2019 IL PDP Value - bcbsil.comi | Blue Cross MedicareRx (PDP) 2019 Formulary (List of Covered Drugs) Note to existing members: This formulary has changed since last year. Please review

2019 Formulary (List of Covered Drugs) Blue Cross MedicareRx Value (PDP)SM

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File ID: 00019191, Version 19 This formulary was updated on 11/18/2019. For more recent information or other questions, please contact Blue Cross MedicareRxSM Customer Service at 1-888-285-2249 or, for TTY users, 711, 8:00 a.m. – 8:00 p.m., local time, 7 days a week. If you are calling from April 1 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays, or visit www.getblueil.com/pdp/druglist.

Y0096_MRK_IL_PDPFRM_Value19_C 850969.1119 Value

http://www.getblueil.com/pdp/druglist

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Blue Cross MedicareRx (PDP)

2019 Formulary (List of Covered Drugs)

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

When this drug list (formulary) refers to “we”, “us”, or “our”, it means HCSC Insurance Services Company (HISC). When it refers to “plan” or “our plan,” it means Blue Cross MedicareRx.

This document includes a list of the drugs (formulary) for our plan which is current as of November 2019. 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.

This information is available for free in other languages. Please call our Customer Service number at 1-888-285-2249. (TTY users should call 711). We are open between 8:00 a.m. – 8:00 p.m., local time, 7 days a week. If you are calling from April 1 through September 30, alternate technologies (for example, voicemail) will be used on the weekends and holidays. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese a nuestro número de Servicio al cliente al 1-888-285-2249 (los usuarios de TTY deben llamar al 711). Nuestro horario es de 8:00 a.m. a 8:00 p.m., hora local, los 7 días de la semana. Si usted llama del 1 de abril al 30 de septiembre, durante los fines de semana y feriados, se usarán tecnologías alternas (por ejemplo, correo de voz).

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What is the Blue Cross MedicareRx Formulary? A formulary is a list of covered drugs selected by Blue Cross MedicareRx 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. Blue Cross MedicareRx will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Blue Cross MedicareRx network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug:

• New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to

cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Blue Cross MedicareRx’s Formulary?”

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

• Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug.

The enclosed formulary is current as of November 18, 2019. To get updated information about the drugs covered by Blue Cross MedicareRx, please contact us. Our contact information appears on the front and back cover pages.

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

Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 113. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

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

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

• Step Therapy: In some cases, Blue Cross MedicareRx 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, Blue Cross MedicareRx may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Blue Cross MedicareRx will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Website. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Blue Cross MedicareRx 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 Blue Cross MedicareRx’s formulary?” on page iv for information about how to request an exception.

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What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that Blue Cross MedicareRx does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugs that are covered by Blue Cross MedicareRx. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Blue Cross MedicareRx.

• You can ask Blue Cross MedicareRx 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 Blue Cross MedicareRx’s Formulary? You can ask Blue Cross MedicareRx to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

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

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.

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

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

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum of a 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility and if you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.

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Circumstances exist in which unplanned transitions for current members could arise and in which prescribed drug regimens may not be on the Plan Sponsor’s formulary. These circumstances usually involve level of care changes in which a member is changing from one treatment setting to another. For these unplanned transitions, members and prescribers must use our exceptions and appeals processes. Coverage determinations are processed and redeterminations are made as expeditiously as your health condition requires.

In order to prevent a temporary gap in care when a member is discharged to home, members are permitted to have a full outpatient supply available to continue therapy once their limited supply provided at discharge is exhausted. This outpatient supply is available in advance of discharge from a Part A stay.

When a member is admitted to or discharged from an LTC facility, and does not have access to the remainder of the previously dispensed prescription, a one-time override of the “refill too soon” edits is processed for each medication which would be impacted due to a member being admitted to or discharged from a LTC facility. Early refill edits are not used to limit appropriate and necessary access to a member’s Part D benefit, and such members are allowed to access a refill upon admission or discharge.

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

https://www.medicare.gov

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Blue Cross MedicareRx’s Formulary The formulary below provides coverage information about the drugs covered by Blue Cross MedicareRx. If you have trouble finding your drug in the list, turn to the Index that begins on page 113. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LANTUS) and generic drugs are listed in lower-case italics (e.g., metformin). The information in the Requirements/Limits column tells you if Blue Cross MedicareRx has any special requirements for coverage of your drug.

All drugs included in this formulary are available via mail-order benefit. Contact us for details. Our contact information appears on the front and back cover pages.

KEY Tier 1 = Preferred Generic Drugs

Tier 2 = Generic Drugs

Tier 3 = Preferred Brand Drugs

Tier 4 = Non-Preferred Brand Drugs

Tier 5 = Specialty Drugs

BD = Drugs that may be covered under Medicare Part B or Part D depending on the circumstance. These drugs require prior authorization to determine coverage under Part B or Part D. Information may need to be provided that describes the use or the place where the drug is received to determine coverage.

PA = Prior Authorization

QL = Quantity Limits

ST = Step Therapy

* = Limited Distribution Drug. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at 1-888-285-2249, 8:00 a.m. – 8:00 p.m., local time, 7 days a week. If you are calling from April 1 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays. TTY users should call 711.

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

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Copayment and Coinsurance Amounts: Tier 1 = Preferred Generic Drugs: $0/$5

Tier 2 = Generic Drugs: $8/$14

Tier 3 = Preferred Brand Drugs: $42/$47

Tier 4 = Non-Preferred Brand Drugs: 40%/50%

Tier 5 = Specialty Drugs: 25%/25%

This information is not a complete description of benefits. Call 1-888-285-2249/TTY 711 for more information.

Below is the key for abbreviations used within the drug list.

KEY

act actuation

ad adsorbed

aerosol powder blister

aer, aero aerosol

app applicator

ba, breath act, breath activ breath activated

bau bioequivalent allergy units

cap, caps capsules

cart cartridge

chew tab chewable tablets

conc concentrate

conj conjugate, conjugated

crys crystals

deter deterrent

disint disintegrating

dr delayed-release

ec enteric coated

el, elu enzyme-linked immunosorbent assay

er, ext, extend- release, extended, extended rel

extended-release

ext extract

mcg microgram

meq milliequivalent

aepb mg milligram

ml milliliter

mu million units

nebu nebules

orally disintegr tab orally disintegrating tablets

oin, oint ointment

op, ophth ophthalmic

osm osmotic

pak pack

pf preservative-free

pfu plaque forming units

pow, powd powder

pref, prefill prefilled

pttw patch twice weekly

ptwk patch weekly

recomb recombinant

refrig

refrigerate

sl sublingual

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KEY Continued

gm gram

gu genitourinary

hr hour

ig immune globulin

im intramuscular

inh, inhal inhalation

inj injection

ir index of reactivity

iv intravenous

l liter

lf, Ifu flocculation units

liq, liqd liquid

sol, soln solution

sqcm square centimeter

supp, suppos suppositories

sus, susp suspension

syr syringe

tab, tabs tablets

td transdermal

tl translingual

unt unit

va vaginal

vac vaccine

2019

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

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Drug Name Drug Tier Requirements/LimitsAnalgesicsABSTRAL - fentanyl citrate sl tab 100 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 200 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 300 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 400 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 600 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 800 mcg 5 PA, QL (120 tablets/30 days)acetaminophen w/ codeine soln 120-12 mg/5ml 4 QL (2700 mls/30 days)acetaminophen w/ codeine tab 300-15 mg 4 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-30 mg 4 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-60 mg 4 QL (180 tablets/30 days)butalbital-acetaminophen tab 50-325 mg# 4 PA, QL (180 tablets/30 days)butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg# 3 PA, QL (180 capsules/30 days)butalbital-acetaminophen-caffeine cap 50-300-40 mg# 4 PA, QL (180 capsules/30 days)butalbital-acetaminophen-caffeine cap 50-325-40 mg# 4 PA, QL (180 capsules/30 days)butalbital-acetaminophen-caffeine tab 50-325-40 mg# 4 PA, QL (180 tablets/30 days)butalbital-aspirin-caffeine cap 50-325-40 mg# 4 PA, QL (180 capsules/30 days)BUTORPHANOL TARTRATE - butorphanol tartrate inj 1 mg/ml 3butorphanol tartrate inj 2 mg/ml 3butorphanol tartrate nasal soln 10 mg/ml 4 QL (87.5 mls/30 days)celecoxib cap 50 mg 2 QL (60 capsules/30 days)celecoxib cap 100 mg 2 QL (60 capsules/30 days)celecoxib cap 200 mg 2 QL (60 capsules/30 days)celecoxib cap 400 mg 2 QL (30 capsules/30 days)codeine sulfate tab 30 mg 4 QL (180 tablets/30 days)codeine sulfate tab 60 mg 4 QL (180 tablets/30 days)diclofenac potassium tab 50 mg 2 QL (120 tablets/30 days)diclofenac sodium gel 1% 3 PAdiclofenac sodium soln 1.5% 3 PAdiclofenac sodium tab delayed release 25 mg 2 QL (240 tablets/30 days)diclofenac sodium tab delayed release 50 mg 2 QL (120 tablets/30 days)diclofenac sodium tab delayed release 75 mg 2 QL (60 tablets/30 days)diclofenac sodium tab er 24hr 100 mg 2 QL (60 tablets/30 days)diclofenac w/ misoprostol tab delayed release 50-0.2 mg 2 QL (120 tablets/30 days)diclofenac w/ misoprostol tab delayed release 75-0.2 mg 2 QL (90 tablets/30 days)diflunisal tab 500 mg 3 QL (90 tablets/30 days)EC-NAPROXEN - naproxen tab ec 375 mg 2 QL (120 tablets/30 days)EC-NAPROXEN - naproxen tab ec 500 mg 2 QL (90 tablets/30 days)

2019

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.2

Drug Name Drug Tier Requirements/Limitsetodolac cap 200 mg 2 QL (150 capsules/30 days)etodolac cap 300 mg 2 QL (90 capsules/30 days)etodolac tab er 24hr 400 mg 2 QL (60 tablets/30 days)etodolac tab er 24hr 500 mg 2 QL (60 tablets/30 days)etodolac tab er 24hr 600 mg 2 QL (30 tablets/30 days)etodolac tab 400 mg 2 QL (60 tablets/30 days)etodolac tab 500 mg 2 QL (60 tablets/30 days)fentanyl citrate lozenge on a handle 200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 400 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 800 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl td patch 72hr 12 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 25 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 37.5 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 50 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 62.5 mcg/hr 5 PA, QL (15 patches/30 days)fentanyl td patch 72hr 75 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 87.5 mcg/hr 5 PA, QL (15 patches/30 days)fentanyl td patch 72hr 100 mcg/hr 4 PA, QL (15 patches/30 days)flurbiprofen tab 50 mg 2 QL (180 tablets/30 days)flurbiprofen tab 100 mg 2 QL (90 tablets/30 days)hydrocodone-acetaminophen soln 7.5-325 mg/15ml 4 QL (3600 mls/30 days)hydrocodone-acetaminophen tab 10-325 mg 4 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-300 mg 4 QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-300 mg 4 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-325 mg 4 QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-325 mg 4 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 10-300 mg 4 QL (180 tablets/30 days)hydrocodone-ibuprofen tab 5-200 mg 4 QL (150 tablets/30 days)hydrocodone-ibuprofen tab 7.5-200 mg 4 QL (150 tablets/30 days)hydrocodone-ibuprofen tab 10-200 mg 4 QL (150 tablets/30 days)hydromorphone hcl inj 2 mg/ml 4 BDhydromorphone hcl liqd 1 mg/ml 4 QL (1440 mls/30 days)hydromorphone hcl preservative free inj 2 mg/ml 4 BDhydromorphone hcl preservative free inj 10 mg/ml 4 BDhydromorphone hcl tab 2 mg 4 QL (180 tablets/30 days)

2019


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Drug Name Drug Tier Requirements/Limitshydromorphone hcl tab 4 mg 4 QL (180 tablets/30 days)hydromorphone hcl tab 8 mg 4 QL (180 tablets/30 days)ibuprofen susp 100 mg/5ml 2ibuprofen tab 400 mg 2 QL (240 tablets/30 days)ibuprofen tab 600 mg 2 QL (150 tablets/30 days)ibuprofen tab 800 mg 2 QL (120 tablets/30 days)LAZANDA - fentanyl citrate nasal spray 100 mcg/act 5 PA, QL (30 bottles/30 days)LAZANDA - fentanyl citrate nasal spray 300 mcg/act 5 PA, QL (30 bottles/30 days)LAZANDA - fentanyl citrate nasal spray 400 mcg/act 5 PA, QL (30 bottles/30 days)LEVORPHANOL TARTRATE - levorphanol tartrate tab 3 mg 5 QL (120 tablets/30 days)levorphanol tartrate tab 2 mg 5 QL (120 tablets/30 days)meloxicam tab 7.5 mg 2 QL (60 tablets/30 days)meloxicam tab 15 mg 2 QL (30 tablets/30 days)methadone hcl tab 5 mg 3 QL (180 tablets/30 days)methadone hcl tab 10 mg 3 QL (360 tablets/30 days)morphine sulfate inj pf 0.5 mg/ml 4 BDmorphine sulfate inj pf 1 mg/ml 4 BDmorphine sulfate oral soln 10 mg/5ml 4 QL (2700 mls/30 days)morphine sulfate oral soln 20 mg/5ml 4 QL (1350 mls/30 days)morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 4 QL (270 mls/30 days)morphine sulfate tab er 15 mg 3 PA, QL (90 tablets/30 days)morphine sulfate tab er 30 mg 3 PA, QL (90 tablets/30 days)morphine sulfate tab er 60 mg 4 PA, QL (90 tablets/30 days)morphine sulfate tab er 100 mg 4 PA, QL (90 tablets/30 days)morphine sulfate tab er 200 mg 4 PA, QL (90 tablets/30 days)morphine sulfate tab 15 mg 4 QL (240 tablets/30 days)morphine sulfate tab 30 mg 4 QL (180 tablets/30 days)nabumetone tab 500 mg 2 QL (120 tablets/30 days)nabumetone tab 750 mg 2 QL (60 tablets/30 days)naproxen sodium tab er 24hr 375 mg 3 QL (120 tablets/30 days)naproxen sodium tab er 24hr 500 mg 3 QL (90 tablets/30 days)naproxen sodium tab 275 mg 3 QL (150 tablets/30 days)naproxen sodium tab 550 mg 3 QL (90 tablets/30 days)naproxen susp 125 mg/5ml 3 QL (1800 mls/30 days)naproxen tab ec 375 mg 2 QL (120 tablets/30 days)naproxen tab ec 500 mg 2 QL (90 tablets/30 days)naproxen tab 250 mg 2 QL (180 tablets/30 days)naproxen tab 375 mg 2 QL (120 tablets/30 days)

2019


Drug Name Drug Tier Requirements/Limitsnaproxen tab 500 mg 2 QL (90 tablets/30 days)oxaprozin tab 600 mg 3 QL (90 tablets/30 days)oxycodone hcl tab 5 mg 4 QL (360 tablets/30 days)oxycodone hcl tab 10 mg 4 QL (180 tablets/30 days)oxycodone hcl tab 15 mg 4 QL (180 tablets/30 days)oxycodone hcl tab 20 mg 4 QL (180 tablets/30 days)oxycodone hcl tab 30 mg 4 QL (180 tablets/30 days)oxycodone w/ acetaminophen tab 2.5-325 mg 4 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 5-325 mg 4 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 7.5-325 mg 4 QL (240 tablets/30 days)oxycodone w/ acetaminophen tab 10-325 mg 4 QL (180 tablets/30 days)oxycodone-aspirin tab 4.8355-325 mg 4 QL (360 tablets/30 days)piroxicam cap 10 mg 3 QL (60 capsules/30 days)piroxicam cap 20 mg 3 QL (30 capsules/30 days)sulindac tab 150 mg 2 QL (60 tablets/30 days)sulindac tab 200 mg 2 QL (60 tablets/30 days)TENCON - butalbital-acetaminophen tab 50-325 mg# 4 PA, QL (180 tablets/30 days)TOLMETIN SODIUM - tolmetin sodium cap 400 mg 3 QL (120 capsules/30 days)tramadol hcl tab er 24hr 100 mg 3 PA, QL (30 tablets/30 days)tramadol hcl tab er 24hr 200 mg 3 PA, QL (30 tablets/30 days)tramadol hcl tab er 24hr 300 mg 3 PA, QL (30 tablets/30 days)tramadol hcl tab 50 mg 3 QL (240 tablets/30 days)tramadol-acetaminophen tab 37.5-325 mg 2 QL (240 tablets/30 days)Anestheticslidocaine hcl soln 4% 2 PA, QL (150 mls/30 days)lidocaine hcl urethral/mucosal gel prefilled syringe 2% 2 PA, QL (150 mls/30 days)lidocaine hcl urethral/mucosal gel 2% 2 PA, QL (150 mls/30 days)lidocaine hcl viscous soln 2% 2lidocaine oint 5% 2 PA, QL (100 grams/30 days)lidocaine patch 5% 3 PA, QL (90 patches/30 days)lidocaine-prilocaine cream 2.5-2.5% 3 PA, QL (60 grams/30 days)Anti-Addiction/Substance Abuse Treatment Agentsacamprosate calcium tab delayed release 333 mg 2buprenorphine hcl sl tab 2 mg 2 QL (90 tablets/30 days)buprenorphine hcl sl tab 8 mg 2 QL (90 tablets/30 days)buprenorphine hcl-naloxone hcl sl film 2-0.5 mg 2 QL (120 films/30 days)buprenorphine hcl-naloxone hcl sl film 4-1 mg 2 QL (30 films/30 days)buprenorphine hcl-naloxone hcl sl film 8-2 mg 2 QL (60 films/30 days)buprenorphine hcl-naloxone hcl sl film 12-3 mg 2 QL (60 films/30 days)

2019


5

Drug Name Drug Tier Requirements/Limitsbuprenorphine hcl-naloxone hcl sl tab 2-0.5 mg 2 QL (120 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 8-2 mg 2 QL (90 tablets/30 days)bupropion hcl (smoking deterrent) tab er 12hr 150 mg 2CHANTIX - varenicline tartrate tab 0.5 mg 3CHANTIX - varenicline tartrate tab 1 mg 3CHANTIX CONTINUING MONTH PACK - varenicline tartrate tab

1 mg3

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

3

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

delivered)4

NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/spray) 4SUBOXONE - buprenorphine hcl-naloxone hcl sl film 2-0.5 mg 3 QL (120 films/30 days)SUBOXONE - buprenorphine hcl-naloxone hcl sl film 4-1 mg 3 QL (30 films/30 days)SUBOXONE - buprenorphine hcl-naloxone hcl sl film 8-2 mg 3 QL (60 films/30 days)SUBOXONE - buprenorphine hcl-naloxone hcl sl film 12-3 mg 3 QL (60 films/30 days)VIVITROL - naltrexone for im extended release susp 380 mg 5Antibacterialsamikacin sulfate inj 500 mg/2ml (250 mg/ml) 3amikacin sulfate inj 1 gm/4ml (250 mg/ml) 3AMOXICILLIN - amoxicillin (trihydrate) chew tab 125 mg 3AMOXICILLIN - amoxicillin (trihydrate) chew tab 250 mg 3amoxicillin (trihydrate) cap 250 mg 2amoxicillin (trihydrate) cap 500 mg 2amoxicillin (trihydrate) for susp 125 mg/5ml 2amoxicillin (trihydrate) for susp 200 mg/5ml 2amoxicillin (trihydrate) for susp 250 mg/5ml 2amoxicillin (trihydrate) for susp 400 mg/5ml 2amoxicillin (trihydrate) tab 500 mg 2amoxicillin (trihydrate) tab 875 mg 2amoxicillin & k clavulanate for susp 200-28.5 mg/5ml 3

2019


Drug Name Drug Tier Requirements/Limitsamoxicillin & k clavulanate for susp 250-62.5 mg/5ml 3amoxicillin & k clavulanate for susp 400-57 mg/5ml 3amoxicillin & k clavulanate for susp 600-42.9 mg/5ml 3amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg 3amoxicillin & k clavulanate tab 250-125 mg 3amoxicillin & k clavulanate tab 500-125 mg 3amoxicillin & k clavulanate tab 875-125 mg 3AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin & k

clavulanate chew tab 200-28.5 mg3

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

3

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

soln 3 (2-1) gm3

AUGMENTIN - amoxicillin & k clavulanate for susp125-31.25 mg/5ml

4

AZACTAM - aztreonam for inj 1 gm 4AZACTAM - aztreonam for inj 2 gm 4AZITHROMYCIN - azithromycin powd pack for susp 1 gm 3azithromycin for susp 100 mg/5ml 3azithromycin for susp 200 mg/5ml 3azithromycin iv for soln 500 mg 3azithromycin tab 250 mg 2azithromycin tab 500 mg 2azithromycin tab 600 mg 2aztreonam for inj 1 gm 3aztreonam for inj 2 gm 3BICILLIN L-A - penicillin g benzathine intramuscular susp 600000

unit/ml4

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

4

2019


7

Drug Name Drug Tier Requirements/LimitsBICILLIN L-A - penicillin g benzathine intramuscular susp 2400000

unit/4ml4

cefaclor cap 250 mg 2cefaclor cap 500 mg 2cefadroxil cap 500 mg 2cefadroxil for susp 250 mg/5ml 2cefadroxil for susp 500 mg/5ml 2cefadroxil tab 1 gm 2cefazolin sodium for inj 500 mg 3cefazolin sodium for inj 1 gm 3cefazolin sodium for inj 10 gm 3cefdinir cap 300 mg 2cefdinir for susp 125 mg/5ml 3cefdinir for susp 250 mg/5ml 3cefepime hcl for inj 1 gm 3cefepime hcl for inj 2 gm 3cefixime cap 400 mg 3cefixime for susp 100 mg/5ml 3cefixime for susp 200 mg/5ml 3CEFOTAXIME SODIUM - cefotaxime sodium for inj 500 mg 3cefotaxime sodium for inj 1 gm 3cefoxitin sodium for inj 10 gm 3cefoxitin sodium for iv soln 1 gm 3cefoxitin sodium for iv soln 2 gm 3cefpodoxime proxetil for susp 50 mg/5ml 3cefpodoxime proxetil for susp 100 mg/5ml 3cefpodoxime proxetil tab 100 mg 3cefpodoxime proxetil tab 200 mg 3cefprozil for susp 125 mg/5ml 3cefprozil for susp 250 mg/5ml 3cefprozil tab 250 mg 2cefprozil tab 500 mg 2ceftazidime for inj 1 gm 3ceftazidime for inj 2 gm 3ceftazidime for inj 6 gm 3ceftazidime for iv soln 2 gm 3CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE - ceftriaxone

sodium in dextrose inj 20 mg/ml3

2019


Drug Name Drug Tier Requirements/LimitsCEFTRIAXONE IN ISO-OSMOTIC DEXTROSE - ceftriaxone

sodium in dextrose inj 40 mg/ml3

ceftriaxone sodium for inj 250 mg 3ceftriaxone sodium for inj 500 mg 3ceftriaxone sodium for inj 1 gm 3ceftriaxone sodium for inj 2 gm 3ceftriaxone sodium for inj 10 gm 3ceftriaxone sodium for iv soln 1 gm 3ceftriaxone sodium for iv soln 2 gm 3CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 1 gm

and dextrose 3.74%3

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

3

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

sodium succinate for iv inj 1 gm3

ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) 2CIPROFLOXACIN HCL - ciprofloxacin hcl tab 100 mg 3ciprofloxacin hcl tab 250 mg 2ciprofloxacin hcl tab 500 mg 2ciprofloxacin hcl tab 750 mg 2ciprofloxacin 200 mg/100ml in d5w 3ciprofloxacin 400 mg/200ml in d5w 3clarithromycin for susp 125 mg/5ml 3clarithromycin for susp 250 mg/5ml 3clarithromycin tab er 24hr 500 mg 3clarithromycin tab 250 mg 2clarithromycin tab 500 mg 2CLEOCIN - clindamycin phosphate vaginal cream 2% 4clindamycin hcl cap 75 mg 2

2019


9

Drug Name Drug Tier Requirements/Limitsclindamycin hcl cap 150 mg 2clindamycin hcl cap 300 mg 2clindamycin palmitate hcl for soln 75 mg/5ml 3clindamycin phosphate gel 1% 2clindamycin phosphate in d5w iv soln 300 mg/50ml 3clindamycin phosphate in d5w iv soln 600 mg/50ml 3clindamycin phosphate in d5w iv soln 900 mg/50ml 3clindamycin phosphate inj 300 mg/2ml 3clindamycin phosphate inj 600 mg/4ml 3clindamycin phosphate inj 900 mg/6ml 3clindamycin phosphate inj 9 gm/60ml 3clindamycin phosphate iv soln 300 mg/2ml 3clindamycin phosphate iv soln 600 mg/4ml 3clindamycin phosphate iv soln 900 mg/6ml 3clindamycin phosphate lotion 1% 2clindamycin phosphate soln 1% 2clindamycin phosphate swab 1% 2clindamycin phosphate vaginal cream 2% 3colistimethate sod for inj 150 mg 5DALVANCE - dalbavancin hcl for iv soln 500 mg 5daptomycin for iv soln 500 mg 5demeclocycline hcl tab 150 mg 3demeclocycline hcl tab 300 mg 3dicloxacillin sodium cap 250 mg 3dicloxacillin sodium cap 500 mg 3DIFICID - fidaxomicin tab 200 mg 5doxycycline hyclate cap 50 mg 2doxycycline hyclate cap 100 mg 2doxycycline hyclate for inj 100 mg 3doxycycline hyclate tab 20 mg 2doxycycline hyclate tab 100 mg 2doxycycline monohydrate cap 50 mg 3doxycycline monohydrate cap 75 mg 3doxycycline monohydrate cap 100 mg 3doxycycline monohydrate cap 150 mg 3doxycycline monohydrate tab 50 mg 3doxycycline monohydrate tab 75 mg 3doxycycline monohydrate tab 100 mg 3

2019


Drug Name Drug Tier Requirements/Limitsdoxycycline monohydrate tab 150 mg 3ertapenem sodium for inj 1 gm 4ERYPED 400 - erythromycin ethylsuccinate for susp 400 mg/5ml 4ERYTHROCIN LACTOBIONATE - erythromycin lactobionate for inj

500 mg5

ERYTHROCIN STEARATE - erythromycin stearate tab 250 mg 4erythromycin ethylsuccinate for susp 200 mg/5ml 3erythromycin ethylsuccinate for susp 400 mg/5ml 3erythromycin pads 2% 2erythromycin soln 2% 2erythromycin tab delayed release 250 mg 4erythromycin tab delayed release 333 mg 4erythromycin tab delayed release 500 mg 4erythromycin tab 250 mg 3erythromycin tab 500 mg 3erythromycin w/ delayed release particles cap 250 mg 3gentamicin in saline inj 0.8 mg/ml 3gentamicin in saline inj 1 mg/ml 3gentamicin in saline inj 1.6 mg/ml 3gentamicin in saline inj 1.2 mg/ml 3gentamicin sulfate inj 10 mg/ml 3gentamicin sulfate inj 40 mg/ml 3imipenem-cilastatin intravenous for soln 250 mg 3imipenem-cilastatin intravenous for soln 500 mg 3IMPAVIDO - miltefosine cap 50 mg 5INVANZ - ertapenem sodium for inj 1 gm 4INVANZ - ertapenem sodium for iv inj 1 gm 4levofloxacin in d5w iv soln 250 mg/50ml 3levofloxacin in d5w iv soln 500 mg/100ml 3levofloxacin in d5w iv soln 750 mg/150ml 3levofloxacin iv soln 25 mg/ml 3levofloxacin oral soln 25 mg/ml 3levofloxacin tab 250 mg 2levofloxacin tab 500 mg 2levofloxacin tab 750 mg 2LINEZOLID - linezolid in sodium chloride iv soln

600 mg/300ml-0.9%5

linezolid for susp 100 mg/5ml 5 PAlinezolid iv soln 600 mg/300ml (2 mg/ml) 5

2019


11

Drug Name Drug Tier Requirements/Limitslinezolid tab 600 mg 3 PAmeropenem iv for soln 500 mg 3meropenem iv for soln 1 gm 3methenamine hippurate tab 1 gm 2metronidazole cap 375 mg 3metronidazole in nacl 0.74% iv soln 500 mg/100ml 3metronidazole in nacl 0.79% iv soln 500 mg/100ml 3metronidazole iv soln 5 mg/ml 3metronidazole tab 250 mg 2metronidazole tab 500 mg 2metronidazole vaginal gel 0.75% 3minocycline hcl cap 50 mg 3minocycline hcl cap 75 mg 3minocycline hcl cap 100 mg 3minocycline hcl tab 50 mg 3minocycline hcl tab 75 mg 3minocycline hcl tab 100 mg 3MOXIFLOXACIN HCL - moxifloxacin hcl iv solution 400 mg/250ml 3moxifloxacin hcl tab 400 mg 2moxifloxacin hcl 400 mg/250ml in sodium chloride 0.8% inj 3NAFCILLIN SODIUM - nafcillin sodium for inj 10 gm 5NAFCILLIN SODIUM - nafcillin sodium for iv soln 1 gm 3NAFCILLIN SODIUM - nafcillin sodium for iv soln 2 gm 3nafcillin sodium for inj 1 gm 3nafcillin sodium for inj 2 gm 3nafcillin sodium for iv soln 10 gm 5neomycin sulfate tab 500 mg 2neomycin-polymyxin b gu irrigation soln 2nitrofurantoin macrocrystalline cap 50 mg# 3nitrofurantoin macrocrystalline cap 100 mg# 3nitrofurantoin monohydrate macrocrystalline cap 100 mg# 3nitrofurantoin susp 25 mg/5ml# 4ofloxacin tab 400 mg 2paromomycin sulfate cap 250 mg 3penicillin g potassium for inj 5000000 unit 3penicillin g potassium for inj 20000000 unit 3PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g

potassium inj 20000 unit/ml in dextrose3

2019


Drug Name Drug Tier Requirements/LimitsPENICILLIN G POTASSIUM IN DEXTROSE - penicillin g

potassium inj 40000 unit/ml in dextrose3

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

3

PENICILLIN G SODIUM - penicillin g sodium for inj 5000000 unit 3penicillin v potassium for soln 125 mg/5ml 2penicillin v potassium for soln 250 mg/5ml 2penicillin v potassium tab 250 mg 2penicillin v potassium tab 500 mg 2piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm) 3piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm) 3piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) 3SIVEXTRO - tedizolid phosphate for iv soln 200 mg 5SIVEXTRO - tedizolid phosphate tab 200 mg 5 PASTREPTOMYCIN SULFATE - streptomycin sulfate for inj 1 gm 3sulfacetamide sodium lotion 10% 2SULFADIAZINE - sulfadiazine tab 500 mg 3sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml 3sulfamethoxazole-trimethoprim susp 200-40 mg/5ml 3sulfamethoxazole-trimethoprim tab 400-80 mg 2sulfamethoxazole-trimethoprim tab 800-160 mg 2SUPRAX - cefixime cap 400 mg 4SUPRAX - cefixime chew tab 100 mg 4SUPRAX - cefixime chew tab 200 mg 4SYNERCID - quinupristin-dalfopristin for inj 500 mg (150-350 mg) 5TAZICEF - ceftazidime for iv soln 1 gm 3TEFLARO - ceftaroline fosamil for iv soln 400 mg 5TEFLARO - ceftaroline fosamil for iv soln 600 mg 5tetracycline hcl cap 250 mg 3tetracycline hcl cap 500 mg 3tigecycline for iv soln 50 mg 5tinidazole tab 250 mg 3tinidazole tab 500 mg 3TOBRAMYCIN SULFATE - tobramycin sulfate inj 10 mg/ml 3TOBRAMYCIN SULFATE - tobramycin sulfate inj 2 gm/50ml

(40 mg/ml)3

tobramycin sulfate for inj 1.2 gm 3tobramycin sulfate inj 80 mg/2ml (40 mg/ml) 3tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) 3

2019


13

Drug Name Drug Tier Requirements/Limitstrimethoprim tab 100 mg 2TYGACIL - tigecycline for iv soln 50 mg 5vancomycin hcl cap 125 mg 3vancomycin hcl cap 250 mg 3vancomycin hcl for iv soln 500 mg 3vancomycin hcl for iv soln 750 mg 3vancomycin hcl for iv soln 1 gm 3vancomycin hcl for iv soln 5 gm 3vancomycin hcl for iv soln 10 gm 3vancomycin hcl for iv soln 100 gm 3VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl-dextrose iv

soln 500 mg/100ml-5%4

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

4

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

4

VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv soln250 mg

3

VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv soln1.25 gm

3

VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv soln1.5 gm

3

ZOSYN - piperacillin sod-tazobactam sod in dex iv soln2-0.25gm/50ml

4

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

4

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

4

AnticonvulsantsAPTIOM - eslicarbazepine acetate tab 200 mg 5APTIOM - eslicarbazepine acetate tab 400 mg 5APTIOM - eslicarbazepine acetate tab 600 mg 5APTIOM - eslicarbazepine acetate tab 800 mg 5BANZEL - rufinamide susp 40 mg/ml 5BANZEL - rufinamide tab 200 mg 4BANZEL - rufinamide tab 400 mg 5BRIVIACT - brivaracetam iv soln 50 mg/5ml 4BRIVIACT - brivaracetam oral soln 10 mg/ml 5BRIVIACT - brivaracetam tab 10 mg 5BRIVIACT - brivaracetam tab 25 mg 5BRIVIACT - brivaracetam tab 50 mg 5

2019


Drug Name Drug Tier Requirements/LimitsBRIVIACT - brivaracetam tab 75 mg 5BRIVIACT - brivaracetam tab 100 mg 5carbamazepine cap er 12hr 100 mg 2carbamazepine cap er 12hr 200 mg 2carbamazepine cap er 12hr 300 mg 2carbamazepine chew tab 100 mg 2carbamazepine susp 100 mg/5ml 2carbamazepine tab er 12hr 100 mg 2carbamazepine tab er 12hr 200 mg 2carbamazepine tab er 12hr 400 mg 2carbamazepine tab 200 mg 2CELONTIN - methsuximide cap 300 mg 4clobazam suspension 2.5 mg/ml 4 PA, QL (480 mls/30 days)clobazam tab 10 mg 2 PA, QL (60 tablets/30 days)clobazam tab 20 mg 2 PA, QL (60 tablets/30 days)DIASTAT ACUDIAL - diazepam rectal gel delivery system 10 mg 4 QL (5 twin pack(s)/30 days)DIASTAT ACUDIAL - diazepam rectal gel delivery system 20 mg 4 QL (5 twin pack(s)/30 days)DIASTAT PEDIATRIC - diazepam rectal gel delivery system 2.5 mg 4 QL (5 twin pack(s)/30 days)DIAZEPAM - diazepam rectal gel delivery system 10 mg 4 QL (5 twin pack(s)/30 days)DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system

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

DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system10 mg

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

DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system20 mg

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

DILANTIN - phenytoin sodium extended cap 30 mg 3divalproex sodium cap delayed release sprinkle 125 mg 2divalproex sodium tab delayed release 125 mg 2divalproex sodium tab delayed release 250 mg 2divalproex sodium tab delayed release 500 mg 2divalproex sodium tab er 24 hr 250 mg 2divalproex sodium tab er 24 hr 500 mg 2EPIDIOLEX - cannabidiol soln 100 mg/ml 5 PAethosuximide cap 250 mg 2ethosuximide soln 250 mg/5ml 2felbamate susp 600 mg/5ml 5felbamate tab 400 mg 3felbamate tab 600 mg 3fosphenytoin sodium inj 100 mg/2ml 3

2019


15

Drug Name Drug Tier Requirements/Limitsfosphenytoin sodium inj 500 mg/10ml 3FYCOMPA - perampanel susp 0.5 mg/ml 5FYCOMPA - perampanel tab 2 mg 4FYCOMPA - perampanel tab 4 mg 5FYCOMPA - perampanel tab 6 mg 5FYCOMPA - perampanel tab 8 mg 5FYCOMPA - perampanel tab 10 mg 5FYCOMPA - perampanel tab 12 mg 5gabapentin cap 100 mg 2 QL (1080 capsules/30 days)gabapentin cap 300 mg 2 QL (360 capsules/30 days)gabapentin cap 400 mg 2 QL (270 capsules/30 days)gabapentin oral soln 250 mg/5ml 2 QL (2160 mls/30 days)gabapentin tab 600 mg 2 QL (180 tablets/30 days)gabapentin tab 800 mg 2 QL (135 tablets/30 days)lamotrigine tab chewable dispersible 5 mg 2lamotrigine tab chewable dispersible 25 mg 2lamotrigine tab 25 mg 2lamotrigine tab 100 mg 2lamotrigine tab 150 mg 2lamotrigine tab 200 mg 2levetiracetam in sodium chloride iv soln 500 mg/100ml 3levetiracetam in sodium chloride iv soln 1000 mg/100ml 3levetiracetam in sodium chloride iv soln 1500 mg/100ml 3levetiracetam inj 500 mg/5ml (100 mg/ml) 3levetiracetam oral soln 100 mg/ml 2levetiracetam tab 250 mg 2levetiracetam tab 500 mg 2levetiracetam tab 750 mg 2levetiracetam tab 1000 mg 2LYRICA - pregabalin cap 25 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 50 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 75 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 100 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 150 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 200 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 225 mg 3 QL (60 capsules/30 days)LYRICA - pregabalin cap 300 mg 3 QL (60 capsules/30 days)LYRICA - pregabalin soln 20 mg/ml 3 QL (900 mls/30 days)

2019


Drug Name Drug Tier Requirements/LimitsNAYZILAM - midazolam nasal spray soln 5 mg/0.1 ml 4 QL (10 bottles/30 days)ONFI - clobazam suspension 2.5 mg/ml 5 PA, QL (480 mls/30 days)ONFI - clobazam tab 10 mg 5 PA, QL (60 tablets/30 days)ONFI - clobazam tab 20 mg 5 PA, QL (60 tablets/30 days)oxcarbazepine susp 300 mg/5ml (60 mg/ml) 3oxcarbazepine tab 150 mg 2oxcarbazepine tab 300 mg 2oxcarbazepine tab 600 mg 2PEGANONE - ethotoin tab 250 mg 4phenobarbital elixir 20 mg/5ml# 4 PAPHENOBARBITAL SODIUM - phenobarbital sodium inj 65 mg/ml# 4 PAPHENOBARBITAL SODIUM - phenobarbital sodium inj 130 mg/ml# 4 PAphenobarbital tab 15 mg# 4 PAphenobarbital tab 16.2 mg# 4 PAphenobarbital tab 30 mg# 4 PAphenobarbital tab 32.4 mg# 4 PAphenobarbital tab 60 mg# 4 PAphenobarbital tab 64.8 mg# 4 PAphenobarbital tab 97.2 mg# 4 PAphenobarbital tab 100 mg# 4 PAphenytoin chew tab 50 mg 2phenytoin sodium extended cap 100 mg 2phenytoin sodium extended cap 200 mg 2phenytoin sodium extended cap 300 mg 2phenytoin susp 125 mg/5ml 2pregabalin cap 25 mg 3 QL (90 capsules/30 days)pregabalin cap 50 mg 3 QL (90 capsules/30 days)pregabalin cap 75 mg 3 QL (90 capsules/30 days)pregabalin cap 100 mg 3 QL (90 capsules/30 days)pregabalin cap 150 mg 3 QL (90 capsules/30 days)pregabalin cap 200 mg 3 QL (90 capsules/30 days)pregabalin cap 225 mg 3 QL (60 capsules/30 days)pregabalin cap 300 mg 3 QL (60 capsules/30 days)pregabalin soln 20 mg/ml 3 QL (900 mls/30 days)primidone tab 50 mg 2primidone tab 250 mg 2SABRIL - vigabatrin tab 500 mg* 5SPRITAM - levetiracetam tab disintegrating soluble 250 mg 4

2019


17

Drug Name Drug Tier Requirements/LimitsSPRITAM - levetiracetam tab disintegrating soluble 500 mg 4SPRITAM - levetiracetam tab disintegrating soluble 750 mg 5SPRITAM - levetiracetam tab disintegrating soluble 1000 mg 4SYMPAZAN - clobazam oral film 5 mg 5 PA, QL (240 films/30 days)SYMPAZAN - clobazam oral film 10 mg 5 PA, QL (60 films/30 days)SYMPAZAN - clobazam oral film 20 mg 5 PA, QL (60 films/30 days)tiagabine hcl tab 2 mg 3tiagabine hcl tab 4 mg 3tiagabine hcl tab 12 mg 3tiagabine hcl tab 16 mg 3topiramate sprinkle cap 15 mg 2topiramate sprinkle cap 25 mg 2topiramate tab 25 mg 2topiramate tab 50 mg 2topiramate tab 100 mg 2topiramate tab 200 mg 2valproate sodium inj 100 mg/ml 3valproate sodium oral soln 250 mg/5ml 2valproic acid cap 250 mg 2vigabatrin powd pack 500 mg* 5vigabatrin tab 500 mg* 5VIMPAT - lacosamide iv inj 200 mg/20ml (10 mg/ml) 3VIMPAT - lacosamide oral solution 10 mg/ml 3VIMPAT - lacosamide tab 50 mg 3VIMPAT - lacosamide tab 100 mg 3VIMPAT - lacosamide tab 150 mg 3VIMPAT - lacosamide tab 200 mg 3zonisamide cap 25 mg 2zonisamide cap 50 mg 2zonisamide cap 100 mg 2Antidementia Agentsdonepezil hydrochloride orally disintegrating tab 5 mg 2donepezil hydrochloride orally disintegrating tab 10 mg 2donepezil hydrochloride tab 5 mg 2donepezil hydrochloride tab 10 mg 2donepezil hydrochloride tab 23 mg 2ERGOLOID MESYLATES - ergoloid mesylates tab 1 mg# 3 PAGALANTAMINE HYDROBROMIDE - galantamine hydrobromide

oral soln 4 mg/ml3

2019


Drug Name Drug Tier Requirements/Limitsgalantamine hydrobromide cap er 24hr 8 mg 2galantamine hydrobromide cap er 24hr 16 mg 2galantamine hydrobromide cap er 24hr 24 mg 2galantamine hydrobromide tab 4 mg 2galantamine hydrobromide tab 8 mg 2galantamine hydrobromide tab 12 mg 2memantine hcl oral solution 2 mg/ml 3 PAmemantine hcl tab 5 mg 2 PAmemantine hcl tab 10 mg 2 PAmemantine hcl tab 5 mg (28) & 10 mg (21) titration pak 2 PArivastigmine tartrate cap 1.5 mg 2rivastigmine tartrate cap 3 mg 2rivastigmine tartrate cap 4.5 mg 2rivastigmine tartrate cap 6 mg 2rivastigmine td patch 24hr 4.6 mg/24hr 3rivastigmine td patch 24hr 9.5 mg/24hr 3rivastigmine td patch 24hr 13.3 mg/24hr 3Antidepressantsamitriptyline hcl tab 10 mg# 4 PAamitriptyline hcl tab 25 mg# 4 PAamitriptyline hcl tab 50 mg# 4 PAamitriptyline hcl tab 75 mg# 4 PAamitriptyline hcl tab 100 mg# 4 PAamitriptyline hcl tab 150 mg# 4 PAAMOXAPINE - amoxapine tab 25 mg# 3 PAAMOXAPINE - amoxapine tab 50 mg# 3 PAAMOXAPINE - amoxapine tab 100 mg# 3 PAAMOXAPINE - amoxapine tab 150 mg# 3 PAbupropion hcl tab er 12hr 100 mg 2 QL (90 tablets/30 days)bupropion hcl tab er 12hr 150 mg 2 QL (60 tablets/30 days)bupropion hcl tab er 12hr 200 mg 2 QL (60 tablets/30 days)bupropion hcl tab er 24hr 150 mg 3 QL (90 tablets/30 days)bupropion hcl tab er 24hr 300 mg 3 QL (30 tablets/30 days)bupropion hcl tab 75 mg 2 QL (60 tablets/30 days)bupropion hcl tab 100 mg 2 QL (120 tablets/30 days)CELEXA - citalopram hydrobromide tab 10 mg 4 QL (45 tablets/30 days)CELEXA - citalopram hydrobromide tab 20 mg 4 QL (45 tablets/30 days)CELEXA - citalopram hydrobromide tab 40 mg 4 QL (30 tablets/30 days)

2019


19

Drug Name Drug Tier Requirements/Limitscitalopram hydrobromide oral soln 10 mg/5ml 2 QL (600 mls/30 days)citalopram hydrobromide tab 10 mg 1 QL (45 tablets/30 days)citalopram hydrobromide tab 20 mg 1 QL (45 tablets/30 days)citalopram hydrobromide tab 40 mg 1 QL (30 tablets/30 days)clomipramine hcl cap 25 mg# 4 PAclomipramine hcl cap 50 mg# 4 PAclomipramine hcl cap 75 mg# 4 PAdesipramine hcl tab 10 mg# 4 PAdesipramine hcl tab 25 mg# 4 PAdesipramine hcl tab 50 mg# 4 PAdesipramine hcl tab 75 mg# 4 PAdesipramine hcl tab 100 mg# 4 PAdesipramine hcl tab 150 mg# 4 PAdesvenlafaxine succinate tab er 24hr 25 mg 3 QL (30 tablets/30 days)desvenlafaxine succinate tab er 24hr 50 mg 3 QL (30 tablets/30 days)desvenlafaxine succinate tab er 24hr 100 mg 3 QL (30 tablets/30 days)doxepin hcl cap 10 mg# 4 PAdoxepin hcl cap 25 mg# 4 PAdoxepin hcl cap 50 mg# 4 PAdoxepin hcl cap 75 mg# 4 PAdoxepin hcl cap 100 mg# 4 PAdoxepin hcl cap 150 mg# 4 PAdoxepin hcl conc 10 mg/ml# 3 PAduloxetine hcl enteric coated pellets cap 20 mg 3 QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 30 mg 3 QL (90 capsules/30 days)duloxetine hcl enteric coated pellets cap 60 mg 3 QL (60 capsules/30 days)EMSAM - selegiline td patch 24hr 6 mg/24hr 5EMSAM - selegiline td patch 24hr 9 mg/24hr 5EMSAM - selegiline td patch 24hr 12 mg/24hr 5escitalopram oxalate soln 5 mg/5ml 3 QL (600 mls/30 days)escitalopram oxalate tab 5 mg 1 QL (45 tablets/30 days)escitalopram oxalate tab 10 mg 1 QL (45 tablets/30 days)escitalopram oxalate tab 20 mg 1 QL (30 tablets/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 20 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 40 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 80 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 120 mg 4 QL (30 capsules/30 days)FETZIMA TITRATION PACK - levomilnacipran hcl cap er 24hr 20 &

