapdis 2mg tab rapdis 2 mg tablet 3 mgtablet 3 mg tab rapdis 4 mg tabrapdis 4 mg tablet
2-MedicalCarve out
SAPHRIS (asenapine maleate) 25MG TAB 5 MG TAB 10 MG TAB
2-MedicalCarve out
SECUADO (asenapine) 38 MG24HR PATCH 57 MG24 HR PATCH76 MG24 HR PATCH
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
33
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SEROQUEL (quetiapine fumarate)25 MG TABLET 50 MG TABLET 100MG TABLET 200 MG TABLET 300MG TABLET 400 MG TABLET
2-MedicalCarve out
SEROQUEL XR (quetiapinefumarate) 50 MG TABLET 150 MGTABLET 200 MG TABLET 300 MGTABLET 400 MG TABLET
2-MedicalCarve out
VRAYLAR (cariprazine hcl) 15 MG-3 MG PACK 15 MG CAPSULE 3MG CAPSULE 45 MG CAPSULE 6MG CAPSULE
2-MedicalCarve out
ziprasidone hcl 20 mg capsule 40mg capsule 60 mg capsule 80 mgcapsule
2-MedicalCarve out
ZIPRASIDONE HCL 20 MG CAPSULE40 MG CAPSULE 60 MG CAPSULE80 MG CAPSULE
2-MedicalCarve out
ZIPRASIDONE MESYLATE 20 MGMLVIAL
2-MedicalCarve out
ziprasidone mesylate fnl 20mg1vial
2-MedicalCarve out
ZYPREXA (olanzapine) 25 MGTABLET 5 MG TABLET 75 MGTABLET 10 MG VIAL 10 MG TABLET15 MG TABLET 20 MG TABLET
2-MedicalCarve out
ZYPREXA RELPREVV (olanzapinepamoate) 210 MG VL KIT 300 MGVL KIT 405 MG VL KIT
2-MedicalCarve out
ZYPREXA ZYDIS (olanzapine) 5 MGTABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET
2-MedicalCarve out
TREATMENT-RESISTANTclozapine 125 mg tab rapdis 25mg tab rapdis 25 mg tablet 50mg tablet 100 mg tablet 100 mgtab rapdis 150 mg tab rapdis 200mg tablet 200 mg tab rapdis
2-MedicalCarve out
CLOZAPINE 25 MG TABLET 50 MGTABLET 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
CLOZAPINE ODT ODT 150 MGTABLET ODT 200 MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
34
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CLOZARIL (clozapine) 25 MGTABLET 50 MG TABLET 100 MGTABLET 200 MG TABLET
2-MedicalCarve out
FAZACLO (clozapine) 125 MGODT 25 MG ODT 100 MG ODT 150MG ODT 200 MG ODT
2-MedicalCarve out
VERSACLOZ (clozapine) 50 MGMLSUSPENSION
2-MedicalCarve out
ANTISPASTICITY AGENTS (Drugs for Muscle Spasm)baclofen 10 mg tablet 20 mgtablet
1-Covered QL (90 PER 30 DAYS)
BACLOFEN 10 MG TABLET 20 MGTABLET
1-Covered QL (90 PER 30 DAYS)
tizanidine hcl 2 mg tablet 4 mgtablet
1-Covered QL (90 PER 30 DAY(S))
ANTIVIRALS (Drugs for Viral Infections)
ANTI-HEPATITIS B (HBV) AGENTSEPIVIR HBV (lamivudine) 100 MGTABLET
2-MedicalCarve out
EPIVIR HBV (lamivudine) 25 MG5ML SOLN
1-Covered PA
lamivudine 100 mg tablet 1-Covered PA
VEMLIDY (tenofovir alafenamide)25 MG TABLET
2-MedicalCarve out
ANTI-HEPATITIS C (HCV) AGENTS DIRECT ACTING AGENTSsofosbuvirvelpatasvir 400-100 mgtablet
1-Covered PA SP
ANTI-HEPATITIS C (HCV) AGENTS OTHERINTRON A (interferon alfa-2brecomb) 10 MILLION UNITS VIL -18 MILLION UNITS VIL - 18 MILLIONUNIT3 ML - 25 MILLION UNIT25ML- 50 MILLION UNITS VIL -
1-Covered PA SP
PEGINTRON REDIPEN(peginterferon alfa-2b) 50 MCG -
1-Covered PA SP
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
35
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ribavirin (RIBASPHERE) 200 mgtablet
1-Covered PA
ribavirin 200 mg tablet 1-Covered PA
ANTI-HIV AGENTSCIMDUO (lamivudinetenofovirdisoproxil fumarate) 300-300 MGTABLET
2-MedicalCarve out
EFAVIRENZ-LAMIVU-TENOFOVDISOP --600-300-300
2-MedicalCarve out
SYMFI(efavirenzlamivudinetenofovirdisoproxil fumarate) 600-300-300MG TABLET
2-MedicalCarve out
TEMIXYS (lamivudinetenofovirdisoproxil fumarate) 300-300 MGTABLET
2-MedicalCarve out
ANTI-HIV AGENTS INTEGRASE INHIBITORS (INSTI)BIKTARVY (bictegravirsodiumemtricitabinetenofoviralafenamide fumar) 50-200-25 MGTABLET
2-MedicalCarve out
GENVOYA(elvitegravircobicistatemtricitabinetenofovir alafenamide) TABLET
2-MedicalCarve out
ISENTRESS (raltegravir potassium) 25MG TABLET CHEW 100 MG TABLETCHEW 100 MG POWDER PACKET400 MG TABLET
2-MedicalCarve out
ISENTRESS HD (raltegravirpotassium) 600 MG TABLET
2-MedicalCarve out
STRIBILD(elvitegravircobicistatemtricitabinetenofovir disoproxil) TABLET
2-MedicalCarve out
TIVICAY (dolutegravir sodium) 10MG TABLET 25 MG TABLET 50 MGTABLET
2-MedicalCarve out
TIVICAY PD 5 MG TAB FOR SUSP 2-MedicalCarve out
VITEKTA (elvitegravir) 85 MGTABLET 150 MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
36
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTI-HIV AGENTS NON-NUCLEOSIDE REVERSE TRANSCRIPTASEINHIBITORS (NNRTI)
ATRIPLA(efavirenzemtricitabinetenofovirdisoproxil fumarate) TABLET
2-MedicalCarve out
COMPLERA(emtricitabinerilpivirinehcltenofovir disoproxil fumarate)TABLET
2-MedicalCarve out
DELSTRIGO(doravirinelamivudinetenofovirdisoproxil fumarate) 100-300-300MG TAB
2-MedicalCarve out
EDURANT (rilpivirine hcl) 25 MGTABLET
2-MedicalCarve out
efavirenz 50 mg capsule 200 mgcapsule 600 mg tablet
2-MedicalCarve out
EFAVIRENZ-EMTRIC-TENOFOVDISOP --600-200-300
2-MedicalCarve out
EFAVIRENZ-LAMIVU-TENOFOVDISOP --400-300-300
2-MedicalCarve out
INTELENCE (etravirine) 25 MGTABLET 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
nevirapine 50 mg5 ml oral susp100 mg tab er 24h 200 mg tablet400 mg tab er 24h
2-MedicalCarve out
ODEFSEY (emtricitabinerilpivirinehcltenofovir alafenamidefumarate) TABLET
2-MedicalCarve out
PIFELTRO (doravirine) 100 MGTABLET
2-MedicalCarve out
RESCRIPTOR (delavirdine mesylate)100 MG TABLET 200 MG TABLET
2-MedicalCarve out
SUSTIVA (efavirenz) 50 MGCAPSULE 200 MG CAPSULE 600MG TABLET
2-MedicalCarve out
SYMFI LO(efavirenzlamivudinetenofovirdisoproxil fumarate) 400-300-300MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
37
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
VIRAMUNE (nevirapine) 50 MG5ML SUSP 200 MG TABLET
2-MedicalCarve out
VIRAMUNE XR (nevirapine) 100 MGTABLET 400 MG TABLET
2-MedicalCarve out
ANTI-HIV AGENTS NUCLEOSIDE AND NUCLEOTIDE REVERSETRANSCRIPTASE INHIBITORS (NRTI)
abacavir sulfate 20 mgml solution300 mg tablet
2-MedicalCarve out
abacavir sulfatelamivudine 600-300mg tablet
2-MedicalCarve out
abacavirsulfatelamivudinezidovudineabacavirlamivudinezidovudine150-300 mg tablet
2-MedicalCarve out
ABACAVIR-LAMIVUDINE -600-300MG
2-MedicalCarve out
COMBIVIR (lamivudinezidovudine)TABLET
2-MedicalCarve out
EMTRICITABINE 200 MG CAPSULE 2-MedicalCarve out
EMTRICITABINE-TENOFOVIR DISOP -TENOFV 200-300MG
2-MedicalCarve out
EMTRIVA (emtricitabine) 10 MGMLSOLUTION 200 MG CAPSULE
2-MedicalCarve out
EPIVIR (lamivudine) 10 MGMLORAL SOLN 150 MG TABLET 300MG TABLET
2-MedicalCarve out
EPZICOM (abacavirsulfatelamivudine) TABLET
2-MedicalCarve out
lamivudine 10 mgml solution 150mg tablet 300 mg tablet
2-MedicalCarve out
lamivudinezidovudine 150-300mgtablet 150-300 mg tablet
2-MedicalCarve out
stavudine 1 mgml soln recon 15mg capsule 20 mg capsule 30 mgcapsule 40 mg capsule
2-MedicalCarve out
tenofovir disoproxil fumarate 300mg tablet
2-MedicalCarve out
TRIZIVIR (abacavirsulfatelamivudinezidovudine)TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
38
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRUVADA (emtricitabinetenofovirdisoproxil fumarate) 100 MG-150MG TABLET 133 MG-200 MGTABLET 167 MG-250 MG TABLET200 MG-300 MG TABLET
2-MedicalCarve out
VIREAD (tenofovir disoproxilfumarate) 150 MG TABLET 200 MGTABLET 250 MG TABLET 300 MGTABLET POWDER
2-MedicalCarve out
ZERIT (stavudine) 1 MGMLSOLUTION 15 MG CAPSULE 20 MGCAPSULE 30 MG CAPSULE 40 MGCAPSULE
2-MedicalCarve out
ZIAGEN (abacavir sulfate) 20MGML SOLUTION 300 MG TABLET
2-MedicalCarve out
ANTI-HIV AGENTS OTHERDESCOVY (emtricitabinetenofoviralafenamide fumarate) 200-25 MGTABLET
2-MedicalCarve out
DOVATO (dolutegravirsodiumlamivudine) 50-300 MGTABLET
2-MedicalCarve out
FUZEON (enfuvirtide) 90 MG VIAL 2-MedicalCarve out
SP
JULUCA (dolutegravirsodiumrilpivirine hcl) 50-25 MGTABLET
2-MedicalCarve out
RUKOBIA ER 600 MG TABLET 2-MedicalCarve out
SELZENTRY (maraviroc) 20 MGMLORAL SOLN 25 MG TABLET 75 MGTABLET 150 MG TABLET 300 MGTABLET
2-MedicalCarve out
TRIUMEQ (abacavirsulfatedolutegravirsodiumlamivudine) 600-50-300 MGTABLET
2-MedicalCarve out
TROGARZO (ibalizumab-uiyk) 200MG133 ML VIAL -
2-MedicalCarve out
TYBOST (cobicistat) 150 MG TABLET 2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
39
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTI-HIV AGENTS PROTEASE INHIBITORSAPTIVUS (tipranavir) 250 MGCAPSULE
2-MedicalCarve out
APTIVUS (tipranavirvitamin e tpgs)100 MGML SOLUTION
2-MedicalCarve out
ATAZANAVIR SULFATE 150 MG CAP200 MG CAP 300 MG CAP
2-MedicalCarve out
atazanavir sulfate 150 mg capsule200 mg capsule 300 mg capsule
2-MedicalCarve out
CRIXIVAN (indinavir sulfate) 200MG CAPSULE 400 MG CAPSULE
2-MedicalCarve out
EVOTAZ (atazanavirsulfatecobicistat) 300 MG-150 MGTABLET
2-MedicalCarve out
fosamprenavir calcium 700 mgtablet
2-MedicalCarve out
FOSAMPRENAVIR CALCIUM 700MG TABLET
2-MedicalCarve out
INVIRASE (saquinavir mesylate) 200MG CAPSULE 500 MG TABLET
2-MedicalCarve out
KALETRA (lopinavirritonavir) 80MG-20 MGML SOLN 100-25 MGTABLET 200-50 MG TABLET
2-MedicalCarve out
LEXIVA (fosamprenavir calcium) 50MGML SUSPENSION 700 MGTABLET
2-MedicalCarve out
lopinavirritonavir 400-1005solution
2-MedicalCarve out
NORVIR (ritonavir) 80 MGMLSOLUTION 100 MG TABLET 100 MGSOFTGEL CAP 100 MG POWDERPACKET
2-MedicalCarve out
PREZCOBIX (darunavirethanolatecobicistat) 800 MG-150MG TABLET
2-MedicalCarve out
PREZISTA (darunavir ethanolate) 75MG TABLET 100 MGMLSUSPENSION 150 MG TABLET 400MG TABLET 600 MG TABLET 800MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
40
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
REYATAZ (atazanavir sulfate) 50MG POWDER PACKET 150 MGCAPSULE 200 MG CAPSULE 300MG CAPSULE
2-MedicalCarve out
ritonavir 100 mg tablet 2-MedicalCarve out
SYMTUZA (darunavirethcobicistatemtricitabinetenofovir alafenamide) 800-150-200-10MG TAB
2-MedicalCarve out
VIRACEPT (nelfinavir mesylate) 250MG TABLET 625 MG TABLET
2-MedicalCarve out
ANTI-INFLUENZA AGENTSoseltamivir phosphate 30 mgcapsule 45 mg capsule 75 mgcapsule
1-Covered QL (10 PER 30 DAY(S)) MFL (1 180 day(s))
OSELTAMIVIR PHOSPHATE 30 MGCAPSULE 45 MG CAPSULE 75 MGCAPSULE
1-Covered QL (10 PER 30 DAY(S)) MFL (1 180 day(s))
oseltamivir phosphate 6 mgmlsusp recon
1-Covered QL (120 PER FILL(S)) MFL (120 180day(s))
OSELTAMIVIR PHOSPHATE 6 MGMLSUSPENSION
1-Covered QL (120 PER FILL(S)) MFL (120 180day(s))
RELENZA (zanamivir) 5 MGDISKHALER
1-Covered QL (20 PER 30 DAY(S))
ANTIHERPETIC AGENTSacyclovir 200 mg capsule 200mg5ml oral susp 400 mg tablet800 mg tablet
1-Covered
ACYCLOVIR 200 MG5 ML SUSP400 MG TABLET 800 MG TABLET
1-Covered
trifluridine 1 drops 1-Covered
valacyclovir hcl 500 mg tablet1000 mg tablet
1-Covered QL (60 PER 30 DAY(S))
ANXIOLYTICS (Drugs for Anxiety)
ANXIOLYTICS OTHER (Other Drugs for Anxiety)BUSPIRONE HCL 5 MG TABLET 10MG TABLET 15 MG TABLET 30 MGTABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
41
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
buspirone hcl 5 mg tablet 75 mgtablet 10 mg tablet 15 mg tablet30 mg tablet
1-Covered
BENZODIAZEPINESalprazolam (ALPRAZOLAMINTENSOL) 1 mgml oral conc
1-Covered
alprazolam 025 mg tablet 05 mgtablet 1 mg tablet 2 mg tablet
1-Covered QL (100 PER 30 DAYS)
clonazepam 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered QL (120 PER 30 DAY(S))
diazepam 2 mg tablet 5 mgtablet 10 mg tablet
1-Covered QL (100 PER 30 DAYS)
diazepam 5 mg5 ml solution 5mgml oral conc
1-Covered
lorazepam (LORAZEPAM INTENSOL)2 mgml oral conc
1-Covered
lorazepam 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered QL (100 PER 30 DAYS)
lorazepam 2 mgml oral conc 1-Covered
oxazepam 10 mg capsule 15 mgcapsule 30 mg capsule
1-Covered
BIPOLAR AGENTS (Drugs for Bipolar Disorder)
MOOD STABILIZERSlithium carbonate 150 mg capsule300 mg tablet er 300 mg capsule300 mg tablet 450 mg tablet er600 mg capsule
2-MedicalCarve out
lithium citrate 8 meq5 ml solution 2-MedicalCarve out
LITHOBID (lithium carbonate) ER300 MG TABLET
2-MedicalCarve out
BLOOD GLUCOSE REGULATORS (Drugs for Diabetes)
ANTIDIABETIC AGENTS (Drugs for High Blood Sugar)acarbose 100 mg tablet 1-Covered QL (3 PER 1 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
42
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acarbose 25 mg tablet 1-Covered QL (12 PER 1 DAYS)
acarbose 50 mg tablet 1-Covered QL (6 PER 1 DAYS)
ADLYXIN (lixisenatide) 10-20 MCGSTARTER PACK 20 MCGMAINTENANCE PK
1-Covered PA
alogliptin benzoate 625 mg tablet125 mg tablet 25 mg tablet
1-Covered ST
alogliptin benzoatemetformin hclbenzmetformin 125-1000 tabletbenzmetformin 125-500mg tablet
1-Covered ST
alogliptin benzoatepioglitazonehcl benzpioglitazone 125-15 mgtablet benzpioglitazone 125-45mg tablet benzpioglitazone 125-30 mg tablet benzpioglitazone 25mg-30mg tabletbenzpioglitazone 25 mg-45mgtablet benzpioglitazone 25 mg-15mg tablet
1-Covered ST
AVANDIA (rosiglitazone maleate) 2MG TABLET 4 MG TABLET
1-Covered QL (60 PER 30 DAYS)
glimepiride 1 mg tablet 2 mgtablet 4 mg tablet
1-Covered STAR (Preferred Drug)
glipizide 25 mg tab er 24 5 mgtablet 5 mg tab er 24 10 mg taber 24 10 mg tablet
1-Covered STAR (Preferred Drug)
glyburide 125 mg tablet 25 mgtablet 5 mg tablet
1-Covered STAR (Preferred Drug)
glyburidemetformin hcl 125-250mg tablet 25-500 mg tablet 5mg-500mg tablet
1-Covered STAR (Preferred Drug)
JARDIANCE (empagliflozin) 10 MGTABLET 25 MG TABLET
1-Covered PA QL (1 PER 1 DAYS)
metformin hcl 500 mg tablet 500mg tab er 24h 750 mg tab er 24h850 mg tablet 1000 mg tablet
1-Covered STAR (Preferred Drug)
METFORMIN HCL ER ER 500 MGTABLET ER 750 MG TABLET
1-Covered STAR (Preferred Drug)
nateglinide 60 mg tablet 120 mgtablet
1-Covered ST
pioglitazone hcl 15 mg tablet 30mg tablet 45 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
43
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PIOGLITAZONE HCL 15 MG TABLET30 MG TABLET 45 MG TABLET
1-Covered
SYNJARDY(empagliflozinmetformin hcl) 5-1000 MG TABLET
1-Covered PA QL (2 PER 1 DAY(S))
SYNJARDY(empagliflozinmetformin hcl) 5-500 MG TABLET 125-500 MGTABLET 125-1000 MG TABLET
1-Covered PA QL (2 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 10-MG TABLET 125-MG TAB
1-Covered PA QL (2 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 25-1000 MG TABLET
1-Covered PA QL (1 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 5-1000 MG TABLET
1-Covered PA QL (2 PER 1)
tolbutamide 500 mg tablet 1-Covered
TRULICITY (dulaglutide) 075MG05 ML PEN 15 MG05 ML PEN
1-Covered PA QLC (1 penweek)
TRULICITY 3 MG05 ML PEN 45MG05 ML PEN
1-Covered PA QL (05 PER 1 WEEK(S))
VICTOZA 2-PAK (liraglutide) -18MG3 ML PEN
1-Covered PA QLC (6 ml (2 pens)30 days)
VICTOZA 3-PAK (liraglutide) -18MGML PEN
1-Covered PA QLC (9 ml (3 pens)30 days)
GLYCEMIC AGENTS (Drugs for Low Blood Sugar)BAQSIMI (glucagon) 3 MG SPRAYTWO PACK 3 MG SPRAY ONEPACK
1-Covered QL (2 PER 30 DAY(S))
GLUCAGON EMERGENCY KIT(glucagon hcl) 1 MG
1-Covered
GLUCAGON EMERGENCY KIT(glucagonhuman recombinant) 1MG
1-Covered
terbinafine hcl (JOCK ITCH) 1 cream (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
44
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
INSULINSADMELOG (insulin lispro) 100UNITML VIAL
1-Covered
ADMELOG SOLOSTAR (insulin lispro)100 UNITML
1-Covered PA
BASAGLAR KWIKPEN U-100 (insulinglarginehuman recombinantanalog) UNITML
1-Covered
HUMALOG (insulin lispro) 100UNITML CARTRIDGE
1-Covered PA
HUMALOG MIX 75-25 (insulin lisproprotamine and insulin lispro) -VIAL (
1-Covered
HUMALOG MIX 75-25 KWIKPEN(insulin lispro protamine and insulinlispro) -(
1-Covered PA
HUMULIN 70-30 (insulin nph humanisophaneinsulin regular human) -VIAL
1-Covered
HUMULIN 7030 KWIKPEN (insulinnph human isophaneinsulinregular human)
1-Covered PA
HUMULIN N (insulin nph humanisophane) 100 UITML VIAL
1-Covered
HUMULIN R (insulin regular human)100 UNITML VIAL
1-Covered
HUMULIN R U-500 (insulin regularhuman) UNITML VIAL
1-Covered
insulin lispro 100ml insuln pen 1-Covered PA
insulin lispro 100ml vial 1-Covered
INSULIN LISPRO PROTAMINE MIX(insulin lispro protamine and insulinlispro) 75-25 KWKPN (
1-Covered PA
NOVOLIN 70-30 (insulin nph humanisophaneinsulin regular human)70-30 100 UNITML VIAL RELION 70-30 VIAL
1-Covered
NOVOLIN N (insulin nph humanisophane) N 100 UNITML VIALRELION N 100 UNITML
1-Covered
NOVOLIN R (insulin regular human)R 100 UNITML VIAL RELION R 100UNITML
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
45
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
BLOOD PRODUCTSMODIFIERSVOLUME EXPANDERS (Drugs forBlood Disorders)
ANTICOAGULANTS (Blood Thinners)COUMADIN (warfarin sodium) 1MG TABLET 2 MG TABLET 25 MGTABLET 3 MG TABLET 4 MG TABLET5 MG TABLET 6 MG TABLET 75 MGTABLET 10 MG TABLET
1-Covered
ELIQUIS (apixaban) 25 MG TABLET5 MG TABLET
1-Covered QL (2 PER 1 DAY(S))
ELIQUIS (apixaban) DVT-PE TREATSTART 5MG
1-Covered QLC (1 PACK6 MONTHS)
ENOXAPARIN SODIUM 120 MG08ML SYR
1-Covered
ENOXAPARIN SODIUM 30 MG03ML SYR 40 MG04 ML SYR 60MG06 ML SYR 80 MG08 ML SYR100 MGML SYRINGE 150 MGMLSYRINGE
1-Covered PA
enoxaparin sodium 30mg03ml40mg04ml 60mg06ml80mg08ml 100 mgml120mg8ml 150 mgml
1-Covered PA
HEPARIN SODIUM SOD 5000UNITML VIAL SOD 10000 UNITMLVL SOD 20000 UNITML VL 50000UNIT5 ML VIAL
1-Covered
heparin sodiumporcine 5000mlvial 10000ml vial 20000ml vial
1-Covered
heparin sodiumporcinepf 1000mlvial
1-Covered
warfarin sodium (JANTOVEN) 1 mgtablet 2 mg tablet 25 mg tablet3 mg tablet 4 mg tablet 5 mgtablet 6 mg tablet 75 mg tablet10 mg tablet
1-Covered
warfarin sodium 1 mg tablet 2 mgtablet 25 mg tablet 3 mg tablet4 mg tablet 5 mg tablet 6 mgtablet 75 mg tablet 10 mg tablet
1-Covered
XARELTO (rivaroxaban) 10 MGTABLET 15 MG TABLET 20 MGTABLET
1-Covered QL (1 PER 1 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
46
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
XARELTO (rivaroxaban) DVT-PETREAT START 30D
1-Covered QLC (1 PACK6 MONTHS)
BLOOD FORMATION MODIFIERS (Blood Formation Drugs)anagrelide hcl 05 mg capsule 1mg capsule
1-Covered
EPOGEN (epoetin alfa) 2000UNITSML VIAL 3000 UNITSMLVIAL 4000 UNITSML VIAL 10000UNITSML VIAL 20000 UNITSMLVIAL
1-Covered PA SP
PROCRIT (epoetin alfa) 2000UNITSML VIAL 3000 UNITSMLVIAL 4000 UNITSML VIAL 10000UNITSML VIAL 20000 UNITSMLVIAL 40000 UNITSML VIAL
1-Covered PA SP
HEMOSTASIS AGENTS (Drugs to Stop Bleeding)ADVATE (antihemophilic factor(fviii) recombinantfull length) 200-400 VIAL 401-800 VIAL 801-1200VIAL 1201-1800 VIAL 1801-2400VIAL 2401-3600 VIAL 3601-4800VIAL
2-MedicalCarve out
ADYNOVATE (antihemophilicfactor (fviii) recombinant fulllength peg) 200-400 VIAL 401-800VIAL 750 VIAL 801-1250 VIAL1251-2500 VL 1500 VIAL 3000VIAL
2-MedicalCarve out
AFSTYLA (antihemophilic factor viiirecombsingle-chnb-domtruncated) 250 VIAL -- 500 VIAL --1000 VIAL -- 1500 RANGE VIAL --2000 VIAL -- 2500 RANGE VIAL --3000 VIAL --
2-MedicalCarve out
ALPHANATE (antihemophilic factorhumanvon willebrandfactorhuman) 250-100 VIALhuman) 500-200 VIAL human)1000-400 VIAL human) 1500-600VIAL human) 2000-800 VIALhuman)
2-MedicalCarve out
ALPHANINE SD (factor ix) SD 500VIAL SD 1000 VIAL SD 1500 VIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
47
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALPROLIX (factor ix recombinantfc fusion protein) 250 500 10002000 3000 4000
2-MedicalCarve out
BENEFIX (factor ix humanrecombinant) 250 500 10002000 3000
2-MedicalCarve out
COAGADEX (coagulation factor x)250 VIAL 500 VIAL
2-MedicalCarve out
CORIFACT (factor xiii) KIT 2-MedicalCarve out
ELOCTATE (antihemophilic factor(fviii) recombinant fc fusionprotein) 250 500 750 1000 15002000 3000 4000 5000 6000
2-MedicalCarve out
ESPEROCT (antihemophilic factor(fviii) rec b-dom truncated peg-exei) 500 VIAL -- 1000 VIAL --1500 VIAL -- 2000 VIAL -- 3000VIAL --
2-MedicalCarve out
FEIBA NF (anti-inhibitor coagulantcomplex) 500 (NOMINAL) - 1000(NOMINAL) - 2500 (NOMINAL) -
2-MedicalCarve out
FIBRYGA (fibrinogen) 1 GRAMRANGE VIAL
2-MedicalCarve out
HELIXATE FS (antihemophilic factor(fviii) recombinantfull length) 250UNIT VIAL 500 UNIT VIAL 1000 UNITVIAL 2000 UNIT VIAL 3000 UNITSVIAL
2-MedicalCarve out
HEMLIBRA (emicizumab-kxwh) 30MGML VIAL - 60 MG04 ML VIAL - 105 MG07 ML VIAL - 150 MGMLVIAL -
2-MedicalCarve out
HEMOFIL M (antihemophilic factorhuman) 250 500 1000 1700
2-MedicalCarve out
HUMATE-P (antihemophilic factorhumanvon willebrandfactorhuman) -600 human) -1200human) -2400 human)
2-MedicalCarve out
IDELVION (factor ixrecombinantalbumin fusionprotein) 250 VIAL 500 VIAL 1000VIAL 2000 VIAL 3500 VIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
48
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
IXINITY (factor ix humanrecombinant threonine 148) 500RANGE 500 VIAL 1000 VIAL 1000RANGE 1000 VIAL -2 VLS 1000RANGE-2 VLS 1500 RANGE-2 VLS1500 VIAL -2 VLS 1500 VIAL 1500RANGE
2-MedicalCarve out
JIVI (antihemophilic factor (fviii)rec b-domain deleted peg-aucl)500 VIAL -- 1000 VIAL -- 2000 VIAL-- 3000 VIAL --
2-MedicalCarve out
KCENTRA (human prothrombincomplex concentrate (pcc) 4-factor) 500 VIAL 4- 1000 VIAL 4-
2-MedicalCarve out
KOGENATE FS (antihemophilicfactor (fviii) recombinantfulllength) 250 UNIT VIAL 500 UNITVIAL 1000 UNITS VIAL 2000 UNITVIAL 3000 UNITS VIAL
2-MedicalCarve out
KOVALTRY (antihemophilic factor(fviii) recombinantfull length) 250KIT 500 KIT 1000 KIT 2000 KIT3000 KIT
2-MedicalCarve out
MONONINE (factor ix) 1000 UNITVIAL
2-MedicalCarve out
NOVOEIGHT (antihemophilic factorviii recombinant b-domaintruncated) 250 VIAL RECOMINANT- 500 VIAL RECOMINANT - 1000VIAL RECOMINANT - 1500 VIALRECOMINANT - 2000 VIALRECOMINANT - 3000 VIALRECOMINANT -
2-MedicalCarve out
NOVOSEVEN RT (coagulationfactor viia (recombinant)) 1 MGVIAL 2 MG VIAL 5 MG VIAL 8 MGVIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
49
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NUWIQ (antihemophilic factor viiirec hek cell b-domain deleted)250 VIAL - 250 VIAL PACK - 500VIAL - 500 VIAL PACK - 1000 VIAL - 1000 VIAL PACK - 2000 VIALPACK - 2000 VIAL - 2500 VIALPACK - 2500 VIAL - 3000 VIAL -3000 VIAL PACK - 4000 VIAL PACK- 4000 VIAL -
2-MedicalCarve out
OBIZUR (antihemophilic factor viiirecombinant porcine sequence)500 VIAL 500 VIAL - 5 VIALS 500VIAL -10 VIALS
2-MedicalCarve out
phytonadione (vit k1) 5 mg tablet 1-Covered
PROFILNINE (factor ix complexprothrombin cplx conc(pcc) no43-factor) 500 VIAL 3- 1000 VIAL 3-1500 VIAL 3-
2-MedicalCarve out
REBINYN (factor ix (human)recombinant pegylated) 500 VIAL1000 VIAL 2000 VIAL
2-MedicalCarve out
RECOMBINATE (antihemophilicfactor viii human recombinant)220-400 VIAL 401-800 VIAL 801-1240 VL 1241-1800 V 1801-2400V
2-MedicalCarve out
RIASTAP (fibrinogen) VIAL 2-MedicalCarve out
RIXUBIS (factor ix humanrecombinant) 250 500 10002000 3000
2-MedicalCarve out
SEVENFACT 1 MG VIAL 5 MG VIAL 2-MedicalCarve out
TRETTEN (factor xiii a-subunitrecombinant) 2500 UNIT VIAL(fctor -recombinnt)
2-MedicalCarve out
VONVENDI (von willebrand factor(recombinant)) 650 VIAL 1300VIAL
2-MedicalCarve out
WILATE (antihemophilic factorhumanvon willebrandfactorhuman) 450-450 VIALhuman) 500-500 VIAL human)900-900 VIAL human) 1000-1000VIAL human)
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
50
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
XYNTHA (antihemophilic factor(factor viii) recombb-domaindeleted) 250 KIT - 500 KIT - 1000KIT - 2000 KIT -
2-MedicalCarve out
XYNTHA SOLOFUSE (antihemophilicfactor (factor viii) recombb-domain deleted) 250 KIT - 500 KIT -1000 KIT - 2000 KIT - 3000 KIT -
2-MedicalCarve out
PLATELET MODIFYING AGENTScilostazol 50 mg tablet 100 mgtablet
1-Covered
clopidogrel bisulfate 75 mg tablet 1-Covered AL1 (At least 18 yrs old)
dipyridamole 25 mg tablet 50 mgtablet 75 mg tablet
1-Covered
CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation)
ALPHA-ADRENERGIC AGONISTSclonidine hcl 01 mg tablet 02 mgtablet 03 mg tablet
1-Covered
CLONIDINE HCL 01 MG TABLET 02MG TABLET 03 MG TABLET
1-Covered
guanfacine hcl 1 mg tablet 2 mgtablet
1-Covered
methyldopa 250 mg tablet 500mg tablet
1-Covered
ALPHA-ADRENERGIC BLOCKING AGENTSdoxazosin mesylate 1 mg tablet 2mg tablet 4 mg tablet 8 mgtablet
1-Covered
PHENOXYBENZAMINE HCL 10 MGCAP
1-Covered
phenoxybenzamine hcl 10 mgcapsule
1-Covered
prazosin hcl 1 mg capsule 2 mgcapsule 5 mg capsule
1-Covered
PRAZOSIN HCL 1 MG CAPSULE 2MG CAPSULE 5 MG CAPSULE
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
51
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terazosin hcl 1 mg capsule 2 mgcapsule 5 mg capsule 10 mgcapsule
1-Covered
TERAZOSIN HCL 1 MG CAPSULE 2MG CAPSULE 5 MG CAPSULE 10MG CAPSULE
1-Covered
ANGIOTENSIN II RECEPTOR ANTAGONISTSirbesartan 75 mg tablet 150 mgtablet 300 mg tablet
1-Covered ST
LOSARTAN POTASSIUM 25 MG TAB50 MG TAB 100 MG TAB
1-Covered STAR (Preferred Drug)
losartan potassium 25 mg tablet50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
valsartan 40 mg tablet 80 mgtablet 160 mg tablet 320 mgtablet
1-Covered ST
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORSbenazepril hcl 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered STAR (Preferred Drug)
captopril 125 mg tablet 25 mgtablet 50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
CAPTOPRIL 125 MG TABLET 25 MGTABLET 50 MG TABLET 100 MGTABLET
1-Covered STAR (Preferred Drug)
ENALAPRIL MALEATE 25 MG TAB 5MG TABLET 10 MG TAB 20 MG TAB
1-Covered STAR (Preferred Drug)
enalapril maleate 25 mg tablet 5mg tablet 10 mg tablet 20 mgtablet
1-Covered STAR (Preferred Drug)
fosinopril sodium 10 mg tablet 20mg tablet 40 mg tablet
1-Covered
lisinopril 25 mg tablet 5 mg tablet10 mg tablet 20 mg tablet 30 mgtablet 40 mg tablet
1-Covered STAR (Preferred Drug)
moexipril hcl 75 mg tablet 15 mgtablet
1-Covered
quinapril hcl 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered
ramipril 125 mg capsule 25 mgcapsule 5 mg capsule 10 mgcapsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
52
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
RAMIPRIL 125 MG CAPSULE 25MG CAPSULE 5 MG CAPSULE 10MG CAPSULE
1-Covered
trandolapril 1 mg tablet 2 mgtablet 4 mg tablet
1-Covered
ANTIARRHYTHMICS (Drugs for Irregular Heart Rhythm)amiodarone hcl (PACERONE) 200mg tablet
1-Covered
amiodarone hcl 200 mg tablet 1-Covered
disopyramide phosphate 100 mgcapsule
1-Covered
flecainide acetate 50 mg tablet100 mg tablet 150 mg tablet
1-Covered
mexiletine hcl 150 mg capsule 200mg capsule 250 mg capsule
1-Covered
MEXILETINE HCL 150 MG CAPSULE200 MG CAPSULE 250 MGCAPSULE
1-Covered
propafenone hcl 150 mg tablet225 mg tablet 300 mg tablet
1-Covered
quinidine gluconate 324 mg tableter
1-Covered
quinidine sulfate 200 mg tablet300 mg tablet
1-Covered
SOTALOL 80 MG TABLET 120 MGTABLET 160 MG TABLET 240 MGTABLET
1-Covered
SOTALOL AF 80 MG TABLET 120 MGTABLET
1-Covered
sotalol hcl (SORINE) 80 mg tablet120 mg tablet 160 mg tablet 240mg tablet
1-Covered
sotalol hcl 80 mg tablet 120 mgtablet 160 mg tablet 240 mgtablet
1-Covered
BETA-ADRENERGIC BLOCKING AGENTSatenolol 25 mg tablet 50 mgtablet 100 mg tablet
1-Covered STAR (Preferred Drug)
ATENOLOL 25 MG TABLET 50 MGTABLET 100 MG TABLET
1-Covered STAR (Preferred Drug)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
53
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
bisoprolol fumarate 5 mg tablet 10mg tablet
1-Covered
carvedilol 3125 mg tablet 625 mgtablet 125 mg tablet 25 mgtablet
1-Covered STAR (Preferred Drug)
labetalol hcl 100 mg tablet 200mg tablet 300 mg tablet
1-Covered
LABETALOL HCL 100 MG TABLET200 MG TABLET 300 MG TABLET
1-Covered
metoprolol succinate 200 mg taber 24h
1-Covered QL (60 PER 30 DAYS) MDD (2 PerDay) STAR (Preferred Drug)
metoprolol succinate 25 mg taber 50 mg tab er 100 mg tab er
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
METOPROLOL SUCCINATE ER 200MG TAB
1-Covered QL (60 PER 30 DAYS) MDD (2 PerDay) STAR (Preferred Drug)
METOPROLOL SUCCINATE ER 25MG TAB ER 50 MG TAB ER 100 MGTAB
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
metoprolol tartrate 25 mg tablet50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
nadolol 20 mg tablet 40 mgtablet 80 mg tablet
1-Covered STAR (Preferred Drug)
NADOLOL 20 MG TABLET 40 MGTABLET 80 MG TABLET
1-Covered STAR (Preferred Drug)
pindolol 5 mg tablet 10 mg tablet 1-Covered STAR (Preferred Drug)
propranolol hcl 10 mg tablet 20mg5 ml solution 20 mg tablet 40mg tablet 40mg5ml solution 60mg tablet 60 mg cap sa 24h 80mg tablet 80 mg cap sa 24h 120mg cap sa 24h 160 mg cap sa 24h
1-Covered
CALCIUM CHANNEL BLOCKING AGENTSAMLODIPINE BESYLATE 25 MG TAB5 MG TAB 10 MG TAB
1-Covered STAR (Preferred Drug)
amlodipine besylate 25 mg tablet5 mg tablet 10 mg tablet
1-Covered STAR (Preferred Drug)
DILTIAZEM 24HR ER (CD) 24HER(CD) 120 MG CP 24H ER(CD)240 MG CP 24H ER(CD) 180 MGCP 24H ER(CD) 360 MG CP 24HER(CD) 300 MG CP
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
54
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DILTIAZEM 24HR ER (XR) 24H ER(XR)240 MG CP 24H ER(XR) 180 MG CP
1-Covered
diltiazem hcl (CARTIA XT) 120 mgcap er 180 mg cap er 240 mgcap er 300 mg cap er
1-Covered
diltiazem hcl (DILT-XR) 120 mg caper - 180 mg cap er - 240 mg caper -
1-Covered
diltiazem hcl (TAZTIA XT) 120 mgcap 180 mg cap 240 mg cap 300mg cap 360 mg cap
1-Covered
diltiazem hcl 30 mg tablet 60 mgcap er 12h 60 mg tablet 90 mgtablet 90 mg cap er 12h 120 mgcap sa 24h 120 mg tablet 120 mgcap er 24h 120 mg cap er deg120 mg cap er 12h 180 mg cap sa24h 180 mg cap er deg 180 mgcap er 24h 240 mg cap er 24h 240mg cap er deg 240 mg cap sa24h 300 mg cap er 24h 300 mgcap sa 24h 360 mg cap sa 24h360 mg cap er 24h
1-Covered
felodipine 25 mg tab er 5 mg taber 10 mg tab er
1-Covered
FELODIPINE ER ER 25 MG TABLETER 5 MG TABLET ER 10 MG TABLET
1-Covered
nicardipine hcl 20 mg capsule 30mg capsule
1-Covered
nifedipine (AFEDITAB CR) 30 mgtablet er 60 mg tablet er
1-Covered
nifedipine (NIFEDICAL XL) 30 mgtab er 24 60 mg tab er 24
1-Covered
NIFEDIPINE 10 MG CAPSULE 1-Covered
nifedipine 10 mg capsule 20 mgcapsule 30 mg tablet er 30 mgtab er 24 60 mg tablet er 60 mgtab er 24 90 mg tablet er 90 mgtab er 24
1-Covered
nisoldipine 20 mg tab er 30 mgtab er 40 mg tab er
1-Covered
verapamil hcl 40 mg tablet 80 mgtablet 120 mg tablet 120 mgtablet er 180 mg tablet er 240 mgtablet er
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
55
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CARDIOVASCULAR AGENTS OTHERamiloride hclhydrochlorothiazideamiloridehydrochlorothiazide 5mg-50 mg tablet
1-Covered
amlodipine besylatebenazeprilhcl 25mg-10mg capsule 5 mg-20mg capsule 5 mg-10 mg capsule5 mg-40 mg capsule 10 mg-20mgcapsule 10 mg-40mg capsule
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day) STAR(Preferred Drug)
atenololchlorthalidone 50 mg-tablet 100mg-tablet
1-Covered STAR (Preferred Drug)
benazepril hclhydrochlorothiazidebenazeprilhydrochlorothiazide 5-625mg tabletbenazeprilhydrochlorothiazide 10-125mg tabletbenazeprilhydrochlorothiazide 20mg-25mg tabletbenazeprilhydrochlorothiazide 20-125 mg tablet
1-Covered STAR (Preferred Drug)
bisoprololfumaratehydrochlorothiazidebisoprololhydrochlorothiazide 25-tabletbisoprololhydrochlorothiazide 5-tabletbisoprololhydrochlorothiazide 10-tablet
1-Covered
BISOPROLOL-HYDROCHLOROTHIAZIDE -10-625MG TAB -25-625 MG TB -5-625MG TAB
1-Covered
captoprilhydrochlorothiazide 25mg-25mg tablet 25 mg-15mgtablet 50 mg-25mg tablet 50 mg-15mg tablet
1-Covered STAR (Preferred Drug)
digoxin (DIGITEK) 125 mcg tablet250 mcg tablet
1-Covered STAR (Preferred Drug)
digoxin (DIGOX) 125 mcg tablet250 mcg tablet
1-Covered STAR (Preferred Drug)
digoxin 125 mcg tablet 250 mcgtablet
1-Covered STAR (Preferred Drug)
digoxin 50 mcgml solution 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
56
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fosinoprilsodiumhydrochlorothiazidefosinoprilhydrochlorothiazide 10-125mg tabletfosinoprilhydrochlorothiazide 20-125 mg tablet
1-Covered
FOSINOPRIL-HYDROCHLOROTHIAZIDE -10-125MG TAB -20-125 MG TAB
1-Covered
irbesartanhydrochlorothiazide150-tablet 300-tablet
1-Covered ST
LANOXIN (digoxin) 125 MCGTABLET 250 MCG TABLET
1-Covered STAR (Preferred Drug)
lisinoprilhydrochlorothiazide 10-125mg tablet 20-125 mg tablet20 mg-25mg tablet
1-Covered STAR (Preferred Drug)
losartanpotassiumhydrochlorothiazidelosartanhydrochlorothiazide 50-125 mg tabletlosartanhydrochlorothiazide100mg-25mg tabletlosartanhydrochlorothiazide 100-125mg tablet
1-Covered STAR (Preferred Drug)
LOSARTAN-HYDROCHLOROTHIAZIDE -50-125MG TAB -100-125 MG TAB -100-25MG TAB
1-Covered STAR (Preferred Drug)
pentoxifylline 400 mg tablet er 1-Covered
spironolactonehydrochlorothiazide spironolacthydrochlorothiazid25 mg-25mg tablet
1-Covered
triamterenehydrochlorothiazide375-25 mg capsule 375-25 mgtablet 50 mg-25mg capsule 75mg-50mg tablet
1-Covered
valsartanhydrochlorothiazide 80-125mg tablet 160-125mg tablet160mg-25mg tablet 320-125mgtablet 320mg-25mg tablet
1-Covered ST
DIURETICS CARBONIC ANHYDRASE INHIBITORSacetazolamide 125 mg tablet 250mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
57
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ACETAZOLAMIDE 125 MG TABLET250 MG TABLET
1-Covered
DIURETICS LOOPbumetanide 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered
furosemide 10 mgml solution 20mg tablet 40mg5ml solution 40mg tablet 80 mg tablet
1-Covered STAR (Preferred Drug)
DIURETICS POTASSIUM-SPARINGamiloride hcl 5 mg tablet 1-Covered
spironolactone 25 mg tablet 50mg tablet 100 mg tablet
1-Covered
SPIRONOLACTONE 25 MG TABLET50 MG TABLET 100 MG TABLET
1-Covered
DIURETICS THIAZIDEchlorothiazide 250 mg tablet 500mg tablet
1-Covered
chlorthalidone 25 mg tablet 50 mgtablet
1-Covered
CHLORTHALIDONE 25 MG TABLET50 MG TABLET
1-Covered
DIURIL (chlorothiazide) 250 MG5ML ORAL SUSP
1-Covered
hydrochlorothiazide 125 mgcapsule 25 mg tablet 50 mgtablet
1-Covered STAR (Preferred Drug)
indapamide 125 mg tablet 25mg tablet
1-Covered
methyclothiazide 5 mg tablet 1-Covered
metolazone 25 mg tablet 5 mgtablet 10 mg tablet
1-Covered
DYSLIPIDEMICS FIBRIC ACID DERIVATIVES (Drugs for HighCholesterol)
fenofibrate 54 mg tablet 160 mgtablet
1-Covered ST
FENOFIBRATE 54 MG TABLET 160MG TABLET
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
58
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fenofibratemicronized 67 mgcapsule 134 mg capsule 200 mgcapsule
1-Covered ST
gemfibrozil 600 mg tablet 1-Covered
GEMFIBROZIL 600 MG TABLET 1-Covered
TRIGLIDE (fenofibratenanocrystallized) 160 MG TABLET
1-Covered ST
DYSLIPIDEMICS HMG COA REDUCTASE INHIBITORS (Drugs for HighCholesterol)
atorvastatin calcium 10 mg tablet20 mg tablet 40 mg tablet 80 mgtablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
ATORVASTATIN CALCIUM 10 MGTABLET 20 MG TABLET 40 MGTABLET 80 MG TABLET
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
lovastatin 10 mg tablet 20 mgtablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
rosuvastatin calcium 5 mg tablet10 mg tablet 20 mg tablet 40 mgtablet
1-Covered ST QL (30 PER 30 DAY(S))
simvastatin 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered STAR (Preferred Drug)
DYSLIPIDEMICS OTHER (Other Drugs for High Cholesterol)cholestyramine (with sugar) suar) 4powder
1-Covered
cholestyramineaspartame(PREVALITE) 4 g powder
1-Covered
cholestyramineaspartame 4 gpowder
1-Covered
COLESTID (colestipol hcl)FLAVORED GRANULES
1-Covered
colestipol hcl 1 tablet 5 ranules 5packet
1-Covered
ezetimibe 10 mg tablet 1-Covered
niacin (ENDUR-ACIN) 250 mgtablet er - 500 mg tablet er - 750mg tablet er -
1-Covered
niacin (SLO-NIACIN) 500 mg tableter -
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
59
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NIACIN 100 MG TABLET TR 500 MGTABLET
1-Covered
niacin 50 mg tablet 100 mg tablet250 mg capsule er 250 mg tablet250 mg tablet er 500 mg tablet500 mg tablet er 500 mg tab er24h 500 mg capsule er 750 mgtablet er 1000 mg tablet er
1-Covered
OMEGA-3 ACID ETHYL ESTERS -1GM CAP
1-Covered QL (4 PER 1 DAY(S))
omega-3 acid ethyl esters omea-1capsule
1-Covered QL (4 PER 1 DAY(S))
VASODILATORS DIRECT-ACTING ARTERIAL (Drugs for RelaxingArteries)
hydralazine hcl 10 mg tablet 25mg tablet 50 mg tablet 100 mgtablet
1-Covered
minoxidil 25 mg tablet 10 mgtablet
1-Covered
VASODILATORS DIRECT-ACTING ARTERIALVENOUS (Drugs forRelaxing Arteries and Veins)
ISOSORBIDE DINITRATE 5 MG TAB10 MG TAB 20 MG TAB 30 MG TAB
1-Covered STAR (Preferred Drug)
isosorbide dinitrate 5 mg tablet 10mg tablet 20 mg tablet 30 mgtablet 40 mg tablet er
1-Covered STAR (Preferred Drug)
isosorbide mononitrate 10 mgtablet 20 mg tablet 30 mg tab er24h 60 mg tab er 24h 120 mg taber 24h
1-Covered STAR (Preferred Drug)
NITRO-BID (nitroglycerin) -2OINTMENT
1-Covered
nitroglycerin (MINITRAN) 01mghrpatch 02mghr patch 04mghrpatch 06mghr patch
1-Covered
nitroglycerin (NITRO-TIME) 25 mgcapsule er - 65 mg capsule er - 9mg capsule er -
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
60
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
nitroglycerin 01mghr patch td2402mghr patch td24 03 mg tabsubl 04mghr patch td24 04 mgtab subl 06 mg tab subl 06mghrpatch td24 25 mg capsule er 65mg capsule er 9 mg capsule er400mcgspr spray
1-Covered
NITROGLYCERIN 400 MCG SPRAY 1-Covered
CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions)
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTSAMPHETAMINES
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 15 mg cap er 24h
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old) MDD (1 Per Day)
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 5 mg cap erdextroamphetamineamphetamine 10 mg cap erdextroamphetamineamphetamine 20 mg cap erdextroamphetamineamphetamine 25 mg cap erdextroamphetamineamphetamine 30 mg cap er
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old)
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 5 mg tabletdextroamphetamineamphetamine 75 mg tabletdextroamphetamineamphetamine 10 mg tabletdextroamphetamineamphetamine 125 mg tabletdextroamphetamineamphetamine 15 mg tabletdextroamphetamineamphetamine 20 mg tabletdextroamphetamineamphetamine 30 mg tablet
1-Covered AL1 (3 to 18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
61
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
dextroamphetamine sulfate(ZENZEDI) 5 mg tablet 10 mgtablet
1-Covered AL1 (3 to 18 yrs old)
dextroamphetamine sulfate 5 mgcapsule er 5 mg tablet 10 mgcapsule er 10 mg tablet 15 mgcapsule er
1-Covered AL1 (3 to 18 yrs old)
DEXTROAMPHETAMINE SULFATE 5MG TAB 10 MG TAB
1-Covered AL1 (3 to 18 yrs old)
DEXTROAMPHETAMINE-AMPHET ER-15 MG CAP
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old) MDD (1 Per Day)
DEXTROAMPHETAMINE-AMPHET ER-ER 5 MG CAP -ER 10 MG CAP -ER20 MG CAP -ER 25 MG CAP -ER 30MG CAP
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old)
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS NON-AMPHETAMINES
atomoxetine hcl 10 mg capsule 18mg capsule 25 mg capsule 40 mgcapsule 60 mg capsule 80 mgcapsule 100 mg capsule
1-Covered PA
guanfacine hcl 1 mg tab er 2 mgtab er 3 mg tab er 4 mg tab er
1-Covered QL (1 PER 1 DAY(S))
METHYLPHENIDATE ER ER 18 MGTAB ER 27 MG TAB ER 36 MG TABER 54 MG TAB
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl (METADATEER) 20 mg tablet er
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl 10 mg tableter 18 mg tab er 24 20 mg tableter 27 mg tab er 24 36 mg tab er24 54 mg tab er 24
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl 5 mg tablet10 mg cpbp 30-70 10 mg tablet20 mg tablet 20 mg cpbp 30-7030 mg cpbp 30-70 40 mg cpbp 30-70 50 mg cpbp 30-70 60 mg cpbp30-70
1-Covered AL1 (6 to 18 yrs old)
METHYLPHENIDATE HCL 5 MGTABLET 10 MG TABLET 20 MGTABLET
1-Covered AL1 (6 to 18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
62
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CENTRAL NERVOUS SYSTEM OTHERacetaminophen (ATHENOL) 325mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (CHILD FEVERREDUCER) 120 mg supprect
1-Covered
acetaminophen (CHILD PAIN REL-FEVER REDUCER) 120 mg supprect-
1-Covered
acetaminophen (CHILDRENSFEVER REDUCER) 120 mg supprect
1-Covered
acetaminophen (CHILDRENSFEVER REDUCING) 120 mgsupprect
1-Covered
acetaminophen (CHILDRENS PAINAND FEVER) 160 mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (CHILDRENSSILAPAP) 160 mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (ED-APAP) 160mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (LITTLE REMEDIESFEVER-PAIN) 160 mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (M-PAP) 160mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (MAPAP) 160mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (MAPAP) 325 mgtablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (MASOPHEN) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRINEXTRA STRENGTH) 500 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRINPAIN RELIEF) 500 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRIN)160 mg5ml elixir -
1-Covered QLC (LIMIT TO 2 FILLS OF 120ML IN30 DAYS)
acetaminophen (NON-ASPIRIN)325 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN amp FEVER)500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
63
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acetaminophen (PAIN RELIEFEXTRA STRENGTH) 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN RELIEF) 160mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (PAIN RELIEF) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN RELIEVER)325 mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PHARBETOL) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (SHAKE THATACHE) 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (TACTINAL) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen 120 mg 650 mg 1-Covered
acetaminophen 160 mg5ml elixir 1-Covered QLC (LIMIT TO 2 FILLS OF 120ML IN30 DAYS)
acetaminophen 160 mg5ml liquid 1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 160 mg5ml oralsusp
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 160 mg5mlsolution
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 325 mg tablet500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
ACETAMINOPHEN CVS 325 MGGELCP 325 MG TABLET 500 MGTABLET 500 MG GELCAP
1-Covered QL (60 PER 30 DAY(S))
butalbitalacetaminophen(TENCON) 50mg-325mg tablet
1-Covered QL (48 PER 30 DAY(S))
butalbitalacetaminophen 50mg-325mg tablet
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
butalbitalacetaminophencaffeine butalbacetaminophencaffeine50-325-40 tablet
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
PAIN amp FEVER (acetaminophen)500 MG TABLET
1-Covered QL (60 PER 30 DAY(S))
PAIN RELIEF 325 MG TABLET 500MG GELCAP 500 MG TABLET
1-Covered QL (60 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
64
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
riluzole 50 mg tablet 1-Covered PA
RILUZOLE 50 MG TABLET 1-Covered PA
FIBROMYALGIA AGENTSduloxetine hcl 20 mg capsule dr30 mg capsule dr 60 mg capsuledr
1-Covered
pregabalin 20 mgml solution 1-Covered PA QLC (30 MLDAY)
pregabalin 225 mg capsule 300mg capsule
1-Covered PA QL (2 PER 1 DAY(S))
PREGABALIN 225 MG CAPSULE 300MG CAPSULE
1-Covered PA QL (2 PER 1 DAY(S))
pregabalin 25 mg capsule 50 mgcapsule 75 mg capsule 100 mgcapsule 150 mg capsule 200 mgcapsule
1-Covered PA QL (3 PER 1 DAY(S))
PREGABALIN 25 MG CAPSULE 50MG CAPSULE 75 MG CAPSULE 100MG CAPSULE 150 MG CAPSULE200 MG CAPSULE
1-Covered PA QL (3 PER 1 DAY(S))
SAVELLA (milnacipran hcl) 125 MGTABLET 25 MG TABLET 50 MGTABLET 100 MG TABLET TITRATIONPACK
1-Covered PA
MULTIPLE SCLEROSIS AGENTSAVONEX (interferon beta-1a)PREFILLED SYR 30 MCG KT -
1-Covered PA SP
AVONEX (interferon beta-1aalbumin human) 30 MCG VIALKIT -
1-Covered PA SP
AVONEX PEN (interferon beta-1a)30 MCG05 ML KIT -
1-Covered PA SP
DIMETHYL FUMARATE 30D START PK 1-Covered PA SP
DIMETHYL FUMARATE DR 120 MGCP DR 240 MG CP
1-Covered PA SP QL (2 PER 1 DAY(S))
glatiramer acetate (GLATOPA) 20mgml syringe
1-Covered PA SP QLC (1 SYRINGEDAY)
glatiramer acetate (GLATOPA) 40mgml syringe
1-Covered PA SP QLC (12SYRINGESMONTH)
glatiramer acetate 20 mgmlsyringe
1-Covered PA SP QLC (1 SYRINGEDAY)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
65
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
glatiramer acetate 40 mgmlsyringe
1-Covered PA SP QLC (12SYRINGESMONTH)
PLEGRIDY (peginterferon beta-1a)125 MCG05 ML SYRING - SYRINGESTARTER PACK -
1-Covered PA SP
PLEGRIDY PEN (peginterferon beta-1a) 125 MCG05 ML PEN - PEN INJSTARTER PACK -
1-Covered PA SP
TECFIDERA (dimethyl fumarate) DR120 MG CAPSULE DR 240 MGCAPSULE STARTER PACK
1-Covered PA SP
DENTAL AND ORAL AGENTS (Drugs for the Mouth)
DENTAL AND ORAL AGENTSchlorhexidine gluconate (PAROEX)012 mouthwash
1-Covered
chlorhexidine gluconate 012 mouthwash
1-Covered
PHOS-FLUR (fluoride (sodium)) -ORAL RINSE
1-Covered
triamcinolone acetonide(ORALONE) 01 paste (g)
1-Covered
triamcinolone acetonide 01 paste (g)
1-Covered
TRIAMCINOLONE ACETONIDE 01PASTE
1-Covered
DERMATOLOGICAL AGENTS (Drugs for the Skin)ACNE MEDICATION (benzoylperoxide) 5 GEL
1-Covered
ACNE MEDICATION 25 GEL 1-Covered
ammonium lactate (SKINTREATMENT) 12 lotion
1-Covered
ammonium lactate 12 cream(g) 12 lotion
1-Covered
benzoyl peroxide (ACNE CONTROLCLEANSER) 10 cleanser
1-Covered
benzoyl peroxide (ACNE FOAMINGWASH) 10 cleanser
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
66
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
benzoyl peroxide (ACNETREATMENT) 10 gel (gram)
1-Covered
benzoyl peroxide (ACNECLEAR) 10 gel (gram)
1-Covered
benzoyl peroxide (ADVANCEDEXFOLIATING CLEANSER) 5 cleanser
1-Covered
benzoyl peroxide (BP WASH) 5 10
1-Covered
benzoyl peroxide (BP) 5 gel(gram) 10 gel (gram)
1-Covered
benzoyl peroxide (BPO-10) cleanser -
1-Covered
benzoyl peroxide (BPO-5) cleanser -)
1-Covered
benzoyl peroxide (CLEAN-CLEARCONTINUOUS CONTROL) 10 cleanser -
1-Covered
benzoyl peroxide (DAYLOGICACNE FOAMING WASH) 10 cleanser
1-Covered
benzoyl peroxide (DAYLOGICACNE TREATMENT) 10 gel (gram)
1-Covered
benzoyl peroxide (FOAMING ACNEFACE WASH) 10 cleanser
1-Covered
benzoyl peroxide (PANOXYL) 10 cleanser
1-Covered
benzoyl peroxide 25 gel (gram)5 cleanser 5 gel (gram) 10 gel (gram) 10 cleanser
1-Covered
CALADRYL (pramoxinehclcalamine) 1-8 LOTION
1-Covered
calcipotriene 0005 cream (g)0005 oint (g) 0005 solution
1-Covered PA
chlorhexidine gluconate 4 liquid 1-Covered
CORTISPORIN(neomycinbacitracinpolymyxinbhydrocortisone) OINTMENT
1-Covered
DIFFERIN (adapalene) 01 GEL 1-Covered AL1 (Up to 25 yrs old)
DRITHOCREME HP (anthralin) 1CREAM
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
67
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DRYSOL (aluminum chloride) DAB--MATIC SLUTIN
1-Covered
EPIFOAM (hydrocortisoneacetatepramoxine hcl)
1-Covered
hydrocortisoneacetatepramoxine hclhydrocortisonepramoxine 1 -1 creamapplhydrocortisonepramoxine 25 -1 cream (g)hydrocortisonepramoxine 25 -1 creamapplhydrocortisonepramoxine 25-1(4g) creamappl
1-Covered
isotretinoin (AMNESTEEM) 10 mgcapsule 20 mg capsule 40 mgcapsule
1-Covered PA
isotretinoin (CLARAVIS) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin (MYORISAN) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin (ZENATANE) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin 10 mg capsule 20 mgcapsule 30 mg capsule 40 mgcapsule
1-Covered PA
LICE KILLING SHAMPOO 1-Covered
metronidazole 075 cream (g)075 gel (gram) 1 gel (gram)
1-Covered
pimecrolimus 1 cream (g) 1-Covered PA
piperonyl butoxidepyrethrins (LICEKILLING) 4-033 shampoo
1-Covered
piperonyl butoxidepyrethrins (LICEPYRINYL SHAMPOO) 4-033shampoo
1-Covered
piperonyl butoxidepyrethrins (LICETREATMENT) 4-033 shampoo
1-Covered
piperonyl butoxidepyrethrins (RID)4-033 shampoo
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
68
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
piperonylbutoxidepyrethrinspermethrin(COMPLETE LICE TREATMENT)butoxpyrethrpermet 4-33-5 kit
1-Covered
piperonylbutoxidepyrethrinspermethrin(LICE SOLUTION)butoxpyrethrpermet 4-33-5 kit
1-Covered
podofilox 05 solution 1-Covered
pramoxine hclcalamine(CALAHIST) 1 -8 lotion
1-Covered
pramoxine hclcalamine(CALAMINE MEDICATED) 1 -8 lotion
1-Covered
PROCTOFOAM-HC (hydrocortisoneacetatepramoxine hcl) PROCTO-1-1
1-Covered
RID (piperonylbutoxidepyrethrinspermethrin) 1-2-3 KIT KIT
1-Covered
SANTYL (collagenase clostridiumhistolyticum) OINTMENT
1-Covered QL (60 PER 30 DAYS)
selenium sulfide (ANTI-DANDRUFF)1 shampoo -
1-Covered
selenium sulfide (MEDICATEDDANDRUFF SHAMPOO) 1 shampoo
1-Covered
selenium sulfide (SELSUN BLUE) 1 shampoo
1-Covered
selenium sulfide 25 lotion 1-Covered
selenium sulfidealoe vera (SELSUNBLUE MOISTURIZING) 1 shampoo
1-Covered
tacrolimus 003 (g) 01 (g) 1-Covered PA
ELECTROLYTESMINERALSMETALSVITAMINS
ELECTROLYTEMINERAL REPLACEMENT09 sodium chloride iv soln 1-Covered PA
calcium carbonate 600 mg tablet 1-Covered
dextrose 5 in water in iv soln 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
69
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levocarnitine 330 mg tablet 1-Covered
potassium chloride in 09 sodiumchloride 09nacl 10 meql iv soln
1-Covered PA
ringers solution iv soln 1-Covered
sodium chloride irrigating solution09 soln
1-Covered
ELECTROLYTEMINERALMETAL MODIFIERSCHEMET (succimer) 100 MGCAPSULE
1-Covered PA
09 sodium chloride iv soln 1-Covered PA
CLINIMIX (amino acids 425 indextrose 5 in water) -SOLUTION
1-Covered PA
dextrose 10 and 045 sodiumchloride nacl -iv soln
1-Covered PA
dextrose 10 in water 10 10 dehp fr bg 10 10 iv soln
1-Covered PA
dextrose 5 and 045 sodiumchloride -04chlord -04iv soln
1-Covered PA
dextrose 5 in water 5 5 ivsoln 5 5 vial
1-Covered PA
levocarnitine (with sugar) 100mgml solution
1-Covered
levocarnitine 100 mgml solution330 mg tablet
1-Covered
MYNATAL (prenatal vitamins withcalciumferrous fumaratefolicacid) CAPSULE
1-Covered
O-CAL PRENATAL (prenatal vit withcalcium no127ferrousfumaratefolic acid) -TABLET
1-Covered
potassium chloride (KLOR-CONM10) meq tab er prt -
1-Covered
potassium chloride (KLOR-CONM20) meq tab er prt -
1-Covered
potassium chloride 8 meq tableter 10 meq tablet er 10 meqcapsule er 10 meq tab er prt 20meq tablet er 20 meq tab er prt20meq15ml liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
70
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
POTASSIUM CHLORIDE ER 8 MEQTABLET 10 (20 MEQ15ML) 10(40 MEQ30ML) ER 10 MEQ TABLETER 20 MEQ TABLET
1-Covered
potassium chloride in 09 sodiumchloride 20 meql soln 40 meqlsoln
1-Covered PA
PRENATABS FA (prenatal vits withcalcium no78ferrousfumaratefolic acid) TABLET
1-Covered
PRENATABS RX (prenatal vitaminwith calciumno76ironcarbonylfolic acid)TABLET
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid (MYNATAL PLUS) vitironfumfolic 65 mg-1 mg tablet
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid (MYNATAL-Z) vitiron fumfolic65 mg-1 mg tablet -
1-Covered
prenatal vits with calcium118ferrous fumaratefolic acid (SE-NATAL 19) pnv no8ironfumaratefa 29 mg-mg tab chew -9)
1-Covered
prenatal vits with calcium136ferrous fumaratefolic acid(VINATE-M) vit36ironfolic acd 27mg-mg tablet -
1-Covered
prenatal vits with calciumno115iron fumaratefolic acidno5ironfolic 29 mg-mg tab chew
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acid(M-NATAL PLUS) pnvcalcium72ironfolic 27 mg-1 mg tablet -
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acid(PREPLUS) pnvcalcium 72ironfolic27 mg-1 mg tablet
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acidpnvcalcium 72ironfolic 27 mg-1mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
71
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
prenatal vits with calciumno72ironcarbonylfolic acidpnvcalcium 72ironcarbfolic 29mg-1 mg tablet
1-Covered
prenatal vits with calciumno74ferrous fumaratefolic acidvitcal 74ironfolic 27 mg-1 mgtablet
1-Covered
SE-NATAL-19 (prenatal vitaminsno119iron fumaratefolic acid) --TABLET
1-Covered
sodium chloride irrigating solution09 soln
1-Covered
sodium polystyrene sulfonate 15g60 ml oral susp
1-Covered
sodium polystyrenesulfonatesorbitol solution (KIONEX)sulfonsorb 15 g60 ml oral susp
1-Covered
SPS (sodium polystyrenesulfonatesorbitol solution) 15GM60 ML SUSPENSION
1-Covered
TRINATE (prenatal vits with calciumno73ferrous fumaratefolic acid)TABLET
1-Covered
VITAMINS09 sodium chloride iv soln 1-Covered PA
ascorbate calcium 500 mg tablet 1-Covered
ascorbic acid (SOOTHINGPUREWAY-C) 500 mg tablet -
1-Covered
ascorbic acid 250 mg tablet 500mg5ml syrup 500 mg tablet 1000mg tablet
1-Covered
CALCIUM 500-VIT D3 MG-MCG TB 1-Covered
CALCIUM 600 MG TABLET 1-Covered
CALCIUM 600-VIT D3 MG-10MCGTB
1-Covered
calcium carbonate (OYSCO-500)500(1250) tablet -
1-Covered
calcium carbonate (SUPERCALCIUM) 600 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
72
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcium carbonate 500(1250)tablet 600 mg tablet
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (HI-CAL)carbonatevitamin 500 mg-200tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OS-CAL 500-VIT D3)carbonatevitamin mg-200 tablet --
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OYSCO 500-VIT D3)carbonatevitamin mg-200 tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OYSTERCAL-D)carbonatevitamin 500 mg-400tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) carbonatevitamin250 mg-125 tabletcarbonatevitamin 500 mg-600tablet carbonatevitamin 500 mg-400 tablet carbonatevitamin 500mg-200 tablet carbonatevitamin600 mg-400 tablet
1-Covered
calcium gluconate 60(650) mgtablet
1-Covered
calcium lactate 84 mg(648) tablet 1-Covered
cyanocobalamin (vitamin b-12) (B-12 DOTS) cyanocoalamin -) 500mcg talet -
1-Covered
cyanocobalamin (vitamin b-12)cyanocoalamin -500 mcg talet
1-Covered
dextrose 10 in water iv soln 1-Covered PA
dextrose 5 and 045 sodiumchloride -04chlord -04iv soln
1-Covered PA
dextrose 5 in lactated ringers -ivsoln
1-Covered PA
dextrose 5 in water in iv soln 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
73
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DEXTROSE IN WATER 5-IV SOLN10-IV SOLUTION
1-Covered PA
electrolytesdextrose(ELECTROLYTE) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (ORALYTE)solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (PEDIATRICELECTROLYTE) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (PEDIATRICFREEZER POPS) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
ferrous sulfate (CHILDRENS IRON)15 mgml drops
1-Covered
ferrous sulfate (FEOSOL) 325(65)mg tablet
1-Covered
ferrous sulfate (FEROSUL) 325(65)mg tablet
1-Covered
ferrous sulfate (FERRO-TIME) 325(65)mg tablet -
1-Covered
ferrous sulfate (FERROUSUL) 325(65)mg tablet
1-Covered
ferrous sulfate (PEDIA IRON) 15mgml drops
1-Covered
ferrous sulfate 15 mgml drops 220(44)5 solution 220 (44)5 elixir324(65)mg tablet dr 325(65) mgtablet dr 325(65) mg tablet
1-Covered
FERROUS SULFATE SULF 220 MG5ML LIQ SULF EC 325 MG TABLETSULFATE 325 MG TABLET
1-Covered
fluoride (sodium) 025(055) tabchew 05(11)mg tab chew 05mgml drops 1mg(22mg) tabchew
1-Covered STAR (Preferred Drug)
folic acid 04 mg tablet 08 mgtablet 1 mg tablet 20 mg capsule
1-Covered
FOLIC ACID 400 MCG TABLET 800MCG TABLET
1-Covered
IRON 65 MG TABLET 1-Covered
OYSTER SHELL CALCIUM 500 MG TB 1-Covered
OYSTER SHELL CALCIUM-VIT D3 250MG-312MCG
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
74
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PEDIATRIC IRON PHARM CHC15MGML DRP
1-Covered
pediatric multivit with acd3no21sodium fluorideno21fluoride 025 mgml dropsno21fluoride 05 mgml drops
1-Covered STAR (Preferred Drug)
pediatric multivitaminno16sodium fluoride -025 mg tabche -05 mg tab che -1 mg tabche
1-Covered
pediatric multivitamin no2sodiumfluoride w-025 mgml drops
1-Covered
pediatric multivitamin no2sodiumfluoride w-05 mgml drops
1-Covered STAR (Preferred Drug)
pediatric multivitaminno45sodium fluorideferroussulfate 45fluorideiron 025-10mldrops
1-Covered STAR (Preferred Drug)
pediatric multivitamins no17 withsodium fluoride -025 mg tab che -05 mg tab che -1 mg tab che
1-Covered STAR (Preferred Drug)
POLY-VITAMIN (multivitamin) -TABCHEW
1-Covered STAR (Preferred Drug)
POTASSIUM 99 MG TABLET 1-Covered
potassium bicarbonatecitric acid(EFFER-K) 25 meq tablet eff -
1-Covered
potassium bicarbonatecitric acid(K EFFERVESCENT) 25 meq tableteff
1-Covered
potassium bicarbonatecitric acid(KLOR-CON-EF) 25 meq tablet eff --
1-Covered
potassium bicarbonatecitric acid25 meq tablet eff
1-Covered
POTASSIUM CHL-NORMAL SALINE20 -ML IV SOLN 40 -ML IV SOLN
1-Covered
potassium chloride (KLOR-CONSPRINKLE) 10 meq capsule er -
1-Covered
potassium chloride 20meq15mlliquid
1-Covered
potassium chloridepotassiumbicarbonatecitric acidchloridebicarbcit 25 meq tableteff
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
75
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
potassium gluconate 595(99)mgtablet
1-Covered
PRENATAL MULTIVITAMIN TABLET 1-Covered
prenatal vit with calciumno129ferrous fumaratefolic acidno129ironfolic 27mg-08mgtablet
1-Covered
prenatal vit with calciumno130ferrous fumaratefolic acidno130ironfolic 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vitamins no121ferrousfumaratefolic acid pnvno121ironfolic 28mg-08mgtablet
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid vitiron fumfolic 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vitamins withcalciumferrous fumaratefolicacid vitiron fumfolic 28mg-08mgtablet
1-Covered
prenatal vits with calcium118ferrous fumaratefolic acidpnv no8iron fumaratefa 29 mg-mg tab chew
1-Covered
prenatal vits with calcium137ferrous fumaratefolic acidno137ironfolic acd 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vits with calcium95ferrous fumaratefolic acid pnvno95ferrous fumfolic 28mg-08mg tablet
1-Covered
prenatal vits with calciumno96ferrous fumaratefolic acidvits96iron fumfolic 27mg-08mgtablet
1-Covered
pyridoxine hcl (vitamin b6) 25 mgtablet 50 mg tablet 100 mgtablet 250 mg tablet
1-Covered
ringers solution iv soln 1-Covered PA
SODIUM CHLORIDE 09 IRRIG 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
76
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SODIUM CHLORIDE 09 SOLUTION 1-Covered PA
sodium chloride irrigating solution(AQUA CARE SODIUM CHLORIDE)09 soln
1-Covered
sodium chloride irrigating solution(CURITY) 09 soln
1-Covered
sodium chloride irrigating solution09 soln
1-Covered
TRI-VI-SOL (vitamin apalmitateascorbicacidcholecalciferol (vit d3)) --DROPS (vitmin plmittescorbiccidcholeclciferol
1-Covered STAR (Preferred Drug)
VITAMIN B-12 -500 MCG TALET 1-Covered
VITAMIN C 1000 MG TABLET 1-Covered
GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach)
ANTISPASMODICS GASTROINTESTINAL (Drugs to Prevent Bowel andStomach Spasam)
CHLORDIAZEPOXIDE-CLIDINIUM -CAP
1-Covered MDD (8 Per Day)
chlordiazepoxideclidiniumbromide 5 mg-25mg capsule
1-Covered MDD (8 Per Day)
DICYCLOMINE HCL 10 MG5 MLSOLN
1-Covered
dicyclomine hcl 10 mg5 mlsolution 10 mg capsule 20 mgtablet
1-Covered
hyoscyamine sulfate (HYOSYNE)0125mgml drops 125mcg5mlelixir
1-Covered
hyoscyamine sulfate 0125 mg tabsubl 0125 mg tablet 0125mgmldrops 0375 mg tab er 12h125mcg5ml elixir
1-Covered
propantheline bromide 15 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
77
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GASTROINTESTINAL AGENTS OTHER (Other Drugs for the Bowel andStomach)
ALLI (orlistat) 60 MG CAPSULE 1-Covered PA
ANTACID 500 MG CHEW TABLET 1-Covered
ANTACID EXTRA STRENGTH -750 MGTAB CHEW CVS -750 MG CHEW
1-Covered
ANTI-DIARRHEAL HM -2 MGSOFTGEL
1-Covered
bismuth subsalicylate (BISMATROL)262 mg tab chew
1-Covered
bismuth subsalicylate (DIOTAME)262 mg tab chew
1-Covered
bismuth subsalicylate (PEP-T-MED)262 mg tab chew --
1-Covered
bismuth subsalicylate (PEPTICRELIEF) 262 mg tab chew
1-Covered
bismuth subsalicylate (PINKBISMUTH) 262 mg tab chew
1-Covered
bismuth subsalicylate (SOOTHE)262 mg tab chew
1-Covered
bismuth subsalicylate (STOMACHRELIEF) 262 mg tab chew
1-Covered
bismuth subsalicylate 262 mg tabchew
1-Covered
calcium carbonate (ANTACIDCALCIUM) 215(500)mg tab chew
1-Covered
calcium carbonate (ANTACIDEXTRA STRENGTH) 300mg(750) tabchew
1-Covered
calcium carbonate (ANTACID)200(500)mg tab chew 215(500)mgtab chew 300mg(750) tab chew
1-Covered
calcium carbonate (BAN-ACID)300mg(750) tab chew -
1-Covered
calcium carbonate (CAL-GEST)200(500)mg tab chew -
1-Covered
calcium carbonate (CALCIUMANTACID) 200(500)mg tab chew215(500)mg tab chew 300mg(750)tab chew
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
78
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcium carbonate (CHILDRENSPEPTO) 400 mg tab chew
1-Covered
calcium carbonate (CHILDRENSSOOTHE) 400 mg tab chew
1-Covered
calcium carbonate (FLAVORCHEWS ANTACID) 300mg(750) tabchew
1-Covered
calcium carbonate (SMOOTHANTACID) 300mg(750) tab chew
1-Covered
calcium carbonate (SMOOTHDISSOLVING ANTACID) 300mg(750)tab chew
1-Covered
calcium carbonate 200(500)mgtab chew 300mg(750) tab chew
1-Covered
diphenoxylate hclatropine sulfate25-0255 liquid 25-025mg tablet
1-Covered
DIPHENOXYLATE-ATROPINE -25-0025
1-Covered
GAS RELIEF (simethicone) (SIMETH)80 MG CHEW
1-Covered
GAS RELIEF GAS 125 MG CHEWTABLET GAS (SIMETH) 80 MGCHEW HM GAS 125 MG SOFTGELHM GAS 125 MG CHEW TAB
1-Covered
GAS-X (simethicone) -E-STR 125 MGTAB CHEW
1-Covered
INFANTS GAS RELIEF RLF 20 MG03ML
1-Covered
loperamide hcl (ANTI-DIARRHEAL) 2mg capsule - 2 mg tablet -
1-Covered
loperamide hcl (DIAMODE) 2 mgtablet
1-Covered
loperamide hcl (ULTRA A-D) 2 mgtablet -
1-Covered
loperamide hcl 1 mg5 ml liquid 2mg capsule 2 mg tablet
1-Covered
PEPTO-BISMOL (bismuthsubsalicylate) -TABLET CHEW
1-Covered
PEPTO-BISMOL TO-GO (bismuthsubsalicylate) --262 MG CHEW
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
79
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
simethicone (GAS RELIEF)40mg06ml drops susp 80 mg tabchew 125 mg tab chew 125 mgcapsule
1-Covered
simethicone (GAS-X) 125 mgcapsule -
1-Covered
simethicone (INFANT GAS RELIEF)40mg06ml drops susp
1-Covered
simethicone (INFANTS GAS RELIEF)40mg06ml drops susp
1-Covered
simethicone (MI-ACID) 80 mg tabchew -
1-Covered
simethicone 40mg06ml dropssusp 80 mg tab chew 125 mgcapsule 125 mg tab chew
1-Covered
STOMACH RELIEF 262 MG CHEWTAB
1-Covered
ursodiol 300 mg capsule 1-Covered
HISTAMINE2 (H2) RECEPTOR ANTAGONISTSACID CONTROLLER 20 MG TABLET 1-Covered
ACID REDUCER 10 MG TABLET 1-Covered PA
ACID REDUCER 20 MG TABLET 1-Covered
cimetidine (ACID REDUCER) 200mg tablet
1-Covered
cimetidine (HEARTBURN RELIEF) 200mg tablet
1-Covered
cimetidine 200 mg tablet 300 mgtablet 400 mg tablet 800 mgtablet
1-Covered
CIMETIDINE 300 MG5 ML SOLN 1-Covered
cimetidine hcl 300 mg5ml solution 1-Covered
famotidine (ACID CONTROLLER) 10mg tablet
1-Covered PA
famotidine (ACID CONTROLLER) 20mg tablet
1-Covered
famotidine (ACID REDUCER) 10 mgtablet
1-Covered PA
famotidine (ACID REDUCER) 20 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
80
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
famotidine (HEARTBURNPREVENTION) 10 mg tablet
1-Covered PA
famotidine (HEARTBURNPREVENTION) 20 mg tablet
1-Covered
famotidine (HEARTBURN RELIEF) 10mg tablet
1-Covered PA
famotidine (HEARTBURN RELIEF) 20mg tablet
1-Covered
famotidine (PEPCID) 20 mg tablet 1-Covered
famotidine 10 mg tablet 1-Covered PA
FAMOTIDINE 10 MG TABLET 1-Covered PA
famotidine 20 mg tablet 40 mgtablet
1-Covered
FAMOTIDINE 20 MG TABLET EQ 20MG TABLET 40 MG TABLET
1-Covered
IRRITABLE BOWEL SYNDROME AGENTSAMITIZA (lubiprostone) 8 MCGCAPSULE 24 MCG CAPSULES
1-Covered PA
LAXATIVES (Drugs for Bowel Cleansing and Constipation)bisacodyl (ALOPHEN PILLS) 5 mgtablet dr
1-Covered
bisacodyl (BISA-LAX) 5 mg tablet dr-
1-Covered
bisacodyl (BISACODYL) 5 mgtablet dr
1-Covered
bisacodyl (BISCOLAX) 10 mgsupprect
1-Covered
bisacodyl (C-LAX LAXATIVE) 5 mgtablet dr -ATIVE)
1-Covered
bisacodyl (DUCODYL) 5 mg tabletdr
1-Covered
bisacodyl (FAST RELIEF LAXATIVE)10 mg supprect
1-Covered
bisacodyl (GENTLE LAXATIVE) 5 mgtablet dr 10 mg supprect
1-Covered
bisacodyl (LAXATIVE SUPPOSITORY)10 mg supprect
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
81
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
bisacodyl (LAXATIVE) 5 mg tabletdr
1-Covered
bisacodyl (MAGIC BULLET) 10 mgsupprect
1-Covered
bisacodyl (WOMENS GENTLELAXATIVE) 5 mg tablet dr
1-Covered
bisacodyl (WOMENS LAXATIVE) 5mg tablet dr
1-Covered
bisacodyl 5 mg tablet dr 10 mgsupprect
1-Covered
BISACODYL EC 5 MG TABLET 10MG SUPPOSITORY
1-Covered
docusate sodium (COL-RITE) 100mg capsule - 250 mg capsule -
1-Covered
docusate sodium (DIOCTYL) 60mg15ml syrup
1-Covered
docusate sodium (DOCU LIQUID)50 mg5 ml liquid
1-Covered
docusate sodium (DOCUSIL) 100mg capsule
1-Covered
docusate sodium (DSS) 250 mgcapsule
1-Covered
docusate sodium (DULCOEASE)100 mg capsule
1-Covered
docusate sodium (DULCOLAXSTOOL SOFTENER) 100 mg capsule
1-Covered
docusate sodium (LAXA BASIC 100)mg capsule )
1-Covered
docusate sodium (PHILLIPSLAXATIVE) 100 mg capsule
1-Covered
docusate sodium (SOF-LAX) 100mg capsule -
1-Covered
docusate sodium (STOOLSOFTENER) 50 mg capsule 50 mg5ml liquid 60 mg15ml syrup 100mg capsule 250 mg capsule
1-Covered
DOCUSATE SODIUM 50 MG5 MLLIQ 100 MG SOFTGEL
1-Covered
docusate sodium 50 mg5 mlliquid 60 mg15ml syrup 100 mgcapsule 250 mg capsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
82
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DOK (docusate sodium) 100 MG250 MG
1-Covered
GENTLE LAXATIVE 10 MG SUPPOSIT 1-Covered
glycerin (ADULT GLYCERIN) adultsupprect
1-Covered
glycerin (LAXATIVE SUPPOSITORY)pediatric supprect
1-Covered
glycerin (PEDIA-LAX) pediatricsupprect -
1-Covered
glycerin (SUPPOSITORY) adultsupprect
1-Covered
glycerin adult pediatric 1-Covered
lactulose (CONSTULOSE) 10 g15 mlsolution
1-Covered
lactulose (ENULOSE) 10 g15 mlsolution
1-Covered
lactulose (GENERLAC) 10 g15 mlsolution
1-Covered
lactulose 10 g15 ml 20 g30 ml 1-Covered
MAGNESIUM CITRATE HM SOLUTION 1-Covered
magnesium citrate solution 1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloride(GAVILYTE-C) peg3350sodsulfbicarbclkcl 240-2272g solnrecon -
1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloride(GAVILYTE-G) peg3350sodsulfbicarbclkcl 236-2274g solnrecon -
1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloridepeg3350sod sulfbicarbclkcl 236-2274g soln peg3350sodsulfbicarbclkcl 240-2272g soln
1-Covered
PEG-3350 AND ELECTROLYTES -SOLN
1-Covered
polyethylene glycol 3350(CLEARLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
83
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
polyethylene glycol 3350(GAVILAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(GENTLELAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(GLYCOLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(LAXACLEAR) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350 (NATURA-LAX) 17gdose powder -
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(POWDERLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(PURELAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(SMOOTHLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350 17gdosepowder
1-Covered QL (527 PER 30 DAY(S))
SILACE (docusate sodium) 50MG5 ML LIQUID
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepeg (GAVILYTE-N)chloridenahco3kclpeg 420gsoln recon -
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepeg (TRILYTE WITH FLAVORPACKETS)chloridenahco3kclpeg 420gsoln recon
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepegchloridenahco3kclpeg 420gsoln recon
1-Covered
STOOL SOFTENER (docusatesodium) 100 MG SOFTGEL 100 MGCAPSULE 250 MG SOFTGEL
1-Covered
STOOL SOFTENER HM 100 MGSFTGL 100 MG SOFTGEL HM 250MG SFTGL
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
84
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PROTECTANTSmisoprostol 100 mcg tablet 200mcg tablet
1-Covered PA
sucralfate 1 g tablet 1-Covered
PROTON PUMP INHIBITORSlansoprazole 15 mg capsule dr 1-Covered ST
lansoprazole 30 mg capsule dr 1-Covered
LANSOPRAZOLE DR 15 MGCAPSULE
1-Covered ST
LANSOPRAZOLE DR 30 MGCAPSULE
1-Covered
omeprazole 10 mg capsule dr 20mg tablet dr
1-Covered
omeprazole 20 mg capsule dr 1-Covered QL (60 PER 30 DAYS)
omeprazole 40 mg capsule dr 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
OMEPRAZOLE DR 20 MG CAPSULE 1-Covered QL (60 PER 30 DAYS)
OMEPRAZOLE DR 20 MG TABLET 1-Covered
pantoprazole sodium 20 mg tabletdr 40 mg tablet dr
1-Covered
PANTOPRAZOLE SODIUM DR 20 MGTAB DR 40 MG TAB
1-Covered
PREVACID (lansoprazole) DR 15MG CAPSULE
1-Covered
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERSTREATMENT (Drugs for Genetic or Enzyme Disorders)
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERSTREATMENT
CREON (lipaseproteaseamylase)DR 6000 UNITS CAPSULE
1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
85
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GENITOURINARY AGENTS (Drugs for the Genital Bladder andKidney)
ANTISPASMODICS URINARY (Drugs for Bladder Spasms)oxybutynin chloride 5 mg5 mlsyrup 5 mg tab er 24 5 mg tablet10 mg tab er 24 15 mg tab er 24
1-Covered
OXYBUTYNIN CHLORIDE ER ER 5 MGTABLET ER 10 MG TABLET ER 15 MGTABLET
1-Covered
OXYTROL FOR WOMEN(oxybutynin) 39 MG24HR
1-Covered ST
trospium chloride 20 mg tablet 1-Covered ST
TROSPIUM CHLORIDE 20 MG TABLET 1-Covered ST
BENIGN PROSTATIC HYPERTROPHY AGENTSalfuzosin hcl 10 mg tab er 24h 1-Covered PA
finasteride 5 mg tablet 1-Covered
tamsulosin hcl 04 mg capsule 1-Covered
GENITOURINARY AGENTS OTHER (Other Drugs for the GenitalBladder and Kidney)
bethanechol chloride 5 mg tablet10 mg tablet 25 mg tablet 50 mgtablet
1-Covered
citric acidsodium citrate (CYTRA-2) 334-500mg solution -
1-Covered
citric acidsodium citrate(VIRTRATE-2) 334-500mg solution -
1-Covered
citric acidsodium citrate 334-500mg solution
1-Covered
nonoxynol 9 (VCF) 125 foamappl
1-Covered
penicillamine 250 mg capsule 1-Covered PA QL (16 PER 1 DAY(S))
PENICILLAMINE 250 MG CAPSULE 1-Covered PA QL (16 PER 1 DAY(S))
phenazopyridine hcl (URINARYPAIN RELIEF) 95 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
86
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PHENAZOPYRIDINE HCL 100 MGTAB 200 MG TAB
1-Covered
phenazopyridine hcl 100 mgtablet 200 mg tablet
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit ac(CYTRA-3) sodpotk citsod citcitacid 500-5505 solution -
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit ac(TRICITRATES) sodpotk citsodcitcit acid 500-5505 solution
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit acsodpotk citsod citcit acid 500-5505 solution
1-Covered
URINARY PAIN RELIEF HM RLF 95 MGTAB
1-Covered
PHOSPHATE BINDERScalcium acetate (ELIPHOS) 667 mgtablet
1-Covered QL (270 PER 30 DAYS) AL1 (Atleast 21 yrs old)
calcium acetate 667 mg capsule667 mg tablet
1-Covered QL (270 PER 30 DAYS) AL1 (Atleast 21 yrs old)
lanthanum carbonate 500 mg tabchew 750 mg tab chew 1000 mgtab chew
1-Covered PA
sevelamer carbonate 800 mgtablet
1-Covered PA
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(ADRENAL) (Drugs for ReplacingStimulating Adrenal GlandHormones)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(ADRENAL) (Glucocorticoids)
betamethasone dipropionate 005 lotion
1-Covered
betamethasone dipropionate 005 oint (g) 005 cream (g)
1-Covered ST
BETAMETHASONE DIPROPIONATEDP 005 OINT
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
87
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
betamethasonedipropionatepropylene glycolbetamethasonepropylene 005 cream (g)
1-Covered ST
betamethasone valerate 01 lotion 01 cream (g) 01 oint(g)
1-Covered
clobetasol propionate 005 gel(gram) 005 solution 005 cream (g) 005 oint (g)
1-Covered ST
CLOBETASOL PROPIONATE 005CREAM
1-Covered ST
DELTASONE (prednisone) 20 MGTABLET
1-Covered
desonide 005 lotion 005 oint(g) 005 cream (g)
1-Covered ST
DESONIDE 005 LOTION 005CREAM
1-Covered ST
dexamethasone(DEXAMETHASONE INTENSOL) 1mgml drops
1-Covered
dexamethasone 05 mg5mlsolution 05 mg tablet 05 mg5mlelixir 075 mg tablet 1 mg tablet15 mg tablet 2 mg tablet 4 mgtablet 6 mg tablet
1-Covered
DEXAMETHASONE 4 MG TABLET 1-Covered
fludrocortisone acetate 01 mgtablet
1-Covered
fluocinolone acetonide 001 cream (g) 001 solution 0025 cream (g) 0025 oint (g)
1-Covered ST
fluocinonide 005 cream (g) 005 gel (gram) 005 oint (g) 005 solution
1-Covered
FLUOCINONIDE 005 OINTMENT 1-Covered
hydrocortisone (ANTI-ITCH) 1 cream (g) -
1-Covered
hydrocortisone (ANUSOL-HC) 25 crmpe app -
1-Covered
hydrocortisone (CORTISONE) 1 cream (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
88
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
hydrocortisone (CORTIZONE-10PLUS) cream (g) -0
1-Covered
hydrocortisone (CORTIZONE-10) cream (g) -
1-Covered
hydrocortisone (HYDROCREAM) 1 cream (g)
1-Covered
hydrocortisone (NOBLE FORMULAHC) 1 cream (g)
1-Covered
hydrocortisone (PREPARATION H) 1 cream (g)
1-Covered
hydrocortisone (PROCTO-MED HC)25 crmpe app -
1-Covered
hydrocortisone (PROCTO-PAK) 1 crmpe app -
1-Covered
hydrocortisone (PROCTOSOL-HC)25 crmpe app -
1-Covered
hydrocortisone (PROCTOZONE-HC)25 crmpe app -
1-Covered
hydrocortisone (SOOTHING CARE)1 cream (g)
1-Covered
hydrocortisone 05 oint (g) 1 cream (g) 1 oint (g) 1 crmpe app 25 cream (g) 25 crmpe app 25 oint (g) 25 lotion 5 mg tablet 10 mg tablet20 mg tablet
1-Covered
HYDROCORTISONE 5 MG TABLET10 MG TABLET
1-Covered
hydrocortisone acetate(ANUCORT-HC) 25 mg supprect -
1-Covered
hydrocortisone acetate (ANUSOL-HC) 25 mg supprect -
1-Covered
hydrocortisone acetate(HEMMOREX-HC) 25 mg supprect -
1-Covered
HYDROCORTISONE ACETATE 25 MGSUPP
1-Covered
hydrocortisone acetate 25 mgsupprect
1-Covered
methylprednisolone 4 mg tablet 4mg tab ds pk 8 mg tablet 16 mgtablet 32 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
89
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
mometasone furoate 01 cream(g) 01 oint (g)
1-Covered
prednisolone (MILLIPRED DP) 5 mg(48) tab 5 mg (21) tab
1-Covered
prednisolone (MILLIPRED) 5 mgtablet
1-Covered
prednisolone 15 mg5 ml solution 1-Covered
prednisolone sodium phosphate 5mg5 ml 15 mg5 ml
1-Covered
prednisone (PREDNISONEINTENSOL) 5 mgml oral conc
1-Covered
prednisone 1 mg tablet 25 mgtablet 5 mg tab ds pk 5 mgtablet 5 mg5 ml solution 10 mgtablet 10 mg tab ds pk 20 mgtablet 50 mg tablet
1-Covered
triamcinolone acetonide 0025 oint (g) 0025 cream (g) 0025 lotion 01 cream (g) 01 lotion 01 oint (g) 0147mggaerosol 05 cream (g) 05 oint(g)
1-Covered
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(PITUITARY) (Drugs for ReplacingStimulating Pituitary GlandHormones)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(PITUITARY) (Drugs to ReplaceStimulate Pituitary Gland Hormones)
desmopressin acetate (non-refrigerated) (nonrefrigerated)10spray spraypump
1-Covered PA AL1 (8 to 14 yrs old)
desmopressin acetate 01 mgmlsolution 01 mg tablet 02 mgtablet
1-Covered AL1 (8 to 14 yrs old)
desmopressin acetate 4 mcgmlvial 4 mcgml ampul 10sprayspraypump
1-Covered PA AL1 (8 to 14 yrs old)
DESMOPRESSIN ACETATE 40MCG10 ML VIAL
1-Covered PA AL1 (8 to 14 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
90
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEXHORMONESMODIFIERS) (Drugs for ReplacingStimulating SexHormones)
ANDROGENSdanazol 50 mg capsule 100 mgcapsule 200 mg capsule
1-Covered
fluoxymesterone (ANDROXY) 10mg tablet
1-Covered
testosterone 125125g gel mdpmp 50 mg (1) gel packet
1-Covered PA
testosterone cypionate 100 mgmlvial 200 mgml vial
1-Covered PA
ESTROGENS (Contraceptives and Drugs for Menopause)desogestrel-ethinyl estradiol (APRI)-015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(CYRED EQ) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(CYRED) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(EMOQUETTE) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(ENSKYCE) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(ISIBLOOM) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(JULEBER) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(KALLIGA) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(RECLIPSEN) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol -015-003 tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (AZURETTE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
91
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
desogestrel-ethinyl estradiolethinylestradiol (BEKYREE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (KARIVA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (KIMIDESS) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (PIMTREA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (SIMLIYA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (VIORELE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (VOLNEA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol -eestradioleestradiol 21-5 (28) tablet
1-Covered
DROSPIRENONE-ETHINYL ESTRADIOL-EE 3-002 MG TAB
1-Covered
estradiol (DOTTI) 025mg24hpatch 0375mg24 patch005mg24h patch 075mg24hpatch 01mg24hr patch
1-Covered QL (16 PER 28 DAY(S))
estradiol 025mg24h patch0375mg24 patch 005mg24hpatch 075mg24h patch01mg24hr patch
1-Covered QL (16 PER 28 DAY(S))
estradiol 001 creamappl025mg24h patch tdwk005mg24h patch tdwk075mg24h patch tdwk01mg24hr patch tdwk 05 mgtablet 1 mg tablet 2 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
92
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ESTRADIOL 1 MG TABLET 2 MGTABLET
1-Covered
estrogensesterifiedmethyltestosterone (COVARYX HS)estrogenesterme-0625-125tablet
1-Covered PA
estrogensesterifiedmethyltestosterone (EEMT HS) estrogenesterme-0625-125 tablet
1-Covered PA
estrogensesterifiedmethyltestosterone estrogenesterme-0625-125tablet
1-Covered PA
ethinyl estradioldrospirenone(GIANVI) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(JASMIEL) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone (LO-ZUMANDIMINE) 002-3(28) tablet -
1-Covered
ethinyl estradioldrospirenone(LORYNA) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(NIKKI) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(VESTURA) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone 002-3(28) tablet
1-Covered
ethynodiol diacetate-ethinylestradiol (KELNOR 1-35) ethynoiol -estraiol mg-35mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol (KELNOR 1-50) ethynoiol -estraiol mg-50mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol (ZOVIA 1-35E) ethynoiol -estraiol mg-35mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol ethynoiol -estraiol 1 mg-50mcg tablet ethynoiol -estraiol 1mg-35mcg tablet
1-Covered
etonogestrelethinyl estradiol(ELURYNG) 12-015mg vag ring
1-Covered QL (1 PER 28 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
93
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
etonogestrelethinyl estradiol 12-015mg vag ring
1-Covered QL (1 PER 28 DAY(S))
HAILEY FE 1-20 TABLET 15-30 TABLET 1-Covered
LEVONORGESTREL-ETH ESTRADIOL -TRIPHASIC
1-Covered
levonorgestrelethinyl estradiol(AFIRMELLE)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(ALTAVERA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(AUBRA EQ)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AUBRA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AVIANE)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AYUNA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(CHATEAL EQ)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(CHATEAL)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(DELYLA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(ENPRESSE)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
94
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrelethinyl estradiol(FALMINA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(KURVELO)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(LARISSIA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(LESSINA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(LEVONEST)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
levonorgestrelethinyl estradiol(LEVORA-28)levonorgestrelethinestradiol 015-003 tablet -
1-Covered
levonorgestrelethinyl estradiol(LILLOW)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(LUTERA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(MARLISSA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(MYZILRA)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
levonorgestrelethinyl estradiol(ORSYTHIA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
95
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrelethinyl estradiol(PORTIA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(SRONYX)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(TRIVORA-28)levonorgestrelethinestradiol 6-5-10 tablet -
1-Covered
levonorgestrelethinyl estradiol(VIENVA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiollevonorgestrelethinestradiol 01-002mg tabletlevonorgestrelethinestradiol 015-003 tabletlevonorgestrelethinestradiol 6-5-10 tablet
1-Covered
LYLLANA 0025 MG PATCH 00375MG PATCH 005 MG PATCH 0075MG PATCH 01 MG PATCH
1-Covered QL (16 PER 28 DAY(S))
MENEST (estrogensesterified) 03MG TABLET 0625 MG TABLET 125MG TABLET 25 MG TABLET
1-Covered
MICROGESTIN 21 1-20 TABLET 1-Covered
MICROGESTIN FE 1-20 TABLET 1-Covered
norelgestrominethinyl estradiol(XULANE)norelgestrominethinestradiol 150-3524h patch tdwk
1-Covered QL (3 PER 28 DAY(S))
norethindrone acetate-ethinylestradiol (AUROVELA) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (GILDESS) -15-003mgtablet
1-Covered
norethindrone acetate-ethinylestradiol (HAILEY) -15-003mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
96
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone acetate-ethinylestradiol (JUNEL) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (LARIN) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (MICROGESTIN) -1mg-20mcg tablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol -1mg-20mcg tablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate(AUROVELA FE) -eestradiol-iron15-30(21) tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (BLISOVIFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (JUNELFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (LARINFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate(MICROGESTIN FE) --1mg-20(21)tablet --15-30(21) tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TARINAFE 1-20 EQ) -eestradiol-iron mg-(2)tablet -
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TARINAFE) -eestradiol-iron 1mg-20(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TILIA FE)-eestradiol-iron 5-7-9-7 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
97
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone acetate-ethinylestradiolferrous fumarate (TRI-LEGEST FE) -eestradiol-iron 5-7-9-7tablet -
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate --1mg-20(21) tablet --15-30(21) tablet
1-Covered
norethindrone-ethinyl estradiol(ALYACEN) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(ARANELLE) -ethin 7-9-5 tablet
1-Covered
norethindrone-ethinyl estradiol(BALZIVA) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(BRIELLYN) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(CYCLAFEM) -1 mg-35mcg tablet -7 days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(DASETTA) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(LEENA) -ethin 7-9-5 tablet
1-Covered
norethindrone-ethinyl estradiol(NECON) -ethin 05-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(NORTREL) -05-0035 tablet -1 mg-35mcg tablet -7 days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(PHILITH) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(PIRMELLA) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(VYFEMLA) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(WERA) -ethin 05-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(ZENCHENT) -ethin 04-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(ESTARYLLA) -025-0035 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
98
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norgestimate-ethinyl estradiol(FEMYNOR) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(MILI) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(MONO-LINYAH) -025-0035 tablet -
1-Covered
norgestimate-ethinyl estradiol(MONONESSA) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(PREVIFEM) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(SPRINTEC) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol (TRIFEMYNOR) -7daysx3 28 tablet
1-Covered
norgestimate-ethinyl estradiol (TRI-ESTARYLLA) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-LINYAH) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-ESTARYLLA) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-MARZIA) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-MILI) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-SPRINTEC) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-PREVIFEM) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-SPRINTEC) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-VYLIBRA LO) -7daysx3 lo tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-VYLIBRA) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol(TRINESSA LO) -7daysx3 lo tablet
1-Covered
norgestimate-ethinyl estradiol(TRINESSA) -7daysx3 28 tablet
1-Covered
norgestimate-ethinyl estradiol(VYLIBRA) -025-0035 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
99
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NORGESTIMATE-ETHINYL ESTRADIOL-025-0035 MG
1-Covered
norgestimate-ethinyl estradiol -025-0035 tablet -7daysx3 28tablet -7daysx3 lo tablet
1-Covered
norgestrel-ethinyl estradiol(CRYSELLE) -03-003mg tablet
1-Covered
norgestrel-ethinyl estradiol (ELINEST)-03-003mg tablet
1-Covered
norgestrel-ethinyl estradiol (LOW-OGESTREL) -03-003mg tablet -
1-Covered
norgestrel-ethinyl estradiol(OGESTREL) -05 mg-50 tablet
1-Covered
PREMARIN (estrogens conjugated)03 MG TABLET 045 MG TABLET0625 MG TABLET 09 MG TABLET125 MG TABLET
1-Covered
PREMARIN (estrogens conjugated)VAGINAL CREAM-APPL
1-Covered QL (43 PER 30 DAY(S))
PREMPHASE (estrogensconjugatedmedroxyprogesteroneacetate) 0625-5 MG TABLET
1-Covered
PREMPRO (estrogensconjugatedmedroxyprogesteroneacetate) 03 MG-15 MG TABLET045-15 MG TABLET 0625-5 MGTABLET 0625-25 MG TABLET
1-Covered
ZOVIA 1-35 -TABLET 1-Covered
PROGESTINSDEPO-PROVERA(medroxyprogesterone acetate) -400 MGML VIAL
1-Covered
DEPO-SUBQ PROVERA 104(medroxyprogesterone acetate) -SYRINGE
1-Covered
hydroxyprogesterone caproate250 mgml vial
1-Covered PA SP
hydroxyprogesterone caproatepfcaproatpf 250 mgml vial
1-Covered PA SP
JENCYCLA 035 MG TABLET 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
100
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrel (AFTERA) 15 mgtablet
1-Covered
levonorgestrel (ECONTRA EZ) 15mg tablet
1-Covered
levonorgestrel (ECONTRA ONE-STEP) 15 mg tablet -
1-Covered
levonorgestrel (FALLBACK SOLO)15 mg tablet
1-Covered
levonorgestrel (MY CHOICE) 15mg tablet
1-Covered
levonorgestrel (MY WAY) 15 mgtablet
1-Covered
levonorgestrel (NEW DAY) 15 mgtablet
1-Covered
levonorgestrel (OPCICON ONE-STEP) 15 mg tablet -
1-Covered
levonorgestrel (OPTION 2) 15 mgtablet
1-Covered
levonorgestrel (TAKE ACTION) 15mg tablet
1-Covered
levonorgestrel 15 mg tablet 1-Covered QL (1 PER 1 DAYS)
MEDROXYPROGESTERONE ACETATE150 MGML
1-Covered QL (1 PER 84 DAYS)
medroxyprogesterone acetate 150mgml vial 150 mgml syringe
1-Covered QL (1 PER 84 DAYS)
MEDROXYPROGESTERONE ACETATE25 MG TAB
1-Covered
medroxyprogesterone acetate 25mg tablet 5 mg tablet 10 mgtablet
1-Covered
megestrol acetate 20 mg tablet40 mg tablet
1-Covered
megestrol acetate 400mg10mloral susp
1-Covered PA
norethindrone (CAMILA) 035 mgtablet
1-Covered
norethindrone (DEBLITANE) 035 mgtablet
1-Covered
norethindrone (ERRIN) 035 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
101
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone (HEATHER) 035 mgtablet
1-Covered
norethindrone (INCASSIA) 035 mgtablet
1-Covered
norethindrone (JENCYCLA) 035mg tablet
1-Covered
norethindrone (JOLIVETTE) 035 mgtablet
1-Covered
norethindrone (LYZA) 035 mgtablet
1-Covered
norethindrone (NORA-BE) 035 mgtablet -
1-Covered
norethindrone (NORLYDA) 035 mgtablet
1-Covered
norethindrone (NORLYROC) 035mg tablet
1-Covered
norethindrone (SHAROBEL) 035 mgtablet
1-Covered
norethindrone (TULANA) 035 mgtablet
1-Covered
norethindrone 035 mg tablet 1-Covered
norethindrone acetate 5 mg tablet 1-Covered
PLAN B ONE-STEP (levonorgestrel) -15 MG TALET
1-Covered
TAKE ACTION (levonorgestrel) 15MG TABLET
1-Covered
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(THYROID) (Drugs for the Thyroid)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(THYROID) (Drugs to Replace Thyroid Hormone)
ARMOUR THYROID (thyroidpork) 15MG TABLET 30 MG TABLET 60 MGTABLET 90 MG TABLET 120 MGTABLET 180 MG TABLET 240 MGTABLET 300 MG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
102
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LEVO-T (levothyroxine sodium) -25MCG ABLE -50 MCG ABLE -75MCG ABLE -88 MCG ABLE -100MCG ABLE -112 MCG ABLE -125MCG ABLE -137 MCG ABLE -150MCG ABLE -175 MCG ABLE -200MCG ABLE -300 MCG ABLE
1-Covered
levothyroxine sodium 25 mcgtablet 50 mcg tablet 75 mcgtablet 88 mcg tablet 100 mcgtablet 112 mcg tablet 125 mcgtablet 137 mcg tablet 150 mcgtablet 175 mcg tablet 200 mcgtablet 300 mcg tablet
1-Covered STAR (Preferred Drug)
LEVOTHYROXINE SODIUM 25 MCGTABLET 50 MCG TABLET 75 MCGTABLET 88 MCG TABLET 100 MCGTABLET 112 MCG TABLET 125 MCGTABLET 137 MCG TABLET 150 MCGTABLET 175 MCG TABLET 200 MCGTABLET 300 MCG TABLET
1-Covered STAR (Preferred Drug)
LEVOXYL (levothyroxine sodium) 25MCG TABLET 50 MCG TABLET 75MCG TABLET 88 MCG TABLET 100MCG TABLET 112 MCG TABLET 125MCG TABLET 137 MCG TABLET 150MCG TABLET 175 MCG TABLET 200MCG TABLET
1-Covered
SYNTHROID (levothyroxine sodium)25 MCG TABLET 50 MCG TABLET75 MCG TABLET 88 MCG TABLET100 MCG TABLET 112 MCG TABLET125 MCG TABLET 137 MCG TABLET150 MCG TABLET 175 MCG TABLET200 MCG TABLET 300 MCG TABLET
1-Covered
thyroidpork (NP THYROID) 15 mgtablet 30 mg tablet 60 mg tablet90 mg tablet 120 mg tablet
1-Covered STAR (Preferred Drug)
UNITHROID (levothyroxine sodium)25 MCG TABLET 50 MCG TABLET75 MCG TABLET 88 MCG TABLET100 MCG TABLET 112 MCG TABLET125 MCG TABLET 137 MCG TABLET150 MCG TABLET 175 MCG TABLET200 MCG TABLET 300 MCG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
103
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs forSuppressing Hormones from the Pituitary Gland)
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs to SuppressPituitary Hormones)
leuprolide acetate 1 mg02ml kit 1-Covered PA SP
LUPRON DEPOT-PED (leuprolideacetate) -15 MG KIT
1-Covered PA
SYNAREL (nafarelin acetate) 2MGML NASAL SPRAY
1-Covered PA
HORMONAL AGENTS SUPPRESSANT (THYROID) (Drugs for theThyroid)
ANTITHYROID AGENTS (Drugs to Suppress Thyroid Hormone)methimazole 5 mg tablet 10 mgtablet
1-Covered
propylthiouracil 50 mg tablet 1-Covered
IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing theImmune System)
IMMUNE SUPPRESSANTS (Drugs to Suppress the Immune System)azathioprine 50 mg tablet 1-Covered
AZATHIOPRINE 50 MG TABLET 1-Covered
cyclosporine 25 mg capsule 100mg capsule
1-Covered
cyclosporine modified (GENGRAF)25 mg capsule 100 mgml solution100 mg capsule
1-Covered
cyclosporine modified 25 mgcapsule 100 mgml solution 100mg capsule
1-Covered
ENBREL (etanercept) 25 MG KIT 1-Covered PA SP QLC (8 vials28 days)
ENBREL (etanercept) 25 MG05 MLSYRINGE 50 MGML SYRINGE
1-Covered PA SP QLC (4 syringes [1 kit]28days)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
104
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ENBREL 25 MG05 ML VIAL 1-Covered PA QL (4 PER 28 DAY(S))
ENBREL SURECLICK (etanercept) 50MGML
1-Covered PA SP QLC (4 pens [1 kit]28days)
HUMIRA (adalimumab) 10 MG02ML SYRINGE 20 MG04 MLSYRINGE 40 MG08 ML SYRINGE
1-Covered PA SP QLC (2 syringes [1 kit]28days)
HUMIRA PEDIATRIC CROHNS(adalimumab) 40 MG08 ML
1-Covered PA SP QLC (3 or 6 syringesyeardepending upon package size)
HUMIRA PEN (adalimumab) 40MG08 ML
1-Covered PA SP QLC (2 pens [1 kit]28days)
HUMIRA PEN CROHNS-UC-HS(adalimumab) --40 MG
1-Covered PA SP QLC (6 pens [1 kit]year)
HUMIRA PEN PSOR-UVEITS-ADOL HS(adalimumab) --40 MG
1-Covered PA SP QLC (4 pens [1 kit]year)
HUMIRA(CF) (adalimumab) 10MG01 ML SYRING 20 MG02 MLSYRING 40 MG04 ML SYRING
1-Covered PA SP QLC (2 syringes [1 kit]28days)
HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 80-40 MG
1-Covered PA SP QLC (2 syringes [1kit]year)
HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 80MG08
1-Covered PA SP QLC (3 syringes [1kit]year)
HUMIRA(CF) PEN (adalimumab) 40MG04 ML
1-Covered PA SP QLC (2 pens [1 kit]28days)
HUMIRA(CF) PEN CROHNS-UC-HS(adalimumab) CRHN--80MG
1-Covered PA SP QLC (3 pens [1 kit]year)
HUMIRA(CF) PEN PSOR-UV-ADOLHS (adalimumab) --AHS 80-40
1-Covered PA SP QLC (3 pens [1 kit]year)
METHOTREXATE 25 MG TABLET 1-Covered
methotrexate sodium 25 mgtablet
1-Covered
mycophenolate mofetil 200 mgmlsusp recon
1-Covered PA
mycophenolate mofetil 250 mgcapsule 500 mg tablet
1-Covered AL1 (At least 21 yrs old)
RHEUMATREX (methotrexatesodium) 25 MG TABLET
1-Covered
SANDIMMUNE (cyclosporine) 25MG CAPSULE 100 MGML SOLN
1-Covered
sirolimus 1 mgml solution 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
105
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
tacrolimus 05 mg capsule 1 mgcapsule 5 mg capsule
1-Covered AL1 (At least 21 yrs old)
TACROLIMUS 05 MG CAPSULE 1MG CAPSULE 5 MG CAPSULE
1-Covered AL1 (At least 21 yrs old)
IMMUNIZING AGENTS PASSIVE (Vaccines)HYPERTET S-D (tetanus immuneglobulinpf) -250 UNIT YRINGE
3-MedicalBenefit
NABI-HB (hepatitis b immuneglobulin) -VIAL gloulin)
3-MedicalBenefit
IMMUNOMODULATORSleflunomide 10 mg tablet 20 mgtablet
1-Covered
LEFLUNOMIDE 10 MG TABLET 20MG TABLET
1-Covered
RIDAURA (auranofin) 3 MGCAPSULE
1-Covered PA
VACCINESADACEL TDAP(diphtheriapertussis(acellular)tetanus vaccinepf) VIAL
1-Covered AL1 (At least 19 yrs old)
AFLURIA QUAD 2020-2021 -VIAL 1-Covered AL1 (At least 19 yrs old)
AFLURIA QUAD 2020-21 (3YR UP) - 1-Covered AL1 (At least 19 yrs old)
BEXSERO (meningococcal group bvaccine 4-component) PREFILLEDSYRINGE -
1-Covered QL (2 PER LIFETIME) AL1 (19 to 25yrs old)
BOOSTRIX TDAP(diphtheriapertussis(acellular)tetanus vaccine) SYRINGE VIAL
1-Covered AL1 (At least 19 yrs old)
ENGERIX-B ADULT (hepatitis b virusvaccine recombinantpf) -20MCGML VIAL recominantpf) -20MCGML SYRN recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
FLUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 65 yrs old)
FLUAD QUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 19 yrs old)
FLUARIX QUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 19 yrs old)
FLUBLOK QUAD 2018-2019(influenza virus vaccine qv 2018-19(18 yrs and older)rcmbpf) -SYRINGE -
1-Covered AL1 (19 to 999 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
106
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
FLUBLOK QUAD 2020-2021 -SYRINGE
1-Covered AL1 (At least 19 yrs old)
FLUCELVAX QUAD 2020-2021 2020-2021 SYR 2020-2021 VIAL
1-Covered AL1 (At least 19 yrs old)
FLULAVAL QUAD 2019-2020(influenza virus vaccinequadrivalent 2019-20 (6 mos andup)) -VIAL -
1-Covered AL1 (At least 19 yrs old)
FLULAVAL QUAD 2020-2021 -SYR 1-Covered AL1 (At least 19 yrs old)
FLUZONE HIGH-DOSE QUAD 2020-21 --
1-Covered AL1 (At least 65 yrs old)
FLUZONE QUAD 2019-2020(influenza virus vaccine quadrival2019-2020(6 mos and up)pf) -VIAL-
1-Covered AL1 (At least 19 yrs old)
FLUZONE QUAD 2020-2021 2020-2021 VIAL 2020-2021 SYRINGE
1-Covered AL1 (At least 19 yrs old)
GARDASIL 9 (human papillomavirusvaccine 9-valentpf) 9 SYRINGE 9-9 VIAL 9-
1-Covered QL (3 PER LIFETIME) AL1 (19 to 27yrs old)
HAVRIX (hepatitis a virusvaccinepf) 720 UNIT05 MLSYRINGE (heptitis vccinepf) 720UNITS05 ML VIAL (heptitisvccinepf) 1440 UNITSMLSYRINGE (heptitis vccinepf) 1440UNITSML VIAL (heptitis vccinepf)
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
HEPLISAV-B (hepatitis b vaccinerecombinantvaccine adjuvantcpg 1018pf) -20 MCG05 MLSYRNG RECOMINANT -20MCG05 ML VIAL RECOMINANT
1-Covered AL1 (At least 19 yrs old) QLC (2perlifetime)
IMOVAX RABIES VACCINE (rabiesvaccine human diploid cellpf)VIAL
3-MedicalBenefit
M-M-R II VACCINE (measlesmumps and rubella vaccinelivepf) --VIAL
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
MENACTRA(meningococcalvaccine acyw-135diphtheria toxoid conjpf) VIAL-
1-Covered AL1 (At least 19 yrs old)
MENQUADFI VIAL 1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
107
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
MENVEO A-C-Y-W-135-DIP(meningococcalvaccine acyw-135diphtheria toxoid conjpf) -----VIL KT -DIPHTHERIA
1-Covered QL (1 PER LIFETIME) AL1 (19 to 55yrs old)
PNEUMOVAX 23 (pneumococcal23-valent polysaccharide vaccine)23 VIAL 23- 23 SYRINGE 23-
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
PREVNAR 13 (pneumococcal 13-valent conjugate vaccine(diphtheria crm)pf) SYRINGE -
1-Covered QL (1 PER LIFETIME) AL1 (At least19 yrs old)
RABAVERT (rabies vaccine purifiedchicken embryo cell (pcec)pf)RABIES VACC W-DILUENT
1-Covered AL1 (At least 19 yrs old)
RECOMBIVAX HB (hepatitis b virusvaccine recombinantpf) 5MCG05 ML SYR recominantpf)10 MCGML SYR recominantpf)40 MCGML VIAL recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
RECOMBIVAX HB (hepatitis b virusvaccine recombinantpf) 5MCG05 ML VL recominantpf) 10MCGML VIAL recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
SHINGRIX (varicella-zoster virusglycoprotein erecas01badjuvantpf) VIAL KIT -
1-Covered QL (2 PER LIFETIME) AL1 (At least50 yrs old)
TDVAX (tetanus and diphtheriatoxoids adult) VIAL
1-Covered AL1 (At least 19 yrs old)
TENIVAC (tetanus and diphtheriatoxoids adsorbed adultpf) VIAL
1-Covered AL1 (At least 19 yrs old)
tetanus and diphtheria toxoidsadult tetanus toxadult 2-2 lf05vial
1-Covered AL1 (At least 19 yrs old)
TRUMENBA (neisseria meningitidisgroup b lipidated fhbprecombinant) 120 MCG05 MLVACCIN
1-Covered QL (2 PER LIFETIME) AL1 (19 to 25yrs old)
TWINRIX (hepatitis a virus andhepatitis b virus vaccinepf)VACCINE SYRINGE (heptitis ndheptitis vccinepf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
108
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
VAQTA (hepatitis a virusvaccinepf) 25 UNITS05 ML VIAL(heptitis vccinepf) 25 UNITS05ML SYRINGE (heptitis vccinepf) 50UNITSML VIAL (heptitis vccinepf)50 UNITSML SYRINGE (heptitisvccinepf)
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
VARIVAX VACCINE (varicella virusvaccine livepf) WITH DILUENT
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
ZOSTAVAX (zoster vaccine livepf)VIAL
1-Covered QL (1 PER LIFETIME) AL1 (At least60 yrs old)
INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for InflammatoryBowel Disease)
AMINOSALICYLATESbalsalazide disodium 750 mgcapsule
1-Covered
mesalamine 4 g60 ml enema 1-Covered
mesalamine 400 mg cap(drtab) 1-Covered QL (6 PER 1 DAY(S))
GLUCOCORTICOIDShydrocortisone (COLOCORT)100mg60ml enema
1-Covered
hydrocortisone 100mg60mlenema
1-Covered
SULFONAMIDESsulfasalazine 500 mg tablet dr 500mg tablet
1-Covered
METABOLIC BONE DISEASE AGENTS (Drugs for the Bone)
METABOLIC BONE DISEASE AGENTSalendronate sodium 10 mg tablet40 mg tablet
1-Covered PA STAR (Preferred Drug)
alendronate sodium 35 mg tablet70 mg tablet
1-Covered STAR (Preferred Drug)
alendronate sodium 5 mg tablet 1-Covered AL1 (At least 65 yrs old) STAR(Preferred Drug)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
109
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcitoninsalmonsynthetic200spray spraypump
1-Covered PA
CALCITRIOL 025 MCG CAPSULE05 MCG CAPSULE
1-Covered
calcitriol 025 mcg capsule 05mcg capsule 1 mcgml solution
1-Covered
cholecalciferol (vitamin d3) 10mcg capsule 10 mcg tablet
1-Covered
cinacalcet hcl 30 mg tablet 60 mgtablet 90 mg tablet
1-Covered PA
CINACALCET HCL 30 MG TABLET60 MG TABLET 90 MG TABLET
1-Covered PA
ergocalciferol (vitamin d2)(CALCIDOL) 200 mcgml drops
1-Covered
ergocalciferol (vitamin d2) 10 mcgtablet 200 mcgml drops 1250mcg capsule
1-Covered
ERGOCALCIFEROL 200 MCGMLDROP
1-Covered
FOSAMAX PLUS D (alendronatesodiumcholecalciferol (vitamind3)) 70 MG-2800 IU
1-Covered PA
MISCELLANEOUS THERAPEUTIC AGENTSalcohol antiseptic pads s med 1-Covered
ALCOHOL WIPES 70 1-Covered
ASSURE ID DUO-SHIELD -30GX316-30GX516
1-Covered
ASSURE ID INSULIN SAFETY SYR05ML 31GX1564 SYR 1 ML31GX1564
1-Covered
condoms female each 1-Covered
condoms latex lubricated each 1-Covered
cromolyn sodium 52 mgspraypump
1-Covered
DROPLET MICRON PEN NEEDLE 34GX 964
1-Covered
freestyle insulix test strips 1-Covered QL (100 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
110
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
freestyle lite test strips 1-Covered QL (100 PER 30 DAYS)
freestyle test strips 1-Covered QL (100 PER 30 DAYS)
inhalerassist device with largemask devicelg spacer
1-Covered
inhalerassist device with mediummask devicemed spacer
1-Covered
inhalerassist device with smallmask devsmall spacer
1-Covered
INSULIN PEN NEEDLES INSULIN PENNEEDLES INSULIN PEN NEEDLES
1-Covered
insulin syringe 03 ml 1-Covered
insulin syringe 05 ml 1-Covered
insulin syringe 1 ml 1-Covered
lancets 28 gauge 30 gauge 33gauge
1-Covered
methylergonovine maleate 02 mgtablet
1-Covered
PEN NEEDLE 29G 12MM 1-Covered
pen needle diabetic 29 g x12 30gx516 31 g x14 31 gx316 31gx516 32gx 532 32 gx 14 32gx316 32 gx516 33 gx532
1-Covered
pen needle diabetic disposablesafety 30 gx516 30 gx316
1-Covered
pen needle diabetic removerand disposal unit 31 gx316 32gx532
1-Covered
pen needle diabetic safety 30gx316 dis
1-Covered
RID (permethrin) PEDICULICIDESSPRAY
1-Covered
syringe with needle insulin safety1 ml geneedleinsulnsafe1ml 30gx316 disp
1-Covered
syringe withneedledisposableinsulin 1 ml30gx12 disp 31 gx516 disp31gx1564 disp
1-Covered
syringe with needleinsulin03 ml -needldispinsul03 29 x12 disp
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
111
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
syringe with needleinsulin05 ml -ml 30gx12 disp -ml 31 gx516disp -ml 31gx1564 disp
1-Covered
UNIFINE PENTIPS MAXFLOW30GX316
1-Covered
OPHTHALMIC AGENTS (Drugs for the Eyes)
OPHTHALMIC AGENTS OTHER (Other Drugs for the Eyes)atropine sulfate 1 drops 1-Covered
bacitracinpolymyxin b sulfate (AK-POLY-BAC) 500-10kg oint (g) --
1-Covered
bacitracinpolymyxin b sulfate(POLYCIN) 500-10kg oint (g)
1-Covered
bacitracinpolymyxin b sulfate 500-10kg oint (g)
1-Covered
BEOVU (brolucizumab-dbll) 6MG005 ML VIAL -
3-MedicalBenefit
BLEPHAMIDE (sulfacetamidesodiumprednisolone acetate) EYEDROPS
1-Covered
CORTISPORIN (neomycinsulfatepolymyxin bsulfatehydrocortisone) CREAM
1-Covered
cyclopentolate hcl 05 drops 1 drops 2 drops
1-Covered
homatropine hbr (HOMATROPAIRE)5 drops
1-Covered
homatropine hbr 5 drops 1-Covered
MURO-128 (sodium chloride) -5EYE DROPS
1-Covered
neomycin sulfatebacitracinzincpolymyxin bhydrocortisone(NEO-POLYCIN HC)neomycinbacitp-myxhydrocort35-10k-1 oint (g) -
1-Covered
neomycin sulfatebacitracinzincpolymyxin bhydrocortisoneneomycinbacitp-myxhydrocort35-10k-1 oint (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
112
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
neomycinsulfatebacitracinpolymyxin b(NEO-POLYCIN)sulfbacitracinpoly 35mg-400oint (g) -
1-Covered
neomycinsulfatebacitracinpolymyxin bsulfbacitracinpoly 35mg-400oint (g)
1-Covered
neomycin sulfatepolymyxin bsulfategramicidin dneomycinpolymyxn bgramicidin175mg-10k drops
1-Covered
neomycin sulfatepolymyxin bsulfatehydrocortisoneneomycinpolymyxin bhydrocort35-10k-10 drops susp
1-Covered
neomycinpolymyxin bsulfatedexamethasonebdexametha 01 drops suspbdexametha 35-10k-1 oint (g)
1-Covered
phenylephrine hcl 25 drops 10 drops
1-Covered
polymyxin b sulfatetrimethoprimsulftrimethoprim 10000-1ml drops
1-Covered
proparacaine hcl 05 drops 1-Covered PA
sodium chloride (MURO-128) drops -18)
1-Covered
sodium chloride 5 drops 1-Covered
sulfacetamidesodiumprednisolone sodiumphosphatesulfacetamideprednisolone 10 -023 drops
1-Covered
TOBRADEX(tobramycindexamethasone) EYEOINTMENT
1-Covered
tobramycindexamethasone 03-01 drops susp
1-Covered
OPHTHALMIC ANTI-ALLERGY AGENTS (Drugs for Eye Allergies)ALAWAY (ketotifen fumarate)0025 EYE DROPS
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
113
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALOMIDE (lodoxamidetromethamine) 01 EYE DROPS
1-Covered
cromolyn sodium 4 drops 1-Covered
EYE ITCH RELIEF 0025 DROPS HM0025 DROP
1-Covered
ketotifen fumarate (ALLERGY EYEDROPS) 0025 drops
1-Covered
ketotifen fumarate (EYE ITCHRELIEF) 0025 drops
1-Covered
ketotifen fumarate (ITCHY EYE)0025 drops
1-Covered
ketotifen fumarate (WAL-ZYR) 0025 drops -
1-Covered
ketotifen fumarate (ZADITOR) 0025 drops
1-Covered
ketotifen fumarate 0025 drops 1-Covered
OPHTHALMIC ANTI-INFLAMMATORIES (Drugs to Reduce EyeSwelling)
dexamethasone sodiumphosphate 01 drops
1-Covered
diclofenac sodium 01 drops 1-Covered
fluorometholone 01 drops susp 1-Covered
flurbiprofen sodium 003 drops 1-Covered
FML FORTE (fluorometholone)025 EYE DROPS
1-Covered
FML SOP (fluorometholone) 01OINTMENT
1-Covered
ketorolac tromethamine 05 drops
1-Covered
PRED MILD (prednisolone acetate)012 EYE DROPS
1-Covered
prednisolone acetate 1 dropssusp
1-Covered
prednisolone sodium phosphate 1 drops
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
114
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
OPHTHALMIC ANTIGLAUCOMA AGENTS (Drugs for Glaucoma)ALPHAGAN P (brimonidinetartrate) ALHAGAN 01 DROS
1-Covered QL (1 PER 30 DAYS)
apraclonidine hcl 05 drops 1-Covered
betaxolol hcl 05 drops 1-Covered
BETIMOL (timolol) 025 DROPS05 DROPS
1-Covered
BETOPTIC S (betaxolol hcl) 025EYE DROP
1-Covered
brimonidine tartrate 02 drops 1-Covered
dorzolamide hcl 2 drops 1-Covered
dorzolamide hcltimolol maleate223-681 drops
1-Covered QL (10 PER 30 DAY(S))
DORZOLAMIDE-TIMOLOL -EYEDROPS
1-Covered QL (10 PER 30 DAY(S))
IOPIDINE (apraclonidine hcl) 1EYE DROPS
1-Covered
levobunolol hcl 05 drops 1-Covered
methazolamide 25 mg tablet 50mg tablet
1-Covered
METHAZOLAMIDE 25 MG TABLET 50MG TABLET
1-Covered
PHOSPHOLINE IODIDE(echothiophate iodide) 0125
1-Covered
pilocarpine hcl 1 drops 2 drops 4 drops
1-Covered
PILOCARPINE HCL 1 DROPS 2DROPS
1-Covered
timolol maleate 025 sol-gel 025 drops 05 drops 05 sol-gel
1-Covered
TIMOLOL MALEATE 05 EYE DROPS 1-Covered
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS (Drugsfor Glaucoma)
latanoprost 0005 drops 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
115
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
OTIC AGENTS (Drugs for the Ears)
OTIC AGENTS (Drugs for Ear Infection)acetic acid 2 solution 1-Covered
ACETIC ACID 2 EAR SOLUTION 1-Covered
carbamide peroxide(CARBAMOXIDE) 65 drops
1-Covered
carbamide peroxide (EAR DROPS)65 drops
1-Covered
carbamide peroxide (EAR SYSTEM)65 drops
1-Covered
carbamide peroxide (EAR WAXREMOVAL) 65 drops
1-Covered
carbamide peroxide (MURINE EARWAX REMOVAL SYSTEM) 65 drops
1-Covered
DEBROX (carbamide peroxide)65 EAR DROPS
1-Covered
EAR DROPS (carbamide peroxide)65
1-Covered
hydrocortisoneacetic acid(ACETASOL HC) 1 -2 drops
1-Covered
hydrocortisoneacetic acid 1 -2 drops
1-Covered
MURINE EAR DROPS (carbamideperoxide) 65
1-Covered
neomycin sulfatepolymyxin bsulfatehydrocortisoneneomycinpolymyxin bhydrocort35--1 solutionneomycinpolymyxin bhydrocort35--1 drops susp
1-Covered
NEOMYCIN-POLYMYXIN-HC --EARSUSP
1-Covered
RESPIRATORY TRACTPULMONARY AGENTS (Drugs for the Lungs)
ANTI-INFLAMMATORIES INHALED CORTICOSTEROIDS (Inhaled Drugsto Prevent Swelling of the Airways)
BUDESONIDE 025 MG2 ML SUSP 1-Covered AL1 (Up to 6 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
116
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
budesonide 025mg2ml - 05mg2ml -
1-Covered AL1 (Up to 6 yrs old)
CHILDRENS NASACORT(triamcinolone acetonide)ALLERGY 24 HR
1-Covered QL (17 PER 30 DAY(S))
FLOVENT DISKUS (fluticasonepropionate) 50 MCG 100 MCG250 MCG
1-Covered
FLOVENT HFA (fluticasonepropionate) HFA 44 MCG INHALERHFA 110 MCG INHALER HFA 220MCG INHALER
1-Covered
fluticasone propionate (ALLERGYRELIEF) 50 mcg spray susp
1-Covered QL (16 PER 30 DAY(S))
fluticasone propionate 50 mcgspray susp
1-Covered QL (16 PER 30 DAY(S))
NASACORT (triamcinoloneacetonide) ALLERGY 24HR SPRAY
1-Covered
PULMICORT FLEXHALER(budesonide) 180 MCG
1-Covered
QVAR REDIHALER(beclomethasone dipropionate)40 MCG 80 MCG
1-Covered
triamcinolone acetonide 55 mcgspray
1-Covered QL (17 PER 30 DAY(S))
ANTIHISTAMINESALAVERT (loratadine) 10 MG ODT 1-Covered AL1 (Up to 12 yrs old)
ALL DAY ALLERGY ERGY 10 MGTABLET SM ERGY 10 MG TAB
1-Covered
ALLERGY RELIEF (LORATADINE) 10MG TAB RELIEF 10 MG TABLET
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
ALLERGY RELIEF 4 MG TABLET HM 4MG TABLET HM 25 MG CAP 25 MGSOFTGEL GS 25 MG TABLET
1-Covered
ALLERGY RELIEF HM 180 MG TAB180 MG TABLET
1-Covered ST
AZELASTINE HCL 01 (137 MCG)SPRY
1-Covered QL (1 PER 30 DAYS)
azelastine hcl 137 mcgspraypump
1-Covered QL (1 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
117
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
cetirizine hcl (24HOUR ALLERGY) 10mg tablet
1-Covered
cetirizine hcl (ALL DAY ALLERGYRELIEF) 10 mg tablet
1-Covered
cetirizine hcl (ALL DAY ALLERGY) 10mg tablet
1-Covered
cetirizine hcl (ALLER-TEC) 10 mgtablet -
1-Covered
cetirizine hcl (ALLERGY RELIEF) 10mg tablet
1-Covered
cetirizine hcl (WAL-ZYR) 10 mgtablet -
1-Covered
cetirizine hcl 1 mgml 5 mg5 ml 1-Covered ST AL1 (Up to 5 yrs old)
CETIRIZINE HCL 10 MG TABLET 1-Covered
cetirizine hcl 5 mg tablet 10 mgtablet
1-Covered
CHILDRENS ALLERGY RELIEF 5MG5 ML
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
CHILDRENS ALLERGY RELIEF RLF125 MG5 ML
1-Covered
chlorpheniramine maleate(ALLERGY 4-HOUR) mg tablet -
1-Covered
chlorpheniramine maleate(ALLERGY RELIEF) 4 mg tablet
1-Covered
chlorpheniramine maleate(ALLERGY) 4 mg tablet
1-Covered
chlorpheniramine maleate(ALLERGY-TIME) 4 mg tablet -
1-Covered
chlorpheniramine maleate(CHLORHIST) 4 mg tablet
1-Covered
chlorpheniramine maleate(CHLORTABS) 4 mg tablet
1-Covered
chlorpheniramine maleate (EDCHLORPED JR) 2 mg5 ml syrup
1-Covered
chlorpheniramine maleate(PHARBECHLOR) 4 mg tablet
1-Covered
chlorpheniramine maleate (WAL-FINATE) 4 mg tablet -
1-Covered
chlorpheniramine maleate 4 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
118
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
clemastine fumarate 268 mgtablet
1-Covered
cyproheptadine hcl 2 mg5 mlsyrup 4 mg tablet 4 mg10 mlsyrup
1-Covered
diphenhydramine hcl (ALER-CAPS)25 mg capsule -
1-Covered
diphenhydramine hcl (ALLER-G-TIME) 25 mg tablet --
1-Covered
diphenhydramine hcl (ALLERGYMEDICATION) 25 mg capsule 25mg tablet
1-Covered
diphenhydramine hcl (ALLERGYMEDICINE) 25 mg tablet
1-Covered
diphenhydramine hcl (ALLERGYRELIEF) 125mg5ml liquid 25 mgcapsule 25 mg tablet
1-Covered
diphenhydramine hcl (ALLERGY)125mg5ml liquid 25 mg capsule25 mg tablet
1-Covered
diphenhydramine hcl (BANOPHEN)125mg5ml liquid 25 mg tablet 25mg capsule 50 mg capsule
1-Covered
diphenhydramine hcl (BENADRYLALLERGY) 25 mg tablet
1-Covered
diphenhydramine hcl (CHILDRENSALLERGY RELIEF) 125mg5ml liquid
1-Covered
diphenhydramine hcl (CHILDRENSALLERGY) 125mg5ml elixir125mg5ml liquid
1-Covered
diphenhydramine hcl (CHILDRENSBENADRYL ALLERGY) 125mg5mlliquid
1-Covered
diphenhydramine hcl (CHILDRENSWAL-DRYL ALLERGY) 125mg5mlliquid -
1-Covered
diphenhydramine hcl (COMPLETEALLERGY) 25 mg capsule 25 mgtablet
1-Covered
diphenhydramine hcl (DIPHEDRYLALLERGY) 125mg5ml liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
119
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
diphenhydramine hcl (DIPHEDRYL)125mg5ml liquid 25 mg capsule
1-Covered
diphenhydramine hcl (DIPHEN)125mg5ml elixir 25 mg tablet
1-Covered
diphenhydramine hcl (DIPHENHIST)125mg5ml liquid 25 mg tablet
1-Covered
diphenhydramine hcl (GERI-DRYL)125mg5ml liquid - 25 mg tablet -
1-Covered
diphenhydramine hcl (M-DRYL)125mg5ml liquid -
1-Covered
diphenhydramine hcl (NIGHTTIMEALLERGY RELIEF) 25 mg tablet
1-Covered
diphenhydramine hcl (NIGHTTIMESLEEP AID) 25 mg tablet
1-Covered
diphenhydramine hcl(PHARBEDRYL) 25 mg capsule 50mg capsule
1-Covered
diphenhydramine hcl (SILADRYL)125mg5ml liquid
1-Covered
diphenhydramine hcl (SIMPLYSLEEP) 25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP AID)25 mg tablet
1-Covered
diphenhydramine hcl (TOTALALLERGY) 25 mg tablet
1-Covered
diphenhydramine hcl (WAL-DRYLALLERGY) 125mg5ml liquid - 25mg tablet -
1-Covered
diphenhydramine hcl (WAL-DRYL)25 mg capsule -
1-Covered
DIPHENHYDRAMINE HCL 125 MG5ML 25 MG10 ML
1-Covered
diphenhydramine hcl 125mg5mlelixir 125mg5ml syrup125mg5ml liquid 25 mg tablet 25mg capsule 50 mg capsule
1-Covered
fexofenadine hcl (ALLER-EASE) 60mg tablet - 180 mg tablet -
1-Covered ST
fexofenadine hcl (ALLER-FEX) 180mg tablet -
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
120
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fexofenadine hcl (ALLERGY RELIEF)60 mg tablet 180 mg tablet
1-Covered ST
fexofenadine hcl (WAL-FEXALLERGY) 60 mg tablet - 180 mgtablet -
1-Covered ST
fexofenadine hcl 60 mg tablet 180mg tablet
1-Covered ST
FEXOFENADINE HCL HM 60 MGTAB 60 MG TABLET 180 MG TABLET
1-Covered ST
GERI-DRYL -125 MG5 ML LIQUID 1-Covered
hydroxyzine hcl 10 mg tablet 10mg5 ml solution 25 mg tablet 50mg tablet 50 mg25ml solution
1-Covered
HYDROXYZINE PAMOATE 25 MGCAP 50 MG CAP
1-Covered
hydroxyzine pamoate 25 mgcapsule 50 mg capsule 100 mgcapsule
1-Covered
loratadine (ALLERCLEAR) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (ALLERGY RELIEF) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (ALLERGY RELIEF) 5mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (ALLERGY) 10 mg tablet 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (CHILDRENS ALLERGYRELIEF) 5 mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (CHILDRENS ALLERGY) 5mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (LORADAMED) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (NON-DROWSYALLERGY) 10 mg tablet -
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (WAL-ITIN) 10 mg tablet-
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (WAL-ITIN) 5 mg5 mlsolution -
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine 10 mg tablet 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
121
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LORATADINE 10 MG TABLET 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine 5 mg5 ml solution 1-Covered QL (150 PER 30 DAYS) AL1 (Up to6 yrs old)
NIGHTTIME SLEEP AID HM 25 MGCPLT
1-Covered
promethazine hcl 125 mg tablet25 mg tablet
1-Covered
PROMETHAZINE HCL 625 MG5 MLSOLN
1-Covered AL1 (At least 2 yrs old)
promethazine hcl 625mg5mlsyrup
1-Covered AL1 (At least 2 yrs old)
ANTILEUKOTRIENESmontelukast sodium 4 mg granpack
1-Covered ST
MONTELUKAST SODIUM 4 MGGRANULES
1-Covered ST
montelukast sodium 4 mg tabchew 5 mg tab chew 10 mgtablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
BRONCHODILATORS ANTICHOLINERGIC (Anticholinergic Drugs toOpen the Airway)
ATROVENT HFA (ipratropiumbromide) 17 MCG INHALER
1-Covered
INCRUSE ELLIPTA (umeclidiniumbromide) 625 MCG INH
1-Covered C (RESTRICTED TO THE DIAGNOSISOF CHRONIC OBSTRUCTIVEPULMONARY DISEASE (COPD))
ipratropium bromide 02 mgmlsolution 21 mcg spray 42 mcgspray
1-Covered
BRONCHODILATORS SYMPATHOMIMETIC (Sympathomimetic Drugsto Open the Airway)
albuterol 90mcg hfa inhaler(generic proair)
1-Covered QL (2 PER 30 [DAYS])
albuterol 90mcg hfa inhaler(generic proventil)
1-Covered QL (2 PER 30 [DAYS])
albuterol 90mcg hfa inhaler(generic ventolin)
1-Covered QL (2 PER 30 [DAYS])
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
122
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALBUTEROL SULFATE 100 MG20 MLSOLN
1-Covered
albuterol sulfate 2 mg tablet 2mg5 ml syrup 25 mg3ml vial-neb 25 mg05 vial-neb 4 mg taber 12h 4 mg tablet 5 mgmlsolution 8 mg tab er 12h
1-Covered
albuterol sulfate 90 mcg hfa aerad
1-Covered QL (2 PER 30 [DAYS])
ALBUTEROL SULFATE HFA 90 MCGINHALER
1-Covered QL (2 PER 30 [DAYS])
epinephrine 015mg03 03mg03 1-Covered QL (2 PER FILL(S))
FORADIL (formoterol fumarate)AEROLIZER 12 MCG CAP
1-Covered ST
levalbuterol tartrate 45 mcg hfaaer ad
1-Covered QL (30 PER 30 DAY(S))
metaproterenol sulfate 10 mg5 mlsyrup 10 mg tablet 20 mg tablet
1-Covered
NASAL DECONGESTANT(pseudoephedrine hcl) 30 MG TAB
1-Covered
pseudoephedrine hcl (NASALDECONGESTANT) 30 mg tablet
1-Covered
pseudoephedrine hcl (SUDOGEST)30 mg tablet 60 mg tablet
1-Covered
pseudoephedrine hcl (SUPHEDRIN)30 mg tablet
1-Covered
pseudoephedrine hcl (SUPHEDRINESINUS CONGESTION) 30 mg tablet
1-Covered
pseudoephedrine hcl(SUPHEDRINE) 30 mg tablet
1-Covered
pseudoephedrine hcl (WAL-PHED)30 mg tablet -
1-Covered
pseudoephedrine hcl 30 mgtablet 60 mg tablet
1-Covered
SEREVENT DISKUS (salmeterolxinafoate) 50 MCG
1-Covered QL (60 PER 30 DAYS)
SUDAFED (pseudoephedrine hcl)30 MG TABLET
1-Covered
TERBUTALINE SULFATE 25 MG TAB 5MG TAB
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
123
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terbutaline sulfate 25 mg tablet 5mg tablet
1-Covered
PHOSPHODIESTERASE INHIBITORS AIRWAYS DISEASE (Drugs thatBlock Phosphodiesterase)
ELIXOPHYLLIN (theophyllineanhydrous) OPHYLLIN 80 MG15 ML
1-Covered
THEO-24 (theophylline anhydrous) -24 ER 200 MG CAPSULE -24 ER 300MG CAPSULE -24 ER 100 MGCAPSULE -24 ER 400 MG CAPSULE
1-Covered
theophylline anhydrous(THEOCHRON) 100 mg tab er 200mg tab er 300 mg tab er
1-Covered
theophylline anhydrous 80mg15ml solution 80 mg15ml elixir100 mg tab er 12h 200 mg tab er12h 300 mg tab er 12h 400 mgtab er 24h 450 mg tab er 12h 600mg tab er 24h
1-Covered
PULMONARY ANTIHYPERTENSIVES (Drugs for PulmonaryHypertension)
ambrisentan 5 mg tablet 10 mgtablet
1-Covered PA QL (1 PER 1 DAY(S)) SP
bosentan 625 mg tablet 125 mgtablet
1-Covered PA QL (2 PER 1 DAY(S)) SP
sildenafil citrate 20 mg tablet 1-Covered PA QL (3 PER 1 DAY(S)) SP
SILDENAFIL CITRATE 20 MG TABLET 1-Covered PA QL (3 PER 1 DAY(S)) SP
tadalafil (ALYQ) 20 mg tablet 1-Covered PA QL (2 PER 1 DAY(S)) SP
tadalafil 20 mg tablet 1-Covered PA QL (2 PER 1 DAY(S)) SP
RESPIRATORY TRACT AGENTS OTHER (Other Drugs for BreathingConditions)
acetylcysteine 100 mgml vial 200mgml vial
1-Covered
benzonatate 100 mg capsule 1-Covered
BEVESPI AEROSPHERE(glycopyrrolateformoterolfumarate) INHALER
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
124
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
brompheniraminemaleatepseudoephedrine hcl(RYNEX PSE)brompheniraminpseudoephedrine 1-15mg5ml liquid
1-Covered
BROTAPP DM (brompheniraminemaleatepseudoephedrinehcldextromethorphan) 1-15-5MG5 ML LIQ
1-Covered
chlorpheniraminemaleatepseudoephedrinedextromethorphan (KIDKARE)chlorpheniraminpseudoepheddm 1-15-5mg5 liquid
1-Covered
codeine phosphateguaifenesin(CHERATUSSIN AC) 10-100mg5liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(G TUSSIN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(GUAIATUSSIN AC) 10-100mg5 20-20010
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(GUAIFENESIN AC) 10-100mg5liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(ROBAFEN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(VIRTUSSIN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin10-100mg5 20-20010
1-Covered AL1 (At least 12 yrs old)
CODEINE-GUAIFENESIN -10-100MG5 ML
1-Covered AL1 (At least 12 yrs old)
COMBIVENT RESPIMAT (ipratropiumbromidealbuterol sulfate) 20-100MCG
1-Covered
COUGH FORMULA DM(guaifenesindextromethorphanhbr) SYRUP
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
125
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fluticasone propionatesalmeterolxinafoate (WIXELA INHUB)propionsalmeterol 100-50 mcgwdev propionsalmeterol 250-50mcg wdev propionsalmeterol500-50 mcg wdev
1-Covered QL (60 PER 30 DAY(S))
fluticasone propionatesalmeterolxinafoate propionsalmeterol 100-50 mcg wdev propionsalmeterol250-50 mcg wdevpropionsalmeterol 500-50 mcgwdev
1-Covered QL (60 PER 30 DAY(S))
fluticasone propionatesalmeterolxinafoate propionsalmeterol 55-14mcg propionsalmeterol 113-14mcg propionsalmeterol 232-14mcg
1-Covered QL (1 PER 30 DAYS)
GUAIASORB DM LIQUID 1-Covered
guaifenesin (MUCUS ER) 600 mgtab er 12h
1-Covered
guaifenesin (MUCUS RELIEF ER) 600mg tab er 12h
1-Covered
GUAIFENESIN-DEXTROMETHORPHAN DM SYRUP
1-Covered
guaifenesindextromethorphanhbr (ADULT ROBITUSSIN PEAK COLDDM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ADULT TUSSIN COUGHCONGEST DM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ADULT TUSSIN DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (ADULT WAL-TUSSIN DM) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (ANTITUSSIVE DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (BIOCOTRON) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (COUGH DM) 100-10mg5syrup
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
126
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesindextromethorphanhbr (DIABETIC SILTUSSIN-DM) 100-10mg5 liquid -
1-Covered
guaifenesindextromethorphanhbr (DIABETIC TUSSIN DM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (EXPECTORANT DM) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (EXTRA ACTION COUGH) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (GERI-TUSSIN DM) 100-10mg5liquid - 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (GILTUSS DIABETIC) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (GILTUSS HBP) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (GUAIASORB DM) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (RI-TUSSIN DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM COUGH) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM COUGH-CHESTCONGEST) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM PEAK COLD)100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN-DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr (SAFETUSSIN DM) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (SILTUSSIN DM DAS) 100-10mg5liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
127
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesindextromethorphanhbr (SILTUSSIN DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (SORBUGEN NR) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSNEL DIABETIC) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSSIN COUGH) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM CLEAR) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM COUGH) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM COUGH-CHESTCONGEST) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM) 100-10mg5 liquid100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (ULTRA DM FREE amp CLEAR) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ULTRA TUSS) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (WAL-TUSSIN DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr 100-10mg5 syrup 100-10mg5liquid
1-Covered
guaifenesinpseudoephedrine hcl(MUCUS D)guaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
guaifenesinpseudoephedrine hcl(MUCUS RELIEF D)guaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
128
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesinpseudoephedrine hclguaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
ipratropium bromidealbuterolsulfate ipratropiumalbuterol 05-3mg3 ampul-neb
1-Covered QL (540 PER 30 DAY(S))
IPRATROPIUM-ALBUTEROL -05-3(25) MG3 ML
1-Covered QL (540 PER 30 DAY(S))
MAXI-TUSS G -LIQUID 1-Covered
MUCUS ER CVS 600 MG TABLET 1-Covered
MUCUS RELIEF ER HM 600 MG TAB 1-Covered
phenylephrine hclpromethazinehcl prometh 5-625mg5 syrup
1-Covered AL1 (At least 2 yrs old)
promethazine hclcodeine 625-105 syrup
1-Covered QL (240 PER 30 DAYS) AL1 (Atleast 12 yrs old) QLC (LIMIT 240ML(8OZ) PER 30 DAYS)
promethazinehcldextromethorphan hbrpromethazinedextromethorphan625-155 syrup
1-Covered AL1 (At least 2 yrs old)
PROMETHAZINE-DM -625-15MG5ML
1-Covered AL1 (At least 2 yrs old)
promethazinephenylephrinehclcodeinepromethazinephenylephcodeine625-5-10 syrup
1-Covered AL1 (At least 12 yrs old)
sodium chloride for inhalation 09 vial- 3 vial- 10 vial-
1-Covered
triprolidine hclpseudoephedrinehcl (APRODINE)triprolidinepseudoephedrine25mg-60mg tablet
1-Covered
triprolidine hclpseudoephedrinehcl (ED A-HIST PSE)triprolidinepseudoephedrine25mg-60mg tablet -
1-Covered
triprolidine hclpseudoephedrinehcl (RITIFED)triprolidinepseudoephedrine 125-305 syrup
1-Covered
triprolidine hclpseudoephedrinehcl (WAL-ACT D COLD amp ALLERGY)triprolidinepseudoephedrine25mg-60mg tablet -col
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
129
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles)
SKELETAL MUSCLE RELAXANTS (Drugs to Relax the Muscles)carisoprodol 350 mg tablet 1-Covered QL (90 PER 30 DAYS)
CARISOPRODOL 350 MG TABLET 1-Covered QL (90 PER 30 DAYS)
cyclobenzaprine hcl 10 mg tablet 1-Covered QL (90 PER 30 DAYS)
cyclobenzaprine hcl 5 mg tablet 1-Covered QL (90 PER 30 DAY(S))
methocarbamol 500 mg tablet750 mg tablet
1-Covered QL (90 PER 30 DAYS)
METHOCARBAMOL 500 MG TABLET750 MG TABLET
1-Covered QL (90 PER 30 DAYS)
VANADOM 350 MG TABLET 1-Covered QL (90 PER 30 DAY(S))
SLEEP DISORDER AGENTS (Drugs for Insomnia)
GABA RECEPTOR MODULATORSflurazepam hcl 15 mg capsule 30mg capsule
1-Covered AL1 (Up to 65 yrs old)
temazepam 75 mg capsule 15mg capsule 30 mg capsule
1-Covered
triazolam 0125 mg tablet 025 mgtablet
1-Covered QL (14 PER 30 DAY(S))
zaleplon 5 mg capsule 10 mgcapsule
1-Covered ST
zolpidem tartrate 5 mg tablet 10mg tablet
1-Covered
SLEEP DISORDERS OTHERdiphenhydramine hcl (ALKA-SELTZER PLUS ALLERGY) 25 mgtablet -
1-Covered
diphenhydramine hcl (COMPOZ)25 mg tablet
1-Covered
diphenhydramine hcl (NIGHTTIMESLEEP AID) 25 mg tablet
1-Covered
diphenhydramine hcl (NYTOLQUICKCAPS) 25 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
130
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
diphenhydramine hcl (SIMPLYSLEEP) 25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP AID)25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP II) 25mg tablet
1-Covered
diphenhydramine hcl (SLEEPTABLET) 25 mg tablet
1-Covered
modafinil 100 mg tablet 200 mgtablet
1-Covered PA QL (3 PER 1 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
131
Alphabetical Index of Prescription Drugs
009 sodium chloride 697072
Aabacavir sulfate 38abacavir sulfatelamivudine 38abacavir sulfatelamivudinezidovudine 38ABACAVIR-LAMIVUDINE 38ABILIFY (aripiprazole) 31ABILIFY MAINTENA (aripiprazole) 31ABILIFY MYCITE (aripiprazole) 31acamprosate calcium 6acarbose 4243acetaminophen 64ACETAMINOPHEN 64acetaminophen (ATHENOL) 63acetaminophen (CHILD FEVER REDUCER) 63acetaminophen (CHILD PAIN REL-FEVERREDUCER) 63acetaminophen (CHILDRENS FEVERREDUCER) 63acetaminophen (CHILDRENS FEVERREDUCING) 63acetaminophen (CHILDRENS PAIN ANDFEVER) 63acetaminophen (CHILDRENS SILAPAP) 63acetaminophen (ED-APAP) 63acetaminophen (LITTLE REMEDIES FEVER-PAIN) 63acetaminophen (M-PAP) 63acetaminophen (MAPAP) 63acetaminophen (MASOPHEN) 63acetaminophen (NON-ASPIRIN EXTRASTRENGTH) 63acetaminophen (NON-ASPIRIN PAIN RELIEF) 63acetaminophen (NON-ASPIRIN) 63acetaminophen (PAIN amp FEVER) 63acetaminophen (PAIN RELIEF EXTRASTRENGTH) 64acetaminophen (PAIN RELIEF) 64
acetaminophen (PAIN RELIEVER) 64acetaminophen (PHARBETOL) 64acetaminophen (SHAKE THAT ACHE) 64acetaminophen (TACTINAL) 64ACETAMINOPHEN 160 MG5ML ORAL SUSP 64ACETAMINOPHEN 160 MG5ML SOLUTION 64acetaminophen with codeine phosphate 45acetazolamide 57ACETAZOLAMIDE 58acetic acid 116ACETIC ACID 116acetylcysteine 124ACID CONTROLLER 80ACID REDUCER 80ACNE MEDICATION 66ACNE MEDICATION (benzoyl peroxide) 66acyclovir 41ACYCLOVIR 41ADACEL TDAP(diphtheriapertussis(acellular)tetanusvaccinepf) 106ADASUVE (loxapine) 30ADLYXIN (lixisenatide) 43ADMELOG (insulin lispro) 45ADMELOG SOLOSTAR (insulin lispro) 45ADVATE (antihemophilic factor (fviii)recombinantfull length) 47ADYNOVATE (antihemophilic factor (fviii)recombinant full length peg) 47AFLURIA QUAD 2020-2021 106AFLURIA QUAD 2020-21 (3YR UP) 106AFSTYLA (antihemophilic factor viiirecombsingle-chnb-dom truncated) 47ALAVERT (loratadine) 117ALAWAY (ketotifen fumarate) 113Albuterol 90mcg HFA inhaler (GenericProair) 122Albuterol 90mcg HFA inhaler (GenericProventil) 122Albuterol 90mcg HFA inhaler (GenericVentolin) 122
LAST UPDATED 12012020132
ALBUTEROL SULFATE 123albuterol sulfate 123ALBUTEROL SULFATE HFA 123alcohol antiseptic pads 110ALCOHOL WIPES 110alendronate sodium 109alfuzosin hcl 86ALL DAY ALLERGY 117ALLERGY RELIEF 117ALLI (orlistat) 78allopurinol 24ALLOPURINOL 24alogliptin benzoate 43alogliptin benzoatemetformin hcl 43alogliptin benzoatepioglitazone hcl 43ALOMIDE (lodoxamide tromethamine) 114ALPHAGAN P (brimonidine tartrate) 115ALPHANATE (antihemophilic factorhumanvon willebrand factorhuman) 47ALPHANINE SD (factor ix) 47alprazolam 42alprazolam (ALPRAZOLAM INTENSOL) 42ALPROLIX (factor ix recombinant fc fusionprotein) 48AMANTADINE 29amantadine hcl 29ambrisentan 124amiloride hcl 58amiloride hclhydrochlorothiazide 56amiodarone hcl 53amiodarone hcl (PACERONE) 53AMITIZA (lubiprostone) 81amitriptyline hcl 19AMLODIPINE BESYLATE 54amlodipine besylate 54amlodipine besylatebenazepril hcl 56ammonium lactate 66ammonium lactate (SKIN TREATMENT) 66amoxapine 19amoxicillin 11AMOXICILLIN-CLAVULANATE POTASS 11
amoxicillinpotassium clavulanate 1112ampicillin trihydrate 12anagrelide hcl 47anastrozole 28ANASTROZOLE 28ANTACID 78ANTACID EXTRA STRENGTH 78ANTI-DIARRHEAL 78ANTIFUNGAL 21apraclonidine hcl 115aprepitant 21APTIVUS (tipranavir) 40APTIVUS (tipranavirvitamin e tpgs) 40aripiprazole 32ARIPIPRAZOLE 32ARISTADA (aripiprazole lauroxil) 32ARISTADA INITIO (aripiprazole lauroxilsubmicronized) 32ARMOUR THYROID (thyroidpork) 102ascorbate calcium 72ascorbic acid 72ascorbic acid (SOOTHING PUREWAY-C) 72aspirin 1aspirin (ADULT ASPIRIN REGIMEN) 1aspirin (ADULT LOW DOSE ASPIRIN EC) 1aspirin (ASPIR 81) 1aspirin (ASPIR-TRIN) 1aspirin (ASPIRIN) 1aspirin (ECOTRIN) 1aspirin (ECPIRIN) 1aspirin (ST JOSEPH ASPIRIN EC) 1aspirin (ST JOSEPH ASPIRIN) 1ASPIRIN 325MG TABLET 1ASPIRIN 81MG TABLET 1aspirinacetaminophencaffeine (ADDEDSTRENGTH HEADACHE) 1aspirinacetaminophencaffeine (BAYERMIGRAINE) 1aspirinacetaminophencaffeine (EXTRA PAINRELIEF) 1
LAST UPDATED 12012020133
aspirinacetaminophencaffeine(EXTRAPRIN) 1aspirinacetaminophencaffeine (HEADACHERELIEF) 1aspirinacetaminophencaffeine (MIGRAINEFORMULA) 2aspirinacetaminophencaffeine (MIGRAINERELIEF) 2aspirinacetaminophencaffeine (PAINRELIEVER PLUS) 2aspirinacetaminophencaffeine (PAINRELIEVER) 2aspirinacetaminophencaffeine (PAIN-OFF) 2ASSURE ID DUO-SHIELD 110ASSURE ID INSULIN SAFETY 110ATAZANAVIR SULFATE 40atazanavir sulfate 40atenolol 53ATENOLOL 53atenololchlorthalidone 56ATHLETES FOOT (terbinafine hcl) 21atomoxetine hcl 62atorvastatin calcium 59ATORVASTATIN CALCIUM 59ATRIPLA (efavirenzemtricitabinetenofovirdisoproxil fumarate) 37atropine sulfate 112ATROVENT HFA (ipratropium bromide) 122AVANDIA (rosiglitazone maleate) 43AVONEX (interferon beta-1a) 65AVONEX (interferon beta-1aalbuminhuman) 65AVONEX PEN (interferon beta-1a) 65azathioprine 104AZATHIOPRINE 104AZELASTINE HCL 117azelastine hcl 117azithromycin 12AZITHROMYCIN 12
Bbacitracin 9BACITRACIN 9bacitracin (BACITRAYCIN PLUS) 9bacitracin zinc 9BACITRACIN ZINC 9bacitracin zinc (ANTIBIOTIC) 9bacitracinpolymyxin b sulfate 112bacitracinpolymyxin b sulfate (AK-POLY-BAC) 112bacitracinpolymyxin b sulfate (POLYCIN) 112baclofen 35BACLOFEN 35balsalazide disodium 109BAQSIMI (glucagon) 44BASAGLAR KWIKPEN U-100 (insulinglarginehuman recombinant analog) 45BELBUCA (buprenorphine hcl) 3benazepril hcl 52benazepril hclhydrochlorothiazide 56BENEFIX (factor ix human recombinant) 48benzonatate 124benzoyl peroxide 67benzoyl peroxide (ACNE CONTROLCLEANSER) 66benzoyl peroxide (ACNE FOAMING WASH) 66benzoyl peroxide (ACNE TREATMENT) 67benzoyl peroxide (ACNECLEAR) 67benzoyl peroxide (ADVANCED EXFOLIATINGCLEANSER) 67benzoyl peroxide (BP WASH) 67benzoyl peroxide (BP) 67benzoyl peroxide (BPO-10) 67benzoyl peroxide (BPO-5) 67benzoyl peroxide (CLEAN-CLEARCONTINUOUS CONTROL) 67benzoyl peroxide (DAYLOGIC ACNEFOAMING WASH) 67benzoyl peroxide (DAYLOGIC ACNETREATMENT) 67
LAST UPDATED 12012020134
benzoyl peroxide (FOAMING ACNE FACEWASH) 67benzoyl peroxide (PANOXYL) 67benztropine mesylate 29BEOVU (brolucizumab-dbll) 112betamethasone dipropionate 87BETAMETHASONE DIPROPIONATE 87betamethasone dipropionatepropyleneglycol 88betamethasone valerate 88betaxolol hcl 115bethanechol chloride 86BETIMOL (timolol) 115BETOPTIC S (betaxolol hcl) 115BEVESPI AEROSPHERE(glycopyrrolateformoterol fumarate) 124BEXSERO (meningococcal group b vaccine4-component) 106bicalutamide 27BIKTARVY (bictegravirsodiumemtricitabinetenofovir alafenamidefumar) 36bisacodyl 82BISACODYL 82bisacodyl (ALOPHEN PILLS) 81bisacodyl (BISA-LAX) 81bisacodyl (BISACODYL) 81bisacodyl (BISCOLAX) 81bisacodyl (C-LAX LAXATIVE) 81bisacodyl (DUCODYL) 81bisacodyl (FAST RELIEF LAXATIVE) 81bisacodyl (GENTLE LAXATIVE) 81bisacodyl (LAXATIVE SUPPOSITORY) 81bisacodyl (LAXATIVE) 82bisacodyl (MAGIC BULLET) 82bisacodyl (WOMENS GENTLE LAXATIVE) 82bisacodyl (WOMENS LAXATIVE) 82bismuth subsalicylate 78bismuth subsalicylate (BISMATROL) 78bismuth subsalicylate (DIOTAME) 78bismuth subsalicylate (PEP-T-MED) 78
bismuth subsalicylate (PEPTIC RELIEF) 78bismuth subsalicylate (PINK BISMUTH) 78bismuth subsalicylate (SOOTHE) 78bismuth subsalicylate (STOMACH RELIEF) 78bisoprolol fumarate 54bisoprolol fumaratehydrochlorothiazide 56BISOPROLOL-HYDROCHLOROTHIAZIDE 56BLEPH-10 (sulfacetamide sodium) 13BLEPHAMIDE (sulfacetamidesodiumprednisolone acetate) 112BOOSTRIX TDAP(diphtheriapertussis(acellular)tetanusvaccine) 106bosentan 124brimonidine tartrate 115bromocriptine mesylate 29brompheniramine maleatepseudoephedrinehcl (RYNEX PSE) 125BROTAPP DM (brompheniraminemaleatepseudoephedrinehcldextromethorphan) 125BUDESONIDE 116budesonide 117bumetanide 58BUNAVAIL (buprenorphine hclnaloxone hcl) 7BUPRENEX (buprenorphine hcl) 7buprenorphine 4buprenorphine hcl 7buprenorphine hclnaloxone hcl 7bupropion hcl 817bupropion hcl (BUPROBAN) 8BUPROPION HCL SR 17BUPROPION XL 17BUSPIRONE HCL 41buspirone hcl 42butalbitalacetaminophen 64butalbitalacetaminophen (TENCON) 64butalbitalacetaminophencaffeine 64butalbitalaspirincaffeine 2butorphanol tartrate 5BUTRANS (buprenorphine) 4
LAST UPDATED 12012020135
CCALADRYL (pramoxine hclcalamine) 67calcipotriene 67calcitoninsalmonsynthetic 110CALCITRIOL 110calcitriol 110CALCIUM 72CALCIUM 500-VIT D3 72CALCIUM 600-VIT D3 72calcium acetate 87calcium acetate (ELIPHOS) 87calcium carbonate 697379calcium carbonate (ANTACID CALCIUM) 78calcium carbonate (ANTACID EXTRASTRENGTH) 78calcium carbonate (ANTACID) 78calcium carbonate (BAN-ACID) 78calcium carbonate (CAL-GEST) 78calcium carbonate (CALCIUM ANTACID) 78calcium carbonate (CHILDRENS PEPTO) 79calcium carbonate (CHILDRENS SOOTHE) 79calcium carbonate (FLAVOR CHEWSANTACID) 79calcium carbonate (OYSCO-500) 72calcium carbonate (SMOOTH ANTACID) 79calcium carbonate (SMOOTH DISSOLVINGANTACID) 79calcium carbonate (SUPER CALCIUM) 72calcium carbonatecholecalciferol (vitamind3) 73calcium carbonatecholecalciferol (vitamind3) (HI-CAL) 73calcium carbonatecholecalciferol (vitamind3) (OS-CAL 500-VIT D3) 73calcium carbonatecholecalciferol (vitamind3) (OYSCO 500-VIT D3) 73calcium carbonatecholecalciferol (vitamind3) (OYSTERCAL-D) 73calcium gluconate 73calcium lactate 73
capecitabine 27CAPECITABINE 27CAPLYTA (lumateperone tosylate) 32captopril 52CAPTOPRIL 52captoprilhydrochlorothiazide 56carbamazepine 16carbamazepine (EPITOL) 16carbamide peroxide (CARBAMOXIDE) 116carbamide peroxide (EAR DROPS) 116carbamide peroxide (EAR SYSTEM) 116carbamide peroxide (EAR WAXREMOVAL) 116carbamide peroxide (MURINE EAR WAXREMOVAL SYSTEM) 116CARBATROL (carbamazepine) 16carbidopalevodopa 30carisoprodol 130CARISOPRODOL 130carvedilol 54cefaclor 11CEFDINIR 11cefdinir 11celecoxib 2CELECOXIB 2CELONTIN (methsuximide) 14cephalexin 11cetirizine hcl 118CETIRIZINE HCL 118cetirizine hcl (24HOUR ALLERGY) 118cetirizine hcl (ALL DAY ALLERGY RELIEF) 118cetirizine hcl (ALL DAY ALLERGY) 118cetirizine hcl (ALLER-TEC) 118cetirizine hcl (ALLERGY RELIEF) 118cetirizine hcl (WAL-ZYR) 118CHANTIX (varenicline tartrate) 8CHEMET (succimer) 70CHILDRENS ALLERGY RELIEF 118CHILDRENS IBUPROFEN 2CHILDRENS NASACORT (triamcinoloneacetonide) 117
LAST UPDATED 12012020136
CHLORDIAZEPOXIDE-CLIDINIUM 77chlordiazepoxideclidinium bromide 77chlorhexidine gluconate 6667chlorhexidine gluconate (PAROEX) 66chloroquine phosphate 28chlorothiazide 58chlorpheniramine maleate 118chlorpheniramine maleate (ALLERGY 4-HOUR) 118chlorpheniramine maleate (ALLERGYRELIEF) 118chlorpheniramine maleate (ALLERGY) 118chlorpheniramine maleate (ALLERGY-TIME) 118chlorpheniramine maleate (CHLORHIST) 118chlorpheniramine maleate (CHLORTABS) 118chlorpheniramine maleate (ED CHLORPEDJR) 118chlorpheniramine maleate(PHARBECHLOR) 118chlorpheniramine maleate (WAL-FINATE) 118chlorpheniraminemaleatepseudoephedrinedextromethorphan (KIDKARE) 125chlorpromazine hcl 30CHLORPROMAZINE HCL 30chlorthalidone 58CHLORTHALIDONE 58cholecalciferol (vitamin d3) 110cholestyramine (with sugar) 59cholestyramineaspartame 59cholestyramineaspartame (PREVALITE) 59ciclopirox 21ciclopirox olamine 2122cilostazol 51CILOXAN (ciprofloxacin hcl) 13CIMDUO (lamivudinetenofovir disoproxilfumarate) 36cimetidine 80CIMETIDINE 80cimetidine (ACID REDUCER) 80
cimetidine (HEARTBURN RELIEF) 80cimetidine hcl 80cinacalcet hcl 110CINACALCET HCL 110ciprofloxacin hcl 13CIPROFLOXACIN HCL 13citalopram hydrobromide 18citric acidsodium citrate 86citric acidsodium citrate (CYTRA-2) 86citric acidsodium citrate (VIRTRATE-2) 86clarithromycin 12clemastine fumarate 119CLEOCIN (clindamycin phosphate) 9clindamycin hcl 9clindamycin palmitate hcl 9clindamycin phosphate 9CLINDAMYCIN PHOSPHATE 9CLINIMIX (amino acids 425 in dextrose 5 in water) 70clobetasol propionate 88CLOBETASOL PROPIONATE 88clomipramine hcl 19CLOMIPRAMINE HCL 19clonazepam 42clonidine hcl 51CLONIDINE HCL 51clopidogrel bisulfate 51clotrimazole 22CLOTRIMAZOLE 22clotrimazole (ANTIFUNGAL RINGWORM) 22clotrimazole (ANTIFUNGAL) 22clotrimazole (ATHLETES FOOT) 22clotrimazole (ATHLETIC FOOT CREAM) 22clotrimazole (CLOTRIMAZOLE AF) 22clotrimazole (ITCH RELIEF) 22clotrimazole (JOCK ITCH RELIEF) 22clotrimazole (JOCK ITCH) 22clotrimazole (RINGWORM) 22clozapine 34CLOZAPINE 34CLOZAPINE ODT 34
LAST UPDATED 12012020137
CLOZARIL (clozapine) 35COAGADEX (coagulation factor x) 48codeinephosphatebutalbitalaspirincaffeine 5codeine phosphateguaifenesin 125codeine phosphateguaifenesin(CHERATUSSIN AC) 125codeine phosphateguaifenesin (G TUSSINAC) 125codeine phosphateguaifenesin(GUAIATUSSIN AC) 125codeine phosphateguaifenesin(GUAIFENESIN AC) 125codeine phosphateguaifenesin (ROBAFENAC) 125codeine phosphateguaifenesin (VIRTUSSINAC) 125codeine sulfate 5CODEINE-GUAIFENESIN 125COGENTIN (benztropine mesylate) 29colchicine 24COLCHICINE 24COLESTID (colestipol hcl) 59colestipol hcl 59COMBIVENT RESPIMAT (ipratropiumbromidealbuterol sulfate) 125COMBIVIR (lamivudinezidovudine) 38COMPLERA (emtricitabinerilpivirinehcltenofovir disoproxil fumarate) 37condoms female 110condoms latex lubricated 110CORIFACT (factor xiii) 48CORTISPORIN (neomycin sulfatepolymyxin bsulfatehydrocortisone) 112CORTISPORIN(neomycinbacitracinpolymyxinbhydrocortisone) 67COUGH FORMULA DM(guaifenesindextromethorphan hbr) 125COUMADIN (warfarin sodium) 46CREON (lipaseproteaseamylase) 85
CRIXIVAN (indinavir sulfate) 40cromolyn sodium 110114cyanocobalamin (vitamin b-12) 73cyanocobalamin (vitamin b-12) (B-12DOTS) 73cyclobenzaprine hcl 130cyclopentolate hcl 112cyclophosphamide 26CYCLOPHOSPHAMIDE 26cyclosporine 104cyclosporine modified 104cyclosporine modified (GENGRAF) 104cyproheptadine hcl 119
Ddanazol 91dapsone 26DEBROX (carbamide peroxide) 116DELSTRIGO (doravirinelamivudinetenofovirdisoproxil fumarate) 37DELTASONE (prednisone) 88DEPAKENE (valproic acid (as sodium salt)(valproate sodium)) 15DEPAKENE (valproic acid) 15DEPO-PROVERA (medroxyprogesteroneacetate) 100DEPO-SUBQ PROVERA 104(medroxyprogesterone acetate) 100DESCOVY (emtricitabinetenofoviralafenamide fumarate) 39desipramine hcl 19desmopressin acetate 90DESMOPRESSIN ACETATE 90desmopressin acetate (non-refrigerated) 90desogestrel-ethinyl estradiol 91desogestrel-ethinyl estradiol (APRI) 91desogestrel-ethinyl estradiol (CYRED EQ) 91desogestrel-ethinyl estradiol (CYRED) 91desogestrel-ethinyl estradiol (EMOQUETTE) 91desogestrel-ethinyl estradiol (ENSKYCE) 91desogestrel-ethinyl estradiol (ISIBLOOM) 91
LAST UPDATED 12012020138
desogestrel-ethinyl estradiol (JULEBER) 91desogestrel-ethinyl estradiol (KALLIGA) 91desogestrel-ethinyl estradiol (RECLIPSEN) 91desogestrel-ethinyl estradiolethinylestradiol 92desogestrel-ethinyl estradiolethinyl estradiol(AZURETTE) 91desogestrel-ethinyl estradiolethinyl estradiol(BEKYREE) 92desogestrel-ethinyl estradiolethinyl estradiol(KARIVA) 92desogestrel-ethinyl estradiolethinyl estradiol(KIMIDESS) 92desogestrel-ethinyl estradiolethinyl estradiol(PIMTREA) 92desogestrel-ethinyl estradiolethinyl estradiol(SIMLIYA) 92desogestrel-ethinyl estradiolethinyl estradiol(VIORELE) 92desogestrel-ethinyl estradiolethinyl estradiol(VOLNEA) 92desonide 88DESONIDE 88dexamethasone 88DEXAMETHASONE 88dexamethasone (DEXAMETHASONEINTENSOL) 88dexamethasone sodium phosphate 114dextroamphetamine sulf-saccharateamphetamine sulf-aspartate 61dextroamphetamine sulfate 62DEXTROAMPHETAMINE SULFATE 62dextroamphetamine sulfate (ZENZEDI) 62DEXTROAMPHETAMINE-AMPHET ER 62dextrose 10 and 045 sodium chloride 70dextrose 10 in water 7073dextrose 5 and 045 sodium chloride 7073dextrose 5 in lactated ringers 73dextrose 5 in water 697073DEXTROSE IN WATER 74diazepam 1542
diclofenac sodium 2114dicloxacillin sodium 12DICYCLOMINE HCL 77dicyclomine hcl 77DIFFERIN (adapalene) 67diflunisal 2digoxin 56digoxin (DIGITEK) 56digoxin (DIGOX) 56DILANTIN (phenytoin sodium extended) 16DILANTIN (phenytoin) 16DILANTIN-125 16DILANTIN-125 (phenytoin) 16DILTIAZEM 24HR ER (CD) 54DILTIAZEM 24HR ER (XR) 55diltiazem hcl 55diltiazem hcl (CARTIA XT) 55diltiazem hcl (DILT-XR) 55diltiazem hcl (TAZTIA XT) 55DIMETHYL FUMARATE 65DIPHENHYDRAMINE HCL 120diphenhydramine hcl 120diphenhydramine hcl (ALER-CAPS) 119diphenhydramine hcl (ALKA-SELTZER PLUSALLERGY) 130diphenhydramine hcl (ALLER-G-TIME) 119diphenhydramine hcl (ALLERGYMEDICATION) 119diphenhydramine hcl (ALLERGYMEDICINE) 119diphenhydramine hcl (ALLERGY RELIEF) 119diphenhydramine hcl (ALLERGY) 119diphenhydramine hcl (BANOPHEN) 119diphenhydramine hcl (BENADRYLALLERGY) 119diphenhydramine hcl (CHILDRENS ALLERGYRELIEF) 119diphenhydramine hcl (CHILDRENSALLERGY) 119diphenhydramine hcl (CHILDRENS BENADRYLALLERGY) 119
LAST UPDATED 12012020139
diphenhydramine hcl (CHILDRENS WAL-DRYLALLERGY) 119diphenhydramine hcl (COMPLETEALLERGY) 119diphenhydramine hcl (COMPOZ) 130diphenhydramine hcl (DIPHEDRYLALLERGY) 119diphenhydramine hcl (DIPHEDRYL) 120diphenhydramine hcl (DIPHEN) 120diphenhydramine hcl (DIPHENHIST) 120diphenhydramine hcl (GERI-DRYL) 120diphenhydramine hcl (M-DRYL) 120diphenhydramine hcl (NIGHTTIME ALLERGYRELIEF) 120diphenhydramine hcl (NIGHTTIME SLEEPAID) 120130diphenhydramine hcl (NYTOL QUICKCAPS)130diphenhydramine hcl (PHARBEDRYL) 120diphenhydramine hcl (SILADRYL) 120diphenhydramine hcl (SIMPLY SLEEP) 120131diphenhydramine hcl (SLEEP AID) 120131diphenhydramine hcl (SLEEP II) 131diphenhydramine hcl (SLEEP TABLET) 131diphenhydramine hcl (TOTAL ALLERGY) 120diphenhydramine hcl (WAL-DRYLALLERGY) 120diphenhydramine hcl (WAL-DRYL) 120diphenoxylate hclatropine sulfate 79DIPHENOXYLATE-ATROPINE 79dipyridamole 51disopyramide phosphate 53disulfiram 6DIURIL (chlorothiazide) 58divalproex sodium 15DIVALPROEX SODIUM 15DOCUSATE SODIUM 82docusate sodium 82docusate sodium (COL-RITE) 82docusate sodium (DIOCTYL) 82docusate sodium (DOCU LIQUID) 82docusate sodium (DOCUSIL) 82
docusate sodium (DSS) 82docusate sodium (DULCOEASE) 82docusate sodium (DULCOLAX STOOLSOFTENER) 82docusate sodium (LAXA BASIC 100) 82docusate sodium (PHILLIPS LAXATIVE) 82docusate sodium (SOF-LAX) 82docusate sodium (STOOL SOFTENER) 82DOK (docusate sodium) 83donepezil hcl 17dorzolamide hcl 115dorzolamide hcltimolol maleate 115DORZOLAMIDE-TIMOLOL 115DOVATO (dolutegravir sodiumlamivudine) 39doxazosin mesylate 51DOXEPIN HCL 19doxepin hcl 19DOXYCYCLINE HYCLATE 14doxycycline hyclate 14doxycycline monohydrate 14DRITHOCREME HP (anthralin) 67dronabinol 21DROPLET MICRON PEN NEEDLE 110DROSPIRENONE-ETHINYL ESTRADIOL 92DROXIA (hydroxyurea) 27DRYSOL (aluminum chloride) 68duloxetine hcl 65
EEES 200 (erythromycin ethylsuccinate) 12EES 400 (erythromycin ethylsuccinate) 12EAR DROPS (carbamide peroxide) 116EDURANT (rilpivirine hcl) 37efavirenz 37EFAVIRENZ-EMTRIC-TENOFOV DISOP 37EFAVIRENZ-LAMIVU-TENOFOV DISOP 3637electrolytesdextrose (ELECTROLYTE) 74electrolytesdextrose (ORALYTE) 74electrolytesdextrose (PEDIATRICELECTROLYTE) 74
LAST UPDATED 12012020140
electrolytesdextrose (PEDIATRIC FREEZERPOPS) 74ELIQUIS (apixaban) 46ELIXOPHYLLIN (theophylline anhydrous) 124ELOCTATE (antihemophilic factor (fviii)recombinant fc fusion protein) 48EMCYT (estramustine phosphate sodium) 27EMSAM (selegiline) 18EMTRICITABINE 38EMTRICITABINE-TENOFOVIR DISOP 38EMTRIVA (emtricitabine) 38ENALAPRIL MALEATE 52enalapril maleate 52ENBREL 105ENBREL (etanercept) 104ENBREL SURECLICK (etanercept) 105ENGERIX-B ADULT (hepatitis b virus vaccinerecombinantpf) 106ENOXAPARIN SODIUM 46enoxaparin sodium 46entacapone 29EPIFOAM (hydrocortisone acetatepramoxinehcl) 68epinephrine 123EPIVIR (lamivudine) 38EPIVIR HBV (lamivudine) 35EPOGEN (epoetin alfa) 47EPZICOM (abacavir sulfatelamivudine) 38ERGOCALCIFEROL 110ergocalciferol (vitamin d2) 110ergocalciferol (vitamin d2) (CALCIDOL) 110ergotamine tartratecaffeine 25ERYTHROCIN STEARATE (erythromycinstearate) 12ERYTHROMYCIN 13erythromycin base 13erythromycin base in ethanol 13erythromycin base in ethanol (ERY) 13erythromycin basebenzoyl peroxide 9ERYTHROMYCIN ETHYLSUCCINATE 13erythromycin ethylsuccinate 13
escitalopram oxalate 18ESCITALOPRAM OXALATE 18ESPEROCT (antihemophilic factor (fviii) rec b-dom truncated peg-exei) 48estradiol 92ESTRADIOL 93estradiol (DOTTI) 92estrogensesterifiedmethyltestosterone 93estrogensesterifiedmethyltestosterone(COVARYX HS) 93estrogensesterifiedmethyltestosterone (EEMTHS) 93ethambutol hcl 26ETHAMBUTOL HCL 26ethinyl estradioldrospirenone 93ethinyl estradioldrospirenone (GIANVI) 93ethinyl estradioldrospirenone (JASMIEL) 93ethinyl estradioldrospirenone (LO-ZUMANDIMINE) 93ethinyl estradioldrospirenone (LORYNA) 93ethinyl estradioldrospirenone (NIKKI) 93ethinyl estradioldrospirenone (VESTURA) 93ETHOSUXIMIDE 14ethosuximide 14ethynodiol diacetate-ethinyl estradiol 93ethynodiol diacetate-ethinyl estradiol(KELNOR 1-35) 93ethynodiol diacetate-ethinyl estradiol(KELNOR 1-50) 93ethynodiol diacetate-ethinyl estradiol (ZOVIA1-35E) 93etodolac 2etonogestrelethinyl estradiol 94etonogestrelethinyl estradiol (ELURYNG) 93etoposide 28EVOTAZ (atazanavir sulfatecobicistat) 40EVZIO (naloxone hcl) 7EXCEDRIN EXTRA STRENGTH(aspirinacetaminophencaffeine) 2EXCEDRIN MIGRAINE(aspirinacetaminophencaffeine) 2
LAST UPDATED 12012020141
EYE ITCH RELIEF 114ezetimibe 59
Ffamotidine 81FAMOTIDINE 81famotidine (ACID CONTROLLER) 80famotidine (ACID REDUCER) 80famotidine (HEARTBURN PREVENTION) 81famotidine (HEARTBURN RELIEF) 81famotidine (PEPCID) 81FANAPT (iloperidone) 32FAZACLO (clozapine) 35FEIBA NF (anti-inhibitor coagulant complex) 48felodipine 55FELODIPINE ER 55fenofibrate 58FENOFIBRATE 58fenofibratemicronized 59fentanyl 4ferrous sulfate 74FERROUS SULFATE 74ferrous sulfate (CHILDRENS IRON) 74ferrous sulfate (FEOSOL) 74ferrous sulfate (FEROSUL) 74ferrous sulfate (FERRO-TIME) 74ferrous sulfate (FERROUSUL) 74ferrous sulfate (PEDIA IRON) 74fexofenadine hcl 121FEXOFENADINE HCL 121fexofenadine hcl (ALLER-EASE) 120fexofenadine hcl (ALLER-FEX) 120fexofenadine hcl (ALLERGY RELIEF) 121fexofenadine hcl (WAL-FEX ALLERGY) 121FIBRYGA (fibrinogen) 48finasteride 86flecainide acetate 53FLOVENT DISKUS (fluticasone propionate) 117FLOVENT HFA (fluticasone propionate) 117FLUAD 2020-2021 106FLUAD QUAD 2020-2021 106
FLUARIX QUAD 2020-2021 106FLUBLOK QUAD 2018-2019 (influenza virusvaccine qv 2018-19(18 yrs andolder)rcmbpf) 106FLUBLOK QUAD 2020-2021 107FLUCELVAX QUAD 2020-2021 107fluconazole 22FLUCONAZOLE 22fluconazole in dextrose iso-osmotic 22flucytosine 22FLUCYTOSINE 22fludrocortisone acetate 88FLULAVAL QUAD 2019-2020 (influenza virusvaccine quadrivalent 2019-20 (6 mos andup)) 107FLULAVAL QUAD 2020-2021 107fluocinolone acetonide 88fluocinonide 88FLUOCINONIDE 88fluoride (sodium) 74fluorometholone 114fluorouracil (ADRUCIL) 27fluoxetine hcl 18FLUOXETINE HCL 18fluoxymesterone (ANDROXY) 91fluphenazine decanoate 30fluphenazine hcl 30FLUPHENAZINE HCL 30flurazepam hcl 130flurbiprofen 2flurbiprofen sodium 114flutamide 27fluticasone propionate 117fluticasone propionate (ALLERGY RELIEF) 117fluticasone propionatesalmeterolxinafoate 126fluticasone propionatesalmeterol xinafoate(WIXELA INHUB) 126fluvoxamine maleate 18FLUZONE HIGH-DOSE QUAD 2020-21 107
LAST UPDATED 12012020142
FLUZONE QUAD 2019-2020 (influenza virusvaccine quadrival 2019-2020(6 mos andup)pf) 107FLUZONE QUAD 2020-2021 107FML FORTE (fluorometholone) 114FML SOP (fluorometholone) 114folic acid 74FOLIC ACID 74FORADIL (formoterol fumarate) 123FOSAMAX PLUS D (alendronatesodiumcholecalciferol (vitamin d3)) 110fosamprenavir calcium 40FOSAMPRENAVIR CALCIUM 40fosinopril sodium 52fosinopril sodiumhydrochlorothiazide 57FOSINOPRIL-HYDROCHLOROTHIAZIDE 57Freestyle Insulix Test Strips 110Freestyle Lite Test Strips 111Freestyle Test Strips 111furosemide 58FUZEON (enfuvirtide) 39
Ggabapentin 15GABAPENTIN 15GARDASIL 9 (human papillomavirus vaccine9-valentpf) 107GAS RELIEF 79GAS RELIEF (simethicone) 79GAS-X (simethicone) 79gemfibrozil 59GEMFIBROZIL 59gentamicin sulfate 8GENTAMICIN SULFATE 9gentamicin sulfate (GENTAK) 8GENTLE LAXATIVE 83GENVOYA(elvitegravircobicistatemtricitabinetenofovir alafenamide) 36GEODON (ziprasidone hcl) 32GEODON (ziprasidone mesylate) 32
GERI-DRYL 121glatiramer acetate 6566glatiramer acetate (GLATOPA) 65GLEOSTINE (lomustine) 26glimepiride 43glipizide 43GLUCAGON EMERGENCY KIT (glucagonhcl) 44GLUCAGON EMERGENCY KIT(glucagonhuman recombinant) 44glyburide 43glyburidemetformin hcl 43glycerin 83glycerin (ADULT GLYCERIN) 83glycerin (LAXATIVE SUPPOSITORY) 83glycerin (PEDIA-LAX) 83glycerin (SUPPOSITORY) 83GOCOVRI (amantadine hcl) 29granisetron hcl 21griseofulvin ultramicrosize 22griseofulvin microsize 23GUAIASORB DM 126guaifenesin (MUCUS ER) 126guaifenesin (MUCUS RELIEF ER) 126GUAIFENESIN-DEXTROMETHORPHAN 126guaifenesindextromethorphan hbr 128guaifenesindextromethorphan hbr (ADULTROBITUSSIN PEAK COLD DM) 126guaifenesindextromethorphan hbr (ADULTTUSSIN COUGH CONGEST DM) 126guaifenesindextromethorphan hbr (ADULTTUSSIN DM) 126guaifenesindextromethorphan hbr (ADULTWAL-TUSSIN DM) 126guaifenesindextromethorphan hbr(ANTITUSSIVE DM) 126guaifenesindextromethorphan hbr(BIOCOTRON) 126guaifenesindextromethorphan hbr (COUGHDM) 126
LAST UPDATED 12012020143
guaifenesindextromethorphan hbr (DIABETICSILTUSSIN-DM) 127guaifenesindextromethorphan hbr (DIABETICTUSSIN DM) 127guaifenesindextromethorphan hbr(EXPECTORANT DM) 127guaifenesindextromethorphan hbr (EXTRAACTION COUGH) 127guaifenesindextromethorphan hbr (GERI-TUSSIN DM) 127guaifenesindextromethorphan hbr (GILTUSSDIABETIC) 127guaifenesindextromethorphan hbr (GILTUSSHBP) 127guaifenesindextromethorphan hbr(GUAIASORB DM) 127guaifenesindextromethorphan hbr (RI-TUSSINDM) 127guaifenesindextromethorphan hbr (ROBAFENDM COUGH) 127guaifenesindextromethorphan hbr (ROBAFENDM COUGH-CHEST CONGEST) 127guaifenesindextromethorphan hbr (ROBAFENDM PEAK COLD) 127guaifenesindextromethorphan hbr(ROBAFEN-DM) 127guaifenesindextromethorphan hbr(SAFETUSSIN DM) 127guaifenesindextromethorphan hbr (SILTUSSINDM DAS) 127guaifenesindextromethorphan hbr (SILTUSSINDM) 128guaifenesindextromethorphan hbr(SORBUGEN NR) 128guaifenesindextromethorphan hbr (TUSNELDIABETIC) 128guaifenesindextromethorphan hbr (TUSSINCOUGH) 128guaifenesindextromethorphan hbr (TUSSINDM CLEAR) 128
guaifenesindextromethorphan hbr (TUSSINDM COUGH) 128guaifenesindextromethorphan hbr (TUSSINDM COUGH-CHEST CONGEST) 128guaifenesindextromethorphan hbr (TUSSINDM) 128guaifenesindextromethorphan hbr (ULTRADM FREE amp CLEAR) 128guaifenesindextromethorphan hbr (ULTRATUSS) 128guaifenesindextromethorphan hbr (WAL-TUSSIN DM) 128guaifenesinpseudoephedrine hcl 129guaifenesinpseudoephedrine hcl (MUCUSD) 128guaifenesinpseudoephedrine hcl (MUCUSRELIEF D) 128guanfacine hcl 5162
HHAILEY FE 94HALDOL (haloperidol lactate) 30HALDOL DECANOATE 100 (haloperidoldecanoate) 30HALDOL DECANOATE 50 (haloperidoldecanoate) 30haloperidol 31HALOPERIDOL 31haloperidol decanoate 31haloperidol lactate 31HALOPERIDOL LACTATE 31HAVRIX (hepatitis a virus vaccinepf) 107HEADACHE RELIEF 2HELIXATE FS (antihemophilic factor (fviii)recombinantfull length) 48HEMLIBRA (emicizumab-kxwh) 48HEMOFIL M (antihemophilic factor human) 48HEPARIN SODIUM 46heparin sodiumporcine 46heparin sodiumporcinepf 46
LAST UPDATED 12012020144
HEPLISAV-B (hepatitis b vaccinerecombinantvaccine adjuvant cpg1018pf) 107HEXALEN (altretamine) 26homatropine hbr 112homatropine hbr (HOMATROPAIRE) 112HUMALOG (insulin lispro) 45HUMALOG MIX 75-25 (insulin lispro protamineand insulin lispro) 45HUMALOG MIX 75-25 KWIKPEN (insulin lisproprotamine and insulin lispro) 45HUMATE-P (antihemophilic factor humanvonwillebrand factorhuman) 48HUMIRA (adalimumab) 105HUMIRA PEDIATRIC CROHNS(adalimumab) 105HUMIRA PEN (adalimumab) 105HUMIRA PEN CROHNS-UC-HS(adalimumab) 105HUMIRA PEN PSOR-UVEITS-ADOL HS(adalimumab) 105HUMIRA(CF) (adalimumab) 105HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 105HUMIRA(CF) PEN (adalimumab) 105HUMIRA(CF) PEN CROHNS-UC-HS(adalimumab) 105HUMIRA(CF) PEN PSOR-UV-ADOL HS(adalimumab) 105HUMULIN 70-30 (insulin nph humanisophaneinsulin regular human) 45HUMULIN 7030 KWIKPEN (insulin nph humanisophaneinsulin regular human) 45HUMULIN N (insulin nph human isophane) 45HUMULIN R (insulin regular human) 45HUMULIN R U-500 (insulin regular human) 45hydralazine hcl 60hydrochlorothiazide 58hydrocodone bitartrateacetaminophen 5hydrocodone bitartrateacetaminophen(LORCET HD) 5
hydrocodone bitartrateacetaminophen(LORTAB) 5hydrocortisone 89109HYDROCORTISONE 89hydrocortisone (ANTI-ITCH) 88hydrocortisone (ANUSOL-HC) 88hydrocortisone (COLOCORT) 109hydrocortisone (CORTISONE) 88hydrocortisone (CORTIZONE-10 PLUS) 89hydrocortisone (CORTIZONE-10) 89hydrocortisone (HYDROCREAM) 89hydrocortisone (NOBLE FORMULA HC) 89hydrocortisone (PREPARATION H) 89hydrocortisone (PROCTO-MED HC) 89hydrocortisone (PROCTO-PAK) 89hydrocortisone (PROCTOSOL-HC) 89hydrocortisone (PROCTOZONE-HC) 89hydrocortisone (SOOTHING CARE) 89HYDROCORTISONE ACETATE 89hydrocortisone acetate 89hydrocortisone acetate (ANUCORT-HC) 89hydrocortisone acetate (ANUSOL-HC) 89hydrocortisone acetate (HEMMOREX-HC) 89hydrocortisone acetatepramoxine hcl 68hydrocortisoneacetic acid 116hydrocortisoneacetic acid (ACETASOLHC) 116hydromorphone hcl 5HYDROXYCHLOROQUINE SULFATE 28hydroxychloroquine sulfate 28hydroxyprogesterone caproate 100hydroxyprogesterone caproatepf 100hydroxyurea 27hydroxyzine hcl 121HYDROXYZINE PAMOATE 121hydroxyzine pamoate 121hyoscyamine sulfate 77hyoscyamine sulfate (HYOSYNE) 77HYPERTET S-D (tetanus immuneglobulinpf) 106
LAST UPDATED 12012020145
Iibuprofen 3IBUPROFEN 3ibuprofen (ADDAPRIN) 2ibuprofen (I-PRIN) 3ibuprofen (IBU) 3ibuprofen (IBU-200) 3ibuprofen (PROVIL) 3ibuprofen (WAL-PROFEN) 3IDELVION (factor ix recombinantalbuminfusion protein) 48imipramine hcl 19IMIPRAMINE HCL 19IMOVAX RABIES VACCINE (rabies vaccinehuman diploid cellpf) 107INCRUSE ELLIPTA (umeclidinium bromide) 122indapamide 58indomethacin 3INFANTS GAS RELIEF 79inhalerassist device with large mask 111inhalerassist device with medium mask 111inhalerassist device with small mask 111insulin lispro 45INSULIN LISPRO PROTAMINE MIX (insulin lisproprotamine and insulin lispro) 45Insulin pen needles 111INSULIN SYRINGE 03 ML 111INSULIN SYRINGE 05 ML 111INSULIN SYRINGE 1 ML 111INTELENCE (etravirine) 37INTRON A (interferon alfa-2brecomb) 35INVEGA (paliperidone) 32INVEGA SUSTENNA (paliperidone palmitate)32INVEGA TRINZA (paliperidone palmitate) 32INVIRASE (saquinavir mesylate) 40IOPIDINE (apraclonidine hcl) 115ipratropium bromide 122ipratropium bromidealbuterol sulfate 129IPRATROPIUM-ALBUTEROL 129irbesartan 52
irbesartanhydrochlorothiazide 57IRON 74ISENTRESS (raltegravir potassium) 36ISENTRESS HD (raltegravir potassium) 36isoniazid 26ISOSORBIDE DINITRATE 60isosorbide dinitrate 60isosorbide mononitrate 60isotretinoin 68isotretinoin (AMNESTEEM) 68isotretinoin (CLARAVIS) 68isotretinoin (MYORISAN) 68isotretinoin (ZENATANE) 68itraconazole 23IXINITY (factor ix human recombinantthreonine 148) 49
JJAKAFI (ruxolitinib phosphate) 28JARDIANCE (empagliflozin) 43JENCYCLA 100JIVI (antihemophilic factor (fviii) rec b-domain deleted peg-aucl) 49JULUCA (dolutegravir sodiumrilpivirine hcl) 39
KKALETRA (lopinavirritonavir) 40KCENTRA (human prothrombin complexconcentrate (pcc) 4-factor) 49ketoconazole 23ketoprofen 3ketorolac tromethamine 114ketotifen fumarate 114ketotifen fumarate (ALLERGY EYE DROPS) 114ketotifen fumarate (EYE ITCH RELIEF) 114ketotifen fumarate (ITCHY EYE) 114ketotifen fumarate (WAL-ZYR) 114ketotifen fumarate (ZADITOR) 114KOGENATE FS (antihemophilic factor (fviii)recombinantfull length) 49
LAST UPDATED 12012020146
KOVALTRY (antihemophilic factor (fviii)recombinantfull length) 49
Llabetalol hcl 54LABETALOL HCL 54lactulose 83lactulose (CONSTULOSE) 83lactulose (ENULOSE) 83lactulose (GENERLAC) 83LAMISIL (terbinafine hcl) 23lamivudine 3538lamivudinezidovudine 38lamotrigine 15lancets 111LANOXIN (digoxin) 57lansoprazole 85LANSOPRAZOLE 85lanthanum carbonate 87latanoprost 115LATUDA (lurasidone hcl) 32leflunomide 106LEFLUNOMIDE 106letrozole 28LEUCOVORIN CALCIUM 27leucovorin calcium 27LEUKERAN (chlorambucil) 26leuprolide acetate 104levalbuterol tartrate 123LEVETIRACETAM 14levetiracetam 14LEVETIRACETAM ER 14LEVO-T (levothyroxine sodium) 103levobunolol hcl 115levocarnitine 70levocarnitine (with sugar) 70levofloxacin 13levonorgestrel 101levonorgestrel (AFTERA) 101levonorgestrel (ECONTRA EZ) 101levonorgestrel (ECONTRA ONE-STEP) 101
levonorgestrel (FALLBACK SOLO) 101levonorgestrel (MY CHOICE) 101levonorgestrel (MY WAY) 101levonorgestrel (NEW DAY) 101levonorgestrel (OPCICON ONE-STEP) 101levonorgestrel (OPTION 2) 101levonorgestrel (TAKE ACTION) 101LEVONORGESTREL-ETH ESTRADIOL 94levonorgestrelethinyl estradiol 96levonorgestrelethinyl estradiol (AFIRMELLE) 94levonorgestrelethinyl estradiol (ALTAVERA) 94levonorgestrelethinyl estradiol (AUBRA EQ) 94levonorgestrelethinyl estradiol (AUBRA) 94levonorgestrelethinyl estradiol (AVIANE) 94levonorgestrelethinyl estradiol (AYUNA) 94levonorgestrelethinyl estradiol (CHATEALEQ) 94levonorgestrelethinyl estradiol (CHATEAL) 94levonorgestrelethinyl estradiol (DELYLA) 94levonorgestrelethinyl estradiol (ENPRESSE) 94levonorgestrelethinyl estradiol (FALMINA) 95levonorgestrelethinyl estradiol (KURVELO) 95levonorgestrelethinyl estradiol (LARISSIA) 95levonorgestrelethinyl estradiol (LESSINA) 95levonorgestrelethinyl estradiol (LEVONEST) 95levonorgestrelethinyl estradiol (LEVORA-28)95levonorgestrelethinyl estradiol (LILLOW) 95levonorgestrelethinyl estradiol (LUTERA) 95levonorgestrelethinyl estradiol (MARLISSA) 95levonorgestrelethinyl estradiol (MYZILRA) 95levonorgestrelethinyl estradiol (ORSYTHIA) 95levonorgestrelethinyl estradiol (PORTIA) 96levonorgestrelethinyl estradiol (SRONYX) 96levonorgestrelethinyl estradiol (TRIVORA-28) 96levonorgestrelethinyl estradiol (VIENVA) 96levothyroxine sodium 103LEVOTHYROXINE SODIUM 103LEVOXYL (levothyroxine sodium) 103LEXIVA (fosamprenavir calcium) 40LICE KILLING 68
LAST UPDATED 12012020147
lidocaine hcl 6LIDOCAINE HCL VISCOUS 6lidocaine hclpf 6lisinopril 52lisinoprilhydrochlorothiazide 57lithium carbonate 42lithium citrate 42LITHOBID (lithium carbonate) 42loperamide hcl 79loperamide hcl (ANTI-DIARRHEAL) 79loperamide hcl (DIAMODE) 79loperamide hcl (ULTRA A-D) 79lopinavirritonavir 40loratadine 121122LORATADINE 122loratadine (ALLERCLEAR) 121loratadine (ALLERGY RELIEF) 121loratadine (ALLERGY) 121loratadine (CHILDRENS ALLERGY RELIEF) 121loratadine (CHILDRENS ALLERGY) 121loratadine (LORADAMED) 121loratadine (NON-DROWSY ALLERGY) 121loratadine (WAL-ITIN) 121lorazepam 42lorazepam (LORAZEPAM INTENSOL) 42LOSARTAN POTASSIUM 52losartan potassium 52losartan potassiumhydrochlorothiazide 57LOSARTAN-HYDROCHLOROTHIAZIDE 57LOTRIMIN AF (clotrimazole) 23lovastatin 59loxapine succinate 31LUCEMYRA (lofexidine hcl) 7LUPRON DEPOT-PED (leuprolide acetate) 104LYLLANA 96LYSODREN (mitotane) 28
MM-M-R II VACCINE (measles mumps andrubella vaccine livepf) 107MAGNESIUM CITRATE 83
magnesium citrate 83MARPLAN (isocarboxazid) 18MATULANE (procarbazine hcl) 26MAXI-TUSS G 129mebendazole (EMVERM) 28MECLIZINE HCL 20meclizine hcl 20meclizine hcl (DRAMAMINE LESS DROWSY) 20meclizine hcl (MEDI-MECLIZINE) 20meclizine hcl (MOTION RELIEF) 20meclizine hcl (MOTION SICKNESS II) 20meclizine hcl (MOTION SICKNESS RELIEF) 20meclizine hcl (MOTION SICKNESS) 20meclizine hcl (MOTION-TIME) 20meclizine hcl (TRAVEL-EASE) 20meclizine hcl (VERTICALM) 20meclizine hcl (WAL-DRAM 2) 20MEDROXYPROGESTERONE ACETATE 101medroxyprogesterone acetate 101mefloquine hcl 28megestrol acetate 101meloxicam 3melphalan 26memantine hcl 17MEMANTINE HCL 17MENACTRA (meningococcalvaccine acyw-135diphtheria toxoid conjpf) 107MENEST (estrogensesterified) 96MENQUADFI 107MENVEO A-C-Y-W-135-DIP(meningococcalvaccine acyw-135diphtheria toxoid conjpf) 108meperidine hcl 5mercaptopurine 27mesalamine 109MESTINON (pyridostigmine bromide) 25metaproterenol sulfate 123metformin hcl 43METFORMIN HCL ER 43METHADONE HCL 4methadone hcl 4
LAST UPDATED 12012020148
methadone hcl (METHADONE INTENSOL) 4methadone hcl (METHADOSE) 4methazolamide 115METHAZOLAMIDE 115methenaminemethylene bluesodphospsalicylatehyoscyamine(PHOSPHASAL) 9methenaminemethylene bluesodphospsalicylatehyoscyamine (URIN DS) 10methimazole 104methocarbamol 130METHOCARBAMOL 130METHOTREXATE 105methotrexate sodium 105methyclothiazide 58methyldopa 51methylergonovine maleate 111METHYLPHENIDATE ER 62methylphenidate hcl 62METHYLPHENIDATE HCL 62methylphenidate hcl (METADATE ER) 62methylprednisolone 89metoclopramide hcl 20metolazone 58metoprolol succinate 54METOPROLOL SUCCINATE 54metoprolol tartrate 54METRO IV (metronidazole in sodiumchloride) 10metronidazole 1068METRONIDAZOLE 10metronidazole in sodium chloride 10mexiletine hcl 53MEXILETINE HCL 53miconazole nitrate 23miconazole nitrate (ANTI-FUNGAL CREAM) 23miconazole nitrate (ANTIFUNGAL CREAM) 23miconazole nitrate (BAZA ANTIFUNGAL) 23miconazole nitrate (INZO ANTIFUNGAL) 23miconazole nitrate (LOTRIMIN AF) 23miconazole nitrate (MICATIN) 23
miconazole nitrate (SECURA ANTIFUNGAL) 23MICROGESTIN 96MICROGESTIN FE 96minocycline hcl 14minoxidil 60mirtazapine 17misoprostol 85modafinil 131moexipril hcl 52molindone hcl 31mometasone furoate 90MONISTAT 3 (miconazole nitrate) 23MONISTAT 7 (miconazole nitrate) 23MONONINE (factor ix) 49montelukast sodium 122MONTELUKAST SODIUM 122morphine sulfate 45moxifloxacin hcl 13MUCUS ER 129MUCUS RELIEF ER 129mupirocin 10mupirocin calcium 10MURINE EAR DROPS (carbamide peroxide) 116MURO-128 (sodium chloride) 112mycophenolate mofetil 105MYLERAN (busulfan) 27MYNATAL (prenatal vitamins withcalciumferrous fumaratefolic acid) 70
NNABI-HB (hepatitis b immune globulin) 106nadolol 54NADOLOL 54naloxone hcl 7naltrexone hcl 7NALTREXONE HCL 7naproxen 3naproxen sodium 3NARCAN (naloxone hcl) 8NARDIL (phenelzine sulfate) 18NASACORT (triamcinolone acetonide) 117
LAST UPDATED 12012020149
NASAL DECONGESTANT (pseudoephedrinehcl) 123nateglinide 43neomycin sulfate 9neomycin sulfatebacitracin zincpolymyxin b(ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxin b(FIRST AID ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxin b(TRIPLE ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxinbhydrocortisone 112neomycin sulfatebacitracin zincpolymyxinbhydrocortisone (NEO-POLYCIN HC) 112neomycin sulfatebacitracinpolymyxin b 113neomycin sulfatebacitracinpolymyxin b(NEO-POLYCIN) 113neomycin sulfatepolymyxin bsulfategramicidin d 113neomycin sulfatepolymyxin bsulfatehydrocortisone 113116NEOMYCIN-POLYMYXIN-HC 116neomycinpolymyxin bsulfatedexamethasone 113nevirapine 37NIACIN 60niacin 60niacin (ENDUR-ACIN) 59niacin (SLO-NIACIN) 59nicardipine hcl 55NICOTINE 14MG PATCH 8NICOTINE 21MG PATCH 8NICOTINE 2MG GUM 8NICOTINE 4MG GUM 8NICOTINE 7MG PATCH 8NICOTINE LOZENGE 8nicotine polacrilex 8nicotine polacrilex (QUIT 2) 8nicotine polacrilex (QUIT 4) 8nicotine polacrilex (STOP SMOKING AID) 8NICOTROL (nicotine) 8
NICOTROL NS (nicotine) 8NIFEDIPINE 55nifedipine 55nifedipine (AFEDITAB CR) 55nifedipine (NIFEDICAL XL) 55NIGHTTIME SLEEP AID 122nisoldipine 55NITRO-BID (nitroglycerin) 60nitrofurantoin 10NITROFURANTOIN 10nitrofurantoin macrocrystal 10nitrofurantoin monohydratemacrocrystals 10nitroglycerin 61NITROGLYCERIN 61nitroglycerin (MINITRAN) 60nitroglycerin (NITRO-TIME) 60nonoxynol 9 (VCF) 86norelgestrominethinyl estradiol (XULANE) 96norethindrone 102norethindrone (CAMILA) 101norethindrone (DEBLITANE) 101norethindrone (ERRIN) 101norethindrone (HEATHER) 102norethindrone (INCASSIA) 102norethindrone (JENCYCLA) 102norethindrone (JOLIVETTE) 102norethindrone (LYZA) 102norethindrone (NORA-BE) 102norethindrone (NORLYDA) 102norethindrone (NORLYROC) 102norethindrone (SHAROBEL) 102norethindrone (TULANA) 102norethindrone acetate 102norethindrone acetate-ethinyl estradiol 97norethindrone acetate-ethinyl estradiol(AUROVELA) 96norethindrone acetate-ethinyl estradiol(GILDESS) 96norethindrone acetate-ethinyl estradiol(HAILEY) 96
LAST UPDATED 12012020150
norethindrone acetate-ethinyl estradiol(JUNEL) 97norethindrone acetate-ethinyl estradiol(LARIN) 97norethindrone acetate-ethinyl estradiol(MICROGESTIN) 97norethindrone acetate-ethinylestradiolferrous fumarate 98norethindrone acetate-ethinylestradiolferrous fumarate (AUROVELA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (BLISOVI FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (JUNEL FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (LARIN FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (MICROGESTINFE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TARINA FE 1-20EQ) 97norethindrone acetate-ethinylestradiolferrous fumarate (TARINA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TILIA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TRI-LEGEST FE) 98norethindrone-ethinyl estradiol (ALYACEN) 98norethindrone-ethinyl estradiol (ARANELLE) 98norethindrone-ethinyl estradiol (BALZIVA) 98norethindrone-ethinyl estradiol (BRIELLYN) 98norethindrone-ethinyl estradiol (CYCLAFEM)98norethindrone-ethinyl estradiol (DASETTA) 98norethindrone-ethinyl estradiol (LEENA) 98norethindrone-ethinyl estradiol (NECON) 98norethindrone-ethinyl estradiol (NORTREL) 98norethindrone-ethinyl estradiol (PHILITH) 98norethindrone-ethinyl estradiol (PIRMELLA) 98norethindrone-ethinyl estradiol (VYFEMLA) 98norethindrone-ethinyl estradiol (WERA) 98
norethindrone-ethinyl estradiol (ZENCHENT) 98NORGESTIMATE-ETHINYL ESTRADIOL 100norgestimate-ethinyl estradiol 100norgestimate-ethinyl estradiol (ESTARYLLA) 98norgestimate-ethinyl estradiol (FEMYNOR) 99norgestimate-ethinyl estradiol (MILI) 99norgestimate-ethinyl estradiol (MONO-LINYAH) 99norgestimate-ethinyl estradiol(MONONESSA) 99norgestimate-ethinyl estradiol (PREVIFEM) 99norgestimate-ethinyl estradiol (SPRINTEC) 99norgestimate-ethinyl estradiol (TRIFEMYNOR) 99norgestimate-ethinyl estradiol (TRI-ESTARYLLA) 99norgestimate-ethinyl estradiol (TRI-LINYAH) 99norgestimate-ethinyl estradiol (TRI-LO-ESTARYLLA) 99norgestimate-ethinyl estradiol (TRI-LO-MARZIA) 99norgestimate-ethinyl estradiol (TRI-LO-MILI) 99norgestimate-ethinyl estradiol (TRI-LO-SPRINTEC) 99norgestimate-ethinyl estradiol (TRI-PREVIFEM) 99norgestimate-ethinyl estradiol (TRI-SPRINTEC) 99norgestimate-ethinyl estradiol (TRI-VYLIBRALO) 99norgestimate-ethinyl estradiol (TRI-VYLIBRA) 99norgestimate-ethinyl estradiol (TRINESSA LO)99norgestimate-ethinyl estradiol (TRINESSA) 99norgestimate-ethinyl estradiol (VYLIBRA) 99norgestrel-ethinyl estradiol (CRYSELLE) 100norgestrel-ethinyl estradiol (ELINEST) 100norgestrel-ethinyl estradiol (LOW-OGESTREL) 100norgestrel-ethinyl estradiol (OGESTREL) 100nortriptyline hcl 19NORVIR (ritonavir) 40
LAST UPDATED 12012020151
NOVOEIGHT (antihemophilic factor viiirecombinant b-domain truncated) 49NOVOLIN 70-30 (insulin nph humanisophaneinsulin regular human) 45NOVOLIN N (insulin nph human isophane) 45NOVOLIN R (insulin regular human) 45NOVOSEVEN RT (coagulation factor viia(recombinant)) 49NUPLAZID (pimavanserin tartrate) 32NUWIQ (antihemophilic factor viii rec hek cellb-domain deleted) 50NYSTATIN 23nystatin 23
OO-CAL PRENATAL (prenatal vit with calciumno127ferrous fumaratefolic acid) 70OBIZUR (antihemophilic factor viiirecombinant porcine sequence) 50ODEFSEY (emtricitabinerilpivirinehcltenofovir alafenamide fumarate) 37ofloxacin 13olanzapine 33olanzapinefluoxetine hcl 17OMEGA-3 ACID ETHYL ESTERS 60omega-3 acid ethyl esters 60omeprazole 85OMEPRAZOLE 85ondansetron 21ondansetron hcl 21ORAP (pimozide) 31oseltamivir phosphate 41OSELTAMIVIR PHOSPHATE 41OSMOLEX ER (amantadine hcl) 29oxazepam 42oxcarbazepine 16oxybutynin chloride 86OXYBUTYNIN CHLORIDE ER 86oxycodone hcl 46oxycodone hclacetaminophen 6oxycodone hclacetaminophen (ENDOCET) 6
oxycodone hclaspirin 6OXYTROL FOR WOMEN (oxybutynin) 86OYSTER SHELL CALCIUM 74OYSTER SHELL CALCIUM-VIT D3 74
PPAIN amp FEVER (acetaminophen) 64PAIN RELIEF 64paliperidone 33pantoprazole sodium 85PANTOPRAZOLE SODIUM 85PARNATE (tranylcypromine sulfate) 18paromomycin sulfate 9paroxetine hcl 18PEDIATRIC IRON 75pediatric multivit with acd3 no21sodiumfluoride 75pediatric multivitamin no16sodiumfluoride 75pediatric multivitamin no2sodium fluoride 75pediatric multivitamin no45sodiumfluorideferrous sulfate 75pediatric multivitamins no17 with sodiumfluoride 75peg 3350sod sulfsod bicarbsodchloridepotassium chloride 83peg 3350sod sulfsod bicarbsodchloridepotassium chloride (GAVILYTE-C) 83peg 3350sod sulfsod bicarbsodchloridepotassium chloride (GAVILYTE-G) 83PEG-3350 AND ELECTROLYTES 83PEGINTRON REDIPEN (peginterferon alfa-2b) 35PEN NEEDLE 111pen needle diabetic 111pen needle diabetic disposable safety 111pen needle diabetic remover and disposalunit 111pen needle diabetic safety 111penicillamine 86PENICILLAMINE 86
LAST UPDATED 12012020152
penicillin v potassium 12pentoxifylline 57PEPTO-BISMOL (bismuth subsalicylate) 79PEPTO-BISMOL TO-GO (bismuthsubsalicylate) 79permethrin 29permethrin (LICE TREATMENT) 29perphenazine 20PERSERIS (risperidone) 33PHENAZOPYRIDINE HCL 87phenazopyridine hcl 87phenazopyridine hcl (URINARY PAIN RELIEF) 86phenelzine sulfate 18phenobarbital 15PHENOBARBITAL 15PHENOXYBENZAMINE HCL 51phenoxybenzamine hcl 51phenylephrine hcl 113phenylephrine hclpromethazine hcl 129phenytoin 16phenytoin sodium extended 16PHOS-FLUR (fluoride (sodium)) 66PHOSPHOLINE IODIDE (echothiophateiodide) 115phytonadione (vit k1) 50PIFELTRO (doravirine) 37pilocarpine hcl 115PILOCARPINE HCL 115pimecrolimus 68pimozide 31pindolol 54pioglitazone hcl 43PIOGLITAZONE HCL 44piperonyl butoxidepyrethrins (LICE KILLING)68piperonyl butoxidepyrethrins (LICE PYRINYLSHAMPOO) 68piperonyl butoxidepyrethrins (LICETREATMENT) 68piperonyl butoxidepyrethrins (RID) 68piperonyl butoxidepyrethrinspermethrin(COMPLETE LICE TREATMENT) 69
piperonyl butoxidepyrethrinspermethrin(LICE SOLUTION) 69piroxicam 3PLAN B ONE-STEP (levonorgestrel) 102PLEGRIDY (peginterferon beta-1a) 66PLEGRIDY PEN (peginterferon beta-1a) 66PNEUMOVAX 23 (pneumococcal 23-valentpolysaccharide vaccine) 108podofilox 69POLY-VITAMIN (multivitamin) 75polyethylene glycol 3350 84polyethylene glycol 3350 (CLEARLAX) 83polyethylene glycol 3350 (GAVILAX) 84polyethylene glycol 3350 (GENTLELAX) 84polyethylene glycol 3350 (GLYCOLAX) 84polyethylene glycol 3350 (LAXACLEAR) 84polyethylene glycol 3350 (NATURA-LAX) 84polyethylene glycol 3350 (POWDERLAX) 84polyethylene glycol 3350 (PURELAX) 84polyethylene glycol 3350 (SMOOTHLAX) 84polymyxin b sulfatetrimethoprim 113POTASSIUM 75potassium bicarbonatecitric acid 75potassium bicarbonatecitric acid (EFFER-K)75potassium bicarbonatecitric acid (KEFFERVESCENT) 75potassium bicarbonatecitric acid (KLOR-CON-EF) 75POTASSIUM CHL-NORMAL SALINE 75potassium chloride 7075POTASSIUM CHLORIDE 71potassium chloride (KLOR-CON M10) 70potassium chloride (KLOR-CON M20) 70potassium chloride (KLOR-CON SPRINKLE) 75potassium chloride in 09 sodiumchloride 7071potassium chloridepotassiumbicarbonatecitric acid 75potassium gluconate 76pramipexole di-hcl 29pramoxine hclcalamine (CALAHIST) 69
