View
36
Download
0
Category
Preview:
Citation preview
Magellan Rx Standard Formulary
Welcome to Magellan Rx Management’s Standard Formulary. A formulary is a list of covered prescription drugs. Please use this formulary drug list when you receive a prescription from your doctor. This formulary list is not intended to imply coverage and may change over time. Please refer to your plan document for detailed information about your drug benefit coverage.
The formulary is organized by categories depending on the type of medical conditions that they are used to treat. Medications are listed as Tier 1 Generic, Tier 2 preferred Brand, and Tier 3 non-preferred Brand. Medications listed as “Specialty Drugs” are used to treat complex medical conditions that require special handling, administration, and member care management. Depending on your pharmacy benefit design, specialty drugs may be part of a specialty benefit with specific coverage and copay requirements that differ from drugs in Tiers 1 – 3. If you do not have a defined specialty benefit, your copay may be based on whether the drug is Generic or Brand, therefore Tier 1 or Tier 3 copays may apply.
Our Pharmacy and Therapeutics Committee (P&T) and Value Assessment Committee (VAC) dedicates many hours to the clinical analysis and evaluation of peer reviewed literature and medical care guidelines to determine a drug’s safety and efficacy. After this rigorous clinical evaluation, the committee weighs the financial implications of a drug compared to other similar drugs and selects appropriate Tier placement based on the drugs’ safety, efficacy and cost- effectiveness. Please note all drugs on the Formulary Drug List are subjected to periodic review and amendment without notice.
Please keep in mind when a generic medication is chosen, patients pay the lowest copay available under their pharmacy benefit plan. When clinically appropriate, please consider choosing a generic product. If a preferred brand drug from the formulary is prescribed, your copay may be less than if a non-preferred brand drug is prescribed for you.
For the most up-to-date Formulary Drug list visit our website at www.magellanrx.com.
TIER DESCRIPTION
1 Generics
2 Preferred Brands
3 Non-Preferred Brands
TYPE DESCRIPTION
QL Quantity LimitThere is a limit on the amount of this drug that is covered per
prescription, or within a specific time frame.
ST Step Therapy
In some cases, you may be required to first try certain drugs to
treat your medical condition before you move up a “step” to
other drug options.
GL Gender Limit This prescription drug is restricted for a single gender.
AL Age LimitThis prescription drug may only be covered if you meet the
minimum or maximum age limit.
C Custom This drug has unique restrictions.
S Specialty Drug
Specialty drugs are high-cost drugs used to treat complex or
rare conditions. Some examples of the diseases include;
multiple sclerosis, rheumatoid arthritis, hepatitis C, and
hemophilia.
MED Medical Drug
This medication is not on our drug list. Click on the
THERAPEUTIC CLASS or sub class to find covered alternative
medications. If you have questions, please contact member
services.
PR Preventive Medication
Preventive health drugs can help prevent, treat, and manage
several health concerns that can lead to serious illness or
complications in the future. The copays for these products
may vary so check with your plan for further information.
PAGE 2 LAST UPDATED 01/2021
HCRHealth Care Reform
Products
The Affordable Care Act (ACA) requires certain preventive
generic products to be covered at zero dollar copay. This does
not include plans that are grandfathered.
NTINarrow Therapeutic
Indicator
NTI products may have to be monitored by your doctor or
pharmacist more frequently because small changes in doses
can have harmful impacts.
PS Preferred Specialty Preferred Specialty.
PA PA Applies
Your provider is required to get prior authorization before you
fill your prescription, which ensures appropriate use of the
selected drug. Without prior approval, we may not cover this
drug.
B4G Brand For GenericBrand products that would bypass the DAW penalty. The
strategy prefers brands over generics.
HCG High Cost Generic High Cost Generic.
MVB Minimal Value Brand Minimal Value Brand.
MV Minimal Value Generic Minimal Value Generic.
NFD Non-FDA Approved Non-FDA Approved.
BSP Benefit Shift Program Benefit Shift Program.
SBA Select Brand Alternative Select Brand Alternative
PS1 Preferred 1st line
PS2 Preferred 2nd line
PAGE 3 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)
NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS
CAFERGOT 3 SBA Select BrandAlternative
D.H.E.45 3
QL 10 / 30 days
MED Medical Drug
PA
DIBENZYLINE 3
PR
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
dihydroergotamine 1 mg/ml amp 1PA
BSP BENEFIT SHIFTPROGRAM
dihydroergotamine 4 mg/ml spry 1QL 8 / 30 days
PA
ergoloid mesylates 1
ERGOMAR 3
ergotamine-caffeine 1
MIGERGOT 3QL 0.72 / day
MVB MINIMALVALUE BRAND
MIGRANAL 3
QL 8 / 30 days
PA
MVB MINIMALVALUE BRAND
phenoxybenzamine hcl 1
HCG
MVGMINIMALVALUEGENERIC
PAGE 4 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
phentolamine mesylate 1 MED Medical Drug
SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT
alfuzosin hcl er 1QL 1 / day
GL Male
FLOMAX 3QL 2 / day
ST
RAPAFLO 3
QL 1 / day
GL Male
SBA Select BrandAlternative
silodosin 1QL 1 / day
GL Male
tamsulosin hcl 1 QL 2 / day
UROXATRAL 3
QL 1 / day
GL Male
SBA Select BrandAlternative
ANALGESICS AND ANTIPYRETICS
ANALGESICS AND ANTIPYRETICS, MISC.
acetaminophen (325mg/32.5ml syr, 500 mg/50 ml syr,650 mg/65 ml bag) 1 MED Medical Drug
ALLZITAL 3
QL 12 / day
HCG
MVB Minimal ValueBrand
BUPAP 1 QL 6 / day
butalbital-acetaminophn 50-300 1
QL 6 / day
HCG
MVGMINIMALVALUEGENERIC
PAGE 5 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
butalbital-acetaminophn 25-325 1 QL 12 / day
butalbital-acetaminophn 50-325 1 QL 6 / day
butalbital-acetaminophen-caffe 1 QL 6 / day
clonidine hcl (1,000 mcg/10 ml vial, 5,000 mcg/10 ml vial) 1 MED Medical Drug
CORICIDIN HBP COLD AND FLU 3
DURACLON 3 MED Medical Drug
ESGIC CAPSULE 1
QL 6 / day
HCG
MVGMINIMALVALUEGENERIC
ESGIC 50-325-40 MG TABLET 3QL 6 / day
SBA Select BrandAlternative
FIORICET 3
QL 6 / day
ST
SBA Select BrandAlternative
GRALISE 30-DAY STARTER PACK 3 ST
GRALISE ER 300 MG TABLET 3QL 1 / day
ST
GRALISE ER 600 MG TABLET 3QL 3 / day
ST
LYRICA CR (CR 82.5 MG TABLET, CR 165 MG TABLET) 3
QL 3 / day
PA
MVB MINIMALVALUE BRAND
LYRICA CR 330 MG TABLET 3
QL 2 / day
PA
MVB MINIMALVALUE BRAND
PAGE 6 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PHRENILIN FORTE 1 QL 6 / day
PRIALT 3S
MED Medical Drug
TENCON 1 QL 6 / day
VANATOL LQ 3
VTOL LQ 1
ZEBUTAL 1 QL 6 / day
OPIATE AGONISTS
ABSTRAL 3
QL 4 / day
AL At least 18 yrsold
PA
MVB MINIMALVALUE BRAND
acetamn-caf-dihydrcodein 320.5 1QL 10 / day
AL At least 18 yrsold
acetamin-caf-dihydrocodein 325 1
QL 10 / day
AL At least 18 yrsold
HCG
MVGMINIMALVALUEGENERIC
acetamin-codein 300-30 mg/12.5 1QL 139 / day
AL At least 12 yrsold
acetaminop-codeine 120-12 mg/5 1QL 140 / day
AL At least 12 yrsold
PAGE 7 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
acetaminophen-cod #2 tablet 1QL 22 / day
AL At least 12 yrsold
acetaminophen-cod #3 tablet 1QL 12 / day
AL At least 12 yrsold
acetaminophen-cod #4 tablet 1QL 6 / day
AL At least 12 yrsold
ACTIQ 3
QL 4 / day
AL At least 18 yrsold
PA
SBA Select BrandAlternative
APADAZ 3
QL 12 / day
AL At least 18 yrsold
SBA Select BrandAlternative
ARYMO ER 3QL 3 / day
PA
asa-butalb-caffeine-codeine 1QL 6 / day
AL At least 18 yrsold
ASCOMP WITH CODEINE 1QL 6 / day
AL At least 18 yrsold
belladonna-opium 16.2-30 supp 1 QL 2 / day
belladonna-opium 16.2-60 supp 1 QL 1 / day
benzhydrocodone-acetaminophen 1QL 12 / day
AL At least 18 yrsold
PAGE 8 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
butalb-acetaminoph-caff-codein 1 QL 6 / day
butalbital compound-codeine 1QL 6 / day
AL At least 18 yrsold
codeine sulfate 1QL 6 / day
AL At least 18 yrsold
CONZIP (100 MG CAPSULE, 200 MG CAPSULE, 300 MGCAPSULE) 3
QL 1 / day
AL At least 18 yrsold
PA
MVB Minimal ValueBrand
DEMEROL (25 MG/0.5 ML AMPUL, 50 MG/ML AMPUL, 50MG/ML CARPUJECT, 50 MG/ML VIAL, 75 MG/1.5 MLAMPUL, 100 MG/2 ML AMPUL)
3
QL 10 / day
AL At least 18 yrsold
MED Medical Drug
DEMEROL 25 MG/ML CARPUJECT 3
QL 20 / day
AL At least 18 yrsold
MED Medical Drug
DEMEROL 75 MG/ML CARPUJECT 3QL 7 / day
AL At least 18 yrsold
DEMEROL 100 MG TABLET 3
QL 5 / day
AL At least 18 yrsold
SBA Select BrandAlternative
DEMEROL (100 MG/ML AMPUL, 100 MG/ML CARPUJECT,100 MG/ML VIAL) 3
QL 5 / day
AL At least 18 yrsold
MED Medical Drug
PAGE 9 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DILAUDID 5 MG/5 ML ORAL LIQUID 3
QL 13 / day
AL At least 18 yrsold
SBA Select BrandAlternative
DILAUDID (0.2 MG/ML SYRINGE, 0.5 MG/0.5 ML SYRINGE,1 MG/ML SYRINGE, 2 MG/ML SYRINGE, 4 MG/MLSYRINGE)
3AL At least 18 yrs
oldMED Medical Drug
DILAUDID (2 MG TABLET, 4 MG TABLET, 8 MG TABLET) 3
QL 6 / day
AL At least 18 yrsold
SBA Select BrandAlternative
DOLOPHINE HCL 3QL 3 / day
PA
DSUVIA 3 MED Medical Drug
DURAGESIC 3QL 0.5 / day
PA
DURAMORPH 10 MG/10 ML AMPUL 1QL 5 / day
MED Medical Drug
DURAMORPH 5 MG/10 ML AMPUL 1QL 10 / day
MED Medical Drug
DVORAH 3
QL 10 / day
AL At least 18 yrsold
MVB Minimal ValueBrand
ENDOCET (5-325 TABLET, 7.5-325 MG TABLET, 10-325 MGTABLET) 1
QL 12 / day
AL At least 18 yrsold
HCG
PAGE 10 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ENDOCET 2.5-325 MG TABLET 1QL 12 / day
AL At least 18 yrsold
EXALGO 3
QL 2 / day
PA
SBA Select BrandAlternative
fentanyl (12 mcg/hr patch, 25 mcg/hr patch, 50 mcg/hrpatch, 75 mcg/hr patch, 87.5 mcg/hr patch, 100 mcg/hrpatch)
1QL 0.5 / day
PA
fentanyl (37.5 mcg/hr patch, 62.5 mcg/hr patch) 1
QL 0.5 / day
PA
HCG
fentanyl 100 mcg/2 ml carpujct 1 QL 8 / day
fentanyl citrate otfc 800 mcg 1
QL 4 / day
AL At least 18 yrsold
PA
fentanyl citrate (1,000 mcg/20 ml, 1,250 mcg/25 ml) 1 MED Medical Drug
fentanyl citrate (100 mcg/2 ml syringe, 1,500 mcg/30 mlsyr) 1
QL 8 / day
MED Medical Drug
fentanyl citrate (cit 100 mcg buccal tb, cit 200 mcg buccaltb, cit 400 mcg buccal tb, cit 600 mcg buccal tb, cit 800mcg buccal tb, cit otfc 1,200 mcg, cit otfc 1,600 mcg,citrate otfc 200 mcg, citrate otfc 400 mcg, citrate otfc 600mcg)
1
QL 4 / day
AL At least 18 yrsold
PA
HCG
fentanyl 1,375 mcg/55-0.9%nacl 1QL 15 / day
MED Medical Drug
fentanyl 600 mcg/30ml-0.9%nacl 1QL 19 / day
MED Medical Drug
PAGE 11 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fentanyl citrate-0.9% nacl (5 mcg/ml-0.9% nacl, 25mcg/2.5ml-0.9%nacl, 50 mcg/5 ml-0.9% nacl, 500mcg/50ml-0.9%nacl, 1,000 mcg/100 ml-ns, 1,000mcg/50-0.9% nacl, 1,100 mcg/55 ml-ns, 1,100 mcg/55-0.9%nacl,1,250 mcg/25 ml-ns, 1,250 mcg/50-0.9%nacl,1,250mcg/125-0.9%nacl, 1,250mcg/250-0.9%nacl,2,500mcg/100-0.9%nacl, 5,000mcg/250-0.9%nacl)
1 MED Medical Drug
fentanyl citrate-0.9% nacl (10 mcg/ml-0.9% nacl,1,000mcg/100-0.9%nacl) 1
QL 38 / day
MED Medical Drug
fentanyl 2 mcg-bupivac 0.1%-ns 1 MED Medical Drug
FENTORA 3
QL 4 / day
AL At least 18 yrsold
PA
MVB MINIMALVALUE BRAND
SBA Select BrandAlternative
FIORINAL WITH CODEINE #3 3
QL 6 / day
AL At least 18 yrsold
SBA Select BrandAlternative
hydrocodone bitartrate er 1QL 2 / day
PA
hydrocodone er 10 mg capsule (persion-macoven) 1QL 2 / day
PA
hydrocodone er 15 mg capsule (persion-macoven) 1QL 2 / day
PA
hydrocodone er 30 mg capsule (persion-macoven) 1QL 2 / day
PA
PAGE 12 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
hydrocodone er 40 mg capsule (persion-macoven) 1QL 2 / day
PA
hydrocodone er 50 mg capsule (persion-macoven) 1QL 2 / day
PA
hydrocodone-acetamin 10-325/15 1 AL At least 2 yrsold
hydrocodone-acetaminophen (2.5-108/5, 5-217/10) 1QL 180/day
AL At least 2 yrsold
hydrocodone-acetamn 7.5-325/15 1
QL 180/day
AL At least 2 yrsold
HCG
hydrocodone-acetamin 2.5-325 1QL 20 / day
AL At least 18 yrsold
hydrocodone-acetaminophen (5-300 mg, 7.5-300, 10-300mg) 1
QL 13 / day
AL At least 18 yrsold
HCG
hydrocodone-acetaminophen (5-325 mg, 7.5-325, 10-325mg) 1
QL 12 / day
AL At least 18 yrsold
hydrocodone-ibuprofen 10-200 1
QL 5 / day
AL At least 16 yrsold
HCG
hydrocodone-ibuprofen 5-200 mg 1
QL 6 / day
AL At least 16 yrsold
HCG
PAGE 13 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
hydrocodone-ibuprofen 7.5-200 1QL 5 / day
AL At least 16 yrsold
hydromor 5 mcg-bupiva 0.1%-ns 1QL 10 / day
MED Medical Drug
hydromorp 20 mcg-bupiv 0.1%-ns 1QL 3 / day
MED Medical Drug
hydromorph-bupivac-0.9% nacl (10 mcg-bupiva 0.1%-ns,20 mcg-bupi 0.125%-ns) 1 MED Medical Drug
hydromorph-ropiva-0.9% nacl 1QL 6 / day
MED Medical Drug
hydromorphone er 1
QL 2 / day
PA
HCG
hydromorphone hcl 1 mg/ml amp 1QL 13 / day
MED Medical Drug
hydromorphone hcl 4 mg/ml amp 1QL 3 / day
MED Medical Drug
hydromorphone 4 mg/ml carpujct 1
QL 3 / day
AL At least 18 yrsold
MED Medical Drug
hydromorphone hcl (1 mg/ml solution, 5 mg/5 ml soln) 1
QL 13 / day
AL At least 18 yrsold
HCG
hydromorphone 0.5 mg/0.5 ml 1
QL 50 / day
AL At least 18 yrsold
MED Medical Drug
PAGE 14 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
hydromorphone hcl (1 mg/ml carpujct, 1 mg/ml syringe) 1
QL 13 / day
AL At least 18 yrsold
MED Medical Drug
hydromorphone hcl (2 mg/ml carpujct, 2 mg/ml isecure) 1
QL 6 / day
AL At least 18 yrsold
MED Medical Drug
hydromorphone hcl (2 mg tablet, 4 mg tablet, 8 mgtablet) 1
QL 6 / day
AL At least 18 yrsold
hydromorphone hcl (2 mg/ml vial, hcl 2 mg/ml amp, 60mg/30 ml syr) 1
QL 6 / day
MED Medical Drug
hydromorphone 25 mg/25 ml-ns 1 MED Medical Drug
hydromorphone hcl-0.9% nacl (1 mg/5 ml-ns, 12 mg/30ml-ns, 250 mg/250 ml-ns) 1 MED Medical Drug
hydromorphone hcl-0.9% nacl (10 mg/50 ml-ns, 50 mg/50ml-ns) 1
QL 1 / day
MED Medical Drug
hydromorphone hcl-0.9% nacl (15 mg/30 ml-ns, 25 mg/50ml-ns) 1
QL 25 / day
MED Medical Drug
hydromorphone hcl-0.9% nacl (30 mg/30 ml-ns, 55 mg/55ml-ns) 1
QL 13 / day
MED Medical Drug
hydromorphone 0.5 mg/50 ml-ns 1QL 5000 / day
MED Medical Drug
hydromorphone 1 mg/50 ml-ns 1QL 50 / day
MED Medical Drug
hydromorphone 2 mg/50 ml-ns 1QL 313 / day
MED Medical Drug
PAGE 15 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
hydromorphone hcl-0.9% nacl (100 mg/50 ml-ns, 200mg/100 ml-ns) 1
QL 6 / day
MED Medical Drug
hydromorphone hcl-0.9% nacl (6 mg/30 ml-ns, 20 mg/100ml-ns) 1
QL 63 / day
MED Medical Drug
HYSINGLA ER 3QL 1 / day
PA
IBUDONE 10-200 MG TABLET 3
QL 5 / day
AL At least 16 yrsold
SBA Select BrandAlternative
IBUDONE 5-200 MG TABLET 1QL 6 / day
AL At least 16 yrsold
KADIAN (ER 10 MG CAPSULE, ER 20 MG CAPSULE, ER 50MG CAPSULE, ER 100 MG CAPSULE) 3
QL 2 / day
PA
SBA Select BrandAlternative
KADIAN (ER 30 MG CAPSULE, ER 40 MG CAPSULE, ER 60MG CAPSULE, ER 80 MG CAPSULE) 3
QL 1 / day
PA
SBA Select BrandAlternative
KADIAN ER 200 MG CAPSULE 3QL 1 / day
PA
LAZANDA 3
QL 1 / day
AL At least 18 yrsold
PA
MVB MINIMALVALUE BRAND
LORCET 1QL 12 / day
AL At least 18 yrsold
PAGE 16 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LORCET HD 1QL 12 / day
AL At least 18 yrsold
LORCET PLUS 1QL 12 / day
AL At least 18 yrsold
LORTAB 3QL 90 / day
AL At least 2 yrsold
meperidine 10 mg/ml cartrdge 1
QL 50 / day
AL At least 18 yrsold
MED Medical Drug
meperidine 50 mg/5 ml solution 1QL 50 / day
AL At least 18 yrsold
meperidine 100 mg tablet 1QL 5 / day
AL At least 18 yrsold
meperidine 50 mg tablet 1QL 10 / day
AL At least 18 yrsold
meperidine 100 mg/ml vial 1
QL 5 / day
AL At least 18 yrsold
MED Medical Drug
meperidine 25 mg/ml vial 1
QL 20 / day
AL At least 18 yrsold
MED Medical Drug
meperidine 50 mg/ml vial 1
QL 10 / day
AL At least 18 yrsold
MED Medical Drug
PAGE 17 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
meperidine 300 mg/30 ml-ns syr 1 MED Medical Drug
meperidine 550 mg/55 ml-ns syr 1QL 50 / day
MED Medical Drug
methadone 10 mg/ml oral conc 1QL 2 / day
PA
methadone 10 mg/5 ml solution 1QL 8 / day
PA
methadone 5 mg/5 ml solution 1QL 18 / day
PA
methadone hcl 10 mg/ml syringe 1
QL 2 / day
MED Medical Drug
PA
methadone hcl (5 mg tablet, 10 mg tablet) 1QL 3 / day
PA
methadone hcl (10 mg/ml vial, 200 mg/20 ml vl) 1QL 2 / day
MED Medical Drug
METHADONE INTENSOL 1QL 2 / day
PA
METHADOSE 10 MG/ML ORAL CONC 3QL 2 / day
PA
MORPHABOND ER 3QL 2 / day
PA
morphine 2 mg/ml carpuject 1
QL 25 / day
MED Medical Drug
PA
HCG
PAGE 18 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
morphine sulfate (5 mg/ml syringe, 5 mg/ml vial) 1
QL 10 / day
MED Medical Drug
PA
morphine sulfate (sulfate 1 mg/ml vial, 10 mg/10 ml vial) 1
QL 50 / day
MED Medical Drug
PA
morphine 10 mg/0.7 ml auto-inj 1
QL 3 / day
MED Medical Drug
PA
morphine sulf 10 mg/5 ml soln 1 QL 25 / day
morphine sulf 100 mg/5 ml conc 1 QL 3 / day
morphine sulf 20 mg/5 ml soln 1 QL 13 / day
morphine sulf 10 mg suppos 1 QL 5 / day
morphine sulfate (10 mg/ml carpuject, 10 mg/ml isecuresyrg, 10 mg/ml syringe, sulfate 10 mg/ml vial, 100 mg/10ml vial)
1
QL 5 / day
MED Medical Drug
PA
morphine sulfate (2 mg/ml isecure syr, 2 mg/ml syringe) 1
QL 25 / day
MED Medical Drug
PA
morphine sulfate (4 mg/ml carpuject, 4 mg/ml isecure syr,4 mg/ml syringe, sulfate 4 mg/ml vial) 1
QL 13 / day
MED Medical Drug
PA
morphine sulfate (8 mg/ml carpuject, 8 mg/ml isecuresyrng, 8 mg/ml syringe, sulfate 8 mg/ml vial) 1
QL 6 / day
MED Medical Drug
PA
morphine sulfate ir 15 mg tab 1QL 3 / day
AL At least 18 yrsold
PAGE 19 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
morphine sulfate ir 30 mg tab 1QL 2 / day
AL At least 18 yrsold
morphine sulfate (1 mg/2 ml syringe, 5 mg/10 ml vial) 1
QL 100 / day
MED Medical Drug
PA
morphine sulfate er (er 10 mg cap, er 20 mg cap, er 50 mgcap, er 100 mg cap) 1
QL 2 / day
PA
morphine sulfate er (er 30 mg cap, er 45 mg cap) 1QL 1 / day
PA
morphine sulfate er (er 40 mg cap, er 60 mg cap, er 75 mgcap, er 80 mg cap, er 90 mg cap, er 120 mg cap) 1
QL 1 / day
PA
HCG
morphine sulf er 200 mg tablet 1
QL 3 / day
PA
HCG
morphine sulfate er (er 15 mg tablet, er 30 mg tablet, er60 mg tablet, er 100 mg tablet) 1
QL 3 / day
PA
morphine 300 mg/30ml-0.9% nacl 1
QL 5 / day
MED Medical Drug
PA
morphine sulfate-0.9% nacl (150 mg/30 ml-0.9%nacl, 250mg/50 ml-ns, 250mg/250ml-0.9% nacl, 275 mg/55 ml-0.9%nacl)
1MED Medical Drug
PA
morphine 1,000 mg/100 ml-ns 1 MED Medical Drug
morphine sulfate-0.9% nacl (1 mg/ml-0.9% nacl syr, 2mg/2 ml-0.9% nacl, 10 mg/10 ml-ns syrng, 30 mg/30 ml-0.9% nacl, 50 mg/50 ml-0.9% nacl, 100mg/100ml-0.9%nacl)
1
QL 50 / day
MED Medical Drug
PA
PAGE 20 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
morphine sulfate-0.9% nacl (500mg/100ml-0.9% nacl,1,250 mg/250 ml-ns) 1
QL 10 / day
MED Medical Drug
PA
morphine 0.5 mg/0.5ml-0.9%nacl 1
QL 100/ day
MED Medical Drug
PA
morphine 0.5 mg/ml-0.9% nacl 1
QL 100 / day
MED Medical Drug
PA
morphine sulfate-d5w 1MED Medical Drug
PA
MS CONTIN 3
QL 3 / day
PA
SBA Select BrandAlternative
NALOCET 3
QL 12 / day
AL At least 18 yrsold
MVB Minimal ValueBrand
NORCO 3
QL 12 / day
AL At least 18 yrsold
SBA Select BrandAlternative
NUCYNTA (50 MG TABLET, 75 MG TABLET) 3QL 6 / day
AL At least 18 yrsold
NUCYNTA 100 MG TABLET 3QL 7 / day
AL At least 18 yrsold
PAGE 21 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NUCYNTA ER 3
QL 2 / day
AL At least 18 yrsold
PA
OLINVYK (1 MG/ML VIAL, 2 MG/2 ML VIAL, 30 MG/30 MLPCA VIAL) 1 MED Medical Drug
OPANA 3
QL 12 / day
AL At least 18 yrsold
SBA Select BrandAlternative
OXAYDO 3QL 8 / day
AL At least 18 yrsold
oxycodone hcl 5 mg capsule 1
QL 8 / day
AL At least 18 yrsold
HCG
oxycodone hcl 100 mg/5 ml conc 1QL 2 / day
HCG
oxycodone hcl 5 mg/5 ml soln 1QL 33 / day
HCG
oxycodone hcl (5 mg tablet, 10 mg tablet, 15 mg tablet,20 mg tablet, 30 mg tablet) 1
QL 8 / day
AL At least 18 yrsold
oxycodone hcl-aspirin 1QL 7 / day
AL At least 18 yrsold
oxycodone hcl-ibuprofen 1QL 4 / day
AL At least 18 yrsold
PAGE 22 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
oxycodon-acetaminophen 2.5-325 1
QL 12 / day
AL At least 18 yrsold
HCG
oxycodone-acetaminophen (oxycodon-acetaminophen2.5-300, oxycodon-acetaminophen 7.5-325, oxycodone-acetaminophen 5-325, oxycodone-acetaminophen 10-325)
1QL 12 / day
AL At least 18 yrsold
oxymorphone hcl 1QL 12 / day
AL At least 18 yrsold
oxymorphone hcl er (er 5 mg tablet, er 10 mg tab, er 15mg tab, er 20 mg tab, er 30 mg tab, er 40 mg tab) 1
QL 2 / day
AL At least 18 yrsold
PA
HCG
oxymorphone hcl er 7.5 mg tab 1
QL 2 / day
AL At least 18 yrsold
PA
PERCOCET 3
QL 12 / day
AL At least 18 yrsold
SBA Select BrandAlternative
PRIMLEV 10-300 MG TABLET 3
QL 3 / day
AL At least 18 yrsold
MVB MINIMALVALUE BRAND
PRIMLEV 5-300 MG TABLET 3
QL 7 / day
AL At least 18 yrsold
MVB MINIMALVALUE BRAND
PAGE 23 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PRIMLEV 7.5-300 MG TABLET 3QL 4 / day
AL At least 18 yrsold
PROLATE 3QL 13 / day
AL At least 18 yrsold
ROXICODONE 3
QL 8 / day
AL At least 18 yrsold
SBA Select BrandAlternative
ROXYBOND (15 MG TABLET, 30 MG TABLET) 3 QL 6 / day
ROXYBOND 5 MG TABLET 3 QL 8 / day
SUBSYS 3
QL 12 / day
AL At least 18 yrsold
PA
MVB MINIMALVALUE BRAND
tramadol hcl 100 mg tablet 1QL 4 / day
AL At least 18 yrsold
tramadol hcl 50 mg tablet 1QL 8 / day
AL At least 18 yrsold
tramadol hcl er (er 100 mg capsule, er 200 mg capsule, er300 mg capsule) 1
QL 1 / day
AL At least 18 yrsold
PA
HCG
PAGE 24 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
tramadol hcl er (er 100 mg tablet, er 200 mg tablet, er300 mg tablet, hcl er 100 mg tablet, hcl er 150 mgcapsule, hcl er 200 mg tablet, hcl er 300 mg tablet)
1
QL 1 / day
AL At least 18 yrsold
PA
tramadol hcl-acetaminophen 1QL 8 / day
AL At least 18 yrsold
TREZIX 3QL 10 / day
AL At least 18 yrsold
TYLENOL-CODEINE NO.3 3QL 12 / day
AL At least 12 yrsold
TYLENOL-CODEINE NO.4 3QL 6 / day
AL At least 12 yrsold
ULTRACET 3QL 8 / day
AL At least 18 yrsold
ULTRAM 3
QL 8 / day
AL At least 18 yrsold
SBA Select BrandAlternative
VICODIN 1
QL 13 / day
AL At least 18 yrsold
HCG
MVGMINIMALVALUEGENERIC
VICODIN HP 1
QL 13 / day
AL At least 18 yrsold
HCG
MVGMINIMALVALUEGENERIC
PAGE 25 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
XTAMPZA ER 2QL 2 / day
PA
ZOHYDRO ER 3QL 2 / day
PA
OPIATE PARTIAL AGONISTS
BELBUCA 3
QL 2 / day
AL At least 18 yrsold
PA
BUNAVAIL (2.1-0.3 MG FILM, 6.3-1 MG FILM) 3QL 3 / day
PA
BUNAVAIL 4.2-0.7 MG FILM 3QL 2 / day
PA
BUPRENEX 3QL 17 / day
MED Medical Drug
buprenorphine 1QL 0.144 / day
PA
buprenorphine 0.3 mg/ml crpjct 1 QL 17 / day
buprenorphine hcl (2 mg tablet, 8 mg tablet) 1QL 3 / day
PA
buprenorphine 0.3 mg/ml vial 1QL 17 / day
MED Medical Drug
buprenorphine-naloxone (buprenor-nalox 12-3 mg film,buprenorp-nalox 4-1 mg film) 1
QL 2 / day
PA
buprenorphine-naloxone (bupreno-nalox 2-0.5 mg film,buprenorp-nalox 8-2 mg film, buprenorphin-naloxon 8-2mg, buprenorphn-naloxn 2-0.5 mg)
1QL 3 / day
PA
PAGE 26 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
butorphanol 10 mg/ml spray 1QL 0.3 / day
AL At least 18 yrsold
butorphanol 1 mg/ml vial 1
QL 7 / day
AL At least 18 yrsold
MED Medical Drug
butorphanol tartrate (2 mg/ml vial, 4 mg/2 ml vial) 1
QL 4 / day
AL At least 18 yrsold
MED Medical Drug
BUTRANS 3QL 0.144 / day
PA
nalbuphine hcl (10 mg/ml ampul, 100 mg/10 ml vial) 1QL 5 / day
BSP BENEFIT SHIFTPROGRAM
nalbuphine hcl (20 mg/ml ampul, 200 mg/10 ml vial) 1QL 3 / day
BSP BENEFIT SHIFTPROGRAM
pentazocine-naloxone hcl 1QL 12 / day
AL At least 12 yrsold
SUBLOCADE 100 MG/0.5 ML SYRING 3
QL 0.02 / day
S
MED Medical Drug
PA
SUBLOCADE 300 MG/1.5 ML SYRING 3
QL 0.057 / day
S
MED Medical Drug
PA
PAGE 27 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SUBOXONE (2 MG-0.5 MG FILM, 8 MG-2 MG FILM) 3QL 3 / day
PA
SUBOXONE (4 MG-1 MG FILM, 12 MG-3 MG FILM) 3QL 2 / day
PA
TALWIN 3QL 5 / day
MED Medical Drug
ZUBSOLV 2QL 3 / day
PA
ANOREXIGENIC AGENTS
AMPHETAMINE DERIVATIVES
ADIPEX-P 37.5 MG CAPSULE 3
QL 2 / day
AL At least 17 yrsold
PA
ADIPEX-P 37.5 MG TABLET 3
QL 2 / day
AL At least 17 yrsold
PA
SBA Select BrandAlternative
diethylpropion hcl 1
QL 3 / day
AL At least 16 yrsold
PA
diethylpropion hcl er 1QL 1 / day
PA
LOMAIRA 1
QL 3 / day
AL At least 17 yrsold
PA
PAGE 28 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
phendimetrazine tartrate 1QL 3 / day
PA
phendimetrazine tartrate er 1QL 1 / day
PA
phentermine hcl (15 mg capsule, 30 mg capsule) 1QL 1 / day
PA
phentermine hcl (37.5 mg capsule, 37.5 mg tablet) 1
QL 2 / day
AL At least 17 yrsold
PA
QSYMIA 3
QL 1 / day
AL At least 18 yrsold
PA
ANOREXIGENIC AGENTS, MISCELLANEOUS
CONTRAVE 3
QL 4 / day
AL At least 18 yrsold
PA
SELECTIVE SEROTONIN RECEPTOR AGONISTS
BELVIQ 3
QL 2 / day
AL At least 18 yrsold
PA
BELVIQ XR 3
QL 1 / day
AL At least 18 yrsold
PA
PAGE 29 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANOREXIGENICS;RESPIRATORY,CNS STIMULANTS
AMPHETAMINES
ADDERALL (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET,12.5 MG TABLET, 15 MG TABLET, 20 MG TABLET) 3
QL 3 / day
ST
ADDERALL 30 MG TABLET 3QL 2 / day
ST
ADDERALL XR 3QL 2 / day
ST
ADZENYS ER 3
QL 15 / day
ST
AL At least 6 yrsold
ADZENYS XR-ODT 3
QL 1 / day
ST
AL At least 6 yrsold
amphetamine 3
QL 15 / day
ST
AL At least 6 yrsold
amphetamine sulfate 1 QL 6 / day
benzphetamine hcl 25 mg tablet 1
QL 3 / day
AL At least 12 yrsold
PA
benzphetamine hcl 50 mg tablet 1QL 3 / day
PA
DESOXYN 3
QL 5 / day
ST
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
PAGE 30 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DEXEDRINE SPANSULE 10 MG 3QL 5 / day
ST
DEXEDRINE SPANSULE 15 MG 3QL 4 / day
ST
DEXEDRINE SPANSULE 5 MG 3QL 2 / day
ST
dextroamphetamine 5 mg/5 ml 1 QL 60 / day
dextroamphetamine 10 mg tab 1 QL 6 / day
dextroamphetamine 5 mg tab 1 QL 2 / day
dextroamphetamine er 10 mg cap 1 QL 5 / day
dextroamphetamine er 15 mg cap 1 QL 4 / day
dextroamphetamine er 5 mg cap 1 QL 2 / day
dextroamphetamine-amphet er 1 QL 2 / day
dextroamp-amphetamin 30 mg tab 1 QL 2 / day
dextroamphetamine-amphetamine (dextroamp-amphetam 7.5 mg tab, dextroamp-amphetam 12.5 mgtab, dextroamp-amphetamin 10 mg tab, dextroamp-amphetamin 15 mg tab, dextroamp-amphetamin 20 mgtab, dextroamp-amphetamine 5 mg tab)
1 QL 3 / day
DYANAVEL XR 3
QL 8 / day
ST
AL At least 6 yrsold
EVEKEO 3QL 6 / day
ST
EVEKEO ODT (ODT 5 MG, ODT 10 MG) 3QL 6 / day
ST
PAGE 31 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EVEKEO ODT 15 MG 3QL 4 / day
ST
EVEKEO ODT 20 MG 3QL 3 / day
ST
methamphetamine hcl 1QL 5 / day
HCG
MYDAYIS 3QL 1 / day
ST
PROCENTRA 3QL 60 / day
ST
REGIMEX 3
QL 3 / day
AL At least 12 yrsold
PA
VYVANSE (10 MG CAPSULE, 10 MG CHEWABLE TABLET,20 MG CAPSULE, 20 MG CHEWABLE TABLET, 30 MGCAPSULE, 30 MG CHEWABLE TABLET, 40 MG CAPSULE, 40MG CHEWABLE TABLET, 50 MG CAPSULE, 50 MGCHEWABLE TABLET, 60 MG CAPSULE, 60 MG CHEWABLETABLET, 70 MG CAPSULE)
2 QL 1 / day
ZENZEDI (15 MG TABLET, 30 MG TABLET) 3QL 2 / day
ST
ZENZEDI (2.5 MG TABLET, 20 MG TABLET) 3QL 3 / day
ST
ZENZEDI 10 MG TABLET 1 QL 6 / day
ZENZEDI 5 MG TABLET 1 QL 2 / day
ZENZEDI 7.5 MG TABLET 3QL 8 / day
ST
PAGE 32 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RESPIRATORY AND CNS STIMULANTS
ADHANSIA XR 3QL 1 / day
ST
APTENSIO XR 3QL 1 / day
ST
caffeine cit 60 mg/3 ml oral 1
HCG
MVGMINIMALVALUEGENERIC
CONCERTA (ER 18 MG TABLET, ER 27 MG TABLET, ER 36MG TABLET) 3
QL 2 / day
ST
CONCERTA ER 54 MG TABLET 3QL 1 / day
ST
COTEMPLA XR-ODT 3QL 1 / day
ST
DAYTRANA 3QL 1 / day
ST
dexmethylphenidate 10 mg tab 1 QL 2 / day
dexmethylphenidate hcl (2.5 mg tab, 5 mg tab) 1 QL 3 / day
dexmethylphenidate er 20 mg cp 1 QL 2 / day
dexmethylphenidate hcl er (er 5 mg cap, er 10 mg cp, er15 mg cp, er 25 mg cp, er 30 mg cp, er 35 mg cp, er 40 mgcp)
1 QL 1 / day
DOPRAM 3 MED Medical Drug
doxapram hcl 1 MED Medical Drug
FOCALIN (2.5 MG TABLET, 5 MG TABLET) 3QL 3 / day
ST
PAGE 33 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FOCALIN 10 MG TABLET 3QL 2 / day
ST
FOCALIN XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MGCAPSULE, 25 MG CAPSULE, 30 MG CAPSULE, 35 MGCAPSULE, 40 MG CAPSULE)
3QL 1 / day
ST
FOCALIN XR 20 MG CAPSULE 3QL 2 / day
ST
JORNAY PM 3QL 1 / day
ST
METADATE ER 1 QL 3 / day
METHYLIN 10 MG/5 ML SOLUTION 3QL 30 / day
ST
METHYLIN 5 MG/5 ML SOLUTION 3QL 60 / day
ST
methylphenidate er (er 10 mg cap, er 15 mg cap, er 20 mgcap, er 30 mg cap, er 40 mg cap, er 50 mg cap, er 60 mgcap)
1QL 1 / day
ST
methylphenidate er (er 18 mg tab, er 27 mg tab, er 36 mgtab) 1 QL 2 / day
methylphenidate er (er 54 mg tab, er 72 mg tab) 1 QL 1 / day
methylphenidate er 10 mg tab 1 QL 5 / day
methylphenidate er 20 mg tab 1 QL 3 / day
methylphenidate er (la) (10mg cp, 20mg cp, 40mg cp) 1 QL 1 / day
methylphenidate er(la) 30mg cp 1 QL 2 / day
methylphenidate 10 mg/5 ml sol 1 QL 30 / day
methylphenidate 5 mg/5 ml soln 1 QL 60 / day
PAGE 34 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
methylphenidate 2.5 mg chew tb 1
methylphenidate hcl (5 mg chew tab, 10 mg chew tab, 20mg tablet) 1 QL 3 / day
methylphenidate 10 mg tablet 1 QL 5 / day
methylphenidate 5 mg tablet 1 QL 3 / day
methylphenidate cd 30 mg cap 1 QL 2 / day
methylphenidate hcl cd (10 mg cap, 20 mg cap, 40 mgcap, 50 mg cap, 60 mg cap) 1 QL 1 / day
methylphenidate er(cd) 30mg cp 1 QL 2 / day
methylphenidate hcl er (cd) (10mg cp, 20mg cp, 40mg cp,50mg cp, 60mg cp) 1 QL 1 / day
methylphenidate la (10 mg cap, 20 mg cap, 40 mg cap, 60mg cap) 1 QL 1 / day
methylphenidate la 30 mg cap 1 QL 2 / day
QUILLICHEW ER (ER 20 MG CHEW TAB, ER 40 MG CHEWTAB) 3
QL 1 / day
ST
AL At least 6 yrsold
QUILLICHEW ER 30 MG CHEW TAB 3
QL 2 / day
ST
AL At least 6 yrsold
QUILLIVANT XR 3QL 12 / day
ST
RELEXXII 1 QL 1 / day
RITALIN (5 MG TABLET, 20 MG TABLET) 3QL 3 / day
ST
RITALIN 10 MG TABLET 3QL 5 / day
ST
PAGE 35 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RITALIN LA (10 MG CAPSULE, 20 MG CAPSULE, 40 MGCAPSULE) 3
QL 1 / day
ST
RITALIN LA 30 MG CAPSULE 3QL 2 / day
ST
WAKEFULNESS-PROMOTING AGENTS
armodafinil 1QL 1 / day
PA
modafinil 1QL 1 / day
PA
NUVIGIL (150 MG TABLET, 200 MG TABLET, 250 MGTABLET) 3
QL 1 / day
PA
SBA SELECT BRANDALTERNATIVE
NUVIGIL 50 MG TABLET 3QL 1 / day
PA
PROVIGIL 3
QL 1 / day
PA
SBA SELECT BRANDALTERNATIVE
SUNOSI 2
QL 1 / day
AL At least 18 yrsold
PA
WAKIX 3
QL 2 / day
S
PA
PAGE 36 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTI-INFECTIVE AGENTS
ANTHELMINTICS
albendazole 1QL 4 / day
PA
ALBENZA 3
QL 4 / day
PA
SBA Select BrandAlternative
BILTRICIDE 3PA
SBA Select BrandAlternative
EGATEN 3
EMVERM 2 PA
ivermectin 3 mg tablet 1 PA
praziquantel 1 PA
STROMECTOL 3 PA
URINARY ANTI-INFECTIVES
fosfomycin tromethamine 1
FURADANTIN 3
HIPREX 3
MACROBID 3 SBA Select BrandAlternative
MACRODANTIN 3 SBA Select BrandAlternative
methenamine hippurate 1
methenamine mandelate 1
PAGE 37 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MONUROL 3
nitrofurantoin (25 mg/5 ml susp, mcr 25 mg cap, mcr 50mg cap, mcr 100 mg cap) 1
nitrofurantoin mono-macro 1
trimethoprim 1
TRIMPEX 3 QL max 10 days
URIBEL 1
QL 4 / day
HCG
MVGMINIMALVALUEGENERIC
UROGESIC-BLUE 3
ANTI-INFECTIVES (EENT)
ANTIBACTERIALS (EENT)
AK-POLY-BAC 1 QL 0.434 / day
AZASITE 3 QL 0.36/day
BACIGUENT 3 QL 0.434 / day
bacitracin 500 unit/gm ophth 1QL 0.434 / day
HCG
bacitracin-polymyxin 1QL 0.434 / day
HCG
BACTROBAN NASAL 2 PA
BESIVANCE 3 QL 0.767 / day
BLEPH-10 3QL 5 / fill
SBA Select BrandAlternative
PAGE 38 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BLEPHAMIDE 3 QL 5 / fill
BLEPHAMIDE S.O.P. 3 QL 4 / fill
CETRAXAL 3
QL 0.567 / day
ST
MVB Minimal ValueBrand
CILOXAN (EYE DROPS, OINTMENT) 3 QL 0.767 / day
CIPRO HC 3QL 0.434 / day
ST
CIPRODEX 2QL 0.257 / day
B4G
ciprofloxacin 0.2% otic soln 1 QL 0.567 / day
ciprofloxacin 0.3% eye drop 1 QL 0.767 / day
ciprofloxacin hcl-fluocinolone 1
ciprofloxacin-dexamethasone 1 QL 0.257 / day
COLY-MYCIN S 3 QL 10 / fill
doxycycline hyclate 20 mg tab 1
HCG
MVGMINIMALVALUEGENERIC
erythromycin 0.5% eye ointment 1 QL 0.54 / day
gatifloxacin 1QL 0.36/day
HCG
GENTAK 1 QL 0.54 / day
gentamicin sulfate (0.3% drop, 3 mg/ml drop) 1 QL 2.143 / day
levofloxacin 0.5% eye drops 1 QL 0.767 / day
PAGE 39 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MAXITROL EYE DROPS 3 QL 5 / fill
MAXITROL EYE OINTMENT 3 QL 4 / fill
MOXEZA 2 QL 0.434 / day
moxifloxacin 0.5% eye drops 1 QL 0.434 / day
NEO-POLYCIN 1 QL 0.124 / day
NEO-POLYCIN HC 1QL 4 / fill
HCG
neomycin-bacitracin-poly-hc 1 QL 4 / fill
neomycin-bacitracin-polymyxin 1 QL 0.124 / day
neomyc-polym-dexameth eye drop 1 QL 5 / fill
neomyc-polym-dexamet eye ointm 1 QL 4 / fill
neomycin-polymyxin-gramicidin 1 QL 1.47 / day
neomycin-poly-hc eye drops 1 QL 10/ fill
neomycin-polymyxin-hc ear susp 1 QL 10 / fill
neomycin-polymyxin-hydrocort 1 QL 10 / fill
OCUFLOX 3 QL 1.47 / day
ofloxacin 0.3% ear drops 1 QL 10 / 30 days
ofloxacin 0.3% eye drops 1 QL 1.47 / day
OTIPRIO 3 MVB MINIMALVALUE BRAND
OTOVEL 3
QL 0.4722 / day
ST
MVB Minimal ValueBrand
SBA SELECT BRANDALTERNATIVE
PAGE 40 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
POLYCIN 1 QL 0.434 / day
polymyxin b sul-trimethoprim 1 QL 1.47 / day
POLYTRIM 3 QL 1.47 / day
PRED-G 1% EYE DROPS 3 QL 5 / fill
PRED-G S.O.P. EYE OINTMENT 3 QL 4 / fill
sulfacetamide 10% eye drops 1 QL 5 / fill
sulfacetamide 10% eye ointment 1 QL 4 / fill
sulfacetamide-prednisolone 1 QL 5 / fill
TOBRADEX EYE DROPS 3QL 5 / fill
SBA Select BrandAlternative
TOBRADEX EYE OINTMENT 3 QL 4 / fill
TOBRADEX ST 3 QL 5 / fill
tobramycin 0.3% eye drop 1 QL 2.143 / day
tobramycin-dexamethasone 1 QL 5 / fill
TOBREX 0.3% EYE DROP 3 QL 2.143 / day
TOBREX 0.3% EYE OINTMENT 3 QL 0.54 / day
vancomycin 2 mg/0.2 ml syringe 1 MED Medical Drug
VIGAMOX 3
QL 0.434 / day
ST
SBA Select BrandAlternative
ZYLET 3QL 5 / fill
MVB MINIMALVALUE BRAND
ZYMAXID 3 QL 0.36/day
PAGE 41 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIFUNGALS (EENT)
NATACYN 3 QL 0.767 / day
ANTIVIRALS (EENT)
trifluridine 1
ZIRGAN 3 QL 0.167 / day
EENT ANTI-INFECTIVES, MISCELLANEOUS
acetic acid 2% ear solution 1
BETADINE 5% EYE SOLUTION 3
chlorhexidine 0.12% rinse 1
hydrocortisone-acetic acid 1
PAROEX 1
PERIDEX 3
PERIOGARD 1
povidone iodine 1
ANTI-INFECTIVES (SKIN, MUCOUS MEMBRANE)
ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)
ACANYA 3
QL 1.667 / day
PA
MVB MINIMALVALUE BRAND
SBA Select BrandAlternative
AKTIPAK 3PA
MVB MINIMALVALUE BRAND
ALTABAX 3 PA
PAGE 42 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AMZEEQ 3 QL 1 / day
BACTROBAN 3
BENZACLIN (GEL, GEL 35G PUMP, GEL 50G PUMP) 3
QL 1.667 / day
PA
SBA Select BrandAlternative
BENZAMYCIN 3
QL 1.6 / day
PA
MVB MINIMALVALUE BRAND
SBA Select BrandAlternative
CENTANY 3 PA
CLEOCIN 2% VAGINAL CREAM 3MVB MINIMAL
VALUE BRAND
SBA SELECT BRANDALTERNATIVE
CLEOCIN 100 MG VAGINAL OVULE 2 MVB MINIMALVALUE BRAND
CLEOCIN T 1% GEL 3 QL 75 / 30 days
CLEOCIN T 1% PLEDGETS 3 SBA SELECT BRANDALTERNATIVE
CLEOCIN T (LOION, SOLUION) 3
CLINDACIN ETZ 1% PLEDGET 1 HCG
CLINDACIN P 1 HCG
CLINDAGEL 3
QL 75 / 30 days
PA
SBA Select BrandAlternative
clind ph-benzoyl perox 1.2-5% 1 QL 1.5 / day
PAGE 43 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
clind ph-benzoyl pero 1.2-2.5% 3QL 1.667 / day
PA
clindamycin phos-tretinoin 1
QL 2 / day
HCG
MVGMINIMALVALUEGENERIC
clindamycin phosphate 1% foam 1
QL 1.667 / day
HCG
MVGMINIMALVALUEGENERIC
clindamycin ph 1% gel 1 QL 75 / 30 days
clindamycin phosphate 1% gel 1QL 75 / 30 days
PA
clindamycin phosphate (phos 1% pledget, phosp 1%lotion, 2% vaginal cream) 1
clindamycin ph 1% solution 1 QL 2 / day
clindamycin-benzoyl peroxide (clinda-benzoyl 1-5% pump,clindamycin-benzoyl 1-5%) 1 QL 1.667 / day
CLINDESSE 3
CORTISPORIN CREAM 3 QL 0.25 / day
CORTISPORIN OINTMENT 3 QL 0.5 / day
DUAC 3
QL 1.5 / day
PA
SBA Select BrandAlternative
ERY 1
ERYGEL 3 QL 1 / day
PAGE 44 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
erythromycin 2% gel 1 QL 1 / day
erythromycin (pledgets, solution) 1
erythromycin-benzoyl peroxide 1 QL 1.60 / day
EVOCLIN 3
QL 1.667 / day
PA
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
gentamicin sulfate (cream, ointment) 1
METROCREAM 3 SBA Select BrandAlternative
METROGEL TOPICAL 1% GEL 3
QL 2 / day
ST
PA
METROGEL TOPICAL 1% PUMP 3
QL 1.84 / day
ST
PA
METROGEL-VAGINAL 3MVB MINIMAL
VALUE BRAND
SBA SELECT BRANDALTERNATIVE
METROLOTION 3
metronidazole (0.75% cream, 0.75% lotion, top 1% gelpump, topical 0.75% gl, topical 1% gel, vaginal 0.75% gl) 1
mupirocin 2% cream 1 QL 2 / day
mupirocin 2% ointment 1 QL 2.5 / day
NEO-SYNALAR 0.5%-0.025% CREAM 3
NEUAC GEL 1 QL 1.5 / day
PAGE 45 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NORITATE 3
QL 2 / day
PA
MVB MINIMALVALUE BRAND
NUVESSA 3 MVB MINIMALVALUE BRAND
ONEXTON 1.2%-3.75% GEL 3 QL 1.667 / day
ONEXTON GEL PUMP 3 QL 1.967 / day
ROSADAN (CREAM, GEL) 1
ROSADAN 0.75% CREAM KIT 3 MVB MINIMALVALUE BRAND
ROSADAN 0.75% GEL KIT 3
VANDAZOLE 3
VELTIN 3
QL 2 / day
PA
MVB MINIMALVALUE BRAND
XEPI 3 PA
ZIANA 3
QL 2 / day
PA
SBA Select BrandAlternative
ZILXI 3QL 1 / day
PA
ANTIVIRALS (SKIN AND MUCOUS MEMBRANE)
acyclovir 5% cream 1
QL 0.167 / day
AL At least 12 yrsold
PA
PAGE 46 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
acyclovir 5% ointment 1
DENAVIR 3
QL 0.167 / day
AL At least 12 yrsold
PA
XERESE 3
QL 0.167 / day
AL At least 6 yrsold
PA
MVB MINIMALVALUE BRAND
ZOVIRAX 5% CREAM 3
QL 0.167 / day
AL At least 12 yrsold
PA
SBA Select BrandAlternative
ZOVIRAX 5% OINTMENT 3
QL 30 / fill
AL At least 12 yrsold
PA
SBA Select BrandAlternative
LOCAL ANTI-INFECTIVES, MISCELLANEOUS
AVC 3 MVB MINIMALVALUE BRAND
BP CLEANSING WASH 1
FEM PH 3
hydrocortisone-iodoquinol 1
iodine (2% mild tincture, 5% strong solution, mild tincture,strong solution) 1
PAGE 47 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
IODOFLEX 3
IODOSORB 3
KLARON 3 QL 4 / day
LUGOL'S 1
SILVADENE 3 ST
silver sulfadiazine 1
sodium sulf-sulfur cleanser 3
sod sulface-sulfur 9-4.5% kit 3
SSD 1
sulfacetamide sodium (sod top susp, sodium lotn) 1 QL 4 / day
SULFAMYLON 8.5% CREAM 3
SCABICIDES AND PEDICULICIDES
CROTAN 1
ELIMITE 3
EURAX (CREAM, LOTION) 3 ST
lindane 1 HCG
malathion 1 HCG
NATROBA 3ST
MVB MINIMALVALUE BRAND
OVIDE 3 ST
permethrin 1
SKLICE 3 ST
spinosad 1
HCG
MVGMINIMALVALUEGENERIC
PAGE 48 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ULESFIA 3 ST
ANTI-INFLAMMATORY AGENTS (EENT)
CORTICOSTEROIDS (EENT)
ALREX 3 QL 0.5 / day
BECONASE AQ 3QL 1.667 / day
MVB MINIMALVALUE BRAND
DERMOTIC 3
dexamethasone 0.1% eye drop 1 QL 10 / fill
DUREZOL 3 QL 10 / 30 days
FLAC OTIC OIL 1
FLAREX 3 QL 10 / fill
flunisolide 1 QL .834 / day
fluocinolone acetonide oil 1 HCG
fluorometholone 1 QL 10 / fill
fluticasone prop 50 mcg spray 1 QL 0.6 / day
FML 3 QL 10 / fill
FML FORTE 3 QL 10 / fill
FML S.O.P. 3 QL 4 / fill
ILUVIEN 3
QL max 1 per 365days
S
MED Medical Drug
INVELTYS 3 QL 0.4 / day
LOTEMAX 0.5% OPHTHALMIC GEL 3 QL 10 / fill
PAGE 49 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LOTEMAX 0.5% EYE DROPS 3QL 21 / fill
SBA Select BrandAlternative
LOTEMAX 0.5% EYE OINTMENT 3QL 4 / fill
MVB MINIMALVALUE BRAND
LOTEMAX SM 3 QL 10 / fill
loteprednol etabonate 1 QL 21 / fill
MAXIDEX 3QL 10 / fill
MVB MINIMALVALUE BRAND
mometasone furoate 50 mcg spry 1 QL 0.567 / day
NASONEX 3QL 0.567 / day
SBA Select BrandAlternative
OMNARIS 3 QL 0.434 / day
OMNIPRED 3QL 21 / fill
ST
OZURDEX 3
QL 0.04 / day
S
MED Medical Drug
PRED FORTE 3
QL 21 / fill
ST
SBA Select BrandAlternative
PRED MILD 3 QL 21 / fill
prednisolone ac 1% eye drop 1 QL 21 / fill
prednisolone sod 1% eye drop 1 QL 20 / 30 days
PAGE 50 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QNASL 3 QL 0.4 / day
QNASL CHILDREN 3 QL 0.3 / day
RETISERT 3
QL max 1 per 365days
S
MED Medical Drug
triamcinolone 55 mcg nasal spr 1 QL 0.55 / day
TRIESENCE 3QL 1 / day
MED Medical Drug
XHANCE 3
QL 1.25 / day
ST
MVB MINIMALVALUE BRAND
YUTIQ 3S
MED Medical Drug
ZETONNA 3 QL 0.22 / day
EENT ANTI-INFLAMMATORY AGENTS, MISC.
