2018 Cigna-HealthSpring Rx COMPREHENSIVE …...2018 Cigna-HealthSpring Rx COMPREHENSIVE DRUG LIST (Formulary) This drug list was updated in November 2018. For more recent information

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

2018 Cigna-HealthSpring Rx COMPREHENSIVE DRUG LIST (Formulary)

This drug list was updated in November 2018. For more recent information or other questions, please contact Cigna-HealthSpring Customer Service, at 1-800-222-6700 or, for TTY users, 711, 8 a.m. - 8 p.m., local time, 7 days a week. Our automated phone system may answer your call during weekends from Feb. 15 – Sept. 30., or visit www.CignaHealthSpring.com. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Cigna-HealthSpring Rx is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring Rx depends on contract renewal.HPMS Approved Formulary File Submission ID 18082, Version 18 Y0036_18_55624a_Final_5k Populated Template 08042017

Plan coveredCigna-HealthSpring Rx Secure (PDP)

1

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

Can the Drug List (formulary) change?Generally, if you are taking a drug on our 2018 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic equivalent of the drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of drug list changes, such as removing a drug from our drug list, will not affect customers who are currently taking the drug. It will remain available at the same cost-sharing for those customers taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the drugs that were available when you chose our plan, except for cases in which you can save additional money on the generic equivalent or we can ensure your safety. If we remove drugs from our drug list, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected customers of the change at least 60 days before the change becomes effective, or at the time the customer requests

a refill of the drug, at which time the customer will receive a 60-day supply of the drug. If the Food and Drug Administration (FDA) deems a drug on our drug list to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our drug list and provide notice to customers who take the drug. The enclosed drug list is current as of November 2018. To get updated information about the drugs covered by Cigna-HealthSpring Rx, please contact us. Our contact information appears on the front and back cover pages. If there are significant changes made to the printed drug list within the covered year, you may be notified by mail identifying the changes. Drug lists located on our website are reviewed and updated on a monthly basis.

How do I use the Drug List? There are two ways to find your drug within the drug list:Medical ConditionThe drug list begins on page 16. The drugs in this drug list are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “CARDIOVASCULAR AGENTS”. If you know what your drug is used for, look for the category name in the list that begins on page 16. Then look under the category name for your drug. Covered Drug IndexIf you are not sure what category to look under, you should look for your drug in the Covered Drugs Index section that begins on page 59. The Covered Drugs Index provides a list of all of the drugs included in this document. Both brand name drugs and generic drugs are in the Drug List. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Covered Drug Index and find the name of your drug in the drug name column of the list.

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

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Cigna-HealthSpring Rx. When it refers to “plan” or “our plan,” it means Cigna-HealthSpring Rx Secure (PDP).

This document includes a list of the drugs (formulary) for our plans, which is current as of November 2018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2019, and from time to time during the year.

2

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

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

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

• Quantity Limits: For certain drugs, Cigna-HealthSpring Rx limits the amount of the drug that Cigna-HealthSpring Rx will cover. For example, Cigna-HealthSpring Rx allows for 1 tablet per day for BYSTOLIC 10MG. This applies to a standard one-month supply (for total quantity of 30 per 30 days) or three-month supply (for total quantity of 90 per 90 days).

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

You can find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 16. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.You can ask Cigna-HealthSpring Rx to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Cigna-HealthSpring Rx Drug List” on this page for information about how to request an exception.

Options for Maintenance MedicationsTaking the medications prescribed by your doctor (or other prescriber) is important to your health. We are committed to helping you achieve control of chronic conditions by making it easy for you to receive your maintenance medications. As part of our commitment to

coordinating your healthcare needs, we have set a goal of helping you take your medications at least 80% of the time. There are several ways we can work together to accomplish this goal:• Talk with your doctor about whether a 90-day supply of your

ongoing, stable medications may be appropriate. Taking these medications every day as prescribed is important for your overall health, and getting 90-day prescriptions of these medications can help ensure that you do not miss a dose.

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

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

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

cost generic alternatives available for any of your current medications.

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

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

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

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

• You can ask Cigna-HealthSpring Rx to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Cigna-HealthSpring Rx Drug List?You can ask Cigna-HealthSpring Rx to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

3

• You can ask us to cover a drug even if it is not in our drug list. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Cigna-HealthSpring Rx limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

• You can ask us to provide a tiering exception for a higher cost sharing drug to be covered at a lower cost-sharing tier. If your drug is contained in the Non-Preferred Drugs tier, you can ask us to cover it at the Preferred Brand Drugs tier, and if your drug is contained in the Generic Drugs tier, you can ask us to cover it at the Preferred Generic Drugs tier. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not in our drug list, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier.

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

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or existing customer in our plan you may be taking drugs that are not in our drug list. Or, you may be taking a drug that is on our drug list but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a drug list exception so that we will cover the

drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a customer of our plan.For each of your drugs that is not on our drug list or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs without a drug list exception, even if you have been a customer of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91- to 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a customer of our plan. If you need a drug that is not in our drug list or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a drug list exception. In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning, such as level-of-care changes due to discharge from a hospital to a nursing facility or to a home, Cigna-HealthSpring Rx will allow a one-time 31-day supply (unless the prescription is written for fewer days). Cigna-HealthSpring Rx’s Drug ListThe comprehensive drug list provides coverage information about all of the drugs covered by Cigna-HealthSpring Rx. If you have trouble finding your drug in the list, turn to the Covered Drug Index that begins on page 59. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., BYSTOLIC) and generic drugs are listed in lower-case italics (e.g., simvastatin).The information in the Requirements/Limits column tells you if Cigna-HealthSpring Rx has any special requirements for coverage of your drug.We provide quantity limits on certain drugs which are indicated with a QL in the Covered Drugs by Category list on page 16 along with the amount dispensed per the days supplied. (For example: BYSTOLIC 10MG QL 30/30; this means the drug BYSTOLIC 10MG is limited to 30 tablets per 30 days. For 90-day supplies, this quantity limit would be expanded to 90 tablets per 90 days).

4

What is a preferred network pharmacy?If your plan has preferred network pharmacies, you will typically save money by using these pharmacies. Your prescription drug costs (like a copay or coinsurance) will typically be less at a preferred network pharmacy because it has a preferred agreement with your plan. You will receive a Pharmacy Directory in your Welcome Kit after you enroll, or you can visit www.CignaHealthSpring.com for the most current Pharmacy Directory.

For more information

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

Key:B/D – This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending on circumstances.

PA – This drug requires prior authorization

QL – This drug has quantity limits

ST – This drug has step therapy requirements

Generally all medications in the drug list are available through mail order, except when special circumstances or situations prohibit mailing a particular medication to your home.

5

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

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

To locate your drug cost, please refer to the table(s) below to find your service area and the Prescription Drug plan in which you are currently enrolled or would like to enroll.Cigna-HealthSpring Rx has pharmacies with preferred cost-shares. See your Pharmacy Directory or visit www.CignaHealthSpring.com for information on which stores with preferred cost-shares are near you.

Cigna-HealthSpring Rx Secure (PDP)

Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing

Preferred Mail Order

Cost-Sharing

Standard Mail Order

Cost-Sharing

Long-term Care 31 days

Out-of-network 30 days*30/60/90 Days 30/60/90 Days 30/60/90 Days 30/60/90 Days

ALABAMATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6

Tier 2: Generic Drugs $5 / $10 / $15 $10 / $20 / $30 $5 / $10 / $15 $10 / $20 / $30 $10

Tier 3: Preferred Brand Drugs $30 / $60 / $90 $35 / $70 / $105 $30 / $60 / $90 $35 / $70 / $105 $35

Tier 4: Non-Preferred Drugs 39% 39% 39% 39% 39%

Tier 5: Specialty Tier 25% (30 days) 25% (30 days) 25% (30 days) 25% (30 days) 25%

ALASKATier 1: Preferred Generic Drugs $2 / $4 / $6 $7 / $14 / $21 $2 / $4 / $6 $7 / $14 / $21 $7





* You will pay the copay or percentage of the drug cost shown above plus the difference between the Out–of–Network pharmacy billed charge and our typical Standard Retail pharmacy billed costs.

6


Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



ARIZONATier 1: Preferred Generic Drugs $2 / $4 / $6 $7 / $14 / $21 $2 / $4 / $6 $7 / $14 / $21 $7





ARKANSASTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





CALIFORNIATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





COLORADOTier 1: Preferred Generic Drugs $0 / $0 / $0 $5 / $10 / $15 $0 / $0 / $0 $5 / $10 / $15 $5





CONNECTICUTTier 1: Preferred Generic Drugs $0 / $0 / $0 $5 / $10 / $15 $0 / $0 / $0 $5 / $10 / $15 $5






7



Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



DELAWARETier 1: Preferred Generic Drugs $2 / $4 / $6 $7 / $14 / $21 $2 / $4 / $6 $7 / $14 / $21 $7





DISTRICT OF COLUMBIATier 1: Preferred Generic Drugs $2 / $4 / $6 $7 / $14 / $21 $2 / $4 / $6 $7 / $14 / $21 $7





FLORIDATier 1: Preferred Generic Drugs $0 / $0 / $0 $5 / $10 / $15 $0 / $0 / $0 $5 / $10 / $15 $5





GEORGIATier 1: Preferred Generic Drugs $0 / $0 / $0 $5 / $10 / $15 $0 / $0 / $0 $5 / $10 / $15 $5





HAWAIITier 1: Preferred Generic Drugs $2 / $4 / $6 $7 / $14 / $21 $2 / $4 / $6 $7 / $14 / $21 $7





8


Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



IDAHOTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





ILLINOISTier 1: Preferred Generic Drugs $2 / $4 / $6 $7 / $14 / $21 $2 / $4 / $6 $7 / $14 / $21 $7





INDIANATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





IOWATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





KANSASTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6






9



Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



KENTUCKYTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





LOUISIANATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





MAINETier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





MARYLANDTier 1: Preferred Generic Drugs $2 / $4 / $6 $7 / $14 / $21 $2 / $4 / $6 $7 / $14 / $21 $7





MASSACHUSETTSTier 1: Preferred Generic Drugs $0 / $0 / $0 $5 / $10 / $15 $0 / $0 / $0 $5 / $10 / $15 $5





10


Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



MICHIGANTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





MINNESOTATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





MISSISSIPPITier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





MISSOURITier 1: Preferred Generic Drugs $0 / $0 / $0 $5 / $10 / $15 $0 / $0 / $0 $5 / $10 / $15 $5





MONTANATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6






11



Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



NEBRASKATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





NEVADATier 1: Preferred Generic Drugs $0 / $0 / $0 $5 / $10 / $15 $0 / $0 / $0 $5 / $10 / $15 $5





NEW HAMPSHIRETier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





NEW JERSEYTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





NEW MEXICOTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





12


Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



NEW YORKTier 1: Preferred Generic Drugs $2 / $4 / $6 $7 / $14 / $21 $2 / $4 / $6 $7 / $14 / $21 $7





NORTH CAROLINATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





NORTH DAKOTATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





OHIOTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





OKLAHOMATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6






13



Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



OREGONTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





PENNSYLVANIATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





RHODE ISLANDTier 1: Preferred Generic Drugs $0 / $0 / $0 $5 / $10 / $15 $0 / $0 / $0 $5 / $10 / $15 $5





SOUTH CAROLINATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





SOUTH DAKOTA Tier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





14


Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



TENNESSEETier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





TEXASTier 1: Preferred Generic Drugs $2 / $4 / $6 $7 / $14 / $21 $2 / $4 / $6 $7 / $14 / $21 $7





UTAHTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





VERMONTTier 1: Preferred Generic Drugs $0 / $0 / $0 $5 / $10 / $15 $0 / $0 / $0 $5 / $10 / $15 $5





VIRGINIATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6






15



Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail Order

Cost-Sharing



WASHINGTONTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





WEST VIRGINIATier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





WISCONSINTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





WYOMINGTier 1: Preferred Generic Drugs $1 / $2 / $3 $6 / $12 / $18 $1 / $2 / $3 $6 / $12 / $18 $6





16

Covered Drugs By Category

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Analgesics

Analgesicsbutalbital/acetaminophen/caffeine caps

3 PA QL(180/30)

butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg

3 PA QL(180/30)

butalbital/aspirin/caffeine caps 3 PA QL(180/30)esgic caps 3 PA QL(180/30)zebutal caps 325mg; 50mg; 40mg

3 PA QL(180/30)

Nonsteroidal Anti-inflammatory Drugscelecoxib caps 400mg 3 QL(30/30)celecoxib caps 100mg, 200mg, 50mg

3 QL(60/30)

diclofenac potassium 2diclofenac sodium dr tbec 25mg, 50mg

2

diclofenac sodium dr tbec 75mg 1diclofenac sodium er 2diflunisal 2etodolac 2etodolac er 2fenoprofen calcium caps 400mg

2

fenoprofen calcium tabs 2flurbiprofen 2ibu tabs 600mg, 800mg 1ibuprofen susp 1ibuprofen tabs 400mg, 600mg, 800mg

1

meclofenamate sodium 2meloxicam 1 QL(30/30)nabumetone 2naproxen dr 2naproxen sodium tabs 275mg, 550mg

2

naproxen susp 2naproxen tabs 250mg 2naproxen tabs 375mg, 500mg 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

oxaprozin 2piroxicam 2salsalate 2sulindac 2tolmetin sodium 2Opioid Analgesics, Long-actingbuprenorphine hcl inj 4 QL(150/30)DURAMORPH 4 QL(180/30)fentanyl 4 QL(10/30)INFUMORPH 200 4 QL(200/30)INFUMORPH 500 4 QL(200/30)levorphanol tartrate 5 QL(120/30)methadone hcl conc 2 QL(500/30)methadone hcl inj 4 QL(150/30)methadone hcl intensol 2 QL(500/30)methadone hcl oral soln 10mg/5ml

2 QL(450/30)

methadone hcl oral soln 5mg/5ml

2 QL(600/30)

methadone hcl tabs 10mg 2 QL(120/30)methadone hcl tabs 5mg 2 QL(180/30)mitigo 4 QL(200/30)morphine sulfate er tbcr 3 QL(90/30)morphine sulfate inj 0.5mg/ml, 1mg/ml

4 QL(180/30)

XTAMPZA ER 3 QL(60/30)Opioid Analgesics, Short-actingacetaminophen/codeine oral soln

2 QL(2700/30)

acetaminophen/codeine tabs 300mg; 60mg

2 QL(180/30)

acetaminophen/codeine tabs 300mg; 15mg, 300mg; 30mg

2 QL(360/30)

ascomp/codeine 3 PA QL(180/30)butalbital/acetaminophen/caffeine/codeine

3 PA QL(180/30)

butalbital/aspirin/caffeine/codeine

3 PA QL(180/30)

butorphanol tartrate inj 1mg/ml 4 QL(480/30)butorphanol tartrate inj 2mg/ml 4 QL(240/30)butorphanol tartrate nasal soln 2 QL(5/30)

17


CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drugQL = Quantity Limits listed as (qty/days) ST = Step Therapy rules applyPA = Prior Authorization may be required B/D = Drugs covered under Medicare Part B or Part DYou can find more information on the symbols by going to page 4.

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

endocet tabs 325mg; 10mg 3 QL(180/30)endocet tabs 325mg; 7.5mg 3 QL(240/30)endocet tabs 325mg; 2.5mg, 325mg; 5mg

3 QL(360/30)

fentanyl citrate inj 1000mcg/20ml, 100mcg/2ml, 2500mcg/50ml, 250mcg/5ml

4 B/D PA

fentanyl citrate oral transmucosal lpop 200mcg, 400mcg, 600mcg

4 PA QL(120/30)

fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 800mcg

5 PA QL(120/30)

hydrocodone bitartrate/acetaminophen oral soln

3 QL(2700/30)

hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg, 300mg; 7.5mg

3 QL(180/30)

hydrocodone bitartrate/acetaminophen tabs 300mg; 5mg, 325mg; 2.5mg

3 QL(360/30)

hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 7.5mg

3 QL(180/30)

hydrocodone/acetaminophen tabs 325mg; 5mg

3 QL(360/30)

hydrocodone/ibuprofen 3 QL(150/30)hydromorphone hcl dosette 4hydromorphone hcl inj 4hydromorphone hcl liqd 3 QL(1200/30)hydromorphone hcl tabs 8mg 3 QL(120/30)hydromorphone hcl tabs 2mg, 4mg

3 QL(180/30)

ibudone tabs 5mg; 200mg 3 QL(150/30)lorcet 3 QL(360/30)lorcet hd 3 QL(180/30)lorcet plus tabs 325mg; 7.5mg 3 QL(180/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

morphine sulfate inj 150mg/30ml, 50mg/ml, 5mg/ml

4

morphine sulfate inj 1mg/ml 4 QL(180/30)morphine sulfate inj 10mg/ml 4 QL(200/30)morphine sulfate inj 8mg/ml 4 QL(250/30)MORPHINE SULFATE INJ 4MG/ML

4 QL(630/30)

MORPHINE SULFATE INJ 2MG/ML

4 QL(1260/30)

morphine sulfate oral soln 100mg/5ml

2 QL(180/30)


2 QL(300/30)


2 QL(700/30)

MORPHINE SULFATE TABS 3 QL(120/30)nalbuphine hcl inj 20mg/ml 4 QL(90/30)nalbuphine hcl inj 10mg/ml 4 QL(180/30)oxycodone hcl caps 3 QL(120/30)oxycodone hcl conc 3 QL(120/30)oxycodone hcl oral soln 3 QL(1200/30)oxycodone hcl tabs 30mg 3 QL(90/30)oxycodone hcl tabs 10mg, 15mg, 20mg, 5mg

3 QL(120/30)

oxycodone/acetaminophen tabs 325mg; 10mg

3 QL(180/30)

oxycodone/acetaminophen tabs 325mg; 7.5mg

3 QL(240/30)

oxycodone/acetaminophen tabs 325mg; 2.5mg, 325mg; 5mg

3 QL(360/30)

oxycodone/aspirin 3 QL(180/30)oxycodone/ibuprofen 3 QL(28/30)tramadol hcl 2 QL(240/30)vicodin es tabs 300mg; 7.5mg 3 QL(180/30)vicodin hp tabs 300mg; 10mg 3 QL(180/30)vicodin tabs 300mg; 5mg 3 QL(360/30)

18


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antibacterials

Aminoglycosidesamikacin sulfate 4gentak 2gentamicin sulfate crea 2gentamicin sulfate inj 4gentamicin sulfate oint 2gentamicin sulfate ophthalmic soln

4

gentamicin sulfate pediatric 4gentamicin sulfate/0.9% sodium chloride

4

isotonic gentamicin 4neomycin sulfate 2neomycin/polymyxin b sulfates 4paromomycin sulfate 4streptomycin sulfate 4tobramycin ophthalmic soln 2tobramycin sulfate inj 1.2gm, 10mg/ml, 80mg/2ml

4

tobramycin sulfate ophthalmic soln

2

TOBREX OINT 3ZYLET 3 STAntibacterials, Otheralcohol prep pads 1baciim 4bacitracin inj 4bacitracin ophthalmic oint 2bacitracin/polymyxin b 2BACTROBAN NASAL 3chloramphenicol sodium succinate

1

clindacin etz pledgets 2clindacin-p 2clindamycin 4clindamycin hcl 2clindamycin hydrochloride 2clindamycin phosphate crea 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Anesthetics

Local Anestheticsglydo 2lidocaine hcl external soln 2lidocaine hcl gel 2lidocaine hcl inj 4lidocaine hcl jelly 2lidocaine hcl mouth/throat soln 2lidocaine hcl viscous 1lidocaine oint 4 QL(120/30)lidocaine ptch 4 PA QL(90/30)lidocaine viscous 1lidocaine/prilocaine crea 4

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-cravingacamprosate calcium dr 2disulfiram 2Opioid Dependence Treatmentsbuprenorphine hcl subl 4 PA QL(90/30)buprenorphine hcl/naloxone hcl 3 PA QL(90/30)naltrexone hcl 2SUBOXONE 3 PA QL(90/30)ZUBSOLV SUBL 0.7MG; 0.18MG

3 PA QL(30/30)

ZUBSOLV SUBL 1.4MG; 0.36MG, 11.4MG; 2.9MG, 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG

3 PA QL(90/30)

Opioid Reversal Agentsnaloxone hcl 2NARCAN 3 QL(4/30)Smoking Cessation Agentsbupropion hcl sr 3 QL(60/30)CHANTIX 3 QL(336/365)CHANTIX CONTINUING MONTH PAK

3 QL(336/365)

CHANTIX STARTING MONTH PAK

3 QL(336/365)

NICOTROL INHALER 4 QL(1008/90)

19



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nitrofurantoin 4nitrofurantoin macrocrystals 2nitrofurantoin monohydrate 2nitrofurantoin monohydrate/macrocrystals

2

polycin 2polymyxin b sulfate 4polymyxin b sulfate/trimethoprim sulfate

2

rosadan 2silver sulfadiazine 3ssd 3SYNERCID 5tigecycline 5trimethoprim 2trimethoprim sulfate/polymyxin b sulfate

2

TYGACIL 5vancomycin 4vancomycin hcl caps 125mg 4 QL(40/10)vancomycin hcl caps 250mg 4 QL(80/10)vancomycin hcl in dextrose 4vancomycin hcl inj 0.9%; 1gm/200ml, 10gm, 1gm, 500mg, 5gm, 750mg

4

VANCOMYCIN HYDROCHLORIDE INJ 250MG

4

vancomycin hydrochloride/sodium chloride inj 0.9%; 750mg/150ml

4

vandazole 2XIFAXAN TABS 200MG 4 PA QL(9/30)XIFAXAN TABS 550MG 5 PA QL(90/30)Beta-lactam, Cephalosporinscefaclor caps 2cefaclor er 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clindamycin phosphate external soln

2

clindamycin phosphate gel 2clindamycin phosphate in d5w 4clindamycin phosphate inj 150mg/ml, 300mg/2ml, 600mg/4ml, 900mg/6ml

4

clindamycin phosphate lotn 2clindamycin phosphate swab 2clindamycin/sodium chloride 4colistimethate sodium 4daptomycin inj 500mg 5 B/D PAlincomycin hcl 4linezolid inj 4linezolid susr 5 QL(1800/30)linezolid tabs 5 QL(60/30)methenamine hippurate 2metronidazole crea 2metronidazole gel 2metronidazole in nacl 0.79% 4metronidazole inj 500mg/100ml; 0.79%, 5mg/ml

4

metronidazole lotn 2metronidazole tabs 1metronidazole vaginal 2mupirocin crea 4mupirocin oint 2neo-polycin 2neo-polycin hc 2neomycin/bacitracin/polymyxin 2neomycin/polymyxin/bacitracin/hydrocortisone

2

neomycin/polymyxin/gramicidin 2neomycin/polymyxin/hydrocortisone

2

20


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

imipenem/cilastatin inj 250mg; 250mg

2

INVANZ 4meropenem 4meropenem/sodium chloride 4Beta-lactam, Penicillinsamoxicillin caps 1amoxicillin chew 2amoxicillin susr 1amoxicillin tabs 2amoxicillin/clavulanate potassium

2

amoxicillin/clavulanate potassium er

2

ampicillin 2ampicillin sodium 4ampicillin-sulbactam 4AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML

3

BICILLIN L-A 4dicloxacillin sodium 2nafcillin sodium inj 10gm, 1gm, 2gm

4

nafcillin sodium inj 2gm 5oxacillin sodium 4penicillin g potassium 4penicillin v potassium oral soln 1penicillin v potassium tabs 250mg

1

penicillin v potassium tabs 500mg

2

pfizerpen inj 20mu, 5000000unit

4

piperacillin sodium/tazobactam sodium

4

piperacillin/tazobactam 4ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML; 0.5GM/100ML

4

MacrolidesAZASITE 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cefaclor susr 3cefadroxil 2CEFAZOLIN 4cefazolin sodium inj 10gm, 1gm, 1gm/50ml; 4%, 500mg

4

cefazolin sodium/dextrose inj 2gm; 3%

4

cefdinir 2cefepime 4cefepime/dextrose 4cefixime 4cefotaxime sodium 4cefoxitin sodium inj 10gm, 1gm, 2gm

4

cefpodoxime proxetil 4cefprozil 2ceftazidime 4ceftazidime/dextrose 4ceftriaxone in iso-osmotic dextrose

4

ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg

4

cefuroxime axetil 3cefuroxime sodium 4cephalexin caps 250mg, 500mg 2cephalexin susr 2cephalexin tabs 2SUPRAX SUSR 500MG/5ML 3tazicef inj 1gm, 2gm, 6gm 4TEFLARO 5Beta-lactam, OtherAZACTAM 4AZACTAM IN ISO-OSMOTIC DEXTROSE

4

aztreonam inj 1gm 4aztreonam inj 2gm 5cefotetan 4ertapenem 4ertapenem sodium 4imipenem/cilastatin inj 500mg; 500mg

4

21



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ciprofloxacin hcl tabs 100mg, 250mg, 750mg

2

ciprofloxacin hydrochloride 2ciprofloxacin i.v.-in d5w 4ciprofloxacin susr 2levofloxacin in d5w 4levofloxacin inj 4levofloxacin oral soln 2levofloxacin tabs 2 QL(30/30)moxifloxacinhydrochloride/sodium hydrochloride

4

moxifloxacin hcl inj 4moxifloxacin hcl tabs 4 QL(30/30)moxifloxacin hydrochloride ophthalmic soln

3

ofloxacin 2VIGAMOX 3SulfonamidesBLEPHAMIDE 3BLEPHAMIDE S.O.P. 3sodium sulfacetamide ophthalmic soln

2

sulfacetamide sodium lotn 2sulfacetamide sodium ophthalmic soln

2

sulfacetamide sodium/prednisolone sodium phosphate

2

sulfadiazine 2sulfamethoxazole/trimethoprim ds

1

sulfamethoxazole/trimethoprim inj

4

sulfamethoxazole/trimethoprim susp

1

sulfamethoxazole/trimethoprim tabs

1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

azithromycin inj 4azithromycin pack 3azithromycin susr 200mg/5ml 2 QL(75/30)azithromycin susr 100mg/5ml 2 QL(150/30)azithromycin tabs 250mg, 500mg

2 QL(12/28)

azithromycin tabs 600mg 2 QL(60/30)clarithromycin er 2 QL(60/30)clarithromycin susr 2clarithromycin tabs 2 QL(42/14)e.e.s. 400 3ery 2ERY-TAB 3ERYPED 400 5ERYTHROCIN LACTOBIONATE

4

erythrocin stearate 2erythromycin base 4erythromycin ethylsuccinate 3erythromycin external soln 2erythromycin gel 2erythromycin oint 2erythromycin pads 2QuinolonesAVELOX INJ 4BAXDELA 4BESIVANCE 4CILOXAN OINT 3CIPRO HC 3CIPRODEX 3ciprofloxacin er tb24 500mg; 0 2 QL(3/3)ciprofloxacin er tb24 1000mg; 0 2 QL(14/14)ciprofloxacin hcl ophthalmic soln

2

22


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SPRITAM TB3D 1000MG, 250MG, 500MG

4 QL(60/30)

SPRITAM TB3D 750MG 4 QL(120/30)Calcium Channel Modifying AgentsCELONTIN 3ethosuximide 2LYRICA CAPS 225MG, 300MG 3 QL(60/30)LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG

3 QL(90/30)

LYRICA ORAL SOLN 3 QL(900/30)zonisamide 2Gamma-aminobutyric Acid (GABA) Augmenting Agentsclonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg

4 QL(90/30)

clonazepam odt tbdp 1mg 4 QL(120/30)clonazepam odt tbdp 2mg 4 QL(300/30)clonazepam tabs 0.5mg 2 QL(90/30)clonazepam tabs 1mg 2 QL(120/30)clonazepam tabs 2mg 2 QL(300/30)DIASTAT ACUDIAL GEL 10MG 4 QL(20/30)DIASTAT ACUDIAL GEL 20MG 4 QL(40/30)DIASTAT PEDIATRIC 4 QL(5/30)diazepam rectal gel gel 2.5mg 3 QL(5/30)diazepam rectal gel gel 10mg 3 QL(20/30)diazepam rectal gel gel 20mg 3 QL(40/30)divalproex sodium 2divalproex sodium dr 2divalproex sodium er 2gabapentin caps 100mg 2 QL(180/30)gabapentin caps 300mg, 400mg

2 QL(270/30)

gabapentin oral soln 2 QL(2160/30)gabapentin tabs 800mg 2gabapentin tabs 600mg 2 QL(180/30)GABITRIL TABS 16MG 4 QL(90/30) STGABITRIL TABS 12MG 4 QL(120/30) STONFI SUSP 5 QL(480/30)ONFI TABS 20MG 5 QL(60/30)ONFI TABS 10MG 4 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sulfatrim pediatric 1Tetracyclinesdoxy 100 4doxycycline hyclate caps 2doxycycline hyclate tabs 100mg, 20mg

2

doxycycline monohydrate caps 100mg, 50mg

2 QL(60/30)

doxycycline monohydrate caps 75mg

3 QL(60/30)

doxycycline monohydrate tabs 2doxycycline susr 2minocycline hcl 2mondoxyne nl 2 QL(60/30)morgidox 1x100mg caps 2morgidox 1x50mg 2morgidox 2x100mg caps 2tetracycline hydrochloride 1

Anticonvulsants

Anticonvulsants, OtherAPTIOM TABS 200MG, 400MG, 800MG

5 QL(30/30) ST

APTIOM TABS 600MG 5 QL(60/30) STBRIVIACT INJ 5 QL(600/30)BRIVIACT ORAL SOLN 5 QL(1200/30)BRIVIACT TABS 10MG, 25MG, 50MG, 75MG

5 QL(60/30)

BRIVIACT TABS 100MG 5 QL(120/30)FYCOMPA SUSP 4 PA QL(720/30)FYCOMPA TABS 4 PA QL(30/30)levetiracetam er tb24 750mg 2 QL(120/30)levetiracetam er tb24 500mg 2 QL(180/30)levetiracetam inj 4levetiracetam oral soln 2levetiracetam tabs 2magnesium sulfate in d5w 4 B/D PAroweepra 2roweepra xr tb24 750mg 2 QL(120/30)roweepra xr tb24 500mg 2 QL(180/30)

23



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

oxcarbazepine tabs 3PEGANONE 3phenytoin 2phenytoin infatabs 2phenytoin sodium 4phenytoin sodium extended 2VIMPAT INJ 4 QL(1200/30)VIMPAT ORAL SOLN 4 QL(1200/30)VIMPAT TABS 4 QL(60/30)

Antidementia Agents

Antidementia Agents, Otherergoloid mesylates 2 PANAMZARIC C4PK 3 QL(56/365)NAMZARIC CP24 3 QL(30/30)Cholinesterase Inhibitorsdonepezil hcl tabs 23mg 3 QL(30/30)donepezil hcl tabs 5mg 2 QL(30/30)donepezil hcl tabs 10mg 2 QL(60/30)donepezil hcl tbdp 5mg 2 QL(30/30)donepezil hcl tbdp 10mg 2 QL(60/30)donepezil hydrochloride tabs 5mg

2 QL(30/30)

donepezil hydrochloride tabs 10mg

2 QL(60/30)

galantamine hydrobromide er 4 QL(30/30)galantamine hydrobromide oral soln

4 QL(200/30)

galantamine hydrobromide tabs 4 QL(60/30)rivastigmine tartrate 4 QL(60/30)rivastigmine transdermal system

4 QL(30/30)

N-methyl-D-aspartate (NMDA) Receptor Antagonistmemantine hcl tabs 10mg 4 PA QL(60/30)memantine hcl tabs 5mg 4 PA QL(90/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

phenobarbital elix 2 QL(1500/30)phenobarbital tabs 2 QL(120/30)primidone 2SABRIL PACK 5 PA QL(200/30)SABRIL TABS 5 PA QL(180/30)tiagabine hydrochloride tabs 4mg

4 ST

tiagabine hydrochloride tabs 16mg

4 QL(90/30) ST


4 QL(120/30) ST


4 QL(240/30) ST

valproate sodium 4valproic acid 2vigabatrin 5 PA QL(200/30)Glutamate Reducing Agentsfelbamate susp 5felbamate tabs 4lamotrigine 2lamotrigine er 4lamotrigine odt 4topiramate 2Sodium Channel AgentsBANZEL SUSP 5 PA QL(2400/30)BANZEL TABS 200MG 5 PA QL(60/30)BANZEL TABS 400MG 5 PA QL(240/30)carbamazepine 2carbamazepine er cp12 2carbamazepine er tb12 3DILANTIN 4DILANTIN INFATABS 4epitol 2fosphenytoin sodium 4oxcarbazepine susp 2

24


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

desvenlafaxine er 4 QL(30/30)duloxetine hcl cpep 20mg 2 QL(60/30)duloxetine hydrochloride cpep 60mg

2 QL(60/30)

duloxetine hydrochloride cpep 30mg

2 QL(90/30)

escitalopram oxalate oral soln 2 QL(600/30)escitalopram oxalate tabs 5mg 2 QL(30/30)escitalopram oxalate tabs 10mg 2 QL(60/30)escitalopram oxalate tabs 20mg 2 QL(90/30)FETZIMA 4 QL(30/30) STFETZIMA TITRATION PACK 4 QL(56/365) STfluoxetine caps 10mg 2 QL(30/30)fluoxetine caps 20mg 2 QL(120/30)fluoxetine dr 2 QL(4/28)fluoxetine hcl caps 10mg 2 QL(30/30)fluoxetine hcl caps 40mg 2 QL(60/30)fluoxetine hcl caps 20mg 2 QL(120/30)fluoxetine hcl oral soln 2 QL(600/30)fluoxetine hydrochloride tabs 10mg

2 QL(30/30)

fluoxetine hydrochloride tabs 20mg

2 QL(120/30)

fluvoxamine maleate tabs 25mg, 50mg

3 QL(30/30)

fluvoxamine maleate tabs 100mg

3 QL(90/30)

olanzapine/fluoxetine 4 QL(30/30)paroxetine hcl tabs 30mg, 40mg

2 QL(60/30)

paroxetine hcl tabs 10mg 1 QL(30/30)paroxetine hcl tabs 20mg 1 QL(90/30)PAXIL SUSP 3 QL(900/30) STPRISTIQ 4 QL(30/30)sertraline hcl conc 2 QL(300/30)sertraline hcl tabs 25mg 2 QL(30/30)sertraline hcl tabs 100mg 2 QL(60/30)sertraline hcl tabs 50mg 2 QL(120/30)venlafaxine hcl 2 QL(90/30)venlafaxine hcl er cp24 37.5mg 2 QL(30/30)venlafaxine hcl er cp24 150mg 2 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

memantine hcl titration pak 4 PA QL(49/28)memantine hydrochloride er 3 PA QL(30/30)memantine hydrochloride oral soln

4 PA QL(300/30)

NAMENDA XR 3 PA QL(30/30)NAMENDA XR TITRATION PACK

3 PA QL(56/365)

Antidepressants

Antidepressants, Otherbupropion hcl er tb12 100mg, 200mg

3 QL(60/30)

bupropion hcl sr 3 QL(60/30)bupropion hcl tabs 100mg 3 QL(120/30)bupropion hcl xl 3 QL(30/30)bupropion hydrochloride tabs 75mg

3 QL(180/30)

maprotiline hcl 4 QL(90/30)mirtazapine 2 QL(30/30)mirtazapine odt 2 QL(30/30)nefazodone hcl 4 QL(60/30)nefazodone hydrochloride 4 QL(60/30)trazodone hydrochloride tabs 300mg

2

trazodone hydrochloride tabs 100mg, 150mg, 50mg

1

TRINTELLIX 4 QL(30/30) STMonoamine Oxidase InhibitorsEMSAM 5 QL(30/30)MARPLAN 4 QL(180/30)phenelzine sulfate 2tranylcypromine sulfate 2SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitorcitalopram hydrobromide oral soln

1 QL(600/30)

citalopram hydrobromide tabs 10mg

1


1 QL(30/30)


1 QL(60/30)

25



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

granisetron hcl inj 4 B/D PAgranisetron hcl tabs 2 B/D PA QL(30/30)ondansetron hcl inj 40mg/20ml, 4mg/2ml

4

ondansetron hcl oral soln 2 B/D PA QL(450/30)ondansetron hcl tabs 24mg 2 B/D PA QL(15/30)ondansetron hcl tabs 4mg, 8mg 2 B/D PA QL(90/30)ondansetron odt 2 B/D PA QL(90/30)SANCUSO 5 QL(4/28)