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

2019


Drug Name Drug Tier Requirements/LimitsFLUOXETINE DR - fluoxetine hcl cap delayed release 90 mg 2 QL (4 capsules/28 days)fluoxetine hcl cap 10 mg 2 QL (90 capsules/30 days)fluoxetine hcl cap 20 mg 2 QL (120 capsules/30 days)fluoxetine hcl cap 40 mg 2 QL (60 capsules/30 days)fluoxetine hcl solution 20 mg/5ml 2 QL (600 mls/30 days)fluoxetine hcl tab 10 mg 2 QL (90 tablets/30 days)fluoxetine hcl tab 20 mg 2 QL (120 tablets/30 days)fluvoxamine maleate tab 25 mg 2 QL (30 tablets/30 days)fluvoxamine maleate tab 50 mg 2 QL (30 tablets/30 days)fluvoxamine maleate tab 100 mg 2 QL (90 tablets/30 days)imipramine hcl tab 10 mg# 3 PAimipramine hcl tab 25 mg# 3 PAimipramine hcl tab 50 mg# 3 PALEXAPRO - escitalopram oxalate tab 5 mg 4 QL (45 tablets/30 days)LEXAPRO - escitalopram oxalate tab 10 mg 4 QL (45 tablets/30 days)LEXAPRO - escitalopram oxalate tab 20 mg 4 QL (30 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 25 mg 3 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 50 mg 3 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 75 mg 3 QL (90 tablets/30 days)MARPLAN - isocarboxazid tab 10 mg 5mirtazapine orally disintegrating tab 15 mg 2 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 30 mg 2 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 45 mg 2 QL (30 tablets/30 days)mirtazapine tab 7.5 mg 1 QL (30 tablets/30 days)mirtazapine tab 15 mg 1 QL (45 tablets/30 days)mirtazapine tab 30 mg 1 QL (30 tablets/30 days)mirtazapine tab 45 mg 1 QL (30 tablets/30 days)NARDIL - phenelzine sulfate tab 15 mg 4NEFAZODONE HCL - nefazodone hcl tab 100 mg 3NEFAZODONE HCL - nefazodone hcl tab 150 mg 3nefazodone hcl tab 50 mg 2nefazodone hcl tab 250 mg 2NEFAZODONE HYDROCHLORIDE - nefazodone hcl tab 200 mg 3nortriptyline hcl cap 10 mg# 3 PAnortriptyline hcl cap 25 mg# 3 PAnortriptyline hcl cap 50 mg# 3 PAnortriptyline hcl cap 75 mg# 3 PAnortriptyline hcl soln 10 mg/5ml# 3 PA

2019


21

Drug Name Drug Tier Requirements/LimitsPARNATE - tranylcypromine sulfate tab 10 mg 4paroxetine hcl tab 10 mg# 3 PA, QL (45 tablets/30 days)paroxetine hcl tab 20 mg# 3 PA, QL (30 tablets/30 days)paroxetine hcl tab 30 mg# 3 PA, QL (60 tablets/30 days)paroxetine hcl tab 40 mg# 3 PA, QL (45 tablets/30 days)PAXIL - paroxetine hcl oral susp 10 mg/5ml# 4 PA, QL (900 mls/30 days)PAXIL - paroxetine hcl tab 10 mg# 4 PA, QL (45 tablets/30 days)PAXIL - paroxetine hcl tab 20 mg# 4 PA, QL (30 tablets/30 days)PAXIL - paroxetine hcl tab 30 mg# 4 PA, QL (60 tablets/30 days)PAXIL - paroxetine hcl tab 40 mg# 4 PA, QL (45 tablets/30 days)phenelzine sulfate tab 15 mg 2protriptyline hcl tab 5 mg# 3 PAprotriptyline hcl tab 10 mg# 3 PAPROZAC - fluoxetine hcl cap 10 mg 4 QL (90 capsules/30 days)PROZAC - fluoxetine hcl cap 20 mg 4 QL (120 capsules/30 days)PROZAC - fluoxetine hcl cap 40 mg 4 QL (60 capsules/30 days)REMERON - mirtazapine tab 15 mg 4 QL (45 tablets/30 days)REMERON - mirtazapine tab 30 mg 4 QL (30 tablets/30 days)REMERON SOLTAB - mirtazapine orally disintegrating tab 15 mg 4 QL (30 tablets/30 days)REMERON SOLTAB - mirtazapine orally disintegrating tab 30 mg 4 QL (30 tablets/30 days)REMERON SOLTAB - mirtazapine orally disintegrating tab 45 mg 4 QL (30 tablets/30 days)sertraline hcl oral concentrate for solution 20 mg/ml 2 QL (300 mls/30 days)sertraline hcl tab 25 mg 1 QL (45 tablets/30 days)sertraline hcl tab 50 mg 1 QL (45 tablets/30 days)sertraline hcl tab 100 mg 1 QL (60 tablets/30 days)SPRAVATO 56MG DOSE - esketamine hcl nasal soln 28 mg/device

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

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

5 PA, QL (24 bottles/28 days)

tranylcypromine sulfate tab 10 mg 3trazodone hcl tab 50 mg 2trazodone hcl tab 100 mg 2trazodone hcl tab 150 mg 2trazodone hcl tab 300 mg 2trimipramine maleate cap 25 mg# 3 PAtrimipramine maleate cap 50 mg# 3 PAtrimipramine maleate cap 100 mg# 3 PATRINTELLIX - vortioxetine hbr tab 5 mg 4 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 10 mg 4 QL (30 tablets/30 days)

2019


Drug Name Drug Tier Requirements/LimitsTRINTELLIX - vortioxetine hbr tab 20 mg 4 QL (30 tablets/30 days)venlafaxine hcl cap er 24hr 37.5 mg 2 QL (60 capsules/30 days)venlafaxine hcl cap er 24hr 75 mg 2 QL (90 capsules/30 days)venlafaxine hcl cap er 24hr 150 mg 2 QL (30 capsules/30 days)venlafaxine hcl tab er 24hr 37.5 mg 3 QL (60 tablets/30 days)venlafaxine hcl tab er 24hr 75 mg 3 QL (90 tablets/30 days)venlafaxine hcl tab er 24hr 150 mg 3 QL (30 tablets/30 days)venlafaxine hcl tab 25 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 37.5 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 50 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 75 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 100 mg 2 QL (90 tablets/30 days)VIIBRYD - vilazodone hcl tab 10 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 20 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 40 mg 4 QL (30 tablets/30 days)VIIBRYD STARTER PACK - vilazodone hcl tab starter kit 10 (7) &

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

ZOLOFT - sertraline hcl tab 25 mg 4 QL (45 tablets/30 days)ZOLOFT - sertraline hcl tab 50 mg 4 QL (45 tablets/30 days)ZOLOFT - sertraline hcl tab 100 mg 4 QL (60 tablets/30 days)Antiemeticsaprepitant capsule therapy pack 80 & 125 mg 3 BDaprepitant capsule 40 mg 3 BDaprepitant capsule 80 mg 3 BDaprepitant capsule 125 mg 3 BDCHLORPROMAZINE HCL - chlorpromazine hcl inj 25 mg/ml 4 PACHLORPROMAZINE HCL - chlorpromazine hcl inj 50 mg/2ml 4 PAchlorpromazine hcl tab 10 mg 3 PAchlorpromazine hcl tab 25 mg 3 PAchlorpromazine hcl tab 50 mg 3 PAchlorpromazine hcl tab 100 mg 3 PAchlorpromazine hcl tab 200 mg 3 PAdronabinol cap 2.5 mg 4 BDdronabinol cap 5 mg 4 BDdronabinol cap 10 mg 4 BDEMEND - fosaprepitant dimeglumine for iv infusion 150 mg 4fosaprepitant dimeglumine for iv infusion 150 mg 4granisetron hcl inj 1 mg/ml 3granisetron hcl inj 4 mg/4ml (1 mg/ml) 3

2019


23

Drug Name Drug Tier Requirements/Limitsgranisetron hcl tab 1 mg 2 BDmeclizine hcl tab 12.5 mg# 3ondansetron hcl inj 4 mg/2ml (2 mg/ml) 3ondansetron hcl inj 40 mg/20ml (2 mg/ml) 3ondansetron hcl oral soln 4 mg/5ml 3 BDondansetron hcl tab 4 mg 2 BDondansetron hcl tab 8 mg 2 BDondansetron hcl tab 24 mg 2 BDondansetron orally disintegrating tab 4 mg 2 BDondansetron orally disintegrating tab 8 mg 2 BDpalonosetron hcl iv soln pref syr 0.25 mg/5ml 5palonosetron hcl iv soln 0.25 mg/5ml 5PALONOSETRON HYDROCHLORIDE - palonosetron hcl iv soln

0.25 mg/2ml5

perphenazine tab 2 mg 2 PAperphenazine tab 4 mg 2 PAperphenazine tab 8 mg 2 PAperphenazine tab 16 mg 2 PAprochlorperazine edisylate inj 10 mg/2ml 4prochlorperazine edisylate inj 50 mg/10ml 4prochlorperazine maleate tab 5 mg 2prochlorperazine maleate tab 10 mg 2prochlorperazine suppos 25 mg 3promethazine hcl suppos 12.5 mg# 3 PApromethazine hcl suppos 25 mg# 3 PApromethazine hcl syrup 6.25 mg/5ml# 3 PApromethazine hcl tab 12.5 mg# 3 PApromethazine hcl tab 25 mg# 3 PApromethazine hcl tab 50 mg# 3 PAscopolamine td patch 72hr 1 mg/3days# 3 PAtrimethobenzamide hcl cap 300 mg 3AntifungalsAMBISOME - amphotericin b liposome iv for susp 50 mg 5 BDAMPHOTERICIN B - amphotericin b for iv soln 50 mg 3 BDCANCIDAS - caspofungin acetate for iv soln 70 mg 5caspofungin acetate for iv soln 50 mg 5caspofungin acetate for iv soln 70 mg 5ciclopirox gel 0.77% 2ciclopirox olamine cream 0.77% 2

2019


Drug Name Drug Tier Requirements/Limitsciclopirox olamine susp 0.77% 2ciclopirox shampoo 1% 2ciclopirox solution 8% 2clotrimazole cream 1% 2clotrimazole troche 10 mg 2CRESEMBA - isavuconazonium sulfate cap 186 mg 5 PACRESEMBA - isavuconazonium sulfate for iv soln 372 mg 5 PAeconazole nitrate cream 1% 3fluconazole for susp 10 mg/ml 3fluconazole for susp 40 mg/ml 3fluconazole in dextrose inj 200 mg/100ml 3fluconazole in dextrose inj 400 mg/200ml 3fluconazole in nacl 0.9% inj 200 mg/100ml 3fluconazole in nacl 0.9% inj 400 mg/200ml 3fluconazole tab 50 mg 2fluconazole tab 100 mg 2fluconazole tab 150 mg 2fluconazole tab 200 mg 2flucytosine cap 250 mg 5flucytosine cap 500 mg 5griseofulvin microsize susp 125 mg/5ml 3griseofulvin microsize tab 500 mg 3griseofulvin ultramicrosize tab 125 mg 3griseofulvin ultramicrosize tab 250 mg 3itraconazole cap 100 mg 3ketoconazole cream 2% 2ketoconazole shampoo 2% 2ketoconazole tab 200 mg 2MYCAMINE - micafungin sodium for iv soln 50 mg 5MYCAMINE - micafungin sodium for iv soln 100 mg 5NOXAFIL - posaconazole iv soln 300 mg/16.7ml (18 mg/ml) 4 PANOXAFIL - posaconazole susp 40 mg/ml 5 PANOXAFIL - posaconazole tab delayed release 100 mg 5 PAnystatin cream 100000 unit/gm 2nystatin oint 100000 unit/gm 2nystatin susp 100000 unit/ml 2nystatin tab 500000 unit 2nystatin topical powder 100000 unit/gm 2

2019


25

Drug Name Drug Tier Requirements/Limitsposaconazole tab delayed release 100 mg 5 PAterbinafine hcl tab 250 mg 2terconazole vaginal cream 0.8% 3terconazole vaginal cream 0.4% 3terconazole vaginal suppos 80 mg 3voriconazole for inj 200 mg 3 PAvoriconazole for susp 40 mg/ml 5 PAvoriconazole tab 50 mg 5 PAvoriconazole tab 200 mg 5 PAAntigout Agentsallopurinol sodium for inj 500 mg 2allopurinol tab 100 mg 1allopurinol tab 300 mg 1colchicine w/ probenecid tab 0.5-500 mg 2COLCRYS - colchicine tab 0.6 mg 3febuxostat tab 40 mg 3 STfebuxostat tab 80 mg 3 STprobenecid tab 500 mg 2ULORIC - febuxostat tab 40 mg 3 STULORIC - febuxostat tab 80 mg 3 STZYLOPRIM - allopurinol tab 100 mg 4ZYLOPRIM - allopurinol tab 300 mg 4Antimigraine AgentsAIMOVIG - erenumab-aooe subcutaneous soln auto-injector 70 mg/

ml3 PA, QL (2 pens/30 days)

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

3 PA, QL (1 pen/30 days)

AMERGE - naratriptan hcl tab 1 mg 4 QL (18 tablets/30 days)AMERGE - naratriptan hcl tab 2.5 mg 4 QL (18 tablets/30 days)EMGALITY - galcanezumab-gnlm subcutaneous soln auto-injector

120 mg/ml3 PA, QL (2 pens/30 days)

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

3 PA, QL (3 syringes/30 days)

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


frovatriptan succinate tab 2.5 mg 3 QL (18 tablets/30 days)IMITREX - sumatriptan nasal spray 5 mg/act 4 QL (12 units (2

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

packages)/30 days)IMITREX - sumatriptan succinate inj 6 mg/0.5ml 4

2019


Drug Name Drug Tier Requirements/LimitsIMITREX - sumatriptan succinate tab 25 mg 4 QL (18 tablets/30 days)IMITREX - sumatriptan succinate tab 50 mg 4 QL (18 tablets/30 days)IMITREX - sumatriptan succinate tab 100 mg 4 QL (18 tablets/30 days)IMITREX STATDOSE REFILL - sumatriptan succinate solution

cartridge 4 mg/0.5ml4

IMITREX STATDOSE REFILL - sumatriptan succinate solutioncartridge 6 mg/0.5ml

4

IMITREX STATDOSE SYSTEM - sumatriptan succinate solutionauto-injector 4 mg/0.5ml

4

IMITREX STATDOSE SYSTEM - sumatriptan succinate solutionauto-injector 6 mg/0.5ml

4

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

packages)/30 days)sumatriptan nasal spray 20 mg/act 3 QL (12 units (2

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

prefilled syringe 6 mg/0.5ml4

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

2019


27

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

2019


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

2019


29

Drug Name Drug Tier Requirements/Limitscisplatin inj 100 mg/100ml (1 mg/ml) 3cladribine iv soln 10 mg/10ml (1 mg/ml) 5 BDclofarabine iv soln 1 mg/ml 5COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100

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

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

5 PA, QL (112 capsules/28 days)

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


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

50 mg/10ml3

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

2019


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

2019


31

Drug Name Drug Tier Requirements/Limitsfluorouracil iv soln 1 gm/20ml (50 mg/ml) 3 BDfluorouracil iv soln 2.5 gm/50ml (50 mg/ml) 3 BDfluorouracil iv soln 5 gm/100ml (50 mg/ml) 3 BDflutamide cap 125 mg 2FOLOTYN - pralatrexate iv inj 20 mg/ml 5 PAFOLOTYN - pralatrexate iv inj 40 mg/2ml 5 PAfulvestrant inj 250 mg/5ml 5GAZYVA - obinutuzumab soln for iv infusion 1000 mg/40ml (25 mg/

ml)5 PA

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

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

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

2019


Drug Name Drug Tier Requirements/Limitsifosfamide iv inj 1 gm/20ml (50 mg/ml) 4ifosfamide iv inj 3 gm/60ml (50 mg/ml) 4imatinib mesylate tab 100 mg 5 PA, QL (90 tablets/30 days)imatinib mesylate tab 400 mg 5 PA, QL (60 tablets/30 days)IMBRUVICA - ibrutinib cap 70 mg 5 PA, QL (30 capsules/30 days)IMBRUVICA - ibrutinib cap 140 mg 5 PA, QL (120 capsules/30 days)IMBRUVICA - ibrutinib tab 140 mg 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 280 mg 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 420 mg 5 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 560 mg 5 PA, QL (30 tablets/30 days)IMFINZI - durvalumab soln for iv infusion 120 mg/2.4ml (50 mg/ml) 5 PAIMFINZI - durvalumab soln for iv infusion 500 mg/10ml (50 mg/ml) 5 PAIMLYGIC - talimogene laherparepvec intralesional inj 1000000 unit/

ml*4

IMLYGIC - talimogene laherparepvec intralesional inj 100000000unit/ml*

5

INLYTA - axitinib tab 1 mg* 5 PA, QL (180 tablets/30 days)INLYTA - axitinib tab 5 mg* 5 PA, QL (120 tablets/30 days)INREBIC - fedratinib hcl cap 100 mg 5 PA, QL (120 capsules/30 days)IRESSA - gefitinib tab 250 mg* 5 PA, QL (30 tablets/30 days)IRINOTECAN - irinotecan hcl inj 500 mg/25ml (20 mg/ml) 3irinotecan hcl inj 40 mg/2ml (20 mg/ml) 3irinotecan hcl inj 100 mg/5ml (20 mg/ml) 3ISTODAX (OVERFILL) - romidepsin for iv inj 10 mg 5 PAIXEMPRA KIT - ixabepilone for iv infusion 15 mg 5IXEMPRA KIT - ixabepilone for iv infusion 45 mg 5JAKAFI - ruxolitinib phosphate tab 5 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 10 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 15 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 20 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 25 mg* 5 PA, QL (60 tablets/30 days)JEVTANA - cabazitaxel inj 60 mg/1.5ml (for iv infusion) 5 PAKADCYLA - ado-trastuzumab emtansine for iv soln 100 mg 5 PAKADCYLA - ado-trastuzumab emtansine for iv soln 160 mg 5 PAKANJINTI - trastuzumab-anns for iv soln 420 mg 5 PAKEYTRUDA - pembrolizumab iv soln 100 mg/4ml (25 mg/ml)* 5 PAKISQALI - ribociclib succinate tab pack 200 mg daily dose 5 PA, QL (63 tablets/28 days)KISQALI - ribociclib succinate tab pack 400 mg daily dose (200 mg

tab)5 PA, QL (63 tablets/28 days)

2019


33

Drug Name Drug Tier Requirements/LimitsKISQALI - ribociclib succinate tab pack 600 mg daily dose (200 mg

tab)5 PA, QL (63 tablets/28 days)

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

5 PA, QL (91 tablets/28 days)





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

ml)5 PA

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

5 PA

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


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


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


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


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


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


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

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

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

(10 mg/ml)3

LEUCOVORIN CALCIUM - leucovorin calcium tab 10 mg 3LEUCOVORIN CALCIUM - leucovorin calcium tab 15 mg 3leucovorin calcium for inj 50 mg 3leucovorin calcium for inj 100 mg 3leucovorin calcium for inj 200 mg 3leucovorin calcium for inj 350 mg 3leucovorin calcium for inj 500 mg 3leucovorin calcium inj 500 mg/50ml (10 mg/ml) 3leucovorin calcium tab 5 mg 3

2019


Drug Name Drug Tier Requirements/Limitsleucovorin calcium tab 25 mg 3LEUKERAN - chlorambucil tab 2 mg 5LIBTAYO - cemiplimab-rwlc iv soln 350 mg/7ml (50 mg/ml) 5 PALONSURF - trifluridine-tipiracil tab 15-6.14 mg 5 PA, QL (100 tablets/28 days)LONSURF - trifluridine-tipiracil tab 20-8.19 mg 5 PA, QL (80 tablets/28 days)LORBRENA - lorlatinib tab 25 mg 5 PA, QL (90 tablets/30 days)LORBRENA - lorlatinib tab 100 mg 5 PA, QL (30 tablets/30 days)LUMOXITI - moxetumomab pasudotox-tdfk for iv soln 1 mg 5 PALYNPARZA - olaparib tab 100 mg* 5 PA, QL (120 tablets/30 days)LYNPARZA - olaparib tab 150 mg* 5 PA, QL (120 tablets/30 days)MARQIBO - vincristine sulfate liposome iv susp 5 mg/31ml

(0.16 mg/ml)5

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

2019


35

Drug Name Drug Tier Requirements/LimitsONIVYDE - irinotecan hcl liposome iv inj 43 mg/10ml (4.3 mg/ml) 5 PAOPDIVO - nivolumab iv soln 40 mg/4ml* 5 PAOPDIVO - nivolumab iv soln 100 mg/10ml* 5 PAOPDIVO - nivolumab iv soln 240 mg/24ml* 5 PAoxaliplatin for iv inj 50 mg 5oxaliplatin for iv inj 100 mg 5oxaliplatin iv soln 50 mg/10ml 3oxaliplatin iv soln 100 mg/20ml 3paclitaxel iv conc 30 mg/5ml (6 mg/ml) 3paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) 3paclitaxel iv conc 300 mg/50ml (6 mg/ml) 3PANRETIN - alitretinoin gel 0.1% 5PERJETA - pertuzumab soln for iv infusion 420 mg/14ml (30 mg/

ml)*5 PA

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


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


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


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

1400-23400 mg-unit/11.7ml5 PA

2019


Drug Name Drug Tier Requirements/LimitsRITUXAN HYCELA - rituximab-hyaluronidase human inj

1600-26800 mg-unit/13.4ml5 PA

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

2019


37

Drug Name Drug Tier Requirements/LimitsTEMODAR - temozolomide for iv soln 100 mg 5temsirolimus soln for iv infusion 25 mg/ml 5THALOMID - thalidomide cap 50 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 100 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 150 mg 5 PA, QL (60 capsules/30 days)THALOMID - thalidomide cap 200 mg 5 PA, QL (60 capsules/30 days)thiotepa for inj 15 mg 5TIBSOVO - ivosidenib tab 250 mg 5 PA, QL (60 tablets/30 days)topotecan hcl for inj 4 mg 4topotecan hcl inj 4 mg/4ml (for infusion) 4toremifene citrate tab 60 mg 5TREANDA - bendamustine hcl for iv soln 25 mg 5TREANDA - bendamustine hcl for iv soln 100 mg 5tretinoin cap 10 mg 5 PATRISENOX - arsenic trioxide iv soln 12 mg/6ml (2 mg/ml) 5TURALIO - pexidartinib hcl cap 200 mg 5 PA, QL (120 capsules/30 days)TYKERB - lapatinib ditosylate tab 250 mg* 5 PA, QL (180 tablets/30 days)UNITUXIN - dinutuximab iv soln 17.5 mg/5ml (3.5 mg/ml)* 5 PAVALCHLOR - mechlorethamine hcl gel 0.016%* 5VECTIBIX - panitumumab iv soln 100 mg/5ml 5 PAVECTIBIX - panitumumab iv soln 400 mg/20ml 5 PAVELCADE - bortezomib for inj 3.5 mg 5 PAVENCLEXTA - venetoclax tab 10 mg* 3 PA, QL (60 tablets/30 days)VENCLEXTA - venetoclax tab 50 mg* 4 PA, QL (30 tablets/30 days)VENCLEXTA - venetoclax tab 100 mg* 5 PA, QL (180 tablets/30 days)VENCLEXTA STARTING PACK - venetoclax tab therapy starter

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

tablets)/28 days)VERZENIO - abemaciclib tab 50 mg 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 100 mg 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 150 mg 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 200 mg 5 PA, QL (60 tablets/30 days)VINBLASTINE SULFATE - vinblastine sulfate inj 1 mg/ml 3 BDvincristine sulfate iv soln 1 mg/ml 3 BDvinorelbine tartrate inj 10 mg/ml 3vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) 3VITRAKVI - larotrectinib sulfate cap 25 mg 5 PA, QL (180 capsules/30 days)VITRAKVI - larotrectinib sulfate cap 100 mg 5 PA, QL (60 capsules/30 days)VITRAKVI - larotrectinib sulfate oral soln 20 mg/ml 5 PA, QL (300 mls/30 days)VIZIMPRO - dacomitinib tab 15 mg 5 PA, QL (30 tablets/30 days)

2019


Drug Name Drug Tier Requirements/LimitsVIZIMPRO - dacomitinib tab 30 mg 5 PA, QL (30 tablets/30 days)VIZIMPRO - dacomitinib tab 45 mg 5 PA, QL (30 tablets/30 days)VOTRIENT - pazopanib hcl tab 200 mg* 5 PA, QL (120 tablets/30 days)VYXEOS - daunorubicin-cytarabine liposome for iv inj 44-100 mg 5 PAXALKORI - crizotinib cap 200 mg* 5 PA, QL (60 capsules/30 days)XALKORI - crizotinib cap 250 mg* 5 PA, QL (60 capsules/30 days)XOSPATA - gilteritinib fumarate tablet 40 mg 5 PA, QL (90 tablets/30 days)XPOVIO 100 MG ONCE WEEKLY - selinexor tab therapy pack

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

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

5 PA, QL (1 box/28 days)

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


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


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

2019


39

Drug Name Drug Tier Requirements/LimitsBENZNIDAZOLE - benznidazole tab 12.5 mg 4BENZNIDAZOLE - benznidazole tab 100 mg 4BILTRICIDE - praziquantel tab 600 mg 5CHLOROQUINE PHOSPHATE - chloroquine phosphate tab

250 mg3

chloroquine phosphate tab 500 mg 3COARTEM - artemether-lumefantrine tab 20-120 mg 4DARAPRIM - pyrimethamine tab 25 mg 5hydroxychloroquine sulfate tab 200 mg 2ivermectin tab 3 mg 2lindane shampoo 1% 3malathion lotion 0.5% 3mefloquine hcl tab 250 mg 2NEBUPENT - pentamidine isethionate for nebulization soln 300 mg 4 BDPENTAM 300 - pentamidine isethionate for soln 300 mg 4pentamidine isethionate for soln 300 mg 3permethrin cream 5% 3praziquantel tab 600 mg 4primaquine phosphate tab 26.3 mg 3Antiparkinson Agentsamantadine hcl cap 100 mg 2amantadine hcl syrup 50 mg/5ml 2amantadine hcl tab 100 mg 2APOKYN - apomorphine hcl soln cartridge 30 mg/3ml* 5 PA, QL (60 mls/30 days)benztropine mesylate tab 0.5 mg# 3 PAbenztropine mesylate tab 1 mg# 3 PAbenztropine mesylate tab 2 mg# 3 PAbromocriptine mesylate cap 5 mg 3bromocriptine mesylate tab 2.5 mg 3carbidopa & levodopa orally disintegrating tab 10-100 mg 2carbidopa & levodopa orally disintegrating tab 25-100 mg 2carbidopa & levodopa orally disintegrating tab 25-250 mg 2carbidopa & levodopa tab er 25-100 mg 2carbidopa & levodopa tab er 50-200 mg 2carbidopa & levodopa tab 10-100 mg 2carbidopa & levodopa tab 25-100 mg 2carbidopa & levodopa tab 25-250 mg 2carbidopa tab 25 mg 5

2019


Drug Name Drug Tier Requirements/LimitsCARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-

entacapone tabs 12.5-50-200 mg3

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

3

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

3


3


3

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

3

entacapone tab 200 mg 3INBRIJA - levodopa inhal powder cap 42 mg 5 PA, QL (300 capsules/30 days)pramipexole dihydrochloride tab 0.125 mg 2pramipexole dihydrochloride tab 0.25 mg 2pramipexole dihydrochloride tab 0.5 mg 2pramipexole dihydrochloride tab 0.75 mg 2pramipexole dihydrochloride tab 1 mg 2pramipexole dihydrochloride tab 1.5 mg 2rasagiline mesylate tab 0.5 mg 3rasagiline mesylate tab 1 mg 3ropinirole hydrochloride tab 0.25 mg 2ropinirole hydrochloride tab 0.5 mg 2ropinirole hydrochloride tab 1 mg 2ropinirole hydrochloride tab 2 mg 2ropinirole hydrochloride tab 3 mg 2ropinirole hydrochloride tab 4 mg 2ropinirole hydrochloride tab 5 mg 2selegiline hcl cap 5 mg 3selegiline hcl tab 5 mg 3tolcapone tab 100 mg 5AntipsychoticsADASUVE - loxapine aerosol powder breath activated 10 mg 4 PAaripiprazole oral solution 1 mg/ml 3 PA, QL (750 mls/30 days)aripiprazole orally disintegrating tab 10 mg 5 PA, QL (60 tablets/30 days)aripiprazole orally disintegrating tab 15 mg 5 PA, QL (60 tablets/30 days)aripiprazole tab 2 mg 3 PA, QL (45 tablets/30 days)aripiprazole tab 5 mg 3 PA, QL (45 tablets/30 days)aripiprazole tab 10 mg 3 PA, QL (30 tablets/30 days)

2019


41

Drug Name Drug Tier Requirements/Limitsaripiprazole tab 15 mg 3 PA, QL (30 tablets/30 days)aripiprazole tab 20 mg 3 PA, QL (30 tablets/30 days)aripiprazole tab 30 mg 3 PA, QL (30 tablets/30 days)ARISTADA - aripiprazole lauroxil im er susp prefilled syr

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

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

5 PA, QL (1 syringe/28 days)





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


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

& 6 mg titration pak4 PA, QL (7 packs (56

tablets)/28 days)fluphenazine decanoate inj 25 mg/ml 3 PAFLUPHENAZINE HCL - fluphenazine hcl inj 2.5 mg/ml 3 PAFLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml 3 PAfluphenazine hcl tab 1 mg 2 PAfluphenazine hcl tab 2.5 mg 2 PAfluphenazine hcl tab 5 mg 2 PAfluphenazine hcl tab 10 mg 2 PAFLUPHENAZINE HYDROCHLORIDE - fluphenazine hcl elixir

2.5 mg/5ml3 PA

GEODON - ziprasidone mesylate for inj 20 mg 4 PA, QL (60 vials/30 days)haloperidol decanoate im soln 50 mg/ml 3 PA

2019


Drug Name Drug Tier Requirements/Limitshaloperidol decanoate im soln 100 mg/ml 3 PAhaloperidol lactate inj 5 mg/ml 3 PAhaloperidol lactate oral conc 2 mg/ml 2 PAhaloperidol tab 0.5 mg 2 PAhaloperidol tab 1 mg 2 PAhaloperidol tab 2 mg 2 PAhaloperidol tab 5 mg 2 PAhaloperidol tab 10 mg 2 PAhaloperidol tab 20 mg 2 PAINVEGA SUSTENNA - paliperidone palmitate er susp pref syr

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

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

5 PA, QL (1 kit/28 days)



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




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








LATUDA - lurasidone hcl tab 20 mg 5 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 40 mg 5 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 60 mg 5 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 80 mg 5 PA, QL (60 tablets/30 days)LATUDA - lurasidone hcl tab 120 mg 5 PA, QL (30 tablets/30 days)loxapine succinate cap 5 mg 2 PAloxapine succinate cap 10 mg 2 PAloxapine succinate cap 25 mg 2 PAloxapine succinate cap 50 mg 2 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 5 mg 4 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 10 mg 4 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 25 mg 4 PANUPLAZID - pimavanserin tartrate cap 34 mg* 5 PA, QL (30 capsules/30 days)NUPLAZID - pimavanserin tartrate tab 10 mg* 5 PA, QL (30 tablets/30 days)

2019


43

Drug Name Drug Tier Requirements/Limitsolanzapine for im inj 10 mg 3 PA, QL (90 vials/30 days)olanzapine orally disintegrating tab 5 mg 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 10 mg 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 15 mg 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 20 mg 2 PA, QL (30 tablets/30 days)olanzapine tab 2.5 mg 2 PA, QL (45 tablets/30 days)olanzapine tab 5 mg 2 PA, QL (45 tablets/30 days)olanzapine tab 7.5 mg 2 PA, QL (45 tablets/30 days)olanzapine tab 10 mg 2 PA, QL (45 tablets/30 days)olanzapine tab 15 mg 2 PA, QL (30 tablets/30 days)olanzapine tab 20 mg 2 PA, QL (30 tablets/30 days)paliperidone tab er 24hr 1.5 mg 4 PA, QL (30 tablets/30 days)paliperidone tab er 24hr 3 mg 4 PA, QL (30 tablets/30 days)paliperidone tab er 24hr 6 mg 4 PA, QL (60 tablets/30 days)paliperidone tab er 24hr 9 mg 5 PA, QL (30 tablets/30 days)PERSERIS - risperidone subcutaneous for er susp prefilled syr

90 mg5 PA, QL (1 syringe/30 days)

PERSERIS - risperidone subcutaneous for er susp prefilled syr120 mg


pimozide tab 1 mg 3pimozide tab 2 mg 3quetiapine fumarate tab er 24hr 50 mg 3 PA, QL (60 tablets/30 days)quetiapine fumarate tab er 24hr 150 mg 3 PA, QL (30 tablets/30 days)quetiapine fumarate tab er 24hr 200 mg 3 PA, QL (30 tablets/30 days)quetiapine fumarate tab er 24hr 300 mg 3 PA, QL (60 tablets/30 days)quetiapine fumarate tab er 24hr 400 mg 3 PA, QL (60 tablets/30 days)quetiapine fumarate tab 25 mg 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 50 mg 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 100 mg 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 200 mg 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 300 mg 2 PA, QL (60 tablets/30 days)quetiapine fumarate tab 400 mg 2 PA, QL (60 tablets/30 days)REXULTI - brexpiprazole tab 0.25 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 0.5 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 1 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 2 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 3 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 4 mg 5 PA, QL (30 tablets/30 days)

2019


Drug Name Drug Tier Requirements/LimitsRISPERDAL CONSTA - risperidone microspheres for im extended

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

RISPERDAL CONSTA - risperidone microspheres for im extendedrel susp 25 mg

5 PA, QL (2 vials/28 days)

RISPERDAL CONSTA - risperidone microspheres for im extendedrel susp 37.5 mg


RISPERDAL CONSTA - risperidone microspheres for im extendedrel susp 50 mg


risperidone orally disintegrating tab 0.25 mg 3 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 0.5 mg 3 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 1 mg 3 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 2 mg 3 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 3 mg 3 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 4 mg 3 PA, QL (120 tablets/30 days)risperidone soln 1 mg/ml 2 PA, QL (480 mls/30 days)risperidone tab 0.25 mg 2 PA, QL (60 tablets/30 days)risperidone tab 0.5 mg 2 PA, QL (60 tablets/30 days)risperidone tab 1 mg 2 PA, QL (60 tablets/30 days)risperidone tab 2 mg 2 PA, QL (60 tablets/30 days)risperidone tab 3 mg 2 PA, QL (60 tablets/30 days)risperidone tab 4 mg 2 PA, QL (120 tablets/30 days)SAPHRIS - asenapine maleate sl tab 2.5 mg 4 PA, QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 5 mg 4 PA, QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 10 mg 4 PA, QL (60 tablets/30 days)thioridazine hcl tab 10 mg 3 PAthioridazine hcl tab 25 mg 3 PAthioridazine hcl tab 50 mg 3 PAthioridazine hcl tab 100 mg 3 PAthiothixene cap 1 mg 2 PAthiothixene cap 2 mg 2 PAthiothixene cap 5 mg 2 PAthiothixene cap 10 mg 2 PAtrifluoperazine hcl tab 1 mg 2 PAtrifluoperazine hcl tab 2 mg 2 PAtrifluoperazine hcl tab 5 mg 2 PAtrifluoperazine hcl tab 10 mg 2 PAVERSACLOZ - clozapine susp 50 mg/ml 5 PA, QL (540 mls/30 days)VRAYLAR - cariprazine hcl cap 1.5 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 3 mg 5 PA, QL (30 capsules/30 days)

2019


45

Drug Name Drug Tier Requirements/LimitsVRAYLAR - cariprazine hcl cap 4.5 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 6 mg 5 PA, QL (30 capsules/30 days)ziprasidone hcl cap 20 mg 2 PA, QL (90 capsules/30 days)ziprasidone hcl cap 40 mg 2 PA, QL (90 capsules/30 days)ziprasidone hcl cap 60 mg 2 PA, QL (60 capsules/30 days)ziprasidone hcl cap 80 mg 2 PA, QL (60 capsules/30 days)ZYPREXA RELPREVV - olanzapine pamoate for extended rel im

susp 210 mg5 PA, QL (2 vials/28 days)

ZYPREXA RELPREVV - olanzapine pamoate for extended rel imsusp 300 mg


ZYPREXA RELPREVV - olanzapine pamoate for extended rel imsusp 405 mg

5 PA, QL (1 vial/28 days)

Antispasticity Agentsbaclofen tab 10 mg 1baclofen tab 20 mg 1dantrolene sodium cap 25 mg 2dantrolene sodium cap 50 mg 2dantrolene sodium cap 100 mg 2tizanidine hcl cap 2 mg 2tizanidine hcl cap 4 mg 2tizanidine hcl cap 6 mg 2tizanidine hcl tab 2 mg 1tizanidine hcl tab 4 mg 1Antiviralsabacavir sulfate soln 20 mg/ml 3 QL (960 mls/30 days)abacavir sulfate tab 300 mg 3 QL (60 tablets/30 days)abacavir sulfate-lamivudine tab 600-300 mg 3 QL (30 tablets/30 days)abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg 5 QL (60 tablets/30 days)acyclovir cap 200 mg 2acyclovir oint 5% 4acyclovir sodium iv soln 50 mg/ml 3 BDacyclovir susp 200 mg/5ml 3acyclovir tab 400 mg 2acyclovir tab 800 mg 2adefovir dipivoxil tab 10 mg 5APTIVUS - tipranavir cap 250 mg 5 QL (120 capsules/30 days)APTIVUS - tipranavir oral soln 100 mg/ml 5 QL (380 mls/30 days)atazanavir sulfate cap 150 mg 5 QL (30 capsules/30 days)atazanavir sulfate cap 200 mg 5 QL (60 capsules/30 days)atazanavir sulfate cap 300 mg 5 QL (30 capsules/30 days)

2019


Drug Name Drug Tier Requirements/LimitsATRIPLA - efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg 5 QL (30 tablets/30 days)BARACLUDE - entecavir oral soln 0.05 mg/ml 5BIKTARVY - bictegravir-emtricitabine-tenofovir af tab 50-200-25 mg 5 QL (30 tablets/30 days)cidofovir iv inj 75 mg/ml 5CIMDUO - lamivudine-tenofovir disoproxil fumarate tab 300-300 mg 5 QL (30 tablets/30 days)COMPLERA - emtricitabine-rilpivirine-tenofovir df tab

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

CRIXIVAN - indinavir sulfate cap 200 mg 3 QL (270 capsules/30 days)CRIXIVAN - indinavir sulfate cap 400 mg 3 QL (180 capsules/30 days)DELSTRIGO - doravirine-lamivudine-tenofovir df tab

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

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

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

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

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

HARVONI - ledipasvir-sofosbuvir tab 45-200 mg 5 PAHARVONI - ledipasvir-sofosbuvir tab 90-400 mg 5 PA

2019


47

Drug Name Drug Tier Requirements/LimitsINTELENCE - etravirine tab 25 mg 4 QL (120 tablets/30 days)INTELENCE - etravirine tab 100 mg 5 QL (60 tablets/30 days)INTELENCE - etravirine tab 200 mg 5 QL (60 tablets/30 days)INTRON A - interferon alfa-2b inj 6000000 unit/ml 5INTRON A - interferon alfa-2b inj 10000000 unit/ml 5INTRON A - interferon alfa-2b for inj 10000000 unit 5INTRON A - interferon alfa-2b for inj 18000000 unit 5INTRON A - interferon alfa-2b for inj 50000000 unit 5INTRON A W/DILUENT - interferon alfa-2b for inj 10000000 unit 5INTRON A W/DILUENT - interferon alfa-2b for inj 18000000 unit 5INTRON A W/DILUENT - interferon alfa-2b for inj 50000000 unit 5INVIRASE - saquinavir mesylate tab 500 mg 5 QL (120 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 25 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 100 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium packet for susp 100 mg 4 QL (60 packets/30 days)ISENTRESS - raltegravir potassium tab 400 mg 5 QL (60 tablets/30 days)ISENTRESS HD - raltegravir potassium tab 600 mg 5 QL (60 tablets/30 days)JULUCA - dolutegravir sodium-rilpivirine hcl tab 50-25 mg 5 QL (30 tablets/30 days)KALETRA - lopinavir-ritonavir tab 100-25 mg 5 QL (300 tablets/30 days)KALETRA - lopinavir-ritonavir tab 200-50 mg 5 QL (120 tablets/30 days)lamivudine oral soln 10 mg/ml 3 QL (960 mls/30 days)lamivudine tab 100 mg (hbv) 3lamivudine tab 150 mg 2 QL (60 tablets/30 days)lamivudine tab 300 mg 2 QL (30 tablets/30 days)lamivudine-zidovudine tab 150-300 mg 3 QL (60 tablets/30 days)LEXIVA - fosamprenavir calcium susp 50 mg/ml 4 QL (1800 mls/30 days)LEXIVA - fosamprenavir calcium tab 700 mg 5 QL (120 tablets/30 days)lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 5 QL (480 mls/30 days)MAVYRET - glecaprevir-pibrentasvir tab 100-40 mg 5 PAnevirapine susp 50 mg/5ml 3 QL (1200 mls/30 days)nevirapine tab er 24hr 100 mg 3 QL (90 tablets/30 days)nevirapine tab er 24hr 400 mg 3 QL (30 tablets/30 days)nevirapine tab 200 mg 2 QL (60 tablets/30 days)NORVIR - ritonavir oral soln 80 mg/ml 4 QL (480 mls/30 days)NORVIR - ritonavir powder packet 100 mg 4 QL (360 packets/30 days)ODEFSEY - emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg 5 QL (30 tablets/30 days)oseltamivir phosphate cap 30 mg 3oseltamivir phosphate cap 45 mg 3

2019


Drug Name Drug Tier Requirements/Limitsoseltamivir phosphate cap 75 mg 3oseltamivir phosphate for susp 6 mg/ml 2PEGASYS - peginterferon alfa-2a inj 180 mcg/ml 5 PAPEGASYS - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PAPEGASYS PROCLICK - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PAPIFELTRO - doravirine tab 100 mg 5 QL (30 tablets/30 days)PREVYMIS - letermovir tab 240 mg 5PREVYMIS - letermovir tab 480 mg 5PREZCOBIX - darunavir-cobicistat tab 800-150 mg 5 QL (30 tablets/30 days)PREZISTA - darunavir ethanolate susp 100 mg/ml 5 QL (400 mls/30 days)PREZISTA - darunavir ethanolate tab 75 mg 4 QL (300 tablets/30 days)PREZISTA - darunavir ethanolate tab 150 mg 4 QL (180 tablets/30 days)PREZISTA - darunavir ethanolate tab 600 mg 5 QL (60 tablets/30 days)PREZISTA - darunavir ethanolate tab 800 mg 5 QL (30 tablets/30 days)RELENZA DISKHALER - zanamivir aero powder breath activated

5 mg/blister4

RESCRIPTOR - delavirdine mesylate tab 200 mg 4 QL (180 tablets/30 days)RETROVIR IV INFUSION - zidovudine iv soln 10 mg/ml 4REYATAZ - atazanavir sulfate cap 150 mg 5 QL (30 capsules/30 days)REYATAZ - atazanavir sulfate cap 200 mg 5 QL (60 capsules/30 days)REYATAZ - atazanavir sulfate cap 300 mg 5 QL (30 capsules/30 days)REYATAZ - atazanavir sulfate oral powder packet 50 mg 5 QL (240 packets/30 days)ribavirin cap 200 mg 3ribavirin tab 200 mg 3ritonavir tab 100 mg 3 QL (360 tablets/30 days)SELZENTRY - maraviroc oral soln 20 mg/ml 5 QL (1840 mls/30 days)SELZENTRY - maraviroc tab 25 mg 4 QL (240 tablets/30 days)SELZENTRY - maraviroc tab 75 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 150 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 300 mg 5 QL (120 tablets/30 days)SOVALDI - sofosbuvir tab 400 mg 5 PAstavudine cap 15 mg 2 QL (60 capsules/30 days)stavudine cap 20 mg 2 QL (60 capsules/30 days)stavudine cap 30 mg 2 QL (60 capsules/30 days)stavudine cap 40 mg 2 QL (60 capsules/30 days)STRIBILD - elvitegrav-cobic-emtricitab-tenofovdf tab


SUSTIVA - efavirenz cap 50 mg 4 QL (90 capsules/30 days)SUSTIVA - efavirenz cap 200 mg 5 QL (60 capsules/30 days)

2019


49

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


TAMIFLU - oseltamivir phosphate for susp 6 mg/ml 4tenofovir disoproxil fumarate tab 300 mg 5 QL (30 tablets/30 days)TIVICAY - dolutegravir sodium tab 10 mg 4 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 25 mg 5 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 50 mg 5 QL (60 tablets/30 days)TRIUMEQ - abacavir-dolutegravir-lamivudine tab 600-50-300 mg 5 QL (30 tablets/30 days)TROGARZO - ibalizumab-uiyk iv soln 200 mg/1.33ml (150 mg/ml) 5 QL (14 vials/28 days)TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab


TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab133-200 mg

5 QL (30 tablets/30 days)





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

& 250 mg5 PA

VIRACEPT - nelfinavir mesylate tab 250 mg 5 QL (270 tablets/30 days)VIRACEPT - nelfinavir mesylate tab 625 mg 5 QL (120 tablets/30 days)VIRAMUNE - nevirapine susp 50 mg/5ml 4 QL (1200 mls/30 days)VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/gm 5 QL (240 grams/30 days)VIREAD - tenofovir disoproxil fumarate tab 150 mg 5 QL (30 tablets/30 days)

2019


Drug Name Drug Tier Requirements/LimitsVIREAD - tenofovir disoproxil fumarate tab 200 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 250 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 300 mg 5 QL (30 tablets/30 days)VOSEVI - sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mg 5 PAXOFLUZA - baloxavir marboxil tab therapy pack 20 (2) mg (40 mg

dose)4

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

4

ZEPATIER - elbasvir-grazoprevir tab 50-100 mg 5 PAZIAGEN - abacavir sulfate soln 20 mg/ml 4 QL (960 mls/30 days)zidovudine cap 100 mg 2 QL (180 capsules/30 days)zidovudine syrup 10 mg/ml 3 QL (1920 mls/30 days)zidovudine tab 300 mg 2 QL (60 tablets/30 days)Anxiolyticsalprazolam tab 0.25 mg 4 QL (120 tablets/30 days)alprazolam tab 0.5 mg 4 QL (120 tablets/30 days)alprazolam tab 1 mg 4 QL (120 tablets/30 days)alprazolam tab 2 mg 4 QL (150 tablets/30 days)buspirone hcl tab 5 mg 2buspirone hcl tab 7.5 mg 2buspirone hcl tab 10 mg 2buspirone hcl tab 15 mg 2buspirone hcl tab 30 mg 2chlordiazepoxide hcl cap 5 mg 3 PA, QL (120 capsules/30 days)chlordiazepoxide hcl cap 10 mg 3 PA, QL (120 capsules/30 days)chlordiazepoxide hcl cap 25 mg 3 PA, QL (360 capsules/30 days)clonazepam orally disintegrating tab 0.125 mg 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.25 mg 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.5 mg 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 1 mg 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 2 mg 2 PA, QL (300 tablets/30 days)clonazepam tab 0.5 mg 2 PA, QL (120 tablets/30 days)clonazepam tab 1 mg 2 PA, QL (120 tablets/30 days)clonazepam tab 2 mg 2 PA, QL (300 tablets/30 days)clorazepate dipotassium tab 3.75 mg 2 PA, QL (120 tablets/30 days)clorazepate dipotassium tab 7.5 mg 2 PA, QL (360 tablets/30 days)clorazepate dipotassium tab 15 mg 2 PA, QL (180 tablets/30 days)DIAZEPAM - diazepam oral soln 1 mg/ml 3 PA, QL (1200 mls/30 days)diazepam conc 5 mg/ml 2 PA, QL (240 mls/30 days)