CEQUA 3QL 2 / day
PA
RESTASIS 2QL 2 / day
PA
RESTASIS MULTIDOSE 2QL 0.2 / day
PA
XIIDRA 2
QL 2 / day
AL At least 17 yrsold
PA
PAGE 51 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EENT NONSTEROIDAL ANTI-INFLAM. AGENTS
ACULAR 3 QL 15 / 30 days
ACULAR LS 3 QL 5 / fill
ACUVAIL 3QL 1 / day
MVB Minimal ValueBrand
bromfenac sodium 1QL 8 / rx
HCG
BROMSITE 3QL 15/ 180 days
PA
diclofenac 0.1% eye drops 1 QL 5 / fill
flurbiprofen sodium 1 QL 3/ fill
ILEVRO 3QL 4 / fill
PA
ketorolac 0.4% ophth solution 1 QL 5 / fill
ketorolac 0.5% ophth solution 1 QL 15 / 30 days
NEVANAC 3QL 3/ fill
PA
PROLENSA 2 QL 3/ fill
ANTI-INFLAMMATORY AGENTS (RESPIRATORY)
INTERLEUKIN ANTAGONISTS
DUPIXENT 200 MG/1.14 ML SYRING 3
QL 0.15 / day
AL At least 6 yrsold
S
PS
PA
PAGE 52 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FASENRA 3
QL 0.04 / day
AL At least 12 yrsold
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
FASENRA PEN 3
QL 0.04 / day
AL At least 12 yrsold
S
PS
PA
NUCALA (100 MG/ML AUTO-INJECTOR, 100 MG/MLSYRINGE) 3
QL 0.04 / day
AL At least 12 yrsold
S
PS
PA
NUCALA 100 MG VIAL 3
QL 0.04 / day
AL At least 12 yrsold
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
LEUKOTRIENE MODIFIERS
ACCOLATE 3QL 2 / day
PR
PAGE 53 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
montelukast sod 4 mg granules 1
QL 1 / day
PR
HCG
montelukast sodium (4 mg tab chew, 5 mg tab chew, 10mg tablet) 1
QL 1 / day
PR
SINGULAIR (4 MG GRANULES, 4 MG TABLET CHEW, 5 MGTABLET CHEW, 10 MG TABLET) 3
QL 1 / day
PR
SBA Select BrandAlternative
zafirlukast 1QL 2 / day
PR
zileuton er 1
QL 4 / day
ST
PR
HCG
ZYFLO 3
QL 4 / day
ST
PR
ZYFLO CR 3
QL 4 / day
ST
PR
SBA Select BrandAlternative
MAST-CELL STABILIZERS
ALOCRIL 3QL 5 / fill
MVB MINIMALVALUE BRAND
cromolyn 20 mg/2 ml neb soln 1 PR
PAGE 54 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
cromolyn 4% eye drops 1 QL 10 / fill
cromolyn 100 mg/5 ml oral conc 1
GASTROCROM 3
ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)
ANTI-INFLAMMATORY AGENTS, MISC (SKIN)
EUCRISA 2QL 2.143 / day
ST
CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE)
ALA-CORT 1
ALA-SCALP 3 MVB Minimal ValueBrand
alclometasone dipro 0.05% crm 1 HCG
alclometasone dipr 0.05% oint 1
amcinonide (cream, lotion) 1
HCG
MVGMINIMALVALUEGENERIC
ANALPRAM HC (CRM SINGLE, LOTION) 3
ANALPRAM HC 1% CREAM 3MVB Minimal Value
Brand
SBA Select BrandAlternative
ANALPRAM HC 2.5%-1% CREAM 3MVB Minimal Value
Brand
SBA SELECT BRANDALTERNATIVE
ANUCORT-HC 1
ANUSOL-HC 2.5% CREAM 3MVB MINIMAL
VALUE BRAND
SBA Select BrandAlternative
PAGE 55 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANUSOL-HC 25 MG SUPPOSITORY 1
APEXICON E 3 MVB MINIMALVALUE BRAND
BESER 1
betamethasone diprop augmented (crm, gel, lot, oin) 1
betamethasone dipropionate (crm, lot, oint) 1
betamethasone valer 0.12% foam 1 HCG
betamethasone valerate (va cream, va lotion, valer ointm) 1
BRYHALI 3 PA
CAPEX SHAMPOO 3
clobetasol emollient 0.05% crm 1
clobetasol emollnt 0.05% foam 1 HCG
clobetasol emulsion 1 HCG
clobetasol propionate (cream, gel, ointment, shampoo,solution) 1
clobetasol propionate (prop foam, prop spray, topicallotn) 1 HCG
CLOBEX (SHAMPOO, TOPICAL LOTION) 3 ST
CLOBEX 0.05% SPRAY 3ST
SBA Select BrandAlternative
clocortolone pivalate 1 HCG
CLODAN 0.05% SHAMPOO 1 HCG
CLODERM 3 ST
COLOCORT 1
CORDRAN 0.025% CREAM 3 QL 4 / day
PAGE 56 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CORDRAN 0.05% CREAM 3
QL 2 / day
MVB MINIMALVALUE BRAND
SBA Select BrandAlternative
CORDRAN 0.05% LOTION 3
QL 4 / day
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
CORDRAN 0.05% OINTMENT 3MVB MINIMAL
VALUE BRAND
SBA SELECT BRANDALTERNATIVE
CORMAX 1
CORTENEMA 3
CORTIFOAM 3 MVB MINIMALVALUE BRAND
CUTIVATE 0.05% CREAM 3
CUTIVATE 0.05% LOTION 3MVB MINIMAL
VALUE BRAND
SBA Select BrandAlternative
DERMA-SMOOTHE-FS BODY OIL 3 SBA Select BrandAlternative
DERMA-SMOOTHE-FS SCALP OIL 3
DERMATOP 3
DESONATE 3
desonide (cream, gel, lotion, ointment) 1
DESOWEN (CREAM, LOTION) 3
desoximetasone (cream, ointment) 1 HCG
PAGE 57 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
desoximetasone (0.05% gel, 0.25% cream, 0.25%ointment, 0.25% spray) 1
diflorasone diacetate (cream, ointment) 1 HCG
DIPROLENE 3
ELOCON (CREAM, OINTMENT) 3
EPIFOAM 3
fluocinolone acetonide (0.01% scalp oil, 0.01% solution,0.025% cream, 0.025% ointment) 1 HCG
fluocinolone acetonide (body oil, cream) 1
fluocinonide 0.1% cream 1
HCG
MVGMINIMALVALUEGENERIC
fluocinonide (cream, gel, ointment, solution) 1
fluocinonide-e 1
flurandrenolide 0.05% cream 3
QL 2 / day
HCG
MVGMINIMALVALUEGENERIC
flurandrenolide 0.05% lotion 3
QL 4 / day
HCG
MVGMINIMALVALUEGENERIC
flurandrenolide 0.05% ointment 3
HCG
MVGMINIMALVALUEGENERIC
fluticasone prop 0.05% lotion 1
HCG
MVGMINIMALVALUEGENERIC
PAGE 58 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fluticasone propionate (0.005% oint, 0.05% cream) 1
halcinonide 1 PA
halobetasol propionate (cream, ointmnt) 1
halobetasol prop 0.05% foam 1 PA
HALOG 0.1% CREAM 3
PA
MVB Minimal ValueBrand
SBA SELECT BRANDALTERNATIVE
HALOG (OINTMENT, SOLUTION) 3 PA
hydrocortisone (1% cream, 1% ointment, 2.5% cream,2.5% lotion, 2.5% ointment, 100 mg/60 ml) 1
hydrocortisone 1% absorbase 1
HCG
MVGMINIMALVALUEGENERIC
hydrocortisone acetate (25 mg, 30 mg) 1
hydrocortisone butyrate (lipid crm, lipo cream) 1
HCG
MVGMINIMALVALUEGENERIC
hydrocortisone butyrate (buty cream, butyr lotn, butyroint, butyr soln) 1
hydrocortisone valerate (cream, ointmt) 1
hydrocortisone-pramoxine 1
IMPOYZ 3 QL 4 / day
KENALOG 3 ST
LEXETTE 3PA
MVB Minimal ValueBrand
PAGE 59 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
lidocaine-hc 3-0.5% cream 1
LOCOID 0.1% CREAM 3MVB MINIMAL
VALUE BRAND
SBA Select BrandAlternative
LOCOID (LOTION, SOLUTION) 3 SBA Select BrandAlternative
LUXIQ 3
MICORT HC 2.5% CREAM 3
MICORT-HC 2.5% CREAM 3 MVB MINIMALVALUE BRAND
mometasone furoate (cream, oint, soln) 1
NOLIX 0.05% CREAM 3 QL 8 / day
NOLIX 0.05% LOTION 3 QL 4 / day
OLUX 3 SBA Select BrandAlternative
OLUX-E 3 SBA Select BrandAlternative
ORALONE 1
PANDEL 3
PRAMOSONE (1% LOTION, 1%-1% CREAM, 1%-1%OINTMENT, 2.5%-1% LOTION, 2.5%-1% OINTMENT) 3
PRAMOSONE E 3
prednicarbate (cream, ointment) 1
PROCORT 3
PROCTO-MED HC 1
PROCTO-PAK 1
PROCTOCORT (1% CREAM, 30 MG SUPPOSITORY) 3
PAGE 60 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PROCTOFOAM-HC 2
PROCTOSOL-HC 1
PROCTOZONE-HC 1 HCG
PSORCON 3
SANADERMRX 1
SCALACORT 1
SERNIVO 3
SYNALAR (0.01% SOLUTION, 0.025% CREAM) 3
TEMOVATE (CREAM, OINTMENT) 3
TEXACORT 3 MVB Minimal ValueBrand
TOPICORT (0.05% CREAM, 0.05% GEL, 0.05% OINTMENT,0.25% CREAM, 0.25% OINTMENT) 3 SBA Select Brand
Alternative
TOPICORT 0.25% SPRAY 3
PA
MVB Minimal ValueBrand
SBA Select BrandAlternative
TOVET EMOLLIENT 1 HCG
triamcinolone 0.147 mg/g spray 1
HCG
MVGMINIMALVALUEGENERIC
triamcinolone acetonide (0.025% cream, 0.025% lotion,0.025% oint, 0.05% ointment, 0.1% cream, 0.1% lotion,0.1% ointment, 0.1% paste, 0.5% cream, 0.5% ointment)
1
TRIANEX 3
TRIDERM 1
PAGE 61 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRIDESILON 3
ULTRAVATE 0.05% LOTION 3 MVB Minimal ValueBrand
ULTRAVATE (CREAM, OINTMENT) 3
VANOS 3 MVB MINIMALVALUE BRAND
VANOXIDE-HC 3 QL 0.84 / day
VERDESO 3 MVB Minimal ValueBrand
ANTIANEMIA DRUGS
IRON PREPARATIONS
FERAHEME 3S
MED Medical Drug
FERRLECIT 3S
MED Medical Drug
INFED 1S
MED Medical Drug
INJECTAFER 3S
BSP BENEFIT SHIFTPROGRAM
IRO-PLEX CAPLET 3
MONOFERRIC 3S
MED Medical Drug
SIDEROL 3
sod ferric gluconate complex 1S
MED Medical Drug
TRIFERIC (27.2 MG/5 ML AMPULE, 272 MG POWDERPACKET) 3
S
MED Medical Drug
PAGE 62 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VENOFER 3S
MED Medical Drug
ANTIARRHYTHMIC AGENTS
CLASS IA ANTIARRHYTHMICS
disopyramide phosphate 1
NORPACE 3
NORPACE CR 100 MG CAPSULE 2
NORPACE CR 150 MG CAPSULE 3
procainamide hcl (1 gram/2 ml vial, 1,000 mg/2 ml vl) 1 MED Medical Drug
quinidine gluc er 324 mg tab 1
quinidine gluc 80 mg/ml vial 1 MED Medical Drug
quinidine sulfate 1
CLASS IB ANTIARRHYTHMICS
lidocaine hcl (1% abboject, 1% syringe, 2% abboject, 2%luer-jet, 2% syringe, 2% vial) 1 MED Medical Drug
lidocaine hcl in 5% dextrose (0.4% in soln, 0.8% in soln) 1 MED Medical Drug
mexiletine hcl 1
XYLOCAINE IV 3 MED Medical Drug
CLASS IC ANTIARRHYTHMICS
flecainide acetate 1
propafenone hcl 1
propafenone hcl er 1
RYTHMOL SR 3
PAGE 63 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CLASS III ANTIARRHYTHMICS
amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mgtablet) 1
amiodarone hcl (150 mg/3 ml syringe, 150 mg/3 ml vial,450 mg/9 ml vial, 900 mg/18 ml vial) 1 MED Medical Drug
bretylium tosylate 1 MED Medical Drug
CORVERT 3 MED Medical Drug
dofetilide 1 S
ibutilide fumarate 1 MED Medical Drug
MULTAQ 3 PA
NEXTERONE 3 MED Medical Drug
PACERONE 1
TIKOSYN 3
ST
S
SBA Select BrandAlternative
CLASS IV ANTIARRHYTHMICS
adenosine (6 mg/2 ml syringe, 6 mg/2 ml vial, 12 mg/4 mlsyringe, 12 mg/4 ml vial) 1 MED Medical Drug
ANTIBACTERIALS
AMINOGLYCOSIDE ANTIBIOTICS
amikacin sulfate 1 MED Medical Drug
ARIKAYCE 3
QL 9 / day
S
PA
BETHKIS 3S
PA
PAGE 64 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
gentamicin sulfate (10 mg/ml vial, 20 mg/2 ml vial, ped20 mg/2 ml vial, 40 mg/ml vial, 80 mg/2 ml vial, 800mg/20 ml vial)
1 BSP BENEFIT SHIFTPROGRAM
gentamicin sulfate in ns (70 mg/ns 50 ml, 90 mg/ns 100ml) 1 BSP BENEFIT SHIFT
PROGRAM
gentamicin sulfate in ns (iso 100 mg/100 ml, iso 120mg/100 ml, isoton 60 mg/50 ml, isoton 80 mg/100 ml,isoton 80 mg/50 ml, isoton 100 mg/50 ml)
1 MED Medical Drug
gentamicin 0.9mg/3ml-sod citra 1 BSP BENEFIT SHIFTPROGRAM
KITABIS PAK 3S
PA
neomycin sulfate 1
streptomycin sulfate 1 MED Medical Drug
TOBI 3
S
PA
SBA Select BrandAlternative
TOBI PODHALER 3S
PA
tobramycin (300 mg/4 ml ampule, pak 300 mg/5 ml) 1S
PA
tobramycin 300 mg/5 ml ampule 1S
PA
tobramycin sulfate (1.2 gm vial, 1.2 gram/30 ml vial, 10mg/ml vial, 40 mg/ml vial, 80 mg/2 ml vial, 1,200 mg/30ml vial)
1 MED Medical Drug
tobramycin sulfate in ns 1 MED Medical Drug
PAGE 65 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CHLORAMPHENICOL ANTIBIOTICS
chloramphenicol sod succinate 1 MED Medical Drug
QUINOLONE ANTIBIOTICS
AVELOX 3 QL 21 / fill
AVELOX IV 3 MED Medical Drug
BAXDELA 450 MG TABLET 3QL max 14 days
PA
BAXDELA 300 MG VIAL 3
QL max 14 days
MED Medical Drug
PA
CIPRO 10% SUSPENSION 3 QL 10 / day
CIPRO 5% SUSPENSION 3 QL 7 / day
CIPRO (250 MG TABLET, 500 MG TABLET) 3 QL 2 / day
ciprofloxacin 250 mg/5 ml susp 1 QL 7 / day
ciprofloxacin 500 mg/5 ml susp 1 QL 10 / day
ciprofloxacin er 1,000 mg tab 1 QL 14 / 1 rx
ciprofloxacin er 500 mg tablet 1 QL 28 / fill
ciprofloxacin hcl (100 mg tab, 250 mg tab, 750 mg tab) 1 QL 2 / day
ciprofloxacin hcl 500 mg tab 1 QL 2 / day
ciprofloxacin-d5w 1 MED Medical Drug
FACTIVE 3QL 7 / day
PA
LEVAQUIN 3 QL 30 / fill
levofloxacin 25 mg/ml solution 1
PAGE 66 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
levofloxacin (250 mg tablet, 500 mg tablet, 750 mgtablet) 1 QL 30 / fill
levofloxacin (500 mg/20 ml vial, 750 mg/30 ml vial) 1 MED Medical Drug
levofloxacin-d5w 1 MED Medical Drug
moxifloxacin 400 mg/250 ml bag 1 MED Medical Drug
moxifloxacin hcl 400 mg tablet 1 QL 21 / fill
ofloxacin (300 mg tablet, 400 mg tablet) 1 QL 56 / fill
SULFONAMIDE ANTIBIOTICS (SYSTEMIC)
AZULFIDINE (500 MG TABLET, ENTAB 500 MG) 3
BACTRIM 3
BACTRIM DS 3
sulfadiazine 1
sulfamethoxazole-tmp ds tablet 1
sulfamethoxazole-trimethoprim (ss tablet, susp) 1
sulfamethoxazole-tmp iv vial 1 MED Medical Drug
sulfasalazine 1
sulfasalazine dr 1
SULFATRIM 1
TETRACYCLINE ANTIBIOTICS
ACTICLATE 3
ST
MVB MINIMALVALUE BRAND
SBA Select BrandAlternative
AVIDOXY 1
COREMINO (ER 90 MG TABLET, ER 135 MG TABLET) 1QL 1 / day
ST
PAGE 67 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
COREMINO ER 45 MG TABLET 1QL 3 / day
ST
demeclocycline hcl 1
DORYX DR 200 MG TABLET 3
QL 7/ rx
ST
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
DORYX DR 50 MG TABLET 3
ST
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
DORYX DR 80 MG TABLET 3
ST
MVB Minimal ValueBrand
SBA Select BrandAlternative
DORYX MPC 3ST
MVB MINIMALVALUE BRAND
DOXY 100 1 MED Medical Drug
doxycycline hyclate (50 mg tablet, hyc dr 80 mg tab,hyclate 50 mg cap, hyclate 100 mg cap, hyclate 100 mgtab)
1
doxycycline hyc dr 200 mg tab 1
QL 7/ rx
ST
HCG
MVGMINIMALVALUEGENERIC
PAGE 68 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
doxycycline hyclate (dr 50 mg tab, dr 100 mg tab) 1 ST
doxycycline hyclate (hyc dr 75 mg tab, hyc dr 150 mg tab,hyclate 75 mg tab, hyclate 150 mg tab) 1
ST
HCG
MVGMINIMALVALUEGENERIC
doxycycline hyclate 100 mg vl 1 MED Medical Drug
doxycycline ir-dr 1
QL 1 / day
HCG
MVGMINIMALVALUEGENERIC
doxycycline mono 150 mg cap 1
QL 30 / fill
HCG
MVGMINIMALVALUEGENERIC
doxycycline monohydrate (25 mg/5 ml susp, mono 50 mgcap, mono 50 mg tablet, mono 100 mg cap, mono 100 mgtablet)
1
doxycycline monohydrate (75 mg capsule, 75 mg tablet,150 mg tablet) 1
HCG
MVGMINIMALVALUEGENERIC
MINOCIN 50 MG PELLETIZED CAP 3
QL 4 / day
ST
MVB MINIMALVALUE BRAND
SBA Select BrandAlternative
MINOCIN 100 MG VIAL 3MED Medical Drug
MVB MINIMALVALUE BRAND
PAGE 69 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
minocycline er (er 45 mg capsule, er 90 mg capsule) 1
QL 1 / day
PA
HCG
MVGMINIMALVALUEGENERIC
minocycline er 135 mg capsule 1QL 1 / day
PA
minocycline hcl (50 mg capsule, 75 mg capsule, 100 mgcapsule) 1
minocycline hcl (50 mg tablet, 75 mg tablet, 100 mgtablet) 1
ST
HCG
MVGMINIMALVALUEGENERIC
minocycline er 45 mg tablet 1
QL 3 / day
ST
HCG
MVGMINIMALVALUEGENERIC
minocycline hcl er (er 55 mg tablet, er 65 mg tablet, er 80mg tablet, er 90 mg tablet, er 105 mg tablet, er 115 mgtablet, er 135 mg tablet)
1
QL 1 / day
ST
HCG
MVGMINIMALVALUEGENERIC
MINOLIRA ER 3QL 1 / day
PA
MONDOXYNE NL 100 MG CAPSULE 1
MONDOXYNE NL 75 MG CAPSULE 1
HCG
MVGMINIMALVALUEGENERIC
PAGE 70 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MONODOX 3
ST
MVB MINIMALVALUE BRAND
SBA Select BrandAlternative
MORGIDOX (50 MG CAPSULE, 100 MG CAPSULE) 1
OKEBO 1
ORACEA 3QL 1 / day
PA
SOLODYN 3 QL 1 / day
SOLOXIDE 1
TARGADOX 3
ST
MVB MINIMALVALUE BRAND
SBA Select BrandAlternative
tetracycline hcl 1
VIBRAMYCIN 100 MG CAPSULE 3
ST
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
VIBRAMYCIN 25 MG/5 ML SUSP 3 ST
VIBRAMYCIN 50 MG/5 ML SYRUP 3ST
MVB MINIMALVALUE BRAND
XIMINO 3QL 1 / day
PA
PAGE 71 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIBACTERIALS, MISCELLANEOUS
BACITRACIN ANTIBIOTICS
BACIIM 1 MED Medical Drug
bacitracin 50,000 unit vial 1 MED Medical Drug
CYCLIC LIPOPEPTIDE ANTIBIOTICS
CUBICIN 3MED Medical Drug
SBA Select BrandAlternative
CUBICIN RF 3 MED Medical Drug
daptomycin 500 mg vial 1 BSP BENEFIT SHIFTPROGRAM
GLYCOPEPTIDE ANTIBIOTICS
FIRVANQ 3
VANCOCIN HCL 3
vancomycin 1 MED Medical Drug
vancomycin hcl (hcl 125 mg capsule, 250 mg/5 ml soln, hcl250 mg capsule) 1
vancomycin 1 gm vial 1MED Medical Drug
BSP BENEFIT SHIFTPROGRAM
PAGE 72 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
vancomycin hcl (1 gm add-van vial, 1 gram/200 ml bag,hcl 1g/200 ml bag, 1.25 gm/250 ml bag, hcl 1.25 gramvial, 1.5 gram/300 ml bag, hcl 1.5 gram vial, 1.75 gm/350ml bag, 2 gram/400 ml bag, hcl 10 gm vial, hcl 100 gmsmartpak, hcl 250 mg vial, 500 mg add-van vial, 500 mgvial, 500 mg/100 ml bag, 750 mg add-van vial, 750mg/150 ml bag, hcl 750 mg vial)
1 MED Medical Drug
vancomycin hcl 5 gm vial 1 BSP BENEFIT SHIFTPROGRAM
vancomycin hcl-0.9% nacl (vanco 1 gram/150 ml-0.9%,vanco 1 gram/250 ml-0.9%, vanco 1.25 gm/150 ml-0.9%,vanco 1.25 gm/250 ml-0.9%, vanco 1.5 gm/150 ml-0.9%,vanco 1.5 gm/250 ml-0.9%, vanco 1.5 gm/300 ml-0.9%,vanco 1.5 gm/500 ml-0.9%, vanco 1.75 g/250 ml-0.9%,vanco 1.75 gm/500 ml-0.9%, vanco 2 gram/250 ml-0.9%,vanco 2 gram/500 ml-0.9%, vanco 500 mg/100 ml-0.9%,vanco 750 mg/150 ml-0.9%, vanco 750 mg/250 ml-0.9%,vancomycin 1 g/100ml-0.9%, vancomycin 1 g/200ml-0.9%)
1 MED Medical Drug
vancomycin hcl-d5w (vancomycin 1 gram/100 ml-d5w,vancomycin 1 gram/250 ml-d5w, vancomycin 1.25gram/250ml-d5w, vancomycin 1.5 gram/250 ml-d5w,vancomycin 1.5 gram/500 ml-d5w, vancomycin 1.75gram/500ml-d5w, vancomycin 2 gram/500 ml-d5w,vancomycin-d5w 500 mg/100 ml)
1 MED Medical Drug
VIBATIV 3 MED Medical Drug
LINCOMYCIN ANTIBIOTICS
CLEOCIN HCL 3 QL 4 / day
CLEOCIN PEDIATRIC 3 QL 70/ day
CLEOCIN PHOSPHATE (9 G/60 ML VIAL, 150 MG/ML VIAL,300 MG/2 ML VIAL, 300 MG/2ML ADDVAN, 600 MG/4 MLVIAL, 900 MG/6 ML VIAL)
3 MED Medical Drug
PAGE 73 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CLEOCIN PHOSPHATE (600 MG/4ML, 900 MG/6ML) 3
clindamycin (pediatric) 1 QL 70/ day
clindamycin hcl 1 QL 4 / day
clindamycin phosphate (ph 9 g/60 ml vial, 300 mg/2 mladdvan, ph 300 mg/2 ml vl, 600 mg/4 ml addvan, ph 600mg/4 ml vl, 900 mg/6 ml addvan, ph 900 mg/6 ml vl)
1 MED Medical Drug
clindamycin phosphate-d5w 1 MED Medical Drug
clindamycin-0.9% nacl 1 MED Medical Drug
LINCOCIN 3 MED Medical Drug
lincomycin hcl 1QL 10 / day
MED Medical Drug
OTHER MISC. ANTIBACTERIAL AGENTS
HELIDAC 3 QL max 1 per 365days
PYLERA 2 QL 120 / 365 days
OXAZOLIDINONE ANTIBIOTICS
linezolid 100 mg/5 ml susp 1 QL 900 / rx
linezolid 600 mg tablet 1 QL 2 / day
linezolid-0.9% nacl 1 MED Medical Drug
linezolid-d5w 1 MED Medical Drug
SIVEXTRO 200 MG TABLET 3QL 6 / 30 days
PA
SIVEXTRO 200 MG VIAL 3
QL 6 / 30 days
MED Medical Drug
PA
PAGE 74 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZYVOX (200 MG/100, 600 MG/300) 3MED Medical Drug
PA
ZYVOX 100 MG/5 ML SUSPENSION 3QL 900 / rx
PA
ZYVOX 600 MG TABLET 3QL 2 / day
PA
PLEUROMUTILINS
XENLETA 600 MG TABLET 3S
PA
XENLETA 150 MG/15 ML VIAL 3S
MED Medical Drug
POLYMYXIN ANTIBIOTICS
colistimethate 1 MED Medical Drug
COLY-MYCIN M PARENTERAL 3 MED Medical Drug
polymyxin b sulfate 1 MED Medical Drug
RIFAMYCIN ANTIBIOTICS
AEMCOLO 3
XIFAXAN 3 PA
STREPTOGRAMIN ANTIBIOTICS
SYNERCID 3 MED Medical Drug
ANTICHOLINERGIC AGENTS
ANTIMUSCARINICS/ANTISPASMODICS
ANASPAZ 3
ANORO ELLIPTA 2QL 2 / day
PR
PAGE 75 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ATROVENT HFA 3QL 1.29 / day
PR
belladonna-phenobarbital 1
BENTYL 3 MED Medical Drug
BEVESPI AEROSPHERE 3QL 0.357 / day
PA
chlordiazepoxide-clidinium 1
COMBIVENT RESPIMAT 2QL 0.267 / day
PR
CUVPOSA 3
dicyclomine 20 mg/2 ml ampul 1 MED Medical Drug
dicyclomine hcl (10 mg capsule, 10 mg/5 ml soln, 20 mgtablet) 1
dicyclomine 20 mg/2 ml vial 1 MED Medical Drug
DONNATAL (ELIXIR, TABLET) 3
DUAKLIR PRESSAIR 3QL 0.0333 / day
PA
ED-SPAZ 1
GLYCATE 3
glycopyrrolate (0.2 mg/ml syrng, 0.2 mg/ml vial, 0.4 mg/2ml syr, 0.4 mg/2 ml vl, 0.6 mg/3 ml syr, 1 mg/5 ml syrng,1 mg/5 ml vial, 4 mg/20 ml vial)
1 MED Medical Drug
glycopyrrolate (1 mg tablet, 1.5 mg tablet, 2 mg tablet) 1
glycopyrrolate-water 1 MED Medical Drug
GLYRX-PF 0.2 MG/ML VIAL 3 MED Medical Drug
GLYRX-PF 0.4 MG/2 ML VIAL 3
PAGE 76 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
hyoscyamine sulfate (0.125 mg odt, 0.125 mg tab sl,0.125 mg/5 ml elix, 0.125 mg/ml drop, sulf 0.125 mg tab) 1
hyoscyamine sulfate er 1
hyoscyamine sulfate sr 1
HYOSYNE (0.125 MG/ML DROP, 125 MCG/5 ML ELIXIR) 1
INCRUSE ELLIPTA 3QL 1 / day
PA
ipratropium br 0.02% soln 1QL 12.5 / day
PR
ipratropium-albuterol 1 PR
LEVBID 3 SBA Select BrandAlternative
LEVSIN 0.125 MG TABLET 3
LEVSIN-SL 3
LIBRAX 3 SBA Select BrandAlternative
LONHALA MAGNAIR REFILL 3QL 2 / day
PA
LONHALA MAGNAIR STARTER 3QL 2 / day
PA
methscopolamine bromide 1
NULEV 1
OSCIMIN (0.125 MG ODT, 0.125 MG TABLET) 1
OSCIMIN SL 1
OSCIMIN SR 1
phenobarbital-belladonna 1
PAGE 77 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
phenobarbital-hyosc-atrop-scop (phenobarb-hyo-atrop-scop elix, phenobarb-hyosc-atrop-scop tab) 1
PHENOHYTRO TABLET 1 HCG
propantheline bromide 1
QBREXZA 3QL 1 / day
PA
SEEBRI NEOHALER 3QL 2 / day
PA
SPIRIVA 2QL 1 / day
PR
SPIRIVA RESPIMAT 2QL 1 / day
PR
STIOLTO RESPIMAT 2QL 0.134 / day
PR
SYMAX 1
SYMAX DUOTAB 3
SYMAX-SL 1
SYMAX-SR 1
TUDORZA PRESSAIR 3
QL 0.04 / day
PR
PA
YUPELRI 3
QL 3 / day
AL At least 18 yrsold
PA
PAGE 78 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTICOAGULANTS
ANTICOAGULANTS, MISCELLANEOUS
ARIXTRA 3S
PR
fondaparinux sodium 1S
PR
sodium citrate 4% syringe 1
COUMARIN DERIVATIVES
COUMADIN 2PR
NTI
JANTOVEN (1 MG TABLET, 2.5 MG TABLET, 3 MG TABLET,4 MG TABLET, 5 MG TABLET) 1
PR
NTI
JANTOVEN (2 MG TABLET, 6 MG TABLET, 7.5 MG TABLET,10 MG TABLET) 1
PR
NTI
warfarin sodium (1 mg tablet, 2 mg tablet, 2.5 mg tablet,3 mg tablet, 4 mg tablet, 5 mg tablet) 1
PR
NTI
warfarin sodium (6 mg tablet, 7.5 mg tablet, 10 mgtablet) 1
PR
NTI
DIRECT FACTOR XA INHIBITORS
BEVYXXA 3
QL 1.25 / day
AL At least 18 yrsold
PA
ELIQUIS DVT-PE TREAT START 5MG 2QL 100 / 30 days
PR
ELIQUIS (2.5 MG TABLET, 5 MG TABLET) 2QL 2 / day
PR
PAGE 79 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SAVAYSA 3QL 1 / day
PA
XARELTO DVT-PE TREAT START 30D 2 QL 56 / fill
XARELTO (10 MG TABLET, 20 MG TABLET) 2QL 1 / day
PR
XARELTO (2.5 MG TABLET, 15 MG TABLET) 2QL 2 / day
PR
DIRECT THROMBIN INHIBITORS
ANGIOMAX 3 MED Medical Drug
argatroban 1 MED Medical Drug
argatrobn-0.9% nacl 250 mg/250 3 MED Medical Drug
argatroban-0.9% nacl (50 mg/50ml-0.9%nacl, 125mg/125-0.9%nacl) 1 MED Medical Drug
argatroban-sodium chloride 1 MED Medical Drug
bivalirudin rtu 250 mg/50 ml 1 MED Medical Drug
bivalirudin (250 mg add-vant vl, 250 mg vial) 1 MED Medical Drug
bivalirudin-0.9% nacl 1 MED Medical Drug
PRADAXA 2QL 2 / day
PR
HEPARINS
enoxaparin sodium (30 mg/0.3 ml syr, 40 mg/0.4 ml syr,60 mg/0.6 ml syr, 80 mg/0.8 ml syr, 100 mg/ml syringe,120 mg/0.8 ml syr, 150 mg/ml syringe)
1S
PR
enoxaparin 300 mg/3 ml vial 1S
PR
PAGE 80 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FRAGMIN (2,500 UNIT/0.2 ML SYR, 5,000 UNIT/0.2 MLSYR, 7,500 UNIT/0.3 ML SYR, 10,000 UNIT/ML SYRINGE,12,500 UNIT/0.5 ML SYR, 15,000 UNIT/0.6 ML SYR, 18,000UNIT/0.72 ML, 95,000 UNIT/3.8 ML VL)
3S
PR
hep-lock flush 100 unit/ml kit 1MED Medical Drug
PR
heparin flush (flush 10 units/ml syr, 20 units/2 ml (10/ml),200 unit/2 ml (100/ml)) 1 BSP BENEFIT SHIFT
PROGRAM
heparin flush (iv flush 1 unit/ml syr, 2 unit/2 ml (1/ml) syr,3 unit/3 ml (1/ml) syr, 5 unit/5 ml (1/ml) syr, 10 unit/10ml (1/ml), 30 units/3 ml (10/ml), 50 units/5 ml (10/ml), 60units/6 ml (10/ml), iv flush 100 units/ml, 300 unit/3 ml(100/ml), 1,000 unit/10 (100/ml))
1PR
BSP BENEFIT SHIFTPROGRAM
heparin lock (10 units/ml, 100 unit/ml) 1 BSP BENEFIT SHIFTPROGRAM
heparin lock (100 unit/10 ml (10/ml), 500 unit/5 ml(100/ml)) 1
PR
BSP BENEFIT SHIFTPROGRAM
heparin 5,000 unit/ml carpujct 1
heparin sodium (5,000 unit/0.5 ml, 5,000 unit/ml syrg,20,000 unit/ml vl) 1 BSP BENEFIT SHIFT
PROGRAM
heparin sodium (sod 1,000 unit/ml vial, 2,000 unit/2 mlvial, sod 5,000 unit/ml vial, 10,000 unit/10 ml vial, sod10,000 unit/ml vl, 30,000 unit/30 ml vial, 40,000 unit/4 mlvial, 50,000 unit/10 ml vial, 50,000 unit/5 ml vial)
1PR
BSP BENEFIT SHIFTPROGRAM
heparin sodium in 0.45% nacl 1PR
BSP BENEFIT SHIFTPROGRAM
heparin sodium-0.45% nacl (2.5 unit/10 ml-1/2 ns, 3unit/3 ml-1/2 ns, 10 unit/10 ml-1/2 ns, 100 unit/100 ml-1/2 ns, 5,000 unit/1,000-1/2ns)
1 BSP BENEFIT SHIFTPROGRAM
PAGE 81 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
heparin sodium-0.45% nacl (heparin-12,500 unit/250-1/2,heparin 25,000 unit/250-1/2, heparin 25,000 unit/500-1/2)
1PR
BSP BENEFIT SHIFTPROGRAM
heparin 1,000 unit/1,000 ml-ns 1PR
BSP BENEFIT SHIFTPROGRAM
heparin sodium-0.9% nacl (100 unit/100 ml-ns, 250unit/250 ml-ns, 500 unit/500 ml-ns, 2,000 unit/500 ml-ns,2,500 unit/500 ml-ns, 3,000 unit/500 ml-ns, 4,000unit/1,000 ml-ns, 4,000 unit/500 ml-ns, 5,000 unit/1,000ml-ns, 5,000 unit/5 ml-ns, 5,000 unit/500 ml-ns, 6,000unit/1,000 ml-ns, 10,000 unit/1,000ml-ns, 25,000unit/250 ml-ns, 30,000 unit/1,000-ns)
1 BSP BENEFIT SHIFTPROGRAM
heparin sodium-0.9% nacl (2,500 unit/5 ml-ns syr, 6,000unit/3 ml-ns syr) 1 MED Medical Drug
heparin sodium-d5w (12,500 unit/250, 20,000 unit/500) 1 BSP BENEFIT SHIFTPROGRAM
heparin sodium-d5w (unit/250, unit/500) 1PR
BSP BENEFIT SHIFTPROGRAM
LOVENOX (30 MG/0.3 ML SYRINGE, 40 MG/0.4 MLSYRINGE, 60 MG/0.6 ML SYRINGE, 80 MG/0.8 MLSYRINGE, 100 MG/ML SYRINGE, 120 MG/0.8 ML SYRINGE,150 MG/ML SYRINGE, 300 MG/3 ML VIAL)
3
S
PR
SBA Select BrandAlternative
ANTICONVULSANTS
ANTICONVULSANTS, MISCELLANEOUS
APTIOM (400 MG TABLET, 600 MG TABLET, 800 MGTABLET) 3
QL 2 / day
PA
APTIOM 200 MG TABLET 3QL 3 / day
PA
PAGE 82 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400MG TABLET) 3 PA
BRIVIACT 10 MG/ML ORAL SOLN 3QL 20 / day
PA
BRIVIACT (10 MG TABLET, 50 MG TABLET) 3QL 4 / day
PA
BRIVIACT 100 MG TABLET 3QL 2 / day
PA
BRIVIACT 25 MG TABLET 3QL 8 / day
PA
BRIVIACT 75 MG TABLET 3QL 3 / day
PA
BRIVIACT 50 MG/5 ML VIAL 3
QL 20 / day
MED Medical Drug
PA
carbamazepine (100 mg tab chew, 100 mg/5 ml susp, 200mg tablet) 1 NTI
carbamazepine er (er 100 mg cap, er 100 mg tablet, er200 mg cap, er 200 mg tablet, er 300 mg cap, er 400 mgtablet)
1 NTI
CARBATROL 3ST
NTI
DEPACON 3MED Medical Drug
NTI
DEPAKENE (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 3 NTI
DEPAKOTE 3ST
NTI
PAGE 83 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DEPAKOTE ER 2ST
NTI
DEPAKOTE SPRINKLE 2ST
NTI
DIACOMIT (250 MG CAPSULE, 250 MG POWDER PACKET,500 MG CAPSULE, 500 MG POWDER PACKET) 3
QL 2 / day
S
PA
divalproex sodium (dr 125 mg cap sprnk, sod dr 125 mgtab, sod dr 250 mg tab, sod dr 500 mg tab) 1 NTI
divalproex sodium er 1 NTI
EPIDIOLEX 3S
PA
EPITOL 1 NTI
EQUETRO 3PR
NTI
felbamate (400 mg tablet, 600 mg tablet, 600 mg/5 mlsusp) 1
FELBATOL (400 MG TABLET, 600 MG TABLET, 600 MG/5ML SUSP) 3 PA
FINTEPLA 3
QL 12 / day
S
PA
FYCOMPA 0.5 MG/ML ORAL SUSP 3 QL 6 / day
FYCOMPA (2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8MG TABLET, 10 MG TABLET, 12 MG TABLET) 3 QL 1 / day
gabapentin (100 mg capsule, 300 mg capsule, 400 mgcapsule) 1 QL 9 / day
PAGE 84 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
gabapentin (250 mg/5 ml soln, 300 mg/6 ml soln) 1 QL 72 / day
gabapentin 600 mg tablet 1 QL 6 / day
gabapentin 800 mg tablet 1 QL 5 / day
GABITRIL 3
HORIZANT ER 300 MG TABLET 3
QL 4 / day
PA
MVB MINIMALVALUE BRAND
HORIZANT ER 600 MG TABLET 3
QL 2 / day
PA
MVB MINIMALVALUE BRAND
KEPPRA (100 MG/ML ORAL SOLN, 250 MG TABLET, 500MG TABLET, 750 MG TABLET, 1,000 MG TABLET) 3
ST
NTI
KEPPRA 500 MG/5 ML VIAL 3ST
MED Medical Drug
KEPPRA XR 3ST
NTI
LAMICTAL (5 MG DISPER TABLET, 25 MG DISPER TABLET,25 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MGTABLET)
3ST
NTI
LAMICTAL (BLUE) 3ST
NTI
LAMICTAL (GREEN) 3ST
NTI
LAMICTAL (ORANGE) 3ST
NTI
LAMICTAL ODT 3ST
NTI
PAGE 85 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LAMICTAL ODT (BLUE) 3ST
NTI
LAMICTAL ODT (GREEN) 3ST
NTI
LAMICTAL ODT (ORANGE) 3ST
NTI
LAMICTAL XR 3ST
NTI
LAMICTAL XR (BLUE) 3ST
NTI
LAMICTAL XR (GREEN) 3ST
NTI
LAMICTAL XR (ORANGE) 3ST
NTI
lamotrigine (5 mg disper tablet, 25 mg disper tab, 25 mgtablet, 100 mg tablet, 150 mg tablet, 200 mg tablet) 1 NTI
lamotrigine (blue) 1 NTI
lamotrigine (green) 1 NTI
lamotrigine (orange) 1 NTI
lamotrigine er 1 NTI
lamotrigine odt 1 NTI
lamotrigine odt (blue) 1 NTI
lamotrigine odt (green) 1 NTI
lamotrigine odt (orange) 1 NTI
levetiracetam 500 mg/5 ml soln 1QL 946 / 30 days
NTI
PAGE 86 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
levetiracetam (100 mg/ml soln, 250 mg tablet, 500 mgtablet, 750 mg tablet, 1,000 mg tablet) 1 NTI
levetiracetam 500 mg/5 ml vial 1 MED Medical Drug
levetiracetam er 1 NTI
levetiracetam-nacl 1 MED Medical Drug
LYRICA (225 MG CAPSULE, 300 MG CAPSULE) 3
QL 2 / day
ST
SBA SELECT BRANDALTERNATIVE
LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MGCAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MGCAPSULE)
3
QL 3 / day
ST
SBA SELECT BRANDALTERNATIVE
LYRICA 20 MG/ML ORAL SOLUTION 3
QL 30 / day
ST
SBA SELECT BRANDALTERNATIVE
magnesium sulfate-0.9% nacl (1 g/100 ml-0.9% nacl, 6gm/50 ml-0.9% nacl, 40 g/1000ml-0.9%nacl) 1 MED Medical Drug
magnesium sulfate-d5w (5 gram/100, 6 gram/100, 6gram/50, 40 gram/1000, 40 gram/500) 1 MED Medical Drug
NEURONTIN (100 MG CAPSULE, 300 MG CAPSULE, 400MG CAPSULE) 3
QL 9 / day
ST
SBA Select BrandAlternative
NEURONTIN (250 MG/5 ML SOLN, 250 MG/5 MLSOLUTION) 3
QL 72 / day
ST
SBA Select BrandAlternative
NEURONTIN 600 MG TABLET 3
QL 6 / day
ST
SBA Select BrandAlternative
PAGE 87 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NEURONTIN 800 MG TABLET 3
QL 5 / day
ST
SBA Select BrandAlternative
oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml susp, 600 mg tablet) 1 NTI
OXTELLAR XR 3 NTI
pregabalin (225 mg capsule, 300 mg capsule) 1 QL 2 / day
pregabalin (25 mg capsule, 50 mg capsule, 75 mg capsule,100 mg capsule, 150 mg capsule, 200 mg capsule) 1 QL 3 / day
pregabalin 20 mg/ml solution 1 QL 30 / day
QUDEXY XR 3 ST
ROWEEPRA 1 NTI
ROWEEPRA XR 1 NTI
rufinamide 1
SABRIL (500 MG POWDER PACKET, 500 MG TABLET) 3
QL 6 / day
S
PA
SPRITAM 3
QL 3 / day
AL At least 4 yrsold
NTI
SUBVENITE 1 NTI
SUBVENITE (BLUE) 1 NTI
SUBVENITE (GREEN) 1 NTI
SUBVENITE (ORANGE) 1 NTI
TEGRETOL (100 MG/5 ML SUSP, 200 MG TABLET) 3ST
NTI
PAGE 88 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TEGRETOL XR 3ST
NTI
tiagabine hcl 1
TOPAMAX (15 MG SPRINKLE CAP, 25 MG SPRINKLE CAP,25 MG TABLET, 50 MG TABLET, 100 MG TABLET, 200 MGTABLET)
2ST
NTI
topiramate 15 mg sprinkle cap 1 NTI
topiramate (25 mg sprinkle cap, 25 mg tablet, 50 mgtablet, 100 mg tablet, 200 mg tablet) 1 NTI
topiramate er 1 NTI
TRILEPTAL (150 MG TABLET, 300 MG TABLET, 300 MG/5ML SUSP, 600 MG TABLET) 3
ST
NTI
TROKENDI XR 3 ST
valproate sodium 1MED Medical Drug
NTI
valproic acid (250 mg capsule, 250 mg/5 ml soln) 1 NTI
valproic acid 500 mg/10 ml sol 1 NTI
vigabatrin 500 mg powder packt 1
QL 6 / day
S
PS
PA
vigabatrin 500 mg tablet 3
QL 6 / day
S
PA
VIGADRONE 3
QL 6 / day
S
PA
PAGE 89 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VIMPAT 10 MG/ML SOLUTION 3
VIMPAT (150 MG TABLET, 200 MG TABLET, STARTER KIT) 3 QL 2 / day
VIMPAT (50 MG TABLET, 100 MG TABLET) 3 QL 4 / day
VIMPAT 200 MG/20 ML VIAL 3 MED Medical Drug
XCOPRI (12.5-25 MG PK, 50-100 MG PAK, 150-200 MG PK) 3QL 1 / day
PA
XCOPRI (150 MG TABLET, 200 MG TABLET, 250 MG DAILYDOSE PACK, 350 MG DAILY DOSE PACK) 3
QL 2 / day
PA
XCOPRI (50 MG TABLET, 100 MG TABLET) 3QL 4 / day
PA
ZONEGRAN 2ST
NTI
zonisamide (25 mg capsule, 100 mg capsule) 1 NTI
zonisamide 50 mg capsule 1 NTI
BARBITURATES (ANTICONVULSANTS)
MYSOLINE 3
primidone 1
BENZODIAZEPINES (ANTICONVULSANTS)
clobazam 2.5 mg/ml suspension 1S
PA
clobazam (10 mg tablet, 20 mg tablet) 1 PA
clonazepam (2 mg odt, 2 mg tablet) 1 QL 10 / day
clonazepam (0.125 mg dis tab, 0.125 mg odt, 0.25 mgodt, 0.5 mg dis tablet, 0.5 mg odt, 0.5 mg tablet, 1 mg distablet, 1 mg odt, 1 mg tablet)
1 QL 3 / day
PAGE 90 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
KLONOPIN (0.5 MG TABLET, 1 MG TABLET) 3
QL 3 / day
ST
SBA Select BrandAlternative
KLONOPIN 2 MG TABLET 3
QL 10 / day
ST
SBA Select BrandAlternative
NAYZILAM 3 QL 10 / 30 days
ONFI 2.5 MG/ML SUSPENSION 3S
PA
ONFI (10 MG TABLET, 20 MG TABLET) 3 PA
SYMPAZAN 3
QL 2 / day
S
PA
HYDANTOINS
CEREBYX 3 MED Medical Drug
DILANTIN (30 MG CAPSULE, 50 MG INFATAB, 100 MGCAPSULE) 2 NTI
DILANTIN-125 1 NTI
fosphenytoin sodium 1 MED Medical Drug
PEGANONE 3
PHENYTEK 2 NTI
phenytoin (50 mg infatab, 50 mg tablet chew, 100 mg/4ml susp, 125 mg/5 ml susp) 1 NTI
phenytoin sodium (50 mg/ml ampul, 50 mg/ml syringe, 50mg/ml vial, 100 mg/2 ml vial, 250 mg/5 ml vial) 1
MED Medical Drug
NTI
PAGE 91 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
phenytoin sodium extended 1 NTI
SUCCINIMIDES
CELONTIN 3
ethosuximide (250 mg capsule, 250 mg/5 ml soln) 1 NTI
ZARONTIN (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 2 NTI
ANTIDEPRESSANTS
ANTIDEPRESSANTS, MISCELLANEOUS
APLENZIN 3
QL 1 / day
ST
MVB Minimal ValueBrand
bupropion hcl 100 mg tablet 1 QL 5 / day
bupropion hcl 75 mg tablet 1 QL 6 / day
bupropion hcl sr 100 mg tablet 1 QL 4 / day
bupropion hcl sr 150 mg tablet 1QL 2 / day
HCR
bupropion hcl sr 200 mg tablet 1 QL 2 / day
bupropion hcl xl 150 mg tablet 1 QL 3 / day
bupropion hcl xl 300 mg tablet 1 QL 1 / day
bupropion hcl xl 450 mg tablet 1QL 1 / day
ST
FORFIVO XL 3QL 1 / day
ST
mirtazapine 7.5 mg tablet 1 QL 2 / day
mirtazapine (15 mg odt, 15 mg tablet, 30 mg odt, 30 mgtablet, 45 mg odt, 45 mg tablet) 1 QL 1 / day
PAGE 92 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
REMERON (15 MG SOLTAB, 15 MG TABLET, 30 MGSOLTAB, 30 MG TABLET, 45 MG SOLTAB) 3
QL 1 / day
SBA Select BrandAlternative
SPRAVATO 3
QL 8 / 28 days
S
PA
WELLBUTRIN SR (SR 150 MG TABLET, SR 200 MG TABLET) 3QL 2 / day
SBA Select BrandAlternative
WELLBUTRIN SR 100 MG TABLET 3QL 4 / day
SBA Select BrandAlternative
WELLBUTRIN XL 150 MG TABLET 3QL 3 / day
SBA Select BrandAlternative
WELLBUTRIN XL 300 MG TABLET 3QL 1 / day
SBA Select BrandAlternative
ZYBAN 3 QL 2 / day
MONOAMINE OXIDASE INHIBITORS
MARPLAN 3 QL 6 / day
NARDIL 3 QL 6 / day
PARNATE 3 QL 6 / day
phenelzine sulfate 1 QL 6 / day
tranylcypromine sulfate 1 QL 6 / day
SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR
CYMBALTA (20 MG CAPSULE, 30 MG CAPSULE) 3QL 1 / day
SBA Select BrandAlternative
PAGE 93 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CYMBALTA 60 MG CAPSULE 3QL 2 / day
SBA Select BrandAlternative
desvenlafaxine er 1
QL 1 / day
HCG
MVGMINIMALVALUEGENERIC
desvenlafaxine succinate er 1 QL 1 / day
DRIZALMA SPRINKLE 3 QL 2 / day
duloxetine hcl (dr 20 mg cap, dr 30 mg cap) 1 QL 1 / day
duloxetine hcl (dr 40 mg cap, dr 60 mg cap) 1 QL 2 / day
EFFEXOR XR (37.5 MG CAPSULE, 150 MG CAPSULE) 3QL 1 / day
SBA Select BrandAlternative
EFFEXOR XR 75 MG CAPSULE 3QL 3 / day
SBA Select BrandAlternative
FETZIMA (20-40 MG TITRATION PAK, ER 20 MG CAPSULE,ER 40 MG CAPSULE, ER 80 MG CAPSULE, ER 120 MGCAPSULE)
3QL 1 / day
ST
KHEDEZLA 3 QL 1 / day
PRISTIQ 3QL 1 / day
SBA Select BrandAlternative
venlafaxine hcl (37.5 mg tablet, 50 mg tablet, 75 mgtablet, 100 mg tablet) 1
venlafaxine hcl 25 mg tablet 1
venlafaxine hcl er (er 37.5 mg cap, er 150 mg cap) 1 QL 1 / day
PAGE 94 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
venlafaxine hcl er 75 mg cap 1 QL 3 / day
venlafaxine hcl er (er 37.5 mg tab, er 75 mg tab, er 150mg tab, er 225 mg tab) 1
QL 1 / day
HCG
MVGMINIMALVALUEGENERIC
SELECTIVE-SEROTONIN REUPTAKE INHIBITORS
BRISDELLE 3
QL 1 / day
ST
SBA Select BrandAlternative
CELEXA 3
QL 1 / day
ST
SBA Select BrandAlternative
citalopram hbr (10 mg/5 ml soln, 20 mg/10 ml sol) 1 QL 20 / day
citalopram hbr (10 mg tablet, 20 mg tablet, 40 mg tablet) 1 QL 1 / day
escitalopram oxalate 5 mg/5 ml 1 QL 20 / day
escitalopram 20 mg tablet 1 QL 1 / day
escitalopram oxalate (5 mg tablet, 10 mg tablet) 1 QL 1.5 / day
fluoxetine dr 1QL 0.15 / day
HCG
fluoxetine hcl 10 mg capsule 1 QL 1 / day
fluoxetine hcl 20 mg capsule 1 QL 4 / day
fluoxetine hcl 40 mg capsule 1 QL 2 / day
fluoxetine 20 mg/5 ml solution 1 QL 20 / day
fluoxetine hcl 10 mg tablet 1QL 1.5 / day
HCG
PAGE 95 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fluoxetine hcl 20 mg tablet 1QL 4 / day
HCG
fluoxetine hcl 60 mg tablet 1QL 1.5 / day
HCG
fluvoxamine maleate (25 mg tab, 50 mg tab) 1 QL 1 / day
fluvoxamine maleate 100 mg tab 1 QL 3 / day
fluvoxamine maleate er 1 QL 2 / day
LEXAPRO (5 MG TABLET, 10 MG TABLET) 3QL 1.5 / day
SBA Select BrandAlternative
LEXAPRO 20 MG TABLET 3QL 1 / day
SBA Select BrandAlternative
olanzapine-fluoxetine hcl 1
QL 1 / day
AL At least 10 yrsold
PR
paroxetine cr (cr 25 mg tablet, cr 37.5 mg tablet) 1 QL 2 / day
paroxetine cr 12.5 mg tablet 1 QL 1 / day
paroxetine er (er 25 mg tablet, er 37.5 mg tablet) 1 QL 2 / day
paroxetine er 12.5 mg tablet 1 QL 1 / day
paroxetine hcl 10 mg tablet 1 QL 1.5 / day
paroxetine hcl 20 mg tablet 1 QL 1 / day
paroxetine hcl 30 mg tablet 1 QL 2 / day
paroxetine hcl 40 mg tablet 1 QL 1 / day
paroxetine mesylate 1 QL 1 / day
PAGE 96 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PAXIL 10 MG/5 ML SUSPENSION 3QL 42 / day
PA
PAXIL (20 MG TABLET, 40 MG TABLET) 3
QL 1 / day
ST
SBA Select BrandAlternative
PAXIL 10 MG TABLET 3
QL 1.5 / day
ST
SBA Select BrandAlternative
PAXIL 30 MG TABLET 3
QL 2 / day
ST
SBA Select BrandAlternative
PAXIL CR (CR 25 MG TABLET, CR 37.5 MG TABLET) 3
QL 2 / day
ST
SBA Select BrandAlternative
PAXIL CR 12.5 MG TABLET 3
QL 1 / day
ST
SBA Select BrandAlternative
PEXEVA 3QL 1 / day
PA
PROZAC 10 MG PULVULE 3 SBA Select BrandAlternative
PROZAC 20 MG PULVULE 3QL 4 / day
SBA Select BrandAlternative
PROZAC 40 MG PULVULE 3QL 2 / day
SBA Select BrandAlternative
PAGE 97 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SARAFEM 10 MG TABLET 3 QL 1.5 / day
SARAFEM 20 MG TABLET 3 QL 4 / day
sertraline 20 mg/ml oral conc 1 QL 10 / day
sertraline hcl (25 mg tablet, 50 mg tablet) 1 QL 1.5 / day
sertraline hcl 100 mg tablet 1 QL 2 / day
SYMBYAX 3
QL 1 / day
AL At least 10 yrsold
PR
ZOLOFT 20 MG/ML ORAL CONC 3QL 10 / day
SBA Select BrandAlternative
ZOLOFT (25 MG TABLET, 50 MG TABLET) 3QL 1.5 / day
SBA Select BrandAlternative
ZOLOFT 100 MG TABLET 3QL 2 / day
SBA Select BrandAlternative
SEROTONIN MODULATORS
nefazodone hcl 100 mg tablet 1 QL 6 / day
nefazodone hcl 150 mg tablet 1 QL 4 / day
nefazodone hcl 200 mg tablet 1 QL 3 / day
nefazodone hcl 250 mg tablet 1 QL 2.5 / day
nefazodone hcl 50 mg tablet 1 QL 12 / day
trazodone 100 mg tablet 1 QL 4 / day
trazodone 150 mg tablet 1 QL 2 / day
PAGE 98 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
trazodone 300 mg tablet 1 QL 1 / day
trazodone 50 mg tablet 1 QL 3 / day
TRINTELLIX 3QL 1 / day
ST
VIIBRYD 10-20 MG STARTER PACK 3
VIIBRYD (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 QL 1 / day
TRICYCLICS, OTHER NOREPI-RU INHIBITORS
amitriptyline hcl 1
amoxapine 1
ANAFRANIL 3 SBA Select BrandAlternative
chlordiazepoxide-amitriptyline 1
clomipramine hcl 1
desipramine hcl 1
doxepin hcl (10 mg capsule, 25 mg capsule, 50 mgcapsule, 100 mg capsule) 1
doxepin hcl (10 mg/ml oral conc, 75 mg capsule, 150 mgcapsule) 1
doxepin hcl (3 mg tablet, 6 mg tablet) 1 QL 1 / day
ELAVIL 3
imipramine hcl 1
imipramine pamoate 1
maprotiline hcl 1
NORPRAMIN 3
nortriptyline hcl (10 mg/5 ml soln, hcl 10 mg cap, hcl 25mg cap, hcl 50 mg cap, hcl 75 mg cap) 1
PAGE 99 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PAMELOR (10 MG CAPSULE, 25 MG CAPSULE, 75 MGCAPSULE) 3
PAMELOR 50 MG CAPSULE 3 SBA Select BrandAlternative
perphenazine-amitriptyline 1
protriptyline hcl 1
SILENOR 3QL 1 / day
B4G
SURMONTIL 3
TOFRANIL (10 MG TABLET, 50 MG TABLET) 3
TOFRANIL 25 MG TABLET 3 SBA Select BrandAlternative
trimipramine maleate 1
ANTIDIABETIC AGENTS
ALPHA-GLUCOSIDASE INHIBITORS
acarbose 100 mg tablet 1QL 3 / day
PR
acarbose 25 mg tablet 1QL 12 / day
PR
acarbose 50 mg tablet 1QL 6 / day
PR
GLYSET 3QL 3 / day
PR
miglitol 1QL 3 / day
PR
PRECOSE 100 MG TABLET 3QL 3 / day
PR
PAGE 100 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PRECOSE 25 MG TABLET 3QL 12 / day
PR
PRECOSE 50 MG TABLET 3QL 6 / day
PR
AMYLINOMIMETICS
SYMLINPEN 120 2
QL 0.4 / day
PR
PA
SYMLINPEN 60 2
QL 0.2 / day
PR
PA
ANTIDIABETIC AGENTS, MISCELLANEOUS
KORLYM 3S
PA
BIGUANIDES
GLUCOPHAGE 1,000 MG TABLET 3
QL 2.5 / day
ST
PR
SBA Select BrandAlternative
GLUCOPHAGE 500 MG TABLET 3
QL 5 / day
ST
PR
SBA Select BrandAlternative
GLUCOPHAGE 850 MG TABLET 3
QL 3 / day
ST
PR
SBA Select BrandAlternative
PAGE 101 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GLUCOPHAGE XR 500 MG TAB 3
QL 5 / day
ST
PR
SBA Select BrandAlternative
GLUCOPHAGE XR 750 MG TAB 3
QL 3 / day
ST
PR
SBA Select BrandAlternative
metformin hcl 500 mg/5 ml soln 1QL 25 / day
PR
metformin hcl 1,000 mg tablet 1QL 2.5 / day
PR
metformin hcl 500 mg tablet 1QL 5 / day
PR
metformin hcl 850 mg tablet 1QL 3 / day
PR
metformin hcl er 500 mg tablet 1
QL 5 / day
COnlyGlucophage ERgenericcovered
PR
metformin hcl er 750 mg tablet 1
QL 3 / day
COnlyGlucophage ERgenericcovered
PR
PAGE 102 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RIOMET ER 3
QL 20 / day
PR
PA
MVB Minimal ValueBrand
SBA Select BrandAlternative
DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS
alogliptin 3
QL 1 / day
PR
PA
alogliptin-metformin 3
QL 2 / day
PR
PA
alogliptin-pioglitazone 3
QL 1 / day
PR
PA
JANUMET 2QL 2 / day
PR
JANUMET XR (50-1,000 MG TABLET, 50-500 MG TABLET) 2QL 2 / day
PR
JANUMET XR 100-1,000 MG TABLET 2QL 1 / day
PR
JANUVIA 2QL 1 / day
PR
JENTADUETO 2QL 2 / day
PR
JENTADUETO XR 2.5 MG-1,000 MG 2QL 2 / day
PR
PAGE 103 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
JENTADUETO XR 5 MG-1,000 MG TB 2QL 1 / day
PR
KAZANO 3
QL 2 / day
PR
PA
B4G
KOMBIGLYZE XR 3
QL 1 / day
PR
PA
NESINA 3
QL 1 / day
PR
PA
B4G
ONGLYZA 3
QL 1 / day
PR
PA
OSENI 3
QL 1 / day
PR
PA
B4G
TRADJENTA 2QL 1 / day
PR
INCRETIN MIMETICS
ADLYXIN 10-20 MCG STARTER PACK 3QL 14 / 1 rx
PA
ADLYXIN 20 MCG MAINTENANCE PK 3QL 0.22 / day
PA
PAGE 104 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BYDUREON 2QL 0.15 / day
PR
BYDUREON BCISE 2QL 0.15 / day
PR
BYDUREON PEN 2QL .15 / day
PR
BYETTA 10 MCG DOSE PEN INJ 2QL 0.08 / day
PR
BYETTA 5 MCG DOSE PEN INJ 2QL 0.04 / day
PR
OZEMPIC 0.25-0.5 MG DOSE PEN 2QL 0.067 / day
PR
OZEMPIC 1 MG DOSE PEN 2QL 0.124 / day
PR
RYBELSUS 2QL 1 / day
PA
SAXENDA 3
QL 0.5 / day
AL At least 18 yrsold
PA
TRULICITY 2QL 0.08 / day
PR
VICTOZA 2-PAK 2QL 0.3 / day
PR
VICTOZA 3-PAK 2QL 0.3 / day
PR
PAGE 105 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MEGLITINIDES
nateglinide 1QL 3 / day
PR
PRANDIN 1 MG TABLET 3QL 4 / day
PR
PRANDIN 2 MG TABLET 3QL 8 / day
PR
repaglinide (0.5 mg tablet, 1 mg tablet) 1QL 4 / day
PR
repaglinide 2 mg tablet 1QL 8 / day
PR
repaglinide-metformin hcl 1QL 5 / day
PR
STARLIX 3QL 3 / day
PR
SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB
FARXIGA 2QL 1 / day
PR
GLYXAMBI 2QL 1 / day
PR
INVOKAMET 3
QL 2 / day
PR
PA
INVOKAMET XR 3
QL 2 / day
PR
PA
PAGE 106 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
INVOKANA 3
QL 1 / day
PR
PA
JARDIANCE 2QL 1 / day
PR
QTERN 3QL 1 / day
PA
SEGLUROMET 3QL 2 / day
PA
STEGLATRO 3QL 1 / day
PA
STEGLUJAN 3QL 1 / day
PA
SYNJARDY 2 QL 2 / day
SYNJARDY XR (5-1,000 MG TABLET, 10-1,000 MG TABLET,12.5-1,000 MG TAB) 2 QL 2 / day
SYNJARDY XR 25-1,000 MG TABLET 2 QL 1 / day
TRIJARDY XR (10-5-1,000 MG TAB, 25-5-1,000 MG TAB) 2QL 1 / day
PR
TRIJARDY XR (5-2.5-1,000 MG TAB, 12.5-2.5-1,000 MG) 2QL 2 / day
PR
XIGDUO XR (2.5 MG TAB, 5 MG TABLET) 2QL 2 / day
PR
XIGDUO XR (5 MG-500 MG TABLET, 10 MG-1,000 MGTAB, 10 MG-500 MG TABLET) 2
QL 1 / day
PR
PAGE 107 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SULFONYLUREAS
AMARYL 3 PR
chlorpropamide 100 mg tablet 1 PR
chlorpropamide 250 mg tablet 1QL 3 / day
PR
glimepiride 1 PR
glipizide 1 PR
glipizide er 1 PR
glipizide xl 1 PR
glipizide-metformin (2.5-500 mg, 5-500 mg) 1QL 4 / day
PR
glipizide-metformin 2.5-250 mg 1QL 8 / day
PR
GLUCOTROL 3 PR
GLUCOTROL XL 3 PR
glyburide 1 PR
glyburide micronized 1 PR
glyburid-metformin 1.25-250 mg 1QL 8 / day
PR
glyburide-metformin hcl (2.5-500 mg, 5-500 mg) 1QL 4 / day
PR
GLYNASE 3 PR
tolazamide 250 mg tablet 1QL 4 / day
PR
PAGE 108 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
tolazamide 500 mg tablet 1QL 2 / day
PR
tolbutamide 1QL 6 / day
PR
THIAZOLIDINEDIONES
ACTOPLUS MET 3QL 3 / day
PR
ACTOPLUS MET XR 15-1,000 MG TB 2
QL 3 / day
ST
PR
MVB MINIMALVALUE BRAND
ACTOPLUS MET XR 30-1,000 MG TB 2
QL 1 / day
ST
PR
MVB MINIMALVALUE BRAND
ACTOS 3
QL 1 / day
PR
SBA Select BrandAlternative
AVANDIA 2 MG TABLET 2
QL 3 / day
PR
PA
AVANDIA 4 MG TABLET 2
QL 2 / day
PR
PA
DUETACT 3QL 1 / day
PR
PAGE 109 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
pioglitazone hcl 1QL 1 / day
PR
pioglitazone-glimepiride 1QL 1 / day
PR
pioglitazone-metformin 1QL 3 / day
PR
ANTIEMETICS
5-HT3 RECEPTOR ANTAGONISTS
ANZEMET 3 QL 0.15 / day
granisetron hcl 1 mg tablet 1 QL 6 / 30 days
granisetron hcl (0.1 mg/ml vial, 1 mg/ml vial, 4 mg/4 mlvial) 1
S
MED Medical Drug
ondansetron hcl (4 mg/2 ml isecure, hcl 4 mg/2 ml amp,hcl 4 mg/2 ml syr, hcl 4 mg/2 ml vial, 40 mg/20 ml vial) 1
S
BSP BENEFIT SHIFTPROGRAM
ondansetron 4 mg/5 ml solution 1 QL 20 / day
ondansetron hcl (4 mg tablet, 8 mg tablet) 1
QL 24 / 30 days
CMax allowable-3/day with maxof 24 / 30 days
ondansetron hcl 24 mg tablet 1 QL 3 days
ondansetron hcl-0.9% nacl (8mg/50ml-0.9% nacl,16mg/50ml-0.9%nacl) 1
S
BSP BENEFIT SHIFTPROGRAM
ondansetron hcl-d5w 1S
BSP BENEFIT SHIFTPROGRAM
ondansetron odt 1
QL 24 / 30 days
CMax allowable-3/day with maxof 24 / 30 days
PAGE 110 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SANCUSO 3
QL 0.144 / day
PA
MVB Minimal ValueBrand
ZOFRAN 4 MG/5 ML ORAL SOLN 3QL 20 / day
SBA Select BrandAlternative
ZOFRAN (4 MG TABLET, 8 MG TABLET) 3
QL 24 / 30 days
CMax allowable-3/day with maxof 24 / 30 days
SBA Select BrandAlternative
ZUPLENZ 3QL 24 / 30 days
MVB MINIMALVALUE BRAND
ANTIEMETICS, MISCELLANEOUS
BARHEMSYS 3 MED Medical Drug
CESAMET 3
QL 0.67 / day
S
PA
dronabinol 1 QL 5 / day
MARINOL 3QL 5 / day
PA
scopolamine 1
SYNDROS 3
QL 13 / day
AL At least 18 yrsold
PA
TRANSDERM-SCOP 3 SBA Select BrandAlternative
PAGE 111 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIHISTAMINES (GI DRUGS)
BONJESTA 3QL 2 / day
PA
COMPAZINE 25 MG SUPPOSITORY 1 PR
COMPAZINE (5 MG TABLET, 10 MG TABLET) 3
COMPRO 1 PR
DICLEGIS 3
QL 4 / day
PA
MVB Minimal ValueBrand
SBA Select BrandAlternative
dimenhydrinate 50 mg/ml vial 1 MED Medical Drug
doxylamine succ-pyridoxine hcl 1QL 4 / day
PA
meclizine hcl (12.5 mg tablet, 25 mg tablet) 1
prochlorperazine 1 PR
prochlorperazine 10 mg/2 ml vl 1MED Medical Drug
PR
prochlorperazine 50 mg/10 ml 1 PR
prochlorperazine maleate 1 PR
TIGAN 300 MG CAPSULE 3
TIGAN 100 MG/ML VIAL 3 MED Medical Drug
trimethobenzamide hcl 1
NEUROKININ-1 RECEPTOR ANTAGONISTS
AKYNZEO 300-0.5 MG CAPSULE 3QL 0.15 / day
PA
PAGE 112 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
aprepitant 125-80-80 mg pack 1QL 3/ fill
HCG
aprepitant (40 mg capsule, 125 mg capsule) 1 QL 0.08 / day
aprepitant 80 mg capsule 1 QL 0.15 / day
CINVANTI 3S
MED Medical Drug
EMEND TRIPACK 3QL 3/ fill
SBA Select BrandAlternative
EMEND (40 MG CAPSULE, 125 MG CAPSULE) 3QL 0.08 / day
SBA Select BrandAlternative
EMEND 80 MG CAPSULE 3QL 0.15 / day
SBA Select BrandAlternative
EMEND 125 MG POWDER PACKET 3 QL 0.08 / day
EMEND 150 MG VIAL 3
QL 2 / fill
S
MED Medical Drug
fosaprepitant dimeglumine 1
QL 2 / fill
S
MED Medical Drug
VARUBI 90 MG TABLET 3
QL 0.15 / day
S
PA
VARUBI 166.5 MG/92.5 ML VIAL 3
S
MED Medical Drug
PA
PAGE 113 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIFUNGAL (SYSTEMIC)
ALLYLAMINE ANTIFUNGALS
terbinafine hcl 1
ANTIFUNGALS, MISCELLANEOUS
griseofulvin 125 mg/5 ml susp 1
griseofulvin micro 500 mg tab 1 HCG
griseofulvin ultramicrosize 1 HCG
AZOLE ANTIFUNGALS
CRESEMBA 186 MG CAPSULE 3 PA
CRESEMBA 372 MG VIAL 3
S
MED Medical Drug
PA
DIFLUCAN (10 MG/ML SUSPENSION, 40 MG/MLSUSPENSION, 50 MG TABLET, 100 MG TABLET, 200 MGTABLET)
3
DIFLUCAN 150 MG TABLET 3 QL 1 / day
fluconazole (10 mg/ml susp, 40 mg/ml susp, 50 mg tablet,100 mg tablet, 200 mg tablet) 1
fluconazole 150 mg tablet 1 QL 1 / day
fluconazole in saline 1 MED Medical Drug
fluconazole-nacl 1 MED Medical Drug
itraconazole (10 mg/ml solution, 100 mg capsule) 1
ketoconazole 200 mg tablet 1
NOXAFIL 40 MG/ML SUSPENSION 3
NOXAFIL DR 100 MG TABLET 3MVB Minimal Value
Brand
SBA Select BrandAlternative
PAGE 114 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NOXAFIL 300 MG/16.7 ML VIAL 3 MED Medical Drug
ONMEL 3 PA
posaconazole dr 100 mg tablet 1
SPORANOX 100 MG CAPSULE 3 PA
SPORANOX 10 MG/ML SOLUTION 3PA
SBA Select BrandAlternative
TOLSURA 3S
PA
VFEND 40 MG/ML SUSPENSION 3QL 20 / day
S
VFEND (50 MG TABLET, 200 MG TABLET) 3 QL 4 / day
VFEND IV 3MED Medical Drug
PA
voriconazole 40 mg/ml susp 1QL 20 / day
S
voriconazole (50 mg tablet, 200 mg tablet) 1 QL 4 / day
voriconazole 200 mg vial 1MED Medical Drug
PA
ECHINOCANDIN ANTIFUNGALS
CANCIDAS 3 MED Medical Drug
caspofungin acetate 1 MED Medical Drug
ERAXIS (WATER DILUENT) 3 MED Medical Drug
micafungin 1 MED Medical Drug
MYCAMINE 3 MED Medical Drug
PAGE 115 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
POLYENE ANTIFUNGALS
ABELCET 3 MED Medical Drug
AMBISOME 3 MED Medical Drug
amphotericin b 1 MED Medical Drug
nystatin (100,000 unit/ml susp, 500,000 unit oral tab,500,000 unit/5 ml sus) 1
PYRIMIDINE ANTIFUNGALS
ANCOBON 3
flucytosine 1
ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE)
ALLYLAMINES (SKIN AND MUCOUS MEMBRANE)
naftifine hcl (1% cream, 1% gel, 2% cream) 1
ST
HCG
MVGMINIMALVALUEGENERIC
NAFTIN 2% CREAM 3
ST
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
NAFTIN 1% GEL 3ST
SBA Select BrandAlternative
NAFTIN 2% GEL 3 ST
ANTIFULGALS (SKIN, MUCOUS MEMBRANE),MISC
TRIPLE DYE 3
PAGE 116 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AZOLES (SKIN AND MUCOUS MEMBRANE)
clotrimazole (1% solution, 1% topical cream, 10 mgtroche) 1
clotrimazole-betamethasone crm 1
clotrimazole-betamethasone lot 1
ST
AL At least 17 yrsold
HCG
econazole nitrate 1
ECOZA 3ST
AL At least 12 yrsold
ERTACZO 3ST
AL At least 12 yrsold
EXELDERM (CREAM, SOLUTION) 3ST
AL At least 18 yrsold
EXTINA 3ST
AL At least 12 yrsold
GYNAZOLE 1 3 MVB MINIMALVALUE BRAND
JUBLIA 3
QL 0.54 / day
AL At least 6 yrsold
PA
ketoconazole 2% cream 1 QL 2 / day
ketoconazole 2% foam 1ST
HCG
PAGE 117 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ketoconazole 2% shampoo 1
LOTRISONE 3
luliconazole 1QL 2 / day
PA
LUZU 3
QL 2 / day
PA
SBA Select BrandAlternative
miconazole 3 200 mg vag supp 3 GL Female
NIZORAL 3
ORAVIG 3
oxiconazole nitrate 1
ST
HCG
MVGMINIMALVALUEGENERIC
OXISTAT 1% CREAM 3
ST
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
OXISTAT 1% LOTION 3ST
AL At least 18 yrsold
sulconazole nitrate (cream, soln) 3ST
AL At least 18 yrsold
terconazole 0.4% cream 1QL 1.5 / day
GL Female
terconazole 0.8% cream 1 GL Female
PAGE 118 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
terconazole 80 mg suppository 1
QL 1.5 / day
GL Female
HCG
XOLEGEL 3
ST
AL At least 12 yrsold
MVB MINIMALVALUE BRAND
HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)
CICLODAN 8% SOLUTION 1 QL 0.22 / day
ciclopirox (0.77% cream, 0.77% gel, 0.77% topical susp,1% shampoo) 1
ciclopirox 8% solution 1 QL 0.22 / day
LOPROX 1% SHAMPOO 3 SBA Select BrandAlternative
LOPROX 0.77% TOPICAL SUSP 3ST
AL At least 10 yrsold
PENLAC 3 QL 0.3 / day
OXABOROLES
KERYDIN 3
QL 0.67 / day
AL At least 6 yrsold
PA
POLYENES (SKIN AND MUCOUS MEMBRANE)
NYAMYC 1
nystatin (unit/gm cream, unit/gm oint) 1
nystatin 100,000 unit/gm powd 1 QL 1 / day
PAGE 119 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
nystatin-triamcinolone cream 1
nystatin-triamcinolone ointm 1 HCG
NYSTOP 1
ANTIGLAUCOMA AGENTS
ALPHA-ADRENERGIC AGONISTS (EENT)
ALPHAGAN P 0.1% DROPS 2 QL 0.4 / day
ALPHAGAN P 0.15% EYE DROPS 3QL 0.4 / day
SBA Select BrandAlternative
brimonidine 0.2% eye drop 1 QL 0.4 / day
brimonidine tartrate 0.15% drp 1QL 0.4 / day
HCG
COMBIGAN 2 QL 0.334 / day
BETA-ADRENERGIC BLOCKING AGENTS (EENT)
betaxolol hcl 0.5% eye drop 1 QL 0.54 / day
BETIMOL 0.25% EYE DROPS 3 QL 0.286 / day
BETIMOL 0.5% EYE DROPS 3 QL 0.334 / day
BETOPTIC S 3 QL 0.54 / day
carteolol hcl 1 QL 0.334 / day
ISTALOL 3QL 0.286 / day
SBA SELECT BRANDALTERNATIVE
levobunolol hcl 1 QL 0.4 / day
metipranolol 1 QL 0.334 / day
timolol maleate (drop, maleate drop, maleate drops) 1 QL 0.334 / day
PAGE 120 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
timolol maleate (0.25% gel-solution, 0.25% gfs gel-solution, maleate 0.25% eye drop, 0.5% gel-solution, 0.5%gfs gel-solution)
1 QL 0.286 / day
TIMOPTIC 0.25% EYE DROP 3QL 0.286 / day
ST
TIMOPTIC 0.5% EYE DROP 3QL 0.334 / day
ST
TIMOPTIC 0.25% OCUDOSE DROP 3QL 2 / day
ST
TIMOPTIC 0.5% OCUDOSE DROP 3
QL 2 / day
ST
MVB MINIMALVALUE BRAND
TIMOPTIC-XE 3QL 0.286 / day
ST
CARBONIC ANHYDRASE INHIBITORS (EENT)
acetazolamide 1
acetazolamide er 1
acetazolamide sodium 1 MED Medical Drug
AZOPT 2 QL 0.334 / day
COSOPT 3
QL 0.334 / day
ST
SBA Select BrandAlternative
COSOPT PF 3
QL 2 / day
ST
SBA Select BrandAlternative
PAGE 121 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
dorzolamide hcl 1 QL 0.4 / day
dorzolamide-timolol 2%-0.5% 1 QL 2 / day
dorzolamide-timolol eye drops 1 QL 0.334 / day
methazolamide 25 mg tablet 1
methazolamide 50 mg tablet 1 HCG
SIMBRINZA 2 QL 0.4 / day
TRUSOPT 3 QL 0.4 / day
MIOTICS
ISOPTO CARPINE 3 QL 0.54 / day
MIOCHOL-E 3 MED Medical Drug
MIOSTAT 3 MED Medical Drug
PHOSPHOLINE IODIDE 3
pilocarpine hcl (1% drops, 2% drops, 4% drops) 1 QL 0.54 / day
PROSTAGLANDIN ANALOGS
bimatoprost 0.03% eye drops 1QL 0.13 / day
HCG
bimatoprost 0.03% eyelash soln 1
HCG
MVGMINIMALVALUEGENERIC
latanoprost 0.005% eye drops 1 QL 0.13 / day
LATISSE 3 ST
LUMIGAN 2 QL 0.13 / day
TRAVATAN Z 3QL 0.167 / day
ST
PAGE 122 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
travoprost 1 QL 0.167 / day
VYZULTA 3QL 0.25 / day
MVB MINIMALVALUE BRAND
XALATAN 3
QL 0.13 / day
ST
SBA Select BrandAlternative
XELPROS 2 QL 0.1 / day
ZIOPTAN 3 QL 1 / day
RHO KINASE INHIBITORS
RHOPRESSA 3 QL 0.1 / day
ROCKLATAN 3 QL 0.1 / day
ANTIHEMORRHAGIC AGENTS
ANTIHEPARIN AGENTS
protamine sulfate 1 MED Medical Drug
HEMOSTATICS
ADVATE 3S
PA
ADYNOVATE 3S
PA
AFSTYLA 3S
PA
ALPHANATE 3S
PA
ALPHANINE SD 3 S
PAGE 123 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ALPROLIX 3S
PA
AMICAR (0.25 GRAM/ML ORAL SOLN, 500 MG TABLET,1,000 MG TABLET) 3
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
aminocaproic acid (0.25 gram/ml, 500 mg tab, 1,000 mgtab) 1
BENEFIX 3S
PA
COAGADEX 3S
PA
CORIFACT 3 S
ELOCTATE 3S
PA
ESPEROCT 3S
PA
FEIBA NF 3S
PA
HELIXATE FS 3S
PA
HEMLIBRA 3
QL 12 / day
S
PA
HEMOFIL M 3S
PA
HUMATE-P 3S
PA
PAGE 124 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
IDELVION 3S
PA
IXINITY 3S
PA
JIVI 3S
PA
KCENTRA 3 MED Medical Drug
KOATE 3S
PA
KOGENATE FS 3S
PA
KOVALTRY 3S
PA
LYSTEDA 3QL 6/ day plus 90/
90 day limitGL Female
MONONINE 3S
PA
NOVOEIGHT 3S
PA
NOVOSEVEN RT 3S
PA
NUWIQ 3S
PA
OBIZUR 3S
PA
PROFILNINE 3S
PA
PAGE 125 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
REBINYN 3S
PA
RECOMBINATE 3S
PA
RIXUBIS 3S
PA
SEVENFACT 3S
PA
tranexamic acid 650 mg tablet 1QL 6 / day
GL Female
tranexamic acid-nacl 1S
MED Medical Drug
TRETTEN 3S
PA
VISTASEAL FIBRIN SEALANT 3 MED Medical Drug
VONVENDI 3S
PA
WILATE 3S
PA
XYNTHA 3S
PA
XYNTHA SOLOFUSE 3S
PA
PAGE 126 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIHISTAMINE DRUGS
SECOND GENERATION ANTIHISTAMINES
cetirizine hcl (1 mg/ml soln, 1 mg/ml syrup) 1 QL 10 / day
CLARINEX 0.5 MG/ML (2.5 MG/5) 3
QL 10 / day
PA
MVB MINIMALVALUE BRAND
CLARINEX 5 MG TABLET 3QL 1 / day
SBA Select BrandAlternative
CLARINEX-D 12 HOUR 3QL 2 / day
MVB MINIMALVALUE BRAND
desloratadine 5 mg tablet 1 QL 1 / day
desloratadine (2.5 mg odt, 5 mg odt) 1
QL 1 / day
HCG
MVGMINIMALVALUEGENERIC
levocetirizine 2.5 mg/5 ml sol 1 QL 30 / day
levocetirizine 5 mg tablet 1 QL 1 / day
QUZYTTIR 3 MED Medical Drug
SEMPREX-D 3QL 4 / day
MVB Minimal ValueBrand
XYZAL 2.5 MG/5 ML SOLUTION 3 QL 30 / day
PAGE 127 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIHYPOGLYCEMIC AGENTS
ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS
diazoxide 1
PROGLYCEM 3
GLYCOGENOLYTIC AGENTS
BAQSIMI 2
GLUCAGEN 1 MG HYPOKIT 3 ST
GLUCAGON EMERGENCY KIT 2
GVOKE HYPOPEN 1-PACK 2
GVOKE HYPOPEN 2-PACK 2
GVOKE PFS 1-PACK SYRINGE 2
GVOKE PFS 2-PACK SYRINGE 2
ANTILIPEMIC AGENTS
ANTILIPEMIC AGENTS, MISCELLANEOUS
JUXTAPID (20 MG CAPSULE, 30 MG CAPSULE, 40 MGCAPSULE, 60 MG CAPSULE) 3
QL 1 / day
S
PR
PA
JUXTAPID (5 MG CAPSULE, 10 MG CAPSULE) 3
QL 2 / day
S
PR
PA
LOVAZA 3
QL 4 / day
PR
PA
SBA Select BrandAlternative
PAGE 128 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NEXLETOL 2QL 1 / day
PA
NEXLIZET 2QL 1 / day
PA
niacin er (er 750 mg tablet, er 1,000 mg tablet) 1
QL 2 / day
PR
HCG
niacin er 500 mg tablet 1
QL 3 / day
PR
HCG
NIACOR 3QL 12 / day
PR
NIASPAN ER 1,000 MG TABLET 3
QL 2 / day
ST
PR
SBA SELECT BRANDALTERNATIVE
NIASPAN ER 500 MG TABLET 3
QL 3 / day
ST
PR
NIASPAN ER 750 MG TABLET 3
QL 2 / day
ST
PR
cvs omega-3 gummy fish 1
omega-3 acid ethyl esters 1QL 4 / day
PR
THEROMEGA SPORT 1
PAGE 129 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRIKLO 1QL 4 / day
PR
VASCEPA 0.5 GM CAPSULE 2
QL 4 / day
PR
PA
VASCEPA 1 GM CAPSULE 2
QL 4 / day
PR
PA
B4G
BILE ACID SEQUESTRANTS
cholestyramine powder 1QL 24 / day
PR
cholestyramine packet 1QL 4 / day
PR
cholestyramine light powder 1QL 24 / day
PR
cholestyramine light packet 1QL 4 / day
PR
colesevelam hcl 3.75 g packet 1QL 1 / day
PR
colesevelam 625 mg tablet 1QL 6 / day
PR
COLESTID (FLAVORED GRANULES, GRANULES) 3
QL 30 / day
ST
PR
COLESTID GRANULES PACKET 3
QL 6 / day
ST
PR
PAGE 130 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
COLESTID 1 GM TABLET 3
QL 4 / day
ST
PR
colestipol hcl (granules, granules packet) 1
QL 6 / day
PR
HCG
colestipol hcl (hcl 1 gm tablet, micronized 1 gm tab) 1
QL 4 / day
PR
HCG
PREVALITE POWDER 1QL 24 / day
PR
PREVALITE PACKET 1QL 4 / day
PR
QUESTRAN POWDER 3
QL 24 / day
ST
PR
QUESTRAN PACKET 3QL 4 / day
PR
QUESTRAN LIGHT 3QL 24 / day
PR
WELCHOL 3.75G PACKET 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
WELCHOL 625 MG TABLET 3
QL 6 / day
ST
PR
PAGE 131 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CHOLESTEROL ABSORPTION INHIBITORS
ezetimibe 1QL 1 / day
PR
ezetimibe-simvastatin 1QL 1 / day
PR
VYTORIN 3
QL 1 / day
PR
SBA Select BrandAlternative
ZETIA 3
QL 1 / day
PR
SBA Select BrandAlternative
FIBRIC ACID DERIVATIVES
ANTARA 30 MG CAPSULE 3
QL 2 / day
PR
PA
ANTARA 90 MG CAPSULE 3
QL 1 / day
PR
PA
fenofibrate (130 mg capsule, 150 mg capsule) 1
QL 1 / day
PR
HCG
MVGMINIMALVALUEGENERIC
fenofibrate (40 mg tablet, 50 mg capsule) 1
QL 2 / day
HCG
MVGMINIMALVALUEGENERIC
PAGE 132 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fenofibrate (67 mg capsule, 134 mg capsule, 145 mgtablet, 160 mg tablet, 200 mg capsule) 1
QL 1 / day
PR
fenofibrate (43 mg capsule, 48 mg tablet, 54 mg tablet) 1QL 2 / day
PR
fenofibrate 120 mg tablet 1
QL 1 / day
HCG
MVGMINIMALVALUEGENERIC
fenofibric acid (105 mg tablet, dr 135 mg cap) 1QL 1 / day
PR
fenofibric acid (35 mg tablet, dr 45 mg cap) 1QL 2 / day
PR
FENOGLIDE 120 MG TABLET 3
QL 1 / day
PR
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
FENOGLIDE 40 MG TABLET 3
QL 2 / day
PR
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
FIBRICOR 105 MG TABLET 3QL 1 / day
PR
FIBRICOR 35 MG TABLET 3QL 2 / day
PR
gemfibrozil 1QL 2 / day
PR
PAGE 133 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LIPOFEN 150 MG CAPSULE 3
QL 1 / day
PR
PA
MVB MINIMALVALUE BRAND
LIPOFEN 50 MG CAPSULE 3
QL 2 / day
PR
PA
LOPID 3QL 2 / day
PR
TRICOR 145 MG TABLET 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
TRICOR 48 MG TABLET 3
QL 2 / day
ST
PR
SBA Select BrandAlternative
TRIGLIDE 3
QL 1 / day
PR
PA
TRILIPIX DR 135 MG CAPSULE 3QL 1 / day
PR
TRILIPIX DR 45 MG CAPSULE 3QL 2 / day
PR
PAGE 134 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HMG-COA REDUCTASE INHIBITORS
ALTOPREV 3
QL 1 / day
ST
PR
MVB MINIMALVALUE BRAND
amlodipine-atorvastatin 1QL 1 / day
PR
atorvastatin calcium (10 mg tablet, 20 mg tablet) 1
QL 1 / day
PR
HCR
atorvastatin calcium (40 mg tablet, 80 mg tablet) 1QL 1 / day
PR
CADUET 3
QL 1 / day
PR
MVB MINIMALVALUE BRAND
SBA Select BrandAlternative
CRESTOR 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
EZALLOR SPRINKLE 3
QL 1 / day
ST
PR
FLOLIPID 20 MG/5 ML ORAL SUSP 3
QL 10 / day
ST
SBA SELECT BRANDALTERNATIVE
PAGE 135 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FLOLIPID 40 MG/5 ML ORAL SUSP 3QL 5 / day
ST
fluvastatin er 1
QL 1 / day
PR
HCG
fluvastatin sodium 20 mg cap 1
QL 1 / day
PR
HCG
fluvastatin sodium 40 mg cap 1
QL 2 / day
PR
HCG
LESCOL 20 MG CAPSULE 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
LESCOL 40 MG CAPSULE 3
QL 2 / day
ST
PR
SBA Select BrandAlternative
LESCOL XL 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
LIPITOR (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
PAGE 136 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LIPITOR 80 MG TABLET 3
ST
PR
SBA Select BrandAlternative
LIVALO 2
QL 1 / day
ST
PR
lovastatin (10 mg tablet, 20 mg tablet) 1
QL 1 / day
PR
HCR
lovastatin 40 mg tablet 1
QL 2 / day
PR
HCR
PRAVACHOL 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
pravastatin sodium (10 mg tab, 20 mg tab, 40 mg tab) 1
QL 1 / day
PR
HCR
pravastatin sodium 80 mg tab 1PR
HCR
rosuvastatin calcium (20 mg tab, 40 mg tab) 1QL 1 / day
PR
rosuvastatin calcium (5 mg tab, 10 mg tab) 1
QL 1 / day
PR
HCR
PAGE 137 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
simvastatin 20 mg/5 ml susp 3
QL 5 / day
ST
PR
simvastatin (10 mg tablet, 20 mg tablet, 40 mg tablet) 1
QL 1.5 / day
PR
HCR
simvastatin 5 mg tablet 1
QL 1 / day
PR
HCR
simvastatin 80 mg tablet 1
QL 1 / day
PR
PA
ZOCOR (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3
QL 1.5 / day
ST
PR
SBA Select BrandAlternative
ZOCOR 80 MG TABLET 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
ZYPITAMAG 3QL 1 / day
ST
PCSK9 INHIBITORS
PRALUENT PEN 3
QL 0.08 / day
S
PS
PA
PAGE 138 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
REPATHA PUSHTRONEX 3
QL 0.13 / day
S
PS
PA
REPATHA SURECLICK 3
QL 0.08 / day
S
PS
PA
REPATHA SYRINGE 3
QL 0.08 / day
S
PS
PA
ANTIMIGRAINE AGENTS
CALCITONIN GENE-RELATED PEPTIDE ANTAG.