LAST UPDATED 12012020153
pramoxine hclcalamine (CALAMINEMEDICATED) 69praziquantel 28prazosin hcl 51PRAZOSIN HCL 51PRED MILD (prednisolone acetate) 114prednisolone 90prednisolone (MILLIPRED DP) 90prednisolone (MILLIPRED) 90prednisolone acetate 114prednisolone sodium phosphate 90114prednisone 90prednisone (PREDNISONE INTENSOL) 90pregabalin 65PREGABALIN 65PREMARIN (estrogens conjugated) 100PREMPHASE (estrogensconjugatedmedroxyprogesteroneacetate) 100PREMPRO (estrogensconjugatedmedroxyprogesteroneacetate) 100PRENATABS FA (prenatal vits with calciumno78ferrous fumaratefolic acid) 71PRENATABS RX (prenatal vitamin with calciumno76ironcarbonylfolic acid) 71PRENATAL MULTIVITAMIN 76prenatal vit with calcium no129ferrousfumaratefolic acid 76prenatal vit with calcium no130ferrousfumaratefolic acid 76prenatal vitamins no121ferrousfumaratefolic acid 76prenatal vitamins with calciumferrousfumaratefolic acid 76prenatal vitamins with calciumferrousfumaratefolic acid (MYNATAL PLUS) 71prenatal vitamins with calciumferrousfumaratefolic acid (MYNATAL-Z) 71prenatal vits with calcium 118ferrousfumaratefolic acid 76
prenatal vits with calcium 118ferrousfumaratefolic acid (SE-NATAL 19) 71prenatal vits with calcium 136ferrousfumaratefolic acid (VINATE-M) 71prenatal vits with calcium 137ferrousfumaratefolic acid 76prenatal vits with calcium 95ferrousfumaratefolic acid 76prenatal vits with calcium no115ironfumaratefolic acid 71prenatal vits with calcium no72ferrousfumaratefolic acid 71prenatal vits with calcium no72ferrousfumaratefolic acid (M-NATAL PLUS) 71prenatal vits with calcium no72ferrousfumaratefolic acid (PREPLUS) 71prenatal vits with calciumno72ironcarbonylfolic acid 72prenatal vits with calcium no74ferrousfumaratefolic acid 72prenatal vits with calcium no96ferrousfumaratefolic acid 76PREVACID (lansoprazole) 85PREVNAR 13 (pneumococcal 13-valentconjugate vaccine (diphtheria crm)pf) 108PREZCOBIX (darunavirethanolatecobicistat) 40PREZISTA (darunavir ethanolate) 40PRIFTIN (rifapentine) 26primaquine phosphate 28primidone 15probenecid 24probenecidcolchicine 24PROBUPHINE (buprenorphine hcl) 7prochlorperazine 20prochlorperazine (COMPRO) 20prochlorperazine maleate 20PROCRIT (epoetin alfa) 47PROCTOFOAM-HC (hydrocortisoneacetatepramoxine hcl) 69
LAST UPDATED 12012020154
PROFILNINE (factor ix complex prothrombincplx conc(pcc) no4 3-factor) 50promethazine hcl 21122PROMETHAZINE HCL 122promethazine hcl (PHENADOZ) 21promethazine hcl (PROMETHEGAN) 21promethazine hclcodeine 129promethazine hcldextromethorphan hbr 129PROMETHAZINE-DM 129promethazinephenylephrine hclcodeine 129propafenone hcl 53propantheline bromide 77proparacaine hcl 113propranolol hcl 54propylthiouracil 104pseudoephedrine hcl 123pseudoephedrine hcl (NASALDECONGESTANT) 123pseudoephedrine hcl (SUDOGEST) 123pseudoephedrine hcl (SUPHEDRIN) 123pseudoephedrine hcl (SUPHEDRINE SINUSCONGESTION) 123pseudoephedrine hcl (SUPHEDRINE) 123pseudoephedrine hcl (WAL-PHED) 123PULMICORT FLEXHALER (budesonide) 117pyrazinamide 26pyridostigmine bromide 25pyridoxine hcl (vitamin b6) 76
Qquetiapine fumarate 33quinapril hcl 52quinidine gluconate 53quinidine sulfate 53QVAR REDIHALER (beclomethasonedipropionate) 117
RRABAVERT (rabies vaccine purified chickenembryo cell (pcec)pf) 108ramipril 52
RAMIPRIL 53REBINYN (factor ix (human) recombinantpegylated) 50RECOMBINATE (antihemophilic factor viiihuman recombinant) 50RECOMBIVAX HB (hepatitis b virus vaccinerecombinantpf) 108RELENZA (zanamivir) 41RESCRIPTOR (delavirdine mesylate) 37REXULTI (brexpiprazole) 33REYATAZ (atazanavir sulfate) 41RHEUMATREX (methotrexate sodium) 105RIASTAP (fibrinogen) 50ribavirin 36ribavirin (RIBASPHERE) 36RID (permethrin) 111RID (piperonylbutoxidepyrethrinspermethrin) 69RIDAURA (auranofin) 106rifabutin 26rifampin 26riluzole 65RILUZOLE 65ringers solution 7076RISPERDAL (risperidone) 33RISPERDAL CONSTA (risperidonemicrospheres) 33RISPERDAL M-TAB (risperidone) 33risperidone 33ritonavir 41RIXUBIS (factor ix human recombinant) 50rizatriptan benzoate 25ropinirole hcl 29rosuvastatin calcium 59RUKOBIA 39
Ssalsalate 3SANDIMMUNE (cyclosporine) 105SANTYL (collagenase clostridiumhistolyticum) 69
LAST UPDATED 12012020155
SAPHRIS (asenapine maleate) 33SAVELLA (milnacipran hcl) 65SE-NATAL-19 (prenatal vitamins no119ironfumaratefolic acid) 72SECUADO (asenapine) 33selegiline hcl 30selenium sulfide 69selenium sulfide (ANTI-DANDRUFF) 69selenium sulfide (MEDICATED DANDRUFFSHAMPOO) 69selenium sulfide (SELSUN BLUE) 69selenium sulfidealoe vera (SELSUN BLUEMOISTURIZING) 69SELZENTRY (maraviroc) 39SEREVENT DISKUS (salmeterol xinafoate) 123SEROQUEL (quetiapine fumarate) 34SEROQUEL XR (quetiapine fumarate) 34sertraline hcl 18sevelamer carbonate 87SEVENFACT 50SHINGRIX (varicella-zoster virus glycoproteinerecas01b adjuvantpf) 108SILACE (docusate sodium) 84sildenafil citrate 124SILDENAFIL CITRATE 124silver sulfadiazine 13simethicone 80simethicone (GAS RELIEF) 80simethicone (GAS-X) 80simethicone (INFANT GAS RELIEF) 80simethicone (INFANTS GAS RELIEF) 80simethicone (MI-ACID) 80simvastatin 59sirolimus 105SODIUM CHLORIDE 7677sodium chloride 113sodium chloride (MURO-128) 113sodium chloride for inhalation 129sodium chloride irrigating solution 707277sodium chloride irrigating solution (AQUACARE SODIUM CHLORIDE) 77
sodium chloride irrigating solution (CURITY) 77sodium chloridesodiumbicarbonatepotassium chloridepeg 84sodium chloridesodiumbicarbonatepotassium chloridepeg(GAVILYTE-N) 84sodium chloridesodiumbicarbonatepotassium chloridepeg (TRILYTEWITH FLAVOR PACKETS) 84sodium polystyrene sulfonate 72sodium polystyrene sulfonatesorbitol solution(KIONEX) 72sodiumpotassiumpotassium citratesodiumcitratecit ac 87sodiumpotassiumpotassium citratesodiumcitratecit ac (CYTRA-3) 87sodiumpotassiumpotassium citratesodiumcitratecit ac (TRICITRATES) 87sofosbuvirvelpatasvir 35SOTALOL 53SOTALOL AF 53sotalol hcl 53sotalol hcl (SORINE) 53spironolactone 58SPIRONOLACTONE 58spironolactonehydrochlorothiazide 57SPS (sodium polystyrene sulfonatesorbitolsolution) 72SSD (silver sulfadiazine) 13stavudine 38STOMACH RELIEF 80STOOL SOFTENER 84STOOL SOFTENER (docusate sodium) 84STRIBILD(elvitegravircobicistatemtricitabinetenofovir disoproxil) 36SUBLOCADE (buprenorphine) 4SUBOXONE (buprenorphine hclnaloxonehcl) 7sucralfate 85SUDAFED (pseudoephedrine hcl) 123
LAST UPDATED 12012020156
sulfacetamide sodium 13sulfacetamide sodiumprednisolone sodiumphosphate 113sulfamethoxazoletrimethoprim 13sulfasalazine 109SULFATRIM (sulfamethoxazoletrimethoprim)14sulindac 3SUMATRIPTAN 25sumatriptan 25sumatriptan succinate 25SUMATRIPTAN SUCCINATE 25SUSTIVA (efavirenz) 37SYMBYAX (olanzapinefluoxetine hcl) 18SYMFI (efavirenzlamivudinetenofovirdisoproxil fumarate) 36SYMFI LO (efavirenzlamivudinetenofovirdisoproxil fumarate) 37SYMTUZA (darunavirethcobicistatemtricitabinetenofoviralafenamide) 41SYNAREL (nafarelin acetate) 104SYNJARDY (empagliflozinmetformin hcl) 44SYNJARDY XR (empagliflozinmetformin hcl) 44SYNTHROID (levothyroxine sodium) 103syringe with needle insulin safety 1 ml 111syringe with needledisposableinsulin 1 ml 111syringe with needleinsulin03 ml 111syringe with needleinsulin05 ml 112
TTABLOID (thioguanine) 27tacrolimus 69106TACROLIMUS 106tadalafil 124tadalafil (ALYQ) 124TAKE ACTION (levonorgestrel) 102TAMOXIFEN CITRATE 27tamoxifen citrate 27tamsulosin hcl 86TDVAX (tetanus and diphtheria toxoidsadult) 108
TECFIDERA (dimethyl fumarate) 66TEGRETOL (carbamazepine) 16TEGRETOL XR (carbamazepine) 16temazepam 130TEMIXYS (lamivudinetenofovir disoproxilfumarate) 36temozolomide 27TENIVAC (tetanus and diphtheria toxoidsadsorbed adultpf) 108tenofovir disoproxil fumarate 38terazosin hcl 52TERAZOSIN HCL 52terbinafine hcl 24terbinafine hcl (ANTIFUNGAL) 24terbinafine hcl (ATHLETES FOOT AF) 24terbinafine hcl (ATHLETES FOOT) 24terbinafine hcl (JOCK ITCH) 2444terbinafine hcl (LAMISIL AT) 24TERBUTALINE SULFATE 123terbutaline sulfate 124testosterone 91testosterone cypionate 91tetanus and diphtheria toxoids adult 108THALOMID (thalidomide) 27THEO-24 (theophylline anhydrous) 124theophylline anhydrous 124theophylline anhydrous (THEOCHRON) 124thioridazine hcl 31thiothixene 31thyroidpork (NP THYROID) 103timolol maleate 115TIMOLOL MALEATE 115tioconazole 24TIVICAY (dolutegravir sodium) 36TIVICAY PD 36tizanidine hcl 35TOBRADEX (tobramycindexamethasone) 113tobramycin 9tobramycindexamethasone 113TOBREX (tobramycin) 9tolbutamide 44
LAST UPDATED 12012020157
tolmetin sodium 3tolnaftate 24tolnaftate (ANTIFUNGAL CREAM) 24tolnaftate (ATHLETES FOOT) 24tolnaftate (FUNGOID-D) 24topiramate 16TOPIRAMATE 16TOREMIFENE CITRATE 27toremifene citrate 27tramadol hcl 6TRAMADOL HCL 6trandolapril 53tranylcypromine sulfate 18TRAVEL SICKNESS (meclizine hcl) 21TRAZODONE HCL 19trazodone hcl 19tretinoin 28TRETTEN (factor xiii a-subunit recombinant) 50TRI-VI-SOL (vitamin a palmitateascorbicacidcholecalciferol (vit d3)) 77triamcinolone acetonide 6690117TRIAMCINOLONE ACETONIDE 66triamcinolone acetonide (ORALONE) 66triamterenehydrochlorothiazide 57triazolam 130trifluoperazine hcl 31trifluridine 41TRIGLIDE (fenofibrate nanocrystallized) 59trihexyphenidyl hcl 29trimethobenzamide hcl 21trimethoprim 10TRINATE (prenatal vits with calciumno73ferrous fumaratefolic acid) 72TRIPLE ANTIBIOTIC 11TRIPLE ANTIBIOTIC (neomycinsulfatebacitracin zincpolymyxin b) 11triprolidine hclpseudoephedrine hcl(APRODINE) 129triprolidine hclpseudoephedrine hcl (ED A-HIST PSE) 129
triprolidine hclpseudoephedrine hcl(RITIFED) 129triprolidine hclpseudoephedrine hcl (WAL-ACT D COLD amp ALLERGY) 129TRIUMEQ (abacavir sulfatedolutegravirsodiumlamivudine) 39TRIZIVIR (abacavirsulfatelamivudinezidovudine) 38TROGARZO (ibalizumab-uiyk) 39trospium chloride 86TROSPIUM CHLORIDE 86TRULICITY 44TRULICITY (dulaglutide) 44TRUMENBA (neisseria meningitidis group blipidated fhbp recombinant) 108TRUVADA (emtricitabinetenofovir disoproxilfumarate) 39TWINRIX (hepatitis a virus and hepatitis b virusvaccinepf) 108TYBOST (cobicistat) 39
UUNIFINE PENTIPS MAXFLOW 112UNITHROID (levothyroxine sodium) 103URETRON D-S (methenaminemethylenebluesod phospsalicylatehyoscyamine) 11URINARY PAIN RELIEF 87ursodiol 80
Vvalacyclovir hcl 41valproic acid 15VALPROIC ACID 15valproic acid (as sodium salt) (valproatesodium) 15valsartan 52valsartanhydrochlorothiazide 57VANADOM 130VANDAZOLE (metronidazole) 11VAQTA (hepatitis a virus vaccinepf) 109
LAST UPDATED 12012020158
VARIVAX VACCINE (varicella virus vaccinelivepf) 109VEMLIDY (tenofovir alafenamide) 35venlafaxine hcl 19VENLAFAXINE HCL ER 19verapamil hcl 55VERSACLOZ (clozapine) 35VICTOZA 2-PAK (liraglutide) 44VICTOZA 3-PAK (liraglutide) 44VIRACEPT (nelfinavir mesylate) 41VIRAMUNE (nevirapine) 38VIRAMUNE XR (nevirapine) 38VIREAD (tenofovir disoproxil fumarate) 39VITAMIN B-12 77VITAMIN C 77VITEKTA (elvitegravir) 36VIVITROL (naltrexone microspheres) 7VONVENDI (von willebrand factor(recombinant)) 50VRAYLAR (cariprazine hcl) 34
Wwarfarin sodium 46warfarin sodium (JANTOVEN) 46WILATE (antihemophilic factor humanvonwillebrand factorhuman) 50
XXARELTO (rivaroxaban) 4647XYNTHA (antihemophilic factor (factor viii)recombb-domain deleted) 51XYNTHA SOLOFUSE (antihemophilic factor(factor viii) recombb-domain deleted) 51
Zzaleplon 130ZERIT (stavudine) 39ZIAGEN (abacavir sulfate) 39ziprasidone hcl 34ZIPRASIDONE HCL 34ZIPRASIDONE MESYLATE 34
ziprasidone mesylate 34zolpidem tartrate 130zonisamide 14ZOSTAVAX (zoster vaccine livepf) 109ZOVIA 1-35 100ZUBSOLV (buprenorphine hclnaloxone hcl) 7ZYPREXA (olanzapine) 34ZYPREXA RELPREVV (olanzapine pamoate) 34ZYPREXA ZYDIS (olanzapine) 34
LAST UPDATED 12012020159
iii
How do I use the Blue Shield of California Promise Health Plan Medi-Cal
Formulary
To look for a drug check the index at the end It lists all of the drugs on the Formulary Next to
your drug you will see the page number where you can find it The drugs are listed in
alphabetical order under the column ldquoPrescription Drug Namerdquo under its category and class
To look for a drug class check the Table of Contents
Even if the drug is on the list this does not guarantee that your doctor will prescribe it
The Formulary covers generics and certain brands when available If there is an approved
generic drug then we will cover the generic only
bull A generic name for a brand name drug is listed after the brand name of the drug in all
lowercase italics
o If both a generic and brand are covered we will list the generic separately from
the brand name in all lowercase italics
o When a drug is sold as a brand name we will list the brand name after the
generic name in parentheses in all CAPITALS
bull We will list a brand name drug in all CAPITALS followed by the name in parentheses in
lowercase italics
Example
Drug Type How the drug name will appear
in the formulary drug list
generic drug atorvastatin calcium
generic drug marketed with a
brand name
oxycodoneacetaminophen
(ENDOCET)
brand drug LIPITOR (atorvastatin calcium)
Some drugs are injections that are not listed but they may be covered for up to a 10-day
supply after you leave the hospital These include drugs for parenteral nutrition (TPN) lipids
and other unlisted drugs and antibiotics
iv
What are drug tiers
Drugs are placed into drug tiers
Drug Tier What Does it mean
Covered (Tier 1) These drugs are covered on the Drug
List (Formulary) at $0 co-payment
Medi-Cal Carve Out (Tier 2) These drugs are carved out by the
Department of Health Care Services
This means these drugs are covered by
the Medi-Cal Fee-for Service program
and can be billed to the State
Medical Benefit (Tier 3) These drugs may be available at the
doctorrsquos office or medical setting
How to read the formulary
The column titled ldquoCoverage Requirements and Limitationsrdquo shows how the drug is covered
and if there are limits
Coverage Requirements
and Limitations
What does it stand for What does it mean
AL1 Age Restrictions We cover some drugs only
for some ages
PA Prior Authorization
Required
Your doctor must ask for
approval from us before
we cover some drugs
QL Quantity Limit We only cover some drugs
for a certain amount
ST Step Therapy Required In some cases you must
first try certain drugs
before we cover another
drug for your condition
STAR Extended Day Supply You may fill this drug for a
90 day supply
MDD Max Daily Dose We limit the amount of this
drug covered per day
C Custom This drug has special limits
QLC Quantity Limit (Custom) We limit the amount of this
drug covered each fill or
within a time frame
SP Specialty Pharmacy A network specialty
pharmacy will fill this drug
v
How often will the formulary change
The formulary may change monthly Some changes that can happen without notice include
bull When we remove a brand name drug if a generic is available
bull When we remove a drug taken off the market because the Food and Drug
Administration (FDA) has found it unsafe or if the manufacturer has removed it
bull When we add a drug to the formulary or if we remove a limit (like prior authorization or
step therapy)
Changes to formulary that we will notify you of at least 30 days before include
bull When we remove a drug or dosage form
bull When we add or change limits on the drug
What is a medical benefit drug
A medical benefit drug is a drug that usually is given as an injection or infusion in a medical
setting
What if my drug requires a prior authorization or step therapy
A prior authorization means that your doctor asks for approval for the drug because it is
medically necessary A step therapy means that you need to try certain drugs before we
cover your drug
You may ask for an exception by calling Customer Care at (800) 605-2556 (Los Angeles
County) or (855) 699-5557 (San Diego County) Or your doctor can call us at (877) 792-2731 or
fax at (866) 712-2731 to request that drug be covered
What if my drug is not on the Blue Shield of California Promise Health Plan Medi-
Cal Formulary
If your doctor gives you a drug that is not on the drug list you can ask your doctor for another
drug that is on formulary or you may request for us to cover the drug (exception) by calling
Customer Care at (800) 605-2556 (Los Angeles County) or (855) 699-5557 (San Diego County)
Your doctor can call us at (877) 792-2731 or fax at (866) 712-2731 to request that drug be
covered
You might now take a drug and your doctor still prescribes it If the drug is safe and effective
for your condition we will continue to cover it if we covered it before
vi
Participating retail pharmacies
You can fill prescriptions at any participating pharmacy (network pharmacy) unless it is for a
specialty drug You may find a network pharmacy by visiting
httpspromiseblueshieldcacomcapharmacysearchversion=2020amplob=mcal
What are specialty drugs
Specialty drugs require extra training before you take them extra visits with your doctor need
special handling and transport and are usually high-cost These drugs may require prior
authorization or non-formulary exception If approved a network specialty pharmacy will
deliver them by mail Please visit wwwblueshieldcacompromisemedi-cal for more
information
What if I have additional questions
If you want a copy of the Blue Shield of California Promise Health Plan Medi-Cal Formulary or
have questions please call Customer Care at (800) 605-2556 (Los Angeles County) or (855)
699-5557 (San Diego County)
Blue Shield of California Promise Health Plan
601 Potrero Grande Drive Monterey Park CA 91755
vii
H5928_19_269A2_C 08302019
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Discrimination is Against the Law
Blue Shield of California Promise Health Plan complies with applicable state laws and federal civil rights laws and does not discriminate on the basis of race color national origin ancestry religion sex marital status gender gender identity sexual orientation age or disability Blue Shield of California Promise Health Plan does not exclude people or treat them differently because of race color national origin ancestry religion sex marital status gender gender identity sexual orientation age or disability
Blue Shield of California Promise Health Plan provides bull Aids and services at no cost to people with disabilities to communicate effectively with us
such aso Qualified sign language interpreterso Written information in other formats (large print audio accessible electronic
formats other formats)bull Language services at no cost to people whose primary language is not English such as
o Qualified interpreterso Information written in other languages
If you need these services contact the Blue Shield of California Promise Health Plan Civil Rights Coordinator
If you believe that Blue Shield of California Promise Health Plan has failed to provide these
services or discriminated in another way on the basis of race color national origin
ancestry religion sex marital status gender gender identity sexual orientation age or
disability you can file a grievance with
Blue Shield of California Promise Health Plan
Civil Rights Coordinator
601 Potrero Grande Dr
Monterey Park CA 91755
Phone (844) 883-2233 (TTY 711)
Fax (323) 889-2228
Email BSCPHPCivilRightsblueshieldcacom
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 Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD)
Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language Assistance Notice for LA County
viii
English
ATTENTION Language assistance services free of charge are available to you Call 1-800-605-
2556 (TTY 711)
繁體中文 (Chinese)
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1-800-605-2556(TTY
711)
한국어 (Korean)
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-800-
605-2556 (TTY 711)번으로 전화해 주십시오
Русский (Russian)
ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги
перевода Звоните 1-800-605-2556 (телетайп 711)
Kreyogravel Ayisyen (Haitian-Creole)
ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele 1-
800-605-2556 (TTY 711)
Franccedilais (French)
ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes
gratuitement Appelez le 1-800-605-2556 (TTY 711)
Portuguecircs (Portuguese)
ATENCcedilAtildeO Se fala portuguecircs encontram-se disponiacuteveis serviccedilos linguiacutesticos graacutetis Ligue para 1-
800-605-2556 (TTY 711)
Italiano (Italian)
ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza
linguistica gratuiti Chiamare il numero 1-800-605-2556 (TTY 711)
(Farsi) فارسی
2556-605-800-1 با باشد می فراهم شما برای رایگان بصورت زبانی تسهیلات کنید می گفتگو فارسی زبان به اگر توجه
(TTY 771) بگیرید تماس
ह िदी (Hindi)
धयान द यदद आप द िदी बोलत तो आपक ललए मफत म भाषा स ायता सवाएि उपलबध 1-800-605-
2556 (TTY 711) पर कॉल करHmong (Hmong)
LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb rau koj Hu rau
1-800-605-2556 (TTY 711)
Espantildeol (Spanish)
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica
Llame al 1-800-605-2556 (TTY 711)
Language Assistance Notice for LA County (Continued)
ix
Tiếng Việt (Vietnamese)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-
800-605-2556 (TTY 711)
Tagalog (Tagalog - Filipino)
PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa
wika nang walang bayad Tumawag sa 1-800-605-2556 (TTY 711)
(Arabic) العربية
2556-605-800-1مجان اتصل برقم ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بال
(711YTT)
Polski (Polish)
UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń
pod numer 1-800-605-2556 (TTY 711)
ພາສາລາວ (Lao)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ ໂທຣ 1-800-605-2556 (TTY 711)
日本語 (Japanese)
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1-800-605-
2556(TTY711)までお電話にてご連絡ください
ภาษาไทย (Thai)
เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-800-605-2556 (TTY 711)
λληνικά (Greek)
ΠΡΟΣΟΧΗ Αν μιλάτε ελληνικά στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης
οι οποίες παρέχονται δωρεάν Καλέστε 1-800-605-2556 (TTY 711)
ਪਜਾਬੀ ਦ (Punjabi)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-800-605-
2556 (TTY 711) ਤ ਕਾਲ ਕਰ
ខមែរ (Cambodian)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល
គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-800-605-2556 (TTY 711)
Հայերեն (Armenian)
ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող են
տրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք 1-800-605-2556
(TTY (հեռատիպ)711)
Language Assistance Notice for San Diego County
x
English
ATTENTION Language assistance services free of charge are available to you
Call 1-855-699-5557 (TTY 711)
繁體中文 (Chinese)
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1-855-699-5557(TTY
711)
한국어 (Korean)
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-855-
699-5557 (TTY 711)번으로 전화해 주십시오
Русский (Russian)
ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные
услуги перевода Звоните 1-855-699-5557 (телетайп 711)
Italiano (Italian)
ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di
assistenza linguistica gratuiti Chiamare il numero 1-855-699-5557 (TTY 711)
(Farsi) فارسی
-699-855-1 با باشد می فراهم شما برای رایگان بصورت زبانی تسهیلات کنید می گفتگو فارسی زبان به اگر توجه
5557 (TTY 771) بگیرید تماس
ह िदी (Hindi)
धयान द यदद आप द िदी बोलत तो आपक ललए मफत म भाषा स ायता सवाएि उपलबध 1-855-699-
5557 (TTY 711) पर कॉल कर
Hmong (Hmong)
LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb
rau koj Hu rau 1-855-699-5557 (TTY 711)
Espantildeol (Spanish)
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia
linguumliacutestica Llame al 1-855-699-5557 (TTY 711)
Tiếng Việt (Vietnamese)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho
bạn Gọi số 1-855-699-5557 (TTY 711)
Tagalog (Tagalog - Filipino)
PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga
serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-855-699-5557 (TTY
711)
Language Assistance Notice for San Diego County (Continued)
xi
(Arabic) العربية
5557-699-855-1 برقم اتصل بالمجان لك تتوافر اللغویة المساعدة خدمات فإن اللغة اذكر تتحدث كنت إذا ملحوظة
(711YTT)
ພາສາລາວ (Lao)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ ໂທຣ 1-855-699-5557 (TTY 711)
日本語 (Japanese)
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1-855-699-
5557(TTY711)までお電話にてご連絡ください
ภาษาไทย (Thai)
เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-855-699-5557 (TTY 711)
ਪਜਾਬੀ ਦ (Punjabi)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-855-
699-5557 (TTY 711) ਤ ਕਾਲ ਕਰ
ខមែរ (Cambodian)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល
គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-855-699-5557 (TTY 711)
Հայերեն (Armenian)
ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող են
տրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք 1-855-699-
5557 (TTY (հեռատիպ)711)
Categorical List of Prescription DrugsANALGESICS (Drugs for Pain) 1
ANESTHETICS (Drugs for Numbing) 6
ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS (Drugs for AddictionSubstance Abuse) 6
ANTIBACTERIALS (Drugs for Bacterial Infections) 8
ANTICONVULSANTS (Drugs for Seizures) 14
ANTIDEMENTIA AGENTS (Drugs for Alzheimers Disease and Dementia) 17
ANTIDEPRESSANTS (Drugs for Depression) 17
ANTIEMETICS (Drugs for Nausea and Vomiting) 20
ANTIFUNGALS (Drugs for Fungal Infections) 21
ANTIGOUT AGENTS (Drugs for Gout) 24
ANTIMIGRAINE AGENTS (Drugs for Migraine) 25
ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis) 25
ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections) 26
ANTINEOPLASTICS (Drugs for Cancer) 26
ANTIPARASITICS (Drugs for Parasitic Infections) 28
ANTIPARKINSON AGENTS (Drugs for Parkinsons Disease) 29
ANTIPSYCHOTICS (Drugs for Mental Health) 30
ANTISPASTICITY AGENTS (Drugs for Muscle Spasm) 35
ANTIVIRALS (Drugs for Viral Infections) 35
ANXIOLYTICS (Drugs for Anxiety) 41
BIPOLAR AGENTS (Drugs for Bipolar Disorder) 42
BLOOD GLUCOSE REGULATORS (Drugs for Diabetes) 42
BLOOD PRODUCTSMODIFIERSVOLUME EXPANDERS (Drugs for Blood Disorders) 46
CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation) 51
CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions) 61
DENTAL AND ORAL AGENTS (Drugs for the Mouth) 66
DERMATOLOGICAL AGENTS (Drugs for the Skin) 66
ELECTROLYTESMINERALSMETALSVITAMINS 69
GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach) 77
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERS TREATMENT (Drugs for Genetic or
Enzyme Disorders) 85
GENITOURINARY AGENTS (Drugs for the Genital Bladder and Kidney) 86
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (ADRENAL) (Drugs for
ReplacingStimulating Adrenal Gland Hormones) 87
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (PITUITARY) (Drugs for
ReplacingStimulating Pituitary Gland Hormones) 90
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEX HORMONESMODIFIERS) (Drugs
for ReplacingStimulating Sex Hormones) 91
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (THYROID) (Drugs for the Thyroid) 102
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs for Suppressing Hormones from the Pituitary
Gland) 104
HORMONAL AGENTS SUPPRESSANT (THYROID) (Drugs for the Thyroid) 104
LAST UPDATED 12012020
IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing the Immune System) 104
INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for Inflammatory Bowel Disease) 109
METABOLIC BONE DISEASE AGENTS (Drugs for the Bone) 109
MISCELLANEOUS THERAPEUTIC AGENTS 110
OPHTHALMIC AGENTS (Drugs for the Eyes) 112
OTIC AGENTS (Drugs for the Ears) 116
RESPIRATORY TRACTPULMONARY AGENTS (Drugs for the Lungs) 116
SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles) 130
SLEEP DISORDER AGENTS (Drugs for Insomnia) 130
LAST UPDATED 12012020
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANALGESICS (Drugs for Pain)
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (Pain and ArthritisDrugs)
aspirin (ADULT ASPIRIN REGIMEN)81 mg tablet dr
1-Covered
aspirin (ADULT LOW DOSE ASPIRINEC) 81 mg tablet dr
1-Covered
aspirin (ASPIR 81) mg tablet dr ) 1-Covered
aspirin (ASPIR-TRIN) 325 mg tabletdr -
1-Covered
aspirin (ASPIRIN) 325 mg tablet 1-Covered
aspirin (ECOTRIN) 81 mg tablet dr 1-Covered
aspirin (ECPIRIN) 325 mg tablet dr 1-Covered
aspirin (ST JOSEPH ASPIRIN EC) 81mg tablet dr
1-Covered
aspirin (ST JOSEPH ASPIRIN) 81 mgtab chew
1-Covered
aspirin 325mg tablet 1-Covered
aspirin 81 mg tab chew 81 mgtablet dr 325 mg tablet
1-Covered
ASPIRIN 81MG TABLET ASPIRIN81MG TABLET ASPIRIN 81MGTABLET
1-Covered
aspirinacetaminophencaffeine(ADDED STRENGTH HEADACHE)250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(BAYER MIGRAINE) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(EXTRA PAIN RELIEF) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(EXTRAPRIN) 250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(HEADACHE RELIEF) 250-250-65tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
1
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
aspirinacetaminophencaffeine(MIGRAINE FORMULA) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(MIGRAINE RELIEF) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(PAIN RELIEVER PLUS) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(PAIN RELIEVER) 250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(PAIN-OFF) 250-250-65 tablet -
1-Covered
butalbitalaspirincaffeine 50-325-40 capsule
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
butalbitalaspirincaffeine 50-325-40 tablet
1-Covered
celecoxib 50 mg capsule 100 mgcapsule 200 mg capsule 400 mgcapsule
1-Covered ST
CELECOXIB 50 MG CAPSULE 100MG CAPSULE 200 MG CAPSULE400 MG CAPSULE
1-Covered ST
CHILDRENS IBUPROFEN CHILD 200MG10 ML CHILDREN 100 MG5 ML
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
diclofenac sodium 25 mg tablet dr50 mg tablet dr 75 mg tablet dr100 mg tab er 24h
1-Covered
diflunisal 500 mg tablet 1-Covered
etodolac 600 mg tab er 24h 1-Covered PA
EXCEDRIN EXTRA STRENGTH(aspirinacetaminophencaffeine)CAPLET
1-Covered
EXCEDRIN MIGRAINE(aspirinacetaminophencaffeine)CAPLET GELTAB
1-Covered
flurbiprofen 50 mg tablet 100 mgtablet
1-Covered
HEADACHE RELIEF HM 250-250-65MG CPLT
1-Covered
ibuprofen (ADDAPRIN) 200 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
2
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ibuprofen (I-PRIN) 200 mg tablet - 1-Covered
ibuprofen (IBU) 400 mg tablet 600mg tablet 800 mg tablet
1-Covered
ibuprofen (IBU-200) mg tablet -) 1-Covered
ibuprofen (PROVIL) 200 mg tablet 1-Covered
ibuprofen (WAL-PROFEN) 200 mgtablet -
1-Covered
ibuprofen 100 mg5ml oral susp 1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
IBUPROFEN 400 MG TABLET 600 MGTABLET 800 MG TABLET
1-Covered
ibuprofen 50 mg125 drops susp100 mg tab chew 200 mg tablet400 mg tablet 600 mg tablet 800mg tablet
1-Covered
indomethacin 25 mg capsule 50mg capsule 75 mg capsule er
1-Covered
ketoprofen 50 mg capsule 75 mgcapsule
1-Covered
meloxicam 75 mg tablet 15 mgtablet
1-Covered
naproxen 250 mg tablet 375 mgtablet 500 mg tablet
1-Covered
naproxen sodium 275 mg tablet550 mg tablet
1-Covered
piroxicam 10 mg capsule 20 mgcapsule
1-Covered
salsalate 500 mg tablet 750 mgtablet
1-Covered
sulindac 150 mg tablet 200 mgtablet
1-Covered
tolmetin sodium 200 mg tablet 400mg capsule 600 mg tablet
1-Covered
OPIOID ANALGESICS LONG-ACTING (Long-acting Narcotic PainRelievers)
BELBUCA (buprenorphine hcl) 75MCG FILM 150 MCG FILM 300MCG FILM 450 MCG FILM 600MCG FILM 750 MCG FILM 900MCG FILM
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
3
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
buprenorphine 5 mcghr patch75 mcghr patch 10 mcghrpatch 15 mcghr patch 20mcghr patch
2-MedicalCarve out
BUTRANS (buprenorphine) 5MCGHR PATCH 75 MCGHRPATCH 10 MCGHR PATCH 15MCGHR PATCH 20 MCGHRPATCH
2-MedicalCarve out
fentanyl 25 mcghr patch50mcghr patch 75mcghr patch100 mcghr patch
1-Covered PA QL (10 PER 30 DAY(S))
methadone hcl (METHADONEINTENSOL) 10 mgml oral conc
1-Covered PA
methadone hcl (METHADOSE) 40mg tablet sol
1-Covered PA
METHADONE HCL 10 MG TABLET 1-Covered QL (60 PER 30 DAYS)
METHADONE HCL 10 MGML ORALCONC
1-Covered PA
methadone hcl 5 mg tablet 10 mgtablet
1-Covered QL (60 PER 30 DAYS)
methadone hcl 5 mg5 ml solution10 mg5 ml solution 10 mgml oralconc
1-Covered PA
morphine sulfate 15 mg tablet er 1-Covered QL (90 PER 30 DAYS)
morphine sulfate 30 mg tablet er 1-Covered QL (60 PER 30 DAYS)
morphine sulfate 60 mg tablet er100 mg tablet er 200 mg tablet er
1-Covered PA
oxycodone hcl 10 mg tab er 20mg tab er 40 mg tab er 80 mgtab er
1-Covered PA QL (60 PER 30 DAYS)
SUBLOCADE (buprenorphine) 100MG05 ML SYRING 300 MG15 MLSYRING
2-MedicalCarve out
OPIOID ANALGESICS SHORT-ACTING (Short-acting Narcotic PainRelievers)
acetaminophen with codeinephosphate -15mg tablet -30mgtablet -60mg tablet
1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old) QLC (LIMIT 100TABS TOTAL APAPCODEINETABLETS PER MONTH)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
4
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acetaminophen with codeinephosphate 120-12mg5 solution
1-Covered QL (240 PER 30 DAYS) AL1 (Atleast 12 yrs old)
butorphanol tartrate 10 mgmlspray
1-Covered PA
codeinephosphatebutalbitalaspirincaffeine codeinebutalbitalasacaffein30-50-325 capsule
1-Covered QL (60 PER 30 DAYS) AL1 (At least12 yrs old)
codeine sulfate 15 mg tablet 30mg tablet 60 mg tablet
1-Covered PA AL1 (At least 12 yrs old)
hydrocodonebitartrateacetaminophen(LORCET HD)hydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAY(S))
hydrocodonebitartrateacetaminophen(LORTAB)hydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAY(S))
hydrocodonebitartrateacetaminophenhydrocodoneacetaminophen 5mg-325mg tablethydrocodoneacetaminophen75-325 mg tablethydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS OF HYDROCODONEPRODUCTS PER 30 DAYS)
hydromorphone hcl 1 mgml liquid3 mg supprect
1-Covered
hydromorphone hcl 2 mg tablet 4mg tablet 8 mg tablet
1-Covered QL (60 PER 30 DAYS)
meperidine hcl 50 mg tablet 100mg tablet
1-Covered QL (100 PER 30 DAYS)
morphine sulfate 10 mg5 ml 20mg5 ml 100 mg5ml
1-Covered PA
morphine sulfate 15 mg tablet 30mg tablet
1-Covered QL (90 PER 30 DAYS)
morphine sulfate 30 mg supprect 1-Covered QL (24 PER 30 DAY(S)) QLC (LIMIT24 SUPPOSITORIES IN 30 DAYS)
morphine sulfate 5 mg 10 mg 20mg
1-Covered QL (24 PER 30 DAY(S)) QLC (LIMIT24 SUPPOSITORIES IN 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
5
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
oxycodone hcl 5 mg capsule 5mg tablet 5 mg5 ml solution 15mg tablet 20 mgml oral conc 30mg tablet
1-Covered PA
oxycodone hclacetaminophen(ENDOCET) 5 mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS PER 30 DAYS OF TOTALOXYCODONE APAP ANDOXYCODONE ASA PER MONTH)
oxycodone hclacetaminophen 5mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS PER 30 DAYS OF TOTALOXYCODONE APAP ANDOXYCODONE ASA PER MONTH)
oxycodone hclacetaminophen 5-3255 ml solution
1-Covered PA
oxycodone hclaspirin 48355-325tablet
1-Covered QL (100 PER 30 DAY(S))
tramadol hcl 50 mg tablet 1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old)
TRAMADOL HCL 50 MG TABLET 1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old)
ANESTHETICS (Drugs for Numbing)
LOCAL ANESTHETICS (Skin Numbing Drugs)lidocaine hcl 10 mgml vial 1-Covered PA
lidocaine hcl 2 solution 1-Covered
LIDOCAINE HCL VISCOUS 2 SOLN 1-Covered
lidocaine hclpf 10 mgml vial 10mgml ampul
1-Covered PA
ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS (Drugs forAddictionSubstance Abuse)
ALCOHOL DETERRENTSANTI-CRAVING (Drugs for AlcoholDependence)
acamprosate calcium 333 mgtablet dr
2-MedicalCarve out
disulfiram 250 mg tablet 500 mgtablet
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
6
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
naltrexone hcl 50 mg tablet 2-MedicalCarve out
NALTREXONE HCL 50 MG TABLET 2-MedicalCarve out
VIVITROL (naltrexonemicrospheres) 380 MG VIAL +DILUENT
2-MedicalCarve out
OPIOID DEPENDENCE TREATMENTS (Drugs for Opioid Dependence)BUNAVAIL (buprenorphinehclnaloxone hcl) 21-03 MG FILM42-07 MG FILM 63-1 MG FILM
2-MedicalCarve out
BUPRENEX (buprenorphine hcl) 03MGML AMPUL
2-MedicalCarve out
buprenorphine hcl 03 mgml vial03 mgml cartridge 2 mg tab subl8 mg tab subl
2-MedicalCarve out
buprenorphine hclnaloxone hclnaloxone 2 mg-05mg filmnaloxone 2 mg-05mg tab sublnaloxone 4mg-1mg filmnaloxone 8 mg-2 mg filmnaloxone 8 mg-2 mg tab subl
2-MedicalCarve out
LUCEMYRA (lofexidine hcl) 018 MGTABLET
2-MedicalCarve out
PROBUPHINE (buprenorphine hcl)742 MG IMPLANT
2-MedicalCarve out
SUBOXONE (buprenorphinehclnaloxone hcl) 2 MG-05 MGFILM 4 MG-1 MG FILM 8 MG-2 MGFILM 12 MG-3 MG FILM
2-MedicalCarve out
ZUBSOLV (buprenorphinehclnaloxone hcl) 07-018 MGTABLET 14-036 MG TABLET 29-071 MG TABLET 57-14 MG TABLET86-21 MG TABLET 114-29 MGTABLET
2-MedicalCarve out
OPIOID REVERSAL AGENTS (Drugs for Opioid Overdose)EVZIO (naloxone hcl) 04 MGAUTO- 2 MG AUTO-
2-MedicalCarve out
naloxone hcl 04 mgml cartridge04 mgml vial 1 mgml syringe 2mg04ml auto injct
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
7
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NARCAN (naloxone hcl) 4 MGNASAL SPRAY
2-MedicalCarve out
SMOKING CESSATION AGENTS (Drugs to Help Quit Smoking)bupropion hcl (BUPROBAN) 150 mgtab er 12h
1-Covered QL (2 PER 1 DAY(S))
bupropion hcl 150 mg tab er 12h 1-Covered QL (2 PER 1 DAY(S))
CHANTIX (varenicline tartrate) 05MG TABLET 1 MG TABLET 1 MGCONT MONTH BOX STARTINGMONTH BOX
1-Covered PA
nicotine 14mg patch 1-Covered QL (1 PER 1 DAY(S))
nicotine 21mg patch 1-Covered QL (1 PER 1 DAY(S))
nicotine 2mg gum 1-Covered QL (24 PER 1 DAY(S))
nicotine 4mg gum 1-Covered QL (24 PER 1 DAY(S))
nicotine 7mg patch 1-Covered QL (1 PER 1 DAY(S))
NICOTINE LOZENGE 2 MGLOZENGE HM 2 MG LOZENGE 4MG LOZENGE HM 4 MG LOZENGE
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (QUIT 2) mglozenge )
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (QUIT 4) mglozenge )
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (STOP SMOKINGAID) 2 mg 4 mg
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex 2 mg 4 mg 1-Covered QL (24 PER 1 DAY(S))
NICOTROL (nicotine) CARTRIDGEINHALER
1-Covered PA
NICOTROL NS (nicotine) 10 MGMLSPRAY
1-Covered PA
ANTIBACTERIALS (Drugs for Bacterial Infections)
AMINOGLYCOSIDESgentamicin sulfate (GENTAK) 03 oint (g)
1-Covered
gentamicin sulfate 01 oint (g)01 cream (g) 03 oint (g) 03 drops
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
8
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GENTAMICIN SULFATE 01 CREAM 1-Covered
neomycin sulfate 500 mg tablet 1-Covered
paromomycin sulfate 250 mgcapsule
1-Covered
tobramycin 03 drops 1-Covered
TOBREX (tobramycin) 03 EYEOINTMENT
1-Covered
ANTIBACTERIALS OTHERbacitracin (BACITRAYCIN PLUS) 500unitg oint (g)
1-Covered
bacitracin 500 unitg packet 500unitg oint (g)
1-Covered
BACITRACIN 500 UNITGM OINTMNT 1-Covered
bacitracin zinc (ANTIBIOTIC) 500unitg oint (g)
1-Covered
bacitracin zinc 500 unitg ointpack 500 unitg oint (g)
1-Covered
BACITRACIN ZINC ZN 500 UNITGMOINT
1-Covered
CLEOCIN (clindamycin phosphate)100 MG VAGINAL OVULE
1-Covered
clindamycin hcl 75 mg capsule150 mg capsule 300 mg capsule
1-Covered
clindamycin palmitate hcl 75 mg5ml soln recon
1-Covered
clindamycin phosphate 1 gel(gram) 1 lotion 1 med swab1 solution 1 gel daily 2 creamappl
1-Covered
CLINDAMYCIN PHOSPHATE 1SOLUTION 1 GEL
1-Covered
erythromycin basebenzoylperoxide erythromycinbenzoyl 3-5 gel (gram)
1-Covered ST
methenaminemethylenebluesodphospsalicylatehyoscyamine(PHOSPHASAL) methmebluesodphospsalhyos 816-108 tablet
1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
9
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
methenaminemethylenebluesodphospsalicylatehyoscyamine(URIN DS) methmebluesodphospsalhyos 816-108 tablet
1-Covered PA
METRO IV (metronidazole in sodiumchloride) 500 MG100 ML
1-Covered
metronidazole 075 gel wappl250 mg tablet 375 mg capsule500 mg tablet
1-Covered
METRONIDAZOLE 250 MG TABLET500 MG TABLET
1-Covered
metronidazole in sodium chloridemetronidazolesodium 500mg01lpiggyback
1-Covered PA
mupirocin 2 oint (g) 1-Covered QL (22 PER 30 DAY(S))
mupirocin calcium 2 cream (g) 1-Covered PA
neomycin sulfatebacitracinzincpolymyxin b (ANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
neomycin sulfatebacitracinzincpolymyxin b (FIRST AIDANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
neomycin sulfatebacitracinzincpolymyxin b (TRIPLEANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
nitrofurantoin 25 mg5 ml oral susp 1-Covered
NITROFURANTOIN 50 MG CAP 100MG CAP
1-Covered
nitrofurantoin macrocrystal 50 mgcapsule 100 mg capsule
1-Covered
nitrofurantoinmonohydratemacrocrystalsmonohydm-100 mg capsule
1-Covered
trimethoprim 100 mg tablet 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
10
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRIPLE ANTIBIOTIC (neomycinsulfatebacitracin zincpolymyxinb) CURAD OINT MEDI-FIRSTMEDICHOICE OINTMENTOINTMENT PKT
1-Covered
TRIPLE ANTIBIOTIC HM PKT 1-Covered
URETRON D-S(methenaminemethylenebluesodphospsalicylatehyoscyamine) -TABLET
1-Covered PA
VANDAZOLE (metronidazole)VAGINAL 075 GEL
1-Covered
BETA-LACTAM CEPHALOSPORINScefaclor 125 mg5ml susp recon250 mg5ml susp recon 250 mgcapsule 375 mg5ml susp recon500 mg capsule
1-Covered
CEFDINIR 125 MG5 ML SUSP 250MG5 ML SUSP
1-Covered QL (200 PER 10 DAY(S))
cefdinir 125 mg5ml 250 mg5ml 1-Covered QL (200 PER 10 DAY(S))
cefdinir 300 mg capsule 1-Covered QL (20 PER 10 DAY(S))
cephalexin 125 mg5ml susprecon 250 mg capsule 250mg5ml susp recon 500 mgcapsule
1-Covered
BETA-LACTAM PENICILLINSamoxicillin 125 mg5ml susp recon125 mg tab chew 200 mg5mlsusp recon 250 mg tab chew 250mg5ml susp recon 250 mgcapsule 400 mg5ml susp recon500 mg tablet 500 mg capsule875 mg tablet
1-Covered
AMOXICILLIN-CLAVULANATEPOTASS -600-429 MG5 ML SUS
1-Covered QL (300 PER FILL) QLC (1 FILL IN 30DAYS)
AMOXICILLIN-CLAVULANATEPOTASS -875-125 MG TABLET
1-Covered
amoxicillinpotassium clavulanate1000-625 tab er 12h
1-Covered QL (40 PER FILL(S)) MFL (1 30day(s))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
11
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
amoxicillinpotassium clavulanate200-2855 susp recon 200-285mgtab chew 250-125 mg tablet 400-57mg5 susp recon 400-57mg tabchew 500-125 mg tablet 875-125mg tablet
1-Covered
amoxicillinpotassium clavulanate600-4295 susp recon
1-Covered QL (300 PER FILL) QLC (1 FILL IN 30DAYS)
ampicillin trihydrate 125 mg5mlsusp recon 250 mg capsule 250mg5ml susp recon 500 mgcapsule
1-Covered
dicloxacillin sodium 250 mgcapsule 500 mg capsule
1-Covered
penicillin v potassium 125 mg5mlsoln recon 250 mg5ml soln recon250 mg tablet 500 mg tablet
1-Covered
MACROLIDESazithromycin 1 g packet 1-Covered QL (1 PER 30 DAYS)
azithromycin 100 mg5ml 200mg5ml
1-Covered
AZITHROMYCIN 200 MG5 ML SUSP 1-Covered
azithromycin 250 mg tablet 1-Covered QL (6 PER FILL(S)) MFL (2 30day(s))
AZITHROMYCIN 250 MG TABLET 1-Covered QL (6 PER FILL(S)) MFL (2 30day(s))
azithromycin 500 mg tablet 1-Covered QL (3 PER FILL(S)) MFL (2 30day(s))
AZITHROMYCIN 500 MG TABLET 1-Covered QL (3 PER FILL(S)) MFL (2 30day(s))
azithromycin 600 mg tablet 1-Covered QL (2 PER 7 DAY(S)) MFL (8 28day(s))
clarithromycin 500 mg tablet 1-Covered ST
EES 200 (erythromycinethylsuccinate) MG5 MLSUSPENSION
1-Covered
EES 400 (erythromycinethylsuccinate) FILMTAB
1-Covered
ERYTHROCIN STEARATE(erythromycin stearate) 250 MGFILMTAB
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
12
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ERYTHROMYCIN 250 MG 500 MG 1-Covered
erythromycin base 5 mggramoint (g) 250 mg capsule dr 250mg tablet dr 250 mg tablet 333mg tablet dr 500 mg tablet 500mg tablet dr
1-Covered
erythromycin base in ethanol (ERY)2 med swab
1-Covered
erythromycin base in ethanol 2 solution 2 med swab
1-Covered
ERYTHROMYCIN ETHYLSUCCINATE200 MG5 ML SUSP
1-Covered
erythromycin ethylsuccinate 200mg5ml susp recon 400 mg tablet
1-Covered
QUINOLONESCILOXAN (ciprofloxacin hcl) 03OINTMENT
1-Covered
ciprofloxacin hcl 03 drops 1-Covered
ciprofloxacin hcl 100 mg tablet 1-Covered PA AL1 (At least 18 yrs old)
ciprofloxacin hcl 250 mg tablet500 mg tablet 750 mg tablet
1-Covered AL1 (At least 18 yrs old)
CIPROFLOXACIN HCL 500 MG TAB 1-Covered AL1 (At least 18 yrs old)
levofloxacin 250 mg tablet 500 mgtablet 750 mg tablet
1-Covered AL1 (At least 18 yrs old)
moxifloxacin hcl 400 mg tablet 1-Covered PA AL1 (At least 18 yrs old)
ofloxacin 03 drops 1-Covered QL (5 PER 30 DAY(S))
SULFONAMIDESBLEPH-10 (sulfacetamide sodium) - EYE DROPS
1-Covered
silver sulfadiazine 1 cream (g) 1-Covered
SSD (silver sulfadiazine) 1 CREAM 1-Covered
sulfacetamide sodium 10 oint(g) 10 drops
1-Covered
sulfamethoxazoletrimethoprim200-40mg5 oral susp 400mg-80mgtablet 800-16020 oral susp 800-160 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
13
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SULFATRIM(sulfamethoxazoletrimethoprim)PEDIATRIC SUSPENSION
1-Covered
TETRACYCLINESDOXYCYCLINE HYCLATE 100 MGCAP
1-Covered AL1 (At least 8 yrs old)
doxycycline hyclate 100 mgcapsule
1-Covered AL1 (At least 8 yrs old)
DOXYCYCLINE HYCLATE 20 MG TAB 1-Covered QL (60 PER 30 DAYS)
doxycycline hyclate 20 mg tablet 1-Covered QL (60 PER 30 DAYS)
doxycycline monohydrate 50 mgcapsule 100 mg capsule
1-Covered AL1 (At least 8 yrs old)
minocycline hcl 50 mg capsule100 mg capsule
1-Covered
ANTICONVULSANTS (Drugs for Seizures)
ANTICONVULSANTS OTHER (Other Seizure Control Drugs)LEVETIRACETAM 100 MGML SOLN250 MG TABLET 500 MG5 ML SOLN
1-Covered
levetiracetam 100 mgml solution250 mg tablet 500 mg tablet 500mg5ml solution 750 mg tablet1000 mg tablet
1-Covered
levetiracetam 500 mg tab er 24h 1-Covered MDD (6 Per Day)
levetiracetam 750 mg tab er 24h 1-Covered QL (120 PER 30 DAY(S))
LEVETIRACETAM ER 500 MG TABLET 1-Covered MDD (6 Per Day)
LEVETIRACETAM ER 750 MG TABLET 1-Covered QL (120 PER 30 DAY(S))
CALCIUM CHANNEL MODIFYING AGENTSCELONTIN (methsuximide) 300 MGKAPSEAL
1-Covered
ETHOSUXIMIDE 250 MG CAPSULE 1-Covered
ethosuximide 250 mg5ml solution250 mg capsule
1-Covered
zonisamide 25 mg capsule 50 mgcapsule 100 mg capsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
14
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTSDEPAKENE (valproic acid (assodium salt) (valproate sodium))250 MG5 ML SOLUTION
1-Covered
DEPAKENE (valproic acid) 250 MGCAPSULE
1-Covered
diazepam 5-75-10mg kit 1-Covered
divalproex sodium 125 mg tabletdr 125 mg cap dr spr 250 mgtablet dr 500 mg tablet dr
1-Covered
DIVALPROEX SODIUM DR 125 MGCAP SPRNK
1-Covered
gabapentin 100 mg capsule 250mg5ml solution 300 mg capsule400 mg capsule 600 mg tablet800 mg tablet
1-Covered
GABAPENTIN 100 MG CAPSULE 300MG CAPSULE 400 MG CAPSULE
1-Covered
phenobarbital 15 mg tablet 20mg5 ml elixir 30 mg tablet 324mg tablet 60 mg tablet 648 mgtablet 972mg tablet 100 mgtablet
1-Covered
PHENOBARBITAL 20 MG5 ML SOLN324 MG TABLET 648 MG TABLET972 MG TABLET
1-Covered
primidone 50 mg tablet 250 mgtablet
1-Covered
valproic acid (as sodium salt)(valproate sodium) 250 mg5ml500mg10ml
1-Covered
valproic acid 250 mg capsule 1-Covered
VALPROIC ACID 250 MG CAPSULE 1-Covered
GLUTAMATE REDUCING AGENTSlamotrigine 25 mg tablet 100 mgtablet 150 mg tablet 200 mgtablet
1-Covered
lamotrigine 5 mg 25 mg 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
15
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
topiramate 15 mg cap sprink 25mg tablet 25 mg cap sprink 50mg tablet 100 mg tablet 200 mgtablet
1-Covered
TOPIRAMATE 25 MG TABLET 50 MGTABLET 100 MG TABLET 200 MGTABLET
1-Covered
SODIUM CHANNEL AGENTScarbamazepine (EPITOL) 200 mgtablet
1-Covered
carbamazepine 100 mg cpmp12hr 100 mg5ml oral susp 100 mgtab chew 100 mg tab er 12h 200mg cpmp 12hr 200 mg tab er 12h200 mg tablet 300 mg cpmp 12hr400 mg tab er 12h
1-Covered
CARBATROL (carbamazepine) ER100 MG CAPSULE ER 200 MGCAPSULE ER 300 MG CAPSULE
1-Covered
DILANTIN (phenytoin sodiumextended) 30 MG CAPSULE 100MG CAPSULE
1-Covered
DILANTIN (phenytoin) 50 MGINFATAB
1-Covered
DILANTIN-125 (phenytoin) MG5 MLSUSP
1-Covered
DILANTIN-125 MG5 ML SUSP 1-Covered
oxcarbazepine 150 mg tablet 300mg tablet 600 mg tablet
1-Covered
phenytoin 50 mg tab chew 100mg4ml oral susp 125 mg5ml oralsusp
1-Covered
phenytoin sodium extended 100mg capsule
1-Covered
TEGRETOL (carbamazepine) 100MG5 ML SUSP 200 MG TABLET
1-Covered
TEGRETOL XR (carbamazepine) 100MG TABLET 200 MG TABLET 400MG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
16
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIDEMENTIA AGENTS (Drugs for Alzheimers Disease andDementia)
CHOLINESTERASE INHIBITORSdonepezil hcl 5 mg tab rapdis 5mg tablet 10 mg tab rapdis 10mg tablet
1-Covered
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine hcl 5 mg tablet 10 mgtablet
1-Covered
MEMANTINE HCL 5 MG TABLET 10MG TABLET
1-Covered
ANTIDEPRESSANTS (Drugs for Depression)
ANTIDEPRESSANTS OTHERbupropion hcl 100 mg tab 150 mgtab 200 mg tab
1-Covered QL (60 PER 30 DAYS)
bupropion hcl 150 mg tab er 300mg tab er
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
bupropion hcl 75 mg tablet 100mg tablet
1-Covered
BUPROPION HCL SR SR 100 MGTABLET SR 150 MG TABLET SR 200MG TABLET
1-Covered QL (60 PER 30 DAYS)
BUPROPION XL 150 MG TABLET 300MG TABLET
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
mirtazapine 15 mg tab rapdis 1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old)
mirtazapine 15 mg tablet 30 mgtab rapdis 30 mg tablet 45 mgtab rapdis 45 mg tablet
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
olanzapinefluoxetine hcl 3 mg-25mg capsule 6mg-25mg capsule6mg-50mg capsule 12mg-50mgcapsule 12mg-25mg capsule
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
17
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SYMBYAX (olanzapinefluoxetinehcl) 3-25 MG CAPSULE 6-50 MGCAPSULE 6-25 MG CAPSULE 12-50MG CAPSULE 12-25 MG CAPSULE
2-MedicalCarve out
MONOAMINE OXIDASE INHIBITORSEMSAM (selegiline) 6 MG24PATCH 9 MG24 PATCH 12 MG24PATCH
2-MedicalCarve out
MARPLAN (isocarboxazid) 10 MGTABLET
2-MedicalCarve out
NARDIL (phenelzine sulfate) 15 MGTABLET
2-MedicalCarve out
PARNATE (tranylcypromine sulfate)10 MG TABLET
2-MedicalCarve out
phenelzine sulfate 15 mg tablet 2-MedicalCarve out
tranylcypromine sulfate 10 mgtablet
2-MedicalCarve out
SSRISSNRIS (SELECTIVE SEROTONIN REUPTAKEINHIBITORSEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)
citalopram hydrobromide 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
escitalopram oxalate 5 mg tablet10 mg tablet 20 mg tablet
1-Covered
ESCITALOPRAM OXALATE 5 MGTABLET 10 MG TABLET 20 MGTABLET
1-Covered
fluoxetine hcl 10 mg capsule 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
fluoxetine hcl 20 mg capsule 1-Covered QL (120 PER 30 DAY(S))
fluoxetine hcl 20 mg5 ml solution 1-Covered
FLUOXETINE HCL 20 MG5 MLSOLUTION
1-Covered
fluvoxamine maleate 25 mg tablet50 mg tablet 100 mg tablet
1-Covered AL1 (At least 8 yrs old)
paroxetine hcl 10 mg tablet 20 mgtablet 30 mg tablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
sertraline hcl 25 mg tablet 50 mgtablet 100 mg tablet
1-Covered QL (60 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
18
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRAZODONE HCL 50 MG TABLET100 MG TABLET
1-Covered
trazodone hcl 50 mg tablet 100mg tablet 150 mg tablet
1-Covered
venlafaxine hcl 25 mg tablet 375mg tablet 50 mg tablet 75 mgtablet 100 mg tablet
1-Covered QL (60 PER 30 DAYS)
venlafaxine hcl 375 mg cap er 75mg cap er 150 mg cap er
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
VENLAFAXINE HCL ER ER 375 MGCAP ER 75 MG CAP ER 150 MGCAP
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
TRICYCLICSamitriptyline hcl 10 mg tablet 25mg tablet 50 mg tablet 75 mgtablet 100 mg tablet 150 mgtablet
1-Covered
amoxapine 25 mg tablet 50 mgtablet 100 mg tablet 150 mgtablet
1-Covered
clomipramine hcl 25 mg capsule50 mg capsule 75 mg capsule
1-Covered PA
CLOMIPRAMINE HCL 25 MGCAPSULE 50 MG CAPSULE 75 MGCAPSULE
1-Covered PA
desipramine hcl 10 mg tablet 25mg tablet 50 mg tablet 75 mgtablet 100 mg tablet 150 mgtablet
1-Covered
DOXEPIN HCL 10 MG CAPSULE 25MG CAPSULE 50 MG CAPSULE 75MG CAPSULE 100 MG CAPSULE
1-Covered
doxepin hcl 10 mgml oral conc10 mg capsule 25 mg capsule 50mg capsule 75 mg capsule 100mg capsule 150 mg capsule
1-Covered
imipramine hcl 10 mg tablet 25mg tablet 50 mg tablet
1-Covered
IMIPRAMINE HCL 10 MG TABLET 25MG TABLET 50 MG TABLET
1-Covered
nortriptyline hcl 10 mg capsule 25mg capsule 50 mg capsule 75 mgcapsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
19
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIEMETICS (Drugs for Nausea and Vomiting)
ANTIEMETICS OTHER (Other Drugs for Nausea and Vomiting)meclizine hcl (DRAMAMINE LESSDROWSY) 25 mg tablet
1-Covered
meclizine hcl (MEDI-MECLIZINE) 25mg tablet -
1-Covered
meclizine hcl (MOTION RELIEF) 25mg tablet
1-Covered
meclizine hcl (MOTION SICKNESS II)25 mg tablet
1-Covered
meclizine hcl (MOTION SICKNESSRELIEF) 25 mg tablet 25 mg tabchew
1-Covered
meclizine hcl (MOTION SICKNESS)25 mg tablet
1-Covered
meclizine hcl (MOTION-TIME) 25 mgtab chew -
1-Covered
meclizine hcl (TRAVEL-EASE) 25 mgtablet -
1-Covered
meclizine hcl (VERTICALM) 25 mgtablet
1-Covered
meclizine hcl (WAL-DRAM 2) 25 mgtablet -
1-Covered
MECLIZINE HCL 125 MG CAPLET 25MG TABLET CHEW
1-Covered
meclizine hcl 125 mg tablet 25mg tab chew 25 mg tablet
1-Covered
metoclopramide hcl 5 mg tablet 5mg5 ml solution 10 mg tablet 10mg10ml solution
1-Covered
perphenazine 2 mg tablet 4 mgtablet 8 mg tablet 16 mg tablet
2-MedicalCarve out
prochlorperazine (COMPRO) 25mg supprect
1-Covered
prochlorperazine 25 mg supprect 1-Covered
prochlorperazine maleate 5 mgtablet 10 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
20
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
promethazine hcl (PHENADOZ)125 mg 25 mg
1-Covered
promethazine hcl (PROMETHEGAN)125 mg 25 mg 50 mg
1-Covered
promethazine hcl 125 mgsupprect 25 mg supprect 50 mgtablet 50 mg supprect
1-Covered
TRAVEL SICKNESS (meclizine hcl) 25MG TAB CHEW
1-Covered
trimethobenzamide hcl 300 mgcapsule
1-Covered
EMETOGENIC THERAPY ADJUNCTS (Drugs for Nausea and Vomiting)aprepitant 40 mg capsule 80 mgcapsule 125mg-80mg cap ds pk125 mg capsule
1-Covered PA
dronabinol 25 mg capsule 5 mgcapsule 10 mg capsule
1-Covered PA
granisetron hcl 1 mg tablet 1-Covered PA
ondansetron 4 mg tab rapdis 8mg tab rapdis
1-Covered QL (12 PER FILL(S)) MDD (3 PerDay) QLC (LIMIT TO 2 FILLS OF 12TABLETS IN 30 DAYS)
ondansetron hcl 4 mg tablet 8 mgtablet
1-Covered QL (12 PER FILL(S)) MDD (3 PerDay) QLC (LIMIT TO 2 FILLS OF 12TABLETS IN 30 DAYS)
ondansetron hcl 4 mg5 mlsolution 24 mg tablet
1-Covered PA
ANTIFUNGALS (Drugs for Fungal Infections)
ANTIFUNGALSANTIFUNGAL 1 TOPICAL CREAM 1-Covered
ATHLETES FOOT (terbinafine hcl) 1CREAM
1-Covered
ciclopirox 077 gel (gram) 1-Covered QLC (100 GRAMSMONTH)
ciclopirox 1 shampoo 1-Covered QLC (120 ozMONTH)
ciclopirox 8 solution 1-Covered
ciclopirox olamine 077 cream(g)
1-Covered QLC (90 GRAMSMONTH)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
21
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ciclopirox olamine 077 suspension
1-Covered QLC (60 MLMONTH)
clotrimazole (ANTIFUNGALRINGWORM) 1 cream (g)
1-Covered
clotrimazole (ANTIFUNGAL) 1 cream (g)
1-Covered
clotrimazole (ATHLETES FOOT) 1 cream (g)
1-Covered
clotrimazole (ATHLETIC FOOTCREAM) 1 cream (g)
1-Covered
clotrimazole (CLOTRIMAZOLE AF) 1 cream (g)
1-Covered
clotrimazole (ITCH RELIEF) 1 cream (g)
1-Covered
clotrimazole (JOCK ITCH RELIEF) 1 cream (g)
1-Covered
clotrimazole (JOCK ITCH) 1 cream (g)
1-Covered
clotrimazole (RINGWORM) 1 cream (g)
1-Covered
clotrimazole 1 cream (g) 1 solution 1 creamappl 10 mgtroche
1-Covered
CLOTRIMAZOLE 1 SOLUTION 1TOPICAL CREAM
1-Covered
fluconazole 10 mgml 40 mgml 1-Covered QL (70 PER 30 DAY(S))
fluconazole 150 mg tablet 1-Covered QL (2 PER 30 DAY(S))
FLUCONAZOLE 200 MG TABLET 1-Covered
fluconazole 50 mg tablet 100 mgtablet 200 mg tablet
1-Covered
fluconazole in dextrose iso-osmotic in dextreiso-200mg01l indextreiso-400mg02l
1-Covered PA
flucytosine 250 mg capsule 500mg capsule
1-Covered
FLUCYTOSINE 250 MG CAPSULE500 MG CAPSULE
1-Covered
griseofulvin ultramicrosize 125 mgtablet 250 mg tablet
1-Covered QL (60 PER 30 DAYS) AL1 (Up to18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
22
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
griseofulvin microsize 125 mg5mloral susp
1-Covered AL1 (Up to 12 yrs old) MDD (20Per Day)
griseofulvin microsize 500 mgtablet
1-Covered QL (60 PER 30 DAYS) AL1 (Up to18 yrs old)
itraconazole 100 mg capsule 1-Covered PA
ketoconazole 2 cream (g) 2 shampoo
1-Covered
ketoconazole 200 mg tablet 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
LAMISIL (terbinafine hcl)ANTIFUNGAL 1 SPRAY
1-Covered
LOTRIMIN AF (clotrimazole) 1CREAM
1-Covered
miconazole nitrate (ANTI-FUNGALCREAM) 2 cream (g) -
1-Covered
miconazole nitrate (ANTIFUNGALCREAM) 2 cream (g)
1-Covered
miconazole nitrate (BAZAANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate (INZOANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate (LOTRIMIN AF) 2 spray
1-Covered
miconazole nitrate (MICATIN) 2 cream (g)
1-Covered
miconazole nitrate (SECURAANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate 2 aero powd2 creamappl 2 cream (g)100 mg suppvag
1-Covered
MONISTAT 3 (miconazole nitrate)4 CREAM
1-Covered
MONISTAT 7 (miconazole nitrate)CREAM
1-Covered
NYSTATIN 100000 UNITGM CREAM100000 UNITGM OINT 100000UNITML SUSP 500000 UNIT5 MLSUS
1-Covered
nystatin 500k unit tablet 100000mloral susp 100000g cream (g)100000g oint (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
23
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terbinafine hcl (ANTIFUNGAL) 1 cream (g)
1-Covered
terbinafine hcl (ATHLETES FOOT AF)1 cream (g)
1-Covered
terbinafine hcl (ATHLETES FOOT) 1 cream (g)
1-Covered
terbinafine hcl (JOCK ITCH) 1 cream (g)
1-Covered
terbinafine hcl (LAMISIL AT) 1 cream (g)
1-Covered
terbinafine hcl 1 cream (g) 250mg tablet
1-Covered
tioconazole 65 oinpf app 1-Covered
tolnaftate (ANTIFUNGAL CREAM) 1 cream (g)
1-Covered
tolnaftate (ATHLETES FOOT) 1 cream (g)
1-Covered
tolnaftate (FUNGOID-D) 1 cream(g) -
1-Covered
tolnaftate 1 cream (g) 1-Covered
ANTIGOUT AGENTS (Drugs for Gout)
ANTIGOUT AGENTSallopurinol 100 mg tablet 300 mgtablet
1-Covered
ALLOPURINOL 100 MG TABLET 300MG TABLET
1-Covered
colchicine 06 mg tablet 1-Covered
COLCHICINE 06 MG TABLET 1-Covered
probenecid 500 mg tablet 1-Covered
probenecidcolchicine 500-05 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
24
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIMIGRAINE AGENTS (Drugs for Migraine)
ERGOT ALKALOIDSergotamine tartratecaffeine 1mg-100mg tablet
1-Covered
SEROTONIN (5-HT) 1B1D RECEPTOR AGONISTSrizatriptan benzoate 5 mg tablet10 mg tablet
1-Covered QL (12 PER 30 DAY(S)) AL1 (Atleast 6 yrs old)
SUMATRIPTAN 5 MG SPRAY 20 MGSPRAY
1-Covered QL (6 PER 30 DAY(S))
sumatriptan 5 mg 20 mg 1-Covered QL (6 PER 30 DAY(S))
sumatriptan succinate 25 mgtablet 50 mg tablet 100 mg tablet
1-Covered QL (9 PER 30 DAY(S))
SUMATRIPTAN SUCCINATE 25 MGTABLET 50 MG TABLET 100 MGTABLET
1-Covered QL (9 PER 30 DAY(S))
SUMATRIPTAN SUCCINATE 6 MG05ML CART
1-Covered QL (2 PER FILL(S)) MFL (1 30day(s))
SUMATRIPTAN SUCCINATE 6 MG05ML INJECT
1-Covered QL (2 PER 30 DAY(S)) MFL (1 30day(s))
sumatriptan succinate 6 mg05mlcartridge 6 mg05ml vial
1-Covered QL (2 PER FILL(S)) MFL (1 30day(s))
sumatriptan succinate 6 mg05mlpen injctr 6 mg05ml syringe
1-Covered QL (2 PER 30 DAY(S)) MFL (1 30day(s))
ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis)
PARASYMPATHOMIMETICSMESTINON (pyridostigminebromide) 60 MG5 ML SOLUTION
1-Covered
pyridostigmine bromide 60 mg5ml solution 60 mg tablet 180 mgtablet er
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
25
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections)
ANTIMYCOBACTERIALS OTHER (Other Drugs for MycobacterialInfection)
dapsone 25 mg tablet 100 mgtablet
1-Covered
rifabutin 150 mg capsule 1-Covered
ANTITUBERCULARS (Drugs for Tuberculosis)ethambutol hcl 100 mg tablet 400mg tablet
1-Covered
ETHAMBUTOL HCL 100 MG TABLET400 MG TABLET
1-Covered
isoniazid 50 mg5 ml solution 100mg tablet 300 mg tablet
1-Covered
PRIFTIN (rifapentine) 150 MG TABLET 1-Covered AL1 (At least 12 yrs old)
pyrazinamide 500 mg tablet 1-Covered
rifampin 150 mg capsule 300 mgcapsule
1-Covered
ANTINEOPLASTICS (Drugs for Cancer)
ALKYLATING AGENTScyclophosphamide 25 mgcapsule 50 mg capsule
1-Covered PA
CYCLOPHOSPHAMIDE 25 MGCAPSULE 50 MG CAPSULE
1-Covered PA
GLEOSTINE (lomustine) 10 MGCAPSULE 40 MG CAPSULE 100 MGCAPSULE
1-Covered PA
HEXALEN (altretamine) 50 MGCAPSULE
1-Covered
LEUKERAN (chlorambucil) 2 MGTABLET
1-Covered PA
MATULANE (procarbazine hcl) 50MG CAPSULE
1-Covered PA SP
melphalan 2 mg tablet 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
26
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
MYLERAN (busulfan) 2 MG TABLET 1-Covered
temozolomide 20 mg capsule 1-Covered PA SP
ANTIANDROGENSbicalutamide 50 mg tablet 1-Covered PA
flutamide 125 mg capsule 1-Covered PA
ANTIANGIOGENIC AGENTSTHALOMID (thalidomide) 50 MGCAPSULE
1-Covered PA SP
ANTIESTROGENSMODIFIERSEMCYT (estramustine phosphatesodium) 140 MG CAPSULE
1-Covered PA
TAMOXIFEN CITRATE 10 MG TABLET 1-Covered
tamoxifen citrate 10 mg tablet 20mg tablet
1-Covered
TOREMIFENE CITRATE 60 MG TAB 1-Covered PA
toremifene citrate 60 mg tablet 1-Covered PA
ANTIMETABOLITEScapecitabine 500 mg tablet 1-Covered PA SP
CAPECITABINE 500 MG TABLET 1-Covered PA SP
DROXIA (hydroxyurea) 200 MGCAPSULE 300 MG CAPSULE 400MG CAPSULE
1-Covered
fluorouracil (ADRUCIL) 25 g50mlvial 5 g100 ml vial
1-Covered PA
hydroxyurea 500 mg capsule 1-Covered PA
mercaptopurine 50 mg tablet 1-Covered PA
TABLOID (thioguanine) 40 MGTABLET
1-Covered PA
ANTINEOPLASTICS OTHERLEUCOVORIN CALCIUM 5 MG TAB25 MG TAB
1-Covered
leucovorin calcium 5 mg tablet 10mg tablet 15 mg tablet 25 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
27
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LYSODREN (mitotane) 500 MGTABLET
1-Covered PA
AROMATASE INHIBITORS 3RD GENERATIONanastrozole 1 mg tablet 1-Covered
ANASTROZOLE 1 MG TABLET 1-Covered
letrozole 25 mg tablet 1-Covered
ENZYME INHIBITORSetoposide 50 mg capsule 1-Covered PA
MOLECULAR TARGET INHIBITORSJAKAFI (ruxolitinib phosphate) 5MG TABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET 25 MGTABLET
1-Covered PA SP QL (2 PER 1 DAY(S))
RETINOIDStretinoin 10 mg capsule 1-Covered PA
ANTIPARASITICS (Drugs for Parasitic Infections)
ANTIHELMINTHICS (Drugs for Worm Infection)mebendazole (EMVERM) 100 mgtab chew
1-Covered
praziquantel 600 mg tablet 1-Covered
ANTIPROTOZOALS (Drugs for Protozoal Infection)chloroquine phosphate 250 mgtablet
1-Covered QL (25 PER 30 DAY(S))
chloroquine phosphate 500 mgtablet
1-Covered PA QL (25 PER 30 DAY(S))
HYDROXYCHLOROQUINE SULFATE200 MG TAB
1-Covered QL (3 PER 1 DAY(S))
hydroxychloroquine sulfate 200 mgtablet
1-Covered QL (3 PER 1 DAY(S))
mefloquine hcl 250 mg tablet 1-Covered
primaquine phosphate 263 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
28
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PEDICULICIDESSCABICIDES (Drugs for Scabies and Lice)permethrin (LICE TREATMENT) 1 liquid
1-Covered
permethrin 5 cream (g) 1-Covered
ANTIPARKINSON AGENTS (Drugs for Parkinsons Disease)
ANTICHOLINERGICSbenztropine mesylate 05 mgtablet 1 mg tablet 2 mg tablet 2mg2 ml ampul 2 mg2 ml vial
2-MedicalCarve out
COGENTIN (benztropine mesylate)2 MG2 ML AMPULE
2-MedicalCarve out
trihexyphenidyl hcl 2 mg5 ml elixir2 mg tablet 5 mg tablet
2-MedicalCarve out
ANTIPARKINSON AGENTS OTHERAMANTADINE 100 MG CAPSULE 2-Medical
Carve out
amantadine hcl 50 mg5 mlsolution 100 mg capsule 100 mgtablet
2-MedicalCarve out
entacapone 200 mg tablet 1-Covered ST
GOCOVRI (amantadine hcl) ER685 MG CAPSULE ER 137 MGCAPSULE
2-MedicalCarve out
OSMOLEX ER (amantadine hcl) ER129 MG TABLET ER 193 MG TABLETER 258 MG TABLET ER 322 MGDAILY DOSE
2-MedicalCarve out
DOPAMINE AGONISTSbromocriptine mesylate 25 mgtablet
1-Covered
pramipexole di-hcl -0125 mgtablet -025 mg tablet -05 mgtablet -075 mg tablet -1 mgtablet -15 mg tablet
1-Covered
ropinirole hcl 025 mg tablet 05mg tablet 1 mg tablet 2 mgtablet 3 mg tablet 4 mg tablet 5mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
29
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DOPAMINE PRECURSORSL-AMINO ACID DECARBOXYLASEINHIBITORS
carbidopalevodopa 10mg-100mgtablet 25mg-100mg tablet 25mg-100mg tablet er 25mg-250mgtablet 50mg-200mg tablet er
1-Covered
MONOAMINE OXIDASE B (MAO-B) INHIBITORSselegiline hcl 5 mg tablet 5 mgcapsule
1-Covered
ANTIPSYCHOTICS (Drugs for Mental Health)
1ST GENERATIONTYPICALADASUVE (loxapine) 10 MG POWD10 MG POWDR
2-MedicalCarve out
chlorpromazine hcl 10 mg tablet25 mg tablet 25 mgml ampul 50mg tablet 100 mg tablet 200 mgtablet
2-MedicalCarve out
CHLORPROMAZINE HCL 10 MGTABLET 25 MGML AMPULE 25 MGTABLET 50 MG TABLET 50 MG2 MLAMP 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
fluphenazine decanoate 25 mgmlvial
2-MedicalCarve out
fluphenazine hcl 1 mg tablet 25mg tablet 25 mg5ml elixir 25mgml vial 5 mgml oral conc 5mg tablet 10 mg tablet
2-MedicalCarve out
FLUPHENAZINE HCL 1 MG TABLET25 MG TABLET 5 MG TABLET 10MG TABLET
2-MedicalCarve out
HALDOL (haloperidol lactate) 5MGML AMPUL
2-MedicalCarve out
HALDOL DECANOATE 100(haloperidol decanoate) AMPUL
2-MedicalCarve out
HALDOL DECANOATE 50(haloperidol decanoate) AMPUL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
30
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
haloperidol 05 mg tablet 1 mgtablet 2 mg tablet 5 mg tablet 10mg tablet 20 mg tablet
2-MedicalCarve out
HALOPERIDOL 5 MG TABLET 2-MedicalCarve out
haloperidol decanoate 50 mgmlvial 50 mgml ampul 100 mgmlampul 100 mgml vial
2-MedicalCarve out
haloperidol lactate 2 mgml oralconc 5 mgml vial 5 mgmlampul 5 mgml syringe
2-MedicalCarve out
HALOPERIDOL LACTATE 5 MGMLSYRING
2-MedicalCarve out
loxapine succinate 5 mg capsule10 mg capsule 25 mg capsule 50mg capsule
2-MedicalCarve out
molindone hcl 5 mg tablet 10 mgtablet 25 mg tablet
2-MedicalCarve out
ORAP (pimozide) 1 MG TABLET 2MG TABLET
2-MedicalCarve out
pimozide 1 mg tablet 2 mg tablet 2-MedicalCarve out
thioridazine hcl 10 mg tablet 25mg tablet 50 mg tablet 100 mgtablet
2-MedicalCarve out
thiothixene 1 mg capsule 2 mgcapsule 5 mg capsule 10 mgcapsule
2-MedicalCarve out
trifluoperazine hcl 1 mg tablet 2mg tablet 5 mg tablet 10 mgtablet
2-MedicalCarve out
2ND GENERATIONATYPICALABILIFY (aripiprazole) 2 MG TABLET5 MG TABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET 30 MGTABLET
2-MedicalCarve out
ABILIFY MAINTENA (aripiprazole) ER300 MG VL ER 300 MG SYR ER 400MG SYR ER 400 MG VL
2-MedicalCarve out
ABILIFY MYCITE (aripiprazole) 2 MGKIT 5 MG KIT 10 MG KIT 15 MG KIT20 MG KIT 30 MG KIT
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
31
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
aripiprazole 1 mgml solution 2 mgtablet 5 mg tablet 10 mg tabrapdis 10 mg tablet 15 mg tablet15 mg tab rapdis 20 mg tablet 30mg tablet
2-MedicalCarve out
ARIPIPRAZOLE 1 MGML SOLUTION2 MG TABLET 5 MG TABLET 10 MGTABLET 15 MG TABLET 20 MGTABLET 30 MG TABLET
2-MedicalCarve out
ARISTADA (aripiprazole lauroxil) ER441 MG16 ML SYRN ER 662MG24 ML SYRN ER 882 MG32ML SYRN ER 1064 MG39 ML SYR
2-MedicalCarve out
ARISTADA INITIO (aripiprazolelauroxil submicronized) ER 675MG24
2-MedicalCarve out
CAPLYTA (lumateperone tosylate)42 MG CAPSULE
2-MedicalCarve out
FANAPT (iloperidone) 1 MG TABLET2 MG TABLET 4 MG TABLET 6 MGTABLET 8 MG TABLET 10 MGTABLET 12 MG TABLET TITRATIONPACK
2-MedicalCarve out
GEODON (ziprasidone hcl) 20 MGCAPSULE 40 MG CAPSULE 60 MGCAPSULE 80 MG CAPSULE
2-MedicalCarve out
GEODON (ziprasidone mesylate)20 MGML VIAL
2-MedicalCarve out
INVEGA (paliperidone) ER 15 MGTABLET ER 3 MG TABLET ER 6 MGTABLET ER 9 MG TABLET
2-MedicalCarve out
INVEGA SUSTENNA (paliperidonepalmitate) 39 MG025 ML 78MG05 ML 117 MG075 ML 156MGML SYRG 234 MG15 ML
2-MedicalCarve out
INVEGA TRINZA (paliperidonepalmitate) 273 MG0875 ML 410MG1315 ML 546 MG175 ML 819MG2625 ML
2-MedicalCarve out
LATUDA (lurasidone hcl) 20 MGTABLET 40 MG TABLET 60 MGTABLET 80 MG TABLET 120 MGTABLET
2-MedicalCarve out
NUPLAZID (pimavanserin tartrate)10 MG TABLET 17 MG TABLET 34MG CAPSULE
2-MedicalCarve out
SP
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
32
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
olanzapine 25 mg tablet 5 mgtab rapdis 5 mg tablet 75 mgtablet 10 mg tab rapdis 10 mgtablet 10 mg vial 15 mg tabrapdis 15 mg tablet 20 mg tablet20 mg tab rapdis
2-MedicalCarve out
paliperidone 15 mg tab er 24 3mg tab er 24 6 mg tab er 24 9 mgtab er 24
2-MedicalCarve out
PERSERIS (risperidone) ER 90 MGSYRINGE KIT ER 120 MG SYRINGEKIT
2-MedicalCarve out
quetiapine fumarate 25 mg tablet50 mg tab er 24h 50 mg tablet100 mg tablet 150 mg tab er 24h200 mg tab er 24h 200 mg tablet300 mg tablet 300 mg tab er 24h400 mg tab er 24h 400 mg tablet
2-MedicalCarve out
REXULTI (brexpiprazole) 025 MGTABLET 05 MG TABLET 1 MGTABLET 2 MG TABLET 3 MG TABLET4 MG TABLET
2-MedicalCarve out
RISPERDAL (risperidone) 025 MGTABLET 05 MG TABLET 1 MGMLSOLUTION 1 MG TABLET 2 MGTABLET 3 MG TABLET 4 MG TABLET
2-MedicalCarve out
RISPERDAL CONSTA (risperidonemicrospheres) 125 MG VIAL 25MG VIAL 375 MG VIAL 50 MGVIAL
2-MedicalCarve out
RISPERDAL M-TAB (risperidone) -TAB05 G ODT -TAB 1 G ODT -TAB 2 GODT -TAB 3 G ODT -TAB 4 G ODT
2-MedicalCarve out
risperidone 025 mg tab rapdis025 mg tablet 05 mg tab rapdis05 mg tablet 1 mg tablet 1mgml solution 1 mg tab rapdis 2mg tab rapdis 2 mg tablet 3 mgtablet 3 mg tab rapdis 4 mg tabrapdis 4 mg tablet
2-MedicalCarve out
SAPHRIS (asenapine maleate) 25MG TAB 5 MG TAB 10 MG TAB
2-MedicalCarve out
SECUADO (asenapine) 38 MG24HR PATCH 57 MG24 HR PATCH76 MG24 HR PATCH
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
33
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SEROQUEL (quetiapine fumarate)25 MG TABLET 50 MG TABLET 100MG TABLET 200 MG TABLET 300MG TABLET 400 MG TABLET
2-MedicalCarve out
SEROQUEL XR (quetiapinefumarate) 50 MG TABLET 150 MGTABLET 200 MG TABLET 300 MGTABLET 400 MG TABLET
2-MedicalCarve out
VRAYLAR (cariprazine hcl) 15 MG-3 MG PACK 15 MG CAPSULE 3MG CAPSULE 45 MG CAPSULE 6MG CAPSULE
2-MedicalCarve out
ziprasidone hcl 20 mg capsule 40mg capsule 60 mg capsule 80 mgcapsule
2-MedicalCarve out
ZIPRASIDONE HCL 20 MG CAPSULE40 MG CAPSULE 60 MG CAPSULE80 MG CAPSULE
2-MedicalCarve out
ZIPRASIDONE MESYLATE 20 MGMLVIAL
2-MedicalCarve out
ziprasidone mesylate fnl 20mg1vial
2-MedicalCarve out
ZYPREXA (olanzapine) 25 MGTABLET 5 MG TABLET 75 MGTABLET 10 MG VIAL 10 MG TABLET15 MG TABLET 20 MG TABLET
2-MedicalCarve out
ZYPREXA RELPREVV (olanzapinepamoate) 210 MG VL KIT 300 MGVL KIT 405 MG VL KIT
2-MedicalCarve out
ZYPREXA ZYDIS (olanzapine) 5 MGTABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET
2-MedicalCarve out
TREATMENT-RESISTANTclozapine 125 mg tab rapdis 25mg tab rapdis 25 mg tablet 50mg tablet 100 mg tablet 100 mgtab rapdis 150 mg tab rapdis 200mg tablet 200 mg tab rapdis
2-MedicalCarve out
CLOZAPINE 25 MG TABLET 50 MGTABLET 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
CLOZAPINE ODT ODT 150 MGTABLET ODT 200 MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
34
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CLOZARIL (clozapine) 25 MGTABLET 50 MG TABLET 100 MGTABLET 200 MG TABLET
2-MedicalCarve out
FAZACLO (clozapine) 125 MGODT 25 MG ODT 100 MG ODT 150MG ODT 200 MG ODT
2-MedicalCarve out
VERSACLOZ (clozapine) 50 MGMLSUSPENSION
2-MedicalCarve out
ANTISPASTICITY AGENTS (Drugs for Muscle Spasm)baclofen 10 mg tablet 20 mgtablet
1-Covered QL (90 PER 30 DAYS)
BACLOFEN 10 MG TABLET 20 MGTABLET
1-Covered QL (90 PER 30 DAYS)
tizanidine hcl 2 mg tablet 4 mgtablet
1-Covered QL (90 PER 30 DAY(S))
ANTIVIRALS (Drugs for Viral Infections)
ANTI-HEPATITIS B (HBV) AGENTSEPIVIR HBV (lamivudine) 100 MGTABLET
2-MedicalCarve out
EPIVIR HBV (lamivudine) 25 MG5ML SOLN
1-Covered PA
lamivudine 100 mg tablet 1-Covered PA
VEMLIDY (tenofovir alafenamide)25 MG TABLET
2-MedicalCarve out
ANTI-HEPATITIS C (HCV) AGENTS DIRECT ACTING AGENTSsofosbuvirvelpatasvir 400-100 mgtablet
1-Covered PA SP
ANTI-HEPATITIS C (HCV) AGENTS OTHERINTRON A (interferon alfa-2brecomb) 10 MILLION UNITS VIL -18 MILLION UNITS VIL - 18 MILLIONUNIT3 ML - 25 MILLION UNIT25ML- 50 MILLION UNITS VIL -
1-Covered PA SP
PEGINTRON REDIPEN(peginterferon alfa-2b) 50 MCG -
1-Covered PA SP
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
35
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ribavirin (RIBASPHERE) 200 mgtablet
1-Covered PA
ribavirin 200 mg tablet 1-Covered PA
ANTI-HIV AGENTSCIMDUO (lamivudinetenofovirdisoproxil fumarate) 300-300 MGTABLET
2-MedicalCarve out
EFAVIRENZ-LAMIVU-TENOFOVDISOP --600-300-300
2-MedicalCarve out
SYMFI(efavirenzlamivudinetenofovirdisoproxil fumarate) 600-300-300MG TABLET
2-MedicalCarve out
TEMIXYS (lamivudinetenofovirdisoproxil fumarate) 300-300 MGTABLET
2-MedicalCarve out
ANTI-HIV AGENTS INTEGRASE INHIBITORS (INSTI)BIKTARVY (bictegravirsodiumemtricitabinetenofoviralafenamide fumar) 50-200-25 MGTABLET
2-MedicalCarve out
GENVOYA(elvitegravircobicistatemtricitabinetenofovir alafenamide) TABLET
2-MedicalCarve out
ISENTRESS (raltegravir potassium) 25MG TABLET CHEW 100 MG TABLETCHEW 100 MG POWDER PACKET400 MG TABLET
2-MedicalCarve out
ISENTRESS HD (raltegravirpotassium) 600 MG TABLET
2-MedicalCarve out
STRIBILD(elvitegravircobicistatemtricitabinetenofovir disoproxil) TABLET
2-MedicalCarve out
TIVICAY (dolutegravir sodium) 10MG TABLET 25 MG TABLET 50 MGTABLET
2-MedicalCarve out
TIVICAY PD 5 MG TAB FOR SUSP 2-MedicalCarve out
VITEKTA (elvitegravir) 85 MGTABLET 150 MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
36
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTI-HIV AGENTS NON-NUCLEOSIDE REVERSE TRANSCRIPTASEINHIBITORS (NNRTI)
ATRIPLA(efavirenzemtricitabinetenofovirdisoproxil fumarate) TABLET
2-MedicalCarve out
COMPLERA(emtricitabinerilpivirinehcltenofovir disoproxil fumarate)TABLET
2-MedicalCarve out
DELSTRIGO(doravirinelamivudinetenofovirdisoproxil fumarate) 100-300-300MG TAB
2-MedicalCarve out
EDURANT (rilpivirine hcl) 25 MGTABLET
2-MedicalCarve out
efavirenz 50 mg capsule 200 mgcapsule 600 mg tablet
2-MedicalCarve out
EFAVIRENZ-EMTRIC-TENOFOVDISOP --600-200-300
2-MedicalCarve out
EFAVIRENZ-LAMIVU-TENOFOVDISOP --400-300-300
2-MedicalCarve out
INTELENCE (etravirine) 25 MGTABLET 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
nevirapine 50 mg5 ml oral susp100 mg tab er 24h 200 mg tablet400 mg tab er 24h
2-MedicalCarve out
ODEFSEY (emtricitabinerilpivirinehcltenofovir alafenamidefumarate) TABLET
2-MedicalCarve out
PIFELTRO (doravirine) 100 MGTABLET
2-MedicalCarve out
RESCRIPTOR (delavirdine mesylate)100 MG TABLET 200 MG TABLET
2-MedicalCarve out
SUSTIVA (efavirenz) 50 MGCAPSULE 200 MG CAPSULE 600MG TABLET
2-MedicalCarve out
SYMFI LO(efavirenzlamivudinetenofovirdisoproxil fumarate) 400-300-300MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
37
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
VIRAMUNE (nevirapine) 50 MG5ML SUSP 200 MG TABLET
2-MedicalCarve out
VIRAMUNE XR (nevirapine) 100 MGTABLET 400 MG TABLET
2-MedicalCarve out
ANTI-HIV AGENTS NUCLEOSIDE AND NUCLEOTIDE REVERSETRANSCRIPTASE INHIBITORS (NRTI)
abacavir sulfate 20 mgml solution300 mg tablet
2-MedicalCarve out
abacavir sulfatelamivudine 600-300mg tablet
2-MedicalCarve out
abacavirsulfatelamivudinezidovudineabacavirlamivudinezidovudine150-300 mg tablet
2-MedicalCarve out
ABACAVIR-LAMIVUDINE -600-300MG
2-MedicalCarve out
COMBIVIR (lamivudinezidovudine)TABLET
2-MedicalCarve out
EMTRICITABINE 200 MG CAPSULE 2-MedicalCarve out
EMTRICITABINE-TENOFOVIR DISOP -TENOFV 200-300MG
2-MedicalCarve out
EMTRIVA (emtricitabine) 10 MGMLSOLUTION 200 MG CAPSULE
2-MedicalCarve out
EPIVIR (lamivudine) 10 MGMLORAL SOLN 150 MG TABLET 300MG TABLET
2-MedicalCarve out
EPZICOM (abacavirsulfatelamivudine) TABLET
2-MedicalCarve out
lamivudine 10 mgml solution 150mg tablet 300 mg tablet
2-MedicalCarve out
lamivudinezidovudine 150-300mgtablet 150-300 mg tablet
2-MedicalCarve out
stavudine 1 mgml soln recon 15mg capsule 20 mg capsule 30 mgcapsule 40 mg capsule
2-MedicalCarve out
tenofovir disoproxil fumarate 300mg tablet
2-MedicalCarve out
TRIZIVIR (abacavirsulfatelamivudinezidovudine)TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
38
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRUVADA (emtricitabinetenofovirdisoproxil fumarate) 100 MG-150MG TABLET 133 MG-200 MGTABLET 167 MG-250 MG TABLET200 MG-300 MG TABLET
2-MedicalCarve out
VIREAD (tenofovir disoproxilfumarate) 150 MG TABLET 200 MGTABLET 250 MG TABLET 300 MGTABLET POWDER
2-MedicalCarve out
ZERIT (stavudine) 1 MGMLSOLUTION 15 MG CAPSULE 20 MGCAPSULE 30 MG CAPSULE 40 MGCAPSULE
2-MedicalCarve out
ZIAGEN (abacavir sulfate) 20MGML SOLUTION 300 MG TABLET
2-MedicalCarve out
ANTI-HIV AGENTS OTHERDESCOVY (emtricitabinetenofoviralafenamide fumarate) 200-25 MGTABLET
2-MedicalCarve out
DOVATO (dolutegravirsodiumlamivudine) 50-300 MGTABLET
2-MedicalCarve out
FUZEON (enfuvirtide) 90 MG VIAL 2-MedicalCarve out
SP
JULUCA (dolutegravirsodiumrilpivirine hcl) 50-25 MGTABLET
2-MedicalCarve out
RUKOBIA ER 600 MG TABLET 2-MedicalCarve out
SELZENTRY (maraviroc) 20 MGMLORAL SOLN 25 MG TABLET 75 MGTABLET 150 MG TABLET 300 MGTABLET
2-MedicalCarve out
TRIUMEQ (abacavirsulfatedolutegravirsodiumlamivudine) 600-50-300 MGTABLET
2-MedicalCarve out
TROGARZO (ibalizumab-uiyk) 200MG133 ML VIAL -
2-MedicalCarve out
TYBOST (cobicistat) 150 MG TABLET 2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
39
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTI-HIV AGENTS PROTEASE INHIBITORSAPTIVUS (tipranavir) 250 MGCAPSULE
2-MedicalCarve out
APTIVUS (tipranavirvitamin e tpgs)100 MGML SOLUTION
2-MedicalCarve out
ATAZANAVIR SULFATE 150 MG CAP200 MG CAP 300 MG CAP
2-MedicalCarve out
atazanavir sulfate 150 mg capsule200 mg capsule 300 mg capsule
2-MedicalCarve out
CRIXIVAN (indinavir sulfate) 200MG CAPSULE 400 MG CAPSULE
2-MedicalCarve out
EVOTAZ (atazanavirsulfatecobicistat) 300 MG-150 MGTABLET
2-MedicalCarve out
fosamprenavir calcium 700 mgtablet
2-MedicalCarve out
FOSAMPRENAVIR CALCIUM 700MG TABLET
2-MedicalCarve out
INVIRASE (saquinavir mesylate) 200MG CAPSULE 500 MG TABLET
2-MedicalCarve out
KALETRA (lopinavirritonavir) 80MG-20 MGML SOLN 100-25 MGTABLET 200-50 MG TABLET
2-MedicalCarve out
LEXIVA (fosamprenavir calcium) 50MGML SUSPENSION 700 MGTABLET
2-MedicalCarve out
lopinavirritonavir 400-1005solution
2-MedicalCarve out
NORVIR (ritonavir) 80 MGMLSOLUTION 100 MG TABLET 100 MGSOFTGEL CAP 100 MG POWDERPACKET
2-MedicalCarve out
PREZCOBIX (darunavirethanolatecobicistat) 800 MG-150MG TABLET
2-MedicalCarve out
PREZISTA (darunavir ethanolate) 75MG TABLET 100 MGMLSUSPENSION 150 MG TABLET 400MG TABLET 600 MG TABLET 800MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
40
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
REYATAZ (atazanavir sulfate) 50MG POWDER PACKET 150 MGCAPSULE 200 MG CAPSULE 300MG CAPSULE
2-MedicalCarve out
ritonavir 100 mg tablet 2-MedicalCarve out
SYMTUZA (darunavirethcobicistatemtricitabinetenofovir alafenamide) 800-150-200-10MG TAB
2-MedicalCarve out
VIRACEPT (nelfinavir mesylate) 250MG TABLET 625 MG TABLET
2-MedicalCarve out
ANTI-INFLUENZA AGENTSoseltamivir phosphate 30 mgcapsule 45 mg capsule 75 mgcapsule
1-Covered QL (10 PER 30 DAY(S)) MFL (1 180 day(s))
OSELTAMIVIR PHOSPHATE 30 MGCAPSULE 45 MG CAPSULE 75 MGCAPSULE
1-Covered QL (10 PER 30 DAY(S)) MFL (1 180 day(s))
oseltamivir phosphate 6 mgmlsusp recon
1-Covered QL (120 PER FILL(S)) MFL (120 180day(s))
OSELTAMIVIR PHOSPHATE 6 MGMLSUSPENSION
1-Covered QL (120 PER FILL(S)) MFL (120 180day(s))
RELENZA (zanamivir) 5 MGDISKHALER
1-Covered QL (20 PER 30 DAY(S))
ANTIHERPETIC AGENTSacyclovir 200 mg capsule 200mg5ml oral susp 400 mg tablet800 mg tablet
1-Covered
ACYCLOVIR 200 MG5 ML SUSP400 MG TABLET 800 MG TABLET
1-Covered
trifluridine 1 drops 1-Covered
valacyclovir hcl 500 mg tablet1000 mg tablet
1-Covered QL (60 PER 30 DAY(S))
ANXIOLYTICS (Drugs for Anxiety)
ANXIOLYTICS OTHER (Other Drugs for Anxiety)BUSPIRONE HCL 5 MG TABLET 10MG TABLET 15 MG TABLET 30 MGTABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
41
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
buspirone hcl 5 mg tablet 75 mgtablet 10 mg tablet 15 mg tablet30 mg tablet
1-Covered
BENZODIAZEPINESalprazolam (ALPRAZOLAMINTENSOL) 1 mgml oral conc
1-Covered
alprazolam 025 mg tablet 05 mgtablet 1 mg tablet 2 mg tablet
1-Covered QL (100 PER 30 DAYS)
clonazepam 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered QL (120 PER 30 DAY(S))
diazepam 2 mg tablet 5 mgtablet 10 mg tablet
1-Covered QL (100 PER 30 DAYS)
diazepam 5 mg5 ml solution 5mgml oral conc
1-Covered
lorazepam (LORAZEPAM INTENSOL)2 mgml oral conc
1-Covered
lorazepam 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered QL (100 PER 30 DAYS)
lorazepam 2 mgml oral conc 1-Covered
oxazepam 10 mg capsule 15 mgcapsule 30 mg capsule
1-Covered
BIPOLAR AGENTS (Drugs for Bipolar Disorder)
MOOD STABILIZERSlithium carbonate 150 mg capsule300 mg tablet er 300 mg capsule300 mg tablet 450 mg tablet er600 mg capsule
2-MedicalCarve out
lithium citrate 8 meq5 ml solution 2-MedicalCarve out
LITHOBID (lithium carbonate) ER300 MG TABLET
2-MedicalCarve out
BLOOD GLUCOSE REGULATORS (Drugs for Diabetes)
ANTIDIABETIC AGENTS (Drugs for High Blood Sugar)acarbose 100 mg tablet 1-Covered QL (3 PER 1 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
42
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acarbose 25 mg tablet 1-Covered QL (12 PER 1 DAYS)
acarbose 50 mg tablet 1-Covered QL (6 PER 1 DAYS)
ADLYXIN (lixisenatide) 10-20 MCGSTARTER PACK 20 MCGMAINTENANCE PK
1-Covered PA
alogliptin benzoate 625 mg tablet125 mg tablet 25 mg tablet
1-Covered ST
alogliptin benzoatemetformin hclbenzmetformin 125-1000 tabletbenzmetformin 125-500mg tablet
1-Covered ST
alogliptin benzoatepioglitazonehcl benzpioglitazone 125-15 mgtablet benzpioglitazone 125-45mg tablet benzpioglitazone 125-30 mg tablet benzpioglitazone 25mg-30mg tabletbenzpioglitazone 25 mg-45mgtablet benzpioglitazone 25 mg-15mg tablet
1-Covered ST
AVANDIA (rosiglitazone maleate) 2MG TABLET 4 MG TABLET
1-Covered QL (60 PER 30 DAYS)
glimepiride 1 mg tablet 2 mgtablet 4 mg tablet
1-Covered STAR (Preferred Drug)
glipizide 25 mg tab er 24 5 mgtablet 5 mg tab er 24 10 mg taber 24 10 mg tablet
1-Covered STAR (Preferred Drug)
glyburide 125 mg tablet 25 mgtablet 5 mg tablet
1-Covered STAR (Preferred Drug)
glyburidemetformin hcl 125-250mg tablet 25-500 mg tablet 5mg-500mg tablet
1-Covered STAR (Preferred Drug)
JARDIANCE (empagliflozin) 10 MGTABLET 25 MG TABLET
1-Covered PA QL (1 PER 1 DAYS)
metformin hcl 500 mg tablet 500mg tab er 24h 750 mg tab er 24h850 mg tablet 1000 mg tablet
1-Covered STAR (Preferred Drug)
METFORMIN HCL ER ER 500 MGTABLET ER 750 MG TABLET
1-Covered STAR (Preferred Drug)
nateglinide 60 mg tablet 120 mgtablet
1-Covered ST
pioglitazone hcl 15 mg tablet 30mg tablet 45 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
43
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PIOGLITAZONE HCL 15 MG TABLET30 MG TABLET 45 MG TABLET
1-Covered
SYNJARDY(empagliflozinmetformin hcl) 5-1000 MG TABLET
1-Covered PA QL (2 PER 1 DAY(S))
SYNJARDY(empagliflozinmetformin hcl) 5-500 MG TABLET 125-500 MGTABLET 125-1000 MG TABLET
1-Covered PA QL (2 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 10-MG TABLET 125-MG TAB
1-Covered PA QL (2 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 25-1000 MG TABLET
1-Covered PA QL (1 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 5-1000 MG TABLET
1-Covered PA QL (2 PER 1)
tolbutamide 500 mg tablet 1-Covered
TRULICITY (dulaglutide) 075MG05 ML PEN 15 MG05 ML PEN
1-Covered PA QLC (1 penweek)
TRULICITY 3 MG05 ML PEN 45MG05 ML PEN
1-Covered PA QL (05 PER 1 WEEK(S))
VICTOZA 2-PAK (liraglutide) -18MG3 ML PEN
1-Covered PA QLC (6 ml (2 pens)30 days)
VICTOZA 3-PAK (liraglutide) -18MGML PEN
1-Covered PA QLC (9 ml (3 pens)30 days)
GLYCEMIC AGENTS (Drugs for Low Blood Sugar)BAQSIMI (glucagon) 3 MG SPRAYTWO PACK 3 MG SPRAY ONEPACK
1-Covered QL (2 PER 30 DAY(S))
GLUCAGON EMERGENCY KIT(glucagon hcl) 1 MG
1-Covered
GLUCAGON EMERGENCY KIT(glucagonhuman recombinant) 1MG
1-Covered
terbinafine hcl (JOCK ITCH) 1 cream (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
44
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
INSULINSADMELOG (insulin lispro) 100UNITML VIAL
1-Covered
ADMELOG SOLOSTAR (insulin lispro)100 UNITML
1-Covered PA
BASAGLAR KWIKPEN U-100 (insulinglarginehuman recombinantanalog) UNITML
1-Covered
HUMALOG (insulin lispro) 100UNITML CARTRIDGE
1-Covered PA
HUMALOG MIX 75-25 (insulin lisproprotamine and insulin lispro) -VIAL (
1-Covered
HUMALOG MIX 75-25 KWIKPEN(insulin lispro protamine and insulinlispro) -(
1-Covered PA
HUMULIN 70-30 (insulin nph humanisophaneinsulin regular human) -VIAL
1-Covered
HUMULIN 7030 KWIKPEN (insulinnph human isophaneinsulinregular human)
1-Covered PA
HUMULIN N (insulin nph humanisophane) 100 UITML VIAL
1-Covered
HUMULIN R (insulin regular human)100 UNITML VIAL
1-Covered
HUMULIN R U-500 (insulin regularhuman) UNITML VIAL
1-Covered
insulin lispro 100ml insuln pen 1-Covered PA
insulin lispro 100ml vial 1-Covered
INSULIN LISPRO PROTAMINE MIX(insulin lispro protamine and insulinlispro) 75-25 KWKPN (
1-Covered PA
NOVOLIN 70-30 (insulin nph humanisophaneinsulin regular human)70-30 100 UNITML VIAL RELION 70-30 VIAL
1-Covered
NOVOLIN N (insulin nph humanisophane) N 100 UNITML VIALRELION N 100 UNITML
1-Covered
NOVOLIN R (insulin regular human)R 100 UNITML VIAL RELION R 100UNITML
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
45
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
BLOOD PRODUCTSMODIFIERSVOLUME EXPANDERS (Drugs forBlood Disorders)
ANTICOAGULANTS (Blood Thinners)COUMADIN (warfarin sodium) 1MG TABLET 2 MG TABLET 25 MGTABLET 3 MG TABLET 4 MG TABLET5 MG TABLET 6 MG TABLET 75 MGTABLET 10 MG TABLET
1-Covered
ELIQUIS (apixaban) 25 MG TABLET5 MG TABLET
1-Covered QL (2 PER 1 DAY(S))
ELIQUIS (apixaban) DVT-PE TREATSTART 5MG
1-Covered QLC (1 PACK6 MONTHS)
ENOXAPARIN SODIUM 120 MG08ML SYR
1-Covered
ENOXAPARIN SODIUM 30 MG03ML SYR 40 MG04 ML SYR 60MG06 ML SYR 80 MG08 ML SYR100 MGML SYRINGE 150 MGMLSYRINGE
1-Covered PA
enoxaparin sodium 30mg03ml40mg04ml 60mg06ml80mg08ml 100 mgml120mg8ml 150 mgml
1-Covered PA
HEPARIN SODIUM SOD 5000UNITML VIAL SOD 10000 UNITMLVL SOD 20000 UNITML VL 50000UNIT5 ML VIAL
1-Covered
heparin sodiumporcine 5000mlvial 10000ml vial 20000ml vial
1-Covered
heparin sodiumporcinepf 1000mlvial
1-Covered
warfarin sodium (JANTOVEN) 1 mgtablet 2 mg tablet 25 mg tablet3 mg tablet 4 mg tablet 5 mgtablet 6 mg tablet 75 mg tablet10 mg tablet
1-Covered
warfarin sodium 1 mg tablet 2 mgtablet 25 mg tablet 3 mg tablet4 mg tablet 5 mg tablet 6 mgtablet 75 mg tablet 10 mg tablet
1-Covered
XARELTO (rivaroxaban) 10 MGTABLET 15 MG TABLET 20 MGTABLET
1-Covered QL (1 PER 1 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
46
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
XARELTO (rivaroxaban) DVT-PETREAT START 30D
1-Covered QLC (1 PACK6 MONTHS)
BLOOD FORMATION MODIFIERS (Blood Formation Drugs)anagrelide hcl 05 mg capsule 1mg capsule
1-Covered
EPOGEN (epoetin alfa) 2000UNITSML VIAL 3000 UNITSMLVIAL 4000 UNITSML VIAL 10000UNITSML VIAL 20000 UNITSMLVIAL
1-Covered PA SP
PROCRIT (epoetin alfa) 2000UNITSML VIAL 3000 UNITSMLVIAL 4000 UNITSML VIAL 10000UNITSML VIAL 20000 UNITSMLVIAL 40000 UNITSML VIAL
1-Covered PA SP
HEMOSTASIS AGENTS (Drugs to Stop Bleeding)ADVATE (antihemophilic factor(fviii) recombinantfull length) 200-400 VIAL 401-800 VIAL 801-1200VIAL 1201-1800 VIAL 1801-2400VIAL 2401-3600 VIAL 3601-4800VIAL
2-MedicalCarve out
ADYNOVATE (antihemophilicfactor (fviii) recombinant fulllength peg) 200-400 VIAL 401-800VIAL 750 VIAL 801-1250 VIAL1251-2500 VL 1500 VIAL 3000VIAL
2-MedicalCarve out
AFSTYLA (antihemophilic factor viiirecombsingle-chnb-domtruncated) 250 VIAL -- 500 VIAL --1000 VIAL -- 1500 RANGE VIAL --2000 VIAL -- 2500 RANGE VIAL --3000 VIAL --
2-MedicalCarve out
ALPHANATE (antihemophilic factorhumanvon willebrandfactorhuman) 250-100 VIALhuman) 500-200 VIAL human)1000-400 VIAL human) 1500-600VIAL human) 2000-800 VIALhuman)
2-MedicalCarve out
ALPHANINE SD (factor ix) SD 500VIAL SD 1000 VIAL SD 1500 VIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
47
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALPROLIX (factor ix recombinantfc fusion protein) 250 500 10002000 3000 4000
2-MedicalCarve out
BENEFIX (factor ix humanrecombinant) 250 500 10002000 3000
2-MedicalCarve out
COAGADEX (coagulation factor x)250 VIAL 500 VIAL
2-MedicalCarve out
CORIFACT (factor xiii) KIT 2-MedicalCarve out
ELOCTATE (antihemophilic factor(fviii) recombinant fc fusionprotein) 250 500 750 1000 15002000 3000 4000 5000 6000
2-MedicalCarve out
ESPEROCT (antihemophilic factor(fviii) rec b-dom truncated peg-exei) 500 VIAL -- 1000 VIAL --1500 VIAL -- 2000 VIAL -- 3000VIAL --
2-MedicalCarve out
FEIBA NF (anti-inhibitor coagulantcomplex) 500 (NOMINAL) - 1000(NOMINAL) - 2500 (NOMINAL) -
2-MedicalCarve out
FIBRYGA (fibrinogen) 1 GRAMRANGE VIAL
2-MedicalCarve out
HELIXATE FS (antihemophilic factor(fviii) recombinantfull length) 250UNIT VIAL 500 UNIT VIAL 1000 UNITVIAL 2000 UNIT VIAL 3000 UNITSVIAL
2-MedicalCarve out
HEMLIBRA (emicizumab-kxwh) 30MGML VIAL - 60 MG04 ML VIAL - 105 MG07 ML VIAL - 150 MGMLVIAL -
2-MedicalCarve out
HEMOFIL M (antihemophilic factorhuman) 250 500 1000 1700
2-MedicalCarve out
HUMATE-P (antihemophilic factorhumanvon willebrandfactorhuman) -600 human) -1200human) -2400 human)
2-MedicalCarve out
IDELVION (factor ixrecombinantalbumin fusionprotein) 250 VIAL 500 VIAL 1000VIAL 2000 VIAL 3500 VIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
48
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
IXINITY (factor ix humanrecombinant threonine 148) 500RANGE 500 VIAL 1000 VIAL 1000RANGE 1000 VIAL -2 VLS 1000RANGE-2 VLS 1500 RANGE-2 VLS1500 VIAL -2 VLS 1500 VIAL 1500RANGE
2-MedicalCarve out
JIVI (antihemophilic factor (fviii)rec b-domain deleted peg-aucl)500 VIAL -- 1000 VIAL -- 2000 VIAL-- 3000 VIAL --
2-MedicalCarve out
KCENTRA (human prothrombincomplex concentrate (pcc) 4-factor) 500 VIAL 4- 1000 VIAL 4-
2-MedicalCarve out
KOGENATE FS (antihemophilicfactor (fviii) recombinantfulllength) 250 UNIT VIAL 500 UNITVIAL 1000 UNITS VIAL 2000 UNITVIAL 3000 UNITS VIAL
2-MedicalCarve out
KOVALTRY (antihemophilic factor(fviii) recombinantfull length) 250KIT 500 KIT 1000 KIT 2000 KIT3000 KIT
2-MedicalCarve out
MONONINE (factor ix) 1000 UNITVIAL
2-MedicalCarve out
NOVOEIGHT (antihemophilic factorviii recombinant b-domaintruncated) 250 VIAL RECOMINANT- 500 VIAL RECOMINANT - 1000VIAL RECOMINANT - 1500 VIALRECOMINANT - 2000 VIALRECOMINANT - 3000 VIALRECOMINANT -
2-MedicalCarve out
NOVOSEVEN RT (coagulationfactor viia (recombinant)) 1 MGVIAL 2 MG VIAL 5 MG VIAL 8 MGVIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
49
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NUWIQ (antihemophilic factor viiirec hek cell b-domain deleted)250 VIAL - 250 VIAL PACK - 500VIAL - 500 VIAL PACK - 1000 VIAL - 1000 VIAL PACK - 2000 VIALPACK - 2000 VIAL - 2500 VIALPACK - 2500 VIAL - 3000 VIAL -3000 VIAL PACK - 4000 VIAL PACK- 4000 VIAL -
2-MedicalCarve out
OBIZUR (antihemophilic factor viiirecombinant porcine sequence)500 VIAL 500 VIAL - 5 VIALS 500VIAL -10 VIALS
2-MedicalCarve out
phytonadione (vit k1) 5 mg tablet 1-Covered
PROFILNINE (factor ix complexprothrombin cplx conc(pcc) no43-factor) 500 VIAL 3- 1000 VIAL 3-1500 VIAL 3-
2-MedicalCarve out
REBINYN (factor ix (human)recombinant pegylated) 500 VIAL1000 VIAL 2000 VIAL
2-MedicalCarve out
RECOMBINATE (antihemophilicfactor viii human recombinant)220-400 VIAL 401-800 VIAL 801-1240 VL 1241-1800 V 1801-2400V
2-MedicalCarve out
RIASTAP (fibrinogen) VIAL 2-MedicalCarve out
RIXUBIS (factor ix humanrecombinant) 250 500 10002000 3000
2-MedicalCarve out
SEVENFACT 1 MG VIAL 5 MG VIAL 2-MedicalCarve out
TRETTEN (factor xiii a-subunitrecombinant) 2500 UNIT VIAL(fctor -recombinnt)
2-MedicalCarve out
VONVENDI (von willebrand factor(recombinant)) 650 VIAL 1300VIAL
2-MedicalCarve out
WILATE (antihemophilic factorhumanvon willebrandfactorhuman) 450-450 VIALhuman) 500-500 VIAL human)900-900 VIAL human) 1000-1000VIAL human)
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
50
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
XYNTHA (antihemophilic factor(factor viii) recombb-domaindeleted) 250 KIT - 500 KIT - 1000KIT - 2000 KIT -
2-MedicalCarve out
XYNTHA SOLOFUSE (antihemophilicfactor (factor viii) recombb-domain deleted) 250 KIT - 500 KIT -1000 KIT - 2000 KIT - 3000 KIT -
2-MedicalCarve out
PLATELET MODIFYING AGENTScilostazol 50 mg tablet 100 mgtablet
1-Covered
clopidogrel bisulfate 75 mg tablet 1-Covered AL1 (At least 18 yrs old)
dipyridamole 25 mg tablet 50 mgtablet 75 mg tablet
1-Covered
CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation)
ALPHA-ADRENERGIC AGONISTSclonidine hcl 01 mg tablet 02 mgtablet 03 mg tablet
1-Covered
CLONIDINE HCL 01 MG TABLET 02MG TABLET 03 MG TABLET
1-Covered
guanfacine hcl 1 mg tablet 2 mgtablet
1-Covered
methyldopa 250 mg tablet 500mg tablet
1-Covered
ALPHA-ADRENERGIC BLOCKING AGENTSdoxazosin mesylate 1 mg tablet 2mg tablet 4 mg tablet 8 mgtablet
1-Covered
PHENOXYBENZAMINE HCL 10 MGCAP
1-Covered
phenoxybenzamine hcl 10 mgcapsule
1-Covered
prazosin hcl 1 mg capsule 2 mgcapsule 5 mg capsule
1-Covered
PRAZOSIN HCL 1 MG CAPSULE 2MG CAPSULE 5 MG CAPSULE
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
51
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terazosin hcl 1 mg capsule 2 mgcapsule 5 mg capsule 10 mgcapsule
1-Covered
TERAZOSIN HCL 1 MG CAPSULE 2MG CAPSULE 5 MG CAPSULE 10MG CAPSULE
1-Covered
ANGIOTENSIN II RECEPTOR ANTAGONISTSirbesartan 75 mg tablet 150 mgtablet 300 mg tablet
1-Covered ST
LOSARTAN POTASSIUM 25 MG TAB50 MG TAB 100 MG TAB
1-Covered STAR (Preferred Drug)
losartan potassium 25 mg tablet50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
valsartan 40 mg tablet 80 mgtablet 160 mg tablet 320 mgtablet
1-Covered ST
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORSbenazepril hcl 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered STAR (Preferred Drug)
captopril 125 mg tablet 25 mgtablet 50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
CAPTOPRIL 125 MG TABLET 25 MGTABLET 50 MG TABLET 100 MGTABLET
1-Covered STAR (Preferred Drug)
ENALAPRIL MALEATE 25 MG TAB 5MG TABLET 10 MG TAB 20 MG TAB
1-Covered STAR (Preferred Drug)
enalapril maleate 25 mg tablet 5mg tablet 10 mg tablet 20 mgtablet
1-Covered STAR (Preferred Drug)
fosinopril sodium 10 mg tablet 20mg tablet 40 mg tablet
1-Covered
lisinopril 25 mg tablet 5 mg tablet10 mg tablet 20 mg tablet 30 mgtablet 40 mg tablet
1-Covered STAR (Preferred Drug)
moexipril hcl 75 mg tablet 15 mgtablet
1-Covered
quinapril hcl 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered
ramipril 125 mg capsule 25 mgcapsule 5 mg capsule 10 mgcapsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
52
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
RAMIPRIL 125 MG CAPSULE 25MG CAPSULE 5 MG CAPSULE 10MG CAPSULE
1-Covered
trandolapril 1 mg tablet 2 mgtablet 4 mg tablet
1-Covered
ANTIARRHYTHMICS (Drugs for Irregular Heart Rhythm)amiodarone hcl (PACERONE) 200mg tablet
1-Covered
amiodarone hcl 200 mg tablet 1-Covered
disopyramide phosphate 100 mgcapsule
1-Covered
flecainide acetate 50 mg tablet100 mg tablet 150 mg tablet
1-Covered
mexiletine hcl 150 mg capsule 200mg capsule 250 mg capsule
1-Covered
MEXILETINE HCL 150 MG CAPSULE200 MG CAPSULE 250 MGCAPSULE
1-Covered
propafenone hcl 150 mg tablet225 mg tablet 300 mg tablet
1-Covered
quinidine gluconate 324 mg tableter
1-Covered
quinidine sulfate 200 mg tablet300 mg tablet
1-Covered
SOTALOL 80 MG TABLET 120 MGTABLET 160 MG TABLET 240 MGTABLET
1-Covered
SOTALOL AF 80 MG TABLET 120 MGTABLET
1-Covered
sotalol hcl (SORINE) 80 mg tablet120 mg tablet 160 mg tablet 240mg tablet
1-Covered
sotalol hcl 80 mg tablet 120 mgtablet 160 mg tablet 240 mgtablet
1-Covered
BETA-ADRENERGIC BLOCKING AGENTSatenolol 25 mg tablet 50 mgtablet 100 mg tablet
1-Covered STAR (Preferred Drug)
ATENOLOL 25 MG TABLET 50 MGTABLET 100 MG TABLET
1-Covered STAR (Preferred Drug)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
53
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
bisoprolol fumarate 5 mg tablet 10mg tablet
1-Covered
carvedilol 3125 mg tablet 625 mgtablet 125 mg tablet 25 mgtablet
1-Covered STAR (Preferred Drug)
labetalol hcl 100 mg tablet 200mg tablet 300 mg tablet
1-Covered
LABETALOL HCL 100 MG TABLET200 MG TABLET 300 MG TABLET
1-Covered
metoprolol succinate 200 mg taber 24h
1-Covered QL (60 PER 30 DAYS) MDD (2 PerDay) STAR (Preferred Drug)
metoprolol succinate 25 mg taber 50 mg tab er 100 mg tab er
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
METOPROLOL SUCCINATE ER 200MG TAB
1-Covered QL (60 PER 30 DAYS) MDD (2 PerDay) STAR (Preferred Drug)
METOPROLOL SUCCINATE ER 25MG TAB ER 50 MG TAB ER 100 MGTAB
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
metoprolol tartrate 25 mg tablet50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
nadolol 20 mg tablet 40 mgtablet 80 mg tablet
1-Covered STAR (Preferred Drug)
NADOLOL 20 MG TABLET 40 MGTABLET 80 MG TABLET
1-Covered STAR (Preferred Drug)
pindolol 5 mg tablet 10 mg tablet 1-Covered STAR (Preferred Drug)
propranolol hcl 10 mg tablet 20mg5 ml solution 20 mg tablet 40mg tablet 40mg5ml solution 60mg tablet 60 mg cap sa 24h 80mg tablet 80 mg cap sa 24h 120mg cap sa 24h 160 mg cap sa 24h
1-Covered
CALCIUM CHANNEL BLOCKING AGENTSAMLODIPINE BESYLATE 25 MG TAB5 MG TAB 10 MG TAB
1-Covered STAR (Preferred Drug)
amlodipine besylate 25 mg tablet5 mg tablet 10 mg tablet
1-Covered STAR (Preferred Drug)
DILTIAZEM 24HR ER (CD) 24HER(CD) 120 MG CP 24H ER(CD)240 MG CP 24H ER(CD) 180 MGCP 24H ER(CD) 360 MG CP 24HER(CD) 300 MG CP
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
54
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DILTIAZEM 24HR ER (XR) 24H ER(XR)240 MG CP 24H ER(XR) 180 MG CP
1-Covered
diltiazem hcl (CARTIA XT) 120 mgcap er 180 mg cap er 240 mgcap er 300 mg cap er
1-Covered
diltiazem hcl (DILT-XR) 120 mg caper - 180 mg cap er - 240 mg caper -
1-Covered
diltiazem hcl (TAZTIA XT) 120 mgcap 180 mg cap 240 mg cap 300mg cap 360 mg cap
1-Covered
diltiazem hcl 30 mg tablet 60 mgcap er 12h 60 mg tablet 90 mgtablet 90 mg cap er 12h 120 mgcap sa 24h 120 mg tablet 120 mgcap er 24h 120 mg cap er deg120 mg cap er 12h 180 mg cap sa24h 180 mg cap er deg 180 mgcap er 24h 240 mg cap er 24h 240mg cap er deg 240 mg cap sa24h 300 mg cap er 24h 300 mgcap sa 24h 360 mg cap sa 24h360 mg cap er 24h
1-Covered
felodipine 25 mg tab er 5 mg taber 10 mg tab er
1-Covered
FELODIPINE ER ER 25 MG TABLETER 5 MG TABLET ER 10 MG TABLET
1-Covered
nicardipine hcl 20 mg capsule 30mg capsule
1-Covered
nifedipine (AFEDITAB CR) 30 mgtablet er 60 mg tablet er
1-Covered
nifedipine (NIFEDICAL XL) 30 mgtab er 24 60 mg tab er 24
1-Covered
NIFEDIPINE 10 MG CAPSULE 1-Covered
nifedipine 10 mg capsule 20 mgcapsule 30 mg tablet er 30 mgtab er 24 60 mg tablet er 60 mgtab er 24 90 mg tablet er 90 mgtab er 24
1-Covered
nisoldipine 20 mg tab er 30 mgtab er 40 mg tab er
1-Covered
verapamil hcl 40 mg tablet 80 mgtablet 120 mg tablet 120 mgtablet er 180 mg tablet er 240 mgtablet er
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
55
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CARDIOVASCULAR AGENTS OTHERamiloride hclhydrochlorothiazideamiloridehydrochlorothiazide 5mg-50 mg tablet
1-Covered
amlodipine besylatebenazeprilhcl 25mg-10mg capsule 5 mg-20mg capsule 5 mg-10 mg capsule5 mg-40 mg capsule 10 mg-20mgcapsule 10 mg-40mg capsule
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day) STAR(Preferred Drug)
atenololchlorthalidone 50 mg-tablet 100mg-tablet
1-Covered STAR (Preferred Drug)
benazepril hclhydrochlorothiazidebenazeprilhydrochlorothiazide 5-625mg tabletbenazeprilhydrochlorothiazide 10-125mg tabletbenazeprilhydrochlorothiazide 20mg-25mg tabletbenazeprilhydrochlorothiazide 20-125 mg tablet
1-Covered STAR (Preferred Drug)
bisoprololfumaratehydrochlorothiazidebisoprololhydrochlorothiazide 25-tabletbisoprololhydrochlorothiazide 5-tabletbisoprololhydrochlorothiazide 10-tablet
1-Covered
BISOPROLOL-HYDROCHLOROTHIAZIDE -10-625MG TAB -25-625 MG TB -5-625MG TAB
1-Covered
captoprilhydrochlorothiazide 25mg-25mg tablet 25 mg-15mgtablet 50 mg-25mg tablet 50 mg-15mg tablet
1-Covered STAR (Preferred Drug)
digoxin (DIGITEK) 125 mcg tablet250 mcg tablet
1-Covered STAR (Preferred Drug)
digoxin (DIGOX) 125 mcg tablet250 mcg tablet
1-Covered STAR (Preferred Drug)
digoxin 125 mcg tablet 250 mcgtablet
1-Covered STAR (Preferred Drug)
digoxin 50 mcgml solution 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
56
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fosinoprilsodiumhydrochlorothiazidefosinoprilhydrochlorothiazide 10-125mg tabletfosinoprilhydrochlorothiazide 20-125 mg tablet
1-Covered
FOSINOPRIL-HYDROCHLOROTHIAZIDE -10-125MG TAB -20-125 MG TAB
1-Covered
irbesartanhydrochlorothiazide150-tablet 300-tablet
1-Covered ST
LANOXIN (digoxin) 125 MCGTABLET 250 MCG TABLET
1-Covered STAR (Preferred Drug)
lisinoprilhydrochlorothiazide 10-125mg tablet 20-125 mg tablet20 mg-25mg tablet
1-Covered STAR (Preferred Drug)
losartanpotassiumhydrochlorothiazidelosartanhydrochlorothiazide 50-125 mg tabletlosartanhydrochlorothiazide100mg-25mg tabletlosartanhydrochlorothiazide 100-125mg tablet
1-Covered STAR (Preferred Drug)
LOSARTAN-HYDROCHLOROTHIAZIDE -50-125MG TAB -100-125 MG TAB -100-25MG TAB
1-Covered STAR (Preferred Drug)
pentoxifylline 400 mg tablet er 1-Covered
spironolactonehydrochlorothiazide spironolacthydrochlorothiazid25 mg-25mg tablet
1-Covered
triamterenehydrochlorothiazide375-25 mg capsule 375-25 mgtablet 50 mg-25mg capsule 75mg-50mg tablet
1-Covered
valsartanhydrochlorothiazide 80-125mg tablet 160-125mg tablet160mg-25mg tablet 320-125mgtablet 320mg-25mg tablet
1-Covered ST
DIURETICS CARBONIC ANHYDRASE INHIBITORSacetazolamide 125 mg tablet 250mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
57
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ACETAZOLAMIDE 125 MG TABLET250 MG TABLET
1-Covered
DIURETICS LOOPbumetanide 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered
furosemide 10 mgml solution 20mg tablet 40mg5ml solution 40mg tablet 80 mg tablet
1-Covered STAR (Preferred Drug)
DIURETICS POTASSIUM-SPARINGamiloride hcl 5 mg tablet 1-Covered
spironolactone 25 mg tablet 50mg tablet 100 mg tablet
1-Covered
SPIRONOLACTONE 25 MG TABLET50 MG TABLET 100 MG TABLET
1-Covered
DIURETICS THIAZIDEchlorothiazide 250 mg tablet 500mg tablet
1-Covered
chlorthalidone 25 mg tablet 50 mgtablet
1-Covered
CHLORTHALIDONE 25 MG TABLET50 MG TABLET
1-Covered
DIURIL (chlorothiazide) 250 MG5ML ORAL SUSP
1-Covered
hydrochlorothiazide 125 mgcapsule 25 mg tablet 50 mgtablet
1-Covered STAR (Preferred Drug)
indapamide 125 mg tablet 25mg tablet
1-Covered
methyclothiazide 5 mg tablet 1-Covered
metolazone 25 mg tablet 5 mgtablet 10 mg tablet
1-Covered
DYSLIPIDEMICS FIBRIC ACID DERIVATIVES (Drugs for HighCholesterol)
fenofibrate 54 mg tablet 160 mgtablet
1-Covered ST
FENOFIBRATE 54 MG TABLET 160MG TABLET
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
58
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fenofibratemicronized 67 mgcapsule 134 mg capsule 200 mgcapsule
1-Covered ST
gemfibrozil 600 mg tablet 1-Covered
GEMFIBROZIL 600 MG TABLET 1-Covered
TRIGLIDE (fenofibratenanocrystallized) 160 MG TABLET
1-Covered ST
DYSLIPIDEMICS HMG COA REDUCTASE INHIBITORS (Drugs for HighCholesterol)
atorvastatin calcium 10 mg tablet20 mg tablet 40 mg tablet 80 mgtablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
ATORVASTATIN CALCIUM 10 MGTABLET 20 MG TABLET 40 MGTABLET 80 MG TABLET
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
lovastatin 10 mg tablet 20 mgtablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
rosuvastatin calcium 5 mg tablet10 mg tablet 20 mg tablet 40 mgtablet
1-Covered ST QL (30 PER 30 DAY(S))
simvastatin 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered STAR (Preferred Drug)
DYSLIPIDEMICS OTHER (Other Drugs for High Cholesterol)cholestyramine (with sugar) suar) 4powder
1-Covered
cholestyramineaspartame(PREVALITE) 4 g powder
1-Covered
cholestyramineaspartame 4 gpowder
1-Covered
COLESTID (colestipol hcl)FLAVORED GRANULES
1-Covered
colestipol hcl 1 tablet 5 ranules 5packet
1-Covered
ezetimibe 10 mg tablet 1-Covered
niacin (ENDUR-ACIN) 250 mgtablet er - 500 mg tablet er - 750mg tablet er -
1-Covered
niacin (SLO-NIACIN) 500 mg tableter -
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
59
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NIACIN 100 MG TABLET TR 500 MGTABLET
1-Covered
niacin 50 mg tablet 100 mg tablet250 mg capsule er 250 mg tablet250 mg tablet er 500 mg tablet500 mg tablet er 500 mg tab er24h 500 mg capsule er 750 mgtablet er 1000 mg tablet er
1-Covered
OMEGA-3 ACID ETHYL ESTERS -1GM CAP
1-Covered QL (4 PER 1 DAY(S))
omega-3 acid ethyl esters omea-1capsule
1-Covered QL (4 PER 1 DAY(S))
VASODILATORS DIRECT-ACTING ARTERIAL (Drugs for RelaxingArteries)
hydralazine hcl 10 mg tablet 25mg tablet 50 mg tablet 100 mgtablet
1-Covered
minoxidil 25 mg tablet 10 mgtablet
1-Covered
VASODILATORS DIRECT-ACTING ARTERIALVENOUS (Drugs forRelaxing Arteries and Veins)
ISOSORBIDE DINITRATE 5 MG TAB10 MG TAB 20 MG TAB 30 MG TAB
1-Covered STAR (Preferred Drug)
isosorbide dinitrate 5 mg tablet 10mg tablet 20 mg tablet 30 mgtablet 40 mg tablet er
1-Covered STAR (Preferred Drug)
isosorbide mononitrate 10 mgtablet 20 mg tablet 30 mg tab er24h 60 mg tab er 24h 120 mg taber 24h
1-Covered STAR (Preferred Drug)
NITRO-BID (nitroglycerin) -2OINTMENT
1-Covered
nitroglycerin (MINITRAN) 01mghrpatch 02mghr patch 04mghrpatch 06mghr patch
1-Covered
nitroglycerin (NITRO-TIME) 25 mgcapsule er - 65 mg capsule er - 9mg capsule er -
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
60
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
nitroglycerin 01mghr patch td2402mghr patch td24 03 mg tabsubl 04mghr patch td24 04 mgtab subl 06 mg tab subl 06mghrpatch td24 25 mg capsule er 65mg capsule er 9 mg capsule er400mcgspr spray
1-Covered
NITROGLYCERIN 400 MCG SPRAY 1-Covered
CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions)
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTSAMPHETAMINES
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 15 mg cap er 24h
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old) MDD (1 Per Day)
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 5 mg cap erdextroamphetamineamphetamine 10 mg cap erdextroamphetamineamphetamine 20 mg cap erdextroamphetamineamphetamine 25 mg cap erdextroamphetamineamphetamine 30 mg cap er
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old)
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 5 mg tabletdextroamphetamineamphetamine 75 mg tabletdextroamphetamineamphetamine 10 mg tabletdextroamphetamineamphetamine 125 mg tabletdextroamphetamineamphetamine 15 mg tabletdextroamphetamineamphetamine 20 mg tabletdextroamphetamineamphetamine 30 mg tablet
1-Covered AL1 (3 to 18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
61
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
dextroamphetamine sulfate(ZENZEDI) 5 mg tablet 10 mgtablet
1-Covered AL1 (3 to 18 yrs old)
dextroamphetamine sulfate 5 mgcapsule er 5 mg tablet 10 mgcapsule er 10 mg tablet 15 mgcapsule er
1-Covered AL1 (3 to 18 yrs old)
DEXTROAMPHETAMINE SULFATE 5MG TAB 10 MG TAB
1-Covered AL1 (3 to 18 yrs old)
DEXTROAMPHETAMINE-AMPHET ER-15 MG CAP
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old) MDD (1 Per Day)
DEXTROAMPHETAMINE-AMPHET ER-ER 5 MG CAP -ER 10 MG CAP -ER20 MG CAP -ER 25 MG CAP -ER 30MG CAP
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old)
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS NON-AMPHETAMINES
atomoxetine hcl 10 mg capsule 18mg capsule 25 mg capsule 40 mgcapsule 60 mg capsule 80 mgcapsule 100 mg capsule
1-Covered PA
guanfacine hcl 1 mg tab er 2 mgtab er 3 mg tab er 4 mg tab er
1-Covered QL (1 PER 1 DAY(S))
METHYLPHENIDATE ER ER 18 MGTAB ER 27 MG TAB ER 36 MG TABER 54 MG TAB
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl (METADATEER) 20 mg tablet er
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl 10 mg tableter 18 mg tab er 24 20 mg tableter 27 mg tab er 24 36 mg tab er24 54 mg tab er 24
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl 5 mg tablet10 mg cpbp 30-70 10 mg tablet20 mg tablet 20 mg cpbp 30-7030 mg cpbp 30-70 40 mg cpbp 30-70 50 mg cpbp 30-70 60 mg cpbp30-70
1-Covered AL1 (6 to 18 yrs old)
METHYLPHENIDATE HCL 5 MGTABLET 10 MG TABLET 20 MGTABLET
1-Covered AL1 (6 to 18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
62
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CENTRAL NERVOUS SYSTEM OTHERacetaminophen (ATHENOL) 325mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (CHILD FEVERREDUCER) 120 mg supprect
1-Covered
acetaminophen (CHILD PAIN REL-FEVER REDUCER) 120 mg supprect-
1-Covered
acetaminophen (CHILDRENSFEVER REDUCER) 120 mg supprect
1-Covered
acetaminophen (CHILDRENSFEVER REDUCING) 120 mgsupprect
1-Covered
acetaminophen (CHILDRENS PAINAND FEVER) 160 mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (CHILDRENSSILAPAP) 160 mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (ED-APAP) 160mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (LITTLE REMEDIESFEVER-PAIN) 160 mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (M-PAP) 160mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (MAPAP) 160mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (MAPAP) 325 mgtablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (MASOPHEN) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRINEXTRA STRENGTH) 500 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRINPAIN RELIEF) 500 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRIN)160 mg5ml elixir -
1-Covered QLC (LIMIT TO 2 FILLS OF 120ML IN30 DAYS)
acetaminophen (NON-ASPIRIN)325 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN amp FEVER)500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
63
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acetaminophen (PAIN RELIEFEXTRA STRENGTH) 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN RELIEF) 160mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (PAIN RELIEF) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN RELIEVER)325 mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PHARBETOL) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (SHAKE THATACHE) 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (TACTINAL) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen 120 mg 650 mg 1-Covered
acetaminophen 160 mg5ml elixir 1-Covered QLC (LIMIT TO 2 FILLS OF 120ML IN30 DAYS)
acetaminophen 160 mg5ml liquid 1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 160 mg5ml oralsusp
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 160 mg5mlsolution
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 325 mg tablet500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
ACETAMINOPHEN CVS 325 MGGELCP 325 MG TABLET 500 MGTABLET 500 MG GELCAP
1-Covered QL (60 PER 30 DAY(S))
butalbitalacetaminophen(TENCON) 50mg-325mg tablet
1-Covered QL (48 PER 30 DAY(S))
butalbitalacetaminophen 50mg-325mg tablet
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
butalbitalacetaminophencaffeine butalbacetaminophencaffeine50-325-40 tablet
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
PAIN amp FEVER (acetaminophen)500 MG TABLET
1-Covered QL (60 PER 30 DAY(S))
PAIN RELIEF 325 MG TABLET 500MG GELCAP 500 MG TABLET
1-Covered QL (60 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
64
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
riluzole 50 mg tablet 1-Covered PA
RILUZOLE 50 MG TABLET 1-Covered PA
FIBROMYALGIA AGENTSduloxetine hcl 20 mg capsule dr30 mg capsule dr 60 mg capsuledr
1-Covered
pregabalin 20 mgml solution 1-Covered PA QLC (30 MLDAY)
pregabalin 225 mg capsule 300mg capsule
1-Covered PA QL (2 PER 1 DAY(S))
PREGABALIN 225 MG CAPSULE 300MG CAPSULE
1-Covered PA QL (2 PER 1 DAY(S))
pregabalin 25 mg capsule 50 mgcapsule 75 mg capsule 100 mgcapsule 150 mg capsule 200 mgcapsule
1-Covered PA QL (3 PER 1 DAY(S))
PREGABALIN 25 MG CAPSULE 50MG CAPSULE 75 MG CAPSULE 100MG CAPSULE 150 MG CAPSULE200 MG CAPSULE
1-Covered PA QL (3 PER 1 DAY(S))
SAVELLA (milnacipran hcl) 125 MGTABLET 25 MG TABLET 50 MGTABLET 100 MG TABLET TITRATIONPACK
1-Covered PA
MULTIPLE SCLEROSIS AGENTSAVONEX (interferon beta-1a)PREFILLED SYR 30 MCG KT -
1-Covered PA SP
AVONEX (interferon beta-1aalbumin human) 30 MCG VIALKIT -
1-Covered PA SP
AVONEX PEN (interferon beta-1a)30 MCG05 ML KIT -
1-Covered PA SP
DIMETHYL FUMARATE 30D START PK 1-Covered PA SP
DIMETHYL FUMARATE DR 120 MGCP DR 240 MG CP
1-Covered PA SP QL (2 PER 1 DAY(S))
glatiramer acetate (GLATOPA) 20mgml syringe
1-Covered PA SP QLC (1 SYRINGEDAY)
glatiramer acetate (GLATOPA) 40mgml syringe
1-Covered PA SP QLC (12SYRINGESMONTH)
glatiramer acetate 20 mgmlsyringe
1-Covered PA SP QLC (1 SYRINGEDAY)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
65
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
glatiramer acetate 40 mgmlsyringe
1-Covered PA SP QLC (12SYRINGESMONTH)
PLEGRIDY (peginterferon beta-1a)125 MCG05 ML SYRING - SYRINGESTARTER PACK -
1-Covered PA SP
PLEGRIDY PEN (peginterferon beta-1a) 125 MCG05 ML PEN - PEN INJSTARTER PACK -
1-Covered PA SP
TECFIDERA (dimethyl fumarate) DR120 MG CAPSULE DR 240 MGCAPSULE STARTER PACK
1-Covered PA SP
DENTAL AND ORAL AGENTS (Drugs for the Mouth)
DENTAL AND ORAL AGENTSchlorhexidine gluconate (PAROEX)012 mouthwash
1-Covered
chlorhexidine gluconate 012 mouthwash
1-Covered
PHOS-FLUR (fluoride (sodium)) -ORAL RINSE
1-Covered
triamcinolone acetonide(ORALONE) 01 paste (g)
1-Covered
triamcinolone acetonide 01 paste (g)
1-Covered
TRIAMCINOLONE ACETONIDE 01PASTE
1-Covered
DERMATOLOGICAL AGENTS (Drugs for the Skin)ACNE MEDICATION (benzoylperoxide) 5 GEL
1-Covered
ACNE MEDICATION 25 GEL 1-Covered
ammonium lactate (SKINTREATMENT) 12 lotion
1-Covered
ammonium lactate 12 cream(g) 12 lotion
1-Covered
benzoyl peroxide (ACNE CONTROLCLEANSER) 10 cleanser
1-Covered
benzoyl peroxide (ACNE FOAMINGWASH) 10 cleanser
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
66
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
benzoyl peroxide (ACNETREATMENT) 10 gel (gram)
1-Covered
benzoyl peroxide (ACNECLEAR) 10 gel (gram)
1-Covered
benzoyl peroxide (ADVANCEDEXFOLIATING CLEANSER) 5 cleanser
1-Covered
benzoyl peroxide (BP WASH) 5 10
1-Covered
benzoyl peroxide (BP) 5 gel(gram) 10 gel (gram)
1-Covered
benzoyl peroxide (BPO-10) cleanser -
1-Covered
benzoyl peroxide (BPO-5) cleanser -)
1-Covered
benzoyl peroxide (CLEAN-CLEARCONTINUOUS CONTROL) 10 cleanser -
1-Covered
benzoyl peroxide (DAYLOGICACNE FOAMING WASH) 10 cleanser
1-Covered
benzoyl peroxide (DAYLOGICACNE TREATMENT) 10 gel (gram)
1-Covered
benzoyl peroxide (FOAMING ACNEFACE WASH) 10 cleanser
1-Covered
benzoyl peroxide (PANOXYL) 10 cleanser
1-Covered
benzoyl peroxide 25 gel (gram)5 cleanser 5 gel (gram) 10 gel (gram) 10 cleanser
1-Covered
CALADRYL (pramoxinehclcalamine) 1-8 LOTION
1-Covered
calcipotriene 0005 cream (g)0005 oint (g) 0005 solution
1-Covered PA
chlorhexidine gluconate 4 liquid 1-Covered
CORTISPORIN(neomycinbacitracinpolymyxinbhydrocortisone) OINTMENT
1-Covered
DIFFERIN (adapalene) 01 GEL 1-Covered AL1 (Up to 25 yrs old)
DRITHOCREME HP (anthralin) 1CREAM
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
67
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DRYSOL (aluminum chloride) DAB--MATIC SLUTIN
1-Covered
EPIFOAM (hydrocortisoneacetatepramoxine hcl)
1-Covered
hydrocortisoneacetatepramoxine hclhydrocortisonepramoxine 1 -1 creamapplhydrocortisonepramoxine 25 -1 cream (g)hydrocortisonepramoxine 25 -1 creamapplhydrocortisonepramoxine 25-1(4g) creamappl
1-Covered
isotretinoin (AMNESTEEM) 10 mgcapsule 20 mg capsule 40 mgcapsule
1-Covered PA
isotretinoin (CLARAVIS) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin (MYORISAN) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin (ZENATANE) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin 10 mg capsule 20 mgcapsule 30 mg capsule 40 mgcapsule
1-Covered PA
LICE KILLING SHAMPOO 1-Covered
metronidazole 075 cream (g)075 gel (gram) 1 gel (gram)
1-Covered
pimecrolimus 1 cream (g) 1-Covered PA
piperonyl butoxidepyrethrins (LICEKILLING) 4-033 shampoo
1-Covered
piperonyl butoxidepyrethrins (LICEPYRINYL SHAMPOO) 4-033shampoo
1-Covered
piperonyl butoxidepyrethrins (LICETREATMENT) 4-033 shampoo
1-Covered
piperonyl butoxidepyrethrins (RID)4-033 shampoo
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
68
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
piperonylbutoxidepyrethrinspermethrin(COMPLETE LICE TREATMENT)butoxpyrethrpermet 4-33-5 kit
1-Covered
piperonylbutoxidepyrethrinspermethrin(LICE SOLUTION)butoxpyrethrpermet 4-33-5 kit
1-Covered
podofilox 05 solution 1-Covered
pramoxine hclcalamine(CALAHIST) 1 -8 lotion
1-Covered
pramoxine hclcalamine(CALAMINE MEDICATED) 1 -8 lotion
1-Covered
PROCTOFOAM-HC (hydrocortisoneacetatepramoxine hcl) PROCTO-1-1
1-Covered
RID (piperonylbutoxidepyrethrinspermethrin) 1-2-3 KIT KIT
1-Covered
SANTYL (collagenase clostridiumhistolyticum) OINTMENT
1-Covered QL (60 PER 30 DAYS)
selenium sulfide (ANTI-DANDRUFF)1 shampoo -
1-Covered
selenium sulfide (MEDICATEDDANDRUFF SHAMPOO) 1 shampoo
1-Covered
selenium sulfide (SELSUN BLUE) 1 shampoo
1-Covered
selenium sulfide 25 lotion 1-Covered
selenium sulfidealoe vera (SELSUNBLUE MOISTURIZING) 1 shampoo
1-Covered
tacrolimus 003 (g) 01 (g) 1-Covered PA
ELECTROLYTESMINERALSMETALSVITAMINS
ELECTROLYTEMINERAL REPLACEMENT09 sodium chloride iv soln 1-Covered PA
calcium carbonate 600 mg tablet 1-Covered
dextrose 5 in water in iv soln 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
69
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levocarnitine 330 mg tablet 1-Covered
potassium chloride in 09 sodiumchloride 09nacl 10 meql iv soln
1-Covered PA
ringers solution iv soln 1-Covered
sodium chloride irrigating solution09 soln
1-Covered
ELECTROLYTEMINERALMETAL MODIFIERSCHEMET (succimer) 100 MGCAPSULE
1-Covered PA
09 sodium chloride iv soln 1-Covered PA
CLINIMIX (amino acids 425 indextrose 5 in water) -SOLUTION
1-Covered PA
dextrose 10 and 045 sodiumchloride nacl -iv soln
1-Covered PA
dextrose 10 in water 10 10 dehp fr bg 10 10 iv soln
1-Covered PA
dextrose 5 and 045 sodiumchloride -04chlord -04iv soln
1-Covered PA
dextrose 5 in water 5 5 ivsoln 5 5 vial
1-Covered PA
levocarnitine (with sugar) 100mgml solution
1-Covered
levocarnitine 100 mgml solution330 mg tablet
1-Covered
MYNATAL (prenatal vitamins withcalciumferrous fumaratefolicacid) CAPSULE
1-Covered
O-CAL PRENATAL (prenatal vit withcalcium no127ferrousfumaratefolic acid) -TABLET
1-Covered
potassium chloride (KLOR-CONM10) meq tab er prt -
1-Covered
potassium chloride (KLOR-CONM20) meq tab er prt -
1-Covered
potassium chloride 8 meq tableter 10 meq tablet er 10 meqcapsule er 10 meq tab er prt 20meq tablet er 20 meq tab er prt20meq15ml liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
70
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
POTASSIUM CHLORIDE ER 8 MEQTABLET 10 (20 MEQ15ML) 10(40 MEQ30ML) ER 10 MEQ TABLETER 20 MEQ TABLET
1-Covered
potassium chloride in 09 sodiumchloride 20 meql soln 40 meqlsoln
1-Covered PA
PRENATABS FA (prenatal vits withcalcium no78ferrousfumaratefolic acid) TABLET
1-Covered
PRENATABS RX (prenatal vitaminwith calciumno76ironcarbonylfolic acid)TABLET
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid (MYNATAL PLUS) vitironfumfolic 65 mg-1 mg tablet
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid (MYNATAL-Z) vitiron fumfolic65 mg-1 mg tablet -
1-Covered
prenatal vits with calcium118ferrous fumaratefolic acid (SE-NATAL 19) pnv no8ironfumaratefa 29 mg-mg tab chew -9)
1-Covered
prenatal vits with calcium136ferrous fumaratefolic acid(VINATE-M) vit36ironfolic acd 27mg-mg tablet -
1-Covered
prenatal vits with calciumno115iron fumaratefolic acidno5ironfolic 29 mg-mg tab chew
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acid(M-NATAL PLUS) pnvcalcium72ironfolic 27 mg-1 mg tablet -
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acid(PREPLUS) pnvcalcium 72ironfolic27 mg-1 mg tablet
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acidpnvcalcium 72ironfolic 27 mg-1mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
71
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
prenatal vits with calciumno72ironcarbonylfolic acidpnvcalcium 72ironcarbfolic 29mg-1 mg tablet
1-Covered
prenatal vits with calciumno74ferrous fumaratefolic acidvitcal 74ironfolic 27 mg-1 mgtablet
1-Covered
SE-NATAL-19 (prenatal vitaminsno119iron fumaratefolic acid) --TABLET
1-Covered
sodium chloride irrigating solution09 soln
1-Covered
sodium polystyrene sulfonate 15g60 ml oral susp
1-Covered
sodium polystyrenesulfonatesorbitol solution (KIONEX)sulfonsorb 15 g60 ml oral susp
1-Covered
SPS (sodium polystyrenesulfonatesorbitol solution) 15GM60 ML SUSPENSION
1-Covered
TRINATE (prenatal vits with calciumno73ferrous fumaratefolic acid)TABLET
1-Covered
VITAMINS09 sodium chloride iv soln 1-Covered PA
ascorbate calcium 500 mg tablet 1-Covered
ascorbic acid (SOOTHINGPUREWAY-C) 500 mg tablet -
1-Covered
ascorbic acid 250 mg tablet 500mg5ml syrup 500 mg tablet 1000mg tablet
1-Covered
CALCIUM 500-VIT D3 MG-MCG TB 1-Covered
CALCIUM 600 MG TABLET 1-Covered
CALCIUM 600-VIT D3 MG-10MCGTB
1-Covered
calcium carbonate (OYSCO-500)500(1250) tablet -
1-Covered
calcium carbonate (SUPERCALCIUM) 600 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
72
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcium carbonate 500(1250)tablet 600 mg tablet
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (HI-CAL)carbonatevitamin 500 mg-200tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OS-CAL 500-VIT D3)carbonatevitamin mg-200 tablet --
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OYSCO 500-VIT D3)carbonatevitamin mg-200 tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OYSTERCAL-D)carbonatevitamin 500 mg-400tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) carbonatevitamin250 mg-125 tabletcarbonatevitamin 500 mg-600tablet carbonatevitamin 500 mg-400 tablet carbonatevitamin 500mg-200 tablet carbonatevitamin600 mg-400 tablet
1-Covered
calcium gluconate 60(650) mgtablet
1-Covered
calcium lactate 84 mg(648) tablet 1-Covered
cyanocobalamin (vitamin b-12) (B-12 DOTS) cyanocoalamin -) 500mcg talet -
1-Covered
cyanocobalamin (vitamin b-12)cyanocoalamin -500 mcg talet
1-Covered
dextrose 10 in water iv soln 1-Covered PA
dextrose 5 and 045 sodiumchloride -04chlord -04iv soln
1-Covered PA
dextrose 5 in lactated ringers -ivsoln
1-Covered PA
dextrose 5 in water in iv soln 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
73
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DEXTROSE IN WATER 5-IV SOLN10-IV SOLUTION
1-Covered PA
electrolytesdextrose(ELECTROLYTE) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (ORALYTE)solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (PEDIATRICELECTROLYTE) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (PEDIATRICFREEZER POPS) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
ferrous sulfate (CHILDRENS IRON)15 mgml drops
1-Covered
ferrous sulfate (FEOSOL) 325(65)mg tablet
1-Covered
ferrous sulfate (FEROSUL) 325(65)mg tablet
1-Covered
ferrous sulfate (FERRO-TIME) 325(65)mg tablet -
1-Covered
ferrous sulfate (FERROUSUL) 325(65)mg tablet
1-Covered
ferrous sulfate (PEDIA IRON) 15mgml drops
1-Covered
ferrous sulfate 15 mgml drops 220(44)5 solution 220 (44)5 elixir324(65)mg tablet dr 325(65) mgtablet dr 325(65) mg tablet
1-Covered
FERROUS SULFATE SULF 220 MG5ML LIQ SULF EC 325 MG TABLETSULFATE 325 MG TABLET
1-Covered
fluoride (sodium) 025(055) tabchew 05(11)mg tab chew 05mgml drops 1mg(22mg) tabchew
1-Covered STAR (Preferred Drug)
folic acid 04 mg tablet 08 mgtablet 1 mg tablet 20 mg capsule
1-Covered
FOLIC ACID 400 MCG TABLET 800MCG TABLET
1-Covered
IRON 65 MG TABLET 1-Covered
OYSTER SHELL CALCIUM 500 MG TB 1-Covered
OYSTER SHELL CALCIUM-VIT D3 250MG-312MCG
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
74
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PEDIATRIC IRON PHARM CHC15MGML DRP
1-Covered
pediatric multivit with acd3no21sodium fluorideno21fluoride 025 mgml dropsno21fluoride 05 mgml drops
1-Covered STAR (Preferred Drug)
pediatric multivitaminno16sodium fluoride -025 mg tabche -05 mg tab che -1 mg tabche
1-Covered
pediatric multivitamin no2sodiumfluoride w-025 mgml drops
1-Covered
pediatric multivitamin no2sodiumfluoride w-05 mgml drops
1-Covered STAR (Preferred Drug)
pediatric multivitaminno45sodium fluorideferroussulfate 45fluorideiron 025-10mldrops
1-Covered STAR (Preferred Drug)
pediatric multivitamins no17 withsodium fluoride -025 mg tab che -05 mg tab che -1 mg tab che
1-Covered STAR (Preferred Drug)
POLY-VITAMIN (multivitamin) -TABCHEW
1-Covered STAR (Preferred Drug)
POTASSIUM 99 MG TABLET 1-Covered
potassium bicarbonatecitric acid(EFFER-K) 25 meq tablet eff -
1-Covered
potassium bicarbonatecitric acid(K EFFERVESCENT) 25 meq tableteff
1-Covered
potassium bicarbonatecitric acid(KLOR-CON-EF) 25 meq tablet eff --
1-Covered
potassium bicarbonatecitric acid25 meq tablet eff
1-Covered
POTASSIUM CHL-NORMAL SALINE20 -ML IV SOLN 40 -ML IV SOLN
1-Covered
potassium chloride (KLOR-CONSPRINKLE) 10 meq capsule er -
1-Covered
potassium chloride 20meq15mlliquid
1-Covered
potassium chloridepotassiumbicarbonatecitric acidchloridebicarbcit 25 meq tableteff
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
75
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
potassium gluconate 595(99)mgtablet
1-Covered
PRENATAL MULTIVITAMIN TABLET 1-Covered
prenatal vit with calciumno129ferrous fumaratefolic acidno129ironfolic 27mg-08mgtablet
1-Covered
prenatal vit with calciumno130ferrous fumaratefolic acidno130ironfolic 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vitamins no121ferrousfumaratefolic acid pnvno121ironfolic 28mg-08mgtablet
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid vitiron fumfolic 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vitamins withcalciumferrous fumaratefolicacid vitiron fumfolic 28mg-08mgtablet
1-Covered
prenatal vits with calcium118ferrous fumaratefolic acidpnv no8iron fumaratefa 29 mg-mg tab chew
1-Covered
prenatal vits with calcium137ferrous fumaratefolic acidno137ironfolic acd 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vits with calcium95ferrous fumaratefolic acid pnvno95ferrous fumfolic 28mg-08mg tablet
1-Covered
prenatal vits with calciumno96ferrous fumaratefolic acidvits96iron fumfolic 27mg-08mgtablet
1-Covered
pyridoxine hcl (vitamin b6) 25 mgtablet 50 mg tablet 100 mgtablet 250 mg tablet
1-Covered
ringers solution iv soln 1-Covered PA
SODIUM CHLORIDE 09 IRRIG 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
76
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SODIUM CHLORIDE 09 SOLUTION 1-Covered PA
sodium chloride irrigating solution(AQUA CARE SODIUM CHLORIDE)09 soln
1-Covered
sodium chloride irrigating solution(CURITY) 09 soln
1-Covered
sodium chloride irrigating solution09 soln
1-Covered
TRI-VI-SOL (vitamin apalmitateascorbicacidcholecalciferol (vit d3)) --DROPS (vitmin plmittescorbiccidcholeclciferol
1-Covered STAR (Preferred Drug)
VITAMIN B-12 -500 MCG TALET 1-Covered
VITAMIN C 1000 MG TABLET 1-Covered
GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach)
ANTISPASMODICS GASTROINTESTINAL (Drugs to Prevent Bowel andStomach Spasam)
CHLORDIAZEPOXIDE-CLIDINIUM -CAP
1-Covered MDD (8 Per Day)
chlordiazepoxideclidiniumbromide 5 mg-25mg capsule
1-Covered MDD (8 Per Day)
DICYCLOMINE HCL 10 MG5 MLSOLN
1-Covered
dicyclomine hcl 10 mg5 mlsolution 10 mg capsule 20 mgtablet
1-Covered
hyoscyamine sulfate (HYOSYNE)0125mgml drops 125mcg5mlelixir
1-Covered
hyoscyamine sulfate 0125 mg tabsubl 0125 mg tablet 0125mgmldrops 0375 mg tab er 12h125mcg5ml elixir
1-Covered
propantheline bromide 15 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
77
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GASTROINTESTINAL AGENTS OTHER (Other Drugs for the Bowel andStomach)
ALLI (orlistat) 60 MG CAPSULE 1-Covered PA
ANTACID 500 MG CHEW TABLET 1-Covered
ANTACID EXTRA STRENGTH -750 MGTAB CHEW CVS -750 MG CHEW
1-Covered
ANTI-DIARRHEAL HM -2 MGSOFTGEL
1-Covered
bismuth subsalicylate (BISMATROL)262 mg tab chew
1-Covered
bismuth subsalicylate (DIOTAME)262 mg tab chew
1-Covered
bismuth subsalicylate (PEP-T-MED)262 mg tab chew --
1-Covered
bismuth subsalicylate (PEPTICRELIEF) 262 mg tab chew
1-Covered
bismuth subsalicylate (PINKBISMUTH) 262 mg tab chew
1-Covered
bismuth subsalicylate (SOOTHE)262 mg tab chew
1-Covered
bismuth subsalicylate (STOMACHRELIEF) 262 mg tab chew
1-Covered
bismuth subsalicylate 262 mg tabchew
1-Covered
calcium carbonate (ANTACIDCALCIUM) 215(500)mg tab chew
1-Covered
calcium carbonate (ANTACIDEXTRA STRENGTH) 300mg(750) tabchew
1-Covered
calcium carbonate (ANTACID)200(500)mg tab chew 215(500)mgtab chew 300mg(750) tab chew
1-Covered
calcium carbonate (BAN-ACID)300mg(750) tab chew -
1-Covered
calcium carbonate (CAL-GEST)200(500)mg tab chew -
1-Covered
calcium carbonate (CALCIUMANTACID) 200(500)mg tab chew215(500)mg tab chew 300mg(750)tab chew
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
78
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcium carbonate (CHILDRENSPEPTO) 400 mg tab chew
1-Covered
calcium carbonate (CHILDRENSSOOTHE) 400 mg tab chew
1-Covered
calcium carbonate (FLAVORCHEWS ANTACID) 300mg(750) tabchew
1-Covered
calcium carbonate (SMOOTHANTACID) 300mg(750) tab chew
1-Covered
calcium carbonate (SMOOTHDISSOLVING ANTACID) 300mg(750)tab chew
1-Covered
calcium carbonate 200(500)mgtab chew 300mg(750) tab chew
1-Covered
diphenoxylate hclatropine sulfate25-0255 liquid 25-025mg tablet
1-Covered
DIPHENOXYLATE-ATROPINE -25-0025
1-Covered
GAS RELIEF (simethicone) (SIMETH)80 MG CHEW
1-Covered
GAS RELIEF GAS 125 MG CHEWTABLET GAS (SIMETH) 80 MGCHEW HM GAS 125 MG SOFTGELHM GAS 125 MG CHEW TAB
1-Covered
GAS-X (simethicone) -E-STR 125 MGTAB CHEW
1-Covered
INFANTS GAS RELIEF RLF 20 MG03ML
1-Covered
loperamide hcl (ANTI-DIARRHEAL) 2mg capsule - 2 mg tablet -
1-Covered
loperamide hcl (DIAMODE) 2 mgtablet
1-Covered
loperamide hcl (ULTRA A-D) 2 mgtablet -
1-Covered
loperamide hcl 1 mg5 ml liquid 2mg capsule 2 mg tablet
1-Covered
PEPTO-BISMOL (bismuthsubsalicylate) -TABLET CHEW
1-Covered
PEPTO-BISMOL TO-GO (bismuthsubsalicylate) --262 MG CHEW
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
79
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
simethicone (GAS RELIEF)40mg06ml drops susp 80 mg tabchew 125 mg tab chew 125 mgcapsule
1-Covered
simethicone (GAS-X) 125 mgcapsule -
1-Covered
simethicone (INFANT GAS RELIEF)40mg06ml drops susp
1-Covered
simethicone (INFANTS GAS RELIEF)40mg06ml drops susp
1-Covered
simethicone (MI-ACID) 80 mg tabchew -
1-Covered
simethicone 40mg06ml dropssusp 80 mg tab chew 125 mgcapsule 125 mg tab chew
1-Covered
STOMACH RELIEF 262 MG CHEWTAB
1-Covered
ursodiol 300 mg capsule 1-Covered
HISTAMINE2 (H2) RECEPTOR ANTAGONISTSACID CONTROLLER 20 MG TABLET 1-Covered
ACID REDUCER 10 MG TABLET 1-Covered PA
ACID REDUCER 20 MG TABLET 1-Covered
cimetidine (ACID REDUCER) 200mg tablet
1-Covered
cimetidine (HEARTBURN RELIEF) 200mg tablet
1-Covered
cimetidine 200 mg tablet 300 mgtablet 400 mg tablet 800 mgtablet
1-Covered
CIMETIDINE 300 MG5 ML SOLN 1-Covered
cimetidine hcl 300 mg5ml solution 1-Covered
famotidine (ACID CONTROLLER) 10mg tablet
1-Covered PA
famotidine (ACID CONTROLLER) 20mg tablet
1-Covered
famotidine (ACID REDUCER) 10 mgtablet
1-Covered PA
famotidine (ACID REDUCER) 20 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
80
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
famotidine (HEARTBURNPREVENTION) 10 mg tablet
1-Covered PA
famotidine (HEARTBURNPREVENTION) 20 mg tablet
1-Covered
famotidine (HEARTBURN RELIEF) 10mg tablet
1-Covered PA
famotidine (HEARTBURN RELIEF) 20mg tablet
1-Covered
famotidine (PEPCID) 20 mg tablet 1-Covered
famotidine 10 mg tablet 1-Covered PA
FAMOTIDINE 10 MG TABLET 1-Covered PA
famotidine 20 mg tablet 40 mgtablet
1-Covered
FAMOTIDINE 20 MG TABLET EQ 20MG TABLET 40 MG TABLET
1-Covered
IRRITABLE BOWEL SYNDROME AGENTSAMITIZA (lubiprostone) 8 MCGCAPSULE 24 MCG CAPSULES
1-Covered PA
LAXATIVES (Drugs for Bowel Cleansing and Constipation)bisacodyl (ALOPHEN PILLS) 5 mgtablet dr
1-Covered
bisacodyl (BISA-LAX) 5 mg tablet dr-
1-Covered
bisacodyl (BISACODYL) 5 mgtablet dr
1-Covered
bisacodyl (BISCOLAX) 10 mgsupprect
1-Covered
bisacodyl (C-LAX LAXATIVE) 5 mgtablet dr -ATIVE)
1-Covered
bisacodyl (DUCODYL) 5 mg tabletdr
1-Covered
bisacodyl (FAST RELIEF LAXATIVE)10 mg supprect
1-Covered
bisacodyl (GENTLE LAXATIVE) 5 mgtablet dr 10 mg supprect
1-Covered
bisacodyl (LAXATIVE SUPPOSITORY)10 mg supprect
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
81
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
bisacodyl (LAXATIVE) 5 mg tabletdr
1-Covered
bisacodyl (MAGIC BULLET) 10 mgsupprect
1-Covered
bisacodyl (WOMENS GENTLELAXATIVE) 5 mg tablet dr
1-Covered
bisacodyl (WOMENS LAXATIVE) 5mg tablet dr
1-Covered
bisacodyl 5 mg tablet dr 10 mgsupprect
1-Covered
BISACODYL EC 5 MG TABLET 10MG SUPPOSITORY
1-Covered
docusate sodium (COL-RITE) 100mg capsule - 250 mg capsule -
1-Covered
docusate sodium (DIOCTYL) 60mg15ml syrup
1-Covered
docusate sodium (DOCU LIQUID)50 mg5 ml liquid
1-Covered
docusate sodium (DOCUSIL) 100mg capsule
1-Covered
docusate sodium (DSS) 250 mgcapsule
1-Covered
docusate sodium (DULCOEASE)100 mg capsule
1-Covered
docusate sodium (DULCOLAXSTOOL SOFTENER) 100 mg capsule
1-Covered
docusate sodium (LAXA BASIC 100)mg capsule )
1-Covered
docusate sodium (PHILLIPSLAXATIVE) 100 mg capsule
1-Covered
docusate sodium (SOF-LAX) 100mg capsule -
1-Covered
docusate sodium (STOOLSOFTENER) 50 mg capsule 50 mg5ml liquid 60 mg15ml syrup 100mg capsule 250 mg capsule
1-Covered
DOCUSATE SODIUM 50 MG5 MLLIQ 100 MG SOFTGEL
1-Covered
docusate sodium 50 mg5 mlliquid 60 mg15ml syrup 100 mgcapsule 250 mg capsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
82
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DOK (docusate sodium) 100 MG250 MG
1-Covered
GENTLE LAXATIVE 10 MG SUPPOSIT 1-Covered
glycerin (ADULT GLYCERIN) adultsupprect
1-Covered
glycerin (LAXATIVE SUPPOSITORY)pediatric supprect
1-Covered
glycerin (PEDIA-LAX) pediatricsupprect -
1-Covered
glycerin (SUPPOSITORY) adultsupprect
1-Covered
glycerin adult pediatric 1-Covered
lactulose (CONSTULOSE) 10 g15 mlsolution
1-Covered
lactulose (ENULOSE) 10 g15 mlsolution
1-Covered
lactulose (GENERLAC) 10 g15 mlsolution
1-Covered
lactulose 10 g15 ml 20 g30 ml 1-Covered
MAGNESIUM CITRATE HM SOLUTION 1-Covered
magnesium citrate solution 1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloride(GAVILYTE-C) peg3350sodsulfbicarbclkcl 240-2272g solnrecon -
1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloride(GAVILYTE-G) peg3350sodsulfbicarbclkcl 236-2274g solnrecon -
1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloridepeg3350sod sulfbicarbclkcl 236-2274g soln peg3350sodsulfbicarbclkcl 240-2272g soln
1-Covered
PEG-3350 AND ELECTROLYTES -SOLN
1-Covered
polyethylene glycol 3350(CLEARLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
83
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
polyethylene glycol 3350(GAVILAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(GENTLELAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(GLYCOLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(LAXACLEAR) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350 (NATURA-LAX) 17gdose powder -
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(POWDERLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(PURELAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(SMOOTHLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350 17gdosepowder
1-Covered QL (527 PER 30 DAY(S))
SILACE (docusate sodium) 50MG5 ML LIQUID
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepeg (GAVILYTE-N)chloridenahco3kclpeg 420gsoln recon -
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepeg (TRILYTE WITH FLAVORPACKETS)chloridenahco3kclpeg 420gsoln recon
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepegchloridenahco3kclpeg 420gsoln recon
1-Covered
STOOL SOFTENER (docusatesodium) 100 MG SOFTGEL 100 MGCAPSULE 250 MG SOFTGEL
1-Covered
STOOL SOFTENER HM 100 MGSFTGL 100 MG SOFTGEL HM 250MG SFTGL
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
84
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PROTECTANTSmisoprostol 100 mcg tablet 200mcg tablet
1-Covered PA
sucralfate 1 g tablet 1-Covered
PROTON PUMP INHIBITORSlansoprazole 15 mg capsule dr 1-Covered ST
lansoprazole 30 mg capsule dr 1-Covered
LANSOPRAZOLE DR 15 MGCAPSULE
1-Covered ST
LANSOPRAZOLE DR 30 MGCAPSULE
1-Covered
omeprazole 10 mg capsule dr 20mg tablet dr
1-Covered
omeprazole 20 mg capsule dr 1-Covered QL (60 PER 30 DAYS)
omeprazole 40 mg capsule dr 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
OMEPRAZOLE DR 20 MG CAPSULE 1-Covered QL (60 PER 30 DAYS)
OMEPRAZOLE DR 20 MG TABLET 1-Covered
pantoprazole sodium 20 mg tabletdr 40 mg tablet dr
1-Covered
PANTOPRAZOLE SODIUM DR 20 MGTAB DR 40 MG TAB
1-Covered
PREVACID (lansoprazole) DR 15MG CAPSULE
1-Covered
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERSTREATMENT (Drugs for Genetic or Enzyme Disorders)
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERSTREATMENT
CREON (lipaseproteaseamylase)DR 6000 UNITS CAPSULE
1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
85
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GENITOURINARY AGENTS (Drugs for the Genital Bladder andKidney)
ANTISPASMODICS URINARY (Drugs for Bladder Spasms)oxybutynin chloride 5 mg5 mlsyrup 5 mg tab er 24 5 mg tablet10 mg tab er 24 15 mg tab er 24
1-Covered
OXYBUTYNIN CHLORIDE ER ER 5 MGTABLET ER 10 MG TABLET ER 15 MGTABLET
1-Covered
OXYTROL FOR WOMEN(oxybutynin) 39 MG24HR
1-Covered ST
trospium chloride 20 mg tablet 1-Covered ST
TROSPIUM CHLORIDE 20 MG TABLET 1-Covered ST
BENIGN PROSTATIC HYPERTROPHY AGENTSalfuzosin hcl 10 mg tab er 24h 1-Covered PA
finasteride 5 mg tablet 1-Covered
tamsulosin hcl 04 mg capsule 1-Covered
GENITOURINARY AGENTS OTHER (Other Drugs for the GenitalBladder and Kidney)
bethanechol chloride 5 mg tablet10 mg tablet 25 mg tablet 50 mgtablet
1-Covered
citric acidsodium citrate (CYTRA-2) 334-500mg solution -
1-Covered
citric acidsodium citrate(VIRTRATE-2) 334-500mg solution -
1-Covered
citric acidsodium citrate 334-500mg solution
1-Covered
nonoxynol 9 (VCF) 125 foamappl
1-Covered
penicillamine 250 mg capsule 1-Covered PA QL (16 PER 1 DAY(S))
PENICILLAMINE 250 MG CAPSULE 1-Covered PA QL (16 PER 1 DAY(S))
phenazopyridine hcl (URINARYPAIN RELIEF) 95 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
86
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PHENAZOPYRIDINE HCL 100 MGTAB 200 MG TAB
1-Covered
phenazopyridine hcl 100 mgtablet 200 mg tablet
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit ac(CYTRA-3) sodpotk citsod citcitacid 500-5505 solution -
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit ac(TRICITRATES) sodpotk citsodcitcit acid 500-5505 solution
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit acsodpotk citsod citcit acid 500-5505 solution
1-Covered
URINARY PAIN RELIEF HM RLF 95 MGTAB
1-Covered
PHOSPHATE BINDERScalcium acetate (ELIPHOS) 667 mgtablet
1-Covered QL (270 PER 30 DAYS) AL1 (Atleast 21 yrs old)
calcium acetate 667 mg capsule667 mg tablet
1-Covered QL (270 PER 30 DAYS) AL1 (Atleast 21 yrs old)
lanthanum carbonate 500 mg tabchew 750 mg tab chew 1000 mgtab chew
1-Covered PA
sevelamer carbonate 800 mgtablet
1-Covered PA
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(ADRENAL) (Drugs for ReplacingStimulating Adrenal GlandHormones)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(ADRENAL) (Glucocorticoids)
betamethasone dipropionate 005 lotion
1-Covered
betamethasone dipropionate 005 oint (g) 005 cream (g)
1-Covered ST
BETAMETHASONE DIPROPIONATEDP 005 OINT
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
87
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
betamethasonedipropionatepropylene glycolbetamethasonepropylene 005 cream (g)
1-Covered ST
betamethasone valerate 01 lotion 01 cream (g) 01 oint(g)
1-Covered
clobetasol propionate 005 gel(gram) 005 solution 005 cream (g) 005 oint (g)
1-Covered ST
CLOBETASOL PROPIONATE 005CREAM
1-Covered ST
DELTASONE (prednisone) 20 MGTABLET
1-Covered
desonide 005 lotion 005 oint(g) 005 cream (g)
1-Covered ST
DESONIDE 005 LOTION 005CREAM
1-Covered ST
dexamethasone(DEXAMETHASONE INTENSOL) 1mgml drops
1-Covered
dexamethasone 05 mg5mlsolution 05 mg tablet 05 mg5mlelixir 075 mg tablet 1 mg tablet15 mg tablet 2 mg tablet 4 mgtablet 6 mg tablet
1-Covered
DEXAMETHASONE 4 MG TABLET 1-Covered
fludrocortisone acetate 01 mgtablet
1-Covered
fluocinolone acetonide 001 cream (g) 001 solution 0025 cream (g) 0025 oint (g)
1-Covered ST
fluocinonide 005 cream (g) 005 gel (gram) 005 oint (g) 005 solution
1-Covered
FLUOCINONIDE 005 OINTMENT 1-Covered
hydrocortisone (ANTI-ITCH) 1 cream (g) -
1-Covered
hydrocortisone (ANUSOL-HC) 25 crmpe app -
1-Covered
hydrocortisone (CORTISONE) 1 cream (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
88
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
hydrocortisone (CORTIZONE-10PLUS) cream (g) -0
1-Covered
hydrocortisone (CORTIZONE-10) cream (g) -
1-Covered
hydrocortisone (HYDROCREAM) 1 cream (g)
1-Covered
hydrocortisone (NOBLE FORMULAHC) 1 cream (g)
1-Covered
hydrocortisone (PREPARATION H) 1 cream (g)
1-Covered
hydrocortisone (PROCTO-MED HC)25 crmpe app -
1-Covered
hydrocortisone (PROCTO-PAK) 1 crmpe app -
1-Covered
hydrocortisone (PROCTOSOL-HC)25 crmpe app -
1-Covered
hydrocortisone (PROCTOZONE-HC)25 crmpe app -
1-Covered
hydrocortisone (SOOTHING CARE)1 cream (g)
1-Covered
hydrocortisone 05 oint (g) 1 cream (g) 1 oint (g) 1 crmpe app 25 cream (g) 25 crmpe app 25 oint (g) 25 lotion 5 mg tablet 10 mg tablet20 mg tablet
1-Covered
HYDROCORTISONE 5 MG TABLET10 MG TABLET
1-Covered
hydrocortisone acetate(ANUCORT-HC) 25 mg supprect -
1-Covered
hydrocortisone acetate (ANUSOL-HC) 25 mg supprect -
1-Covered
hydrocortisone acetate(HEMMOREX-HC) 25 mg supprect -
1-Covered
HYDROCORTISONE ACETATE 25 MGSUPP
1-Covered
hydrocortisone acetate 25 mgsupprect
1-Covered
methylprednisolone 4 mg tablet 4mg tab ds pk 8 mg tablet 16 mgtablet 32 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
89
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
mometasone furoate 01 cream(g) 01 oint (g)
1-Covered
prednisolone (MILLIPRED DP) 5 mg(48) tab 5 mg (21) tab
1-Covered
prednisolone (MILLIPRED) 5 mgtablet
1-Covered
prednisolone 15 mg5 ml solution 1-Covered
prednisolone sodium phosphate 5mg5 ml 15 mg5 ml
1-Covered
prednisone (PREDNISONEINTENSOL) 5 mgml oral conc
1-Covered
prednisone 1 mg tablet 25 mgtablet 5 mg tab ds pk 5 mgtablet 5 mg5 ml solution 10 mgtablet 10 mg tab ds pk 20 mgtablet 50 mg tablet
1-Covered
triamcinolone acetonide 0025 oint (g) 0025 cream (g) 0025 lotion 01 cream (g) 01 lotion 01 oint (g) 0147mggaerosol 05 cream (g) 05 oint(g)
1-Covered
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(PITUITARY) (Drugs for ReplacingStimulating Pituitary GlandHormones)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(PITUITARY) (Drugs to ReplaceStimulate Pituitary Gland Hormones)
desmopressin acetate (non-refrigerated) (nonrefrigerated)10spray spraypump
1-Covered PA AL1 (8 to 14 yrs old)
desmopressin acetate 01 mgmlsolution 01 mg tablet 02 mgtablet
1-Covered AL1 (8 to 14 yrs old)
desmopressin acetate 4 mcgmlvial 4 mcgml ampul 10sprayspraypump
1-Covered PA AL1 (8 to 14 yrs old)
DESMOPRESSIN ACETATE 40MCG10 ML VIAL
1-Covered PA AL1 (8 to 14 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
90
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEXHORMONESMODIFIERS) (Drugs for ReplacingStimulating SexHormones)
ANDROGENSdanazol 50 mg capsule 100 mgcapsule 200 mg capsule
1-Covered
fluoxymesterone (ANDROXY) 10mg tablet
1-Covered
testosterone 125125g gel mdpmp 50 mg (1) gel packet
1-Covered PA
testosterone cypionate 100 mgmlvial 200 mgml vial
1-Covered PA
ESTROGENS (Contraceptives and Drugs for Menopause)desogestrel-ethinyl estradiol (APRI)-015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(CYRED EQ) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(CYRED) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(EMOQUETTE) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(ENSKYCE) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(ISIBLOOM) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(JULEBER) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(KALLIGA) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(RECLIPSEN) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol -015-003 tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (AZURETTE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
91
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
desogestrel-ethinyl estradiolethinylestradiol (BEKYREE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (KARIVA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (KIMIDESS) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (PIMTREA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (SIMLIYA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (VIORELE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (VOLNEA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol -eestradioleestradiol 21-5 (28) tablet
1-Covered
DROSPIRENONE-ETHINYL ESTRADIOL-EE 3-002 MG TAB
1-Covered
estradiol (DOTTI) 025mg24hpatch 0375mg24 patch005mg24h patch 075mg24hpatch 01mg24hr patch
1-Covered QL (16 PER 28 DAY(S))
estradiol 025mg24h patch0375mg24 patch 005mg24hpatch 075mg24h patch01mg24hr patch
1-Covered QL (16 PER 28 DAY(S))
estradiol 001 creamappl025mg24h patch tdwk005mg24h patch tdwk075mg24h patch tdwk01mg24hr patch tdwk 05 mgtablet 1 mg tablet 2 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
92
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ESTRADIOL 1 MG TABLET 2 MGTABLET
1-Covered
estrogensesterifiedmethyltestosterone (COVARYX HS)estrogenesterme-0625-125tablet
1-Covered PA
estrogensesterifiedmethyltestosterone (EEMT HS) estrogenesterme-0625-125 tablet
1-Covered PA
estrogensesterifiedmethyltestosterone estrogenesterme-0625-125tablet
1-Covered PA
ethinyl estradioldrospirenone(GIANVI) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(JASMIEL) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone (LO-ZUMANDIMINE) 002-3(28) tablet -
1-Covered
ethinyl estradioldrospirenone(LORYNA) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(NIKKI) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(VESTURA) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone 002-3(28) tablet
1-Covered
ethynodiol diacetate-ethinylestradiol (KELNOR 1-35) ethynoiol -estraiol mg-35mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol (KELNOR 1-50) ethynoiol -estraiol mg-50mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol (ZOVIA 1-35E) ethynoiol -estraiol mg-35mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol ethynoiol -estraiol 1 mg-50mcg tablet ethynoiol -estraiol 1mg-35mcg tablet
1-Covered
etonogestrelethinyl estradiol(ELURYNG) 12-015mg vag ring
1-Covered QL (1 PER 28 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
93
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
etonogestrelethinyl estradiol 12-015mg vag ring
1-Covered QL (1 PER 28 DAY(S))
HAILEY FE 1-20 TABLET 15-30 TABLET 1-Covered
LEVONORGESTREL-ETH ESTRADIOL -TRIPHASIC
1-Covered
levonorgestrelethinyl estradiol(AFIRMELLE)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(ALTAVERA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(AUBRA EQ)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AUBRA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AVIANE)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AYUNA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(CHATEAL EQ)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(CHATEAL)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(DELYLA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(ENPRESSE)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
94
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrelethinyl estradiol(FALMINA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(KURVELO)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(LARISSIA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(LESSINA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(LEVONEST)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
levonorgestrelethinyl estradiol(LEVORA-28)levonorgestrelethinestradiol 015-003 tablet -
1-Covered
levonorgestrelethinyl estradiol(LILLOW)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(LUTERA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(MARLISSA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(MYZILRA)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
levonorgestrelethinyl estradiol(ORSYTHIA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
95
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrelethinyl estradiol(PORTIA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(SRONYX)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(TRIVORA-28)levonorgestrelethinestradiol 6-5-10 tablet -
1-Covered
levonorgestrelethinyl estradiol(VIENVA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiollevonorgestrelethinestradiol 01-002mg tabletlevonorgestrelethinestradiol 015-003 tabletlevonorgestrelethinestradiol 6-5-10 tablet
1-Covered
LYLLANA 0025 MG PATCH 00375MG PATCH 005 MG PATCH 0075MG PATCH 01 MG PATCH
1-Covered QL (16 PER 28 DAY(S))
MENEST (estrogensesterified) 03MG TABLET 0625 MG TABLET 125MG TABLET 25 MG TABLET
1-Covered
MICROGESTIN 21 1-20 TABLET 1-Covered
MICROGESTIN FE 1-20 TABLET 1-Covered
norelgestrominethinyl estradiol(XULANE)norelgestrominethinestradiol 150-3524h patch tdwk
1-Covered QL (3 PER 28 DAY(S))
norethindrone acetate-ethinylestradiol (AUROVELA) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (GILDESS) -15-003mgtablet
1-Covered
norethindrone acetate-ethinylestradiol (HAILEY) -15-003mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
96
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone acetate-ethinylestradiol (JUNEL) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (LARIN) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (MICROGESTIN) -1mg-20mcg tablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol -1mg-20mcg tablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate(AUROVELA FE) -eestradiol-iron15-30(21) tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (BLISOVIFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (JUNELFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (LARINFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate(MICROGESTIN FE) --1mg-20(21)tablet --15-30(21) tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TARINAFE 1-20 EQ) -eestradiol-iron mg-(2)tablet -
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TARINAFE) -eestradiol-iron 1mg-20(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TILIA FE)-eestradiol-iron 5-7-9-7 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
97
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone acetate-ethinylestradiolferrous fumarate (TRI-LEGEST FE) -eestradiol-iron 5-7-9-7tablet -
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate --1mg-20(21) tablet --15-30(21) tablet
1-Covered
norethindrone-ethinyl estradiol(ALYACEN) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(ARANELLE) -ethin 7-9-5 tablet
1-Covered
norethindrone-ethinyl estradiol(BALZIVA) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(BRIELLYN) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(CYCLAFEM) -1 mg-35mcg tablet -7 days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(DASETTA) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(LEENA) -ethin 7-9-5 tablet
1-Covered
norethindrone-ethinyl estradiol(NECON) -ethin 05-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(NORTREL) -05-0035 tablet -1 mg-35mcg tablet -7 days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(PHILITH) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(PIRMELLA) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(VYFEMLA) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(WERA) -ethin 05-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(ZENCHENT) -ethin 04-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(ESTARYLLA) -025-0035 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
98
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norgestimate-ethinyl estradiol(FEMYNOR) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(MILI) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(MONO-LINYAH) -025-0035 tablet -
1-Covered
norgestimate-ethinyl estradiol(MONONESSA) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(PREVIFEM) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(SPRINTEC) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol (TRIFEMYNOR) -7daysx3 28 tablet
1-Covered
norgestimate-ethinyl estradiol (TRI-ESTARYLLA) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-LINYAH) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-ESTARYLLA) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-MARZIA) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-MILI) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-SPRINTEC) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-PREVIFEM) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-SPRINTEC) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-VYLIBRA LO) -7daysx3 lo tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-VYLIBRA) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol(TRINESSA LO) -7daysx3 lo tablet
1-Covered
norgestimate-ethinyl estradiol(TRINESSA) -7daysx3 28 tablet
1-Covered
norgestimate-ethinyl estradiol(VYLIBRA) -025-0035 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
99
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NORGESTIMATE-ETHINYL ESTRADIOL-025-0035 MG
1-Covered
norgestimate-ethinyl estradiol -025-0035 tablet -7daysx3 28tablet -7daysx3 lo tablet
1-Covered
norgestrel-ethinyl estradiol(CRYSELLE) -03-003mg tablet
1-Covered
norgestrel-ethinyl estradiol (ELINEST)-03-003mg tablet
1-Covered
norgestrel-ethinyl estradiol (LOW-OGESTREL) -03-003mg tablet -
1-Covered
norgestrel-ethinyl estradiol(OGESTREL) -05 mg-50 tablet
1-Covered
PREMARIN (estrogens conjugated)03 MG TABLET 045 MG TABLET0625 MG TABLET 09 MG TABLET125 MG TABLET
1-Covered
PREMARIN (estrogens conjugated)VAGINAL CREAM-APPL
1-Covered QL (43 PER 30 DAY(S))
PREMPHASE (estrogensconjugatedmedroxyprogesteroneacetate) 0625-5 MG TABLET
1-Covered
PREMPRO (estrogensconjugatedmedroxyprogesteroneacetate) 03 MG-15 MG TABLET045-15 MG TABLET 0625-5 MGTABLET 0625-25 MG TABLET
1-Covered
ZOVIA 1-35 -TABLET 1-Covered
PROGESTINSDEPO-PROVERA(medroxyprogesterone acetate) -400 MGML VIAL
1-Covered
DEPO-SUBQ PROVERA 104(medroxyprogesterone acetate) -SYRINGE
1-Covered
hydroxyprogesterone caproate250 mgml vial
1-Covered PA SP
hydroxyprogesterone caproatepfcaproatpf 250 mgml vial
1-Covered PA SP
JENCYCLA 035 MG TABLET 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
100
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrel (AFTERA) 15 mgtablet
1-Covered
levonorgestrel (ECONTRA EZ) 15mg tablet
1-Covered
levonorgestrel (ECONTRA ONE-STEP) 15 mg tablet -
1-Covered
levonorgestrel (FALLBACK SOLO)15 mg tablet
1-Covered
levonorgestrel (MY CHOICE) 15mg tablet
1-Covered
levonorgestrel (MY WAY) 15 mgtablet
1-Covered
levonorgestrel (NEW DAY) 15 mgtablet
1-Covered
levonorgestrel (OPCICON ONE-STEP) 15 mg tablet -
1-Covered
levonorgestrel (OPTION 2) 15 mgtablet
1-Covered
levonorgestrel (TAKE ACTION) 15mg tablet
1-Covered
levonorgestrel 15 mg tablet 1-Covered QL (1 PER 1 DAYS)
MEDROXYPROGESTERONE ACETATE150 MGML
1-Covered QL (1 PER 84 DAYS)
medroxyprogesterone acetate 150mgml vial 150 mgml syringe
1-Covered QL (1 PER 84 DAYS)
MEDROXYPROGESTERONE ACETATE25 MG TAB
1-Covered
medroxyprogesterone acetate 25mg tablet 5 mg tablet 10 mgtablet
1-Covered
megestrol acetate 20 mg tablet40 mg tablet
1-Covered
megestrol acetate 400mg10mloral susp
1-Covered PA
norethindrone (CAMILA) 035 mgtablet
1-Covered
norethindrone (DEBLITANE) 035 mgtablet
1-Covered
norethindrone (ERRIN) 035 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
101
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone (HEATHER) 035 mgtablet
1-Covered
norethindrone (INCASSIA) 035 mgtablet
1-Covered
norethindrone (JENCYCLA) 035mg tablet
1-Covered
norethindrone (JOLIVETTE) 035 mgtablet
1-Covered
norethindrone (LYZA) 035 mgtablet
1-Covered
norethindrone (NORA-BE) 035 mgtablet -
1-Covered
norethindrone (NORLYDA) 035 mgtablet
1-Covered
norethindrone (NORLYROC) 035mg tablet
1-Covered
norethindrone (SHAROBEL) 035 mgtablet
1-Covered
norethindrone (TULANA) 035 mgtablet
1-Covered
norethindrone 035 mg tablet 1-Covered
norethindrone acetate 5 mg tablet 1-Covered
PLAN B ONE-STEP (levonorgestrel) -15 MG TALET
1-Covered
TAKE ACTION (levonorgestrel) 15MG TABLET
1-Covered
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(THYROID) (Drugs for the Thyroid)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(THYROID) (Drugs to Replace Thyroid Hormone)
ARMOUR THYROID (thyroidpork) 15MG TABLET 30 MG TABLET 60 MGTABLET 90 MG TABLET 120 MGTABLET 180 MG TABLET 240 MGTABLET 300 MG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
102
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LEVO-T (levothyroxine sodium) -25MCG ABLE -50 MCG ABLE -75MCG ABLE -88 MCG ABLE -100MCG ABLE -112 MCG ABLE -125MCG ABLE -137 MCG ABLE -150MCG ABLE -175 MCG ABLE -200MCG ABLE -300 MCG ABLE
1-Covered
levothyroxine sodium 25 mcgtablet 50 mcg tablet 75 mcgtablet 88 mcg tablet 100 mcgtablet 112 mcg tablet 125 mcgtablet 137 mcg tablet 150 mcgtablet 175 mcg tablet 200 mcgtablet 300 mcg tablet
1-Covered STAR (Preferred Drug)
LEVOTHYROXINE SODIUM 25 MCGTABLET 50 MCG TABLET 75 MCGTABLET 88 MCG TABLET 100 MCGTABLET 112 MCG TABLET 125 MCGTABLET 137 MCG TABLET 150 MCGTABLET 175 MCG TABLET 200 MCGTABLET 300 MCG TABLET
1-Covered STAR (Preferred Drug)
LEVOXYL (levothyroxine sodium) 25MCG TABLET 50 MCG TABLET 75MCG TABLET 88 MCG TABLET 100MCG TABLET 112 MCG TABLET 125MCG TABLET 137 MCG TABLET 150MCG TABLET 175 MCG TABLET 200MCG TABLET
1-Covered
SYNTHROID (levothyroxine sodium)25 MCG TABLET 50 MCG TABLET75 MCG TABLET 88 MCG TABLET100 MCG TABLET 112 MCG TABLET125 MCG TABLET 137 MCG TABLET150 MCG TABLET 175 MCG TABLET200 MCG TABLET 300 MCG TABLET
1-Covered
thyroidpork (NP THYROID) 15 mgtablet 30 mg tablet 60 mg tablet90 mg tablet 120 mg tablet
1-Covered STAR (Preferred Drug)
UNITHROID (levothyroxine sodium)25 MCG TABLET 50 MCG TABLET75 MCG TABLET 88 MCG TABLET100 MCG TABLET 112 MCG TABLET125 MCG TABLET 137 MCG TABLET150 MCG TABLET 175 MCG TABLET200 MCG TABLET 300 MCG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
103
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs forSuppressing Hormones from the Pituitary Gland)
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs to SuppressPituitary Hormones)
leuprolide acetate 1 mg02ml kit 1-Covered PA SP
LUPRON DEPOT-PED (leuprolideacetate) -15 MG KIT
1-Covered PA
SYNAREL (nafarelin acetate) 2MGML NASAL SPRAY
1-Covered PA
HORMONAL AGENTS SUPPRESSANT (THYROID) (Drugs for theThyroid)
ANTITHYROID AGENTS (Drugs to Suppress Thyroid Hormone)methimazole 5 mg tablet 10 mgtablet
1-Covered
propylthiouracil 50 mg tablet 1-Covered
IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing theImmune System)
IMMUNE SUPPRESSANTS (Drugs to Suppress the Immune System)azathioprine 50 mg tablet 1-Covered
AZATHIOPRINE 50 MG TABLET 1-Covered
cyclosporine 25 mg capsule 100mg capsule
1-Covered
cyclosporine modified (GENGRAF)25 mg capsule 100 mgml solution100 mg capsule
1-Covered
cyclosporine modified 25 mgcapsule 100 mgml solution 100mg capsule
1-Covered
ENBREL (etanercept) 25 MG KIT 1-Covered PA SP QLC (8 vials28 days)
ENBREL (etanercept) 25 MG05 MLSYRINGE 50 MGML SYRINGE
1-Covered PA SP QLC (4 syringes [1 kit]28days)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
104
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ENBREL 25 MG05 ML VIAL 1-Covered PA QL (4 PER 28 DAY(S))
ENBREL SURECLICK (etanercept) 50MGML
1-Covered PA SP QLC (4 pens [1 kit]28days)
HUMIRA (adalimumab) 10 MG02ML SYRINGE 20 MG04 MLSYRINGE 40 MG08 ML SYRINGE
1-Covered PA SP QLC (2 syringes [1 kit]28days)
HUMIRA PEDIATRIC CROHNS(adalimumab) 40 MG08 ML
1-Covered PA SP QLC (3 or 6 syringesyeardepending upon package size)
HUMIRA PEN (adalimumab) 40MG08 ML
1-Covered PA SP QLC (2 pens [1 kit]28days)
HUMIRA PEN CROHNS-UC-HS(adalimumab) --40 MG
1-Covered PA SP QLC (6 pens [1 kit]year)
HUMIRA PEN PSOR-UVEITS-ADOL HS(adalimumab) --40 MG
1-Covered PA SP QLC (4 pens [1 kit]year)
HUMIRA(CF) (adalimumab) 10MG01 ML SYRING 20 MG02 MLSYRING 40 MG04 ML SYRING
1-Covered PA SP QLC (2 syringes [1 kit]28days)
HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 80-40 MG
1-Covered PA SP QLC (2 syringes [1kit]year)
HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 80MG08
1-Covered PA SP QLC (3 syringes [1kit]year)
HUMIRA(CF) PEN (adalimumab) 40MG04 ML
1-Covered PA SP QLC (2 pens [1 kit]28days)
HUMIRA(CF) PEN CROHNS-UC-HS(adalimumab) CRHN--80MG
1-Covered PA SP QLC (3 pens [1 kit]year)
HUMIRA(CF) PEN PSOR-UV-ADOLHS (adalimumab) --AHS 80-40
1-Covered PA SP QLC (3 pens [1 kit]year)
METHOTREXATE 25 MG TABLET 1-Covered
methotrexate sodium 25 mgtablet
1-Covered
mycophenolate mofetil 200 mgmlsusp recon
1-Covered PA
mycophenolate mofetil 250 mgcapsule 500 mg tablet
1-Covered AL1 (At least 21 yrs old)
RHEUMATREX (methotrexatesodium) 25 MG TABLET
1-Covered
SANDIMMUNE (cyclosporine) 25MG CAPSULE 100 MGML SOLN
1-Covered
sirolimus 1 mgml solution 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
105
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
tacrolimus 05 mg capsule 1 mgcapsule 5 mg capsule
1-Covered AL1 (At least 21 yrs old)
TACROLIMUS 05 MG CAPSULE 1MG CAPSULE 5 MG CAPSULE
1-Covered AL1 (At least 21 yrs old)
IMMUNIZING AGENTS PASSIVE (Vaccines)HYPERTET S-D (tetanus immuneglobulinpf) -250 UNIT YRINGE
3-MedicalBenefit
NABI-HB (hepatitis b immuneglobulin) -VIAL gloulin)
3-MedicalBenefit
IMMUNOMODULATORSleflunomide 10 mg tablet 20 mgtablet
1-Covered
LEFLUNOMIDE 10 MG TABLET 20MG TABLET
1-Covered
RIDAURA (auranofin) 3 MGCAPSULE
1-Covered PA
VACCINESADACEL TDAP(diphtheriapertussis(acellular)tetanus vaccinepf) VIAL
1-Covered AL1 (At least 19 yrs old)
AFLURIA QUAD 2020-2021 -VIAL 1-Covered AL1 (At least 19 yrs old)
AFLURIA QUAD 2020-21 (3YR UP) - 1-Covered AL1 (At least 19 yrs old)
BEXSERO (meningococcal group bvaccine 4-component) PREFILLEDSYRINGE -
1-Covered QL (2 PER LIFETIME) AL1 (19 to 25yrs old)
BOOSTRIX TDAP(diphtheriapertussis(acellular)tetanus vaccine) SYRINGE VIAL
1-Covered AL1 (At least 19 yrs old)
ENGERIX-B ADULT (hepatitis b virusvaccine recombinantpf) -20MCGML VIAL recominantpf) -20MCGML SYRN recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
FLUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 65 yrs old)
FLUAD QUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 19 yrs old)
FLUARIX QUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 19 yrs old)
FLUBLOK QUAD 2018-2019(influenza virus vaccine qv 2018-19(18 yrs and older)rcmbpf) -SYRINGE -
1-Covered AL1 (19 to 999 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
106
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
FLUBLOK QUAD 2020-2021 -SYRINGE
1-Covered AL1 (At least 19 yrs old)
FLUCELVAX QUAD 2020-2021 2020-2021 SYR 2020-2021 VIAL
1-Covered AL1 (At least 19 yrs old)
FLULAVAL QUAD 2019-2020(influenza virus vaccinequadrivalent 2019-20 (6 mos andup)) -VIAL -
1-Covered AL1 (At least 19 yrs old)
FLULAVAL QUAD 2020-2021 -SYR 1-Covered AL1 (At least 19 yrs old)
FLUZONE HIGH-DOSE QUAD 2020-21 --
1-Covered AL1 (At least 65 yrs old)
FLUZONE QUAD 2019-2020(influenza virus vaccine quadrival2019-2020(6 mos and up)pf) -VIAL-
1-Covered AL1 (At least 19 yrs old)
FLUZONE QUAD 2020-2021 2020-2021 VIAL 2020-2021 SYRINGE
1-Covered AL1 (At least 19 yrs old)
GARDASIL 9 (human papillomavirusvaccine 9-valentpf) 9 SYRINGE 9-9 VIAL 9-
1-Covered QL (3 PER LIFETIME) AL1 (19 to 27yrs old)
HAVRIX (hepatitis a virusvaccinepf) 720 UNIT05 MLSYRINGE (heptitis vccinepf) 720UNITS05 ML VIAL (heptitisvccinepf) 1440 UNITSMLSYRINGE (heptitis vccinepf) 1440UNITSML VIAL (heptitis vccinepf)
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
HEPLISAV-B (hepatitis b vaccinerecombinantvaccine adjuvantcpg 1018pf) -20 MCG05 MLSYRNG RECOMINANT -20MCG05 ML VIAL RECOMINANT
1-Covered AL1 (At least 19 yrs old) QLC (2perlifetime)
IMOVAX RABIES VACCINE (rabiesvaccine human diploid cellpf)VIAL
3-MedicalBenefit
M-M-R II VACCINE (measlesmumps and rubella vaccinelivepf) --VIAL
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
MENACTRA(meningococcalvaccine acyw-135diphtheria toxoid conjpf) VIAL-
1-Covered AL1 (At least 19 yrs old)
MENQUADFI VIAL 1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
107
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
MENVEO A-C-Y-W-135-DIP(meningococcalvaccine acyw-135diphtheria toxoid conjpf) -----VIL KT -DIPHTHERIA
1-Covered QL (1 PER LIFETIME) AL1 (19 to 55yrs old)
PNEUMOVAX 23 (pneumococcal23-valent polysaccharide vaccine)23 VIAL 23- 23 SYRINGE 23-
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
PREVNAR 13 (pneumococcal 13-valent conjugate vaccine(diphtheria crm)pf) SYRINGE -
1-Covered QL (1 PER LIFETIME) AL1 (At least19 yrs old)
RABAVERT (rabies vaccine purifiedchicken embryo cell (pcec)pf)RABIES VACC W-DILUENT
1-Covered AL1 (At least 19 yrs old)
RECOMBIVAX HB (hepatitis b virusvaccine recombinantpf) 5MCG05 ML SYR recominantpf)10 MCGML SYR recominantpf)40 MCGML VIAL recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
RECOMBIVAX HB (hepatitis b virusvaccine recombinantpf) 5MCG05 ML VL recominantpf) 10MCGML VIAL recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
SHINGRIX (varicella-zoster virusglycoprotein erecas01badjuvantpf) VIAL KIT -
1-Covered QL (2 PER LIFETIME) AL1 (At least50 yrs old)
TDVAX (tetanus and diphtheriatoxoids adult) VIAL
1-Covered AL1 (At least 19 yrs old)
TENIVAC (tetanus and diphtheriatoxoids adsorbed adultpf) VIAL
1-Covered AL1 (At least 19 yrs old)
tetanus and diphtheria toxoidsadult tetanus toxadult 2-2 lf05vial
1-Covered AL1 (At least 19 yrs old)
TRUMENBA (neisseria meningitidisgroup b lipidated fhbprecombinant) 120 MCG05 MLVACCIN
1-Covered QL (2 PER LIFETIME) AL1 (19 to 25yrs old)
TWINRIX (hepatitis a virus andhepatitis b virus vaccinepf)VACCINE SYRINGE (heptitis ndheptitis vccinepf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
108
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
VAQTA (hepatitis a virusvaccinepf) 25 UNITS05 ML VIAL(heptitis vccinepf) 25 UNITS05ML SYRINGE (heptitis vccinepf) 50UNITSML VIAL (heptitis vccinepf)50 UNITSML SYRINGE (heptitisvccinepf)
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
VARIVAX VACCINE (varicella virusvaccine livepf) WITH DILUENT
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
ZOSTAVAX (zoster vaccine livepf)VIAL
1-Covered QL (1 PER LIFETIME) AL1 (At least60 yrs old)
INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for InflammatoryBowel Disease)
AMINOSALICYLATESbalsalazide disodium 750 mgcapsule
1-Covered
mesalamine 4 g60 ml enema 1-Covered
mesalamine 400 mg cap(drtab) 1-Covered QL (6 PER 1 DAY(S))
GLUCOCORTICOIDShydrocortisone (COLOCORT)100mg60ml enema
1-Covered
hydrocortisone 100mg60mlenema
1-Covered
SULFONAMIDESsulfasalazine 500 mg tablet dr 500mg tablet
1-Covered
METABOLIC BONE DISEASE AGENTS (Drugs for the Bone)
METABOLIC BONE DISEASE AGENTSalendronate sodium 10 mg tablet40 mg tablet
1-Covered PA STAR (Preferred Drug)
alendronate sodium 35 mg tablet70 mg tablet
1-Covered STAR (Preferred Drug)
alendronate sodium 5 mg tablet 1-Covered AL1 (At least 65 yrs old) STAR(Preferred Drug)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
109
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcitoninsalmonsynthetic200spray spraypump
1-Covered PA
CALCITRIOL 025 MCG CAPSULE05 MCG CAPSULE
1-Covered
calcitriol 025 mcg capsule 05mcg capsule 1 mcgml solution
1-Covered
cholecalciferol (vitamin d3) 10mcg capsule 10 mcg tablet
1-Covered
cinacalcet hcl 30 mg tablet 60 mgtablet 90 mg tablet
1-Covered PA
CINACALCET HCL 30 MG TABLET60 MG TABLET 90 MG TABLET
1-Covered PA
ergocalciferol (vitamin d2)(CALCIDOL) 200 mcgml drops
1-Covered
ergocalciferol (vitamin d2) 10 mcgtablet 200 mcgml drops 1250mcg capsule
1-Covered
ERGOCALCIFEROL 200 MCGMLDROP
1-Covered
FOSAMAX PLUS D (alendronatesodiumcholecalciferol (vitamind3)) 70 MG-2800 IU
1-Covered PA
MISCELLANEOUS THERAPEUTIC AGENTSalcohol antiseptic pads s med 1-Covered
ALCOHOL WIPES 70 1-Covered
ASSURE ID DUO-SHIELD -30GX316-30GX516
1-Covered
ASSURE ID INSULIN SAFETY SYR05ML 31GX1564 SYR 1 ML31GX1564
1-Covered
condoms female each 1-Covered
condoms latex lubricated each 1-Covered
cromolyn sodium 52 mgspraypump
1-Covered
DROPLET MICRON PEN NEEDLE 34GX 964
1-Covered
freestyle insulix test strips 1-Covered QL (100 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
110
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
freestyle lite test strips 1-Covered QL (100 PER 30 DAYS)
freestyle test strips 1-Covered QL (100 PER 30 DAYS)
inhalerassist device with largemask devicelg spacer
1-Covered
inhalerassist device with mediummask devicemed spacer
1-Covered
inhalerassist device with smallmask devsmall spacer
1-Covered
INSULIN PEN NEEDLES INSULIN PENNEEDLES INSULIN PEN NEEDLES
1-Covered
insulin syringe 03 ml 1-Covered
insulin syringe 05 ml 1-Covered
insulin syringe 1 ml 1-Covered
lancets 28 gauge 30 gauge 33gauge
1-Covered
methylergonovine maleate 02 mgtablet
1-Covered
PEN NEEDLE 29G 12MM 1-Covered
pen needle diabetic 29 g x12 30gx516 31 g x14 31 gx316 31gx516 32gx 532 32 gx 14 32gx316 32 gx516 33 gx532
1-Covered
pen needle diabetic disposablesafety 30 gx516 30 gx316
1-Covered
pen needle diabetic removerand disposal unit 31 gx316 32gx532
1-Covered
pen needle diabetic safety 30gx316 dis
1-Covered
RID (permethrin) PEDICULICIDESSPRAY
1-Covered
syringe with needle insulin safety1 ml geneedleinsulnsafe1ml 30gx316 disp
1-Covered
syringe withneedledisposableinsulin 1 ml30gx12 disp 31 gx516 disp31gx1564 disp
1-Covered
syringe with needleinsulin03 ml -needldispinsul03 29 x12 disp
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
111
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
syringe with needleinsulin05 ml -ml 30gx12 disp -ml 31 gx516disp -ml 31gx1564 disp
1-Covered
UNIFINE PENTIPS MAXFLOW30GX316
1-Covered
OPHTHALMIC AGENTS (Drugs for the Eyes)
OPHTHALMIC AGENTS OTHER (Other Drugs for the Eyes)atropine sulfate 1 drops 1-Covered
bacitracinpolymyxin b sulfate (AK-POLY-BAC) 500-10kg oint (g) --
1-Covered
bacitracinpolymyxin b sulfate(POLYCIN) 500-10kg oint (g)
1-Covered
bacitracinpolymyxin b sulfate 500-10kg oint (g)
1-Covered
BEOVU (brolucizumab-dbll) 6MG005 ML VIAL -
3-MedicalBenefit
BLEPHAMIDE (sulfacetamidesodiumprednisolone acetate) EYEDROPS
1-Covered
CORTISPORIN (neomycinsulfatepolymyxin bsulfatehydrocortisone) CREAM
1-Covered
cyclopentolate hcl 05 drops 1 drops 2 drops
1-Covered