Antifungals

AntifungalsABELCET 5 PAAMBISOME 5 PAamphotericin b 4 PACANCIDAS 5 PAcaspofungin acetate 5 PAciclodan 2ciclopirox nail lacquer 2ciclopirox olamine 2ciclopirox sham 2ciclopirox susp 2clotrimazole external crea 2clotrimazole external soln 2clotrimazole lozg 2clotrimazole/betamethasone dipropionate

2

econazole nitrate 3fluconazole in nacl 4fluconazole susr 2fluconazole tabs 100mg, 200mg, 50mg

2

fluconazole tabs 150mg 1flucytosine 5griseofulvin microsize 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

venlafaxine hcl er cp24 75mg 2 QL(90/30)VIIBRYD 4 QL(30/30) STVIIBRYD STARTER PACK 4 QL(30/30) STTricyclicsamitriptyline hcl 2 PAamoxapine 2clomipramine hcl 4 PAdesipramine hcl 2imipramine hcl tabs 25mg, 50mg

2 PA

imipramine hydrochloride 2 PAnortriptyline hcl 2perphenazine/amitriptyline 4 PAprotriptyline hcl 2trimipramine maleate 3 PA

Antiemetics

Antiemetics, Othermeclizine hcl tabs 2phenadoz 2promethazine hcl supp 2promethazine hcl syrp 2 PApromethazine hcl tabs 2 PApromethazine hydrochloride tabs 50mg

2 PA

promethegan 2scopolamine 4 QL(10/30)TRANSDERM-SCOP 4 QL(10/30)Emetogenic Therapy Adjunctsaprepitant caps 40mg 3 B/D PA QL(1/30)aprepitant caps 125mg 3 B/D PA QL(2/28)aprepitant caps 80mg 3 B/D PA QL(4/28)aprepitant caps 3 B/D PA QL(6/28)dronabinol 4 PA QL(60/30)EMEND SUSR 3 B/D PA QL(6/28)

26


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antimigraine Agents

Ergot Alkaloidsdihydroergotamine mesylate inj 4 QL(30/28)ergotamine tartrate/caffeine 2 QL(40/28)migergot 5 QL(20/28)Serotonin (5-HT) 1b/1d Receptor Agonistsnaratriptan hcl 2 QL(9/30)rizatriptan benzoate 2 QL(12/30)rizatriptan benzoate odt 2 QL(12/30)sumatriptan 3 QL(12/30)sumatriptan succinate inj 6mg/0.5ml

4 QL(4/30)

sumatriptan succinate inj 4mg/0.5ml

4 QL(8/30)

sumatriptan succinate refill inj 6mg/0.5ml

4 QL(4/30)

sumatriptan succinate refill inj 4mg/0.5ml

4 QL(8/30)

sumatriptan succinate tabs 2 QL(9/30)

Antimyasthenic Agents

ParasympathomimeticsGUANIDINE HCL 3pyridostigmine bromide 2pyridostigmine bromide er 3REGONOL 4

Antimycobacterials

Antimycobacterials, Otherdapsone tabs 3rifabutin 4AntitubercularsCAPASTAT SULFATE 4cycloserine 2ethambutol hcl 2isoniazid inj 4isoniazid syrp 2isoniazid tabs 100mg 2isoniazid tabs 300mg 1PASER 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

griseofulvin ultramicrosize 4itraconazole caps 4 PA QL(120/30)itraconazole oral soln 5 PAketoconazole crea 2ketoconazole sham 2ketoconazole tabs 2naftifine hcl 2naftifine hydrochloride 2NAFTIN GEL 3NATACYN 3NOXAFIL SUSP 5 PA QL(600/30)NOXAFIL TBEC 5 PA QL(96/30)nyamyc 3nystatin crea 2nystatin oint 2nystatin powd 3nystatin susp 2nystatin tabs 2nystatin/triamcinolone 4nystop 3SPORANOX ORAL SOLN 5 PAterbinafine hcl tabs 1 QL(90/365)terconazole 2voriconazole inj 5 PAvoriconazole susr 5 PA QL(300/30)voriconazole tabs 4 PA QL(90/30)

Antigout Agents

Antigout Agentsallopurinol 1allopurinol sodium 4colchicine caps 3 QL(60/30)colchicine tabs 3 QL(120/30)MITIGARE 3 QL(60/30)probenecid 2probenecid/colchicine 2ULORIC 3 QL(30/30) ST

27



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

YONDELIS 5 PAZANOSAR 4 B/D PAAntiandrogensbicalutamide 3 QL(30/30)ERLEADA 5 PA QL(120/30)flutamide 3nilutamide 5 QL(60/30)XTANDI 5 PA QL(120/30)YONSA 5 PA QL(120/30)ZYTIGA TABS 500MG 5 PA QL(60/30)ZYTIGA TABS 250MG 5 PA QL(120/30)Antiangiogenic AgentsPOMALYST 5 PA QL(21/28)REVLIMID CAPS 15MG, 20MG, 25MG

5 PA QL(21/28)

REVLIMID CAPS 10MG, 2.5MG, 5MG

5 PA QL(28/28)

THALOMID CAPS 100MG, 150MG, 50MG

5 PA QL(28/28)

THALOMID CAPS 200MG 5 PA QL(56/28)Antiestrogens/ModifiersEMCYT 3FARESTON 5 QL(30/30)FASLODEX 5 B/D PA QL(30/30)SOLTAMOX 5tamoxifen citrate 2Antimetabolitesadrucil 4 B/D PAALIMTA 5 PAARRANON 4cladribine 4 B/D PAclofarabine 4 B/D PAcytarabine 4 B/D PAcytarabine aqueous 4 B/D PADROXIA 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PRIFTIN 4pyrazinamide 2rifampin caps 2rifampin inj 4RIFATER 3SIRTURO 4 PA QL(188/365)TRECATOR 3

Antineoplastics

Alkylating AgentsBENDEKA 5 B/D PA QL(8/21)BICNU 4 B/D PAbusulfan 5 B/D PABUSULFEX 5 B/D PAcarmustine 2 B/D PAcyclophosphamide caps 3 B/D PAcyclophosphamide inj 1gm, 500mg

4 B/D PA

cyclophosphamide inj 2gm 5 B/D PAdacarbazine 4 B/D PAEVOMELA 5 PAGLEOSTINE 3HEXALEN 5ifosfamide inj 1gm, 3gm 4 B/D PAKISQALI FEMARA 200 DOSE 5 PA QL(49/28)KISQALI FEMARA 400 DOSE 5 PA QL(70/28)KISQALI FEMARA 600 DOSE 5 PA QL(91/28)LEUKERAN 3MATULANE 5melphalan hydrochloride 5 B/D PAMUSTARGEN 4 B/D PAthiotepa 4 PATREANDA INJ 100MG 5 B/D PATREANDA INJ 25MG 5 B/D PA QL(8/21)VALCHLOR 5 PA QL(60/30)

28


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

doxorubicin hcl liposome 5 B/D PAepirubicin hcl inj 200mg/100ml 4 B/D PAERWINAZE 5 B/D PA QL(60/28)ETHYOL 5 B/D PAfludarabine phosphate inj 50mg 4 B/D PAFUSILEV 5HALAVEN 5 PAidarubicin hcl inj 10mg/10ml 5 B/D PAirinotecan 4 B/D PAirinotecan hcl 4 B/D PAirinotecan hydrochloride inj 40mg/2ml

4 B/D PA

ISTODAX (OVERFILL) 5 PAJEVTANA 5 PAKISQALI 5 PA QL(63/28)LARTRUVO 5 PAleucovorin calcium inj 100mg, 350mg, 500mg, 50mg

4

leucovorin calcium tabs 2levoleucovorin calcium inj 175mg/17.5ml

5

levoleucovorin inj 175mg/17.5ml, 250mg/25ml, 50mg

5

lipodox 50 5 B/D PALYNPARZA TABS 5 PA QL(120/30)MEKTOVI 5 PA QL(180/30)mesna 2 B/D PAMESNEX TABS 5mitomycin inj 40mg 5 B/D PAmitomycin inj 20mg, 5mg 4 B/D PAmitoxantrone hcl 2 B/D PANERLYNX 5 PA QL(180/30)NINLARO 5 PA QL(3/28)ODOMZO 5 PA QL(30/30)oxaliplatin inj 100mg 5 B/D PAoxaliplatin inj 100mg/20ml, 50mg/10ml

4 B/D PA

paclitaxel inj 100mg/16.7ml, 150mg/25ml, 300mg/50ml

4 B/D PA

PORTRAZZA 5 PA QL(100/21)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ELITEK 5 B/D PAfluorouracil inj 4 B/D PAFOLOTYN 5 B/D PAgemcitabine 4 B/D PAgemcitabine hcl inj 200mg, 2gm 4 B/D PAgemcitabine hcl inj 1gm 5 B/D PAgemcitabine hydrochloride inj 1.5gm/15ml, 1gm/10ml, 200mg/2ml, 2gm/20ml

5 B/D PA

hydroxyurea 2LONSURF TABS 8.19MG; 20MG

5 PA QL(80/28)

LONSURF TABS 6.14MG; 15MG

5 PA QL(100/28)

mercaptopurine 3NIPENT 5 B/D PAPURIXAN 5 PA QL(300/30)TABLOID 3VYXEOS 5 B/D PAAntineoplastics, OtherABRAXANE 5 PAadriamycin inj 2mg/ml 2 B/D PAazacitidine 5 B/D PABELEODAQ 5 PAbleomycin sulfate 4 B/D PABORTEZOMIB 5 PA QL(14/21)BRAFTOVI 5 PA QL(180/30)carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml

4 B/D PA

cisplatin 4 B/D PACOSMEGEN 5 B/D PAdactinomycin 5 B/D PAdaunorubicin hcl 4 B/D PAdaunorubicin hydrochloride 4 B/D PAdecitabine 5dexrazoxane 4 B/D PADOCETAXEL INJ 200MG/10ML 5 B/D PAdocetaxel inj 160mg/16ml, 160mg/8ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml

5 B/D PA

doxorubicin hcl 2 B/D PA

29



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

AFINITOR TABS 2.5MG, 5MG, 7.5MG

5 PA QL(28/28)

AFINITOR TABS 10MG 5 PA QL(56/28)ALECENSA 5 PA QL(240/30)ALIQOPA 5 PA QL(3/28)ALUNBRIG TABS 180MG, 90MG

5 PA QL(30/30)

ALUNBRIG TABS 30MG 5 PA QL(180/30)ALUNBRIG TBPK 5 PA QL(60/365)BOSULIF TABS 400MG, 500MG

5 PA QL(30/30)

BOSULIF TABS 100MG 5 PA QL(120/30)CABOMETYX TABS 20MG, 60MG

5 PA QL(30/30)

CABOMETYX TABS 40MG 5 PA QL(60/30)CALQUENCE 5 PA QL(60/30)CAPRELSA TABS 300MG 5 PA QL(30/30)CAPRELSA TABS 100MG 5 PA QL(60/30)COMETRIQ KIT 5 PA QL(56/28)COMETRIQ KIT 20MG 5 PA QL(84/28)COMETRIQ KIT 5 PA QL(112/28)COTELLIC 5 PA QL(63/28)ERIVEDGE 5 PA QL(28/28)FARYDAK 5 PA QL(6/21)GILOTRIF 5 PA QL(30/30)IBRANCE 5 PA QL(21/28)ICLUSIG TABS 45MG 5 PA QL(30/30)ICLUSIG TABS 15MG 5 PA QL(60/30)IDHIFA 5 PA QL(30/30)imatinib mesylate 5 PA QL(60/30)IMBRUVICA CAPS 70MG 5 PA QL(30/30)IMBRUVICA CAPS 140MG 5 PA QL(120/30)IMBRUVICA TABS 5 PA QL(30/30)INLYTA 5 PA QL(120/30)IRESSA 5 PA QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PROLEUKIN 5 B/D PAromidepsin 5 PARUBRACA 5 PA QL(120/30)RYDAPT 5 PA QL(224/28)SYLATRON 5 PA QL(4/28)SYNRIBO 5 PA QL(28/28)TRISENOX 4 B/D PAVELCADE 5 PA QL(14/21)VENCLEXTA STARTING PACK 5 PA QL(84/365)VENCLEXTA TABS 100MG 5 PA QL(120/30)VENCLEXTA TABS 50MG 4 PA QL(30/30)VENCLEXTA TABS 10MG 4 PA QL(60/30)VERZENIO 5 PA QL(60/30)vinblastine sulfate 4 B/D PAvincasar pfs 4 B/D PAvincristine sulfate 4 B/D PAvinorelbine tartrate inj 50mg/5ml

4 B/D PA

ZEJULA 5 PA QL(90/30)ZOLINZA 5 QL(120/30)Aromatase Inhibitors, 3rd Generationanastrozole 2 QL(30/30)exemestane 4 QL(60/30)letrozole 2 QL(30/30)Enzyme Inhibitorsetoposide inj 3 B/D PAKYPROLIS 5 B/D PAtoposar 3 B/D PAtopotecan hcl inj 4mg 5Molecular Target InhibitorsAFINITOR DISPERZ TBSO 2MG, 3MG

5 PA QL(56/28)

AFINITOR DISPERZ TBSO 5MG

5 PA QL(112/28)

30


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ERBITUX 5 PAGAZYVA 5 PAHERCEPTIN INJ 440MG 5 PAHERCEPTIN INJ 150MG 5 B/D PAIMFINZI 5 PAKADCYLA 5 PAKEYTRUDA 5 PAMYLOTARG 5 PAOPDIVO INJ 240MG/24ML 5 PA QL(48/28)OPDIVO INJ 100MG/10ML, 40MG/4ML

5 PA QL(80/28)

PERJETA 5 PAPOTELIGEO 5 PARITUXAN 5 PARITUXAN HYCELA 5 PATECENTRIQ 5 PA QL(20/21)UNITUXIN 5 PAVECTIBIX 5 PAYERVOY INJ 50MG/10ML 5 PAYERVOY INJ 200MG/40ML 5 PA QL(80/21)Retinoidsbexarotene 5PANRETIN 5TARGRETIN GEL 5 QL(60/30)tretinoin caps 5

Antiparasitics

AnthelminticsALBENZA 4BILTRICIDE 4ivermectin 2praziquantel 4AntiprotozoalsALINIA SUSR 3 QL(150/30)ALINIA TABS 5 QL(20/30)atovaquone 4atovaquone/proguanil hcl 2chloroquine phosphate 2COARTEM 3 QL(24/30)DARAPRIM 5 QL(90/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

JAKAFI 5 PA QL(60/30)LENVIMA 10 MG DAILY DOSE 5 PA QL(30/30)LENVIMA 12MG DAILY DOSE 5 PA QL(90/30)LENVIMA 14 MG DAILY DOSE 5 PA QL(60/30)LENVIMA 18 MG DAILY DOSE 5 PA QL(90/30)LENVIMA 20 MG DAILY DOSE 5 PA QL(60/30)LENVIMA 24 MG DAILY DOSE 5 PA QL(90/30)LENVIMA 4 MG DAILY DOSE 5 PA QL(30/30)LENVIMA 8 MG DAILY DOSE 5 PA QL(60/30)LYNPARZA CAPS 5 PA QL(448/28)MEKINIST TABS 2MG 5 PA QL(30/30)MEKINIST TABS 0.5MG 5 PA QL(90/30)NEXAVAR 5 PA QL(120/30)SPRYCEL 5 PA QL(30/30)STIVARGA 5 PASUTENT 5 PA QL(28/28)TAFINLAR 5 PA QL(120/30)TAGRISSO 5 PA QL(30/30)TARCEVA TABS 100MG, 150MG

5 PA QL(30/30)

TARCEVA TABS 25MG 5 PA QL(60/30)TASIGNA CAPS 150MG, 200MG

5 PA QL(112/28)

TASIGNA CAPS 50MG 5 PA QL(420/30)temsirolimus 5 B/D PA QL(4/28)TIBSOVO 5 PA QL(60/30)TYKERB 5 PA QL(180/30)VOTRIENT 5 PA QL(120/30)XALKORI 5 PA QL(60/30)ZALTRAP 5 PA QL(40/28)ZELBORAF 5 PA QL(240/30)ZYDELIG 5 PA QL(60/30)ZYKADIA 5 PA QL(140/28)Monoclonal Antibody/Antibody-Drug ConjugateAVASTIN 5 PABAVENCIO 5 PABESPONSA 5 PACYRAMZA 5 PADARZALEX 5 PAEMPLICITI 5 PA

31



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

carbidopa/levodopa odt 2carbidopa/levodopa/entacapone

3

RYTARY 4 STMonoamine Oxidase B (MAO-B) Inhibitorsrasagiline mesylate 3 QL(30/30)selegiline hcl 2

Antipsychotics

1st Generation/Typicalchlorpromazine hcl 4compro 2fluphenazine decanoate 4fluphenazine hcl conc 2fluphenazine hcl elix 2fluphenazine hcl inj 4fluphenazine hcl tabs 10mg, 2.5mg, 5mg

2

fluphenazine hcl tabs 1mg 1haloperidol 2haloperidol decanoate 4haloperidol lactate 4loxapine caps 25mg, 50mg 2loxapine caps 10mg, 5mg 2 QL(120/30)loxapine succinate caps 25mg, 50mg

2

loxapine succinate caps 10mg, 5mg

2 QL(120/30)

perphenazine 2pimozide 2prochlorperazine 2prochlorperazine edisylate 4prochlorperazine maleate tabs 5mg

2

prochlorperazine maleate tabs 10mg

1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

hydroxychloroquine sulfate 2mefloquine hcl 2NEBUPENT 3 B/D PA QL(6/28)PENTAM 300 3PRIMAQUINE PHOSPHATE 3quinine sulfate 4 QL(42/7)Pediculicides/Scabicideslindane 2malathion 4permethrin 3

Antiparkinson Agents

Anticholinergicsbenztropine mesylate inj 4benztropine mesylate tabs 2 PAtrihexyphenidyl hcl 2 PAAntiparkinson Agents, Otheramantadine hcl 2entacapone 4 QL(240/30)tolcapone 5Dopamine AgonistsAPOKYN 5 PA QL(60/30)bromocriptine mesylate 4NEUPRO 4 QL(30/30)pramipexole dihydrochloride 2 QL(90/30)pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 3mg, 4.5mg

4 QL(30/30)

pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg

4 QL(90/30)

ropinirole hcl 2Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitorscarbidopa/levodopa 2carbidopa/levodopa er 2

32


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NUPLAZID CAPS 5 PA QL(30/30)NUPLAZID TABS 10MG 5 PA QL(30/30)NUPLAZID TABS 17MG 5 PA QL(60/30)olanzapine inj 4 QL(30/30)olanzapine odt 4 QL(30/30)olanzapine tabs 2 QL(30/30)paliperidone er tb24 1.5mg, 3mg

4 QL(30/30) ST

paliperidone er tb24 6mg 4 QL(60/30) STpaliperidone er tb24 9mg 5 QL(30/30) STquetiapine fumarate 2 QL(60/30)quetiapine fumarate er tb24 150mg, 200mg

3 QL(30/30)

quetiapine fumarate er tb24 300mg, 400mg, 50mg

3 QL(60/30)

REXULTI 5 QL(30/30)RISPERDAL CONSTA INJ 50MG

5 QL(2/28)

RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG

4 QL(2/28)

risperidone m-tab 3 QL(60/30)risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg

3 QL(60/30)

risperidone odt tbdp 4mg 3 QL(120/30)risperidone oral soln 2 QL(240/30)risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg

2 QL(60/30)

risperidone tabs 4mg 2 QL(120/30)SAPHRIS 4 QL(60/30)VRAYLAR CAPS 5 QL(30/30) STVRAYLAR CPPK 4 QL(14/365) STziprasidone hcl 4 QL(60/30)ZYPREXA RELPREVV INJ 210MG

4 QL(2/28)

ZYPREXA RELPREVV INJ 405MG

5 QL(1/28)

ZYPREXA RELPREVV INJ 300MG

5 QL(2/28)

Treatment-Resistantclozapine odt tbdp 12.5mg, 25mg

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

thioridazine hcl 2thiothixene caps 10mg, 1mg, 5mg

2

thiothixene caps 2mg 1trifluoperazine hcl 22nd Generation/AtypicalABILIFY MAINTENA 5 QL(1/28)aripiprazole odt 5 QL(60/30)aripiprazole oral soln 4 QL(900/30)aripiprazole tabs 4 QL(30/30)ARISTADA INITIO 5 QL(4.8/365)ARISTADA INJ 441MG/1.6ML 5 QL(1.6/30)ARISTADA INJ 662MG/2.4ML 5 QL(2.4/30)ARISTADA INJ 882MG/3.2ML 5 QL(3.2/30)ARISTADA INJ 1064MG/3.9ML 5 QL(3.9/60)FANAPT TABS 10MG, 12MG, 6MG, 8MG

5 QL(60/30) ST

FANAPT TABS 1MG, 2MG, 4MG

4 QL(60/30) ST

FANAPT TITRATION PACK 4 QL(16/365) STGEODON INJ 4 QL(6/30)INVEGA SUSTENNA INJ 39MG/0.25ML

4 QL(0.25/28)

INVEGA SUSTENNA INJ 78MG/0.5ML

5 QL(0.5/28)


5 QL(0.75/28)

INVEGA SUSTENNA INJ 156MG/ML

5 QL(1/28)


5 QL(1.5/28)

INVEGA TRINZA INJ 273MG/0.875ML

5 QL(0.88/90)


5 QL(1.32/90)


5 QL(1.75/90)


5 QL(2.63/90)

LATUDA TABS 120MG, 20MG, 40MG, 60MG

5 QL(30/30) ST

LATUDA TABS 80MG 5 QL(60/30) ST

33



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Anti-hepatitis C (HCV) Agents, OtherPEGASYS INJ 180MCG/0.5ML 5 PA QL(2/28)PEGASYS INJ 180MCG/ML 5 PA QL(4/28)PEGASYS PROCLICK 5 PA QL(2/28)ribavirin caps 4 QL(168/28)ribavirin tabs 4 QL(168/28)Anti-HIV Agents, Integrase Inhibitors (INSTI)BIKTARVY 5 QL(30/30)GENVOYA 5 QL(30/30)ISENTRESS CHEW 100MG 5 QL(180/30)ISENTRESS CHEW 25MG 3 QL(180/30)ISENTRESS PACK 5 QL(180/30)ISENTRESS TABS 5 QL(60/30)JULUCA 5 QL(30/30)TIVICAY TABS 50MG 5 QL(60/30)TIVICAY TABS 10MG, 25MG 4 QL(60/30)Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)COMPLERA 5 QL(30/30)EDURANT 5 QL(30/30)efavirenz caps 200mg 3 QL(60/30)efavirenz caps 50mg 3 QL(90/30)efavirenz tabs 5 QL(30/30)INTELENCE TABS 100MG, 200MG

5 QL(60/30)

INTELENCE TABS 25MG 4 QL(120/30)nevirapine er tb24 400mg 4 QL(30/30)nevirapine er tb24 100mg 4 QL(90/30)nevirapine tabs 2 QL(60/30)ODEFSEY 5 QL(30/30)RESCRIPTOR TABS 200MG 3 QL(180/30)RESCRIPTOR TABS 100MG 3 QL(270/30)STRIBILD 5 QL(30/30)SUSTIVA CAPS 200MG 5 QL(60/30)SUSTIVA CAPS 50MG 3 QL(90/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clozapine odt tbdp 150mg 4 QL(180/30)clozapine odt tbdp 100mg 4 QL(270/30)clozapine odt tbdp 200mg 5 QL(120/30)clozapine tabs 25mg, 50mg 3clozapine tabs 200mg 3 QL(120/30)clozapine tabs 100mg 3 QL(270/30)VERSACLOZ 4 QL(540/30)

Antispasticity Agents

Antispasticity Agentsbaclofen tabs 2dantrolene sodium 2tizanidine hcl 2

Antivirals

Anti-cytomegalovirus (CMV) Agentscidofovir 5FOSCAVIR 4ganciclovir inj 500mg, 500mg/10ml

4 B/D PA

valganciclovir 5valganciclovir hydrochlorde 5ZIRGAN 3Anti-hepatitis B (HBV) Agentsadefovir dipivoxil 5 QL(30/30)entecavir 4 QL(30/30)EPIVIR HBV ORAL SOLN 3INTRON A INJ 18MU, 6000000UNIT/ML

4

INTRON A INJ 10MU, 10MU/ML, 50MU

5

lamivudine tabs 100mg 2Anti-hepatitis C (HCV) Agents, Direct Acting AgentsEPCLUSA 5 PA QL(28/28)HARVONI 5 PA QL(28/28)VOSEVI 5 PA QL(30/30)

34


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SELZENTRY TABS 150MG, 75MG

5 QL(60/30)

SELZENTRY TABS 300MG 5 QL(120/30)SELZENTRY TABS 25MG 4 QL(240/30)TROGARZO 5 B/D PATYBOST 3 QL(30/30)Anti-HIV Agents, Protease InhibitorsAPTIVUS CAPS 5 QL(120/30)APTIVUS ORAL SOLN 5 QL(285/28)atazanavir caps 300mg 5 QL(30/30)atazanavir caps 200mg 5 QL(60/30)atazanavir sulfate caps 300mg 5 QL(30/30)atazanavir sulfate caps 200mg 5 QL(60/30)atazanavir sulfate caps 150mg 4 QL(30/30)CRIXIVAN CAPS 400MG 3 QL(180/30)CRIXIVAN CAPS 200MG 3 QL(270/30)EVOTAZ 5 QL(30/30)fosamprenavir calcium 5 QL(120/30)INVIRASE CAPS 5 QL(300/30)INVIRASE TABS 5 QL(120/30)KALETRA ORAL SOLN 4 QL(480/30)KALETRA TABS 100MG; 25MG

4 QL(300/30)

KALETRA TABS 200MG; 50MG

5 QL(120/30)

LEXIVA SUSP 4 QL(1575/28)LEXIVA TABS 5 QL(120/30)lopinavir/ritonavir 4 QL(480/30)NORVIR CAPS 4 QL(360/30)NORVIR ORAL SOLN 4 QL(480/30)NORVIR PACK 4 QL(360/30)NORVIR TABS 4 QL(360/30)PREZCOBIX 5 QL(30/30)PREZISTA SUSP 5 QL(400/30)PREZISTA TABS 800MG 5 QL(30/30)PREZISTA TABS 600MG 5 QL(60/30)PREZISTA TABS 150MG 4 QL(180/30)PREZISTA TABS 75MG 4 QL(210/30)REYATAZ CAPS 150MG, 300MG

5 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SUSTIVA TABS 5 QL(30/30)SYMFI 5 QL(30/30)SYMFI LO 5 QL(30/30)VIRAMUNE SUSP 4 QL(1200/30)Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)abacavir oral soln 3 QL(960/30)abacavir sulfate/lamivudine/zidovudine

5 QL(60/30)

abacavir tabs 4 QL(60/30)abacavir/lamivudine 5 QL(30/30)CIMDUO 5 QL(30/30)DESCOVY 5 QL(30/30)didanosine 2 QL(30/30)EMTRIVA CAPS 3 QL(30/30)EMTRIVA ORAL SOLN 3 QL(680/28)lamivudine oral soln 2 QL(900/30)lamivudine tabs 300mg 2 QL(30/30)lamivudine tabs 150mg 2 QL(60/30)lamivudine/zidovudine 4 QL(60/30)RETROVIR IV INFUSION 4stavudine 2 QL(60/30)tenofovir disoproxil fumarate 5 QL(30/30)TRIUMEQ 5 QL(30/30)TRUVADA 5 QL(30/30)VIDEX EC CPDR 125MG 4 QL(30/30)VIDEX PEDIATRIC 3 QL(1200/30)VIREAD POWD 5 QL(240/30)VIREAD TABS 5 QL(30/30)ZERIT ORAL SOLN 3 QL(2400/30)ZIAGEN ORAL SOLN 3 QL(960/30)zidovudine caps 2 QL(180/30)zidovudine syrp 2 QL(1680/28)zidovudine tabs 2 QL(60/30)Anti-HIV Agents, OtherATRIPLA 5 QL(30/30)FUZEON 5 QL(60/30)ISENTRESS HD 5 QL(60/30)SELZENTRY ORAL SOLN 5 QL(1610/26)

35



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

alprazolam odt tbdp 2mg 2 QL(150/30)alprazolam tabs 0.25mg, 0.5mg, 1mg

2 QL(90/30)

alprazolam tabs 2mg 2 QL(150/30)clorazepate dipotassium tabs 3.75mg, 7.5mg

3 QL(90/30)

clorazepate dipotassium tabs 15mg

3 QL(180/30)

diazepam inj 5mg/ml 2diazepam oral soln 2 QL(1200/30)diazepam tabs 2 QL(120/30)lorazepam conc 2 QL(150/30)lorazepam inj 2mg/ml, 4mg/ml 4lorazepam intensol 2 QL(150/30)lorazepam tabs 0.5mg, 1mg 2 QL(90/30)lorazepam tabs 2mg 2 QL(150/30)oxazepam 2 QL(120/30)

Bipolar Agents

Mood Stabilizerslithium carbonate caps 300mg 1lithium carbonate caps 150mg, 600mg

2

lithium carbonate er 2lithium carbonate tabs 2

Blood Glucose Regulators

Antidiabetic Agentsacarbose 2 QL(90/30)BYDUREON 3 QL(4/28)BYDUREON BCISE 3 QL(4/28)BYDUREON PEN 3 QL(4/28)BYETTA INJ 5MCG/0.02ML 3 QL(1.2/30)BYETTA INJ 10MCG/0.04ML 3 QL(2.4/30)FARXIGA 3 QL(30/30)glimepiride tabs 4mg 1 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

REYATAZ CAPS 200MG 5 QL(60/30)REYATAZ PACK 5 QL(180/30)ritonavir 4 QL(360/30)SYMTUZA 5 QL(30/30)VIRACEPT TABS 625MG 5 QL(120/30)VIRACEPT TABS 250MG 5 QL(270/30)Anti-influenza Agentsoseltamivir phosphate caps 45mg, 75mg

3 QL(56/365)

oseltamivir phosphate caps 30mg

3 QL(112/365)

oseltamivir phosphate susr 3 QL(700/365)rimantadine hcl 2TAMIFLU CAPS 45MG, 75MG 4 QL(56/365)TAMIFLU CAPS 30MG 4 QL(112/365)TAMIFLU SUSR 4 QL(700/365)Antiherpetic Agentsacyclovir caps 2acyclovir oint 4 QL(30/30)acyclovir sodium 4 B/D PAacyclovir susp 2acyclovir tabs 2famciclovir 2 QL(60/30)trifluridine 2valacyclovir hcl 3 QL(30/30)valacyclovir hydrochloride 3 QL(30/30)

Anxiolytics

Anxiolytics, Otherbuspirone hcl tabs 10mg, 5mg 1buspirone hcl tabs 15mg, 30mg, 7.5mg

2

doxepin hcl 2 PABenzodiazepinesalprazolam odt tbdp 0.25mg, 0.5mg, 1mg

2 QL(90/30)

36


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

metformin hydrochloride tabs 500mg

1 QL(150/30)

miglitol 4 QL(90/30)nateglinide 2 QL(90/30)OZEMPIC 3 QL(3/28)pioglitazone hcl 1 QL(30/30)pioglitazone hcl/metformin hcl 2 QL(90/30)repaglinide tabs 0.5mg, 1mg 4 QL(120/30)repaglinide tabs 2mg 4 QL(240/30)RIOMET 3 QL(750/30)SYNJARDY 4 QL(60/30)SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG

4 QL(30/30)

SYNJARDY XR TB24 12.5MG; 1000MG, 5MG; 1000MG

4 QL(60/30)

TRADJENTA 3 QL(30/30)TRULICITY 3 QL(2/28)VICTOZA 3 QL(9/30)XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, 2.5MG; 1000MG, 5MG; 500MG

3 QL(30/30)

XIGDUO XR TB24 5MG; 1000MG

3 QL(60/30)

Glycemic AgentsGLUCAGEN HYPOKIT 3 QL(4/30)GLUCAGON EMERGENCY KIT

3 QL(4/30)

PROGLYCEM 4InsulinsHUMALOG 3HUMALOG JUNIOR KWIKPEN 3HUMALOG KWIKPEN 3HUMALOG MIX 50/50 3HUMALOG MIX 50/50 KWIKPEN

3

HUMALOG MIX 75/25 3HUMALOG MIX 75/25 KWIKPEN

3

HUMULIN 70/30 3HUMULIN 70/30 KWIKPEN 3HUMULIN N 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

glimepiride tabs 2mg 1 QL(120/30)glimepiride tabs 1mg 1 QL(240/30)glipizide er tb24 10mg 2 QL(60/30)glipizide er tb24 5mg 2 QL(120/30)glipizide er tb24 2.5mg 2 QL(240/30)glipizide tabs 5mg 1 QL(60/30)glipizide tabs 10mg 1 QL(120/30)glipizide xl tb24 10mg 2 QL(60/30)glipizide xl tb24 5mg 2 QL(120/30)glipizide xl tb24 2.5mg 2 QL(240/30)glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg

1 QL(120/30)

glipizide/metformin hcl tabs 2.5mg; 250mg

1 QL(240/30)

GLYXAMBI 4 QL(30/30)INVOKAMET 3 QL(60/30)INVOKAMET XR 3 QL(60/30)INVOKANA 3 QL(30/30)JANUMET 3 QL(60/30)JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG

3 QL(30/30)

JANUMET XR TB24 1000MG; 50MG

3 QL(60/30)

JANUVIA 3 QL(30/30)JARDIANCE 4 QL(30/30)JENTADUETO 3 QL(60/30)JENTADUETO XR TB24 5MG; 1000MG

3 QL(30/30)

JENTADUETO XR TB24 2.5MG; 1000MG

3 QL(60/30)

metformin hcl er tb24 1000mg, 500mg, (generic for Fortamet)

1 QL(60/30)

metformin hcl er tb24 750mg (generic for Glucophage XR)

1 QL(60/30)

metformin hcl er tb24 500mg (generic for Glucophage XR)

1 QL(120/30)

metformin hcl tabs 1000mg 1 QL(60/30)metformin hcl tabs 850mg 1 QL(90/30)metformin hydrochloride oral soln

3 QL(750/30)

37



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fondaparinux sodium inj 10mg/0.8ml

5 QL(24/90)

heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml

4

heparin sodium/d5w 4heparin sodium/nacl 0.45% inj 50unit/ml; 0.45%

4

heparin sodium/nacl 0.9% 4heparin sodium/sodium chloride 0.9%

4

heparin sodium/sodium chloride 0.9% premix

4

jantoven 1PRADAXA 3 QL(60/30)SAVAYSA 4 QL(30/30)warfarin sodium 1XARELTO STARTER PACK 3 QL(102/365)XARELTO TABS 20MG 3 QL(30/30)XARELTO TABS 15MG 3 QL(60/30)XARELTO TABS 10MG 3 QL(90/90)Blood Formation Modifiersanagrelide hydrochloride 2ARANESP ALBUMIN FREE INJ 60MCG/0.3ML

4 PA QL(1.2/28)

ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML

4 PA QL(1.6/28)

ARANESP ALBUMIN FREE INJ 25MCG/0.42ML

4 PA QL(1.68/28)

ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML

4 PA QL(4/28)

ARANESP ALBUMIN FREE INJ 500MCG/ML

5 PA QL(1/21)


5 PA QL(1.2/28)


5 PA QL(1.6/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HUMULIN N KWIKPEN 3HUMULIN R 3HUMULIN R U-500 (CONCENTRATED)

3

HUMULIN R U-500 KWIKPEN 3LANTUS 3LANTUS SOLOSTAR 3LEVEMIR 3LEVEMIR FLEXTOUCH 3SOLIQUA 100/33 3 QL(18/30) STTOUJEO MAX SOLOSTAR 3TOUJEO SOLOSTAR 3TRESIBA FLEXTOUCH 3XULTOPHY 100/3.6 3 QL(15/30) ST

Blood Products/Modifiers/Volume Expanders

AnticoagulantsCOUMADIN 4ELIQUIS STARTER PACK 4 QL(74/30)ELIQUIS TABS 2.5MG 4 QL(60/30)ELIQUIS TABS 5MG 4 QL(74/30)enoxaparin sodium inj 30mg/0.3ml

4 QL(9/90)

enoxaparin sodium inj 40mg/0.4ml

4 QL(12/90)

enoxaparin sodium inj 60mg/0.6ml

4 QL(18/90)

enoxaparin sodium inj 120mg/0.8ml, 80mg/0.8ml

4 QL(24/90)

enoxaparin sodium inj 100mg/ml, 150mg/ml, 300mg/3ml

4 QL(30/90)

fondaparinux sodium inj 2.5mg/0.5ml

4 QL(15/90)

fondaparinux sodium inj 5mg/0.4ml

5 QL(12/90)

fondaparinux sodium inj 7.5mg/0.6ml

5 QL(18/90)

38


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Angiotensin II Receptor AntagonistsBENICAR 4 QL(30/30) STBENICAR HCT 4 QL(30/30) STcandesartan cilexetil 2 QL(30/30)candesartan cilexetil/hydrochlorothiazide