AIMOVIG 140 MG/ML AUTOINJECTOR 2
QL 0.04 / day
AL At least 18 yrsold
PA
AIMOVIG 70 MG/ML AUTOINJECTOR 2
QL 2 / 30 days
AL At least 18 yrsold
PA
AIMOVIG AUTOINJECTOR (2 PACK) 2
QL 2/ 30 days
AL At least 18 yrsold
PA
AJOVY AUTOINJECTOR 3
QL 0.057 / day
AL At least 18 yrsold
PA
PAGE 139 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AJOVY SYRINGE 3
QL 0.057 / day
AL At least 18 yrsold
PA
EMGALITY PEN 2
QL 0.04 / day
AL At least 18 yrsold
PA
EMGALITY 120 MG/ML SYRINGE 2
QL 0.04 / day
AL At least 18 yrsold
PA
EMGALITY SYRINGE (100 MG/ML SYR(1 OF 3), 300 MG(100 MG X3SYR)) 2
QL 0.1 / day
AL At least 18 yrsold
PA
NURTEC ODT 2
QL 0.54 / day
AL At least 18 yrsold
PA
UBRELVY 2
QL 0.54 / day
AL At least 18 yrsold
PA
SELECTIVE SEROTONIN AGONISTS
almotriptan malate 1QL 0.4 / day
HCG
AMERGE 3
QL 0.6 / day
ST
SBA Select BrandAlternative
PAGE 140 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
eletriptan hbr 1 QL 0.4 / day
FROVA 3
QL 0.6 / day
ST
MVB MINIMALVALUE BRAND
SBA Select BrandAlternative
frovatriptan succinate 1QL 0.6 / day
HCG
IMITREX (4 MG/0.5 ML CARTRIDGES, 4 MG/0.5 ML PENINJECT, 6 MG/0.5 ML CARTRIDGES, 6 MG/0.5 ML PENINJECT, 6 MG/0.5 ML VIAL)
3
QL 0.167 / day
ST
SBA Select BrandAlternative
IMITREX (5 MG NASAL SPRAY, 20 MG NASAL SPRAY) 3
QL 6 / 30 days
ST
SBA Select BrandAlternative
IMITREX (25 MG TABLET, 50 MG TABLET, 100 MG TABLET) 3
QL 0.3 / day
ST
SBA Select BrandAlternative
MAXALT 3
QL 0.6 / day
ST
SBA Select BrandAlternative
MAXALT MLT 3
QL 0.6 / day
ST
SBA Select BrandAlternative
naratriptan hcl 1 QL 0.6 / day
ONZETRA XSAIL 3 ST
PAGE 141 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RELPAX 3
QL 0.4 / day
ST
SBA Select BrandAlternative
REYVOW 100 MG TABLET 3
QL 0.3 / day
AL At least 18 yrsold
PA
REYVOW 50 MG TABLET 3
QL 4 / 30 days
AL At least 18 yrsold
PA
rizatriptan (5 mg odt, 5 mg tablet, 10 mg odt, 10 mgtablet) 1 QL 0.6 / day
sumatriptan 1 QL 6 / 30 days
sumatriptan succ-naproxen sod 1
QL 0.3 / day
HCG
MVGMINIMALVALUEGENERIC
sumatriptan succinate (4 mg/0.5 ml cart, 4 mg/0.5 mlinject, 6 mg/0.5 ml cart, 6 mg/0.5 ml inject, 6 mg/0.5 mlsyrng, 6 mg/0.5 ml vial)
1 QL 0.167 / day
sumatriptan succinate (25 mg tablet, 50 mg tablet, 100mg tablet) 1 QL 0.3 / day
SUMAVEL DOSEPRO 3QL 0.134 / day
ST
TOSYMRA 3QL 0.4 / day
ST
TREXIMET 10-60 MG TABLET 3
QL 0.3 / day
ST
PA
MVB MINIMALVALUE BRAND
PAGE 142 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TREXIMET 85-500 MG TABLET 3
QL 0.3 / day
ST
PA
MVB MINIMALVALUE BRAND
SBA Select BrandAlternative
ZEMBRACE SYMTOUCH 3QL 0.134 / day
ST
zolmitriptan 1 QL 0.2 / day
zolmitriptan odt 1 QL 0.2 / day
ZOMIG 2.5 MG NASAL SPRAY 3
QL 0.2 / day
ST
MVB MINIMALVALUE BRAND
ZOMIG 5 MG NASAL SPRAY 3QL 0.2 / day
ST
ZOMIG (2.5 MG TABLET, 5 MG TABLET) 3
QL 0.2 / day
ST
SBA Select BrandAlternative
ZOMIG ZMT 3
QL 0.2 / day
ST
SBA Select BrandAlternative
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, MISCELLANEOUS
dapsone (25 mg tablet, 100 mg tablet) 1
PAGE 143 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTITUBERCULOSIS AGENTS
CAPASTAT SULFATE 3 MED Medical Drug
cycloserine 1
ethambutol hcl 1
isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mgtablet) 1
isoniazid 100 mg/ml vial 1 MED Medical Drug
MYAMBUTOL 3
MYCOBUTIN 3
PASER 3
pretomanid 3
QL 1 / day
AL At least 18 yrsold
PA
PRIFTIN 3 QL 1.25 / day
pyrazinamide 1
rifabutin 1
RIFADIN (150 MG CAPSULE, 300 MG CAPSULE) 3
RIFADIN IV 600 MG VIAL 3 MED Medical Drug
RIFAMATE 3
rifampin (150 mg capsule, 300 mg capsule) 1
rifampin iv 600 mg vial 1 MED Medical Drug
RIFATER 3
SIRTURO 3 PA
TRECATOR 3
PAGE 144 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTINEOPLASTIC AGENTS
ABRAXANE 3
S
MED Medical Drug
PA
ADCETRIS 3
S
MED Medical Drug
PA
ADRIAMYCIN (10 MG VIAL, 50 MG VIAL, 200 MG/100 MLVIAL) 1
S
MED Medical Drug
ADRIAMYCIN (10 MG/5 ML VIAL, 20 MG/10 ML VIAL, 50MG/25 ML VIAL) 3
S
MED Medical Drug
ADRUCIL 1S
MED Medical Drug
AFINITOR (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET) 3
QL 2 / day
S
PA
AFINITOR 2.5 MG TABLET 3
QL 1 / day
S
PA
AFINITOR DISPERZ (2 MG TABLET, 3 MG TABLET) 3
QL 1 / day
S
PA
AFINITOR DISPERZ 5 MG TABLET 3
QL 2 / day
S
PA
ALECENSA 3
QL 8 / day
AL At least 18 yrsold
S
PA
PAGE 145 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ALIMTA 3
S
MED Medical Drug
PA
ALIQOPA 3
S
MED Medical Drug
PA
ALKERAN 2 MG TABLET 3
ALKERAN 50 MG VIAL 3S
MED Medical Drug
ALUNBRIG (90 MG TABLET, 90 MG-180 MG TAB PACK) 3
QL 2 / day
AL At least 18 yrsold
S
PA
ALUNBRIG 180 MG TABLET 3
QL 1 / day
AL At least 18 yrsold
S
PA
ALUNBRIG 30 MG TABLET 3
QL 6 / day
AL At least 18 yrsold
S
PA
anastrozole 1PR
HCR
ARIMIDEX 3ST
PR
AROMASIN 3 PR
PAGE 146 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ARRANON 3S
MED Medical Drug
arsenic trioxide 1S
MED Medical Drug
ARZERRA 3
S
MED Medical Drug
PA
ASPARLAS 3
S
MED Medical Drug
PA
AVASTIN 3
S
PA
BSP BENEFIT SHIFTPROGRAM
AYVAKIT 3
QL 1 / day
S
PA
azacitidine 1S
MED Medical Drug
BALVERSA 3 MG TABLET 3
QL 3 / day
S
PA
BALVERSA 4 MG TABLET 3
QL 2 / day
S
PA
BALVERSA 5 MG TABLET 3
QL 1 / day
S
PA
PAGE 147 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BAVENCIO 3
S
MED Medical Drug
PA
bcg (tice strain) 3S
MED Medical Drug
BELEODAQ 3
S
MED Medical Drug
PA
bendamustine hcl 1S
MED Medical Drug
bexarotene 1S
PA
bicalutamide 1
BICNU 3S
MED Medical Drug
BLENREP 3
QL 0.142 / day
S
MED Medical Drug
PA
bleomycin sulfate 1S
MED Medical Drug
BLINCYTO (35 MCG VIAL, 35MCG VL W-STABILIZER) 3S
MED Medical Drug
bortezomib 3
S
MED Medical Drug
PA
BOSULIF (400 MG TABLET, 500 MG TABLET) 3
QL 1 / day
S
PS
PA
PAGE 148 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BOSULIF 100 MG TABLET 3
QL 4 / day
S
PS
PA
BRAFTOVI 3S
PA
BRUKINSA 3
QL 4 / day
S
PA
busulfan 3S
MED Medical Drug
BUSULFEX 3S
MED Medical Drug
CABOMETYX 3
QL 1 / day
S
PA
CALQUENCE 3
QL 2 / day
AL At least 18 yrsold
S
PA
CAMPATH 3
S
MED Medical Drug
PA
CAMPTOSAR 3S
MED Medical Drug
capecitabine 1S
PA
PAGE 149 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CAPRELSA 100 MG TABLET 3
QL 2 / day
S
PA
CAPRELSA 300 MG TABLET 3
QL 1 / day
S
PA
CARAC 3PA
MVB MINIMALVALUE BRAND
carboplatin (50 mg/5 ml vial, 150 mg vial, 150 mg/15 mlvial, 450 mg/45 ml vial, 600 mg/60 ml vial) 1
S
MED Medical Drug
carmustine 1S
MED Medical Drug
CASODEX 3
cisplatin (50 mg vial, 50 mg/50 ml vial, 100 mg/100 mlvial, 200 mg/200 ml vial) 1
S
MED Medical Drug
cladribine 1S
MED Medical Drug
clofarabine 1S
MED Medical Drug
CLOLAR 3S
MED Medical Drug
COMETRIQ 100 MG DAILY-DOSE PK 3
QL 2 / day
S
PA
COMETRIQ 140 MG DAILY-DOSE PK 3
QL 4 / day
S
PA
PAGE 150 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
COMETRIQ 60 MG DAILY-DOSE PACK 3
QL 3 / day
S
PA
COPIKTRA 3S
PA
COSMEGEN 3S
MED Medical Drug
COTELLIC 3
QL 2.5 / day
AL At least 18 yrsold
S
PA
cyclophosphamide (25 mg capsule, 50 mg capsule) 1 PA
cyclophosphamide (1 gm vial, 1 gm/5 ml vl, 2 gm vial, 500mg vial, 500 mg/2.5 ml) 1
S
MED Medical Drug
PA
CYRAMZA 3
S
MED Medical Drug
PA
cytarabine 1S
MED Medical Drug
dacarbazine 1S
MED Medical Drug
DACOGEN 3S
MED Medical Drug
dactinomycin 1S
MED Medical Drug
PAGE 151 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DARZALEX 3
S
MED Medical Drug
PA
DARZALEX FASPRO 3
QL 2.15 / day
S
MED Medical Drug
PA
daunorubicin hcl (20 mg vial, 20 mg/4 ml vial, 50 mg/10ml vial) 1
S
MED Medical Drug
DAURISMO 3
QL 1 / day
S
PA
decitabine 1S
MED Medical Drug
diclofenac sodium 3% gel 1
QL 100 / 30 days
PA
HCG
MVGMINIMALVALUEGENERIC
DOCEFREZ 3S
MED Medical Drug
docetaxel 1S
MED Medical Drug
DOXIL 3S
MED Medical Drug
doxorubicin hcl (10 mg vial, 10 mg/5 ml vial, 20 mg/10 mlvial, 50 mg vial, 50 mg/25 ml vial, 150 mg/75 ml vial, 200mg/100 ml vial)
1S
MED Medical Drug
PAGE 152 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
doxorubicin hcl liposome 1S
MED Medical Drug
DROXIA 3
EFUDEX 3
ELLENCE 3S
MED Medical Drug
ELZONRIS 3
S
MED Medical Drug
PA
EMCYT 3 S
ENHERTU 3S
MED Medical Drug
epirubicin hcl (50 mg/25 ml vial, hcl 50 mg vial, 200mg/100 ml vial, hcl 200 mg vial) 1
S
MED Medical Drug
ERBITUX 3
S
MED Medical Drug
PA
ERIVEDGE 3
QL 1 / day
S
PA
ERLEADA 3
QL 4 / day
S
PA
erlotinib hcl 3
QL 1 / day
S
PA
ERWINAZE 3S
MED Medical Drug
PAGE 153 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ETOPOPHOS 3S
MED Medical Drug
etoposide 50 mg capsule 1 S
etoposide (100 mg/5 ml vial, 500 mg/25 ml vial, 1,000mg/50 ml vial) 1
S
MED Medical Drug
everolimus (5 mg tablet, 7.5 mg tablet) 1
QL 2 / day
S
PA
everolimus 2.5 mg tablet 1
QL 1 / day
S
PA
EVOMELA 3S
MED Medical Drug
exemestane 1PR
HCR
FARYDAK 3S
PA
FASLODEX 3
QL 1.25 / day
S
MED Medical Drug
PA
FEMARA 3PR
PA
floxuridine 1S
MED Medical Drug
fludarabine phosphate (50 mg vial, 50 mg/2 ml vial) 1S
MED Medical Drug
PAGE 154 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FLUOROPLEX 3
fluorouracil (0.5% cream, 2% topical soln, 5% cream, 5%topical soln) 1
fluorouracil (2.5 gm/50 ml btl, 2.5 gm/50 ml vial, 5gm/100 ml btl, 5 gm/100 ml vial, 500 mg/10 ml vial,1,000 mg/20 ml vl, 2,500 mg/50 ml vl, 5,000 mg/100 ml)
1S
MED Medical Drug
flutamide 1
FOLOTYN 3
S
MED Medical Drug
PA
fulvestrant 1
QL 1.25 / day
S
MED Medical Drug
PA
GAVRETO 3
QL 4 / day
S
PA
GAZYVA 3
S
MED Medical Drug
PA
gemcitabine hcl (1 gram/26.3 ml vl, hcl 1 gram vial, hcl 1gram/10 ml, hcl 1.5 gram/15 ml, 2 gram/52.6 ml vl, hcl 2gram vial, hcl 2 gram/20 ml, 200 mg/5.26 ml vl, hcl 200mg vial, hcl 200 mg/2 ml vl)
1S
MED Medical Drug
GEMZAR 3S
MED Medical Drug
GILOTRIF 3
QL 1 / day
S
PA
PAGE 155 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GLEEVEC 100 MG TABLET 3
QL 8 / day
S
PA
SBA Select BrandAlternative
GLEEVEC 400 MG TABLET 3
QL 2 / day
S
PA
GLEOSTINE 3
GLIADEL 3 MED Medical Drug
HALAVEN 3
S
MED Medical Drug
PA
HERCEPTIN 3
S
PA
BSP BENEFIT SHIFTPROGRAM
HERCEPTIN HYLECTA 3
S
PA
BSP BENEFIT SHIFTPROGRAM
HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) 3S
PA
HYCAMTIN 4 MG VIAL 3
S
MED Medical Drug
PA
HYDREA 3
hydroxyurea 1
PAGE 156 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
IBRANCE (100 MG CAPSULE, 100 MG TABLET) 3
QL 1.25 / day
S
PS
PA
IBRANCE (75 MG CAPSULE, 75 MG TABLET) 3
QL 1.667 / day
S
PS
PA
IBRANCE (125 MG CAPSULE, 125 MG TABLET) 3
QL 1 / day
S
PS
PA
ICLUSIG 15 MG TABLET 3
QL 2 / day
S
PA
ICLUSIG 45 MG TABLET 3
QL 1 / day
S
PA
IDAMYCIN PFS 3S
MED Medical Drug
idarubicin hcl 1S
MED Medical Drug
IDHIFA 3
QL 1 / day
AL At least 18 yrsold
S
PA
IFEX 3S
MED Medical Drug
PAGE 157 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ifosfamide (1 gm vial, 1 gm/20 ml vial, 3 gm vial, 3 gm/60ml vial) 1
S
MED Medical Drug
ifosfamide-mesna 1S
MED Medical Drug
imatinib mesylate 100 mg tab 1
QL 8 / day
S
PS
PA
imatinib mesylate 400 mg tab 1
QL 2 / day
S
PS
PA
IMBRUVICA (140 MG CAPSULE, 140 MG TABLET) 3
QL 4 / day
S
PA
IMBRUVICA 70 MG CAPSULE 3
QL 8 / day
S
PA
IMBRUVICA 280 MG TABLET 3
QL 2 / day
S
PA
IMBRUVICA 420 MG TABLET 3
QL 1.47 / day
S
PA
IMBRUVICA 560 MG TABLET 3
QL 1 / day
S
PA
PAGE 158 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
IMFINZI 3S
MED Medical Drug
INLYTA 3
QL 4 / day
S
PA
INQOVI 3
QL 0.18 / day
S
PA
INREBIC 3
QL 4 / day
S
PA
IRESSA 3
QL 1 / day
S
PA
irinotecan hcl 1S
MED Medical Drug
ISTODAX 3
S
MED Medical Drug
PA
IXEMPRA 3
S
MED Medical Drug
PA
JAKAFI 3
QL 2 / day
S
PA
JELMYTO 3S
MED Medical Drug
PAGE 159 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
JEVTANA 3
QL 0.15 / day
S
MED Medical Drug
PA
KADCYLA 3
S
MED Medical Drug
PA
KANJINTI 3
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
KEYTRUDA 3
S
MED Medical Drug
PA
KISQALI 200 MG DAILY DOSE 3
QL 1 / day
AL At least 18 yrsold
S
PA
KISQALI 400 MG DAILY DOSE 3
QL 2 / day
AL At least 18 yrsold
S
PA
KISQALI 600 MG DAILY DOSE 3
QL 3 / day
AL At least 18 yrsold
S
PA
PAGE 160 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
KISQALI FEMARA 200 MG CO-PACK 3
QL 2 / day
AL At least 18 yrsold
S
PA
KISQALI FEMARA 400 MG CO-PACK 3
QL 2.5 / day
AL At least 18 yrsold
S
PA
KISQALI FEMARA 600 MG CO-PACK 3
QL 3.334 / day
AL At least 18 yrsold
S
PA
KOSELUGO 3
QL 4 / day
S
PA
KYPROLIS 3
S
MED Medical Drug
PA
lapatinib 3
QL 6 / day
S
PA
LENVIMA 3
QL 3 / day
S
PA
letrozole 1PR
HCR
PAGE 161 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LEUKERAN 3
LONSURF 15 MG-6.14 MG TABLET 3
QL 2.15 / day
S
PA
LONSURF 20 MG-8.19 MG TABLET 3
QL 3 / day
S
PA
LORBRENA 3
QL 1 / day
S
PA
LUMOXITI 3
S
MED Medical Drug
PA
LYNPARZA 3
AL At least 18 yrsold
S
PA
LYSODREN 3 S
MARQIBO 3
S
MED Medical Drug
PA
MATULANE 3 S
MEKINIST 0.5 MG TABLET 3
QL 4 / day
S
PA
MEKINIST 2 MG TABLET 3
QL 1 / day
S
PA
PAGE 162 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MEKTOVI 3S
PA
melphalan 1
melphalan hcl 1S
MED Medical Drug
mercaptopurine 1
methotrexate 2.5 mg tablet 1
methotrexate (1 gm vial, 50 mg/2 ml vial, 250 mg/10 mlvial) 1 BSP BENEFIT SHIFT
PROGRAM
methotrexate sodium 1 BSP BENEFIT SHIFTPROGRAM
mitomycin 1S
MED Medical Drug
mitoxantrone hcl 1
S
MED Medical Drug
PA
MONJUVI 3
QL 1.25 / day
S
MED Medical Drug
PA
MUSTARGEN 3S
MED Medical Drug
MUTAMYCIN 1S
MED Medical Drug
MVASI 3
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
PAGE 163 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MYLERAN 3 S
MYLOTARG 3S
MED Medical Drug
NAVELBINE 3S
MED Medical Drug
NERLYNX 3
QL 6 / day
AL At least 18 yrsold
S
PA
NEXAVAR 3
QL 4 / day
S
PA
NILANDRON 3S
SBA Select BrandAlternative
nilutamide 1 S
NINLARO 3
QL 0.124 / day
AL At least 18 yrsold
S
PA
NIPENT 3S
MED Medical Drug
NUBEQA 3
QL 4 / day
S
PS
PA
PAGE 164 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ODOMZO 3
QL 1 / day
S
PA
OGIVRI 3
S
PA
BSP BENEFIT SHIFTPROGRAM
ONCASPAR 3S
MED Medical Drug
ONUREG 3
QL 0.5 / day
S
PA
OPDIVO 3
S
MED Medical Drug
PA
OTREXUP 3QL 0.08 / day
PA
oxaliplatin (50 mg vial, 50 mg/10 ml vial, 100 mg vial, 100mg/20 ml vial) 1
S
MED Medical Drug
oxaliplatin 200 mg/40 ml vial 1S
MED Medical Drug
paclitaxel 1S
MED Medical Drug
PADCEV 3
S
MED Medical Drug
PA
PANRETIN 3
PAGE 165 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PARAPLATIN (50 MG/5 ML VIAL, 150 MG/15 ML VIAL, 450MG/45 ML VIAL, 600 MG/60 ML VIAL) 1
S
MED Medical Drug
PARAPLATIN 1,000 MG/100 ML VL 3S
MED Medical Drug
PEMAZYRE 3
QL 0.67 / day
S
PA
PERJETA 3
S
MED Medical Drug
PA
PHOTOFRIN 3S
MED Medical Drug
PICATO 3ST
MVB MINIMALVALUE BRAND
PIQRAY (250 MG DAILY, 300 MG DAILY) 3
QL 2 / day
S
PA
PIQRAY 200 MG DAILY DOSE 3
QL 1 / day
S
PA
POLIVY 3
QL 1 / day
S
MED Medical Drug
PA
POMALYST 3
QL 1 / day
S
PA
PAGE 166 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PROLEUKIN 3
S
MED Medical Drug
PA
PURIXAN 3S
PA
QINLOCK 3
QL 3 / day
S
PA
RASUVO 3QL 0.08 / day
PA
RETEVMO 40 MG CAPSULE 3
QL 2 / day
S
PA
RETEVMO 80 MG CAPSULE 3
QL 4 / day
S
PA
REVLIMID 3
QL 1 / day
S
PA
RITUXAN 3
S
PA
BSP BENEFIT SHIFTPROGRAM
RITUXAN HYCELA 3
S
PA
BSP BENEFIT SHIFTPROGRAM
romidepsin (10 mg kit, 10 mg vial, 27.5 mg/5.5 ml vial) 3
S
MED Medical Drug
PA
PAGE 167 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ROZLYTREK 100 MG CAPSULE 3
QL 5 / day
S
PA
ROZLYTREK 200 MG CAPSULE 3
QL 3 / day
S
PA
RUBRACA 3
QL 2 / day
AL At least 18 yrsold
S
PA
RUXIENCE 3
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
RYDAPT 3
QL 2 / day
AL At least 18 yrsold
S
PA
SIKLOS 3 S
SOLARAZE 3
QL 100 / 30 days
PA
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
SPRYCEL (100 MG TABLET, 140 MG TABLET) 3
QL 1 / day
S
PA
PAGE 168 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SPRYCEL (70 MG TABLET, 80 MG TABLET) 3
QL 2 / day
S
PA
SPRYCEL 20 MG TABLET 3
QL 9 / day
S
PA
SPRYCEL 50 MG TABLET 3
QL 3 / day
S
PA
STIVARGA 3
QL 4 / day
S
PA
SUTENT (37.5 MG CAPSULE, 50 MG CAPSULE) 3
QL 1 / day
S
PA
SUTENT 12.5 MG CAPSULE 3
QL 7 / day
S
PA
SUTENT 25 MG CAPSULE 3
QL 3 / day
S
PA
SYLVANT 3
S
MED Medical Drug
PA
SYNRIBO 3S
PA
TABLOID 3 S
PAGE 169 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TABRECTA 3
QL 4 / day
S
PA
TAFINLAR 50 MG CAPSULE 3
QL 6 / day
S
PA
TAFINLAR 75 MG CAPSULE 3
QL 4 / day
S
PA
TAGRISSO 3
QL 1 / day
AL At least 18 yrsold
S
PA
TALZENNA 3S
PA
TARCEVA (100 MG TABLET, 150 MG TABLET) 3
QL 1 / day
S
PA
TARCEVA 25 MG TABLET 3
QL 6 / day
S
PA
TARGRETIN 75 MG CAPSULE 3S
PA
TARGRETIN 1% GEL 3S
PA
TASIGNA (150 MG CAPSULE, 200 MG CAPSULE) 3
QL 4 / day
S
PA
PAGE 170 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TASIGNA 50 MG CAPSULE 3
QL 6 / day
S
PA
TAXOTERE 3S
MED Medical Drug
TAZVERIK 3S
PA
TECENTRIQ 3
S
MED Medical Drug
PA
TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MGCAPSULE, 140 MG CAPSULE, 180 MG CAPSULE, 250 MGCAPSULE)
3S
PA
TEMODAR 100 MG VIAL 3
S
MED Medical Drug
PA
temozolomide 1S
PA
temsirolimus 1
QL 0.29 / day
S
MED Medical Drug
PA
teniposide 1S
MED Medical Drug
TIBSOVO 3S
PA
TOLAK 3 QL 1.47 / day
PAGE 171 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TOPOSAR 1S
MED Medical Drug
topotecan hcl (1 mg/ml vial, 4 mg vial, 4 mg/4 ml vial) 1S
MED Medical Drug
TORISEL 3
QL 0.29 / day
S
MED Medical Drug
PA
TRAZIMERA 3
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
TREANDA 3
S
MED Medical Drug
PA
tretinoin 10 mg capsule 1QL 90 / 365 days
S
TREXALL 2
TRISENOX 3S
MED Medical Drug
TRODELVY 3
QL 0.58 / day
S
MED Medical Drug
PA
TUKYSA 3
QL 4 / day
S
PA
PAGE 172 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TURALIO 3
QL 4 / day
S
PA
TYKERB 3
QL 6 / day
S
PA
UNITUXIN 3
S
MED Medical Drug
PA
VALCHLOR 3
QL 3 / day
S
PA
valrubicin 1S
MED Medical Drug
VALSTAR 3S
MED Medical Drug
VECTIBIX 3
S
MED Medical Drug
PA
VELCADE 3
S
MED Medical Drug
PA
VENCLEXTA 3
QL 4 / day
S
PA
VENCLEXTA STARTING PACK 3
QL 1.5 / day
S
PA
PAGE 173 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VERZENIO 3
QL 2 / day
AL At least 18 yrsold
S
PA
VIDAZA 3S
MED Medical Drug
vinblastine sulfate 1S
MED Medical Drug
VINCASAR PFS 1S
MED Medical Drug
vincristine sulfate 1S
MED Medical Drug
vinorelbine tartrate 1S
MED Medical Drug
VITRAKVI (20 MG/ML SOLUTION, 25 MG CAPSULE, 100MG CAPSULE) 3
QL 2 / day
S
PA
VIZIMPRO 3S
PA
VOTRIENT 3
QL 4 / day
S
PA
XALKORI 3
QL 2 / day
S
PA
XATMEP 3
QL 4 / day
AL Up to 18 yrs old
PA
PAGE 174 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
XELODA 3
QL 4 / day
S
PA
XOSPATA 3
QL 3 / day
S
PA
XPOVIO (40 MG TWICE, 80 MG ONCE) 3
QL 0.574 / day
S
PA
XPOVIO 100 MG ONCE WEEKLY DOSE 3
QL 0.767 / day
S
PA
XPOVIO 40 MG ONCE WEEKLY DOSE 3
QL 0.267 / day
S
PA
XPOVIO 60 MG ONCE WEEKLY DOSE 3
QL 0.434 / day
S
PA
XPOVIO 60 MG TWICE WEEKLY DOSE 3
QL 0.8 / day
S
PA
XPOVIO 80 MG TWICE WEEKLY DOSE 3
QL 1.25 / day
S
PA
XTANDI 3
QL 4 / day
S
PA
PAGE 175 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
YERVOY 3
S
MED Medical Drug
PA
YONSA 3
QL 4 / day
S
PA
ZALTRAP 3
S
MED Medical Drug
PA
ZANOSAR 3S
MED Medical Drug
ZEJULA 3
QL 3 / day
AL At least 18 yrsold
S
PA
ZELBORAF 3
QL 8 / day
S
PA
ZEPZELCA 3
QL 0.1 / day
S
MED Medical Drug
PA
ZEVALIN 3S
MED Medical Drug
ZIRABEV 3
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
PAGE 176 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZOLINZA 3
QL 4 / day
S
PA
ZYDELIG 3
QL 2 / day
S
PA
ZYKADIA (150 MG CAPSULE, 150 MG TABLET) 3
QL 8 / day
AL At least 18 yrsold
S
PA
ZYTIGA 250 MG TABLET 3
QL 4 / day
S
PS
PA
B4G
ZYTIGA 500 MG TABLET 3
QL 2 / day
S
PS
PA
B4G
ANTIPARKINSONIAN AGENTS (CNS)
ADAMANTANES (CNS)
amantadine (50 mg/5 ml solution, 100 mg capsule, 100mg tablet, 100 mg/10 ml soln) 1
GOCOVRI ER 137 MG CAPSULE 3
QL 2 / day
S
PA
MVB MINIMALVALUE BRAND
PAGE 177 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GOCOVRI ER 68.5 MG CAPSULE 3
QL 1 / day
S
PA
MVB MINIMALVALUE BRAND
OSMOLEX ER (ER 129 MG TABLET, ER 193 MG TABLET, ER258 MG TABLET) 3
QL 1 / day
S
PA
OSMOLEX ER 322 MG DAILY DOSE 3
QL 2 / day
S
PA
ANTICHOLINERGIC AGENTS (CNS)
benztropine 2 mg/2 ml ampule 1MED Medical Drug
HCG
benztropine mesylate (0.5 mg tab, 1 mg tablet, 2 mgtablet) 1
benztropine 2 mg/2 ml vial 1 MED Medical Drug
COGENTIN 3 MED Medical Drug
trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elx, 5 mgtablet) 1
CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.
COMTAN 3
entacapone 1 HCG
ONGENTYS 3
TASMAR 3
tolcapone 1
PAGE 178 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DOPAMINE PRECURSORS
carbidopa-levodopa (carbidopa-levo 10-100 mg odt,carbidopa-levo 25-100 mg odt, carbidopa-levo 25-250 mgodt, carbidopa-levodopa 10-100 tab, carbidopa-levodopa25-100 tab, carbidopa-levodopa 25-250 tab)
1
carbidopa-levodopa er 1
carbidopa-levodopa-entacapone 1
DUOPA 3
QL 1 / day
S
PA
INBRIJA 3
QL 1 / day
S
PA
RYTARY 3
SINEMET 10-100 3
SINEMET 25-100 3
SINEMET 25-250 3
SINEMET CR 3
STALEVO 100 3
STALEVO 125 3
STALEVO 150 3
STALEVO 200 3
STALEVO 50 3
STALEVO 75 3
MONOAMINE OXIDASE B INHIBITORS
AZILECT 3
PAGE 179 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EMSAM 3 QL 1 / day
rasagiline mesylate 1
selegiline hcl (5 mg capsule, 5 mg tablet) 1
XADAGO 3
QL 1 / day
AL At least 18 yrsold
PA
ZELAPAR 3
ANTIPROTOZOALS
AMEBICIDES
paromomycin sulfate 1
ANTIMALARIALS
ARAKODA 3 PA
atovaquone-proguanil hcl 1 PA
chloroquine phosphate 1 PA
COARTEM 3
hydroxychloroquine sulfate 1 PA
KRINTAFEL 3
MALARONE 3 PA
mefloquine hcl 1
PLAQUENIL 3PA
SBA Select BrandAlternative
primaquine 1
QUALAQUIN 3QL 42 / 365 days
PA
PAGE 180 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
quinine sulfate 1QL 42 / 365 days
PA
ANTIPROTOZOALS, MISCELLANEOUS
ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) 3 PA
atovaquone 1 PA
benznidazole 2QL max 60 days
AL 2 to 12 yrs old
FLAGYL (250 MG TABLET, 375 CAPSULE) 3
FLAGYL 500 MG TABLET 3 SBA Select BrandAlternative
IMPAVIDO 3 S
LAMPIT 120 MG TABLET 3
QL 7.5
AL Up to 17 yrs old
PA
LAMPIT 30 MG TABLET 3
QL 12 / day
AL Up to 17 yrs old
PA
MEPRON 3 PA
METRO IV 3 MED Medical Drug
metronidazole 500 mg/100 ml 1 MED Medical Drug
metronidazole (250 mg tablet, 375 mg capsule, 500 mgtablet) 1
NEBUPENT 3 SBA SELECT BRANDALTERNATIVE
PENTAM 300 3 MED Medical Drug
pentamidine 300 mg vial 1 MED Medical Drug
PAGE 181 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
pentamidine 300 mg inhal powdr 1
SOLOSEC 3QL 1/ fill
GL Female
TINDAMAX 3
tinidazole 1
ANTIPSYCHOTIC AGENTS
ANTIPSYCHOTICS, MISCELLANEOUS
ADASUVE 3AL At least 18 yrs
oldPR
loxapine 1AL At least 18 yrs
oldPR
molindone hcl 1
ORAP 3
pimozide 1
ATYPICAL ANTIPSYCHOTICS
ABILIFY 3
QL 1 / day
ST
AL At least 6 yrsold
PR
SBA Select BrandAlternative
ABILIFY MAINTENA (ER 300 MG SYR, ER 300 MG VL, ER400 MG SYR, ER 400 MG VL) 3
QL 0.04 / day
AL At least 18 yrsold
PR
PA
PAGE 182 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ABILIFY MYCITE 3
QL 1 / day
ST
AL At least 18 yrsold
PR
PA
aripiprazole 1 mg/ml solution 1
QL 30 / day
AL At least 6 yrsold
PR
aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet, 15mg tablet, 20 mg tablet, 30 mg tablet) 1
QL 1 / day
AL At least 6 yrsold
PR
aripiprazole odt 1
QL 1 / day
AL At least 6 yrsold
PR
ARISTADA ER 1064 MG/3.9 ML SYR 3
QL 0.15 / day
AL At least 18 yrsold
PA
ARISTADA ER 441 MG/1.6 ML SYRN 3
QL 0.07 / day
AL At least 18 yrsold
PA
ARISTADA ER 662 MG/2.4 ML SYRN 3
QL 0.08 / day
AL At least 18 yrsold
PA
ARISTADA ER 882 MG/3.2 ML SYRN 3
QL 0.12 / day
AL At least 18 yrsold
PA
PAGE 183 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ARISTADA INITIO 3
QL 0.08 / day
AL At least 18 yrsold
PA
CAPLYTA 3
QL 1 / day
AL At least 18 yrsold
PR
PA
clozapine 100 mg tablet 1
QL 9 / day
AL At least 18 yrsold
PR
clozapine 200 mg tablet 1
QL 4 / day
AL At least 18 yrsold
PR
clozapine 25 mg tablet 1
QL 18 / day
AL At least 18 yrsold
PR
clozapine 50 mg tablet 1
QL 3 / day
AL At least 18 yrsold
PR
clozapine odt (odt 12.5 mg tablet, odt 25 mg tablet, odt150 mg tablet, odt 200 mg tablet) 1
QL 3 / day
AL At least 18 yrsold
PR
clozapine odt 100 mg tablet 1
QL 9 / day
AL At least 18 yrsold
PR
PAGE 184 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CLOZARIL 100 MG TABLET 3
QL 9 / day
AL At least 18 yrsold
PR
CLOZARIL 200 MG TABLET 3
QL 4 / day
AL At least 18 yrsold
PR
CLOZARIL 25 MG TABLET 3
QL 18 / day
AL At least 18 yrsold
PR
CLOZARIL 50 MG TABLET 3
QL 3 / day
AL At least 18 yrsold
PR
FANAPT TITRATION PACK 3
QL 8 / rx
ST
AL At least 18 yrsold
PR
FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MGTABLET)
3
QL 2 / day
ST
AL At least 18 yrsold
PR
FAZACLO (12.5 MG ODT, 25 MG ODT, 150 MG ODT, 200MG ODT) 3
QL 3 / day
AL At least 18 yrsold
PR
FAZACLO 100 MG ODT 3
QL 9 / day
AL At least 18 yrsold
PR
PAGE 185 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60 MGCAPSULE, 80 MG CAPSULE) 3
QL 2 / day
ST
AL At least 18 yrsold
PR
GEODON 20 MG/ML VIAL 3ST
PR
INVEGA ER 1.5 MG TABLET 3
QL 8 / day
ST
AL At least 12 yrsold
PR
INVEGA ER 3 MG TABLET 3
QL 4 / day
ST
AL At least 12 yrsold
PR
INVEGA ER 6 MG TABLET 3
QL 2 / day
ST
AL At least 12 yrsold
PR
INVEGA ER 9 MG TABLET 3
QL 1 / day
ST
AL At least 12 yrsold
PR
INVEGA SUSTENNA 117 MG/0.75 ML 3
QL 0.0333 / day
AL At least 18 yrsold
PR
PA
PAGE 186 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
INVEGA SUSTENNA 156 MG/ML SYRG 3
QL 0.04 / day
AL At least 18 yrsold
PR
PA
INVEGA SUSTENNA 234 MG/1.5 ML 3
QL 0.057 / day
AL At least 18 yrsold
PR
PA
INVEGA SUSTENNA 39 MG/0.25 ML 3
QL 0.0111 / day
AL At least 18 yrsold
PR
PA
INVEGA SUSTENNA 78 MG/0.5 ML 3
QL 0.02 / day
AL At least 18 yrsold
PR
PA
INVEGA TRINZA 273 MG/0.875 ML 3
QL 0.0333 / day
AL At least 18 yrsold
PA
INVEGA TRINZA 410 MG/1.315 ML 3
QL 0.057 / day
AL At least 18 yrsold
PA
INVEGA TRINZA 546 MG/1.75 ML 3
QL 0.067 / day
AL At least 18 yrsold
PA
PAGE 187 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
INVEGA TRINZA 819 MG/2.625 ML 3
QL 0.1 / day
AL At least 18 yrsold
PA
LATUDA 3
QL 1 / day
AL At least 10 yrsold
PR
NUPLAZID (10 MG TABLET, 34 MG CAPSULE) 3
QL 1 / day
S
PA
NUPLAZID 17 MG TABLET 3
QL 2 / day
S
PA
olanzapine (2.5 mg tablet, 5 mg tablet) 1QL 6 / day
PR
olanzapine 10 mg tablet 1QL 3 / day
PR
olanzapine 15 mg tablet 1QL 2 / day
PR
olanzapine 20 mg tablet 1QL 1 / day
PR
olanzapine 7.5 mg tablet 1QL 4 / day
PR
olanzapine 10 mg vial 1 PR
olanzapine odt 10 mg tablet 1QL 3 / day
PR
olanzapine odt 15 mg tablet 1QL 2 / day
PR
PAGE 188 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
olanzapine odt 20 mg tablet 1QL 1 / day
PR
olanzapine odt 5 mg tablet 1QL 6 / day
PR
paliperidone er 1.5 mg tablet 1
QL 8 / day
AL At least 12 yrsold
PR
paliperidone er 3 mg tablet 1
QL 4 / day
AL At least 12 yrsold
PR
paliperidone er 6 mg tablet 1
QL 2 / day
AL At least 12 yrsold
PR
paliperidone er 9 mg tablet 1
QL 1 / day
AL At least 12 yrsold
PR
PERSERIS 3
QL 0.0333 / day
AL At least 18 yrsold
PR
PA
quetiapine fumarate (25 mg tab, 50 mg tab) 1
QL 6 / day
AL At least 10 yrsold
PR
quetiapine fumarate 100 mg tab 1
QL 3 / day
AL At least 10 yrsold
PR
PAGE 189 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
quetiapine fumarate 200 mg tab 1
QL 1.5 / day
AL At least 10 yrsold
PR
quetiapine fumarate 300 mg tab 1
QL 1 / day
AL At least 10 yrsold
PR
quetiapine fumarate 400 mg tab 1
QL 2 / day
AL At least 10 yrsold
PR
quetiapine er 150 mg tablet 1
QL 5 / day
AL At least 10 yrsold
PR
quetiapine er 200 mg tablet 1
QL 4 / day
AL At least 10 yrsold
PR
quetiapine er 50 mg tablet 1
QL 6 / day
AL At least 10 yrsold
PR
quetiapine fumarate er (er 300 mg tablet, er 400 mgtablet) 1
QL 2 / day
AL At least 10 yrsold
PR
REXULTI 3
QL 1 / day
AL At least 18 yrsold
PA
PAGE 190 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RISPERDAL 1 MG/ML SOLUTION 3
QL 16/day
ST
AL At least 5 yrsold
PR
SBA Select BrandAlternative
RISPERDAL (0.25 MG TABLET, 0.5 MG TABLET, 1 MGTABLET, 2 MG TABLET) 3
QL 8 / day
ST
AL At least 5 yrsold
PR
SBA Select BrandAlternative
RISPERDAL 3 MG TABLET 3
QL 5 / day
ST
AL At least 5 yrsold
PR
SBA Select BrandAlternative
RISPERDAL 4 MG TABLET 3
QL 4 / day
ST
AL At least 5 yrsold
PR
SBA Select BrandAlternative
RISPERDAL CONSTA 3
QL 0.1 / day
AL At least 18 yrsold
PR
PA
PAGE 191 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
risperidone 1 mg/ml solution 1
QL 16/day
AL At least 5 yrsold
PR
risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2mg tablet) 1
QL 8 / day
AL At least 5 yrsold
PR
risperidone 3 mg tablet 1
QL 5 / day
AL At least 5 yrsold
PR
risperidone 4 mg tablet 1
QL 4 / day
AL At least 5 yrsold
PR
risperidone 3 mg odt 1
QL 5 / day
AL At least 5 yrsold
PR
risperidone 4 mg odt 1
QL 4 / day
AL At least 5 yrsold
PR
risperidone odt (0.25 mg odt, 0.5 mg odt, 1 mg odt, 2 mgodt) 1
QL 8 / day
AL At least 5 yrsold
PR
SAPHRIS 2
QL 2 / day
AL At least 10 yrsold
PR
PAGE 192 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SECUADO 3QL 1 / day
ST
SEROQUEL (25 MG TABLET, 50 MG TABLET) 3
QL 6 / day
ST
AL At least 10 yrsold
PR
SBA Select BrandAlternative
SEROQUEL 100 MG TABLET 3
QL 3 / day
ST
AL At least 10 yrsold
PR
SBA Select BrandAlternative
SEROQUEL 200 MG TABLET 3
QL 1.5 / day
ST
AL At least 10 yrsold
PR
SBA Select BrandAlternative
SEROQUEL 300 MG TABLET 3
QL 1 / day
ST
AL At least 10 yrsold
PR
SBA Select BrandAlternative
SEROQUEL 400 MG TABLET 3
QL 2 / day
ST
AL At least 10 yrsold
PR
SBA Select BrandAlternative
PAGE 193 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SEROQUEL XR SAMPLE KIT 3 AL At least 10 yrsold
SEROQUEL XR (300 MG TABLET, 400 MG TABLET) 3
QL 2 / day
ST
AL At least 10 yrsold
PR
SBA Select BrandAlternative
SEROQUEL XR 150 MG TABLET 3
QL 5 / day
ST
AL At least 10 yrsold
PR
SBA Select BrandAlternative
SEROQUEL XR 200 MG TABLET 3
QL 4 / day
ST
AL At least 10 yrsold
PR
SBA Select BrandAlternative
SEROQUEL XR 50 MG TABLET 3
QL 6 / day
ST
AL At least 10 yrsold
PR
SBA Select BrandAlternative
VERSACLOZ 3
QL 20 / day
AL At least 18 yrsold
PR
PAGE 194 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VRAYLAR (1.5 MG CAPSULE, 1.5 MG-3 MG PACK, 3 MGCAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE) 3
QL 1 / day
ST
AL At least 18 yrsold
ziprasidone hcl 1
QL 2 / day
AL At least 18 yrsold
PR
ziprasidone mesylate 1 PR
ZYPREXA (2.5 MG TABLET, 5 MG TABLET) 3
QL 6 / day
ST
AL At least 13 yrsold
PR
SBA Select BrandAlternative
ZYPREXA 10 MG TABLET 3
QL 3 / day
ST
AL At least 13 yrsold
PR
SBA Select BrandAlternative
ZYPREXA 15 MG TABLET 3
QL 2 / day
ST
AL At least 13 yrsold
PR
SBA Select BrandAlternative
ZYPREXA 20 MG TABLET 3
QL 1 / day
ST
AL At least 13 yrsold
PR
SBA Select BrandAlternative
PAGE 195 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZYPREXA 7.5 MG TABLET 3
QL 4 / day
ST
AL At least 13 yrsold
PR
SBA Select BrandAlternative
ZYPREXA 10 MG VIAL 3
ST
AL At least 13 yrsold
PR
SBA Select BrandAlternative
ZYPREXA RELPREVV 3
QL 0.08 / day
AL At least 18 yrsold
PR
PA
ZYPREXA ZYDIS 10 MG TABLET 3
QL 3 / day
AL At least 13 yrsold
PR
ZYPREXA ZYDIS 15 MG TABLET 3
QL 2 / day
AL At least 13 yrsold
PR
ZYPREXA ZYDIS 20 MG TABLET 3
QL 1 / day
AL At least 13 yrsold
PR
ZYPREXA ZYDIS 5 MG TABLET 3
QL 6 / day
AL At least 13 yrsold
PR
PAGE 196 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BUTYROPHENONES
HALDOL 3MED Medical Drug
PR
HALDOL DECANOATE 100 3
HALDOL DECANOATE 50 3
haloperidol (0.5 mg tablet, 2 mg tablet, 5 mg tablet, 10mg tablet, 20 mg tablet) 1 PR
haloperidol 1 mg tablet 1 PR
haloperidol decanoate (dec 50 mg/ml vial, dec 100 mg/mlamp, dec 100 mg/ml vial, dec 250 mg/5 ml vl, dec 500mg/5 ml vl, decan 50 mg/ml amp)
1 PR
haloperidol decanoate 100 1 PR
haloperidol lac 5 mg/ml ampul 1 PR
haloperidol lac 2 mg/ml conc 1
haloperidol lac 5 mg/ml syring 1
haloperidol lactate (5 mg/ml vial, 50 mg/10 ml vl) 1 MED Medical Drug
PHENOTHIAZINES
chlorpromazine hcl (25 mg/ml amp, 25 mg/ml ampule, 50mg/2 ml amp) 1
MED Medical Drug
PR
chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mgtablet, 100 mg tablet, 200 mg tablet) 1 PR
fluphenazine decanoate 1PR
BSP BENEFIT SHIFTPROGRAM
fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5 mlelix, 5 mg tablet, 5 mg/ml conc, 10 mg tablet) 1 PR
fluphenazine 2.5 mg/ml vial 1PR
BSP BENEFIT SHIFTPROGRAM
PAGE 197 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
perphenazine 1AL At least 12 yrs
oldPR
thioridazine hcl 1 PR
trifluoperazine hcl 1 PR
THIOXANTHENES
thiothixene 1 PR
ANTIRETROVIRALS
HIV ENTRY AND FUSION INHIBITORS
FUZEON 3
QL 2 / day
S
PR
RUKOBIA 3S
PR
SELZENTRY (20 MG/ML ORAL SOLN, 25 MG TABLET, 75MG TABLET, 150 MG TABLET, 300 MG TABLET) 3
S
PR
HIV INTEGRASE INHIBITOR ANTIRETROVIRALS
DOVATO 3QL 1 / day
S
ISENTRESS 100 MG POWDER PACKET 3 S
ISENTRESS (25 MG TABLET CHEW, 100 MG TABLET CHEW,400 MG TABLET) 3
S
PR
ISENTRESS HD 3S
PR
JULUCA 3QL 1 / day
S
PAGE 198 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TIVICAY 3S
PR
TIVICAY PD 3S
PR
HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.