homatropine hbr (HOMATROPAIRE)5 drops
1-Covered
homatropine hbr 5 drops 1-Covered
MURO-128 (sodium chloride) -5EYE DROPS
1-Covered
neomycin sulfatebacitracinzincpolymyxin bhydrocortisone(NEO-POLYCIN HC)neomycinbacitp-myxhydrocort35-10k-1 oint (g) -
1-Covered
neomycin sulfatebacitracinzincpolymyxin bhydrocortisoneneomycinbacitp-myxhydrocort35-10k-1 oint (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
112
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
neomycinsulfatebacitracinpolymyxin b(NEO-POLYCIN)sulfbacitracinpoly 35mg-400oint (g) -
1-Covered
neomycinsulfatebacitracinpolymyxin bsulfbacitracinpoly 35mg-400oint (g)
1-Covered
neomycin sulfatepolymyxin bsulfategramicidin dneomycinpolymyxn bgramicidin175mg-10k drops
1-Covered
neomycin sulfatepolymyxin bsulfatehydrocortisoneneomycinpolymyxin bhydrocort35-10k-10 drops susp
1-Covered
neomycinpolymyxin bsulfatedexamethasonebdexametha 01 drops suspbdexametha 35-10k-1 oint (g)
1-Covered
phenylephrine hcl 25 drops 10 drops
1-Covered
polymyxin b sulfatetrimethoprimsulftrimethoprim 10000-1ml drops
1-Covered
proparacaine hcl 05 drops 1-Covered PA
sodium chloride (MURO-128) drops -18)
1-Covered
sodium chloride 5 drops 1-Covered
sulfacetamidesodiumprednisolone sodiumphosphatesulfacetamideprednisolone 10 -023 drops
1-Covered
TOBRADEX(tobramycindexamethasone) EYEOINTMENT
1-Covered
tobramycindexamethasone 03-01 drops susp
1-Covered
OPHTHALMIC ANTI-ALLERGY AGENTS (Drugs for Eye Allergies)ALAWAY (ketotifen fumarate)0025 EYE DROPS
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
113
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALOMIDE (lodoxamidetromethamine) 01 EYE DROPS
1-Covered
cromolyn sodium 4 drops 1-Covered
EYE ITCH RELIEF 0025 DROPS HM0025 DROP
1-Covered
ketotifen fumarate (ALLERGY EYEDROPS) 0025 drops
1-Covered
ketotifen fumarate (EYE ITCHRELIEF) 0025 drops
1-Covered
ketotifen fumarate (ITCHY EYE)0025 drops
1-Covered
ketotifen fumarate (WAL-ZYR) 0025 drops -
1-Covered
ketotifen fumarate (ZADITOR) 0025 drops
1-Covered
ketotifen fumarate 0025 drops 1-Covered
OPHTHALMIC ANTI-INFLAMMATORIES (Drugs to Reduce EyeSwelling)
dexamethasone sodiumphosphate 01 drops
1-Covered
diclofenac sodium 01 drops 1-Covered
fluorometholone 01 drops susp 1-Covered
flurbiprofen sodium 003 drops 1-Covered
FML FORTE (fluorometholone)025 EYE DROPS
1-Covered
FML SOP (fluorometholone) 01OINTMENT
1-Covered
ketorolac tromethamine 05 drops
1-Covered
PRED MILD (prednisolone acetate)012 EYE DROPS
1-Covered
prednisolone acetate 1 dropssusp
1-Covered
prednisolone sodium phosphate 1 drops
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
114
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
OPHTHALMIC ANTIGLAUCOMA AGENTS (Drugs for Glaucoma)ALPHAGAN P (brimonidinetartrate) ALHAGAN 01 DROS
1-Covered QL (1 PER 30 DAYS)
apraclonidine hcl 05 drops 1-Covered
betaxolol hcl 05 drops 1-Covered
BETIMOL (timolol) 025 DROPS05 DROPS
1-Covered
BETOPTIC S (betaxolol hcl) 025EYE DROP
1-Covered
brimonidine tartrate 02 drops 1-Covered
dorzolamide hcl 2 drops 1-Covered
dorzolamide hcltimolol maleate223-681 drops
1-Covered QL (10 PER 30 DAY(S))
DORZOLAMIDE-TIMOLOL -EYEDROPS
1-Covered QL (10 PER 30 DAY(S))
IOPIDINE (apraclonidine hcl) 1EYE DROPS
1-Covered
levobunolol hcl 05 drops 1-Covered
methazolamide 25 mg tablet 50mg tablet
1-Covered
METHAZOLAMIDE 25 MG TABLET 50MG TABLET
1-Covered
PHOSPHOLINE IODIDE(echothiophate iodide) 0125
1-Covered
pilocarpine hcl 1 drops 2 drops 4 drops
1-Covered
PILOCARPINE HCL 1 DROPS 2DROPS
1-Covered
timolol maleate 025 sol-gel 025 drops 05 drops 05 sol-gel
1-Covered
TIMOLOL MALEATE 05 EYE DROPS 1-Covered
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS (Drugsfor Glaucoma)
latanoprost 0005 drops 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
115
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
OTIC AGENTS (Drugs for the Ears)
OTIC AGENTS (Drugs for Ear Infection)acetic acid 2 solution 1-Covered
ACETIC ACID 2 EAR SOLUTION 1-Covered
carbamide peroxide(CARBAMOXIDE) 65 drops
1-Covered
carbamide peroxide (EAR DROPS)65 drops
1-Covered
carbamide peroxide (EAR SYSTEM)65 drops
1-Covered
carbamide peroxide (EAR WAXREMOVAL) 65 drops
1-Covered
carbamide peroxide (MURINE EARWAX REMOVAL SYSTEM) 65 drops
1-Covered
DEBROX (carbamide peroxide)65 EAR DROPS
1-Covered
EAR DROPS (carbamide peroxide)65
1-Covered
hydrocortisoneacetic acid(ACETASOL HC) 1 -2 drops
1-Covered
hydrocortisoneacetic acid 1 -2 drops
1-Covered
MURINE EAR DROPS (carbamideperoxide) 65
1-Covered
neomycin sulfatepolymyxin bsulfatehydrocortisoneneomycinpolymyxin bhydrocort35--1 solutionneomycinpolymyxin bhydrocort35--1 drops susp
1-Covered
NEOMYCIN-POLYMYXIN-HC --EARSUSP
1-Covered
RESPIRATORY TRACTPULMONARY AGENTS (Drugs for the Lungs)
ANTI-INFLAMMATORIES INHALED CORTICOSTEROIDS (Inhaled Drugsto Prevent Swelling of the Airways)
BUDESONIDE 025 MG2 ML SUSP 1-Covered AL1 (Up to 6 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
116
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
budesonide 025mg2ml - 05mg2ml -
1-Covered AL1 (Up to 6 yrs old)
CHILDRENS NASACORT(triamcinolone acetonide)ALLERGY 24 HR
1-Covered QL (17 PER 30 DAY(S))
FLOVENT DISKUS (fluticasonepropionate) 50 MCG 100 MCG250 MCG
1-Covered
FLOVENT HFA (fluticasonepropionate) HFA 44 MCG INHALERHFA 110 MCG INHALER HFA 220MCG INHALER
1-Covered
fluticasone propionate (ALLERGYRELIEF) 50 mcg spray susp
1-Covered QL (16 PER 30 DAY(S))
fluticasone propionate 50 mcgspray susp
1-Covered QL (16 PER 30 DAY(S))
NASACORT (triamcinoloneacetonide) ALLERGY 24HR SPRAY
1-Covered
PULMICORT FLEXHALER(budesonide) 180 MCG
1-Covered
QVAR REDIHALER(beclomethasone dipropionate)40 MCG 80 MCG
1-Covered
triamcinolone acetonide 55 mcgspray
1-Covered QL (17 PER 30 DAY(S))
ANTIHISTAMINESALAVERT (loratadine) 10 MG ODT 1-Covered AL1 (Up to 12 yrs old)
ALL DAY ALLERGY ERGY 10 MGTABLET SM ERGY 10 MG TAB
1-Covered
ALLERGY RELIEF (LORATADINE) 10MG TAB RELIEF 10 MG TABLET
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
ALLERGY RELIEF 4 MG TABLET HM 4MG TABLET HM 25 MG CAP 25 MGSOFTGEL GS 25 MG TABLET
1-Covered
ALLERGY RELIEF HM 180 MG TAB180 MG TABLET
1-Covered ST
AZELASTINE HCL 01 (137 MCG)SPRY
1-Covered QL (1 PER 30 DAYS)
azelastine hcl 137 mcgspraypump
1-Covered QL (1 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
117
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
cetirizine hcl (24HOUR ALLERGY) 10mg tablet
1-Covered
cetirizine hcl (ALL DAY ALLERGYRELIEF) 10 mg tablet
1-Covered
cetirizine hcl (ALL DAY ALLERGY) 10mg tablet
1-Covered
cetirizine hcl (ALLER-TEC) 10 mgtablet -
1-Covered
cetirizine hcl (ALLERGY RELIEF) 10mg tablet
1-Covered
cetirizine hcl (WAL-ZYR) 10 mgtablet -
1-Covered
cetirizine hcl 1 mgml 5 mg5 ml 1-Covered ST AL1 (Up to 5 yrs old)
CETIRIZINE HCL 10 MG TABLET 1-Covered
cetirizine hcl 5 mg tablet 10 mgtablet
1-Covered
CHILDRENS ALLERGY RELIEF 5MG5 ML
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
CHILDRENS ALLERGY RELIEF RLF125 MG5 ML
1-Covered
chlorpheniramine maleate(ALLERGY 4-HOUR) mg tablet -
1-Covered
chlorpheniramine maleate(ALLERGY RELIEF) 4 mg tablet
1-Covered
chlorpheniramine maleate(ALLERGY) 4 mg tablet
1-Covered
chlorpheniramine maleate(ALLERGY-TIME) 4 mg tablet -
1-Covered
chlorpheniramine maleate(CHLORHIST) 4 mg tablet
1-Covered
chlorpheniramine maleate(CHLORTABS) 4 mg tablet
1-Covered
chlorpheniramine maleate (EDCHLORPED JR) 2 mg5 ml syrup
1-Covered
chlorpheniramine maleate(PHARBECHLOR) 4 mg tablet
1-Covered
chlorpheniramine maleate (WAL-FINATE) 4 mg tablet -
1-Covered
chlorpheniramine maleate 4 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
118
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
clemastine fumarate 268 mgtablet
1-Covered
cyproheptadine hcl 2 mg5 mlsyrup 4 mg tablet 4 mg10 mlsyrup
1-Covered
diphenhydramine hcl (ALER-CAPS)25 mg capsule -
1-Covered
diphenhydramine hcl (ALLER-G-TIME) 25 mg tablet --
1-Covered
diphenhydramine hcl (ALLERGYMEDICATION) 25 mg capsule 25mg tablet
1-Covered
diphenhydramine hcl (ALLERGYMEDICINE) 25 mg tablet
1-Covered
diphenhydramine hcl (ALLERGYRELIEF) 125mg5ml liquid 25 mgcapsule 25 mg tablet
1-Covered
diphenhydramine hcl (ALLERGY)125mg5ml liquid 25 mg capsule25 mg tablet
1-Covered
diphenhydramine hcl (BANOPHEN)125mg5ml liquid 25 mg tablet 25mg capsule 50 mg capsule
1-Covered
diphenhydramine hcl (BENADRYLALLERGY) 25 mg tablet
1-Covered
diphenhydramine hcl (CHILDRENSALLERGY RELIEF) 125mg5ml liquid
1-Covered
diphenhydramine hcl (CHILDRENSALLERGY) 125mg5ml elixir125mg5ml liquid
1-Covered
diphenhydramine hcl (CHILDRENSBENADRYL ALLERGY) 125mg5mlliquid
1-Covered
diphenhydramine hcl (CHILDRENSWAL-DRYL ALLERGY) 125mg5mlliquid -
1-Covered
diphenhydramine hcl (COMPLETEALLERGY) 25 mg capsule 25 mgtablet
1-Covered
diphenhydramine hcl (DIPHEDRYLALLERGY) 125mg5ml liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
119
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
diphenhydramine hcl (DIPHEDRYL)125mg5ml liquid 25 mg capsule
1-Covered
diphenhydramine hcl (DIPHEN)125mg5ml elixir 25 mg tablet
1-Covered
diphenhydramine hcl (DIPHENHIST)125mg5ml liquid 25 mg tablet
1-Covered
diphenhydramine hcl (GERI-DRYL)125mg5ml liquid - 25 mg tablet -
1-Covered
diphenhydramine hcl (M-DRYL)125mg5ml liquid -
1-Covered
diphenhydramine hcl (NIGHTTIMEALLERGY RELIEF) 25 mg tablet
1-Covered
diphenhydramine hcl (NIGHTTIMESLEEP AID) 25 mg tablet
1-Covered
diphenhydramine hcl(PHARBEDRYL) 25 mg capsule 50mg capsule
1-Covered
diphenhydramine hcl (SILADRYL)125mg5ml liquid
1-Covered
diphenhydramine hcl (SIMPLYSLEEP) 25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP AID)25 mg tablet
1-Covered
diphenhydramine hcl (TOTALALLERGY) 25 mg tablet
1-Covered
diphenhydramine hcl (WAL-DRYLALLERGY) 125mg5ml liquid - 25mg tablet -
1-Covered
diphenhydramine hcl (WAL-DRYL)25 mg capsule -
1-Covered
DIPHENHYDRAMINE HCL 125 MG5ML 25 MG10 ML
1-Covered
diphenhydramine hcl 125mg5mlelixir 125mg5ml syrup125mg5ml liquid 25 mg tablet 25mg capsule 50 mg capsule
1-Covered
fexofenadine hcl (ALLER-EASE) 60mg tablet - 180 mg tablet -
1-Covered ST
fexofenadine hcl (ALLER-FEX) 180mg tablet -
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
120
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fexofenadine hcl (ALLERGY RELIEF)60 mg tablet 180 mg tablet
1-Covered ST
fexofenadine hcl (WAL-FEXALLERGY) 60 mg tablet - 180 mgtablet -
1-Covered ST
fexofenadine hcl 60 mg tablet 180mg tablet
1-Covered ST
FEXOFENADINE HCL HM 60 MGTAB 60 MG TABLET 180 MG TABLET
1-Covered ST
GERI-DRYL -125 MG5 ML LIQUID 1-Covered
hydroxyzine hcl 10 mg tablet 10mg5 ml solution 25 mg tablet 50mg tablet 50 mg25ml solution
1-Covered
HYDROXYZINE PAMOATE 25 MGCAP 50 MG CAP
1-Covered
hydroxyzine pamoate 25 mgcapsule 50 mg capsule 100 mgcapsule
1-Covered
loratadine (ALLERCLEAR) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (ALLERGY RELIEF) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (ALLERGY RELIEF) 5mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (ALLERGY) 10 mg tablet 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (CHILDRENS ALLERGYRELIEF) 5 mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (CHILDRENS ALLERGY) 5mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (LORADAMED) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (NON-DROWSYALLERGY) 10 mg tablet -
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (WAL-ITIN) 10 mg tablet-
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (WAL-ITIN) 5 mg5 mlsolution -
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine 10 mg tablet 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
121
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LORATADINE 10 MG TABLET 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine 5 mg5 ml solution 1-Covered QL (150 PER 30 DAYS) AL1 (Up to6 yrs old)
NIGHTTIME SLEEP AID HM 25 MGCPLT
1-Covered
promethazine hcl 125 mg tablet25 mg tablet
1-Covered
PROMETHAZINE HCL 625 MG5 MLSOLN
1-Covered AL1 (At least 2 yrs old)
promethazine hcl 625mg5mlsyrup
1-Covered AL1 (At least 2 yrs old)
ANTILEUKOTRIENESmontelukast sodium 4 mg granpack
1-Covered ST
MONTELUKAST SODIUM 4 MGGRANULES
1-Covered ST
montelukast sodium 4 mg tabchew 5 mg tab chew 10 mgtablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
BRONCHODILATORS ANTICHOLINERGIC (Anticholinergic Drugs toOpen the Airway)
ATROVENT HFA (ipratropiumbromide) 17 MCG INHALER
1-Covered
INCRUSE ELLIPTA (umeclidiniumbromide) 625 MCG INH
1-Covered C (RESTRICTED TO THE DIAGNOSISOF CHRONIC OBSTRUCTIVEPULMONARY DISEASE (COPD))
ipratropium bromide 02 mgmlsolution 21 mcg spray 42 mcgspray
1-Covered
BRONCHODILATORS SYMPATHOMIMETIC (Sympathomimetic Drugsto Open the Airway)
albuterol 90mcg hfa inhaler(generic proair)
1-Covered QL (2 PER 30 [DAYS])
albuterol 90mcg hfa inhaler(generic proventil)
1-Covered QL (2 PER 30 [DAYS])
albuterol 90mcg hfa inhaler(generic ventolin)
1-Covered QL (2 PER 30 [DAYS])
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
122
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALBUTEROL SULFATE 100 MG20 MLSOLN
1-Covered
albuterol sulfate 2 mg tablet 2mg5 ml syrup 25 mg3ml vial-neb 25 mg05 vial-neb 4 mg taber 12h 4 mg tablet 5 mgmlsolution 8 mg tab er 12h
1-Covered
albuterol sulfate 90 mcg hfa aerad
1-Covered QL (2 PER 30 [DAYS])
ALBUTEROL SULFATE HFA 90 MCGINHALER
1-Covered QL (2 PER 30 [DAYS])
epinephrine 015mg03 03mg03 1-Covered QL (2 PER FILL(S))
FORADIL (formoterol fumarate)AEROLIZER 12 MCG CAP
1-Covered ST
levalbuterol tartrate 45 mcg hfaaer ad
1-Covered QL (30 PER 30 DAY(S))
metaproterenol sulfate 10 mg5 mlsyrup 10 mg tablet 20 mg tablet
1-Covered
NASAL DECONGESTANT(pseudoephedrine hcl) 30 MG TAB
1-Covered
pseudoephedrine hcl (NASALDECONGESTANT) 30 mg tablet
1-Covered
pseudoephedrine hcl (SUDOGEST)30 mg tablet 60 mg tablet
1-Covered
pseudoephedrine hcl (SUPHEDRIN)30 mg tablet
1-Covered
pseudoephedrine hcl (SUPHEDRINESINUS CONGESTION) 30 mg tablet
1-Covered
pseudoephedrine hcl(SUPHEDRINE) 30 mg tablet
1-Covered
pseudoephedrine hcl (WAL-PHED)30 mg tablet -
1-Covered
pseudoephedrine hcl 30 mgtablet 60 mg tablet
1-Covered
SEREVENT DISKUS (salmeterolxinafoate) 50 MCG
1-Covered QL (60 PER 30 DAYS)
SUDAFED (pseudoephedrine hcl)30 MG TABLET
1-Covered
TERBUTALINE SULFATE 25 MG TAB 5MG TAB
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
123
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terbutaline sulfate 25 mg tablet 5mg tablet
1-Covered
PHOSPHODIESTERASE INHIBITORS AIRWAYS DISEASE (Drugs thatBlock Phosphodiesterase)
ELIXOPHYLLIN (theophyllineanhydrous) OPHYLLIN 80 MG15 ML
1-Covered
THEO-24 (theophylline anhydrous) -24 ER 200 MG CAPSULE -24 ER 300MG CAPSULE -24 ER 100 MGCAPSULE -24 ER 400 MG CAPSULE
1-Covered
theophylline anhydrous(THEOCHRON) 100 mg tab er 200mg tab er 300 mg tab er
1-Covered
theophylline anhydrous 80mg15ml solution 80 mg15ml elixir100 mg tab er 12h 200 mg tab er12h 300 mg tab er 12h 400 mgtab er 24h 450 mg tab er 12h 600mg tab er 24h
1-Covered
PULMONARY ANTIHYPERTENSIVES (Drugs for PulmonaryHypertension)
ambrisentan 5 mg tablet 10 mgtablet
1-Covered PA QL (1 PER 1 DAY(S)) SP
bosentan 625 mg tablet 125 mgtablet
1-Covered PA QL (2 PER 1 DAY(S)) SP
sildenafil citrate 20 mg tablet 1-Covered PA QL (3 PER 1 DAY(S)) SP
SILDENAFIL CITRATE 20 MG TABLET 1-Covered PA QL (3 PER 1 DAY(S)) SP
tadalafil (ALYQ) 20 mg tablet 1-Covered PA QL (2 PER 1 DAY(S)) SP
tadalafil 20 mg tablet 1-Covered PA QL (2 PER 1 DAY(S)) SP
RESPIRATORY TRACT AGENTS OTHER (Other Drugs for BreathingConditions)
acetylcysteine 100 mgml vial 200mgml vial
1-Covered
benzonatate 100 mg capsule 1-Covered
BEVESPI AEROSPHERE(glycopyrrolateformoterolfumarate) INHALER
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
124
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
brompheniraminemaleatepseudoephedrine hcl(RYNEX PSE)brompheniraminpseudoephedrine 1-15mg5ml liquid
1-Covered
BROTAPP DM (brompheniraminemaleatepseudoephedrinehcldextromethorphan) 1-15-5MG5 ML LIQ
1-Covered
chlorpheniraminemaleatepseudoephedrinedextromethorphan (KIDKARE)chlorpheniraminpseudoepheddm 1-15-5mg5 liquid
1-Covered
codeine phosphateguaifenesin(CHERATUSSIN AC) 10-100mg5liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(G TUSSIN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(GUAIATUSSIN AC) 10-100mg5 20-20010
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(GUAIFENESIN AC) 10-100mg5liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(ROBAFEN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(VIRTUSSIN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin10-100mg5 20-20010
1-Covered AL1 (At least 12 yrs old)
CODEINE-GUAIFENESIN -10-100MG5 ML
1-Covered AL1 (At least 12 yrs old)
COMBIVENT RESPIMAT (ipratropiumbromidealbuterol sulfate) 20-100MCG
1-Covered
COUGH FORMULA DM(guaifenesindextromethorphanhbr) SYRUP
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
125
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fluticasone propionatesalmeterolxinafoate (WIXELA INHUB)propionsalmeterol 100-50 mcgwdev propionsalmeterol 250-50mcg wdev propionsalmeterol500-50 mcg wdev
1-Covered QL (60 PER 30 DAY(S))
fluticasone propionatesalmeterolxinafoate propionsalmeterol 100-50 mcg wdev propionsalmeterol250-50 mcg wdevpropionsalmeterol 500-50 mcgwdev
1-Covered QL (60 PER 30 DAY(S))
fluticasone propionatesalmeterolxinafoate propionsalmeterol 55-14mcg propionsalmeterol 113-14mcg propionsalmeterol 232-14mcg
1-Covered QL (1 PER 30 DAYS)
GUAIASORB DM LIQUID 1-Covered
guaifenesin (MUCUS ER) 600 mgtab er 12h
1-Covered
guaifenesin (MUCUS RELIEF ER) 600mg tab er 12h
1-Covered
GUAIFENESIN-DEXTROMETHORPHAN DM SYRUP
1-Covered
guaifenesindextromethorphanhbr (ADULT ROBITUSSIN PEAK COLDDM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ADULT TUSSIN COUGHCONGEST DM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ADULT TUSSIN DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (ADULT WAL-TUSSIN DM) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (ANTITUSSIVE DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (BIOCOTRON) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (COUGH DM) 100-10mg5syrup
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
126
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesindextromethorphanhbr (DIABETIC SILTUSSIN-DM) 100-10mg5 liquid -
1-Covered
guaifenesindextromethorphanhbr (DIABETIC TUSSIN DM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (EXPECTORANT DM) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (EXTRA ACTION COUGH) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (GERI-TUSSIN DM) 100-10mg5liquid - 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (GILTUSS DIABETIC) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (GILTUSS HBP) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (GUAIASORB DM) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (RI-TUSSIN DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM COUGH) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM COUGH-CHESTCONGEST) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM PEAK COLD)100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN-DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr (SAFETUSSIN DM) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (SILTUSSIN DM DAS) 100-10mg5liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
127
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesindextromethorphanhbr (SILTUSSIN DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (SORBUGEN NR) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSNEL DIABETIC) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSSIN COUGH) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM CLEAR) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM COUGH) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM COUGH-CHESTCONGEST) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM) 100-10mg5 liquid100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (ULTRA DM FREE amp CLEAR) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ULTRA TUSS) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (WAL-TUSSIN DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr 100-10mg5 syrup 100-10mg5liquid
1-Covered
guaifenesinpseudoephedrine hcl(MUCUS D)guaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
guaifenesinpseudoephedrine hcl(MUCUS RELIEF D)guaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
128
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesinpseudoephedrine hclguaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
ipratropium bromidealbuterolsulfate ipratropiumalbuterol 05-3mg3 ampul-neb
1-Covered QL (540 PER 30 DAY(S))
IPRATROPIUM-ALBUTEROL -05-3(25) MG3 ML
1-Covered QL (540 PER 30 DAY(S))
MAXI-TUSS G -LIQUID 1-Covered
MUCUS ER CVS 600 MG TABLET 1-Covered
MUCUS RELIEF ER HM 600 MG TAB 1-Covered
phenylephrine hclpromethazinehcl prometh 5-625mg5 syrup
1-Covered AL1 (At least 2 yrs old)
promethazine hclcodeine 625-105 syrup
1-Covered QL (240 PER 30 DAYS) AL1 (Atleast 12 yrs old) QLC (LIMIT 240ML(8OZ) PER 30 DAYS)
promethazinehcldextromethorphan hbrpromethazinedextromethorphan625-155 syrup
1-Covered AL1 (At least 2 yrs old)
PROMETHAZINE-DM -625-15MG5ML
1-Covered AL1 (At least 2 yrs old)
promethazinephenylephrinehclcodeinepromethazinephenylephcodeine625-5-10 syrup
1-Covered AL1 (At least 12 yrs old)
sodium chloride for inhalation 09 vial- 3 vial- 10 vial-
1-Covered
triprolidine hclpseudoephedrinehcl (APRODINE)triprolidinepseudoephedrine25mg-60mg tablet
1-Covered
triprolidine hclpseudoephedrinehcl (ED A-HIST PSE)triprolidinepseudoephedrine25mg-60mg tablet -
1-Covered
triprolidine hclpseudoephedrinehcl (RITIFED)triprolidinepseudoephedrine 125-305 syrup
1-Covered
triprolidine hclpseudoephedrinehcl (WAL-ACT D COLD amp ALLERGY)triprolidinepseudoephedrine25mg-60mg tablet -col
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
129
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles)
SKELETAL MUSCLE RELAXANTS (Drugs to Relax the Muscles)carisoprodol 350 mg tablet 1-Covered QL (90 PER 30 DAYS)
CARISOPRODOL 350 MG TABLET 1-Covered QL (90 PER 30 DAYS)
cyclobenzaprine hcl 10 mg tablet 1-Covered QL (90 PER 30 DAYS)
cyclobenzaprine hcl 5 mg tablet 1-Covered QL (90 PER 30 DAY(S))
methocarbamol 500 mg tablet750 mg tablet
1-Covered QL (90 PER 30 DAYS)
METHOCARBAMOL 500 MG TABLET750 MG TABLET
1-Covered QL (90 PER 30 DAYS)
VANADOM 350 MG TABLET 1-Covered QL (90 PER 30 DAY(S))
SLEEP DISORDER AGENTS (Drugs for Insomnia)
GABA RECEPTOR MODULATORSflurazepam hcl 15 mg capsule 30mg capsule
1-Covered AL1 (Up to 65 yrs old)
temazepam 75 mg capsule 15mg capsule 30 mg capsule
1-Covered
triazolam 0125 mg tablet 025 mgtablet
1-Covered QL (14 PER 30 DAY(S))
zaleplon 5 mg capsule 10 mgcapsule
1-Covered ST
zolpidem tartrate 5 mg tablet 10mg tablet
1-Covered
SLEEP DISORDERS OTHERdiphenhydramine hcl (ALKA-SELTZER PLUS ALLERGY) 25 mgtablet -
1-Covered
diphenhydramine hcl (COMPOZ)25 mg tablet
1-Covered
diphenhydramine hcl (NIGHTTIMESLEEP AID) 25 mg tablet
1-Covered
diphenhydramine hcl (NYTOLQUICKCAPS) 25 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
130
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
diphenhydramine hcl (SIMPLYSLEEP) 25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP AID)25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP II) 25mg tablet
1-Covered
diphenhydramine hcl (SLEEPTABLET) 25 mg tablet
1-Covered
modafinil 100 mg tablet 200 mgtablet
1-Covered PA QL (3 PER 1 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
131
Alphabetical Index of Prescription Drugs
009 sodium chloride 697072
Aabacavir sulfate 38abacavir sulfatelamivudine 38abacavir sulfatelamivudinezidovudine 38ABACAVIR-LAMIVUDINE 38ABILIFY (aripiprazole) 31ABILIFY MAINTENA (aripiprazole) 31ABILIFY MYCITE (aripiprazole) 31acamprosate calcium 6acarbose 4243acetaminophen 64ACETAMINOPHEN 64acetaminophen (ATHENOL) 63acetaminophen (CHILD FEVER REDUCER) 63acetaminophen (CHILD PAIN REL-FEVERREDUCER) 63acetaminophen (CHILDRENS FEVERREDUCER) 63acetaminophen (CHILDRENS FEVERREDUCING) 63acetaminophen (CHILDRENS PAIN ANDFEVER) 63acetaminophen (CHILDRENS SILAPAP) 63acetaminophen (ED-APAP) 63acetaminophen (LITTLE REMEDIES FEVER-PAIN) 63acetaminophen (M-PAP) 63acetaminophen (MAPAP) 63acetaminophen (MASOPHEN) 63acetaminophen (NON-ASPIRIN EXTRASTRENGTH) 63acetaminophen (NON-ASPIRIN PAIN RELIEF) 63acetaminophen (NON-ASPIRIN) 63acetaminophen (PAIN amp FEVER) 63acetaminophen (PAIN RELIEF EXTRASTRENGTH) 64acetaminophen (PAIN RELIEF) 64
acetaminophen (PAIN RELIEVER) 64acetaminophen (PHARBETOL) 64acetaminophen (SHAKE THAT ACHE) 64acetaminophen (TACTINAL) 64ACETAMINOPHEN 160 MG5ML ORAL SUSP 64ACETAMINOPHEN 160 MG5ML SOLUTION 64acetaminophen with codeine phosphate 45acetazolamide 57ACETAZOLAMIDE 58acetic acid 116ACETIC ACID 116acetylcysteine 124ACID CONTROLLER 80ACID REDUCER 80ACNE MEDICATION 66ACNE MEDICATION (benzoyl peroxide) 66acyclovir 41ACYCLOVIR 41ADACEL TDAP(diphtheriapertussis(acellular)tetanusvaccinepf) 106ADASUVE (loxapine) 30ADLYXIN (lixisenatide) 43ADMELOG (insulin lispro) 45ADMELOG SOLOSTAR (insulin lispro) 45ADVATE (antihemophilic factor (fviii)recombinantfull length) 47ADYNOVATE (antihemophilic factor (fviii)recombinant full length peg) 47AFLURIA QUAD 2020-2021 106AFLURIA QUAD 2020-21 (3YR UP) 106AFSTYLA (antihemophilic factor viiirecombsingle-chnb-dom truncated) 47ALAVERT (loratadine) 117ALAWAY (ketotifen fumarate) 113Albuterol 90mcg HFA inhaler (GenericProair) 122Albuterol 90mcg HFA inhaler (GenericProventil) 122Albuterol 90mcg HFA inhaler (GenericVentolin) 122
LAST UPDATED 12012020132
ALBUTEROL SULFATE 123albuterol sulfate 123ALBUTEROL SULFATE HFA 123alcohol antiseptic pads 110ALCOHOL WIPES 110alendronate sodium 109alfuzosin hcl 86ALL DAY ALLERGY 117ALLERGY RELIEF 117ALLI (orlistat) 78allopurinol 24ALLOPURINOL 24alogliptin benzoate 43alogliptin benzoatemetformin hcl 43alogliptin benzoatepioglitazone hcl 43ALOMIDE (lodoxamide tromethamine) 114ALPHAGAN P (brimonidine tartrate) 115ALPHANATE (antihemophilic factorhumanvon willebrand factorhuman) 47ALPHANINE SD (factor ix) 47alprazolam 42alprazolam (ALPRAZOLAM INTENSOL) 42ALPROLIX (factor ix recombinant fc fusionprotein) 48AMANTADINE 29amantadine hcl 29ambrisentan 124amiloride hcl 58amiloride hclhydrochlorothiazide 56amiodarone hcl 53amiodarone hcl (PACERONE) 53AMITIZA (lubiprostone) 81amitriptyline hcl 19AMLODIPINE BESYLATE 54amlodipine besylate 54amlodipine besylatebenazepril hcl 56ammonium lactate 66ammonium lactate (SKIN TREATMENT) 66amoxapine 19amoxicillin 11AMOXICILLIN-CLAVULANATE POTASS 11
amoxicillinpotassium clavulanate 1112ampicillin trihydrate 12anagrelide hcl 47anastrozole 28ANASTROZOLE 28ANTACID 78ANTACID EXTRA STRENGTH 78ANTI-DIARRHEAL 78ANTIFUNGAL 21apraclonidine hcl 115aprepitant 21APTIVUS (tipranavir) 40APTIVUS (tipranavirvitamin e tpgs) 40aripiprazole 32ARIPIPRAZOLE 32ARISTADA (aripiprazole lauroxil) 32ARISTADA INITIO (aripiprazole lauroxilsubmicronized) 32ARMOUR THYROID (thyroidpork) 102ascorbate calcium 72ascorbic acid 72ascorbic acid (SOOTHING PUREWAY-C) 72aspirin 1aspirin (ADULT ASPIRIN REGIMEN) 1aspirin (ADULT LOW DOSE ASPIRIN EC) 1aspirin (ASPIR 81) 1aspirin (ASPIR-TRIN) 1aspirin (ASPIRIN) 1aspirin (ECOTRIN) 1aspirin (ECPIRIN) 1aspirin (ST JOSEPH ASPIRIN EC) 1aspirin (ST JOSEPH ASPIRIN) 1ASPIRIN 325MG TABLET 1ASPIRIN 81MG TABLET 1aspirinacetaminophencaffeine (ADDEDSTRENGTH HEADACHE) 1aspirinacetaminophencaffeine (BAYERMIGRAINE) 1aspirinacetaminophencaffeine (EXTRA PAINRELIEF) 1
LAST UPDATED 12012020133
aspirinacetaminophencaffeine(EXTRAPRIN) 1aspirinacetaminophencaffeine (HEADACHERELIEF) 1aspirinacetaminophencaffeine (MIGRAINEFORMULA) 2aspirinacetaminophencaffeine (MIGRAINERELIEF) 2aspirinacetaminophencaffeine (PAINRELIEVER PLUS) 2aspirinacetaminophencaffeine (PAINRELIEVER) 2aspirinacetaminophencaffeine (PAIN-OFF) 2ASSURE ID DUO-SHIELD 110ASSURE ID INSULIN SAFETY 110ATAZANAVIR SULFATE 40atazanavir sulfate 40atenolol 53ATENOLOL 53atenololchlorthalidone 56ATHLETES FOOT (terbinafine hcl) 21atomoxetine hcl 62atorvastatin calcium 59ATORVASTATIN CALCIUM 59ATRIPLA (efavirenzemtricitabinetenofovirdisoproxil fumarate) 37atropine sulfate 112ATROVENT HFA (ipratropium bromide) 122AVANDIA (rosiglitazone maleate) 43AVONEX (interferon beta-1a) 65AVONEX (interferon beta-1aalbuminhuman) 65AVONEX PEN (interferon beta-1a) 65azathioprine 104AZATHIOPRINE 104AZELASTINE HCL 117azelastine hcl 117azithromycin 12AZITHROMYCIN 12
Bbacitracin 9BACITRACIN 9bacitracin (BACITRAYCIN PLUS) 9bacitracin zinc 9BACITRACIN ZINC 9bacitracin zinc (ANTIBIOTIC) 9bacitracinpolymyxin b sulfate 112bacitracinpolymyxin b sulfate (AK-POLY-BAC) 112bacitracinpolymyxin b sulfate (POLYCIN) 112baclofen 35BACLOFEN 35balsalazide disodium 109BAQSIMI (glucagon) 44BASAGLAR KWIKPEN U-100 (insulinglarginehuman recombinant analog) 45BELBUCA (buprenorphine hcl) 3benazepril hcl 52benazepril hclhydrochlorothiazide 56BENEFIX (factor ix human recombinant) 48benzonatate 124benzoyl peroxide 67benzoyl peroxide (ACNE CONTROLCLEANSER) 66benzoyl peroxide (ACNE FOAMING WASH) 66benzoyl peroxide (ACNE TREATMENT) 67benzoyl peroxide (ACNECLEAR) 67benzoyl peroxide (ADVANCED EXFOLIATINGCLEANSER) 67benzoyl peroxide (BP WASH) 67benzoyl peroxide (BP) 67benzoyl peroxide (BPO-10) 67benzoyl peroxide (BPO-5) 67benzoyl peroxide (CLEAN-CLEARCONTINUOUS CONTROL) 67benzoyl peroxide (DAYLOGIC ACNEFOAMING WASH) 67benzoyl peroxide (DAYLOGIC ACNETREATMENT) 67
LAST UPDATED 12012020134
benzoyl peroxide (FOAMING ACNE FACEWASH) 67benzoyl peroxide (PANOXYL) 67benztropine mesylate 29BEOVU (brolucizumab-dbll) 112betamethasone dipropionate 87BETAMETHASONE DIPROPIONATE 87betamethasone dipropionatepropyleneglycol 88betamethasone valerate 88betaxolol hcl 115bethanechol chloride 86BETIMOL (timolol) 115BETOPTIC S (betaxolol hcl) 115BEVESPI AEROSPHERE(glycopyrrolateformoterol fumarate) 124BEXSERO (meningococcal group b vaccine4-component) 106bicalutamide 27BIKTARVY (bictegravirsodiumemtricitabinetenofovir alafenamidefumar) 36bisacodyl 82BISACODYL 82bisacodyl (ALOPHEN PILLS) 81bisacodyl (BISA-LAX) 81bisacodyl (BISACODYL) 81bisacodyl (BISCOLAX) 81bisacodyl (C-LAX LAXATIVE) 81bisacodyl (DUCODYL) 81bisacodyl (FAST RELIEF LAXATIVE) 81bisacodyl (GENTLE LAXATIVE) 81bisacodyl (LAXATIVE SUPPOSITORY) 81bisacodyl (LAXATIVE) 82bisacodyl (MAGIC BULLET) 82bisacodyl (WOMENS GENTLE LAXATIVE) 82bisacodyl (WOMENS LAXATIVE) 82bismuth subsalicylate 78bismuth subsalicylate (BISMATROL) 78bismuth subsalicylate (DIOTAME) 78bismuth subsalicylate (PEP-T-MED) 78
bismuth subsalicylate (PEPTIC RELIEF) 78bismuth subsalicylate (PINK BISMUTH) 78bismuth subsalicylate (SOOTHE) 78bismuth subsalicylate (STOMACH RELIEF) 78bisoprolol fumarate 54bisoprolol fumaratehydrochlorothiazide 56BISOPROLOL-HYDROCHLOROTHIAZIDE 56BLEPH-10 (sulfacetamide sodium) 13BLEPHAMIDE (sulfacetamidesodiumprednisolone acetate) 112BOOSTRIX TDAP(diphtheriapertussis(acellular)tetanusvaccine) 106bosentan 124brimonidine tartrate 115bromocriptine mesylate 29brompheniramine maleatepseudoephedrinehcl (RYNEX PSE) 125BROTAPP DM (brompheniraminemaleatepseudoephedrinehcldextromethorphan) 125BUDESONIDE 116budesonide 117bumetanide 58BUNAVAIL (buprenorphine hclnaloxone hcl) 7BUPRENEX (buprenorphine hcl) 7buprenorphine 4buprenorphine hcl 7buprenorphine hclnaloxone hcl 7bupropion hcl 817bupropion hcl (BUPROBAN) 8BUPROPION HCL SR 17BUPROPION XL 17BUSPIRONE HCL 41buspirone hcl 42butalbitalacetaminophen 64butalbitalacetaminophen (TENCON) 64butalbitalacetaminophencaffeine 64butalbitalaspirincaffeine 2butorphanol tartrate 5BUTRANS (buprenorphine) 4
LAST UPDATED 12012020135
CCALADRYL (pramoxine hclcalamine) 67calcipotriene 67calcitoninsalmonsynthetic 110CALCITRIOL 110calcitriol 110CALCIUM 72CALCIUM 500-VIT D3 72CALCIUM 600-VIT D3 72calcium acetate 87calcium acetate (ELIPHOS) 87calcium carbonate 697379calcium carbonate (ANTACID CALCIUM) 78calcium carbonate (ANTACID EXTRASTRENGTH) 78calcium carbonate (ANTACID) 78calcium carbonate (BAN-ACID) 78calcium carbonate (CAL-GEST) 78calcium carbonate (CALCIUM ANTACID) 78calcium carbonate (CHILDRENS PEPTO) 79calcium carbonate (CHILDRENS SOOTHE) 79calcium carbonate (FLAVOR CHEWSANTACID) 79calcium carbonate (OYSCO-500) 72calcium carbonate (SMOOTH ANTACID) 79calcium carbonate (SMOOTH DISSOLVINGANTACID) 79calcium carbonate (SUPER CALCIUM) 72calcium carbonatecholecalciferol (vitamind3) 73calcium carbonatecholecalciferol (vitamind3) (HI-CAL) 73calcium carbonatecholecalciferol (vitamind3) (OS-CAL 500-VIT D3) 73calcium carbonatecholecalciferol (vitamind3) (OYSCO 500-VIT D3) 73calcium carbonatecholecalciferol (vitamind3) (OYSTERCAL-D) 73calcium gluconate 73calcium lactate 73
capecitabine 27CAPECITABINE 27CAPLYTA (lumateperone tosylate) 32captopril 52CAPTOPRIL 52captoprilhydrochlorothiazide 56carbamazepine 16carbamazepine (EPITOL) 16carbamide peroxide (CARBAMOXIDE) 116carbamide peroxide (EAR DROPS) 116carbamide peroxide (EAR SYSTEM) 116carbamide peroxide (EAR WAXREMOVAL) 116carbamide peroxide (MURINE EAR WAXREMOVAL SYSTEM) 116CARBATROL (carbamazepine) 16carbidopalevodopa 30carisoprodol 130CARISOPRODOL 130carvedilol 54cefaclor 11CEFDINIR 11cefdinir 11celecoxib 2CELECOXIB 2CELONTIN (methsuximide) 14cephalexin 11cetirizine hcl 118CETIRIZINE HCL 118cetirizine hcl (24HOUR ALLERGY) 118cetirizine hcl (ALL DAY ALLERGY RELIEF) 118cetirizine hcl (ALL DAY ALLERGY) 118cetirizine hcl (ALLER-TEC) 118cetirizine hcl (ALLERGY RELIEF) 118cetirizine hcl (WAL-ZYR) 118CHANTIX (varenicline tartrate) 8CHEMET (succimer) 70CHILDRENS ALLERGY RELIEF 118CHILDRENS IBUPROFEN 2CHILDRENS NASACORT (triamcinoloneacetonide) 117
LAST UPDATED 12012020136
CHLORDIAZEPOXIDE-CLIDINIUM 77chlordiazepoxideclidinium bromide 77chlorhexidine gluconate 6667chlorhexidine gluconate (PAROEX) 66chloroquine phosphate 28chlorothiazide 58chlorpheniramine maleate 118chlorpheniramine maleate (ALLERGY 4-HOUR) 118chlorpheniramine maleate (ALLERGYRELIEF) 118chlorpheniramine maleate (ALLERGY) 118chlorpheniramine maleate (ALLERGY-TIME) 118chlorpheniramine maleate (CHLORHIST) 118chlorpheniramine maleate (CHLORTABS) 118chlorpheniramine maleate (ED CHLORPEDJR) 118chlorpheniramine maleate(PHARBECHLOR) 118chlorpheniramine maleate (WAL-FINATE) 118chlorpheniraminemaleatepseudoephedrinedextromethorphan (KIDKARE) 125chlorpromazine hcl 30CHLORPROMAZINE HCL 30chlorthalidone 58CHLORTHALIDONE 58cholecalciferol (vitamin d3) 110cholestyramine (with sugar) 59cholestyramineaspartame 59cholestyramineaspartame (PREVALITE) 59ciclopirox 21ciclopirox olamine 2122cilostazol 51CILOXAN (ciprofloxacin hcl) 13CIMDUO (lamivudinetenofovir disoproxilfumarate) 36cimetidine 80CIMETIDINE 80cimetidine (ACID REDUCER) 80
cimetidine (HEARTBURN RELIEF) 80cimetidine hcl 80cinacalcet hcl 110CINACALCET HCL 110ciprofloxacin hcl 13CIPROFLOXACIN HCL 13citalopram hydrobromide 18citric acidsodium citrate 86citric acidsodium citrate (CYTRA-2) 86citric acidsodium citrate (VIRTRATE-2) 86clarithromycin 12clemastine fumarate 119CLEOCIN (clindamycin phosphate) 9clindamycin hcl 9clindamycin palmitate hcl 9clindamycin phosphate 9CLINDAMYCIN PHOSPHATE 9CLINIMIX (amino acids 425 in dextrose 5 in water) 70clobetasol propionate 88CLOBETASOL PROPIONATE 88clomipramine hcl 19CLOMIPRAMINE HCL 19clonazepam 42clonidine hcl 51CLONIDINE HCL 51clopidogrel bisulfate 51clotrimazole 22CLOTRIMAZOLE 22clotrimazole (ANTIFUNGAL RINGWORM) 22clotrimazole (ANTIFUNGAL) 22clotrimazole (ATHLETES FOOT) 22clotrimazole (ATHLETIC FOOT CREAM) 22clotrimazole (CLOTRIMAZOLE AF) 22clotrimazole (ITCH RELIEF) 22clotrimazole (JOCK ITCH RELIEF) 22clotrimazole (JOCK ITCH) 22clotrimazole (RINGWORM) 22clozapine 34CLOZAPINE 34CLOZAPINE ODT 34
LAST UPDATED 12012020137
CLOZARIL (clozapine) 35COAGADEX (coagulation factor x) 48codeinephosphatebutalbitalaspirincaffeine 5codeine phosphateguaifenesin 125codeine phosphateguaifenesin(CHERATUSSIN AC) 125codeine phosphateguaifenesin (G TUSSINAC) 125codeine phosphateguaifenesin(GUAIATUSSIN AC) 125codeine phosphateguaifenesin(GUAIFENESIN AC) 125codeine phosphateguaifenesin (ROBAFENAC) 125codeine phosphateguaifenesin (VIRTUSSINAC) 125codeine sulfate 5CODEINE-GUAIFENESIN 125COGENTIN (benztropine mesylate) 29colchicine 24COLCHICINE 24COLESTID (colestipol hcl) 59colestipol hcl 59COMBIVENT RESPIMAT (ipratropiumbromidealbuterol sulfate) 125COMBIVIR (lamivudinezidovudine) 38COMPLERA (emtricitabinerilpivirinehcltenofovir disoproxil fumarate) 37condoms female 110condoms latex lubricated 110CORIFACT (factor xiii) 48CORTISPORIN (neomycin sulfatepolymyxin bsulfatehydrocortisone) 112CORTISPORIN(neomycinbacitracinpolymyxinbhydrocortisone) 67COUGH FORMULA DM(guaifenesindextromethorphan hbr) 125COUMADIN (warfarin sodium) 46CREON (lipaseproteaseamylase) 85
CRIXIVAN (indinavir sulfate) 40cromolyn sodium 110114cyanocobalamin (vitamin b-12) 73cyanocobalamin (vitamin b-12) (B-12DOTS) 73cyclobenzaprine hcl 130cyclopentolate hcl 112cyclophosphamide 26CYCLOPHOSPHAMIDE 26cyclosporine 104cyclosporine modified 104cyclosporine modified (GENGRAF) 104cyproheptadine hcl 119
Ddanazol 91dapsone 26DEBROX (carbamide peroxide) 116DELSTRIGO (doravirinelamivudinetenofovirdisoproxil fumarate) 37DELTASONE (prednisone) 88DEPAKENE (valproic acid (as sodium salt)(valproate sodium)) 15DEPAKENE (valproic acid) 15DEPO-PROVERA (medroxyprogesteroneacetate) 100DEPO-SUBQ PROVERA 104(medroxyprogesterone acetate) 100DESCOVY (emtricitabinetenofoviralafenamide fumarate) 39desipramine hcl 19desmopressin acetate 90DESMOPRESSIN ACETATE 90desmopressin acetate (non-refrigerated) 90desogestrel-ethinyl estradiol 91desogestrel-ethinyl estradiol (APRI) 91desogestrel-ethinyl estradiol (CYRED EQ) 91desogestrel-ethinyl estradiol (CYRED) 91desogestrel-ethinyl estradiol (EMOQUETTE) 91desogestrel-ethinyl estradiol (ENSKYCE) 91desogestrel-ethinyl estradiol (ISIBLOOM) 91
LAST UPDATED 12012020138
desogestrel-ethinyl estradiol (JULEBER) 91desogestrel-ethinyl estradiol (KALLIGA) 91desogestrel-ethinyl estradiol (RECLIPSEN) 91desogestrel-ethinyl estradiolethinylestradiol 92desogestrel-ethinyl estradiolethinyl estradiol(AZURETTE) 91desogestrel-ethinyl estradiolethinyl estradiol(BEKYREE) 92desogestrel-ethinyl estradiolethinyl estradiol(KARIVA) 92desogestrel-ethinyl estradiolethinyl estradiol(KIMIDESS) 92desogestrel-ethinyl estradiolethinyl estradiol(PIMTREA) 92desogestrel-ethinyl estradiolethinyl estradiol(SIMLIYA) 92desogestrel-ethinyl estradiolethinyl estradiol(VIORELE) 92desogestrel-ethinyl estradiolethinyl estradiol(VOLNEA) 92desonide 88DESONIDE 88dexamethasone 88DEXAMETHASONE 88dexamethasone (DEXAMETHASONEINTENSOL) 88dexamethasone sodium phosphate 114dextroamphetamine sulf-saccharateamphetamine sulf-aspartate 61dextroamphetamine sulfate 62DEXTROAMPHETAMINE SULFATE 62dextroamphetamine sulfate (ZENZEDI) 62DEXTROAMPHETAMINE-AMPHET ER 62dextrose 10 and 045 sodium chloride 70dextrose 10 in water 7073dextrose 5 and 045 sodium chloride 7073dextrose 5 in lactated ringers 73dextrose 5 in water 697073DEXTROSE IN WATER 74diazepam 1542
diclofenac sodium 2114dicloxacillin sodium 12DICYCLOMINE HCL 77dicyclomine hcl 77DIFFERIN (adapalene) 67diflunisal 2digoxin 56digoxin (DIGITEK) 56digoxin (DIGOX) 56DILANTIN (phenytoin sodium extended) 16DILANTIN (phenytoin) 16DILANTIN-125 16DILANTIN-125 (phenytoin) 16DILTIAZEM 24HR ER (CD) 54DILTIAZEM 24HR ER (XR) 55diltiazem hcl 55diltiazem hcl (CARTIA XT) 55diltiazem hcl (DILT-XR) 55diltiazem hcl (TAZTIA XT) 55DIMETHYL FUMARATE 65DIPHENHYDRAMINE HCL 120diphenhydramine hcl 120diphenhydramine hcl (ALER-CAPS) 119diphenhydramine hcl (ALKA-SELTZER PLUSALLERGY) 130diphenhydramine hcl (ALLER-G-TIME) 119diphenhydramine hcl (ALLERGYMEDICATION) 119diphenhydramine hcl (ALLERGYMEDICINE) 119diphenhydramine hcl (ALLERGY RELIEF) 119diphenhydramine hcl (ALLERGY) 119diphenhydramine hcl (BANOPHEN) 119diphenhydramine hcl (BENADRYLALLERGY) 119diphenhydramine hcl (CHILDRENS ALLERGYRELIEF) 119diphenhydramine hcl (CHILDRENSALLERGY) 119diphenhydramine hcl (CHILDRENS BENADRYLALLERGY) 119
LAST UPDATED 12012020139
diphenhydramine hcl (CHILDRENS WAL-DRYLALLERGY) 119diphenhydramine hcl (COMPLETEALLERGY) 119diphenhydramine hcl (COMPOZ) 130diphenhydramine hcl (DIPHEDRYLALLERGY) 119diphenhydramine hcl (DIPHEDRYL) 120diphenhydramine hcl (DIPHEN) 120diphenhydramine hcl (DIPHENHIST) 120diphenhydramine hcl (GERI-DRYL) 120diphenhydramine hcl (M-DRYL) 120diphenhydramine hcl (NIGHTTIME ALLERGYRELIEF) 120diphenhydramine hcl (NIGHTTIME SLEEPAID) 120130diphenhydramine hcl (NYTOL QUICKCAPS)130diphenhydramine hcl (PHARBEDRYL) 120diphenhydramine hcl (SILADRYL) 120diphenhydramine hcl (SIMPLY SLEEP) 120131diphenhydramine hcl (SLEEP AID) 120131diphenhydramine hcl (SLEEP II) 131diphenhydramine hcl (SLEEP TABLET) 131diphenhydramine hcl (TOTAL ALLERGY) 120diphenhydramine hcl (WAL-DRYLALLERGY) 120diphenhydramine hcl (WAL-DRYL) 120diphenoxylate hclatropine sulfate 79DIPHENOXYLATE-ATROPINE 79dipyridamole 51disopyramide phosphate 53disulfiram 6DIURIL (chlorothiazide) 58divalproex sodium 15DIVALPROEX SODIUM 15DOCUSATE SODIUM 82docusate sodium 82docusate sodium (COL-RITE) 82docusate sodium (DIOCTYL) 82docusate sodium (DOCU LIQUID) 82docusate sodium (DOCUSIL) 82
docusate sodium (DSS) 82docusate sodium (DULCOEASE) 82docusate sodium (DULCOLAX STOOLSOFTENER) 82docusate sodium (LAXA BASIC 100) 82docusate sodium (PHILLIPS LAXATIVE) 82docusate sodium (SOF-LAX) 82docusate sodium (STOOL SOFTENER) 82DOK (docusate sodium) 83donepezil hcl 17dorzolamide hcl 115dorzolamide hcltimolol maleate 115DORZOLAMIDE-TIMOLOL 115DOVATO (dolutegravir sodiumlamivudine) 39doxazosin mesylate 51DOXEPIN HCL 19doxepin hcl 19DOXYCYCLINE HYCLATE 14doxycycline hyclate 14doxycycline monohydrate 14DRITHOCREME HP (anthralin) 67dronabinol 21DROPLET MICRON PEN NEEDLE 110DROSPIRENONE-ETHINYL ESTRADIOL 92DROXIA (hydroxyurea) 27DRYSOL (aluminum chloride) 68duloxetine hcl 65
EEES 200 (erythromycin ethylsuccinate) 12EES 400 (erythromycin ethylsuccinate) 12EAR DROPS (carbamide peroxide) 116EDURANT (rilpivirine hcl) 37efavirenz 37EFAVIRENZ-EMTRIC-TENOFOV DISOP 37EFAVIRENZ-LAMIVU-TENOFOV DISOP 3637electrolytesdextrose (ELECTROLYTE) 74electrolytesdextrose (ORALYTE) 74electrolytesdextrose (PEDIATRICELECTROLYTE) 74
LAST UPDATED 12012020140
electrolytesdextrose (PEDIATRIC FREEZERPOPS) 74ELIQUIS (apixaban) 46ELIXOPHYLLIN (theophylline anhydrous) 124ELOCTATE (antihemophilic factor (fviii)recombinant fc fusion protein) 48EMCYT (estramustine phosphate sodium) 27EMSAM (selegiline) 18EMTRICITABINE 38EMTRICITABINE-TENOFOVIR DISOP 38EMTRIVA (emtricitabine) 38ENALAPRIL MALEATE 52enalapril maleate 52ENBREL 105ENBREL (etanercept) 104ENBREL SURECLICK (etanercept) 105ENGERIX-B ADULT (hepatitis b virus vaccinerecombinantpf) 106ENOXAPARIN SODIUM 46enoxaparin sodium 46entacapone 29EPIFOAM (hydrocortisone acetatepramoxinehcl) 68epinephrine 123EPIVIR (lamivudine) 38EPIVIR HBV (lamivudine) 35EPOGEN (epoetin alfa) 47EPZICOM (abacavir sulfatelamivudine) 38ERGOCALCIFEROL 110ergocalciferol (vitamin d2) 110ergocalciferol (vitamin d2) (CALCIDOL) 110ergotamine tartratecaffeine 25ERYTHROCIN STEARATE (erythromycinstearate) 12ERYTHROMYCIN 13erythromycin base 13erythromycin base in ethanol 13erythromycin base in ethanol (ERY) 13erythromycin basebenzoyl peroxide 9ERYTHROMYCIN ETHYLSUCCINATE 13erythromycin ethylsuccinate 13
escitalopram oxalate 18ESCITALOPRAM OXALATE 18ESPEROCT (antihemophilic factor (fviii) rec b-dom truncated peg-exei) 48estradiol 92ESTRADIOL 93estradiol (DOTTI) 92estrogensesterifiedmethyltestosterone 93estrogensesterifiedmethyltestosterone(COVARYX HS) 93estrogensesterifiedmethyltestosterone (EEMTHS) 93ethambutol hcl 26ETHAMBUTOL HCL 26ethinyl estradioldrospirenone 93ethinyl estradioldrospirenone (GIANVI) 93ethinyl estradioldrospirenone (JASMIEL) 93ethinyl estradioldrospirenone (LO-ZUMANDIMINE) 93ethinyl estradioldrospirenone (LORYNA) 93ethinyl estradioldrospirenone (NIKKI) 93ethinyl estradioldrospirenone (VESTURA) 93ETHOSUXIMIDE 14ethosuximide 14ethynodiol diacetate-ethinyl estradiol 93ethynodiol diacetate-ethinyl estradiol(KELNOR 1-35) 93ethynodiol diacetate-ethinyl estradiol(KELNOR 1-50) 93ethynodiol diacetate-ethinyl estradiol (ZOVIA1-35E) 93etodolac 2etonogestrelethinyl estradiol 94etonogestrelethinyl estradiol (ELURYNG) 93etoposide 28EVOTAZ (atazanavir sulfatecobicistat) 40EVZIO (naloxone hcl) 7EXCEDRIN EXTRA STRENGTH(aspirinacetaminophencaffeine) 2EXCEDRIN MIGRAINE(aspirinacetaminophencaffeine) 2
LAST UPDATED 12012020141
EYE ITCH RELIEF 114ezetimibe 59
Ffamotidine 81FAMOTIDINE 81famotidine (ACID CONTROLLER) 80famotidine (ACID REDUCER) 80famotidine (HEARTBURN PREVENTION) 81famotidine (HEARTBURN RELIEF) 81famotidine (PEPCID) 81FANAPT (iloperidone) 32FAZACLO (clozapine) 35FEIBA NF (anti-inhibitor coagulant complex) 48felodipine 55FELODIPINE ER 55fenofibrate 58FENOFIBRATE 58fenofibratemicronized 59fentanyl 4ferrous sulfate 74FERROUS SULFATE 74ferrous sulfate (CHILDRENS IRON) 74ferrous sulfate (FEOSOL) 74ferrous sulfate (FEROSUL) 74ferrous sulfate (FERRO-TIME) 74ferrous sulfate (FERROUSUL) 74ferrous sulfate (PEDIA IRON) 74fexofenadine hcl 121FEXOFENADINE HCL 121fexofenadine hcl (ALLER-EASE) 120fexofenadine hcl (ALLER-FEX) 120fexofenadine hcl (ALLERGY RELIEF) 121fexofenadine hcl (WAL-FEX ALLERGY) 121FIBRYGA (fibrinogen) 48finasteride 86flecainide acetate 53FLOVENT DISKUS (fluticasone propionate) 117FLOVENT HFA (fluticasone propionate) 117FLUAD 2020-2021 106FLUAD QUAD 2020-2021 106
FLUARIX QUAD 2020-2021 106FLUBLOK QUAD 2018-2019 (influenza virusvaccine qv 2018-19(18 yrs andolder)rcmbpf) 106FLUBLOK QUAD 2020-2021 107FLUCELVAX QUAD 2020-2021 107fluconazole 22FLUCONAZOLE 22fluconazole in dextrose iso-osmotic 22flucytosine 22FLUCYTOSINE 22fludrocortisone acetate 88FLULAVAL QUAD 2019-2020 (influenza virusvaccine quadrivalent 2019-20 (6 mos andup)) 107FLULAVAL QUAD 2020-2021 107fluocinolone acetonide 88fluocinonide 88FLUOCINONIDE 88fluoride (sodium) 74fluorometholone 114fluorouracil (ADRUCIL) 27fluoxetine hcl 18FLUOXETINE HCL 18fluoxymesterone (ANDROXY) 91fluphenazine decanoate 30fluphenazine hcl 30FLUPHENAZINE HCL 30flurazepam hcl 130flurbiprofen 2flurbiprofen sodium 114flutamide 27fluticasone propionate 117fluticasone propionate (ALLERGY RELIEF) 117fluticasone propionatesalmeterolxinafoate 126fluticasone propionatesalmeterol xinafoate(WIXELA INHUB) 126fluvoxamine maleate 18FLUZONE HIGH-DOSE QUAD 2020-21 107
LAST UPDATED 12012020142
FLUZONE QUAD 2019-2020 (influenza virusvaccine quadrival 2019-2020(6 mos andup)pf) 107FLUZONE QUAD 2020-2021 107FML FORTE (fluorometholone) 114FML SOP (fluorometholone) 114folic acid 74FOLIC ACID 74FORADIL (formoterol fumarate) 123FOSAMAX PLUS D (alendronatesodiumcholecalciferol (vitamin d3)) 110fosamprenavir calcium 40FOSAMPRENAVIR CALCIUM 40fosinopril sodium 52fosinopril sodiumhydrochlorothiazide 57FOSINOPRIL-HYDROCHLOROTHIAZIDE 57Freestyle Insulix Test Strips 110Freestyle Lite Test Strips 111Freestyle Test Strips 111furosemide 58FUZEON (enfuvirtide) 39
Ggabapentin 15GABAPENTIN 15GARDASIL 9 (human papillomavirus vaccine9-valentpf) 107GAS RELIEF 79GAS RELIEF (simethicone) 79GAS-X (simethicone) 79gemfibrozil 59GEMFIBROZIL 59gentamicin sulfate 8GENTAMICIN SULFATE 9gentamicin sulfate (GENTAK) 8GENTLE LAXATIVE 83GENVOYA(elvitegravircobicistatemtricitabinetenofovir alafenamide) 36GEODON (ziprasidone hcl) 32GEODON (ziprasidone mesylate) 32
GERI-DRYL 121glatiramer acetate 6566glatiramer acetate (GLATOPA) 65GLEOSTINE (lomustine) 26glimepiride 43glipizide 43GLUCAGON EMERGENCY KIT (glucagonhcl) 44GLUCAGON EMERGENCY KIT(glucagonhuman recombinant) 44glyburide 43glyburidemetformin hcl 43glycerin 83glycerin (ADULT GLYCERIN) 83glycerin (LAXATIVE SUPPOSITORY) 83glycerin (PEDIA-LAX) 83glycerin (SUPPOSITORY) 83GOCOVRI (amantadine hcl) 29granisetron hcl 21griseofulvin ultramicrosize 22griseofulvin microsize 23GUAIASORB DM 126guaifenesin (MUCUS ER) 126guaifenesin (MUCUS RELIEF ER) 126GUAIFENESIN-DEXTROMETHORPHAN 126guaifenesindextromethorphan hbr 128guaifenesindextromethorphan hbr (ADULTROBITUSSIN PEAK COLD DM) 126guaifenesindextromethorphan hbr (ADULTTUSSIN COUGH CONGEST DM) 126guaifenesindextromethorphan hbr (ADULTTUSSIN DM) 126guaifenesindextromethorphan hbr (ADULTWAL-TUSSIN DM) 126guaifenesindextromethorphan hbr(ANTITUSSIVE DM) 126guaifenesindextromethorphan hbr(BIOCOTRON) 126guaifenesindextromethorphan hbr (COUGHDM) 126
LAST UPDATED 12012020143
guaifenesindextromethorphan hbr (DIABETICSILTUSSIN-DM) 127guaifenesindextromethorphan hbr (DIABETICTUSSIN DM) 127guaifenesindextromethorphan hbr(EXPECTORANT DM) 127guaifenesindextromethorphan hbr (EXTRAACTION COUGH) 127guaifenesindextromethorphan hbr (GERI-TUSSIN DM) 127guaifenesindextromethorphan hbr (GILTUSSDIABETIC) 127guaifenesindextromethorphan hbr (GILTUSSHBP) 127guaifenesindextromethorphan hbr(GUAIASORB DM) 127guaifenesindextromethorphan hbr (RI-TUSSINDM) 127guaifenesindextromethorphan hbr (ROBAFENDM COUGH) 127guaifenesindextromethorphan hbr (ROBAFENDM COUGH-CHEST CONGEST) 127guaifenesindextromethorphan hbr (ROBAFENDM PEAK COLD) 127guaifenesindextromethorphan hbr(ROBAFEN-DM) 127guaifenesindextromethorphan hbr(SAFETUSSIN DM) 127guaifenesindextromethorphan hbr (SILTUSSINDM DAS) 127guaifenesindextromethorphan hbr (SILTUSSINDM) 128guaifenesindextromethorphan hbr(SORBUGEN NR) 128guaifenesindextromethorphan hbr (TUSNELDIABETIC) 128guaifenesindextromethorphan hbr (TUSSINCOUGH) 128guaifenesindextromethorphan hbr (TUSSINDM CLEAR) 128
guaifenesindextromethorphan hbr (TUSSINDM COUGH) 128guaifenesindextromethorphan hbr (TUSSINDM COUGH-CHEST CONGEST) 128guaifenesindextromethorphan hbr (TUSSINDM) 128guaifenesindextromethorphan hbr (ULTRADM FREE amp CLEAR) 128guaifenesindextromethorphan hbr (ULTRATUSS) 128guaifenesindextromethorphan hbr (WAL-TUSSIN DM) 128guaifenesinpseudoephedrine hcl 129guaifenesinpseudoephedrine hcl (MUCUSD) 128guaifenesinpseudoephedrine hcl (MUCUSRELIEF D) 128guanfacine hcl 5162
HHAILEY FE 94HALDOL (haloperidol lactate) 30HALDOL DECANOATE 100 (haloperidoldecanoate) 30HALDOL DECANOATE 50 (haloperidoldecanoate) 30haloperidol 31HALOPERIDOL 31haloperidol decanoate 31haloperidol lactate 31HALOPERIDOL LACTATE 31HAVRIX (hepatitis a virus vaccinepf) 107HEADACHE RELIEF 2HELIXATE FS (antihemophilic factor (fviii)recombinantfull length) 48HEMLIBRA (emicizumab-kxwh) 48HEMOFIL M (antihemophilic factor human) 48HEPARIN SODIUM 46heparin sodiumporcine 46heparin sodiumporcinepf 46
LAST UPDATED 12012020144
HEPLISAV-B (hepatitis b vaccinerecombinantvaccine adjuvant cpg1018pf) 107HEXALEN (altretamine) 26homatropine hbr 112homatropine hbr (HOMATROPAIRE) 112HUMALOG (insulin lispro) 45HUMALOG MIX 75-25 (insulin lispro protamineand insulin lispro) 45HUMALOG MIX 75-25 KWIKPEN (insulin lisproprotamine and insulin lispro) 45HUMATE-P (antihemophilic factor humanvonwillebrand factorhuman) 48HUMIRA (adalimumab) 105HUMIRA PEDIATRIC CROHNS(adalimumab) 105HUMIRA PEN (adalimumab) 105HUMIRA PEN CROHNS-UC-HS(adalimumab) 105HUMIRA PEN PSOR-UVEITS-ADOL HS(adalimumab) 105HUMIRA(CF) (adalimumab) 105HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 105HUMIRA(CF) PEN (adalimumab) 105HUMIRA(CF) PEN CROHNS-UC-HS(adalimumab) 105HUMIRA(CF) PEN PSOR-UV-ADOL HS(adalimumab) 105HUMULIN 70-30 (insulin nph humanisophaneinsulin regular human) 45HUMULIN 7030 KWIKPEN (insulin nph humanisophaneinsulin regular human) 45HUMULIN N (insulin nph human isophane) 45HUMULIN R (insulin regular human) 45HUMULIN R U-500 (insulin regular human) 45hydralazine hcl 60hydrochlorothiazide 58hydrocodone bitartrateacetaminophen 5hydrocodone bitartrateacetaminophen(LORCET HD) 5
hydrocodone bitartrateacetaminophen(LORTAB) 5hydrocortisone 89109HYDROCORTISONE 89hydrocortisone (ANTI-ITCH) 88hydrocortisone (ANUSOL-HC) 88hydrocortisone (COLOCORT) 109hydrocortisone (CORTISONE) 88hydrocortisone (CORTIZONE-10 PLUS) 89hydrocortisone (CORTIZONE-10) 89hydrocortisone (HYDROCREAM) 89hydrocortisone (NOBLE FORMULA HC) 89hydrocortisone (PREPARATION H) 89hydrocortisone (PROCTO-MED HC) 89hydrocortisone (PROCTO-PAK) 89hydrocortisone (PROCTOSOL-HC) 89hydrocortisone (PROCTOZONE-HC) 89hydrocortisone (SOOTHING CARE) 89HYDROCORTISONE ACETATE 89hydrocortisone acetate 89hydrocortisone acetate (ANUCORT-HC) 89hydrocortisone acetate (ANUSOL-HC) 89hydrocortisone acetate (HEMMOREX-HC) 89hydrocortisone acetatepramoxine hcl 68hydrocortisoneacetic acid 116hydrocortisoneacetic acid (ACETASOLHC) 116hydromorphone hcl 5HYDROXYCHLOROQUINE SULFATE 28hydroxychloroquine sulfate 28hydroxyprogesterone caproate 100hydroxyprogesterone caproatepf 100hydroxyurea 27hydroxyzine hcl 121HYDROXYZINE PAMOATE 121hydroxyzine pamoate 121hyoscyamine sulfate 77hyoscyamine sulfate (HYOSYNE) 77HYPERTET S-D (tetanus immuneglobulinpf) 106
LAST UPDATED 12012020145
Iibuprofen 3IBUPROFEN 3ibuprofen (ADDAPRIN) 2ibuprofen (I-PRIN) 3ibuprofen (IBU) 3ibuprofen (IBU-200) 3ibuprofen (PROVIL) 3ibuprofen (WAL-PROFEN) 3IDELVION (factor ix recombinantalbuminfusion protein) 48imipramine hcl 19IMIPRAMINE HCL 19IMOVAX RABIES VACCINE (rabies vaccinehuman diploid cellpf) 107INCRUSE ELLIPTA (umeclidinium bromide) 122indapamide 58indomethacin 3INFANTS GAS RELIEF 79inhalerassist device with large mask 111inhalerassist device with medium mask 111inhalerassist device with small mask 111insulin lispro 45INSULIN LISPRO PROTAMINE MIX (insulin lisproprotamine and insulin lispro) 45Insulin pen needles 111INSULIN SYRINGE 03 ML 111INSULIN SYRINGE 05 ML 111INSULIN SYRINGE 1 ML 111INTELENCE (etravirine) 37INTRON A (interferon alfa-2brecomb) 35INVEGA (paliperidone) 32INVEGA SUSTENNA (paliperidone palmitate)32INVEGA TRINZA (paliperidone palmitate) 32INVIRASE (saquinavir mesylate) 40IOPIDINE (apraclonidine hcl) 115ipratropium bromide 122ipratropium bromidealbuterol sulfate 129IPRATROPIUM-ALBUTEROL 129irbesartan 52
irbesartanhydrochlorothiazide 57IRON 74ISENTRESS (raltegravir potassium) 36ISENTRESS HD (raltegravir potassium) 36isoniazid 26ISOSORBIDE DINITRATE 60isosorbide dinitrate 60isosorbide mononitrate 60isotretinoin 68isotretinoin (AMNESTEEM) 68isotretinoin (CLARAVIS) 68isotretinoin (MYORISAN) 68isotretinoin (ZENATANE) 68itraconazole 23IXINITY (factor ix human recombinantthreonine 148) 49
JJAKAFI (ruxolitinib phosphate) 28JARDIANCE (empagliflozin) 43JENCYCLA 100JIVI (antihemophilic factor (fviii) rec b-domain deleted peg-aucl) 49JULUCA (dolutegravir sodiumrilpivirine hcl) 39
KKALETRA (lopinavirritonavir) 40KCENTRA (human prothrombin complexconcentrate (pcc) 4-factor) 49ketoconazole 23ketoprofen 3ketorolac tromethamine 114ketotifen fumarate 114ketotifen fumarate (ALLERGY EYE DROPS) 114ketotifen fumarate (EYE ITCH RELIEF) 114ketotifen fumarate (ITCHY EYE) 114ketotifen fumarate (WAL-ZYR) 114ketotifen fumarate (ZADITOR) 114KOGENATE FS (antihemophilic factor (fviii)recombinantfull length) 49
LAST UPDATED 12012020146
KOVALTRY (antihemophilic factor (fviii)recombinantfull length) 49
Llabetalol hcl 54LABETALOL HCL 54lactulose 83lactulose (CONSTULOSE) 83lactulose (ENULOSE) 83lactulose (GENERLAC) 83LAMISIL (terbinafine hcl) 23lamivudine 3538lamivudinezidovudine 38lamotrigine 15lancets 111LANOXIN (digoxin) 57lansoprazole 85LANSOPRAZOLE 85lanthanum carbonate 87latanoprost 115LATUDA (lurasidone hcl) 32leflunomide 106LEFLUNOMIDE 106letrozole 28LEUCOVORIN CALCIUM 27leucovorin calcium 27LEUKERAN (chlorambucil) 26leuprolide acetate 104levalbuterol tartrate 123LEVETIRACETAM 14levetiracetam 14LEVETIRACETAM ER 14LEVO-T (levothyroxine sodium) 103levobunolol hcl 115levocarnitine 70levocarnitine (with sugar) 70levofloxacin 13levonorgestrel 101levonorgestrel (AFTERA) 101levonorgestrel (ECONTRA EZ) 101levonorgestrel (ECONTRA ONE-STEP) 101
levonorgestrel (FALLBACK SOLO) 101levonorgestrel (MY CHOICE) 101levonorgestrel (MY WAY) 101levonorgestrel (NEW DAY) 101levonorgestrel (OPCICON ONE-STEP) 101levonorgestrel (OPTION 2) 101levonorgestrel (TAKE ACTION) 101LEVONORGESTREL-ETH ESTRADIOL 94levonorgestrelethinyl estradiol 96levonorgestrelethinyl estradiol (AFIRMELLE) 94levonorgestrelethinyl estradiol (ALTAVERA) 94levonorgestrelethinyl estradiol (AUBRA EQ) 94levonorgestrelethinyl estradiol (AUBRA) 94levonorgestrelethinyl estradiol (AVIANE) 94levonorgestrelethinyl estradiol (AYUNA) 94levonorgestrelethinyl estradiol (CHATEALEQ) 94levonorgestrelethinyl estradiol (CHATEAL) 94levonorgestrelethinyl estradiol (DELYLA) 94levonorgestrelethinyl estradiol (ENPRESSE) 94levonorgestrelethinyl estradiol (FALMINA) 95levonorgestrelethinyl estradiol (KURVELO) 95levonorgestrelethinyl estradiol (LARISSIA) 95levonorgestrelethinyl estradiol (LESSINA) 95levonorgestrelethinyl estradiol (LEVONEST) 95levonorgestrelethinyl estradiol (LEVORA-28)95levonorgestrelethinyl estradiol (LILLOW) 95levonorgestrelethinyl estradiol (LUTERA) 95levonorgestrelethinyl estradiol (MARLISSA) 95levonorgestrelethinyl estradiol (MYZILRA) 95levonorgestrelethinyl estradiol (ORSYTHIA) 95levonorgestrelethinyl estradiol (PORTIA) 96levonorgestrelethinyl estradiol (SRONYX) 96levonorgestrelethinyl estradiol (TRIVORA-28) 96levonorgestrelethinyl estradiol (VIENVA) 96levothyroxine sodium 103LEVOTHYROXINE SODIUM 103LEVOXYL (levothyroxine sodium) 103LEXIVA (fosamprenavir calcium) 40LICE KILLING 68
LAST UPDATED 12012020147
lidocaine hcl 6LIDOCAINE HCL VISCOUS 6lidocaine hclpf 6lisinopril 52lisinoprilhydrochlorothiazide 57lithium carbonate 42lithium citrate 42LITHOBID (lithium carbonate) 42loperamide hcl 79loperamide hcl (ANTI-DIARRHEAL) 79loperamide hcl (DIAMODE) 79loperamide hcl (ULTRA A-D) 79lopinavirritonavir 40loratadine 121122LORATADINE 122loratadine (ALLERCLEAR) 121loratadine (ALLERGY RELIEF) 121loratadine (ALLERGY) 121loratadine (CHILDRENS ALLERGY RELIEF) 121loratadine (CHILDRENS ALLERGY) 121loratadine (LORADAMED) 121loratadine (NON-DROWSY ALLERGY) 121loratadine (WAL-ITIN) 121lorazepam 42lorazepam (LORAZEPAM INTENSOL) 42LOSARTAN POTASSIUM 52losartan potassium 52losartan potassiumhydrochlorothiazide 57LOSARTAN-HYDROCHLOROTHIAZIDE 57LOTRIMIN AF (clotrimazole) 23lovastatin 59loxapine succinate 31LUCEMYRA (lofexidine hcl) 7LUPRON DEPOT-PED (leuprolide acetate) 104LYLLANA 96LYSODREN (mitotane) 28
MM-M-R II VACCINE (measles mumps andrubella vaccine livepf) 107MAGNESIUM CITRATE 83
magnesium citrate 83MARPLAN (isocarboxazid) 18MATULANE (procarbazine hcl) 26MAXI-TUSS G 129mebendazole (EMVERM) 28MECLIZINE HCL 20meclizine hcl 20meclizine hcl (DRAMAMINE LESS DROWSY) 20meclizine hcl (MEDI-MECLIZINE) 20meclizine hcl (MOTION RELIEF) 20meclizine hcl (MOTION SICKNESS II) 20meclizine hcl (MOTION SICKNESS RELIEF) 20meclizine hcl (MOTION SICKNESS) 20meclizine hcl (MOTION-TIME) 20meclizine hcl (TRAVEL-EASE) 20meclizine hcl (VERTICALM) 20meclizine hcl (WAL-DRAM 2) 20MEDROXYPROGESTERONE ACETATE 101medroxyprogesterone acetate 101mefloquine hcl 28megestrol acetate 101meloxicam 3melphalan 26memantine hcl 17MEMANTINE HCL 17MENACTRA (meningococcalvaccine acyw-135diphtheria toxoid conjpf) 107MENEST (estrogensesterified) 96MENQUADFI 107MENVEO A-C-Y-W-135-DIP(meningococcalvaccine acyw-135diphtheria toxoid conjpf) 108meperidine hcl 5mercaptopurine 27mesalamine 109MESTINON (pyridostigmine bromide) 25metaproterenol sulfate 123metformin hcl 43METFORMIN HCL ER 43METHADONE HCL 4methadone hcl 4
LAST UPDATED 12012020148
methadone hcl (METHADONE INTENSOL) 4methadone hcl (METHADOSE) 4methazolamide 115METHAZOLAMIDE 115methenaminemethylene bluesodphospsalicylatehyoscyamine(PHOSPHASAL) 9methenaminemethylene bluesodphospsalicylatehyoscyamine (URIN DS) 10methimazole 104methocarbamol 130METHOCARBAMOL 130METHOTREXATE 105methotrexate sodium 105methyclothiazide 58methyldopa 51methylergonovine maleate 111METHYLPHENIDATE ER 62methylphenidate hcl 62METHYLPHENIDATE HCL 62methylphenidate hcl (METADATE ER) 62methylprednisolone 89metoclopramide hcl 20metolazone 58metoprolol succinate 54METOPROLOL SUCCINATE 54metoprolol tartrate 54METRO IV (metronidazole in sodiumchloride) 10metronidazole 1068METRONIDAZOLE 10metronidazole in sodium chloride 10mexiletine hcl 53MEXILETINE HCL 53miconazole nitrate 23miconazole nitrate (ANTI-FUNGAL CREAM) 23miconazole nitrate (ANTIFUNGAL CREAM) 23miconazole nitrate (BAZA ANTIFUNGAL) 23miconazole nitrate (INZO ANTIFUNGAL) 23miconazole nitrate (LOTRIMIN AF) 23miconazole nitrate (MICATIN) 23
miconazole nitrate (SECURA ANTIFUNGAL) 23MICROGESTIN 96MICROGESTIN FE 96minocycline hcl 14minoxidil 60mirtazapine 17misoprostol 85modafinil 131moexipril hcl 52molindone hcl 31mometasone furoate 90MONISTAT 3 (miconazole nitrate) 23MONISTAT 7 (miconazole nitrate) 23MONONINE (factor ix) 49montelukast sodium 122MONTELUKAST SODIUM 122morphine sulfate 45moxifloxacin hcl 13MUCUS ER 129MUCUS RELIEF ER 129mupirocin 10mupirocin calcium 10MURINE EAR DROPS (carbamide peroxide) 116MURO-128 (sodium chloride) 112mycophenolate mofetil 105MYLERAN (busulfan) 27MYNATAL (prenatal vitamins withcalciumferrous fumaratefolic acid) 70
NNABI-HB (hepatitis b immune globulin) 106nadolol 54NADOLOL 54naloxone hcl 7naltrexone hcl 7NALTREXONE HCL 7naproxen 3naproxen sodium 3NARCAN (naloxone hcl) 8NARDIL (phenelzine sulfate) 18NASACORT (triamcinolone acetonide) 117
LAST UPDATED 12012020149
NASAL DECONGESTANT (pseudoephedrinehcl) 123nateglinide 43neomycin sulfate 9neomycin sulfatebacitracin zincpolymyxin b(ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxin b(FIRST AID ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxin b(TRIPLE ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxinbhydrocortisone 112neomycin sulfatebacitracin zincpolymyxinbhydrocortisone (NEO-POLYCIN HC) 112neomycin sulfatebacitracinpolymyxin b 113neomycin sulfatebacitracinpolymyxin b(NEO-POLYCIN) 113neomycin sulfatepolymyxin bsulfategramicidin d 113neomycin sulfatepolymyxin bsulfatehydrocortisone 113116NEOMYCIN-POLYMYXIN-HC 116neomycinpolymyxin bsulfatedexamethasone 113nevirapine 37NIACIN 60niacin 60niacin (ENDUR-ACIN) 59niacin (SLO-NIACIN) 59nicardipine hcl 55NICOTINE 14MG PATCH 8NICOTINE 21MG PATCH 8NICOTINE 2MG GUM 8NICOTINE 4MG GUM 8NICOTINE 7MG PATCH 8NICOTINE LOZENGE 8nicotine polacrilex 8nicotine polacrilex (QUIT 2) 8nicotine polacrilex (QUIT 4) 8nicotine polacrilex (STOP SMOKING AID) 8NICOTROL (nicotine) 8
NICOTROL NS (nicotine) 8NIFEDIPINE 55nifedipine 55nifedipine (AFEDITAB CR) 55nifedipine (NIFEDICAL XL) 55NIGHTTIME SLEEP AID 122nisoldipine 55NITRO-BID (nitroglycerin) 60nitrofurantoin 10NITROFURANTOIN 10nitrofurantoin macrocrystal 10nitrofurantoin monohydratemacrocrystals 10nitroglycerin 61NITROGLYCERIN 61nitroglycerin (MINITRAN) 60nitroglycerin (NITRO-TIME) 60nonoxynol 9 (VCF) 86norelgestrominethinyl estradiol (XULANE) 96norethindrone 102norethindrone (CAMILA) 101norethindrone (DEBLITANE) 101norethindrone (ERRIN) 101norethindrone (HEATHER) 102norethindrone (INCASSIA) 102norethindrone (JENCYCLA) 102norethindrone (JOLIVETTE) 102norethindrone (LYZA) 102norethindrone (NORA-BE) 102norethindrone (NORLYDA) 102norethindrone (NORLYROC) 102norethindrone (SHAROBEL) 102norethindrone (TULANA) 102norethindrone acetate 102norethindrone acetate-ethinyl estradiol 97norethindrone acetate-ethinyl estradiol(AUROVELA) 96norethindrone acetate-ethinyl estradiol(GILDESS) 96norethindrone acetate-ethinyl estradiol(HAILEY) 96
LAST UPDATED 12012020150
norethindrone acetate-ethinyl estradiol(JUNEL) 97norethindrone acetate-ethinyl estradiol(LARIN) 97norethindrone acetate-ethinyl estradiol(MICROGESTIN) 97norethindrone acetate-ethinylestradiolferrous fumarate 98norethindrone acetate-ethinylestradiolferrous fumarate (AUROVELA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (BLISOVI FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (JUNEL FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (LARIN FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (MICROGESTINFE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TARINA FE 1-20EQ) 97norethindrone acetate-ethinylestradiolferrous fumarate (TARINA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TILIA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TRI-LEGEST FE) 98norethindrone-ethinyl estradiol (ALYACEN) 98norethindrone-ethinyl estradiol (ARANELLE) 98norethindrone-ethinyl estradiol (BALZIVA) 98norethindrone-ethinyl estradiol (BRIELLYN) 98norethindrone-ethinyl estradiol (CYCLAFEM)98norethindrone-ethinyl estradiol (DASETTA) 98norethindrone-ethinyl estradiol (LEENA) 98norethindrone-ethinyl estradiol (NECON) 98norethindrone-ethinyl estradiol (NORTREL) 98norethindrone-ethinyl estradiol (PHILITH) 98norethindrone-ethinyl estradiol (PIRMELLA) 98norethindrone-ethinyl estradiol (VYFEMLA) 98norethindrone-ethinyl estradiol (WERA) 98
norethindrone-ethinyl estradiol (ZENCHENT) 98NORGESTIMATE-ETHINYL ESTRADIOL 100norgestimate-ethinyl estradiol 100norgestimate-ethinyl estradiol (ESTARYLLA) 98norgestimate-ethinyl estradiol (FEMYNOR) 99norgestimate-ethinyl estradiol (MILI) 99norgestimate-ethinyl estradiol (MONO-LINYAH) 99norgestimate-ethinyl estradiol(MONONESSA) 99norgestimate-ethinyl estradiol (PREVIFEM) 99norgestimate-ethinyl estradiol (SPRINTEC) 99norgestimate-ethinyl estradiol (TRIFEMYNOR) 99norgestimate-ethinyl estradiol (TRI-ESTARYLLA) 99norgestimate-ethinyl estradiol (TRI-LINYAH) 99norgestimate-ethinyl estradiol (TRI-LO-ESTARYLLA) 99norgestimate-ethinyl estradiol (TRI-LO-MARZIA) 99norgestimate-ethinyl estradiol (TRI-LO-MILI) 99norgestimate-ethinyl estradiol (TRI-LO-SPRINTEC) 99norgestimate-ethinyl estradiol (TRI-PREVIFEM) 99norgestimate-ethinyl estradiol (TRI-SPRINTEC) 99norgestimate-ethinyl estradiol (TRI-VYLIBRALO) 99norgestimate-ethinyl estradiol (TRI-VYLIBRA) 99norgestimate-ethinyl estradiol (TRINESSA LO)99norgestimate-ethinyl estradiol (TRINESSA) 99norgestimate-ethinyl estradiol (VYLIBRA) 99norgestrel-ethinyl estradiol (CRYSELLE) 100norgestrel-ethinyl estradiol (ELINEST) 100norgestrel-ethinyl estradiol (LOW-OGESTREL) 100norgestrel-ethinyl estradiol (OGESTREL) 100nortriptyline hcl 19NORVIR (ritonavir) 40
LAST UPDATED 12012020151
NOVOEIGHT (antihemophilic factor viiirecombinant b-domain truncated) 49NOVOLIN 70-30 (insulin nph humanisophaneinsulin regular human) 45NOVOLIN N (insulin nph human isophane) 45NOVOLIN R (insulin regular human) 45NOVOSEVEN RT (coagulation factor viia(recombinant)) 49NUPLAZID (pimavanserin tartrate) 32NUWIQ (antihemophilic factor viii rec hek cellb-domain deleted) 50NYSTATIN 23nystatin 23
OO-CAL PRENATAL (prenatal vit with calciumno127ferrous fumaratefolic acid) 70OBIZUR (antihemophilic factor viiirecombinant porcine sequence) 50ODEFSEY (emtricitabinerilpivirinehcltenofovir alafenamide fumarate) 37ofloxacin 13olanzapine 33olanzapinefluoxetine hcl 17OMEGA-3 ACID ETHYL ESTERS 60omega-3 acid ethyl esters 60omeprazole 85OMEPRAZOLE 85ondansetron 21ondansetron hcl 21ORAP (pimozide) 31oseltamivir phosphate 41OSELTAMIVIR PHOSPHATE 41OSMOLEX ER (amantadine hcl) 29oxazepam 42oxcarbazepine 16oxybutynin chloride 86OXYBUTYNIN CHLORIDE ER 86oxycodone hcl 46oxycodone hclacetaminophen 6oxycodone hclacetaminophen (ENDOCET) 6
oxycodone hclaspirin 6OXYTROL FOR WOMEN (oxybutynin) 86OYSTER SHELL CALCIUM 74OYSTER SHELL CALCIUM-VIT D3 74
PPAIN amp FEVER (acetaminophen) 64PAIN RELIEF 64paliperidone 33pantoprazole sodium 85PANTOPRAZOLE SODIUM 85PARNATE (tranylcypromine sulfate) 18paromomycin sulfate 9paroxetine hcl 18PEDIATRIC IRON 75pediatric multivit with acd3 no21sodiumfluoride 75pediatric multivitamin no16sodiumfluoride 75pediatric multivitamin no2sodium fluoride 75pediatric multivitamin no45sodiumfluorideferrous sulfate 75pediatric multivitamins no17 with sodiumfluoride 75peg 3350sod sulfsod bicarbsodchloridepotassium chloride 83peg 3350sod sulfsod bicarbsodchloridepotassium chloride (GAVILYTE-C) 83peg 3350sod sulfsod bicarbsodchloridepotassium chloride (GAVILYTE-G) 83PEG-3350 AND ELECTROLYTES 83PEGINTRON REDIPEN (peginterferon alfa-2b) 35PEN NEEDLE 111pen needle diabetic 111pen needle diabetic disposable safety 111pen needle diabetic remover and disposalunit 111pen needle diabetic safety 111penicillamine 86PENICILLAMINE 86
LAST UPDATED 12012020152
penicillin v potassium 12pentoxifylline 57PEPTO-BISMOL (bismuth subsalicylate) 79PEPTO-BISMOL TO-GO (bismuthsubsalicylate) 79permethrin 29permethrin (LICE TREATMENT) 29perphenazine 20PERSERIS (risperidone) 33PHENAZOPYRIDINE HCL 87phenazopyridine hcl 87phenazopyridine hcl (URINARY PAIN RELIEF) 86phenelzine sulfate 18phenobarbital 15PHENOBARBITAL 15PHENOXYBENZAMINE HCL 51phenoxybenzamine hcl 51phenylephrine hcl 113phenylephrine hclpromethazine hcl 129phenytoin 16phenytoin sodium extended 16PHOS-FLUR (fluoride (sodium)) 66PHOSPHOLINE IODIDE (echothiophateiodide) 115phytonadione (vit k1) 50PIFELTRO (doravirine) 37pilocarpine hcl 115PILOCARPINE HCL 115pimecrolimus 68pimozide 31pindolol 54pioglitazone hcl 43PIOGLITAZONE HCL 44piperonyl butoxidepyrethrins (LICE KILLING)68piperonyl butoxidepyrethrins (LICE PYRINYLSHAMPOO) 68piperonyl butoxidepyrethrins (LICETREATMENT) 68piperonyl butoxidepyrethrins (RID) 68piperonyl butoxidepyrethrinspermethrin(COMPLETE LICE TREATMENT) 69
piperonyl butoxidepyrethrinspermethrin(LICE SOLUTION) 69piroxicam 3PLAN B ONE-STEP (levonorgestrel) 102PLEGRIDY (peginterferon beta-1a) 66PLEGRIDY PEN (peginterferon beta-1a) 66PNEUMOVAX 23 (pneumococcal 23-valentpolysaccharide vaccine) 108podofilox 69POLY-VITAMIN (multivitamin) 75polyethylene glycol 3350 84polyethylene glycol 3350 (CLEARLAX) 83polyethylene glycol 3350 (GAVILAX) 84polyethylene glycol 3350 (GENTLELAX) 84polyethylene glycol 3350 (GLYCOLAX) 84polyethylene glycol 3350 (LAXACLEAR) 84polyethylene glycol 3350 (NATURA-LAX) 84polyethylene glycol 3350 (POWDERLAX) 84polyethylene glycol 3350 (PURELAX) 84polyethylene glycol 3350 (SMOOTHLAX) 84polymyxin b sulfatetrimethoprim 113POTASSIUM 75potassium bicarbonatecitric acid 75potassium bicarbonatecitric acid (EFFER-K)75potassium bicarbonatecitric acid (KEFFERVESCENT) 75potassium bicarbonatecitric acid (KLOR-CON-EF) 75POTASSIUM CHL-NORMAL SALINE 75potassium chloride 7075POTASSIUM CHLORIDE 71potassium chloride (KLOR-CON M10) 70potassium chloride (KLOR-CON M20) 70potassium chloride (KLOR-CON SPRINKLE) 75potassium chloride in 09 sodiumchloride 7071potassium chloridepotassiumbicarbonatecitric acid 75potassium gluconate 76pramipexole di-hcl 29pramoxine hclcalamine (CALAHIST) 69
LAST UPDATED 12012020153
pramoxine hclcalamine (CALAMINEMEDICATED) 69praziquantel 28prazosin hcl 51PRAZOSIN HCL 51PRED MILD (prednisolone acetate) 114prednisolone 90prednisolone (MILLIPRED DP) 90prednisolone (MILLIPRED) 90prednisolone acetate 114prednisolone sodium phosphate 90114prednisone 90prednisone (PREDNISONE INTENSOL) 90pregabalin 65PREGABALIN 65PREMARIN (estrogens conjugated) 100PREMPHASE (estrogensconjugatedmedroxyprogesteroneacetate) 100PREMPRO (estrogensconjugatedmedroxyprogesteroneacetate) 100PRENATABS FA (prenatal vits with calciumno78ferrous fumaratefolic acid) 71PRENATABS RX (prenatal vitamin with calciumno76ironcarbonylfolic acid) 71PRENATAL MULTIVITAMIN 76prenatal vit with calcium no129ferrousfumaratefolic acid 76prenatal vit with calcium no130ferrousfumaratefolic acid 76prenatal vitamins no121ferrousfumaratefolic acid 76prenatal vitamins with calciumferrousfumaratefolic acid 76prenatal vitamins with calciumferrousfumaratefolic acid (MYNATAL PLUS) 71prenatal vitamins with calciumferrousfumaratefolic acid (MYNATAL-Z) 71prenatal vits with calcium 118ferrousfumaratefolic acid 76
prenatal vits with calcium 118ferrousfumaratefolic acid (SE-NATAL 19) 71prenatal vits with calcium 136ferrousfumaratefolic acid (VINATE-M) 71prenatal vits with calcium 137ferrousfumaratefolic acid 76prenatal vits with calcium 95ferrousfumaratefolic acid 76prenatal vits with calcium no115ironfumaratefolic acid 71prenatal vits with calcium no72ferrousfumaratefolic acid 71prenatal vits with calcium no72ferrousfumaratefolic acid (M-NATAL PLUS) 71prenatal vits with calcium no72ferrousfumaratefolic acid (PREPLUS) 71prenatal vits with calciumno72ironcarbonylfolic acid 72prenatal vits with calcium no74ferrousfumaratefolic acid 72prenatal vits with calcium no96ferrousfumaratefolic acid 76PREVACID (lansoprazole) 85PREVNAR 13 (pneumococcal 13-valentconjugate vaccine (diphtheria crm)pf) 108PREZCOBIX (darunavirethanolatecobicistat) 40PREZISTA (darunavir ethanolate) 40PRIFTIN (rifapentine) 26primaquine phosphate 28primidone 15probenecid 24probenecidcolchicine 24PROBUPHINE (buprenorphine hcl) 7prochlorperazine 20prochlorperazine (COMPRO) 20prochlorperazine maleate 20PROCRIT (epoetin alfa) 47PROCTOFOAM-HC (hydrocortisoneacetatepramoxine hcl) 69
LAST UPDATED 12012020154
PROFILNINE (factor ix complex prothrombincplx conc(pcc) no4 3-factor) 50promethazine hcl 21122PROMETHAZINE HCL 122promethazine hcl (PHENADOZ) 21promethazine hcl (PROMETHEGAN) 21promethazine hclcodeine 129promethazine hcldextromethorphan hbr 129PROMETHAZINE-DM 129promethazinephenylephrine hclcodeine 129propafenone hcl 53propantheline bromide 77proparacaine hcl 113propranolol hcl 54propylthiouracil 104pseudoephedrine hcl 123pseudoephedrine hcl (NASALDECONGESTANT) 123pseudoephedrine hcl (SUDOGEST) 123pseudoephedrine hcl (SUPHEDRIN) 123pseudoephedrine hcl (SUPHEDRINE SINUSCONGESTION) 123pseudoephedrine hcl (SUPHEDRINE) 123pseudoephedrine hcl (WAL-PHED) 123PULMICORT FLEXHALER (budesonide) 117pyrazinamide 26pyridostigmine bromide 25pyridoxine hcl (vitamin b6) 76
Qquetiapine fumarate 33quinapril hcl 52quinidine gluconate 53quinidine sulfate 53QVAR REDIHALER (beclomethasonedipropionate) 117
RRABAVERT (rabies vaccine purified chickenembryo cell (pcec)pf) 108ramipril 52
RAMIPRIL 53REBINYN (factor ix (human) recombinantpegylated) 50RECOMBINATE (antihemophilic factor viiihuman recombinant) 50RECOMBIVAX HB (hepatitis b virus vaccinerecombinantpf) 108RELENZA (zanamivir) 41RESCRIPTOR (delavirdine mesylate) 37REXULTI (brexpiprazole) 33REYATAZ (atazanavir sulfate) 41RHEUMATREX (methotrexate sodium) 105RIASTAP (fibrinogen) 50ribavirin 36ribavirin (RIBASPHERE) 36RID (permethrin) 111RID (piperonylbutoxidepyrethrinspermethrin) 69RIDAURA (auranofin) 106rifabutin 26rifampin 26riluzole 65RILUZOLE 65ringers solution 7076RISPERDAL (risperidone) 33RISPERDAL CONSTA (risperidonemicrospheres) 33RISPERDAL M-TAB (risperidone) 33risperidone 33ritonavir 41RIXUBIS (factor ix human recombinant) 50rizatriptan benzoate 25ropinirole hcl 29rosuvastatin calcium 59RUKOBIA 39
Ssalsalate 3SANDIMMUNE (cyclosporine) 105SANTYL (collagenase clostridiumhistolyticum) 69
LAST UPDATED 12012020155
SAPHRIS (asenapine maleate) 33SAVELLA (milnacipran hcl) 65SE-NATAL-19 (prenatal vitamins no119ironfumaratefolic acid) 72SECUADO (asenapine) 33selegiline hcl 30selenium sulfide 69selenium sulfide (ANTI-DANDRUFF) 69selenium sulfide (MEDICATED DANDRUFFSHAMPOO) 69selenium sulfide (SELSUN BLUE) 69selenium sulfidealoe vera (SELSUN BLUEMOISTURIZING) 69SELZENTRY (maraviroc) 39SEREVENT DISKUS (salmeterol xinafoate) 123SEROQUEL (quetiapine fumarate) 34SEROQUEL XR (quetiapine fumarate) 34sertraline hcl 18sevelamer carbonate 87SEVENFACT 50SHINGRIX (varicella-zoster virus glycoproteinerecas01b adjuvantpf) 108SILACE (docusate sodium) 84sildenafil citrate 124SILDENAFIL CITRATE 124silver sulfadiazine 13simethicone 80simethicone (GAS RELIEF) 80simethicone (GAS-X) 80simethicone (INFANT GAS RELIEF) 80simethicone (INFANTS GAS RELIEF) 80simethicone (MI-ACID) 80simvastatin 59sirolimus 105SODIUM CHLORIDE 7677sodium chloride 113sodium chloride (MURO-128) 113sodium chloride for inhalation 129sodium chloride irrigating solution 707277sodium chloride irrigating solution (AQUACARE SODIUM CHLORIDE) 77
sodium chloride irrigating solution (CURITY) 77sodium chloridesodiumbicarbonatepotassium chloridepeg 84sodium chloridesodiumbicarbonatepotassium chloridepeg(GAVILYTE-N) 84sodium chloridesodiumbicarbonatepotassium chloridepeg (TRILYTEWITH FLAVOR PACKETS) 84sodium polystyrene sulfonate 72sodium polystyrene sulfonatesorbitol solution(KIONEX) 72sodiumpotassiumpotassium citratesodiumcitratecit ac 87sodiumpotassiumpotassium citratesodiumcitratecit ac (CYTRA-3) 87sodiumpotassiumpotassium citratesodiumcitratecit ac (TRICITRATES) 87sofosbuvirvelpatasvir 35SOTALOL 53SOTALOL AF 53sotalol hcl 53sotalol hcl (SORINE) 53spironolactone 58SPIRONOLACTONE 58spironolactonehydrochlorothiazide 57SPS (sodium polystyrene sulfonatesorbitolsolution) 72SSD (silver sulfadiazine) 13stavudine 38STOMACH RELIEF 80STOOL SOFTENER 84STOOL SOFTENER (docusate sodium) 84STRIBILD(elvitegravircobicistatemtricitabinetenofovir disoproxil) 36SUBLOCADE (buprenorphine) 4SUBOXONE (buprenorphine hclnaloxonehcl) 7sucralfate 85SUDAFED (pseudoephedrine hcl) 123
LAST UPDATED 12012020156
sulfacetamide sodium 13sulfacetamide sodiumprednisolone sodiumphosphate 113sulfamethoxazoletrimethoprim 13sulfasalazine 109SULFATRIM (sulfamethoxazoletrimethoprim)14sulindac 3SUMATRIPTAN 25sumatriptan 25sumatriptan succinate 25SUMATRIPTAN SUCCINATE 25SUSTIVA (efavirenz) 37SYMBYAX (olanzapinefluoxetine hcl) 18SYMFI (efavirenzlamivudinetenofovirdisoproxil fumarate) 36SYMFI LO (efavirenzlamivudinetenofovirdisoproxil fumarate) 37SYMTUZA (darunavirethcobicistatemtricitabinetenofoviralafenamide) 41SYNAREL (nafarelin acetate) 104SYNJARDY (empagliflozinmetformin hcl) 44SYNJARDY XR (empagliflozinmetformin hcl) 44SYNTHROID (levothyroxine sodium) 103syringe with needle insulin safety 1 ml 111syringe with needledisposableinsulin 1 ml 111syringe with needleinsulin03 ml 111syringe with needleinsulin05 ml 112
TTABLOID (thioguanine) 27tacrolimus 69106TACROLIMUS 106tadalafil 124tadalafil (ALYQ) 124TAKE ACTION (levonorgestrel) 102TAMOXIFEN CITRATE 27tamoxifen citrate 27tamsulosin hcl 86TDVAX (tetanus and diphtheria toxoidsadult) 108
TECFIDERA (dimethyl fumarate) 66TEGRETOL (carbamazepine) 16TEGRETOL XR (carbamazepine) 16temazepam 130TEMIXYS (lamivudinetenofovir disoproxilfumarate) 36temozolomide 27TENIVAC (tetanus and diphtheria toxoidsadsorbed adultpf) 108tenofovir disoproxil fumarate 38terazosin hcl 52TERAZOSIN HCL 52terbinafine hcl 24terbinafine hcl (ANTIFUNGAL) 24terbinafine hcl (ATHLETES FOOT AF) 24terbinafine hcl (ATHLETES FOOT) 24terbinafine hcl (JOCK ITCH) 2444terbinafine hcl (LAMISIL AT) 24TERBUTALINE SULFATE 123terbutaline sulfate 124testosterone 91testosterone cypionate 91tetanus and diphtheria toxoids adult 108THALOMID (thalidomide) 27THEO-24 (theophylline anhydrous) 124theophylline anhydrous 124theophylline anhydrous (THEOCHRON) 124thioridazine hcl 31thiothixene 31thyroidpork (NP THYROID) 103timolol maleate 115TIMOLOL MALEATE 115tioconazole 24TIVICAY (dolutegravir sodium) 36TIVICAY PD 36tizanidine hcl 35TOBRADEX (tobramycindexamethasone) 113tobramycin 9tobramycindexamethasone 113TOBREX (tobramycin) 9tolbutamide 44
LAST UPDATED 12012020157
tolmetin sodium 3tolnaftate 24tolnaftate (ANTIFUNGAL CREAM) 24tolnaftate (ATHLETES FOOT) 24tolnaftate (FUNGOID-D) 24topiramate 16TOPIRAMATE 16TOREMIFENE CITRATE 27toremifene citrate 27tramadol hcl 6TRAMADOL HCL 6trandolapril 53tranylcypromine sulfate 18TRAVEL SICKNESS (meclizine hcl) 21TRAZODONE HCL 19trazodone hcl 19tretinoin 28TRETTEN (factor xiii a-subunit recombinant) 50TRI-VI-SOL (vitamin a palmitateascorbicacidcholecalciferol (vit d3)) 77triamcinolone acetonide 6690117TRIAMCINOLONE ACETONIDE 66triamcinolone acetonide (ORALONE) 66triamterenehydrochlorothiazide 57triazolam 130trifluoperazine hcl 31trifluridine 41TRIGLIDE (fenofibrate nanocrystallized) 59trihexyphenidyl hcl 29trimethobenzamide hcl 21trimethoprim 10TRINATE (prenatal vits with calciumno73ferrous fumaratefolic acid) 72TRIPLE ANTIBIOTIC 11TRIPLE ANTIBIOTIC (neomycinsulfatebacitracin zincpolymyxin b) 11triprolidine hclpseudoephedrine hcl(APRODINE) 129triprolidine hclpseudoephedrine hcl (ED A-HIST PSE) 129
triprolidine hclpseudoephedrine hcl(RITIFED) 129triprolidine hclpseudoephedrine hcl (WAL-ACT D COLD amp ALLERGY) 129TRIUMEQ (abacavir sulfatedolutegravirsodiumlamivudine) 39TRIZIVIR (abacavirsulfatelamivudinezidovudine) 38TROGARZO (ibalizumab-uiyk) 39trospium chloride 86TROSPIUM CHLORIDE 86TRULICITY 44TRULICITY (dulaglutide) 44TRUMENBA (neisseria meningitidis group blipidated fhbp recombinant) 108TRUVADA (emtricitabinetenofovir disoproxilfumarate) 39TWINRIX (hepatitis a virus and hepatitis b virusvaccinepf) 108TYBOST (cobicistat) 39
UUNIFINE PENTIPS MAXFLOW 112UNITHROID (levothyroxine sodium) 103URETRON D-S (methenaminemethylenebluesod phospsalicylatehyoscyamine) 11URINARY PAIN RELIEF 87ursodiol 80
Vvalacyclovir hcl 41valproic acid 15VALPROIC ACID 15valproic acid (as sodium salt) (valproatesodium) 15valsartan 52valsartanhydrochlorothiazide 57VANADOM 130VANDAZOLE (metronidazole) 11VAQTA (hepatitis a virus vaccinepf) 109
LAST UPDATED 12012020158
VARIVAX VACCINE (varicella virus vaccinelivepf) 109VEMLIDY (tenofovir alafenamide) 35venlafaxine hcl 19VENLAFAXINE HCL ER 19verapamil hcl 55VERSACLOZ (clozapine) 35VICTOZA 2-PAK (liraglutide) 44VICTOZA 3-PAK (liraglutide) 44VIRACEPT (nelfinavir mesylate) 41VIRAMUNE (nevirapine) 38VIRAMUNE XR (nevirapine) 38VIREAD (tenofovir disoproxil fumarate) 39VITAMIN B-12 77VITAMIN C 77VITEKTA (elvitegravir) 36VIVITROL (naltrexone microspheres) 7VONVENDI (von willebrand factor(recombinant)) 50VRAYLAR (cariprazine hcl) 34
Wwarfarin sodium 46warfarin sodium (JANTOVEN) 46WILATE (antihemophilic factor humanvonwillebrand factorhuman) 50
XXARELTO (rivaroxaban) 4647XYNTHA (antihemophilic factor (factor viii)recombb-domain deleted) 51XYNTHA SOLOFUSE (antihemophilic factor(factor viii) recombb-domain deleted) 51
Zzaleplon 130ZERIT (stavudine) 39ZIAGEN (abacavir sulfate) 39ziprasidone hcl 34ZIPRASIDONE HCL 34ZIPRASIDONE MESYLATE 34
ziprasidone mesylate 34zolpidem tartrate 130zonisamide 14ZOSTAVAX (zoster vaccine livepf) 109ZOVIA 1-35 100ZUBSOLV (buprenorphine hclnaloxone hcl) 7ZYPREXA (olanzapine) 34ZYPREXA RELPREVV (olanzapine pamoate) 34ZYPREXA ZYDIS (olanzapine) 34
LAST UPDATED 12012020159
iv
What are drug tiers
Drugs are placed into drug tiers
Drug Tier What Does it mean
Covered (Tier 1) These drugs are covered on the Drug
List (Formulary) at $0 co-payment
Medi-Cal Carve Out (Tier 2) These drugs are carved out by the
Department of Health Care Services
This means these drugs are covered by
the Medi-Cal Fee-for Service program
and can be billed to the State
Medical Benefit (Tier 3) These drugs may be available at the
doctorrsquos office or medical setting
How to read the formulary
The column titled ldquoCoverage Requirements and Limitationsrdquo shows how the drug is covered
and if there are limits
Coverage Requirements
and Limitations
What does it stand for What does it mean
AL1 Age Restrictions We cover some drugs only
for some ages
PA Prior Authorization
Required
Your doctor must ask for
approval from us before
we cover some drugs
QL Quantity Limit We only cover some drugs
for a certain amount
ST Step Therapy Required In some cases you must
first try certain drugs
before we cover another
drug for your condition
STAR Extended Day Supply You may fill this drug for a
90 day supply
MDD Max Daily Dose We limit the amount of this
drug covered per day
C Custom This drug has special limits
QLC Quantity Limit (Custom) We limit the amount of this
drug covered each fill or
within a time frame
SP Specialty Pharmacy A network specialty
pharmacy will fill this drug
v
How often will the formulary change
The formulary may change monthly Some changes that can happen without notice include
bull When we remove a brand name drug if a generic is available
bull When we remove a drug taken off the market because the Food and Drug
Administration (FDA) has found it unsafe or if the manufacturer has removed it
bull When we add a drug to the formulary or if we remove a limit (like prior authorization or
step therapy)
Changes to formulary that we will notify you of at least 30 days before include
bull When we remove a drug or dosage form
bull When we add or change limits on the drug
What is a medical benefit drug
A medical benefit drug is a drug that usually is given as an injection or infusion in a medical
setting
What if my drug requires a prior authorization or step therapy
A prior authorization means that your doctor asks for approval for the drug because it is
medically necessary A step therapy means that you need to try certain drugs before we
cover your drug
You may ask for an exception by calling Customer Care at (800) 605-2556 (Los Angeles
County) or (855) 699-5557 (San Diego County) Or your doctor can call us at (877) 792-2731 or
fax at (866) 712-2731 to request that drug be covered
What if my drug is not on the Blue Shield of California Promise Health Plan Medi-
Cal Formulary
If your doctor gives you a drug that is not on the drug list you can ask your doctor for another
drug that is on formulary or you may request for us to cover the drug (exception) by calling
Customer Care at (800) 605-2556 (Los Angeles County) or (855) 699-5557 (San Diego County)
Your doctor can call us at (877) 792-2731 or fax at (866) 712-2731 to request that drug be
covered
You might now take a drug and your doctor still prescribes it If the drug is safe and effective
for your condition we will continue to cover it if we covered it before
vi
Participating retail pharmacies
You can fill prescriptions at any participating pharmacy (network pharmacy) unless it is for a
specialty drug You may find a network pharmacy by visiting
httpspromiseblueshieldcacomcapharmacysearchversion=2020amplob=mcal
What are specialty drugs
Specialty drugs require extra training before you take them extra visits with your doctor need
special handling and transport and are usually high-cost These drugs may require prior
authorization or non-formulary exception If approved a network specialty pharmacy will
deliver them by mail Please visit wwwblueshieldcacompromisemedi-cal for more
information
What if I have additional questions
If you want a copy of the Blue Shield of California Promise Health Plan Medi-Cal Formulary or
have questions please call Customer Care at (800) 605-2556 (Los Angeles County) or (855)
699-5557 (San Diego County)
Blue Shield of California Promise Health Plan
601 Potrero Grande Drive Monterey Park CA 91755
vii
H5928_19_269A2_C 08302019
Blu
e S
hie
ld o
f C
alif
orn
ia P
rom
ise
He
alth
Pla
n is
an
ind
ep
en
de
nt
lice
nse
e o
f th
e B
lue
Sh
ield
Ass
oc
iatio
n
A512
47-C
MS (
91
8)
Discrimination is Against the Law
Blue Shield of California Promise Health Plan complies with applicable state laws and federal civil rights laws and does not discriminate on the basis of race color national origin ancestry religion sex marital status gender gender identity sexual orientation age or disability Blue Shield of California Promise Health Plan does not exclude people or treat them differently because of race color national origin ancestry religion sex marital status gender gender identity sexual orientation age or disability
Blue Shield of California Promise Health Plan provides bull Aids and services at no cost to people with disabilities to communicate effectively with us
such aso Qualified sign language interpreterso Written information in other formats (large print audio accessible electronic
formats other formats)bull Language services at no cost to people whose primary language is not English such as
o Qualified interpreterso Information written in other languages
If you need these services contact the Blue Shield of California Promise Health Plan Civil Rights Coordinator
If you believe that Blue Shield of California Promise Health Plan has failed to provide these
services or discriminated in another way on the basis of race color national origin
ancestry religion sex marital status gender gender identity sexual orientation age or
disability you can file a grievance with
Blue Shield of California Promise Health Plan
Civil Rights Coordinator
601 Potrero Grande Dr
Monterey Park CA 91755
Phone (844) 883-2233 (TTY 711)
Fax (323) 889-2228
Email BSCPHPCivilRightsblueshieldcacom
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 Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD)
Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language Assistance Notice for LA County
viii
English
ATTENTION Language assistance services free of charge are available to you Call 1-800-605-
2556 (TTY 711)
繁體中文 (Chinese)
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1-800-605-2556(TTY
711)
한국어 (Korean)
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-800-
605-2556 (TTY 711)번으로 전화해 주십시오
Русский (Russian)
ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги
перевода Звоните 1-800-605-2556 (телетайп 711)
Kreyogravel Ayisyen (Haitian-Creole)
ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele 1-
800-605-2556 (TTY 711)
Franccedilais (French)
ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes
gratuitement Appelez le 1-800-605-2556 (TTY 711)
Portuguecircs (Portuguese)
ATENCcedilAtildeO Se fala portuguecircs encontram-se disponiacuteveis serviccedilos linguiacutesticos graacutetis Ligue para 1-
800-605-2556 (TTY 711)
Italiano (Italian)
ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza
linguistica gratuiti Chiamare il numero 1-800-605-2556 (TTY 711)
(Farsi) فارسی
2556-605-800-1 با باشد می فراهم شما برای رایگان بصورت زبانی تسهیلات کنید می گفتگو فارسی زبان به اگر توجه
(TTY 771) بگیرید تماس
ह िदी (Hindi)
धयान द यदद आप द िदी बोलत तो आपक ललए मफत म भाषा स ायता सवाएि उपलबध 1-800-605-
2556 (TTY 711) पर कॉल करHmong (Hmong)
LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb rau koj Hu rau
1-800-605-2556 (TTY 711)
Espantildeol (Spanish)
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica
Llame al 1-800-605-2556 (TTY 711)
Language Assistance Notice for LA County (Continued)
ix
Tiếng Việt (Vietnamese)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-
800-605-2556 (TTY 711)
Tagalog (Tagalog - Filipino)
PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa
wika nang walang bayad Tumawag sa 1-800-605-2556 (TTY 711)
(Arabic) العربية
2556-605-800-1مجان اتصل برقم ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بال
(711YTT)
Polski (Polish)
UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń
pod numer 1-800-605-2556 (TTY 711)
ພາສາລາວ (Lao)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ ໂທຣ 1-800-605-2556 (TTY 711)
日本語 (Japanese)
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1-800-605-
2556(TTY711)までお電話にてご連絡ください
ภาษาไทย (Thai)
เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-800-605-2556 (TTY 711)
λληνικά (Greek)
ΠΡΟΣΟΧΗ Αν μιλάτε ελληνικά στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης
οι οποίες παρέχονται δωρεάν Καλέστε 1-800-605-2556 (TTY 711)
ਪਜਾਬੀ ਦ (Punjabi)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-800-605-
2556 (TTY 711) ਤ ਕਾਲ ਕਰ
ខមែរ (Cambodian)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល
គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-800-605-2556 (TTY 711)
Հայերեն (Armenian)
ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող են
տրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք 1-800-605-2556
(TTY (հեռատիպ)711)
Language Assistance Notice for San Diego County
x
English
ATTENTION Language assistance services free of charge are available to you
Call 1-855-699-5557 (TTY 711)
繁體中文 (Chinese)
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1-855-699-5557(TTY
711)
한국어 (Korean)
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-855-
699-5557 (TTY 711)번으로 전화해 주십시오
Русский (Russian)
ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные
услуги перевода Звоните 1-855-699-5557 (телетайп 711)
Italiano (Italian)
ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di
assistenza linguistica gratuiti Chiamare il numero 1-855-699-5557 (TTY 711)
(Farsi) فارسی
-699-855-1 با باشد می فراهم شما برای رایگان بصورت زبانی تسهیلات کنید می گفتگو فارسی زبان به اگر توجه
5557 (TTY 771) بگیرید تماس
ह िदी (Hindi)
धयान द यदद आप द िदी बोलत तो आपक ललए मफत म भाषा स ायता सवाएि उपलबध 1-855-699-
5557 (TTY 711) पर कॉल कर
Hmong (Hmong)
LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb
rau koj Hu rau 1-855-699-5557 (TTY 711)
Espantildeol (Spanish)
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia
linguumliacutestica Llame al 1-855-699-5557 (TTY 711)
Tiếng Việt (Vietnamese)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho
bạn Gọi số 1-855-699-5557 (TTY 711)
Tagalog (Tagalog - Filipino)
PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga
serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-855-699-5557 (TTY
711)
Language Assistance Notice for San Diego County (Continued)
xi
(Arabic) العربية
5557-699-855-1 برقم اتصل بالمجان لك تتوافر اللغویة المساعدة خدمات فإن اللغة اذكر تتحدث كنت إذا ملحوظة
(711YTT)
ພາສາລາວ (Lao)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ ໂທຣ 1-855-699-5557 (TTY 711)
日本語 (Japanese)
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1-855-699-
5557(TTY711)までお電話にてご連絡ください
ภาษาไทย (Thai)
เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-855-699-5557 (TTY 711)
ਪਜਾਬੀ ਦ (Punjabi)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-855-
699-5557 (TTY 711) ਤ ਕਾਲ ਕਰ
ខមែរ (Cambodian)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល
គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-855-699-5557 (TTY 711)
Հայերեն (Armenian)
ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող են
տրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք 1-855-699-
5557 (TTY (հեռատիպ)711)
Categorical List of Prescription DrugsANALGESICS (Drugs for Pain) 1
ANESTHETICS (Drugs for Numbing) 6
ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS (Drugs for AddictionSubstance Abuse) 6
ANTIBACTERIALS (Drugs for Bacterial Infections) 8
ANTICONVULSANTS (Drugs for Seizures) 14
ANTIDEMENTIA AGENTS (Drugs for Alzheimers Disease and Dementia) 17
ANTIDEPRESSANTS (Drugs for Depression) 17
ANTIEMETICS (Drugs for Nausea and Vomiting) 20
ANTIFUNGALS (Drugs for Fungal Infections) 21
ANTIGOUT AGENTS (Drugs for Gout) 24
ANTIMIGRAINE AGENTS (Drugs for Migraine) 25
ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis) 25
ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections) 26
ANTINEOPLASTICS (Drugs for Cancer) 26
ANTIPARASITICS (Drugs for Parasitic Infections) 28
ANTIPARKINSON AGENTS (Drugs for Parkinsons Disease) 29
ANTIPSYCHOTICS (Drugs for Mental Health) 30
ANTISPASTICITY AGENTS (Drugs for Muscle Spasm) 35
ANTIVIRALS (Drugs for Viral Infections) 35
ANXIOLYTICS (Drugs for Anxiety) 41
BIPOLAR AGENTS (Drugs for Bipolar Disorder) 42
BLOOD GLUCOSE REGULATORS (Drugs for Diabetes) 42
BLOOD PRODUCTSMODIFIERSVOLUME EXPANDERS (Drugs for Blood Disorders) 46
CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation) 51
CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions) 61
DENTAL AND ORAL AGENTS (Drugs for the Mouth) 66
DERMATOLOGICAL AGENTS (Drugs for the Skin) 66
ELECTROLYTESMINERALSMETALSVITAMINS 69
GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach) 77
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERS TREATMENT (Drugs for Genetic or
Enzyme Disorders) 85
GENITOURINARY AGENTS (Drugs for the Genital Bladder and Kidney) 86
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (ADRENAL) (Drugs for
ReplacingStimulating Adrenal Gland Hormones) 87
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (PITUITARY) (Drugs for
ReplacingStimulating Pituitary Gland Hormones) 90
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEX HORMONESMODIFIERS) (Drugs
for ReplacingStimulating Sex Hormones) 91
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (THYROID) (Drugs for the Thyroid) 102
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs for Suppressing Hormones from the Pituitary
Gland) 104
HORMONAL AGENTS SUPPRESSANT (THYROID) (Drugs for the Thyroid) 104
LAST UPDATED 12012020
IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing the Immune System) 104
INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for Inflammatory Bowel Disease) 109
METABOLIC BONE DISEASE AGENTS (Drugs for the Bone) 109
MISCELLANEOUS THERAPEUTIC AGENTS 110
OPHTHALMIC AGENTS (Drugs for the Eyes) 112
OTIC AGENTS (Drugs for the Ears) 116
RESPIRATORY TRACTPULMONARY AGENTS (Drugs for the Lungs) 116
SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles) 130
SLEEP DISORDER AGENTS (Drugs for Insomnia) 130
LAST UPDATED 12012020
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANALGESICS (Drugs for Pain)
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (Pain and ArthritisDrugs)
aspirin (ADULT ASPIRIN REGIMEN)81 mg tablet dr
1-Covered
aspirin (ADULT LOW DOSE ASPIRINEC) 81 mg tablet dr
1-Covered
aspirin (ASPIR 81) mg tablet dr ) 1-Covered
aspirin (ASPIR-TRIN) 325 mg tabletdr -
1-Covered
aspirin (ASPIRIN) 325 mg tablet 1-Covered
aspirin (ECOTRIN) 81 mg tablet dr 1-Covered
aspirin (ECPIRIN) 325 mg tablet dr 1-Covered
aspirin (ST JOSEPH ASPIRIN EC) 81mg tablet dr
1-Covered
aspirin (ST JOSEPH ASPIRIN) 81 mgtab chew
1-Covered
aspirin 325mg tablet 1-Covered
aspirin 81 mg tab chew 81 mgtablet dr 325 mg tablet
1-Covered
ASPIRIN 81MG TABLET ASPIRIN81MG TABLET ASPIRIN 81MGTABLET
1-Covered
aspirinacetaminophencaffeine(ADDED STRENGTH HEADACHE)250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(BAYER MIGRAINE) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(EXTRA PAIN RELIEF) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(EXTRAPRIN) 250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(HEADACHE RELIEF) 250-250-65tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
1
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
aspirinacetaminophencaffeine(MIGRAINE FORMULA) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(MIGRAINE RELIEF) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(PAIN RELIEVER PLUS) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(PAIN RELIEVER) 250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(PAIN-OFF) 250-250-65 tablet -
1-Covered
butalbitalaspirincaffeine 50-325-40 capsule
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
butalbitalaspirincaffeine 50-325-40 tablet
1-Covered
celecoxib 50 mg capsule 100 mgcapsule 200 mg capsule 400 mgcapsule
1-Covered ST
CELECOXIB 50 MG CAPSULE 100MG CAPSULE 200 MG CAPSULE400 MG CAPSULE
1-Covered ST
CHILDRENS IBUPROFEN CHILD 200MG10 ML CHILDREN 100 MG5 ML
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
diclofenac sodium 25 mg tablet dr50 mg tablet dr 75 mg tablet dr100 mg tab er 24h
1-Covered
diflunisal 500 mg tablet 1-Covered
etodolac 600 mg tab er 24h 1-Covered PA
EXCEDRIN EXTRA STRENGTH(aspirinacetaminophencaffeine)CAPLET
1-Covered
EXCEDRIN MIGRAINE(aspirinacetaminophencaffeine)CAPLET GELTAB
1-Covered
flurbiprofen 50 mg tablet 100 mgtablet
1-Covered
HEADACHE RELIEF HM 250-250-65MG CPLT
1-Covered
ibuprofen (ADDAPRIN) 200 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
2
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ibuprofen (I-PRIN) 200 mg tablet - 1-Covered
ibuprofen (IBU) 400 mg tablet 600mg tablet 800 mg tablet
1-Covered
ibuprofen (IBU-200) mg tablet -) 1-Covered
ibuprofen (PROVIL) 200 mg tablet 1-Covered
ibuprofen (WAL-PROFEN) 200 mgtablet -
1-Covered
ibuprofen 100 mg5ml oral susp 1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
IBUPROFEN 400 MG TABLET 600 MGTABLET 800 MG TABLET
1-Covered
ibuprofen 50 mg125 drops susp100 mg tab chew 200 mg tablet400 mg tablet 600 mg tablet 800mg tablet
1-Covered
indomethacin 25 mg capsule 50mg capsule 75 mg capsule er
1-Covered
ketoprofen 50 mg capsule 75 mgcapsule
1-Covered
meloxicam 75 mg tablet 15 mgtablet
1-Covered
naproxen 250 mg tablet 375 mgtablet 500 mg tablet
1-Covered
naproxen sodium 275 mg tablet550 mg tablet
1-Covered
piroxicam 10 mg capsule 20 mgcapsule
1-Covered
salsalate 500 mg tablet 750 mgtablet
1-Covered
sulindac 150 mg tablet 200 mgtablet
1-Covered
tolmetin sodium 200 mg tablet 400mg capsule 600 mg tablet
1-Covered
OPIOID ANALGESICS LONG-ACTING (Long-acting Narcotic PainRelievers)
BELBUCA (buprenorphine hcl) 75MCG FILM 150 MCG FILM 300MCG FILM 450 MCG FILM 600MCG FILM 750 MCG FILM 900MCG FILM
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
3
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
buprenorphine 5 mcghr patch75 mcghr patch 10 mcghrpatch 15 mcghr patch 20mcghr patch
2-MedicalCarve out
BUTRANS (buprenorphine) 5MCGHR PATCH 75 MCGHRPATCH 10 MCGHR PATCH 15MCGHR PATCH 20 MCGHRPATCH
2-MedicalCarve out
fentanyl 25 mcghr patch50mcghr patch 75mcghr patch100 mcghr patch
1-Covered PA QL (10 PER 30 DAY(S))
methadone hcl (METHADONEINTENSOL) 10 mgml oral conc
1-Covered PA
methadone hcl (METHADOSE) 40mg tablet sol
1-Covered PA
METHADONE HCL 10 MG TABLET 1-Covered QL (60 PER 30 DAYS)
METHADONE HCL 10 MGML ORALCONC
1-Covered PA
methadone hcl 5 mg tablet 10 mgtablet
1-Covered QL (60 PER 30 DAYS)
methadone hcl 5 mg5 ml solution10 mg5 ml solution 10 mgml oralconc
1-Covered PA
morphine sulfate 15 mg tablet er 1-Covered QL (90 PER 30 DAYS)
morphine sulfate 30 mg tablet er 1-Covered QL (60 PER 30 DAYS)
morphine sulfate 60 mg tablet er100 mg tablet er 200 mg tablet er
1-Covered PA
oxycodone hcl 10 mg tab er 20mg tab er 40 mg tab er 80 mgtab er
1-Covered PA QL (60 PER 30 DAYS)
SUBLOCADE (buprenorphine) 100MG05 ML SYRING 300 MG15 MLSYRING
2-MedicalCarve out
OPIOID ANALGESICS SHORT-ACTING (Short-acting Narcotic PainRelievers)
acetaminophen with codeinephosphate -15mg tablet -30mgtablet -60mg tablet
1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old) QLC (LIMIT 100TABS TOTAL APAPCODEINETABLETS PER MONTH)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
4
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acetaminophen with codeinephosphate 120-12mg5 solution
1-Covered QL (240 PER 30 DAYS) AL1 (Atleast 12 yrs old)
butorphanol tartrate 10 mgmlspray
1-Covered PA
codeinephosphatebutalbitalaspirincaffeine codeinebutalbitalasacaffein30-50-325 capsule
1-Covered QL (60 PER 30 DAYS) AL1 (At least12 yrs old)
codeine sulfate 15 mg tablet 30mg tablet 60 mg tablet
1-Covered PA AL1 (At least 12 yrs old)
hydrocodonebitartrateacetaminophen(LORCET HD)hydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAY(S))
hydrocodonebitartrateacetaminophen(LORTAB)hydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAY(S))
hydrocodonebitartrateacetaminophenhydrocodoneacetaminophen 5mg-325mg tablethydrocodoneacetaminophen75-325 mg tablethydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS OF HYDROCODONEPRODUCTS PER 30 DAYS)
hydromorphone hcl 1 mgml liquid3 mg supprect
1-Covered
hydromorphone hcl 2 mg tablet 4mg tablet 8 mg tablet
1-Covered QL (60 PER 30 DAYS)
meperidine hcl 50 mg tablet 100mg tablet
1-Covered QL (100 PER 30 DAYS)
morphine sulfate 10 mg5 ml 20mg5 ml 100 mg5ml
1-Covered PA
morphine sulfate 15 mg tablet 30mg tablet
1-Covered QL (90 PER 30 DAYS)
morphine sulfate 30 mg supprect 1-Covered QL (24 PER 30 DAY(S)) QLC (LIMIT24 SUPPOSITORIES IN 30 DAYS)
morphine sulfate 5 mg 10 mg 20mg
1-Covered QL (24 PER 30 DAY(S)) QLC (LIMIT24 SUPPOSITORIES IN 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
5
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
oxycodone hcl 5 mg capsule 5mg tablet 5 mg5 ml solution 15mg tablet 20 mgml oral conc 30mg tablet
1-Covered PA
oxycodone hclacetaminophen(ENDOCET) 5 mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS PER 30 DAYS OF TOTALOXYCODONE APAP ANDOXYCODONE ASA PER MONTH)
oxycodone hclacetaminophen 5mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS PER 30 DAYS OF TOTALOXYCODONE APAP ANDOXYCODONE ASA PER MONTH)
oxycodone hclacetaminophen 5-3255 ml solution
1-Covered PA
oxycodone hclaspirin 48355-325tablet
1-Covered QL (100 PER 30 DAY(S))
tramadol hcl 50 mg tablet 1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old)
TRAMADOL HCL 50 MG TABLET 1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old)
ANESTHETICS (Drugs for Numbing)
LOCAL ANESTHETICS (Skin Numbing Drugs)lidocaine hcl 10 mgml vial 1-Covered PA
lidocaine hcl 2 solution 1-Covered
LIDOCAINE HCL VISCOUS 2 SOLN 1-Covered
lidocaine hclpf 10 mgml vial 10mgml ampul
1-Covered PA
ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS (Drugs forAddictionSubstance Abuse)
ALCOHOL DETERRENTSANTI-CRAVING (Drugs for AlcoholDependence)
acamprosate calcium 333 mgtablet dr
2-MedicalCarve out
disulfiram 250 mg tablet 500 mgtablet
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
6
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
naltrexone hcl 50 mg tablet 2-MedicalCarve out
NALTREXONE HCL 50 MG TABLET 2-MedicalCarve out
VIVITROL (naltrexonemicrospheres) 380 MG VIAL +DILUENT
2-MedicalCarve out
OPIOID DEPENDENCE TREATMENTS (Drugs for Opioid Dependence)BUNAVAIL (buprenorphinehclnaloxone hcl) 21-03 MG FILM42-07 MG FILM 63-1 MG FILM
2-MedicalCarve out
BUPRENEX (buprenorphine hcl) 03MGML AMPUL
2-MedicalCarve out
buprenorphine hcl 03 mgml vial03 mgml cartridge 2 mg tab subl8 mg tab subl
2-MedicalCarve out
buprenorphine hclnaloxone hclnaloxone 2 mg-05mg filmnaloxone 2 mg-05mg tab sublnaloxone 4mg-1mg filmnaloxone 8 mg-2 mg filmnaloxone 8 mg-2 mg tab subl
2-MedicalCarve out
LUCEMYRA (lofexidine hcl) 018 MGTABLET
2-MedicalCarve out
PROBUPHINE (buprenorphine hcl)742 MG IMPLANT
2-MedicalCarve out
SUBOXONE (buprenorphinehclnaloxone hcl) 2 MG-05 MGFILM 4 MG-1 MG FILM 8 MG-2 MGFILM 12 MG-3 MG FILM
2-MedicalCarve out
ZUBSOLV (buprenorphinehclnaloxone hcl) 07-018 MGTABLET 14-036 MG TABLET 29-071 MG TABLET 57-14 MG TABLET86-21 MG TABLET 114-29 MGTABLET
2-MedicalCarve out
OPIOID REVERSAL AGENTS (Drugs for Opioid Overdose)EVZIO (naloxone hcl) 04 MGAUTO- 2 MG AUTO-
2-MedicalCarve out
naloxone hcl 04 mgml cartridge04 mgml vial 1 mgml syringe 2mg04ml auto injct
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
7
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NARCAN (naloxone hcl) 4 MGNASAL SPRAY
2-MedicalCarve out
SMOKING CESSATION AGENTS (Drugs to Help Quit Smoking)bupropion hcl (BUPROBAN) 150 mgtab er 12h
1-Covered QL (2 PER 1 DAY(S))
bupropion hcl 150 mg tab er 12h 1-Covered QL (2 PER 1 DAY(S))
CHANTIX (varenicline tartrate) 05MG TABLET 1 MG TABLET 1 MGCONT MONTH BOX STARTINGMONTH BOX
1-Covered PA
nicotine 14mg patch 1-Covered QL (1 PER 1 DAY(S))
nicotine 21mg patch 1-Covered QL (1 PER 1 DAY(S))
nicotine 2mg gum 1-Covered QL (24 PER 1 DAY(S))
nicotine 4mg gum 1-Covered QL (24 PER 1 DAY(S))
nicotine 7mg patch 1-Covered QL (1 PER 1 DAY(S))
NICOTINE LOZENGE 2 MGLOZENGE HM 2 MG LOZENGE 4MG LOZENGE HM 4 MG LOZENGE
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (QUIT 2) mglozenge )
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (QUIT 4) mglozenge )
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (STOP SMOKINGAID) 2 mg 4 mg
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex 2 mg 4 mg 1-Covered QL (24 PER 1 DAY(S))
NICOTROL (nicotine) CARTRIDGEINHALER
1-Covered PA
NICOTROL NS (nicotine) 10 MGMLSPRAY
1-Covered PA
ANTIBACTERIALS (Drugs for Bacterial Infections)
AMINOGLYCOSIDESgentamicin sulfate (GENTAK) 03 oint (g)
1-Covered
gentamicin sulfate 01 oint (g)01 cream (g) 03 oint (g) 03 drops
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
8
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GENTAMICIN SULFATE 01 CREAM 1-Covered
neomycin sulfate 500 mg tablet 1-Covered
paromomycin sulfate 250 mgcapsule
1-Covered
tobramycin 03 drops 1-Covered
TOBREX (tobramycin) 03 EYEOINTMENT
1-Covered
ANTIBACTERIALS OTHERbacitracin (BACITRAYCIN PLUS) 500unitg oint (g)
1-Covered
bacitracin 500 unitg packet 500unitg oint (g)
1-Covered
BACITRACIN 500 UNITGM OINTMNT 1-Covered
bacitracin zinc (ANTIBIOTIC) 500unitg oint (g)
1-Covered
bacitracin zinc 500 unitg ointpack 500 unitg oint (g)
1-Covered
BACITRACIN ZINC ZN 500 UNITGMOINT
1-Covered
CLEOCIN (clindamycin phosphate)100 MG VAGINAL OVULE
1-Covered
clindamycin hcl 75 mg capsule150 mg capsule 300 mg capsule
1-Covered
clindamycin palmitate hcl 75 mg5ml soln recon
1-Covered
clindamycin phosphate 1 gel(gram) 1 lotion 1 med swab1 solution 1 gel daily 2 creamappl
1-Covered
CLINDAMYCIN PHOSPHATE 1SOLUTION 1 GEL
1-Covered
erythromycin basebenzoylperoxide erythromycinbenzoyl 3-5 gel (gram)
1-Covered ST
methenaminemethylenebluesodphospsalicylatehyoscyamine(PHOSPHASAL) methmebluesodphospsalhyos 816-108 tablet
1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
9
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
methenaminemethylenebluesodphospsalicylatehyoscyamine(URIN DS) methmebluesodphospsalhyos 816-108 tablet
1-Covered PA
METRO IV (metronidazole in sodiumchloride) 500 MG100 ML
1-Covered
metronidazole 075 gel wappl250 mg tablet 375 mg capsule500 mg tablet
1-Covered
METRONIDAZOLE 250 MG TABLET500 MG TABLET
1-Covered
metronidazole in sodium chloridemetronidazolesodium 500mg01lpiggyback
1-Covered PA
mupirocin 2 oint (g) 1-Covered QL (22 PER 30 DAY(S))
mupirocin calcium 2 cream (g) 1-Covered PA
neomycin sulfatebacitracinzincpolymyxin b (ANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
neomycin sulfatebacitracinzincpolymyxin b (FIRST AIDANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
neomycin sulfatebacitracinzincpolymyxin b (TRIPLEANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
nitrofurantoin 25 mg5 ml oral susp 1-Covered
NITROFURANTOIN 50 MG CAP 100MG CAP
1-Covered
nitrofurantoin macrocrystal 50 mgcapsule 100 mg capsule
1-Covered
nitrofurantoinmonohydratemacrocrystalsmonohydm-100 mg capsule
1-Covered
trimethoprim 100 mg tablet 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
10
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRIPLE ANTIBIOTIC (neomycinsulfatebacitracin zincpolymyxinb) CURAD OINT MEDI-FIRSTMEDICHOICE OINTMENTOINTMENT PKT
1-Covered
TRIPLE ANTIBIOTIC HM PKT 1-Covered
URETRON D-S(methenaminemethylenebluesodphospsalicylatehyoscyamine) -TABLET
1-Covered PA
VANDAZOLE (metronidazole)VAGINAL 075 GEL
1-Covered
BETA-LACTAM CEPHALOSPORINScefaclor 125 mg5ml susp recon250 mg5ml susp recon 250 mgcapsule 375 mg5ml susp recon500 mg capsule
1-Covered
CEFDINIR 125 MG5 ML SUSP 250MG5 ML SUSP
1-Covered QL (200 PER 10 DAY(S))
cefdinir 125 mg5ml 250 mg5ml 1-Covered QL (200 PER 10 DAY(S))
cefdinir 300 mg capsule 1-Covered QL (20 PER 10 DAY(S))
cephalexin 125 mg5ml susprecon 250 mg capsule 250mg5ml susp recon 500 mgcapsule
1-Covered
BETA-LACTAM PENICILLINSamoxicillin 125 mg5ml susp recon125 mg tab chew 200 mg5mlsusp recon 250 mg tab chew 250mg5ml susp recon 250 mgcapsule 400 mg5ml susp recon500 mg tablet 500 mg capsule875 mg tablet
1-Covered
AMOXICILLIN-CLAVULANATEPOTASS -600-429 MG5 ML SUS
1-Covered QL (300 PER FILL) QLC (1 FILL IN 30DAYS)
AMOXICILLIN-CLAVULANATEPOTASS -875-125 MG TABLET
1-Covered
amoxicillinpotassium clavulanate1000-625 tab er 12h
1-Covered QL (40 PER FILL(S)) MFL (1 30day(s))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
11
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
amoxicillinpotassium clavulanate200-2855 susp recon 200-285mgtab chew 250-125 mg tablet 400-57mg5 susp recon 400-57mg tabchew 500-125 mg tablet 875-125mg tablet
1-Covered
amoxicillinpotassium clavulanate600-4295 susp recon
1-Covered QL (300 PER FILL) QLC (1 FILL IN 30DAYS)
ampicillin trihydrate 125 mg5mlsusp recon 250 mg capsule 250mg5ml susp recon 500 mgcapsule
1-Covered
dicloxacillin sodium 250 mgcapsule 500 mg capsule
1-Covered
penicillin v potassium 125 mg5mlsoln recon 250 mg5ml soln recon250 mg tablet 500 mg tablet
1-Covered
MACROLIDESazithromycin 1 g packet 1-Covered QL (1 PER 30 DAYS)
azithromycin 100 mg5ml 200mg5ml
1-Covered
AZITHROMYCIN 200 MG5 ML SUSP 1-Covered
azithromycin 250 mg tablet 1-Covered QL (6 PER FILL(S)) MFL (2 30day(s))
AZITHROMYCIN 250 MG TABLET 1-Covered QL (6 PER FILL(S)) MFL (2 30day(s))
azithromycin 500 mg tablet 1-Covered QL (3 PER FILL(S)) MFL (2 30day(s))
AZITHROMYCIN 500 MG TABLET 1-Covered QL (3 PER FILL(S)) MFL (2 30day(s))
azithromycin 600 mg tablet 1-Covered QL (2 PER 7 DAY(S)) MFL (8 28day(s))
clarithromycin 500 mg tablet 1-Covered ST
EES 200 (erythromycinethylsuccinate) MG5 MLSUSPENSION
1-Covered
EES 400 (erythromycinethylsuccinate) FILMTAB
1-Covered
ERYTHROCIN STEARATE(erythromycin stearate) 250 MGFILMTAB
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
12
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ERYTHROMYCIN 250 MG 500 MG 1-Covered
erythromycin base 5 mggramoint (g) 250 mg capsule dr 250mg tablet dr 250 mg tablet 333mg tablet dr 500 mg tablet 500mg tablet dr
1-Covered
erythromycin base in ethanol (ERY)2 med swab
1-Covered
erythromycin base in ethanol 2 solution 2 med swab
1-Covered
ERYTHROMYCIN ETHYLSUCCINATE200 MG5 ML SUSP
1-Covered
erythromycin ethylsuccinate 200mg5ml susp recon 400 mg tablet
1-Covered
QUINOLONESCILOXAN (ciprofloxacin hcl) 03OINTMENT
1-Covered
ciprofloxacin hcl 03 drops 1-Covered
ciprofloxacin hcl 100 mg tablet 1-Covered PA AL1 (At least 18 yrs old)
ciprofloxacin hcl 250 mg tablet500 mg tablet 750 mg tablet
1-Covered AL1 (At least 18 yrs old)
CIPROFLOXACIN HCL 500 MG TAB 1-Covered AL1 (At least 18 yrs old)
levofloxacin 250 mg tablet 500 mgtablet 750 mg tablet
1-Covered AL1 (At least 18 yrs old)
moxifloxacin hcl 400 mg tablet 1-Covered PA AL1 (At least 18 yrs old)
ofloxacin 03 drops 1-Covered QL (5 PER 30 DAY(S))
SULFONAMIDESBLEPH-10 (sulfacetamide sodium) - EYE DROPS
1-Covered
silver sulfadiazine 1 cream (g) 1-Covered
SSD (silver sulfadiazine) 1 CREAM 1-Covered
sulfacetamide sodium 10 oint(g) 10 drops
1-Covered
sulfamethoxazoletrimethoprim200-40mg5 oral susp 400mg-80mgtablet 800-16020 oral susp 800-160 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
13
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SULFATRIM(sulfamethoxazoletrimethoprim)PEDIATRIC SUSPENSION
1-Covered
TETRACYCLINESDOXYCYCLINE HYCLATE 100 MGCAP
1-Covered AL1 (At least 8 yrs old)
doxycycline hyclate 100 mgcapsule
1-Covered AL1 (At least 8 yrs old)
DOXYCYCLINE HYCLATE 20 MG TAB 1-Covered QL (60 PER 30 DAYS)
doxycycline hyclate 20 mg tablet 1-Covered QL (60 PER 30 DAYS)
doxycycline monohydrate 50 mgcapsule 100 mg capsule
1-Covered AL1 (At least 8 yrs old)
minocycline hcl 50 mg capsule100 mg capsule
1-Covered
ANTICONVULSANTS (Drugs for Seizures)
ANTICONVULSANTS OTHER (Other Seizure Control Drugs)LEVETIRACETAM 100 MGML SOLN250 MG TABLET 500 MG5 ML SOLN
1-Covered
levetiracetam 100 mgml solution250 mg tablet 500 mg tablet 500mg5ml solution 750 mg tablet1000 mg tablet
1-Covered
levetiracetam 500 mg tab er 24h 1-Covered MDD (6 Per Day)
levetiracetam 750 mg tab er 24h 1-Covered QL (120 PER 30 DAY(S))
LEVETIRACETAM ER 500 MG TABLET 1-Covered MDD (6 Per Day)
LEVETIRACETAM ER 750 MG TABLET 1-Covered QL (120 PER 30 DAY(S))
CALCIUM CHANNEL MODIFYING AGENTSCELONTIN (methsuximide) 300 MGKAPSEAL
1-Covered
ETHOSUXIMIDE 250 MG CAPSULE 1-Covered
ethosuximide 250 mg5ml solution250 mg capsule
1-Covered
zonisamide 25 mg capsule 50 mgcapsule 100 mg capsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
14
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTSDEPAKENE (valproic acid (assodium salt) (valproate sodium))250 MG5 ML SOLUTION
1-Covered
DEPAKENE (valproic acid) 250 MGCAPSULE
1-Covered
diazepam 5-75-10mg kit 1-Covered
divalproex sodium 125 mg tabletdr 125 mg cap dr spr 250 mgtablet dr 500 mg tablet dr
1-Covered
DIVALPROEX SODIUM DR 125 MGCAP SPRNK
1-Covered
gabapentin 100 mg capsule 250mg5ml solution 300 mg capsule400 mg capsule 600 mg tablet800 mg tablet
1-Covered
GABAPENTIN 100 MG CAPSULE 300MG CAPSULE 400 MG CAPSULE
1-Covered
phenobarbital 15 mg tablet 20mg5 ml elixir 30 mg tablet 324mg tablet 60 mg tablet 648 mgtablet 972mg tablet 100 mgtablet
1-Covered
PHENOBARBITAL 20 MG5 ML SOLN324 MG TABLET 648 MG TABLET972 MG TABLET
1-Covered
primidone 50 mg tablet 250 mgtablet
1-Covered
valproic acid (as sodium salt)(valproate sodium) 250 mg5ml500mg10ml
1-Covered
valproic acid 250 mg capsule 1-Covered
VALPROIC ACID 250 MG CAPSULE 1-Covered
GLUTAMATE REDUCING AGENTSlamotrigine 25 mg tablet 100 mgtablet 150 mg tablet 200 mgtablet
1-Covered
lamotrigine 5 mg 25 mg 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
15
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
topiramate 15 mg cap sprink 25mg tablet 25 mg cap sprink 50mg tablet 100 mg tablet 200 mgtablet
1-Covered
TOPIRAMATE 25 MG TABLET 50 MGTABLET 100 MG TABLET 200 MGTABLET
1-Covered
SODIUM CHANNEL AGENTScarbamazepine (EPITOL) 200 mgtablet
1-Covered
carbamazepine 100 mg cpmp12hr 100 mg5ml oral susp 100 mgtab chew 100 mg tab er 12h 200mg cpmp 12hr 200 mg tab er 12h200 mg tablet 300 mg cpmp 12hr400 mg tab er 12h
1-Covered
CARBATROL (carbamazepine) ER100 MG CAPSULE ER 200 MGCAPSULE ER 300 MG CAPSULE
1-Covered
DILANTIN (phenytoin sodiumextended) 30 MG CAPSULE 100MG CAPSULE
1-Covered
DILANTIN (phenytoin) 50 MGINFATAB
1-Covered
DILANTIN-125 (phenytoin) MG5 MLSUSP
1-Covered
DILANTIN-125 MG5 ML SUSP 1-Covered
oxcarbazepine 150 mg tablet 300mg tablet 600 mg tablet
1-Covered
phenytoin 50 mg tab chew 100mg4ml oral susp 125 mg5ml oralsusp
1-Covered
phenytoin sodium extended 100mg capsule
1-Covered
TEGRETOL (carbamazepine) 100MG5 ML SUSP 200 MG TABLET
1-Covered
TEGRETOL XR (carbamazepine) 100MG TABLET 200 MG TABLET 400MG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
16
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIDEMENTIA AGENTS (Drugs for Alzheimers Disease andDementia)
CHOLINESTERASE INHIBITORSdonepezil hcl 5 mg tab rapdis 5mg tablet 10 mg tab rapdis 10mg tablet
1-Covered
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine hcl 5 mg tablet 10 mgtablet
1-Covered
MEMANTINE HCL 5 MG TABLET 10MG TABLET
1-Covered
ANTIDEPRESSANTS (Drugs for Depression)
ANTIDEPRESSANTS OTHERbupropion hcl 100 mg tab 150 mgtab 200 mg tab
1-Covered QL (60 PER 30 DAYS)
bupropion hcl 150 mg tab er 300mg tab er
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
bupropion hcl 75 mg tablet 100mg tablet
1-Covered
BUPROPION HCL SR SR 100 MGTABLET SR 150 MG TABLET SR 200MG TABLET
1-Covered QL (60 PER 30 DAYS)
BUPROPION XL 150 MG TABLET 300MG TABLET
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
mirtazapine 15 mg tab rapdis 1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old)
mirtazapine 15 mg tablet 30 mgtab rapdis 30 mg tablet 45 mgtab rapdis 45 mg tablet
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
olanzapinefluoxetine hcl 3 mg-25mg capsule 6mg-25mg capsule6mg-50mg capsule 12mg-50mgcapsule 12mg-25mg capsule
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
17
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SYMBYAX (olanzapinefluoxetinehcl) 3-25 MG CAPSULE 6-50 MGCAPSULE 6-25 MG CAPSULE 12-50MG CAPSULE 12-25 MG CAPSULE
2-MedicalCarve out
MONOAMINE OXIDASE INHIBITORSEMSAM (selegiline) 6 MG24PATCH 9 MG24 PATCH 12 MG24PATCH
2-MedicalCarve out
MARPLAN (isocarboxazid) 10 MGTABLET
2-MedicalCarve out
NARDIL (phenelzine sulfate) 15 MGTABLET
2-MedicalCarve out
PARNATE (tranylcypromine sulfate)10 MG TABLET
2-MedicalCarve out
phenelzine sulfate 15 mg tablet 2-MedicalCarve out
tranylcypromine sulfate 10 mgtablet
2-MedicalCarve out
SSRISSNRIS (SELECTIVE SEROTONIN REUPTAKEINHIBITORSEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)
citalopram hydrobromide 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
escitalopram oxalate 5 mg tablet10 mg tablet 20 mg tablet
1-Covered
ESCITALOPRAM OXALATE 5 MGTABLET 10 MG TABLET 20 MGTABLET
1-Covered
fluoxetine hcl 10 mg capsule 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
fluoxetine hcl 20 mg capsule 1-Covered QL (120 PER 30 DAY(S))
fluoxetine hcl 20 mg5 ml solution 1-Covered
FLUOXETINE HCL 20 MG5 MLSOLUTION
1-Covered
fluvoxamine maleate 25 mg tablet50 mg tablet 100 mg tablet
1-Covered AL1 (At least 8 yrs old)
paroxetine hcl 10 mg tablet 20 mgtablet 30 mg tablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
sertraline hcl 25 mg tablet 50 mgtablet 100 mg tablet
1-Covered QL (60 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
18
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRAZODONE HCL 50 MG TABLET100 MG TABLET
1-Covered
trazodone hcl 50 mg tablet 100mg tablet 150 mg tablet
1-Covered
venlafaxine hcl 25 mg tablet 375mg tablet 50 mg tablet 75 mgtablet 100 mg tablet
1-Covered QL (60 PER 30 DAYS)
venlafaxine hcl 375 mg cap er 75mg cap er 150 mg cap er
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
VENLAFAXINE HCL ER ER 375 MGCAP ER 75 MG CAP ER 150 MGCAP
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
TRICYCLICSamitriptyline hcl 10 mg tablet 25mg tablet 50 mg tablet 75 mgtablet 100 mg tablet 150 mgtablet
1-Covered
amoxapine 25 mg tablet 50 mgtablet 100 mg tablet 150 mgtablet
1-Covered
clomipramine hcl 25 mg capsule50 mg capsule 75 mg capsule
1-Covered PA
CLOMIPRAMINE HCL 25 MGCAPSULE 50 MG CAPSULE 75 MGCAPSULE
1-Covered PA
desipramine hcl 10 mg tablet 25mg tablet 50 mg tablet 75 mgtablet 100 mg tablet 150 mgtablet
1-Covered
DOXEPIN HCL 10 MG CAPSULE 25MG CAPSULE 50 MG CAPSULE 75MG CAPSULE 100 MG CAPSULE
1-Covered
doxepin hcl 10 mgml oral conc10 mg capsule 25 mg capsule 50mg capsule 75 mg capsule 100mg capsule 150 mg capsule
1-Covered
imipramine hcl 10 mg tablet 25mg tablet 50 mg tablet
1-Covered
IMIPRAMINE HCL 10 MG TABLET 25MG TABLET 50 MG TABLET
1-Covered
nortriptyline hcl 10 mg capsule 25mg capsule 50 mg capsule 75 mgcapsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
19
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIEMETICS (Drugs for Nausea and Vomiting)
ANTIEMETICS OTHER (Other Drugs for Nausea and Vomiting)meclizine hcl (DRAMAMINE LESSDROWSY) 25 mg tablet
1-Covered
meclizine hcl (MEDI-MECLIZINE) 25mg tablet -
1-Covered
meclizine hcl (MOTION RELIEF) 25mg tablet
1-Covered
meclizine hcl (MOTION SICKNESS II)25 mg tablet
1-Covered
meclizine hcl (MOTION SICKNESSRELIEF) 25 mg tablet 25 mg tabchew
1-Covered
meclizine hcl (MOTION SICKNESS)25 mg tablet
1-Covered
meclizine hcl (MOTION-TIME) 25 mgtab chew -
1-Covered
meclizine hcl (TRAVEL-EASE) 25 mgtablet -
1-Covered
meclizine hcl (VERTICALM) 25 mgtablet
1-Covered
meclizine hcl (WAL-DRAM 2) 25 mgtablet -
1-Covered
MECLIZINE HCL 125 MG CAPLET 25MG TABLET CHEW
1-Covered
meclizine hcl 125 mg tablet 25mg tab chew 25 mg tablet
1-Covered
metoclopramide hcl 5 mg tablet 5mg5 ml solution 10 mg tablet 10mg10ml solution
1-Covered
perphenazine 2 mg tablet 4 mgtablet 8 mg tablet 16 mg tablet
2-MedicalCarve out
prochlorperazine (COMPRO) 25mg supprect
1-Covered
prochlorperazine 25 mg supprect 1-Covered
prochlorperazine maleate 5 mgtablet 10 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
20
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
promethazine hcl (PHENADOZ)125 mg 25 mg
1-Covered
promethazine hcl (PROMETHEGAN)125 mg 25 mg 50 mg
1-Covered
promethazine hcl 125 mgsupprect 25 mg supprect 50 mgtablet 50 mg supprect
1-Covered
TRAVEL SICKNESS (meclizine hcl) 25MG TAB CHEW
1-Covered
trimethobenzamide hcl 300 mgcapsule
1-Covered
EMETOGENIC THERAPY ADJUNCTS (Drugs for Nausea and Vomiting)aprepitant 40 mg capsule 80 mgcapsule 125mg-80mg cap ds pk125 mg capsule
1-Covered PA
dronabinol 25 mg capsule 5 mgcapsule 10 mg capsule
1-Covered PA
granisetron hcl 1 mg tablet 1-Covered PA
ondansetron 4 mg tab rapdis 8mg tab rapdis
1-Covered QL (12 PER FILL(S)) MDD (3 PerDay) QLC (LIMIT TO 2 FILLS OF 12TABLETS IN 30 DAYS)
ondansetron hcl 4 mg tablet 8 mgtablet
1-Covered QL (12 PER FILL(S)) MDD (3 PerDay) QLC (LIMIT TO 2 FILLS OF 12TABLETS IN 30 DAYS)
ondansetron hcl 4 mg5 mlsolution 24 mg tablet
1-Covered PA
ANTIFUNGALS (Drugs for Fungal Infections)
ANTIFUNGALSANTIFUNGAL 1 TOPICAL CREAM 1-Covered
ATHLETES FOOT (terbinafine hcl) 1CREAM
1-Covered
ciclopirox 077 gel (gram) 1-Covered QLC (100 GRAMSMONTH)
ciclopirox 1 shampoo 1-Covered QLC (120 ozMONTH)
ciclopirox 8 solution 1-Covered
ciclopirox olamine 077 cream(g)
1-Covered QLC (90 GRAMSMONTH)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
21
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ciclopirox olamine 077 suspension
1-Covered QLC (60 MLMONTH)
clotrimazole (ANTIFUNGALRINGWORM) 1 cream (g)
1-Covered
clotrimazole (ANTIFUNGAL) 1 cream (g)
1-Covered
clotrimazole (ATHLETES FOOT) 1 cream (g)
1-Covered
clotrimazole (ATHLETIC FOOTCREAM) 1 cream (g)
1-Covered
clotrimazole (CLOTRIMAZOLE AF) 1 cream (g)
1-Covered
clotrimazole (ITCH RELIEF) 1 cream (g)
1-Covered
clotrimazole (JOCK ITCH RELIEF) 1 cream (g)
1-Covered
clotrimazole (JOCK ITCH) 1 cream (g)
1-Covered
clotrimazole (RINGWORM) 1 cream (g)
1-Covered
clotrimazole 1 cream (g) 1 solution 1 creamappl 10 mgtroche
1-Covered
CLOTRIMAZOLE 1 SOLUTION 1TOPICAL CREAM
1-Covered
fluconazole 10 mgml 40 mgml 1-Covered QL (70 PER 30 DAY(S))
fluconazole 150 mg tablet 1-Covered QL (2 PER 30 DAY(S))
FLUCONAZOLE 200 MG TABLET 1-Covered
fluconazole 50 mg tablet 100 mgtablet 200 mg tablet
1-Covered
fluconazole in dextrose iso-osmotic in dextreiso-200mg01l indextreiso-400mg02l
1-Covered PA
flucytosine 250 mg capsule 500mg capsule
1-Covered
FLUCYTOSINE 250 MG CAPSULE500 MG CAPSULE
1-Covered
griseofulvin ultramicrosize 125 mgtablet 250 mg tablet
1-Covered QL (60 PER 30 DAYS) AL1 (Up to18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
22
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
griseofulvin microsize 125 mg5mloral susp
1-Covered AL1 (Up to 12 yrs old) MDD (20Per Day)
griseofulvin microsize 500 mgtablet
1-Covered QL (60 PER 30 DAYS) AL1 (Up to18 yrs old)
itraconazole 100 mg capsule 1-Covered PA
ketoconazole 2 cream (g) 2 shampoo
1-Covered
ketoconazole 200 mg tablet 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
LAMISIL (terbinafine hcl)ANTIFUNGAL 1 SPRAY
1-Covered
LOTRIMIN AF (clotrimazole) 1CREAM
1-Covered
miconazole nitrate (ANTI-FUNGALCREAM) 2 cream (g) -
1-Covered
miconazole nitrate (ANTIFUNGALCREAM) 2 cream (g)
1-Covered
miconazole nitrate (BAZAANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate (INZOANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate (LOTRIMIN AF) 2 spray
1-Covered
miconazole nitrate (MICATIN) 2 cream (g)
1-Covered
miconazole nitrate (SECURAANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate 2 aero powd2 creamappl 2 cream (g)100 mg suppvag
1-Covered
MONISTAT 3 (miconazole nitrate)4 CREAM
1-Covered
MONISTAT 7 (miconazole nitrate)CREAM
1-Covered
NYSTATIN 100000 UNITGM CREAM100000 UNITGM OINT 100000UNITML SUSP 500000 UNIT5 MLSUS
1-Covered
nystatin 500k unit tablet 100000mloral susp 100000g cream (g)100000g oint (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
23
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terbinafine hcl (ANTIFUNGAL) 1 cream (g)
1-Covered
terbinafine hcl (ATHLETES FOOT AF)1 cream (g)
1-Covered
terbinafine hcl (ATHLETES FOOT) 1 cream (g)
1-Covered
terbinafine hcl (JOCK ITCH) 1 cream (g)
1-Covered
terbinafine hcl (LAMISIL AT) 1 cream (g)
1-Covered
terbinafine hcl 1 cream (g) 250mg tablet
1-Covered
tioconazole 65 oinpf app 1-Covered
tolnaftate (ANTIFUNGAL CREAM) 1 cream (g)
1-Covered
tolnaftate (ATHLETES FOOT) 1 cream (g)
1-Covered
tolnaftate (FUNGOID-D) 1 cream(g) -
1-Covered
tolnaftate 1 cream (g) 1-Covered
ANTIGOUT AGENTS (Drugs for Gout)
ANTIGOUT AGENTSallopurinol 100 mg tablet 300 mgtablet
1-Covered
ALLOPURINOL 100 MG TABLET 300MG TABLET
1-Covered
colchicine 06 mg tablet 1-Covered
COLCHICINE 06 MG TABLET 1-Covered
probenecid 500 mg tablet 1-Covered
probenecidcolchicine 500-05 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
24
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIMIGRAINE AGENTS (Drugs for Migraine)
ERGOT ALKALOIDSergotamine tartratecaffeine 1mg-100mg tablet
1-Covered
SEROTONIN (5-HT) 1B1D RECEPTOR AGONISTSrizatriptan benzoate 5 mg tablet10 mg tablet
1-Covered QL (12 PER 30 DAY(S)) AL1 (Atleast 6 yrs old)
SUMATRIPTAN 5 MG SPRAY 20 MGSPRAY
1-Covered QL (6 PER 30 DAY(S))
sumatriptan 5 mg 20 mg 1-Covered QL (6 PER 30 DAY(S))
sumatriptan succinate 25 mgtablet 50 mg tablet 100 mg tablet
1-Covered QL (9 PER 30 DAY(S))
SUMATRIPTAN SUCCINATE 25 MGTABLET 50 MG TABLET 100 MGTABLET
1-Covered QL (9 PER 30 DAY(S))
SUMATRIPTAN SUCCINATE 6 MG05ML CART
1-Covered QL (2 PER FILL(S)) MFL (1 30day(s))
SUMATRIPTAN SUCCINATE 6 MG05ML INJECT
1-Covered QL (2 PER 30 DAY(S)) MFL (1 30day(s))
sumatriptan succinate 6 mg05mlcartridge 6 mg05ml vial
1-Covered QL (2 PER FILL(S)) MFL (1 30day(s))
sumatriptan succinate 6 mg05mlpen injctr 6 mg05ml syringe
1-Covered QL (2 PER 30 DAY(S)) MFL (1 30day(s))
ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis)
PARASYMPATHOMIMETICSMESTINON (pyridostigminebromide) 60 MG5 ML SOLUTION
1-Covered
pyridostigmine bromide 60 mg5ml solution 60 mg tablet 180 mgtablet er
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
25
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections)
ANTIMYCOBACTERIALS OTHER (Other Drugs for MycobacterialInfection)
dapsone 25 mg tablet 100 mgtablet
1-Covered
rifabutin 150 mg capsule 1-Covered
ANTITUBERCULARS (Drugs for Tuberculosis)ethambutol hcl 100 mg tablet 400mg tablet
1-Covered
ETHAMBUTOL HCL 100 MG TABLET400 MG TABLET
1-Covered
isoniazid 50 mg5 ml solution 100mg tablet 300 mg tablet
1-Covered
PRIFTIN (rifapentine) 150 MG TABLET 1-Covered AL1 (At least 12 yrs old)
pyrazinamide 500 mg tablet 1-Covered
rifampin 150 mg capsule 300 mgcapsule
1-Covered
ANTINEOPLASTICS (Drugs for Cancer)
ALKYLATING AGENTScyclophosphamide 25 mgcapsule 50 mg capsule
1-Covered PA
CYCLOPHOSPHAMIDE 25 MGCAPSULE 50 MG CAPSULE
1-Covered PA
GLEOSTINE (lomustine) 10 MGCAPSULE 40 MG CAPSULE 100 MGCAPSULE
1-Covered PA
HEXALEN (altretamine) 50 MGCAPSULE
1-Covered
LEUKERAN (chlorambucil) 2 MGTABLET
1-Covered PA
MATULANE (procarbazine hcl) 50MG CAPSULE
1-Covered PA SP
melphalan 2 mg tablet 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
26
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
MYLERAN (busulfan) 2 MG TABLET 1-Covered
temozolomide 20 mg capsule 1-Covered PA SP
ANTIANDROGENSbicalutamide 50 mg tablet 1-Covered PA
flutamide 125 mg capsule 1-Covered PA
ANTIANGIOGENIC AGENTSTHALOMID (thalidomide) 50 MGCAPSULE
1-Covered PA SP
ANTIESTROGENSMODIFIERSEMCYT (estramustine phosphatesodium) 140 MG CAPSULE
1-Covered PA
TAMOXIFEN CITRATE 10 MG TABLET 1-Covered
tamoxifen citrate 10 mg tablet 20mg tablet
1-Covered
TOREMIFENE CITRATE 60 MG TAB 1-Covered PA
toremifene citrate 60 mg tablet 1-Covered PA
ANTIMETABOLITEScapecitabine 500 mg tablet 1-Covered PA SP
CAPECITABINE 500 MG TABLET 1-Covered PA SP
DROXIA (hydroxyurea) 200 MGCAPSULE 300 MG CAPSULE 400MG CAPSULE
1-Covered
fluorouracil (ADRUCIL) 25 g50mlvial 5 g100 ml vial
1-Covered PA
hydroxyurea 500 mg capsule 1-Covered PA
mercaptopurine 50 mg tablet 1-Covered PA
TABLOID (thioguanine) 40 MGTABLET
1-Covered PA
ANTINEOPLASTICS OTHERLEUCOVORIN CALCIUM 5 MG TAB25 MG TAB
1-Covered
leucovorin calcium 5 mg tablet 10mg tablet 15 mg tablet 25 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
27
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LYSODREN (mitotane) 500 MGTABLET
1-Covered PA
AROMATASE INHIBITORS 3RD GENERATIONanastrozole 1 mg tablet 1-Covered
ANASTROZOLE 1 MG TABLET 1-Covered
letrozole 25 mg tablet 1-Covered
ENZYME INHIBITORSetoposide 50 mg capsule 1-Covered PA
MOLECULAR TARGET INHIBITORSJAKAFI (ruxolitinib phosphate) 5MG TABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET 25 MGTABLET
1-Covered PA SP QL (2 PER 1 DAY(S))
RETINOIDStretinoin 10 mg capsule 1-Covered PA
ANTIPARASITICS (Drugs for Parasitic Infections)
ANTIHELMINTHICS (Drugs for Worm Infection)mebendazole (EMVERM) 100 mgtab chew
1-Covered
praziquantel 600 mg tablet 1-Covered
ANTIPROTOZOALS (Drugs for Protozoal Infection)chloroquine phosphate 250 mgtablet
1-Covered QL (25 PER 30 DAY(S))
chloroquine phosphate 500 mgtablet
1-Covered PA QL (25 PER 30 DAY(S))
HYDROXYCHLOROQUINE SULFATE200 MG TAB
1-Covered QL (3 PER 1 DAY(S))
hydroxychloroquine sulfate 200 mgtablet
1-Covered QL (3 PER 1 DAY(S))
mefloquine hcl 250 mg tablet 1-Covered
primaquine phosphate 263 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
28
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PEDICULICIDESSCABICIDES (Drugs for Scabies and Lice)permethrin (LICE TREATMENT) 1 liquid
1-Covered
permethrin 5 cream (g) 1-Covered
ANTIPARKINSON AGENTS (Drugs for Parkinsons Disease)
ANTICHOLINERGICSbenztropine mesylate 05 mgtablet 1 mg tablet 2 mg tablet 2mg2 ml ampul 2 mg2 ml vial
2-MedicalCarve out
COGENTIN (benztropine mesylate)2 MG2 ML AMPULE
2-MedicalCarve out
trihexyphenidyl hcl 2 mg5 ml elixir2 mg tablet 5 mg tablet
2-MedicalCarve out
ANTIPARKINSON AGENTS OTHERAMANTADINE 100 MG CAPSULE 2-Medical
Carve out
amantadine hcl 50 mg5 mlsolution 100 mg capsule 100 mgtablet
2-MedicalCarve out
entacapone 200 mg tablet 1-Covered ST
GOCOVRI (amantadine hcl) ER685 MG CAPSULE ER 137 MGCAPSULE
2-MedicalCarve out
OSMOLEX ER (amantadine hcl) ER129 MG TABLET ER 193 MG TABLETER 258 MG TABLET ER 322 MGDAILY DOSE
2-MedicalCarve out
DOPAMINE AGONISTSbromocriptine mesylate 25 mgtablet
1-Covered
pramipexole di-hcl -0125 mgtablet -025 mg tablet -05 mgtablet -075 mg tablet -1 mgtablet -15 mg tablet
1-Covered
ropinirole hcl 025 mg tablet 05mg tablet 1 mg tablet 2 mgtablet 3 mg tablet 4 mg tablet 5mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
29
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DOPAMINE PRECURSORSL-AMINO ACID DECARBOXYLASEINHIBITORS
carbidopalevodopa 10mg-100mgtablet 25mg-100mg tablet 25mg-100mg tablet er 25mg-250mgtablet 50mg-200mg tablet er
1-Covered
MONOAMINE OXIDASE B (MAO-B) INHIBITORSselegiline hcl 5 mg tablet 5 mgcapsule
1-Covered
ANTIPSYCHOTICS (Drugs for Mental Health)
1ST GENERATIONTYPICALADASUVE (loxapine) 10 MG POWD10 MG POWDR
2-MedicalCarve out
chlorpromazine hcl 10 mg tablet25 mg tablet 25 mgml ampul 50mg tablet 100 mg tablet 200 mgtablet
2-MedicalCarve out
CHLORPROMAZINE HCL 10 MGTABLET 25 MGML AMPULE 25 MGTABLET 50 MG TABLET 50 MG2 MLAMP 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
fluphenazine decanoate 25 mgmlvial
2-MedicalCarve out
fluphenazine hcl 1 mg tablet 25mg tablet 25 mg5ml elixir 25mgml vial 5 mgml oral conc 5mg tablet 10 mg tablet
2-MedicalCarve out
FLUPHENAZINE HCL 1 MG TABLET25 MG TABLET 5 MG TABLET 10MG TABLET
2-MedicalCarve out
HALDOL (haloperidol lactate) 5MGML AMPUL
2-MedicalCarve out
HALDOL DECANOATE 100(haloperidol decanoate) AMPUL
2-MedicalCarve out
HALDOL DECANOATE 50(haloperidol decanoate) AMPUL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
30
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
haloperidol 05 mg tablet 1 mgtablet 2 mg tablet 5 mg tablet 10mg tablet 20 mg tablet
2-MedicalCarve out
HALOPERIDOL 5 MG TABLET 2-MedicalCarve out
haloperidol decanoate 50 mgmlvial 50 mgml ampul 100 mgmlampul 100 mgml vial
2-MedicalCarve out
haloperidol lactate 2 mgml oralconc 5 mgml vial 5 mgmlampul 5 mgml syringe
2-MedicalCarve out
HALOPERIDOL LACTATE 5 MGMLSYRING
2-MedicalCarve out
loxapine succinate 5 mg capsule10 mg capsule 25 mg capsule 50mg capsule
2-MedicalCarve out
molindone hcl 5 mg tablet 10 mgtablet 25 mg tablet
2-MedicalCarve out
ORAP (pimozide) 1 MG TABLET 2MG TABLET
2-MedicalCarve out
pimozide 1 mg tablet 2 mg tablet 2-MedicalCarve out
thioridazine hcl 10 mg tablet 25mg tablet 50 mg tablet 100 mgtablet
2-MedicalCarve out
thiothixene 1 mg capsule 2 mgcapsule 5 mg capsule 10 mgcapsule
2-MedicalCarve out
trifluoperazine hcl 1 mg tablet 2mg tablet 5 mg tablet 10 mgtablet
2-MedicalCarve out
2ND GENERATIONATYPICALABILIFY (aripiprazole) 2 MG TABLET5 MG TABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET 30 MGTABLET
2-MedicalCarve out
ABILIFY MAINTENA (aripiprazole) ER300 MG VL ER 300 MG SYR ER 400MG SYR ER 400 MG VL
2-MedicalCarve out
ABILIFY MYCITE (aripiprazole) 2 MGKIT 5 MG KIT 10 MG KIT 15 MG KIT20 MG KIT 30 MG KIT
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
31
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
aripiprazole 1 mgml solution 2 mgtablet 5 mg tablet 10 mg tabrapdis 10 mg tablet 15 mg tablet15 mg tab rapdis 20 mg tablet 30mg tablet
2-MedicalCarve out
ARIPIPRAZOLE 1 MGML SOLUTION2 MG TABLET 5 MG TABLET 10 MGTABLET 15 MG TABLET 20 MGTABLET 30 MG TABLET
2-MedicalCarve out
ARISTADA (aripiprazole lauroxil) ER441 MG16 ML SYRN ER 662MG24 ML SYRN ER 882 MG32ML SYRN ER 1064 MG39 ML SYR
2-MedicalCarve out
ARISTADA INITIO (aripiprazolelauroxil submicronized) ER 675MG24
2-MedicalCarve out
CAPLYTA (lumateperone tosylate)42 MG CAPSULE
2-MedicalCarve out
FANAPT (iloperidone) 1 MG TABLET2 MG TABLET 4 MG TABLET 6 MGTABLET 8 MG TABLET 10 MGTABLET 12 MG TABLET TITRATIONPACK
2-MedicalCarve out
GEODON (ziprasidone hcl) 20 MGCAPSULE 40 MG CAPSULE 60 MGCAPSULE 80 MG CAPSULE
2-MedicalCarve out
GEODON (ziprasidone mesylate)20 MGML VIAL
2-MedicalCarve out
INVEGA (paliperidone) ER 15 MGTABLET ER 3 MG TABLET ER 6 MGTABLET ER 9 MG TABLET
2-MedicalCarve out
INVEGA SUSTENNA (paliperidonepalmitate) 39 MG025 ML 78MG05 ML 117 MG075 ML 156MGML SYRG 234 MG15 ML
2-MedicalCarve out
INVEGA TRINZA (paliperidonepalmitate) 273 MG0875 ML 410MG1315 ML 546 MG175 ML 819MG2625 ML
2-MedicalCarve out
LATUDA (lurasidone hcl) 20 MGTABLET 40 MG TABLET 60 MGTABLET 80 MG TABLET 120 MGTABLET
2-MedicalCarve out
NUPLAZID (pimavanserin tartrate)10 MG TABLET 17 MG TABLET 34MG CAPSULE
2-MedicalCarve out
SP
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
32
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
olanzapine 25 mg tablet 5 mgtab rapdis 5 mg tablet 75 mgtablet 10 mg tab rapdis 10 mgtablet 10 mg vial 15 mg tabrapdis 15 mg tablet 20 mg tablet20 mg tab rapdis
2-MedicalCarve out
paliperidone 15 mg tab er 24 3mg tab er 24 6 mg tab er 24 9 mgtab er 24
2-MedicalCarve out
PERSERIS (risperidone) ER 90 MGSYRINGE KIT ER 120 MG SYRINGEKIT
2-MedicalCarve out
quetiapine fumarate 25 mg tablet50 mg tab er 24h 50 mg tablet100 mg tablet 150 mg tab er 24h200 mg tab er 24h 200 mg tablet300 mg tablet 300 mg tab er 24h400 mg tab er 24h 400 mg tablet
2-MedicalCarve out
REXULTI (brexpiprazole) 025 MGTABLET 05 MG TABLET 1 MGTABLET 2 MG TABLET 3 MG TABLET4 MG TABLET
2-MedicalCarve out
RISPERDAL (risperidone) 025 MGTABLET 05 MG TABLET 1 MGMLSOLUTION 1 MG TABLET 2 MGTABLET 3 MG TABLET 4 MG TABLET
2-MedicalCarve out
RISPERDAL CONSTA (risperidonemicrospheres) 125 MG VIAL 25MG VIAL 375 MG VIAL 50 MGVIAL
2-MedicalCarve out
RISPERDAL M-TAB (risperidone) -TAB05 G ODT -TAB 1 G ODT -TAB 2 GODT -TAB 3 G ODT -TAB 4 G ODT
2-MedicalCarve out
risperidone 025 mg tab rapdis025 mg tablet 05 mg tab rapdis05 mg tablet 1 mg tablet 1mgml solution 1 mg tab rapdis 2mg tab rapdis 2 mg tablet 3 mgtablet 3 mg tab rapdis 4 mg tabrapdis 4 mg tablet
2-MedicalCarve out
SAPHRIS (asenapine maleate) 25MG TAB 5 MG TAB 10 MG TAB
2-MedicalCarve out
SECUADO (asenapine) 38 MG24HR PATCH 57 MG24 HR PATCH76 MG24 HR PATCH
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
33
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SEROQUEL (quetiapine fumarate)25 MG TABLET 50 MG TABLET 100MG TABLET 200 MG TABLET 300MG TABLET 400 MG TABLET
2-MedicalCarve out
SEROQUEL XR (quetiapinefumarate) 50 MG TABLET 150 MGTABLET 200 MG TABLET 300 MGTABLET 400 MG TABLET
2-MedicalCarve out
VRAYLAR (cariprazine hcl) 15 MG-3 MG PACK 15 MG CAPSULE 3MG CAPSULE 45 MG CAPSULE 6MG CAPSULE
2-MedicalCarve out
ziprasidone hcl 20 mg capsule 40mg capsule 60 mg capsule 80 mgcapsule
2-MedicalCarve out
ZIPRASIDONE HCL 20 MG CAPSULE40 MG CAPSULE 60 MG CAPSULE80 MG CAPSULE
2-MedicalCarve out
ZIPRASIDONE MESYLATE 20 MGMLVIAL
2-MedicalCarve out
ziprasidone mesylate fnl 20mg1vial
2-MedicalCarve out
ZYPREXA (olanzapine) 25 MGTABLET 5 MG TABLET 75 MGTABLET 10 MG VIAL 10 MG TABLET15 MG TABLET 20 MG TABLET
2-MedicalCarve out
ZYPREXA RELPREVV (olanzapinepamoate) 210 MG VL KIT 300 MGVL KIT 405 MG VL KIT
2-MedicalCarve out
ZYPREXA ZYDIS (olanzapine) 5 MGTABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET
2-MedicalCarve out
TREATMENT-RESISTANTclozapine 125 mg tab rapdis 25mg tab rapdis 25 mg tablet 50mg tablet 100 mg tablet 100 mgtab rapdis 150 mg tab rapdis 200mg tablet 200 mg tab rapdis
2-MedicalCarve out
CLOZAPINE 25 MG TABLET 50 MGTABLET 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
CLOZAPINE ODT ODT 150 MGTABLET ODT 200 MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
34
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CLOZARIL (clozapine) 25 MGTABLET 50 MG TABLET 100 MGTABLET 200 MG TABLET
2-MedicalCarve out
FAZACLO (clozapine) 125 MGODT 25 MG ODT 100 MG ODT 150MG ODT 200 MG ODT
2-MedicalCarve out
VERSACLOZ (clozapine) 50 MGMLSUSPENSION
2-MedicalCarve out
ANTISPASTICITY AGENTS (Drugs for Muscle Spasm)baclofen 10 mg tablet 20 mgtablet
1-Covered QL (90 PER 30 DAYS)
BACLOFEN 10 MG TABLET 20 MGTABLET
1-Covered QL (90 PER 30 DAYS)
tizanidine hcl 2 mg tablet 4 mgtablet
1-Covered QL (90 PER 30 DAY(S))
ANTIVIRALS (Drugs for Viral Infections)
ANTI-HEPATITIS B (HBV) AGENTSEPIVIR HBV (lamivudine) 100 MGTABLET
2-MedicalCarve out
EPIVIR HBV (lamivudine) 25 MG5ML SOLN
1-Covered PA
lamivudine 100 mg tablet 1-Covered PA
VEMLIDY (tenofovir alafenamide)25 MG TABLET
2-MedicalCarve out
ANTI-HEPATITIS C (HCV) AGENTS DIRECT ACTING AGENTSsofosbuvirvelpatasvir 400-100 mgtablet
1-Covered PA SP
ANTI-HEPATITIS C (HCV) AGENTS OTHERINTRON A (interferon alfa-2brecomb) 10 MILLION UNITS VIL -18 MILLION UNITS VIL - 18 MILLIONUNIT3 ML - 25 MILLION UNIT25ML- 50 MILLION UNITS VIL -
1-Covered PA SP
PEGINTRON REDIPEN(peginterferon alfa-2b) 50 MCG -
1-Covered PA SP
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
35
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ribavirin (RIBASPHERE) 200 mgtablet
1-Covered PA
ribavirin 200 mg tablet 1-Covered PA
ANTI-HIV AGENTSCIMDUO (lamivudinetenofovirdisoproxil fumarate) 300-300 MGTABLET
2-MedicalCarve out
EFAVIRENZ-LAMIVU-TENOFOVDISOP --600-300-300
2-MedicalCarve out
SYMFI(efavirenzlamivudinetenofovirdisoproxil fumarate) 600-300-300MG TABLET
2-MedicalCarve out
TEMIXYS (lamivudinetenofovirdisoproxil fumarate) 300-300 MGTABLET
2-MedicalCarve out
ANTI-HIV AGENTS INTEGRASE INHIBITORS (INSTI)BIKTARVY (bictegravirsodiumemtricitabinetenofoviralafenamide fumar) 50-200-25 MGTABLET
2-MedicalCarve out
GENVOYA(elvitegravircobicistatemtricitabinetenofovir alafenamide) TABLET
2-MedicalCarve out
ISENTRESS (raltegravir potassium) 25MG TABLET CHEW 100 MG TABLETCHEW 100 MG POWDER PACKET400 MG TABLET
2-MedicalCarve out
ISENTRESS HD (raltegravirpotassium) 600 MG TABLET
2-MedicalCarve out
STRIBILD(elvitegravircobicistatemtricitabinetenofovir disoproxil) TABLET
2-MedicalCarve out
TIVICAY (dolutegravir sodium) 10MG TABLET 25 MG TABLET 50 MGTABLET
2-MedicalCarve out
TIVICAY PD 5 MG TAB FOR SUSP 2-MedicalCarve out
VITEKTA (elvitegravir) 85 MGTABLET 150 MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
36
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTI-HIV AGENTS NON-NUCLEOSIDE REVERSE TRANSCRIPTASEINHIBITORS (NNRTI)
ATRIPLA(efavirenzemtricitabinetenofovirdisoproxil fumarate) TABLET
2-MedicalCarve out
COMPLERA(emtricitabinerilpivirinehcltenofovir disoproxil fumarate)TABLET
2-MedicalCarve out
DELSTRIGO(doravirinelamivudinetenofovirdisoproxil fumarate) 100-300-300MG TAB
2-MedicalCarve out
EDURANT (rilpivirine hcl) 25 MGTABLET
2-MedicalCarve out
efavirenz 50 mg capsule 200 mgcapsule 600 mg tablet
2-MedicalCarve out
EFAVIRENZ-EMTRIC-TENOFOVDISOP --600-200-300
2-MedicalCarve out
EFAVIRENZ-LAMIVU-TENOFOVDISOP --400-300-300
2-MedicalCarve out
INTELENCE (etravirine) 25 MGTABLET 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
nevirapine 50 mg5 ml oral susp100 mg tab er 24h 200 mg tablet400 mg tab er 24h
2-MedicalCarve out
ODEFSEY (emtricitabinerilpivirinehcltenofovir alafenamidefumarate) TABLET
2-MedicalCarve out
PIFELTRO (doravirine) 100 MGTABLET
2-MedicalCarve out
RESCRIPTOR (delavirdine mesylate)100 MG TABLET 200 MG TABLET
2-MedicalCarve out
SUSTIVA (efavirenz) 50 MGCAPSULE 200 MG CAPSULE 600MG TABLET
2-MedicalCarve out
SYMFI LO(efavirenzlamivudinetenofovirdisoproxil fumarate) 400-300-300MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
37
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
VIRAMUNE (nevirapine) 50 MG5ML SUSP 200 MG TABLET
2-MedicalCarve out
VIRAMUNE XR (nevirapine) 100 MGTABLET 400 MG TABLET
2-MedicalCarve out
ANTI-HIV AGENTS NUCLEOSIDE AND NUCLEOTIDE REVERSETRANSCRIPTASE INHIBITORS (NRTI)
abacavir sulfate 20 mgml solution300 mg tablet
2-MedicalCarve out
abacavir sulfatelamivudine 600-300mg tablet
2-MedicalCarve out
abacavirsulfatelamivudinezidovudineabacavirlamivudinezidovudine150-300 mg tablet
2-MedicalCarve out
ABACAVIR-LAMIVUDINE -600-300MG
2-MedicalCarve out
COMBIVIR (lamivudinezidovudine)TABLET
2-MedicalCarve out
EMTRICITABINE 200 MG CAPSULE 2-MedicalCarve out
EMTRICITABINE-TENOFOVIR DISOP -TENOFV 200-300MG
2-MedicalCarve out
EMTRIVA (emtricitabine) 10 MGMLSOLUTION 200 MG CAPSULE
2-MedicalCarve out
EPIVIR (lamivudine) 10 MGMLORAL SOLN 150 MG TABLET 300MG TABLET
2-MedicalCarve out
EPZICOM (abacavirsulfatelamivudine) TABLET
2-MedicalCarve out
lamivudine 10 mgml solution 150mg tablet 300 mg tablet
2-MedicalCarve out
lamivudinezidovudine 150-300mgtablet 150-300 mg tablet
2-MedicalCarve out
stavudine 1 mgml soln recon 15mg capsule 20 mg capsule 30 mgcapsule 40 mg capsule
2-MedicalCarve out
tenofovir disoproxil fumarate 300mg tablet
2-MedicalCarve out
TRIZIVIR (abacavirsulfatelamivudinezidovudine)TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
38
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRUVADA (emtricitabinetenofovirdisoproxil fumarate) 100 MG-150MG TABLET 133 MG-200 MGTABLET 167 MG-250 MG TABLET200 MG-300 MG TABLET
2-MedicalCarve out
VIREAD (tenofovir disoproxilfumarate) 150 MG TABLET 200 MGTABLET 250 MG TABLET 300 MGTABLET POWDER
2-MedicalCarve out
ZERIT (stavudine) 1 MGMLSOLUTION 15 MG CAPSULE 20 MGCAPSULE 30 MG CAPSULE 40 MGCAPSULE
2-MedicalCarve out
ZIAGEN (abacavir sulfate) 20MGML SOLUTION 300 MG TABLET
2-MedicalCarve out
ANTI-HIV AGENTS OTHERDESCOVY (emtricitabinetenofoviralafenamide fumarate) 200-25 MGTABLET
2-MedicalCarve out
DOVATO (dolutegravirsodiumlamivudine) 50-300 MGTABLET
2-MedicalCarve out
FUZEON (enfuvirtide) 90 MG VIAL 2-MedicalCarve out
SP
JULUCA (dolutegravirsodiumrilpivirine hcl) 50-25 MGTABLET
2-MedicalCarve out
RUKOBIA ER 600 MG TABLET 2-MedicalCarve out
SELZENTRY (maraviroc) 20 MGMLORAL SOLN 25 MG TABLET 75 MGTABLET 150 MG TABLET 300 MGTABLET
2-MedicalCarve out
TRIUMEQ (abacavirsulfatedolutegravirsodiumlamivudine) 600-50-300 MGTABLET
2-MedicalCarve out
TROGARZO (ibalizumab-uiyk) 200MG133 ML VIAL -
2-MedicalCarve out
TYBOST (cobicistat) 150 MG TABLET 2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
39
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTI-HIV AGENTS PROTEASE INHIBITORSAPTIVUS (tipranavir) 250 MGCAPSULE
2-MedicalCarve out
APTIVUS (tipranavirvitamin e tpgs)100 MGML SOLUTION
2-MedicalCarve out
ATAZANAVIR SULFATE 150 MG CAP200 MG CAP 300 MG CAP
2-MedicalCarve out
atazanavir sulfate 150 mg capsule200 mg capsule 300 mg capsule
2-MedicalCarve out
CRIXIVAN (indinavir sulfate) 200MG CAPSULE 400 MG CAPSULE
2-MedicalCarve out
EVOTAZ (atazanavirsulfatecobicistat) 300 MG-150 MGTABLET
2-MedicalCarve out
fosamprenavir calcium 700 mgtablet
2-MedicalCarve out
FOSAMPRENAVIR CALCIUM 700MG TABLET
2-MedicalCarve out
INVIRASE (saquinavir mesylate) 200MG CAPSULE 500 MG TABLET
2-MedicalCarve out
KALETRA (lopinavirritonavir) 80MG-20 MGML SOLN 100-25 MGTABLET 200-50 MG TABLET
2-MedicalCarve out
LEXIVA (fosamprenavir calcium) 50MGML SUSPENSION 700 MGTABLET
2-MedicalCarve out
lopinavirritonavir 400-1005solution
2-MedicalCarve out
NORVIR (ritonavir) 80 MGMLSOLUTION 100 MG TABLET 100 MGSOFTGEL CAP 100 MG POWDERPACKET
2-MedicalCarve out
PREZCOBIX (darunavirethanolatecobicistat) 800 MG-150MG TABLET
2-MedicalCarve out
PREZISTA (darunavir ethanolate) 75MG TABLET 100 MGMLSUSPENSION 150 MG TABLET 400MG TABLET 600 MG TABLET 800MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
40
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
REYATAZ (atazanavir sulfate) 50MG POWDER PACKET 150 MGCAPSULE 200 MG CAPSULE 300MG CAPSULE
2-MedicalCarve out
ritonavir 100 mg tablet 2-MedicalCarve out
SYMTUZA (darunavirethcobicistatemtricitabinetenofovir alafenamide) 800-150-200-10MG TAB
2-MedicalCarve out
VIRACEPT (nelfinavir mesylate) 250MG TABLET 625 MG TABLET
2-MedicalCarve out
ANTI-INFLUENZA AGENTSoseltamivir phosphate 30 mgcapsule 45 mg capsule 75 mgcapsule
1-Covered QL (10 PER 30 DAY(S)) MFL (1 180 day(s))
OSELTAMIVIR PHOSPHATE 30 MGCAPSULE 45 MG CAPSULE 75 MGCAPSULE
1-Covered QL (10 PER 30 DAY(S)) MFL (1 180 day(s))
oseltamivir phosphate 6 mgmlsusp recon
1-Covered QL (120 PER FILL(S)) MFL (120 180day(s))
OSELTAMIVIR PHOSPHATE 6 MGMLSUSPENSION
1-Covered QL (120 PER FILL(S)) MFL (120 180day(s))
RELENZA (zanamivir) 5 MGDISKHALER
1-Covered QL (20 PER 30 DAY(S))
ANTIHERPETIC AGENTSacyclovir 200 mg capsule 200mg5ml oral susp 400 mg tablet800 mg tablet
1-Covered
ACYCLOVIR 200 MG5 ML SUSP400 MG TABLET 800 MG TABLET
1-Covered
trifluridine 1 drops 1-Covered
valacyclovir hcl 500 mg tablet1000 mg tablet
1-Covered QL (60 PER 30 DAY(S))
ANXIOLYTICS (Drugs for Anxiety)
ANXIOLYTICS OTHER (Other Drugs for Anxiety)BUSPIRONE HCL 5 MG TABLET 10MG TABLET 15 MG TABLET 30 MGTABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
41
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
buspirone hcl 5 mg tablet 75 mgtablet 10 mg tablet 15 mg tablet30 mg tablet
1-Covered
BENZODIAZEPINESalprazolam (ALPRAZOLAMINTENSOL) 1 mgml oral conc
1-Covered
alprazolam 025 mg tablet 05 mgtablet 1 mg tablet 2 mg tablet
1-Covered QL (100 PER 30 DAYS)
clonazepam 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered QL (120 PER 30 DAY(S))
diazepam 2 mg tablet 5 mgtablet 10 mg tablet
1-Covered QL (100 PER 30 DAYS)
diazepam 5 mg5 ml solution 5mgml oral conc
1-Covered
lorazepam (LORAZEPAM INTENSOL)2 mgml oral conc
1-Covered
lorazepam 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered QL (100 PER 30 DAYS)
lorazepam 2 mgml oral conc 1-Covered
oxazepam 10 mg capsule 15 mgcapsule 30 mg capsule
1-Covered
BIPOLAR AGENTS (Drugs for Bipolar Disorder)
MOOD STABILIZERSlithium carbonate 150 mg capsule300 mg tablet er 300 mg capsule300 mg tablet 450 mg tablet er600 mg capsule
2-MedicalCarve out
lithium citrate 8 meq5 ml solution 2-MedicalCarve out
LITHOBID (lithium carbonate) ER300 MG TABLET
2-MedicalCarve out
BLOOD GLUCOSE REGULATORS (Drugs for Diabetes)
ANTIDIABETIC AGENTS (Drugs for High Blood Sugar)acarbose 100 mg tablet 1-Covered QL (3 PER 1 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
42
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acarbose 25 mg tablet 1-Covered QL (12 PER 1 DAYS)
acarbose 50 mg tablet 1-Covered QL (6 PER 1 DAYS)
ADLYXIN (lixisenatide) 10-20 MCGSTARTER PACK 20 MCGMAINTENANCE PK
1-Covered PA
alogliptin benzoate 625 mg tablet125 mg tablet 25 mg tablet
1-Covered ST
alogliptin benzoatemetformin hclbenzmetformin 125-1000 tabletbenzmetformin 125-500mg tablet
1-Covered ST
alogliptin benzoatepioglitazonehcl benzpioglitazone 125-15 mgtablet benzpioglitazone 125-45mg tablet benzpioglitazone 125-30 mg tablet benzpioglitazone 25mg-30mg tabletbenzpioglitazone 25 mg-45mgtablet benzpioglitazone 25 mg-15mg tablet
1-Covered ST
AVANDIA (rosiglitazone maleate) 2MG TABLET 4 MG TABLET
1-Covered QL (60 PER 30 DAYS)
glimepiride 1 mg tablet 2 mgtablet 4 mg tablet
1-Covered STAR (Preferred Drug)
glipizide 25 mg tab er 24 5 mgtablet 5 mg tab er 24 10 mg taber 24 10 mg tablet
1-Covered STAR (Preferred Drug)
glyburide 125 mg tablet 25 mgtablet 5 mg tablet
1-Covered STAR (Preferred Drug)
glyburidemetformin hcl 125-250mg tablet 25-500 mg tablet 5mg-500mg tablet
1-Covered STAR (Preferred Drug)
JARDIANCE (empagliflozin) 10 MGTABLET 25 MG TABLET
1-Covered PA QL (1 PER 1 DAYS)
metformin hcl 500 mg tablet 500mg tab er 24h 750 mg tab er 24h850 mg tablet 1000 mg tablet
1-Covered STAR (Preferred Drug)
METFORMIN HCL ER ER 500 MGTABLET ER 750 MG TABLET
1-Covered STAR (Preferred Drug)
nateglinide 60 mg tablet 120 mgtablet
1-Covered ST
pioglitazone hcl 15 mg tablet 30mg tablet 45 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
43
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PIOGLITAZONE HCL 15 MG TABLET30 MG TABLET 45 MG TABLET
1-Covered
SYNJARDY(empagliflozinmetformin hcl) 5-1000 MG TABLET
1-Covered PA QL (2 PER 1 DAY(S))
SYNJARDY(empagliflozinmetformin hcl) 5-500 MG TABLET 125-500 MGTABLET 125-1000 MG TABLET
1-Covered PA QL (2 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 10-MG TABLET 125-MG TAB
1-Covered PA QL (2 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 25-1000 MG TABLET
1-Covered PA QL (1 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 5-1000 MG TABLET
1-Covered PA QL (2 PER 1)
tolbutamide 500 mg tablet 1-Covered
TRULICITY (dulaglutide) 075MG05 ML PEN 15 MG05 ML PEN
1-Covered PA QLC (1 penweek)
TRULICITY 3 MG05 ML PEN 45MG05 ML PEN
1-Covered PA QL (05 PER 1 WEEK(S))
VICTOZA 2-PAK (liraglutide) -18MG3 ML PEN
1-Covered PA QLC (6 ml (2 pens)30 days)
VICTOZA 3-PAK (liraglutide) -18MGML PEN
1-Covered PA QLC (9 ml (3 pens)30 days)
GLYCEMIC AGENTS (Drugs for Low Blood Sugar)BAQSIMI (glucagon) 3 MG SPRAYTWO PACK 3 MG SPRAY ONEPACK
1-Covered QL (2 PER 30 DAY(S))
GLUCAGON EMERGENCY KIT(glucagon hcl) 1 MG
1-Covered
GLUCAGON EMERGENCY KIT(glucagonhuman recombinant) 1MG
1-Covered
terbinafine hcl (JOCK ITCH) 1 cream (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
44
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
INSULINSADMELOG (insulin lispro) 100UNITML VIAL
1-Covered
ADMELOG SOLOSTAR (insulin lispro)100 UNITML
1-Covered PA
BASAGLAR KWIKPEN U-100 (insulinglarginehuman recombinantanalog) UNITML
1-Covered
HUMALOG (insulin lispro) 100UNITML CARTRIDGE
1-Covered PA
HUMALOG MIX 75-25 (insulin lisproprotamine and insulin lispro) -VIAL (
1-Covered
HUMALOG MIX 75-25 KWIKPEN(insulin lispro protamine and insulinlispro) -(
1-Covered PA
HUMULIN 70-30 (insulin nph humanisophaneinsulin regular human) -VIAL
1-Covered
HUMULIN 7030 KWIKPEN (insulinnph human isophaneinsulinregular human)
1-Covered PA
HUMULIN N (insulin nph humanisophane) 100 UITML VIAL
1-Covered
HUMULIN R (insulin regular human)100 UNITML VIAL
1-Covered
HUMULIN R U-500 (insulin regularhuman) UNITML VIAL
1-Covered
insulin lispro 100ml insuln pen 1-Covered PA
insulin lispro 100ml vial 1-Covered
INSULIN LISPRO PROTAMINE MIX(insulin lispro protamine and insulinlispro) 75-25 KWKPN (
1-Covered PA
NOVOLIN 70-30 (insulin nph humanisophaneinsulin regular human)70-30 100 UNITML VIAL RELION 70-30 VIAL
1-Covered
NOVOLIN N (insulin nph humanisophane) N 100 UNITML VIALRELION N 100 UNITML
1-Covered
NOVOLIN R (insulin regular human)R 100 UNITML VIAL RELION R 100UNITML
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
45
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
BLOOD PRODUCTSMODIFIERSVOLUME EXPANDERS (Drugs forBlood Disorders)
ANTICOAGULANTS (Blood Thinners)COUMADIN (warfarin sodium) 1MG TABLET 2 MG TABLET 25 MGTABLET 3 MG TABLET 4 MG TABLET5 MG TABLET 6 MG TABLET 75 MGTABLET 10 MG TABLET
1-Covered
ELIQUIS (apixaban) 25 MG TABLET5 MG TABLET
1-Covered QL (2 PER 1 DAY(S))
ELIQUIS (apixaban) DVT-PE TREATSTART 5MG
1-Covered QLC (1 PACK6 MONTHS)
ENOXAPARIN SODIUM 120 MG08ML SYR
1-Covered
ENOXAPARIN SODIUM 30 MG03ML SYR 40 MG04 ML SYR 60MG06 ML SYR 80 MG08 ML SYR100 MGML SYRINGE 150 MGMLSYRINGE
1-Covered PA
enoxaparin sodium 30mg03ml40mg04ml 60mg06ml80mg08ml 100 mgml120mg8ml 150 mgml
1-Covered PA
HEPARIN SODIUM SOD 5000UNITML VIAL SOD 10000 UNITMLVL SOD 20000 UNITML VL 50000UNIT5 ML VIAL
1-Covered
heparin sodiumporcine 5000mlvial 10000ml vial 20000ml vial
1-Covered
heparin sodiumporcinepf 1000mlvial
1-Covered
warfarin sodium (JANTOVEN) 1 mgtablet 2 mg tablet 25 mg tablet3 mg tablet 4 mg tablet 5 mgtablet 6 mg tablet 75 mg tablet10 mg tablet
1-Covered
warfarin sodium 1 mg tablet 2 mgtablet 25 mg tablet 3 mg tablet4 mg tablet 5 mg tablet 6 mgtablet 75 mg tablet 10 mg tablet
1-Covered
XARELTO (rivaroxaban) 10 MGTABLET 15 MG TABLET 20 MGTABLET
1-Covered QL (1 PER 1 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
46
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
XARELTO (rivaroxaban) DVT-PETREAT START 30D
1-Covered QLC (1 PACK6 MONTHS)
BLOOD FORMATION MODIFIERS (Blood Formation Drugs)anagrelide hcl 05 mg capsule 1mg capsule
1-Covered
EPOGEN (epoetin alfa) 2000UNITSML VIAL 3000 UNITSMLVIAL 4000 UNITSML VIAL 10000UNITSML VIAL 20000 UNITSMLVIAL
1-Covered PA SP
PROCRIT (epoetin alfa) 2000UNITSML VIAL 3000 UNITSMLVIAL 4000 UNITSML VIAL 10000UNITSML VIAL 20000 UNITSMLVIAL 40000 UNITSML VIAL
1-Covered PA SP
HEMOSTASIS AGENTS (Drugs to Stop Bleeding)ADVATE (antihemophilic factor(fviii) recombinantfull length) 200-400 VIAL 401-800 VIAL 801-1200VIAL 1201-1800 VIAL 1801-2400VIAL 2401-3600 VIAL 3601-4800VIAL
2-MedicalCarve out
ADYNOVATE (antihemophilicfactor (fviii) recombinant fulllength peg) 200-400 VIAL 401-800VIAL 750 VIAL 801-1250 VIAL1251-2500 VL 1500 VIAL 3000VIAL
2-MedicalCarve out
AFSTYLA (antihemophilic factor viiirecombsingle-chnb-domtruncated) 250 VIAL -- 500 VIAL --1000 VIAL -- 1500 RANGE VIAL --2000 VIAL -- 2500 RANGE VIAL --3000 VIAL --
2-MedicalCarve out
ALPHANATE (antihemophilic factorhumanvon willebrandfactorhuman) 250-100 VIALhuman) 500-200 VIAL human)1000-400 VIAL human) 1500-600VIAL human) 2000-800 VIALhuman)
2-MedicalCarve out
ALPHANINE SD (factor ix) SD 500VIAL SD 1000 VIAL SD 1500 VIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
47
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALPROLIX (factor ix recombinantfc fusion protein) 250 500 10002000 3000 4000
2-MedicalCarve out
BENEFIX (factor ix humanrecombinant) 250 500 10002000 3000
2-MedicalCarve out
COAGADEX (coagulation factor x)250 VIAL 500 VIAL
2-MedicalCarve out
CORIFACT (factor xiii) KIT 2-MedicalCarve out
ELOCTATE (antihemophilic factor(fviii) recombinant fc fusionprotein) 250 500 750 1000 15002000 3000 4000 5000 6000
2-MedicalCarve out
ESPEROCT (antihemophilic factor(fviii) rec b-dom truncated peg-exei) 500 VIAL -- 1000 VIAL --1500 VIAL -- 2000 VIAL -- 3000VIAL --
2-MedicalCarve out
FEIBA NF (anti-inhibitor coagulantcomplex) 500 (NOMINAL) - 1000(NOMINAL) - 2500 (NOMINAL) -
2-MedicalCarve out
FIBRYGA (fibrinogen) 1 GRAMRANGE VIAL
2-MedicalCarve out
HELIXATE FS (antihemophilic factor(fviii) recombinantfull length) 250UNIT VIAL 500 UNIT VIAL 1000 UNITVIAL 2000 UNIT VIAL 3000 UNITSVIAL
2-MedicalCarve out
HEMLIBRA (emicizumab-kxwh) 30MGML VIAL - 60 MG04 ML VIAL - 105 MG07 ML VIAL - 150 MGMLVIAL -
2-MedicalCarve out
HEMOFIL M (antihemophilic factorhuman) 250 500 1000 1700
2-MedicalCarve out
HUMATE-P (antihemophilic factorhumanvon willebrandfactorhuman) -600 human) -1200human) -2400 human)
2-MedicalCarve out
IDELVION (factor ixrecombinantalbumin fusionprotein) 250 VIAL 500 VIAL 1000VIAL 2000 VIAL 3500 VIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
48
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
IXINITY (factor ix humanrecombinant threonine 148) 500RANGE 500 VIAL 1000 VIAL 1000RANGE 1000 VIAL -2 VLS 1000RANGE-2 VLS 1500 RANGE-2 VLS1500 VIAL -2 VLS 1500 VIAL 1500RANGE
2-MedicalCarve out
JIVI (antihemophilic factor (fviii)rec b-domain deleted peg-aucl)500 VIAL -- 1000 VIAL -- 2000 VIAL-- 3000 VIAL --
2-MedicalCarve out
KCENTRA (human prothrombincomplex concentrate (pcc) 4-factor) 500 VIAL 4- 1000 VIAL 4-
2-MedicalCarve out
KOGENATE FS (antihemophilicfactor (fviii) recombinantfulllength) 250 UNIT VIAL 500 UNITVIAL 1000 UNITS VIAL 2000 UNITVIAL 3000 UNITS VIAL
2-MedicalCarve out
KOVALTRY (antihemophilic factor(fviii) recombinantfull length) 250KIT 500 KIT 1000 KIT 2000 KIT3000 KIT
2-MedicalCarve out
MONONINE (factor ix) 1000 UNITVIAL
2-MedicalCarve out
NOVOEIGHT (antihemophilic factorviii recombinant b-domaintruncated) 250 VIAL RECOMINANT- 500 VIAL RECOMINANT - 1000VIAL RECOMINANT - 1500 VIALRECOMINANT - 2000 VIALRECOMINANT - 3000 VIALRECOMINANT -
2-MedicalCarve out
NOVOSEVEN RT (coagulationfactor viia (recombinant)) 1 MGVIAL 2 MG VIAL 5 MG VIAL 8 MGVIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
49
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NUWIQ (antihemophilic factor viiirec hek cell b-domain deleted)250 VIAL - 250 VIAL PACK - 500VIAL - 500 VIAL PACK - 1000 VIAL - 1000 VIAL PACK - 2000 VIALPACK - 2000 VIAL - 2500 VIALPACK - 2500 VIAL - 3000 VIAL -3000 VIAL PACK - 4000 VIAL PACK- 4000 VIAL -
2-MedicalCarve out
OBIZUR (antihemophilic factor viiirecombinant porcine sequence)500 VIAL 500 VIAL - 5 VIALS 500VIAL -10 VIALS
2-MedicalCarve out
phytonadione (vit k1) 5 mg tablet 1-Covered
PROFILNINE (factor ix complexprothrombin cplx conc(pcc) no43-factor) 500 VIAL 3- 1000 VIAL 3-1500 VIAL 3-
2-MedicalCarve out
REBINYN (factor ix (human)recombinant pegylated) 500 VIAL1000 VIAL 2000 VIAL
2-MedicalCarve out
RECOMBINATE (antihemophilicfactor viii human recombinant)220-400 VIAL 401-800 VIAL 801-1240 VL 1241-1800 V 1801-2400V
2-MedicalCarve out
RIASTAP (fibrinogen) VIAL 2-MedicalCarve out
RIXUBIS (factor ix humanrecombinant) 250 500 10002000 3000
2-MedicalCarve out
SEVENFACT 1 MG VIAL 5 MG VIAL 2-MedicalCarve out
TRETTEN (factor xiii a-subunitrecombinant) 2500 UNIT VIAL(fctor -recombinnt)
2-MedicalCarve out
VONVENDI (von willebrand factor(recombinant)) 650 VIAL 1300VIAL
2-MedicalCarve out
WILATE (antihemophilic factorhumanvon willebrandfactorhuman) 450-450 VIALhuman) 500-500 VIAL human)900-900 VIAL human) 1000-1000VIAL human)
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
50
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
XYNTHA (antihemophilic factor(factor viii) recombb-domaindeleted) 250 KIT - 500 KIT - 1000KIT - 2000 KIT -
2-MedicalCarve out
XYNTHA SOLOFUSE (antihemophilicfactor (factor viii) recombb-domain deleted) 250 KIT - 500 KIT -1000 KIT - 2000 KIT - 3000 KIT -
2-MedicalCarve out
PLATELET MODIFYING AGENTScilostazol 50 mg tablet 100 mgtablet
1-Covered
clopidogrel bisulfate 75 mg tablet 1-Covered AL1 (At least 18 yrs old)
dipyridamole 25 mg tablet 50 mgtablet 75 mg tablet
1-Covered
CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation)
ALPHA-ADRENERGIC AGONISTSclonidine hcl 01 mg tablet 02 mgtablet 03 mg tablet
1-Covered
CLONIDINE HCL 01 MG TABLET 02MG TABLET 03 MG TABLET
1-Covered
guanfacine hcl 1 mg tablet 2 mgtablet
1-Covered
methyldopa 250 mg tablet 500mg tablet
1-Covered
ALPHA-ADRENERGIC BLOCKING AGENTSdoxazosin mesylate 1 mg tablet 2mg tablet 4 mg tablet 8 mgtablet
1-Covered
PHENOXYBENZAMINE HCL 10 MGCAP
1-Covered
phenoxybenzamine hcl 10 mgcapsule
1-Covered
prazosin hcl 1 mg capsule 2 mgcapsule 5 mg capsule
1-Covered
PRAZOSIN HCL 1 MG CAPSULE 2MG CAPSULE 5 MG CAPSULE
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
51
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terazosin hcl 1 mg capsule 2 mgcapsule 5 mg capsule 10 mgcapsule
1-Covered
TERAZOSIN HCL 1 MG CAPSULE 2MG CAPSULE 5 MG CAPSULE 10MG CAPSULE
1-Covered
ANGIOTENSIN II RECEPTOR ANTAGONISTSirbesartan 75 mg tablet 150 mgtablet 300 mg tablet
1-Covered ST
LOSARTAN POTASSIUM 25 MG TAB50 MG TAB 100 MG TAB
1-Covered STAR (Preferred Drug)
losartan potassium 25 mg tablet50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
valsartan 40 mg tablet 80 mgtablet 160 mg tablet 320 mgtablet
1-Covered ST
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORSbenazepril hcl 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered STAR (Preferred Drug)
captopril 125 mg tablet 25 mgtablet 50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
CAPTOPRIL 125 MG TABLET 25 MGTABLET 50 MG TABLET 100 MGTABLET
1-Covered STAR (Preferred Drug)
ENALAPRIL MALEATE 25 MG TAB 5MG TABLET 10 MG TAB 20 MG TAB
1-Covered STAR (Preferred Drug)
enalapril maleate 25 mg tablet 5mg tablet 10 mg tablet 20 mgtablet
1-Covered STAR (Preferred Drug)
fosinopril sodium 10 mg tablet 20mg tablet 40 mg tablet
1-Covered
lisinopril 25 mg tablet 5 mg tablet10 mg tablet 20 mg tablet 30 mgtablet 40 mg tablet
1-Covered STAR (Preferred Drug)
moexipril hcl 75 mg tablet 15 mgtablet
1-Covered
quinapril hcl 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered
ramipril 125 mg capsule 25 mgcapsule 5 mg capsule 10 mgcapsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
52
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
RAMIPRIL 125 MG CAPSULE 25MG CAPSULE 5 MG CAPSULE 10MG CAPSULE
1-Covered
trandolapril 1 mg tablet 2 mgtablet 4 mg tablet
1-Covered
ANTIARRHYTHMICS (Drugs for Irregular Heart Rhythm)amiodarone hcl (PACERONE) 200mg tablet
1-Covered
amiodarone hcl 200 mg tablet 1-Covered
disopyramide phosphate 100 mgcapsule
1-Covered
flecainide acetate 50 mg tablet100 mg tablet 150 mg tablet
1-Covered
mexiletine hcl 150 mg capsule 200mg capsule 250 mg capsule
1-Covered
MEXILETINE HCL 150 MG CAPSULE200 MG CAPSULE 250 MGCAPSULE
1-Covered
propafenone hcl 150 mg tablet225 mg tablet 300 mg tablet
1-Covered
quinidine gluconate 324 mg tableter
1-Covered
quinidine sulfate 200 mg tablet300 mg tablet
1-Covered
SOTALOL 80 MG TABLET 120 MGTABLET 160 MG TABLET 240 MGTABLET
1-Covered
SOTALOL AF 80 MG TABLET 120 MGTABLET
1-Covered
sotalol hcl (SORINE) 80 mg tablet120 mg tablet 160 mg tablet 240mg tablet
1-Covered
sotalol hcl 80 mg tablet 120 mgtablet 160 mg tablet 240 mgtablet
1-Covered
BETA-ADRENERGIC BLOCKING AGENTSatenolol 25 mg tablet 50 mgtablet 100 mg tablet
1-Covered STAR (Preferred Drug)
ATENOLOL 25 MG TABLET 50 MGTABLET 100 MG TABLET
1-Covered STAR (Preferred Drug)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
53
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
bisoprolol fumarate 5 mg tablet 10mg tablet
1-Covered
carvedilol 3125 mg tablet 625 mgtablet 125 mg tablet 25 mgtablet
1-Covered STAR (Preferred Drug)
labetalol hcl 100 mg tablet 200mg tablet 300 mg tablet
1-Covered
LABETALOL HCL 100 MG TABLET200 MG TABLET 300 MG TABLET
1-Covered
metoprolol succinate 200 mg taber 24h
1-Covered QL (60 PER 30 DAYS) MDD (2 PerDay) STAR (Preferred Drug)
metoprolol succinate 25 mg taber 50 mg tab er 100 mg tab er
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
METOPROLOL SUCCINATE ER 200MG TAB
1-Covered QL (60 PER 30 DAYS) MDD (2 PerDay) STAR (Preferred Drug)
METOPROLOL SUCCINATE ER 25MG TAB ER 50 MG TAB ER 100 MGTAB
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
metoprolol tartrate 25 mg tablet50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
nadolol 20 mg tablet 40 mgtablet 80 mg tablet
1-Covered STAR (Preferred Drug)
NADOLOL 20 MG TABLET 40 MGTABLET 80 MG TABLET
1-Covered STAR (Preferred Drug)
pindolol 5 mg tablet 10 mg tablet 1-Covered STAR (Preferred Drug)
propranolol hcl 10 mg tablet 20mg5 ml solution 20 mg tablet 40mg tablet 40mg5ml solution 60mg tablet 60 mg cap sa 24h 80mg tablet 80 mg cap sa 24h 120mg cap sa 24h 160 mg cap sa 24h
1-Covered
CALCIUM CHANNEL BLOCKING AGENTSAMLODIPINE BESYLATE 25 MG TAB5 MG TAB 10 MG TAB
1-Covered STAR (Preferred Drug)
amlodipine besylate 25 mg tablet5 mg tablet 10 mg tablet
1-Covered STAR (Preferred Drug)
DILTIAZEM 24HR ER (CD) 24HER(CD) 120 MG CP 24H ER(CD)240 MG CP 24H ER(CD) 180 MGCP 24H ER(CD) 360 MG CP 24HER(CD) 300 MG CP
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
54
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DILTIAZEM 24HR ER (XR) 24H ER(XR)240 MG CP 24H ER(XR) 180 MG CP
1-Covered
diltiazem hcl (CARTIA XT) 120 mgcap er 180 mg cap er 240 mgcap er 300 mg cap er
1-Covered
diltiazem hcl (DILT-XR) 120 mg caper - 180 mg cap er - 240 mg caper -
1-Covered
diltiazem hcl (TAZTIA XT) 120 mgcap 180 mg cap 240 mg cap 300mg cap 360 mg cap
1-Covered
diltiazem hcl 30 mg tablet 60 mgcap er 12h 60 mg tablet 90 mgtablet 90 mg cap er 12h 120 mgcap sa 24h 120 mg tablet 120 mgcap er 24h 120 mg cap er deg120 mg cap er 12h 180 mg cap sa24h 180 mg cap er deg 180 mgcap er 24h 240 mg cap er 24h 240mg cap er deg 240 mg cap sa24h 300 mg cap er 24h 300 mgcap sa 24h 360 mg cap sa 24h360 mg cap er 24h
1-Covered
felodipine 25 mg tab er 5 mg taber 10 mg tab er
1-Covered
FELODIPINE ER ER 25 MG TABLETER 5 MG TABLET ER 10 MG TABLET
1-Covered
nicardipine hcl 20 mg capsule 30mg capsule
1-Covered
nifedipine (AFEDITAB CR) 30 mgtablet er 60 mg tablet er
1-Covered
nifedipine (NIFEDICAL XL) 30 mgtab er 24 60 mg tab er 24
1-Covered
NIFEDIPINE 10 MG CAPSULE 1-Covered
nifedipine 10 mg capsule 20 mgcapsule 30 mg tablet er 30 mgtab er 24 60 mg tablet er 60 mgtab er 24 90 mg tablet er 90 mgtab er 24
1-Covered
nisoldipine 20 mg tab er 30 mgtab er 40 mg tab er
1-Covered
verapamil hcl 40 mg tablet 80 mgtablet 120 mg tablet 120 mgtablet er 180 mg tablet er 240 mgtablet er
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
55
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CARDIOVASCULAR AGENTS OTHERamiloride hclhydrochlorothiazideamiloridehydrochlorothiazide 5mg-50 mg tablet
1-Covered
amlodipine besylatebenazeprilhcl 25mg-10mg capsule 5 mg-20mg capsule 5 mg-10 mg capsule5 mg-40 mg capsule 10 mg-20mgcapsule 10 mg-40mg capsule
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day) STAR(Preferred Drug)
atenololchlorthalidone 50 mg-tablet 100mg-tablet
1-Covered STAR (Preferred Drug)
benazepril hclhydrochlorothiazidebenazeprilhydrochlorothiazide 5-625mg tabletbenazeprilhydrochlorothiazide 10-125mg tabletbenazeprilhydrochlorothiazide 20mg-25mg tabletbenazeprilhydrochlorothiazide 20-125 mg tablet
1-Covered STAR (Preferred Drug)
bisoprololfumaratehydrochlorothiazidebisoprololhydrochlorothiazide 25-tabletbisoprololhydrochlorothiazide 5-tabletbisoprololhydrochlorothiazide 10-tablet
1-Covered
BISOPROLOL-HYDROCHLOROTHIAZIDE -10-625MG TAB -25-625 MG TB -5-625MG TAB
1-Covered
captoprilhydrochlorothiazide 25mg-25mg tablet 25 mg-15mgtablet 50 mg-25mg tablet 50 mg-15mg tablet
1-Covered STAR (Preferred Drug)
digoxin (DIGITEK) 125 mcg tablet250 mcg tablet
1-Covered STAR (Preferred Drug)
digoxin (DIGOX) 125 mcg tablet250 mcg tablet
1-Covered STAR (Preferred Drug)
digoxin 125 mcg tablet 250 mcgtablet
1-Covered STAR (Preferred Drug)
digoxin 50 mcgml solution 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
56
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fosinoprilsodiumhydrochlorothiazidefosinoprilhydrochlorothiazide 10-125mg tabletfosinoprilhydrochlorothiazide 20-125 mg tablet
1-Covered
FOSINOPRIL-HYDROCHLOROTHIAZIDE -10-125MG TAB -20-125 MG TAB
1-Covered
irbesartanhydrochlorothiazide150-tablet 300-tablet
1-Covered ST
LANOXIN (digoxin) 125 MCGTABLET 250 MCG TABLET
1-Covered STAR (Preferred Drug)
lisinoprilhydrochlorothiazide 10-125mg tablet 20-125 mg tablet20 mg-25mg tablet
1-Covered STAR (Preferred Drug)
losartanpotassiumhydrochlorothiazidelosartanhydrochlorothiazide 50-125 mg tabletlosartanhydrochlorothiazide100mg-25mg tabletlosartanhydrochlorothiazide 100-125mg tablet
1-Covered STAR (Preferred Drug)
LOSARTAN-HYDROCHLOROTHIAZIDE -50-125MG TAB -100-125 MG TAB -100-25MG TAB
1-Covered STAR (Preferred Drug)
pentoxifylline 400 mg tablet er 1-Covered
spironolactonehydrochlorothiazide spironolacthydrochlorothiazid25 mg-25mg tablet
1-Covered
triamterenehydrochlorothiazide375-25 mg capsule 375-25 mgtablet 50 mg-25mg capsule 75mg-50mg tablet
1-Covered
valsartanhydrochlorothiazide 80-125mg tablet 160-125mg tablet160mg-25mg tablet 320-125mgtablet 320mg-25mg tablet
1-Covered ST
DIURETICS CARBONIC ANHYDRASE INHIBITORSacetazolamide 125 mg tablet 250mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
57
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ACETAZOLAMIDE 125 MG TABLET250 MG TABLET
1-Covered
DIURETICS LOOPbumetanide 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered
furosemide 10 mgml solution 20mg tablet 40mg5ml solution 40mg tablet 80 mg tablet
1-Covered STAR (Preferred Drug)
DIURETICS POTASSIUM-SPARINGamiloride hcl 5 mg tablet 1-Covered
spironolactone 25 mg tablet 50mg tablet 100 mg tablet
1-Covered
SPIRONOLACTONE 25 MG TABLET50 MG TABLET 100 MG TABLET
1-Covered
DIURETICS THIAZIDEchlorothiazide 250 mg tablet 500mg tablet
1-Covered
chlorthalidone 25 mg tablet 50 mgtablet
1-Covered
CHLORTHALIDONE 25 MG TABLET50 MG TABLET
1-Covered
DIURIL (chlorothiazide) 250 MG5ML ORAL SUSP
1-Covered
hydrochlorothiazide 125 mgcapsule 25 mg tablet 50 mgtablet
1-Covered STAR (Preferred Drug)
indapamide 125 mg tablet 25mg tablet
1-Covered
methyclothiazide 5 mg tablet 1-Covered
metolazone 25 mg tablet 5 mgtablet 10 mg tablet
1-Covered
DYSLIPIDEMICS FIBRIC ACID DERIVATIVES (Drugs for HighCholesterol)
fenofibrate 54 mg tablet 160 mgtablet
1-Covered ST
FENOFIBRATE 54 MG TABLET 160MG TABLET
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
58
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fenofibratemicronized 67 mgcapsule 134 mg capsule 200 mgcapsule
1-Covered ST
gemfibrozil 600 mg tablet 1-Covered
GEMFIBROZIL 600 MG TABLET 1-Covered
TRIGLIDE (fenofibratenanocrystallized) 160 MG TABLET