2019


51

Drug Name Drug Tier Requirements/Limitsdiazepam tab 2 mg 2 PA, QL (120 tablets/30 days)diazepam tab 5 mg 2 PA, QL (120 tablets/30 days)diazepam tab 10 mg 2 PA, QL (120 tablets/30 days)hydroxyzine hcl syrup 10 mg/5ml# 3 PAhydroxyzine hcl tab 10 mg# 3 PAhydroxyzine hcl tab 25 mg# 3 PAhydroxyzine hcl tab 50 mg# 3 PAlorazepam tab 0.5 mg 2 PA, QL (120 tablets/30 days)lorazepam tab 1 mg 2 PA, QL (120 tablets/30 days)lorazepam tab 2 mg 2 PA, QL (150 tablets/30 days)Bipolar AgentsLITHIUM - lithium oral solution 8 meq/5ml 3lithium carbonate cap 150 mg 2lithium carbonate cap 300 mg 2lithium carbonate cap 600 mg 2lithium carbonate tab er 300 mg 2lithium carbonate tab er 450 mg 2lithium carbonate tab 300 mg 2Blood Glucose Regulatorsacarbose tab 25 mg 2 QL (360 tablets/30 days)acarbose tab 50 mg 2 QL (180 tablets/30 days)acarbose tab 100 mg 2 QL (90 tablets/30 days)ACTOS - pioglitazone hcl tab 15 mg 4 QL (90 tablets/30 days)ACTOS - pioglitazone hcl tab 30 mg 4 QL (30 tablets/30 days)ACTOS - pioglitazone hcl tab 45 mg 4 QL (30 tablets/30 days)ALCOHOL SWABS 3AMARYL - glimepiride tab 1 mg 4 QL (240 tablets/30 days)AMARYL - glimepiride tab 2 mg 4 QL (120 tablets/30 days)AMARYL - glimepiride tab 4 mg 4 QL (60 tablets/30 days)ASSURE ID INSULIN SAFETY SYRINGE/U-100/0.5ML/29G X 1/2" 3ASSURE ID INSULIN SAFETY SYRINGE/U-100/1ML/29G X 1/2" 3ASSURE ID SAFETY PEN NEEDLES 31G X 5MM (1/5" OR 3/16") 3BD SAFETYGLIDE INSULIN SYRINGE/0.3ML/31G X 15/64" 3BD SAFETYGLIDE INSULIN SYRINGE/0.5ML/31G X 15/64" 3BD SAFETYGLIDE INSULIN SYRINGE/1ML/31G X 15/64" 3BYDUREON BCISE - exenatide extended release susp auto-

injector 2 mg/0.85ml3 QL (4 pens/28 days), ST

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

3 QL (4 pens/28 days), ST

2019


Drug Name Drug Tier Requirements/LimitsCYCLOSET - bromocriptine mesylate tab 0.8 mg 4 QL (180 tablets/30 days)EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML/30G

X 1/2"3

EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/0.5ML/29G X1/2"

3

EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/1ML/30G X1/2"

3

EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE1ML/29G X 1/2"

3

EASY TOUCH SHEATHLOCK SAFETY SYRINGE 1ML/30G X 1/2" 3GAUZE PADS 2" X 2" 3glimepiride tab 1 mg 1 QL (240 tablets/30 days)glimepiride tab 2 mg 1 QL (120 tablets/30 days)glimepiride tab 4 mg 1 QL (60 tablets/30 days)glipizide tab er 24hr 2.5 mg 1 QL (240 tablets/30 days)glipizide tab er 24hr 5 mg 1 QL (120 tablets/30 days)glipizide tab er 24hr 10 mg 1 QL (60 tablets/30 days)glipizide tab 5 mg 1 QL (240 tablets/30 days)glipizide tab 10 mg 1 QL (120 tablets/30 days)glipizide-metformin hcl tab 2.5-250 mg 2 QL (240 tablets/30 days)glipizide-metformin hcl tab 2.5-500 mg 2 QL (120 tablets/30 days)glipizide-metformin hcl tab 5-500 mg 2 QL (120 tablets/30 days)GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg 4 QL (4 kits/30 days)GLUCAGON EMERGENCY KIT - glucagon (rdna) for inj kit 1 mg 4 QL (4 kits/30 days)GLUCOPHAGE - metformin hcl tab 500 mg 4 QL (150 tablets/30 days)GLUCOPHAGE - metformin hcl tab 850 mg 4 QL (90 tablets/30 days)GLUCOPHAGE - metformin hcl tab 1000 mg 4 QL (75 tablets/30 days)GLUCOPHAGE XR - metformin hcl tab er 24hr 500 mg 4 QL (120 tablets/30 days)GLUCOPHAGE XR - metformin hcl tab er 24hr 750 mg 4 QL (60 tablets/30 days)GLUCOTROL - glipizide tab 5 mg 4 QL (240 tablets/30 days)GLUCOTROL - glipizide tab 10 mg 4 QL (120 tablets/30 days)GLUCOTROL XL - glipizide tab er 24hr 2.5 mg 4 QL (240 tablets/30 days)GLUCOTROL XL - glipizide tab er 24hr 5 mg 4 QL (120 tablets/30 days)GLUCOTROL XL - glipizide tab er 24hr 10 mg 4 QL (60 tablets/30 days)GLYXAMBI - empagliflozin-linagliptin tab 10-5 mg 4 QL (30 tablets/30 days)GLYXAMBI - empagliflozin-linagliptin tab 25-5 mg 4 QL (30 tablets/30 days)HUMALOG - insulin lispro inj 100 unit/ml 2 QL (60 mls/30 days)HUMALOG - insulin lispro soln cartridge 100 unit/ml 2 QL (20 cartridges/30 days)HUMALOG JUNIOR KWIKPEN - insulin lispro soln pen-injector 100

unit/ml (0.5 unit dial)2 QL (20 pens/30 days)

2019


53

Drug Name Drug Tier Requirements/LimitsHUMALOG KWIKPEN - insulin lispro soln pen-injector 100 unit/ml

(1 unit dial)2 QL (20 pens/30 days)

HUMALOG KWIKPEN - insulin lispro soln pen-injector 200 unit/ml 2 QL (20 pens/30 days)HUMALOG MIX 50/50 - insulin lispro protamine & lispro inj 100

unit/ml (50-50)2 QL (6 vials/30 days)

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

2 QL (20 pens/30 days)

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

2 QL (6 vials/30 days)

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


HUMULIN N - insulin nph (human) (isophane) inj 100 unit/ml 2 QL (60 mls/30 days)HUMULIN N KWIKPEN - insulin nph (human) (isophane) susp pen-

injector 100 unit/ml2 QL (20 pens/30 days)

HUMULIN R - insulin regular (human) inj 100 unit/ml 2 QL (60 mls/30 days)HUMULIN R U-500 (CONCENTRATE) - insulin regular (human) inj

500 unit/ml2 BD

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


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

2 QL (60 mls/30 days)

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


INJECTION DEVICE FOR INSULIN 3INSULIN PEN NEEDLE 29G X 12.7MM (1/2") 3INSULIN PEN NEEDLE 29G X 5MM (1/5" OR 3/16") 3INSULIN PEN NEEDLE 29G X 8MM (1/3" OR 5/16") 3INSULIN PEN NEEDLE 30G X 5MM (1/5" OR 3/16") 3INSULIN PEN NEEDLE 30G X 8MM (1/3" OR 5/16") 3INSULIN PEN NEEDLE 31G X 4MM (1/6" OR 5/32") 3INSULIN PEN NEEDLE 32G X 5MM (1/5" OR 3/16") 3INSULIN PEN NEEDLE 33G X 4MM (1/6" OR 5/32") 3INSULIN PEN NEEDLE 33G X 5MM (1/5" OR 3/16") 3INSULIN PEN NEEDLE 33G X 6MM (1/4" OR 15/64") 3INSULIN PEN NEEDLE 33G X 8MM (1/3" OR 5/16") 3INSULIN SYRINGE (DISP) U-100/0.3ML 3INSULIN SYRINGE (DISP) U-100/0.5ML 3INSULIN SYRINGE (DISP) U-100/1ML 3INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 15/64" 3INSULIN SYRINGE/NEEDLE U-100 0.5 ML 30 X 15/64" 3INSULIN SYRINGE/NEEDLE U-100 0.5 ML 32 X 5/16" 3

2019


Drug Name Drug Tier Requirements/LimitsINSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 15/64" 3INSULIN SYRINGE/NEEDLE U-100 1 ML 32 X 5/16" 3INSULIN SYRINGE/NEEDLE U-100/0.3ML/28G X 1/2" 3INSULIN SYRINGE/NEEDLE U-100/0.3ML/29G 3INSULIN SYRINGE/NEEDLE U-100/0.3ML/29G X 1" 3INSULIN SYRINGE/NEEDLE U-100/0.3ML/30G 3INSULIN SYRINGE/NEEDLE U-100/0.3ML/31G X 1/4" (6MM) 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/27G X 1/2" 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/28G X 5/16" 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/29G 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/29G X 5/16" 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/30G 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/30G X 3/16" (5MM) 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/30G X 3/8" 3INSULIN SYRINGE/NEEDLE U-100/0.5ML/31G X 1/4" (6MM) 3INSULIN SYRINGE/NEEDLE U-100/1ML/25G X 1" 3INSULIN SYRINGE/NEEDLE U-100/1ML/25G X 5/8" 3INSULIN SYRINGE/NEEDLE U-100/1ML/26G X 1/2" 3INSULIN SYRINGE/NEEDLE U-100/1ML/27G X 1/2" 3INSULIN SYRINGE/NEEDLE U-100/1ML/27G X 5/8" 3INSULIN SYRINGE/NEEDLE U-100/1ML/28G X 5/16" 3INSULIN SYRINGE/NEEDLE U-100/1ML/29G X 5/16" 3INSULIN SYRINGE/NEEDLE U-100/1ML/30G 3INSULIN SYRINGE/NEEDLE U-100/1ML/30G X 3/16" (5MM) 3INSULIN SYRINGE/NEEDLE U-100/1ML/31G X 1/4" (6MM) 3INSULIN SYRINGE/NEEDLE U-100/2ML/27.5G X 5/8" 3INSULIN SYRINGE/NEEDLE U-40/1ML/25G X 5/8" 3INSULIN SYRINGE/NEEDLE U-500/0.5ML/31G X 6MM (15/64") 3INVOKAMET - canagliflozin-metformin hcl tab 50-500 mg 3 QL (120 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-500 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-1000 mg 3 QL (60 tablets/30 days)INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr


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


INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr150-500 mg


2019


55

Drug Name Drug Tier Requirements/LimitsINVOKAMET XR - canagliflozin-metformin hcl tab er 24hr


INVOKANA - canagliflozin tab 100 mg 3 QL (90 tablets/30 days)INVOKANA - canagliflozin tab 300 mg 3 QL (30 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-500 mg 3 QL (60 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-500 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 100-1000 mg 3 QL (30 tablets/30 days)JANUVIA - sitagliptin phosphate tab 25 mg 3 QL (120 tablets/30 days)JANUVIA - sitagliptin phosphate tab 50 mg 3 QL (60 tablets/30 days)JANUVIA - sitagliptin phosphate tab 100 mg 3 QL (30 tablets/30 days)JARDIANCE - empagliflozin tab 10 mg 3 QL (60 tablets/30 days)JARDIANCE - empagliflozin tab 25 mg 3 QL (30 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-500 mg 4 QL (60 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-850 mg 4 QL (60 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-1000 mg 4 QL (60 tablets/30 days)JENTADUETO XR - linagliptin-metformin hcl tab er 24hr

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

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

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

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


LANTUS - insulin glargine inj 100 unit/ml 2 QL (6 vials/30 days)LANTUS SOLOSTAR - insulin glargine soln pen-injector 100 unit/ml 2 QL (20 pens/30 days)LEVEMIR - insulin detemir inj 100 unit/ml 2 QL (6 vials/30 days)LEVEMIR FLEXTOUCH - insulin detemir soln pen-injector 100 unit/

ml2 QL (20 pens/30 days)

metformin hcl tab er 24hr 500 mg 1 QL (120 tablets/30 days)metformin hcl tab er 24hr 750 mg 1 QL (60 tablets/30 days)metformin hcl tab 500 mg 1 QL (150 tablets/30 days)metformin hcl tab 850 mg 1 QL (90 tablets/30 days)metformin hcl tab 1000 mg 1 QL (75 tablets/30 days)miglitol tab 25 mg 3 QL (360 tablets/30 days)miglitol tab 50 mg 3 QL (180 tablets/30 days)miglitol tab 100 mg 3 QL (90 tablets/30 days)MONOJECT INSULIN SYRINGE/SAFETY/PERM

NEEDLE/0.3ML/29G X 1/2"3

2019


Drug Name Drug Tier Requirements/LimitsMONOJECT INSULIN SYRINGE/SAFETY/PERM

NEEDLE/0.5ML/29G X 1/2"3

MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/1ML/29G X 1/2"

3

nateglinide tab 60 mg 2 QL (180 tablets/30 days)nateglinide tab 120 mg 2 QL (90 tablets/30 days)ONGLYZA - saxagliptin hcl tab 2.5 mg 3 QL (60 tablets/30 days)ONGLYZA - saxagliptin hcl tab 5 mg 3 QL (30 tablets/30 days)OZEMPIC - semaglutide soln pen-inj 0.25 or 0.5 mg/dose

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

OZEMPIC - semaglutide soln pen-inj 1 mg/dose (2 mg/1.5ml) 3 QL (2 pens/28 days), STpioglitazone hcl tab 15 mg 1 QL (90 tablets/30 days)pioglitazone hcl tab 30 mg 1 QL (30 tablets/30 days)pioglitazone hcl tab 45 mg 1 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-2 mg 2 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-4 mg 2 QL (30 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-500 mg 2 QL (90 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-850 mg 2 QL (90 tablets/30 days)PRECOSE - acarbose tab 25 mg 4 QL (360 tablets/30 days)PRECOSE - acarbose tab 50 mg 4 QL (180 tablets/30 days)PRECOSE - acarbose tab 100 mg 4 QL (90 tablets/30 days)PREVENT SAFETY PEN NEEDLES 31G X 1/4" 3PREVENT SAFETY PEN NEEDLES 31G X 5/16" 3PROGLYCEM - diazoxide susp 50 mg/ml 3repaglinide tab 0.5 mg 2 QL (960 tablets/30 days)repaglinide tab 1 mg 2 QL (480 tablets/30 days)repaglinide tab 2 mg 2 QL (240 tablets/30 days)SAFETY INSULIN SYRINGES 1ML/30G X 1/2" 3STARLIX - nateglinide tab 60 mg 4 QL (180 tablets/30 days)STARLIX - nateglinide tab 120 mg 4 QL (90 tablets/30 days)SYMLINPEN 120 - pramlintide acetate pen-inj 2700 mcg/2.7ml

(1000 mcg/ml)5

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

5

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


2019


57

Drug Name Drug Tier Requirements/LimitsSYNJARDY XR - empagliflozin-metformin hcl tab er 24hr


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


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


TECHLITE INSULIN SYRINGE U-100/0.3ML/29G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/0.3ML/30G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/0.3ML/30G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/0.3ML/31G X 15/64" 3TECHLITE INSULIN SYRINGE U-100/0.3ML/31G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/0.5ML/29G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/0.5ML/30G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/0.5ML/30G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/0.5ML/31G X 15/64" 3TECHLITE INSULIN SYRINGE U-100/0.5ML/31G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/1ML/29G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/1ML/30G X 1/2" 3TECHLITE INSULIN SYRINGE U-100/1ML/30G X 5/16" 3TECHLITE INSULIN SYRINGE U-100/1ML/31G X 15/64" 3TECHLITE INSULIN SYRINGE U-100/1ML/31G X 5/16" 3TECHLITE PEN NEEDLES 29G X 10MM 3TECHLITE PEN NEEDLES 29G X 12MM 3TECHLITE PEN NEEDLES 31G X 5MM 3TECHLITE PEN NEEDLES/31G X 6MM 3TECHLITE PEN NEEDLES/31G X 8MM 3TECHLITE PEN NEEDLES/32G X 4MM 3TECHLITE PEN NEEDLES/32G X 6MM 3TECHLITE PEN NEEDLES/32G X 8MM 3TOUJEO MAX SOLOSTAR - insulin glargine soln pen-injector 300

unit/ml (2 unit dial)2 QL (60 mls/30 days)

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

2 QL (60 mls/30 days)

TRADJENTA - linagliptin tab 5 mg 4 QL (30 tablets/30 days)TRESIBA - insulin degludec inj 100 unit/ml 2 QL (6 vials/30 days)TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 100

unit/ml2 QL (20 pens/30 days)

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


TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 3

2019


Drug Name Drug Tier Requirements/LimitsTRUEPLUS INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" 3TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 3TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/1ML/28G X 1/2" 3TRUEPLUS INSULIN SYRINGE/U-100/1ML/29G X 1/2" 3TRUEPLUS INSULIN SYRINGE/U-100/1ML/30G X 5/16" 3TRUEPLUS INSULIN SYRINGE/U-100/1ML/31G X 5/16" 3TRUEPLUS PEN NEEDLES 29G X 12MM 3TRUEPLUS PEN NEEDLES 31G X 5MM 3TRUEPLUS PEN NEEDLES 31G X 6MM 3TRUEPLUS PEN NEEDLES 31G X 8MM 3TRUEPLUS PEN NEEDLES 32G X 4MM 3TRUEPLUS 5-BEVEL PEN NEEDLES 31GX5MM 3TRUEPLUS 5-BEVEL PEN NEEDLES 31GX6MM 3TRUEPLUS 5-BEVEL PEN NEEDLES 31GX8MM 3TRUEPLUS 5-BEVEL PEN NEEDLES 32GX4MM 3TRULICITY - dulaglutide soln pen-injector 0.75 mg/0.5ml 3 QL (4 pens/28 days), STTRULICITY - dulaglutide soln pen-injector 1.5 mg/0.5ml 3 QL (4 pens/28 days), STULTICARE INSULIN SAFETY SYRINGE/0.5ML/29G X 1/2" 3ULTICARE INSULIN SAFETY SYRINGE/1ML/29G X 1/2" 3VANISHPOINT INSULIN SYRINGE/0.5ML/30G X 1/2" 3VICTOZA - liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) 3 QL (1 package/30 days), STBlood Products/Modifiers/Volume Expandersanagrelide hcl cap 0.5 mg 3anagrelide hcl cap 1 mg 3ARANESP ALBUMIN FREE - darbepoetin alfa soln inj 25 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 40 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 60 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 100 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 200 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 300 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe

10 mcg/0.4ml4 PA

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

4 PA

2019


59

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

40 mcg/0.4ml4 PA


5 PA


5 PA


5 PA


5 PA


5 PA

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

5 PA

aspirin-dipyridamole cap er 12hr 25-200 mg 3azacitidine for inj 100 mg 5BEVYXXA - betrixaban maleate cap 40 mg 4 QL (43 capsules/42 days)BEVYXXA - betrixaban maleate cap 80 mg 4 QL (43 capsules/42 days)BRILINTA - ticagrelor tab 60 mg 3BRILINTA - ticagrelor tab 90 mg 3cilostazol tab 50 mg 1cilostazol tab 100 mg 1clopidogrel bisulfate tab 75 mg 2clopidogrel bisulfate tab 300 mg 3COUMADIN - warfarin sodium tab 1 mg 4COUMADIN - warfarin sodium tab 2 mg 4COUMADIN - warfarin sodium tab 2.5 mg 4COUMADIN - warfarin sodium tab 3 mg 4COUMADIN - warfarin sodium tab 4 mg 4COUMADIN - warfarin sodium tab 5 mg 4COUMADIN - warfarin sodium tab 6 mg 4COUMADIN - warfarin sodium tab 7.5 mg 4COUMADIN - warfarin sodium tab 10 mg 4dipyridamole tab 25 mg# 3dipyridamole tab 50 mg# 3dipyridamole tab 75 mg# 3ELIQUIS - apixaban tab 2.5 mg 3 QL (60 tablets/30 days)ELIQUIS - apixaban tab 5 mg 3 QL (74 tablets/30 days)ELIQUIS STARTER PACK - apixaban tab 5 mg 3 QL (74 tablets/30 days)enoxaparin sodium inj 30 mg/0.3ml 4 QL (30 syringes/90 days)

2019


Drug Name Drug Tier Requirements/Limitsenoxaparin sodium inj 40 mg/0.4ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 60 mg/0.6ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 80 mg/0.8ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 100 mg/ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 120 mg/0.8ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 150 mg/ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 300 mg/3ml 4 QL (10 vials/90 days)EPOGEN - epoetin alfa inj 2000 unit/ml 4 PAEPOGEN - epoetin alfa inj 3000 unit/ml 4 PAEPOGEN - epoetin alfa inj 4000 unit/ml 4 PAEPOGEN - epoetin alfa inj 10000 unit/ml 4 PAEPOGEN - epoetin alfa inj 20000 unit/ml 5 PAfondaparinux sodium subcutaneous inj 2.5 mg/0.5ml 4 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 5 mg/0.4ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 10 mg/0.8ml 5 QL (30 syringes/90 days)GRANIX - tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml 5GRANIX - tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml 5GRANIX - tbo-filgrastim subcutaneous inj 300 mcg/ml 5GRANIX - tbo-filgrastim subcutaneous inj 480 mcg/1.6ml (300 mcg/

ml)5

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

3

HEPARIN SODIUM - heparin sodium (porcine) pf inj 5000 unit/ml 3heparin sodium (porcine) inj 1000 unit/ml 3heparin sodium (porcine) inj 5000 unit/ml 3heparin sodium (porcine) inj 10000 unit/ml 3heparin sodium (porcine) inj 20000 unit/ml 3heparin sodium (porcine) pf inj 5000 unit/0.5ml 3heparin sodium (porcine)-dextrose iv sol 20000 unit/500ml-5% 3LEUKINE - sargramostim lyophilized for inj 250 mcg 5MOZOBIL - plerixafor subcutaneous inj 24 mg/1.2ml (20 mg/ml) 5NEULASTA - pegfilgrastim soln prefilled syringe 6 mg/0.6ml 5NEULASTA ONPRO KIT - pegfilgrastim soln prefilled syringe kit

6 mg/0.6ml5

NEUPOGEN - filgrastim inj 300 mcg/ml 5NEUPOGEN - filgrastim inj 480 mcg/1.6ml (300 mcg/ml) 5NEUPOGEN - filgrastim soln prefilled syringe 300 mcg/0.5ml 5

2019


61

Drug Name Drug Tier Requirements/LimitsNEUPOGEN - filgrastim soln prefilled syringe 480 mcg/0.8ml

(600 mcg/ml)5

PRADAXA - dabigatran etexilate mesylate cap 75 mg 4 QL (60 capsules/30 days)PRADAXA - dabigatran etexilate mesylate cap 110 mg 4 QL (71 capsules/90 days)PRADAXA - dabigatran etexilate mesylate cap 150 mg 4 QL (60 capsules/30 days)prasugrel hcl tab 5 mg 3prasugrel hcl tab 10 mg 3PROCRIT - epoetin alfa inj 2000 unit/ml 4 PAPROCRIT - epoetin alfa inj 3000 unit/ml 4 PAPROCRIT - epoetin alfa inj 4000 unit/ml 4 PAPROCRIT - epoetin alfa inj 10000 unit/ml 4 PAPROCRIT - epoetin alfa inj 20000 unit/ml 5 PAPROCRIT - epoetin alfa inj 40000 unit/ml 5 PAPROMACTA - eltrombopag olamine powder pack for susp 12.5 mg* 5 PAPROMACTA - eltrombopag olamine tab 12.5 mg* 5 PAPROMACTA - eltrombopag olamine tab 25 mg* 5 PAPROMACTA - eltrombopag olamine tab 50 mg* 5 PAPROMACTA - eltrombopag olamine tab 75 mg* 5 PARETACRIT - epoetin alfa-epbx inj 2000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 3000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 4000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 10000 unit/ml 4 PARETACRIT - epoetin alfa-epbx inj 40000 unit/ml 4 PAtranexamic acid iv soln 1000 mg/10ml (100 mg/ml) 3tranexamic acid tab 650 mg 3warfarin sodium tab 1 mg 2warfarin sodium tab 2 mg 2warfarin sodium tab 2.5 mg 2warfarin sodium tab 3 mg 2warfarin sodium tab 4 mg 2warfarin sodium tab 5 mg 2warfarin sodium tab 6 mg 2warfarin sodium tab 7.5 mg 2warfarin sodium tab 10 mg 2XARELTO - rivaroxaban tab 2.5 mg 3 QL (60 tablets/30 days)XARELTO - rivaroxaban tab 10 mg 3 QL (30 tablets/30 days)XARELTO - rivaroxaban tab 15 mg 3 QL (60 tablets/30 days)XARELTO - rivaroxaban tab 20 mg 3 QL (30 tablets/30 days)

2019


Drug Name Drug Tier Requirements/LimitsXARELTO STARTER PACK - rivaroxaban tab starter therapy pack

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

ZONTIVITY - vorapaxar sulfate tab 2.08 mg 4Cardiovascular AgentsACCUPRIL - quinapril hcl tab 5 mg 4ACCUPRIL - quinapril hcl tab 10 mg 4ACCUPRIL - quinapril hcl tab 20 mg 4ACCUPRIL - quinapril hcl tab 40 mg 4ACCURETIC - quinapril-hydrochlorothiazide tab 10-12.5 mg 4ACCURETIC - quinapril-hydrochlorothiazide tab 20-12.5 mg 4ACCURETIC - quinapril-hydrochlorothiazide tab 20-25 mg 4acebutolol hcl cap 200 mg 2acebutolol hcl cap 400 mg 2acetazolamide cap er 12hr 500 mg 3acetazolamide tab 125 mg 3acetazolamide tab 250 mg 3ADALAT CC - nifedipine tab er 24hr 30 mg 4ADALAT CC - nifedipine tab er 24hr 60 mg 4ADALAT CC - nifedipine tab er 24hr 90 mg 4ALDACTONE - spironolactone tab 25 mg 4ALDACTONE - spironolactone tab 50 mg 4ALDACTONE - spironolactone tab 100 mg 4aliskiren fumarate tab 150 mg 3 QL (30 tablets/30 days)aliskiren fumarate tab 300 mg 3 QL (30 tablets/30 days)ALTACE - ramipril cap 1.25 mg 4ALTACE - ramipril cap 2.5 mg 4ALTACE - ramipril cap 5 mg 4ALTACE - ramipril cap 10 mg 4amiloride & hydrochlorothiazide tab 5-50 mg 2amiloride hcl tab 5 mg 2amiodarone hcl tab 100 mg 3amiodarone hcl tab 200 mg 2amiodarone hcl tab 400 mg 3amlodipine besylate tab 2.5 mg 1amlodipine besylate tab 5 mg 1amlodipine besylate tab 10 mg 1amlodipine besylate-atorvastatin calcium tab 2.5-10 mg 3amlodipine besylate-atorvastatin calcium tab 2.5-20 mg 3amlodipine besylate-atorvastatin calcium tab 2.5-40 mg 3

2019


63

Drug Name Drug Tier Requirements/Limitsamlodipine besylate-atorvastatin calcium tab 5-10 mg 3amlodipine besylate-atorvastatin calcium tab 5-20 mg 3amlodipine besylate-atorvastatin calcium tab 5-40 mg 3amlodipine besylate-atorvastatin calcium tab 5-80 mg 3amlodipine besylate-atorvastatin calcium tab 10-10 mg 3amlodipine besylate-atorvastatin calcium tab 10-20 mg 3amlodipine besylate-atorvastatin calcium tab 10-40 mg 3amlodipine besylate-atorvastatin calcium tab 10-80 mg 3amlodipine besylate-benazepril hcl cap 2.5-10 mg 2amlodipine besylate-benazepril hcl cap 5-10 mg 2amlodipine besylate-benazepril hcl cap 5-20 mg 2amlodipine besylate-benazepril hcl cap 5-40 mg 2amlodipine besylate-benazepril hcl cap 10-20 mg 2amlodipine besylate-benazepril hcl cap 10-40 mg 2amlodipine besylate-olmesartan medoxomil tab 5-20 mg 2 QL (30 tablets/30 days)amlodipine besylate-olmesartan medoxomil tab 5-40 mg 2 QL (30 tablets/30 days)amlodipine besylate-olmesartan medoxomil tab 10-20 mg 2 QL (30 tablets/30 days)amlodipine besylate-olmesartan medoxomil tab 10-40 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 5-160 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 5-320 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-160 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-320 mg 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg 3 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg 3 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg 3 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg 3 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg 3 QL (30 tablets/30 days)ATACAND - candesartan cilexetil tab 4 mg 4 QL (60 tablets/30 days)ATACAND - candesartan cilexetil tab 8 mg 4 QL (60 tablets/30 days)ATACAND - candesartan cilexetil tab 16 mg 4 QL (60 tablets/30 days)ATACAND - candesartan cilexetil tab 32 mg 4 QL (30 tablets/30 days)ATACAND HCT - candesartan cilexetil-hydrochlorothiazide tab

16-12.5 mg4 QL (30 tablets/30 days)

ATACAND HCT - candesartan cilexetil-hydrochlorothiazide tab32-12.5 mg


ATACAND HCT - candesartan cilexetil-hydrochlorothiazide tab32-25 mg


atenolol & chlorthalidone tab 50-25 mg 2atenolol & chlorthalidone tab 100-25 mg 2

2019


Drug Name Drug Tier Requirements/Limitsatenolol tab 25 mg 1atenolol tab 50 mg 1atenolol tab 100 mg 1atorvastatin calcium tab 10 mg 1 QL (45 tablets/30 days)atorvastatin calcium tab 20 mg 1 QL (45 tablets/30 days)atorvastatin calcium tab 40 mg 1 QL (45 tablets/30 days)atorvastatin calcium tab 80 mg 1 QL (30 tablets/30 days)AVALIDE - irbesartan-hydrochlorothiazide tab 150-12.5 mg 4 QL (30 tablets/30 days)AVALIDE - irbesartan-hydrochlorothiazide tab 300-12.5 mg 4 QL (30 tablets/30 days)AVAPRO - irbesartan tab 75 mg 4 QL (30 tablets/30 days)AVAPRO - irbesartan tab 150 mg 4 QL (60 tablets/30 days)AVAPRO - irbesartan tab 300 mg 4 QL (30 tablets/30 days)AZOR - amlodipine besylate-olmesartan medoxomil tab 5-20 mg 4 QL (30 tablets/30 days)AZOR - amlodipine besylate-olmesartan medoxomil tab 5-40 mg 4 QL (30 tablets/30 days)AZOR - amlodipine besylate-olmesartan medoxomil tab 10-20 mg 4 QL (30 tablets/30 days)AZOR - amlodipine besylate-olmesartan medoxomil tab 10-40 mg 4 QL (30 tablets/30 days)benazepril & hydrochlorothiazide tab 5-6.25 mg 2benazepril & hydrochlorothiazide tab 10-12.5 mg 2benazepril & hydrochlorothiazide tab 20-12.5 mg 2benazepril & hydrochlorothiazide tab 20-25 mg 2benazepril hcl tab 5 mg 1benazepril hcl tab 10 mg 1benazepril hcl tab 20 mg 1benazepril hcl tab 40 mg 1BENICAR - olmesartan medoxomil tab 5 mg 4 QL (60 tablets/30 days)BENICAR - olmesartan medoxomil tab 20 mg 4 QL (30 tablets/30 days)BENICAR - olmesartan medoxomil tab 40 mg 4 QL (30 tablets/30 days)BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab


BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab40-12.5 mg


BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab40-25 mg


betaxolol hcl tab 10 mg 2betaxolol hcl tab 20 mg 2bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg 2bisoprolol & hydrochlorothiazide tab 5-6.25 mg 2bisoprolol & hydrochlorothiazide tab 10-6.25 mg 2bisoprolol fumarate tab 5 mg 2

2019


65

Drug Name Drug Tier Requirements/Limitsbisoprolol fumarate tab 10 mg 2bumetanide inj 0.25 mg/ml 3bumetanide tab 0.5 mg 2bumetanide tab 1 mg 2bumetanide tab 2 mg 2BYSTOLIC - nebivolol hcl tab 2.5 mg 4BYSTOLIC - nebivolol hcl tab 5 mg 4BYSTOLIC - nebivolol hcl tab 10 mg 4BYSTOLIC - nebivolol hcl tab 20 mg 4CALAN - verapamil hcl tab 120 mg 4CALAN SR - verapamil hcl tab er 120 mg 4CALAN SR - verapamil hcl tab er 240 mg 4candesartan cilexetil tab 4 mg 2 QL (60 tablets/30 days)candesartan cilexetil tab 8 mg 2 QL (60 tablets/30 days)candesartan cilexetil tab 16 mg 2 QL (60 tablets/30 days)candesartan cilexetil tab 32 mg 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-25 mg 2 QL (30 tablets/30 days)captopril tab 12.5 mg 2captopril tab 25 mg 2captopril tab 50 mg 2captopril tab 100 mg 2CARDIZEM - diltiazem hcl tab 30 mg 4CARDIZEM - diltiazem hcl tab 60 mg 4CARDIZEM - diltiazem hcl tab 120 mg 4CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 120 mg 4CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 180 mg 4CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 240 mg 4CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 300 mg 4CARDIZEM CD - diltiazem hcl coated beads cap er 24hr 360 mg 4carvedilol tab 3.125 mg 1carvedilol tab 6.25 mg 1carvedilol tab 12.5 mg 1carvedilol tab 25 mg 1CHLOROTHIAZIDE - chlorothiazide tab 250 mg 3chlorothiazide tab 500 mg 2chlorthalidone tab 25 mg 2

2019


Drug Name Drug Tier Requirements/Limitschlorthalidone tab 50 mg 2cholestyramine light powder packets 4 gm 2cholestyramine light powder 4 gm/dose 2cholestyramine powder packets 4 gm 2cholestyramine powder 4 gm/dose 2choline fenofibrate cap dr 45 mg 2 QL (60 capsules/30 days)choline fenofibrate cap dr 135 mg 2 QL (30 capsules/30 days)clonidine hcl tab 0.1 mg 1clonidine hcl tab 0.2 mg 1clonidine hcl tab 0.3 mg 1clonidine td patch weekly 0.1 mg/24hr 2clonidine td patch weekly 0.2 mg/24hr 2clonidine td patch weekly 0.3 mg/24hr 2colestipol hcl granule packets 5 gm 2colestipol hcl granules 5 gm 2colestipol hcl tab 1 gm 2COREG - carvedilol tab 3.125 mg 4COREG - carvedilol tab 6.25 mg 4COREG - carvedilol tab 12.5 mg 4COREG - carvedilol tab 25 mg 4CORLANOR - ivabradine hcl oral soln 5 mg/5ml 3 PA, QL (600 mls/30 days)CORLANOR - ivabradine hcl tab 5 mg 3 PA, QL (60 tablets/30 days)CORLANOR - ivabradine hcl tab 7.5 mg 3 PA, QL (60 tablets/30 days)COZAAR - losartan potassium tab 25 mg 4 QL (60 tablets/30 days)COZAAR - losartan potassium tab 50 mg 4 QL (60 tablets/30 days)COZAAR - losartan potassium tab 100 mg 4 QL (30 tablets/30 days)DEMSER - metyrosine cap 250 mg 5digoxin oral soln 0.05 mg/ml# 3 QL (150 mls/30 days)digoxin tab 125 mcg (0.125 mg)# 2 QL (30 tablets/30 days)digoxin tab 250 mcg (0.25 mg)# 3 PA, QL (30 tablets/30 days)diltiazem hcl cap er 12hr 60 mg 3diltiazem hcl cap er 12hr 90 mg 3diltiazem hcl cap er 12hr 120 mg 3diltiazem hcl cap er 24hr 120 mg 3diltiazem hcl cap er 24hr 180 mg 3diltiazem hcl cap er 24hr 240 mg 3diltiazem hcl coated beads cap er 24hr 120 mg 3diltiazem hcl coated beads cap er 24hr 180 mg 3

2019


67

Drug Name Drug Tier Requirements/Limitsdiltiazem hcl coated beads cap er 24hr 240 mg 3diltiazem hcl coated beads cap er 24hr 300 mg 3diltiazem hcl coated beads cap er 24hr 360 mg 3diltiazem hcl coated beads tab er 24hr 180 mg 3diltiazem hcl coated beads tab er 24hr 240 mg 3diltiazem hcl coated beads tab er 24hr 300 mg 3diltiazem hcl coated beads tab er 24hr 360 mg 3diltiazem hcl coated beads tab er 24hr 420 mg 3diltiazem hcl extended release beads cap er 24hr 120 mg 3diltiazem hcl extended release beads cap er 24hr 180 mg 3diltiazem hcl extended release beads cap er 24hr 240 mg 3diltiazem hcl extended release beads cap er 24hr 300 mg 3diltiazem hcl extended release beads cap er 24hr 360 mg 3diltiazem hcl extended release beads cap er 24hr 420 mg 3diltiazem hcl tab 30 mg 3diltiazem hcl tab 60 mg 3diltiazem hcl tab 90 mg 3diltiazem hcl tab 120 mg 3DIOVAN - valsartan tab 40 mg 4 QL (60 tablets/30 days)DIOVAN - valsartan tab 80 mg 4 QL (60 tablets/30 days)DIOVAN - valsartan tab 160 mg 4 QL (60 tablets/30 days)DIOVAN - valsartan tab 320 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 80-12.5 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 160-12.5 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 160-25 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 320-12.5 mg 4 QL (30 tablets/30 days)DIOVAN HCT - valsartan-hydrochlorothiazide tab 320-25 mg 4 QL (30 tablets/30 days)dofetilide cap 125 mcg (0.125 mg) 3dofetilide cap 250 mcg (0.25 mg) 3dofetilide cap 500 mcg (0.5 mg) 3doxazosin mesylate tab 1 mg 2 QL (60 tablets/30 days)doxazosin mesylate tab 2 mg 2 QL (60 tablets/30 days)doxazosin mesylate tab 4 mg 2 QL (60 tablets/30 days)doxazosin mesylate tab 8 mg 2 QL (60 tablets/30 days)enalapril maleate & hydrochlorothiazide tab 5-12.5 mg 1enalapril maleate & hydrochlorothiazide tab 10-25 mg 1enalapril maleate tab 2.5 mg 1enalapril maleate tab 5 mg 1

2019


Drug Name Drug Tier Requirements/Limitsenalapril maleate tab 10 mg 1enalapril maleate tab 20 mg 1ENTRESTO - sacubitril-valsartan tab 24-26 mg 3 QL (60 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 49-51 mg 3 QL (60 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 97-103 mg 3 QL (60 tablets/30 days)eplerenone tab 25 mg 2eplerenone tab 50 mg 2EXFORGE - amlodipine besylate-valsartan tab 5-160 mg 4 QL (30 tablets/30 days)EXFORGE - amlodipine besylate-valsartan tab 5-320 mg 4 QL (30 tablets/30 days)EXFORGE - amlodipine besylate-valsartan tab 10-160 mg 4 QL (30 tablets/30 days)EXFORGE - amlodipine besylate-valsartan tab 10-320 mg 4 QL (30 tablets/30 days)EXFORGE HCT - amlodipine-valsartan-hydrochlorothiazide tab

5-160-12.5 mg4 QL (30 tablets/30 days)

EXFORGE HCT - amlodipine-valsartan-hydrochlorothiazide tab5-160-25 mg


EXFORGE HCT - amlodipine-valsartan-hydrochlorothiazide tab10-160-12.5 mg






ezetimibe tab 10 mg 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-10 mg 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-20 mg 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-40 mg 2 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-80 mg 2 QL (30 tablets/30 days)felodipine tab er 24hr 2.5 mg 2felodipine tab er 24hr 5 mg 2felodipine tab er 24hr 10 mg 2fenofibrate micronized cap 67 mg 2 QL (30 capsules/30 days)fenofibrate micronized cap 134 mg 2 QL (30 capsules/30 days)fenofibrate micronized cap 200 mg 2 QL (30 capsules/30 days)fenofibrate tab 48 mg 2 QL (60 tablets/30 days)fenofibrate tab 54 mg 2 QL (60 tablets/30 days)fenofibrate tab 145 mg 2 QL (30 tablets/30 days)fenofibrate tab 160 mg 2 QL (30 tablets/30 days)flecainide acetate tab 50 mg 2flecainide acetate tab 100 mg 2flecainide acetate tab 150 mg 2fluvastatin sodium cap 20 mg 3 QL (60 capsules/30 days)

2019


69

Drug Name Drug Tier Requirements/Limitsfluvastatin sodium cap 40 mg 3 QL (60 capsules/30 days)fluvastatin sodium tab er 24 hr 80 mg 3 QL (30 tablets/30 days)fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg 2fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg 2fosinopril sodium tab 10 mg 1fosinopril sodium tab 20 mg 1fosinopril sodium tab 40 mg 1furosemide inj 10 mg/ml 3furosemide oral soln 10 mg/ml 2furosemide tab 20 mg 1furosemide tab 40 mg 1furosemide tab 80 mg 1gemfibrozil tab 600 mg 2 QL (60 tablets/30 days)hydralazine hcl tab 10 mg 2hydralazine hcl tab 25 mg 2hydralazine hcl tab 50 mg 2hydralazine hcl tab 100 mg 2hydrochlorothiazide cap 12.5 mg 1hydrochlorothiazide tab 12.5 mg 1hydrochlorothiazide tab 25 mg 1hydrochlorothiazide tab 50 mg 1HYZAAR - losartan potassium & hydrochlorothiazide tab


HYZAAR - losartan potassium & hydrochlorothiazide tab100-12.5 mg


HYZAAR - losartan potassium & hydrochlorothiazide tab 100-25 mg 4 QL (30 tablets/30 days)indapamide tab 1.25 mg 2indapamide tab 2.5 mg 2irbesartan tab 75 mg 1 QL (30 tablets/30 days)irbesartan tab 150 mg 1 QL (60 tablets/30 days)irbesartan tab 300 mg 1 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 150-12.5 mg 1 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 300-12.5 mg 1 QL (30 tablets/30 days)isosorbide dinitrate tab 5 mg 2isosorbide dinitrate tab 10 mg 2isosorbide dinitrate tab 20 mg 2isosorbide dinitrate tab 30 mg 2isosorbide mononitrate tab er 24hr 30 mg 2isosorbide mononitrate tab er 24hr 60 mg 2

2019


Drug Name Drug Tier Requirements/Limitsisosorbide mononitrate tab er 24hr 120 mg 2isosorbide mononitrate tab 10 mg 2isosorbide mononitrate tab 20 mg 2isradipine cap 2.5 mg 2isradipine cap 5 mg 2JUXTAPID - lomitapide mesylate cap 5 mg* 5 PAJUXTAPID - lomitapide mesylate cap 10 mg* 5 PAJUXTAPID - lomitapide mesylate cap 20 mg* 5 PAJUXTAPID - lomitapide mesylate cap 30 mg* 5 PAJUXTAPID - lomitapide mesylate cap 40 mg* 5 PAJUXTAPID - lomitapide mesylate cap 60 mg* 5 PAlabetalol hcl tab 100 mg 2labetalol hcl tab 200 mg 2labetalol hcl tab 300 mg 2LASIX - furosemide tab 20 mg 4LASIX - furosemide tab 40 mg 4LASIX - furosemide tab 80 mg 4LIDOCAINE HCL - lidocaine hcl (cardiac) iv pf soln pref syr

50 mg/5ml(1%)4

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

4

LIPITOR - atorvastatin calcium tab 10 mg 4 QL (45 tablets/30 days)LIPITOR - atorvastatin calcium tab 20 mg 4 QL (45 tablets/30 days)LIPITOR - atorvastatin calcium tab 40 mg 4 QL (45 tablets/30 days)LIPITOR - atorvastatin calcium tab 80 mg 4 QL (30 tablets/30 days)lisinopril & hydrochlorothiazide tab 10-12.5 mg 1lisinopril & hydrochlorothiazide tab 20-12.5 mg 1lisinopril & hydrochlorothiazide tab 20-25 mg 1lisinopril tab 2.5 mg 1lisinopril tab 5 mg 1lisinopril tab 10 mg 1lisinopril tab 20 mg 1lisinopril tab 30 mg 1lisinopril tab 40 mg 1LOPRESSOR - metoprolol tartrate tab 50 mg 4LOPRESSOR - metoprolol tartrate tab 100 mg 4losartan potassium & hydrochlorothiazide tab 50-12.5 mg 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-12.5 mg 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-25 mg 1 QL (30 tablets/30 days)

2019


71

Drug Name Drug Tier Requirements/Limitslosartan potassium tab 25 mg 1 QL (60 tablets/30 days)losartan potassium tab 50 mg 1 QL (60 tablets/30 days)losartan potassium tab 100 mg 1 QL (30 tablets/30 days)LOTENSIN - benazepril hcl tab 10 mg 4LOTENSIN - benazepril hcl tab 20 mg 4LOTENSIN - benazepril hcl tab 40 mg 4lovastatin tab 10 mg 1 QL (60 tablets/30 days)lovastatin tab 20 mg 1 QL (60 tablets/30 days)lovastatin tab 40 mg 1 QL (60 tablets/30 days)methazolamide tab 25 mg 3methazolamide tab 50 mg 3metolazone tab 2.5 mg 2metolazone tab 5 mg 2metolazone tab 10 mg 2metoprolol & hydrochlorothiazide tab 50-25 mg 2metoprolol & hydrochlorothiazide tab 100-25 mg 2metoprolol succinate tab er 24hr 25 mg 2metoprolol succinate tab er 24hr 50 mg 2metoprolol succinate tab er 24hr 100 mg 2metoprolol succinate tab er 24hr 200 mg 2metoprolol tartrate tab 25 mg 1metoprolol tartrate tab 50 mg 1metoprolol tartrate tab 100 mg 1mexiletine hcl cap 150 mg 2mexiletine hcl cap 200 mg 2mexiletine hcl cap 250 mg 2MICARDIS - telmisartan tab 20 mg 4 QL (30 tablets/30 days)MICARDIS - telmisartan tab 40 mg 4 QL (30 tablets/30 days)MICARDIS - telmisartan tab 80 mg 4 QL (30 tablets/30 days)MICARDIS HCT - telmisartan-hydrochlorothiazide tab 40-12.5 mg 4 QL (30 tablets/30 days)MICARDIS HCT - telmisartan-hydrochlorothiazide tab 80-12.5 mg 4 QL (60 tablets/30 days)MICARDIS HCT - telmisartan-hydrochlorothiazide tab 80-25 mg 4 QL (30 tablets/30 days)midodrine hcl tab 2.5 mg 2midodrine hcl tab 5 mg 2midodrine hcl tab 10 mg 2minoxidil tab 2.5 mg 2minoxidil tab 10 mg 2moexipril hcl tab 7.5 mg 2