DELSTRIGO 3S
PR
EDURANT 3S
PR
efavirenz (50 mg capsule, 200 mg capsule, 600 mg tablet) 1
S
PR
PS
INTELENCE 3S
PR
nevirapine (50 mg/5 ml susp, 200 mg tablet) 1
S
PR
PS
nevirapine er 1
S
PR
PS
PIFELTRO 3S
PR
RESCRIPTOR 3S
PR
SUSTIVA (50 MG CAPSULE, 200 MG CAPSULE, 600 MGTABLET) 3
S
PR
PAGE 199 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SYMFI 3
S
PS
B4G
SYMFI LO 3
S
PS
B4G
VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET) 3S
PR
VIRAMUNE XR 3S
PR
HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS
abacavir (20 mg/ml solution, 300 mg tablet) 1
S
PR
PS
abacavir-lamivudine 1
S
PR
PS
abacavir-lamivudine-zidovudine 1
S
PR
PS
ATRIPLA 3
ST
S
PR
BIKTARVY 3 S
CIMDUO 3
S
PR
PS
PAGE 200 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
COMBIVIR 3S
PR
COMPLERA 3S
PR
DESCOVY 3
QL 1 / day
S
HCR
didanosine 1
S
PR
PS
emtricitabine 1S
PR
emtricitabine-tenofovir disop 1
S
PR
HCR
PS
EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) 3S
PR
EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 MGTABLET) 3
S
PR
EPIVIR HBV (25 MG/5 ML SOLN, 100 MG TABLET) 3S
PR
EPZICOM 3S
PR
GENVOYA 3 S
lamivudine 10 mg/ml oral soln 1S
PS
PAGE 201 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
lamivudine (150 mg tablet, 300 mg tablet) 1
S
PR
PS
lamivudine 100 mg tablet 1S
PR
lamivudine hbv 1S
PR
lamivudine-zidovudine 1
S
PR
PS
ODEFSEY 3 S
RETROVIR (10 MG/ML SYRUP, 100 MG CAPSULE) 3S
PR
RETROVIR 200 MG/20 ML VIAL 3
S
MED Medical Drug
PR
stavudine 1
S
PR
PS
STRIBILD 3S
PR
TEMIXYS 3QL 1 / day
S
tenofovir disoproxil fumarate 1
S
PR
PS
TRIUMEQ 3 S
PAGE 202 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRIZIVIR 3S
PR
TRUVADA 3S
PR
VIDEX 3S
PR
VIDEX EC 3S
PR
VIREAD (150 MG TABLET, 200 MG TABLET, 250 MGTABLET, 300 MG TABLET, POWDER) 3
S
PR
ZERIT 3S
PR
ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET) 3S
PR
zidovudine (50 mg/5 ml syrup, 100 mg capsule, 300 mgtablet) 1
S
PR
PS
HIV PROTEASE INHIBITOR ANTIRETROVIRALS
APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 3S
PR
atazanavir sulfate 1
S
PR
PS
CRIXIVAN 3S
PR
EVOTAZ 3 S
PAGE 203 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fosamprenavir calcium 1
S
PR
PS
INVIRASE 3S
PR
KALETRA (80 MG-20 MG/ML SOLN, 100-25 MG TABLET,200-50 MG TABLET) 3
S
PR
PA
LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) 3S
PR
lopinavir-ritonavir 1
S
PS
PA
NORVIR (80 MG/ML SOLUTION, 100 MG POWDERPACKET, 100 MG TABLET) 3
S
PR
PREZCOBIX 3 S
PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150MG TABLET, 600 MG TABLET, 800 MG TABLET) 3
S
PR
REYATAZ (150 MG CAPSULE, 200 MG CAPSULE, 300 MGCAPSULE) 3
S
PR
REYATAZ 50 MG POWDER PACKET 3 S
ritonavir 1
S
PR
PS
SYMTUZA 3S
PR
PAGE 204 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VIRACEPT 3S
PR
ANTITHROMBOTIC AGENTS
ANTITHROMBOTIC AGENTS, MISCELLANEOUS
CABLIVI (11 MG KIT, 11 MG VIAL) 3 S
PLATELET-AGGREGATION INHIBITORS
AGGRASTAT (3.75 MG/15 ML VIAL, 5 MG/100 ML VIAL,12.5 MG/250 ML) 3 MED Medical Drug
BRILINTA 2QL 2 / day
PR
cilostazol 1QL 2 / day
PR
clopidogrel 1QL 1 / day
PR
EFFIENT 3
QL 1 / day
PR
SBA Select BrandAlternative
eptifibatide (20 mg/10 ml vial, 75 mg/100 ml bag, 75mg/100 ml vial, 200 mg/100 ml vl) 1 MED Medical Drug
INTEGRILIN 3 MED Medical Drug
KENGREAL 3 MED Medical Drug
PLAVIX 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
PAGE 205 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
prasugrel hcl 1QL 1 / day
PR
REOPRO 3 MED Medical Drug
ZONTIVITY 3QL 1 / day
PA
PLATELET-REDUCING AGENTS
AGRYLIN 3 QL 4 / day
anagrelide hcl 1 QL 4 / day
THROMBOLYTIC AGENTS
ACTIVASE 3S
MED Medical Drug
CATHFLO ACTIVASE 3S
MED Medical Drug
TNKASE 50 MG KIT 3 MED Medical Drug
ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES
ALLERGENIC EXTRACTS (THERAPEUTIC)
aspergillus fumigatus 3 MED Medical Drug
aureobasidium pullulans 3 MED Medical Drug
botrytis cinerea 3 MED Medical Drug
cladosporium cladosporioides 3 MED Medical Drug
epicoccum nigrum 3 MED Medical Drug
GRASTEK 3QL 1 / day
PA
mixed vespid venom 3,900 mcg 1 MED Medical Drug
PAGE 206 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
mucor plumbeus 3 MED Medical Drug
ODACTRA 3QL 1 / day
PA
ORALAIR (100-300 IR CHILD SAMPL, 300 IR ADULTSAMPLE KT, 300 IR STARTER PACK, 300 IR SUBLINGUALTAB)
3S
PA
ORALAIR 100 IR STARTER PACK 3 S
PALFORZIA (3 MG 1), 12 MG 3)) 3
QL 1.5 / day
S
PA
PALFORZIA (40 MG (LEVEL 5), 120 MG (LEVEL 7), 200 MG(LEVEL 9), 300 MG (MAINTENANCE)) 3
QL 31 / 30 days
S
PA
PALFORZIA (80 MG 6), 160 MG 8), 240 MG 10)) 3
QL 2 / day
S
PA
PALFORZIA 6 MG (LEVEL 2) 3
QL 3 / day
S
PA
PALFORZIA INITIAL DOSE PACK 3
QL 0.434 / day
S
PA
PALFORZIA (20 MG 4), 300 MG 11)) 3
QL 15 / 30 days
S
PA
penicillium notatum 3 MED Medical Drug
RAGWITEK 3QL 1 / day
PA
PAGE 207 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
saccharomyces cerevisiae 3 MED Medical Drug
trichophyton mentagrophytes 3 MED Medical Drug
ANTITOXINS AND IMMUNE GLOBULINS
ASCENIV 3
S
MED Medical Drug
PA
BIVIGAM 3
S
PA
BSP BENEFIT SHIFTPROGRAM
CUTAQUIG 3
S
PS
PA
CUVITRU 3S
PA
CYTOGAM 3S
MED Medical Drug
FLEBOGAMMA DIF 3
S
PA
BSP BENEFIT SHIFTPROGRAM
GAMASTAN 3
S
MED Medical Drug
PA
GAMASTAN S-D 3
S
MED Medical Drug
PA
GAMMAGARD LIQUID 3S
PA
PAGE 208 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GAMMAGARD S-D 3
S
MED Medical Drug
PA
GAMMAKED 3S
PA
GAMMAPLEX (5 GRAM/100 ML VIAL, 5 GRAM/50 MLVIAL, 10 GRAM/100 ML VIAL, 10 GRAM/200 ML VIAL, 20GRAM/200 ML VIAL, 20 GRAM/400 ML VIAL)
3
S
PA
BSP BENEFIT SHIFTPROGRAM
GAMUNEX-C 3S
PA
HEPAGAM B 3S
MED Medical Drug
HIZENTRA (1 GRAM/5 ML SYRINGE, 1 GRAM/5 ML VIAL, 2GRAM/10 ML SYRINGE, 2 GRAM/10 ML VIAL, 4 GRAM/20ML SYRINGE, 4 GRAM/20 ML VIAL, 10 GRAM/50 ML VIAL)
3S
PA
HYPERHEP B S-D (NEONATAL SYRIN., SYRINGE, VIAL) 3S
MED Medical Drug
HYPERRAB 3S
MED Medical Drug
HYPERRAB S-D 3S
MED Medical Drug
HYPERRHO S-D 3S
MED Medical Drug
HYPERTET S-D 3S
MED Medical Drug
HYQVIA 3S
PA
PAGE 209 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HYQVIA IG COMPONENT 3S
PA
IMOGAM RABIES-HT 3S
MED Medical Drug
KEDRAB 3S
MED Medical Drug
MICRHOGAM ULTRA-FILTERED PLUS 3S
MED Medical Drug
NABI-HB 3S
MED Medical Drug
OCTAGAM 3
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
PANZYGA 3
S
MED Medical Drug
PA
PRIVIGEN 3
S
PA
BSP BENEFIT SHIFTPROGRAM
RHOGAM ULTRA-FILTERED PLUS 3S
MED Medical Drug
RHOPHYLAC 3S
MED Medical Drug
VARIZIG 3S
MED Medical Drug
PAGE 210 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
WINRHO SDF 3S
MED Medical Drug
XEMBIFY 3S
PA
TOXOIDS
ADACEL TDAP (SYRINGE, VIAL) 2 HCR
BOOSTRIX TDAP (SYRINGE, VIAL) 2 HCR
DAPTACEL DTAP 2 HCR
diphtheria-tetanus toxoids-ped 1
INFANRIX DTAP (SYRINGE, VIAL) 2
tdvax 1 HCR
TENIVAC (SYRINGE, VIAL) 2 HCR
VACCINES
ACTHIB VACCINE WITH DILUENT 2
AFLURIA QUAD 2019-20 (3YR UP) 2AL At least 3 yrs
oldHCR
AFLURIA QUAD 2019-20 (6-35MO) 2AL Up to 3 yrs old
HCR
AFLURIA QUAD 2019-2020 2 HCR
AFLURIA QUAD 2020-2021 2 HCR
AFLURIA QUAD 2020-21 (3YR UP) 2AL At least 3 yrs
oldHCR
AFLURIA QUAD 2020-21 (6-35MO) 2AL Up to 3 yrs old
HCR
PAGE 211 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
bcg vaccine (tice strain) 3 MED Medical Drug
BEXSERO 2
ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML VIAL) 2 HCR
ENGERIX-B PEDIATRIC-ADOLESCENT 2 HCR
FLUAD 2019-2020 2AL At least 65 yrs
oldHCR
FLUAD 2020-2021 2AL At least 65 yrs
oldHCR
FLUAD QUAD 2020-2021 2AL At least 65 yrs
oldHCR
FLUARIX QUAD 2019-2020 2 HCR
FLUARIX QUAD 2020-2021 2 HCR
FLUBLOK QUAD 2019-2020 2AL At least 18 yrs
oldHCR
FLUBLOK QUAD 2020-2021 2AL At least 18 yrs
oldHCR
FLUCELVAX QUAD 2019-2020 (2019-2020 SYR, 2019-2020VIAL) 2
AL At least 4 yrsold
HCR
FLUCELVAX QUAD 2020-2021 (2020-2021 SYR, 2020-2021VIAL) 2
AL At least 4 yrsold
HCR
FLULAVAL QUAD 2019-2020 (2019-2020 SYR, 2019-2020VIAL) 2 HCR
PAGE 212 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FLULAVAL QUAD 2020-2021 2 HCR
FLUMIST QUAD 2019-2020 2AL 2 to 49 yrs old
HCR
FLUMIST QUAD 2020-2021 2AL 2 to 49 yrs old
HCR
FLUZONE HIGH-DOSE 2019-2020 2AL At least 65 yrs
oldHCR
FLUZONE HIGH-DOSE QUAD 2020-21 2AL At least 65 yrs
oldHCR
FLUZONE QUAD 2019-2020 (2019-2020 SYRINGE, 2019-2020 VIAL) 2 HCR
FLUZONE QUAD 2020-2021 (2020-2021 SYRINGE, 2020-2021 VIAL) 2 HCR
FLUZONE QUAD PEDI 2019-2020 2AL Up to 3 yrs old
HCR
GARDASIL 9 (9 SYRINGE, 9 VIAL) 2 HCR
HAVRIX (720 UNIT/0.5 ML SYRINGE, 720 UNITS/0.5 MLVIAL, 1,440 UNITS/ML SYRINGE, 1,440 UNITS/ML VIAL) 2 HCR
HEPLISAV-B 20 MCG/0.5 ML SYRNG 2 HCR
HEPLISAV-B 20 MCG/0.5 ML VIAL 2 HCR
HIBERIX 2
IMOVAX RABIES VACCINE 2
IPOL (SINGLE DOSE SYRINGE, VIAL) 2
IXIARO 2
KINRIX (TIP-LOK SYRINGE, VIAL) 2
PAGE 213 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
M-M-R II VACCINE 2 HCR
MENACTRA 2 HCR
MENQUADFI 2
MENVEO A-C-Y-W-135-DIP 2 HCR
MENVEO MENA COMPONENT 2
MENVEO MENCYW-135 COMPONENT 2
PEDIARIX 2
PEDVAXHIB 2
PENTACEL 2
PENTACEL ACTHIB COMPONENT 3
PENTACEL DTAP-IPV COMPONENT 2
PNEUMOVAX 23 (23 SYRINGE, 23 VIAL) 2 HCR
PREVNAR 13 2 HCR
PROQUAD 2
QUADRACEL DTAP-IPV 2
RABAVERT 2
RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 ML VL,10 MCG/ML SYR, 10 MCG/ML VIAL, 40 MCG/ML VIAL) 2 HCR
ROTARIX 2
ROTATEQ 2
SHINGRIX 2AL At least 50 yrs
oldHCR
SHINGRIX GE ANTIGEN COMPONENT 2AL At least 50 yrs
oldHCR
PAGE 214 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
STAMARIL 2
TRUMENBA 3
TWINRIX 2 HCR
TYPHIM VI (25 MCG/0.5 ML AL, 25 MCG/0.5 ML SYRNG) 2
VAQTA (25 UNITS/0.5 ML SYRINGE, 25 UNITS/0.5 MLVIAL, 50 UNITS/ML SYRINGE, 50 UNITS/ML VIAL) 2 HCR
VARIVAX VACCINE 2 HCR
VAXCHORA ACTIVE COMPONENT 2
VAXCHORA VACCINE 2
VIVOTIF 2
YF-VAX 2
ZOSTAVAX 2 HCR
ANTIULCER AGENTS AND ACID SUPPRESSANTS
ANTIULCER AGENTS AND ACID SUPPRESS.,MISC
TALICIA 3 QL 12 / day
HISTAMINE H2-ANTAGONISTS
cimetidine (200 mg tablet, 300 mg tablet, 300 mg/5 mlsoln, 400 mg tablet, 800 mg tablet) 1
famotidine 40 mg/5 ml susp 1 HCG
famotidine 20 mg piggyback 1
MED Medical Drug
HCG
MVGMINIMALVALUEGENERIC
famotidine (20 mg tablet, 40 mg tablet) 1
famotidine (20 mg/2 ml syringe, 20 mg/2 ml vial, 40 mg/4ml vial, 200 mg/20 ml vial, 500 mg/50 ml vial) 1 MED Medical Drug
PAGE 215 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
famotidine-0.9% nacl 1 MED Medical Drug
nizatidine 150 mg capsule 1 QL 2 / day
nizatidine 300 mg capsule 1
nizatidine 15 mg/ml solution 1 HCG
PEPCID (20 MG TABLET, 40 MG TABLET, 40 MG/5 MLORAL SUSP) 3
MVB Minimal ValueBrand
SBA Select BrandAlternative
ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 150 mgtablet, 150 mg/10 ml syrup, 300 mg capsule, 300 mgtablet)
1
ranitidine hcl (hcl 50 mg/2 ml vial, hcl 150 mg/6 ml vl,1,000 mg/40 ml vial) 1 MED Medical Drug
ZANTAC 300 MG TABLET 3 SBA Select BrandAlternative
ZANTAC (50 MG/2 ML VIAL, 150 MG/6 ML VIAL, 1,000MG/40 ML VIAL) 3
MED Medical Drug
SBA Select BrandAlternative
PROSTAGLANDINS
CYTOTEC 3
misoprostol 1
PROTECTANTS
CARAFATE 1 GM/10 ML SUSP 2
CARAFATE 1 GM TABLET 3 SBA Select BrandAlternative
sucralfate (1 gm tablet, 1 gm/10 ml susp) 1
PROTON-PUMP INHIBITORS
ACIPHEX 3
QL 2 / day
ST
SBA Select BrandAlternative
PAGE 216 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ACIPHEX SPRINKLE 3QL 1 / day
ST
DEXILANT 2QL 1 / day
ST
esomeprazole magnesium (dr 20 mg cap, dr 40 mg cap) 1 QL 1 / day
esomeprazole magnesium (dr 10 mg packet, dr 20 mgpacket, dr 40 mg packet) 1
QL 1 / day
HCG
esomeprazole sodium 1 MED Medical Drug
esomeprazole strontium 1
QL 1 / day
ST
HCG
MVGMINIMALVALUEGENERIC
lansoprazol-amoxicil-clarithro 1 QL 112 / 365 days
lansoprazole dr 15 mg capsule 1
lansoprazole (dr 30 mg capsule, odt 15 mg tablet, odt 30mg tablet) 1 QL 1 / day
NEXIUM (DR 20 MG CAPSULE, DR 40 MG CAPSULE) 3
QL 1 / day
ST
SBA Select BrandAlternative
NEXIUM (DR 2.5 MG PACKET, DR 5 MG PACKET, DR 10MG PACKET, DR 20 MG PACKET, DR 40 MG PACKET) 3
QL 1 / day
ST
NEXIUM I.V. 3 MED Medical Drug
OMECLAMOX-PAK 3 QL 80 / 365 days
omeprazole (dr 10 mg capsule, dr 20 mg capsule, dr 40mg capsule) 1 QL 1 / day
PAGE 217 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
omeprazole-sodium bicarbonate (20-1,100 cap, 20-1,680pkt, 40-1,100 cap, 40-1,680 pkt) 1
ST
HCG
MVGMINIMALVALUEGENERIC
pantoprazole 40 mg suspension 1
pantoprazole sod dr 20 mg tab 1 QL 1 / day
pantoprazole sod dr 40 mg tab 1 QL 2 / day
pantoprazole sodium 40 mg vial 1 MED Medical Drug
PREVACID (15 MG SOLUTAB, DR 15 MG CAPSULE, 30 MGSOLUTAB, DR 30 MG CAPSULE) 3
QL 1 / day
ST
SBA Select BrandAlternative
PRILOSEC 3 ST
PROTONIX 40 MG SUSPENSION 3QL 1 / day
ST
PROTONIX DR 20 MG TABLET 3
QL 1 / day
ST
SBA Select BrandAlternative
PROTONIX DR 40 MG TABLET 3
QL 2 / day
ST
SBA Select BrandAlternative
PROTONIX IV 3 MED Medical Drug
rabeprazole sod dr 20 mg tab 1 QL 2 / day
ZEGERID (20 MG CAPSULE, 40 MG CAPSULE) 3
ST
MVB MINIMALVALUE BRAND
SBA Select BrandAlternative
PAGE 218 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZEGERID 20 MG PACKET 3ST
SBA Select BrandAlternative
ZEGERID 40 MG PACKET 3
QL 1 / day
ST
SBA Select BrandAlternative
ANTIVIRALS (SYSTEMIC)
ADAMANTANE ANTIVIRALS
FLUMADINE 3
rimantadine hcl 1
ANTIVIRALS, MISCELLANEOUS
FOSCAVIR 3 MED Medical Drug
PREVYMIS (240 MG TABLET, 480 MG TABLET) 3
AL At least 18 yrsold
S
PA
PREVYMIS (240 MG/12 ML VIAL, 480 MG/24 ML VIAL) 3
AL At least 18 yrsold
S
MED Medical Drug
PA
XOFLUZA 3 QL 2 / fill
INTERFERON ANTIVIRALS
ALFERON N 3S
MED Medical Drug
INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML,18 MILLION UNITS VIL, 25 MILLION UNIT/2.5ML, 50MILLION UNITS VIL)
3S
PA
PAGE 219 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PEGASYS (180 MCG/0.5 ML SYRINGE, 180 MCG/ML VIAL) 3S
PA
PEGASYS PROCLICK 3S
PA
PEGINTRON 3S
PA
SYLATRON 3S
PA
MONOCLONAL ANTIBODY ANTIVIRALS
SYNAGIS 3S
PA
NEURAMINIDASE INHIBITOR ANTIVIRALS
oseltamivir phosphate (30 mg capsule, 45 mg capsule, 75mg capsule) 1 QL 20 / 365 days
oseltamivir 6 mg/ml suspension 1 QL 180 / 30 days
RELENZA 3 QL 40 / 365 days
TAMIFLU (30 MG CAPSULE, 45 MG CAPSULE, 75 MGCAPSULE) 3
QL 20 / 365 days
ST
TAMIFLU 6 MG/ML SUSPENSION 3QL 180 / 30 days
ST
NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS
acyclovir (200 mg capsule, 200 mg/5 ml susp, 400 mgtablet, 800 mg tablet) 1
acyclovir sodium (sodium 1 gm vial, 500 mg/10 ml vial,sodium 500 mg vial, 1,000 mg/20 ml vial) 1 MED Medical Drug
acyclovir sodium-0.9% nacl 1 MED Medical Drug
PAGE 220 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
acyclovir sodium-d5w 1 MED Medical Drug
adefovir dipivoxil 1 S
BARACLUDE 0.05 MG/ML SOLUTION 3
QL 20 / day
S
PA
BARACLUDE (0.5 MG TABLET, 1 MG TABLET) 3
QL 1 / day
S
PA
cidofovir 1S
MED Medical Drug
CYTOVENE 3S
MED Medical Drug
entecavir 1QL 1 / day
S
famciclovir 1
ganciclovir 1S
MED Medical Drug
ganciclovir sodium (500 mg vial, 500 mg/10 ml vial) 1S
MED Medical Drug
HEPSERA 3
QL 1 / day
S
PA
MODERIBA 1
QL 6 / day
S
PA
REBETOL 3
QL 30 / day
S
PA
PAGE 221 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RIBASPHERE (200 MG CAPSULE, 200 MG TABLET) 1
QL 6 / day
S
PA
RIBASPHERE 400 MG TABLET 3
QL 3 / day
S
PA
RIBASPHERE 600 MG TABLET 3
QL 2 / day
S
PA
RIBASPHERE RIBAPAK 3
QL 2 / day
S
PA
ribavirin (200 mg capsule, 200 mg tablet) 1
QL 6 / day
S
PA
ribavirin 6 gm inhalation vial 1
SITAVIG 3
QL 2 / fill
AL At least 18 yrsold
PA
MVB MINIMALVALUE BRAND
valacyclovir 1
VALCYTE 50 MG/ML SOLUTION 3 SBA Select BrandAlternative
VALCYTE 450 MG TABLET 3QL 4 / day
SBA Select BrandAlternative
valganciclovir hcl 50 mg/ml 1
PAGE 222 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
valganciclovir 450 mg tablet 1 QL 4 / day
VALTREX 3ST
SBA Select BrandAlternative
VEMLIDY 3
QL 1 / day
AL At least 18 yrsold
S
PA
VIRAZOLE 3
ZOVIRAX (200 MG CAPSULE, 200 MG/5 ML SUSP, 400 MGTABLET, 800 MG TABLET) 3 SBA Select Brand
Alternative
ANXIOLYTICS, SEDATIVES AND HYPNOTICS
ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC
AMBIEN 3
QL 1 / day
ST
MVB Minimal ValueBrand
SBA Select BrandAlternative
AMBIEN CR 3
QL 1 / day
ST
MVB Minimal ValueBrand
SBA Select BrandAlternative
BELSOMRA 3 ST
buspirone hcl 1
DAYVIGO 3QL 1 / day
ST
PAGE 223 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
dexmedetomidine 200 mcg/2 ml 1 MED Medical Drug
droperidol (5 mg/2 ml ampul, 5 mg/2 ml vial) 1 MED Medical Drug
EDLUAR 3
QL 1 / day
ST
MVB Minimal ValueBrand
eszopiclone (1 mg tablet, 2 mg tablet) 1 QL 1 / day
eszopiclone 3 mg tablet 1QL 1 / day
AL Up to 65 yrs old
HETLIOZ 3
QL 1 / day
S
PA
hydroxyzine hcl (10 mg/5 ml soln, 10 mg/5 ml syrup, hcl10 mg tablet, hcl 25 mg tablet, 50 mg/25 ml syrup, hcl 50mg tablet)
1 AL At least 2 yrsold
hydroxyzine hcl (25 mg/ml vial, 50 mg/ml vial, 100 mg/2ml vial, 500 mg/10 ml vial) 1
AL At least 2 yrsold
MED Medical Drug
hydroxyzine pam 100 mg cap 1
hydroxyzine pamoate (25 mg cap, 50 mg cap) 1 AL At least 2 yrsold
INTERMEZZO 3
QL 1 / day
ST
MVB MINIMALVALUE BRAND
SBA Select BrandAlternative
LUNESTA (1 MG TABLET, 2 MG TABLET) 3
QL 1 / day
ST
SBA Select BrandAlternative
PAGE 224 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LUNESTA 3 MG TABLET 3
QL 1 / day
ST
AL Up to 65 yrs old
SBA Select BrandAlternative
meprobamate 1
PRECEDEX (80 MCG/20 ML VIAL, 200 MCG/2 ML VIAL, 200MCG/50 ML INJECT, 400 MCG/100 ML INJECT, 1,000MCG/250 ML BTL)
3 MED Medical Drug
ramelteon 1 QL 1 / day
ROZEREM 3
QL 1 / day
ST
SBA Select BrandAlternative
VISTARIL 3 AL At least 2 yrsold
zaleplon 1 QL 1 / day
zolpidem tartrate (5 mg tablet, 10 mg tablet) 1 QL 1 / day
zolpidem tartrate (1.75 mg tab, 3.5 mg tablet) 1QL 1 / day
HCG
zolpidem tartrate er 1 QL 1 / day
ZOLPIMIST 3QL 0.257 / day
MVB Minimal ValueBrand
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)
NEMBUTAL SODIUM 3 MED Medical Drug
PAGE 225 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 mlelix, 20 mg/5 ml soln, 30 mg tablet, 32.4 mg tablet, 60 mgtablet, 64.8 mg tablet, 97.2 mg tablet, 100 mg tablet)
1
phenobarbital sodium 1 MED Medical Drug
SECONAL SODIUM 3
BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)
alprazolam (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet) 1 QL 4 / day
alprazolam 2 mg tablet 1 QL 5 / day
alprazolam er (er 0.5 mg tablet, er 1 mg tablet) 1 QL 1 / day
alprazolam er 2 mg tablet 1 QL 5 / day
alprazolam er 3 mg tablet 1 QL 3 / day
ALPRAZOLAM INTENSOL 3 QL 10 / day
alprazolam odt (odt 0.25 mg tab, odt 0.5 mg tab, odt 1mg tab) 1 QL 4 / day
alprazolam odt 2 mg tab 1 QL 5 / day
alprazolam xr (0.5 mg tablet, 1 mg tablet) 1 QL 1 / day
alprazolam xr 2 mg tablet 1 QL 5 / day
alprazolam xr 3 mg tablet 1 QL 3 / day
ATIVAN (0.5 MG TABLET, 1 MG TABLET) 3
QL 3 / day
MVB MINIMALVALUE BRAND
SBA Select BrandAlternative
ATIVAN 2 MG TABLET 3
QL 5 / day
MVB MINIMALVALUE BRAND
SBA Select BrandAlternative
PAGE 226 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ATIVAN (4 MG/ML VIAL, 40 MG/10 ML VIAL) 3 MED Medical Drug
ATIVAN 2 MG/ML VIAL 3MED Medical Drug
SBA Select BrandAlternative
chlordiazepoxide 10 mg capsule 1 QL 30 / day
chlordiazepoxide 25 mg capsule 1 QL 12 / day
chlordiazepoxide 5 mg capsule 1 QL 4 / day
clorazepate 15 mg tablet 1 QL 6 / day
clorazepate 3.75 mg tablet 1 QL 24 / day
clorazepate 7.5 mg tablet 1 QL 12 / day
DIASTAT 3 QL 0.07 / day
DIASTAT ACUDIAL 3 QL 0.07 / day
diazepam (2.5 mg rectal gel sys, 10 mg rectal gel syst, 20mg rectal gel syst) 1 QL 0.07 / day
diazepam (2 mg tablet, 5 mg tablet, 5 mg/5 ml solution, 5mg/ml oral conc, 10 mg tablet) 1
diazepam (10 mg/2 ml carpuject, 10 mg/2 ml syringe, 50mg/10 ml vial) 1 MED Medical Drug
DORAL 3 QL 1 / day
estazolam 1 QL 1 / day
flurazepam hcl 1 QL 1 / day
HALCION 3QL 2 / day
SBA Select BrandAlternative
lorazepam (2 mg tablet, 2 mg/ml oral concent) 1 QL 5 / day
lorazepam (0.5 mg tablet, 1 mg tablet) 1 QL 3 / day
PAGE 227 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
lorazepam (2 mg/ml carpuject, 2 mg/ml syringe, 4 mg/mlcarpuject, 4 mg/ml vial, 40 mg/10 ml vial) 1 MED Medical Drug
lorazepam (2 mg/ml vial, 20 mg/10 ml vial) 1 MED Medical Drug
LORAZEPAM INTENSOL 1 QL 5 / day
lorazepam-0.9% nacl 1 MED Medical Drug
lorazepam-d5w 1 MED Medical Drug
midazolam hcl 2 mg/ml syrup 1
midazolam 55 mg/55 ml-0.9%nacl 1 MED Medical Drug
midazolam 50 mg/50 ml-d5w bag 1 MED Medical Drug
midazolam-0.9% nacl 1 MED Medical Drug
oxazepam 1 QL 4 / day
quazepam 1 QL 1 / day
RESTORIL 3QL 1 / day
ST
temazepam 1 QL 1 / day
TRANXENE T-TAB 3 QL 12 / day
triazolam 0.125 mg tablet 1 QL 1 / day
triazolam 0.25 mg tablet 1 QL 2 / day
VALIUM 3 SBA Select BrandAlternative
VALTOCO 3 QL 10 / 30 days
XANAX (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET) 3QL 4 / day
SBA Select BrandAlternative
XANAX 2 MG TABLET 3QL 5 / day
SBA Select BrandAlternative
PAGE 228 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
XANAX XR (0.5 MG TABLET, 1 MG TABLET) 3QL 1 / day
SBA Select BrandAlternative
XANAX XR 2 MG TABLET 3QL 5 / day
SBA Select BrandAlternative
XANAX XR 3 MG TABLET 3QL 3 / day
SBA Select BrandAlternative
AUTONOMIC DRUGS
AUTONOMIC DRUGS, MISCELLANEOUS
CHANTIX STARTING MONTH BOX 3 HCR
CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1MG TABLET) 3
QL 2 / day
HCR
NICOTROL 3 QL 16/day
NICOTROL NS 3 QL 20 / day
PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)
ARICEPT 3 AL At least 40 yrsold
bethanechol chloride 1
BLOXIVERZ 3 MED Medical Drug
cevimeline hcl 1
donepezil hcl 1 AL At least 40 yrsold
donepezil hcl odt 1 AL At least 40 yrsold
EVOXAC 3 SBA Select BrandAlternative
PAGE 229 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EXELON 3 AL At least 40 yrsold
galantamine er 1 AL At least 40 yrsold
galantamine hbr 1 AL At least 40 yrsold
galantamine hydrobromide 1 AL At least 40 yrsold
guanidine hcl 1
MESTINON (60 MG TABLET, 60 MG/5 ML SOLUTION, 180MG TIMESPAN) 3 SBA Select Brand
Alternative
neostigmine methylsulfate (2 mg/2 ml syringe, 4 mg/4 mlsyringe, 5 mg/10 ml vial, 5 mg/5 ml syringe, 10 mg/10 mlvial)
1 MED Medical Drug
physostigmine salicylate 1 MED Medical Drug
pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1
pyridostigmine br 30 mg tablet 1 HCG
pyridostigmine bromide (60 mg/5 ml soln, br 60 mgtablet) 1
pyridostigmine bromide er 1 HCG
RAZADYNE 3 AL At least 40 yrsold
RAZADYNE ER 3 AL At least 40 yrsold
REGONOL 3 MED Medical Drug
rivastigmine (1.5 mg capsule, 3 mg capsule, 4.5 mgcapsule, 4.6 mg/24hr patch, 6 mg capsule, 9.5 mg/24hrpatch, 13.3 mg/24hr ptch)
1 AL At least 40 yrsold
SALAGEN 3
PAGE 230 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
URECHOLINE 3
BETA-3-ADRENERGIC AGONISTS
SELECTIVE BETA-3-ADRENERGIC AGONISTS
MYRBETRIQ 2 QL 1 / day
BETA-ADRENERGIC AGONISTS
SELECTIVE BETA-2-ADRENERGIC AGONISTS
albuterol hfa 90 mcg inhaler (par) 1QL 0.6 / day
PR
albuterol hfa 90 mcg inhaler (perrigo) 1QL 0.8 / day
PR
albuterol hfa 90 mcg inhaler (prasco) 3
QL 1.5 / day
PR
PA
albuterol hfa 90 mcg inhaler (teva) 1QL 0.8 / day
PR
albuterol sulfate (2.5 mg/0.5 ml sol, sul 2.5 mg/3 ml soln,5 mg/ml solution, 100 mg/20 ml soln) 1
QL 18 / day
PR
albuterol sulfate (sulf 2 mg/5 ml syrup, sulfate er 4 mgtab, sulfate er 8 mg tab) 1 PR
albuterol sulfate (2 mg tab, 4 mg tab) 1 PR
albuterol sulfate (0.63 mg/3 ml sol, 1.25 mg/3 ml sol) 1QL 18 / day
PR
albuterol sulfate hfa 1QL 1.5 / day
PR
ARCAPTA NEOHALER 3
QL 1 / day
ST
PR
PAGE 231 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BROVANA 3QL 4 / day
PR
levalbuterol concentrate 1 PR
levalbuterol hcl 1 PR
levalbuterol tartrate hfa 3
QL 1.5 / day
PR
PA
metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syr, 20mg tablet) 1 PR
PERFOROMIST 3QL 120 / 30 days
PR
PROAIR DIGIHALER 3
QL 0.8 / day
PR
PA
PROAIR HFA 3
QL 0.8 / day
PR
PA
PROAIR RESPICLICK 3
QL 0.07 / day
PR
PA
PROVENTIL HFA 3
QL 0.6 / day
PR
PA
B4G
SEREVENT DISKUS 2QL 2 / day
PR
STRIVERDI RESPIMAT 2 QL .144 / day
PAGE 232 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
terbutaline sulfate (2.5 mg tab, 5 mg tab) 1PR
HCG
terbutaline sulf 1 mg/ml vial 1 PR
UTIBRON NEOHALER 3QL 2 / day
PA
VENTOLIN HFA 3
QL 1.5 / day
PR
PA
XOPENEX 3PR
SBA Select BrandAlternative
XOPENEX CONCENTRATE 3 PR
XOPENEX HFA 3
QL 1.5 / day
PR
PA
B4G
BLOOD DERIVATIVES
ALBUMINEX 3 MED Medical Drug
BLOOD FORMATION, COAGULATION, THROMBOSIS
BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC.
ADAKVEO 3S
MED Medical Drug
OXBRYTA 3
QL 3 / day
S
PA
TAVALISSE 3S
PA
PAGE 233 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HEMATOPOIETIC AGENTS
ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/0.42 MLSYRING, 25 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 40MCG/ML VIAL, 60 MCG/0.3 ML SYRINGE, 60 MCG/MLVIAL, 100 MCG/0.5 ML SYRINGE, 100 MCG/ML VIAL, 150MCG/0.3 ML SYRINGE, 150 MCG/0.75 ML VIAL, 200MCG/0.4 ML SYRINGE, 200 MCG/ML VIAL, 300 MCG/0.6ML SYRINGE, 300 MCG/ML VIAL, 500 MCG/1 ML SYRINGE)
3
S
PS
PA
DOPTELET 3S
PA
EPOGEN 3S
PA
FULPHILA 3S
PA
GRANIX (300 MCG/0.5 ML SAFE SYR, 300 MCG/0.5 MLSYRINGE, 300 MCG/ML VIAL, 480 MCG/0.8 ML SAFE SYR,480 MCG/0.8 ML SYRINGE, 480 MCG/1.6 ML VIAL)
3S
PA
LEUKINE 3S
PA
MIRCERA 3S
PA
MOZOBIL 3S
PA
MULPLETA 3
QL 1 / day
S
PA
NEULASTA 3S
PA
PAGE 234 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NEULASTA ONPRO 3S
PA
NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL,480 MCG/0.8 ML SYR, 480 MCG/1.6 ML VIAL) 3
S
PA
NIVESTYM (300 MCG/0.5 ML SYRING, 300 MCG/ML VIAL,480 MCG/0.8 ML SYRING, 480 MCG/1.6 ML VIAL) 3
S
PA
NPLATE 3
S
MED Medical Drug
PA
PROCRIT 3S
PA
PROMACTA (12.5 MG SUSPEN PACKET, 12.5 MG TABLET,25 MG SUSPENSION PCKT, 25 MG TABLET, 50 MG TABLET,75 MG TABLET)
3S
PA
REBLOZYL 3
S
MED Medical Drug
PA
RETACRIT 3
S
PS
PA
UDENYCA 3S
PA
ZARXIO 3S
PA
ZIEXTENZO 3S
PA
PAGE 235 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HEMORRHEOLOGIC AGENTS
pentoxifylline 1
CALCIUM-CHANNEL BLOCKING AGENTS
CALCIUM-CHANNEL BLOCKING AGENTS, MISC.
CALAN 3QL 3 / day
PR
CALAN SR 3
QL 1 / day
PR
SBA Select BrandAlternative
CARDIZEM 3
QL 4 / day
PR
SBA Select BrandAlternative
CARDIZEM CD (300 MG CAPSULE, 360 MG CAPSULE) 3
QL 1 / day
PR
SBA Select BrandAlternative
CARDIZEM CD 120 MG CAPSULE 3
QL 4 / day
PR
SBA Select BrandAlternative
CARDIZEM CD 180 MG CAPSULE 3
QL 3 / day
PR
SBA Select BrandAlternative
CARDIZEM CD 240 MG CAPSULE 3
QL 2 / day
PR
SBA Select BrandAlternative
PAGE 236 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CARDIZEM LA (300 MG TABLET, 360 MG TABLET, 420 MGTABLET) 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
CARDIZEM LA 120 MG TABLET 3
QL 4 / day
ST
PR
CARDIZEM LA 180 MG TABLET 3
QL 3 / day
ST
PR
SBA Select BrandAlternative
CARDIZEM LA 240 MG TABLET 3
QL 2 / day
ST
PR
SBA Select BrandAlternative
CARTIA XT 120 MG CAPSULE 1QL 4 / day
PR
CARTIA XT 180 MG CAPSULE 1QL 3 / day
PR
CARTIA XT 240 MG CAPSULE 1QL 2 / day
PR
CARTIA XT 300 MG CAPSULE 1QL 1 / day
PR
DILT XR 120 MG CAPSULE 3QL 4 / day
PR
DILT-XR (180 MG CAPSULE, 240 MG CAPSULE) 1 PR
PAGE 237 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
diltiazem 12hr er 1 PR
diltiazem 24hr er (24hr er 240 mg cap, 24hr er 300 mgcap, 24hr er 360 mg cap, 24hr er 420 mg cap) 1 PR
diltiazem 24hr er 120 mg cap 1QL 4 / day
PR
diltiazem 24hr er 180 mg cap 1QL 3 / day
PR
diltiazem 24h er(cd) 120 mg cp 1QL 4 / day
PR
diltiazem 24h er(cd) 180 mg cp 1QL 3 / day
PR
diltiazem 24h er(cd) 240 mg cp 1QL 2 / day
PR
diltiazem 24hr er (cd) (24h 300 mg cp, 24h 360 mg cp) 1QL 1 / day
PR
diltiazem 24h er(la) 180 mg tb 1QL 3 / day
PR
diltiazem 24h er(la) 240 mg tb 1QL 2 / day
PR
diltiazem 24hr er (la) (24h 300 mg tb, 24h 360 mg tb, 24h420 mg tb) 1
QL 1 / day
PR
diltiazem 24h er(xr) 120 mg cp 1QL 4 / day
PR
diltiazem 24h er(xr) 180 mg cp 1QL 3 / day
PR
diltiazem 24h er(xr) 240 mg cp 1 PR
PAGE 238 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
diltiazem 90 mg tablet 1 PR
diltiazem hcl (30 mg tablet, 60 mg tablet, 120 mg tablet) 1QL 4 / day
PR
diltiazem hcl (25 mg/5 ml vial, 50 mg/10 ml vial, 100 mgadd-van vial, 125 mg/25 ml vial) 1
MED Medical Drug
PR
diltiazem hcl-0.7% nacl 1 MED Medical Drug
diltiazem hcl-0.9% nacl 1 MED Medical Drug
diltiazem-d5w 1 MED Medical Drug
MATZIM LA (300 MG TABLET, 360 MG TABLET, 420 MGTABLET) 1
QL 1 / day
PR
MATZIM LA 180 MG TABLET 1QL 3 / day
PR
MATZIM LA 240 MG TABLET 1QL 2 / day
PR
TAZTIA XT (240 MG CAPSULE, 300 MG CAPSULE, 360 MGCAPSULE) 1 PR
TAZTIA XT 120 MG CAPSULE 1QL 4 / day
PR
TAZTIA XT 180 MG CAPSULE 1QL 3 / day
PR
TIADYLT ER (ER 240 MG CAPSULE, ER 300 MG CAPSULE,ER 360 MG CAPSULE, ER 420 MG CAPSULE) 1 PR
TIADYLT ER 120 MG CAPSULE 1QL 4 / day
PR
TIADYLT ER 180 MG CAPSULE 1QL 3 / day
PR
PAGE 239 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TIAZAC (ER 240 MG CAPSULE, ER 300 MG CAPSULE, ER360 MG CAPSULE, ER 420 MG CAPSULE) 3
PR
SBA Select BrandAlternative
TIAZAC ER 120 MG CAPSULE 3
QL 4 / day
PR
SBA Select BrandAlternative
TIAZAC ER 180 MG CAPSULE 3
QL 3 / day
PR
SBA Select BrandAlternative
verapamil er (er 120 mg capsule, er 120 mg tablet, er 180mg capsule, er 180 mg tablet, er 240 mg capsule, er 240mg tablet)
1QL 1 / day
PR
verapamil er pm 1QL 1 / day
PR
verapamil 360 mg cap pellet 1
QL 1 / day
PR
HCG
verapamil 40 mg tablet 1 PR
verapamil hcl (80 mg tablet, 120 mg tablet) 1QL 3 / day
PR
verapamil hcl (5 mg/2 ml ampul, 5 mg/2 ml vial, 10 mg/4ml syringe, 10 mg/4 ml vial) 1
MED Medical Drug
PR
verapamil sr 1QL 1 / day
PR
VERELAN (120 MG CAP PELLET, 180 MG CAP PELLET, 360MG CAP PELLET) 3
QL 1 / day
PR
VERELAN 240 MG CAP PELLET 3
QL 1 / day
PR
SBA SELECT BRANDALTERNATIVE
PAGE 240 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VERELAN PM 3
QL 1 / day
PR
SBA Select BrandAlternative
DIHYDROPYRIDINES
ADALAT CC 30 MG TABLET 3QL 1 / day
PR
ADALAT CC 60 MG TABLET 3QL 2 / day
PR
ADALAT CC 90 MG TABLET 3 PR
AFEDITAB CR 1QL 1 / day
PR
amlodipine besylate 1QL 1 / day
PR
amlodipine besylate-benazepril 1QL 1 / day
PR
amlodipine-olmesartan 1QL 1 / day
PR
amlodipine-valsartan (5-320 mg, 10-160 mg, 10-320 mg) 1QL 1 / day
PR
amlodipine-valsartan 5-160 mg 1QL 2 / day
PR
amlodipine-valsartan-hctz 1QL 1 / day
PR
AZOR 3
QL 1 / day
PR
SBA Select BrandAlternative
PAGE 241 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CARDENE I.V. 25 MG/10 ML AMPUL 3 MED Medical Drug
CARDENE I.V. (CARDENE-DEX 20 MG/200 ML SOLN,CARDENE-NACL 20 MG/200 ML SOLN, CARDENE-NACL 40MG/200 ML IV)
3MED Medical Drug
PR
CLEVIPREX 3 MED Medical Drug
CONJUPRI 3
QL 1 / day
ST
PR
CONSENSI 3
QL 1 / day
PA
MVB MINIMALVALUE BRAND
EXFORGE 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
EXFORGE HCT 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
felodipine er 1QL 1 / day
PR
isradipine 2.5 mg capsule 1QL 2 / day
PR
isradipine 5 mg capsule 1QL 4 / day
PR
KATERZIA 3QL 10 / day
AL Up to 18 yrs old
PAGE 242 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LOTREL 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
nicardipine 20 mg capsule 1 PR
nicardipine 30 mg capsule 1PR
HCG
nicardipine 2.5 mg/ml syringe 1 MED Medical Drug
nicardipine hcl (25 mg/10 ml ampule, 25 mg/10 ml vial) 1MED Medical Drug
PR
nicardipine hcl-0.9% nacl (20mg/200ml-0.9%nacl,40mg/200ml-0.9%nacl) 1
MED Medical Drug
PR
nicardipine hcl-0.9% nacl (0.5 mg/5 ml-ns syr, 1 mg/10 ml-ns syrg) 1 MED Medical Drug
nicardipine hcl-d5w 1MED Medical Drug
PR
nifedipine 1QL 4 / day
PR
nifedipine er (er 30 mg tablet, er 90 mg tablet) 1QL 1 / day
PR
nifedipine er 60 mg tablet 1QL 2 / day
PR
nimodipine 1 PR
nisoldipine 1
QL 1 / day
PR
HCG
PAGE 243 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NORVASC 3
QL 1 / day
PR
SBA Select BrandAlternative
NYMALIZE (30 MG/10 ML SOLUTION, 60 MG/20 MLSOLUTION) 3
QL 120 / day
PR
NYMALIZE (30 MG/5 ML ORAL SYRNG, 60 MG/10 MLORAL SYRN) 3
QL 60 / day
PR
PROCARDIA 3
QL 4 / day
PR
MVB Minimal ValueBrand
SBA SELECT BRANDALTERNATIVE
PROCARDIA XL (30 MG TABLET, 90 MG TABLET) 3
QL 1 / day
PR
SBA Select BrandAlternative
PROCARDIA XL 60 MG TABLET 3
QL 2 / day
PR
SBA Select BrandAlternative
SULAR 3QL 1 / day
PR
CARDIAC DRUGS
CARDIAC DRUGS, MISCELLANEOUS
CORLANOR 5 MG/5 ML ORAL SOLN 3QL 15 / day
PA
CORLANOR (5 MG TABLET, 7.5 MG TABLET) 3
QL 2 / day
ST
PA
PAGE 244 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RANEXA 3
QL 2 / day
ST
SBA Select BrandAlternative
ranolazine er 1 QL 2 / day
VYNDAMAX 3
QL 1 / day
S
PA
VYNDAQEL 3
QL 4 / day
S
PA
CARDIOTONIC AGENTS
DIGITEK 1 NTI
DIGOX 1 NTI
digoxin 0.05 mg/ml solution 1NTI
HCG
digoxin (0.25 mg/ml syringe, 500 mcg/2 ml ampule) 1MED Medical Drug
NTI
digoxin (0.125 mg tablet, 0.25 mg tablet, 125 mcg tablet,250 mcg tablet) 1 NTI
LANOXIN 500 MCG/2 ML AMPULE 2MED Medical Drug
NTI
LANOXIN (62.5 MCG TABLET, 125 MCG TABLET, 187.5MCG TABLET, 250 MCG TABLET) 2 NTI
LANOXIN 500 MCG/2 ML VIAL 3MED Medical Drug
NTI
LANOXIN PEDIATRIC (100 MCG/ML AMPUL, 100 MCG/MLVIAL) 2
MED Medical Drug
NTI
PAGE 245 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CARDIOVASCULAR DRUGS
ALPHA-ADRENERGIC BLOCKING AGENTS
CARDURA 3 PR
CARDURA XL 3
QL 1 / day
ST
PR
doxazosin mesylate 1 PR
MINIPRESS 3 PR
prazosin hcl 1 PR
terazosin hcl 1 PR
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl 1 PR
atenolol (25 mg tablet, 50 mg tablet) 1 PR
atenolol 100 mg tablet 1 PR
atenolol-chlorthalidone 1 PR
BETAPACE 3PR
SBA Select BrandAlternative
BETAPACE AF 3PR
SBA Select BrandAlternative
betaxolol hcl (10 mg tablet, 20 mg tablet) 1 PR
bisoprolol fumarate 1 PR
bisoprolol-hydrochlorothiazide 1 PR
BREVIBLOC (100 MG/10 ML VIAL, 2,000 MG/100 ML BAG,2,500 MG/250 ML BAG) 3 MED Medical Drug
PAGE 246 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BYSTOLIC (5 MG TABLET, 10 MG TABLET) 2QL 3 / day
PR
BYSTOLIC 2.5 MG TABLET 2QL 1 / day
PR
BYSTOLIC 20 MG TABLET 2QL 2 / day
PR
BYVALSON 2 QL 1 / day
carvedilol 1 PR
carvedilol er (er 10 mg capsule, er 20 mg capsule, er 40mg capsule) 1
QL 2 / day
PR
HCG
carvedilol er 80 mg capsule 1
QL 1 / day
PR
HCG
COREG 3
ST
PR
SBA Select BrandAlternative
COREG CR (CR 10 MG CAPSULE, CR 20 MG CAPSULE, CR40 MG CAPSULE) 3
QL 2 / day
ST
PR
SBA Select BrandAlternative
COREG CR 80 MG CAPSULE 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
PAGE 247 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CORGARD 3PR
SBA Select BrandAlternative
CORZIDE 3 PR
DUTOPROL 3
PR
B4G
MVB MINIMALVALUE BRAND
esmolol hcl 100 mg/10 ml syrg 1 MED Medical Drug
esmolol hcl 100 mg/10 ml vial 1MED Medical Drug
PR
esmolol hcl-sodium chloride 1 MED Medical Drug
HEMANGEOL 3 S
INDERAL LA 3
ST
PR
MVB MINIMALVALUE BRAND
SBA Select BrandAlternative
INDERAL XL 3
ST
PR
MVB MINIMALVALUE BRAND
INNOPRAN XL 3
ST
PR
MVB MINIMALVALUE BRAND
KAPSPARGO SPRINKLE 3
labetalol hcl (20 mg/4 ml crpjt, 20 mg/4 ml syrng) 1MED Medical Drug
PR
PAGE 248 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
labetalol hcl 25 mg/5 ml syr 1 MED Medical Drug
labetalol hcl (100 mg tablet, 200 mg tablet, 300 mgtablet) 1 PR
labetalol hcl (20 mg/4 ml vial, 25 mg/5 ml syrng, 50mg/10 ml syrg, 100 mg/20 ml vl, 200 mg/40 ml vl) 1 MED Medical Drug
labetalol hcl-d5w 1 MED Medical Drug
LOPRESSOR 5 MG/5 ML AMPUL 3
MED Medical Drug
PR
SBA Select BrandAlternative
LOPRESSOR (50 MG TABLET, 100 MG TABLET) 3PR
SBA Select BrandAlternative
LOPRESSOR HCT 3PR
SBA Select BrandAlternative
metoprolol succinate 1 PR
metoprolol tartrate (5 mg/5 ml amp, 5 mg/5 ml vial) 1MED Medical Drug
PR
metoprolol 5 mg/5 ml carpuject 1 PR
metoprolol tartrate (25 mg tab, 50 mg tab) 1 PR
metoprolol tartrate (37.5 mg tb, 75 mg tab) 1
metoprolol tartrate 100 mg tab 1 PR
metoprolol-hydrochlorothiazide 1 PR
nadolol 1 PR
nadolol-bendroflu 40-5 mg tab 1 PR
nadolol-bendroflu 80-5 mg tab 1PR
HCG
PAGE 249 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
pindolol 1 PR
propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 mlsoln, 40 mg tablet, 40 mg/5 ml soln, 60 mg tablet, 80 mgtablet)
1 PR
propranolol 1 mg/ml vial 1MED Medical Drug
PR
propranolol hcl er 1 PR
propranolol-hydrochlorothiazid 1 PR
SORINE 1 PR
sotalol 1 PR
sotalol af 1 PR
sotalol hcl 1 MED Medical Drug
SOTYLIZE 3
TENORETIC 100 3PR
SBA Select BrandAlternative
TENORETIC 50 3
PR
MVB Minimal ValueBrand
SBA Select BrandAlternative
TENORMIN 3
ST
PR
SBA Select BrandAlternative
timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 1 PR
TOPROL XL 3PR
SBA Select BrandAlternative
PAGE 250 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZIAC 3 PR
CELLULAR AND GENE THERAPY
CELLULAR THERAPY
PROVENGE 3
QL 18 / day
S
MED Medical Drug
PA
CENTRAL NERVOUS SYSTEM AGENTS
ANTIMANIC AGENTS
lithium 1 NTI
lithium carbonate (150 mg cap, 300 mg cap, 300 mg tab,600 mg cap) 1 NTI
lithium carbonate er 1 NTI
LITHOBID 3 NTI
CENTRAL NERVOUS SYSTEM AGENTS, MISC.
acamprosate calcium 1
ADDYI 3
QL 1 / day
GL Female
AL 18 to 60 yrs old
PA
atomoxetine hcl 1QL 2 / day
AL At least 6 yrsold
carbidopa 1
flumazenil 1 MED Medical Drug
PAGE 251 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
guanfacine hcl er 1QL 1 / day
PR
INTUNIV 3
QL 1 / day
ST
SBA Select BrandAlternative
LODOSYN 3
memantine hcl 2 mg/ml solution 1QL 360 / 30 days
AL At least 40 yrsold
memantine 5-10 mg titration pk 1 AL At least 40 yrsold
memantine hcl 10 mg tablet 1QL 2 / day
AL At least 40 yrsold
memantine hcl 5 mg tablet 1QL 3 / day
AL At least 40 yrsold
memantine hcl er 1 AL At least 40 yrsold
NAMENDA (5 MG TABLET, 5-10 MG TITRATION PK, 10 MGTABLET) 3 AL At least 40 yrs
old
NAMENDA XR TITRATION PACK 3 AL At least 40 yrsold
NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MGCAPSULE, 28 MG CAPSULE) 3
AL At least 40 yrsold
SBA Select BrandAlternative
NAMZARIC (7 MG-10 MG CAPSULE, 14 MG-10 MGCAPSULE, 21 MG-10 MG CAPSULE, 28 MG-10 MGCAPSULE, TITRATION PACK)
3ST
AL At least 40 yrsold
PAGE 252 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NOURIANZ 3
QL 1 / day
S
PA
NUEDEXTA 2 PA
riluzole 1
STRATTERA 3
QL 2 / day
ST
AL At least 6 yrsold
SBA Select BrandAlternative
TIGLUTIK 3 PA
VYLEESI 3
QL 0.08 / day
GL Female
S
PA
XYREM 3
QL 18 / day
S
PA
XYWAV 3
QL 18 / day
S
PA
FIBROMYALGIA AGENTS
SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MGTABLET, 100 MG TABLET, TITRATION PACK) 3
QL 2 / day
ST
OPIATE ANTAGONISTS
naloxone 2 mg auto-injector 3 PA
PAGE 253 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
naloxone hcl (0.4 mg/ml carpuject, 0.4 mg/ml vial, 2 mg/2ml syringe, 4 mg/10 ml vial) 1
naltrexone hcl 1
NARCAN 2 QL 2 / 30 days
VIVITROL 3
S
PA
BSP BENEFIT SHIFTPROGRAM
VESICULAR MONOAMINE TRANSPORT2 INHIBITOR
AUSTEDO 3
QL 4 / day
AL At least 18 yrsold
S
PA
INGREZZA 40 MG CAPSULE 3
QL 2 / day
AL At least 18 yrsold
S
PA
INGREZZA 80 MG CAPSULE 3
QL 1 / day
AL At least 18 yrsold
S
PA
INGREZZA INITIATION PACK 3
QL 1 / day
AL At least 18 yrsold
S
PA
tetrabenazine 1S
PA
PAGE 254 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
XENAZINE 3
S
PA
SBA Select BrandAlternative
CEPHALOSPORIN ANTIBIOTICS
1ST GENERATION CEPHALOSPORIN ANTIBIOTICS
cefadroxil (1 gm tablet, 250 mg/5 ml susp, 500 mgcapsule, 500 mg/5 ml susp) 1
cefazolin sodium (1 gm add-van vial, 1 gm vial, 10 gm vial,20 gm bulk vial, sod 100 gm bulk bag, sod 300 gm bulkbag, 500 mg vial)
1 MED Medical Drug
cefazolin sodium-0.9% nacl (1 g/10 ml-ns syringe, 2 g/10ml-ns syringe, 2 g/100 ml-0.9% nacl, 2 g/50 ml-0.9% nacl,3 g/100 ml-0.9% nacl)
1 MED Medical Drug
cefazolin sodium-d5w (2 gram/100, 2 gram/50 bag, 3gram/100) 1 MED Medical Drug
cefazolin sodium-dextrose (1 g/50, 2 g/100, 2 g/50) 1 MED Medical Drug
cefazolin sodium-sterile water 1 MED Medical Drug
cefazolin-d5w 1 MED Medical Drug
cephalexin (125 mg/5 ml susp, 250 mg capsule, 250 mgtablet, 250 mg/5 ml susp, 500 mg capsule, 500 mg tablet,750 mg capsule)
1
KEFLEX 3
2ND GENERATION CEPHALOSPORIN ANTIBIOTICS
cefaclor (125 mg/5 ml susp, 250 mg capsule, 250 mg/5 mlsusp, 375 mg/5 ml suspen, 500 mg capsule) 1
cefaclor er 1 QL 20 / 30 days
cefprozil (125 mg/5 ml susp, 250 mg tablet, 250 mg/5 mlsusp, 500 mg tablet) 1
PAGE 255 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
cefuroxime 1
cefuroxime sodium 1 MED Medical Drug
3RD GENERATION CEPHALOSPORIN ANTIBIOTICS
AVYCAZ 3 MED Medical Drug
cefdinir (125 mg/5 ml susp, 250 mg/5 ml susp, 300 mgcapsule) 1
cefditoren pivoxil 1
cefixime 400 mg capsule 1
cefixime (100 mg/5 ml susp, 200 mg/5 ml susp) 1 QL 1200 / 90 days
cefotaxime sodium 1 MED Medical Drug
cefpodoxime proxetil (50 mg/5 ml susp, 100 mg tablet,100 mg/5 ml susp, 200 mg tablet) 1
ceftazidime (1 gm piggyback, 1 gm vial, 2 gm piggyback, 2gm vial, 6 gm vial) 1 MED Medical Drug
ceftriaxone (1 gm add-vant vial, 1 gm piggyback, 1 gmvial, 1 gm-d5w bag, 2 gm add vial, 2 gm piggyback, 2 gmvial, 2 gm-d5w bag, 10 gm vial, 100 gram bulk bag, 250mg vial, 500 mg vial)
1 BSP BENEFIT SHIFTPROGRAM
CLAFORAN (1 GM ADD-VANTAGE VL, 1 GM VIAL, 2 GMADD-VANTAGE VL, 2 GM VIAL, 10 GM VIAL) 3 MED Medical Drug
FORTAZ 3 MED Medical Drug
SPECTRACEF 3
SUPRAX 400 MG CAPSULE 3 SBA Select BrandAlternative
SUPRAX (100 MG/5 ML SUSPENSION, 200 MG/5 MLSUSPENSION) 3 QL 1200 / 90 days
SUPRAX (100 MG TABLET CHEWABLE, 200 MG TABLETCHEWABLE, 500 MG/5 ML SUSPENSION) 3
PAGE 256 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TAZICEF (1 GM ADD-VANTAGE VIAL, 1 GRAM VIAL, 2 GMADD-VANTAGE VIAL, 2 GRAM VIAL, 6 GRAM VIAL) 1 MED Medical Drug
4TH GENERATION CEPHALOSPORIN ANTIBIOTICS
cefepime 1 MED Medical Drug
cefepime hcl (1 gm vial, 2 gram vial) 1 MED Medical Drug
cefepime-dextrose 1 MED Medical Drug
MAXIPIME (1 GM ADD-VANTAGE VL, 1 GRAM VIAL, 2 GMADD-VANTAGE VL, 2 GRAM VIAL) 3 MED Medical Drug
5TH GENERATION CEPHALOSPORIN ANTIBIOTICS
TEFLARO 3MED Medical Drug
PA
SIDEROPHORE CEPHALOSPORINS
FETROJA 3 MED Medical Drug
CORTICOSTEROIDS (RESPIRATORY TRACT)
ORALLY INHALED PREPARATIONS (STEROIDS)
ADVAIR DISKUS 2
QL 2 / day
PR
B4G
ADVAIR HFA 2QL 0.4 / day
PR
AIRDUO DIGIHALER 3
QL 0.04 / day
AL At least 12 yrsold
PA
AIRDUO RESPICLICK 3
QL 0.04 / day
AL At least 12 yrsold
PA
PAGE 257 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ALVESCO 3
QL 0.434 / day
PR
PA
ARMONAIR DIGIHALER 3QL 0.04 / day
PA
ARMONAIR RESPICLICK 3QL 0.04 / day
PA
ARNUITY ELLIPTA 100 MCG INH 2QL 2 / day
PR
ARNUITY ELLIPTA 200 MCG INH 2QL 1 / day
PR
ARNUITY ELLIPTA 50 MCG INH 2QL 4 / day
PR
ASMANEX 3
QL 0.04 / day
PR
PA
ASMANEX HFA 3
QL 0.434 / day
PR
PA
BREO ELLIPTA 2QL 2 / day
PR
budesonide (0.25 mg/2 ml susp, 0.5 mg/2 ml susp) 1QL 120 / 30 days
PR
budesonide 1 mg/2 ml inh susp 1
QL 120 / 30 days
PR
HCG
budesonide-formoterol 160-4.5 3
QL 0.4 / day
PR
PA
PAGE 258 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
budesonide-formoterol 80-4.5 3QL 0.4 / day
PA
DULERA 3
QL 0.434 / day
PR
PA
FLOVENT 250 MCG DISKUS 2QL 8 / day
PR
FLOVENT DISKUS (50 MCG, 100 MCG) 2QL 4 / day
PR
FLOVENT HFA (HFA 110 MCG INHALER, HFA 220 MCGINHALER) 2
QL 0.8 / day
PR
FLOVENT HFA 44 MCG INHALER 2QL 0.767 / day
PR
fluticasone-salmeterol (55-14, 113-14, 232-14) 1QL 0.04 / day
AL At least 12 yrsold
fluticasone-salmeterol (100-50, 250-50, 500-50) 1QL 2 / day
PR
PULMICORT 3
QL 120 / 30 days
PR
SBA Select BrandAlternative
PULMICORT FLEXHALER 2QL 0.07 / day
PR
QVAR REDIHALER 40 MCG 2QL 0.6 / day
PR
QVAR REDIHALER 80 MCG 2QL 0.87 / day
PR
PAGE 259 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SYMBICORT 2
QL 0.4 / day
PR
B4G
TRELEGY ELLIPTA 2 QL 2 / day
WIXELA INHUB 1QL 2 / day
PR
CYSTIC FIBROSIS (CFTR) MODULATORS
CYSTIC FIBROSIS (CFTR) CORRECTORS
SYMDEKO 3
QL 2 / day
S
PA
TRIKAFTA 3
QL 3 / day
S
PA
CYSTIC FIBROSIS (CFTR) POTENTIATORS
KALYDECO (25 MG GRANULES PACKET, 50 MG GRANULESPACKET, 75 MG GRANULES PACKET, 150 MG TABLET) 3
QL 2 / day
S
PA
ORKAMBI (100-125 MG GRANULE PKT, 150-188 MGGRANULE PKT) 3
QL 2 / day
S
PA
ORKAMBI (100 MG TABLET, 200 MG TABLET) 3
QL 4 / day
S
PA
DENTAL AGENTS
ORAQIX 3 MED Medical Drug
PAGE 260 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DEPIGMENTING AND PIGMENTING AGENTS
DEPIGMENTING AGENTS
BLANCHE 1
hydroquinone (cream, tr cream) 1
TRI-LUMA 3
PIGMENTING AGENTS
methoxsalen 1
OXSORALEN-ULTRA 3
UVADEX 3S
MED Medical Drug
DEVICES
1st tier unifine pentips 2 PR
1st tier unifine pentips plus 2 PR
1st tier unilet comfortouch 2 PR
2-in-1 lancet device 2 PR
2tek control solution 3
abouttime pen needle 2 PR
accu-chek aviva solution 3
accu-chek (lancet kit, lancets) 2 PR
accu-chek aviva plus meter 3PR
PA
accu-chek compact plus control 3
accu-chek fastclix lancet drum 2 PR
accu-chek fastclix lancing dev 2 PR
PAGE 261 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
accu-chek guide control soln 3
accu-chek guide me glucose mtr 3PR
PA
accu-chek guide monitor system 3PR
PA
accu-chek nano smartview 3PR
PA
accu-chek safe-t-pro 2 PR
accu-chek safe-t-pro plus 2 PR
accu-chek smartview contrl sol 3
accu-chek softclix (lancet kit, lancets) 2 PR
accutrend glucose control 3
acti-lance 2 PR
adjustable lancing device 2 PR
advanced glucose meter 3PR
PA
advanced lancing device 2 PR
advanced travel lancets 2 PR
advocate blood glucose monitor 3PR
PA
advocate control solution (solution high, solution low) 3
advocate duo meter 3PR
PA
advocate lancet 2 PR
advocate lancets 2 PR
PAGE 262 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
advocate lancing device 2 PR
advocate pen needle 2 PR
advocate pen needles 2 PR
advocate rapid-safe 2 PR
advocate redi-code (meter, monitor) 3PR
PA
advocate redi-code duo 3PR
PA
advocate redi-code plus 3PR
PA
advocate redi-code+ ctrl soln 3
agamatrix amp gluc monitor sys 3PR
PA
agamatrix control (high soln, norm-hi soln) 3
agamatrix control solution (2, 4) 3
cvs alkaline batteries 3
alternate site lancets 2 PR
alternate site lancing device 2 PR
aqua lance lancing device 2 PR
assure 4 control solution 3 PA
assure dose 3
assure haemolance plus (18g, 21g, 25g, 28g, blade) 2 PR
assure id duo-shield 2 PR
assure id insulin safety (syr 0.5ml 31gx15/64", syr 1 ml31gx15/64") 2 PR
PAGE 263 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
assure id pen needle 2 PR
assure lance 2 PR
assure lance plus 2 PR
assure platinum glucose meter 3PR
PA
assure prism 3
assure prism multi meter 3PR
PA
auto-lancet mini 2 PR
autolet impression 2 PR
autolet lancing device 2 PR
autolet plus 2 PR
autoshield duo pen needle 2 PR
AVENOVA 3
bd microtainer lancets 2 PR
bd ultra-fine 2 PR
bd ultra-fine ii 2 PR
blood glucose control 3
blood glucose meter 3PR
PA
blood glucose monitoring 3PR
PA
blood lancets 2 PR
blood-glucose control 3
PAGE 264 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
blood-glucose meter 3PR
PA
blunt needle 3
breeze 2 solution 3
bullseye mini safety lancets 2 PR
carefine pen needle 2 PR
carelance ult lancing device 2 PR
careone (lancing device, thin lancet, ultra thin lancet) 2 PR
caresens control solution 3
caresens ultra thin 30g lancet 2 PR
caresens n blood glucose syst 3PR
PA
caresens n voice (n meter, n sys) 3PR
PA
caresens prem lancing device 2 PR
caretouch glucose monitoring 3PR
PA
caretouch insulin syringe (syr 1 ml 28gx5/16", syr 1 ml29gx5/16") 2 PR
caretouch lancing device 2 PR
caretouch pen needle 2 PR
caretouch safety lancets 2 PR
caretouch twist lancet 2 PR
chemstrip bg diary 3 PA
choicedm clarus 3PR
PA
PAGE 265 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
choicedm clarus control soln 3
clever chek blood glucose syst 3PR
PA
clever chek lancets 2 PR
clever choice glucose monitor 3PR
PA
clever choice blood gluc sys 3PR
PA
clever choice control solution (1 sol, 2 sol, 3 sol) 3
clever choice hd glucose syst 3PR
PA
clever choice micro 3PR
PA
clever choice pro glucose mtr 3PR
PA
clever choice talk glucose sys 3PR
PA
clickfine 2 PR
coaguchek lancets 2 PR
color lancets 2 PR
comfort ez 2 PR
comfort ez pen needle 2 PR
comfort lancets 2 PR
contour solution 3
contour (, system) 2 PR
PAGE 266 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
contour next 2 PR
contour next control solution (1 sol, 2 sol) 2
contour next ez meter 2 PR
contour next ez meter system 3 PR
contour next link 2 PR
contour next link 2.4 3 PR
contour next one 3 PR
control ast 3PR
PA
control solution (fora high solution, fora low solution,medpoint solution) 3
cool blood glucose 3PR
PA
cool blood glucose meter 3PR
PA
cool control solution (a solution, b solution) 3
dexcom 2 AL At least 2 yrsold
dexcom g4 ((ped) receiver kit, receiver kit, receiver-share(ped), receiver-share kit, transmitter kit) 2 AL At least 2 yrs
old
dexcom g5 (receiver kit, transmitter kit) 2 AL At least 2 yrsold
dexcom g5-g4 sensor 2 AL At least 2 yrsold
dexcom g6 (receiver, sensor, transmitter) 2 AL At least 2 yrsold
diatrue (1 soln, 2 soln, 3 soln) 3
PAGE 267 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
diatrue plus blood glucose sys 3PR
PA
droplet insulin syringe (0.5 ml 29gx12.5mm(1/2), 0.5 ml30gx12.5mm(1/2), 0.5ml 30gx12.5mm(1/2), ins 0.5ml30gx6mm(1/2), ins 0.5ml 30gx8mm(1/2), ins 0.5ml31gx6mm(1/2), ins 0.5ml 31gx8mm(1/2), ins syr 0.3 ml30gx6mm, ins syr 1 ml 30gx6mm)
2 PR
droplet lancets 2 PR
droplet lancing device 2 PR
droplet micron pen needle 2 PR
droplet pen needle 2 PR
dropsafe pen needle 2 PR
DUROLANE 3
S
PA
BSP BENEFIT SHIFTPROGRAM
e-z ject lancets 2 PR
e-zject lancets 2 PR
easy comfort 2 PR
easy comfort insulin syringe (0.5 ml 32gx5/16", 1 ml32gx5/16") 2 PR
easy comfort pen needle 2 PR
easy comfort pen needles 2 PR
easy glide pen needle 2 PR
easy mini eject lancing device 2 PR
easy plus ii (soln high, soln low) 3
PAGE 268 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
easy plus ii blood glucose sys 3PR
PA
easy step blood glucose meter 3PR
PA
easy step control solution (contrl soln-high, control soln-low, control soln-normal) 3
easy talk (high soln, soln low) 3
easy talk blood glucose meter 3PR
PA
easy touch (button 30g lancets, pressure 30g lancet, pull-top 26g lancet, pull-top 28g lancet, pull-top 30g lancet,pull-top 32g lancet, safety 21g lancets, safety 23g lancets,safety 26g lancets, safety 28g lancets, safety 32g lancets,twist 26g lancets, twist 28g lancets, twist 30g lancets,twist 32g lancets, twist 33g lancets)
2 PR
easy touch control solution 3
easy touch fliplok ndl 25gx5/8 3
easy touch glucose monitor 3PR
PA
easy touch lancing device 2 PR
easy touch pen needle 2 PR
easy touch safety pen needle 2 PR
easy trak (soln high, soln low) 3
easy trak blood glucose meter 3PR
PA
easy trak ii control solution 3
easy twist & cap lancets 2 PR
PAGE 269 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
easy-touch 3PR
PA
easygluco 3PR
PA
easygluco meter 3PR
PA
easygluco meter starter kit 3PR
PA
easygluco plus control normal 3
easymax (low soln, normal soln) 3
easymax 15 (15 1 solution, 15 2 solution) 3
easymax l 3PR
PA
easymax ng (blood sys, system kit) 3PR
PA
easymax v speaking 3PR
PA
easymax v2 3PR
PA
easypoint needle (needle 18g 1", needle 18g 1-1/2",needle 20g 1", needle 20g 1-1/2", needle 21g 1", needle21g 1-1/2", needle 22g 1", needle 22g 1-1/2")
3
eclipse needle (needle 21gx1", needle 22gx1", needle23gx1", needle 25gx1", needle 25gx5/8", needle27gx1/2", needles 21gx1.5")
3
element compact glucose meter 3PR
PA
PAGE 270 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
element compact control soln (soln high, soln normal) 3
element compact v 3PR
PA
element control solution (soln normal, solution high,solution low) 3
element plus 3PR
PA
embrace (blood kit, blood system) 3PR
PA
embrace 30g lancets 2 PR
embrace gluc control soln high 3
embrace evo level 1 ctrl soln 3
embrace evo blood glucose kit 3PR
PA
embrace glucose control soln 3
embrace pro 3
embrace pro blood glucose mtr 3PR
PA
embrace talk (blood mtr, blood sys) 3PR
PA
embrace talk control solution (sol-high(l2), soln-low(l1)) 3
enlite 3
enteral gravity bag set-enfit 3
EPISIL 3
EUFLEXXA 3
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
PAGE 271 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
evencare control solution 3
evencare monitoring system 3PR
PA
evencare g2 blood glucose sys 3PR
PA
evencare g2 control solution 3
evencare g3 control solution 3
evencare g3 blood glucose sys 3PR
PA
evencare mini glucose control 3
evencare mini monitor system 3PR
PA
evencare proview control soln 3
eversense sensor-holder 3
evolution blood glucose meter 3PR
PA
evolution control solution 3
exel hypo needle 30gx0.5" 3
exel mti drawing needle 1
ez smart (high solution, low solution, normal soln) 3
ez smart system kit 3PR
PA
ez smart lancets 2 PR
ez smart plus system kit 3PR
PA
PAGE 272 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ez-lets 2 PR
ez-vac 3
fifty50 safety seal lancets 2 PR
filter aspirator needle 3
filter needle 1
filter needle 19gx1-1/2" 3
filter needle 5 micron 3
fine 30 universal lancets 2 PR
fingerstix 2 PR
fora control solution 3
fora d10 3 PR
fora d15 glucose-bp monitor 3PR
PA
fora d20 blood glucose system 3PR
PA
fora d40d glucose-bp monitor 3PR
PA
fora d40g glucose-bp monitor 3PR
PA
fora g20 blood glucose system 3PR
PA
fora g30a 3PR
PA
fora gd50 3PR
PA
PAGE 273 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fora lancets 2 PR
fora lancing device 2 PR
fora premium v10 3PR
PA
fora test n'go voice 3PR
PA
fora tn'g voice 3PR
PA
fora v10 blood glucose system 3PR
PA
fora v10-v12-d10-d20 strp-lnct 3 PA
fora v12 blood glucose system 3PR
PA
fora v20 blood glucose system 3PR
PA
fora v30a blood glucose system 3PR
PA
foracare gd20 glucose system 3PR
PA
foracare gd40a 3PR
PA
foracare gd40b 3PR
PA
foracare gdh (high soln, low soln, norm soln) 3
foracare lancets 2 PR
PAGE 274 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fortiscare (soln high, soln low, soln normal) 3
fortiscare blood glucose syst 3PR
PA
freestyle control solution 3
freestyle flash system 3PR
PA
freestyle freedom 3PR
PA
freestyle freedom lite 3PR
PA
freestyle insulinx glucose sys 3PR
PA
freestyle lancets 2 PR
freestyle libre 10 day reader 2 AL At least 18 yrsold
freestyle libre 10 day sensor 2 AL At least 18 yrsold
freestyle libre 14 day reader 2 AL At least 18 yrsold
freestyle libre 14 day sensor 2 AL At least 18 yrsold
freestyle libre 2 reader 2 AL At least 4 yrsold
freestyle libre 2 sensor 2 AL At least 4 yrsold
freestyle lite meter 3PR
PA
freestyle navigator 3
PAGE 275 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
freestyle precision neo meter 3PR
PA
freestyle sidekick ii 3PR
PA
freestyle system 3PR
PA
freestyle unistik 2 2 PR
gdrive 3PR
PA
ge100 blood glucose system 3PR
PA
ge100 control solution normal 3
GEL-ONE 3
S
PA
BSP BENEFIT SHIFTPROGRAM
genteel vacuum lancing device 2 PR
GENVISC 850 3
S
PA
BSP BENEFIT SHIFTPROGRAM
gluco navii glucose monitor kt 3PR