2 QL(30/30)

EDARBI 4 STEDARBYCLOR 4 STENTRESTO 3 QL(60/30)irbesartan 1 QL(30/30)irbesartan/hydrochlorothiazide 1 QL(30/30)losartan potassium tabs 100mg 1 QL(30/30)losartan potassium tabs 25mg, 50mg

1 QL(60/30)

losartan potassium/hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg

1 QL(30/30)

losartan potassium/hydrochlorothiazide tabs 12.5mg; 50mg

1 QL(60/30)

olmesartan medoxomil 2 QL(30/30)olmesartan medoxomil/hydrochlorothiazide

4 QL(30/30)

telmisartan 2 QL(30/30)telmisartan/amlodipine 2 QL(30/30)telmisartan/hydrochlorothiazide 2 QL(30/30)valsartan 2 QL(30/30)valsartan/hydrochlorothiazide 2 QL(30/30)Angiotensin-converting Enzyme (ACE) Inhibitorsbenazepril hcl 1 QL(60/30)benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg, 20mg; 25mg, 5mg; 6.25mg

2 QL(30/30)

benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg

2 QL(60/30)

captopril tabs 100mg, 50mg 2captopril tabs 12.5mg, 25mg 2 QL(90/30)captopril/hydrochlorothiazide 2enalapril maleate 1 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS


5 PA QL(2/28)


5 PA QL(2.4/28)

ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML, 60MCG/ML

5 PA QL(4/28)

LEUKINE INJ 250MCG 5 PAMOZOBIL 5 QL(9.6/30)PROCRIT INJ 40000UNIT/ML 5 PA QL(6/28)PROCRIT INJ 20000UNIT/ML 5 PA QL(12/28)PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

4 PA QL(12/28)

PROMACTA 5 PA QL(30/30)ZARXIO 5 PAHemostasis Agentstranexamic acid inj 2tranexamic acid tabs 2 QL(30/28)Platelet Modifying AgentsAGGRENOX 4 QL(60/30) STaspirin/dipyridamole 4 QL(60/30)BRILINTA 3 QL(60/30)cilostazol 2clopidogrel tabs 300mg 2 QL(2/365)clopidogrel tabs 75mg 2 QL(30/30)dipyridamole tabs 2 PAprasugrel 4 QL(30/30)

Cardiovascular Agents

Alpha-adrenergic Agonistsclonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr

3 QL(4/28)

clonidine hcl ptwk 0.3mg/24hr 3 QL(8/28)clonidine hcl tabs 0.3mg 2clonidine hcl tabs 0.1mg, 0.2mg 1midodrine hcl 2Alpha-adrenergic Blocking Agentsphenoxybenzamine hydrochloride

5

prazosin hcl 2

39



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

propafenone hcl er cp12 225mg, 325mg

4

propafenone hydrochloride er cp12 425mg

4

quinidine sulfate 2sorine 2sotalol hcl 2sotalol hcl (af) 2sotalol hcl af 2sotalol hydrochloride (af) tabs 80mg

2

sotalol hydrochloride tabs 120mg

2

Beta-adrenergic Blocking Agentsacebutolol hcl 2atenolol 1atenolol/chlorthalidone 1betaxolol hcl 2bisoprolol fumarate 2bisoprolol fumarate/hydrochlorothiazide

1

BYSTOLIC TABS 10MG, 2.5MG, 5MG

3 QL(30/30)

BYSTOLIC TABS 20MG 3 QL(60/30)BYVALSON 3 QL(30/30)carvedilol 1carvedilol phosphate 3 QL(30/30)COREG CR 3 QL(30/30)labetalol hcl inj 4labetalol hcl tabs 2metoprolol succinate er 1 QL(60/30)metoprolol tartrate inj 4metoprolol tartrate tabs 1metoprolol/hydrochlorothiazide 2nadolol 4nadolol/bendroflumethiazide 4 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

enalapril maleate/hydrochlorothiazide

1 QL(60/30)

fosinopril sodium 2 QL(60/30)fosinopril sodium/hydrochlorothiazide

2 QL(120/30)

lisinopril 1 QL(60/30)lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg, 25mg; 20mg

1 QL(60/30)

lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg

1 QL(120/30)

moexipril hcl 2moexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg

2 QL(30/30)

moexipril/hydrochlorothiazide tabs 12.5mg; 15mg, 25mg; 15mg

2 QL(60/30)

perindopril erbumine 1 QL(60/30)quinapril hcl 1 QL(60/30)quinapril/hydrochlorothiazide tabs 12.5mg; 10mg

2 QL(30/30)

quinapril/hydrochlorothiazide tabs 12.5mg; 20mg, 25mg; 20mg

2 QL(60/30)

ramipril 1 QL(60/30)trandolapril tabs 1mg 2 QL(30/30)trandolapril tabs 2mg, 4mg 2 QL(60/30)Antiarrhythmicsamiodarone hcl inj 4amiodarone hcl tabs 2dofetilide 3 QL(60/30)flecainide acetate 2lidocaine hcl inj 4mexiletine hcl 2MULTAQ 3 QL(60/30)pacerone 2propafenone hcl 2

40


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg

2 QL(30/30)

verapamil hcl er cp24 200mg 2 QL(60/30)verapamil hcl er tbcr 2verapamil hcl inj 4verapamil hcl sr cp24 360mg 2 QL(30/30)verapamil hcl tabs 40mg 2verapamil hcl tabs 120mg, 80mg

1

Cardiovascular Agents, Otheratropine sulfate inj 0.5mg/5ml 4CORLANOR 4 PA QL(60/30)DEMSER 5digitek tabs 0.125mg 3 QL(30/30)digitek tabs 0.25mg 3 PAdigox tabs 125mcg 3 QL(30/30)digox tabs 250mcg 3 PAdigoxin inj 4 PAdigoxin tabs 125mcg 3 QL(30/30)digoxin tabs 250mcg 3 PALANOXIN TABS 125MCG 4 QL(30/30)LANOXIN TABS 250MCG 4 PANORTHERA CAPS 100MG 5 PA QL(90/30)NORTHERA CAPS 200MG, 300MG

5 PA QL(180/30)

pentoxifylline er 2PRALUENT 5 PARANEXA 3 QL(60/30)Diuretics, Carbonic Anhydrase Inhibitorsacetazolamide 2acetazolamide sodium 4methazolamide 4Diuretics, Loopbumetanide inj 4bumetanide tabs 0.5mg, 1mg 2bumetanide tabs 2mg 3ethacrynate sodium 4furosemide inj 2furosemide oral soln 2furosemide tabs 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

pindolol 2propranolol hcl er 4propranolol hcl inj 4propranolol hcl oral soln 2propranolol hcl tabs 2propranolol hydrochloride tabs 60mg

2

propranolol/hydrochlorothiazide 2timolol maleate tabs 4Calcium Channel Blocking Agentsafeditab cr 3 QL(60/30)amlodipine besylate tabs 10mg 1 QL(30/30)amlodipine besylate tabs 5mg 1 QL(60/30)amlodipine besylate tabs 2.5mg 1 QL(120/30)amlodipine besylate/benazepril hydrochloride caps 10mg; 20mg, 10mg; 40mg

2 QL(30/30)

amlodipine besylate/benazepril hydrochloride caps 2.5mg; 10mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg

2 QL(60/30)

amlodipine besylate/valsartan 2 QL(30/30)amlodipine/valsartan/hctz 2 QL(30/30)cartia xt 3dilt-xr 3diltiazem hcl er cp12 3diltiazem hcl er cp24 120mg, 180mg, 240mg, 300mg, 420mg

3

diltiazem hcl er tb24 3diltiazem hcl inj 4diltiazem hcl tabs 2felodipine er 2 QL(60/30)isradipine 2matzim la 3nicardipine hcl caps 2nicardipine hcl inj 4nifedipine er tb24 90mg 3 QL(30/30)nifedipine er tb24 30mg, 60mg 3 QL(60/30)nimodipine 4taztia xt cp24 120mg, 180mg, 240mg, 300mg

3

41



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

rosuvastatin calcium 2 QL(30/30)simvastatin 1 QL(30/30)Dyslipidemics, Othercholestyramine 2cholestyramine light 2colestipol hcl 2ezetimibe 3 QL(30/30)ezetimibe/simvastatin 4 QL(30/30)niacin er tbcr 500mg 2 QL(30/30)niacin er tbcr 1000mg, 750mg 2 QL(60/30)niacor 2omega-3-acid ethyl esters 4 QL(120/30)prevalite 2REPATHA 5 PA QL(3/30)REPATHA PUSHTRONEX SYSTEM

5 PA QL(3.5/30)

REPATHA SURECLICK 5 PA QL(3/30)VASCEPA CAPS 1GM 4 QL(120/30)VASCEPA CAPS 0.5GM 4 QL(240/30)ZETIA 4 QL(30/30) STVasodilators, Direct-acting Arterialhydralazine hcl inj 4hydralazine hcl tabs 2minoxidil 2Vasodilators, Direct-acting Arterial/VenousBIDIL 3 QL(180/30)isosorbide dinitrate er 2isosorbide dinitrate tabs 2isosorbide mononitrate 2isosorbide mononitrate er 2minitran 2 QL(30/30)nitroglycerin inj 4nitroglycerin lingual 4nitroglycerin subl 2nitroglycerin transdermal 2 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

torsemide 2Diuretics, Potassium-sparingamiloride hcl 2amiloride/hydrochlorothiazide 1spironolactone tabs 25mg 1spironolactone tabs 100mg, 50mg

2

spironolactone/hydrochlorothiazide

2

triamterene/hydrochlorothiazide 1Diuretics, Thiazidechlorothiazide 2chlorothiazide sodium 4chlorthalidone 2hydrochlorothiazide 1indapamide 1metolazone 3Dyslipidemics, Fibric Acid Derivativesfenofibrate caps 130mg, 150mg 4 QL(30/30)fenofibrate caps 43mg, 50mg 4 QL(60/30)fenofibrate micronized caps 134mg, 200mg

3 QL(30/30)

fenofibrate micronized caps 67mg

3 QL(60/30)

fenofibrate tabs 145mg, 160mg 4 QL(30/30)fenofibrate tabs 48mg, 54mg 4 QL(60/30)fenofibric acid dr cpdr 135mg 4 QL(30/30)fenofibric acid dr cpdr 45mg 4 QL(60/30)gemfibrozil 2 QL(60/30)Dyslipidemics, HMG CoA Reductase Inhibitorsatorvastatin calcium 1 QL(30/30)LIVALO 3 QL(30/30) STlovastatin tabs 10mg, 20mg 1 QL(30/30)lovastatin tabs 40mg 1 QL(60/30)pravastatin sodium 1 QL(30/30)

42


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clonidine hcl er 4 QL(120/30)dexmethylphenidate hcl 2 QL(60/30)metadate er 3 QL(90/30)methylphenidate hydrochloride er tb24 27mg, 54mg

3 QL(30/30)

methylphenidate hydrochloride er tb24 36mg

3 QL(60/30)

methylphenidate hydrochloride er tb24 18mg

3 QL(120/30)

methylphenidate hydrochloride er tbcr 10mg, 27mg, 54mg

3 QL(30/30)

methylphenidate hydrochloride er tbcr 36mg

3 QL(60/30)


3 QL(90/30)


3 QL(120/30)

methylphenidate hydrochloride tabs

3 QL(90/30)

Central Nervous System, OtherHETLIOZ 5 PA QL(30/30)NUEDEXTA 3 QL(60/30)riluzole 4tetrabenazine tabs 12.5mg 5 PA QL(90/30)tetrabenazine tabs 25mg 5 PA QL(120/30)Fibromyalgia AgentsLYRICA CR TB24 330MG 3 QL(60/30)LYRICA CR TB24 165MG, 82.5MG

3 QL(90/30)

Multiple Sclerosis AgentsAMPYRA 5 PA QL(60/30)AVONEX 5 PA QL(4/28)AVONEX PEN 5 PA QL(4/28)BETASERON 5 PA QL(14/28)COPAXONE INJ 40MG/ML 5 PA QL(12/28)COPAXONE INJ 20MG/ML 5 PA QL(30/30)GILENYA 5 PA QL(30/30)TECFIDERA CPDR 120MG 5 PA QL(14/30)TECFIDERA CPDR 240MG 5 PA QL(60/30)TECFIDERA STARTER PACK 5 PA QL(120/365)TYSABRI 5 PA QL(15/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetaminesamphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 5mg; 5mg; 5mg; 5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg

3 QL(30/30)

amphetamine/dextroamphetamine cp24 1.25mg; 1.25mg; 1.25mg; 1.25mg, 6.25mg; 6.25mg; 6.25mg; 6.25mg

3 QL(60/30)

amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg

2 QL(60/30)

amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg

2 QL(90/30)

dextroamphetamine sulfate er cp24 5mg

2 QL(60/30)


2 QL(90/30)


2 QL(120/30)

dextroamphetamine sulfate oral soln

2 QL(1800/30)

dextroamphetamine sulfate tabs 5mg

2 QL(60/30)

dextroamphetamine sulfate tabs 10mg

2 QL(180/30)

Attention Deficit Hyperactivity Disorder Agents, Non-amphetaminesatomoxetine caps 100mg, 60mg, 80mg

4 QL(30/30)

atomoxetine caps 10mg, 18mg, 25mg, 40mg

4 QL(60/30)

43



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

imiquimod pump 5 QL(56/30)isotretinoin 2methoxsalen 5myorisan 2PICATO GEL 0.05% 4 QL(2/56)PICATO GEL 0.015% 4 QL(3/56)podofilox 2REGRANEX 5 PA QL(15/30)SANTYL 3selenium sulfide lotn 1tacrolimus oint 3 QL(100/90)tazarotene 4 QL(120/30)TAZORAC CREA 4 QL(120/30)TAZORAC GEL 4 QL(100/30)tretinoin crea 2 PA QL(45/30)tretinoin gel 2 PA QL(45/30)tretinoin microsphere 4 PAtretinoin microsphere pump gel 0.1%

4 PA

zenatane 2ZYCLARA 5 QL(56/30)ZYCLARA PUMP CREA 2.5% 5 QL(15/30)ZYCLARA PUMP CREA 3.75% 5 QL(56/30)

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral ReplacementAMINOSYN 4 B/D PAAMINOSYN 7%/ELECTROLYTES

4 B/D PA

AMINOSYN 8.5%/ELECTROLYTES

4 B/D PA

AMINOSYN II 4 B/D PAAMINOSYN II 8.5%/ELECTROLYTES

4 B/D PA

AMINOSYN M 4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Dental and Oral Agents

Dental and Oral Agentschlorhexidine gluconate mouth/throat soln

1

oralone dental paste 2paroex 1periogard 1pilocarpine hcl tabs 2pilocarpine hydrochloride 2triamcinolone acetonide dental paste

2

Dermatological Agents

Dermatological Agentsacitretin 4 PAammonium lactate 2amnesteem 2avita 2 PA QL(45/30)calcipotriene crea 4 QL(120/30)calcipotriene external soln 4 QL(60/30)calcipotriene oint 4 QL(120/30)calcitrene 4 QL(120/30)calcitriol oint 3 QL(800/30)claravis 2curity gauze pads 2”x2” 2diclofenac sodium gel 1% 3 QL(1000/30)diclofenac sodium transdermal soln

4 QL(1050/30)

doxepin hydrochloride 3ELIDEL 3 QL(100/90)erythromycin/benzoyl peroxide 2fluorouracil crea 5% 4fluorouracil crea 0.5% 5fluorouracil external soln 4imiquimod 2 QL(12/30)

44


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dextrose 5%/nacl 0.2% 4dextrose 5%/nacl 0.225% 4DEXTROSE 5%/NACL 0.3% 4dextrose 5%/nacl 0.33% 4dextrose 5%/nacl 0.45% 4dextrose 5%/nacl 0.9% 4DEXTROSE 50% 4 B/D PADEXTROSE 70% 4fluoride chew 0.25mg 1fluoritab chew 0.5mg, 1mg 1FREAMINE HBC 6.9% 4 B/D PAFREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML

4 B/D PA

HEPATAMINE 4 B/D PAKABIVEN 4 B/D PAkcl 0.075%/d5w/nacl 0.45% 4 B/D PAkcl 0.15%/d5w/nacl 0.2% 4 B/D PAkcl 0.15%/d5w/nacl 0.225% 4 B/D PAkcl 0.15%/d5w/nacl 0.45% 4 B/D PAkcl 0.15%/d5w/nacl 0.9% 4 B/D PAkcl 0.3%/d5w/nacl 0.45% 4 B/D PAkcl 0.3%/d5w/nacl 0.9% 4 B/D PAklor-con 2klor-con 10 1klor-con 8 1klor-con m10 1klor-con m20 1klor-con sprinkle 2LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L

4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

AMINOSYN-HBC 4 B/D PAAMINOSYN-PF 4 B/D PAAMINOSYN-PF 7% 4 B/D PAAMINOSYN-RF 4 B/D PACARBAGLU 5 PACLINIMIX 2.75%/DEXTROSE 5%

4 B/D PA

CLINIMIX 4.25%/DEXTROSE 10%

4 B/D PA


4 B/D PA


4 B/D PA


4 B/D PA

CLINIMIX 5%/DEXTROSE 15% 4 B/D PACLINIMIX 5%/DEXTROSE 20% 4 B/D PACLINIMIX 5%/DEXTROSE 25% 4 B/D PACLINIMIX E 2.75%/DEXTROSE 10%

4 B/D PA

CLINIMIX E 4.25%/DEXTROSE 10%

4 B/D PA

CLINIMIX E 4.25%/DEXTROSE 25%

4 B/D PA

CLINIMIX E 5%/DEXTROSE 25%

4 B/D PA

CLINIMIX N14G30E 4 B/D PACLINIMIX N9G15E 4 B/D PACLINISOL SF 15% 4 B/D PAdextrose10%/nacl 0.45% 4 B/D PAdextrose5% /electrolyte #48 viaflex

4 B/D PA

DEXTROSE 10% 4 B/D PAdextrose 10%/nacl 0.2% 4 B/D PAdextrose 2.5%/nacl 0.45% 4 B/D PADEXTROSE 20% 4 B/D PADEXTROSE 25% 4 B/D PADEXTROSE 30% 4 B/D PADEXTROSE 40% 4 B/D PADEXTROSE 5% 4dextrose 5%/lactated ringers 4 B/D PA

45



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PROSOL 4 B/D PAringers injection 4 B/D PAsodium bicarbonate inj 4sodium bicarbonate partial fill 4sodium chloride 0.45% 4sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5%

4

sodium fluoride chew 0.5mg, 1mg

1

SODIUM LACTATE INJ 5MEQ/ML

4 B/D PA

TPN ELECTROLYTES 4 B/D PATRAVASOL 4 B/D PATROPHAMINE 4 B/D PAElectrolyte/Mineral/Metal ModifiersCHEMET 5CUPRIMINE 5DEPEN TITRATABS 5JADENU 5JADENU SPRINKLE 5kionex 3SAMSCA TABS 15MG 5 PA QL(30/30)SAMSCA TABS 30MG 5 PA QL(60/30)sodium polystyrene sulfonate powd

3

sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml

3

sps 3SYPRINE 5trientine hydrochloride 5VELTASSA 3Phosphate BindersAURYXIA 4 QL(360/30)calcium acetate caps 2calcium acetate tabs 667mg 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LACTATED RINGERS VIAFLEX

4 B/D PA

ludent 1MAGNESIUM SULFATE INJ 20GM/500ML, 2GM/50ML, 40GM/1000ML

4 B/D PA

magnesium sulfate inj 20gm/500ml, 2gm/50ml, 40gm/1000ml, 4gm/100ml, 4gm/50ml, 50%

4 B/D PA

NEPHRAMINE 4 B/D PANORMOSOL -R 4 B/D PANORMOSOL-M IN D5W 4 B/D PANORMOSOL-R 4 B/D PANORMOSOL-R IN D5W 4 B/D PAPERIKABIVEN 4 B/D PAPLENAMINE 4 B/D PApotassium chloride cr 1potassium chloride er cpcr 2potassium chloride er tbcr 1potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml

4 B/D PA

potassium chloride oral soln 2potassium chloride sr 1potassium chloride/dextrose inj 5%; 20meq/l, 5%; 40meq/l

4 B/D PA

potassium chloride/dextrose/lactated ringers

4 B/D PA

potassium chloride/dextrose/sodium chloride

4 B/D PA

potassium chloride/sodium chloride inj 20meq/l; 0.45%, 20meq/l; 0.9%, 40meq/l; 0.9%

4 B/D PA

potassium citrate er 2PREMASOL 4 B/D PAPROCALAMINE 4 B/D PA

46


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TRULANCE 4 QL(30/30)ursodiol 3Histamine2 (H2) Receptor Antagonistscimetidine 2cimetidine hcl 2famotidine inj 4famotidine premixed 4famotidine tabs 20mg, 40mg 2nizatidine caps 2ranitidine hcl caps 2ranitidine hcl inj 4ranitidine hcl syrp 2ranitidine hcl tabs 1Irritable Bowel Syndrome Agentsalosetron hydrochloride tabs 0.5mg

4 PA QL(60/30)

alosetron hydrochloride tabs 1mg

5 PA QL(60/30)

AMITIZA 3 QL(60/30)LINZESS 3 QL(30/30)VIBERZI 4 PA QL(60/30)Laxativesconstulose 2enulose 2gavilyte-c 2gavilyte-g 2gavilyte-n/flavor pack 2generlac 2lactulose oral soln 2MOVIPREP 4peg 3350/electrolytes 2peg-3350/electrolytes 2peg-3350/nacl/na bicarbonate/kcl

2

polyethylene glycol 3350 powd 2SUPREP BOWEL PREP KIT 4trilyte 2ProtectantsCARAFATE SUSP 4misoprostol 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PHOSLYRA 4RENVELA PACK 3 QL(180/30)RENVELA TABS 3 QL(540/30)VELPHORO 4 QL(180/30)Vitaminsmultivitamin with fluoride chew 2VP-PNV-DHA 3

Gastrointestinal Agents

Antispasmodics, Gastrointestinalanaspaz 2atropine sulfate inj 0.25mg/5ml, 1mg/ml, 8mg/20ml

4

dicyclomine hcl caps 1dicyclomine hcl oral soln 2dicyclomine hydrochloride 1ed-spaz 2glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml

4

glycopyrrolate tabs 2hyoscyamine sulfate elix 2hyoscyamine sulfate odt 2hyoscyamine sulfate subl 2hyoscyamine sulfate tabs 2hyoscyamine sulfate tbdp 2methscopolamine bromide 2nulev 2oscimin 2propantheline bromide 2Gastrointestinal Agents, Othercromolyn sodium conc 2diphenoxylate/atropine 2GATTEX 5 PA QL(30/30)loperamide hcl caps 2metoclopramide hcl inj 4metoclopramide hcl oral soln 2metoclopramide hcl tabs 2OSMOPREP 4RELISTOR INJ 8MG/0.4ML 5 PA QL(11.2/28)RELISTOR INJ 12MG/0.6ML 5 PA QL(16.8/28)

47



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MYRBETRIQ 3 QL(30/30)oxybutynin chloride er tb24 10mg, 5mg

2 QL(30/30)

oxybutynin chloride er tb24 15mg

2 QL(60/30)

oxybutynin chloride syrp 2 QL(600/30)oxybutynin chloride tabs 2 QL(120/30)tolterodine tartrate 4 QL(60/30)VESICARE 4 QL(30/30)Benign Prostatic Hypertrophy Agentsalfuzosin hcl er 2 QL(30/30)doxazosin mesylate tabs 1mg, 2mg, 4mg

2 QL(30/30)

doxazosin mesylate tabs 8mg 2 QL(60/30)dutasteride 2 QL(30/30)dutasteride/tamsulosin hydrochloride

4 QL(30/30)

finasteride tabs 5mg 2 QL(30/30)tamsulosin hcl 2 QL(60/30)terazosin hcl caps 1mg, 2mg, 5mg

1

terazosin hcl caps 10mg 1 QL(60/30)Genitourinary Agents, Otherbethanechol chloride 2ELMIRON 4phenazopyridine hydrochloride 2phenazopyridine hydrocholride 2

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)a-methapred 4ala-cort crea 1% 1alclometasone dipropionate 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sucralfate 2Proton Pump Inhibitorsesomeprazole magnesium 4 QL(60/30)esomeprazole sodium 4omeprazole cpdr 2 QL(60/30)pantoprazole sodium tbec 2 QL(60/30)

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

Genetic or Enzyme Disorder: Replacement, Modifiers, TreatmentADAGEN 5 PAALDURAZYME 5 PABUPHENYL TABS 5 PACEREZYME 5 B/D PACREON 3CYSTADANE 5CYSTAGON 3ELAPRASE 5 PAFABRAZYME 5 B/D PAKUVAN 5 PALUMIZYME 5 PAmiglustat 5 QL(90/30)NAGLAZYME 5 PAORFADIN 5sodium phenylbutyrate 5 PAVPRIV 5 PAZAVESCA 5 QL(90/30)ZENPEP 3

Genitourinary Agents

Antispasmodics, Urinarydarifenacin hydrobromide er 4 QL(30/30)ENABLEX 4 QL(30/30) STflavoxate hcl 2

48


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluocinolone acetonide external soln

1

fluocinolone acetonide oint 2fluocinolone acetonide scalp 2fluocinonide crea 0.05% 2fluocinonide crea 0.1% 4fluocinonide external soln 2fluocinonide gel 2fluocinonide oint 2fluticasone propionate crea 2fluticasone propionate oint 2halobetasol propionate 2hydrocortisone butyrate (lipid) 2hydrocortisone butyrate (lipophilic)

2

hydrocortisone butyrate crea 2hydrocortisone butyrate external soln

2

hydrocortisone butyrate oint 2hydrocortisone external crea 1hydrocortisone lotn 2.5% 2hydrocortisone oint 1%, 2.5% 2hydrocortisone rectal crea 1hydrocortisone tabs 2hydrocortisone valerate 2MEDROL TABS 2MG 3methylprednisolone acetate inj 40mg/ml, 80mg/ml

4

methylprednisolone dose pack 2methylprednisolone sodiumsuccinate inj 125mg, 40mg

4

methylprednisolone tabs 2mometasone furoate crea 2mometasone furoate external soln

2

mometasone furoate oint 2prednicarbate oint 2prednisolone 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

augmented betamethasone dipropionate

2

betamethasone dipropionate 3betamethasone valerate crea 2betamethasone valerate foam 3betamethasone valerate lotn 2betamethasone valerate oint 2clobetasol propionate crea 2clobetasol propionate emollient crea

2

clobetasol propionate emollient foam

4

clobetasol propionate external soln

2

clobetasol propionate foam 4clobetasol propionate gel 2clobetasol propionate oint 2clobetasol propionate sham 2clodan 2cortisone acetate 4DEPO-MEDROL INJ 20MG/ML 4desonide lotn 4desonide oint 4desoximetasone crea 4desoximetasone gel 4desoximetasone oint 4dexamethasone elix 2dexamethasone intensol 2dexamethasone oral soln 2dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml

4

dexamethasone tabs 1.5mg, 1mg, 2mg, 6mg

2

dexamethasone tabs 0.5mg, 0.75mg, 4mg

1

fludrocortisone acetate 2fluocinolone acetonide body 2fluocinolone acetonide crea 2

49



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG

5 PA

GENOTROPIN MINIQUICK INJ 0.2MG

4 PA

INCRELEX 4 PANOVAREL 4 PAPREGNYL W/DILUENT BENZYL ALCOHOL/NACL

4 PA

STIMATE 3

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

Anabolic SteroidsANADROL-50 5 PAoxandrolone tabs 10mg 5 PA QL(60/30)oxandrolone tabs 2.5mg 3 PA QL(120/30)Androgensdanazol caps 50mg 3danazol caps 100mg, 200mg 4testosterone cypionate 4testosterone enanthate 4 QL(5/30)testosterone gel 25mg/2.5gm, 50mg/5gm

4 PA QL(300/30)

testosterone pump 4 PA QL(300/30)EstrogensALORA 3 PA QL(8/28)altavera 2alyacen 1/35 2alyacen 7/7/7 2amethia 2 QL(91/91)amethia lo 2 QL(91/91)apri 2aranelle 2ashlyna 2 QL(91/91)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml

2

prednisone intensol 2prednisone oral soln 2prednisone tabs 50mg 2prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg

1

prednisone tbpk 1procto-med hc 1procto-pak 1proctosol hc 1proctozone-hc 1SOLU-CORTEF 4texacort 3triamcinolone acetonide crea 0.1%

1

triamcinolone acetonide crea 0.025%, 0.5%

2

triamcinolone acetonide inj 40mg/ml

4

triamcinolone acetonide lotn 2triamcinolone acetonide oint 2trianex 5triderm crea 0.1% 1TRIPTODUR 5 PA QL(1/168)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)chorionic gonadotropin 4 PAdesmopressin acetate inj 4desmopressin acetate nasal soln

4 QL(15/30)

desmopressin acetate tabs 2GENOTROPIN 5 PA

50


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

femynor 2fyavolv tabs 2.5mcg; 0.5mg 3 PAintrovale 2 QL(91/91)isibloom 2jevantique lo 3 PAjolessa 2 QL(91/91)juleber 2junel 1.5/30 2junel 1/20 2junel fe 1.5/30 2junel fe 1/20 2kariva 2kelnor 1/35 2kelnor 1/50 2kimidess 2kurvelo 2larin 1.5/30 2larin 1/20 2larin fe 1.5/30 2larin fe 1/20 2larissia 2lessina 2levonest 2levonorgestrel and ethinyl estradiol tabs 0; 0

2 QL(91/91)

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, 20mcg; 0.1mg

2

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0

2 QL(91/91)

levora 0.15/30-28 2low-ogestrel 2lutera 2marlissa 2melodetta 24 fe 2MENEST 3 PAMENOSTAR 3 PA QL(4/28)mibelas 24 fe 2microgestin 1.5/30 2microgestin 1/20 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

aubra 2aviane 2balziva 2bekyree 2blisovi fe 1.5/30 2blisovi fe 1/20 2briellyn 2camrese 2 QL(91/91)camrese lo 2 QL(91/91)caziant 2cesia 2chateal 2cryselle-28 2cyclafem 1/35 2cyclafem 7/7/7 2cyred 2dasetta 1/35 2dasetta 7/7/7 2daysee 2 QL(91/91)DELESTROGEN INJ 10MG/ML 4delyla 2DEPO-ESTRADIOL 4desogestrel/ethinyl estradiol 2elinest 2emoquette 2enpresse-28 2enskyce 2estarylla 2estradiol crea 4estradiol pttw 2 PA QL(8/28)estradiol ptwk 2 PA QL(4/28)estradiol tabs 0.5mg, 1mg, 2mg 2 PAestradiol tabs 10mcg 4 QL(18/28)estradiol valerate 4ESTRING 3 QL(1/90)ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg

2

falmina 2FEMRING 3 QL(1/90)

51



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tri-estarylla 2tri-legest fe 2tri-linyah 2tri-mili 2tri-previfem 2tri-sprintec 2tri-vylibra 2trinessa 2trivora-28 2tydemy 2velivet 2vienva 2viorele 2vyfemla 2vylibra 2wera 2yuvafem 4 QL(18/28)zenchent 2zovia 1/35e 2Progesterone Agonists/AntagonistsELLA 3MAKENA 5 PAProgestinscamila 2deblitane 2DEPO-PROVERA 4 QL(10/28)errin 2heather 2hydroxyprogesterone caproate 5 PAincassia 2jencycla 2jolivette 2lyza 2MAKENA 5 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

microgestin fe 2microgestin fe 1.5/30 2mili 2MINIVELLE 3 PA QL(8/28)mono-linyah 2myzilra 2necon 0.5/35-28 2necon 7/7/7 2norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg

2

norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg

3 PA

norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs

2

norgestimate/ethinyl estradiol 2nortrel 0.5/35 (28) 2nortrel 1/35 2nortrel 7/7/7 2ogestrel 2orsythia 2philith 2pimtrea 2pirmella 1/35 2pirmella 7/7/7 2portia-28 2PREMARIN CREA 3PREMARIN INJ 4PREMARIN TABS 4 PA QL(30/30)previfem 2quasense 2 QL(91/91)reclipsen 2setlakin 2 QL(91/91)sprintec 28 2sronyx 2tarina fe 1/20 2

52


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)cabergoline 2 QL(16/28)ELIGARD INJ 30MG 4 PA QL(1/120)ELIGARD INJ 45MG 4 PA QL(1/180)ELIGARD INJ 7.5MG 4 PA QL(1/30)ELIGARD INJ 22.5MG 4 PA QL(1/90)FIRMAGON INJ 80MG 4 B/D PA QL(1/28)FIRMAGON INJ 120MG 5 B/D PA QL(4/365)leuprolide acetate 4 PALUPRON DEPOT (1-MONTH) 5 PA QL(1/30)LUPRON DEPOT (3-MONTH) 5 PA QL(1/84)LUPRON DEPOT (4-MONTH) 5 PA QL(1/112)LUPRON DEPOT (6-MONTH) 5 PA QL(1/168)LUPRON DEPOT-PED (1-MONTH)

5 PA QL(1/30)

LUPRON DEPOT-PED (3-MONTH)

5 PA QL(1/84)

octreotide acetate inj 500mcg/ml

5 PA

octreotide acetate inj 1000mcg/ml, 100mcg/ml, 200mcg/ml, 50mcg/ml

4 PA

SIGNIFOR 5 PA QL(60/30)SOMATULINE DEPOT INJ 60MG/0.2ML

5 PA QL(0.2/28)

SOMATULINE DEPOT INJ 90MG/0.3ML

5 PA QL(0.3/28)

SOMATULINE DEPOT INJ 120MG/0.5ML

5 PA QL(0.5/28)

SOMAVERT 5 PA QL(30/30)SYNAREL 5 PATRELSTAR MIXJECT INJ 22.5MG

5 PA QL(1/168)

TRELSTAR MIXJECT INJ 3.75MG

5 PA QL(1/28)

TRELSTAR MIXJECT INJ 11.25MG

5 PA QL(1/84)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

medroxyprogesterone acetate inj 150mg/ml

4 QL(1/90)

medroxyprogesterone acetate inj 150mg/ml

2 QL(1/90)

medroxyprogesterone acetate tabs

1

megestrol acetate susp 40mg/ml

3 PA

megestrol acetate tabs 3 PAnora-be 2norethindrone 2norethindrone acetate 2norlyroc 2progesterone caps 2sharobel 2Selective Estrogen Receptor Modifying Agentsraloxifene hydrochloride 2 QL(30/30)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium tabs 1LEVOXYL TABS 125MCG, 137MCG, 150MCG, 200MCG, 25MCG, 50MCG, 75MCG, 88MCG

4

levoxyl tabs 100mcg, 112mcg, 175mcg

4

liothyronine sodium inj 4liothyronine sodium tabs 2SYNTHROID 4THYROLAR-1 3THYROLAR-1/2 3THYROLAR-1/4 3THYROLAR-2 3THYROLAR-3 3UNITHROID 4

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)LYSODREN 5

53



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML, 80MG/0.8ML

5 PA QL(6/365)

HUMIRA PEN 5 PA QL(4/28)HUMIRA PEN-CD/UC/HS STARTER INJ 80MG/0.8ML

5 PA QL(6/365)

HUMIRA PEN-CD/UC/HS STARTER INJ 40MG/0.8ML

5 PA QL(12/365)

HUMIRA PEN-PS/UV STARTER INJ

5 PA QL(6/365)

HUMIRA PEN-PS/UV STARTER INJ 40MG/0.8ML

5 PA QL(8/365)

KINERET 5 PA QL(20.1/30)methotrexate sodium 4methotrexate tabs 2mycophenolate mofetil caps 4 PAmycophenolate mofetil inj 4 PAmycophenolate mofetil susr 5 PAmycophenolate mofetil tabs 4 PAmycophenolic acid dr 4 PANULOJIX 5 PA QL(150/30)PROGRAF INJ 4 PARAPAMUNE ORAL SOLN 5 PAREMICADE 5 PARENFLEXIS 5 PASANDIMMUNE ORAL SOLN 4 PAsirolimus 4 PAtacrolimus caps 3 PATORISEL 5 B/D PA QL(4/28)XATMEP 4 PAZORTRESS TABS 0.25MG, 0.75MG