1-Covered ST
DYSLIPIDEMICS HMG COA REDUCTASE INHIBITORS (Drugs for HighCholesterol)
atorvastatin calcium 10 mg tablet20 mg tablet 40 mg tablet 80 mgtablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
ATORVASTATIN CALCIUM 10 MGTABLET 20 MG TABLET 40 MGTABLET 80 MG TABLET
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
lovastatin 10 mg tablet 20 mgtablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
rosuvastatin calcium 5 mg tablet10 mg tablet 20 mg tablet 40 mgtablet
1-Covered ST QL (30 PER 30 DAY(S))
simvastatin 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered STAR (Preferred Drug)
DYSLIPIDEMICS OTHER (Other Drugs for High Cholesterol)cholestyramine (with sugar) suar) 4powder
1-Covered
cholestyramineaspartame(PREVALITE) 4 g powder
1-Covered
cholestyramineaspartame 4 gpowder
1-Covered
COLESTID (colestipol hcl)FLAVORED GRANULES
1-Covered
colestipol hcl 1 tablet 5 ranules 5packet
1-Covered
ezetimibe 10 mg tablet 1-Covered
niacin (ENDUR-ACIN) 250 mgtablet er - 500 mg tablet er - 750mg tablet er -
1-Covered
niacin (SLO-NIACIN) 500 mg tableter -
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
59
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NIACIN 100 MG TABLET TR 500 MGTABLET
1-Covered
niacin 50 mg tablet 100 mg tablet250 mg capsule er 250 mg tablet250 mg tablet er 500 mg tablet500 mg tablet er 500 mg tab er24h 500 mg capsule er 750 mgtablet er 1000 mg tablet er
1-Covered
OMEGA-3 ACID ETHYL ESTERS -1GM CAP
1-Covered QL (4 PER 1 DAY(S))
omega-3 acid ethyl esters omea-1capsule
1-Covered QL (4 PER 1 DAY(S))
VASODILATORS DIRECT-ACTING ARTERIAL (Drugs for RelaxingArteries)
hydralazine hcl 10 mg tablet 25mg tablet 50 mg tablet 100 mgtablet
1-Covered
minoxidil 25 mg tablet 10 mgtablet
1-Covered
VASODILATORS DIRECT-ACTING ARTERIALVENOUS (Drugs forRelaxing Arteries and Veins)
ISOSORBIDE DINITRATE 5 MG TAB10 MG TAB 20 MG TAB 30 MG TAB
1-Covered STAR (Preferred Drug)
isosorbide dinitrate 5 mg tablet 10mg tablet 20 mg tablet 30 mgtablet 40 mg tablet er
1-Covered STAR (Preferred Drug)
isosorbide mononitrate 10 mgtablet 20 mg tablet 30 mg tab er24h 60 mg tab er 24h 120 mg taber 24h
1-Covered STAR (Preferred Drug)
NITRO-BID (nitroglycerin) -2OINTMENT
1-Covered
nitroglycerin (MINITRAN) 01mghrpatch 02mghr patch 04mghrpatch 06mghr patch
1-Covered
nitroglycerin (NITRO-TIME) 25 mgcapsule er - 65 mg capsule er - 9mg capsule er -
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
60
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
nitroglycerin 01mghr patch td2402mghr patch td24 03 mg tabsubl 04mghr patch td24 04 mgtab subl 06 mg tab subl 06mghrpatch td24 25 mg capsule er 65mg capsule er 9 mg capsule er400mcgspr spray
1-Covered
NITROGLYCERIN 400 MCG SPRAY 1-Covered
CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions)
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTSAMPHETAMINES
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 15 mg cap er 24h
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old) MDD (1 Per Day)
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 5 mg cap erdextroamphetamineamphetamine 10 mg cap erdextroamphetamineamphetamine 20 mg cap erdextroamphetamineamphetamine 25 mg cap erdextroamphetamineamphetamine 30 mg cap er
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old)
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 5 mg tabletdextroamphetamineamphetamine 75 mg tabletdextroamphetamineamphetamine 10 mg tabletdextroamphetamineamphetamine 125 mg tabletdextroamphetamineamphetamine 15 mg tabletdextroamphetamineamphetamine 20 mg tabletdextroamphetamineamphetamine 30 mg tablet
1-Covered AL1 (3 to 18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
61
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
dextroamphetamine sulfate(ZENZEDI) 5 mg tablet 10 mgtablet
1-Covered AL1 (3 to 18 yrs old)
dextroamphetamine sulfate 5 mgcapsule er 5 mg tablet 10 mgcapsule er 10 mg tablet 15 mgcapsule er
1-Covered AL1 (3 to 18 yrs old)
DEXTROAMPHETAMINE SULFATE 5MG TAB 10 MG TAB
1-Covered AL1 (3 to 18 yrs old)
DEXTROAMPHETAMINE-AMPHET ER-15 MG CAP
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old) MDD (1 Per Day)
DEXTROAMPHETAMINE-AMPHET ER-ER 5 MG CAP -ER 10 MG CAP -ER20 MG CAP -ER 25 MG CAP -ER 30MG CAP
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old)
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS NON-AMPHETAMINES
atomoxetine hcl 10 mg capsule 18mg capsule 25 mg capsule 40 mgcapsule 60 mg capsule 80 mgcapsule 100 mg capsule
1-Covered PA
guanfacine hcl 1 mg tab er 2 mgtab er 3 mg tab er 4 mg tab er
1-Covered QL (1 PER 1 DAY(S))
METHYLPHENIDATE ER ER 18 MGTAB ER 27 MG TAB ER 36 MG TABER 54 MG TAB
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl (METADATEER) 20 mg tablet er
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl 10 mg tableter 18 mg tab er 24 20 mg tableter 27 mg tab er 24 36 mg tab er24 54 mg tab er 24
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl 5 mg tablet10 mg cpbp 30-70 10 mg tablet20 mg tablet 20 mg cpbp 30-7030 mg cpbp 30-70 40 mg cpbp 30-70 50 mg cpbp 30-70 60 mg cpbp30-70
1-Covered AL1 (6 to 18 yrs old)
METHYLPHENIDATE HCL 5 MGTABLET 10 MG TABLET 20 MGTABLET
1-Covered AL1 (6 to 18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
62
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CENTRAL NERVOUS SYSTEM OTHERacetaminophen (ATHENOL) 325mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (CHILD FEVERREDUCER) 120 mg supprect
1-Covered
acetaminophen (CHILD PAIN REL-FEVER REDUCER) 120 mg supprect-
1-Covered
acetaminophen (CHILDRENSFEVER REDUCER) 120 mg supprect
1-Covered
acetaminophen (CHILDRENSFEVER REDUCING) 120 mgsupprect
1-Covered
acetaminophen (CHILDRENS PAINAND FEVER) 160 mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (CHILDRENSSILAPAP) 160 mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (ED-APAP) 160mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (LITTLE REMEDIESFEVER-PAIN) 160 mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (M-PAP) 160mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (MAPAP) 160mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (MAPAP) 325 mgtablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (MASOPHEN) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRINEXTRA STRENGTH) 500 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRINPAIN RELIEF) 500 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRIN)160 mg5ml elixir -
1-Covered QLC (LIMIT TO 2 FILLS OF 120ML IN30 DAYS)
acetaminophen (NON-ASPIRIN)325 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN amp FEVER)500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
63
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acetaminophen (PAIN RELIEFEXTRA STRENGTH) 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN RELIEF) 160mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (PAIN RELIEF) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN RELIEVER)325 mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PHARBETOL) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (SHAKE THATACHE) 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (TACTINAL) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen 120 mg 650 mg 1-Covered
acetaminophen 160 mg5ml elixir 1-Covered QLC (LIMIT TO 2 FILLS OF 120ML IN30 DAYS)
acetaminophen 160 mg5ml liquid 1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 160 mg5ml oralsusp
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 160 mg5mlsolution
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 325 mg tablet500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
ACETAMINOPHEN CVS 325 MGGELCP 325 MG TABLET 500 MGTABLET 500 MG GELCAP
1-Covered QL (60 PER 30 DAY(S))
butalbitalacetaminophen(TENCON) 50mg-325mg tablet
1-Covered QL (48 PER 30 DAY(S))
butalbitalacetaminophen 50mg-325mg tablet
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
butalbitalacetaminophencaffeine butalbacetaminophencaffeine50-325-40 tablet
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
PAIN amp FEVER (acetaminophen)500 MG TABLET
1-Covered QL (60 PER 30 DAY(S))
PAIN RELIEF 325 MG TABLET 500MG GELCAP 500 MG TABLET
1-Covered QL (60 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
64
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
riluzole 50 mg tablet 1-Covered PA
RILUZOLE 50 MG TABLET 1-Covered PA
FIBROMYALGIA AGENTSduloxetine hcl 20 mg capsule dr30 mg capsule dr 60 mg capsuledr
1-Covered
pregabalin 20 mgml solution 1-Covered PA QLC (30 MLDAY)
pregabalin 225 mg capsule 300mg capsule
1-Covered PA QL (2 PER 1 DAY(S))
PREGABALIN 225 MG CAPSULE 300MG CAPSULE
1-Covered PA QL (2 PER 1 DAY(S))
pregabalin 25 mg capsule 50 mgcapsule 75 mg capsule 100 mgcapsule 150 mg capsule 200 mgcapsule
1-Covered PA QL (3 PER 1 DAY(S))
PREGABALIN 25 MG CAPSULE 50MG CAPSULE 75 MG CAPSULE 100MG CAPSULE 150 MG CAPSULE200 MG CAPSULE
1-Covered PA QL (3 PER 1 DAY(S))
SAVELLA (milnacipran hcl) 125 MGTABLET 25 MG TABLET 50 MGTABLET 100 MG TABLET TITRATIONPACK
1-Covered PA
MULTIPLE SCLEROSIS AGENTSAVONEX (interferon beta-1a)PREFILLED SYR 30 MCG KT -
1-Covered PA SP
AVONEX (interferon beta-1aalbumin human) 30 MCG VIALKIT -
1-Covered PA SP
AVONEX PEN (interferon beta-1a)30 MCG05 ML KIT -
1-Covered PA SP
DIMETHYL FUMARATE 30D START PK 1-Covered PA SP
DIMETHYL FUMARATE DR 120 MGCP DR 240 MG CP
1-Covered PA SP QL (2 PER 1 DAY(S))
glatiramer acetate (GLATOPA) 20mgml syringe
1-Covered PA SP QLC (1 SYRINGEDAY)
glatiramer acetate (GLATOPA) 40mgml syringe
1-Covered PA SP QLC (12SYRINGESMONTH)
glatiramer acetate 20 mgmlsyringe
1-Covered PA SP QLC (1 SYRINGEDAY)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
65
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
glatiramer acetate 40 mgmlsyringe
1-Covered PA SP QLC (12SYRINGESMONTH)
PLEGRIDY (peginterferon beta-1a)125 MCG05 ML SYRING - SYRINGESTARTER PACK -
1-Covered PA SP
PLEGRIDY PEN (peginterferon beta-1a) 125 MCG05 ML PEN - PEN INJSTARTER PACK -
1-Covered PA SP
TECFIDERA (dimethyl fumarate) DR120 MG CAPSULE DR 240 MGCAPSULE STARTER PACK
1-Covered PA SP
DENTAL AND ORAL AGENTS (Drugs for the Mouth)
DENTAL AND ORAL AGENTSchlorhexidine gluconate (PAROEX)012 mouthwash
1-Covered
chlorhexidine gluconate 012 mouthwash
1-Covered
PHOS-FLUR (fluoride (sodium)) -ORAL RINSE
1-Covered
triamcinolone acetonide(ORALONE) 01 paste (g)
1-Covered
triamcinolone acetonide 01 paste (g)
1-Covered
TRIAMCINOLONE ACETONIDE 01PASTE
1-Covered
DERMATOLOGICAL AGENTS (Drugs for the Skin)ACNE MEDICATION (benzoylperoxide) 5 GEL
1-Covered
ACNE MEDICATION 25 GEL 1-Covered
ammonium lactate (SKINTREATMENT) 12 lotion
1-Covered
ammonium lactate 12 cream(g) 12 lotion
1-Covered
benzoyl peroxide (ACNE CONTROLCLEANSER) 10 cleanser
1-Covered
benzoyl peroxide (ACNE FOAMINGWASH) 10 cleanser
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
66
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
benzoyl peroxide (ACNETREATMENT) 10 gel (gram)
1-Covered
benzoyl peroxide (ACNECLEAR) 10 gel (gram)
1-Covered
benzoyl peroxide (ADVANCEDEXFOLIATING CLEANSER) 5 cleanser
1-Covered
benzoyl peroxide (BP WASH) 5 10
1-Covered
benzoyl peroxide (BP) 5 gel(gram) 10 gel (gram)
1-Covered
benzoyl peroxide (BPO-10) cleanser -
1-Covered
benzoyl peroxide (BPO-5) cleanser -)
1-Covered
benzoyl peroxide (CLEAN-CLEARCONTINUOUS CONTROL) 10 cleanser -
1-Covered
benzoyl peroxide (DAYLOGICACNE FOAMING WASH) 10 cleanser
1-Covered
benzoyl peroxide (DAYLOGICACNE TREATMENT) 10 gel (gram)
1-Covered
benzoyl peroxide (FOAMING ACNEFACE WASH) 10 cleanser
1-Covered
benzoyl peroxide (PANOXYL) 10 cleanser
1-Covered
benzoyl peroxide 25 gel (gram)5 cleanser 5 gel (gram) 10 gel (gram) 10 cleanser
1-Covered
CALADRYL (pramoxinehclcalamine) 1-8 LOTION
1-Covered
calcipotriene 0005 cream (g)0005 oint (g) 0005 solution
1-Covered PA
chlorhexidine gluconate 4 liquid 1-Covered
CORTISPORIN(neomycinbacitracinpolymyxinbhydrocortisone) OINTMENT
1-Covered
DIFFERIN (adapalene) 01 GEL 1-Covered AL1 (Up to 25 yrs old)
DRITHOCREME HP (anthralin) 1CREAM
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
67
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DRYSOL (aluminum chloride) DAB--MATIC SLUTIN
1-Covered
EPIFOAM (hydrocortisoneacetatepramoxine hcl)
1-Covered
hydrocortisoneacetatepramoxine hclhydrocortisonepramoxine 1 -1 creamapplhydrocortisonepramoxine 25 -1 cream (g)hydrocortisonepramoxine 25 -1 creamapplhydrocortisonepramoxine 25-1(4g) creamappl
1-Covered
isotretinoin (AMNESTEEM) 10 mgcapsule 20 mg capsule 40 mgcapsule
1-Covered PA
isotretinoin (CLARAVIS) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin (MYORISAN) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin (ZENATANE) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin 10 mg capsule 20 mgcapsule 30 mg capsule 40 mgcapsule
1-Covered PA
LICE KILLING SHAMPOO 1-Covered
metronidazole 075 cream (g)075 gel (gram) 1 gel (gram)
1-Covered
pimecrolimus 1 cream (g) 1-Covered PA
piperonyl butoxidepyrethrins (LICEKILLING) 4-033 shampoo
1-Covered
piperonyl butoxidepyrethrins (LICEPYRINYL SHAMPOO) 4-033shampoo
1-Covered
piperonyl butoxidepyrethrins (LICETREATMENT) 4-033 shampoo
1-Covered
piperonyl butoxidepyrethrins (RID)4-033 shampoo
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
68
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
piperonylbutoxidepyrethrinspermethrin(COMPLETE LICE TREATMENT)butoxpyrethrpermet 4-33-5 kit
1-Covered
piperonylbutoxidepyrethrinspermethrin(LICE SOLUTION)butoxpyrethrpermet 4-33-5 kit
1-Covered
podofilox 05 solution 1-Covered
pramoxine hclcalamine(CALAHIST) 1 -8 lotion
1-Covered
pramoxine hclcalamine(CALAMINE MEDICATED) 1 -8 lotion
1-Covered
PROCTOFOAM-HC (hydrocortisoneacetatepramoxine hcl) PROCTO-1-1
1-Covered
RID (piperonylbutoxidepyrethrinspermethrin) 1-2-3 KIT KIT
1-Covered
SANTYL (collagenase clostridiumhistolyticum) OINTMENT
1-Covered QL (60 PER 30 DAYS)
selenium sulfide (ANTI-DANDRUFF)1 shampoo -
1-Covered
selenium sulfide (MEDICATEDDANDRUFF SHAMPOO) 1 shampoo
1-Covered
selenium sulfide (SELSUN BLUE) 1 shampoo
1-Covered
selenium sulfide 25 lotion 1-Covered
selenium sulfidealoe vera (SELSUNBLUE MOISTURIZING) 1 shampoo
1-Covered
tacrolimus 003 (g) 01 (g) 1-Covered PA
ELECTROLYTESMINERALSMETALSVITAMINS
ELECTROLYTEMINERAL REPLACEMENT09 sodium chloride iv soln 1-Covered PA
calcium carbonate 600 mg tablet 1-Covered
dextrose 5 in water in iv soln 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
69
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levocarnitine 330 mg tablet 1-Covered
potassium chloride in 09 sodiumchloride 09nacl 10 meql iv soln
1-Covered PA
ringers solution iv soln 1-Covered
sodium chloride irrigating solution09 soln
1-Covered
ELECTROLYTEMINERALMETAL MODIFIERSCHEMET (succimer) 100 MGCAPSULE
1-Covered PA
09 sodium chloride iv soln 1-Covered PA
CLINIMIX (amino acids 425 indextrose 5 in water) -SOLUTION
1-Covered PA
dextrose 10 and 045 sodiumchloride nacl -iv soln
1-Covered PA
dextrose 10 in water 10 10 dehp fr bg 10 10 iv soln
1-Covered PA
dextrose 5 and 045 sodiumchloride -04chlord -04iv soln
1-Covered PA
dextrose 5 in water 5 5 ivsoln 5 5 vial
1-Covered PA
levocarnitine (with sugar) 100mgml solution
1-Covered
levocarnitine 100 mgml solution330 mg tablet
1-Covered
MYNATAL (prenatal vitamins withcalciumferrous fumaratefolicacid) CAPSULE
1-Covered
O-CAL PRENATAL (prenatal vit withcalcium no127ferrousfumaratefolic acid) -TABLET
1-Covered
potassium chloride (KLOR-CONM10) meq tab er prt -
1-Covered
potassium chloride (KLOR-CONM20) meq tab er prt -
1-Covered
potassium chloride 8 meq tableter 10 meq tablet er 10 meqcapsule er 10 meq tab er prt 20meq tablet er 20 meq tab er prt20meq15ml liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
70
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
POTASSIUM CHLORIDE ER 8 MEQTABLET 10 (20 MEQ15ML) 10(40 MEQ30ML) ER 10 MEQ TABLETER 20 MEQ TABLET
1-Covered
potassium chloride in 09 sodiumchloride 20 meql soln 40 meqlsoln
1-Covered PA
PRENATABS FA (prenatal vits withcalcium no78ferrousfumaratefolic acid) TABLET
1-Covered
PRENATABS RX (prenatal vitaminwith calciumno76ironcarbonylfolic acid)TABLET
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid (MYNATAL PLUS) vitironfumfolic 65 mg-1 mg tablet
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid (MYNATAL-Z) vitiron fumfolic65 mg-1 mg tablet -
1-Covered
prenatal vits with calcium118ferrous fumaratefolic acid (SE-NATAL 19) pnv no8ironfumaratefa 29 mg-mg tab chew -9)
1-Covered
prenatal vits with calcium136ferrous fumaratefolic acid(VINATE-M) vit36ironfolic acd 27mg-mg tablet -
1-Covered
prenatal vits with calciumno115iron fumaratefolic acidno5ironfolic 29 mg-mg tab chew
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acid(M-NATAL PLUS) pnvcalcium72ironfolic 27 mg-1 mg tablet -
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acid(PREPLUS) pnvcalcium 72ironfolic27 mg-1 mg tablet
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acidpnvcalcium 72ironfolic 27 mg-1mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
71
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
prenatal vits with calciumno72ironcarbonylfolic acidpnvcalcium 72ironcarbfolic 29mg-1 mg tablet
1-Covered
prenatal vits with calciumno74ferrous fumaratefolic acidvitcal 74ironfolic 27 mg-1 mgtablet
1-Covered
SE-NATAL-19 (prenatal vitaminsno119iron fumaratefolic acid) --TABLET
1-Covered
sodium chloride irrigating solution09 soln
1-Covered
sodium polystyrene sulfonate 15g60 ml oral susp
1-Covered
sodium polystyrenesulfonatesorbitol solution (KIONEX)sulfonsorb 15 g60 ml oral susp
1-Covered
SPS (sodium polystyrenesulfonatesorbitol solution) 15GM60 ML SUSPENSION
1-Covered
TRINATE (prenatal vits with calciumno73ferrous fumaratefolic acid)TABLET
1-Covered
VITAMINS09 sodium chloride iv soln 1-Covered PA
ascorbate calcium 500 mg tablet 1-Covered
ascorbic acid (SOOTHINGPUREWAY-C) 500 mg tablet -
1-Covered
ascorbic acid 250 mg tablet 500mg5ml syrup 500 mg tablet 1000mg tablet
1-Covered
CALCIUM 500-VIT D3 MG-MCG TB 1-Covered
CALCIUM 600 MG TABLET 1-Covered
CALCIUM 600-VIT D3 MG-10MCGTB
1-Covered
calcium carbonate (OYSCO-500)500(1250) tablet -
1-Covered
calcium carbonate (SUPERCALCIUM) 600 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
72
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcium carbonate 500(1250)tablet 600 mg tablet
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (HI-CAL)carbonatevitamin 500 mg-200tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OS-CAL 500-VIT D3)carbonatevitamin mg-200 tablet --
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OYSCO 500-VIT D3)carbonatevitamin mg-200 tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OYSTERCAL-D)carbonatevitamin 500 mg-400tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) carbonatevitamin250 mg-125 tabletcarbonatevitamin 500 mg-600tablet carbonatevitamin 500 mg-400 tablet carbonatevitamin 500mg-200 tablet carbonatevitamin600 mg-400 tablet
1-Covered
calcium gluconate 60(650) mgtablet
1-Covered
calcium lactate 84 mg(648) tablet 1-Covered
cyanocobalamin (vitamin b-12) (B-12 DOTS) cyanocoalamin -) 500mcg talet -
1-Covered
cyanocobalamin (vitamin b-12)cyanocoalamin -500 mcg talet
1-Covered
dextrose 10 in water iv soln 1-Covered PA
dextrose 5 and 045 sodiumchloride -04chlord -04iv soln
1-Covered PA
dextrose 5 in lactated ringers -ivsoln
1-Covered PA
dextrose 5 in water in iv soln 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
73
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DEXTROSE IN WATER 5-IV SOLN10-IV SOLUTION
1-Covered PA
electrolytesdextrose(ELECTROLYTE) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (ORALYTE)solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (PEDIATRICELECTROLYTE) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (PEDIATRICFREEZER POPS) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
ferrous sulfate (CHILDRENS IRON)15 mgml drops
1-Covered
ferrous sulfate (FEOSOL) 325(65)mg tablet
1-Covered
ferrous sulfate (FEROSUL) 325(65)mg tablet
1-Covered
ferrous sulfate (FERRO-TIME) 325(65)mg tablet -
1-Covered
ferrous sulfate (FERROUSUL) 325(65)mg tablet
1-Covered
ferrous sulfate (PEDIA IRON) 15mgml drops
1-Covered
ferrous sulfate 15 mgml drops 220(44)5 solution 220 (44)5 elixir324(65)mg tablet dr 325(65) mgtablet dr 325(65) mg tablet
1-Covered
FERROUS SULFATE SULF 220 MG5ML LIQ SULF EC 325 MG TABLETSULFATE 325 MG TABLET
1-Covered
fluoride (sodium) 025(055) tabchew 05(11)mg tab chew 05mgml drops 1mg(22mg) tabchew
1-Covered STAR (Preferred Drug)
folic acid 04 mg tablet 08 mgtablet 1 mg tablet 20 mg capsule
1-Covered
FOLIC ACID 400 MCG TABLET 800MCG TABLET
1-Covered
IRON 65 MG TABLET 1-Covered
OYSTER SHELL CALCIUM 500 MG TB 1-Covered
OYSTER SHELL CALCIUM-VIT D3 250MG-312MCG
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
74
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PEDIATRIC IRON PHARM CHC15MGML DRP
1-Covered
pediatric multivit with acd3no21sodium fluorideno21fluoride 025 mgml dropsno21fluoride 05 mgml drops
1-Covered STAR (Preferred Drug)
pediatric multivitaminno16sodium fluoride -025 mg tabche -05 mg tab che -1 mg tabche
1-Covered
pediatric multivitamin no2sodiumfluoride w-025 mgml drops
1-Covered
pediatric multivitamin no2sodiumfluoride w-05 mgml drops
1-Covered STAR (Preferred Drug)
pediatric multivitaminno45sodium fluorideferroussulfate 45fluorideiron 025-10mldrops
1-Covered STAR (Preferred Drug)
pediatric multivitamins no17 withsodium fluoride -025 mg tab che -05 mg tab che -1 mg tab che
1-Covered STAR (Preferred Drug)
POLY-VITAMIN (multivitamin) -TABCHEW
1-Covered STAR (Preferred Drug)
POTASSIUM 99 MG TABLET 1-Covered
potassium bicarbonatecitric acid(EFFER-K) 25 meq tablet eff -
1-Covered
potassium bicarbonatecitric acid(K EFFERVESCENT) 25 meq tableteff
1-Covered
potassium bicarbonatecitric acid(KLOR-CON-EF) 25 meq tablet eff --
1-Covered
potassium bicarbonatecitric acid25 meq tablet eff
1-Covered
POTASSIUM CHL-NORMAL SALINE20 -ML IV SOLN 40 -ML IV SOLN
1-Covered
potassium chloride (KLOR-CONSPRINKLE) 10 meq capsule er -
1-Covered
potassium chloride 20meq15mlliquid
1-Covered
potassium chloridepotassiumbicarbonatecitric acidchloridebicarbcit 25 meq tableteff
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
75
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
potassium gluconate 595(99)mgtablet
1-Covered
PRENATAL MULTIVITAMIN TABLET 1-Covered
prenatal vit with calciumno129ferrous fumaratefolic acidno129ironfolic 27mg-08mgtablet
1-Covered
prenatal vit with calciumno130ferrous fumaratefolic acidno130ironfolic 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vitamins no121ferrousfumaratefolic acid pnvno121ironfolic 28mg-08mgtablet
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid vitiron fumfolic 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vitamins withcalciumferrous fumaratefolicacid vitiron fumfolic 28mg-08mgtablet
1-Covered
prenatal vits with calcium118ferrous fumaratefolic acidpnv no8iron fumaratefa 29 mg-mg tab chew
1-Covered
prenatal vits with calcium137ferrous fumaratefolic acidno137ironfolic acd 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vits with calcium95ferrous fumaratefolic acid pnvno95ferrous fumfolic 28mg-08mg tablet
1-Covered
prenatal vits with calciumno96ferrous fumaratefolic acidvits96iron fumfolic 27mg-08mgtablet
1-Covered
pyridoxine hcl (vitamin b6) 25 mgtablet 50 mg tablet 100 mgtablet 250 mg tablet
1-Covered
ringers solution iv soln 1-Covered PA
SODIUM CHLORIDE 09 IRRIG 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
76
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SODIUM CHLORIDE 09 SOLUTION 1-Covered PA
sodium chloride irrigating solution(AQUA CARE SODIUM CHLORIDE)09 soln
1-Covered
sodium chloride irrigating solution(CURITY) 09 soln
1-Covered
sodium chloride irrigating solution09 soln
1-Covered
TRI-VI-SOL (vitamin apalmitateascorbicacidcholecalciferol (vit d3)) --DROPS (vitmin plmittescorbiccidcholeclciferol
1-Covered STAR (Preferred Drug)
VITAMIN B-12 -500 MCG TALET 1-Covered
VITAMIN C 1000 MG TABLET 1-Covered
GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach)
ANTISPASMODICS GASTROINTESTINAL (Drugs to Prevent Bowel andStomach Spasam)
CHLORDIAZEPOXIDE-CLIDINIUM -CAP
1-Covered MDD (8 Per Day)
chlordiazepoxideclidiniumbromide 5 mg-25mg capsule
1-Covered MDD (8 Per Day)
DICYCLOMINE HCL 10 MG5 MLSOLN
1-Covered
dicyclomine hcl 10 mg5 mlsolution 10 mg capsule 20 mgtablet
1-Covered
hyoscyamine sulfate (HYOSYNE)0125mgml drops 125mcg5mlelixir
1-Covered
hyoscyamine sulfate 0125 mg tabsubl 0125 mg tablet 0125mgmldrops 0375 mg tab er 12h125mcg5ml elixir
1-Covered
propantheline bromide 15 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
77
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GASTROINTESTINAL AGENTS OTHER (Other Drugs for the Bowel andStomach)
ALLI (orlistat) 60 MG CAPSULE 1-Covered PA
ANTACID 500 MG CHEW TABLET 1-Covered
ANTACID EXTRA STRENGTH -750 MGTAB CHEW CVS -750 MG CHEW
1-Covered
ANTI-DIARRHEAL HM -2 MGSOFTGEL
1-Covered
bismuth subsalicylate (BISMATROL)262 mg tab chew
1-Covered
bismuth subsalicylate (DIOTAME)262 mg tab chew
1-Covered
bismuth subsalicylate (PEP-T-MED)262 mg tab chew --
1-Covered
bismuth subsalicylate (PEPTICRELIEF) 262 mg tab chew
1-Covered
bismuth subsalicylate (PINKBISMUTH) 262 mg tab chew
1-Covered
bismuth subsalicylate (SOOTHE)262 mg tab chew
1-Covered
bismuth subsalicylate (STOMACHRELIEF) 262 mg tab chew
1-Covered
bismuth subsalicylate 262 mg tabchew
1-Covered
calcium carbonate (ANTACIDCALCIUM) 215(500)mg tab chew
1-Covered
calcium carbonate (ANTACIDEXTRA STRENGTH) 300mg(750) tabchew
1-Covered
calcium carbonate (ANTACID)200(500)mg tab chew 215(500)mgtab chew 300mg(750) tab chew
1-Covered
calcium carbonate (BAN-ACID)300mg(750) tab chew -
1-Covered
calcium carbonate (CAL-GEST)200(500)mg tab chew -
1-Covered
calcium carbonate (CALCIUMANTACID) 200(500)mg tab chew215(500)mg tab chew 300mg(750)tab chew
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
78
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcium carbonate (CHILDRENSPEPTO) 400 mg tab chew
1-Covered
calcium carbonate (CHILDRENSSOOTHE) 400 mg tab chew
1-Covered
calcium carbonate (FLAVORCHEWS ANTACID) 300mg(750) tabchew
1-Covered
calcium carbonate (SMOOTHANTACID) 300mg(750) tab chew
1-Covered
calcium carbonate (SMOOTHDISSOLVING ANTACID) 300mg(750)tab chew
1-Covered
calcium carbonate 200(500)mgtab chew 300mg(750) tab chew
1-Covered
diphenoxylate hclatropine sulfate25-0255 liquid 25-025mg tablet
1-Covered
DIPHENOXYLATE-ATROPINE -25-0025
1-Covered
GAS RELIEF (simethicone) (SIMETH)80 MG CHEW
1-Covered
GAS RELIEF GAS 125 MG CHEWTABLET GAS (SIMETH) 80 MGCHEW HM GAS 125 MG SOFTGELHM GAS 125 MG CHEW TAB
1-Covered
GAS-X (simethicone) -E-STR 125 MGTAB CHEW
1-Covered
INFANTS GAS RELIEF RLF 20 MG03ML
1-Covered
loperamide hcl (ANTI-DIARRHEAL) 2mg capsule - 2 mg tablet -
1-Covered
loperamide hcl (DIAMODE) 2 mgtablet
1-Covered
loperamide hcl (ULTRA A-D) 2 mgtablet -
1-Covered
loperamide hcl 1 mg5 ml liquid 2mg capsule 2 mg tablet
1-Covered
PEPTO-BISMOL (bismuthsubsalicylate) -TABLET CHEW
1-Covered
PEPTO-BISMOL TO-GO (bismuthsubsalicylate) --262 MG CHEW
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
79
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
simethicone (GAS RELIEF)40mg06ml drops susp 80 mg tabchew 125 mg tab chew 125 mgcapsule
1-Covered
simethicone (GAS-X) 125 mgcapsule -
1-Covered
simethicone (INFANT GAS RELIEF)40mg06ml drops susp
1-Covered
simethicone (INFANTS GAS RELIEF)40mg06ml drops susp
1-Covered
simethicone (MI-ACID) 80 mg tabchew -
1-Covered
simethicone 40mg06ml dropssusp 80 mg tab chew 125 mgcapsule 125 mg tab chew
1-Covered
STOMACH RELIEF 262 MG CHEWTAB
1-Covered
ursodiol 300 mg capsule 1-Covered
HISTAMINE2 (H2) RECEPTOR ANTAGONISTSACID CONTROLLER 20 MG TABLET 1-Covered
ACID REDUCER 10 MG TABLET 1-Covered PA
ACID REDUCER 20 MG TABLET 1-Covered
cimetidine (ACID REDUCER) 200mg tablet
1-Covered
cimetidine (HEARTBURN RELIEF) 200mg tablet
1-Covered
cimetidine 200 mg tablet 300 mgtablet 400 mg tablet 800 mgtablet
1-Covered
CIMETIDINE 300 MG5 ML SOLN 1-Covered
cimetidine hcl 300 mg5ml solution 1-Covered
famotidine (ACID CONTROLLER) 10mg tablet
1-Covered PA
famotidine (ACID CONTROLLER) 20mg tablet
1-Covered
famotidine (ACID REDUCER) 10 mgtablet
1-Covered PA
famotidine (ACID REDUCER) 20 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
80
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
famotidine (HEARTBURNPREVENTION) 10 mg tablet
1-Covered PA
famotidine (HEARTBURNPREVENTION) 20 mg tablet
1-Covered
famotidine (HEARTBURN RELIEF) 10mg tablet
1-Covered PA
famotidine (HEARTBURN RELIEF) 20mg tablet
1-Covered
famotidine (PEPCID) 20 mg tablet 1-Covered
famotidine 10 mg tablet 1-Covered PA
FAMOTIDINE 10 MG TABLET 1-Covered PA
famotidine 20 mg tablet 40 mgtablet
1-Covered
FAMOTIDINE 20 MG TABLET EQ 20MG TABLET 40 MG TABLET
1-Covered
IRRITABLE BOWEL SYNDROME AGENTSAMITIZA (lubiprostone) 8 MCGCAPSULE 24 MCG CAPSULES
1-Covered PA
LAXATIVES (Drugs for Bowel Cleansing and Constipation)bisacodyl (ALOPHEN PILLS) 5 mgtablet dr
1-Covered
bisacodyl (BISA-LAX) 5 mg tablet dr-
1-Covered
bisacodyl (BISACODYL) 5 mgtablet dr
1-Covered
bisacodyl (BISCOLAX) 10 mgsupprect
1-Covered
bisacodyl (C-LAX LAXATIVE) 5 mgtablet dr -ATIVE)
1-Covered
bisacodyl (DUCODYL) 5 mg tabletdr
1-Covered
bisacodyl (FAST RELIEF LAXATIVE)10 mg supprect
1-Covered
bisacodyl (GENTLE LAXATIVE) 5 mgtablet dr 10 mg supprect
1-Covered
bisacodyl (LAXATIVE SUPPOSITORY)10 mg supprect
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
81
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
bisacodyl (LAXATIVE) 5 mg tabletdr
1-Covered
bisacodyl (MAGIC BULLET) 10 mgsupprect
1-Covered
bisacodyl (WOMENS GENTLELAXATIVE) 5 mg tablet dr
1-Covered
bisacodyl (WOMENS LAXATIVE) 5mg tablet dr
1-Covered
bisacodyl 5 mg tablet dr 10 mgsupprect
1-Covered
BISACODYL EC 5 MG TABLET 10MG SUPPOSITORY
1-Covered
docusate sodium (COL-RITE) 100mg capsule - 250 mg capsule -
1-Covered
docusate sodium (DIOCTYL) 60mg15ml syrup
1-Covered
docusate sodium (DOCU LIQUID)50 mg5 ml liquid
1-Covered
docusate sodium (DOCUSIL) 100mg capsule
1-Covered
docusate sodium (DSS) 250 mgcapsule
1-Covered
docusate sodium (DULCOEASE)100 mg capsule
1-Covered
docusate sodium (DULCOLAXSTOOL SOFTENER) 100 mg capsule
1-Covered
docusate sodium (LAXA BASIC 100)mg capsule )
1-Covered
docusate sodium (PHILLIPSLAXATIVE) 100 mg capsule
1-Covered
docusate sodium (SOF-LAX) 100mg capsule -
1-Covered
docusate sodium (STOOLSOFTENER) 50 mg capsule 50 mg5ml liquid 60 mg15ml syrup 100mg capsule 250 mg capsule
1-Covered
DOCUSATE SODIUM 50 MG5 MLLIQ 100 MG SOFTGEL
1-Covered
docusate sodium 50 mg5 mlliquid 60 mg15ml syrup 100 mgcapsule 250 mg capsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
82
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DOK (docusate sodium) 100 MG250 MG
1-Covered
GENTLE LAXATIVE 10 MG SUPPOSIT 1-Covered
glycerin (ADULT GLYCERIN) adultsupprect
1-Covered
glycerin (LAXATIVE SUPPOSITORY)pediatric supprect
1-Covered
glycerin (PEDIA-LAX) pediatricsupprect -
1-Covered
glycerin (SUPPOSITORY) adultsupprect
1-Covered
glycerin adult pediatric 1-Covered
lactulose (CONSTULOSE) 10 g15 mlsolution
1-Covered
lactulose (ENULOSE) 10 g15 mlsolution
1-Covered
lactulose (GENERLAC) 10 g15 mlsolution
1-Covered
lactulose 10 g15 ml 20 g30 ml 1-Covered
MAGNESIUM CITRATE HM SOLUTION 1-Covered
magnesium citrate solution 1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloride(GAVILYTE-C) peg3350sodsulfbicarbclkcl 240-2272g solnrecon -
1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloride(GAVILYTE-G) peg3350sodsulfbicarbclkcl 236-2274g solnrecon -
1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloridepeg3350sod sulfbicarbclkcl 236-2274g soln peg3350sodsulfbicarbclkcl 240-2272g soln
1-Covered
PEG-3350 AND ELECTROLYTES -SOLN
1-Covered
polyethylene glycol 3350(CLEARLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
83
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
polyethylene glycol 3350(GAVILAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(GENTLELAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(GLYCOLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(LAXACLEAR) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350 (NATURA-LAX) 17gdose powder -
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(POWDERLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(PURELAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(SMOOTHLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350 17gdosepowder
1-Covered QL (527 PER 30 DAY(S))
SILACE (docusate sodium) 50MG5 ML LIQUID
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepeg (GAVILYTE-N)chloridenahco3kclpeg 420gsoln recon -
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepeg (TRILYTE WITH FLAVORPACKETS)chloridenahco3kclpeg 420gsoln recon
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepegchloridenahco3kclpeg 420gsoln recon
1-Covered
STOOL SOFTENER (docusatesodium) 100 MG SOFTGEL 100 MGCAPSULE 250 MG SOFTGEL
1-Covered
STOOL SOFTENER HM 100 MGSFTGL 100 MG SOFTGEL HM 250MG SFTGL
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
84
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PROTECTANTSmisoprostol 100 mcg tablet 200mcg tablet
1-Covered PA
sucralfate 1 g tablet 1-Covered
PROTON PUMP INHIBITORSlansoprazole 15 mg capsule dr 1-Covered ST
lansoprazole 30 mg capsule dr 1-Covered
LANSOPRAZOLE DR 15 MGCAPSULE
1-Covered ST
LANSOPRAZOLE DR 30 MGCAPSULE
1-Covered
omeprazole 10 mg capsule dr 20mg tablet dr
1-Covered
omeprazole 20 mg capsule dr 1-Covered QL (60 PER 30 DAYS)
omeprazole 40 mg capsule dr 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
OMEPRAZOLE DR 20 MG CAPSULE 1-Covered QL (60 PER 30 DAYS)
OMEPRAZOLE DR 20 MG TABLET 1-Covered
pantoprazole sodium 20 mg tabletdr 40 mg tablet dr
1-Covered
PANTOPRAZOLE SODIUM DR 20 MGTAB DR 40 MG TAB
1-Covered
PREVACID (lansoprazole) DR 15MG CAPSULE
1-Covered
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERSTREATMENT (Drugs for Genetic or Enzyme Disorders)
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERSTREATMENT
CREON (lipaseproteaseamylase)DR 6000 UNITS CAPSULE
1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
85
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GENITOURINARY AGENTS (Drugs for the Genital Bladder andKidney)
ANTISPASMODICS URINARY (Drugs for Bladder Spasms)oxybutynin chloride 5 mg5 mlsyrup 5 mg tab er 24 5 mg tablet10 mg tab er 24 15 mg tab er 24
1-Covered
OXYBUTYNIN CHLORIDE ER ER 5 MGTABLET ER 10 MG TABLET ER 15 MGTABLET
1-Covered
OXYTROL FOR WOMEN(oxybutynin) 39 MG24HR
1-Covered ST
trospium chloride 20 mg tablet 1-Covered ST
TROSPIUM CHLORIDE 20 MG TABLET 1-Covered ST
BENIGN PROSTATIC HYPERTROPHY AGENTSalfuzosin hcl 10 mg tab er 24h 1-Covered PA
finasteride 5 mg tablet 1-Covered
tamsulosin hcl 04 mg capsule 1-Covered
GENITOURINARY AGENTS OTHER (Other Drugs for the GenitalBladder and Kidney)
bethanechol chloride 5 mg tablet10 mg tablet 25 mg tablet 50 mgtablet
1-Covered
citric acidsodium citrate (CYTRA-2) 334-500mg solution -
1-Covered
citric acidsodium citrate(VIRTRATE-2) 334-500mg solution -
1-Covered
citric acidsodium citrate 334-500mg solution
1-Covered
nonoxynol 9 (VCF) 125 foamappl
1-Covered
penicillamine 250 mg capsule 1-Covered PA QL (16 PER 1 DAY(S))
PENICILLAMINE 250 MG CAPSULE 1-Covered PA QL (16 PER 1 DAY(S))
phenazopyridine hcl (URINARYPAIN RELIEF) 95 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
86
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PHENAZOPYRIDINE HCL 100 MGTAB 200 MG TAB
1-Covered
phenazopyridine hcl 100 mgtablet 200 mg tablet
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit ac(CYTRA-3) sodpotk citsod citcitacid 500-5505 solution -
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit ac(TRICITRATES) sodpotk citsodcitcit acid 500-5505 solution
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit acsodpotk citsod citcit acid 500-5505 solution
1-Covered
URINARY PAIN RELIEF HM RLF 95 MGTAB
1-Covered
PHOSPHATE BINDERScalcium acetate (ELIPHOS) 667 mgtablet
1-Covered QL (270 PER 30 DAYS) AL1 (Atleast 21 yrs old)
calcium acetate 667 mg capsule667 mg tablet
1-Covered QL (270 PER 30 DAYS) AL1 (Atleast 21 yrs old)
lanthanum carbonate 500 mg tabchew 750 mg tab chew 1000 mgtab chew
1-Covered PA
sevelamer carbonate 800 mgtablet
1-Covered PA
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(ADRENAL) (Drugs for ReplacingStimulating Adrenal GlandHormones)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(ADRENAL) (Glucocorticoids)
betamethasone dipropionate 005 lotion
1-Covered
betamethasone dipropionate 005 oint (g) 005 cream (g)
1-Covered ST
BETAMETHASONE DIPROPIONATEDP 005 OINT
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
87
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
betamethasonedipropionatepropylene glycolbetamethasonepropylene 005 cream (g)
1-Covered ST
betamethasone valerate 01 lotion 01 cream (g) 01 oint(g)
1-Covered
clobetasol propionate 005 gel(gram) 005 solution 005 cream (g) 005 oint (g)
1-Covered ST
CLOBETASOL PROPIONATE 005CREAM
1-Covered ST
DELTASONE (prednisone) 20 MGTABLET
1-Covered
desonide 005 lotion 005 oint(g) 005 cream (g)
1-Covered ST
DESONIDE 005 LOTION 005CREAM
1-Covered ST
dexamethasone(DEXAMETHASONE INTENSOL) 1mgml drops
1-Covered
dexamethasone 05 mg5mlsolution 05 mg tablet 05 mg5mlelixir 075 mg tablet 1 mg tablet15 mg tablet 2 mg tablet 4 mgtablet 6 mg tablet
1-Covered
DEXAMETHASONE 4 MG TABLET 1-Covered
fludrocortisone acetate 01 mgtablet
1-Covered
fluocinolone acetonide 001 cream (g) 001 solution 0025 cream (g) 0025 oint (g)
1-Covered ST
fluocinonide 005 cream (g) 005 gel (gram) 005 oint (g) 005 solution
1-Covered
FLUOCINONIDE 005 OINTMENT 1-Covered
hydrocortisone (ANTI-ITCH) 1 cream (g) -
1-Covered
hydrocortisone (ANUSOL-HC) 25 crmpe app -
1-Covered
hydrocortisone (CORTISONE) 1 cream (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
88
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
hydrocortisone (CORTIZONE-10PLUS) cream (g) -0
1-Covered
hydrocortisone (CORTIZONE-10) cream (g) -
1-Covered
hydrocortisone (HYDROCREAM) 1 cream (g)
1-Covered
hydrocortisone (NOBLE FORMULAHC) 1 cream (g)
1-Covered
hydrocortisone (PREPARATION H) 1 cream (g)
1-Covered
hydrocortisone (PROCTO-MED HC)25 crmpe app -
1-Covered
hydrocortisone (PROCTO-PAK) 1 crmpe app -
1-Covered
hydrocortisone (PROCTOSOL-HC)25 crmpe app -
1-Covered
hydrocortisone (PROCTOZONE-HC)25 crmpe app -
1-Covered
hydrocortisone (SOOTHING CARE)1 cream (g)
1-Covered
hydrocortisone 05 oint (g) 1 cream (g) 1 oint (g) 1 crmpe app 25 cream (g) 25 crmpe app 25 oint (g) 25 lotion 5 mg tablet 10 mg tablet20 mg tablet
1-Covered
HYDROCORTISONE 5 MG TABLET10 MG TABLET
1-Covered
hydrocortisone acetate(ANUCORT-HC) 25 mg supprect -
1-Covered
hydrocortisone acetate (ANUSOL-HC) 25 mg supprect -
1-Covered
hydrocortisone acetate(HEMMOREX-HC) 25 mg supprect -
1-Covered
HYDROCORTISONE ACETATE 25 MGSUPP
1-Covered
hydrocortisone acetate 25 mgsupprect
1-Covered
methylprednisolone 4 mg tablet 4mg tab ds pk 8 mg tablet 16 mgtablet 32 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
89
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
mometasone furoate 01 cream(g) 01 oint (g)
1-Covered
prednisolone (MILLIPRED DP) 5 mg(48) tab 5 mg (21) tab
1-Covered
prednisolone (MILLIPRED) 5 mgtablet
1-Covered
prednisolone 15 mg5 ml solution 1-Covered
prednisolone sodium phosphate 5mg5 ml 15 mg5 ml
1-Covered
prednisone (PREDNISONEINTENSOL) 5 mgml oral conc
1-Covered
prednisone 1 mg tablet 25 mgtablet 5 mg tab ds pk 5 mgtablet 5 mg5 ml solution 10 mgtablet 10 mg tab ds pk 20 mgtablet 50 mg tablet
1-Covered
triamcinolone acetonide 0025 oint (g) 0025 cream (g) 0025 lotion 01 cream (g) 01 lotion 01 oint (g) 0147mggaerosol 05 cream (g) 05 oint(g)
1-Covered
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(PITUITARY) (Drugs for ReplacingStimulating Pituitary GlandHormones)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(PITUITARY) (Drugs to ReplaceStimulate Pituitary Gland Hormones)
desmopressin acetate (non-refrigerated) (nonrefrigerated)10spray spraypump
1-Covered PA AL1 (8 to 14 yrs old)
desmopressin acetate 01 mgmlsolution 01 mg tablet 02 mgtablet
1-Covered AL1 (8 to 14 yrs old)
desmopressin acetate 4 mcgmlvial 4 mcgml ampul 10sprayspraypump
1-Covered PA AL1 (8 to 14 yrs old)
DESMOPRESSIN ACETATE 40MCG10 ML VIAL
1-Covered PA AL1 (8 to 14 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
90
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEXHORMONESMODIFIERS) (Drugs for ReplacingStimulating SexHormones)
ANDROGENSdanazol 50 mg capsule 100 mgcapsule 200 mg capsule
1-Covered
fluoxymesterone (ANDROXY) 10mg tablet
1-Covered
testosterone 125125g gel mdpmp 50 mg (1) gel packet
1-Covered PA
testosterone cypionate 100 mgmlvial 200 mgml vial
1-Covered PA
ESTROGENS (Contraceptives and Drugs for Menopause)desogestrel-ethinyl estradiol (APRI)-015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(CYRED EQ) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(CYRED) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(EMOQUETTE) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(ENSKYCE) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(ISIBLOOM) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(JULEBER) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(KALLIGA) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(RECLIPSEN) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol -015-003 tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (AZURETTE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
91
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
desogestrel-ethinyl estradiolethinylestradiol (BEKYREE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (KARIVA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (KIMIDESS) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (PIMTREA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (SIMLIYA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (VIORELE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (VOLNEA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol -eestradioleestradiol 21-5 (28) tablet
1-Covered
DROSPIRENONE-ETHINYL ESTRADIOL-EE 3-002 MG TAB
1-Covered
estradiol (DOTTI) 025mg24hpatch 0375mg24 patch005mg24h patch 075mg24hpatch 01mg24hr patch
1-Covered QL (16 PER 28 DAY(S))
estradiol 025mg24h patch0375mg24 patch 005mg24hpatch 075mg24h patch01mg24hr patch
1-Covered QL (16 PER 28 DAY(S))
estradiol 001 creamappl025mg24h patch tdwk005mg24h patch tdwk075mg24h patch tdwk01mg24hr patch tdwk 05 mgtablet 1 mg tablet 2 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
92
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ESTRADIOL 1 MG TABLET 2 MGTABLET
1-Covered
estrogensesterifiedmethyltestosterone (COVARYX HS)estrogenesterme-0625-125tablet
1-Covered PA
estrogensesterifiedmethyltestosterone (EEMT HS) estrogenesterme-0625-125 tablet
1-Covered PA
estrogensesterifiedmethyltestosterone estrogenesterme-0625-125tablet
1-Covered PA
ethinyl estradioldrospirenone(GIANVI) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(JASMIEL) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone (LO-ZUMANDIMINE) 002-3(28) tablet -
1-Covered
ethinyl estradioldrospirenone(LORYNA) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(NIKKI) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(VESTURA) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone 002-3(28) tablet
1-Covered
ethynodiol diacetate-ethinylestradiol (KELNOR 1-35) ethynoiol -estraiol mg-35mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol (KELNOR 1-50) ethynoiol -estraiol mg-50mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol (ZOVIA 1-35E) ethynoiol -estraiol mg-35mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol ethynoiol -estraiol 1 mg-50mcg tablet ethynoiol -estraiol 1mg-35mcg tablet
1-Covered
etonogestrelethinyl estradiol(ELURYNG) 12-015mg vag ring
1-Covered QL (1 PER 28 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
93
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
etonogestrelethinyl estradiol 12-015mg vag ring
1-Covered QL (1 PER 28 DAY(S))
HAILEY FE 1-20 TABLET 15-30 TABLET 1-Covered
LEVONORGESTREL-ETH ESTRADIOL -TRIPHASIC
1-Covered
levonorgestrelethinyl estradiol(AFIRMELLE)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(ALTAVERA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(AUBRA EQ)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AUBRA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AVIANE)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AYUNA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(CHATEAL EQ)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(CHATEAL)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(DELYLA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(ENPRESSE)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
94
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrelethinyl estradiol(FALMINA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(KURVELO)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(LARISSIA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(LESSINA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(LEVONEST)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
levonorgestrelethinyl estradiol(LEVORA-28)levonorgestrelethinestradiol 015-003 tablet -
1-Covered
levonorgestrelethinyl estradiol(LILLOW)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(LUTERA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(MARLISSA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(MYZILRA)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
levonorgestrelethinyl estradiol(ORSYTHIA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
95
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrelethinyl estradiol(PORTIA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(SRONYX)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(TRIVORA-28)levonorgestrelethinestradiol 6-5-10 tablet -
1-Covered
levonorgestrelethinyl estradiol(VIENVA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiollevonorgestrelethinestradiol 01-002mg tabletlevonorgestrelethinestradiol 015-003 tabletlevonorgestrelethinestradiol 6-5-10 tablet
1-Covered
LYLLANA 0025 MG PATCH 00375MG PATCH 005 MG PATCH 0075MG PATCH 01 MG PATCH
1-Covered QL (16 PER 28 DAY(S))
MENEST (estrogensesterified) 03MG TABLET 0625 MG TABLET 125MG TABLET 25 MG TABLET
1-Covered
MICROGESTIN 21 1-20 TABLET 1-Covered
MICROGESTIN FE 1-20 TABLET 1-Covered
norelgestrominethinyl estradiol(XULANE)norelgestrominethinestradiol 150-3524h patch tdwk
1-Covered QL (3 PER 28 DAY(S))
norethindrone acetate-ethinylestradiol (AUROVELA) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (GILDESS) -15-003mgtablet
1-Covered
norethindrone acetate-ethinylestradiol (HAILEY) -15-003mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
96
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone acetate-ethinylestradiol (JUNEL) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (LARIN) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (MICROGESTIN) -1mg-20mcg tablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol -1mg-20mcg tablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate(AUROVELA FE) -eestradiol-iron15-30(21) tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (BLISOVIFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (JUNELFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (LARINFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate(MICROGESTIN FE) --1mg-20(21)tablet --15-30(21) tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TARINAFE 1-20 EQ) -eestradiol-iron mg-(2)tablet -
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TARINAFE) -eestradiol-iron 1mg-20(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TILIA FE)-eestradiol-iron 5-7-9-7 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
97
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone acetate-ethinylestradiolferrous fumarate (TRI-LEGEST FE) -eestradiol-iron 5-7-9-7tablet -
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate --1mg-20(21) tablet --15-30(21) tablet
1-Covered
norethindrone-ethinyl estradiol(ALYACEN) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(ARANELLE) -ethin 7-9-5 tablet
1-Covered
norethindrone-ethinyl estradiol(BALZIVA) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(BRIELLYN) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(CYCLAFEM) -1 mg-35mcg tablet -7 days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(DASETTA) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(LEENA) -ethin 7-9-5 tablet
1-Covered
norethindrone-ethinyl estradiol(NECON) -ethin 05-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(NORTREL) -05-0035 tablet -1 mg-35mcg tablet -7 days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(PHILITH) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(PIRMELLA) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(VYFEMLA) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(WERA) -ethin 05-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(ZENCHENT) -ethin 04-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(ESTARYLLA) -025-0035 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
98
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norgestimate-ethinyl estradiol(FEMYNOR) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(MILI) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(MONO-LINYAH) -025-0035 tablet -
1-Covered
norgestimate-ethinyl estradiol(MONONESSA) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(PREVIFEM) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(SPRINTEC) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol (TRIFEMYNOR) -7daysx3 28 tablet
1-Covered
norgestimate-ethinyl estradiol (TRI-ESTARYLLA) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-LINYAH) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-ESTARYLLA) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-MARZIA) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-MILI) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-SPRINTEC) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-PREVIFEM) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-SPRINTEC) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-VYLIBRA LO) -7daysx3 lo tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-VYLIBRA) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol(TRINESSA LO) -7daysx3 lo tablet
1-Covered
norgestimate-ethinyl estradiol(TRINESSA) -7daysx3 28 tablet
1-Covered
norgestimate-ethinyl estradiol(VYLIBRA) -025-0035 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
99
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NORGESTIMATE-ETHINYL ESTRADIOL-025-0035 MG
1-Covered
norgestimate-ethinyl estradiol -025-0035 tablet -7daysx3 28tablet -7daysx3 lo tablet
1-Covered
norgestrel-ethinyl estradiol(CRYSELLE) -03-003mg tablet
1-Covered
norgestrel-ethinyl estradiol (ELINEST)-03-003mg tablet
1-Covered
norgestrel-ethinyl estradiol (LOW-OGESTREL) -03-003mg tablet -
1-Covered
norgestrel-ethinyl estradiol(OGESTREL) -05 mg-50 tablet
1-Covered
PREMARIN (estrogens conjugated)03 MG TABLET 045 MG TABLET0625 MG TABLET 09 MG TABLET125 MG TABLET
1-Covered
PREMARIN (estrogens conjugated)VAGINAL CREAM-APPL
1-Covered QL (43 PER 30 DAY(S))
PREMPHASE (estrogensconjugatedmedroxyprogesteroneacetate) 0625-5 MG TABLET
1-Covered
PREMPRO (estrogensconjugatedmedroxyprogesteroneacetate) 03 MG-15 MG TABLET045-15 MG TABLET 0625-5 MGTABLET 0625-25 MG TABLET
1-Covered
ZOVIA 1-35 -TABLET 1-Covered
PROGESTINSDEPO-PROVERA(medroxyprogesterone acetate) -400 MGML VIAL
1-Covered
DEPO-SUBQ PROVERA 104(medroxyprogesterone acetate) -SYRINGE
1-Covered
hydroxyprogesterone caproate250 mgml vial
1-Covered PA SP
hydroxyprogesterone caproatepfcaproatpf 250 mgml vial
1-Covered PA SP
JENCYCLA 035 MG TABLET 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
100
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrel (AFTERA) 15 mgtablet
1-Covered
levonorgestrel (ECONTRA EZ) 15mg tablet
1-Covered
levonorgestrel (ECONTRA ONE-STEP) 15 mg tablet -
1-Covered
levonorgestrel (FALLBACK SOLO)15 mg tablet
1-Covered
levonorgestrel (MY CHOICE) 15mg tablet
1-Covered
levonorgestrel (MY WAY) 15 mgtablet
1-Covered
levonorgestrel (NEW DAY) 15 mgtablet
1-Covered
levonorgestrel (OPCICON ONE-STEP) 15 mg tablet -
1-Covered
levonorgestrel (OPTION 2) 15 mgtablet
1-Covered
levonorgestrel (TAKE ACTION) 15mg tablet
1-Covered
levonorgestrel 15 mg tablet 1-Covered QL (1 PER 1 DAYS)
MEDROXYPROGESTERONE ACETATE150 MGML
1-Covered QL (1 PER 84 DAYS)
medroxyprogesterone acetate 150mgml vial 150 mgml syringe
1-Covered QL (1 PER 84 DAYS)
MEDROXYPROGESTERONE ACETATE25 MG TAB
1-Covered
medroxyprogesterone acetate 25mg tablet 5 mg tablet 10 mgtablet
1-Covered
megestrol acetate 20 mg tablet40 mg tablet
1-Covered
megestrol acetate 400mg10mloral susp
1-Covered PA
norethindrone (CAMILA) 035 mgtablet
1-Covered
norethindrone (DEBLITANE) 035 mgtablet
1-Covered
norethindrone (ERRIN) 035 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
101
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone (HEATHER) 035 mgtablet
1-Covered
norethindrone (INCASSIA) 035 mgtablet
1-Covered
norethindrone (JENCYCLA) 035mg tablet
1-Covered
norethindrone (JOLIVETTE) 035 mgtablet
1-Covered
norethindrone (LYZA) 035 mgtablet
1-Covered
norethindrone (NORA-BE) 035 mgtablet -
1-Covered
norethindrone (NORLYDA) 035 mgtablet
1-Covered
norethindrone (NORLYROC) 035mg tablet
1-Covered
norethindrone (SHAROBEL) 035 mgtablet
1-Covered
norethindrone (TULANA) 035 mgtablet
1-Covered
norethindrone 035 mg tablet 1-Covered
norethindrone acetate 5 mg tablet 1-Covered
PLAN B ONE-STEP (levonorgestrel) -15 MG TALET
1-Covered
TAKE ACTION (levonorgestrel) 15MG TABLET
1-Covered
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(THYROID) (Drugs for the Thyroid)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(THYROID) (Drugs to Replace Thyroid Hormone)
ARMOUR THYROID (thyroidpork) 15MG TABLET 30 MG TABLET 60 MGTABLET 90 MG TABLET 120 MGTABLET 180 MG TABLET 240 MGTABLET 300 MG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
102
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LEVO-T (levothyroxine sodium) -25MCG ABLE -50 MCG ABLE -75MCG ABLE -88 MCG ABLE -100MCG ABLE -112 MCG ABLE -125MCG ABLE -137 MCG ABLE -150MCG ABLE -175 MCG ABLE -200MCG ABLE -300 MCG ABLE
1-Covered
levothyroxine sodium 25 mcgtablet 50 mcg tablet 75 mcgtablet 88 mcg tablet 100 mcgtablet 112 mcg tablet 125 mcgtablet 137 mcg tablet 150 mcgtablet 175 mcg tablet 200 mcgtablet 300 mcg tablet
1-Covered STAR (Preferred Drug)
LEVOTHYROXINE SODIUM 25 MCGTABLET 50 MCG TABLET 75 MCGTABLET 88 MCG TABLET 100 MCGTABLET 112 MCG TABLET 125 MCGTABLET 137 MCG TABLET 150 MCGTABLET 175 MCG TABLET 200 MCGTABLET 300 MCG TABLET
1-Covered STAR (Preferred Drug)
LEVOXYL (levothyroxine sodium) 25MCG TABLET 50 MCG TABLET 75MCG TABLET 88 MCG TABLET 100MCG TABLET 112 MCG TABLET 125MCG TABLET 137 MCG TABLET 150MCG TABLET 175 MCG TABLET 200MCG TABLET
1-Covered
SYNTHROID (levothyroxine sodium)25 MCG TABLET 50 MCG TABLET75 MCG TABLET 88 MCG TABLET100 MCG TABLET 112 MCG TABLET125 MCG TABLET 137 MCG TABLET150 MCG TABLET 175 MCG TABLET200 MCG TABLET 300 MCG TABLET
1-Covered
thyroidpork (NP THYROID) 15 mgtablet 30 mg tablet 60 mg tablet90 mg tablet 120 mg tablet
1-Covered STAR (Preferred Drug)
UNITHROID (levothyroxine sodium)25 MCG TABLET 50 MCG TABLET75 MCG TABLET 88 MCG TABLET100 MCG TABLET 112 MCG TABLET125 MCG TABLET 137 MCG TABLET150 MCG TABLET 175 MCG TABLET200 MCG TABLET 300 MCG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
103
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs forSuppressing Hormones from the Pituitary Gland)
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs to SuppressPituitary Hormones)
leuprolide acetate 1 mg02ml kit 1-Covered PA SP
LUPRON DEPOT-PED (leuprolideacetate) -15 MG KIT
1-Covered PA
SYNAREL (nafarelin acetate) 2MGML NASAL SPRAY
1-Covered PA
HORMONAL AGENTS SUPPRESSANT (THYROID) (Drugs for theThyroid)
ANTITHYROID AGENTS (Drugs to Suppress Thyroid Hormone)methimazole 5 mg tablet 10 mgtablet
1-Covered
propylthiouracil 50 mg tablet 1-Covered
IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing theImmune System)
IMMUNE SUPPRESSANTS (Drugs to Suppress the Immune System)azathioprine 50 mg tablet 1-Covered
AZATHIOPRINE 50 MG TABLET 1-Covered
cyclosporine 25 mg capsule 100mg capsule
1-Covered
cyclosporine modified (GENGRAF)25 mg capsule 100 mgml solution100 mg capsule
1-Covered
cyclosporine modified 25 mgcapsule 100 mgml solution 100mg capsule
1-Covered
ENBREL (etanercept) 25 MG KIT 1-Covered PA SP QLC (8 vials28 days)
ENBREL (etanercept) 25 MG05 MLSYRINGE 50 MGML SYRINGE
1-Covered PA SP QLC (4 syringes [1 kit]28days)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
104
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ENBREL 25 MG05 ML VIAL 1-Covered PA QL (4 PER 28 DAY(S))
ENBREL SURECLICK (etanercept) 50MGML
1-Covered PA SP QLC (4 pens [1 kit]28days)
HUMIRA (adalimumab) 10 MG02ML SYRINGE 20 MG04 MLSYRINGE 40 MG08 ML SYRINGE
1-Covered PA SP QLC (2 syringes [1 kit]28days)
HUMIRA PEDIATRIC CROHNS(adalimumab) 40 MG08 ML
1-Covered PA SP QLC (3 or 6 syringesyeardepending upon package size)
HUMIRA PEN (adalimumab) 40MG08 ML
1-Covered PA SP QLC (2 pens [1 kit]28days)
HUMIRA PEN CROHNS-UC-HS(adalimumab) --40 MG
1-Covered PA SP QLC (6 pens [1 kit]year)
HUMIRA PEN PSOR-UVEITS-ADOL HS(adalimumab) --40 MG
1-Covered PA SP QLC (4 pens [1 kit]year)
HUMIRA(CF) (adalimumab) 10MG01 ML SYRING 20 MG02 MLSYRING 40 MG04 ML SYRING
1-Covered PA SP QLC (2 syringes [1 kit]28days)
HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 80-40 MG
1-Covered PA SP QLC (2 syringes [1kit]year)
HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 80MG08
1-Covered PA SP QLC (3 syringes [1kit]year)
HUMIRA(CF) PEN (adalimumab) 40MG04 ML
1-Covered PA SP QLC (2 pens [1 kit]28days)
HUMIRA(CF) PEN CROHNS-UC-HS(adalimumab) CRHN--80MG
1-Covered PA SP QLC (3 pens [1 kit]year)
HUMIRA(CF) PEN PSOR-UV-ADOLHS (adalimumab) --AHS 80-40
1-Covered PA SP QLC (3 pens [1 kit]year)
METHOTREXATE 25 MG TABLET 1-Covered
methotrexate sodium 25 mgtablet
1-Covered
mycophenolate mofetil 200 mgmlsusp recon
1-Covered PA
mycophenolate mofetil 250 mgcapsule 500 mg tablet
1-Covered AL1 (At least 21 yrs old)
RHEUMATREX (methotrexatesodium) 25 MG TABLET
1-Covered
SANDIMMUNE (cyclosporine) 25MG CAPSULE 100 MGML SOLN
1-Covered
sirolimus 1 mgml solution 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
105
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
tacrolimus 05 mg capsule 1 mgcapsule 5 mg capsule
1-Covered AL1 (At least 21 yrs old)
TACROLIMUS 05 MG CAPSULE 1MG CAPSULE 5 MG CAPSULE
1-Covered AL1 (At least 21 yrs old)
IMMUNIZING AGENTS PASSIVE (Vaccines)HYPERTET S-D (tetanus immuneglobulinpf) -250 UNIT YRINGE
3-MedicalBenefit
NABI-HB (hepatitis b immuneglobulin) -VIAL gloulin)
3-MedicalBenefit
IMMUNOMODULATORSleflunomide 10 mg tablet 20 mgtablet
1-Covered
LEFLUNOMIDE 10 MG TABLET 20MG TABLET
1-Covered
RIDAURA (auranofin) 3 MGCAPSULE
1-Covered PA
VACCINESADACEL TDAP(diphtheriapertussis(acellular)tetanus vaccinepf) VIAL
1-Covered AL1 (At least 19 yrs old)
AFLURIA QUAD 2020-2021 -VIAL 1-Covered AL1 (At least 19 yrs old)
AFLURIA QUAD 2020-21 (3YR UP) - 1-Covered AL1 (At least 19 yrs old)
BEXSERO (meningococcal group bvaccine 4-component) PREFILLEDSYRINGE -
1-Covered QL (2 PER LIFETIME) AL1 (19 to 25yrs old)
BOOSTRIX TDAP(diphtheriapertussis(acellular)tetanus vaccine) SYRINGE VIAL
1-Covered AL1 (At least 19 yrs old)
ENGERIX-B ADULT (hepatitis b virusvaccine recombinantpf) -20MCGML VIAL recominantpf) -20MCGML SYRN recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
FLUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 65 yrs old)
FLUAD QUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 19 yrs old)
FLUARIX QUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 19 yrs old)
FLUBLOK QUAD 2018-2019(influenza virus vaccine qv 2018-19(18 yrs and older)rcmbpf) -SYRINGE -
1-Covered AL1 (19 to 999 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
106
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
FLUBLOK QUAD 2020-2021 -SYRINGE
1-Covered AL1 (At least 19 yrs old)
FLUCELVAX QUAD 2020-2021 2020-2021 SYR 2020-2021 VIAL
1-Covered AL1 (At least 19 yrs old)
FLULAVAL QUAD 2019-2020(influenza virus vaccinequadrivalent 2019-20 (6 mos andup)) -VIAL -
1-Covered AL1 (At least 19 yrs old)
FLULAVAL QUAD 2020-2021 -SYR 1-Covered AL1 (At least 19 yrs old)
FLUZONE HIGH-DOSE QUAD 2020-21 --
1-Covered AL1 (At least 65 yrs old)
FLUZONE QUAD 2019-2020(influenza virus vaccine quadrival2019-2020(6 mos and up)pf) -VIAL-
1-Covered AL1 (At least 19 yrs old)
FLUZONE QUAD 2020-2021 2020-2021 VIAL 2020-2021 SYRINGE
1-Covered AL1 (At least 19 yrs old)
GARDASIL 9 (human papillomavirusvaccine 9-valentpf) 9 SYRINGE 9-9 VIAL 9-
1-Covered QL (3 PER LIFETIME) AL1 (19 to 27yrs old)
HAVRIX (hepatitis a virusvaccinepf) 720 UNIT05 MLSYRINGE (heptitis vccinepf) 720UNITS05 ML VIAL (heptitisvccinepf) 1440 UNITSMLSYRINGE (heptitis vccinepf) 1440UNITSML VIAL (heptitis vccinepf)
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
HEPLISAV-B (hepatitis b vaccinerecombinantvaccine adjuvantcpg 1018pf) -20 MCG05 MLSYRNG RECOMINANT -20MCG05 ML VIAL RECOMINANT
1-Covered AL1 (At least 19 yrs old) QLC (2perlifetime)
IMOVAX RABIES VACCINE (rabiesvaccine human diploid cellpf)VIAL
3-MedicalBenefit
M-M-R II VACCINE (measlesmumps and rubella vaccinelivepf) --VIAL
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
MENACTRA(meningococcalvaccine acyw-135diphtheria toxoid conjpf) VIAL-
1-Covered AL1 (At least 19 yrs old)
MENQUADFI VIAL 1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
107
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
MENVEO A-C-Y-W-135-DIP(meningococcalvaccine acyw-135diphtheria toxoid conjpf) -----VIL KT -DIPHTHERIA
1-Covered QL (1 PER LIFETIME) AL1 (19 to 55yrs old)
PNEUMOVAX 23 (pneumococcal23-valent polysaccharide vaccine)23 VIAL 23- 23 SYRINGE 23-
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
PREVNAR 13 (pneumococcal 13-valent conjugate vaccine(diphtheria crm)pf) SYRINGE -
1-Covered QL (1 PER LIFETIME) AL1 (At least19 yrs old)
RABAVERT (rabies vaccine purifiedchicken embryo cell (pcec)pf)RABIES VACC W-DILUENT
1-Covered AL1 (At least 19 yrs old)
RECOMBIVAX HB (hepatitis b virusvaccine recombinantpf) 5MCG05 ML SYR recominantpf)10 MCGML SYR recominantpf)40 MCGML VIAL recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
RECOMBIVAX HB (hepatitis b virusvaccine recombinantpf) 5MCG05 ML VL recominantpf) 10MCGML VIAL recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
SHINGRIX (varicella-zoster virusglycoprotein erecas01badjuvantpf) VIAL KIT -
1-Covered QL (2 PER LIFETIME) AL1 (At least50 yrs old)
TDVAX (tetanus and diphtheriatoxoids adult) VIAL
1-Covered AL1 (At least 19 yrs old)
TENIVAC (tetanus and diphtheriatoxoids adsorbed adultpf) VIAL
1-Covered AL1 (At least 19 yrs old)
tetanus and diphtheria toxoidsadult tetanus toxadult 2-2 lf05vial
1-Covered AL1 (At least 19 yrs old)
TRUMENBA (neisseria meningitidisgroup b lipidated fhbprecombinant) 120 MCG05 MLVACCIN
1-Covered QL (2 PER LIFETIME) AL1 (19 to 25yrs old)
TWINRIX (hepatitis a virus andhepatitis b virus vaccinepf)VACCINE SYRINGE (heptitis ndheptitis vccinepf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
108
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
VAQTA (hepatitis a virusvaccinepf) 25 UNITS05 ML VIAL(heptitis vccinepf) 25 UNITS05ML SYRINGE (heptitis vccinepf) 50UNITSML VIAL (heptitis vccinepf)50 UNITSML SYRINGE (heptitisvccinepf)
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
VARIVAX VACCINE (varicella virusvaccine livepf) WITH DILUENT
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
ZOSTAVAX (zoster vaccine livepf)VIAL
1-Covered QL (1 PER LIFETIME) AL1 (At least60 yrs old)
INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for InflammatoryBowel Disease)
AMINOSALICYLATESbalsalazide disodium 750 mgcapsule
1-Covered
mesalamine 4 g60 ml enema 1-Covered
mesalamine 400 mg cap(drtab) 1-Covered QL (6 PER 1 DAY(S))
GLUCOCORTICOIDShydrocortisone (COLOCORT)100mg60ml enema
1-Covered
hydrocortisone 100mg60mlenema
1-Covered
SULFONAMIDESsulfasalazine 500 mg tablet dr 500mg tablet
1-Covered
METABOLIC BONE DISEASE AGENTS (Drugs for the Bone)
METABOLIC BONE DISEASE AGENTSalendronate sodium 10 mg tablet40 mg tablet
1-Covered PA STAR (Preferred Drug)
alendronate sodium 35 mg tablet70 mg tablet
1-Covered STAR (Preferred Drug)
alendronate sodium 5 mg tablet 1-Covered AL1 (At least 65 yrs old) STAR(Preferred Drug)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
109
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcitoninsalmonsynthetic200spray spraypump
1-Covered PA
CALCITRIOL 025 MCG CAPSULE05 MCG CAPSULE
1-Covered
calcitriol 025 mcg capsule 05mcg capsule 1 mcgml solution
1-Covered
cholecalciferol (vitamin d3) 10mcg capsule 10 mcg tablet
1-Covered
cinacalcet hcl 30 mg tablet 60 mgtablet 90 mg tablet
1-Covered PA
CINACALCET HCL 30 MG TABLET60 MG TABLET 90 MG TABLET
1-Covered PA
ergocalciferol (vitamin d2)(CALCIDOL) 200 mcgml drops
1-Covered
ergocalciferol (vitamin d2) 10 mcgtablet 200 mcgml drops 1250mcg capsule
1-Covered
ERGOCALCIFEROL 200 MCGMLDROP
1-Covered
FOSAMAX PLUS D (alendronatesodiumcholecalciferol (vitamind3)) 70 MG-2800 IU
1-Covered PA
MISCELLANEOUS THERAPEUTIC AGENTSalcohol antiseptic pads s med 1-Covered
ALCOHOL WIPES 70 1-Covered
ASSURE ID DUO-SHIELD -30GX316-30GX516
1-Covered
ASSURE ID INSULIN SAFETY SYR05ML 31GX1564 SYR 1 ML31GX1564
1-Covered
condoms female each 1-Covered
condoms latex lubricated each 1-Covered
cromolyn sodium 52 mgspraypump
1-Covered
DROPLET MICRON PEN NEEDLE 34GX 964
1-Covered
freestyle insulix test strips 1-Covered QL (100 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
110
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
freestyle lite test strips 1-Covered QL (100 PER 30 DAYS)
freestyle test strips 1-Covered QL (100 PER 30 DAYS)
inhalerassist device with largemask devicelg spacer
1-Covered
inhalerassist device with mediummask devicemed spacer
1-Covered
inhalerassist device with smallmask devsmall spacer
1-Covered
INSULIN PEN NEEDLES INSULIN PENNEEDLES INSULIN PEN NEEDLES
1-Covered
insulin syringe 03 ml 1-Covered
insulin syringe 05 ml 1-Covered
insulin syringe 1 ml 1-Covered
lancets 28 gauge 30 gauge 33gauge
1-Covered
methylergonovine maleate 02 mgtablet
1-Covered
PEN NEEDLE 29G 12MM 1-Covered
pen needle diabetic 29 g x12 30gx516 31 g x14 31 gx316 31gx516 32gx 532 32 gx 14 32gx316 32 gx516 33 gx532
1-Covered
pen needle diabetic disposablesafety 30 gx516 30 gx316
1-Covered
pen needle diabetic removerand disposal unit 31 gx316 32gx532
1-Covered
pen needle diabetic safety 30gx316 dis
1-Covered
RID (permethrin) PEDICULICIDESSPRAY
1-Covered
syringe with needle insulin safety1 ml geneedleinsulnsafe1ml 30gx316 disp
1-Covered
syringe withneedledisposableinsulin 1 ml30gx12 disp 31 gx516 disp31gx1564 disp
1-Covered
syringe with needleinsulin03 ml -needldispinsul03 29 x12 disp
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
111
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
syringe with needleinsulin05 ml -ml 30gx12 disp -ml 31 gx516disp -ml 31gx1564 disp
1-Covered
UNIFINE PENTIPS MAXFLOW30GX316
1-Covered
OPHTHALMIC AGENTS (Drugs for the Eyes)
OPHTHALMIC AGENTS OTHER (Other Drugs for the Eyes)atropine sulfate 1 drops 1-Covered
bacitracinpolymyxin b sulfate (AK-POLY-BAC) 500-10kg oint (g) --
1-Covered
bacitracinpolymyxin b sulfate(POLYCIN) 500-10kg oint (g)
1-Covered
bacitracinpolymyxin b sulfate 500-10kg oint (g)
1-Covered
BEOVU (brolucizumab-dbll) 6MG005 ML VIAL -
3-MedicalBenefit
BLEPHAMIDE (sulfacetamidesodiumprednisolone acetate) EYEDROPS
1-Covered
CORTISPORIN (neomycinsulfatepolymyxin bsulfatehydrocortisone) CREAM
1-Covered
cyclopentolate hcl 05 drops 1 drops 2 drops
1-Covered
homatropine hbr (HOMATROPAIRE)5 drops
1-Covered
homatropine hbr 5 drops 1-Covered
MURO-128 (sodium chloride) -5EYE DROPS
1-Covered
neomycin sulfatebacitracinzincpolymyxin bhydrocortisone(NEO-POLYCIN HC)neomycinbacitp-myxhydrocort35-10k-1 oint (g) -
1-Covered
neomycin sulfatebacitracinzincpolymyxin bhydrocortisoneneomycinbacitp-myxhydrocort35-10k-1 oint (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
112
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
neomycinsulfatebacitracinpolymyxin b(NEO-POLYCIN)sulfbacitracinpoly 35mg-400oint (g) -
1-Covered
neomycinsulfatebacitracinpolymyxin bsulfbacitracinpoly 35mg-400oint (g)
1-Covered
neomycin sulfatepolymyxin bsulfategramicidin dneomycinpolymyxn bgramicidin175mg-10k drops
1-Covered
neomycin sulfatepolymyxin bsulfatehydrocortisoneneomycinpolymyxin bhydrocort35-10k-10 drops susp
1-Covered
neomycinpolymyxin bsulfatedexamethasonebdexametha 01 drops suspbdexametha 35-10k-1 oint (g)
1-Covered
phenylephrine hcl 25 drops 10 drops
1-Covered
polymyxin b sulfatetrimethoprimsulftrimethoprim 10000-1ml drops
1-Covered
proparacaine hcl 05 drops 1-Covered PA
sodium chloride (MURO-128) drops -18)
1-Covered
sodium chloride 5 drops 1-Covered
sulfacetamidesodiumprednisolone sodiumphosphatesulfacetamideprednisolone 10 -023 drops
1-Covered
TOBRADEX(tobramycindexamethasone) EYEOINTMENT
1-Covered
tobramycindexamethasone 03-01 drops susp
1-Covered
OPHTHALMIC ANTI-ALLERGY AGENTS (Drugs for Eye Allergies)ALAWAY (ketotifen fumarate)0025 EYE DROPS
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
113
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALOMIDE (lodoxamidetromethamine) 01 EYE DROPS
1-Covered
cromolyn sodium 4 drops 1-Covered
EYE ITCH RELIEF 0025 DROPS HM0025 DROP
1-Covered
ketotifen fumarate (ALLERGY EYEDROPS) 0025 drops
1-Covered
ketotifen fumarate (EYE ITCHRELIEF) 0025 drops
1-Covered
ketotifen fumarate (ITCHY EYE)0025 drops
1-Covered
ketotifen fumarate (WAL-ZYR) 0025 drops -
1-Covered
ketotifen fumarate (ZADITOR) 0025 drops
1-Covered
ketotifen fumarate 0025 drops 1-Covered
OPHTHALMIC ANTI-INFLAMMATORIES (Drugs to Reduce EyeSwelling)
dexamethasone sodiumphosphate 01 drops
1-Covered
diclofenac sodium 01 drops 1-Covered
fluorometholone 01 drops susp 1-Covered
flurbiprofen sodium 003 drops 1-Covered
FML FORTE (fluorometholone)025 EYE DROPS
1-Covered
FML SOP (fluorometholone) 01OINTMENT
1-Covered
ketorolac tromethamine 05 drops
1-Covered
PRED MILD (prednisolone acetate)012 EYE DROPS
1-Covered
prednisolone acetate 1 dropssusp
1-Covered
prednisolone sodium phosphate 1 drops
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
114
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
OPHTHALMIC ANTIGLAUCOMA AGENTS (Drugs for Glaucoma)ALPHAGAN P (brimonidinetartrate) ALHAGAN 01 DROS
1-Covered QL (1 PER 30 DAYS)
apraclonidine hcl 05 drops 1-Covered
betaxolol hcl 05 drops 1-Covered
BETIMOL (timolol) 025 DROPS05 DROPS
1-Covered
BETOPTIC S (betaxolol hcl) 025EYE DROP
1-Covered
brimonidine tartrate 02 drops 1-Covered
dorzolamide hcl 2 drops 1-Covered
dorzolamide hcltimolol maleate223-681 drops
1-Covered QL (10 PER 30 DAY(S))
DORZOLAMIDE-TIMOLOL -EYEDROPS
1-Covered QL (10 PER 30 DAY(S))
IOPIDINE (apraclonidine hcl) 1EYE DROPS
1-Covered
levobunolol hcl 05 drops 1-Covered
methazolamide 25 mg tablet 50mg tablet
1-Covered
METHAZOLAMIDE 25 MG TABLET 50MG TABLET
1-Covered
PHOSPHOLINE IODIDE(echothiophate iodide) 0125
1-Covered
pilocarpine hcl 1 drops 2 drops 4 drops
1-Covered
PILOCARPINE HCL 1 DROPS 2DROPS
1-Covered
timolol maleate 025 sol-gel 025 drops 05 drops 05 sol-gel
1-Covered
TIMOLOL MALEATE 05 EYE DROPS 1-Covered
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS (Drugsfor Glaucoma)
latanoprost 0005 drops 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
115
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
OTIC AGENTS (Drugs for the Ears)
OTIC AGENTS (Drugs for Ear Infection)acetic acid 2 solution 1-Covered
ACETIC ACID 2 EAR SOLUTION 1-Covered
carbamide peroxide(CARBAMOXIDE) 65 drops
1-Covered
carbamide peroxide (EAR DROPS)65 drops
1-Covered
carbamide peroxide (EAR SYSTEM)65 drops
1-Covered
carbamide peroxide (EAR WAXREMOVAL) 65 drops
1-Covered
carbamide peroxide (MURINE EARWAX REMOVAL SYSTEM) 65 drops
1-Covered
DEBROX (carbamide peroxide)65 EAR DROPS
1-Covered
EAR DROPS (carbamide peroxide)65
1-Covered
hydrocortisoneacetic acid(ACETASOL HC) 1 -2 drops
1-Covered
hydrocortisoneacetic acid 1 -2 drops
1-Covered
MURINE EAR DROPS (carbamideperoxide) 65
1-Covered
neomycin sulfatepolymyxin bsulfatehydrocortisoneneomycinpolymyxin bhydrocort35--1 solutionneomycinpolymyxin bhydrocort35--1 drops susp
1-Covered
NEOMYCIN-POLYMYXIN-HC --EARSUSP
1-Covered
RESPIRATORY TRACTPULMONARY AGENTS (Drugs for the Lungs)
ANTI-INFLAMMATORIES INHALED CORTICOSTEROIDS (Inhaled Drugsto Prevent Swelling of the Airways)
BUDESONIDE 025 MG2 ML SUSP 1-Covered AL1 (Up to 6 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
116
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
budesonide 025mg2ml - 05mg2ml -
1-Covered AL1 (Up to 6 yrs old)
CHILDRENS NASACORT(triamcinolone acetonide)ALLERGY 24 HR
1-Covered QL (17 PER 30 DAY(S))
FLOVENT DISKUS (fluticasonepropionate) 50 MCG 100 MCG250 MCG
1-Covered
FLOVENT HFA (fluticasonepropionate) HFA 44 MCG INHALERHFA 110 MCG INHALER HFA 220MCG INHALER
1-Covered
fluticasone propionate (ALLERGYRELIEF) 50 mcg spray susp
1-Covered QL (16 PER 30 DAY(S))
fluticasone propionate 50 mcgspray susp
1-Covered QL (16 PER 30 DAY(S))
NASACORT (triamcinoloneacetonide) ALLERGY 24HR SPRAY
1-Covered
PULMICORT FLEXHALER(budesonide) 180 MCG
1-Covered
QVAR REDIHALER(beclomethasone dipropionate)40 MCG 80 MCG
1-Covered
triamcinolone acetonide 55 mcgspray
1-Covered QL (17 PER 30 DAY(S))
ANTIHISTAMINESALAVERT (loratadine) 10 MG ODT 1-Covered AL1 (Up to 12 yrs old)
ALL DAY ALLERGY ERGY 10 MGTABLET SM ERGY 10 MG TAB
1-Covered
ALLERGY RELIEF (LORATADINE) 10MG TAB RELIEF 10 MG TABLET
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
ALLERGY RELIEF 4 MG TABLET HM 4MG TABLET HM 25 MG CAP 25 MGSOFTGEL GS 25 MG TABLET
1-Covered
ALLERGY RELIEF HM 180 MG TAB180 MG TABLET
1-Covered ST
AZELASTINE HCL 01 (137 MCG)SPRY
1-Covered QL (1 PER 30 DAYS)
azelastine hcl 137 mcgspraypump
1-Covered QL (1 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
117
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
cetirizine hcl (24HOUR ALLERGY) 10mg tablet
1-Covered
cetirizine hcl (ALL DAY ALLERGYRELIEF) 10 mg tablet
1-Covered
cetirizine hcl (ALL DAY ALLERGY) 10mg tablet
1-Covered
cetirizine hcl (ALLER-TEC) 10 mgtablet -
1-Covered
cetirizine hcl (ALLERGY RELIEF) 10mg tablet
1-Covered
cetirizine hcl (WAL-ZYR) 10 mgtablet -
1-Covered
cetirizine hcl 1 mgml 5 mg5 ml 1-Covered ST AL1 (Up to 5 yrs old)
CETIRIZINE HCL 10 MG TABLET 1-Covered
cetirizine hcl 5 mg tablet 10 mgtablet
1-Covered
CHILDRENS ALLERGY RELIEF 5MG5 ML
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
CHILDRENS ALLERGY RELIEF RLF125 MG5 ML
1-Covered
chlorpheniramine maleate(ALLERGY 4-HOUR) mg tablet -
1-Covered
chlorpheniramine maleate(ALLERGY RELIEF) 4 mg tablet
1-Covered
chlorpheniramine maleate(ALLERGY) 4 mg tablet
1-Covered
chlorpheniramine maleate(ALLERGY-TIME) 4 mg tablet -
1-Covered
chlorpheniramine maleate(CHLORHIST) 4 mg tablet
1-Covered
chlorpheniramine maleate(CHLORTABS) 4 mg tablet
1-Covered
chlorpheniramine maleate (EDCHLORPED JR) 2 mg5 ml syrup
1-Covered
chlorpheniramine maleate(PHARBECHLOR) 4 mg tablet
1-Covered
chlorpheniramine maleate (WAL-FINATE) 4 mg tablet -
1-Covered
chlorpheniramine maleate 4 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
118
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
clemastine fumarate 268 mgtablet
1-Covered
cyproheptadine hcl 2 mg5 mlsyrup 4 mg tablet 4 mg10 mlsyrup
1-Covered
diphenhydramine hcl (ALER-CAPS)25 mg capsule -
1-Covered
diphenhydramine hcl (ALLER-G-TIME) 25 mg tablet --
1-Covered
diphenhydramine hcl (ALLERGYMEDICATION) 25 mg capsule 25mg tablet
1-Covered
diphenhydramine hcl (ALLERGYMEDICINE) 25 mg tablet
1-Covered
diphenhydramine hcl (ALLERGYRELIEF) 125mg5ml liquid 25 mgcapsule 25 mg tablet
1-Covered
diphenhydramine hcl (ALLERGY)125mg5ml liquid 25 mg capsule25 mg tablet
1-Covered
diphenhydramine hcl (BANOPHEN)125mg5ml liquid 25 mg tablet 25mg capsule 50 mg capsule
1-Covered
diphenhydramine hcl (BENADRYLALLERGY) 25 mg tablet
1-Covered
diphenhydramine hcl (CHILDRENSALLERGY RELIEF) 125mg5ml liquid
1-Covered
diphenhydramine hcl (CHILDRENSALLERGY) 125mg5ml elixir125mg5ml liquid
1-Covered
diphenhydramine hcl (CHILDRENSBENADRYL ALLERGY) 125mg5mlliquid
1-Covered
diphenhydramine hcl (CHILDRENSWAL-DRYL ALLERGY) 125mg5mlliquid -
1-Covered
diphenhydramine hcl (COMPLETEALLERGY) 25 mg capsule 25 mgtablet
1-Covered
diphenhydramine hcl (DIPHEDRYLALLERGY) 125mg5ml liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
119
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
diphenhydramine hcl (DIPHEDRYL)125mg5ml liquid 25 mg capsule
1-Covered
diphenhydramine hcl (DIPHEN)125mg5ml elixir 25 mg tablet
1-Covered
diphenhydramine hcl (DIPHENHIST)125mg5ml liquid 25 mg tablet
1-Covered
diphenhydramine hcl (GERI-DRYL)125mg5ml liquid - 25 mg tablet -
1-Covered
diphenhydramine hcl (M-DRYL)125mg5ml liquid -
1-Covered
diphenhydramine hcl (NIGHTTIMEALLERGY RELIEF) 25 mg tablet
1-Covered
diphenhydramine hcl (NIGHTTIMESLEEP AID) 25 mg tablet
1-Covered
diphenhydramine hcl(PHARBEDRYL) 25 mg capsule 50mg capsule
1-Covered
diphenhydramine hcl (SILADRYL)125mg5ml liquid
1-Covered
diphenhydramine hcl (SIMPLYSLEEP) 25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP AID)25 mg tablet
1-Covered
diphenhydramine hcl (TOTALALLERGY) 25 mg tablet
1-Covered
diphenhydramine hcl (WAL-DRYLALLERGY) 125mg5ml liquid - 25mg tablet -
1-Covered
diphenhydramine hcl (WAL-DRYL)25 mg capsule -
1-Covered
DIPHENHYDRAMINE HCL 125 MG5ML 25 MG10 ML
1-Covered
diphenhydramine hcl 125mg5mlelixir 125mg5ml syrup125mg5ml liquid 25 mg tablet 25mg capsule 50 mg capsule
1-Covered
fexofenadine hcl (ALLER-EASE) 60mg tablet - 180 mg tablet -
1-Covered ST
fexofenadine hcl (ALLER-FEX) 180mg tablet -
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
120
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fexofenadine hcl (ALLERGY RELIEF)60 mg tablet 180 mg tablet
1-Covered ST
fexofenadine hcl (WAL-FEXALLERGY) 60 mg tablet - 180 mgtablet -
1-Covered ST
fexofenadine hcl 60 mg tablet 180mg tablet
1-Covered ST
FEXOFENADINE HCL HM 60 MGTAB 60 MG TABLET 180 MG TABLET
1-Covered ST
GERI-DRYL -125 MG5 ML LIQUID 1-Covered
hydroxyzine hcl 10 mg tablet 10mg5 ml solution 25 mg tablet 50mg tablet 50 mg25ml solution
1-Covered
HYDROXYZINE PAMOATE 25 MGCAP 50 MG CAP
1-Covered
hydroxyzine pamoate 25 mgcapsule 50 mg capsule 100 mgcapsule
1-Covered
loratadine (ALLERCLEAR) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (ALLERGY RELIEF) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (ALLERGY RELIEF) 5mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (ALLERGY) 10 mg tablet 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (CHILDRENS ALLERGYRELIEF) 5 mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (CHILDRENS ALLERGY) 5mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (LORADAMED) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (NON-DROWSYALLERGY) 10 mg tablet -
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (WAL-ITIN) 10 mg tablet-
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (WAL-ITIN) 5 mg5 mlsolution -
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine 10 mg tablet 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
121
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LORATADINE 10 MG TABLET 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine 5 mg5 ml solution 1-Covered QL (150 PER 30 DAYS) AL1 (Up to6 yrs old)
NIGHTTIME SLEEP AID HM 25 MGCPLT
1-Covered
promethazine hcl 125 mg tablet25 mg tablet
1-Covered
PROMETHAZINE HCL 625 MG5 MLSOLN
1-Covered AL1 (At least 2 yrs old)
promethazine hcl 625mg5mlsyrup
1-Covered AL1 (At least 2 yrs old)
ANTILEUKOTRIENESmontelukast sodium 4 mg granpack
1-Covered ST
MONTELUKAST SODIUM 4 MGGRANULES
1-Covered ST
montelukast sodium 4 mg tabchew 5 mg tab chew 10 mgtablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
BRONCHODILATORS ANTICHOLINERGIC (Anticholinergic Drugs toOpen the Airway)
ATROVENT HFA (ipratropiumbromide) 17 MCG INHALER
1-Covered
INCRUSE ELLIPTA (umeclidiniumbromide) 625 MCG INH
1-Covered C (RESTRICTED TO THE DIAGNOSISOF CHRONIC OBSTRUCTIVEPULMONARY DISEASE (COPD))
ipratropium bromide 02 mgmlsolution 21 mcg spray 42 mcgspray
1-Covered
BRONCHODILATORS SYMPATHOMIMETIC (Sympathomimetic Drugsto Open the Airway)
albuterol 90mcg hfa inhaler(generic proair)
1-Covered QL (2 PER 30 [DAYS])
albuterol 90mcg hfa inhaler(generic proventil)
1-Covered QL (2 PER 30 [DAYS])
albuterol 90mcg hfa inhaler(generic ventolin)
1-Covered QL (2 PER 30 [DAYS])
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
122
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALBUTEROL SULFATE 100 MG20 MLSOLN
1-Covered
albuterol sulfate 2 mg tablet 2mg5 ml syrup 25 mg3ml vial-neb 25 mg05 vial-neb 4 mg taber 12h 4 mg tablet 5 mgmlsolution 8 mg tab er 12h
1-Covered
albuterol sulfate 90 mcg hfa aerad
1-Covered QL (2 PER 30 [DAYS])
ALBUTEROL SULFATE HFA 90 MCGINHALER
1-Covered QL (2 PER 30 [DAYS])
epinephrine 015mg03 03mg03 1-Covered QL (2 PER FILL(S))
FORADIL (formoterol fumarate)AEROLIZER 12 MCG CAP
1-Covered ST
levalbuterol tartrate 45 mcg hfaaer ad
1-Covered QL (30 PER 30 DAY(S))
metaproterenol sulfate 10 mg5 mlsyrup 10 mg tablet 20 mg tablet
1-Covered
NASAL DECONGESTANT(pseudoephedrine hcl) 30 MG TAB
1-Covered
pseudoephedrine hcl (NASALDECONGESTANT) 30 mg tablet
1-Covered
pseudoephedrine hcl (SUDOGEST)30 mg tablet 60 mg tablet
1-Covered
pseudoephedrine hcl (SUPHEDRIN)30 mg tablet
1-Covered
pseudoephedrine hcl (SUPHEDRINESINUS CONGESTION) 30 mg tablet
1-Covered
pseudoephedrine hcl(SUPHEDRINE) 30 mg tablet
1-Covered
pseudoephedrine hcl (WAL-PHED)30 mg tablet -
1-Covered
pseudoephedrine hcl 30 mgtablet 60 mg tablet
1-Covered
SEREVENT DISKUS (salmeterolxinafoate) 50 MCG
1-Covered QL (60 PER 30 DAYS)
SUDAFED (pseudoephedrine hcl)30 MG TABLET
1-Covered
TERBUTALINE SULFATE 25 MG TAB 5MG TAB
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
123
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terbutaline sulfate 25 mg tablet 5mg tablet
1-Covered
PHOSPHODIESTERASE INHIBITORS AIRWAYS DISEASE (Drugs thatBlock Phosphodiesterase)
ELIXOPHYLLIN (theophyllineanhydrous) OPHYLLIN 80 MG15 ML
1-Covered
THEO-24 (theophylline anhydrous) -24 ER 200 MG CAPSULE -24 ER 300MG CAPSULE -24 ER 100 MGCAPSULE -24 ER 400 MG CAPSULE
1-Covered
theophylline anhydrous(THEOCHRON) 100 mg tab er 200mg tab er 300 mg tab er
1-Covered
theophylline anhydrous 80mg15ml solution 80 mg15ml elixir100 mg tab er 12h 200 mg tab er12h 300 mg tab er 12h 400 mgtab er 24h 450 mg tab er 12h 600mg tab er 24h
1-Covered
PULMONARY ANTIHYPERTENSIVES (Drugs for PulmonaryHypertension)
ambrisentan 5 mg tablet 10 mgtablet
1-Covered PA QL (1 PER 1 DAY(S)) SP
bosentan 625 mg tablet 125 mgtablet
1-Covered PA QL (2 PER 1 DAY(S)) SP
sildenafil citrate 20 mg tablet 1-Covered PA QL (3 PER 1 DAY(S)) SP
SILDENAFIL CITRATE 20 MG TABLET 1-Covered PA QL (3 PER 1 DAY(S)) SP
tadalafil (ALYQ) 20 mg tablet 1-Covered PA QL (2 PER 1 DAY(S)) SP
tadalafil 20 mg tablet 1-Covered PA QL (2 PER 1 DAY(S)) SP
RESPIRATORY TRACT AGENTS OTHER (Other Drugs for BreathingConditions)
acetylcysteine 100 mgml vial 200mgml vial
1-Covered
benzonatate 100 mg capsule 1-Covered
BEVESPI AEROSPHERE(glycopyrrolateformoterolfumarate) INHALER
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
124
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
brompheniraminemaleatepseudoephedrine hcl(RYNEX PSE)brompheniraminpseudoephedrine 1-15mg5ml liquid
1-Covered
BROTAPP DM (brompheniraminemaleatepseudoephedrinehcldextromethorphan) 1-15-5MG5 ML LIQ
1-Covered
chlorpheniraminemaleatepseudoephedrinedextromethorphan (KIDKARE)chlorpheniraminpseudoepheddm 1-15-5mg5 liquid
1-Covered
codeine phosphateguaifenesin(CHERATUSSIN AC) 10-100mg5liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(G TUSSIN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(GUAIATUSSIN AC) 10-100mg5 20-20010
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(GUAIFENESIN AC) 10-100mg5liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(ROBAFEN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(VIRTUSSIN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin10-100mg5 20-20010
1-Covered AL1 (At least 12 yrs old)
CODEINE-GUAIFENESIN -10-100MG5 ML
1-Covered AL1 (At least 12 yrs old)
COMBIVENT RESPIMAT (ipratropiumbromidealbuterol sulfate) 20-100MCG
1-Covered
COUGH FORMULA DM(guaifenesindextromethorphanhbr) SYRUP
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
125
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fluticasone propionatesalmeterolxinafoate (WIXELA INHUB)propionsalmeterol 100-50 mcgwdev propionsalmeterol 250-50mcg wdev propionsalmeterol500-50 mcg wdev
1-Covered QL (60 PER 30 DAY(S))
fluticasone propionatesalmeterolxinafoate propionsalmeterol 100-50 mcg wdev propionsalmeterol250-50 mcg wdevpropionsalmeterol 500-50 mcgwdev
1-Covered QL (60 PER 30 DAY(S))
fluticasone propionatesalmeterolxinafoate propionsalmeterol 55-14mcg propionsalmeterol 113-14mcg propionsalmeterol 232-14mcg
1-Covered QL (1 PER 30 DAYS)
GUAIASORB DM LIQUID 1-Covered
guaifenesin (MUCUS ER) 600 mgtab er 12h
1-Covered
guaifenesin (MUCUS RELIEF ER) 600mg tab er 12h
1-Covered
GUAIFENESIN-DEXTROMETHORPHAN DM SYRUP
1-Covered
guaifenesindextromethorphanhbr (ADULT ROBITUSSIN PEAK COLDDM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ADULT TUSSIN COUGHCONGEST DM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ADULT TUSSIN DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (ADULT WAL-TUSSIN DM) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (ANTITUSSIVE DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (BIOCOTRON) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (COUGH DM) 100-10mg5syrup
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
126
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesindextromethorphanhbr (DIABETIC SILTUSSIN-DM) 100-10mg5 liquid -
1-Covered
guaifenesindextromethorphanhbr (DIABETIC TUSSIN DM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (EXPECTORANT DM) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (EXTRA ACTION COUGH) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (GERI-TUSSIN DM) 100-10mg5liquid - 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (GILTUSS DIABETIC) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (GILTUSS HBP) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (GUAIASORB DM) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (RI-TUSSIN DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM COUGH) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM COUGH-CHESTCONGEST) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM PEAK COLD)100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN-DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr (SAFETUSSIN DM) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (SILTUSSIN DM DAS) 100-10mg5liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
127
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesindextromethorphanhbr (SILTUSSIN DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (SORBUGEN NR) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSNEL DIABETIC) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSSIN COUGH) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM CLEAR) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM COUGH) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM COUGH-CHESTCONGEST) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM) 100-10mg5 liquid100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (ULTRA DM FREE amp CLEAR) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ULTRA TUSS) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (WAL-TUSSIN DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr 100-10mg5 syrup 100-10mg5liquid
1-Covered
guaifenesinpseudoephedrine hcl(MUCUS D)guaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
guaifenesinpseudoephedrine hcl(MUCUS RELIEF D)guaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
128
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesinpseudoephedrine hclguaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
ipratropium bromidealbuterolsulfate ipratropiumalbuterol 05-3mg3 ampul-neb
1-Covered QL (540 PER 30 DAY(S))
IPRATROPIUM-ALBUTEROL -05-3(25) MG3 ML
1-Covered QL (540 PER 30 DAY(S))
MAXI-TUSS G -LIQUID 1-Covered
MUCUS ER CVS 600 MG TABLET 1-Covered
MUCUS RELIEF ER HM 600 MG TAB 1-Covered
phenylephrine hclpromethazinehcl prometh 5-625mg5 syrup
1-Covered AL1 (At least 2 yrs old)
promethazine hclcodeine 625-105 syrup
1-Covered QL (240 PER 30 DAYS) AL1 (Atleast 12 yrs old) QLC (LIMIT 240ML(8OZ) PER 30 DAYS)
promethazinehcldextromethorphan hbrpromethazinedextromethorphan625-155 syrup
1-Covered AL1 (At least 2 yrs old)
PROMETHAZINE-DM -625-15MG5ML
1-Covered AL1 (At least 2 yrs old)
promethazinephenylephrinehclcodeinepromethazinephenylephcodeine625-5-10 syrup
1-Covered AL1 (At least 12 yrs old)
sodium chloride for inhalation 09 vial- 3 vial- 10 vial-
1-Covered
triprolidine hclpseudoephedrinehcl (APRODINE)triprolidinepseudoephedrine25mg-60mg tablet
1-Covered
triprolidine hclpseudoephedrinehcl (ED A-HIST PSE)triprolidinepseudoephedrine25mg-60mg tablet -
1-Covered
triprolidine hclpseudoephedrinehcl (RITIFED)triprolidinepseudoephedrine 125-305 syrup
1-Covered
triprolidine hclpseudoephedrinehcl (WAL-ACT D COLD amp ALLERGY)triprolidinepseudoephedrine25mg-60mg tablet -col
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
129
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles)
SKELETAL MUSCLE RELAXANTS (Drugs to Relax the Muscles)carisoprodol 350 mg tablet 1-Covered QL (90 PER 30 DAYS)
CARISOPRODOL 350 MG TABLET 1-Covered QL (90 PER 30 DAYS)
cyclobenzaprine hcl 10 mg tablet 1-Covered QL (90 PER 30 DAYS)
cyclobenzaprine hcl 5 mg tablet 1-Covered QL (90 PER 30 DAY(S))
methocarbamol 500 mg tablet750 mg tablet
1-Covered QL (90 PER 30 DAYS)
METHOCARBAMOL 500 MG TABLET750 MG TABLET
1-Covered QL (90 PER 30 DAYS)
VANADOM 350 MG TABLET 1-Covered QL (90 PER 30 DAY(S))
SLEEP DISORDER AGENTS (Drugs for Insomnia)
GABA RECEPTOR MODULATORSflurazepam hcl 15 mg capsule 30mg capsule
1-Covered AL1 (Up to 65 yrs old)
temazepam 75 mg capsule 15mg capsule 30 mg capsule
1-Covered
triazolam 0125 mg tablet 025 mgtablet
1-Covered QL (14 PER 30 DAY(S))
zaleplon 5 mg capsule 10 mgcapsule
1-Covered ST
zolpidem tartrate 5 mg tablet 10mg tablet
1-Covered
SLEEP DISORDERS OTHERdiphenhydramine hcl (ALKA-SELTZER PLUS ALLERGY) 25 mgtablet -
1-Covered
diphenhydramine hcl (COMPOZ)25 mg tablet
1-Covered
diphenhydramine hcl (NIGHTTIMESLEEP AID) 25 mg tablet
1-Covered
diphenhydramine hcl (NYTOLQUICKCAPS) 25 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
130
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
diphenhydramine hcl (SIMPLYSLEEP) 25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP AID)25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP II) 25mg tablet
1-Covered
diphenhydramine hcl (SLEEPTABLET) 25 mg tablet
1-Covered
modafinil 100 mg tablet 200 mgtablet
1-Covered PA QL (3 PER 1 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
131
Alphabetical Index of Prescription Drugs
009 sodium chloride 697072
Aabacavir sulfate 38abacavir sulfatelamivudine 38abacavir sulfatelamivudinezidovudine 38ABACAVIR-LAMIVUDINE 38ABILIFY (aripiprazole) 31ABILIFY MAINTENA (aripiprazole) 31ABILIFY MYCITE (aripiprazole) 31acamprosate calcium 6acarbose 4243acetaminophen 64ACETAMINOPHEN 64acetaminophen (ATHENOL) 63acetaminophen (CHILD FEVER REDUCER) 63acetaminophen (CHILD PAIN REL-FEVERREDUCER) 63acetaminophen (CHILDRENS FEVERREDUCER) 63acetaminophen (CHILDRENS FEVERREDUCING) 63acetaminophen (CHILDRENS PAIN ANDFEVER) 63acetaminophen (CHILDRENS SILAPAP) 63acetaminophen (ED-APAP) 63acetaminophen (LITTLE REMEDIES FEVER-PAIN) 63acetaminophen (M-PAP) 63acetaminophen (MAPAP) 63acetaminophen (MASOPHEN) 63acetaminophen (NON-ASPIRIN EXTRASTRENGTH) 63acetaminophen (NON-ASPIRIN PAIN RELIEF) 63acetaminophen (NON-ASPIRIN) 63acetaminophen (PAIN amp FEVER) 63acetaminophen (PAIN RELIEF EXTRASTRENGTH) 64acetaminophen (PAIN RELIEF) 64
acetaminophen (PAIN RELIEVER) 64acetaminophen (PHARBETOL) 64acetaminophen (SHAKE THAT ACHE) 64acetaminophen (TACTINAL) 64ACETAMINOPHEN 160 MG5ML ORAL SUSP 64ACETAMINOPHEN 160 MG5ML SOLUTION 64acetaminophen with codeine phosphate 45acetazolamide 57ACETAZOLAMIDE 58acetic acid 116ACETIC ACID 116acetylcysteine 124ACID CONTROLLER 80ACID REDUCER 80ACNE MEDICATION 66ACNE MEDICATION (benzoyl peroxide) 66acyclovir 41ACYCLOVIR 41ADACEL TDAP(diphtheriapertussis(acellular)tetanusvaccinepf) 106ADASUVE (loxapine) 30ADLYXIN (lixisenatide) 43ADMELOG (insulin lispro) 45ADMELOG SOLOSTAR (insulin lispro) 45ADVATE (antihemophilic factor (fviii)recombinantfull length) 47ADYNOVATE (antihemophilic factor (fviii)recombinant full length peg) 47AFLURIA QUAD 2020-2021 106AFLURIA QUAD 2020-21 (3YR UP) 106AFSTYLA (antihemophilic factor viiirecombsingle-chnb-dom truncated) 47ALAVERT (loratadine) 117ALAWAY (ketotifen fumarate) 113Albuterol 90mcg HFA inhaler (GenericProair) 122Albuterol 90mcg HFA inhaler (GenericProventil) 122Albuterol 90mcg HFA inhaler (GenericVentolin) 122
LAST UPDATED 12012020132
ALBUTEROL SULFATE 123albuterol sulfate 123ALBUTEROL SULFATE HFA 123alcohol antiseptic pads 110ALCOHOL WIPES 110alendronate sodium 109alfuzosin hcl 86ALL DAY ALLERGY 117ALLERGY RELIEF 117ALLI (orlistat) 78allopurinol 24ALLOPURINOL 24alogliptin benzoate 43alogliptin benzoatemetformin hcl 43alogliptin benzoatepioglitazone hcl 43ALOMIDE (lodoxamide tromethamine) 114ALPHAGAN P (brimonidine tartrate) 115ALPHANATE (antihemophilic factorhumanvon willebrand factorhuman) 47ALPHANINE SD (factor ix) 47alprazolam 42alprazolam (ALPRAZOLAM INTENSOL) 42ALPROLIX (factor ix recombinant fc fusionprotein) 48AMANTADINE 29amantadine hcl 29ambrisentan 124amiloride hcl 58amiloride hclhydrochlorothiazide 56amiodarone hcl 53amiodarone hcl (PACERONE) 53AMITIZA (lubiprostone) 81amitriptyline hcl 19AMLODIPINE BESYLATE 54amlodipine besylate 54amlodipine besylatebenazepril hcl 56ammonium lactate 66ammonium lactate (SKIN TREATMENT) 66amoxapine 19amoxicillin 11AMOXICILLIN-CLAVULANATE POTASS 11
amoxicillinpotassium clavulanate 1112ampicillin trihydrate 12anagrelide hcl 47anastrozole 28ANASTROZOLE 28ANTACID 78ANTACID EXTRA STRENGTH 78ANTI-DIARRHEAL 78ANTIFUNGAL 21apraclonidine hcl 115aprepitant 21APTIVUS (tipranavir) 40APTIVUS (tipranavirvitamin e tpgs) 40aripiprazole 32ARIPIPRAZOLE 32ARISTADA (aripiprazole lauroxil) 32ARISTADA INITIO (aripiprazole lauroxilsubmicronized) 32ARMOUR THYROID (thyroidpork) 102ascorbate calcium 72ascorbic acid 72ascorbic acid (SOOTHING PUREWAY-C) 72aspirin 1aspirin (ADULT ASPIRIN REGIMEN) 1aspirin (ADULT LOW DOSE ASPIRIN EC) 1aspirin (ASPIR 81) 1aspirin (ASPIR-TRIN) 1aspirin (ASPIRIN) 1aspirin (ECOTRIN) 1aspirin (ECPIRIN) 1aspirin (ST JOSEPH ASPIRIN EC) 1aspirin (ST JOSEPH ASPIRIN) 1ASPIRIN 325MG TABLET 1ASPIRIN 81MG TABLET 1aspirinacetaminophencaffeine (ADDEDSTRENGTH HEADACHE) 1aspirinacetaminophencaffeine (BAYERMIGRAINE) 1aspirinacetaminophencaffeine (EXTRA PAINRELIEF) 1
LAST UPDATED 12012020133
aspirinacetaminophencaffeine(EXTRAPRIN) 1aspirinacetaminophencaffeine (HEADACHERELIEF) 1aspirinacetaminophencaffeine (MIGRAINEFORMULA) 2aspirinacetaminophencaffeine (MIGRAINERELIEF) 2aspirinacetaminophencaffeine (PAINRELIEVER PLUS) 2aspirinacetaminophencaffeine (PAINRELIEVER) 2aspirinacetaminophencaffeine (PAIN-OFF) 2ASSURE ID DUO-SHIELD 110ASSURE ID INSULIN SAFETY 110ATAZANAVIR SULFATE 40atazanavir sulfate 40atenolol 53ATENOLOL 53atenololchlorthalidone 56ATHLETES FOOT (terbinafine hcl) 21atomoxetine hcl 62atorvastatin calcium 59ATORVASTATIN CALCIUM 59ATRIPLA (efavirenzemtricitabinetenofovirdisoproxil fumarate) 37atropine sulfate 112ATROVENT HFA (ipratropium bromide) 122AVANDIA (rosiglitazone maleate) 43AVONEX (interferon beta-1a) 65AVONEX (interferon beta-1aalbuminhuman) 65AVONEX PEN (interferon beta-1a) 65azathioprine 104AZATHIOPRINE 104AZELASTINE HCL 117azelastine hcl 117azithromycin 12AZITHROMYCIN 12
Bbacitracin 9BACITRACIN 9bacitracin (BACITRAYCIN PLUS) 9bacitracin zinc 9BACITRACIN ZINC 9bacitracin zinc (ANTIBIOTIC) 9bacitracinpolymyxin b sulfate 112bacitracinpolymyxin b sulfate (AK-POLY-BAC) 112bacitracinpolymyxin b sulfate (POLYCIN) 112baclofen 35BACLOFEN 35balsalazide disodium 109BAQSIMI (glucagon) 44BASAGLAR KWIKPEN U-100 (insulinglarginehuman recombinant analog) 45BELBUCA (buprenorphine hcl) 3benazepril hcl 52benazepril hclhydrochlorothiazide 56BENEFIX (factor ix human recombinant) 48benzonatate 124benzoyl peroxide 67benzoyl peroxide (ACNE CONTROLCLEANSER) 66benzoyl peroxide (ACNE FOAMING WASH) 66benzoyl peroxide (ACNE TREATMENT) 67benzoyl peroxide (ACNECLEAR) 67benzoyl peroxide (ADVANCED EXFOLIATINGCLEANSER) 67benzoyl peroxide (BP WASH) 67benzoyl peroxide (BP) 67benzoyl peroxide (BPO-10) 67benzoyl peroxide (BPO-5) 67benzoyl peroxide (CLEAN-CLEARCONTINUOUS CONTROL) 67benzoyl peroxide (DAYLOGIC ACNEFOAMING WASH) 67benzoyl peroxide (DAYLOGIC ACNETREATMENT) 67
LAST UPDATED 12012020134
benzoyl peroxide (FOAMING ACNE FACEWASH) 67benzoyl peroxide (PANOXYL) 67benztropine mesylate 29BEOVU (brolucizumab-dbll) 112betamethasone dipropionate 87BETAMETHASONE DIPROPIONATE 87betamethasone dipropionatepropyleneglycol 88betamethasone valerate 88betaxolol hcl 115bethanechol chloride 86BETIMOL (timolol) 115BETOPTIC S (betaxolol hcl) 115BEVESPI AEROSPHERE(glycopyrrolateformoterol fumarate) 124BEXSERO (meningococcal group b vaccine4-component) 106bicalutamide 27BIKTARVY (bictegravirsodiumemtricitabinetenofovir alafenamidefumar) 36bisacodyl 82BISACODYL 82bisacodyl (ALOPHEN PILLS) 81bisacodyl (BISA-LAX) 81bisacodyl (BISACODYL) 81bisacodyl (BISCOLAX) 81bisacodyl (C-LAX LAXATIVE) 81bisacodyl (DUCODYL) 81bisacodyl (FAST RELIEF LAXATIVE) 81bisacodyl (GENTLE LAXATIVE) 81bisacodyl (LAXATIVE SUPPOSITORY) 81bisacodyl (LAXATIVE) 82bisacodyl (MAGIC BULLET) 82bisacodyl (WOMENS GENTLE LAXATIVE) 82bisacodyl (WOMENS LAXATIVE) 82bismuth subsalicylate 78bismuth subsalicylate (BISMATROL) 78bismuth subsalicylate (DIOTAME) 78bismuth subsalicylate (PEP-T-MED) 78
bismuth subsalicylate (PEPTIC RELIEF) 78bismuth subsalicylate (PINK BISMUTH) 78bismuth subsalicylate (SOOTHE) 78bismuth subsalicylate (STOMACH RELIEF) 78bisoprolol fumarate 54bisoprolol fumaratehydrochlorothiazide 56BISOPROLOL-HYDROCHLOROTHIAZIDE 56BLEPH-10 (sulfacetamide sodium) 13BLEPHAMIDE (sulfacetamidesodiumprednisolone acetate) 112BOOSTRIX TDAP(diphtheriapertussis(acellular)tetanusvaccine) 106bosentan 124brimonidine tartrate 115bromocriptine mesylate 29brompheniramine maleatepseudoephedrinehcl (RYNEX PSE) 125BROTAPP DM (brompheniraminemaleatepseudoephedrinehcldextromethorphan) 125BUDESONIDE 116budesonide 117bumetanide 58BUNAVAIL (buprenorphine hclnaloxone hcl) 7BUPRENEX (buprenorphine hcl) 7buprenorphine 4buprenorphine hcl 7buprenorphine hclnaloxone hcl 7bupropion hcl 817bupropion hcl (BUPROBAN) 8BUPROPION HCL SR 17BUPROPION XL 17BUSPIRONE HCL 41buspirone hcl 42butalbitalacetaminophen 64butalbitalacetaminophen (TENCON) 64butalbitalacetaminophencaffeine 64butalbitalaspirincaffeine 2butorphanol tartrate 5BUTRANS (buprenorphine) 4
LAST UPDATED 12012020135
CCALADRYL (pramoxine hclcalamine) 67calcipotriene 67calcitoninsalmonsynthetic 110CALCITRIOL 110calcitriol 110CALCIUM 72CALCIUM 500-VIT D3 72CALCIUM 600-VIT D3 72calcium acetate 87calcium acetate (ELIPHOS) 87calcium carbonate 697379calcium carbonate (ANTACID CALCIUM) 78calcium carbonate (ANTACID EXTRASTRENGTH) 78calcium carbonate (ANTACID) 78calcium carbonate (BAN-ACID) 78calcium carbonate (CAL-GEST) 78calcium carbonate (CALCIUM ANTACID) 78calcium carbonate (CHILDRENS PEPTO) 79calcium carbonate (CHILDRENS SOOTHE) 79calcium carbonate (FLAVOR CHEWSANTACID) 79calcium carbonate (OYSCO-500) 72calcium carbonate (SMOOTH ANTACID) 79calcium carbonate (SMOOTH DISSOLVINGANTACID) 79calcium carbonate (SUPER CALCIUM) 72calcium carbonatecholecalciferol (vitamind3) 73calcium carbonatecholecalciferol (vitamind3) (HI-CAL) 73calcium carbonatecholecalciferol (vitamind3) (OS-CAL 500-VIT D3) 73calcium carbonatecholecalciferol (vitamind3) (OYSCO 500-VIT D3) 73calcium carbonatecholecalciferol (vitamind3) (OYSTERCAL-D) 73calcium gluconate 73calcium lactate 73
capecitabine 27CAPECITABINE 27CAPLYTA (lumateperone tosylate) 32captopril 52CAPTOPRIL 52captoprilhydrochlorothiazide 56carbamazepine 16carbamazepine (EPITOL) 16carbamide peroxide (CARBAMOXIDE) 116carbamide peroxide (EAR DROPS) 116carbamide peroxide (EAR SYSTEM) 116carbamide peroxide (EAR WAXREMOVAL) 116carbamide peroxide (MURINE EAR WAXREMOVAL SYSTEM) 116CARBATROL (carbamazepine) 16carbidopalevodopa 30carisoprodol 130CARISOPRODOL 130carvedilol 54cefaclor 11CEFDINIR 11cefdinir 11celecoxib 2CELECOXIB 2CELONTIN (methsuximide) 14cephalexin 11cetirizine hcl 118CETIRIZINE HCL 118cetirizine hcl (24HOUR ALLERGY) 118cetirizine hcl (ALL DAY ALLERGY RELIEF) 118cetirizine hcl (ALL DAY ALLERGY) 118cetirizine hcl (ALLER-TEC) 118cetirizine hcl (ALLERGY RELIEF) 118cetirizine hcl (WAL-ZYR) 118CHANTIX (varenicline tartrate) 8CHEMET (succimer) 70CHILDRENS ALLERGY RELIEF 118CHILDRENS IBUPROFEN 2CHILDRENS NASACORT (triamcinoloneacetonide) 117
LAST UPDATED 12012020136
CHLORDIAZEPOXIDE-CLIDINIUM 77chlordiazepoxideclidinium bromide 77chlorhexidine gluconate 6667chlorhexidine gluconate (PAROEX) 66chloroquine phosphate 28chlorothiazide 58chlorpheniramine maleate 118chlorpheniramine maleate (ALLERGY 4-HOUR) 118chlorpheniramine maleate (ALLERGYRELIEF) 118chlorpheniramine maleate (ALLERGY) 118chlorpheniramine maleate (ALLERGY-TIME) 118chlorpheniramine maleate (CHLORHIST) 118chlorpheniramine maleate (CHLORTABS) 118chlorpheniramine maleate (ED CHLORPEDJR) 118chlorpheniramine maleate(PHARBECHLOR) 118chlorpheniramine maleate (WAL-FINATE) 118chlorpheniraminemaleatepseudoephedrinedextromethorphan (KIDKARE) 125chlorpromazine hcl 30CHLORPROMAZINE HCL 30chlorthalidone 58CHLORTHALIDONE 58cholecalciferol (vitamin d3) 110cholestyramine (with sugar) 59cholestyramineaspartame 59cholestyramineaspartame (PREVALITE) 59ciclopirox 21ciclopirox olamine 2122cilostazol 51CILOXAN (ciprofloxacin hcl) 13CIMDUO (lamivudinetenofovir disoproxilfumarate) 36cimetidine 80CIMETIDINE 80cimetidine (ACID REDUCER) 80
cimetidine (HEARTBURN RELIEF) 80cimetidine hcl 80cinacalcet hcl 110CINACALCET HCL 110ciprofloxacin hcl 13CIPROFLOXACIN HCL 13citalopram hydrobromide 18citric acidsodium citrate 86citric acidsodium citrate (CYTRA-2) 86citric acidsodium citrate (VIRTRATE-2) 86clarithromycin 12clemastine fumarate 119CLEOCIN (clindamycin phosphate) 9clindamycin hcl 9clindamycin palmitate hcl 9clindamycin phosphate 9CLINDAMYCIN PHOSPHATE 9CLINIMIX (amino acids 425 in dextrose 5 in water) 70clobetasol propionate 88CLOBETASOL PROPIONATE 88clomipramine hcl 19CLOMIPRAMINE HCL 19clonazepam 42clonidine hcl 51CLONIDINE HCL 51clopidogrel bisulfate 51clotrimazole 22CLOTRIMAZOLE 22clotrimazole (ANTIFUNGAL RINGWORM) 22clotrimazole (ANTIFUNGAL) 22clotrimazole (ATHLETES FOOT) 22clotrimazole (ATHLETIC FOOT CREAM) 22clotrimazole (CLOTRIMAZOLE AF) 22clotrimazole (ITCH RELIEF) 22clotrimazole (JOCK ITCH RELIEF) 22clotrimazole (JOCK ITCH) 22clotrimazole (RINGWORM) 22clozapine 34CLOZAPINE 34CLOZAPINE ODT 34
LAST UPDATED 12012020137
CLOZARIL (clozapine) 35COAGADEX (coagulation factor x) 48codeinephosphatebutalbitalaspirincaffeine 5codeine phosphateguaifenesin 125codeine phosphateguaifenesin(CHERATUSSIN AC) 125codeine phosphateguaifenesin (G TUSSINAC) 125codeine phosphateguaifenesin(GUAIATUSSIN AC) 125codeine phosphateguaifenesin(GUAIFENESIN AC) 125codeine phosphateguaifenesin (ROBAFENAC) 125codeine phosphateguaifenesin (VIRTUSSINAC) 125codeine sulfate 5CODEINE-GUAIFENESIN 125COGENTIN (benztropine mesylate) 29colchicine 24COLCHICINE 24COLESTID (colestipol hcl) 59colestipol hcl 59COMBIVENT RESPIMAT (ipratropiumbromidealbuterol sulfate) 125COMBIVIR (lamivudinezidovudine) 38COMPLERA (emtricitabinerilpivirinehcltenofovir disoproxil fumarate) 37condoms female 110condoms latex lubricated 110CORIFACT (factor xiii) 48CORTISPORIN (neomycin sulfatepolymyxin bsulfatehydrocortisone) 112CORTISPORIN(neomycinbacitracinpolymyxinbhydrocortisone) 67COUGH FORMULA DM(guaifenesindextromethorphan hbr) 125COUMADIN (warfarin sodium) 46CREON (lipaseproteaseamylase) 85
CRIXIVAN (indinavir sulfate) 40cromolyn sodium 110114cyanocobalamin (vitamin b-12) 73cyanocobalamin (vitamin b-12) (B-12DOTS) 73cyclobenzaprine hcl 130cyclopentolate hcl 112cyclophosphamide 26CYCLOPHOSPHAMIDE 26cyclosporine 104cyclosporine modified 104cyclosporine modified (GENGRAF) 104cyproheptadine hcl 119
Ddanazol 91dapsone 26DEBROX (carbamide peroxide) 116DELSTRIGO (doravirinelamivudinetenofovirdisoproxil fumarate) 37DELTASONE (prednisone) 88DEPAKENE (valproic acid (as sodium salt)(valproate sodium)) 15DEPAKENE (valproic acid) 15DEPO-PROVERA (medroxyprogesteroneacetate) 100DEPO-SUBQ PROVERA 104(medroxyprogesterone acetate) 100DESCOVY (emtricitabinetenofoviralafenamide fumarate) 39desipramine hcl 19desmopressin acetate 90DESMOPRESSIN ACETATE 90desmopressin acetate (non-refrigerated) 90desogestrel-ethinyl estradiol 91desogestrel-ethinyl estradiol (APRI) 91desogestrel-ethinyl estradiol (CYRED EQ) 91desogestrel-ethinyl estradiol (CYRED) 91desogestrel-ethinyl estradiol (EMOQUETTE) 91desogestrel-ethinyl estradiol (ENSKYCE) 91desogestrel-ethinyl estradiol (ISIBLOOM) 91
LAST UPDATED 12012020138
desogestrel-ethinyl estradiol (JULEBER) 91desogestrel-ethinyl estradiol (KALLIGA) 91desogestrel-ethinyl estradiol (RECLIPSEN) 91desogestrel-ethinyl estradiolethinylestradiol 92desogestrel-ethinyl estradiolethinyl estradiol(AZURETTE) 91desogestrel-ethinyl estradiolethinyl estradiol(BEKYREE) 92desogestrel-ethinyl estradiolethinyl estradiol(KARIVA) 92desogestrel-ethinyl estradiolethinyl estradiol(KIMIDESS) 92desogestrel-ethinyl estradiolethinyl estradiol(PIMTREA) 92desogestrel-ethinyl estradiolethinyl estradiol(SIMLIYA) 92desogestrel-ethinyl estradiolethinyl estradiol(VIORELE) 92desogestrel-ethinyl estradiolethinyl estradiol(VOLNEA) 92desonide 88DESONIDE 88dexamethasone 88DEXAMETHASONE 88dexamethasone (DEXAMETHASONEINTENSOL) 88dexamethasone sodium phosphate 114dextroamphetamine sulf-saccharateamphetamine sulf-aspartate 61dextroamphetamine sulfate 62DEXTROAMPHETAMINE SULFATE 62dextroamphetamine sulfate (ZENZEDI) 62DEXTROAMPHETAMINE-AMPHET ER 62dextrose 10 and 045 sodium chloride 70dextrose 10 in water 7073dextrose 5 and 045 sodium chloride 7073dextrose 5 in lactated ringers 73dextrose 5 in water 697073DEXTROSE IN WATER 74diazepam 1542
diclofenac sodium 2114dicloxacillin sodium 12DICYCLOMINE HCL 77dicyclomine hcl 77DIFFERIN (adapalene) 67diflunisal 2digoxin 56digoxin (DIGITEK) 56digoxin (DIGOX) 56DILANTIN (phenytoin sodium extended) 16DILANTIN (phenytoin) 16DILANTIN-125 16DILANTIN-125 (phenytoin) 16DILTIAZEM 24HR ER (CD) 54DILTIAZEM 24HR ER (XR) 55diltiazem hcl 55diltiazem hcl (CARTIA XT) 55diltiazem hcl (DILT-XR) 55diltiazem hcl (TAZTIA XT) 55DIMETHYL FUMARATE 65DIPHENHYDRAMINE HCL 120diphenhydramine hcl 120diphenhydramine hcl (ALER-CAPS) 119diphenhydramine hcl (ALKA-SELTZER PLUSALLERGY) 130diphenhydramine hcl (ALLER-G-TIME) 119diphenhydramine hcl (ALLERGYMEDICATION) 119diphenhydramine hcl (ALLERGYMEDICINE) 119diphenhydramine hcl (ALLERGY RELIEF) 119diphenhydramine hcl (ALLERGY) 119diphenhydramine hcl (BANOPHEN) 119diphenhydramine hcl (BENADRYLALLERGY) 119diphenhydramine hcl (CHILDRENS ALLERGYRELIEF) 119diphenhydramine hcl (CHILDRENSALLERGY) 119diphenhydramine hcl (CHILDRENS BENADRYLALLERGY) 119
LAST UPDATED 12012020139
diphenhydramine hcl (CHILDRENS WAL-DRYLALLERGY) 119diphenhydramine hcl (COMPLETEALLERGY) 119diphenhydramine hcl (COMPOZ) 130diphenhydramine hcl (DIPHEDRYLALLERGY) 119diphenhydramine hcl (DIPHEDRYL) 120diphenhydramine hcl (DIPHEN) 120diphenhydramine hcl (DIPHENHIST) 120diphenhydramine hcl (GERI-DRYL) 120diphenhydramine hcl (M-DRYL) 120diphenhydramine hcl (NIGHTTIME ALLERGYRELIEF) 120diphenhydramine hcl (NIGHTTIME SLEEPAID) 120130diphenhydramine hcl (NYTOL QUICKCAPS)130diphenhydramine hcl (PHARBEDRYL) 120diphenhydramine hcl (SILADRYL) 120diphenhydramine hcl (SIMPLY SLEEP) 120131diphenhydramine hcl (SLEEP AID) 120131diphenhydramine hcl (SLEEP II) 131diphenhydramine hcl (SLEEP TABLET) 131diphenhydramine hcl (TOTAL ALLERGY) 120diphenhydramine hcl (WAL-DRYLALLERGY) 120diphenhydramine hcl (WAL-DRYL) 120diphenoxylate hclatropine sulfate 79DIPHENOXYLATE-ATROPINE 79dipyridamole 51disopyramide phosphate 53disulfiram 6DIURIL (chlorothiazide) 58divalproex sodium 15DIVALPROEX SODIUM 15DOCUSATE SODIUM 82docusate sodium 82docusate sodium (COL-RITE) 82docusate sodium (DIOCTYL) 82docusate sodium (DOCU LIQUID) 82docusate sodium (DOCUSIL) 82
docusate sodium (DSS) 82docusate sodium (DULCOEASE) 82docusate sodium (DULCOLAX STOOLSOFTENER) 82docusate sodium (LAXA BASIC 100) 82docusate sodium (PHILLIPS LAXATIVE) 82docusate sodium (SOF-LAX) 82docusate sodium (STOOL SOFTENER) 82DOK (docusate sodium) 83donepezil hcl 17dorzolamide hcl 115dorzolamide hcltimolol maleate 115DORZOLAMIDE-TIMOLOL 115DOVATO (dolutegravir sodiumlamivudine) 39doxazosin mesylate 51DOXEPIN HCL 19doxepin hcl 19DOXYCYCLINE HYCLATE 14doxycycline hyclate 14doxycycline monohydrate 14DRITHOCREME HP (anthralin) 67dronabinol 21DROPLET MICRON PEN NEEDLE 110DROSPIRENONE-ETHINYL ESTRADIOL 92DROXIA (hydroxyurea) 27DRYSOL (aluminum chloride) 68duloxetine hcl 65
EEES 200 (erythromycin ethylsuccinate) 12EES 400 (erythromycin ethylsuccinate) 12EAR DROPS (carbamide peroxide) 116EDURANT (rilpivirine hcl) 37efavirenz 37EFAVIRENZ-EMTRIC-TENOFOV DISOP 37EFAVIRENZ-LAMIVU-TENOFOV DISOP 3637electrolytesdextrose (ELECTROLYTE) 74electrolytesdextrose (ORALYTE) 74electrolytesdextrose (PEDIATRICELECTROLYTE) 74
LAST UPDATED 12012020140
electrolytesdextrose (PEDIATRIC FREEZERPOPS) 74ELIQUIS (apixaban) 46ELIXOPHYLLIN (theophylline anhydrous) 124ELOCTATE (antihemophilic factor (fviii)recombinant fc fusion protein) 48EMCYT (estramustine phosphate sodium) 27EMSAM (selegiline) 18EMTRICITABINE 38EMTRICITABINE-TENOFOVIR DISOP 38EMTRIVA (emtricitabine) 38ENALAPRIL MALEATE 52enalapril maleate 52ENBREL 105ENBREL (etanercept) 104ENBREL SURECLICK (etanercept) 105ENGERIX-B ADULT (hepatitis b virus vaccinerecombinantpf) 106ENOXAPARIN SODIUM 46enoxaparin sodium 46entacapone 29EPIFOAM (hydrocortisone acetatepramoxinehcl) 68epinephrine 123EPIVIR (lamivudine) 38EPIVIR HBV (lamivudine) 35EPOGEN (epoetin alfa) 47EPZICOM (abacavir sulfatelamivudine) 38ERGOCALCIFEROL 110ergocalciferol (vitamin d2) 110ergocalciferol (vitamin d2) (CALCIDOL) 110ergotamine tartratecaffeine 25ERYTHROCIN STEARATE (erythromycinstearate) 12ERYTHROMYCIN 13erythromycin base 13erythromycin base in ethanol 13erythromycin base in ethanol (ERY) 13erythromycin basebenzoyl peroxide 9ERYTHROMYCIN ETHYLSUCCINATE 13erythromycin ethylsuccinate 13
escitalopram oxalate 18ESCITALOPRAM OXALATE 18ESPEROCT (antihemophilic factor (fviii) rec b-dom truncated peg-exei) 48estradiol 92ESTRADIOL 93estradiol (DOTTI) 92estrogensesterifiedmethyltestosterone 93estrogensesterifiedmethyltestosterone(COVARYX HS) 93estrogensesterifiedmethyltestosterone (EEMTHS) 93ethambutol hcl 26ETHAMBUTOL HCL 26ethinyl estradioldrospirenone 93ethinyl estradioldrospirenone (GIANVI) 93ethinyl estradioldrospirenone (JASMIEL) 93ethinyl estradioldrospirenone (LO-ZUMANDIMINE) 93ethinyl estradioldrospirenone (LORYNA) 93ethinyl estradioldrospirenone (NIKKI) 93ethinyl estradioldrospirenone (VESTURA) 93ETHOSUXIMIDE 14ethosuximide 14ethynodiol diacetate-ethinyl estradiol 93ethynodiol diacetate-ethinyl estradiol(KELNOR 1-35) 93ethynodiol diacetate-ethinyl estradiol(KELNOR 1-50) 93ethynodiol diacetate-ethinyl estradiol (ZOVIA1-35E) 93etodolac 2etonogestrelethinyl estradiol 94etonogestrelethinyl estradiol (ELURYNG) 93etoposide 28EVOTAZ (atazanavir sulfatecobicistat) 40EVZIO (naloxone hcl) 7EXCEDRIN EXTRA STRENGTH(aspirinacetaminophencaffeine) 2EXCEDRIN MIGRAINE(aspirinacetaminophencaffeine) 2
LAST UPDATED 12012020141
EYE ITCH RELIEF 114ezetimibe 59
Ffamotidine 81FAMOTIDINE 81famotidine (ACID CONTROLLER) 80famotidine (ACID REDUCER) 80famotidine (HEARTBURN PREVENTION) 81famotidine (HEARTBURN RELIEF) 81famotidine (PEPCID) 81FANAPT (iloperidone) 32FAZACLO (clozapine) 35FEIBA NF (anti-inhibitor coagulant complex) 48felodipine 55FELODIPINE ER 55fenofibrate 58FENOFIBRATE 58fenofibratemicronized 59fentanyl 4ferrous sulfate 74FERROUS SULFATE 74ferrous sulfate (CHILDRENS IRON) 74ferrous sulfate (FEOSOL) 74ferrous sulfate (FEROSUL) 74ferrous sulfate (FERRO-TIME) 74ferrous sulfate (FERROUSUL) 74ferrous sulfate (PEDIA IRON) 74fexofenadine hcl 121FEXOFENADINE HCL 121fexofenadine hcl (ALLER-EASE) 120fexofenadine hcl (ALLER-FEX) 120fexofenadine hcl (ALLERGY RELIEF) 121fexofenadine hcl (WAL-FEX ALLERGY) 121FIBRYGA (fibrinogen) 48finasteride 86flecainide acetate 53FLOVENT DISKUS (fluticasone propionate) 117FLOVENT HFA (fluticasone propionate) 117FLUAD 2020-2021 106FLUAD QUAD 2020-2021 106
FLUARIX QUAD 2020-2021 106FLUBLOK QUAD 2018-2019 (influenza virusvaccine qv 2018-19(18 yrs andolder)rcmbpf) 106FLUBLOK QUAD 2020-2021 107FLUCELVAX QUAD 2020-2021 107fluconazole 22FLUCONAZOLE 22fluconazole in dextrose iso-osmotic 22flucytosine 22FLUCYTOSINE 22fludrocortisone acetate 88FLULAVAL QUAD 2019-2020 (influenza virusvaccine quadrivalent 2019-20 (6 mos andup)) 107FLULAVAL QUAD 2020-2021 107fluocinolone acetonide 88fluocinonide 88FLUOCINONIDE 88fluoride (sodium) 74fluorometholone 114fluorouracil (ADRUCIL) 27fluoxetine hcl 18FLUOXETINE HCL 18fluoxymesterone (ANDROXY) 91fluphenazine decanoate 30fluphenazine hcl 30FLUPHENAZINE HCL 30flurazepam hcl 130flurbiprofen 2flurbiprofen sodium 114flutamide 27fluticasone propionate 117fluticasone propionate (ALLERGY RELIEF) 117fluticasone propionatesalmeterolxinafoate 126fluticasone propionatesalmeterol xinafoate(WIXELA INHUB) 126fluvoxamine maleate 18FLUZONE HIGH-DOSE QUAD 2020-21 107
LAST UPDATED 12012020142
FLUZONE QUAD 2019-2020 (influenza virusvaccine quadrival 2019-2020(6 mos andup)pf) 107FLUZONE QUAD 2020-2021 107FML FORTE (fluorometholone) 114FML SOP (fluorometholone) 114folic acid 74FOLIC ACID 74FORADIL (formoterol fumarate) 123FOSAMAX PLUS D (alendronatesodiumcholecalciferol (vitamin d3)) 110fosamprenavir calcium 40FOSAMPRENAVIR CALCIUM 40fosinopril sodium 52fosinopril sodiumhydrochlorothiazide 57FOSINOPRIL-HYDROCHLOROTHIAZIDE 57Freestyle Insulix Test Strips 110Freestyle Lite Test Strips 111Freestyle Test Strips 111furosemide 58FUZEON (enfuvirtide) 39
Ggabapentin 15GABAPENTIN 15GARDASIL 9 (human papillomavirus vaccine9-valentpf) 107GAS RELIEF 79GAS RELIEF (simethicone) 79GAS-X (simethicone) 79gemfibrozil 59GEMFIBROZIL 59gentamicin sulfate 8GENTAMICIN SULFATE 9gentamicin sulfate (GENTAK) 8GENTLE LAXATIVE 83GENVOYA(elvitegravircobicistatemtricitabinetenofovir alafenamide) 36GEODON (ziprasidone hcl) 32GEODON (ziprasidone mesylate) 32
GERI-DRYL 121glatiramer acetate 6566glatiramer acetate (GLATOPA) 65GLEOSTINE (lomustine) 26glimepiride 43glipizide 43GLUCAGON EMERGENCY KIT (glucagonhcl) 44GLUCAGON EMERGENCY KIT(glucagonhuman recombinant) 44glyburide 43glyburidemetformin hcl 43glycerin 83glycerin (ADULT GLYCERIN) 83glycerin (LAXATIVE SUPPOSITORY) 83glycerin (PEDIA-LAX) 83glycerin (SUPPOSITORY) 83GOCOVRI (amantadine hcl) 29granisetron hcl 21griseofulvin ultramicrosize 22griseofulvin microsize 23GUAIASORB DM 126guaifenesin (MUCUS ER) 126guaifenesin (MUCUS RELIEF ER) 126GUAIFENESIN-DEXTROMETHORPHAN 126guaifenesindextromethorphan hbr 128guaifenesindextromethorphan hbr (ADULTROBITUSSIN PEAK COLD DM) 126guaifenesindextromethorphan hbr (ADULTTUSSIN COUGH CONGEST DM) 126guaifenesindextromethorphan hbr (ADULTTUSSIN DM) 126guaifenesindextromethorphan hbr (ADULTWAL-TUSSIN DM) 126guaifenesindextromethorphan hbr(ANTITUSSIVE DM) 126guaifenesindextromethorphan hbr(BIOCOTRON) 126guaifenesindextromethorphan hbr (COUGHDM) 126
LAST UPDATED 12012020143
guaifenesindextromethorphan hbr (DIABETICSILTUSSIN-DM) 127guaifenesindextromethorphan hbr (DIABETICTUSSIN DM) 127guaifenesindextromethorphan hbr(EXPECTORANT DM) 127guaifenesindextromethorphan hbr (EXTRAACTION COUGH) 127guaifenesindextromethorphan hbr (GERI-TUSSIN DM) 127guaifenesindextromethorphan hbr (GILTUSSDIABETIC) 127guaifenesindextromethorphan hbr (GILTUSSHBP) 127guaifenesindextromethorphan hbr(GUAIASORB DM) 127guaifenesindextromethorphan hbr (RI-TUSSINDM) 127guaifenesindextromethorphan hbr (ROBAFENDM COUGH) 127guaifenesindextromethorphan hbr (ROBAFENDM COUGH-CHEST CONGEST) 127guaifenesindextromethorphan hbr (ROBAFENDM PEAK COLD) 127guaifenesindextromethorphan hbr(ROBAFEN-DM) 127guaifenesindextromethorphan hbr(SAFETUSSIN DM) 127guaifenesindextromethorphan hbr (SILTUSSINDM DAS) 127guaifenesindextromethorphan hbr (SILTUSSINDM) 128guaifenesindextromethorphan hbr(SORBUGEN NR) 128guaifenesindextromethorphan hbr (TUSNELDIABETIC) 128guaifenesindextromethorphan hbr (TUSSINCOUGH) 128guaifenesindextromethorphan hbr (TUSSINDM CLEAR) 128
guaifenesindextromethorphan hbr (TUSSINDM COUGH) 128guaifenesindextromethorphan hbr (TUSSINDM COUGH-CHEST CONGEST) 128guaifenesindextromethorphan hbr (TUSSINDM) 128guaifenesindextromethorphan hbr (ULTRADM FREE amp CLEAR) 128guaifenesindextromethorphan hbr (ULTRATUSS) 128guaifenesindextromethorphan hbr (WAL-TUSSIN DM) 128guaifenesinpseudoephedrine hcl 129guaifenesinpseudoephedrine hcl (MUCUSD) 128guaifenesinpseudoephedrine hcl (MUCUSRELIEF D) 128guanfacine hcl 5162
HHAILEY FE 94HALDOL (haloperidol lactate) 30HALDOL DECANOATE 100 (haloperidoldecanoate) 30HALDOL DECANOATE 50 (haloperidoldecanoate) 30haloperidol 31HALOPERIDOL 31haloperidol decanoate 31haloperidol lactate 31HALOPERIDOL LACTATE 31HAVRIX (hepatitis a virus vaccinepf) 107HEADACHE RELIEF 2HELIXATE FS (antihemophilic factor (fviii)recombinantfull length) 48HEMLIBRA (emicizumab-kxwh) 48HEMOFIL M (antihemophilic factor human) 48HEPARIN SODIUM 46heparin sodiumporcine 46heparin sodiumporcinepf 46
LAST UPDATED 12012020144
HEPLISAV-B (hepatitis b vaccinerecombinantvaccine adjuvant cpg1018pf) 107HEXALEN (altretamine) 26homatropine hbr 112homatropine hbr (HOMATROPAIRE) 112HUMALOG (insulin lispro) 45HUMALOG MIX 75-25 (insulin lispro protamineand insulin lispro) 45HUMALOG MIX 75-25 KWIKPEN (insulin lisproprotamine and insulin lispro) 45HUMATE-P (antihemophilic factor humanvonwillebrand factorhuman) 48HUMIRA (adalimumab) 105HUMIRA PEDIATRIC CROHNS(adalimumab) 105HUMIRA PEN (adalimumab) 105HUMIRA PEN CROHNS-UC-HS(adalimumab) 105HUMIRA PEN PSOR-UVEITS-ADOL HS(adalimumab) 105HUMIRA(CF) (adalimumab) 105HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 105HUMIRA(CF) PEN (adalimumab) 105HUMIRA(CF) PEN CROHNS-UC-HS(adalimumab) 105HUMIRA(CF) PEN PSOR-UV-ADOL HS(adalimumab) 105HUMULIN 70-30 (insulin nph humanisophaneinsulin regular human) 45HUMULIN 7030 KWIKPEN (insulin nph humanisophaneinsulin regular human) 45HUMULIN N (insulin nph human isophane) 45HUMULIN R (insulin regular human) 45HUMULIN R U-500 (insulin regular human) 45hydralazine hcl 60hydrochlorothiazide 58hydrocodone bitartrateacetaminophen 5hydrocodone bitartrateacetaminophen(LORCET HD) 5
hydrocodone bitartrateacetaminophen(LORTAB) 5hydrocortisone 89109HYDROCORTISONE 89hydrocortisone (ANTI-ITCH) 88hydrocortisone (ANUSOL-HC) 88hydrocortisone (COLOCORT) 109hydrocortisone (CORTISONE) 88hydrocortisone (CORTIZONE-10 PLUS) 89hydrocortisone (CORTIZONE-10) 89hydrocortisone (HYDROCREAM) 89hydrocortisone (NOBLE FORMULA HC) 89hydrocortisone (PREPARATION H) 89hydrocortisone (PROCTO-MED HC) 89hydrocortisone (PROCTO-PAK) 89hydrocortisone (PROCTOSOL-HC) 89hydrocortisone (PROCTOZONE-HC) 89hydrocortisone (SOOTHING CARE) 89HYDROCORTISONE ACETATE 89hydrocortisone acetate 89hydrocortisone acetate (ANUCORT-HC) 89hydrocortisone acetate (ANUSOL-HC) 89hydrocortisone acetate (HEMMOREX-HC) 89hydrocortisone acetatepramoxine hcl 68hydrocortisoneacetic acid 116hydrocortisoneacetic acid (ACETASOLHC) 116hydromorphone hcl 5HYDROXYCHLOROQUINE SULFATE 28hydroxychloroquine sulfate 28hydroxyprogesterone caproate 100hydroxyprogesterone caproatepf 100hydroxyurea 27hydroxyzine hcl 121HYDROXYZINE PAMOATE 121hydroxyzine pamoate 121hyoscyamine sulfate 77hyoscyamine sulfate (HYOSYNE) 77HYPERTET S-D (tetanus immuneglobulinpf) 106
LAST UPDATED 12012020145
Iibuprofen 3IBUPROFEN 3ibuprofen (ADDAPRIN) 2ibuprofen (I-PRIN) 3ibuprofen (IBU) 3ibuprofen (IBU-200) 3ibuprofen (PROVIL) 3ibuprofen (WAL-PROFEN) 3IDELVION (factor ix recombinantalbuminfusion protein) 48imipramine hcl 19IMIPRAMINE HCL 19IMOVAX RABIES VACCINE (rabies vaccinehuman diploid cellpf) 107INCRUSE ELLIPTA (umeclidinium bromide) 122indapamide 58indomethacin 3INFANTS GAS RELIEF 79inhalerassist device with large mask 111inhalerassist device with medium mask 111inhalerassist device with small mask 111insulin lispro 45INSULIN LISPRO PROTAMINE MIX (insulin lisproprotamine and insulin lispro) 45Insulin pen needles 111INSULIN SYRINGE 03 ML 111INSULIN SYRINGE 05 ML 111INSULIN SYRINGE 1 ML 111INTELENCE (etravirine) 37INTRON A (interferon alfa-2brecomb) 35INVEGA (paliperidone) 32INVEGA SUSTENNA (paliperidone palmitate)32INVEGA TRINZA (paliperidone palmitate) 32INVIRASE (saquinavir mesylate) 40IOPIDINE (apraclonidine hcl) 115ipratropium bromide 122ipratropium bromidealbuterol sulfate 129IPRATROPIUM-ALBUTEROL 129irbesartan 52
irbesartanhydrochlorothiazide 57IRON 74ISENTRESS (raltegravir potassium) 36ISENTRESS HD (raltegravir potassium) 36isoniazid 26ISOSORBIDE DINITRATE 60isosorbide dinitrate 60isosorbide mononitrate 60isotretinoin 68isotretinoin (AMNESTEEM) 68isotretinoin (CLARAVIS) 68isotretinoin (MYORISAN) 68isotretinoin (ZENATANE) 68itraconazole 23IXINITY (factor ix human recombinantthreonine 148) 49
JJAKAFI (ruxolitinib phosphate) 28JARDIANCE (empagliflozin) 43JENCYCLA 100JIVI (antihemophilic factor (fviii) rec b-domain deleted peg-aucl) 49JULUCA (dolutegravir sodiumrilpivirine hcl) 39
KKALETRA (lopinavirritonavir) 40KCENTRA (human prothrombin complexconcentrate (pcc) 4-factor) 49ketoconazole 23ketoprofen 3ketorolac tromethamine 114ketotifen fumarate 114ketotifen fumarate (ALLERGY EYE DROPS) 114ketotifen fumarate (EYE ITCH RELIEF) 114ketotifen fumarate (ITCHY EYE) 114ketotifen fumarate (WAL-ZYR) 114ketotifen fumarate (ZADITOR) 114KOGENATE FS (antihemophilic factor (fviii)recombinantfull length) 49
LAST UPDATED 12012020146
KOVALTRY (antihemophilic factor (fviii)recombinantfull length) 49
Llabetalol hcl 54LABETALOL HCL 54lactulose 83lactulose (CONSTULOSE) 83lactulose (ENULOSE) 83lactulose (GENERLAC) 83LAMISIL (terbinafine hcl) 23lamivudine 3538lamivudinezidovudine 38lamotrigine 15lancets 111LANOXIN (digoxin) 57lansoprazole 85LANSOPRAZOLE 85lanthanum carbonate 87latanoprost 115LATUDA (lurasidone hcl) 32leflunomide 106LEFLUNOMIDE 106letrozole 28LEUCOVORIN CALCIUM 27leucovorin calcium 27LEUKERAN (chlorambucil) 26leuprolide acetate 104levalbuterol tartrate 123LEVETIRACETAM 14levetiracetam 14LEVETIRACETAM ER 14LEVO-T (levothyroxine sodium) 103levobunolol hcl 115levocarnitine 70levocarnitine (with sugar) 70levofloxacin 13levonorgestrel 101levonorgestrel (AFTERA) 101levonorgestrel (ECONTRA EZ) 101levonorgestrel (ECONTRA ONE-STEP) 101
levonorgestrel (FALLBACK SOLO) 101levonorgestrel (MY CHOICE) 101levonorgestrel (MY WAY) 101levonorgestrel (NEW DAY) 101levonorgestrel (OPCICON ONE-STEP) 101levonorgestrel (OPTION 2) 101levonorgestrel (TAKE ACTION) 101LEVONORGESTREL-ETH ESTRADIOL 94levonorgestrelethinyl estradiol 96levonorgestrelethinyl estradiol (AFIRMELLE) 94levonorgestrelethinyl estradiol (ALTAVERA) 94levonorgestrelethinyl estradiol (AUBRA EQ) 94levonorgestrelethinyl estradiol (AUBRA) 94levonorgestrelethinyl estradiol (AVIANE) 94levonorgestrelethinyl estradiol (AYUNA) 94levonorgestrelethinyl estradiol (CHATEALEQ) 94levonorgestrelethinyl estradiol (CHATEAL) 94levonorgestrelethinyl estradiol (DELYLA) 94levonorgestrelethinyl estradiol (ENPRESSE) 94levonorgestrelethinyl estradiol (FALMINA) 95levonorgestrelethinyl estradiol (KURVELO) 95levonorgestrelethinyl estradiol (LARISSIA) 95levonorgestrelethinyl estradiol (LESSINA) 95levonorgestrelethinyl estradiol (LEVONEST) 95levonorgestrelethinyl estradiol (LEVORA-28)95levonorgestrelethinyl estradiol (LILLOW) 95levonorgestrelethinyl estradiol (LUTERA) 95levonorgestrelethinyl estradiol (MARLISSA) 95levonorgestrelethinyl estradiol (MYZILRA) 95levonorgestrelethinyl estradiol (ORSYTHIA) 95levonorgestrelethinyl estradiol (PORTIA) 96levonorgestrelethinyl estradiol (SRONYX) 96levonorgestrelethinyl estradiol (TRIVORA-28) 96levonorgestrelethinyl estradiol (VIENVA) 96levothyroxine sodium 103LEVOTHYROXINE SODIUM 103LEVOXYL (levothyroxine sodium) 103LEXIVA (fosamprenavir calcium) 40LICE KILLING 68
LAST UPDATED 12012020147
lidocaine hcl 6LIDOCAINE HCL VISCOUS 6lidocaine hclpf 6lisinopril 52lisinoprilhydrochlorothiazide 57lithium carbonate 42lithium citrate 42LITHOBID (lithium carbonate) 42loperamide hcl 79loperamide hcl (ANTI-DIARRHEAL) 79loperamide hcl (DIAMODE) 79loperamide hcl (ULTRA A-D) 79lopinavirritonavir 40loratadine 121122LORATADINE 122loratadine (ALLERCLEAR) 121loratadine (ALLERGY RELIEF) 121loratadine (ALLERGY) 121loratadine (CHILDRENS ALLERGY RELIEF) 121loratadine (CHILDRENS ALLERGY) 121loratadine (LORADAMED) 121loratadine (NON-DROWSY ALLERGY) 121loratadine (WAL-ITIN) 121lorazepam 42lorazepam (LORAZEPAM INTENSOL) 42LOSARTAN POTASSIUM 52losartan potassium 52losartan potassiumhydrochlorothiazide 57LOSARTAN-HYDROCHLOROTHIAZIDE 57LOTRIMIN AF (clotrimazole) 23lovastatin 59loxapine succinate 31LUCEMYRA (lofexidine hcl) 7LUPRON DEPOT-PED (leuprolide acetate) 104LYLLANA 96LYSODREN (mitotane) 28
MM-M-R II VACCINE (measles mumps andrubella vaccine livepf) 107MAGNESIUM CITRATE 83
magnesium citrate 83MARPLAN (isocarboxazid) 18MATULANE (procarbazine hcl) 26MAXI-TUSS G 129mebendazole (EMVERM) 28MECLIZINE HCL 20meclizine hcl 20meclizine hcl (DRAMAMINE LESS DROWSY) 20meclizine hcl (MEDI-MECLIZINE) 20meclizine hcl (MOTION RELIEF) 20meclizine hcl (MOTION SICKNESS II) 20meclizine hcl (MOTION SICKNESS RELIEF) 20meclizine hcl (MOTION SICKNESS) 20meclizine hcl (MOTION-TIME) 20meclizine hcl (TRAVEL-EASE) 20meclizine hcl (VERTICALM) 20meclizine hcl (WAL-DRAM 2) 20MEDROXYPROGESTERONE ACETATE 101medroxyprogesterone acetate 101mefloquine hcl 28megestrol acetate 101meloxicam 3melphalan 26memantine hcl 17MEMANTINE HCL 17MENACTRA (meningococcalvaccine acyw-135diphtheria toxoid conjpf) 107MENEST (estrogensesterified) 96MENQUADFI 107MENVEO A-C-Y-W-135-DIP(meningococcalvaccine acyw-135diphtheria toxoid conjpf) 108meperidine hcl 5mercaptopurine 27mesalamine 109MESTINON (pyridostigmine bromide) 25metaproterenol sulfate 123metformin hcl 43METFORMIN HCL ER 43METHADONE HCL 4methadone hcl 4
LAST UPDATED 12012020148
methadone hcl (METHADONE INTENSOL) 4methadone hcl (METHADOSE) 4methazolamide 115METHAZOLAMIDE 115methenaminemethylene bluesodphospsalicylatehyoscyamine(PHOSPHASAL) 9methenaminemethylene bluesodphospsalicylatehyoscyamine (URIN DS) 10methimazole 104methocarbamol 130METHOCARBAMOL 130METHOTREXATE 105methotrexate sodium 105methyclothiazide 58methyldopa 51methylergonovine maleate 111METHYLPHENIDATE ER 62methylphenidate hcl 62METHYLPHENIDATE HCL 62methylphenidate hcl (METADATE ER) 62methylprednisolone 89metoclopramide hcl 20metolazone 58metoprolol succinate 54METOPROLOL SUCCINATE 54metoprolol tartrate 54METRO IV (metronidazole in sodiumchloride) 10metronidazole 1068METRONIDAZOLE 10metronidazole in sodium chloride 10mexiletine hcl 53MEXILETINE HCL 53miconazole nitrate 23miconazole nitrate (ANTI-FUNGAL CREAM) 23miconazole nitrate (ANTIFUNGAL CREAM) 23miconazole nitrate (BAZA ANTIFUNGAL) 23miconazole nitrate (INZO ANTIFUNGAL) 23miconazole nitrate (LOTRIMIN AF) 23miconazole nitrate (MICATIN) 23
miconazole nitrate (SECURA ANTIFUNGAL) 23MICROGESTIN 96MICROGESTIN FE 96minocycline hcl 14minoxidil 60mirtazapine 17misoprostol 85modafinil 131moexipril hcl 52molindone hcl 31mometasone furoate 90MONISTAT 3 (miconazole nitrate) 23MONISTAT 7 (miconazole nitrate) 23MONONINE (factor ix) 49montelukast sodium 122MONTELUKAST SODIUM 122morphine sulfate 45moxifloxacin hcl 13MUCUS ER 129MUCUS RELIEF ER 129mupirocin 10mupirocin calcium 10MURINE EAR DROPS (carbamide peroxide) 116MURO-128 (sodium chloride) 112mycophenolate mofetil 105MYLERAN (busulfan) 27MYNATAL (prenatal vitamins withcalciumferrous fumaratefolic acid) 70
NNABI-HB (hepatitis b immune globulin) 106nadolol 54NADOLOL 54naloxone hcl 7naltrexone hcl 7NALTREXONE HCL 7naproxen 3naproxen sodium 3NARCAN (naloxone hcl) 8NARDIL (phenelzine sulfate) 18NASACORT (triamcinolone acetonide) 117
LAST UPDATED 12012020149
NASAL DECONGESTANT (pseudoephedrinehcl) 123nateglinide 43neomycin sulfate 9neomycin sulfatebacitracin zincpolymyxin b(ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxin b(FIRST AID ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxin b(TRIPLE ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxinbhydrocortisone 112neomycin sulfatebacitracin zincpolymyxinbhydrocortisone (NEO-POLYCIN HC) 112neomycin sulfatebacitracinpolymyxin b 113neomycin sulfatebacitracinpolymyxin b(NEO-POLYCIN) 113neomycin sulfatepolymyxin bsulfategramicidin d 113neomycin sulfatepolymyxin bsulfatehydrocortisone 113116NEOMYCIN-POLYMYXIN-HC 116neomycinpolymyxin bsulfatedexamethasone 113nevirapine 37NIACIN 60niacin 60niacin (ENDUR-ACIN) 59niacin (SLO-NIACIN) 59nicardipine hcl 55NICOTINE 14MG PATCH 8NICOTINE 21MG PATCH 8NICOTINE 2MG GUM 8NICOTINE 4MG GUM 8NICOTINE 7MG PATCH 8NICOTINE LOZENGE 8nicotine polacrilex 8nicotine polacrilex (QUIT 2) 8nicotine polacrilex (QUIT 4) 8nicotine polacrilex (STOP SMOKING AID) 8NICOTROL (nicotine) 8
NICOTROL NS (nicotine) 8NIFEDIPINE 55nifedipine 55nifedipine (AFEDITAB CR) 55nifedipine (NIFEDICAL XL) 55NIGHTTIME SLEEP AID 122nisoldipine 55NITRO-BID (nitroglycerin) 60nitrofurantoin 10NITROFURANTOIN 10nitrofurantoin macrocrystal 10nitrofurantoin monohydratemacrocrystals 10nitroglycerin 61NITROGLYCERIN 61nitroglycerin (MINITRAN) 60nitroglycerin (NITRO-TIME) 60nonoxynol 9 (VCF) 86norelgestrominethinyl estradiol (XULANE) 96norethindrone 102norethindrone (CAMILA) 101norethindrone (DEBLITANE) 101norethindrone (ERRIN) 101norethindrone (HEATHER) 102norethindrone (INCASSIA) 102norethindrone (JENCYCLA) 102norethindrone (JOLIVETTE) 102norethindrone (LYZA) 102norethindrone (NORA-BE) 102norethindrone (NORLYDA) 102norethindrone (NORLYROC) 102norethindrone (SHAROBEL) 102norethindrone (TULANA) 102norethindrone acetate 102norethindrone acetate-ethinyl estradiol 97norethindrone acetate-ethinyl estradiol(AUROVELA) 96norethindrone acetate-ethinyl estradiol(GILDESS) 96norethindrone acetate-ethinyl estradiol(HAILEY) 96
LAST UPDATED 12012020150
norethindrone acetate-ethinyl estradiol(JUNEL) 97norethindrone acetate-ethinyl estradiol(LARIN) 97norethindrone acetate-ethinyl estradiol(MICROGESTIN) 97norethindrone acetate-ethinylestradiolferrous fumarate 98norethindrone acetate-ethinylestradiolferrous fumarate (AUROVELA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (BLISOVI FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (JUNEL FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (LARIN FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (MICROGESTINFE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TARINA FE 1-20EQ) 97norethindrone acetate-ethinylestradiolferrous fumarate (TARINA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TILIA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TRI-LEGEST FE) 98norethindrone-ethinyl estradiol (ALYACEN) 98norethindrone-ethinyl estradiol (ARANELLE) 98norethindrone-ethinyl estradiol (BALZIVA) 98norethindrone-ethinyl estradiol (BRIELLYN) 98norethindrone-ethinyl estradiol (CYCLAFEM)98norethindrone-ethinyl estradiol (DASETTA) 98norethindrone-ethinyl estradiol (LEENA) 98norethindrone-ethinyl estradiol (NECON) 98norethindrone-ethinyl estradiol (NORTREL) 98norethindrone-ethinyl estradiol (PHILITH) 98norethindrone-ethinyl estradiol (PIRMELLA) 98norethindrone-ethinyl estradiol (VYFEMLA) 98norethindrone-ethinyl estradiol (WERA) 98
norethindrone-ethinyl estradiol (ZENCHENT) 98NORGESTIMATE-ETHINYL ESTRADIOL 100norgestimate-ethinyl estradiol 100norgestimate-ethinyl estradiol (ESTARYLLA) 98norgestimate-ethinyl estradiol (FEMYNOR) 99norgestimate-ethinyl estradiol (MILI) 99norgestimate-ethinyl estradiol (MONO-LINYAH) 99norgestimate-ethinyl estradiol(MONONESSA) 99norgestimate-ethinyl estradiol (PREVIFEM) 99norgestimate-ethinyl estradiol (SPRINTEC) 99norgestimate-ethinyl estradiol (TRIFEMYNOR) 99norgestimate-ethinyl estradiol (TRI-ESTARYLLA) 99norgestimate-ethinyl estradiol (TRI-LINYAH) 99norgestimate-ethinyl estradiol (TRI-LO-ESTARYLLA) 99norgestimate-ethinyl estradiol (TRI-LO-MARZIA) 99norgestimate-ethinyl estradiol (TRI-LO-MILI) 99norgestimate-ethinyl estradiol (TRI-LO-SPRINTEC) 99norgestimate-ethinyl estradiol (TRI-PREVIFEM) 99norgestimate-ethinyl estradiol (TRI-SPRINTEC) 99norgestimate-ethinyl estradiol (TRI-VYLIBRALO) 99norgestimate-ethinyl estradiol (TRI-VYLIBRA) 99norgestimate-ethinyl estradiol (TRINESSA LO)99norgestimate-ethinyl estradiol (TRINESSA) 99norgestimate-ethinyl estradiol (VYLIBRA) 99norgestrel-ethinyl estradiol (CRYSELLE) 100norgestrel-ethinyl estradiol (ELINEST) 100norgestrel-ethinyl estradiol (LOW-OGESTREL) 100norgestrel-ethinyl estradiol (OGESTREL) 100nortriptyline hcl 19NORVIR (ritonavir) 40
LAST UPDATED 12012020151
NOVOEIGHT (antihemophilic factor viiirecombinant b-domain truncated) 49NOVOLIN 70-30 (insulin nph humanisophaneinsulin regular human) 45NOVOLIN N (insulin nph human isophane) 45NOVOLIN R (insulin regular human) 45NOVOSEVEN RT (coagulation factor viia(recombinant)) 49NUPLAZID (pimavanserin tartrate) 32NUWIQ (antihemophilic factor viii rec hek cellb-domain deleted) 50NYSTATIN 23nystatin 23
OO-CAL PRENATAL (prenatal vit with calciumno127ferrous fumaratefolic acid) 70OBIZUR (antihemophilic factor viiirecombinant porcine sequence) 50ODEFSEY (emtricitabinerilpivirinehcltenofovir alafenamide fumarate) 37ofloxacin 13olanzapine 33olanzapinefluoxetine hcl 17OMEGA-3 ACID ETHYL ESTERS 60omega-3 acid ethyl esters 60omeprazole 85OMEPRAZOLE 85ondansetron 21ondansetron hcl 21ORAP (pimozide) 31oseltamivir phosphate 41OSELTAMIVIR PHOSPHATE 41OSMOLEX ER (amantadine hcl) 29oxazepam 42oxcarbazepine 16oxybutynin chloride 86OXYBUTYNIN CHLORIDE ER 86oxycodone hcl 46oxycodone hclacetaminophen 6oxycodone hclacetaminophen (ENDOCET) 6
oxycodone hclaspirin 6OXYTROL FOR WOMEN (oxybutynin) 86OYSTER SHELL CALCIUM 74OYSTER SHELL CALCIUM-VIT D3 74
PPAIN amp FEVER (acetaminophen) 64PAIN RELIEF 64paliperidone 33pantoprazole sodium 85PANTOPRAZOLE SODIUM 85PARNATE (tranylcypromine sulfate) 18paromomycin sulfate 9paroxetine hcl 18PEDIATRIC IRON 75pediatric multivit with acd3 no21sodiumfluoride 75pediatric multivitamin no16sodiumfluoride 75pediatric multivitamin no2sodium fluoride 75pediatric multivitamin no45sodiumfluorideferrous sulfate 75pediatric multivitamins no17 with sodiumfluoride 75peg 3350sod sulfsod bicarbsodchloridepotassium chloride 83peg 3350sod sulfsod bicarbsodchloridepotassium chloride (GAVILYTE-C) 83peg 3350sod sulfsod bicarbsodchloridepotassium chloride (GAVILYTE-G) 83PEG-3350 AND ELECTROLYTES 83PEGINTRON REDIPEN (peginterferon alfa-2b) 35PEN NEEDLE 111pen needle diabetic 111pen needle diabetic disposable safety 111pen needle diabetic remover and disposalunit 111pen needle diabetic safety 111penicillamine 86PENICILLAMINE 86
LAST UPDATED 12012020152
penicillin v potassium 12pentoxifylline 57PEPTO-BISMOL (bismuth subsalicylate) 79PEPTO-BISMOL TO-GO (bismuthsubsalicylate) 79permethrin 29permethrin (LICE TREATMENT) 29perphenazine 20PERSERIS (risperidone) 33PHENAZOPYRIDINE HCL 87phenazopyridine hcl 87phenazopyridine hcl (URINARY PAIN RELIEF) 86phenelzine sulfate 18phenobarbital 15PHENOBARBITAL 15PHENOXYBENZAMINE HCL 51phenoxybenzamine hcl 51phenylephrine hcl 113phenylephrine hclpromethazine hcl 129phenytoin 16phenytoin sodium extended 16PHOS-FLUR (fluoride (sodium)) 66PHOSPHOLINE IODIDE (echothiophateiodide) 115phytonadione (vit k1) 50PIFELTRO (doravirine) 37pilocarpine hcl 115PILOCARPINE HCL 115pimecrolimus 68pimozide 31pindolol 54pioglitazone hcl 43PIOGLITAZONE HCL 44piperonyl butoxidepyrethrins (LICE KILLING)68piperonyl butoxidepyrethrins (LICE PYRINYLSHAMPOO) 68piperonyl butoxidepyrethrins (LICETREATMENT) 68piperonyl butoxidepyrethrins (RID) 68piperonyl butoxidepyrethrinspermethrin(COMPLETE LICE TREATMENT) 69
piperonyl butoxidepyrethrinspermethrin(LICE SOLUTION) 69piroxicam 3PLAN B ONE-STEP (levonorgestrel) 102PLEGRIDY (peginterferon beta-1a) 66PLEGRIDY PEN (peginterferon beta-1a) 66PNEUMOVAX 23 (pneumococcal 23-valentpolysaccharide vaccine) 108podofilox 69POLY-VITAMIN (multivitamin) 75polyethylene glycol 3350 84polyethylene glycol 3350 (CLEARLAX) 83polyethylene glycol 3350 (GAVILAX) 84polyethylene glycol 3350 (GENTLELAX) 84polyethylene glycol 3350 (GLYCOLAX) 84polyethylene glycol 3350 (LAXACLEAR) 84polyethylene glycol 3350 (NATURA-LAX) 84polyethylene glycol 3350 (POWDERLAX) 84polyethylene glycol 3350 (PURELAX) 84polyethylene glycol 3350 (SMOOTHLAX) 84polymyxin b sulfatetrimethoprim 113POTASSIUM 75potassium bicarbonatecitric acid 75potassium bicarbonatecitric acid (EFFER-K)75potassium bicarbonatecitric acid (KEFFERVESCENT) 75potassium bicarbonatecitric acid (KLOR-CON-EF) 75POTASSIUM CHL-NORMAL SALINE 75potassium chloride 7075POTASSIUM CHLORIDE 71potassium chloride (KLOR-CON M10) 70potassium chloride (KLOR-CON M20) 70potassium chloride (KLOR-CON SPRINKLE) 75potassium chloride in 09 sodiumchloride 7071potassium chloridepotassiumbicarbonatecitric acid 75potassium gluconate 76pramipexole di-hcl 29pramoxine hclcalamine (CALAHIST) 69
LAST UPDATED 12012020153
pramoxine hclcalamine (CALAMINEMEDICATED) 69praziquantel 28prazosin hcl 51PRAZOSIN HCL 51PRED MILD (prednisolone acetate) 114prednisolone 90prednisolone (MILLIPRED DP) 90prednisolone (MILLIPRED) 90prednisolone acetate 114prednisolone sodium phosphate 90114prednisone 90prednisone (PREDNISONE INTENSOL) 90pregabalin 65PREGABALIN 65PREMARIN (estrogens conjugated) 100PREMPHASE (estrogensconjugatedmedroxyprogesteroneacetate) 100PREMPRO (estrogensconjugatedmedroxyprogesteroneacetate) 100PRENATABS FA (prenatal vits with calciumno78ferrous fumaratefolic acid) 71PRENATABS RX (prenatal vitamin with calciumno76ironcarbonylfolic acid) 71PRENATAL MULTIVITAMIN 76prenatal vit with calcium no129ferrousfumaratefolic acid 76prenatal vit with calcium no130ferrousfumaratefolic acid 76prenatal vitamins no121ferrousfumaratefolic acid 76prenatal vitamins with calciumferrousfumaratefolic acid 76prenatal vitamins with calciumferrousfumaratefolic acid (MYNATAL PLUS) 71prenatal vitamins with calciumferrousfumaratefolic acid (MYNATAL-Z) 71prenatal vits with calcium 118ferrousfumaratefolic acid 76
prenatal vits with calcium 118ferrousfumaratefolic acid (SE-NATAL 19) 71prenatal vits with calcium 136ferrousfumaratefolic acid (VINATE-M) 71prenatal vits with calcium 137ferrousfumaratefolic acid 76prenatal vits with calcium 95ferrousfumaratefolic acid 76prenatal vits with calcium no115ironfumaratefolic acid 71prenatal vits with calcium no72ferrousfumaratefolic acid 71prenatal vits with calcium no72ferrousfumaratefolic acid (M-NATAL PLUS) 71prenatal vits with calcium no72ferrousfumaratefolic acid (PREPLUS) 71prenatal vits with calciumno72ironcarbonylfolic acid 72prenatal vits with calcium no74ferrousfumaratefolic acid 72prenatal vits with calcium no96ferrousfumaratefolic acid 76PREVACID (lansoprazole) 85PREVNAR 13 (pneumococcal 13-valentconjugate vaccine (diphtheria crm)pf) 108PREZCOBIX (darunavirethanolatecobicistat) 40PREZISTA (darunavir ethanolate) 40PRIFTIN (rifapentine) 26primaquine phosphate 28primidone 15probenecid 24probenecidcolchicine 24PROBUPHINE (buprenorphine hcl) 7prochlorperazine 20prochlorperazine (COMPRO) 20prochlorperazine maleate 20PROCRIT (epoetin alfa) 47PROCTOFOAM-HC (hydrocortisoneacetatepramoxine hcl) 69
LAST UPDATED 12012020154
PROFILNINE (factor ix complex prothrombincplx conc(pcc) no4 3-factor) 50promethazine hcl 21122PROMETHAZINE HCL 122promethazine hcl (PHENADOZ) 21promethazine hcl (PROMETHEGAN) 21promethazine hclcodeine 129promethazine hcldextromethorphan hbr 129PROMETHAZINE-DM 129promethazinephenylephrine hclcodeine 129propafenone hcl 53propantheline bromide 77proparacaine hcl 113propranolol hcl 54propylthiouracil 104pseudoephedrine hcl 123pseudoephedrine hcl (NASALDECONGESTANT) 123pseudoephedrine hcl (SUDOGEST) 123pseudoephedrine hcl (SUPHEDRIN) 123pseudoephedrine hcl (SUPHEDRINE SINUSCONGESTION) 123pseudoephedrine hcl (SUPHEDRINE) 123pseudoephedrine hcl (WAL-PHED) 123PULMICORT FLEXHALER (budesonide) 117pyrazinamide 26pyridostigmine bromide 25pyridoxine hcl (vitamin b6) 76
Qquetiapine fumarate 33quinapril hcl 52quinidine gluconate 53quinidine sulfate 53QVAR REDIHALER (beclomethasonedipropionate) 117
RRABAVERT (rabies vaccine purified chickenembryo cell (pcec)pf) 108ramipril 52
RAMIPRIL 53REBINYN (factor ix (human) recombinantpegylated) 50RECOMBINATE (antihemophilic factor viiihuman recombinant) 50RECOMBIVAX HB (hepatitis b virus vaccinerecombinantpf) 108RELENZA (zanamivir) 41RESCRIPTOR (delavirdine mesylate) 37REXULTI (brexpiprazole) 33REYATAZ (atazanavir sulfate) 41RHEUMATREX (methotrexate sodium) 105RIASTAP (fibrinogen) 50ribavirin 36ribavirin (RIBASPHERE) 36RID (permethrin) 111RID (piperonylbutoxidepyrethrinspermethrin) 69RIDAURA (auranofin) 106rifabutin 26rifampin 26riluzole 65RILUZOLE 65ringers solution 7076RISPERDAL (risperidone) 33RISPERDAL CONSTA (risperidonemicrospheres) 33RISPERDAL M-TAB (risperidone) 33risperidone 33ritonavir 41RIXUBIS (factor ix human recombinant) 50rizatriptan benzoate 25ropinirole hcl 29rosuvastatin calcium 59RUKOBIA 39
Ssalsalate 3SANDIMMUNE (cyclosporine) 105SANTYL (collagenase clostridiumhistolyticum) 69
LAST UPDATED 12012020155
SAPHRIS (asenapine maleate) 33SAVELLA (milnacipran hcl) 65SE-NATAL-19 (prenatal vitamins no119ironfumaratefolic acid) 72SECUADO (asenapine) 33selegiline hcl 30selenium sulfide 69selenium sulfide (ANTI-DANDRUFF) 69selenium sulfide (MEDICATED DANDRUFFSHAMPOO) 69selenium sulfide (SELSUN BLUE) 69selenium sulfidealoe vera (SELSUN BLUEMOISTURIZING) 69SELZENTRY (maraviroc) 39SEREVENT DISKUS (salmeterol xinafoate) 123SEROQUEL (quetiapine fumarate) 34SEROQUEL XR (quetiapine fumarate) 34sertraline hcl 18sevelamer carbonate 87SEVENFACT 50SHINGRIX (varicella-zoster virus glycoproteinerecas01b adjuvantpf) 108SILACE (docusate sodium) 84sildenafil citrate 124SILDENAFIL CITRATE 124silver sulfadiazine 13simethicone 80simethicone (GAS RELIEF) 80simethicone (GAS-X) 80simethicone (INFANT GAS RELIEF) 80simethicone (INFANTS GAS RELIEF) 80simethicone (MI-ACID) 80simvastatin 59sirolimus 105SODIUM CHLORIDE 7677sodium chloride 113sodium chloride (MURO-128) 113sodium chloride for inhalation 129sodium chloride irrigating solution 707277sodium chloride irrigating solution (AQUACARE SODIUM CHLORIDE) 77
sodium chloride irrigating solution (CURITY) 77sodium chloridesodiumbicarbonatepotassium chloridepeg 84sodium chloridesodiumbicarbonatepotassium chloridepeg(GAVILYTE-N) 84sodium chloridesodiumbicarbonatepotassium chloridepeg (TRILYTEWITH FLAVOR PACKETS) 84sodium polystyrene sulfonate 72sodium polystyrene sulfonatesorbitol solution(KIONEX) 72sodiumpotassiumpotassium citratesodiumcitratecit ac 87sodiumpotassiumpotassium citratesodiumcitratecit ac (CYTRA-3) 87sodiumpotassiumpotassium citratesodiumcitratecit ac (TRICITRATES) 87sofosbuvirvelpatasvir 35SOTALOL 53SOTALOL AF 53sotalol hcl 53sotalol hcl (SORINE) 53spironolactone 58SPIRONOLACTONE 58spironolactonehydrochlorothiazide 57SPS (sodium polystyrene sulfonatesorbitolsolution) 72SSD (silver sulfadiazine) 13stavudine 38STOMACH RELIEF 80STOOL SOFTENER 84STOOL SOFTENER (docusate sodium) 84STRIBILD(elvitegravircobicistatemtricitabinetenofovir disoproxil) 36SUBLOCADE (buprenorphine) 4SUBOXONE (buprenorphine hclnaloxonehcl) 7sucralfate 85SUDAFED (pseudoephedrine hcl) 123
LAST UPDATED 12012020156
sulfacetamide sodium 13sulfacetamide sodiumprednisolone sodiumphosphate 113sulfamethoxazoletrimethoprim 13sulfasalazine 109SULFATRIM (sulfamethoxazoletrimethoprim)14sulindac 3SUMATRIPTAN 25sumatriptan 25sumatriptan succinate 25SUMATRIPTAN SUCCINATE 25SUSTIVA (efavirenz) 37SYMBYAX (olanzapinefluoxetine hcl) 18SYMFI (efavirenzlamivudinetenofovirdisoproxil fumarate) 36SYMFI LO (efavirenzlamivudinetenofovirdisoproxil fumarate) 37SYMTUZA (darunavirethcobicistatemtricitabinetenofoviralafenamide) 41SYNAREL (nafarelin acetate) 104SYNJARDY (empagliflozinmetformin hcl) 44SYNJARDY XR (empagliflozinmetformin hcl) 44SYNTHROID (levothyroxine sodium) 103syringe with needle insulin safety 1 ml 111syringe with needledisposableinsulin 1 ml 111syringe with needleinsulin03 ml 111syringe with needleinsulin05 ml 112
TTABLOID (thioguanine) 27tacrolimus 69106TACROLIMUS 106tadalafil 124tadalafil (ALYQ) 124TAKE ACTION (levonorgestrel) 102TAMOXIFEN CITRATE 27tamoxifen citrate 27tamsulosin hcl 86TDVAX (tetanus and diphtheria toxoidsadult) 108
TECFIDERA (dimethyl fumarate) 66TEGRETOL (carbamazepine) 16TEGRETOL XR (carbamazepine) 16temazepam 130TEMIXYS (lamivudinetenofovir disoproxilfumarate) 36temozolomide 27TENIVAC (tetanus and diphtheria toxoidsadsorbed adultpf) 108tenofovir disoproxil fumarate 38terazosin hcl 52TERAZOSIN HCL 52terbinafine hcl 24terbinafine hcl (ANTIFUNGAL) 24terbinafine hcl (ATHLETES FOOT AF) 24terbinafine hcl (ATHLETES FOOT) 24terbinafine hcl (JOCK ITCH) 2444terbinafine hcl (LAMISIL AT) 24TERBUTALINE SULFATE 123terbutaline sulfate 124testosterone 91testosterone cypionate 91tetanus and diphtheria toxoids adult 108THALOMID (thalidomide) 27THEO-24 (theophylline anhydrous) 124theophylline anhydrous 124theophylline anhydrous (THEOCHRON) 124thioridazine hcl 31thiothixene 31thyroidpork (NP THYROID) 103timolol maleate 115TIMOLOL MALEATE 115tioconazole 24TIVICAY (dolutegravir sodium) 36TIVICAY PD 36tizanidine hcl 35TOBRADEX (tobramycindexamethasone) 113tobramycin 9tobramycindexamethasone 113TOBREX (tobramycin) 9tolbutamide 44
LAST UPDATED 12012020157
tolmetin sodium 3tolnaftate 24tolnaftate (ANTIFUNGAL CREAM) 24tolnaftate (ATHLETES FOOT) 24tolnaftate (FUNGOID-D) 24topiramate 16TOPIRAMATE 16TOREMIFENE CITRATE 27toremifene citrate 27tramadol hcl 6TRAMADOL HCL 6trandolapril 53tranylcypromine sulfate 18TRAVEL SICKNESS (meclizine hcl) 21TRAZODONE HCL 19trazodone hcl 19tretinoin 28TRETTEN (factor xiii a-subunit recombinant) 50TRI-VI-SOL (vitamin a palmitateascorbicacidcholecalciferol (vit d3)) 77triamcinolone acetonide 6690117TRIAMCINOLONE ACETONIDE 66triamcinolone acetonide (ORALONE) 66triamterenehydrochlorothiazide 57triazolam 130trifluoperazine hcl 31trifluridine 41TRIGLIDE (fenofibrate nanocrystallized) 59trihexyphenidyl hcl 29trimethobenzamide hcl 21trimethoprim 10TRINATE (prenatal vits with calciumno73ferrous fumaratefolic acid) 72TRIPLE ANTIBIOTIC 11TRIPLE ANTIBIOTIC (neomycinsulfatebacitracin zincpolymyxin b) 11triprolidine hclpseudoephedrine hcl(APRODINE) 129triprolidine hclpseudoephedrine hcl (ED A-HIST PSE) 129
triprolidine hclpseudoephedrine hcl(RITIFED) 129triprolidine hclpseudoephedrine hcl (WAL-ACT D COLD amp ALLERGY) 129TRIUMEQ (abacavir sulfatedolutegravirsodiumlamivudine) 39TRIZIVIR (abacavirsulfatelamivudinezidovudine) 38TROGARZO (ibalizumab-uiyk) 39trospium chloride 86TROSPIUM CHLORIDE 86TRULICITY 44TRULICITY (dulaglutide) 44TRUMENBA (neisseria meningitidis group blipidated fhbp recombinant) 108TRUVADA (emtricitabinetenofovir disoproxilfumarate) 39TWINRIX (hepatitis a virus and hepatitis b virusvaccinepf) 108TYBOST (cobicistat) 39
UUNIFINE PENTIPS MAXFLOW 112UNITHROID (levothyroxine sodium) 103URETRON D-S (methenaminemethylenebluesod phospsalicylatehyoscyamine) 11URINARY PAIN RELIEF 87ursodiol 80
Vvalacyclovir hcl 41valproic acid 15VALPROIC ACID 15valproic acid (as sodium salt) (valproatesodium) 15valsartan 52valsartanhydrochlorothiazide 57VANADOM 130VANDAZOLE (metronidazole) 11VAQTA (hepatitis a virus vaccinepf) 109
LAST UPDATED 12012020158
VARIVAX VACCINE (varicella virus vaccinelivepf) 109VEMLIDY (tenofovir alafenamide) 35venlafaxine hcl 19VENLAFAXINE HCL ER 19verapamil hcl 55VERSACLOZ (clozapine) 35VICTOZA 2-PAK (liraglutide) 44VICTOZA 3-PAK (liraglutide) 44VIRACEPT (nelfinavir mesylate) 41VIRAMUNE (nevirapine) 38VIRAMUNE XR (nevirapine) 38VIREAD (tenofovir disoproxil fumarate) 39VITAMIN B-12 77VITAMIN C 77VITEKTA (elvitegravir) 36VIVITROL (naltrexone microspheres) 7VONVENDI (von willebrand factor(recombinant)) 50VRAYLAR (cariprazine hcl) 34
Wwarfarin sodium 46warfarin sodium (JANTOVEN) 46WILATE (antihemophilic factor humanvonwillebrand factorhuman) 50
XXARELTO (rivaroxaban) 4647XYNTHA (antihemophilic factor (factor viii)recombb-domain deleted) 51XYNTHA SOLOFUSE (antihemophilic factor(factor viii) recombb-domain deleted) 51
Zzaleplon 130ZERIT (stavudine) 39ZIAGEN (abacavir sulfate) 39ziprasidone hcl 34ZIPRASIDONE HCL 34ZIPRASIDONE MESYLATE 34
ziprasidone mesylate 34zolpidem tartrate 130zonisamide 14ZOSTAVAX (zoster vaccine livepf) 109ZOVIA 1-35 100ZUBSOLV (buprenorphine hclnaloxone hcl) 7ZYPREXA (olanzapine) 34ZYPREXA RELPREVV (olanzapine pamoate) 34ZYPREXA ZYDIS (olanzapine) 34
LAST UPDATED 12012020159
v
How often will the formulary change
The formulary may change monthly Some changes that can happen without notice include
bull When we remove a brand name drug if a generic is available
bull When we remove a drug taken off the market because the Food and Drug
Administration (FDA) has found it unsafe or if the manufacturer has removed it
bull When we add a drug to the formulary or if we remove a limit (like prior authorization or
step therapy)
Changes to formulary that we will notify you of at least 30 days before include
bull When we remove a drug or dosage form
bull When we add or change limits on the drug
What is a medical benefit drug
A medical benefit drug is a drug that usually is given as an injection or infusion in a medical
setting
What if my drug requires a prior authorization or step therapy
A prior authorization means that your doctor asks for approval for the drug because it is
medically necessary A step therapy means that you need to try certain drugs before we
cover your drug
You may ask for an exception by calling Customer Care at (800) 605-2556 (Los Angeles
County) or (855) 699-5557 (San Diego County) Or your doctor can call us at (877) 792-2731 or
fax at (866) 712-2731 to request that drug be covered
What if my drug is not on the Blue Shield of California Promise Health Plan Medi-
Cal Formulary
If your doctor gives you a drug that is not on the drug list you can ask your doctor for another
drug that is on formulary or you may request for us to cover the drug (exception) by calling
Customer Care at (800) 605-2556 (Los Angeles County) or (855) 699-5557 (San Diego County)
Your doctor can call us at (877) 792-2731 or fax at (866) 712-2731 to request that drug be
covered
You might now take a drug and your doctor still prescribes it If the drug is safe and effective
for your condition we will continue to cover it if we covered it before
vi
Participating retail pharmacies
You can fill prescriptions at any participating pharmacy (network pharmacy) unless it is for a
specialty drug You may find a network pharmacy by visiting
httpspromiseblueshieldcacomcapharmacysearchversion=2020amplob=mcal
What are specialty drugs
Specialty drugs require extra training before you take them extra visits with your doctor need
special handling and transport and are usually high-cost These drugs may require prior
authorization or non-formulary exception If approved a network specialty pharmacy will
deliver them by mail Please visit wwwblueshieldcacompromisemedi-cal for more
information
What if I have additional questions
If you want a copy of the Blue Shield of California Promise Health Plan Medi-Cal Formulary or
have questions please call Customer Care at (800) 605-2556 (Los Angeles County) or (855)
699-5557 (San Diego County)
Blue Shield of California Promise Health Plan
601 Potrero Grande Drive Monterey Park CA 91755
vii
H5928_19_269A2_C 08302019
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91
8)
Discrimination is Against the Law
Blue Shield of California Promise Health Plan complies with applicable state laws and federal civil rights laws and does not discriminate on the basis of race color national origin ancestry religion sex marital status gender gender identity sexual orientation age or disability Blue Shield of California Promise Health Plan does not exclude people or treat them differently because of race color national origin ancestry religion sex marital status gender gender identity sexual orientation age or disability
Blue Shield of California Promise Health Plan provides bull Aids and services at no cost to people with disabilities to communicate effectively with us
such aso Qualified sign language interpreterso Written information in other formats (large print audio accessible electronic
formats other formats)bull Language services at no cost to people whose primary language is not English such as
o Qualified interpreterso Information written in other languages
If you need these services contact the Blue Shield of California Promise Health Plan Civil Rights Coordinator
If you believe that Blue Shield of California Promise Health Plan has failed to provide these
services or discriminated in another way on the basis of race color national origin
ancestry religion sex marital status gender gender identity sexual orientation age or
disability you can file a grievance with
Blue Shield of California Promise Health Plan
Civil Rights Coordinator
601 Potrero Grande Dr
Monterey Park CA 91755
Phone (844) 883-2233 (TTY 711)
Fax (323) 889-2228
Email BSCPHPCivilRightsblueshieldcacom
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 Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD)
Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language Assistance Notice for LA County
viii
English
ATTENTION Language assistance services free of charge are available to you Call 1-800-605-
2556 (TTY 711)
繁體中文 (Chinese)
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1-800-605-2556(TTY
711)
한국어 (Korean)
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-800-
605-2556 (TTY 711)번으로 전화해 주십시오
Русский (Russian)
ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги
перевода Звоните 1-800-605-2556 (телетайп 711)
Kreyogravel Ayisyen (Haitian-Creole)
ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele 1-
800-605-2556 (TTY 711)
Franccedilais (French)
ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes
gratuitement Appelez le 1-800-605-2556 (TTY 711)
Portuguecircs (Portuguese)
ATENCcedilAtildeO Se fala portuguecircs encontram-se disponiacuteveis serviccedilos linguiacutesticos graacutetis Ligue para 1-
800-605-2556 (TTY 711)
Italiano (Italian)
ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza
linguistica gratuiti Chiamare il numero 1-800-605-2556 (TTY 711)
(Farsi) فارسی
2556-605-800-1 با باشد می فراهم شما برای رایگان بصورت زبانی تسهیلات کنید می گفتگو فارسی زبان به اگر توجه
(TTY 771) بگیرید تماس
ह िदी (Hindi)
धयान द यदद आप द िदी बोलत तो आपक ललए मफत म भाषा स ायता सवाएि उपलबध 1-800-605-
2556 (TTY 711) पर कॉल करHmong (Hmong)
LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb rau koj Hu rau
1-800-605-2556 (TTY 711)
Espantildeol (Spanish)
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica
Llame al 1-800-605-2556 (TTY 711)
Language Assistance Notice for LA County (Continued)
ix
Tiếng Việt (Vietnamese)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-
800-605-2556 (TTY 711)
Tagalog (Tagalog - Filipino)
PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa
wika nang walang bayad Tumawag sa 1-800-605-2556 (TTY 711)
(Arabic) العربية
2556-605-800-1مجان اتصل برقم ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بال
(711YTT)
Polski (Polish)
UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń
pod numer 1-800-605-2556 (TTY 711)
ພາສາລາວ (Lao)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ ໂທຣ 1-800-605-2556 (TTY 711)
日本語 (Japanese)
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1-800-605-
2556(TTY711)までお電話にてご連絡ください
ภาษาไทย (Thai)
เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-800-605-2556 (TTY 711)
λληνικά (Greek)
ΠΡΟΣΟΧΗ Αν μιλάτε ελληνικά στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης
οι οποίες παρέχονται δωρεάν Καλέστε 1-800-605-2556 (TTY 711)
ਪਜਾਬੀ ਦ (Punjabi)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-800-605-
2556 (TTY 711) ਤ ਕਾਲ ਕਰ
ខមែរ (Cambodian)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល
គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-800-605-2556 (TTY 711)
Հայերեն (Armenian)
ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող են
տրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք 1-800-605-2556
(TTY (հեռատիպ)711)
Language Assistance Notice for San Diego County
x
English
ATTENTION Language assistance services free of charge are available to you
Call 1-855-699-5557 (TTY 711)
繁體中文 (Chinese)
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1-855-699-5557(TTY
711)
한국어 (Korean)
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-855-
699-5557 (TTY 711)번으로 전화해 주십시오
Русский (Russian)
ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные
услуги перевода Звоните 1-855-699-5557 (телетайп 711)
Italiano (Italian)
ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di
assistenza linguistica gratuiti Chiamare il numero 1-855-699-5557 (TTY 711)
(Farsi) فارسی
-699-855-1 با باشد می فراهم شما برای رایگان بصورت زبانی تسهیلات کنید می گفتگو فارسی زبان به اگر توجه
5557 (TTY 771) بگیرید تماس
ह िदी (Hindi)
धयान द यदद आप द िदी बोलत तो आपक ललए मफत म भाषा स ायता सवाएि उपलबध 1-855-699-
5557 (TTY 711) पर कॉल कर
Hmong (Hmong)
LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb
rau koj Hu rau 1-855-699-5557 (TTY 711)
Espantildeol (Spanish)
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia
linguumliacutestica Llame al 1-855-699-5557 (TTY 711)
Tiếng Việt (Vietnamese)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho
bạn Gọi số 1-855-699-5557 (TTY 711)
Tagalog (Tagalog - Filipino)
PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga
serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-855-699-5557 (TTY
711)
Language Assistance Notice for San Diego County (Continued)
xi
(Arabic) العربية
5557-699-855-1 برقم اتصل بالمجان لك تتوافر اللغویة المساعدة خدمات فإن اللغة اذكر تتحدث كنت إذا ملحوظة
(711YTT)
ພາສາລາວ (Lao)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ ໂທຣ 1-855-699-5557 (TTY 711)
日本語 (Japanese)
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1-855-699-
5557(TTY711)までお電話にてご連絡ください
ภาษาไทย (Thai)
เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-855-699-5557 (TTY 711)
ਪਜਾਬੀ ਦ (Punjabi)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-855-
699-5557 (TTY 711) ਤ ਕਾਲ ਕਰ
ខមែរ (Cambodian)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល
គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-855-699-5557 (TTY 711)
Հայերեն (Armenian)
ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող են
տրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք 1-855-699-
5557 (TTY (հեռատիպ)711)
Categorical List of Prescription DrugsANALGESICS (Drugs for Pain) 1
ANESTHETICS (Drugs for Numbing) 6
ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS (Drugs for AddictionSubstance Abuse) 6
ANTIBACTERIALS (Drugs for Bacterial Infections) 8
ANTICONVULSANTS (Drugs for Seizures) 14
ANTIDEMENTIA AGENTS (Drugs for Alzheimers Disease and Dementia) 17
ANTIDEPRESSANTS (Drugs for Depression) 17
ANTIEMETICS (Drugs for Nausea and Vomiting) 20
ANTIFUNGALS (Drugs for Fungal Infections) 21
ANTIGOUT AGENTS (Drugs for Gout) 24
ANTIMIGRAINE AGENTS (Drugs for Migraine) 25
ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis) 25
ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections) 26
ANTINEOPLASTICS (Drugs for Cancer) 26
ANTIPARASITICS (Drugs for Parasitic Infections) 28
ANTIPARKINSON AGENTS (Drugs for Parkinsons Disease) 29
ANTIPSYCHOTICS (Drugs for Mental Health) 30
ANTISPASTICITY AGENTS (Drugs for Muscle Spasm) 35
ANTIVIRALS (Drugs for Viral Infections) 35
ANXIOLYTICS (Drugs for Anxiety) 41
BIPOLAR AGENTS (Drugs for Bipolar Disorder) 42
BLOOD GLUCOSE REGULATORS (Drugs for Diabetes) 42
BLOOD PRODUCTSMODIFIERSVOLUME EXPANDERS (Drugs for Blood Disorders) 46
CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation) 51
CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions) 61
DENTAL AND ORAL AGENTS (Drugs for the Mouth) 66
DERMATOLOGICAL AGENTS (Drugs for the Skin) 66
ELECTROLYTESMINERALSMETALSVITAMINS 69
GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach) 77
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERS TREATMENT (Drugs for Genetic or
Enzyme Disorders) 85
GENITOURINARY AGENTS (Drugs for the Genital Bladder and Kidney) 86
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (ADRENAL) (Drugs for
ReplacingStimulating Adrenal Gland Hormones) 87
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (PITUITARY) (Drugs for
ReplacingStimulating Pituitary Gland Hormones) 90
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEX HORMONESMODIFIERS) (Drugs
for ReplacingStimulating Sex Hormones) 91
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (THYROID) (Drugs for the Thyroid) 102
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs for Suppressing Hormones from the Pituitary
Gland) 104
HORMONAL AGENTS SUPPRESSANT (THYROID) (Drugs for the Thyroid) 104
LAST UPDATED 12012020
IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing the Immune System) 104
INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for Inflammatory Bowel Disease) 109
METABOLIC BONE DISEASE AGENTS (Drugs for the Bone) 109
MISCELLANEOUS THERAPEUTIC AGENTS 110
OPHTHALMIC AGENTS (Drugs for the Eyes) 112
OTIC AGENTS (Drugs for the Ears) 116
RESPIRATORY TRACTPULMONARY AGENTS (Drugs for the Lungs) 116
SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles) 130
SLEEP DISORDER AGENTS (Drugs for Insomnia) 130
LAST UPDATED 12012020
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANALGESICS (Drugs for Pain)
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (Pain and ArthritisDrugs)
aspirin (ADULT ASPIRIN REGIMEN)81 mg tablet dr
1-Covered
aspirin (ADULT LOW DOSE ASPIRINEC) 81 mg tablet dr
1-Covered
aspirin (ASPIR 81) mg tablet dr ) 1-Covered
aspirin (ASPIR-TRIN) 325 mg tabletdr -
1-Covered
aspirin (ASPIRIN) 325 mg tablet 1-Covered
aspirin (ECOTRIN) 81 mg tablet dr 1-Covered
aspirin (ECPIRIN) 325 mg tablet dr 1-Covered
aspirin (ST JOSEPH ASPIRIN EC) 81mg tablet dr
1-Covered
aspirin (ST JOSEPH ASPIRIN) 81 mgtab chew
1-Covered
aspirin 325mg tablet 1-Covered
aspirin 81 mg tab chew 81 mgtablet dr 325 mg tablet
1-Covered
ASPIRIN 81MG TABLET ASPIRIN81MG TABLET ASPIRIN 81MGTABLET
1-Covered
aspirinacetaminophencaffeine(ADDED STRENGTH HEADACHE)250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(BAYER MIGRAINE) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(EXTRA PAIN RELIEF) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(EXTRAPRIN) 250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(HEADACHE RELIEF) 250-250-65tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
1
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
aspirinacetaminophencaffeine(MIGRAINE FORMULA) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(MIGRAINE RELIEF) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(PAIN RELIEVER PLUS) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(PAIN RELIEVER) 250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(PAIN-OFF) 250-250-65 tablet -
1-Covered
butalbitalaspirincaffeine 50-325-40 capsule
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
butalbitalaspirincaffeine 50-325-40 tablet
1-Covered
celecoxib 50 mg capsule 100 mgcapsule 200 mg capsule 400 mgcapsule
1-Covered ST
CELECOXIB 50 MG CAPSULE 100MG CAPSULE 200 MG CAPSULE400 MG CAPSULE
1-Covered ST
CHILDRENS IBUPROFEN CHILD 200MG10 ML CHILDREN 100 MG5 ML
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
diclofenac sodium 25 mg tablet dr50 mg tablet dr 75 mg tablet dr100 mg tab er 24h
1-Covered
diflunisal 500 mg tablet 1-Covered
etodolac 600 mg tab er 24h 1-Covered PA
EXCEDRIN EXTRA STRENGTH(aspirinacetaminophencaffeine)CAPLET
1-Covered
EXCEDRIN MIGRAINE(aspirinacetaminophencaffeine)CAPLET GELTAB
1-Covered
flurbiprofen 50 mg tablet 100 mgtablet
1-Covered
HEADACHE RELIEF HM 250-250-65MG CPLT
1-Covered
ibuprofen (ADDAPRIN) 200 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
2
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ibuprofen (I-PRIN) 200 mg tablet - 1-Covered
ibuprofen (IBU) 400 mg tablet 600mg tablet 800 mg tablet
1-Covered
ibuprofen (IBU-200) mg tablet -) 1-Covered
ibuprofen (PROVIL) 200 mg tablet 1-Covered
ibuprofen (WAL-PROFEN) 200 mgtablet -
1-Covered
ibuprofen 100 mg5ml oral susp 1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
IBUPROFEN 400 MG TABLET 600 MGTABLET 800 MG TABLET
1-Covered
ibuprofen 50 mg125 drops susp100 mg tab chew 200 mg tablet400 mg tablet 600 mg tablet 800mg tablet
1-Covered
indomethacin 25 mg capsule 50mg capsule 75 mg capsule er
1-Covered
ketoprofen 50 mg capsule 75 mgcapsule
1-Covered
meloxicam 75 mg tablet 15 mgtablet
1-Covered
naproxen 250 mg tablet 375 mgtablet 500 mg tablet
1-Covered
naproxen sodium 275 mg tablet550 mg tablet
1-Covered
piroxicam 10 mg capsule 20 mgcapsule
1-Covered
salsalate 500 mg tablet 750 mgtablet
1-Covered
sulindac 150 mg tablet 200 mgtablet
1-Covered
tolmetin sodium 200 mg tablet 400mg capsule 600 mg tablet
1-Covered
OPIOID ANALGESICS LONG-ACTING (Long-acting Narcotic PainRelievers)
BELBUCA (buprenorphine hcl) 75MCG FILM 150 MCG FILM 300MCG FILM 450 MCG FILM 600MCG FILM 750 MCG FILM 900MCG FILM
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
3
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
buprenorphine 5 mcghr patch75 mcghr patch 10 mcghrpatch 15 mcghr patch 20mcghr patch
2-MedicalCarve out
BUTRANS (buprenorphine) 5MCGHR PATCH 75 MCGHRPATCH 10 MCGHR PATCH 15MCGHR PATCH 20 MCGHRPATCH
2-MedicalCarve out
fentanyl 25 mcghr patch50mcghr patch 75mcghr patch100 mcghr patch
1-Covered PA QL (10 PER 30 DAY(S))
methadone hcl (METHADONEINTENSOL) 10 mgml oral conc
1-Covered PA
methadone hcl (METHADOSE) 40mg tablet sol
1-Covered PA
METHADONE HCL 10 MG TABLET 1-Covered QL (60 PER 30 DAYS)
METHADONE HCL 10 MGML ORALCONC
1-Covered PA
methadone hcl 5 mg tablet 10 mgtablet
1-Covered QL (60 PER 30 DAYS)
methadone hcl 5 mg5 ml solution10 mg5 ml solution 10 mgml oralconc
1-Covered PA
morphine sulfate 15 mg tablet er 1-Covered QL (90 PER 30 DAYS)
morphine sulfate 30 mg tablet er 1-Covered QL (60 PER 30 DAYS)
morphine sulfate 60 mg tablet er100 mg tablet er 200 mg tablet er
1-Covered PA
oxycodone hcl 10 mg tab er 20mg tab er 40 mg tab er 80 mgtab er
1-Covered PA QL (60 PER 30 DAYS)
SUBLOCADE (buprenorphine) 100MG05 ML SYRING 300 MG15 MLSYRING
2-MedicalCarve out
OPIOID ANALGESICS SHORT-ACTING (Short-acting Narcotic PainRelievers)
acetaminophen with codeinephosphate -15mg tablet -30mgtablet -60mg tablet
1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old) QLC (LIMIT 100TABS TOTAL APAPCODEINETABLETS PER MONTH)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
4
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acetaminophen with codeinephosphate 120-12mg5 solution
1-Covered QL (240 PER 30 DAYS) AL1 (Atleast 12 yrs old)
butorphanol tartrate 10 mgmlspray
1-Covered PA
codeinephosphatebutalbitalaspirincaffeine codeinebutalbitalasacaffein30-50-325 capsule
1-Covered QL (60 PER 30 DAYS) AL1 (At least12 yrs old)
codeine sulfate 15 mg tablet 30mg tablet 60 mg tablet
1-Covered PA AL1 (At least 12 yrs old)
hydrocodonebitartrateacetaminophen(LORCET HD)hydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAY(S))
hydrocodonebitartrateacetaminophen(LORTAB)hydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAY(S))
hydrocodonebitartrateacetaminophenhydrocodoneacetaminophen 5mg-325mg tablethydrocodoneacetaminophen75-325 mg tablethydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS OF HYDROCODONEPRODUCTS PER 30 DAYS)
hydromorphone hcl 1 mgml liquid3 mg supprect
1-Covered
hydromorphone hcl 2 mg tablet 4mg tablet 8 mg tablet
1-Covered QL (60 PER 30 DAYS)
meperidine hcl 50 mg tablet 100mg tablet
1-Covered QL (100 PER 30 DAYS)
morphine sulfate 10 mg5 ml 20mg5 ml 100 mg5ml
1-Covered PA
morphine sulfate 15 mg tablet 30mg tablet
1-Covered QL (90 PER 30 DAYS)
morphine sulfate 30 mg supprect 1-Covered QL (24 PER 30 DAY(S)) QLC (LIMIT24 SUPPOSITORIES IN 30 DAYS)
morphine sulfate 5 mg 10 mg 20mg
1-Covered QL (24 PER 30 DAY(S)) QLC (LIMIT24 SUPPOSITORIES IN 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
5
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
oxycodone hcl 5 mg capsule 5mg tablet 5 mg5 ml solution 15mg tablet 20 mgml oral conc 30mg tablet
1-Covered PA
oxycodone hclacetaminophen(ENDOCET) 5 mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS PER 30 DAYS OF TOTALOXYCODONE APAP ANDOXYCODONE ASA PER MONTH)
oxycodone hclacetaminophen 5mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS PER 30 DAYS OF TOTALOXYCODONE APAP ANDOXYCODONE ASA PER MONTH)
oxycodone hclacetaminophen 5-3255 ml solution
1-Covered PA
oxycodone hclaspirin 48355-325tablet
1-Covered QL (100 PER 30 DAY(S))
tramadol hcl 50 mg tablet 1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old)
TRAMADOL HCL 50 MG TABLET 1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old)
ANESTHETICS (Drugs for Numbing)
LOCAL ANESTHETICS (Skin Numbing Drugs)lidocaine hcl 10 mgml vial 1-Covered PA
lidocaine hcl 2 solution 1-Covered
LIDOCAINE HCL VISCOUS 2 SOLN 1-Covered
lidocaine hclpf 10 mgml vial 10mgml ampul
1-Covered PA
ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS (Drugs forAddictionSubstance Abuse)
ALCOHOL DETERRENTSANTI-CRAVING (Drugs for AlcoholDependence)
acamprosate calcium 333 mgtablet dr
2-MedicalCarve out
disulfiram 250 mg tablet 500 mgtablet
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
6
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
naltrexone hcl 50 mg tablet 2-MedicalCarve out
NALTREXONE HCL 50 MG TABLET 2-MedicalCarve out
VIVITROL (naltrexonemicrospheres) 380 MG VIAL +DILUENT
2-MedicalCarve out
OPIOID DEPENDENCE TREATMENTS (Drugs for Opioid Dependence)BUNAVAIL (buprenorphinehclnaloxone hcl) 21-03 MG FILM42-07 MG FILM 63-1 MG FILM
2-MedicalCarve out
BUPRENEX (buprenorphine hcl) 03MGML AMPUL
2-MedicalCarve out
buprenorphine hcl 03 mgml vial03 mgml cartridge 2 mg tab subl8 mg tab subl
2-MedicalCarve out
buprenorphine hclnaloxone hclnaloxone 2 mg-05mg filmnaloxone 2 mg-05mg tab sublnaloxone 4mg-1mg filmnaloxone 8 mg-2 mg filmnaloxone 8 mg-2 mg tab subl
2-MedicalCarve out
LUCEMYRA (lofexidine hcl) 018 MGTABLET
2-MedicalCarve out
PROBUPHINE (buprenorphine hcl)742 MG IMPLANT
2-MedicalCarve out
SUBOXONE (buprenorphinehclnaloxone hcl) 2 MG-05 MGFILM 4 MG-1 MG FILM 8 MG-2 MGFILM 12 MG-3 MG FILM
2-MedicalCarve out
ZUBSOLV (buprenorphinehclnaloxone hcl) 07-018 MGTABLET 14-036 MG TABLET 29-071 MG TABLET 57-14 MG TABLET86-21 MG TABLET 114-29 MGTABLET
2-MedicalCarve out
OPIOID REVERSAL AGENTS (Drugs for Opioid Overdose)EVZIO (naloxone hcl) 04 MGAUTO- 2 MG AUTO-
2-MedicalCarve out
naloxone hcl 04 mgml cartridge04 mgml vial 1 mgml syringe 2mg04ml auto injct