PA
glucocard 01 3PR
PA
glucocard 01 control 3
glucocard expression (, kit) 3PR
PA
PAGE 276 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
glucocard expression cntrl sln 3
glucocard shine (, kit) 3PR
PA
glucocard shine control soln 3
glucocard shine connex meter 3PR
PA
glucocard shine express meter 3PR
PA
glucocard shine xl 3PR
PA
glucocard vital meter kit 3PR
PA
glucocom 2 PR
glucocom blood glucose 3PR
PA
glucocom control solution 3
glucocom lancets 2 PR
glucose control 3
glucose control solution 3
gojji glucose control solution 3
gojji lancet-glucose test strp 3 PA
gojji lancets 2 PR
gojji lancing device 2 PR
gojji multifunctional meter kt 3PR
PA
PAGE 277 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
goodlife ac-302 glucose meter 3PR
PA
harmony control solution 3
healthpro glucose control soln 3
healthpro glucose monitor 3PR
PA
healthwise pen needle 2 PR
healthy accents autolet 2 PR
healthy accents unifine pentip (pentip 4mm 32g, pentip5mm 31g, pentip 6mm 31g, pentip 8mm 31g, pentp12mm 29g)
2 PR
healthy accents unilet lancet 2 PR
HPR PLUS EMOLLIENT FOAM 3
HYALGAN (20 MG/2 ML SYRINGE, 20 MG/2 ML VIAL) 3
S
PA
BSP BENEFIT SHIFTPROGRAM
HYCLODEX 3
HYLATOPICPLUS (CREAM, EMOLLIENT FOAM, LOTION) 3
HYMOVIS 3
S
PA
BSP BENEFIT SHIFTPROGRAM
PAGE 278 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
hypodermic needle (hypo needle,polypropyl hub,hypodermic needle,alum hub, monoject hypo ndl 27gx1-1/2", monoject hypo needle 18x1a, monoject hypo needle19x1, monoject hypo needle 19x1-1/2, monoject hyponeedle 20x1, monoject hypo needle 20x1-1/2, monojecthypo needle 21x1, monoject hypo needle 21x1-1/2,monoject hypodermic needle)
3
hypodermic needle (needle 22x1, needle 22x1.5, needle23x1, needle 25x1, needle 25x1.5, needle 25x5/8, needle26x1.5, needle 27x0.5, needle 30x3/4)
3
hypolance 2 PR
iglucose blood glucose monitor 3PR
PA
incontrol lancing device 2 PR
incontrol pen needle 2 PR
incontrol super thin lancets 2 PR
incontrol ultra thin lancets 2 PR
infinity 3PR
PA
infinity control solution (soln high, soln low, soln normal) 3
infinity voice control soln 3
infinity voice glucose monitor 3PR
PA
inject ease lancets 2 PR
insul-cap 3
insul-eze 3
insulin pen needle 2 PR
PAGE 279 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
insupen 2 PR
integra precisionglide needle 3
invacare lancets 2 PR
jazz wireless 2 3PR
PA
lancets 2 PR
lancets thin 2 PR
lancets ultra thin 2 PR
lancing device (autolet impression lancing dev, cvs lancingdevice, e-z pull & click lancing dev, fifty50 lancing device,ge lancing device, gs lancing device and lancets, invacarelancing device, kro lancing device, kroger lancing device,lancing device, live better advanced lancing, meijerlancing device, ra health care lancing device, relionlancing device, simple diagnstic lancet device, value pluslancing device)
2 PR
lancing system 2 PR
lanzo 2 PR
latex gloves 1
LIDOTREX 2% WOUND GEL 3
lite touch (pen needle 29g, 31gx1/4" pen needle, penneedle 31g) 2 PR
lite touch (28g lancets, 30g lancets, 33g lancets, lancingpen) 2 PR
magellan safety needle 3
magellan safety syringe 3
magni-guide magnifier 3
PAGE 280 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
maxicomfort ii pen needle 2 PR
maxicomfort safety pen needle 2 PR
medisense (h-l solution, h-m-l soln) 3 PA
medisense mid control solution 3
medisense control 3 PA
medisense glucose ketone 3 PA
medisense glucose ketone contr 3
medisense thin lancets 2 PR
medlance plus 2 PR
medlance plus special blade 2 PR
meter-check 3
micro thin lancet 2 PR
micro thin lancets 2 PR
microdot (high-low sol, normal solut) 3
microdot blood glucose system 3PR
PA
microdot insulin pen needle 2 PR
microlet 2 PR
microlet 2 2 PR
microlet next lancing device 2 PR
microtainer lancets 2 PR
mini lancing device 2 PR
mini ultra-thin ii 2 PR
PAGE 281 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
minilink real-time transmitter 3
monoject blood collection 3
monoject enfit syringe (1 ml syringe, 3 ml syringe, 6 mlsyringe, 12 ml syringe, 35 ml syringe, 60 ml syringe) 1
monoject enfit syringe cap 1
monolet lancets 2 PR
monolet thin lancets 2 PR
MONOVISC 3
S
PA
BSP BENEFIT SHIFTPROGRAM
multi-lancet 2 PR
myglucohealth monitoring kit 3PR
PA
myglucohealth control solution 3
myglucohealth lancets 2 PR
nano 2nd gen pen needle 2 PR
needle (needle 18gx1 1/2", needle 30gx1/2") 3
reli on 31g x 1/4" needles 2 PR
nova max blood glucose meter 3PR
PA
nova max glucose control soln 3
nova safety lancets 2 PR
nova sureflex 2 PR
novamax plus glu-ket 3 PA
PAGE 282 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
novofine 32 2 PR
novofine autocover 2 PR
novofine plus 2 PR
novotwist 2 PR
NUMOISYN LOZENGE 3
NUVAIL 3
on call express control soln 3
on call express meter (, system) 3PR
PA
on call lancet 2 PR
on call lancing device 2 PR
on call plus control 3
on call plus lancet 2 PR
on call plus lancing device 2 PR
on call plus meter 3PR
PA
on call vivid control 3
on call vivid meter 3PR
PA
on call vivid pal 3PR
PA
on-the-go 2 PR
onetouch delica (30g lancets, 33g lancets, lancing dev) 2 PR
onetouch delica plus lanc dev 2 PR
PAGE 283 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
onetouch delica plus lancet 2 PR
onetouch lancets 2 PR
onetouch suresoft 2 PR
onetouch ultra control soln 3 PR
onetouch ultra2 3PR
PA
onetouch ultramini 3PR
PA
onetouch verio flex meter 3PR
PA
onetouch verio flex startr kit 3
QL 10 / day
PR
PA
onetouch verio high cntrl soln 3
onetouch verio iq meter 3PR
PA
onetouch verio iq system kit 3PR
PA
onetouch verio meter 3PR
PA
onetouch verio mid cntrl soln 3 PR
onetouch verio reflect kit 3PR
PA
onetouch verio reflect meter 3PR
PA
PAGE 284 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
optumrx (blood meter, blood system) 3PR
PA
optumrx glucose control soln 3
ORAFATE 1 S
ORTHOVISC 3
S
PA
BSP BENEFIT SHIFTPROGRAM
PAIN EASE MEDIUM STREAM SPRAY 3
PAIN EASE MIST SPRAY 3
paradigm real-time 3
paradigm remote control 3
PAGE 285 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
pen needle (fifty50 pen 31g x 3/16" needle, fifty50 pen31g x 5/16" needle, fifty50 pen needle 32g x 1/4", fifty50pen needle 32g x 5/32", gnp clickfine pen ndl 31gx1/4",gnp clickfine pen ndl 31gx5/16, gs pen needle 31g x 1/4",gs pen needle 31g x 5/16", gs pen needle 31g x 5mm, gspen needle 31g x 6mm, gs pen needle 31g x 8mm, gs penneedle 32g x 4mm, gs pen needle 32g x 6mm, kro penneedle 4mm x 32g, kro pen needle 4mm x 33g, kro penneedle 5mm x 31g, kro pen needle 6mm x 31g, kro penneedle 8mm x 31g, kroger pen needles 31g x 5/16", livebetter pen needles 8mm, ms pen needle 6mm 31g, penneedle 4mm 32g, pen needle 5mm 31g, pen needle 6mm31g, pen needle 8mm 31g, pen needle 12mm 29g, penneedle 29g 12mm, pen needle 30g x 5/16", pen needle30g x 8mm, pen needle 31g 5mm, pen needle 31g 6mm,pen needle 31g 8mm, pen needle 31g x 1/4", pen needle31g x 3/16", pen needle 31g x 5/16", pen needle 31g x8mm, pen needle 32g 4mm, pen needle 32g x 1/4", penneedle 32g x 3/16", pen needle 32g x 5/32", pub pen 8mm31g needles, pub pen 12mm 29g needles, pub pen needle6mm 31g, ra pen needle 31gx3/16", ra pen needle31gx5/16", relion mini pen 31g x 1/4" ndl, relion pen 29gneedle, relion pen 31g needle, relion pen needle 29gx1/2",relion pen needle 31gx1/4", relion pen needle 31gx5/16",relion pen needle 32gx5/32", today's hlth pn needle 6mm31g)
2 PR
pen needles 2 PR
pentips 2 PR
pharmacist choice (glucose, mini glu) 3PR
PA
phaseal protector 3
pip 28g lancet 2 PR
pip 30g lancet 2 PR
PAGE 286 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
poly hub needle 30gx1/2" 3
precision control solution 3 PA
precision link direct monit 3PR
PA
precision glucose control 3 PA
precision xtra (, nfrs) 3PR
PA
precision xtr b-ketone strip 3
precision xtra ketone-glucose 3PR
PA
premier blu 3PR
PA
premier compact glucose meter 3PR
PA
premier voice 3PR
PA
premium blood glucose 3PR
PA
premium v10 blood glucose mtr 3PR
PA
pressure activated lancets 2 PR
presto pro 3PR
PA
prevent dropsafe pen needle 2 PR
pro comfort lancet 2 PR
PAGE 287 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
pro comfort lancets 2 PR
pro comfort pen needle 2 PR
pro voice v8 glucose monitor 3PR
PA
pro voice v9 glucose monitor 3PR
PA
prodigy 3PR
PA
prodigy autocode 3PR
PA
prodigy control solution 3
prodigy lancets 2 PR
prodigy lancing device 2 PR
prodigy pocket 3PR
PA
prodigy twist top lancet 2 PR
prodigy voice 3PR
PA
PROTHELIAL 1 S
pure comfort lancets 2 PR
pure comfort pen needle 2 PR
pure comfort safety lancets 2 PR
push button safety lancets 2 PR
quintet blood glucose system 3PR
PA
PAGE 288 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
quintet ac blood glucose meter 3PR
PA
readylance safety lancets 2 PR
refuah plus monitoring system 3PR
PA
refuah plus glucose control 3
REGENECARE 3
reliamed 2 PR
reliamed mini lancing device 2 PR
reliamed safety seal lancets 2 PR
relion all-in-one 3PR
PA
relion confirm 3PR
PA
relion micro (blood glucose sys, system kit) 3PR
PA
relion pen needles 2 PR
relion prime 3PR
PA
relion thin 2 PR
replacement pediatric monitor 3
reveal blood glucose meter 3PR
PA
rightest control solution (soln normal, solution high) 3
rightest gc250s control soln 3
PAGE 289 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
rightest gd500 2 PR
rightest gl300 lancets 2 PR
rightest gm100 system 3PR
PA
rightest gm250s meter 3PR
PA
rightest gm260 meter 3PR
PA
rightest gm300 system 3 PA
rightest gm550 system 3PR
PA
bd safe-clip needl storage dev 3
safety lancets 2 PR
safety pen needle 2 PR
safety seal lancets 2 PR
safety-let 2 PR
safety-lok collection set 3
safetyglide insulin syringe (safetyglid ins 1 ml, saftygld ins0.3 ml, saftygld ins 0.5 ml) 2 PR
safetyglide needle 3
sidekick 3PR
PA
SILVASORB GEL 3
SILVRSTAT 3
single-let 2 PR
PAGE 290 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
smart caresens n 3PR
PA
smart sense 2 PR
smart sense lancets 2 PR
smart sense monitoring system 3PR
PA
smartdiabetes vantage 2 PR
smartest 3
smartest eject 3PR
PA
smartest lancet 2 PR
smartest persona (glucose meter, starter kit) 3PR
PA
smartest pronto (glucose meter, starter kit) 3PR
PA
smartest protege 3PR
PA
smartest smart code 3PR
PA
smartest talking 3PR
PA
sodium hyaluronate 3
S
MED Medical Drug
PA
sof-sensor 3
soft touch 2 PR
PAGE 291 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
solus v2 (, sys kit) 3PR
PA
solus v2 28g lancets 2 PR
solus v2 control solution (solution high, solution low) 3
solus v2 lancets 2 PR
solus v2 lancing device 2 PR
SPRAY AND STRETCH 3
sterilance tl 2 PR
SUPARTZ FX 3
S
PA
BSP BENEFIT SHIFTPROGRAM
super thin lancets 2 PR
sure comfort (pen ndl 29gx1/2", 30g pen needle, 31g penneedle, pen ndl 31gx3/16", pen ndl 32gx1/4", pen ndl32gx5/32")
2 PR
sure comfort lancets 2 PR
sure comfort lancing pen 2 PR
sure-fine pen needles 2 PR
sure-lance 2 PR
sure-pen 2 PR
sure-test easyplus mini meter 3PR
PA
sure-test easyplus mini soln 3
sure-touch 2 PR
sureflex 2 PR
PAGE 292 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SYNVISC 3
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
SYNVISC-ONE 3
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
td gold blood glucose monitor 3PR
PA
td gold level 1 control sol 3
td gold level 2 control sol 3
td gold level 3 control sol 3
td gold voice glucose monitor 3PR
PA
techlite insulin syringe (0.3 ml 30gx12mm (1/2), 0.5 ml29gx12mm (1/2), 0.5 ml 30gx12mm (1/2), 0.5 ml30gx8mm (1/2), 0.5 ml 31gx6mm (1/2), 0.5 ml 31gx8mm(1/2))
2 PR
techlite lancets 2 PR
techlite pen needle 2 PR
telcare ultra thin 30g lancets 2 PR
telcare blood glucose monitor 3PR
PA
telcare bgm 3PR
PA
PAGE 293 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
telcare control solution 3
terumo surguard2 (ndl 21gx1 1.5, ndl 22x1-1/2", ndl 23x1-1/2", needle 18gx1", needle 18x1.5, needle 19gx1", needle19x1.5, needle 20gx1", needle 20x1.5, needle 21gx1",needle 22gx1", needle 23gx1", needle 25gx1", needle25x1.5, needle 25x5/8, needle 26x1/2, needle 27x1/2,needle 30x1/2)
3
test n'go blood glucose system 3PR
PA
thin lancets 2 PR
topcare clickfine 2 PR
topcare universal1 lancet 2 PR
topcare universal1 thin lancet 2 PR
TRILURON 3
S
MED Medical Drug
PA
TRIVISC 3
S
PA
BSP BENEFIT SHIFTPROGRAM
true comfort lancet 2 PR
true comfort pen needle 2 PR
true metrix (1 soln, 2 soln, 3 soln) 3
true metrix air glucose meter (glucose meter, humana glumtr, humana meter) 3
PR
PA
true metrix blood glucose mtr 3PR
PA
PAGE 294 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
true metrix go 3PR
PA
true2go blood glucose system 3PR
PA
truecontrol 3
truedraw 2 PR
trueplus lancet 2 PR
trueplus lancets 2 PR
trueplus pen needle 2 PR
trueresult blood glucose systm 3PR
PA
truetrack blood glucose system 3PR
PA
truetrack smart system 3PR
PA
twist lancets 2 PR
ulti-lance (auto-ad, automatic) 2 PR
ulticare pen needle 2 PR
ulticare tb safety 1ml 27gx5/8 3
ultiguard safe pack 2 PR
ultilet basic 2 PR
ultilet classic 2 PR
ultilet lancets 2 PR
ultilet pen needle 2 PR
PAGE 295 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ultilet safety 2 PR
relion ultima glucose meter 3PR
PA
ultra fine lancets 2 PR
ultra flo pen needle 2 PR
ultra thin 2 PR
ultra thin lancet 2 PR
ultra thin lancets 2 PR
ultra thin plus 2 PR
ultra thin plus lancets 2 PR
ultra-care lancets 2 PR
ultra-fine micro pen needle 2 PR
ultra-fine mini pen needle 2 PR
ultra-fine nano pen needle 2 PR
ultra-fine original pen needle 2 PR
ultra-fine short pen needle 2 PR
ultra-thin ii (pen ndl 29gx1/2", pen ndl 31gx5/16) 2 PR
ultra-thin ii (28g, 30g) 2 PR
ultracare pen needle 2 PR
ultralance 2 PR
ultratlc lancets 2 PR
ultratrak (sol normal, solution) 3
ultratrak blood glucose meter 3PR
PA
PAGE 296 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ultratrak pro (glucose mtr sys, meter kit) 3PR
PA
ultratrak ultimate cntrl soln 3
ultratrak ultimate glucose mtr 3PR
PA
unifine pentips 2 PR
unifine pentips maxflow 2 PR
pv unifine pentip plus 31gx8mm 2 PR
unifine pentips plus (careone pentp 29gx1/2", careonepentp 31gx1/4", careone pntp 31gx3/16", careone pntp31gx5/16", careone pntp 32gx5/32", heb pntp plus31gx3/16, heb pntp plus 32gx5/32, pentips plus 29gx1/2",pentips plus 31gx1/4", pentips plus 31gx3/16", pentipsplus 31gx5/16", pentips plus 32gx5/32", pentips plus33gx5/32", pub pntp plus 31gx3/16, pv pentip plus31gx5mm, pv pentip plus 31gx6mm, pv pentip plus32gx4mm, pv pentip plus 33gx4mm, shopko pentips 4mm32g, shopko pentips 5mm 31g, shopko pentips 8mm 31g,shopko pntips 12mm 29g, wm pentip plus 4mm 32g, wmpentip plus 5mm 31g, wm pentip plus 6mm 31g, wmpentip plus 8mm 31g)
2 PR
unifine pentips plus maxflow 2 PR
unifine safecontrol 2 PR
unilet comfortouch 2 PR
unilet excelite 2 PR
unilet excelite ii 2 PR
unilet gp lancet 2 PR
unilet lancet 2 PR
PAGE 297 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
unilet lancets 2 PR
unistik 2 2 PR
unistik 2 extra 2 PR
unistik 2 normal 2 PR
unistik 3 (3 1.8 mm lancing devic, 3 comfort lancet, 3gentle 30g lancets, 3 gentle on-the-go 30g, 3 normal 23glancets, 3 safety 21g lancets)
2 PR
unistik 3 comfort 2 PR
unistik 3 extra 2 PR
unistik 3 neonatal 2 PR
unistik czt 2 PR
unistik pro 2 PR
unistik safety 2 PR
unistik touch 2 PR
unistrip (solution high, solution low) 3
universal 1 2 PR
vanishpoint insulin syringe 2 PR
verasens blood glucose meter 3PR
PA
verasens control solution 3
verasens meter starter kit 3PR
PA
verifine pen needle 2 PR
vivaguard ino control solution (soln-l1, l3, soln-l2, soln-l1,2,3) 3
PAGE 298 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
vivaguard ino glucose meter 3PR
PA
vivaguard ino smart gluc meter 3PR
PA
vivaguard lancet 2 PR
vivaguard lancing device 2 PR
wavesense amp 3PR
PA
wavesense control solution 3
wavesense presto system kit 3PR
PA
yale needle 3
DIAGNOSTIC AGENTS
ADRENOCORTICAL INSUFFICIENCY
ACTHAR 3S
PA
CORTROSYN 3 MED Medical Drug
cosyntropin 1 MED Medical Drug
DIABETES MELLITUS
accu-chek aviva plus test strp 3
QL 10 / day
PR
PA
accu-chek compact plus strips 3
QL 10 / day
PR
PA
PAGE 299 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
accu-chek guide test strip 3
QL 10 / day
PR
PA
accu-chek smartview test strip 3
QL 10 / day
PR
PA
accutrend glucose test strip 3
QL 10 / day
PR
PA
advanced glucose test strip 3
QL 10 / day
PR
PA
advanced glucose test strips 3
QL 10 / day
PR
PA
advocate redi-code test strip 3
QL 10 / day
PR
PA
advocate redi-code+ 3
QL 10 / day
PR
PA
advocate test strip 3
QL 10 / day
PR
PA
agamatrix amp test strips 3
QL 10 / day
PR
PA
PAGE 300 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
agamatrix presto 3
QL 10 / day
PR
PA
assure 4 test strips 3
QL 10 / day
PR
PA
assure platinum test strips 3
QL 10 / day
PR
PA
assure platinum test strip 3
QL 10 / day
PR
PA
assure prism multi test strips 3
QL 10 / day
PR
PA
blood glucose test strip 3
QL 10 / day
PR
PA
breeze 2 disc test strip 3
QL 10 / day
PR
PA
caresens n test strips 3
QL 10 / day
PR
PA
caretouch test strip 3
QL 10 / day
PR
PA
PAGE 301 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
choicedm clarus test strips 3
QL 10 / day
PR
PA
clever choice micro test strip 3
QL 10 / day
PR
PA
clever choice pro test strip 3
QL 10 / day
PR
PA
clever choice talk test strips 3
QL 10 / day
PR
PA
clever choice test strips 3
QL 10 / day
PR
PA
clever choice voice+ tst strip 3
QL 10 / day
PR
PA
contour next test strip 2QL 10 / day
PR
contour test strip 2QL 10 / day
PR
cool glucose test strip 3
QL 10 / day
PR
PA
dario blood glucose test strip 3
QL 10 / day
PR
PA
PAGE 302 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
diatrue plus test strip 3
QL 10 / day
PR
PA
easy gluco g2 3
QL 10 / day
PR
PA
easy plus ii test strip 3
QL 10 / day
PR
PA
easy step glucose test strips 3
QL 10 / day
PR
PA
easy talk glucose test strip 3
QL 10 / day
PR
PA
easy touch test strip 3
QL 10 / day
PR
PA
easy trak glucose test strip 3
QL 10 / day
PR
PA
easy trak ii test strip 3
QL 10 / day
PR
PA
easygluco plus 3
QL 10 / day
PR
PA
PAGE 303 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
easygluco test strips 3
QL 10 / day
PR
PA
easymax glucose test strips 3
QL 10 / day
PR
PA
easymax 15 glucose test strip 3
QL 10 / day
PR
PA
element compact test strips 3
QL 10 / day
PR
PA
element test strips 3
QL 10 / day
PR
PA
embrace (, glucose) 3
QL 10 / day
PR
PA
embrace evo test strips 3
QL 10 / day
PR
PA
embrace pro test strip 3
QL 10 / day
PR
PA
embrace talk test strip 3
QL 10 / day
PR
PA
PAGE 304 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
evencare glucose tst strips 3
QL 10 / day
PR
PA
evencare g2 test strip 3
QL 10 / day
PR
PA
evencare g3 test strip 3
QL 10 / day
PR
PA
evencare mini glucose test str 3
QL 10 / day
PR
PA
evencare proview test strip 3
QL 10 / day
PR
PA
evolution test strips 3
QL 10 / day
PR
PA
ez smart test strips 3
QL 10 / day
PR
PA
ez smart plus test strips 3
QL 10 / day
PR
PA
fifty50 test strip 3
QL 10 / day
PR
PA
PAGE 305 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fora 6 connect glucose strip 3
QL 10 / day
PR
PA
fora d15g 3
QL 10 / day
PR
PA
fora d20 glucose test strips 3
QL 10 / day
PR
PA
fora d40-g31 test strips 3
QL 10 / day
PR
PA
fora g20 glucose test strips 3
QL 10 / day
PR
PA
fora g30-premium v10 test strp 3
QL 10 / day
PR
PA
fora gd50 test strips 3
QL 10 / day
PR
PA
fora gtel glucose test strip 3
QL 10 / day
PR
PA
fora test strip 3
QL 10 / day
PR
PA
PAGE 306 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fora tn'g voice test strips 3
QL 10 / day
PR
PA
fora v10 glucose test strip 3
QL 10 / day
PR
PA
fora v10-v12-d10-d20 strips 3
QL 10 / day
PR
PA
fora v12 glucose test strip 3
QL 10 / day
PR
PA
fora v20 glucose test strips 3
QL 10 / day
PR
PA
fora v30a glucose test strip 3
QL 10 / day
PR
PA
foracare gd20 test strips 3
QL 10 / day
PR
PA
foracare gd40 3
QL 10 / day
PR
PA
fortiscare glucose test strips 3
QL 10 / day
PR
PA
PAGE 307 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
freestyle insulinx (strip nfrs, test strip) 3
QL 10 / day
PR
PA
freestyle insulinx test strips 3
QL 10 / day
PR
PA
freestyle lite test strip 3
QL 10 / day
PR
PA
freestyle precision neo 3
QL 10 / day
PR
PA
freestyle test strips 3
QL 10 / day
PR
PA
ge100 blood glucose test strip 3
QL 10 / day
PR
PA
genstrip 3
QL 10 / day
PR
PA
genultimate test strip 3
QL 10 / day
PR
PA
gluco navii glucose test strip 3
QL 10 / day
PR
PA
PAGE 308 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
glucocard 01 sensor plus 3
QL 10 / day
PR
PA
glucocard expression test strp 3
QL 10 / day
PR
PA
glucocard shine test strips 3
QL 10 / day
PR
PA
glucocard vital test strips 3
QL 10 / day
PR
PA
glucocard vital sensor 3
QL 10 / day
PR
PA
glucocom glucose 3
QL 10 / day
PR
PA
glucose test strip 3
QL 10 / day
PR
PA
gojji blood glucose test strip 3
QL 10 / day
PR
PA
goodlife ac-302 test strip 3
QL 10 / day
PR
PA
PAGE 309 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
harmony glucose test strip 3
QL 10 / day
PR
PA
healthpro glucose test strips 3
QL 10 / day
PR
PA
iglucose test strip 3
QL 10 / day
PR
PA
infinity test strips 3
QL 10 / day
PR
PA
infinity voice test strip 3
QL 10 / day
PR
PA
micro 3
QL 10 / day
PR
PA
microdot test strips 3
QL 10 / day
PR
PA
microdot xtra 3
QL 10 / day
PR
PA
myglucohealth test strips 3
QL 10 / day
PR
PA
PAGE 310 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
neutek 2tek test strips 3
QL 10 / day
PR
PA
nova max glucose test strips 3
QL 10 / day
PR
PA
on call express test strip 3
QL 10 / day
PR
PA
on call plus test strip 3
QL 10 / day
PR
PA
on call vivid test strip 3
QL 10 / day
PR
PA
onetouch ultra blue test strp 3
QL 10 / day
PR
PA
onetouch verio test strip 3
QL 10 / day
PR
PA
optium 3
QL 10 / day
PR
PA
optium ez 3
QL 10 / day
PR
PA
PAGE 311 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
optumrx test strip 3
QL 10 / day
PR
PA
pharmacist choice test strips 3
QL 10 / day
PR
PA
precision pcx 3
QL 10 / day
PR
PA
precision pcx plus 3
QL 10 / day
PR
PA
precision point of care 3
QL 10 / day
PR
PA
precision q-i-d 3
QL 10 / day
PR
PA
precision xtra test strips 3
QL 10 / day
PR
PA
premier test strip 3
QL 10 / day
PR
PA
premium blood glucose test 3
QL 10 / day
PR
PA
PAGE 312 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
premium v10 glucose test strip 3
QL 10 / day
PR
PA
pro voice v8-v9 test strip 3
QL 10 / day
PR
PA
prodigy no coding 3
QL 10 / day
PR
PA
quintet glucose test strips 3
QL 10 / day
PR
PA
quintet ac glucose test strips 3
QL 10 / day
PR
PA
refuah plus test strips 3
QL 10 / day
PR
PA
relion confirm-micro 3
QL 10 / day
PR
PA
relion prime test strips 3
QL 10 / day
PR
PA
reveal test strip 3
QL 10 / day
PR
PA
PAGE 313 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
rightest gs100 test strips 3
QL 10 / day
PR
PA
rightest gs250s test strips 3
QL 10 / day
PR
PA
rightest gs260 test strips 3
QL 10 / day
PR
PA
rightest gs300 test strips 3
QL 10 / day
PR
PA
rightest gs550 test strips 3
QL 10 / day
PR
PA
smart sense test strips 3
QL 10 / day
PR
PA
smartest test 3
QL 10 / day
PR
PA
solus v2 test strips 3
QL 10 / day
PR
PA
sure-test easyplus mini strip 3
QL 10 / day
PR
PA
PAGE 314 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
td gold test strip 3
QL 10 / day
PR
PA
telcare test strips 3
QL 10 / day
PR
PA
test n'go glucose test strip 3
QL 10 / day
PR
PA
test strips 3
QL 10 / day
PR
PA
true metrix glucose test strip 3
QL 10 / day
PR
PA
true metrix pro test strip 3
QL 10 / day
PR
PA
truetest test strips 3
QL 10 / day
PR
PA
truetrack test strip 3
QL 10 / day
PR
PA
ultima (, relion) 3
QL 10 / day
PR
PA
PAGE 315 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ultratrak test strip 3
QL 10 / day
PR
PA
ultratrak ultimate test strips 3
QL 10 / day
PR
PA
unistrip1 3
QL 10 / day
PR
PA
verasens test strip 3
QL 10 / day
PR
PA
vivaguard ino test strip 3
QL 10 / day
PR
PA
wavesense jazz 3
QL 10 / day
PR
PA
wavesense presto test strips 3
QL 10 / day
PR
PA
OCULAR DISORDERS
TISSUEBLUE 3 MED Medical Drug
PITUITARY FUNCTION
ACTHREL 3
S
MED Medical Drug
PA
PAGE 316 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MACRILEN 3S
PA
RESPIRATORY FUNCTION
methacholine chloride 1 MED Medical Drug
ROENTGENOGRAPHY AND OTHER IMAGING AGENTS
CERETEC 0.5 MG VIAL 3 MED Medical Drug
CONRAY-43 VIAL 3 MED Medical Drug
DOTAREM 2.5 MMOL/5 ML VIAL 3 MED Medical Drug
OMNIPAQUE 12 MG/ML ORAL SOLN 3
OMNIPAQUE 9 MG/ML ORAL SOLN 3 MED Medical Drug
OPTIRAY 240 (240 MG/ML) SYRN 3 MED Medical Drug
READI-CAT 2 3
TECHNESCAN HDP 3 MED Medical Drug
THYROID FUNCTION
THYROGEN 3
S
PA
BSP BENEFIT SHIFTPROGRAM
URINE AND FECES CONTENTS
azo 3
chek-stix 3 QL 6.66 / day
chemstrip 10 md 3
chemstrip 10 with sg 3
chemstrip 2 gp 3
PAGE 317 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
chemstrip 50b 3
chemstrip 7 3
chemstrip 9 3
combistix reagent 3
hema-combistix 3
ictotest 3
keto-diastix reagent 3
labstix reagent 3
multistix 3
multistix 10 sg 3
multistix 5 3
multistix 7 3
multistix 8 sg 3
multistix 9 3
multistix 9 sg 3
urinary tract infection 3
uristix 4 3
uristix reagent 3
DIURETICS
LOOP DIURETICS
bumetanide (1 mg tablet, 2 mg tablet) 1PR
HCG
bumetanide 0.5 mg tablet 1 PR
DEMADEX 3 PR
PAGE 318 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EDECRIN 3
PR
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
ethacrynic acid 1
PR
HCG
MVGMINIMALVALUEGENERIC
furosemide (10 mg/ml solution, 20 mg tablet, 40 mgtablet, 40 mg/5 ml soln, 80 mg tablet) 1 PR
LASIX 3ST
PR
torsemide 1 PR
OSMOTIC DIURETICS
mannitol (5% iv solution, 10% iv solution, 20% iv solution,25% vial) 1 MED Medical Drug
OSMITROL 1 MED Medical Drug
POTASSIUM-SPARING DIURETICS
amiloride hcl 1 PR
amiloride-hydrochlorothiazide 1 PR
DYAZIDE 3
ST
PR
SBA Select BrandAlternative
DYRENIUM 3
PR
PA
MVB Minimal ValueBrand
SBA SELECT BRANDALTERNATIVE
PAGE 319 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MAXZIDE 3
ST
PR
SBA Select BrandAlternative
MAXZIDE-25 MG 3
ST
PR
SBA Select BrandAlternative
triamterene 1PR
PA
triamterene-hydrochlorothiazid (37.5-25 mg cp, 37.5-25mg tb, 50-25 mg cap, 75-50 mg tab) 1 PR
THIAZIDE DIURETICS
chlorothiazide 1 PR
chlorothiazide sodium 1 MED Medical Drug
DIURIL 3 PR
hydrochlorothiazide (12.5 mg cp, 12.5 mg tb, 50 mg tab) 1 PR
hydrochlorothiazide 25 mg tab 1 PR
methyclothiazide 1 PR
MICROZIDE 3 PR
SODIUM DIURIL 3 MED Medical Drug
THIAZIDE-LIKE DIURETICS
chlorthalidone 1 PR
indapamide 1 PR
metolazone 1 PR
PAGE 320 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VASOPRESSIN ANTAGONISTS
JYNARQUE 15 MG TABLET 3
QL 1 / day
S
PA
JYNARQUE (15 MG-15 MG TABLET, 30 MG TABLET, 30MG-15 MG TABLET, 45 MG-15 MG TABLET, 60 MG-30 MGTABLET, 90 MG-30 MG TABLET)
3
QL 2 / day
S
PA
SAMSCA 15 MG TABLET 3
QL 1 / day
S
PA
SAMSCA 30 MG TABLET 3
QL 2 / day
S
PA
tolvaptan 15 mg tablet 1
QL 1 / day
S
PA
tolvaptan 30 mg tablet 1
QL 2 / day
S
PA
DOPAMINE RECEPTOR AGONISTS
ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS
bromocriptine mesylate (2.5 mg tablet, 5 mg capsule) 1 HCG
cabergoline 1
CYCLOSET 3
QL 6 / day
PR
PA
PAGE 321 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PARLODEL (2.5 MG TABLET, 5 MG CAPSULE) 3
NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST
APOKYN 3
QL 2 / day
S
PA
KYNMOBI (10 MG FILM, 15 MG FILM, 20 MG FILM, 25 MGFILM, 30 MG FILM) 3
QL 5 / day
S
PA
KYNMOBI TITRATION KIT 3
QL 10 / 30 days
S
PA
MIRAPEX 3
MIRAPEX ER 3
NEUPRO 3 PA
pramipexole dihydrochloride 1
pramipexole er 1
REQUIP 3
REQUIP XL 3
ropinirole er 1
ropinirole hcl 1
ELECTROLYTIC, CALORIC, AND WATER BALANCE
ACIDIFYING AGENTS
K-PHOS ORIGINAL 3
ALKALINIZING AGENTS
CYTRA-K CRYSTALS PACKET 1
PAGE 322 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
potassium citrate er 1
UROCIT-K 3
AMMONIA DETOXICANTS
BUPHENYL 500 MG TABLET 3 S
CARBAGLU 3 S
CONSTULOSE 1
ENULOSE 1
GENERLAC 1
KRISTALOSE 1
lactulose 10 gm packet 1
HCG
MVGMINIMALVALUEGENERIC
lactulose (10 gm/15 ml solution, 20 gm/30 ml solution) 1
RAVICTI 3
QL 20 / day
S
PA
sodium phenylbutyrate 500mg tb 1 S
CALORIC AGENTS
ACD-A 30 ML VIAL 1 MED Medical Drug
CLINOLIPID 3 MED Medical Drug
CYCLINEX-1 3
DOJOLVI 3S
PA
EAA 3
PAGE 323 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GLYCOSADE 60 G POWDER PACKET 3
GLYTACTIN 10 PE COMPLETE 3
GLYTACTIN 15 PE BETTERMILK 3
GLYTACTIN 15 PE COMPLETE 3
GLYTACTIN 20PE BETTERMILK LITE 3
GLYTACTIN BUILD 10 PE 3
GLYTACTIN BUILD 20-20 3
GLYTACTIN BURST 10-10 3
GLYTACTIN BURST 20-20 3
GLYTACTIN RESTORE 10 PE 3
GLYTACTIN RESTORE 10 PE LITE 3
GLYTACTIN RESTORE 5 PE 3
GLYTACTIN RTD 10 PE 3
GLYTACTIN RTD 15 PE 3
GLYTACTIN RTD LITE 15 3
GLYTACTIN SWIRL 15 PE 3
HCY 1 3
HOMINEX-1 3
LANAFLEX 3
OMEGAVEN 3 MED Medical Drug
PHENYLADE GMP DRINK POWDER 3
PHENYLADE GMP MIX-IN POWDER 3
PLENAMINE 1 MED Medical Drug
PAGE 324 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
IRRIGATING SOLUTIONS
DELFLEX-2.5% DEXTROSE 3 MED Medical Drug
RESECTISOL 3 MED Medical Drug
RIMSO-50 3 MED Medical Drug
REPLACEMENT PREPARATIONS
calcium gluconate-0.9% nacl (1 g/50-0.9%, 2 g/50-0.9%) 1 MED Medical Drug
calcium gluconate-nacl 1 MED Medical Drug
dextrose 5%-0.2% nacl-kcl 1 MED Medical Drug
dextrose 5%-0.225% nacl-kcl 1 MED Medical Drug
dextrose 5%-0.3% nacl-kcl 1 MED Medical Drug
dextrose 5%-0.45% nacl-kcl 1 MED Medical Drug
dextrose 5%-1/2ns-kcl 1 MED Medical Drug
dextrose 5%-1/4ns-kcl 1 MED Medical Drug
dextrose 5%-ns-kcl 1 MED Medical Drug
dextrose 5%-potassium chloride 1 MED Medical Drug
EFFER-K (10 TABLET EFF, 20 TABLET EFF) 3
EFFER-K 25 MEQ TABLET EFF 1
K EFFERVESCENT 1
K-TAB ER 3 ST
KLOR-CON 1
KLOR-CON 10 1
KLOR-CON 8 1
KLOR-CON M10 1
PAGE 325 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
KLOR-CON M15 3
KLOR-CON M20 1
KLOR-CON-EF 1
potassium acetate 1 MED Medical Drug
potassium bicarbonate 1
potassium cl 20 meq packet 1 HCG
potassium chloride (er 8 meq capsule, er 8 meq tablet,10% (20 meq/15ml), 10% (40 meq/30ml), er 10 meqcapsule, er 10 meq tablet, 20% (40 meq/15ml), er 20 meqtablet, 25 meq tab eff)
1
potassium chloride (2 meq/ml conc, 10 meq/100 ml sol,10 meq/5 ml conc, 10 meq/50 ml sol, 20 meq/10 ml conc,20 meq/100 ml sol, 20 meq/50 ml sol, 30 meq/100 ml sol,40 meq/100 ml sol, 40 meq/20 ml conc, 60 meq/30 mlconc)
1 MED Medical Drug
potassium chloride in d5lr 1 MED Medical Drug
potassium chloride proamp 1 MED Medical Drug
potassium chloride-nacl 1 MED Medical Drug
potassium cl-lidocaine-ns 1 MED Medical Drug
potassium ph 30 mmol/250 ml-ns 1 MED Medical Drug
potassium phosphates 1 MED Medical Drug
sodium chloride 0.9% ampule 1 BSP BENEFIT SHIFTPROGRAM
sodium phos 30 mmol/250 ml-ns 1 MED Medical Drug
sodium phosphate-d5w 1 MED Medical Drug
zinc chloride 1 MED Medical Drug
PAGE 326 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
URICOSURIC AGENTS
probenecid 1 QL 4 / day
probenecid-colchicine 1 QL 2 / day
ENZYMES
ADAGEN 3S
MED Medical Drug
ALDURAZYME 3
S
PA
BSP BENEFIT SHIFTPROGRAM
CEREZYME 3
S
PA
BSP BENEFIT SHIFTPROGRAM
ELAPRASE 3
S
PA
BSP BENEFIT SHIFTPROGRAM
ELELYSO 3
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
ELITEK 3S
MED Medical Drug
FABRAZYME 3
S
PA
BSP BENEFIT SHIFTPROGRAM
PAGE 327 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HYLENEX 3 MED Medical Drug
HYQVIA HY COMPONENT 3S
PA
LUMIZYME 3
S
PA
BSP BENEFIT SHIFTPROGRAM
MEPSEVII 3
S
MED Medical Drug
PA
NAGLAZYME 3
S
PA
BSP BENEFIT SHIFTPROGRAM
PALYNZIQ (10 MG/0.5 ML SYRINGE, 20 MG/ML SYRINGE) 3
QL 2 / day
S
PA
PALYNZIQ 2.5 MG/0.5 ML SYRINGE 3
QL 8 / day
S
PA
REVCOVI 3S
MED Medical Drug
STRENSIQ 3
S
PS
PA
SUCRAID 3S
PA
VIMIZIM 3S
MED Medical Drug
PAGE 328 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VITRASE 3 MED Medical Drug
VPRIV 3
S
PA
BSP BENEFIT SHIFTPROGRAM
XIAFLEX 3
S
PA
BSP BENEFIT SHIFTPROGRAM
ESTROGENS AND ANTIESTROGENS
ESTROGEN AGONIST-ANTAGONISTS
clomiphene citrate 1 GL Female
EVISTA 3QL 1 / day
PR
FARESTON 3PR
SBA Select BrandAlternative
OSPHENA 3 PR
raloxifene hcl 1PR
HCR
SEROPHENE 1 GL Female
SOLTAMOX 3 PR
tamoxifen citrate 1PR
HCR
toremifene citrate 1 PR
PAGE 329 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ESTROGENS
ACTIVELLA 0.5-0.1 MG TABLET 3
QL 1 / day
GL Female
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
ACTIVELLA 1 MG-0.5 MG TABLET 3
QL 1 / day
GL Female
MVB Minimal ValueBrand
SBA Select BrandAlternative
ALORA 3
QL 0.29 / day
ST
GL Female
AMABELZ 1QL 1 / day
GL Female
ANGELIQ 3QL 1 / day
GL Female
BIJUVA 3QL 1 / day
GL Female
CLIMARA 3
QL 0.15 / day
ST
GL Female
CLIMARA PRO 2QL 0.15 / day
GL Female
COMBIPATCH 3QL 0.29 / day
GL Female
PAGE 330 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DELESTROGEN (50 MG/5 ML VIAL, 200 MG/5 ML VIAL) 3ST
GL Female
DELESTROGEN 100 MG/5 ML VIAL 3
ST
GL Female
SBA SELECT BRANDALTERNATIVE
DEPO-ESTRADIOL 3 GL Female
DIVIGEL (0.25 MG GEL PACKET, 0.5 MG GEL PACKET, 0.75MG GEL PACKET, 1 MG GEL PACKET, 1.25 MG GELPACKET)
2QL 1 / day
GL Female
DOTTI 1QL 0.29 / day
GL Female
DUAVEE 2
ELESTRIN 3 GL Female
ESTRACE 0.01% CREAM 3
QL 4 / day
ST
GL Female
ESTRACE (0.5 MG TABLET, 1 MG TABLET) 3
QL 1 / day
ST
GL Female
ESTRACE 2 MG TABLET 3
QL 1 / day
ST
GL Female
SBA SELECT BRANDALTERNATIVE
estradiol 0.01% cream 1QL 4 / day
GL Female
estradiol (0.5 mg tablet, 1 mg tablet) 1QL 1 / day
GL Female
PAGE 331 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
estradiol 10 mcg vaginal insrt 1QL 0.643 / day
GL Female
estradiol 2 mg tablet 1QL 1 / day
GL Female
estradiol (once weekly) (0.025 mg patch(1/wk), 0.0375mgpatch(1/wk), 0.05 mg patch (1/wk), 0.06 mg patch (1/wk),0.1 mg patch (1/wk))
1QL 0.15 / day
GL Female
estradiol 0.075 mg patch(1/wk) 1
QL 0.15 / day
GL Female
HCG
estradiol (twice weekly) 1QL 0.29 / day
GL Female
estradiol valerate 1GL Female
HCG
estradiol-norethindrone acetat 1QL 1 / day
GL Female
ESTRING 3QL 90 days
GL Female
ESTROGEL 3QL 1.667 / day
GL Female
EVAMIST 2QL 0.54 / day
GL Female
FEMHRT 3QL 1 / day
GL Female
FEMRING 3
QL 0.02 / day
ST
GL Female
PAGE 332 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FYAVOLV 1
QL 1 / day
GL Female
HCR
IMVEXXY (4 MCG MAINTENANCE PACK, 4 MCG STARTERPACK, 10 MCG MAINTENANCE PAK, 10 MCG STARTERPACK)
3 QL 1 / day
JEVANTIQUE LO 1
QL 1 / day
GL Female
HCR
JINTELI 1
QL 1 / day
GL Female
HCR
LOPREEZA 1QL 1 / day
GL Female
MENEST (0.625 MG TABLET, 1.25 MG TABLET) 3QL 1 / day
GL Female
MENEST 0.3 MG TABLET 2QL 1 / day
GL Female
MENOSTAR 3QL 0.15 / day
GL Female
MIMVEY 1QL 1 / day
GL Female
MIMVEY LO 1
HCG
MVGMINIMALVALUEGENERIC
MINIVELLE 3
QL 0.29 / day
ST
GL Female
PAGE 333 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
norethindron-ethinyl estradiol (norethin-eth 1 mg-5 mcg,norethind-eth 0.5-2.5) 1
QL 1 / day
HCR
PREFEST 3QL 1 / day
GL Female
PREMARIN VAGINAL CREAM-APPL 2QL 2 / day
GL Female
PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MGTABLET, 0.9 MG TABLET, 1.25 MG TABLET) 2
QL 1 / day
GL Female
PREMARIN 25 MG VIAL 2
PREMPHASE 2QL 1 / day
GL Female
PREMPRO 2QL 1 / day
GL Female
VAGIFEM 3
QL 0.643 / day
GL Female
SBA Select BrandAlternative
VIVELLE-DOT 3
QL 0.29 / day
ST
GL Female
YUVAFEM 1QL 0.643 / day
GL Female
EYE, EAR, NOSE AND THROAT (EENT) PREPS.
ANTIALLERGIC AGENTS
ALOMIDE 3QL 10 / fill
MVB MINIMALVALUE BRAND
PAGE 334 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
azelastine hcl 0.05% drops 1 QL 0.267 / day
azelastine hcl (0.1% (137 mcg) spry, 0.15% nasal spray) 1 QL 2 / day
azelastine-fluticasone 1QL 0.8 / day
ST
BEPREVE 3QL 0.334 / day
ST
DYMISTA 2QL 0.8 / day
B4G
ELESTAT 3 QL 0.286 / day
EMADINE 3 QL 5 / fill
epinastine hcl 1 QL 0.286 / day
ketotifen fumarate 1 QL 0.167 / day
LASTACAFT 3QL 3 / 30 days
ST
olopatadine hcl (0.1% drops, 0.2% drop) 1 QL 0.286 / day
olopatadine 665 mcg nasal spry 1 QL 31 / 30 days
PATADAY 0.2% EYE DROPS 3QL 0.286 / day
ST
PATANASE 3 QL 31 / 30 days
PATANOL 3QL 0.286 / day
ST
PAZEO 2 QL 0.286 / day
ZERVIATE 3QL 2 / day
ST
PAGE 335 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EENT DRUGS, MISCELLANEOUS
apraclonidine hcl 1 QL 0.8 / day
BEOVU 3
QL 1 / rx
S
MED Medical Drug
PA
bevacizumab (1 mg/0.04 ml syrng, 1.25 mg/0.05 ml, 2.5mg/0.1 ml syrg) 1
S
MED Medical Drug
PA
CYSTADROPS 3
QL 0.72 / day
S
PA
CYSTARAN 3
QL 1 / day
S
PA
EYLEA 2 MG/0.05 ML SYRINGE 3
QL 0.04 / day
S
PA
BSP BENEFIT SHIFTPROGRAM
IOPIDINE (0.5% DROPS, 1% DROPS) 3 QL 0.8 / day
ipratropium bromide (0.03% spray, 0.06% spray) 1 QL 2 / day
LUCENTIS (0.3 MG/0.05 ML SYRING, 0.3 MG/0.05 MLVIAL, 0.5 MG/0.05 ML SYRING, 0.5 MG/0.05 ML VIAL) 3
QL 0.04 / day
S
PA
BSP BENEFIT SHIFTPROGRAM
OXERVATE 3
QL 1 / day
S
PA
PAGE 336 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TEPEZZA 3S
MED Medical Drug
VISUDYNE 3S
MED Medical Drug
LOCAL ANESTHETICS (EENT)
AKTEN 3
NUMBRINO 3 MED Medical Drug
proparacaine hcl 1
TETCAINE 1
tetracaine hcl (eye drop, steri-unit sol) 1
MYDRIATICS
atropine sulfate (drops, ointment) 1
HOMATROPAIRE 1
homatropine hydrobromide 1
OMIDRIA 3 MED Medical Drug
VASOCONSTRICTORS
ADRENALIN CHLORIDE 3 PA
phenylephrine hcl (2.5% drop, 10% drops) 1
UPNEEQ 3
QL 1 / day
AL At least 18 yrsold
PA
VISINE TOTALITY 3
PAGE 337 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FIRST GENERATION ANTIHISTAMINES
ETHANOLAMINE DERIVATIVES
carbinoxamine 4 mg/5 ml liquid 1 AL At least 2 yrsold
carbinoxamine maleate 4 mg tab 1 AL At least 6 yrsold
carbinoxamine maleate 6 mg tab 1
AL At least 6 yrsold
HCG
MVGMINIMALVALUEGENERIC
clemastine fumarate 1 AL At least 2 yrsold
diphenhydramine 50 mg/ml crpjt 1
diphenhydramine hcl (12.5 mg/5 ml, 25 mg/10 ml) 1
diphenhydramine hcl (50 mg/ml syrng, 50 mg/ml vial) 1 BSP BENEFIT SHIFTPROGRAM
diphenhydramine-0.9% nacl 1 BSP BENEFIT SHIFTPROGRAM
KARBINAL ER 3 AL At least 2 yrsold
RYVENT 3
ST
HCG
MVGMINIMALVALUEGENERIC
FIRST GEN. ANTIHIST. DERIVATIVES, MISC.
cyproheptadine hcl (2 mg/5 ml soln, 2 mg/5 ml syrup, 4mg tablet, 4 mg/10 ml syrp) 1 AL At least 2 yrs
old
PAGE 338 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PHENOTHIAZINE DERIVATIVES
PHENADOZ 1 AL At least 2 yrsold
PHENERGAN (25 MG/ML AMPUL, 25 MG/ML VIAL, 50MG/ML AMPUL, 50 MG/ML VIAL) 3
AL At least 2 yrsold
MED Medical Drug
promethazine hcl (6.25 mg/5 ml soln, 6.25 mg/5 ml syrp,12.5 mg suppos, 12.5 mg tablet, 25 mg suppository, 50mg suppository, 50 mg tablet)
1 AL At least 2 yrsold
promethazine 25 mg tablet 1 AL At least 2 yrsold
promethazine hcl (25 mg/ml ampul, 25 mg/ml vial, 50mg/ml ampul, 50 mg/ml vial) 1
AL At least 2 yrsold
BSP BENEFIT SHIFTPROGRAM
promethazine hcl-0.9% nacl 1 BSP BENEFIT SHIFTPROGRAM
promethazine-phenylephrine 1
PROMETHEGAN 1 AL At least 2 yrsold
PROPYLAMINE DERIVATIVES
ABATUSS DMX 1 AL At least 2 yrsold
ALLER-CHLOR 1
CONEX SOLUTION 3
dexchlorpheniramine maleate 1
AL At least 2 yrsold
HCG
MVGMINIMALVALUEGENERIC
PAGE 339 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RESPA A.R. 3
RYCLORA 3 AL At least 2 yrsold
GASTROINTESTINAL DRUGS
ANTI-INFLAMMATORY AGENTS (GI DRUGS)
alosetron hcl 1GL Female
AL At least 18 yrsold
APRISO 2 B4G
ASACOL HD 3PA
B4G
balsalazide disodium 1
CANASA 3ST
SBA Select BrandAlternative
COLAZAL 3 SBA Select BrandAlternative
DELZICOL 3PA
SBA Select BrandAlternative
DIPENTUM 3 PA
LIALDA 3PA
SBA Select BrandAlternative
LOTRONEX 3
GL Female
AL At least 18 yrsold
PA
mesalamine 4 gm/60 ml kit 1 HCG
PAGE 340 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
mesalamine (dr 1.2 gm tablet, 4 gm/60 ml enema, 1,000mg supp) 1
mesalamine 800 mg dr tablet 3 PA
mesalamine dr 1
mesalamine er 1
PENTASA 3
ROWASA (4 GM/60 ML ENEMA, 4 GM/60 ML ENEMA KIT) 3
SFROWASA 3
ANTIDIARRHEA AGENTS
diphenoxylate-atropine (diphenoxylat-atrop 2.5-0.025/5,diphenoxylate-atrop 2.5-0.025) 1
LOMOTIL 3
loperamide 2 mg capsule 1
MOTOFEN 3 MVB MINIMALVALUE BRAND
MYTESI 3 S
opium tincture 1 QL 5 / day
paregoric 1
XERMELO 3
AL At least 18 yrsold
S
PA
CATHARTICS AND LAXATIVES
AMITIZA 3
QL 2 / day
AL At least 18 yrsold
PA
PAGE 341 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CLENPIQ 3 QL 11 / day
COLYTE WITH FLAVOR PACKETS 3
ST
MVB Minimal ValueBrand
SBA SELECT BRANDALTERNATIVE
GAVILYTE-C 1 HCR
GAVILYTE-G 1 HCR
GAVILYTE-N 1
HCR
HCG
MVGMINIMALVALUEGENERIC
GOLYTELY PACKET 3QL 1/ fill
ST
GOLYTELY SOLUTION 3QL 134 / day
ST
HYDROCIL INSTANT POWDER 3
KONSYL ORIGINAL FIBER POWDER 3
MOVIPREP 3QL 1/ fill
ST
NULYTELY WITH FLAVOR PACKS 3
QL 134 / day
ST
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
OSMOPREP 3QL 100 / 30 days
ST
PAGE 342 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
peg 3350-electrolyte (3350 electrolyte soln, 3350-electrolyte solution) 1 HCR
peg-3350 and electrolytes 1 HCR
PEG-PREP 1
peg3350-sod sul-nacl-kcl-asb-c 1 HCR
PLENVU 3QL 3/ fill
ST
PREPOPIK 3 QL 2 / fill
SUPREP 3 QL 354 / fill
TRILYTE WITH FLAVOR PACKETS 1 HCR
CHOLELITHOLYTIC AGENTS
ACTIGALL 3
CHENODAL 3 S
URSO 3
URSO FORTE 3
ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) 1
DIGESTANTS
CREON 2
PANCREAZE 3 PA
PERTZYE 3 PA
VIOKACE 3 PA
ZENPEP 2
GI DRUGS, MISCELLANEOUS
CHOLBAM 250 MG CAPSULE 3
QL 7 / day
S
PA
PAGE 343 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CHOLBAM 50 MG CAPSULE 3
QL 4 / day
S
PA
ENTEREG 3MED Medical Drug
PA
ENTYVIO 3
QL 2/ 30 days
S
PA
BSP BENEFIT SHIFTPROGRAM
GATTEX 3S
PA
HUMIRA(CF) PEDI CROHN 80-40 MG 3
QL 0.22 / day
S
PS
PA
PS1 Preferred 1stline
LINZESS 2QL 1 / day
ST
MOVANTIK 2QL 1 / day
PA
OCALIVA 3
QL 1 / day
S
PA
RELISTOR (8 MG/0.4 ML SYRINGE, 12 MG/0.6 MLSYRINGE, 12 MG/0.6 ML VIAL) 3 PA
RELISTOR 150 MG TABLET 3QL 3 / day
PA
PAGE 344 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SYMPROIC 2
QL 1 / day
AL At least 18 yrsold
PA
TRULANCE 3
QL 1 / day
AL At least 18 yrsold
PA
VIBERZI 2QL 2 / day
PA
XENICAL 3
PROKINETIC AGENTS
GIMOTI 3
QL 0.334 / day
AL At least 18 yrsold
PA
metoclopramide hcl (5 mg tablet, 5 mg/5 ml soln, 10 mgtablet, 10 mg/10 ml sol) 1
metoclopramide 10 mg/2 ml syr 1 MED Medical Drug
metoclopramide 10 mg/2 ml vial 1 MED Medical Drug
metoclopramide hcl odt 1
MOTEGRITY 3
QL 1 / day
AL At least 18 yrsold
PA
REGLAN 3
ZELNORM 3
QL 2 / day
AL Up to 65 yrs old
PA
PAGE 345 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GENERAL ANESTHETICS
BARBITURATES (GENERAL ANESTHETICS)
methohexital-sterile water 1 MED Medical Drug
GENITOURINARY SMOOTH MUSCLE RELAXANTS
ANTIMUSCARINICS
darifenacin er 1 QL 1 / day
DETROL 3QL 2 / day
SBA Select BrandAlternative
DETROL LA 3QL 1 / day
SBA Select BrandAlternative
DITROPAN XL 10 MG TABLET 3QL 2 / day
SBA Select BrandAlternative
DITROPAN XL 5 MG TABLET 3QL 1 / day
SBA Select BrandAlternative
ENABLEX 3QL 1 / day
SBA Select BrandAlternative
flavoxate hcl 1
GELNIQUE (GEL PUMP, GEL SACHET) 3QL 1 / day
ST
oxybutynin 5 mg/5 ml syrup 1 QL 20 / day
oxybutynin 5 mg tablet 1 QL 4 / day
oxybutynin chloride er (er 10 mg tablet, er 15 mg tablet) 1 QL 2 / day
PAGE 346 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
oxybutynin cl er 5 mg tablet 1 QL 1 / day
OXYTROL 3QL 0.357 / day
ST
solifenacin succinate 1 QL 1 / day
tolterodine tartrate 1 QL 2 / day
tolterodine tartrate er 1 QL 1 / day
TOVIAZ 3 QL 1 / day
trospium chloride 1 QL 2 / day
trospium chloride er 1 QL 1 / day
VESICARE 3QL 1 / day
ST
GOLD COMPOUNDS
RIDAURA 2
GONADOTROPINS AND ANTIGONADOTROPINS
ANTIGONADTROPINS
CETROTIDE 3
GL Female
S
PS
PA
FIRMAGON 3
S
MED Medical Drug
PA
ganirelix acetate 3
GL Female
S
PA
PAGE 347 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ORIAHNN 2
QL 2 / day
AL At least 18 yrsold
PA
ORILISSA 150 MG TABLET 2
QL 1 / day
AL At least 18 yrsold
PA
ORILISSA 200 MG TABLET 2
QL 2 / day
AL At least 18 yrsold
PA
GONADOTROPINS
chorionic gonad 10,000 unit vl 3S
PA
ELIGARD 3
S
PA
BSP BENEFIT SHIFTPROGRAM
FOLLISTIM AQ 3S
PA
GONAL-F 3
S
PS
PA
GONAL-F RFF 3
GL Female
S
PS
PA
GONAL-F RFF REDI-JECT 3
GL Female
S
PS
PA
PAGE 348 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
leuprolide 2wk 1 mg/0.2 ml kit 1S
PA
leuprolide acetate (14 mg/2.8 ml kt, 14 mg/2.8 ml vl) 1S
PA
LUPRON DEPOT (DEPOT-4 MONTH KIT, DEPOT 7.5 MGKIT, DEPOT 22.5 MG 3MO KIT, DEPOT 45 MG 6MO KIT) 3
S
PA
BSP BENEFIT SHIFTPROGRAM
LUPRON DEPOT 11.25 MG 3MO KIT 3
S
PA
BSP BENEFIT SHIFTPROGRAM
LUPRON DEPOT 3.75 MG KIT 3
S
PA
BSP BENEFIT SHIFTPROGRAM
LUPRON DEPO 11.25MG (LUPANETA) 3
S
PA
BSP BENEFIT SHIFTPROGRAM
LUPRON DEPOT 3.75MG (LUPANETA) 3
S
PA
BSP BENEFIT SHIFTPROGRAM
LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG KIT, 15 MGKIT) 3
S
PA
BSP BENEFIT SHIFTPROGRAM
LUPRON DEPOT-PED (11.25 MG 3MO, 30 MG 3MO KIT) 3
S
PA
BSP BENEFIT SHIFTPROGRAM
PAGE 349 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MENOPUR 3
GL Female
S
PA
NOVAREL 3S
PA
OVIDREL 3
S
PS
PA
PREGNYL 3S
PA
SUPPRELIN LA 3
S
PA
BSP BENEFIT SHIFTPROGRAM
SYNAREL 3S
PA
TRELSTAR 3
S
MED Medical Drug
PA
VANTAS 3
S
PA
BSP BENEFIT SHIFTPROGRAM
ZOLADEX 10.8 MG IMPLANT SYRN 3
S
PA
BSP BENEFIT SHIFTPROGRAM
ZOLADEX 3.6 MG IMPLANT SYRN 3
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
PAGE 350 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HCV ANTIVIRALS
HCV POLYMERASE INHIBITOR ANTIVIRALS
EPCLUSA 3
QL 1 / day
S
PS
PA
HARVONI (33.75-150 MG PELLET PK, 45-200 MG TABLET,90-400 MG TABLET) 3
QL 1 / day
S
PS
PA
HARVONI 45-200 MG PELLET PACKT 3
QL 2 / day
S
PS
PA
ledipasvir-sofosbuvir 3
QL 1 / day
S
PS
PA
sofosbuvir-velpatasvir 3
QL 1 / day
S
PS
PA
SOVALDI 200 MG PELLET PACKET 3
QL 2 / day
S
PS
PA
SOVALDI (150 MG PELLET PACKET, 200 MG TABLET, 400MG TABLET) 3
QL 1 / day
S
PS
PA
PAGE 351 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VOSEVI 3
QL 1 / day
AL At least 18 yrsold
S
PS
PA
HCV PROTEASE INHIBITOR ANTIVIRALS
MAVYRET 3
QL 3 / day
AL At least 18 yrsold
S
PS
PA
HCV REPLICATION COMPLEX INHIBITORS
DAKLINZA 3
QL 1 / day
S
PA
VIEKIRA PAK 3
QL 4 / day
S
PA
ZEPATIER 3
QL 1 / day
S
PA
HEAVY METAL ANTAGONISTS
BAL IN OIL 3 MED Medical Drug
calcium disodium versenate 1 MED Medical Drug
CHEMET 3
PAGE 352 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CUPRIMINE 3S
PA
D-PENAMINE 2S
PA
deferasirox (90 mg granule, 90 mg tablet, 125 mg tb forsusp, 180 mg granule, 180 mg tablet, 250 mg tb for susp,360 mg granule, 360 mg tablet, 500 mg tb for susp)
1S
PA
deferiprone 1S
PA
deferoxamine mesylate 1 MED Medical Drug
DEPEN 2
S
PA
B4G
SBA SELECT BRANDALTERNATIVE
DESFERAL 3 MED Medical Drug
DESFERAL MESYLATE 3 MED Medical Drug
EXJADE 3S
PA
FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET,1,000 MG TABLET) 3
S
PA
FERRIPROX (2 TIMES A DAY) 3S
PA
GALZIN 3
JADENU 3S
PA
JADENU SPRINKLE 3S
PA
PAGE 353 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
penicillamine (250 mg capsule, 250 mg tablet) 1S
PA
pentetate calcium trisodium 1 MED Medical Drug
pentetate zinc trisodium 1 MED Medical Drug
trientine hcl 1S
PA
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
A-HYDROCORT 3 MED Medical Drug
ALKINDI SPRINKLE 3 PA
ARISTOSPAN 3 MED Medical Drug
betamethasone acetate-sod phos (6 mg/ml vial, 7 mg/mlvial) 1 MED Medical Drug
betamethasone sod phos-acetate 1 MED Medical Drug
BREZTRI AEROSPHERE 3
QL 0.36/day
PR
PA
budesonide ec 1 HCG
budesonide er 1 PA
CELESTONE 3 MED Medical Drug
CORTEF 3ST
SBA Select BrandAlternative
cortisone acetate 1 HCG
DECADRON (0.5 MG TABLET, 0.5 MG/5 ML ELIXIR, 0.75MG TABLET, 4 MG TABLET, 6 MG TABLET) 1
PAGE 354 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DEPO-MEDROL 3 BSP BENEFIT SHIFTPROGRAM
DEXABLISS 3
dexamethasone (0.5 mg tablet, 0.5 mg/5 ml elx, 0.5 mg/5ml liq, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mgtablet, 4 mg tablet, 6 mg tablet)
1
dexamethasone (6 1.5 mg tab, 10 1.5 mg tb, 13 1.5 mg tb) 1
HCG
MVGMINIMALVALUEGENERIC
dexamethasone acetate la 1 BSP BENEFIT SHIFTPROGRAM
dexamethasone acetate-sod phos 1 BSP BENEFIT SHIFTPROGRAM
DEXAMETHASONE INTENSOL 2
dexamethasone sodium phosphate (4 mg/ml syringe, 4mg/ml vial, 10 mg/ml syring, 10 mg/ml vial, 20 mg/5 mlvial, 100 mg/10 ml vl, 120 mg/30 ml vl)
1 BSP BENEFIT SHIFTPROGRAM
dexamethasone-0.9% nacl 1 BSP BENEFIT SHIFTPROGRAM
DEXPAK 3MVB MINIMAL
VALUE BRAND
SBA Select BrandAlternative
DXEVO 3 MVB Minimal ValueBrand
EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 MG/MLORAL SUSP, 30 MG TABLET, 36 MG TABLET) 3
AL At least 2 yrsold
S
PA
ENTOCORT EC 3
fludrocortisone acetate 1
PAGE 355 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HEMADY 3 QL 2 / day
HIDEX 1
HCG
MVGMINIMALVALUEGENERIC
hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet) 1
INTRAROSA 3
QL 1 / day
ST
AL At least 18 yrsold
KENALOG-10 3 BSP BENEFIT SHIFTPROGRAM
KENALOG-40 3ST
BSP BENEFIT SHIFTPROGRAM
KENALOG-80 3 MED Medical Drug
MEDROL (4 MG DOSEPAK, 4 MG TABLET, 8 MG TABLET,16 MG TABLET, 32 MG TABLET) 3
MEDROL 2 MG TABLET 2
methylprednisolone (4 mg dosepk, 4 mg tablet, 8 mg tab,16 mg tab, 32 mg tab) 1
methylprednisolone acetate (methylprednisolon ac160mg/2ml, methylprednisolone 40 mg/ml vl,methylprednisolone 80 mg/ml vl, methylprednisolone ac50 mg/ml, methylprednisolone ac 80mg/2ml,methylprednisolone ac 100mg/ml)
1 MED Medical Drug
methylprednisolone sodium succ 1 MED Medical Drug
MILLIPRED 3
MILLIPRED DP 3
ORAPRED ODT 3
PAGE 356 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ORTIKOS 3 PA
PEDIAPRED 3
prednisolone 1
prednisolone sodium phos odt 1
prednisolone sodium phosphate (5 mg/5 ml soln, 10 mg/5ml soln, 15 mg/5 ml soln, 20 mg/5 ml soln, sod ph 25mg/5 ml)
1
prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab dosepack, 5 mg tablet, 5 mg/5 ml solution, 10 mg tab dosepack, 10 mg tablet, 20 mg tablet, 50 mg tablet)
1
PREDNISONE INTENSOL 3
SOLU-CORTEF (100 MG ACT-O-VIAL, 100 MG VIAL, 250MG ACT-O-VIAL, 500 MG ACT-O-VIAL, 1,000 MG ACT-O-VL)
3 BSP BENEFIT SHIFTPROGRAM
SOLU-MEDROL (1 GRAM VIAL, 40 MG VIAL, 125 MG VIAL,500 MG VIAL, 1,000 MG VIAL, 2,000 MG VIAL) 3 MED Medical Drug
TAPERDEX 3
triamcinolone acet 200 mg/5 ml 1MED Medical Drug
BSP BENEFIT SHIFTPROGRAM
triamcinolone acetonide (40 mg/ml vl, 40mg/ml vl, 50mg/ml vl, 50mg/5ml vl, 100 mg/2 ml, 400 mg/10ml) 1 BSP BENEFIT SHIFT
PROGRAM
triamcinolone diacetate (40 mg/ml, 80 mg/2ml, 80mg/ml) 1 BSP BENEFIT SHIFT
PROGRAM
UCERIS 2 MG RECTAL FOAM 3
UCERIS 9 MG ER TABLET 3 PA
VERIPRED 20 3
ZCORT 3 MVB Minimal ValueBrand
PAGE 357 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANDROGENS
ANADROL-50 3 GL Male
ANDRODERM 2
QL 1 / day
GL Male
PA
ANDROGEL (1% (50 MG/5 G) PKT, 1.62% GEL PUMP,1.62%(1.25G) GEL PCKT, 1.62%(2.5G) GEL PCKT) 3
QL 5 / day
GL Male
PA
SBA Select BrandAlternative
ANDROGEL 1% (25 MG/2.5 G) PKT 3
QL 2.5 / day
GL Male
PA
SBA Select BrandAlternative
ANDROID 3
GL Male
PA
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
AVEED 3
S
MED Medical Drug
PA
AXIRON 3
QL 6 / day
GL Male
PA
SBA Select BrandAlternative
danazol 1
PAGE 358 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DEPO-TESTOSTERONE 3GL Male
SBA Select BrandAlternative
estrogen-methyltestosterone 1 GL Female
FORTESTA 3
QL 4 / day
GL Male
PA
JATENZO 3GL Male
PA
METHITEST 3
GL Male
PA
MVB Minimal ValueBrand
methyltestosterone 1
GL Male
HCG
MVGMINIMALVALUEGENERIC
NATESTO 3
QL 3 / day
GL Male
AL At least 18 yrsold
PA
MVB Minimal ValueBrand
OXANDRIN 3 PA
oxandrolone 1 PA
STRIANT 3GL Male
PA
TESTIM 3
QL 300 / 30 days
GL Male
PA
SBA Select BrandAlternative
PAGE 359 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TESTOPEL 3
GL Male
S
PA
MVB Minimal ValueBrand
BSP BENEFIT SHIFTPROGRAM
testosterone 50 mg/5 gram gel 1QL 300 / 30 days
GL Male
testosterone (1% (50 mg/5 g) pk, 1.62% (2.5 g) pkt, 1.62%gel pump, 1.62%(1.25 g) pkt, 50 mg/5 gram pkt) 1
QL 5 / day
GL Male
testosterone 10 mg gel pump 1QL 4 / day
GL Male
testosterone 12.5 mg/1.25 gram 1QL 10 / day
GL Male
testosterone 1% (25mg/2.5g) pk 1QL 2.5 / day
GL Male
testosterone 30 mg/1.5 ml pump 1
QL 6 / day
GL Male
PA
HCG
testosterone cypionate (testosteron 1,000 mg/10 ml,testosteron 2,000 mg/10 ml, testosterone 100 mg/ml,testosterone 200 mg/ml, testosterone 500 mg/2.5 ml,testosterone 500 mg/5 ml, testosterone 1,000 mg/5 ml,testosterone 6,000 mg/30ml)
1 GL Male
testosterone enanthate 1 GL Male
TESTRED 3
GL Male
PA
MVB Minimal ValueBrand
SBA SELECT BRANDALTERNATIVE
PAGE 360 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VOGELXO (12.5 MG/1.25 PUMP, 50 MG/5 GEL, 50 MG/5GEL PACKT) 3
QL 10 / day
PA
XYOSTED 3 PA
CONTRACEPTIVES
AFIRMELLE 1GL Female
HCR
ALTAVERA 1GL Female
HCR
ALYACEN 1GL Female
HCR
AMETHIA 1
QL 91 days
GL Female
HCR
AMETHIA LO 1
QL 91 days
GL Female
HCR
AMETHYST 1
QL 1 / day
GL Female
HCR
ANNOVERA 3
ST
GL Female
HCR
APRI 1GL Female
HCR
ARANELLE 1GL Female
HCR
PAGE 361 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ASHLYNA 1
QL 91 days
GL Female
HCR
AUBRA 1GL Female
HCR
AUBRA EQ 1GL Female
HCR
AUROVELA 1GL Female
HCR
AUROVELA 24 FE 1GL Female
HCR
AUROVELA FE 1GL Female
HCR
AVIANE 1GL Female
HCR
AYUNA 1GL Female
HCR
AZURETTE 1GL Female
HCR
BALCOLTRA 3 GL Female
BALZIVA 1GL Female
HCR
BEKYREE 1GL Female
HCR
BEYAZ 3
GL Female
MVB MINIMALVALUE BRAND
SBA Select BrandAlternative
PAGE 362 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BLISOVI 24 FE 1GL Female
HCR
BLISOVI FE 1GL Female
HCR
BRIELLYN 1GL Female
HCR
CAMILA 1GL Female
HCR
CAMRESE 1
QL 91 days
GL Female
HCR
CAMRESE LO 1
QL 91 days
GL Female
HCR
CAZIANT 1GL Female
HCR
CHARLOTTE 24 FE 1GL Female
HCR
CHATEAL 1GL Female
HCR
CHATEAL EQ 1GL Female
HCR
CRYSELLE 1GL Female
HCR
CYCLAFEM 1GL Female
HCR
PAGE 363 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CYRED 1GL Female
HCR
CYRED EQ 1GL Female
HCR
DASETTA 1GL Female
HCR
DAYSEE 1
QL 91 days
GL Female
HCR
DEBLITANE 1GL Female
HCR
desogestr-eth estrad eth estra 1GL Female
HCR
desogestrel-ethinyl estradiol 1GL Female
HCR
drosp-ee-levomef 3-0.02-0.451 1
GL Female
HCR
HCG
drosp-ee-levomef 3-0.03-0.451 1GL Female
HCR
drospirenone-ethinyl estradiol 1GL Female
HCR
ELINEST 1GL Female
HCR
ELLA 3
QL 1 / day
GL Female
HCR
PAGE 364 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ELURYNG 1GL Female
HCR
EMOQUETTE 1GL Female
HCR
ENPRESSE 1GL Female
HCR
ENSKYCE 1GL Female
HCR
ERRIN 1GL Female
HCR
ESTARYLLA 1GL Female
HCR
ESTROSTEP FE 3 GL Female
ethynodiol-ethinyl estradiol 1GL Female
HCR
etonogestrel-ethinyl estradiol 1GL Female
HCR
FALMINA 1GL Female
HCR
FAYOSIM 1
QL 91 days
GL Female
HCR
FEMYNOR 1GL Female
HCR
GEMMILY 1GL Female
HCR