5 PA QL(60/30)

ZORTRESS TABS 0.5MG 5 PA QL(120/30)Immunizing Agents, PassiveATGAM 4 PAGAMMAKED INJ 1GM/10ML 4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agentsmethimazole 2propylthiouracil 2

Immunological Agents

Angioedema AgentsCINRYZE 5 PA QL(100/30)FIRAZYR 5 PA QL(18/30)RUCONEST 5 PA QL(8/30)Immune SuppressantsASTAGRAF XL CP24 5MG 5 PAASTAGRAF XL CP24 0.5MG, 1MG

4 PA

AZASAN 3 PAazathioprine inj 4 PAazathioprine tabs 2 PAcyclosporine 4 PAcyclosporine modified 4 PAENBREL INJ 25MG/0.5ML 5 PA QL(4.08/28)ENBREL INJ 25MG, 50MG/ML 5 PA QL(8/28)ENBREL MINI 5 PA QL(8/28)ENBREL SURECLICK 5 PA QL(8/28)ENVARSUS XR TB24 4MG 5 PAENVARSUS XR TB24 0.75MG, 1MG

4 PA

gengraf 4 PAHUMIRA INJ 10MG/0.1ML, 10MG/0.2ML, 20MG/0.2ML, 20MG/0.4ML

5 PA QL(2/28)

HUMIRA INJ 40MG/0.4ML, 40MG/0.8ML

5 PA QL(4/28)

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ

5 PA QL(4/365)

54


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

IXIARO 4KINRIX 4M-M-R II 4 QL(2/365)MENACTRA 4MENVEO 4PEDIARIX 4PEDVAX HIB 4PROQUAD 4 QL(2/365)QUADRACEL 4RABAVERT 4 B/D PARECOMBIVAX HB 4 B/D PA QL(3/365)ROTARIX 3ROTATEQ 3SHINGRIX 4 QL(2/999)STAMARIL 4 QL(1/999)TENIVAC 4 QL(0.5/28)TETANUS/DIPHTHERIA TOXOIDS-ADSORBED

4

TRUMENBA 4TWINRIX 4TYPHIM VI 4VAQTA 4VARIVAX 4 QL(1/365)VARIZIG 4 QL(12/30)VAXCHORA 4YF-VAX 4ZOSTAVAX 4 QL(1/999)

Inflammatory Bowel Disease Agents

AminosalicylatesAPRISO 3 QL(120/30)balsalazide disodium 4LIALDA 3 QL(120/30)mesalamine 4Glucocorticoidsbudesonide cpep 4colocort 2hydrocortisone enem 2Sulfonamidessulfasalazine 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

GAMMAKED INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 5GM/50ML

5 B/D PA

GAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 40GM/400ML, 5GM/50ML

5 B/D PA

GAMUNEX-C INJ 1GM/10ML 4 B/D PATHYMOGLOBULIN 3 B/D PAImmunomodulatorsACTEMRA INJ 162MG/0.9ML 5 PA QL(3.6/28)ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML

5 PA QL(40/28)

ACTIMMUNE 5 PAARCALYST 5 PABENLYSTA INJ 400MG 5 PA QL(9/28)BENLYSTA INJ 120MG 5 PA QL(30/28)ILARIS 5 PA QL(2/28)leflunomide 3 QL(30/30)RIDAURA 4SIMULECT 5 B/D PASYNAGIS 5 PAVaccinesACTHIB 4ADACEL 4 QL(0.5/365)BCG VACCINE 4BEXSERO 4BOOSTRIX 4 QL(0.5/365)DAPTACEL 4DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC

4

ENGERIX-B INJ 10MCG/0.5ML 4 B/D PA QL(3/365)ENGERIX-B INJ 20MCG/ML 4 B/D PA QL(8/365)GARDASIL 9 4 QL(1.5/365)HAVRIX 4HEPLISAV-B 4 B/D PA QL(3/365)HIBERIX 4IMOVAX RABIES (H.D.C.V.) 4 B/D PAINFANRIX 4IPOL INACTIVATED IPV 4

55



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

bd insulin syringe ultrafine/0.3ml/31g x 5/16”

2 QL(200/30)

bd insulin syringe ultrafine/0.5ml/30g x 1/2”

2 QL(200/30)

bd insulin syringe ultrafine/1ml/31g x 5/16”

2 QL(200/30)

bd pen needle/mini/ultrafine/31g x 3/16”

2 QL(200/30)

bd pen needle/nano/ultra fine/32g x 4mm

2 QL(200/30)

bd pen needle/ultrafine/29g x 12.7mm

2 QL(200/30)

bd safetyglide 27g x 5/8” 2 QL(200/30)CARNITOR INJ 4 B/D PAFERRIPROX 5 PAfomepizole 5INTRALIPID 4 B/D PAKORLYM 5 PA QL(120/30)LACTATED RINGERS IRRIGATION

4

levocarnitine 2LIPOSYN III 4 B/D PANATPARA 5 PA QL(2/28)novofine 31 2 QL(200/30)novofine 32gx6mm 2 QL(200/30)novofine autocover 30gx8mm 2 QL(200/30)novotwist 32gx5mm 2 QL(200/30)NUTRILIPID 4 B/D PAOMNIPOD 5 PACK 3 QL(30/30)OMNIPOD DASH 5 PACK 3 QL(30/30)OMNIPOD DASH SYSTEM 3 QL(1/365)OMNIPOD STARTER KIT 3 QL(1/365)PHYSIOLYTE 4physiosol irrigation 4RINGERS IRRIGATION 4sodium chloride0.9% 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Metabolic Bone Disease Agents

Metabolic Bone Disease Agentsalendronate sodium tabs 35mg, 70mg

1 QL(4/28)

alendronate sodium tabs 10mg, 40mg, 5mg

1 QL(30/30)

BINOSTO 4calcitonin-salmon 2 QL(3.7/30)calcitriol caps 2calcitriol inj 4calcitriol oral soln 2doxercalciferol caps 0.5mcg 4 QL(90/30)doxercalciferol caps 1mcg 4 QL(240/30)doxercalciferol caps 2.5mcg 5 QL(120/30)doxercalciferol inj 4etidronate disodium 2FORTEO 5 PA QL(2.4/28)ibandronate sodium tabs 3 QL(1/28)MIACALCIN 5pamidronate disodium 4 B/D PAparicalcitol caps 4mcg 4 QL(60/30)paricalcitol caps 1mcg, 2mcg 4 QL(90/30)PROLIA 4 QL(1/180)SENSIPAR TABS 30MG 3 QL(60/30)SENSIPAR TABS 60MG 5 QL(60/30)SENSIPAR TABS 90MG 5 QL(120/30)XGEVA 5 PA QL(1.7/28)zoledronic acid inj 4mg/5ml 4 B/D PA QL(15/21)zoledronic acid inj 5mg/100ml 4 B/D PA QL(100/365)

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic Agentsbd eclipse syringe/1ml/30gx1/2” 2 QL(200/30)bd insulin syringe safetyglide/1ml/29g x 1/2”

2 QL(200/30)

56


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Ophthalmic Anti-inflammatoriesbromfenac 4dexamethasone sodium phosphate ophthalmic soln

2

diclofenac sodium ophthalmic soln

2

DUREZOL 3fluorometholone 3flurbiprofen sodium 2ILEVRO 3ketorolac tromethamine ophthalmic soln

2

LOTEMAX 4neomycin/polymyxin/dexamethasone

2

PRED MILD 3PRED-G 3PRED-G S.O.P. 3prednisolone acetate 3prednisolone sodium phosphate ophthalmic soln

1

PROLENSA 3TOBRADEX OINT 3tobramycin/dexamethasone 3Ophthalmic Antiglaucoma Agentsacetazolamide er 2apraclonidine 2AZOPT 3betaxolol hcl 2brimonidine tartrate ophthalmic soln 0.2%

2

brimonidine tartrate ophthalmic soln 0.15%

3

carteolol hcl 2dorzolamide hcl 2 QL(10/30)dorzolamide hcl/timolol maleate 2 QL(10/30)levobunolol hcl 1metipranolol 2PHOSPHOLINE IODIDE 4pilocarpine hcl ophthalmic soln 3SIMBRINZA 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sodium chloride 0.9% 4sterile water irrigation 4sterile water irrigation plastic bottle

4

techlite pen needles/31g x 6 mm

2 QL(200/30)

techlite pen needles/31g x 8mm 2 QL(200/30)techlite pen needles/32g x 4mm 2 QL(200/30)techlite pen needles/32g x 6mm 2 QL(200/30)techlite pen needles/32g x 8mm 2 QL(200/30)TIS-U-SOL 4V-GO 20 3V-GO 30 3V-GO 40 3

Ophthalmic Agents

Ophthalmic Prostaglandin and Prostamide Analogsbimatoprost ophthalmic soln 2 QL(5/30)COMBIGAN 3latanoprost 2 QL(5/30)LUMIGAN 4 QL(5/30) STTRAVATAN Z 3 QL(5/30)ZIOPTAN 4 QL(30/30)Ophthalmic Agents, Otheratropine sulfate ophthalmic soln 2CYSTARAN 5 PA QL(60/28)LACRISERT 3proparacaine hcl 2RESTASIS 3 QL(60/30)tropicamide 2Ophthalmic Anti-allergy AgentsALOCRIL 3azelastine hcl ophthalmic soln 2cromolyn sodium ophthalmic soln

2

epinastine hcl 2olopatadine hcl ophthalmic soln 2 QL(5/30)olopatadine hydrochloride ophthalmic soln 0.2%

2 QL(2.5/30)

PAZEO 3 QL(2.5/30)

57



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

levocetirizine dihydrochloride tabs

2 QL(30/30)

Antileukotrienesmontelukast sodium 2 QL(30/30)zafirlukast 2 QL(60/30)Bronchodilators, AnticholinergicATROVENT HFA 4 QL(25.8/30)COMBIVENT RESPIMAT 3 QL(8/30)INCRUSE ELLIPTA 3 QL(30/30)ipratropium bromide inhalation soln

2 B/D PA QL(300/30)

ipratropium bromide nasal soln 2 QL(30/30)ipratropium bromide/albuterol sulfate

2 B/D PA QL(540/30)

Bronchodilators, Sympathomimeticalbuterol sulfate er 2albuterol sulfate nebu 0.5% 2 B/D PA QL(180/30)albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml

2 B/D PA QL(360/30)

albuterol sulfate syrp 1albuterol sulfate tabs 1ANORO ELLIPTA 3 QL(60/30)epinephrine hcl inj 1mg/10ml, 1mg/ml, 30mg/30ml

4

epinephrine inj 0.15mg/0.15ml, 0.15mg/0.3ml, 0.3mg/0.3ml

2 QL(2/30)

EPIPEN 2-PAK 3 QL(2/30)EPIPEN-JR 2-PAK 3 QL(2/30)levalbuterol tartrate hfa 3 QL(30/30)metaproterenol sulfate 2PERFOROMIST 4 B/D PA QL(120/30)PROAIR HFA 3 QL(17/30)PROAIR RESPICLICK 3 QL(2/30)SEREVENT DISKUS 3 QL(60/30)terbutaline sulfate 4VENTOLIN HFA 4 QL(36/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

timolol maleate ophthalmic soln 1

Otic Agents

Otic Agentsacetic acid 2fluocinolone acetonide oil 4hydrocortisone/acetic acid 2neomycin/polymyxin/hc 2neomycin/polymyxin/hydrocortisone

2

Respiratory Tract/Pulmonary Agents

Anti-inflammatories, Inhaled CorticosteroidsADVAIR DISKUS 3 QL(60/30)ADVAIR HFA 3 QL(12/30)ARNUITY ELLIPTA 3 QL(30/30)BREO ELLIPTA 3 QL(60/30)budesonide susp 4 B/D PA QL(120/30)FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST

3 QL(60/30)

FLOVENT DISKUS AEPB 250MCG/BLIST

3 QL(240/30)

FLOVENT HFA AERO 44MCG/ACT

3 QL(10.6/30)


3 QL(12/30)


3 QL(24/30)

flunisolide 1 QL(50/30)fluticasone propionate susp 2 QL(16/30)Antihistaminesazelastine hcl nasal soln 2 QL(30/25)desloratadine 2 QL(30/30)diphenhydramine hcl inj 4levocetirizine dihydrochloride oral soln

2 QL(300/30)

58


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Respiratory Tract Agents, Otheracetylcysteine inhalation soln 2 B/D PAARALAST NP 4 B/D PAPROLASTIN-C 5 B/D PAribavirin inhalation soln 5 B/D PATRELEGY ELLIPTA 3 QL(60/30)XOLAIR 5 PA QL(6/28)ZEMAIRA 5 B/D PA

Skeletal Muscle Relaxants

Skeletal Muscle Relaxantscyclobenzaprine hcl tabs 10mg, 5mg

2 PA QL(90/30)

methocarbamol tabs 2 PAorphenadrine citrate er 2 PA QL(60/30)

Sleep Disorder Agents

GABA Receptor Modulatorstemazepam 2 QL(60/365)zaleplon 2 QL(30/30)zolpidem tartrate tabs 2 PA QL(30/30)Sleep Disorders, Otherarmodafinil 4 PA QL(30/30)modafinil 4 PA QL(30/30)ROZEREM 3 QL(30/30)SILENOR 3 QL(30/30)XYREM 5 PA QL(540/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Cystic Fibrosis AgentsCAYSTON 5 PA QL(84/56)KALYDECO 5 PA QL(60/30)ORKAMBI PACK 5 PA QL(56/28)ORKAMBI TABS 5 PA QL(120/30)PULMOZYME 5 B/D PA QL(150/30)TOBI PODHALER 5 QL(1568/365)tobramycin nebu 5 B/D PA QL(280/56)Mast Cell Stabilizerscromolyn sodium nebu 2 B/D PA QL(240/30)Phosphodiesterase Inhibitors, Airways Diseaseaminophylline 4DALIRESP TABS 500MCG 4 PA QL(30/30)DALIRESP TABS 250MCG 4 PA QL(60/365)THEO-24 4theophylline cr 2theophylline er tb12 300mg, 450mg

2

theophylline er tb24 2Pulmonary AntihypertensivesADEMPAS 5 PA QL(90/30)LETAIRIS 5 PA QL(30/30)OPSUMIT 5 PA QL(30/30)REMODULIN 5 B/D PAsildenafil tabs 20mg 3 PA QL(90/30)TRACLEER 5 PA QL(60/30)VENTAVIS 5 PA QL(270/30)Pulmonary Fibrosis AgentsESBRIET CAPS 5 PA QL(270/30)ESBRIET TABS 801MG 5 PA QL(90/30)ESBRIET TABS 267MG 5 PA QL(270/30)OFEV 5 PA QL(60/30)

59

DRUG PAGE DRUG PAGE DRUG PAGE

Covered Drugs Index

Aabacavir/lamivudine . . . . . . . . . . . . . . . 34abacavir oral soln . . . . . . . . . . . . . . . . . 34abacavir sulfate/ lamivudine/zidovudine . . . . . . . . . . . . . 34abacavir tabs . . . . . . . . . . . . . . . . . . . . . 34ABELCET . . . . . . . . . . . . . . . . . . . . . . . . . 25ABILIFY MAINTENA . . . . . . . . . . . . . . . 32ABRAXANE . . . . . . . . . . . . . . . . . . . . . . . 28acamprosate calcium dr . . . . . . . . . . . . 18acarbose . . . . . . . . . . . . . . . . . . . . . . . . . . 35acebutolol hcl . . . . . . . . . . . . . . . . . . . . . 39acetaminophen/codeine oral soln . . . 16acetaminophen/codeine tabs 300mg; 15mg, 300mg; 30mg . . . . . . . 16acetaminophen/codeine tabs 300mg; 60mg . . . . . . . . . . . . . . . . . . . . . 16acetazolamide . . . . . . . . . . . . . . . . . . . . . 40acetazolamide er . . . . . . . . . . . . . . . . . . 56acetazolamide sodium . . . . . . . . . . . . . 40acetic acid . . . . . . . . . . . . . . . . . . . . . . . . 57acetylcysteine inhalation soln . . . . . . 58acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . . 43ACTEMRA INJ 162MG/0.9ML . . . . . . 54ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML . . . . . . . . . . 54ACTHIB . . . . . . . . . . . . . . . . . . . . . . . . . . . 54ACTIMMUNE . . . . . . . . . . . . . . . . . . . . . 54acyclovir caps . . . . . . . . . . . . . . . . . . . . 35acyclovir oint . . . . . . . . . . . . . . . . . . . . . 35acyclovir sodium . . . . . . . . . . . . . . . . . . . 35acyclovir susp . . . . . . . . . . . . . . . . . . . . 35acyclovir tabs . . . . . . . . . . . . . . . . . . . . . 35ADACEL . . . . . . . . . . . . . . . . . . . . . . . . . . 54ADAGEN . . . . . . . . . . . . . . . . . . . . . . . . . 47adefovir dipivoxil . . . . . . . . . . . . . . . . . . . 33ADEMPAS . . . . . . . . . . . . . . . . . . . . . . . . 58adriamycin inj 2mg/ml . . . . . . . . . . . . . . 28adrucil . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27ADVAIR DISKUS . . . . . . . . . . . . . . . . . . 57

ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . . 57afeditab cr . . . . . . . . . . . . . . . . . . . . . . . . 40AFINITOR DISPERZ TBSO 2MG, 3MG . . . . . . . . . . . . . . . . . . . . . . . . 29AFINITOR DISPERZ TBSO 5MG . . . 29AFINITOR TABS 2.5MG, 5MG, 7.5MG . . . . . . . . . . . . . . 29AFINITOR TABS 10MG . . . . . . . . . . . . 29AGGRENOX . . . . . . . . . . . . . . . . . . . . . . 38ala-cort crea 1% . . . . . . . . . . . . . . . . . . . 47ALBENZA . . . . . . . . . . . . . . . . . . . . . . . . . 30albuterol sulfate er . . . . . . . . . . . . . . . . . 57albuterol sulfate nebu 0.5% . . . . . . . . 57albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml . . . . . . . . . . . 57albuterol sulfate syrp . . . . . . . . . . . . . . 57albuterol sulfate tabs . . . . . . . . . . . . . . 57alclometasone dipropionate . . . . . . . . 47alcohol prep pads . . . . . . . . . . . . . . . . . 18ALDURAZYME . . . . . . . . . . . . . . . . . . . . 47ALECENSA . . . . . . . . . . . . . . . . . . . . . . . 29alendronate sodium tabs 10mg, 40mg, 5mg . . . . . . . . . . . . . . . . . 55alendronate sodium tabs 35mg, 70mg . . . . . . . . . . . . . . . . . . . . . . . 55alfuzosin hcl er . . . . . . . . . . . . . . . . . . . . 47ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 27ALINIA SUSR . . . . . . . . . . . . . . . . . . . . . 30ALINIA TABS . . . . . . . . . . . . . . . . . . . . . 30ALIQOPA . . . . . . . . . . . . . . . . . . . . . . . . . 29allopurinol . . . . . . . . . . . . . . . . . . . . . . . . . 26allopurinol sodium . . . . . . . . . . . . . . . . . 26ALOCRIL . . . . . . . . . . . . . . . . . . . . . . . . . 56ALORA . . . . . . . . . . . . . . . . . . . . . . . . . . . 49alosetron hydrochloride tabs 0.5mg . . 46alosetron hydrochloride tabs 1mg . . . 46alprazolam odt tbdp 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 35alprazolam odt tbdp 2mg . . . . . . . . . . . 35alprazolam tabs 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 35

alprazolam tabs 2mg . . . . . . . . . . . . . . 35altavera . . . . . . . . . . . . . . . . . . . . . . . . . . . 49ALUNBRIG TABS 30MG . . . . . . . . . . . 29ALUNBRIG TABS 180MG, 90MG . . . 29ALUNBRIG TBPK . . . . . . . . . . . . . . . . . 29alyacen 1/35 . . . . . . . . . . . . . . . . . . . . . . 49alyacen 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 49amantadine hcl . . . . . . . . . . . . . . . . . . . . 31AMBISOME . . . . . . . . . . . . . . . . . . . . . . . 25a-methapred . . . . . . . . . . . . . . . . . . . . . . 47amethia . . . . . . . . . . . . . . . . . . . . . . . . . . . 49amethia lo . . . . . . . . . . . . . . . . . . . . . . . . . 49amikacin sulfate . . . . . . . . . . . . . . . . . . . 18amiloride hcl . . . . . . . . . . . . . . . . . . . . . . 41amiloride/hydrochlorothiazide . . . . . . 41aminophylline . . . . . . . . . . . . . . . . . . . . . 58AMINOSYN . . . . . . . . . . . . . . . . . . . . . . . 43AMINOSYN 7%/ELECTROLYTES . . 43AMINOSYN 8.5%/ ELECTROLYTES . . . . . . . . . . . . . . . . . . 43AMINOSYN-HBC . . . . . . . . . . . . . . . . . . 44AMINOSYN II . . . . . . . . . . . . . . . . . . . . . 43AMINOSYN II 8.5%/ ELECTROLYTES . . . . . . . . . . . . . . . . . . 43AMINOSYN M . . . . . . . . . . . . . . . . . . . . . 43AMINOSYN-PF . . . . . . . . . . . . . . . . . . . . 44AMINOSYN-PF 7% . . . . . . . . . . . . . . . . 44AMINOSYN-RF . . . . . . . . . . . . . . . . . . . 44amiodarone hcl inj . . . . . . . . . . . . . . . . 39amiodarone hcl tabs . . . . . . . . . . . . . . 39AMITIZA . . . . . . . . . . . . . . . . . . . . . . . . . . 46amitriptyline hcl . . . . . . . . . . . . . . . . . . . . 25amlodipine besylate/benazepril hydrochloride caps 2.5mg; 10mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg . . . . . . . . . . . . . . . . . 40amlodipine besylate/benazepril hydrochloride caps 10mg; 20mg, 10mg; 40mg . . . . . . . . . . . . . . . . 40amlodipine besylate tabs 2.5mg . . . . 40amlodipine besylate tabs 5mg . . . . . . 40

60


Covered Drugs Index

ARISTADA INJ 882MG/3.2ML . . . . . . 32ARISTADA INJ 1064MG/3.9ML . . . . . 32armodafinil . . . . . . . . . . . . . . . . . . . . . . . . 58ARNUITY ELLIPTA . . . . . . . . . . . . . . . . 57ARRANON . . . . . . . . . . . . . . . . . . . . . . . . 27ascomp/codeine . . . . . . . . . . . . . . . . . . . 16ashlyna . . . . . . . . . . . . . . . . . . . . . . . . . . . 49aspirin/dipyridamole . . . . . . . . . . . . . . . 38ASTAGRAF XL CP24 0.5MG, 1MG . . 53ASTAGRAF XL CP24 5MG . . . . . . . . . 53atazanavir caps 200mg . . . . . . . . . . . . 34atazanavir caps 300mg . . . . . . . . . . . . 34atazanavir sulfate caps 150mg . . . . . 34atazanavir sulfate caps 200mg . . . . . 34atazanavir sulfate caps 300mg . . . . . 34atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 39atenolol/chlorthalidone . . . . . . . . . . . . . 39ATGAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 53atomoxetine caps 10mg, 18mg, 25mg, 40mg . . . . . . . . . 42atomoxetine caps 100mg, 60mg, 80mg . . . . . . . . . . . . . . . 42atorvastatin calcium . . . . . . . . . . . . . . . 41atovaquone . . . . . . . . . . . . . . . . . . . . . . . 30atovaquone/proguanil hcl . . . . . . . . . . 30ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . . 34atropine sulfate inj 0.5mg/5ml . . . . . . 40atropine sulfate inj 0.25mg/5ml, 1mg/ml, 8mg/20ml . . . . 46atropine sulfate ophthalmic soln . . . . 56ATROVENT HFA . . . . . . . . . . . . . . . . . . 57aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50augmented betamethasone dipropionate . . . . . . . . . . . . . . . . . . . . . . . 48AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML . . . . . . . . 20AURYXIA . . . . . . . . . . . . . . . . . . . . . . . . . 45AVASTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 30AVELOX INJ . . . . . . . . . . . . . . . . . . . . . . 21aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50avita . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

apraclonidine . . . . . . . . . . . . . . . . . . . . . . 56aprepitant caps . . . . . . . . . . . . . . . . . . . 25aprepitant caps 40mg . . . . . . . . . . . . . . 25aprepitant caps 80mg . . . . . . . . . . . . . . 25aprepitant caps 125mg . . . . . . . . . . . . . 25apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49APRISO . . . . . . . . . . . . . . . . . . . . . . . . . . 54APTIOM TABS 200MG, 400MG, 800MG . . . . . . . . . . . 22APTIOM TABS 600MG . . . . . . . . . . . . . 22APTIVUS CAPS . . . . . . . . . . . . . . . . . . 34APTIVUS ORAL SOLN . . . . . . . . . . . . 34ARALAST NP . . . . . . . . . . . . . . . . . . . . . 58aranelle . . . . . . . . . . . . . . . . . . . . . . . . . . . 49ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML . . . . . 37ARANESP ALBUMIN FREE INJ 25MCG/0.42ML . . . . . . . . . . . . . . . . . . . 37ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML . . . . . . . . . . . 37ARANESP ALBUMIN FREE INJ 60MCG/0.3ML . . . . . . . . . . . . . . . . . . . . 37ARANESP ALBUMIN FREE INJ 100MCG/0.5ML . . . . . . . . . . . . . . . . . . . 38ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML, 60MCG/ML . . . . . . . . . . 38ARANESP ALBUMIN FREE INJ 150MCG/0.3ML . . . . . . . . . . . . . . . . . . . 37ARANESP ALBUMIN FREE INJ 200MCG/0.4ML . . . . . . . . . . . . . . . . . . . 37ARANESP ALBUMIN FREE INJ 300MCG/0.6ML . . . . . . . . . . . . . . . . . . . 38ARANESP ALBUMIN FREE INJ 500MCG/ML . . . . . . . . . . . . . . . . . . . . . . 37ARCALYST . . . . . . . . . . . . . . . . . . . . . . . 54aripiprazole odt . . . . . . . . . . . . . . . . . . . . 32aripiprazole oral soln . . . . . . . . . . . . . . 32aripiprazole tabs . . . . . . . . . . . . . . . . . . 32ARISTADA INITIO . . . . . . . . . . . . . . . . . 32ARISTADA INJ 441MG/1.6ML . . . . . . 32ARISTADA INJ 662MG/2.4ML . . . . . . 32

amlodipine besylate tabs 10mg . . . . . 40amlodipine besylate/valsartan . . . . . . 40amlodipine/valsartan/hctz . . . . . . . . . . 40ammonium lactate . . . . . . . . . . . . . . . . . 43amnesteem . . . . . . . . . . . . . . . . . . . . . . . 43amoxapine . . . . . . . . . . . . . . . . . . . . . . . . 25amoxicillin caps . . . . . . . . . . . . . . . . . . . 20amoxicillin chew . . . . . . . . . . . . . . . . . . 20amoxicillin/clavulanate potassium . . . 20amoxicillin/clavulanate potassium er . . . . . . . . . . . . . . . . . . . . . . 20amoxicillin susr . . . . . . . . . . . . . . . . . . . 20amoxicillin tabs . . . . . . . . . . . . . . . . . . . 20amphetamine/dextroamphetamine cp24 1.25mg; 1.25mg; 1.25mg; 1.25mg, 6.25mg; 6.25mg; 6.25mg; 6.25mg . . . . . . . . . . . . . . . . . . . 42amphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 5mg; 5mg; 5mg; 5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg . . . . . . . 42amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg . . . . . . . 42amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg . . . . . . . . . 42amphotericin b . . . . . . . . . . . . . . . . . . . . 25ampicillin . . . . . . . . . . . . . . . . . . . . . . . . . . 20ampicillin sodium . . . . . . . . . . . . . . . . . . 20ampicillin-sulbactam . . . . . . . . . . . . . . . 20AMPYRA . . . . . . . . . . . . . . . . . . . . . . . . . 42ANADROL-50 . . . . . . . . . . . . . . . . . . . . . 49anagrelide hydrochloride . . . . . . . . . . . 37anaspaz . . . . . . . . . . . . . . . . . . . . . . . . . . 46anastrozole . . . . . . . . . . . . . . . . . . . . . . . 29ANORO ELLIPTA . . . . . . . . . . . . . . . . . . 57APOKYN . . . . . . . . . . . . . . . . . . . . . . . . . . 31

61


Covered Drugs Index

BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . . 20BICNU . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41BIKTARVY . . . . . . . . . . . . . . . . . . . . . . . . 33BILTRICIDE . . . . . . . . . . . . . . . . . . . . . . . 30bimatoprost ophthalmic soln . . . . . . . 56BINOSTO . . . . . . . . . . . . . . . . . . . . . . . . . 55bisoprolol fumarate . . . . . . . . . . . . . . . . 39bisoprolol fumarate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 39bleomycin sulfate . . . . . . . . . . . . . . . . . . 28BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . . 21BLEPHAMIDE S.O.P. . . . . . . . . . . . . . . 21blisovi fe 1.5/30 . . . . . . . . . . . . . . . . . . . . 50blisovi fe 1/20 . . . . . . . . . . . . . . . . . . . . . 50BOOSTRIX . . . . . . . . . . . . . . . . . . . . . . . 54BORTEZOMIB . . . . . . . . . . . . . . . . . . . . 28BOSULIF TABS 100MG . . . . . . . . . . . . 29BOSULIF TABS 400MG, 500MG . . . 29BRAFTOVI . . . . . . . . . . . . . . . . . . . . . . . . 28BREO ELLIPTA . . . . . . . . . . . . . . . . . . . 57briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . . 38brimonidine tartrate ophthalmic soln 0.2% . . . . . . . . . . . . . . 56brimonidine tartrate ophthalmic soln 0.15% . . . . . . . . . . . . . 56BRIVIACT INJ . . . . . . . . . . . . . . . . . . . . 22BRIVIACT ORAL SOLN . . . . . . . . . . . 22BRIVIACT TABS 10MG, 25MG, 50MG, 75MG . . . . . . . 22BRIVIACT TABS 100MG . . . . . . . . . . . 22bromfenac . . . . . . . . . . . . . . . . . . . . . . . . 56bromocriptine mesylate . . . . . . . . . . . . 31budesonide cpep . . . . . . . . . . . . . . . . . 54budesonide susp . . . . . . . . . . . . . . . . . . 57bumetanide inj . . . . . . . . . . . . . . . . . . . . 40bumetanide tabs 0.5mg, 1mg . . . . . . . 40bumetanide tabs 2mg . . . . . . . . . . . . . . 40BUPHENYL TABS . . . . . . . . . . . . . . . . 47

bd insulin syringe ultrafine/ 0.3ml/31g x 5/16” . . . . . . . . . . . . . . . . . . 55bd insulin syringe ultrafine/ 0.5ml/30g x 1/2” . . . . . . . . . . . . . . . . . . . 55bd insulin syringe ultrafine/ 1ml/31g x 5/16” . . . . . . . . . . . . . . . . . . . . 55bd pen needle/mini/ultrafine/ 31g x 3/16” . . . . . . . . . . . . . . . . . . . . . . . . 55bd pen needle/nano/ultra fine/ 32g x 4mm . . . . . . . . . . . . . . . . . . . . . . . . 55bd pen needle/ultrafine/ 29g x 12.7mm . . . . . . . . . . . . . . . . . . . . . 55bd safetyglide 27g x 5/8” . . . . . . . . . . . 55bekyree . . . . . . . . . . . . . . . . . . . . . . . . . . . 50BELEODAQ . . . . . . . . . . . . . . . . . . . . . . . 28benazepril hcl . . . . . . . . . . . . . . . . . . . . . 38benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg, 20mg; 25mg, 5mg; 6.25mg . . . . . . . . . . . . . . . 38benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg . . . . . . . . . . . . . . . . 38BENDEKA . . . . . . . . . . . . . . . . . . . . . . . . 27BENICAR . . . . . . . . . . . . . . . . . . . . . . . . . 38BENICAR HCT . . . . . . . . . . . . . . . . . . . . 38BENLYSTA INJ 120MG . . . . . . . . . . . . 54BENLYSTA INJ 400MG . . . . . . . . . . . . 54benztropine mesylate inj . . . . . . . . . . . 31benztropine mesylate tabs . . . . . . . . . 31BESIVANCE . . . . . . . . . . . . . . . . . . . . . . 21BESPONSA . . . . . . . . . . . . . . . . . . . . . . . 30betamethasone dipropionate . . . . . . . 48betamethasone valerate crea . . . . . . 48betamethasone valerate foam . . . . . 48betamethasone valerate lotn . . . . . . . 48betamethasone valerate oint . . . . . . . 48BETASERON . . . . . . . . . . . . . . . . . . . . . 42betaxolol hcl . . . . . . . . . . . . . . . . . . . . . . . 39betaxolol hcl . . . . . . . . . . . . . . . . . . . . . . . 56bethanechol chloride . . . . . . . . . . . . . . . 47bexarotene . . . . . . . . . . . . . . . . . . . . . . . . 30BEXSERO . . . . . . . . . . . . . . . . . . . . . . . . 54bicalutamide . . . . . . . . . . . . . . . . . . . . . . 27

AVONEX . . . . . . . . . . . . . . . . . . . . . . . . . . 42AVONEX PEN . . . . . . . . . . . . . . . . . . . . . 42azacitidine . . . . . . . . . . . . . . . . . . . . . . . . 28AZACTAM . . . . . . . . . . . . . . . . . . . . . . . . 20AZACTAM IN ISO-OSMOTIC DEXTROSE . . . . . . . . . . . . . . . . . . . . . . . 20AZASAN . . . . . . . . . . . . . . . . . . . . . . . . . . 53AZASITE . . . . . . . . . . . . . . . . . . . . . . . . . . 20azathioprine inj . . . . . . . . . . . . . . . . . . . 53azathioprine tabs . . . . . . . . . . . . . . . . . 53azelastine hcl nasal soln . . . . . . . . . . . 57azelastine hcl ophthalmic soln . . . . . 56azithromycin inj . . . . . . . . . . . . . . . . . . . 21azithromycin pack . . . . . . . . . . . . . . . . . 21azithromycin susr 100mg/5ml . . . . . . 21azithromycin susr 200mg/5ml . . . . . . 21azithromycin tabs 250mg, 500mg . . . 21azithromycin tabs 600mg . . . . . . . . . . . 21AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . . 56aztreonam inj 1gm . . . . . . . . . . . . . . . . . 20aztreonam inj 2gm . . . . . . . . . . . . . . . . . 20

Bbaciim . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18bacitracin inj . . . . . . . . . . . . . . . . . . . . . . 18bacitracin ophthalmic oint . . . . . . . . . . 18bacitracin/polymyxin b . . . . . . . . . . . . . 18baclofen tabs . . . . . . . . . . . . . . . . . . . . . 33BACTROBAN NASAL . . . . . . . . . . . . . 18balsalazide disodium . . . . . . . . . . . . . . 54balziva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50BANZEL SUSP . . . . . . . . . . . . . . . . . . . 23BANZEL TABS 200MG . . . . . . . . . . . . 23BANZEL TABS 400MG . . . . . . . . . . . . 23BAVENCIO . . . . . . . . . . . . . . . . . . . . . . . . 30BAXDELA . . . . . . . . . . . . . . . . . . . . . . . . . 21BCG VACCINE . . . . . . . . . . . . . . . . . . . . 54bd eclipse syringe/1ml/30gx1/2” . . . . 55bd insulin syringe safetyglide/ 1ml/29g x 1/2” . . . . . . . . . . . . . . . . . . . . . 55