2019


Drug Name Drug Tier Requirements/Limitsmoexipril hcl tab 15 mg 2MULTAQ - dronedarone hcl tab 400 mg 3nadolol tab 20 mg 2nadolol tab 40 mg 2nadolol tab 80 mg 2niacin tab er 500 mg 2 QL (30 tablets/30 days)niacin tab er 750 mg 2 QL (60 tablets/30 days)niacin tab er 1000 mg 2 QL (60 tablets/30 days)nicardipine hcl cap 20 mg 2nicardipine hcl cap 30 mg 2nifedipine tab er 24hr 30 mg 3nifedipine tab er 24hr 60 mg 3nifedipine tab er 24hr 90 mg 3nifedipine tab er 24hr osmotic release 30 mg 3nifedipine tab er 24hr osmotic release 60 mg 3nifedipine tab er 24hr osmotic release 90 mg 3nimodipine cap 30 mg 5NISOLDIPINE ER - nisoldipine tab er 24hr 25.5 mg 3nisoldipine tab er 24hr 8.5 mg 3nisoldipine tab er 24hr 17 mg 3nisoldipine tab er 24hr 34 mg 3NITRO-BID - nitroglycerin oint 2% 3nitroglycerin sl tab 0.3 mg 2nitroglycerin sl tab 0.4 mg 2nitroglycerin sl tab 0.6 mg 2nitroglycerin td patch 24hr 0.1 mg/hr 2nitroglycerin td patch 24hr 0.2 mg/hr 2nitroglycerin td patch 24hr 0.4 mg/hr 2nitroglycerin td patch 24hr 0.6 mg/hr 2nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) 3NORTHERA - droxidopa cap 100 mg* 5 PANORTHERA - droxidopa cap 200 mg* 5 PANORTHERA - droxidopa cap 300 mg* 5 PANORVASC - amlodipine besylate tab 2.5 mg 4NORVASC - amlodipine besylate tab 5 mg 4NORVASC - amlodipine besylate tab 10 mg 4olmesartan medoxomil tab 5 mg 1 QL (60 tablets/30 days)olmesartan medoxomil tab 20 mg 1 QL (30 tablets/30 days)

2019


73

Drug Name Drug Tier Requirements/Limitsolmesartan medoxomil tab 40 mg 1 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg 1 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg 1 QL (30 tablets/30 days)olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg 1 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg 3 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 40-5-12.5 mg 3 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 40-5-25 mg 3 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 40-10-12.5 mg 3 QL (30 tablets/30 days)olmesartan-amlodipine-hydrochlorothiazide tab 40-10-25 mg 3 QL (30 tablets/30 days)omega-3-acid ethyl esters cap 1 gm 2pentoxifylline tab er 400 mg 2perindopril erbumine tab 2 mg 2perindopril erbumine tab 4 mg 2perindopril erbumine tab 8 mg 2phenoxybenzamine hcl cap 10 mg 5pindolol tab 5 mg 2pindolol tab 10 mg 2PRAVACHOL - pravastatin sodium tab 20 mg 4 QL (45 tablets/30 days)PRAVACHOL - pravastatin sodium tab 40 mg 4 QL (45 tablets/30 days)PRAVACHOL - pravastatin sodium tab 80 mg 4 QL (30 tablets/30 days)pravastatin sodium tab 10 mg 1 QL (45 tablets/30 days)pravastatin sodium tab 20 mg 1 QL (45 tablets/30 days)pravastatin sodium tab 40 mg 1 QL (45 tablets/30 days)pravastatin sodium tab 80 mg 1 QL (30 tablets/30 days)prazosin hcl cap 1 mg 2prazosin hcl cap 2 mg 2prazosin hcl cap 5 mg 2PRINIVIL - lisinopril tab 5 mg 4PRINIVIL - lisinopril tab 10 mg 4PRINIVIL - lisinopril tab 20 mg 4PROCARDIA XL - nifedipine tab er 24hr osmotic release 30 mg 4PROCARDIA XL - nifedipine tab er 24hr osmotic release 60 mg 4PROCARDIA XL - nifedipine tab er 24hr osmotic release 90 mg 4propafenone hcl cap er 12hr 225 mg 3propafenone hcl cap er 12hr 325 mg 3propafenone hcl cap er 12hr 425 mg 3propafenone hcl tab 150 mg 2propafenone hcl tab 225 mg 2

2019


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

140 mg/ml5 PA, QL (2 syringes/28 days)

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

5 PA, QL (1 system/30 days)

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

5 PA, QL (2 pens/28 days)

rosuvastatin calcium tab 5 mg 2 QL (45 tablets/30 days)rosuvastatin calcium tab 10 mg 2 QL (45 tablets/30 days)rosuvastatin calcium tab 20 mg 2 QL (45 tablets/30 days)rosuvastatin calcium tab 40 mg 2 QL (30 tablets/30 days)

2019


75

Drug Name Drug Tier Requirements/Limitssimvastatin tab 5 mg 1 QL (45 tablets/30 days)simvastatin tab 10 mg 1 QL (45 tablets/30 days)simvastatin tab 20 mg 1 QL (60 tablets/30 days)simvastatin tab 40 mg 1 QL (45 tablets/30 days)simvastatin tab 80 mg 1 QL (30 tablets/30 days)sotalol hcl (afib/afl) tab 80 mg 2sotalol hcl (afib/afl) tab 120 mg 2sotalol hcl (afib/afl) tab 160 mg 2sotalol hcl tab 80 mg 2sotalol hcl tab 120 mg 2sotalol hcl tab 160 mg 2sotalol hcl tab 240 mg 2spironolactone & hydrochlorothiazide tab 25-25 mg 2spironolactone tab 25 mg 2spironolactone tab 50 mg 2spironolactone tab 100 mg 2TEKTURNA - aliskiren fumarate tab 150 mg 3 QL (30 tablets/30 days)TEKTURNA - aliskiren fumarate tab 300 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-12.5 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-25 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-12.5 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-25 mg 3 QL (30 tablets/30 days)telmisartan tab 20 mg 2 QL (30 tablets/30 days)telmisartan tab 40 mg 2 QL (30 tablets/30 days)telmisartan tab 80 mg 2 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 40-12.5 mg 2 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-12.5 mg 2 QL (60 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-25 mg 2 QL (30 tablets/30 days)terazosin hcl cap 1 mg 1 QL (90 capsules/30 days)terazosin hcl cap 2 mg 1 QL (60 capsules/30 days)terazosin hcl cap 5 mg 1 QL (60 capsules/30 days)terazosin hcl cap 10 mg 1 QL (60 capsules/30 days)TIAZAC - diltiazem hcl extended release beads cap er 24hr 120 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 180 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 240 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 300 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 360 mg 4TIAZAC - diltiazem hcl extended release beads cap er 24hr 420 mg 4

2019


Drug Name Drug Tier Requirements/LimitsTIMOLOL MALEATE - timolol maleate tab 10 mg 3TIMOLOL MALEATE - timolol maleate tab 20 mg 3timolol maleate tab 5 mg 2torsemide tab 5 mg 1torsemide tab 10 mg 1torsemide tab 20 mg 1torsemide tab 100 mg 1trandolapril tab 1 mg 1trandolapril tab 2 mg 1trandolapril tab 4 mg 1triamterene & hydrochlorothiazide cap 37.5-25 mg 2triamterene & hydrochlorothiazide tab 37.5-25 mg 2triamterene & hydrochlorothiazide tab 75-50 mg 2TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab

20-5-12.5 mg4 QL (30 tablets/30 days)

TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab40-5-12.5 mg


TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab40-5-25 mg


TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab40-10-12.5 mg


TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazide tab40-10-25 mg


valsartan tab 40 mg 2 QL (60 tablets/30 days)valsartan tab 80 mg 2 QL (60 tablets/30 days)valsartan tab 160 mg 2 QL (60 tablets/30 days)valsartan tab 320 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 80-12.5 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-12.5 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-25 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 320-12.5 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 320-25 mg 2 QL (30 tablets/30 days)VASCEPA - icosapent ethyl cap 0.5 gm 3VASCEPA - icosapent ethyl cap 1 gm 3VASERETIC - enalapril maleate & hydrochlorothiazide tab

10-25 mg4

VASOTEC - enalapril maleate tab 2.5 mg 4VASOTEC - enalapril maleate tab 5 mg 4VASOTEC - enalapril maleate tab 10 mg 4VASOTEC - enalapril maleate tab 20 mg 4

2019


77

Drug Name Drug Tier Requirements/Limitsverapamil hcl cap er 24hr 360 mg 2verapamil hcl cap er 24hr 100 mg 2verapamil hcl cap er 24hr 120 mg 2verapamil hcl cap er 24hr 180 mg 2verapamil hcl cap er 24hr 200 mg 2verapamil hcl cap er 24hr 240 mg 2verapamil hcl cap er 24hr 300 mg 2verapamil hcl tab er 120 mg 2verapamil hcl tab er 180 mg 2verapamil hcl tab er 240 mg 2verapamil hcl tab 40 mg 1verapamil hcl tab 80 mg 1verapamil hcl tab 120 mg 1VYNDAMAX - tafamidis cap 61 mg 5 PA, QL (30 capsules/30 days)VYNDAQEL - tafamidis meglumine (cardiac) cap 20 mg 5 PA, QL (120 capsules/30 days)ZESTORETIC - lisinopril & hydrochlorothiazide tab 10-12.5 mg 4ZESTORETIC - lisinopril & hydrochlorothiazide tab 20-12.5 mg 4ZESTORETIC - lisinopril & hydrochlorothiazide tab 20-25 mg 4ZESTRIL - lisinopril tab 2.5 mg 4ZESTRIL - lisinopril tab 5 mg 4ZESTRIL - lisinopril tab 10 mg 4ZESTRIL - lisinopril tab 20 mg 4ZESTRIL - lisinopril tab 30 mg 4ZESTRIL - lisinopril tab 40 mg 4ZOCOR - simvastatin tab 10 mg 4 QL (45 tablets/30 days)ZOCOR - simvastatin tab 20 mg 4 QL (60 tablets/30 days)ZOCOR - simvastatin tab 40 mg 4 QL (45 tablets/30 days)ZOCOR - simvastatin tab 80 mg 4 QL (30 tablets/30 days)Central Nervous System Agentsamphetamine-dextroamphetamine cap er 24hr 5 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 10 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 15 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 20 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 25 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 30 mg 4 QL (30 capsules/30 days)amphetamine-dextroamphetamine tab 5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 7.5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 10 mg 3 QL (60 tablets/30 days)

2019


Drug Name Drug Tier Requirements/Limitsamphetamine-dextroamphetamine tab 12.5 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 15 mg 3 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 20 mg 3 QL (90 tablets/30 days)amphetamine-dextroamphetamine tab 30 mg 3 QL (60 tablets/30 days)AMPYRA - dalfampridine tab er 12hr 10 mg* 5 PAatomoxetine hcl cap 10 mg 3 QL (60 capsules/30 days)atomoxetine hcl cap 18 mg 3 QL (60 capsules/30 days)atomoxetine hcl cap 25 mg 3 QL (60 capsules/30 days)atomoxetine hcl cap 40 mg 3 QL (60 capsules/30 days)atomoxetine hcl cap 60 mg 3 QL (30 capsules/30 days)atomoxetine hcl cap 80 mg 3 QL (30 capsules/30 days)atomoxetine hcl cap 100 mg 3 QL (30 capsules/30 days)AVONEX - interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)AVONEX PEN - interferon beta-1a im auto-injector kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)BETASERON - interferon beta-1b for inj kit 0.3 mg 5 PA, QL (15 vials/

syringes/30 days)clonidine hcl tab er 12hr 0.1 mg 3 QL (120 tablets/30 days)COPAXONE - glatiramer acetate soln prefilled syringe 40 mg/ml 5 PA, QL (12 syringes/28 days)dalfampridine tab er 12hr 10 mg 5 PAdexmethylphenidate hcl tab 2.5 mg 4 QL (60 tablets/30 days)dexmethylphenidate hcl tab 5 mg 4 QL (60 tablets/30 days)dexmethylphenidate hcl tab 10 mg 4 QL (60 tablets/30 days)dextroamphetamine sulfate cap er 24hr 5 mg 4 QL (90 capsules/30 days)dextroamphetamine sulfate cap er 24hr 10 mg 4 QL (120 capsules/30 days)dextroamphetamine sulfate cap er 24hr 15 mg 4 QL (120 capsules/30 days)dextroamphetamine sulfate tab 5 mg 4 QL (90 tablets/30 days)dextroamphetamine sulfate tab 10 mg 4 QL (180 tablets/30 days)GILENYA - fingolimod hcl cap 0.5 mg 5 PA, QL (30 capsules/30 days)glatiramer acetate soln prefilled syringe 20 mg/ml 5 PA, QL (30 syringes/30 days)glatiramer acetate soln prefilled syringe 40 mg/ml 5 PA, QL (12 syringes/28 days)MAYZENT - siponimod fumarate tab 0.25 mg 5 PA, QL (120 tablets/30 days)MAYZENT - siponimod fumarate tab 2 mg 5 PA, QL (30 tablets/30 days)methylphenidate hcl tab er 20 mg 4 QL (90 tablets/30 days)methylphenidate hcl tab 5 mg 3 QL (90 tablets/30 days)methylphenidate hcl tab 10 mg 3 QL (90 tablets/30 days)methylphenidate hcl tab 20 mg 3 QL (90 tablets/30 days)NUEDEXTA - dextromethorphan hbr-quinidine sulfate cap

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

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

2019


79

Drug Name Drug Tier Requirements/LimitsPLEGRIDY - peginterferon beta-1a soln prefilled syringe

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

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


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


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

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

tetrabenazine tab 12.5 mg 5 PA, QL (240 tablets/30 days)tetrabenazine tab 25 mg 5 PA, QL (120 tablets/30 days)TYSABRI - natalizumab for iv inj conc 300 mg/15ml* 5 PADental and Oral Agentscevimeline hcl cap 30 mg 3chlorhexidine gluconate soln 0.12% 1KEPIVANCE - palifermin for iv inj 6.25 mg 5pilocarpine hcl tab 5 mg 2pilocarpine hcl tab 7.5 mg 2triamcinolone acetonide dental paste 0.1% 2Dermatological Agentsacitretin cap 10 mg 3acitretin cap 17.5 mg 3acitretin cap 25 mg 3alclometasone dipropionate cream 0.05% 2alclometasone dipropionate oint 0.05% 2azelaic acid gel 15% 3AZELEX - azelaic acid cream 20% 4benzoyl peroxide-erythromycin gel 5-3% 3betamethasone dipropionate augmented cream 0.05% 2betamethasone dipropionate augmented gel 0.05% 2betamethasone dipropionate augmented lotion 0.05% 2betamethasone dipropionate augmented oint 0.05% 2betamethasone dipropionate cream 0.05% 2betamethasone dipropionate lotion 0.05% 2betamethasone dipropionate oint 0.05% 2betamethasone valerate cream 0.1% 2betamethasone valerate lotion 0.1% 2betamethasone valerate oint 0.1% 2

2019


Drug Name Drug Tier Requirements/Limitscalcipotriene cream 0.005% 3calcipotriene oint 0.005% 3calcipotriene soln 0.005% (50 mcg/ml) 3CARAC - fluorouracil cream 0.5% 5clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% 3clindamycin phosphate-benzoyl peroxide gel 1-5% 3clobetasol propionate cream 0.05% 3clobetasol propionate emollient base cream 0.05% 3clobetasol propionate gel 0.05% 3clobetasol propionate oint 0.05% 3clobetasol propionate soln 0.05% 3clotrimazole w/ betamethasone cream 1-0.05% 2clotrimazole w/ betamethasone lotion 1-0.05% 2desonide cream 0.05% 3desonide lotion 0.05% 3desonide oint 0.05% 3desoximetasone cream 0.05% 3desoximetasone cream 0.25% 3desoximetasone gel 0.05% 3desoximetasone oint 0.25% 3diclofenac sodium gel 3% 5diflorasone diacetate oint 0.05% 4ELIDEL - pimecrolimus cream 1% 4 PAFINACEA - azelaic acid foam 15% 3FINACEA - azelaic acid gel 15% 3fluocinolone acetonide cream 0.01% 2fluocinonide cream 0.05% 2fluocinonide emulsified base cream 0.05% 2fluocinonide gel 0.05% 2fluocinonide oint 0.05% 2fluocinonide soln 0.05% 2FLUOROURACIL - fluorouracil soln 2% 2FLUOROURACIL - fluorouracil soln 5% 2fluorouracil cream 5% 3fluticasone propionate cream 0.05% 2fluticasone propionate oint 0.005% 2gentamicin sulfate cream 0.1% 2gentamicin sulfate oint 0.1% 2

2019


81

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

2019


Drug Name Drug Tier Requirements/Limitsprednicarbate oint 0.1% 2REGRANEX - becaplermin gel 0.01% 5 PA, QL (15 grams/30 days)SANTYL - collagenase oint 250 unit/gm 3selenium sulfide lotion 2.5% 2silver sulfadiazine cream 1% 3SOOLANTRA - ivermectin cream 1% 3tacrolimus oint 0.03% 2 PAtacrolimus oint 0.1% 2 PAtazarotene cream 0.1% 3TAZORAC - tazarotene cream 0.05% 4TAZORAC - tazarotene gel 0.05% 4TAZORAC - tazarotene gel 0.1% 4tretinoin cream 0.025% 3tretinoin cream 0.05% 3tretinoin cream 0.1% 3tretinoin gel 0.01% 3tretinoin gel 0.025% 3triamcinolone acetonide cream 0.025% 2triamcinolone acetonide cream 0.1% 2triamcinolone acetonide cream 0.5% 2triamcinolone acetonide lotion 0.025% 2triamcinolone acetonide lotion 0.1% 2triamcinolone acetonide oint 0.025% 2triamcinolone acetonide oint 0.1% 2triamcinolone acetonide oint 0.5% 2Electrolytes/Minerals/Metals/Vitaminsamino acid infusion 6% 3 BDamino acid infusion 15% 3 BDAMINOSYN II - amino acid infusion 10% 4 BDAMINOSYN-PF - amino acid infusion 10% 4 BDAMINOSYN-PF 7% - amino acid infusion 7% 4 BDAURYXIA - ferric citrate tab 1 gm (210 mg ferric iron) 5 PAcalcium acetate cap 667 mg 2calcium acetate tab 667 mg 2CARBAGLU - carglumic acid tab 200 mg 5 PACHEMET - succimer cap 100 mg 4CLINIMIX E 2.75%/DEXTROSE 5% - amino acid electrolyte w/cal

infusion 2.75% in d5w4 BD

2019


83

Drug Name Drug Tier Requirements/LimitsCLINIMIX E 4.25%/DEXTROSE 10% - amino acid electrolyte w/cal

infusion 4.25% in d10w4 BD

CLINIMIX E 4.25%/DEXTROSE 5% - amino acid electrolyte w/calinfusion 4.25% in d5w

4 BD

CLINIMIX E 5%/DEXTROSE 15% - amino acid electrolyte w/calinfusion 5% in d15w

4 BD

CLINIMIX E 5%/DEXTROSE 20% - amino acid electrolyte w/calinfusion 5% in d20w

4 BD

CLINIMIX 4.25%/DEXTROSE 10% - amino acid infusion 4.25% ind10w

4 BD


4 BD


4 BD

CLINIMIX 5%/DEXTROSE 15% - amino acid infusion 5% in d15w 4 BDCLINIMIX 5%/DEXTROSE 20% - amino acid infusion 5% in d20w 4 BDCLINIMIX 5%/DEXTROSE 25% - amino acid infusion 5% in d25w 4 BDdeferasirox tab for oral susp 125 mg 5 PAdeferasirox tab for oral susp 250 mg 5 PAdeferasirox tab for oral susp 500 mg 5 PAdextrose inj 5% 3dextrose inj 10% 3dextrose 2.5% w/ sodium chloride 0.45% 3dextrose 5% in lactated ringers 3dextrose 5% w/ sodium chloride 0.2% 3dextrose 5% w/ sodium chloride 0.33% 3dextrose 5% w/ sodium chloride 0.45% 3dextrose 5% w/ sodium chloride 0.9% 3EXJADE - deferasirox tab for oral susp 125 mg* 5 PAEXJADE - deferasirox tab for oral susp 250 mg* 5 PAEXJADE - deferasirox tab for oral susp 500 mg* 5 PAfat emulsion plant based iv emulsion 20% 4 BDfomepizole inj 1 gm/ml (for iv infusion) 5FOSRENOL - lanthanum carbonate oral powder pack 750 mg 5FOSRENOL - lanthanum carbonate oral powder pack 1000 mg 5FREAMINE HBC 6.9% - amino acid infusion 6.9% 4 BDFREAMINE III - amino acid infusion 10% 4 BDHEPATAMINE - amino acid infusion 8% 4 BDJADENU - deferasirox tab 90 mg 5 PAJADENU - deferasirox tab 180 mg 5 PA

2019


Drug Name Drug Tier Requirements/LimitsJADENU - deferasirox tab 360 mg 5 PAJADENU SPRINKLE - deferasirox granules packet 90 mg 5 PAJADENU SPRINKLE - deferasirox granules packet 180 mg 5 PAJADENU SPRINKLE - deferasirox granules packet 360 mg 5 PAK-TAB - potassium chloride tab er 20 meq (1500 mg) 3kcl 20 meq/l (0.15%) in nacl 0.45% inj 3kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj 3kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj 3kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj 3kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj 3kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj 3kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj 3lactated ringer's solution 4lanthanum carbonate chew tab 500 mg 5lanthanum carbonate chew tab 750 mg 5lanthanum carbonate chew tab 1000 mg 5levocarnitine oral soln 1 gm/10ml (10%) 3levocarnitine tab 330 mg 3magnesium sulfate inj 50% 3NEPHRAMINE - amino acid infusion 5.4% 4 BDNORMOSOL-M IN D5W - electrolyte-m in d5w soln 4PHOSLYRA - calcium acetate oral soln 667 mg/5ml 4potassium chloride cap er 8 meq 2potassium chloride cap er 10 meq 2POTASSIUM CHLORIDE ER - potassium chloride tab er 20 meq

(1500 mg)3

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

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

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

3

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

3

2019


85

Drug Name Drug Tier Requirements/Limitspotassium citrate tab er 5 meq (540 mg) 2potassium citrate tab er 10 meq (1080 mg) 2potassium citrate tab er 15 meq (1620 mg) 2PREMASOL - amino acid infusion 10% 4 BDPROCALAMINE - amino acid electrolyte infusion 3% 4 BDPROSOL - amino acid infusion 20% 4 BDSAMSCA - tolvaptan tab 15 mg 5 PASAMSCA - tolvaptan tab 30 mg 5 PAsevelamer carbonate packet 0.8 gm 5sevelamer carbonate packet 2.4 gm 5sevelamer carbonate tab 800 mg 3sodium chloride irrigation soln 0.9% 2sodium chloride iv soln 0.45% 3sodium chloride iv soln 0.9% 3sodium polystyrene sulfonate oral susp 15 gm/60ml 2sodium polystyrene sulfonate powder 2sodium polystyrene sulfonate rectal susp 30 gm/120ml 2TRAVASOL - amino acid infusion 10% 4 BDtrientine hcl cap 250 mg 5 PA, QL (240 capsules/30 days)TROPHAMINE - amino acid infusion 10% 4 BDVELPHORO - sucroferric oxyhydroxide chew tab 500 mg 5VELTASSA - patiromer sorbitex calcium for susp packet 8.4 gm 4VELTASSA - patiromer sorbitex calcium for susp packet 16.8 gm 4VELTASSA - patiromer sorbitex calcium for susp packet 25.2 gm 4water for irrigation, sterile irrigation soln 3Gastrointestinal Agentsalosetron hcl tab 0.5 mg 5alosetron hcl tab 1 mg 5AMITIZA - lubiprostone cap 8 mcg 3 PAAMITIZA - lubiprostone cap 24 mcg 3 PACARAFATE - sucralfate susp 1 gm/10ml 4CHENODAL - chenodiol tab 250 mg* 5 PAcimetidine hcl soln 300 mg/5ml 2cimetidine tab 200 mg 2cimetidine tab 300 mg 2cimetidine tab 400 mg 2cimetidine tab 800 mg 2COLYTE-FLAVOR PACKS - peg 3350-kcl-na bicarb-nacl-na sulfate

for soln 240 gm4

2019


Drug Name Drug Tier Requirements/Limitscromolyn sodium oral conc 100 mg/5ml 3dicyclomine hcl tab 20 mg# 3 PAesomeprazole magnesium cap delayed release 20 mg 2 QL (30 capsules/30 days)esomeprazole magnesium cap delayed release 40 mg 2 QL (30 capsules/30 days)esomeprazole sodium for intravenous soln 40 mg 3famotidine inj 20 mg/2ml 3famotidine inj 40 mg/4ml 3famotidine inj 200 mg/20ml 3famotidine tab 20 mg 2famotidine tab 40 mg 2GATTEX - teduglutide (rdna) for inj kit 5 mg* 5 PAglycopyrrolate tab 1 mg 2glycopyrrolate tab 2 mg 2GOLYTELY - peg 3350-kcl-na bicarb-nacl-na sulfate for soln

236 gm4

lactulose (encephalopathy) solution 10 gm/15ml 2lactulose solution 10 gm/15ml 2lansoprazole cap delayed release 15 mg 2 QL (30 capsules/30 days)lansoprazole cap delayed release 30 mg 2 QL (30 capsules/30 days)LINZESS - linaclotide cap 72 mcg 3 PALINZESS - linaclotide cap 145 mcg 3 PALINZESS - linaclotide cap 290 mcg 3 PAloperamide hcl cap 2 mg 2methscopolamine bromide tab 2.5 mg 2methscopolamine bromide tab 5 mg 2metoclopramide hcl inj 5 mg/ml 3metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) 3metoclopramide hcl tab 5 mg 2metoclopramide hcl tab 10 mg 2misoprostol tab 100 mcg 2misoprostol tab 200 mcg 2MOVIPREP - peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln

100 gm4

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

packet 5 mg4 QL (30 packets/30 days)

NEXIUM - esomeprazole magnesium for delayed release susppacket 10 mg

4 QL (30 packets/30 days)

NEXIUM - esomeprazole magnesium for delayed release susppacket 20 mg


2019


87

Drug Name Drug Tier Requirements/LimitsNEXIUM - esomeprazole magnesium for delayed release susp

packet 40 mg4 QL (30 packets/30 days)

NEXIUM - esomeprazole magnesium for delayed release susppacket 2.5 mg


nizatidine cap 150 mg 2nizatidine cap 300 mg 2NULYTELY/FLAVOR PACKS - peg 3350-kcl-sod bicarb-nacl for

soln 420 gm4

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

140-125-125 mg5

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

17.5-3.13-1.6 gm/177ml4

ursodiol cap 300 mg 3ursodiol tab 250 mg 3ursodiol tab 500 mg 3XIFAXAN - rifaximin tab 550 mg 5Genetic or Enzyme Disorder: Replacement, Modifiers, TreatmentALDURAZYME - laronidase soln for iv infusion 2.9 mg/5ml (500

unit/5ml)*5

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

unit3

2019


Drug Name Drug Tier Requirements/LimitsCREON - pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000

unit3

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

3

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

3

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

2.5 mg/0.5ml5 PA

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

5 PA

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

5 PA

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

5 PA

2019


89

Drug Name Drug Tier Requirements/LimitsPROLASTIN-C - alpha1-proteinase inhibitor (human) inj

1000 mg/20ml*5 PA

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

unit3

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

3


3


3


3


3

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

3

Genitourinary Agentsalfuzosin hcl tab er 24hr 10 mg 2 QL (30 tablets/30 days)bethanechol chloride tab 5 mg 2bethanechol chloride tab 10 mg 2bethanechol chloride tab 25 mg 2bethanechol chloride tab 50 mg 2D-PENAMINE - penicillamine tab 125 mg 5DEPEN TITRATABS - penicillamine tab 250 mg 5dutasteride cap 0.5 mg 2 QL (30 capsules/30 days)dutasteride-tamsulosin hcl cap 0.5-0.4 mg 2 QL (30 capsules/30 days)finasteride tab 5 mg 2 QL (30 tablets/30 days)FLOMAX - tamsulosin hcl cap 0.4 mg 4 QL (60 capsules/30 days)methylergonovine maleate tab 0.2 mg 5MYRBETRIQ - mirabegron tab er 24 hr 25 mg 4 QL (30 tablets/30 days)MYRBETRIQ - mirabegron tab er 24 hr 50 mg 4 QL (30 tablets/30 days)oxybutynin chloride syrup 5 mg/5ml 2 QL (600 mls/30 days)oxybutynin chloride tab er 24hr 5 mg 2 QL (30 tablets/30 days)

2019


Drug Name Drug Tier Requirements/Limitsoxybutynin chloride tab er 24hr 10 mg 2 QL (90 tablets/30 days)oxybutynin chloride tab er 24hr 15 mg 2 QL (60 tablets/30 days)oxybutynin chloride tab 5 mg 2 QL (120 tablets/30 days)PROSCAR - finasteride tab 5 mg 4 QL (30 tablets/30 days)RAPAFLO - silodosin cap 4 mg 3 QL (30 capsules/30 days)RAPAFLO - silodosin cap 8 mg 3 QL (30 capsules/30 days)silodosin cap 4 mg 3 QL (30 capsules/30 days)silodosin cap 8 mg 3 QL (30 capsules/30 days)tamsulosin hcl cap 0.4 mg 2 QL (60 capsules/30 days)tolterodine tartrate cap er 24hr 2 mg 2 QL (30 capsules/30 days)tolterodine tartrate cap er 24hr 4 mg 2 QL (30 capsules/30 days)tolterodine tartrate tab 1 mg 2 QL (60 tablets/30 days)tolterodine tartrate tab 2 mg 2 QL (60 tablets/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 4 mg 3 QL (30 tablets/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 8 mg 3 QL (30 tablets/30 days)trospium chloride cap er 24hr 60 mg 2 QL (30 capsules/30 days)trospium chloride tab 20 mg 2 QL (60 tablets/30 days)Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)ACTHAR - corticotropin inj gel 80 unit/ml* 5 PACORTISONE ACETATE - cortisone acetate tab 25 mg 3DEXAMETHASONE - dexamethasone tab 1 mg 2DEXAMETHASONE - dexamethasone tab 2 mg 2dexamethasone elixir 0.5 mg/5ml 3dexamethasone sodium phosphate inj 4 mg/ml 3dexamethasone sodium phosphate inj 20 mg/5ml 3dexamethasone sodium phosphate inj 120 mg/30ml 3dexamethasone tab 0.5 mg 2dexamethasone tab 0.75 mg 2dexamethasone tab 1.5 mg 2dexamethasone tab 4 mg 2dexamethasone tab 6 mg 2fludrocortisone acetate tab 0.1 mg 2hydrocortisone tab 5 mg 2hydrocortisone tab 10 mg 2hydrocortisone tab 20 mg 2methylprednisolone sod succ for inj 40 mg 3methylprednisolone sod succ for inj 125 mg 3methylprednisolone sod succ for inj 500 mg 3

2019


91

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

10000 unit4 PA

DDAVP - desmopressin acetate nasal soln 0.01% (refrigerated) 4desmopressin acetate inj 4 mcg/ml 3desmopressin acetate nasal spray soln 0.01% 3desmopressin acetate nasal spray soln 0.01% (refrigerated) 3desmopressin acetate tab 0.1 mg 2desmopressin acetate tab 0.2 mg 2EGRIFTA - tesamorelin acetate for inj 1 mg* 5 PAINCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml)* 5OMNITROPE - somatropin for inj 5.8 mg 5 PAOMNITROPE - somatropin inj 5 mg/1.5ml 5 PAOMNITROPE - somatropin inj 10 mg/1.5ml 5 PAPREGNYL W/DILUENT BENZYL ALCOHOL/NACL -

chorionic gonadotropin for im inj 10000 unit4 PA

STIMATE - desmopressin acetate nasal soln 1.5 mg/ml 5

2019


Drug Name Drug Tier Requirements/LimitsHormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)ANADROL-50 - oxymetholone tab 50 mg 5 PAANDRODERM - testosterone td patch 24hr 2 mg/24hr 3 PA, QL (30 patches/30 days)ANDRODERM - testosterone td patch 24hr 4 mg/24hr 3 PA, QL (30 patches/30 days)ANDROGEL - testosterone td gel 20.25 mg/1.25gm (1.62%) 3 PA, QL (30 packets/30 days)ANDROGEL - testosterone td gel 40.5 mg/2.5gm (1.62%) 3 PA, QL (60 packets/30 days)ANDROGEL PUMP - testosterone td gel 20.25 mg/act (1.62%) 3 PA, QL (2 pump bottles/30 days)COMBIPATCH - estradiol-norethindrone ace td pttw 0.05-0.14 mg/

day#4

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

4

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

ml4

desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) 3desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg 3desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg 3DIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%)# 4DIVIGEL - estradiol td gel 0.5 mg/0.5gm (0.1%)# 4DIVIGEL - estradiol td gel 0.75 mg/0.75gm (0.1%)# 4DIVIGEL - estradiol td gel 1 mg/gm (0.1%)# 4drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg 3drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451 mg 3drospirenone-ethinyl estradiol tab 3-0.02 mg 3drospirenone-ethinyl estradiol tab 3-0.03 mg 3DUAVEE - conjugated estrogens-bazedoxifene tab 0.45-20 mg# 4ELLA - ulipristal acetate tab 30 mg 3estradiol & norethindrone acetate tab 0.5-0.1 mg# 4estradiol & norethindrone acetate tab 1-0.5 mg# 4estradiol tab 0.5 mg# 3estradiol tab 1 mg# 3estradiol tab 2 mg# 3estradiol td patch twice weekly 0.025 mg/24hr# 4estradiol td patch twice weekly 0.0375 mg/24hr# 4estradiol td patch twice weekly 0.05 mg/24hr# 4estradiol td patch twice weekly 0.075 mg/24hr# 4estradiol td patch twice weekly 0.1 mg/24hr# 4

2019


93

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

caproate im in oil 1.25 gm/5ml5

levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) 3levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) 3levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg 3levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg 3levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg 3levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg 3levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg 2medroxyprogesterone acetate im susp prefilled syr 150 mg/ml 3medroxyprogesterone acetate im susp 150 mg/ml 3medroxyprogesterone acetate tab 2.5 mg 2medroxyprogesterone acetate tab 5 mg 2medroxyprogesterone acetate tab 10 mg 2megestrol acetate susp 40 mg/ml# 3 PAmegestrol acetate tab 20 mg# 3 PAmegestrol acetate tab 40 mg# 3 PAmethyltestosterone cap 10 mg 5 PAnorethindrone & ethinyl estradiol tab 0.4 mg-35 mcg 3norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg 3norethindrone & ethinyl estradiol tab 1 mg-35 mcg 3norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg 3norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg 3norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg 3norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg 3norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg 3norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg 3norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg 3norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) 3

2019


Drug Name Drug Tier Requirements/Limitsnorethindrone acetate tab 5 mg 2norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg# 4norethindrone tab 0.35 mg 3norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg 3norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg 3norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg 3norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg 3norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg 3norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg 3oxandrolone tab 2.5 mg 3 PAoxandrolone tab 10 mg 5 PAPREMARIN - estrogens, conjugated vaginal cream 0.625 mg/gm 3PREMPHASE - conj est 0.625(14)/conj est-medroxypro ac tab

0.625-5mg(14)#4

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

4


4


4

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

4

progesterone micronized cap 100 mg 3progesterone micronized cap 200 mg 3raloxifene hcl tab 60 mg 2testosterone cypionate im inj in oil 100 mg/ml 3 PAtestosterone cypionate im inj in oil 200 mg/ml 3 PAtestosterone enanthate im inj in oil 200 mg/ml 3 PAtestosterone td gel 25 mg/2.5gm (1%) 3 PA, QL (90 packets/30 days)testosterone td gel 50 mg/5gm (1%) 3 PA, QL (60 units/30 days)testosterone td gel 12.5 mg/act (1%) 3 PA, QL (4 pump bottles/30 days)testosterone td gel 20.25 mg/1.25gm (1.62%) 3 PA, QL (30 packets/30 days)testosterone td gel 40.5 mg/2.5gm (1.62%) 3 PA, QL (60 packets/30 days)testosterone td gel 20.25 mg/act (1.62%) 3 PA, QL (2 pump bottles/30 days)testosterone td soln 30 mg/act 4 PA, QL (2 pump bottles/30 days)VAGIFEM - estradiol vaginal tab 10 mcg 4Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium tab 25 mcg (levo-t, levoxyl, unithroid,

unithroid direct)2

levothyroxine sodium tab 50 mcg (levo-t, levoxyl, unithroid,unithroid direct)

2

2019


95

Drug Name Drug Tier Requirements/Limitslevothyroxine sodium tab 75 mcg (levo-t, levoxyl, unithroid,

unithroid direct)2


2


2


2


2

levothyroxine sodium tab 137 mcg (levo-t, levoxyl, unithroid) 2levothyroxine sodium tab 150 mcg (levo-t, levoxyl, unithroid,

unithroid direct)2


2


2

levothyroxine sodium tab 300 mcg (levo-t, unithroid, unithroiddirect)

2

liothyronine sodium tab 5 mcg 2liothyronine sodium tab 25 mcg 2liothyronine sodium tab 50 mcg 2SYNTHROID - levothyroxine sodium tab 25 mcg 4SYNTHROID - levothyroxine sodium tab 50 mcg 4SYNTHROID - levothyroxine sodium tab 75 mcg 4SYNTHROID - levothyroxine sodium tab 88 mcg 4SYNTHROID - levothyroxine sodium tab 100 mcg 4SYNTHROID - levothyroxine sodium tab 112 mcg 4SYNTHROID - levothyroxine sodium tab 125 mcg 4SYNTHROID - levothyroxine sodium tab 137 mcg 4SYNTHROID - levothyroxine sodium tab 150 mcg 4SYNTHROID - levothyroxine sodium tab 175 mcg 4SYNTHROID - levothyroxine sodium tab 200 mcg 4SYNTHROID - levothyroxine sodium tab 300 mcg 4Hormonal Agents, Suppressant (Adrenal)KORLYM - mifepristone tab 300 mg* 5 PA, QL (120 tablets/30 days)LYSODREN - mitotane tab 500 mg 5Hormonal Agents, Suppressant (Pituitary)cabergoline tab 0.5 mg 2ELIGARD - leuprolide acetate (3 month) for subcutaneous inj kit

22.5mg4

2019


Drug Name Drug Tier Requirements/LimitsELIGARD - leuprolide acetate (4 month) for subcutaneous inj kit

30 mg4

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

4

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

3.75 mg5

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

kit 11.25 mg5

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

5

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

5

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

5

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

5

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

5

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

5

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

5

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

5

octreotide acetate inj 50 mcg/ml (0.05 mg/ml) 3 PAoctreotide acetate inj 100 mcg/ml (0.1 mg/ml) 3 PAoctreotide acetate inj 200 mcg/ml (0.2 mg/ml) 3 PAoctreotide acetate inj 500 mcg/ml (0.5 mg/ml) 3 PAoctreotide acetate inj 1000 mcg/ml (1 mg/ml) 5 PASIGNIFOR - pasireotide diaspartate inj 0.3 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.6 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.9 mg/ml* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 10 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 20 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 30 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 40 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 60 mg* 5 PA

2019


97

Drug Name Drug Tier Requirements/LimitsSOMATULINE DEPOT - lanreotide acetate extended release inj

60 mg/0.2ml5 PA

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

5 PA

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

5 PA

SOMAVERT - pegvisomant for inj 10 mg* 5 PASOMAVERT - pegvisomant for inj 15 mg* 5 PASOMAVERT - pegvisomant for inj 20 mg* 5 PASOMAVERT - pegvisomant for inj 25 mg* 5 PASOMAVERT - pegvisomant for inj 30 mg* 5 PASYNAREL - nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) 5TRELSTAR - triptorelin pamoate for im susp 3.75 mg 5 PATRELSTAR - triptorelin pamoate for im susp 11.25 mg 5 PATRELSTAR MIXJECT - triptorelin pamoate for im susp 3.75 mg 5 PATRELSTAR MIXJECT - triptorelin pamoate for im susp 11.25 mg 5 PATRELSTAR MIXJECT - triptorelin pamoate for im susp 22.5 mg 5 PAHormonal Agents, Suppressant (Thyroid)methimazole tab 5 mg 2methimazole tab 10 mg 2propylthiouracil tab 50 mg 2Immunological AgentsACTHIB - haemophilus b polysaccharide conjugate vaccine for inj 4ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000

unit/0.5ml)*5 PA

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

ml(eq)5 BD

AZASAN - azathioprine tab 75 mg 4 BDAZASAN - azathioprine tab 100 mg 4 BDAZATHIOPRINE - azathioprine sodium for inj 100 mg 3 BDazathioprine tab 50 mg 2 BDBCG VACCINE - bcg vaccine inj 3BENLYSTA - belimumab for iv soln 120 mg 5 PABENLYSTA - belimumab for iv soln 400 mg 5 PABENLYSTA - belimumab subcutaneous solution auto-injector

200 mg/ml5 PA

BENLYSTA - belimumab subcutaneous solution prefilled syringe200 mg/ml

5 PA

2019


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

syringe4

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

3

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

(300 mg dose)*5 PA

COSENTYX - secukinumab subcutaneous soln prefilled syringe150 mg/ml*

5 PA

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

5 PA

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

5 PA

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

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

DUPIXENT - dupilumab subcutaneous soln prefilled syringe200 mg/1.14ml

5 PA

DUPIXENT - dupilumab subcutaneous soln prefilled syringe300 mg/2ml

5 PA

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

25 mg/0.5ml5 PA

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

ml5 PA

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

5 PA

ENGERIX-B - hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml 4 BDENGERIX-B - hepatitis b vaccine (recombinant) susp 20 mcg/ml 4 BDFIRAZYR - icatibant acetate inj 30 mg/3ml 5 PA, QL (6 syringes/30 days)GAMMAGARD LIQUID - immune globulin (human) iv or

subcutaneous soln 1 gm/10ml5 BD, PA

2019


99

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

subcutaneous soln 2.5 gm/25ml5 BD, PA

GAMMAGARD LIQUID - immune globulin (human) iv orsubcutaneous soln 5 gm/50ml

5 BD, PA


5 BD, PA


5 BD, PA


5 BD, PA

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

1 gm/10ml5 BD, PA

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

5 BD, PA

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

5 BD, PA


5 BD, PA


5 BD, PA


5 BD, PA

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

4

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

4

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


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


HAVRIX - hepatitis a vaccine inj susp 720 el unit/0.5ml 4HAVRIX - hepatitis a vaccine inj susp 1440 el unit/ml 4HIBERIX - haemophilus b polysaccharide conjugate vac for inj

10 mcg4

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

2019


Drug Name Drug Tier Requirements/LimitsHUMIRA - adalimumab prefilled syringe kit 10 mg/0.2ml 5 PAHUMIRA - adalimumab prefilled syringe kit 20 mg/0.2ml 5 PAHUMIRA - adalimumab prefilled syringe kit 20 mg/0.4ml 5 PAHUMIRA - adalimumab prefilled syringe kit 40 mg/0.8ml 5 PAHUMIRA - adalimumab prefilled syringe kit 40 mg/0.4ml 5 PAHUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -

adalimumab prefilled syringe kit 40 mg/0.8ml5 PA

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

5 PA

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

5 PA

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

40 mg/0.8ml5 PA

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

5 PA

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

5 PA

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

5 PA

icatibant acetate inj 30 mg/3ml 5 PA, QL (6 syringes/30 days)ILARIS - canakinumab subcutaneous inj 150 mg/ml* 5 PAIMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj 4 BDINFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml 4IPOL INACTIVATED IPV - poliovirus vaccine, ipv injection 4IXIARO - japanese encephalitis vaccine inactivated adsorbed inj 4KINERET - anakinra subcutaneous soln prefilled syringe

100 mg/0.67ml5 PA

KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj 4leflunomide tab 10 mg 2leflunomide tab 20 mg 2M-M-R II - measles-mumps-rubella virus vaccines for inj soln 4MENACTRA - meningococcal (a, c, y, and w-135) conjugate

vaccine inj4

MENVEO - meningococcal (a, c, y, and w-135) oligo conj vac for inj 4METHOTREXATE SODIUM - methotrexate sodium inj

250 mg/10ml (25 mg/ml)3

methotrexate sodium for inj 1 gm 3methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) 3methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) 3

2019


101

Drug Name Drug Tier Requirements/Limitsmethotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) 3methotrexate sodium inj 50 mg/2ml (25 mg/ml) 3methotrexate sodium tab 2.5 mg 2mycophenolate mofetil cap 250 mg 2 BDmycophenolate mofetil for oral susp 200 mg/ml 5 BDmycophenolate mofetil hcl for iv soln 500 mg 3 BDmycophenolate mofetil tab 500 mg 2 BDmycophenolate sodium tab dr 180 mg 3 BDmycophenolate sodium tab dr 360 mg 3 BDNULOJIX - belatacept for iv infusion 250 mg 5 BDORENCIA - abatacept for iv soln 250 mg 5 PAORENCIA - abatacept subcutaneous soln prefilled syringe

50 mg/0.4ml5 PA

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

5 PA

ORENCIA - abatacept subcutaneous soln prefilled syringe 125 mg/ml

5 PA

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

5 PA

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

5 PA

OTEZLA - apremilast tab 30 mg* 5 PAPEDIARIX - diph-tetanus tox-acell pert-hepatitis b-polio ipv vac inj 4PEDVAX HIB - haemophilus b polysaccharide conj vac im susp

7.5 mcg/0.5 ml4

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

4

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

susp4

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

4

RABAVERT - rabies vaccine, pcec for inj 4 BDRAPAMUNE - sirolimus oral soln 1 mg/ml 5 BDRECOMBIVAX HB - hepatitis b vaccine (recombinant) susp