PAGE 365 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GENERESS FE 3ST
GL Female
GIANVI 1GL Female
HCR
HAILEY 1GL Female
HCR
HAILEY 24 FE 1GL Female
HCR
HAILEY FE 1GL Female
HCR
HEATHER 1GL Female
HCR
INCASSIA 1GL Female
HCR
INTROVALE 1
QL 91 days
GL Female
HCR
ISIBLOOM 1GL Female
HCR
JAIMIESS 1
QL 91 days
GL Female
HCR
JASMIEL 1GL Female
HCR
JENCYCLA 1GL Female
HCR
PAGE 366 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
JOLESSA 1
QL 91 days
GL Female
HCR
JOLIVETTE 1GL Female
HCR
JULEBER 1GL Female
HCR
JUNEL 1GL Female
HCR
JUNEL FE 1GL Female
HCR
JUNEL FE 24 1GL Female
HCR
KAITLIB FE 1GL Female
HCR
KALLIGA 1GL Female
HCR
KARIVA 1GL Female
HCR
KELNOR 1-35 1GL Female
HCR
KELNOR 1-50 1GL Female
HCR
KURVELO 1GL Female
HCR
KYLEENA 3
GL Female
S
HCR
PS
BSP BENEFIT SHIFTPROGRAM
PAGE 367 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LARIN 1GL Female
HCR
LARIN 24 FE 1GL Female
HCR
LARIN FE 1GL Female
HCR
LARISSIA 1GL Female
HCR
LAYOLIS FE 1GL Female
HCR
LEENA 1GL Female
HCR
LESSINA 1GL Female
HCR
LEVONEST 1GL Female
HCR
levonorg-eth estrad eth estrad 1
QL 91 days
GL Female
HCR
levonorgestrel-eth estradiol 1GL Female
HCR
LEVORA-28 1GL Female
HCR
LILETTA 3S
MED Medical Drug
LILLOW 1GL Female
HCR
PAGE 368 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LO LOESTRIN FE 3GL Female
HCR
LO-ZUMANDIMINE 1GL Female
HCR
LOESTRIN 3
ST
GL Female
SBA Select BrandAlternative
LOESTRIN FE 3
ST
GL Female
SBA Select BrandAlternative
LOJAIMIESS 1
QL 91 days
GL Female
HCR
LORYNA 1GL Female
HCR
LOSEASONIQUE 3QL 91 days
GL Female
LOW-OGESTREL 1GL Female
HCR
LUTERA 1GL Female
HCR
LYZA 1GL Female
HCR
MARLISSA 1GL Female
HCR
MELODETTA 24 FE 1
GL Female
HCR
HCG
PAGE 369 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MIBELAS 24 FE 1
GL Female
HCR
HCG
MICROGESTIN 1GL Female
HCR
MICROGESTIN 24 FE 1GL Female
HCR
MICROGESTIN FE 1GL Female
HCR
MILI 1GL Female
HCR
MINASTRIN 24 FE 3GL Female
SBA Select BrandAlternative
MIRCETTE 3 GL Female
MIRENA 3
GL Female
S
HCR
PS
BSP BENEFIT SHIFTPROGRAM
MONO-LINYAH 1GL Female
HCR
MONONESSA 1GL Female
HCR
MYZILRA 1GL Female
HCR
NATAZIA 2 GL Female
PAGE 370 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NECON 1GL Female
HCR
NEXPLANON 3
S
HCR
BSP BENEFIT SHIFTPROGRAM
NIKKI 1GL Female
HCR
NORA-BE 1GL Female
HCR
noreth-estrad-fe 1-0.02(24)-75 1
GL Female
HCR
HCG
MVGMINIMALVALUEGENERIC
norethin-eth estra-ferrous fum (noret-estr-fe 0.4-0.035(21)-75, noreth-estrad-fe 1-0.02(21)-75, norethin-estra-fe 0.8-0.025 mg)
1GL Female
HCR
norethin-ee 1.5-0.03 mg(21) tb 1GL Female
HCR
norethind-eth estrad 1-0.02 mg 1
QL 1 / day
GL Female
HCR
norethindrone 1GL Female
HCR
norethindrone-eth estradiol-fe 1GL Female
HCR
norgestimate-ethinyl estradiol 1GL Female
HCR
PAGE 371 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NORLYDA 1GL Female
HCR
NORTREL 1GL Female
HCR
NUVARING 2GL Female
B4G
OCELLA 1GL Female
HCR
OGESTREL 1GL Female
HCR
ORSYTHIA 1GL Female
HCR
ORTHO MICRONOR 3ST
GL Female
ORTHO TRI-CYCLEN 3GL Female
SBA Select BrandAlternative
ORTHO TRI-CYCLEN LO 3GL Female
SBA Select BrandAlternative
ORTHO-CYCLEN 3ST
GL Female
ORTHO-NOVUM 3ST
GL Female
PARAGARD T 380-A 3
S
HCR
BSP BENEFIT SHIFTPROGRAM
PAGE 372 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PHILITH 1GL Female
HCR
PIMTREA 1GL Female
HCR
PIRMELLA 1GL Female
HCR
PORTIA 1GL Female
HCR
PREVIFEM 1GL Female
HCR
QUARTETTE 3
GL Female
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
QUASENSE 1
QL 91 days
GL Female
HCR
RECLIPSEN 1GL Female
HCR
RIVELSA 1
QL 91 days
GL Female
HCR
HCG
MVGMINIMALVALUEGENERIC
SAFYRAL 3ST
GL Female
PAGE 373 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SEASONIQUE 3
QL 91 days
ST
GL Female
SETLAKIN 1
QL 91 days
GL Female
HCR
SHAROBEL 1GL Female
HCR
SIMLIYA 1GL Female
HCR
SIMPESSE 1
QL 91 days
GL Female
HCR
SKYLA 3
GL Female
S
HCR
PS
BSP BENEFIT SHIFTPROGRAM
SLYND 3 GL Female
SPRINTEC 1GL Female
HCR
SRONYX 1GL Female
HCR
SYEDA 1GL Female
HCR
TARINA 24 FE 1GL Female
HCR
PAGE 374 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TARINA FE 1GL Female
HCR
TARINA FE 1-20 EQ 1GL Female
HCR
TAYTULLA 3 GL Female
TILIA FE 1GL Female
HCR
TRI FEMYNOR 1GL Female
HCR
TRI-ESTARYLLA 1GL Female
HCR
TRI-LEGEST FE 1GL Female
HCR
TRI-LINYAH 1GL Female
HCR
TRI-LO-ESTARYLLA 1GL Female
HCR
TRI-LO-MARZIA 1GL Female
HCR
TRI-LO-MILI 1GL Female
HCR
TRI-LO-SPRINTEC 1GL Female
HCR
TRI-MILI 1GL Female
HCR
TRI-NORINYL 3 GL Female
PAGE 375 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRI-PREVIFEM 1GL Female
HCR
TRI-SPRINTEC 1GL Female
HCR
TRI-VYLIBRA 1GL Female
HCR
TRI-VYLIBRA LO 1GL Female
HCR
TRIVORA-28 1GL Female
HCR
TULANA 1GL Female
HCR
TWIRLA 3
QL 0.124 / day
GL Female
HCR
TYBLUME 1GL Female
HCR
TYDEMY 1GL Female
HCR
VELIVET 1GL Female
HCR
VIENVA 1GL Female
HCR
VIORELE 1GL Female
HCR
VOLNEA 1GL Female
HCR
PAGE 376 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VYFEMLA 1GL Female
HCR
VYLIBRA 1GL Female
HCR
WERA 1GL Female
HCR
WYMZYA FE 1
GL Female
HCR
HCG
XULANE 3
QL 0.12 / day
GL Female
HCR
YASMIN 28 3
ST
GL Female
SBA Select BrandAlternative
YAZ 3GL Female
SBA Select BrandAlternative
ZARAH 1GL Female
HCR
ZOVIA 1-35 1GL Female
HCR
ZOVIA 1-35E 1GL Female
HCR
ZUMANDIMINE 1GL Female
HCR
PAGE 377 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LEPTINS
MYALEPT 3S
PA
PITUITARY
DDAVP (0.01% NASAL SPRAY, 0.1 MG TABLET, 0.2 MGTABLET, 10 MCG/0.1 ML SOLUTION) 3
DDAVP (4 MCG/ML AMPUL, 4 MCG/ML VIAL) 3 MED Medical Drug
desmopressin acetate (0.01% solution, 0.01% spray,acetate 0.1 mg tb, acetate 0.2 mg tb, 10 mcg/0.1 ml spr) 1
desmopressin ac 4 mcg/ml vial 1MED Medical Drug
HCG
desmopressin acetate (ac 4 mcg/ml ampul, 40 mcg/10 mlvial) 1 MED Medical Drug
NOCDURNA 3QL 1 / day
PA
NOCTIVA 3
QL 0.1 / day
PA
MVB MINIMALVALUE BRAND
NORDITROPIN FLEXPRO 3
S
PS
PA
SEROSTIM 3
QL 1 / day
S
PA
STIMATE 3 S
vasopressin 20 unit/100 ml-ns 1MED Medical Drug
NFDA Non-FDAApproved
PAGE 378 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
vasopressin-0.9% nacl (20 unit/50 ml-ns, 40 unit/100 ml-ns, 50 unit/250 ml-ns, 60 unit/100 ml-ns, 100 unit/100 ml-ns, 100 unit/250 ml-ns)
1 MED Medical Drug
vasopressin-d5w (60 unit/100 ml-d5w, 100 unit/100ml-d5w) 1 MED Medical Drug
ZORBTIVE 3
QL 1 / day
S
PA
PROGESTINS
AYGESTIN 3 GL Female
CRINONE 4% GEL 3 GL Female
CRINONE 8% GEL 3QL 2.5 / day
GL Female
DEPO-PROVERA 150 MG/ML SYRINGE 3QL 90 days
GL Female
DEPO-PROVERA 150 MG/ML VIAL 3 GL Female
DEPO-PROVERA 400 MG/ML VIAL 3
DEPO-SUBQ PROVERA 104 3
QL 90 days
GL Female
HCR
PA
ENDOMETRIN 2QL 3 / day
GL Female
hydroxyprogesterone caproate (hydroxyprogest 250mg/ml vial, hydroxyprogest 1,250 mg/5 ml,hydroxyprogesterone 1.25 g/5ml)
1
GL Female
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
PAGE 379 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MAKENA 275 MG/1.1 ML AUTOINJCT 3
GL Female
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
MAKENA (250 MG/ML VIAL, 1,250 MG/5 ML VIAL) 3
GL Female
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
medroxyprogesterone 150 mg/ml 1
QL 0.04 / day
GL Female
HCR
medroxyprogesterone acetate (2.5 mg tab, 5 mg tab, 10mg tab) 1 GL Female
MEGACE ES 3 GL Female
megestrol acetate (acet 40 mg/ml susp, acet 400 mg/10ml, 625 mg/5 ml susp) 1
megestrol acetate (20 mg tablet, 40 mg tablet) 1
norethindrone ac (lupaneta) 1 GL Female
norethindrone acetate 1 GL Female
progesterone (100 mg capsule, 200 mg capsule) 1 GL Female
progesterone 500 mg/10 ml vial 1 GL Female
PROMETRIUM 3ST
GL Female
PROVERA 3 GL Female
PAGE 380 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HYPOTENSIVE AGENTS
CENTRAL ALPHA-AGONISTS
CATAPRES 3PR
SBA Select BrandAlternative
CATAPRES-TTS 1 3
QL 0.15 / day
ST
PR
CATAPRES-TTS 2 3
QL 0.4 / day
ST
PR
CATAPRES-TTS 3 3
QL 0.4 / day
ST
PR
clonidine (0.2 mg/day patch, 0.3 mg/day patch) 1
QL 0.4 / day
PR
HCG
clonidine 0.1 mg/day patch 1
QL 0.15 / day
PR
HCG
clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1 PR
clonidine hcl er 1QL 4 / day
HCG
guanfacine hcl 1 PR
KAPVAY 3
QL 4 / day
ST
SBA Select BrandAlternative
PAGE 381 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
methyldopa 1 PR
methyldopa-hydrochlorothiazide 1 PR
methyldopate hcl 1MED Medical Drug
PR
DIRECT VASODILATORS
BIDIL 3QL 6 / day
PR
hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet,100 mg tablet) 1 PR
hydralazine 20 mg/ml vial 1MED Medical Drug
PR
minoxidil (2.5 mg tablet, 10 mg tablet) 1 PR
NITROPRESS 3 MED Medical Drug
sodium nitroprusside 1 MED Medical Drug
HYPOTENSIVE AGENTS, MISCELLANEOUS
CORLOPAM (10 MG/ML AMPUL, 10 MG/ML VIAL, 20MG/2 ML AMPUL, 20 MG/2 ML VIAL) 3 MED Medical Drug
VECAMYL 3
S
PR
PA
INSULINS
INTERMEDIATE-ACTING INSULINS
HUMULIN 70-30 2QL 90 days
PR
HUMULIN 70/30 KWIKPEN 2QL 90 days
PR
PAGE 382 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HUMULIN N 2QL 90 days
PR
HUMULIN N KWIKPEN 2QL 90 days
PR
NOVOLIN 70-30 100 UNIT/ML VIAL 2QL 90 days
PR
NOVOLIN 70-30 FLEXPEN 2QL 90 days
PR
NOVOLIN N 100 UNIT/ML VIAL 2QL 90 days
PR
NOVOLIN N FLEXPEN 2QL 90 days
PR
LONG-ACTING INSULINS
BASAGLAR KWIKPEN U-100 3
QL 90 days
PR
PA
LANTUS 2QL 90 days
PR
LANTUS SOLOSTAR 2QL 90 days
PR
LEVEMIR 2QL 90 days
PR
LEVEMIR FLEXTOUCH 2QL 90 days
PR
SEMGLEE 3
QL 90 days
PR
PA
PAGE 383 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SEMGLEE PEN 3
QL 90 days
PR
PA
SOLIQUA 100-33 2 QL 0.6 / day
TOUJEO MAX SOLOSTAR 2QL 90 days
PR
TOUJEO SOLOSTAR 2QL 90 days
PR
TRESIBA 2QL 90 days
PR
TRESIBA FLEXTOUCH U-100 2QL 90 days
PR
TRESIBA FLEXTOUCH U-200 2QL 90 days
PR
XULTOPHY 100-3.6 3QL 0.5 / day
PA
RAPID-ACTING INSULINS
ADMELOG 3QL 90 days
PA
ADMELOG SOLOSTAR 3QL 90 days
PA
AFREZZA 3QL 90 days
PA
APIDRA 3
QL 90 days
PR
PA
PAGE 384 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
APIDRA SOLOSTAR 3
QL 90 days
PR
PA
FIASP 3QL 90 days
PA
FIASP FLEXTOUCH 3QL 90 days
PA
FIASP PENFILL 3QL 90 days
PA
HUMALOG 100 UNIT/ML CARTRIDGE 2QL 90 days
PR
HUMALOG 100 UNIT/ML VIAL 2
QL 90 days
PR
B4G
HUMALOG JUNIOR KWIKPEN 2
QL 90 days
PR
B4G
HUMALOG KWIKPEN U-100 2
QL 90 days
PR
B4G
HUMALOG KWIKPEN U-200 2QL 90 days
PR
HUMALOG MIX 50-50 2QL 90 days
PR
HUMALOG MIX 50-50 KWIKPEN 2QL 90 days
PR
HUMALOG MIX 75-25 2QL 90 days
PR
PAGE 385 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HUMALOG MIX 75-25 KWIKPEN 2
QL 90 days
PR
B4G
insulin aspart 2
QL 90 days
PR
PA
insulin aspart flexpen 2
QL 90 days
PR
PA
insulin aspart penfill 2
QL 90 days
PR
PA
insulin aspart prot-insuln asp 2
QL 90 days
PR
PA
insulin lispro 2
QL 90 days
PR
PA
insulin lispro junior kwikpen 2
QL 90 days
PR
PA
insulin lispro kwikpen u-100 2
QL 90 days
PR
PA
insulin lispro protamine mix 2
QL 90 days
PR
PA
PAGE 386 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LYUMJEV 3
QL 90 days
PR
PA
LYUMJEV KWIKPEN U-100 3
QL 90 days
PR
PA
LYUMJEV KWIKPEN U-200 3
QL 90 days
PR
PA
NOVOLOG (100 UNIT/ML CARTRIDGE, 100 UNIT/ML VIAL) 2
QL 90 days
PR
B4G
NOVOLOG FLEXPEN 2
QL 90 days
PR
B4G
NOVOLOG MIX 70-30 2
QL 90 days
PR
B4G
NOVOLOG MIX 70-30 FLEXPEN 2
QL 90 days
PR
B4G
SHORT-ACTING INSULINS
HUMULIN R 2QL 90 days
PR
HUMULIN R U-500 2QL 90 days
PR
HUMULIN R U-500 KWIKPEN 2QL 90 days
PR
PAGE 387 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MYXREDLIN 3QL 90 days
MED Medical Drug
NOVOLIN R 100 UNIT/ML VIAL 2QL 90 days
PR
NOVOLIN R FLEXPEN 2QL 90 days
PR
ION-REMOVING AGENTS
OTHER ION-REMOVING AGENTS
RADIOGARDASE 3
PHOSPHATE-REMOVING AGENTS
AURYXIA 3
calcium acetate (667 mg capsule, 667 mg gelcap, 667 mgtablet) 1
FOSRENOL (750 MG POWDER PACKET, 1,000 MGPOWDER PACK) 3
FOSRENOL (500 MG TABLET CHEW, 750 MG TABLETCHEW) 3 SBA Select Brand
Alternative
FOSRENOL 1,000 MG TABLET CHEW 3MVB MINIMAL
VALUE BRAND
SBA Select BrandAlternative
lanthanum carb 1,000 mg tb chw 1
HCG
MVGMINIMALVALUEGENERIC
lanthanum carbonate (500 mg tab chew, 750 mg tabchew) 1
PHOSLYRA 3
PAGE 388 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RENAGEL 3ST
SBA Select BrandAlternative
RENVELA (0.8 GM POWDER PACKET, 2.4 GM POWDERPACKET, 800 MG TABLET) 3
sevelamer 2.4 gm powder packet 1 HCG
sevelamer carbonate (0.8 gm powder packet, carbonate800 mg tab) 1
sevelamer hcl 1
VELPHORO 3
POTASSIUM-REMOVING AGENTS
KIONEX 1
LOKELMA 3 QL 1 / day
sodium polystyrene sulfonate (sod polystyren sulf 15 g/60ml, sodium polystyrene sulf powder, sps 15 gm/60 mlsuspension, sps 30 gm/120 ml enema, sps 50 gm/200 mlenema)
1
SPS (15 GM/60 ML SUSPENSION, 30 GM/120 ML ENEMASUSP) 1
VELTASSA 3 QL 1 / day
LOCAL ANESTHETICS (PARENTERAL)
buffered lidocaine (syring, syrng) 3 MED Medical Drug
lidocaine hcl (40 mg/2 ml (2%) syrg, 50 mg/5 ml (1%) syrg,hcl 50 mg/5 ml syrng, 100 mg/5 ml (2%) syr, 400mg/20ml(2%) syr)
1 MED Medical Drug
lidocaine 5 mg/ml-0.9% nacl 1 MED Medical Drug
ropivacaine 0.5% 1000 mg/200ml 1 MED Medical Drug
PAGE 389 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ropivacaine 0.5% 500 mg/100 ml 1 MED Medical Drug
MACROLIDE ANTIBIOTICS
ERYTHROMYCIN ANTIBIOTICS
E.E.S. 200 3 SBA Select BrandAlternative
E.E.S. 400 3
ERY-TAB 3
ERYPED 200 2
ERYPED 400 3 SBA Select BrandAlternative
ERYTHROCIN LACTOBIONATE (1 GM ADDVANT VIAL, 500MG ADDVAN VIAL, LACT 500 MG VIAL) 3 MED Medical Drug
ERYTHROCIN STEARATE 3
erythromycin (250 mg filmtab, dr 250 mg cap, dr 250 mgtablet, dr 333 mg tablet, 500 mg filmtab, dr 500 mgtablet)
1
erythromycin ethylsuccinate (200 mg/5 ml susp, 400 mg/5ml susp, es 400 mg tab) 1
OTHER MACROLIDE ANTIBIOTICS
azithromycin (1 gm pwd packet, 100 mg/5 ml susp, 200mg/5 ml susp, 500 mg tablet, 600 mg tablet) 1
azithromycin 250 mg tablet 1 QL 6 / 5 days
azithromycin (500 mg add-van vl, i.v. 500 mg vial) 1 MED Medical Drug
clarithromycin (125 mg/5 ml sus, 250 mg tablet, 250mg/5 ml sus, 500 mg tablet) 1
clarithromycin er 1
DIFICID 3 PA
PAGE 390 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZITHROMAX 100 MG/5 ML SUSP 3 QL 30 / fill
ZITHROMAX 200 MG/5 ML SUSP 3 QL 60 / fill
ZITHROMAX (1 GM POWDER PACKET, 250 MG Z-PAKTABLET) 3
ZITHROMAX 250 MG TABLET 3 QL 6 / 5 days
ZITHROMAX 500 MG TABLET 3 QL 5 / fill
ZITHROMAX I.V. 500 MG VIAL 3 MED Medical Drug
ZITHROMAX TRI-PAK 3
MISC. BETA-LACTAM ANTIBIOTICS
CARBAPENEM ANTIBIOTICS
doripenem 1 MED Medical Drug
imipenem-cilastatin sodium 1 MED Medical Drug
INVANZ 3BSP BENEFIT SHIFT
PROGRAM
SBA Select BrandAlternative
meropenem 1 MED Medical Drug
meropenem-0.9% nacl 1 MED Medical Drug
MERREM 3 MED Medical Drug
PRIMAXIN 3 MED Medical Drug
RECARBRIO 3 MED Medical Drug
CEPHAMYCIN ANTIBIOTICS
CEFOTAN 3 MED Medical Drug
cefotetan 1 MED Medical Drug
cefotetan & dextrose 1 MED Medical Drug
PAGE 391 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
cefoxitin 1 MED Medical Drug
cefoxitin sodium 1 MED Medical Drug
MONOBACTAM ANTIBIOTICS
AZACTAM 3 MED Medical Drug
AZACTAM-ISO-OSMOTIC DEXTROSE 3 MED Medical Drug
aztreonam 1 MED Medical Drug
CAYSTON 3S
PA
MISCELLANEOUS THERAPEUTIC AGENTS
5-ALPHA-REDUCTASE INHIBITORS
AVODART 3
QL 1 / day
ST
GL Male
SBA Select BrandAlternative
dutasteride 1QL 1 / day
GL Male
dutasteride-tamsulosin 1QL 1 / day
GL Male
finasteride 5 mg tablet 1QL 1 / day
GL Male
JALYN 3
QL 1 / day
GL Male
SBA Select BrandAlternative
PROSCAR 3QL 1 / day
GL Male
PAGE 392 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ALCOHOL DETERRENTS
ANTABUSE 3
disulfiram 1
ANTIDOTES
DUODOTE 3
FUSILEV 3S
MED Medical Drug
KHAPZORY 3S
MED Medical Drug
leucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab, 25mg tab) 1
leucovorin calcium (cal 100 mg/10 ml vl, cal 500 mg/50 mlvl, calcium 50 mg vial, calcium 100 mg vial, calcium 200mg vial, calcium 350 mg vial, calcium 500 mg vl)
1S
MED Medical Drug
levoleucovorin calcium (50 mg vial, 175 mg vial, 175mg/17.5 ml, 250 mg/25 ml vl) 1
S
MED Medical Drug
methylene blue 1% vial 1 MED Medical Drug
NITHIODOTE 3 MED Medical Drug
pralidoxime chloride 1
PROTOPAM CHLORIDE 3 MED Medical Drug
sodium thiosulfate 1 MED Medical Drug
VISTOGARD 3 S
VORAXAZE 3S
MED Medical Drug
PAGE 393 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIGOUT AGENTS
allopurinol 100 mg tablet 1 QL 3 / day
allopurinol 300 mg tablet 1 QL 2 / day
allopurinol sodium 1 MED Medical Drug
ALOPRIM 3 MED Medical Drug
colchicine 0.6 mg capsule 1QL 2 / day
ST
colchicine 0.6 mg tablet 1QL 4 / day
ST
COLCRYS 3 QL 4 / day
febuxostat 1QL 1 / day
ST
GLOPERBA 3 PA
KRYSTEXXA 3
QL 0.07 / day
S
MED Medical Drug
PA
MITIGARE 3QL 2 / day
ST
ULORIC 3QL 1 / day
ST
ZYLOPRIM 100 MG TABLET 3 QL 3 / day
ZYLOPRIM 300 MG TABLET 3QL 2 / day
SBA Select BrandAlternative
PAGE 394 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTISENSE OLIGONUCLEOTIDES
TEGSEDI 3S
PA
BONE ANABOLIC AGENTS
EVENITY 3
S
MED Medical Drug
PA
EVENITY (2 SYRINGES) 3
S
MED Medical Drug
PA
BONE RESORPTION INHIBITORS
ACTONEL 150 MG TABLET 3QL 0.04 / day
PR
ACTONEL 35 MG TABLET 3QL 0.15 / day
PR
ACTONEL 5 MG TABLET 3QL 1 / day
PR
alendronate sod 70 mg/75 ml 1QL 12.5 / day
PR
alendronate sodium (35 mg tab, 40 mg tab, 70 mg tab) 1QL .15 / day
PR
alendronate sodium (5 mg tablet, 10 mg tab) 1QL 1 / day
PR
ATELVIA 3
QL 0.15 / day
ST
PR
PAGE 395 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BINOSTO 3QL .15 / day
PR
BONIVA 3 MG/3 ML SYRINGE 3
S
MED Medical Drug
PR
PA
BONIVA 150 MG TABLET 3
QL 0.04 / day
PR
SBA Select BrandAlternative
etidronate disodium 1 PR
FOSAMAX 3QL .15 / day
PR
FOSAMAX PLUS D 3QL 0.15 / day
PR
ibandronate 3 mg/3 ml syringe 1S
MED Medical Drug
ibandronate sodium 150 mg tab 1QL 0.04 / day
PR
ibandronate 3 mg/3 ml vial 1
S
MED Medical Drug
PR
pamidronate disodium (30 mg/10 ml vial, disod 30 mgvial, 60 mg/10 ml vial, 90 mg/10 ml vial, disod 90 mg vial) 1
S
MED Medical Drug
PROLIA 3
QL 0.13 / day
S
PA
BSP BENEFIT SHIFTPROGRAM
PAGE 396 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RECLAST 3
S
MED Medical Drug
PR
risedronate sodium 150 mg tab 1
QL 0.04 / day
PR
HCG
risedronate sodium 30 mg tab 1
risedronate sodium 35 mg tab 1QL 0.15 / day
PR
risedronate sodium 5 mg tablet 1 QL 1 / day
risedronate sodium dr 1 HCG
XGEVA 3
QL 0.07 / day
S
PA
BSP BENEFIT SHIFTPROGRAM
zoledronic acid (4 mg vial, 4 mg/100 ml, 4 mg/5 ml vial, 5mg/100 ml) 1
S
PR
BSP BENEFIT SHIFTPROGRAM
ZOMETA (4 MG/100 ML INJECTION, 4 MG/5 ML VIAL) 3
S
MED Medical Drug
PR
CARBONIC ANHYDRASE INHIBITORS (MISC.)
KEVEYIS 3
QL 4 / day
S
PA
PAGE 397 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CARIOSTATIC AGENTS
DENTA 5000 PLUS 1
DENTAGEL 1
fluoride 1 HCR
FLUORITAB 1 HCR
FLURA-DROPS 3 HCR
LUDENT FLUORIDE 1 HCR
PREVIDENT 1.1% GEL 3 SBA Select BrandAlternative
PREVIDENT (0.2% RINSE, 5000 BOOSTER PLUS, DENTALRINSE) 3
PREVIDENT 5000 3
PREVIDENT 5000 ENAMEL PROTECT 3
PREVIDENT 5000 ORTHO DEFENSE 3
PREVIDENT 5000 PLUS 3 SBA Select BrandAlternative
PREVIDENT 5000 SENSITIVE 3
SF 1
SF 5000 PLUS 1
sodium fluoride (1.1% cream, 5000 ppm cream, 5000 ppmpaste) 1
sodium fluoride (0.5 mg(1.1 mg), 0.5 mg/ml drop, 1 mg(2.2 mg)) 1 HCR
sodium fluoride 2.2 mg (fluoride ion 1 mg) oral tablet 1 HCR
sodium fluoride sensitive 1
PAGE 398 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
COMPLEMENT INHIBITORS
BERINERT (500 UNIT KIT, 500 UNIT VIAL) 3S
PA
CINRYZE 3S
PA
FIRAZYR 3S
PA
HAEGARDA 3
QL 1.25 / day
S
PA
icatibant 1S
PA
KALBITOR 3
S
PA
BSP BENEFIT SHIFTPROGRAM
RUCONEST 3
QL 0.87 / day
S
PA
SOLIRIS 3
S
PA
BSP BENEFIT SHIFTPROGRAM
TAKHZYRO 3
QL 0.144 / day
S
PA
ULTOMIRIS 3
S
MED Medical Drug
PA
PAGE 399 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DISEASE-MODIFYING ANTIRHEUMATIC AGENTS
ACTEMRA 162 MG/0.9 ML SYRINGE 3
QL 0.15 / day
S
PS
PA
PS2 Preferred 2ndline
ACTEMRA 200 MG/10 ML VIAL 3
QL 0.36/day
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
PS2 Preferred 2ndline
ACTEMRA 400 MG/20 ML VIAL 3
QL 1.5 / day
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
PS2 Preferred 2ndline
ACTEMRA 80 MG/4 ML VIAL 3
QL 0.15 / day
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
PS2 Preferred 2ndline
PAGE 400 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ARAVA 3
AVSOLA 3
QL 10 / 30 days
S
MED Medical Drug
PA
CIMZIA 200 MG VIAL KIT 3
QL 3/ fill
S
PS
PA
PS1 Preferred 1stline
CIMZIA (MG/ML SYRINGE KIT, MG/ML(X3)START KT) 3
QL 3/ fill
S
PS
PA
PS1 Preferred 1stline
ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 25 MG/0.5ML VIAL, 50 MG/ML SYRINGE) 3
QL 0.29 / day
S
PA
ENBREL MINI 3
QL 0.15 / day
S
PA
ENBREL SURECLICK 3
QL 0.15 / day
S
PA
HUMIRA (20 MG/0.4 ML SYRINGE, 40 MG/0.8 MLSYRINGE) 3
QL 0.22 / day
S
PS
PA
PS1 Preferred 1stline
PAGE 401 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HUMIRA 10 MG/0.2 ML SYRINGE 3
QL 0.15 / day
S
PS
PA
PS1 Preferred 1stline
HUMIRA PEDIATRIC CROHN'S 3
QL 0.22 / day
S
PS
PA
PS1 Preferred 1stline
HUMIRA PEN 3
QL 0.22 / day
S
PS
PA
PS1 Preferred 1stline
HUMIRA PEN CROHN'S-UC-HS 3
QL 0.22 / day
S
PS
PA
PS1 Preferred 1stline
HUMIRA PEN PSOR-UVEITS-ADOL HS 3
QL 0.22 / day
S
PS
PA
PS1 Preferred 1stline
HUMIRA(CF) 3
QL 0.22 / day
S
PS
PA
PS1 Preferred 1stline
PAGE 402 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HUMIRA(CF) PEDI CROHN 80MG/0.8 3
QL 0.22 / day
S
PS
PA
PS1 Preferred 1stline
HUMIRA(CF) PEN 3
QL 0.22 / day
S
PS
PA
PS1 Preferred 1stline
HUMIRA(CF) PEN CROHN'S-UC-HS 3
QL 0.22 / day
S
PS
PA
PS1 Preferred 1stline
HUMIRA(CF) PEN PSOR-UV-ADOL HS 3
QL 0.22 / day
S
PS
PA
PS1 Preferred 1stline
INFLECTRA 3
QL 0.5 / day
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
PS1 Preferred 1stline
PAGE 403 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
KEVZARA (150 MG/1.14 ML PEN INJ, 150 MG/1.14 MLSYRINGE, 200 MG/1.14 ML PEN INJ, 200 MG/1.14 MLSYRINGE)
3
QL 0.1 / day
AL At least 18 yrsold
S
PA
KINERET 3
QL 10 / day
S
PA
leflunomide 1
OLUMIANT 3
QL 1 / day
S
PA
ORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 MLSYRINGE, 125 MG/ML SYRINGE) 3
QL 0.15 / day
S
PS
PA
PS2 Preferred 2ndline
ORENCIA 250 MG VIAL 3
QL 0.15 / day
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
PS2 Preferred 2ndline
ORENCIA CLICKJECT 3
QL 0.15 / day
S
PS
PA
PS2 Preferred 2ndline
PAGE 404 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
OTEZLA (28 DAY STARTER PACK, 30 MG TABLET, STARTERPACK) 3
QL 2 / day
S
PS
PA
PS1 Preferred 1stline
REMICADE 3
QL 10 / 30 days
S
MED Medical Drug
PA
RENFLEXIS 3
QL 10 / 30 days
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
PS1 Preferred 1stline
RINVOQ 3
QL 1 / day
S
PS
PA
PS1 Preferred 1stline
SIMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 MLSYRINGE, 100 MG/ML PEN INJECTOR, 100 MG/MLSYRINGE)
3
QL 0.04 / day
S
PS
PA
PS1 Preferred 1stline
PAGE 405 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
XELJANZ 3
QL 2 / day
S
PS
PA
PS1 Preferred 1stline
XELJANZ XR 3
QL 1 / day
S
PS
PA
PS1 Preferred 1stline
IMMUNOMODULATORY AGENTS
ACTIMMUNE 3S
PA
AUBAGIO 3
QL 1 / day
S
PR
PA
AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG KT) 3
QL 0.15 / day
S
PR
PS
PA
AVONEX PEN 3
QL 0.15 / day
S
PR
PS
PA
PAGE 406 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BAFIERTAM 3
QL 4 / day
S
PA
BETASERON (0.3 MG KIT, 0.3 MG VIAL) 3
QL 0.5 / day
S
PR
PS
PA
COPAXONE 20 MG/ML SYRINGE 3
QL 1 / day
S
PS
PA
B4G
COPAXONE 40 MG/ML SYRINGE 3
QL 0.434 / day
S
PS
PA
B4G
ENSPRYNG 3
QL 0.11 / day
S
PA
EXTAVIA (0.3 MG KIT, 0.3 MG VIAL) 3
QL 0.5 / day
S
PR
PA
GILENYA 0.25 MG CAPSULE 3
QL 2 / day
S
PR
PS
PA
PAGE 407 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GILENYA 0.5 MG CAPSULE 3
QL 1 / day
S
PR
PS
PA
glatiramer 20 mg/ml syringe 3
QL 1 / day
S
PS
PA
glatiramer 40 mg/ml syringe 3
QL 0.434 / day
S
PS
PA
GLATOPA 20 MG/ML SYRINGE 3
QL 1 / day
S
PA
GLATOPA 40 MG/ML SYRINGE 3
QL 0.434 / day
S
PA
KESIMPTA PEN 3
QL 0.057 / day
S
PS
PA
MAYZENT 0.25 MG STARTER PACK 3
QL 2.5 / day
S
PS
PA
MAYZENT 0.25 MG TABLET 3
QL 120 / 30 days
S
PS
PA
PAGE 408 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MAYZENT 2 MG TABLET 3
QL 1 / day
S
PS
PA
PLEGRIDY 125 MCG/0.5 ML SYRING 3
QL 0.04 / day
S
PS
PA
PLEGRIDY SYRINGE STARTER PACK 3
QL 1/ lifetime
S
PS
PA
PLEGRIDY 125 MCG/0.5 ML PEN 3
QL 0.04 / day
S
PS
PA
PLEGRIDY PEN INJ STARTER PACK 3
QL 1/ lifetime
S
PS
PA
REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 MLSYRINGE) 3
QL 0.22 / day
S
PR
PA
REBIF TITRATION PACK 3
QL 4.2 / 365 days
S
PR
PA
PAGE 409 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML) 3
QL 0.22 / day
S
PR
PA
REBIF REBIDOSE TITRATION PACK 3
QL 4.2 / 365 days
S
PR
PA
TECFIDERA 3
QL 2 / day
S
PR
PS
PA
B4G
THALOMID (150 MG CAPSULE, 200 MG CAPSULE) 3
QL 2 / day
S
PA
THALOMID (50 MG CAPSULE, 100 MG CAPSULE) 3
QL 1 / day
S
PA
TYSABRI 3
QL 0.6 / day
S
PA
BSP BENEFIT SHIFTPROGRAM
UPLIZNA 3
QL 2 / day
S
MED Medical Drug
PA
PAGE 410 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VUMERITY 3
QL 4 / day
S
PR
PS
PA
ZEPOSIA (0.23-0.46 MG START PCK, 0.23-0.46-0.92 MGKIT, 0.92 MG CAPSULE) 3
QL 1 / day
S
PA
IMMUNOSUPPRESSIVE AGENTS
ASTAGRAF XL 0.5 MG CAPSULE 3
QL 15 / day
S
PR
NTI
PA
ASTAGRAF XL 1 MG CAPSULE 3
QL 30 / day
S
PR
NTI
PA
ASTAGRAF XL 5 MG CAPSULE 3
QL 6 / day
S
PR
NTI
PA
ATGAM 3S
MED Medical Drug
AZASAN 100 MG TABLET 3 PR
AZASAN 75 MG TABLET 3PR
MVB Minimal ValueBrand
PAGE 411 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
azathioprine 1 PR
azathioprine sodium 1 MED Medical Drug
BENLYSTA (200 MG/ML AUTOINJECT, 200 MG/MLSYRINGE) 3
S
PA
BENLYSTA 120 MG VIAL 3
QL 0.25 / day
S
PA
BSP BENEFIT SHIFTPROGRAM
BENLYSTA 400 MG VIAL 3
QL 0.334 / day
S
PA
BSP BENEFIT SHIFTPROGRAM
CELLCEPT (200 MG/ML ORAL SUSP, 250 MG CAPSULE, 500MG TABLET) 3
S
PR
CELLCEPT 500 MG VIAL 3
S
MED Medical Drug
PR
cyclosporine 250 mg/5 ml ampul 1
S
MED Medical Drug
NTI
cyclosporine (25 mg capsule, 100 mg capsule) 1
S
PR
NTI
cyclosporine modified (25 mg, 50 mg, 100 mg, 100mg/ml) 1
S
PR
NTI
PAGE 412 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ENVARSUS XR 3
QL 1 / day
S
NTI
PA
everolimus (0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet) 1
S
PR
PA
GAMIFANT 3
S
MED Medical Drug
PA
GENGRAF (25 MG CAPSULE, 100 MG CAPSULE, 100MG/ML SOLUTION) 1
S
PR
NTI
IMURAN 3 PR
MAVENCLAD 3
QL 20 / 30 days
S
PA
mycophenolate 200 mg/ml susp 1 S
mycophenolate mofetil (250 mg capsule, 500 mg tablet) 1S
PR
mycophenolate 500 mg vial 1S
MED Medical Drug
mycophenolic acid 1S
PR
MYFORTIC 3S
PR
NEORAL (25 MG GELATIN CAPSULE, 100 MG GELATINCAPSULE, 100 MG/ML SOLUTION) 3
S
PR
NTI
PAGE 413 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NULOJIX 3
S
MED Medical Drug
PA
PROGRAF 5 MG/ML AMPULE 2
S
MED Medical Drug
NTI
PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MGCAPSULE) 2
S
PR
NTI
PROGRAF (0.2 MG GRANULE PACKET, 1 MG GRANULEPACKET) 2
S
PR
NTI
RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/MLORAL SOLN, 2 MG TABLET) 3
S
PR
SANDIMMUNE 50 MG/ML AMPUL 3
S
MED Medical Drug
NTI
SANDIMMUNE (25 MG CAPSULE, 100 MG CAPSULE, 100MG/ML SOLN) 3
S
PR
NTI
SIMULECT 3 MED Medical Drug
sirolimus (0.5 mg tablet, 1 mg tablet, 1 mg/ml solution, 2mg tablet) 1
S
PR
tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule) 1
S
PR
NTI
THYMOGLOBULIN 3 MED Medical Drug
PAGE 414 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZORTRESS 3
S
PR
PA
OTHER MISCELLANEOUS THERAPEUTIC AGENTS
alpha lipoic acid 100 mg cap 1
AMPYRA 3
QL 2 / day
S
PR
PA
ARCALYST 3S
PA
BOTOX 3
S
PA
BSP BENEFIT SHIFTPROGRAM
BOTOX COSMETIC 3
S
PA
BSP BENEFIT SHIFTPROGRAM
CARNITOR (100 MG/ML ORAL SOLN, 330 MG TABLET) 3 ST
CARNITOR 1 GM/5 ML VIAL 3ST
MED Medical Drug
CARNITOR SF 3ST
SBA SELECT BRANDALTERNATIVE
CERDELGA 3S
PA
citrus bioflavonoids 3
PAGE 415 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CYSTADANE 3 S
CYSTAGON 150 MG CAPSULE 3
QL 13 / day
S
PA
CYSTAGON 50 MG CAPSULE 3
QL 40/ day
S
PA
dalfampridine er 1
QL 2 / day
S
PR
PA
DEMSER 3 PR
DYSPORT 3
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
EVRYSDI 3
QL 6.67 / day
S
PA
FIRDAPSE 3
S
PR
PA
GALAFOLD 3S
PA
ILARIS 3
QL 0.08 / day
S
MED Medical Drug
PA
PAGE 416 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ISTURISA 1 MG TABLET 3
QL 8 / day
S
PA
ISTURISA 10 MG TABLET 3
QL 6 / day
S
PA
ISTURISA 5 MG TABLET 3
QL 2 / day
S
PA
JEUVEAU 3
S
PA
BSP BENEFIT SHIFTPROGRAM
KUVAN (100 MG POWDER PACKET, 100 MG TABLET, 500MG POWDER PACKET) 3
S
PA
levocarnitine (1 g/10 ml soln, 330 mg tablet) 1
levocarnitine sf 1
melatonin 3 mg tablet 1
methylene blue powder 3
metyrosine 1 PR
MIDNITE FOR MENOPAUSE 3
MIDNITE MENOPAUSE 3
MIDNITE PM 3
miglustat 1S
PA
MYOBLOC 3
S
MED Medical Drug
PA
PAGE 417 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NEXAVIR 3 MED Medical Drug
nitisinone 1S
PA
NITYR 3S
PA
ORFADIN (2 MG CAPSULE, 4 MG/ML SUSPENSION, 5 MGCAPSULE, 10 MG CAPSULE, 20 MG CAPSULE) 3
S
PA
PANHEMATIN 3S
MED Medical Drug
POTABA 3
PROCYSBI DR 25 MG CAPSULE 3
QL 4 / day
S
PA
PROCYSBI DR 75 MG CAPSULE 3
QL 72 / day
S
PA
PROCYSBI (DR 75 MG GRANULE PKT, DR 300 MGGRANULE PKT) 3
S
PA
RUZURGI 3
QL 1 / day
S
PR
PA
sapropterin dihydrochloride (100 mg powder pkt, 100 mgtablet, 500 mg powder pkt) 1
S
PA
THIOLA 3S
PA
PAGE 418 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
THIOLA EC 3S
PA
TYBOST 3 S
XEOMIN 3
S
MED Medical Drug
PA
XURIDEN 3 S
ZAVESCA 3S
PA
PROTECTIVE AGENTS
amifostine 1S
MED Medical Drug
dexrazoxane 1
S
MED Medical Drug
PA
ELMIRON 2QL 3 / day
PA
ETHYOL 3S
MED Medical Drug
mesna 1S
MED Medical Drug
MESNEX 400 MG TABLET 3 S
MESNEX 1 GRAM/10 ML VIAL 3S
MED Medical Drug
ZINECARD 3
S
MED Medical Drug
PA
PAGE 419 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NONHORMONAL CONTRACEPTIVES
PHEXXI 3
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
CYCLOOXYGENASE-2 (COX-2) INHIBITORS
CELEBREX (50 MG CAPSULE, 200 MG CAPSULE) 3QL 2 / day
SBA Select BrandAlternative
CELEBREX 100 MG CAPSULE 3QL 3 / day
SBA Select BrandAlternative
CELEBREX 400 MG CAPSULE 3QL 1 / day
SBA Select BrandAlternative
celecoxib (50 mg capsule, 200 mg capsule) 1 QL 2 / day
celecoxib 100 mg capsule 1 QL 3 / day
celecoxib 400 mg capsule 1 QL 1 / day
OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS
ANAPROX DS 3MVB MINIMAL
VALUE BRAND
SBA SELECT BRANDALTERNATIVE
ARTHROTEC 50 3ST
SBA Select BrandAlternative
ARTHROTEC 75 3ST
SBA Select BrandAlternative
CALDOLOR (800 MG/200 ML BAG, 800 MG/8 ML VIAL) 3 MED Medical Drug
PAGE 420 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CAMBIA 3
QL 1 / day
PA
MVB MINIMALVALUE BRAND
DAYPRO 3
diclofenac 3
QL 3 / day
ST
HCG
MVGMINIMALVALUEGENERIC
diclofenac epolamine 1QL 2 / day
HCG
diclofenac potassium 1
diclofenac 1.5% topical soln 1
HCG
MVGMINIMALVALUEGENERIC
diclofenac sodium 1% gel 1QL 1000/ 30 days
ST
diclofenac sod dr 25 mg tab 1 HCG
diclofenac sodium (dr 50 mg tab, dr 75 mg tab, ec 25 mgtab, ec 50 mg tab, ec 75 mg tab) 1
diclofenac sodium er 1
diclofenac sodium-misoprostol 1
diflunisal 1
EC-NAPROSYN 3MVB Minimal Value
Brand
SBA Select BrandAlternative
PAGE 421 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ec-naproxen 3MVB Minimal Value
Brand
SBA SELECT BRANDALTERNATIVE
etodolac (200 mg capsule, 300 mg capsule, 400 mg tablet,500 mg tablet) 1
etodolac er (er 400 mg tablet, er 600 mg tablet) 1
etodolac er 500 mg tablet 1
HCG
MVGMINIMALVALUEGENERIC
FELDENE 3
fenoprofen calcium (200 mg capsule, 400 mg capsule) 1
HCG
MVGMINIMALVALUEGENERIC
fenoprofen 600 mg tablet 1
FENORTHO 3 MVB MINIMALVALUE BRAND
FLECTOR 3QL 2 / day
SBA SELECT BRANDALTERNATIVE
flurbiprofen 1
IBU 1
ibuprofen 100 mg/5 ml susp 1
ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) 1
ibuprofen lysine 3 MED Medical Drug
INDOCIN 25 MG/5 ML SUSPENSION 3QL 6 / day
PA
INDOCIN 50 MG SUPPOSITORY 3QL 4 / day
PA
PAGE 422 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
indomethacin 25 mg capsule 1
indomethacin 50 mg capsule 1
indomethacin 1 mg vial 1 MED Medical Drug
indomethacin er 1
ketoprofen er 200 mg capsule 1 HCG
ketoprofen (25 mg capsule, 75 mg capsule) 1
ketoprofen 50 mg capsule 1 HCG
ketorolac 30 mg/ml carpuject 1QL 20 / 30 days
BSP BENEFIT SHIFTPROGRAM
ketorolac tromethamine (15 mg/ml carpuject, 15 mg/mlisecure syr, 15 mg/ml vial) 1
QL 40 / 23 days
BSP BENEFIT SHIFTPROGRAM
ketorolac tromethamine (60 mg/2 ml carpuject, 60 mg/2ml vial) 1 QL 20 / 30 days
ketorolac 15.75 mg nasal spray 3QL 5 days
PA
ketorolac 60 mg/2 ml syringe 1 QL 20 / 30 days
ketorolac tromethamine (30 mg/ml isecure syr, 30 mg/mlsyringe) 1
QL 20 / 23 days
BSP BENEFIT SHIFTPROGRAM
ketorolac 10 mg tablet 1 QL 21 / fill
ketorolac 30 mg/ml vial 1QL 20 / 23 days
BSP BENEFIT SHIFTPROGRAM
ketorolac 300 mg/10 ml vial 1QL 20 / 30 days
BSP BENEFIT SHIFTPROGRAM
PAGE 423 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LICART 3 QL 1 / day
LODINE 3
meclofenamate sodium 1 HCG
mefenamic acid 1
QL 5 / day
HCG
MVGMINIMALVALUEGENERIC
meloxicam 1 QL 1 / day
MOBIC 3
QL 1 / day
ST
SBA Select BrandAlternative
nabumetone 1
NALFON 400 MG CAPSULE 3PA
MVB MINIMALVALUE BRAND
NALFON 600 MG TABLET 3 PA
NAPRELAN (CR 375 MG TABLET, CR 500 MG TABLET) 3 SBA Select BrandAlternative
NAPRELAN CR 750 MG TABLET 3 QL 1 / day
NAPROSYN 125 MG/5 ML SUSPEN 3MVB MINIMAL
VALUE BRAND
SBA Select BrandAlternative
NAPROSYN 500 MG TABLET 3MVB Minimal Value
Brand
SBA Select BrandAlternative
naproxen 125 mg/5 ml suspen 1
HCG
MVGMINIMALVALUEGENERIC
PAGE 424 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
naproxen (250 mg tablet, dr 375 mg tablet, dr 500 mgtablet) 1
naproxen (375 mg tablet, 500 mg kit, 500 mg tablet) 1
naproxen sodium (275 mg tab, 550 mg tab) 1
HCG
MVGMINIMALVALUEGENERIC
naproxen sodium cr 1
HCG
MVGMINIMALVALUEGENERIC
naproxen sod er 375 mg tablet 1
naproxen sod er 500 mg tablet 1
HCG
MVGMINIMALVALUEGENERIC
NEOPROFEN 3 MED Medical Drug
oxaprozin 1 HCG
PENNSAID 2% PUMP 3QL 3.8 / day
ST
piroxicam 1 AL Up to 75 yrs old
PROFENO 1
QMIIZ ODT 3
QL 1 / day
AL Up to 18 yrs old
MVB Minimal ValueBrand
RELAFEN 1 ST
RELAFEN DS 3ST
MVB MINIMALVALUE BRAND
PAGE 425 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SPRIX 3
QL 5 days
PA
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
sulindac 1
tolmetin sodium 400 mg cap 1 HCG
tolmetin sodium (200 mg tab, 600 mg tab) 1
VIVLODEX 10 MG CAPSULE 3
QL 1 / day
AL At least 18 yrsold
PA
MVB Minimal ValueBrand
VIVLODEX 5 MG CAPSULE 3
QL 1 / day
AL At least 18 yrsold
PA
VOLTAREN 3QL 1000/ 30 days
SBA Select BrandAlternative
VOLTAREN-XR 3 SBA Select BrandAlternative
ZIPSOR 3
QL 4 / day
PA
MVB MINIMALVALUE BRAND
ZORVOLEX 3
QL 3 / day
PA
MVB MINIMALVALUE BRAND
PAGE 426 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SALICYLATES
butalbital-aspirin-caffeine (butalb-aspirin-caffe 50-325-40, butalbital-asa-caffeine cap) 1 QL 6 / day
choline mag trisalicylate 1
DURLAZA 3
QL 1 / day
PA
MVB MINIMALVALUE BRAND
FIORINAL 3QL 6 / day
SBA Select BrandAlternative
GOODY'S EXTRA STRENGTH 3
salsalate 1
OXYTOCICS
carboprost tromethamine 3 MED Medical Drug
METHERGINE 1 QL 6 / day
methylergonovine 0.2 mg tablet 1 QL 6 / day
MIFEPREX 3
mifepristone 1
PARATHYROID AND ANTIPARATHYROID AGENTS
ANTIPARATHYROID AGENTS
calcitonin-salmon 1QL 0.13 / day
PR
cinacalcet hcl 1
QL 2 / day
S
PA
PAGE 427 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MIACALCIN 3S
PR
SENSIPAR (30 MG TABLET, 60 MG TABLET) 3
QL 2 / day
S
PA
SENSIPAR 90 MG TABLET 3
QL 4 / day
S
PA
PARATHYROID AGENTS
FORTEO 3
S
PR
PA
NATPARA 3S
PA
teriparatide 1
S
PR
PA
TYMLOS 3
QL 1.60 / day
AL At least 18 yrsold
S
PA
PENICILLIN ANTIBIOTICS
AMINOPENICILLIN ANTIBIOTICS
amoxicillin (125 mg tab chew, 250 mg tab chew, 250mg/5 ml susp, 500 mg capsule, 500 mg tablet) 1
amoxicillin (125 mg/5 ml susp, 200 mg/5 ml susp, 250 mgcapsule, 400 mg/5 ml susp, 875 mg tablet) 1
PAGE 428 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
amoxicillin-clavulanate pot er 1
amoxicillin-clavulanate potass (200-28.5 mg tab chew,200-28.5 mg/5 ml sus, 250-125 mg tablet, 250-62.5 mg/5ml sus, 400-57 mg tab chew, 400-57 mg/5 ml susp, 500-125 mg tablet, 600-42.9 mg/5 ml sus, 875-125 mg tablet)
1
ampicillin sodium (1 gm add-vantage vl, 1 gm vial, 2 gmadd-vantage vl, 2 gm vial, 10 gm bottle, 10 gm vial, 125mg vial, 250 mg vial, 500 mg vial)
1 MED Medical Drug
ampicillin trihydrate 1
ampicillin-sulbactam (ampicillin-sulb 1.5 g add vial,ampicillin-sulb 3 gm add vial, ampicillin-sulbactam 1.5 gmvl, ampicillin-sulbactam 3 gm vial, ampicillin-sulbactam 15gm vl)
1 MED Medical Drug
AUGMENTIN (125-31.25 MG/5 ML, 250-62.5 MG/5 ML,500-125 TABLET, 875-125 TABLET) 3
AUGMENTIN ES-600 3
AUGMENTIN XR 3
MOXATAG 3
UNASYN 3 MED Medical Drug
EXTENDED-SPECTRUM PENICILLINS
piperacil-tazobact 13.5 gm vl 3 MED Medical Drug
piperacillin-tazobactam (piperacil-tazo 2.25 gm add vl,piperacil-tazo 3.375 gm add vl, piperacil-tazo 4.5 gm addvial, piperacil-tazobact 2.25 gm vl, piperacil-tazobact3.375 gm vl, piperacil-tazobact 4.5 gm vial, piperacil-tazobact 40.5 gram)
1 MED Medical Drug
ZOSYN (2.25 GM/50 ML GALAXY BAG, 2.25 GRAM VIAL,3.375 GM/50 ML GALAXY, 3.375 GRAM VIAL, 4.5 GM/100ML GALAXY BAG, 4.5 GRAM VIAL, 40.5 GRAM BULK VIAL)
3 MED Medical Drug
PAGE 429 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NATURAL PENICILLIN ANTIBIOTICS
BICILLIN C-R 3
BICILLIN L-A 3
penicillin g potassium 1 MED Medical Drug
penicillin g procaine 1
penicillin g sodium 1 MED Medical Drug
penicillin gk-iso-osm dextrose 1 MED Medical Drug
penicillin v potassium (250 mg tablet, 250 mg/5 ml soln,500 mg tablet) 1
penicillin vk 125 mg/5 ml soln 1
PFIZERPEN 3 MED Medical Drug
PENICILLINASE-RESISTANT PENICILLINS
dicloxacillin 250 mg capsule 1
dicloxacillin 500 mg capsule 1
nafcillin 3 MED Medical Drug
nafcillin sodium (1 gm add-van vial, 1 gm vial, 2 gm add-vant vial, 2 gm vial, 10 gm bulk vial) 1 MED Medical Drug
oxacillin 3 MED Medical Drug
oxacillin sodium (1 gm add-vantage vl, 1 gm vial, 2 gmadd-vantage vl, 2 gm vial, 10 gm vial) 1 MED Medical Drug
PHARMACEUTICAL AIDS
dexrazoxane diluent-sodium lac 1S
MED Medical Drug
diluent for decitabine 1S
MED Medical Drug
PAGE 430 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DILUENT FOR ELITEK 3S
MED Medical Drug
DILUENT FOR ISTODAX 3S
MED Medical Drug
DILUENT FOR JEVTANA 3S
MED Medical Drug
DILUENT FOR LEFAMULIN(XENLETA) 3S
MED Medical Drug
eucalyptol 1
lumoxiti iv soln stabilizer 3
S
MED Medical Drug
PA
sassafras oil 1
SHINGRIX ADJUVANT COMPONENT 2AL At least 50 yrs
oldHCR
spearmint oil 1
STERILE WATER DILUENT-CABLIVI 1S
MED Medical Drug
sterile water for inject syrng 1S
MED Medical Drug
RADIOACTIVE AGENTS
HICON 3S
MED Medical Drug
METASTRON 3S
MED Medical Drug
PAGE 431 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QUADRAMET 3S
MED Medical Drug
sodium iodide i-123 1
sodium iodide i-131 1S
MED Medical Drug
XOFIGO 3
S
MED Medical Drug
PA
RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB
ANGIOTENSIN II RECEPTOR ANTAGONISTS
ATACAND 3
QL 1 / day
ST
PR
MVB Minimal ValueBrand
SBA Select BrandAlternative
ATACAND HCT (32-12.5 MG TAB, 32-25 MG TABLET) 3
QL 1 / day
PR
SBA Select BrandAlternative
ATACAND HCT 16-12.5 MG TAB 3
QL 2 / day
PR
SBA Select BrandAlternative
AVALIDE 150-12.5 MG TABLET 3
QL 2 / day
PR
SBA Select BrandAlternative
PAGE 432 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AVALIDE 300-12.5 MG TABLET 3
QL 1 / day
PR
SBA Select BrandAlternative
AVAPRO 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
BENICAR 3
QL 3 / day
PR
SBA Select BrandAlternative
BENICAR HCT 3
QL 1 / day
PR
SBA Select BrandAlternative
candesartan cilexetil 1QL 1 / day
PR
candesartan-hctz 16-12.5 mg tb 1QL 2 / day
PR
candesartan-hydrochlorothiazid (32-12.5 mg tb, 32-25 mgtab) 1
QL 1 / day
PR
COZAAR (25 MG TABLET, 50 MG TABLET) 3
QL 2 / day
ST
PR
SBA Select BrandAlternative
COZAAR 100 MG TABLET 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
PAGE 433 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DIOVAN (40 MG TABLET, 80 MG TABLET, 160 MG TABLET) 3
QL 2 / day
PR
SBA Select BrandAlternative
DIOVAN 320 MG TABLET 3
QL 1 / day
PR
SBA Select BrandAlternative
DIOVAN HCT (320-12.5 MG TAB, 320-25 MG TABLET) 3
QL 1 / day
PR
SBA Select BrandAlternative
DIOVAN HCT (80-12.5 MG TABLET, 160-12.5 MG TAB,160-25 MG TABLET) 3
QL 2 / day
PR
SBA Select BrandAlternative
EDARBI 3
QL 1 / day
ST
PR
EDARBYCLOR 3
QL 1 / day
ST
PR
ENTRESTO 2 QL 2 / day
eprosartan mesylate 1QL 1 / day
PR
HYZAAR (100-12.5 TABLET, 100-25 TABLET) 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
PAGE 434 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HYZAAR 50-12.5 TABLET 3
QL 2 / day
ST
PR
SBA Select BrandAlternative
irbesartan 1QL 1 / day
PR
irbesartan-hctz 150-12.5 mg tb 1QL 2 / day
PR
irbesartan-hctz 300-12.5 mg tb 1QL 1 / day
PR
losartan potassium (25 mg tab, 50 mg tab) 1QL 2 / day
PR
losartan potassium 100 mg tab 1QL 1 / day
PR
losartan-hctz 50-12.5 mg tab 1QL 2 / day
PR
losartan-hydrochlorothiazide (100-12.5 mg tab, 100-25mg tab) 1
QL 1 / day
PR
MICARDIS 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
MICARDIS HCT (40-12.5 MG TABLET, 80-25 MG TABLET) 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
PAGE 435 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MICARDIS HCT 80-12.5 MG TABLET 3
QL 2 / day
ST
PR
SBA Select BrandAlternative
olmesartan medoxomil 1QL 3 / day
PR
olmesartan-amlodipine-hctz 1QL 1 / day
PR
olmesartan-hydrochlorothiazide 1QL 1 / day
PR
telmisartan 1QL 1 / day
PR
telmisartan-amlodipine 1QL 1 / day
PR
telmisartan-hctz 80-12.5 mg tb 1QL 2 / day
PR
telmisartan-hydrochlorothiazid (40-12.5 mg tb, 80-25 mgtab) 1
QL 1 / day
PR
TRIBENZOR 3
QL 1 / day
PR
SBA Select BrandAlternative
TWYNSTA 3QL 1 / day
PR
valsartan (40 mg tablet, 80 mg tablet, 160 mg tablet) 1QL 2 / day
PR
valsartan 320 mg tablet 1QL 1 / day
PR
PAGE 436 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
valsartan-hydrochlorothiazide (320-12.5 mg tab, 320-25mg tab) 1
QL 1 / day
PR
valsartan-hydrochlorothiazide (80-12.5 mg tab, 160-12.5mg tab, 160-25 mg tab) 1
QL 2 / day
PR
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS
ACCUPRIL 3QL 2 / day
PR
ACCURETIC (10-12.5 MG TABLET, 20-12.5 MG TABLET) 3QL 2 / day
PR
ACCURETIC 20-25 MG TABLET 3QL 1 / day
PR
ALTACE 3
QL 2 / day
ST
PR
SBA Select BrandAlternative
benazepril hcl (10 mg tablet, 40 mg tablet) 1QL 2 / day
PR
benazepril hcl 20 mg tablet 1QL 4 / day
PR
benazepril hcl 5 mg tablet 1QL 3 / day
PR
benazepril-hydrochlorothiazide 1
QL 1 / day
PR
HCG
captopril 1
QL 4 / day
PR
HCG
PAGE 437 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
captopril-hydrochlorothiazide 1QL 2 / day
PR
enalapril maleate 1QL 2 / day
PR
enalapril-hctz 10-25 mg tablet 1QL 2 / day
PR
enalapril-hctz 5-12.5 mg tab 1 PR
enalaprilat 1MED Medical Drug
PR
EPANED 3QL 5 / day
PR
fosinopril sodium 1QL 2 / day
PR
fosinopril-hydrochlorothiazide 1QL 2 / day
PR
lisinopril (2.5 mg tablet, 10 mg tablet, 20 mg tablet) 1QL 1 / day
PR
lisinopril (5 mg tablet, 30 mg tablet) 1QL 1 / day
PR
lisinopril 40 mg tablet 1QL 2 / day
PR
lisinopril-hctz 20-25 mg tab 1QL 2 / day
PR
lisinopril-hydrochlorothiazide (10-12.5 mg tab, 20-12.5mg tab) 1
QL 2 / day
PR
LOTENSIN (10 MG TABLET, 40 MG TABLET) 3QL 2 / day
PR
PAGE 438 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LOTENSIN 20 MG TABLET 3QL 4 / day
PR
LOTENSIN HCT 3QL 1 / day
PR
moexipril hcl 1QL 1 / day
PR
perindopril erbumine 1QL 1 / day
PR
PRESTALIA 3QL 1 / day
ST
PRINIVIL 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
QBRELIS 3 QL 40/ day
quinapril hcl 1QL 2 / day
PR
quinapril-hctz 20-25 mg tab 1QL 1 / day
PR
quinapril-hydrochlorothiazide (10-12.5 mg tab, 20-12.5mg tab) 1
QL 2 / day
PR
ramipril 1QL 2 / day
PR
TARKA 3
QL 1 / day
PR
SBA Select BrandAlternative
PAGE 439 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
trandolapril 1QL 2 / day
PR
trandolapril-verapamil er 1 PR
VASERETIC 3QL 2 / day
PR
VASOTEC 3
QL 2 / day
PR
SBA Select BrandAlternative
ZESTORETIC 3QL 2 / day
PR
ZESTRIL (2.5 MG TABLET, 5 MG TABLET, 10 MG TABLET,20 MG TABLET, 30 MG TABLET) 3
QL 1 / day
ST
PR
SBA Select BrandAlternative
ZESTRIL 40 MG TABLET 3
QL 2 / day
ST
PR
SBA Select BrandAlternative
MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS
ALDACTAZIDE 3 PR
ALDACTONE 3PR
SBA Select BrandAlternative
CAROSPIR 2PA
MVB MINIMALVALUE BRAND
PAGE 440 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
eplerenone 1PR
HCG
INSPRA 25 MG TABLET 3PR
SBA SELECT BRANDALTERNATIVE
INSPRA 50 MG TABLET 3 PR
spironolactone 1 PR
spironolactone-hctz 1 PR
RENIN INHIBITORS
aliskiren 1QL 1 / day
PR
TEKTURNA 3QL 1 / day
PR
TEKTURNA HCT 3QL 1 / day
PR
RESPIRATORY TRACT AGENTS
ANTIFIBROTIC AGENTS
ESBRIET (267 MG CAPSULE, 267 MG TABLET) 3
QL 9 / day
S
PA
ESBRIET 801 MG TABLET 3
QL 3 / day
S
PA
OFEV 3
QL 2 / day
S
PA
PAGE 441 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTITUSSIVES
benzonatate (100 mg capsule, perle 100 mg cap) 1 AL At least 10 yrsold
benzonatate (150 mg capsule, 200 mg capsule) 1AL At least 10 yrs
oldHCG
BROMFED DM 1 AL At least 2 yrsold
brompheniramine-pseudoephed-dm 1 AL At least 2 yrsold
codeine-guaifenesin 1QL 60 / day
AL At least 6 yrsold
CORICIDIN HBP COUGH AND COLD 3
guaifenesin-codeine 1QL 60 / day
AL At least 6 yrsold
hydrocod-cpm-pseudoephedrine 1
QL 20 / day
AL At least 18 yrsold
HCG
hydrocodone-chlorpheniramne er 1QL 10 / day
AL At least 6 yrsold
hydrocodone-guaifenesin 1QL 60 / day
AL At least 18 yrsold
hydrocodone-homatropine mbr (soln, syrup) 1QL 30 / day
AL At least 2 yrsold
hydrocodone-homatropine 5-1.5 1
QL 6 / day
AL At least 6 yrsold
HCG
PAGE 442 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HYDROMET 1QL 30 / day
AL At least 18 yrsold
NEOTUSS PLUS 3
NIVA-HIST DM 1
OBREDON 3
QL 60 / day
AL At least 18 yrsold
MVB Minimal ValueBrand
SBA Select BrandAlternative
promethazine-codeine 1
promethazine-dm 1 AL At least 2 yrsold
promethazine-phenyleph-codeine 1QL 30 / day
AL At least 6 yrsold
TESSALON PERLE 3AL At least 11 yrs
old
SBA SELECT BRANDALTERNATIVE
TUSNEL CAPLET 3
TUSNEL DM PEDIATRIC DROPS 3
TUSSICAPS 3
QL 6 / day
AL At least 6 yrsold
MVB MINIMALVALUE BRAND
TUSSIONEX 3
QL 10 / day
AL At least 18 yrsold
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
PAGE 443 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TUXARIN ER 3QL 2 / day
AL At least 18 yrsold
TUZISTRA XR 3
QL 20 / day
AL At least 18 yrsold
MVB Minimal ValueBrand
ZODRYL DAC 50 3
ZODRYL DAC 60 3
ZODRYL DAC 80 3
ZODRYL DEC 50 3
ZODRYL DEC 60 3
ZODRYL DEC 80 3
EXPECTORANTS
GILPHEX TR 3
GILTUSS TR 3
TUSNEL PEDIATRIC DROPS 3
TUSSI-PRES PEDIATRIC LIQUID 3
TUSSLIN PEDIATRIC DROPS 1
MUCOLYTIC AGENTS
acetylcysteine (10% vial, 20% vial) 1
PULMOZYME 3
QL 5 / day
S
PA
PAGE 444 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PHOSPHODIESTERASE TYPE 4 INHIBITORS
DALIRESP 3QL 1 / day
PA
PULMONARY SURFACTANTS
CUROSURF 3
INFASURF 3
SURVANTA 3
RESPIRATORY TRACT AGENTS, MISCELLANEOUS
ARALAST NP 3
S
PA
BSP BENEFIT SHIFTPROGRAM
GLASSIA 3
S
PA
BSP BENEFIT SHIFTPROGRAM
PROLASTIN C 3
S
PA
BSP BENEFIT SHIFTPROGRAM
XOLAIR 150 MG/ML SYRINGE 3
QL 0.15 / day
AL At least 6 yrsold
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
PAGE 445 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
XOLAIR 150 MG VIAL 3
QL 0.22 / day
AL At least 6 yrsold
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
ZEMAIRA 3
S
PA
BSP BENEFIT SHIFTPROGRAM
VASODILATING AGENTS (RESPIRATORY TRACT)
ADEMPAS 3
QL 3 / day
S
PA
ambrisentan 1
QL 1 / day
S
PA
bosentan 3
QL 2 / day
S
PA
epoprostenol sodium 1 S
FLOLAN 3S
PA
LETAIRIS 3
QL 1 / day
S
PA
OPSUMIT 3
QL 1 / day
S
PA
PAGE 446 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ORENITRAM ER 3
QL 3 / day
S
PA
REMODULIN 3S
PA
TRACLEER (32 MG TABLET FOR SUSP, 62.5 MG TABLET,125 MG TABLET) 3
QL 2 / day
S
PA
treprostinil 1S
PA
TYVASO 3
QL 1 / day
S
PA
TYVASO INSTITUTIONAL START KIT 3
QL 1 / day
S
PA
TYVASO REFILL KIT 3
QL 3 / day
S
PA
TYVASO STARTER KIT 3
QL 3 / day
S
PA
UPTRAVI 200-800 TITRATION PACK 3
AL At least 18 yrsold
S
PA
PAGE 447 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
UPTRAVI (200 MCG TABLET, 400 MCG TABLET, 600 MCGTABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200MCG TABLET, 1,400 MCG TABLET, 1,600 MCG TABLET)
3
QL 2 / day
AL At least 18 yrsold
S
PA
VELETRI 3S
PA
VENTAVIS 3
QL 9 / day
S
PA
SKELETAL MUSCLE RELAXANTS
CENTRALLY ACTING SKELETAL MUSCLE RELAXNT
AMRIX 3
ST
MVB MINIMALVALUE BRAND
SBA Select BrandAlternative
carisoprodol 250 mg tablet 1 HCG
carisoprodol 350 mg tablet 1
carisoprodol compound 1
carisoprodol-aspirin 1
carisoprodol-aspirin-codeine 1 QL 21 / day
chlorzoxazone (375 mg tablet, 500 mg tablet, 750 mgtablet) 1
chlorzoxazone 250 mg tablet 1
HCG
MVGMINIMALVALUEGENERIC
cyclobenzaprine 10 mg tablet 1
PAGE 448 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
cyclobenzaprine 5 mg tablet 1
cyclobenzaprine 7.5 mg tablet 1 HCG
cyclobenzaprine hcl er 1 HCG
FEXMID 3MVB Minimal Value
Brand
SBA SELECT BRANDALTERNATIVE
LORZONE 3
METAXALL 1
metaxalone 1 HCG
methocarbamol (500 mg tablet, 750 mg tablet) 1
methocarbamol 1,000 mg/10 ml 1 MED Medical Drug
ROBAXIN 500 MG TABLET 3
ROBAXIN 1,000 MG/10 ML VIAL 3 MED Medical Drug
ROBAXIN-750 3 SBA Select BrandAlternative
SKELAXIN 3ST
SBA Select BrandAlternative
SOMA 3ST
SBA Select BrandAlternative
tizanidine hcl (2 mg capsule, 4 mg capsule, 6 mg capsule) 1 HCG
tizanidine hcl (2 mg tablet, 4 mg tablet) 1
ZANAFLEX (2 MG CAPSULE, 4 MG CAPSULE, 4 MG TABLET,6 MG CAPSULE) 3
ST
SBA Select BrandAlternative
PAGE 449 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DIRECT-ACTING SKELETAL MUSCLE RELAXANTS
DANTRIUM (25 MG CAPSULE, 50 MG CAPSULE) 3
DANTRIUM 20 MG VIAL 3 MED Medical Drug
dantrolene sodium (25 mg cap, 50 mg cap, 100 mg cap) 1 HCG
dantrolene sodium 20 mg vial 1 MED Medical Drug
REVONTO 1 MED Medical Drug
GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT
baclofen (5 mg tablet, 10 mg tablet, 20 mg tablet) 1
OZOBAX 3 PA
SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS
NORGESIC FORTE 3MVB Minimal Value
Brand
SBA Select BrandAlternative
orphenadrine citrate 1 MED Medical Drug
orphenadrine citrate er 1
orphenadrine-aspirin-caffeine 1
ORPHENGESIC FORTE 3 SBA Select BrandAlternative
SKIN AND MUCOUS MEMBRANE AGENTS
ANTIPRURITICS AND LOCAL ANESTHETICS
ANACAINE 3
ANASTIA 3
CETACAINE 3
doxepin 5% cream 1
QL 49 / fill
PA
HCG
PAGE 450 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ethyl chloride 1
lidocaine 5% patch 1 QL 3 / day
lidocaine 5% ointment 1
lidocaine hcl 3% lotion 1
HCG
MVGMINIMALVALUEGENERIC
lidocaine hcl (3% cream, hcl 4% solution) 1
lidocaine-hc 2.8-0.55% gel 1
lidocaine-prilocaine 1
HCG
MVGMINIMALVALUEGENERIC
lidocaine-tetracaine 3
HCG
MVGMINIMALVALUEGENERIC
LIDODERM 3QL 3 / day
SBA Select BrandAlternative
LIDODOSE 2QL 1 / day
PA
LIDOPIN 3% CREAM 1
LIDOPRIL 1
LIDTOPIC MAX 3
NUMBONEX 3
phenazopyridine hcl 1
PLIAGLIS 3 MVB Minimal ValueBrand
PAGE 451 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PONTOCAINE 3
pramoxine hcl 1
PRE-ATTACHED LTA KIT 3
PRIKAAN 1
HCG
MVGMINIMALVALUEGENERIC
PRIKAAN LITE 1
PRUDOXIN 3
QL 49 / fill
PA
MVB MINIMALVALUE BRAND
PYRIDIUM 100 MG TABLET 3
PYRIDIUM 200 MG TABLET 3 SBA Select BrandAlternative
RADIAGUARD 3
SYNERA 3 MVB Minimal ValueBrand
WAL-DRYL 2%-0.1% CREAM 1
ZONALON 3QL 30 / fill
PA
ZTLIDO 3QL 3 / day
PA
ASTRINGENTS
DRYSOL 3
CVS MEDICATED PADS 1
XERAC AC 3
PAGE 452 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CELL STIMULANTS AND PROLIFERANTS
ALTRENO 3QL 1.5 / day
PA
ATRALIN 3QL 1.5 / day
PA
AVITA (CREAM, GEL) 1
KEPIVANCE 3S
MED Medical Drug
REFISSA 3
REGRANEX 3 QL 1 / day
RENOVA 3 MVB Minimal ValueBrand
RENOVA PUMP 3 MVB Minimal ValueBrand
RETIN-A (0.01% GEL, 0.025% CREAM, 0.025% GEL, 0.05%CREAM, 0.1% CREAM) 3
QL 50 / 30 days
PA
RETIN-A MICRO 3
QL 50 / 30 days
PA
MVB MINIMALVALUE BRAND
SBA Select BrandAlternative
RETIN-A MICRO PUMP (PUMP 0.04% GEL, PUMP 0.1%GEL) 3
QL 50 / 30 days
PA
RETIN-A MICRO PUMP (PUMP 0.06% GEL, PUMP 0.08%GEL) 2
QL 50 / 30 days
AL Up to 25 yrs old
TRETIN-X 0.075% CREAM 3 PA
tretinoin (0.01% gel, 0.025% cream, 0.025% gel, 0.05%cream, 0.1% cream) 1
PAGE 453 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
tretinoin 0.05% emollient crm 1
tretinoin 0.05% gel 1 QL 1.5 / day
tretinoin microsphere (gel 0.04% pump, gel 0.04% tube,gel 0.1% pump, gel 0.1% tube) 1
QL 1.667 / day
PA
HCG
MVGMINIMALVALUEGENERIC
DETERGENTS
iv sol stabilizer for blincyto 1S
MED Medical Drug
polysorbate 60 1
polysorbate 80 1
triton x-100 3
KERATOLYTIC AGENTS
AVAR CLEANSER 1
AVAR (9.5%-5% FOAM, 9.5-5% CLEANSING PADS) 3
AVAR LS (10%-2% FOAM, 10-2% CLEANSING PADS,CLEANSER) 3
AVAR-E 1
AVAR-E GREEN 1 HCG
AVAR-E LS 3
BENZEFOAM 3 QL 2 / day
BENZEFOAM ULTRA 3 QL 3.334 / day
BENZEPRO (6% FOAMING CLOTHS, 7% CREAMY WASH) 1
BENZEPRO 5.2% EMOLLIENT FOAM 3
PAGE 454 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
benzoyl peroxide (pr 7% wash, 9.8% foam) 1
BP 10-1 1
HCG
MVGMINIMALVALUEGENERIC
BPO (4% GEL, 8% GEL) 3
BPO 6% FOAMING CLOTHS 1 QL 2 / day
PACNEX 1
PLEXION (9.8-4.8% CLEANSER, 9.8-4.8% LOTION) 3 SBA Select BrandAlternative
PLEXION 9.8-4.8% CREAM 3MVB Minimal Value
Brand
SBA Select BrandAlternative
PLEXION 9.8-4.8% CLNSING CLOTH 3
pr benzoyl peroxide 1
ROSANIL 1
ROSULA 10%-4.5% WASH 3
ROSULA 10%-5% CLOTHS 1
SALEX 6% SHAMPOO 3MVB Minimal Value
Brand
SBA Select BrandAlternative
salicylic acid (foam, gel) 1
HCG
MVGMINIMALVALUEGENERIC
salicylic acid (6% cream, 6% lotion, 6% shampoo, 26%liquid, 27.5% liquid) 1
salicylic acid er 1
HCG
MVGMINIMALVALUEGENERIC
PAGE 455 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SALIMEZ FORTE 3
SALVAX 3
sod sulfacet-sulfur 10-2% clsr 1
HCG
MVGMINIMALVALUEGENERIC
sod sulfacet-sulfur 10-5% clsr 1
sodium sulfacetamide-sulfur (sod sulfac-sulfur 9.8-4.8%crm, sod sulfac-sulfur 9.8-4.8% lot, sod sulface-sulf 9.8-4.8% clsr, sod sulfacetamide-sulfur lotn, sodsulfacetamide-sulfur susp, sodium sulfacet-sulfur wash,sulfacetamide-sulfur 10-2% crm, sulfacetamide-sulfur 10-5% crm)
3
HCG
MVGMINIMALVALUEGENERIC
sod sulfacet-sulfur 10-4% pad 1
sodium sulfacetamide-sulfur (sod sulface-sulfur 9-4.5%wash, sulfacetamide-sulfur 8-4% susp) 3
SSS 10-5 (10-5 CREAM, 10-5 FOAM) 1
SULFACLEANSE 8-4 1
SUMADAN 9%-4.5% WASH 3
SUMAXIN (9%-4% WASH, CLEANSING PADS) 3
SUMAXIN TS 3
ULTRASAL-ER 3 SBA Select BrandAlternative
urea (35% foam, 39% cream, 40% lotion, 45% cream, 45%nail gel) 1
UTOPIC 3 SBA Select BrandAlternative
VIRASAL 3
PAGE 456 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
KERATOPLASTIC AGENTS
DRITHOCREME HP 3
SKIN AND MUCOUS MEMBRANE AGENTS, MISC.