62


Covered Drugs Index

carvedilol . . . . . . . . . . . . . . . . . . . . . . . . . 39carvedilol phosphate . . . . . . . . . . . . . . . 39caspofungin acetate . . . . . . . . . . . . . . . 25CAYSTON . . . . . . . . . . . . . . . . . . . . . . . . 58caziant . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50cefaclor caps . . . . . . . . . . . . . . . . . . . . . 19cefaclor er . . . . . . . . . . . . . . . . . . . . . . . . 19cefaclor susr . . . . . . . . . . . . . . . . . . . . . . 20cefadroxil . . . . . . . . . . . . . . . . . . . . . . . . . 20CEFAZOLIN . . . . . . . . . . . . . . . . . . . . . . . 20cefazolin sodium/ dextrose inj 2gm; 3% . . . . . . . . . . . . . . 20cefazolin sodium inj 10gm, 1gm, 1gm/50ml; 4%, 500mg . . . . . . . . 20cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20cefepime . . . . . . . . . . . . . . . . . . . . . . . . . . 20cefepime/dextrose . . . . . . . . . . . . . . . . . 20cefixime . . . . . . . . . . . . . . . . . . . . . . . . . . . 20cefotaxime sodium . . . . . . . . . . . . . . . . . 20cefotetan . . . . . . . . . . . . . . . . . . . . . . . . . . 20cefoxitin sodium inj 10gm, 1gm, 2gm . . . . . . . . . . . . . . . . . . 20cefpodoxime proxetil . . . . . . . . . . . . . . . 20cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . 20ceftazidime . . . . . . . . . . . . . . . . . . . . . . . . 20ceftazidime/dextrose . . . . . . . . . . . . . . . 20ceftriaxone in iso-osmotic dextrose . . 20ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg . . . . . . . . . 20cefuroxime axetil . . . . . . . . . . . . . . . . . . 20cefuroxime sodium . . . . . . . . . . . . . . . . 20celecoxib caps 100mg, 200mg, 50mg . . . . . . . . . . . . . . 16celecoxib caps 400mg . . . . . . . . . . . . . 16CELONTIN . . . . . . . . . . . . . . . . . . . . . . . . 22cephalexin caps 250mg, 500mg . . . . 20cephalexin susr . . . . . . . . . . . . . . . . . . . 20cephalexin tabs . . . . . . . . . . . . . . . . . . . 20CEREZYME . . . . . . . . . . . . . . . . . . . . . . . 47cesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . . 18

calcipotriene crea . . . . . . . . . . . . . . . . . 43calcipotriene external soln . . . . . . . . . 43calcipotriene oint . . . . . . . . . . . . . . . . . . 43calcitonin-salmon . . . . . . . . . . . . . . . . . . 55calcitrene . . . . . . . . . . . . . . . . . . . . . . . . . 43calcitriol caps . . . . . . . . . . . . . . . . . . . . . 55calcitriol inj . . . . . . . . . . . . . . . . . . . . . . . 55calcitriol oint . . . . . . . . . . . . . . . . . . . . . . 43calcitriol oral soln . . . . . . . . . . . . . . . . . 55calcium acetate caps . . . . . . . . . . . . . . 45calcium acetate tabs 667mg . . . . . . . . 45CALQUENCE . . . . . . . . . . . . . . . . . . . . . 29camila . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51camrese . . . . . . . . . . . . . . . . . . . . . . . . . . 50camrese lo . . . . . . . . . . . . . . . . . . . . . . . . 50CANCIDAS . . . . . . . . . . . . . . . . . . . . . . . 25candesartan cilexetil . . . . . . . . . . . . . . . 38candesartan cilexetil/ hydrochlorothiazide . . . . . . . . . . . . . . . . 38CAPASTAT SULFATE . . . . . . . . . . . . . . 26CAPRELSA TABS 100MG . . . . . . . . . 29CAPRELSA TABS 300MG . . . . . . . . . 29captopril/hydrochlorothiazide . . . . . . . 38captopril tabs 12.5mg, 25mg . . . . . . . 38captopril tabs 100mg, 50mg . . . . . . . . 38CARAFATE SUSP . . . . . . . . . . . . . . . . 46CARBAGLU . . . . . . . . . . . . . . . . . . . . . . . 44carbamazepine . . . . . . . . . . . . . . . . . . . . 23carbamazepine er cp12 . . . . . . . . . . . 23carbamazepine er tb12 . . . . . . . . . . . . 23carbidopa/levodopa . . . . . . . . . . . . . . . . 31carbidopa/levodopa/entacapone . . . . 31carbidopa/levodopa er . . . . . . . . . . . . . 31carbidopa/levodopa odt . . . . . . . . . . . . 31carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml . . . . . . . . . . . . 28carmustine . . . . . . . . . . . . . . . . . . . . . . . . 27CARNITOR INJ . . . . . . . . . . . . . . . . . . . 55carteolol hcl . . . . . . . . . . . . . . . . . . . . . . . 56cartia xt . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

buprenorphine hcl inj . . . . . . . . . . . . . . 16buprenorphine hcl/naloxone hcl . . . . . 18buprenorphine hcl subl . . . . . . . . . . . . 18bupropion hcl er tb12 100mg, 200mg . . . . . . . . . . . . . . . . . . . . 24bupropion hcl sr . . . . . . . . . . . . . . . . . . . 18bupropion hcl sr . . . . . . . . . . . . . . . . . . . 24bupropion hcl tabs 100mg . . . . . . . . . . 24bupropion hcl xl . . . . . . . . . . . . . . . . . . . 24bupropion hydrochloride tabs 75mg . . . . . . . . . . . . . . . . . . . . . . . . 24buspirone hcl tabs 10mg, 5mg . . . . . . 35buspirone hcl tabs 15mg, 30mg, 7.5mg . . . . . . . . . . . . . . . 35busulfan . . . . . . . . . . . . . . . . . . . . . . . . . . 27BUSULFEX . . . . . . . . . . . . . . . . . . . . . . . 27butalbital/acetaminophen/ caffeine caps . . . . . . . . . . . . . . . . . . . . . 16butalbital/acetaminophen/ caffeine/codeine . . . . . . . . . . . . . . . . . . . 16butalbital/acetaminophen/ caffeine tabs 325mg; 50mg; 40mg . . 16butalbital/aspirin/caffeine caps . . . . . 16butalbital/aspirin/caffeine/codeine . . . 16butorphanol tartrate inj 1mg/ml . . . . . 16butorphanol tartrate inj 2mg/ml . . . . . 16butorphanol tartrate nasal soln . . . . . 16BYDUREON . . . . . . . . . . . . . . . . . . . . . . 35BYDUREON BCISE . . . . . . . . . . . . . . . 35BYDUREON PEN . . . . . . . . . . . . . . . . . 35BYETTA INJ 5MCG/0.02ML . . . . . . . . 35BYETTA INJ 10MCG/0.04ML . . . . . . . 35BYSTOLIC TABS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 39BYSTOLIC TABS 20MG . . . . . . . . . . . 39BYVALSON . . . . . . . . . . . . . . . . . . . . . . . 39

Ccabergoline . . . . . . . . . . . . . . . . . . . . . . . 52CABOMETYX TABS 20MG, 60MG . . . 29CABOMETYX TABS 40MG . . . . . . . . 29

63


Covered Drugs Index

CLINIMIX E 5%/DEXTROSE 25% . . . 44CLINIMIX N9G15E . . . . . . . . . . . . . . . . 44CLINIMIX N14G30E . . . . . . . . . . . . . . . 44CLINISOL SF 15% . . . . . . . . . . . . . . . . 44clobetasol propionate crea . . . . . . . . . 48clobetasol propionate emollient crea . . . . . . . . . . . . . . . . . . . . 48clobetasol propionate emollient foam . . . . . . . . . . . . . . . . . . . . 48clobetasol propionate external soln . . . . . . . . . . . . . . . . . . . . . . 48clobetasol propionate foam . . . . . . . . 48clobetasol propionate gel . . . . . . . . . . 48clobetasol propionate oint . . . . . . . . . 48clobetasol propionate sham . . . . . . . . 48clodan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48clofarabine . . . . . . . . . . . . . . . . . . . . . . . . 27clomipramine hcl . . . . . . . . . . . . . . . . . . 25clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg . . . . . . . . . . . 22clonazepam odt tbdp 1mg . . . . . . . . . . 22clonazepam odt tbdp 2mg . . . . . . . . . . 22clonazepam tabs 0.5mg . . . . . . . . . . . . 22clonazepam tabs 1mg . . . . . . . . . . . . . 22clonazepam tabs 2mg . . . . . . . . . . . . . 22clonidine hcl er . . . . . . . . . . . . . . . . . . . . 42clonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr . . . . . . . . . . . . 38clonidine hcl ptwk 0.3mg/24hr . . . . . . 38clonidine hcl tabs 0.1mg, 0.2mg . . . . 38clonidine hcl tabs 0.3mg . . . . . . . . . . . 38clopidogrel tabs 75mg . . . . . . . . . . . . . 38clopidogrel tabs 300mg . . . . . . . . . . . . 38clorazepate dipotassium tabs 3.75mg, 7.5mg . . . . . . . . . . . . . . . 35clorazepate dipotassium tabs 15mg . . . . . . . . . . . . . . . . . . . . . . . . 35clotrimazole/betamethasone dipropionate . . . . . . . . . . . . . . . . . . . . . . . 25clotrimazole external crea . . . . . . . . . 25clotrimazole external soln . . . . . . . . . . 25

citalopram hydrobromide oral soln . . 24citalopram hydrobromide tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 24citalopram hydrobromide tabs 20mg . . . . . . . . . . . . . . . . . . . . . . . . 24citalopram hydrobromide tabs 40mg . . . . . . . . . . . . . . . . . . . . . . . . 24cladribine . . . . . . . . . . . . . . . . . . . . . . . . . 27claravis . . . . . . . . . . . . . . . . . . . . . . . . . . . 43clarithromycin er . . . . . . . . . . . . . . . . . . . 21clarithromycin susr . . . . . . . . . . . . . . . . 21clarithromycin tabs . . . . . . . . . . . . . . . . 21clindacin etz pledgets . . . . . . . . . . . . . . 18clindacin-p . . . . . . . . . . . . . . . . . . . . . . . . 18clindamycin . . . . . . . . . . . . . . . . . . . . . . . 18clindamycin hcl . . . . . . . . . . . . . . . . . . . . 18clindamycin hydrochloride . . . . . . . . . . 18clindamycin phosphate crea . . . . . . . 18clindamycin phosphate external soln . . . . . . . . . . . . . . . . . . . . . . 19clindamycin phosphate gel . . . . . . . . 19clindamycin phosphate in d5w . . . . . . 19clindamycin phosphate inj 150mg/ml, 300mg/2ml, 600mg/4ml, 900mg/6ml . . . . . . . . . . . . 19clindamycin phosphate lotn . . . . . . . . 19clindamycin phosphate swab . . . . . . 19clindamycin/sodium chloride . . . . . . . . 19CLINIMIX 2.75%/DEXTROSE 5% . . 44CLINIMIX 4.25%/DEXTROSE 5% . . 44CLINIMIX 4.25%/DEXTROSE 10% . . 44CLINIMIX 4.25%/DEXTROSE 20% . . 44CLINIMIX 4.25%/DEXTROSE 25% . . 44CLINIMIX 5%/DEXTROSE 15% . . . . 44CLINIMIX 5%/DEXTROSE 20% . . . . 44CLINIMIX 5%/DEXTROSE 25% . . . . 44CLINIMIX E 2.75%/ DEXTROSE 10% . . . . . . . . . . . . . . . . . . 44CLINIMIX E 4.25%/ DEXTROSE 10% . . . . . . . . . . . . . . . . . . 44CLINIMIX E 4.25%/ DEXTROSE 25% . . . . . . . . . . . . . . . . . . 44

CHANTIX CONTINUING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . 18CHANTIX STARTING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . 18chateal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50CHEMET . . . . . . . . . . . . . . . . . . . . . . . . . 45chloramphenicol sodium succinate . . 18chlorhexidine gluconate mouth/throat soln . . . . . . . . . . . . . . . . . 43chloroquine phosphate . . . . . . . . . . . . . 30chlorothiazide . . . . . . . . . . . . . . . . . . . . . 41chlorothiazide sodium . . . . . . . . . . . . . . 41chlorpromazine hcl . . . . . . . . . . . . . . . . 31chlorthalidone . . . . . . . . . . . . . . . . . . . . . 41cholestyramine . . . . . . . . . . . . . . . . . . . . 41cholestyramine light . . . . . . . . . . . . . . . 41chorionic gonadotropin . . . . . . . . . . . . . 49ciclodan . . . . . . . . . . . . . . . . . . . . . . . . . . . 25ciclopirox nail lacquer . . . . . . . . . . . . . . 25ciclopirox olamine . . . . . . . . . . . . . . . . . 25ciclopirox sham . . . . . . . . . . . . . . . . . . . 25ciclopirox susp . . . . . . . . . . . . . . . . . . . . 25cidofovir . . . . . . . . . . . . . . . . . . . . . . . . . . 33cilostazol . . . . . . . . . . . . . . . . . . . . . . . . . . 38CILOXAN OINT . . . . . . . . . . . . . . . . . . . 21CIMDUO . . . . . . . . . . . . . . . . . . . . . . . . . . 34cimetidine . . . . . . . . . . . . . . . . . . . . . . . . . 46cimetidine hcl . . . . . . . . . . . . . . . . . . . . . 46CINRYZE . . . . . . . . . . . . . . . . . . . . . . . . . 53CIPRODEX . . . . . . . . . . . . . . . . . . . . . . . 21ciprofloxacin er tb24 500mg; 0 . . . . . . 21ciprofloxacin er tb24 1000mg; 0 . . . . 21ciprofloxacin hcl ophthalmic soln . . . 21ciprofloxacin hcl tabs 100mg, 250mg, 750mg . . . . . . . . . . . . 21ciprofloxacin hydrochloride . . . . . . . . . 21ciprofloxacin i.v.-in d5w . . . . . . . . . . . . 21ciprofloxacin susr . . . . . . . . . . . . . . . . . 21CIPRO HC . . . . . . . . . . . . . . . . . . . . . . . . 21cisplatin . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

64


Covered Drugs Index

delyla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50DEMSER . . . . . . . . . . . . . . . . . . . . . . . . . 40DEPEN TITRATABS . . . . . . . . . . . . . . . 45DEPO-ESTRADIOL . . . . . . . . . . . . . . . 50DEPO-MEDROL INJ 20MG/ML . . . . . 48DEPO-PROVERA . . . . . . . . . . . . . . . . . 51DESCOVY . . . . . . . . . . . . . . . . . . . . . . . . 34desipramine hcl . . . . . . . . . . . . . . . . . . . 25desloratadine . . . . . . . . . . . . . . . . . . . . . . 57desmopressin acetate inj . . . . . . . . . . 49desmopressin acetate nasal soln . . . 49desmopressin acetate tabs . . . . . . . . 49desogestrel/ethinyl estradiol . . . . . . . . 50desonide lotn . . . . . . . . . . . . . . . . . . . . . 48desonide oint . . . . . . . . . . . . . . . . . . . . . 48desoximetasone crea . . . . . . . . . . . . . 48desoximetasone gel . . . . . . . . . . . . . . . 48desoximetasone oint . . . . . . . . . . . . . . 48desvenlafaxine er . . . . . . . . . . . . . . . . . . 24dexamethasone elix . . . . . . . . . . . . . . . 48dexamethasone intensol . . . . . . . . . . . 48dexamethasone oral soln . . . . . . . . . . 48dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml . . . . 48dexamethasone sodium phosphate ophthalmic soln . . . . . . . . 56dexamethasone tabs 0.5mg, 0.75mg, 4mg . . . . . . . . . . . . . . . 48dexamethasone tabs 1.5mg, 1mg, 2mg, 6mg . . . . . . . . . . . . 48dexmethylphenidate hcl . . . . . . . . . . . . 42dexrazoxane . . . . . . . . . . . . . . . . . . . . . . 28dextroamphetamine sulfate er cp24 5mg . . . . . . . . . . . . . . . . . . . . . . . 42dextroamphetamine sulfate er cp24 10mg . . . . . . . . . . . . . . . . . . . . . 42dextroamphetamine sulfate er cp24 15mg . . . . . . . . . . . . . . . . . . . . . 42dextroamphetamine sulfate oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 42

cyclafem 7/7/7 . . . . . . . . . . . . . . . . . . . . . 50cyclobenzaprine hcl tabs 10mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 58cyclophosphamide caps . . . . . . . . . . . 27cyclophosphamide inj 1gm, 500mg . . . . . . . . . . . . . . . . . . . . . . . 27cyclophosphamide inj 2gm . . . . . . . . . 27cycloserine . . . . . . . . . . . . . . . . . . . . . . . . 26cyclosporine . . . . . . . . . . . . . . . . . . . . . . . 53cyclosporine modified . . . . . . . . . . . . . . 53CYRAMZA . . . . . . . . . . . . . . . . . . . . . . . . 30cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50CYSTADANE . . . . . . . . . . . . . . . . . . . . . 47CYSTAGON . . . . . . . . . . . . . . . . . . . . . . . 47CYSTARAN . . . . . . . . . . . . . . . . . . . . . . . 56cytarabine . . . . . . . . . . . . . . . . . . . . . . . . . 27cytarabine aqueous . . . . . . . . . . . . . . . . 27

Ddacarbazine . . . . . . . . . . . . . . . . . . . . . . . 27dactinomycin . . . . . . . . . . . . . . . . . . . . . . 28DALIRESP TABS 250MCG . . . . . . . . . 58DALIRESP TABS 500MCG . . . . . . . . . 58danazol caps 50mg . . . . . . . . . . . . . . . . 49danazol caps 100mg, 200mg . . . . . . . 49dantrolene sodium . . . . . . . . . . . . . . . . . 33dapsone tabs . . . . . . . . . . . . . . . . . . . . . 26DAPTACEL . . . . . . . . . . . . . . . . . . . . . . . 54daptomycin inj 500mg . . . . . . . . . . . . . . 19DARAPRIM . . . . . . . . . . . . . . . . . . . . . . . 30darifenacin hydrobromide er . . . . . . . . 47DARZALEX . . . . . . . . . . . . . . . . . . . . . . . 30dasetta 1/35 . . . . . . . . . . . . . . . . . . . . . . . 50dasetta 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 50daunorubicin hcl . . . . . . . . . . . . . . . . . . . 28daunorubicin hydrochloride . . . . . . . . . 28daysee . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50deblitane . . . . . . . . . . . . . . . . . . . . . . . . . . 51decitabine . . . . . . . . . . . . . . . . . . . . . . . . . 28DELESTROGEN INJ 10MG/ML . . . . 50

clotrimazole lozg . . . . . . . . . . . . . . . . . . 25clozapine odt tbdp 12.5mg, 25mg . . . 32clozapine odt tbdp 100mg . . . . . . . . . . 33clozapine odt tbdp 150mg . . . . . . . . . . 33clozapine odt tbdp 200mg . . . . . . . . . . 33clozapine tabs 25mg, 50mg . . . . . . . . 33clozapine tabs 100mg . . . . . . . . . . . . . . 33clozapine tabs 200mg . . . . . . . . . . . . . . 33COARTEM . . . . . . . . . . . . . . . . . . . . . . . . 30colchicine caps . . . . . . . . . . . . . . . . . . . 26colchicine tabs . . . . . . . . . . . . . . . . . . . . 26colestipol hcl . . . . . . . . . . . . . . . . . . . . . . 41colistimethate sodium . . . . . . . . . . . . . . 19colocort . . . . . . . . . . . . . . . . . . . . . . . . . . . 54COMBIGAN . . . . . . . . . . . . . . . . . . . . . . . 56COMBIVENT RESPIMAT . . . . . . . . . . 57COMETRIQ KIT . . . . . . . . . . . . . . . . . . 29COMETRIQ KIT . . . . . . . . . . . . . . . . . . 29COMETRIQ KIT 20MG . . . . . . . . . . . . 29COMPLERA . . . . . . . . . . . . . . . . . . . . . . 33compro . . . . . . . . . . . . . . . . . . . . . . . . . . . 31constulose . . . . . . . . . . . . . . . . . . . . . . . . 46COPAXONE INJ 20MG/ML . . . . . . . . . 42COPAXONE INJ 40MG/ML . . . . . . . . . 42COREG CR . . . . . . . . . . . . . . . . . . . . . . . 39CORLANOR . . . . . . . . . . . . . . . . . . . . . . 40cortisone acetate . . . . . . . . . . . . . . . . . . 48COSMEGEN . . . . . . . . . . . . . . . . . . . . . . 28COTELLIC . . . . . . . . . . . . . . . . . . . . . . . . 29COUMADIN . . . . . . . . . . . . . . . . . . . . . . . 37CREON . . . . . . . . . . . . . . . . . . . . . . . . . . . 47CRIXIVAN CAPS 200MG . . . . . . . . . . 34CRIXIVAN CAPS 400MG . . . . . . . . . . 34cromolyn sodium conc . . . . . . . . . . . . 46cromolyn sodium nebu . . . . . . . . . . . . 58cromolyn sodium ophthalmic soln . . . 56cryselle-28 . . . . . . . . . . . . . . . . . . . . . . . . 50CUPRIMINE . . . . . . . . . . . . . . . . . . . . . . 45curity gauze pads 2”x2” . . . . . . . . . . . . 43cyclafem 1/35 . . . . . . . . . . . . . . . . . . . . . 50

65


Covered Drugs Index

donepezil hcl tabs 10mg . . . . . . . . . . . 23donepezil hcl tabs 23mg . . . . . . . . . . . 23donepezil hcl tbdp 5mg . . . . . . . . . . . . 23donepezil hcl tbdp 10mg . . . . . . . . . . . 23donepezil hydrochloride tabs 5mg . . 23donepezil hydrochloride tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 23dorzolamide hcl . . . . . . . . . . . . . . . . . . . 56dorzolamide hcl/timolol maleate . . . . 56doxazosin mesylate tabs 1mg, 2mg, 4mg . . . . . . . . . . . . . . . . . . . . 47doxazosin mesylate tabs 8mg . . . . . . 47doxepin hcl . . . . . . . . . . . . . . . . . . . . . . . . 35doxepin hydrochloride . . . . . . . . . . . . . 43doxercalciferol caps 0.5mcg . . . . . . . . 55doxercalciferol caps 1mcg . . . . . . . . . . 55doxercalciferol caps 2.5mcg . . . . . . . . 55doxercalciferol inj . . . . . . . . . . . . . . . . . 55doxorubicin hcl . . . . . . . . . . . . . . . . . . . . 28doxorubicin hcl liposome . . . . . . . . . . . 28doxy 100 . . . . . . . . . . . . . . . . . . . . . . . . . . 22doxycycline hyclate caps . . . . . . . . . . 22doxycycline hyclate tabs 100mg, 20mg . . . . . . . . . . . . . . . . . . . . . 22doxycycline monohydrate caps 75mg . . . . . . . . . . . . . . . . . . . . . . . . 22doxycycline monohydrate caps 100mg, 50mg . . . . . . . . . . . . . . . . 22doxycycline monohydrate tabs . . . . . 22doxycycline susr . . . . . . . . . . . . . . . . . . 22dronabinol . . . . . . . . . . . . . . . . . . . . . . . . 25DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . . 27duloxetine hcl cpep 20mg . . . . . . . . . . 24duloxetine hydrochloride cpep 30mg . . . . . . . . . . . . . . . . . . . . . . . . 24duloxetine hydrochloride cpep 60mg . . . . . . . . . . . . . . . . . . . . . . . . 24DURAMORPH . . . . . . . . . . . . . . . . . . . . 16DUREZOL . . . . . . . . . . . . . . . . . . . . . . . . 56dutasteride . . . . . . . . . . . . . . . . . . . . . . . . 47

diclofenac sodium transdermal soln . . . . . . . . . . . . . . . . . . 43dicloxacillin sodium . . . . . . . . . . . . . . . . 20dicyclomine hcl caps . . . . . . . . . . . . . . 46dicyclomine hcl oral soln . . . . . . . . . . . 46dicyclomine hydrochloride . . . . . . . . . . 46didanosine . . . . . . . . . . . . . . . . . . . . . . . . 34diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . . 16digitek tabs 0.25mg . . . . . . . . . . . . . . . . 40digitek tabs 0.125mg . . . . . . . . . . . . . . . 40digoxin inj . . . . . . . . . . . . . . . . . . . . . . . . 40digoxin tabs 125mcg . . . . . . . . . . . . . . . 40digoxin tabs 250mcg . . . . . . . . . . . . . . . 40digox tabs 125mcg . . . . . . . . . . . . . . . . 40digox tabs 250mcg . . . . . . . . . . . . . . . . 40dihydroergotamine mesylate inj . . . . 26DILANTIN . . . . . . . . . . . . . . . . . . . . . . . . . 23DILANTIN INFATABS . . . . . . . . . . . . . . 23diltiazem hcl er cp12 . . . . . . . . . . . . . . 40diltiazem hcl er cp24 120mg, 180mg, 240mg, 300mg, 420mg . . . . . 40diltiazem hcl er tb24 . . . . . . . . . . . . . . . 40diltiazem hcl inj . . . . . . . . . . . . . . . . . . . 40diltiazem hcl tabs . . . . . . . . . . . . . . . . . 40dilt-xr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40diphenhydramine hcl inj . . . . . . . . . . . 57diphenoxylate/atropine . . . . . . . . . . . . . 46DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC . . . . . . . . . . . . . . . . . . . . . . . 54dipyridamole tabs . . . . . . . . . . . . . . . . . 38disulfiram . . . . . . . . . . . . . . . . . . . . . . . . . 18divalproex sodium . . . . . . . . . . . . . . . . . 22divalproex sodium dr . . . . . . . . . . . . . . . 22divalproex sodium er . . . . . . . . . . . . . . . 22docetaxel inj 160mg/16ml, 160mg/8ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml . . . . . . . . . . . . . . 28DOCETAXEL INJ 200MG/10ML . . . . 28dofetilide . . . . . . . . . . . . . . . . . . . . . . . . . . 39donepezil hcl tabs 5mg . . . . . . . . . . . . 23

dextroamphetamine sulfate tabs 5mg . . . . . . . . . . . . . . . . . . . . . . . . . . 42dextroamphetamine sulfate tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 42dextrose 2.5%/nacl 0.45% . . . . . . . . . 44DEXTROSE 5% . . . . . . . . . . . . . . . . . . . 44dextrose5% / electrolyte #48 viaflex . . . . . . . . . . . . . . 44dextrose 5%/lactated ringers . . . . . . . 44dextrose 5%/nacl 0.2% . . . . . . . . . . . . 44DEXTROSE 5%/NACL 0.3% . . . . . . . 44dextrose 5%/nacl 0.9% . . . . . . . . . . . . 44dextrose 5%/nacl 0.33% . . . . . . . . . . . 44dextrose 5%/nacl 0.45% . . . . . . . . . . . 44dextrose 5%/nacl 0.225% . . . . . . . . . . 44DEXTROSE 10% . . . . . . . . . . . . . . . . . . 44dextrose 10%/nacl 0.2% . . . . . . . . . . . 44dextrose10%/nacl 0.45% . . . . . . . . . . . 44DEXTROSE 20% . . . . . . . . . . . . . . . . . . 44DEXTROSE 25% . . . . . . . . . . . . . . . . . . 44DEXTROSE 30% . . . . . . . . . . . . . . . . . . 44DEXTROSE 40% . . . . . . . . . . . . . . . . . . 44DEXTROSE 50% . . . . . . . . . . . . . . . . . . 44DEXTROSE 70% . . . . . . . . . . . . . . . . . . 44DIASTAT ACUDIAL GEL 10MG . . . . . 22DIASTAT ACUDIAL GEL 20MG . . . . . 22DIASTAT PEDIATRIC . . . . . . . . . . . . . . 22diazepam inj 5mg/ml . . . . . . . . . . . . . . . 35diazepam oral soln . . . . . . . . . . . . . . . . 35diazepam rectal gel gel 2.5mg . . . . . . 22diazepam rectal gel gel 10mg . . . . . . 22diazepam rectal gel gel 20mg . . . . . . 22diazepam tabs . . . . . . . . . . . . . . . . . . . . 35diclofenac potassium . . . . . . . . . . . . . . 16diclofenac sodium dr tbec 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 16diclofenac sodium dr tbec 75mg . . . . 16diclofenac sodium er . . . . . . . . . . . . . . . 16diclofenac sodium gel 1% . . . . . . . . . . 43diclofenac sodium ophthalmic soln . . . . . . . . . . . . . . . . . . . 56

66


Covered Drugs Index

ertapenem sodium . . . . . . . . . . . . . . . . . 20ERWINAZE . . . . . . . . . . . . . . . . . . . . . . . 28ery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21ERYPED 400 . . . . . . . . . . . . . . . . . . . . . 21ERY-TAB . . . . . . . . . . . . . . . . . . . . . . . . . . 21ERYTHROCIN LACTOBIONATE . . . 21erythrocin stearate . . . . . . . . . . . . . . . . . 21erythromycin base . . . . . . . . . . . . . . . . . 21erythromycin/benzoyl peroxide . . . . . 43erythromycin ethylsuccinate . . . . . . . . 21erythromycin external soln . . . . . . . . . 21erythromycin gel . . . . . . . . . . . . . . . . . . 21erythromycin oint . . . . . . . . . . . . . . . . . 21erythromycin pads . . . . . . . . . . . . . . . . 21ESBRIET CAPS . . . . . . . . . . . . . . . . . . 58ESBRIET TABS 267MG . . . . . . . . . . . . 58ESBRIET TABS 801MG . . . . . . . . . . . . 58escitalopram oxalate oral soln . . . . . 24escitalopram oxalate tabs 5mg . . . . . 24escitalopram oxalate tabs 10mg . . . . 24escitalopram oxalate tabs 20mg . . . . 24esgic caps . . . . . . . . . . . . . . . . . . . . . . . . 16esomeprazole magnesium . . . . . . . . . 47esomeprazole sodium . . . . . . . . . . . . . 47estarylla . . . . . . . . . . . . . . . . . . . . . . . . . . 50estradiol crea . . . . . . . . . . . . . . . . . . . . . 50estradiol pttw . . . . . . . . . . . . . . . . . . . . . 50estradiol ptwk . . . . . . . . . . . . . . . . . . . . . 50estradiol tabs 0.5mg, 1mg, 2mg . . . . 50estradiol tabs 10mcg . . . . . . . . . . . . . . . 50estradiol valerate . . . . . . . . . . . . . . . . . . 50ESTRING . . . . . . . . . . . . . . . . . . . . . . . . . 50ethacrynate sodium . . . . . . . . . . . . . . . . 40ethambutol hcl . . . . . . . . . . . . . . . . . . . . 26ethosuximide . . . . . . . . . . . . . . . . . . . . . . 22ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg . . . . . . . . . 50ETHYOL . . . . . . . . . . . . . . . . . . . . . . . . . . 28etidronate disodium . . . . . . . . . . . . . . . . 55etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . 16

ENBREL SURECLICK . . . . . . . . . . . . . 53endocet tabs 325mg; 2.5mg, 325mg; 5mg . . . . . . . . 17endocet tabs 325mg; 7.5mg . . . . . . . . 17endocet tabs 325mg; 10mg . . . . . . . . 17ENGERIX-B INJ 10MCG/0.5ML . . . . 54ENGERIX-B INJ 20MCG/ML . . . . . . . 54enoxaparin sodium inj 30mg/0.3ml . . 37enoxaparin sodium inj 40mg/0.4ml . . 37enoxaparin sodium inj 60mg/0.6ml . . 37enoxaparin sodium inj 100mg/ml, 150mg/ml, 300mg/3ml . . 37enoxaparin sodium inj 120mg/0.8ml, 80mg/0.8ml . . . . . . . . . . 37enpresse-28 . . . . . . . . . . . . . . . . . . . . . . . 50enskyce . . . . . . . . . . . . . . . . . . . . . . . . . . . 50entacapone . . . . . . . . . . . . . . . . . . . . . . . 31entecavir . . . . . . . . . . . . . . . . . . . . . . . . . . 33ENTRESTO . . . . . . . . . . . . . . . . . . . . . . . 38enulose . . . . . . . . . . . . . . . . . . . . . . . . . . . 46ENVARSUS XR TB24 0.75MG, 1MG . . . . . . . . . . . . . . . . . . . . . 53ENVARSUS XR TB24 4MG . . . . . . . . 53EPCLUSA . . . . . . . . . . . . . . . . . . . . . . . . 33epinastine hcl . . . . . . . . . . . . . . . . . . . . . 56epinephrine hcl inj 1mg/10ml, 1mg/ml, 30mg/30ml . . . . . 57epinephrine inj 0.15mg/0.15ml, 0.15mg/0.3ml, 0.3mg/0.3ml . . . . . . . . 57EPIPEN 2-PAK . . . . . . . . . . . . . . . . . . . . 57EPIPEN-JR 2-PAK . . . . . . . . . . . . . . . . . 57epirubicin hcl inj 200mg/100ml . . . . . 28epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23EPIVIR HBV ORAL SOLN . . . . . . . . . 33ERBITUX . . . . . . . . . . . . . . . . . . . . . . . . . 30ergoloid mesylates . . . . . . . . . . . . . . . . . 23ergotamine tartrate/caffeine . . . . . . . . 26ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . . 29ERLEADA . . . . . . . . . . . . . . . . . . . . . . . . 27errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51ertapenem . . . . . . . . . . . . . . . . . . . . . . . . 20

dutasteride/tamsulosin hydrochloride . . . . . . . . . . . . . . . . . . . . . . 47

Eeconazole nitrate . . . . . . . . . . . . . . . . . . 25EDARBI . . . . . . . . . . . . . . . . . . . . . . . . . . 38EDARBYCLOR . . . . . . . . . . . . . . . . . . . . 38ed-spaz . . . . . . . . . . . . . . . . . . . . . . . . . . . 46EDURANT . . . . . . . . . . . . . . . . . . . . . . . . 33e.e.s. 400 . . . . . . . . . . . . . . . . . . . . . . . . . 21efavirenz caps 50mg . . . . . . . . . . . . . . . 33efavirenz caps 200mg . . . . . . . . . . . . . 33efavirenz tabs . . . . . . . . . . . . . . . . . . . . 33ELAPRASE . . . . . . . . . . . . . . . . . . . . . . . 47ELIDEL . . . . . . . . . . . . . . . . . . . . . . . . . . . 43ELIGARD INJ 7.5MG . . . . . . . . . . . . . . 52ELIGARD INJ 22.5MG . . . . . . . . . . . . . 52ELIGARD INJ 30MG . . . . . . . . . . . . . . . 52ELIGARD INJ 45MG . . . . . . . . . . . . . . . 52elinest . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50ELIQUIS STARTER PACK . . . . . . . . . 37ELIQUIS TABS 2.5MG . . . . . . . . . . . . . 37ELIQUIS TABS 5MG . . . . . . . . . . . . . . . 37ELITEK . . . . . . . . . . . . . . . . . . . . . . . . . . . 28ELLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51ELMIRON . . . . . . . . . . . . . . . . . . . . . . . . . 47EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . . 27EMEND SUSR . . . . . . . . . . . . . . . . . . . . 25emoquette . . . . . . . . . . . . . . . . . . . . . . . . 50EMPLICITI . . . . . . . . . . . . . . . . . . . . . . . . 30EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 24EMTRIVA CAPS . . . . . . . . . . . . . . . . . . 34EMTRIVA ORAL SOLN . . . . . . . . . . . . 34ENABLEX . . . . . . . . . . . . . . . . . . . . . . . . . 47enalapril maleate . . . . . . . . . . . . . . . . . . 38enalapril maleate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 39ENBREL INJ 25MG/0.5ML . . . . . . . . . 53ENBREL INJ 25MG, 50MG/ML . . . . . 53ENBREL MINI . . . . . . . . . . . . . . . . . . . . . 53