5 mcg/0.5ml4 BD

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

4 BD

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

4 BD

2019


Drug Name Drug Tier Requirements/LimitsRENFLEXIS - infliximab-abda for iv inj 100 mg 5 PARIDAURA - auranofin cap 3 mg 5ROTARIX - rotavirus vaccine, live for oral susp 4ROTATEQ - rotavirus vaccine, live oral pentavalent soln 4SANDIMMUNE - cyclosporine oral soln 100 mg/ml 4 BDSHINGRIX - zoster vac recombinant adjuvanted for im inj

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

SIMULECT - basiliximab for iv soln 10 mg 5 BDSIMULECT - basiliximab for iv soln 20 mg 5 BDsirolimus oral soln 1 mg/ml 5 BDsirolimus tab 0.5 mg 3 BDsirolimus tab 1 mg 3 BDsirolimus tab 2 mg 5 BDSTAMARIL - yellow fever vaccine for inj suspension 4STELARA - ustekinumab inj 45 mg/0.5ml 5 PASTELARA - ustekinumab iv soln 130 mg/26ml (5 mg/ml) (for iv

infusion)5 PA

STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml 5 PASTELARA - ustekinumab soln prefilled syringe 90 mg/ml 5 PASYLVANT - siltuximab for iv infusion 100 mg 5SYLVANT - siltuximab for iv infusion 400 mg 5SYNAGIS - palivizumab im soln 50 mg/0.5ml* 5SYNAGIS - palivizumab im soln 100 mg/ml* 5tacrolimus cap 0.5 mg 3 BDtacrolimus cap 1 mg 3 BDtacrolimus cap 5 mg 3 BDTDVAX - tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml 3TENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu 4THYMOGLOBULIN - anti-thymocyte globulin for iv soln 25 mg

(lymphocyte ig)5 BD

TRUMENBA - meningococcal group b vac (recomb) im suspprefilled syr

4

TWINRIX - hep a-hep b vaccine susp pref syr 720-20 elu-mcg/ml 4TYPHIM VI - typhoid vi polysaccharide intramuscular vac inj

25 mcg/0.5ml4

VAQTA - hepatitis a vaccine inj susp 25 unit/0.5ml 4VAQTA - hepatitis a vaccine inj susp 50 unit/ml 4VARIVAX - varicella virus vac live for subcutaneous inj 1350

pfu/0.5ml4

XATMEP - methotrexate oral soln 2.5 mg/ml 5 BD

2019


103

Drug Name Drug Tier Requirements/LimitsXOLAIR - omalizumab for inj 150 mg* 5 PAXOLAIR - omalizumab subcutaneous soln prefilled syringe

75 mg/0.5ml*5 PA

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

5 PA

YF-VAX - yellow fever vaccine subcutaneous inj 4ZORTRESS - everolimus tab 0.25 mg 5 BDZORTRESS - everolimus tab 0.5 mg 5 BDZORTRESS - everolimus tab 0.75 mg 5 BDZORTRESS - everolimus tab 1 mg 5 BDZOSTAVAX - zoster vaccine live for subcutaneous susp 19400

unit/0.65ml3 QL (1 vaccine/lifetime)

Inflammatory Bowel Disease AgentsAPRISO - mesalamine cap er 24hr 0.375 gm 4ASACOL HD - mesalamine tab delayed release 800 mg 3balsalazide disodium cap 750 mg 2budesonide delayed release particles cap 3 mg 4CANASA - mesalamine suppos 1000 mg 5DELZICOL - mesalamine cap dr 400 mg 3DIPENTUM - olsalazine sodium cap 250 mg 5hydrocortisone enema 100 mg/60ml 3hydrocortisone rectal cream 1% 2hydrocortisone rectal cream 2.5% 2mesalamine cap dr 400 mg 3mesalamine enema 4 gm 2mesalamine rectal enema 4 gm & cleanser wipe kit 2mesalamine suppos 1000 mg 5mesalamine tab delayed release 800 mg 3mesalamine tab delayed release 1.2 gm 3PENTASA - mesalamine cap er 250 mg 4PENTASA - mesalamine cap er 500 mg 4sulfasalazine tab delayed release 500 mg 2sulfasalazine tab 500 mg 2Metabolic Bone Disease Agentsalendronate sodium tab 5 mg 1 QL (30 tablets/30 days)alendronate sodium tab 10 mg 1 QL (120 tablets/30 days)alendronate sodium tab 35 mg 1 QL (4 tablets/28 days)alendronate sodium tab 70 mg 1 QL (4 tablets/28 days)calcitonin (salmon) nasal soln 200 unit/act 2calcitriol cap 0.25 mcg 2

2019


Drug Name Drug Tier Requirements/Limitscalcitriol cap 0.5 mcg 2calcitriol inj 1 mcg/ml 4calcitriol oral soln 1 mcg/ml 3cinacalcet hcl tab 30 mg 5 PAcinacalcet hcl tab 60 mg 5 PAcinacalcet hcl tab 90 mg 5 PAETIDRONATE DISODIUM - etidronate disodium tab 200 mg 3ETIDRONATE DISODIUM - etidronate disodium tab 400 mg 3FORTEO - teriparatide (recombinant) inj 600 mcg/2.4ml 5 PAibandronate sodium iv soln 3 mg/3ml 3ibandronate sodium tab 150 mg 2 QL (1 tablet/28 days)MIACALCIN - calcitonin (salmon) inj 200 unit/ml 5NATPARA - parathyroid hormone (recombinant) for inj cartridge

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

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

5 PA, QL (2 cartridges/28 days)





paricalcitol cap 1 mcg 3paricalcitol cap 2 mcg 3paricalcitol cap 4 mcg 3paricalcitol iv soln 2 mcg/ml 3paricalcitol iv soln 5 mcg/ml 3PROLIA - denosumab inj soln prefilled syringe 60 mg/ml 4 PArisedronate sodium tab delayed release 35 mg 2 QL (4 tablets/28 days)risedronate sodium tab 5 mg 2 QL (30 tablets/30 days)risedronate sodium tab 30 mg 2 QL (30 tablets/30 days)risedronate sodium tab 35 mg 2 QL (4 tablets/28 days)risedronate sodium tab 150 mg 2 QL (1 tablet/28 days)SENSIPAR - cinacalcet hcl tab 30 mg 5 PASENSIPAR - cinacalcet hcl tab 60 mg 5 PASENSIPAR - cinacalcet hcl tab 90 mg 5 PATYMLOS - abaloparatide subcutaneous soln pen-injector

3120 mcg/1.56ml5 PA

XGEVA - denosumab inj 120 mg/1.7ml 5 PAzoledronic acid inj conc for iv infusion 4 mg/5ml 4zoledronic acid iv soln 5 mg/100ml 4

2019


105

Drug Name Drug Tier Requirements/LimitsOphthalmic AgentsALPHAGAN P - brimonidine tartrate ophth soln 0.1% 3azelastine hcl ophth soln 0.05% 2AZOPT - brinzolamide ophth susp 1% 4BACITRACIN - bacitracin ophth oint 500 unit/gm 3bacitracin-polymyxin b ophth oint 2bacitracin-polymyxin-neomycin-hc ophth oint 1% 2BESIVANCE - besifloxacin hcl ophth susp 0.6% 4betaxolol hcl ophth soln 0.5% 2BETOPTIC-S - betaxolol hcl ophth susp 0.25% 4bimatoprost ophth soln 0.03% 2brimonidine tartrate ophth soln 0.15% 2brimonidine tartrate ophth soln 0.2% 2bromfenac sodium ophth soln 0.09% (once-daily) 2carteolol hcl ophth soln 1% 2CILOXAN - ciprofloxacin hcl ophth soln 0.3% 4ciprofloxacin hcl ophth soln 0.3% 2COMBIGAN - brimonidine tartrate-timolol maleate ophth soln

0.2-0.5%3

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

sodium phosphate ophth soln 0.1%3

diclofenac sodium ophth soln 0.1% 2dorzolamide hcl ophth soln 2% 2dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml 2DUREZOL - difluprednate ophth emulsion 0.05% 3epinastine hcl ophth soln 0.05% 2erythromycin ophth oint 5 mg/gm 2fluorometholone ophth susp 0.1% 3flurbiprofen sodium ophth soln 0.03% 2FML LIQUIFILM - fluorometholone ophth susp 0.1% 4gatifloxacin ophth soln 0.5% 3gentamicin sulfate ophth oint 0.3% 2gentamicin sulfate ophth soln 0.3% 2ILEVRO - nepafenac ophth susp 0.3% 3ISTALOL - timolol maleate ophth soln 0.5% (once-daily) 4ketorolac tromethamine ophth soln 0.4% 2ketorolac tromethamine ophth soln 0.5% 2

2019


Drug Name Drug Tier Requirements/LimitsLACRISERT - artificial tear ophth insert 4latanoprost ophth soln 0.005% 2levobunolol hcl ophth soln 0.5% 2levofloxacin ophth soln 0.5% 3LUMIGAN - bimatoprost ophth soln 0.01% 3MAXITROL - neomycin-polymyxin-dexamethasone ophth oint 0.1% 4MOXEZA - moxifloxacin hcl ophth soln 0.5% (2 times daily) 4moxifloxacin hcl ophth soln 0.5% 2NATACYN - natamycin ophth susp 5% 4neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin 2neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml 2neomycin-polymyxin-dexamethasone ophth oint 0.1% 2neomycin-polymyxin-dexamethasone ophth susp 0.1% 2OCUFLOX - ofloxacin ophth soln 0.3% 4ofloxacin ophth soln 0.3% 2olopatadine hcl ophth soln 0.1% 2olopatadine hcl ophth soln 0.2% 2PAZEO - olopatadine hcl ophth soln 0.7% 3PHOSPHOLINE IODIDE - echothiophate iodide ophth for soln

0.125%4

pilocarpine hcl ophth soln 1% 3pilocarpine hcl ophth soln 2% 3pilocarpine hcl ophth soln 4% 3polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% 2POLYTRIM - polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1%4

PRED FORTE - prednisolone acetate ophth susp 1% 4prednisolone acetate ophth susp 1% 3PROLENSA - bromfenac sodium ophth soln 0.07% 4RESTASIS - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (60 vials/30 days)RESTASIS MULTIDOSE - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (2 bottles/30 days)SIMBRINZA - brinzolamide-brimonidine tartrate ophth susp 1-0.2% 3sulfacetamide sodium ophth soln 10% 2sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% 2timolol maleate ophth gel forming soln 0.25% 2timolol maleate ophth gel forming soln 0.5% 2timolol maleate ophth soln 0.25% 2timolol maleate ophth soln 0.5% 2timolol maleate ophth soln 0.5% (once-daily) 3

2019


107

Drug Name Drug Tier Requirements/LimitsTIMOPTIC - timolol maleate ophth soln 0.25% 4TIMOPTIC - timolol maleate ophth soln 0.5% 4TIMOPTIC-XE - timolol maleate ophth gel forming soln 0.25% 4TOBRADEX - tobramycin-dexamethasone ophth oint 0.3-0.1% 4tobramycin ophth soln 0.3% 2tobramycin-dexamethasone ophth susp 0.3-0.1% 2TRAVATAN Z - travoprost ophth soln 0.004% 3trifluridine ophth soln 1% 2Otic Agentsacetic acid otic soln 2% 2CIPRODEX - ciprofloxacin-dexamethasone otic susp 0.3-0.1% 4fluocinolone acetonide (otic) oil 0.01% 3hydrocortisone w/ acetic acid otic soln 1-2% 3neomycin-polymyxin-hc otic soln 1% 2neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% 2ofloxacin otic soln 0.3% 3Respiratory Tract/Pulmonary Agentsacetylcysteine inhal soln 10% 2 BDacetylcysteine inhal soln 20% 2 BDADCIRCA - tadalafil tab 20 mg (pah) 5 PA, QL (60 tablets/30 days)ADEMPAS - riociguat tab 0.5 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1.5 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2.5 mg 5 PA, QL (90 tablets/30 days)ADVAIR DISKUS - fluticasone-salmeterol aer powder ba

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

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

3 QL (1 inhaler/30 days)

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


ADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21 mcg/act 3 QL (1 canister/30 days)ADVAIR HFA - fluticasone-salmeterol inhal aerosol 115-21 mcg/act 3 QL (1 canister/30 days)ADVAIR HFA - fluticasone-salmeterol inhal aerosol 230-21 mcg/act 3 QL (1 canister/30 days)albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 2 BDalbuterol sulfate soln nebu 0.5% (5 mg/ml) 2 BDalbuterol sulfate soln nebu 0.63 mg/3ml 2 BDalbuterol sulfate soln nebu 1.25 mg/3ml 2 BDalbuterol sulfate syrup 2 mg/5ml 2albuterol sulfate tab er 12hr 4 mg 3

2019


Drug Name Drug Tier Requirements/Limitsalbuterol sulfate tab er 12hr 8 mg 3albuterol sulfate tab 2 mg 3albuterol sulfate tab 4 mg 3ambrisentan tab 5 mg* 5 PA, QL (30 tablets/30 days)ambrisentan tab 10 mg* 5 PA, QL (30 tablets/30 days)ANORO ELLIPTA - umeclidinium-vilanterol aero powd ba

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

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

3 QL (30 blisters/30 days)





ASMANEX HFA - mometasone furoate inhal aerosol suspension100 mcg/act

3 QL (1 canister/30 days)

ASMANEX HFA - mometasone furoate inhal aerosol suspension200 mcg/act


ASMANEX TWISTHALER 120 METERED DOSES - mometasonefuroate inhal powd 220 mcg/inh












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

4 QL (2 canisters/30 days)

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

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

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

3 QL (1 package/30 days)

budesonide inhalation susp 0.25 mg/2ml 3 BDbudesonide inhalation susp 0.5 mg/2ml 3 BDbudesonide inhalation susp 1 mg/2ml 3 BDcaffeine citrate oral soln 60 mg/3ml 2

2019


109

Drug Name Drug Tier Requirements/LimitsCLEMASTINE FUMARATE - clemastine fumarate tab 2.68 mg# 4 PACOMBIVENT RESPIMAT - ipratropium-albuterol inhal aerosol soln

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

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

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

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


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

for EpiPen 2-Pak)3

ESBRIET - pirfenidone cap 267 mg* 5 PA, QL (270 capsules/30 days)ESBRIET - pirfenidone tab 267 mg* 5 PA, QL (270 tablets/30 days)ESBRIET - pirfenidone tab 801 mg* 5 PA, QL (90 tablets/30 days)FLOVENT DISKUS - fluticasone propionate aer pow ba 50 mcg/

blister3 QL (1 inhaler/30 days)

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


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

3 QL (4 inhalers/30 days)

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


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


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


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

salmeterol aer powder ba 55-14 mcg/act2 QL (1 inhaler/30 days)

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


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


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


ipratropium bromide inhal soln 0.02% 2 BDipratropium bromide nasal soln 0.03% (21 mcg/spray) 2 QL (2 bottles/30 days)ipratropium bromide nasal soln 0.06% (42 mcg/spray) 2 QL (3 bottles/30 days)KALYDECO - ivacaftor packet 25 mg 5 PA, QL (60 packets/30 days)

2019


Drug Name Drug Tier Requirements/LimitsKALYDECO - ivacaftor packet 50 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor packet 75 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor tab 150 mg 5 PA, QL (60 tablets/30 days)LETAIRIS - ambrisentan tab 5 mg* 5 PA, QL (30 tablets/30 days)LETAIRIS - ambrisentan tab 10 mg* 5 PA, QL (30 tablets/30 days)levocetirizine dihydrochloride tab 5 mg 1mometasone furoate nasal susp 50 mcg/act 2 QL (2 bottles/30 days)montelukast sodium chew tab 4 mg 2montelukast sodium chew tab 5 mg 2montelukast sodium oral granules packet 4 mg 3montelukast sodium tab 10 mg 2OFEV - nintedanib esylate cap 100 mg* 5 PA, QL (60 capsules/30 days)OFEV - nintedanib esylate cap 150 mg* 5 PA, QL (60 capsules/30 days)olopatadine hcl nasal soln 0.6% 2 QL (1 bottle/30 days)OPSUMIT - macitentan tab 10 mg* 5 PA, QL (30 tablets/30 days)ORALAIR - grass mixed pollen ext sl tab 300 ir 4 PA, QL (30 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor granules packet 100-125 mg* 5 PA, QL (60 packets/30 days)ORKAMBI - lumacaftor-ivacaftor granules packet 150-188 mg* 5 PA, QL (60 packets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 100-125 mg* 5 PA, QL (120 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 200-125 mg* 5 PA, QL (120 tablets/30 days)PROAIR HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (36 grams/30 days)PROAIR RESPICLICK - albuterol sulfate aer pow ba 108 mcg/act 3 QL (2 canisters/30 days)PULMOZYME - dornase alfa inhal soln 1 mg/ml 5 BDQVAR REDIHALER - beclomethasone diprop hfa breath act inh aer

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

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


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

dose3 QL (1 inhaler/30 days)

sildenafil citrate tab 20 mg 2 PA, QL (90 tablets/30 days)SPIRIVA HANDIHALER - tiotropium bromide monohydrate inhal

cap 18 mcg3 QL (30 capsules/30 days)

SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhalaerosol 1.25 mcg/act


2019


111

Drug Name Drug Tier Requirements/LimitsSPIRIVA RESPIMAT - tiotropium bromide monohydrate inhal

aerosol 2.5 mcg/act3 QL (1 inhaler/30 days)

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


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


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


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


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


tadalafil tab 20 mg (pah) 5 PA, QL (60 tablets/30 days)terbutaline sulfate tab 2.5 mg 3terbutaline sulfate tab 5 mg 3theophylline tab er 12hr 300 mg 2theophylline tab er 12hr 450 mg 2theophylline tab er 24hr 400 mg 2theophylline tab er 24hr 600 mg 2tobramycin nebu soln 300 mg/5ml 5 BDTRACLEER - bosentan tab for oral susp 32 mg* 5 PA, QL (120 tablets/30 days)TRACLEER - bosentan tab 62.5 mg* 5 PA, QL (60 tablets/30 days)TRACLEER - bosentan tab 125 mg* 5 PA, QL (60 tablets/30 days)TRELEGY ELLIPTA - fluticasone-umeclidinium-vilanterol aepb

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

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

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

tablets)/28 days)UPTRAVI - selexipag tab 200 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 400 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 600 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 800 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1000 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1200 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1400 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1600 mcg* 5 PA, QL (60 tablets/30 days)VENTAVIS - iloprost inhalation solution 10 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTAVIS - iloprost inhalation solution 20 mcg/ml 5 BD, PA, QL (270 mls/30 days)

2019

112

Drug Name Drug Tier Requirements/LimitsVENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (36 grams/30 days)XOPENEX HFA - levalbuterol tartrate inhal aerosol 45 mcg/act 4 QL (2 canisters/30 days)zafirlukast tab 10 mg 3zafirlukast tab 20 mg 3Skeletal Muscle Relaxantscyclobenzaprine hcl tab 5 mg# 4 PAcyclobenzaprine hcl tab 7.5 mg# 4 PAcyclobenzaprine hcl tab 10 mg# 4 PAmethocarbamol tab 500 mg# 4 PAmethocarbamol tab 750 mg# 4 PASleep Disorder Agentsarmodafinil tab 50 mg 3 PA, QL (30 tablets/30 days)armodafinil tab 150 mg 3 PA, QL (30 tablets/30 days)armodafinil tab 200 mg 3 PA, QL (30 tablets/30 days)armodafinil tab 250 mg 3 PA, QL (30 tablets/30 days)BELSOMRA - suvorexant tab 5 mg 3 QL (30 tablets/30 days)BELSOMRA - suvorexant tab 10 mg 3 QL (30 tablets/30 days)BELSOMRA - suvorexant tab 15 mg 3 QL (30 tablets/30 days)BELSOMRA - suvorexant tab 20 mg 3 QL (30 tablets/30 days)HETLIOZ - tasimelteon capsule 20 mg* 5 PA, QL (30 capsules/30 days)modafinil tab 100 mg 3 PA, QL (30 tablets/30 days)modafinil tab 200 mg 3 PA, QL (30 tablets/30 days)SILENOR - doxepin hcl tab 3 mg 3 QL (30 tablets/30 days)SILENOR - doxepin hcl tab 6 mg 3 QL (30 tablets/30 days)temazepam cap 15 mg 3 QL (30 capsules/30 days)temazepam cap 30 mg 3 QL (30 capsules/30 days)XYREM - sodium oxybate oral solution 500 mg/ml* 5 PA, QL (540 mls/30 days)zaleplon cap 5 mg# 4 PAzaleplon cap 10 mg# 4 PAzolpidem tartrate tab 5 mg# 4 PAzolpidem tartrate tab 10 mg# 4 PA


2019

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INDEX

Aabacavir sulfate-lamivudine tab 600-300

mg................................................................................45abacavir sulfate-lamivudine-zidovudine tab

300-150-300 mg........................................................45abacavir sulfate soln 20 mg/ml.................................. 45abacavir sulfate tab 300 mg.......................................45abiraterone acetate tab 250 mg.................................27ABRAXANE...................................................................27ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1acamprosate calcium tab delayed release 333

mg..................................................................................4acarbose tab 100 mg.................................................. 51acarbose tab 25 mg.................................................... 51acarbose tab 50 mg.................................................... 51ACCUPRIL.................................................................... 62ACCUPRIL.................................................................... 62ACCUPRIL.................................................................... 62ACCUPRIL.................................................................... 62ACCURETIC................................................................. 62ACCURETIC................................................................. 62ACCURETIC................................................................. 62acebutolol hcl cap 200 mg..........................................62acebutolol hcl cap 400 mg..........................................62acetaminophen w/ codeine soln 120-12

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

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

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

mg..................................................................................1acetazolamide cap er 12hr 500 mg...........................62acetazolamide tab 125 mg......................................... 62acetazolamide tab 250 mg......................................... 62acetic acid otic soln 2%............................................ 107acetylcysteine inhal soln 10%..................................107acetylcysteine inhal soln 20%..................................107acitretin cap 10 mg......................................................79acitretin cap 17.5 mg...................................................79acitretin cap 25 mg......................................................79ACTHAR........................................................................90ACTHIB..........................................................................97ACTIMMUNE................................................................ 97

ACTOS...........................................................................51ACTOS...........................................................................51ACTOS...........................................................................51acyclovir cap 200 mg.................................................. 45acyclovir oint 5%..........................................................45acyclovir sodium iv soln 50 mg/ml.............................45acyclovir susp 200 mg/5ml......................................... 45acyclovir tab 400 mg................................................... 45acyclovir tab 800 mg................................................... 45ADACEL........................................................................ 97ADALAT CC..................................................................62ADALAT CC..................................................................62ADALAT CC..................................................................62ADASUVE..................................................................... 40ADCIRCA.................................................................... 107adefovir dipivoxil tab 10 mg........................................45ADEMPAS...................................................................107ADEMPAS...................................................................107ADEMPAS...................................................................107ADEMPAS...................................................................107ADEMPAS...................................................................107ADVAIR DISKUS....................................................... 107ADVAIR DISKUS....................................................... 107ADVAIR DISKUS....................................................... 107ADVAIR HFA.............................................................. 107ADVAIR HFA.............................................................. 107ADVAIR HFA.............................................................. 107AFINITOR......................................................................27AFINITOR......................................................................27AFINITOR......................................................................27AFINITOR......................................................................27AFINITOR DISPERZ................................................... 27AFINITOR DISPERZ................................................... 27AFINITOR DISPERZ................................................... 27AIMOVIG....................................................................... 25AIMOVIG....................................................................... 25albendazole tab 200 mg............................................. 38ALBENZA...................................................................... 38albuterol sulfate soln nebu 0.083% (2.5

mg/3ml).....................................................................107albuterol sulfate soln nebu 0.5% (5 mg/

ml)............................................................................. 107albuterol sulfate soln nebu 0.63

mg/3ml......................................................................107albuterol sulfate soln nebu 1.25

mg/3ml......................................................................107albuterol sulfate syrup 2 mg/5ml..............................107albuterol sulfate tab 2 mg.........................................108albuterol sulfate tab 4 mg.........................................108albuterol sulfate tab er 12hr 4 mg........................... 107albuterol sulfate tab er 12hr 8 mg........................... 108

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114

alclometasone dipropionate cream0.05%..........................................................................79

alclometasone dipropionate oint0.05%..........................................................................79

ALCOHOL SWABS......................................................51ALDACTONE................................................................ 62ALDACTONE................................................................ 62ALDACTONE................................................................ 62ALDURAZYME............................................................. 87ALECENSA................................................................... 27alendronate sodium tab 10 mg................................ 103alendronate sodium tab 35 mg................................ 103alendronate sodium tab 5 mg.................................. 103alendronate sodium tab 70 mg................................ 103alfuzosin hcl tab er 24hr 10 mg................................. 89ALIMTA.......................................................................... 27ALIMTA.......................................................................... 27ALINIA............................................................................38ALINIA............................................................................38ALIQOPA....................................................................... 27aliskiren fumarate tab 150 mg....................................62aliskiren fumarate tab 300 mg....................................62allopurinol sodium for inj 500 mg...............................25allopurinol tab 100 mg.................................................25allopurinol tab 300 mg.................................................25alosetron hcl tab 0.5 mg............................................. 85alosetron hcl tab 1 mg................................................ 85ALPHAGAN P............................................................ 105alprazolam tab 0.25 mg.............................................. 50alprazolam tab 0.5 mg................................................ 50alprazolam tab 1 mg....................................................50alprazolam tab 2 mg....................................................50ALTACE......................................................................... 62ALTACE......................................................................... 62ALTACE......................................................................... 62ALTACE......................................................................... 62ALUNBRIG....................................................................27ALUNBRIG....................................................................27ALUNBRIG....................................................................27ALUNBRIG....................................................................27amantadine hcl cap 100 mg.......................................39amantadine hcl syrup 50 mg/5ml...............................39amantadine hcl tab 100 mg........................................39AMARYL........................................................................ 51AMARYL........................................................................ 51AMARYL........................................................................ 51AMBISOME...................................................................23ambrisentan tab 10 mg.............................................108ambrisentan tab 5 mg............................................... 108AMERGE....................................................................... 25AMERGE....................................................................... 25

amikacin sulfate inj 1 gm/4ml (250 mg/ml)..................................................................................5

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

amiloride & hydrochlorothiazide tab 5-50mg................................................................................62

amiloride hcl tab 5 mg.................................................62amino acid infusion 15%.............................................82amino acid infusion 6%...............................................82AMINOSYN II............................................................... 82AMINOSYN-PF.............................................................82AMINOSYN-PF 7%......................................................82amiodarone hcl tab 100 mg........................................62amiodarone hcl tab 200 mg........................................62amiodarone hcl tab 400 mg........................................62AMITIZA.........................................................................85AMITIZA.........................................................................85amitriptyline hcl tab 100 mg....................................... 18amitriptyline hcl tab 10 mg..........................................18amitriptyline hcl tab 150 mg....................................... 18amitriptyline hcl tab 25 mg..........................................18amitriptyline hcl tab 50 mg..........................................18amitriptyline hcl tab 75 mg..........................................18amlodipine besylate-atorvastatin calcium tab 10-10

mg................................................................................63amlodipine besylate-atorvastatin calcium tab 10-20



mg................................................................................63amlodipine besylate-atorvastatin calcium tab 2.5-10







mg................................................................................63amlodipine besylate-benazepril hcl cap 10-20

mg................................................................................63amlodipine besylate-benazepril hcl cap 10-40

mg................................................................................63amlodipine besylate-benazepril hcl cap 2.5-10

mg................................................................................63

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115

amlodipine besylate-benazepril hcl cap 5-10mg................................................................................63



amlodipine besylate-olmesartan medoxomil tab10-20 mg....................................................................63

amlodipine besylate-olmesartan medoxomil tab10-40 mg....................................................................63

amlodipine besylate-olmesartan medoxomil tab 5-20mg................................................................................63

amlodipine besylate-olmesartan medoxomil tab 5-40mg................................................................................63

amlodipine besylate tab 10 mg..................................62amlodipine besylate tab 2.5 mg.................................62amlodipine besylate tab 5 mg.................................... 62amlodipine besylate-valsartan tab 10-160

mg................................................................................63amlodipine besylate-valsartan tab 10-320



mg................................................................................63amlodipine-valsartan-hydrochlorothiazide tab

10-160-12.5 mg.........................................................63amlodipine-valsartan-hydrochlorothiazide tab

10-160-25 mg............................................................63amlodipine-valsartan-hydrochlorothiazide tab

10-320-25 mg............................................................63amlodipine-valsartan-hydrochlorothiazide tab

5-160-12.5 mg...........................................................63amlodipine-valsartan-hydrochlorothiazide tab

5-160-25 mg.............................................................. 63AMOXAPINE.................................................................18AMOXAPINE.................................................................18AMOXAPINE.................................................................18AMOXAPINE.................................................................18AMOXICILLIN................................................................. 5AMOXICILLIN................................................................. 5AMOXICILLIN/CLAVULANATE

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

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

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

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

amoxicillin (trihydrate) for susp 250mg/5ml.......................................................................... 5

amoxicillin (trihydrate) for susp 400mg/5ml.......................................................................... 5

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

mg/5ml.......................................................................... 5amoxicillin & k clavulanate for susp 250-62.5

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

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

mg/5ml.......................................................................... 6amoxicillin & k clavulanate tab 250-125

mg..................................................................................6amoxicillin & k clavulanate tab 500-125

mg..................................................................................6amoxicillin & k clavulanate tab 875-125

mg..................................................................................6amoxicillin & k clavulanate tab er 12hr 1000-62.5

mg..................................................................................6amphetamine-dextroamphetamine cap er 24hr 10

mg................................................................................77amphetamine-dextroamphetamine cap er 24hr 15





mg................................................................................77amphetamine-dextroamphetamine tab 10

mg................................................................................77amphetamine-dextroamphetamine tab 12.5





mg................................................................................77amphetamine-dextroamphetamine tab 7.5

mg................................................................................77AMPHOTERICIN B......................................................23ampicillin & sulbactam sodium for inj 3 (2-1)

gm..................................................................................6ampicillin cap 500 mg....................................................6

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AMPICILLIN SODIUM................................................... 6ampicillin sodium for inj 1 gm.......................................6ampicillin sodium for inj 250 mg...................................6ampicillin sodium for inj 2 gm.......................................6ampicillin sodium for inj 500 mg...................................6ampicillin sodium for iv soln 10 gm..............................6ampicillin sodium for iv soln 2 gm................................6AMPICILLIN-SULBACTAM........................................... 6AMPYRA........................................................................78ANADROL-50............................................................... 92anagrelide hcl cap 0.5 mg.......................................... 58anagrelide hcl cap 1 mg............................................. 58anastrozole tab 1 mg...................................................27ANDRODERM.............................................................. 92ANDRODERM.............................................................. 92ANDROGEL.................................................................. 92ANDROGEL.................................................................. 92ANDROGEL PUMP..................................................... 92ANORO ELLIPTA.......................................................108APOKYN........................................................................39aprepitant capsule 125 mg.........................................22aprepitant capsule 40 mg........................................... 22aprepitant capsule 80 mg........................................... 22aprepitant capsule therapy pack 80 & 125

mg................................................................................22APRISO....................................................................... 103APTIOM......................................................................... 13APTIOM......................................................................... 13APTIOM......................................................................... 13APTIOM......................................................................... 13APTIVUS....................................................................... 45APTIVUS....................................................................... 45ARANESP ALBUMIN FREE.......................................58ARANESP ALBUMIN FREE.......................................58ARANESP ALBUMIN FREE.......................................58ARANESP ALBUMIN FREE.......................................58ARANESP ALBUMIN FREE.......................................58ARANESP ALBUMIN FREE.......................................58ARANESP ALBUMIN FREE.......................................58ARANESP ALBUMIN FREE.......................................58ARANESP ALBUMIN FREE.......................................59ARANESP ALBUMIN FREE.......................................59ARANESP ALBUMIN FREE.......................................59ARANESP ALBUMIN FREE.......................................59ARANESP ALBUMIN FREE.......................................59ARANESP ALBUMIN FREE.......................................59ARANESP ALBUMIN FREE.......................................59ARCALYST....................................................................97aripiprazole orally disintegrating tab 10

mg................................................................................40aripiprazole orally disintegrating tab 15

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

aripiprazole oral solution 1 mg/ml..............................40aripiprazole tab 10 mg................................................ 40aripiprazole tab 15 mg................................................ 41aripiprazole tab 20 mg................................................ 41aripiprazole tab 2 mg...................................................40aripiprazole tab 30 mg................................................ 41aripiprazole tab 5 mg...................................................40ARISTADA.....................................................................41ARISTADA.....................................................................41ARISTADA.....................................................................41ARISTADA.....................................................................41ARISTADA INITIO........................................................41armodafinil tab 150 mg............................................. 112armodafinil tab 200 mg............................................. 112armodafinil tab 250 mg............................................. 112armodafinil tab 50 mg............................................... 112ARNUITY ELLIPTA....................................................108ARNUITY ELLIPTA....................................................108ARNUITY ELLIPTA....................................................108ARRANON.................................................................... 28arsenic trioxide iv soln 10 mg/10ml (1 mg/

ml)................................................................................28arsenic trioxide iv soln 12 mg/6ml (2 mg/

ml)................................................................................28ARZERRA..................................................................... 28ARZERRA..................................................................... 28ASACOL HD...............................................................103ASMANEX HFA..........................................................108ASMANEX HFA..........................................................108ASMANEX TWISTHALER 120 METERED

DOSES.....................................................................108ASMANEX TWISTHALER 14 METERED





DOSES.....................................................................108aspirin-dipyridamole cap er 12hr 25-200

mg................................................................................59ASSURE ID INSULIN SAFETY SYRINGE/

U-100/0.5ML/29G X 1/2"......................................... 51ASSURE ID INSULIN SAFETY SYRINGE/

U-100/1ML/29G X 1/2".............................................51ASSURE ID SAFETY PEN NEEDLES 31G X 5MM

(1/5" OR 3/16")..........................................................51ATACAND......................................................................63ATACAND......................................................................63ATACAND......................................................................63

2019

117

ATACAND......................................................................63ATACAND HCT............................................................ 63ATACAND HCT............................................................ 63ATACAND HCT............................................................ 63atazanavir sulfate cap 150 mg...................................45atazanavir sulfate cap 200 mg...................................45atazanavir sulfate cap 300 mg...................................45atenolol & chlorthalidone tab 100-25

mg................................................................................63atenolol & chlorthalidone tab 50-25 mg.................... 63atenolol tab 100 mg.....................................................64atenolol tab 25 mg.......................................................64atenolol tab 50 mg.......................................................64ATGAM.......................................................................... 97atomoxetine hcl cap 100 mg...................................... 78atomoxetine hcl cap 10 mg........................................ 78atomoxetine hcl cap 18 mg........................................ 78atomoxetine hcl cap 25 mg........................................ 78atomoxetine hcl cap 40 mg........................................ 78atomoxetine hcl cap 60 mg........................................ 78atomoxetine hcl cap 80 mg........................................ 78atorvastatin calcium tab 10 mg.................................. 64atorvastatin calcium tab 20 mg.................................. 64atorvastatin calcium tab 40 mg.................................. 64atorvastatin calcium tab 80 mg.................................. 64atovaquone-proguanil hcl tab 250-100

mg................................................................................38atovaquone-proguanil hcl tab 62.5-25

mg................................................................................38atovaquone susp 750 mg/5ml....................................38ATRIPLA........................................................................ 46ATROVENT HFA........................................................108AUGMENTIN...................................................................6AURYXIA.......................................................................82AVALIDE........................................................................ 64AVALIDE........................................................................ 64AVAPRO........................................................................ 64AVAPRO........................................................................ 64AVAPRO........................................................................ 64AVASTIN........................................................................28AVASTIN........................................................................28AVONEX........................................................................ 78AVONEX PEN.............................................................. 78azacitidine for inj 100 mg............................................59AZACTAM........................................................................6AZACTAM........................................................................6AZASAN........................................................................ 97AZASAN........................................................................ 97AZATHIOPRINE........................................................... 97azathioprine tab 50 mg............................................... 97azelaic acid gel 15%................................................... 79

azelastine hcl nasal spray 0.1% (137 mcg/spray)........................................................................108

azelastine hcl nasal spray 0.15% (205.5 mcg/spray)........................................................................108

azelastine hcl ophth soln 0.05%..............................105AZELEX......................................................................... 79AZITHROMYCIN............................................................ 6azithromycin for susp 100 mg/5ml...............................6azithromycin for susp 200 mg/5ml...............................6azithromycin iv for soln 500 mg................................... 6azithromycin tab 250 mg...............................................6azithromycin tab 500 mg...............................................6azithromycin tab 600 mg...............................................6AZOPT.........................................................................105AZOR............................................................................. 64AZOR............................................................................. 64AZOR............................................................................. 64AZOR............................................................................. 64aztreonam for inj 1 gm.................................................. 6aztreonam for inj 2 gm.................................................. 6BBACITRACIN.............................................................. 105bacitracin-polymyxin b ophth oint............................ 105bacitracin-polymyxin-neomycin-hc ophth oint

1%............................................................................. 105baclofen tab 10 mg......................................................45baclofen tab 20 mg......................................................45balsalazide disodium cap 750 mg........................... 103BALVERSA....................................................................28BALVERSA....................................................................28BALVERSA....................................................................28BANZEL.........................................................................13BANZEL.........................................................................13BANZEL.........................................................................13BARACLUDE................................................................ 46BAVENCIO.................................................................... 28BCG VACCINE.............................................................97BD SAFETYGLIDE INSULIN SYRINGE/0.3ML/31G

X 15/64"......................................................................51BD SAFETYGLIDE INSULIN SYRINGE/0.5ML/31G

X 15/64"......................................................................51BD SAFETYGLIDE INSULIN SYRINGE/1ML/31G X

15/64"..........................................................................51BELEODAQ.................................................................. 28BELSOMRA................................................................ 112BELSOMRA................................................................ 112BELSOMRA................................................................ 112BELSOMRA................................................................ 112benazepril & hydrochlorothiazide tab 10-12.5

mg................................................................................64

2019

118

benazepril & hydrochlorothiazide tab 20-12.5mg................................................................................64

benazepril & hydrochlorothiazide tab 20-25mg................................................................................64

benazepril & hydrochlorothiazide tab 5-6.25mg................................................................................64

benazepril hcl tab 10 mg............................................ 64benazepril hcl tab 20 mg............................................ 64benazepril hcl tab 40 mg............................................ 64benazepril hcl tab 5 mg.............................................. 64BENDEKA..................................................................... 28BENICAR.......................................................................64BENICAR.......................................................................64BENICAR.......................................................................64BENICAR HCT............................................................. 64BENICAR HCT............................................................. 64BENICAR HCT............................................................. 64BENLYSTA.................................................................... 97BENLYSTA.................................................................... 97BENLYSTA.................................................................... 97BENLYSTA.................................................................... 97BENZNIDAZOLE..........................................................39BENZNIDAZOLE..........................................................39benzoyl peroxide-erythromycin gel

5-3%............................................................................79benztropine mesylate tab 0.5 mg.............................. 39benztropine mesylate tab 1 mg..................................39benztropine mesylate tab 2 mg..................................39BESIVANCE................................................................105BESPONSA.................................................................. 28betamethasone dipropionate augmented cream

0.05%..........................................................................79betamethasone dipropionate augmented gel

0.05%..........................................................................79betamethasone dipropionate augmented lotion

0.05%..........................................................................79betamethasone dipropionate augmented oint

0.05%..........................................................................79betamethasone dipropionate cream

0.05%..........................................................................79betamethasone dipropionate lotion

0.05%..........................................................................79betamethasone dipropionate oint

0.05%..........................................................................79betamethasone valerate cream 0.1%....................... 79betamethasone valerate lotion 0.1%.........................79betamethasone valerate oint 0.1%............................79BETASERON................................................................ 78betaxolol hcl ophth soln 0.5%..................................105betaxolol hcl tab 10 mg...............................................64betaxolol hcl tab 20 mg...............................................64bethanechol chloride tab 10 mg.................................89

bethanechol chloride tab 25 mg.................................89bethanechol chloride tab 50 mg.................................89bethanechol chloride tab 5 mg...................................89BETOPTIC-S.............................................................. 105BEVYXXA......................................................................59BEVYXXA......................................................................59bexarotene cap 75 mg................................................ 28BEXSERO..................................................................... 98bicalutamide tab 50 mg...............................................28BICILLIN L-A...................................................................6BICILLIN L-A...................................................................6BICILLIN L-A...................................................................7BICNU............................................................................28BIKTARVY..................................................................... 46BILTRICIDE...................................................................39bimatoprost ophth soln 0.03%................................. 105bisoprolol & hydrochlorothiazide tab 10-6.25

mg................................................................................64bisoprolol & hydrochlorothiazide tab 2.5-6.25

mg................................................................................64bisoprolol & hydrochlorothiazide tab 5-6.25

mg................................................................................64bisoprolol fumarate tab 10 mg................................... 65bisoprolol fumarate tab 5 mg..................................... 64bleomycin sulfate for inj 15 unit................................. 28bleomycin sulfate for inj 30 unit................................. 28BLINCYTO.....................................................................28BOOSTRIX....................................................................98bosentan tab 125 mg................................................ 108bosentan tab 62.5 mg............................................... 108BOSULIF....................................................................... 28BOSULIF....................................................................... 28BOSULIF....................................................................... 28BRAFTOVI.....................................................................28BREO ELLIPTA..........................................................108BREO ELLIPTA..........................................................108BRILINTA.......................................................................59BRILINTA.......................................................................59brimonidine tartrate ophth soln 0.15%.................... 105brimonidine tartrate ophth soln 0.2%...................... 105BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................14BRIVIACT......................................................................14bromfenac sodium ophth soln 0.09% (once-

daily)......................................................................... 105bromocriptine mesylate cap 5 mg..............................39bromocriptine mesylate tab 2.5 mg........................... 39

2019

119

budesonide delayed release particles cap 3mg............................................................................. 103

budesonide inhalation susp 0.25mg/2ml......................................................................108

budesonide inhalation susp 0.5mg/2ml......................................................................108

budesonide inhalation susp 1 mg/2ml.....................108bumetanide inj 0.25 mg/ml......................................... 65bumetanide tab 0.5 mg............................................... 65bumetanide tab 1 mg.................................................. 65bumetanide tab 2 mg.................................................. 65buprenorphine hcl-naloxone hcl sl film 12-3

mg..................................................................................4buprenorphine hcl-naloxone hcl sl film 2-0.5

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

mg..................................................................................4buprenorphine hcl-naloxone hcl sl film 8-2

mg..................................................................................4buprenorphine hcl-naloxone hcl sl tab 2-0.5

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

mg..................................................................................5buprenorphine hcl sl tab 2 mg......................................4buprenorphine hcl sl tab 8 mg......................................4bupropion hcl (smoking deterrent) tab er 12hr 150

mg..................................................................................5bupropion hcl tab 100 mg...........................................18bupropion hcl tab 75 mg.............................................18bupropion hcl tab er 12hr 100 mg............................. 18bupropion hcl tab er 12hr 150 mg............................. 18bupropion hcl tab er 12hr 200 mg............................. 18bupropion hcl tab er 24hr 150 mg............................. 18bupropion hcl tab er 24hr 300 mg............................. 18buspirone hcl tab 10 mg............................................. 50buspirone hcl tab 15 mg............................................. 50buspirone hcl tab 30 mg............................................. 50buspirone hcl tab 5 mg............................................... 50buspirone hcl tab 7.5 mg............................................ 50busulfan inj 6 mg/ml.................................................... 28butalbital-acetaminophen-caffeine cap 50-300-40

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

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

mg..................................................................................1butalbital-acetaminophen-caff w/ cod cap

50-325-40-30 mg.........................................................1butalbital-acetaminophen tab 50-325

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

mg..................................................................................1

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

ml................................................................................... 1BYDUREON BCISE.....................................................51BYDUREON PEN........................................................ 51BYSTOLIC.....................................................................65BYSTOLIC.....................................................................65BYSTOLIC.....................................................................65BYSTOLIC.....................................................................65Ccabergoline tab 0.5 mg............................................... 95CABLIVI......................................................................... 98CABOMETYX............................................................... 28CABOMETYX............................................................... 28CABOMETYX............................................................... 28caffeine citrate oral soln 60 mg/3ml........................ 108CALAN........................................................................... 65CALAN SR.................................................................... 65CALAN SR.................................................................... 65calcipotriene cream 0.005%.......................................80calcipotriene oint 0.005%............................................80calcipotriene soln 0.005% (50 mcg/ml).....................80calcitonin (salmon) nasal soln 200 unit/

act..............................................................................103calcitriol cap 0.25 mcg.............................................. 103calcitriol cap 0.5 mcg................................................ 104calcitriol inj 1 mcg/ml.................................................104calcitriol oral soln 1 mcg/ml......................................104calcium acetate cap 667 mg...................................... 82calcium acetate tab 667 mg....................................... 82CALQUENCE................................................................28CANASA......................................................................103CANCIDAS....................................................................23candesartan cilexetil-hydrochlorothiazide tab 16-12.5

mg................................................................................65candesartan cilexetil-hydrochlorothiazide tab 32-12.5

mg................................................................................65candesartan cilexetil-hydrochlorothiazide tab 32-25

mg................................................................................65candesartan cilexetil tab 16 mg................................. 65candesartan cilexetil tab 32 mg................................. 65candesartan cilexetil tab 4 mg................................... 65candesartan cilexetil tab 8 mg................................... 65CAPASTAT SULFATE..................................................27CAPRELSA................................................................... 28CAPRELSA................................................................... 28captopril tab 100 mg....................................................65captopril tab 12.5 mg...................................................65captopril tab 25 mg......................................................65captopril tab 50 mg......................................................65

2019

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CARAC.......................................................................... 80CARAFATE....................................................................85CARBAGLU.................................................................. 82carbamazepine cap er 12hr 100 mg......................... 14carbamazepine cap er 12hr 200 mg......................... 14carbamazepine cap er 12hr 300 mg......................... 14carbamazepine chew tab 100 mg..............................14carbamazepine susp 100 mg/5ml..............................14carbamazepine tab 200 mg........................................14carbamazepine tab er 12hr 100 mg.......................... 14carbamazepine tab er 12hr 200 mg.......................... 14carbamazepine tab er 12hr 400 mg.......................... 14CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................40CARBIDOPA/LEVODOPA/





ENTACAPONE..........................................................40carbidopa & levodopa orally disintegrating tab

10-100 mg..................................................................39carbidopa & levodopa orally disintegrating tab

25-100 mg..................................................................39carbidopa & levodopa orally disintegrating tab