ABSORICA 3 PA
ABSORICA LD 3 PA
acitretin (17.5 mg capsule, 25 mg capsule) 1 QL 2 / day
acitretin 10 mg capsule 1 QL 4 / day
ACZONE 5% GEL 3
QL 3 / day
PA
SBA Select BrandAlternative
ACZONE 7.5% GEL PUMP 3 QL 3 / day
adapalene (0.1% cream, 0.3% gel, 0.3% gel pump) 1 QL 1.5 / day
adapalene 0.1% swab 1QL 1 / day
PA
adapalene (lotion, solution) 1QL 2 / day
PA
adapalene-benzoyl peroxide 1 QL 1.5 / day
AKLIEF 3QL 1.5 / day
PA
ALDARA 3QL 0.434 / day
AL At least 12 yrsold
AMNESTEEM 1 PA
ARAZLO 3 QL 1.5 / day
PAGE 457 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AVAGE 3 QL 1.47 / day
azelaic acid 3QL 50 / 30 days
PA
AZELEX 3 QL 1.667 / day
calcipotriene 0.005% cream 1QL 2 / day
HCG
calcipotriene (ointment, solution) 1 QL 2 / day
calcipotriene-betamethasone dp 1QL 3 / day
PA
CALCITRENE 1
QL 2 / day
HCG
MVGMINIMALVALUEGENERIC
calcitriol 3 mcg/g ointment 1
QL 3.334 / day
HCG
MVGMINIMALVALUEGENERIC
CLARAVIS 1 PA
CONDYLOX 3
COSENTYX (2 SYRINGES) 3
QL 0.357 / day
S
PA
COSENTYX PEN 3
QL 0.357 / day
S
PA
COSENTYX PEN (2 PENS) 3
QL 0.357 / day
S
PA
PAGE 458 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
COSENTYX SYRINGE 3
QL 0.357 / day
S
PA
dapsone 5% gel 1
QL 3 / day
HCG
MVGMINIMALVALUEGENERIC
dapsone 7.5% gel pump 3 QL 3 / day
DEBACTEROL SWABSTICK 3
DIFFERIN (0.1% CREAM, 0.3% GEL, 0.3% GEL PUMP) 3QL 1.5 / day
PA
DIFFERIN 0.1% LOTION 3QL 1.967 / day
PA
DOVONEX 3
QL 2 / day
PA
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
DUOBRII 3QL 7 / day
PA
DUPIXENT PEN 3
QL 0.15 / day
AL At least 6 yrsold
S
PS
PA
DUPIXENT 300 MG/2 ML SYRINGE 3
QL 0.15 / day
AL At least 6 yrsold
S
PS
PA
PAGE 459 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ELIDEL 3
QL 2.5 / day
ST
AL At least 2 yrsold
ENSTILAR 3 QL 2 / day
EPIDUO 3QL 1.5 / day
ST
EPIDUO FORTE 3 QL 1.667 / day
FABIOR 3
QL 3.73 / day
AL Up to 34 yrs old
PA
FINACEA 15% FOAM 3 QL 50 / 30 days
FINACEA 15% GEL 3
QL 50 / 30 days
PA
B4G
finasteride 1 mg tablet 1
FORMADON 1
imiquimod 5% cream packet 1QL 0.434 / day
AL At least 12 yrsold
imiquimod 3.75% cream pump 1
QL 0.25 / day
AL At least 12 yrsold
HCG
MVGMINIMALVALUEGENERIC
isotretinoin 1 PA
ivermectin 1% cream 1 QL 1.5 / day
PAGE 460 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MIRVASO (GEL, GEL PUMP) 3 QL 1 / day
MYORISAN 1 PA
pimecrolimus 1
QL 2.5 / day
ST
AL At least 2 yrsold
PODOCON-25 3
podofilox 1
PROPECIA 3 ST
PROTOPIC 0.03% OINTMENT 3
QL 2.5 / day
ST
AL At least 2 yrsold
PROTOPIC 0.1% OINTMENT 3
QL 2.5 / day
ST
AL At least 16 yrsold
QUTENZA 3S
MED Medical Drug
RECTIV 3
RHOFADE 3 QL 1.25 / day
SANTYL 3
SILIQ 3
AL At least 18 yrsold
S
PA
SKYRIZI 3
QL 0.07 / day
S
PS
PA
PS1 Preferred 1stline
PAGE 461 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SKYRIZI (2 SYRINGES) KIT 3
QL 0.04 / day
S
PS
PA
PS1 Preferred 1stline
SOOLANTRA 3QL 1.5 / day
B4G
SORIATANE 10 MG CAPSULE 3 QL 4 / day
SORIATANE 25 MG CAPSULE 3 QL 2 / day
SORILUX 3
QL 2 / day
PA
B4G
MVB MINIMALVALUE BRAND
SBA SELECT BRANDALTERNATIVE
STELARA (45 MG/0.5 ML SYRINGE, 45 MG/0.5 ML VIAL, 90MG/ML SYRINGE) 3
QL 0.08 / day
S
PS
PA
PS1 Preferred 1stline
STELARA 130 MG/26 ML VIAL 3
QL 3.73 / day
S
PS
PA
BSP BENEFIT SHIFTPROGRAM
PS1 Preferred 1stline
PAGE 462 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TACLONEX OINTMENT 3
QL 3 / day
PA
SBA Select BrandAlternative
TACLONEX 0.005%-0.064% SUSPENS 3QL 4 / day
B4G
tacrolimus (0.03% ointment, 0.1% ointment) 1QL 100 / 30 days
ST
TALTZ AUTOINJECTOR 3
QL 0.15 / day
S
PS
PA
PS2 Preferred 2ndline
TALTZ AUTOINJECTOR (2 PACK) 3
QL 0.15 / day
S
PS
PA
PS2 Preferred 2ndline
TALTZ AUTOINJECTOR (3 PACK) 3
QL 0.15 / day
S
PS
PA
PS2 Preferred 2ndline
TALTZ SYRINGE 3
QL 0.15 / day
S
PS
PA
PS2 Preferred 2ndline
PAGE 463 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
tazarotene 1 QL 1.47 / day
TAZORAC 0.05% CREAM 3QL 2 / day
PA
TAZORAC 0.1% CREAM 3
QL 2 / day
PA
SBA Select BrandAlternative
TAZORAC 0.05% GEL 3QL 3.334 / day
PA
TAZORAC 0.1% GEL 3
QL 3.334 / day
PA
MVB Minimal ValueBrand
TISSEEL VHSD (2 ML KIT, FROZEN 2 ML SYR, 4 ML KIT,FROZEN 4 ML SYR, 10 ML KIT, FROZEN 10 ML SYR) 3 MED Medical Drug
TREMFYA (100 MG/ML INJECTOR, 100 MG/ML SYRINGE) 3
QL 0.04 / day
AL At least 18 yrsold
S
PS
PA
PS1 Preferred 1stline
TRI-CHLOR 3
trichloroacetic acid (20%, 25%, 50%, 75%, 80%, 85%, 90%,100%) 1
VANIQA 3 MVB Minimal ValueBrand
VECTICAL 3QL 3.334 / day
ST
PAGE 464 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VENELEX OINTMENT 3
VEREGEN 3 MVB MINIMALVALUE BRAND
ZENATANE 1 PA
ZYCLARA 3.75% CREAM 3
QL 56 / 60 days
ST
AL At least 12 yrsold
ZYCLARA 2.5% CREAM PUMP 3
QL 56 / 30 days
ST
AL At least 12 yrsold
ZYCLARA 3.75% CREAM PUMP 3
QL 56 / 60 days
ST
AL At least 12 yrsold
SBA Select BrandAlternative
SMOOTH MUSCLE RELAXANTS
RESPIRATORY SMOOTH MUSCLE RELAXANTS
aminophylline 1MED Medical Drug
PR
ELIXOPHYLLIN 3PR
NTI
THEO-24 3PR
NTI
theophylline 80 mg/15 ml soln 1PR
NTI
PAGE 465 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
theophylline (er 400 mg tablet, er 600 mg tablet) 1PR
NTI
theophylline anhydrous 1PR
NTI
theophylline in 5% dextrose 1
MED Medical Drug
PR
NTI
SOMATOSTATIN AGONISTS AND ANTAGONISTS
SOMATOSTATIN AGONISTS
BYNFEZIA 3
QL 0.6 / day
S
PA
MYCAPSSA 3
QL 4 / day
S
PA
octreotide acetate (acet 0.05 mg/ml vl, acet 50 mcg/mlamp, acet 50 mcg/ml syr, acet 50 mcg/ml vial, acet 100mcg/ml amp, acet 100 mcg/ml syr, acet 100 mcg/ml vl,acet 200 mcg/ml vl, acet 500 mcg/ml amp, acet 500mcg/ml syr, acet 500 mcg/ml vl, 1,000 mcg/5 ml vial,1,000 mcg/ml vial, 5,000 mcg/5 ml vial)
1S
PA
SANDOSTATIN 0.05 MG/ML AMPUL 3
QL 30 / day
S
PA
SBA Select BrandAlternative
SANDOSTATIN 0.1 MG/ML AMPUL 3
QL 15 / day
S
PA
SBA Select BrandAlternative
PAGE 466 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SANDOSTATIN 0.5 MG/ML AMPUL 3
QL 3 / day
S
PA
SBA Select BrandAlternative
SANDOSTATIN LAR DEPOT (10 MG KT, 10 MG VL, 30 MGKT, 30 MG VL) 3
QL 0.04 / day
S
PA
BSP BENEFIT SHIFTPROGRAM
SANDOSTATIN LAR DEPOT (20 MG KT, 20 MG VL) 3
QL 0.07 / day
S
PA
BSP BENEFIT SHIFTPROGRAM
SIGNIFOR 3S
PA
SIGNIFOR LAR 3S
PA
SOMATULINE DEPOT 3
QL 0.02 / day
S
PA
BSP BENEFIT SHIFTPROGRAM
SOMATOTROPIN AGONISTS AND ANTAGONISTS
SOMATOTROPIN AGONISTS
EGRIFTA 3
QL 2 / day
S
PA
PAGE 467 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EGRIFTA SV 3
QL 2 / day
S
PA
INCRELEX 3S
PA
SOMATOTROPIN ANTAGONISTS
SOMAVERT 3 S
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
ALPHA- AND BETA-ADRENERGIC AGONISTS
ADRENALIN 3 MED Medical Drug
AUVI-Q (0.15 MG, 0.3 MG) 3
QL 2 / fill
PA
MVB MINIMALVALUE BRAND
AUVI-Q 0.1 MG AUTO-INJECTOR 3
QL 2 / fill
PA
MVB Minimal ValueBrand
epinephrine (0.15 mg auto-injct, 0.3 mg auto-inject) 1 QL 4 / fill
epinephrine (0.1 mg/ml syringe, 1 mg/10 ml abbojct, 1mg/ml ampul) 1 MED Medical Drug
epinephrine 30 mg/30 ml vial 1 MED Medical Drug
epinephrine hcl-0.9% nacl (0.16 mg/10 ml-ns, 0.8 mg/50ml-ns) 1 MED Medical Drug
epinephrine 5 mg/250 ml-d5w 1 MED Medical Drug
epinephrine 100 mcg/10 ml-d5w 1 MED Medical Drug
EPINEPHRINESNAP-EMS 3 QL 2 / fill
PAGE 468 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EPINEPHRINESNAP-V 3 QL 2 / fill
EPIPEN 3QL 4 / fill
PA
EPIPEN 2-PAK 3QL 4 / fill
PA
EPIPEN JR 3QL 4 / fill
PA
EPIPEN JR 2-PAK 3QL 4 / fill
PA
norepinephrine bitar-0.9% nacl (norepineph 0.8 mg/50-0.9% nacl, norepineph 15 mg/250-0.9% nacl, norepinephr0.16 mg/10 ml-ns)
1 MED Medical Drug
norepinephrine bitartrate-d5w (100 mcg/10, 160 mcg/10) 1 MED Medical Drug
NORTHERA 3
QL 84 / 14 days
S
PA
SYMJEPI 3 QL 2 / fill
ALPHA-ADRENERGIC AGONISTS
BIORPHEN 3 MED Medical Drug
LUCEMYRA 3QL 48 tablets/180
daysPA
midodrine hcl 1
phenylephrine hcl-0.9% nacl (1 mg/10 ml-ns, 5 mg/50 ml-ns, 10 mg/250 ml-ns, 100 mcg/10 ml-ns, 200 mcg/2 ml-ns, 200 mg/250 ml-ns, 1,200mcg/10ml-ns)
1 MED Medical Drug
phenylephrine hcl-d5w (8 mg/100, 20 mg/500, 25mg/250, 30 mg/250) 1 MED Medical Drug
PAGE 469 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
phenylephrine hcl-water (0.4mg/10ml-water, 1 mg/10 ml-water) 1 MED Medical Drug
TETRACYCLINE ANTIBIOTICS
AMINOMETHYLCYCLINES
NUZYRA (150 MG TABLET, 150 MG TABLET-7 DAY, 150MG-7 DAY WITH LOAD) 3 PA
NUZYRA 100 MG VIAL 3 MED Medical Drug
SEYSARA 3QL 1 / day
PA
GLYCYLCYCLINE ANTIBIOTICS
tigecycline 1 MED Medical Drug
TYGACIL 3 MED Medical Drug
THYROID AND ANTITHYROID AGENTS
ANTITHYROID AGENTS
methimazole 1
propylthiouracil 1
SSKI 3
TAPAZOLE 10 MG TABLET 3
TAPAZOLE 5 MG TABLET 3 SBA Select BrandAlternative
THYROID AGENTS
ARMOUR THYROID 3 ST
CYTOMEL 3 SBA Select BrandAlternative
EUTHYROX 1 NTI
PAGE 470 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LEVO-T 1 NTI
levothyroxine 1QL 1 / day
NTI
levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 100mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcgtablet, 150 mcg tablet, 175 mcg tablet)
1 NTI
levothyroxine sodium (75 mcg tablet, 88 mcg tablet, 200mcg tablet, 300 mcg tablet) 1 NTI
levothyroxine sodium (100 mcg vial, 200 mcg vial, 500mcg vial) 1
MED Medical Drug
NTI
levothyroxine sodium (100 mcg/5 ml vl, 200 mcg/5 ml vl,500 mcg/5 ml vl) 1
LEVOXYL (25 MCG TABLET, 50 MCG TABLET, 100 MCGTABLET) 1 NTI
LEVOXYL (75 MCG TABLET, 88 MCG TABLET, 112 MCGTABLET, 125 MCG TABLET, 137 MCG TABLET, 150 MCGTABLET, 175 MCG TABLET, 200 MCG TABLET)
1 NTI
liothyronine sodium (5 mcg tab, 25 mcg tab, 50 mcg tab) 1
liothyronine sod 10 mcg/ml vl 1 MED Medical Drug
NATURE-THROID 3
NP THYROID 1
SYNTHROID 3ST
NTI
thyroid (15 mg tablet, 30 mg tablet, 60 mg tablet, 90 mgtablet, 120 mg tablet) 1
THYROLAR-1 3
THYROLAR-1/2 3
THYROLAR-1/4 3
PAGE 471 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
THYROLAR-2 3
THYROLAR-3 3
TIROSINT 3QL 1 / day
NTI
TIROSINT-SOL 3QL 1 / day
NTI
TRIOSTAT 3 MED Medical Drug
UNITHROID (25 MCG TABLET, 50 MCG TABLET, 100 MCGTABLET, 112 MCG TABLET) 1 NTI
UNITHROID (75 MCG TABLET, 88 MCG TABLET, 125 MCGTABLET, 137 MCG TABLET, 150 MCG TABLET, 175 MCGTABLET, 200 MCG TABLET, 300 MCG TABLET)
1 NTI
WESTHROID 3
WP THYROID 3 ST
URINE AND FECES CONTENTS
KETONES
ketone care test strip 3 QL 6.66 / day
ketone test strip 3 QL 6.66 / day
ketostix reagent 3 QL 6.66 / day
trueplus ketone test strip 3 QL 6.66 / day
PH
chemstrip 2 ln 3
nitratest paper 3
PROTEIN
albustix reagent 3
PAGE 472 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
chemstrip micral 3
SUGAR
diastix reagent 3 QL 10 / day
no-stick glucose 3
Uncategorized
Unclassified
CAVERJECT 40 MCG/2 ML AMPUL 3
yohimbine hcl 1
VASODILATING AGENTS
NITRATES AND NITRITES
DILATRATE-SR 3QL 4 / day
MVB Minimal ValueBrand
GONITRO 3
QL 1.25 / day
AL At least 18 yrsold
PA
ISOCHRON 1 QL 4 / day
ISORDIL 3QL 12 / day
SBA SELECT BRANDALTERNATIVE
ISORDIL TITRADOSE 3QL 12 / day
SBA SELECT BRANDALTERNATIVE
isosorbide dinitrate 1 QL 12 / day
isosorbide dinitrate er 1 QL 4 / day
PAGE 473 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
isosorbide mononitrate 1 QL 2 / day
isosorbide mononitrate er 1 QL 2 / day
MINITRAN 1 QL 1 / day
NITRO-BID 2 QL 4 / day
NITRO-DUR 3 QL 1 / day
NITRO-TIME (ER 2.5 MG CAPSULE, ER 6.5 MG CAPSULE) 1 QL 4 / day
nitroglycerin (er 2.5 mg cap, er 6.5 mg cap, er 9 mgcapsule) 1 QL 4 / day
nitroglycerin 400 mcg spray 1 QL 0.8 / day
nitroglycerin (0.3 mg tablet, 0.4 mg tablet, 0.6 mg tablet) 1 QL 6 / day
nitroglycerin 5 mg/ml vial 1 MED Medical Drug
nitroglycerin in d5w 1 MED Medical Drug
nitroglycerin patch 1 QL 1 / day
NITROLINGUAL 3 QL 0.8 / day
NITROMIST 3 QL 0.3 / day
NITROSTAT 3QL 6 / day
SBA Select BrandAlternative
PHOSPHODIESTERASE TYPE 5 INHIBITORS
ADCIRCA 3
QL 2 / day
S
PA
SBA Select BrandAlternative
ALYQ 1
QL 2 / day
S
PA
PAGE 474 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CIALIS (10 MG TABLET, 20 MG TABLET) 3
QL 0.2 / day
ST
GL Male
SBA Select BrandAlternative
CIALIS (2.5 MG TABLET, 5 MG TABLET) 3
QL 1 / day
ST
GL Male
SBA Select BrandAlternative
LEVITRA 3
QL 0.2 / day
GL Male
AL At least 18 yrsold
SBA Select BrandAlternative
REVATIO 10 MG/ML ORAL SUSP 3
QL 6 / day
AL At least 18 yrsold
S
PA
REVATIO 20 MG TABLET 3
QL 3 / day
AL At least 18 yrsold
S
PA
REVATIO 10 MG/12.5 ML VIAL 3
AL At least 18 yrsold
S
MED Medical Drug
PA
sildenafil 20 mg tablet (pah) 1
QL 3 / day
S
PA
PAGE 475 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
sildenafil 10 mg/ml oral susp 1
QL 6 / day
AL At least 18 yrsold
S
PA
sildenafil citrate (25 mg tablet, 50 mg tablet, 100 mgtablet) 1
QL 0.2 / day
GL Male
AL At least 18 yrsold
sildenafil 10 mg/12.5 ml vial 1
AL At least 18 yrsold
S
MED Medical Drug
PA
STAXYN 3
QL 0.2 / day
GL Male
SBA Select BrandAlternative
STENDRA 3QL 0.2 / day
GL Male
tadalafil (2.5 mg tablet, 5 mg tablet) 1QL 1 / day
GL Male
tadalafil 10 mg tablet 1QL 0.2 / day
GL Male
tadalafil 20 mg tablet (ed/bph) 1QL 0.2 / day
GL Male
tadalafil 20 mg tablet (pah) 1
QL 2 / day
S
PA
PAGE 476 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
vardenafil hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet,20 mg tablet) 1
QL 0.2 / day
GL Male
AL At least 18 yrsold
HCG
vardenafil hcl 10 mg odt 1
QL 0.2 / day
GL Male
AL At least 18 yrsold
HCG
MVGMINIMALVALUEGENERIC
VIAGRA 3
QL 0.2 / day
GL Male
AL At least 18 yrsold
SBA Select BrandAlternative
VASODILATING AGENTS, MISCELLANEOUS
AGGRENOX 3
QL 2 / day
PR
SBA SELECT BRANDALTERNATIVE
aspirin-dipyridamole er 1QL 2 / day
PR
CAVERJECT (IMPULSE 10 MCG KIT, 20 MCG VIAL, IMPULSE20 MCG KIT, 40 MCG VIAL) 3 GL Male
CAVERJECT (10 MCG, 20 MCG) 3
dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) 1QL 4 / day
PR
PAGE 477 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EDEX 3 GL Male
isoxsuprine 10 mg tablet 1
MUSE 3 GL Male
NATRECOR 3 MED Medical Drug
papaverine hcl 1 MED Medical Drug
VITAMINS
MULTIVITAMIN PREPARATIONS
CADEAU DHA 3 GL Female
INFUVITE PEDIATRIC 1 MED Medical Drug
M.V.I. PEDIATRIC 3 MED Medical Drug
MVW COMPLETE FORMLTN PEDIATRIC 3
MVW COMPLETE FORMUL D3000 SFGL 3
MYNATAL 3GL Female
PR
MYNATAL PLUS 3GL Female
PR
MYNATAL-Z 3GL Female
PR
NEWGEN 3GL Female
PR
OBTREX DHA 3GL Female
PR
ONEVITE 3
PRENA1 CHEW 3GL Female
PR
PAGE 478 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PRENA1 PEARL 3GL Female
PR
PRENA1 TRUE 3GL Female
PR
PRENATABS RX 3GL Female
PR
prenatal low iron 3GL Female
PR
PRENATAL VITAMIN WITH MINERALS AND FOLIC ACIDGREATER THAN 0.8 MG ORAL TABLET 3
GL Female
PR
prenatal-u 3GL Female
PR
R-NATAL OB 3GL Female
PR
TOBAKIENT 3
TRINATE 3GL Female
PR
TRUST NATAL DHA 3GL Female
PR
VINATE DHA RF 3GL Female
PR
VINATE ONE 3GL Female
PR
VINATE-M 3GL Female
PR
VIRT-C DHA 3
PAGE 479 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VITATRUE 3GL Female
PR
VITAMIN A
AQUASOL A 3
VITAMIN B COMPLEX
B-12 COMPLIANCE 3
cyanocobalamin injection 1
folic acid 1 mg tablet 1
folic acid (5 mg/ml vial, 50 mg/10 ml vial) 1 MED Medical Drug
hydroxocobalamin 1
METANX 3
NASCOBAL 3
NEPHRONEX-SL 1
pyridoxine 100 mg/ml vial 1 MED Medical Drug
thiamine 200 mg/2 ml vial 1 BSP BENEFIT SHIFTPROGRAM
VITAMIN C
ascorbic acid granules 3
ascorbic acid 500 mg/ml vial 1 MED Medical Drug
VITAMIN D
calcitriol 1 mcg/ml ampul 1 MED Medical Drug
calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/mlsolution) 1
doxercalciferol (0.5 mcg cap, 1 mcg capsule, 2.5 mcg cap) 1 S
PAGE 480 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
doxercalciferol 4 mcg/2 ml vl 1S
MED Medical Drug
DRISDOL 3MVB Minimal Value
Brand
SBA SELECT BRANDALTERNATIVE
HECTOROL 3S
MED Medical Drug
paricalcitol (1 mcg capsule, 2 mcg capsule, 4 mcg capsule) 1 S
paricalcitol (2 mcg/ml vial, 5 mcg/ml vial, 10 mcg/2 mlvial) 1
S
MED Medical Drug
RAYALDEE 3 S
ROCALTROL (0.25 MCG CAPSULE, 0.5 MCG CAPSULE, 1MCG/ML ORAL SOLN) 3
vitamin d2 1.25mg(50,000 unit) 1
ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE) 3S
PA
ZEMPLAR (2 MCG/ML VIAL, 5 MCG/ML VIAL, 10 MCG/2ML VIAL) 3
S
MED Medical Drug
PA
VITAMIN E
wheat germ oil 1
VITAMIN K ACTIVITY
MEPHYTON 3 SBA Select BrandAlternative
phytonadione (1 mg/0.5 ml syr, 10 mg/ml ampul) 1 MED Medical Drug
phytonadione 5 mg tablet 1
PAGE 481 LAST UPDATED 01/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
vitamin k1 1 MED Medical Drug
PAGE 482 LAST UPDATED 01/2021
Index of Covered Drugs
11st tier unifine pentips 2611st tier unifine pentips plus 2611st tier unilet comfortouch 261
22-in-1 lancet device 2612tek 261
AA-HYDROCORT 354abacavir 200abacavir-lamivudine 200abacavir-lamivudine-zidovudine 200ABATUSS DMX 339ABELCET 116ABILIFY 182ABILIFY MAINTENA 182ABILIFY MYCITE 183abouttime pen needle 261ABRAXANE 145ABSORICA 457ABSORICA LD 457ABSTRAL 7acamprosate calcium 251ACANYA 42acarbose 100ACCOLATE 53accu-chek 261accu-chek aviva plus 261,299accu-chek compact plus control 261accu-chek compact plus strips 299accu-chek fastclix lancet drum 261accu-chek fastclix lancing dev 261accu-chek guide control soln 262accu-chek guide me glucose mtr 262accu-chek guide monitor system 262accu-chek guide test strip 300accu-chek nano smartview 262accu-chek safe-t-pro 262
accu-chek safe-t-pro plus 262accu-chek smartview 262,300accu-chek softclix 262ACCUPRIL 437ACCURETIC 437accutrend glucose 262,300ACD-A 323acebutolol hcl 246acetamin-caff-dihydrocodeine 7acetaminophen 5acetaminophen-codeine 7,8acetazolamide 121acetazolamide er 121acetazolamide sodium 121acetic acid 42acetylcysteine 444ACIPHEX 216ACIPHEX SPRINKLE 217acitretin 457ACTEMRA 400ACTEMRA ACTPEN 401ACTHAR 299ACTHIB 211ACTHREL 316acti-lance 262ACTICLATE 67ACTIGALL 343ACTIMMUNE 406ACTIQ 8ACTIVASE 206ACTIVELLA 330ACTONEL 395ACTOPLUS MET 109ACTOPLUS MET XR 109ACTOS 109ACULAR 52ACULAR LS 52ACUVAIL 52acyclovir 46,47,220acyclovir sodium 220acyclovir sodium-0.9% nacl 220
acyclovir sodium-d5w 221ACZONE 457ADACEL TDAP 211ADAGEN 327ADAKVEO 233ADALAT CC 241adapalene 457adapalene-benzoyl peroxide 457ADASUVE 182ADCETRIS 145ADCIRCA 474ADDERALL 30ADDERALL XR 30ADDYI 251adefovir dipivoxil 221ADEMPAS 446adenosine 64ADHANSIA XR 33ADIPEX-P 28adjustable lancing device 262ADLYXIN 104ADMELOG 384ADMELOG SOLOSTAR 384ADRENALIN 468ADRENALIN CHLORIDE 337ADRIAMYCIN 145ADRUCIL 145ADVAIR DISKUS 257ADVAIR HFA 257advanced glucose meter 262advanced glucose test strip 300advanced glucose test strips 300advanced lancing device 262advanced travel lancets 262ADVATE 123advocate blood glucose monitor 262advocate control solution 262advocate duo 262advocate lancet 262advocate lancets 262advocate lancing device 263
advocate pen needle 263advocate pen needles 263advocate rapid-safe 263advocate redi-code 263,300advocate redi-code duo 263advocate redi-code plus 263advocate redi-code+ 300advocate redi-code+ ctrl soln 263advocate test strip 300ADYNOVATE 123ADZENYS ER 30ADZENYS XR-ODT 30AEMCOLO 75AFEDITAB CR 241AFINITOR 145AFINITOR DISPERZ 145AFIRMELLE 361AFLURIA QUAD 2019-20 (3YR UP) 211AFLURIA QUAD 2019-20 (6-35MO) 211AFLURIA QUAD 2019-2020 211AFLURIA QUAD 2020-2021 211AFLURIA QUAD 2020-21 (3YR UP) 211AFLURIA QUAD 2020-21 (6-35MO) 211AFREZZA 384AFSTYLA 123agamatrix amp 263,300agamatrix control 263agamatrix control solution 263agamatrix presto 301AGGRASTAT 205AGGRENOX 477AGRYLIN 206AIMOVIG AUTOINJECTOR 139AIMOVIG AUTOINJECTOR (2 PACK) 139AIRDUO DIGIHALER 257AIRDUO RESPICLICK 257AJOVY AUTOINJECTOR 139AJOVY SYRINGE 140AK-POLY-BAC 38AKLIEF 457AKTEN 337
AKTIPAK 42AKYNZEO 112ALA-CORT 55ALA-SCALP 55albendazole 37ALBENZA 37ALBUMINEX 233albustix reagent 472albuterol hfa 90 mcg inhaler (par) 231albuterol hfa 90 mcg inhaler (perrigo) 231albuterol hfa 90 mcg inhaler (prasco) 231albuterol hfa 90 mcg inhaler (teva) 231albuterol sulfate 231albuterol sulfate hfa 231alclometasone dipropionate 55ALDACTAZIDE 440ALDACTONE 440ALDARA 457ALDURAZYME 327ALECENSA 145alendronate sodium 395ALFERON N 219alfuzosin hcl er 5ALIMTA 146ALINIA 181ALIQOPA 146aliskiren 441alkaline batteries 263ALKERAN 146ALKINDI SPRINKLE 354ALLER-CHLOR 339allopurinol 394allopurinol sodium 394ALLZITAL 5almotriptan malate 140ALOCRIL 54alogliptin 103alogliptin-metformin 103alogliptin-pioglitazone 103ALOMIDE 334ALOPRIM 394
ALORA 330alosetron hcl 340alpha lipoic acid 415ALPHAGAN P 120ALPHANATE 123ALPHANINE SD 123alprazolam 226alprazolam er 226ALPRAZOLAM INTENSOL 226alprazolam odt 226alprazolam xr 226ALPROLIX 124ALREX 49ALTABAX 42ALTACE 437ALTAVERA 361alternate site lancets 263alternate site lancing device 263ALTOPREV 135ALTRENO 453ALUNBRIG 146ALVESCO 258ALYACEN 361ALYQ 474AMABELZ 330amantadine 177AMARYL 108AMBIEN 223AMBIEN CR 223AMBISOME 116ambrisentan 446amcinonide 55AMERGE 140AMETHIA 361AMETHIA LO 361AMETHYST 361AMICAR 124amifostine 419amikacin sulfate 64amiloride hcl 319amiloride-hydrochlorothiazide 319
aminocaproic acid 124aminophylline 465amiodarone hcl 64AMITIZA 341amitriptyline hcl 99amlodipine besylate 241amlodipine besylate-benazepril 241amlodipine-atorvastatin 135amlodipine-olmesartan 241amlodipine-valsartan 241amlodipine-valsartan-hctz 241AMNESTEEM 457amoxapine 99amoxicillin 428amoxicillin-clavulanate pot er 429amoxicillin-clavulanate potass 429amphetamine 30amphetamine sulfate 30amphotericin b 116ampicillin sodium 429ampicillin trihydrate 429ampicillin-sulbactam 429AMPYRA 415AMRIX 448AMZEEQ 43ANACAINE 450ANADROL-50 358ANAFRANIL 99anagrelide hcl 206ANALPRAM HC 55ANAPROX DS 420ANASPAZ 75ANASTIA 450anastrozole 146ANCOBON 116ANDRODERM 358ANDROGEL 358ANDROID 358ANGELIQ 330ANGIOMAX 80ANNOVERA 361
ANORO ELLIPTA 75ANTABUSE 393ANTARA 132ANUCORT-HC 55ANUSOL-HC 55,56ANZEMET 110APADAZ 8APEXICON E 56APIDRA 384APIDRA SOLOSTAR 385APLENZIN 92APOKYN 322apraclonidine hcl 336aprepitant 113APRI 361APRISO 340APTENSIO XR 33APTIOM 82APTIVUS 203aqua lance lancing device 263AQUASOL A 480ARAKODA 180ARALAST NP 445ARANELLE 361ARANESP 234ARAVA 401ARAZLO 457ARCALYST 415ARCAPTA NEOHALER 231argatroban 80argatroban-0.9% nacl 80argatroban-sodium chloride 80ARICEPT 229ARIKAYCE 64ARIMIDEX 146aripiprazole 183aripiprazole odt 183ARISTADA 183ARISTADA INITIO 184ARISTOSPAN 354ARIXTRA 79
armodafinil 36ARMONAIR DIGIHALER 258ARMONAIR RESPICLICK 258ARMOUR THYROID 470ARNUITY ELLIPTA 258AROMASIN 146ARRANON 147arsenic trioxide 147ARTHROTEC 50 420ARTHROTEC 75 420ARYMO ER 8ARZERRA 147asa-butalb-caffeine-codeine 8ASACOL HD 340ASCENIV 208ASCOMP WITH CODEINE 8ascorbic acid 480ASHLYNA 362ASMANEX 258ASMANEX HFA 258ASPARLAS 147aspergillus fumigatus 206aspirin-dipyridamole er 477assure 4 263,301assure dose 263assure haemolance plus 263assure id duo-shield 263assure id insulin safety 263assure id pen needle 264assure lance 264assure lance plus 264assure platinum 264,301assure platinum test strip 301assure prism 264assure prism multi 264,301ASTAGRAF XL 411ATACAND 432ATACAND HCT 432atazanavir sulfate 203ATELVIA 395atenolol 246
atenolol-chlorthalidone 246ATGAM 411ATIVAN 226,227atomoxetine hcl 251atorvastatin calcium 135atovaquone 181atovaquone-proguanil hcl 180ATRALIN 453ATRIPLA 200atropine sulfate 337ATROVENT HFA 76AUBAGIO 406AUBRA 362AUBRA EQ 362AUGMENTIN 429AUGMENTIN ES-600 429AUGMENTIN XR 429aureobasidium pullulans 206AUROVELA 362AUROVELA 24 FE 362AUROVELA FE 362AURYXIA 388AUSTEDO 254auto-lancet mini 264autolet impression 264autolet lancing device 264autolet plus 264autoshield duo pen needle 264AUVI-Q 468AVAGE 458AVALIDE 432,433AVANDIA 109AVAPRO 433AVAR 454AVAR LS 454AVAR-E 454AVAR-E GREEN 454AVAR-E LS 454AVASTIN 147AVC 47AVEED 358
AVELOX 66AVELOX IV 66AVENOVA 264AVIANE 362AVIDOXY 67AVITA 453AVODART 392AVONEX 406AVONEX PEN 406AVSOLA 401AVYCAZ 256AXIRON 358AYGESTIN 379AYUNA 362AYVAKIT 147azacitidine 147AZACTAM 392AZACTAM-ISO-OSMOTIC DEXTROSE 392AZASAN 411AZASITE 38azathioprine 412azathioprine sodium 412azelaic acid 458azelastine hcl 335azelastine-fluticasone 335AZELEX 458AZILECT 179azithromycin 390azo 317AZOPT 121AZOR 241aztreonam 392AZULFIDINE 67AZURETTE 362
BB-12 COMPLIANCE 480BACIGUENT 38BACIIM 72bacitracin 38,72bacitracin-polymyxin 38
baclofen 450BACTRIM 67BACTRIM DS 67BACTROBAN 43BACTROBAN NASAL 38BAFIERTAM 407BAL IN OIL 352BALCOLTRA 362balsalazide disodium 340BALVERSA 147BALZIVA 362BANZEL 83BAQSIMI 128BARACLUDE 221BARHEMSYS 111BASAGLAR KWIKPEN U-100 383BAVENCIO 148BAXDELA 66bcg (tice strain) 148bcg vaccine (tice strain) 212bd microtainer lancets 264bd ultra-fine 264bd ultra-fine ii 264BECONASE AQ 49BEKYREE 362BELBUCA 26BELEODAQ 148belladonna-opium 8belladonna-phenobarbital 76BELSOMRA 223BELVIQ 29BELVIQ XR 29benazepril hcl 437benazepril-hydrochlorothiazide 437bendamustine hcl 148BENEFIX 124BENICAR 433BENICAR HCT 433BENLYSTA 412BENTYL 76BENZACLIN 43
BENZAMYCIN 43BENZEFOAM 454BENZEFOAM ULTRA 454BENZEPRO 454benzhydrocodone-acetaminophen 8benznidazole 181benzonatate 442benzoyl peroxide 455benzphetamine hcl 30benztropine mesylate 178BEOVU 336BEPREVE 335BERINERT 399BESER 56BESIVANCE 38BETADINE 42betamethasone acetate-sod phos 354betamethasone diprop augmented 56betamethasone dipropionate 56betamethasone sod phos-acetate 354betamethasone valerate 56BETAPACE 246BETAPACE AF 246BETASERON 407betaxolol hcl 120,246bethanechol chloride 229BETHKIS 64BETIMOL 120BETOPTIC S 120bevacizumab 336BEVESPI AEROSPHERE 76BEVYXXA 79bexarotene 148BEXSERO 212BEYAZ 362bicalutamide 148BICILLIN C-R 430BICILLIN L-A 430BICNU 148BIDIL 382BIJUVA 330
BIKTARVY 200BILTRICIDE 37bimatoprost 122BINOSTO 396BIORPHEN 469bisoprolol fumarate 246bisoprolol-hydrochlorothiazide 246bivalirudin 80bivalirudin-0.9% nacl 80BIVIGAM 208BLANCHE 261BLENREP 148bleomycin sulfate 148BLEPH-10 38BLEPHAMIDE 39BLEPHAMIDE S.O.P. 39BLINCYTO 148BLISOVI 24 FE 363BLISOVI FE 363blood glucose control 264blood glucose meter 264blood glucose monitoring 264blood glucose test strip 301blood lancets 264blood-glucose control 264blood-glucose meter 265BLOXIVERZ 229blunt needle 265BONIVA 396BONJESTA 112BOOSTRIX TDAP 211bortezomib 148bosentan 446BOSULIF 148,149BOTOX 415BOTOX COSMETIC 415botrytis cinerea 206BP 10-1 455BPO 455BRAFTOVI 149breeze 2 265,301
BREO ELLIPTA 258bretylium tosylate 64BREVIBLOC 246BREZTRI AEROSPHERE 354BRIELLYN 363BRILINTA 205brimonidine tartrate 120BRISDELLE 95BRIVIACT 83BROMFED DM 442bromfenac sodium 52bromocriptine mesylate 321brompheniramine-pseudoephed-dm 442BROMSITE 52BROVANA 232BRUKINSA 149BRYHALI 56budesonide 258budesonide ec 354budesonide er 354budesonide-formoterol fumarate 258,259buffered lidocaine 389bullseye mini safety lancets 265bumetanide 318BUNAVAIL 26BUPAP 5BUPHENYL 323BUPRENEX 26buprenorphine 26buprenorphine hcl 26buprenorphine-naloxone 26bupropion hcl 92bupropion hcl sr 92bupropion xl 92buspirone hcl 223busulfan 149BUSULFEX 149butalb-acetaminoph-caff-codein 9butalbital compound-codeine 9butalbital-acetaminophen 5,6butalbital-acetaminophen-caffe 6
butalbital-aspirin-caffeine 427butorphanol tartrate 27BUTRANS 27BYDUREON 105BYDUREON BCISE 105BYDUREON PEN 105BYETTA 105BYNFEZIA 466BYSTOLIC 247BYVALSON 247
Ccabergoline 321CABLIVI 205CABOMETYX 149CADEAU DHA 478CADUET 135CAFERGOT 4caffeine citrate 33CALAN 236CALAN SR 236calcipotriene 458calcipotriene-betamethasone dp 458calcitonin-salmon 427CALCITRENE 458calcitriol 458,480calcium acetate 388calcium disodium versenate 352calcium gluconate-0.9% nacl 325calcium gluconate-nacl 325CALDOLOR 420CALQUENCE 149CAMBIA 421CAMILA 363CAMPATH 149CAMPTOSAR 149CAMRESE 363CAMRESE LO 363CANASA 340CANCIDAS 115candesartan cilexetil 433
candesartan-hydrochlorothiazid 433CAPASTAT SULFATE 144capecitabine 149CAPEX SHAMPOO 56CAPLYTA 184CAPRELSA 150captopril 437captopril-hydrochlorothiazide 438CARAC 150CARAFATE 216CARBAGLU 323carbamazepine 83carbamazepine er 83CARBATROL 83carbidopa 251carbidopa-levodopa 179carbidopa-levodopa er 179carbidopa-levodopa-entacapone 179carbinoxamine maleate 338carboplatin 150carboprost tromethamine 427CARDENE I.V. 242CARDIZEM 236CARDIZEM CD 236CARDIZEM LA 237CARDURA 246CARDURA XL 246carefine pen needle 265carelance ult lancing device 265careone 265caresens 265caresens n 265,301caresens n voice 265caresens prem lancing device 265caretouch glucose monitoring 265caretouch insulin syringe 265caretouch lancing device 265caretouch pen needle 265caretouch safety lancets 265caretouch test strip 301caretouch twist lancet 265
carisoprodol 448carisoprodol compound 448carisoprodol-aspirin 448carisoprodol-aspirin-codeine 448carmustine 150CARNITOR 415CARNITOR SF 415CAROSPIR 440carteolol hcl 120CARTIA XT 237carvedilol 247carvedilol er 247CASODEX 150caspofungin acetate 115CATAPRES 381CATAPRES-TTS 1 381CATAPRES-TTS 2 381CATAPRES-TTS 3 381CATHFLO ACTIVASE 206CAVERJECT 473,477CAYSTON 392CAZIANT 363cefaclor 255cefaclor er 255cefadroxil 255cefazolin sodium 255cefazolin sodium-0.9% nacl 255cefazolin sodium-d5w 255cefazolin sodium-dextrose 255cefazolin sodium-sterile water 255cefazolin-d5w 255cefdinir 256cefditoren pivoxil 256cefepime 257cefepime hcl 257cefepime-dextrose 257cefixime 256CEFOTAN 391cefotaxime sodium 256cefotetan 391cefotetan & dextrose 391
cefoxitin 392cefoxitin sodium 392cefpodoxime proxetil 256cefprozil 255ceftazidime 256ceftriaxone 256cefuroxime 256cefuroxime sodium 256CELEBREX 420celecoxib 420CELESTONE 354CELEXA 95CELLCEPT 412CELONTIN 92CENTANY 43cephalexin 255CEQUA 51CERDELGA 415CEREBYX 91CERETEC 317CEREZYME 327CESAMET 111CETACAINE 450cetirizine hcl 127CETRAXAL 39CETROTIDE 347cevimeline hcl 229CHANTIX 229CHARLOTTE 24 FE 363CHATEAL 363CHATEAL EQ 363chek-stix 317CHEMET 352chemstrip 317chemstrip 10 with sg 317chemstrip 2 gp 317chemstrip 2 ln 472chemstrip 50b 318chemstrip 7 318chemstrip 9 318chemstrip bg diary 265
chemstrip micral 473CHENODAL 343chloramphenicol sod succinate 66chlordiazepoxide hcl 227chlordiazepoxide-amitriptyline 99chlordiazepoxide-clidinium 76chlorhexidine gluconate 42chloroquine phosphate 180chlorothiazide 320chlorothiazide sodium 320chlorpromazine hcl 197chlorpropamide 108chlorthalidone 320chlorzoxazone 448choicedm clarus 265choicedm clarus control soln 266choicedm clarus test strips 302CHOLBAM 343,344cholestyramine 130cholestyramine light 130choline mag trisalicylate 427chorionic gonadotropin 348CIALIS 475CICLODAN 119ciclopirox 119cidofovir 221cilostazol 205CILOXAN 39CIMDUO 200cimetidine 215CIMZIA 401cinacalcet hcl 427CINRYZE 399CINVANTI 113CIPRO 66CIPRO HC 39CIPRODEX 39ciprofloxacin 66ciprofloxacin er 66ciprofloxacin hcl 39,66ciprofloxacin hcl-fluocinolone 39
ciprofloxacin-d5w 66ciprofloxacin-dexamethasone 39cisplatin 150citalopram hbr 95citrus bioflavonoids 415cladosporium cladosporioides 206cladribine 150CLAFORAN 256CLARAVIS 458CLARINEX 127CLARINEX-D 12 HOUR 127clarithromycin 390clarithromycin er 390CLEANSING WASH 47clemastine fumarate 338CLENPIQ 342CLEOCIN 43CLEOCIN HCL 73CLEOCIN PEDIATRIC 73CLEOCIN PHOSPHATE 73,74CLEOCIN T 43clever chek blood glucose syst 266clever chek lancets 266clever choice 266clever choice blood gluc sys 266clever choice control solution 266clever choice hd glucose syst 266clever choice micro 266clever choice micro test strip 302clever choice pro 266,302clever choice talk 266,302clever choice test strips 302clever choice voice+ tst strip 302CLEVIPREX 242clickfine 266CLIMARA 330CLIMARA PRO 330CLINDACIN ETZ 43CLINDACIN P 43CLINDAGEL 43clindamycin (pediatric) 74
clindamycin hcl 74clindamycin phos-benzoyl perox 43,44clindamycin phos-tretinoin 44clindamycin phosphate 44,74clindamycin phosphate-d5w 74clindamycin-0.9% nacl 74clindamycin-benzoyl peroxide 44CLINDESSE 44CLINOLIPID 323clobazam 90clobetasol emollient 56clobetasol emulsion 56clobetasol propionate 56CLOBEX 56clocortolone pivalate 56CLODAN 56CLODERM 56clofarabine 150CLOLAR 150clomiphene citrate 329clomipramine hcl 99clonazepam 90clonidine 381clonidine hcl 6,381clonidine hcl er 381clopidogrel 205clorazepate dipotassium 227clotrimazole 117clotrimazole-betamethasone 117clozapine 184clozapine odt 184CLOZARIL 185COAGADEX 124coaguchek 266COARTEM 180codeine sulfate 9codeine-guaifenesin 442COGENTIN 178COLAZAL 340colchicine 394COLCRYS 394
colesevelam hcl 130COLESTID 130,131colestipol hcl 131colistimethate 75COLOCORT 56color lancets 266COLY-MYCIN M PARENTERAL 75COLY-MYCIN S 39COLYTE WITH FLAVOR PACKETS 342COMBIGAN 120COMBIPATCH 330combistix reagent 318COMBIVENT RESPIMAT 76COMBIVIR 201COMETRIQ 150,151comfort ez 266comfort ez pen needle 266comfort lancets 266COMPAZINE 112COMPLERA 201COMPRO 112COMTAN 178CONCERTA 33CONDYLOX 458CONEX 339CONJUPRI 242CONRAY-43 317CONSENSI 242CONSTULOSE 323contour 266contour next 267contour next control solution 267contour next ez 267contour next link 267contour next link 2.4 267contour next one 267contour next test strip 302contour test strip 302CONTRAVE 29control ast 267control solution 267
CONZIP 9cool blood glucose 267cool blood glucose meter 267cool control solution 267cool glucose test strip 302COPAXONE 407COPIKTRA 151CORDRAN 56,57COREG 247COREG CR 247COREMINO 67,68CORGARD 248CORICIDIN HBP COLD AND FLU 6CORICIDIN HBP COUGH AND COLD 442CORIFACT 124CORLANOR 244CORLOPAM 382CORMAX 57CORTEF 354CORTENEMA 57CORTIFOAM 57cortisone acetate 354CORTISPORIN 44CORTROSYN 299CORVERT 64CORZIDE 248COSENTYX (2 SYRINGES) 458COSENTYX PEN 458COSENTYX PEN (2 PENS) 458COSENTYX SYRINGE 459COSMEGEN 151COSOPT 121COSOPT PF 121cosyntropin 299COTELLIC 151COTEMPLA XR-ODT 33COUMADIN 79COZAAR 433CREON 343CRESEMBA 114CRESTOR 135
CRINONE 379CRIXIVAN 203cromolyn sodium 54,55CROTAN 48CRYSELLE 363CUBICIN 72CUBICIN RF 72CUPRIMINE 353CUROSURF 445CUTAQUIG 208CUTIVATE 57CUVITRU 208CUVPOSA 76cyanocobalamin injection 480CYCLAFEM 363CYCLINEX-1 323cyclobenzaprine hcl 448,449cyclobenzaprine hcl er 449cyclophosphamide 151cycloserine 144CYCLOSET 321cyclosporine 412cyclosporine modified 412CYMBALTA 93,94cyproheptadine hcl 338CYRAMZA 151CYRED 364CYRED EQ 364CYSTADANE 416CYSTADROPS 336CYSTAGON 416CYSTARAN 336cytarabine 151CYTOGAM 208CYTOMEL 470CYTOTEC 216CYTOVENE 221CYTRA-K 322
DD-PENAMINE 353
D.H.E.45 4dacarbazine 151DACOGEN 151dactinomycin 151DAKLINZA 352dalfampridine er 416DALIRESP 445danazol 358DANTRIUM 450dantrolene sodium 450dapsone 143,459DAPTACEL DTAP 211daptomycin 72darifenacin er 346dario blood glucose test strip 302DARZALEX 152DARZALEX FASPRO 152DASETTA 364daunorubicin hcl 152DAURISMO 152DAYPRO 421DAYSEE 364DAYTRANA 33DAYVIGO 223DDAVP 378DEBACTEROL 459DEBLITANE 364DECADRON 354decitabine 152deferasirox 353deferiprone 353deferoxamine mesylate 353DELESTROGEN 331DELFLEX-2.5% DEXTROSE 325DELSTRIGO 199DELZICOL 340DEMADEX 318demeclocycline hcl 68DEMEROL 9DEMSER 416DENAVIR 47
DENTA 5000 PLUS 398DENTAGEL 398DEPACON 83DEPAKENE 83DEPAKOTE 83DEPAKOTE ER 84DEPAKOTE SPRINKLE 84DEPEN 353DEPO-ESTRADIOL 331DEPO-MEDROL 355DEPO-PROVERA 379DEPO-SUBQ PROVERA 104 379DEPO-TESTOSTERONE 359DERMA-SMOOTHE-FS 57DERMATOP 57DERMOTIC 49DESCOVY 201DESFERAL 353DESFERAL MESYLATE 353desipramine hcl 99desloratadine 127desmopressin acetate 378desogestr-eth estrad eth estra 364desogestrel-ethinyl estradiol 364DESONATE 57desonide 57DESOWEN 57desoximetasone 57,58DESOXYN 30desvenlafaxine er 94desvenlafaxine succinate er 94DETROL 346DETROL LA 346DEXABLISS 355dexamethasone 355dexamethasone acetate la 355dexamethasone acetate-sod phos 355DEXAMETHASONE INTENSOL 355dexamethasone sodium phosphate 49,355dexamethasone-0.9% nacl 355dexchlorpheniramine maleate 339
dexcom 267dexcom g4 267dexcom g5 267dexcom g5-g4 sensor 267dexcom g6 267DEXEDRINE 31DEXILANT 217dexmedetomidine hcl 224dexmethylphenidate hcl 33dexmethylphenidate hcl er 33DEXPAK 355dexrazoxane 419dexrazoxane diluent-sodium lac 430dextroamphetamine sulfate 31dextroamphetamine sulfate er 31dextroamphetamine-amphet er 31dextroamphetamine-amphetamine 31dextrose 5%-0.2% nacl-kcl 325dextrose 5%-0.225% nacl-kcl 325dextrose 5%-0.3% nacl-kcl 325dextrose 5%-0.45% nacl-kcl 325dextrose 5%-1/2ns-kcl 325dextrose 5%-1/4ns-kcl 325dextrose 5%-ns-kcl 325dextrose 5%-potassium chloride 325DIACOMIT 84DIASTAT 227DIASTAT ACUDIAL 227diastix reagent 473diatrue 267diatrue plus 268,303diazepam 227diazoxide 128DIBENZYLINE 4DICLEGIS 112diclofenac 421diclofenac epolamine 421diclofenac potassium 421diclofenac sodium 52,152,421diclofenac sodium er 421diclofenac sodium-misoprostol 421
dicloxacillin sodium 430dicyclomine hcl 76didanosine 201diethylpropion hcl 28diethylpropion hcl er 28DIFFERIN 459DIFICID 390diflorasone diacetate 58DIFLUCAN 114diflunisal 421DIGITEK 245DIGOX 245digoxin 245dihydroergotamine mesylate 4DILANTIN 91DILANTIN-125 91DILATRATE-SR 473DILAUDID 10DILT-XR 237diltiazem 12hr er 238diltiazem 24hr er 238diltiazem 24hr er (cd) 238diltiazem 24hr er (la) 238diltiazem 24hr er (xr) 238diltiazem hcl 239diltiazem hcl-0.7% nacl 239diltiazem hcl-0.9% nacl 239diltiazem-d5w 239diluent for decitabine 430DILUENT FOR ELITEK 431DILUENT FOR ISTODAX 431DILUENT FOR JEVTANA 431DILUENT FOR LEFAMULIN(XENLETA) 431dimenhydrinate 112DIOVAN 434DIOVAN HCT 434DIPENTUM 340diphenhydramine hcl 338diphenhydramine-0.9% nacl 338diphenoxylate-atropine 341diphtheria-tetanus toxoids-ped 211
DIPROLENE 58dipyridamole 477disopyramide phosphate 63disulfiram 393DITROPAN XL 346DIURIL 320divalproex sodium 84divalproex sodium er 84DIVIGEL 331DOCEFREZ 152docetaxel 152dofetilide 64DOJOLVI 323DOLOPHINE HCL 10donepezil hcl 229donepezil hcl odt 229DONNATAL 76DOPRAM 33DOPTELET 234DORAL 227doripenem 391DORYX 68DORYX MPC 68dorzolamide hcl 122dorzolamide-timolol 122DOTAREM 317DOTTI 331DOVATO 198DOVONEX 459doxapram hcl 33doxazosin mesylate 246doxepin hcl 99,450doxercalciferol 480,481DOXIL 152doxorubicin hcl 152doxorubicin hcl liposome 153DOXY 100 68doxycycline hyclate 39,68,69doxycycline ir-dr 69doxycycline monohydrate 69doxylamine succ-pyridoxine hcl 112
DRISDOL 481DRITHOCREME HP 457DRIZALMA SPRINKLE 94dronabinol 111droperidol 224droplet insulin syringe 268droplet lancets 268droplet lancing device 268droplet micron pen needle 268droplet pen needle 268dropsafe pen needle 268drospirenone-eth estra-levomef 364drospirenone-ethinyl estradiol 364DROXIA 153DRYSOL 452DSUVIA 10DUAC 44DUAKLIR PRESSAIR 76DUAVEE 331DUETACT 109DULERA 259duloxetine hcl 94DUOBRII 459DUODOTE 393DUOPA 179DUPIXENT PEN 459DUPIXENT SYRINGE 52,459DURACLON 6DURAGESIC 10DURAMORPH 10DUREZOL 49DURLAZA 427DUROLANE 268dutasteride 392dutasteride-tamsulosin 392DUTOPROL 248DVORAH 10DXEVO 355DYANAVEL XR 31DYAZIDE 319DYMISTA 335
DYRENIUM 319DYSPORT 416
Ee-z ject lancets 268e-zject lancets 268E.E.S. 200 390E.E.S. 400 390EAA 323easy comfort 268easy comfort insulin syringe 268easy comfort pen needle 268easy comfort pen needles 268easy glide pen needle 268easy gluco g2 303easy mini eject lancing device 268easy plus ii 268,269,303easy step 269,303easy step control solution 269easy talk 269,303easy touch 269easy touch control solution 269easy touch fliplock needles 269easy touch glucose monitor 269easy touch lancing device 269easy touch pen needle 269easy touch safety pen needle 269easy touch test strip 303easy trak 269,303easy trak ii control solution 269easy trak ii test strip 303easy twist & cap lancets 269easy-touch 270easygluco 270easygluco meter 270easygluco meter starter kit 270easygluco plus 303easygluco plus control normal 270easygluco test strips 304easymax 270,304easymax 15 270,304
easymax l 270easymax ng 270easymax v speaking 270easymax v2 270easypoint needle 270EC-NAPROSYN 421ec-naproxen 422eclipse needle 270econazole nitrate 117ECOZA 117ED-SPAZ 76EDARBI 434EDARBYCLOR 434EDECRIN 319EDEX 478EDLUAR 224EDURANT 199efavirenz 199EFFER-K 325EFFEXOR XR 94EFFIENT 205EFUDEX 153EGATEN 37EGRIFTA 467EGRIFTA SV 468ELAPRASE 327ELAVIL 99ELELYSO 327element compact 270,304element compact control soln 271element compact v 271element control solution 271element plus 271element test strips 304ELESTAT 335ELESTRIN 331eletriptan hbr 141ELIDEL 460ELIGARD 348ELIMITE 48ELINEST 364
ELIQUIS 79ELITEK 327ELIXOPHYLLIN 465ELLA 364ELLENCE 153ELMIRON 419ELOCON 58ELOCTATE 124ELURYNG 365ELZONRIS 153EMADINE 335embrace 271,304embrace evo 271,304embrace glucose control soln 271embrace pro 271embrace pro blood glucose mtr 271embrace pro test strip 304embrace talk 271embrace talk control solution 271embrace talk test strip 304EMCYT 153EMEND 113EMFLAZA 355EMGALITY PEN 140EMGALITY SYRINGE 140EMOQUETTE 365EMSAM 180emtricitabine 201emtricitabine-tenofovir disop 201EMTRIVA 201EMVERM 37ENABLEX 346enalapril maleate 438enalapril-hydrochlorothiazide 438enalaprilat 438ENBREL 401ENBREL MINI 401ENBREL SURECLICK 401ENDOCET 10,11ENDOMETRIN 379ENGERIX-B ADULT 212
ENGERIX-B PEDIATRIC-ADOLESCENT 212ENHERTU 153enlite 271enoxaparin sodium 80ENPRESSE 365ENSKYCE 365ENSPRYNG 407ENSTILAR 460entacapone 178entecavir 221enteral gravity bag set-enfit 271ENTEREG 344ENTOCORT EC 355ENTRESTO 434ENTYVIO 344ENULOSE 323ENVARSUS XR 413EPANED 438EPCLUSA 351epicoccum nigrum 206EPIDIOLEX 84EPIDUO 460EPIDUO FORTE 460EPIFOAM 58epinastine hcl 335epinephrine 468epinephrine hcl-0.9% nacl 468epinephrine hcl-d5w 468epinephrine-d5w 468EPINEPHRINESNAP-EMS 468EPINEPHRINESNAP-V 469EPIPEN 469EPIPEN 2-PAK 469EPIPEN JR 469EPIPEN JR 2-PAK 469epirubicin hcl 153EPISIL 271EPITOL 84EPIVIR 201EPIVIR HBV 201eplerenone 441
EPOGEN 234epoprostenol sodium 446eprosartan mesylate 434eptifibatide 205EPZICOM 201EQUETRO 84ERAXIS (WATER DILUENT) 115ERBITUX 153ergoloid mesylates 4ERGOMAR 4ergotamine-caffeine 4ERIVEDGE 153ERLEADA 153erlotinib hcl 153ERRIN 365ERTACZO 117ERWINAZE 153ERY 44ERY-TAB 390ERYGEL 44ERYPED 200 390ERYPED 400 390ERYTHROCIN LACTOBIONATE 390ERYTHROCIN STEARATE 390erythromycin 39,45,390erythromycin ethylsuccinate 390erythromycin-benzoyl peroxide 45ESBRIET 441escitalopram oxalate 95ESGIC 6esmolol hcl 248esmolol hcl-sodium chloride 248esomeprazole magnesium 217esomeprazole sodium 217esomeprazole strontium 217ESPEROCT 124ESTARYLLA 365estazolam 227ESTRACE 331estradiol 331,332estradiol (once weekly) 332
estradiol (twice weekly) 332estradiol valerate 332estradiol-norethindrone acetat 332ESTRING 332ESTROGEL 332estrogen-methyltestosterone 359ESTROSTEP FE 365eszopiclone 224ethacrynic acid 319ethambutol hcl 144ethosuximide 92ethyl chloride 451ethynodiol-ethinyl estradiol 365ETHYOL 419etidronate disodium 396etodolac 422etodolac er 422etonogestrel-ethinyl estradiol 365ETOPOPHOS 154etoposide 154eucalyptol 431EUCRISA 55EUFLEXXA 271EURAX 48EUTHYROX 470EVAMIST 332EVEKEO 31EVEKEO ODT 31,32evencare 272,305evencare g2 272,305evencare g3 272,305evencare mini glucose control 272evencare mini glucose test str 305evencare mini monitor system 272evencare proview control soln 272evencare proview test strip 305EVENITY 395EVENITY (2 SYRINGES) 395everolimus 154,413eversense sensor-holder 272EVISTA 329
EVOCLIN 45evolution blood glucose meter 272evolution control solution 272evolution test strips 305EVOMELA 154EVOTAZ 203EVOXAC 229EVRYSDI 416EXALGO 11exel hypodermic needle 272exel mti drawing needle 272EXELDERM 117EXELON 230exemestane 154EXFORGE 242EXFORGE HCT 242EXJADE 353EXTAVIA 407EXTINA 117EYLEA 336ez smart 272,305ez smart lancets 272ez smart plus 272,305ez-lets 273ez-vac 273EZALLOR SPRINKLE 135ezetimibe 132ezetimibe-simvastatin 132
FFABIOR 460FABRAZYME 327FACTIVE 66FALMINA 365famciclovir 221famotidine 215famotidine-0.9% nacl 216FANAPT 185FARESTON 329FARXIGA 106FARYDAK 154
FASENRA 53FASENRA PEN 53FASLODEX 154FAYOSIM 365FAZACLO 185febuxostat 394FEIBA NF 124felbamate 84FELBATOL 84FELDENE 422felodipine er 242FEM PH 47FEMARA 154FEMHRT 332FEMRING 332FEMYNOR 365fenofibrate 132,133fenofibric acid 133FENOGLIDE 133fenoprofen calcium 422FENORTHO 422fentanyl 11fentanyl citrate 11fentanyl citrate-0.9% nacl 11,12fentanyl-bupivacaine-0.9% nacl 12FENTORA 12FERAHEME 62FERRIPROX 353FERRIPROX (2 TIMES A DAY) 353FERRLECIT 62FETROJA 257FETZIMA 94FEXMID 449FIASP 385FIASP FLEXTOUCH 385FIASP PENFILL 385FIBRICOR 133fifty50 safety seal lancets 273fifty50 test strip 305filter aspirator needle 273filter needle 273
FINACEA 460finasteride 392,460fine 30 universal lancets 273fingerstix 273FINTEPLA 84FIORICET 6FIORINAL 427FIORINAL WITH CODEINE #3 12FIRAZYR 399FIRDAPSE 416FIRMAGON 347FIRVANQ 72FLAC OTIC OIL 49FLAGYL 181FLAREX 49flavoxate hcl 346FLEBOGAMMA DIF 208flecainide acetate 63FLECTOR 422FLOLAN 446FLOLIPID 135,136FLOMAX 5FLOVENT DISKUS 259FLOVENT HFA 259floxuridine 154FLUAD 2019-2020 212FLUAD 2020-2021 212FLUAD QUAD 2020-2021 212FLUARIX QUAD 2019-2020 212FLUARIX QUAD 2020-2021 212FLUBLOK QUAD 2019-2020 212FLUBLOK QUAD 2020-2021 212FLUCELVAX QUAD 2019-2020 212FLUCELVAX QUAD 2020-2021 212fluconazole 114fluconazole in saline 114fluconazole-nacl 114flucytosine 116fludarabine phosphate 154fludrocortisone acetate 355FLULAVAL QUAD 2019-2020 212
FLULAVAL QUAD 2020-2021 213FLUMADINE 219flumazenil 251FLUMIST QUAD 2019-2020 213FLUMIST QUAD 2020-2021 213flunisolide 49fluocinolone acetonide 58fluocinolone acetonide oil 49fluocinonide 58fluocinonide-e 58fluoride 398FLUORITAB 398fluorometholone 49FLUOROPLEX 155fluorouracil 155fluoxetine dr 95fluoxetine hcl 95,96fluphenazine decanoate 197fluphenazine hcl 197FLURA-DROPS 398flurandrenolide 58flurazepam hcl 227flurbiprofen 422flurbiprofen sodium 52flutamide 155fluticasone propionate 49,58,59fluticasone-salmeterol 259fluvastatin er 136fluvastatin sodium 136fluvoxamine maleate 96fluvoxamine maleate er 96FLUZONE HIGH-DOSE 2019-2020 213FLUZONE HIGH-DOSE QUAD 2020-21 213FLUZONE QUAD 2019-2020 213FLUZONE QUAD 2020-2021 213FLUZONE QUAD PEDI 2019-2020 213FML 49FML FORTE 49FML S.O.P. 49FOCALIN 33,34FOCALIN XR 34
folic acid 480FOLLISTIM AQ 348FOLOTYN 155fondaparinux sodium 79fora 6 connect glucose strip 306fora control solution 273fora d10 273fora d15 glucose-bp monitor 273fora d15g 306fora d20 273,306fora d40-g31 test strips 306fora d40d glucose-bp monitor 273fora d40g glucose-bp monitor 273fora g20 273,306fora g30-premium v10 test strp 306fora g30a 273fora gd50 273fora gd50 test strips 306fora gtel glucose test strip 306fora lancets 274fora lancing device 274fora premium v10 274fora test n'go voice 274fora test strip 306fora tn'g voice 274fora tn'g voice test strips 307fora v10 274,307fora v10-v12-d10-d20 274,307fora v12 274,307fora v20 274,307fora v30a 274,307foracare gd20 274,307foracare gd40 307foracare gd40a 274foracare gd40b 274foracare gdh 274foracare lancets 274FORFIVO XL 92FORMADON 460FORTAZ 256FORTEO 428
FORTESTA 359fortiscare 275fortiscare blood glucose syst 275fortiscare glucose test strips 307FOSAMAX 396FOSAMAX PLUS D 396fosamprenavir calcium 204fosaprepitant dimeglumine 113FOSCAVIR 219fosfomycin tromethamine 37fosinopril sodium 438fosinopril-hydrochlorothiazide 438fosphenytoin sodium 91FOSRENOL 388FRAGMIN 81freestyle control solution 275freestyle flash system 275freestyle freedom 275freestyle freedom lite 275freestyle insulinx 275,308freestyle insulinx test strips 308freestyle lancets 275freestyle libre 10 day reader 275freestyle libre 10 day sensor 275freestyle libre 14 day reader 275freestyle libre 14 day sensor 275freestyle libre 2 reader 275freestyle libre 2 sensor 275freestyle lite meter 275freestyle lite test strip 308freestyle navigator 275freestyle precision neo 308freestyle precision neo meter 276freestyle sidekick ii 276freestyle system 276freestyle test strips 308freestyle unistik 2 276FROVA 141frovatriptan succinate 141FULPHILA 234fulvestrant 155
FURADANTIN 37furosemide 319FUSILEV 393FUZEON 198FYAVOLV 333FYCOMPA 84
Ggabapentin 84,85GABITRIL 85GALAFOLD 416galantamine er 230galantamine hbr 230galantamine hydrobromide 230GALZIN 353GAMASTAN 208GAMASTAN S-D 208GAMIFANT 413GAMMAGARD LIQUID 208GAMMAGARD S-D 209GAMMAKED 209GAMMAPLEX 209GAMUNEX-C 209ganciclovir 221ganciclovir sodium 221ganirelix acetate 347GARDASIL 9 213GASTROCROM 55gatifloxacin 39GATTEX 344GAVILYTE-C 342GAVILYTE-G 342GAVILYTE-N 342GAVRETO 155GAZYVA 155gdrive 276ge100 blood glucose system 276ge100 blood glucose test strip 308ge100 control solution normal 276GEL-ONE 276GELNIQUE 346
gemcitabine hcl 155gemfibrozil 133GEMMILY 365GEMZAR 155GENERESS FE 366GENERLAC 323GENGRAF 413genstrip 308GENTAK 39gentamicin sulfate 39,45,65gentamicin sulfate in ns 65gentamicin-sodium citrate 65genteel vacuum lancing device 276genultimate test strip 308GENVISC 850 276GENVOYA 201GEODON 186GIANVI 366GILENYA 407,408GILOTRIF 155GILPHEX TR 444GILTUSS TR 444GIMOTI 345GLASSIA 445glatiramer acetate 408GLATOPA 408GLEEVEC 156GLEOSTINE 156GLIADEL 156glimepiride 108glipizide 108glipizide er 108glipizide xl 108glipizide-metformin 108GLOPERBA 394GLUCAGEN 128GLUCAGON EMERGENCY KIT 128gluco navii 276,308glucocard 01 276glucocard 01 control 276glucocard 01 sensor plus 309