67


Covered Drugs Index

fluocinonide crea 0.1% . . . . . . . . . . . . . 48fluocinonide crea 0.05% . . . . . . . . . . . 48fluocinonide external soln . . . . . . . . . . 48fluocinonide gel . . . . . . . . . . . . . . . . . . . 48fluocinonide oint . . . . . . . . . . . . . . . . . . 48fluoride chew 0.25mg . . . . . . . . . . . . . . 44fluoritab chew 0.5mg, 1mg . . . . . . . . . 44fluorometholone . . . . . . . . . . . . . . . . . . . 56fluorouracil crea 0.5% . . . . . . . . . . . . . . 43fluorouracil crea 5% . . . . . . . . . . . . . . . 43fluorouracil external soln . . . . . . . . . . . 43fluorouracil inj . . . . . . . . . . . . . . . . . . . . . 28fluoxetine caps 10mg . . . . . . . . . . . . . . 24fluoxetine caps 20mg . . . . . . . . . . . . . . 24fluoxetine dr . . . . . . . . . . . . . . . . . . . . . . . 24fluoxetine hcl caps 10mg . . . . . . . . . . . 24fluoxetine hcl caps 20mg . . . . . . . . . . . 24fluoxetine hcl caps 40mg . . . . . . . . . . . 24fluoxetine hcl oral soln . . . . . . . . . . . . . 24fluoxetine hydrochloride tabs 10mg . . 24fluoxetine hydrochloride tabs 20mg . . 24fluphenazine decanoate . . . . . . . . . . . . 31fluphenazine hcl conc . . . . . . . . . . . . . 31fluphenazine hcl elix . . . . . . . . . . . . . . 31fluphenazine hcl inj . . . . . . . . . . . . . . . . 31fluphenazine hcl tabs 1mg . . . . . . . . . 31fluphenazine hcl tabs 10mg, 2.5mg, 5mg . . . . . . . . . . . . . . . . . 31flurbiprofen . . . . . . . . . . . . . . . . . . . . . . . . 16flurbiprofen sodium . . . . . . . . . . . . . . . . 56flutamide . . . . . . . . . . . . . . . . . . . . . . . . . . 27fluticasone propionate crea . . . . . . . . 48fluticasone propionate oint . . . . . . . . . 48fluticasone propionate susp . . . . . . . . 57fluvoxamine maleate tabs 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 24fluvoxamine maleate tabs 100mg . . . 24FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . . 28fomepizole . . . . . . . . . . . . . . . . . . . . . . . . 55

fentanyl citrate inj 1000mcg/20ml, 100mcg/2ml, 2500mcg/50ml, 250mcg/5ml . . . . . . . 17fentanyl citrate oral transmucosal lpop 200mcg, 400mcg, 600mcg . . . . 17fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 800mcg . . 17FERRIPROX . . . . . . . . . . . . . . . . . . . . . . 55FETZIMA . . . . . . . . . . . . . . . . . . . . . . . . . 24FETZIMA TITRATION PACK . . . . . . . 24finasteride tabs 5mg . . . . . . . . . . . . . . . 47FIRAZYR . . . . . . . . . . . . . . . . . . . . . . . . . 53FIRMAGON INJ 80MG . . . . . . . . . . . . . 52FIRMAGON INJ 120MG . . . . . . . . . . . 52flavoxate hcl . . . . . . . . . . . . . . . . . . . . . . . 47flecainide acetate . . . . . . . . . . . . . . . . . . 39FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST . . . . 57FLOVENT DISKUS AEPB 250MCG/BLIST . . . . . . . . . . . . . . . . . . . 57FLOVENT HFA AERO 44MCG/ACT . . . . . . . . . . . . . . . . . . . . . . 57FLOVENT HFA AERO 110MCG/ACT . . . . . . . . . . . . . . . . . . . . . 57FLOVENT HFA AERO 220MCG/ACT . . . . . . . . . . . . . . . . . . . . . 57fluconazole in nacl . . . . . . . . . . . . . . . . . 25fluconazole susr . . . . . . . . . . . . . . . . . . 25fluconazole tabs 100mg, 200mg, 50mg . . . . . . . . . . . . . . 25fluconazole tabs 150mg . . . . . . . . . . . . 25flucytosine . . . . . . . . . . . . . . . . . . . . . . . . 25fludarabine phosphate inj 50mg . . . . 28fludrocortisone acetate . . . . . . . . . . . . . 48flunisolide . . . . . . . . . . . . . . . . . . . . . . . . . 57fluocinolone acetonide body . . . . . . . . 48fluocinolone acetonide crea . . . . . . . . 48fluocinolone acetonide external soln . . . . . . . . . . . . . . . . . . . . . . 48fluocinolone acetonide oil . . . . . . . . . . 57fluocinolone acetonide oint . . . . . . . . 48fluocinolone acetonide scalp . . . . . . . 48

etodolac er . . . . . . . . . . . . . . . . . . . . . . . . 16etoposide inj . . . . . . . . . . . . . . . . . . . . . . 29EVOMELA . . . . . . . . . . . . . . . . . . . . . . . . 27EVOTAZ . . . . . . . . . . . . . . . . . . . . . . . . . . 34exemestane . . . . . . . . . . . . . . . . . . . . . . . 29ezetimibe . . . . . . . . . . . . . . . . . . . . . . . . . 41ezetimibe/simvastatin . . . . . . . . . . . . . . 41

FFABRAZYME . . . . . . . . . . . . . . . . . . . . . 47falmina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50famciclovir . . . . . . . . . . . . . . . . . . . . . . . . 35famotidine inj . . . . . . . . . . . . . . . . . . . . . 46famotidine premixed . . . . . . . . . . . . . . . 46famotidine tabs 20mg, 40mg . . . . . . . 46FANAPT TABS 1MG, 2MG, 4MG . . . 32FANAPT TABS 10MG, 12MG, 6MG, 8MG . . . . . . . . . . 32FANAPT TITRATION PACK . . . . . . . . 32FARESTON . . . . . . . . . . . . . . . . . . . . . . . 27FARXIGA . . . . . . . . . . . . . . . . . . . . . . . . . 35FARYDAK . . . . . . . . . . . . . . . . . . . . . . . . 29FASLODEX . . . . . . . . . . . . . . . . . . . . . . . 27felbamate susp . . . . . . . . . . . . . . . . . . . 23felbamate tabs . . . . . . . . . . . . . . . . . . . . 23felodipine er . . . . . . . . . . . . . . . . . . . . . . . 40FEMRING . . . . . . . . . . . . . . . . . . . . . . . . . 50femynor . . . . . . . . . . . . . . . . . . . . . . . . . . . 50fenofibrate caps 43mg, 50mg . . . . . . . 41fenofibrate caps 130mg, 150mg . . . . 41fenofibrate micronized caps 67mg . . . 41fenofibrate micronized caps 134mg, 200mg . . . . . . . . . . . . . . . . . . . . 41fenofibrate tabs 48mg, 54mg . . . . . . . 41fenofibrate tabs 145mg, 160mg . . . . . 41fenofibric acid dr cpdr 45mg . . . . . . . . 41fenofibric acid dr cpdr 135mg . . . . . . . 41fenoprofen calcium caps 400mg . . . . 16fenoprofen calcium tabs . . . . . . . . . . . 16fentanyl . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

68


Covered Drugs Index

gentamicin sulfate oint . . . . . . . . . . . . 18gentamicin sulfate ophthalmic soln . . 18gentamicin sulfate pediatric . . . . . . . . 18GENVOYA . . . . . . . . . . . . . . . . . . . . . . . . 33GEODON INJ . . . . . . . . . . . . . . . . . . . . 32GILENYA . . . . . . . . . . . . . . . . . . . . . . . . . 42GILOTRIF . . . . . . . . . . . . . . . . . . . . . . . . . 29GLEOSTINE . . . . . . . . . . . . . . . . . . . . . . 27glimepiride tabs 1mg . . . . . . . . . . . . . . . 36glimepiride tabs 2mg . . . . . . . . . . . . . . . 36glimepiride tabs 4mg . . . . . . . . . . . . . . . 35glipizide er tb24 2.5mg . . . . . . . . . . . . . 36glipizide er tb24 5mg . . . . . . . . . . . . . . . 36glipizide er tb24 10mg . . . . . . . . . . . . . 36glipizide/metformin hcl tabs 2.5mg; 250mg . . . . . . . . . . . . . . . . . . . . . 36glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg . . . . . . . . 36glipizide tabs 5mg . . . . . . . . . . . . . . . . . 36glipizide tabs 10mg . . . . . . . . . . . . . . . . 36glipizide xl tb24 2.5mg . . . . . . . . . . . . . 36glipizide xl tb24 5mg . . . . . . . . . . . . . . . 36glipizide xl tb24 10mg . . . . . . . . . . . . . . 36GLUCAGEN HYPOKIT . . . . . . . . . . . . 36GLUCAGON EMERGENCY KIT . . . . 36glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml . . . . 46glycopyrrolate tabs . . . . . . . . . . . . . . . . 46glydo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18GLYXAMBI . . . . . . . . . . . . . . . . . . . . . . . . 36granisetron hcl inj . . . . . . . . . . . . . . . . . 25granisetron hcl tabs . . . . . . . . . . . . . . . 25griseofulvin microsize . . . . . . . . . . . . . . 25griseofulvin ultramicrosize . . . . . . . . . . 26GUANIDINE HCL . . . . . . . . . . . . . . . . . . 26

HHALAVEN . . . . . . . . . . . . . . . . . . . . . . . . . 28halobetasol propionate . . . . . . . . . . . . . 48haloperidol . . . . . . . . . . . . . . . . . . . . . . . . 31

GABITRIL TABS 12MG . . . . . . . . . . . . 22GABITRIL TABS 16MG . . . . . . . . . . . . 22galantamine hydrobromide er . . . . . . 23galantamine hydrobromide oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 23galantamine hydrobromide tabs . . . . 23GAMMAKED INJ 1GM/10ML . . . . . . . 53GAMMAKED INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 5GM/50ML . . . . . . . . . . 54GAMUNEX-C INJ 1GM/10ML . . . . . . 54GAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 40GM/400ML, 5GM/50ML . . . . . . . . . . 54ganciclovir inj 500mg, 500mg/10ml . . . . . . . . . . . . . . . 33GARDASIL 9 . . . . . . . . . . . . . . . . . . . . . . 54GATTEX . . . . . . . . . . . . . . . . . . . . . . . . . . 46gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . . 46gavilyte-g . . . . . . . . . . . . . . . . . . . . . . . . . 46gavilyte-n/flavor pack . . . . . . . . . . . . . . 46GAZYVA . . . . . . . . . . . . . . . . . . . . . . . . . . 30gemcitabine . . . . . . . . . . . . . . . . . . . . . . . 28gemcitabine hcl inj 1gm . . . . . . . . . . . . 28gemcitabine hcl inj 200mg, 2gm . . . . 28gemcitabine hydrochloride inj 1.5gm/15ml, 1gm/10ml, 200mg/2ml, 2gm/20ml . . . . . . . . . . . . . 28gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . . 41generlac . . . . . . . . . . . . . . . . . . . . . . . . . . 46gengraf . . . . . . . . . . . . . . . . . . . . . . . . . . . 53GENOTROPIN . . . . . . . . . . . . . . . . . . . . 49GENOTROPIN MINIQUICK INJ 0.2MG . . . . . . . . . . . . . . . . . . . . . . . . 49GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG . . 49gentak . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18gentamicin sulfate/ 0.9% sodium chloride . . . . . . . . . . . . . . 18gentamicin sulfate crea . . . . . . . . . . . . 18gentamicin sulfate inj . . . . . . . . . . . . . . 18

fondaparinux sodium inj 2.5mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . 37fondaparinux sodium inj 5mg/0.4ml . . . . . . . . . . . . . . . . . . . . . . . . 37fondaparinux sodium inj 7.5mg/0.6ml . . . . . . . . . . . . . . . . . . . . . . . 37fondaparinux sodium inj 10mg/0.8ml . . . . . . . . . . . . . . . . . . . . . . . 37FORTEO . . . . . . . . . . . . . . . . . . . . . . . . . . 55fosamprenavir calcium . . . . . . . . . . . . . 34FOSCAVIR . . . . . . . . . . . . . . . . . . . . . . . . 33fosinopril sodium . . . . . . . . . . . . . . . . . . 39fosinopril sodium/ hydrochlorothiazide . . . . . . . . . . . . . . . . 39fosphenytoin sodium . . . . . . . . . . . . . . . 23FREAMINE HBC 6.9% . . . . . . . . . . . . . 44FREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML . . . . . 44furosemide inj . . . . . . . . . . . . . . . . . . . . 40furosemide oral soln . . . . . . . . . . . . . . 40furosemide tabs . . . . . . . . . . . . . . . . . . . 40FUSILEV . . . . . . . . . . . . . . . . . . . . . . . . . . 28FUZEON . . . . . . . . . . . . . . . . . . . . . . . . . . 34fyavolv tabs 2.5mcg; 0.5mg . . . . . . . . 50FYCOMPA SUSP . . . . . . . . . . . . . . . . . 22FYCOMPA TABS . . . . . . . . . . . . . . . . . 22

Ggabapentin caps 100mg . . . . . . . . . . . 22gabapentin caps 300mg, 400mg . . . . 22gabapentin oral soln . . . . . . . . . . . . . . 22gabapentin tabs 600mg . . . . . . . . . . . . 22gabapentin tabs 800mg . . . . . . . . . . . . 22

69


Covered Drugs Index

hydrocortisone oint 1%, 2.5% . . . . . . 48hydrocortisone rectal crea . . . . . . . . . 48hydrocortisone tabs . . . . . . . . . . . . . . . 48hydrocortisone valerate . . . . . . . . . . . . 48hydromorphone hcl dosette . . . . . . . . 17hydromorphone hcl inj . . . . . . . . . . . . . 17hydromorphone hcl liqd . . . . . . . . . . . 17hydromorphone hcl tabs 2mg, 4mg . 17hydromorphone hcl tabs 8mg . . . . . . . 17hydroxychloroquine sulfate . . . . . . . . . 31hydroxyprogesterone caproate . . . . . 51hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . 28hyoscyamine sulfate elix . . . . . . . . . . . 46hyoscyamine sulfate odt . . . . . . . . . . . 46hyoscyamine sulfate subl . . . . . . . . . . 46hyoscyamine sulfate tabs . . . . . . . . . . 46hyoscyamine sulfate tbdp . . . . . . . . . . 46

Iibandronate sodium tabs . . . . . . . . . . 55IBRANCE . . . . . . . . . . . . . . . . . . . . . . . . . 29ibudone tabs 5mg; 200mg . . . . . . . . . . 17ibuprofen susp . . . . . . . . . . . . . . . . . . . . 16ibuprofen tabs 400mg, 600mg, 800mg . . . . . . . . . . . . 16ibu tabs 600mg, 800mg . . . . . . . . . . . . 16ICLUSIG TABS 15MG . . . . . . . . . . . . . 29ICLUSIG TABS 45MG . . . . . . . . . . . . . 29idarubicin hcl inj 10mg/10ml . . . . . . . . 28IDHIFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29ifosfamide inj 1gm, 3gm . . . . . . . . . . . . 27ILARIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54ILEVRO . . . . . . . . . . . . . . . . . . . . . . . . . . . 56imatinib mesylate . . . . . . . . . . . . . . . . . . 29IMBRUVICA CAPS 70MG . . . . . . . . . . 29IMBRUVICA CAPS 140MG. . . . . . . . . 29IMBRUVICA TABS . . . . . . . . . . . . . . . . 29IMFINZI . . . . . . . . . . . . . . . . . . . . . . . . . . . 30imipenem/cilastatin inj 250mg; 250mg . . . . . . . . . . . . . . . . . . . . 20

HUMIRA PEN-CD/UC/HS STARTER INJ 40MG/0.8ML . . . . . . . . 53HUMIRA PEN-CD/UC/HS STARTER INJ 80MG/0.8ML . . . . . . . . 53HUMIRA PEN-PS/UV STARTER INJ . . . . . . . . . . . . . . . . . . . . 53HUMIRA PEN-PS/UV STARTER INJ 40MG/0.8ML . . . . . . . . 53HUMULIN 70/30 . . . . . . . . . . . . . . . . . . . 36HUMULIN 70/30 KWIKPEN . . . . . . . . 36HUMULIN N . . . . . . . . . . . . . . . . . . . . . . . 36HUMULIN N KWIKPEN . . . . . . . . . . . . 37HUMULIN R . . . . . . . . . . . . . . . . . . . . . . . 37HUMULIN R U-500 (CONCENTRATED) . . . . . . . . . . . . . . . 37HUMULIN R U-500 KWIKPEN. . . . . . 37hydralazine hcl inj . . . . . . . . . . . . . . . . . 41hydralazine hcl tabs . . . . . . . . . . . . . . . 41hydrochlorothiazide . . . . . . . . . . . . . . . . 41hydrocodone/acetaminophen tabs 325mg; 5mg . . . . . . . . . . . . . . . . . . . . . . . 17hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 7.5mg . . . . . . 17hydrocodone bitartrate/ acetaminophen oral soln . . . . . . . . . . 17hydrocodone bitartrate/ acetaminophen tabs 300mg; 5mg, 325mg; 2.5mg . . . . . . . . . . . . . . . 17hydrocodone bitartrate/ acetaminophen tabs 300mg; 10mg, 300mg; 7.5mg . . . . . . . . . . . . . . 17hydrocodone/ibuprofen . . . . . . . . . . . . 17hydrocortisone/acetic acid . . . . . . . . . . 57hydrocortisone butyrate crea . . . . . . . 48hydrocortisone butyrate external soln . . . . . . . . . . . . . . . . . . . . . . 48hydrocortisone butyrate (lipid) . . . . . . 48hydrocortisone butyrate (lipophilic) . . 48hydrocortisone butyrate oint . . . . . . . 48hydrocortisone enem . . . . . . . . . . . . . . 54hydrocortisone external crea . . . . . . . 48hydrocortisone lotn 2.5% . . . . . . . . . . . 48

haloperidol decanoate . . . . . . . . . . . . . 31haloperidol lactate . . . . . . . . . . . . . . . . . 31HARVONI . . . . . . . . . . . . . . . . . . . . . . . . . 33HAVRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 54heather . . . . . . . . . . . . . . . . . . . . . . . . . . . 51heparin sodium/d5w . . . . . . . . . . . . . . . 37heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml . . . . . . . . 37heparin sodium/nacl 0.9% . . . . . . . . . . 37heparin sodium/ nacl 0.45% inj 50unit/ml; 0.45% . . . . 37heparin sodium/ sodium chloride 0.9% . . . . . . . . . . . . . . 37heparin sodium/ sodium chloride 0.9% premix . . . . . . . 37HEPATAMINE . . . . . . . . . . . . . . . . . . . . . 44HEPLISAV-B . . . . . . . . . . . . . . . . . . . . . . 54HERCEPTIN INJ 150MG . . . . . . . . . . . 30HERCEPTIN INJ 440MG . . . . . . . . . . . 30HETLIOZ . . . . . . . . . . . . . . . . . . . . . . . . . 42HEXALEN . . . . . . . . . . . . . . . . . . . . . . . . 27HIBERIX . . . . . . . . . . . . . . . . . . . . . . . . . . 54HUMALOG . . . . . . . . . . . . . . . . . . . . . . . . 36HUMALOG JUNIOR KWIKPEN . . . . 36HUMALOG KWIKPEN . . . . . . . . . . . . . 36HUMALOG MIX 50/50 . . . . . . . . . . . . . 36HUMALOG MIX 50/50 KWIKPEN . . . 36HUMALOG MIX 75/25 . . . . . . . . . . . . . 36HUMALOG MIX 75/25 KWIKPEN . . . 36HUMIRA INJ 10MG/0.1ML, 10MG/0.2ML, 20MG/0.2ML, 20MG/0.4ML . . . . . . . . 53HUMIRA INJ 40MG/0.4ML, 40MG/0.8ML . . . . . . . . 53HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ . . . . 53HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML, 80MG/0.8ML . . . . . . . . 53HUMIRA PEN . . . . . . . . . . . . . . . . . . . . . 53

70


Covered Drugs Index

ivermectin . . . . . . . . . . . . . . . . . . . . . . . . . 30IXIARO . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

JJADENU . . . . . . . . . . . . . . . . . . . . . . . . . . 45JADENU SPRINKLE . . . . . . . . . . . . . . . 45JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . . 30jantoven . . . . . . . . . . . . . . . . . . . . . . . . . . 37JANUMET . . . . . . . . . . . . . . . . . . . . . . . . 36JANUMET XR TB24 1000MG; 50MG . . . . . . . . . . . . . . . . . . . 36JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG . . . 36JANUVIA . . . . . . . . . . . . . . . . . . . . . . . . . 36JARDIANCE . . . . . . . . . . . . . . . . . . . . . . 36jencycla . . . . . . . . . . . . . . . . . . . . . . . . . . . 51JENTADUETO . . . . . . . . . . . . . . . . . . . . 36JENTADUETO XR TB24 2.5MG; 1000MG . . . . . . . . . . . . . . . . . . . 36JENTADUETO XR TB24 5MG; 1000MG . . . . . . . . . . . . . . . . . . . . 36jevantique lo . . . . . . . . . . . . . . . . . . . . . . 50JEVTANA . . . . . . . . . . . . . . . . . . . . . . . . . 28jolessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50jolivette . . . . . . . . . . . . . . . . . . . . . . . . . . . 51juleber . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50JULUCA . . . . . . . . . . . . . . . . . . . . . . . . . . 33junel 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . 50junel 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . 50junel fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 50junel fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 50

KKABIVEN . . . . . . . . . . . . . . . . . . . . . . . . . 44KADCYLA . . . . . . . . . . . . . . . . . . . . . . . . 30KALETRA ORAL SOLN . . . . . . . . . . . 34KALETRA TABS 100MG; 25MG . . . . 34KALETRA TABS 200MG; 50MG . . . . 34KALYDECO . . . . . . . . . . . . . . . . . . . . . . . 58kariva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

INVEGA TRINZA INJ 819MG/2.625ML . . . . . . . . . . . . . . . . . . 32INVIRASE CAPS . . . . . . . . . . . . . . . . . 34INVIRASE TABS . . . . . . . . . . . . . . . . . . 34INVOKAMET . . . . . . . . . . . . . . . . . . . . . . 36INVOKAMET XR . . . . . . . . . . . . . . . . . . 36INVOKANA . . . . . . . . . . . . . . . . . . . . . . . 36IPOL INACTIVATED IPV . . . . . . . . . . . 54ipratropium bromide/ albuterol sulfate . . . . . . . . . . . . . . . . . . . 57ipratropium bromide inhalation soln . . . . . . . . . . . . . . . . . . . . 57ipratropium bromide nasal soln . . . . . 57irbesartan . . . . . . . . . . . . . . . . . . . . . . . . . 38irbesartan/hydrochlorothiazide . . . . . . 38IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 29irinotecan . . . . . . . . . . . . . . . . . . . . . . . . . 28irinotecan hcl . . . . . . . . . . . . . . . . . . . . . . 28irinotecan hydrochloride inj 40mg/2ml . . . . . . . . . . . . . . . . . . . . . . 28ISENTRESS CHEW 25MG . . . . . . . . . 33ISENTRESS CHEW 100MG . . . . . . . 33ISENTRESS HD . . . . . . . . . . . . . . . . . . . 34ISENTRESS PACK . . . . . . . . . . . . . . . 33ISENTRESS TABS . . . . . . . . . . . . . . . . 33isibloom . . . . . . . . . . . . . . . . . . . . . . . . . . . 50isoniazid inj . . . . . . . . . . . . . . . . . . . . . . . 26isoniazid syrp . . . . . . . . . . . . . . . . . . . . . 26isoniazid tabs 100mg . . . . . . . . . . . . . . 26isoniazid tabs 300mg . . . . . . . . . . . . . . 26isosorbide dinitrate er . . . . . . . . . . . . . . 41isosorbide dinitrate tabs . . . . . . . . . . . 41isosorbide mononitrate . . . . . . . . . . . . . 41isosorbide mononitrate er . . . . . . . . . . 41isotonic gentamicin . . . . . . . . . . . . . . . . 18isotretinoin . . . . . . . . . . . . . . . . . . . . . . . . 43isradipine . . . . . . . . . . . . . . . . . . . . . . . . . 40ISTODAX (OVERFILL) . . . . . . . . . . . . . 28itraconazole caps . . . . . . . . . . . . . . . . . 26itraconazole oral soln . . . . . . . . . . . . . . 26

imipenem/cilastatin inj 500mg; 500mg . . . . . . . . . . . . . . . . . . . . 20imipramine hcl tabs 25mg, 50mg . . . 25imipramine hydrochloride . . . . . . . . . . 25imiquimod . . . . . . . . . . . . . . . . . . . . . . . . . 43imiquimod pump . . . . . . . . . . . . . . . . . . . 43IMOVAX RABIES (H.D.C.V.) . . . . . . . 54incassia . . . . . . . . . . . . . . . . . . . . . . . . . . . 51INCRELEX . . . . . . . . . . . . . . . . . . . . . . . . 49INCRUSE ELLIPTA . . . . . . . . . . . . . . . . 57indapamide . . . . . . . . . . . . . . . . . . . . . . . 41INFANRIX . . . . . . . . . . . . . . . . . . . . . . . . . 54INFUMORPH 200 . . . . . . . . . . . . . . . . . 16INFUMORPH 500 . . . . . . . . . . . . . . . . . 16INLYTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 29INTELENCE TABS 25MG . . . . . . . . . . 33INTELENCE TABS 100MG, 200MG . . . . . . . . . . . . . . . . . . . 33INTRALIPID . . . . . . . . . . . . . . . . . . . . . . . 55INTRON A INJ 10MU, 10MU/ML, 50MU . . . . . . . . . . . 33INTRON A INJ 18MU, 6000000UNIT/ML . . . . . . . . . . . 33introvale . . . . . . . . . . . . . . . . . . . . . . . . . . 50INVANZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 20INVEGA SUSTENNA INJ 39MG/0.25ML . . . . . . . . . . . . . . . . . . . . . 32INVEGA SUSTENNA INJ 78MG/0.5ML . . . . . . . . . . . . . . . . . . . . . . 32INVEGA SUSTENNA INJ 117MG/0.75ML . . . . . . . . . . . . . . . . . . . . 32INVEGA SUSTENNA INJ 156MG/ML . . . . . . . . . . . . . . . . . . . . . . . . 32INVEGA SUSTENNA INJ 234MG/1.5ML . . . . . . . . . . . . . . . . . . . . . 32INVEGA TRINZA INJ 273MG/0.875ML . . . . . . . . . . . . . . . . . . 32INVEGA TRINZA INJ 410MG/1.315ML . . . . . . . . . . . . . . . . . . 32INVEGA TRINZA INJ 546MG/1.75ML . . . . . . . . . . . . . . . . . . . . 32

71


Covered Drugs Index

letrozole . . . . . . . . . . . . . . . . . . . . . . . . . . 29leucovorin calcium inj 100mg, 350mg, 500mg, 50mg . . . . . . 28leucovorin calcium tabs . . . . . . . . . . . 28LEUKERAN . . . . . . . . . . . . . . . . . . . . . . . 27LEUKINE INJ 250MCG . . . . . . . . . . . . 38leuprolide acetate . . . . . . . . . . . . . . . . . 52levalbuterol tartrate hfa . . . . . . . . . . . . 57LEVEMIR . . . . . . . . . . . . . . . . . . . . . . . . . 37LEVEMIR FLEXTOUCH . . . . . . . . . . . 37levetiracetam er tb24 500mg . . . . . . . 22levetiracetam er tb24 750mg . . . . . . . 22levetiracetam inj . . . . . . . . . . . . . . . . . . 22levetiracetam oral soln . . . . . . . . . . . . 22levetiracetam tabs . . . . . . . . . . . . . . . . 22levobunolol hcl . . . . . . . . . . . . . . . . . . . . 56levocarnitine . . . . . . . . . . . . . . . . . . . . . . 55levocetirizine dihydrochloride oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 57levocetirizine dihydrochloride tabs . . 57levofloxacin in d5w . . . . . . . . . . . . . . . . 21levofloxacin inj . . . . . . . . . . . . . . . . . . . . 21levofloxacin oral soln . . . . . . . . . . . . . . 21levofloxacin tabs . . . . . . . . . . . . . . . . . . 21levoleucovorin calcium inj 175mg/17.5ml . . . . . . . . . . . . . . . . . . . . . 28levoleucovorin inj 175mg/17.5ml, 250mg/25ml, 50mg . . . . . . . . . . . . . . . . 28levonest . . . . . . . . . . . . . . . . . . . . . . . . . . 50levonorgestrel and ethinyl estradiol tabs 0; 0 . . . . . . . . . . . . . . . . . 50levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0 . . . . . . . . . 50levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, 20mcg; 0.1mg . . . . . . . . . . . . . . . . . . 50levora 0.15/30-28 . . . . . . . . . . . . . . . . . . 50levorphanol tartrate . . . . . . . . . . . . . . . . 16levothyroxine sodium tabs . . . . . . . . . 52levoxyl tabs 100mcg, 112mcg, 175mcg . . . . . . . . . 52

LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L . . . . . . . . . . . . . . . 44LACTATED RINGERS IRRIGATION . . . . . . . . . . . . . . . . . . . . . . 55LACTATED RINGERS VIAFLEX . . . . 45lactulose oral soln . . . . . . . . . . . . . . . . . 46lamivudine oral soln . . . . . . . . . . . . . . . 34lamivudine tabs 100mg . . . . . . . . . . . . 33lamivudine tabs 150mg . . . . . . . . . . . . 34lamivudine tabs 300mg . . . . . . . . . . . . 34lamivudine/zidovudine . . . . . . . . . . . . . 34lamotrigine . . . . . . . . . . . . . . . . . . . . . . . . 23lamotrigine er . . . . . . . . . . . . . . . . . . . . . 23lamotrigine odt . . . . . . . . . . . . . . . . . . . . 23LANOXIN TABS 125MCG . . . . . . . . . . 40LANOXIN TABS 250MCG . . . . . . . . . . 40LANTUS . . . . . . . . . . . . . . . . . . . . . . . . . . 37LANTUS SOLOSTAR . . . . . . . . . . . . . . 37larin 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . . 50larin 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . . 50larin fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 50larin fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 50larissia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50LARTRUVO . . . . . . . . . . . . . . . . . . . . . . . 28latanoprost . . . . . . . . . . . . . . . . . . . . . . . . 56LATUDA TABS 80MG . . . . . . . . . . . . . . 32LATUDA TABS 120MG, 20MG, 40MG, 60MG . . . . . . 32leflunomide . . . . . . . . . . . . . . . . . . . . . . . 54LENVIMA 4 MG DAILY DOSE . . . . . . 30LENVIMA 8 MG DAILY DOSE . . . . . . 30LENVIMA 10 MG DAILY DOSE . . . . . 30LENVIMA 12MG DAILY DOSE . . . . . 30LENVIMA 14 MG DAILY DOSE . . . . . 30LENVIMA 18 MG DAILY DOSE . . . . . 30LENVIMA 20 MG DAILY DOSE . . . . . 30LENVIMA 24 MG DAILY DOSE . . . . . 30lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50LETAIRIS . . . . . . . . . . . . . . . . . . . . . . . . . 58

kcl 0.3%/d5w/nacl 0.9% . . . . . . . . . . . . 44kcl 0.3%/d5w/nacl 0.45% . . . . . . . . . . . 44kcl 0.15%/d5w/nacl 0.2% . . . . . . . . . . . 44kcl 0.15%/d5w/nacl 0.9% . . . . . . . . . . . 44kcl 0.15%/d5w/nacl 0.45% . . . . . . . . . 44kcl 0.15%/d5w/nacl 0.225% . . . . . . . . 44kcl 0.075%/d5w/nacl 0.45% . . . . . . . . 44kelnor 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 50kelnor 1/50 . . . . . . . . . . . . . . . . . . . . . . . . 50ketoconazole crea . . . . . . . . . . . . . . . . 26ketoconazole sham . . . . . . . . . . . . . . . 26ketoconazole tabs . . . . . . . . . . . . . . . . . 26ketorolac tromethamine ophthalmic soln . . . . . . . . . . . . . . . . . . . 56KEYTRUDA . . . . . . . . . . . . . . . . . . . . . . . 30kimidess . . . . . . . . . . . . . . . . . . . . . . . . . . 50KINERET . . . . . . . . . . . . . . . . . . . . . . . . . 53KINRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 54kionex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45KISQALI . . . . . . . . . . . . . . . . . . . . . . . . . . 28KISQALI FEMARA 200 DOSE . . . . . . 27KISQALI FEMARA 400 DOSE . . . . . . 27KISQALI FEMARA 600 DOSE . . . . . . 27klor-con . . . . . . . . . . . . . . . . . . . . . . . . . . . 44klor-con 8 . . . . . . . . . . . . . . . . . . . . . . . . . 44klor-con 10 . . . . . . . . . . . . . . . . . . . . . . . . 44klor-con m10 . . . . . . . . . . . . . . . . . . . . . . 44klor-con m20 . . . . . . . . . . . . . . . . . . . . . . 44klor-con sprinkle . . . . . . . . . . . . . . . . . . . 44KORLYM . . . . . . . . . . . . . . . . . . . . . . . . . . 55kurvelo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50KUVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . 47KYPROLIS . . . . . . . . . . . . . . . . . . . . . . . . 29

Llabetalol hcl inj . . . . . . . . . . . . . . . . . . . . 39labetalol hcl tabs . . . . . . . . . . . . . . . . . . 39LACRISERT . . . . . . . . . . . . . . . . . . . . . . 56

72


Covered Drugs Index

LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG . . . . . . 22LYRICA CAPS 225MG, 300MG . . . . . 22LYRICA CR TB24 165MG, 82.5MG . . 42LYRICA CR TB24 330MG . . . . . . . . . . 42LYRICA ORAL SOLN . . . . . . . . . . . . . . 22LYSODREN . . . . . . . . . . . . . . . . . . . . . . . 52lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Mmagnesium sulfate in d5w . . . . . . . . . . 22MAGNESIUM SULFATE INJ 20GM/500ML, 2GM/50ML, 40GM/1000ML . . . . . . . . . . . . . . . . . . . . 45magnesium sulfate inj 20gm/500ml, 2gm/50ml, 40gm/1000ml, 4gm/100ml, 4gm/50ml, 50% . . . . . . . . . . . . . . . . . . . . 45MAKENA . . . . . . . . . . . . . . . . . . . . . . . . . 51MAKENA . . . . . . . . . . . . . . . . . . . . . . . . . 51malathion . . . . . . . . . . . . . . . . . . . . . . . . . 31maprotiline hcl . . . . . . . . . . . . . . . . . . . . . 24marlissa . . . . . . . . . . . . . . . . . . . . . . . . . . 50MARPLAN . . . . . . . . . . . . . . . . . . . . . . . . 24MATULANE . . . . . . . . . . . . . . . . . . . . . . . 27matzim la . . . . . . . . . . . . . . . . . . . . . . . . . 40meclizine hcl tabs . . . . . . . . . . . . . . . . . 25meclofenamate sodium . . . . . . . . . . . . 16MEDROL TABS 2MG . . . . . . . . . . . . . . 48medroxyprogesterone acetate inj 150mg/ml . . . . . . . . . . . . . . . 52medroxyprogesterone acetate inj 150mg/ml . . . . . . . . . . . . . . . 52medroxyprogesterone acetate tabs . . . . . . . . . . . . . . . . . . . . . . 52mefloquine hcl . . . . . . . . . . . . . . . . . . . . . 31megestrol acetate susp 40mg/ml . . . 52megestrol acetate tabs . . . . . . . . . . . . 52MEKINIST TABS 0.5MG . . . . . . . . . . . 30MEKINIST TABS 2MG . . . . . . . . . . . . . 30MEKTOVI . . . . . . . . . . . . . . . . . . . . . . . . . 28

lopinavir/ritonavir . . . . . . . . . . . . . . . . . . 34lorazepam conc . . . . . . . . . . . . . . . . . . . 35lorazepam inj 2mg/ml, 4mg/ml . . . . . . 35lorazepam intensol . . . . . . . . . . . . . . . . 35lorazepam tabs 0.5mg, 1mg . . . . . . . . 35lorazepam tabs 2mg . . . . . . . . . . . . . . . 35lorcet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17lorcet hd . . . . . . . . . . . . . . . . . . . . . . . . . . 17lorcet plus tabs 325mg; 7.5mg . . . . . . 17losartan potassium/ hydrochlorothiazide tabs 12.5mg; 50mg . . . . . . . . . . . . . . . . . . . . . 38losartan potassium/ hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg . . . . . 38losartan potassium tabs 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 38losartan potassium tabs 100mg . . . . . 38LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . . 56lovastatin tabs 10mg, 20mg . . . . . . . . 41lovastatin tabs 40mg . . . . . . . . . . . . . . . 41low-ogestrel . . . . . . . . . . . . . . . . . . . . . . . 50loxapine caps 10mg, 5mg . . . . . . . . . . 31loxapine caps 25mg, 50mg . . . . . . . . . 31loxapine succinate caps 10mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 31loxapine succinate caps 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 31ludent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45LUMIGAN . . . . . . . . . . . . . . . . . . . . . . . . . 56LUMIZYME . . . . . . . . . . . . . . . . . . . . . . . 47LUPRON DEPOT (1-MONTH) . . . . . . 52LUPRON DEPOT (3-MONTH) . . . . . . 52LUPRON DEPOT (4-MONTH) . . . . . . 52LUPRON DEPOT (6-MONTH) . . . . . . 52LUPRON DEPOT-PED (1-MONTH) . . . . . . . . . . . . . . . . . . . . . . . 52LUPRON DEPOT-PED (3-MONTH) . . . . . . . . . . . . . . . . . . . . . . . 52lutera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50LYNPARZA CAPS . . . . . . . . . . . . . . . . 30LYNPARZA TABS . . . . . . . . . . . . . . . . . 28