25-250 mg..................................................................39carbidopa & levodopa tab 10-100 mg....................... 39carbidopa & levodopa tab 25-100 mg....................... 39carbidopa & levodopa tab 25-250 mg....................... 39carbidopa & levodopa tab er 25-100

mg................................................................................39carbidopa & levodopa tab er 50-200

mg................................................................................39carbidopa tab 25 mg................................................... 39carboplatin iv soln 150 mg/15ml................................ 28carboplatin iv soln 450 mg/45ml................................ 28carboplatin iv soln 50 mg/5ml.................................... 28carboplatin iv soln 600 mg/60ml................................ 28CARDIZEM....................................................................65CARDIZEM....................................................................65CARDIZEM....................................................................65CARDIZEM CD............................................................ 65CARDIZEM CD............................................................ 65CARDIZEM CD............................................................ 65CARDIZEM CD............................................................ 65CARDIZEM CD............................................................ 65carmustine for inj 100 mg...........................................28carteolol hcl ophth soln 1%...................................... 105

carvedilol tab 12.5 mg.................................................65carvedilol tab 25 mg....................................................65carvedilol tab 3.125 mg...............................................65carvedilol tab 6.25 mg.................................................65caspofungin acetate for iv soln 50 mg...................... 23caspofungin acetate for iv soln 70 mg...................... 23cefaclor cap 250 mg......................................................7cefaclor cap 500 mg......................................................7cefadroxil cap 500 mg...................................................7cefadroxil for susp 250 mg/5ml....................................7cefadroxil for susp 500 mg/5ml....................................7cefadroxil tab 1 gm........................................................ 7cefazolin sodium for inj 10 gm..................................... 7cefazolin sodium for inj 1 gm....................................... 7cefazolin sodium for inj 500 mg................................... 7cefdinir cap 300 mg....................................................... 7cefdinir for susp 125 mg/5ml........................................7cefdinir for susp 250 mg/5ml........................................7cefepime hcl for inj 1 gm.............................................. 7cefepime hcl for inj 2 gm.............................................. 7cefixime cap 400 mg..................................................... 7cefixime for susp 100 mg/5ml...................................... 7cefixime for susp 200 mg/5ml...................................... 7CEFOTAXIME SODIUM................................................7cefotaxime sodium for inj 1 gm.................................... 7cefoxitin sodium for inj 10 gm...................................... 7cefoxitin sodium for iv soln 1 gm................................. 7cefoxitin sodium for iv soln 2 gm................................. 7cefpodoxime proxetil for susp 100

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

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

DEXTROSE................................................................. 7CEFTRIAXONE IN ISO-OSMOTIC

DEXTROSE................................................................. 8ceftriaxone sodium for inj 10 gm..................................8ceftriaxone sodium for inj 1 gm....................................8ceftriaxone sodium for inj 250 mg................................8ceftriaxone sodium for inj 2 gm....................................8

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ceftriaxone sodium for inj 500 mg................................8ceftriaxone sodium for iv soln 1 gm.............................8ceftriaxone sodium for iv soln 2 gm.............................8cefuroxime axetil tab 250 mg....................................... 8cefuroxime axetil tab 500 mg....................................... 8cefuroxime sodium for inj 7.5 gm.................................8cefuroxime sodium for inj 750 mg................................8cefuroxime sodium for iv soln 1.5 gm..........................8celecoxib cap 100 mg................................................... 1celecoxib cap 200 mg................................................... 1celecoxib cap 400 mg................................................... 1celecoxib cap 50 mg......................................................1CELEXA.........................................................................18CELEXA.........................................................................18CELEXA.........................................................................18CELONTIN.................................................................... 14cephalexin cap 250 mg.................................................8cephalexin cap 500 mg.................................................8cephalexin cap 750 mg.................................................8cephalexin for susp 125 mg/5ml..................................8cephalexin for susp 250 mg/5ml..................................8CEREZYME.................................................................. 87cevimeline hcl cap 30 mg...........................................79CHANTIX......................................................................... 5CHANTIX......................................................................... 5CHANTIX CONTINUING MONTH

PACK.............................................................................5CHANTIX STARTING MONTH PACK.........................5CHEMET........................................................................82CHENODAL.................................................................. 85CHLORAMPHENICOL SODIUM

SUCCINATE.................................................................8chlordiazepoxide hcl cap 10 mg................................ 50chlordiazepoxide hcl cap 25 mg................................ 50chlordiazepoxide hcl cap 5 mg.................................. 50chlorhexidine gluconate soln 0.12%..........................79CHLOROQUINE PHOSPHATE................................. 39chloroquine phosphate tab 500 mg...........................39CHLOROTHIAZIDE..................................................... 65chlorothiazide tab 500 mg.......................................... 65CHLORPROMAZINE HCL..........................................22CHLORPROMAZINE HCL..........................................22chlorpromazine hcl tab 100 mg..................................22chlorpromazine hcl tab 10 mg....................................22chlorpromazine hcl tab 200 mg..................................22chlorpromazine hcl tab 25 mg....................................22chlorpromazine hcl tab 50 mg....................................22chlorthalidone tab 25 mg............................................ 65chlorthalidone tab 50 mg............................................ 66cholestyramine light powder 4 gm/

dose............................................................................ 66

cholestyramine light powder packets 4gm................................................................................66

cholestyramine powder 4 gm/dose............................66cholestyramine powder packets 4 gm.......................66choline fenofibrate cap dr 135 mg............................. 66choline fenofibrate cap dr 45 mg............................... 66CHORIONIC GONADOTROPIN................................91ciclopirox gel 0.77%.................................................... 23ciclopirox olamine cream 0.77%................................23ciclopirox olamine susp 0.77%...................................24ciclopirox shampoo 1%............................................... 24ciclopirox solution 8%..................................................24cidofovir iv inj 75 mg/ml.............................................. 46cilostazol tab 100 mg.................................................. 59cilostazol tab 50 mg.................................................... 59CILOXAN.....................................................................105CIMDUO........................................................................ 46cimetidine hcl soln 300 mg/5ml..................................85cimetidine tab 200 mg.................................................85cimetidine tab 300 mg.................................................85cimetidine tab 400 mg.................................................85cimetidine tab 800 mg.................................................85cinacalcet hcl tab 30 mg...........................................104cinacalcet hcl tab 60 mg...........................................104cinacalcet hcl tab 90 mg...........................................104CINRYZE.......................................................................98CIPRODEX................................................................. 107ciprofloxacin 200 mg/100ml in d5w............................. 8ciprofloxacin 400 mg/200ml in d5w............................. 8ciprofloxacin for oral susp 500 mg/5ml (10%) (10

gm/100ml).....................................................................8CIPROFLOXACIN HCL.................................................8ciprofloxacin hcl ophth soln 0.3%............................ 105ciprofloxacin hcl tab 250 mg.........................................8ciprofloxacin hcl tab 500 mg.........................................8ciprofloxacin hcl tab 750 mg.........................................8CISPLATIN.................................................................... 28cisplatin inj 100 mg/100ml (1 mg/ml).........................29cisplatin inj 50 mg/50ml (1 mg/ml).............................28citalopram hydrobromide oral soln 10

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

ml)................................................................................29clarithromycin for susp 125 mg/5ml.............................8clarithromycin for susp 250 mg/5ml.............................8clarithromycin tab 250 mg............................................ 8clarithromycin tab 500 mg............................................ 8clarithromycin tab er 24hr 500 mg...............................8CLEMASTINE FUMARATE......................................109

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CLEOCIN.........................................................................8clindamycin hcl cap 150 mg......................................... 9clindamycin hcl cap 300 mg......................................... 9clindamycin hcl cap 75 mg........................................... 8clindamycin palmitate hcl for soln 75

mg/5ml.......................................................................... 9clindamycin phosphate-benzoyl peroxide gel

1-5%............................................................................80clindamycin phosphate gel 1%.................................... 9clindamycin phosphate in d5w iv soln 300

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

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

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

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

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

mg/6ml.......................................................................... 9clindamycin phosphate lotion 1%................................ 9clindamycin phosphate soln 1%...................................9clindamycin phosphate swab 1%.................................9clindamycin phosphate vaginal cream

2%..................................................................................9clindamycin phosph-benzoyl peroxide (refrig) gel 1.2

(1)-5%......................................................................... 80CLINIMIX 4.25%/DEXTROSE 10%...........................83CLINIMIX 4.25%/DEXTROSE 25%...........................83CLINIMIX 4.25%/DEXTROSE 5%.............................83CLINIMIX 5%/DEXTROSE 15%................................ 83CLINIMIX 5%/DEXTROSE 20%................................ 83CLINIMIX 5%/DEXTROSE 25%................................ 83CLINIMIX E 2.75%/DEXTROSE 5%......................... 82CLINIMIX E 4.25%/DEXTROSE 10%.......................83CLINIMIX E 4.25%/DEXTROSE 5%......................... 83CLINIMIX E 5%/DEXTROSE 15%............................ 83CLINIMIX E 5%/DEXTROSE 20%............................ 83clobazam suspension 2.5 mg/ml............................... 14clobazam tab 10 mg....................................................14clobazam tab 20 mg....................................................14clobetasol propionate cream 0.05%..........................80clobetasol propionate emollient base cream

0.05%..........................................................................80clobetasol propionate gel 0.05%................................80clobetasol propionate oint 0.05%.............................. 80clobetasol propionate soln 0.05%..............................80

clofarabine iv soln 1 mg/ml.........................................29clomipramine hcl cap 25 mg...................................... 19clomipramine hcl cap 50 mg...................................... 19clomipramine hcl cap 75 mg...................................... 19clonazepam orally disintegrating tab 0.125

mg................................................................................50clonazepam orally disintegrating tab 0.25

mg................................................................................50clonazepam orally disintegrating tab 0.5

mg................................................................................50clonazepam orally disintegrating tab 1

mg................................................................................50clonazepam orally disintegrating tab 2

mg................................................................................50clonazepam tab 0.5 mg.............................................. 50clonazepam tab 1 mg..................................................50clonazepam tab 2 mg..................................................50clonidine hcl tab 0.1 mg..............................................66clonidine hcl tab 0.2 mg..............................................66clonidine hcl tab 0.3 mg..............................................66clonidine hcl tab er 12hr 0.1 mg................................ 78clonidine td patch weekly 0.1 mg/24hr......................66clonidine td patch weekly 0.2 mg/24hr......................66clonidine td patch weekly 0.3 mg/24hr......................66clopidogrel bisulfate tab 300 mg................................59clopidogrel bisulfate tab 75 mg..................................59clorazepate dipotassium tab 15 mg...........................50clorazepate dipotassium tab 3.75 mg....................... 50clorazepate dipotassium tab 7.5 mg......................... 50clotrimazole cream 1%................................................24clotrimazole troche 10 mg.......................................... 24clotrimazole w/ betamethasone cream

1-0.05%...................................................................... 80clotrimazole w/ betamethasone lotion

1-0.05%...................................................................... 80clozapine orally disintegrating tab 100

mg................................................................................41clozapine orally disintegrating tab 12.5

mg................................................................................41clozapine orally disintegrating tab 25

mg................................................................................41clozapine tab 100 mg..................................................41clozapine tab 200 mg..................................................41clozapine tab 25 mg....................................................41clozapine tab 50 mg....................................................41COARTEM.....................................................................39codeine sulfate tab 30 mg............................................ 1codeine sulfate tab 60 mg............................................ 1colchicine w/ probenecid tab 0.5-500

mg................................................................................25COLCRYS..................................................................... 25colestipol hcl granule packets 5 gm.......................... 66

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colestipol hcl granules 5 gm.......................................66colestipol hcl tab 1 gm................................................ 66colistimethate sod for inj 150 mg................................. 9COLYTE-FLAVOR PACKS......................................... 85COMBIGAN................................................................ 105COMBIPATCH.............................................................. 92COMBIPATCH.............................................................. 92COMBIVENT RESPIMAT......................................... 109COMETRIQ...................................................................29COMETRIQ...................................................................29COMETRIQ...................................................................29COMPLERA.................................................................. 46COPAXONE.................................................................. 78COPIKTRA....................................................................29COPIKTRA....................................................................29COREG..........................................................................66COREG..........................................................................66COREG..........................................................................66COREG..........................................................................66CORLANOR..................................................................66CORLANOR..................................................................66CORLANOR..................................................................66CORTISONE ACETATE..............................................90COSENTYX.................................................................. 98COSENTYX.................................................................. 98COSENTYX SENSOREADY PEN............................ 98COSENTYX SENSOREADY PEN............................ 98COSMEGEN................................................................. 29COTELLIC.....................................................................29COUMADIN...................................................................59COUMADIN...................................................................59COUMADIN...................................................................59COUMADIN...................................................................59COUMADIN...................................................................59COUMADIN...................................................................59COUMADIN...................................................................59COUMADIN...................................................................59COUMADIN...................................................................59COZAAR........................................................................66COZAAR........................................................................66COZAAR........................................................................66CREON..........................................................................87CREON..........................................................................87CREON..........................................................................88CREON..........................................................................88CREON..........................................................................88CRESEMBA.................................................................. 24CRESEMBA.................................................................. 24CRIXIVAN......................................................................46CRIXIVAN......................................................................46cromolyn sodium ophth soln 4%..............................105

cromolyn sodium oral conc 100mg/5ml........................................................................ 86

cromolyn sodium soln nebu 20mg/2ml......................................................................109

CRYSVITA.....................................................................88CRYSVITA.....................................................................88CRYSVITA.....................................................................88cyclobenzaprine hcl tab 10 mg................................ 112cyclobenzaprine hcl tab 5 mg.................................. 112cyclobenzaprine hcl tab 7.5 mg...............................112cyclophosphamide cap 25 mg................................... 29cyclophosphamide cap 50 mg................................... 29cyclophosphamide for inj 1 gm.................................. 29cyclophosphamide for inj 2 gm.................................. 29cyclophosphamide for inj 500 mg..............................29cycloserine cap 250 mg..............................................27CYCLOSET...................................................................52cyclosporine cap 100 mg............................................98cyclosporine cap 25 mg..............................................98cyclosporine iv soln 50 mg/ml....................................98CYCLOSPORINE MODIFIED.................................... 98cyclosporine modified cap 100 mg............................ 98cyclosporine modified cap 25 mg.............................. 98cyclosporine modified oral soln 100 mg/

ml.................................................................................98CYRAMZA.....................................................................29CYRAMZA.....................................................................29CYSTADANE................................................................ 88CYSTAGON.................................................................. 88CYSTAGON.................................................................. 88CYSTARAN.................................................................105CYTARABINE............................................................... 29cytarabine inj pf 100 mg/ml........................................ 29cytarabine inj pf 20 mg/ml.......................................... 29DDACARBAZINE............................................................ 29dacarbazine for inj 200 mg.........................................29dactinomycin for inj 0.5 mg........................................ 29dalfampridine tab er 12hr 10 mg................................78DALIRESP.................................................................. 109DALIRESP.................................................................. 109DALVANCE......................................................................9danazol cap 100 mg....................................................92danazol cap 200 mg....................................................92danazol cap 50 mg......................................................92dantrolene sodium cap 100 mg................................. 45dantrolene sodium cap 25 mg....................................45dantrolene sodium cap 50 mg....................................45dapsone tab 100 mg................................................... 27dapsone tab 25 mg......................................................27DAPTACEL....................................................................98

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daptomycin for iv soln 500 mg..................................... 9DARAPRIM................................................................... 39DARZALEX................................................................... 29DARZALEX................................................................... 29daunorubicin hcl iv soln 20 mg/4ml........................... 29DAUNORUBICIN HYDROCHLORIDE......................29DAURISMO...................................................................29DAURISMO...................................................................29DDAVP...........................................................................91decitabine for inj 50 mg.............................................. 29deferasirox tab for oral susp 125 mg.........................83deferasirox tab for oral susp 250 mg.........................83deferasirox tab for oral susp 500 mg.........................83DELSTRIGO................................................................. 46DELZICOL...................................................................103demeclocycline hcl tab 150 mg....................................9demeclocycline hcl tab 300 mg....................................9DEMSER....................................................................... 66DENAVIR.......................................................................46DEPEN TITRATABS.................................................... 89DEPO-PROVERA........................................................ 92DESCOVY.....................................................................46desipramine hcl tab 100 mg.......................................19desipramine hcl tab 10 mg......................................... 19desipramine hcl tab 150 mg.......................................19desipramine hcl tab 25 mg......................................... 19desipramine hcl tab 50 mg......................................... 19desipramine hcl tab 75 mg......................................... 19desmopressin acetate inj 4 mcg/ml...........................91desmopressin acetate nasal spray soln

0.01%..........................................................................91desmopressin acetate nasal spray soln 0.01%

(refrigerated).............................................................. 91desmopressin acetate tab 0.1 mg............................. 91desmopressin acetate tab 0.2 mg............................. 91desogest-eth estrad & eth estrad tab 0.15-0.02/0.01

mg(21/5)..................................................................... 92desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg................................................................................92

desogestrel & ethinyl estradiol tab 0.15 mg-30mcg..............................................................................92

desonide cream 0.05%............................................... 80desonide lotion 0.05%.................................................80desonide oint 0.05%....................................................80desoximetasone cream 0.05%...................................80desoximetasone cream 0.25%...................................80desoximetasone gel 0.05%........................................ 80desoximetasone oint 0.25%....................................... 80desvenlafaxine succinate tab er 24hr 100

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

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

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

DEXAMETHASONE.................................................... 90DEXAMETHASONE.................................................... 90dexamethasone elixir 0.5 mg/5ml..............................90DEXAMETHASONE SODIUM

PHOSPHATE...........................................................105dexamethasone sodium phosphate inj 120

mg/30ml......................................................................90dexamethasone sodium phosphate inj 20

mg/5ml........................................................................ 90dexamethasone sodium phosphate inj 4 mg/

ml.................................................................................90dexamethasone tab 0.5 mg........................................90dexamethasone tab 0.75 mg......................................90dexamethasone tab 1.5 mg........................................90dexamethasone tab 4 mg...........................................90dexamethasone tab 6 mg...........................................90dexmethylphenidate hcl tab 10 mg............................78dexmethylphenidate hcl tab 2.5 mg...........................78dexmethylphenidate hcl tab 5 mg..............................78dexrazoxane hcl for inj 250 mg..................................29dexrazoxane hcl for inj 500 mg..................................29dextroamphetamine sulfate cap er 24hr 10

mg................................................................................78dextroamphetamine sulfate cap er 24hr 15

mg................................................................................78dextroamphetamine sulfate cap er 24hr 5

mg................................................................................78dextroamphetamine sulfate tab 10 mg......................78dextroamphetamine sulfate tab 5 mg........................78dextrose 2.5% w/ sodium chloride

0.45%..........................................................................83dextrose 5% in lactated ringers................................. 83dextrose 5% w/ sodium chloride 0.2%...................... 83dextrose 5% w/ sodium chloride

0.33%..........................................................................83dextrose 5% w/ sodium chloride

0.45%..........................................................................83dextrose 5% w/ sodium chloride 0.9%...................... 83dextrose inj 10%.......................................................... 83dextrose inj 5%.............................................................83DIASTAT ACUDIAL......................................................14DIASTAT ACUDIAL......................................................14DIASTAT PEDIATRIC..................................................14DIAZEPAM.................................................................... 14DIAZEPAM.................................................................... 50diazepam conc 5 mg/ml..............................................50DIAZEPAM RECTAL GEL.......................................... 14DIAZEPAM RECTAL GEL.......................................... 14

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DIAZEPAM RECTAL GEL.......................................... 14diazepam tab 10 mg....................................................51diazepam tab 2 mg......................................................51diazepam tab 5 mg......................................................51diclofenac potassium tab 50 mg.................................. 1diclofenac sodium gel 1%.............................................1diclofenac sodium gel 3%...........................................80diclofenac sodium ophth soln 0.1%.........................105diclofenac sodium soln 1.5%........................................1diclofenac sodium tab delayed release 25

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

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

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

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

mg..................................................................................1dicloxacillin sodium cap 250 mg.................................. 9dicloxacillin sodium cap 500 mg.................................. 9dicyclomine hcl tab 20 mg..........................................86didanosine delayed release capsule 200

mg................................................................................46didanosine delayed release capsule 250

mg................................................................................46didanosine delayed release capsule 400

mg................................................................................46DIFICID............................................................................ 9diflorasone diacetate oint 0.05%................................80diflunisal tab 500 mg..................................................... 1digoxin oral soln 0.05 mg/ml...................................... 66digoxin tab 125 mcg (0.125 mg)................................66digoxin tab 250 mcg (0.25 mg).................................. 66DILANTIN...................................................................... 14diltiazem hcl cap er 12hr 120 mg.............................. 66diltiazem hcl cap er 12hr 60 mg.................................66diltiazem hcl cap er 12hr 90 mg.................................66diltiazem hcl cap er 24hr 120 mg.............................. 66diltiazem hcl cap er 24hr 180 mg.............................. 66diltiazem hcl cap er 24hr 240 mg.............................. 66diltiazem hcl coated beads cap er 24hr 120

mg................................................................................66diltiazem hcl coated beads cap er 24hr 180




mg................................................................................67

diltiazem hcl coated beads tab er 24hr 180mg................................................................................67





diltiazem hcl extended release beads cap er 24hr120 mg....................................................................... 67






diltiazem hcl tab 120 mg.............................................67diltiazem hcl tab 30 mg...............................................67diltiazem hcl tab 60 mg...............................................67diltiazem hcl tab 90 mg...............................................67DIOVAN......................................................................... 67DIOVAN......................................................................... 67DIOVAN......................................................................... 67DIOVAN......................................................................... 67DIOVAN HCT................................................................67DIOVAN HCT................................................................67DIOVAN HCT................................................................67DIOVAN HCT................................................................67DIOVAN HCT................................................................67DIPENTUM................................................................. 103diphenhydramine hcl inj 50 mg/ml...........................109DIPHTHERIA/TETANUS TOXOIDS

ADSORBED...............................................................98dipyridamole tab 25 mg.............................................. 59dipyridamole tab 50 mg.............................................. 59dipyridamole tab 75 mg.............................................. 59disulfiram tab 250 mg....................................................5disulfiram tab 500 mg....................................................5divalproex sodium cap delayed release sprinkle 125

mg................................................................................14divalproex sodium tab delayed release 125



mg................................................................................14

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divalproex sodium tab er 24 hr 250 mg.....................14divalproex sodium tab er 24 hr 500 mg.....................14DIVIGEL.........................................................................92DIVIGEL.........................................................................92DIVIGEL.........................................................................92DIVIGEL.........................................................................92DOCETAXEL.................................................................29docetaxel for inj conc 160 mg/8ml (20 mg/

ml)................................................................................30docetaxel for inj conc 20 mg/ml................................. 29docetaxel for inj conc 80 mg/4ml (20 mg/

ml)................................................................................29docetaxel soln for iv infusion 160

mg/16ml......................................................................30docetaxel soln for iv infusion 20

mg/2ml........................................................................ 30docetaxel soln for iv infusion 80

mg/8ml........................................................................ 30dofetilide cap 125 mcg (0.125 mg)............................67dofetilide cap 250 mcg (0.25 mg).............................. 67dofetilide cap 500 mcg (0.5 mg)................................ 67donepezil hydrochloride orally disintegrating tab 10

mg................................................................................17donepezil hydrochloride orally disintegrating tab 5

mg................................................................................17donepezil hydrochloride tab 10 mg........................... 17donepezil hydrochloride tab 23 mg........................... 17donepezil hydrochloride tab 5 mg..............................17dorzolamide hcl ophth soln 2%................................105dorzolamide hcl-timolol maleate ophth soln 22.3-6.8

mg/ml........................................................................ 105DOVATO........................................................................ 46doxazosin mesylate tab 1 mg.................................... 67doxazosin mesylate tab 2 mg.................................... 67doxazosin mesylate tab 4 mg.................................... 67doxazosin mesylate tab 8 mg.................................... 67doxepin hcl cap 100 mg..............................................19doxepin hcl cap 10 mg................................................19doxepin hcl cap 150 mg..............................................19doxepin hcl cap 25 mg................................................19doxepin hcl cap 50 mg................................................19doxepin hcl cap 75 mg................................................19doxepin hcl conc 10 mg/ml.........................................19doxorubicin hcl for inj 10 mg...................................... 30doxorubicin hcl for inj 50 mg...................................... 30doxorubicin hcl inj 2 mg/ml.........................................30doxorubicin hcl liposomal inj (for iv infusion) 2 mg/

ml.................................................................................30doxycycline hyclate cap 100 mg..................................9doxycycline hyclate cap 50 mg.................................... 9doxycycline hyclate for inj 100 mg...............................9doxycycline hyclate tab 100 mg...................................9

doxycycline hyclate tab 20 mg.....................................9doxycycline monohydrate cap 100 mg........................9doxycycline monohydrate cap 150 mg........................9doxycycline monohydrate cap 50 mg..........................9doxycycline monohydrate cap 75 mg..........................9doxycycline monohydrate tab 100 mg.........................9doxycycline monohydrate tab 150 mg...................... 10doxycycline monohydrate tab 50 mg...........................9doxycycline monohydrate tab 75 mg...........................9D-PENAMINE............................................................... 89dronabinol cap 10 mg................................................. 22dronabinol cap 2.5 mg................................................ 22dronabinol cap 5 mg....................................................22drospirenone-ethinyl estradiol tab 3-0.02

mg................................................................................92drospirenone-ethinyl estradiol tab 3-0.03

mg................................................................................92drospirenone-ethinyl estrad-levomefolate tab

3-0.02-0.451 mg........................................................92drospirenone-ethinyl estrad-levomefolate tab

3-0.03-0.451 mg........................................................92DUAVEE........................................................................ 92DULERA......................................................................109DULERA......................................................................109duloxetine hcl enteric coated pellets cap 20

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

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

mg................................................................................19DUPIXENT.................................................................... 98DUPIXENT.................................................................... 98DUREZOL................................................................... 105dutasteride cap 0.5 mg............................................... 89dutasteride-tamsulosin hcl cap 0.5-0.4

mg................................................................................89EEASY TOUCH FLIPLOCK SAFETY INSULIN

SYRINGE 1ML/30G X 1/2"......................................52EASY TOUCH INSULIN SYRINGE/SAFETY/

U-100/0.5ML/29G X 1/2"......................................... 52EASY TOUCH INSULIN SYRINGE/SAFETY/

U-100/1ML/30G X 1/2".............................................52EASY TOUCH SHEATHLOCK SAFETY INSULIN

SYRINGE 1ML/29G X 1/2"......................................52EASY TOUCH SHEATHLOCK SAFETY SYRINGE

1ML/30G X 1/2"........................................................ 52EC-NAPROXEN............................................................. 1EC-NAPROXEN............................................................. 1econazole nitrate cream 1%.......................................24EDURANT..................................................................... 46

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efavirenz cap 200 mg..................................................46efavirenz cap 50 mg....................................................46efavirenz tab 600 mg...................................................46EGRIFTA....................................................................... 91ELAPRASE................................................................... 88ELELYSO.......................................................................88ELIDEL...........................................................................80ELIGARD.......................................................................95ELIGARD.......................................................................96ELIGARD.......................................................................96ELIGARD.......................................................................96ELIQUIS.........................................................................59ELIQUIS.........................................................................59ELIQUIS STARTER PACK......................................... 59ELITEK...........................................................................30ELITEK...........................................................................30ELLA...............................................................................92EMCYT.......................................................................... 30EMEND..........................................................................22EMGALITY.................................................................... 25EMGALITY.................................................................... 25EMGALITY.................................................................... 25EMPLICITI.....................................................................30EMPLICITI.....................................................................30EMSAM..........................................................................19EMSAM..........................................................................19EMSAM..........................................................................19EMTRIVA.......................................................................46EMTRIVA.......................................................................46enalapril maleate & hydrochlorothiazide tab 10-25

mg................................................................................67enalapril maleate & hydrochlorothiazide tab 5-12.5

mg................................................................................67enalapril maleate tab 10 mg.......................................68enalapril maleate tab 2.5 mg......................................67enalapril maleate tab 20 mg.......................................68enalapril maleate tab 5 mg.........................................67ENBREL........................................................................ 98ENBREL........................................................................ 98ENBREL........................................................................ 98ENBREL MINI...............................................................98ENBREL SURECLICK................................................ 98ENGERIX-B.................................................................. 98ENGERIX-B.................................................................. 98enoxaparin sodium inj 100 mg/ml..............................60enoxaparin sodium inj 120 mg/0.8ml........................ 60enoxaparin sodium inj 150 mg/ml..............................60enoxaparin sodium inj 300 mg/3ml............................60enoxaparin sodium inj 30 mg/0.3ml...........................59enoxaparin sodium inj 40 mg/0.4ml...........................60enoxaparin sodium inj 60 mg/0.6ml...........................60enoxaparin sodium inj 80 mg/0.8ml...........................60

entacapone tab 200 mg..............................................40entecavir tab 0.5 mg....................................................46entecavir tab 1 mg.......................................................46ENTRESTO...................................................................68ENTRESTO...................................................................68ENTRESTO...................................................................68EPCLUSA......................................................................46EPIDIOLEX................................................................... 14epinastine hcl ophth soln 0.05%..............................105epinephrine solution auto-injector 0.15 mg/0.3ml

(1:2000).................................................................... 109epinephrine solution auto-injector 0.3 mg/0.3ml

(1:1000) (generic for EpiPen 2-Pak).................... 109epirubicin hcl iv soln 200 mg/100ml (2 mg/

ml)................................................................................30epirubicin hcl iv soln 50 mg/25ml (2 mg/

ml)................................................................................30EPIVIR HBV..................................................................46eplerenone tab 25 mg.................................................68eplerenone tab 50 mg.................................................68EPOGEN....................................................................... 60EPOGEN....................................................................... 60EPOGEN....................................................................... 60EPOGEN....................................................................... 60EPOGEN....................................................................... 60ERBITUX....................................................................... 30ERBITUX....................................................................... 30ERGOLOID MESYLATES...........................................17ERIVEDGE....................................................................30ERLEADA......................................................................30erlotinib hcl tab 100 mg.............................................. 30erlotinib hcl tab 150 mg.............................................. 30erlotinib hcl tab 25 mg.................................................30ertapenem sodium for inj 1 gm.................................. 10ERWINAZE................................................................... 30ERYPED 400................................................................10ERYTHROCIN LACTOBIONATE...............................10ERYTHROCIN STEARATE........................................ 10erythromycin ethylsuccinate for susp 200

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

mg/5ml........................................................................ 10erythromycin ophth oint 5 mg/gm............................ 105erythromycin pads 2%.................................................10erythromycin soln 2%..................................................10erythromycin tab 250 mg............................................ 10erythromycin tab 500 mg............................................ 10erythromycin tab delayed release 250

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

mg................................................................................10

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

erythromycin w/ delayed release particles cap 250mg................................................................................10

ESBRIET..................................................................... 109ESBRIET..................................................................... 109ESBRIET..................................................................... 109escitalopram oxalate soln 5 mg/5ml..........................19escitalopram oxalate tab 10 mg.................................19escitalopram oxalate tab 20 mg.................................19escitalopram oxalate tab 5 mg...................................19esomeprazole magnesium cap delayed release 20

mg................................................................................86esomeprazole magnesium cap delayed release 40

mg................................................................................86esomeprazole sodium for intravenous soln 40

mg................................................................................86estradiol & norethindrone acetate tab 0.5-0.1

mg................................................................................92estradiol & norethindrone acetate tab 1-0.5

mg................................................................................92estradiol tab 0.5 mg.....................................................92estradiol tab 1 mg........................................................92estradiol tab 2 mg........................................................92estradiol td patch twice weekly 0.025

mg/24hr...................................................................... 92estradiol td patch twice weekly 0.0375




mg/24hr...................................................................... 92estradiol td patch weekly 0.025

mg/24hr...................................................................... 93estradiol td patch weekly 0.0375 mg/24hr (37.5

mcg/24hr)................................................................... 93estradiol td patch weekly 0.05 mg/24hr.................... 93estradiol td patch weekly 0.06 mg/24hr.................... 93estradiol td patch weekly 0.075

mg/24hr...................................................................... 93estradiol td patch weekly 0.1 mg/24hr...................... 93estradiol vaginal cream 0.1 mg/gm........................... 93estradiol vaginal tab 10 mcg...................................... 93ethambutol hcl tab 100 mg.........................................27ethambutol hcl tab 400 mg.........................................27ethosuximide cap 250 mg...........................................14ethosuximide soln 250 mg/5ml.................................. 14ethynodiol diacetate & ethinyl estradiol tab 1 mg-35

mcg..............................................................................93

ethynodiol diacetate & ethinyl estradiol tab 1 mg-50mcg..............................................................................93

ETHYOL........................................................................ 30ETIDRONATE DISODIUM........................................104ETIDRONATE DISODIUM........................................104etodolac cap 200 mg.....................................................2etodolac cap 300 mg.....................................................2etodolac tab 400 mg......................................................2etodolac tab 500 mg......................................................2etodolac tab er 24hr 400 mg........................................ 2etodolac tab er 24hr 500 mg........................................ 2etodolac tab er 24hr 600 mg........................................ 2ETOPOPHOS............................................................... 30etoposide inj 100 mg/5ml (20 mg/ml)........................30etoposide inj 1 gm/50ml (20 mg/ml).......................... 30etoposide inj 500 mg/25ml (20 mg/ml)......................30EVOMELA..................................................................... 30EVOTAZ.........................................................................46exemestane tab 25 mg............................................... 30EXFORGE.....................................................................68EXFORGE.....................................................................68EXFORGE.....................................................................68EXFORGE.....................................................................68EXFORGE HCT........................................................... 68EXFORGE HCT........................................................... 68EXFORGE HCT........................................................... 68EXFORGE HCT........................................................... 68EXFORGE HCT........................................................... 68EXJADE.........................................................................83EXJADE.........................................................................83EXJADE.........................................................................83ezetimibe-simvastatin tab 10-10 mg..........................68ezetimibe-simvastatin tab 10-20 mg..........................68ezetimibe-simvastatin tab 10-40 mg..........................68ezetimibe-simvastatin tab 10-80 mg..........................68ezetimibe tab 10 mg....................................................68FFABRAZYME................................................................ 88FABRAZYME................................................................ 88famciclovir tab 125 mg................................................46famciclovir tab 250 mg................................................46famciclovir tab 500 mg................................................46famotidine inj 200 mg/20ml........................................ 86famotidine inj 20 mg/2ml.............................................86famotidine inj 40 mg/4ml.............................................86famotidine tab 20 mg...................................................86famotidine tab 40 mg...................................................86FANAPT.........................................................................41FANAPT.........................................................................41FANAPT.........................................................................41FANAPT.........................................................................41

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FANAPT.........................................................................41FANAPT.........................................................................41FANAPT.........................................................................41FANAPT TITRATION PACK....................................... 41FARESTON...................................................................30FARYDAK......................................................................30FARYDAK......................................................................30FARYDAK......................................................................30FASLODEX................................................................... 30fat emulsion plant based iv emulsion

20%............................................................................. 83febuxostat tab 40 mg...................................................25febuxostat tab 80 mg...................................................25felbamate susp 600 mg/5ml....................................... 14felbamate tab 400 mg................................................. 14felbamate tab 600 mg................................................. 14felodipine tab er 24hr 10 mg...................................... 68felodipine tab er 24hr 2.5 mg..................................... 68felodipine tab er 24hr 5 mg........................................ 68fenofibrate micronized cap 134 mg........................... 68fenofibrate micronized cap 200 mg........................... 68fenofibrate micronized cap 67 mg............................. 68fenofibrate tab 145 mg................................................68fenofibrate tab 160 mg................................................68fenofibrate tab 48 mg.................................................. 68fenofibrate tab 54 mg.................................................. 68fentanyl citrate lozenge on a handle 1200

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





mcg................................................................................2fentanyl td patch 72hr 100 mcg/hr...............................2fentanyl td patch 72hr 12 mcg/hr................................. 2fentanyl td patch 72hr 25 mcg/hr................................. 2fentanyl td patch 72hr 37.5 mcg/hr..............................2fentanyl td patch 72hr 50 mcg/hr................................. 2fentanyl td patch 72hr 62.5 mcg/hr..............................2fentanyl td patch 72hr 75 mcg/hr................................. 2fentanyl td patch 72hr 87.5 mcg/hr..............................2FETZIMA....................................................................... 19FETZIMA....................................................................... 19FETZIMA....................................................................... 19FETZIMA....................................................................... 19FETZIMA TITRATION PACK......................................19FINACEA....................................................................... 80

FINACEA....................................................................... 80finasteride tab 5 mg.....................................................89FIRAZYR....................................................................... 98FIRMAGON...................................................................96FIRMAGON...................................................................96flecainide acetate tab 100 mg....................................68flecainide acetate tab 150 mg....................................68flecainide acetate tab 50 mg...................................... 68FLOMAX........................................................................89FLOVENT DISKUS....................................................109FLOVENT DISKUS....................................................109FLOVENT DISKUS....................................................109FLOVENT HFA...........................................................109FLOVENT HFA...........................................................109FLOVENT HFA...........................................................109fluconazole for susp 10 mg/ml................................... 24fluconazole for susp 40 mg/ml................................... 24fluconazole in dextrose inj 200

mg/100ml....................................................................24fluconazole in dextrose inj 400

mg/200ml....................................................................24fluconazole in nacl 0.9% inj 200

mg/100ml....................................................................24fluconazole in nacl 0.9% inj 400

mg/200ml....................................................................24fluconazole tab 100 mg...............................................24fluconazole tab 150 mg...............................................24fluconazole tab 200 mg...............................................24fluconazole tab 50 mg.................................................24flucytosine cap 250 mg............................................... 24flucytosine cap 500 mg............................................... 24fludarabine phosphate for inj 50 mg..........................30fludarabine phosphate inj 25 mg/ml.......................... 30fludrocortisone acetate tab 0.1 mg............................ 90fluocinolone acetonide (otic) oil

0.01%........................................................................107fluocinolone acetonide cream 0.01%........................ 80fluocinonide cream 0.05%.......................................... 80fluocinonide emulsified base cream

0.05%..........................................................................80fluocinonide gel 0.05%................................................80fluocinonide oint 0.05%...............................................80fluocinonide soln 0.05%..............................................80fluorometholone ophth susp 0.1%...........................105FLUOROURACIL......................................................... 80FLUOROURACIL......................................................... 80fluorouracil cream 5%................................................. 80fluorouracil iv soln 1 gm/20ml (50 mg/

ml)................................................................................31fluorouracil iv soln 2.5 gm/50ml (50 mg/

ml)................................................................................31

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130

fluorouracil iv soln 500 mg/10ml (50 mg/ml)................................................................................30

fluorouracil iv soln 5 gm/100ml (50 mg/ml)................................................................................31

FLUOXETINE DR........................................................ 20fluoxetine hcl cap 10 mg.............................................20fluoxetine hcl cap 20 mg.............................................20fluoxetine hcl cap 40 mg.............................................20fluoxetine hcl solution 20 mg/5ml.............................. 20fluoxetine hcl tab 10 mg..............................................20fluoxetine hcl tab 20 mg..............................................20fluphenazine decanoate inj 25 mg/ml........................41FLUPHENAZINE HCL.................................................41FLUPHENAZINE HCL.................................................41fluphenazine hcl tab 10 mg........................................ 41fluphenazine hcl tab 1 mg.......................................... 41fluphenazine hcl tab 2.5 mg....................................... 41fluphenazine hcl tab 5 mg.......................................... 41FLUPHENAZINE HYDROCHLORIDE...................... 41flurbiprofen sodium ophth soln 0.03%.....................105flurbiprofen tab 100 mg.................................................2flurbiprofen tab 50 mg................................................... 2flutamide cap 125 mg..................................................31FLUTICASONE PROPIONATE/

SALMETEROL........................................................ 109FLUTICASONE PROPIONATE/

SALMETEROL........................................................ 109FLUTICASONE PROPIONATE/

SALMETEROL........................................................ 109fluticasone propionate cream 0.05%.........................80fluticasone propionate nasal susp 50 mcg/

act..............................................................................109fluticasone propionate oint 0.005%........................... 80fluvastatin sodium cap 20 mg.................................... 68fluvastatin sodium cap 40 mg.................................... 69fluvastatin sodium tab er 24 hr 80 mg.......................69fluvoxamine maleate tab 100 mg...............................20fluvoxamine maleate tab 25 mg.................................20fluvoxamine maleate tab 50 mg.................................20FML LIQUIFILM......................................................... 105FOLOTYN......................................................................31FOLOTYN......................................................................31fomepizole inj 1 gm/ml (for iv infusion)......................83fondaparinux sodium subcutaneous inj 10

mg/0.8ml.....................................................................60fondaparinux sodium subcutaneous inj 2.5

mg/0.5ml.....................................................................60fondaparinux sodium subcutaneous inj 5

mg/0.4ml.....................................................................60fondaparinux sodium subcutaneous inj 7.5

mg/0.6ml.....................................................................60FORTEO......................................................................104

fosamprenavir calcium tab 700 mg........................... 46fosaprepitant dimeglumine for iv infusion 150

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

mg................................................................................69fosinopril sodium & hydrochlorothiazide tab 20-12.5

mg................................................................................69fosinopril sodium tab 10 mg....................................... 69fosinopril sodium tab 20 mg....................................... 69fosinopril sodium tab 40 mg....................................... 69fosphenytoin sodium inj 100 mg/2ml.........................14fosphenytoin sodium inj 500 mg/10ml.......................15FOSRENOL.................................................................. 83FOSRENOL.................................................................. 83FREAMINE HBC 6.9%................................................83FREAMINE III............................................................... 83frovatriptan succinate tab 2.5 mg.............................. 25fulvestrant inj 250 mg/5ml...........................................31furosemide inj 10 mg/ml..............................................69furosemide oral soln 10 mg/ml...................................69furosemide tab 20 mg................................................. 69furosemide tab 40 mg................................................. 69furosemide tab 80 mg................................................. 69FUZEON........................................................................46FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15Ggabapentin cap 100 mg.............................................. 15gabapentin cap 300 mg.............................................. 15gabapentin cap 400 mg.............................................. 15gabapentin oral soln 250 mg/5ml.............................. 15gabapentin tab 600 mg............................................... 15gabapentin tab 800 mg............................................... 15GALANTAMINE HYDROBROMIDE.......................... 17galantamine hydrobromide cap er 24hr 16

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

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

mg................................................................................18galantamine hydrobromide tab 12 mg...................... 18galantamine hydrobromide tab 4 mg.........................18galantamine hydrobromide tab 8 mg.........................18GAMMAGARD LIQUID............................................... 98GAMMAGARD LIQUID............................................... 99GAMMAGARD LIQUID............................................... 99

2019

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GAMMAGARD LIQUID............................................... 99GAMMAGARD LIQUID............................................... 99GAMMAGARD LIQUID............................................... 99GAMMAGARD S/D......................................................99GAMMAGARD S/D......................................................99GAMMAPLEX............................................................... 99GAMMAPLEX............................................................... 99GAMMAPLEX............................................................... 99GAMMAPLEX............................................................... 99GAMMAPLEX............................................................... 99GAMMAPLEX............................................................... 99GAMUNEX-C................................................................ 99GAMUNEX-C................................................................ 99GAMUNEX-C................................................................ 99GAMUNEX-C................................................................ 99GAMUNEX-C................................................................ 99GAMUNEX-C................................................................ 99ganciclovir sodium for inj 500 mg.............................. 46GARDASIL 9.................................................................99GARDASIL 9.................................................................99gatifloxacin ophth soln 0.5%.................................... 105GATTEX.........................................................................86GAUZE PADS 2" X 2".................................................52GAZYVA.........................................................................31gemcitabine hcl for inj 1 gm....................................... 31gemcitabine hcl for inj 200 mg...................................31gemcitabine hcl for inj 2 gm....................................... 31gemcitabine hcl inj 1 gm/26.3ml (38 mg/

ml)................................................................................31gemcitabine hcl inj 200 mg/5.26ml (38 mg/

ml)................................................................................31gemcitabine hcl inj 2 gm/52.6ml (38 mg/

ml)................................................................................31gemfibrozil tab 600 mg............................................... 69gentamicin in saline inj 0.8 mg/ml............................. 10gentamicin in saline inj 1.2 mg/ml............................. 10gentamicin in saline inj 1.6 mg/ml............................. 10gentamicin in saline inj 1 mg/ml.................................10gentamicin sulfate cream 0.1%..................................80gentamicin sulfate inj 10 mg/ml................................. 10gentamicin sulfate inj 40 mg/ml................................. 10gentamicin sulfate oint 0.1%...................................... 80gentamicin sulfate ophth oint 0.3%......................... 105gentamicin sulfate ophth soln 0.3%........................ 105GENVOYA.....................................................................46GEODON.......................................................................41GILENYA....................................................................... 78GILOTRIF......................................................................31GILOTRIF......................................................................31GILOTRIF......................................................................31glatiramer acetate soln prefilled syringe 20 mg/

ml.................................................................................78

glatiramer acetate soln prefilled syringe 40 mg/ml.................................................................................78

GLEOSTINE..................................................................31GLEOSTINE..................................................................31GLEOSTINE..................................................................31glimepiride tab 1 mg....................................................52glimepiride tab 2 mg....................................................52glimepiride tab 4 mg....................................................52glipizide-metformin hcl tab 2.5-250 mg.....................52glipizide-metformin hcl tab 2.5-500 mg.....................52glipizide-metformin hcl tab 5-500 mg........................ 52glipizide tab 10 mg...................................................... 52glipizide tab 5 mg.........................................................52glipizide tab er 24hr 10 mg.........................................52glipizide tab er 24hr 2.5 mg........................................52glipizide tab er 24hr 5 mg...........................................52GLUCAGEN HYPOKIT............................................... 52GLUCAGON EMERGENCY KIT............................... 52GLUCOPHAGE............................................................ 52GLUCOPHAGE............................................................ 52GLUCOPHAGE............................................................ 52GLUCOPHAGE XR..................................................... 52GLUCOPHAGE XR..................................................... 52GLUCOTROL................................................................52GLUCOTROL................................................................52GLUCOTROL XL......................................................... 52GLUCOTROL XL......................................................... 52GLUCOTROL XL......................................................... 52glycopyrrolate tab 1 mg.............................................. 86glycopyrrolate tab 2 mg.............................................. 86GLYXAMBI.................................................................... 52GLYXAMBI.................................................................... 52GOLYTELY....................................................................86granisetron hcl inj 1 mg/ml......................................... 22granisetron hcl inj 4 mg/4ml (1 mg/ml)......................22granisetron hcl tab 1 mg.............................................23GRANIX......................................................................... 60GRANIX......................................................................... 60GRANIX......................................................................... 60GRANIX......................................................................... 60griseofulvin microsize susp 125

mg/5ml........................................................................ 24griseofulvin microsize tab 500 mg............................. 24griseofulvin ultramicrosize tab 125 mg......................24griseofulvin ultramicrosize tab 250 mg......................24GUANIDINE HCL.........................................................26HHAEGARDA.................................................................. 99HAEGARDA.................................................................. 99HALAVEN...................................................................... 31halobetasol propionate cream 0.05%........................81