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
7
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NARCAN (naloxone hcl) 4 MGNASAL SPRAY
2-MedicalCarve out
SMOKING CESSATION AGENTS (Drugs to Help Quit Smoking)bupropion hcl (BUPROBAN) 150 mgtab er 12h
1-Covered QL (2 PER 1 DAY(S))
bupropion hcl 150 mg tab er 12h 1-Covered QL (2 PER 1 DAY(S))
CHANTIX (varenicline tartrate) 05MG TABLET 1 MG TABLET 1 MGCONT MONTH BOX STARTINGMONTH BOX
1-Covered PA
nicotine 14mg patch 1-Covered QL (1 PER 1 DAY(S))
nicotine 21mg patch 1-Covered QL (1 PER 1 DAY(S))
nicotine 2mg gum 1-Covered QL (24 PER 1 DAY(S))
nicotine 4mg gum 1-Covered QL (24 PER 1 DAY(S))
nicotine 7mg patch 1-Covered QL (1 PER 1 DAY(S))
NICOTINE LOZENGE 2 MGLOZENGE HM 2 MG LOZENGE 4MG LOZENGE HM 4 MG LOZENGE
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (QUIT 2) mglozenge )
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (QUIT 4) mglozenge )
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (STOP SMOKINGAID) 2 mg 4 mg
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex 2 mg 4 mg 1-Covered QL (24 PER 1 DAY(S))
NICOTROL (nicotine) CARTRIDGEINHALER
1-Covered PA
NICOTROL NS (nicotine) 10 MGMLSPRAY
1-Covered PA
ANTIBACTERIALS (Drugs for Bacterial Infections)
AMINOGLYCOSIDESgentamicin sulfate (GENTAK) 03 oint (g)
1-Covered
gentamicin sulfate 01 oint (g)01 cream (g) 03 oint (g) 03 drops
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
8
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GENTAMICIN SULFATE 01 CREAM 1-Covered
neomycin sulfate 500 mg tablet 1-Covered
paromomycin sulfate 250 mgcapsule
1-Covered
tobramycin 03 drops 1-Covered
TOBREX (tobramycin) 03 EYEOINTMENT
1-Covered
ANTIBACTERIALS OTHERbacitracin (BACITRAYCIN PLUS) 500unitg oint (g)
1-Covered
bacitracin 500 unitg packet 500unitg oint (g)
1-Covered
BACITRACIN 500 UNITGM OINTMNT 1-Covered
bacitracin zinc (ANTIBIOTIC) 500unitg oint (g)
1-Covered
bacitracin zinc 500 unitg ointpack 500 unitg oint (g)
1-Covered
BACITRACIN ZINC ZN 500 UNITGMOINT
1-Covered
CLEOCIN (clindamycin phosphate)100 MG VAGINAL OVULE
1-Covered
clindamycin hcl 75 mg capsule150 mg capsule 300 mg capsule
1-Covered
clindamycin palmitate hcl 75 mg5ml soln recon
1-Covered
clindamycin phosphate 1 gel(gram) 1 lotion 1 med swab1 solution 1 gel daily 2 creamappl
1-Covered
CLINDAMYCIN PHOSPHATE 1SOLUTION 1 GEL
1-Covered
erythromycin basebenzoylperoxide erythromycinbenzoyl 3-5 gel (gram)
1-Covered ST
methenaminemethylenebluesodphospsalicylatehyoscyamine(PHOSPHASAL) methmebluesodphospsalhyos 816-108 tablet
1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
9
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
methenaminemethylenebluesodphospsalicylatehyoscyamine(URIN DS) methmebluesodphospsalhyos 816-108 tablet
1-Covered PA
METRO IV (metronidazole in sodiumchloride) 500 MG100 ML
1-Covered
metronidazole 075 gel wappl250 mg tablet 375 mg capsule500 mg tablet
1-Covered
METRONIDAZOLE 250 MG TABLET500 MG TABLET
1-Covered
metronidazole in sodium chloridemetronidazolesodium 500mg01lpiggyback
1-Covered PA
mupirocin 2 oint (g) 1-Covered QL (22 PER 30 DAY(S))
mupirocin calcium 2 cream (g) 1-Covered PA
neomycin sulfatebacitracinzincpolymyxin b (ANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
neomycin sulfatebacitracinzincpolymyxin b (FIRST AIDANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
neomycin sulfatebacitracinzincpolymyxin b (TRIPLEANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
nitrofurantoin 25 mg5 ml oral susp 1-Covered
NITROFURANTOIN 50 MG CAP 100MG CAP
1-Covered
nitrofurantoin macrocrystal 50 mgcapsule 100 mg capsule
1-Covered
nitrofurantoinmonohydratemacrocrystalsmonohydm-100 mg capsule
1-Covered
trimethoprim 100 mg tablet 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
10
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRIPLE ANTIBIOTIC (neomycinsulfatebacitracin zincpolymyxinb) CURAD OINT MEDI-FIRSTMEDICHOICE OINTMENTOINTMENT PKT
1-Covered
TRIPLE ANTIBIOTIC HM PKT 1-Covered
URETRON D-S(methenaminemethylenebluesodphospsalicylatehyoscyamine) -TABLET
1-Covered PA
VANDAZOLE (metronidazole)VAGINAL 075 GEL
1-Covered
BETA-LACTAM CEPHALOSPORINScefaclor 125 mg5ml susp recon250 mg5ml susp recon 250 mgcapsule 375 mg5ml susp recon500 mg capsule
1-Covered
CEFDINIR 125 MG5 ML SUSP 250MG5 ML SUSP
1-Covered QL (200 PER 10 DAY(S))
cefdinir 125 mg5ml 250 mg5ml 1-Covered QL (200 PER 10 DAY(S))
cefdinir 300 mg capsule 1-Covered QL (20 PER 10 DAY(S))
cephalexin 125 mg5ml susprecon 250 mg capsule 250mg5ml susp recon 500 mgcapsule
1-Covered
BETA-LACTAM PENICILLINSamoxicillin 125 mg5ml susp recon125 mg tab chew 200 mg5mlsusp recon 250 mg tab chew 250mg5ml susp recon 250 mgcapsule 400 mg5ml susp recon500 mg tablet 500 mg capsule875 mg tablet
1-Covered
AMOXICILLIN-CLAVULANATEPOTASS -600-429 MG5 ML SUS
1-Covered QL (300 PER FILL) QLC (1 FILL IN 30DAYS)
AMOXICILLIN-CLAVULANATEPOTASS -875-125 MG TABLET
1-Covered
amoxicillinpotassium clavulanate1000-625 tab er 12h
1-Covered QL (40 PER FILL(S)) MFL (1 30day(s))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
11
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
amoxicillinpotassium clavulanate200-2855 susp recon 200-285mgtab chew 250-125 mg tablet 400-57mg5 susp recon 400-57mg tabchew 500-125 mg tablet 875-125mg tablet
1-Covered
amoxicillinpotassium clavulanate600-4295 susp recon
1-Covered QL (300 PER FILL) QLC (1 FILL IN 30DAYS)
ampicillin trihydrate 125 mg5mlsusp recon 250 mg capsule 250mg5ml susp recon 500 mgcapsule
1-Covered
dicloxacillin sodium 250 mgcapsule 500 mg capsule
1-Covered
penicillin v potassium 125 mg5mlsoln recon 250 mg5ml soln recon250 mg tablet 500 mg tablet
1-Covered
MACROLIDESazithromycin 1 g packet 1-Covered QL (1 PER 30 DAYS)
azithromycin 100 mg5ml 200mg5ml
1-Covered
AZITHROMYCIN 200 MG5 ML SUSP 1-Covered
azithromycin 250 mg tablet 1-Covered QL (6 PER FILL(S)) MFL (2 30day(s))
AZITHROMYCIN 250 MG TABLET 1-Covered QL (6 PER FILL(S)) MFL (2 30day(s))
azithromycin 500 mg tablet 1-Covered QL (3 PER FILL(S)) MFL (2 30day(s))
AZITHROMYCIN 500 MG TABLET 1-Covered QL (3 PER FILL(S)) MFL (2 30day(s))
azithromycin 600 mg tablet 1-Covered QL (2 PER 7 DAY(S)) MFL (8 28day(s))
clarithromycin 500 mg tablet 1-Covered ST
EES 200 (erythromycinethylsuccinate) MG5 MLSUSPENSION
1-Covered
EES 400 (erythromycinethylsuccinate) FILMTAB
1-Covered
ERYTHROCIN STEARATE(erythromycin stearate) 250 MGFILMTAB
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
12
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ERYTHROMYCIN 250 MG 500 MG 1-Covered
erythromycin base 5 mggramoint (g) 250 mg capsule dr 250mg tablet dr 250 mg tablet 333mg tablet dr 500 mg tablet 500mg tablet dr
1-Covered
erythromycin base in ethanol (ERY)2 med swab
1-Covered
erythromycin base in ethanol 2 solution 2 med swab
1-Covered
ERYTHROMYCIN ETHYLSUCCINATE200 MG5 ML SUSP
1-Covered
erythromycin ethylsuccinate 200mg5ml susp recon 400 mg tablet
1-Covered
QUINOLONESCILOXAN (ciprofloxacin hcl) 03OINTMENT
1-Covered
ciprofloxacin hcl 03 drops 1-Covered
ciprofloxacin hcl 100 mg tablet 1-Covered PA AL1 (At least 18 yrs old)
ciprofloxacin hcl 250 mg tablet500 mg tablet 750 mg tablet
1-Covered AL1 (At least 18 yrs old)
CIPROFLOXACIN HCL 500 MG TAB 1-Covered AL1 (At least 18 yrs old)
levofloxacin 250 mg tablet 500 mgtablet 750 mg tablet
1-Covered AL1 (At least 18 yrs old)
moxifloxacin hcl 400 mg tablet 1-Covered PA AL1 (At least 18 yrs old)
ofloxacin 03 drops 1-Covered QL (5 PER 30 DAY(S))
SULFONAMIDESBLEPH-10 (sulfacetamide sodium) - EYE DROPS
1-Covered
silver sulfadiazine 1 cream (g) 1-Covered
SSD (silver sulfadiazine) 1 CREAM 1-Covered
sulfacetamide sodium 10 oint(g) 10 drops
1-Covered
sulfamethoxazoletrimethoprim200-40mg5 oral susp 400mg-80mgtablet 800-16020 oral susp 800-160 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
13
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SULFATRIM(sulfamethoxazoletrimethoprim)PEDIATRIC SUSPENSION
1-Covered
TETRACYCLINESDOXYCYCLINE HYCLATE 100 MGCAP
1-Covered AL1 (At least 8 yrs old)
doxycycline hyclate 100 mgcapsule
1-Covered AL1 (At least 8 yrs old)
DOXYCYCLINE HYCLATE 20 MG TAB 1-Covered QL (60 PER 30 DAYS)
doxycycline hyclate 20 mg tablet 1-Covered QL (60 PER 30 DAYS)
doxycycline monohydrate 50 mgcapsule 100 mg capsule
1-Covered AL1 (At least 8 yrs old)
minocycline hcl 50 mg capsule100 mg capsule
1-Covered
ANTICONVULSANTS (Drugs for Seizures)
ANTICONVULSANTS OTHER (Other Seizure Control Drugs)LEVETIRACETAM 100 MGML SOLN250 MG TABLET 500 MG5 ML SOLN
1-Covered
levetiracetam 100 mgml solution250 mg tablet 500 mg tablet 500mg5ml solution 750 mg tablet1000 mg tablet
1-Covered
levetiracetam 500 mg tab er 24h 1-Covered MDD (6 Per Day)
levetiracetam 750 mg tab er 24h 1-Covered QL (120 PER 30 DAY(S))
LEVETIRACETAM ER 500 MG TABLET 1-Covered MDD (6 Per Day)
LEVETIRACETAM ER 750 MG TABLET 1-Covered QL (120 PER 30 DAY(S))
CALCIUM CHANNEL MODIFYING AGENTSCELONTIN (methsuximide) 300 MGKAPSEAL
1-Covered
ETHOSUXIMIDE 250 MG CAPSULE 1-Covered
ethosuximide 250 mg5ml solution250 mg capsule
1-Covered
zonisamide 25 mg capsule 50 mgcapsule 100 mg capsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
14
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTSDEPAKENE (valproic acid (assodium salt) (valproate sodium))250 MG5 ML SOLUTION
1-Covered
DEPAKENE (valproic acid) 250 MGCAPSULE
1-Covered
diazepam 5-75-10mg kit 1-Covered
divalproex sodium 125 mg tabletdr 125 mg cap dr spr 250 mgtablet dr 500 mg tablet dr
1-Covered
DIVALPROEX SODIUM DR 125 MGCAP SPRNK
1-Covered
gabapentin 100 mg capsule 250mg5ml solution 300 mg capsule400 mg capsule 600 mg tablet800 mg tablet
1-Covered
GABAPENTIN 100 MG CAPSULE 300MG CAPSULE 400 MG CAPSULE
1-Covered
phenobarbital 15 mg tablet 20mg5 ml elixir 30 mg tablet 324mg tablet 60 mg tablet 648 mgtablet 972mg tablet 100 mgtablet
1-Covered
PHENOBARBITAL 20 MG5 ML SOLN324 MG TABLET 648 MG TABLET972 MG TABLET
1-Covered
primidone 50 mg tablet 250 mgtablet
1-Covered
valproic acid (as sodium salt)(valproate sodium) 250 mg5ml500mg10ml
1-Covered
valproic acid 250 mg capsule 1-Covered
VALPROIC ACID 250 MG CAPSULE 1-Covered
GLUTAMATE REDUCING AGENTSlamotrigine 25 mg tablet 100 mgtablet 150 mg tablet 200 mgtablet
1-Covered
lamotrigine 5 mg 25 mg 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
15
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
topiramate 15 mg cap sprink 25mg tablet 25 mg cap sprink 50mg tablet 100 mg tablet 200 mgtablet
1-Covered
TOPIRAMATE 25 MG TABLET 50 MGTABLET 100 MG TABLET 200 MGTABLET
1-Covered
SODIUM CHANNEL AGENTScarbamazepine (EPITOL) 200 mgtablet
1-Covered
carbamazepine 100 mg cpmp12hr 100 mg5ml oral susp 100 mgtab chew 100 mg tab er 12h 200mg cpmp 12hr 200 mg tab er 12h200 mg tablet 300 mg cpmp 12hr400 mg tab er 12h
1-Covered
CARBATROL (carbamazepine) ER100 MG CAPSULE ER 200 MGCAPSULE ER 300 MG CAPSULE
1-Covered
DILANTIN (phenytoin sodiumextended) 30 MG CAPSULE 100MG CAPSULE
1-Covered
DILANTIN (phenytoin) 50 MGINFATAB
1-Covered
DILANTIN-125 (phenytoin) MG5 MLSUSP
1-Covered
DILANTIN-125 MG5 ML SUSP 1-Covered
oxcarbazepine 150 mg tablet 300mg tablet 600 mg tablet
1-Covered
phenytoin 50 mg tab chew 100mg4ml oral susp 125 mg5ml oralsusp
1-Covered
phenytoin sodium extended 100mg capsule
1-Covered
TEGRETOL (carbamazepine) 100MG5 ML SUSP 200 MG TABLET
1-Covered
TEGRETOL XR (carbamazepine) 100MG TABLET 200 MG TABLET 400MG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
16
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIDEMENTIA AGENTS (Drugs for Alzheimers Disease andDementia)
CHOLINESTERASE INHIBITORSdonepezil hcl 5 mg tab rapdis 5mg tablet 10 mg tab rapdis 10mg tablet
1-Covered
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine hcl 5 mg tablet 10 mgtablet
1-Covered
MEMANTINE HCL 5 MG TABLET 10MG TABLET
1-Covered
ANTIDEPRESSANTS (Drugs for Depression)
ANTIDEPRESSANTS OTHERbupropion hcl 100 mg tab 150 mgtab 200 mg tab
1-Covered QL (60 PER 30 DAYS)
bupropion hcl 150 mg tab er 300mg tab er
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
bupropion hcl 75 mg tablet 100mg tablet
1-Covered
BUPROPION HCL SR SR 100 MGTABLET SR 150 MG TABLET SR 200MG TABLET
1-Covered QL (60 PER 30 DAYS)
BUPROPION XL 150 MG TABLET 300MG TABLET
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
mirtazapine 15 mg tab rapdis 1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old)
mirtazapine 15 mg tablet 30 mgtab rapdis 30 mg tablet 45 mgtab rapdis 45 mg tablet
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
olanzapinefluoxetine hcl 3 mg-25mg capsule 6mg-25mg capsule6mg-50mg capsule 12mg-50mgcapsule 12mg-25mg capsule
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
17
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SYMBYAX (olanzapinefluoxetinehcl) 3-25 MG CAPSULE 6-50 MGCAPSULE 6-25 MG CAPSULE 12-50MG CAPSULE 12-25 MG CAPSULE
2-MedicalCarve out
MONOAMINE OXIDASE INHIBITORSEMSAM (selegiline) 6 MG24PATCH 9 MG24 PATCH 12 MG24PATCH
2-MedicalCarve out
MARPLAN (isocarboxazid) 10 MGTABLET
2-MedicalCarve out
NARDIL (phenelzine sulfate) 15 MGTABLET
2-MedicalCarve out
PARNATE (tranylcypromine sulfate)10 MG TABLET
2-MedicalCarve out
phenelzine sulfate 15 mg tablet 2-MedicalCarve out
tranylcypromine sulfate 10 mgtablet
2-MedicalCarve out
SSRISSNRIS (SELECTIVE SEROTONIN REUPTAKEINHIBITORSEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)
citalopram hydrobromide 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
escitalopram oxalate 5 mg tablet10 mg tablet 20 mg tablet
1-Covered
ESCITALOPRAM OXALATE 5 MGTABLET 10 MG TABLET 20 MGTABLET
1-Covered
fluoxetine hcl 10 mg capsule 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
fluoxetine hcl 20 mg capsule 1-Covered QL (120 PER 30 DAY(S))
fluoxetine hcl 20 mg5 ml solution 1-Covered
FLUOXETINE HCL 20 MG5 MLSOLUTION
1-Covered
fluvoxamine maleate 25 mg tablet50 mg tablet 100 mg tablet
1-Covered AL1 (At least 8 yrs old)
paroxetine hcl 10 mg tablet 20 mgtablet 30 mg tablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
sertraline hcl 25 mg tablet 50 mgtablet 100 mg tablet
1-Covered QL (60 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
18
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRAZODONE HCL 50 MG TABLET100 MG TABLET
1-Covered
trazodone hcl 50 mg tablet 100mg tablet 150 mg tablet
1-Covered
venlafaxine hcl 25 mg tablet 375mg tablet 50 mg tablet 75 mgtablet 100 mg tablet
1-Covered QL (60 PER 30 DAYS)
venlafaxine hcl 375 mg cap er 75mg cap er 150 mg cap er
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
VENLAFAXINE HCL ER ER 375 MGCAP ER 75 MG CAP ER 150 MGCAP
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
TRICYCLICSamitriptyline hcl 10 mg tablet 25mg tablet 50 mg tablet 75 mgtablet 100 mg tablet 150 mgtablet
1-Covered
amoxapine 25 mg tablet 50 mgtablet 100 mg tablet 150 mgtablet
1-Covered
clomipramine hcl 25 mg capsule50 mg capsule 75 mg capsule
1-Covered PA
CLOMIPRAMINE HCL 25 MGCAPSULE 50 MG CAPSULE 75 MGCAPSULE
1-Covered PA
desipramine hcl 10 mg tablet 25mg tablet 50 mg tablet 75 mgtablet 100 mg tablet 150 mgtablet
1-Covered
DOXEPIN HCL 10 MG CAPSULE 25MG CAPSULE 50 MG CAPSULE 75MG CAPSULE 100 MG CAPSULE
1-Covered
doxepin hcl 10 mgml oral conc10 mg capsule 25 mg capsule 50mg capsule 75 mg capsule 100mg capsule 150 mg capsule
1-Covered
imipramine hcl 10 mg tablet 25mg tablet 50 mg tablet
1-Covered
IMIPRAMINE HCL 10 MG TABLET 25MG TABLET 50 MG TABLET
1-Covered
nortriptyline hcl 10 mg capsule 25mg capsule 50 mg capsule 75 mgcapsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
19
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIEMETICS (Drugs for Nausea and Vomiting)
ANTIEMETICS OTHER (Other Drugs for Nausea and Vomiting)meclizine hcl (DRAMAMINE LESSDROWSY) 25 mg tablet
1-Covered
meclizine hcl (MEDI-MECLIZINE) 25mg tablet -
1-Covered
meclizine hcl (MOTION RELIEF) 25mg tablet
1-Covered
meclizine hcl (MOTION SICKNESS II)25 mg tablet
1-Covered
meclizine hcl (MOTION SICKNESSRELIEF) 25 mg tablet 25 mg tabchew
1-Covered
meclizine hcl (MOTION SICKNESS)25 mg tablet
1-Covered
meclizine hcl (MOTION-TIME) 25 mgtab chew -
1-Covered
meclizine hcl (TRAVEL-EASE) 25 mgtablet -
1-Covered
meclizine hcl (VERTICALM) 25 mgtablet
1-Covered
meclizine hcl (WAL-DRAM 2) 25 mgtablet -
1-Covered
MECLIZINE HCL 125 MG CAPLET 25MG TABLET CHEW
1-Covered
meclizine hcl 125 mg tablet 25mg tab chew 25 mg tablet
1-Covered
metoclopramide hcl 5 mg tablet 5mg5 ml solution 10 mg tablet 10mg10ml solution
1-Covered
perphenazine 2 mg tablet 4 mgtablet 8 mg tablet 16 mg tablet
2-MedicalCarve out
prochlorperazine (COMPRO) 25mg supprect
1-Covered
prochlorperazine 25 mg supprect 1-Covered
prochlorperazine maleate 5 mgtablet 10 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
20
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
promethazine hcl (PHENADOZ)125 mg 25 mg
1-Covered
promethazine hcl (PROMETHEGAN)125 mg 25 mg 50 mg
1-Covered
promethazine hcl 125 mgsupprect 25 mg supprect 50 mgtablet 50 mg supprect
1-Covered
TRAVEL SICKNESS (meclizine hcl) 25MG TAB CHEW
1-Covered
trimethobenzamide hcl 300 mgcapsule
1-Covered
EMETOGENIC THERAPY ADJUNCTS (Drugs for Nausea and Vomiting)aprepitant 40 mg capsule 80 mgcapsule 125mg-80mg cap ds pk125 mg capsule
1-Covered PA
dronabinol 25 mg capsule 5 mgcapsule 10 mg capsule
1-Covered PA
granisetron hcl 1 mg tablet 1-Covered PA
ondansetron 4 mg tab rapdis 8mg tab rapdis
1-Covered QL (12 PER FILL(S)) MDD (3 PerDay) QLC (LIMIT TO 2 FILLS OF 12TABLETS IN 30 DAYS)
ondansetron hcl 4 mg tablet 8 mgtablet
1-Covered QL (12 PER FILL(S)) MDD (3 PerDay) QLC (LIMIT TO 2 FILLS OF 12TABLETS IN 30 DAYS)
ondansetron hcl 4 mg5 mlsolution 24 mg tablet
1-Covered PA
ANTIFUNGALS (Drugs for Fungal Infections)
ANTIFUNGALSANTIFUNGAL 1 TOPICAL CREAM 1-Covered
ATHLETES FOOT (terbinafine hcl) 1CREAM
1-Covered
ciclopirox 077 gel (gram) 1-Covered QLC (100 GRAMSMONTH)
ciclopirox 1 shampoo 1-Covered QLC (120 ozMONTH)
ciclopirox 8 solution 1-Covered
ciclopirox olamine 077 cream(g)
1-Covered QLC (90 GRAMSMONTH)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
21
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ciclopirox olamine 077 suspension
1-Covered QLC (60 MLMONTH)
clotrimazole (ANTIFUNGALRINGWORM) 1 cream (g)
1-Covered
clotrimazole (ANTIFUNGAL) 1 cream (g)
1-Covered
clotrimazole (ATHLETES FOOT) 1 cream (g)
1-Covered
clotrimazole (ATHLETIC FOOTCREAM) 1 cream (g)
1-Covered
clotrimazole (CLOTRIMAZOLE AF) 1 cream (g)
1-Covered
clotrimazole (ITCH RELIEF) 1 cream (g)
1-Covered
clotrimazole (JOCK ITCH RELIEF) 1 cream (g)
1-Covered
clotrimazole (JOCK ITCH) 1 cream (g)
1-Covered
clotrimazole (RINGWORM) 1 cream (g)
1-Covered
clotrimazole 1 cream (g) 1 solution 1 creamappl 10 mgtroche
1-Covered
CLOTRIMAZOLE 1 SOLUTION 1TOPICAL CREAM
1-Covered
fluconazole 10 mgml 40 mgml 1-Covered QL (70 PER 30 DAY(S))
fluconazole 150 mg tablet 1-Covered QL (2 PER 30 DAY(S))
FLUCONAZOLE 200 MG TABLET 1-Covered
fluconazole 50 mg tablet 100 mgtablet 200 mg tablet
1-Covered
fluconazole in dextrose iso-osmotic in dextreiso-200mg01l indextreiso-400mg02l
1-Covered PA
flucytosine 250 mg capsule 500mg capsule
1-Covered
FLUCYTOSINE 250 MG CAPSULE500 MG CAPSULE
1-Covered
griseofulvin ultramicrosize 125 mgtablet 250 mg tablet
1-Covered QL (60 PER 30 DAYS) AL1 (Up to18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
22
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
griseofulvin microsize 125 mg5mloral susp
1-Covered AL1 (Up to 12 yrs old) MDD (20Per Day)
griseofulvin microsize 500 mgtablet
1-Covered QL (60 PER 30 DAYS) AL1 (Up to18 yrs old)
itraconazole 100 mg capsule 1-Covered PA
ketoconazole 2 cream (g) 2 shampoo
1-Covered
ketoconazole 200 mg tablet 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
LAMISIL (terbinafine hcl)ANTIFUNGAL 1 SPRAY
1-Covered
LOTRIMIN AF (clotrimazole) 1CREAM
1-Covered
miconazole nitrate (ANTI-FUNGALCREAM) 2 cream (g) -
1-Covered
miconazole nitrate (ANTIFUNGALCREAM) 2 cream (g)
1-Covered
miconazole nitrate (BAZAANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate (INZOANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate (LOTRIMIN AF) 2 spray
1-Covered
miconazole nitrate (MICATIN) 2 cream (g)
1-Covered
miconazole nitrate (SECURAANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate 2 aero powd2 creamappl 2 cream (g)100 mg suppvag
1-Covered
MONISTAT 3 (miconazole nitrate)4 CREAM
1-Covered
MONISTAT 7 (miconazole nitrate)CREAM
1-Covered
NYSTATIN 100000 UNITGM CREAM100000 UNITGM OINT 100000UNITML SUSP 500000 UNIT5 MLSUS
1-Covered
nystatin 500k unit tablet 100000mloral susp 100000g cream (g)100000g oint (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
23
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terbinafine hcl (ANTIFUNGAL) 1 cream (g)
1-Covered
terbinafine hcl (ATHLETES FOOT AF)1 cream (g)
1-Covered
terbinafine hcl (ATHLETES FOOT) 1 cream (g)
1-Covered
terbinafine hcl (JOCK ITCH) 1 cream (g)
1-Covered
terbinafine hcl (LAMISIL AT) 1 cream (g)
1-Covered
terbinafine hcl 1 cream (g) 250mg tablet
1-Covered
tioconazole 65 oinpf app 1-Covered
tolnaftate (ANTIFUNGAL CREAM) 1 cream (g)
1-Covered
tolnaftate (ATHLETES FOOT) 1 cream (g)
1-Covered
tolnaftate (FUNGOID-D) 1 cream(g) -
1-Covered
tolnaftate 1 cream (g) 1-Covered
ANTIGOUT AGENTS (Drugs for Gout)
ANTIGOUT AGENTSallopurinol 100 mg tablet 300 mgtablet
1-Covered
ALLOPURINOL 100 MG TABLET 300MG TABLET
1-Covered
colchicine 06 mg tablet 1-Covered
COLCHICINE 06 MG TABLET 1-Covered
probenecid 500 mg tablet 1-Covered
probenecidcolchicine 500-05 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
24
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIMIGRAINE AGENTS (Drugs for Migraine)
ERGOT ALKALOIDSergotamine tartratecaffeine 1mg-100mg tablet
1-Covered
SEROTONIN (5-HT) 1B1D RECEPTOR AGONISTSrizatriptan benzoate 5 mg tablet10 mg tablet
1-Covered QL (12 PER 30 DAY(S)) AL1 (Atleast 6 yrs old)
SUMATRIPTAN 5 MG SPRAY 20 MGSPRAY
1-Covered QL (6 PER 30 DAY(S))
sumatriptan 5 mg 20 mg 1-Covered QL (6 PER 30 DAY(S))
sumatriptan succinate 25 mgtablet 50 mg tablet 100 mg tablet
1-Covered QL (9 PER 30 DAY(S))
SUMATRIPTAN SUCCINATE 25 MGTABLET 50 MG TABLET 100 MGTABLET
1-Covered QL (9 PER 30 DAY(S))
SUMATRIPTAN SUCCINATE 6 MG05ML CART
1-Covered QL (2 PER FILL(S)) MFL (1 30day(s))
SUMATRIPTAN SUCCINATE 6 MG05ML INJECT
1-Covered QL (2 PER 30 DAY(S)) MFL (1 30day(s))
sumatriptan succinate 6 mg05mlcartridge 6 mg05ml vial
1-Covered QL (2 PER FILL(S)) MFL (1 30day(s))
sumatriptan succinate 6 mg05mlpen injctr 6 mg05ml syringe
1-Covered QL (2 PER 30 DAY(S)) MFL (1 30day(s))
ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis)
PARASYMPATHOMIMETICSMESTINON (pyridostigminebromide) 60 MG5 ML SOLUTION
1-Covered
pyridostigmine bromide 60 mg5ml solution 60 mg tablet 180 mgtablet er
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
25
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections)
ANTIMYCOBACTERIALS OTHER (Other Drugs for MycobacterialInfection)
dapsone 25 mg tablet 100 mgtablet
1-Covered
rifabutin 150 mg capsule 1-Covered
ANTITUBERCULARS (Drugs for Tuberculosis)ethambutol hcl 100 mg tablet 400mg tablet
1-Covered
ETHAMBUTOL HCL 100 MG TABLET400 MG TABLET
1-Covered
isoniazid 50 mg5 ml solution 100mg tablet 300 mg tablet
1-Covered
PRIFTIN (rifapentine) 150 MG TABLET 1-Covered AL1 (At least 12 yrs old)
pyrazinamide 500 mg tablet 1-Covered
rifampin 150 mg capsule 300 mgcapsule
1-Covered
ANTINEOPLASTICS (Drugs for Cancer)
ALKYLATING AGENTScyclophosphamide 25 mgcapsule 50 mg capsule
1-Covered PA
CYCLOPHOSPHAMIDE 25 MGCAPSULE 50 MG CAPSULE
1-Covered PA
GLEOSTINE (lomustine) 10 MGCAPSULE 40 MG CAPSULE 100 MGCAPSULE
1-Covered PA
HEXALEN (altretamine) 50 MGCAPSULE
1-Covered
LEUKERAN (chlorambucil) 2 MGTABLET
1-Covered PA
MATULANE (procarbazine hcl) 50MG CAPSULE
1-Covered PA SP
melphalan 2 mg tablet 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
26
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
MYLERAN (busulfan) 2 MG TABLET 1-Covered
temozolomide 20 mg capsule 1-Covered PA SP
ANTIANDROGENSbicalutamide 50 mg tablet 1-Covered PA
flutamide 125 mg capsule 1-Covered PA
ANTIANGIOGENIC AGENTSTHALOMID (thalidomide) 50 MGCAPSULE
1-Covered PA SP
ANTIESTROGENSMODIFIERSEMCYT (estramustine phosphatesodium) 140 MG CAPSULE
1-Covered PA
TAMOXIFEN CITRATE 10 MG TABLET 1-Covered
tamoxifen citrate 10 mg tablet 20mg tablet
1-Covered
TOREMIFENE CITRATE 60 MG TAB 1-Covered PA
toremifene citrate 60 mg tablet 1-Covered PA
ANTIMETABOLITEScapecitabine 500 mg tablet 1-Covered PA SP
CAPECITABINE 500 MG TABLET 1-Covered PA SP
DROXIA (hydroxyurea) 200 MGCAPSULE 300 MG CAPSULE 400MG CAPSULE
1-Covered
fluorouracil (ADRUCIL) 25 g50mlvial 5 g100 ml vial
1-Covered PA
hydroxyurea 500 mg capsule 1-Covered PA
mercaptopurine 50 mg tablet 1-Covered PA
TABLOID (thioguanine) 40 MGTABLET
1-Covered PA
ANTINEOPLASTICS OTHERLEUCOVORIN CALCIUM 5 MG TAB25 MG TAB
1-Covered
leucovorin calcium 5 mg tablet 10mg tablet 15 mg tablet 25 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
27
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LYSODREN (mitotane) 500 MGTABLET
1-Covered PA
AROMATASE INHIBITORS 3RD GENERATIONanastrozole 1 mg tablet 1-Covered
ANASTROZOLE 1 MG TABLET 1-Covered
letrozole 25 mg tablet 1-Covered
ENZYME INHIBITORSetoposide 50 mg capsule 1-Covered PA
MOLECULAR TARGET INHIBITORSJAKAFI (ruxolitinib phosphate) 5MG TABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET 25 MGTABLET
1-Covered PA SP QL (2 PER 1 DAY(S))
RETINOIDStretinoin 10 mg capsule 1-Covered PA
ANTIPARASITICS (Drugs for Parasitic Infections)
ANTIHELMINTHICS (Drugs for Worm Infection)mebendazole (EMVERM) 100 mgtab chew
1-Covered
praziquantel 600 mg tablet 1-Covered
ANTIPROTOZOALS (Drugs for Protozoal Infection)chloroquine phosphate 250 mgtablet
1-Covered QL (25 PER 30 DAY(S))
chloroquine phosphate 500 mgtablet
1-Covered PA QL (25 PER 30 DAY(S))
HYDROXYCHLOROQUINE SULFATE200 MG TAB
1-Covered QL (3 PER 1 DAY(S))
hydroxychloroquine sulfate 200 mgtablet
1-Covered QL (3 PER 1 DAY(S))
mefloquine hcl 250 mg tablet 1-Covered
primaquine phosphate 263 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
28
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PEDICULICIDESSCABICIDES (Drugs for Scabies and Lice)permethrin (LICE TREATMENT) 1 liquid
1-Covered
permethrin 5 cream (g) 1-Covered
ANTIPARKINSON AGENTS (Drugs for Parkinsons Disease)
ANTICHOLINERGICSbenztropine mesylate 05 mgtablet 1 mg tablet 2 mg tablet 2mg2 ml ampul 2 mg2 ml vial
2-MedicalCarve out
COGENTIN (benztropine mesylate)2 MG2 ML AMPULE
2-MedicalCarve out
trihexyphenidyl hcl 2 mg5 ml elixir2 mg tablet 5 mg tablet
2-MedicalCarve out
ANTIPARKINSON AGENTS OTHERAMANTADINE 100 MG CAPSULE 2-Medical
Carve out
amantadine hcl 50 mg5 mlsolution 100 mg capsule 100 mgtablet
2-MedicalCarve out
entacapone 200 mg tablet 1-Covered ST
GOCOVRI (amantadine hcl) ER685 MG CAPSULE ER 137 MGCAPSULE
2-MedicalCarve out
OSMOLEX ER (amantadine hcl) ER129 MG TABLET ER 193 MG TABLETER 258 MG TABLET ER 322 MGDAILY DOSE
2-MedicalCarve out
DOPAMINE AGONISTSbromocriptine mesylate 25 mgtablet
1-Covered
pramipexole di-hcl -0125 mgtablet -025 mg tablet -05 mgtablet -075 mg tablet -1 mgtablet -15 mg tablet
1-Covered
ropinirole hcl 025 mg tablet 05mg tablet 1 mg tablet 2 mgtablet 3 mg tablet 4 mg tablet 5mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
29
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DOPAMINE PRECURSORSL-AMINO ACID DECARBOXYLASEINHIBITORS
carbidopalevodopa 10mg-100mgtablet 25mg-100mg tablet 25mg-100mg tablet er 25mg-250mgtablet 50mg-200mg tablet er
1-Covered
MONOAMINE OXIDASE B (MAO-B) INHIBITORSselegiline hcl 5 mg tablet 5 mgcapsule
1-Covered
ANTIPSYCHOTICS (Drugs for Mental Health)
1ST GENERATIONTYPICALADASUVE (loxapine) 10 MG POWD10 MG POWDR
2-MedicalCarve out
chlorpromazine hcl 10 mg tablet25 mg tablet 25 mgml ampul 50mg tablet 100 mg tablet 200 mgtablet
2-MedicalCarve out
CHLORPROMAZINE HCL 10 MGTABLET 25 MGML AMPULE 25 MGTABLET 50 MG TABLET 50 MG2 MLAMP 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
fluphenazine decanoate 25 mgmlvial
2-MedicalCarve out
fluphenazine hcl 1 mg tablet 25mg tablet 25 mg5ml elixir 25mgml vial 5 mgml oral conc 5mg tablet 10 mg tablet
2-MedicalCarve out
FLUPHENAZINE HCL 1 MG TABLET25 MG TABLET 5 MG TABLET 10MG TABLET
2-MedicalCarve out
HALDOL (haloperidol lactate) 5MGML AMPUL
2-MedicalCarve out
HALDOL DECANOATE 100(haloperidol decanoate) AMPUL
2-MedicalCarve out
HALDOL DECANOATE 50(haloperidol decanoate) AMPUL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
30
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
haloperidol 05 mg tablet 1 mgtablet 2 mg tablet 5 mg tablet 10mg tablet 20 mg tablet
2-MedicalCarve out
HALOPERIDOL 5 MG TABLET 2-MedicalCarve out
haloperidol decanoate 50 mgmlvial 50 mgml ampul 100 mgmlampul 100 mgml vial
2-MedicalCarve out
haloperidol lactate 2 mgml oralconc 5 mgml vial 5 mgmlampul 5 mgml syringe
2-MedicalCarve out
HALOPERIDOL LACTATE 5 MGMLSYRING
2-MedicalCarve out
loxapine succinate 5 mg capsule10 mg capsule 25 mg capsule 50mg capsule
2-MedicalCarve out
molindone hcl 5 mg tablet 10 mgtablet 25 mg tablet
2-MedicalCarve out
ORAP (pimozide) 1 MG TABLET 2MG TABLET
2-MedicalCarve out
pimozide 1 mg tablet 2 mg tablet 2-MedicalCarve out
thioridazine hcl 10 mg tablet 25mg tablet 50 mg tablet 100 mgtablet
2-MedicalCarve out
thiothixene 1 mg capsule 2 mgcapsule 5 mg capsule 10 mgcapsule
2-MedicalCarve out
trifluoperazine hcl 1 mg tablet 2mg tablet 5 mg tablet 10 mgtablet
2-MedicalCarve out
2ND GENERATIONATYPICALABILIFY (aripiprazole) 2 MG TABLET5 MG TABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET 30 MGTABLET
2-MedicalCarve out
ABILIFY MAINTENA (aripiprazole) ER300 MG VL ER 300 MG SYR ER 400MG SYR ER 400 MG VL
2-MedicalCarve out
ABILIFY MYCITE (aripiprazole) 2 MGKIT 5 MG KIT 10 MG KIT 15 MG KIT20 MG KIT 30 MG KIT
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
31
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
aripiprazole 1 mgml solution 2 mgtablet 5 mg tablet 10 mg tabrapdis 10 mg tablet 15 mg tablet15 mg tab rapdis 20 mg tablet 30mg tablet
2-MedicalCarve out
ARIPIPRAZOLE 1 MGML SOLUTION2 MG TABLET 5 MG TABLET 10 MGTABLET 15 MG TABLET 20 MGTABLET 30 MG TABLET
2-MedicalCarve out
ARISTADA (aripiprazole lauroxil) ER441 MG16 ML SYRN ER 662MG24 ML SYRN ER 882 MG32ML SYRN ER 1064 MG39 ML SYR
2-MedicalCarve out
ARISTADA INITIO (aripiprazolelauroxil submicronized) ER 675MG24
2-MedicalCarve out
CAPLYTA (lumateperone tosylate)42 MG CAPSULE
2-MedicalCarve out
FANAPT (iloperidone) 1 MG TABLET2 MG TABLET 4 MG TABLET 6 MGTABLET 8 MG TABLET 10 MGTABLET 12 MG TABLET TITRATIONPACK
2-MedicalCarve out
GEODON (ziprasidone hcl) 20 MGCAPSULE 40 MG CAPSULE 60 MGCAPSULE 80 MG CAPSULE
2-MedicalCarve out
GEODON (ziprasidone mesylate)20 MGML VIAL
2-MedicalCarve out
INVEGA (paliperidone) ER 15 MGTABLET ER 3 MG TABLET ER 6 MGTABLET ER 9 MG TABLET
2-MedicalCarve out
INVEGA SUSTENNA (paliperidonepalmitate) 39 MG025 ML 78MG05 ML 117 MG075 ML 156MGML SYRG 234 MG15 ML
2-MedicalCarve out
INVEGA TRINZA (paliperidonepalmitate) 273 MG0875 ML 410MG1315 ML 546 MG175 ML 819MG2625 ML
2-MedicalCarve out
LATUDA (lurasidone hcl) 20 MGTABLET 40 MG TABLET 60 MGTABLET 80 MG TABLET 120 MGTABLET
2-MedicalCarve out
NUPLAZID (pimavanserin tartrate)10 MG TABLET 17 MG TABLET 34MG CAPSULE
2-MedicalCarve out
SP
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
32
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
olanzapine 25 mg tablet 5 mgtab rapdis 5 mg tablet 75 mgtablet 10 mg tab rapdis 10 mgtablet 10 mg vial 15 mg tabrapdis 15 mg tablet 20 mg tablet20 mg tab rapdis
2-MedicalCarve out
paliperidone 15 mg tab er 24 3mg tab er 24 6 mg tab er 24 9 mgtab er 24
2-MedicalCarve out
PERSERIS (risperidone) ER 90 MGSYRINGE KIT ER 120 MG SYRINGEKIT
2-MedicalCarve out
quetiapine fumarate 25 mg tablet50 mg tab er 24h 50 mg tablet100 mg tablet 150 mg tab er 24h200 mg tab er 24h 200 mg tablet300 mg tablet 300 mg tab er 24h400 mg tab er 24h 400 mg tablet
2-MedicalCarve out
REXULTI (brexpiprazole) 025 MGTABLET 05 MG TABLET 1 MGTABLET 2 MG TABLET 3 MG TABLET4 MG TABLET
2-MedicalCarve out
RISPERDAL (risperidone) 025 MGTABLET 05 MG TABLET 1 MGMLSOLUTION 1 MG TABLET 2 MGTABLET 3 MG TABLET 4 MG TABLET
2-MedicalCarve out
RISPERDAL CONSTA (risperidonemicrospheres) 125 MG VIAL 25MG VIAL 375 MG VIAL 50 MGVIAL
2-MedicalCarve out
RISPERDAL M-TAB (risperidone) -TAB05 G ODT -TAB 1 G ODT -TAB 2 GODT -TAB 3 G ODT -TAB 4 G ODT
2-MedicalCarve out
risperidone 025 mg tab rapdis025 mg tablet 05 mg tab rapdis05 mg tablet 1 mg tablet 1mgml solution 1 mg tab rapdis 2mg tab rapdis 2 mg tablet 3 mgtablet 3 mg tab rapdis 4 mg tabrapdis 4 mg tablet
2-MedicalCarve out
SAPHRIS (asenapine maleate) 25MG TAB 5 MG TAB 10 MG TAB
2-MedicalCarve out
SECUADO (asenapine) 38 MG24HR PATCH 57 MG24 HR PATCH76 MG24 HR PATCH
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
33
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SEROQUEL (quetiapine fumarate)25 MG TABLET 50 MG TABLET 100MG TABLET 200 MG TABLET 300MG TABLET 400 MG TABLET
2-MedicalCarve out
SEROQUEL XR (quetiapinefumarate) 50 MG TABLET 150 MGTABLET 200 MG TABLET 300 MGTABLET 400 MG TABLET
2-MedicalCarve out
VRAYLAR (cariprazine hcl) 15 MG-3 MG PACK 15 MG CAPSULE 3MG CAPSULE 45 MG CAPSULE 6MG CAPSULE
2-MedicalCarve out
ziprasidone hcl 20 mg capsule 40mg capsule 60 mg capsule 80 mgcapsule
2-MedicalCarve out
ZIPRASIDONE HCL 20 MG CAPSULE40 MG CAPSULE 60 MG CAPSULE80 MG CAPSULE
2-MedicalCarve out
ZIPRASIDONE MESYLATE 20 MGMLVIAL
2-MedicalCarve out
ziprasidone mesylate fnl 20mg1vial
2-MedicalCarve out
ZYPREXA (olanzapine) 25 MGTABLET 5 MG TABLET 75 MGTABLET 10 MG VIAL 10 MG TABLET15 MG TABLET 20 MG TABLET
2-MedicalCarve out
ZYPREXA RELPREVV (olanzapinepamoate) 210 MG VL KIT 300 MGVL KIT 405 MG VL KIT
2-MedicalCarve out
ZYPREXA ZYDIS (olanzapine) 5 MGTABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET
2-MedicalCarve out
TREATMENT-RESISTANTclozapine 125 mg tab rapdis 25mg tab rapdis 25 mg tablet 50mg tablet 100 mg tablet 100 mgtab rapdis 150 mg tab rapdis 200mg tablet 200 mg tab rapdis
2-MedicalCarve out
CLOZAPINE 25 MG TABLET 50 MGTABLET 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
CLOZAPINE ODT ODT 150 MGTABLET ODT 200 MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
34
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CLOZARIL (clozapine) 25 MGTABLET 50 MG TABLET 100 MGTABLET 200 MG TABLET
2-MedicalCarve out
FAZACLO (clozapine) 125 MGODT 25 MG ODT 100 MG ODT 150MG ODT 200 MG ODT
2-MedicalCarve out
VERSACLOZ (clozapine) 50 MGMLSUSPENSION
2-MedicalCarve out
ANTISPASTICITY AGENTS (Drugs for Muscle Spasm)baclofen 10 mg tablet 20 mgtablet
1-Covered QL (90 PER 30 DAYS)
BACLOFEN 10 MG TABLET 20 MGTABLET
1-Covered QL (90 PER 30 DAYS)
tizanidine hcl 2 mg tablet 4 mgtablet
1-Covered QL (90 PER 30 DAY(S))
ANTIVIRALS (Drugs for Viral Infections)
ANTI-HEPATITIS B (HBV) AGENTSEPIVIR HBV (lamivudine) 100 MGTABLET
2-MedicalCarve out
EPIVIR HBV (lamivudine) 25 MG5ML SOLN
1-Covered PA
lamivudine 100 mg tablet 1-Covered PA
VEMLIDY (tenofovir alafenamide)25 MG TABLET
2-MedicalCarve out
ANTI-HEPATITIS C (HCV) AGENTS DIRECT ACTING AGENTSsofosbuvirvelpatasvir 400-100 mgtablet
1-Covered PA SP
ANTI-HEPATITIS C (HCV) AGENTS OTHERINTRON A (interferon alfa-2brecomb) 10 MILLION UNITS VIL -18 MILLION UNITS VIL - 18 MILLIONUNIT3 ML - 25 MILLION UNIT25ML- 50 MILLION UNITS VIL -
1-Covered PA SP
PEGINTRON REDIPEN(peginterferon alfa-2b) 50 MCG -
1-Covered PA SP
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
35
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ribavirin (RIBASPHERE) 200 mgtablet
1-Covered PA
ribavirin 200 mg tablet 1-Covered PA
ANTI-HIV AGENTSCIMDUO (lamivudinetenofovirdisoproxil fumarate) 300-300 MGTABLET
2-MedicalCarve out
EFAVIRENZ-LAMIVU-TENOFOVDISOP --600-300-300
2-MedicalCarve out
SYMFI(efavirenzlamivudinetenofovirdisoproxil fumarate) 600-300-300MG TABLET
2-MedicalCarve out
TEMIXYS (lamivudinetenofovirdisoproxil fumarate) 300-300 MGTABLET
2-MedicalCarve out
ANTI-HIV AGENTS INTEGRASE INHIBITORS (INSTI)BIKTARVY (bictegravirsodiumemtricitabinetenofoviralafenamide fumar) 50-200-25 MGTABLET
2-MedicalCarve out
GENVOYA(elvitegravircobicistatemtricitabinetenofovir alafenamide) TABLET
2-MedicalCarve out
ISENTRESS (raltegravir potassium) 25MG TABLET CHEW 100 MG TABLETCHEW 100 MG POWDER PACKET400 MG TABLET
2-MedicalCarve out
ISENTRESS HD (raltegravirpotassium) 600 MG TABLET
2-MedicalCarve out
STRIBILD(elvitegravircobicistatemtricitabinetenofovir disoproxil) TABLET
2-MedicalCarve out
TIVICAY (dolutegravir sodium) 10MG TABLET 25 MG TABLET 50 MGTABLET
2-MedicalCarve out
TIVICAY PD 5 MG TAB FOR SUSP 2-MedicalCarve out
VITEKTA (elvitegravir) 85 MGTABLET 150 MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
36
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTI-HIV AGENTS NON-NUCLEOSIDE REVERSE TRANSCRIPTASEINHIBITORS (NNRTI)
ATRIPLA(efavirenzemtricitabinetenofovirdisoproxil fumarate) TABLET
2-MedicalCarve out
COMPLERA(emtricitabinerilpivirinehcltenofovir disoproxil fumarate)TABLET
2-MedicalCarve out
DELSTRIGO(doravirinelamivudinetenofovirdisoproxil fumarate) 100-300-300MG TAB
2-MedicalCarve out
EDURANT (rilpivirine hcl) 25 MGTABLET
2-MedicalCarve out
efavirenz 50 mg capsule 200 mgcapsule 600 mg tablet
2-MedicalCarve out
EFAVIRENZ-EMTRIC-TENOFOVDISOP --600-200-300
2-MedicalCarve out
EFAVIRENZ-LAMIVU-TENOFOVDISOP --400-300-300
2-MedicalCarve out
INTELENCE (etravirine) 25 MGTABLET 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
nevirapine 50 mg5 ml oral susp100 mg tab er 24h 200 mg tablet400 mg tab er 24h
2-MedicalCarve out
ODEFSEY (emtricitabinerilpivirinehcltenofovir alafenamidefumarate) TABLET
2-MedicalCarve out
PIFELTRO (doravirine) 100 MGTABLET
2-MedicalCarve out
RESCRIPTOR (delavirdine mesylate)100 MG TABLET 200 MG TABLET
2-MedicalCarve out
SUSTIVA (efavirenz) 50 MGCAPSULE 200 MG CAPSULE 600MG TABLET
2-MedicalCarve out
SYMFI LO(efavirenzlamivudinetenofovirdisoproxil fumarate) 400-300-300MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
37
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
VIRAMUNE (nevirapine) 50 MG5ML SUSP 200 MG TABLET
2-MedicalCarve out
VIRAMUNE XR (nevirapine) 100 MGTABLET 400 MG TABLET
2-MedicalCarve out
ANTI-HIV AGENTS NUCLEOSIDE AND NUCLEOTIDE REVERSETRANSCRIPTASE INHIBITORS (NRTI)
abacavir sulfate 20 mgml solution300 mg tablet
2-MedicalCarve out
abacavir sulfatelamivudine 600-300mg tablet
2-MedicalCarve out
abacavirsulfatelamivudinezidovudineabacavirlamivudinezidovudine150-300 mg tablet
2-MedicalCarve out
ABACAVIR-LAMIVUDINE -600-300MG
2-MedicalCarve out
COMBIVIR (lamivudinezidovudine)TABLET
2-MedicalCarve out
EMTRICITABINE 200 MG CAPSULE 2-MedicalCarve out
EMTRICITABINE-TENOFOVIR DISOP -TENOFV 200-300MG
2-MedicalCarve out
EMTRIVA (emtricitabine) 10 MGMLSOLUTION 200 MG CAPSULE
2-MedicalCarve out
EPIVIR (lamivudine) 10 MGMLORAL SOLN 150 MG TABLET 300MG TABLET
2-MedicalCarve out
EPZICOM (abacavirsulfatelamivudine) TABLET
2-MedicalCarve out
lamivudine 10 mgml solution 150mg tablet 300 mg tablet
2-MedicalCarve out
lamivudinezidovudine 150-300mgtablet 150-300 mg tablet
2-MedicalCarve out
stavudine 1 mgml soln recon 15mg capsule 20 mg capsule 30 mgcapsule 40 mg capsule
2-MedicalCarve out
tenofovir disoproxil fumarate 300mg tablet
2-MedicalCarve out
TRIZIVIR (abacavirsulfatelamivudinezidovudine)TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
38
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRUVADA (emtricitabinetenofovirdisoproxil fumarate) 100 MG-150MG TABLET 133 MG-200 MGTABLET 167 MG-250 MG TABLET200 MG-300 MG TABLET
2-MedicalCarve out
VIREAD (tenofovir disoproxilfumarate) 150 MG TABLET 200 MGTABLET 250 MG TABLET 300 MGTABLET POWDER
2-MedicalCarve out
ZERIT (stavudine) 1 MGMLSOLUTION 15 MG CAPSULE 20 MGCAPSULE 30 MG CAPSULE 40 MGCAPSULE
2-MedicalCarve out
ZIAGEN (abacavir sulfate) 20MGML SOLUTION 300 MG TABLET
2-MedicalCarve out
ANTI-HIV AGENTS OTHERDESCOVY (emtricitabinetenofoviralafenamide fumarate) 200-25 MGTABLET
2-MedicalCarve out
DOVATO (dolutegravirsodiumlamivudine) 50-300 MGTABLET
2-MedicalCarve out
FUZEON (enfuvirtide) 90 MG VIAL 2-MedicalCarve out
SP
JULUCA (dolutegravirsodiumrilpivirine hcl) 50-25 MGTABLET
2-MedicalCarve out
RUKOBIA ER 600 MG TABLET 2-MedicalCarve out
SELZENTRY (maraviroc) 20 MGMLORAL SOLN 25 MG TABLET 75 MGTABLET 150 MG TABLET 300 MGTABLET
2-MedicalCarve out
TRIUMEQ (abacavirsulfatedolutegravirsodiumlamivudine) 600-50-300 MGTABLET
2-MedicalCarve out
TROGARZO (ibalizumab-uiyk) 200MG133 ML VIAL -
2-MedicalCarve out
TYBOST (cobicistat) 150 MG TABLET 2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
39
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTI-HIV AGENTS PROTEASE INHIBITORSAPTIVUS (tipranavir) 250 MGCAPSULE
2-MedicalCarve out
APTIVUS (tipranavirvitamin e tpgs)100 MGML SOLUTION
2-MedicalCarve out
ATAZANAVIR SULFATE 150 MG CAP200 MG CAP 300 MG CAP
2-MedicalCarve out
atazanavir sulfate 150 mg capsule200 mg capsule 300 mg capsule
2-MedicalCarve out
CRIXIVAN (indinavir sulfate) 200MG CAPSULE 400 MG CAPSULE
2-MedicalCarve out
EVOTAZ (atazanavirsulfatecobicistat) 300 MG-150 MGTABLET
2-MedicalCarve out
fosamprenavir calcium 700 mgtablet
2-MedicalCarve out
FOSAMPRENAVIR CALCIUM 700MG TABLET
2-MedicalCarve out
INVIRASE (saquinavir mesylate) 200MG CAPSULE 500 MG TABLET
2-MedicalCarve out
KALETRA (lopinavirritonavir) 80MG-20 MGML SOLN 100-25 MGTABLET 200-50 MG TABLET
2-MedicalCarve out
LEXIVA (fosamprenavir calcium) 50MGML SUSPENSION 700 MGTABLET
2-MedicalCarve out
lopinavirritonavir 400-1005solution
2-MedicalCarve out
NORVIR (ritonavir) 80 MGMLSOLUTION 100 MG TABLET 100 MGSOFTGEL CAP 100 MG POWDERPACKET
2-MedicalCarve out
PREZCOBIX (darunavirethanolatecobicistat) 800 MG-150MG TABLET
2-MedicalCarve out
PREZISTA (darunavir ethanolate) 75MG TABLET 100 MGMLSUSPENSION 150 MG TABLET 400MG TABLET 600 MG TABLET 800MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
40
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
REYATAZ (atazanavir sulfate) 50MG POWDER PACKET 150 MGCAPSULE 200 MG CAPSULE 300MG CAPSULE
2-MedicalCarve out
ritonavir 100 mg tablet 2-MedicalCarve out
SYMTUZA (darunavirethcobicistatemtricitabinetenofovir alafenamide) 800-150-200-10MG TAB
2-MedicalCarve out
VIRACEPT (nelfinavir mesylate) 250MG TABLET 625 MG TABLET
2-MedicalCarve out
ANTI-INFLUENZA AGENTSoseltamivir phosphate 30 mgcapsule 45 mg capsule 75 mgcapsule
1-Covered QL (10 PER 30 DAY(S)) MFL (1 180 day(s))
OSELTAMIVIR PHOSPHATE 30 MGCAPSULE 45 MG CAPSULE 75 MGCAPSULE
1-Covered QL (10 PER 30 DAY(S)) MFL (1 180 day(s))
oseltamivir phosphate 6 mgmlsusp recon
1-Covered QL (120 PER FILL(S)) MFL (120 180day(s))
OSELTAMIVIR PHOSPHATE 6 MGMLSUSPENSION
1-Covered QL (120 PER FILL(S)) MFL (120 180day(s))
RELENZA (zanamivir) 5 MGDISKHALER
1-Covered QL (20 PER 30 DAY(S))
ANTIHERPETIC AGENTSacyclovir 200 mg capsule 200mg5ml oral susp 400 mg tablet800 mg tablet
1-Covered
ACYCLOVIR 200 MG5 ML SUSP400 MG TABLET 800 MG TABLET
1-Covered
trifluridine 1 drops 1-Covered
valacyclovir hcl 500 mg tablet1000 mg tablet
1-Covered QL (60 PER 30 DAY(S))
ANXIOLYTICS (Drugs for Anxiety)
ANXIOLYTICS OTHER (Other Drugs for Anxiety)BUSPIRONE HCL 5 MG TABLET 10MG TABLET 15 MG TABLET 30 MGTABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
41
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
buspirone hcl 5 mg tablet 75 mgtablet 10 mg tablet 15 mg tablet30 mg tablet
1-Covered
BENZODIAZEPINESalprazolam (ALPRAZOLAMINTENSOL) 1 mgml oral conc
1-Covered
alprazolam 025 mg tablet 05 mgtablet 1 mg tablet 2 mg tablet
1-Covered QL (100 PER 30 DAYS)
clonazepam 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered QL (120 PER 30 DAY(S))
diazepam 2 mg tablet 5 mgtablet 10 mg tablet
1-Covered QL (100 PER 30 DAYS)
diazepam 5 mg5 ml solution 5mgml oral conc
1-Covered
lorazepam (LORAZEPAM INTENSOL)2 mgml oral conc
1-Covered
lorazepam 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered QL (100 PER 30 DAYS)
lorazepam 2 mgml oral conc 1-Covered
oxazepam 10 mg capsule 15 mgcapsule 30 mg capsule
1-Covered
BIPOLAR AGENTS (Drugs for Bipolar Disorder)
MOOD STABILIZERSlithium carbonate 150 mg capsule300 mg tablet er 300 mg capsule300 mg tablet 450 mg tablet er600 mg capsule
2-MedicalCarve out
lithium citrate 8 meq5 ml solution 2-MedicalCarve out
LITHOBID (lithium carbonate) ER300 MG TABLET
2-MedicalCarve out
BLOOD GLUCOSE REGULATORS (Drugs for Diabetes)
ANTIDIABETIC AGENTS (Drugs for High Blood Sugar)acarbose 100 mg tablet 1-Covered QL (3 PER 1 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
42
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acarbose 25 mg tablet 1-Covered QL (12 PER 1 DAYS)
acarbose 50 mg tablet 1-Covered QL (6 PER 1 DAYS)
ADLYXIN (lixisenatide) 10-20 MCGSTARTER PACK 20 MCGMAINTENANCE PK
1-Covered PA
alogliptin benzoate 625 mg tablet125 mg tablet 25 mg tablet
1-Covered ST
alogliptin benzoatemetformin hclbenzmetformin 125-1000 tabletbenzmetformin 125-500mg tablet
1-Covered ST
alogliptin benzoatepioglitazonehcl benzpioglitazone 125-15 mgtablet benzpioglitazone 125-45mg tablet benzpioglitazone 125-30 mg tablet benzpioglitazone 25mg-30mg tabletbenzpioglitazone 25 mg-45mgtablet benzpioglitazone 25 mg-15mg tablet
1-Covered ST
AVANDIA (rosiglitazone maleate) 2MG TABLET 4 MG TABLET
1-Covered QL (60 PER 30 DAYS)
glimepiride 1 mg tablet 2 mgtablet 4 mg tablet
1-Covered STAR (Preferred Drug)
glipizide 25 mg tab er 24 5 mgtablet 5 mg tab er 24 10 mg taber 24 10 mg tablet
1-Covered STAR (Preferred Drug)
glyburide 125 mg tablet 25 mgtablet 5 mg tablet
1-Covered STAR (Preferred Drug)
glyburidemetformin hcl 125-250mg tablet 25-500 mg tablet 5mg-500mg tablet
1-Covered STAR (Preferred Drug)
JARDIANCE (empagliflozin) 10 MGTABLET 25 MG TABLET
1-Covered PA QL (1 PER 1 DAYS)
metformin hcl 500 mg tablet 500mg tab er 24h 750 mg tab er 24h850 mg tablet 1000 mg tablet
1-Covered STAR (Preferred Drug)
METFORMIN HCL ER ER 500 MGTABLET ER 750 MG TABLET
1-Covered STAR (Preferred Drug)
nateglinide 60 mg tablet 120 mgtablet
1-Covered ST
pioglitazone hcl 15 mg tablet 30mg tablet 45 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
43
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PIOGLITAZONE HCL 15 MG TABLET30 MG TABLET 45 MG TABLET
1-Covered
SYNJARDY(empagliflozinmetformin hcl) 5-1000 MG TABLET
1-Covered PA QL (2 PER 1 DAY(S))
SYNJARDY(empagliflozinmetformin hcl) 5-500 MG TABLET 125-500 MGTABLET 125-1000 MG TABLET
1-Covered PA QL (2 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 10-MG TABLET 125-MG TAB
1-Covered PA QL (2 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 25-1000 MG TABLET
1-Covered PA QL (1 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 5-1000 MG TABLET
1-Covered PA QL (2 PER 1)
tolbutamide 500 mg tablet 1-Covered
TRULICITY (dulaglutide) 075MG05 ML PEN 15 MG05 ML PEN
1-Covered PA QLC (1 penweek)
TRULICITY 3 MG05 ML PEN 45MG05 ML PEN
1-Covered PA QL (05 PER 1 WEEK(S))
VICTOZA 2-PAK (liraglutide) -18MG3 ML PEN
1-Covered PA QLC (6 ml (2 pens)30 days)
VICTOZA 3-PAK (liraglutide) -18MGML PEN
1-Covered PA QLC (9 ml (3 pens)30 days)
GLYCEMIC AGENTS (Drugs for Low Blood Sugar)BAQSIMI (glucagon) 3 MG SPRAYTWO PACK 3 MG SPRAY ONEPACK
1-Covered QL (2 PER 30 DAY(S))
GLUCAGON EMERGENCY KIT(glucagon hcl) 1 MG
1-Covered
GLUCAGON EMERGENCY KIT(glucagonhuman recombinant) 1MG
1-Covered
terbinafine hcl (JOCK ITCH) 1 cream (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
44
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
INSULINSADMELOG (insulin lispro) 100UNITML VIAL
1-Covered
ADMELOG SOLOSTAR (insulin lispro)100 UNITML
1-Covered PA
BASAGLAR KWIKPEN U-100 (insulinglarginehuman recombinantanalog) UNITML
1-Covered
HUMALOG (insulin lispro) 100UNITML CARTRIDGE
1-Covered PA
HUMALOG MIX 75-25 (insulin lisproprotamine and insulin lispro) -VIAL (
1-Covered
HUMALOG MIX 75-25 KWIKPEN(insulin lispro protamine and insulinlispro) -(
1-Covered PA
HUMULIN 70-30 (insulin nph humanisophaneinsulin regular human) -VIAL
1-Covered
HUMULIN 7030 KWIKPEN (insulinnph human isophaneinsulinregular human)
1-Covered PA
HUMULIN N (insulin nph humanisophane) 100 UITML VIAL
1-Covered
HUMULIN R (insulin regular human)100 UNITML VIAL
1-Covered
HUMULIN R U-500 (insulin regularhuman) UNITML VIAL
1-Covered
insulin lispro 100ml insuln pen 1-Covered PA
insulin lispro 100ml vial 1-Covered
INSULIN LISPRO PROTAMINE MIX(insulin lispro protamine and insulinlispro) 75-25 KWKPN (
1-Covered PA
NOVOLIN 70-30 (insulin nph humanisophaneinsulin regular human)70-30 100 UNITML VIAL RELION 70-30 VIAL
1-Covered
NOVOLIN N (insulin nph humanisophane) N 100 UNITML VIALRELION N 100 UNITML
1-Covered
NOVOLIN R (insulin regular human)R 100 UNITML VIAL RELION R 100UNITML
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
45
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
BLOOD PRODUCTSMODIFIERSVOLUME EXPANDERS (Drugs forBlood Disorders)
ANTICOAGULANTS (Blood Thinners)COUMADIN (warfarin sodium) 1MG TABLET 2 MG TABLET 25 MGTABLET 3 MG TABLET 4 MG TABLET5 MG TABLET 6 MG TABLET 75 MGTABLET 10 MG TABLET
1-Covered
ELIQUIS (apixaban) 25 MG TABLET5 MG TABLET
1-Covered QL (2 PER 1 DAY(S))
ELIQUIS (apixaban) DVT-PE TREATSTART 5MG
1-Covered QLC (1 PACK6 MONTHS)
ENOXAPARIN SODIUM 120 MG08ML SYR
1-Covered
ENOXAPARIN SODIUM 30 MG03ML SYR 40 MG04 ML SYR 60MG06 ML SYR 80 MG08 ML SYR100 MGML SYRINGE 150 MGMLSYRINGE
1-Covered PA
enoxaparin sodium 30mg03ml40mg04ml 60mg06ml80mg08ml 100 mgml120mg8ml 150 mgml
1-Covered PA
HEPARIN SODIUM SOD 5000UNITML VIAL SOD 10000 UNITMLVL SOD 20000 UNITML VL 50000UNIT5 ML VIAL
1-Covered
heparin sodiumporcine 5000mlvial 10000ml vial 20000ml vial
1-Covered
heparin sodiumporcinepf 1000mlvial
1-Covered
warfarin sodium (JANTOVEN) 1 mgtablet 2 mg tablet 25 mg tablet3 mg tablet 4 mg tablet 5 mgtablet 6 mg tablet 75 mg tablet10 mg tablet
1-Covered
warfarin sodium 1 mg tablet 2 mgtablet 25 mg tablet 3 mg tablet4 mg tablet 5 mg tablet 6 mgtablet 75 mg tablet 10 mg tablet
1-Covered
XARELTO (rivaroxaban) 10 MGTABLET 15 MG TABLET 20 MGTABLET
1-Covered QL (1 PER 1 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
46
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
XARELTO (rivaroxaban) DVT-PETREAT START 30D
1-Covered QLC (1 PACK6 MONTHS)
BLOOD FORMATION MODIFIERS (Blood Formation Drugs)anagrelide hcl 05 mg capsule 1mg capsule
1-Covered
EPOGEN (epoetin alfa) 2000UNITSML VIAL 3000 UNITSMLVIAL 4000 UNITSML VIAL 10000UNITSML VIAL 20000 UNITSMLVIAL
1-Covered PA SP
PROCRIT (epoetin alfa) 2000UNITSML VIAL 3000 UNITSMLVIAL 4000 UNITSML VIAL 10000UNITSML VIAL 20000 UNITSMLVIAL 40000 UNITSML VIAL
1-Covered PA SP
HEMOSTASIS AGENTS (Drugs to Stop Bleeding)ADVATE (antihemophilic factor(fviii) recombinantfull length) 200-400 VIAL 401-800 VIAL 801-1200VIAL 1201-1800 VIAL 1801-2400VIAL 2401-3600 VIAL 3601-4800VIAL
2-MedicalCarve out
ADYNOVATE (antihemophilicfactor (fviii) recombinant fulllength peg) 200-400 VIAL 401-800VIAL 750 VIAL 801-1250 VIAL1251-2500 VL 1500 VIAL 3000VIAL
2-MedicalCarve out
AFSTYLA (antihemophilic factor viiirecombsingle-chnb-domtruncated) 250 VIAL -- 500 VIAL --1000 VIAL -- 1500 RANGE VIAL --2000 VIAL -- 2500 RANGE VIAL --3000 VIAL --
2-MedicalCarve out
ALPHANATE (antihemophilic factorhumanvon willebrandfactorhuman) 250-100 VIALhuman) 500-200 VIAL human)1000-400 VIAL human) 1500-600VIAL human) 2000-800 VIALhuman)
2-MedicalCarve out
ALPHANINE SD (factor ix) SD 500VIAL SD 1000 VIAL SD 1500 VIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
47
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALPROLIX (factor ix recombinantfc fusion protein) 250 500 10002000 3000 4000
2-MedicalCarve out
BENEFIX (factor ix humanrecombinant) 250 500 10002000 3000
2-MedicalCarve out
COAGADEX (coagulation factor x)250 VIAL 500 VIAL
2-MedicalCarve out
CORIFACT (factor xiii) KIT 2-MedicalCarve out
ELOCTATE (antihemophilic factor(fviii) recombinant fc fusionprotein) 250 500 750 1000 15002000 3000 4000 5000 6000
2-MedicalCarve out
ESPEROCT (antihemophilic factor(fviii) rec b-dom truncated peg-exei) 500 VIAL -- 1000 VIAL --1500 VIAL -- 2000 VIAL -- 3000VIAL --
2-MedicalCarve out
FEIBA NF (anti-inhibitor coagulantcomplex) 500 (NOMINAL) - 1000(NOMINAL) - 2500 (NOMINAL) -
2-MedicalCarve out
FIBRYGA (fibrinogen) 1 GRAMRANGE VIAL
2-MedicalCarve out
HELIXATE FS (antihemophilic factor(fviii) recombinantfull length) 250UNIT VIAL 500 UNIT VIAL 1000 UNITVIAL 2000 UNIT VIAL 3000 UNITSVIAL
2-MedicalCarve out
HEMLIBRA (emicizumab-kxwh) 30MGML VIAL - 60 MG04 ML VIAL - 105 MG07 ML VIAL - 150 MGMLVIAL -
2-MedicalCarve out
HEMOFIL M (antihemophilic factorhuman) 250 500 1000 1700
2-MedicalCarve out
HUMATE-P (antihemophilic factorhumanvon willebrandfactorhuman) -600 human) -1200human) -2400 human)
2-MedicalCarve out
IDELVION (factor ixrecombinantalbumin fusionprotein) 250 VIAL 500 VIAL 1000VIAL 2000 VIAL 3500 VIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
48
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
IXINITY (factor ix humanrecombinant threonine 148) 500RANGE 500 VIAL 1000 VIAL 1000RANGE 1000 VIAL -2 VLS 1000RANGE-2 VLS 1500 RANGE-2 VLS1500 VIAL -2 VLS 1500 VIAL 1500RANGE
2-MedicalCarve out
JIVI (antihemophilic factor (fviii)rec b-domain deleted peg-aucl)500 VIAL -- 1000 VIAL -- 2000 VIAL-- 3000 VIAL --
2-MedicalCarve out
KCENTRA (human prothrombincomplex concentrate (pcc) 4-factor) 500 VIAL 4- 1000 VIAL 4-
2-MedicalCarve out
KOGENATE FS (antihemophilicfactor (fviii) recombinantfulllength) 250 UNIT VIAL 500 UNITVIAL 1000 UNITS VIAL 2000 UNITVIAL 3000 UNITS VIAL
2-MedicalCarve out
KOVALTRY (antihemophilic factor(fviii) recombinantfull length) 250KIT 500 KIT 1000 KIT 2000 KIT3000 KIT
2-MedicalCarve out
MONONINE (factor ix) 1000 UNITVIAL
2-MedicalCarve out
NOVOEIGHT (antihemophilic factorviii recombinant b-domaintruncated) 250 VIAL RECOMINANT- 500 VIAL RECOMINANT - 1000VIAL RECOMINANT - 1500 VIALRECOMINANT - 2000 VIALRECOMINANT - 3000 VIALRECOMINANT -
2-MedicalCarve out
NOVOSEVEN RT (coagulationfactor viia (recombinant)) 1 MGVIAL 2 MG VIAL 5 MG VIAL 8 MGVIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
49
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NUWIQ (antihemophilic factor viiirec hek cell b-domain deleted)250 VIAL - 250 VIAL PACK - 500VIAL - 500 VIAL PACK - 1000 VIAL - 1000 VIAL PACK - 2000 VIALPACK - 2000 VIAL - 2500 VIALPACK - 2500 VIAL - 3000 VIAL -3000 VIAL PACK - 4000 VIAL PACK- 4000 VIAL -
2-MedicalCarve out
OBIZUR (antihemophilic factor viiirecombinant porcine sequence)500 VIAL 500 VIAL - 5 VIALS 500VIAL -10 VIALS
2-MedicalCarve out
phytonadione (vit k1) 5 mg tablet 1-Covered
PROFILNINE (factor ix complexprothrombin cplx conc(pcc) no43-factor) 500 VIAL 3- 1000 VIAL 3-1500 VIAL 3-
2-MedicalCarve out
REBINYN (factor ix (human)recombinant pegylated) 500 VIAL1000 VIAL 2000 VIAL
2-MedicalCarve out
RECOMBINATE (antihemophilicfactor viii human recombinant)220-400 VIAL 401-800 VIAL 801-1240 VL 1241-1800 V 1801-2400V
2-MedicalCarve out
RIASTAP (fibrinogen) VIAL 2-MedicalCarve out
RIXUBIS (factor ix humanrecombinant) 250 500 10002000 3000
2-MedicalCarve out
SEVENFACT 1 MG VIAL 5 MG VIAL 2-MedicalCarve out
TRETTEN (factor xiii a-subunitrecombinant) 2500 UNIT VIAL(fctor -recombinnt)
2-MedicalCarve out
VONVENDI (von willebrand factor(recombinant)) 650 VIAL 1300VIAL
2-MedicalCarve out
WILATE (antihemophilic factorhumanvon willebrandfactorhuman) 450-450 VIALhuman) 500-500 VIAL human)900-900 VIAL human) 1000-1000VIAL human)
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
50
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
XYNTHA (antihemophilic factor(factor viii) recombb-domaindeleted) 250 KIT - 500 KIT - 1000KIT - 2000 KIT -
2-MedicalCarve out
XYNTHA SOLOFUSE (antihemophilicfactor (factor viii) recombb-domain deleted) 250 KIT - 500 KIT -1000 KIT - 2000 KIT - 3000 KIT -
2-MedicalCarve out
PLATELET MODIFYING AGENTScilostazol 50 mg tablet 100 mgtablet
1-Covered
clopidogrel bisulfate 75 mg tablet 1-Covered AL1 (At least 18 yrs old)
dipyridamole 25 mg tablet 50 mgtablet 75 mg tablet
1-Covered
CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation)
ALPHA-ADRENERGIC AGONISTSclonidine hcl 01 mg tablet 02 mgtablet 03 mg tablet
1-Covered
CLONIDINE HCL 01 MG TABLET 02MG TABLET 03 MG TABLET
1-Covered
guanfacine hcl 1 mg tablet 2 mgtablet
1-Covered
methyldopa 250 mg tablet 500mg tablet
1-Covered
ALPHA-ADRENERGIC BLOCKING AGENTSdoxazosin mesylate 1 mg tablet 2mg tablet 4 mg tablet 8 mgtablet
1-Covered
PHENOXYBENZAMINE HCL 10 MGCAP
1-Covered
phenoxybenzamine hcl 10 mgcapsule
1-Covered
prazosin hcl 1 mg capsule 2 mgcapsule 5 mg capsule
1-Covered
PRAZOSIN HCL 1 MG CAPSULE 2MG CAPSULE 5 MG CAPSULE
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
51
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terazosin hcl 1 mg capsule 2 mgcapsule 5 mg capsule 10 mgcapsule
1-Covered
TERAZOSIN HCL 1 MG CAPSULE 2MG CAPSULE 5 MG CAPSULE 10MG CAPSULE
1-Covered
ANGIOTENSIN II RECEPTOR ANTAGONISTSirbesartan 75 mg tablet 150 mgtablet 300 mg tablet
1-Covered ST
LOSARTAN POTASSIUM 25 MG TAB50 MG TAB 100 MG TAB
1-Covered STAR (Preferred Drug)
losartan potassium 25 mg tablet50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
valsartan 40 mg tablet 80 mgtablet 160 mg tablet 320 mgtablet
1-Covered ST
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORSbenazepril hcl 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered STAR (Preferred Drug)
captopril 125 mg tablet 25 mgtablet 50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
CAPTOPRIL 125 MG TABLET 25 MGTABLET 50 MG TABLET 100 MGTABLET
1-Covered STAR (Preferred Drug)
ENALAPRIL MALEATE 25 MG TAB 5MG TABLET 10 MG TAB 20 MG TAB
1-Covered STAR (Preferred Drug)
enalapril maleate 25 mg tablet 5mg tablet 10 mg tablet 20 mgtablet
1-Covered STAR (Preferred Drug)
fosinopril sodium 10 mg tablet 20mg tablet 40 mg tablet
1-Covered
lisinopril 25 mg tablet 5 mg tablet10 mg tablet 20 mg tablet 30 mgtablet 40 mg tablet
1-Covered STAR (Preferred Drug)
moexipril hcl 75 mg tablet 15 mgtablet
1-Covered
quinapril hcl 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered
ramipril 125 mg capsule 25 mgcapsule 5 mg capsule 10 mgcapsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
52
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
RAMIPRIL 125 MG CAPSULE 25MG CAPSULE 5 MG CAPSULE 10MG CAPSULE
1-Covered
trandolapril 1 mg tablet 2 mgtablet 4 mg tablet
1-Covered
ANTIARRHYTHMICS (Drugs for Irregular Heart Rhythm)amiodarone hcl (PACERONE) 200mg tablet
1-Covered
amiodarone hcl 200 mg tablet 1-Covered
disopyramide phosphate 100 mgcapsule
1-Covered
flecainide acetate 50 mg tablet100 mg tablet 150 mg tablet
1-Covered
mexiletine hcl 150 mg capsule 200mg capsule 250 mg capsule
1-Covered
MEXILETINE HCL 150 MG CAPSULE200 MG CAPSULE 250 MGCAPSULE
1-Covered
propafenone hcl 150 mg tablet225 mg tablet 300 mg tablet
1-Covered
quinidine gluconate 324 mg tableter
1-Covered
quinidine sulfate 200 mg tablet300 mg tablet
1-Covered
SOTALOL 80 MG TABLET 120 MGTABLET 160 MG TABLET 240 MGTABLET
1-Covered
SOTALOL AF 80 MG TABLET 120 MGTABLET
1-Covered
sotalol hcl (SORINE) 80 mg tablet120 mg tablet 160 mg tablet 240mg tablet
1-Covered
sotalol hcl 80 mg tablet 120 mgtablet 160 mg tablet 240 mgtablet
1-Covered
BETA-ADRENERGIC BLOCKING AGENTSatenolol 25 mg tablet 50 mgtablet 100 mg tablet
1-Covered STAR (Preferred Drug)
ATENOLOL 25 MG TABLET 50 MGTABLET 100 MG TABLET
1-Covered STAR (Preferred Drug)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
53
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
bisoprolol fumarate 5 mg tablet 10mg tablet
1-Covered
carvedilol 3125 mg tablet 625 mgtablet 125 mg tablet 25 mgtablet
1-Covered STAR (Preferred Drug)
labetalol hcl 100 mg tablet 200mg tablet 300 mg tablet
1-Covered
LABETALOL HCL 100 MG TABLET200 MG TABLET 300 MG TABLET
1-Covered
metoprolol succinate 200 mg taber 24h
1-Covered QL (60 PER 30 DAYS) MDD (2 PerDay) STAR (Preferred Drug)
metoprolol succinate 25 mg taber 50 mg tab er 100 mg tab er
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
METOPROLOL SUCCINATE ER 200MG TAB
1-Covered QL (60 PER 30 DAYS) MDD (2 PerDay) STAR (Preferred Drug)
METOPROLOL SUCCINATE ER 25MG TAB ER 50 MG TAB ER 100 MGTAB
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
metoprolol tartrate 25 mg tablet50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
nadolol 20 mg tablet 40 mgtablet 80 mg tablet
1-Covered STAR (Preferred Drug)
NADOLOL 20 MG TABLET 40 MGTABLET 80 MG TABLET
1-Covered STAR (Preferred Drug)
pindolol 5 mg tablet 10 mg tablet 1-Covered STAR (Preferred Drug)
propranolol hcl 10 mg tablet 20mg5 ml solution 20 mg tablet 40mg tablet 40mg5ml solution 60mg tablet 60 mg cap sa 24h 80mg tablet 80 mg cap sa 24h 120mg cap sa 24h 160 mg cap sa 24h
1-Covered
CALCIUM CHANNEL BLOCKING AGENTSAMLODIPINE BESYLATE 25 MG TAB5 MG TAB 10 MG TAB
1-Covered STAR (Preferred Drug)
amlodipine besylate 25 mg tablet5 mg tablet 10 mg tablet
1-Covered STAR (Preferred Drug)
DILTIAZEM 24HR ER (CD) 24HER(CD) 120 MG CP 24H ER(CD)240 MG CP 24H ER(CD) 180 MGCP 24H ER(CD) 360 MG CP 24HER(CD) 300 MG CP
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
54
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DILTIAZEM 24HR ER (XR) 24H ER(XR)240 MG CP 24H ER(XR) 180 MG CP
1-Covered
diltiazem hcl (CARTIA XT) 120 mgcap er 180 mg cap er 240 mgcap er 300 mg cap er
1-Covered
diltiazem hcl (DILT-XR) 120 mg caper - 180 mg cap er - 240 mg caper -
1-Covered
diltiazem hcl (TAZTIA XT) 120 mgcap 180 mg cap 240 mg cap 300mg cap 360 mg cap
1-Covered
diltiazem hcl 30 mg tablet 60 mgcap er 12h 60 mg tablet 90 mgtablet 90 mg cap er 12h 120 mgcap sa 24h 120 mg tablet 120 mgcap er 24h 120 mg cap er deg120 mg cap er 12h 180 mg cap sa24h 180 mg cap er deg 180 mgcap er 24h 240 mg cap er 24h 240mg cap er deg 240 mg cap sa24h 300 mg cap er 24h 300 mgcap sa 24h 360 mg cap sa 24h360 mg cap er 24h
1-Covered
felodipine 25 mg tab er 5 mg taber 10 mg tab er
1-Covered
FELODIPINE ER ER 25 MG TABLETER 5 MG TABLET ER 10 MG TABLET
1-Covered
nicardipine hcl 20 mg capsule 30mg capsule
1-Covered
nifedipine (AFEDITAB CR) 30 mgtablet er 60 mg tablet er
1-Covered
nifedipine (NIFEDICAL XL) 30 mgtab er 24 60 mg tab er 24
1-Covered
NIFEDIPINE 10 MG CAPSULE 1-Covered
nifedipine 10 mg capsule 20 mgcapsule 30 mg tablet er 30 mgtab er 24 60 mg tablet er 60 mgtab er 24 90 mg tablet er 90 mgtab er 24
1-Covered
nisoldipine 20 mg tab er 30 mgtab er 40 mg tab er
1-Covered
verapamil hcl 40 mg tablet 80 mgtablet 120 mg tablet 120 mgtablet er 180 mg tablet er 240 mgtablet er
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
55
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CARDIOVASCULAR AGENTS OTHERamiloride hclhydrochlorothiazideamiloridehydrochlorothiazide 5mg-50 mg tablet
1-Covered
amlodipine besylatebenazeprilhcl 25mg-10mg capsule 5 mg-20mg capsule 5 mg-10 mg capsule5 mg-40 mg capsule 10 mg-20mgcapsule 10 mg-40mg capsule
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day) STAR(Preferred Drug)
atenololchlorthalidone 50 mg-tablet 100mg-tablet
1-Covered STAR (Preferred Drug)
benazepril hclhydrochlorothiazidebenazeprilhydrochlorothiazide 5-625mg tabletbenazeprilhydrochlorothiazide 10-125mg tabletbenazeprilhydrochlorothiazide 20mg-25mg tabletbenazeprilhydrochlorothiazide 20-125 mg tablet
1-Covered STAR (Preferred Drug)
bisoprololfumaratehydrochlorothiazidebisoprololhydrochlorothiazide 25-tabletbisoprololhydrochlorothiazide 5-tabletbisoprololhydrochlorothiazide 10-tablet
1-Covered
BISOPROLOL-HYDROCHLOROTHIAZIDE -10-625MG TAB -25-625 MG TB -5-625MG TAB
1-Covered
captoprilhydrochlorothiazide 25mg-25mg tablet 25 mg-15mgtablet 50 mg-25mg tablet 50 mg-15mg tablet
1-Covered STAR (Preferred Drug)
digoxin (DIGITEK) 125 mcg tablet250 mcg tablet
1-Covered STAR (Preferred Drug)
digoxin (DIGOX) 125 mcg tablet250 mcg tablet
1-Covered STAR (Preferred Drug)
digoxin 125 mcg tablet 250 mcgtablet
1-Covered STAR (Preferred Drug)
digoxin 50 mcgml solution 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
56
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fosinoprilsodiumhydrochlorothiazidefosinoprilhydrochlorothiazide 10-125mg tabletfosinoprilhydrochlorothiazide 20-125 mg tablet
1-Covered
FOSINOPRIL-HYDROCHLOROTHIAZIDE -10-125MG TAB -20-125 MG TAB
1-Covered
irbesartanhydrochlorothiazide150-tablet 300-tablet
1-Covered ST
LANOXIN (digoxin) 125 MCGTABLET 250 MCG TABLET
1-Covered STAR (Preferred Drug)
lisinoprilhydrochlorothiazide 10-125mg tablet 20-125 mg tablet20 mg-25mg tablet
1-Covered STAR (Preferred Drug)
losartanpotassiumhydrochlorothiazidelosartanhydrochlorothiazide 50-125 mg tabletlosartanhydrochlorothiazide100mg-25mg tabletlosartanhydrochlorothiazide 100-125mg tablet
1-Covered STAR (Preferred Drug)
LOSARTAN-HYDROCHLOROTHIAZIDE -50-125MG TAB -100-125 MG TAB -100-25MG TAB
1-Covered STAR (Preferred Drug)
pentoxifylline 400 mg tablet er 1-Covered
spironolactonehydrochlorothiazide spironolacthydrochlorothiazid25 mg-25mg tablet
1-Covered
triamterenehydrochlorothiazide375-25 mg capsule 375-25 mgtablet 50 mg-25mg capsule 75mg-50mg tablet
1-Covered
valsartanhydrochlorothiazide 80-125mg tablet 160-125mg tablet160mg-25mg tablet 320-125mgtablet 320mg-25mg tablet
1-Covered ST
DIURETICS CARBONIC ANHYDRASE INHIBITORSacetazolamide 125 mg tablet 250mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
57
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ACETAZOLAMIDE 125 MG TABLET250 MG TABLET
1-Covered
DIURETICS LOOPbumetanide 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered
furosemide 10 mgml solution 20mg tablet 40mg5ml solution 40mg tablet 80 mg tablet
1-Covered STAR (Preferred Drug)
DIURETICS POTASSIUM-SPARINGamiloride hcl 5 mg tablet 1-Covered
spironolactone 25 mg tablet 50mg tablet 100 mg tablet
1-Covered
SPIRONOLACTONE 25 MG TABLET50 MG TABLET 100 MG TABLET
1-Covered
DIURETICS THIAZIDEchlorothiazide 250 mg tablet 500mg tablet
1-Covered
chlorthalidone 25 mg tablet 50 mgtablet
1-Covered
CHLORTHALIDONE 25 MG TABLET50 MG TABLET
1-Covered
DIURIL (chlorothiazide) 250 MG5ML ORAL SUSP
1-Covered
hydrochlorothiazide 125 mgcapsule 25 mg tablet 50 mgtablet
1-Covered STAR (Preferred Drug)
indapamide 125 mg tablet 25mg tablet
1-Covered
methyclothiazide 5 mg tablet 1-Covered
metolazone 25 mg tablet 5 mgtablet 10 mg tablet
1-Covered
DYSLIPIDEMICS FIBRIC ACID DERIVATIVES (Drugs for HighCholesterol)
fenofibrate 54 mg tablet 160 mgtablet
1-Covered ST
FENOFIBRATE 54 MG TABLET 160MG TABLET
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
58
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fenofibratemicronized 67 mgcapsule 134 mg capsule 200 mgcapsule
1-Covered ST
gemfibrozil 600 mg tablet 1-Covered
GEMFIBROZIL 600 MG TABLET 1-Covered
TRIGLIDE (fenofibratenanocrystallized) 160 MG TABLET
1-Covered ST
DYSLIPIDEMICS HMG COA REDUCTASE INHIBITORS (Drugs for HighCholesterol)
atorvastatin calcium 10 mg tablet20 mg tablet 40 mg tablet 80 mgtablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
ATORVASTATIN CALCIUM 10 MGTABLET 20 MG TABLET 40 MGTABLET 80 MG TABLET
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
lovastatin 10 mg tablet 20 mgtablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
rosuvastatin calcium 5 mg tablet10 mg tablet 20 mg tablet 40 mgtablet
1-Covered ST QL (30 PER 30 DAY(S))
simvastatin 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered STAR (Preferred Drug)
DYSLIPIDEMICS OTHER (Other Drugs for High Cholesterol)cholestyramine (with sugar) suar) 4powder
1-Covered
cholestyramineaspartame(PREVALITE) 4 g powder
1-Covered
cholestyramineaspartame 4 gpowder
1-Covered
COLESTID (colestipol hcl)FLAVORED GRANULES
1-Covered
colestipol hcl 1 tablet 5 ranules 5packet
1-Covered
ezetimibe 10 mg tablet 1-Covered
niacin (ENDUR-ACIN) 250 mgtablet er - 500 mg tablet er - 750mg tablet er -
1-Covered
niacin (SLO-NIACIN) 500 mg tableter -
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
59
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NIACIN 100 MG TABLET TR 500 MGTABLET
1-Covered
niacin 50 mg tablet 100 mg tablet250 mg capsule er 250 mg tablet250 mg tablet er 500 mg tablet500 mg tablet er 500 mg tab er24h 500 mg capsule er 750 mgtablet er 1000 mg tablet er
1-Covered
OMEGA-3 ACID ETHYL ESTERS -1GM CAP
1-Covered QL (4 PER 1 DAY(S))
omega-3 acid ethyl esters omea-1capsule
1-Covered QL (4 PER 1 DAY(S))
VASODILATORS DIRECT-ACTING ARTERIAL (Drugs for RelaxingArteries)
hydralazine hcl 10 mg tablet 25mg tablet 50 mg tablet 100 mgtablet
1-Covered
minoxidil 25 mg tablet 10 mgtablet
1-Covered
VASODILATORS DIRECT-ACTING ARTERIALVENOUS (Drugs forRelaxing Arteries and Veins)
ISOSORBIDE DINITRATE 5 MG TAB10 MG TAB 20 MG TAB 30 MG TAB
1-Covered STAR (Preferred Drug)
isosorbide dinitrate 5 mg tablet 10mg tablet 20 mg tablet 30 mgtablet 40 mg tablet er
1-Covered STAR (Preferred Drug)
isosorbide mononitrate 10 mgtablet 20 mg tablet 30 mg tab er24h 60 mg tab er 24h 120 mg taber 24h
1-Covered STAR (Preferred Drug)
NITRO-BID (nitroglycerin) -2OINTMENT
1-Covered
nitroglycerin (MINITRAN) 01mghrpatch 02mghr patch 04mghrpatch 06mghr patch
1-Covered
nitroglycerin (NITRO-TIME) 25 mgcapsule er - 65 mg capsule er - 9mg capsule er -
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
60
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
nitroglycerin 01mghr patch td2402mghr patch td24 03 mg tabsubl 04mghr patch td24 04 mgtab subl 06 mg tab subl 06mghrpatch td24 25 mg capsule er 65mg capsule er 9 mg capsule er400mcgspr spray
1-Covered
NITROGLYCERIN 400 MCG SPRAY 1-Covered
CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions)
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTSAMPHETAMINES
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 15 mg cap er 24h
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old) MDD (1 Per Day)
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 5 mg cap erdextroamphetamineamphetamine 10 mg cap erdextroamphetamineamphetamine 20 mg cap erdextroamphetamineamphetamine 25 mg cap erdextroamphetamineamphetamine 30 mg cap er
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old)
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 5 mg tabletdextroamphetamineamphetamine 75 mg tabletdextroamphetamineamphetamine 10 mg tabletdextroamphetamineamphetamine 125 mg tabletdextroamphetamineamphetamine 15 mg tabletdextroamphetamineamphetamine 20 mg tabletdextroamphetamineamphetamine 30 mg tablet
1-Covered AL1 (3 to 18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
61
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
dextroamphetamine sulfate(ZENZEDI) 5 mg tablet 10 mgtablet
1-Covered AL1 (3 to 18 yrs old)
dextroamphetamine sulfate 5 mgcapsule er 5 mg tablet 10 mgcapsule er 10 mg tablet 15 mgcapsule er
1-Covered AL1 (3 to 18 yrs old)
DEXTROAMPHETAMINE SULFATE 5MG TAB 10 MG TAB
1-Covered AL1 (3 to 18 yrs old)
DEXTROAMPHETAMINE-AMPHET ER-15 MG CAP
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old) MDD (1 Per Day)
DEXTROAMPHETAMINE-AMPHET ER-ER 5 MG CAP -ER 10 MG CAP -ER20 MG CAP -ER 25 MG CAP -ER 30MG CAP
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old)
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS NON-AMPHETAMINES
atomoxetine hcl 10 mg capsule 18mg capsule 25 mg capsule 40 mgcapsule 60 mg capsule 80 mgcapsule 100 mg capsule
1-Covered PA
guanfacine hcl 1 mg tab er 2 mgtab er 3 mg tab er 4 mg tab er
1-Covered QL (1 PER 1 DAY(S))
METHYLPHENIDATE ER ER 18 MGTAB ER 27 MG TAB ER 36 MG TABER 54 MG TAB
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl (METADATEER) 20 mg tablet er
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl 10 mg tableter 18 mg tab er 24 20 mg tableter 27 mg tab er 24 36 mg tab er24 54 mg tab er 24
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl 5 mg tablet10 mg cpbp 30-70 10 mg tablet20 mg tablet 20 mg cpbp 30-7030 mg cpbp 30-70 40 mg cpbp 30-70 50 mg cpbp 30-70 60 mg cpbp30-70
1-Covered AL1 (6 to 18 yrs old)
METHYLPHENIDATE HCL 5 MGTABLET 10 MG TABLET 20 MGTABLET
1-Covered AL1 (6 to 18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
62
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CENTRAL NERVOUS SYSTEM OTHERacetaminophen (ATHENOL) 325mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (CHILD FEVERREDUCER) 120 mg supprect
1-Covered
acetaminophen (CHILD PAIN REL-FEVER REDUCER) 120 mg supprect-
1-Covered
acetaminophen (CHILDRENSFEVER REDUCER) 120 mg supprect
1-Covered
acetaminophen (CHILDRENSFEVER REDUCING) 120 mgsupprect
1-Covered
acetaminophen (CHILDRENS PAINAND FEVER) 160 mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (CHILDRENSSILAPAP) 160 mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (ED-APAP) 160mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (LITTLE REMEDIESFEVER-PAIN) 160 mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (M-PAP) 160mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (MAPAP) 160mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (MAPAP) 325 mgtablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (MASOPHEN) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRINEXTRA STRENGTH) 500 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRINPAIN RELIEF) 500 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRIN)160 mg5ml elixir -
1-Covered QLC (LIMIT TO 2 FILLS OF 120ML IN30 DAYS)
acetaminophen (NON-ASPIRIN)325 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN amp FEVER)500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
63
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acetaminophen (PAIN RELIEFEXTRA STRENGTH) 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN RELIEF) 160mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (PAIN RELIEF) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN RELIEVER)325 mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PHARBETOL) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (SHAKE THATACHE) 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (TACTINAL) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen 120 mg 650 mg 1-Covered
acetaminophen 160 mg5ml elixir 1-Covered QLC (LIMIT TO 2 FILLS OF 120ML IN30 DAYS)
acetaminophen 160 mg5ml liquid 1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 160 mg5ml oralsusp
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 160 mg5mlsolution
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 325 mg tablet500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
ACETAMINOPHEN CVS 325 MGGELCP 325 MG TABLET 500 MGTABLET 500 MG GELCAP
1-Covered QL (60 PER 30 DAY(S))
butalbitalacetaminophen(TENCON) 50mg-325mg tablet
1-Covered QL (48 PER 30 DAY(S))
butalbitalacetaminophen 50mg-325mg tablet
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
butalbitalacetaminophencaffeine butalbacetaminophencaffeine50-325-40 tablet
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
PAIN amp FEVER (acetaminophen)500 MG TABLET
1-Covered QL (60 PER 30 DAY(S))
PAIN RELIEF 325 MG TABLET 500MG GELCAP 500 MG TABLET
1-Covered QL (60 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
64
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
riluzole 50 mg tablet 1-Covered PA
RILUZOLE 50 MG TABLET 1-Covered PA
FIBROMYALGIA AGENTSduloxetine hcl 20 mg capsule dr30 mg capsule dr 60 mg capsuledr
1-Covered
pregabalin 20 mgml solution 1-Covered PA QLC (30 MLDAY)
pregabalin 225 mg capsule 300mg capsule
1-Covered PA QL (2 PER 1 DAY(S))
PREGABALIN 225 MG CAPSULE 300MG CAPSULE
1-Covered PA QL (2 PER 1 DAY(S))
pregabalin 25 mg capsule 50 mgcapsule 75 mg capsule 100 mgcapsule 150 mg capsule 200 mgcapsule
1-Covered PA QL (3 PER 1 DAY(S))
PREGABALIN 25 MG CAPSULE 50MG CAPSULE 75 MG CAPSULE 100MG CAPSULE 150 MG CAPSULE200 MG CAPSULE
1-Covered PA QL (3 PER 1 DAY(S))
SAVELLA (milnacipran hcl) 125 MGTABLET 25 MG TABLET 50 MGTABLET 100 MG TABLET TITRATIONPACK
1-Covered PA
MULTIPLE SCLEROSIS AGENTSAVONEX (interferon beta-1a)PREFILLED SYR 30 MCG KT -
1-Covered PA SP
AVONEX (interferon beta-1aalbumin human) 30 MCG VIALKIT -
1-Covered PA SP
AVONEX PEN (interferon beta-1a)30 MCG05 ML KIT -
1-Covered PA SP
DIMETHYL FUMARATE 30D START PK 1-Covered PA SP
DIMETHYL FUMARATE DR 120 MGCP DR 240 MG CP
1-Covered PA SP QL (2 PER 1 DAY(S))
glatiramer acetate (GLATOPA) 20mgml syringe
1-Covered PA SP QLC (1 SYRINGEDAY)
glatiramer acetate (GLATOPA) 40mgml syringe
1-Covered PA SP QLC (12SYRINGESMONTH)
glatiramer acetate 20 mgmlsyringe
1-Covered PA SP QLC (1 SYRINGEDAY)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
65
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
glatiramer acetate 40 mgmlsyringe
1-Covered PA SP QLC (12SYRINGESMONTH)
PLEGRIDY (peginterferon beta-1a)125 MCG05 ML SYRING - SYRINGESTARTER PACK -
1-Covered PA SP
PLEGRIDY PEN (peginterferon beta-1a) 125 MCG05 ML PEN - PEN INJSTARTER PACK -
1-Covered PA SP
TECFIDERA (dimethyl fumarate) DR120 MG CAPSULE DR 240 MGCAPSULE STARTER PACK
1-Covered PA SP
DENTAL AND ORAL AGENTS (Drugs for the Mouth)
DENTAL AND ORAL AGENTSchlorhexidine gluconate (PAROEX)012 mouthwash
1-Covered
chlorhexidine gluconate 012 mouthwash
1-Covered
PHOS-FLUR (fluoride (sodium)) -ORAL RINSE
1-Covered
triamcinolone acetonide(ORALONE) 01 paste (g)
1-Covered
triamcinolone acetonide 01 paste (g)
1-Covered
TRIAMCINOLONE ACETONIDE 01PASTE
1-Covered
DERMATOLOGICAL AGENTS (Drugs for the Skin)ACNE MEDICATION (benzoylperoxide) 5 GEL
1-Covered
ACNE MEDICATION 25 GEL 1-Covered
ammonium lactate (SKINTREATMENT) 12 lotion
1-Covered
ammonium lactate 12 cream(g) 12 lotion
1-Covered
benzoyl peroxide (ACNE CONTROLCLEANSER) 10 cleanser
1-Covered
benzoyl peroxide (ACNE FOAMINGWASH) 10 cleanser
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
66
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
benzoyl peroxide (ACNETREATMENT) 10 gel (gram)
1-Covered
benzoyl peroxide (ACNECLEAR) 10 gel (gram)
1-Covered
benzoyl peroxide (ADVANCEDEXFOLIATING CLEANSER) 5 cleanser
1-Covered
benzoyl peroxide (BP WASH) 5 10
1-Covered
benzoyl peroxide (BP) 5 gel(gram) 10 gel (gram)
1-Covered
benzoyl peroxide (BPO-10) cleanser -
1-Covered
benzoyl peroxide (BPO-5) cleanser -)
1-Covered
benzoyl peroxide (CLEAN-CLEARCONTINUOUS CONTROL) 10 cleanser -
1-Covered
benzoyl peroxide (DAYLOGICACNE FOAMING WASH) 10 cleanser
1-Covered
benzoyl peroxide (DAYLOGICACNE TREATMENT) 10 gel (gram)
1-Covered
benzoyl peroxide (FOAMING ACNEFACE WASH) 10 cleanser
1-Covered
benzoyl peroxide (PANOXYL) 10 cleanser
1-Covered
benzoyl peroxide 25 gel (gram)5 cleanser 5 gel (gram) 10 gel (gram) 10 cleanser
1-Covered
CALADRYL (pramoxinehclcalamine) 1-8 LOTION
1-Covered
calcipotriene 0005 cream (g)0005 oint (g) 0005 solution
1-Covered PA
chlorhexidine gluconate 4 liquid 1-Covered
CORTISPORIN(neomycinbacitracinpolymyxinbhydrocortisone) OINTMENT
1-Covered
DIFFERIN (adapalene) 01 GEL 1-Covered AL1 (Up to 25 yrs old)
DRITHOCREME HP (anthralin) 1CREAM
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
67
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DRYSOL (aluminum chloride) DAB--MATIC SLUTIN
1-Covered
EPIFOAM (hydrocortisoneacetatepramoxine hcl)
1-Covered
hydrocortisoneacetatepramoxine hclhydrocortisonepramoxine 1 -1 creamapplhydrocortisonepramoxine 25 -1 cream (g)hydrocortisonepramoxine 25 -1 creamapplhydrocortisonepramoxine 25-1(4g) creamappl
1-Covered
isotretinoin (AMNESTEEM) 10 mgcapsule 20 mg capsule 40 mgcapsule
1-Covered PA
isotretinoin (CLARAVIS) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin (MYORISAN) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin (ZENATANE) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin 10 mg capsule 20 mgcapsule 30 mg capsule 40 mgcapsule
1-Covered PA
LICE KILLING SHAMPOO 1-Covered
metronidazole 075 cream (g)075 gel (gram) 1 gel (gram)
1-Covered
pimecrolimus 1 cream (g) 1-Covered PA
piperonyl butoxidepyrethrins (LICEKILLING) 4-033 shampoo
1-Covered
piperonyl butoxidepyrethrins (LICEPYRINYL SHAMPOO) 4-033shampoo
1-Covered
piperonyl butoxidepyrethrins (LICETREATMENT) 4-033 shampoo
1-Covered
piperonyl butoxidepyrethrins (RID)4-033 shampoo
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
68
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
piperonylbutoxidepyrethrinspermethrin(COMPLETE LICE TREATMENT)butoxpyrethrpermet 4-33-5 kit
1-Covered
piperonylbutoxidepyrethrinspermethrin(LICE SOLUTION)butoxpyrethrpermet 4-33-5 kit
1-Covered
podofilox 05 solution 1-Covered
pramoxine hclcalamine(CALAHIST) 1 -8 lotion
1-Covered
pramoxine hclcalamine(CALAMINE MEDICATED) 1 -8 lotion
1-Covered
PROCTOFOAM-HC (hydrocortisoneacetatepramoxine hcl) PROCTO-1-1
1-Covered
RID (piperonylbutoxidepyrethrinspermethrin) 1-2-3 KIT KIT
1-Covered
SANTYL (collagenase clostridiumhistolyticum) OINTMENT
1-Covered QL (60 PER 30 DAYS)
selenium sulfide (ANTI-DANDRUFF)1 shampoo -
1-Covered
selenium sulfide (MEDICATEDDANDRUFF SHAMPOO) 1 shampoo
1-Covered
selenium sulfide (SELSUN BLUE) 1 shampoo
1-Covered
selenium sulfide 25 lotion 1-Covered
selenium sulfidealoe vera (SELSUNBLUE MOISTURIZING) 1 shampoo
1-Covered
tacrolimus 003 (g) 01 (g) 1-Covered PA
ELECTROLYTESMINERALSMETALSVITAMINS
ELECTROLYTEMINERAL REPLACEMENT09 sodium chloride iv soln 1-Covered PA
calcium carbonate 600 mg tablet 1-Covered
dextrose 5 in water in iv soln 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
69
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levocarnitine 330 mg tablet 1-Covered
potassium chloride in 09 sodiumchloride 09nacl 10 meql iv soln
1-Covered PA
ringers solution iv soln 1-Covered
sodium chloride irrigating solution09 soln
1-Covered
ELECTROLYTEMINERALMETAL MODIFIERSCHEMET (succimer) 100 MGCAPSULE
1-Covered PA
09 sodium chloride iv soln 1-Covered PA
CLINIMIX (amino acids 425 indextrose 5 in water) -SOLUTION
1-Covered PA
dextrose 10 and 045 sodiumchloride nacl -iv soln
1-Covered PA
dextrose 10 in water 10 10 dehp fr bg 10 10 iv soln
1-Covered PA
dextrose 5 and 045 sodiumchloride -04chlord -04iv soln
1-Covered PA
dextrose 5 in water 5 5 ivsoln 5 5 vial
1-Covered PA
levocarnitine (with sugar) 100mgml solution
1-Covered
levocarnitine 100 mgml solution330 mg tablet
1-Covered
MYNATAL (prenatal vitamins withcalciumferrous fumaratefolicacid) CAPSULE
1-Covered
O-CAL PRENATAL (prenatal vit withcalcium no127ferrousfumaratefolic acid) -TABLET
1-Covered
potassium chloride (KLOR-CONM10) meq tab er prt -
1-Covered
potassium chloride (KLOR-CONM20) meq tab er prt -
1-Covered
potassium chloride 8 meq tableter 10 meq tablet er 10 meqcapsule er 10 meq tab er prt 20meq tablet er 20 meq tab er prt20meq15ml liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
70
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
POTASSIUM CHLORIDE ER 8 MEQTABLET 10 (20 MEQ15ML) 10(40 MEQ30ML) ER 10 MEQ TABLETER 20 MEQ TABLET
1-Covered
potassium chloride in 09 sodiumchloride 20 meql soln 40 meqlsoln
1-Covered PA
PRENATABS FA (prenatal vits withcalcium no78ferrousfumaratefolic acid) TABLET
1-Covered
PRENATABS RX (prenatal vitaminwith calciumno76ironcarbonylfolic acid)TABLET
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid (MYNATAL PLUS) vitironfumfolic 65 mg-1 mg tablet
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid (MYNATAL-Z) vitiron fumfolic65 mg-1 mg tablet -
1-Covered
prenatal vits with calcium118ferrous fumaratefolic acid (SE-NATAL 19) pnv no8ironfumaratefa 29 mg-mg tab chew -9)
1-Covered
prenatal vits with calcium136ferrous fumaratefolic acid(VINATE-M) vit36ironfolic acd 27mg-mg tablet -
1-Covered
prenatal vits with calciumno115iron fumaratefolic acidno5ironfolic 29 mg-mg tab chew
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acid(M-NATAL PLUS) pnvcalcium72ironfolic 27 mg-1 mg tablet -
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acid(PREPLUS) pnvcalcium 72ironfolic27 mg-1 mg tablet
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acidpnvcalcium 72ironfolic 27 mg-1mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
71
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
prenatal vits with calciumno72ironcarbonylfolic acidpnvcalcium 72ironcarbfolic 29mg-1 mg tablet
1-Covered
prenatal vits with calciumno74ferrous fumaratefolic acidvitcal 74ironfolic 27 mg-1 mgtablet
1-Covered
SE-NATAL-19 (prenatal vitaminsno119iron fumaratefolic acid) --TABLET
1-Covered
sodium chloride irrigating solution09 soln
1-Covered
sodium polystyrene sulfonate 15g60 ml oral susp
1-Covered
sodium polystyrenesulfonatesorbitol solution (KIONEX)sulfonsorb 15 g60 ml oral susp
1-Covered
SPS (sodium polystyrenesulfonatesorbitol solution) 15GM60 ML SUSPENSION
1-Covered
TRINATE (prenatal vits with calciumno73ferrous fumaratefolic acid)TABLET
1-Covered
VITAMINS09 sodium chloride iv soln 1-Covered PA
ascorbate calcium 500 mg tablet 1-Covered
ascorbic acid (SOOTHINGPUREWAY-C) 500 mg tablet -
1-Covered
ascorbic acid 250 mg tablet 500mg5ml syrup 500 mg tablet 1000mg tablet
1-Covered
CALCIUM 500-VIT D3 MG-MCG TB 1-Covered
CALCIUM 600 MG TABLET 1-Covered
CALCIUM 600-VIT D3 MG-10MCGTB
1-Covered
calcium carbonate (OYSCO-500)500(1250) tablet -
1-Covered
calcium carbonate (SUPERCALCIUM) 600 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
72
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcium carbonate 500(1250)tablet 600 mg tablet
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (HI-CAL)carbonatevitamin 500 mg-200tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OS-CAL 500-VIT D3)carbonatevitamin mg-200 tablet --
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OYSCO 500-VIT D3)carbonatevitamin mg-200 tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OYSTERCAL-D)carbonatevitamin 500 mg-400tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) carbonatevitamin250 mg-125 tabletcarbonatevitamin 500 mg-600tablet carbonatevitamin 500 mg-400 tablet carbonatevitamin 500mg-200 tablet carbonatevitamin600 mg-400 tablet
1-Covered
calcium gluconate 60(650) mgtablet
1-Covered
calcium lactate 84 mg(648) tablet 1-Covered
cyanocobalamin (vitamin b-12) (B-12 DOTS) cyanocoalamin -) 500mcg talet -
1-Covered
cyanocobalamin (vitamin b-12)cyanocoalamin -500 mcg talet
1-Covered
dextrose 10 in water iv soln 1-Covered PA
dextrose 5 and 045 sodiumchloride -04chlord -04iv soln
1-Covered PA
dextrose 5 in lactated ringers -ivsoln
1-Covered PA
dextrose 5 in water in iv soln 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
73
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DEXTROSE IN WATER 5-IV SOLN10-IV SOLUTION
1-Covered PA
electrolytesdextrose(ELECTROLYTE) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (ORALYTE)solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (PEDIATRICELECTROLYTE) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (PEDIATRICFREEZER POPS) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
ferrous sulfate (CHILDRENS IRON)15 mgml drops
1-Covered
ferrous sulfate (FEOSOL) 325(65)mg tablet
1-Covered
ferrous sulfate (FEROSUL) 325(65)mg tablet
1-Covered
ferrous sulfate (FERRO-TIME) 325(65)mg tablet -
1-Covered
ferrous sulfate (FERROUSUL) 325(65)mg tablet
1-Covered
ferrous sulfate (PEDIA IRON) 15mgml drops
1-Covered
ferrous sulfate 15 mgml drops 220(44)5 solution 220 (44)5 elixir324(65)mg tablet dr 325(65) mgtablet dr 325(65) mg tablet
1-Covered
FERROUS SULFATE SULF 220 MG5ML LIQ SULF EC 325 MG TABLETSULFATE 325 MG TABLET
1-Covered
fluoride (sodium) 025(055) tabchew 05(11)mg tab chew 05mgml drops 1mg(22mg) tabchew
1-Covered STAR (Preferred Drug)
folic acid 04 mg tablet 08 mgtablet 1 mg tablet 20 mg capsule
1-Covered
FOLIC ACID 400 MCG TABLET 800MCG TABLET
1-Covered
IRON 65 MG TABLET 1-Covered
OYSTER SHELL CALCIUM 500 MG TB 1-Covered
OYSTER SHELL CALCIUM-VIT D3 250MG-312MCG
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
74
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PEDIATRIC IRON PHARM CHC15MGML DRP
1-Covered
pediatric multivit with acd3no21sodium fluorideno21fluoride 025 mgml dropsno21fluoride 05 mgml drops
1-Covered STAR (Preferred Drug)
pediatric multivitaminno16sodium fluoride -025 mg tabche -05 mg tab che -1 mg tabche
1-Covered
pediatric multivitamin no2sodiumfluoride w-025 mgml drops
1-Covered
pediatric multivitamin no2sodiumfluoride w-05 mgml drops
1-Covered STAR (Preferred Drug)
pediatric multivitaminno45sodium fluorideferroussulfate 45fluorideiron 025-10mldrops
1-Covered STAR (Preferred Drug)
pediatric multivitamins no17 withsodium fluoride -025 mg tab che -05 mg tab che -1 mg tab che
1-Covered STAR (Preferred Drug)
POLY-VITAMIN (multivitamin) -TABCHEW
1-Covered STAR (Preferred Drug)
POTASSIUM 99 MG TABLET 1-Covered
potassium bicarbonatecitric acid(EFFER-K) 25 meq tablet eff -
1-Covered
potassium bicarbonatecitric acid(K EFFERVESCENT) 25 meq tableteff
1-Covered
potassium bicarbonatecitric acid(KLOR-CON-EF) 25 meq tablet eff --
1-Covered
potassium bicarbonatecitric acid25 meq tablet eff
1-Covered
POTASSIUM CHL-NORMAL SALINE20 -ML IV SOLN 40 -ML IV SOLN
1-Covered
potassium chloride (KLOR-CONSPRINKLE) 10 meq capsule er -
1-Covered
potassium chloride 20meq15mlliquid
1-Covered
potassium chloridepotassiumbicarbonatecitric acidchloridebicarbcit 25 meq tableteff
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
75
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
potassium gluconate 595(99)mgtablet
1-Covered
PRENATAL MULTIVITAMIN TABLET 1-Covered
prenatal vit with calciumno129ferrous fumaratefolic acidno129ironfolic 27mg-08mgtablet
1-Covered
prenatal vit with calciumno130ferrous fumaratefolic acidno130ironfolic 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vitamins no121ferrousfumaratefolic acid pnvno121ironfolic 28mg-08mgtablet
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid vitiron fumfolic 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vitamins withcalciumferrous fumaratefolicacid vitiron fumfolic 28mg-08mgtablet
1-Covered
prenatal vits with calcium118ferrous fumaratefolic acidpnv no8iron fumaratefa 29 mg-mg tab chew
1-Covered
prenatal vits with calcium137ferrous fumaratefolic acidno137ironfolic acd 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vits with calcium95ferrous fumaratefolic acid pnvno95ferrous fumfolic 28mg-08mg tablet
1-Covered
prenatal vits with calciumno96ferrous fumaratefolic acidvits96iron fumfolic 27mg-08mgtablet
1-Covered
pyridoxine hcl (vitamin b6) 25 mgtablet 50 mg tablet 100 mgtablet 250 mg tablet
1-Covered
ringers solution iv soln 1-Covered PA
SODIUM CHLORIDE 09 IRRIG 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
76
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SODIUM CHLORIDE 09 SOLUTION 1-Covered PA
sodium chloride irrigating solution(AQUA CARE SODIUM CHLORIDE)09 soln
1-Covered
sodium chloride irrigating solution(CURITY) 09 soln
1-Covered
sodium chloride irrigating solution09 soln
1-Covered
TRI-VI-SOL (vitamin apalmitateascorbicacidcholecalciferol (vit d3)) --DROPS (vitmin plmittescorbiccidcholeclciferol
1-Covered STAR (Preferred Drug)
VITAMIN B-12 -500 MCG TALET 1-Covered
VITAMIN C 1000 MG TABLET 1-Covered
GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach)
ANTISPASMODICS GASTROINTESTINAL (Drugs to Prevent Bowel andStomach Spasam)
CHLORDIAZEPOXIDE-CLIDINIUM -CAP
1-Covered MDD (8 Per Day)
chlordiazepoxideclidiniumbromide 5 mg-25mg capsule
1-Covered MDD (8 Per Day)
DICYCLOMINE HCL 10 MG5 MLSOLN
1-Covered
dicyclomine hcl 10 mg5 mlsolution 10 mg capsule 20 mgtablet
1-Covered
hyoscyamine sulfate (HYOSYNE)0125mgml drops 125mcg5mlelixir
1-Covered
hyoscyamine sulfate 0125 mg tabsubl 0125 mg tablet 0125mgmldrops 0375 mg tab er 12h125mcg5ml elixir
1-Covered
propantheline bromide 15 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
77
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GASTROINTESTINAL AGENTS OTHER (Other Drugs for the Bowel andStomach)
ALLI (orlistat) 60 MG CAPSULE 1-Covered PA
ANTACID 500 MG CHEW TABLET 1-Covered
ANTACID EXTRA STRENGTH -750 MGTAB CHEW CVS -750 MG CHEW
1-Covered
ANTI-DIARRHEAL HM -2 MGSOFTGEL
1-Covered
bismuth subsalicylate (BISMATROL)262 mg tab chew
1-Covered
bismuth subsalicylate (DIOTAME)262 mg tab chew
1-Covered
bismuth subsalicylate (PEP-T-MED)262 mg tab chew --
1-Covered
bismuth subsalicylate (PEPTICRELIEF) 262 mg tab chew
1-Covered
bismuth subsalicylate (PINKBISMUTH) 262 mg tab chew
1-Covered
bismuth subsalicylate (SOOTHE)262 mg tab chew
1-Covered
bismuth subsalicylate (STOMACHRELIEF) 262 mg tab chew
1-Covered
bismuth subsalicylate 262 mg tabchew
1-Covered
calcium carbonate (ANTACIDCALCIUM) 215(500)mg tab chew
1-Covered
calcium carbonate (ANTACIDEXTRA STRENGTH) 300mg(750) tabchew
1-Covered
calcium carbonate (ANTACID)200(500)mg tab chew 215(500)mgtab chew 300mg(750) tab chew
1-Covered
calcium carbonate (BAN-ACID)300mg(750) tab chew -
1-Covered
calcium carbonate (CAL-GEST)200(500)mg tab chew -
1-Covered
calcium carbonate (CALCIUMANTACID) 200(500)mg tab chew215(500)mg tab chew 300mg(750)tab chew
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
78
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcium carbonate (CHILDRENSPEPTO) 400 mg tab chew
1-Covered
calcium carbonate (CHILDRENSSOOTHE) 400 mg tab chew
1-Covered
calcium carbonate (FLAVORCHEWS ANTACID) 300mg(750) tabchew
1-Covered
calcium carbonate (SMOOTHANTACID) 300mg(750) tab chew
1-Covered
calcium carbonate (SMOOTHDISSOLVING ANTACID) 300mg(750)tab chew
1-Covered
calcium carbonate 200(500)mgtab chew 300mg(750) tab chew
1-Covered
diphenoxylate hclatropine sulfate25-0255 liquid 25-025mg tablet
1-Covered
DIPHENOXYLATE-ATROPINE -25-0025
1-Covered
GAS RELIEF (simethicone) (SIMETH)80 MG CHEW
1-Covered
GAS RELIEF GAS 125 MG CHEWTABLET GAS (SIMETH) 80 MGCHEW HM GAS 125 MG SOFTGELHM GAS 125 MG CHEW TAB
1-Covered
GAS-X (simethicone) -E-STR 125 MGTAB CHEW
1-Covered
INFANTS GAS RELIEF RLF 20 MG03ML
1-Covered
loperamide hcl (ANTI-DIARRHEAL) 2mg capsule - 2 mg tablet -
1-Covered
loperamide hcl (DIAMODE) 2 mgtablet
1-Covered
loperamide hcl (ULTRA A-D) 2 mgtablet -
1-Covered
loperamide hcl 1 mg5 ml liquid 2mg capsule 2 mg tablet
1-Covered
PEPTO-BISMOL (bismuthsubsalicylate) -TABLET CHEW
1-Covered
PEPTO-BISMOL TO-GO (bismuthsubsalicylate) --262 MG CHEW
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
79
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
simethicone (GAS RELIEF)40mg06ml drops susp 80 mg tabchew 125 mg tab chew 125 mgcapsule
1-Covered
simethicone (GAS-X) 125 mgcapsule -
1-Covered
simethicone (INFANT GAS RELIEF)40mg06ml drops susp
1-Covered
simethicone (INFANTS GAS RELIEF)40mg06ml drops susp
1-Covered
simethicone (MI-ACID) 80 mg tabchew -
1-Covered
simethicone 40mg06ml dropssusp 80 mg tab chew 125 mgcapsule 125 mg tab chew
1-Covered
STOMACH RELIEF 262 MG CHEWTAB
1-Covered
ursodiol 300 mg capsule 1-Covered
HISTAMINE2 (H2) RECEPTOR ANTAGONISTSACID CONTROLLER 20 MG TABLET 1-Covered
ACID REDUCER 10 MG TABLET 1-Covered PA
ACID REDUCER 20 MG TABLET 1-Covered
cimetidine (ACID REDUCER) 200mg tablet
1-Covered
cimetidine (HEARTBURN RELIEF) 200mg tablet
1-Covered
cimetidine 200 mg tablet 300 mgtablet 400 mg tablet 800 mgtablet
1-Covered
CIMETIDINE 300 MG5 ML SOLN 1-Covered
cimetidine hcl 300 mg5ml solution 1-Covered
famotidine (ACID CONTROLLER) 10mg tablet
1-Covered PA
famotidine (ACID CONTROLLER) 20mg tablet
1-Covered
famotidine (ACID REDUCER) 10 mgtablet
1-Covered PA
famotidine (ACID REDUCER) 20 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
80
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
famotidine (HEARTBURNPREVENTION) 10 mg tablet
1-Covered PA
famotidine (HEARTBURNPREVENTION) 20 mg tablet
1-Covered
famotidine (HEARTBURN RELIEF) 10mg tablet
1-Covered PA
famotidine (HEARTBURN RELIEF) 20mg tablet
1-Covered
famotidine (PEPCID) 20 mg tablet 1-Covered
famotidine 10 mg tablet 1-Covered PA
FAMOTIDINE 10 MG TABLET 1-Covered PA
famotidine 20 mg tablet 40 mgtablet
1-Covered
FAMOTIDINE 20 MG TABLET EQ 20MG TABLET 40 MG TABLET
1-Covered
IRRITABLE BOWEL SYNDROME AGENTSAMITIZA (lubiprostone) 8 MCGCAPSULE 24 MCG CAPSULES
1-Covered PA
LAXATIVES (Drugs for Bowel Cleansing and Constipation)bisacodyl (ALOPHEN PILLS) 5 mgtablet dr
1-Covered
bisacodyl (BISA-LAX) 5 mg tablet dr-
1-Covered
bisacodyl (BISACODYL) 5 mgtablet dr
1-Covered
bisacodyl (BISCOLAX) 10 mgsupprect
1-Covered
bisacodyl (C-LAX LAXATIVE) 5 mgtablet dr -ATIVE)
1-Covered
bisacodyl (DUCODYL) 5 mg tabletdr
1-Covered
bisacodyl (FAST RELIEF LAXATIVE)10 mg supprect
1-Covered
bisacodyl (GENTLE LAXATIVE) 5 mgtablet dr 10 mg supprect
1-Covered
bisacodyl (LAXATIVE SUPPOSITORY)10 mg supprect
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
81
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
bisacodyl (LAXATIVE) 5 mg tabletdr
1-Covered
bisacodyl (MAGIC BULLET) 10 mgsupprect
1-Covered
bisacodyl (WOMENS GENTLELAXATIVE) 5 mg tablet dr
1-Covered
bisacodyl (WOMENS LAXATIVE) 5mg tablet dr
1-Covered
bisacodyl 5 mg tablet dr 10 mgsupprect
1-Covered
BISACODYL EC 5 MG TABLET 10MG SUPPOSITORY
1-Covered
docusate sodium (COL-RITE) 100mg capsule - 250 mg capsule -
1-Covered
docusate sodium (DIOCTYL) 60mg15ml syrup
1-Covered
docusate sodium (DOCU LIQUID)50 mg5 ml liquid
1-Covered
docusate sodium (DOCUSIL) 100mg capsule
1-Covered
docusate sodium (DSS) 250 mgcapsule
1-Covered
docusate sodium (DULCOEASE)100 mg capsule
1-Covered
docusate sodium (DULCOLAXSTOOL SOFTENER) 100 mg capsule
1-Covered
docusate sodium (LAXA BASIC 100)mg capsule )
1-Covered
docusate sodium (PHILLIPSLAXATIVE) 100 mg capsule
1-Covered
docusate sodium (SOF-LAX) 100mg capsule -
1-Covered
docusate sodium (STOOLSOFTENER) 50 mg capsule 50 mg5ml liquid 60 mg15ml syrup 100mg capsule 250 mg capsule
1-Covered
DOCUSATE SODIUM 50 MG5 MLLIQ 100 MG SOFTGEL
1-Covered
docusate sodium 50 mg5 mlliquid 60 mg15ml syrup 100 mgcapsule 250 mg capsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
82
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DOK (docusate sodium) 100 MG250 MG
1-Covered
GENTLE LAXATIVE 10 MG SUPPOSIT 1-Covered
glycerin (ADULT GLYCERIN) adultsupprect
1-Covered
glycerin (LAXATIVE SUPPOSITORY)pediatric supprect
1-Covered
glycerin (PEDIA-LAX) pediatricsupprect -
1-Covered
glycerin (SUPPOSITORY) adultsupprect
1-Covered
glycerin adult pediatric 1-Covered
lactulose (CONSTULOSE) 10 g15 mlsolution
1-Covered
lactulose (ENULOSE) 10 g15 mlsolution
1-Covered
lactulose (GENERLAC) 10 g15 mlsolution
1-Covered
lactulose 10 g15 ml 20 g30 ml 1-Covered
MAGNESIUM CITRATE HM SOLUTION 1-Covered
magnesium citrate solution 1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloride(GAVILYTE-C) peg3350sodsulfbicarbclkcl 240-2272g solnrecon -
1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloride(GAVILYTE-G) peg3350sodsulfbicarbclkcl 236-2274g solnrecon -
1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloridepeg3350sod sulfbicarbclkcl 236-2274g soln peg3350sodsulfbicarbclkcl 240-2272g soln
1-Covered
PEG-3350 AND ELECTROLYTES -SOLN
1-Covered
polyethylene glycol 3350(CLEARLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
83
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
polyethylene glycol 3350(GAVILAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(GENTLELAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(GLYCOLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(LAXACLEAR) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350 (NATURA-LAX) 17gdose powder -
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(POWDERLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(PURELAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(SMOOTHLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350 17gdosepowder
1-Covered QL (527 PER 30 DAY(S))
SILACE (docusate sodium) 50MG5 ML LIQUID
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepeg (GAVILYTE-N)chloridenahco3kclpeg 420gsoln recon -
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepeg (TRILYTE WITH FLAVORPACKETS)chloridenahco3kclpeg 420gsoln recon
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepegchloridenahco3kclpeg 420gsoln recon
1-Covered
STOOL SOFTENER (docusatesodium) 100 MG SOFTGEL 100 MGCAPSULE 250 MG SOFTGEL
1-Covered
STOOL SOFTENER HM 100 MGSFTGL 100 MG SOFTGEL HM 250MG SFTGL
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
84
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PROTECTANTSmisoprostol 100 mcg tablet 200mcg tablet
1-Covered PA
sucralfate 1 g tablet 1-Covered
PROTON PUMP INHIBITORSlansoprazole 15 mg capsule dr 1-Covered ST
lansoprazole 30 mg capsule dr 1-Covered
LANSOPRAZOLE DR 15 MGCAPSULE
1-Covered ST
LANSOPRAZOLE DR 30 MGCAPSULE
1-Covered
omeprazole 10 mg capsule dr 20mg tablet dr
1-Covered
omeprazole 20 mg capsule dr 1-Covered QL (60 PER 30 DAYS)
omeprazole 40 mg capsule dr 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
OMEPRAZOLE DR 20 MG CAPSULE 1-Covered QL (60 PER 30 DAYS)
OMEPRAZOLE DR 20 MG TABLET 1-Covered
pantoprazole sodium 20 mg tabletdr 40 mg tablet dr
1-Covered
PANTOPRAZOLE SODIUM DR 20 MGTAB DR 40 MG TAB
1-Covered
PREVACID (lansoprazole) DR 15MG CAPSULE
1-Covered
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERSTREATMENT (Drugs for Genetic or Enzyme Disorders)
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERSTREATMENT
CREON (lipaseproteaseamylase)DR 6000 UNITS CAPSULE
1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
85
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GENITOURINARY AGENTS (Drugs for the Genital Bladder andKidney)
ANTISPASMODICS URINARY (Drugs for Bladder Spasms)oxybutynin chloride 5 mg5 mlsyrup 5 mg tab er 24 5 mg tablet10 mg tab er 24 15 mg tab er 24
1-Covered
OXYBUTYNIN CHLORIDE ER ER 5 MGTABLET ER 10 MG TABLET ER 15 MGTABLET
1-Covered
OXYTROL FOR WOMEN(oxybutynin) 39 MG24HR
1-Covered ST
trospium chloride 20 mg tablet 1-Covered ST
TROSPIUM CHLORIDE 20 MG TABLET 1-Covered ST
BENIGN PROSTATIC HYPERTROPHY AGENTSalfuzosin hcl 10 mg tab er 24h 1-Covered PA
finasteride 5 mg tablet 1-Covered
tamsulosin hcl 04 mg capsule 1-Covered
GENITOURINARY AGENTS OTHER (Other Drugs for the GenitalBladder and Kidney)
bethanechol chloride 5 mg tablet10 mg tablet 25 mg tablet 50 mgtablet
1-Covered
citric acidsodium citrate (CYTRA-2) 334-500mg solution -
1-Covered
citric acidsodium citrate(VIRTRATE-2) 334-500mg solution -
1-Covered
citric acidsodium citrate 334-500mg solution
1-Covered
nonoxynol 9 (VCF) 125 foamappl
1-Covered
penicillamine 250 mg capsule 1-Covered PA QL (16 PER 1 DAY(S))
PENICILLAMINE 250 MG CAPSULE 1-Covered PA QL (16 PER 1 DAY(S))
phenazopyridine hcl (URINARYPAIN RELIEF) 95 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
86
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PHENAZOPYRIDINE HCL 100 MGTAB 200 MG TAB
1-Covered
phenazopyridine hcl 100 mgtablet 200 mg tablet
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit ac(CYTRA-3) sodpotk citsod citcitacid 500-5505 solution -
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit ac(TRICITRATES) sodpotk citsodcitcit acid 500-5505 solution
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit acsodpotk citsod citcit acid 500-5505 solution
1-Covered
URINARY PAIN RELIEF HM RLF 95 MGTAB
1-Covered
PHOSPHATE BINDERScalcium acetate (ELIPHOS) 667 mgtablet
1-Covered QL (270 PER 30 DAYS) AL1 (Atleast 21 yrs old)
calcium acetate 667 mg capsule667 mg tablet
1-Covered QL (270 PER 30 DAYS) AL1 (Atleast 21 yrs old)
lanthanum carbonate 500 mg tabchew 750 mg tab chew 1000 mgtab chew
1-Covered PA
sevelamer carbonate 800 mgtablet
1-Covered PA
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(ADRENAL) (Drugs for ReplacingStimulating Adrenal GlandHormones)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(ADRENAL) (Glucocorticoids)
betamethasone dipropionate 005 lotion
1-Covered
betamethasone dipropionate 005 oint (g) 005 cream (g)
1-Covered ST
BETAMETHASONE DIPROPIONATEDP 005 OINT
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
87
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
betamethasonedipropionatepropylene glycolbetamethasonepropylene 005 cream (g)
1-Covered ST
betamethasone valerate 01 lotion 01 cream (g) 01 oint(g)
1-Covered
clobetasol propionate 005 gel(gram) 005 solution 005 cream (g) 005 oint (g)
1-Covered ST
CLOBETASOL PROPIONATE 005CREAM
1-Covered ST
DELTASONE (prednisone) 20 MGTABLET
1-Covered
desonide 005 lotion 005 oint(g) 005 cream (g)
1-Covered ST
DESONIDE 005 LOTION 005CREAM
1-Covered ST
dexamethasone(DEXAMETHASONE INTENSOL) 1mgml drops
1-Covered
dexamethasone 05 mg5mlsolution 05 mg tablet 05 mg5mlelixir 075 mg tablet 1 mg tablet15 mg tablet 2 mg tablet 4 mgtablet 6 mg tablet
1-Covered
DEXAMETHASONE 4 MG TABLET 1-Covered
fludrocortisone acetate 01 mgtablet
1-Covered
fluocinolone acetonide 001 cream (g) 001 solution 0025 cream (g) 0025 oint (g)
1-Covered ST
fluocinonide 005 cream (g) 005 gel (gram) 005 oint (g) 005 solution
1-Covered
FLUOCINONIDE 005 OINTMENT 1-Covered
hydrocortisone (ANTI-ITCH) 1 cream (g) -
1-Covered
hydrocortisone (ANUSOL-HC) 25 crmpe app -
1-Covered
hydrocortisone (CORTISONE) 1 cream (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
88
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
hydrocortisone (CORTIZONE-10PLUS) cream (g) -0
1-Covered
hydrocortisone (CORTIZONE-10) cream (g) -
1-Covered
hydrocortisone (HYDROCREAM) 1 cream (g)
1-Covered
hydrocortisone (NOBLE FORMULAHC) 1 cream (g)
1-Covered
hydrocortisone (PREPARATION H) 1 cream (g)
1-Covered
hydrocortisone (PROCTO-MED HC)25 crmpe app -
1-Covered
hydrocortisone (PROCTO-PAK) 1 crmpe app -
1-Covered
hydrocortisone (PROCTOSOL-HC)25 crmpe app -
1-Covered
hydrocortisone (PROCTOZONE-HC)25 crmpe app -
1-Covered
hydrocortisone (SOOTHING CARE)1 cream (g)
1-Covered
hydrocortisone 05 oint (g) 1 cream (g) 1 oint (g) 1 crmpe app 25 cream (g) 25 crmpe app 25 oint (g) 25 lotion 5 mg tablet 10 mg tablet20 mg tablet
1-Covered
HYDROCORTISONE 5 MG TABLET10 MG TABLET
1-Covered
hydrocortisone acetate(ANUCORT-HC) 25 mg supprect -
1-Covered
hydrocortisone acetate (ANUSOL-HC) 25 mg supprect -
1-Covered
hydrocortisone acetate(HEMMOREX-HC) 25 mg supprect -
1-Covered
HYDROCORTISONE ACETATE 25 MGSUPP
1-Covered
hydrocortisone acetate 25 mgsupprect
1-Covered
methylprednisolone 4 mg tablet 4mg tab ds pk 8 mg tablet 16 mgtablet 32 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
89
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
mometasone furoate 01 cream(g) 01 oint (g)
1-Covered
prednisolone (MILLIPRED DP) 5 mg(48) tab 5 mg (21) tab
1-Covered
prednisolone (MILLIPRED) 5 mgtablet
1-Covered
prednisolone 15 mg5 ml solution 1-Covered
prednisolone sodium phosphate 5mg5 ml 15 mg5 ml
1-Covered
prednisone (PREDNISONEINTENSOL) 5 mgml oral conc
1-Covered
prednisone 1 mg tablet 25 mgtablet 5 mg tab ds pk 5 mgtablet 5 mg5 ml solution 10 mgtablet 10 mg tab ds pk 20 mgtablet 50 mg tablet
1-Covered
triamcinolone acetonide 0025 oint (g) 0025 cream (g) 0025 lotion 01 cream (g) 01 lotion 01 oint (g) 0147mggaerosol 05 cream (g) 05 oint(g)
1-Covered
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(PITUITARY) (Drugs for ReplacingStimulating Pituitary GlandHormones)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(PITUITARY) (Drugs to ReplaceStimulate Pituitary Gland Hormones)
desmopressin acetate (non-refrigerated) (nonrefrigerated)10spray spraypump
1-Covered PA AL1 (8 to 14 yrs old)
desmopressin acetate 01 mgmlsolution 01 mg tablet 02 mgtablet
1-Covered AL1 (8 to 14 yrs old)
desmopressin acetate 4 mcgmlvial 4 mcgml ampul 10sprayspraypump
1-Covered PA AL1 (8 to 14 yrs old)
DESMOPRESSIN ACETATE 40MCG10 ML VIAL
1-Covered PA AL1 (8 to 14 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
90
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEXHORMONESMODIFIERS) (Drugs for ReplacingStimulating SexHormones)
ANDROGENSdanazol 50 mg capsule 100 mgcapsule 200 mg capsule
1-Covered
fluoxymesterone (ANDROXY) 10mg tablet
1-Covered
testosterone 125125g gel mdpmp 50 mg (1) gel packet
1-Covered PA
testosterone cypionate 100 mgmlvial 200 mgml vial
1-Covered PA
ESTROGENS (Contraceptives and Drugs for Menopause)desogestrel-ethinyl estradiol (APRI)-015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(CYRED EQ) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(CYRED) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(EMOQUETTE) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(ENSKYCE) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(ISIBLOOM) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(JULEBER) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(KALLIGA) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(RECLIPSEN) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol -015-003 tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (AZURETTE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
91
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
desogestrel-ethinyl estradiolethinylestradiol (BEKYREE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (KARIVA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (KIMIDESS) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (PIMTREA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (SIMLIYA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (VIORELE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (VOLNEA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol -eestradioleestradiol 21-5 (28) tablet
1-Covered
DROSPIRENONE-ETHINYL ESTRADIOL-EE 3-002 MG TAB
1-Covered
estradiol (DOTTI) 025mg24hpatch 0375mg24 patch005mg24h patch 075mg24hpatch 01mg24hr patch
1-Covered QL (16 PER 28 DAY(S))
estradiol 025mg24h patch0375mg24 patch 005mg24hpatch 075mg24h patch01mg24hr patch
1-Covered QL (16 PER 28 DAY(S))
estradiol 001 creamappl025mg24h patch tdwk005mg24h patch tdwk075mg24h patch tdwk01mg24hr patch tdwk 05 mgtablet 1 mg tablet 2 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
92
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ESTRADIOL 1 MG TABLET 2 MGTABLET
1-Covered
estrogensesterifiedmethyltestosterone (COVARYX HS)estrogenesterme-0625-125tablet
1-Covered PA
estrogensesterifiedmethyltestosterone (EEMT HS) estrogenesterme-0625-125 tablet
1-Covered PA
estrogensesterifiedmethyltestosterone estrogenesterme-0625-125tablet
1-Covered PA
ethinyl estradioldrospirenone(GIANVI) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(JASMIEL) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone (LO-ZUMANDIMINE) 002-3(28) tablet -
1-Covered
ethinyl estradioldrospirenone(LORYNA) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(NIKKI) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(VESTURA) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone 002-3(28) tablet
1-Covered
ethynodiol diacetate-ethinylestradiol (KELNOR 1-35) ethynoiol -estraiol mg-35mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol (KELNOR 1-50) ethynoiol -estraiol mg-50mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol (ZOVIA 1-35E) ethynoiol -estraiol mg-35mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol ethynoiol -estraiol 1 mg-50mcg tablet ethynoiol -estraiol 1mg-35mcg tablet
1-Covered
etonogestrelethinyl estradiol(ELURYNG) 12-015mg vag ring
1-Covered QL (1 PER 28 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
93
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
etonogestrelethinyl estradiol 12-015mg vag ring
1-Covered QL (1 PER 28 DAY(S))
HAILEY FE 1-20 TABLET 15-30 TABLET 1-Covered
LEVONORGESTREL-ETH ESTRADIOL -TRIPHASIC
1-Covered
levonorgestrelethinyl estradiol(AFIRMELLE)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(ALTAVERA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(AUBRA EQ)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AUBRA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AVIANE)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AYUNA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(CHATEAL EQ)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(CHATEAL)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(DELYLA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(ENPRESSE)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
94
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrelethinyl estradiol(FALMINA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(KURVELO)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(LARISSIA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(LESSINA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(LEVONEST)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
levonorgestrelethinyl estradiol(LEVORA-28)levonorgestrelethinestradiol 015-003 tablet -
1-Covered
levonorgestrelethinyl estradiol(LILLOW)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(LUTERA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(MARLISSA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(MYZILRA)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
levonorgestrelethinyl estradiol(ORSYTHIA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
95
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrelethinyl estradiol(PORTIA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(SRONYX)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(TRIVORA-28)levonorgestrelethinestradiol 6-5-10 tablet -
1-Covered
levonorgestrelethinyl estradiol(VIENVA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiollevonorgestrelethinestradiol 01-002mg tabletlevonorgestrelethinestradiol 015-003 tabletlevonorgestrelethinestradiol 6-5-10 tablet
1-Covered
LYLLANA 0025 MG PATCH 00375MG PATCH 005 MG PATCH 0075MG PATCH 01 MG PATCH
1-Covered QL (16 PER 28 DAY(S))
MENEST (estrogensesterified) 03MG TABLET 0625 MG TABLET 125MG TABLET 25 MG TABLET
1-Covered
MICROGESTIN 21 1-20 TABLET 1-Covered
MICROGESTIN FE 1-20 TABLET 1-Covered
norelgestrominethinyl estradiol(XULANE)norelgestrominethinestradiol 150-3524h patch tdwk
1-Covered QL (3 PER 28 DAY(S))
norethindrone acetate-ethinylestradiol (AUROVELA) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (GILDESS) -15-003mgtablet
1-Covered
norethindrone acetate-ethinylestradiol (HAILEY) -15-003mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
96
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone acetate-ethinylestradiol (JUNEL) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (LARIN) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (MICROGESTIN) -1mg-20mcg tablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol -1mg-20mcg tablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate(AUROVELA FE) -eestradiol-iron15-30(21) tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (BLISOVIFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (JUNELFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (LARINFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate(MICROGESTIN FE) --1mg-20(21)tablet --15-30(21) tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TARINAFE 1-20 EQ) -eestradiol-iron mg-(2)tablet -
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TARINAFE) -eestradiol-iron 1mg-20(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TILIA FE)-eestradiol-iron 5-7-9-7 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
97
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone acetate-ethinylestradiolferrous fumarate (TRI-LEGEST FE) -eestradiol-iron 5-7-9-7tablet -
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate --1mg-20(21) tablet --15-30(21) tablet
1-Covered
norethindrone-ethinyl estradiol(ALYACEN) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(ARANELLE) -ethin 7-9-5 tablet
1-Covered
norethindrone-ethinyl estradiol(BALZIVA) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(BRIELLYN) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(CYCLAFEM) -1 mg-35mcg tablet -7 days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(DASETTA) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(LEENA) -ethin 7-9-5 tablet
1-Covered
norethindrone-ethinyl estradiol(NECON) -ethin 05-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(NORTREL) -05-0035 tablet -1 mg-35mcg tablet -7 days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(PHILITH) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(PIRMELLA) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(VYFEMLA) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(WERA) -ethin 05-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(ZENCHENT) -ethin 04-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(ESTARYLLA) -025-0035 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
98
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norgestimate-ethinyl estradiol(FEMYNOR) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(MILI) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(MONO-LINYAH) -025-0035 tablet -
1-Covered
norgestimate-ethinyl estradiol(MONONESSA) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(PREVIFEM) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(SPRINTEC) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol (TRIFEMYNOR) -7daysx3 28 tablet
1-Covered
norgestimate-ethinyl estradiol (TRI-ESTARYLLA) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-LINYAH) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-ESTARYLLA) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-MARZIA) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-MILI) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-SPRINTEC) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-PREVIFEM) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-SPRINTEC) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-VYLIBRA LO) -7daysx3 lo tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-VYLIBRA) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol(TRINESSA LO) -7daysx3 lo tablet
1-Covered
norgestimate-ethinyl estradiol(TRINESSA) -7daysx3 28 tablet
1-Covered
norgestimate-ethinyl estradiol(VYLIBRA) -025-0035 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
99
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NORGESTIMATE-ETHINYL ESTRADIOL-025-0035 MG
1-Covered
norgestimate-ethinyl estradiol -025-0035 tablet -7daysx3 28tablet -7daysx3 lo tablet
1-Covered
norgestrel-ethinyl estradiol(CRYSELLE) -03-003mg tablet
1-Covered
norgestrel-ethinyl estradiol (ELINEST)-03-003mg tablet
1-Covered
norgestrel-ethinyl estradiol (LOW-OGESTREL) -03-003mg tablet -
1-Covered
norgestrel-ethinyl estradiol(OGESTREL) -05 mg-50 tablet
1-Covered
PREMARIN (estrogens conjugated)03 MG TABLET 045 MG TABLET0625 MG TABLET 09 MG TABLET125 MG TABLET
1-Covered
PREMARIN (estrogens conjugated)VAGINAL CREAM-APPL
1-Covered QL (43 PER 30 DAY(S))
PREMPHASE (estrogensconjugatedmedroxyprogesteroneacetate) 0625-5 MG TABLET
1-Covered
PREMPRO (estrogensconjugatedmedroxyprogesteroneacetate) 03 MG-15 MG TABLET045-15 MG TABLET 0625-5 MGTABLET 0625-25 MG TABLET
1-Covered
ZOVIA 1-35 -TABLET 1-Covered
PROGESTINSDEPO-PROVERA(medroxyprogesterone acetate) -400 MGML VIAL
1-Covered
DEPO-SUBQ PROVERA 104(medroxyprogesterone acetate) -SYRINGE
1-Covered
hydroxyprogesterone caproate250 mgml vial
1-Covered PA SP
hydroxyprogesterone caproatepfcaproatpf 250 mgml vial
1-Covered PA SP
JENCYCLA 035 MG TABLET 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
100
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrel (AFTERA) 15 mgtablet
1-Covered
levonorgestrel (ECONTRA EZ) 15mg tablet
1-Covered
levonorgestrel (ECONTRA ONE-STEP) 15 mg tablet -
1-Covered
levonorgestrel (FALLBACK SOLO)15 mg tablet
1-Covered
levonorgestrel (MY CHOICE) 15mg tablet
1-Covered
levonorgestrel (MY WAY) 15 mgtablet
1-Covered
levonorgestrel (NEW DAY) 15 mgtablet
1-Covered
levonorgestrel (OPCICON ONE-STEP) 15 mg tablet -
1-Covered
levonorgestrel (OPTION 2) 15 mgtablet
1-Covered
levonorgestrel (TAKE ACTION) 15mg tablet
1-Covered
levonorgestrel 15 mg tablet 1-Covered QL (1 PER 1 DAYS)
MEDROXYPROGESTERONE ACETATE150 MGML
1-Covered QL (1 PER 84 DAYS)
medroxyprogesterone acetate 150mgml vial 150 mgml syringe
1-Covered QL (1 PER 84 DAYS)
MEDROXYPROGESTERONE ACETATE25 MG TAB
1-Covered
medroxyprogesterone acetate 25mg tablet 5 mg tablet 10 mgtablet
1-Covered
megestrol acetate 20 mg tablet40 mg tablet
1-Covered
megestrol acetate 400mg10mloral susp
1-Covered PA
norethindrone (CAMILA) 035 mgtablet
1-Covered
norethindrone (DEBLITANE) 035 mgtablet
1-Covered
norethindrone (ERRIN) 035 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
101
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone (HEATHER) 035 mgtablet
1-Covered
norethindrone (INCASSIA) 035 mgtablet
1-Covered
norethindrone (JENCYCLA) 035mg tablet
1-Covered
norethindrone (JOLIVETTE) 035 mgtablet
1-Covered
norethindrone (LYZA) 035 mgtablet
1-Covered
norethindrone (NORA-BE) 035 mgtablet -
1-Covered
norethindrone (NORLYDA) 035 mgtablet
1-Covered
norethindrone (NORLYROC) 035mg tablet
1-Covered
norethindrone (SHAROBEL) 035 mgtablet
1-Covered
norethindrone (TULANA) 035 mgtablet
1-Covered
norethindrone 035 mg tablet 1-Covered
norethindrone acetate 5 mg tablet 1-Covered
PLAN B ONE-STEP (levonorgestrel) -15 MG TALET
1-Covered
TAKE ACTION (levonorgestrel) 15MG TABLET
1-Covered
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(THYROID) (Drugs for the Thyroid)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(THYROID) (Drugs to Replace Thyroid Hormone)
ARMOUR THYROID (thyroidpork) 15MG TABLET 30 MG TABLET 60 MGTABLET 90 MG TABLET 120 MGTABLET 180 MG TABLET 240 MGTABLET 300 MG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
102
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LEVO-T (levothyroxine sodium) -25MCG ABLE -50 MCG ABLE -75MCG ABLE -88 MCG ABLE -100MCG ABLE -112 MCG ABLE -125MCG ABLE -137 MCG ABLE -150MCG ABLE -175 MCG ABLE -200MCG ABLE -300 MCG ABLE
1-Covered
levothyroxine sodium 25 mcgtablet 50 mcg tablet 75 mcgtablet 88 mcg tablet 100 mcgtablet 112 mcg tablet 125 mcgtablet 137 mcg tablet 150 mcgtablet 175 mcg tablet 200 mcgtablet 300 mcg tablet
1-Covered STAR (Preferred Drug)
LEVOTHYROXINE SODIUM 25 MCGTABLET 50 MCG TABLET 75 MCGTABLET 88 MCG TABLET 100 MCGTABLET 112 MCG TABLET 125 MCGTABLET 137 MCG TABLET 150 MCGTABLET 175 MCG TABLET 200 MCGTABLET 300 MCG TABLET
1-Covered STAR (Preferred Drug)
LEVOXYL (levothyroxine sodium) 25MCG TABLET 50 MCG TABLET 75MCG TABLET 88 MCG TABLET 100MCG TABLET 112 MCG TABLET 125MCG TABLET 137 MCG TABLET 150MCG TABLET 175 MCG TABLET 200MCG TABLET
1-Covered
SYNTHROID (levothyroxine sodium)25 MCG TABLET 50 MCG TABLET75 MCG TABLET 88 MCG TABLET100 MCG TABLET 112 MCG TABLET125 MCG TABLET 137 MCG TABLET150 MCG TABLET 175 MCG TABLET200 MCG TABLET 300 MCG TABLET
1-Covered
thyroidpork (NP THYROID) 15 mgtablet 30 mg tablet 60 mg tablet90 mg tablet 120 mg tablet
1-Covered STAR (Preferred Drug)
UNITHROID (levothyroxine sodium)25 MCG TABLET 50 MCG TABLET75 MCG TABLET 88 MCG TABLET100 MCG TABLET 112 MCG TABLET125 MCG TABLET 137 MCG TABLET150 MCG TABLET 175 MCG TABLET200 MCG TABLET 300 MCG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
103
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs forSuppressing Hormones from the Pituitary Gland)
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs to SuppressPituitary Hormones)
leuprolide acetate 1 mg02ml kit 1-Covered PA SP
LUPRON DEPOT-PED (leuprolideacetate) -15 MG KIT
1-Covered PA
SYNAREL (nafarelin acetate) 2MGML NASAL SPRAY
1-Covered PA
HORMONAL AGENTS SUPPRESSANT (THYROID) (Drugs for theThyroid)
ANTITHYROID AGENTS (Drugs to Suppress Thyroid Hormone)methimazole 5 mg tablet 10 mgtablet
1-Covered
propylthiouracil 50 mg tablet 1-Covered
IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing theImmune System)
IMMUNE SUPPRESSANTS (Drugs to Suppress the Immune System)azathioprine 50 mg tablet 1-Covered
AZATHIOPRINE 50 MG TABLET 1-Covered
cyclosporine 25 mg capsule 100mg capsule
1-Covered
cyclosporine modified (GENGRAF)25 mg capsule 100 mgml solution100 mg capsule
1-Covered
cyclosporine modified 25 mgcapsule 100 mgml solution 100mg capsule
1-Covered
ENBREL (etanercept) 25 MG KIT 1-Covered PA SP QLC (8 vials28 days)
ENBREL (etanercept) 25 MG05 MLSYRINGE 50 MGML SYRINGE
1-Covered PA SP QLC (4 syringes [1 kit]28days)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
104
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ENBREL 25 MG05 ML VIAL 1-Covered PA QL (4 PER 28 DAY(S))
ENBREL SURECLICK (etanercept) 50MGML
1-Covered PA SP QLC (4 pens [1 kit]28days)
HUMIRA (adalimumab) 10 MG02ML SYRINGE 20 MG04 MLSYRINGE 40 MG08 ML SYRINGE
1-Covered PA SP QLC (2 syringes [1 kit]28days)
HUMIRA PEDIATRIC CROHNS(adalimumab) 40 MG08 ML
1-Covered PA SP QLC (3 or 6 syringesyeardepending upon package size)
HUMIRA PEN (adalimumab) 40MG08 ML
1-Covered PA SP QLC (2 pens [1 kit]28days)
HUMIRA PEN CROHNS-UC-HS(adalimumab) --40 MG
1-Covered PA SP QLC (6 pens [1 kit]year)
HUMIRA PEN PSOR-UVEITS-ADOL HS(adalimumab) --40 MG
1-Covered PA SP QLC (4 pens [1 kit]year)
HUMIRA(CF) (adalimumab) 10MG01 ML SYRING 20 MG02 MLSYRING 40 MG04 ML SYRING
1-Covered PA SP QLC (2 syringes [1 kit]28days)
HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 80-40 MG
1-Covered PA SP QLC (2 syringes [1kit]year)
HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 80MG08
1-Covered PA SP QLC (3 syringes [1kit]year)
HUMIRA(CF) PEN (adalimumab) 40MG04 ML
1-Covered PA SP QLC (2 pens [1 kit]28days)
HUMIRA(CF) PEN CROHNS-UC-HS(adalimumab) CRHN--80MG
1-Covered PA SP QLC (3 pens [1 kit]year)
HUMIRA(CF) PEN PSOR-UV-ADOLHS (adalimumab) --AHS 80-40
1-Covered PA SP QLC (3 pens [1 kit]year)
METHOTREXATE 25 MG TABLET 1-Covered
methotrexate sodium 25 mgtablet
1-Covered
mycophenolate mofetil 200 mgmlsusp recon
1-Covered PA
mycophenolate mofetil 250 mgcapsule 500 mg tablet
1-Covered AL1 (At least 21 yrs old)
RHEUMATREX (methotrexatesodium) 25 MG TABLET
1-Covered
SANDIMMUNE (cyclosporine) 25MG CAPSULE 100 MGML SOLN
1-Covered
sirolimus 1 mgml solution 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
105
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
tacrolimus 05 mg capsule 1 mgcapsule 5 mg capsule
1-Covered AL1 (At least 21 yrs old)
TACROLIMUS 05 MG CAPSULE 1MG CAPSULE 5 MG CAPSULE
1-Covered AL1 (At least 21 yrs old)
IMMUNIZING AGENTS PASSIVE (Vaccines)HYPERTET S-D (tetanus immuneglobulinpf) -250 UNIT YRINGE
3-MedicalBenefit
NABI-HB (hepatitis b immuneglobulin) -VIAL gloulin)
3-MedicalBenefit
IMMUNOMODULATORSleflunomide 10 mg tablet 20 mgtablet
1-Covered
LEFLUNOMIDE 10 MG TABLET 20MG TABLET
1-Covered
RIDAURA (auranofin) 3 MGCAPSULE
1-Covered PA
VACCINESADACEL TDAP(diphtheriapertussis(acellular)tetanus vaccinepf) VIAL
1-Covered AL1 (At least 19 yrs old)
AFLURIA QUAD 2020-2021 -VIAL 1-Covered AL1 (At least 19 yrs old)
AFLURIA QUAD 2020-21 (3YR UP) - 1-Covered AL1 (At least 19 yrs old)
BEXSERO (meningococcal group bvaccine 4-component) PREFILLEDSYRINGE -
1-Covered QL (2 PER LIFETIME) AL1 (19 to 25yrs old)
BOOSTRIX TDAP(diphtheriapertussis(acellular)tetanus vaccine) SYRINGE VIAL
1-Covered AL1 (At least 19 yrs old)
ENGERIX-B ADULT (hepatitis b virusvaccine recombinantpf) -20MCGML VIAL recominantpf) -20MCGML SYRN recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
FLUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 65 yrs old)
FLUAD QUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 19 yrs old)
FLUARIX QUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 19 yrs old)
FLUBLOK QUAD 2018-2019(influenza virus vaccine qv 2018-19(18 yrs and older)rcmbpf) -SYRINGE -
1-Covered AL1 (19 to 999 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
106
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
FLUBLOK QUAD 2020-2021 -SYRINGE
1-Covered AL1 (At least 19 yrs old)
FLUCELVAX QUAD 2020-2021 2020-2021 SYR 2020-2021 VIAL
1-Covered AL1 (At least 19 yrs old)
FLULAVAL QUAD 2019-2020(influenza virus vaccinequadrivalent 2019-20 (6 mos andup)) -VIAL -
1-Covered AL1 (At least 19 yrs old)
FLULAVAL QUAD 2020-2021 -SYR 1-Covered AL1 (At least 19 yrs old)
FLUZONE HIGH-DOSE QUAD 2020-21 --
1-Covered AL1 (At least 65 yrs old)
FLUZONE QUAD 2019-2020(influenza virus vaccine quadrival2019-2020(6 mos and up)pf) -VIAL-
1-Covered AL1 (At least 19 yrs old)
FLUZONE QUAD 2020-2021 2020-2021 VIAL 2020-2021 SYRINGE
1-Covered AL1 (At least 19 yrs old)
GARDASIL 9 (human papillomavirusvaccine 9-valentpf) 9 SYRINGE 9-9 VIAL 9-
1-Covered QL (3 PER LIFETIME) AL1 (19 to 27yrs old)
HAVRIX (hepatitis a virusvaccinepf) 720 UNIT05 MLSYRINGE (heptitis vccinepf) 720UNITS05 ML VIAL (heptitisvccinepf) 1440 UNITSMLSYRINGE (heptitis vccinepf) 1440UNITSML VIAL (heptitis vccinepf)
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
HEPLISAV-B (hepatitis b vaccinerecombinantvaccine adjuvantcpg 1018pf) -20 MCG05 MLSYRNG RECOMINANT -20MCG05 ML VIAL RECOMINANT
1-Covered AL1 (At least 19 yrs old) QLC (2perlifetime)
IMOVAX RABIES VACCINE (rabiesvaccine human diploid cellpf)VIAL
3-MedicalBenefit
M-M-R II VACCINE (measlesmumps and rubella vaccinelivepf) --VIAL
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
MENACTRA(meningococcalvaccine acyw-135diphtheria toxoid conjpf) VIAL-
1-Covered AL1 (At least 19 yrs old)
MENQUADFI VIAL 1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
107
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
MENVEO A-C-Y-W-135-DIP(meningococcalvaccine acyw-135diphtheria toxoid conjpf) -----VIL KT -DIPHTHERIA
1-Covered QL (1 PER LIFETIME) AL1 (19 to 55yrs old)
PNEUMOVAX 23 (pneumococcal23-valent polysaccharide vaccine)23 VIAL 23- 23 SYRINGE 23-
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
PREVNAR 13 (pneumococcal 13-valent conjugate vaccine(diphtheria crm)pf) SYRINGE -
1-Covered QL (1 PER LIFETIME) AL1 (At least19 yrs old)
RABAVERT (rabies vaccine purifiedchicken embryo cell (pcec)pf)RABIES VACC W-DILUENT
1-Covered AL1 (At least 19 yrs old)
RECOMBIVAX HB (hepatitis b virusvaccine recombinantpf) 5MCG05 ML SYR recominantpf)10 MCGML SYR recominantpf)40 MCGML VIAL recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
RECOMBIVAX HB (hepatitis b virusvaccine recombinantpf) 5MCG05 ML VL recominantpf) 10MCGML VIAL recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
SHINGRIX (varicella-zoster virusglycoprotein erecas01badjuvantpf) VIAL KIT -
1-Covered QL (2 PER LIFETIME) AL1 (At least50 yrs old)
TDVAX (tetanus and diphtheriatoxoids adult) VIAL
1-Covered AL1 (At least 19 yrs old)
TENIVAC (tetanus and diphtheriatoxoids adsorbed adultpf) VIAL
1-Covered AL1 (At least 19 yrs old)
tetanus and diphtheria toxoidsadult tetanus toxadult 2-2 lf05vial
1-Covered AL1 (At least 19 yrs old)
TRUMENBA (neisseria meningitidisgroup b lipidated fhbprecombinant) 120 MCG05 MLVACCIN
1-Covered QL (2 PER LIFETIME) AL1 (19 to 25yrs old)
TWINRIX (hepatitis a virus andhepatitis b virus vaccinepf)VACCINE SYRINGE (heptitis ndheptitis vccinepf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
108
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
VAQTA (hepatitis a virusvaccinepf) 25 UNITS05 ML VIAL(heptitis vccinepf) 25 UNITS05ML SYRINGE (heptitis vccinepf) 50UNITSML VIAL (heptitis vccinepf)50 UNITSML SYRINGE (heptitisvccinepf)
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
VARIVAX VACCINE (varicella virusvaccine livepf) WITH DILUENT
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
ZOSTAVAX (zoster vaccine livepf)VIAL
1-Covered QL (1 PER LIFETIME) AL1 (At least60 yrs old)
INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for InflammatoryBowel Disease)
AMINOSALICYLATESbalsalazide disodium 750 mgcapsule
1-Covered
mesalamine 4 g60 ml enema 1-Covered
mesalamine 400 mg cap(drtab) 1-Covered QL (6 PER 1 DAY(S))
GLUCOCORTICOIDShydrocortisone (COLOCORT)100mg60ml enema
1-Covered
hydrocortisone 100mg60mlenema
1-Covered
SULFONAMIDESsulfasalazine 500 mg tablet dr 500mg tablet
1-Covered
METABOLIC BONE DISEASE AGENTS (Drugs for the Bone)
METABOLIC BONE DISEASE AGENTSalendronate sodium 10 mg tablet40 mg tablet
1-Covered PA STAR (Preferred Drug)
alendronate sodium 35 mg tablet70 mg tablet
1-Covered STAR (Preferred Drug)
alendronate sodium 5 mg tablet 1-Covered AL1 (At least 65 yrs old) STAR(Preferred Drug)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
109
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcitoninsalmonsynthetic200spray spraypump
1-Covered PA
CALCITRIOL 025 MCG CAPSULE05 MCG CAPSULE
1-Covered
calcitriol 025 mcg capsule 05mcg capsule 1 mcgml solution
1-Covered
cholecalciferol (vitamin d3) 10mcg capsule 10 mcg tablet
1-Covered
cinacalcet hcl 30 mg tablet 60 mgtablet 90 mg tablet
1-Covered PA
CINACALCET HCL 30 MG TABLET60 MG TABLET 90 MG TABLET
1-Covered PA
ergocalciferol (vitamin d2)(CALCIDOL) 200 mcgml drops
1-Covered
ergocalciferol (vitamin d2) 10 mcgtablet 200 mcgml drops 1250mcg capsule
1-Covered
ERGOCALCIFEROL 200 MCGMLDROP
1-Covered
FOSAMAX PLUS D (alendronatesodiumcholecalciferol (vitamind3)) 70 MG-2800 IU
1-Covered PA
MISCELLANEOUS THERAPEUTIC AGENTSalcohol antiseptic pads s med 1-Covered
ALCOHOL WIPES 70 1-Covered
ASSURE ID DUO-SHIELD -30GX316-30GX516
1-Covered
ASSURE ID INSULIN SAFETY SYR05ML 31GX1564 SYR 1 ML31GX1564
1-Covered
condoms female each 1-Covered
condoms latex lubricated each 1-Covered
cromolyn sodium 52 mgspraypump
1-Covered
DROPLET MICRON PEN NEEDLE 34GX 964
1-Covered
freestyle insulix test strips 1-Covered QL (100 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
110
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
freestyle lite test strips 1-Covered QL (100 PER 30 DAYS)
freestyle test strips 1-Covered QL (100 PER 30 DAYS)
inhalerassist device with largemask devicelg spacer
1-Covered
inhalerassist device with mediummask devicemed spacer
1-Covered
inhalerassist device with smallmask devsmall spacer
1-Covered
INSULIN PEN NEEDLES INSULIN PENNEEDLES INSULIN PEN NEEDLES
1-Covered
insulin syringe 03 ml 1-Covered
insulin syringe 05 ml 1-Covered
insulin syringe 1 ml 1-Covered
lancets 28 gauge 30 gauge 33gauge
1-Covered
methylergonovine maleate 02 mgtablet
1-Covered
PEN NEEDLE 29G 12MM 1-Covered
pen needle diabetic 29 g x12 30gx516 31 g x14 31 gx316 31gx516 32gx 532 32 gx 14 32gx316 32 gx516 33 gx532
1-Covered
pen needle diabetic disposablesafety 30 gx516 30 gx316
1-Covered
pen needle diabetic removerand disposal unit 31 gx316 32gx532
1-Covered
pen needle diabetic safety 30gx316 dis
1-Covered
RID (permethrin) PEDICULICIDESSPRAY
1-Covered
syringe with needle insulin safety1 ml geneedleinsulnsafe1ml 30gx316 disp
1-Covered
syringe withneedledisposableinsulin 1 ml30gx12 disp 31 gx516 disp31gx1564 disp
1-Covered
syringe with needleinsulin03 ml -needldispinsul03 29 x12 disp
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
111
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
syringe with needleinsulin05 ml -ml 30gx12 disp -ml 31 gx516disp -ml 31gx1564 disp
1-Covered
UNIFINE PENTIPS MAXFLOW30GX316
1-Covered
OPHTHALMIC AGENTS (Drugs for the Eyes)
OPHTHALMIC AGENTS OTHER (Other Drugs for the Eyes)atropine sulfate 1 drops 1-Covered
bacitracinpolymyxin b sulfate (AK-POLY-BAC) 500-10kg oint (g) --
1-Covered
bacitracinpolymyxin b sulfate(POLYCIN) 500-10kg oint (g)
1-Covered
bacitracinpolymyxin b sulfate 500-10kg oint (g)
1-Covered
BEOVU (brolucizumab-dbll) 6MG005 ML VIAL -
3-MedicalBenefit
BLEPHAMIDE (sulfacetamidesodiumprednisolone acetate) EYEDROPS
1-Covered
CORTISPORIN (neomycinsulfatepolymyxin bsulfatehydrocortisone) CREAM
1-Covered
cyclopentolate hcl 05 drops 1 drops 2 drops
1-Covered
homatropine hbr (HOMATROPAIRE)5 drops
1-Covered
homatropine hbr 5 drops 1-Covered
MURO-128 (sodium chloride) -5EYE DROPS
1-Covered
neomycin sulfatebacitracinzincpolymyxin bhydrocortisone(NEO-POLYCIN HC)neomycinbacitp-myxhydrocort35-10k-1 oint (g) -
1-Covered
neomycin sulfatebacitracinzincpolymyxin bhydrocortisoneneomycinbacitp-myxhydrocort35-10k-1 oint (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
112
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
neomycinsulfatebacitracinpolymyxin b(NEO-POLYCIN)sulfbacitracinpoly 35mg-400oint (g) -
1-Covered
neomycinsulfatebacitracinpolymyxin bsulfbacitracinpoly 35mg-400oint (g)
1-Covered
neomycin sulfatepolymyxin bsulfategramicidin dneomycinpolymyxn bgramicidin175mg-10k drops
1-Covered
neomycin sulfatepolymyxin bsulfatehydrocortisoneneomycinpolymyxin bhydrocort35-10k-10 drops susp
1-Covered
neomycinpolymyxin bsulfatedexamethasonebdexametha 01 drops suspbdexametha 35-10k-1 oint (g)
1-Covered
phenylephrine hcl 25 drops 10 drops
1-Covered
polymyxin b sulfatetrimethoprimsulftrimethoprim 10000-1ml drops
1-Covered
proparacaine hcl 05 drops 1-Covered PA
sodium chloride (MURO-128) drops -18)
1-Covered
sodium chloride 5 drops 1-Covered
sulfacetamidesodiumprednisolone sodiumphosphatesulfacetamideprednisolone 10 -023 drops
1-Covered
TOBRADEX(tobramycindexamethasone) EYEOINTMENT
1-Covered
tobramycindexamethasone 03-01 drops susp
1-Covered
OPHTHALMIC ANTI-ALLERGY AGENTS (Drugs for Eye Allergies)ALAWAY (ketotifen fumarate)0025 EYE DROPS
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
113
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALOMIDE (lodoxamidetromethamine) 01 EYE DROPS
1-Covered
cromolyn sodium 4 drops 1-Covered
EYE ITCH RELIEF 0025 DROPS HM0025 DROP
1-Covered
ketotifen fumarate (ALLERGY EYEDROPS) 0025 drops
1-Covered
ketotifen fumarate (EYE ITCHRELIEF) 0025 drops
1-Covered
ketotifen fumarate (ITCHY EYE)0025 drops
1-Covered
ketotifen fumarate (WAL-ZYR) 0025 drops -
1-Covered
ketotifen fumarate (ZADITOR) 0025 drops
1-Covered
ketotifen fumarate 0025 drops 1-Covered
OPHTHALMIC ANTI-INFLAMMATORIES (Drugs to Reduce EyeSwelling)
dexamethasone sodiumphosphate 01 drops
1-Covered
diclofenac sodium 01 drops 1-Covered
fluorometholone 01 drops susp 1-Covered
flurbiprofen sodium 003 drops 1-Covered
FML FORTE (fluorometholone)025 EYE DROPS
1-Covered
FML SOP (fluorometholone) 01OINTMENT
1-Covered
ketorolac tromethamine 05 drops
1-Covered
PRED MILD (prednisolone acetate)012 EYE DROPS
1-Covered
prednisolone acetate 1 dropssusp
1-Covered
prednisolone sodium phosphate 1 drops
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
114
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
OPHTHALMIC ANTIGLAUCOMA AGENTS (Drugs for Glaucoma)ALPHAGAN P (brimonidinetartrate) ALHAGAN 01 DROS
1-Covered QL (1 PER 30 DAYS)
apraclonidine hcl 05 drops 1-Covered
betaxolol hcl 05 drops 1-Covered
BETIMOL (timolol) 025 DROPS05 DROPS
1-Covered
BETOPTIC S (betaxolol hcl) 025EYE DROP
1-Covered
brimonidine tartrate 02 drops 1-Covered
dorzolamide hcl 2 drops 1-Covered
dorzolamide hcltimolol maleate223-681 drops
1-Covered QL (10 PER 30 DAY(S))
DORZOLAMIDE-TIMOLOL -EYEDROPS
1-Covered QL (10 PER 30 DAY(S))
IOPIDINE (apraclonidine hcl) 1EYE DROPS
1-Covered
levobunolol hcl 05 drops 1-Covered
methazolamide 25 mg tablet 50mg tablet
1-Covered
METHAZOLAMIDE 25 MG TABLET 50MG TABLET
1-Covered
PHOSPHOLINE IODIDE(echothiophate iodide) 0125
1-Covered
pilocarpine hcl 1 drops 2 drops 4 drops
1-Covered
PILOCARPINE HCL 1 DROPS 2DROPS
1-Covered
timolol maleate 025 sol-gel 025 drops 05 drops 05 sol-gel
1-Covered
TIMOLOL MALEATE 05 EYE DROPS 1-Covered
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS (Drugsfor Glaucoma)
latanoprost 0005 drops 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
115
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
OTIC AGENTS (Drugs for the Ears)
OTIC AGENTS (Drugs for Ear Infection)acetic acid 2 solution 1-Covered
ACETIC ACID 2 EAR SOLUTION 1-Covered
carbamide peroxide(CARBAMOXIDE) 65 drops
1-Covered
carbamide peroxide (EAR DROPS)65 drops
1-Covered
carbamide peroxide (EAR SYSTEM)65 drops
1-Covered
carbamide peroxide (EAR WAXREMOVAL) 65 drops
1-Covered
carbamide peroxide (MURINE EARWAX REMOVAL SYSTEM) 65 drops
1-Covered
DEBROX (carbamide peroxide)65 EAR DROPS
1-Covered
EAR DROPS (carbamide peroxide)65
1-Covered
hydrocortisoneacetic acid(ACETASOL HC) 1 -2 drops
1-Covered
hydrocortisoneacetic acid 1 -2 drops
1-Covered
MURINE EAR DROPS (carbamideperoxide) 65
1-Covered
neomycin sulfatepolymyxin bsulfatehydrocortisoneneomycinpolymyxin bhydrocort35--1 solutionneomycinpolymyxin bhydrocort35--1 drops susp
1-Covered
NEOMYCIN-POLYMYXIN-HC --EARSUSP
1-Covered
RESPIRATORY TRACTPULMONARY AGENTS (Drugs for the Lungs)
ANTI-INFLAMMATORIES INHALED CORTICOSTEROIDS (Inhaled Drugsto Prevent Swelling of the Airways)
BUDESONIDE 025 MG2 ML SUSP 1-Covered AL1 (Up to 6 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
116
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
budesonide 025mg2ml - 05mg2ml -
1-Covered AL1 (Up to 6 yrs old)
CHILDRENS NASACORT(triamcinolone acetonide)ALLERGY 24 HR
1-Covered QL (17 PER 30 DAY(S))
FLOVENT DISKUS (fluticasonepropionate) 50 MCG 100 MCG250 MCG
1-Covered
FLOVENT HFA (fluticasonepropionate) HFA 44 MCG INHALERHFA 110 MCG INHALER HFA 220MCG INHALER
1-Covered
fluticasone propionate (ALLERGYRELIEF) 50 mcg spray susp
1-Covered QL (16 PER 30 DAY(S))
fluticasone propionate 50 mcgspray susp
1-Covered QL (16 PER 30 DAY(S))
NASACORT (triamcinoloneacetonide) ALLERGY 24HR SPRAY
1-Covered
PULMICORT FLEXHALER(budesonide) 180 MCG
1-Covered
QVAR REDIHALER(beclomethasone dipropionate)40 MCG 80 MCG
1-Covered
triamcinolone acetonide 55 mcgspray
1-Covered QL (17 PER 30 DAY(S))
ANTIHISTAMINESALAVERT (loratadine) 10 MG ODT 1-Covered AL1 (Up to 12 yrs old)
ALL DAY ALLERGY ERGY 10 MGTABLET SM ERGY 10 MG TAB
1-Covered
ALLERGY RELIEF (LORATADINE) 10MG TAB RELIEF 10 MG TABLET
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
ALLERGY RELIEF 4 MG TABLET HM 4MG TABLET HM 25 MG CAP 25 MGSOFTGEL GS 25 MG TABLET
1-Covered
ALLERGY RELIEF HM 180 MG TAB180 MG TABLET
1-Covered ST
AZELASTINE HCL 01 (137 MCG)SPRY
1-Covered QL (1 PER 30 DAYS)
azelastine hcl 137 mcgspraypump
1-Covered QL (1 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
117
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
cetirizine hcl (24HOUR ALLERGY) 10mg tablet
1-Covered
cetirizine hcl (ALL DAY ALLERGYRELIEF) 10 mg tablet
1-Covered
cetirizine hcl (ALL DAY ALLERGY) 10mg tablet
1-Covered
cetirizine hcl (ALLER-TEC) 10 mgtablet -
1-Covered
cetirizine hcl (ALLERGY RELIEF) 10mg tablet
1-Covered
cetirizine hcl (WAL-ZYR) 10 mgtablet -
1-Covered
cetirizine hcl 1 mgml 5 mg5 ml 1-Covered ST AL1 (Up to 5 yrs old)
CETIRIZINE HCL 10 MG TABLET 1-Covered
cetirizine hcl 5 mg tablet 10 mgtablet
1-Covered
CHILDRENS ALLERGY RELIEF 5MG5 ML
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
CHILDRENS ALLERGY RELIEF RLF125 MG5 ML
1-Covered
chlorpheniramine maleate(ALLERGY 4-HOUR) mg tablet -
1-Covered
chlorpheniramine maleate(ALLERGY RELIEF) 4 mg tablet
1-Covered
chlorpheniramine maleate(ALLERGY) 4 mg tablet
1-Covered
chlorpheniramine maleate(ALLERGY-TIME) 4 mg tablet -
1-Covered
chlorpheniramine maleate(CHLORHIST) 4 mg tablet
1-Covered
chlorpheniramine maleate(CHLORTABS) 4 mg tablet
1-Covered
chlorpheniramine maleate (EDCHLORPED JR) 2 mg5 ml syrup
1-Covered
chlorpheniramine maleate(PHARBECHLOR) 4 mg tablet
1-Covered
chlorpheniramine maleate (WAL-FINATE) 4 mg tablet -
1-Covered
chlorpheniramine maleate 4 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
118
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
clemastine fumarate 268 mgtablet
1-Covered
cyproheptadine hcl 2 mg5 mlsyrup 4 mg tablet 4 mg10 mlsyrup
1-Covered
diphenhydramine hcl (ALER-CAPS)25 mg capsule -
1-Covered
diphenhydramine hcl (ALLER-G-TIME) 25 mg tablet --
1-Covered
diphenhydramine hcl (ALLERGYMEDICATION) 25 mg capsule 25mg tablet
1-Covered
diphenhydramine hcl (ALLERGYMEDICINE) 25 mg tablet
1-Covered
diphenhydramine hcl (ALLERGYRELIEF) 125mg5ml liquid 25 mgcapsule 25 mg tablet
1-Covered
diphenhydramine hcl (ALLERGY)125mg5ml liquid 25 mg capsule25 mg tablet
1-Covered
diphenhydramine hcl (BANOPHEN)125mg5ml liquid 25 mg tablet 25mg capsule 50 mg capsule
1-Covered
diphenhydramine hcl (BENADRYLALLERGY) 25 mg tablet
1-Covered
diphenhydramine hcl (CHILDRENSALLERGY RELIEF) 125mg5ml liquid
1-Covered
diphenhydramine hcl (CHILDRENSALLERGY) 125mg5ml elixir125mg5ml liquid
1-Covered
diphenhydramine hcl (CHILDRENSBENADRYL ALLERGY) 125mg5mlliquid
1-Covered
diphenhydramine hcl (CHILDRENSWAL-DRYL ALLERGY) 125mg5mlliquid -
1-Covered
diphenhydramine hcl (COMPLETEALLERGY) 25 mg capsule 25 mgtablet
1-Covered
diphenhydramine hcl (DIPHEDRYLALLERGY) 125mg5ml liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
119
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
diphenhydramine hcl (DIPHEDRYL)125mg5ml liquid 25 mg capsule
1-Covered
diphenhydramine hcl (DIPHEN)125mg5ml elixir 25 mg tablet
1-Covered
diphenhydramine hcl (DIPHENHIST)125mg5ml liquid 25 mg tablet
1-Covered
diphenhydramine hcl (GERI-DRYL)125mg5ml liquid - 25 mg tablet -
1-Covered
diphenhydramine hcl (M-DRYL)125mg5ml liquid -
1-Covered
diphenhydramine hcl (NIGHTTIMEALLERGY RELIEF) 25 mg tablet
1-Covered
diphenhydramine hcl (NIGHTTIMESLEEP AID) 25 mg tablet
1-Covered
diphenhydramine hcl(PHARBEDRYL) 25 mg capsule 50mg capsule
1-Covered
diphenhydramine hcl (SILADRYL)125mg5ml liquid
1-Covered
diphenhydramine hcl (SIMPLYSLEEP) 25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP AID)25 mg tablet
1-Covered
diphenhydramine hcl (TOTALALLERGY) 25 mg tablet
1-Covered
diphenhydramine hcl (WAL-DRYLALLERGY) 125mg5ml liquid - 25mg tablet -
1-Covered
diphenhydramine hcl (WAL-DRYL)25 mg capsule -
1-Covered
DIPHENHYDRAMINE HCL 125 MG5ML 25 MG10 ML
1-Covered
diphenhydramine hcl 125mg5mlelixir 125mg5ml syrup125mg5ml liquid 25 mg tablet 25mg capsule 50 mg capsule
1-Covered
fexofenadine hcl (ALLER-EASE) 60mg tablet - 180 mg tablet -
1-Covered ST
fexofenadine hcl (ALLER-FEX) 180mg tablet -
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
120
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fexofenadine hcl (ALLERGY RELIEF)60 mg tablet 180 mg tablet
1-Covered ST
fexofenadine hcl (WAL-FEXALLERGY) 60 mg tablet - 180 mgtablet -
1-Covered ST
fexofenadine hcl 60 mg tablet 180mg tablet
1-Covered ST
FEXOFENADINE HCL HM 60 MGTAB 60 MG TABLET 180 MG TABLET
1-Covered ST
GERI-DRYL -125 MG5 ML LIQUID 1-Covered
hydroxyzine hcl 10 mg tablet 10mg5 ml solution 25 mg tablet 50mg tablet 50 mg25ml solution
1-Covered
HYDROXYZINE PAMOATE 25 MGCAP 50 MG CAP
1-Covered
hydroxyzine pamoate 25 mgcapsule 50 mg capsule 100 mgcapsule
1-Covered
loratadine (ALLERCLEAR) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (ALLERGY RELIEF) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (ALLERGY RELIEF) 5mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (ALLERGY) 10 mg tablet 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (CHILDRENS ALLERGYRELIEF) 5 mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (CHILDRENS ALLERGY) 5mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (LORADAMED) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (NON-DROWSYALLERGY) 10 mg tablet -
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (WAL-ITIN) 10 mg tablet-
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (WAL-ITIN) 5 mg5 mlsolution -
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine 10 mg tablet 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
121
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LORATADINE 10 MG TABLET 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine 5 mg5 ml solution 1-Covered QL (150 PER 30 DAYS) AL1 (Up to6 yrs old)
NIGHTTIME SLEEP AID HM 25 MGCPLT
1-Covered
promethazine hcl 125 mg tablet25 mg tablet
1-Covered
PROMETHAZINE HCL 625 MG5 MLSOLN
1-Covered AL1 (At least 2 yrs old)
promethazine hcl 625mg5mlsyrup
1-Covered AL1 (At least 2 yrs old)
ANTILEUKOTRIENESmontelukast sodium 4 mg granpack
1-Covered ST
MONTELUKAST SODIUM 4 MGGRANULES
1-Covered ST
montelukast sodium 4 mg tabchew 5 mg tab chew 10 mgtablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
BRONCHODILATORS ANTICHOLINERGIC (Anticholinergic Drugs toOpen the Airway)
ATROVENT HFA (ipratropiumbromide) 17 MCG INHALER
1-Covered
INCRUSE ELLIPTA (umeclidiniumbromide) 625 MCG INH
1-Covered C (RESTRICTED TO THE DIAGNOSISOF CHRONIC OBSTRUCTIVEPULMONARY DISEASE (COPD))
ipratropium bromide 02 mgmlsolution 21 mcg spray 42 mcgspray
1-Covered
BRONCHODILATORS SYMPATHOMIMETIC (Sympathomimetic Drugsto Open the Airway)
albuterol 90mcg hfa inhaler(generic proair)
1-Covered QL (2 PER 30 [DAYS])
albuterol 90mcg hfa inhaler(generic proventil)
1-Covered QL (2 PER 30 [DAYS])
albuterol 90mcg hfa inhaler(generic ventolin)
1-Covered QL (2 PER 30 [DAYS])
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
122
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALBUTEROL SULFATE 100 MG20 MLSOLN
1-Covered
albuterol sulfate 2 mg tablet 2mg5 ml syrup 25 mg3ml vial-neb 25 mg05 vial-neb 4 mg taber 12h 4 mg tablet 5 mgmlsolution 8 mg tab er 12h
1-Covered
albuterol sulfate 90 mcg hfa aerad
1-Covered QL (2 PER 30 [DAYS])
ALBUTEROL SULFATE HFA 90 MCGINHALER
1-Covered QL (2 PER 30 [DAYS])
epinephrine 015mg03 03mg03 1-Covered QL (2 PER FILL(S))
FORADIL (formoterol fumarate)AEROLIZER 12 MCG CAP
1-Covered ST
levalbuterol tartrate 45 mcg hfaaer ad
1-Covered QL (30 PER 30 DAY(S))
metaproterenol sulfate 10 mg5 mlsyrup 10 mg tablet 20 mg tablet
1-Covered
NASAL DECONGESTANT(pseudoephedrine hcl) 30 MG TAB
1-Covered
pseudoephedrine hcl (NASALDECONGESTANT) 30 mg tablet
1-Covered
pseudoephedrine hcl (SUDOGEST)30 mg tablet 60 mg tablet
1-Covered
pseudoephedrine hcl (SUPHEDRIN)30 mg tablet
1-Covered
pseudoephedrine hcl (SUPHEDRINESINUS CONGESTION) 30 mg tablet
1-Covered
pseudoephedrine hcl(SUPHEDRINE) 30 mg tablet
1-Covered
pseudoephedrine hcl (WAL-PHED)30 mg tablet -
1-Covered
pseudoephedrine hcl 30 mgtablet 60 mg tablet
1-Covered
SEREVENT DISKUS (salmeterolxinafoate) 50 MCG
1-Covered QL (60 PER 30 DAYS)
SUDAFED (pseudoephedrine hcl)30 MG TABLET
1-Covered
TERBUTALINE SULFATE 25 MG TAB 5MG TAB
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
123
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terbutaline sulfate 25 mg tablet 5mg tablet
1-Covered
PHOSPHODIESTERASE INHIBITORS AIRWAYS DISEASE (Drugs thatBlock Phosphodiesterase)
ELIXOPHYLLIN (theophyllineanhydrous) OPHYLLIN 80 MG15 ML
1-Covered
THEO-24 (theophylline anhydrous) -24 ER 200 MG CAPSULE -24 ER 300MG CAPSULE -24 ER 100 MGCAPSULE -24 ER 400 MG CAPSULE
1-Covered
theophylline anhydrous(THEOCHRON) 100 mg tab er 200mg tab er 300 mg tab er
1-Covered
theophylline anhydrous 80mg15ml solution 80 mg15ml elixir100 mg tab er 12h 200 mg tab er12h 300 mg tab er 12h 400 mgtab er 24h 450 mg tab er 12h 600mg tab er 24h
1-Covered
PULMONARY ANTIHYPERTENSIVES (Drugs for PulmonaryHypertension)
ambrisentan 5 mg tablet 10 mgtablet
1-Covered PA QL (1 PER 1 DAY(S)) SP
bosentan 625 mg tablet 125 mgtablet
1-Covered PA QL (2 PER 1 DAY(S)) SP
sildenafil citrate 20 mg tablet 1-Covered PA QL (3 PER 1 DAY(S)) SP
SILDENAFIL CITRATE 20 MG TABLET 1-Covered PA QL (3 PER 1 DAY(S)) SP
tadalafil (ALYQ) 20 mg tablet 1-Covered PA QL (2 PER 1 DAY(S)) SP
tadalafil 20 mg tablet 1-Covered PA QL (2 PER 1 DAY(S)) SP
RESPIRATORY TRACT AGENTS OTHER (Other Drugs for BreathingConditions)
acetylcysteine 100 mgml vial 200mgml vial
1-Covered
benzonatate 100 mg capsule 1-Covered
BEVESPI AEROSPHERE(glycopyrrolateformoterolfumarate) INHALER
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
124
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
brompheniraminemaleatepseudoephedrine hcl(RYNEX PSE)brompheniraminpseudoephedrine 1-15mg5ml liquid
1-Covered
BROTAPP DM (brompheniraminemaleatepseudoephedrinehcldextromethorphan) 1-15-5MG5 ML LIQ
1-Covered
chlorpheniraminemaleatepseudoephedrinedextromethorphan (KIDKARE)chlorpheniraminpseudoepheddm 1-15-5mg5 liquid
1-Covered
codeine phosphateguaifenesin(CHERATUSSIN AC) 10-100mg5liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(G TUSSIN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(GUAIATUSSIN AC) 10-100mg5 20-20010
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(GUAIFENESIN AC) 10-100mg5liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(ROBAFEN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(VIRTUSSIN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin10-100mg5 20-20010
1-Covered AL1 (At least 12 yrs old)
CODEINE-GUAIFENESIN -10-100MG5 ML
1-Covered AL1 (At least 12 yrs old)
COMBIVENT RESPIMAT (ipratropiumbromidealbuterol sulfate) 20-100MCG
1-Covered
COUGH FORMULA DM(guaifenesindextromethorphanhbr) SYRUP
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
125
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fluticasone propionatesalmeterolxinafoate (WIXELA INHUB)propionsalmeterol 100-50 mcgwdev propionsalmeterol 250-50mcg wdev propionsalmeterol500-50 mcg wdev
1-Covered QL (60 PER 30 DAY(S))
fluticasone propionatesalmeterolxinafoate propionsalmeterol 100-50 mcg wdev propionsalmeterol250-50 mcg wdevpropionsalmeterol 500-50 mcgwdev
1-Covered QL (60 PER 30 DAY(S))
fluticasone propionatesalmeterolxinafoate propionsalmeterol 55-14mcg propionsalmeterol 113-14mcg propionsalmeterol 232-14mcg
1-Covered QL (1 PER 30 DAYS)
GUAIASORB DM LIQUID 1-Covered
guaifenesin (MUCUS ER) 600 mgtab er 12h
1-Covered
guaifenesin (MUCUS RELIEF ER) 600mg tab er 12h
1-Covered
GUAIFENESIN-DEXTROMETHORPHAN DM SYRUP
1-Covered
guaifenesindextromethorphanhbr (ADULT ROBITUSSIN PEAK COLDDM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ADULT TUSSIN COUGHCONGEST DM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ADULT TUSSIN DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (ADULT WAL-TUSSIN DM) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (ANTITUSSIVE DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (BIOCOTRON) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (COUGH DM) 100-10mg5syrup
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
126
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesindextromethorphanhbr (DIABETIC SILTUSSIN-DM) 100-10mg5 liquid -
1-Covered
guaifenesindextromethorphanhbr (DIABETIC TUSSIN DM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (EXPECTORANT DM) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (EXTRA ACTION COUGH) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (GERI-TUSSIN DM) 100-10mg5liquid - 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (GILTUSS DIABETIC) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (GILTUSS HBP) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (GUAIASORB DM) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (RI-TUSSIN DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM COUGH) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM COUGH-CHESTCONGEST) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM PEAK COLD)100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN-DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr (SAFETUSSIN DM) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (SILTUSSIN DM DAS) 100-10mg5liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
127
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesindextromethorphanhbr (SILTUSSIN DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (SORBUGEN NR) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSNEL DIABETIC) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSSIN COUGH) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM CLEAR) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM COUGH) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM COUGH-CHESTCONGEST) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM) 100-10mg5 liquid100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (ULTRA DM FREE amp CLEAR) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ULTRA TUSS) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (WAL-TUSSIN DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr 100-10mg5 syrup 100-10mg5liquid
1-Covered
guaifenesinpseudoephedrine hcl(MUCUS D)guaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
guaifenesinpseudoephedrine hcl(MUCUS RELIEF D)guaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
128
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesinpseudoephedrine hclguaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
ipratropium bromidealbuterolsulfate ipratropiumalbuterol 05-3mg3 ampul-neb
1-Covered QL (540 PER 30 DAY(S))
IPRATROPIUM-ALBUTEROL -05-3(25) MG3 ML
1-Covered QL (540 PER 30 DAY(S))
MAXI-TUSS G -LIQUID 1-Covered
MUCUS ER CVS 600 MG TABLET 1-Covered
MUCUS RELIEF ER HM 600 MG TAB 1-Covered
phenylephrine hclpromethazinehcl prometh 5-625mg5 syrup
1-Covered AL1 (At least 2 yrs old)
promethazine hclcodeine 625-105 syrup
1-Covered QL (240 PER 30 DAYS) AL1 (Atleast 12 yrs old) QLC (LIMIT 240ML(8OZ) PER 30 DAYS)
promethazinehcldextromethorphan hbrpromethazinedextromethorphan625-155 syrup
1-Covered AL1 (At least 2 yrs old)
PROMETHAZINE-DM -625-15MG5ML
1-Covered AL1 (At least 2 yrs old)
promethazinephenylephrinehclcodeinepromethazinephenylephcodeine625-5-10 syrup
1-Covered AL1 (At least 12 yrs old)
sodium chloride for inhalation 09 vial- 3 vial- 10 vial-
1-Covered
triprolidine hclpseudoephedrinehcl (APRODINE)triprolidinepseudoephedrine25mg-60mg tablet
1-Covered
triprolidine hclpseudoephedrinehcl (ED A-HIST PSE)triprolidinepseudoephedrine25mg-60mg tablet -
1-Covered
triprolidine hclpseudoephedrinehcl (RITIFED)triprolidinepseudoephedrine 125-305 syrup
1-Covered
triprolidine hclpseudoephedrinehcl (WAL-ACT D COLD amp ALLERGY)triprolidinepseudoephedrine25mg-60mg tablet -col
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
129
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles)
SKELETAL MUSCLE RELAXANTS (Drugs to Relax the Muscles)carisoprodol 350 mg tablet 1-Covered QL (90 PER 30 DAYS)
CARISOPRODOL 350 MG TABLET 1-Covered QL (90 PER 30 DAYS)
cyclobenzaprine hcl 10 mg tablet 1-Covered QL (90 PER 30 DAYS)
cyclobenzaprine hcl 5 mg tablet 1-Covered QL (90 PER 30 DAY(S))
methocarbamol 500 mg tablet750 mg tablet
1-Covered QL (90 PER 30 DAYS)
METHOCARBAMOL 500 MG TABLET750 MG TABLET
1-Covered QL (90 PER 30 DAYS)
VANADOM 350 MG TABLET 1-Covered QL (90 PER 30 DAY(S))
SLEEP DISORDER AGENTS (Drugs for Insomnia)
GABA RECEPTOR MODULATORSflurazepam hcl 15 mg capsule 30mg capsule
1-Covered AL1 (Up to 65 yrs old)
temazepam 75 mg capsule 15mg capsule 30 mg capsule
1-Covered
triazolam 0125 mg tablet 025 mgtablet
1-Covered QL (14 PER 30 DAY(S))
zaleplon 5 mg capsule 10 mgcapsule
1-Covered ST
zolpidem tartrate 5 mg tablet 10mg tablet
1-Covered
SLEEP DISORDERS OTHERdiphenhydramine hcl (ALKA-SELTZER PLUS ALLERGY) 25 mgtablet -
1-Covered
diphenhydramine hcl (COMPOZ)25 mg tablet
1-Covered
diphenhydramine hcl (NIGHTTIMESLEEP AID) 25 mg tablet
1-Covered
diphenhydramine hcl (NYTOLQUICKCAPS) 25 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
130
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
diphenhydramine hcl (SIMPLYSLEEP) 25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP AID)25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP II) 25mg tablet
1-Covered
diphenhydramine hcl (SLEEPTABLET) 25 mg tablet
1-Covered
modafinil 100 mg tablet 200 mgtablet
1-Covered PA QL (3 PER 1 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
131
Alphabetical Index of Prescription Drugs
009 sodium chloride 697072
Aabacavir sulfate 38abacavir sulfatelamivudine 38abacavir sulfatelamivudinezidovudine 38ABACAVIR-LAMIVUDINE 38ABILIFY (aripiprazole) 31ABILIFY MAINTENA (aripiprazole) 31ABILIFY MYCITE (aripiprazole) 31acamprosate calcium 6acarbose 4243acetaminophen 64ACETAMINOPHEN 64acetaminophen (ATHENOL) 63acetaminophen (CHILD FEVER REDUCER) 63acetaminophen (CHILD PAIN REL-FEVERREDUCER) 63acetaminophen (CHILDRENS FEVERREDUCER) 63acetaminophen (CHILDRENS FEVERREDUCING) 63acetaminophen (CHILDRENS PAIN ANDFEVER) 63acetaminophen (CHILDRENS SILAPAP) 63acetaminophen (ED-APAP) 63acetaminophen (LITTLE REMEDIES FEVER-PAIN) 63acetaminophen (M-PAP) 63acetaminophen (MAPAP) 63acetaminophen (MASOPHEN) 63acetaminophen (NON-ASPIRIN EXTRASTRENGTH) 63acetaminophen (NON-ASPIRIN PAIN RELIEF) 63acetaminophen (NON-ASPIRIN) 63acetaminophen (PAIN amp FEVER) 63acetaminophen (PAIN RELIEF EXTRASTRENGTH) 64acetaminophen (PAIN RELIEF) 64
acetaminophen (PAIN RELIEVER) 64acetaminophen (PHARBETOL) 64acetaminophen (SHAKE THAT ACHE) 64acetaminophen (TACTINAL) 64ACETAMINOPHEN 160 MG5ML ORAL SUSP 64ACETAMINOPHEN 160 MG5ML SOLUTION 64acetaminophen with codeine phosphate 45acetazolamide 57ACETAZOLAMIDE 58acetic acid 116ACETIC ACID 116acetylcysteine 124ACID CONTROLLER 80ACID REDUCER 80ACNE MEDICATION 66ACNE MEDICATION (benzoyl peroxide) 66acyclovir 41ACYCLOVIR 41ADACEL TDAP(diphtheriapertussis(acellular)tetanusvaccinepf) 106ADASUVE (loxapine) 30ADLYXIN (lixisenatide) 43ADMELOG (insulin lispro) 45ADMELOG SOLOSTAR (insulin lispro) 45ADVATE (antihemophilic factor (fviii)recombinantfull length) 47ADYNOVATE (antihemophilic factor (fviii)recombinant full length peg) 47AFLURIA QUAD 2020-2021 106AFLURIA QUAD 2020-21 (3YR UP) 106AFSTYLA (antihemophilic factor viiirecombsingle-chnb-dom truncated) 47ALAVERT (loratadine) 117ALAWAY (ketotifen fumarate) 113Albuterol 90mcg HFA inhaler (GenericProair) 122Albuterol 90mcg HFA inhaler (GenericProventil) 122Albuterol 90mcg HFA inhaler (GenericVentolin) 122
LAST UPDATED 12012020132
ALBUTEROL SULFATE 123albuterol sulfate 123ALBUTEROL SULFATE HFA 123alcohol antiseptic pads 110ALCOHOL WIPES 110alendronate sodium 109alfuzosin hcl 86ALL DAY ALLERGY 117ALLERGY RELIEF 117ALLI (orlistat) 78allopurinol 24ALLOPURINOL 24alogliptin benzoate 43alogliptin benzoatemetformin hcl 43alogliptin benzoatepioglitazone hcl 43ALOMIDE (lodoxamide tromethamine) 114ALPHAGAN P (brimonidine tartrate) 115ALPHANATE (antihemophilic factorhumanvon willebrand factorhuman) 47ALPHANINE SD (factor ix) 47alprazolam 42alprazolam (ALPRAZOLAM INTENSOL) 42ALPROLIX (factor ix recombinant fc fusionprotein) 48AMANTADINE 29amantadine hcl 29ambrisentan 124amiloride hcl 58amiloride hclhydrochlorothiazide 56amiodarone hcl 53amiodarone hcl (PACERONE) 53AMITIZA (lubiprostone) 81amitriptyline hcl 19AMLODIPINE BESYLATE 54amlodipine besylate 54amlodipine besylatebenazepril hcl 56ammonium lactate 66ammonium lactate (SKIN TREATMENT) 66amoxapine 19amoxicillin 11AMOXICILLIN-CLAVULANATE POTASS 11
amoxicillinpotassium clavulanate 1112ampicillin trihydrate 12anagrelide hcl 47anastrozole 28ANASTROZOLE 28ANTACID 78ANTACID EXTRA STRENGTH 78ANTI-DIARRHEAL 78ANTIFUNGAL 21apraclonidine hcl 115aprepitant 21APTIVUS (tipranavir) 40APTIVUS (tipranavirvitamin e tpgs) 40aripiprazole 32ARIPIPRAZOLE 32ARISTADA (aripiprazole lauroxil) 32ARISTADA INITIO (aripiprazole lauroxilsubmicronized) 32ARMOUR THYROID (thyroidpork) 102ascorbate calcium 72ascorbic acid 72ascorbic acid (SOOTHING PUREWAY-C) 72aspirin 1aspirin (ADULT ASPIRIN REGIMEN) 1aspirin (ADULT LOW DOSE ASPIRIN EC) 1aspirin (ASPIR 81) 1aspirin (ASPIR-TRIN) 1aspirin (ASPIRIN) 1aspirin (ECOTRIN) 1aspirin (ECPIRIN) 1aspirin (ST JOSEPH ASPIRIN EC) 1aspirin (ST JOSEPH ASPIRIN) 1ASPIRIN 325MG TABLET 1ASPIRIN 81MG TABLET 1aspirinacetaminophencaffeine (ADDEDSTRENGTH HEADACHE) 1aspirinacetaminophencaffeine (BAYERMIGRAINE) 1aspirinacetaminophencaffeine (EXTRA PAINRELIEF) 1
LAST UPDATED 12012020133
aspirinacetaminophencaffeine(EXTRAPRIN) 1aspirinacetaminophencaffeine (HEADACHERELIEF) 1aspirinacetaminophencaffeine (MIGRAINEFORMULA) 2aspirinacetaminophencaffeine (MIGRAINERELIEF) 2aspirinacetaminophencaffeine (PAINRELIEVER PLUS) 2aspirinacetaminophencaffeine (PAINRELIEVER) 2aspirinacetaminophencaffeine (PAIN-OFF) 2ASSURE ID DUO-SHIELD 110ASSURE ID INSULIN SAFETY 110ATAZANAVIR SULFATE 40atazanavir sulfate 40atenolol 53ATENOLOL 53atenololchlorthalidone 56ATHLETES FOOT (terbinafine hcl) 21atomoxetine hcl 62atorvastatin calcium 59ATORVASTATIN CALCIUM 59ATRIPLA (efavirenzemtricitabinetenofovirdisoproxil fumarate) 37atropine sulfate 112ATROVENT HFA (ipratropium bromide) 122AVANDIA (rosiglitazone maleate) 43AVONEX (interferon beta-1a) 65AVONEX (interferon beta-1aalbuminhuman) 65AVONEX PEN (interferon beta-1a) 65azathioprine 104AZATHIOPRINE 104AZELASTINE HCL 117azelastine hcl 117azithromycin 12AZITHROMYCIN 12
Bbacitracin 9BACITRACIN 9bacitracin (BACITRAYCIN PLUS) 9bacitracin zinc 9BACITRACIN ZINC 9bacitracin zinc (ANTIBIOTIC) 9bacitracinpolymyxin b sulfate 112bacitracinpolymyxin b sulfate (AK-POLY-BAC) 112bacitracinpolymyxin b sulfate (POLYCIN) 112baclofen 35BACLOFEN 35balsalazide disodium 109BAQSIMI (glucagon) 44BASAGLAR KWIKPEN U-100 (insulinglarginehuman recombinant analog) 45BELBUCA (buprenorphine hcl) 3benazepril hcl 52benazepril hclhydrochlorothiazide 56BENEFIX (factor ix human recombinant) 48benzonatate 124benzoyl peroxide 67benzoyl peroxide (ACNE CONTROLCLEANSER) 66benzoyl peroxide (ACNE FOAMING WASH) 66benzoyl peroxide (ACNE TREATMENT) 67benzoyl peroxide (ACNECLEAR) 67benzoyl peroxide (ADVANCED EXFOLIATINGCLEANSER) 67benzoyl peroxide (BP WASH) 67benzoyl peroxide (BP) 67benzoyl peroxide (BPO-10) 67benzoyl peroxide (BPO-5) 67benzoyl peroxide (CLEAN-CLEARCONTINUOUS CONTROL) 67benzoyl peroxide (DAYLOGIC ACNEFOAMING WASH) 67benzoyl peroxide (DAYLOGIC ACNETREATMENT) 67
LAST UPDATED 12012020134
benzoyl peroxide (FOAMING ACNE FACEWASH) 67benzoyl peroxide (PANOXYL) 67benztropine mesylate 29BEOVU (brolucizumab-dbll) 112betamethasone dipropionate 87BETAMETHASONE DIPROPIONATE 87betamethasone dipropionatepropyleneglycol 88betamethasone valerate 88betaxolol hcl 115bethanechol chloride 86BETIMOL (timolol) 115BETOPTIC S (betaxolol hcl) 115BEVESPI AEROSPHERE(glycopyrrolateformoterol fumarate) 124BEXSERO (meningococcal group b vaccine4-component) 106bicalutamide 27BIKTARVY (bictegravirsodiumemtricitabinetenofovir alafenamidefumar) 36bisacodyl 82BISACODYL 82bisacodyl (ALOPHEN PILLS) 81bisacodyl (BISA-LAX) 81bisacodyl (BISACODYL) 81bisacodyl (BISCOLAX) 81bisacodyl (C-LAX LAXATIVE) 81bisacodyl (DUCODYL) 81bisacodyl (FAST RELIEF LAXATIVE) 81bisacodyl (GENTLE LAXATIVE) 81bisacodyl (LAXATIVE SUPPOSITORY) 81bisacodyl (LAXATIVE) 82bisacodyl (MAGIC BULLET) 82bisacodyl (WOMENS GENTLE LAXATIVE) 82bisacodyl (WOMENS LAXATIVE) 82bismuth subsalicylate 78bismuth subsalicylate (BISMATROL) 78bismuth subsalicylate (DIOTAME) 78bismuth subsalicylate (PEP-T-MED) 78
bismuth subsalicylate (PEPTIC RELIEF) 78bismuth subsalicylate (PINK BISMUTH) 78bismuth subsalicylate (SOOTHE) 78bismuth subsalicylate (STOMACH RELIEF) 78bisoprolol fumarate 54bisoprolol fumaratehydrochlorothiazide 56BISOPROLOL-HYDROCHLOROTHIAZIDE 56BLEPH-10 (sulfacetamide sodium) 13BLEPHAMIDE (sulfacetamidesodiumprednisolone acetate) 112BOOSTRIX TDAP(diphtheriapertussis(acellular)tetanusvaccine) 106bosentan 124brimonidine tartrate 115bromocriptine mesylate 29brompheniramine maleatepseudoephedrinehcl (RYNEX PSE) 125BROTAPP DM (brompheniraminemaleatepseudoephedrinehcldextromethorphan) 125BUDESONIDE 116budesonide 117bumetanide 58BUNAVAIL (buprenorphine hclnaloxone hcl) 7BUPRENEX (buprenorphine hcl) 7buprenorphine 4buprenorphine hcl 7buprenorphine hclnaloxone hcl 7bupropion hcl 817bupropion hcl (BUPROBAN) 8BUPROPION HCL SR 17BUPROPION XL 17BUSPIRONE HCL 41buspirone hcl 42butalbitalacetaminophen 64butalbitalacetaminophen (TENCON) 64butalbitalacetaminophencaffeine 64butalbitalaspirincaffeine 2butorphanol tartrate 5BUTRANS (buprenorphine) 4
LAST UPDATED 12012020135
CCALADRYL (pramoxine hclcalamine) 67calcipotriene 67calcitoninsalmonsynthetic 110CALCITRIOL 110calcitriol 110CALCIUM 72CALCIUM 500-VIT D3 72CALCIUM 600-VIT D3 72calcium acetate 87calcium acetate (ELIPHOS) 87calcium carbonate 697379calcium carbonate (ANTACID CALCIUM) 78calcium carbonate (ANTACID EXTRASTRENGTH) 78calcium carbonate (ANTACID) 78calcium carbonate (BAN-ACID) 78calcium carbonate (CAL-GEST) 78calcium carbonate (CALCIUM ANTACID) 78calcium carbonate (CHILDRENS PEPTO) 79calcium carbonate (CHILDRENS SOOTHE) 79calcium carbonate (FLAVOR CHEWSANTACID) 79calcium carbonate (OYSCO-500) 72calcium carbonate (SMOOTH ANTACID) 79calcium carbonate (SMOOTH DISSOLVINGANTACID) 79calcium carbonate (SUPER CALCIUM) 72calcium carbonatecholecalciferol (vitamind3) 73calcium carbonatecholecalciferol (vitamind3) (HI-CAL) 73calcium carbonatecholecalciferol (vitamind3) (OS-CAL 500-VIT D3) 73calcium carbonatecholecalciferol (vitamind3) (OYSCO 500-VIT D3) 73calcium carbonatecholecalciferol (vitamind3) (OYSTERCAL-D) 73calcium gluconate 73calcium lactate 73
capecitabine 27CAPECITABINE 27CAPLYTA (lumateperone tosylate) 32captopril 52CAPTOPRIL 52captoprilhydrochlorothiazide 56carbamazepine 16carbamazepine (EPITOL) 16carbamide peroxide (CARBAMOXIDE) 116carbamide peroxide (EAR DROPS) 116carbamide peroxide (EAR SYSTEM) 116carbamide peroxide (EAR WAXREMOVAL) 116carbamide peroxide (MURINE EAR WAXREMOVAL SYSTEM) 116CARBATROL (carbamazepine) 16carbidopalevodopa 30carisoprodol 130CARISOPRODOL 130carvedilol 54cefaclor 11CEFDINIR 11cefdinir 11celecoxib 2CELECOXIB 2CELONTIN (methsuximide) 14cephalexin 11cetirizine hcl 118CETIRIZINE HCL 118cetirizine hcl (24HOUR ALLERGY) 118cetirizine hcl (ALL DAY ALLERGY RELIEF) 118cetirizine hcl (ALL DAY ALLERGY) 118cetirizine hcl (ALLER-TEC) 118cetirizine hcl (ALLERGY RELIEF) 118cetirizine hcl (WAL-ZYR) 118CHANTIX (varenicline tartrate) 8CHEMET (succimer) 70CHILDRENS ALLERGY RELIEF 118CHILDRENS IBUPROFEN 2CHILDRENS NASACORT (triamcinoloneacetonide) 117
LAST UPDATED 12012020136
CHLORDIAZEPOXIDE-CLIDINIUM 77chlordiazepoxideclidinium bromide 77chlorhexidine gluconate 6667chlorhexidine gluconate (PAROEX) 66chloroquine phosphate 28chlorothiazide 58chlorpheniramine maleate 118chlorpheniramine maleate (ALLERGY 4-HOUR) 118chlorpheniramine maleate (ALLERGYRELIEF) 118chlorpheniramine maleate (ALLERGY) 118chlorpheniramine maleate (ALLERGY-TIME) 118chlorpheniramine maleate (CHLORHIST) 118chlorpheniramine maleate (CHLORTABS) 118chlorpheniramine maleate (ED CHLORPEDJR) 118chlorpheniramine maleate(PHARBECHLOR) 118chlorpheniramine maleate (WAL-FINATE) 118chlorpheniraminemaleatepseudoephedrinedextromethorphan (KIDKARE) 125chlorpromazine hcl 30CHLORPROMAZINE HCL 30chlorthalidone 58CHLORTHALIDONE 58cholecalciferol (vitamin d3) 110cholestyramine (with sugar) 59cholestyramineaspartame 59cholestyramineaspartame (PREVALITE) 59ciclopirox 21ciclopirox olamine 2122cilostazol 51CILOXAN (ciprofloxacin hcl) 13CIMDUO (lamivudinetenofovir disoproxilfumarate) 36cimetidine 80CIMETIDINE 80cimetidine (ACID REDUCER) 80
cimetidine (HEARTBURN RELIEF) 80cimetidine hcl 80cinacalcet hcl 110CINACALCET HCL 110ciprofloxacin hcl 13CIPROFLOXACIN HCL 13citalopram hydrobromide 18citric acidsodium citrate 86citric acidsodium citrate (CYTRA-2) 86citric acidsodium citrate (VIRTRATE-2) 86clarithromycin 12clemastine fumarate 119CLEOCIN (clindamycin phosphate) 9clindamycin hcl 9clindamycin palmitate hcl 9clindamycin phosphate 9CLINDAMYCIN PHOSPHATE 9CLINIMIX (amino acids 425 in dextrose 5 in water) 70clobetasol propionate 88CLOBETASOL PROPIONATE 88clomipramine hcl 19CLOMIPRAMINE HCL 19clonazepam 42clonidine hcl 51CLONIDINE HCL 51clopidogrel bisulfate 51clotrimazole 22CLOTRIMAZOLE 22clotrimazole (ANTIFUNGAL RINGWORM) 22clotrimazole (ANTIFUNGAL) 22clotrimazole (ATHLETES FOOT) 22clotrimazole (ATHLETIC FOOT CREAM) 22clotrimazole (CLOTRIMAZOLE AF) 22clotrimazole (ITCH RELIEF) 22clotrimazole (JOCK ITCH RELIEF) 22clotrimazole (JOCK ITCH) 22clotrimazole (RINGWORM) 22clozapine 34CLOZAPINE 34CLOZAPINE ODT 34
LAST UPDATED 12012020137
CLOZARIL (clozapine) 35COAGADEX (coagulation factor x) 48codeinephosphatebutalbitalaspirincaffeine 5codeine phosphateguaifenesin 125codeine phosphateguaifenesin(CHERATUSSIN AC) 125codeine phosphateguaifenesin (G TUSSINAC) 125codeine phosphateguaifenesin(GUAIATUSSIN AC) 125codeine phosphateguaifenesin(GUAIFENESIN AC) 125codeine phosphateguaifenesin (ROBAFENAC) 125codeine phosphateguaifenesin (VIRTUSSINAC) 125codeine sulfate 5CODEINE-GUAIFENESIN 125COGENTIN (benztropine mesylate) 29colchicine 24COLCHICINE 24COLESTID (colestipol hcl) 59colestipol hcl 59COMBIVENT RESPIMAT (ipratropiumbromidealbuterol sulfate) 125COMBIVIR (lamivudinezidovudine) 38COMPLERA (emtricitabinerilpivirinehcltenofovir disoproxil fumarate) 37condoms female 110condoms latex lubricated 110CORIFACT (factor xiii) 48CORTISPORIN (neomycin sulfatepolymyxin bsulfatehydrocortisone) 112CORTISPORIN(neomycinbacitracinpolymyxinbhydrocortisone) 67COUGH FORMULA DM(guaifenesindextromethorphan hbr) 125COUMADIN (warfarin sodium) 46CREON (lipaseproteaseamylase) 85
CRIXIVAN (indinavir sulfate) 40cromolyn sodium 110114cyanocobalamin (vitamin b-12) 73cyanocobalamin (vitamin b-12) (B-12DOTS) 73cyclobenzaprine hcl 130cyclopentolate hcl 112cyclophosphamide 26CYCLOPHOSPHAMIDE 26cyclosporine 104cyclosporine modified 104cyclosporine modified (GENGRAF) 104cyproheptadine hcl 119