LEVOXYL TABS 125MCG, 137MCG, 150MCG, 200MCG, 25MCG, 50MCG, 75MCG, 88MCG . . . 52LEXIVA SUSP . . . . . . . . . . . . . . . . . . . . 34LEXIVA TABS . . . . . . . . . . . . . . . . . . . . . 34LIALDA . . . . . . . . . . . . . . . . . . . . . . . . . . . 54lidocaine hcl external soln . . . . . . . . . 18lidocaine hcl gel . . . . . . . . . . . . . . . . . . . 18lidocaine hcl inj . . . . . . . . . . . . . . . . . . . 18lidocaine hcl inj . . . . . . . . . . . . . . . . . . . 39lidocaine hcl jelly . . . . . . . . . . . . . . . . . . 18lidocaine hcl mouth/throat soln . . . . . 18lidocaine hcl viscous . . . . . . . . . . . . . . . 18lidocaine oint . . . . . . . . . . . . . . . . . . . . . 18lidocaine/prilocaine crea . . . . . . . . . . . 18lidocaine ptch . . . . . . . . . . . . . . . . . . . . . 18lidocaine viscous . . . . . . . . . . . . . . . . . . 18lincomycin hcl . . . . . . . . . . . . . . . . . . . . . 19lindane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31linezolid inj . . . . . . . . . . . . . . . . . . . . . . . 19linezolid susr . . . . . . . . . . . . . . . . . . . . . 19linezolid tabs . . . . . . . . . . . . . . . . . . . . . 19LINZESS . . . . . . . . . . . . . . . . . . . . . . . . . . 46liothyronine sodium inj . . . . . . . . . . . . . 52liothyronine sodium tabs . . . . . . . . . . . 52lipodox 50 . . . . . . . . . . . . . . . . . . . . . . . . . 28LIPOSYN III . . . . . . . . . . . . . . . . . . . . . . . 55lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . 39lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg, 25mg; 20mg . . . . . . . . 39lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg . . . . . . . . . . . . . . . . . . . . . 39lithium carbonate caps 150mg, 600mg . . . . . . . . . . . . . . . . . . . . 35lithium carbonate caps 300mg . . . . . . 35lithium carbonate er . . . . . . . . . . . . . . . . 35lithium carbonate tabs . . . . . . . . . . . . . 35LIVALO . . . . . . . . . . . . . . . . . . . . . . . . . . . 41LONSURF TABS 6.14MG; 15MG . . . 28LONSURF TABS 8.19MG; 20MG . . . 28loperamide hcl caps . . . . . . . . . . . . . . . 46

73


Covered Drugs Index

metronidazole lotn . . . . . . . . . . . . . . . . 19metronidazole tabs . . . . . . . . . . . . . . . . 19metronidazole vaginal . . . . . . . . . . . . . . 19mexiletine hcl . . . . . . . . . . . . . . . . . . . . . 39MIACALCIN . . . . . . . . . . . . . . . . . . . . . . . 55mibelas 24 fe . . . . . . . . . . . . . . . . . . . . . . 50microgestin 1.5/30 . . . . . . . . . . . . . . . . . 50microgestin 1/20 . . . . . . . . . . . . . . . . . . . 50microgestin fe . . . . . . . . . . . . . . . . . . . . . 51microgestin fe 1.5/30 . . . . . . . . . . . . . . 51midodrine hcl . . . . . . . . . . . . . . . . . . . . . . 38migergot . . . . . . . . . . . . . . . . . . . . . . . . . . 26miglitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36miglustat . . . . . . . . . . . . . . . . . . . . . . . . . . 47mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51minitran . . . . . . . . . . . . . . . . . . . . . . . . . . . 41MINIVELLE . . . . . . . . . . . . . . . . . . . . . . . 51minocycline hcl . . . . . . . . . . . . . . . . . . . . 22minoxidil . . . . . . . . . . . . . . . . . . . . . . . . . . 41mirtazapine . . . . . . . . . . . . . . . . . . . . . . . 24mirtazapine odt . . . . . . . . . . . . . . . . . . . . 24misoprostol . . . . . . . . . . . . . . . . . . . . . . . 46MITIGARE . . . . . . . . . . . . . . . . . . . . . . . . 26mitigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16mitomycin inj 20mg, 5mg . . . . . . . . . . . 28mitomycin inj 40mg . . . . . . . . . . . . . . . . 28mitoxantrone hcl . . . . . . . . . . . . . . . . . . . 28M-M-R II . . . . . . . . . . . . . . . . . . . . . . . . . . 54modafinil . . . . . . . . . . . . . . . . . . . . . . . . . . 58moexipril hcl . . . . . . . . . . . . . . . . . . . . . . . 39moexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg . . . . . . . . . . . . . . . . . . . . 39moexipril/hydrochlorothiazide tabs 12.5mg; 15mg, 25mg; 15mg . . . . . . . . 39mometasone furoate crea . . . . . . . . . 48mometasone furoate external soln . . 48mometasone furoate oint . . . . . . . . . . 48mondoxyne nl . . . . . . . . . . . . . . . . . . . . . 22mono-linyah . . . . . . . . . . . . . . . . . . . . . . . 51montelukast sodium . . . . . . . . . . . . . . . 57

methimazole . . . . . . . . . . . . . . . . . . . . . . 53methocarbamol tabs . . . . . . . . . . . . . . 58methotrexate sodium . . . . . . . . . . . . . . 53methotrexate tabs . . . . . . . . . . . . . . . . . 53methoxsalen . . . . . . . . . . . . . . . . . . . . . . 43methscopolamine bromide . . . . . . . . . 46methylphenidate hydrochloride er tb24 18mg . . . . . . . . . . . . . . . . . . . . . . 42methylphenidate hydrochloride er tb24 27mg, 54mg . . . . . . . . . . . . . . . 42methylphenidate hydrochloride er tb24 36mg . . . . . . . . . . . . . . . . . . . . . . 42methylphenidate hydrochloride er tbcr 10mg, 27mg, 54mg . . . . . . . . . 42methylphenidate hydrochloride er tbcr 18mg . . . . . . . . . . . . . . . . . . . . . . 42methylphenidate hydrochloride er tbcr 20mg . . . . . . . . . . . . . . . . . . . . . . 42methylphenidate hydrochloride er tbcr 36mg . . . . . . . . . . . . . . . . . . . . . . 42methylphenidate hydrochloride tabs . . . . . . . . . . . . . . . . 42methylprednisolone acetate inj 40mg/ml, 80mg/ml . . . . . . 48methylprednisolone dose pack . . . . . 48methylprednisolone sodiumsuccinate inj 125mg, 40mg . . 48methylprednisolone tabs . . . . . . . . . . . 48metipranolol . . . . . . . . . . . . . . . . . . . . . . . 56metoclopramide hcl inj . . . . . . . . . . . . 46metoclopramide hcl oral soln . . . . . . 46metoclopramide hcl tabs . . . . . . . . . . . 46metolazone . . . . . . . . . . . . . . . . . . . . . . . 41metoprolol/hydrochlorothiazide . . . . . 39metoprolol succinate er . . . . . . . . . . . . 39metoprolol tartrate inj . . . . . . . . . . . . . . 39metoprolol tartrate tabs . . . . . . . . . . . . 39metronidazole crea . . . . . . . . . . . . . . . . 19metronidazole gel . . . . . . . . . . . . . . . . . 19metronidazole inj 500mg/100ml; 0.79%, 5mg/ml . . . . . . 19metronidazole in nacl 0.79% . . . . . . . 19

melodetta 24 fe . . . . . . . . . . . . . . . . . . . . 50meloxicam . . . . . . . . . . . . . . . . . . . . . . . . 16melphalan hydrochloride . . . . . . . . . . . 27memantine hcl tabs 5mg . . . . . . . . . . . 23memantine hcl tabs 10mg . . . . . . . . . . 23memantine hcl titration pak . . . . . . . . . 24memantine hydrochloride er . . . . . . . . 24memantine hydrochloride oral soln . . 24MENACTRA . . . . . . . . . . . . . . . . . . . . . . 54MENEST . . . . . . . . . . . . . . . . . . . . . . . . . . 50MENOSTAR . . . . . . . . . . . . . . . . . . . . . . 50MENVEO . . . . . . . . . . . . . . . . . . . . . . . . . 54mercaptopurine . . . . . . . . . . . . . . . . . . . . 28meropenem . . . . . . . . . . . . . . . . . . . . . . . 20meropenem/sodium chloride . . . . . . . 20mesalamine . . . . . . . . . . . . . . . . . . . . . . . 54mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28MESNEX TABS . . . . . . . . . . . . . . . . . . . 28metadate er . . . . . . . . . . . . . . . . . . . . . . . 42metaproterenol sulfate . . . . . . . . . . . . . 57metformin hcl er tb24 500mg (generic for Glucophage XR) . . . . . . . 36metformin hcl er tb24 750mg (generic for Glucophage XR) . . . . . . . 36metformin hcl er tb24 1000mg, 500mg, (generic for Fortamet) . . . . . . 36metformin hcl tabs 850mg . . . . . . . . . . 36metformin hcl tabs 1000mg . . . . . . . . 36metformin hydrochloride oral soln . . . 36metformin hydrochloride tabs 500mg . . . . . . . . . . . . . . . . . . . . . . . 36methadone hcl conc . . . . . . . . . . . . . . . 16methadone hcl inj . . . . . . . . . . . . . . . . . 16methadone hcl intensol . . . . . . . . . . . . 16methadone hcl oral soln 5mg/5ml . . . 16methadone hcl oral soln 10mg/5ml . . 16methadone hcl tabs 5mg . . . . . . . . . . . 16methadone hcl tabs 10mg . . . . . . . . . . 16methazolamide . . . . . . . . . . . . . . . . . . . . 40methenamine hippurate . . . . . . . . . . . . 19

74


Covered Drugs Index

neomycin/polymyxin b sulfates . . . . . 18neomycin/polymyxin/ dexamethasone . . . . . . . . . . . . . . . . . . . 56neomycin/polymyxin/gramicidin . . . . . 19neomycin/polymyxin/hc . . . . . . . . . . . . 57neomycin/polymyxin/ hydrocortisone . . . . . . . . . . . . . . . . . . . . 19neomycin/polymyxin/ hydrocortisone . . . . . . . . . . . . . . . . . . . . 57neomycin sulfate . . . . . . . . . . . . . . . . . . 18neo-polycin . . . . . . . . . . . . . . . . . . . . . . . 19neo-polycin hc . . . . . . . . . . . . . . . . . . . . . 19NEPHRAMINE . . . . . . . . . . . . . . . . . . . . 45NERLYNX . . . . . . . . . . . . . . . . . . . . . . . . 28NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . . 31nevirapine er tb24 100mg . . . . . . . . . . 33nevirapine er tb24 400mg . . . . . . . . . . 33nevirapine tabs . . . . . . . . . . . . . . . . . . . 33NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . . . 30niacin er tbcr 500mg . . . . . . . . . . . . . . . 41niacin er tbcr 1000mg, 750mg . . . . . . 41niacor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41nicardipine hcl caps . . . . . . . . . . . . . . . 40nicardipine hcl inj . . . . . . . . . . . . . . . . . 40NICOTROL INHALER. . . . . . . . . . . . . . 18nifedipine er tb24 30mg, 60mg . . . . . 40nifedipine er tb24 90mg . . . . . . . . . . . . 40nilutamide . . . . . . . . . . . . . . . . . . . . . . . . . 27nimodipine . . . . . . . . . . . . . . . . . . . . . . . . 40NINLARO . . . . . . . . . . . . . . . . . . . . . . . . . 28NIPENT . . . . . . . . . . . . . . . . . . . . . . . . . . . 28nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . 19nitrofurantoin macrocrystals . . . . . . . . 19nitrofurantoin monohydrate . . . . . . . . . 19nitrofurantoin monohydrate/macrocrystals . . . . . . . . . . . . . . . . . . . . . 19nitroglycerin inj . . . . . . . . . . . . . . . . . . . . 41nitroglycerin lingual . . . . . . . . . . . . . . . . 41nitroglycerin subl . . . . . . . . . . . . . . . . . . 41nitroglycerin transdermal . . . . . . . . . . . 41

myzilra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Nnabumetone . . . . . . . . . . . . . . . . . . . . . . . 16nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39nadolol/bendroflumethiazide . . . . . . . . 39nafcillin sodium inj 2gm . . . . . . . . . . . . 20nafcillin sodium inj 10gm, 1gm, 2gm . . . . . . . . . . . . . . . . . . 20naftifine hcl . . . . . . . . . . . . . . . . . . . . . . . . 26naftifine hydrochloride . . . . . . . . . . . . . 26NAFTIN GEL . . . . . . . . . . . . . . . . . . . . . 26NAGLAZYME . . . . . . . . . . . . . . . . . . . . . 47nalbuphine hcl inj 10mg/ml . . . . . . . . . 17nalbuphine hcl inj 20mg/ml . . . . . . . . . 17naloxone hcl . . . . . . . . . . . . . . . . . . . . . . 18naltrexone hcl . . . . . . . . . . . . . . . . . . . . . 18NAMENDA XR . . . . . . . . . . . . . . . . . . . . 24NAMENDA XR TITRATION PACK . . 24NAMZARIC C4PK . . . . . . . . . . . . . . . . 23NAMZARIC CP24 . . . . . . . . . . . . . . . . . 23naproxen dr . . . . . . . . . . . . . . . . . . . . . . . 16naproxen sodium tabs 275mg, 550mg . . . . . . . . . . . . . . . . . . . . 16naproxen susp . . . . . . . . . . . . . . . . . . . . 16naproxen tabs 250mg . . . . . . . . . . . . . . 16naproxen tabs 375mg, 500mg . . . . . . 16naratriptan hcl . . . . . . . . . . . . . . . . . . . . . 26NARCAN . . . . . . . . . . . . . . . . . . . . . . . . . 18NATACYN . . . . . . . . . . . . . . . . . . . . . . . . . 26nateglinide . . . . . . . . . . . . . . . . . . . . . . . . 36NATPARA . . . . . . . . . . . . . . . . . . . . . . . . . 55NEBUPENT . . . . . . . . . . . . . . . . . . . . . . . 31necon 0.5/35-28 . . . . . . . . . . . . . . . . . . . 51necon 7/7/7 . . . . . . . . . . . . . . . . . . . . . . . 51nefazodone hcl . . . . . . . . . . . . . . . . . . . . 24nefazodone hydrochloride . . . . . . . . . . 24neomycin/bacitracin/polymyxin . . . . . 19neomycin/polymyxin/ bacitracin/hydrocortisone . . . . . . . . . . . 19

morgidox 1x50mg . . . . . . . . . . . . . . . . . 22morgidox 1x100mg caps . . . . . . . . . . 22morgidox 2x100mg caps . . . . . . . . . . 22morphine sulfate er tbcr . . . . . . . . . . . 16morphine sulfate inj 0.5mg/ml, 1mg/ml . . . . . . . . . . . . . . . . . 16morphine sulfate inj 1mg/ml . . . . . . . . 17MORPHINE SULFATE INJ 2MG/ML . . 17MORPHINE SULFATE INJ 4MG/ML . . 17morphine sulfate inj 8mg/ml . . . . . . . . 17morphine sulfate inj 10mg/ml . . . . . . . 17morphine sulfate inj 150mg/30ml, 50mg/ml, 5mg/ml . . . . . . . . . . . . . . . . . . 17morphine sulfate oral soln 10mg/5ml . . . . . . . . . . . . . . . . 17morphine sulfate oral soln 20mg/5ml . . . . . . . . . . . . . . . . 17morphine sulfate oral soln 100mg/5ml . . . . . . . . . . . . . . . 17MORPHINE SULFATE TABS . . . . . . 17MOVIPREP . . . . . . . . . . . . . . . . . . . . . . . 46moxifloxacin hcl inj . . . . . . . . . . . . . . . . 21moxifloxacin hcl tabs . . . . . . . . . . . . . . 21moxifloxacin hydrochloride ophthalmic soln . . . . . . . . . . . . . . . . . . . 21moxifloxacinhydrochloride/ sodium hydrochloride . . . . . . . . . . . . . . 21MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . . 38MULTAQ . . . . . . . . . . . . . . . . . . . . . . . . . . 39multivitamin with fluoride chew . . . . . 46mupirocin crea . . . . . . . . . . . . . . . . . . . . 19mupirocin oint . . . . . . . . . . . . . . . . . . . . 19MUSTARGEN . . . . . . . . . . . . . . . . . . . . . 27mycophenolate mofetil caps . . . . . . . 53mycophenolate mofetil inj . . . . . . . . . . 53mycophenolate mofetil susr . . . . . . . . 53mycophenolate mofetil tabs . . . . . . . . 53mycophenolic acid dr . . . . . . . . . . . . . . 53MYLOTARG . . . . . . . . . . . . . . . . . . . . . . . 30myorisan . . . . . . . . . . . . . . . . . . . . . . . . . . 43MYRBETRIQ . . . . . . . . . . . . . . . . . . . . . . 47

75


Covered Drugs Index

ondansetron hcl tabs 24mg . . . . . . . . 25ondansetron odt . . . . . . . . . . . . . . . . . . . 25ONFI SUSP . . . . . . . . . . . . . . . . . . . . . . 22ONFI TABS 10MG . . . . . . . . . . . . . . . . . 22ONFI TABS 20MG . . . . . . . . . . . . . . . . . 22OPDIVO INJ 100MG/10ML, 40MG/4ML . . . . . . . . . . 30OPDIVO INJ 240MG/24ML . . . . . . . . . 30OPSUMIT . . . . . . . . . . . . . . . . . . . . . . . . . 58oralone dental paste . . . . . . . . . . . . . . . 43ORFADIN . . . . . . . . . . . . . . . . . . . . . . . . . 47ORKAMBI PACK . . . . . . . . . . . . . . . . . . 58ORKAMBI TABS . . . . . . . . . . . . . . . . . . 58orphenadrine citrate er . . . . . . . . . . . . . 58orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . . 51oscimin . . . . . . . . . . . . . . . . . . . . . . . . . . . 46oseltamivir phosphate caps 30mg . . 35oseltamivir phosphate caps 45mg, 75mg . . . . . . . . . . . . . . . . . . . . . . . 35oseltamivir phosphate susr . . . . . . . . 35OSMOPREP . . . . . . . . . . . . . . . . . . . . . . 46oxacillin sodium . . . . . . . . . . . . . . . . . . . 20oxaliplatin inj 100mg . . . . . . . . . . . . . . . 28oxaliplatin inj 100mg/20ml, 50mg/10ml . . . . . . . . . . . 28oxandrolone tabs 2.5mg . . . . . . . . . . . 49oxandrolone tabs 10mg . . . . . . . . . . . . 49oxaprozin . . . . . . . . . . . . . . . . . . . . . . . . . 16oxazepam . . . . . . . . . . . . . . . . . . . . . . . . . 35oxcarbazepine susp . . . . . . . . . . . . . . . 23oxcarbazepine tabs . . . . . . . . . . . . . . . 23oxybutynin chloride er tb24 10mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 47oxybutynin chloride er tb24 15mg . . . 47oxybutynin chloride syrp . . . . . . . . . . . 47oxybutynin chloride tabs . . . . . . . . . . . 47oxycodone/acetaminophen tabs 325mg; 2.5mg, 325mg; 5mg . . . 17oxycodone/acetaminophen tabs 325mg; 7.5mg . . . . . . . . . . . . . . . . 17

NUTRILIPID . . . . . . . . . . . . . . . . . . . . . . . 55nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . . 26nystatin crea . . . . . . . . . . . . . . . . . . . . . . 26nystatin oint . . . . . . . . . . . . . . . . . . . . . . 26nystatin powd . . . . . . . . . . . . . . . . . . . . . 26nystatin susp . . . . . . . . . . . . . . . . . . . . . 26nystatin tabs . . . . . . . . . . . . . . . . . . . . . . 26nystatin/triamcinolone . . . . . . . . . . . . . . 26nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Ooctreotide acetate inj 500mcg/ml . . . 52octreotide acetate inj 1000mcg/ml, 100mcg/ml, 200mcg/ml, 50mcg/ml . . . . . . . . . . . . . 52ODEFSEY . . . . . . . . . . . . . . . . . . . . . . . . 33ODOMZO . . . . . . . . . . . . . . . . . . . . . . . . . 28OFEV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58ofloxacin . . . . . . . . . . . . . . . . . . . . . . . . . . 21ogestrel . . . . . . . . . . . . . . . . . . . . . . . . . . . 51olanzapine/fluoxetine . . . . . . . . . . . . . . 24olanzapine inj . . . . . . . . . . . . . . . . . . . . . 32olanzapine odt . . . . . . . . . . . . . . . . . . . . 32olanzapine tabs . . . . . . . . . . . . . . . . . . . 32olmesartan medoxomil . . . . . . . . . . . . . 38olmesartan medoxomil/hydrochlorothiazide . . . . . . . . . . . . . . . . 38olopatadine hcl ophthalmic soln . . . . 56olopatadine hydrochloride ophthalmic soln 0.2% . . . . . . . . . . . . . . 56omega-3-acid ethyl esters . . . . . . . . . . 41omeprazole cpdr . . . . . . . . . . . . . . . . . . 47OMNIPOD 5 PACK . . . . . . . . . . . . . . . . 55OMNIPOD DASH 5 PACK. . . . . . . . . . 55OMNIPOD DASH SYSTEM . . . . . . . . 55OMNIPOD STARTER KIT . . . . . . . . . . 55ondansetron hcl inj 40mg/20ml, 4mg/2ml . . . . . . . . . . . . . . 25ondansetron hcl oral soln . . . . . . . . . . 25ondansetron hcl tabs 4mg, 8mg . . . . 25

nizatidine caps . . . . . . . . . . . . . . . . . . . . 46nora-be . . . . . . . . . . . . . . . . . . . . . . . . . . . 52norethindrone . . . . . . . . . . . . . . . . . . . . . 52norethindrone acetate . . . . . . . . . . . . . . 52norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs . . . . . 51norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg . . . . . . . 51norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg . . . . . . . . . 51norgestimate/ethinyl estradiol . . . . . . 51norlyroc . . . . . . . . . . . . . . . . . . . . . . . . . . . 52NORMOSOL-M IN D5W . . . . . . . . . . . 45NORMOSOL -R . . . . . . . . . . . . . . . . . . . 45NORMOSOL-R . . . . . . . . . . . . . . . . . . . . 45NORMOSOL-R IN D5W. . . . . . . . . . . . 45NORTHERA CAPS 100MG . . . . . . . . 40NORTHERA CAPS 200MG, 300MG . . . . . . . . . . . . . . . . . . . 40nortrel 0.5/35 (28) . . . . . . . . . . . . . . . . . 51nortrel 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 51nortrel 7/7/7 . . . . . . . . . . . . . . . . . . . . . . . 51nortriptyline hcl . . . . . . . . . . . . . . . . . . . . 25NORVIR CAPS . . . . . . . . . . . . . . . . . . . 34NORVIR ORAL SOLN . . . . . . . . . . . . . 34NORVIR PACK . . . . . . . . . . . . . . . . . . . 34NORVIR TABS . . . . . . . . . . . . . . . . . . . . 34NOVAREL . . . . . . . . . . . . . . . . . . . . . . . . 49novofine 31 . . . . . . . . . . . . . . . . . . . . . . . 55novofine 32gx6mm . . . . . . . . . . . . . . . . 55novofine autocover 30gx8mm . . . . . . 55novotwist 32gx5mm . . . . . . . . . . . . . . . 55NOXAFIL SUSP . . . . . . . . . . . . . . . . . . 26NOXAFIL TBEC . . . . . . . . . . . . . . . . . . 26NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . . 42nulev . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . . 53NUPLAZID CAPS . . . . . . . . . . . . . . . . . 32NUPLAZID TABS 10MG . . . . . . . . . . . 32NUPLAZID TABS 17MG . . . . . . . . . . . 32

76


Covered Drugs Index

pioglitazone hcl . . . . . . . . . . . . . . . . . . . . 36pioglitazone hcl/metformin hcl . . . . . . 36piperacillin sodium/ tazobactam sodium . . . . . . . . . . . . . . . . 20piperacillin/tazobactam . . . . . . . . . . . . . 20pirmella 1/35 . . . . . . . . . . . . . . . . . . . . . . 51pirmella 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 51piroxicam . . . . . . . . . . . . . . . . . . . . . . . . . 16PLENAMINE . . . . . . . . . . . . . . . . . . . . . . 45podofilox . . . . . . . . . . . . . . . . . . . . . . . . . . 43polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19polyethylene glycol 3350 powd . . . . . 46polymyxin b sulfate . . . . . . . . . . . . . . . . 19polymyxin b sulfate/ trimethoprim sulfate . . . . . . . . . . . . . . . . 19POMALYST . . . . . . . . . . . . . . . . . . . . . . . 27portia-28 . . . . . . . . . . . . . . . . . . . . . . . . . . 51PORTRAZZA . . . . . . . . . . . . . . . . . . . . . 28potassium chloride cr . . . . . . . . . . . . . . 45potassium chloride/dextrose inj 5%; 20meq/l, 5%; 40meq/l . . . . . . . . . 45potassium chloride/ dextrose/lactated ringers . . . . . . . . . . . 45potassium chloride/ dextrose/sodium chloride . . . . . . . . . . . 45potassium chloride er cpcr . . . . . . . . . 45potassium chloride er tbcr . . . . . . . . . 45potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml . . . . . . . . . . . . 45potassium chloride oral soln . . . . . . . 45potassium chloride/sodium chloride inj 20meq/l; 0.45%, 20meq/l; 0.9%, 40meq/l; 0.9% . . . . . . 45potassium chloride sr . . . . . . . . . . . . . . 45potassium citrate er . . . . . . . . . . . . . . . . 45POTELIGEO . . . . . . . . . . . . . . . . . . . . . . 30PRADAXA . . . . . . . . . . . . . . . . . . . . . . . . 37PRALUENT . . . . . . . . . . . . . . . . . . . . . . . 40pramipexole dihydrochloride . . . . . . . . 31pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg . . . 31

PEGASYS PROCLICK . . . . . . . . . . . . . 33penicillin g potassium . . . . . . . . . . . . . . 20penicillin v potassium oral soln . . . . . 20penicillin v potassium tabs 250mg . . 20penicillin v potassium tabs 500mg . . 20PENTAM 300 . . . . . . . . . . . . . . . . . . . . . 31pentoxifylline er . . . . . . . . . . . . . . . . . . . . 40PERFOROMIST . . . . . . . . . . . . . . . . . . . 57PERIKABIVEN . . . . . . . . . . . . . . . . . . . . 45perindopril erbumine . . . . . . . . . . . . . . . 39periogard . . . . . . . . . . . . . . . . . . . . . . . . . 43PERJETA . . . . . . . . . . . . . . . . . . . . . . . . . 30permethrin . . . . . . . . . . . . . . . . . . . . . . . . 31perphenazine . . . . . . . . . . . . . . . . . . . . . 31perphenazine/amitriptyline . . . . . . . . . 25pfizerpen inj 20mu, 5000000unit . . . . 20phenadoz . . . . . . . . . . . . . . . . . . . . . . . . . 25phenazopyridine hydrochloride . . . . . 47phenazopyridine hydrocholride . . . . . 47phenelzine sulfate . . . . . . . . . . . . . . . . . 24phenobarbital elix . . . . . . . . . . . . . . . . . 23phenobarbital tabs . . . . . . . . . . . . . . . . 23phenoxybenzamine hydrochloride . . 38phenytoin . . . . . . . . . . . . . . . . . . . . . . . . . 23phenytoin infatabs . . . . . . . . . . . . . . . . . 23phenytoin sodium . . . . . . . . . . . . . . . . . . 23phenytoin sodium extended . . . . . . . . 23philith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51PHOSLYRA . . . . . . . . . . . . . . . . . . . . . . . 46PHOSPHOLINE IODIDE . . . . . . . . . . . 56PHYSIOLYTE . . . . . . . . . . . . . . . . . . . . . 55physiosol irrigation . . . . . . . . . . . . . . . . . 55PICATO GEL 0.05% . . . . . . . . . . . . . . . 43PICATO GEL 0.015% . . . . . . . . . . . . . . 43pilocarpine hcl ophthalmic soln . . . . . 56pilocarpine hcl tabs . . . . . . . . . . . . . . . 43pilocarpine hydrochloride . . . . . . . . . . . 43pimozide . . . . . . . . . . . . . . . . . . . . . . . . . . 31pimtrea . . . . . . . . . . . . . . . . . . . . . . . . . . . 51pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

oxycodone/acetaminophen tabs 325mg; 10mg . . . . . . . . . . . . . . . . . 17oxycodone/aspirin . . . . . . . . . . . . . . . . . 17oxycodone hcl caps . . . . . . . . . . . . . . . 17oxycodone hcl conc . . . . . . . . . . . . . . . 17oxycodone hcl oral soln . . . . . . . . . . . 17oxycodone hcl tabs 10mg, 15mg, 20mg, 5mg . . . . . . . . . . . 17oxycodone hcl tabs 30mg . . . . . . . . . . 17oxycodone/ibuprofen . . . . . . . . . . . . . . 17OZEMPIC . . . . . . . . . . . . . . . . . . . . . . . . . 36

Ppacerone . . . . . . . . . . . . . . . . . . . . . . . . . . 39paclitaxel inj 100mg/16.7ml, 150mg/25ml, 300mg/50ml . . . . . . . . . . 28paliperidone er tb24 1.5mg, 3mg . . . 32paliperidone er tb24 6mg . . . . . . . . . . . 32paliperidone er tb24 9mg . . . . . . . . . . . 32pamidronate disodium . . . . . . . . . . . . . 55PANRETIN . . . . . . . . . . . . . . . . . . . . . . . . 30pantoprazole sodium tbec . . . . . . . . . 47paricalcitol caps 1mcg, 2mcg . . . . . . . 55paricalcitol caps 4mcg . . . . . . . . . . . . . 55paroex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43paromomycin sulfate . . . . . . . . . . . . . . . 18paroxetine hcl tabs 10mg . . . . . . . . . . 24paroxetine hcl tabs 20mg . . . . . . . . . . 24paroxetine hcl tabs 30mg, 40mg . . . . 24PASER . . . . . . . . . . . . . . . . . . . . . . . . . . . 26PAXIL SUSP . . . . . . . . . . . . . . . . . . . . . . 24PAZEO . . . . . . . . . . . . . . . . . . . . . . . . . . . 56PEDIARIX . . . . . . . . . . . . . . . . . . . . . . . . 54PEDVAX HIB . . . . . . . . . . . . . . . . . . . . . . 54peg 3350/electrolytes . . . . . . . . . . . . . . 46peg-3350/electrolytes . . . . . . . . . . . . . . 46peg-3350/nacl/na bicarbonate/kcl . . . 46PEGANONE . . . . . . . . . . . . . . . . . . . . . . 23PEGASYS INJ 180MCG/0.5ML . . . . . 33PEGASYS INJ 180MCG/ML . . . . . . . . 33

77


Covered Drugs Index

proparacaine hcl . . . . . . . . . . . . . . . . . . . 56propranolol hcl er . . . . . . . . . . . . . . . . . . 40propranolol hcl inj . . . . . . . . . . . . . . . . . 40propranolol hcl oral soln . . . . . . . . . . . 40propranolol hcl tabs . . . . . . . . . . . . . . . 40propranolol hydrochloride tabs 60mg . . . . . . . . . . . . . . . . . . . . . . . . 40propranolol/hydrochlorothiazide . . . . 40propylthiouracil . . . . . . . . . . . . . . . . . . . . 53PROQUAD . . . . . . . . . . . . . . . . . . . . . . . . 54PROSOL . . . . . . . . . . . . . . . . . . . . . . . . . . 45protriptyline hcl . . . . . . . . . . . . . . . . . . . . 25PULMOZYME . . . . . . . . . . . . . . . . . . . . . 58PURIXAN . . . . . . . . . . . . . . . . . . . . . . . . . 28pyrazinamide . . . . . . . . . . . . . . . . . . . . . . 27pyridostigmine bromide . . . . . . . . . . . . 26pyridostigmine bromide er . . . . . . . . . . 26

QQUADRACEL . . . . . . . . . . . . . . . . . . . . . 54quasense . . . . . . . . . . . . . . . . . . . . . . . . . 51quetiapine fumarate . . . . . . . . . . . . . . . 32quetiapine fumarate er tb24 150mg, 200mg . . . . . . . . . . . . . 32quetiapine fumarate er tb24 300mg, 400mg, 50mg . . . . . . 32quinapril hcl . . . . . . . . . . . . . . . . . . . . . . . 39quinapril/hydrochlorothiazide tabs 12.5mg; 10mg . . . . . . . . . . . . . . . . . . . . . 39quinapril/hydrochlorothiazide tabs 12.5mg; 20mg, 25mg; 20mg . . . . . . . . 39quinidine sulfate . . . . . . . . . . . . . . . . . . . 39quinine sulfate . . . . . . . . . . . . . . . . . . . . . 31

RRABAVERT . . . . . . . . . . . . . . . . . . . . . . . 54raloxifene hydrochloride . . . . . . . . . . . . 52ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . . 39RANEXA . . . . . . . . . . . . . . . . . . . . . . . . . . 40ranitidine hcl caps . . . . . . . . . . . . . . . . . 46

PRISTIQ . . . . . . . . . . . . . . . . . . . . . . . . . . 24PROAIR HFA . . . . . . . . . . . . . . . . . . . . . 57PROAIR RESPICLICK . . . . . . . . . . . . . 57probenecid . . . . . . . . . . . . . . . . . . . . . . . . 26probenecid/colchicine . . . . . . . . . . . . . . 26PROCALAMINE . . . . . . . . . . . . . . . . . . . 45prochlorperazine . . . . . . . . . . . . . . . . . . 31prochlorperazine edisylate . . . . . . . . . 31prochlorperazine maleate tabs 5mg . . . . . . . . . . . . . . . . . . . . . . . . . . 31prochlorperazine maleate tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 31PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML . . . . . . 38PROCRIT INJ 20000UNIT/ML . . . . . . 38PROCRIT INJ 40000UNIT/ML . . . . . . 38procto-med hc . . . . . . . . . . . . . . . . . . . . . 49procto-pak . . . . . . . . . . . . . . . . . . . . . . . . 49proctosol hc . . . . . . . . . . . . . . . . . . . . . . . 49proctozone-hc . . . . . . . . . . . . . . . . . . . . . 49progesterone caps . . . . . . . . . . . . . . . . 52PROGLYCEM . . . . . . . . . . . . . . . . . . . . . 36PROGRAF INJ . . . . . . . . . . . . . . . . . . . 53PROLASTIN-C . . . . . . . . . . . . . . . . . . . . 58PROLENSA . . . . . . . . . . . . . . . . . . . . . . . 56PROLEUKIN . . . . . . . . . . . . . . . . . . . . . . 29PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 55PROMACTA . . . . . . . . . . . . . . . . . . . . . . 38promethazine hcl supp . . . . . . . . . . . . 25promethazine hcl syrp . . . . . . . . . . . . . 25promethazine hcl tabs . . . . . . . . . . . . . 25promethazine hydrochloride tabs 50mg . . . . . . . . . . . . . . . . . . . . . . . . 25promethegan . . . . . . . . . . . . . . . . . . . . . . 25propafenone hcl . . . . . . . . . . . . . . . . . . . 39propafenone hcl er cp12 225mg, 325mg . . . . . . . . . . . . . . . . . . . . 39propafenone hydrochloride er cp12 425mg . . . . . . . . . . . . . . . . . . . . 39propantheline bromide . . . . . . . . . . . . . 46

pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 3mg, 4.5mg . . . . . . . . . . . . . . . . . . . . . . . 31prasugrel . . . . . . . . . . . . . . . . . . . . . . . . . . 38pravastatin sodium . . . . . . . . . . . . . . . . 41praziquantel . . . . . . . . . . . . . . . . . . . . . . . 30prazosin hcl . . . . . . . . . . . . . . . . . . . . . . . 38PRED-G . . . . . . . . . . . . . . . . . . . . . . . . . . 56PRED-G S.O.P. . . . . . . . . . . . . . . . . . . . 56PRED MILD . . . . . . . . . . . . . . . . . . . . . . . 56prednicarbate oint . . . . . . . . . . . . . . . . . 48prednisolone . . . . . . . . . . . . . . . . . . . . . . 48prednisolone acetate . . . . . . . . . . . . . . 56prednisolone sodium phosphate ophthalmic soln . . . . . . . . . . . . . . . . . . . 56prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml . . . . . . . . . . . . . . . . 49prednisone intensol . . . . . . . . . . . . . . . . 49prednisone oral soln . . . . . . . . . . . . . . 49prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg . . . . . 49prednisone tabs 50mg . . . . . . . . . . . . . 49prednisone tbpk . . . . . . . . . . . . . . . . . . . 49PREGNYL W/DILUENT BENZYL ALCOHOL/NACL . . . . . . . . . 49PREMARIN CREA . . . . . . . . . . . . . . . . 51PREMARIN INJ . . . . . . . . . . . . . . . . . . . 51PREMARIN TABS . . . . . . . . . . . . . . . . 51PREMASOL . . . . . . . . . . . . . . . . . . . . . . . 45prevalite . . . . . . . . . . . . . . . . . . . . . . . . . . 41previfem . . . . . . . . . . . . . . . . . . . . . . . . . . 51PREZCOBIX . . . . . . . . . . . . . . . . . . . . . . 34PREZISTA SUSP . . . . . . . . . . . . . . . . . 34PREZISTA TABS 75MG . . . . . . . . . . . . 34PREZISTA TABS 150MG . . . . . . . . . . . 34PREZISTA TABS 600MG . . . . . . . . . . . 34PREZISTA TABS 800MG . . . . . . . . . . . 34PRIFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 27PRIMAQUINE PHOSPHATE . . . . . . . 31primidone . . . . . . . . . . . . . . . . . . . . . . . . . 23