glucocard expression 276,277,309glucocard shine 277,309glucocard shine connex meter 277glucocard shine express meter 277glucocard shine xl 277glucocard vital 277,309glucocard vital sensor 309glucocom 277glucocom blood glucose 277glucocom control solution 277glucocom glucose 309glucocom lancets 277GLUCOPHAGE 101GLUCOPHAGE XR 102glucose control 277glucose control solution 277glucose test strip 309GLUCOTROL 108GLUCOTROL XL 108glyburide 108glyburide micronized 108glyburide-metformin hcl 108GLYCATE 76glycopyrrolate 76glycopyrrolate-water 76GLYCOSADE 324GLYNASE 108GLYRX-PF 76GLYSET 100GLYTACTIN 10 PE COMPLETE 324GLYTACTIN 15 PE BETTERMILK 324GLYTACTIN 15 PE COMPLETE 324GLYTACTIN 20PE BETTERMILK LITE 324GLYTACTIN BUILD 10 PE 324GLYTACTIN BUILD 20-20 324GLYTACTIN BURST 10-10 324GLYTACTIN BURST 20-20 324GLYTACTIN RESTORE 10 PE 324GLYTACTIN RESTORE 10 PE LITE 324GLYTACTIN RESTORE 5 PE 324GLYTACTIN RTD 10 PE 324
GLYTACTIN RTD 15 PE 324GLYTACTIN RTD LITE 15 324GLYTACTIN SWIRL 15 PE 324GLYXAMBI 106GOCOVRI 177,178gojji blood glucose test strip 309gojji glucose control solution 277gojji lancet-glucose test strp 277gojji lancets 277gojji lancing device 277gojji multi-functional meter 277GOLYTELY 342GONAL-F 348GONAL-F RFF 348GONAL-F RFF REDI-JECT 348GONITRO 473goodlife ac-302 glucose meter 278goodlife ac-302 test strip 309GOODY'S EXTRA STRENGTH 427GRALISE 6granisetron hcl 110GRANIX 234GRASTEK 206griseofulvin 114griseofulvin ultramicrosize 114guaifenesin-codeine 442guanfacine hcl 381guanfacine hcl er 252guanidine hcl 230GVOKE HYPOPEN 1-PACK 128GVOKE HYPOPEN 2-PACK 128GVOKE PFS 1-PACK SYRINGE 128GVOKE PFS 2-PACK SYRINGE 128GYNAZOLE 1 117
HHAEGARDA 399HAILEY 366HAILEY 24 FE 366HAILEY FE 366HALAVEN 156
halcinonide 59HALCION 227HALDOL 197HALDOL DECANOATE 100 197HALDOL DECANOATE 50 197halobetasol propionate 59HALOG 59haloperidol 197haloperidol decanoate 197haloperidol decanoate 100 197haloperidol lactate 197harmony control solution 278harmony glucose test strip 310HARVONI 351HAVRIX 213HCY 1 324healthpro glucose control soln 278healthpro glucose monitor 278healthpro glucose test strips 310healthwise pen needle 278healthy accents autolet 278healthy accents unifine pentip 278healthy accents unilet lancet 278HEATHER 366HECTOROL 481HELIDAC 74HELIXATE FS 124hema-combistix 318HEMADY 356HEMANGEOL 248HEMLIBRA 124HEMOFIL M 124HEPAGAM B 209heparin flush 81heparin lock 81heparin sodium 81heparin sodium in 0.45% nacl 81heparin sodium-0.45% nacl 81,82heparin sodium-0.9% nacl 82heparin sodium-d5w 82HEPLISAV-B 213
HEPSERA 221HERCEPTIN 156HERCEPTIN HYLECTA 156HETLIOZ 224HIBERIX 213HICON 431HIDEX 356HIPREX 37HIZENTRA 209HOMATROPAIRE 337homatropine hydrobromide 337HOMINEX-1 324HORIZANT 85HPR PLUS 278HUMALOG 385HUMALOG JUNIOR KWIKPEN 385HUMALOG KWIKPEN U-100 385HUMALOG KWIKPEN U-200 385HUMALOG MIX 50-50 385HUMALOG MIX 50-50 KWIKPEN 385HUMALOG MIX 75-25 385HUMALOG MIX 75-25 KWIKPEN 386HUMATE-P 124HUMIRA 401,402HUMIRA PEDIATRIC CROHN'S 402HUMIRA PEN 402HUMIRA PEN CROHN'S-UC-HS 402HUMIRA PEN PSOR-UVEITS-ADOL HS 402HUMIRA(CF) 402HUMIRA(CF) PEDIATRIC CROHN'S 344,403HUMIRA(CF) PEN 403HUMIRA(CF) PEN CROHN'S-UC-HS 403HUMIRA(CF) PEN PSOR-UV-ADOL HS 403HUMULIN 70-30 382HUMULIN 70/30 KWIKPEN 382HUMULIN N 383HUMULIN N KWIKPEN 383HUMULIN R 387HUMULIN R U-500 387HUMULIN R U-500 KWIKPEN 387HYALGAN 278
HYCAMTIN 156HYCLODEX 278hydralazine hcl 382HYDREA 156hydrochlorothiazide 320HYDROCIL INSTANT 342hydrocod-cpm-pseudoephedrine 442hydrocodone bitartrate er 12hydrocodone er 10 mg capsule (persion-macoven) 12hydrocodone er 15 mg capsule (persion-macoven) 12hydrocodone er 30 mg capsule (persion-macoven) 12hydrocodone er 40 mg capsule (persion-macoven) 13hydrocodone er 50 mg capsule (persion-macoven) 13hydrocodone-acetaminophen 13hydrocodone-chlorpheniramne er 442hydrocodone-guaifenesin 442hydrocodone-homatropine mbr 442hydrocodone-ibuprofen 13,14hydrocortisone 59,356hydrocortisone acetate 59hydrocortisone butyrate 59hydrocortisone valerate 59hydrocortisone-acetic acid 42hydrocortisone-iodoquinol 47hydrocortisone-pramoxine 59HYDROMET 443hydromorph-bupivac-0.9% nacl 14hydromorph-ropiva-0.9% nacl 14hydromorphone er 14hydromorphone hcl 14,15hydromorphone hcl-0.9% nacl 15,16hydroquinone 261hydroxocobalamin 480hydroxychloroquine sulfate 180hydroxyprogesterone caproate 379hydroxyurea 156
hydroxyzine hcl 224hydroxyzine pamoate 224HYLATOPICPLUS 278HYLENEX 328HYMOVIS 278hyoscyamine sulfate 77hyoscyamine sulfate er 77hyoscyamine sulfate sr 77HYOSYNE 77HYPERHEP B S-D 209HYPERRAB 209HYPERRAB S-D 209HYPERRHO S-D 209HYPERTET S-D 209hypodermic needle 279hypolance 279HYQVIA 209HYQVIA HY COMPONENT 328HYQVIA IG COMPONENT 210HYSINGLA ER 16HYZAAR 434,435
Iibandronate sodium 396IBRANCE 157IBU 422IBUDONE 16ibuprofen 422ibuprofen lysine 422ibutilide fumarate 64icatibant 399ICLUSIG 157ictotest 318IDAMYCIN PFS 157idarubicin hcl 157IDELVION 125IDHIFA 157IFEX 157ifosfamide 158ifosfamide-mesna 158iglucose blood glucose monitor 279
iglucose test strip 310ILARIS 416ILEVRO 52ILUVIEN 49imatinib mesylate 158IMBRUVICA 158IMFINZI 159imipenem-cilastatin sodium 391imipramine hcl 99imipramine pamoate 99imiquimod 460IMITREX 141IMOGAM RABIES-HT 210IMOVAX RABIES VACCINE 213IMPAVIDO 181IMPOYZ 59IMURAN 413IMVEXXY 333INBRIJA 179INCASSIA 366incontrol lancing device 279incontrol pen needle 279incontrol super thin lancets 279incontrol ultra thin lancets 279INCRELEX 468INCRUSE ELLIPTA 77indapamide 320INDERAL LA 248INDERAL XL 248INDOCIN 422indomethacin 423indomethacin er 423INFANRIX DTAP 211INFASURF 445INFED 62infinity 279infinity control solution 279infinity test strips 310infinity voice control soln 279infinity voice glucose monitor 279infinity voice test strip 310
INFLECTRA 403INFUVITE PEDIATRIC 478INGREZZA 254INGREZZA INITIATION PACK 254inject ease lancets 279INJECTAFER 62INLYTA 159INNOPRAN XL 248INQOVI 159INREBIC 159INSPRA 441insul-cap 279insul-eze 279insulin aspart 386insulin aspart flexpen 386insulin aspart penfill 386insulin aspart prot-insuln asp 386insulin lispro 386insulin lispro junior kwikpen 386insulin lispro kwikpen u-100 386insulin lispro protamine mix 386insulin pen needle 279insupen 280integra precisionglide needle 280INTEGRILIN 205INTELENCE 199INTERMEZZO 224INTRAROSA 356INTRON A 219INTROVALE 366INTUNIV 252invacare lancets 280INVANZ 391INVEGA 186INVEGA SUSTENNA 186,187INVEGA TRINZA 187,188INVELTYS 49INVIRASE 204INVOKAMET 106INVOKAMET XR 106INVOKANA 107
iodine 47IODOFLEX 48IODOSORB 48IOPIDINE 336IPOL 213ipratropium bromide 77,336ipratropium-albuterol 77irbesartan 435irbesartan-hydrochlorothiazide 435IRESSA 159irinotecan hcl 159IRO-PLEX 62ISENTRESS 198ISENTRESS HD 198ISIBLOOM 366ISOCHRON 473isoniazid 144ISOPTO CARPINE 122ISORDIL 473ISORDIL TITRADOSE 473isosorbide dinitrate 473isosorbide dinitrate er 473isosorbide mononitrate 474isosorbide mononitrate er 474isotretinoin 460isoxsuprine hcl 478isradipine 242ISTALOL 120ISTODAX 159ISTURISA 417itraconazole 114iv sol stabilizer for blincyto 454ivermectin 37,460IXEMPRA 159IXIARO 213IXINITY 125
JJADENU 353JADENU SPRINKLE 353JAIMIESS 366
JAKAFI 159JALYN 392JANTOVEN 79JANUMET 103JANUMET XR 103JANUVIA 103JARDIANCE 107JASMIEL 366JATENZO 359jazz wireless 2 280JELMYTO 159JENCYCLA 366JENTADUETO 103JENTADUETO XR 103,104JEUVEAU 417JEVANTIQUE LO 333JEVTANA 160JINTELI 333JIVI 125JOLESSA 367JOLIVETTE 367JORNAY PM 34JUBLIA 117JULEBER 367JULUCA 198JUNEL 367JUNEL FE 367JUNEL FE 24 367JUXTAPID 128JYNARQUE 321
KK EFFERVESCENT 325K-PHOS ORIGINAL 322K-TAB ER 325KADCYLA 160KADIAN 16KAITLIB FE 367KALBITOR 399KALETRA 204KALLIGA 367
KALYDECO 260KANJINTI 160KAPSPARGO SPRINKLE 248KAPVAY 381KARBINAL ER 338KARIVA 367KATERZIA 242KAZANO 104KCENTRA 125KEDRAB 210KEFLEX 255KELNOR 1-35 367KELNOR 1-50 367KENALOG 59KENALOG-10 356KENALOG-40 356KENALOG-80 356KENGREAL 205KEPIVANCE 453KEPPRA 85KEPPRA XR 85KERYDIN 119KESIMPTA PEN 408keto-diastix reagent 318ketoconazole 114,117,118ketone care test strip 472ketone test strip 472ketoprofen 423ketorolac tromethamine 52,423ketostix reagent 472ketotifen fumarate 335KEVEYIS 397KEVZARA 404KEYTRUDA 160KHAPZORY 393KHEDEZLA 94KINERET 404KINRIX 213KIONEX 389KISQALI 160KISQALI FEMARA CO-PACK 161
KITABIS PAK 65KLARON 48KLONOPIN 91KLOR-CON 325KLOR-CON 10 325KLOR-CON 8 325KLOR-CON M10 325KLOR-CON M15 326KLOR-CON M20 326KLOR-CON-EF 326KOATE 125KOGENATE FS 125KOMBIGLYZE XR 104KONSYL 342KORLYM 101KOSELUGO 161KOVALTRY 125KRINTAFEL 180KRISTALOSE 323KRYSTEXXA 394KURVELO 367KUVAN 417KYLEENA 367KYNMOBI 322KYPROLIS 161
Llabetalol hcl 248,249labetalol hcl-d5w 249labstix reagent 318lactulose 323LAMICTAL 85LAMICTAL (BLUE) 85LAMICTAL (GREEN) 85LAMICTAL (ORANGE) 85LAMICTAL ODT 85LAMICTAL ODT (BLUE) 86LAMICTAL ODT (GREEN) 86LAMICTAL ODT (ORANGE) 86LAMICTAL XR 86LAMICTAL XR (BLUE) 86
LAMICTAL XR (GREEN) 86LAMICTAL XR (ORANGE) 86lamivudine 201,202lamivudine hbv 202lamivudine-zidovudine 202lamotrigine 86lamotrigine (blue) 86lamotrigine (green) 86lamotrigine (orange) 86lamotrigine er 86lamotrigine odt 86lamotrigine odt (blue) 86lamotrigine odt (green) 86lamotrigine odt (orange) 86LAMPIT 181LANAFLEX 324lancets 280lancets thin 280lancets ultra thin 280lancing device 280lancing system 280LANOXIN 245LANOXIN PEDIATRIC 245lansoprazol-amoxicil-clarithro 217lansoprazole 217lanthanum carbonate 388LANTUS 383LANTUS SOLOSTAR 383lanzo 280lapatinib 161LARIN 368LARIN 24 FE 368LARIN FE 368LARISSIA 368LASIX 319LASTACAFT 335latanoprost 122latex gloves 280LATISSE 122LATUDA 188LAYOLIS FE 368
LAZANDA 16ledipasvir-sofosbuvir 351LEENA 368leflunomide 404LENVIMA 161LESCOL 136LESCOL XL 136LESSINA 368LETAIRIS 446letrozole 161leucovorin calcium 393LEUKERAN 162LEUKINE 234leuprolide acetate 349levalbuterol concentrate 232levalbuterol hcl 232levalbuterol tartrate hfa 232LEVAQUIN 66LEVBID 77LEVEMIR 383LEVEMIR FLEXTOUCH 383levetiracetam 86,87levetiracetam er 87levetiracetam-nacl 87LEVITRA 475LEVO-T 471levobunolol hcl 120levocarnitine 417levocarnitine sf 417levocetirizine dihydrochloride 127levofloxacin 39,66,67levofloxacin-d5w 67levoleucovorin calcium 393LEVONEST 368levonorg-eth estrad eth estrad 368levonorgestrel-eth estradiol 368LEVORA-28 368levothyroxine 471levothyroxine sodium 471LEVOXYL 471LEVSIN 77
LEVSIN-SL 77LEXAPRO 96LEXETTE 59LEXIVA 204LIALDA 340LIBRAX 77LICART 424lidocaine 451lidocaine hcl 63,389,451lidocaine hcl in 5% dextrose 63lidocaine hcl-0.9% nacl 389lidocaine-hydrocortisone 60,451lidocaine-prilocaine 451lidocaine-tetracaine 451LIDODERM 451LIDODOSE 451LIDOPIN 451LIDOPRIL 451LIDOTREX 280LIDTOPIC MAX 451LILETTA 368LILLOW 368LINCOCIN 74lincomycin hcl 74lindane 48linezolid 74linezolid-0.9% nacl 74linezolid-d5w 74LINZESS 344liothyronine sodium 471LIPITOR 136,137LIPOFEN 134lisinopril 438lisinopril-hydrochlorothiazide 438lite touch 280lithium 251lithium carbonate 251lithium carbonate er 251LITHOBID 251LIVALO 137LO LOESTRIN FE 369
LO-ZUMANDIMINE 369LOCOID 60LODINE 424LODOSYN 252LOESTRIN 369LOESTRIN FE 369LOJAIMIESS 369LOKELMA 389LOMAIRA 28LOMOTIL 341LONHALA MAGNAIR REFILL 77LONHALA MAGNAIR STARTER 77LONSURF 162loperamide 341LOPID 134lopinavir-ritonavir 204LOPREEZA 333LOPRESSOR 249LOPRESSOR HCT 249LOPROX 119lorazepam 227,228LORAZEPAM INTENSOL 228lorazepam-0.9% nacl 228lorazepam-d5w 228LORBRENA 162LORCET 16LORCET HD 17LORCET PLUS 17LORTAB 17LORYNA 369LORZONE 449losartan potassium 435losartan-hydrochlorothiazide 435LOSEASONIQUE 369LOTEMAX 49,50LOTEMAX SM 50LOTENSIN 438,439LOTENSIN HCT 439loteprednol etabonate 50LOTREL 243LOTRISONE 118
LOTRONEX 340lovastatin 137LOVAZA 128LOVENOX 82LOW-OGESTREL 369loxapine 182LUCEMYRA 469LUCENTIS 336LUDENT FLUORIDE 398LUGOL'S 48luliconazole 118LUMIGAN 122LUMIZYME 328LUMOXITI 162lumoxiti iv soln stabilizer 431LUNESTA 224,225LUPRON DEPOT 349LUPRON DEPOT (LUPANETA) 349LUPRON DEPOT-PED 349LUTERA 369LUXIQ 60LUZU 118LYNPARZA 162LYRICA 87LYRICA CR 6LYSODREN 162LYSTEDA 125LYUMJEV 387LYUMJEV KWIKPEN U-100 387LYUMJEV KWIKPEN U-200 387LYZA 369
MM-M-R II VACCINE 214M.V.I. PEDIATRIC 478MACRILEN 317MACROBID 37MACRODANTIN 37magellan safety needle 280magellan safety syringe 280magnesium sulfate-0.9% nacl 87
magnesium sulfate-d5w 87magni-guide magnifier 280MAKENA 380MALARONE 180malathion 48mannitol 319maprotiline hcl 99MARINOL 111MARLISSA 369MARPLAN 93MARQIBO 162MATULANE 162MATZIM LA 239MAVENCLAD 413MAVYRET 352MAXALT 141MAXALT MLT 141maxicomfort ii pen needle 281maxicomfort safety pen needle 281MAXIDEX 50MAXIPIME 257MAXITROL 40MAXZIDE 320MAXZIDE-25 MG 320MAYZENT 408,409meclizine hcl 112meclofenamate sodium 424MEDICATED PADS 452medisense 281medisense control 281medisense glucose ketone 281medisense glucose ketone contr 281medisense thin lancets 281medlance plus 281medlance plus special blade 281MEDROL 356medroxyprogesterone acetate 380mefenamic acid 424mefloquine hcl 180MEGACE ES 380megestrol acetate 380
MEKINIST 162MEKTOVI 163melatonin 417MELODETTA 24 FE 369meloxicam 424melphalan 163melphalan hcl 163memantine hcl 252memantine hcl er 252MENACTRA 214MENEST 333MENOPUR 350MENOSTAR 333MENQUADFI 214MENVEO A-C-Y-W-135-DIP 214MENVEO MENA COMPONENT 214MENVEO MENCYW-135 COMPONENT 214meperidine hcl 17meperidine hcl-0.9% nacl 18MEPHYTON 481meprobamate 225MEPRON 181MEPSEVII 328mercaptopurine 163meropenem 391meropenem-0.9% nacl 391MERREM 391mesalamine 340,341mesalamine dr 341mesalamine er 341mesna 419MESNEX 419MESTINON 230METADATE ER 34METANX 480metaproterenol sulfate 232METASTRON 431METAXALL 449metaxalone 449meter-check 281metformin hcl 102
metformin hcl er 102methacholine chloride 317methadone hcl 18METHADONE INTENSOL 18METHADOSE 18methamphetamine hcl 32methazolamide 122methenamine hippurate 37methenamine mandelate 37METHERGINE 427methimazole 470METHITEST 359methocarbamol 449methohexital-sterile water 346methotrexate 163methotrexate sodium 163methoxsalen 261methscopolamine bromide 77methyclothiazide 320methyldopa 382methyldopa-hydrochlorothiazide 382methyldopate hcl 382methylene blue 393,417methylergonovine maleate 427METHYLIN 34methylphenidate er 34methylphenidate er (la) 34methylphenidate hcl 34,35methylphenidate hcl cd 35methylphenidate hcl er (cd) 35methylphenidate la 35methylprednisolone 356methylprednisolone acetate 356methylprednisolone sodium succ 356methyltestosterone 359metipranolol 120metoclopramide hcl 345metoclopramide hcl odt 345metolazone 320metoprolol succinate 249metoprolol tartrate 249
metoprolol-hydrochlorothiazide 249METRO IV 181METROCREAM 45METROGEL 45METROGEL-VAGINAL 45METROLOTION 45metronidazole 45,181metyrosine 417mexiletine hcl 63MIACALCIN 428MIBELAS 24 FE 370micafungin 115MICARDIS 435MICARDIS HCT 435,436miconazole 3 118MICORT-HC 60MICRHOGAM ULTRA-FILTERED PLUS 210micro 310micro thin lancet 281micro thin lancets 281microdot 281,310microdot insulin pen needle 281microdot xtra 310MICROGESTIN 370MICROGESTIN 24 FE 370MICROGESTIN FE 370microlet 281microlet 2 281microlet next lancing device 281microtainer lancets 281MICROZIDE 320midazolam hcl 228midazolam hcl-0.9% nacl 228midazolam hcl-d5w 228midazolam-0.9% nacl 228MIDNITE FOR MENOPAUSE 417MIDNITE MENOPAUSE 417MIDNITE PM 417midodrine hcl 469MIFEPREX 427mifepristone 427
MIGERGOT 4miglitol 100miglustat 417MIGRANAL 4MILI 370MILLIPRED 356MILLIPRED DP 356MIMVEY 333MIMVEY LO 333MINASTRIN 24 FE 370mini lancing device 281mini ultra-thin ii 281minilink real-time transmitter 282MINIPRESS 246MINITRAN 474MINIVELLE 333MINOCIN 69minocycline er 70minocycline hcl 70minocycline hcl er 70MINOLIRA ER 70minoxidil 382MIOCHOL-E 122MIOSTAT 122MIRAPEX 322MIRAPEX ER 322MIRCERA 234MIRCETTE 370MIRENA 370mirtazapine 92MIRVASO 461misoprostol 216MITIGARE 394mitomycin 163mitoxantrone hcl 163mixed vespid venom protein 206MOBIC 424modafinil 36MODERIBA 221moexipril hcl 439molindone hcl 182
mometasone furoate 50,60MONDOXYNE NL 70MONJUVI 163MONO-LINYAH 370MONODOX 71MONOFERRIC 62monoject blood collection 282monoject enfit syringe 282monoject enfit syringe cap 282monolet lancets 282monolet thin lancets 282MONONESSA 370MONONINE 125MONOVISC 282montelukast sodium 54MONUROL 38MORGIDOX 71MORPHABOND ER 18morphine sulfate 18,19,20morphine sulfate er 20morphine sulfate-0.9% nacl 20,21morphine sulfate-d5w 21MOTEGRITY 345MOTOFEN 341MOVANTIK 344MOVIPREP 342MOXATAG 429MOXEZA 40moxifloxacin 40,67moxifloxacin hcl 67MOZOBIL 234MS CONTIN 21mucor plumbeus 207MULPLETA 234MULTAQ 64multi-lancet 282multistix 318multistix 10 sg 318multistix 5 318multistix 7 318multistix 8 sg 318
multistix 9 318multistix 9 sg 318mupirocin 45MUSE 478MUSTARGEN 163MUTAMYCIN 163MVASI 163MVW COMPLETE FORMLTN PEDIATRIC 478MVW COMPLETE FORMULATION D3000 478MYALEPT 378MYAMBUTOL 144MYCAMINE 115MYCAPSSA 466MYCOBUTIN 144mycophenolate mofetil 413mycophenolic acid 413MYDAYIS 32MYFORTIC 413myglucohealth 282,310myglucohealth control solution 282myglucohealth lancets 282MYLERAN 164MYLOTARG 164MYNATAL 478MYNATAL PLUS 478MYNATAL-Z 478MYOBLOC 417MYORISAN 461MYRBETRIQ 231MYSOLINE 90MYTESI 341MYXREDLIN 388MYZILRA 370
NNABI-HB 210nabumetone 424nadolol 249nadolol-bendroflumethiazide 249nafcillin 430nafcillin sodium 430
naftifine hcl 116NAFTIN 116NAGLAZYME 328nalbuphine hcl 27NALFON 424NALOCET 21naloxone hcl 253,254naltrexone hcl 254NAMENDA 252NAMENDA XR 252NAMZARIC 252nano 2nd gen pen needle 282NAPRELAN 424NAPROSYN 424naproxen 424,425naproxen sodium 425naproxen sodium cr 425naproxen sodium er 425naratriptan hcl 141NARCAN 254NARDIL 93NASCOBAL 480NASONEX 50NATACYN 42NATAZIA 370nateglinide 106NATESTO 359NATPARA 428NATRECOR 478NATROBA 48NATURE-THROID 471NAVELBINE 164NAYZILAM 91NEBUPENT 181NECON 371needle 282needles 282nefazodone hcl 98NEMBUTAL SODIUM 225NEO-POLYCIN 40NEO-POLYCIN HC 40
NEO-SYNALAR 45neomycin sulfate 65neomycin-bacitracin-poly-hc 40neomycin-bacitracin-polymyxin 40neomycin-polymyxin-dexameth 40neomycin-polymyxin-gramicidin 40neomycin-polymyxin-hc 40neomycin-polymyxin-hydrocort 40NEOPROFEN 425NEORAL 413neostigmine methylsulfate 230NEOTUSS PLUS 443NEPHRONEX-SL 480NERLYNX 164NESINA 104NEUAC 45NEULASTA 234NEULASTA ONPRO 235NEUPOGEN 235NEUPRO 322NEURONTIN 87,88neutek 2tek test strips 311NEVANAC 52nevirapine 199nevirapine er 199NEWGEN 478NEXAVAR 164NEXAVIR 418NEXIUM 217NEXIUM I.V. 217NEXLETOL 129NEXLIZET 129NEXPLANON 371NEXTERONE 64niacin er 129NIACOR 129NIASPAN 129nicardipine hcl 243nicardipine hcl-0.9% nacl 243nicardipine hcl-d5w 243NICOTROL 229
NICOTROL NS 229nifedipine 243nifedipine er 243NIKKI 371NILANDRON 164nilutamide 164nimodipine 243NINLARO 164NIPENT 164nisoldipine 243NITHIODOTE 393nitisinone 418nitratest paper 472NITRO-BID 474NITRO-DUR 474NITRO-TIME 474nitrofurantoin 38nitrofurantoin mono-macro 38nitroglycerin 474nitroglycerin in d5w 474nitroglycerin patch 474NITROLINGUAL 474NITROMIST 474NITROPRESS 382NITROSTAT 474NITYR 418NIVA-HIST DM 443NIVESTYM 235nizatidine 216NIZORAL 118no-stick glucose 473NOCDURNA 378NOCTIVA 378NOLIX 60NORA-BE 371NORCO 21NORDITROPIN FLEXPRO 378norepinephrine bitar-0.9% nacl 469norepinephrine bitartrate-d5w 469norethin-eth estra-ferrous fum 371norethindron-ethinyl estradiol 334,371
norethindrone 371norethindrone ac (lupaneta) 380norethindrone acetate 380norethindrone-eth estradiol-fe 371NORGESIC FORTE 450norgestimate-ethinyl estradiol 371NORITATE 46NORLYDA 372NORPACE 63NORPACE CR 63NORPRAMIN 99NORTHERA 469NORTREL 372nortriptyline hcl 99NORVASC 244NORVIR 204NOURIANZ 253nova max blood glucose meter 282nova max glucose control soln 282nova max glucose test strips 311nova safety lancets 282nova sureflex 282novamax plus glu-ket 282NOVAREL 350NOVOEIGHT 125novofine 32 283novofine autocover 283novofine plus 283NOVOLIN 70-30 383NOVOLIN 70-30 FLEXPEN 383NOVOLIN N 383NOVOLIN N FLEXPEN 383NOVOLIN R 388NOVOLIN R FLEXPEN 388NOVOLOG 387NOVOLOG FLEXPEN 387NOVOLOG MIX 70-30 387NOVOLOG MIX 70-30 FLEXPEN 387NOVOSEVEN RT 125novotwist 283NOXAFIL 114,115
NP THYROID 471NPLATE 235NUBEQA 164NUCALA 53NUCYNTA 21NUCYNTA ER 22NUEDEXTA 253NULEV 77NULOJIX 414NULYTELY WITH FLAVOR PACKS 342NUMBONEX 451NUMBRINO 337NUMOISYN 283NUPLAZID 188NURTEC ODT 140NUVAIL 283NUVARING 372NUVESSA 46NUVIGIL 36NUWIQ 125NUZYRA 470NYAMYC 119NYMALIZE 244nystatin 116,119nystatin-triamcinolone 120NYSTOP 120
OOBIZUR 125OBREDON 443OBTREX DHA 478OCALIVA 344OCELLA 372OCTAGAM 210octreotide acetate 466OCUFLOX 40ODACTRA 207ODEFSEY 202ODOMZO 165OFEV 441ofloxacin 40,67
OGESTREL 372OGIVRI 165OKEBO 71olanzapine 188olanzapine odt 188,189olanzapine-fluoxetine hcl 96OLINVYK 22olmesartan medoxomil 436olmesartan-amlodipine-hctz 436olmesartan-hydrochlorothiazide 436olopatadine hcl 335OLUMIANT 404OLUX 60OLUX-E 60OMECLAMOX-PAK 217omega-3 129omega-3 acid ethyl esters 129OMEGAVEN 324omeprazole 217omeprazole-sodium bicarbonate 218OMIDRIA 337OMNARIS 50OMNIPAQUE 317OMNIPRED 50on call express control soln 283on call express meter 283on call express test strip 311on call lancet 283on call lancing device 283on call plus control 283on call plus lancet 283on call plus lancing device 283on call plus meter 283on call plus test strip 311on call vivid control 283on call vivid meter 283on call vivid pal 283on call vivid test strip 311on-the-go 283ONCASPAR 165ondansetron hcl 110
ondansetron hcl-0.9% nacl 110ondansetron hcl-d5w 110ondansetron odt 110onetouch delica 283onetouch delica plus lanc dev 283onetouch delica plus lancet 284onetouch lancets 284onetouch suresoft 284onetouch ultra blue test strp 311onetouch ultra control soln 284onetouch ultra2 284onetouch ultramini 284onetouch verio flex meter 284onetouch verio flex startr kit 284onetouch verio high cntrl soln 284onetouch verio iq meter 284onetouch verio iq system kit 284onetouch verio meter 284onetouch verio mid cntrl soln 284onetouch verio reflect kit 284onetouch verio reflect meter 284onetouch verio test strip 311ONEVITE 478ONEXTON 46ONFI 91ONGENTYS 178ONGLYZA 104ONMEL 115ONUREG 165ONZETRA XSAIL 141OPANA 22OPDIVO 165opium tincture 341OPSUMIT 446OPTIRAY 240 317optium 311optium ez 311optumrx 285,312ORACEA 71ORAFATE 285ORALAIR 207
ORALONE 60ORAP 182ORAPRED ODT 356ORAQIX 260ORAVIG 118ORENCIA 404ORENCIA CLICKJECT 404ORENITRAM ER 447ORFADIN 418ORIAHNN 348ORILISSA 348ORKAMBI 260orphenadrine citrate 450orphenadrine citrate er 450orphenadrine-aspirin-caffeine 450ORPHENGESIC FORTE 450ORSYTHIA 372ORTHO MICRONOR 372ORTHO TRI-CYCLEN 372ORTHO TRI-CYCLEN LO 372ORTHO-CYCLEN 372ORTHO-NOVUM 372ORTHOVISC 285ORTIKOS 357OSCIMIN 77OSCIMIN SL 77OSCIMIN SR 77oseltamivir phosphate 220OSENI 104OSMITROL 319OSMOLEX ER 178OSMOPREP 342OSPHENA 329OTEZLA 405OTIPRIO 40OTOVEL 40OTREXUP 165OVIDE 48OVIDREL 350oxacillin 430oxacillin sodium 430
oxaliplatin 165OXANDRIN 359oxandrolone 359oxaprozin 425OXAYDO 22oxazepam 228OXBRYTA 233oxcarbazepine 88OXERVATE 336oxiconazole nitrate 118OXISTAT 118OXSORALEN-ULTRA 261OXTELLAR XR 88oxybutynin chloride 346oxybutynin chloride er 346,347oxycodone hcl 22oxycodone hcl-aspirin 22oxycodone hcl-ibuprofen 22oxycodone-acetaminophen 23oxymorphone hcl 23oxymorphone hcl er 23OXYTROL 347OZEMPIC 105OZOBAX 450OZURDEX 50
PPACERONE 64paclitaxel 165PACNEX 455PADCEV 165PAIN EASE MEDIUM STREAM SPRAY 285PAIN EASE MIST SPRAY 285PALFORZIA 207paliperidone er 189PALYNZIQ 328PAMELOR 100pamidronate disodium 396PANCREAZE 343PANDEL 60PANHEMATIN 418
PANRETIN 165pantoprazole sodium 218PANZYGA 210papaverine hcl 478paradigm real-time 285paradigm remote control 285PARAGARD T 380-A 372PARAPLATIN 166paregoric 341paricalcitol 481PARLODEL 322PARNATE 93PAROEX 42paromomycin sulfate 180paroxetine cr 96paroxetine er 96paroxetine hcl 96paroxetine mesylate 96PASER 144PATADAY 335PATANASE 335PATANOL 335PAXIL 97PAXIL CR 97PAZEO 335PEDIAPRED 357PEDIARIX 214PEDVAXHIB 214peg 3350-electrolyte 343peg-3350 and electrolytes 343PEG-PREP 343peg3350-sod sul-nacl-kcl-asb-c 343PEGANONE 91PEGASYS 220PEGASYS PROCLICK 220PEGINTRON 220PEMAZYRE 166pen needle 286pen needles 286penicillamine 354penicillin g potassium 430
penicillin g procaine 430penicillin g sodium 430penicillin gk-iso-osm dextrose 430penicillin v potassium 430penicillium notatum 207PENLAC 119PENNSAID 425PENTACEL 214PENTACEL ACTHIB COMPONENT 214PENTACEL DTAP-IPV COMPONENT 214PENTAM 300 181pentamidine isethionate 181,182PENTASA 341pentazocine-naloxone hcl 27pentetate calcium trisodium 354pentetate zinc trisodium 354pentips 286pentoxifylline 236PEPCID 216PERCOCET 23PERFOROMIST 232PERIDEX 42perindopril erbumine 439PERIOGARD 42PERJETA 166permethrin 48perphenazine 198perphenazine-amitriptyline 100PERSERIS 189PERTZYE 343PEXEVA 97PFIZERPEN 430pharmacist choice 286,312phaseal protector 286PHENADOZ 339phenazopyridine hcl 451phendimetrazine tartrate 29phendimetrazine tartrate er 29phenelzine sulfate 93PHENERGAN 339phenobarbital 226
phenobarbital sodium 226phenobarbital-belladonna 77phenobarbital-hyosc-atrop-scop 78PHENOHYTRO 78phenoxybenzamine hcl 4phentermine hcl 29phentolamine mesylate 5PHENYLADE GMP 324PHENYLADE GMP MIX-IN 324phenylephrine hcl 337phenylephrine hcl-0.9% nacl 469phenylephrine hcl-d5w 469phenylephrine hcl-water 470PHENYTEK 91phenytoin 91phenytoin sodium 91phenytoin sodium extended 92PHEXXI 420PHILITH 373PHOSLYRA 388PHOSPHOLINE IODIDE 122PHOTOFRIN 166PHRENILIN FORTE 7physostigmine salicylate 230phytonadione 481PICATO 166PIFELTRO 199pilocarpine hcl 122,230pimecrolimus 461pimozide 182PIMTREA 373pindolol 250pioglitazone hcl 110pioglitazone-glimepiride 110pioglitazone-metformin 110pip lancet 286piperacillin-tazobactam 429PIQRAY 166PIRMELLA 373piroxicam 425PLAQUENIL 180
PLAVIX 205PLEGRIDY 409PLEGRIDY PEN 409PLENAMINE 324PLENVU 343PLEXION 455PLIAGLIS 451PNEUMOVAX 23 214PODOCON-25 461podofilox 461POLIVY 166poly hub needle 287POLYCIN 41polymyxin b sul-trimethoprim 41polymyxin b sulfate 75polysorbate 60 454polysorbate 80 454POLYTRIM 41POMALYST 166PONTOCAINE 452PORTIA 373posaconazole 115POTABA 418potassium acetate 326potassium bicarbonate 326potassium chloride 326potassium chloride in d5lr 326potassium chloride proamp 326potassium chloride-nacl 326potassium citrate er 323potassium cl-lidocaine-ns 326potassium phosphate-0.9% nacl 326potassium phosphates 326povidone iodine 42pr benzoyl peroxide 455PRADAXA 80pralidoxime chloride 393PRALUENT PEN 138pramipexole dihydrochloride 322pramipexole er 322PRAMOSONE 60
PRAMOSONE E 60pramoxine hcl 452PRANDIN 106prasugrel hcl 206PRAVACHOL 137pravastatin sodium 137praziquantel 37prazosin hcl 246PRE-ATTACHED LTA KIT 452PRECEDEX 225precision 287precision glucose control 287precision pcx 312precision pcx plus 312precision point of care 312precision q-i-d 312precision xtra 287,312precision xtra ketone-glucose 287PRECOSE 100,101PRED FORTE 50PRED MILD 50PRED-G 41prednicarbate 60prednisolone 357prednisolone acetate 50prednisolone sodium phos odt 357prednisolone sodium phosphate 50,357prednisone 357PREDNISONE INTENSOL 357PREFEST 334pregabalin 88PREGNYL 350PREMARIN 334premier blu 287premier compact glucose meter 287premier test strip 312premier voice 287premium blood glucose 287premium blood glucose test 312premium v10 287,313PREMPHASE 334
PREMPRO 334PRENA1 CHEW 478PRENA1 PEARL 479PRENA1 TRUE 479PRENATABS RX 479prenatal low iron 479PRENATAL VITAMIN WITH MINERALS AND FOLICACID GREATER THAN 0.8 MG ORAL TABLET 479prenatal-u 479PREPOPIK 343pressure activated lancets 287PRESTALIA 439presto pro 287pretomanid 144PREVACID 218PREVALITE 131prevent dropsafe pen needle 287PREVIDENT 398PREVIDENT 5000 398PREVIDENT 5000 ENAMEL PROTECT 398PREVIDENT 5000 ORTHO DEFENSE 398PREVIDENT 5000 PLUS 398PREVIDENT 5000 SENSITIVE 398PREVIFEM 373PREVNAR 13 214PREVYMIS 219PREZCOBIX 204PREZISTA 204PRIALT 7PRIFTIN 144PRIKAAN 452PRIKAAN LITE 452PRILOSEC 218primaquine 180PRIMAXIN 391primidone 90PRIMLEV 23,24PRINIVIL 439PRISTIQ 94PRIVIGEN 210pro comfort lancet 287
pro comfort lancets 288pro comfort pen needle 288pro voice v8 glucose monitor 288pro voice v8-v9 test strip 313pro voice v9 glucose monitor 288PROAIR DIGIHALER 232PROAIR HFA 232PROAIR RESPICLICK 232probenecid 327probenecid-colchicine 327procainamide hcl 63PROCARDIA 244PROCARDIA XL 244PROCENTRA 32prochlorperazine 112prochlorperazine edisylate 112prochlorperazine maleate 112PROCORT 60PROCRIT 235PROCTO-MED HC 60PROCTO-PAK 60PROCTOCORT 60PROCTOFOAM-HC 61PROCTOSOL-HC 61PROCTOZONE-HC 61PROCYSBI 418prodigy 288prodigy autocode 288prodigy control solution 288prodigy lancets 288prodigy lancing device 288prodigy no coding 313prodigy pocket 288prodigy twist top lancet 288prodigy voice 288PROFENO 425PROFILNINE 125progesterone 380PROGLYCEM 128PROGRAF 414PROLASTIN C 445
PROLATE 24PROLENSA 52PROLEUKIN 167PROLIA 396PROMACTA 235promethazine hcl 339promethazine hcl-0.9% nacl 339promethazine-codeine 443promethazine-dm 443promethazine-phenyleph-codeine 443promethazine-phenylephrine 339PROMETHEGAN 339PROMETRIUM 380propafenone hcl 63propafenone hcl er 63propantheline bromide 78proparacaine hcl 337PROPECIA 461propranolol hcl 250propranolol hcl er 250propranolol-hydrochlorothiazid 250propylthiouracil 470PROQUAD 214PROSCAR 392protamine sulfate 123PROTHELIAL 288PROTONIX 218PROTONIX IV 218PROTOPAM CHLORIDE 393PROTOPIC 461protriptyline hcl 100PROVENGE 251PROVENTIL HFA 232PROVERA 380PROVIGIL 36PROZAC 97PRUDOXIN 452PSORCON 61PULMICORT 259PULMICORT FLEXHALER 259PULMOZYME 444
pure comfort lancets 288pure comfort pen needle 288pure comfort safety lancets 288PURIXAN 167push button safety lancets 288PYLERA 74pyrazinamide 144PYRIDIUM 452pyridostigmine bromide 230pyridostigmine bromide er 230pyridoxine hcl 480
QQBRELIS 439QBREXZA 78QINLOCK 167QMIIZ ODT 425QNASL 51QNASL CHILDREN 51QSYMIA 29QTERN 107QUADRACEL DTAP-IPV 214QUADRAMET 432QUALAQUIN 180QUARTETTE 373QUASENSE 373quazepam 228QUDEXY XR 88QUESTRAN 131QUESTRAN LIGHT 131quetiapine fumarate 189,190quetiapine fumarate er 190QUILLICHEW ER 35QUILLIVANT XR 35quinapril hcl 439quinapril-hydrochlorothiazide 439quinidine gluconate 63quinidine sulfate 63quinine sulfate 181quintet 288,313quintet ac 289,313
QUTENZA 461QUZYTTIR 127QVAR REDIHALER 259
RR-NATAL OB 479RABAVERT 214rabeprazole sodium 218RADIAGUARD 452RADIOGARDASE 388RAGWITEK 207raloxifene hcl 329ramelteon 225ramipril 439RANEXA 245ranitidine hcl 216ranolazine er 245RAPAFLO 5RAPAMUNE 414rasagiline mesylate 180RASUVO 167RAVICTI 323RAYALDEE 481RAZADYNE 230RAZADYNE ER 230READI-CAT 2 317readylance safety lancets 289REBETOL 221REBIF 409REBIF REBIDOSE 410REBINYN 126REBLOZYL 235RECARBRIO 391RECLAST 397RECLIPSEN 373RECOMBINATE 126RECOMBIVAX HB 214RECTIV 461REFISSA 453refuah plus 289,313refuah plus glucose control 289
REGENECARE 289REGIMEX 32REGLAN 345REGONOL 230REGRANEX 453RELAFEN 425RELAFEN DS 425RELENZA 220RELEXXII 35reliamed 289reliamed mini lancing device 289reliamed safety seal lancets 289relion all-in-one 289relion confirm 289relion confirm-micro 313relion micro 289relion pen needles 289relion prime 289relion prime test strips 313relion thin 289RELISTOR 344RELPAX 142REMERON 93REMICADE 405REMODULIN 447RENAGEL 389RENFLEXIS 405RENOVA 453RENOVA PUMP 453RENVELA 389REOPRO 206repaglinide 106repaglinide-metformin hcl 106REPATHA PUSHTRONEX 139REPATHA SURECLICK 139REPATHA SYRINGE 139replacement pediatric monitor 289REQUIP 322REQUIP XL 322RESCRIPTOR 199RESECTISOL 325
RESPA A.R. 340RESTASIS 51RESTASIS MULTIDOSE 51RESTORIL 228RETACRIT 235RETEVMO 167RETIN-A 453RETIN-A MICRO 453RETIN-A MICRO PUMP 453RETISERT 51RETROVIR 202REVATIO 475REVCOVI 328reveal blood glucose meter 289reveal test strip 313REVLIMID 167REVONTO 450REXULTI 190REYATAZ 204REYVOW 142RHOFADE 461RHOGAM ULTRA-FILTERED PLUS 210RHOPHYLAC 210RHOPRESSA 123RIBASPHERE 222RIBASPHERE RIBAPAK 222ribavirin 222RIDAURA 347rifabutin 144RIFADIN 144RIFAMATE 144rifampin 144RIFATER 144rightest control solution 289rightest gc250s control soln 289rightest gd500 290rightest gl300 lancets 290rightest gm100 system 290rightest gm250s meter 290rightest gm260 meter 290rightest gm300 system 290
rightest gm550 system 290rightest gs100 test strips 314rightest gs250s test strips 314rightest gs260 test strips 314rightest gs300 test strips 314rightest gs550 test strips 314riluzole 253rimantadine hcl 219RIMSO-50 325RINVOQ 405RIOMET 103RIOMET ER 103risedronate sodium 397risedronate sodium dr 397RISPERDAL 191RISPERDAL CONSTA 191risperidone 192risperidone odt 192RITALIN 35RITALIN LA 36ritonavir 204RITUXAN 167RITUXAN HYCELA 167rivastigmine 230RIVELSA 373RIXUBIS 126rizatriptan 142ROBAXIN 449ROBAXIN-750 449ROCALTROL 481ROCKLATAN 123romidepsin 167ropinirole er 322ropinirole hcl 322ropivacaine hcl 389,390ROSADAN 46ROSANIL 455ROSULA 455rosuvastatin calcium 137ROTARIX 214ROTATEQ 214
ROWASA 341ROWEEPRA 88ROWEEPRA XR 88ROXICODONE 24ROXYBOND 24ROZEREM 225ROZLYTREK 168RUBRACA 168RUCONEST 399rufinamide 88RUKOBIA 198RUXIENCE 168RUZURGI 418RYBELSUS 105RYCLORA 340RYDAPT 168RYTARY 179RYTHMOL SR 63RYVENT 338
SSABRIL 88saccharomyces cerevisiae 208safe-clip 290safety lancets 290safety pen needle 290safety seal lancets 290safety-let 290safety-lok collection set 290safetyglide insulin syringe 290safetyglide needle 290SAFYRAL 373SALAGEN 230SALEX 455salicylic acid 455salicylic acid er 455SALIMEZ FORTE 456salsalate 427SALVAX 456SAMSCA 321SANADERMRX 61
SANCUSO 111SANDIMMUNE 414SANDOSTATIN 466,467SANDOSTATIN LAR DEPOT 467SANTYL 461SAPHRIS 192sapropterin dihydrochloride 418SARAFEM 98sassafras oil 431SAVAYSA 80SAVELLA 253SAXENDA 105SCALACORT 61scopolamine 111SEASONIQUE 374SECONAL SODIUM 226SECUADO 193SEEBRI NEOHALER 78SEGLUROMET 107selegiline hcl 180SELZENTRY 198SEMGLEE 383SEMGLEE PEN 384SEMPREX-D 127SENSIPAR 428SEREVENT DISKUS 232SERNIVO 61SEROPHENE 329SEROQUEL 193SEROQUEL XR 194SEROSTIM 378sertraline hcl 98SETLAKIN 374sevelamer carbonate 389sevelamer hcl 389SEVENFACT 126SEYSARA 470SF 398SF 5000 PLUS 398SFROWASA 341SHAROBEL 374
SHINGRIX 214SHINGRIX ADJUVANT COMPONENT 431SHINGRIX GE ANTIGEN COMPONENT 214sidekick 290SIDEROL 62SIGNIFOR 467SIGNIFOR LAR 467SIKLOS 168sildenafil 20 mg tablet (pah) 475sildenafil citrate 476SILENOR 100SILIQ 461silodosin 5SILVADENE 48SILVASORB 290silver sulfadiazine 48SILVRSTAT 290SIMBRINZA 122SIMLIYA 374SIMPESSE 374SIMPONI 405SIMPONI ARIA 406SIMULECT 414simvastatin 138SINEMET 10-100 179SINEMET 25-100 179SINEMET 25-250 179SINEMET CR 179single-let 290SINGULAIR 54sirolimus 414SIRTURO 144SITAVIG 222SIVEXTRO 74SKELAXIN 449SKLICE 48SKYLA 374SKYRIZI 461SKYRIZI (2 SYRINGES) KIT 462SLYND 374smart caresens n 291
smart sense 291smart sense lancets 291smart sense monitoring system 291smart sense test strips 314smartdiabetes vantage 291smartest 291smartest eject 291smartest lancet 291smartest persona 291smartest pronto 291smartest protege 291smartest smart code 291smartest talking 291smartest test 314sod ferric gluconate complex 62sodium chloride 326sodium citrate 79SODIUM DIURIL 320sodium fluoride 398sodium fluoride 2.2 mg (fluoride ion 1 mg) oraltablet 398sodium fluoride sensitive 398sodium hyaluronate 291sodium iodide i-123 432sodium iodide i-131 432sodium nitroprusside 382sodium phenylbutyrate 323sodium phosphate-0.9% nacl 326sodium phosphate-d5w 326sodium polystyrene sulfonate 389sodium sulfacetamide-sulfur 48,456sodium thiosulfate 393sof-sensor 291sofosbuvir-velpatasvir 351soft touch 291SOLARAZE 168solifenacin succinate 347SOLIQUA 100-33 384SOLIRIS 399SOLODYN 71SOLOSEC 182
SOLOXIDE 71SOLTAMOX 329SOLU-CORTEF 357SOLU-MEDROL 357solus v2 292solus v2 control solution 292solus v2 lancets 292solus v2 lancing device 292solus v2 test strips 314SOMA 449SOMATULINE DEPOT 467SOMAVERT 468SOOLANTRA 462SORIATANE 462SORILUX 462SORINE 250sotalol 250sotalol af 250sotalol hcl 250SOTYLIZE 250SOVALDI 351spearmint oil 431SPECTRACEF 256spinosad 48SPIRIVA 78SPIRIVA RESPIMAT 78spironolactone 441spironolactone-hctz 441SPORANOX 115SPRAVATO 93SPRAY AND STRETCH 292SPRINTEC 374SPRITAM 88SPRIX 426SPRYCEL 168,169SPS 389SRONYX 374SSD 48SSKI 470SSS 10-5 456STALEVO 100 179
STALEVO 125 179STALEVO 150 179STALEVO 200 179STALEVO 50 179STALEVO 75 179STAMARIL 215STARLIX 106stavudine 202STAXYN 476STEGLATRO 107STEGLUJAN 107STELARA 462STENDRA 476sterilance tl 292STERILE WATER DILUENT-CABLIVI 431STIMATE 378STIOLTO RESPIMAT 78STIVARGA 169STRATTERA 253STRENSIQ 328streptomycin sulfate 65STRIANT 359STRIBILD 202STRIVERDI RESPIMAT 232STROMECTOL 37SUBLOCADE 27SUBOXONE 28SUBSYS 24SUBVENITE 88SUBVENITE (BLUE) 88SUBVENITE (GREEN) 88SUBVENITE (ORANGE) 88SUCRAID 328sucralfate 216SULAR 244sulconazole nitrate 118sulfacetamide sodium 41,48sulfacetamide-prednisolone 41SULFACLEANSE 8-4 456sulfadiazine 67sulfamethoxazole-trimethoprim 67
SULFAMYLON 48sulfasalazine 67sulfasalazine dr 67SULFATRIM 67sulindac 426SUMADAN 456sumatriptan 142sumatriptan succ-naproxen sod 142sumatriptan succinate 142SUMAVEL DOSEPRO 142SUMAXIN 456SUMAXIN TS 456SUNOSI 36SUPARTZ FX 292super thin lancets 292SUPPRELIN LA 350SUPRAX 256SUPREP 343sure comfort 292sure comfort lancets 292sure comfort lancing pen 292sure-fine pen needles 292sure-lance 292sure-pen 292sure-test easyplus mini 292,314sure-touch 292sureflex 292SURMONTIL 100SURVANTA 445SUSTIVA 199SUTENT 169SYEDA 374SYLATRON 220SYLVANT 169SYMAX 78SYMAX DUOTAB 78SYMAX-SL 78SYMAX-SR 78SYMBICORT 260SYMBYAX 98SYMDEKO 260
SYMFI 200SYMFI LO 200SYMJEPI 469SYMLINPEN 120 101SYMLINPEN 60 101SYMPAZAN 91SYMPROIC 345SYMTUZA 204SYNAGIS 220SYNALAR 61SYNAREL 350SYNDROS 111SYNERA 452SYNERCID 75SYNJARDY 107SYNJARDY XR 107SYNRIBO 169SYNTHROID 471SYNVISC 293SYNVISC-ONE 293
TTABLOID 169TABRECTA 170TACLONEX 463tacrolimus 414,463tadalafil 476tadalafil 20 mg tablet (ed/bph) 476tadalafil 20 mg tablet (pah) 476TAFINLAR 170TAGRISSO 170TAKHZYRO 399TALICIA 215TALTZ AUTOINJECTOR 463TALTZ AUTOINJECTOR (2 PACK) 463TALTZ AUTOINJECTOR (3 PACK) 463TALTZ SYRINGE 463TALWIN 28TALZENNA 170TAMIFLU 220tamoxifen citrate 329
tamsulosin hcl 5TAPAZOLE 470TAPERDEX 357TARCEVA 170TARGADOX 71TARGRETIN 170TARINA 24 FE 374TARINA FE 375TARINA FE 1-20 EQ 375TARKA 439TASIGNA 170,171TASMAR 178TAVALISSE 233TAXOTERE 171TAYTULLA 375tazarotene 464TAZICEF 257TAZORAC 464TAZTIA XT 239TAZVERIK 171td gold blood glucose monitor 293td gold level 1 control sol 293td gold level 2 control sol 293td gold level 3 control sol 293td gold test strip 315td gold voice glucose monitor 293tdvax 211TECENTRIQ 171TECFIDERA 410techlite insulin syringe 293techlite lancets 293techlite pen needle 293TECHNESCAN HDP 317TEFLARO 257TEGRETOL 88TEGRETOL XR 89TEGSEDI 395TEKTURNA 441TEKTURNA HCT 441telcare 293,315telcare bgm 293
telcare control solution 294telmisartan 436telmisartan-amlodipine 436telmisartan-hydrochlorothiazid 436temazepam 228TEMIXYS 202TEMODAR 171TEMOVATE 61temozolomide 171temsirolimus 171TENCON 7teniposide 171TENIVAC 211tenofovir disoproxil fumarate 202TENORETIC 100 250TENORETIC 50 250TENORMIN 250TEPEZZA 337terazosin hcl 246terbinafine hcl 114terbutaline sulfate 233terconazole 118,119teriparatide 428terumo surguard2 294TESSALON PERLE 443test n'go 294,315test strips 315TESTIM 359TESTOPEL 360testosterone 360testosterone cypionate 360testosterone enanthate 360TESTRED 360TETCAINE 337tetrabenazine 254tetracaine hcl 337tetracycline hcl 71TEXACORT 61THALOMID 410THEO-24 465theophylline 465,466
theophylline anhydrous 466theophylline in 5% dextrose 466THEROMEGA SPORT 129thiamine hcl 480thin lancets 294THIOLA 418THIOLA EC 419thioridazine hcl 198thiothixene 198THYMOGLOBULIN 414THYROGEN 317thyroid 471THYROLAR-1 471THYROLAR-1/2 471THYROLAR-1/4 471THYROLAR-2 472THYROLAR-3 472TIADYLT ER 239tiagabine hcl 89TIAZAC 240TIBSOVO 171TIGAN 112tigecycline 470TIGLUTIK 253TIKOSYN 64TILIA FE 375timolol maleate 120,121,250TIMOPTIC 121TIMOPTIC OCUDOSE 121TIMOPTIC-XE 121TINDAMAX 182tinidazole 182TIROSINT 472TIROSINT-SOL 472TISSEEL VHSD 464TISSUEBLUE 316TIVICAY 199TIVICAY PD 199tizanidine hcl 449TNKASE 206TOBAKIENT 479
TOBI 65TOBI PODHALER 65TOBRADEX 41TOBRADEX ST 41tobramycin 41,65tobramycin sulfate 65tobramycin sulfate in ns 65tobramycin-dexamethasone 41TOBREX 41TOFRANIL 100TOLAK 171tolazamide 108,109tolbutamide 109tolcapone 178tolmetin sodium 426TOLSURA 115tolterodine tartrate 347tolterodine tartrate er 347tolvaptan 321TOPAMAX 89topcare clickfine 294topcare universal1 lancet 294topcare universal1 thin lancet 294TOPICORT 61topiramate 89topiramate er 89TOPOSAR 172topotecan hcl 172TOPROL XL 250toremifene citrate 329TORISEL 172torsemide 319TOSYMRA 142TOUJEO MAX SOLOSTAR 384TOUJEO SOLOSTAR 384TOVET EMOLLIENT 61TOVIAZ 347TRACLEER 447TRADJENTA 104tramadol hcl 24tramadol hcl er 24,25
tramadol hcl-acetaminophen 25trandolapril 440trandolapril-verapamil er 440tranexamic acid 126tranexamic acid-nacl 126TRANSDERM-SCOP 111TRANXENE T-TAB 228tranylcypromine sulfate 93TRAVATAN Z 122travoprost 123TRAZIMERA 172trazodone hcl 98,99TREANDA 172TRECATOR 144TRELEGY ELLIPTA 260TRELSTAR 350TREMFYA 464treprostinil 447TRESIBA 384TRESIBA FLEXTOUCH U-100 384TRESIBA FLEXTOUCH U-200 384TRETIN-X 453tretinoin 172,453,454tretinoin microsphere 454TRETTEN 126TREXALL 172TREXIMET 142,143TREZIX 25TRI FEMYNOR 375TRI-CHLOR 464TRI-ESTARYLLA 375TRI-LEGEST FE 375TRI-LINYAH 375TRI-LO-ESTARYLLA 375TRI-LO-MARZIA 375TRI-LO-MILI 375TRI-LO-SPRINTEC 375TRI-LUMA 261TRI-MILI 375TRI-NORINYL 375TRI-PREVIFEM 376
TRI-SPRINTEC 376TRI-VYLIBRA 376TRI-VYLIBRA LO 376triamcinolone acetonide 51,61,357triamcinolone diacetate 357triamterene 320triamterene-hydrochlorothiazid 320TRIANEX 61triazolam 228TRIBENZOR 436trichloroacetic acid 464trichophyton mentagrophytes 208TRICOR 134TRIDERM 61TRIDESILON 62trientine hcl 354TRIESENCE 51TRIFERIC 62trifluoperazine hcl 198trifluridine 42TRIGLIDE 134trihexyphenidyl hcl 178TRIJARDY XR 107TRIKAFTA 260TRIKLO 130TRILEPTAL 89TRILIPIX 134TRILURON 294TRILYTE WITH FLAVOR PACKETS 343trimethobenzamide hcl 112trimethoprim 38trimipramine maleate 100TRIMPEX 38TRINATE 479TRINTELLIX 99TRIOSTAT 472TRIPLE DYE 116TRISENOX 172triton x-100 454TRIUMEQ 202TRIVISC 294
TRIVORA-28 376TRIZIVIR 203TRODELVY 172TROKENDI XR 89trospium chloride 347trospium chloride er 347true comfort lancet 294true comfort pen needle 294true metrix 294true metrix air glucose meter 294true metrix blood glucose mtr 294true metrix glucose test strip 315true metrix go 295true metrix pro test strip 315true2go blood glucose system 295truecontrol 295truedraw 295trueplus ketone test strip 472trueplus lancet 295trueplus lancets 295trueplus pen needle 295trueresult blood glucose systm 295truetest test strips 315truetrack blood glucose system 295truetrack smart system 295truetrack test strip 315TRULANCE 345TRULICITY 105TRUMENBA 215TRUSOPT 122TRUST NATAL DHA 479TRUVADA 203TUDORZA PRESSAIR 78TUKYSA 172TULANA 376TURALIO 173TUSNEL 443TUSNEL DM PEDIATRIC 443TUSNEL PEDIATRIC 444TUSSI-PRES PEDIATRIC 444TUSSICAPS 443
TUSSIONEX 443TUSSLIN 444TUXARIN ER 444TUZISTRA XR 444TWINRIX 215TWIRLA 376twist lancets 295TWYNSTA 436TYBLUME 376TYBOST 419TYDEMY 376TYGACIL 470TYKERB 173TYLENOL-CODEINE NO.3 25TYLENOL-CODEINE NO.4 25TYMLOS 428TYPHIM VI 215TYSABRI 410TYVASO 447TYVASO INSTITUTIONAL START KIT 447TYVASO REFILL KIT 447TYVASO STARTER KIT 447
UUBRELVY 140UCERIS 357UDENYCA 235ULESFIA 49ULORIC 394ulti-lance 295ulticare pen needle 295ulticare tb safety syringe 295ultiguard safe pack 295ultilet basic 295ultilet classic 295ultilet lancets 295ultilet pen needle 295ultilet safety 296ultima 296,315ULTOMIRIS 399ultra fine lancets 296
ultra flo pen needle 296ultra thin 296ultra thin lancet 296ultra thin lancets 296ultra thin plus 296ultra thin plus lancets 296ultra-care lancets 296ultra-fine micro pen needle 296ultra-fine mini pen needle 296ultra-fine nano pen needle 296ultra-fine original pen needle 296ultra-fine short pen needle 296ultra-thin ii 296ultracare pen needle 296ULTRACET 25ultralance 296ULTRAM 25ULTRASAL-ER 456ultratlc lancets 296ultratrak 296,316ultratrak pro 297ultratrak ultimate 297,316ULTRAVATE 62UNASYN 429unifine pentips 297unifine pentips maxflow 297unifine pentips plus 297unifine pentips plus maxflow 297unifine safecontrol 297unilet comfortouch 297unilet excelite 297unilet excelite ii 297unilet gp lancet 297unilet lancet 297unilet lancets 298unistik 2 298unistik 2 extra 298unistik 2 normal 298unistik 3 298unistik 3 comfort 298unistik 3 extra 298
unistik 3 neonatal 298unistik czt 298unistik pro 298unistik safety 298unistik touch 298unistrip 298unistrip1 316UNITHROID 472UNITUXIN 173universal 1 298UPLIZNA 410UPNEEQ 337UPTRAVI 447,448urea 456URECHOLINE 231URIBEL 38urinary tract infection 318uristix 4 318uristix reagent 318UROCIT-K 323UROGESIC-BLUE 38UROXATRAL 5URSO 343URSO FORTE 343ursodiol 343UTIBRON NEOHALER 233UTOPIC 456UVADEX 261
VVAGIFEM 334valacyclovir 222VALCHLOR 173VALCYTE 222valganciclovir hcl 222,223VALIUM 228valproate sodium 89valproic acid 89valrubicin 173valsartan 436valsartan-hydrochlorothiazide 437
VALSTAR 173VALTOCO 228VALTREX 223VANATOL LQ 7VANCOCIN HCL 72vancomycin 72vancomycin hcl 41,72,73vancomycin hcl-0.9% nacl 73vancomycin hcl-d5w 73VANDAZOLE 46VANIQA 464vanishpoint insulin syringe 298VANOS 62VANOXIDE-HC 62VANTAS 350VAQTA 215vardenafil hcl 477VARIVAX VACCINE 215VARIZIG 210VARUBI 113VASCEPA 130VASERETIC 440vasopressin-0.9% nacl 378,379vasopressin-d5w 379VASOTEC 440VAXCHORA ACTIVE COMPONENT 215VAXCHORA VACCINE 215VECAMYL 382VECTIBIX 173VECTICAL 464VELCADE 173VELETRI 448VELIVET 376VELPHORO 389VELTASSA 389VELTIN 46VEMLIDY 223VENCLEXTA 173VENCLEXTA STARTING PACK 173VENELEX 465venlafaxine hcl 94
venlafaxine hcl er 94,95VENOFER 63VENTAVIS 448VENTOLIN HFA 233verapamil er 240verapamil er pm 240verapamil hcl 240verapamil sr 240verasens blood glucose meter 298verasens control solution 298verasens meter starter kit 298verasens test strip 316VERDESO 62VEREGEN 465VERELAN 240VERELAN PM 241verifine pen needle 298VERIPRED 20 357VERSACLOZ 194VERZENIO 174VESICARE 347VFEND 115VFEND IV 115VIAGRA 477VIBATIV 73VIBERZI 345VIBRAMYCIN 71VICODIN 25VICODIN HP 25VICTOZA 2-PAK 105VICTOZA 3-PAK 105VIDAZA 174VIDEX 203VIDEX EC 203VIEKIRA PAK 352VIENVA 376vigabatrin 89VIGADRONE 89VIGAMOX 41VIIBRYD 99VIMIZIM 328
VIMPAT 90VINATE DHA RF 479VINATE ONE 479VINATE-M 479vinblastine sulfate 174VINCASAR PFS 174vincristine sulfate 174vinorelbine tartrate 174VIOKACE 343VIORELE 376VIRACEPT 205VIRAMUNE 200VIRAMUNE XR 200VIRASAL 456VIRAZOLE 223VIREAD 203VIRT-C DHA 479VISINE TOTALITY 337VISTARIL 225VISTASEAL FIBRIN SEALANT 126VISTOGARD 393VISUDYNE 337vitamin d2 481vitamin k1 482VITATRUE 480VITRAKVI 174VITRASE 329vivaguard ino control solution 298vivaguard ino glucose meter 299vivaguard ino smart gluc meter 299vivaguard ino test strip 316vivaguard lancet 299vivaguard lancing device 299VIVELLE-DOT 334VIVITROL 254VIVLODEX 426VIVOTIF 215VIZIMPRO 174VOGELXO 361VOLNEA 376VOLTAREN 426
VOLTAREN-XR 426VONVENDI 126VORAXAZE 393voriconazole 115VOSEVI 352VOTRIENT 174VPRIV 329VRAYLAR 195VTOL LQ 7VUMERITY 411VYFEMLA 377VYLEESI 253VYLIBRA 377VYNDAMAX 245VYNDAQEL 245VYTORIN 132VYVANSE 32VYZULTA 123
WWAKIX 36WAL-DRYL 452warfarin sodium 79water 431wavesense amp 299wavesense control solution 299wavesense jazz 316wavesense presto 299,316WELCHOL 131WELLBUTRIN SR 93WELLBUTRIN XL 93WERA 377WESTHROID 472wheat germ oil 481WILATE 126WINRHO SDF 211WIXELA INHUB 260WP THYROID 472WYMZYA FE 377
XXADAGO 180XALATAN 123XALKORI 174XANAX 228XANAX XR 229XARELTO 80XATMEP 174XCOPRI 90XELJANZ 406XELJANZ XR 406XELODA 175XELPROS 123XEMBIFY 211XENAZINE 255XENICAL 345XENLETA 75XEOMIN 419XEPI 46XERAC AC 452XERESE 47XERMELO 341XGEVA 397XHANCE 51XIAFLEX 329XIFAXAN 75XIGDUO XR 107XIIDRA 51XIMINO 71XOFIGO 432XOFLUZA 219XOLAIR 445,446XOLEGEL 119XOPENEX 233XOPENEX CONCENTRATE 233XOPENEX HFA 233XOSPATA 175XPOVIO 175XTAMPZA ER 26XTANDI 175
XULANE 377XULTOPHY 100-3.6 384XURIDEN 419XYLOCAINE IV 63XYNTHA 126XYNTHA SOLOFUSE 126XYOSTED 361XYREM 253XYWAV 253XYZAL 127
Yyale needle 299YASMIN 28 377YAZ 377YERVOY 176YF-VAX 215yohimbine hcl 473YONSA 176YUPELRI 78YUTIQ 51YUVAFEM 334
Zzafirlukast 54zaleplon 225ZALTRAP 176ZANAFLEX 449ZANOSAR 176ZANTAC 216ZARAH 377ZARONTIN 92ZARXIO 235ZAVESCA 419ZCORT 357ZEBUTAL 7ZEGERID 218,219ZEJULA 176ZELAPAR 180ZELBORAF 176ZELNORM 345
ZEMAIRA 446ZEMBRACE SYMTOUCH 143ZEMPLAR 481ZENATANE 465ZENPEP 343ZENZEDI 32ZEPATIER 352ZEPOSIA 411ZEPZELCA 176ZERIT 203ZERVIATE 335ZESTORETIC 440ZESTRIL 440ZETIA 132ZETONNA 51ZEVALIN 176ZIAC 251ZIAGEN 203ZIANA 46zidovudine 203ZIEXTENZO 235zileuton er 54ZILXI 46zinc chloride 326ZINECARD 419ZIOPTAN 123ziprasidone hcl 195ziprasidone mesylate 195ZIPSOR 426ZIRABEV 176ZIRGAN 42ZITHROMAX 391ZITHROMAX TRI-PAK 391ZOCOR 138ZODRYL DAC 50 444ZODRYL DAC 60 444ZODRYL DAC 80 444ZODRYL DEC 50 444ZODRYL DEC 60 444ZODRYL DEC 80 444ZOFRAN 111
ZOHYDRO ER 26ZOLADEX 350zoledronic acid 397ZOLINZA 177zolmitriptan 143zolmitriptan odt 143ZOLOFT 98zolpidem tartrate 225zolpidem tartrate er 225ZOLPIMIST 225ZOMETA 397ZOMIG 143ZOMIG ZMT 143ZONALON 452ZONEGRAN 90zonisamide 90ZONTIVITY 206ZORBTIVE 379ZORTRESS 415ZORVOLEX 426ZOSTAVAX 215ZOSYN 429ZOVIA 1-35 377ZOVIA 1-35E 377ZOVIRAX 47,223ZTLIDO 452ZUBSOLV 28ZUMANDIMINE 377ZUPLENZ 111ZYBAN 93ZYCLARA 465ZYDELIG 177ZYFLO 54ZYFLO CR 54ZYKADIA 177ZYLET 41ZYLOPRIM 394ZYMAXID 41ZYPITAMAG 138ZYPREXA 195,196ZYPREXA RELPREVV 196
ZYPREXA ZYDIS 196ZYTIGA 177ZYVOX 75
Recommended