Ddanazol 91dapsone 26DEBROX (carbamide peroxide) 116DELSTRIGO (doravirinelamivudinetenofovirdisoproxil fumarate) 37DELTASONE (prednisone) 88DEPAKENE (valproic acid (as sodium salt)(valproate sodium)) 15DEPAKENE (valproic acid) 15DEPO-PROVERA (medroxyprogesteroneacetate) 100DEPO-SUBQ PROVERA 104(medroxyprogesterone acetate) 100DESCOVY (emtricitabinetenofoviralafenamide fumarate) 39desipramine hcl 19desmopressin acetate 90DESMOPRESSIN ACETATE 90desmopressin acetate (non-refrigerated) 90desogestrel-ethinyl estradiol 91desogestrel-ethinyl estradiol (APRI) 91desogestrel-ethinyl estradiol (CYRED EQ) 91desogestrel-ethinyl estradiol (CYRED) 91desogestrel-ethinyl estradiol (EMOQUETTE) 91desogestrel-ethinyl estradiol (ENSKYCE) 91desogestrel-ethinyl estradiol (ISIBLOOM) 91
LAST UPDATED 12012020138
desogestrel-ethinyl estradiol (JULEBER) 91desogestrel-ethinyl estradiol (KALLIGA) 91desogestrel-ethinyl estradiol (RECLIPSEN) 91desogestrel-ethinyl estradiolethinylestradiol 92desogestrel-ethinyl estradiolethinyl estradiol(AZURETTE) 91desogestrel-ethinyl estradiolethinyl estradiol(BEKYREE) 92desogestrel-ethinyl estradiolethinyl estradiol(KARIVA) 92desogestrel-ethinyl estradiolethinyl estradiol(KIMIDESS) 92desogestrel-ethinyl estradiolethinyl estradiol(PIMTREA) 92desogestrel-ethinyl estradiolethinyl estradiol(SIMLIYA) 92desogestrel-ethinyl estradiolethinyl estradiol(VIORELE) 92desogestrel-ethinyl estradiolethinyl estradiol(VOLNEA) 92desonide 88DESONIDE 88dexamethasone 88DEXAMETHASONE 88dexamethasone (DEXAMETHASONEINTENSOL) 88dexamethasone sodium phosphate 114dextroamphetamine sulf-saccharateamphetamine sulf-aspartate 61dextroamphetamine sulfate 62DEXTROAMPHETAMINE SULFATE 62dextroamphetamine sulfate (ZENZEDI) 62DEXTROAMPHETAMINE-AMPHET ER 62dextrose 10 and 045 sodium chloride 70dextrose 10 in water 7073dextrose 5 and 045 sodium chloride 7073dextrose 5 in lactated ringers 73dextrose 5 in water 697073DEXTROSE IN WATER 74diazepam 1542
diclofenac sodium 2114dicloxacillin sodium 12DICYCLOMINE HCL 77dicyclomine hcl 77DIFFERIN (adapalene) 67diflunisal 2digoxin 56digoxin (DIGITEK) 56digoxin (DIGOX) 56DILANTIN (phenytoin sodium extended) 16DILANTIN (phenytoin) 16DILANTIN-125 16DILANTIN-125 (phenytoin) 16DILTIAZEM 24HR ER (CD) 54DILTIAZEM 24HR ER (XR) 55diltiazem hcl 55diltiazem hcl (CARTIA XT) 55diltiazem hcl (DILT-XR) 55diltiazem hcl (TAZTIA XT) 55DIMETHYL FUMARATE 65DIPHENHYDRAMINE HCL 120diphenhydramine hcl 120diphenhydramine hcl (ALER-CAPS) 119diphenhydramine hcl (ALKA-SELTZER PLUSALLERGY) 130diphenhydramine hcl (ALLER-G-TIME) 119diphenhydramine hcl (ALLERGYMEDICATION) 119diphenhydramine hcl (ALLERGYMEDICINE) 119diphenhydramine hcl (ALLERGY RELIEF) 119diphenhydramine hcl (ALLERGY) 119diphenhydramine hcl (BANOPHEN) 119diphenhydramine hcl (BENADRYLALLERGY) 119diphenhydramine hcl (CHILDRENS ALLERGYRELIEF) 119diphenhydramine hcl (CHILDRENSALLERGY) 119diphenhydramine hcl (CHILDRENS BENADRYLALLERGY) 119
LAST UPDATED 12012020139
diphenhydramine hcl (CHILDRENS WAL-DRYLALLERGY) 119diphenhydramine hcl (COMPLETEALLERGY) 119diphenhydramine hcl (COMPOZ) 130diphenhydramine hcl (DIPHEDRYLALLERGY) 119diphenhydramine hcl (DIPHEDRYL) 120diphenhydramine hcl (DIPHEN) 120diphenhydramine hcl (DIPHENHIST) 120diphenhydramine hcl (GERI-DRYL) 120diphenhydramine hcl (M-DRYL) 120diphenhydramine hcl (NIGHTTIME ALLERGYRELIEF) 120diphenhydramine hcl (NIGHTTIME SLEEPAID) 120130diphenhydramine hcl (NYTOL QUICKCAPS)130diphenhydramine hcl (PHARBEDRYL) 120diphenhydramine hcl (SILADRYL) 120diphenhydramine hcl (SIMPLY SLEEP) 120131diphenhydramine hcl (SLEEP AID) 120131diphenhydramine hcl (SLEEP II) 131diphenhydramine hcl (SLEEP TABLET) 131diphenhydramine hcl (TOTAL ALLERGY) 120diphenhydramine hcl (WAL-DRYLALLERGY) 120diphenhydramine hcl (WAL-DRYL) 120diphenoxylate hclatropine sulfate 79DIPHENOXYLATE-ATROPINE 79dipyridamole 51disopyramide phosphate 53disulfiram 6DIURIL (chlorothiazide) 58divalproex sodium 15DIVALPROEX SODIUM 15DOCUSATE SODIUM 82docusate sodium 82docusate sodium (COL-RITE) 82docusate sodium (DIOCTYL) 82docusate sodium (DOCU LIQUID) 82docusate sodium (DOCUSIL) 82
docusate sodium (DSS) 82docusate sodium (DULCOEASE) 82docusate sodium (DULCOLAX STOOLSOFTENER) 82docusate sodium (LAXA BASIC 100) 82docusate sodium (PHILLIPS LAXATIVE) 82docusate sodium (SOF-LAX) 82docusate sodium (STOOL SOFTENER) 82DOK (docusate sodium) 83donepezil hcl 17dorzolamide hcl 115dorzolamide hcltimolol maleate 115DORZOLAMIDE-TIMOLOL 115DOVATO (dolutegravir sodiumlamivudine) 39doxazosin mesylate 51DOXEPIN HCL 19doxepin hcl 19DOXYCYCLINE HYCLATE 14doxycycline hyclate 14doxycycline monohydrate 14DRITHOCREME HP (anthralin) 67dronabinol 21DROPLET MICRON PEN NEEDLE 110DROSPIRENONE-ETHINYL ESTRADIOL 92DROXIA (hydroxyurea) 27DRYSOL (aluminum chloride) 68duloxetine hcl 65
EEES 200 (erythromycin ethylsuccinate) 12EES 400 (erythromycin ethylsuccinate) 12EAR DROPS (carbamide peroxide) 116EDURANT (rilpivirine hcl) 37efavirenz 37EFAVIRENZ-EMTRIC-TENOFOV DISOP 37EFAVIRENZ-LAMIVU-TENOFOV DISOP 3637electrolytesdextrose (ELECTROLYTE) 74electrolytesdextrose (ORALYTE) 74electrolytesdextrose (PEDIATRICELECTROLYTE) 74
LAST UPDATED 12012020140
electrolytesdextrose (PEDIATRIC FREEZERPOPS) 74ELIQUIS (apixaban) 46ELIXOPHYLLIN (theophylline anhydrous) 124ELOCTATE (antihemophilic factor (fviii)recombinant fc fusion protein) 48EMCYT (estramustine phosphate sodium) 27EMSAM (selegiline) 18EMTRICITABINE 38EMTRICITABINE-TENOFOVIR DISOP 38EMTRIVA (emtricitabine) 38ENALAPRIL MALEATE 52enalapril maleate 52ENBREL 105ENBREL (etanercept) 104ENBREL SURECLICK (etanercept) 105ENGERIX-B ADULT (hepatitis b virus vaccinerecombinantpf) 106ENOXAPARIN SODIUM 46enoxaparin sodium 46entacapone 29EPIFOAM (hydrocortisone acetatepramoxinehcl) 68epinephrine 123EPIVIR (lamivudine) 38EPIVIR HBV (lamivudine) 35EPOGEN (epoetin alfa) 47EPZICOM (abacavir sulfatelamivudine) 38ERGOCALCIFEROL 110ergocalciferol (vitamin d2) 110ergocalciferol (vitamin d2) (CALCIDOL) 110ergotamine tartratecaffeine 25ERYTHROCIN STEARATE (erythromycinstearate) 12ERYTHROMYCIN 13erythromycin base 13erythromycin base in ethanol 13erythromycin base in ethanol (ERY) 13erythromycin basebenzoyl peroxide 9ERYTHROMYCIN ETHYLSUCCINATE 13erythromycin ethylsuccinate 13
escitalopram oxalate 18ESCITALOPRAM OXALATE 18ESPEROCT (antihemophilic factor (fviii) rec b-dom truncated peg-exei) 48estradiol 92ESTRADIOL 93estradiol (DOTTI) 92estrogensesterifiedmethyltestosterone 93estrogensesterifiedmethyltestosterone(COVARYX HS) 93estrogensesterifiedmethyltestosterone (EEMTHS) 93ethambutol hcl 26ETHAMBUTOL HCL 26ethinyl estradioldrospirenone 93ethinyl estradioldrospirenone (GIANVI) 93ethinyl estradioldrospirenone (JASMIEL) 93ethinyl estradioldrospirenone (LO-ZUMANDIMINE) 93ethinyl estradioldrospirenone (LORYNA) 93ethinyl estradioldrospirenone (NIKKI) 93ethinyl estradioldrospirenone (VESTURA) 93ETHOSUXIMIDE 14ethosuximide 14ethynodiol diacetate-ethinyl estradiol 93ethynodiol diacetate-ethinyl estradiol(KELNOR 1-35) 93ethynodiol diacetate-ethinyl estradiol(KELNOR 1-50) 93ethynodiol diacetate-ethinyl estradiol (ZOVIA1-35E) 93etodolac 2etonogestrelethinyl estradiol 94etonogestrelethinyl estradiol (ELURYNG) 93etoposide 28EVOTAZ (atazanavir sulfatecobicistat) 40EVZIO (naloxone hcl) 7EXCEDRIN EXTRA STRENGTH(aspirinacetaminophencaffeine) 2EXCEDRIN MIGRAINE(aspirinacetaminophencaffeine) 2
LAST UPDATED 12012020141
EYE ITCH RELIEF 114ezetimibe 59
Ffamotidine 81FAMOTIDINE 81famotidine (ACID CONTROLLER) 80famotidine (ACID REDUCER) 80famotidine (HEARTBURN PREVENTION) 81famotidine (HEARTBURN RELIEF) 81famotidine (PEPCID) 81FANAPT (iloperidone) 32FAZACLO (clozapine) 35FEIBA NF (anti-inhibitor coagulant complex) 48felodipine 55FELODIPINE ER 55fenofibrate 58FENOFIBRATE 58fenofibratemicronized 59fentanyl 4ferrous sulfate 74FERROUS SULFATE 74ferrous sulfate (CHILDRENS IRON) 74ferrous sulfate (FEOSOL) 74ferrous sulfate (FEROSUL) 74ferrous sulfate (FERRO-TIME) 74ferrous sulfate (FERROUSUL) 74ferrous sulfate (PEDIA IRON) 74fexofenadine hcl 121FEXOFENADINE HCL 121fexofenadine hcl (ALLER-EASE) 120fexofenadine hcl (ALLER-FEX) 120fexofenadine hcl (ALLERGY RELIEF) 121fexofenadine hcl (WAL-FEX ALLERGY) 121FIBRYGA (fibrinogen) 48finasteride 86flecainide acetate 53FLOVENT DISKUS (fluticasone propionate) 117FLOVENT HFA (fluticasone propionate) 117FLUAD 2020-2021 106FLUAD QUAD 2020-2021 106
FLUARIX QUAD 2020-2021 106FLUBLOK QUAD 2018-2019 (influenza virusvaccine qv 2018-19(18 yrs andolder)rcmbpf) 106FLUBLOK QUAD 2020-2021 107FLUCELVAX QUAD 2020-2021 107fluconazole 22FLUCONAZOLE 22fluconazole in dextrose iso-osmotic 22flucytosine 22FLUCYTOSINE 22fludrocortisone acetate 88FLULAVAL QUAD 2019-2020 (influenza virusvaccine quadrivalent 2019-20 (6 mos andup)) 107FLULAVAL QUAD 2020-2021 107fluocinolone acetonide 88fluocinonide 88FLUOCINONIDE 88fluoride (sodium) 74fluorometholone 114fluorouracil (ADRUCIL) 27fluoxetine hcl 18FLUOXETINE HCL 18fluoxymesterone (ANDROXY) 91fluphenazine decanoate 30fluphenazine hcl 30FLUPHENAZINE HCL 30flurazepam hcl 130flurbiprofen 2flurbiprofen sodium 114flutamide 27fluticasone propionate 117fluticasone propionate (ALLERGY RELIEF) 117fluticasone propionatesalmeterolxinafoate 126fluticasone propionatesalmeterol xinafoate(WIXELA INHUB) 126fluvoxamine maleate 18FLUZONE HIGH-DOSE QUAD 2020-21 107
LAST UPDATED 12012020142
FLUZONE QUAD 2019-2020 (influenza virusvaccine quadrival 2019-2020(6 mos andup)pf) 107FLUZONE QUAD 2020-2021 107FML FORTE (fluorometholone) 114FML SOP (fluorometholone) 114folic acid 74FOLIC ACID 74FORADIL (formoterol fumarate) 123FOSAMAX PLUS D (alendronatesodiumcholecalciferol (vitamin d3)) 110fosamprenavir calcium 40FOSAMPRENAVIR CALCIUM 40fosinopril sodium 52fosinopril sodiumhydrochlorothiazide 57FOSINOPRIL-HYDROCHLOROTHIAZIDE 57Freestyle Insulix Test Strips 110Freestyle Lite Test Strips 111Freestyle Test Strips 111furosemide 58FUZEON (enfuvirtide) 39
Ggabapentin 15GABAPENTIN 15GARDASIL 9 (human papillomavirus vaccine9-valentpf) 107GAS RELIEF 79GAS RELIEF (simethicone) 79GAS-X (simethicone) 79gemfibrozil 59GEMFIBROZIL 59gentamicin sulfate 8GENTAMICIN SULFATE 9gentamicin sulfate (GENTAK) 8GENTLE LAXATIVE 83GENVOYA(elvitegravircobicistatemtricitabinetenofovir alafenamide) 36GEODON (ziprasidone hcl) 32GEODON (ziprasidone mesylate) 32
GERI-DRYL 121glatiramer acetate 6566glatiramer acetate (GLATOPA) 65GLEOSTINE (lomustine) 26glimepiride 43glipizide 43GLUCAGON EMERGENCY KIT (glucagonhcl) 44GLUCAGON EMERGENCY KIT(glucagonhuman recombinant) 44glyburide 43glyburidemetformin hcl 43glycerin 83glycerin (ADULT GLYCERIN) 83glycerin (LAXATIVE SUPPOSITORY) 83glycerin (PEDIA-LAX) 83glycerin (SUPPOSITORY) 83GOCOVRI (amantadine hcl) 29granisetron hcl 21griseofulvin ultramicrosize 22griseofulvin microsize 23GUAIASORB DM 126guaifenesin (MUCUS ER) 126guaifenesin (MUCUS RELIEF ER) 126GUAIFENESIN-DEXTROMETHORPHAN 126guaifenesindextromethorphan hbr 128guaifenesindextromethorphan hbr (ADULTROBITUSSIN PEAK COLD DM) 126guaifenesindextromethorphan hbr (ADULTTUSSIN COUGH CONGEST DM) 126guaifenesindextromethorphan hbr (ADULTTUSSIN DM) 126guaifenesindextromethorphan hbr (ADULTWAL-TUSSIN DM) 126guaifenesindextromethorphan hbr(ANTITUSSIVE DM) 126guaifenesindextromethorphan hbr(BIOCOTRON) 126guaifenesindextromethorphan hbr (COUGHDM) 126
LAST UPDATED 12012020143
guaifenesindextromethorphan hbr (DIABETICSILTUSSIN-DM) 127guaifenesindextromethorphan hbr (DIABETICTUSSIN DM) 127guaifenesindextromethorphan hbr(EXPECTORANT DM) 127guaifenesindextromethorphan hbr (EXTRAACTION COUGH) 127guaifenesindextromethorphan hbr (GERI-TUSSIN DM) 127guaifenesindextromethorphan hbr (GILTUSSDIABETIC) 127guaifenesindextromethorphan hbr (GILTUSSHBP) 127guaifenesindextromethorphan hbr(GUAIASORB DM) 127guaifenesindextromethorphan hbr (RI-TUSSINDM) 127guaifenesindextromethorphan hbr (ROBAFENDM COUGH) 127guaifenesindextromethorphan hbr (ROBAFENDM COUGH-CHEST CONGEST) 127guaifenesindextromethorphan hbr (ROBAFENDM PEAK COLD) 127guaifenesindextromethorphan hbr(ROBAFEN-DM) 127guaifenesindextromethorphan hbr(SAFETUSSIN DM) 127guaifenesindextromethorphan hbr (SILTUSSINDM DAS) 127guaifenesindextromethorphan hbr (SILTUSSINDM) 128guaifenesindextromethorphan hbr(SORBUGEN NR) 128guaifenesindextromethorphan hbr (TUSNELDIABETIC) 128guaifenesindextromethorphan hbr (TUSSINCOUGH) 128guaifenesindextromethorphan hbr (TUSSINDM CLEAR) 128
guaifenesindextromethorphan hbr (TUSSINDM COUGH) 128guaifenesindextromethorphan hbr (TUSSINDM COUGH-CHEST CONGEST) 128guaifenesindextromethorphan hbr (TUSSINDM) 128guaifenesindextromethorphan hbr (ULTRADM FREE amp CLEAR) 128guaifenesindextromethorphan hbr (ULTRATUSS) 128guaifenesindextromethorphan hbr (WAL-TUSSIN DM) 128guaifenesinpseudoephedrine hcl 129guaifenesinpseudoephedrine hcl (MUCUSD) 128guaifenesinpseudoephedrine hcl (MUCUSRELIEF D) 128guanfacine hcl 5162
HHAILEY FE 94HALDOL (haloperidol lactate) 30HALDOL DECANOATE 100 (haloperidoldecanoate) 30HALDOL DECANOATE 50 (haloperidoldecanoate) 30haloperidol 31HALOPERIDOL 31haloperidol decanoate 31haloperidol lactate 31HALOPERIDOL LACTATE 31HAVRIX (hepatitis a virus vaccinepf) 107HEADACHE RELIEF 2HELIXATE FS (antihemophilic factor (fviii)recombinantfull length) 48HEMLIBRA (emicizumab-kxwh) 48HEMOFIL M (antihemophilic factor human) 48HEPARIN SODIUM 46heparin sodiumporcine 46heparin sodiumporcinepf 46
LAST UPDATED 12012020144
HEPLISAV-B (hepatitis b vaccinerecombinantvaccine adjuvant cpg1018pf) 107HEXALEN (altretamine) 26homatropine hbr 112homatropine hbr (HOMATROPAIRE) 112HUMALOG (insulin lispro) 45HUMALOG MIX 75-25 (insulin lispro protamineand insulin lispro) 45HUMALOG MIX 75-25 KWIKPEN (insulin lisproprotamine and insulin lispro) 45HUMATE-P (antihemophilic factor humanvonwillebrand factorhuman) 48HUMIRA (adalimumab) 105HUMIRA PEDIATRIC CROHNS(adalimumab) 105HUMIRA PEN (adalimumab) 105HUMIRA PEN CROHNS-UC-HS(adalimumab) 105HUMIRA PEN PSOR-UVEITS-ADOL HS(adalimumab) 105HUMIRA(CF) (adalimumab) 105HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 105HUMIRA(CF) PEN (adalimumab) 105HUMIRA(CF) PEN CROHNS-UC-HS(adalimumab) 105HUMIRA(CF) PEN PSOR-UV-ADOL HS(adalimumab) 105HUMULIN 70-30 (insulin nph humanisophaneinsulin regular human) 45HUMULIN 7030 KWIKPEN (insulin nph humanisophaneinsulin regular human) 45HUMULIN N (insulin nph human isophane) 45HUMULIN R (insulin regular human) 45HUMULIN R U-500 (insulin regular human) 45hydralazine hcl 60hydrochlorothiazide 58hydrocodone bitartrateacetaminophen 5hydrocodone bitartrateacetaminophen(LORCET HD) 5
hydrocodone bitartrateacetaminophen(LORTAB) 5hydrocortisone 89109HYDROCORTISONE 89hydrocortisone (ANTI-ITCH) 88hydrocortisone (ANUSOL-HC) 88hydrocortisone (COLOCORT) 109hydrocortisone (CORTISONE) 88hydrocortisone (CORTIZONE-10 PLUS) 89hydrocortisone (CORTIZONE-10) 89hydrocortisone (HYDROCREAM) 89hydrocortisone (NOBLE FORMULA HC) 89hydrocortisone (PREPARATION H) 89hydrocortisone (PROCTO-MED HC) 89hydrocortisone (PROCTO-PAK) 89hydrocortisone (PROCTOSOL-HC) 89hydrocortisone (PROCTOZONE-HC) 89hydrocortisone (SOOTHING CARE) 89HYDROCORTISONE ACETATE 89hydrocortisone acetate 89hydrocortisone acetate (ANUCORT-HC) 89hydrocortisone acetate (ANUSOL-HC) 89hydrocortisone acetate (HEMMOREX-HC) 89hydrocortisone acetatepramoxine hcl 68hydrocortisoneacetic acid 116hydrocortisoneacetic acid (ACETASOLHC) 116hydromorphone hcl 5HYDROXYCHLOROQUINE SULFATE 28hydroxychloroquine sulfate 28hydroxyprogesterone caproate 100hydroxyprogesterone caproatepf 100hydroxyurea 27hydroxyzine hcl 121HYDROXYZINE PAMOATE 121hydroxyzine pamoate 121hyoscyamine sulfate 77hyoscyamine sulfate (HYOSYNE) 77HYPERTET S-D (tetanus immuneglobulinpf) 106
LAST UPDATED 12012020145
Iibuprofen 3IBUPROFEN 3ibuprofen (ADDAPRIN) 2ibuprofen (I-PRIN) 3ibuprofen (IBU) 3ibuprofen (IBU-200) 3ibuprofen (PROVIL) 3ibuprofen (WAL-PROFEN) 3IDELVION (factor ix recombinantalbuminfusion protein) 48imipramine hcl 19IMIPRAMINE HCL 19IMOVAX RABIES VACCINE (rabies vaccinehuman diploid cellpf) 107INCRUSE ELLIPTA (umeclidinium bromide) 122indapamide 58indomethacin 3INFANTS GAS RELIEF 79inhalerassist device with large mask 111inhalerassist device with medium mask 111inhalerassist device with small mask 111insulin lispro 45INSULIN LISPRO PROTAMINE MIX (insulin lisproprotamine and insulin lispro) 45Insulin pen needles 111INSULIN SYRINGE 03 ML 111INSULIN SYRINGE 05 ML 111INSULIN SYRINGE 1 ML 111INTELENCE (etravirine) 37INTRON A (interferon alfa-2brecomb) 35INVEGA (paliperidone) 32INVEGA SUSTENNA (paliperidone palmitate)32INVEGA TRINZA (paliperidone palmitate) 32INVIRASE (saquinavir mesylate) 40IOPIDINE (apraclonidine hcl) 115ipratropium bromide 122ipratropium bromidealbuterol sulfate 129IPRATROPIUM-ALBUTEROL 129irbesartan 52
irbesartanhydrochlorothiazide 57IRON 74ISENTRESS (raltegravir potassium) 36ISENTRESS HD (raltegravir potassium) 36isoniazid 26ISOSORBIDE DINITRATE 60isosorbide dinitrate 60isosorbide mononitrate 60isotretinoin 68isotretinoin (AMNESTEEM) 68isotretinoin (CLARAVIS) 68isotretinoin (MYORISAN) 68isotretinoin (ZENATANE) 68itraconazole 23IXINITY (factor ix human recombinantthreonine 148) 49
JJAKAFI (ruxolitinib phosphate) 28JARDIANCE (empagliflozin) 43JENCYCLA 100JIVI (antihemophilic factor (fviii) rec b-domain deleted peg-aucl) 49JULUCA (dolutegravir sodiumrilpivirine hcl) 39
KKALETRA (lopinavirritonavir) 40KCENTRA (human prothrombin complexconcentrate (pcc) 4-factor) 49ketoconazole 23ketoprofen 3ketorolac tromethamine 114ketotifen fumarate 114ketotifen fumarate (ALLERGY EYE DROPS) 114ketotifen fumarate (EYE ITCH RELIEF) 114ketotifen fumarate (ITCHY EYE) 114ketotifen fumarate (WAL-ZYR) 114ketotifen fumarate (ZADITOR) 114KOGENATE FS (antihemophilic factor (fviii)recombinantfull length) 49
LAST UPDATED 12012020146
KOVALTRY (antihemophilic factor (fviii)recombinantfull length) 49
Llabetalol hcl 54LABETALOL HCL 54lactulose 83lactulose (CONSTULOSE) 83lactulose (ENULOSE) 83lactulose (GENERLAC) 83LAMISIL (terbinafine hcl) 23lamivudine 3538lamivudinezidovudine 38lamotrigine 15lancets 111LANOXIN (digoxin) 57lansoprazole 85LANSOPRAZOLE 85lanthanum carbonate 87latanoprost 115LATUDA (lurasidone hcl) 32leflunomide 106LEFLUNOMIDE 106letrozole 28LEUCOVORIN CALCIUM 27leucovorin calcium 27LEUKERAN (chlorambucil) 26leuprolide acetate 104levalbuterol tartrate 123LEVETIRACETAM 14levetiracetam 14LEVETIRACETAM ER 14LEVO-T (levothyroxine sodium) 103levobunolol hcl 115levocarnitine 70levocarnitine (with sugar) 70levofloxacin 13levonorgestrel 101levonorgestrel (AFTERA) 101levonorgestrel (ECONTRA EZ) 101levonorgestrel (ECONTRA ONE-STEP) 101
levonorgestrel (FALLBACK SOLO) 101levonorgestrel (MY CHOICE) 101levonorgestrel (MY WAY) 101levonorgestrel (NEW DAY) 101levonorgestrel (OPCICON ONE-STEP) 101levonorgestrel (OPTION 2) 101levonorgestrel (TAKE ACTION) 101LEVONORGESTREL-ETH ESTRADIOL 94levonorgestrelethinyl estradiol 96levonorgestrelethinyl estradiol (AFIRMELLE) 94levonorgestrelethinyl estradiol (ALTAVERA) 94levonorgestrelethinyl estradiol (AUBRA EQ) 94levonorgestrelethinyl estradiol (AUBRA) 94levonorgestrelethinyl estradiol (AVIANE) 94levonorgestrelethinyl estradiol (AYUNA) 94levonorgestrelethinyl estradiol (CHATEALEQ) 94levonorgestrelethinyl estradiol (CHATEAL) 94levonorgestrelethinyl estradiol (DELYLA) 94levonorgestrelethinyl estradiol (ENPRESSE) 94levonorgestrelethinyl estradiol (FALMINA) 95levonorgestrelethinyl estradiol (KURVELO) 95levonorgestrelethinyl estradiol (LARISSIA) 95levonorgestrelethinyl estradiol (LESSINA) 95levonorgestrelethinyl estradiol (LEVONEST) 95levonorgestrelethinyl estradiol (LEVORA-28)95levonorgestrelethinyl estradiol (LILLOW) 95levonorgestrelethinyl estradiol (LUTERA) 95levonorgestrelethinyl estradiol (MARLISSA) 95levonorgestrelethinyl estradiol (MYZILRA) 95levonorgestrelethinyl estradiol (ORSYTHIA) 95levonorgestrelethinyl estradiol (PORTIA) 96levonorgestrelethinyl estradiol (SRONYX) 96levonorgestrelethinyl estradiol (TRIVORA-28) 96levonorgestrelethinyl estradiol (VIENVA) 96levothyroxine sodium 103LEVOTHYROXINE SODIUM 103LEVOXYL (levothyroxine sodium) 103LEXIVA (fosamprenavir calcium) 40LICE KILLING 68
LAST UPDATED 12012020147
lidocaine hcl 6LIDOCAINE HCL VISCOUS 6lidocaine hclpf 6lisinopril 52lisinoprilhydrochlorothiazide 57lithium carbonate 42lithium citrate 42LITHOBID (lithium carbonate) 42loperamide hcl 79loperamide hcl (ANTI-DIARRHEAL) 79loperamide hcl (DIAMODE) 79loperamide hcl (ULTRA A-D) 79lopinavirritonavir 40loratadine 121122LORATADINE 122loratadine (ALLERCLEAR) 121loratadine (ALLERGY RELIEF) 121loratadine (ALLERGY) 121loratadine (CHILDRENS ALLERGY RELIEF) 121loratadine (CHILDRENS ALLERGY) 121loratadine (LORADAMED) 121loratadine (NON-DROWSY ALLERGY) 121loratadine (WAL-ITIN) 121lorazepam 42lorazepam (LORAZEPAM INTENSOL) 42LOSARTAN POTASSIUM 52losartan potassium 52losartan potassiumhydrochlorothiazide 57LOSARTAN-HYDROCHLOROTHIAZIDE 57LOTRIMIN AF (clotrimazole) 23lovastatin 59loxapine succinate 31LUCEMYRA (lofexidine hcl) 7LUPRON DEPOT-PED (leuprolide acetate) 104LYLLANA 96LYSODREN (mitotane) 28
MM-M-R II VACCINE (measles mumps andrubella vaccine livepf) 107MAGNESIUM CITRATE 83
magnesium citrate 83MARPLAN (isocarboxazid) 18MATULANE (procarbazine hcl) 26MAXI-TUSS G 129mebendazole (EMVERM) 28MECLIZINE HCL 20meclizine hcl 20meclizine hcl (DRAMAMINE LESS DROWSY) 20meclizine hcl (MEDI-MECLIZINE) 20meclizine hcl (MOTION RELIEF) 20meclizine hcl (MOTION SICKNESS II) 20meclizine hcl (MOTION SICKNESS RELIEF) 20meclizine hcl (MOTION SICKNESS) 20meclizine hcl (MOTION-TIME) 20meclizine hcl (TRAVEL-EASE) 20meclizine hcl (VERTICALM) 20meclizine hcl (WAL-DRAM 2) 20MEDROXYPROGESTERONE ACETATE 101medroxyprogesterone acetate 101mefloquine hcl 28megestrol acetate 101meloxicam 3melphalan 26memantine hcl 17MEMANTINE HCL 17MENACTRA (meningococcalvaccine acyw-135diphtheria toxoid conjpf) 107MENEST (estrogensesterified) 96MENQUADFI 107MENVEO A-C-Y-W-135-DIP(meningococcalvaccine acyw-135diphtheria toxoid conjpf) 108meperidine hcl 5mercaptopurine 27mesalamine 109MESTINON (pyridostigmine bromide) 25metaproterenol sulfate 123metformin hcl 43METFORMIN HCL ER 43METHADONE HCL 4methadone hcl 4
LAST UPDATED 12012020148
methadone hcl (METHADONE INTENSOL) 4methadone hcl (METHADOSE) 4methazolamide 115METHAZOLAMIDE 115methenaminemethylene bluesodphospsalicylatehyoscyamine(PHOSPHASAL) 9methenaminemethylene bluesodphospsalicylatehyoscyamine (URIN DS) 10methimazole 104methocarbamol 130METHOCARBAMOL 130METHOTREXATE 105methotrexate sodium 105methyclothiazide 58methyldopa 51methylergonovine maleate 111METHYLPHENIDATE ER 62methylphenidate hcl 62METHYLPHENIDATE HCL 62methylphenidate hcl (METADATE ER) 62methylprednisolone 89metoclopramide hcl 20metolazone 58metoprolol succinate 54METOPROLOL SUCCINATE 54metoprolol tartrate 54METRO IV (metronidazole in sodiumchloride) 10metronidazole 1068METRONIDAZOLE 10metronidazole in sodium chloride 10mexiletine hcl 53MEXILETINE HCL 53miconazole nitrate 23miconazole nitrate (ANTI-FUNGAL CREAM) 23miconazole nitrate (ANTIFUNGAL CREAM) 23miconazole nitrate (BAZA ANTIFUNGAL) 23miconazole nitrate (INZO ANTIFUNGAL) 23miconazole nitrate (LOTRIMIN AF) 23miconazole nitrate (MICATIN) 23
miconazole nitrate (SECURA ANTIFUNGAL) 23MICROGESTIN 96MICROGESTIN FE 96minocycline hcl 14minoxidil 60mirtazapine 17misoprostol 85modafinil 131moexipril hcl 52molindone hcl 31mometasone furoate 90MONISTAT 3 (miconazole nitrate) 23MONISTAT 7 (miconazole nitrate) 23MONONINE (factor ix) 49montelukast sodium 122MONTELUKAST SODIUM 122morphine sulfate 45moxifloxacin hcl 13MUCUS ER 129MUCUS RELIEF ER 129mupirocin 10mupirocin calcium 10MURINE EAR DROPS (carbamide peroxide) 116MURO-128 (sodium chloride) 112mycophenolate mofetil 105MYLERAN (busulfan) 27MYNATAL (prenatal vitamins withcalciumferrous fumaratefolic acid) 70
NNABI-HB (hepatitis b immune globulin) 106nadolol 54NADOLOL 54naloxone hcl 7naltrexone hcl 7NALTREXONE HCL 7naproxen 3naproxen sodium 3NARCAN (naloxone hcl) 8NARDIL (phenelzine sulfate) 18NASACORT (triamcinolone acetonide) 117
LAST UPDATED 12012020149
NASAL DECONGESTANT (pseudoephedrinehcl) 123nateglinide 43neomycin sulfate 9neomycin sulfatebacitracin zincpolymyxin b(ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxin b(FIRST AID ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxin b(TRIPLE ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxinbhydrocortisone 112neomycin sulfatebacitracin zincpolymyxinbhydrocortisone (NEO-POLYCIN HC) 112neomycin sulfatebacitracinpolymyxin b 113neomycin sulfatebacitracinpolymyxin b(NEO-POLYCIN) 113neomycin sulfatepolymyxin bsulfategramicidin d 113neomycin sulfatepolymyxin bsulfatehydrocortisone 113116NEOMYCIN-POLYMYXIN-HC 116neomycinpolymyxin bsulfatedexamethasone 113nevirapine 37NIACIN 60niacin 60niacin (ENDUR-ACIN) 59niacin (SLO-NIACIN) 59nicardipine hcl 55NICOTINE 14MG PATCH 8NICOTINE 21MG PATCH 8NICOTINE 2MG GUM 8NICOTINE 4MG GUM 8NICOTINE 7MG PATCH 8NICOTINE LOZENGE 8nicotine polacrilex 8nicotine polacrilex (QUIT 2) 8nicotine polacrilex (QUIT 4) 8nicotine polacrilex (STOP SMOKING AID) 8NICOTROL (nicotine) 8
NICOTROL NS (nicotine) 8NIFEDIPINE 55nifedipine 55nifedipine (AFEDITAB CR) 55nifedipine (NIFEDICAL XL) 55NIGHTTIME SLEEP AID 122nisoldipine 55NITRO-BID (nitroglycerin) 60nitrofurantoin 10NITROFURANTOIN 10nitrofurantoin macrocrystal 10nitrofurantoin monohydratemacrocrystals 10nitroglycerin 61NITROGLYCERIN 61nitroglycerin (MINITRAN) 60nitroglycerin (NITRO-TIME) 60nonoxynol 9 (VCF) 86norelgestrominethinyl estradiol (XULANE) 96norethindrone 102norethindrone (CAMILA) 101norethindrone (DEBLITANE) 101norethindrone (ERRIN) 101norethindrone (HEATHER) 102norethindrone (INCASSIA) 102norethindrone (JENCYCLA) 102norethindrone (JOLIVETTE) 102norethindrone (LYZA) 102norethindrone (NORA-BE) 102norethindrone (NORLYDA) 102norethindrone (NORLYROC) 102norethindrone (SHAROBEL) 102norethindrone (TULANA) 102norethindrone acetate 102norethindrone acetate-ethinyl estradiol 97norethindrone acetate-ethinyl estradiol(AUROVELA) 96norethindrone acetate-ethinyl estradiol(GILDESS) 96norethindrone acetate-ethinyl estradiol(HAILEY) 96
LAST UPDATED 12012020150
norethindrone acetate-ethinyl estradiol(JUNEL) 97norethindrone acetate-ethinyl estradiol(LARIN) 97norethindrone acetate-ethinyl estradiol(MICROGESTIN) 97norethindrone acetate-ethinylestradiolferrous fumarate 98norethindrone acetate-ethinylestradiolferrous fumarate (AUROVELA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (BLISOVI FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (JUNEL FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (LARIN FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (MICROGESTINFE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TARINA FE 1-20EQ) 97norethindrone acetate-ethinylestradiolferrous fumarate (TARINA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TILIA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TRI-LEGEST FE) 98norethindrone-ethinyl estradiol (ALYACEN) 98norethindrone-ethinyl estradiol (ARANELLE) 98norethindrone-ethinyl estradiol (BALZIVA) 98norethindrone-ethinyl estradiol (BRIELLYN) 98norethindrone-ethinyl estradiol (CYCLAFEM)98norethindrone-ethinyl estradiol (DASETTA) 98norethindrone-ethinyl estradiol (LEENA) 98norethindrone-ethinyl estradiol (NECON) 98norethindrone-ethinyl estradiol (NORTREL) 98norethindrone-ethinyl estradiol (PHILITH) 98norethindrone-ethinyl estradiol (PIRMELLA) 98norethindrone-ethinyl estradiol (VYFEMLA) 98norethindrone-ethinyl estradiol (WERA) 98
norethindrone-ethinyl estradiol (ZENCHENT) 98NORGESTIMATE-ETHINYL ESTRADIOL 100norgestimate-ethinyl estradiol 100norgestimate-ethinyl estradiol (ESTARYLLA) 98norgestimate-ethinyl estradiol (FEMYNOR) 99norgestimate-ethinyl estradiol (MILI) 99norgestimate-ethinyl estradiol (MONO-LINYAH) 99norgestimate-ethinyl estradiol(MONONESSA) 99norgestimate-ethinyl estradiol (PREVIFEM) 99norgestimate-ethinyl estradiol (SPRINTEC) 99norgestimate-ethinyl estradiol (TRIFEMYNOR) 99norgestimate-ethinyl estradiol (TRI-ESTARYLLA) 99norgestimate-ethinyl estradiol (TRI-LINYAH) 99norgestimate-ethinyl estradiol (TRI-LO-ESTARYLLA) 99norgestimate-ethinyl estradiol (TRI-LO-MARZIA) 99norgestimate-ethinyl estradiol (TRI-LO-MILI) 99norgestimate-ethinyl estradiol (TRI-LO-SPRINTEC) 99norgestimate-ethinyl estradiol (TRI-PREVIFEM) 99norgestimate-ethinyl estradiol (TRI-SPRINTEC) 99norgestimate-ethinyl estradiol (TRI-VYLIBRALO) 99norgestimate-ethinyl estradiol (TRI-VYLIBRA) 99norgestimate-ethinyl estradiol (TRINESSA LO)99norgestimate-ethinyl estradiol (TRINESSA) 99norgestimate-ethinyl estradiol (VYLIBRA) 99norgestrel-ethinyl estradiol (CRYSELLE) 100norgestrel-ethinyl estradiol (ELINEST) 100norgestrel-ethinyl estradiol (LOW-OGESTREL) 100norgestrel-ethinyl estradiol (OGESTREL) 100nortriptyline hcl 19NORVIR (ritonavir) 40
LAST UPDATED 12012020151
NOVOEIGHT (antihemophilic factor viiirecombinant b-domain truncated) 49NOVOLIN 70-30 (insulin nph humanisophaneinsulin regular human) 45NOVOLIN N (insulin nph human isophane) 45NOVOLIN R (insulin regular human) 45NOVOSEVEN RT (coagulation factor viia(recombinant)) 49NUPLAZID (pimavanserin tartrate) 32NUWIQ (antihemophilic factor viii rec hek cellb-domain deleted) 50NYSTATIN 23nystatin 23
OO-CAL PRENATAL (prenatal vit with calciumno127ferrous fumaratefolic acid) 70OBIZUR (antihemophilic factor viiirecombinant porcine sequence) 50ODEFSEY (emtricitabinerilpivirinehcltenofovir alafenamide fumarate) 37ofloxacin 13olanzapine 33olanzapinefluoxetine hcl 17OMEGA-3 ACID ETHYL ESTERS 60omega-3 acid ethyl esters 60omeprazole 85OMEPRAZOLE 85ondansetron 21ondansetron hcl 21ORAP (pimozide) 31oseltamivir phosphate 41OSELTAMIVIR PHOSPHATE 41OSMOLEX ER (amantadine hcl) 29oxazepam 42oxcarbazepine 16oxybutynin chloride 86OXYBUTYNIN CHLORIDE ER 86oxycodone hcl 46oxycodone hclacetaminophen 6oxycodone hclacetaminophen (ENDOCET) 6
oxycodone hclaspirin 6OXYTROL FOR WOMEN (oxybutynin) 86OYSTER SHELL CALCIUM 74OYSTER SHELL CALCIUM-VIT D3 74
PPAIN amp FEVER (acetaminophen) 64PAIN RELIEF 64paliperidone 33pantoprazole sodium 85PANTOPRAZOLE SODIUM 85PARNATE (tranylcypromine sulfate) 18paromomycin sulfate 9paroxetine hcl 18PEDIATRIC IRON 75pediatric multivit with acd3 no21sodiumfluoride 75pediatric multivitamin no16sodiumfluoride 75pediatric multivitamin no2sodium fluoride 75pediatric multivitamin no45sodiumfluorideferrous sulfate 75pediatric multivitamins no17 with sodiumfluoride 75peg 3350sod sulfsod bicarbsodchloridepotassium chloride 83peg 3350sod sulfsod bicarbsodchloridepotassium chloride (GAVILYTE-C) 83peg 3350sod sulfsod bicarbsodchloridepotassium chloride (GAVILYTE-G) 83PEG-3350 AND ELECTROLYTES 83PEGINTRON REDIPEN (peginterferon alfa-2b) 35PEN NEEDLE 111pen needle diabetic 111pen needle diabetic disposable safety 111pen needle diabetic remover and disposalunit 111pen needle diabetic safety 111penicillamine 86PENICILLAMINE 86
LAST UPDATED 12012020152
penicillin v potassium 12pentoxifylline 57PEPTO-BISMOL (bismuth subsalicylate) 79PEPTO-BISMOL TO-GO (bismuthsubsalicylate) 79permethrin 29permethrin (LICE TREATMENT) 29perphenazine 20PERSERIS (risperidone) 33PHENAZOPYRIDINE HCL 87phenazopyridine hcl 87phenazopyridine hcl (URINARY PAIN RELIEF) 86phenelzine sulfate 18phenobarbital 15PHENOBARBITAL 15PHENOXYBENZAMINE HCL 51phenoxybenzamine hcl 51phenylephrine hcl 113phenylephrine hclpromethazine hcl 129phenytoin 16phenytoin sodium extended 16PHOS-FLUR (fluoride (sodium)) 66PHOSPHOLINE IODIDE (echothiophateiodide) 115phytonadione (vit k1) 50PIFELTRO (doravirine) 37pilocarpine hcl 115PILOCARPINE HCL 115pimecrolimus 68pimozide 31pindolol 54pioglitazone hcl 43PIOGLITAZONE HCL 44piperonyl butoxidepyrethrins (LICE KILLING)68piperonyl butoxidepyrethrins (LICE PYRINYLSHAMPOO) 68piperonyl butoxidepyrethrins (LICETREATMENT) 68piperonyl butoxidepyrethrins (RID) 68piperonyl butoxidepyrethrinspermethrin(COMPLETE LICE TREATMENT) 69
piperonyl butoxidepyrethrinspermethrin(LICE SOLUTION) 69piroxicam 3PLAN B ONE-STEP (levonorgestrel) 102PLEGRIDY (peginterferon beta-1a) 66PLEGRIDY PEN (peginterferon beta-1a) 66PNEUMOVAX 23 (pneumococcal 23-valentpolysaccharide vaccine) 108podofilox 69POLY-VITAMIN (multivitamin) 75polyethylene glycol 3350 84polyethylene glycol 3350 (CLEARLAX) 83polyethylene glycol 3350 (GAVILAX) 84polyethylene glycol 3350 (GENTLELAX) 84polyethylene glycol 3350 (GLYCOLAX) 84polyethylene glycol 3350 (LAXACLEAR) 84polyethylene glycol 3350 (NATURA-LAX) 84polyethylene glycol 3350 (POWDERLAX) 84polyethylene glycol 3350 (PURELAX) 84polyethylene glycol 3350 (SMOOTHLAX) 84polymyxin b sulfatetrimethoprim 113POTASSIUM 75potassium bicarbonatecitric acid 75potassium bicarbonatecitric acid (EFFER-K)75potassium bicarbonatecitric acid (KEFFERVESCENT) 75potassium bicarbonatecitric acid (KLOR-CON-EF) 75POTASSIUM CHL-NORMAL SALINE 75potassium chloride 7075POTASSIUM CHLORIDE 71potassium chloride (KLOR-CON M10) 70potassium chloride (KLOR-CON M20) 70potassium chloride (KLOR-CON SPRINKLE) 75potassium chloride in 09 sodiumchloride 7071potassium chloridepotassiumbicarbonatecitric acid 75potassium gluconate 76pramipexole di-hcl 29pramoxine hclcalamine (CALAHIST) 69
LAST UPDATED 12012020153
pramoxine hclcalamine (CALAMINEMEDICATED) 69praziquantel 28prazosin hcl 51PRAZOSIN HCL 51PRED MILD (prednisolone acetate) 114prednisolone 90prednisolone (MILLIPRED DP) 90prednisolone (MILLIPRED) 90prednisolone acetate 114prednisolone sodium phosphate 90114prednisone 90prednisone (PREDNISONE INTENSOL) 90pregabalin 65PREGABALIN 65PREMARIN (estrogens conjugated) 100PREMPHASE (estrogensconjugatedmedroxyprogesteroneacetate) 100PREMPRO (estrogensconjugatedmedroxyprogesteroneacetate) 100PRENATABS FA (prenatal vits with calciumno78ferrous fumaratefolic acid) 71PRENATABS RX (prenatal vitamin with calciumno76ironcarbonylfolic acid) 71PRENATAL MULTIVITAMIN 76prenatal vit with calcium no129ferrousfumaratefolic acid 76prenatal vit with calcium no130ferrousfumaratefolic acid 76prenatal vitamins no121ferrousfumaratefolic acid 76prenatal vitamins with calciumferrousfumaratefolic acid 76prenatal vitamins with calciumferrousfumaratefolic acid (MYNATAL PLUS) 71prenatal vitamins with calciumferrousfumaratefolic acid (MYNATAL-Z) 71prenatal vits with calcium 118ferrousfumaratefolic acid 76
prenatal vits with calcium 118ferrousfumaratefolic acid (SE-NATAL 19) 71prenatal vits with calcium 136ferrousfumaratefolic acid (VINATE-M) 71prenatal vits with calcium 137ferrousfumaratefolic acid 76prenatal vits with calcium 95ferrousfumaratefolic acid 76prenatal vits with calcium no115ironfumaratefolic acid 71prenatal vits with calcium no72ferrousfumaratefolic acid 71prenatal vits with calcium no72ferrousfumaratefolic acid (M-NATAL PLUS) 71prenatal vits with calcium no72ferrousfumaratefolic acid (PREPLUS) 71prenatal vits with calciumno72ironcarbonylfolic acid 72prenatal vits with calcium no74ferrousfumaratefolic acid 72prenatal vits with calcium no96ferrousfumaratefolic acid 76PREVACID (lansoprazole) 85PREVNAR 13 (pneumococcal 13-valentconjugate vaccine (diphtheria crm)pf) 108PREZCOBIX (darunavirethanolatecobicistat) 40PREZISTA (darunavir ethanolate) 40PRIFTIN (rifapentine) 26primaquine phosphate 28primidone 15probenecid 24probenecidcolchicine 24PROBUPHINE (buprenorphine hcl) 7prochlorperazine 20prochlorperazine (COMPRO) 20prochlorperazine maleate 20PROCRIT (epoetin alfa) 47PROCTOFOAM-HC (hydrocortisoneacetatepramoxine hcl) 69
LAST UPDATED 12012020154
PROFILNINE (factor ix complex prothrombincplx conc(pcc) no4 3-factor) 50promethazine hcl 21122PROMETHAZINE HCL 122promethazine hcl (PHENADOZ) 21promethazine hcl (PROMETHEGAN) 21promethazine hclcodeine 129promethazine hcldextromethorphan hbr 129PROMETHAZINE-DM 129promethazinephenylephrine hclcodeine 129propafenone hcl 53propantheline bromide 77proparacaine hcl 113propranolol hcl 54propylthiouracil 104pseudoephedrine hcl 123pseudoephedrine hcl (NASALDECONGESTANT) 123pseudoephedrine hcl (SUDOGEST) 123pseudoephedrine hcl (SUPHEDRIN) 123pseudoephedrine hcl (SUPHEDRINE SINUSCONGESTION) 123pseudoephedrine hcl (SUPHEDRINE) 123pseudoephedrine hcl (WAL-PHED) 123PULMICORT FLEXHALER (budesonide) 117pyrazinamide 26pyridostigmine bromide 25pyridoxine hcl (vitamin b6) 76
Qquetiapine fumarate 33quinapril hcl 52quinidine gluconate 53quinidine sulfate 53QVAR REDIHALER (beclomethasonedipropionate) 117
RRABAVERT (rabies vaccine purified chickenembryo cell (pcec)pf) 108ramipril 52
RAMIPRIL 53REBINYN (factor ix (human) recombinantpegylated) 50RECOMBINATE (antihemophilic factor viiihuman recombinant) 50RECOMBIVAX HB (hepatitis b virus vaccinerecombinantpf) 108RELENZA (zanamivir) 41RESCRIPTOR (delavirdine mesylate) 37REXULTI (brexpiprazole) 33REYATAZ (atazanavir sulfate) 41RHEUMATREX (methotrexate sodium) 105RIASTAP (fibrinogen) 50ribavirin 36ribavirin (RIBASPHERE) 36RID (permethrin) 111RID (piperonylbutoxidepyrethrinspermethrin) 69RIDAURA (auranofin) 106rifabutin 26rifampin 26riluzole 65RILUZOLE 65ringers solution 7076RISPERDAL (risperidone) 33RISPERDAL CONSTA (risperidonemicrospheres) 33RISPERDAL M-TAB (risperidone) 33risperidone 33ritonavir 41RIXUBIS (factor ix human recombinant) 50rizatriptan benzoate 25ropinirole hcl 29rosuvastatin calcium 59RUKOBIA 39
Ssalsalate 3SANDIMMUNE (cyclosporine) 105SANTYL (collagenase clostridiumhistolyticum) 69
LAST UPDATED 12012020155
SAPHRIS (asenapine maleate) 33SAVELLA (milnacipran hcl) 65SE-NATAL-19 (prenatal vitamins no119ironfumaratefolic acid) 72SECUADO (asenapine) 33selegiline hcl 30selenium sulfide 69selenium sulfide (ANTI-DANDRUFF) 69selenium sulfide (MEDICATED DANDRUFFSHAMPOO) 69selenium sulfide (SELSUN BLUE) 69selenium sulfidealoe vera (SELSUN BLUEMOISTURIZING) 69SELZENTRY (maraviroc) 39SEREVENT DISKUS (salmeterol xinafoate) 123SEROQUEL (quetiapine fumarate) 34SEROQUEL XR (quetiapine fumarate) 34sertraline hcl 18sevelamer carbonate 87SEVENFACT 50SHINGRIX (varicella-zoster virus glycoproteinerecas01b adjuvantpf) 108SILACE (docusate sodium) 84sildenafil citrate 124SILDENAFIL CITRATE 124silver sulfadiazine 13simethicone 80simethicone (GAS RELIEF) 80simethicone (GAS-X) 80simethicone (INFANT GAS RELIEF) 80simethicone (INFANTS GAS RELIEF) 80simethicone (MI-ACID) 80simvastatin 59sirolimus 105SODIUM CHLORIDE 7677sodium chloride 113sodium chloride (MURO-128) 113sodium chloride for inhalation 129sodium chloride irrigating solution 707277sodium chloride irrigating solution (AQUACARE SODIUM CHLORIDE) 77
sodium chloride irrigating solution (CURITY) 77sodium chloridesodiumbicarbonatepotassium chloridepeg 84sodium chloridesodiumbicarbonatepotassium chloridepeg(GAVILYTE-N) 84sodium chloridesodiumbicarbonatepotassium chloridepeg (TRILYTEWITH FLAVOR PACKETS) 84sodium polystyrene sulfonate 72sodium polystyrene sulfonatesorbitol solution(KIONEX) 72sodiumpotassiumpotassium citratesodiumcitratecit ac 87sodiumpotassiumpotassium citratesodiumcitratecit ac (CYTRA-3) 87sodiumpotassiumpotassium citratesodiumcitratecit ac (TRICITRATES) 87sofosbuvirvelpatasvir 35SOTALOL 53SOTALOL AF 53sotalol hcl 53sotalol hcl (SORINE) 53spironolactone 58SPIRONOLACTONE 58spironolactonehydrochlorothiazide 57SPS (sodium polystyrene sulfonatesorbitolsolution) 72SSD (silver sulfadiazine) 13stavudine 38STOMACH RELIEF 80STOOL SOFTENER 84STOOL SOFTENER (docusate sodium) 84STRIBILD(elvitegravircobicistatemtricitabinetenofovir disoproxil) 36SUBLOCADE (buprenorphine) 4SUBOXONE (buprenorphine hclnaloxonehcl) 7sucralfate 85SUDAFED (pseudoephedrine hcl) 123
LAST UPDATED 12012020156
sulfacetamide sodium 13sulfacetamide sodiumprednisolone sodiumphosphate 113sulfamethoxazoletrimethoprim 13sulfasalazine 109SULFATRIM (sulfamethoxazoletrimethoprim)14sulindac 3SUMATRIPTAN 25sumatriptan 25sumatriptan succinate 25SUMATRIPTAN SUCCINATE 25SUSTIVA (efavirenz) 37SYMBYAX (olanzapinefluoxetine hcl) 18SYMFI (efavirenzlamivudinetenofovirdisoproxil fumarate) 36SYMFI LO (efavirenzlamivudinetenofovirdisoproxil fumarate) 37SYMTUZA (darunavirethcobicistatemtricitabinetenofoviralafenamide) 41SYNAREL (nafarelin acetate) 104SYNJARDY (empagliflozinmetformin hcl) 44SYNJARDY XR (empagliflozinmetformin hcl) 44SYNTHROID (levothyroxine sodium) 103syringe with needle insulin safety 1 ml 111syringe with needledisposableinsulin 1 ml 111syringe with needleinsulin03 ml 111syringe with needleinsulin05 ml 112
TTABLOID (thioguanine) 27tacrolimus 69106TACROLIMUS 106tadalafil 124tadalafil (ALYQ) 124TAKE ACTION (levonorgestrel) 102TAMOXIFEN CITRATE 27tamoxifen citrate 27tamsulosin hcl 86TDVAX (tetanus and diphtheria toxoidsadult) 108
TECFIDERA (dimethyl fumarate) 66TEGRETOL (carbamazepine) 16TEGRETOL XR (carbamazepine) 16temazepam 130TEMIXYS (lamivudinetenofovir disoproxilfumarate) 36temozolomide 27TENIVAC (tetanus and diphtheria toxoidsadsorbed adultpf) 108tenofovir disoproxil fumarate 38terazosin hcl 52TERAZOSIN HCL 52terbinafine hcl 24terbinafine hcl (ANTIFUNGAL) 24terbinafine hcl (ATHLETES FOOT AF) 24terbinafine hcl (ATHLETES FOOT) 24terbinafine hcl (JOCK ITCH) 2444terbinafine hcl (LAMISIL AT) 24TERBUTALINE SULFATE 123terbutaline sulfate 124testosterone 91testosterone cypionate 91tetanus and diphtheria toxoids adult 108THALOMID (thalidomide) 27THEO-24 (theophylline anhydrous) 124theophylline anhydrous 124theophylline anhydrous (THEOCHRON) 124thioridazine hcl 31thiothixene 31thyroidpork (NP THYROID) 103timolol maleate 115TIMOLOL MALEATE 115tioconazole 24TIVICAY (dolutegravir sodium) 36TIVICAY PD 36tizanidine hcl 35TOBRADEX (tobramycindexamethasone) 113tobramycin 9tobramycindexamethasone 113TOBREX (tobramycin) 9tolbutamide 44
LAST UPDATED 12012020157
tolmetin sodium 3tolnaftate 24tolnaftate (ANTIFUNGAL CREAM) 24tolnaftate (ATHLETES FOOT) 24tolnaftate (FUNGOID-D) 24topiramate 16TOPIRAMATE 16TOREMIFENE CITRATE 27toremifene citrate 27tramadol hcl 6TRAMADOL HCL 6trandolapril 53tranylcypromine sulfate 18TRAVEL SICKNESS (meclizine hcl) 21TRAZODONE HCL 19trazodone hcl 19tretinoin 28TRETTEN (factor xiii a-subunit recombinant) 50TRI-VI-SOL (vitamin a palmitateascorbicacidcholecalciferol (vit d3)) 77triamcinolone acetonide 6690117TRIAMCINOLONE ACETONIDE 66triamcinolone acetonide (ORALONE) 66triamterenehydrochlorothiazide 57triazolam 130trifluoperazine hcl 31trifluridine 41TRIGLIDE (fenofibrate nanocrystallized) 59trihexyphenidyl hcl 29trimethobenzamide hcl 21trimethoprim 10TRINATE (prenatal vits with calciumno73ferrous fumaratefolic acid) 72TRIPLE ANTIBIOTIC 11TRIPLE ANTIBIOTIC (neomycinsulfatebacitracin zincpolymyxin b) 11triprolidine hclpseudoephedrine hcl(APRODINE) 129triprolidine hclpseudoephedrine hcl (ED A-HIST PSE) 129
triprolidine hclpseudoephedrine hcl(RITIFED) 129triprolidine hclpseudoephedrine hcl (WAL-ACT D COLD amp ALLERGY) 129TRIUMEQ (abacavir sulfatedolutegravirsodiumlamivudine) 39TRIZIVIR (abacavirsulfatelamivudinezidovudine) 38TROGARZO (ibalizumab-uiyk) 39trospium chloride 86TROSPIUM CHLORIDE 86TRULICITY 44TRULICITY (dulaglutide) 44TRUMENBA (neisseria meningitidis group blipidated fhbp recombinant) 108TRUVADA (emtricitabinetenofovir disoproxilfumarate) 39TWINRIX (hepatitis a virus and hepatitis b virusvaccinepf) 108TYBOST (cobicistat) 39
UUNIFINE PENTIPS MAXFLOW 112UNITHROID (levothyroxine sodium) 103URETRON D-S (methenaminemethylenebluesod phospsalicylatehyoscyamine) 11URINARY PAIN RELIEF 87ursodiol 80
Vvalacyclovir hcl 41valproic acid 15VALPROIC ACID 15valproic acid (as sodium salt) (valproatesodium) 15valsartan 52valsartanhydrochlorothiazide 57VANADOM 130VANDAZOLE (metronidazole) 11VAQTA (hepatitis a virus vaccinepf) 109
LAST UPDATED 12012020158
VARIVAX VACCINE (varicella virus vaccinelivepf) 109VEMLIDY (tenofovir alafenamide) 35venlafaxine hcl 19VENLAFAXINE HCL ER 19verapamil hcl 55VERSACLOZ (clozapine) 35VICTOZA 2-PAK (liraglutide) 44VICTOZA 3-PAK (liraglutide) 44VIRACEPT (nelfinavir mesylate) 41VIRAMUNE (nevirapine) 38VIRAMUNE XR (nevirapine) 38VIREAD (tenofovir disoproxil fumarate) 39VITAMIN B-12 77VITAMIN C 77VITEKTA (elvitegravir) 36VIVITROL (naltrexone microspheres) 7VONVENDI (von willebrand factor(recombinant)) 50VRAYLAR (cariprazine hcl) 34
Wwarfarin sodium 46warfarin sodium (JANTOVEN) 46WILATE (antihemophilic factor humanvonwillebrand factorhuman) 50
XXARELTO (rivaroxaban) 4647XYNTHA (antihemophilic factor (factor viii)recombb-domain deleted) 51XYNTHA SOLOFUSE (antihemophilic factor(factor viii) recombb-domain deleted) 51
Zzaleplon 130ZERIT (stavudine) 39ZIAGEN (abacavir sulfate) 39ziprasidone hcl 34ZIPRASIDONE HCL 34ZIPRASIDONE MESYLATE 34
ziprasidone mesylate 34zolpidem tartrate 130zonisamide 14ZOSTAVAX (zoster vaccine livepf) 109ZOVIA 1-35 100ZUBSOLV (buprenorphine hclnaloxone hcl) 7ZYPREXA (olanzapine) 34ZYPREXA RELPREVV (olanzapine pamoate) 34ZYPREXA ZYDIS (olanzapine) 34
LAST UPDATED 12012020159
vi
Participating retail pharmacies
You can fill prescriptions at any participating pharmacy (network pharmacy) unless it is for a
specialty drug You may find a network pharmacy by visiting
httpspromiseblueshieldcacomcapharmacysearchversion=2020amplob=mcal
What are specialty drugs
Specialty drugs require extra training before you take them extra visits with your doctor need
special handling and transport and are usually high-cost These drugs may require prior
authorization or non-formulary exception If approved a network specialty pharmacy will
deliver them by mail Please visit wwwblueshieldcacompromisemedi-cal for more
information
What if I have additional questions
If you want a copy of the Blue Shield of California Promise Health Plan Medi-Cal Formulary or
have questions please call Customer Care at (800) 605-2556 (Los Angeles County) or (855)
699-5557 (San Diego County)
Blue Shield of California Promise Health Plan
601 Potrero Grande Drive Monterey Park CA 91755
vii
H5928_19_269A2_C 08302019
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91
8)
Discrimination is Against the Law
Blue Shield of California Promise Health Plan complies with applicable state laws and federal civil rights laws and does not discriminate on the basis of race color national origin ancestry religion sex marital status gender gender identity sexual orientation age or disability Blue Shield of California Promise Health Plan does not exclude people or treat them differently because of race color national origin ancestry religion sex marital status gender gender identity sexual orientation age or disability
Blue Shield of California Promise Health Plan provides bull Aids and services at no cost to people with disabilities to communicate effectively with us
such aso Qualified sign language interpreterso Written information in other formats (large print audio accessible electronic
formats other formats)bull Language services at no cost to people whose primary language is not English such as
o Qualified interpreterso Information written in other languages
If you need these services contact the Blue Shield of California Promise Health Plan Civil Rights Coordinator
If you believe that Blue Shield of California Promise Health Plan has failed to provide these
services or discriminated in another way on the basis of race color national origin
ancestry religion sex marital status gender gender identity sexual orientation age or
disability you can file a grievance with
Blue Shield of California Promise Health Plan
Civil Rights Coordinator
601 Potrero Grande Dr
Monterey Park CA 91755
Phone (844) 883-2233 (TTY 711)
Fax (323) 889-2228
Email BSCPHPCivilRightsblueshieldcacom
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 Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD)
Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language Assistance Notice for LA County
viii
English
ATTENTION Language assistance services free of charge are available to you Call 1-800-605-
2556 (TTY 711)
繁體中文 (Chinese)
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1-800-605-2556(TTY
711)
한국어 (Korean)
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-800-
605-2556 (TTY 711)번으로 전화해 주십시오
Русский (Russian)
ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги
перевода Звоните 1-800-605-2556 (телетайп 711)
Kreyogravel Ayisyen (Haitian-Creole)
ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele 1-
800-605-2556 (TTY 711)
Franccedilais (French)
ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes
gratuitement Appelez le 1-800-605-2556 (TTY 711)
Portuguecircs (Portuguese)
ATENCcedilAtildeO Se fala portuguecircs encontram-se disponiacuteveis serviccedilos linguiacutesticos graacutetis Ligue para 1-
800-605-2556 (TTY 711)
Italiano (Italian)
ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza
linguistica gratuiti Chiamare il numero 1-800-605-2556 (TTY 711)
(Farsi) فارسی
2556-605-800-1 با باشد می فراهم شما برای رایگان بصورت زبانی تسهیلات کنید می گفتگو فارسی زبان به اگر توجه
(TTY 771) بگیرید تماس
ह िदी (Hindi)
धयान द यदद आप द िदी बोलत तो आपक ललए मफत म भाषा स ायता सवाएि उपलबध 1-800-605-
2556 (TTY 711) पर कॉल करHmong (Hmong)
LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb rau koj Hu rau
1-800-605-2556 (TTY 711)
Espantildeol (Spanish)
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica
Llame al 1-800-605-2556 (TTY 711)
Language Assistance Notice for LA County (Continued)
ix
Tiếng Việt (Vietnamese)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-
800-605-2556 (TTY 711)
Tagalog (Tagalog - Filipino)
PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa
wika nang walang bayad Tumawag sa 1-800-605-2556 (TTY 711)
(Arabic) العربية
2556-605-800-1مجان اتصل برقم ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بال
(711YTT)
Polski (Polish)
UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń
pod numer 1-800-605-2556 (TTY 711)
ພາສາລາວ (Lao)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ ໂທຣ 1-800-605-2556 (TTY 711)
日本語 (Japanese)
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1-800-605-
2556(TTY711)までお電話にてご連絡ください
ภาษาไทย (Thai)
เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-800-605-2556 (TTY 711)
λληνικά (Greek)
ΠΡΟΣΟΧΗ Αν μιλάτε ελληνικά στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης
οι οποίες παρέχονται δωρεάν Καλέστε 1-800-605-2556 (TTY 711)
ਪਜਾਬੀ ਦ (Punjabi)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-800-605-
2556 (TTY 711) ਤ ਕਾਲ ਕਰ
ខមែរ (Cambodian)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល
គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-800-605-2556 (TTY 711)
Հայերեն (Armenian)
ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող են
տրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք 1-800-605-2556
(TTY (հեռատիպ)711)
Language Assistance Notice for San Diego County
x
English
ATTENTION Language assistance services free of charge are available to you
Call 1-855-699-5557 (TTY 711)
繁體中文 (Chinese)
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1-855-699-5557(TTY
711)
한국어 (Korean)
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-855-
699-5557 (TTY 711)번으로 전화해 주십시오
Русский (Russian)
ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные
услуги перевода Звоните 1-855-699-5557 (телетайп 711)
Italiano (Italian)
ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di
assistenza linguistica gratuiti Chiamare il numero 1-855-699-5557 (TTY 711)
(Farsi) فارسی
-699-855-1 با باشد می فراهم شما برای رایگان بصورت زبانی تسهیلات کنید می گفتگو فارسی زبان به اگر توجه
5557 (TTY 771) بگیرید تماس
ह िदी (Hindi)
धयान द यदद आप द िदी बोलत तो आपक ललए मफत म भाषा स ायता सवाएि उपलबध 1-855-699-
5557 (TTY 711) पर कॉल कर
Hmong (Hmong)
LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb
rau koj Hu rau 1-855-699-5557 (TTY 711)
Espantildeol (Spanish)
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia
linguumliacutestica Llame al 1-855-699-5557 (TTY 711)
Tiếng Việt (Vietnamese)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho
bạn Gọi số 1-855-699-5557 (TTY 711)
Tagalog (Tagalog - Filipino)
PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga
serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-855-699-5557 (TTY
711)
Language Assistance Notice for San Diego County (Continued)
xi
(Arabic) العربية
5557-699-855-1 برقم اتصل بالمجان لك تتوافر اللغویة المساعدة خدمات فإن اللغة اذكر تتحدث كنت إذا ملحوظة
(711YTT)
ພາສາລາວ (Lao)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ ໂທຣ 1-855-699-5557 (TTY 711)
日本語 (Japanese)
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1-855-699-
5557(TTY711)までお電話にてご連絡ください
ภาษาไทย (Thai)
เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-855-699-5557 (TTY 711)
ਪਜਾਬੀ ਦ (Punjabi)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-855-
699-5557 (TTY 711) ਤ ਕਾਲ ਕਰ
ខមែរ (Cambodian)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល
គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-855-699-5557 (TTY 711)
Հայերեն (Armenian)
ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող են
տրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք 1-855-699-
5557 (TTY (հեռատիպ)711)
Categorical List of Prescription DrugsANALGESICS (Drugs for Pain) 1
ANESTHETICS (Drugs for Numbing) 6
ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS (Drugs for AddictionSubstance Abuse) 6
ANTIBACTERIALS (Drugs for Bacterial Infections) 8
ANTICONVULSANTS (Drugs for Seizures) 14
ANTIDEMENTIA AGENTS (Drugs for Alzheimers Disease and Dementia) 17
ANTIDEPRESSANTS (Drugs for Depression) 17
ANTIEMETICS (Drugs for Nausea and Vomiting) 20
ANTIFUNGALS (Drugs for Fungal Infections) 21
ANTIGOUT AGENTS (Drugs for Gout) 24
ANTIMIGRAINE AGENTS (Drugs for Migraine) 25
ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis) 25
ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections) 26
ANTINEOPLASTICS (Drugs for Cancer) 26
ANTIPARASITICS (Drugs for Parasitic Infections) 28
ANTIPARKINSON AGENTS (Drugs for Parkinsons Disease) 29
ANTIPSYCHOTICS (Drugs for Mental Health) 30
ANTISPASTICITY AGENTS (Drugs for Muscle Spasm) 35
ANTIVIRALS (Drugs for Viral Infections) 35
ANXIOLYTICS (Drugs for Anxiety) 41
BIPOLAR AGENTS (Drugs for Bipolar Disorder) 42
BLOOD GLUCOSE REGULATORS (Drugs for Diabetes) 42
BLOOD PRODUCTSMODIFIERSVOLUME EXPANDERS (Drugs for Blood Disorders) 46
CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation) 51
CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions) 61
DENTAL AND ORAL AGENTS (Drugs for the Mouth) 66
DERMATOLOGICAL AGENTS (Drugs for the Skin) 66
ELECTROLYTESMINERALSMETALSVITAMINS 69
GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach) 77
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERS TREATMENT (Drugs for Genetic or
Enzyme Disorders) 85
GENITOURINARY AGENTS (Drugs for the Genital Bladder and Kidney) 86
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (ADRENAL) (Drugs for
ReplacingStimulating Adrenal Gland Hormones) 87
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (PITUITARY) (Drugs for
ReplacingStimulating Pituitary Gland Hormones) 90
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEX HORMONESMODIFIERS) (Drugs
for ReplacingStimulating Sex Hormones) 91
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (THYROID) (Drugs for the Thyroid) 102
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs for Suppressing Hormones from the Pituitary
Gland) 104
HORMONAL AGENTS SUPPRESSANT (THYROID) (Drugs for the Thyroid) 104
LAST UPDATED 12012020
IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing the Immune System) 104
INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for Inflammatory Bowel Disease) 109
METABOLIC BONE DISEASE AGENTS (Drugs for the Bone) 109
MISCELLANEOUS THERAPEUTIC AGENTS 110
OPHTHALMIC AGENTS (Drugs for the Eyes) 112
OTIC AGENTS (Drugs for the Ears) 116
RESPIRATORY TRACTPULMONARY AGENTS (Drugs for the Lungs) 116
SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles) 130
SLEEP DISORDER AGENTS (Drugs for Insomnia) 130
LAST UPDATED 12012020
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANALGESICS (Drugs for Pain)
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (Pain and ArthritisDrugs)
aspirin (ADULT ASPIRIN REGIMEN)81 mg tablet dr
1-Covered
aspirin (ADULT LOW DOSE ASPIRINEC) 81 mg tablet dr
1-Covered
aspirin (ASPIR 81) mg tablet dr ) 1-Covered
aspirin (ASPIR-TRIN) 325 mg tabletdr -
1-Covered
aspirin (ASPIRIN) 325 mg tablet 1-Covered
aspirin (ECOTRIN) 81 mg tablet dr 1-Covered
aspirin (ECPIRIN) 325 mg tablet dr 1-Covered
aspirin (ST JOSEPH ASPIRIN EC) 81mg tablet dr
1-Covered
aspirin (ST JOSEPH ASPIRIN) 81 mgtab chew
1-Covered
aspirin 325mg tablet 1-Covered
aspirin 81 mg tab chew 81 mgtablet dr 325 mg tablet
1-Covered
ASPIRIN 81MG TABLET ASPIRIN81MG TABLET ASPIRIN 81MGTABLET
1-Covered
aspirinacetaminophencaffeine(ADDED STRENGTH HEADACHE)250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(BAYER MIGRAINE) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(EXTRA PAIN RELIEF) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(EXTRAPRIN) 250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(HEADACHE RELIEF) 250-250-65tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
1
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
aspirinacetaminophencaffeine(MIGRAINE FORMULA) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(MIGRAINE RELIEF) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(PAIN RELIEVER PLUS) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(PAIN RELIEVER) 250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(PAIN-OFF) 250-250-65 tablet -
1-Covered
butalbitalaspirincaffeine 50-325-40 capsule
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
butalbitalaspirincaffeine 50-325-40 tablet
1-Covered
celecoxib 50 mg capsule 100 mgcapsule 200 mg capsule 400 mgcapsule
1-Covered ST
CELECOXIB 50 MG CAPSULE 100MG CAPSULE 200 MG CAPSULE400 MG CAPSULE
1-Covered ST
CHILDRENS IBUPROFEN CHILD 200MG10 ML CHILDREN 100 MG5 ML
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
diclofenac sodium 25 mg tablet dr50 mg tablet dr 75 mg tablet dr100 mg tab er 24h
1-Covered
diflunisal 500 mg tablet 1-Covered
etodolac 600 mg tab er 24h 1-Covered PA
EXCEDRIN EXTRA STRENGTH(aspirinacetaminophencaffeine)CAPLET
1-Covered
EXCEDRIN MIGRAINE(aspirinacetaminophencaffeine)CAPLET GELTAB
1-Covered
flurbiprofen 50 mg tablet 100 mgtablet
1-Covered
HEADACHE RELIEF HM 250-250-65MG CPLT
1-Covered
ibuprofen (ADDAPRIN) 200 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
2
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ibuprofen (I-PRIN) 200 mg tablet - 1-Covered
ibuprofen (IBU) 400 mg tablet 600mg tablet 800 mg tablet
1-Covered
ibuprofen (IBU-200) mg tablet -) 1-Covered
ibuprofen (PROVIL) 200 mg tablet 1-Covered
ibuprofen (WAL-PROFEN) 200 mgtablet -
1-Covered
ibuprofen 100 mg5ml oral susp 1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
IBUPROFEN 400 MG TABLET 600 MGTABLET 800 MG TABLET
1-Covered
ibuprofen 50 mg125 drops susp100 mg tab chew 200 mg tablet400 mg tablet 600 mg tablet 800mg tablet
1-Covered
indomethacin 25 mg capsule 50mg capsule 75 mg capsule er
1-Covered
ketoprofen 50 mg capsule 75 mgcapsule
1-Covered
meloxicam 75 mg tablet 15 mgtablet
1-Covered
naproxen 250 mg tablet 375 mgtablet 500 mg tablet
1-Covered
naproxen sodium 275 mg tablet550 mg tablet
1-Covered
piroxicam 10 mg capsule 20 mgcapsule
1-Covered
salsalate 500 mg tablet 750 mgtablet
1-Covered
sulindac 150 mg tablet 200 mgtablet
1-Covered
tolmetin sodium 200 mg tablet 400mg capsule 600 mg tablet
1-Covered
OPIOID ANALGESICS LONG-ACTING (Long-acting Narcotic PainRelievers)
BELBUCA (buprenorphine hcl) 75MCG FILM 150 MCG FILM 300MCG FILM 450 MCG FILM 600MCG FILM 750 MCG FILM 900MCG FILM
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
3
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
buprenorphine 5 mcghr patch75 mcghr patch 10 mcghrpatch 15 mcghr patch 20mcghr patch
2-MedicalCarve out
BUTRANS (buprenorphine) 5MCGHR PATCH 75 MCGHRPATCH 10 MCGHR PATCH 15MCGHR PATCH 20 MCGHRPATCH
2-MedicalCarve out
fentanyl 25 mcghr patch50mcghr patch 75mcghr patch100 mcghr patch
1-Covered PA QL (10 PER 30 DAY(S))
methadone hcl (METHADONEINTENSOL) 10 mgml oral conc
1-Covered PA
methadone hcl (METHADOSE) 40mg tablet sol
1-Covered PA
METHADONE HCL 10 MG TABLET 1-Covered QL (60 PER 30 DAYS)
METHADONE HCL 10 MGML ORALCONC
1-Covered PA
methadone hcl 5 mg tablet 10 mgtablet
1-Covered QL (60 PER 30 DAYS)
methadone hcl 5 mg5 ml solution10 mg5 ml solution 10 mgml oralconc
1-Covered PA
morphine sulfate 15 mg tablet er 1-Covered QL (90 PER 30 DAYS)
morphine sulfate 30 mg tablet er 1-Covered QL (60 PER 30 DAYS)
morphine sulfate 60 mg tablet er100 mg tablet er 200 mg tablet er
1-Covered PA
oxycodone hcl 10 mg tab er 20mg tab er 40 mg tab er 80 mgtab er
1-Covered PA QL (60 PER 30 DAYS)
SUBLOCADE (buprenorphine) 100MG05 ML SYRING 300 MG15 MLSYRING
2-MedicalCarve out
OPIOID ANALGESICS SHORT-ACTING (Short-acting Narcotic PainRelievers)
acetaminophen with codeinephosphate -15mg tablet -30mgtablet -60mg tablet
1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old) QLC (LIMIT 100TABS TOTAL APAPCODEINETABLETS PER MONTH)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
4
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acetaminophen with codeinephosphate 120-12mg5 solution
1-Covered QL (240 PER 30 DAYS) AL1 (Atleast 12 yrs old)
butorphanol tartrate 10 mgmlspray
1-Covered PA
codeinephosphatebutalbitalaspirincaffeine codeinebutalbitalasacaffein30-50-325 capsule
1-Covered QL (60 PER 30 DAYS) AL1 (At least12 yrs old)
codeine sulfate 15 mg tablet 30mg tablet 60 mg tablet
1-Covered PA AL1 (At least 12 yrs old)
hydrocodonebitartrateacetaminophen(LORCET HD)hydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAY(S))
hydrocodonebitartrateacetaminophen(LORTAB)hydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAY(S))
hydrocodonebitartrateacetaminophenhydrocodoneacetaminophen 5mg-325mg tablethydrocodoneacetaminophen75-325 mg tablethydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS OF HYDROCODONEPRODUCTS PER 30 DAYS)
hydromorphone hcl 1 mgml liquid3 mg supprect
1-Covered
hydromorphone hcl 2 mg tablet 4mg tablet 8 mg tablet
1-Covered QL (60 PER 30 DAYS)
meperidine hcl 50 mg tablet 100mg tablet
1-Covered QL (100 PER 30 DAYS)
morphine sulfate 10 mg5 ml 20mg5 ml 100 mg5ml
1-Covered PA
morphine sulfate 15 mg tablet 30mg tablet
1-Covered QL (90 PER 30 DAYS)
morphine sulfate 30 mg supprect 1-Covered QL (24 PER 30 DAY(S)) QLC (LIMIT24 SUPPOSITORIES IN 30 DAYS)
morphine sulfate 5 mg 10 mg 20mg
1-Covered QL (24 PER 30 DAY(S)) QLC (LIMIT24 SUPPOSITORIES IN 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
5
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
oxycodone hcl 5 mg capsule 5mg tablet 5 mg5 ml solution 15mg tablet 20 mgml oral conc 30mg tablet
1-Covered PA
oxycodone hclacetaminophen(ENDOCET) 5 mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS PER 30 DAYS OF TOTALOXYCODONE APAP ANDOXYCODONE ASA PER MONTH)
oxycodone hclacetaminophen 5mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS PER 30 DAYS OF TOTALOXYCODONE APAP ANDOXYCODONE ASA PER MONTH)
oxycodone hclacetaminophen 5-3255 ml solution
1-Covered PA
oxycodone hclaspirin 48355-325tablet
1-Covered QL (100 PER 30 DAY(S))
tramadol hcl 50 mg tablet 1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old)
TRAMADOL HCL 50 MG TABLET 1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old)
ANESTHETICS (Drugs for Numbing)
LOCAL ANESTHETICS (Skin Numbing Drugs)lidocaine hcl 10 mgml vial 1-Covered PA
lidocaine hcl 2 solution 1-Covered
LIDOCAINE HCL VISCOUS 2 SOLN 1-Covered
lidocaine hclpf 10 mgml vial 10mgml ampul
1-Covered PA
ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS (Drugs forAddictionSubstance Abuse)
ALCOHOL DETERRENTSANTI-CRAVING (Drugs for AlcoholDependence)
acamprosate calcium 333 mgtablet dr
2-MedicalCarve out
disulfiram 250 mg tablet 500 mgtablet
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
6
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
naltrexone hcl 50 mg tablet 2-MedicalCarve out
NALTREXONE HCL 50 MG TABLET 2-MedicalCarve out
VIVITROL (naltrexonemicrospheres) 380 MG VIAL +DILUENT
2-MedicalCarve out
OPIOID DEPENDENCE TREATMENTS (Drugs for Opioid Dependence)BUNAVAIL (buprenorphinehclnaloxone hcl) 21-03 MG FILM42-07 MG FILM 63-1 MG FILM
2-MedicalCarve out
BUPRENEX (buprenorphine hcl) 03MGML AMPUL
2-MedicalCarve out
buprenorphine hcl 03 mgml vial03 mgml cartridge 2 mg tab subl8 mg tab subl
2-MedicalCarve out
buprenorphine hclnaloxone hclnaloxone 2 mg-05mg filmnaloxone 2 mg-05mg tab sublnaloxone 4mg-1mg filmnaloxone 8 mg-2 mg filmnaloxone 8 mg-2 mg tab subl
2-MedicalCarve out
LUCEMYRA (lofexidine hcl) 018 MGTABLET
2-MedicalCarve out
PROBUPHINE (buprenorphine hcl)742 MG IMPLANT
2-MedicalCarve out
SUBOXONE (buprenorphinehclnaloxone hcl) 2 MG-05 MGFILM 4 MG-1 MG FILM 8 MG-2 MGFILM 12 MG-3 MG FILM
2-MedicalCarve out
ZUBSOLV (buprenorphinehclnaloxone hcl) 07-018 MGTABLET 14-036 MG TABLET 29-071 MG TABLET 57-14 MG TABLET86-21 MG TABLET 114-29 MGTABLET
2-MedicalCarve out
OPIOID REVERSAL AGENTS (Drugs for Opioid Overdose)EVZIO (naloxone hcl) 04 MGAUTO- 2 MG AUTO-
2-MedicalCarve out
naloxone hcl 04 mgml cartridge04 mgml vial 1 mgml syringe 2mg04ml auto injct
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
7
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NARCAN (naloxone hcl) 4 MGNASAL SPRAY
2-MedicalCarve out
SMOKING CESSATION AGENTS (Drugs to Help Quit Smoking)bupropion hcl (BUPROBAN) 150 mgtab er 12h
1-Covered QL (2 PER 1 DAY(S))
bupropion hcl 150 mg tab er 12h 1-Covered QL (2 PER 1 DAY(S))
CHANTIX (varenicline tartrate) 05MG TABLET 1 MG TABLET 1 MGCONT MONTH BOX STARTINGMONTH BOX
1-Covered PA
nicotine 14mg patch 1-Covered QL (1 PER 1 DAY(S))
nicotine 21mg patch 1-Covered QL (1 PER 1 DAY(S))
nicotine 2mg gum 1-Covered QL (24 PER 1 DAY(S))
nicotine 4mg gum 1-Covered QL (24 PER 1 DAY(S))
nicotine 7mg patch 1-Covered QL (1 PER 1 DAY(S))
NICOTINE LOZENGE 2 MGLOZENGE HM 2 MG LOZENGE 4MG LOZENGE HM 4 MG LOZENGE
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (QUIT 2) mglozenge )
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (QUIT 4) mglozenge )
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (STOP SMOKINGAID) 2 mg 4 mg
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex 2 mg 4 mg 1-Covered QL (24 PER 1 DAY(S))
NICOTROL (nicotine) CARTRIDGEINHALER
1-Covered PA
NICOTROL NS (nicotine) 10 MGMLSPRAY
1-Covered PA
ANTIBACTERIALS (Drugs for Bacterial Infections)
AMINOGLYCOSIDESgentamicin sulfate (GENTAK) 03 oint (g)
1-Covered
gentamicin sulfate 01 oint (g)01 cream (g) 03 oint (g) 03 drops
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
8
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GENTAMICIN SULFATE 01 CREAM 1-Covered
neomycin sulfate 500 mg tablet 1-Covered
paromomycin sulfate 250 mgcapsule
1-Covered
tobramycin 03 drops 1-Covered
TOBREX (tobramycin) 03 EYEOINTMENT
1-Covered
ANTIBACTERIALS OTHERbacitracin (BACITRAYCIN PLUS) 500unitg oint (g)
1-Covered
bacitracin 500 unitg packet 500unitg oint (g)
1-Covered
BACITRACIN 500 UNITGM OINTMNT 1-Covered
bacitracin zinc (ANTIBIOTIC) 500unitg oint (g)
1-Covered
bacitracin zinc 500 unitg ointpack 500 unitg oint (g)
1-Covered
BACITRACIN ZINC ZN 500 UNITGMOINT
1-Covered
CLEOCIN (clindamycin phosphate)100 MG VAGINAL OVULE
1-Covered
clindamycin hcl 75 mg capsule150 mg capsule 300 mg capsule
1-Covered
clindamycin palmitate hcl 75 mg5ml soln recon
1-Covered
clindamycin phosphate 1 gel(gram) 1 lotion 1 med swab1 solution 1 gel daily 2 creamappl
1-Covered
CLINDAMYCIN PHOSPHATE 1SOLUTION 1 GEL
1-Covered
erythromycin basebenzoylperoxide erythromycinbenzoyl 3-5 gel (gram)
1-Covered ST
methenaminemethylenebluesodphospsalicylatehyoscyamine(PHOSPHASAL) methmebluesodphospsalhyos 816-108 tablet
1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
9
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
methenaminemethylenebluesodphospsalicylatehyoscyamine(URIN DS) methmebluesodphospsalhyos 816-108 tablet
1-Covered PA
METRO IV (metronidazole in sodiumchloride) 500 MG100 ML
1-Covered
metronidazole 075 gel wappl250 mg tablet 375 mg capsule500 mg tablet
1-Covered
METRONIDAZOLE 250 MG TABLET500 MG TABLET
1-Covered
metronidazole in sodium chloridemetronidazolesodium 500mg01lpiggyback
1-Covered PA
mupirocin 2 oint (g) 1-Covered QL (22 PER 30 DAY(S))
mupirocin calcium 2 cream (g) 1-Covered PA
neomycin sulfatebacitracinzincpolymyxin b (ANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
neomycin sulfatebacitracinzincpolymyxin b (FIRST AIDANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
neomycin sulfatebacitracinzincpolymyxin b (TRIPLEANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
nitrofurantoin 25 mg5 ml oral susp 1-Covered
NITROFURANTOIN 50 MG CAP 100MG CAP
1-Covered
nitrofurantoin macrocrystal 50 mgcapsule 100 mg capsule
1-Covered
nitrofurantoinmonohydratemacrocrystalsmonohydm-100 mg capsule
1-Covered
trimethoprim 100 mg tablet 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
10
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRIPLE ANTIBIOTIC (neomycinsulfatebacitracin zincpolymyxinb) CURAD OINT MEDI-FIRSTMEDICHOICE OINTMENTOINTMENT PKT
1-Covered
TRIPLE ANTIBIOTIC HM PKT 1-Covered
URETRON D-S(methenaminemethylenebluesodphospsalicylatehyoscyamine) -TABLET
1-Covered PA
VANDAZOLE (metronidazole)VAGINAL 075 GEL
1-Covered
BETA-LACTAM CEPHALOSPORINScefaclor 125 mg5ml susp recon250 mg5ml susp recon 250 mgcapsule 375 mg5ml susp recon500 mg capsule
1-Covered
CEFDINIR 125 MG5 ML SUSP 250MG5 ML SUSP
1-Covered QL (200 PER 10 DAY(S))
cefdinir 125 mg5ml 250 mg5ml 1-Covered QL (200 PER 10 DAY(S))
cefdinir 300 mg capsule 1-Covered QL (20 PER 10 DAY(S))
cephalexin 125 mg5ml susprecon 250 mg capsule 250mg5ml susp recon 500 mgcapsule
1-Covered
BETA-LACTAM PENICILLINSamoxicillin 125 mg5ml susp recon125 mg tab chew 200 mg5mlsusp recon 250 mg tab chew 250mg5ml susp recon 250 mgcapsule 400 mg5ml susp recon500 mg tablet 500 mg capsule875 mg tablet
1-Covered
AMOXICILLIN-CLAVULANATEPOTASS -600-429 MG5 ML SUS
1-Covered QL (300 PER FILL) QLC (1 FILL IN 30DAYS)
AMOXICILLIN-CLAVULANATEPOTASS -875-125 MG TABLET
1-Covered
amoxicillinpotassium clavulanate1000-625 tab er 12h
1-Covered QL (40 PER FILL(S)) MFL (1 30day(s))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
11
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
amoxicillinpotassium clavulanate200-2855 susp recon 200-285mgtab chew 250-125 mg tablet 400-57mg5 susp recon 400-57mg tabchew 500-125 mg tablet 875-125mg tablet
1-Covered
amoxicillinpotassium clavulanate600-4295 susp recon
1-Covered QL (300 PER FILL) QLC (1 FILL IN 30DAYS)
ampicillin trihydrate 125 mg5mlsusp recon 250 mg capsule 250mg5ml susp recon 500 mgcapsule
1-Covered
dicloxacillin sodium 250 mgcapsule 500 mg capsule
1-Covered
penicillin v potassium 125 mg5mlsoln recon 250 mg5ml soln recon250 mg tablet 500 mg tablet
1-Covered
MACROLIDESazithromycin 1 g packet 1-Covered QL (1 PER 30 DAYS)
azithromycin 100 mg5ml 200mg5ml
1-Covered
AZITHROMYCIN 200 MG5 ML SUSP 1-Covered
azithromycin 250 mg tablet 1-Covered QL (6 PER FILL(S)) MFL (2 30day(s))
AZITHROMYCIN 250 MG TABLET 1-Covered QL (6 PER FILL(S)) MFL (2 30day(s))
azithromycin 500 mg tablet 1-Covered QL (3 PER FILL(S)) MFL (2 30day(s))
AZITHROMYCIN 500 MG TABLET 1-Covered QL (3 PER FILL(S)) MFL (2 30day(s))
azithromycin 600 mg tablet 1-Covered QL (2 PER 7 DAY(S)) MFL (8 28day(s))
clarithromycin 500 mg tablet 1-Covered ST
EES 200 (erythromycinethylsuccinate) MG5 MLSUSPENSION
1-Covered
EES 400 (erythromycinethylsuccinate) FILMTAB
1-Covered
ERYTHROCIN STEARATE(erythromycin stearate) 250 MGFILMTAB
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
12
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ERYTHROMYCIN 250 MG 500 MG 1-Covered
erythromycin base 5 mggramoint (g) 250 mg capsule dr 250mg tablet dr 250 mg tablet 333mg tablet dr 500 mg tablet 500mg tablet dr
1-Covered
erythromycin base in ethanol (ERY)2 med swab
1-Covered
erythromycin base in ethanol 2 solution 2 med swab
1-Covered
ERYTHROMYCIN ETHYLSUCCINATE200 MG5 ML SUSP
1-Covered
erythromycin ethylsuccinate 200mg5ml susp recon 400 mg tablet
1-Covered
QUINOLONESCILOXAN (ciprofloxacin hcl) 03OINTMENT
1-Covered
ciprofloxacin hcl 03 drops 1-Covered
ciprofloxacin hcl 100 mg tablet 1-Covered PA AL1 (At least 18 yrs old)
ciprofloxacin hcl 250 mg tablet500 mg tablet 750 mg tablet
1-Covered AL1 (At least 18 yrs old)
CIPROFLOXACIN HCL 500 MG TAB 1-Covered AL1 (At least 18 yrs old)
levofloxacin 250 mg tablet 500 mgtablet 750 mg tablet
1-Covered AL1 (At least 18 yrs old)
moxifloxacin hcl 400 mg tablet 1-Covered PA AL1 (At least 18 yrs old)
ofloxacin 03 drops 1-Covered QL (5 PER 30 DAY(S))
SULFONAMIDESBLEPH-10 (sulfacetamide sodium) - EYE DROPS
1-Covered
silver sulfadiazine 1 cream (g) 1-Covered
SSD (silver sulfadiazine) 1 CREAM 1-Covered
sulfacetamide sodium 10 oint(g) 10 drops
1-Covered
sulfamethoxazoletrimethoprim200-40mg5 oral susp 400mg-80mgtablet 800-16020 oral susp 800-160 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
13
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SULFATRIM(sulfamethoxazoletrimethoprim)PEDIATRIC SUSPENSION
1-Covered
TETRACYCLINESDOXYCYCLINE HYCLATE 100 MGCAP
1-Covered AL1 (At least 8 yrs old)
doxycycline hyclate 100 mgcapsule
1-Covered AL1 (At least 8 yrs old)
DOXYCYCLINE HYCLATE 20 MG TAB 1-Covered QL (60 PER 30 DAYS)
doxycycline hyclate 20 mg tablet 1-Covered QL (60 PER 30 DAYS)
doxycycline monohydrate 50 mgcapsule 100 mg capsule
1-Covered AL1 (At least 8 yrs old)
minocycline hcl 50 mg capsule100 mg capsule
1-Covered
ANTICONVULSANTS (Drugs for Seizures)
ANTICONVULSANTS OTHER (Other Seizure Control Drugs)LEVETIRACETAM 100 MGML SOLN250 MG TABLET 500 MG5 ML SOLN
1-Covered
levetiracetam 100 mgml solution250 mg tablet 500 mg tablet 500mg5ml solution 750 mg tablet1000 mg tablet
1-Covered
levetiracetam 500 mg tab er 24h 1-Covered MDD (6 Per Day)
levetiracetam 750 mg tab er 24h 1-Covered QL (120 PER 30 DAY(S))
LEVETIRACETAM ER 500 MG TABLET 1-Covered MDD (6 Per Day)
LEVETIRACETAM ER 750 MG TABLET 1-Covered QL (120 PER 30 DAY(S))
CALCIUM CHANNEL MODIFYING AGENTSCELONTIN (methsuximide) 300 MGKAPSEAL
1-Covered
ETHOSUXIMIDE 250 MG CAPSULE 1-Covered
ethosuximide 250 mg5ml solution250 mg capsule
1-Covered
zonisamide 25 mg capsule 50 mgcapsule 100 mg capsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
14
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTSDEPAKENE (valproic acid (assodium salt) (valproate sodium))250 MG5 ML SOLUTION
1-Covered
DEPAKENE (valproic acid) 250 MGCAPSULE
1-Covered
diazepam 5-75-10mg kit 1-Covered
divalproex sodium 125 mg tabletdr 125 mg cap dr spr 250 mgtablet dr 500 mg tablet dr
1-Covered
DIVALPROEX SODIUM DR 125 MGCAP SPRNK
1-Covered
gabapentin 100 mg capsule 250mg5ml solution 300 mg capsule400 mg capsule 600 mg tablet800 mg tablet
1-Covered
GABAPENTIN 100 MG CAPSULE 300MG CAPSULE 400 MG CAPSULE
1-Covered
phenobarbital 15 mg tablet 20mg5 ml elixir 30 mg tablet 324mg tablet 60 mg tablet 648 mgtablet 972mg tablet 100 mgtablet
1-Covered
PHENOBARBITAL 20 MG5 ML SOLN324 MG TABLET 648 MG TABLET972 MG TABLET
1-Covered
primidone 50 mg tablet 250 mgtablet
1-Covered
valproic acid (as sodium salt)(valproate sodium) 250 mg5ml500mg10ml
1-Covered
valproic acid 250 mg capsule 1-Covered
VALPROIC ACID 250 MG CAPSULE 1-Covered
GLUTAMATE REDUCING AGENTSlamotrigine 25 mg tablet 100 mgtablet 150 mg tablet 200 mgtablet
1-Covered
lamotrigine 5 mg 25 mg 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
15
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
topiramate 15 mg cap sprink 25mg tablet 25 mg cap sprink 50mg tablet 100 mg tablet 200 mgtablet
1-Covered
TOPIRAMATE 25 MG TABLET 50 MGTABLET 100 MG TABLET 200 MGTABLET
1-Covered
SODIUM CHANNEL AGENTScarbamazepine (EPITOL) 200 mgtablet
1-Covered
carbamazepine 100 mg cpmp12hr 100 mg5ml oral susp 100 mgtab chew 100 mg tab er 12h 200mg cpmp 12hr 200 mg tab er 12h200 mg tablet 300 mg cpmp 12hr400 mg tab er 12h
1-Covered
CARBATROL (carbamazepine) ER100 MG CAPSULE ER 200 MGCAPSULE ER 300 MG CAPSULE
1-Covered
DILANTIN (phenytoin sodiumextended) 30 MG CAPSULE 100MG CAPSULE
1-Covered
DILANTIN (phenytoin) 50 MGINFATAB
1-Covered
DILANTIN-125 (phenytoin) MG5 MLSUSP
1-Covered
DILANTIN-125 MG5 ML SUSP 1-Covered
oxcarbazepine 150 mg tablet 300mg tablet 600 mg tablet
1-Covered
phenytoin 50 mg tab chew 100mg4ml oral susp 125 mg5ml oralsusp
1-Covered
phenytoin sodium extended 100mg capsule
1-Covered
TEGRETOL (carbamazepine) 100MG5 ML SUSP 200 MG TABLET
1-Covered
TEGRETOL XR (carbamazepine) 100MG TABLET 200 MG TABLET 400MG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
16
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIDEMENTIA AGENTS (Drugs for Alzheimers Disease andDementia)
CHOLINESTERASE INHIBITORSdonepezil hcl 5 mg tab rapdis 5mg tablet 10 mg tab rapdis 10mg tablet
1-Covered
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine hcl 5 mg tablet 10 mgtablet
1-Covered
MEMANTINE HCL 5 MG TABLET 10MG TABLET
1-Covered
ANTIDEPRESSANTS (Drugs for Depression)
ANTIDEPRESSANTS OTHERbupropion hcl 100 mg tab 150 mgtab 200 mg tab
1-Covered QL (60 PER 30 DAYS)
bupropion hcl 150 mg tab er 300mg tab er
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
bupropion hcl 75 mg tablet 100mg tablet
1-Covered
BUPROPION HCL SR SR 100 MGTABLET SR 150 MG TABLET SR 200MG TABLET
1-Covered QL (60 PER 30 DAYS)
BUPROPION XL 150 MG TABLET 300MG TABLET
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
mirtazapine 15 mg tab rapdis 1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old)
mirtazapine 15 mg tablet 30 mgtab rapdis 30 mg tablet 45 mgtab rapdis 45 mg tablet
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
olanzapinefluoxetine hcl 3 mg-25mg capsule 6mg-25mg capsule6mg-50mg capsule 12mg-50mgcapsule 12mg-25mg capsule
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
17
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SYMBYAX (olanzapinefluoxetinehcl) 3-25 MG CAPSULE 6-50 MGCAPSULE 6-25 MG CAPSULE 12-50MG CAPSULE 12-25 MG CAPSULE
2-MedicalCarve out
MONOAMINE OXIDASE INHIBITORSEMSAM (selegiline) 6 MG24PATCH 9 MG24 PATCH 12 MG24PATCH
2-MedicalCarve out
MARPLAN (isocarboxazid) 10 MGTABLET
2-MedicalCarve out
NARDIL (phenelzine sulfate) 15 MGTABLET
2-MedicalCarve out
PARNATE (tranylcypromine sulfate)10 MG TABLET
2-MedicalCarve out
phenelzine sulfate 15 mg tablet 2-MedicalCarve out
tranylcypromine sulfate 10 mgtablet
2-MedicalCarve out
SSRISSNRIS (SELECTIVE SEROTONIN REUPTAKEINHIBITORSEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)
citalopram hydrobromide 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
escitalopram oxalate 5 mg tablet10 mg tablet 20 mg tablet
1-Covered
ESCITALOPRAM OXALATE 5 MGTABLET 10 MG TABLET 20 MGTABLET
1-Covered
fluoxetine hcl 10 mg capsule 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
fluoxetine hcl 20 mg capsule 1-Covered QL (120 PER 30 DAY(S))
fluoxetine hcl 20 mg5 ml solution 1-Covered
FLUOXETINE HCL 20 MG5 MLSOLUTION
1-Covered
fluvoxamine maleate 25 mg tablet50 mg tablet 100 mg tablet
1-Covered AL1 (At least 8 yrs old)
paroxetine hcl 10 mg tablet 20 mgtablet 30 mg tablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
sertraline hcl 25 mg tablet 50 mgtablet 100 mg tablet
1-Covered QL (60 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
18
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRAZODONE HCL 50 MG TABLET100 MG TABLET
1-Covered
trazodone hcl 50 mg tablet 100mg tablet 150 mg tablet
1-Covered
venlafaxine hcl 25 mg tablet 375mg tablet 50 mg tablet 75 mgtablet 100 mg tablet
1-Covered QL (60 PER 30 DAYS)
venlafaxine hcl 375 mg cap er 75mg cap er 150 mg cap er
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
VENLAFAXINE HCL ER ER 375 MGCAP ER 75 MG CAP ER 150 MGCAP
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
TRICYCLICSamitriptyline hcl 10 mg tablet 25mg tablet 50 mg tablet 75 mgtablet 100 mg tablet 150 mgtablet
1-Covered
amoxapine 25 mg tablet 50 mgtablet 100 mg tablet 150 mgtablet
1-Covered
clomipramine hcl 25 mg capsule50 mg capsule 75 mg capsule
1-Covered PA
CLOMIPRAMINE HCL 25 MGCAPSULE 50 MG CAPSULE 75 MGCAPSULE
1-Covered PA
desipramine hcl 10 mg tablet 25mg tablet 50 mg tablet 75 mgtablet 100 mg tablet 150 mgtablet
1-Covered
DOXEPIN HCL 10 MG CAPSULE 25MG CAPSULE 50 MG CAPSULE 75MG CAPSULE 100 MG CAPSULE
1-Covered
doxepin hcl 10 mgml oral conc10 mg capsule 25 mg capsule 50mg capsule 75 mg capsule 100mg capsule 150 mg capsule
1-Covered
imipramine hcl 10 mg tablet 25mg tablet 50 mg tablet
1-Covered
IMIPRAMINE HCL 10 MG TABLET 25MG TABLET 50 MG TABLET
1-Covered
nortriptyline hcl 10 mg capsule 25mg capsule 50 mg capsule 75 mgcapsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
19
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIEMETICS (Drugs for Nausea and Vomiting)
ANTIEMETICS OTHER (Other Drugs for Nausea and Vomiting)meclizine hcl (DRAMAMINE LESSDROWSY) 25 mg tablet
1-Covered
meclizine hcl (MEDI-MECLIZINE) 25mg tablet -
1-Covered
meclizine hcl (MOTION RELIEF) 25mg tablet
1-Covered
meclizine hcl (MOTION SICKNESS II)25 mg tablet
1-Covered
meclizine hcl (MOTION SICKNESSRELIEF) 25 mg tablet 25 mg tabchew
1-Covered
meclizine hcl (MOTION SICKNESS)25 mg tablet
1-Covered
meclizine hcl (MOTION-TIME) 25 mgtab chew -
1-Covered
meclizine hcl (TRAVEL-EASE) 25 mgtablet -
1-Covered
meclizine hcl (VERTICALM) 25 mgtablet
1-Covered
meclizine hcl (WAL-DRAM 2) 25 mgtablet -
1-Covered
MECLIZINE HCL 125 MG CAPLET 25MG TABLET CHEW
1-Covered
meclizine hcl 125 mg tablet 25mg tab chew 25 mg tablet
1-Covered
metoclopramide hcl 5 mg tablet 5mg5 ml solution 10 mg tablet 10mg10ml solution
1-Covered
perphenazine 2 mg tablet 4 mgtablet 8 mg tablet 16 mg tablet
2-MedicalCarve out
prochlorperazine (COMPRO) 25mg supprect
1-Covered
prochlorperazine 25 mg supprect 1-Covered
prochlorperazine maleate 5 mgtablet 10 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
20
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
promethazine hcl (PHENADOZ)125 mg 25 mg
1-Covered
promethazine hcl (PROMETHEGAN)125 mg 25 mg 50 mg
1-Covered
promethazine hcl 125 mgsupprect 25 mg supprect 50 mgtablet 50 mg supprect
1-Covered
TRAVEL SICKNESS (meclizine hcl) 25MG TAB CHEW
1-Covered
trimethobenzamide hcl 300 mgcapsule
1-Covered
EMETOGENIC THERAPY ADJUNCTS (Drugs for Nausea and Vomiting)aprepitant 40 mg capsule 80 mgcapsule 125mg-80mg cap ds pk125 mg capsule
1-Covered PA
dronabinol 25 mg capsule 5 mgcapsule 10 mg capsule
1-Covered PA
granisetron hcl 1 mg tablet 1-Covered PA
ondansetron 4 mg tab rapdis 8mg tab rapdis
1-Covered QL (12 PER FILL(S)) MDD (3 PerDay) QLC (LIMIT TO 2 FILLS OF 12TABLETS IN 30 DAYS)
ondansetron hcl 4 mg tablet 8 mgtablet
1-Covered QL (12 PER FILL(S)) MDD (3 PerDay) QLC (LIMIT TO 2 FILLS OF 12TABLETS IN 30 DAYS)
ondansetron hcl 4 mg5 mlsolution 24 mg tablet
1-Covered PA
ANTIFUNGALS (Drugs for Fungal Infections)
ANTIFUNGALSANTIFUNGAL 1 TOPICAL CREAM 1-Covered
ATHLETES FOOT (terbinafine hcl) 1CREAM
1-Covered
ciclopirox 077 gel (gram) 1-Covered QLC (100 GRAMSMONTH)
ciclopirox 1 shampoo 1-Covered QLC (120 ozMONTH)
ciclopirox 8 solution 1-Covered
ciclopirox olamine 077 cream(g)
1-Covered QLC (90 GRAMSMONTH)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
21
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ciclopirox olamine 077 suspension
1-Covered QLC (60 MLMONTH)
clotrimazole (ANTIFUNGALRINGWORM) 1 cream (g)
1-Covered
clotrimazole (ANTIFUNGAL) 1 cream (g)
1-Covered
clotrimazole (ATHLETES FOOT) 1 cream (g)
1-Covered
clotrimazole (ATHLETIC FOOTCREAM) 1 cream (g)
1-Covered
clotrimazole (CLOTRIMAZOLE AF) 1 cream (g)
1-Covered
clotrimazole (ITCH RELIEF) 1 cream (g)
1-Covered
clotrimazole (JOCK ITCH RELIEF) 1 cream (g)
1-Covered
clotrimazole (JOCK ITCH) 1 cream (g)
1-Covered
clotrimazole (RINGWORM) 1 cream (g)
1-Covered
clotrimazole 1 cream (g) 1 solution 1 creamappl 10 mgtroche
1-Covered
CLOTRIMAZOLE 1 SOLUTION 1TOPICAL CREAM
1-Covered
fluconazole 10 mgml 40 mgml 1-Covered QL (70 PER 30 DAY(S))
fluconazole 150 mg tablet 1-Covered QL (2 PER 30 DAY(S))
FLUCONAZOLE 200 MG TABLET 1-Covered
fluconazole 50 mg tablet 100 mgtablet 200 mg tablet
1-Covered
fluconazole in dextrose iso-osmotic in dextreiso-200mg01l indextreiso-400mg02l
1-Covered PA
flucytosine 250 mg capsule 500mg capsule
1-Covered
FLUCYTOSINE 250 MG CAPSULE500 MG CAPSULE
1-Covered
griseofulvin ultramicrosize 125 mgtablet 250 mg tablet
1-Covered QL (60 PER 30 DAYS) AL1 (Up to18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
22
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
griseofulvin microsize 125 mg5mloral susp
1-Covered AL1 (Up to 12 yrs old) MDD (20Per Day)
griseofulvin microsize 500 mgtablet
1-Covered QL (60 PER 30 DAYS) AL1 (Up to18 yrs old)
itraconazole 100 mg capsule 1-Covered PA
ketoconazole 2 cream (g) 2 shampoo
1-Covered
ketoconazole 200 mg tablet 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
LAMISIL (terbinafine hcl)ANTIFUNGAL 1 SPRAY
1-Covered
LOTRIMIN AF (clotrimazole) 1CREAM
1-Covered
miconazole nitrate (ANTI-FUNGALCREAM) 2 cream (g) -
1-Covered
miconazole nitrate (ANTIFUNGALCREAM) 2 cream (g)
1-Covered
miconazole nitrate (BAZAANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate (INZOANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate (LOTRIMIN AF) 2 spray
1-Covered
miconazole nitrate (MICATIN) 2 cream (g)
1-Covered
miconazole nitrate (SECURAANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate 2 aero powd2 creamappl 2 cream (g)100 mg suppvag
1-Covered
MONISTAT 3 (miconazole nitrate)4 CREAM
1-Covered
MONISTAT 7 (miconazole nitrate)CREAM
1-Covered
NYSTATIN 100000 UNITGM CREAM100000 UNITGM OINT 100000UNITML SUSP 500000 UNIT5 MLSUS
1-Covered
nystatin 500k unit tablet 100000mloral susp 100000g cream (g)100000g oint (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
23
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terbinafine hcl (ANTIFUNGAL) 1 cream (g)
1-Covered
terbinafine hcl (ATHLETES FOOT AF)1 cream (g)
1-Covered
terbinafine hcl (ATHLETES FOOT) 1 cream (g)
1-Covered
terbinafine hcl (JOCK ITCH) 1 cream (g)
1-Covered
terbinafine hcl (LAMISIL AT) 1 cream (g)
1-Covered
terbinafine hcl 1 cream (g) 250mg tablet
1-Covered
tioconazole 65 oinpf app 1-Covered
tolnaftate (ANTIFUNGAL CREAM) 1 cream (g)
1-Covered
tolnaftate (ATHLETES FOOT) 1 cream (g)
1-Covered
tolnaftate (FUNGOID-D) 1 cream(g) -
1-Covered
tolnaftate 1 cream (g) 1-Covered
ANTIGOUT AGENTS (Drugs for Gout)
ANTIGOUT AGENTSallopurinol 100 mg tablet 300 mgtablet
1-Covered
ALLOPURINOL 100 MG TABLET 300MG TABLET
1-Covered
colchicine 06 mg tablet 1-Covered
COLCHICINE 06 MG TABLET 1-Covered
probenecid 500 mg tablet 1-Covered
probenecidcolchicine 500-05 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
24
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIMIGRAINE AGENTS (Drugs for Migraine)
ERGOT ALKALOIDSergotamine tartratecaffeine 1mg-100mg tablet
1-Covered
SEROTONIN (5-HT) 1B1D RECEPTOR AGONISTSrizatriptan benzoate 5 mg tablet10 mg tablet
1-Covered QL (12 PER 30 DAY(S)) AL1 (Atleast 6 yrs old)
SUMATRIPTAN 5 MG SPRAY 20 MGSPRAY
1-Covered QL (6 PER 30 DAY(S))
sumatriptan 5 mg 20 mg 1-Covered QL (6 PER 30 DAY(S))
sumatriptan succinate 25 mgtablet 50 mg tablet 100 mg tablet
1-Covered QL (9 PER 30 DAY(S))
SUMATRIPTAN SUCCINATE 25 MGTABLET 50 MG TABLET 100 MGTABLET
1-Covered QL (9 PER 30 DAY(S))
SUMATRIPTAN SUCCINATE 6 MG05ML CART
1-Covered QL (2 PER FILL(S)) MFL (1 30day(s))
SUMATRIPTAN SUCCINATE 6 MG05ML INJECT
1-Covered QL (2 PER 30 DAY(S)) MFL (1 30day(s))
sumatriptan succinate 6 mg05mlcartridge 6 mg05ml vial
1-Covered QL (2 PER FILL(S)) MFL (1 30day(s))
sumatriptan succinate 6 mg05mlpen injctr 6 mg05ml syringe
1-Covered QL (2 PER 30 DAY(S)) MFL (1 30day(s))
ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis)
PARASYMPATHOMIMETICSMESTINON (pyridostigminebromide) 60 MG5 ML SOLUTION
1-Covered
pyridostigmine bromide 60 mg5ml solution 60 mg tablet 180 mgtablet er
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
25
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections)
ANTIMYCOBACTERIALS OTHER (Other Drugs for MycobacterialInfection)
dapsone 25 mg tablet 100 mgtablet
1-Covered
rifabutin 150 mg capsule 1-Covered
ANTITUBERCULARS (Drugs for Tuberculosis)ethambutol hcl 100 mg tablet 400mg tablet
1-Covered
ETHAMBUTOL HCL 100 MG TABLET400 MG TABLET
1-Covered
isoniazid 50 mg5 ml solution 100mg tablet 300 mg tablet
1-Covered
PRIFTIN (rifapentine) 150 MG TABLET 1-Covered AL1 (At least 12 yrs old)
pyrazinamide 500 mg tablet 1-Covered
rifampin 150 mg capsule 300 mgcapsule
1-Covered
ANTINEOPLASTICS (Drugs for Cancer)
ALKYLATING AGENTScyclophosphamide 25 mgcapsule 50 mg capsule
1-Covered PA
CYCLOPHOSPHAMIDE 25 MGCAPSULE 50 MG CAPSULE
1-Covered PA
GLEOSTINE (lomustine) 10 MGCAPSULE 40 MG CAPSULE 100 MGCAPSULE
1-Covered PA
HEXALEN (altretamine) 50 MGCAPSULE
1-Covered
LEUKERAN (chlorambucil) 2 MGTABLET
1-Covered PA
MATULANE (procarbazine hcl) 50MG CAPSULE
1-Covered PA SP
melphalan 2 mg tablet 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
26
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
MYLERAN (busulfan) 2 MG TABLET 1-Covered
temozolomide 20 mg capsule 1-Covered PA SP
ANTIANDROGENSbicalutamide 50 mg tablet 1-Covered PA
flutamide 125 mg capsule 1-Covered PA
ANTIANGIOGENIC AGENTSTHALOMID (thalidomide) 50 MGCAPSULE
1-Covered PA SP
ANTIESTROGENSMODIFIERSEMCYT (estramustine phosphatesodium) 140 MG CAPSULE
1-Covered PA
TAMOXIFEN CITRATE 10 MG TABLET 1-Covered
tamoxifen citrate 10 mg tablet 20mg tablet
1-Covered
TOREMIFENE CITRATE 60 MG TAB 1-Covered PA
toremifene citrate 60 mg tablet 1-Covered PA
ANTIMETABOLITEScapecitabine 500 mg tablet 1-Covered PA SP
CAPECITABINE 500 MG TABLET 1-Covered PA SP
DROXIA (hydroxyurea) 200 MGCAPSULE 300 MG CAPSULE 400MG CAPSULE
1-Covered
fluorouracil (ADRUCIL) 25 g50mlvial 5 g100 ml vial
1-Covered PA
hydroxyurea 500 mg capsule 1-Covered PA
mercaptopurine 50 mg tablet 1-Covered PA
TABLOID (thioguanine) 40 MGTABLET
1-Covered PA
ANTINEOPLASTICS OTHERLEUCOVORIN CALCIUM 5 MG TAB25 MG TAB
1-Covered
leucovorin calcium 5 mg tablet 10mg tablet 15 mg tablet 25 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
27
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LYSODREN (mitotane) 500 MGTABLET
1-Covered PA
AROMATASE INHIBITORS 3RD GENERATIONanastrozole 1 mg tablet 1-Covered
ANASTROZOLE 1 MG TABLET 1-Covered
letrozole 25 mg tablet 1-Covered
ENZYME INHIBITORSetoposide 50 mg capsule 1-Covered PA
MOLECULAR TARGET INHIBITORSJAKAFI (ruxolitinib phosphate) 5MG TABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET 25 MGTABLET
1-Covered PA SP QL (2 PER 1 DAY(S))
RETINOIDStretinoin 10 mg capsule 1-Covered PA
ANTIPARASITICS (Drugs for Parasitic Infections)
ANTIHELMINTHICS (Drugs for Worm Infection)mebendazole (EMVERM) 100 mgtab chew
1-Covered
praziquantel 600 mg tablet 1-Covered
ANTIPROTOZOALS (Drugs for Protozoal Infection)chloroquine phosphate 250 mgtablet
1-Covered QL (25 PER 30 DAY(S))
chloroquine phosphate 500 mgtablet
1-Covered PA QL (25 PER 30 DAY(S))
HYDROXYCHLOROQUINE SULFATE200 MG TAB
1-Covered QL (3 PER 1 DAY(S))
hydroxychloroquine sulfate 200 mgtablet
1-Covered QL (3 PER 1 DAY(S))
mefloquine hcl 250 mg tablet 1-Covered
primaquine phosphate 263 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
28
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PEDICULICIDESSCABICIDES (Drugs for Scabies and Lice)permethrin (LICE TREATMENT) 1 liquid
1-Covered
permethrin 5 cream (g) 1-Covered
ANTIPARKINSON AGENTS (Drugs for Parkinsons Disease)
ANTICHOLINERGICSbenztropine mesylate 05 mgtablet 1 mg tablet 2 mg tablet 2mg2 ml ampul 2 mg2 ml vial
2-MedicalCarve out
COGENTIN (benztropine mesylate)2 MG2 ML AMPULE
2-MedicalCarve out
trihexyphenidyl hcl 2 mg5 ml elixir2 mg tablet 5 mg tablet
2-MedicalCarve out
ANTIPARKINSON AGENTS OTHERAMANTADINE 100 MG CAPSULE 2-Medical
Carve out
amantadine hcl 50 mg5 mlsolution 100 mg capsule 100 mgtablet
2-MedicalCarve out
entacapone 200 mg tablet 1-Covered ST
GOCOVRI (amantadine hcl) ER685 MG CAPSULE ER 137 MGCAPSULE
2-MedicalCarve out
OSMOLEX ER (amantadine hcl) ER129 MG TABLET ER 193 MG TABLETER 258 MG TABLET ER 322 MGDAILY DOSE
2-MedicalCarve out
DOPAMINE AGONISTSbromocriptine mesylate 25 mgtablet
1-Covered
pramipexole di-hcl -0125 mgtablet -025 mg tablet -05 mgtablet -075 mg tablet -1 mgtablet -15 mg tablet
1-Covered
ropinirole hcl 025 mg tablet 05mg tablet 1 mg tablet 2 mgtablet 3 mg tablet 4 mg tablet 5mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
29
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DOPAMINE PRECURSORSL-AMINO ACID DECARBOXYLASEINHIBITORS
carbidopalevodopa 10mg-100mgtablet 25mg-100mg tablet 25mg-100mg tablet er 25mg-250mgtablet 50mg-200mg tablet er
1-Covered
MONOAMINE OXIDASE B (MAO-B) INHIBITORSselegiline hcl 5 mg tablet 5 mgcapsule
1-Covered
ANTIPSYCHOTICS (Drugs for Mental Health)
1ST GENERATIONTYPICALADASUVE (loxapine) 10 MG POWD10 MG POWDR
2-MedicalCarve out
chlorpromazine hcl 10 mg tablet25 mg tablet 25 mgml ampul 50mg tablet 100 mg tablet 200 mgtablet
2-MedicalCarve out
CHLORPROMAZINE HCL 10 MGTABLET 25 MGML AMPULE 25 MGTABLET 50 MG TABLET 50 MG2 MLAMP 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
fluphenazine decanoate 25 mgmlvial
2-MedicalCarve out
fluphenazine hcl 1 mg tablet 25mg tablet 25 mg5ml elixir 25mgml vial 5 mgml oral conc 5mg tablet 10 mg tablet
2-MedicalCarve out
FLUPHENAZINE HCL 1 MG TABLET25 MG TABLET 5 MG TABLET 10MG TABLET
2-MedicalCarve out
HALDOL (haloperidol lactate) 5MGML AMPUL
2-MedicalCarve out
HALDOL DECANOATE 100(haloperidol decanoate) AMPUL
2-MedicalCarve out
HALDOL DECANOATE 50(haloperidol decanoate) AMPUL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
30
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
haloperidol 05 mg tablet 1 mgtablet 2 mg tablet 5 mg tablet 10mg tablet 20 mg tablet
2-MedicalCarve out
HALOPERIDOL 5 MG TABLET 2-MedicalCarve out
haloperidol decanoate 50 mgmlvial 50 mgml ampul 100 mgmlampul 100 mgml vial
2-MedicalCarve out
haloperidol lactate 2 mgml oralconc 5 mgml vial 5 mgmlampul 5 mgml syringe
2-MedicalCarve out
HALOPERIDOL LACTATE 5 MGMLSYRING
2-MedicalCarve out
loxapine succinate 5 mg capsule10 mg capsule 25 mg capsule 50mg capsule
2-MedicalCarve out
molindone hcl 5 mg tablet 10 mgtablet 25 mg tablet
2-MedicalCarve out
ORAP (pimozide) 1 MG TABLET 2MG TABLET
2-MedicalCarve out
pimozide 1 mg tablet 2 mg tablet 2-MedicalCarve out
thioridazine hcl 10 mg tablet 25mg tablet 50 mg tablet 100 mgtablet
2-MedicalCarve out
thiothixene 1 mg capsule 2 mgcapsule 5 mg capsule 10 mgcapsule
2-MedicalCarve out
trifluoperazine hcl 1 mg tablet 2mg tablet 5 mg tablet 10 mgtablet
2-MedicalCarve out
2ND GENERATIONATYPICALABILIFY (aripiprazole) 2 MG TABLET5 MG TABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET 30 MGTABLET
2-MedicalCarve out
ABILIFY MAINTENA (aripiprazole) ER300 MG VL ER 300 MG SYR ER 400MG SYR ER 400 MG VL
2-MedicalCarve out
ABILIFY MYCITE (aripiprazole) 2 MGKIT 5 MG KIT 10 MG KIT 15 MG KIT20 MG KIT 30 MG KIT
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
31
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
aripiprazole 1 mgml solution 2 mgtablet 5 mg tablet 10 mg tabrapdis 10 mg tablet 15 mg tablet15 mg tab rapdis 20 mg tablet 30mg tablet
2-MedicalCarve out
ARIPIPRAZOLE 1 MGML SOLUTION2 MG TABLET 5 MG TABLET 10 MGTABLET 15 MG TABLET 20 MGTABLET 30 MG TABLET
2-MedicalCarve out
ARISTADA (aripiprazole lauroxil) ER441 MG16 ML SYRN ER 662MG24 ML SYRN ER 882 MG32ML SYRN ER 1064 MG39 ML SYR
2-MedicalCarve out
ARISTADA INITIO (aripiprazolelauroxil submicronized) ER 675MG24
2-MedicalCarve out
CAPLYTA (lumateperone tosylate)42 MG CAPSULE
2-MedicalCarve out
FANAPT (iloperidone) 1 MG TABLET2 MG TABLET 4 MG TABLET 6 MGTABLET 8 MG TABLET 10 MGTABLET 12 MG TABLET TITRATIONPACK
2-MedicalCarve out
GEODON (ziprasidone hcl) 20 MGCAPSULE 40 MG CAPSULE 60 MGCAPSULE 80 MG CAPSULE
2-MedicalCarve out
GEODON (ziprasidone mesylate)20 MGML VIAL
2-MedicalCarve out
INVEGA (paliperidone) ER 15 MGTABLET ER 3 MG TABLET ER 6 MGTABLET ER 9 MG TABLET
2-MedicalCarve out
INVEGA SUSTENNA (paliperidonepalmitate) 39 MG025 ML 78MG05 ML 117 MG075 ML 156MGML SYRG 234 MG15 ML
2-MedicalCarve out
INVEGA TRINZA (paliperidonepalmitate) 273 MG0875 ML 410MG1315 ML 546 MG175 ML 819MG2625 ML
2-MedicalCarve out
LATUDA (lurasidone hcl) 20 MGTABLET 40 MG TABLET 60 MGTABLET 80 MG TABLET 120 MGTABLET
2-MedicalCarve out
NUPLAZID (pimavanserin tartrate)10 MG TABLET 17 MG TABLET 34MG CAPSULE
2-MedicalCarve out
SP
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
32
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
olanzapine 25 mg tablet 5 mgtab rapdis 5 mg tablet 75 mgtablet 10 mg tab rapdis 10 mgtablet 10 mg vial 15 mg tabrapdis 15 mg tablet 20 mg tablet20 mg tab rapdis
2-MedicalCarve out
paliperidone 15 mg tab er 24 3mg tab er 24 6 mg tab er 24 9 mgtab er 24
2-MedicalCarve out
PERSERIS (risperidone) ER 90 MGSYRINGE KIT ER 120 MG SYRINGEKIT
2-MedicalCarve out
quetiapine fumarate 25 mg tablet50 mg tab er 24h 50 mg tablet100 mg tablet 150 mg tab er 24h200 mg tab er 24h 200 mg tablet300 mg tablet 300 mg tab er 24h400 mg tab er 24h 400 mg tablet
2-MedicalCarve out
REXULTI (brexpiprazole) 025 MGTABLET 05 MG TABLET 1 MGTABLET 2 MG TABLET 3 MG TABLET4 MG TABLET
2-MedicalCarve out
RISPERDAL (risperidone) 025 MGTABLET 05 MG TABLET 1 MGMLSOLUTION 1 MG TABLET 2 MGTABLET 3 MG TABLET 4 MG TABLET
2-MedicalCarve out
RISPERDAL CONSTA (risperidonemicrospheres) 125 MG VIAL 25MG VIAL 375 MG VIAL 50 MGVIAL
2-MedicalCarve out
RISPERDAL M-TAB (risperidone) -TAB05 G ODT -TAB 1 G ODT -TAB 2 GODT -TAB 3 G ODT -TAB 4 G ODT
2-MedicalCarve out
risperidone 025 mg tab rapdis025 mg tablet 05 mg tab rapdis05 mg tablet 1 mg tablet 1mgml solution 1 mg tab rapdis 2mg tab rapdis 2 mg tablet 3 mgtablet 3 mg tab rapdis 4 mg tabrapdis 4 mg tablet
2-MedicalCarve out
SAPHRIS (asenapine maleate) 25MG TAB 5 MG TAB 10 MG TAB
2-MedicalCarve out
SECUADO (asenapine) 38 MG24HR PATCH 57 MG24 HR PATCH76 MG24 HR PATCH
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
33
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SEROQUEL (quetiapine fumarate)25 MG TABLET 50 MG TABLET 100MG TABLET 200 MG TABLET 300MG TABLET 400 MG TABLET
2-MedicalCarve out
SEROQUEL XR (quetiapinefumarate) 50 MG TABLET 150 MGTABLET 200 MG TABLET 300 MGTABLET 400 MG TABLET
2-MedicalCarve out
VRAYLAR (cariprazine hcl) 15 MG-3 MG PACK 15 MG CAPSULE 3MG CAPSULE 45 MG CAPSULE 6MG CAPSULE
2-MedicalCarve out
ziprasidone hcl 20 mg capsule 40mg capsule 60 mg capsule 80 mgcapsule
2-MedicalCarve out
ZIPRASIDONE HCL 20 MG CAPSULE40 MG CAPSULE 60 MG CAPSULE80 MG CAPSULE
2-MedicalCarve out
ZIPRASIDONE MESYLATE 20 MGMLVIAL
2-MedicalCarve out
ziprasidone mesylate fnl 20mg1vial
2-MedicalCarve out
ZYPREXA (olanzapine) 25 MGTABLET 5 MG TABLET 75 MGTABLET 10 MG VIAL 10 MG TABLET15 MG TABLET 20 MG TABLET
2-MedicalCarve out
ZYPREXA RELPREVV (olanzapinepamoate) 210 MG VL KIT 300 MGVL KIT 405 MG VL KIT
2-MedicalCarve out
ZYPREXA ZYDIS (olanzapine) 5 MGTABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET
2-MedicalCarve out
TREATMENT-RESISTANTclozapine 125 mg tab rapdis 25mg tab rapdis 25 mg tablet 50mg tablet 100 mg tablet 100 mgtab rapdis 150 mg tab rapdis 200mg tablet 200 mg tab rapdis
2-MedicalCarve out
CLOZAPINE 25 MG TABLET 50 MGTABLET 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
CLOZAPINE ODT ODT 150 MGTABLET ODT 200 MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
34
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CLOZARIL (clozapine) 25 MGTABLET 50 MG TABLET 100 MGTABLET 200 MG TABLET
2-MedicalCarve out
FAZACLO (clozapine) 125 MGODT 25 MG ODT 100 MG ODT 150MG ODT 200 MG ODT
2-MedicalCarve out
VERSACLOZ (clozapine) 50 MGMLSUSPENSION
2-MedicalCarve out
ANTISPASTICITY AGENTS (Drugs for Muscle Spasm)baclofen 10 mg tablet 20 mgtablet
1-Covered QL (90 PER 30 DAYS)
BACLOFEN 10 MG TABLET 20 MGTABLET
1-Covered QL (90 PER 30 DAYS)
tizanidine hcl 2 mg tablet 4 mgtablet
1-Covered QL (90 PER 30 DAY(S))
ANTIVIRALS (Drugs for Viral Infections)
ANTI-HEPATITIS B (HBV) AGENTSEPIVIR HBV (lamivudine) 100 MGTABLET
2-MedicalCarve out
EPIVIR HBV (lamivudine) 25 MG5ML SOLN
1-Covered PA
lamivudine 100 mg tablet 1-Covered PA
VEMLIDY (tenofovir alafenamide)25 MG TABLET
2-MedicalCarve out
ANTI-HEPATITIS C (HCV) AGENTS DIRECT ACTING AGENTSsofosbuvirvelpatasvir 400-100 mgtablet
1-Covered PA SP
ANTI-HEPATITIS C (HCV) AGENTS OTHERINTRON A (interferon alfa-2brecomb) 10 MILLION UNITS VIL -18 MILLION UNITS VIL - 18 MILLIONUNIT3 ML - 25 MILLION UNIT25ML- 50 MILLION UNITS VIL -
1-Covered PA SP
PEGINTRON REDIPEN(peginterferon alfa-2b) 50 MCG -
1-Covered PA SP
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
35
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ribavirin (RIBASPHERE) 200 mgtablet
1-Covered PA
ribavirin 200 mg tablet 1-Covered PA
ANTI-HIV AGENTSCIMDUO (lamivudinetenofovirdisoproxil fumarate) 300-300 MGTABLET
2-MedicalCarve out
EFAVIRENZ-LAMIVU-TENOFOVDISOP --600-300-300
2-MedicalCarve out
SYMFI(efavirenzlamivudinetenofovirdisoproxil fumarate) 600-300-300MG TABLET
2-MedicalCarve out
TEMIXYS (lamivudinetenofovirdisoproxil fumarate) 300-300 MGTABLET
2-MedicalCarve out
ANTI-HIV AGENTS INTEGRASE INHIBITORS (INSTI)BIKTARVY (bictegravirsodiumemtricitabinetenofoviralafenamide fumar) 50-200-25 MGTABLET
2-MedicalCarve out
GENVOYA(elvitegravircobicistatemtricitabinetenofovir alafenamide) TABLET
2-MedicalCarve out
ISENTRESS (raltegravir potassium) 25MG TABLET CHEW 100 MG TABLETCHEW 100 MG POWDER PACKET400 MG TABLET
2-MedicalCarve out
ISENTRESS HD (raltegravirpotassium) 600 MG TABLET
2-MedicalCarve out
STRIBILD(elvitegravircobicistatemtricitabinetenofovir disoproxil) TABLET
2-MedicalCarve out
TIVICAY (dolutegravir sodium) 10MG TABLET 25 MG TABLET 50 MGTABLET
2-MedicalCarve out
TIVICAY PD 5 MG TAB FOR SUSP 2-MedicalCarve out
VITEKTA (elvitegravir) 85 MGTABLET 150 MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
36
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTI-HIV AGENTS NON-NUCLEOSIDE REVERSE TRANSCRIPTASEINHIBITORS (NNRTI)
ATRIPLA(efavirenzemtricitabinetenofovirdisoproxil fumarate) TABLET
2-MedicalCarve out
COMPLERA(emtricitabinerilpivirinehcltenofovir disoproxil fumarate)TABLET
2-MedicalCarve out
DELSTRIGO(doravirinelamivudinetenofovirdisoproxil fumarate) 100-300-300MG TAB
2-MedicalCarve out
EDURANT (rilpivirine hcl) 25 MGTABLET
2-MedicalCarve out
efavirenz 50 mg capsule 200 mgcapsule 600 mg tablet
2-MedicalCarve out
EFAVIRENZ-EMTRIC-TENOFOVDISOP --600-200-300
2-MedicalCarve out
EFAVIRENZ-LAMIVU-TENOFOVDISOP --400-300-300
2-MedicalCarve out
INTELENCE (etravirine) 25 MGTABLET 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
nevirapine 50 mg5 ml oral susp100 mg tab er 24h 200 mg tablet400 mg tab er 24h
2-MedicalCarve out
ODEFSEY (emtricitabinerilpivirinehcltenofovir alafenamidefumarate) TABLET
2-MedicalCarve out
PIFELTRO (doravirine) 100 MGTABLET
2-MedicalCarve out
RESCRIPTOR (delavirdine mesylate)100 MG TABLET 200 MG TABLET
2-MedicalCarve out
SUSTIVA (efavirenz) 50 MGCAPSULE 200 MG CAPSULE 600MG TABLET
2-MedicalCarve out
SYMFI LO(efavirenzlamivudinetenofovirdisoproxil fumarate) 400-300-300MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
37
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
VIRAMUNE (nevirapine) 50 MG5ML SUSP 200 MG TABLET
2-MedicalCarve out
VIRAMUNE XR (nevirapine) 100 MGTABLET 400 MG TABLET
2-MedicalCarve out
ANTI-HIV AGENTS NUCLEOSIDE AND NUCLEOTIDE REVERSETRANSCRIPTASE INHIBITORS (NRTI)
abacavir sulfate 20 mgml solution300 mg tablet
2-MedicalCarve out
abacavir sulfatelamivudine 600-300mg tablet
2-MedicalCarve out
abacavirsulfatelamivudinezidovudineabacavirlamivudinezidovudine150-300 mg tablet
2-MedicalCarve out
ABACAVIR-LAMIVUDINE -600-300MG
2-MedicalCarve out
COMBIVIR (lamivudinezidovudine)TABLET
2-MedicalCarve out
EMTRICITABINE 200 MG CAPSULE 2-MedicalCarve out
EMTRICITABINE-TENOFOVIR DISOP -TENOFV 200-300MG
2-MedicalCarve out
EMTRIVA (emtricitabine) 10 MGMLSOLUTION 200 MG CAPSULE
2-MedicalCarve out
EPIVIR (lamivudine) 10 MGMLORAL SOLN 150 MG TABLET 300MG TABLET
2-MedicalCarve out
EPZICOM (abacavirsulfatelamivudine) TABLET
2-MedicalCarve out
lamivudine 10 mgml solution 150mg tablet 300 mg tablet
2-MedicalCarve out
lamivudinezidovudine 150-300mgtablet 150-300 mg tablet
2-MedicalCarve out
stavudine 1 mgml soln recon 15mg capsule 20 mg capsule 30 mgcapsule 40 mg capsule
2-MedicalCarve out
tenofovir disoproxil fumarate 300mg tablet
2-MedicalCarve out
TRIZIVIR (abacavirsulfatelamivudinezidovudine)TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
38
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRUVADA (emtricitabinetenofovirdisoproxil fumarate) 100 MG-150MG TABLET 133 MG-200 MGTABLET 167 MG-250 MG TABLET200 MG-300 MG TABLET
2-MedicalCarve out
VIREAD (tenofovir disoproxilfumarate) 150 MG TABLET 200 MGTABLET 250 MG TABLET 300 MGTABLET POWDER
2-MedicalCarve out
ZERIT (stavudine) 1 MGMLSOLUTION 15 MG CAPSULE 20 MGCAPSULE 30 MG CAPSULE 40 MGCAPSULE
2-MedicalCarve out
ZIAGEN (abacavir sulfate) 20MGML SOLUTION 300 MG TABLET
2-MedicalCarve out
ANTI-HIV AGENTS OTHERDESCOVY (emtricitabinetenofoviralafenamide fumarate) 200-25 MGTABLET
2-MedicalCarve out
DOVATO (dolutegravirsodiumlamivudine) 50-300 MGTABLET
2-MedicalCarve out
FUZEON (enfuvirtide) 90 MG VIAL 2-MedicalCarve out
SP
JULUCA (dolutegravirsodiumrilpivirine hcl) 50-25 MGTABLET
2-MedicalCarve out
RUKOBIA ER 600 MG TABLET 2-MedicalCarve out
SELZENTRY (maraviroc) 20 MGMLORAL SOLN 25 MG TABLET 75 MGTABLET 150 MG TABLET 300 MGTABLET
2-MedicalCarve out
TRIUMEQ (abacavirsulfatedolutegravirsodiumlamivudine) 600-50-300 MGTABLET
2-MedicalCarve out
TROGARZO (ibalizumab-uiyk) 200MG133 ML VIAL -
2-MedicalCarve out
TYBOST (cobicistat) 150 MG TABLET 2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
39
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTI-HIV AGENTS PROTEASE INHIBITORSAPTIVUS (tipranavir) 250 MGCAPSULE
2-MedicalCarve out
APTIVUS (tipranavirvitamin e tpgs)100 MGML SOLUTION
2-MedicalCarve out
ATAZANAVIR SULFATE 150 MG CAP200 MG CAP 300 MG CAP
2-MedicalCarve out
atazanavir sulfate 150 mg capsule200 mg capsule 300 mg capsule
2-MedicalCarve out
CRIXIVAN (indinavir sulfate) 200MG CAPSULE 400 MG CAPSULE
2-MedicalCarve out
EVOTAZ (atazanavirsulfatecobicistat) 300 MG-150 MGTABLET
2-MedicalCarve out
fosamprenavir calcium 700 mgtablet
2-MedicalCarve out
FOSAMPRENAVIR CALCIUM 700MG TABLET
2-MedicalCarve out
INVIRASE (saquinavir mesylate) 200MG CAPSULE 500 MG TABLET
2-MedicalCarve out
KALETRA (lopinavirritonavir) 80MG-20 MGML SOLN 100-25 MGTABLET 200-50 MG TABLET
2-MedicalCarve out
LEXIVA (fosamprenavir calcium) 50MGML SUSPENSION 700 MGTABLET
2-MedicalCarve out
lopinavirritonavir 400-1005solution
2-MedicalCarve out
NORVIR (ritonavir) 80 MGMLSOLUTION 100 MG TABLET 100 MGSOFTGEL CAP 100 MG POWDERPACKET
2-MedicalCarve out
PREZCOBIX (darunavirethanolatecobicistat) 800 MG-150MG TABLET
2-MedicalCarve out
PREZISTA (darunavir ethanolate) 75MG TABLET 100 MGMLSUSPENSION 150 MG TABLET 400MG TABLET 600 MG TABLET 800MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
40
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
REYATAZ (atazanavir sulfate) 50MG POWDER PACKET 150 MGCAPSULE 200 MG CAPSULE 300MG CAPSULE
2-MedicalCarve out
ritonavir 100 mg tablet 2-MedicalCarve out
SYMTUZA (darunavirethcobicistatemtricitabinetenofovir alafenamide) 800-150-200-10MG TAB
2-MedicalCarve out
VIRACEPT (nelfinavir mesylate) 250MG TABLET 625 MG TABLET
2-MedicalCarve out
ANTI-INFLUENZA AGENTSoseltamivir phosphate 30 mgcapsule 45 mg capsule 75 mgcapsule
1-Covered QL (10 PER 30 DAY(S)) MFL (1 180 day(s))
OSELTAMIVIR PHOSPHATE 30 MGCAPSULE 45 MG CAPSULE 75 MGCAPSULE
1-Covered QL (10 PER 30 DAY(S)) MFL (1 180 day(s))
oseltamivir phosphate 6 mgmlsusp recon
1-Covered QL (120 PER FILL(S)) MFL (120 180day(s))
OSELTAMIVIR PHOSPHATE 6 MGMLSUSPENSION
1-Covered QL (120 PER FILL(S)) MFL (120 180day(s))
RELENZA (zanamivir) 5 MGDISKHALER
1-Covered QL (20 PER 30 DAY(S))
ANTIHERPETIC AGENTSacyclovir 200 mg capsule 200mg5ml oral susp 400 mg tablet800 mg tablet
1-Covered
ACYCLOVIR 200 MG5 ML SUSP400 MG TABLET 800 MG TABLET
1-Covered
trifluridine 1 drops 1-Covered
valacyclovir hcl 500 mg tablet1000 mg tablet
1-Covered QL (60 PER 30 DAY(S))
ANXIOLYTICS (Drugs for Anxiety)
ANXIOLYTICS OTHER (Other Drugs for Anxiety)BUSPIRONE HCL 5 MG TABLET 10MG TABLET 15 MG TABLET 30 MGTABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
41
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
buspirone hcl 5 mg tablet 75 mgtablet 10 mg tablet 15 mg tablet30 mg tablet
1-Covered
BENZODIAZEPINESalprazolam (ALPRAZOLAMINTENSOL) 1 mgml oral conc
1-Covered
alprazolam 025 mg tablet 05 mgtablet 1 mg tablet 2 mg tablet
1-Covered QL (100 PER 30 DAYS)
clonazepam 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered QL (120 PER 30 DAY(S))
diazepam 2 mg tablet 5 mgtablet 10 mg tablet
1-Covered QL (100 PER 30 DAYS)
diazepam 5 mg5 ml solution 5mgml oral conc
1-Covered
lorazepam (LORAZEPAM INTENSOL)2 mgml oral conc
1-Covered
lorazepam 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered QL (100 PER 30 DAYS)
lorazepam 2 mgml oral conc 1-Covered
oxazepam 10 mg capsule 15 mgcapsule 30 mg capsule
1-Covered
BIPOLAR AGENTS (Drugs for Bipolar Disorder)
MOOD STABILIZERSlithium carbonate 150 mg capsule300 mg tablet er 300 mg capsule300 mg tablet 450 mg tablet er600 mg capsule
2-MedicalCarve out
lithium citrate 8 meq5 ml solution 2-MedicalCarve out
LITHOBID (lithium carbonate) ER300 MG TABLET
2-MedicalCarve out
BLOOD GLUCOSE REGULATORS (Drugs for Diabetes)
ANTIDIABETIC AGENTS (Drugs for High Blood Sugar)acarbose 100 mg tablet 1-Covered QL (3 PER 1 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
42
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acarbose 25 mg tablet 1-Covered QL (12 PER 1 DAYS)
acarbose 50 mg tablet 1-Covered QL (6 PER 1 DAYS)
ADLYXIN (lixisenatide) 10-20 MCGSTARTER PACK 20 MCGMAINTENANCE PK
1-Covered PA
alogliptin benzoate 625 mg tablet125 mg tablet 25 mg tablet
1-Covered ST
alogliptin benzoatemetformin hclbenzmetformin 125-1000 tabletbenzmetformin 125-500mg tablet
1-Covered ST
alogliptin benzoatepioglitazonehcl benzpioglitazone 125-15 mgtablet benzpioglitazone 125-45mg tablet benzpioglitazone 125-30 mg tablet benzpioglitazone 25mg-30mg tabletbenzpioglitazone 25 mg-45mgtablet benzpioglitazone 25 mg-15mg tablet
1-Covered ST
AVANDIA (rosiglitazone maleate) 2MG TABLET 4 MG TABLET
1-Covered QL (60 PER 30 DAYS)
glimepiride 1 mg tablet 2 mgtablet 4 mg tablet
1-Covered STAR (Preferred Drug)
glipizide 25 mg tab er 24 5 mgtablet 5 mg tab er 24 10 mg taber 24 10 mg tablet
1-Covered STAR (Preferred Drug)
glyburide 125 mg tablet 25 mgtablet 5 mg tablet
1-Covered STAR (Preferred Drug)
glyburidemetformin hcl 125-250mg tablet 25-500 mg tablet 5mg-500mg tablet
1-Covered STAR (Preferred Drug)
JARDIANCE (empagliflozin) 10 MGTABLET 25 MG TABLET
1-Covered PA QL (1 PER 1 DAYS)
metformin hcl 500 mg tablet 500mg tab er 24h 750 mg tab er 24h850 mg tablet 1000 mg tablet
1-Covered STAR (Preferred Drug)
METFORMIN HCL ER ER 500 MGTABLET ER 750 MG TABLET
1-Covered STAR (Preferred Drug)
nateglinide 60 mg tablet 120 mgtablet
1-Covered ST
pioglitazone hcl 15 mg tablet 30mg tablet 45 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
43
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PIOGLITAZONE HCL 15 MG TABLET30 MG TABLET 45 MG TABLET
1-Covered
SYNJARDY(empagliflozinmetformin hcl) 5-1000 MG TABLET
1-Covered PA QL (2 PER 1 DAY(S))
SYNJARDY(empagliflozinmetformin hcl) 5-500 MG TABLET 125-500 MGTABLET 125-1000 MG TABLET
1-Covered PA QL (2 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 10-MG TABLET 125-MG TAB
1-Covered PA QL (2 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 25-1000 MG TABLET
1-Covered PA QL (1 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 5-1000 MG TABLET
1-Covered PA QL (2 PER 1)
tolbutamide 500 mg tablet 1-Covered
TRULICITY (dulaglutide) 075MG05 ML PEN 15 MG05 ML PEN
1-Covered PA QLC (1 penweek)
TRULICITY 3 MG05 ML PEN 45MG05 ML PEN
1-Covered PA QL (05 PER 1 WEEK(S))
VICTOZA 2-PAK (liraglutide) -18MG3 ML PEN
1-Covered PA QLC (6 ml (2 pens)30 days)
VICTOZA 3-PAK (liraglutide) -18MGML PEN
1-Covered PA QLC (9 ml (3 pens)30 days)
GLYCEMIC AGENTS (Drugs for Low Blood Sugar)BAQSIMI (glucagon) 3 MG SPRAYTWO PACK 3 MG SPRAY ONEPACK
1-Covered QL (2 PER 30 DAY(S))
GLUCAGON EMERGENCY KIT(glucagon hcl) 1 MG
1-Covered
GLUCAGON EMERGENCY KIT(glucagonhuman recombinant) 1MG
1-Covered
terbinafine hcl (JOCK ITCH) 1 cream (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
44
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
INSULINSADMELOG (insulin lispro) 100UNITML VIAL
1-Covered
ADMELOG SOLOSTAR (insulin lispro)100 UNITML
1-Covered PA
BASAGLAR KWIKPEN U-100 (insulinglarginehuman recombinantanalog) UNITML
1-Covered
HUMALOG (insulin lispro) 100UNITML CARTRIDGE
1-Covered PA
HUMALOG MIX 75-25 (insulin lisproprotamine and insulin lispro) -VIAL (
1-Covered
HUMALOG MIX 75-25 KWIKPEN(insulin lispro protamine and insulinlispro) -(
1-Covered PA
HUMULIN 70-30 (insulin nph humanisophaneinsulin regular human) -VIAL
1-Covered
HUMULIN 7030 KWIKPEN (insulinnph human isophaneinsulinregular human)
1-Covered PA
HUMULIN N (insulin nph humanisophane) 100 UITML VIAL
1-Covered
HUMULIN R (insulin regular human)100 UNITML VIAL
1-Covered
HUMULIN R U-500 (insulin regularhuman) UNITML VIAL
1-Covered
insulin lispro 100ml insuln pen 1-Covered PA
insulin lispro 100ml vial 1-Covered
INSULIN LISPRO PROTAMINE MIX(insulin lispro protamine and insulinlispro) 75-25 KWKPN (
1-Covered PA
NOVOLIN 70-30 (insulin nph humanisophaneinsulin regular human)70-30 100 UNITML VIAL RELION 70-30 VIAL
1-Covered
NOVOLIN N (insulin nph humanisophane) N 100 UNITML VIALRELION N 100 UNITML
1-Covered
NOVOLIN R (insulin regular human)R 100 UNITML VIAL RELION R 100UNITML
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
45
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
BLOOD PRODUCTSMODIFIERSVOLUME EXPANDERS (Drugs forBlood Disorders)
ANTICOAGULANTS (Blood Thinners)COUMADIN (warfarin sodium) 1MG TABLET 2 MG TABLET 25 MGTABLET 3 MG TABLET 4 MG TABLET5 MG TABLET 6 MG TABLET 75 MGTABLET 10 MG TABLET
1-Covered
ELIQUIS (apixaban) 25 MG TABLET5 MG TABLET
1-Covered QL (2 PER 1 DAY(S))
ELIQUIS (apixaban) DVT-PE TREATSTART 5MG
1-Covered QLC (1 PACK6 MONTHS)
ENOXAPARIN SODIUM 120 MG08ML SYR
1-Covered
ENOXAPARIN SODIUM 30 MG03ML SYR 40 MG04 ML SYR 60MG06 ML SYR 80 MG08 ML SYR100 MGML SYRINGE 150 MGMLSYRINGE
1-Covered PA
enoxaparin sodium 30mg03ml40mg04ml 60mg06ml80mg08ml 100 mgml120mg8ml 150 mgml
1-Covered PA
HEPARIN SODIUM SOD 5000UNITML VIAL SOD 10000 UNITMLVL SOD 20000 UNITML VL 50000UNIT5 ML VIAL
1-Covered
heparin sodiumporcine 5000mlvial 10000ml vial 20000ml vial
1-Covered
heparin sodiumporcinepf 1000mlvial
1-Covered
warfarin sodium (JANTOVEN) 1 mgtablet 2 mg tablet 25 mg tablet3 mg tablet 4 mg tablet 5 mgtablet 6 mg tablet 75 mg tablet10 mg tablet
1-Covered
warfarin sodium 1 mg tablet 2 mgtablet 25 mg tablet 3 mg tablet4 mg tablet 5 mg tablet 6 mgtablet 75 mg tablet 10 mg tablet
1-Covered
XARELTO (rivaroxaban) 10 MGTABLET 15 MG TABLET 20 MGTABLET
1-Covered QL (1 PER 1 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
46
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
XARELTO (rivaroxaban) DVT-PETREAT START 30D
1-Covered QLC (1 PACK6 MONTHS)
BLOOD FORMATION MODIFIERS (Blood Formation Drugs)anagrelide hcl 05 mg capsule 1mg capsule
1-Covered
EPOGEN (epoetin alfa) 2000UNITSML VIAL 3000 UNITSMLVIAL 4000 UNITSML VIAL 10000UNITSML VIAL 20000 UNITSMLVIAL
1-Covered PA SP
PROCRIT (epoetin alfa) 2000UNITSML VIAL 3000 UNITSMLVIAL 4000 UNITSML VIAL 10000UNITSML VIAL 20000 UNITSMLVIAL 40000 UNITSML VIAL
1-Covered PA SP
HEMOSTASIS AGENTS (Drugs to Stop Bleeding)ADVATE (antihemophilic factor(fviii) recombinantfull length) 200-400 VIAL 401-800 VIAL 801-1200VIAL 1201-1800 VIAL 1801-2400VIAL 2401-3600 VIAL 3601-4800VIAL
2-MedicalCarve out
ADYNOVATE (antihemophilicfactor (fviii) recombinant fulllength peg) 200-400 VIAL 401-800VIAL 750 VIAL 801-1250 VIAL1251-2500 VL 1500 VIAL 3000VIAL
2-MedicalCarve out
AFSTYLA (antihemophilic factor viiirecombsingle-chnb-domtruncated) 250 VIAL -- 500 VIAL --1000 VIAL -- 1500 RANGE VIAL --2000 VIAL -- 2500 RANGE VIAL --3000 VIAL --
2-MedicalCarve out
ALPHANATE (antihemophilic factorhumanvon willebrandfactorhuman) 250-100 VIALhuman) 500-200 VIAL human)1000-400 VIAL human) 1500-600VIAL human) 2000-800 VIALhuman)
2-MedicalCarve out
ALPHANINE SD (factor ix) SD 500VIAL SD 1000 VIAL SD 1500 VIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
47
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALPROLIX (factor ix recombinantfc fusion protein) 250 500 10002000 3000 4000
2-MedicalCarve out
BENEFIX (factor ix humanrecombinant) 250 500 10002000 3000
2-MedicalCarve out
COAGADEX (coagulation factor x)250 VIAL 500 VIAL
2-MedicalCarve out
CORIFACT (factor xiii) KIT 2-MedicalCarve out
ELOCTATE (antihemophilic factor(fviii) recombinant fc fusionprotein) 250 500 750 1000 15002000 3000 4000 5000 6000
2-MedicalCarve out
ESPEROCT (antihemophilic factor(fviii) rec b-dom truncated peg-exei) 500 VIAL -- 1000 VIAL --1500 VIAL -- 2000 VIAL -- 3000VIAL --
2-MedicalCarve out
FEIBA NF (anti-inhibitor coagulantcomplex) 500 (NOMINAL) - 1000(NOMINAL) - 2500 (NOMINAL) -
2-MedicalCarve out
FIBRYGA (fibrinogen) 1 GRAMRANGE VIAL
2-MedicalCarve out
HELIXATE FS (antihemophilic factor(fviii) recombinantfull length) 250UNIT VIAL 500 UNIT VIAL 1000 UNITVIAL 2000 UNIT VIAL 3000 UNITSVIAL
2-MedicalCarve out
HEMLIBRA (emicizumab-kxwh) 30MGML VIAL - 60 MG04 ML VIAL - 105 MG07 ML VIAL - 150 MGMLVIAL -
2-MedicalCarve out
HEMOFIL M (antihemophilic factorhuman) 250 500 1000 1700
2-MedicalCarve out
HUMATE-P (antihemophilic factorhumanvon willebrandfactorhuman) -600 human) -1200human) -2400 human)
2-MedicalCarve out
IDELVION (factor ixrecombinantalbumin fusionprotein) 250 VIAL 500 VIAL 1000VIAL 2000 VIAL 3500 VIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
48
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
IXINITY (factor ix humanrecombinant threonine 148) 500RANGE 500 VIAL 1000 VIAL 1000RANGE 1000 VIAL -2 VLS 1000RANGE-2 VLS 1500 RANGE-2 VLS1500 VIAL -2 VLS 1500 VIAL 1500RANGE
2-MedicalCarve out
JIVI (antihemophilic factor (fviii)rec b-domain deleted peg-aucl)500 VIAL -- 1000 VIAL -- 2000 VIAL-- 3000 VIAL --
2-MedicalCarve out
KCENTRA (human prothrombincomplex concentrate (pcc) 4-factor) 500 VIAL 4- 1000 VIAL 4-
2-MedicalCarve out
KOGENATE FS (antihemophilicfactor (fviii) recombinantfulllength) 250 UNIT VIAL 500 UNITVIAL 1000 UNITS VIAL 2000 UNITVIAL 3000 UNITS VIAL
2-MedicalCarve out
KOVALTRY (antihemophilic factor(fviii) recombinantfull length) 250KIT 500 KIT 1000 KIT 2000 KIT3000 KIT
2-MedicalCarve out
MONONINE (factor ix) 1000 UNITVIAL
2-MedicalCarve out
NOVOEIGHT (antihemophilic factorviii recombinant b-domaintruncated) 250 VIAL RECOMINANT- 500 VIAL RECOMINANT - 1000VIAL RECOMINANT - 1500 VIALRECOMINANT - 2000 VIALRECOMINANT - 3000 VIALRECOMINANT -
2-MedicalCarve out
NOVOSEVEN RT (coagulationfactor viia (recombinant)) 1 MGVIAL 2 MG VIAL 5 MG VIAL 8 MGVIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
49
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NUWIQ (antihemophilic factor viiirec hek cell b-domain deleted)250 VIAL - 250 VIAL PACK - 500VIAL - 500 VIAL PACK - 1000 VIAL - 1000 VIAL PACK - 2000 VIALPACK - 2000 VIAL - 2500 VIALPACK - 2500 VIAL - 3000 VIAL -3000 VIAL PACK - 4000 VIAL PACK- 4000 VIAL -
2-MedicalCarve out
OBIZUR (antihemophilic factor viiirecombinant porcine sequence)500 VIAL 500 VIAL - 5 VIALS 500VIAL -10 VIALS
2-MedicalCarve out
phytonadione (vit k1) 5 mg tablet 1-Covered
PROFILNINE (factor ix complexprothrombin cplx conc(pcc) no43-factor) 500 VIAL 3- 1000 VIAL 3-1500 VIAL 3-
2-MedicalCarve out
REBINYN (factor ix (human)recombinant pegylated) 500 VIAL1000 VIAL 2000 VIAL
2-MedicalCarve out
RECOMBINATE (antihemophilicfactor viii human recombinant)220-400 VIAL 401-800 VIAL 801-1240 VL 1241-1800 V 1801-2400V
2-MedicalCarve out
RIASTAP (fibrinogen) VIAL 2-MedicalCarve out
RIXUBIS (factor ix humanrecombinant) 250 500 10002000 3000
2-MedicalCarve out
SEVENFACT 1 MG VIAL 5 MG VIAL 2-MedicalCarve out
TRETTEN (factor xiii a-subunitrecombinant) 2500 UNIT VIAL(fctor -recombinnt)
2-MedicalCarve out
VONVENDI (von willebrand factor(recombinant)) 650 VIAL 1300VIAL
2-MedicalCarve out
WILATE (antihemophilic factorhumanvon willebrandfactorhuman) 450-450 VIALhuman) 500-500 VIAL human)900-900 VIAL human) 1000-1000VIAL human)
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
50
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
XYNTHA (antihemophilic factor(factor viii) recombb-domaindeleted) 250 KIT - 500 KIT - 1000KIT - 2000 KIT -
2-MedicalCarve out
XYNTHA SOLOFUSE (antihemophilicfactor (factor viii) recombb-domain deleted) 250 KIT - 500 KIT -1000 KIT - 2000 KIT - 3000 KIT -
2-MedicalCarve out
PLATELET MODIFYING AGENTScilostazol 50 mg tablet 100 mgtablet
1-Covered
clopidogrel bisulfate 75 mg tablet 1-Covered AL1 (At least 18 yrs old)
dipyridamole 25 mg tablet 50 mgtablet 75 mg tablet
1-Covered
CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation)
ALPHA-ADRENERGIC AGONISTSclonidine hcl 01 mg tablet 02 mgtablet 03 mg tablet
1-Covered
CLONIDINE HCL 01 MG TABLET 02MG TABLET 03 MG TABLET
1-Covered
guanfacine hcl 1 mg tablet 2 mgtablet
1-Covered
methyldopa 250 mg tablet 500mg tablet
1-Covered
ALPHA-ADRENERGIC BLOCKING AGENTSdoxazosin mesylate 1 mg tablet 2mg tablet 4 mg tablet 8 mgtablet
1-Covered
PHENOXYBENZAMINE HCL 10 MGCAP
1-Covered
phenoxybenzamine hcl 10 mgcapsule
1-Covered
prazosin hcl 1 mg capsule 2 mgcapsule 5 mg capsule
1-Covered
PRAZOSIN HCL 1 MG CAPSULE 2MG CAPSULE 5 MG CAPSULE
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
51
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terazosin hcl 1 mg capsule 2 mgcapsule 5 mg capsule 10 mgcapsule
1-Covered
TERAZOSIN HCL 1 MG CAPSULE 2MG CAPSULE 5 MG CAPSULE 10MG CAPSULE
1-Covered
ANGIOTENSIN II RECEPTOR ANTAGONISTSirbesartan 75 mg tablet 150 mgtablet 300 mg tablet
1-Covered ST
LOSARTAN POTASSIUM 25 MG TAB50 MG TAB 100 MG TAB
1-Covered STAR (Preferred Drug)
losartan potassium 25 mg tablet50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
valsartan 40 mg tablet 80 mgtablet 160 mg tablet 320 mgtablet
1-Covered ST
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORSbenazepril hcl 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered STAR (Preferred Drug)
captopril 125 mg tablet 25 mgtablet 50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
CAPTOPRIL 125 MG TABLET 25 MGTABLET 50 MG TABLET 100 MGTABLET
1-Covered STAR (Preferred Drug)
ENALAPRIL MALEATE 25 MG TAB 5MG TABLET 10 MG TAB 20 MG TAB
1-Covered STAR (Preferred Drug)
enalapril maleate 25 mg tablet 5mg tablet 10 mg tablet 20 mgtablet
1-Covered STAR (Preferred Drug)
fosinopril sodium 10 mg tablet 20mg tablet 40 mg tablet
1-Covered
lisinopril 25 mg tablet 5 mg tablet10 mg tablet 20 mg tablet 30 mgtablet 40 mg tablet
1-Covered STAR (Preferred Drug)
moexipril hcl 75 mg tablet 15 mgtablet
1-Covered
quinapril hcl 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered
ramipril 125 mg capsule 25 mgcapsule 5 mg capsule 10 mgcapsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
52
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
RAMIPRIL 125 MG CAPSULE 25MG CAPSULE 5 MG CAPSULE 10MG CAPSULE
1-Covered
trandolapril 1 mg tablet 2 mgtablet 4 mg tablet
1-Covered
ANTIARRHYTHMICS (Drugs for Irregular Heart Rhythm)amiodarone hcl (PACERONE) 200mg tablet
1-Covered
amiodarone hcl 200 mg tablet 1-Covered
disopyramide phosphate 100 mgcapsule
1-Covered
flecainide acetate 50 mg tablet100 mg tablet 150 mg tablet
1-Covered
mexiletine hcl 150 mg capsule 200mg capsule 250 mg capsule
1-Covered
MEXILETINE HCL 150 MG CAPSULE200 MG CAPSULE 250 MGCAPSULE
1-Covered
propafenone hcl 150 mg tablet225 mg tablet 300 mg tablet
1-Covered
quinidine gluconate 324 mg tableter
1-Covered
quinidine sulfate 200 mg tablet300 mg tablet
1-Covered
SOTALOL 80 MG TABLET 120 MGTABLET 160 MG TABLET 240 MGTABLET
1-Covered
SOTALOL AF 80 MG TABLET 120 MGTABLET
1-Covered
sotalol hcl (SORINE) 80 mg tablet120 mg tablet 160 mg tablet 240mg tablet
1-Covered
sotalol hcl 80 mg tablet 120 mgtablet 160 mg tablet 240 mgtablet
1-Covered
BETA-ADRENERGIC BLOCKING AGENTSatenolol 25 mg tablet 50 mgtablet 100 mg tablet
1-Covered STAR (Preferred Drug)
ATENOLOL 25 MG TABLET 50 MGTABLET 100 MG TABLET
1-Covered STAR (Preferred Drug)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
53
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
bisoprolol fumarate 5 mg tablet 10mg tablet
1-Covered
carvedilol 3125 mg tablet 625 mgtablet 125 mg tablet 25 mgtablet
1-Covered STAR (Preferred Drug)
labetalol hcl 100 mg tablet 200mg tablet 300 mg tablet
1-Covered
LABETALOL HCL 100 MG TABLET200 MG TABLET 300 MG TABLET
1-Covered
metoprolol succinate 200 mg taber 24h
1-Covered QL (60 PER 30 DAYS) MDD (2 PerDay) STAR (Preferred Drug)
metoprolol succinate 25 mg taber 50 mg tab er 100 mg tab er
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
METOPROLOL SUCCINATE ER 200MG TAB
1-Covered QL (60 PER 30 DAYS) MDD (2 PerDay) STAR (Preferred Drug)
METOPROLOL SUCCINATE ER 25MG TAB ER 50 MG TAB ER 100 MGTAB
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
metoprolol tartrate 25 mg tablet50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
nadolol 20 mg tablet 40 mgtablet 80 mg tablet
1-Covered STAR (Preferred Drug)
NADOLOL 20 MG TABLET 40 MGTABLET 80 MG TABLET
1-Covered STAR (Preferred Drug)
pindolol 5 mg tablet 10 mg tablet 1-Covered STAR (Preferred Drug)
propranolol hcl 10 mg tablet 20mg5 ml solution 20 mg tablet 40mg tablet 40mg5ml solution 60mg tablet 60 mg cap sa 24h 80mg tablet 80 mg cap sa 24h 120mg cap sa 24h 160 mg cap sa 24h
1-Covered
CALCIUM CHANNEL BLOCKING AGENTSAMLODIPINE BESYLATE 25 MG TAB5 MG TAB 10 MG TAB
1-Covered STAR (Preferred Drug)
amlodipine besylate 25 mg tablet5 mg tablet 10 mg tablet
1-Covered STAR (Preferred Drug)
DILTIAZEM 24HR ER (CD) 24HER(CD) 120 MG CP 24H ER(CD)240 MG CP 24H ER(CD) 180 MGCP 24H ER(CD) 360 MG CP 24HER(CD) 300 MG CP
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
54
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DILTIAZEM 24HR ER (XR) 24H ER(XR)240 MG CP 24H ER(XR) 180 MG CP
1-Covered
diltiazem hcl (CARTIA XT) 120 mgcap er 180 mg cap er 240 mgcap er 300 mg cap er
1-Covered
diltiazem hcl (DILT-XR) 120 mg caper - 180 mg cap er - 240 mg caper -
1-Covered
diltiazem hcl (TAZTIA XT) 120 mgcap 180 mg cap 240 mg cap 300mg cap 360 mg cap
1-Covered
diltiazem hcl 30 mg tablet 60 mgcap er 12h 60 mg tablet 90 mgtablet 90 mg cap er 12h 120 mgcap sa 24h 120 mg tablet 120 mgcap er 24h 120 mg cap er deg120 mg cap er 12h 180 mg cap sa24h 180 mg cap er deg 180 mgcap er 24h 240 mg cap er 24h 240mg cap er deg 240 mg cap sa24h 300 mg cap er 24h 300 mgcap sa 24h 360 mg cap sa 24h360 mg cap er 24h
1-Covered
felodipine 25 mg tab er 5 mg taber 10 mg tab er
1-Covered
FELODIPINE ER ER 25 MG TABLETER 5 MG TABLET ER 10 MG TABLET
1-Covered
nicardipine hcl 20 mg capsule 30mg capsule
1-Covered
nifedipine (AFEDITAB CR) 30 mgtablet er 60 mg tablet er
1-Covered
nifedipine (NIFEDICAL XL) 30 mgtab er 24 60 mg tab er 24
1-Covered
NIFEDIPINE 10 MG CAPSULE 1-Covered
nifedipine 10 mg capsule 20 mgcapsule 30 mg tablet er 30 mgtab er 24 60 mg tablet er 60 mgtab er 24 90 mg tablet er 90 mgtab er 24
1-Covered
nisoldipine 20 mg tab er 30 mgtab er 40 mg tab er
1-Covered
verapamil hcl 40 mg tablet 80 mgtablet 120 mg tablet 120 mgtablet er 180 mg tablet er 240 mgtablet er
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
55
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CARDIOVASCULAR AGENTS OTHERamiloride hclhydrochlorothiazideamiloridehydrochlorothiazide 5mg-50 mg tablet
1-Covered
amlodipine besylatebenazeprilhcl 25mg-10mg capsule 5 mg-20mg capsule 5 mg-10 mg capsule5 mg-40 mg capsule 10 mg-20mgcapsule 10 mg-40mg capsule
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day) STAR(Preferred Drug)
atenololchlorthalidone 50 mg-tablet 100mg-tablet
1-Covered STAR (Preferred Drug)
benazepril hclhydrochlorothiazidebenazeprilhydrochlorothiazide 5-625mg tabletbenazeprilhydrochlorothiazide 10-125mg tabletbenazeprilhydrochlorothiazide 20mg-25mg tabletbenazeprilhydrochlorothiazide 20-125 mg tablet
1-Covered STAR (Preferred Drug)
bisoprololfumaratehydrochlorothiazidebisoprololhydrochlorothiazide 25-tabletbisoprololhydrochlorothiazide 5-tabletbisoprololhydrochlorothiazide 10-tablet
1-Covered
BISOPROLOL-HYDROCHLOROTHIAZIDE -10-625MG TAB -25-625 MG TB -5-625MG TAB
1-Covered
captoprilhydrochlorothiazide 25mg-25mg tablet 25 mg-15mgtablet 50 mg-25mg tablet 50 mg-15mg tablet
1-Covered STAR (Preferred Drug)
digoxin (DIGITEK) 125 mcg tablet250 mcg tablet
1-Covered STAR (Preferred Drug)
digoxin (DIGOX) 125 mcg tablet250 mcg tablet
1-Covered STAR (Preferred Drug)
digoxin 125 mcg tablet 250 mcgtablet
1-Covered STAR (Preferred Drug)
digoxin 50 mcgml solution 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
56
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fosinoprilsodiumhydrochlorothiazidefosinoprilhydrochlorothiazide 10-125mg tabletfosinoprilhydrochlorothiazide 20-125 mg tablet
1-Covered
FOSINOPRIL-HYDROCHLOROTHIAZIDE -10-125MG TAB -20-125 MG TAB
1-Covered
irbesartanhydrochlorothiazide150-tablet 300-tablet
1-Covered ST
LANOXIN (digoxin) 125 MCGTABLET 250 MCG TABLET
1-Covered STAR (Preferred Drug)
lisinoprilhydrochlorothiazide 10-125mg tablet 20-125 mg tablet20 mg-25mg tablet
1-Covered STAR (Preferred Drug)
losartanpotassiumhydrochlorothiazidelosartanhydrochlorothiazide 50-125 mg tabletlosartanhydrochlorothiazide100mg-25mg tabletlosartanhydrochlorothiazide 100-125mg tablet
1-Covered STAR (Preferred Drug)
LOSARTAN-HYDROCHLOROTHIAZIDE -50-125MG TAB -100-125 MG TAB -100-25MG TAB
1-Covered STAR (Preferred Drug)
pentoxifylline 400 mg tablet er 1-Covered
spironolactonehydrochlorothiazide spironolacthydrochlorothiazid25 mg-25mg tablet
1-Covered
triamterenehydrochlorothiazide375-25 mg capsule 375-25 mgtablet 50 mg-25mg capsule 75mg-50mg tablet
1-Covered
valsartanhydrochlorothiazide 80-125mg tablet 160-125mg tablet160mg-25mg tablet 320-125mgtablet 320mg-25mg tablet
1-Covered ST
DIURETICS CARBONIC ANHYDRASE INHIBITORSacetazolamide 125 mg tablet 250mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
57
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ACETAZOLAMIDE 125 MG TABLET250 MG TABLET
1-Covered
DIURETICS LOOPbumetanide 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered
furosemide 10 mgml solution 20mg tablet 40mg5ml solution 40mg tablet 80 mg tablet
1-Covered STAR (Preferred Drug)
DIURETICS POTASSIUM-SPARINGamiloride hcl 5 mg tablet 1-Covered
spironolactone 25 mg tablet 50mg tablet 100 mg tablet
1-Covered
SPIRONOLACTONE 25 MG TABLET50 MG TABLET 100 MG TABLET
1-Covered
DIURETICS THIAZIDEchlorothiazide 250 mg tablet 500mg tablet
1-Covered
chlorthalidone 25 mg tablet 50 mgtablet
1-Covered
CHLORTHALIDONE 25 MG TABLET50 MG TABLET
1-Covered
DIURIL (chlorothiazide) 250 MG5ML ORAL SUSP
1-Covered
hydrochlorothiazide 125 mgcapsule 25 mg tablet 50 mgtablet
1-Covered STAR (Preferred Drug)
indapamide 125 mg tablet 25mg tablet
1-Covered
methyclothiazide 5 mg tablet 1-Covered
metolazone 25 mg tablet 5 mgtablet 10 mg tablet
1-Covered
DYSLIPIDEMICS FIBRIC ACID DERIVATIVES (Drugs for HighCholesterol)
fenofibrate 54 mg tablet 160 mgtablet
1-Covered ST
FENOFIBRATE 54 MG TABLET 160MG TABLET
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
58
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fenofibratemicronized 67 mgcapsule 134 mg capsule 200 mgcapsule
1-Covered ST
gemfibrozil 600 mg tablet 1-Covered
GEMFIBROZIL 600 MG TABLET 1-Covered
TRIGLIDE (fenofibratenanocrystallized) 160 MG TABLET
1-Covered ST
DYSLIPIDEMICS HMG COA REDUCTASE INHIBITORS (Drugs for HighCholesterol)
atorvastatin calcium 10 mg tablet20 mg tablet 40 mg tablet 80 mgtablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
ATORVASTATIN CALCIUM 10 MGTABLET 20 MG TABLET 40 MGTABLET 80 MG TABLET
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
lovastatin 10 mg tablet 20 mgtablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
rosuvastatin calcium 5 mg tablet10 mg tablet 20 mg tablet 40 mgtablet
1-Covered ST QL (30 PER 30 DAY(S))
simvastatin 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered STAR (Preferred Drug)
DYSLIPIDEMICS OTHER (Other Drugs for High Cholesterol)cholestyramine (with sugar) suar) 4powder
1-Covered
cholestyramineaspartame(PREVALITE) 4 g powder
1-Covered
cholestyramineaspartame 4 gpowder
1-Covered
COLESTID (colestipol hcl)FLAVORED GRANULES
1-Covered
colestipol hcl 1 tablet 5 ranules 5packet
1-Covered
ezetimibe 10 mg tablet 1-Covered
niacin (ENDUR-ACIN) 250 mgtablet er - 500 mg tablet er - 750mg tablet er -
1-Covered
niacin (SLO-NIACIN) 500 mg tableter -
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
59
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NIACIN 100 MG TABLET TR 500 MGTABLET
1-Covered
niacin 50 mg tablet 100 mg tablet250 mg capsule er 250 mg tablet250 mg tablet er 500 mg tablet500 mg tablet er 500 mg tab er24h 500 mg capsule er 750 mgtablet er 1000 mg tablet er
1-Covered
OMEGA-3 ACID ETHYL ESTERS -1GM CAP
1-Covered QL (4 PER 1 DAY(S))
omega-3 acid ethyl esters omea-1capsule
1-Covered QL (4 PER 1 DAY(S))
VASODILATORS DIRECT-ACTING ARTERIAL (Drugs for RelaxingArteries)
hydralazine hcl 10 mg tablet 25mg tablet 50 mg tablet 100 mgtablet
1-Covered
minoxidil 25 mg tablet 10 mgtablet
1-Covered
VASODILATORS DIRECT-ACTING ARTERIALVENOUS (Drugs forRelaxing Arteries and Veins)
ISOSORBIDE DINITRATE 5 MG TAB10 MG TAB 20 MG TAB 30 MG TAB
1-Covered STAR (Preferred Drug)
isosorbide dinitrate 5 mg tablet 10mg tablet 20 mg tablet 30 mgtablet 40 mg tablet er
1-Covered STAR (Preferred Drug)
isosorbide mononitrate 10 mgtablet 20 mg tablet 30 mg tab er24h 60 mg tab er 24h 120 mg taber 24h
1-Covered STAR (Preferred Drug)
NITRO-BID (nitroglycerin) -2OINTMENT
1-Covered
nitroglycerin (MINITRAN) 01mghrpatch 02mghr patch 04mghrpatch 06mghr patch
1-Covered
nitroglycerin (NITRO-TIME) 25 mgcapsule er - 65 mg capsule er - 9mg capsule er -
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
60
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
nitroglycerin 01mghr patch td2402mghr patch td24 03 mg tabsubl 04mghr patch td24 04 mgtab subl 06 mg tab subl 06mghrpatch td24 25 mg capsule er 65mg capsule er 9 mg capsule er400mcgspr spray
1-Covered
NITROGLYCERIN 400 MCG SPRAY 1-Covered
CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions)
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTSAMPHETAMINES
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 15 mg cap er 24h
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old) MDD (1 Per Day)
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 5 mg cap erdextroamphetamineamphetamine 10 mg cap erdextroamphetamineamphetamine 20 mg cap erdextroamphetamineamphetamine 25 mg cap erdextroamphetamineamphetamine 30 mg cap er
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old)
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 5 mg tabletdextroamphetamineamphetamine 75 mg tabletdextroamphetamineamphetamine 10 mg tabletdextroamphetamineamphetamine 125 mg tabletdextroamphetamineamphetamine 15 mg tabletdextroamphetamineamphetamine 20 mg tabletdextroamphetamineamphetamine 30 mg tablet
1-Covered AL1 (3 to 18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
61
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
dextroamphetamine sulfate(ZENZEDI) 5 mg tablet 10 mgtablet
1-Covered AL1 (3 to 18 yrs old)
dextroamphetamine sulfate 5 mgcapsule er 5 mg tablet 10 mgcapsule er 10 mg tablet 15 mgcapsule er
1-Covered AL1 (3 to 18 yrs old)
DEXTROAMPHETAMINE SULFATE 5MG TAB 10 MG TAB
1-Covered AL1 (3 to 18 yrs old)
DEXTROAMPHETAMINE-AMPHET ER-15 MG CAP
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old) MDD (1 Per Day)
DEXTROAMPHETAMINE-AMPHET ER-ER 5 MG CAP -ER 10 MG CAP -ER20 MG CAP -ER 25 MG CAP -ER 30MG CAP
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old)
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS NON-AMPHETAMINES
atomoxetine hcl 10 mg capsule 18mg capsule 25 mg capsule 40 mgcapsule 60 mg capsule 80 mgcapsule 100 mg capsule
1-Covered PA
guanfacine hcl 1 mg tab er 2 mgtab er 3 mg tab er 4 mg tab er
1-Covered QL (1 PER 1 DAY(S))
METHYLPHENIDATE ER ER 18 MGTAB ER 27 MG TAB ER 36 MG TABER 54 MG TAB
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl (METADATEER) 20 mg tablet er
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl 10 mg tableter 18 mg tab er 24 20 mg tableter 27 mg tab er 24 36 mg tab er24 54 mg tab er 24
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl 5 mg tablet10 mg cpbp 30-70 10 mg tablet20 mg tablet 20 mg cpbp 30-7030 mg cpbp 30-70 40 mg cpbp 30-70 50 mg cpbp 30-70 60 mg cpbp30-70
1-Covered AL1 (6 to 18 yrs old)
METHYLPHENIDATE HCL 5 MGTABLET 10 MG TABLET 20 MGTABLET
1-Covered AL1 (6 to 18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
62
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CENTRAL NERVOUS SYSTEM OTHERacetaminophen (ATHENOL) 325mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (CHILD FEVERREDUCER) 120 mg supprect
1-Covered
acetaminophen (CHILD PAIN REL-FEVER REDUCER) 120 mg supprect-
1-Covered
acetaminophen (CHILDRENSFEVER REDUCER) 120 mg supprect
1-Covered
acetaminophen (CHILDRENSFEVER REDUCING) 120 mgsupprect
1-Covered
acetaminophen (CHILDRENS PAINAND FEVER) 160 mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (CHILDRENSSILAPAP) 160 mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (ED-APAP) 160mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (LITTLE REMEDIESFEVER-PAIN) 160 mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (M-PAP) 160mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (MAPAP) 160mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (MAPAP) 325 mgtablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (MASOPHEN) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRINEXTRA STRENGTH) 500 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRINPAIN RELIEF) 500 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRIN)160 mg5ml elixir -
1-Covered QLC (LIMIT TO 2 FILLS OF 120ML IN30 DAYS)
acetaminophen (NON-ASPIRIN)325 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN amp FEVER)500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
63
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acetaminophen (PAIN RELIEFEXTRA STRENGTH) 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN RELIEF) 160mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (PAIN RELIEF) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN RELIEVER)325 mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PHARBETOL) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (SHAKE THATACHE) 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (TACTINAL) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen 120 mg 650 mg 1-Covered
acetaminophen 160 mg5ml elixir 1-Covered QLC (LIMIT TO 2 FILLS OF 120ML IN30 DAYS)
acetaminophen 160 mg5ml liquid 1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 160 mg5ml oralsusp
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 160 mg5mlsolution
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 325 mg tablet500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
ACETAMINOPHEN CVS 325 MGGELCP 325 MG TABLET 500 MGTABLET 500 MG GELCAP
1-Covered QL (60 PER 30 DAY(S))
butalbitalacetaminophen(TENCON) 50mg-325mg tablet
1-Covered QL (48 PER 30 DAY(S))
butalbitalacetaminophen 50mg-325mg tablet
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
butalbitalacetaminophencaffeine butalbacetaminophencaffeine50-325-40 tablet
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
PAIN amp FEVER (acetaminophen)500 MG TABLET
1-Covered QL (60 PER 30 DAY(S))
PAIN RELIEF 325 MG TABLET 500MG GELCAP 500 MG TABLET
1-Covered QL (60 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
64
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
riluzole 50 mg tablet 1-Covered PA
RILUZOLE 50 MG TABLET 1-Covered PA
FIBROMYALGIA AGENTSduloxetine hcl 20 mg capsule dr30 mg capsule dr 60 mg capsuledr
1-Covered
pregabalin 20 mgml solution 1-Covered PA QLC (30 MLDAY)
pregabalin 225 mg capsule 300mg capsule
1-Covered PA QL (2 PER 1 DAY(S))
PREGABALIN 225 MG CAPSULE 300MG CAPSULE
1-Covered PA QL (2 PER 1 DAY(S))
pregabalin 25 mg capsule 50 mgcapsule 75 mg capsule 100 mgcapsule 150 mg capsule 200 mgcapsule
1-Covered PA QL (3 PER 1 DAY(S))
PREGABALIN 25 MG CAPSULE 50MG CAPSULE 75 MG CAPSULE 100MG CAPSULE 150 MG CAPSULE200 MG CAPSULE
1-Covered PA QL (3 PER 1 DAY(S))
SAVELLA (milnacipran hcl) 125 MGTABLET 25 MG TABLET 50 MGTABLET 100 MG TABLET TITRATIONPACK
1-Covered PA
MULTIPLE SCLEROSIS AGENTSAVONEX (interferon beta-1a)PREFILLED SYR 30 MCG KT -
1-Covered PA SP
AVONEX (interferon beta-1aalbumin human) 30 MCG VIALKIT -
1-Covered PA SP
AVONEX PEN (interferon beta-1a)30 MCG05 ML KIT -
1-Covered PA SP
DIMETHYL FUMARATE 30D START PK 1-Covered PA SP
DIMETHYL FUMARATE DR 120 MGCP DR 240 MG CP
1-Covered PA SP QL (2 PER 1 DAY(S))
glatiramer acetate (GLATOPA) 20mgml syringe
1-Covered PA SP QLC (1 SYRINGEDAY)
glatiramer acetate (GLATOPA) 40mgml syringe
1-Covered PA SP QLC (12SYRINGESMONTH)
glatiramer acetate 20 mgmlsyringe
1-Covered PA SP QLC (1 SYRINGEDAY)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
65
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
glatiramer acetate 40 mgmlsyringe
1-Covered PA SP QLC (12SYRINGESMONTH)
PLEGRIDY (peginterferon beta-1a)125 MCG05 ML SYRING - SYRINGESTARTER PACK -
1-Covered PA SP
PLEGRIDY PEN (peginterferon beta-1a) 125 MCG05 ML PEN - PEN INJSTARTER PACK -
1-Covered PA SP
TECFIDERA (dimethyl fumarate) DR120 MG CAPSULE DR 240 MGCAPSULE STARTER PACK
1-Covered PA SP
DENTAL AND ORAL AGENTS (Drugs for the Mouth)
DENTAL AND ORAL AGENTSchlorhexidine gluconate (PAROEX)012 mouthwash
1-Covered
chlorhexidine gluconate 012 mouthwash
1-Covered
PHOS-FLUR (fluoride (sodium)) -ORAL RINSE
1-Covered
triamcinolone acetonide(ORALONE) 01 paste (g)
1-Covered
triamcinolone acetonide 01 paste (g)
1-Covered
TRIAMCINOLONE ACETONIDE 01PASTE
1-Covered
DERMATOLOGICAL AGENTS (Drugs for the Skin)ACNE MEDICATION (benzoylperoxide) 5 GEL
1-Covered
ACNE MEDICATION 25 GEL 1-Covered
ammonium lactate (SKINTREATMENT) 12 lotion
1-Covered
ammonium lactate 12 cream(g) 12 lotion
1-Covered
benzoyl peroxide (ACNE CONTROLCLEANSER) 10 cleanser
1-Covered
benzoyl peroxide (ACNE FOAMINGWASH) 10 cleanser
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
66
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
benzoyl peroxide (ACNETREATMENT) 10 gel (gram)
1-Covered
benzoyl peroxide (ACNECLEAR) 10 gel (gram)
1-Covered
benzoyl peroxide (ADVANCEDEXFOLIATING CLEANSER) 5 cleanser
1-Covered
benzoyl peroxide (BP WASH) 5 10
1-Covered
benzoyl peroxide (BP) 5 gel(gram) 10 gel (gram)
1-Covered
benzoyl peroxide (BPO-10) cleanser -
1-Covered
benzoyl peroxide (BPO-5) cleanser -)
1-Covered
benzoyl peroxide (CLEAN-CLEARCONTINUOUS CONTROL) 10 cleanser -
1-Covered
benzoyl peroxide (DAYLOGICACNE FOAMING WASH) 10 cleanser
1-Covered
benzoyl peroxide (DAYLOGICACNE TREATMENT) 10 gel (gram)
1-Covered
benzoyl peroxide (FOAMING ACNEFACE WASH) 10 cleanser
1-Covered
benzoyl peroxide (PANOXYL) 10 cleanser
1-Covered
benzoyl peroxide 25 gel (gram)5 cleanser 5 gel (gram) 10 gel (gram) 10 cleanser
1-Covered
CALADRYL (pramoxinehclcalamine) 1-8 LOTION
1-Covered
calcipotriene 0005 cream (g)0005 oint (g) 0005 solution
1-Covered PA
chlorhexidine gluconate 4 liquid 1-Covered
CORTISPORIN(neomycinbacitracinpolymyxinbhydrocortisone) OINTMENT
1-Covered
DIFFERIN (adapalene) 01 GEL 1-Covered AL1 (Up to 25 yrs old)
DRITHOCREME HP (anthralin) 1CREAM
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
67
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DRYSOL (aluminum chloride) DAB--MATIC SLUTIN
1-Covered
EPIFOAM (hydrocortisoneacetatepramoxine hcl)
1-Covered
hydrocortisoneacetatepramoxine hclhydrocortisonepramoxine 1 -1 creamapplhydrocortisonepramoxine 25 -1 cream (g)hydrocortisonepramoxine 25 -1 creamapplhydrocortisonepramoxine 25-1(4g) creamappl
1-Covered
isotretinoin (AMNESTEEM) 10 mgcapsule 20 mg capsule 40 mgcapsule
1-Covered PA
isotretinoin (CLARAVIS) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin (MYORISAN) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin (ZENATANE) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin 10 mg capsule 20 mgcapsule 30 mg capsule 40 mgcapsule
1-Covered PA
LICE KILLING SHAMPOO 1-Covered
metronidazole 075 cream (g)075 gel (gram) 1 gel (gram)
1-Covered
pimecrolimus 1 cream (g) 1-Covered PA
piperonyl butoxidepyrethrins (LICEKILLING) 4-033 shampoo
1-Covered
piperonyl butoxidepyrethrins (LICEPYRINYL SHAMPOO) 4-033shampoo
1-Covered
piperonyl butoxidepyrethrins (LICETREATMENT) 4-033 shampoo
1-Covered
piperonyl butoxidepyrethrins (RID)4-033 shampoo
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
68
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
piperonylbutoxidepyrethrinspermethrin(COMPLETE LICE TREATMENT)butoxpyrethrpermet 4-33-5 kit
1-Covered
piperonylbutoxidepyrethrinspermethrin(LICE SOLUTION)butoxpyrethrpermet 4-33-5 kit
1-Covered
podofilox 05 solution 1-Covered
pramoxine hclcalamine(CALAHIST) 1 -8 lotion
1-Covered
pramoxine hclcalamine(CALAMINE MEDICATED) 1 -8 lotion
1-Covered
PROCTOFOAM-HC (hydrocortisoneacetatepramoxine hcl) PROCTO-1-1
1-Covered
RID (piperonylbutoxidepyrethrinspermethrin) 1-2-3 KIT KIT
1-Covered
SANTYL (collagenase clostridiumhistolyticum) OINTMENT
1-Covered QL (60 PER 30 DAYS)
selenium sulfide (ANTI-DANDRUFF)1 shampoo -
1-Covered
selenium sulfide (MEDICATEDDANDRUFF SHAMPOO) 1 shampoo
1-Covered
selenium sulfide (SELSUN BLUE) 1 shampoo
1-Covered
selenium sulfide 25 lotion 1-Covered
selenium sulfidealoe vera (SELSUNBLUE MOISTURIZING) 1 shampoo
1-Covered
tacrolimus 003 (g) 01 (g) 1-Covered PA
ELECTROLYTESMINERALSMETALSVITAMINS
ELECTROLYTEMINERAL REPLACEMENT09 sodium chloride iv soln 1-Covered PA
calcium carbonate 600 mg tablet 1-Covered
dextrose 5 in water in iv soln 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
69
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levocarnitine 330 mg tablet 1-Covered
potassium chloride in 09 sodiumchloride 09nacl 10 meql iv soln
1-Covered PA
ringers solution iv soln 1-Covered
sodium chloride irrigating solution09 soln
1-Covered
ELECTROLYTEMINERALMETAL MODIFIERSCHEMET (succimer) 100 MGCAPSULE
1-Covered PA
09 sodium chloride iv soln 1-Covered PA
CLINIMIX (amino acids 425 indextrose 5 in water) -SOLUTION
1-Covered PA
dextrose 10 and 045 sodiumchloride nacl -iv soln
1-Covered PA
dextrose 10 in water 10 10 dehp fr bg 10 10 iv soln
1-Covered PA
dextrose 5 and 045 sodiumchloride -04chlord -04iv soln
1-Covered PA
dextrose 5 in water 5 5 ivsoln 5 5 vial
1-Covered PA
levocarnitine (with sugar) 100mgml solution
1-Covered
levocarnitine 100 mgml solution330 mg tablet
1-Covered
MYNATAL (prenatal vitamins withcalciumferrous fumaratefolicacid) CAPSULE
1-Covered
O-CAL PRENATAL (prenatal vit withcalcium no127ferrousfumaratefolic acid) -TABLET
1-Covered
potassium chloride (KLOR-CONM10) meq tab er prt -
1-Covered
potassium chloride (KLOR-CONM20) meq tab er prt -
1-Covered
potassium chloride 8 meq tableter 10 meq tablet er 10 meqcapsule er 10 meq tab er prt 20meq tablet er 20 meq tab er prt20meq15ml liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
70
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
POTASSIUM CHLORIDE ER 8 MEQTABLET 10 (20 MEQ15ML) 10(40 MEQ30ML) ER 10 MEQ TABLETER 20 MEQ TABLET
1-Covered
potassium chloride in 09 sodiumchloride 20 meql soln 40 meqlsoln
1-Covered PA
PRENATABS FA (prenatal vits withcalcium no78ferrousfumaratefolic acid) TABLET
1-Covered
PRENATABS RX (prenatal vitaminwith calciumno76ironcarbonylfolic acid)TABLET
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid (MYNATAL PLUS) vitironfumfolic 65 mg-1 mg tablet
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid (MYNATAL-Z) vitiron fumfolic65 mg-1 mg tablet -
1-Covered
prenatal vits with calcium118ferrous fumaratefolic acid (SE-NATAL 19) pnv no8ironfumaratefa 29 mg-mg tab chew -9)
1-Covered
prenatal vits with calcium136ferrous fumaratefolic acid(VINATE-M) vit36ironfolic acd 27mg-mg tablet -
1-Covered
prenatal vits with calciumno115iron fumaratefolic acidno5ironfolic 29 mg-mg tab chew
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acid(M-NATAL PLUS) pnvcalcium72ironfolic 27 mg-1 mg tablet -
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acid(PREPLUS) pnvcalcium 72ironfolic27 mg-1 mg tablet
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acidpnvcalcium 72ironfolic 27 mg-1mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
71
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
prenatal vits with calciumno72ironcarbonylfolic acidpnvcalcium 72ironcarbfolic 29mg-1 mg tablet
1-Covered
prenatal vits with calciumno74ferrous fumaratefolic acidvitcal 74ironfolic 27 mg-1 mgtablet
1-Covered
SE-NATAL-19 (prenatal vitaminsno119iron fumaratefolic acid) --TABLET
1-Covered
sodium chloride irrigating solution09 soln
1-Covered
sodium polystyrene sulfonate 15g60 ml oral susp
1-Covered
sodium polystyrenesulfonatesorbitol solution (KIONEX)sulfonsorb 15 g60 ml oral susp
1-Covered
SPS (sodium polystyrenesulfonatesorbitol solution) 15GM60 ML SUSPENSION
1-Covered
TRINATE (prenatal vits with calciumno73ferrous fumaratefolic acid)TABLET
1-Covered
VITAMINS09 sodium chloride iv soln 1-Covered PA
ascorbate calcium 500 mg tablet 1-Covered
ascorbic acid (SOOTHINGPUREWAY-C) 500 mg tablet -
1-Covered
ascorbic acid 250 mg tablet 500mg5ml syrup 500 mg tablet 1000mg tablet
1-Covered
CALCIUM 500-VIT D3 MG-MCG TB 1-Covered
CALCIUM 600 MG TABLET 1-Covered
CALCIUM 600-VIT D3 MG-10MCGTB
1-Covered
calcium carbonate (OYSCO-500)500(1250) tablet -
1-Covered
calcium carbonate (SUPERCALCIUM) 600 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
72
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcium carbonate 500(1250)tablet 600 mg tablet
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (HI-CAL)carbonatevitamin 500 mg-200tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OS-CAL 500-VIT D3)carbonatevitamin mg-200 tablet --
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OYSCO 500-VIT D3)carbonatevitamin mg-200 tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OYSTERCAL-D)carbonatevitamin 500 mg-400tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) carbonatevitamin250 mg-125 tabletcarbonatevitamin 500 mg-600tablet carbonatevitamin 500 mg-400 tablet carbonatevitamin 500mg-200 tablet carbonatevitamin600 mg-400 tablet
1-Covered
calcium gluconate 60(650) mgtablet
1-Covered
calcium lactate 84 mg(648) tablet 1-Covered
cyanocobalamin (vitamin b-12) (B-12 DOTS) cyanocoalamin -) 500mcg talet -
1-Covered
cyanocobalamin (vitamin b-12)cyanocoalamin -500 mcg talet
1-Covered
dextrose 10 in water iv soln 1-Covered PA
dextrose 5 and 045 sodiumchloride -04chlord -04iv soln
1-Covered PA
dextrose 5 in lactated ringers -ivsoln
1-Covered PA
dextrose 5 in water in iv soln 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
73
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DEXTROSE IN WATER 5-IV SOLN10-IV SOLUTION
1-Covered PA
electrolytesdextrose(ELECTROLYTE) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (ORALYTE)solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (PEDIATRICELECTROLYTE) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (PEDIATRICFREEZER POPS) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
ferrous sulfate (CHILDRENS IRON)15 mgml drops
1-Covered
ferrous sulfate (FEOSOL) 325(65)mg tablet
1-Covered
ferrous sulfate (FEROSUL) 325(65)mg tablet
1-Covered
ferrous sulfate (FERRO-TIME) 325(65)mg tablet -
1-Covered
ferrous sulfate (FERROUSUL) 325(65)mg tablet
1-Covered
ferrous sulfate (PEDIA IRON) 15mgml drops
1-Covered
ferrous sulfate 15 mgml drops 220(44)5 solution 220 (44)5 elixir324(65)mg tablet dr 325(65) mgtablet dr 325(65) mg tablet
1-Covered
FERROUS SULFATE SULF 220 MG5ML LIQ SULF EC 325 MG TABLETSULFATE 325 MG TABLET
1-Covered
fluoride (sodium) 025(055) tabchew 05(11)mg tab chew 05mgml drops 1mg(22mg) tabchew
1-Covered STAR (Preferred Drug)
folic acid 04 mg tablet 08 mgtablet 1 mg tablet 20 mg capsule
1-Covered
FOLIC ACID 400 MCG TABLET 800MCG TABLET
1-Covered
IRON 65 MG TABLET 1-Covered
OYSTER SHELL CALCIUM 500 MG TB 1-Covered
OYSTER SHELL CALCIUM-VIT D3 250MG-312MCG
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
74
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PEDIATRIC IRON PHARM CHC15MGML DRP
1-Covered
pediatric multivit with acd3no21sodium fluorideno21fluoride 025 mgml dropsno21fluoride 05 mgml drops
1-Covered STAR (Preferred Drug)
pediatric multivitaminno16sodium fluoride -025 mg tabche -05 mg tab che -1 mg tabche
1-Covered
pediatric multivitamin no2sodiumfluoride w-025 mgml drops
1-Covered
pediatric multivitamin no2sodiumfluoride w-05 mgml drops
1-Covered STAR (Preferred Drug)
pediatric multivitaminno45sodium fluorideferroussulfate 45fluorideiron 025-10mldrops
1-Covered STAR (Preferred Drug)
pediatric multivitamins no17 withsodium fluoride -025 mg tab che -05 mg tab che -1 mg tab che
1-Covered STAR (Preferred Drug)
POLY-VITAMIN (multivitamin) -TABCHEW
1-Covered STAR (Preferred Drug)
POTASSIUM 99 MG TABLET 1-Covered
potassium bicarbonatecitric acid(EFFER-K) 25 meq tablet eff -
1-Covered
potassium bicarbonatecitric acid(K EFFERVESCENT) 25 meq tableteff
1-Covered
potassium bicarbonatecitric acid(KLOR-CON-EF) 25 meq tablet eff --
1-Covered
potassium bicarbonatecitric acid25 meq tablet eff
1-Covered
POTASSIUM CHL-NORMAL SALINE20 -ML IV SOLN 40 -ML IV SOLN
1-Covered
potassium chloride (KLOR-CONSPRINKLE) 10 meq capsule er -
1-Covered
potassium chloride 20meq15mlliquid
1-Covered
potassium chloridepotassiumbicarbonatecitric acidchloridebicarbcit 25 meq tableteff
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
75
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
potassium gluconate 595(99)mgtablet
1-Covered
PRENATAL MULTIVITAMIN TABLET 1-Covered
prenatal vit with calciumno129ferrous fumaratefolic acidno129ironfolic 27mg-08mgtablet
1-Covered
prenatal vit with calciumno130ferrous fumaratefolic acidno130ironfolic 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vitamins no121ferrousfumaratefolic acid pnvno121ironfolic 28mg-08mgtablet
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid vitiron fumfolic 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vitamins withcalciumferrous fumaratefolicacid vitiron fumfolic 28mg-08mgtablet
1-Covered
prenatal vits with calcium118ferrous fumaratefolic acidpnv no8iron fumaratefa 29 mg-mg tab chew
1-Covered
prenatal vits with calcium137ferrous fumaratefolic acidno137ironfolic acd 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vits with calcium95ferrous fumaratefolic acid pnvno95ferrous fumfolic 28mg-08mg tablet
1-Covered
prenatal vits with calciumno96ferrous fumaratefolic acidvits96iron fumfolic 27mg-08mgtablet
1-Covered
pyridoxine hcl (vitamin b6) 25 mgtablet 50 mg tablet 100 mgtablet 250 mg tablet
1-Covered
ringers solution iv soln 1-Covered PA
SODIUM CHLORIDE 09 IRRIG 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
76
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SODIUM CHLORIDE 09 SOLUTION 1-Covered PA
sodium chloride irrigating solution(AQUA CARE SODIUM CHLORIDE)09 soln
1-Covered
sodium chloride irrigating solution(CURITY) 09 soln
1-Covered
sodium chloride irrigating solution09 soln
1-Covered
TRI-VI-SOL (vitamin apalmitateascorbicacidcholecalciferol (vit d3)) --DROPS (vitmin plmittescorbiccidcholeclciferol
1-Covered STAR (Preferred Drug)
VITAMIN B-12 -500 MCG TALET 1-Covered
VITAMIN C 1000 MG TABLET 1-Covered
GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach)
ANTISPASMODICS GASTROINTESTINAL (Drugs to Prevent Bowel andStomach Spasam)
CHLORDIAZEPOXIDE-CLIDINIUM -CAP
1-Covered MDD (8 Per Day)
chlordiazepoxideclidiniumbromide 5 mg-25mg capsule
1-Covered MDD (8 Per Day)
DICYCLOMINE HCL 10 MG5 MLSOLN
1-Covered
dicyclomine hcl 10 mg5 mlsolution 10 mg capsule 20 mgtablet
1-Covered
hyoscyamine sulfate (HYOSYNE)0125mgml drops 125mcg5mlelixir
1-Covered
hyoscyamine sulfate 0125 mg tabsubl 0125 mg tablet 0125mgmldrops 0375 mg tab er 12h125mcg5ml elixir
1-Covered
propantheline bromide 15 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
77
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GASTROINTESTINAL AGENTS OTHER (Other Drugs for the Bowel andStomach)
ALLI (orlistat) 60 MG CAPSULE 1-Covered PA
ANTACID 500 MG CHEW TABLET 1-Covered
ANTACID EXTRA STRENGTH -750 MGTAB CHEW CVS -750 MG CHEW
1-Covered
ANTI-DIARRHEAL HM -2 MGSOFTGEL
1-Covered
bismuth subsalicylate (BISMATROL)262 mg tab chew
1-Covered
bismuth subsalicylate (DIOTAME)262 mg tab chew
1-Covered
bismuth subsalicylate (PEP-T-MED)262 mg tab chew --
1-Covered
bismuth subsalicylate (PEPTICRELIEF) 262 mg tab chew
1-Covered
bismuth subsalicylate (PINKBISMUTH) 262 mg tab chew
1-Covered
bismuth subsalicylate (SOOTHE)262 mg tab chew
1-Covered
bismuth subsalicylate (STOMACHRELIEF) 262 mg tab chew
1-Covered
bismuth subsalicylate 262 mg tabchew
1-Covered
calcium carbonate (ANTACIDCALCIUM) 215(500)mg tab chew
1-Covered
calcium carbonate (ANTACIDEXTRA STRENGTH) 300mg(750) tabchew
1-Covered
calcium carbonate (ANTACID)200(500)mg tab chew 215(500)mgtab chew 300mg(750) tab chew
1-Covered
calcium carbonate (BAN-ACID)300mg(750) tab chew -
1-Covered
calcium carbonate (CAL-GEST)200(500)mg tab chew -
1-Covered
calcium carbonate (CALCIUMANTACID) 200(500)mg tab chew215(500)mg tab chew 300mg(750)tab chew
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
78
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcium carbonate (CHILDRENSPEPTO) 400 mg tab chew
1-Covered
calcium carbonate (CHILDRENSSOOTHE) 400 mg tab chew
1-Covered
calcium carbonate (FLAVORCHEWS ANTACID) 300mg(750) tabchew
1-Covered
calcium carbonate (SMOOTHANTACID) 300mg(750) tab chew
1-Covered
calcium carbonate (SMOOTHDISSOLVING ANTACID) 300mg(750)tab chew
1-Covered
calcium carbonate 200(500)mgtab chew 300mg(750) tab chew
1-Covered
diphenoxylate hclatropine sulfate25-0255 liquid 25-025mg tablet
1-Covered
DIPHENOXYLATE-ATROPINE -25-0025
1-Covered
GAS RELIEF (simethicone) (SIMETH)80 MG CHEW
1-Covered
GAS RELIEF GAS 125 MG CHEWTABLET GAS (SIMETH) 80 MGCHEW HM GAS 125 MG SOFTGELHM GAS 125 MG CHEW TAB
1-Covered
GAS-X (simethicone) -E-STR 125 MGTAB CHEW
1-Covered
INFANTS GAS RELIEF RLF 20 MG03ML
1-Covered
loperamide hcl (ANTI-DIARRHEAL) 2mg capsule - 2 mg tablet -
1-Covered
loperamide hcl (DIAMODE) 2 mgtablet
1-Covered
loperamide hcl (ULTRA A-D) 2 mgtablet -
1-Covered
loperamide hcl 1 mg5 ml liquid 2mg capsule 2 mg tablet
1-Covered
PEPTO-BISMOL (bismuthsubsalicylate) -TABLET CHEW
1-Covered
PEPTO-BISMOL TO-GO (bismuthsubsalicylate) --262 MG CHEW
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
79
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
simethicone (GAS RELIEF)40mg06ml drops susp 80 mg tabchew 125 mg tab chew 125 mgcapsule
1-Covered
simethicone (GAS-X) 125 mgcapsule -
1-Covered
simethicone (INFANT GAS RELIEF)40mg06ml drops susp
1-Covered
simethicone (INFANTS GAS RELIEF)40mg06ml drops susp
1-Covered
simethicone (MI-ACID) 80 mg tabchew -
1-Covered
simethicone 40mg06ml dropssusp 80 mg tab chew 125 mgcapsule 125 mg tab chew
1-Covered
STOMACH RELIEF 262 MG CHEWTAB
1-Covered
ursodiol 300 mg capsule 1-Covered
HISTAMINE2 (H2) RECEPTOR ANTAGONISTSACID CONTROLLER 20 MG TABLET 1-Covered
ACID REDUCER 10 MG TABLET 1-Covered PA
ACID REDUCER 20 MG TABLET 1-Covered
cimetidine (ACID REDUCER) 200mg tablet
1-Covered
cimetidine (HEARTBURN RELIEF) 200mg tablet
1-Covered
cimetidine 200 mg tablet 300 mgtablet 400 mg tablet 800 mgtablet
1-Covered
CIMETIDINE 300 MG5 ML SOLN 1-Covered
cimetidine hcl 300 mg5ml solution 1-Covered
famotidine (ACID CONTROLLER) 10mg tablet
1-Covered PA
famotidine (ACID CONTROLLER) 20mg tablet
1-Covered
famotidine (ACID REDUCER) 10 mgtablet
1-Covered PA
famotidine (ACID REDUCER) 20 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
80
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
famotidine (HEARTBURNPREVENTION) 10 mg tablet
1-Covered PA
famotidine (HEARTBURNPREVENTION) 20 mg tablet
1-Covered
famotidine (HEARTBURN RELIEF) 10mg tablet
1-Covered PA
famotidine (HEARTBURN RELIEF) 20mg tablet
1-Covered
famotidine (PEPCID) 20 mg tablet 1-Covered
famotidine 10 mg tablet 1-Covered PA
FAMOTIDINE 10 MG TABLET 1-Covered PA
famotidine 20 mg tablet 40 mgtablet
1-Covered
FAMOTIDINE 20 MG TABLET EQ 20MG TABLET 40 MG TABLET
1-Covered
IRRITABLE BOWEL SYNDROME AGENTSAMITIZA (lubiprostone) 8 MCGCAPSULE 24 MCG CAPSULES
1-Covered PA
LAXATIVES (Drugs for Bowel Cleansing and Constipation)bisacodyl (ALOPHEN PILLS) 5 mgtablet dr
1-Covered
bisacodyl (BISA-LAX) 5 mg tablet dr-
1-Covered
bisacodyl (BISACODYL) 5 mgtablet dr
1-Covered
bisacodyl (BISCOLAX) 10 mgsupprect
1-Covered
bisacodyl (C-LAX LAXATIVE) 5 mgtablet dr -ATIVE)
1-Covered
bisacodyl (DUCODYL) 5 mg tabletdr
1-Covered
bisacodyl (FAST RELIEF LAXATIVE)10 mg supprect
1-Covered
bisacodyl (GENTLE LAXATIVE) 5 mgtablet dr 10 mg supprect
1-Covered
bisacodyl (LAXATIVE SUPPOSITORY)10 mg supprect
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
81
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
bisacodyl (LAXATIVE) 5 mg tabletdr
1-Covered
bisacodyl (MAGIC BULLET) 10 mgsupprect
1-Covered
bisacodyl (WOMENS GENTLELAXATIVE) 5 mg tablet dr
1-Covered
bisacodyl (WOMENS LAXATIVE) 5mg tablet dr
1-Covered
bisacodyl 5 mg tablet dr 10 mgsupprect
1-Covered
BISACODYL EC 5 MG TABLET 10MG SUPPOSITORY
1-Covered
docusate sodium (COL-RITE) 100mg capsule - 250 mg capsule -
1-Covered
docusate sodium (DIOCTYL) 60mg15ml syrup
1-Covered
docusate sodium (DOCU LIQUID)50 mg5 ml liquid
1-Covered
docusate sodium (DOCUSIL) 100mg capsule
1-Covered
docusate sodium (DSS) 250 mgcapsule
1-Covered
docusate sodium (DULCOEASE)100 mg capsule
1-Covered
docusate sodium (DULCOLAXSTOOL SOFTENER) 100 mg capsule
1-Covered
docusate sodium (LAXA BASIC 100)mg capsule )
1-Covered
docusate sodium (PHILLIPSLAXATIVE) 100 mg capsule
1-Covered
docusate sodium (SOF-LAX) 100mg capsule -
1-Covered
docusate sodium (STOOLSOFTENER) 50 mg capsule 50 mg5ml liquid 60 mg15ml syrup 100mg capsule 250 mg capsule
1-Covered
DOCUSATE SODIUM 50 MG5 MLLIQ 100 MG SOFTGEL
1-Covered
docusate sodium 50 mg5 mlliquid 60 mg15ml syrup 100 mgcapsule 250 mg capsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
82
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DOK (docusate sodium) 100 MG250 MG
1-Covered
GENTLE LAXATIVE 10 MG SUPPOSIT 1-Covered
glycerin (ADULT GLYCERIN) adultsupprect
1-Covered
glycerin (LAXATIVE SUPPOSITORY)pediatric supprect
1-Covered
glycerin (PEDIA-LAX) pediatricsupprect -
1-Covered
glycerin (SUPPOSITORY) adultsupprect
1-Covered
glycerin adult pediatric 1-Covered
lactulose (CONSTULOSE) 10 g15 mlsolution
1-Covered
lactulose (ENULOSE) 10 g15 mlsolution
1-Covered
lactulose (GENERLAC) 10 g15 mlsolution
1-Covered
lactulose 10 g15 ml 20 g30 ml 1-Covered
MAGNESIUM CITRATE HM SOLUTION 1-Covered
magnesium citrate solution 1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloride(GAVILYTE-C) peg3350sodsulfbicarbclkcl 240-2272g solnrecon -
1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloride(GAVILYTE-G) peg3350sodsulfbicarbclkcl 236-2274g solnrecon -
1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloridepeg3350sod sulfbicarbclkcl 236-2274g soln peg3350sodsulfbicarbclkcl 240-2272g soln
1-Covered
PEG-3350 AND ELECTROLYTES -SOLN
1-Covered
polyethylene glycol 3350(CLEARLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
83
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
polyethylene glycol 3350(GAVILAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(GENTLELAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(GLYCOLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(LAXACLEAR) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350 (NATURA-LAX) 17gdose powder -
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(POWDERLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(PURELAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(SMOOTHLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350 17gdosepowder
1-Covered QL (527 PER 30 DAY(S))
SILACE (docusate sodium) 50MG5 ML LIQUID
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepeg (GAVILYTE-N)chloridenahco3kclpeg 420gsoln recon -
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepeg (TRILYTE WITH FLAVORPACKETS)chloridenahco3kclpeg 420gsoln recon
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepegchloridenahco3kclpeg 420gsoln recon
1-Covered
STOOL SOFTENER (docusatesodium) 100 MG SOFTGEL 100 MGCAPSULE 250 MG SOFTGEL
1-Covered
STOOL SOFTENER HM 100 MGSFTGL 100 MG SOFTGEL HM 250MG SFTGL
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
84
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PROTECTANTSmisoprostol 100 mcg tablet 200mcg tablet
1-Covered PA
sucralfate 1 g tablet 1-Covered
PROTON PUMP INHIBITORSlansoprazole 15 mg capsule dr 1-Covered ST
lansoprazole 30 mg capsule dr 1-Covered
LANSOPRAZOLE DR 15 MGCAPSULE
1-Covered ST
LANSOPRAZOLE DR 30 MGCAPSULE
1-Covered
omeprazole 10 mg capsule dr 20mg tablet dr
1-Covered
omeprazole 20 mg capsule dr 1-Covered QL (60 PER 30 DAYS)
omeprazole 40 mg capsule dr 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
OMEPRAZOLE DR 20 MG CAPSULE 1-Covered QL (60 PER 30 DAYS)
OMEPRAZOLE DR 20 MG TABLET 1-Covered
pantoprazole sodium 20 mg tabletdr 40 mg tablet dr
1-Covered
PANTOPRAZOLE SODIUM DR 20 MGTAB DR 40 MG TAB
1-Covered
PREVACID (lansoprazole) DR 15MG CAPSULE
1-Covered
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERSTREATMENT (Drugs for Genetic or Enzyme Disorders)
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERSTREATMENT
CREON (lipaseproteaseamylase)DR 6000 UNITS CAPSULE
1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
85
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GENITOURINARY AGENTS (Drugs for the Genital Bladder andKidney)
ANTISPASMODICS URINARY (Drugs for Bladder Spasms)oxybutynin chloride 5 mg5 mlsyrup 5 mg tab er 24 5 mg tablet10 mg tab er 24 15 mg tab er 24
1-Covered
OXYBUTYNIN CHLORIDE ER ER 5 MGTABLET ER 10 MG TABLET ER 15 MGTABLET
1-Covered
OXYTROL FOR WOMEN(oxybutynin) 39 MG24HR
1-Covered ST
trospium chloride 20 mg tablet 1-Covered ST
TROSPIUM CHLORIDE 20 MG TABLET 1-Covered ST
BENIGN PROSTATIC HYPERTROPHY AGENTSalfuzosin hcl 10 mg tab er 24h 1-Covered PA
finasteride 5 mg tablet 1-Covered
tamsulosin hcl 04 mg capsule 1-Covered
GENITOURINARY AGENTS OTHER (Other Drugs for the GenitalBladder and Kidney)
bethanechol chloride 5 mg tablet10 mg tablet 25 mg tablet 50 mgtablet
1-Covered
citric acidsodium citrate (CYTRA-2) 334-500mg solution -
1-Covered
citric acidsodium citrate(VIRTRATE-2) 334-500mg solution -
1-Covered
citric acidsodium citrate 334-500mg solution
1-Covered
nonoxynol 9 (VCF) 125 foamappl
1-Covered
penicillamine 250 mg capsule 1-Covered PA QL (16 PER 1 DAY(S))
PENICILLAMINE 250 MG CAPSULE 1-Covered PA QL (16 PER 1 DAY(S))
phenazopyridine hcl (URINARYPAIN RELIEF) 95 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
86
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PHENAZOPYRIDINE HCL 100 MGTAB 200 MG TAB
1-Covered
phenazopyridine hcl 100 mgtablet 200 mg tablet
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit ac(CYTRA-3) sodpotk citsod citcitacid 500-5505 solution -
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit ac(TRICITRATES) sodpotk citsodcitcit acid 500-5505 solution
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit acsodpotk citsod citcit acid 500-5505 solution
1-Covered
URINARY PAIN RELIEF HM RLF 95 MGTAB
1-Covered
PHOSPHATE BINDERScalcium acetate (ELIPHOS) 667 mgtablet
1-Covered QL (270 PER 30 DAYS) AL1 (Atleast 21 yrs old)
calcium acetate 667 mg capsule667 mg tablet
1-Covered QL (270 PER 30 DAYS) AL1 (Atleast 21 yrs old)
lanthanum carbonate 500 mg tabchew 750 mg tab chew 1000 mgtab chew
1-Covered PA
sevelamer carbonate 800 mgtablet
1-Covered PA
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(ADRENAL) (Drugs for ReplacingStimulating Adrenal GlandHormones)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(ADRENAL) (Glucocorticoids)
betamethasone dipropionate 005 lotion
1-Covered
betamethasone dipropionate 005 oint (g) 005 cream (g)
1-Covered ST
BETAMETHASONE DIPROPIONATEDP 005 OINT
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
87
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
betamethasonedipropionatepropylene glycolbetamethasonepropylene 005 cream (g)
1-Covered ST
betamethasone valerate 01 lotion 01 cream (g) 01 oint(g)
1-Covered
clobetasol propionate 005 gel(gram) 005 solution 005 cream (g) 005 oint (g)
1-Covered ST
CLOBETASOL PROPIONATE 005CREAM
1-Covered ST
DELTASONE (prednisone) 20 MGTABLET
1-Covered
desonide 005 lotion 005 oint(g) 005 cream (g)
1-Covered ST
DESONIDE 005 LOTION 005CREAM
1-Covered ST
dexamethasone(DEXAMETHASONE INTENSOL) 1mgml drops
1-Covered
dexamethasone 05 mg5mlsolution 05 mg tablet 05 mg5mlelixir 075 mg tablet 1 mg tablet15 mg tablet 2 mg tablet 4 mgtablet 6 mg tablet
1-Covered
DEXAMETHASONE 4 MG TABLET 1-Covered
fludrocortisone acetate 01 mgtablet
1-Covered
fluocinolone acetonide 001 cream (g) 001 solution 0025 cream (g) 0025 oint (g)
1-Covered ST
fluocinonide 005 cream (g) 005 gel (gram) 005 oint (g) 005 solution
1-Covered
FLUOCINONIDE 005 OINTMENT 1-Covered
hydrocortisone (ANTI-ITCH) 1 cream (g) -
1-Covered
hydrocortisone (ANUSOL-HC) 25 crmpe app -
1-Covered
hydrocortisone (CORTISONE) 1 cream (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
88
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
hydrocortisone (CORTIZONE-10PLUS) cream (g) -0
1-Covered
hydrocortisone (CORTIZONE-10) cream (g) -
1-Covered
hydrocortisone (HYDROCREAM) 1 cream (g)
1-Covered
hydrocortisone (NOBLE FORMULAHC) 1 cream (g)
1-Covered
hydrocortisone (PREPARATION H) 1 cream (g)
1-Covered
hydrocortisone (PROCTO-MED HC)25 crmpe app -
1-Covered
hydrocortisone (PROCTO-PAK) 1 crmpe app -
1-Covered
hydrocortisone (PROCTOSOL-HC)25 crmpe app -
1-Covered
hydrocortisone (PROCTOZONE-HC)25 crmpe app -
1-Covered
hydrocortisone (SOOTHING CARE)1 cream (g)
1-Covered
hydrocortisone 05 oint (g) 1 cream (g) 1 oint (g) 1 crmpe app 25 cream (g) 25 crmpe app 25 oint (g) 25 lotion 5 mg tablet 10 mg tablet20 mg tablet
1-Covered
HYDROCORTISONE 5 MG TABLET10 MG TABLET
1-Covered
hydrocortisone acetate(ANUCORT-HC) 25 mg supprect -
1-Covered
hydrocortisone acetate (ANUSOL-HC) 25 mg supprect -
1-Covered
hydrocortisone acetate(HEMMOREX-HC) 25 mg supprect -
1-Covered
HYDROCORTISONE ACETATE 25 MGSUPP
1-Covered
hydrocortisone acetate 25 mgsupprect
1-Covered
methylprednisolone 4 mg tablet 4mg tab ds pk 8 mg tablet 16 mgtablet 32 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
89
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
mometasone furoate 01 cream(g) 01 oint (g)
1-Covered
prednisolone (MILLIPRED DP) 5 mg(48) tab 5 mg (21) tab
1-Covered
prednisolone (MILLIPRED) 5 mgtablet
1-Covered
prednisolone 15 mg5 ml solution 1-Covered
prednisolone sodium phosphate 5mg5 ml 15 mg5 ml
1-Covered
prednisone (PREDNISONEINTENSOL) 5 mgml oral conc
1-Covered
prednisone 1 mg tablet 25 mgtablet 5 mg tab ds pk 5 mgtablet 5 mg5 ml solution 10 mgtablet 10 mg tab ds pk 20 mgtablet 50 mg tablet
1-Covered
triamcinolone acetonide 0025 oint (g) 0025 cream (g) 0025 lotion 01 cream (g) 01 lotion 01 oint (g) 0147mggaerosol 05 cream (g) 05 oint(g)
1-Covered
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(PITUITARY) (Drugs for ReplacingStimulating Pituitary GlandHormones)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(PITUITARY) (Drugs to ReplaceStimulate Pituitary Gland Hormones)
desmopressin acetate (non-refrigerated) (nonrefrigerated)10spray spraypump
1-Covered PA AL1 (8 to 14 yrs old)
desmopressin acetate 01 mgmlsolution 01 mg tablet 02 mgtablet
1-Covered AL1 (8 to 14 yrs old)
desmopressin acetate 4 mcgmlvial 4 mcgml ampul 10sprayspraypump
1-Covered PA AL1 (8 to 14 yrs old)