78


Covered Drugs Index

SSABRIL PACK . . . . . . . . . . . . . . . . . . . . 23SABRIL TABS . . . . . . . . . . . . . . . . . . . . 23salsalate . . . . . . . . . . . . . . . . . . . . . . . . . . 16SAMSCA TABS 15MG . . . . . . . . . . . . . 45SAMSCA TABS 30MG . . . . . . . . . . . . . 45SANCUSO . . . . . . . . . . . . . . . . . . . . . . . . 25SANDIMMUNE ORAL SOLN . . . . . . 53SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . . 43SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . . 32SAVAYSA . . . . . . . . . . . . . . . . . . . . . . . . . 37scopolamine . . . . . . . . . . . . . . . . . . . . . . 25selegiline hcl . . . . . . . . . . . . . . . . . . . . . . 31selenium sulfide lotn . . . . . . . . . . . . . . 43SELZENTRY ORAL SOLN . . . . . . . . 34SELZENTRY TABS 25MG . . . . . . . . . 34SELZENTRY TABS 150MG, 75MG . . 34SELZENTRY TABS 300MG . . . . . . . . 34SENSIPAR TABS 30MG . . . . . . . . . . . 55SENSIPAR TABS 60MG . . . . . . . . . . . 55SENSIPAR TABS 90MG . . . . . . . . . . . 55SEREVENT DISKUS . . . . . . . . . . . . . . 57sertraline hcl conc . . . . . . . . . . . . . . . . . 24sertraline hcl tabs 25mg . . . . . . . . . . . . 24sertraline hcl tabs 50mg . . . . . . . . . . . . 24sertraline hcl tabs 100mg . . . . . . . . . . 24setlakin . . . . . . . . . . . . . . . . . . . . . . . . . . . 51sharobel . . . . . . . . . . . . . . . . . . . . . . . . . . 52SHINGRIX . . . . . . . . . . . . . . . . . . . . . . . . 54SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . . 52sildenafil tabs 20mg . . . . . . . . . . . . . . . 58SILENOR . . . . . . . . . . . . . . . . . . . . . . . . . 58silver sulfadiazine . . . . . . . . . . . . . . . . . 19SIMBRINZA . . . . . . . . . . . . . . . . . . . . . . . 56SIMULECT . . . . . . . . . . . . . . . . . . . . . . . . 54simvastatin . . . . . . . . . . . . . . . . . . . . . . . . 41sirolimus . . . . . . . . . . . . . . . . . . . . . . . . . . 53SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . . 27sodium bicarbonate inj . . . . . . . . . . . . 45

rifampin inj . . . . . . . . . . . . . . . . . . . . . . . 27RIFATER . . . . . . . . . . . . . . . . . . . . . . . . . . 27riluzole . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42rimantadine hcl . . . . . . . . . . . . . . . . . . . . 35ringers injection . . . . . . . . . . . . . . . . . . . 45RINGERS IRRIGATION . . . . . . . . . . . . 55RIOMET . . . . . . . . . . . . . . . . . . . . . . . . . . 36RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG . . . . . . . . . . . 32RISPERDAL CONSTA INJ 50MG . . . 32risperidone m-tab . . . . . . . . . . . . . . . . . . 32risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 32risperidone odt tbdp 4mg . . . . . . . . . . . 32risperidone oral soln . . . . . . . . . . . . . . 32risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 32risperidone tabs 4mg . . . . . . . . . . . . . . 32ritonavir . . . . . . . . . . . . . . . . . . . . . . . . . . . 35RITUXAN . . . . . . . . . . . . . . . . . . . . . . . . . 30RITUXAN HYCELA . . . . . . . . . . . . . . . . 30rivastigmine tartrate . . . . . . . . . . . . . . . . 23rivastigmine transdermal system . . . . 23rizatriptan benzoate . . . . . . . . . . . . . . . . 26rizatriptan benzoate odt . . . . . . . . . . . . 26romidepsin . . . . . . . . . . . . . . . . . . . . . . . . 29ropinirole hcl . . . . . . . . . . . . . . . . . . . . . . 31rosadan . . . . . . . . . . . . . . . . . . . . . . . . . . . 19rosuvastatin calcium . . . . . . . . . . . . . . . 41ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . . 54ROTATEQ . . . . . . . . . . . . . . . . . . . . . . . . 54roweepra . . . . . . . . . . . . . . . . . . . . . . . . . . 22roweepra xr tb24 500mg . . . . . . . . . . . 22roweepra xr tb24 750mg . . . . . . . . . . . 22ROZEREM . . . . . . . . . . . . . . . . . . . . . . . . 58RUBRACA . . . . . . . . . . . . . . . . . . . . . . . . 29RUCONEST . . . . . . . . . . . . . . . . . . . . . . 53RYDAPT . . . . . . . . . . . . . . . . . . . . . . . . . . 29RYTARY . . . . . . . . . . . . . . . . . . . . . . . . . . 31

ranitidine hcl inj . . . . . . . . . . . . . . . . . . . 46ranitidine hcl syrp . . . . . . . . . . . . . . . . . 46ranitidine hcl tabs . . . . . . . . . . . . . . . . . 46RAPAMUNE ORAL SOLN . . . . . . . . . 53rasagiline mesylate . . . . . . . . . . . . . . . . 31reclipsen . . . . . . . . . . . . . . . . . . . . . . . . . . 51RECOMBIVAX HB . . . . . . . . . . . . . . . . . 54REGONOL . . . . . . . . . . . . . . . . . . . . . . . . 26REGRANEX . . . . . . . . . . . . . . . . . . . . . . 43RELISTOR INJ 8MG/0.4ML . . . . . . . . 46RELISTOR INJ 12MG/0.6ML . . . . . . . 46REMICADE . . . . . . . . . . . . . . . . . . . . . . . 53REMODULIN . . . . . . . . . . . . . . . . . . . . . . 58RENFLEXIS . . . . . . . . . . . . . . . . . . . . . . . 53RENVELA PACK . . . . . . . . . . . . . . . . . . 46RENVELA TABS . . . . . . . . . . . . . . . . . . 46repaglinide tabs 0.5mg, 1mg . . . . . . . 36repaglinide tabs 2mg . . . . . . . . . . . . . . 36REPATHA . . . . . . . . . . . . . . . . . . . . . . . . . 41REPATHA PUSHTRONEX SYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . 41REPATHA SURECLICK . . . . . . . . . . . . 41RESCRIPTOR TABS 100MG . . . . . . . 33RESCRIPTOR TABS 200MG . . . . . . . 33RESTASIS . . . . . . . . . . . . . . . . . . . . . . . . 56RETROVIR IV INFUSION . . . . . . . . . . 34REVLIMID CAPS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 27REVLIMID CAPS 15MG, 20MG, 25MG . . . . . . . . . . . . . . 27REXULTI . . . . . . . . . . . . . . . . . . . . . . . . . . 32REYATAZ CAPS 150MG, 300MG . . . 34REYATAZ CAPS 200MG . . . . . . . . . . . 35REYATAZ PACK . . . . . . . . . . . . . . . . . . 35ribavirin caps . . . . . . . . . . . . . . . . . . . . . 33ribavirin inhalation soln . . . . . . . . . . . . 58ribavirin tabs . . . . . . . . . . . . . . . . . . . . . . 33RIDAURA . . . . . . . . . . . . . . . . . . . . . . . . . 54rifabutin . . . . . . . . . . . . . . . . . . . . . . . . . . . 26rifampin caps . . . . . . . . . . . . . . . . . . . . . 27

79


Covered Drugs Index

SUSTIVA TABS . . . . . . . . . . . . . . . . . . . 34SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . . 30SYLATRON . . . . . . . . . . . . . . . . . . . . . . . 29SYMFI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34SYMFI LO . . . . . . . . . . . . . . . . . . . . . . . . 34SYMTUZA . . . . . . . . . . . . . . . . . . . . . . . . 35SYNAGIS . . . . . . . . . . . . . . . . . . . . . . . . . 54SYNAREL . . . . . . . . . . . . . . . . . . . . . . . . 52SYNERCID . . . . . . . . . . . . . . . . . . . . . . . 19SYNJARDY . . . . . . . . . . . . . . . . . . . . . . . 36SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG . . . 36SYNJARDY XR TB24 12.5MG; 1000MG, 5MG; 1000MG . . 36SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . . 29SYNTHROID . . . . . . . . . . . . . . . . . . . . . . 52SYPRINE . . . . . . . . . . . . . . . . . . . . . . . . . 45

TTABLOID . . . . . . . . . . . . . . . . . . . . . . . . . 28tacrolimus caps . . . . . . . . . . . . . . . . . . . 53tacrolimus oint . . . . . . . . . . . . . . . . . . . . 43TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . . 30TAGRISSO . . . . . . . . . . . . . . . . . . . . . . . . 30TAMIFLU CAPS 30MG . . . . . . . . . . . . 35TAMIFLU CAPS 45MG, 75MG . . . . . 35TAMIFLU SUSR . . . . . . . . . . . . . . . . . . 35tamoxifen citrate . . . . . . . . . . . . . . . . . . . 27tamsulosin hcl . . . . . . . . . . . . . . . . . . . . . 47TARCEVA TABS 25MG . . . . . . . . . . . . 30TARCEVA TABS 100MG, 150MG . . . 30TARGRETIN GEL . . . . . . . . . . . . . . . . . 30tarina fe 1/20 . . . . . . . . . . . . . . . . . . . . . . 51TASIGNA CAPS 50MG . . . . . . . . . . . . 30TASIGNA CAPS 150MG, 200MG . . . 30tazarotene . . . . . . . . . . . . . . . . . . . . . . . . 43tazicef inj 1gm, 2gm, 6gm . . . . . . . . . . 20TAZORAC CREA . . . . . . . . . . . . . . . . . 43TAZORAC GEL . . . . . . . . . . . . . . . . . . . 43

sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51ssd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19STAMARIL . . . . . . . . . . . . . . . . . . . . . . . . 54stavudine . . . . . . . . . . . . . . . . . . . . . . . . . 34sterile water irrigation . . . . . . . . . . . . . . 56sterile water irrigation plastic bottle . . 56STIMATE . . . . . . . . . . . . . . . . . . . . . . . . . 49STIVARGA . . . . . . . . . . . . . . . . . . . . . . . . 30streptomycin sulfate . . . . . . . . . . . . . . . 18STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . . 33SUBOXONE . . . . . . . . . . . . . . . . . . . . . . 18sucralfate . . . . . . . . . . . . . . . . . . . . . . . . . 47sulfacetamide sodium lotn . . . . . . . . . 21sulfacetamide sodium ophthalmic soln . . . . . . . . . . . . . . . . . . . 21sulfacetamide sodium/ prednisolone sodium phosphate . . . . 21sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . 21sulfamethoxazole/trimethoprim ds . . 21sulfamethoxazole/trimethoprim inj . . 21sulfamethoxazole/ trimethoprim susp . . . . . . . . . . . . . . . . . 21sulfamethoxazole/ trimethoprim tabs . . . . . . . . . . . . . . . . . 21sulfasalazine . . . . . . . . . . . . . . . . . . . . . . 54sulfatrim pediatric . . . . . . . . . . . . . . . . . . 22sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . 16sumatriptan . . . . . . . . . . . . . . . . . . . . . . . 26sumatriptan succinate inj 4mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . 26sumatriptan succinate inj 6mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . 26sumatriptan succinate refill inj 4mg/0.5ml . . . . . . . . . . . . . . . . . 26sumatriptan succinate refill inj 6mg/0.5ml . . . . . . . . . . . . . . . . . 26sumatriptan succinate tabs . . . . . . . . 26SUPRAX SUSR 500MG/5ML . . . . . . . 20SUPREP BOWEL PREP KIT . . . . . . . 46SUSTIVA CAPS 50MG . . . . . . . . . . . . . 33SUSTIVA CAPS 200MG . . . . . . . . . . . 33

sodium bicarbonate partial fill . . . . . . . 45sodium chloride 0.9% . . . . . . . . . . . . . . 56sodium chloride0.9% . . . . . . . . . . . . . . 55sodium chloride 0.45% . . . . . . . . . . . . . 45sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5% . . . . . . . . . . 45sodium fluoride chew 0.5mg, 1mg . . 45SODIUM LACTATE INJ 5MEQ/ML . . 45sodium phenylbutyrate . . . . . . . . . . . . . 47sodium polystyrene sulfonate powd . . . . . . . . . . . . . . . . . . . 45sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml . . . . . . 45sodium sulfacetamide ophthalmic soln . . . . . . . . . . . . . . . . . . . 21SOLIQUA 100/33 . . . . . . . . . . . . . . . . . . 37SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . . 27SOLU-CORTEF . . . . . . . . . . . . . . . . . . . 49SOMATULINE DEPOT INJ 60MG/0.2ML . . . . . . . . . . . . . . . . . . . . . . 52SOMATULINE DEPOT INJ 90MG/0.3ML . . . . . . . . . . . . . . . . . . . . . . 52SOMATULINE DEPOT INJ 120MG/0.5ML . . . . . . . . . . . . . . . . . . . . . 52SOMAVERT . . . . . . . . . . . . . . . . . . . . . . . 52sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39sotalol hcl . . . . . . . . . . . . . . . . . . . . . . . . . 39sotalol hcl (af) . . . . . . . . . . . . . . . . . . . . . 39sotalol hcl af . . . . . . . . . . . . . . . . . . . . . . . 39sotalol hydrochloride (af) tabs 80mg . . . . . . . . . . . . . . . . . . . . . . . . 39sotalol hydrochloride tabs 120mg . . . 39spironolactone/hydrochlorothiazide . . 41spironolactone tabs 25mg . . . . . . . . . . 41spironolactone tabs 100mg, 50mg . . 41SPORANOX ORAL SOLN . . . . . . . . . 26sprintec 28 . . . . . . . . . . . . . . . . . . . . . . . . 51SPRITAM TB3D 750MG . . . . . . . . . . . 22SPRITAM TB3D 1000MG, 250MG, 500MG . . . . . . . . . . 22SPRYCEL . . . . . . . . . . . . . . . . . . . . . . . . 30sps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

80


Covered Drugs Index

topotecan hcl inj 4mg . . . . . . . . . . . . . . 29TORISEL . . . . . . . . . . . . . . . . . . . . . . . . . 53torsemide . . . . . . . . . . . . . . . . . . . . . . . . . 41TOUJEO MAX SOLOSTAR . . . . . . . . 37TOUJEO SOLOSTAR . . . . . . . . . . . . . . 37TPN ELECTROLYTES . . . . . . . . . . . . . 45TRACLEER . . . . . . . . . . . . . . . . . . . . . . . 58TRADJENTA . . . . . . . . . . . . . . . . . . . . . . 36tramadol hcl . . . . . . . . . . . . . . . . . . . . . . . 17trandolapril tabs 1mg . . . . . . . . . . . . . . 39trandolapril tabs 2mg, 4mg . . . . . . . . . 39tranexamic acid inj . . . . . . . . . . . . . . . . 38tranexamic acid tabs . . . . . . . . . . . . . . 38TRANSDERM-SCOP . . . . . . . . . . . . . . 25tranylcypromine sulfate . . . . . . . . . . . . 24TRAVASOL . . . . . . . . . . . . . . . . . . . . . . . 45TRAVATAN Z . . . . . . . . . . . . . . . . . . . . . . 56trazodone hydrochloride tabs 100mg, 150mg, 50mg . . . . . . . . . 24trazodone hydrochloride tabs 300mg . . . . . . . . . . . . . . . . . . . . . . . 24TREANDA INJ 25MG . . . . . . . . . . . . . . 27TREANDA INJ 100MG . . . . . . . . . . . . . 27TRECATOR . . . . . . . . . . . . . . . . . . . . . . . 27TRELEGY ELLIPTA . . . . . . . . . . . . . . . 58TRELSTAR MIXJECT INJ 3.75MG . . 52TRELSTAR MIXJECT INJ 11.25MG . . 52TRELSTAR MIXJECT INJ 22.5MG . . 52TRESIBA FLEXTOUCH . . . . . . . . . . . . 37tretinoin caps . . . . . . . . . . . . . . . . . . . . . 30tretinoin crea . . . . . . . . . . . . . . . . . . . . . 43tretinoin gel . . . . . . . . . . . . . . . . . . . . . . . 43tretinoin microsphere . . . . . . . . . . . . . . 43tretinoin microsphere pump gel 0.1% . . . . . . . . . . . . . . . . . . . . 43triamcinolone acetonide crea 0.1% . . . . . . . . . . . . . . . . . . . . . . . . . 49triamcinolone acetonide crea 0.025%, 0.5% . . . . . . . . . . . . . . . . 49triamcinolone acetonide dental paste . . . . . . . . . . . . . . . . . . . . . . . 43

theophylline er tb12 300mg, 450mg . . . . . . . . . . . . . . . . . . . . 58theophylline er tb24 . . . . . . . . . . . . . . . 58thioridazine hcl . . . . . . . . . . . . . . . . . . . . 32thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . . 27thiothixene caps 2mg . . . . . . . . . . . . . . 32thiothixene caps 10mg, 1mg, 5mg . . 32THYMOGLOBULIN . . . . . . . . . . . . . . . . 54THYROLAR-1 . . . . . . . . . . . . . . . . . . . . . 52THYROLAR-1/2 . . . . . . . . . . . . . . . . . . . 52THYROLAR-1/4 . . . . . . . . . . . . . . . . . . . 52THYROLAR-2 . . . . . . . . . . . . . . . . . . . . . 52THYROLAR-3 . . . . . . . . . . . . . . . . . . . . . 52tiagabine hydrochloride tabs 2mg . . . 23tiagabine hydrochloride tabs 4mg . . . 23tiagabine hydrochloride tabs 12mg . . 23tiagabine hydrochloride tabs 16mg . . 23TIBSOVO . . . . . . . . . . . . . . . . . . . . . . . . . 30tigecycline . . . . . . . . . . . . . . . . . . . . . . . . 19timolol maleate ophthalmic soln . . . . 57timolol maleate tabs . . . . . . . . . . . . . . . 40TIS-U-SOL . . . . . . . . . . . . . . . . . . . . . . . . 56TIVICAY TABS 10MG, 25MG . . . . . . . 33TIVICAY TABS 50MG . . . . . . . . . . . . . . 33tizanidine hcl . . . . . . . . . . . . . . . . . . . . . . 33TOBI PODHALER . . . . . . . . . . . . . . . . . 58TOBRADEX OINT . . . . . . . . . . . . . . . . 56tobramycin/dexamethasone . . . . . . . . 56tobramycin nebu . . . . . . . . . . . . . . . . . . 58tobramycin ophthalmic soln . . . . . . . . 18tobramycin sulfate inj 1.2gm, 10mg/ml, 80mg/2ml . . . . . . . . 18tobramycin sulfate ophthalmic soln . . . . . . . . . . . . . . . . . . . . 18TOBREX OINT . . . . . . . . . . . . . . . . . . . 18tolcapone . . . . . . . . . . . . . . . . . . . . . . . . . 31tolmetin sodium . . . . . . . . . . . . . . . . . . . 16tolterodine tartrate . . . . . . . . . . . . . . . . . 47topiramate . . . . . . . . . . . . . . . . . . . . . . . . 23toposar . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

taztia xt cp24 120mg, 180mg, 240mg, 300mg . . . . . 40TECENTRIQ . . . . . . . . . . . . . . . . . . . . . . 30TECFIDERA CPDR 120MG . . . . . . . . 42TECFIDERA CPDR 240MG . . . . . . . . 42TECFIDERA STARTER PACK . . . . . . 42techlite pen needles/31g x 6 mm . . . 56techlite pen needles/31g x 8mm . . . . 56techlite pen needles/32g x 4mm . . . . 56techlite pen needles/32g x 6mm . . . . 56techlite pen needles/32g x 8mm . . . . 56TEFLARO . . . . . . . . . . . . . . . . . . . . . . . . . 20telmisartan . . . . . . . . . . . . . . . . . . . . . . . . 38telmisartan/amlodipine . . . . . . . . . . . . . 38telmisartan/hydrochlorothiazide . . . . . 38temazepam . . . . . . . . . . . . . . . . . . . . . . . 58temsirolimus . . . . . . . . . . . . . . . . . . . . . . 30TENIVAC . . . . . . . . . . . . . . . . . . . . . . . . . 54tenofovir disoproxil fumarate . . . . . . . 34terazosin hcl caps 1mg, 2mg, 5mg . . 47terazosin hcl caps 10mg . . . . . . . . . . . 47terbinafine hcl tabs . . . . . . . . . . . . . . . . 26terbutaline sulfate . . . . . . . . . . . . . . . . . 57terconazole . . . . . . . . . . . . . . . . . . . . . . . 26testosterone cypionate . . . . . . . . . . . . . 49testosterone enanthate . . . . . . . . . . . . 49testosterone gel 25mg/2.5gm, 50mg/5gm . . . . . . . . . . . 49testosterone pump . . . . . . . . . . . . . . . . . 49TETANUS/DIPHTHERIA TOXOIDS-ADSORBED . . . . . . . . . . . . 54tetrabenazine tabs 12.5mg . . . . . . . . . 42tetrabenazine tabs 25mg . . . . . . . . . . . 42tetracycline hydrochloride . . . . . . . . . . 22texacort . . . . . . . . . . . . . . . . . . . . . . . . . . . 49THALOMID CAPS 100MG, 150MG, 50MG . . . . . . . . . . . . 27THALOMID CAPS 200MG . . . . . . . . . 27THEO-24 . . . . . . . . . . . . . . . . . . . . . . . . . 58theophylline cr . . . . . . . . . . . . . . . . . . . . . 58

81


Covered Drugs Index

velivet . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51VELPHORO . . . . . . . . . . . . . . . . . . . . . . . 46VELTASSA . . . . . . . . . . . . . . . . . . . . . . . . 45VENCLEXTA STARTING PACK . . . . 29VENCLEXTA TABS 10MG . . . . . . . . . 29VENCLEXTA TABS 50MG . . . . . . . . . 29VENCLEXTA TABS 100MG . . . . . . . . 29venlafaxine hcl . . . . . . . . . . . . . . . . . . . . 24venlafaxine hcl er cp24 37.5mg . . . . . 24venlafaxine hcl er cp24 75mg . . . . . . 25venlafaxine hcl er cp24 150mg . . . . . 24VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . . 58VENTOLIN HFA . . . . . . . . . . . . . . . . . . . 57verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg . . . . . 40verapamil hcl er cp24 200mg . . . . . . . 40verapamil hcl er tbcr . . . . . . . . . . . . . . 40verapamil hcl inj . . . . . . . . . . . . . . . . . . 40verapamil hcl sr cp24 360mg . . . . . . . 40verapamil hcl tabs 40mg . . . . . . . . . . . 40verapamil hcl tabs 120mg, 80mg . . . 40VERSACLOZ . . . . . . . . . . . . . . . . . . . . . 33VERZENIO . . . . . . . . . . . . . . . . . . . . . . . 29VESICARE . . . . . . . . . . . . . . . . . . . . . . . . 47V-GO 20 . . . . . . . . . . . . . . . . . . . . . . . . . . 56V-GO 30 . . . . . . . . . . . . . . . . . . . . . . . . . . 56V-GO 40 . . . . . . . . . . . . . . . . . . . . . . . . . . 56VIBERZI . . . . . . . . . . . . . . . . . . . . . . . . . . 46vicodin es tabs 300mg; 7.5mg . . . . . . 17vicodin hp tabs 300mg; 10mg . . . . . . 17vicodin tabs 300mg; 5mg . . . . . . . . . . . 17VICTOZA . . . . . . . . . . . . . . . . . . . . . . . . . 36VIDEX EC CPDR 125MG . . . . . . . . . . 34VIDEX PEDIATRIC . . . . . . . . . . . . . . . . 34vienva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51vigabatrin . . . . . . . . . . . . . . . . . . . . . . . . . 23VIGAMOX . . . . . . . . . . . . . . . . . . . . . . . . 21VIIBRYD . . . . . . . . . . . . . . . . . . . . . . . . . . 25VIIBRYD STARTER PACK . . . . . . . . . 25VIMPAT INJ . . . . . . . . . . . . . . . . . . . . . . 23

TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . . 30TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . . 54TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . . 42

UULORIC . . . . . . . . . . . . . . . . . . . . . . . . . . 26UNITHROID . . . . . . . . . . . . . . . . . . . . . . . 52UNITUXIN . . . . . . . . . . . . . . . . . . . . . . . . 30ursodiol . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Vvalacyclovir hcl . . . . . . . . . . . . . . . . . . . . 35valacyclovir hydrochloride . . . . . . . . . . 35VALCHLOR . . . . . . . . . . . . . . . . . . . . . . . 27valganciclovir . . . . . . . . . . . . . . . . . . . . . . 33valganciclovir hydrochlorde . . . . . . . . 33valproate sodium . . . . . . . . . . . . . . . . . . 23valproic acid . . . . . . . . . . . . . . . . . . . . . . . 23valsartan . . . . . . . . . . . . . . . . . . . . . . . . . . 38valsartan/hydrochlorothiazide . . . . . . 38vancomycin . . . . . . . . . . . . . . . . . . . . . . . 19vancomycin hcl caps 125mg . . . . . . . 19vancomycin hcl caps 250mg . . . . . . . 19vancomycin hcl in dextrose . . . . . . . . . 19vancomycin hcl inj 0.9%; 1gm/200ml, 10gm, 1gm, 500mg, 5gm, 750mg . . . . . . . . . 19VANCOMYCIN HYDROCHLORIDE INJ 250MG . . . . 19vancomycin hydrochloride/sodium chloride inj 0.9%; 750mg/150ml . . . . 19vandazole . . . . . . . . . . . . . . . . . . . . . . . . . 19VAQTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54VARIVAX . . . . . . . . . . . . . . . . . . . . . . . . . 54VARIZIG . . . . . . . . . . . . . . . . . . . . . . . . . . 54VASCEPA CAPS 0.5GM . . . . . . . . . . . 41VASCEPA CAPS 1GM . . . . . . . . . . . . . 41VAXCHORA . . . . . . . . . . . . . . . . . . . . . . . 54VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . . . 30VELCADE . . . . . . . . . . . . . . . . . . . . . . . . 29

triamcinolone acetonide inj 40mg/ml . . . . . . . . . . . . . . . . . . . . . . . 49triamcinolone acetonide lotn . . . . . . . 49triamcinolone acetonide oint . . . . . . . 49triamterene/hydrochlorothiazide . . . . 41trianex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49triderm crea 0.1% . . . . . . . . . . . . . . . . . 49trientine hydrochloride . . . . . . . . . . . . . 45tri-estarylla . . . . . . . . . . . . . . . . . . . . . . . . 51trifluoperazine hcl . . . . . . . . . . . . . . . . . . 32trifluridine . . . . . . . . . . . . . . . . . . . . . . . . . 35trihexyphenidyl hcl . . . . . . . . . . . . . . . . . 31tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . . 51tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . . . 51trilyte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46trimethoprim . . . . . . . . . . . . . . . . . . . . . . . 19trimethoprim sulfate/ polymyxin b sulfate . . . . . . . . . . . . . . . . 19tri-mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51trimipramine maleate . . . . . . . . . . . . . . 25trinessa . . . . . . . . . . . . . . . . . . . . . . . . . . . 51TRINTELLIX . . . . . . . . . . . . . . . . . . . . . . 24tri-previfem . . . . . . . . . . . . . . . . . . . . . . . . 51TRIPTODUR . . . . . . . . . . . . . . . . . . . . . . 49TRISENOX . . . . . . . . . . . . . . . . . . . . . . . 29tri-sprintec . . . . . . . . . . . . . . . . . . . . . . . . 51TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . . . 34trivora-28 . . . . . . . . . . . . . . . . . . . . . . . . . 51tri-vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . 51TROGARZO . . . . . . . . . . . . . . . . . . . . . . 34TROPHAMINE . . . . . . . . . . . . . . . . . . . . 45tropicamide . . . . . . . . . . . . . . . . . . . . . . . 56TRULANCE . . . . . . . . . . . . . . . . . . . . . . . 46TRULICITY . . . . . . . . . . . . . . . . . . . . . . . 36TRUMENBA . . . . . . . . . . . . . . . . . . . . . . 54TRUVADA . . . . . . . . . . . . . . . . . . . . . . . . 34TWINRIX . . . . . . . . . . . . . . . . . . . . . . . . . 54TYBOST . . . . . . . . . . . . . . . . . . . . . . . . . . 34tydemy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51TYGACIL . . . . . . . . . . . . . . . . . . . . . . . . . 19

82


Covered Drugs Index

ziprasidone hcl . . . . . . . . . . . . . . . . . . . . 32ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . . 33zoledronic acid inj 4mg/5ml . . . . . . . . 55zoledronic acid inj 5mg/100ml . . . . . . 55ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . . 29zolpidem tartrate tabs . . . . . . . . . . . . . 58zonisamide . . . . . . . . . . . . . . . . . . . . . . . . 22ZORTRESS TABS 0.5MG . . . . . . . . . . 53ZORTRESS TABS 0.25MG, 0.75MG . . . . . . . . . . . . . . . . . . 53ZOSTAVAX . . . . . . . . . . . . . . . . . . . . . . . 54ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML; 0.5GM/100ML . . . 20zovia 1/35e . . . . . . . . . . . . . . . . . . . . . . . 51ZUBSOLV SUBL 0.7MG; 0.18MG . . 18ZUBSOLV SUBL 1.4MG; 0.36MG, 11.4MG; 2.9MG, 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG . . . . . 18ZYCLARA . . . . . . . . . . . . . . . . . . . . . . . . . 43ZYCLARA PUMP CREA 2.5% . . . . . . 43ZYCLARA PUMP CREA 3.75% . . . . . 43ZYDELIG . . . . . . . . . . . . . . . . . . . . . . . . . 30ZYKADIA . . . . . . . . . . . . . . . . . . . . . . . . . 30ZYLET . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18ZYPREXA RELPREVV INJ 210MG . . . . . . . . . . . . . . . . . . . . . . . . 32ZYPREXA RELPREVV INJ 300MG . . . . . . . . . . . . . . . . . . . . . . . . 32ZYPREXA RELPREVV INJ 405MG . . . . . . . . . . . . . . . . . . . . . . . . 32ZYTIGA TABS 250MG . . . . . . . . . . . . . 27ZYTIGA TABS 500MG . . . . . . . . . . . . . 27

XIGDUO XR TB24 5MG; 1000MG . . 36XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, 2.5MG; 1000MG, 5MG; 500MG . . . . 36XOLAIR . . . . . . . . . . . . . . . . . . . . . . . . . . . 58XTAMPZA ER . . . . . . . . . . . . . . . . . . . . . 16XTANDI . . . . . . . . . . . . . . . . . . . . . . . . . . . 27XULTOPHY 100/3.6 . . . . . . . . . . . . . . . 37XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

YYERVOY INJ 50MG/10ML . . . . . . . . . 30YERVOY INJ 200MG/40ML . . . . . . . . 30YF-VAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 54YONDELIS . . . . . . . . . . . . . . . . . . . . . . . . 27YONSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 27yuvafem . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Zzafirlukast . . . . . . . . . . . . . . . . . . . . . . . . . 57zaleplon . . . . . . . . . . . . . . . . . . . . . . . . . . 58ZALTRAP . . . . . . . . . . . . . . . . . . . . . . . . . 30ZANOSAR . . . . . . . . . . . . . . . . . . . . . . . . 27ZARXIO . . . . . . . . . . . . . . . . . . . . . . . . . . 38ZAVESCA . . . . . . . . . . . . . . . . . . . . . . . . . 47zebutal caps 325mg; 50mg; 40mg . . 16ZEJULA . . . . . . . . . . . . . . . . . . . . . . . . . . 29ZELBORAF . . . . . . . . . . . . . . . . . . . . . . . 30ZEMAIRA . . . . . . . . . . . . . . . . . . . . . . . . . 58zenatane . . . . . . . . . . . . . . . . . . . . . . . . . . 43zenchent . . . . . . . . . . . . . . . . . . . . . . . . . . 51ZENPEP . . . . . . . . . . . . . . . . . . . . . . . . . . 47ZERIT ORAL SOLN . . . . . . . . . . . . . . . 34ZETIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41ZIAGEN ORAL SOLN . . . . . . . . . . . . . 34zidovudine caps . . . . . . . . . . . . . . . . . . 34zidovudine syrp . . . . . . . . . . . . . . . . . . . 34zidovudine tabs . . . . . . . . . . . . . . . . . . . 34ZIOPTAN . . . . . . . . . . . . . . . . . . . . . . . . . 56

VIMPAT ORAL SOLN . . . . . . . . . . . . . 23VIMPAT TABS . . . . . . . . . . . . . . . . . . . . 23vinblastine sulfate . . . . . . . . . . . . . . . . . 29vincasar pfs . . . . . . . . . . . . . . . . . . . . . . . 29vincristine sulfate . . . . . . . . . . . . . . . . . . 29vinorelbine tartrate inj 50mg/5ml . . . . 29viorele . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51VIRACEPT TABS 250MG . . . . . . . . . . 35VIRACEPT TABS 625MG . . . . . . . . . . 35VIRAMUNE SUSP . . . . . . . . . . . . . . . . 34VIREAD POWD . . . . . . . . . . . . . . . . . . . 34VIREAD TABS . . . . . . . . . . . . . . . . . . . . 34voriconazole inj . . . . . . . . . . . . . . . . . . . 26voriconazole susr . . . . . . . . . . . . . . . . . 26voriconazole tabs . . . . . . . . . . . . . . . . . 26VOSEVI . . . . . . . . . . . . . . . . . . . . . . . . . . 33VOTRIENT . . . . . . . . . . . . . . . . . . . . . . . . 30VP-PNV-DHA . . . . . . . . . . . . . . . . . . . . . 46VPRIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47VRAYLAR CAPS . . . . . . . . . . . . . . . . . . 32VRAYLAR CPPK . . . . . . . . . . . . . . . . . . 32vyfemla . . . . . . . . . . . . . . . . . . . . . . . . . . . 51vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51VYXEOS . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Wwarfarin sodium . . . . . . . . . . . . . . . . . . . 37wera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

XXALKORI . . . . . . . . . . . . . . . . . . . . . . . . . 30XARELTO STARTER PACK . . . . . . . . 37XARELTO TABS 10MG . . . . . . . . . . . . 37XARELTO TABS 15MG . . . . . . . . . . . . 37XARELTO TABS 20MG . . . . . . . . . . . . 37XATMEP . . . . . . . . . . . . . . . . . . . . . . . . . . 53XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . 55XIFAXAN TABS 200MG . . . . . . . . . . . . 19XIFAXAN TABS 550MG . . . . . . . . . . . . 19

This drug list was updated in November 2018. For more recent information or other questions, please contact Cigna-HealthSpring Customer Service, at 1-800-222-6700 or, for TTY users, 711, 8 a.m. - 8 p.m., local time, 7 days a week. Our automated phone system may answer your call during weekends from Feb. 15 – Sept. 30., or visit www.CignaHealthSpring.com. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-222-6700 (TTY 711), 8 a.m. - 8 p.m., local time, 7 days a week. Our automated phone system may answer your call during weekends from Feb. 15 – Sept. 30. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-222-6700 (TTY 711). 注意：如果您使用繁體/中文，您可以免費獲得語言援助服務請致電 1-800-222-6700 (TTY 711). Cigna-HealthSpring complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna-HealthSpring cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc.. © 2017 Cigna

www.CignaHealthSpring.com

1-800-222-6700 (TTY 711) 8 a.m. - 8 p.m., local time, 7 days a week. Our automated phone system may answer your call during weekends from Feb. 15 – Sept. 30.

Documents

2018 Cigna-HealthSpring Rx COMPREHENSIVE …...2018 Cigna-HealthSpring Rx COMPREHENSIVE DRUG LIST (Formulary) This drug list was updated in November 2018. For more recent information