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halobetasol propionate oint 0.05%............................ 81haloperidol decanoate im soln 100 mg/

ml.................................................................................42haloperidol decanoate im soln 50 mg/

ml.................................................................................41haloperidol lactate inj 5 mg/ml................................... 42haloperidol lactate oral conc 2 mg/ml........................42haloperidol tab 0.5 mg................................................ 42haloperidol tab 10 mg................................................. 42haloperidol tab 1 mg....................................................42haloperidol tab 20 mg................................................. 42haloperidol tab 2 mg....................................................42haloperidol tab 5 mg....................................................42HARVONI...................................................................... 46HARVONI...................................................................... 46HAVRIX..........................................................................99HAVRIX..........................................................................99HEPARIN SODIUM......................................................60HEPARIN SODIUM......................................................60heparin sodium (porcine)-dextrose iv sol 20000

unit/500ml-5%............................................................60heparin sodium (porcine) inj 10000 unit/

ml.................................................................................60heparin sodium (porcine) inj 1000 unit/



ml.................................................................................60heparin sodium (porcine) pf inj 5000

unit/0.5ml....................................................................60HEPATAMINE............................................................... 83HERCEPTIN................................................................. 31HERCEPTIN HYLECTA.............................................. 31HETLIOZ..................................................................... 112HIBERIX........................................................................ 99HUMALOG.................................................................... 52HUMALOG.................................................................... 52HUMALOG JUNIOR KWIKPEN.................................52HUMALOG KWIKPEN.................................................53HUMALOG KWIKPEN.................................................53HUMALOG MIX 50/50.................................................53HUMALOG MIX 50/50 KWIKPEN............................. 53HUMALOG MIX 75/25.................................................53HUMALOG MIX 75/25 KWIKPEN............................. 53HUMIRA.........................................................................99HUMIRA...................................................................... 100HUMIRA...................................................................... 100HUMIRA...................................................................... 100HUMIRA...................................................................... 100HUMIRA...................................................................... 100

HUMIRA PEDIATRIC CROHNS DISEASESTARTER PACK.....................................................100



HUMIRA PEN.............................................................100HUMIRA PEN.............................................................100HUMIRA PEN-CD/UC/HS STARTER..................... 100HUMIRA PEN-CD/UC/HS STARTER..................... 100HUMIRA PEN-PS/UV STARTER.............................100HUMIRA PEN-PS/UV STARTER.............................100HUMULIN 70/30...........................................................53HUMULIN 70/30 KWIKPEN....................................... 53HUMULIN N..................................................................53HUMULIN N KWIKPEN.............................................. 53HUMULIN R..................................................................53HUMULIN R U-500 (CONCENTRATE).....................53HUMULIN R U-500 KWIKPEN...................................53hydralazine hcl tab 100 mg........................................ 69hydralazine hcl tab 10 mg.......................................... 69hydralazine hcl tab 25 mg.......................................... 69hydralazine hcl tab 50 mg.......................................... 69hydrochlorothiazide cap 12.5 mg...............................69hydrochlorothiazide tab 12.5 mg................................69hydrochlorothiazide tab 25 mg...................................69hydrochlorothiazide tab 50 mg...................................69hydrocodone-acetaminophen soln 7.5-325

mg/15ml........................................................................ 2hydrocodone-acetaminophen tab 10-300

mg..................................................................................2hydrocodone-acetaminophen tab 10-325



mg..................................................................................2hydrocodone-acetaminophen tab 7.5-300

mg..................................................................................2hydrocodone-acetaminophen tab 7.5-325

mg..................................................................................2hydrocodone-ibuprofen tab 10-200 mg.......................2hydrocodone-ibuprofen tab 5-200 mg......................... 2hydrocodone-ibuprofen tab 7.5-200 mg......................2hydrocortisone butyrate cream 0.1%........................ 81hydrocortisone butyrate hydrophilic lipo base cream

0.1%............................................................................81hydrocortisone butyrate oint 0.1%.............................81hydrocortisone butyrate soln 0.1%............................ 81hydrocortisone cream 1%...........................................81hydrocortisone cream 2.5%........................................81hydrocortisone enema 100 mg/60ml.......................103

2019

133

hydrocortisone lotion 2.5%......................................... 81hydrocortisone oint 1%............................................... 81hydrocortisone oint 2.5%............................................ 81hydrocortisone rectal cream 1%.............................. 103hydrocortisone rectal cream 2.5%...........................103hydrocortisone tab 10 mg...........................................90hydrocortisone tab 20 mg...........................................90hydrocortisone tab 5 mg............................................. 90hydrocortisone valerate cream 0.2%.........................81hydrocortisone valerate oint 0.2%............................. 81hydrocortisone w/ acetic acid otic soln

1-2%..........................................................................107hydromorphone hcl inj 2 mg/ml....................................2hydromorphone hcl liqd 1 mg/ml..................................2hydromorphone hcl preservative free inj 10 mg/

ml................................................................................... 2hydromorphone hcl preservative free inj 2 mg/

ml................................................................................... 2hydromorphone hcl tab 2 mg....................................... 2hydromorphone hcl tab 4 mg....................................... 3hydromorphone hcl tab 8 mg....................................... 3hydroxychloroquine sulfate tab 200 mg.................... 39HYDROXYPROGESTERONE

CAPROATE................................................................93hydroxyurea cap 500 mg............................................ 31hydroxyzine hcl syrup 10 mg/5ml.............................. 51hydroxyzine hcl tab 10 mg..........................................51hydroxyzine hcl tab 25 mg..........................................51hydroxyzine hcl tab 50 mg..........................................51HYZAAR........................................................................ 69HYZAAR........................................................................ 69HYZAAR........................................................................ 69Iibandronate sodium iv soln 3 mg/3ml..................... 104ibandronate sodium tab 150 mg..............................104IBRANCE.......................................................................31IBRANCE.......................................................................31IBRANCE.......................................................................31ibuprofen susp 100 mg/5ml.......................................... 3ibuprofen tab 400 mg.................................................... 3ibuprofen tab 600 mg.................................................... 3ibuprofen tab 800 mg.................................................... 3icatibant acetate inj 30 mg/3ml................................ 100ICLUSIG........................................................................ 31ICLUSIG........................................................................ 31idarubicin hcl iv inj 10 mg/10ml (1 mg/

ml)................................................................................31idarubicin hcl iv inj 20 mg/20ml (1 mg/

ml)................................................................................31idarubicin hcl iv inj 5 mg/5ml (1 mg/ml).....................31IDHIFA............................................................................31

IDHIFA............................................................................31IFEX............................................................................... 31IFOSFAMIDE................................................................ 31ifosfamide for inj 1 gm.................................................31ifosfamide iv inj 1 gm/20ml (50 mg/ml)..................... 32ifosfamide iv inj 3 gm/60ml (50 mg/ml)..................... 32ILARIS..........................................................................100ILEVRO........................................................................105imatinib mesylate tab 100 mg.................................... 32imatinib mesylate tab 400 mg.................................... 32IMBRUVICA.................................................................. 32IMBRUVICA.................................................................. 32IMBRUVICA.................................................................. 32IMBRUVICA.................................................................. 32IMBRUVICA.................................................................. 32IMBRUVICA.................................................................. 32IMFINZI..........................................................................32IMFINZI..........................................................................32imipenem-cilastatin intravenous for soln 250

mg................................................................................10imipenem-cilastatin intravenous for soln 500

mg................................................................................10imipramine hcl tab 10 mg........................................... 20imipramine hcl tab 25 mg........................................... 20imipramine hcl tab 50 mg........................................... 20imiquimod cream 5%...................................................81IMITREX........................................................................ 25IMITREX........................................................................ 25IMITREX........................................................................ 25IMITREX........................................................................ 26IMITREX........................................................................ 26IMITREX........................................................................ 26IMITREX STATDOSE REFILL....................................26IMITREX STATDOSE REFILL....................................26IMITREX STATDOSE SYSTEM.................................26IMITREX STATDOSE SYSTEM.................................26IMLYGIC........................................................................ 32IMLYGIC........................................................................ 32IMOVAX RABIES (H.D.C.V.).................................... 100IMPAVIDO..................................................................... 10INBRIJA......................................................................... 40INCRELEX.................................................................... 91INCRUSE ELLIPTA................................................... 109indapamide tab 1.25 mg............................................. 69indapamide tab 2.5 mg............................................... 69INFANRIX....................................................................100INJECTION DEVICE FOR INSULIN......................... 53INLYTA...........................................................................32INLYTA...........................................................................32INREBIC........................................................................ 32INSULIN PEN NEEDLE 29G X 12.7MM

(1/2")........................................................................... 53

2019

134

INSULIN PEN NEEDLE 29G X 5MM (1/5" OR3/16")...........................................................................53








INSULIN PEN NEEDLE 33G X 6MM (1/4" OR15/64")........................................................................ 53


INSULIN SYRINGE/NEEDLE U-100/0.3ML/28G X1/2".............................................................................. 54

INSULIN SYRINGE/NEEDLE U-100/0.3ML/29G..................................................................................54

INSULIN SYRINGE/NEEDLE U-100/0.3ML/29G X1"................................................................................. 54

INSULIN SYRINGE/NEEDLEU-100/0.3ML/30G......................................................54

INSULIN SYRINGE/NEEDLE U-100/0.3ML/31G X1/4" (6MM)..................................................................54


INSULIN SYRINGE/NEEDLE U-100/0.5ML/28G X5/16"............................................................................54


INSULIN SYRINGE/NEEDLE U-100/0.5ML/29G X5/16"............................................................................54


INSULIN SYRINGE/NEEDLE U-100/0.5ML/30G X3/16" (5MM)............................................................... 54


INSULIN SYRINGE/NEEDLE U-100/0.5ML/31G X1/4" (6MM)..................................................................54

INSULIN SYRINGE/NEEDLE U-100/1ML/25G X1"................................................................................. 54

INSULIN SYRINGE/NEEDLE U-100/1ML/25G X5/8".............................................................................. 54




INSULIN SYRINGE/NEEDLE U-100/1ML/28G X5/16"............................................................................54

INSULIN SYRINGE/NEEDLE U-100/1ML/29G X5/16"............................................................................54

INSULIN SYRINGE/NEEDLEU-100/1ML/30G.........................................................54

INSULIN SYRINGE/NEEDLE U-100/1ML/30G X3/16" (5MM)............................................................... 54

INSULIN SYRINGE/NEEDLE U-100/1ML/31G X1/4" (6MM)..................................................................54

INSULIN SYRINGE/NEEDLE U-100/2ML/27.5G X5/8".............................................................................. 54

INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X15/64"..........................................................................53

INSULIN SYRINGE/NEEDLE U-100 0.5 ML 30 X15/64"..........................................................................53

INSULIN SYRINGE/NEEDLE U-100 0.5 ML 32 X5/16"............................................................................53

INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X15/64"..........................................................................54

INSULIN SYRINGE/NEEDLE U-100 1 ML 32 X5/16"............................................................................54


INSULIN SYRINGE/NEEDLE U-500/0.5ML/31G X6MM (15/64").............................................................54

INSULIN SYRINGE (DISP)U-100/0.3ML.............................................................. 53

INSULIN SYRINGE (DISP)U-100/0.5ML.............................................................. 53

INSULIN SYRINGE (DISP)U-100/1ML................................................................. 53

INTELENCE.................................................................. 47INTELENCE.................................................................. 47INTELENCE.................................................................. 47INTRON A.....................................................................47INTRON A.....................................................................47INTRON A.....................................................................47INTRON A.....................................................................47INTRON A.....................................................................47INTRON A W/DILUENT..............................................47INTRON A W/DILUENT..............................................47INTRON A W/DILUENT..............................................47INVANZ.......................................................................... 10INVANZ.......................................................................... 10INVEGA SUSTENNA.................................................. 42INVEGA SUSTENNA.................................................. 42INVEGA SUSTENNA.................................................. 42

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INVEGA SUSTENNA.................................................. 42INVEGA SUSTENNA.................................................. 42INVEGA TRINZA..........................................................42INVEGA TRINZA..........................................................42INVEGA TRINZA..........................................................42INVEGA TRINZA..........................................................42INVIRASE......................................................................47INVOKAMET.................................................................54INVOKAMET.................................................................54INVOKAMET.................................................................54INVOKAMET.................................................................54INVOKAMET XR..........................................................54INVOKAMET XR..........................................................54INVOKAMET XR..........................................................54INVOKAMET XR..........................................................55INVOKANA....................................................................55INVOKANA....................................................................55IPOL INACTIVATED IPV.......................................... 100ipratropium bromide inhal soln 0.02%.....................109ipratropium bromide nasal soln 0.03% (21 mcg/

spray)........................................................................109ipratropium bromide nasal soln 0.06% (42 mcg/

spray)........................................................................109irbesartan-hydrochlorothiazide tab 150-12.5

mg................................................................................69irbesartan-hydrochlorothiazide tab 300-12.5

mg................................................................................69irbesartan tab 150 mg.................................................69irbesartan tab 300 mg.................................................69irbesartan tab 75 mg................................................... 69IRESSA..........................................................................32IRINOTECAN................................................................32irinotecan hcl inj 100 mg/5ml (20 mg/

ml)................................................................................32irinotecan hcl inj 40 mg/2ml (20 mg/ml).................... 32ISENTRESS..................................................................47ISENTRESS..................................................................47ISENTRESS..................................................................47ISENTRESS..................................................................47ISENTRESS HD...........................................................47ISONIAZID.................................................................... 27isoniazid tab 100 mg................................................... 27isoniazid tab 300 mg................................................... 27isosorbide dinitrate tab 10 mg....................................69isosorbide dinitrate tab 20 mg....................................69isosorbide dinitrate tab 30 mg....................................69isosorbide dinitrate tab 5 mg......................................69isosorbide mononitrate tab 10 mg............................. 70isosorbide mononitrate tab 20 mg............................. 70isosorbide mononitrate tab er 24hr 120

mg................................................................................70

isosorbide mononitrate tab er 24hr 30mg................................................................................69

isosorbide mononitrate tab er 24hr 60mg................................................................................69

isotretinoin cap 10 mg.................................................81isotretinoin cap 20 mg.................................................81isotretinoin cap 30 mg.................................................81isotretinoin cap 40 mg.................................................81isradipine cap 2.5 mg..................................................70isradipine cap 5 mg..................................................... 70ISTALOL...................................................................... 105ISTODAX (OVERFILL)................................................32itraconazole cap 100 mg............................................ 24ivermectin tab 3 mg.....................................................39IXEMPRA KIT...............................................................32IXEMPRA KIT...............................................................32IXIARO.........................................................................100JJADENU........................................................................ 83JADENU........................................................................ 83JADENU........................................................................ 84JADENU SPRINKLE................................................... 84JADENU SPRINKLE................................................... 84JADENU SPRINKLE................................................... 84JAKAFI...........................................................................32JAKAFI...........................................................................32JAKAFI...........................................................................32JAKAFI...........................................................................32JAKAFI...........................................................................32JANUMET......................................................................55JANUMET......................................................................55JANUMET XR...............................................................55JANUMET XR...............................................................55JANUMET XR...............................................................55JANUVIA........................................................................55JANUVIA........................................................................55JANUVIA........................................................................55JARDIANCE..................................................................55JARDIANCE..................................................................55JENTADUETO.............................................................. 55JENTADUETO.............................................................. 55JENTADUETO.............................................................. 55JENTADUETO XR....................................................... 55JENTADUETO XR....................................................... 55JEVTANA.......................................................................32JULUCA.........................................................................47JUXTAPID..................................................................... 70JUXTAPID..................................................................... 70JUXTAPID..................................................................... 70JUXTAPID..................................................................... 70JUXTAPID..................................................................... 70JUXTAPID..................................................................... 70

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KKADCYLA......................................................................32KADCYLA......................................................................32KALETRA...................................................................... 47KALETRA...................................................................... 47KALYDECO.................................................................109KALYDECO.................................................................110KALYDECO.................................................................110KALYDECO.................................................................110KANJINTI.......................................................................32kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45%

inj................................................................................. 84kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2%



inj................................................................................. 84kcl 20 meq/l (0.15%) in nacl 0.45% inj......................84kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45%


inj................................................................................. 84KEPIVANCE..................................................................79ketoconazole cream 2%..............................................24ketoconazole shampoo 2%........................................ 24ketoconazole tab 200 mg........................................... 24ketorolac tromethamine ophth soln

0.4%..........................................................................105ketorolac tromethamine ophth soln

0.5%..........................................................................105KEYTRUDA...................................................................32KINERET.....................................................................100KINRIX.........................................................................100KISQALI.........................................................................32KISQALI.........................................................................32KISQALI.........................................................................33KISQALI FEMARA 200 DOSE...................................33KISQALI FEMARA 400 DOSE...................................33KISQALI FEMARA 600 DOSE...................................33KOMBIGLYZE XR........................................................55KOMBIGLYZE XR........................................................55KOMBIGLYZE XR........................................................55KORLYM........................................................................95K-TAB.............................................................................84KUVAN...........................................................................88KUVAN...........................................................................88KUVAN...........................................................................88KYPROLIS.................................................................... 33KYPROLIS.................................................................... 33KYPROLIS.................................................................... 33

Llabetalol hcl tab 100 mg..............................................70labetalol hcl tab 200 mg..............................................70labetalol hcl tab 300 mg..............................................70LACRISERT................................................................106lactated ringer's solution............................................. 84lactic acid (ammonium lactate) cream

12%............................................................................. 81lactic acid (ammonium lactate) lotion

12%............................................................................. 81lactulose (encephalopathy) solution 10

gm/15ml......................................................................86lactulose solution 10 gm/15ml....................................86lamivudine oral soln 10 mg/ml................................... 47lamivudine tab 100 mg (hbv)......................................47lamivudine tab 150 mg................................................47lamivudine tab 300 mg................................................47lamivudine-zidovudine tab 150-300 mg.................... 47lamotrigine tab 100 mg............................................... 15lamotrigine tab 150 mg............................................... 15lamotrigine tab 200 mg............................................... 15lamotrigine tab 25 mg................................................. 15lamotrigine tab chewable dispersible 25

mg................................................................................15lamotrigine tab chewable dispersible 5

mg................................................................................15lansoprazole cap delayed release 15

mg................................................................................86lansoprazole cap delayed release 30

mg................................................................................86lanthanum carbonate chew tab 1000



mg................................................................................84LANTUS.........................................................................55LANTUS SOLOSTAR..................................................55LARTRUVO...................................................................33LARTRUVO...................................................................33LASIX............................................................................. 70LASIX............................................................................. 70LASIX............................................................................. 70latanoprost ophth soln 0.005%................................ 106LATUDA.........................................................................42LATUDA.........................................................................42LATUDA.........................................................................42LATUDA.........................................................................42LATUDA.........................................................................42LAZANDA........................................................................ 3LAZANDA........................................................................ 3

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LAZANDA........................................................................ 3leflunomide tab 10 mg.............................................. 100leflunomide tab 20 mg.............................................. 100LENVIMA 10 MG DAILY DOSE.................................33LENVIMA 12MG DAILY DOSE..................................33LENVIMA 14 MG DAILY DOSE.................................33LENVIMA 18 MG DAILY DOSE.................................33LENVIMA 20 MG DAILY DOSE.................................33LENVIMA 24 MG DAILY DOSE.................................33LENVIMA 4 MG DAILY DOSE...................................33LENVIMA 8 MG DAILY DOSE...................................33LETAIRIS.....................................................................110LETAIRIS.....................................................................110letrozole tab 2.5 mg.....................................................33LEUCOVORIN CALCIUM...........................................33LEUCOVORIN CALCIUM...........................................33LEUCOVORIN CALCIUM...........................................33leucovorin calcium for inj 100 mg.............................. 33leucovorin calcium for inj 200 mg.............................. 33leucovorin calcium for inj 350 mg.............................. 33leucovorin calcium for inj 500 mg.............................. 33leucovorin calcium for inj 50 mg................................ 33leucovorin calcium inj 500 mg/50ml (10 mg/

ml)................................................................................33leucovorin calcium tab 25 mg.................................... 34leucovorin calcium tab 5 mg.......................................33LEUKERAN...................................................................34LEUKINE....................................................................... 60leuprolide acetate inj kit 5 mg/ml............................... 96LEVEMIR.......................................................................55LEVEMIR FLEXTOUCH..............................................55levetiracetam inj 500 mg/5ml (100 mg/

ml)................................................................................15levetiracetam in sodium chloride iv soln 1000

mg/100ml....................................................................15levetiracetam in sodium chloride iv soln 1500

mg/100ml....................................................................15levetiracetam in sodium chloride iv soln 500

mg/100ml....................................................................15levetiracetam oral soln 100 mg/ml.............................15levetiracetam tab 1000 mg......................................... 15levetiracetam tab 250 mg........................................... 15levetiracetam tab 500 mg........................................... 15levetiracetam tab 750 mg........................................... 15levobunolol hcl ophth soln 0.5%..............................106levocarnitine oral soln 1 gm/10ml

(10%).......................................................................... 84levocarnitine tab 330 mg............................................ 84levocetirizine dihydrochloride tab 5

mg............................................................................. 110levofloxacin in d5w iv soln 250

mg/50ml......................................................................10

levofloxacin in d5w iv soln 500mg/100ml....................................................................10

levofloxacin in d5w iv soln 750mg/150ml....................................................................10

levofloxacin iv soln 25 mg/ml..................................... 10levofloxacin ophth soln 0.5%................................... 106levofloxacin oral soln 25 mg/ml..................................10levofloxacin tab 250 mg..............................................10levofloxacin tab 500 mg..............................................10levofloxacin tab 750 mg..............................................10levonorgestrel & ethinyl estradiol (91-day) tab

0.15-0.03 mg............................................................. 93levonorgestrel & ethinyl estradiol tab 0.15 mg-30

mcg..............................................................................93levonorgestrel & ethinyl estradiol tab 0.1 mg-20

mcg..............................................................................93levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg........................93levonorgestrel-ethinyl estradiol (continuous) tab

90-20 mcg..................................................................93levonorg-eth est tab 0.1-0.02mg(84) & eth est tab

0.01mg(7)...................................................................93levonorg-eth est tab 0.15-0.03mg(84) & eth est tab

0.01mg(7)...................................................................93LEVORPHANOL TARTRATE....................................... 3levorphanol tartrate tab 2 mg....................................... 3levothyroxine sodium tab 100 mcg (levo-t, levoxyl,

unithroid, unithroid direct)........................................95levothyroxine sodium tab 112 mcg (levo-t, levoxyl,



unithroid).....................................................................95levothyroxine sodium tab 150 mcg (levo-t, levoxyl,




unithroid, unithroid direct)........................................94levothyroxine sodium tab 300 mcg (levo-t, unithroid,

unithroid direct)......................................................... 95levothyroxine sodium tab 50 mcg (levo-t, levoxyl,



unithroid, unithroid direct)........................................95LEXAPRO......................................................................20LEXAPRO......................................................................20

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LEXAPRO......................................................................20LEXIVA...........................................................................47LEXIVA...........................................................................47LIBTAYO........................................................................ 34LIDOCAINE HCL..........................................................70LIDOCAINE HCL..........................................................70lidocaine hcl soln 4%.....................................................4lidocaine hcl urethral/mucosal gel 2%.........................4lidocaine hcl urethral/mucosal gel prefilled syringe

2%..................................................................................4lidocaine hcl viscous soln 2%.......................................4lidocaine oint 5%............................................................4lidocaine patch 5%.........................................................4lidocaine-prilocaine cream 2.5-2.5%........................... 4lindane shampoo 1%...................................................39LINEZOLID....................................................................10linezolid for susp 100 mg/5ml.................................... 10linezolid iv soln 600 mg/300ml (2 mg/

ml)................................................................................10linezolid tab 600 mg.................................................... 11LINZESS........................................................................86LINZESS........................................................................86LINZESS........................................................................86liothyronine sodium tab 25 mcg.................................95liothyronine sodium tab 50 mcg.................................95liothyronine sodium tab 5 mcg................................... 95LIPITOR.........................................................................70LIPITOR.........................................................................70LIPITOR.........................................................................70LIPITOR.........................................................................70lisinopril & hydrochlorothiazide tab 10-12.5

mg................................................................................70lisinopril & hydrochlorothiazide tab 20-12.5

mg................................................................................70lisinopril & hydrochlorothiazide tab 20-25

mg................................................................................70lisinopril tab 10 mg...................................................... 70lisinopril tab 2.5 mg..................................................... 70lisinopril tab 20 mg...................................................... 70lisinopril tab 30 mg...................................................... 70lisinopril tab 40 mg...................................................... 70lisinopril tab 5 mg.........................................................70LITHIUM........................................................................ 51lithium carbonate cap 150 mg....................................51lithium carbonate cap 300 mg....................................51lithium carbonate cap 600 mg....................................51lithium carbonate tab 300 mg.....................................51lithium carbonate tab er 300 mg................................51lithium carbonate tab er 450 mg................................51LONSURF..................................................................... 34LONSURF..................................................................... 34loperamide hcl cap 2 mg............................................ 86

lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)................................................................................47

LOPRESSOR................................................................70LOPRESSOR................................................................70lorazepam tab 0.5 mg................................................. 51lorazepam tab 1 mg.................................................... 51lorazepam tab 2 mg.................................................... 51LORBRENA.................................................................. 34LORBRENA.................................................................. 34losartan potassium & hydrochlorothiazide tab

100-12.5 mg.............................................................. 70losartan potassium & hydrochlorothiazide tab 100-25

mg................................................................................70losartan potassium & hydrochlorothiazide tab

50-12.5 mg.................................................................70losartan potassium tab 100 mg..................................71losartan potassium tab 25 mg....................................71losartan potassium tab 50 mg....................................71LOTENSIN.................................................................... 71LOTENSIN.................................................................... 71LOTENSIN.................................................................... 71lovastatin tab 10 mg....................................................71lovastatin tab 20 mg....................................................71lovastatin tab 40 mg....................................................71loxapine succinate cap 10 mg....................................42loxapine succinate cap 25 mg....................................42loxapine succinate cap 50 mg....................................42loxapine succinate cap 5 mg......................................42LUMIGAN....................................................................106LUMIZYME....................................................................88LUMOXITI......................................................................34LUPRON DEPOT (1-MONTH)...................................96LUPRON DEPOT (1-MONTH)...................................96LUPRON DEPOT (3-MONTH)...................................96LUPRON DEPOT (3-MONTH)...................................96LUPRON DEPOT (4-MONTH)...................................96LUPRON DEPOT (6-MONTH)...................................96LUPRON DEPOT-PED (1-MONTH)..........................96LUPRON DEPOT-PED (1-MONTH)..........................96LUPRON DEPOT-PED (1-MONTH)..........................96LUPRON DEPOT-PED (3-MONTH)..........................96LUPRON DEPOT-PED (3-MONTH)..........................96LYNPARZA....................................................................34LYNPARZA....................................................................34LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15

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LYRICA.......................................................................... 15LYSODREN...................................................................95Mmagnesium sulfate inj 50%........................................ 84malathion lotion 0.5%..................................................39MAPROTILINE HCL.................................................... 20MAPROTILINE HCL.................................................... 20MAPROTILINE HCL.................................................... 20MARPLAN..................................................................... 20MARQIBO......................................................................34MATULANE...................................................................34MAVYRET..................................................................... 47MAXALT.........................................................................26MAXALT-MLT................................................................26MAXITROL..................................................................106MAYZENT......................................................................78MAYZENT......................................................................78meclizine hcl tab 12.5 mg...........................................23medroxyprogesterone acetate im susp 150 mg/

ml.................................................................................93medroxyprogesterone acetate im susp prefilled syr

150 mg/ml.................................................................. 93medroxyprogesterone acetate tab 10

mg................................................................................93medroxyprogesterone acetate tab 2.5

mg................................................................................93medroxyprogesterone acetate tab 5

mg................................................................................93mefloquine hcl tab 250 mg......................................... 39megestrol acetate susp 40 mg/ml..............................93megestrol acetate tab 20 mg..................................... 93megestrol acetate tab 40 mg..................................... 93MEKINIST......................................................................34MEKINIST......................................................................34MEKTOVI.......................................................................34meloxicam tab 15 mg....................................................3meloxicam tab 7.5 mg...................................................3melphalan hcl for inj 50 mg........................................ 34memantine hcl oral solution 2 mg/ml.........................18memantine hcl tab 10 mg...........................................18memantine hcl tab 5 mg............................................. 18memantine hcl tab 5 mg (28) & 10 mg (21) titration

pak...............................................................................18MENACTRA................................................................100MENVEO.....................................................................100mercaptopurine tab 50 mg......................................... 34meropenem iv for soln 1 gm...................................... 11meropenem iv for soln 500 mg.................................. 11mesalamine cap dr 400 mg......................................103mesalamine enema 4 gm.........................................103

mesalamine rectal enema 4 gm & cleanser wipekit...............................................................................103

mesalamine suppos 1000 mg..................................103mesalamine tab delayed release 1.2

gm............................................................................. 103mesalamine tab delayed release 800

mg............................................................................. 103mesna inj 100 mg/ml...................................................34MESNEX........................................................................34MESTINON................................................................... 26metformin hcl tab 1000 mg.........................................55metformin hcl tab 500 mg...........................................55metformin hcl tab 850 mg...........................................55metformin hcl tab er 24hr 500 mg............................. 55metformin hcl tab er 24hr 750 mg............................. 55methadone hcl tab 10 mg.............................................3methadone hcl tab 5 mg............................................... 3methazolamide tab 25 mg.......................................... 71methazolamide tab 50 mg.......................................... 71methenamine hippurate tab 1 gm..............................11methimazole tab 10 mg.............................................. 97methimazole tab 5 mg.................................................97methocarbamol tab 500 mg..................................... 112methocarbamol tab 750 mg..................................... 112METHOTREXATE SODIUM.....................................100methotrexate sodium for inj 1 gm............................100methotrexate sodium inj 50 mg/2ml (25 mg/

ml)............................................................................. 101methotrexate sodium inj pf 1000 mg/40ml (25 mg/



ml)............................................................................. 100methotrexate sodium tab 2.5 mg.............................101methoxsalen rapid cap 10 mg....................................81methscopolamine bromide tab 2.5 mg......................86methscopolamine bromide tab 5 mg......................... 86methylergonovine maleate tab 0.2 mg......................89methylphenidate hcl tab 10 mg..................................78methylphenidate hcl tab 20 mg..................................78methylphenidate hcl tab 5 mg....................................78methylphenidate hcl tab er 20 mg............................. 78methylprednisolone sod succ for inj 1000

mg................................................................................91methylprednisolone sod succ for inj 125



mg................................................................................90methylprednisolone tab 16 mg...................................91

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methylprednisolone tab 32 mg...................................91methylprednisolone tab 4 mg.....................................91methylprednisolone tab 8 mg.....................................91methylprednisolone tab therapy pack 4 mg

(21)..............................................................................91methyltestosterone cap 10 mg...................................93metoclopramide hcl inj 5 mg/ml................................. 86metoclopramide hcl soln 5 mg/5ml (10

mg/10ml).....................................................................86metoclopramide hcl tab 10 mg...................................86metoclopramide hcl tab 5 mg.....................................86metolazone tab 10 mg................................................ 71metolazone tab 2.5 mg............................................... 71metolazone tab 5 mg...................................................71metoprolol & hydrochlorothiazide tab 100-25

mg................................................................................71metoprolol & hydrochlorothiazide tab 50-25

mg................................................................................71metoprolol succinate tab er 24hr 100




mg................................................................................71metoprolol tartrate tab 100 mg...................................71metoprolol tartrate tab 25 mg.....................................71metoprolol tartrate tab 50 mg.....................................71metronidazole cap 375 mg.........................................11metronidazole cream 0.75%.......................................81metronidazole gel 0.75%............................................ 81metronidazole gel 1%..................................................81metronidazole in nacl 0.74% iv soln 500

mg/100ml....................................................................11metronidazole in nacl 0.79% iv soln 500

mg/100ml....................................................................11metronidazole iv soln 5 mg/ml................................... 11metronidazole lotion 0.75%........................................ 81metronidazole tab 250 mg..........................................11metronidazole tab 500 mg..........................................11metronidazole vaginal gel 0.75%...............................11mexiletine hcl cap 150 mg..........................................71mexiletine hcl cap 200 mg..........................................71mexiletine hcl cap 250 mg..........................................71MIACALCIN................................................................ 104MICARDIS.....................................................................71MICARDIS.....................................................................71MICARDIS.....................................................................71MICARDIS HCT........................................................... 71MICARDIS HCT........................................................... 71MICARDIS HCT........................................................... 71

midodrine hcl tab 10 mg............................................. 71midodrine hcl tab 2.5 mg............................................ 71midodrine hcl tab 5 mg............................................... 71MIGERGOT...................................................................26miglitol tab 100 mg...................................................... 55miglitol tab 25 mg........................................................ 55miglitol tab 50 mg........................................................ 55miglustat cap 100 mg..................................................88MIGRANAL....................................................................26minocycline hcl cap 100 mg.......................................11minocycline hcl cap 50 mg......................................... 11minocycline hcl cap 75 mg......................................... 11minocycline hcl tab 100 mg........................................11minocycline hcl tab 50 mg..........................................11minocycline hcl tab 75 mg..........................................11minoxidil tab 10 mg..................................................... 71minoxidil tab 2.5 mg.................................................... 71mirtazapine orally disintegrating tab 15

mg................................................................................20mirtazapine orally disintegrating tab 30

mg................................................................................20mirtazapine orally disintegrating tab 45

mg................................................................................20mirtazapine tab 15 mg................................................ 20mirtazapine tab 30 mg................................................ 20mirtazapine tab 45 mg................................................ 20mirtazapine tab 7.5 mg............................................... 20misoprostol tab 100 mcg............................................ 86misoprostol tab 200 mcg............................................ 86mitomycin for iv soln 20 mg....................................... 34mitomycin for iv soln 40 mg....................................... 34mitomycin for iv soln 5 mg..........................................34mitoxantrone hcl inj conc 20 mg/10ml (2 mg/

ml)................................................................................34mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/

ml)................................................................................34mitoxantrone hcl inj conc 30 mg/15ml (2 mg/

ml)................................................................................34M-M-R II...................................................................... 100modafinil tab 100 mg.................................................112modafinil tab 200 mg.................................................112moexipril hcl tab 15 mg...............................................72moexipril hcl tab 7.5 mg..............................................71MOLINDONE HYDROCHLORIDE............................ 42MOLINDONE HYDROCHLORIDE............................ 42MOLINDONE HYDROCHLORIDE............................ 42mometasone furoate cream 0.1%............................. 81mometasone furoate nasal susp 50 mcg/

act..............................................................................110mometasone furoate oint 0.1%..................................81mometasone furoate solution 0.1%

(lotion).........................................................................81

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MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.3ML/29G X 1/2".................................... 55

MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.5ML/29G X 1/2".................................... 56

MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/1ML/29G X 1/2"........................................56

montelukast sodium chew tab 4 mg........................110montelukast sodium chew tab 5 mg........................110montelukast sodium oral granules packet 4

mg............................................................................. 110montelukast sodium tab 10 mg................................110morphine sulfate inj pf 0.5 mg/ml.................................3morphine sulfate inj pf 1 mg/ml....................................3morphine sulfate oral soln 100 mg/5ml (20 mg/

ml)..................................................................................3morphine sulfate oral soln 10 mg/5ml......................... 3morphine sulfate oral soln 20 mg/5ml......................... 3morphine sulfate tab 15 mg..........................................3morphine sulfate tab 30 mg..........................................3morphine sulfate tab er 100 mg...................................3morphine sulfate tab er 15 mg..................................... 3morphine sulfate tab er 200 mg...................................3morphine sulfate tab er 30 mg..................................... 3morphine sulfate tab er 60 mg..................................... 3MOVIPREP................................................................... 86MOXEZA..................................................................... 106MOXIFLOXACIN HCL................................................. 11moxifloxacin hcl 400 mg/250ml in sodium chloride

0.8% inj.......................................................................11moxifloxacin hcl ophth soln 0.5%............................ 106moxifloxacin hcl tab 400 mg.......................................11MOZOBIL...................................................................... 60MULTAQ........................................................................ 72mupirocin calcium cream 2%..................................... 81mupirocin oint 2%........................................................ 81MVASI............................................................................ 34MVASI............................................................................ 34MYALEPT...................................................................... 86MYCAMINE...................................................................24MYCAMINE...................................................................24mycophenolate mofetil cap 250 mg........................ 101mycophenolate mofetil for oral susp 200 mg/

ml...............................................................................101mycophenolate mofetil hcl for iv soln 500

mg............................................................................. 101mycophenolate mofetil tab 500 mg......................... 101mycophenolate sodium tab dr 180

mg............................................................................. 101mycophenolate sodium tab dr 360

mg............................................................................. 101MYLOTARG.................................................................. 34MYRBETRIQ.................................................................89

MYRBETRIQ.................................................................89Nnabumetone tab 500 mg...............................................3nabumetone tab 750 mg...............................................3nadolol tab 20 mg........................................................72nadolol tab 40 mg........................................................72nadolol tab 80 mg........................................................72NAFCILLIN SODIUM...................................................11NAFCILLIN SODIUM...................................................11NAFCILLIN SODIUM...................................................11nafcillin sodium for inj 1 gm........................................11nafcillin sodium for inj 2 gm........................................11nafcillin sodium for iv soln 10 gm.............................. 11NAGLAZYME................................................................88NALOXONE HCL........................................................... 5NALOXONE HCL........................................................... 5naloxone hcl inj 0.4 mg/ml............................................5naloxone hcl inj 4 mg/10ml...........................................5naltrexone hcl tab 50 mg.............................................. 5naproxen sodium tab 275 mg.......................................3naproxen sodium tab 550 mg.......................................3naproxen sodium tab er 24hr 375 mg......................... 3naproxen sodium tab er 24hr 500 mg......................... 3naproxen susp 125 mg/5ml.......................................... 3naproxen tab 250 mg.................................................... 3naproxen tab 375 mg.................................................... 3naproxen tab 500 mg.................................................... 4naproxen tab ec 375 mg...............................................3naproxen tab ec 500 mg...............................................3naratriptan hcl tab 1 mg..............................................26naratriptan hcl tab 2.5 mg...........................................26NARCAN..........................................................................5NARDIL..........................................................................20NATACYN....................................................................106nateglinide tab 120 mg............................................... 56nateglinide tab 60 mg..................................................56NATPARA....................................................................104NATPARA....................................................................104NATPARA....................................................................104NATPARA....................................................................104NAYZILAM.....................................................................16NEBUPENT...................................................................39NEFAZODONE HCL....................................................20NEFAZODONE HCL....................................................20nefazodone hcl tab 250 mg........................................20nefazodone hcl tab 50 mg..........................................20NEFAZODONE HYDROCHLORIDE.........................20neomycin-bacitrac zn-polymyx

5(3.5)mg-400unt-10000unt op oin........................106neomycin-polymy-gramicid op sol

1.75-10000-0.025mg-unt-mg/ml...........................106

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neomycin-polymyxin b gu irrigationsoln..............................................................................11

neomycin-polymyxin-dexamethasone ophth oint0.1%..........................................................................106

neomycin-polymyxin-dexamethasone ophth susp0.1%..........................................................................106

neomycin-polymyxin-hc otic soln 1%...................... 107neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000

unit/ml-1%................................................................ 107neomycin sulfate tab 500 mg.....................................11NEPHRAMINE..............................................................84NERLYNX......................................................................34NEULASTA....................................................................60NEULASTA ONPRO KIT............................................ 60NEUPOGEN..................................................................60NEUPOGEN..................................................................60NEUPOGEN..................................................................60NEUPOGEN..................................................................61nevirapine susp 50 mg/5ml........................................ 47nevirapine tab 200 mg................................................ 47nevirapine tab er 24hr 100 mg...................................47nevirapine tab er 24hr 400 mg...................................47NEXAVAR......................................................................34NEXIUM.........................................................................86NEXIUM.........................................................................86NEXIUM.........................................................................86NEXIUM.........................................................................87NEXIUM.........................................................................87niacin tab er 1000 mg................................................. 72niacin tab er 500 mg................................................... 72niacin tab er 750 mg................................................... 72nicardipine hcl cap 20 mg...........................................72nicardipine hcl cap 30 mg...........................................72NICOTROL INHALER................................................... 5NICOTROL NS............................................................... 5nifedipine tab er 24hr 30 mg...................................... 72nifedipine tab er 24hr 60 mg...................................... 72nifedipine tab er 24hr 90 mg...................................... 72nifedipine tab er 24hr osmotic release 30

mg................................................................................72nifedipine tab er 24hr osmotic release 60

mg................................................................................72nifedipine tab er 24hr osmotic release 90

mg................................................................................72nilutamide tab 150 mg.................................................34nimodipine cap 30 mg.................................................72NINLARO.......................................................................34NINLARO.......................................................................34NINLARO.......................................................................34NIPENT..........................................................................34NISOLDIPINE ER........................................................ 72nisoldipine tab er 24hr 17 mg.................................... 72

nisoldipine tab er 24hr 34 mg.................................... 72nisoldipine tab er 24hr 8.5 mg................................... 72nitisinone cap 10 mg................................................... 88nitisinone cap 2 mg..................................................... 88nitisinone cap 5 mg..................................................... 88NITRO-BID....................................................................72nitrofurantoin macrocrystalline cap 100

mg................................................................................11nitrofurantoin macrocrystalline cap 50

mg................................................................................11nitrofurantoin monohydrate macrocrystalline cap 100

mg................................................................................11nitrofurantoin susp 25 mg/5ml....................................11nitroglycerin sl tab 0.3 mg.......................................... 72nitroglycerin sl tab 0.4 mg.......................................... 72nitroglycerin sl tab 0.6 mg.......................................... 72nitroglycerin td patch 24hr 0.1 mg/hr.........................72nitroglycerin td patch 24hr 0.2 mg/hr.........................72nitroglycerin td patch 24hr 0.4 mg/hr.........................72nitroglycerin td patch 24hr 0.6 mg/hr.........................72nitroglycerin tl soln 0.4 mg/spray (400 mcg/

spray)..........................................................................72nizatidine cap 150 mg.................................................87nizatidine cap 300 mg.................................................87norethindrone & ethinyl estradiol-fe chew tab 0.4

mg-35 mcg.................................................................93norethindrone & ethinyl estradiol-fe chew tab 0.8

mg-25 mcg.................................................................93norethindrone & ethinyl estradiol tab 0.4 mg-35

mcg..............................................................................93norethindrone & ethinyl estradiol tab 0.5 mg-35

mcg..............................................................................93norethindrone & ethinyl estradiol tab 1 mg-35

mcg..............................................................................93norethindrone ace & ethinyl estradiol-fe tab 1.5

mg-30 mcg.................................................................93norethindrone ace & ethinyl estradiol-fe tab 1 mg-20

mcg..............................................................................93norethindrone ace & ethinyl estradiol tab 1.5 mg-30

mcg..............................................................................93norethindrone ace & ethinyl estradiol tab 1 mg-20

mcg..............................................................................93norethindrone ace-ethinyl estradiol-fe tab 1 mg-20

mcg (24).....................................................................93norethindrone acetate-ethinyl estradiol tab 1 mg-5

mcg..............................................................................94norethindrone acetate tab 5 mg.................................94norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35

mg-mcg.......................................................................93norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35

mg-mcg.......................................................................94

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norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35mg-mcg.......................................................................94

norethindrone tab 0.35 mg......................................... 94norgestimate & ethinyl estradiol tab 0.25 mg-35

mcg..............................................................................94norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg.........................94norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg.........................94norgestrel & ethinyl estradiol tab 0.3 mg-30

mcg..............................................................................94NORMOSOL-M IN D5W............................................. 84NORTHERA.................................................................. 72NORTHERA.................................................................. 72NORTHERA.................................................................. 72nortriptyline hcl cap 10 mg......................................... 20nortriptyline hcl cap 25 mg......................................... 20nortriptyline hcl cap 50 mg......................................... 20nortriptyline hcl cap 75 mg......................................... 20nortriptyline hcl soln 10 mg/5ml................................. 20NORVASC..................................................................... 72NORVASC..................................................................... 72NORVASC..................................................................... 72NORVIR.........................................................................47NORVIR.........................................................................47NOXAFIL....................................................................... 24NOXAFIL....................................................................... 24NOXAFIL....................................................................... 24NUBEQA........................................................................34NUEDEXTA...................................................................78NULOJIX..................................................................... 101NULYTELY/FLAVOR PACKS..................................... 87NUPLAZID.....................................................................42NUPLAZID.....................................................................42nystatin cream 100000 unit/gm..................................24nystatin oint 100000 unit/gm...................................... 24nystatin susp 100000 unit/ml......................................24nystatin tab 500000 unit..............................................24nystatin topical powder 100000 unit/

gm................................................................................24nystatin-triamcinolone cream 100000-0.1 unit/gm-

%..................................................................................81nystatin-triamcinolone oint 100000-0.1 unit/gm-

%..................................................................................81OOCALIVA....................................................................... 88OCALIVA....................................................................... 88octreotide acetate inj 1000 mcg/ml (1 mg/

ml)................................................................................96octreotide acetate inj 100 mcg/ml (0.1 mg/

ml)................................................................................96

octreotide acetate inj 200 mcg/ml (0.2 mg/ml)................................................................................96



OCUFLOX...................................................................106ODEFSEY..................................................................... 47ODOMZO...................................................................... 34OFEV........................................................................... 110OFEV........................................................................... 110ofloxacin ophth soln 0.3%........................................ 106ofloxacin otic soln 0.3%............................................ 107ofloxacin tab 400 mg...................................................11olanzapine for im inj 10 mg........................................ 43olanzapine orally disintegrating tab 10

mg................................................................................43olanzapine orally disintegrating tab 15



mg................................................................................43olanzapine tab 10 mg..................................................43olanzapine tab 15 mg..................................................43olanzapine tab 2.5 mg.................................................43olanzapine tab 20 mg..................................................43olanzapine tab 5 mg....................................................43olanzapine tab 7.5 mg.................................................43olmesartan-amlodipine-hydrochlorothiazide tab

20-5-12.5 mg............................................................. 73olmesartan-amlodipine-hydrochlorothiazide tab

40-10-12.5 mg...........................................................73olmesartan-amlodipine-hydrochlorothiazide tab

40-10-25 mg.............................................................. 73olmesartan-amlodipine-hydrochlorothiazide tab

40-5-12.5 mg............................................................. 73olmesartan-amlodipine-hydrochlorothiazide tab

40-5-25 mg................................................................ 73olmesartan medoxomil-hydrochlorothiazide tab

20-12.5 mg.................................................................73olmesartan medoxomil-hydrochlorothiazide tab

40-12.5 mg.................................................................73olmesartan medoxomil-hydrochlorothiazide tab

40-25 mg....................................................................73olmesartan medoxomil tab 20 mg............................. 72olmesartan medoxomil tab 40 mg............................. 73olmesartan medoxomil tab 5 mg............................... 72olopatadine hcl nasal soln 0.6%..............................110olopatadine hcl ophth soln 0.1%..............................106olopatadine hcl ophth soln 0.2%..............................106omega-3-acid ethyl esters cap 1 gm.........................73

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omeprazole cap delayed release 10mg................................................................................87