DESMOPRESSIN ACETATE 40MCG10 ML VIAL
1-Covered PA AL1 (8 to 14 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
90
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEXHORMONESMODIFIERS) (Drugs for ReplacingStimulating SexHormones)
ANDROGENSdanazol 50 mg capsule 100 mgcapsule 200 mg capsule
1-Covered
fluoxymesterone (ANDROXY) 10mg tablet
1-Covered
testosterone 125125g gel mdpmp 50 mg (1) gel packet
1-Covered PA
testosterone cypionate 100 mgmlvial 200 mgml vial
1-Covered PA
ESTROGENS (Contraceptives and Drugs for Menopause)desogestrel-ethinyl estradiol (APRI)-015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(CYRED EQ) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(CYRED) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(EMOQUETTE) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(ENSKYCE) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(ISIBLOOM) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(JULEBER) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(KALLIGA) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(RECLIPSEN) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol -015-003 tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (AZURETTE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
91
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
desogestrel-ethinyl estradiolethinylestradiol (BEKYREE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (KARIVA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (KIMIDESS) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (PIMTREA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (SIMLIYA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (VIORELE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (VOLNEA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol -eestradioleestradiol 21-5 (28) tablet
1-Covered
DROSPIRENONE-ETHINYL ESTRADIOL-EE 3-002 MG TAB
1-Covered
estradiol (DOTTI) 025mg24hpatch 0375mg24 patch005mg24h patch 075mg24hpatch 01mg24hr patch
1-Covered QL (16 PER 28 DAY(S))
estradiol 025mg24h patch0375mg24 patch 005mg24hpatch 075mg24h patch01mg24hr patch
1-Covered QL (16 PER 28 DAY(S))
estradiol 001 creamappl025mg24h patch tdwk005mg24h patch tdwk075mg24h patch tdwk01mg24hr patch tdwk 05 mgtablet 1 mg tablet 2 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
92
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ESTRADIOL 1 MG TABLET 2 MGTABLET
1-Covered
estrogensesterifiedmethyltestosterone (COVARYX HS)estrogenesterme-0625-125tablet
1-Covered PA
estrogensesterifiedmethyltestosterone (EEMT HS) estrogenesterme-0625-125 tablet
1-Covered PA
estrogensesterifiedmethyltestosterone estrogenesterme-0625-125tablet
1-Covered PA
ethinyl estradioldrospirenone(GIANVI) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(JASMIEL) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone (LO-ZUMANDIMINE) 002-3(28) tablet -
1-Covered
ethinyl estradioldrospirenone(LORYNA) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(NIKKI) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(VESTURA) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone 002-3(28) tablet
1-Covered
ethynodiol diacetate-ethinylestradiol (KELNOR 1-35) ethynoiol -estraiol mg-35mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol (KELNOR 1-50) ethynoiol -estraiol mg-50mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol (ZOVIA 1-35E) ethynoiol -estraiol mg-35mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol ethynoiol -estraiol 1 mg-50mcg tablet ethynoiol -estraiol 1mg-35mcg tablet
1-Covered
etonogestrelethinyl estradiol(ELURYNG) 12-015mg vag ring
1-Covered QL (1 PER 28 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
93
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
etonogestrelethinyl estradiol 12-015mg vag ring
1-Covered QL (1 PER 28 DAY(S))
HAILEY FE 1-20 TABLET 15-30 TABLET 1-Covered
LEVONORGESTREL-ETH ESTRADIOL -TRIPHASIC
1-Covered
levonorgestrelethinyl estradiol(AFIRMELLE)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(ALTAVERA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(AUBRA EQ)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AUBRA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AVIANE)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AYUNA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(CHATEAL EQ)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(CHATEAL)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(DELYLA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(ENPRESSE)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
94
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrelethinyl estradiol(FALMINA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(KURVELO)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(LARISSIA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(LESSINA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(LEVONEST)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
levonorgestrelethinyl estradiol(LEVORA-28)levonorgestrelethinestradiol 015-003 tablet -
1-Covered
levonorgestrelethinyl estradiol(LILLOW)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(LUTERA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(MARLISSA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(MYZILRA)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
levonorgestrelethinyl estradiol(ORSYTHIA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
95
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrelethinyl estradiol(PORTIA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(SRONYX)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(TRIVORA-28)levonorgestrelethinestradiol 6-5-10 tablet -
1-Covered
levonorgestrelethinyl estradiol(VIENVA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiollevonorgestrelethinestradiol 01-002mg tabletlevonorgestrelethinestradiol 015-003 tabletlevonorgestrelethinestradiol 6-5-10 tablet
1-Covered
LYLLANA 0025 MG PATCH 00375MG PATCH 005 MG PATCH 0075MG PATCH 01 MG PATCH
1-Covered QL (16 PER 28 DAY(S))
MENEST (estrogensesterified) 03MG TABLET 0625 MG TABLET 125MG TABLET 25 MG TABLET
1-Covered
MICROGESTIN 21 1-20 TABLET 1-Covered
MICROGESTIN FE 1-20 TABLET 1-Covered
norelgestrominethinyl estradiol(XULANE)norelgestrominethinestradiol 150-3524h patch tdwk
1-Covered QL (3 PER 28 DAY(S))
norethindrone acetate-ethinylestradiol (AUROVELA) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (GILDESS) -15-003mgtablet
1-Covered
norethindrone acetate-ethinylestradiol (HAILEY) -15-003mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
96
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone acetate-ethinylestradiol (JUNEL) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (LARIN) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (MICROGESTIN) -1mg-20mcg tablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol -1mg-20mcg tablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate(AUROVELA FE) -eestradiol-iron15-30(21) tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (BLISOVIFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (JUNELFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (LARINFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate(MICROGESTIN FE) --1mg-20(21)tablet --15-30(21) tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TARINAFE 1-20 EQ) -eestradiol-iron mg-(2)tablet -
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TARINAFE) -eestradiol-iron 1mg-20(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TILIA FE)-eestradiol-iron 5-7-9-7 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
97
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone acetate-ethinylestradiolferrous fumarate (TRI-LEGEST FE) -eestradiol-iron 5-7-9-7tablet -
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate --1mg-20(21) tablet --15-30(21) tablet
1-Covered
norethindrone-ethinyl estradiol(ALYACEN) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(ARANELLE) -ethin 7-9-5 tablet
1-Covered
norethindrone-ethinyl estradiol(BALZIVA) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(BRIELLYN) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(CYCLAFEM) -1 mg-35mcg tablet -7 days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(DASETTA) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(LEENA) -ethin 7-9-5 tablet
1-Covered
norethindrone-ethinyl estradiol(NECON) -ethin 05-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(NORTREL) -05-0035 tablet -1 mg-35mcg tablet -7 days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(PHILITH) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(PIRMELLA) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(VYFEMLA) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(WERA) -ethin 05-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(ZENCHENT) -ethin 04-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(ESTARYLLA) -025-0035 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
98
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norgestimate-ethinyl estradiol(FEMYNOR) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(MILI) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(MONO-LINYAH) -025-0035 tablet -
1-Covered
norgestimate-ethinyl estradiol(MONONESSA) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(PREVIFEM) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(SPRINTEC) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol (TRIFEMYNOR) -7daysx3 28 tablet
1-Covered
norgestimate-ethinyl estradiol (TRI-ESTARYLLA) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-LINYAH) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-ESTARYLLA) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-MARZIA) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-MILI) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-SPRINTEC) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-PREVIFEM) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-SPRINTEC) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-VYLIBRA LO) -7daysx3 lo tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-VYLIBRA) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol(TRINESSA LO) -7daysx3 lo tablet
1-Covered
norgestimate-ethinyl estradiol(TRINESSA) -7daysx3 28 tablet
1-Covered
norgestimate-ethinyl estradiol(VYLIBRA) -025-0035 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
99
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NORGESTIMATE-ETHINYL ESTRADIOL-025-0035 MG
1-Covered
norgestimate-ethinyl estradiol -025-0035 tablet -7daysx3 28tablet -7daysx3 lo tablet
1-Covered
norgestrel-ethinyl estradiol(CRYSELLE) -03-003mg tablet
1-Covered
norgestrel-ethinyl estradiol (ELINEST)-03-003mg tablet
1-Covered
norgestrel-ethinyl estradiol (LOW-OGESTREL) -03-003mg tablet -
1-Covered
norgestrel-ethinyl estradiol(OGESTREL) -05 mg-50 tablet
1-Covered
PREMARIN (estrogens conjugated)03 MG TABLET 045 MG TABLET0625 MG TABLET 09 MG TABLET125 MG TABLET
1-Covered
PREMARIN (estrogens conjugated)VAGINAL CREAM-APPL
1-Covered QL (43 PER 30 DAY(S))
PREMPHASE (estrogensconjugatedmedroxyprogesteroneacetate) 0625-5 MG TABLET
1-Covered
PREMPRO (estrogensconjugatedmedroxyprogesteroneacetate) 03 MG-15 MG TABLET045-15 MG TABLET 0625-5 MGTABLET 0625-25 MG TABLET
1-Covered
ZOVIA 1-35 -TABLET 1-Covered
PROGESTINSDEPO-PROVERA(medroxyprogesterone acetate) -400 MGML VIAL
1-Covered
DEPO-SUBQ PROVERA 104(medroxyprogesterone acetate) -SYRINGE
1-Covered
hydroxyprogesterone caproate250 mgml vial
1-Covered PA SP
hydroxyprogesterone caproatepfcaproatpf 250 mgml vial
1-Covered PA SP
JENCYCLA 035 MG TABLET 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
100
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrel (AFTERA) 15 mgtablet
1-Covered
levonorgestrel (ECONTRA EZ) 15mg tablet
1-Covered
levonorgestrel (ECONTRA ONE-STEP) 15 mg tablet -
1-Covered
levonorgestrel (FALLBACK SOLO)15 mg tablet
1-Covered
levonorgestrel (MY CHOICE) 15mg tablet
1-Covered
levonorgestrel (MY WAY) 15 mgtablet
1-Covered
levonorgestrel (NEW DAY) 15 mgtablet
1-Covered
levonorgestrel (OPCICON ONE-STEP) 15 mg tablet -
1-Covered
levonorgestrel (OPTION 2) 15 mgtablet
1-Covered
levonorgestrel (TAKE ACTION) 15mg tablet
1-Covered
levonorgestrel 15 mg tablet 1-Covered QL (1 PER 1 DAYS)
MEDROXYPROGESTERONE ACETATE150 MGML
1-Covered QL (1 PER 84 DAYS)
medroxyprogesterone acetate 150mgml vial 150 mgml syringe
1-Covered QL (1 PER 84 DAYS)
MEDROXYPROGESTERONE ACETATE25 MG TAB
1-Covered
medroxyprogesterone acetate 25mg tablet 5 mg tablet 10 mgtablet
1-Covered
megestrol acetate 20 mg tablet40 mg tablet
1-Covered
megestrol acetate 400mg10mloral susp
1-Covered PA
norethindrone (CAMILA) 035 mgtablet
1-Covered
norethindrone (DEBLITANE) 035 mgtablet
1-Covered
norethindrone (ERRIN) 035 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
101
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone (HEATHER) 035 mgtablet
1-Covered
norethindrone (INCASSIA) 035 mgtablet
1-Covered
norethindrone (JENCYCLA) 035mg tablet
1-Covered
norethindrone (JOLIVETTE) 035 mgtablet
1-Covered
norethindrone (LYZA) 035 mgtablet
1-Covered
norethindrone (NORA-BE) 035 mgtablet -
1-Covered
norethindrone (NORLYDA) 035 mgtablet
1-Covered
norethindrone (NORLYROC) 035mg tablet
1-Covered
norethindrone (SHAROBEL) 035 mgtablet
1-Covered
norethindrone (TULANA) 035 mgtablet
1-Covered
norethindrone 035 mg tablet 1-Covered
norethindrone acetate 5 mg tablet 1-Covered
PLAN B ONE-STEP (levonorgestrel) -15 MG TALET
1-Covered
TAKE ACTION (levonorgestrel) 15MG TABLET
1-Covered
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(THYROID) (Drugs for the Thyroid)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(THYROID) (Drugs to Replace Thyroid Hormone)
ARMOUR THYROID (thyroidpork) 15MG TABLET 30 MG TABLET 60 MGTABLET 90 MG TABLET 120 MGTABLET 180 MG TABLET 240 MGTABLET 300 MG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
102
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LEVO-T (levothyroxine sodium) -25MCG ABLE -50 MCG ABLE -75MCG ABLE -88 MCG ABLE -100MCG ABLE -112 MCG ABLE -125MCG ABLE -137 MCG ABLE -150MCG ABLE -175 MCG ABLE -200MCG ABLE -300 MCG ABLE
1-Covered
levothyroxine sodium 25 mcgtablet 50 mcg tablet 75 mcgtablet 88 mcg tablet 100 mcgtablet 112 mcg tablet 125 mcgtablet 137 mcg tablet 150 mcgtablet 175 mcg tablet 200 mcgtablet 300 mcg tablet
1-Covered STAR (Preferred Drug)
LEVOTHYROXINE SODIUM 25 MCGTABLET 50 MCG TABLET 75 MCGTABLET 88 MCG TABLET 100 MCGTABLET 112 MCG TABLET 125 MCGTABLET 137 MCG TABLET 150 MCGTABLET 175 MCG TABLET 200 MCGTABLET 300 MCG TABLET
1-Covered STAR (Preferred Drug)
LEVOXYL (levothyroxine sodium) 25MCG TABLET 50 MCG TABLET 75MCG TABLET 88 MCG TABLET 100MCG TABLET 112 MCG TABLET 125MCG TABLET 137 MCG TABLET 150MCG TABLET 175 MCG TABLET 200MCG TABLET
1-Covered
SYNTHROID (levothyroxine sodium)25 MCG TABLET 50 MCG TABLET75 MCG TABLET 88 MCG TABLET100 MCG TABLET 112 MCG TABLET125 MCG TABLET 137 MCG TABLET150 MCG TABLET 175 MCG TABLET200 MCG TABLET 300 MCG TABLET
1-Covered
thyroidpork (NP THYROID) 15 mgtablet 30 mg tablet 60 mg tablet90 mg tablet 120 mg tablet
1-Covered STAR (Preferred Drug)
UNITHROID (levothyroxine sodium)25 MCG TABLET 50 MCG TABLET75 MCG TABLET 88 MCG TABLET100 MCG TABLET 112 MCG TABLET125 MCG TABLET 137 MCG TABLET150 MCG TABLET 175 MCG TABLET200 MCG TABLET 300 MCG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
103
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs forSuppressing Hormones from the Pituitary Gland)
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs to SuppressPituitary Hormones)
leuprolide acetate 1 mg02ml kit 1-Covered PA SP
LUPRON DEPOT-PED (leuprolideacetate) -15 MG KIT
1-Covered PA
SYNAREL (nafarelin acetate) 2MGML NASAL SPRAY
1-Covered PA
HORMONAL AGENTS SUPPRESSANT (THYROID) (Drugs for theThyroid)
ANTITHYROID AGENTS (Drugs to Suppress Thyroid Hormone)methimazole 5 mg tablet 10 mgtablet
1-Covered
propylthiouracil 50 mg tablet 1-Covered
IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing theImmune System)
IMMUNE SUPPRESSANTS (Drugs to Suppress the Immune System)azathioprine 50 mg tablet 1-Covered
AZATHIOPRINE 50 MG TABLET 1-Covered
cyclosporine 25 mg capsule 100mg capsule
1-Covered
cyclosporine modified (GENGRAF)25 mg capsule 100 mgml solution100 mg capsule
1-Covered
cyclosporine modified 25 mgcapsule 100 mgml solution 100mg capsule
1-Covered
ENBREL (etanercept) 25 MG KIT 1-Covered PA SP QLC (8 vials28 days)
ENBREL (etanercept) 25 MG05 MLSYRINGE 50 MGML SYRINGE
1-Covered PA SP QLC (4 syringes [1 kit]28days)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
104
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ENBREL 25 MG05 ML VIAL 1-Covered PA QL (4 PER 28 DAY(S))
ENBREL SURECLICK (etanercept) 50MGML
1-Covered PA SP QLC (4 pens [1 kit]28days)
HUMIRA (adalimumab) 10 MG02ML SYRINGE 20 MG04 MLSYRINGE 40 MG08 ML SYRINGE
1-Covered PA SP QLC (2 syringes [1 kit]28days)
HUMIRA PEDIATRIC CROHNS(adalimumab) 40 MG08 ML
1-Covered PA SP QLC (3 or 6 syringesyeardepending upon package size)
HUMIRA PEN (adalimumab) 40MG08 ML
1-Covered PA SP QLC (2 pens [1 kit]28days)
HUMIRA PEN CROHNS-UC-HS(adalimumab) --40 MG
1-Covered PA SP QLC (6 pens [1 kit]year)
HUMIRA PEN PSOR-UVEITS-ADOL HS(adalimumab) --40 MG
1-Covered PA SP QLC (4 pens [1 kit]year)
HUMIRA(CF) (adalimumab) 10MG01 ML SYRING 20 MG02 MLSYRING 40 MG04 ML SYRING
1-Covered PA SP QLC (2 syringes [1 kit]28days)
HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 80-40 MG
1-Covered PA SP QLC (2 syringes [1kit]year)
HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 80MG08
1-Covered PA SP QLC (3 syringes [1kit]year)
HUMIRA(CF) PEN (adalimumab) 40MG04 ML
1-Covered PA SP QLC (2 pens [1 kit]28days)
HUMIRA(CF) PEN CROHNS-UC-HS(adalimumab) CRHN--80MG
1-Covered PA SP QLC (3 pens [1 kit]year)
HUMIRA(CF) PEN PSOR-UV-ADOLHS (adalimumab) --AHS 80-40
1-Covered PA SP QLC (3 pens [1 kit]year)
METHOTREXATE 25 MG TABLET 1-Covered
methotrexate sodium 25 mgtablet
1-Covered
mycophenolate mofetil 200 mgmlsusp recon
1-Covered PA
mycophenolate mofetil 250 mgcapsule 500 mg tablet
1-Covered AL1 (At least 21 yrs old)
RHEUMATREX (methotrexatesodium) 25 MG TABLET
1-Covered
SANDIMMUNE (cyclosporine) 25MG CAPSULE 100 MGML SOLN
1-Covered
sirolimus 1 mgml solution 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
105
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
tacrolimus 05 mg capsule 1 mgcapsule 5 mg capsule
1-Covered AL1 (At least 21 yrs old)
TACROLIMUS 05 MG CAPSULE 1MG CAPSULE 5 MG CAPSULE
1-Covered AL1 (At least 21 yrs old)
IMMUNIZING AGENTS PASSIVE (Vaccines)HYPERTET S-D (tetanus immuneglobulinpf) -250 UNIT YRINGE
3-MedicalBenefit
NABI-HB (hepatitis b immuneglobulin) -VIAL gloulin)
3-MedicalBenefit
IMMUNOMODULATORSleflunomide 10 mg tablet 20 mgtablet
1-Covered
LEFLUNOMIDE 10 MG TABLET 20MG TABLET
1-Covered
RIDAURA (auranofin) 3 MGCAPSULE
1-Covered PA
VACCINESADACEL TDAP(diphtheriapertussis(acellular)tetanus vaccinepf) VIAL
1-Covered AL1 (At least 19 yrs old)
AFLURIA QUAD 2020-2021 -VIAL 1-Covered AL1 (At least 19 yrs old)
AFLURIA QUAD 2020-21 (3YR UP) - 1-Covered AL1 (At least 19 yrs old)
BEXSERO (meningococcal group bvaccine 4-component) PREFILLEDSYRINGE -
1-Covered QL (2 PER LIFETIME) AL1 (19 to 25yrs old)
BOOSTRIX TDAP(diphtheriapertussis(acellular)tetanus vaccine) SYRINGE VIAL
1-Covered AL1 (At least 19 yrs old)
ENGERIX-B ADULT (hepatitis b virusvaccine recombinantpf) -20MCGML VIAL recominantpf) -20MCGML SYRN recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
FLUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 65 yrs old)
FLUAD QUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 19 yrs old)
FLUARIX QUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 19 yrs old)
FLUBLOK QUAD 2018-2019(influenza virus vaccine qv 2018-19(18 yrs and older)rcmbpf) -SYRINGE -
1-Covered AL1 (19 to 999 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
106
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
FLUBLOK QUAD 2020-2021 -SYRINGE
1-Covered AL1 (At least 19 yrs old)
FLUCELVAX QUAD 2020-2021 2020-2021 SYR 2020-2021 VIAL
1-Covered AL1 (At least 19 yrs old)
FLULAVAL QUAD 2019-2020(influenza virus vaccinequadrivalent 2019-20 (6 mos andup)) -VIAL -
1-Covered AL1 (At least 19 yrs old)
FLULAVAL QUAD 2020-2021 -SYR 1-Covered AL1 (At least 19 yrs old)
FLUZONE HIGH-DOSE QUAD 2020-21 --
1-Covered AL1 (At least 65 yrs old)
FLUZONE QUAD 2019-2020(influenza virus vaccine quadrival2019-2020(6 mos and up)pf) -VIAL-
1-Covered AL1 (At least 19 yrs old)
FLUZONE QUAD 2020-2021 2020-2021 VIAL 2020-2021 SYRINGE
1-Covered AL1 (At least 19 yrs old)
GARDASIL 9 (human papillomavirusvaccine 9-valentpf) 9 SYRINGE 9-9 VIAL 9-
1-Covered QL (3 PER LIFETIME) AL1 (19 to 27yrs old)
HAVRIX (hepatitis a virusvaccinepf) 720 UNIT05 MLSYRINGE (heptitis vccinepf) 720UNITS05 ML VIAL (heptitisvccinepf) 1440 UNITSMLSYRINGE (heptitis vccinepf) 1440UNITSML VIAL (heptitis vccinepf)
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
HEPLISAV-B (hepatitis b vaccinerecombinantvaccine adjuvantcpg 1018pf) -20 MCG05 MLSYRNG RECOMINANT -20MCG05 ML VIAL RECOMINANT
1-Covered AL1 (At least 19 yrs old) QLC (2perlifetime)
IMOVAX RABIES VACCINE (rabiesvaccine human diploid cellpf)VIAL
3-MedicalBenefit
M-M-R II VACCINE (measlesmumps and rubella vaccinelivepf) --VIAL
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
MENACTRA(meningococcalvaccine acyw-135diphtheria toxoid conjpf) VIAL-
1-Covered AL1 (At least 19 yrs old)
MENQUADFI VIAL 1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
107
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
MENVEO A-C-Y-W-135-DIP(meningococcalvaccine acyw-135diphtheria toxoid conjpf) -----VIL KT -DIPHTHERIA
1-Covered QL (1 PER LIFETIME) AL1 (19 to 55yrs old)
PNEUMOVAX 23 (pneumococcal23-valent polysaccharide vaccine)23 VIAL 23- 23 SYRINGE 23-
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
PREVNAR 13 (pneumococcal 13-valent conjugate vaccine(diphtheria crm)pf) SYRINGE -
1-Covered QL (1 PER LIFETIME) AL1 (At least19 yrs old)
RABAVERT (rabies vaccine purifiedchicken embryo cell (pcec)pf)RABIES VACC W-DILUENT
1-Covered AL1 (At least 19 yrs old)
RECOMBIVAX HB (hepatitis b virusvaccine recombinantpf) 5MCG05 ML SYR recominantpf)10 MCGML SYR recominantpf)40 MCGML VIAL recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
RECOMBIVAX HB (hepatitis b virusvaccine recombinantpf) 5MCG05 ML VL recominantpf) 10MCGML VIAL recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
SHINGRIX (varicella-zoster virusglycoprotein erecas01badjuvantpf) VIAL KIT -
1-Covered QL (2 PER LIFETIME) AL1 (At least50 yrs old)
TDVAX (tetanus and diphtheriatoxoids adult) VIAL
1-Covered AL1 (At least 19 yrs old)
TENIVAC (tetanus and diphtheriatoxoids adsorbed adultpf) VIAL
1-Covered AL1 (At least 19 yrs old)
tetanus and diphtheria toxoidsadult tetanus toxadult 2-2 lf05vial
1-Covered AL1 (At least 19 yrs old)
TRUMENBA (neisseria meningitidisgroup b lipidated fhbprecombinant) 120 MCG05 MLVACCIN
1-Covered QL (2 PER LIFETIME) AL1 (19 to 25yrs old)
TWINRIX (hepatitis a virus andhepatitis b virus vaccinepf)VACCINE SYRINGE (heptitis ndheptitis vccinepf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
108
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
VAQTA (hepatitis a virusvaccinepf) 25 UNITS05 ML VIAL(heptitis vccinepf) 25 UNITS05ML SYRINGE (heptitis vccinepf) 50UNITSML VIAL (heptitis vccinepf)50 UNITSML SYRINGE (heptitisvccinepf)
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
VARIVAX VACCINE (varicella virusvaccine livepf) WITH DILUENT
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
ZOSTAVAX (zoster vaccine livepf)VIAL
1-Covered QL (1 PER LIFETIME) AL1 (At least60 yrs old)
INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for InflammatoryBowel Disease)
AMINOSALICYLATESbalsalazide disodium 750 mgcapsule
1-Covered
mesalamine 4 g60 ml enema 1-Covered
mesalamine 400 mg cap(drtab) 1-Covered QL (6 PER 1 DAY(S))
GLUCOCORTICOIDShydrocortisone (COLOCORT)100mg60ml enema
1-Covered
hydrocortisone 100mg60mlenema
1-Covered
SULFONAMIDESsulfasalazine 500 mg tablet dr 500mg tablet
1-Covered
METABOLIC BONE DISEASE AGENTS (Drugs for the Bone)
METABOLIC BONE DISEASE AGENTSalendronate sodium 10 mg tablet40 mg tablet
1-Covered PA STAR (Preferred Drug)
alendronate sodium 35 mg tablet70 mg tablet
1-Covered STAR (Preferred Drug)
alendronate sodium 5 mg tablet 1-Covered AL1 (At least 65 yrs old) STAR(Preferred Drug)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
109
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcitoninsalmonsynthetic200spray spraypump
1-Covered PA
CALCITRIOL 025 MCG CAPSULE05 MCG CAPSULE
1-Covered
calcitriol 025 mcg capsule 05mcg capsule 1 mcgml solution
1-Covered
cholecalciferol (vitamin d3) 10mcg capsule 10 mcg tablet
1-Covered
cinacalcet hcl 30 mg tablet 60 mgtablet 90 mg tablet
1-Covered PA
CINACALCET HCL 30 MG TABLET60 MG TABLET 90 MG TABLET
1-Covered PA
ergocalciferol (vitamin d2)(CALCIDOL) 200 mcgml drops
1-Covered
ergocalciferol (vitamin d2) 10 mcgtablet 200 mcgml drops 1250mcg capsule
1-Covered
ERGOCALCIFEROL 200 MCGMLDROP
1-Covered
FOSAMAX PLUS D (alendronatesodiumcholecalciferol (vitamind3)) 70 MG-2800 IU
1-Covered PA
MISCELLANEOUS THERAPEUTIC AGENTSalcohol antiseptic pads s med 1-Covered
ALCOHOL WIPES 70 1-Covered
ASSURE ID DUO-SHIELD -30GX316-30GX516
1-Covered
ASSURE ID INSULIN SAFETY SYR05ML 31GX1564 SYR 1 ML31GX1564
1-Covered
condoms female each 1-Covered
condoms latex lubricated each 1-Covered
cromolyn sodium 52 mgspraypump
1-Covered
DROPLET MICRON PEN NEEDLE 34GX 964
1-Covered
freestyle insulix test strips 1-Covered QL (100 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
110
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
freestyle lite test strips 1-Covered QL (100 PER 30 DAYS)
freestyle test strips 1-Covered QL (100 PER 30 DAYS)
inhalerassist device with largemask devicelg spacer
1-Covered
inhalerassist device with mediummask devicemed spacer
1-Covered
inhalerassist device with smallmask devsmall spacer
1-Covered
INSULIN PEN NEEDLES INSULIN PENNEEDLES INSULIN PEN NEEDLES
1-Covered
insulin syringe 03 ml 1-Covered
insulin syringe 05 ml 1-Covered
insulin syringe 1 ml 1-Covered
lancets 28 gauge 30 gauge 33gauge
1-Covered
methylergonovine maleate 02 mgtablet
1-Covered
PEN NEEDLE 29G 12MM 1-Covered
pen needle diabetic 29 g x12 30gx516 31 g x14 31 gx316 31gx516 32gx 532 32 gx 14 32gx316 32 gx516 33 gx532
1-Covered
pen needle diabetic disposablesafety 30 gx516 30 gx316
1-Covered
pen needle diabetic removerand disposal unit 31 gx316 32gx532
1-Covered
pen needle diabetic safety 30gx316 dis
1-Covered
RID (permethrin) PEDICULICIDESSPRAY
1-Covered
syringe with needle insulin safety1 ml geneedleinsulnsafe1ml 30gx316 disp
1-Covered
syringe withneedledisposableinsulin 1 ml30gx12 disp 31 gx516 disp31gx1564 disp
1-Covered
syringe with needleinsulin03 ml -needldispinsul03 29 x12 disp
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
111
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
syringe with needleinsulin05 ml -ml 30gx12 disp -ml 31 gx516disp -ml 31gx1564 disp
1-Covered
UNIFINE PENTIPS MAXFLOW30GX316
1-Covered
OPHTHALMIC AGENTS (Drugs for the Eyes)
OPHTHALMIC AGENTS OTHER (Other Drugs for the Eyes)atropine sulfate 1 drops 1-Covered
bacitracinpolymyxin b sulfate (AK-POLY-BAC) 500-10kg oint (g) --
1-Covered
bacitracinpolymyxin b sulfate(POLYCIN) 500-10kg oint (g)
1-Covered
bacitracinpolymyxin b sulfate 500-10kg oint (g)
1-Covered
BEOVU (brolucizumab-dbll) 6MG005 ML VIAL -
3-MedicalBenefit
BLEPHAMIDE (sulfacetamidesodiumprednisolone acetate) EYEDROPS
1-Covered
CORTISPORIN (neomycinsulfatepolymyxin bsulfatehydrocortisone) CREAM
1-Covered
cyclopentolate hcl 05 drops 1 drops 2 drops
1-Covered
homatropine hbr (HOMATROPAIRE)5 drops
1-Covered
homatropine hbr 5 drops 1-Covered
MURO-128 (sodium chloride) -5EYE DROPS
1-Covered
neomycin sulfatebacitracinzincpolymyxin bhydrocortisone(NEO-POLYCIN HC)neomycinbacitp-myxhydrocort35-10k-1 oint (g) -
1-Covered
neomycin sulfatebacitracinzincpolymyxin bhydrocortisoneneomycinbacitp-myxhydrocort35-10k-1 oint (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
112
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
neomycinsulfatebacitracinpolymyxin b(NEO-POLYCIN)sulfbacitracinpoly 35mg-400oint (g) -
1-Covered
neomycinsulfatebacitracinpolymyxin bsulfbacitracinpoly 35mg-400oint (g)
1-Covered
neomycin sulfatepolymyxin bsulfategramicidin dneomycinpolymyxn bgramicidin175mg-10k drops
1-Covered
neomycin sulfatepolymyxin bsulfatehydrocortisoneneomycinpolymyxin bhydrocort35-10k-10 drops susp
1-Covered
neomycinpolymyxin bsulfatedexamethasonebdexametha 01 drops suspbdexametha 35-10k-1 oint (g)
1-Covered
phenylephrine hcl 25 drops 10 drops
1-Covered
polymyxin b sulfatetrimethoprimsulftrimethoprim 10000-1ml drops
1-Covered
proparacaine hcl 05 drops 1-Covered PA
sodium chloride (MURO-128) drops -18)
1-Covered
sodium chloride 5 drops 1-Covered
sulfacetamidesodiumprednisolone sodiumphosphatesulfacetamideprednisolone 10 -023 drops
1-Covered
TOBRADEX(tobramycindexamethasone) EYEOINTMENT
1-Covered
tobramycindexamethasone 03-01 drops susp
1-Covered
OPHTHALMIC ANTI-ALLERGY AGENTS (Drugs for Eye Allergies)ALAWAY (ketotifen fumarate)0025 EYE DROPS
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
113
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALOMIDE (lodoxamidetromethamine) 01 EYE DROPS
1-Covered
cromolyn sodium 4 drops 1-Covered
EYE ITCH RELIEF 0025 DROPS HM0025 DROP
1-Covered
ketotifen fumarate (ALLERGY EYEDROPS) 0025 drops
1-Covered
ketotifen fumarate (EYE ITCHRELIEF) 0025 drops
1-Covered
ketotifen fumarate (ITCHY EYE)0025 drops
1-Covered
ketotifen fumarate (WAL-ZYR) 0025 drops -
1-Covered
ketotifen fumarate (ZADITOR) 0025 drops
1-Covered
ketotifen fumarate 0025 drops 1-Covered
OPHTHALMIC ANTI-INFLAMMATORIES (Drugs to Reduce EyeSwelling)
dexamethasone sodiumphosphate 01 drops
1-Covered
diclofenac sodium 01 drops 1-Covered
fluorometholone 01 drops susp 1-Covered
flurbiprofen sodium 003 drops 1-Covered
FML FORTE (fluorometholone)025 EYE DROPS
1-Covered
FML SOP (fluorometholone) 01OINTMENT
1-Covered
ketorolac tromethamine 05 drops
1-Covered
PRED MILD (prednisolone acetate)012 EYE DROPS
1-Covered
prednisolone acetate 1 dropssusp
1-Covered
prednisolone sodium phosphate 1 drops
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
114
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
OPHTHALMIC ANTIGLAUCOMA AGENTS (Drugs for Glaucoma)ALPHAGAN P (brimonidinetartrate) ALHAGAN 01 DROS
1-Covered QL (1 PER 30 DAYS)
apraclonidine hcl 05 drops 1-Covered
betaxolol hcl 05 drops 1-Covered
BETIMOL (timolol) 025 DROPS05 DROPS
1-Covered
BETOPTIC S (betaxolol hcl) 025EYE DROP
1-Covered
brimonidine tartrate 02 drops 1-Covered
dorzolamide hcl 2 drops 1-Covered
dorzolamide hcltimolol maleate223-681 drops
1-Covered QL (10 PER 30 DAY(S))
DORZOLAMIDE-TIMOLOL -EYEDROPS
1-Covered QL (10 PER 30 DAY(S))
IOPIDINE (apraclonidine hcl) 1EYE DROPS
1-Covered
levobunolol hcl 05 drops 1-Covered
methazolamide 25 mg tablet 50mg tablet
1-Covered
METHAZOLAMIDE 25 MG TABLET 50MG TABLET
1-Covered
PHOSPHOLINE IODIDE(echothiophate iodide) 0125
1-Covered
pilocarpine hcl 1 drops 2 drops 4 drops
1-Covered
PILOCARPINE HCL 1 DROPS 2DROPS
1-Covered
timolol maleate 025 sol-gel 025 drops 05 drops 05 sol-gel
1-Covered
TIMOLOL MALEATE 05 EYE DROPS 1-Covered
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS (Drugsfor Glaucoma)
latanoprost 0005 drops 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
115
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
OTIC AGENTS (Drugs for the Ears)
OTIC AGENTS (Drugs for Ear Infection)acetic acid 2 solution 1-Covered
ACETIC ACID 2 EAR SOLUTION 1-Covered
carbamide peroxide(CARBAMOXIDE) 65 drops
1-Covered
carbamide peroxide (EAR DROPS)65 drops
1-Covered
carbamide peroxide (EAR SYSTEM)65 drops
1-Covered
carbamide peroxide (EAR WAXREMOVAL) 65 drops
1-Covered
carbamide peroxide (MURINE EARWAX REMOVAL SYSTEM) 65 drops
1-Covered
DEBROX (carbamide peroxide)65 EAR DROPS
1-Covered
EAR DROPS (carbamide peroxide)65
1-Covered
hydrocortisoneacetic acid(ACETASOL HC) 1 -2 drops
1-Covered
hydrocortisoneacetic acid 1 -2 drops
1-Covered
MURINE EAR DROPS (carbamideperoxide) 65
1-Covered
neomycin sulfatepolymyxin bsulfatehydrocortisoneneomycinpolymyxin bhydrocort35--1 solutionneomycinpolymyxin bhydrocort35--1 drops susp
1-Covered
NEOMYCIN-POLYMYXIN-HC --EARSUSP
1-Covered
RESPIRATORY TRACTPULMONARY AGENTS (Drugs for the Lungs)
ANTI-INFLAMMATORIES INHALED CORTICOSTEROIDS (Inhaled Drugsto Prevent Swelling of the Airways)
BUDESONIDE 025 MG2 ML SUSP 1-Covered AL1 (Up to 6 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
116
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
budesonide 025mg2ml - 05mg2ml -
1-Covered AL1 (Up to 6 yrs old)
CHILDRENS NASACORT(triamcinolone acetonide)ALLERGY 24 HR
1-Covered QL (17 PER 30 DAY(S))
FLOVENT DISKUS (fluticasonepropionate) 50 MCG 100 MCG250 MCG
1-Covered
FLOVENT HFA (fluticasonepropionate) HFA 44 MCG INHALERHFA 110 MCG INHALER HFA 220MCG INHALER
1-Covered
fluticasone propionate (ALLERGYRELIEF) 50 mcg spray susp
1-Covered QL (16 PER 30 DAY(S))
fluticasone propionate 50 mcgspray susp
1-Covered QL (16 PER 30 DAY(S))
NASACORT (triamcinoloneacetonide) ALLERGY 24HR SPRAY
1-Covered
PULMICORT FLEXHALER(budesonide) 180 MCG
1-Covered
QVAR REDIHALER(beclomethasone dipropionate)40 MCG 80 MCG
1-Covered
triamcinolone acetonide 55 mcgspray
1-Covered QL (17 PER 30 DAY(S))
ANTIHISTAMINESALAVERT (loratadine) 10 MG ODT 1-Covered AL1 (Up to 12 yrs old)
ALL DAY ALLERGY ERGY 10 MGTABLET SM ERGY 10 MG TAB
1-Covered
ALLERGY RELIEF (LORATADINE) 10MG TAB RELIEF 10 MG TABLET
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
ALLERGY RELIEF 4 MG TABLET HM 4MG TABLET HM 25 MG CAP 25 MGSOFTGEL GS 25 MG TABLET
1-Covered
ALLERGY RELIEF HM 180 MG TAB180 MG TABLET
1-Covered ST
AZELASTINE HCL 01 (137 MCG)SPRY
1-Covered QL (1 PER 30 DAYS)
azelastine hcl 137 mcgspraypump
1-Covered QL (1 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
117
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
cetirizine hcl (24HOUR ALLERGY) 10mg tablet
1-Covered
cetirizine hcl (ALL DAY ALLERGYRELIEF) 10 mg tablet
1-Covered
cetirizine hcl (ALL DAY ALLERGY) 10mg tablet
1-Covered
cetirizine hcl (ALLER-TEC) 10 mgtablet -
1-Covered
cetirizine hcl (ALLERGY RELIEF) 10mg tablet
1-Covered
cetirizine hcl (WAL-ZYR) 10 mgtablet -
1-Covered
cetirizine hcl 1 mgml 5 mg5 ml 1-Covered ST AL1 (Up to 5 yrs old)
CETIRIZINE HCL 10 MG TABLET 1-Covered
cetirizine hcl 5 mg tablet 10 mgtablet
1-Covered
CHILDRENS ALLERGY RELIEF 5MG5 ML
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
CHILDRENS ALLERGY RELIEF RLF125 MG5 ML
1-Covered
chlorpheniramine maleate(ALLERGY 4-HOUR) mg tablet -
1-Covered
chlorpheniramine maleate(ALLERGY RELIEF) 4 mg tablet
1-Covered
chlorpheniramine maleate(ALLERGY) 4 mg tablet
1-Covered
chlorpheniramine maleate(ALLERGY-TIME) 4 mg tablet -
1-Covered
chlorpheniramine maleate(CHLORHIST) 4 mg tablet
1-Covered
chlorpheniramine maleate(CHLORTABS) 4 mg tablet
1-Covered
chlorpheniramine maleate (EDCHLORPED JR) 2 mg5 ml syrup
1-Covered
chlorpheniramine maleate(PHARBECHLOR) 4 mg tablet
1-Covered
chlorpheniramine maleate (WAL-FINATE) 4 mg tablet -
1-Covered
chlorpheniramine maleate 4 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
118
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
clemastine fumarate 268 mgtablet
1-Covered
cyproheptadine hcl 2 mg5 mlsyrup 4 mg tablet 4 mg10 mlsyrup
1-Covered
diphenhydramine hcl (ALER-CAPS)25 mg capsule -
1-Covered
diphenhydramine hcl (ALLER-G-TIME) 25 mg tablet --
1-Covered
diphenhydramine hcl (ALLERGYMEDICATION) 25 mg capsule 25mg tablet
1-Covered
diphenhydramine hcl (ALLERGYMEDICINE) 25 mg tablet
1-Covered
diphenhydramine hcl (ALLERGYRELIEF) 125mg5ml liquid 25 mgcapsule 25 mg tablet
1-Covered
diphenhydramine hcl (ALLERGY)125mg5ml liquid 25 mg capsule25 mg tablet
1-Covered
diphenhydramine hcl (BANOPHEN)125mg5ml liquid 25 mg tablet 25mg capsule 50 mg capsule
1-Covered
diphenhydramine hcl (BENADRYLALLERGY) 25 mg tablet
1-Covered
diphenhydramine hcl (CHILDRENSALLERGY RELIEF) 125mg5ml liquid
1-Covered
diphenhydramine hcl (CHILDRENSALLERGY) 125mg5ml elixir125mg5ml liquid
1-Covered
diphenhydramine hcl (CHILDRENSBENADRYL ALLERGY) 125mg5mlliquid
1-Covered
diphenhydramine hcl (CHILDRENSWAL-DRYL ALLERGY) 125mg5mlliquid -
1-Covered
diphenhydramine hcl (COMPLETEALLERGY) 25 mg capsule 25 mgtablet
1-Covered
diphenhydramine hcl (DIPHEDRYLALLERGY) 125mg5ml liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
119
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
diphenhydramine hcl (DIPHEDRYL)125mg5ml liquid 25 mg capsule
1-Covered
diphenhydramine hcl (DIPHEN)125mg5ml elixir 25 mg tablet
1-Covered
diphenhydramine hcl (DIPHENHIST)125mg5ml liquid 25 mg tablet
1-Covered
diphenhydramine hcl (GERI-DRYL)125mg5ml liquid - 25 mg tablet -
1-Covered
diphenhydramine hcl (M-DRYL)125mg5ml liquid -
1-Covered
diphenhydramine hcl (NIGHTTIMEALLERGY RELIEF) 25 mg tablet
1-Covered
diphenhydramine hcl (NIGHTTIMESLEEP AID) 25 mg tablet
1-Covered
diphenhydramine hcl(PHARBEDRYL) 25 mg capsule 50mg capsule
1-Covered
diphenhydramine hcl (SILADRYL)125mg5ml liquid
1-Covered
diphenhydramine hcl (SIMPLYSLEEP) 25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP AID)25 mg tablet
1-Covered
diphenhydramine hcl (TOTALALLERGY) 25 mg tablet
1-Covered
diphenhydramine hcl (WAL-DRYLALLERGY) 125mg5ml liquid - 25mg tablet -
1-Covered
diphenhydramine hcl (WAL-DRYL)25 mg capsule -
1-Covered
DIPHENHYDRAMINE HCL 125 MG5ML 25 MG10 ML
1-Covered
diphenhydramine hcl 125mg5mlelixir 125mg5ml syrup125mg5ml liquid 25 mg tablet 25mg capsule 50 mg capsule
1-Covered
fexofenadine hcl (ALLER-EASE) 60mg tablet - 180 mg tablet -
1-Covered ST
fexofenadine hcl (ALLER-FEX) 180mg tablet -
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
120
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fexofenadine hcl (ALLERGY RELIEF)60 mg tablet 180 mg tablet
1-Covered ST
fexofenadine hcl (WAL-FEXALLERGY) 60 mg tablet - 180 mgtablet -
1-Covered ST
fexofenadine hcl 60 mg tablet 180mg tablet
1-Covered ST
FEXOFENADINE HCL HM 60 MGTAB 60 MG TABLET 180 MG TABLET
1-Covered ST
GERI-DRYL -125 MG5 ML LIQUID 1-Covered
hydroxyzine hcl 10 mg tablet 10mg5 ml solution 25 mg tablet 50mg tablet 50 mg25ml solution
1-Covered
HYDROXYZINE PAMOATE 25 MGCAP 50 MG CAP
1-Covered
hydroxyzine pamoate 25 mgcapsule 50 mg capsule 100 mgcapsule
1-Covered
loratadine (ALLERCLEAR) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (ALLERGY RELIEF) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (ALLERGY RELIEF) 5mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (ALLERGY) 10 mg tablet 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (CHILDRENS ALLERGYRELIEF) 5 mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (CHILDRENS ALLERGY) 5mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (LORADAMED) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (NON-DROWSYALLERGY) 10 mg tablet -
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (WAL-ITIN) 10 mg tablet-
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (WAL-ITIN) 5 mg5 mlsolution -
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine 10 mg tablet 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
121
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LORATADINE 10 MG TABLET 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine 5 mg5 ml solution 1-Covered QL (150 PER 30 DAYS) AL1 (Up to6 yrs old)
NIGHTTIME SLEEP AID HM 25 MGCPLT
1-Covered
promethazine hcl 125 mg tablet25 mg tablet
1-Covered
PROMETHAZINE HCL 625 MG5 MLSOLN
1-Covered AL1 (At least 2 yrs old)
promethazine hcl 625mg5mlsyrup
1-Covered AL1 (At least 2 yrs old)
ANTILEUKOTRIENESmontelukast sodium 4 mg granpack
1-Covered ST
MONTELUKAST SODIUM 4 MGGRANULES
1-Covered ST
montelukast sodium 4 mg tabchew 5 mg tab chew 10 mgtablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
BRONCHODILATORS ANTICHOLINERGIC (Anticholinergic Drugs toOpen the Airway)
ATROVENT HFA (ipratropiumbromide) 17 MCG INHALER
1-Covered
INCRUSE ELLIPTA (umeclidiniumbromide) 625 MCG INH
1-Covered C (RESTRICTED TO THE DIAGNOSISOF CHRONIC OBSTRUCTIVEPULMONARY DISEASE (COPD))
ipratropium bromide 02 mgmlsolution 21 mcg spray 42 mcgspray
1-Covered
BRONCHODILATORS SYMPATHOMIMETIC (Sympathomimetic Drugsto Open the Airway)
albuterol 90mcg hfa inhaler(generic proair)
1-Covered QL (2 PER 30 [DAYS])
albuterol 90mcg hfa inhaler(generic proventil)
1-Covered QL (2 PER 30 [DAYS])
albuterol 90mcg hfa inhaler(generic ventolin)
1-Covered QL (2 PER 30 [DAYS])
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
122
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALBUTEROL SULFATE 100 MG20 MLSOLN
1-Covered
albuterol sulfate 2 mg tablet 2mg5 ml syrup 25 mg3ml vial-neb 25 mg05 vial-neb 4 mg taber 12h 4 mg tablet 5 mgmlsolution 8 mg tab er 12h
1-Covered
albuterol sulfate 90 mcg hfa aerad
1-Covered QL (2 PER 30 [DAYS])
ALBUTEROL SULFATE HFA 90 MCGINHALER
1-Covered QL (2 PER 30 [DAYS])
epinephrine 015mg03 03mg03 1-Covered QL (2 PER FILL(S))
FORADIL (formoterol fumarate)AEROLIZER 12 MCG CAP
1-Covered ST
levalbuterol tartrate 45 mcg hfaaer ad
1-Covered QL (30 PER 30 DAY(S))
metaproterenol sulfate 10 mg5 mlsyrup 10 mg tablet 20 mg tablet
1-Covered
NASAL DECONGESTANT(pseudoephedrine hcl) 30 MG TAB
1-Covered
pseudoephedrine hcl (NASALDECONGESTANT) 30 mg tablet
1-Covered
pseudoephedrine hcl (SUDOGEST)30 mg tablet 60 mg tablet
1-Covered
pseudoephedrine hcl (SUPHEDRIN)30 mg tablet
1-Covered
pseudoephedrine hcl (SUPHEDRINESINUS CONGESTION) 30 mg tablet
1-Covered
pseudoephedrine hcl(SUPHEDRINE) 30 mg tablet
1-Covered
pseudoephedrine hcl (WAL-PHED)30 mg tablet -
1-Covered
pseudoephedrine hcl 30 mgtablet 60 mg tablet
1-Covered
SEREVENT DISKUS (salmeterolxinafoate) 50 MCG
1-Covered QL (60 PER 30 DAYS)
SUDAFED (pseudoephedrine hcl)30 MG TABLET
1-Covered
TERBUTALINE SULFATE 25 MG TAB 5MG TAB
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
123
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terbutaline sulfate 25 mg tablet 5mg tablet
1-Covered
PHOSPHODIESTERASE INHIBITORS AIRWAYS DISEASE (Drugs thatBlock Phosphodiesterase)
ELIXOPHYLLIN (theophyllineanhydrous) OPHYLLIN 80 MG15 ML
1-Covered
THEO-24 (theophylline anhydrous) -24 ER 200 MG CAPSULE -24 ER 300MG CAPSULE -24 ER 100 MGCAPSULE -24 ER 400 MG CAPSULE
1-Covered
theophylline anhydrous(THEOCHRON) 100 mg tab er 200mg tab er 300 mg tab er
1-Covered
theophylline anhydrous 80mg15ml solution 80 mg15ml elixir100 mg tab er 12h 200 mg tab er12h 300 mg tab er 12h 400 mgtab er 24h 450 mg tab er 12h 600mg tab er 24h
1-Covered
PULMONARY ANTIHYPERTENSIVES (Drugs for PulmonaryHypertension)
ambrisentan 5 mg tablet 10 mgtablet
1-Covered PA QL (1 PER 1 DAY(S)) SP
bosentan 625 mg tablet 125 mgtablet
1-Covered PA QL (2 PER 1 DAY(S)) SP
sildenafil citrate 20 mg tablet 1-Covered PA QL (3 PER 1 DAY(S)) SP
SILDENAFIL CITRATE 20 MG TABLET 1-Covered PA QL (3 PER 1 DAY(S)) SP
tadalafil (ALYQ) 20 mg tablet 1-Covered PA QL (2 PER 1 DAY(S)) SP
tadalafil 20 mg tablet 1-Covered PA QL (2 PER 1 DAY(S)) SP
RESPIRATORY TRACT AGENTS OTHER (Other Drugs for BreathingConditions)
acetylcysteine 100 mgml vial 200mgml vial
1-Covered
benzonatate 100 mg capsule 1-Covered
BEVESPI AEROSPHERE(glycopyrrolateformoterolfumarate) INHALER
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
124
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
brompheniraminemaleatepseudoephedrine hcl(RYNEX PSE)brompheniraminpseudoephedrine 1-15mg5ml liquid
1-Covered
BROTAPP DM (brompheniraminemaleatepseudoephedrinehcldextromethorphan) 1-15-5MG5 ML LIQ
1-Covered
chlorpheniraminemaleatepseudoephedrinedextromethorphan (KIDKARE)chlorpheniraminpseudoepheddm 1-15-5mg5 liquid
1-Covered
codeine phosphateguaifenesin(CHERATUSSIN AC) 10-100mg5liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(G TUSSIN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(GUAIATUSSIN AC) 10-100mg5 20-20010
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(GUAIFENESIN AC) 10-100mg5liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(ROBAFEN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(VIRTUSSIN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin10-100mg5 20-20010
1-Covered AL1 (At least 12 yrs old)
CODEINE-GUAIFENESIN -10-100MG5 ML
1-Covered AL1 (At least 12 yrs old)
COMBIVENT RESPIMAT (ipratropiumbromidealbuterol sulfate) 20-100MCG
1-Covered
COUGH FORMULA DM(guaifenesindextromethorphanhbr) SYRUP
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
125
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fluticasone propionatesalmeterolxinafoate (WIXELA INHUB)propionsalmeterol 100-50 mcgwdev propionsalmeterol 250-50mcg wdev propionsalmeterol500-50 mcg wdev
1-Covered QL (60 PER 30 DAY(S))
fluticasone propionatesalmeterolxinafoate propionsalmeterol 100-50 mcg wdev propionsalmeterol250-50 mcg wdevpropionsalmeterol 500-50 mcgwdev
1-Covered QL (60 PER 30 DAY(S))
fluticasone propionatesalmeterolxinafoate propionsalmeterol 55-14mcg propionsalmeterol 113-14mcg propionsalmeterol 232-14mcg
1-Covered QL (1 PER 30 DAYS)
GUAIASORB DM LIQUID 1-Covered
guaifenesin (MUCUS ER) 600 mgtab er 12h
1-Covered
guaifenesin (MUCUS RELIEF ER) 600mg tab er 12h
1-Covered
GUAIFENESIN-DEXTROMETHORPHAN DM SYRUP
1-Covered
guaifenesindextromethorphanhbr (ADULT ROBITUSSIN PEAK COLDDM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ADULT TUSSIN COUGHCONGEST DM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ADULT TUSSIN DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (ADULT WAL-TUSSIN DM) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (ANTITUSSIVE DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (BIOCOTRON) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (COUGH DM) 100-10mg5syrup
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
126
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesindextromethorphanhbr (DIABETIC SILTUSSIN-DM) 100-10mg5 liquid -
1-Covered
guaifenesindextromethorphanhbr (DIABETIC TUSSIN DM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (EXPECTORANT DM) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (EXTRA ACTION COUGH) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (GERI-TUSSIN DM) 100-10mg5liquid - 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (GILTUSS DIABETIC) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (GILTUSS HBP) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (GUAIASORB DM) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (RI-TUSSIN DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM COUGH) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM COUGH-CHESTCONGEST) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM PEAK COLD)100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN-DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr (SAFETUSSIN DM) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (SILTUSSIN DM DAS) 100-10mg5liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
127
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesindextromethorphanhbr (SILTUSSIN DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (SORBUGEN NR) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSNEL DIABETIC) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSSIN COUGH) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM CLEAR) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM COUGH) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM COUGH-CHESTCONGEST) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM) 100-10mg5 liquid100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (ULTRA DM FREE amp CLEAR) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ULTRA TUSS) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (WAL-TUSSIN DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr 100-10mg5 syrup 100-10mg5liquid
1-Covered
guaifenesinpseudoephedrine hcl(MUCUS D)guaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
guaifenesinpseudoephedrine hcl(MUCUS RELIEF D)guaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
128
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesinpseudoephedrine hclguaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
ipratropium bromidealbuterolsulfate ipratropiumalbuterol 05-3mg3 ampul-neb
1-Covered QL (540 PER 30 DAY(S))
IPRATROPIUM-ALBUTEROL -05-3(25) MG3 ML
1-Covered QL (540 PER 30 DAY(S))
MAXI-TUSS G -LIQUID 1-Covered
MUCUS ER CVS 600 MG TABLET 1-Covered
MUCUS RELIEF ER HM 600 MG TAB 1-Covered
phenylephrine hclpromethazinehcl prometh 5-625mg5 syrup
1-Covered AL1 (At least 2 yrs old)
promethazine hclcodeine 625-105 syrup
1-Covered QL (240 PER 30 DAYS) AL1 (Atleast 12 yrs old) QLC (LIMIT 240ML(8OZ) PER 30 DAYS)
promethazinehcldextromethorphan hbrpromethazinedextromethorphan625-155 syrup
1-Covered AL1 (At least 2 yrs old)
PROMETHAZINE-DM -625-15MG5ML
1-Covered AL1 (At least 2 yrs old)
promethazinephenylephrinehclcodeinepromethazinephenylephcodeine625-5-10 syrup
1-Covered AL1 (At least 12 yrs old)
sodium chloride for inhalation 09 vial- 3 vial- 10 vial-
1-Covered
triprolidine hclpseudoephedrinehcl (APRODINE)triprolidinepseudoephedrine25mg-60mg tablet
1-Covered
triprolidine hclpseudoephedrinehcl (ED A-HIST PSE)triprolidinepseudoephedrine25mg-60mg tablet -
1-Covered
triprolidine hclpseudoephedrinehcl (RITIFED)triprolidinepseudoephedrine 125-305 syrup
1-Covered
triprolidine hclpseudoephedrinehcl (WAL-ACT D COLD amp ALLERGY)triprolidinepseudoephedrine25mg-60mg tablet -col
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
129
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles)
SKELETAL MUSCLE RELAXANTS (Drugs to Relax the Muscles)carisoprodol 350 mg tablet 1-Covered QL (90 PER 30 DAYS)
CARISOPRODOL 350 MG TABLET 1-Covered QL (90 PER 30 DAYS)
cyclobenzaprine hcl 10 mg tablet 1-Covered QL (90 PER 30 DAYS)
cyclobenzaprine hcl 5 mg tablet 1-Covered QL (90 PER 30 DAY(S))
methocarbamol 500 mg tablet750 mg tablet
1-Covered QL (90 PER 30 DAYS)
METHOCARBAMOL 500 MG TABLET750 MG TABLET
1-Covered QL (90 PER 30 DAYS)
VANADOM 350 MG TABLET 1-Covered QL (90 PER 30 DAY(S))
SLEEP DISORDER AGENTS (Drugs for Insomnia)
GABA RECEPTOR MODULATORSflurazepam hcl 15 mg capsule 30mg capsule
1-Covered AL1 (Up to 65 yrs old)
temazepam 75 mg capsule 15mg capsule 30 mg capsule
1-Covered
triazolam 0125 mg tablet 025 mgtablet
1-Covered QL (14 PER 30 DAY(S))
zaleplon 5 mg capsule 10 mgcapsule
1-Covered ST
zolpidem tartrate 5 mg tablet 10mg tablet
1-Covered
SLEEP DISORDERS OTHERdiphenhydramine hcl (ALKA-SELTZER PLUS ALLERGY) 25 mgtablet -
1-Covered
diphenhydramine hcl (COMPOZ)25 mg tablet
1-Covered
diphenhydramine hcl (NIGHTTIMESLEEP AID) 25 mg tablet
1-Covered
diphenhydramine hcl (NYTOLQUICKCAPS) 25 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
130
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
diphenhydramine hcl (SIMPLYSLEEP) 25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP AID)25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP II) 25mg tablet
1-Covered
diphenhydramine hcl (SLEEPTABLET) 25 mg tablet
1-Covered
modafinil 100 mg tablet 200 mgtablet
1-Covered PA QL (3 PER 1 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
131
Alphabetical Index of Prescription Drugs
009 sodium chloride 697072
Aabacavir sulfate 38abacavir sulfatelamivudine 38abacavir sulfatelamivudinezidovudine 38ABACAVIR-LAMIVUDINE 38ABILIFY (aripiprazole) 31ABILIFY MAINTENA (aripiprazole) 31ABILIFY MYCITE (aripiprazole) 31acamprosate calcium 6acarbose 4243acetaminophen 64ACETAMINOPHEN 64acetaminophen (ATHENOL) 63acetaminophen (CHILD FEVER REDUCER) 63acetaminophen (CHILD PAIN REL-FEVERREDUCER) 63acetaminophen (CHILDRENS FEVERREDUCER) 63acetaminophen (CHILDRENS FEVERREDUCING) 63acetaminophen (CHILDRENS PAIN ANDFEVER) 63acetaminophen (CHILDRENS SILAPAP) 63acetaminophen (ED-APAP) 63acetaminophen (LITTLE REMEDIES FEVER-PAIN) 63acetaminophen (M-PAP) 63acetaminophen (MAPAP) 63acetaminophen (MASOPHEN) 63acetaminophen (NON-ASPIRIN EXTRASTRENGTH) 63acetaminophen (NON-ASPIRIN PAIN RELIEF) 63acetaminophen (NON-ASPIRIN) 63acetaminophen (PAIN amp FEVER) 63acetaminophen (PAIN RELIEF EXTRASTRENGTH) 64acetaminophen (PAIN RELIEF) 64
acetaminophen (PAIN RELIEVER) 64acetaminophen (PHARBETOL) 64acetaminophen (SHAKE THAT ACHE) 64acetaminophen (TACTINAL) 64ACETAMINOPHEN 160 MG5ML ORAL SUSP 64ACETAMINOPHEN 160 MG5ML SOLUTION 64acetaminophen with codeine phosphate 45acetazolamide 57ACETAZOLAMIDE 58acetic acid 116ACETIC ACID 116acetylcysteine 124ACID CONTROLLER 80ACID REDUCER 80ACNE MEDICATION 66ACNE MEDICATION (benzoyl peroxide) 66acyclovir 41ACYCLOVIR 41ADACEL TDAP(diphtheriapertussis(acellular)tetanusvaccinepf) 106ADASUVE (loxapine) 30ADLYXIN (lixisenatide) 43ADMELOG (insulin lispro) 45ADMELOG SOLOSTAR (insulin lispro) 45ADVATE (antihemophilic factor (fviii)recombinantfull length) 47ADYNOVATE (antihemophilic factor (fviii)recombinant full length peg) 47AFLURIA QUAD 2020-2021 106AFLURIA QUAD 2020-21 (3YR UP) 106AFSTYLA (antihemophilic factor viiirecombsingle-chnb-dom truncated) 47ALAVERT (loratadine) 117ALAWAY (ketotifen fumarate) 113Albuterol 90mcg HFA inhaler (GenericProair) 122Albuterol 90mcg HFA inhaler (GenericProventil) 122Albuterol 90mcg HFA inhaler (GenericVentolin) 122
LAST UPDATED 12012020132
ALBUTEROL SULFATE 123albuterol sulfate 123ALBUTEROL SULFATE HFA 123alcohol antiseptic pads 110ALCOHOL WIPES 110alendronate sodium 109alfuzosin hcl 86ALL DAY ALLERGY 117ALLERGY RELIEF 117ALLI (orlistat) 78allopurinol 24ALLOPURINOL 24alogliptin benzoate 43alogliptin benzoatemetformin hcl 43alogliptin benzoatepioglitazone hcl 43ALOMIDE (lodoxamide tromethamine) 114ALPHAGAN P (brimonidine tartrate) 115ALPHANATE (antihemophilic factorhumanvon willebrand factorhuman) 47ALPHANINE SD (factor ix) 47alprazolam 42alprazolam (ALPRAZOLAM INTENSOL) 42ALPROLIX (factor ix recombinant fc fusionprotein) 48AMANTADINE 29amantadine hcl 29ambrisentan 124amiloride hcl 58amiloride hclhydrochlorothiazide 56amiodarone hcl 53amiodarone hcl (PACERONE) 53AMITIZA (lubiprostone) 81amitriptyline hcl 19AMLODIPINE BESYLATE 54amlodipine besylate 54amlodipine besylatebenazepril hcl 56ammonium lactate 66ammonium lactate (SKIN TREATMENT) 66amoxapine 19amoxicillin 11AMOXICILLIN-CLAVULANATE POTASS 11
amoxicillinpotassium clavulanate 1112ampicillin trihydrate 12anagrelide hcl 47anastrozole 28ANASTROZOLE 28ANTACID 78ANTACID EXTRA STRENGTH 78ANTI-DIARRHEAL 78ANTIFUNGAL 21apraclonidine hcl 115aprepitant 21APTIVUS (tipranavir) 40APTIVUS (tipranavirvitamin e tpgs) 40aripiprazole 32ARIPIPRAZOLE 32ARISTADA (aripiprazole lauroxil) 32ARISTADA INITIO (aripiprazole lauroxilsubmicronized) 32ARMOUR THYROID (thyroidpork) 102ascorbate calcium 72ascorbic acid 72ascorbic acid (SOOTHING PUREWAY-C) 72aspirin 1aspirin (ADULT ASPIRIN REGIMEN) 1aspirin (ADULT LOW DOSE ASPIRIN EC) 1aspirin (ASPIR 81) 1aspirin (ASPIR-TRIN) 1aspirin (ASPIRIN) 1aspirin (ECOTRIN) 1aspirin (ECPIRIN) 1aspirin (ST JOSEPH ASPIRIN EC) 1aspirin (ST JOSEPH ASPIRIN) 1ASPIRIN 325MG TABLET 1ASPIRIN 81MG TABLET 1aspirinacetaminophencaffeine (ADDEDSTRENGTH HEADACHE) 1aspirinacetaminophencaffeine (BAYERMIGRAINE) 1aspirinacetaminophencaffeine (EXTRA PAINRELIEF) 1
LAST UPDATED 12012020133
aspirinacetaminophencaffeine(EXTRAPRIN) 1aspirinacetaminophencaffeine (HEADACHERELIEF) 1aspirinacetaminophencaffeine (MIGRAINEFORMULA) 2aspirinacetaminophencaffeine (MIGRAINERELIEF) 2aspirinacetaminophencaffeine (PAINRELIEVER PLUS) 2aspirinacetaminophencaffeine (PAINRELIEVER) 2aspirinacetaminophencaffeine (PAIN-OFF) 2ASSURE ID DUO-SHIELD 110ASSURE ID INSULIN SAFETY 110ATAZANAVIR SULFATE 40atazanavir sulfate 40atenolol 53ATENOLOL 53atenololchlorthalidone 56ATHLETES FOOT (terbinafine hcl) 21atomoxetine hcl 62atorvastatin calcium 59ATORVASTATIN CALCIUM 59ATRIPLA (efavirenzemtricitabinetenofovirdisoproxil fumarate) 37atropine sulfate 112ATROVENT HFA (ipratropium bromide) 122AVANDIA (rosiglitazone maleate) 43AVONEX (interferon beta-1a) 65AVONEX (interferon beta-1aalbuminhuman) 65AVONEX PEN (interferon beta-1a) 65azathioprine 104AZATHIOPRINE 104AZELASTINE HCL 117azelastine hcl 117azithromycin 12AZITHROMYCIN 12
Bbacitracin 9BACITRACIN 9bacitracin (BACITRAYCIN PLUS) 9bacitracin zinc 9BACITRACIN ZINC 9bacitracin zinc (ANTIBIOTIC) 9bacitracinpolymyxin b sulfate 112bacitracinpolymyxin b sulfate (AK-POLY-BAC) 112bacitracinpolymyxin b sulfate (POLYCIN) 112baclofen 35BACLOFEN 35balsalazide disodium 109BAQSIMI (glucagon) 44BASAGLAR KWIKPEN U-100 (insulinglarginehuman recombinant analog) 45BELBUCA (buprenorphine hcl) 3benazepril hcl 52benazepril hclhydrochlorothiazide 56BENEFIX (factor ix human recombinant) 48benzonatate 124benzoyl peroxide 67benzoyl peroxide (ACNE CONTROLCLEANSER) 66benzoyl peroxide (ACNE FOAMING WASH) 66benzoyl peroxide (ACNE TREATMENT) 67benzoyl peroxide (ACNECLEAR) 67benzoyl peroxide (ADVANCED EXFOLIATINGCLEANSER) 67benzoyl peroxide (BP WASH) 67benzoyl peroxide (BP) 67benzoyl peroxide (BPO-10) 67benzoyl peroxide (BPO-5) 67benzoyl peroxide (CLEAN-CLEARCONTINUOUS CONTROL) 67benzoyl peroxide (DAYLOGIC ACNEFOAMING WASH) 67benzoyl peroxide (DAYLOGIC ACNETREATMENT) 67
LAST UPDATED 12012020134
benzoyl peroxide (FOAMING ACNE FACEWASH) 67benzoyl peroxide (PANOXYL) 67benztropine mesylate 29BEOVU (brolucizumab-dbll) 112betamethasone dipropionate 87BETAMETHASONE DIPROPIONATE 87betamethasone dipropionatepropyleneglycol 88betamethasone valerate 88betaxolol hcl 115bethanechol chloride 86BETIMOL (timolol) 115BETOPTIC S (betaxolol hcl) 115BEVESPI AEROSPHERE(glycopyrrolateformoterol fumarate) 124BEXSERO (meningococcal group b vaccine4-component) 106bicalutamide 27BIKTARVY (bictegravirsodiumemtricitabinetenofovir alafenamidefumar) 36bisacodyl 82BISACODYL 82bisacodyl (ALOPHEN PILLS) 81bisacodyl (BISA-LAX) 81bisacodyl (BISACODYL) 81bisacodyl (BISCOLAX) 81bisacodyl (C-LAX LAXATIVE) 81bisacodyl (DUCODYL) 81bisacodyl (FAST RELIEF LAXATIVE) 81bisacodyl (GENTLE LAXATIVE) 81bisacodyl (LAXATIVE SUPPOSITORY) 81bisacodyl (LAXATIVE) 82bisacodyl (MAGIC BULLET) 82bisacodyl (WOMENS GENTLE LAXATIVE) 82bisacodyl (WOMENS LAXATIVE) 82bismuth subsalicylate 78bismuth subsalicylate (BISMATROL) 78bismuth subsalicylate (DIOTAME) 78bismuth subsalicylate (PEP-T-MED) 78
bismuth subsalicylate (PEPTIC RELIEF) 78bismuth subsalicylate (PINK BISMUTH) 78bismuth subsalicylate (SOOTHE) 78bismuth subsalicylate (STOMACH RELIEF) 78bisoprolol fumarate 54bisoprolol fumaratehydrochlorothiazide 56BISOPROLOL-HYDROCHLOROTHIAZIDE 56BLEPH-10 (sulfacetamide sodium) 13BLEPHAMIDE (sulfacetamidesodiumprednisolone acetate) 112BOOSTRIX TDAP(diphtheriapertussis(acellular)tetanusvaccine) 106bosentan 124brimonidine tartrate 115bromocriptine mesylate 29brompheniramine maleatepseudoephedrinehcl (RYNEX PSE) 125BROTAPP DM (brompheniraminemaleatepseudoephedrinehcldextromethorphan) 125BUDESONIDE 116budesonide 117bumetanide 58BUNAVAIL (buprenorphine hclnaloxone hcl) 7BUPRENEX (buprenorphine hcl) 7buprenorphine 4buprenorphine hcl 7buprenorphine hclnaloxone hcl 7bupropion hcl 817bupropion hcl (BUPROBAN) 8BUPROPION HCL SR 17BUPROPION XL 17BUSPIRONE HCL 41buspirone hcl 42butalbitalacetaminophen 64butalbitalacetaminophen (TENCON) 64butalbitalacetaminophencaffeine 64butalbitalaspirincaffeine 2butorphanol tartrate 5BUTRANS (buprenorphine) 4
LAST UPDATED 12012020135
CCALADRYL (pramoxine hclcalamine) 67calcipotriene 67calcitoninsalmonsynthetic 110CALCITRIOL 110calcitriol 110CALCIUM 72CALCIUM 500-VIT D3 72CALCIUM 600-VIT D3 72calcium acetate 87calcium acetate (ELIPHOS) 87calcium carbonate 697379calcium carbonate (ANTACID CALCIUM) 78calcium carbonate (ANTACID EXTRASTRENGTH) 78calcium carbonate (ANTACID) 78calcium carbonate (BAN-ACID) 78calcium carbonate (CAL-GEST) 78calcium carbonate (CALCIUM ANTACID) 78calcium carbonate (CHILDRENS PEPTO) 79calcium carbonate (CHILDRENS SOOTHE) 79calcium carbonate (FLAVOR CHEWSANTACID) 79calcium carbonate (OYSCO-500) 72calcium carbonate (SMOOTH ANTACID) 79calcium carbonate (SMOOTH DISSOLVINGANTACID) 79calcium carbonate (SUPER CALCIUM) 72calcium carbonatecholecalciferol (vitamind3) 73calcium carbonatecholecalciferol (vitamind3) (HI-CAL) 73calcium carbonatecholecalciferol (vitamind3) (OS-CAL 500-VIT D3) 73calcium carbonatecholecalciferol (vitamind3) (OYSCO 500-VIT D3) 73calcium carbonatecholecalciferol (vitamind3) (OYSTERCAL-D) 73calcium gluconate 73calcium lactate 73
capecitabine 27CAPECITABINE 27CAPLYTA (lumateperone tosylate) 32captopril 52CAPTOPRIL 52captoprilhydrochlorothiazide 56carbamazepine 16carbamazepine (EPITOL) 16carbamide peroxide (CARBAMOXIDE) 116carbamide peroxide (EAR DROPS) 116carbamide peroxide (EAR SYSTEM) 116carbamide peroxide (EAR WAXREMOVAL) 116carbamide peroxide (MURINE EAR WAXREMOVAL SYSTEM) 116CARBATROL (carbamazepine) 16carbidopalevodopa 30carisoprodol 130CARISOPRODOL 130carvedilol 54cefaclor 11CEFDINIR 11cefdinir 11celecoxib 2CELECOXIB 2CELONTIN (methsuximide) 14cephalexin 11cetirizine hcl 118CETIRIZINE HCL 118cetirizine hcl (24HOUR ALLERGY) 118cetirizine hcl (ALL DAY ALLERGY RELIEF) 118cetirizine hcl (ALL DAY ALLERGY) 118cetirizine hcl (ALLER-TEC) 118cetirizine hcl (ALLERGY RELIEF) 118cetirizine hcl (WAL-ZYR) 118CHANTIX (varenicline tartrate) 8CHEMET (succimer) 70CHILDRENS ALLERGY RELIEF 118CHILDRENS IBUPROFEN 2CHILDRENS NASACORT (triamcinoloneacetonide) 117
LAST UPDATED 12012020136
CHLORDIAZEPOXIDE-CLIDINIUM 77chlordiazepoxideclidinium bromide 77chlorhexidine gluconate 6667chlorhexidine gluconate (PAROEX) 66chloroquine phosphate 28chlorothiazide 58chlorpheniramine maleate 118chlorpheniramine maleate (ALLERGY 4-HOUR) 118chlorpheniramine maleate (ALLERGYRELIEF) 118chlorpheniramine maleate (ALLERGY) 118chlorpheniramine maleate (ALLERGY-TIME) 118chlorpheniramine maleate (CHLORHIST) 118chlorpheniramine maleate (CHLORTABS) 118chlorpheniramine maleate (ED CHLORPEDJR) 118chlorpheniramine maleate(PHARBECHLOR) 118chlorpheniramine maleate (WAL-FINATE) 118chlorpheniraminemaleatepseudoephedrinedextromethorphan (KIDKARE) 125chlorpromazine hcl 30CHLORPROMAZINE HCL 30chlorthalidone 58CHLORTHALIDONE 58cholecalciferol (vitamin d3) 110cholestyramine (with sugar) 59cholestyramineaspartame 59cholestyramineaspartame (PREVALITE) 59ciclopirox 21ciclopirox olamine 2122cilostazol 51CILOXAN (ciprofloxacin hcl) 13CIMDUO (lamivudinetenofovir disoproxilfumarate) 36cimetidine 80CIMETIDINE 80cimetidine (ACID REDUCER) 80
cimetidine (HEARTBURN RELIEF) 80cimetidine hcl 80cinacalcet hcl 110CINACALCET HCL 110ciprofloxacin hcl 13CIPROFLOXACIN HCL 13citalopram hydrobromide 18citric acidsodium citrate 86citric acidsodium citrate (CYTRA-2) 86citric acidsodium citrate (VIRTRATE-2) 86clarithromycin 12clemastine fumarate 119CLEOCIN (clindamycin phosphate) 9clindamycin hcl 9clindamycin palmitate hcl 9clindamycin phosphate 9CLINDAMYCIN PHOSPHATE 9CLINIMIX (amino acids 425 in dextrose 5 in water) 70clobetasol propionate 88CLOBETASOL PROPIONATE 88clomipramine hcl 19CLOMIPRAMINE HCL 19clonazepam 42clonidine hcl 51CLONIDINE HCL 51clopidogrel bisulfate 51clotrimazole 22CLOTRIMAZOLE 22clotrimazole (ANTIFUNGAL RINGWORM) 22clotrimazole (ANTIFUNGAL) 22clotrimazole (ATHLETES FOOT) 22clotrimazole (ATHLETIC FOOT CREAM) 22clotrimazole (CLOTRIMAZOLE AF) 22clotrimazole (ITCH RELIEF) 22clotrimazole (JOCK ITCH RELIEF) 22clotrimazole (JOCK ITCH) 22clotrimazole (RINGWORM) 22clozapine 34CLOZAPINE 34CLOZAPINE ODT 34
LAST UPDATED 12012020137
CLOZARIL (clozapine) 35COAGADEX (coagulation factor x) 48codeinephosphatebutalbitalaspirincaffeine 5codeine phosphateguaifenesin 125codeine phosphateguaifenesin(CHERATUSSIN AC) 125codeine phosphateguaifenesin (G TUSSINAC) 125codeine phosphateguaifenesin(GUAIATUSSIN AC) 125codeine phosphateguaifenesin(GUAIFENESIN AC) 125codeine phosphateguaifenesin (ROBAFENAC) 125codeine phosphateguaifenesin (VIRTUSSINAC) 125codeine sulfate 5CODEINE-GUAIFENESIN 125COGENTIN (benztropine mesylate) 29colchicine 24COLCHICINE 24COLESTID (colestipol hcl) 59colestipol hcl 59COMBIVENT RESPIMAT (ipratropiumbromidealbuterol sulfate) 125COMBIVIR (lamivudinezidovudine) 38COMPLERA (emtricitabinerilpivirinehcltenofovir disoproxil fumarate) 37condoms female 110condoms latex lubricated 110CORIFACT (factor xiii) 48CORTISPORIN (neomycin sulfatepolymyxin bsulfatehydrocortisone) 112CORTISPORIN(neomycinbacitracinpolymyxinbhydrocortisone) 67COUGH FORMULA DM(guaifenesindextromethorphan hbr) 125COUMADIN (warfarin sodium) 46CREON (lipaseproteaseamylase) 85
CRIXIVAN (indinavir sulfate) 40cromolyn sodium 110114cyanocobalamin (vitamin b-12) 73cyanocobalamin (vitamin b-12) (B-12DOTS) 73cyclobenzaprine hcl 130cyclopentolate hcl 112cyclophosphamide 26CYCLOPHOSPHAMIDE 26cyclosporine 104cyclosporine modified 104cyclosporine modified (GENGRAF) 104cyproheptadine hcl 119
Ddanazol 91dapsone 26DEBROX (carbamide peroxide) 116DELSTRIGO (doravirinelamivudinetenofovirdisoproxil fumarate) 37DELTASONE (prednisone) 88DEPAKENE (valproic acid (as sodium salt)(valproate sodium)) 15DEPAKENE (valproic acid) 15DEPO-PROVERA (medroxyprogesteroneacetate) 100DEPO-SUBQ PROVERA 104(medroxyprogesterone acetate) 100DESCOVY (emtricitabinetenofoviralafenamide fumarate) 39desipramine hcl 19desmopressin acetate 90DESMOPRESSIN ACETATE 90desmopressin acetate (non-refrigerated) 90desogestrel-ethinyl estradiol 91desogestrel-ethinyl estradiol (APRI) 91desogestrel-ethinyl estradiol (CYRED EQ) 91desogestrel-ethinyl estradiol (CYRED) 91desogestrel-ethinyl estradiol (EMOQUETTE) 91desogestrel-ethinyl estradiol (ENSKYCE) 91desogestrel-ethinyl estradiol (ISIBLOOM) 91
LAST UPDATED 12012020138
desogestrel-ethinyl estradiol (JULEBER) 91desogestrel-ethinyl estradiol (KALLIGA) 91desogestrel-ethinyl estradiol (RECLIPSEN) 91desogestrel-ethinyl estradiolethinylestradiol 92desogestrel-ethinyl estradiolethinyl estradiol(AZURETTE) 91desogestrel-ethinyl estradiolethinyl estradiol(BEKYREE) 92desogestrel-ethinyl estradiolethinyl estradiol(KARIVA) 92desogestrel-ethinyl estradiolethinyl estradiol(KIMIDESS) 92desogestrel-ethinyl estradiolethinyl estradiol(PIMTREA) 92desogestrel-ethinyl estradiolethinyl estradiol(SIMLIYA) 92desogestrel-ethinyl estradiolethinyl estradiol(VIORELE) 92desogestrel-ethinyl estradiolethinyl estradiol(VOLNEA) 92desonide 88DESONIDE 88dexamethasone 88DEXAMETHASONE 88dexamethasone (DEXAMETHASONEINTENSOL) 88dexamethasone sodium phosphate 114dextroamphetamine sulf-saccharateamphetamine sulf-aspartate 61dextroamphetamine sulfate 62DEXTROAMPHETAMINE SULFATE 62dextroamphetamine sulfate (ZENZEDI) 62DEXTROAMPHETAMINE-AMPHET ER 62dextrose 10 and 045 sodium chloride 70dextrose 10 in water 7073dextrose 5 and 045 sodium chloride 7073dextrose 5 in lactated ringers 73dextrose 5 in water 697073DEXTROSE IN WATER 74diazepam 1542
diclofenac sodium 2114dicloxacillin sodium 12DICYCLOMINE HCL 77dicyclomine hcl 77DIFFERIN (adapalene) 67diflunisal 2digoxin 56digoxin (DIGITEK) 56digoxin (DIGOX) 56DILANTIN (phenytoin sodium extended) 16DILANTIN (phenytoin) 16DILANTIN-125 16DILANTIN-125 (phenytoin) 16DILTIAZEM 24HR ER (CD) 54DILTIAZEM 24HR ER (XR) 55diltiazem hcl 55diltiazem hcl (CARTIA XT) 55diltiazem hcl (DILT-XR) 55diltiazem hcl (TAZTIA XT) 55DIMETHYL FUMARATE 65DIPHENHYDRAMINE HCL 120diphenhydramine hcl 120diphenhydramine hcl (ALER-CAPS) 119diphenhydramine hcl (ALKA-SELTZER PLUSALLERGY) 130diphenhydramine hcl (ALLER-G-TIME) 119diphenhydramine hcl (ALLERGYMEDICATION) 119diphenhydramine hcl (ALLERGYMEDICINE) 119diphenhydramine hcl (ALLERGY RELIEF) 119diphenhydramine hcl (ALLERGY) 119diphenhydramine hcl (BANOPHEN) 119diphenhydramine hcl (BENADRYLALLERGY) 119diphenhydramine hcl (CHILDRENS ALLERGYRELIEF) 119diphenhydramine hcl (CHILDRENSALLERGY) 119diphenhydramine hcl (CHILDRENS BENADRYLALLERGY) 119
LAST UPDATED 12012020139
diphenhydramine hcl (CHILDRENS WAL-DRYLALLERGY) 119diphenhydramine hcl (COMPLETEALLERGY) 119diphenhydramine hcl (COMPOZ) 130diphenhydramine hcl (DIPHEDRYLALLERGY) 119diphenhydramine hcl (DIPHEDRYL) 120diphenhydramine hcl (DIPHEN) 120diphenhydramine hcl (DIPHENHIST) 120diphenhydramine hcl (GERI-DRYL) 120diphenhydramine hcl (M-DRYL) 120diphenhydramine hcl (NIGHTTIME ALLERGYRELIEF) 120diphenhydramine hcl (NIGHTTIME SLEEPAID) 120130diphenhydramine hcl (NYTOL QUICKCAPS)130diphenhydramine hcl (PHARBEDRYL) 120diphenhydramine hcl (SILADRYL) 120diphenhydramine hcl (SIMPLY SLEEP) 120131diphenhydramine hcl (SLEEP AID) 120131diphenhydramine hcl (SLEEP II) 131diphenhydramine hcl (SLEEP TABLET) 131diphenhydramine hcl (TOTAL ALLERGY) 120diphenhydramine hcl (WAL-DRYLALLERGY) 120diphenhydramine hcl (WAL-DRYL) 120diphenoxylate hclatropine sulfate 79DIPHENOXYLATE-ATROPINE 79dipyridamole 51disopyramide phosphate 53disulfiram 6DIURIL (chlorothiazide) 58divalproex sodium 15DIVALPROEX SODIUM 15DOCUSATE SODIUM 82docusate sodium 82docusate sodium (COL-RITE) 82docusate sodium (DIOCTYL) 82docusate sodium (DOCU LIQUID) 82docusate sodium (DOCUSIL) 82
docusate sodium (DSS) 82docusate sodium (DULCOEASE) 82docusate sodium (DULCOLAX STOOLSOFTENER) 82docusate sodium (LAXA BASIC 100) 82docusate sodium (PHILLIPS LAXATIVE) 82docusate sodium (SOF-LAX) 82docusate sodium (STOOL SOFTENER) 82DOK (docusate sodium) 83donepezil hcl 17dorzolamide hcl 115dorzolamide hcltimolol maleate 115DORZOLAMIDE-TIMOLOL 115DOVATO (dolutegravir sodiumlamivudine) 39doxazosin mesylate 51DOXEPIN HCL 19doxepin hcl 19DOXYCYCLINE HYCLATE 14doxycycline hyclate 14doxycycline monohydrate 14DRITHOCREME HP (anthralin) 67dronabinol 21DROPLET MICRON PEN NEEDLE 110DROSPIRENONE-ETHINYL ESTRADIOL 92DROXIA (hydroxyurea) 27DRYSOL (aluminum chloride) 68duloxetine hcl 65
EEES 200 (erythromycin ethylsuccinate) 12EES 400 (erythromycin ethylsuccinate) 12EAR DROPS (carbamide peroxide) 116EDURANT (rilpivirine hcl) 37efavirenz 37EFAVIRENZ-EMTRIC-TENOFOV DISOP 37EFAVIRENZ-LAMIVU-TENOFOV DISOP 3637electrolytesdextrose (ELECTROLYTE) 74electrolytesdextrose (ORALYTE) 74electrolytesdextrose (PEDIATRICELECTROLYTE) 74
LAST UPDATED 12012020140
electrolytesdextrose (PEDIATRIC FREEZERPOPS) 74ELIQUIS (apixaban) 46ELIXOPHYLLIN (theophylline anhydrous) 124ELOCTATE (antihemophilic factor (fviii)recombinant fc fusion protein) 48EMCYT (estramustine phosphate sodium) 27EMSAM (selegiline) 18EMTRICITABINE 38EMTRICITABINE-TENOFOVIR DISOP 38EMTRIVA (emtricitabine) 38ENALAPRIL MALEATE 52enalapril maleate 52ENBREL 105ENBREL (etanercept) 104ENBREL SURECLICK (etanercept) 105ENGERIX-B ADULT (hepatitis b virus vaccinerecombinantpf) 106ENOXAPARIN SODIUM 46enoxaparin sodium 46entacapone 29EPIFOAM (hydrocortisone acetatepramoxinehcl) 68epinephrine 123EPIVIR (lamivudine) 38EPIVIR HBV (lamivudine) 35EPOGEN (epoetin alfa) 47EPZICOM (abacavir sulfatelamivudine) 38ERGOCALCIFEROL 110ergocalciferol (vitamin d2) 110ergocalciferol (vitamin d2) (CALCIDOL) 110ergotamine tartratecaffeine 25ERYTHROCIN STEARATE (erythromycinstearate) 12ERYTHROMYCIN 13erythromycin base 13erythromycin base in ethanol 13erythromycin base in ethanol (ERY) 13erythromycin basebenzoyl peroxide 9ERYTHROMYCIN ETHYLSUCCINATE 13erythromycin ethylsuccinate 13
escitalopram oxalate 18ESCITALOPRAM OXALATE 18ESPEROCT (antihemophilic factor (fviii) rec b-dom truncated peg-exei) 48estradiol 92ESTRADIOL 93estradiol (DOTTI) 92estrogensesterifiedmethyltestosterone 93estrogensesterifiedmethyltestosterone(COVARYX HS) 93estrogensesterifiedmethyltestosterone (EEMTHS) 93ethambutol hcl 26ETHAMBUTOL HCL 26ethinyl estradioldrospirenone 93ethinyl estradioldrospirenone (GIANVI) 93ethinyl estradioldrospirenone (JASMIEL) 93ethinyl estradioldrospirenone (LO-ZUMANDIMINE) 93ethinyl estradioldrospirenone (LORYNA) 93ethinyl estradioldrospirenone (NIKKI) 93ethinyl estradioldrospirenone (VESTURA) 93ETHOSUXIMIDE 14ethosuximide 14ethynodiol diacetate-ethinyl estradiol 93ethynodiol diacetate-ethinyl estradiol(KELNOR 1-35) 93ethynodiol diacetate-ethinyl estradiol(KELNOR 1-50) 93ethynodiol diacetate-ethinyl estradiol (ZOVIA1-35E) 93etodolac 2etonogestrelethinyl estradiol 94etonogestrelethinyl estradiol (ELURYNG) 93etoposide 28EVOTAZ (atazanavir sulfatecobicistat) 40EVZIO (naloxone hcl) 7EXCEDRIN EXTRA STRENGTH(aspirinacetaminophencaffeine) 2EXCEDRIN MIGRAINE(aspirinacetaminophencaffeine) 2
LAST UPDATED 12012020141
EYE ITCH RELIEF 114ezetimibe 59
Ffamotidine 81FAMOTIDINE 81famotidine (ACID CONTROLLER) 80famotidine (ACID REDUCER) 80famotidine (HEARTBURN PREVENTION) 81famotidine (HEARTBURN RELIEF) 81famotidine (PEPCID) 81FANAPT (iloperidone) 32FAZACLO (clozapine) 35FEIBA NF (anti-inhibitor coagulant complex) 48felodipine 55FELODIPINE ER 55fenofibrate 58FENOFIBRATE 58fenofibratemicronized 59fentanyl 4ferrous sulfate 74FERROUS SULFATE 74ferrous sulfate (CHILDRENS IRON) 74ferrous sulfate (FEOSOL) 74ferrous sulfate (FEROSUL) 74ferrous sulfate (FERRO-TIME) 74ferrous sulfate (FERROUSUL) 74ferrous sulfate (PEDIA IRON) 74fexofenadine hcl 121FEXOFENADINE HCL 121fexofenadine hcl (ALLER-EASE) 120fexofenadine hcl (ALLER-FEX) 120fexofenadine hcl (ALLERGY RELIEF) 121fexofenadine hcl (WAL-FEX ALLERGY) 121FIBRYGA (fibrinogen) 48finasteride 86flecainide acetate 53FLOVENT DISKUS (fluticasone propionate) 117FLOVENT HFA (fluticasone propionate) 117FLUAD 2020-2021 106FLUAD QUAD 2020-2021 106
FLUARIX QUAD 2020-2021 106FLUBLOK QUAD 2018-2019 (influenza virusvaccine qv 2018-19(18 yrs andolder)rcmbpf) 106FLUBLOK QUAD 2020-2021 107FLUCELVAX QUAD 2020-2021 107fluconazole 22FLUCONAZOLE 22fluconazole in dextrose iso-osmotic 22flucytosine 22FLUCYTOSINE 22fludrocortisone acetate 88FLULAVAL QUAD 2019-2020 (influenza virusvaccine quadrivalent 2019-20 (6 mos andup)) 107FLULAVAL QUAD 2020-2021 107fluocinolone acetonide 88fluocinonide 88FLUOCINONIDE 88fluoride (sodium) 74fluorometholone 114fluorouracil (ADRUCIL) 27fluoxetine hcl 18FLUOXETINE HCL 18fluoxymesterone (ANDROXY) 91fluphenazine decanoate 30fluphenazine hcl 30FLUPHENAZINE HCL 30flurazepam hcl 130flurbiprofen 2flurbiprofen sodium 114flutamide 27fluticasone propionate 117fluticasone propionate (ALLERGY RELIEF) 117fluticasone propionatesalmeterolxinafoate 126fluticasone propionatesalmeterol xinafoate(WIXELA INHUB) 126fluvoxamine maleate 18FLUZONE HIGH-DOSE QUAD 2020-21 107
LAST UPDATED 12012020142
FLUZONE QUAD 2019-2020 (influenza virusvaccine quadrival 2019-2020(6 mos andup)pf) 107FLUZONE QUAD 2020-2021 107FML FORTE (fluorometholone) 114FML SOP (fluorometholone) 114folic acid 74FOLIC ACID 74FORADIL (formoterol fumarate) 123FOSAMAX PLUS D (alendronatesodiumcholecalciferol (vitamin d3)) 110fosamprenavir calcium 40FOSAMPRENAVIR CALCIUM 40fosinopril sodium 52fosinopril sodiumhydrochlorothiazide 57FOSINOPRIL-HYDROCHLOROTHIAZIDE 57Freestyle Insulix Test Strips 110Freestyle Lite Test Strips 111Freestyle Test Strips 111furosemide 58FUZEON (enfuvirtide) 39
Ggabapentin 15GABAPENTIN 15GARDASIL 9 (human papillomavirus vaccine9-valentpf) 107GAS RELIEF 79GAS RELIEF (simethicone) 79GAS-X (simethicone) 79gemfibrozil 59GEMFIBROZIL 59gentamicin sulfate 8GENTAMICIN SULFATE 9gentamicin sulfate (GENTAK) 8GENTLE LAXATIVE 83GENVOYA(elvitegravircobicistatemtricitabinetenofovir alafenamide) 36GEODON (ziprasidone hcl) 32GEODON (ziprasidone mesylate) 32
GERI-DRYL 121glatiramer acetate 6566glatiramer acetate (GLATOPA) 65GLEOSTINE (lomustine) 26glimepiride 43glipizide 43GLUCAGON EMERGENCY KIT (glucagonhcl) 44GLUCAGON EMERGENCY KIT(glucagonhuman recombinant) 44glyburide 43glyburidemetformin hcl 43glycerin 83glycerin (ADULT GLYCERIN) 83glycerin (LAXATIVE SUPPOSITORY) 83glycerin (PEDIA-LAX) 83glycerin (SUPPOSITORY) 83GOCOVRI (amantadine hcl) 29granisetron hcl 21griseofulvin ultramicrosize 22griseofulvin microsize 23GUAIASORB DM 126guaifenesin (MUCUS ER) 126guaifenesin (MUCUS RELIEF ER) 126GUAIFENESIN-DEXTROMETHORPHAN 126guaifenesindextromethorphan hbr 128guaifenesindextromethorphan hbr (ADULTROBITUSSIN PEAK COLD DM) 126guaifenesindextromethorphan hbr (ADULTTUSSIN COUGH CONGEST DM) 126guaifenesindextromethorphan hbr (ADULTTUSSIN DM) 126guaifenesindextromethorphan hbr (ADULTWAL-TUSSIN DM) 126guaifenesindextromethorphan hbr(ANTITUSSIVE DM) 126guaifenesindextromethorphan hbr(BIOCOTRON) 126guaifenesindextromethorphan hbr (COUGHDM) 126
LAST UPDATED 12012020143
guaifenesindextromethorphan hbr (DIABETICSILTUSSIN-DM) 127guaifenesindextromethorphan hbr (DIABETICTUSSIN DM) 127guaifenesindextromethorphan hbr(EXPECTORANT DM) 127guaifenesindextromethorphan hbr (EXTRAACTION COUGH) 127guaifenesindextromethorphan hbr (GERI-TUSSIN DM) 127guaifenesindextromethorphan hbr (GILTUSSDIABETIC) 127guaifenesindextromethorphan hbr (GILTUSSHBP) 127guaifenesindextromethorphan hbr(GUAIASORB DM) 127guaifenesindextromethorphan hbr (RI-TUSSINDM) 127guaifenesindextromethorphan hbr (ROBAFENDM COUGH) 127guaifenesindextromethorphan hbr (ROBAFENDM COUGH-CHEST CONGEST) 127guaifenesindextromethorphan hbr (ROBAFENDM PEAK COLD) 127guaifenesindextromethorphan hbr(ROBAFEN-DM) 127guaifenesindextromethorphan hbr(SAFETUSSIN DM) 127guaifenesindextromethorphan hbr (SILTUSSINDM DAS) 127guaifenesindextromethorphan hbr (SILTUSSINDM) 128guaifenesindextromethorphan hbr(SORBUGEN NR) 128guaifenesindextromethorphan hbr (TUSNELDIABETIC) 128guaifenesindextromethorphan hbr (TUSSINCOUGH) 128guaifenesindextromethorphan hbr (TUSSINDM CLEAR) 128
guaifenesindextromethorphan hbr (TUSSINDM COUGH) 128guaifenesindextromethorphan hbr (TUSSINDM COUGH-CHEST CONGEST) 128guaifenesindextromethorphan hbr (TUSSINDM) 128guaifenesindextromethorphan hbr (ULTRADM FREE amp CLEAR) 128guaifenesindextromethorphan hbr (ULTRATUSS) 128guaifenesindextromethorphan hbr (WAL-TUSSIN DM) 128guaifenesinpseudoephedrine hcl 129guaifenesinpseudoephedrine hcl (MUCUSD) 128guaifenesinpseudoephedrine hcl (MUCUSRELIEF D) 128guanfacine hcl 5162
HHAILEY FE 94HALDOL (haloperidol lactate) 30HALDOL DECANOATE 100 (haloperidoldecanoate) 30HALDOL DECANOATE 50 (haloperidoldecanoate) 30haloperidol 31HALOPERIDOL 31haloperidol decanoate 31haloperidol lactate 31HALOPERIDOL LACTATE 31HAVRIX (hepatitis a virus vaccinepf) 107HEADACHE RELIEF 2HELIXATE FS (antihemophilic factor (fviii)recombinantfull length) 48HEMLIBRA (emicizumab-kxwh) 48HEMOFIL M (antihemophilic factor human) 48HEPARIN SODIUM 46heparin sodiumporcine 46heparin sodiumporcinepf 46
LAST UPDATED 12012020144
HEPLISAV-B (hepatitis b vaccinerecombinantvaccine adjuvant cpg1018pf) 107HEXALEN (altretamine) 26homatropine hbr 112homatropine hbr (HOMATROPAIRE) 112HUMALOG (insulin lispro) 45HUMALOG MIX 75-25 (insulin lispro protamineand insulin lispro) 45HUMALOG MIX 75-25 KWIKPEN (insulin lisproprotamine and insulin lispro) 45HUMATE-P (antihemophilic factor humanvonwillebrand factorhuman) 48HUMIRA (adalimumab) 105HUMIRA PEDIATRIC CROHNS(adalimumab) 105HUMIRA PEN (adalimumab) 105HUMIRA PEN CROHNS-UC-HS(adalimumab) 105HUMIRA PEN PSOR-UVEITS-ADOL HS(adalimumab) 105HUMIRA(CF) (adalimumab) 105HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 105HUMIRA(CF) PEN (adalimumab) 105HUMIRA(CF) PEN CROHNS-UC-HS(adalimumab) 105HUMIRA(CF) PEN PSOR-UV-ADOL HS(adalimumab) 105HUMULIN 70-30 (insulin nph humanisophaneinsulin regular human) 45HUMULIN 7030 KWIKPEN (insulin nph humanisophaneinsulin regular human) 45HUMULIN N (insulin nph human isophane) 45HUMULIN R (insulin regular human) 45HUMULIN R U-500 (insulin regular human) 45hydralazine hcl 60hydrochlorothiazide 58hydrocodone bitartrateacetaminophen 5hydrocodone bitartrateacetaminophen(LORCET HD) 5
hydrocodone bitartrateacetaminophen(LORTAB) 5hydrocortisone 89109HYDROCORTISONE 89hydrocortisone (ANTI-ITCH) 88hydrocortisone (ANUSOL-HC) 88hydrocortisone (COLOCORT) 109hydrocortisone (CORTISONE) 88hydrocortisone (CORTIZONE-10 PLUS) 89hydrocortisone (CORTIZONE-10) 89hydrocortisone (HYDROCREAM) 89hydrocortisone (NOBLE FORMULA HC) 89hydrocortisone (PREPARATION H) 89hydrocortisone (PROCTO-MED HC) 89hydrocortisone (PROCTO-PAK) 89hydrocortisone (PROCTOSOL-HC) 89hydrocortisone (PROCTOZONE-HC) 89hydrocortisone (SOOTHING CARE) 89HYDROCORTISONE ACETATE 89hydrocortisone acetate 89hydrocortisone acetate (ANUCORT-HC) 89hydrocortisone acetate (ANUSOL-HC) 89hydrocortisone acetate (HEMMOREX-HC) 89hydrocortisone acetatepramoxine hcl 68hydrocortisoneacetic acid 116hydrocortisoneacetic acid (ACETASOLHC) 116hydromorphone hcl 5HYDROXYCHLOROQUINE SULFATE 28hydroxychloroquine sulfate 28hydroxyprogesterone caproate 100hydroxyprogesterone caproatepf 100hydroxyurea 27hydroxyzine hcl 121HYDROXYZINE PAMOATE 121hydroxyzine pamoate 121hyoscyamine sulfate 77hyoscyamine sulfate (HYOSYNE) 77HYPERTET S-D (tetanus immuneglobulinpf) 106
LAST UPDATED 12012020145
Iibuprofen 3IBUPROFEN 3ibuprofen (ADDAPRIN) 2ibuprofen (I-PRIN) 3ibuprofen (IBU) 3ibuprofen (IBU-200) 3ibuprofen (PROVIL) 3ibuprofen (WAL-PROFEN) 3IDELVION (factor ix recombinantalbuminfusion protein) 48imipramine hcl 19IMIPRAMINE HCL 19IMOVAX RABIES VACCINE (rabies vaccinehuman diploid cellpf) 107INCRUSE ELLIPTA (umeclidinium bromide) 122indapamide 58indomethacin 3INFANTS GAS RELIEF 79inhalerassist device with large mask 111inhalerassist device with medium mask 111inhalerassist device with small mask 111insulin lispro 45INSULIN LISPRO PROTAMINE MIX (insulin lisproprotamine and insulin lispro) 45Insulin pen needles 111INSULIN SYRINGE 03 ML 111INSULIN SYRINGE 05 ML 111INSULIN SYRINGE 1 ML 111INTELENCE (etravirine) 37INTRON A (interferon alfa-2brecomb) 35INVEGA (paliperidone) 32INVEGA SUSTENNA (paliperidone palmitate)32INVEGA TRINZA (paliperidone palmitate) 32INVIRASE (saquinavir mesylate) 40IOPIDINE (apraclonidine hcl) 115ipratropium bromide 122ipratropium bromidealbuterol sulfate 129IPRATROPIUM-ALBUTEROL 129irbesartan 52
irbesartanhydrochlorothiazide 57IRON 74ISENTRESS (raltegravir potassium) 36ISENTRESS HD (raltegravir potassium) 36isoniazid 26ISOSORBIDE DINITRATE 60isosorbide dinitrate 60isosorbide mononitrate 60isotretinoin 68isotretinoin (AMNESTEEM) 68isotretinoin (CLARAVIS) 68isotretinoin (MYORISAN) 68isotretinoin (ZENATANE) 68itraconazole 23IXINITY (factor ix human recombinantthreonine 148) 49
JJAKAFI (ruxolitinib phosphate) 28JARDIANCE (empagliflozin) 43JENCYCLA 100JIVI (antihemophilic factor (fviii) rec b-domain deleted peg-aucl) 49JULUCA (dolutegravir sodiumrilpivirine hcl) 39
KKALETRA (lopinavirritonavir) 40KCENTRA (human prothrombin complexconcentrate (pcc) 4-factor) 49ketoconazole 23ketoprofen 3ketorolac tromethamine 114ketotifen fumarate 114ketotifen fumarate (ALLERGY EYE DROPS) 114ketotifen fumarate (EYE ITCH RELIEF) 114ketotifen fumarate (ITCHY EYE) 114ketotifen fumarate (WAL-ZYR) 114ketotifen fumarate (ZADITOR) 114KOGENATE FS (antihemophilic factor (fviii)recombinantfull length) 49
LAST UPDATED 12012020146
KOVALTRY (antihemophilic factor (fviii)recombinantfull length) 49
Llabetalol hcl 54LABETALOL HCL 54lactulose 83lactulose (CONSTULOSE) 83lactulose (ENULOSE) 83lactulose (GENERLAC) 83LAMISIL (terbinafine hcl) 23lamivudine 3538lamivudinezidovudine 38lamotrigine 15lancets 111LANOXIN (digoxin) 57lansoprazole 85LANSOPRAZOLE 85lanthanum carbonate 87latanoprost 115LATUDA (lurasidone hcl) 32leflunomide 106LEFLUNOMIDE 106letrozole 28LEUCOVORIN CALCIUM 27leucovorin calcium 27LEUKERAN (chlorambucil) 26leuprolide acetate 104levalbuterol tartrate 123LEVETIRACETAM 14levetiracetam 14LEVETIRACETAM ER 14LEVO-T (levothyroxine sodium) 103levobunolol hcl 115levocarnitine 70levocarnitine (with sugar) 70levofloxacin 13levonorgestrel 101levonorgestrel (AFTERA) 101levonorgestrel (ECONTRA EZ) 101levonorgestrel (ECONTRA ONE-STEP) 101
levonorgestrel (FALLBACK SOLO) 101levonorgestrel (MY CHOICE) 101levonorgestrel (MY WAY) 101levonorgestrel (NEW DAY) 101levonorgestrel (OPCICON ONE-STEP) 101levonorgestrel (OPTION 2) 101levonorgestrel (TAKE ACTION) 101LEVONORGESTREL-ETH ESTRADIOL 94levonorgestrelethinyl estradiol 96levonorgestrelethinyl estradiol (AFIRMELLE) 94levonorgestrelethinyl estradiol (ALTAVERA) 94levonorgestrelethinyl estradiol (AUBRA EQ) 94levonorgestrelethinyl estradiol (AUBRA) 94levonorgestrelethinyl estradiol (AVIANE) 94levonorgestrelethinyl estradiol (AYUNA) 94levonorgestrelethinyl estradiol (CHATEALEQ) 94levonorgestrelethinyl estradiol (CHATEAL) 94levonorgestrelethinyl estradiol (DELYLA) 94levonorgestrelethinyl estradiol (ENPRESSE) 94levonorgestrelethinyl estradiol (FALMINA) 95levonorgestrelethinyl estradiol (KURVELO) 95levonorgestrelethinyl estradiol (LARISSIA) 95levonorgestrelethinyl estradiol (LESSINA) 95levonorgestrelethinyl estradiol (LEVONEST) 95levonorgestrelethinyl estradiol (LEVORA-28)95levonorgestrelethinyl estradiol (LILLOW) 95levonorgestrelethinyl estradiol (LUTERA) 95levonorgestrelethinyl estradiol (MARLISSA) 95levonorgestrelethinyl estradiol (MYZILRA) 95levonorgestrelethinyl estradiol (ORSYTHIA) 95levonorgestrelethinyl estradiol (PORTIA) 96levonorgestrelethinyl estradiol (SRONYX) 96levonorgestrelethinyl estradiol (TRIVORA-28) 96levonorgestrelethinyl estradiol (VIENVA) 96levothyroxine sodium 103LEVOTHYROXINE SODIUM 103LEVOXYL (levothyroxine sodium) 103LEXIVA (fosamprenavir calcium) 40LICE KILLING 68
LAST UPDATED 12012020147
lidocaine hcl 6LIDOCAINE HCL VISCOUS 6lidocaine hclpf 6lisinopril 52lisinoprilhydrochlorothiazide 57lithium carbonate 42lithium citrate 42LITHOBID (lithium carbonate) 42loperamide hcl 79loperamide hcl (ANTI-DIARRHEAL) 79loperamide hcl (DIAMODE) 79loperamide hcl (ULTRA A-D) 79lopinavirritonavir 40loratadine 121122LORATADINE 122loratadine (ALLERCLEAR) 121loratadine (ALLERGY RELIEF) 121loratadine (ALLERGY) 121loratadine (CHILDRENS ALLERGY RELIEF) 121loratadine (CHILDRENS ALLERGY) 121loratadine (LORADAMED) 121loratadine (NON-DROWSY ALLERGY) 121loratadine (WAL-ITIN) 121lorazepam 42lorazepam (LORAZEPAM INTENSOL) 42LOSARTAN POTASSIUM 52losartan potassium 52losartan potassiumhydrochlorothiazide 57LOSARTAN-HYDROCHLOROTHIAZIDE 57LOTRIMIN AF (clotrimazole) 23lovastatin 59loxapine succinate 31LUCEMYRA (lofexidine hcl) 7LUPRON DEPOT-PED (leuprolide acetate) 104LYLLANA 96LYSODREN (mitotane) 28
MM-M-R II VACCINE (measles mumps andrubella vaccine livepf) 107MAGNESIUM CITRATE 83
magnesium citrate 83MARPLAN (isocarboxazid) 18MATULANE (procarbazine hcl) 26MAXI-TUSS G 129mebendazole (EMVERM) 28MECLIZINE HCL 20meclizine hcl 20meclizine hcl (DRAMAMINE LESS DROWSY) 20meclizine hcl (MEDI-MECLIZINE) 20meclizine hcl (MOTION RELIEF) 20meclizine hcl (MOTION SICKNESS II) 20meclizine hcl (MOTION SICKNESS RELIEF) 20meclizine hcl (MOTION SICKNESS) 20meclizine hcl (MOTION-TIME) 20meclizine hcl (TRAVEL-EASE) 20meclizine hcl (VERTICALM) 20meclizine hcl (WAL-DRAM 2) 20MEDROXYPROGESTERONE ACETATE 101medroxyprogesterone acetate 101mefloquine hcl 28megestrol acetate 101meloxicam 3melphalan 26memantine hcl 17MEMANTINE HCL 17MENACTRA (meningococcalvaccine acyw-135diphtheria toxoid conjpf) 107MENEST (estrogensesterified) 96MENQUADFI 107MENVEO A-C-Y-W-135-DIP(meningococcalvaccine acyw-135diphtheria toxoid conjpf) 108meperidine hcl 5mercaptopurine 27mesalamine 109MESTINON (pyridostigmine bromide) 25metaproterenol sulfate 123metformin hcl 43METFORMIN HCL ER 43METHADONE HCL 4methadone hcl 4
LAST UPDATED 12012020148
methadone hcl (METHADONE INTENSOL) 4methadone hcl (METHADOSE) 4methazolamide 115METHAZOLAMIDE 115methenaminemethylene bluesodphospsalicylatehyoscyamine(PHOSPHASAL) 9methenaminemethylene bluesodphospsalicylatehyoscyamine (URIN DS) 10methimazole 104methocarbamol 130METHOCARBAMOL 130METHOTREXATE 105methotrexate sodium 105methyclothiazide 58methyldopa 51methylergonovine maleate 111METHYLPHENIDATE ER 62methylphenidate hcl 62METHYLPHENIDATE HCL 62methylphenidate hcl (METADATE ER) 62methylprednisolone 89metoclopramide hcl 20metolazone 58metoprolol succinate 54METOPROLOL SUCCINATE 54metoprolol tartrate 54METRO IV (metronidazole in sodiumchloride) 10metronidazole 1068METRONIDAZOLE 10metronidazole in sodium chloride 10mexiletine hcl 53MEXILETINE HCL 53miconazole nitrate 23miconazole nitrate (ANTI-FUNGAL CREAM) 23miconazole nitrate (ANTIFUNGAL CREAM) 23miconazole nitrate (BAZA ANTIFUNGAL) 23miconazole nitrate (INZO ANTIFUNGAL) 23miconazole nitrate (LOTRIMIN AF) 23miconazole nitrate (MICATIN) 23
miconazole nitrate (SECURA ANTIFUNGAL) 23MICROGESTIN 96MICROGESTIN FE 96minocycline hcl 14minoxidil 60mirtazapine 17misoprostol 85modafinil 131moexipril hcl 52molindone hcl 31mometasone furoate 90MONISTAT 3 (miconazole nitrate) 23MONISTAT 7 (miconazole nitrate) 23MONONINE (factor ix) 49montelukast sodium 122MONTELUKAST SODIUM 122morphine sulfate 45moxifloxacin hcl 13MUCUS ER 129MUCUS RELIEF ER 129mupirocin 10mupirocin calcium 10MURINE EAR DROPS (carbamide peroxide) 116MURO-128 (sodium chloride) 112mycophenolate mofetil 105MYLERAN (busulfan) 27MYNATAL (prenatal vitamins withcalciumferrous fumaratefolic acid) 70
NNABI-HB (hepatitis b immune globulin) 106nadolol 54NADOLOL 54naloxone hcl 7naltrexone hcl 7NALTREXONE HCL 7naproxen 3naproxen sodium 3NARCAN (naloxone hcl) 8NARDIL (phenelzine sulfate) 18NASACORT (triamcinolone acetonide) 117
LAST UPDATED 12012020149
NASAL DECONGESTANT (pseudoephedrinehcl) 123nateglinide 43neomycin sulfate 9neomycin sulfatebacitracin zincpolymyxin b(ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxin b(FIRST AID ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxin b(TRIPLE ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxinbhydrocortisone 112neomycin sulfatebacitracin zincpolymyxinbhydrocortisone (NEO-POLYCIN HC) 112neomycin sulfatebacitracinpolymyxin b 113neomycin sulfatebacitracinpolymyxin b(NEO-POLYCIN) 113neomycin sulfatepolymyxin bsulfategramicidin d 113neomycin sulfatepolymyxin bsulfatehydrocortisone 113116NEOMYCIN-POLYMYXIN-HC 116neomycinpolymyxin bsulfatedexamethasone 113nevirapine 37NIACIN 60niacin 60niacin (ENDUR-ACIN) 59niacin (SLO-NIACIN) 59nicardipine hcl 55NICOTINE 14MG PATCH 8NICOTINE 21MG PATCH 8NICOTINE 2MG GUM 8NICOTINE 4MG GUM 8NICOTINE 7MG PATCH 8NICOTINE LOZENGE 8nicotine polacrilex 8nicotine polacrilex (QUIT 2) 8nicotine polacrilex (QUIT 4) 8nicotine polacrilex (STOP SMOKING AID) 8NICOTROL (nicotine) 8
NICOTROL NS (nicotine) 8NIFEDIPINE 55nifedipine 55nifedipine (AFEDITAB CR) 55nifedipine (NIFEDICAL XL) 55NIGHTTIME SLEEP AID 122nisoldipine 55NITRO-BID (nitroglycerin) 60nitrofurantoin 10NITROFURANTOIN 10nitrofurantoin macrocrystal 10nitrofurantoin monohydratemacrocrystals 10nitroglycerin 61NITROGLYCERIN 61nitroglycerin (MINITRAN) 60nitroglycerin (NITRO-TIME) 60nonoxynol 9 (VCF) 86norelgestrominethinyl estradiol (XULANE) 96norethindrone 102norethindrone (CAMILA) 101norethindrone (DEBLITANE) 101norethindrone (ERRIN) 101norethindrone (HEATHER) 102norethindrone (INCASSIA) 102norethindrone (JENCYCLA) 102norethindrone (JOLIVETTE) 102norethindrone (LYZA) 102norethindrone (NORA-BE) 102norethindrone (NORLYDA) 102norethindrone (NORLYROC) 102norethindrone (SHAROBEL) 102norethindrone (TULANA) 102norethindrone acetate 102norethindrone acetate-ethinyl estradiol 97norethindrone acetate-ethinyl estradiol(AUROVELA) 96norethindrone acetate-ethinyl estradiol(GILDESS) 96norethindrone acetate-ethinyl estradiol(HAILEY) 96
LAST UPDATED 12012020150
norethindrone acetate-ethinyl estradiol(JUNEL) 97norethindrone acetate-ethinyl estradiol(LARIN) 97norethindrone acetate-ethinyl estradiol(MICROGESTIN) 97norethindrone acetate-ethinylestradiolferrous fumarate 98norethindrone acetate-ethinylestradiolferrous fumarate (AUROVELA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (BLISOVI FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (JUNEL FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (LARIN FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (MICROGESTINFE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TARINA FE 1-20EQ) 97norethindrone acetate-ethinylestradiolferrous fumarate (TARINA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TILIA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TRI-LEGEST FE) 98norethindrone-ethinyl estradiol (ALYACEN) 98norethindrone-ethinyl estradiol (ARANELLE) 98norethindrone-ethinyl estradiol (BALZIVA) 98norethindrone-ethinyl estradiol (BRIELLYN) 98norethindrone-ethinyl estradiol (CYCLAFEM)98norethindrone-ethinyl estradiol (DASETTA) 98norethindrone-ethinyl estradiol (LEENA) 98norethindrone-ethinyl estradiol (NECON) 98norethindrone-ethinyl estradiol (NORTREL) 98norethindrone-ethinyl estradiol (PHILITH) 98norethindrone-ethinyl estradiol (PIRMELLA) 98norethindrone-ethinyl estradiol (VYFEMLA) 98norethindrone-ethinyl estradiol (WERA) 98
norethindrone-ethinyl estradiol (ZENCHENT) 98NORGESTIMATE-ETHINYL ESTRADIOL 100norgestimate-ethinyl estradiol 100norgestimate-ethinyl estradiol (ESTARYLLA) 98norgestimate-ethinyl estradiol (FEMYNOR) 99norgestimate-ethinyl estradiol (MILI) 99norgestimate-ethinyl estradiol (MONO-LINYAH) 99norgestimate-ethinyl estradiol(MONONESSA) 99norgestimate-ethinyl estradiol (PREVIFEM) 99norgestimate-ethinyl estradiol (SPRINTEC) 99norgestimate-ethinyl estradiol (TRIFEMYNOR) 99norgestimate-ethinyl estradiol (TRI-ESTARYLLA) 99norgestimate-ethinyl estradiol (TRI-LINYAH) 99norgestimate-ethinyl estradiol (TRI-LO-ESTARYLLA) 99norgestimate-ethinyl estradiol (TRI-LO-MARZIA) 99norgestimate-ethinyl estradiol (TRI-LO-MILI) 99norgestimate-ethinyl estradiol (TRI-LO-SPRINTEC) 99norgestimate-ethinyl estradiol (TRI-PREVIFEM) 99norgestimate-ethinyl estradiol (TRI-SPRINTEC) 99norgestimate-ethinyl estradiol (TRI-VYLIBRALO) 99norgestimate-ethinyl estradiol (TRI-VYLIBRA) 99norgestimate-ethinyl estradiol (TRINESSA LO)99norgestimate-ethinyl estradiol (TRINESSA) 99norgestimate-ethinyl estradiol (VYLIBRA) 99norgestrel-ethinyl estradiol (CRYSELLE) 100norgestrel-ethinyl estradiol (ELINEST) 100norgestrel-ethinyl estradiol (LOW-OGESTREL) 100norgestrel-ethinyl estradiol (OGESTREL) 100nortriptyline hcl 19NORVIR (ritonavir) 40
LAST UPDATED 12012020151
NOVOEIGHT (antihemophilic factor viiirecombinant b-domain truncated) 49NOVOLIN 70-30 (insulin nph humanisophaneinsulin regular human) 45NOVOLIN N (insulin nph human isophane) 45NOVOLIN R (insulin regular human) 45NOVOSEVEN RT (coagulation factor viia(recombinant)) 49NUPLAZID (pimavanserin tartrate) 32NUWIQ (antihemophilic factor viii rec hek cellb-domain deleted) 50NYSTATIN 23nystatin 23
OO-CAL PRENATAL (prenatal vit with calciumno127ferrous fumaratefolic acid) 70OBIZUR (antihemophilic factor viiirecombinant porcine sequence) 50ODEFSEY (emtricitabinerilpivirinehcltenofovir alafenamide fumarate) 37ofloxacin 13olanzapine 33olanzapinefluoxetine hcl 17OMEGA-3 ACID ETHYL ESTERS 60omega-3 acid ethyl esters 60omeprazole 85OMEPRAZOLE 85ondansetron 21ondansetron hcl 21ORAP (pimozide) 31oseltamivir phosphate 41OSELTAMIVIR PHOSPHATE 41OSMOLEX ER (amantadine hcl) 29oxazepam 42oxcarbazepine 16oxybutynin chloride 86OXYBUTYNIN CHLORIDE ER 86oxycodone hcl 46oxycodone hclacetaminophen 6oxycodone hclacetaminophen (ENDOCET) 6
oxycodone hclaspirin 6OXYTROL FOR WOMEN (oxybutynin) 86OYSTER SHELL CALCIUM 74OYSTER SHELL CALCIUM-VIT D3 74
PPAIN amp FEVER (acetaminophen) 64PAIN RELIEF 64paliperidone 33pantoprazole sodium 85PANTOPRAZOLE SODIUM 85PARNATE (tranylcypromine sulfate) 18paromomycin sulfate 9paroxetine hcl 18PEDIATRIC IRON 75pediatric multivit with acd3 no21sodiumfluoride 75pediatric multivitamin no16sodiumfluoride 75pediatric multivitamin no2sodium fluoride 75pediatric multivitamin no45sodiumfluorideferrous sulfate 75pediatric multivitamins no17 with sodiumfluoride 75peg 3350sod sulfsod bicarbsodchloridepotassium chloride 83peg 3350sod sulfsod bicarbsodchloridepotassium chloride (GAVILYTE-C) 83peg 3350sod sulfsod bicarbsodchloridepotassium chloride (GAVILYTE-G) 83PEG-3350 AND ELECTROLYTES 83PEGINTRON REDIPEN (peginterferon alfa-2b) 35PEN NEEDLE 111pen needle diabetic 111pen needle diabetic disposable safety 111pen needle diabetic remover and disposalunit 111pen needle diabetic safety 111penicillamine 86PENICILLAMINE 86
LAST UPDATED 12012020152
penicillin v potassium 12pentoxifylline 57PEPTO-BISMOL (bismuth subsalicylate) 79PEPTO-BISMOL TO-GO (bismuthsubsalicylate) 79permethrin 29permethrin (LICE TREATMENT) 29perphenazine 20PERSERIS (risperidone) 33PHENAZOPYRIDINE HCL 87phenazopyridine hcl 87phenazopyridine hcl (URINARY PAIN RELIEF) 86phenelzine sulfate 18phenobarbital 15PHENOBARBITAL 15PHENOXYBENZAMINE HCL 51phenoxybenzamine hcl 51phenylephrine hcl 113phenylephrine hclpromethazine hcl 129phenytoin 16phenytoin sodium extended 16PHOS-FLUR (fluoride (sodium)) 66PHOSPHOLINE IODIDE (echothiophateiodide) 115phytonadione (vit k1) 50PIFELTRO (doravirine) 37pilocarpine hcl 115PILOCARPINE HCL 115pimecrolimus 68pimozide 31pindolol 54pioglitazone hcl 43PIOGLITAZONE HCL 44piperonyl butoxidepyrethrins (LICE KILLING)68piperonyl butoxidepyrethrins (LICE PYRINYLSHAMPOO) 68piperonyl butoxidepyrethrins (LICETREATMENT) 68piperonyl butoxidepyrethrins (RID) 68piperonyl butoxidepyrethrinspermethrin(COMPLETE LICE TREATMENT) 69
piperonyl butoxidepyrethrinspermethrin(LICE SOLUTION) 69piroxicam 3PLAN B ONE-STEP (levonorgestrel) 102PLEGRIDY (peginterferon beta-1a) 66PLEGRIDY PEN (peginterferon beta-1a) 66PNEUMOVAX 23 (pneumococcal 23-valentpolysaccharide vaccine) 108podofilox 69POLY-VITAMIN (multivitamin) 75polyethylene glycol 3350 84polyethylene glycol 3350 (CLEARLAX) 83polyethylene glycol 3350 (GAVILAX) 84polyethylene glycol 3350 (GENTLELAX) 84polyethylene glycol 3350 (GLYCOLAX) 84polyethylene glycol 3350 (LAXACLEAR) 84polyethylene glycol 3350 (NATURA-LAX) 84polyethylene glycol 3350 (POWDERLAX) 84polyethylene glycol 3350 (PURELAX) 84polyethylene glycol 3350 (SMOOTHLAX) 84polymyxin b sulfatetrimethoprim 113POTASSIUM 75potassium bicarbonatecitric acid 75potassium bicarbonatecitric acid (EFFER-K)75potassium bicarbonatecitric acid (KEFFERVESCENT) 75potassium bicarbonatecitric acid (KLOR-CON-EF) 75POTASSIUM CHL-NORMAL SALINE 75potassium chloride 7075POTASSIUM CHLORIDE 71potassium chloride (KLOR-CON M10) 70potassium chloride (KLOR-CON M20) 70potassium chloride (KLOR-CON SPRINKLE) 75potassium chloride in 09 sodiumchloride 7071potassium chloridepotassiumbicarbonatecitric acid 75potassium gluconate 76pramipexole di-hcl 29pramoxine hclcalamine (CALAHIST) 69
LAST UPDATED 12012020153
pramoxine hclcalamine (CALAMINEMEDICATED) 69praziquantel 28prazosin hcl 51PRAZOSIN HCL 51PRED MILD (prednisolone acetate) 114prednisolone 90prednisolone (MILLIPRED DP) 90prednisolone (MILLIPRED) 90prednisolone acetate 114prednisolone sodium phosphate 90114prednisone 90prednisone (PREDNISONE INTENSOL) 90pregabalin 65PREGABALIN 65PREMARIN (estrogens conjugated) 100PREMPHASE (estrogensconjugatedmedroxyprogesteroneacetate) 100PREMPRO (estrogensconjugatedmedroxyprogesteroneacetate) 100PRENATABS FA (prenatal vits with calciumno78ferrous fumaratefolic acid) 71PRENATABS RX (prenatal vitamin with calciumno76ironcarbonylfolic acid) 71PRENATAL MULTIVITAMIN 76prenatal vit with calcium no129ferrousfumaratefolic acid 76prenatal vit with calcium no130ferrousfumaratefolic acid 76prenatal vitamins no121ferrousfumaratefolic acid 76prenatal vitamins with calciumferrousfumaratefolic acid 76prenatal vitamins with calciumferrousfumaratefolic acid (MYNATAL PLUS) 71prenatal vitamins with calciumferrousfumaratefolic acid (MYNATAL-Z) 71prenatal vits with calcium 118ferrousfumaratefolic acid 76
prenatal vits with calcium 118ferrousfumaratefolic acid (SE-NATAL 19) 71prenatal vits with calcium 136ferrousfumaratefolic acid (VINATE-M) 71prenatal vits with calcium 137ferrousfumaratefolic acid 76prenatal vits with calcium 95ferrousfumaratefolic acid 76prenatal vits with calcium no115ironfumaratefolic acid 71prenatal vits with calcium no72ferrousfumaratefolic acid 71prenatal vits with calcium no72ferrousfumaratefolic acid (M-NATAL PLUS) 71prenatal vits with calcium no72ferrousfumaratefolic acid (PREPLUS) 71prenatal vits with calciumno72ironcarbonylfolic acid 72prenatal vits with calcium no74ferrousfumaratefolic acid 72prenatal vits with calcium no96ferrousfumaratefolic acid 76PREVACID (lansoprazole) 85PREVNAR 13 (pneumococcal 13-valentconjugate vaccine (diphtheria crm)pf) 108PREZCOBIX (darunavirethanolatecobicistat) 40PREZISTA (darunavir ethanolate) 40PRIFTIN (rifapentine) 26primaquine phosphate 28primidone 15probenecid 24probenecidcolchicine 24PROBUPHINE (buprenorphine hcl) 7prochlorperazine 20prochlorperazine (COMPRO) 20prochlorperazine maleate 20PROCRIT (epoetin alfa) 47PROCTOFOAM-HC (hydrocortisoneacetatepramoxine hcl) 69
LAST UPDATED 12012020154
PROFILNINE (factor ix complex prothrombincplx conc(pcc) no4 3-factor) 50promethazine hcl 21122PROMETHAZINE HCL 122promethazine hcl (PHENADOZ) 21promethazine hcl (PROMETHEGAN) 21promethazine hclcodeine 129promethazine hcldextromethorphan hbr 129PROMETHAZINE-DM 129promethazinephenylephrine hclcodeine 129propafenone hcl 53propantheline bromide 77proparacaine hcl 113propranolol hcl 54propylthiouracil 104pseudoephedrine hcl 123pseudoephedrine hcl (NASALDECONGESTANT) 123pseudoephedrine hcl (SUDOGEST) 123pseudoephedrine hcl (SUPHEDRIN) 123pseudoephedrine hcl (SUPHEDRINE SINUSCONGESTION) 123pseudoephedrine hcl (SUPHEDRINE) 123pseudoephedrine hcl (WAL-PHED) 123PULMICORT FLEXHALER (budesonide) 117pyrazinamide 26pyridostigmine bromide 25pyridoxine hcl (vitamin b6) 76
Qquetiapine fumarate 33quinapril hcl 52quinidine gluconate 53quinidine sulfate 53QVAR REDIHALER (beclomethasonedipropionate) 117
RRABAVERT (rabies vaccine purified chickenembryo cell (pcec)pf) 108ramipril 52
RAMIPRIL 53REBINYN (factor ix (human) recombinantpegylated) 50RECOMBINATE (antihemophilic factor viiihuman recombinant) 50RECOMBIVAX HB (hepatitis b virus vaccinerecombinantpf) 108RELENZA (zanamivir) 41RESCRIPTOR (delavirdine mesylate) 37REXULTI (brexpiprazole) 33REYATAZ (atazanavir sulfate) 41RHEUMATREX (methotrexate sodium) 105RIASTAP (fibrinogen) 50ribavirin 36ribavirin (RIBASPHERE) 36RID (permethrin) 111RID (piperonylbutoxidepyrethrinspermethrin) 69RIDAURA (auranofin) 106rifabutin 26rifampin 26riluzole 65RILUZOLE 65ringers solution 7076RISPERDAL (risperidone) 33RISPERDAL CONSTA (risperidonemicrospheres) 33RISPERDAL M-TAB (risperidone) 33risperidone 33ritonavir 41RIXUBIS (factor ix human recombinant) 50rizatriptan benzoate 25ropinirole hcl 29rosuvastatin calcium 59RUKOBIA 39
Ssalsalate 3SANDIMMUNE (cyclosporine) 105SANTYL (collagenase clostridiumhistolyticum) 69
LAST UPDATED 12012020155
SAPHRIS (asenapine maleate) 33SAVELLA (milnacipran hcl) 65SE-NATAL-19 (prenatal vitamins no119ironfumaratefolic acid) 72SECUADO (asenapine) 33selegiline hcl 30selenium sulfide 69selenium sulfide (ANTI-DANDRUFF) 69selenium sulfide (MEDICATED DANDRUFFSHAMPOO) 69selenium sulfide (SELSUN BLUE) 69selenium sulfidealoe vera (SELSUN BLUEMOISTURIZING) 69SELZENTRY (maraviroc) 39SEREVENT DISKUS (salmeterol xinafoate) 123SEROQUEL (quetiapine fumarate) 34SEROQUEL XR (quetiapine fumarate) 34sertraline hcl 18sevelamer carbonate 87SEVENFACT 50SHINGRIX (varicella-zoster virus glycoproteinerecas01b adjuvantpf) 108SILACE (docusate sodium) 84sildenafil citrate 124SILDENAFIL CITRATE 124silver sulfadiazine 13simethicone 80simethicone (GAS RELIEF) 80simethicone (GAS-X) 80simethicone (INFANT GAS RELIEF) 80simethicone (INFANTS GAS RELIEF) 80simethicone (MI-ACID) 80simvastatin 59sirolimus 105SODIUM CHLORIDE 7677sodium chloride 113sodium chloride (MURO-128) 113sodium chloride for inhalation 129sodium chloride irrigating solution 707277sodium chloride irrigating solution (AQUACARE SODIUM CHLORIDE) 77
sodium chloride irrigating solution (CURITY) 77sodium chloridesodiumbicarbonatepotassium chloridepeg 84sodium chloridesodiumbicarbonatepotassium chloridepeg(GAVILYTE-N) 84sodium chloridesodiumbicarbonatepotassium chloridepeg (TRILYTEWITH FLAVOR PACKETS) 84sodium polystyrene sulfonate 72sodium polystyrene sulfonatesorbitol solution(KIONEX) 72sodiumpotassiumpotassium citratesodiumcitratecit ac 87sodiumpotassiumpotassium citratesodiumcitratecit ac (CYTRA-3) 87sodiumpotassiumpotassium citratesodiumcitratecit ac (TRICITRATES) 87sofosbuvirvelpatasvir 35SOTALOL 53SOTALOL AF 53sotalol hcl 53sotalol hcl (SORINE) 53spironolactone 58SPIRONOLACTONE 58spironolactonehydrochlorothiazide 57SPS (sodium polystyrene sulfonatesorbitolsolution) 72SSD (silver sulfadiazine) 13stavudine 38STOMACH RELIEF 80STOOL SOFTENER 84STOOL SOFTENER (docusate sodium) 84STRIBILD(elvitegravircobicistatemtricitabinetenofovir disoproxil) 36SUBLOCADE (buprenorphine) 4SUBOXONE (buprenorphine hclnaloxonehcl) 7sucralfate 85SUDAFED (pseudoephedrine hcl) 123
LAST UPDATED 12012020156
sulfacetamide sodium 13sulfacetamide sodiumprednisolone sodiumphosphate 113sulfamethoxazoletrimethoprim 13sulfasalazine 109SULFATRIM (sulfamethoxazoletrimethoprim)14sulindac 3SUMATRIPTAN 25sumatriptan 25sumatriptan succinate 25SUMATRIPTAN SUCCINATE 25SUSTIVA (efavirenz) 37SYMBYAX (olanzapinefluoxetine hcl) 18SYMFI (efavirenzlamivudinetenofovirdisoproxil fumarate) 36SYMFI LO (efavirenzlamivudinetenofovirdisoproxil fumarate) 37SYMTUZA (darunavirethcobicistatemtricitabinetenofoviralafenamide) 41SYNAREL (nafarelin acetate) 104SYNJARDY (empagliflozinmetformin hcl) 44SYNJARDY XR (empagliflozinmetformin hcl) 44SYNTHROID (levothyroxine sodium) 103syringe with needle insulin safety 1 ml 111syringe with needledisposableinsulin 1 ml 111syringe with needleinsulin03 ml 111syringe with needleinsulin05 ml 112
TTABLOID (thioguanine) 27tacrolimus 69106TACROLIMUS 106tadalafil 124tadalafil (ALYQ) 124TAKE ACTION (levonorgestrel) 102TAMOXIFEN CITRATE 27tamoxifen citrate 27tamsulosin hcl 86TDVAX (tetanus and diphtheria toxoidsadult) 108
TECFIDERA (dimethyl fumarate) 66TEGRETOL (carbamazepine) 16TEGRETOL XR (carbamazepine) 16temazepam 130TEMIXYS (lamivudinetenofovir disoproxilfumarate) 36temozolomide 27TENIVAC (tetanus and diphtheria toxoidsadsorbed adultpf) 108tenofovir disoproxil fumarate 38terazosin hcl 52TERAZOSIN HCL 52terbinafine hcl 24terbinafine hcl (ANTIFUNGAL) 24terbinafine hcl (ATHLETES FOOT AF) 24terbinafine hcl (ATHLETES FOOT) 24terbinafine hcl (JOCK ITCH) 2444terbinafine hcl (LAMISIL AT) 24TERBUTALINE SULFATE 123terbutaline sulfate 124testosterone 91testosterone cypionate 91tetanus and diphtheria toxoids adult 108THALOMID (thalidomide) 27THEO-24 (theophylline anhydrous) 124theophylline anhydrous 124theophylline anhydrous (THEOCHRON) 124thioridazine hcl 31thiothixene 31thyroidpork (NP THYROID) 103timolol maleate 115TIMOLOL MALEATE 115tioconazole 24TIVICAY (dolutegravir sodium) 36TIVICAY PD 36tizanidine hcl 35TOBRADEX (tobramycindexamethasone) 113tobramycin 9tobramycindexamethasone 113TOBREX (tobramycin) 9tolbutamide 44
LAST UPDATED 12012020157
tolmetin sodium 3tolnaftate 24tolnaftate (ANTIFUNGAL CREAM) 24tolnaftate (ATHLETES FOOT) 24tolnaftate (FUNGOID-D) 24topiramate 16TOPIRAMATE 16TOREMIFENE CITRATE 27toremifene citrate 27tramadol hcl 6TRAMADOL HCL 6trandolapril 53tranylcypromine sulfate 18TRAVEL SICKNESS (meclizine hcl) 21TRAZODONE HCL 19trazodone hcl 19tretinoin 28TRETTEN (factor xiii a-subunit recombinant) 50TRI-VI-SOL (vitamin a palmitateascorbicacidcholecalciferol (vit d3)) 77triamcinolone acetonide 6690117TRIAMCINOLONE ACETONIDE 66triamcinolone acetonide (ORALONE) 66triamterenehydrochlorothiazide 57triazolam 130trifluoperazine hcl 31trifluridine 41TRIGLIDE (fenofibrate nanocrystallized) 59trihexyphenidyl hcl 29trimethobenzamide hcl 21trimethoprim 10TRINATE (prenatal vits with calciumno73ferrous fumaratefolic acid) 72TRIPLE ANTIBIOTIC 11TRIPLE ANTIBIOTIC (neomycinsulfatebacitracin zincpolymyxin b) 11triprolidine hclpseudoephedrine hcl(APRODINE) 129triprolidine hclpseudoephedrine hcl (ED A-HIST PSE) 129
triprolidine hclpseudoephedrine hcl(RITIFED) 129triprolidine hclpseudoephedrine hcl (WAL-ACT D COLD amp ALLERGY) 129TRIUMEQ (abacavir sulfatedolutegravirsodiumlamivudine) 39TRIZIVIR (abacavirsulfatelamivudinezidovudine) 38TROGARZO (ibalizumab-uiyk) 39trospium chloride 86TROSPIUM CHLORIDE 86TRULICITY 44TRULICITY (dulaglutide) 44TRUMENBA (neisseria meningitidis group blipidated fhbp recombinant) 108TRUVADA (emtricitabinetenofovir disoproxilfumarate) 39TWINRIX (hepatitis a virus and hepatitis b virusvaccinepf) 108TYBOST (cobicistat) 39
UUNIFINE PENTIPS MAXFLOW 112UNITHROID (levothyroxine sodium) 103URETRON D-S (methenaminemethylenebluesod phospsalicylatehyoscyamine) 11URINARY PAIN RELIEF 87ursodiol 80
Vvalacyclovir hcl 41valproic acid 15VALPROIC ACID 15valproic acid (as sodium salt) (valproatesodium) 15valsartan 52valsartanhydrochlorothiazide 57VANADOM 130VANDAZOLE (metronidazole) 11VAQTA (hepatitis a virus vaccinepf) 109
LAST UPDATED 12012020158
VARIVAX VACCINE (varicella virus vaccinelivepf) 109VEMLIDY (tenofovir alafenamide) 35venlafaxine hcl 19VENLAFAXINE HCL ER 19verapamil hcl 55VERSACLOZ (clozapine) 35VICTOZA 2-PAK (liraglutide) 44VICTOZA 3-PAK (liraglutide) 44VIRACEPT (nelfinavir mesylate) 41VIRAMUNE (nevirapine) 38VIRAMUNE XR (nevirapine) 38VIREAD (tenofovir disoproxil fumarate) 39VITAMIN B-12 77VITAMIN C 77VITEKTA (elvitegravir) 36VIVITROL (naltrexone microspheres) 7VONVENDI (von willebrand factor(recombinant)) 50VRAYLAR (cariprazine hcl) 34
Wwarfarin sodium 46warfarin sodium (JANTOVEN) 46WILATE (antihemophilic factor humanvonwillebrand factorhuman) 50
XXARELTO (rivaroxaban) 4647XYNTHA (antihemophilic factor (factor viii)recombb-domain deleted) 51XYNTHA SOLOFUSE (antihemophilic factor(factor viii) recombb-domain deleted) 51
Zzaleplon 130ZERIT (stavudine) 39ZIAGEN (abacavir sulfate) 39ziprasidone hcl 34ZIPRASIDONE HCL 34ZIPRASIDONE MESYLATE 34
ziprasidone mesylate 34zolpidem tartrate 130zonisamide 14ZOSTAVAX (zoster vaccine livepf) 109ZOVIA 1-35 100ZUBSOLV (buprenorphine hclnaloxone hcl) 7ZYPREXA (olanzapine) 34ZYPREXA RELPREVV (olanzapine pamoate) 34ZYPREXA ZYDIS (olanzapine) 34
LAST UPDATED 12012020159
Blue Shield of California Promise Health Plan
601 Potrero Grande Drive Monterey Park CA 91755
vii
H5928_19_269A2_C 08302019
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Discrimination is Against the Law
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gratuitement Appelez le 1-800-605-2556 (TTY 711)
Portuguecircs (Portuguese)
ATENCcedilAtildeO Se fala portuguecircs encontram-se disponiacuteveis serviccedilos linguiacutesticos graacutetis Ligue para 1-
800-605-2556 (TTY 711)
Italiano (Italian)
ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza
linguistica gratuiti Chiamare il numero 1-800-605-2556 (TTY 711)
(Farsi) فارسی
2556-605-800-1 با باشد می فراهم شما برای رایگان بصورت زبانی تسهیلات کنید می گفتگو فارسی زبان به اگر توجه
(TTY 771) بگیرید تماس
ह िदी (Hindi)
धयान द यदद आप द िदी बोलत तो आपक ललए मफत म भाषा स ायता सवाएि उपलबध 1-800-605-
2556 (TTY 711) पर कॉल करHmong (Hmong)
LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb rau koj Hu rau
1-800-605-2556 (TTY 711)
Espantildeol (Spanish)
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica
Llame al 1-800-605-2556 (TTY 711)
Language Assistance Notice for LA County (Continued)
ix
Tiếng Việt (Vietnamese)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-
800-605-2556 (TTY 711)
Tagalog (Tagalog - Filipino)
PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa
wika nang walang bayad Tumawag sa 1-800-605-2556 (TTY 711)
(Arabic) العربية
2556-605-800-1مجان اتصل برقم ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بال
(711YTT)
Polski (Polish)
UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń
pod numer 1-800-605-2556 (TTY 711)
ພາສາລາວ (Lao)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ ໂທຣ 1-800-605-2556 (TTY 711)
日本語 (Japanese)
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1-800-605-
2556(TTY711)までお電話にてご連絡ください
ภาษาไทย (Thai)
เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-800-605-2556 (TTY 711)
λληνικά (Greek)
ΠΡΟΣΟΧΗ Αν μιλάτε ελληνικά στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης
οι οποίες παρέχονται δωρεάν Καλέστε 1-800-605-2556 (TTY 711)
ਪਜਾਬੀ ਦ (Punjabi)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-800-605-
2556 (TTY 711) ਤ ਕਾਲ ਕਰ
ខមែរ (Cambodian)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល
គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-800-605-2556 (TTY 711)
Հայերեն (Armenian)
ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող են
տրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք 1-800-605-2556
(TTY (հեռատիպ)711)
Language Assistance Notice for San Diego County
x
English
ATTENTION Language assistance services free of charge are available to you
Call 1-855-699-5557 (TTY 711)
繁體中文 (Chinese)
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1-855-699-5557(TTY
711)
한국어 (Korean)
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-855-
699-5557 (TTY 711)번으로 전화해 주십시오
Русский (Russian)
ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные
услуги перевода Звоните 1-855-699-5557 (телетайп 711)
Italiano (Italian)
ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di
assistenza linguistica gratuiti Chiamare il numero 1-855-699-5557 (TTY 711)
(Farsi) فارسی
-699-855-1 با باشد می فراهم شما برای رایگان بصورت زبانی تسهیلات کنید می گفتگو فارسی زبان به اگر توجه
5557 (TTY 771) بگیرید تماس
ह िदी (Hindi)
धयान द यदद आप द िदी बोलत तो आपक ललए मफत म भाषा स ायता सवाएि उपलबध 1-855-699-
5557 (TTY 711) पर कॉल कर
Hmong (Hmong)
LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb
rau koj Hu rau 1-855-699-5557 (TTY 711)
Espantildeol (Spanish)
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia
linguumliacutestica Llame al 1-855-699-5557 (TTY 711)
Tiếng Việt (Vietnamese)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho
bạn Gọi số 1-855-699-5557 (TTY 711)
Tagalog (Tagalog - Filipino)
PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga
serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-855-699-5557 (TTY
711)
Language Assistance Notice for San Diego County (Continued)
xi
(Arabic) العربية
5557-699-855-1 برقم اتصل بالمجان لك تتوافر اللغویة المساعدة خدمات فإن اللغة اذكر تتحدث كنت إذا ملحوظة
(711YTT)
ພາສາລາວ (Lao)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ ໂທຣ 1-855-699-5557 (TTY 711)
日本語 (Japanese)
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1-855-699-
5557(TTY711)までお電話にてご連絡ください
ภาษาไทย (Thai)
เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-855-699-5557 (TTY 711)
ਪਜਾਬੀ ਦ (Punjabi)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-855-
699-5557 (TTY 711) ਤ ਕਾਲ ਕਰ
ខមែរ (Cambodian)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល
គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-855-699-5557 (TTY 711)
Հայերեն (Armenian)
ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող են
տրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք 1-855-699-
5557 (TTY (հեռատիպ)711)
Categorical List of Prescription DrugsANALGESICS (Drugs for Pain) 1
ANESTHETICS (Drugs for Numbing) 6
ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS (Drugs for AddictionSubstance Abuse) 6
ANTIBACTERIALS (Drugs for Bacterial Infections) 8
ANTICONVULSANTS (Drugs for Seizures) 14
ANTIDEMENTIA AGENTS (Drugs for Alzheimers Disease and Dementia) 17
ANTIDEPRESSANTS (Drugs for Depression) 17
ANTIEMETICS (Drugs for Nausea and Vomiting) 20
ANTIFUNGALS (Drugs for Fungal Infections) 21
ANTIGOUT AGENTS (Drugs for Gout) 24
ANTIMIGRAINE AGENTS (Drugs for Migraine) 25
ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis) 25
ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections) 26
ANTINEOPLASTICS (Drugs for Cancer) 26
ANTIPARASITICS (Drugs for Parasitic Infections) 28
ANTIPARKINSON AGENTS (Drugs for Parkinsons Disease) 29
ANTIPSYCHOTICS (Drugs for Mental Health) 30
ANTISPASTICITY AGENTS (Drugs for Muscle Spasm) 35
ANTIVIRALS (Drugs for Viral Infections) 35
ANXIOLYTICS (Drugs for Anxiety) 41
BIPOLAR AGENTS (Drugs for Bipolar Disorder) 42
BLOOD GLUCOSE REGULATORS (Drugs for Diabetes) 42
BLOOD PRODUCTSMODIFIERSVOLUME EXPANDERS (Drugs for Blood Disorders) 46
CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation) 51
CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions) 61
DENTAL AND ORAL AGENTS (Drugs for the Mouth) 66
DERMATOLOGICAL AGENTS (Drugs for the Skin) 66
ELECTROLYTESMINERALSMETALSVITAMINS 69
GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach) 77
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERS TREATMENT (Drugs for Genetic or
Enzyme Disorders) 85
GENITOURINARY AGENTS (Drugs for the Genital Bladder and Kidney) 86
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (ADRENAL) (Drugs for
ReplacingStimulating Adrenal Gland Hormones) 87
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (PITUITARY) (Drugs for
ReplacingStimulating Pituitary Gland Hormones) 90
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEX HORMONESMODIFIERS) (Drugs
for ReplacingStimulating Sex Hormones) 91
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (THYROID) (Drugs for the Thyroid) 102
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs for Suppressing Hormones from the Pituitary
Gland) 104
HORMONAL AGENTS SUPPRESSANT (THYROID) (Drugs for the Thyroid) 104
LAST UPDATED 12012020
IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing the Immune System) 104
INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for Inflammatory Bowel Disease) 109
METABOLIC BONE DISEASE AGENTS (Drugs for the Bone) 109
MISCELLANEOUS THERAPEUTIC AGENTS 110
OPHTHALMIC AGENTS (Drugs for the Eyes) 112
OTIC AGENTS (Drugs for the Ears) 116
RESPIRATORY TRACTPULMONARY AGENTS (Drugs for the Lungs) 116
SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles) 130
SLEEP DISORDER AGENTS (Drugs for Insomnia) 130
LAST UPDATED 12012020
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANALGESICS (Drugs for Pain)
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (Pain and ArthritisDrugs)
aspirin (ADULT ASPIRIN REGIMEN)81 mg tablet dr
1-Covered
aspirin (ADULT LOW DOSE ASPIRINEC) 81 mg tablet dr
1-Covered
aspirin (ASPIR 81) mg tablet dr ) 1-Covered
aspirin (ASPIR-TRIN) 325 mg tabletdr -
1-Covered
aspirin (ASPIRIN) 325 mg tablet 1-Covered
aspirin (ECOTRIN) 81 mg tablet dr 1-Covered
aspirin (ECPIRIN) 325 mg tablet dr 1-Covered
aspirin (ST JOSEPH ASPIRIN EC) 81mg tablet dr
1-Covered
aspirin (ST JOSEPH ASPIRIN) 81 mgtab chew
1-Covered
aspirin 325mg tablet 1-Covered
aspirin 81 mg tab chew 81 mgtablet dr 325 mg tablet
1-Covered
ASPIRIN 81MG TABLET ASPIRIN81MG TABLET ASPIRIN 81MGTABLET
1-Covered
aspirinacetaminophencaffeine(ADDED STRENGTH HEADACHE)250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(BAYER MIGRAINE) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(EXTRA PAIN RELIEF) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(EXTRAPRIN) 250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(HEADACHE RELIEF) 250-250-65tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
1
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
aspirinacetaminophencaffeine(MIGRAINE FORMULA) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(MIGRAINE RELIEF) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(PAIN RELIEVER PLUS) 250-250-65tablet
1-Covered
aspirinacetaminophencaffeine(PAIN RELIEVER) 250-250-65 tablet
1-Covered
aspirinacetaminophencaffeine(PAIN-OFF) 250-250-65 tablet -
1-Covered
butalbitalaspirincaffeine 50-325-40 capsule
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
butalbitalaspirincaffeine 50-325-40 tablet
1-Covered
celecoxib 50 mg capsule 100 mgcapsule 200 mg capsule 400 mgcapsule
1-Covered ST
CELECOXIB 50 MG CAPSULE 100MG CAPSULE 200 MG CAPSULE400 MG CAPSULE
1-Covered ST
CHILDRENS IBUPROFEN CHILD 200MG10 ML CHILDREN 100 MG5 ML
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
diclofenac sodium 25 mg tablet dr50 mg tablet dr 75 mg tablet dr100 mg tab er 24h
1-Covered
diflunisal 500 mg tablet 1-Covered
etodolac 600 mg tab er 24h 1-Covered PA
EXCEDRIN EXTRA STRENGTH(aspirinacetaminophencaffeine)CAPLET
1-Covered
EXCEDRIN MIGRAINE(aspirinacetaminophencaffeine)CAPLET GELTAB
1-Covered
flurbiprofen 50 mg tablet 100 mgtablet
1-Covered
HEADACHE RELIEF HM 250-250-65MG CPLT
1-Covered
ibuprofen (ADDAPRIN) 200 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
2
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ibuprofen (I-PRIN) 200 mg tablet - 1-Covered
ibuprofen (IBU) 400 mg tablet 600mg tablet 800 mg tablet
1-Covered
ibuprofen (IBU-200) mg tablet -) 1-Covered
ibuprofen (PROVIL) 200 mg tablet 1-Covered
ibuprofen (WAL-PROFEN) 200 mgtablet -
1-Covered
ibuprofen 100 mg5ml oral susp 1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
IBUPROFEN 400 MG TABLET 600 MGTABLET 800 MG TABLET
1-Covered
ibuprofen 50 mg125 drops susp100 mg tab chew 200 mg tablet400 mg tablet 600 mg tablet 800mg tablet
1-Covered
indomethacin 25 mg capsule 50mg capsule 75 mg capsule er
1-Covered
ketoprofen 50 mg capsule 75 mgcapsule
1-Covered
meloxicam 75 mg tablet 15 mgtablet
1-Covered
naproxen 250 mg tablet 375 mgtablet 500 mg tablet
1-Covered
naproxen sodium 275 mg tablet550 mg tablet
1-Covered
piroxicam 10 mg capsule 20 mgcapsule
1-Covered
salsalate 500 mg tablet 750 mgtablet
1-Covered
sulindac 150 mg tablet 200 mgtablet
1-Covered
tolmetin sodium 200 mg tablet 400mg capsule 600 mg tablet
1-Covered
OPIOID ANALGESICS LONG-ACTING (Long-acting Narcotic PainRelievers)
BELBUCA (buprenorphine hcl) 75MCG FILM 150 MCG FILM 300MCG FILM 450 MCG FILM 600MCG FILM 750 MCG FILM 900MCG FILM
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
3
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
buprenorphine 5 mcghr patch75 mcghr patch 10 mcghrpatch 15 mcghr patch 20mcghr patch
2-MedicalCarve out
BUTRANS (buprenorphine) 5MCGHR PATCH 75 MCGHRPATCH 10 MCGHR PATCH 15MCGHR PATCH 20 MCGHRPATCH
2-MedicalCarve out
fentanyl 25 mcghr patch50mcghr patch 75mcghr patch100 mcghr patch
1-Covered PA QL (10 PER 30 DAY(S))
methadone hcl (METHADONEINTENSOL) 10 mgml oral conc
1-Covered PA
methadone hcl (METHADOSE) 40mg tablet sol
1-Covered PA
METHADONE HCL 10 MG TABLET 1-Covered QL (60 PER 30 DAYS)
METHADONE HCL 10 MGML ORALCONC
1-Covered PA
methadone hcl 5 mg tablet 10 mgtablet
1-Covered QL (60 PER 30 DAYS)
methadone hcl 5 mg5 ml solution10 mg5 ml solution 10 mgml oralconc
1-Covered PA
morphine sulfate 15 mg tablet er 1-Covered QL (90 PER 30 DAYS)
morphine sulfate 30 mg tablet er 1-Covered QL (60 PER 30 DAYS)
morphine sulfate 60 mg tablet er100 mg tablet er 200 mg tablet er
1-Covered PA
oxycodone hcl 10 mg tab er 20mg tab er 40 mg tab er 80 mgtab er
1-Covered PA QL (60 PER 30 DAYS)
SUBLOCADE (buprenorphine) 100MG05 ML SYRING 300 MG15 MLSYRING
2-MedicalCarve out
OPIOID ANALGESICS SHORT-ACTING (Short-acting Narcotic PainRelievers)
acetaminophen with codeinephosphate -15mg tablet -30mgtablet -60mg tablet
1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old) QLC (LIMIT 100TABS TOTAL APAPCODEINETABLETS PER MONTH)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
4
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acetaminophen with codeinephosphate 120-12mg5 solution
1-Covered QL (240 PER 30 DAYS) AL1 (Atleast 12 yrs old)
butorphanol tartrate 10 mgmlspray
1-Covered PA
codeinephosphatebutalbitalaspirincaffeine codeinebutalbitalasacaffein30-50-325 capsule
1-Covered QL (60 PER 30 DAYS) AL1 (At least12 yrs old)
codeine sulfate 15 mg tablet 30mg tablet 60 mg tablet
1-Covered PA AL1 (At least 12 yrs old)
hydrocodonebitartrateacetaminophen(LORCET HD)hydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAY(S))
hydrocodonebitartrateacetaminophen(LORTAB)hydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAY(S))
hydrocodonebitartrateacetaminophenhydrocodoneacetaminophen 5mg-325mg tablethydrocodoneacetaminophen75-325 mg tablethydrocodoneacetaminophen10mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS OF HYDROCODONEPRODUCTS PER 30 DAYS)
hydromorphone hcl 1 mgml liquid3 mg supprect
1-Covered
hydromorphone hcl 2 mg tablet 4mg tablet 8 mg tablet
1-Covered QL (60 PER 30 DAYS)
meperidine hcl 50 mg tablet 100mg tablet
1-Covered QL (100 PER 30 DAYS)
morphine sulfate 10 mg5 ml 20mg5 ml 100 mg5ml
1-Covered PA
morphine sulfate 15 mg tablet 30mg tablet
1-Covered QL (90 PER 30 DAYS)
morphine sulfate 30 mg supprect 1-Covered QL (24 PER 30 DAY(S)) QLC (LIMIT24 SUPPOSITORIES IN 30 DAYS)
morphine sulfate 5 mg 10 mg 20mg
1-Covered QL (24 PER 30 DAY(S)) QLC (LIMIT24 SUPPOSITORIES IN 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
5
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
oxycodone hcl 5 mg capsule 5mg tablet 5 mg5 ml solution 15mg tablet 20 mgml oral conc 30mg tablet
1-Covered PA
oxycodone hclacetaminophen(ENDOCET) 5 mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS PER 30 DAYS OF TOTALOXYCODONE APAP ANDOXYCODONE ASA PER MONTH)
oxycodone hclacetaminophen 5mg-325mg tablet
1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS PER 30 DAYS OF TOTALOXYCODONE APAP ANDOXYCODONE ASA PER MONTH)
oxycodone hclacetaminophen 5-3255 ml solution
1-Covered PA
oxycodone hclaspirin 48355-325tablet
1-Covered QL (100 PER 30 DAY(S))
tramadol hcl 50 mg tablet 1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old)
TRAMADOL HCL 50 MG TABLET 1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old)
ANESTHETICS (Drugs for Numbing)
LOCAL ANESTHETICS (Skin Numbing Drugs)lidocaine hcl 10 mgml vial 1-Covered PA
lidocaine hcl 2 solution 1-Covered
LIDOCAINE HCL VISCOUS 2 SOLN 1-Covered
lidocaine hclpf 10 mgml vial 10mgml ampul
1-Covered PA
ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS (Drugs forAddictionSubstance Abuse)
ALCOHOL DETERRENTSANTI-CRAVING (Drugs for AlcoholDependence)
acamprosate calcium 333 mgtablet dr
2-MedicalCarve out
disulfiram 250 mg tablet 500 mgtablet
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
6
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
naltrexone hcl 50 mg tablet 2-MedicalCarve out
NALTREXONE HCL 50 MG TABLET 2-MedicalCarve out
VIVITROL (naltrexonemicrospheres) 380 MG VIAL +DILUENT
2-MedicalCarve out
OPIOID DEPENDENCE TREATMENTS (Drugs for Opioid Dependence)BUNAVAIL (buprenorphinehclnaloxone hcl) 21-03 MG FILM42-07 MG FILM 63-1 MG FILM
2-MedicalCarve out
BUPRENEX (buprenorphine hcl) 03MGML AMPUL
2-MedicalCarve out
buprenorphine hcl 03 mgml vial03 mgml cartridge 2 mg tab subl8 mg tab subl
2-MedicalCarve out
buprenorphine hclnaloxone hclnaloxone 2 mg-05mg filmnaloxone 2 mg-05mg tab sublnaloxone 4mg-1mg filmnaloxone 8 mg-2 mg filmnaloxone 8 mg-2 mg tab subl
2-MedicalCarve out
LUCEMYRA (lofexidine hcl) 018 MGTABLET
2-MedicalCarve out
PROBUPHINE (buprenorphine hcl)742 MG IMPLANT
2-MedicalCarve out
SUBOXONE (buprenorphinehclnaloxone hcl) 2 MG-05 MGFILM 4 MG-1 MG FILM 8 MG-2 MGFILM 12 MG-3 MG FILM
2-MedicalCarve out
ZUBSOLV (buprenorphinehclnaloxone hcl) 07-018 MGTABLET 14-036 MG TABLET 29-071 MG TABLET 57-14 MG TABLET86-21 MG TABLET 114-29 MGTABLET
2-MedicalCarve out
OPIOID REVERSAL AGENTS (Drugs for Opioid Overdose)EVZIO (naloxone hcl) 04 MGAUTO- 2 MG AUTO-
2-MedicalCarve out
naloxone hcl 04 mgml cartridge04 mgml vial 1 mgml syringe 2mg04ml auto injct
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
7
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NARCAN (naloxone hcl) 4 MGNASAL SPRAY
2-MedicalCarve out
SMOKING CESSATION AGENTS (Drugs to Help Quit Smoking)bupropion hcl (BUPROBAN) 150 mgtab er 12h
1-Covered QL (2 PER 1 DAY(S))
bupropion hcl 150 mg tab er 12h 1-Covered QL (2 PER 1 DAY(S))
CHANTIX (varenicline tartrate) 05MG TABLET 1 MG TABLET 1 MGCONT MONTH BOX STARTINGMONTH BOX
1-Covered PA
nicotine 14mg patch 1-Covered QL (1 PER 1 DAY(S))
nicotine 21mg patch 1-Covered QL (1 PER 1 DAY(S))
nicotine 2mg gum 1-Covered QL (24 PER 1 DAY(S))
nicotine 4mg gum 1-Covered QL (24 PER 1 DAY(S))
nicotine 7mg patch 1-Covered QL (1 PER 1 DAY(S))
NICOTINE LOZENGE 2 MGLOZENGE HM 2 MG LOZENGE 4MG LOZENGE HM 4 MG LOZENGE
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (QUIT 2) mglozenge )
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (QUIT 4) mglozenge )
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex (STOP SMOKINGAID) 2 mg 4 mg
1-Covered QL (24 PER 1 DAY(S))
nicotine polacrilex 2 mg 4 mg 1-Covered QL (24 PER 1 DAY(S))
NICOTROL (nicotine) CARTRIDGEINHALER
1-Covered PA
NICOTROL NS (nicotine) 10 MGMLSPRAY
1-Covered PA
ANTIBACTERIALS (Drugs for Bacterial Infections)
AMINOGLYCOSIDESgentamicin sulfate (GENTAK) 03 oint (g)
1-Covered
gentamicin sulfate 01 oint (g)01 cream (g) 03 oint (g) 03 drops
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
8
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GENTAMICIN SULFATE 01 CREAM 1-Covered
neomycin sulfate 500 mg tablet 1-Covered
paromomycin sulfate 250 mgcapsule
1-Covered
tobramycin 03 drops 1-Covered
TOBREX (tobramycin) 03 EYEOINTMENT
1-Covered
ANTIBACTERIALS OTHERbacitracin (BACITRAYCIN PLUS) 500unitg oint (g)
1-Covered
bacitracin 500 unitg packet 500unitg oint (g)
1-Covered
BACITRACIN 500 UNITGM OINTMNT 1-Covered
bacitracin zinc (ANTIBIOTIC) 500unitg oint (g)
1-Covered
bacitracin zinc 500 unitg ointpack 500 unitg oint (g)
1-Covered
BACITRACIN ZINC ZN 500 UNITGMOINT
1-Covered
CLEOCIN (clindamycin phosphate)100 MG VAGINAL OVULE
1-Covered
clindamycin hcl 75 mg capsule150 mg capsule 300 mg capsule
1-Covered
clindamycin palmitate hcl 75 mg5ml soln recon
1-Covered
clindamycin phosphate 1 gel(gram) 1 lotion 1 med swab1 solution 1 gel daily 2 creamappl
1-Covered
CLINDAMYCIN PHOSPHATE 1SOLUTION 1 GEL
1-Covered
erythromycin basebenzoylperoxide erythromycinbenzoyl 3-5 gel (gram)
1-Covered ST
methenaminemethylenebluesodphospsalicylatehyoscyamine(PHOSPHASAL) methmebluesodphospsalhyos 816-108 tablet
1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
9
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
methenaminemethylenebluesodphospsalicylatehyoscyamine(URIN DS) methmebluesodphospsalhyos 816-108 tablet
1-Covered PA
METRO IV (metronidazole in sodiumchloride) 500 MG100 ML
1-Covered
metronidazole 075 gel wappl250 mg tablet 375 mg capsule500 mg tablet
1-Covered
METRONIDAZOLE 250 MG TABLET500 MG TABLET
1-Covered
metronidazole in sodium chloridemetronidazolesodium 500mg01lpiggyback
1-Covered PA
mupirocin 2 oint (g) 1-Covered QL (22 PER 30 DAY(S))
mupirocin calcium 2 cream (g) 1-Covered PA
neomycin sulfatebacitracinzincpolymyxin b (ANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
neomycin sulfatebacitracinzincpolymyxin b (FIRST AIDANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
neomycin sulfatebacitracinzincpolymyxin b (TRIPLEANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)
1-Covered
nitrofurantoin 25 mg5 ml oral susp 1-Covered
NITROFURANTOIN 50 MG CAP 100MG CAP
1-Covered
nitrofurantoin macrocrystal 50 mgcapsule 100 mg capsule
1-Covered
nitrofurantoinmonohydratemacrocrystalsmonohydm-100 mg capsule
1-Covered
trimethoprim 100 mg tablet 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
10
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRIPLE ANTIBIOTIC (neomycinsulfatebacitracin zincpolymyxinb) CURAD OINT MEDI-FIRSTMEDICHOICE OINTMENTOINTMENT PKT
1-Covered
TRIPLE ANTIBIOTIC HM PKT 1-Covered
URETRON D-S(methenaminemethylenebluesodphospsalicylatehyoscyamine) -TABLET
1-Covered PA
VANDAZOLE (metronidazole)VAGINAL 075 GEL
1-Covered
BETA-LACTAM CEPHALOSPORINScefaclor 125 mg5ml susp recon250 mg5ml susp recon 250 mgcapsule 375 mg5ml susp recon500 mg capsule
1-Covered
CEFDINIR 125 MG5 ML SUSP 250MG5 ML SUSP
1-Covered QL (200 PER 10 DAY(S))
cefdinir 125 mg5ml 250 mg5ml 1-Covered QL (200 PER 10 DAY(S))
cefdinir 300 mg capsule 1-Covered QL (20 PER 10 DAY(S))
cephalexin 125 mg5ml susprecon 250 mg capsule 250mg5ml susp recon 500 mgcapsule
1-Covered
BETA-LACTAM PENICILLINSamoxicillin 125 mg5ml susp recon125 mg tab chew 200 mg5mlsusp recon 250 mg tab chew 250mg5ml susp recon 250 mgcapsule 400 mg5ml susp recon500 mg tablet 500 mg capsule875 mg tablet
1-Covered
AMOXICILLIN-CLAVULANATEPOTASS -600-429 MG5 ML SUS
1-Covered QL (300 PER FILL) QLC (1 FILL IN 30DAYS)
AMOXICILLIN-CLAVULANATEPOTASS -875-125 MG TABLET
1-Covered
amoxicillinpotassium clavulanate1000-625 tab er 12h
1-Covered QL (40 PER FILL(S)) MFL (1 30day(s))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
11
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
amoxicillinpotassium clavulanate200-2855 susp recon 200-285mgtab chew 250-125 mg tablet 400-57mg5 susp recon 400-57mg tabchew 500-125 mg tablet 875-125mg tablet
1-Covered
amoxicillinpotassium clavulanate600-4295 susp recon
1-Covered QL (300 PER FILL) QLC (1 FILL IN 30DAYS)
ampicillin trihydrate 125 mg5mlsusp recon 250 mg capsule 250mg5ml susp recon 500 mgcapsule
1-Covered
dicloxacillin sodium 250 mgcapsule 500 mg capsule
1-Covered
penicillin v potassium 125 mg5mlsoln recon 250 mg5ml soln recon250 mg tablet 500 mg tablet
1-Covered
MACROLIDESazithromycin 1 g packet 1-Covered QL (1 PER 30 DAYS)
azithromycin 100 mg5ml 200mg5ml
1-Covered
AZITHROMYCIN 200 MG5 ML SUSP 1-Covered
azithromycin 250 mg tablet 1-Covered QL (6 PER FILL(S)) MFL (2 30day(s))
AZITHROMYCIN 250 MG TABLET 1-Covered QL (6 PER FILL(S)) MFL (2 30day(s))
azithromycin 500 mg tablet 1-Covered QL (3 PER FILL(S)) MFL (2 30day(s))
AZITHROMYCIN 500 MG TABLET 1-Covered QL (3 PER FILL(S)) MFL (2 30day(s))
azithromycin 600 mg tablet 1-Covered QL (2 PER 7 DAY(S)) MFL (8 28day(s))
clarithromycin 500 mg tablet 1-Covered ST
EES 200 (erythromycinethylsuccinate) MG5 MLSUSPENSION
1-Covered
EES 400 (erythromycinethylsuccinate) FILMTAB
1-Covered
ERYTHROCIN STEARATE(erythromycin stearate) 250 MGFILMTAB
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
12
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ERYTHROMYCIN 250 MG 500 MG 1-Covered
erythromycin base 5 mggramoint (g) 250 mg capsule dr 250mg tablet dr 250 mg tablet 333mg tablet dr 500 mg tablet 500mg tablet dr
1-Covered
erythromycin base in ethanol (ERY)2 med swab
1-Covered
erythromycin base in ethanol 2 solution 2 med swab
1-Covered
ERYTHROMYCIN ETHYLSUCCINATE200 MG5 ML SUSP
1-Covered
erythromycin ethylsuccinate 200mg5ml susp recon 400 mg tablet
1-Covered
QUINOLONESCILOXAN (ciprofloxacin hcl) 03OINTMENT
1-Covered
ciprofloxacin hcl 03 drops 1-Covered
ciprofloxacin hcl 100 mg tablet 1-Covered PA AL1 (At least 18 yrs old)
ciprofloxacin hcl 250 mg tablet500 mg tablet 750 mg tablet
1-Covered AL1 (At least 18 yrs old)
CIPROFLOXACIN HCL 500 MG TAB 1-Covered AL1 (At least 18 yrs old)
levofloxacin 250 mg tablet 500 mgtablet 750 mg tablet
1-Covered AL1 (At least 18 yrs old)
moxifloxacin hcl 400 mg tablet 1-Covered PA AL1 (At least 18 yrs old)
ofloxacin 03 drops 1-Covered QL (5 PER 30 DAY(S))
SULFONAMIDESBLEPH-10 (sulfacetamide sodium) - EYE DROPS
1-Covered
silver sulfadiazine 1 cream (g) 1-Covered
SSD (silver sulfadiazine) 1 CREAM 1-Covered
sulfacetamide sodium 10 oint(g) 10 drops
1-Covered
sulfamethoxazoletrimethoprim200-40mg5 oral susp 400mg-80mgtablet 800-16020 oral susp 800-160 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
13
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SULFATRIM(sulfamethoxazoletrimethoprim)PEDIATRIC SUSPENSION
1-Covered
TETRACYCLINESDOXYCYCLINE HYCLATE 100 MGCAP
1-Covered AL1 (At least 8 yrs old)
doxycycline hyclate 100 mgcapsule
1-Covered AL1 (At least 8 yrs old)
DOXYCYCLINE HYCLATE 20 MG TAB 1-Covered QL (60 PER 30 DAYS)
doxycycline hyclate 20 mg tablet 1-Covered QL (60 PER 30 DAYS)
doxycycline monohydrate 50 mgcapsule 100 mg capsule
1-Covered AL1 (At least 8 yrs old)
minocycline hcl 50 mg capsule100 mg capsule
1-Covered
ANTICONVULSANTS (Drugs for Seizures)
ANTICONVULSANTS OTHER (Other Seizure Control Drugs)LEVETIRACETAM 100 MGML SOLN250 MG TABLET 500 MG5 ML SOLN
1-Covered
levetiracetam 100 mgml solution250 mg tablet 500 mg tablet 500mg5ml solution 750 mg tablet1000 mg tablet
1-Covered
levetiracetam 500 mg tab er 24h 1-Covered MDD (6 Per Day)
levetiracetam 750 mg tab er 24h 1-Covered QL (120 PER 30 DAY(S))
LEVETIRACETAM ER 500 MG TABLET 1-Covered MDD (6 Per Day)
LEVETIRACETAM ER 750 MG TABLET 1-Covered QL (120 PER 30 DAY(S))
CALCIUM CHANNEL MODIFYING AGENTSCELONTIN (methsuximide) 300 MGKAPSEAL
1-Covered
ETHOSUXIMIDE 250 MG CAPSULE 1-Covered
ethosuximide 250 mg5ml solution250 mg capsule
1-Covered
zonisamide 25 mg capsule 50 mgcapsule 100 mg capsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
14
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTSDEPAKENE (valproic acid (assodium salt) (valproate sodium))250 MG5 ML SOLUTION
1-Covered
DEPAKENE (valproic acid) 250 MGCAPSULE
1-Covered
diazepam 5-75-10mg kit 1-Covered
divalproex sodium 125 mg tabletdr 125 mg cap dr spr 250 mgtablet dr 500 mg tablet dr
1-Covered
DIVALPROEX SODIUM DR 125 MGCAP SPRNK
1-Covered
gabapentin 100 mg capsule 250mg5ml solution 300 mg capsule400 mg capsule 600 mg tablet800 mg tablet
1-Covered
GABAPENTIN 100 MG CAPSULE 300MG CAPSULE 400 MG CAPSULE
1-Covered
phenobarbital 15 mg tablet 20mg5 ml elixir 30 mg tablet 324mg tablet 60 mg tablet 648 mgtablet 972mg tablet 100 mgtablet
1-Covered
PHENOBARBITAL 20 MG5 ML SOLN324 MG TABLET 648 MG TABLET972 MG TABLET
1-Covered
primidone 50 mg tablet 250 mgtablet
1-Covered
valproic acid (as sodium salt)(valproate sodium) 250 mg5ml500mg10ml
1-Covered
valproic acid 250 mg capsule 1-Covered
VALPROIC ACID 250 MG CAPSULE 1-Covered
GLUTAMATE REDUCING AGENTSlamotrigine 25 mg tablet 100 mgtablet 150 mg tablet 200 mgtablet
1-Covered
lamotrigine 5 mg 25 mg 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
15
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
topiramate 15 mg cap sprink 25mg tablet 25 mg cap sprink 50mg tablet 100 mg tablet 200 mgtablet
1-Covered
TOPIRAMATE 25 MG TABLET 50 MGTABLET 100 MG TABLET 200 MGTABLET
1-Covered
SODIUM CHANNEL AGENTScarbamazepine (EPITOL) 200 mgtablet
1-Covered
carbamazepine 100 mg cpmp12hr 100 mg5ml oral susp 100 mgtab chew 100 mg tab er 12h 200mg cpmp 12hr 200 mg tab er 12h200 mg tablet 300 mg cpmp 12hr400 mg tab er 12h
1-Covered
CARBATROL (carbamazepine) ER100 MG CAPSULE ER 200 MGCAPSULE ER 300 MG CAPSULE
1-Covered
DILANTIN (phenytoin sodiumextended) 30 MG CAPSULE 100MG CAPSULE
1-Covered
DILANTIN (phenytoin) 50 MGINFATAB
1-Covered
DILANTIN-125 (phenytoin) MG5 MLSUSP
1-Covered
DILANTIN-125 MG5 ML SUSP 1-Covered
oxcarbazepine 150 mg tablet 300mg tablet 600 mg tablet
1-Covered
phenytoin 50 mg tab chew 100mg4ml oral susp 125 mg5ml oralsusp
1-Covered
phenytoin sodium extended 100mg capsule
1-Covered
TEGRETOL (carbamazepine) 100MG5 ML SUSP 200 MG TABLET
1-Covered
TEGRETOL XR (carbamazepine) 100MG TABLET 200 MG TABLET 400MG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
16
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIDEMENTIA AGENTS (Drugs for Alzheimers Disease andDementia)
CHOLINESTERASE INHIBITORSdonepezil hcl 5 mg tab rapdis 5mg tablet 10 mg tab rapdis 10mg tablet
1-Covered
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine hcl 5 mg tablet 10 mgtablet
1-Covered
MEMANTINE HCL 5 MG TABLET 10MG TABLET
1-Covered
ANTIDEPRESSANTS (Drugs for Depression)
ANTIDEPRESSANTS OTHERbupropion hcl 100 mg tab 150 mgtab 200 mg tab
1-Covered QL (60 PER 30 DAYS)
bupropion hcl 150 mg tab er 300mg tab er
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
bupropion hcl 75 mg tablet 100mg tablet
1-Covered
BUPROPION HCL SR SR 100 MGTABLET SR 150 MG TABLET SR 200MG TABLET
1-Covered QL (60 PER 30 DAYS)
BUPROPION XL 150 MG TABLET 300MG TABLET
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
mirtazapine 15 mg tab rapdis 1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old)
mirtazapine 15 mg tablet 30 mgtab rapdis 30 mg tablet 45 mgtab rapdis 45 mg tablet
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)
olanzapinefluoxetine hcl 3 mg-25mg capsule 6mg-25mg capsule6mg-50mg capsule 12mg-50mgcapsule 12mg-25mg capsule
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
17
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SYMBYAX (olanzapinefluoxetinehcl) 3-25 MG CAPSULE 6-50 MGCAPSULE 6-25 MG CAPSULE 12-50MG CAPSULE 12-25 MG CAPSULE
2-MedicalCarve out
MONOAMINE OXIDASE INHIBITORSEMSAM (selegiline) 6 MG24PATCH 9 MG24 PATCH 12 MG24PATCH
2-MedicalCarve out
MARPLAN (isocarboxazid) 10 MGTABLET
2-MedicalCarve out
NARDIL (phenelzine sulfate) 15 MGTABLET
2-MedicalCarve out
PARNATE (tranylcypromine sulfate)10 MG TABLET
2-MedicalCarve out
phenelzine sulfate 15 mg tablet 2-MedicalCarve out
tranylcypromine sulfate 10 mgtablet
2-MedicalCarve out
SSRISSNRIS (SELECTIVE SEROTONIN REUPTAKEINHIBITORSEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)
citalopram hydrobromide 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
escitalopram oxalate 5 mg tablet10 mg tablet 20 mg tablet
1-Covered
ESCITALOPRAM OXALATE 5 MGTABLET 10 MG TABLET 20 MGTABLET
1-Covered
fluoxetine hcl 10 mg capsule 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
fluoxetine hcl 20 mg capsule 1-Covered QL (120 PER 30 DAY(S))
fluoxetine hcl 20 mg5 ml solution 1-Covered
FLUOXETINE HCL 20 MG5 MLSOLUTION
1-Covered
fluvoxamine maleate 25 mg tablet50 mg tablet 100 mg tablet
1-Covered AL1 (At least 8 yrs old)
paroxetine hcl 10 mg tablet 20 mgtablet 30 mg tablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
sertraline hcl 25 mg tablet 50 mgtablet 100 mg tablet
1-Covered QL (60 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
18
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRAZODONE HCL 50 MG TABLET100 MG TABLET
1-Covered
trazodone hcl 50 mg tablet 100mg tablet 150 mg tablet
1-Covered
venlafaxine hcl 25 mg tablet 375mg tablet 50 mg tablet 75 mgtablet 100 mg tablet
1-Covered QL (60 PER 30 DAYS)
venlafaxine hcl 375 mg cap er 75mg cap er 150 mg cap er
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
VENLAFAXINE HCL ER ER 375 MGCAP ER 75 MG CAP ER 150 MGCAP
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
TRICYCLICSamitriptyline hcl 10 mg tablet 25mg tablet 50 mg tablet 75 mgtablet 100 mg tablet 150 mgtablet
1-Covered
amoxapine 25 mg tablet 50 mgtablet 100 mg tablet 150 mgtablet
1-Covered
clomipramine hcl 25 mg capsule50 mg capsule 75 mg capsule
1-Covered PA
CLOMIPRAMINE HCL 25 MGCAPSULE 50 MG CAPSULE 75 MGCAPSULE
1-Covered PA
desipramine hcl 10 mg tablet 25mg tablet 50 mg tablet 75 mgtablet 100 mg tablet 150 mgtablet
1-Covered
DOXEPIN HCL 10 MG CAPSULE 25MG CAPSULE 50 MG CAPSULE 75MG CAPSULE 100 MG CAPSULE
1-Covered
doxepin hcl 10 mgml oral conc10 mg capsule 25 mg capsule 50mg capsule 75 mg capsule 100mg capsule 150 mg capsule
1-Covered
imipramine hcl 10 mg tablet 25mg tablet 50 mg tablet
1-Covered
IMIPRAMINE HCL 10 MG TABLET 25MG TABLET 50 MG TABLET
1-Covered
nortriptyline hcl 10 mg capsule 25mg capsule 50 mg capsule 75 mgcapsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
19
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIEMETICS (Drugs for Nausea and Vomiting)
ANTIEMETICS OTHER (Other Drugs for Nausea and Vomiting)meclizine hcl (DRAMAMINE LESSDROWSY) 25 mg tablet
1-Covered
meclizine hcl (MEDI-MECLIZINE) 25mg tablet -
1-Covered
meclizine hcl (MOTION RELIEF) 25mg tablet
1-Covered
meclizine hcl (MOTION SICKNESS II)25 mg tablet
1-Covered
meclizine hcl (MOTION SICKNESSRELIEF) 25 mg tablet 25 mg tabchew
1-Covered
meclizine hcl (MOTION SICKNESS)25 mg tablet
1-Covered
meclizine hcl (MOTION-TIME) 25 mgtab chew -
1-Covered
meclizine hcl (TRAVEL-EASE) 25 mgtablet -
1-Covered
meclizine hcl (VERTICALM) 25 mgtablet
1-Covered
meclizine hcl (WAL-DRAM 2) 25 mgtablet -
1-Covered
MECLIZINE HCL 125 MG CAPLET 25MG TABLET CHEW
1-Covered
meclizine hcl 125 mg tablet 25mg tab chew 25 mg tablet
1-Covered
metoclopramide hcl 5 mg tablet 5mg5 ml solution 10 mg tablet 10mg10ml solution
1-Covered
perphenazine 2 mg tablet 4 mgtablet 8 mg tablet 16 mg tablet
2-MedicalCarve out
prochlorperazine (COMPRO) 25mg supprect
1-Covered
prochlorperazine 25 mg supprect 1-Covered
prochlorperazine maleate 5 mgtablet 10 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
20
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
promethazine hcl (PHENADOZ)125 mg 25 mg
1-Covered
promethazine hcl (PROMETHEGAN)125 mg 25 mg 50 mg
1-Covered
promethazine hcl 125 mgsupprect 25 mg supprect 50 mgtablet 50 mg supprect
1-Covered
TRAVEL SICKNESS (meclizine hcl) 25MG TAB CHEW
1-Covered
trimethobenzamide hcl 300 mgcapsule
1-Covered
EMETOGENIC THERAPY ADJUNCTS (Drugs for Nausea and Vomiting)aprepitant 40 mg capsule 80 mgcapsule 125mg-80mg cap ds pk125 mg capsule
1-Covered PA
dronabinol 25 mg capsule 5 mgcapsule 10 mg capsule
1-Covered PA
granisetron hcl 1 mg tablet 1-Covered PA
ondansetron 4 mg tab rapdis 8mg tab rapdis
1-Covered QL (12 PER FILL(S)) MDD (3 PerDay) QLC (LIMIT TO 2 FILLS OF 12TABLETS IN 30 DAYS)
ondansetron hcl 4 mg tablet 8 mgtablet
1-Covered QL (12 PER FILL(S)) MDD (3 PerDay) QLC (LIMIT TO 2 FILLS OF 12TABLETS IN 30 DAYS)
ondansetron hcl 4 mg5 mlsolution 24 mg tablet
1-Covered PA
ANTIFUNGALS (Drugs for Fungal Infections)
ANTIFUNGALSANTIFUNGAL 1 TOPICAL CREAM 1-Covered
ATHLETES FOOT (terbinafine hcl) 1CREAM
1-Covered
ciclopirox 077 gel (gram) 1-Covered QLC (100 GRAMSMONTH)
ciclopirox 1 shampoo 1-Covered QLC (120 ozMONTH)
ciclopirox 8 solution 1-Covered
ciclopirox olamine 077 cream(g)
1-Covered QLC (90 GRAMSMONTH)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
21
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ciclopirox olamine 077 suspension
1-Covered QLC (60 MLMONTH)
clotrimazole (ANTIFUNGALRINGWORM) 1 cream (g)
1-Covered
clotrimazole (ANTIFUNGAL) 1 cream (g)
1-Covered
clotrimazole (ATHLETES FOOT) 1 cream (g)
1-Covered
clotrimazole (ATHLETIC FOOTCREAM) 1 cream (g)
1-Covered
clotrimazole (CLOTRIMAZOLE AF) 1 cream (g)
1-Covered
clotrimazole (ITCH RELIEF) 1 cream (g)
1-Covered
clotrimazole (JOCK ITCH RELIEF) 1 cream (g)
1-Covered
clotrimazole (JOCK ITCH) 1 cream (g)
1-Covered
clotrimazole (RINGWORM) 1 cream (g)
1-Covered
clotrimazole 1 cream (g) 1 solution 1 creamappl 10 mgtroche
1-Covered
CLOTRIMAZOLE 1 SOLUTION 1TOPICAL CREAM
1-Covered
fluconazole 10 mgml 40 mgml 1-Covered QL (70 PER 30 DAY(S))
fluconazole 150 mg tablet 1-Covered QL (2 PER 30 DAY(S))
FLUCONAZOLE 200 MG TABLET 1-Covered
fluconazole 50 mg tablet 100 mgtablet 200 mg tablet
1-Covered
fluconazole in dextrose iso-osmotic in dextreiso-200mg01l indextreiso-400mg02l
1-Covered PA
flucytosine 250 mg capsule 500mg capsule
1-Covered
FLUCYTOSINE 250 MG CAPSULE500 MG CAPSULE
1-Covered
griseofulvin ultramicrosize 125 mgtablet 250 mg tablet
1-Covered QL (60 PER 30 DAYS) AL1 (Up to18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
22
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
griseofulvin microsize 125 mg5mloral susp
1-Covered AL1 (Up to 12 yrs old) MDD (20Per Day)
griseofulvin microsize 500 mgtablet
1-Covered QL (60 PER 30 DAYS) AL1 (Up to18 yrs old)
itraconazole 100 mg capsule 1-Covered PA
ketoconazole 2 cream (g) 2 shampoo
1-Covered
ketoconazole 200 mg tablet 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
LAMISIL (terbinafine hcl)ANTIFUNGAL 1 SPRAY
1-Covered
LOTRIMIN AF (clotrimazole) 1CREAM
1-Covered
miconazole nitrate (ANTI-FUNGALCREAM) 2 cream (g) -
1-Covered
miconazole nitrate (ANTIFUNGALCREAM) 2 cream (g)
1-Covered
miconazole nitrate (BAZAANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate (INZOANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate (LOTRIMIN AF) 2 spray
1-Covered
miconazole nitrate (MICATIN) 2 cream (g)
1-Covered
miconazole nitrate (SECURAANTIFUNGAL) 2 cream (g)
1-Covered
miconazole nitrate 2 aero powd2 creamappl 2 cream (g)100 mg suppvag
1-Covered
MONISTAT 3 (miconazole nitrate)4 CREAM
1-Covered
MONISTAT 7 (miconazole nitrate)CREAM
1-Covered
NYSTATIN 100000 UNITGM CREAM100000 UNITGM OINT 100000UNITML SUSP 500000 UNIT5 MLSUS
1-Covered
nystatin 500k unit tablet 100000mloral susp 100000g cream (g)100000g oint (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
23
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terbinafine hcl (ANTIFUNGAL) 1 cream (g)
1-Covered
terbinafine hcl (ATHLETES FOOT AF)1 cream (g)
1-Covered
terbinafine hcl (ATHLETES FOOT) 1 cream (g)
1-Covered
terbinafine hcl (JOCK ITCH) 1 cream (g)
1-Covered
terbinafine hcl (LAMISIL AT) 1 cream (g)
1-Covered
terbinafine hcl 1 cream (g) 250mg tablet
1-Covered
tioconazole 65 oinpf app 1-Covered
tolnaftate (ANTIFUNGAL CREAM) 1 cream (g)
1-Covered
tolnaftate (ATHLETES FOOT) 1 cream (g)
1-Covered
tolnaftate (FUNGOID-D) 1 cream(g) -
1-Covered
tolnaftate 1 cream (g) 1-Covered
ANTIGOUT AGENTS (Drugs for Gout)
ANTIGOUT AGENTSallopurinol 100 mg tablet 300 mgtablet
1-Covered
ALLOPURINOL 100 MG TABLET 300MG TABLET
1-Covered
colchicine 06 mg tablet 1-Covered
COLCHICINE 06 MG TABLET 1-Covered
probenecid 500 mg tablet 1-Covered
probenecidcolchicine 500-05 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
24
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIMIGRAINE AGENTS (Drugs for Migraine)
ERGOT ALKALOIDSergotamine tartratecaffeine 1mg-100mg tablet
1-Covered
SEROTONIN (5-HT) 1B1D RECEPTOR AGONISTSrizatriptan benzoate 5 mg tablet10 mg tablet
1-Covered QL (12 PER 30 DAY(S)) AL1 (Atleast 6 yrs old)
SUMATRIPTAN 5 MG SPRAY 20 MGSPRAY
1-Covered QL (6 PER 30 DAY(S))
sumatriptan 5 mg 20 mg 1-Covered QL (6 PER 30 DAY(S))
sumatriptan succinate 25 mgtablet 50 mg tablet 100 mg tablet
1-Covered QL (9 PER 30 DAY(S))
SUMATRIPTAN SUCCINATE 25 MGTABLET 50 MG TABLET 100 MGTABLET
1-Covered QL (9 PER 30 DAY(S))
SUMATRIPTAN SUCCINATE 6 MG05ML CART
1-Covered QL (2 PER FILL(S)) MFL (1 30day(s))
SUMATRIPTAN SUCCINATE 6 MG05ML INJECT
1-Covered QL (2 PER 30 DAY(S)) MFL (1 30day(s))
sumatriptan succinate 6 mg05mlcartridge 6 mg05ml vial
1-Covered QL (2 PER FILL(S)) MFL (1 30day(s))
sumatriptan succinate 6 mg05mlpen injctr 6 mg05ml syringe
1-Covered QL (2 PER 30 DAY(S)) MFL (1 30day(s))
ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis)
PARASYMPATHOMIMETICSMESTINON (pyridostigminebromide) 60 MG5 ML SOLUTION
1-Covered
pyridostigmine bromide 60 mg5ml solution 60 mg tablet 180 mgtablet er
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
25
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections)
ANTIMYCOBACTERIALS OTHER (Other Drugs for MycobacterialInfection)
dapsone 25 mg tablet 100 mgtablet
1-Covered
rifabutin 150 mg capsule 1-Covered
ANTITUBERCULARS (Drugs for Tuberculosis)ethambutol hcl 100 mg tablet 400mg tablet
1-Covered
ETHAMBUTOL HCL 100 MG TABLET400 MG TABLET
1-Covered
isoniazid 50 mg5 ml solution 100mg tablet 300 mg tablet
1-Covered
PRIFTIN (rifapentine) 150 MG TABLET 1-Covered AL1 (At least 12 yrs old)
pyrazinamide 500 mg tablet 1-Covered
rifampin 150 mg capsule 300 mgcapsule
1-Covered
ANTINEOPLASTICS (Drugs for Cancer)
ALKYLATING AGENTScyclophosphamide 25 mgcapsule 50 mg capsule
1-Covered PA
CYCLOPHOSPHAMIDE 25 MGCAPSULE 50 MG CAPSULE
1-Covered PA
GLEOSTINE (lomustine) 10 MGCAPSULE 40 MG CAPSULE 100 MGCAPSULE
1-Covered PA
HEXALEN (altretamine) 50 MGCAPSULE
1-Covered
LEUKERAN (chlorambucil) 2 MGTABLET
1-Covered PA
MATULANE (procarbazine hcl) 50MG CAPSULE
1-Covered PA SP
melphalan 2 mg tablet 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
26
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
MYLERAN (busulfan) 2 MG TABLET 1-Covered
temozolomide 20 mg capsule 1-Covered PA SP
ANTIANDROGENSbicalutamide 50 mg tablet 1-Covered PA
flutamide 125 mg capsule 1-Covered PA
ANTIANGIOGENIC AGENTSTHALOMID (thalidomide) 50 MGCAPSULE
1-Covered PA SP
ANTIESTROGENSMODIFIERSEMCYT (estramustine phosphatesodium) 140 MG CAPSULE
1-Covered PA
TAMOXIFEN CITRATE 10 MG TABLET 1-Covered
tamoxifen citrate 10 mg tablet 20mg tablet
1-Covered
TOREMIFENE CITRATE 60 MG TAB 1-Covered PA
toremifene citrate 60 mg tablet 1-Covered PA
ANTIMETABOLITEScapecitabine 500 mg tablet 1-Covered PA SP
CAPECITABINE 500 MG TABLET 1-Covered PA SP
DROXIA (hydroxyurea) 200 MGCAPSULE 300 MG CAPSULE 400MG CAPSULE
1-Covered
fluorouracil (ADRUCIL) 25 g50mlvial 5 g100 ml vial
1-Covered PA
hydroxyurea 500 mg capsule 1-Covered PA
mercaptopurine 50 mg tablet 1-Covered PA
TABLOID (thioguanine) 40 MGTABLET
1-Covered PA
ANTINEOPLASTICS OTHERLEUCOVORIN CALCIUM 5 MG TAB25 MG TAB
1-Covered
leucovorin calcium 5 mg tablet 10mg tablet 15 mg tablet 25 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
27
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LYSODREN (mitotane) 500 MGTABLET
1-Covered PA
AROMATASE INHIBITORS 3RD GENERATIONanastrozole 1 mg tablet 1-Covered
ANASTROZOLE 1 MG TABLET 1-Covered
letrozole 25 mg tablet 1-Covered
ENZYME INHIBITORSetoposide 50 mg capsule 1-Covered PA
MOLECULAR TARGET INHIBITORSJAKAFI (ruxolitinib phosphate) 5MG TABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET 25 MGTABLET
1-Covered PA SP QL (2 PER 1 DAY(S))
RETINOIDStretinoin 10 mg capsule 1-Covered PA
ANTIPARASITICS (Drugs for Parasitic Infections)
ANTIHELMINTHICS (Drugs for Worm Infection)mebendazole (EMVERM) 100 mgtab chew
1-Covered
praziquantel 600 mg tablet 1-Covered
ANTIPROTOZOALS (Drugs for Protozoal Infection)chloroquine phosphate 250 mgtablet
1-Covered QL (25 PER 30 DAY(S))
chloroquine phosphate 500 mgtablet
1-Covered PA QL (25 PER 30 DAY(S))
HYDROXYCHLOROQUINE SULFATE200 MG TAB
1-Covered QL (3 PER 1 DAY(S))
hydroxychloroquine sulfate 200 mgtablet
1-Covered QL (3 PER 1 DAY(S))
mefloquine hcl 250 mg tablet 1-Covered
primaquine phosphate 263 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
28
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PEDICULICIDESSCABICIDES (Drugs for Scabies and Lice)permethrin (LICE TREATMENT) 1 liquid
1-Covered
permethrin 5 cream (g) 1-Covered
ANTIPARKINSON AGENTS (Drugs for Parkinsons Disease)
ANTICHOLINERGICSbenztropine mesylate 05 mgtablet 1 mg tablet 2 mg tablet 2mg2 ml ampul 2 mg2 ml vial
2-MedicalCarve out
COGENTIN (benztropine mesylate)2 MG2 ML AMPULE
2-MedicalCarve out
trihexyphenidyl hcl 2 mg5 ml elixir2 mg tablet 5 mg tablet
2-MedicalCarve out
ANTIPARKINSON AGENTS OTHERAMANTADINE 100 MG CAPSULE 2-Medical
Carve out
amantadine hcl 50 mg5 mlsolution 100 mg capsule 100 mgtablet
2-MedicalCarve out
entacapone 200 mg tablet 1-Covered ST
GOCOVRI (amantadine hcl) ER685 MG CAPSULE ER 137 MGCAPSULE
2-MedicalCarve out
OSMOLEX ER (amantadine hcl) ER129 MG TABLET ER 193 MG TABLETER 258 MG TABLET ER 322 MGDAILY DOSE
2-MedicalCarve out
DOPAMINE AGONISTSbromocriptine mesylate 25 mgtablet
1-Covered
pramipexole di-hcl -0125 mgtablet -025 mg tablet -05 mgtablet -075 mg tablet -1 mgtablet -15 mg tablet
1-Covered
ropinirole hcl 025 mg tablet 05mg tablet 1 mg tablet 2 mgtablet 3 mg tablet 4 mg tablet 5mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
29
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DOPAMINE PRECURSORSL-AMINO ACID DECARBOXYLASEINHIBITORS
carbidopalevodopa 10mg-100mgtablet 25mg-100mg tablet 25mg-100mg tablet er 25mg-250mgtablet 50mg-200mg tablet er
1-Covered
MONOAMINE OXIDASE B (MAO-B) INHIBITORSselegiline hcl 5 mg tablet 5 mgcapsule
1-Covered
ANTIPSYCHOTICS (Drugs for Mental Health)
1ST GENERATIONTYPICALADASUVE (loxapine) 10 MG POWD10 MG POWDR
2-MedicalCarve out
chlorpromazine hcl 10 mg tablet25 mg tablet 25 mgml ampul 50mg tablet 100 mg tablet 200 mgtablet
2-MedicalCarve out
CHLORPROMAZINE HCL 10 MGTABLET 25 MGML AMPULE 25 MGTABLET 50 MG TABLET 50 MG2 MLAMP 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
fluphenazine decanoate 25 mgmlvial
2-MedicalCarve out
fluphenazine hcl 1 mg tablet 25mg tablet 25 mg5ml elixir 25mgml vial 5 mgml oral conc 5mg tablet 10 mg tablet
2-MedicalCarve out
FLUPHENAZINE HCL 1 MG TABLET25 MG TABLET 5 MG TABLET 10MG TABLET
2-MedicalCarve out
HALDOL (haloperidol lactate) 5MGML AMPUL
2-MedicalCarve out
HALDOL DECANOATE 100(haloperidol decanoate) AMPUL
2-MedicalCarve out
HALDOL DECANOATE 50(haloperidol decanoate) AMPUL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
30
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
haloperidol 05 mg tablet 1 mgtablet 2 mg tablet 5 mg tablet 10mg tablet 20 mg tablet
2-MedicalCarve out
HALOPERIDOL 5 MG TABLET 2-MedicalCarve out
haloperidol decanoate 50 mgmlvial 50 mgml ampul 100 mgmlampul 100 mgml vial
2-MedicalCarve out
haloperidol lactate 2 mgml oralconc 5 mgml vial 5 mgmlampul 5 mgml syringe
2-MedicalCarve out
HALOPERIDOL LACTATE 5 MGMLSYRING
2-MedicalCarve out
loxapine succinate 5 mg capsule10 mg capsule 25 mg capsule 50mg capsule
2-MedicalCarve out
molindone hcl 5 mg tablet 10 mgtablet 25 mg tablet
2-MedicalCarve out
ORAP (pimozide) 1 MG TABLET 2MG TABLET
2-MedicalCarve out
pimozide 1 mg tablet 2 mg tablet 2-MedicalCarve out
thioridazine hcl 10 mg tablet 25mg tablet 50 mg tablet 100 mgtablet
2-MedicalCarve out
thiothixene 1 mg capsule 2 mgcapsule 5 mg capsule 10 mgcapsule
2-MedicalCarve out
trifluoperazine hcl 1 mg tablet 2mg tablet 5 mg tablet 10 mgtablet
2-MedicalCarve out
2ND GENERATIONATYPICALABILIFY (aripiprazole) 2 MG TABLET5 MG TABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET 30 MGTABLET
2-MedicalCarve out
ABILIFY MAINTENA (aripiprazole) ER300 MG VL ER 300 MG SYR ER 400MG SYR ER 400 MG VL
2-MedicalCarve out
ABILIFY MYCITE (aripiprazole) 2 MGKIT 5 MG KIT 10 MG KIT 15 MG KIT20 MG KIT 30 MG KIT
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
31
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
aripiprazole 1 mgml solution 2 mgtablet 5 mg tablet 10 mg tabrapdis 10 mg tablet 15 mg tablet15 mg tab rapdis 20 mg tablet 30mg tablet
2-MedicalCarve out
ARIPIPRAZOLE 1 MGML SOLUTION2 MG TABLET 5 MG TABLET 10 MGTABLET 15 MG TABLET 20 MGTABLET 30 MG TABLET
2-MedicalCarve out
ARISTADA (aripiprazole lauroxil) ER441 MG16 ML SYRN ER 662MG24 ML SYRN ER 882 MG32ML SYRN ER 1064 MG39 ML SYR
2-MedicalCarve out
ARISTADA INITIO (aripiprazolelauroxil submicronized) ER 675MG24
2-MedicalCarve out
CAPLYTA (lumateperone tosylate)42 MG CAPSULE
2-MedicalCarve out
FANAPT (iloperidone) 1 MG TABLET2 MG TABLET 4 MG TABLET 6 MGTABLET 8 MG TABLET 10 MGTABLET 12 MG TABLET TITRATIONPACK
2-MedicalCarve out
GEODON (ziprasidone hcl) 20 MGCAPSULE 40 MG CAPSULE 60 MGCAPSULE 80 MG CAPSULE
2-MedicalCarve out
GEODON (ziprasidone mesylate)20 MGML VIAL
2-MedicalCarve out
INVEGA (paliperidone) ER 15 MGTABLET ER 3 MG TABLET ER 6 MGTABLET ER 9 MG TABLET
2-MedicalCarve out
INVEGA SUSTENNA (paliperidonepalmitate) 39 MG025 ML 78MG05 ML 117 MG075 ML 156MGML SYRG 234 MG15 ML
2-MedicalCarve out
INVEGA TRINZA (paliperidonepalmitate) 273 MG0875 ML 410MG1315 ML 546 MG175 ML 819MG2625 ML
2-MedicalCarve out
LATUDA (lurasidone hcl) 20 MGTABLET 40 MG TABLET 60 MGTABLET 80 MG TABLET 120 MGTABLET
2-MedicalCarve out
NUPLAZID (pimavanserin tartrate)10 MG TABLET 17 MG TABLET 34MG CAPSULE
2-MedicalCarve out
SP
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
32
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
olanzapine 25 mg tablet 5 mgtab rapdis 5 mg tablet 75 mgtablet 10 mg tab rapdis 10 mgtablet 10 mg vial 15 mg tabrapdis 15 mg tablet 20 mg tablet20 mg tab rapdis
2-MedicalCarve out
paliperidone 15 mg tab er 24 3mg tab er 24 6 mg tab er 24 9 mgtab er 24
2-MedicalCarve out
PERSERIS (risperidone) ER 90 MGSYRINGE KIT ER 120 MG SYRINGEKIT
2-MedicalCarve out
quetiapine fumarate 25 mg tablet50 mg tab er 24h 50 mg tablet100 mg tablet 150 mg tab er 24h200 mg tab er 24h 200 mg tablet300 mg tablet 300 mg tab er 24h400 mg tab er 24h 400 mg tablet
2-MedicalCarve out
REXULTI (brexpiprazole) 025 MGTABLET 05 MG TABLET 1 MGTABLET 2 MG TABLET 3 MG TABLET4 MG TABLET
2-MedicalCarve out
RISPERDAL (risperidone) 025 MGTABLET 05 MG TABLET 1 MGMLSOLUTION 1 MG TABLET 2 MGTABLET 3 MG TABLET 4 MG TABLET
2-MedicalCarve out
RISPERDAL CONSTA (risperidonemicrospheres) 125 MG VIAL 25MG VIAL 375 MG VIAL 50 MGVIAL
2-MedicalCarve out
RISPERDAL M-TAB (risperidone) -TAB05 G ODT -TAB 1 G ODT -TAB 2 GODT -TAB 3 G ODT -TAB 4 G ODT
2-MedicalCarve out
risperidone 025 mg tab rapdis025 mg tablet 05 mg tab rapdis05 mg tablet 1 mg tablet 1mgml solution 1 mg tab rapdis 2mg tab rapdis 2 mg tablet 3 mgtablet 3 mg tab rapdis 4 mg tabrapdis 4 mg tablet
2-MedicalCarve out
SAPHRIS (asenapine maleate) 25MG TAB 5 MG TAB 10 MG TAB
2-MedicalCarve out
SECUADO (asenapine) 38 MG24HR PATCH 57 MG24 HR PATCH76 MG24 HR PATCH
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
33
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SEROQUEL (quetiapine fumarate)25 MG TABLET 50 MG TABLET 100MG TABLET 200 MG TABLET 300MG TABLET 400 MG TABLET
2-MedicalCarve out
SEROQUEL XR (quetiapinefumarate) 50 MG TABLET 150 MGTABLET 200 MG TABLET 300 MGTABLET 400 MG TABLET
2-MedicalCarve out
VRAYLAR (cariprazine hcl) 15 MG-3 MG PACK 15 MG CAPSULE 3MG CAPSULE 45 MG CAPSULE 6MG CAPSULE
2-MedicalCarve out
ziprasidone hcl 20 mg capsule 40mg capsule 60 mg capsule 80 mgcapsule
2-MedicalCarve out
ZIPRASIDONE HCL 20 MG CAPSULE40 MG CAPSULE 60 MG CAPSULE80 MG CAPSULE
2-MedicalCarve out
ZIPRASIDONE MESYLATE 20 MGMLVIAL
2-MedicalCarve out
ziprasidone mesylate fnl 20mg1vial
2-MedicalCarve out
ZYPREXA (olanzapine) 25 MGTABLET 5 MG TABLET 75 MGTABLET 10 MG VIAL 10 MG TABLET15 MG TABLET 20 MG TABLET
2-MedicalCarve out
ZYPREXA RELPREVV (olanzapinepamoate) 210 MG VL KIT 300 MGVL KIT 405 MG VL KIT
2-MedicalCarve out
ZYPREXA ZYDIS (olanzapine) 5 MGTABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET
2-MedicalCarve out
TREATMENT-RESISTANTclozapine 125 mg tab rapdis 25mg tab rapdis 25 mg tablet 50mg tablet 100 mg tablet 100 mgtab rapdis 150 mg tab rapdis 200mg tablet 200 mg tab rapdis
2-MedicalCarve out
CLOZAPINE 25 MG TABLET 50 MGTABLET 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
CLOZAPINE ODT ODT 150 MGTABLET ODT 200 MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
34
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CLOZARIL (clozapine) 25 MGTABLET 50 MG TABLET 100 MGTABLET 200 MG TABLET
2-MedicalCarve out
FAZACLO (clozapine) 125 MGODT 25 MG ODT 100 MG ODT 150MG ODT 200 MG ODT
2-MedicalCarve out
VERSACLOZ (clozapine) 50 MGMLSUSPENSION
2-MedicalCarve out
ANTISPASTICITY AGENTS (Drugs for Muscle Spasm)baclofen 10 mg tablet 20 mgtablet
1-Covered QL (90 PER 30 DAYS)
BACLOFEN 10 MG TABLET 20 MGTABLET
1-Covered QL (90 PER 30 DAYS)
tizanidine hcl 2 mg tablet 4 mgtablet
1-Covered QL (90 PER 30 DAY(S))
ANTIVIRALS (Drugs for Viral Infections)
ANTI-HEPATITIS B (HBV) AGENTSEPIVIR HBV (lamivudine) 100 MGTABLET
2-MedicalCarve out
EPIVIR HBV (lamivudine) 25 MG5ML SOLN
1-Covered PA
lamivudine 100 mg tablet 1-Covered PA
VEMLIDY (tenofovir alafenamide)25 MG TABLET
2-MedicalCarve out
ANTI-HEPATITIS C (HCV) AGENTS DIRECT ACTING AGENTSsofosbuvirvelpatasvir 400-100 mgtablet
1-Covered PA SP
ANTI-HEPATITIS C (HCV) AGENTS OTHERINTRON A (interferon alfa-2brecomb) 10 MILLION UNITS VIL -18 MILLION UNITS VIL - 18 MILLIONUNIT3 ML - 25 MILLION UNIT25ML- 50 MILLION UNITS VIL -
1-Covered PA SP
PEGINTRON REDIPEN(peginterferon alfa-2b) 50 MCG -
1-Covered PA SP
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
35
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ribavirin (RIBASPHERE) 200 mgtablet
1-Covered PA
ribavirin 200 mg tablet 1-Covered PA
ANTI-HIV AGENTSCIMDUO (lamivudinetenofovirdisoproxil fumarate) 300-300 MGTABLET
2-MedicalCarve out
EFAVIRENZ-LAMIVU-TENOFOVDISOP --600-300-300
2-MedicalCarve out
SYMFI(efavirenzlamivudinetenofovirdisoproxil fumarate) 600-300-300MG TABLET
2-MedicalCarve out
TEMIXYS (lamivudinetenofovirdisoproxil fumarate) 300-300 MGTABLET
2-MedicalCarve out
ANTI-HIV AGENTS INTEGRASE INHIBITORS (INSTI)BIKTARVY (bictegravirsodiumemtricitabinetenofoviralafenamide fumar) 50-200-25 MGTABLET
2-MedicalCarve out
GENVOYA(elvitegravircobicistatemtricitabinetenofovir alafenamide) TABLET
2-MedicalCarve out
ISENTRESS (raltegravir potassium) 25MG TABLET CHEW 100 MG TABLETCHEW 100 MG POWDER PACKET400 MG TABLET
2-MedicalCarve out
ISENTRESS HD (raltegravirpotassium) 600 MG TABLET
2-MedicalCarve out
STRIBILD(elvitegravircobicistatemtricitabinetenofovir disoproxil) TABLET
2-MedicalCarve out
TIVICAY (dolutegravir sodium) 10MG TABLET 25 MG TABLET 50 MGTABLET
2-MedicalCarve out
TIVICAY PD 5 MG TAB FOR SUSP 2-MedicalCarve out
VITEKTA (elvitegravir) 85 MGTABLET 150 MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
36
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTI-HIV AGENTS NON-NUCLEOSIDE REVERSE TRANSCRIPTASEINHIBITORS (NNRTI)
ATRIPLA(efavirenzemtricitabinetenofovirdisoproxil fumarate) TABLET
2-MedicalCarve out
COMPLERA(emtricitabinerilpivirinehcltenofovir disoproxil fumarate)TABLET
2-MedicalCarve out
DELSTRIGO(doravirinelamivudinetenofovirdisoproxil fumarate) 100-300-300MG TAB
2-MedicalCarve out
EDURANT (rilpivirine hcl) 25 MGTABLET
2-MedicalCarve out
efavirenz 50 mg capsule 200 mgcapsule 600 mg tablet
2-MedicalCarve out
EFAVIRENZ-EMTRIC-TENOFOVDISOP --600-200-300
2-MedicalCarve out
EFAVIRENZ-LAMIVU-TENOFOVDISOP --400-300-300
2-MedicalCarve out
INTELENCE (etravirine) 25 MGTABLET 100 MG TABLET 200 MGTABLET
2-MedicalCarve out
nevirapine 50 mg5 ml oral susp100 mg tab er 24h 200 mg tablet400 mg tab er 24h
2-MedicalCarve out
ODEFSEY (emtricitabinerilpivirinehcltenofovir alafenamidefumarate) TABLET
2-MedicalCarve out
PIFELTRO (doravirine) 100 MGTABLET
2-MedicalCarve out
RESCRIPTOR (delavirdine mesylate)100 MG TABLET 200 MG TABLET
2-MedicalCarve out
SUSTIVA (efavirenz) 50 MGCAPSULE 200 MG CAPSULE 600MG TABLET
2-MedicalCarve out
SYMFI LO(efavirenzlamivudinetenofovirdisoproxil fumarate) 400-300-300MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
37
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
VIRAMUNE (nevirapine) 50 MG5ML SUSP 200 MG TABLET
2-MedicalCarve out
VIRAMUNE XR (nevirapine) 100 MGTABLET 400 MG TABLET
2-MedicalCarve out
ANTI-HIV AGENTS NUCLEOSIDE AND NUCLEOTIDE REVERSETRANSCRIPTASE INHIBITORS (NRTI)
abacavir sulfate 20 mgml solution300 mg tablet
2-MedicalCarve out
abacavir sulfatelamivudine 600-300mg tablet
2-MedicalCarve out
abacavirsulfatelamivudinezidovudineabacavirlamivudinezidovudine150-300 mg tablet
2-MedicalCarve out
ABACAVIR-LAMIVUDINE -600-300MG
2-MedicalCarve out
COMBIVIR (lamivudinezidovudine)TABLET
2-MedicalCarve out
EMTRICITABINE 200 MG CAPSULE 2-MedicalCarve out
EMTRICITABINE-TENOFOVIR DISOP -TENOFV 200-300MG
2-MedicalCarve out
EMTRIVA (emtricitabine) 10 MGMLSOLUTION 200 MG CAPSULE
2-MedicalCarve out
EPIVIR (lamivudine) 10 MGMLORAL SOLN 150 MG TABLET 300MG TABLET
2-MedicalCarve out
EPZICOM (abacavirsulfatelamivudine) TABLET
2-MedicalCarve out
lamivudine 10 mgml solution 150mg tablet 300 mg tablet
2-MedicalCarve out
lamivudinezidovudine 150-300mgtablet 150-300 mg tablet
2-MedicalCarve out
stavudine 1 mgml soln recon 15mg capsule 20 mg capsule 30 mgcapsule 40 mg capsule
2-MedicalCarve out
tenofovir disoproxil fumarate 300mg tablet
2-MedicalCarve out
TRIZIVIR (abacavirsulfatelamivudinezidovudine)TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
38
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
TRUVADA (emtricitabinetenofovirdisoproxil fumarate) 100 MG-150MG TABLET 133 MG-200 MGTABLET 167 MG-250 MG TABLET200 MG-300 MG TABLET
2-MedicalCarve out
VIREAD (tenofovir disoproxilfumarate) 150 MG TABLET 200 MGTABLET 250 MG TABLET 300 MGTABLET POWDER
2-MedicalCarve out
ZERIT (stavudine) 1 MGMLSOLUTION 15 MG CAPSULE 20 MGCAPSULE 30 MG CAPSULE 40 MGCAPSULE
2-MedicalCarve out
ZIAGEN (abacavir sulfate) 20MGML SOLUTION 300 MG TABLET
2-MedicalCarve out
ANTI-HIV AGENTS OTHERDESCOVY (emtricitabinetenofoviralafenamide fumarate) 200-25 MGTABLET
2-MedicalCarve out
DOVATO (dolutegravirsodiumlamivudine) 50-300 MGTABLET
2-MedicalCarve out
FUZEON (enfuvirtide) 90 MG VIAL 2-MedicalCarve out
SP
JULUCA (dolutegravirsodiumrilpivirine hcl) 50-25 MGTABLET
2-MedicalCarve out
RUKOBIA ER 600 MG TABLET 2-MedicalCarve out
SELZENTRY (maraviroc) 20 MGMLORAL SOLN 25 MG TABLET 75 MGTABLET 150 MG TABLET 300 MGTABLET
2-MedicalCarve out
TRIUMEQ (abacavirsulfatedolutegravirsodiumlamivudine) 600-50-300 MGTABLET
2-MedicalCarve out
TROGARZO (ibalizumab-uiyk) 200MG133 ML VIAL -
2-MedicalCarve out
TYBOST (cobicistat) 150 MG TABLET 2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
39
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ANTI-HIV AGENTS PROTEASE INHIBITORSAPTIVUS (tipranavir) 250 MGCAPSULE
2-MedicalCarve out
APTIVUS (tipranavirvitamin e tpgs)100 MGML SOLUTION
2-MedicalCarve out
ATAZANAVIR SULFATE 150 MG CAP200 MG CAP 300 MG CAP
2-MedicalCarve out
atazanavir sulfate 150 mg capsule200 mg capsule 300 mg capsule
2-MedicalCarve out
CRIXIVAN (indinavir sulfate) 200MG CAPSULE 400 MG CAPSULE
2-MedicalCarve out
EVOTAZ (atazanavirsulfatecobicistat) 300 MG-150 MGTABLET
2-MedicalCarve out
fosamprenavir calcium 700 mgtablet
2-MedicalCarve out
FOSAMPRENAVIR CALCIUM 700MG TABLET
2-MedicalCarve out
INVIRASE (saquinavir mesylate) 200MG CAPSULE 500 MG TABLET
2-MedicalCarve out
KALETRA (lopinavirritonavir) 80MG-20 MGML SOLN 100-25 MGTABLET 200-50 MG TABLET
2-MedicalCarve out
LEXIVA (fosamprenavir calcium) 50MGML SUSPENSION 700 MGTABLET
2-MedicalCarve out
lopinavirritonavir 400-1005solution
2-MedicalCarve out
NORVIR (ritonavir) 80 MGMLSOLUTION 100 MG TABLET 100 MGSOFTGEL CAP 100 MG POWDERPACKET
2-MedicalCarve out
PREZCOBIX (darunavirethanolatecobicistat) 800 MG-150MG TABLET
2-MedicalCarve out
PREZISTA (darunavir ethanolate) 75MG TABLET 100 MGMLSUSPENSION 150 MG TABLET 400MG TABLET 600 MG TABLET 800MG TABLET
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
40
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
REYATAZ (atazanavir sulfate) 50MG POWDER PACKET 150 MGCAPSULE 200 MG CAPSULE 300MG CAPSULE
2-MedicalCarve out
ritonavir 100 mg tablet 2-MedicalCarve out
SYMTUZA (darunavirethcobicistatemtricitabinetenofovir alafenamide) 800-150-200-10MG TAB
2-MedicalCarve out
VIRACEPT (nelfinavir mesylate) 250MG TABLET 625 MG TABLET
2-MedicalCarve out
ANTI-INFLUENZA AGENTSoseltamivir phosphate 30 mgcapsule 45 mg capsule 75 mgcapsule
1-Covered QL (10 PER 30 DAY(S)) MFL (1 180 day(s))
OSELTAMIVIR PHOSPHATE 30 MGCAPSULE 45 MG CAPSULE 75 MGCAPSULE
1-Covered QL (10 PER 30 DAY(S)) MFL (1 180 day(s))
oseltamivir phosphate 6 mgmlsusp recon
1-Covered QL (120 PER FILL(S)) MFL (120 180day(s))
OSELTAMIVIR PHOSPHATE 6 MGMLSUSPENSION
1-Covered QL (120 PER FILL(S)) MFL (120 180day(s))
RELENZA (zanamivir) 5 MGDISKHALER
1-Covered QL (20 PER 30 DAY(S))
ANTIHERPETIC AGENTSacyclovir 200 mg capsule 200mg5ml oral susp 400 mg tablet800 mg tablet
1-Covered
ACYCLOVIR 200 MG5 ML SUSP400 MG TABLET 800 MG TABLET
1-Covered
trifluridine 1 drops 1-Covered
valacyclovir hcl 500 mg tablet1000 mg tablet
1-Covered QL (60 PER 30 DAY(S))
ANXIOLYTICS (Drugs for Anxiety)
ANXIOLYTICS OTHER (Other Drugs for Anxiety)BUSPIRONE HCL 5 MG TABLET 10MG TABLET 15 MG TABLET 30 MGTABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
41
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
buspirone hcl 5 mg tablet 75 mgtablet 10 mg tablet 15 mg tablet30 mg tablet
1-Covered
BENZODIAZEPINESalprazolam (ALPRAZOLAMINTENSOL) 1 mgml oral conc
1-Covered
alprazolam 025 mg tablet 05 mgtablet 1 mg tablet 2 mg tablet
1-Covered QL (100 PER 30 DAYS)
clonazepam 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered QL (120 PER 30 DAY(S))
diazepam 2 mg tablet 5 mgtablet 10 mg tablet
1-Covered QL (100 PER 30 DAYS)
diazepam 5 mg5 ml solution 5mgml oral conc
1-Covered
lorazepam (LORAZEPAM INTENSOL)2 mgml oral conc
1-Covered
lorazepam 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered QL (100 PER 30 DAYS)
lorazepam 2 mgml oral conc 1-Covered
oxazepam 10 mg capsule 15 mgcapsule 30 mg capsule
1-Covered
BIPOLAR AGENTS (Drugs for Bipolar Disorder)
MOOD STABILIZERSlithium carbonate 150 mg capsule300 mg tablet er 300 mg capsule300 mg tablet 450 mg tablet er600 mg capsule
2-MedicalCarve out
lithium citrate 8 meq5 ml solution 2-MedicalCarve out
LITHOBID (lithium carbonate) ER300 MG TABLET
2-MedicalCarve out
BLOOD GLUCOSE REGULATORS (Drugs for Diabetes)
ANTIDIABETIC AGENTS (Drugs for High Blood Sugar)acarbose 100 mg tablet 1-Covered QL (3 PER 1 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
42
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acarbose 25 mg tablet 1-Covered QL (12 PER 1 DAYS)
acarbose 50 mg tablet 1-Covered QL (6 PER 1 DAYS)
ADLYXIN (lixisenatide) 10-20 MCGSTARTER PACK 20 MCGMAINTENANCE PK
1-Covered PA
alogliptin benzoate 625 mg tablet125 mg tablet 25 mg tablet
1-Covered ST
alogliptin benzoatemetformin hclbenzmetformin 125-1000 tabletbenzmetformin 125-500mg tablet
1-Covered ST
alogliptin benzoatepioglitazonehcl benzpioglitazone 125-15 mgtablet benzpioglitazone 125-45mg tablet benzpioglitazone 125-30 mg tablet benzpioglitazone 25mg-30mg tabletbenzpioglitazone 25 mg-45mgtablet benzpioglitazone 25 mg-15mg tablet
1-Covered ST
AVANDIA (rosiglitazone maleate) 2MG TABLET 4 MG TABLET
1-Covered QL (60 PER 30 DAYS)
glimepiride 1 mg tablet 2 mgtablet 4 mg tablet
1-Covered STAR (Preferred Drug)
glipizide 25 mg tab er 24 5 mgtablet 5 mg tab er 24 10 mg taber 24 10 mg tablet
1-Covered STAR (Preferred Drug)
glyburide 125 mg tablet 25 mgtablet 5 mg tablet
1-Covered STAR (Preferred Drug)
glyburidemetformin hcl 125-250mg tablet 25-500 mg tablet 5mg-500mg tablet
1-Covered STAR (Preferred Drug)
JARDIANCE (empagliflozin) 10 MGTABLET 25 MG TABLET
1-Covered PA QL (1 PER 1 DAYS)
metformin hcl 500 mg tablet 500mg tab er 24h 750 mg tab er 24h850 mg tablet 1000 mg tablet
1-Covered STAR (Preferred Drug)
METFORMIN HCL ER ER 500 MGTABLET ER 750 MG TABLET
1-Covered STAR (Preferred Drug)
nateglinide 60 mg tablet 120 mgtablet
1-Covered ST
pioglitazone hcl 15 mg tablet 30mg tablet 45 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
43
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PIOGLITAZONE HCL 15 MG TABLET30 MG TABLET 45 MG TABLET
1-Covered
SYNJARDY(empagliflozinmetformin hcl) 5-1000 MG TABLET
1-Covered PA QL (2 PER 1 DAY(S))
SYNJARDY(empagliflozinmetformin hcl) 5-500 MG TABLET 125-500 MGTABLET 125-1000 MG TABLET
1-Covered PA QL (2 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 10-MG TABLET 125-MG TAB
1-Covered PA QL (2 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 25-1000 MG TABLET
1-Covered PA QL (1 PER 1 DAYS)
SYNJARDY XR(empagliflozinmetformin hcl) 5-1000 MG TABLET
1-Covered PA QL (2 PER 1)
tolbutamide 500 mg tablet 1-Covered
TRULICITY (dulaglutide) 075MG05 ML PEN 15 MG05 ML PEN
1-Covered PA QLC (1 penweek)
TRULICITY 3 MG05 ML PEN 45MG05 ML PEN
1-Covered PA QL (05 PER 1 WEEK(S))
VICTOZA 2-PAK (liraglutide) -18MG3 ML PEN
1-Covered PA QLC (6 ml (2 pens)30 days)
VICTOZA 3-PAK (liraglutide) -18MGML PEN
1-Covered PA QLC (9 ml (3 pens)30 days)
GLYCEMIC AGENTS (Drugs for Low Blood Sugar)BAQSIMI (glucagon) 3 MG SPRAYTWO PACK 3 MG SPRAY ONEPACK
1-Covered QL (2 PER 30 DAY(S))
GLUCAGON EMERGENCY KIT(glucagon hcl) 1 MG
1-Covered
GLUCAGON EMERGENCY KIT(glucagonhuman recombinant) 1MG
1-Covered
terbinafine hcl (JOCK ITCH) 1 cream (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
44
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
INSULINSADMELOG (insulin lispro) 100UNITML VIAL
1-Covered
ADMELOG SOLOSTAR (insulin lispro)100 UNITML
1-Covered PA
BASAGLAR KWIKPEN U-100 (insulinglarginehuman recombinantanalog) UNITML
1-Covered
HUMALOG (insulin lispro) 100UNITML CARTRIDGE
1-Covered PA
HUMALOG MIX 75-25 (insulin lisproprotamine and insulin lispro) -VIAL (
1-Covered
HUMALOG MIX 75-25 KWIKPEN(insulin lispro protamine and insulinlispro) -(
1-Covered PA
HUMULIN 70-30 (insulin nph humanisophaneinsulin regular human) -VIAL
1-Covered
HUMULIN 7030 KWIKPEN (insulinnph human isophaneinsulinregular human)
1-Covered PA
HUMULIN N (insulin nph humanisophane) 100 UITML VIAL
1-Covered
HUMULIN R (insulin regular human)100 UNITML VIAL
1-Covered
HUMULIN R U-500 (insulin regularhuman) UNITML VIAL
1-Covered
insulin lispro 100ml insuln pen 1-Covered PA
insulin lispro 100ml vial 1-Covered
INSULIN LISPRO PROTAMINE MIX(insulin lispro protamine and insulinlispro) 75-25 KWKPN (
1-Covered PA
NOVOLIN 70-30 (insulin nph humanisophaneinsulin regular human)70-30 100 UNITML VIAL RELION 70-30 VIAL
1-Covered
NOVOLIN N (insulin nph humanisophane) N 100 UNITML VIALRELION N 100 UNITML
1-Covered
NOVOLIN R (insulin regular human)R 100 UNITML VIAL RELION R 100UNITML
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
45
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
BLOOD PRODUCTSMODIFIERSVOLUME EXPANDERS (Drugs forBlood Disorders)
ANTICOAGULANTS (Blood Thinners)COUMADIN (warfarin sodium) 1MG TABLET 2 MG TABLET 25 MGTABLET 3 MG TABLET 4 MG TABLET5 MG TABLET 6 MG TABLET 75 MGTABLET 10 MG TABLET
1-Covered
ELIQUIS (apixaban) 25 MG TABLET5 MG TABLET
1-Covered QL (2 PER 1 DAY(S))
ELIQUIS (apixaban) DVT-PE TREATSTART 5MG
1-Covered QLC (1 PACK6 MONTHS)
ENOXAPARIN SODIUM 120 MG08ML SYR
1-Covered
ENOXAPARIN SODIUM 30 MG03ML SYR 40 MG04 ML SYR 60MG06 ML SYR 80 MG08 ML SYR100 MGML SYRINGE 150 MGMLSYRINGE
1-Covered PA
enoxaparin sodium 30mg03ml40mg04ml 60mg06ml80mg08ml 100 mgml120mg8ml 150 mgml
1-Covered PA
HEPARIN SODIUM SOD 5000UNITML VIAL SOD 10000 UNITMLVL SOD 20000 UNITML VL 50000UNIT5 ML VIAL
1-Covered
heparin sodiumporcine 5000mlvial 10000ml vial 20000ml vial
1-Covered
heparin sodiumporcinepf 1000mlvial
1-Covered
warfarin sodium (JANTOVEN) 1 mgtablet 2 mg tablet 25 mg tablet3 mg tablet 4 mg tablet 5 mgtablet 6 mg tablet 75 mg tablet10 mg tablet
1-Covered
warfarin sodium 1 mg tablet 2 mgtablet 25 mg tablet 3 mg tablet4 mg tablet 5 mg tablet 6 mgtablet 75 mg tablet 10 mg tablet
1-Covered
XARELTO (rivaroxaban) 10 MGTABLET 15 MG TABLET 20 MGTABLET
1-Covered QL (1 PER 1 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
46
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
XARELTO (rivaroxaban) DVT-PETREAT START 30D
1-Covered QLC (1 PACK6 MONTHS)
BLOOD FORMATION MODIFIERS (Blood Formation Drugs)anagrelide hcl 05 mg capsule 1mg capsule
1-Covered
EPOGEN (epoetin alfa) 2000UNITSML VIAL 3000 UNITSMLVIAL 4000 UNITSML VIAL 10000UNITSML VIAL 20000 UNITSMLVIAL
1-Covered PA SP
PROCRIT (epoetin alfa) 2000UNITSML VIAL 3000 UNITSMLVIAL 4000 UNITSML VIAL 10000UNITSML VIAL 20000 UNITSMLVIAL 40000 UNITSML VIAL
1-Covered PA SP
HEMOSTASIS AGENTS (Drugs to Stop Bleeding)ADVATE (antihemophilic factor(fviii) recombinantfull length) 200-400 VIAL 401-800 VIAL 801-1200VIAL 1201-1800 VIAL 1801-2400VIAL 2401-3600 VIAL 3601-4800VIAL
2-MedicalCarve out
ADYNOVATE (antihemophilicfactor (fviii) recombinant fulllength peg) 200-400 VIAL 401-800VIAL 750 VIAL 801-1250 VIAL1251-2500 VL 1500 VIAL 3000VIAL
2-MedicalCarve out
AFSTYLA (antihemophilic factor viiirecombsingle-chnb-domtruncated) 250 VIAL -- 500 VIAL --1000 VIAL -- 1500 RANGE VIAL --2000 VIAL -- 2500 RANGE VIAL --3000 VIAL --
2-MedicalCarve out
ALPHANATE (antihemophilic factorhumanvon willebrandfactorhuman) 250-100 VIALhuman) 500-200 VIAL human)1000-400 VIAL human) 1500-600VIAL human) 2000-800 VIALhuman)
2-MedicalCarve out
ALPHANINE SD (factor ix) SD 500VIAL SD 1000 VIAL SD 1500 VIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
47
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALPROLIX (factor ix recombinantfc fusion protein) 250 500 10002000 3000 4000
2-MedicalCarve out
BENEFIX (factor ix humanrecombinant) 250 500 10002000 3000
2-MedicalCarve out
COAGADEX (coagulation factor x)250 VIAL 500 VIAL
2-MedicalCarve out
CORIFACT (factor xiii) KIT 2-MedicalCarve out
ELOCTATE (antihemophilic factor(fviii) recombinant fc fusionprotein) 250 500 750 1000 15002000 3000 4000 5000 6000
2-MedicalCarve out
ESPEROCT (antihemophilic factor(fviii) rec b-dom truncated peg-exei) 500 VIAL -- 1000 VIAL --1500 VIAL -- 2000 VIAL -- 3000VIAL --
2-MedicalCarve out
FEIBA NF (anti-inhibitor coagulantcomplex) 500 (NOMINAL) - 1000(NOMINAL) - 2500 (NOMINAL) -
2-MedicalCarve out
FIBRYGA (fibrinogen) 1 GRAMRANGE VIAL
2-MedicalCarve out
HELIXATE FS (antihemophilic factor(fviii) recombinantfull length) 250UNIT VIAL 500 UNIT VIAL 1000 UNITVIAL 2000 UNIT VIAL 3000 UNITSVIAL
2-MedicalCarve out
HEMLIBRA (emicizumab-kxwh) 30MGML VIAL - 60 MG04 ML VIAL - 105 MG07 ML VIAL - 150 MGMLVIAL -
2-MedicalCarve out
HEMOFIL M (antihemophilic factorhuman) 250 500 1000 1700
2-MedicalCarve out
HUMATE-P (antihemophilic factorhumanvon willebrandfactorhuman) -600 human) -1200human) -2400 human)
2-MedicalCarve out
IDELVION (factor ixrecombinantalbumin fusionprotein) 250 VIAL 500 VIAL 1000VIAL 2000 VIAL 3500 VIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
48
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
IXINITY (factor ix humanrecombinant threonine 148) 500RANGE 500 VIAL 1000 VIAL 1000RANGE 1000 VIAL -2 VLS 1000RANGE-2 VLS 1500 RANGE-2 VLS1500 VIAL -2 VLS 1500 VIAL 1500RANGE
2-MedicalCarve out
JIVI (antihemophilic factor (fviii)rec b-domain deleted peg-aucl)500 VIAL -- 1000 VIAL -- 2000 VIAL-- 3000 VIAL --
2-MedicalCarve out
KCENTRA (human prothrombincomplex concentrate (pcc) 4-factor) 500 VIAL 4- 1000 VIAL 4-
2-MedicalCarve out
KOGENATE FS (antihemophilicfactor (fviii) recombinantfulllength) 250 UNIT VIAL 500 UNITVIAL 1000 UNITS VIAL 2000 UNITVIAL 3000 UNITS VIAL
2-MedicalCarve out
KOVALTRY (antihemophilic factor(fviii) recombinantfull length) 250KIT 500 KIT 1000 KIT 2000 KIT3000 KIT
2-MedicalCarve out
MONONINE (factor ix) 1000 UNITVIAL
2-MedicalCarve out
NOVOEIGHT (antihemophilic factorviii recombinant b-domaintruncated) 250 VIAL RECOMINANT- 500 VIAL RECOMINANT - 1000VIAL RECOMINANT - 1500 VIALRECOMINANT - 2000 VIALRECOMINANT - 3000 VIALRECOMINANT -
2-MedicalCarve out
NOVOSEVEN RT (coagulationfactor viia (recombinant)) 1 MGVIAL 2 MG VIAL 5 MG VIAL 8 MGVIAL
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
49
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NUWIQ (antihemophilic factor viiirec hek cell b-domain deleted)250 VIAL - 250 VIAL PACK - 500VIAL - 500 VIAL PACK - 1000 VIAL - 1000 VIAL PACK - 2000 VIALPACK - 2000 VIAL - 2500 VIALPACK - 2500 VIAL - 3000 VIAL -3000 VIAL PACK - 4000 VIAL PACK- 4000 VIAL -
2-MedicalCarve out
OBIZUR (antihemophilic factor viiirecombinant porcine sequence)500 VIAL 500 VIAL - 5 VIALS 500VIAL -10 VIALS
2-MedicalCarve out
phytonadione (vit k1) 5 mg tablet 1-Covered
PROFILNINE (factor ix complexprothrombin cplx conc(pcc) no43-factor) 500 VIAL 3- 1000 VIAL 3-1500 VIAL 3-
2-MedicalCarve out
REBINYN (factor ix (human)recombinant pegylated) 500 VIAL1000 VIAL 2000 VIAL
2-MedicalCarve out
RECOMBINATE (antihemophilicfactor viii human recombinant)220-400 VIAL 401-800 VIAL 801-1240 VL 1241-1800 V 1801-2400V
2-MedicalCarve out
RIASTAP (fibrinogen) VIAL 2-MedicalCarve out
RIXUBIS (factor ix humanrecombinant) 250 500 10002000 3000
2-MedicalCarve out
SEVENFACT 1 MG VIAL 5 MG VIAL 2-MedicalCarve out
TRETTEN (factor xiii a-subunitrecombinant) 2500 UNIT VIAL(fctor -recombinnt)
2-MedicalCarve out
VONVENDI (von willebrand factor(recombinant)) 650 VIAL 1300VIAL
2-MedicalCarve out
WILATE (antihemophilic factorhumanvon willebrandfactorhuman) 450-450 VIALhuman) 500-500 VIAL human)900-900 VIAL human) 1000-1000VIAL human)
2-MedicalCarve out
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
50
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
XYNTHA (antihemophilic factor(factor viii) recombb-domaindeleted) 250 KIT - 500 KIT - 1000KIT - 2000 KIT -
2-MedicalCarve out
XYNTHA SOLOFUSE (antihemophilicfactor (factor viii) recombb-domain deleted) 250 KIT - 500 KIT -1000 KIT - 2000 KIT - 3000 KIT -
2-MedicalCarve out
PLATELET MODIFYING AGENTScilostazol 50 mg tablet 100 mgtablet
1-Covered
clopidogrel bisulfate 75 mg tablet 1-Covered AL1 (At least 18 yrs old)
dipyridamole 25 mg tablet 50 mgtablet 75 mg tablet
1-Covered
CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation)
ALPHA-ADRENERGIC AGONISTSclonidine hcl 01 mg tablet 02 mgtablet 03 mg tablet
1-Covered
CLONIDINE HCL 01 MG TABLET 02MG TABLET 03 MG TABLET
1-Covered
guanfacine hcl 1 mg tablet 2 mgtablet
1-Covered
methyldopa 250 mg tablet 500mg tablet
1-Covered
ALPHA-ADRENERGIC BLOCKING AGENTSdoxazosin mesylate 1 mg tablet 2mg tablet 4 mg tablet 8 mgtablet
1-Covered
PHENOXYBENZAMINE HCL 10 MGCAP
1-Covered
phenoxybenzamine hcl 10 mgcapsule
1-Covered
prazosin hcl 1 mg capsule 2 mgcapsule 5 mg capsule
1-Covered
PRAZOSIN HCL 1 MG CAPSULE 2MG CAPSULE 5 MG CAPSULE
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
51
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terazosin hcl 1 mg capsule 2 mgcapsule 5 mg capsule 10 mgcapsule
1-Covered
TERAZOSIN HCL 1 MG CAPSULE 2MG CAPSULE 5 MG CAPSULE 10MG CAPSULE
1-Covered
ANGIOTENSIN II RECEPTOR ANTAGONISTSirbesartan 75 mg tablet 150 mgtablet 300 mg tablet
1-Covered ST
LOSARTAN POTASSIUM 25 MG TAB50 MG TAB 100 MG TAB
1-Covered STAR (Preferred Drug)
losartan potassium 25 mg tablet50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
valsartan 40 mg tablet 80 mgtablet 160 mg tablet 320 mgtablet
1-Covered ST
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORSbenazepril hcl 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered STAR (Preferred Drug)
captopril 125 mg tablet 25 mgtablet 50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
CAPTOPRIL 125 MG TABLET 25 MGTABLET 50 MG TABLET 100 MGTABLET
1-Covered STAR (Preferred Drug)
ENALAPRIL MALEATE 25 MG TAB 5MG TABLET 10 MG TAB 20 MG TAB
1-Covered STAR (Preferred Drug)
enalapril maleate 25 mg tablet 5mg tablet 10 mg tablet 20 mgtablet
1-Covered STAR (Preferred Drug)
fosinopril sodium 10 mg tablet 20mg tablet 40 mg tablet
1-Covered
lisinopril 25 mg tablet 5 mg tablet10 mg tablet 20 mg tablet 30 mgtablet 40 mg tablet
1-Covered STAR (Preferred Drug)
moexipril hcl 75 mg tablet 15 mgtablet
1-Covered
quinapril hcl 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered
ramipril 125 mg capsule 25 mgcapsule 5 mg capsule 10 mgcapsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
52
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
RAMIPRIL 125 MG CAPSULE 25MG CAPSULE 5 MG CAPSULE 10MG CAPSULE
1-Covered
trandolapril 1 mg tablet 2 mgtablet 4 mg tablet
1-Covered
ANTIARRHYTHMICS (Drugs for Irregular Heart Rhythm)amiodarone hcl (PACERONE) 200mg tablet
1-Covered
amiodarone hcl 200 mg tablet 1-Covered
disopyramide phosphate 100 mgcapsule
1-Covered
flecainide acetate 50 mg tablet100 mg tablet 150 mg tablet
1-Covered
mexiletine hcl 150 mg capsule 200mg capsule 250 mg capsule
1-Covered
MEXILETINE HCL 150 MG CAPSULE200 MG CAPSULE 250 MGCAPSULE
1-Covered
propafenone hcl 150 mg tablet225 mg tablet 300 mg tablet
1-Covered
quinidine gluconate 324 mg tableter
1-Covered
quinidine sulfate 200 mg tablet300 mg tablet
1-Covered
SOTALOL 80 MG TABLET 120 MGTABLET 160 MG TABLET 240 MGTABLET
1-Covered
SOTALOL AF 80 MG TABLET 120 MGTABLET
1-Covered
sotalol hcl (SORINE) 80 mg tablet120 mg tablet 160 mg tablet 240mg tablet
1-Covered
sotalol hcl 80 mg tablet 120 mgtablet 160 mg tablet 240 mgtablet
1-Covered
BETA-ADRENERGIC BLOCKING AGENTSatenolol 25 mg tablet 50 mgtablet 100 mg tablet
1-Covered STAR (Preferred Drug)
ATENOLOL 25 MG TABLET 50 MGTABLET 100 MG TABLET
1-Covered STAR (Preferred Drug)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
53
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
bisoprolol fumarate 5 mg tablet 10mg tablet
1-Covered
carvedilol 3125 mg tablet 625 mgtablet 125 mg tablet 25 mgtablet
1-Covered STAR (Preferred Drug)
labetalol hcl 100 mg tablet 200mg tablet 300 mg tablet
1-Covered
LABETALOL HCL 100 MG TABLET200 MG TABLET 300 MG TABLET
1-Covered
metoprolol succinate 200 mg taber 24h
1-Covered QL (60 PER 30 DAYS) MDD (2 PerDay) STAR (Preferred Drug)
metoprolol succinate 25 mg taber 50 mg tab er 100 mg tab er
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
METOPROLOL SUCCINATE ER 200MG TAB
1-Covered QL (60 PER 30 DAYS) MDD (2 PerDay) STAR (Preferred Drug)
METOPROLOL SUCCINATE ER 25MG TAB ER 50 MG TAB ER 100 MGTAB
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
metoprolol tartrate 25 mg tablet50 mg tablet 100 mg tablet
1-Covered STAR (Preferred Drug)
nadolol 20 mg tablet 40 mgtablet 80 mg tablet
1-Covered STAR (Preferred Drug)
NADOLOL 20 MG TABLET 40 MGTABLET 80 MG TABLET
1-Covered STAR (Preferred Drug)
pindolol 5 mg tablet 10 mg tablet 1-Covered STAR (Preferred Drug)
propranolol hcl 10 mg tablet 20mg5 ml solution 20 mg tablet 40mg tablet 40mg5ml solution 60mg tablet 60 mg cap sa 24h 80mg tablet 80 mg cap sa 24h 120mg cap sa 24h 160 mg cap sa 24h
1-Covered
CALCIUM CHANNEL BLOCKING AGENTSAMLODIPINE BESYLATE 25 MG TAB5 MG TAB 10 MG TAB
1-Covered STAR (Preferred Drug)
amlodipine besylate 25 mg tablet5 mg tablet 10 mg tablet
1-Covered STAR (Preferred Drug)
DILTIAZEM 24HR ER (CD) 24HER(CD) 120 MG CP 24H ER(CD)240 MG CP 24H ER(CD) 180 MGCP 24H ER(CD) 360 MG CP 24HER(CD) 300 MG CP
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
54
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DILTIAZEM 24HR ER (XR) 24H ER(XR)240 MG CP 24H ER(XR) 180 MG CP
1-Covered
diltiazem hcl (CARTIA XT) 120 mgcap er 180 mg cap er 240 mgcap er 300 mg cap er
1-Covered
diltiazem hcl (DILT-XR) 120 mg caper - 180 mg cap er - 240 mg caper -
1-Covered
diltiazem hcl (TAZTIA XT) 120 mgcap 180 mg cap 240 mg cap 300mg cap 360 mg cap
1-Covered
diltiazem hcl 30 mg tablet 60 mgcap er 12h 60 mg tablet 90 mgtablet 90 mg cap er 12h 120 mgcap sa 24h 120 mg tablet 120 mgcap er 24h 120 mg cap er deg120 mg cap er 12h 180 mg cap sa24h 180 mg cap er deg 180 mgcap er 24h 240 mg cap er 24h 240mg cap er deg 240 mg cap sa24h 300 mg cap er 24h 300 mgcap sa 24h 360 mg cap sa 24h360 mg cap er 24h
1-Covered
felodipine 25 mg tab er 5 mg taber 10 mg tab er
1-Covered
FELODIPINE ER ER 25 MG TABLETER 5 MG TABLET ER 10 MG TABLET
1-Covered
nicardipine hcl 20 mg capsule 30mg capsule
1-Covered
nifedipine (AFEDITAB CR) 30 mgtablet er 60 mg tablet er
1-Covered
nifedipine (NIFEDICAL XL) 30 mgtab er 24 60 mg tab er 24
1-Covered
NIFEDIPINE 10 MG CAPSULE 1-Covered
nifedipine 10 mg capsule 20 mgcapsule 30 mg tablet er 30 mgtab er 24 60 mg tablet er 60 mgtab er 24 90 mg tablet er 90 mgtab er 24
1-Covered
nisoldipine 20 mg tab er 30 mgtab er 40 mg tab er
1-Covered
verapamil hcl 40 mg tablet 80 mgtablet 120 mg tablet 120 mgtablet er 180 mg tablet er 240 mgtablet er
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
55
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CARDIOVASCULAR AGENTS OTHERamiloride hclhydrochlorothiazideamiloridehydrochlorothiazide 5mg-50 mg tablet
1-Covered
amlodipine besylatebenazeprilhcl 25mg-10mg capsule 5 mg-20mg capsule 5 mg-10 mg capsule5 mg-40 mg capsule 10 mg-20mgcapsule 10 mg-40mg capsule
1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day) STAR(Preferred Drug)
atenololchlorthalidone 50 mg-tablet 100mg-tablet
1-Covered STAR (Preferred Drug)
benazepril hclhydrochlorothiazidebenazeprilhydrochlorothiazide 5-625mg tabletbenazeprilhydrochlorothiazide 10-125mg tabletbenazeprilhydrochlorothiazide 20mg-25mg tabletbenazeprilhydrochlorothiazide 20-125 mg tablet
1-Covered STAR (Preferred Drug)
bisoprololfumaratehydrochlorothiazidebisoprololhydrochlorothiazide 25-tabletbisoprololhydrochlorothiazide 5-tabletbisoprololhydrochlorothiazide 10-tablet
1-Covered
BISOPROLOL-HYDROCHLOROTHIAZIDE -10-625MG TAB -25-625 MG TB -5-625MG TAB
1-Covered
captoprilhydrochlorothiazide 25mg-25mg tablet 25 mg-15mgtablet 50 mg-25mg tablet 50 mg-15mg tablet
1-Covered STAR (Preferred Drug)
digoxin (DIGITEK) 125 mcg tablet250 mcg tablet
1-Covered STAR (Preferred Drug)
digoxin (DIGOX) 125 mcg tablet250 mcg tablet
1-Covered STAR (Preferred Drug)
digoxin 125 mcg tablet 250 mcgtablet
1-Covered STAR (Preferred Drug)
digoxin 50 mcgml solution 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
56
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fosinoprilsodiumhydrochlorothiazidefosinoprilhydrochlorothiazide 10-125mg tabletfosinoprilhydrochlorothiazide 20-125 mg tablet
1-Covered
FOSINOPRIL-HYDROCHLOROTHIAZIDE -10-125MG TAB -20-125 MG TAB
1-Covered
irbesartanhydrochlorothiazide150-tablet 300-tablet
1-Covered ST
LANOXIN (digoxin) 125 MCGTABLET 250 MCG TABLET
1-Covered STAR (Preferred Drug)
lisinoprilhydrochlorothiazide 10-125mg tablet 20-125 mg tablet20 mg-25mg tablet
1-Covered STAR (Preferred Drug)
losartanpotassiumhydrochlorothiazidelosartanhydrochlorothiazide 50-125 mg tabletlosartanhydrochlorothiazide100mg-25mg tabletlosartanhydrochlorothiazide 100-125mg tablet
1-Covered STAR (Preferred Drug)
LOSARTAN-HYDROCHLOROTHIAZIDE -50-125MG TAB -100-125 MG TAB -100-25MG TAB
1-Covered STAR (Preferred Drug)
pentoxifylline 400 mg tablet er 1-Covered
spironolactonehydrochlorothiazide spironolacthydrochlorothiazid25 mg-25mg tablet
1-Covered
triamterenehydrochlorothiazide375-25 mg capsule 375-25 mgtablet 50 mg-25mg capsule 75mg-50mg tablet
1-Covered
valsartanhydrochlorothiazide 80-125mg tablet 160-125mg tablet160mg-25mg tablet 320-125mgtablet 320mg-25mg tablet
1-Covered ST
DIURETICS CARBONIC ANHYDRASE INHIBITORSacetazolamide 125 mg tablet 250mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
57
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ACETAZOLAMIDE 125 MG TABLET250 MG TABLET
1-Covered
DIURETICS LOOPbumetanide 05 mg tablet 1 mgtablet 2 mg tablet
1-Covered
furosemide 10 mgml solution 20mg tablet 40mg5ml solution 40mg tablet 80 mg tablet
1-Covered STAR (Preferred Drug)
DIURETICS POTASSIUM-SPARINGamiloride hcl 5 mg tablet 1-Covered
spironolactone 25 mg tablet 50mg tablet 100 mg tablet
1-Covered
SPIRONOLACTONE 25 MG TABLET50 MG TABLET 100 MG TABLET
1-Covered
DIURETICS THIAZIDEchlorothiazide 250 mg tablet 500mg tablet
1-Covered
chlorthalidone 25 mg tablet 50 mgtablet
1-Covered
CHLORTHALIDONE 25 MG TABLET50 MG TABLET
1-Covered
DIURIL (chlorothiazide) 250 MG5ML ORAL SUSP
1-Covered
hydrochlorothiazide 125 mgcapsule 25 mg tablet 50 mgtablet
1-Covered STAR (Preferred Drug)
indapamide 125 mg tablet 25mg tablet
1-Covered
methyclothiazide 5 mg tablet 1-Covered
metolazone 25 mg tablet 5 mgtablet 10 mg tablet
1-Covered
DYSLIPIDEMICS FIBRIC ACID DERIVATIVES (Drugs for HighCholesterol)
fenofibrate 54 mg tablet 160 mgtablet
1-Covered ST
FENOFIBRATE 54 MG TABLET 160MG TABLET
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
58
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fenofibratemicronized 67 mgcapsule 134 mg capsule 200 mgcapsule
1-Covered ST
gemfibrozil 600 mg tablet 1-Covered
GEMFIBROZIL 600 MG TABLET 1-Covered
TRIGLIDE (fenofibratenanocrystallized) 160 MG TABLET
1-Covered ST
DYSLIPIDEMICS HMG COA REDUCTASE INHIBITORS (Drugs for HighCholesterol)
atorvastatin calcium 10 mg tablet20 mg tablet 40 mg tablet 80 mgtablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
ATORVASTATIN CALCIUM 10 MGTABLET 20 MG TABLET 40 MGTABLET 80 MG TABLET
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
lovastatin 10 mg tablet 20 mgtablet 40 mg tablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay) STAR (Preferred Drug)
rosuvastatin calcium 5 mg tablet10 mg tablet 20 mg tablet 40 mgtablet
1-Covered ST QL (30 PER 30 DAY(S))
simvastatin 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet
1-Covered STAR (Preferred Drug)
DYSLIPIDEMICS OTHER (Other Drugs for High Cholesterol)cholestyramine (with sugar) suar) 4powder
1-Covered
cholestyramineaspartame(PREVALITE) 4 g powder
1-Covered
cholestyramineaspartame 4 gpowder
1-Covered
COLESTID (colestipol hcl)FLAVORED GRANULES
1-Covered
colestipol hcl 1 tablet 5 ranules 5packet
1-Covered
ezetimibe 10 mg tablet 1-Covered
niacin (ENDUR-ACIN) 250 mgtablet er - 500 mg tablet er - 750mg tablet er -
1-Covered
niacin (SLO-NIACIN) 500 mg tableter -
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
59
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NIACIN 100 MG TABLET TR 500 MGTABLET
1-Covered
niacin 50 mg tablet 100 mg tablet250 mg capsule er 250 mg tablet250 mg tablet er 500 mg tablet500 mg tablet er 500 mg tab er24h 500 mg capsule er 750 mgtablet er 1000 mg tablet er
1-Covered
OMEGA-3 ACID ETHYL ESTERS -1GM CAP
1-Covered QL (4 PER 1 DAY(S))
omega-3 acid ethyl esters omea-1capsule
1-Covered QL (4 PER 1 DAY(S))
VASODILATORS DIRECT-ACTING ARTERIAL (Drugs for RelaxingArteries)
hydralazine hcl 10 mg tablet 25mg tablet 50 mg tablet 100 mgtablet
1-Covered
minoxidil 25 mg tablet 10 mgtablet
1-Covered
VASODILATORS DIRECT-ACTING ARTERIALVENOUS (Drugs forRelaxing Arteries and Veins)
ISOSORBIDE DINITRATE 5 MG TAB10 MG TAB 20 MG TAB 30 MG TAB
1-Covered STAR (Preferred Drug)
isosorbide dinitrate 5 mg tablet 10mg tablet 20 mg tablet 30 mgtablet 40 mg tablet er
1-Covered STAR (Preferred Drug)
isosorbide mononitrate 10 mgtablet 20 mg tablet 30 mg tab er24h 60 mg tab er 24h 120 mg taber 24h
1-Covered STAR (Preferred Drug)
NITRO-BID (nitroglycerin) -2OINTMENT
1-Covered
nitroglycerin (MINITRAN) 01mghrpatch 02mghr patch 04mghrpatch 06mghr patch
1-Covered
nitroglycerin (NITRO-TIME) 25 mgcapsule er - 65 mg capsule er - 9mg capsule er -
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
60
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
nitroglycerin 01mghr patch td2402mghr patch td24 03 mg tabsubl 04mghr patch td24 04 mgtab subl 06 mg tab subl 06mghrpatch td24 25 mg capsule er 65mg capsule er 9 mg capsule er400mcgspr spray
1-Covered
NITROGLYCERIN 400 MCG SPRAY 1-Covered
CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions)
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTSAMPHETAMINES
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 15 mg cap er 24h
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old) MDD (1 Per Day)
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 5 mg cap erdextroamphetamineamphetamine 10 mg cap erdextroamphetamineamphetamine 20 mg cap erdextroamphetamineamphetamine 25 mg cap erdextroamphetamineamphetamine 30 mg cap er
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old)
dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 5 mg tabletdextroamphetamineamphetamine 75 mg tabletdextroamphetamineamphetamine 10 mg tabletdextroamphetamineamphetamine 125 mg tabletdextroamphetamineamphetamine 15 mg tabletdextroamphetamineamphetamine 20 mg tabletdextroamphetamineamphetamine 30 mg tablet
1-Covered AL1 (3 to 18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
61
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
dextroamphetamine sulfate(ZENZEDI) 5 mg tablet 10 mgtablet
1-Covered AL1 (3 to 18 yrs old)
dextroamphetamine sulfate 5 mgcapsule er 5 mg tablet 10 mgcapsule er 10 mg tablet 15 mgcapsule er
1-Covered AL1 (3 to 18 yrs old)
DEXTROAMPHETAMINE SULFATE 5MG TAB 10 MG TAB
1-Covered AL1 (3 to 18 yrs old)
DEXTROAMPHETAMINE-AMPHET ER-15 MG CAP
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old) MDD (1 Per Day)
DEXTROAMPHETAMINE-AMPHET ER-ER 5 MG CAP -ER 10 MG CAP -ER20 MG CAP -ER 25 MG CAP -ER 30MG CAP
1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old)
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS NON-AMPHETAMINES
atomoxetine hcl 10 mg capsule 18mg capsule 25 mg capsule 40 mgcapsule 60 mg capsule 80 mgcapsule 100 mg capsule
1-Covered PA
guanfacine hcl 1 mg tab er 2 mgtab er 3 mg tab er 4 mg tab er
1-Covered QL (1 PER 1 DAY(S))
METHYLPHENIDATE ER ER 18 MGTAB ER 27 MG TAB ER 36 MG TABER 54 MG TAB
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl (METADATEER) 20 mg tablet er
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl 10 mg tableter 18 mg tab er 24 20 mg tableter 27 mg tab er 24 36 mg tab er24 54 mg tab er 24
1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)
methylphenidate hcl 5 mg tablet10 mg cpbp 30-70 10 mg tablet20 mg tablet 20 mg cpbp 30-7030 mg cpbp 30-70 40 mg cpbp 30-70 50 mg cpbp 30-70 60 mg cpbp30-70
1-Covered AL1 (6 to 18 yrs old)
METHYLPHENIDATE HCL 5 MGTABLET 10 MG TABLET 20 MGTABLET
1-Covered AL1 (6 to 18 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
62
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
CENTRAL NERVOUS SYSTEM OTHERacetaminophen (ATHENOL) 325mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (CHILD FEVERREDUCER) 120 mg supprect
1-Covered
acetaminophen (CHILD PAIN REL-FEVER REDUCER) 120 mg supprect-
1-Covered
acetaminophen (CHILDRENSFEVER REDUCER) 120 mg supprect
1-Covered
acetaminophen (CHILDRENSFEVER REDUCING) 120 mgsupprect
1-Covered
acetaminophen (CHILDRENS PAINAND FEVER) 160 mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (CHILDRENSSILAPAP) 160 mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (ED-APAP) 160mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (LITTLE REMEDIESFEVER-PAIN) 160 mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (M-PAP) 160mg5ml liquid -
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (MAPAP) 160mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (MAPAP) 325 mgtablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (MASOPHEN) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRINEXTRA STRENGTH) 500 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRINPAIN RELIEF) 500 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (NON-ASPIRIN)160 mg5ml elixir -
1-Covered QLC (LIMIT TO 2 FILLS OF 120ML IN30 DAYS)
acetaminophen (NON-ASPIRIN)325 mg tablet -
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN amp FEVER)500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
63
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
acetaminophen (PAIN RELIEFEXTRA STRENGTH) 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN RELIEF) 160mg5ml liquid
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen (PAIN RELIEF) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PAIN RELIEVER)325 mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (PHARBETOL) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (SHAKE THATACHE) 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen (TACTINAL) 325mg tablet 500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
acetaminophen 120 mg 650 mg 1-Covered
acetaminophen 160 mg5ml elixir 1-Covered QLC (LIMIT TO 2 FILLS OF 120ML IN30 DAYS)
acetaminophen 160 mg5ml liquid 1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 160 mg5ml oralsusp
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 160 mg5mlsolution
1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)
acetaminophen 325 mg tablet500 mg tablet
1-Covered QL (60 PER 30 DAY(S))
ACETAMINOPHEN CVS 325 MGGELCP 325 MG TABLET 500 MGTABLET 500 MG GELCAP
1-Covered QL (60 PER 30 DAY(S))
butalbitalacetaminophen(TENCON) 50mg-325mg tablet
1-Covered QL (48 PER 30 DAY(S))
butalbitalacetaminophen 50mg-325mg tablet
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
butalbitalacetaminophencaffeine butalbacetaminophencaffeine50-325-40 tablet
1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)
PAIN amp FEVER (acetaminophen)500 MG TABLET
1-Covered QL (60 PER 30 DAY(S))
PAIN RELIEF 325 MG TABLET 500MG GELCAP 500 MG TABLET
1-Covered QL (60 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
64
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
riluzole 50 mg tablet 1-Covered PA
RILUZOLE 50 MG TABLET 1-Covered PA
FIBROMYALGIA AGENTSduloxetine hcl 20 mg capsule dr30 mg capsule dr 60 mg capsuledr
1-Covered
pregabalin 20 mgml solution 1-Covered PA QLC (30 MLDAY)
pregabalin 225 mg capsule 300mg capsule
1-Covered PA QL (2 PER 1 DAY(S))
PREGABALIN 225 MG CAPSULE 300MG CAPSULE
1-Covered PA QL (2 PER 1 DAY(S))
pregabalin 25 mg capsule 50 mgcapsule 75 mg capsule 100 mgcapsule 150 mg capsule 200 mgcapsule
1-Covered PA QL (3 PER 1 DAY(S))
PREGABALIN 25 MG CAPSULE 50MG CAPSULE 75 MG CAPSULE 100MG CAPSULE 150 MG CAPSULE200 MG CAPSULE
1-Covered PA QL (3 PER 1 DAY(S))
SAVELLA (milnacipran hcl) 125 MGTABLET 25 MG TABLET 50 MGTABLET 100 MG TABLET TITRATIONPACK
1-Covered PA
MULTIPLE SCLEROSIS AGENTSAVONEX (interferon beta-1a)PREFILLED SYR 30 MCG KT -
1-Covered PA SP
AVONEX (interferon beta-1aalbumin human) 30 MCG VIALKIT -
1-Covered PA SP
AVONEX PEN (interferon beta-1a)30 MCG05 ML KIT -
1-Covered PA SP
DIMETHYL FUMARATE 30D START PK 1-Covered PA SP
DIMETHYL FUMARATE DR 120 MGCP DR 240 MG CP
1-Covered PA SP QL (2 PER 1 DAY(S))
glatiramer acetate (GLATOPA) 20mgml syringe
1-Covered PA SP QLC (1 SYRINGEDAY)
glatiramer acetate (GLATOPA) 40mgml syringe
1-Covered PA SP QLC (12SYRINGESMONTH)
glatiramer acetate 20 mgmlsyringe
1-Covered PA SP QLC (1 SYRINGEDAY)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
65
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
glatiramer acetate 40 mgmlsyringe
1-Covered PA SP QLC (12SYRINGESMONTH)
PLEGRIDY (peginterferon beta-1a)125 MCG05 ML SYRING - SYRINGESTARTER PACK -
1-Covered PA SP
PLEGRIDY PEN (peginterferon beta-1a) 125 MCG05 ML PEN - PEN INJSTARTER PACK -
1-Covered PA SP
TECFIDERA (dimethyl fumarate) DR120 MG CAPSULE DR 240 MGCAPSULE STARTER PACK
1-Covered PA SP
DENTAL AND ORAL AGENTS (Drugs for the Mouth)
DENTAL AND ORAL AGENTSchlorhexidine gluconate (PAROEX)012 mouthwash
1-Covered
chlorhexidine gluconate 012 mouthwash
1-Covered
PHOS-FLUR (fluoride (sodium)) -ORAL RINSE
1-Covered
triamcinolone acetonide(ORALONE) 01 paste (g)
1-Covered
triamcinolone acetonide 01 paste (g)
1-Covered
TRIAMCINOLONE ACETONIDE 01PASTE
1-Covered
DERMATOLOGICAL AGENTS (Drugs for the Skin)ACNE MEDICATION (benzoylperoxide) 5 GEL
1-Covered
ACNE MEDICATION 25 GEL 1-Covered
ammonium lactate (SKINTREATMENT) 12 lotion
1-Covered
ammonium lactate 12 cream(g) 12 lotion
1-Covered
benzoyl peroxide (ACNE CONTROLCLEANSER) 10 cleanser
1-Covered
benzoyl peroxide (ACNE FOAMINGWASH) 10 cleanser
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
66
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
benzoyl peroxide (ACNETREATMENT) 10 gel (gram)
1-Covered
benzoyl peroxide (ACNECLEAR) 10 gel (gram)
1-Covered
benzoyl peroxide (ADVANCEDEXFOLIATING CLEANSER) 5 cleanser
1-Covered
benzoyl peroxide (BP WASH) 5 10
1-Covered
benzoyl peroxide (BP) 5 gel(gram) 10 gel (gram)
1-Covered
benzoyl peroxide (BPO-10) cleanser -
1-Covered
benzoyl peroxide (BPO-5) cleanser -)
1-Covered
benzoyl peroxide (CLEAN-CLEARCONTINUOUS CONTROL) 10 cleanser -
1-Covered
benzoyl peroxide (DAYLOGICACNE FOAMING WASH) 10 cleanser
1-Covered
benzoyl peroxide (DAYLOGICACNE TREATMENT) 10 gel (gram)
1-Covered
benzoyl peroxide (FOAMING ACNEFACE WASH) 10 cleanser
1-Covered
benzoyl peroxide (PANOXYL) 10 cleanser
1-Covered
benzoyl peroxide 25 gel (gram)5 cleanser 5 gel (gram) 10 gel (gram) 10 cleanser
1-Covered
CALADRYL (pramoxinehclcalamine) 1-8 LOTION
1-Covered
calcipotriene 0005 cream (g)0005 oint (g) 0005 solution
1-Covered PA
chlorhexidine gluconate 4 liquid 1-Covered
CORTISPORIN(neomycinbacitracinpolymyxinbhydrocortisone) OINTMENT
1-Covered
DIFFERIN (adapalene) 01 GEL 1-Covered AL1 (Up to 25 yrs old)
DRITHOCREME HP (anthralin) 1CREAM
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
67
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DRYSOL (aluminum chloride) DAB--MATIC SLUTIN
1-Covered
EPIFOAM (hydrocortisoneacetatepramoxine hcl)
1-Covered
hydrocortisoneacetatepramoxine hclhydrocortisonepramoxine 1 -1 creamapplhydrocortisonepramoxine 25 -1 cream (g)hydrocortisonepramoxine 25 -1 creamapplhydrocortisonepramoxine 25-1(4g) creamappl
1-Covered
isotretinoin (AMNESTEEM) 10 mgcapsule 20 mg capsule 40 mgcapsule
1-Covered PA
isotretinoin (CLARAVIS) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin (MYORISAN) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin (ZENATANE) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule
1-Covered PA
isotretinoin 10 mg capsule 20 mgcapsule 30 mg capsule 40 mgcapsule
1-Covered PA
LICE KILLING SHAMPOO 1-Covered
metronidazole 075 cream (g)075 gel (gram) 1 gel (gram)
1-Covered
pimecrolimus 1 cream (g) 1-Covered PA
piperonyl butoxidepyrethrins (LICEKILLING) 4-033 shampoo
1-Covered
piperonyl butoxidepyrethrins (LICEPYRINYL SHAMPOO) 4-033shampoo
1-Covered
piperonyl butoxidepyrethrins (LICETREATMENT) 4-033 shampoo
1-Covered
piperonyl butoxidepyrethrins (RID)4-033 shampoo
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
68
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
piperonylbutoxidepyrethrinspermethrin(COMPLETE LICE TREATMENT)butoxpyrethrpermet 4-33-5 kit
1-Covered
piperonylbutoxidepyrethrinspermethrin(LICE SOLUTION)butoxpyrethrpermet 4-33-5 kit
1-Covered
podofilox 05 solution 1-Covered
pramoxine hclcalamine(CALAHIST) 1 -8 lotion
1-Covered
pramoxine hclcalamine(CALAMINE MEDICATED) 1 -8 lotion
1-Covered
PROCTOFOAM-HC (hydrocortisoneacetatepramoxine hcl) PROCTO-1-1
1-Covered
RID (piperonylbutoxidepyrethrinspermethrin) 1-2-3 KIT KIT
1-Covered
SANTYL (collagenase clostridiumhistolyticum) OINTMENT
1-Covered QL (60 PER 30 DAYS)
selenium sulfide (ANTI-DANDRUFF)1 shampoo -
1-Covered
selenium sulfide (MEDICATEDDANDRUFF SHAMPOO) 1 shampoo
1-Covered
selenium sulfide (SELSUN BLUE) 1 shampoo
1-Covered
selenium sulfide 25 lotion 1-Covered
selenium sulfidealoe vera (SELSUNBLUE MOISTURIZING) 1 shampoo
1-Covered
tacrolimus 003 (g) 01 (g) 1-Covered PA
ELECTROLYTESMINERALSMETALSVITAMINS
ELECTROLYTEMINERAL REPLACEMENT09 sodium chloride iv soln 1-Covered PA
calcium carbonate 600 mg tablet 1-Covered
dextrose 5 in water in iv soln 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
69
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levocarnitine 330 mg tablet 1-Covered
potassium chloride in 09 sodiumchloride 09nacl 10 meql iv soln
1-Covered PA
ringers solution iv soln 1-Covered
sodium chloride irrigating solution09 soln
1-Covered
ELECTROLYTEMINERALMETAL MODIFIERSCHEMET (succimer) 100 MGCAPSULE
1-Covered PA
09 sodium chloride iv soln 1-Covered PA
CLINIMIX (amino acids 425 indextrose 5 in water) -SOLUTION
1-Covered PA
dextrose 10 and 045 sodiumchloride nacl -iv soln
1-Covered PA
dextrose 10 in water 10 10 dehp fr bg 10 10 iv soln
1-Covered PA
dextrose 5 and 045 sodiumchloride -04chlord -04iv soln
1-Covered PA
dextrose 5 in water 5 5 ivsoln 5 5 vial
1-Covered PA
levocarnitine (with sugar) 100mgml solution
1-Covered
levocarnitine 100 mgml solution330 mg tablet
1-Covered
MYNATAL (prenatal vitamins withcalciumferrous fumaratefolicacid) CAPSULE
1-Covered
O-CAL PRENATAL (prenatal vit withcalcium no127ferrousfumaratefolic acid) -TABLET
1-Covered
potassium chloride (KLOR-CONM10) meq tab er prt -
1-Covered
potassium chloride (KLOR-CONM20) meq tab er prt -
1-Covered
potassium chloride 8 meq tableter 10 meq tablet er 10 meqcapsule er 10 meq tab er prt 20meq tablet er 20 meq tab er prt20meq15ml liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
70
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
POTASSIUM CHLORIDE ER 8 MEQTABLET 10 (20 MEQ15ML) 10(40 MEQ30ML) ER 10 MEQ TABLETER 20 MEQ TABLET
1-Covered
potassium chloride in 09 sodiumchloride 20 meql soln 40 meqlsoln
1-Covered PA
PRENATABS FA (prenatal vits withcalcium no78ferrousfumaratefolic acid) TABLET
1-Covered
PRENATABS RX (prenatal vitaminwith calciumno76ironcarbonylfolic acid)TABLET
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid (MYNATAL PLUS) vitironfumfolic 65 mg-1 mg tablet
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid (MYNATAL-Z) vitiron fumfolic65 mg-1 mg tablet -
1-Covered
prenatal vits with calcium118ferrous fumaratefolic acid (SE-NATAL 19) pnv no8ironfumaratefa 29 mg-mg tab chew -9)
1-Covered
prenatal vits with calcium136ferrous fumaratefolic acid(VINATE-M) vit36ironfolic acd 27mg-mg tablet -
1-Covered
prenatal vits with calciumno115iron fumaratefolic acidno5ironfolic 29 mg-mg tab chew
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acid(M-NATAL PLUS) pnvcalcium72ironfolic 27 mg-1 mg tablet -
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acid(PREPLUS) pnvcalcium 72ironfolic27 mg-1 mg tablet
1-Covered
prenatal vits with calciumno72ferrous fumaratefolic acidpnvcalcium 72ironfolic 27 mg-1mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
71
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
prenatal vits with calciumno72ironcarbonylfolic acidpnvcalcium 72ironcarbfolic 29mg-1 mg tablet
1-Covered
prenatal vits with calciumno74ferrous fumaratefolic acidvitcal 74ironfolic 27 mg-1 mgtablet
1-Covered
SE-NATAL-19 (prenatal vitaminsno119iron fumaratefolic acid) --TABLET
1-Covered
sodium chloride irrigating solution09 soln
1-Covered
sodium polystyrene sulfonate 15g60 ml oral susp
1-Covered
sodium polystyrenesulfonatesorbitol solution (KIONEX)sulfonsorb 15 g60 ml oral susp
1-Covered
SPS (sodium polystyrenesulfonatesorbitol solution) 15GM60 ML SUSPENSION
1-Covered
TRINATE (prenatal vits with calciumno73ferrous fumaratefolic acid)TABLET
1-Covered
VITAMINS09 sodium chloride iv soln 1-Covered PA
ascorbate calcium 500 mg tablet 1-Covered
ascorbic acid (SOOTHINGPUREWAY-C) 500 mg tablet -
1-Covered
ascorbic acid 250 mg tablet 500mg5ml syrup 500 mg tablet 1000mg tablet
1-Covered
CALCIUM 500-VIT D3 MG-MCG TB 1-Covered
CALCIUM 600 MG TABLET 1-Covered
CALCIUM 600-VIT D3 MG-10MCGTB
1-Covered
calcium carbonate (OYSCO-500)500(1250) tablet -
1-Covered
calcium carbonate (SUPERCALCIUM) 600 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
72
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcium carbonate 500(1250)tablet 600 mg tablet
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (HI-CAL)carbonatevitamin 500 mg-200tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OS-CAL 500-VIT D3)carbonatevitamin mg-200 tablet --
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OYSCO 500-VIT D3)carbonatevitamin mg-200 tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) (OYSTERCAL-D)carbonatevitamin 500 mg-400tablet -
1-Covered
calciumcarbonatecholecalciferol(vitamin d3) carbonatevitamin250 mg-125 tabletcarbonatevitamin 500 mg-600tablet carbonatevitamin 500 mg-400 tablet carbonatevitamin 500mg-200 tablet carbonatevitamin600 mg-400 tablet
1-Covered
calcium gluconate 60(650) mgtablet
1-Covered
calcium lactate 84 mg(648) tablet 1-Covered
cyanocobalamin (vitamin b-12) (B-12 DOTS) cyanocoalamin -) 500mcg talet -
1-Covered
cyanocobalamin (vitamin b-12)cyanocoalamin -500 mcg talet
1-Covered
dextrose 10 in water iv soln 1-Covered PA
dextrose 5 and 045 sodiumchloride -04chlord -04iv soln
1-Covered PA
dextrose 5 in lactated ringers -ivsoln
1-Covered PA
dextrose 5 in water in iv soln 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
73
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DEXTROSE IN WATER 5-IV SOLN10-IV SOLUTION
1-Covered PA
electrolytesdextrose(ELECTROLYTE) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (ORALYTE)solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (PEDIATRICELECTROLYTE) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
electrolytesdextrose (PEDIATRICFREEZER POPS) solution
1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))
ferrous sulfate (CHILDRENS IRON)15 mgml drops
1-Covered
ferrous sulfate (FEOSOL) 325(65)mg tablet
1-Covered
ferrous sulfate (FEROSUL) 325(65)mg tablet
1-Covered
ferrous sulfate (FERRO-TIME) 325(65)mg tablet -
1-Covered
ferrous sulfate (FERROUSUL) 325(65)mg tablet
1-Covered
ferrous sulfate (PEDIA IRON) 15mgml drops
1-Covered
ferrous sulfate 15 mgml drops 220(44)5 solution 220 (44)5 elixir324(65)mg tablet dr 325(65) mgtablet dr 325(65) mg tablet
1-Covered
FERROUS SULFATE SULF 220 MG5ML LIQ SULF EC 325 MG TABLETSULFATE 325 MG TABLET
1-Covered
fluoride (sodium) 025(055) tabchew 05(11)mg tab chew 05mgml drops 1mg(22mg) tabchew
1-Covered STAR (Preferred Drug)
folic acid 04 mg tablet 08 mgtablet 1 mg tablet 20 mg capsule
1-Covered
FOLIC ACID 400 MCG TABLET 800MCG TABLET
1-Covered
IRON 65 MG TABLET 1-Covered
OYSTER SHELL CALCIUM 500 MG TB 1-Covered
OYSTER SHELL CALCIUM-VIT D3 250MG-312MCG
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
74
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PEDIATRIC IRON PHARM CHC15MGML DRP
1-Covered
pediatric multivit with acd3no21sodium fluorideno21fluoride 025 mgml dropsno21fluoride 05 mgml drops
1-Covered STAR (Preferred Drug)
pediatric multivitaminno16sodium fluoride -025 mg tabche -05 mg tab che -1 mg tabche
1-Covered
pediatric multivitamin no2sodiumfluoride w-025 mgml drops
1-Covered
pediatric multivitamin no2sodiumfluoride w-05 mgml drops
1-Covered STAR (Preferred Drug)
pediatric multivitaminno45sodium fluorideferroussulfate 45fluorideiron 025-10mldrops
1-Covered STAR (Preferred Drug)
pediatric multivitamins no17 withsodium fluoride -025 mg tab che -05 mg tab che -1 mg tab che
1-Covered STAR (Preferred Drug)
POLY-VITAMIN (multivitamin) -TABCHEW
1-Covered STAR (Preferred Drug)
POTASSIUM 99 MG TABLET 1-Covered
potassium bicarbonatecitric acid(EFFER-K) 25 meq tablet eff -
1-Covered
potassium bicarbonatecitric acid(K EFFERVESCENT) 25 meq tableteff
1-Covered
potassium bicarbonatecitric acid(KLOR-CON-EF) 25 meq tablet eff --
1-Covered
potassium bicarbonatecitric acid25 meq tablet eff
1-Covered
POTASSIUM CHL-NORMAL SALINE20 -ML IV SOLN 40 -ML IV SOLN
1-Covered
potassium chloride (KLOR-CONSPRINKLE) 10 meq capsule er -
1-Covered
potassium chloride 20meq15mlliquid
1-Covered
potassium chloridepotassiumbicarbonatecitric acidchloridebicarbcit 25 meq tableteff
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
75
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
potassium gluconate 595(99)mgtablet
1-Covered
PRENATAL MULTIVITAMIN TABLET 1-Covered
prenatal vit with calciumno129ferrous fumaratefolic acidno129ironfolic 27mg-08mgtablet
1-Covered
prenatal vit with calciumno130ferrous fumaratefolic acidno130ironfolic 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vitamins no121ferrousfumaratefolic acid pnvno121ironfolic 28mg-08mgtablet
1-Covered
prenatal vitamins withcalciumferrous fumaratefolicacid vitiron fumfolic 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vitamins withcalciumferrous fumaratefolicacid vitiron fumfolic 28mg-08mgtablet
1-Covered
prenatal vits with calcium118ferrous fumaratefolic acidpnv no8iron fumaratefa 29 mg-mg tab chew
1-Covered
prenatal vits with calcium137ferrous fumaratefolic acidno137ironfolic acd 27mg-08mgtablet
1-Covered STAR (Preferred Drug)
prenatal vits with calcium95ferrous fumaratefolic acid pnvno95ferrous fumfolic 28mg-08mg tablet
1-Covered
prenatal vits with calciumno96ferrous fumaratefolic acidvits96iron fumfolic 27mg-08mgtablet
1-Covered
pyridoxine hcl (vitamin b6) 25 mgtablet 50 mg tablet 100 mgtablet 250 mg tablet
1-Covered
ringers solution iv soln 1-Covered PA
SODIUM CHLORIDE 09 IRRIG 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
76
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SODIUM CHLORIDE 09 SOLUTION 1-Covered PA
sodium chloride irrigating solution(AQUA CARE SODIUM CHLORIDE)09 soln
1-Covered
sodium chloride irrigating solution(CURITY) 09 soln
1-Covered
sodium chloride irrigating solution09 soln
1-Covered
TRI-VI-SOL (vitamin apalmitateascorbicacidcholecalciferol (vit d3)) --DROPS (vitmin plmittescorbiccidcholeclciferol
1-Covered STAR (Preferred Drug)
VITAMIN B-12 -500 MCG TALET 1-Covered
VITAMIN C 1000 MG TABLET 1-Covered
GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach)
ANTISPASMODICS GASTROINTESTINAL (Drugs to Prevent Bowel andStomach Spasam)
CHLORDIAZEPOXIDE-CLIDINIUM -CAP
1-Covered MDD (8 Per Day)
chlordiazepoxideclidiniumbromide 5 mg-25mg capsule
1-Covered MDD (8 Per Day)
DICYCLOMINE HCL 10 MG5 MLSOLN
1-Covered
dicyclomine hcl 10 mg5 mlsolution 10 mg capsule 20 mgtablet
1-Covered
hyoscyamine sulfate (HYOSYNE)0125mgml drops 125mcg5mlelixir
1-Covered
hyoscyamine sulfate 0125 mg tabsubl 0125 mg tablet 0125mgmldrops 0375 mg tab er 12h125mcg5ml elixir
1-Covered
propantheline bromide 15 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
77
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GASTROINTESTINAL AGENTS OTHER (Other Drugs for the Bowel andStomach)
ALLI (orlistat) 60 MG CAPSULE 1-Covered PA
ANTACID 500 MG CHEW TABLET 1-Covered
ANTACID EXTRA STRENGTH -750 MGTAB CHEW CVS -750 MG CHEW
1-Covered
ANTI-DIARRHEAL HM -2 MGSOFTGEL
1-Covered
bismuth subsalicylate (BISMATROL)262 mg tab chew
1-Covered
bismuth subsalicylate (DIOTAME)262 mg tab chew
1-Covered
bismuth subsalicylate (PEP-T-MED)262 mg tab chew --
1-Covered
bismuth subsalicylate (PEPTICRELIEF) 262 mg tab chew
1-Covered
bismuth subsalicylate (PINKBISMUTH) 262 mg tab chew
1-Covered
bismuth subsalicylate (SOOTHE)262 mg tab chew
1-Covered
bismuth subsalicylate (STOMACHRELIEF) 262 mg tab chew
1-Covered
bismuth subsalicylate 262 mg tabchew
1-Covered
calcium carbonate (ANTACIDCALCIUM) 215(500)mg tab chew
1-Covered
calcium carbonate (ANTACIDEXTRA STRENGTH) 300mg(750) tabchew
1-Covered
calcium carbonate (ANTACID)200(500)mg tab chew 215(500)mgtab chew 300mg(750) tab chew
1-Covered
calcium carbonate (BAN-ACID)300mg(750) tab chew -
1-Covered
calcium carbonate (CAL-GEST)200(500)mg tab chew -
1-Covered
calcium carbonate (CALCIUMANTACID) 200(500)mg tab chew215(500)mg tab chew 300mg(750)tab chew
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
78
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcium carbonate (CHILDRENSPEPTO) 400 mg tab chew
1-Covered
calcium carbonate (CHILDRENSSOOTHE) 400 mg tab chew
1-Covered
calcium carbonate (FLAVORCHEWS ANTACID) 300mg(750) tabchew
1-Covered
calcium carbonate (SMOOTHANTACID) 300mg(750) tab chew
1-Covered
calcium carbonate (SMOOTHDISSOLVING ANTACID) 300mg(750)tab chew
1-Covered
calcium carbonate 200(500)mgtab chew 300mg(750) tab chew
1-Covered
diphenoxylate hclatropine sulfate25-0255 liquid 25-025mg tablet
1-Covered
DIPHENOXYLATE-ATROPINE -25-0025
1-Covered
GAS RELIEF (simethicone) (SIMETH)80 MG CHEW
1-Covered
GAS RELIEF GAS 125 MG CHEWTABLET GAS (SIMETH) 80 MGCHEW HM GAS 125 MG SOFTGELHM GAS 125 MG CHEW TAB
1-Covered
GAS-X (simethicone) -E-STR 125 MGTAB CHEW
1-Covered
INFANTS GAS RELIEF RLF 20 MG03ML
1-Covered
loperamide hcl (ANTI-DIARRHEAL) 2mg capsule - 2 mg tablet -
1-Covered
loperamide hcl (DIAMODE) 2 mgtablet
1-Covered
loperamide hcl (ULTRA A-D) 2 mgtablet -
1-Covered
loperamide hcl 1 mg5 ml liquid 2mg capsule 2 mg tablet
1-Covered
PEPTO-BISMOL (bismuthsubsalicylate) -TABLET CHEW
1-Covered
PEPTO-BISMOL TO-GO (bismuthsubsalicylate) --262 MG CHEW
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
79
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
simethicone (GAS RELIEF)40mg06ml drops susp 80 mg tabchew 125 mg tab chew 125 mgcapsule
1-Covered
simethicone (GAS-X) 125 mgcapsule -
1-Covered
simethicone (INFANT GAS RELIEF)40mg06ml drops susp
1-Covered
simethicone (INFANTS GAS RELIEF)40mg06ml drops susp
1-Covered
simethicone (MI-ACID) 80 mg tabchew -
1-Covered
simethicone 40mg06ml dropssusp 80 mg tab chew 125 mgcapsule 125 mg tab chew
1-Covered
STOMACH RELIEF 262 MG CHEWTAB
1-Covered
ursodiol 300 mg capsule 1-Covered
HISTAMINE2 (H2) RECEPTOR ANTAGONISTSACID CONTROLLER 20 MG TABLET 1-Covered
ACID REDUCER 10 MG TABLET 1-Covered PA
ACID REDUCER 20 MG TABLET 1-Covered
cimetidine (ACID REDUCER) 200mg tablet
1-Covered
cimetidine (HEARTBURN RELIEF) 200mg tablet
1-Covered
cimetidine 200 mg tablet 300 mgtablet 400 mg tablet 800 mgtablet
1-Covered
CIMETIDINE 300 MG5 ML SOLN 1-Covered
cimetidine hcl 300 mg5ml solution 1-Covered
famotidine (ACID CONTROLLER) 10mg tablet
1-Covered PA
famotidine (ACID CONTROLLER) 20mg tablet
1-Covered
famotidine (ACID REDUCER) 10 mgtablet
1-Covered PA
famotidine (ACID REDUCER) 20 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
80
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
famotidine (HEARTBURNPREVENTION) 10 mg tablet
1-Covered PA
famotidine (HEARTBURNPREVENTION) 20 mg tablet
1-Covered
famotidine (HEARTBURN RELIEF) 10mg tablet
1-Covered PA
famotidine (HEARTBURN RELIEF) 20mg tablet
1-Covered
famotidine (PEPCID) 20 mg tablet 1-Covered
famotidine 10 mg tablet 1-Covered PA
FAMOTIDINE 10 MG TABLET 1-Covered PA
famotidine 20 mg tablet 40 mgtablet
1-Covered
FAMOTIDINE 20 MG TABLET EQ 20MG TABLET 40 MG TABLET
1-Covered
IRRITABLE BOWEL SYNDROME AGENTSAMITIZA (lubiprostone) 8 MCGCAPSULE 24 MCG CAPSULES
1-Covered PA
LAXATIVES (Drugs for Bowel Cleansing and Constipation)bisacodyl (ALOPHEN PILLS) 5 mgtablet dr
1-Covered
bisacodyl (BISA-LAX) 5 mg tablet dr-
1-Covered
bisacodyl (BISACODYL) 5 mgtablet dr
1-Covered
bisacodyl (BISCOLAX) 10 mgsupprect
1-Covered
bisacodyl (C-LAX LAXATIVE) 5 mgtablet dr -ATIVE)
1-Covered
bisacodyl (DUCODYL) 5 mg tabletdr
1-Covered
bisacodyl (FAST RELIEF LAXATIVE)10 mg supprect
1-Covered
bisacodyl (GENTLE LAXATIVE) 5 mgtablet dr 10 mg supprect
1-Covered
bisacodyl (LAXATIVE SUPPOSITORY)10 mg supprect
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
81
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
bisacodyl (LAXATIVE) 5 mg tabletdr
1-Covered
bisacodyl (MAGIC BULLET) 10 mgsupprect
1-Covered
bisacodyl (WOMENS GENTLELAXATIVE) 5 mg tablet dr
1-Covered
bisacodyl (WOMENS LAXATIVE) 5mg tablet dr
1-Covered
bisacodyl 5 mg tablet dr 10 mgsupprect
1-Covered
BISACODYL EC 5 MG TABLET 10MG SUPPOSITORY
1-Covered
docusate sodium (COL-RITE) 100mg capsule - 250 mg capsule -
1-Covered
docusate sodium (DIOCTYL) 60mg15ml syrup
1-Covered
docusate sodium (DOCU LIQUID)50 mg5 ml liquid
1-Covered
docusate sodium (DOCUSIL) 100mg capsule
1-Covered
docusate sodium (DSS) 250 mgcapsule
1-Covered
docusate sodium (DULCOEASE)100 mg capsule
1-Covered
docusate sodium (DULCOLAXSTOOL SOFTENER) 100 mg capsule
1-Covered
docusate sodium (LAXA BASIC 100)mg capsule )
1-Covered
docusate sodium (PHILLIPSLAXATIVE) 100 mg capsule
1-Covered
docusate sodium (SOF-LAX) 100mg capsule -
1-Covered
docusate sodium (STOOLSOFTENER) 50 mg capsule 50 mg5ml liquid 60 mg15ml syrup 100mg capsule 250 mg capsule
1-Covered
DOCUSATE SODIUM 50 MG5 MLLIQ 100 MG SOFTGEL
1-Covered
docusate sodium 50 mg5 mlliquid 60 mg15ml syrup 100 mgcapsule 250 mg capsule
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
82
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
DOK (docusate sodium) 100 MG250 MG
1-Covered
GENTLE LAXATIVE 10 MG SUPPOSIT 1-Covered
glycerin (ADULT GLYCERIN) adultsupprect
1-Covered
glycerin (LAXATIVE SUPPOSITORY)pediatric supprect
1-Covered
glycerin (PEDIA-LAX) pediatricsupprect -
1-Covered
glycerin (SUPPOSITORY) adultsupprect
1-Covered
glycerin adult pediatric 1-Covered
lactulose (CONSTULOSE) 10 g15 mlsolution
1-Covered
lactulose (ENULOSE) 10 g15 mlsolution
1-Covered
lactulose (GENERLAC) 10 g15 mlsolution
1-Covered
lactulose 10 g15 ml 20 g30 ml 1-Covered
MAGNESIUM CITRATE HM SOLUTION 1-Covered
magnesium citrate solution 1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloride(GAVILYTE-C) peg3350sodsulfbicarbclkcl 240-2272g solnrecon -
1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloride(GAVILYTE-G) peg3350sodsulfbicarbclkcl 236-2274g solnrecon -
1-Covered
peg 3350sod sulfsod bicarbsodchloridepotassium chloridepeg3350sod sulfbicarbclkcl 236-2274g soln peg3350sodsulfbicarbclkcl 240-2272g soln
1-Covered
PEG-3350 AND ELECTROLYTES -SOLN
1-Covered
polyethylene glycol 3350(CLEARLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
83
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
polyethylene glycol 3350(GAVILAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(GENTLELAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(GLYCOLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(LAXACLEAR) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350 (NATURA-LAX) 17gdose powder -
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(POWDERLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(PURELAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350(SMOOTHLAX) 17gdose powder
1-Covered QL (527 PER 30 DAY(S))
polyethylene glycol 3350 17gdosepowder
1-Covered QL (527 PER 30 DAY(S))
SILACE (docusate sodium) 50MG5 ML LIQUID
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepeg (GAVILYTE-N)chloridenahco3kclpeg 420gsoln recon -
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepeg (TRILYTE WITH FLAVORPACKETS)chloridenahco3kclpeg 420gsoln recon
1-Covered
sodium chloridesodiumbicarbonatepotassiumchloridepegchloridenahco3kclpeg 420gsoln recon
1-Covered
STOOL SOFTENER (docusatesodium) 100 MG SOFTGEL 100 MGCAPSULE 250 MG SOFTGEL
1-Covered
STOOL SOFTENER HM 100 MGSFTGL 100 MG SOFTGEL HM 250MG SFTGL
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
84
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PROTECTANTSmisoprostol 100 mcg tablet 200mcg tablet
1-Covered PA
sucralfate 1 g tablet 1-Covered
PROTON PUMP INHIBITORSlansoprazole 15 mg capsule dr 1-Covered ST
lansoprazole 30 mg capsule dr 1-Covered
LANSOPRAZOLE DR 15 MGCAPSULE
1-Covered ST
LANSOPRAZOLE DR 30 MGCAPSULE
1-Covered
omeprazole 10 mg capsule dr 20mg tablet dr
1-Covered
omeprazole 20 mg capsule dr 1-Covered QL (60 PER 30 DAYS)
omeprazole 40 mg capsule dr 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
OMEPRAZOLE DR 20 MG CAPSULE 1-Covered QL (60 PER 30 DAYS)
OMEPRAZOLE DR 20 MG TABLET 1-Covered
pantoprazole sodium 20 mg tabletdr 40 mg tablet dr
1-Covered
PANTOPRAZOLE SODIUM DR 20 MGTAB DR 40 MG TAB
1-Covered
PREVACID (lansoprazole) DR 15MG CAPSULE
1-Covered
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERSTREATMENT (Drugs for Genetic or Enzyme Disorders)
GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERSTREATMENT
CREON (lipaseproteaseamylase)DR 6000 UNITS CAPSULE
1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
85
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
GENITOURINARY AGENTS (Drugs for the Genital Bladder andKidney)
ANTISPASMODICS URINARY (Drugs for Bladder Spasms)oxybutynin chloride 5 mg5 mlsyrup 5 mg tab er 24 5 mg tablet10 mg tab er 24 15 mg tab er 24
1-Covered
OXYBUTYNIN CHLORIDE ER ER 5 MGTABLET ER 10 MG TABLET ER 15 MGTABLET
1-Covered
OXYTROL FOR WOMEN(oxybutynin) 39 MG24HR
1-Covered ST
trospium chloride 20 mg tablet 1-Covered ST
TROSPIUM CHLORIDE 20 MG TABLET 1-Covered ST
BENIGN PROSTATIC HYPERTROPHY AGENTSalfuzosin hcl 10 mg tab er 24h 1-Covered PA
finasteride 5 mg tablet 1-Covered
tamsulosin hcl 04 mg capsule 1-Covered
GENITOURINARY AGENTS OTHER (Other Drugs for the GenitalBladder and Kidney)
bethanechol chloride 5 mg tablet10 mg tablet 25 mg tablet 50 mgtablet
1-Covered
citric acidsodium citrate (CYTRA-2) 334-500mg solution -
1-Covered
citric acidsodium citrate(VIRTRATE-2) 334-500mg solution -
1-Covered
citric acidsodium citrate 334-500mg solution
1-Covered
nonoxynol 9 (VCF) 125 foamappl
1-Covered
penicillamine 250 mg capsule 1-Covered PA QL (16 PER 1 DAY(S))
PENICILLAMINE 250 MG CAPSULE 1-Covered PA QL (16 PER 1 DAY(S))
phenazopyridine hcl (URINARYPAIN RELIEF) 95 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
86
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
PHENAZOPYRIDINE HCL 100 MGTAB 200 MG TAB
1-Covered
phenazopyridine hcl 100 mgtablet 200 mg tablet
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit ac(CYTRA-3) sodpotk citsod citcitacid 500-5505 solution -
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit ac(TRICITRATES) sodpotk citsodcitcit acid 500-5505 solution
1-Covered
sodiumpotassiumpotassiumcitratesodium citratecit acsodpotk citsod citcit acid 500-5505 solution
1-Covered
URINARY PAIN RELIEF HM RLF 95 MGTAB
1-Covered
PHOSPHATE BINDERScalcium acetate (ELIPHOS) 667 mgtablet
1-Covered QL (270 PER 30 DAYS) AL1 (Atleast 21 yrs old)
calcium acetate 667 mg capsule667 mg tablet
1-Covered QL (270 PER 30 DAYS) AL1 (Atleast 21 yrs old)
lanthanum carbonate 500 mg tabchew 750 mg tab chew 1000 mgtab chew
1-Covered PA
sevelamer carbonate 800 mgtablet
1-Covered PA
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(ADRENAL) (Drugs for ReplacingStimulating Adrenal GlandHormones)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(ADRENAL) (Glucocorticoids)
betamethasone dipropionate 005 lotion
1-Covered
betamethasone dipropionate 005 oint (g) 005 cream (g)
1-Covered ST
BETAMETHASONE DIPROPIONATEDP 005 OINT
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
87
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
betamethasonedipropionatepropylene glycolbetamethasonepropylene 005 cream (g)
1-Covered ST
betamethasone valerate 01 lotion 01 cream (g) 01 oint(g)
1-Covered
clobetasol propionate 005 gel(gram) 005 solution 005 cream (g) 005 oint (g)
1-Covered ST
CLOBETASOL PROPIONATE 005CREAM
1-Covered ST
DELTASONE (prednisone) 20 MGTABLET
1-Covered
desonide 005 lotion 005 oint(g) 005 cream (g)
1-Covered ST
DESONIDE 005 LOTION 005CREAM
1-Covered ST
dexamethasone(DEXAMETHASONE INTENSOL) 1mgml drops
1-Covered
dexamethasone 05 mg5mlsolution 05 mg tablet 05 mg5mlelixir 075 mg tablet 1 mg tablet15 mg tablet 2 mg tablet 4 mgtablet 6 mg tablet
1-Covered
DEXAMETHASONE 4 MG TABLET 1-Covered
fludrocortisone acetate 01 mgtablet
1-Covered
fluocinolone acetonide 001 cream (g) 001 solution 0025 cream (g) 0025 oint (g)
1-Covered ST
fluocinonide 005 cream (g) 005 gel (gram) 005 oint (g) 005 solution
1-Covered
FLUOCINONIDE 005 OINTMENT 1-Covered
hydrocortisone (ANTI-ITCH) 1 cream (g) -
1-Covered
hydrocortisone (ANUSOL-HC) 25 crmpe app -
1-Covered
hydrocortisone (CORTISONE) 1 cream (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
88
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
hydrocortisone (CORTIZONE-10PLUS) cream (g) -0
1-Covered
hydrocortisone (CORTIZONE-10) cream (g) -
1-Covered
hydrocortisone (HYDROCREAM) 1 cream (g)
1-Covered
hydrocortisone (NOBLE FORMULAHC) 1 cream (g)
1-Covered
hydrocortisone (PREPARATION H) 1 cream (g)
1-Covered
hydrocortisone (PROCTO-MED HC)25 crmpe app -
1-Covered
hydrocortisone (PROCTO-PAK) 1 crmpe app -
1-Covered
hydrocortisone (PROCTOSOL-HC)25 crmpe app -
1-Covered
hydrocortisone (PROCTOZONE-HC)25 crmpe app -
1-Covered
hydrocortisone (SOOTHING CARE)1 cream (g)
1-Covered
hydrocortisone 05 oint (g) 1 cream (g) 1 oint (g) 1 crmpe app 25 cream (g) 25 crmpe app 25 oint (g) 25 lotion 5 mg tablet 10 mg tablet20 mg tablet
1-Covered
HYDROCORTISONE 5 MG TABLET10 MG TABLET
1-Covered
hydrocortisone acetate(ANUCORT-HC) 25 mg supprect -
1-Covered
hydrocortisone acetate (ANUSOL-HC) 25 mg supprect -
1-Covered
hydrocortisone acetate(HEMMOREX-HC) 25 mg supprect -
1-Covered
HYDROCORTISONE ACETATE 25 MGSUPP
1-Covered
hydrocortisone acetate 25 mgsupprect
1-Covered
methylprednisolone 4 mg tablet 4mg tab ds pk 8 mg tablet 16 mgtablet 32 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
89
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
mometasone furoate 01 cream(g) 01 oint (g)
1-Covered
prednisolone (MILLIPRED DP) 5 mg(48) tab 5 mg (21) tab
1-Covered
prednisolone (MILLIPRED) 5 mgtablet
1-Covered
prednisolone 15 mg5 ml solution 1-Covered
prednisolone sodium phosphate 5mg5 ml 15 mg5 ml
1-Covered
prednisone (PREDNISONEINTENSOL) 5 mgml oral conc
1-Covered
prednisone 1 mg tablet 25 mgtablet 5 mg tab ds pk 5 mgtablet 5 mg5 ml solution 10 mgtablet 10 mg tab ds pk 20 mgtablet 50 mg tablet
1-Covered
triamcinolone acetonide 0025 oint (g) 0025 cream (g) 0025 lotion 01 cream (g) 01 lotion 01 oint (g) 0147mggaerosol 05 cream (g) 05 oint(g)
1-Covered
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(PITUITARY) (Drugs for ReplacingStimulating Pituitary GlandHormones)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(PITUITARY) (Drugs to ReplaceStimulate Pituitary Gland Hormones)
desmopressin acetate (non-refrigerated) (nonrefrigerated)10spray spraypump
1-Covered PA AL1 (8 to 14 yrs old)
desmopressin acetate 01 mgmlsolution 01 mg tablet 02 mgtablet
1-Covered AL1 (8 to 14 yrs old)
desmopressin acetate 4 mcgmlvial 4 mcgml ampul 10sprayspraypump
1-Covered PA AL1 (8 to 14 yrs old)
DESMOPRESSIN ACETATE 40MCG10 ML VIAL
1-Covered PA AL1 (8 to 14 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
90
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEXHORMONESMODIFIERS) (Drugs for ReplacingStimulating SexHormones)
ANDROGENSdanazol 50 mg capsule 100 mgcapsule 200 mg capsule
1-Covered
fluoxymesterone (ANDROXY) 10mg tablet
1-Covered
testosterone 125125g gel mdpmp 50 mg (1) gel packet
1-Covered PA
testosterone cypionate 100 mgmlvial 200 mgml vial
1-Covered PA
ESTROGENS (Contraceptives and Drugs for Menopause)desogestrel-ethinyl estradiol (APRI)-015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(CYRED EQ) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(CYRED) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(EMOQUETTE) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(ENSKYCE) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(ISIBLOOM) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(JULEBER) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(KALLIGA) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol(RECLIPSEN) -015-003 tablet
1-Covered
desogestrel-ethinyl estradiol -015-003 tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (AZURETTE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
91
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
desogestrel-ethinyl estradiolethinylestradiol (BEKYREE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (KARIVA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (KIMIDESS) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (PIMTREA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (SIMLIYA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (VIORELE) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol (VOLNEA) -eestradioleestradiol 21-5 (28)tablet
1-Covered
desogestrel-ethinyl estradiolethinylestradiol -eestradioleestradiol 21-5 (28) tablet
1-Covered
DROSPIRENONE-ETHINYL ESTRADIOL-EE 3-002 MG TAB
1-Covered
estradiol (DOTTI) 025mg24hpatch 0375mg24 patch005mg24h patch 075mg24hpatch 01mg24hr patch
1-Covered QL (16 PER 28 DAY(S))
estradiol 025mg24h patch0375mg24 patch 005mg24hpatch 075mg24h patch01mg24hr patch
1-Covered QL (16 PER 28 DAY(S))
estradiol 001 creamappl025mg24h patch tdwk005mg24h patch tdwk075mg24h patch tdwk01mg24hr patch tdwk 05 mgtablet 1 mg tablet 2 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
92
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ESTRADIOL 1 MG TABLET 2 MGTABLET
1-Covered
estrogensesterifiedmethyltestosterone (COVARYX HS)estrogenesterme-0625-125tablet
1-Covered PA
estrogensesterifiedmethyltestosterone (EEMT HS) estrogenesterme-0625-125 tablet
1-Covered PA
estrogensesterifiedmethyltestosterone estrogenesterme-0625-125tablet
1-Covered PA
ethinyl estradioldrospirenone(GIANVI) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(JASMIEL) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone (LO-ZUMANDIMINE) 002-3(28) tablet -
1-Covered
ethinyl estradioldrospirenone(LORYNA) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(NIKKI) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone(VESTURA) 002-3(28) tablet
1-Covered
ethinyl estradioldrospirenone 002-3(28) tablet
1-Covered
ethynodiol diacetate-ethinylestradiol (KELNOR 1-35) ethynoiol -estraiol mg-35mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol (KELNOR 1-50) ethynoiol -estraiol mg-50mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol (ZOVIA 1-35E) ethynoiol -estraiol mg-35mcg tablet -
1-Covered
ethynodiol diacetate-ethinylestradiol ethynoiol -estraiol 1 mg-50mcg tablet ethynoiol -estraiol 1mg-35mcg tablet
1-Covered
etonogestrelethinyl estradiol(ELURYNG) 12-015mg vag ring
1-Covered QL (1 PER 28 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
93
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
etonogestrelethinyl estradiol 12-015mg vag ring
1-Covered QL (1 PER 28 DAY(S))
HAILEY FE 1-20 TABLET 15-30 TABLET 1-Covered
LEVONORGESTREL-ETH ESTRADIOL -TRIPHASIC
1-Covered
levonorgestrelethinyl estradiol(AFIRMELLE)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(ALTAVERA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(AUBRA EQ)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AUBRA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AVIANE)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(AYUNA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(CHATEAL EQ)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(CHATEAL)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(DELYLA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(ENPRESSE)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
94
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrelethinyl estradiol(FALMINA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(KURVELO)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(LARISSIA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(LESSINA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(LEVONEST)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
levonorgestrelethinyl estradiol(LEVORA-28)levonorgestrelethinestradiol 015-003 tablet -
1-Covered
levonorgestrelethinyl estradiol(LILLOW)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(LUTERA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(MARLISSA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(MYZILRA)levonorgestrelethinestradiol 6-5-10 tablet
1-Covered
levonorgestrelethinyl estradiol(ORSYTHIA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
95
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrelethinyl estradiol(PORTIA)levonorgestrelethinestradiol 015-003 tablet
1-Covered
levonorgestrelethinyl estradiol(SRONYX)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiol(TRIVORA-28)levonorgestrelethinestradiol 6-5-10 tablet -
1-Covered
levonorgestrelethinyl estradiol(VIENVA)levonorgestrelethinestradiol 01-002mg tablet
1-Covered
levonorgestrelethinyl estradiollevonorgestrelethinestradiol 01-002mg tabletlevonorgestrelethinestradiol 015-003 tabletlevonorgestrelethinestradiol 6-5-10 tablet
1-Covered
LYLLANA 0025 MG PATCH 00375MG PATCH 005 MG PATCH 0075MG PATCH 01 MG PATCH
1-Covered QL (16 PER 28 DAY(S))
MENEST (estrogensesterified) 03MG TABLET 0625 MG TABLET 125MG TABLET 25 MG TABLET
1-Covered
MICROGESTIN 21 1-20 TABLET 1-Covered
MICROGESTIN FE 1-20 TABLET 1-Covered
norelgestrominethinyl estradiol(XULANE)norelgestrominethinestradiol 150-3524h patch tdwk
1-Covered QL (3 PER 28 DAY(S))
norethindrone acetate-ethinylestradiol (AUROVELA) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (GILDESS) -15-003mgtablet
1-Covered
norethindrone acetate-ethinylestradiol (HAILEY) -15-003mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
96
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone acetate-ethinylestradiol (JUNEL) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (LARIN) -1mg-20mcgtablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol (MICROGESTIN) -1mg-20mcg tablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiol -1mg-20mcg tablet -15-003mg tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate(AUROVELA FE) -eestradiol-iron15-30(21) tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (BLISOVIFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (JUNELFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (LARINFE) --1mg-20(21) tablet --15-30(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate(MICROGESTIN FE) --1mg-20(21)tablet --15-30(21) tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TARINAFE 1-20 EQ) -eestradiol-iron mg-(2)tablet -
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TARINAFE) -eestradiol-iron 1mg-20(21)tablet
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate (TILIA FE)-eestradiol-iron 5-7-9-7 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
97
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone acetate-ethinylestradiolferrous fumarate (TRI-LEGEST FE) -eestradiol-iron 5-7-9-7tablet -
1-Covered
norethindrone acetate-ethinylestradiolferrous fumarate --1mg-20(21) tablet --15-30(21) tablet
1-Covered
norethindrone-ethinyl estradiol(ALYACEN) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(ARANELLE) -ethin 7-9-5 tablet
1-Covered
norethindrone-ethinyl estradiol(BALZIVA) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(BRIELLYN) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(CYCLAFEM) -1 mg-35mcg tablet -7 days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(DASETTA) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(LEENA) -ethin 7-9-5 tablet
1-Covered
norethindrone-ethinyl estradiol(NECON) -ethin 05-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(NORTREL) -05-0035 tablet -1 mg-35mcg tablet -7 days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(PHILITH) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(PIRMELLA) -1 mg-35mcg tablet -7days x 3 tablet
1-Covered
norethindrone-ethinyl estradiol(VYFEMLA) -ethin 04-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(WERA) -ethin 05-0035 tablet
1-Covered
norethindrone-ethinyl estradiol(ZENCHENT) -ethin 04-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(ESTARYLLA) -025-0035 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
98
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norgestimate-ethinyl estradiol(FEMYNOR) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(MILI) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(MONO-LINYAH) -025-0035 tablet -
1-Covered
norgestimate-ethinyl estradiol(MONONESSA) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(PREVIFEM) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol(SPRINTEC) -025-0035 tablet
1-Covered
norgestimate-ethinyl estradiol (TRIFEMYNOR) -7daysx3 28 tablet
1-Covered
norgestimate-ethinyl estradiol (TRI-ESTARYLLA) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-LINYAH) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-ESTARYLLA) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-MARZIA) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-MILI) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-LO-SPRINTEC) -7daysx3 lo tablet --
1-Covered
norgestimate-ethinyl estradiol (TRI-PREVIFEM) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-SPRINTEC) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-VYLIBRA LO) -7daysx3 lo tablet -
1-Covered
norgestimate-ethinyl estradiol (TRI-VYLIBRA) -7daysx3 28 tablet -
1-Covered
norgestimate-ethinyl estradiol(TRINESSA LO) -7daysx3 lo tablet
1-Covered
norgestimate-ethinyl estradiol(TRINESSA) -7daysx3 28 tablet
1-Covered
norgestimate-ethinyl estradiol(VYLIBRA) -025-0035 tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
99
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
NORGESTIMATE-ETHINYL ESTRADIOL-025-0035 MG
1-Covered
norgestimate-ethinyl estradiol -025-0035 tablet -7daysx3 28tablet -7daysx3 lo tablet
1-Covered
norgestrel-ethinyl estradiol(CRYSELLE) -03-003mg tablet
1-Covered
norgestrel-ethinyl estradiol (ELINEST)-03-003mg tablet
1-Covered
norgestrel-ethinyl estradiol (LOW-OGESTREL) -03-003mg tablet -
1-Covered
norgestrel-ethinyl estradiol(OGESTREL) -05 mg-50 tablet
1-Covered
PREMARIN (estrogens conjugated)03 MG TABLET 045 MG TABLET0625 MG TABLET 09 MG TABLET125 MG TABLET
1-Covered
PREMARIN (estrogens conjugated)VAGINAL CREAM-APPL
1-Covered QL (43 PER 30 DAY(S))
PREMPHASE (estrogensconjugatedmedroxyprogesteroneacetate) 0625-5 MG TABLET
1-Covered
PREMPRO (estrogensconjugatedmedroxyprogesteroneacetate) 03 MG-15 MG TABLET045-15 MG TABLET 0625-5 MGTABLET 0625-25 MG TABLET
1-Covered
ZOVIA 1-35 -TABLET 1-Covered
PROGESTINSDEPO-PROVERA(medroxyprogesterone acetate) -400 MGML VIAL
1-Covered
DEPO-SUBQ PROVERA 104(medroxyprogesterone acetate) -SYRINGE
1-Covered
hydroxyprogesterone caproate250 mgml vial
1-Covered PA SP
hydroxyprogesterone caproatepfcaproatpf 250 mgml vial
1-Covered PA SP
JENCYCLA 035 MG TABLET 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
100
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
levonorgestrel (AFTERA) 15 mgtablet
1-Covered
levonorgestrel (ECONTRA EZ) 15mg tablet
1-Covered
levonorgestrel (ECONTRA ONE-STEP) 15 mg tablet -
1-Covered
levonorgestrel (FALLBACK SOLO)15 mg tablet
1-Covered
levonorgestrel (MY CHOICE) 15mg tablet
1-Covered
levonorgestrel (MY WAY) 15 mgtablet
1-Covered
levonorgestrel (NEW DAY) 15 mgtablet
1-Covered
levonorgestrel (OPCICON ONE-STEP) 15 mg tablet -
1-Covered
levonorgestrel (OPTION 2) 15 mgtablet
1-Covered
levonorgestrel (TAKE ACTION) 15mg tablet
1-Covered
levonorgestrel 15 mg tablet 1-Covered QL (1 PER 1 DAYS)
MEDROXYPROGESTERONE ACETATE150 MGML
1-Covered QL (1 PER 84 DAYS)
medroxyprogesterone acetate 150mgml vial 150 mgml syringe
1-Covered QL (1 PER 84 DAYS)
MEDROXYPROGESTERONE ACETATE25 MG TAB
1-Covered
medroxyprogesterone acetate 25mg tablet 5 mg tablet 10 mgtablet
1-Covered
megestrol acetate 20 mg tablet40 mg tablet
1-Covered
megestrol acetate 400mg10mloral susp
1-Covered PA
norethindrone (CAMILA) 035 mgtablet
1-Covered
norethindrone (DEBLITANE) 035 mgtablet
1-Covered
norethindrone (ERRIN) 035 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
101
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
norethindrone (HEATHER) 035 mgtablet
1-Covered
norethindrone (INCASSIA) 035 mgtablet
1-Covered
norethindrone (JENCYCLA) 035mg tablet
1-Covered
norethindrone (JOLIVETTE) 035 mgtablet
1-Covered
norethindrone (LYZA) 035 mgtablet
1-Covered
norethindrone (NORA-BE) 035 mgtablet -
1-Covered
norethindrone (NORLYDA) 035 mgtablet
1-Covered
norethindrone (NORLYROC) 035mg tablet
1-Covered
norethindrone (SHAROBEL) 035 mgtablet
1-Covered
norethindrone (TULANA) 035 mgtablet
1-Covered
norethindrone 035 mg tablet 1-Covered
norethindrone acetate 5 mg tablet 1-Covered
PLAN B ONE-STEP (levonorgestrel) -15 MG TALET
1-Covered
TAKE ACTION (levonorgestrel) 15MG TABLET
1-Covered
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(THYROID) (Drugs for the Thyroid)
HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(THYROID) (Drugs to Replace Thyroid Hormone)
ARMOUR THYROID (thyroidpork) 15MG TABLET 30 MG TABLET 60 MGTABLET 90 MG TABLET 120 MGTABLET 180 MG TABLET 240 MGTABLET 300 MG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
102
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LEVO-T (levothyroxine sodium) -25MCG ABLE -50 MCG ABLE -75MCG ABLE -88 MCG ABLE -100MCG ABLE -112 MCG ABLE -125MCG ABLE -137 MCG ABLE -150MCG ABLE -175 MCG ABLE -200MCG ABLE -300 MCG ABLE
1-Covered
levothyroxine sodium 25 mcgtablet 50 mcg tablet 75 mcgtablet 88 mcg tablet 100 mcgtablet 112 mcg tablet 125 mcgtablet 137 mcg tablet 150 mcgtablet 175 mcg tablet 200 mcgtablet 300 mcg tablet
1-Covered STAR (Preferred Drug)
LEVOTHYROXINE SODIUM 25 MCGTABLET 50 MCG TABLET 75 MCGTABLET 88 MCG TABLET 100 MCGTABLET 112 MCG TABLET 125 MCGTABLET 137 MCG TABLET 150 MCGTABLET 175 MCG TABLET 200 MCGTABLET 300 MCG TABLET
1-Covered STAR (Preferred Drug)
LEVOXYL (levothyroxine sodium) 25MCG TABLET 50 MCG TABLET 75MCG TABLET 88 MCG TABLET 100MCG TABLET 112 MCG TABLET 125MCG TABLET 137 MCG TABLET 150MCG TABLET 175 MCG TABLET 200MCG TABLET
1-Covered
SYNTHROID (levothyroxine sodium)25 MCG TABLET 50 MCG TABLET75 MCG TABLET 88 MCG TABLET100 MCG TABLET 112 MCG TABLET125 MCG TABLET 137 MCG TABLET150 MCG TABLET 175 MCG TABLET200 MCG TABLET 300 MCG TABLET
1-Covered
thyroidpork (NP THYROID) 15 mgtablet 30 mg tablet 60 mg tablet90 mg tablet 120 mg tablet
1-Covered STAR (Preferred Drug)
UNITHROID (levothyroxine sodium)25 MCG TABLET 50 MCG TABLET75 MCG TABLET 88 MCG TABLET100 MCG TABLET 112 MCG TABLET125 MCG TABLET 137 MCG TABLET150 MCG TABLET 175 MCG TABLET200 MCG TABLET 300 MCG TABLET
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
103
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs forSuppressing Hormones from the Pituitary Gland)
HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs to SuppressPituitary Hormones)
leuprolide acetate 1 mg02ml kit 1-Covered PA SP
LUPRON DEPOT-PED (leuprolideacetate) -15 MG KIT
1-Covered PA
SYNAREL (nafarelin acetate) 2MGML NASAL SPRAY
1-Covered PA
HORMONAL AGENTS SUPPRESSANT (THYROID) (Drugs for theThyroid)
ANTITHYROID AGENTS (Drugs to Suppress Thyroid Hormone)methimazole 5 mg tablet 10 mgtablet
1-Covered
propylthiouracil 50 mg tablet 1-Covered
IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing theImmune System)
IMMUNE SUPPRESSANTS (Drugs to Suppress the Immune System)azathioprine 50 mg tablet 1-Covered
AZATHIOPRINE 50 MG TABLET 1-Covered
cyclosporine 25 mg capsule 100mg capsule
1-Covered
cyclosporine modified (GENGRAF)25 mg capsule 100 mgml solution100 mg capsule
1-Covered
cyclosporine modified 25 mgcapsule 100 mgml solution 100mg capsule
1-Covered
ENBREL (etanercept) 25 MG KIT 1-Covered PA SP QLC (8 vials28 days)
ENBREL (etanercept) 25 MG05 MLSYRINGE 50 MGML SYRINGE
1-Covered PA SP QLC (4 syringes [1 kit]28days)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
104
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ENBREL 25 MG05 ML VIAL 1-Covered PA QL (4 PER 28 DAY(S))
ENBREL SURECLICK (etanercept) 50MGML
1-Covered PA SP QLC (4 pens [1 kit]28days)
HUMIRA (adalimumab) 10 MG02ML SYRINGE 20 MG04 MLSYRINGE 40 MG08 ML SYRINGE
1-Covered PA SP QLC (2 syringes [1 kit]28days)
HUMIRA PEDIATRIC CROHNS(adalimumab) 40 MG08 ML
1-Covered PA SP QLC (3 or 6 syringesyeardepending upon package size)
HUMIRA PEN (adalimumab) 40MG08 ML
1-Covered PA SP QLC (2 pens [1 kit]28days)
HUMIRA PEN CROHNS-UC-HS(adalimumab) --40 MG
1-Covered PA SP QLC (6 pens [1 kit]year)
HUMIRA PEN PSOR-UVEITS-ADOL HS(adalimumab) --40 MG
1-Covered PA SP QLC (4 pens [1 kit]year)
HUMIRA(CF) (adalimumab) 10MG01 ML SYRING 20 MG02 MLSYRING 40 MG04 ML SYRING
1-Covered PA SP QLC (2 syringes [1 kit]28days)
HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 80-40 MG
1-Covered PA SP QLC (2 syringes [1kit]year)
HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 80MG08
1-Covered PA SP QLC (3 syringes [1kit]year)
HUMIRA(CF) PEN (adalimumab) 40MG04 ML
1-Covered PA SP QLC (2 pens [1 kit]28days)
HUMIRA(CF) PEN CROHNS-UC-HS(adalimumab) CRHN--80MG
1-Covered PA SP QLC (3 pens [1 kit]year)
HUMIRA(CF) PEN PSOR-UV-ADOLHS (adalimumab) --AHS 80-40
1-Covered PA SP QLC (3 pens [1 kit]year)
METHOTREXATE 25 MG TABLET 1-Covered
methotrexate sodium 25 mgtablet
1-Covered
mycophenolate mofetil 200 mgmlsusp recon
1-Covered PA
mycophenolate mofetil 250 mgcapsule 500 mg tablet
1-Covered AL1 (At least 21 yrs old)
RHEUMATREX (methotrexatesodium) 25 MG TABLET
1-Covered
SANDIMMUNE (cyclosporine) 25MG CAPSULE 100 MGML SOLN
1-Covered
sirolimus 1 mgml solution 1-Covered PA
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
105
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
tacrolimus 05 mg capsule 1 mgcapsule 5 mg capsule
1-Covered AL1 (At least 21 yrs old)
TACROLIMUS 05 MG CAPSULE 1MG CAPSULE 5 MG CAPSULE
1-Covered AL1 (At least 21 yrs old)
IMMUNIZING AGENTS PASSIVE (Vaccines)HYPERTET S-D (tetanus immuneglobulinpf) -250 UNIT YRINGE
3-MedicalBenefit
NABI-HB (hepatitis b immuneglobulin) -VIAL gloulin)
3-MedicalBenefit
IMMUNOMODULATORSleflunomide 10 mg tablet 20 mgtablet
1-Covered
LEFLUNOMIDE 10 MG TABLET 20MG TABLET
1-Covered
RIDAURA (auranofin) 3 MGCAPSULE
1-Covered PA
VACCINESADACEL TDAP(diphtheriapertussis(acellular)tetanus vaccinepf) VIAL
1-Covered AL1 (At least 19 yrs old)
AFLURIA QUAD 2020-2021 -VIAL 1-Covered AL1 (At least 19 yrs old)
AFLURIA QUAD 2020-21 (3YR UP) - 1-Covered AL1 (At least 19 yrs old)
BEXSERO (meningococcal group bvaccine 4-component) PREFILLEDSYRINGE -
1-Covered QL (2 PER LIFETIME) AL1 (19 to 25yrs old)
BOOSTRIX TDAP(diphtheriapertussis(acellular)tetanus vaccine) SYRINGE VIAL
1-Covered AL1 (At least 19 yrs old)
ENGERIX-B ADULT (hepatitis b virusvaccine recombinantpf) -20MCGML VIAL recominantpf) -20MCGML SYRN recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
FLUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 65 yrs old)
FLUAD QUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 19 yrs old)
FLUARIX QUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 19 yrs old)
FLUBLOK QUAD 2018-2019(influenza virus vaccine qv 2018-19(18 yrs and older)rcmbpf) -SYRINGE -
1-Covered AL1 (19 to 999 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
106
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
FLUBLOK QUAD 2020-2021 -SYRINGE
1-Covered AL1 (At least 19 yrs old)
FLUCELVAX QUAD 2020-2021 2020-2021 SYR 2020-2021 VIAL
1-Covered AL1 (At least 19 yrs old)
FLULAVAL QUAD 2019-2020(influenza virus vaccinequadrivalent 2019-20 (6 mos andup)) -VIAL -
1-Covered AL1 (At least 19 yrs old)
FLULAVAL QUAD 2020-2021 -SYR 1-Covered AL1 (At least 19 yrs old)
FLUZONE HIGH-DOSE QUAD 2020-21 --
1-Covered AL1 (At least 65 yrs old)
FLUZONE QUAD 2019-2020(influenza virus vaccine quadrival2019-2020(6 mos and up)pf) -VIAL-
1-Covered AL1 (At least 19 yrs old)
FLUZONE QUAD 2020-2021 2020-2021 VIAL 2020-2021 SYRINGE
1-Covered AL1 (At least 19 yrs old)
GARDASIL 9 (human papillomavirusvaccine 9-valentpf) 9 SYRINGE 9-9 VIAL 9-
1-Covered QL (3 PER LIFETIME) AL1 (19 to 27yrs old)
HAVRIX (hepatitis a virusvaccinepf) 720 UNIT05 MLSYRINGE (heptitis vccinepf) 720UNITS05 ML VIAL (heptitisvccinepf) 1440 UNITSMLSYRINGE (heptitis vccinepf) 1440UNITSML VIAL (heptitis vccinepf)
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
HEPLISAV-B (hepatitis b vaccinerecombinantvaccine adjuvantcpg 1018pf) -20 MCG05 MLSYRNG RECOMINANT -20MCG05 ML VIAL RECOMINANT
1-Covered AL1 (At least 19 yrs old) QLC (2perlifetime)
IMOVAX RABIES VACCINE (rabiesvaccine human diploid cellpf)VIAL
3-MedicalBenefit
M-M-R II VACCINE (measlesmumps and rubella vaccinelivepf) --VIAL
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
MENACTRA(meningococcalvaccine acyw-135diphtheria toxoid conjpf) VIAL-
1-Covered AL1 (At least 19 yrs old)
MENQUADFI VIAL 1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
107
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
MENVEO A-C-Y-W-135-DIP(meningococcalvaccine acyw-135diphtheria toxoid conjpf) -----VIL KT -DIPHTHERIA
1-Covered QL (1 PER LIFETIME) AL1 (19 to 55yrs old)
PNEUMOVAX 23 (pneumococcal23-valent polysaccharide vaccine)23 VIAL 23- 23 SYRINGE 23-
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
PREVNAR 13 (pneumococcal 13-valent conjugate vaccine(diphtheria crm)pf) SYRINGE -
1-Covered QL (1 PER LIFETIME) AL1 (At least19 yrs old)
RABAVERT (rabies vaccine purifiedchicken embryo cell (pcec)pf)RABIES VACC W-DILUENT
1-Covered AL1 (At least 19 yrs old)
RECOMBIVAX HB (hepatitis b virusvaccine recombinantpf) 5MCG05 ML SYR recominantpf)10 MCGML SYR recominantpf)40 MCGML VIAL recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
RECOMBIVAX HB (hepatitis b virusvaccine recombinantpf) 5MCG05 ML VL recominantpf) 10MCGML VIAL recominantpf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
SHINGRIX (varicella-zoster virusglycoprotein erecas01badjuvantpf) VIAL KIT -
1-Covered QL (2 PER LIFETIME) AL1 (At least50 yrs old)
TDVAX (tetanus and diphtheriatoxoids adult) VIAL
1-Covered AL1 (At least 19 yrs old)
TENIVAC (tetanus and diphtheriatoxoids adsorbed adultpf) VIAL
1-Covered AL1 (At least 19 yrs old)
tetanus and diphtheria toxoidsadult tetanus toxadult 2-2 lf05vial
1-Covered AL1 (At least 19 yrs old)
TRUMENBA (neisseria meningitidisgroup b lipidated fhbprecombinant) 120 MCG05 MLVACCIN
1-Covered QL (2 PER LIFETIME) AL1 (19 to 25yrs old)
TWINRIX (hepatitis a virus andhepatitis b virus vaccinepf)VACCINE SYRINGE (heptitis ndheptitis vccinepf)
1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
108
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
VAQTA (hepatitis a virusvaccinepf) 25 UNITS05 ML VIAL(heptitis vccinepf) 25 UNITS05ML SYRINGE (heptitis vccinepf) 50UNITSML VIAL (heptitis vccinepf)50 UNITSML SYRINGE (heptitisvccinepf)
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
VARIVAX VACCINE (varicella virusvaccine livepf) WITH DILUENT
1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)
ZOSTAVAX (zoster vaccine livepf)VIAL
1-Covered QL (1 PER LIFETIME) AL1 (At least60 yrs old)
INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for InflammatoryBowel Disease)
AMINOSALICYLATESbalsalazide disodium 750 mgcapsule
1-Covered
mesalamine 4 g60 ml enema 1-Covered
mesalamine 400 mg cap(drtab) 1-Covered QL (6 PER 1 DAY(S))
GLUCOCORTICOIDShydrocortisone (COLOCORT)100mg60ml enema
1-Covered
hydrocortisone 100mg60mlenema
1-Covered
SULFONAMIDESsulfasalazine 500 mg tablet dr 500mg tablet
1-Covered
METABOLIC BONE DISEASE AGENTS (Drugs for the Bone)
METABOLIC BONE DISEASE AGENTSalendronate sodium 10 mg tablet40 mg tablet
1-Covered PA STAR (Preferred Drug)
alendronate sodium 35 mg tablet70 mg tablet
1-Covered STAR (Preferred Drug)
alendronate sodium 5 mg tablet 1-Covered AL1 (At least 65 yrs old) STAR(Preferred Drug)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
109
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
calcitoninsalmonsynthetic200spray spraypump
1-Covered PA
CALCITRIOL 025 MCG CAPSULE05 MCG CAPSULE
1-Covered
calcitriol 025 mcg capsule 05mcg capsule 1 mcgml solution
1-Covered
cholecalciferol (vitamin d3) 10mcg capsule 10 mcg tablet
1-Covered
cinacalcet hcl 30 mg tablet 60 mgtablet 90 mg tablet
1-Covered PA
CINACALCET HCL 30 MG TABLET60 MG TABLET 90 MG TABLET
1-Covered PA
ergocalciferol (vitamin d2)(CALCIDOL) 200 mcgml drops
1-Covered
ergocalciferol (vitamin d2) 10 mcgtablet 200 mcgml drops 1250mcg capsule
1-Covered
ERGOCALCIFEROL 200 MCGMLDROP
1-Covered
FOSAMAX PLUS D (alendronatesodiumcholecalciferol (vitamind3)) 70 MG-2800 IU
1-Covered PA
MISCELLANEOUS THERAPEUTIC AGENTSalcohol antiseptic pads s med 1-Covered
ALCOHOL WIPES 70 1-Covered
ASSURE ID DUO-SHIELD -30GX316-30GX516
1-Covered
ASSURE ID INSULIN SAFETY SYR05ML 31GX1564 SYR 1 ML31GX1564
1-Covered
condoms female each 1-Covered
condoms latex lubricated each 1-Covered
cromolyn sodium 52 mgspraypump
1-Covered
DROPLET MICRON PEN NEEDLE 34GX 964
1-Covered
freestyle insulix test strips 1-Covered QL (100 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
110
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
freestyle lite test strips 1-Covered QL (100 PER 30 DAYS)
freestyle test strips 1-Covered QL (100 PER 30 DAYS)
inhalerassist device with largemask devicelg spacer
1-Covered
inhalerassist device with mediummask devicemed spacer
1-Covered
inhalerassist device with smallmask devsmall spacer
1-Covered
INSULIN PEN NEEDLES INSULIN PENNEEDLES INSULIN PEN NEEDLES
1-Covered
insulin syringe 03 ml 1-Covered
insulin syringe 05 ml 1-Covered
insulin syringe 1 ml 1-Covered
lancets 28 gauge 30 gauge 33gauge
1-Covered
methylergonovine maleate 02 mgtablet
1-Covered
PEN NEEDLE 29G 12MM 1-Covered
pen needle diabetic 29 g x12 30gx516 31 g x14 31 gx316 31gx516 32gx 532 32 gx 14 32gx316 32 gx516 33 gx532
1-Covered
pen needle diabetic disposablesafety 30 gx516 30 gx316
1-Covered
pen needle diabetic removerand disposal unit 31 gx316 32gx532
1-Covered
pen needle diabetic safety 30gx316 dis
1-Covered
RID (permethrin) PEDICULICIDESSPRAY
1-Covered
syringe with needle insulin safety1 ml geneedleinsulnsafe1ml 30gx316 disp
1-Covered
syringe withneedledisposableinsulin 1 ml30gx12 disp 31 gx516 disp31gx1564 disp
1-Covered
syringe with needleinsulin03 ml -needldispinsul03 29 x12 disp
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
111
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
syringe with needleinsulin05 ml -ml 30gx12 disp -ml 31 gx516disp -ml 31gx1564 disp
1-Covered
UNIFINE PENTIPS MAXFLOW30GX316
1-Covered
OPHTHALMIC AGENTS (Drugs for the Eyes)
OPHTHALMIC AGENTS OTHER (Other Drugs for the Eyes)atropine sulfate 1 drops 1-Covered
bacitracinpolymyxin b sulfate (AK-POLY-BAC) 500-10kg oint (g) --
1-Covered
bacitracinpolymyxin b sulfate(POLYCIN) 500-10kg oint (g)
1-Covered
bacitracinpolymyxin b sulfate 500-10kg oint (g)
1-Covered
BEOVU (brolucizumab-dbll) 6MG005 ML VIAL -
3-MedicalBenefit
BLEPHAMIDE (sulfacetamidesodiumprednisolone acetate) EYEDROPS
1-Covered
CORTISPORIN (neomycinsulfatepolymyxin bsulfatehydrocortisone) CREAM
1-Covered
cyclopentolate hcl 05 drops 1 drops 2 drops
1-Covered
homatropine hbr (HOMATROPAIRE)5 drops
1-Covered
homatropine hbr 5 drops 1-Covered
MURO-128 (sodium chloride) -5EYE DROPS
1-Covered
neomycin sulfatebacitracinzincpolymyxin bhydrocortisone(NEO-POLYCIN HC)neomycinbacitp-myxhydrocort35-10k-1 oint (g) -
1-Covered
neomycin sulfatebacitracinzincpolymyxin bhydrocortisoneneomycinbacitp-myxhydrocort35-10k-1 oint (g)
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
112
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
neomycinsulfatebacitracinpolymyxin b(NEO-POLYCIN)sulfbacitracinpoly 35mg-400oint (g) -
1-Covered
neomycinsulfatebacitracinpolymyxin bsulfbacitracinpoly 35mg-400oint (g)
1-Covered
neomycin sulfatepolymyxin bsulfategramicidin dneomycinpolymyxn bgramicidin175mg-10k drops
1-Covered
neomycin sulfatepolymyxin bsulfatehydrocortisoneneomycinpolymyxin bhydrocort35-10k-10 drops susp
1-Covered
neomycinpolymyxin bsulfatedexamethasonebdexametha 01 drops suspbdexametha 35-10k-1 oint (g)
1-Covered
phenylephrine hcl 25 drops 10 drops
1-Covered
polymyxin b sulfatetrimethoprimsulftrimethoprim 10000-1ml drops
1-Covered
proparacaine hcl 05 drops 1-Covered PA
sodium chloride (MURO-128) drops -18)
1-Covered
sodium chloride 5 drops 1-Covered
sulfacetamidesodiumprednisolone sodiumphosphatesulfacetamideprednisolone 10 -023 drops
1-Covered
TOBRADEX(tobramycindexamethasone) EYEOINTMENT
1-Covered
tobramycindexamethasone 03-01 drops susp
1-Covered
OPHTHALMIC ANTI-ALLERGY AGENTS (Drugs for Eye Allergies)ALAWAY (ketotifen fumarate)0025 EYE DROPS
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
113
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALOMIDE (lodoxamidetromethamine) 01 EYE DROPS
1-Covered
cromolyn sodium 4 drops 1-Covered
EYE ITCH RELIEF 0025 DROPS HM0025 DROP
1-Covered
ketotifen fumarate (ALLERGY EYEDROPS) 0025 drops
1-Covered
ketotifen fumarate (EYE ITCHRELIEF) 0025 drops
1-Covered
ketotifen fumarate (ITCHY EYE)0025 drops
1-Covered
ketotifen fumarate (WAL-ZYR) 0025 drops -
1-Covered
ketotifen fumarate (ZADITOR) 0025 drops
1-Covered
ketotifen fumarate 0025 drops 1-Covered
OPHTHALMIC ANTI-INFLAMMATORIES (Drugs to Reduce EyeSwelling)
dexamethasone sodiumphosphate 01 drops
1-Covered
diclofenac sodium 01 drops 1-Covered
fluorometholone 01 drops susp 1-Covered
flurbiprofen sodium 003 drops 1-Covered
FML FORTE (fluorometholone)025 EYE DROPS
1-Covered
FML SOP (fluorometholone) 01OINTMENT
1-Covered
ketorolac tromethamine 05 drops
1-Covered
PRED MILD (prednisolone acetate)012 EYE DROPS
1-Covered
prednisolone acetate 1 dropssusp
1-Covered
prednisolone sodium phosphate 1 drops
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
114
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
OPHTHALMIC ANTIGLAUCOMA AGENTS (Drugs for Glaucoma)ALPHAGAN P (brimonidinetartrate) ALHAGAN 01 DROS
1-Covered QL (1 PER 30 DAYS)
apraclonidine hcl 05 drops 1-Covered
betaxolol hcl 05 drops 1-Covered
BETIMOL (timolol) 025 DROPS05 DROPS
1-Covered
BETOPTIC S (betaxolol hcl) 025EYE DROP
1-Covered
brimonidine tartrate 02 drops 1-Covered
dorzolamide hcl 2 drops 1-Covered
dorzolamide hcltimolol maleate223-681 drops
1-Covered QL (10 PER 30 DAY(S))
DORZOLAMIDE-TIMOLOL -EYEDROPS
1-Covered QL (10 PER 30 DAY(S))
IOPIDINE (apraclonidine hcl) 1EYE DROPS
1-Covered
levobunolol hcl 05 drops 1-Covered
methazolamide 25 mg tablet 50mg tablet
1-Covered
METHAZOLAMIDE 25 MG TABLET 50MG TABLET
1-Covered
PHOSPHOLINE IODIDE(echothiophate iodide) 0125
1-Covered
pilocarpine hcl 1 drops 2 drops 4 drops
1-Covered
PILOCARPINE HCL 1 DROPS 2DROPS
1-Covered
timolol maleate 025 sol-gel 025 drops 05 drops 05 sol-gel
1-Covered
TIMOLOL MALEATE 05 EYE DROPS 1-Covered
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS (Drugsfor Glaucoma)
latanoprost 0005 drops 1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
115
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
OTIC AGENTS (Drugs for the Ears)
OTIC AGENTS (Drugs for Ear Infection)acetic acid 2 solution 1-Covered
ACETIC ACID 2 EAR SOLUTION 1-Covered
carbamide peroxide(CARBAMOXIDE) 65 drops
1-Covered
carbamide peroxide (EAR DROPS)65 drops
1-Covered
carbamide peroxide (EAR SYSTEM)65 drops
1-Covered
carbamide peroxide (EAR WAXREMOVAL) 65 drops
1-Covered
carbamide peroxide (MURINE EARWAX REMOVAL SYSTEM) 65 drops
1-Covered
DEBROX (carbamide peroxide)65 EAR DROPS
1-Covered
EAR DROPS (carbamide peroxide)65
1-Covered
hydrocortisoneacetic acid(ACETASOL HC) 1 -2 drops
1-Covered
hydrocortisoneacetic acid 1 -2 drops
1-Covered
MURINE EAR DROPS (carbamideperoxide) 65
1-Covered
neomycin sulfatepolymyxin bsulfatehydrocortisoneneomycinpolymyxin bhydrocort35--1 solutionneomycinpolymyxin bhydrocort35--1 drops susp
1-Covered
NEOMYCIN-POLYMYXIN-HC --EARSUSP
1-Covered
RESPIRATORY TRACTPULMONARY AGENTS (Drugs for the Lungs)
ANTI-INFLAMMATORIES INHALED CORTICOSTEROIDS (Inhaled Drugsto Prevent Swelling of the Airways)
BUDESONIDE 025 MG2 ML SUSP 1-Covered AL1 (Up to 6 yrs old)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
116
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
budesonide 025mg2ml - 05mg2ml -
1-Covered AL1 (Up to 6 yrs old)
CHILDRENS NASACORT(triamcinolone acetonide)ALLERGY 24 HR
1-Covered QL (17 PER 30 DAY(S))
FLOVENT DISKUS (fluticasonepropionate) 50 MCG 100 MCG250 MCG
1-Covered
FLOVENT HFA (fluticasonepropionate) HFA 44 MCG INHALERHFA 110 MCG INHALER HFA 220MCG INHALER
1-Covered
fluticasone propionate (ALLERGYRELIEF) 50 mcg spray susp
1-Covered QL (16 PER 30 DAY(S))
fluticasone propionate 50 mcgspray susp
1-Covered QL (16 PER 30 DAY(S))
NASACORT (triamcinoloneacetonide) ALLERGY 24HR SPRAY
1-Covered
PULMICORT FLEXHALER(budesonide) 180 MCG
1-Covered
QVAR REDIHALER(beclomethasone dipropionate)40 MCG 80 MCG
1-Covered
triamcinolone acetonide 55 mcgspray
1-Covered QL (17 PER 30 DAY(S))
ANTIHISTAMINESALAVERT (loratadine) 10 MG ODT 1-Covered AL1 (Up to 12 yrs old)
ALL DAY ALLERGY ERGY 10 MGTABLET SM ERGY 10 MG TAB
1-Covered
ALLERGY RELIEF (LORATADINE) 10MG TAB RELIEF 10 MG TABLET
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
ALLERGY RELIEF 4 MG TABLET HM 4MG TABLET HM 25 MG CAP 25 MGSOFTGEL GS 25 MG TABLET
1-Covered
ALLERGY RELIEF HM 180 MG TAB180 MG TABLET
1-Covered ST
AZELASTINE HCL 01 (137 MCG)SPRY
1-Covered QL (1 PER 30 DAYS)
azelastine hcl 137 mcgspraypump
1-Covered QL (1 PER 30 DAYS)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
117
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
cetirizine hcl (24HOUR ALLERGY) 10mg tablet
1-Covered
cetirizine hcl (ALL DAY ALLERGYRELIEF) 10 mg tablet
1-Covered
cetirizine hcl (ALL DAY ALLERGY) 10mg tablet
1-Covered
cetirizine hcl (ALLER-TEC) 10 mgtablet -
1-Covered
cetirizine hcl (ALLERGY RELIEF) 10mg tablet
1-Covered
cetirizine hcl (WAL-ZYR) 10 mgtablet -
1-Covered
cetirizine hcl 1 mgml 5 mg5 ml 1-Covered ST AL1 (Up to 5 yrs old)
CETIRIZINE HCL 10 MG TABLET 1-Covered
cetirizine hcl 5 mg tablet 10 mgtablet
1-Covered
CHILDRENS ALLERGY RELIEF 5MG5 ML
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
CHILDRENS ALLERGY RELIEF RLF125 MG5 ML
1-Covered
chlorpheniramine maleate(ALLERGY 4-HOUR) mg tablet -
1-Covered
chlorpheniramine maleate(ALLERGY RELIEF) 4 mg tablet
1-Covered
chlorpheniramine maleate(ALLERGY) 4 mg tablet
1-Covered
chlorpheniramine maleate(ALLERGY-TIME) 4 mg tablet -
1-Covered
chlorpheniramine maleate(CHLORHIST) 4 mg tablet
1-Covered
chlorpheniramine maleate(CHLORTABS) 4 mg tablet
1-Covered
chlorpheniramine maleate (EDCHLORPED JR) 2 mg5 ml syrup
1-Covered
chlorpheniramine maleate(PHARBECHLOR) 4 mg tablet
1-Covered
chlorpheniramine maleate (WAL-FINATE) 4 mg tablet -
1-Covered
chlorpheniramine maleate 4 mgtablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
118
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
clemastine fumarate 268 mgtablet
1-Covered
cyproheptadine hcl 2 mg5 mlsyrup 4 mg tablet 4 mg10 mlsyrup
1-Covered
diphenhydramine hcl (ALER-CAPS)25 mg capsule -
1-Covered
diphenhydramine hcl (ALLER-G-TIME) 25 mg tablet --
1-Covered
diphenhydramine hcl (ALLERGYMEDICATION) 25 mg capsule 25mg tablet
1-Covered
diphenhydramine hcl (ALLERGYMEDICINE) 25 mg tablet
1-Covered
diphenhydramine hcl (ALLERGYRELIEF) 125mg5ml liquid 25 mgcapsule 25 mg tablet
1-Covered
diphenhydramine hcl (ALLERGY)125mg5ml liquid 25 mg capsule25 mg tablet
1-Covered
diphenhydramine hcl (BANOPHEN)125mg5ml liquid 25 mg tablet 25mg capsule 50 mg capsule
1-Covered
diphenhydramine hcl (BENADRYLALLERGY) 25 mg tablet
1-Covered
diphenhydramine hcl (CHILDRENSALLERGY RELIEF) 125mg5ml liquid
1-Covered
diphenhydramine hcl (CHILDRENSALLERGY) 125mg5ml elixir125mg5ml liquid
1-Covered
diphenhydramine hcl (CHILDRENSBENADRYL ALLERGY) 125mg5mlliquid
1-Covered
diphenhydramine hcl (CHILDRENSWAL-DRYL ALLERGY) 125mg5mlliquid -
1-Covered
diphenhydramine hcl (COMPLETEALLERGY) 25 mg capsule 25 mgtablet
1-Covered
diphenhydramine hcl (DIPHEDRYLALLERGY) 125mg5ml liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
119
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
diphenhydramine hcl (DIPHEDRYL)125mg5ml liquid 25 mg capsule
1-Covered
diphenhydramine hcl (DIPHEN)125mg5ml elixir 25 mg tablet
1-Covered
diphenhydramine hcl (DIPHENHIST)125mg5ml liquid 25 mg tablet
1-Covered
diphenhydramine hcl (GERI-DRYL)125mg5ml liquid - 25 mg tablet -
1-Covered
diphenhydramine hcl (M-DRYL)125mg5ml liquid -
1-Covered
diphenhydramine hcl (NIGHTTIMEALLERGY RELIEF) 25 mg tablet
1-Covered
diphenhydramine hcl (NIGHTTIMESLEEP AID) 25 mg tablet
1-Covered
diphenhydramine hcl(PHARBEDRYL) 25 mg capsule 50mg capsule
1-Covered
diphenhydramine hcl (SILADRYL)125mg5ml liquid
1-Covered
diphenhydramine hcl (SIMPLYSLEEP) 25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP AID)25 mg tablet
1-Covered
diphenhydramine hcl (TOTALALLERGY) 25 mg tablet
1-Covered
diphenhydramine hcl (WAL-DRYLALLERGY) 125mg5ml liquid - 25mg tablet -
1-Covered
diphenhydramine hcl (WAL-DRYL)25 mg capsule -
1-Covered
DIPHENHYDRAMINE HCL 125 MG5ML 25 MG10 ML
1-Covered
diphenhydramine hcl 125mg5mlelixir 125mg5ml syrup125mg5ml liquid 25 mg tablet 25mg capsule 50 mg capsule
1-Covered
fexofenadine hcl (ALLER-EASE) 60mg tablet - 180 mg tablet -
1-Covered ST
fexofenadine hcl (ALLER-FEX) 180mg tablet -
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
120
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fexofenadine hcl (ALLERGY RELIEF)60 mg tablet 180 mg tablet
1-Covered ST
fexofenadine hcl (WAL-FEXALLERGY) 60 mg tablet - 180 mgtablet -
1-Covered ST
fexofenadine hcl 60 mg tablet 180mg tablet
1-Covered ST
FEXOFENADINE HCL HM 60 MGTAB 60 MG TABLET 180 MG TABLET
1-Covered ST
GERI-DRYL -125 MG5 ML LIQUID 1-Covered
hydroxyzine hcl 10 mg tablet 10mg5 ml solution 25 mg tablet 50mg tablet 50 mg25ml solution
1-Covered
HYDROXYZINE PAMOATE 25 MGCAP 50 MG CAP
1-Covered
hydroxyzine pamoate 25 mgcapsule 50 mg capsule 100 mgcapsule
1-Covered
loratadine (ALLERCLEAR) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (ALLERGY RELIEF) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (ALLERGY RELIEF) 5mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (ALLERGY) 10 mg tablet 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (CHILDRENS ALLERGYRELIEF) 5 mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (CHILDRENS ALLERGY) 5mg5 ml solution
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine (LORADAMED) 10 mgtablet
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (NON-DROWSYALLERGY) 10 mg tablet -
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (WAL-ITIN) 10 mg tablet-
1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine (WAL-ITIN) 5 mg5 mlsolution -
1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)
loratadine 10 mg tablet 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
121
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
LORATADINE 10 MG TABLET 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)
loratadine 5 mg5 ml solution 1-Covered QL (150 PER 30 DAYS) AL1 (Up to6 yrs old)
NIGHTTIME SLEEP AID HM 25 MGCPLT
1-Covered
promethazine hcl 125 mg tablet25 mg tablet
1-Covered
PROMETHAZINE HCL 625 MG5 MLSOLN
1-Covered AL1 (At least 2 yrs old)
promethazine hcl 625mg5mlsyrup
1-Covered AL1 (At least 2 yrs old)
ANTILEUKOTRIENESmontelukast sodium 4 mg granpack
1-Covered ST
MONTELUKAST SODIUM 4 MGGRANULES
1-Covered ST
montelukast sodium 4 mg tabchew 5 mg tab chew 10 mgtablet
1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)
BRONCHODILATORS ANTICHOLINERGIC (Anticholinergic Drugs toOpen the Airway)
ATROVENT HFA (ipratropiumbromide) 17 MCG INHALER
1-Covered
INCRUSE ELLIPTA (umeclidiniumbromide) 625 MCG INH
1-Covered C (RESTRICTED TO THE DIAGNOSISOF CHRONIC OBSTRUCTIVEPULMONARY DISEASE (COPD))
ipratropium bromide 02 mgmlsolution 21 mcg spray 42 mcgspray
1-Covered
BRONCHODILATORS SYMPATHOMIMETIC (Sympathomimetic Drugsto Open the Airway)
albuterol 90mcg hfa inhaler(generic proair)
1-Covered QL (2 PER 30 [DAYS])
albuterol 90mcg hfa inhaler(generic proventil)
1-Covered QL (2 PER 30 [DAYS])
albuterol 90mcg hfa inhaler(generic ventolin)
1-Covered QL (2 PER 30 [DAYS])
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
122
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
ALBUTEROL SULFATE 100 MG20 MLSOLN
1-Covered
albuterol sulfate 2 mg tablet 2mg5 ml syrup 25 mg3ml vial-neb 25 mg05 vial-neb 4 mg taber 12h 4 mg tablet 5 mgmlsolution 8 mg tab er 12h
1-Covered
albuterol sulfate 90 mcg hfa aerad
1-Covered QL (2 PER 30 [DAYS])
ALBUTEROL SULFATE HFA 90 MCGINHALER
1-Covered QL (2 PER 30 [DAYS])
epinephrine 015mg03 03mg03 1-Covered QL (2 PER FILL(S))
FORADIL (formoterol fumarate)AEROLIZER 12 MCG CAP
1-Covered ST
levalbuterol tartrate 45 mcg hfaaer ad
1-Covered QL (30 PER 30 DAY(S))
metaproterenol sulfate 10 mg5 mlsyrup 10 mg tablet 20 mg tablet
1-Covered
NASAL DECONGESTANT(pseudoephedrine hcl) 30 MG TAB
1-Covered
pseudoephedrine hcl (NASALDECONGESTANT) 30 mg tablet
1-Covered
pseudoephedrine hcl (SUDOGEST)30 mg tablet 60 mg tablet
1-Covered
pseudoephedrine hcl (SUPHEDRIN)30 mg tablet
1-Covered
pseudoephedrine hcl (SUPHEDRINESINUS CONGESTION) 30 mg tablet
1-Covered
pseudoephedrine hcl(SUPHEDRINE) 30 mg tablet
1-Covered
pseudoephedrine hcl (WAL-PHED)30 mg tablet -
1-Covered
pseudoephedrine hcl 30 mgtablet 60 mg tablet
1-Covered
SEREVENT DISKUS (salmeterolxinafoate) 50 MCG
1-Covered QL (60 PER 30 DAYS)
SUDAFED (pseudoephedrine hcl)30 MG TABLET
1-Covered
TERBUTALINE SULFATE 25 MG TAB 5MG TAB
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
123
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
terbutaline sulfate 25 mg tablet 5mg tablet
1-Covered
PHOSPHODIESTERASE INHIBITORS AIRWAYS DISEASE (Drugs thatBlock Phosphodiesterase)
ELIXOPHYLLIN (theophyllineanhydrous) OPHYLLIN 80 MG15 ML
1-Covered
THEO-24 (theophylline anhydrous) -24 ER 200 MG CAPSULE -24 ER 300MG CAPSULE -24 ER 100 MGCAPSULE -24 ER 400 MG CAPSULE
1-Covered
theophylline anhydrous(THEOCHRON) 100 mg tab er 200mg tab er 300 mg tab er
1-Covered
theophylline anhydrous 80mg15ml solution 80 mg15ml elixir100 mg tab er 12h 200 mg tab er12h 300 mg tab er 12h 400 mgtab er 24h 450 mg tab er 12h 600mg tab er 24h
1-Covered
PULMONARY ANTIHYPERTENSIVES (Drugs for PulmonaryHypertension)
ambrisentan 5 mg tablet 10 mgtablet
1-Covered PA QL (1 PER 1 DAY(S)) SP
bosentan 625 mg tablet 125 mgtablet
1-Covered PA QL (2 PER 1 DAY(S)) SP
sildenafil citrate 20 mg tablet 1-Covered PA QL (3 PER 1 DAY(S)) SP
SILDENAFIL CITRATE 20 MG TABLET 1-Covered PA QL (3 PER 1 DAY(S)) SP
tadalafil (ALYQ) 20 mg tablet 1-Covered PA QL (2 PER 1 DAY(S)) SP
tadalafil 20 mg tablet 1-Covered PA QL (2 PER 1 DAY(S)) SP
RESPIRATORY TRACT AGENTS OTHER (Other Drugs for BreathingConditions)
acetylcysteine 100 mgml vial 200mgml vial
1-Covered
benzonatate 100 mg capsule 1-Covered
BEVESPI AEROSPHERE(glycopyrrolateformoterolfumarate) INHALER
1-Covered ST
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
124
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
brompheniraminemaleatepseudoephedrine hcl(RYNEX PSE)brompheniraminpseudoephedrine 1-15mg5ml liquid
1-Covered
BROTAPP DM (brompheniraminemaleatepseudoephedrinehcldextromethorphan) 1-15-5MG5 ML LIQ
1-Covered
chlorpheniraminemaleatepseudoephedrinedextromethorphan (KIDKARE)chlorpheniraminpseudoepheddm 1-15-5mg5 liquid
1-Covered
codeine phosphateguaifenesin(CHERATUSSIN AC) 10-100mg5liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(G TUSSIN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(GUAIATUSSIN AC) 10-100mg5 20-20010
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(GUAIFENESIN AC) 10-100mg5liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(ROBAFEN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin(VIRTUSSIN AC) 10-100mg5 liquid
1-Covered AL1 (At least 12 yrs old)
codeine phosphateguaifenesin10-100mg5 20-20010
1-Covered AL1 (At least 12 yrs old)
CODEINE-GUAIFENESIN -10-100MG5 ML
1-Covered AL1 (At least 12 yrs old)
COMBIVENT RESPIMAT (ipratropiumbromidealbuterol sulfate) 20-100MCG
1-Covered
COUGH FORMULA DM(guaifenesindextromethorphanhbr) SYRUP
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
125
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
fluticasone propionatesalmeterolxinafoate (WIXELA INHUB)propionsalmeterol 100-50 mcgwdev propionsalmeterol 250-50mcg wdev propionsalmeterol500-50 mcg wdev
1-Covered QL (60 PER 30 DAY(S))
fluticasone propionatesalmeterolxinafoate propionsalmeterol 100-50 mcg wdev propionsalmeterol250-50 mcg wdevpropionsalmeterol 500-50 mcgwdev
1-Covered QL (60 PER 30 DAY(S))
fluticasone propionatesalmeterolxinafoate propionsalmeterol 55-14mcg propionsalmeterol 113-14mcg propionsalmeterol 232-14mcg
1-Covered QL (1 PER 30 DAYS)
GUAIASORB DM LIQUID 1-Covered
guaifenesin (MUCUS ER) 600 mgtab er 12h
1-Covered
guaifenesin (MUCUS RELIEF ER) 600mg tab er 12h
1-Covered
GUAIFENESIN-DEXTROMETHORPHAN DM SYRUP
1-Covered
guaifenesindextromethorphanhbr (ADULT ROBITUSSIN PEAK COLDDM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ADULT TUSSIN COUGHCONGEST DM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ADULT TUSSIN DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (ADULT WAL-TUSSIN DM) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (ANTITUSSIVE DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (BIOCOTRON) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (COUGH DM) 100-10mg5syrup
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
126
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesindextromethorphanhbr (DIABETIC SILTUSSIN-DM) 100-10mg5 liquid -
1-Covered
guaifenesindextromethorphanhbr (DIABETIC TUSSIN DM) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (EXPECTORANT DM) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (EXTRA ACTION COUGH) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (GERI-TUSSIN DM) 100-10mg5liquid - 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (GILTUSS DIABETIC) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (GILTUSS HBP) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (GUAIASORB DM) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (RI-TUSSIN DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM COUGH) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM COUGH-CHESTCONGEST) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN DM PEAK COLD)100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ROBAFEN-DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr (SAFETUSSIN DM) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (SILTUSSIN DM DAS) 100-10mg5liquid
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
127
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesindextromethorphanhbr (SILTUSSIN DM) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (SORBUGEN NR) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSNEL DIABETIC) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSSIN COUGH) 100-10mg5liquid
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM CLEAR) 100-10mg5syrup
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM COUGH) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM COUGH-CHESTCONGEST) 100-10mg5 syrup -
1-Covered
guaifenesindextromethorphanhbr (TUSSIN DM) 100-10mg5 liquid100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (ULTRA DM FREE amp CLEAR) 100-10mg5 liquid
1-Covered
guaifenesindextromethorphanhbr (ULTRA TUSS) 100-10mg5 syrup
1-Covered
guaifenesindextromethorphanhbr (WAL-TUSSIN DM) 100-10mg5syrup -
1-Covered
guaifenesindextromethorphanhbr 100-10mg5 syrup 100-10mg5liquid
1-Covered
guaifenesinpseudoephedrine hcl(MUCUS D)guaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
guaifenesinpseudoephedrine hcl(MUCUS RELIEF D)guaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
128
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
guaifenesinpseudoephedrine hclguaifenesinpseudoephedrne600mg-60mg tab er 12h
1-Covered
ipratropium bromidealbuterolsulfate ipratropiumalbuterol 05-3mg3 ampul-neb
1-Covered QL (540 PER 30 DAY(S))
IPRATROPIUM-ALBUTEROL -05-3(25) MG3 ML
1-Covered QL (540 PER 30 DAY(S))
MAXI-TUSS G -LIQUID 1-Covered
MUCUS ER CVS 600 MG TABLET 1-Covered
MUCUS RELIEF ER HM 600 MG TAB 1-Covered
phenylephrine hclpromethazinehcl prometh 5-625mg5 syrup
1-Covered AL1 (At least 2 yrs old)
promethazine hclcodeine 625-105 syrup
1-Covered QL (240 PER 30 DAYS) AL1 (Atleast 12 yrs old) QLC (LIMIT 240ML(8OZ) PER 30 DAYS)
promethazinehcldextromethorphan hbrpromethazinedextromethorphan625-155 syrup
1-Covered AL1 (At least 2 yrs old)
PROMETHAZINE-DM -625-15MG5ML
1-Covered AL1 (At least 2 yrs old)
promethazinephenylephrinehclcodeinepromethazinephenylephcodeine625-5-10 syrup
1-Covered AL1 (At least 12 yrs old)
sodium chloride for inhalation 09 vial- 3 vial- 10 vial-
1-Covered
triprolidine hclpseudoephedrinehcl (APRODINE)triprolidinepseudoephedrine25mg-60mg tablet
1-Covered
triprolidine hclpseudoephedrinehcl (ED A-HIST PSE)triprolidinepseudoephedrine25mg-60mg tablet -
1-Covered
triprolidine hclpseudoephedrinehcl (RITIFED)triprolidinepseudoephedrine 125-305 syrup
1-Covered
triprolidine hclpseudoephedrinehcl (WAL-ACT D COLD amp ALLERGY)triprolidinepseudoephedrine25mg-60mg tablet -col
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
129
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles)
SKELETAL MUSCLE RELAXANTS (Drugs to Relax the Muscles)carisoprodol 350 mg tablet 1-Covered QL (90 PER 30 DAYS)
CARISOPRODOL 350 MG TABLET 1-Covered QL (90 PER 30 DAYS)
cyclobenzaprine hcl 10 mg tablet 1-Covered QL (90 PER 30 DAYS)
cyclobenzaprine hcl 5 mg tablet 1-Covered QL (90 PER 30 DAY(S))
methocarbamol 500 mg tablet750 mg tablet
1-Covered QL (90 PER 30 DAYS)
METHOCARBAMOL 500 MG TABLET750 MG TABLET
1-Covered QL (90 PER 30 DAYS)
VANADOM 350 MG TABLET 1-Covered QL (90 PER 30 DAY(S))
SLEEP DISORDER AGENTS (Drugs for Insomnia)
GABA RECEPTOR MODULATORSflurazepam hcl 15 mg capsule 30mg capsule
1-Covered AL1 (Up to 65 yrs old)
temazepam 75 mg capsule 15mg capsule 30 mg capsule
1-Covered
triazolam 0125 mg tablet 025 mgtablet
1-Covered QL (14 PER 30 DAY(S))
zaleplon 5 mg capsule 10 mgcapsule
1-Covered ST
zolpidem tartrate 5 mg tablet 10mg tablet
1-Covered
SLEEP DISORDERS OTHERdiphenhydramine hcl (ALKA-SELTZER PLUS ALLERGY) 25 mgtablet -
1-Covered
diphenhydramine hcl (COMPOZ)25 mg tablet
1-Covered
diphenhydramine hcl (NIGHTTIMESLEEP AID) 25 mg tablet
1-Covered
diphenhydramine hcl (NYTOLQUICKCAPS) 25 mg tablet
1-Covered
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
130
PRESCRIPTION DRUGNAME
DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS
diphenhydramine hcl (SIMPLYSLEEP) 25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP AID)25 mg tablet
1-Covered
diphenhydramine hcl (SLEEP II) 25mg tablet
1-Covered
diphenhydramine hcl (SLEEPTABLET) 25 mg tablet
1-Covered
modafinil 100 mg tablet 200 mgtablet
1-Covered PA QL (3 PER 1 DAY(S))
LAST UPDATED 12012020
AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose
C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy
131
Alphabetical Index of Prescription Drugs
009 sodium chloride 697072
Aabacavir sulfate 38abacavir sulfatelamivudine 38abacavir sulfatelamivudinezidovudine 38ABACAVIR-LAMIVUDINE 38ABILIFY (aripiprazole) 31ABILIFY MAINTENA (aripiprazole) 31ABILIFY MYCITE (aripiprazole) 31acamprosate calcium 6acarbose 4243acetaminophen 64ACETAMINOPHEN 64acetaminophen (ATHENOL) 63acetaminophen (CHILD FEVER REDUCER) 63acetaminophen (CHILD PAIN REL-FEVERREDUCER) 63acetaminophen (CHILDRENS FEVERREDUCER) 63acetaminophen (CHILDRENS FEVERREDUCING) 63acetaminophen (CHILDRENS PAIN ANDFEVER) 63acetaminophen (CHILDRENS SILAPAP) 63acetaminophen (ED-APAP) 63acetaminophen (LITTLE REMEDIES FEVER-PAIN) 63acetaminophen (M-PAP) 63acetaminophen (MAPAP) 63acetaminophen (MASOPHEN) 63acetaminophen (NON-ASPIRIN EXTRASTRENGTH) 63acetaminophen (NON-ASPIRIN PAIN RELIEF) 63acetaminophen (NON-ASPIRIN) 63acetaminophen (PAIN amp FEVER) 63acetaminophen (PAIN RELIEF EXTRASTRENGTH) 64acetaminophen (PAIN RELIEF) 64
acetaminophen (PAIN RELIEVER) 64acetaminophen (PHARBETOL) 64acetaminophen (SHAKE THAT ACHE) 64acetaminophen (TACTINAL) 64ACETAMINOPHEN 160 MG5ML ORAL SUSP 64ACETAMINOPHEN 160 MG5ML SOLUTION 64acetaminophen with codeine phosphate 45acetazolamide 57ACETAZOLAMIDE 58acetic acid 116ACETIC ACID 116acetylcysteine 124ACID CONTROLLER 80ACID REDUCER 80ACNE MEDICATION 66ACNE MEDICATION (benzoyl peroxide) 66acyclovir 41ACYCLOVIR 41ADACEL TDAP(diphtheriapertussis(acellular)tetanusvaccinepf) 106ADASUVE (loxapine) 30ADLYXIN (lixisenatide) 43ADMELOG (insulin lispro) 45ADMELOG SOLOSTAR (insulin lispro) 45ADVATE (antihemophilic factor (fviii)recombinantfull length) 47ADYNOVATE (antihemophilic factor (fviii)recombinant full length peg) 47AFLURIA QUAD 2020-2021 106AFLURIA QUAD 2020-21 (3YR UP) 106AFSTYLA (antihemophilic factor viiirecombsingle-chnb-dom truncated) 47ALAVERT (loratadine) 117ALAWAY (ketotifen fumarate) 113Albuterol 90mcg HFA inhaler (GenericProair) 122Albuterol 90mcg HFA inhaler (GenericProventil) 122Albuterol 90mcg HFA inhaler (GenericVentolin) 122
LAST UPDATED 12012020132
ALBUTEROL SULFATE 123albuterol sulfate 123ALBUTEROL SULFATE HFA 123alcohol antiseptic pads 110ALCOHOL WIPES 110alendronate sodium 109alfuzosin hcl 86ALL DAY ALLERGY 117ALLERGY RELIEF 117ALLI (orlistat) 78allopurinol 24ALLOPURINOL 24alogliptin benzoate 43alogliptin benzoatemetformin hcl 43alogliptin benzoatepioglitazone hcl 43ALOMIDE (lodoxamide tromethamine) 114ALPHAGAN P (brimonidine tartrate) 115ALPHANATE (antihemophilic factorhumanvon willebrand factorhuman) 47ALPHANINE SD (factor ix) 47alprazolam 42alprazolam (ALPRAZOLAM INTENSOL) 42ALPROLIX (factor ix recombinant fc fusionprotein) 48AMANTADINE 29amantadine hcl 29ambrisentan 124amiloride hcl 58amiloride hclhydrochlorothiazide 56amiodarone hcl 53amiodarone hcl (PACERONE) 53AMITIZA (lubiprostone) 81amitriptyline hcl 19AMLODIPINE BESYLATE 54amlodipine besylate 54amlodipine besylatebenazepril hcl 56ammonium lactate 66ammonium lactate (SKIN TREATMENT) 66amoxapine 19amoxicillin 11AMOXICILLIN-CLAVULANATE POTASS 11
amoxicillinpotassium clavulanate 1112ampicillin trihydrate 12anagrelide hcl 47anastrozole 28ANASTROZOLE 28ANTACID 78ANTACID EXTRA STRENGTH 78ANTI-DIARRHEAL 78ANTIFUNGAL 21apraclonidine hcl 115aprepitant 21APTIVUS (tipranavir) 40APTIVUS (tipranavirvitamin e tpgs) 40aripiprazole 32ARIPIPRAZOLE 32ARISTADA (aripiprazole lauroxil) 32ARISTADA INITIO (aripiprazole lauroxilsubmicronized) 32ARMOUR THYROID (thyroidpork) 102ascorbate calcium 72ascorbic acid 72ascorbic acid (SOOTHING PUREWAY-C) 72aspirin 1aspirin (ADULT ASPIRIN REGIMEN) 1aspirin (ADULT LOW DOSE ASPIRIN EC) 1aspirin (ASPIR 81) 1aspirin (ASPIR-TRIN) 1aspirin (ASPIRIN) 1aspirin (ECOTRIN) 1aspirin (ECPIRIN) 1aspirin (ST JOSEPH ASPIRIN EC) 1aspirin (ST JOSEPH ASPIRIN) 1ASPIRIN 325MG TABLET 1ASPIRIN 81MG TABLET 1aspirinacetaminophencaffeine (ADDEDSTRENGTH HEADACHE) 1aspirinacetaminophencaffeine (BAYERMIGRAINE) 1aspirinacetaminophencaffeine (EXTRA PAINRELIEF) 1
LAST UPDATED 12012020133
aspirinacetaminophencaffeine(EXTRAPRIN) 1aspirinacetaminophencaffeine (HEADACHERELIEF) 1aspirinacetaminophencaffeine (MIGRAINEFORMULA) 2aspirinacetaminophencaffeine (MIGRAINERELIEF) 2aspirinacetaminophencaffeine (PAINRELIEVER PLUS) 2aspirinacetaminophencaffeine (PAINRELIEVER) 2aspirinacetaminophencaffeine (PAIN-OFF) 2ASSURE ID DUO-SHIELD 110ASSURE ID INSULIN SAFETY 110ATAZANAVIR SULFATE 40atazanavir sulfate 40atenolol 53ATENOLOL 53atenololchlorthalidone 56ATHLETES FOOT (terbinafine hcl) 21atomoxetine hcl 62atorvastatin calcium 59ATORVASTATIN CALCIUM 59ATRIPLA (efavirenzemtricitabinetenofovirdisoproxil fumarate) 37atropine sulfate 112ATROVENT HFA (ipratropium bromide) 122AVANDIA (rosiglitazone maleate) 43AVONEX (interferon beta-1a) 65AVONEX (interferon beta-1aalbuminhuman) 65AVONEX PEN (interferon beta-1a) 65azathioprine 104AZATHIOPRINE 104AZELASTINE HCL 117azelastine hcl 117azithromycin 12AZITHROMYCIN 12
Bbacitracin 9BACITRACIN 9bacitracin (BACITRAYCIN PLUS) 9bacitracin zinc 9BACITRACIN ZINC 9bacitracin zinc (ANTIBIOTIC) 9bacitracinpolymyxin b sulfate 112bacitracinpolymyxin b sulfate (AK-POLY-BAC) 112bacitracinpolymyxin b sulfate (POLYCIN) 112baclofen 35BACLOFEN 35balsalazide disodium 109BAQSIMI (glucagon) 44BASAGLAR KWIKPEN U-100 (insulinglarginehuman recombinant analog) 45BELBUCA (buprenorphine hcl) 3benazepril hcl 52benazepril hclhydrochlorothiazide 56BENEFIX (factor ix human recombinant) 48benzonatate 124benzoyl peroxide 67benzoyl peroxide (ACNE CONTROLCLEANSER) 66benzoyl peroxide (ACNE FOAMING WASH) 66benzoyl peroxide (ACNE TREATMENT) 67benzoyl peroxide (ACNECLEAR) 67benzoyl peroxide (ADVANCED EXFOLIATINGCLEANSER) 67benzoyl peroxide (BP WASH) 67benzoyl peroxide (BP) 67benzoyl peroxide (BPO-10) 67benzoyl peroxide (BPO-5) 67benzoyl peroxide (CLEAN-CLEARCONTINUOUS CONTROL) 67benzoyl peroxide (DAYLOGIC ACNEFOAMING WASH) 67benzoyl peroxide (DAYLOGIC ACNETREATMENT) 67
LAST UPDATED 12012020134
benzoyl peroxide (FOAMING ACNE FACEWASH) 67benzoyl peroxide (PANOXYL) 67benztropine mesylate 29BEOVU (brolucizumab-dbll) 112betamethasone dipropionate 87BETAMETHASONE DIPROPIONATE 87betamethasone dipropionatepropyleneglycol 88betamethasone valerate 88betaxolol hcl 115bethanechol chloride 86BETIMOL (timolol) 115BETOPTIC S (betaxolol hcl) 115BEVESPI AEROSPHERE(glycopyrrolateformoterol fumarate) 124BEXSERO (meningococcal group b vaccine4-component) 106bicalutamide 27BIKTARVY (bictegravirsodiumemtricitabinetenofovir alafenamidefumar) 36bisacodyl 82BISACODYL 82bisacodyl (ALOPHEN PILLS) 81bisacodyl (BISA-LAX) 81bisacodyl (BISACODYL) 81bisacodyl (BISCOLAX) 81bisacodyl (C-LAX LAXATIVE) 81bisacodyl (DUCODYL) 81bisacodyl (FAST RELIEF LAXATIVE) 81bisacodyl (GENTLE LAXATIVE) 81bisacodyl (LAXATIVE SUPPOSITORY) 81bisacodyl (LAXATIVE) 82bisacodyl (MAGIC BULLET) 82bisacodyl (WOMENS GENTLE LAXATIVE) 82bisacodyl (WOMENS LAXATIVE) 82bismuth subsalicylate 78bismuth subsalicylate (BISMATROL) 78bismuth subsalicylate (DIOTAME) 78bismuth subsalicylate (PEP-T-MED) 78
bismuth subsalicylate (PEPTIC RELIEF) 78bismuth subsalicylate (PINK BISMUTH) 78bismuth subsalicylate (SOOTHE) 78bismuth subsalicylate (STOMACH RELIEF) 78bisoprolol fumarate 54bisoprolol fumaratehydrochlorothiazide 56BISOPROLOL-HYDROCHLOROTHIAZIDE 56BLEPH-10 (sulfacetamide sodium) 13BLEPHAMIDE (sulfacetamidesodiumprednisolone acetate) 112BOOSTRIX TDAP(diphtheriapertussis(acellular)tetanusvaccine) 106bosentan 124brimonidine tartrate 115bromocriptine mesylate 29brompheniramine maleatepseudoephedrinehcl (RYNEX PSE) 125BROTAPP DM (brompheniraminemaleatepseudoephedrinehcldextromethorphan) 125BUDESONIDE 116budesonide 117bumetanide 58BUNAVAIL (buprenorphine hclnaloxone hcl) 7BUPRENEX (buprenorphine hcl) 7buprenorphine 4buprenorphine hcl 7buprenorphine hclnaloxone hcl 7bupropion hcl 817bupropion hcl (BUPROBAN) 8BUPROPION HCL SR 17BUPROPION XL 17BUSPIRONE HCL 41buspirone hcl 42butalbitalacetaminophen 64butalbitalacetaminophen (TENCON) 64butalbitalacetaminophencaffeine 64butalbitalaspirincaffeine 2butorphanol tartrate 5BUTRANS (buprenorphine) 4
LAST UPDATED 12012020135
CCALADRYL (pramoxine hclcalamine) 67calcipotriene 67calcitoninsalmonsynthetic 110CALCITRIOL 110calcitriol 110CALCIUM 72CALCIUM 500-VIT D3 72CALCIUM 600-VIT D3 72calcium acetate 87calcium acetate (ELIPHOS) 87calcium carbonate 697379calcium carbonate (ANTACID CALCIUM) 78calcium carbonate (ANTACID EXTRASTRENGTH) 78calcium carbonate (ANTACID) 78calcium carbonate (BAN-ACID) 78calcium carbonate (CAL-GEST) 78calcium carbonate (CALCIUM ANTACID) 78calcium carbonate (CHILDRENS PEPTO) 79calcium carbonate (CHILDRENS SOOTHE) 79calcium carbonate (FLAVOR CHEWSANTACID) 79calcium carbonate (OYSCO-500) 72calcium carbonate (SMOOTH ANTACID) 79calcium carbonate (SMOOTH DISSOLVINGANTACID) 79calcium carbonate (SUPER CALCIUM) 72calcium carbonatecholecalciferol (vitamind3) 73calcium carbonatecholecalciferol (vitamind3) (HI-CAL) 73calcium carbonatecholecalciferol (vitamind3) (OS-CAL 500-VIT D3) 73calcium carbonatecholecalciferol (vitamind3) (OYSCO 500-VIT D3) 73calcium carbonatecholecalciferol (vitamind3) (OYSTERCAL-D) 73calcium gluconate 73calcium lactate 73
capecitabine 27CAPECITABINE 27CAPLYTA (lumateperone tosylate) 32captopril 52CAPTOPRIL 52captoprilhydrochlorothiazide 56carbamazepine 16carbamazepine (EPITOL) 16carbamide peroxide (CARBAMOXIDE) 116carbamide peroxide (EAR DROPS) 116carbamide peroxide (EAR SYSTEM) 116carbamide peroxide (EAR WAXREMOVAL) 116carbamide peroxide (MURINE EAR WAXREMOVAL SYSTEM) 116CARBATROL (carbamazepine) 16carbidopalevodopa 30carisoprodol 130CARISOPRODOL 130carvedilol 54cefaclor 11CEFDINIR 11cefdinir 11celecoxib 2CELECOXIB 2CELONTIN (methsuximide) 14cephalexin 11cetirizine hcl 118CETIRIZINE HCL 118cetirizine hcl (24HOUR ALLERGY) 118cetirizine hcl (ALL DAY ALLERGY RELIEF) 118cetirizine hcl (ALL DAY ALLERGY) 118cetirizine hcl (ALLER-TEC) 118cetirizine hcl (ALLERGY RELIEF) 118cetirizine hcl (WAL-ZYR) 118CHANTIX (varenicline tartrate) 8CHEMET (succimer) 70CHILDRENS ALLERGY RELIEF 118CHILDRENS IBUPROFEN 2CHILDRENS NASACORT (triamcinoloneacetonide) 117
LAST UPDATED 12012020136
CHLORDIAZEPOXIDE-CLIDINIUM 77chlordiazepoxideclidinium bromide 77chlorhexidine gluconate 6667chlorhexidine gluconate (PAROEX) 66chloroquine phosphate 28chlorothiazide 58chlorpheniramine maleate 118chlorpheniramine maleate (ALLERGY 4-HOUR) 118chlorpheniramine maleate (ALLERGYRELIEF) 118chlorpheniramine maleate (ALLERGY) 118chlorpheniramine maleate (ALLERGY-TIME) 118chlorpheniramine maleate (CHLORHIST) 118chlorpheniramine maleate (CHLORTABS) 118chlorpheniramine maleate (ED CHLORPEDJR) 118chlorpheniramine maleate(PHARBECHLOR) 118chlorpheniramine maleate (WAL-FINATE) 118chlorpheniraminemaleatepseudoephedrinedextromethorphan (KIDKARE) 125chlorpromazine hcl 30CHLORPROMAZINE HCL 30chlorthalidone 58CHLORTHALIDONE 58cholecalciferol (vitamin d3) 110cholestyramine (with sugar) 59cholestyramineaspartame 59cholestyramineaspartame (PREVALITE) 59ciclopirox 21ciclopirox olamine 2122cilostazol 51CILOXAN (ciprofloxacin hcl) 13CIMDUO (lamivudinetenofovir disoproxilfumarate) 36cimetidine 80CIMETIDINE 80cimetidine (ACID REDUCER) 80
cimetidine (HEARTBURN RELIEF) 80cimetidine hcl 80cinacalcet hcl 110CINACALCET HCL 110ciprofloxacin hcl 13CIPROFLOXACIN HCL 13citalopram hydrobromide 18citric acidsodium citrate 86citric acidsodium citrate (CYTRA-2) 86citric acidsodium citrate (VIRTRATE-2) 86clarithromycin 12clemastine fumarate 119CLEOCIN (clindamycin phosphate) 9clindamycin hcl 9clindamycin palmitate hcl 9clindamycin phosphate 9CLINDAMYCIN PHOSPHATE 9CLINIMIX (amino acids 425 in dextrose 5 in water) 70clobetasol propionate 88CLOBETASOL PROPIONATE 88clomipramine hcl 19CLOMIPRAMINE HCL 19clonazepam 42clonidine hcl 51CLONIDINE HCL 51clopidogrel bisulfate 51clotrimazole 22CLOTRIMAZOLE 22clotrimazole (ANTIFUNGAL RINGWORM) 22clotrimazole (ANTIFUNGAL) 22clotrimazole (ATHLETES FOOT) 22clotrimazole (ATHLETIC FOOT CREAM) 22clotrimazole (CLOTRIMAZOLE AF) 22clotrimazole (ITCH RELIEF) 22clotrimazole (JOCK ITCH RELIEF) 22clotrimazole (JOCK ITCH) 22clotrimazole (RINGWORM) 22clozapine 34CLOZAPINE 34CLOZAPINE ODT 34
LAST UPDATED 12012020137
CLOZARIL (clozapine) 35COAGADEX (coagulation factor x) 48codeinephosphatebutalbitalaspirincaffeine 5codeine phosphateguaifenesin 125codeine phosphateguaifenesin(CHERATUSSIN AC) 125codeine phosphateguaifenesin (G TUSSINAC) 125codeine phosphateguaifenesin(GUAIATUSSIN AC) 125codeine phosphateguaifenesin(GUAIFENESIN AC) 125codeine phosphateguaifenesin (ROBAFENAC) 125codeine phosphateguaifenesin (VIRTUSSINAC) 125codeine sulfate 5CODEINE-GUAIFENESIN 125COGENTIN (benztropine mesylate) 29colchicine 24COLCHICINE 24COLESTID (colestipol hcl) 59colestipol hcl 59COMBIVENT RESPIMAT (ipratropiumbromidealbuterol sulfate) 125COMBIVIR (lamivudinezidovudine) 38COMPLERA (emtricitabinerilpivirinehcltenofovir disoproxil fumarate) 37condoms female 110condoms latex lubricated 110CORIFACT (factor xiii) 48CORTISPORIN (neomycin sulfatepolymyxin bsulfatehydrocortisone) 112CORTISPORIN(neomycinbacitracinpolymyxinbhydrocortisone) 67COUGH FORMULA DM(guaifenesindextromethorphan hbr) 125COUMADIN (warfarin sodium) 46CREON (lipaseproteaseamylase) 85
CRIXIVAN (indinavir sulfate) 40cromolyn sodium 110114cyanocobalamin (vitamin b-12) 73cyanocobalamin (vitamin b-12) (B-12DOTS) 73cyclobenzaprine hcl 130cyclopentolate hcl 112cyclophosphamide 26CYCLOPHOSPHAMIDE 26cyclosporine 104cyclosporine modified 104cyclosporine modified (GENGRAF) 104cyproheptadine hcl 119
Ddanazol 91dapsone 26DEBROX (carbamide peroxide) 116DELSTRIGO (doravirinelamivudinetenofovirdisoproxil fumarate) 37DELTASONE (prednisone) 88DEPAKENE (valproic acid (as sodium salt)(valproate sodium)) 15DEPAKENE (valproic acid) 15DEPO-PROVERA (medroxyprogesteroneacetate) 100DEPO-SUBQ PROVERA 104(medroxyprogesterone acetate) 100DESCOVY (emtricitabinetenofoviralafenamide fumarate) 39desipramine hcl 19desmopressin acetate 90DESMOPRESSIN ACETATE 90desmopressin acetate (non-refrigerated) 90desogestrel-ethinyl estradiol 91desogestrel-ethinyl estradiol (APRI) 91desogestrel-ethinyl estradiol (CYRED EQ) 91desogestrel-ethinyl estradiol (CYRED) 91desogestrel-ethinyl estradiol (EMOQUETTE) 91desogestrel-ethinyl estradiol (ENSKYCE) 91desogestrel-ethinyl estradiol (ISIBLOOM) 91
LAST UPDATED 12012020138
desogestrel-ethinyl estradiol (JULEBER) 91desogestrel-ethinyl estradiol (KALLIGA) 91desogestrel-ethinyl estradiol (RECLIPSEN) 91desogestrel-ethinyl estradiolethinylestradiol 92desogestrel-ethinyl estradiolethinyl estradiol(AZURETTE) 91desogestrel-ethinyl estradiolethinyl estradiol(BEKYREE) 92desogestrel-ethinyl estradiolethinyl estradiol(KARIVA) 92desogestrel-ethinyl estradiolethinyl estradiol(KIMIDESS) 92desogestrel-ethinyl estradiolethinyl estradiol(PIMTREA) 92desogestrel-ethinyl estradiolethinyl estradiol(SIMLIYA) 92desogestrel-ethinyl estradiolethinyl estradiol(VIORELE) 92desogestrel-ethinyl estradiolethinyl estradiol(VOLNEA) 92desonide 88DESONIDE 88dexamethasone 88DEXAMETHASONE 88dexamethasone (DEXAMETHASONEINTENSOL) 88dexamethasone sodium phosphate 114dextroamphetamine sulf-saccharateamphetamine sulf-aspartate 61dextroamphetamine sulfate 62DEXTROAMPHETAMINE SULFATE 62dextroamphetamine sulfate (ZENZEDI) 62DEXTROAMPHETAMINE-AMPHET ER 62dextrose 10 and 045 sodium chloride 70dextrose 10 in water 7073dextrose 5 and 045 sodium chloride 7073dextrose 5 in lactated ringers 73dextrose 5 in water 697073DEXTROSE IN WATER 74diazepam 1542
diclofenac sodium 2114dicloxacillin sodium 12DICYCLOMINE HCL 77dicyclomine hcl 77DIFFERIN (adapalene) 67diflunisal 2digoxin 56digoxin (DIGITEK) 56digoxin (DIGOX) 56DILANTIN (phenytoin sodium extended) 16DILANTIN (phenytoin) 16DILANTIN-125 16DILANTIN-125 (phenytoin) 16DILTIAZEM 24HR ER (CD) 54DILTIAZEM 24HR ER (XR) 55diltiazem hcl 55diltiazem hcl (CARTIA XT) 55diltiazem hcl (DILT-XR) 55diltiazem hcl (TAZTIA XT) 55DIMETHYL FUMARATE 65DIPHENHYDRAMINE HCL 120diphenhydramine hcl 120diphenhydramine hcl (ALER-CAPS) 119diphenhydramine hcl (ALKA-SELTZER PLUSALLERGY) 130diphenhydramine hcl (ALLER-G-TIME) 119diphenhydramine hcl (ALLERGYMEDICATION) 119diphenhydramine hcl (ALLERGYMEDICINE) 119diphenhydramine hcl (ALLERGY RELIEF) 119diphenhydramine hcl (ALLERGY) 119diphenhydramine hcl (BANOPHEN) 119diphenhydramine hcl (BENADRYLALLERGY) 119diphenhydramine hcl (CHILDRENS ALLERGYRELIEF) 119diphenhydramine hcl (CHILDRENSALLERGY) 119diphenhydramine hcl (CHILDRENS BENADRYLALLERGY) 119
LAST UPDATED 12012020139
diphenhydramine hcl (CHILDRENS WAL-DRYLALLERGY) 119diphenhydramine hcl (COMPLETEALLERGY) 119diphenhydramine hcl (COMPOZ) 130diphenhydramine hcl (DIPHEDRYLALLERGY) 119diphenhydramine hcl (DIPHEDRYL) 120diphenhydramine hcl (DIPHEN) 120diphenhydramine hcl (DIPHENHIST) 120diphenhydramine hcl (GERI-DRYL) 120diphenhydramine hcl (M-DRYL) 120diphenhydramine hcl (NIGHTTIME ALLERGYRELIEF) 120diphenhydramine hcl (NIGHTTIME SLEEPAID) 120130diphenhydramine hcl (NYTOL QUICKCAPS)130diphenhydramine hcl (PHARBEDRYL) 120diphenhydramine hcl (SILADRYL) 120diphenhydramine hcl (SIMPLY SLEEP) 120131diphenhydramine hcl (SLEEP AID) 120131diphenhydramine hcl (SLEEP II) 131diphenhydramine hcl (SLEEP TABLET) 131diphenhydramine hcl (TOTAL ALLERGY) 120diphenhydramine hcl (WAL-DRYLALLERGY) 120diphenhydramine hcl (WAL-DRYL) 120diphenoxylate hclatropine sulfate 79DIPHENOXYLATE-ATROPINE 79dipyridamole 51disopyramide phosphate 53disulfiram 6DIURIL (chlorothiazide) 58divalproex sodium 15DIVALPROEX SODIUM 15DOCUSATE SODIUM 82docusate sodium 82docusate sodium (COL-RITE) 82docusate sodium (DIOCTYL) 82docusate sodium (DOCU LIQUID) 82docusate sodium (DOCUSIL) 82
docusate sodium (DSS) 82docusate sodium (DULCOEASE) 82docusate sodium (DULCOLAX STOOLSOFTENER) 82docusate sodium (LAXA BASIC 100) 82docusate sodium (PHILLIPS LAXATIVE) 82docusate sodium (SOF-LAX) 82docusate sodium (STOOL SOFTENER) 82DOK (docusate sodium) 83donepezil hcl 17dorzolamide hcl 115dorzolamide hcltimolol maleate 115DORZOLAMIDE-TIMOLOL 115DOVATO (dolutegravir sodiumlamivudine) 39doxazosin mesylate 51DOXEPIN HCL 19doxepin hcl 19DOXYCYCLINE HYCLATE 14doxycycline hyclate 14doxycycline monohydrate 14DRITHOCREME HP (anthralin) 67dronabinol 21DROPLET MICRON PEN NEEDLE 110DROSPIRENONE-ETHINYL ESTRADIOL 92DROXIA (hydroxyurea) 27DRYSOL (aluminum chloride) 68duloxetine hcl 65
EEES 200 (erythromycin ethylsuccinate) 12EES 400 (erythromycin ethylsuccinate) 12EAR DROPS (carbamide peroxide) 116EDURANT (rilpivirine hcl) 37efavirenz 37EFAVIRENZ-EMTRIC-TENOFOV DISOP 37EFAVIRENZ-LAMIVU-TENOFOV DISOP 3637electrolytesdextrose (ELECTROLYTE) 74electrolytesdextrose (ORALYTE) 74electrolytesdextrose (PEDIATRICELECTROLYTE) 74
LAST UPDATED 12012020140
electrolytesdextrose (PEDIATRIC FREEZERPOPS) 74ELIQUIS (apixaban) 46ELIXOPHYLLIN (theophylline anhydrous) 124ELOCTATE (antihemophilic factor (fviii)recombinant fc fusion protein) 48EMCYT (estramustine phosphate sodium) 27EMSAM (selegiline) 18EMTRICITABINE 38EMTRICITABINE-TENOFOVIR DISOP 38EMTRIVA (emtricitabine) 38ENALAPRIL MALEATE 52enalapril maleate 52ENBREL 105ENBREL (etanercept) 104ENBREL SURECLICK (etanercept) 105ENGERIX-B ADULT (hepatitis b virus vaccinerecombinantpf) 106ENOXAPARIN SODIUM 46enoxaparin sodium 46entacapone 29EPIFOAM (hydrocortisone acetatepramoxinehcl) 68epinephrine 123EPIVIR (lamivudine) 38EPIVIR HBV (lamivudine) 35EPOGEN (epoetin alfa) 47EPZICOM (abacavir sulfatelamivudine) 38ERGOCALCIFEROL 110ergocalciferol (vitamin d2) 110ergocalciferol (vitamin d2) (CALCIDOL) 110ergotamine tartratecaffeine 25ERYTHROCIN STEARATE (erythromycinstearate) 12ERYTHROMYCIN 13erythromycin base 13erythromycin base in ethanol 13erythromycin base in ethanol (ERY) 13erythromycin basebenzoyl peroxide 9ERYTHROMYCIN ETHYLSUCCINATE 13erythromycin ethylsuccinate 13
escitalopram oxalate 18ESCITALOPRAM OXALATE 18ESPEROCT (antihemophilic factor (fviii) rec b-dom truncated peg-exei) 48estradiol 92ESTRADIOL 93estradiol (DOTTI) 92estrogensesterifiedmethyltestosterone 93estrogensesterifiedmethyltestosterone(COVARYX HS) 93estrogensesterifiedmethyltestosterone (EEMTHS) 93ethambutol hcl 26ETHAMBUTOL HCL 26ethinyl estradioldrospirenone 93ethinyl estradioldrospirenone (GIANVI) 93ethinyl estradioldrospirenone (JASMIEL) 93ethinyl estradioldrospirenone (LO-ZUMANDIMINE) 93ethinyl estradioldrospirenone (LORYNA) 93ethinyl estradioldrospirenone (NIKKI) 93ethinyl estradioldrospirenone (VESTURA) 93ETHOSUXIMIDE 14ethosuximide 14ethynodiol diacetate-ethinyl estradiol 93ethynodiol diacetate-ethinyl estradiol(KELNOR 1-35) 93ethynodiol diacetate-ethinyl estradiol(KELNOR 1-50) 93ethynodiol diacetate-ethinyl estradiol (ZOVIA1-35E) 93etodolac 2etonogestrelethinyl estradiol 94etonogestrelethinyl estradiol (ELURYNG) 93etoposide 28EVOTAZ (atazanavir sulfatecobicistat) 40EVZIO (naloxone hcl) 7EXCEDRIN EXTRA STRENGTH(aspirinacetaminophencaffeine) 2EXCEDRIN MIGRAINE(aspirinacetaminophencaffeine) 2
LAST UPDATED 12012020141
EYE ITCH RELIEF 114ezetimibe 59
Ffamotidine 81FAMOTIDINE 81famotidine (ACID CONTROLLER) 80famotidine (ACID REDUCER) 80famotidine (HEARTBURN PREVENTION) 81famotidine (HEARTBURN RELIEF) 81famotidine (PEPCID) 81FANAPT (iloperidone) 32FAZACLO (clozapine) 35FEIBA NF (anti-inhibitor coagulant complex) 48felodipine 55FELODIPINE ER 55fenofibrate 58FENOFIBRATE 58fenofibratemicronized 59fentanyl 4ferrous sulfate 74FERROUS SULFATE 74ferrous sulfate (CHILDRENS IRON) 74ferrous sulfate (FEOSOL) 74ferrous sulfate (FEROSUL) 74ferrous sulfate (FERRO-TIME) 74ferrous sulfate (FERROUSUL) 74ferrous sulfate (PEDIA IRON) 74fexofenadine hcl 121FEXOFENADINE HCL 121fexofenadine hcl (ALLER-EASE) 120fexofenadine hcl (ALLER-FEX) 120fexofenadine hcl (ALLERGY RELIEF) 121fexofenadine hcl (WAL-FEX ALLERGY) 121FIBRYGA (fibrinogen) 48finasteride 86flecainide acetate 53FLOVENT DISKUS (fluticasone propionate) 117FLOVENT HFA (fluticasone propionate) 117FLUAD 2020-2021 106FLUAD QUAD 2020-2021 106
FLUARIX QUAD 2020-2021 106FLUBLOK QUAD 2018-2019 (influenza virusvaccine qv 2018-19(18 yrs andolder)rcmbpf) 106FLUBLOK QUAD 2020-2021 107FLUCELVAX QUAD 2020-2021 107fluconazole 22FLUCONAZOLE 22fluconazole in dextrose iso-osmotic 22flucytosine 22FLUCYTOSINE 22fludrocortisone acetate 88FLULAVAL QUAD 2019-2020 (influenza virusvaccine quadrivalent 2019-20 (6 mos andup)) 107FLULAVAL QUAD 2020-2021 107fluocinolone acetonide 88fluocinonide 88FLUOCINONIDE 88fluoride (sodium) 74fluorometholone 114fluorouracil (ADRUCIL) 27fluoxetine hcl 18FLUOXETINE HCL 18fluoxymesterone (ANDROXY) 91fluphenazine decanoate 30fluphenazine hcl 30FLUPHENAZINE HCL 30flurazepam hcl 130flurbiprofen 2flurbiprofen sodium 114flutamide 27fluticasone propionate 117fluticasone propionate (ALLERGY RELIEF) 117fluticasone propionatesalmeterolxinafoate 126fluticasone propionatesalmeterol xinafoate(WIXELA INHUB) 126fluvoxamine maleate 18FLUZONE HIGH-DOSE QUAD 2020-21 107
LAST UPDATED 12012020142
FLUZONE QUAD 2019-2020 (influenza virusvaccine quadrival 2019-2020(6 mos andup)pf) 107FLUZONE QUAD 2020-2021 107FML FORTE (fluorometholone) 114FML SOP (fluorometholone) 114folic acid 74FOLIC ACID 74FORADIL (formoterol fumarate) 123FOSAMAX PLUS D (alendronatesodiumcholecalciferol (vitamin d3)) 110fosamprenavir calcium 40FOSAMPRENAVIR CALCIUM 40fosinopril sodium 52fosinopril sodiumhydrochlorothiazide 57FOSINOPRIL-HYDROCHLOROTHIAZIDE 57Freestyle Insulix Test Strips 110Freestyle Lite Test Strips 111Freestyle Test Strips 111furosemide 58FUZEON (enfuvirtide) 39
Ggabapentin 15GABAPENTIN 15GARDASIL 9 (human papillomavirus vaccine9-valentpf) 107GAS RELIEF 79GAS RELIEF (simethicone) 79GAS-X (simethicone) 79gemfibrozil 59GEMFIBROZIL 59gentamicin sulfate 8GENTAMICIN SULFATE 9gentamicin sulfate (GENTAK) 8GENTLE LAXATIVE 83GENVOYA(elvitegravircobicistatemtricitabinetenofovir alafenamide) 36GEODON (ziprasidone hcl) 32GEODON (ziprasidone mesylate) 32
GERI-DRYL 121glatiramer acetate 6566glatiramer acetate (GLATOPA) 65GLEOSTINE (lomustine) 26glimepiride 43glipizide 43GLUCAGON EMERGENCY KIT (glucagonhcl) 44GLUCAGON EMERGENCY KIT(glucagonhuman recombinant) 44glyburide 43glyburidemetformin hcl 43glycerin 83glycerin (ADULT GLYCERIN) 83glycerin (LAXATIVE SUPPOSITORY) 83glycerin (PEDIA-LAX) 83glycerin (SUPPOSITORY) 83GOCOVRI (amantadine hcl) 29granisetron hcl 21griseofulvin ultramicrosize 22griseofulvin microsize 23GUAIASORB DM 126guaifenesin (MUCUS ER) 126guaifenesin (MUCUS RELIEF ER) 126GUAIFENESIN-DEXTROMETHORPHAN 126guaifenesindextromethorphan hbr 128guaifenesindextromethorphan hbr (ADULTROBITUSSIN PEAK COLD DM) 126guaifenesindextromethorphan hbr (ADULTTUSSIN COUGH CONGEST DM) 126guaifenesindextromethorphan hbr (ADULTTUSSIN DM) 126guaifenesindextromethorphan hbr (ADULTWAL-TUSSIN DM) 126guaifenesindextromethorphan hbr(ANTITUSSIVE DM) 126guaifenesindextromethorphan hbr(BIOCOTRON) 126guaifenesindextromethorphan hbr (COUGHDM) 126
LAST UPDATED 12012020143
guaifenesindextromethorphan hbr (DIABETICSILTUSSIN-DM) 127guaifenesindextromethorphan hbr (DIABETICTUSSIN DM) 127guaifenesindextromethorphan hbr(EXPECTORANT DM) 127guaifenesindextromethorphan hbr (EXTRAACTION COUGH) 127guaifenesindextromethorphan hbr (GERI-TUSSIN DM) 127guaifenesindextromethorphan hbr (GILTUSSDIABETIC) 127guaifenesindextromethorphan hbr (GILTUSSHBP) 127guaifenesindextromethorphan hbr(GUAIASORB DM) 127guaifenesindextromethorphan hbr (RI-TUSSINDM) 127guaifenesindextromethorphan hbr (ROBAFENDM COUGH) 127guaifenesindextromethorphan hbr (ROBAFENDM COUGH-CHEST CONGEST) 127guaifenesindextromethorphan hbr (ROBAFENDM PEAK COLD) 127guaifenesindextromethorphan hbr(ROBAFEN-DM) 127guaifenesindextromethorphan hbr(SAFETUSSIN DM) 127guaifenesindextromethorphan hbr (SILTUSSINDM DAS) 127guaifenesindextromethorphan hbr (SILTUSSINDM) 128guaifenesindextromethorphan hbr(SORBUGEN NR) 128guaifenesindextromethorphan hbr (TUSNELDIABETIC) 128guaifenesindextromethorphan hbr (TUSSINCOUGH) 128guaifenesindextromethorphan hbr (TUSSINDM CLEAR) 128
guaifenesindextromethorphan hbr (TUSSINDM COUGH) 128guaifenesindextromethorphan hbr (TUSSINDM COUGH-CHEST CONGEST) 128guaifenesindextromethorphan hbr (TUSSINDM) 128guaifenesindextromethorphan hbr (ULTRADM FREE amp CLEAR) 128guaifenesindextromethorphan hbr (ULTRATUSS) 128guaifenesindextromethorphan hbr (WAL-TUSSIN DM) 128guaifenesinpseudoephedrine hcl 129guaifenesinpseudoephedrine hcl (MUCUSD) 128guaifenesinpseudoephedrine hcl (MUCUSRELIEF D) 128guanfacine hcl 5162
HHAILEY FE 94HALDOL (haloperidol lactate) 30HALDOL DECANOATE 100 (haloperidoldecanoate) 30HALDOL DECANOATE 50 (haloperidoldecanoate) 30haloperidol 31HALOPERIDOL 31haloperidol decanoate 31haloperidol lactate 31HALOPERIDOL LACTATE 31HAVRIX (hepatitis a virus vaccinepf) 107HEADACHE RELIEF 2HELIXATE FS (antihemophilic factor (fviii)recombinantfull length) 48HEMLIBRA (emicizumab-kxwh) 48HEMOFIL M (antihemophilic factor human) 48HEPARIN SODIUM 46heparin sodiumporcine 46heparin sodiumporcinepf 46
LAST UPDATED 12012020144
HEPLISAV-B (hepatitis b vaccinerecombinantvaccine adjuvant cpg1018pf) 107HEXALEN (altretamine) 26homatropine hbr 112homatropine hbr (HOMATROPAIRE) 112HUMALOG (insulin lispro) 45HUMALOG MIX 75-25 (insulin lispro protamineand insulin lispro) 45HUMALOG MIX 75-25 KWIKPEN (insulin lisproprotamine and insulin lispro) 45HUMATE-P (antihemophilic factor humanvonwillebrand factorhuman) 48HUMIRA (adalimumab) 105HUMIRA PEDIATRIC CROHNS(adalimumab) 105HUMIRA PEN (adalimumab) 105HUMIRA PEN CROHNS-UC-HS(adalimumab) 105HUMIRA PEN PSOR-UVEITS-ADOL HS(adalimumab) 105HUMIRA(CF) (adalimumab) 105HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 105HUMIRA(CF) PEN (adalimumab) 105HUMIRA(CF) PEN CROHNS-UC-HS(adalimumab) 105HUMIRA(CF) PEN PSOR-UV-ADOL HS(adalimumab) 105HUMULIN 70-30 (insulin nph humanisophaneinsulin regular human) 45HUMULIN 7030 KWIKPEN (insulin nph humanisophaneinsulin regular human) 45HUMULIN N (insulin nph human isophane) 45HUMULIN R (insulin regular human) 45HUMULIN R U-500 (insulin regular human) 45hydralazine hcl 60hydrochlorothiazide 58hydrocodone bitartrateacetaminophen 5hydrocodone bitartrateacetaminophen(LORCET HD) 5
hydrocodone bitartrateacetaminophen(LORTAB) 5hydrocortisone 89109HYDROCORTISONE 89hydrocortisone (ANTI-ITCH) 88hydrocortisone (ANUSOL-HC) 88hydrocortisone (COLOCORT) 109hydrocortisone (CORTISONE) 88hydrocortisone (CORTIZONE-10 PLUS) 89hydrocortisone (CORTIZONE-10) 89hydrocortisone (HYDROCREAM) 89hydrocortisone (NOBLE FORMULA HC) 89hydrocortisone (PREPARATION H) 89hydrocortisone (PROCTO-MED HC) 89hydrocortisone (PROCTO-PAK) 89hydrocortisone (PROCTOSOL-HC) 89hydrocortisone (PROCTOZONE-HC) 89hydrocortisone (SOOTHING CARE) 89HYDROCORTISONE ACETATE 89hydrocortisone acetate 89hydrocortisone acetate (ANUCORT-HC) 89hydrocortisone acetate (ANUSOL-HC) 89hydrocortisone acetate (HEMMOREX-HC) 89hydrocortisone acetatepramoxine hcl 68hydrocortisoneacetic acid 116hydrocortisoneacetic acid (ACETASOLHC) 116hydromorphone hcl 5HYDROXYCHLOROQUINE SULFATE 28hydroxychloroquine sulfate 28hydroxyprogesterone caproate 100hydroxyprogesterone caproatepf 100hydroxyurea 27hydroxyzine hcl 121HYDROXYZINE PAMOATE 121hydroxyzine pamoate 121hyoscyamine sulfate 77hyoscyamine sulfate (HYOSYNE) 77HYPERTET S-D (tetanus immuneglobulinpf) 106
LAST UPDATED 12012020145
Iibuprofen 3IBUPROFEN 3ibuprofen (ADDAPRIN) 2ibuprofen (I-PRIN) 3ibuprofen (IBU) 3ibuprofen (IBU-200) 3ibuprofen (PROVIL) 3ibuprofen (WAL-PROFEN) 3IDELVION (factor ix recombinantalbuminfusion protein) 48imipramine hcl 19IMIPRAMINE HCL 19IMOVAX RABIES VACCINE (rabies vaccinehuman diploid cellpf) 107INCRUSE ELLIPTA (umeclidinium bromide) 122indapamide 58indomethacin 3INFANTS GAS RELIEF 79inhalerassist device with large mask 111inhalerassist device with medium mask 111inhalerassist device with small mask 111insulin lispro 45INSULIN LISPRO PROTAMINE MIX (insulin lisproprotamine and insulin lispro) 45Insulin pen needles 111INSULIN SYRINGE 03 ML 111INSULIN SYRINGE 05 ML 111INSULIN SYRINGE 1 ML 111INTELENCE (etravirine) 37INTRON A (interferon alfa-2brecomb) 35INVEGA (paliperidone) 32INVEGA SUSTENNA (paliperidone palmitate)32INVEGA TRINZA (paliperidone palmitate) 32INVIRASE (saquinavir mesylate) 40IOPIDINE (apraclonidine hcl) 115ipratropium bromide 122ipratropium bromidealbuterol sulfate 129IPRATROPIUM-ALBUTEROL 129irbesartan 52
irbesartanhydrochlorothiazide 57IRON 74ISENTRESS (raltegravir potassium) 36ISENTRESS HD (raltegravir potassium) 36isoniazid 26ISOSORBIDE DINITRATE 60isosorbide dinitrate 60isosorbide mononitrate 60isotretinoin 68isotretinoin (AMNESTEEM) 68isotretinoin (CLARAVIS) 68isotretinoin (MYORISAN) 68isotretinoin (ZENATANE) 68itraconazole 23IXINITY (factor ix human recombinantthreonine 148) 49
JJAKAFI (ruxolitinib phosphate) 28JARDIANCE (empagliflozin) 43JENCYCLA 100JIVI (antihemophilic factor (fviii) rec b-domain deleted peg-aucl) 49JULUCA (dolutegravir sodiumrilpivirine hcl) 39
KKALETRA (lopinavirritonavir) 40KCENTRA (human prothrombin complexconcentrate (pcc) 4-factor) 49ketoconazole 23ketoprofen 3ketorolac tromethamine 114ketotifen fumarate 114ketotifen fumarate (ALLERGY EYE DROPS) 114ketotifen fumarate (EYE ITCH RELIEF) 114ketotifen fumarate (ITCHY EYE) 114ketotifen fumarate (WAL-ZYR) 114ketotifen fumarate (ZADITOR) 114KOGENATE FS (antihemophilic factor (fviii)recombinantfull length) 49
LAST UPDATED 12012020146
KOVALTRY (antihemophilic factor (fviii)recombinantfull length) 49
Llabetalol hcl 54LABETALOL HCL 54lactulose 83lactulose (CONSTULOSE) 83lactulose (ENULOSE) 83lactulose (GENERLAC) 83LAMISIL (terbinafine hcl) 23lamivudine 3538lamivudinezidovudine 38lamotrigine 15lancets 111LANOXIN (digoxin) 57lansoprazole 85LANSOPRAZOLE 85lanthanum carbonate 87latanoprost 115LATUDA (lurasidone hcl) 32leflunomide 106LEFLUNOMIDE 106letrozole 28LEUCOVORIN CALCIUM 27leucovorin calcium 27LEUKERAN (chlorambucil) 26leuprolide acetate 104levalbuterol tartrate 123LEVETIRACETAM 14levetiracetam 14LEVETIRACETAM ER 14LEVO-T (levothyroxine sodium) 103levobunolol hcl 115levocarnitine 70levocarnitine (with sugar) 70levofloxacin 13levonorgestrel 101levonorgestrel (AFTERA) 101levonorgestrel (ECONTRA EZ) 101levonorgestrel (ECONTRA ONE-STEP) 101
levonorgestrel (FALLBACK SOLO) 101levonorgestrel (MY CHOICE) 101levonorgestrel (MY WAY) 101levonorgestrel (NEW DAY) 101levonorgestrel (OPCICON ONE-STEP) 101levonorgestrel (OPTION 2) 101levonorgestrel (TAKE ACTION) 101LEVONORGESTREL-ETH ESTRADIOL 94levonorgestrelethinyl estradiol 96levonorgestrelethinyl estradiol (AFIRMELLE) 94levonorgestrelethinyl estradiol (ALTAVERA) 94levonorgestrelethinyl estradiol (AUBRA EQ) 94levonorgestrelethinyl estradiol (AUBRA) 94levonorgestrelethinyl estradiol (AVIANE) 94levonorgestrelethinyl estradiol (AYUNA) 94levonorgestrelethinyl estradiol (CHATEALEQ) 94levonorgestrelethinyl estradiol (CHATEAL) 94levonorgestrelethinyl estradiol (DELYLA) 94levonorgestrelethinyl estradiol (ENPRESSE) 94levonorgestrelethinyl estradiol (FALMINA) 95levonorgestrelethinyl estradiol (KURVELO) 95levonorgestrelethinyl estradiol (LARISSIA) 95levonorgestrelethinyl estradiol (LESSINA) 95levonorgestrelethinyl estradiol (LEVONEST) 95levonorgestrelethinyl estradiol (LEVORA-28)95levonorgestrelethinyl estradiol (LILLOW) 95levonorgestrelethinyl estradiol (LUTERA) 95levonorgestrelethinyl estradiol (MARLISSA) 95levonorgestrelethinyl estradiol (MYZILRA) 95levonorgestrelethinyl estradiol (ORSYTHIA) 95levonorgestrelethinyl estradiol (PORTIA) 96levonorgestrelethinyl estradiol (SRONYX) 96levonorgestrelethinyl estradiol (TRIVORA-28) 96levonorgestrelethinyl estradiol (VIENVA) 96levothyroxine sodium 103LEVOTHYROXINE SODIUM 103LEVOXYL (levothyroxine sodium) 103LEXIVA (fosamprenavir calcium) 40LICE KILLING 68
LAST UPDATED 12012020147
lidocaine hcl 6LIDOCAINE HCL VISCOUS 6lidocaine hclpf 6lisinopril 52lisinoprilhydrochlorothiazide 57lithium carbonate 42lithium citrate 42LITHOBID (lithium carbonate) 42loperamide hcl 79loperamide hcl (ANTI-DIARRHEAL) 79loperamide hcl (DIAMODE) 79loperamide hcl (ULTRA A-D) 79lopinavirritonavir 40loratadine 121122LORATADINE 122loratadine (ALLERCLEAR) 121loratadine (ALLERGY RELIEF) 121loratadine (ALLERGY) 121loratadine (CHILDRENS ALLERGY RELIEF) 121loratadine (CHILDRENS ALLERGY) 121loratadine (LORADAMED) 121loratadine (NON-DROWSY ALLERGY) 121loratadine (WAL-ITIN) 121lorazepam 42lorazepam (LORAZEPAM INTENSOL) 42LOSARTAN POTASSIUM 52losartan potassium 52losartan potassiumhydrochlorothiazide 57LOSARTAN-HYDROCHLOROTHIAZIDE 57LOTRIMIN AF (clotrimazole) 23lovastatin 59loxapine succinate 31LUCEMYRA (lofexidine hcl) 7LUPRON DEPOT-PED (leuprolide acetate) 104LYLLANA 96LYSODREN (mitotane) 28
MM-M-R II VACCINE (measles mumps andrubella vaccine livepf) 107MAGNESIUM CITRATE 83
magnesium citrate 83MARPLAN (isocarboxazid) 18MATULANE (procarbazine hcl) 26MAXI-TUSS G 129mebendazole (EMVERM) 28MECLIZINE HCL 20meclizine hcl 20meclizine hcl (DRAMAMINE LESS DROWSY) 20meclizine hcl (MEDI-MECLIZINE) 20meclizine hcl (MOTION RELIEF) 20meclizine hcl (MOTION SICKNESS II) 20meclizine hcl (MOTION SICKNESS RELIEF) 20meclizine hcl (MOTION SICKNESS) 20meclizine hcl (MOTION-TIME) 20meclizine hcl (TRAVEL-EASE) 20meclizine hcl (VERTICALM) 20meclizine hcl (WAL-DRAM 2) 20MEDROXYPROGESTERONE ACETATE 101medroxyprogesterone acetate 101mefloquine hcl 28megestrol acetate 101meloxicam 3melphalan 26memantine hcl 17MEMANTINE HCL 17MENACTRA (meningococcalvaccine acyw-135diphtheria toxoid conjpf) 107MENEST (estrogensesterified) 96MENQUADFI 107MENVEO A-C-Y-W-135-DIP(meningococcalvaccine acyw-135diphtheria toxoid conjpf) 108meperidine hcl 5mercaptopurine 27mesalamine 109MESTINON (pyridostigmine bromide) 25metaproterenol sulfate 123metformin hcl 43METFORMIN HCL ER 43METHADONE HCL 4methadone hcl 4
LAST UPDATED 12012020148
methadone hcl (METHADONE INTENSOL) 4methadone hcl (METHADOSE) 4methazolamide 115METHAZOLAMIDE 115methenaminemethylene bluesodphospsalicylatehyoscyamine(PHOSPHASAL) 9methenaminemethylene bluesodphospsalicylatehyoscyamine (URIN DS) 10methimazole 104methocarbamol 130METHOCARBAMOL 130METHOTREXATE 105methotrexate sodium 105methyclothiazide 58methyldopa 51methylergonovine maleate 111METHYLPHENIDATE ER 62methylphenidate hcl 62METHYLPHENIDATE HCL 62methylphenidate hcl (METADATE ER) 62methylprednisolone 89metoclopramide hcl 20metolazone 58metoprolol succinate 54METOPROLOL SUCCINATE 54metoprolol tartrate 54METRO IV (metronidazole in sodiumchloride) 10metronidazole 1068METRONIDAZOLE 10metronidazole in sodium chloride 10mexiletine hcl 53MEXILETINE HCL 53miconazole nitrate 23miconazole nitrate (ANTI-FUNGAL CREAM) 23miconazole nitrate (ANTIFUNGAL CREAM) 23miconazole nitrate (BAZA ANTIFUNGAL) 23miconazole nitrate (INZO ANTIFUNGAL) 23miconazole nitrate (LOTRIMIN AF) 23miconazole nitrate (MICATIN) 23
miconazole nitrate (SECURA ANTIFUNGAL) 23MICROGESTIN 96MICROGESTIN FE 96minocycline hcl 14minoxidil 60mirtazapine 17misoprostol 85modafinil 131moexipril hcl 52molindone hcl 31mometasone furoate 90MONISTAT 3 (miconazole nitrate) 23MONISTAT 7 (miconazole nitrate) 23MONONINE (factor ix) 49montelukast sodium 122MONTELUKAST SODIUM 122morphine sulfate 45moxifloxacin hcl 13MUCUS ER 129MUCUS RELIEF ER 129mupirocin 10mupirocin calcium 10MURINE EAR DROPS (carbamide peroxide) 116MURO-128 (sodium chloride) 112mycophenolate mofetil 105MYLERAN (busulfan) 27MYNATAL (prenatal vitamins withcalciumferrous fumaratefolic acid) 70
NNABI-HB (hepatitis b immune globulin) 106nadolol 54NADOLOL 54naloxone hcl 7naltrexone hcl 7NALTREXONE HCL 7naproxen 3naproxen sodium 3NARCAN (naloxone hcl) 8NARDIL (phenelzine sulfate) 18NASACORT (triamcinolone acetonide) 117
LAST UPDATED 12012020149
NASAL DECONGESTANT (pseudoephedrinehcl) 123nateglinide 43neomycin sulfate 9neomycin sulfatebacitracin zincpolymyxin b(ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxin b(FIRST AID ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxin b(TRIPLE ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxinbhydrocortisone 112neomycin sulfatebacitracin zincpolymyxinbhydrocortisone (NEO-POLYCIN HC) 112neomycin sulfatebacitracinpolymyxin b 113neomycin sulfatebacitracinpolymyxin b(NEO-POLYCIN) 113neomycin sulfatepolymyxin bsulfategramicidin d 113neomycin sulfatepolymyxin bsulfatehydrocortisone 113116NEOMYCIN-POLYMYXIN-HC 116neomycinpolymyxin bsulfatedexamethasone 113nevirapine 37NIACIN 60niacin 60niacin (ENDUR-ACIN) 59niacin (SLO-NIACIN) 59nicardipine hcl 55NICOTINE 14MG PATCH 8NICOTINE 21MG PATCH 8NICOTINE 2MG GUM 8NICOTINE 4MG GUM 8NICOTINE 7MG PATCH 8NICOTINE LOZENGE 8nicotine polacrilex 8nicotine polacrilex (QUIT 2) 8nicotine polacrilex (QUIT 4) 8nicotine polacrilex (STOP SMOKING AID) 8NICOTROL (nicotine) 8
NICOTROL NS (nicotine) 8NIFEDIPINE 55nifedipine 55nifedipine (AFEDITAB CR) 55nifedipine (NIFEDICAL XL) 55NIGHTTIME SLEEP AID 122nisoldipine 55NITRO-BID (nitroglycerin) 60nitrofurantoin 10NITROFURANTOIN 10nitrofurantoin macrocrystal 10nitrofurantoin monohydratemacrocrystals 10nitroglycerin 61NITROGLYCERIN 61nitroglycerin (MINITRAN) 60nitroglycerin (NITRO-TIME) 60nonoxynol 9 (VCF) 86norelgestrominethinyl estradiol (XULANE) 96norethindrone 102norethindrone (CAMILA) 101norethindrone (DEBLITANE) 101norethindrone (ERRIN) 101norethindrone (HEATHER) 102norethindrone (INCASSIA) 102norethindrone (JENCYCLA) 102norethindrone (JOLIVETTE) 102norethindrone (LYZA) 102norethindrone (NORA-BE) 102norethindrone (NORLYDA) 102norethindrone (NORLYROC) 102norethindrone (SHAROBEL) 102norethindrone (TULANA) 102norethindrone acetate 102norethindrone acetate-ethinyl estradiol 97norethindrone acetate-ethinyl estradiol(AUROVELA) 96norethindrone acetate-ethinyl estradiol(GILDESS) 96norethindrone acetate-ethinyl estradiol(HAILEY) 96
LAST UPDATED 12012020150
norethindrone acetate-ethinyl estradiol(JUNEL) 97norethindrone acetate-ethinyl estradiol(LARIN) 97norethindrone acetate-ethinyl estradiol(MICROGESTIN) 97norethindrone acetate-ethinylestradiolferrous fumarate 98norethindrone acetate-ethinylestradiolferrous fumarate (AUROVELA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (BLISOVI FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (JUNEL FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (LARIN FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (MICROGESTINFE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TARINA FE 1-20EQ) 97norethindrone acetate-ethinylestradiolferrous fumarate (TARINA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TILIA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TRI-LEGEST FE) 98norethindrone-ethinyl estradiol (ALYACEN) 98norethindrone-ethinyl estradiol (ARANELLE) 98norethindrone-ethinyl estradiol (BALZIVA) 98norethindrone-ethinyl estradiol (BRIELLYN) 98norethindrone-ethinyl estradiol (CYCLAFEM)98norethindrone-ethinyl estradiol (DASETTA) 98norethindrone-ethinyl estradiol (LEENA) 98norethindrone-ethinyl estradiol (NECON) 98norethindrone-ethinyl estradiol (NORTREL) 98norethindrone-ethinyl estradiol (PHILITH) 98norethindrone-ethinyl estradiol (PIRMELLA) 98norethindrone-ethinyl estradiol (VYFEMLA) 98norethindrone-ethinyl estradiol (WERA) 98
norethindrone-ethinyl estradiol (ZENCHENT) 98NORGESTIMATE-ETHINYL ESTRADIOL 100norgestimate-ethinyl estradiol 100norgestimate-ethinyl estradiol (ESTARYLLA) 98norgestimate-ethinyl estradiol (FEMYNOR) 99norgestimate-ethinyl estradiol (MILI) 99norgestimate-ethinyl estradiol (MONO-LINYAH) 99norgestimate-ethinyl estradiol(MONONESSA) 99norgestimate-ethinyl estradiol (PREVIFEM) 99norgestimate-ethinyl estradiol (SPRINTEC) 99norgestimate-ethinyl estradiol (TRIFEMYNOR) 99norgestimate-ethinyl estradiol (TRI-ESTARYLLA) 99norgestimate-ethinyl estradiol (TRI-LINYAH) 99norgestimate-ethinyl estradiol (TRI-LO-ESTARYLLA) 99norgestimate-ethinyl estradiol (TRI-LO-MARZIA) 99norgestimate-ethinyl estradiol (TRI-LO-MILI) 99norgestimate-ethinyl estradiol (TRI-LO-SPRINTEC) 99norgestimate-ethinyl estradiol (TRI-PREVIFEM) 99norgestimate-ethinyl estradiol (TRI-SPRINTEC) 99norgestimate-ethinyl estradiol (TRI-VYLIBRALO) 99norgestimate-ethinyl estradiol (TRI-VYLIBRA) 99norgestimate-ethinyl estradiol (TRINESSA LO)99norgestimate-ethinyl estradiol (TRINESSA) 99norgestimate-ethinyl estradiol (VYLIBRA) 99norgestrel-ethinyl estradiol (CRYSELLE) 100norgestrel-ethinyl estradiol (ELINEST) 100norgestrel-ethinyl estradiol (LOW-OGESTREL) 100norgestrel-ethinyl estradiol (OGESTREL) 100nortriptyline hcl 19NORVIR (ritonavir) 40
LAST UPDATED 12012020151
NOVOEIGHT (antihemophilic factor viiirecombinant b-domain truncated) 49NOVOLIN 70-30 (insulin nph humanisophaneinsulin regular human) 45NOVOLIN N (insulin nph human isophane) 45NOVOLIN R (insulin regular human) 45NOVOSEVEN RT (coagulation factor viia(recombinant)) 49NUPLAZID (pimavanserin tartrate) 32NUWIQ (antihemophilic factor viii rec hek cellb-domain deleted) 50NYSTATIN 23nystatin 23
OO-CAL PRENATAL (prenatal vit with calciumno127ferrous fumaratefolic acid) 70OBIZUR (antihemophilic factor viiirecombinant porcine sequence) 50ODEFSEY (emtricitabinerilpivirinehcltenofovir alafenamide fumarate) 37ofloxacin 13olanzapine 33olanzapinefluoxetine hcl 17OMEGA-3 ACID ETHYL ESTERS 60omega-3 acid ethyl esters 60omeprazole 85OMEPRAZOLE 85ondansetron 21ondansetron hcl 21ORAP (pimozide) 31oseltamivir phosphate 41OSELTAMIVIR PHOSPHATE 41OSMOLEX ER (amantadine hcl) 29oxazepam 42oxcarbazepine 16oxybutynin chloride 86OXYBUTYNIN CHLORIDE ER 86oxycodone hcl 46oxycodone hclacetaminophen 6oxycodone hclacetaminophen (ENDOCET) 6
oxycodone hclaspirin 6OXYTROL FOR WOMEN (oxybutynin) 86OYSTER SHELL CALCIUM 74OYSTER SHELL CALCIUM-VIT D3 74
PPAIN amp FEVER (acetaminophen) 64PAIN RELIEF 64paliperidone 33pantoprazole sodium 85PANTOPRAZOLE SODIUM 85PARNATE (tranylcypromine sulfate) 18paromomycin sulfate 9paroxetine hcl 18PEDIATRIC IRON 75pediatric multivit with acd3 no21sodiumfluoride 75pediatric multivitamin no16sodiumfluoride 75pediatric multivitamin no2sodium fluoride 75pediatric multivitamin no45sodiumfluorideferrous sulfate 75pediatric multivitamins no17 with sodiumfluoride 75peg 3350sod sulfsod bicarbsodchloridepotassium chloride 83peg 3350sod sulfsod bicarbsodchloridepotassium chloride (GAVILYTE-C) 83peg 3350sod sulfsod bicarbsodchloridepotassium chloride (GAVILYTE-G) 83PEG-3350 AND ELECTROLYTES 83PEGINTRON REDIPEN (peginterferon alfa-2b) 35PEN NEEDLE 111pen needle diabetic 111pen needle diabetic disposable safety 111pen needle diabetic remover and disposalunit 111pen needle diabetic safety 111penicillamine 86PENICILLAMINE 86
LAST UPDATED 12012020152
penicillin v potassium 12pentoxifylline 57PEPTO-BISMOL (bismuth subsalicylate) 79PEPTO-BISMOL TO-GO (bismuthsubsalicylate) 79permethrin 29permethrin (LICE TREATMENT) 29perphenazine 20PERSERIS (risperidone) 33PHENAZOPYRIDINE HCL 87phenazopyridine hcl 87phenazopyridine hcl (URINARY PAIN RELIEF) 86phenelzine sulfate 18phenobarbital 15PHENOBARBITAL 15PHENOXYBENZAMINE HCL 51phenoxybenzamine hcl 51phenylephrine hcl 113phenylephrine hclpromethazine hcl 129phenytoin 16phenytoin sodium extended 16PHOS-FLUR (fluoride (sodium)) 66PHOSPHOLINE IODIDE (echothiophateiodide) 115phytonadione (vit k1) 50PIFELTRO (doravirine) 37pilocarpine hcl 115PILOCARPINE HCL 115pimecrolimus 68pimozide 31pindolol 54pioglitazone hcl 43PIOGLITAZONE HCL 44piperonyl butoxidepyrethrins (LICE KILLING)68piperonyl butoxidepyrethrins (LICE PYRINYLSHAMPOO) 68piperonyl butoxidepyrethrins (LICETREATMENT) 68piperonyl butoxidepyrethrins (RID) 68piperonyl butoxidepyrethrinspermethrin(COMPLETE LICE TREATMENT) 69
piperonyl butoxidepyrethrinspermethrin(LICE SOLUTION) 69piroxicam 3PLAN B ONE-STEP (levonorgestrel) 102PLEGRIDY (peginterferon beta-1a) 66PLEGRIDY PEN (peginterferon beta-1a) 66PNEUMOVAX 23 (pneumococcal 23-valentpolysaccharide vaccine) 108podofilox 69POLY-VITAMIN (multivitamin) 75polyethylene glycol 3350 84polyethylene glycol 3350 (CLEARLAX) 83polyethylene glycol 3350 (GAVILAX) 84polyethylene glycol 3350 (GENTLELAX) 84polyethylene glycol 3350 (GLYCOLAX) 84polyethylene glycol 3350 (LAXACLEAR) 84polyethylene glycol 3350 (NATURA-LAX) 84polyethylene glycol 3350 (POWDERLAX) 84polyethylene glycol 3350 (PURELAX) 84polyethylene glycol 3350 (SMOOTHLAX) 84polymyxin b sulfatetrimethoprim 113POTASSIUM 75potassium bicarbonatecitric acid 75potassium bicarbonatecitric acid (EFFER-K)75potassium bicarbonatecitric acid (KEFFERVESCENT) 75potassium bicarbonatecitric acid (KLOR-CON-EF) 75POTASSIUM CHL-NORMAL SALINE 75potassium chloride 7075POTASSIUM CHLORIDE 71potassium chloride (KLOR-CON M10) 70potassium chloride (KLOR-CON M20) 70potassium chloride (KLOR-CON SPRINKLE) 75potassium chloride in 09 sodiumchloride 7071potassium chloridepotassiumbicarbonatecitric acid 75potassium gluconate 76pramipexole di-hcl 29pramoxine hclcalamine (CALAHIST) 69
LAST UPDATED 12012020153
pramoxine hclcalamine (CALAMINEMEDICATED) 69praziquantel 28prazosin hcl 51PRAZOSIN HCL 51PRED MILD (prednisolone acetate) 114prednisolone 90prednisolone (MILLIPRED DP) 90prednisolone (MILLIPRED) 90prednisolone acetate 114prednisolone sodium phosphate 90114prednisone 90prednisone (PREDNISONE INTENSOL) 90pregabalin 65PREGABALIN 65PREMARIN (estrogens conjugated) 100PREMPHASE (estrogensconjugatedmedroxyprogesteroneacetate) 100PREMPRO (estrogensconjugatedmedroxyprogesteroneacetate) 100PRENATABS FA (prenatal vits with calciumno78ferrous fumaratefolic acid) 71PRENATABS RX (prenatal vitamin with calciumno76ironcarbonylfolic acid) 71PRENATAL MULTIVITAMIN 76prenatal vit with calcium no129ferrousfumaratefolic acid 76prenatal vit with calcium no130ferrousfumaratefolic acid 76prenatal vitamins no121ferrousfumaratefolic acid 76prenatal vitamins with calciumferrousfumaratefolic acid 76prenatal vitamins with calciumferrousfumaratefolic acid (MYNATAL PLUS) 71prenatal vitamins with calciumferrousfumaratefolic acid (MYNATAL-Z) 71prenatal vits with calcium 118ferrousfumaratefolic acid 76
prenatal vits with calcium 118ferrousfumaratefolic acid (SE-NATAL 19) 71prenatal vits with calcium 136ferrousfumaratefolic acid (VINATE-M) 71prenatal vits with calcium 137ferrousfumaratefolic acid 76prenatal vits with calcium 95ferrousfumaratefolic acid 76prenatal vits with calcium no115ironfumaratefolic acid 71prenatal vits with calcium no72ferrousfumaratefolic acid 71prenatal vits with calcium no72ferrousfumaratefolic acid (M-NATAL PLUS) 71prenatal vits with calcium no72ferrousfumaratefolic acid (PREPLUS) 71prenatal vits with calciumno72ironcarbonylfolic acid 72prenatal vits with calcium no74ferrousfumaratefolic acid 72prenatal vits with calcium no96ferrousfumaratefolic acid 76PREVACID (lansoprazole) 85PREVNAR 13 (pneumococcal 13-valentconjugate vaccine (diphtheria crm)pf) 108PREZCOBIX (darunavirethanolatecobicistat) 40PREZISTA (darunavir ethanolate) 40PRIFTIN (rifapentine) 26primaquine phosphate 28primidone 15probenecid 24probenecidcolchicine 24PROBUPHINE (buprenorphine hcl) 7prochlorperazine 20prochlorperazine (COMPRO) 20prochlorperazine maleate 20PROCRIT (epoetin alfa) 47PROCTOFOAM-HC (hydrocortisoneacetatepramoxine hcl) 69
LAST UPDATED 12012020154
PROFILNINE (factor ix complex prothrombincplx conc(pcc) no4 3-factor) 50promethazine hcl 21122PROMETHAZINE HCL 122promethazine hcl (PHENADOZ) 21promethazine hcl (PROMETHEGAN) 21promethazine hclcodeine 129promethazine hcldextromethorphan hbr 129PROMETHAZINE-DM 129promethazinephenylephrine hclcodeine 129propafenone hcl 53propantheline bromide 77proparacaine hcl 113propranolol hcl 54propylthiouracil 104pseudoephedrine hcl 123pseudoephedrine hcl (NASALDECONGESTANT) 123pseudoephedrine hcl (SUDOGEST) 123pseudoephedrine hcl (SUPHEDRIN) 123pseudoephedrine hcl (SUPHEDRINE SINUSCONGESTION) 123pseudoephedrine hcl (SUPHEDRINE) 123pseudoephedrine hcl (WAL-PHED) 123PULMICORT FLEXHALER (budesonide) 117pyrazinamide 26pyridostigmine bromide 25pyridoxine hcl (vitamin b6) 76
Qquetiapine fumarate 33quinapril hcl 52quinidine gluconate 53quinidine sulfate 53QVAR REDIHALER (beclomethasonedipropionate) 117
RRABAVERT (rabies vaccine purified chickenembryo cell (pcec)pf) 108ramipril 52
RAMIPRIL 53REBINYN (factor ix (human) recombinantpegylated) 50RECOMBINATE (antihemophilic factor viiihuman recombinant) 50RECOMBIVAX HB (hepatitis b virus vaccinerecombinantpf) 108RELENZA (zanamivir) 41RESCRIPTOR (delavirdine mesylate) 37REXULTI (brexpiprazole) 33REYATAZ (atazanavir sulfate) 41RHEUMATREX (methotrexate sodium) 105RIASTAP (fibrinogen) 50ribavirin 36ribavirin (RIBASPHERE) 36RID (permethrin) 111RID (piperonylbutoxidepyrethrinspermethrin) 69RIDAURA (auranofin) 106rifabutin 26rifampin 26riluzole 65RILUZOLE 65ringers solution 7076RISPERDAL (risperidone) 33RISPERDAL CONSTA (risperidonemicrospheres) 33RISPERDAL M-TAB (risperidone) 33risperidone 33ritonavir 41RIXUBIS (factor ix human recombinant) 50rizatriptan benzoate 25ropinirole hcl 29rosuvastatin calcium 59RUKOBIA 39
Ssalsalate 3SANDIMMUNE (cyclosporine) 105SANTYL (collagenase clostridiumhistolyticum) 69
LAST UPDATED 12012020155
SAPHRIS (asenapine maleate) 33SAVELLA (milnacipran hcl) 65SE-NATAL-19 (prenatal vitamins no119ironfumaratefolic acid) 72SECUADO (asenapine) 33selegiline hcl 30selenium sulfide 69selenium sulfide (ANTI-DANDRUFF) 69selenium sulfide (MEDICATED DANDRUFFSHAMPOO) 69selenium sulfide (SELSUN BLUE) 69selenium sulfidealoe vera (SELSUN BLUEMOISTURIZING) 69SELZENTRY (maraviroc) 39SEREVENT DISKUS (salmeterol xinafoate) 123SEROQUEL (quetiapine fumarate) 34SEROQUEL XR (quetiapine fumarate) 34sertraline hcl 18sevelamer carbonate 87SEVENFACT 50SHINGRIX (varicella-zoster virus glycoproteinerecas01b adjuvantpf) 108SILACE (docusate sodium) 84sildenafil citrate 124SILDENAFIL CITRATE 124silver sulfadiazine 13simethicone 80simethicone (GAS RELIEF) 80simethicone (GAS-X) 80simethicone (INFANT GAS RELIEF) 80simethicone (INFANTS GAS RELIEF) 80simethicone (MI-ACID) 80simvastatin 59sirolimus 105SODIUM CHLORIDE 7677sodium chloride 113sodium chloride (MURO-128) 113sodium chloride for inhalation 129sodium chloride irrigating solution 707277sodium chloride irrigating solution (AQUACARE SODIUM CHLORIDE) 77
sodium chloride irrigating solution (CURITY) 77sodium chloridesodiumbicarbonatepotassium chloridepeg 84sodium chloridesodiumbicarbonatepotassium chloridepeg(GAVILYTE-N) 84sodium chloridesodiumbicarbonatepotassium chloridepeg (TRILYTEWITH FLAVOR PACKETS) 84sodium polystyrene sulfonate 72sodium polystyrene sulfonatesorbitol solution(KIONEX) 72sodiumpotassiumpotassium citratesodiumcitratecit ac 87sodiumpotassiumpotassium citratesodiumcitratecit ac (CYTRA-3) 87sodiumpotassiumpotassium citratesodiumcitratecit ac (TRICITRATES) 87sofosbuvirvelpatasvir 35SOTALOL 53SOTALOL AF 53sotalol hcl 53sotalol hcl (SORINE) 53spironolactone 58SPIRONOLACTONE 58spironolactonehydrochlorothiazide 57SPS (sodium polystyrene sulfonatesorbitolsolution) 72SSD (silver sulfadiazine) 13stavudine 38STOMACH RELIEF 80STOOL SOFTENER 84STOOL SOFTENER (docusate sodium) 84STRIBILD(elvitegravircobicistatemtricitabinetenofovir disoproxil) 36SUBLOCADE (buprenorphine) 4SUBOXONE (buprenorphine hclnaloxonehcl) 7sucralfate 85SUDAFED (pseudoephedrine hcl) 123
LAST UPDATED 12012020156
sulfacetamide sodium 13sulfacetamide sodiumprednisolone sodiumphosphate 113sulfamethoxazoletrimethoprim 13sulfasalazine 109SULFATRIM (sulfamethoxazoletrimethoprim)14sulindac 3SUMATRIPTAN 25sumatriptan 25sumatriptan succinate 25SUMATRIPTAN SUCCINATE 25SUSTIVA (efavirenz) 37SYMBYAX (olanzapinefluoxetine hcl) 18SYMFI (efavirenzlamivudinetenofovirdisoproxil fumarate) 36SYMFI LO (efavirenzlamivudinetenofovirdisoproxil fumarate) 37SYMTUZA (darunavirethcobicistatemtricitabinetenofoviralafenamide) 41SYNAREL (nafarelin acetate) 104SYNJARDY (empagliflozinmetformin hcl) 44SYNJARDY XR (empagliflozinmetformin hcl) 44SYNTHROID (levothyroxine sodium) 103syringe with needle insulin safety 1 ml 111syringe with needledisposableinsulin 1 ml 111syringe with needleinsulin03 ml 111syringe with needleinsulin05 ml 112
TTABLOID (thioguanine) 27tacrolimus 69106TACROLIMUS 106tadalafil 124tadalafil (ALYQ) 124TAKE ACTION (levonorgestrel) 102TAMOXIFEN CITRATE 27tamoxifen citrate 27tamsulosin hcl 86TDVAX (tetanus and diphtheria toxoidsadult) 108
TECFIDERA (dimethyl fumarate) 66TEGRETOL (carbamazepine) 16TEGRETOL XR (carbamazepine) 16temazepam 130TEMIXYS (lamivudinetenofovir disoproxilfumarate) 36temozolomide 27TENIVAC (tetanus and diphtheria toxoidsadsorbed adultpf) 108tenofovir disoproxil fumarate 38terazosin hcl 52TERAZOSIN HCL 52terbinafine hcl 24terbinafine hcl (ANTIFUNGAL) 24terbinafine hcl (ATHLETES FOOT AF) 24terbinafine hcl (ATHLETES FOOT) 24terbinafine hcl (JOCK ITCH) 2444terbinafine hcl (LAMISIL AT) 24TERBUTALINE SULFATE 123terbutaline sulfate 124testosterone 91testosterone cypionate 91tetanus and diphtheria toxoids adult 108THALOMID (thalidomide) 27THEO-24 (theophylline anhydrous) 124theophylline anhydrous 124theophylline anhydrous (THEOCHRON) 124thioridazine hcl 31thiothixene 31thyroidpork (NP THYROID) 103timolol maleate 115TIMOLOL MALEATE 115tioconazole 24TIVICAY (dolutegravir sodium) 36TIVICAY PD 36tizanidine hcl 35TOBRADEX (tobramycindexamethasone) 113tobramycin 9tobramycindexamethasone 113TOBREX (tobramycin) 9tolbutamide 44
LAST UPDATED 12012020157
tolmetin sodium 3tolnaftate 24tolnaftate (ANTIFUNGAL CREAM) 24tolnaftate (ATHLETES FOOT) 24tolnaftate (FUNGOID-D) 24topiramate 16TOPIRAMATE 16TOREMIFENE CITRATE 27toremifene citrate 27tramadol hcl 6TRAMADOL HCL 6trandolapril 53tranylcypromine sulfate 18TRAVEL SICKNESS (meclizine hcl) 21TRAZODONE HCL 19trazodone hcl 19tretinoin 28TRETTEN (factor xiii a-subunit recombinant) 50TRI-VI-SOL (vitamin a palmitateascorbicacidcholecalciferol (vit d3)) 77triamcinolone acetonide 6690117TRIAMCINOLONE ACETONIDE 66triamcinolone acetonide (ORALONE) 66triamterenehydrochlorothiazide 57triazolam 130trifluoperazine hcl 31trifluridine 41TRIGLIDE (fenofibrate nanocrystallized) 59trihexyphenidyl hcl 29trimethobenzamide hcl 21trimethoprim 10TRINATE (prenatal vits with calciumno73ferrous fumaratefolic acid) 72TRIPLE ANTIBIOTIC 11TRIPLE ANTIBIOTIC (neomycinsulfatebacitracin zincpolymyxin b) 11triprolidine hclpseudoephedrine hcl(APRODINE) 129triprolidine hclpseudoephedrine hcl (ED A-HIST PSE) 129
triprolidine hclpseudoephedrine hcl(RITIFED) 129triprolidine hclpseudoephedrine hcl (WAL-ACT D COLD amp ALLERGY) 129TRIUMEQ (abacavir sulfatedolutegravirsodiumlamivudine) 39TRIZIVIR (abacavirsulfatelamivudinezidovudine) 38TROGARZO (ibalizumab-uiyk) 39trospium chloride 86TROSPIUM CHLORIDE 86TRULICITY 44TRULICITY (dulaglutide) 44TRUMENBA (neisseria meningitidis group blipidated fhbp recombinant) 108TRUVADA (emtricitabinetenofovir disoproxilfumarate) 39TWINRIX (hepatitis a virus and hepatitis b virusvaccinepf) 108TYBOST (cobicistat) 39
UUNIFINE PENTIPS MAXFLOW 112UNITHROID (levothyroxine sodium) 103URETRON D-S (methenaminemethylenebluesod phospsalicylatehyoscyamine) 11URINARY PAIN RELIEF 87ursodiol 80
Vvalacyclovir hcl 41valproic acid 15VALPROIC ACID 15valproic acid (as sodium salt) (valproatesodium) 15valsartan 52valsartanhydrochlorothiazide 57VANADOM 130VANDAZOLE (metronidazole) 11VAQTA (hepatitis a virus vaccinepf) 109
LAST UPDATED 12012020158
VARIVAX VACCINE (varicella virus vaccinelivepf) 109VEMLIDY (tenofovir alafenamide) 35venlafaxine hcl 19VENLAFAXINE HCL ER 19verapamil hcl 55VERSACLOZ (clozapine) 35VICTOZA 2-PAK (liraglutide) 44VICTOZA 3-PAK (liraglutide) 44VIRACEPT (nelfinavir mesylate) 41VIRAMUNE (nevirapine) 38VIRAMUNE XR (nevirapine) 38VIREAD (tenofovir disoproxil fumarate) 39VITAMIN B-12 77VITAMIN C 77VITEKTA (elvitegravir) 36VIVITROL (naltrexone microspheres) 7VONVENDI (von willebrand factor(recombinant)) 50VRAYLAR (cariprazine hcl) 34
Wwarfarin sodium 46warfarin sodium (JANTOVEN) 46WILATE (antihemophilic factor humanvonwillebrand factorhuman) 50
XXARELTO (rivaroxaban) 4647XYNTHA (antihemophilic factor (factor viii)recombb-domain deleted) 51XYNTHA SOLOFUSE (antihemophilic factor(factor viii) recombb-domain deleted) 51
Zzaleplon 130ZERIT (stavudine) 39ZIAGEN (abacavir sulfate) 39ziprasidone hcl 34ZIPRASIDONE HCL 34ZIPRASIDONE MESYLATE 34
ziprasidone mesylate 34zolpidem tartrate 130zonisamide 14ZOSTAVAX (zoster vaccine livepf) 109ZOVIA 1-35 100ZUBSOLV (buprenorphine hclnaloxone hcl) 7ZYPREXA (olanzapine) 34ZYPREXA RELPREVV (olanzapine pamoate) 34ZYPREXA ZYDIS (olanzapine) 34
LAST UPDATED 12012020159
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