OMNITROPE................................................................ 91OMNITROPE................................................................ 91OMNITROPE................................................................ 91ONCASPAR.................................................................. 34ondansetron hcl inj 40 mg/20ml (2 mg/

ml)................................................................................23ondansetron hcl inj 4 mg/2ml (2 mg/

ml)................................................................................23ondansetron hcl oral soln 4 mg/5ml.......................... 23ondansetron hcl tab 24 mg.........................................23ondansetron hcl tab 4 mg...........................................23ondansetron hcl tab 8 mg...........................................23ondansetron orally disintegrating tab 4

mg................................................................................23ondansetron orally disintegrating tab 8

mg................................................................................23ONFI...............................................................................16ONFI...............................................................................16ONFI...............................................................................16ONGLYZA......................................................................56ONGLYZA......................................................................56ONIVYDE...................................................................... 35OPDIVO.........................................................................35OPDIVO.........................................................................35OPDIVO.........................................................................35OPSUMIT....................................................................110ORACEA........................................................................81ORALAIR.....................................................................110ORENCIA....................................................................101ORENCIA....................................................................101ORENCIA....................................................................101ORENCIA....................................................................101ORENCIA CLICKJECT............................................. 101ORFADIN.......................................................................88ORFADIN.......................................................................88ORFADIN.......................................................................88ORFADIN.......................................................................88ORFADIN.......................................................................88ORKAMBI....................................................................110ORKAMBI....................................................................110ORKAMBI....................................................................110ORKAMBI....................................................................110oseltamivir phosphate cap 30 mg..............................47oseltamivir phosphate cap 45 mg..............................47oseltamivir phosphate cap 75 mg..............................48

oseltamivir phosphate for susp 6 mg/ml.................................................................................48

OTEZLA.......................................................................101OTEZLA.......................................................................101oxaliplatin for iv inj 100 mg.........................................35oxaliplatin for iv inj 50 mg...........................................35oxaliplatin iv soln 100 mg/20ml..................................35oxaliplatin iv soln 50 mg/10ml....................................35oxandrolone tab 10 mg............................................... 94oxandrolone tab 2.5 mg..............................................94oxaprozin tab 600 mg....................................................4oxcarbazepine susp 300 mg/5ml (60 mg/

ml)................................................................................16oxcarbazepine tab 150 mg.........................................16oxcarbazepine tab 300 mg.........................................16oxcarbazepine tab 600 mg.........................................16oxybutynin chloride syrup 5 mg/5ml..........................89oxybutynin chloride tab 5 mg..................................... 90oxybutynin chloride tab er 24hr 10 mg......................90oxybutynin chloride tab er 24hr 15 mg......................90oxybutynin chloride tab er 24hr 5 mg........................89oxycodone-aspirin tab 4.8355-325 mg........................4oxycodone hcl tab 10 mg..............................................4oxycodone hcl tab 15 mg..............................................4oxycodone hcl tab 20 mg..............................................4oxycodone hcl tab 30 mg..............................................4oxycodone hcl tab 5 mg................................................4oxycodone w/ acetaminophen tab 10-325

mg..................................................................................4oxycodone w/ acetaminophen tab 2.5-325

mg..................................................................................4oxycodone w/ acetaminophen tab 5-325

mg..................................................................................4oxycodone w/ acetaminophen tab 7.5-325

mg..................................................................................4OZEMPIC...................................................................... 56OZEMPIC...................................................................... 56Ppaclitaxel iv conc 100 mg/16.7ml (6 mg/

ml)................................................................................35paclitaxel iv conc 300 mg/50ml (6 mg/

ml)................................................................................35paclitaxel iv conc 30 mg/5ml (6 mg/ml).....................35paliperidone tab er 24hr 1.5 mg.................................43paliperidone tab er 24hr 3 mg....................................43paliperidone tab er 24hr 6 mg....................................43paliperidone tab er 24hr 9 mg....................................43palonosetron hcl iv soln 0.25 mg/5ml........................23palonosetron hcl iv soln pref syr 0.25

mg/5ml........................................................................ 23

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PALONOSETRONHYDROCHLORIDE.................................................. 23

PALYNZIQ..................................................................... 88PALYNZIQ..................................................................... 88PALYNZIQ..................................................................... 88PANRETIN.....................................................................35pantoprazole sodium ec tab 20 mg........................... 87pantoprazole sodium ec tab 40 mg........................... 87pantoprazole sodium for iv soln 40 mg..................... 87paricalcitol cap 1 mcg............................................... 104paricalcitol cap 2 mcg............................................... 104paricalcitol cap 4 mcg............................................... 104paricalcitol iv soln 2 mcg/ml..................................... 104paricalcitol iv soln 5 mcg/ml..................................... 104PARNATE...................................................................... 21paromomycin sulfate cap 250 mg..............................11paroxetine hcl tab 10 mg............................................ 21paroxetine hcl tab 20 mg............................................ 21paroxetine hcl tab 30 mg............................................ 21paroxetine hcl tab 40 mg............................................ 21PASER........................................................................... 27PAXIL............................................................................. 21PAXIL............................................................................. 21PAXIL............................................................................. 21PAXIL............................................................................. 21PAXIL............................................................................. 21PAZEO.........................................................................106PEDIARIX....................................................................101PEDVAX HIB.............................................................. 101peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236

gm................................................................................87peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240

gm................................................................................87peg 3350-kcl-sod bicarb-nacl for soln 420

gm................................................................................87PEGANONE..................................................................16PEGASYS..................................................................... 48PEGASYS..................................................................... 48PEGASYS PROCLICK................................................48penicillin g potassium for inj 20000000

unit...............................................................................11penicillin g potassium for inj 5000000

unit...............................................................................11PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 11PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 12PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 12PENICILLIN G SODIUM............................................. 12penicillin v potassium for soln 125

mg/5ml........................................................................ 12

penicillin v potassium for soln 250mg/5ml........................................................................ 12

penicillin v potassium tab 250 mg............................. 12penicillin v potassium tab 500 mg............................. 12PENTACEL................................................................. 101PENTAM 300................................................................39pentamidine isethionate for soln 300

mg................................................................................39PENTASA....................................................................103PENTASA....................................................................103pentoxifylline tab er 400 mg....................................... 73perindopril erbumine tab 2 mg................................... 73perindopril erbumine tab 4 mg................................... 73perindopril erbumine tab 8 mg................................... 73PERJETA.......................................................................35permethrin cream 5%..................................................39perphenazine tab 16 mg.............................................23perphenazine tab 2 mg............................................... 23perphenazine tab 4 mg............................................... 23perphenazine tab 8 mg............................................... 23PERSERIS.................................................................... 43PERSERIS.................................................................... 43phenelzine sulfate tab 15 mg.....................................21phenobarbital elixir 20 mg/5ml...................................16PHENOBARBITAL SODIUM...................................... 16PHENOBARBITAL SODIUM...................................... 16phenobarbital tab 100 mg...........................................16phenobarbital tab 15 mg.............................................16phenobarbital tab 16.2 mg..........................................16phenobarbital tab 30 mg.............................................16phenobarbital tab 32.4 mg..........................................16phenobarbital tab 60 mg.............................................16phenobarbital tab 64.8 mg..........................................16phenobarbital tab 97.2 mg..........................................16phenoxybenzamine hcl cap 10 mg............................73phenytoin chew tab 50 mg......................................... 16phenytoin sodium extended cap 100

mg................................................................................16phenytoin sodium extended cap 200

mg................................................................................16phenytoin sodium extended cap 300

mg................................................................................16phenytoin susp 125 mg/5ml....................................... 16PHOSLYRA...................................................................84PHOSPHOLINE IODIDE.......................................... 106PICATO..........................................................................81PICATO..........................................................................81PIFELTRO..................................................................... 48pilocarpine hcl ophth soln 1%..................................106pilocarpine hcl ophth soln 2%..................................106pilocarpine hcl ophth soln 4%..................................106pilocarpine hcl tab 5 mg..............................................79

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pilocarpine hcl tab 7.5 mg.......................................... 79pimecrolimus cream 1%..............................................81pimozide tab 1 mg....................................................... 43pimozide tab 2 mg....................................................... 43pindolol tab 10 mg....................................................... 73pindolol tab 5 mg......................................................... 73pioglitazone hcl-glimepiride tab 30-2

mg................................................................................56pioglitazone hcl-glimepiride tab 30-4

mg................................................................................56pioglitazone hcl-metformin hcl tab 15-500

mg................................................................................56pioglitazone hcl-metformin hcl tab 15-850

mg................................................................................56pioglitazone hcl tab 15 mg..........................................56pioglitazone hcl tab 30 mg..........................................56pioglitazone hcl tab 45 mg..........................................56piperacillin sod-tazobactam na for inj 3.375 gm

(3-0.375 gm)..............................................................12piperacillin sod-tazobactam sod for inj 2.25 gm

(2-0.25 gm)................................................................ 12piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5

gm).............................................................................. 12PIQRAY 200MG DAILY DOSE...................................35PIQRAY 250MG DAILY DOSE...................................35PIQRAY 300MG DAILY DOSE...................................35piroxicam cap 10 mg..................................................... 4piroxicam cap 20 mg..................................................... 4PLEGRIDY.................................................................... 78PLEGRIDY.................................................................... 79PLEGRIDY STARTER PACK..................................... 79PLEGRIDY STARTER PACK..................................... 79podofilox soln 0.5%..................................................... 81POLIVY..........................................................................35polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1%.................................................................... 106POLYTRIM.................................................................. 106POMALYST...................................................................35POMALYST...................................................................35POMALYST...................................................................35POMALYST...................................................................35PORTRAZZA................................................................ 35posaconazole tab delayed release 100

mg................................................................................25POTASSIUM CHLORIDE/DEXTROSE.....................84POTASSIUM CHLORIDE/DEXTROSE/LACTATED

RINGERS...................................................................84POTASSIUM CHLORIDE/DEXTROSE/LACTATED

RINGERS...................................................................84potassium chloride 20 meq/l (0.15%) in dextrose 5%

inj................................................................................. 84potassium chloride cap er 10 meq............................ 84

potassium chloride cap er 8 meq...............................84POTASSIUM CHLORIDE ER.....................................84potassium chloride inj 2 meq/ml................................ 84potassium chloride microencapsulated crys er tab 10

meq............................................................................. 84potassium chloride microencapsulated crys er tab 20

meq............................................................................. 84potassium chloride oral soln 10% (20

meq/15ml).................................................................. 84potassium chloride tab er 10 meq............................. 84potassium chloride tab er 8 meq (600

mg).............................................................................. 84potassium citrate tab er 10 meq (1080



mg).............................................................................. 85POTELIGEO................................................................. 35PRADAXA..................................................................... 61PRADAXA..................................................................... 61PRADAXA..................................................................... 61pramipexole dihydrochloride tab 0.125

mg................................................................................40pramipexole dihydrochloride tab 0.25




mg................................................................................40pramipexole dihydrochloride tab 1 mg...................... 40prasugrel hcl tab 10 mg..............................................61prasugrel hcl tab 5 mg................................................ 61PRAVACHOL................................................................ 73PRAVACHOL................................................................ 73PRAVACHOL................................................................ 73pravastatin sodium tab 10 mg....................................73pravastatin sodium tab 20 mg....................................73pravastatin sodium tab 40 mg....................................73pravastatin sodium tab 80 mg....................................73praziquantel tab 600 mg............................................. 39prazosin hcl cap 1 mg.................................................73prazosin hcl cap 2 mg.................................................73prazosin hcl cap 5 mg.................................................73PRECOSE.....................................................................56PRECOSE.....................................................................56PRECOSE.....................................................................56PRED FORTE............................................................ 106prednicarbate cream 0.1%......................................... 81prednicarbate oint 0.1%..............................................82

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prednisolone acetate ophth susp 1%......................106prednisolone sod phosphate oral soln 10

mg/5ml........................................................................ 91prednisolone sod phosphate oral soln 15

mg/5ml........................................................................ 91prednisolone sod phosphate oral soln 20

mg/5ml........................................................................ 91prednisolone sod phosph oral soln 6.7 mg/5ml (5

mg/5ml base).............................................................91prednisolone syrup 15 mg/5ml...................................91PREDNISONE.............................................................. 91prednisone tab 10 mg................................................. 91prednisone tab 1 mg................................................... 91prednisone tab 2.5 mg................................................ 91prednisone tab 20 mg................................................. 91prednisone tab 50 mg................................................. 91prednisone tab 5 mg................................................... 91prednisone tab therapy pack 10 mg

(21)..............................................................................91prednisone tab therapy pack 10 mg

(48)..............................................................................91prednisone tab therapy pack 5 mg (21).................... 91prednisone tab therapy pack 5 mg (48).................... 91pregabalin cap 100 mg............................................... 16pregabalin cap 150 mg............................................... 16pregabalin cap 200 mg............................................... 16pregabalin cap 225 mg............................................... 16pregabalin cap 25 mg................................................. 16pregabalin cap 300 mg............................................... 16pregabalin cap 50 mg................................................. 16pregabalin cap 75 mg................................................. 16pregabalin soln 20 mg/ml........................................... 16PREGNYL W/DILUENT BENZYL ALCOHOL/

NACL.......................................................................... 91PREMARIN................................................................... 94PREMASOL.................................................................. 85PREMPHASE............................................................... 94PREMPRO.................................................................... 94PREMPRO.................................................................... 94PREMPRO.................................................................... 94PREMPRO.................................................................... 94PREVENT SAFETY PEN NEEDLES 31G X

1/4".............................................................................. 56PREVENT SAFETY PEN NEEDLES 31G X

5/16"............................................................................56PREVYMIS....................................................................48PREVYMIS....................................................................48PREZCOBIX................................................................. 48PREZISTA..................................................................... 48PREZISTA..................................................................... 48PREZISTA..................................................................... 48PREZISTA..................................................................... 48

PREZISTA..................................................................... 48PRIFTIN.........................................................................27primaquine phosphate tab 26.3 mg...........................39primidone tab 250 mg................................................. 16primidone tab 50 mg................................................... 16PRINIVIL........................................................................73PRINIVIL........................................................................73PRINIVIL........................................................................73PROAIR HFA..............................................................110PROAIR RESPICLICK..............................................110probenecid tab 500 mg............................................... 25PROCALAMINE........................................................... 85PROCARDIA XL.......................................................... 73PROCARDIA XL.......................................................... 73PROCARDIA XL.......................................................... 73prochlorperazine edisylate inj 10

mg/2ml........................................................................ 23prochlorperazine edisylate inj 50

mg/10ml......................................................................23prochlorperazine maleate tab 10 mg.........................23prochlorperazine maleate tab 5 mg...........................23prochlorperazine suppos 25 mg................................ 23PROCRIT...................................................................... 61PROCRIT...................................................................... 61PROCRIT...................................................................... 61PROCRIT...................................................................... 61PROCRIT...................................................................... 61PROCRIT...................................................................... 61progesterone micronized cap 100 mg.......................94progesterone micronized cap 200 mg.......................94PROGLYCEM............................................................... 56PROGRAF.................................................................. 101PROGRAF.................................................................. 101PROGRAF.................................................................. 101PROLASTIN-C..............................................................88PROLASTIN-C..............................................................89PROLENSA................................................................ 106PROLEUKIN................................................................. 35PROLIA........................................................................104PROMACTA.................................................................. 61PROMACTA.................................................................. 61PROMACTA.................................................................. 61PROMACTA.................................................................. 61PROMACTA.................................................................. 61promethazine hcl suppos 12.5 mg............................ 23promethazine hcl suppos 25 mg................................23promethazine hcl syrup 6.25 mg/5ml........................ 23promethazine hcl tab 12.5 mg....................................23promethazine hcl tab 25 mg.......................................23promethazine hcl tab 50 mg.......................................23propafenone hcl cap er 12hr 225 mg........................ 73propafenone hcl cap er 12hr 325 mg........................ 73

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propafenone hcl cap er 12hr 425 mg........................ 73propafenone hcl tab 150 mg...................................... 73propafenone hcl tab 225 mg...................................... 73propafenone hcl tab 300 mg...................................... 74propranolol hcl cap er 24hr 120 mg.......................... 74propranolol hcl cap er 24hr 160 mg.......................... 74propranolol hcl cap er 24hr 60 mg.............................74propranolol hcl cap er 24hr 80 mg.............................74propranolol hcl inj 1 mg/ml......................................... 74propranolol hcl tab 10 mg...........................................74propranolol hcl tab 20 mg...........................................74propranolol hcl tab 40 mg...........................................74propranolol hcl tab 60 mg...........................................74propranolol hcl tab 80 mg...........................................74propylthiouracil tab 50 mg.......................................... 97PROQUAD.................................................................. 101PROSCAR.....................................................................90PROSOL........................................................................85protriptyline hcl tab 10 mg.......................................... 21protriptyline hcl tab 5 mg............................................ 21PROZAC........................................................................21PROZAC........................................................................21PROZAC........................................................................21PULMOZYME.............................................................110PURIXAN.......................................................................35PYLERA.........................................................................87pyrazinamide tab 500 mg........................................... 27pyridostigmine bromide oral soln 60

mg/5ml........................................................................ 26pyridostigmine bromide tab 60 mg............................ 27pyridostigmine bromide tab er 180 mg......................26QQUADRACEL............................................................. 101quetiapine fumarate tab 100 mg................................43quetiapine fumarate tab 200 mg................................43quetiapine fumarate tab 25 mg..................................43quetiapine fumarate tab 300 mg................................43quetiapine fumarate tab 400 mg................................43quetiapine fumarate tab 50 mg..................................43quetiapine fumarate tab er 24hr 150

mg................................................................................43quetiapine fumarate tab er 24hr 200



mg................................................................................43quetiapine fumarate tab er 24hr 50 mg.....................43quinapril hcl tab 10 mg............................................... 74quinapril hcl tab 20 mg............................................... 74quinapril hcl tab 40 mg............................................... 74

quinapril hcl tab 5 mg..................................................74quinapril-hydrochlorothiazide tab 10-12.5

mg................................................................................74quinapril-hydrochlorothiazide tab 20-12.5

mg................................................................................74quinapril-hydrochlorothiazide tab 20-25

mg................................................................................74quinidine gluconate tab er 324 mg............................ 74QUINIDINE SULFATE................................................. 74QUINIDINE SULFATE................................................. 74QVAR REDIHALER................................................... 110QVAR REDIHALER................................................... 110RRABAVERT................................................................. 101raloxifene hcl tab 60 mg............................................. 94ramipril cap 1.25 mg....................................................74ramipril cap 10 mg.......................................................74ramipril cap 2.5 mg......................................................74ramipril cap 5 mg.........................................................74RANEXA........................................................................74RANEXA........................................................................74ranitidine hcl cap 150 mg........................................... 87ranitidine hcl cap 300 mg........................................... 87ranitidine hcl syrup 15 mg/ml (75

mg/5ml).......................................................................87ranitidine hcl tab 150 mg............................................ 87ranitidine hcl tab 300 mg............................................ 87ranolazine tab er 12hr 1000 mg.................................74ranolazine tab er 12hr 500 mg...................................74RAPAFLO...................................................................... 90RAPAFLO...................................................................... 90RAPAMUNE................................................................101rasagiline mesylate tab 0.5 mg.................................. 40rasagiline mesylate tab 1 mg..................................... 40RECOMBIVAX HB..................................................... 101RECOMBIVAX HB..................................................... 101RECOMBIVAX HB..................................................... 101REGRANEX.................................................................. 82RELENZA DISKHALER.............................................. 48RELISTOR.....................................................................87RELISTOR.....................................................................87RELISTOR.....................................................................87REMERON....................................................................21REMERON....................................................................21REMERON SOLTAB....................................................21REMERON SOLTAB....................................................21REMERON SOLTAB....................................................21REMODULIN.............................................................. 110REMODULIN.............................................................. 110REMODULIN.............................................................. 110REMODULIN.............................................................. 110

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RENFLEXIS................................................................ 102repaglinide tab 0.5 mg................................................ 56repaglinide tab 1 mg....................................................56repaglinide tab 2 mg....................................................56REPATHA...................................................................... 74REPATHA PUSHTRONEX SYSTEM........................74REPATHA SURECLICK.............................................. 74RESCRIPTOR.............................................................. 48RESTASIS...................................................................106RESTASIS MULTIDOSE...........................................106RETACRIT.....................................................................61RETACRIT.....................................................................61RETACRIT.....................................................................61RETACRIT.....................................................................61RETACRIT.....................................................................61RETROVIR IV INFUSION...........................................48REVCOVI...................................................................... 89REVLIMID......................................................................35REVLIMID......................................................................35REVLIMID......................................................................35REVLIMID......................................................................35REVLIMID......................................................................35REVLIMID......................................................................35REXULTI........................................................................43REXULTI........................................................................43REXULTI........................................................................43REXULTI........................................................................43REXULTI........................................................................43REXULTI........................................................................43REYATAZ.......................................................................48REYATAZ.......................................................................48REYATAZ.......................................................................48REYATAZ.......................................................................48ribavirin cap 200 mg....................................................48ribavirin for inhal soln 6 gm......................................110ribavirin tab 200 mg.....................................................48RIDAURA.................................................................... 102rifabutin cap 150 mg....................................................27rifampin cap 150 mg....................................................27rifampin cap 300 mg....................................................27rifampin for inj 600 mg................................................ 27riluzole tab 50 mg........................................................ 79risedronate sodium tab 150 mg...............................104risedronate sodium tab 30 mg................................. 104risedronate sodium tab 35 mg................................. 104risedronate sodium tab 5 mg................................... 104risedronate sodium tab delayed release 35

mg............................................................................. 104RISPERDAL CONSTA................................................ 44RISPERDAL CONSTA................................................ 44RISPERDAL CONSTA................................................ 44RISPERDAL CONSTA................................................ 44

risperidone orally disintegrating tab 0.25mg................................................................................44

risperidone orally disintegrating tab 0.5mg................................................................................44

risperidone orally disintegrating tab 1mg................................................................................44




risperidone soln 1 mg/ml............................................ 44risperidone tab 0.25 mg..............................................44risperidone tab 0.5 mg................................................ 44risperidone tab 1 mg................................................... 44risperidone tab 2 mg................................................... 44risperidone tab 3 mg................................................... 44risperidone tab 4 mg................................................... 44ritonavir tab 100 mg.................................................... 48RITUXAN.......................................................................35RITUXAN.......................................................................35RITUXAN HYCELA......................................................35RITUXAN HYCELA......................................................36rivastigmine tartrate cap 1.5 mg................................ 18rivastigmine tartrate cap 3 mg....................................18rivastigmine tartrate cap 4.5 mg................................ 18rivastigmine tartrate cap 6 mg....................................18rivastigmine td patch 24hr 13.3

mg/24hr...................................................................... 18rivastigmine td patch 24hr 4.6 mg/24hr.....................18rivastigmine td patch 24hr 9.5 mg/24hr.....................18rizatriptan benzoate oral disintegrating tab 10

mg................................................................................26rizatriptan benzoate oral disintegrating tab 5

mg................................................................................26rizatriptan benzoate tab 10 mg.................................. 26rizatriptan benzoate tab 5 mg.................................... 26ropinirole hydrochloride tab 0.25 mg.........................40ropinirole hydrochloride tab 0.5 mg...........................40ropinirole hydrochloride tab 1 mg.............................. 40ropinirole hydrochloride tab 2 mg.............................. 40ropinirole hydrochloride tab 3 mg.............................. 40ropinirole hydrochloride tab 4 mg.............................. 40ropinirole hydrochloride tab 5 mg.............................. 40rosuvastatin calcium tab 10 mg................................. 74rosuvastatin calcium tab 20 mg................................. 74rosuvastatin calcium tab 40 mg................................. 74rosuvastatin calcium tab 5 mg................................... 74ROTARIX.....................................................................102ROTATEQ....................................................................102ROZLYTREK.................................................................36

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ROZLYTREK.................................................................36RUBRACA.....................................................................36RUBRACA.....................................................................36RUBRACA.....................................................................36RYDAPT........................................................................ 36SSABRIL.......................................................................... 16SAFETY INSULIN SYRINGES 1ML/30G X

1/2".............................................................................. 56SAMSCA........................................................................85SAMSCA........................................................................85SANDIMMUNE...........................................................102SANTYL.........................................................................82SAPHRIS.......................................................................44SAPHRIS.......................................................................44SAPHRIS.......................................................................44scopolamine td patch 72hr 1 mg/3days.................... 23selegiline hcl cap 5 mg............................................... 40selegiline hcl tab 5 mg................................................ 40selenium sulfide lotion 2.5%.......................................82SELZENTRY.................................................................48SELZENTRY.................................................................48SELZENTRY.................................................................48SELZENTRY.................................................................48SELZENTRY.................................................................48SENSIPAR.................................................................. 104SENSIPAR.................................................................. 104SENSIPAR.................................................................. 104SEREVENT DISKUS.................................................110sertraline hcl oral concentrate for solution 20 mg/

ml.................................................................................21sertraline hcl tab 100 mg............................................ 21sertraline hcl tab 25 mg.............................................. 21sertraline hcl tab 50 mg.............................................. 21sevelamer carbonate packet 0.8 gm......................... 85sevelamer carbonate packet 2.4 gm......................... 85sevelamer carbonate tab 800 mg..............................85SHINGRIX...................................................................102SIGNIFOR..................................................................... 96SIGNIFOR..................................................................... 96SIGNIFOR..................................................................... 96SIGNIFOR LAR............................................................96SIGNIFOR LAR............................................................96SIGNIFOR LAR............................................................96SIGNIFOR LAR............................................................96SIGNIFOR LAR............................................................96sildenafil citrate tab 20 mg....................................... 110SILENOR.....................................................................112SILENOR.....................................................................112silodosin cap 4 mg.......................................................90silodosin cap 8 mg.......................................................90silver sulfadiazine cream 1%......................................82

SIMBRINZA................................................................ 106SIMULECT.................................................................. 102SIMULECT.................................................................. 102simvastatin tab 10 mg.................................................75simvastatin tab 20 mg.................................................75simvastatin tab 40 mg.................................................75simvastatin tab 5 mg................................................... 75simvastatin tab 80 mg.................................................75sirolimus oral soln 1 mg/ml.......................................102sirolimus tab 0.5 mg..................................................102sirolimus tab 1 mg..................................................... 102sirolimus tab 2 mg..................................................... 102SIRTURO.......................................................................27SIVEXTRO.................................................................... 12SIVEXTRO.................................................................... 12sodium chloride irrigation soln 0.9%......................... 85sodium chloride iv soln 0.45%................................... 85sodium chloride iv soln 0.9%..................................... 85sodium phenylbutyrate oral powder 3 gm/

teaspoonful.................................................................89sodium phenylbutyrate tab 500 mg........................... 89sodium polystyrene sulfonate oral susp 15

gm/60ml......................................................................85sodium polystyrene sulfonate powder.......................85sodium polystyrene sulfonate rectal susp 30

gm/120ml....................................................................85SOLTAMOX...................................................................36SOMATULINE DEPOT................................................97SOMATULINE DEPOT................................................97SOMATULINE DEPOT................................................97SOMAVERT.................................................................. 97SOMAVERT.................................................................. 97SOMAVERT.................................................................. 97SOMAVERT.................................................................. 97SOMAVERT.................................................................. 97SOOLANTRA................................................................82sotalol hcl (afib/afl) tab 120 mg..................................75sotalol hcl (afib/afl) tab 160 mg..................................75sotalol hcl (afib/afl) tab 80 mg....................................75sotalol hcl tab 120 mg.................................................75sotalol hcl tab 160 mg.................................................75sotalol hcl tab 240 mg.................................................75sotalol hcl tab 80 mg...................................................75SOVALDI....................................................................... 48SPIRIVA HANDIHALER............................................110SPIRIVA RESPIMAT................................................. 110SPIRIVA RESPIMAT................................................. 111spironolactone & hydrochlorothiazide tab 25-25

mg................................................................................75spironolactone tab 100 mg.........................................75spironolactone tab 25 mg........................................... 75spironolactone tab 50 mg........................................... 75

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SPRAVATO 56MG DOSE........................................... 21SPRAVATO 84MG DOSE........................................... 21SPRITAM.......................................................................16SPRITAM.......................................................................17SPRITAM.......................................................................17SPRITAM.......................................................................17SPRYCEL......................................................................36SPRYCEL......................................................................36SPRYCEL......................................................................36SPRYCEL......................................................................36SPRYCEL......................................................................36SPRYCEL......................................................................36STAMARIL...................................................................102STARLIX........................................................................ 56STARLIX........................................................................ 56stavudine cap 15 mg...................................................48stavudine cap 20 mg...................................................48stavudine cap 30 mg...................................................48stavudine cap 40 mg...................................................48STELARA....................................................................102STELARA....................................................................102STELARA....................................................................102STELARA....................................................................102STIMATE....................................................................... 91STIOLTO RESPIMAT................................................ 111STIVARGA.....................................................................36STRENSIQ....................................................................89STRENSIQ....................................................................89STRENSIQ....................................................................89STRENSIQ....................................................................89STREPTOMYCIN SULFATE...................................... 12STRIBILD...................................................................... 48SUBOXONE....................................................................5SUBOXONE....................................................................5SUBOXONE....................................................................5SUBOXONE....................................................................5sucralfate tab 1 gm......................................................87sulfacetamide sodium lotion 10%.............................. 12sulfacetamide sodium ophth soln

10%...........................................................................106sulfacetamide sodium-prednisolone ophth soln

10-0.23(0.25)%....................................................... 106SULFADIAZINE............................................................ 12sulfamethoxazole-trimethoprim iv soln 400-80

mg/5ml........................................................................ 12sulfamethoxazole-trimethoprim susp 200-40

mg/5ml........................................................................ 12sulfamethoxazole-trimethoprim tab 400-80

mg................................................................................12sulfamethoxazole-trimethoprim tab 800-160

mg................................................................................12sulfasalazine tab 500 mg..........................................103

sulfasalazine tab delayed release 500mg............................................................................. 103

sulindac tab 150 mg...................................................... 4sulindac tab 200 mg...................................................... 4sumatriptan nasal spray 20 mg/act........................... 26sumatriptan nasal spray 5 mg/act..............................26SUMATRIPTAN SUCCINATE.....................................26sumatriptan succinate inj 6 mg/0.5ml........................26sumatriptan succinate solution auto-injector 4

mg/0.5ml.....................................................................26sumatriptan succinate solution auto-injector 6

mg/0.5ml.....................................................................26sumatriptan succinate solution cartridge 4

mg/0.5ml.....................................................................26sumatriptan succinate solution cartridge 6

mg/0.5ml.....................................................................26sumatriptan succinate tab 100 mg............................ 26sumatriptan succinate tab 25 mg...............................26sumatriptan succinate tab 50 mg...............................26SUPRAX........................................................................12SUPRAX........................................................................12SUPRAX........................................................................12SUPREP BOWEL PREP KIT.....................................87SUSTIVA........................................................................48SUSTIVA........................................................................48SUTENT........................................................................ 36SUTENT........................................................................ 36SUTENT........................................................................ 36SUTENT........................................................................ 36SYLATRON................................................................... 49SYLATRON................................................................... 49SYLATRON................................................................... 49SYLVANT.....................................................................102SYLVANT.....................................................................102SYMBICORT...............................................................111SYMBICORT...............................................................111SYMDEKO.................................................................. 111SYMDEKO.................................................................. 111SYMFI............................................................................ 49SYMFI LO..................................................................... 49SYMLINPEN 120......................................................... 56SYMLINPEN 60............................................................56SYMPAZAN...................................................................17SYMPAZAN...................................................................17SYMPAZAN...................................................................17SYMTUZA..................................................................... 49SYNAGIS.................................................................... 102SYNAGIS.................................................................... 102SYNAREL......................................................................97SYNERCID....................................................................12SYNJARDY................................................................... 56SYNJARDY................................................................... 56

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SYNJARDY................................................................... 56SYNJARDY................................................................... 56SYNJARDY XR............................................................ 56SYNJARDY XR............................................................ 57SYNJARDY XR............................................................ 57SYNJARDY XR............................................................ 57SYNRIBO...................................................................... 36SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95TTABLOID........................................................................36tacrolimus cap 0.5 mg...............................................102tacrolimus cap 1 mg..................................................102tacrolimus cap 5 mg..................................................102tacrolimus oint 0.03%..................................................82tacrolimus oint 0.1%.................................................... 82tadalafil tab 20 mg (pah)...........................................111TAFINLAR..................................................................... 36TAFINLAR..................................................................... 36TAGRISSO.................................................................... 36TAGRISSO.................................................................... 36TALZENNA....................................................................36TALZENNA....................................................................36TAMIFLU........................................................................49tamoxifen citrate tab 10 mg........................................36tamoxifen citrate tab 20 mg........................................36tamsulosin hcl cap 0.4 mg..........................................90TARCEVA...................................................................... 36TARCEVA...................................................................... 36TARCEVA...................................................................... 36TARGRETIN..................................................................36TASIGNA....................................................................... 36TASIGNA....................................................................... 36TASIGNA....................................................................... 36tazarotene cream 0.1%...............................................82TAZICEF........................................................................ 12TAZORAC......................................................................82TAZORAC......................................................................82TAZORAC......................................................................82TDVAX......................................................................... 102TECENTRIQ................................................................. 36TECENTRIQ................................................................. 36

TECFIDERA..................................................................79TECFIDERA..................................................................79TECFIDERA STARTER PACK...................................79TECHLITE INSULIN SYRINGE U-100/0.3ML/29G X

1/2".............................................................................. 57TECHLITE INSULIN SYRINGE U-100/0.3ML/30G X


5/16"............................................................................57TECHLITE INSULIN SYRINGE U-100/0.3ML/31G X

15/64"..........................................................................57TECHLITE INSULIN SYRINGE U-100/0.3ML/31G X





15/64"..........................................................................57TECHLITE INSULIN SYRINGE U-100/0.5ML/31G X

5/16"............................................................................57TECHLITE INSULIN SYRINGE U-100/1ML/29G X

1/2".............................................................................. 57TECHLITE INSULIN SYRINGE U-100/1ML/30G X

1/2".............................................................................. 57TECHLITE INSULIN SYRINGE U-100/1ML/30G X

5/16"............................................................................57TECHLITE INSULIN SYRINGE U-100/1ML/31G X

15/64"..........................................................................57TECHLITE INSULIN SYRINGE U-100/1ML/31G X

5/16"............................................................................57TECHLITE PEN NEEDLES/31G X

6MM............................................................................ 57TECHLITE PEN NEEDLES/31G X




8MM............................................................................ 57TECHLITE PEN NEEDLES 29G X

10MM..........................................................................57TECHLITE PEN NEEDLES 29G X

12MM..........................................................................57TECHLITE PEN NEEDLES 31G X

5MM............................................................................ 57TEFLARO......................................................................12TEFLARO......................................................................12TEKTURNA...................................................................75

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TEKTURNA...................................................................75TEKTURNA HCT......................................................... 75TEKTURNA HCT......................................................... 75TEKTURNA HCT......................................................... 75TEKTURNA HCT......................................................... 75telmisartan-hydrochlorothiazide tab 40-12.5

mg................................................................................75telmisartan-hydrochlorothiazide tab 80-12.5

mg................................................................................75telmisartan-hydrochlorothiazide tab 80-25

mg................................................................................75telmisartan tab 20 mg................................................. 75telmisartan tab 40 mg................................................. 75telmisartan tab 80 mg................................................. 75temazepam cap 15 mg............................................. 112temazepam cap 30 mg............................................. 112TEMODAR.................................................................... 37temsirolimus soln for iv infusion 25 mg/

ml.................................................................................37TENCON..........................................................................4TENIVAC..................................................................... 102tenofovir disoproxil fumarate tab 300

mg................................................................................49terazosin hcl cap 10 mg..............................................75terazosin hcl cap 1 mg................................................75terazosin hcl cap 2 mg................................................75terazosin hcl cap 5 mg................................................75terbinafine hcl tab 250 mg..........................................25terbutaline sulfate tab 2.5 mg.................................. 111terbutaline sulfate tab 5 mg......................................111terconazole vaginal cream 0.4%................................25terconazole vaginal cream 0.8%................................25terconazole vaginal suppos 80 mg............................25testosterone cypionate im inj in oil 100 mg/

ml.................................................................................94testosterone cypionate im inj in oil 200 mg/

ml.................................................................................94testosterone enanthate im inj in oil 200 mg/

ml.................................................................................94testosterone td gel 12.5 mg/act (1%)........................ 94testosterone td gel 20.25 mg/1.25gm

(1.62%)....................................................................... 94testosterone td gel 20.25 mg/act

(1.62%)....................................................................... 94testosterone td gel 25 mg/2.5gm (1%)......................94testosterone td gel 40.5 mg/2.5gm

(1.62%)....................................................................... 94testosterone td gel 50 mg/5gm (1%).........................94testosterone td soln 30 mg/act...................................94tetrabenazine tab 12.5 mg..........................................79tetrabenazine tab 25 mg.............................................79tetracycline hcl cap 250 mg........................................12

tetracycline hcl cap 500 mg........................................12THALOMID....................................................................37THALOMID....................................................................37THALOMID....................................................................37THALOMID....................................................................37theophylline tab er 12hr 300 mg..............................111theophylline tab er 12hr 450 mg..............................111theophylline tab er 24hr 400 mg..............................111theophylline tab er 24hr 600 mg..............................111thioridazine hcl tab 100 mg........................................ 44thioridazine hcl tab 10 mg.......................................... 44thioridazine hcl tab 25 mg.......................................... 44thioridazine hcl tab 50 mg.......................................... 44thiotepa for inj 15 mg.................................................. 37thiothixene cap 10 mg.................................................44thiothixene cap 1 mg...................................................44thiothixene cap 2 mg...................................................44thiothixene cap 5 mg...................................................44THYMOGLOBULIN....................................................102tiagabine hcl tab 12 mg.............................................. 17tiagabine hcl tab 16 mg.............................................. 17tiagabine hcl tab 2 mg.................................................17tiagabine hcl tab 4 mg.................................................17TIAZAC.......................................................................... 75TIAZAC.......................................................................... 75TIAZAC.......................................................................... 75TIAZAC.......................................................................... 75TIAZAC.......................................................................... 75TIAZAC.......................................................................... 75TIBSOVO.......................................................................37tigecycline for iv soln 50 mg.......................................12TIMOLOL MALEATE................................................... 76TIMOLOL MALEATE................................................... 76timolol maleate ophth gel forming soln

0.25%........................................................................106timolol maleate ophth gel forming soln

0.5%..........................................................................106timolol maleate ophth soln 0.25%........................... 106timolol maleate ophth soln 0.5%..............................106timolol maleate ophth soln 0.5% (once-

daily)......................................................................... 106timolol maleate tab 5 mg............................................ 76TIMOPTIC................................................................... 107TIMOPTIC................................................................... 107TIMOPTIC-XE.............................................................107tinidazole tab 250 mg..................................................12tinidazole tab 500 mg..................................................12TIVICAY......................................................................... 49TIVICAY......................................................................... 49TIVICAY......................................................................... 49tizanidine hcl cap 2 mg............................................... 45tizanidine hcl cap 4 mg............................................... 45

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tizanidine hcl cap 6 mg............................................... 45tizanidine hcl tab 2 mg................................................45tizanidine hcl tab 4 mg................................................45TOBRADEX................................................................ 107tobramycin-dexamethasone ophth susp

0.3-0.1%...................................................................107tobramycin nebu soln 300 mg/5ml.......................... 111tobramycin ophth soln 0.3%.....................................107TOBRAMYCIN SULFATE........................................... 12TOBRAMYCIN SULFATE........................................... 12tobramycin sulfate for inj 1.2 gm................................12tobramycin sulfate inj 1.2 gm/30ml (40 mg/

ml)................................................................................12tobramycin sulfate inj 80 mg/2ml (40 mg/

ml)................................................................................12tolcapone tab 100 mg................................................. 40TOLMETIN SODIUM..................................................... 4tolterodine tartrate cap er 24hr 2 mg.........................90tolterodine tartrate cap er 24hr 4 mg.........................90tolterodine tartrate tab 1 mg.......................................90tolterodine tartrate tab 2 mg.......................................90topiramate sprinkle cap 15 mg...................................17topiramate sprinkle cap 25 mg...................................17topiramate tab 100 mg................................................17topiramate tab 200 mg................................................17topiramate tab 25 mg.................................................. 17topiramate tab 50 mg.................................................. 17topotecan hcl for inj 4 mg........................................... 37topotecan hcl inj 4 mg/4ml (for

infusion)...................................................................... 37toremifene citrate tab 60 mg...................................... 37torsemide tab 100 mg................................................. 76torsemide tab 10 mg................................................... 76torsemide tab 20 mg................................................... 76torsemide tab 5 mg......................................................76TOUJEO MAX SOLOSTAR........................................57TOUJEO SOLOSTAR..................................................57TOVIAZ.......................................................................... 90TOVIAZ.......................................................................... 90TRACLEER.................................................................111TRACLEER.................................................................111TRACLEER.................................................................111TRADJENTA................................................................. 57tramadol-acetaminophen tab 37.5-325

mg..................................................................................4tramadol hcl tab 50 mg................................................. 4tramadol hcl tab er 24hr 100 mg..................................4tramadol hcl tab er 24hr 200 mg..................................4tramadol hcl tab er 24hr 300 mg..................................4trandolapril tab 1 mg................................................... 76trandolapril tab 2 mg................................................... 76trandolapril tab 4 mg................................................... 76

tranexamic acid iv soln 1000 mg/10ml (100 mg/ml)................................................................................61

tranexamic acid tab 650 mg.......................................61tranylcypromine sulfate tab 10 mg............................ 21TRAVASOL....................................................................85TRAVATAN Z.............................................................. 107trazodone hcl tab 100 mg...........................................21trazodone hcl tab 150 mg...........................................21trazodone hcl tab 300 mg...........................................21trazodone hcl tab 50 mg.............................................21TREANDA..................................................................... 37TREANDA..................................................................... 37TRECATOR...................................................................27TRELEGY ELLIPTA...................................................111TRELSTAR....................................................................97TRELSTAR....................................................................97TRELSTAR MIXJECT..................................................97TRELSTAR MIXJECT..................................................97TRELSTAR MIXJECT..................................................97treprostinil inj soln 100 mg/20ml (5 mg/

ml)............................................................................. 111treprostinil inj soln 200 mg/20ml (10 mg/

ml)............................................................................. 111treprostinil inj soln 20 mg/20ml (1 mg/

ml)............................................................................. 111treprostinil inj soln 50 mg/20ml (2.5 mg/

ml)............................................................................. 111TRESIBA....................................................................... 57TRESIBA FLEXTOUCH.............................................. 57TRESIBA FLEXTOUCH.............................................. 57tretinoin cap 10 mg......................................................37tretinoin cream 0.025%............................................... 82tretinoin cream 0.05%................................................. 82tretinoin cream 0.1%................................................... 82tretinoin gel 0.01%.......................................................82tretinoin gel 0.025%.....................................................82triamcinolone acetonide cream

0.025%........................................................................82triamcinolone acetonide cream 0.1%........................82triamcinolone acetonide cream 0.5%........................82triamcinolone acetonide dental paste

0.1%............................................................................79triamcinolone acetonide lotion 0.025%..................... 82triamcinolone acetonide lotion 0.1%..........................82triamcinolone acetonide oint 0.025%........................ 82triamcinolone acetonide oint 0.1%.............................82triamcinolone acetonide oint 0.5%.............................82triamterene & hydrochlorothiazide cap 37.5-25

mg................................................................................76triamterene & hydrochlorothiazide tab 37.5-25

mg................................................................................76

2019

155

triamterene & hydrochlorothiazide tab 75-50mg................................................................................76

TRIBENZOR................................................................. 76TRIBENZOR................................................................. 76TRIBENZOR................................................................. 76TRIBENZOR................................................................. 76TRIBENZOR................................................................. 76trientine hcl cap 250 mg............................................. 85trifluoperazine hcl tab 10 mg......................................44trifluoperazine hcl tab 1 mg........................................44trifluoperazine hcl tab 2 mg........................................44trifluoperazine hcl tab 5 mg........................................44trifluridine ophth soln 1%.......................................... 107trimethobenzamide hcl cap 300 mg.......................... 23trimethoprim tab 100 mg.............................................13trimipramine maleate cap 100 mg............................. 21trimipramine maleate cap 25 mg............................... 21trimipramine maleate cap 50 mg............................... 21TRINTELLIX..................................................................21TRINTELLIX..................................................................21TRINTELLIX..................................................................22TRISENOX....................................................................37TRIUMEQ......................................................................49TROGARZO..................................................................49TROPHAMINE..............................................................85trospium chloride cap er 24hr 60 mg.........................90trospium chloride tab 20 mg.......................................90TRUEPLUS 5-BEVEL PEN NEEDLES

31GX5MM.................................................................. 58TRUEPLUS 5-BEVEL PEN NEEDLES



32GX4MM.................................................................. 58TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G

X 1/2"..........................................................................57TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/30G

X 5/16"........................................................................58TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/31G





X 5/16"........................................................................58TRUEPLUS INSULIN SYRINGE/U-100/1ML/28G X

1/2".............................................................................. 58

TRUEPLUS INSULIN SYRINGE/U-100/1ML/29G X1/2".............................................................................. 58

TRUEPLUS INSULIN SYRINGE/U-100/1ML/30G X5/16"............................................................................58

TRUEPLUS INSULIN SYRINGE/U-100/1ML/31G X5/16"............................................................................58

TRUEPLUS PEN NEEDLES 29G X12MM..........................................................................58

TRUEPLUS PEN NEEDLES 31G X5MM............................................................................ 58




TRULICITY....................................................................58TRULICITY....................................................................58TRUMENBA................................................................102TRUVADA......................................................................49TRUVADA......................................................................49TRUVADA......................................................................49TRUVADA......................................................................49TURALIO....................................................................... 37TWINRIX..................................................................... 102TYBOST........................................................................ 49TYGACIL....................................................................... 13TYKERB........................................................................ 37TYMLOS......................................................................104TYPHIM VI..................................................................102TYSABRI....................................................................... 79UULORIC......................................................................... 25ULORIC......................................................................... 25ULTICARE INSULIN SAFETY SYRINGE/0.5ML/29G

X 1/2"..........................................................................58ULTICARE INSULIN SAFETY SYRINGE/1ML/29G X

1/2".............................................................................. 58UNITUXIN......................................................................37UPTRAVI..................................................................... 111UPTRAVI..................................................................... 111UPTRAVI..................................................................... 111UPTRAVI..................................................................... 111UPTRAVI..................................................................... 111UPTRAVI..................................................................... 111UPTRAVI..................................................................... 111UPTRAVI..................................................................... 111UPTRAVI..................................................................... 111ursodiol cap 300 mg....................................................87ursodiol tab 250 mg.....................................................87ursodiol tab 500 mg.....................................................87

2019

156

VVAGIFEM.......................................................................94valacyclovir hcl tab 1 gm............................................ 49valacyclovir hcl tab 500 mg........................................49VALCHLOR................................................................... 37valganciclovir hcl for soln 50 mg/ml.......................... 49valganciclovir hcl tab 450 mg.....................................49valproate sodium inj 100 mg/ml.................................17valproate sodium oral soln 250 mg/5ml.................... 17valproic acid cap 250 mg............................................17valsartan-hydrochlorothiazide tab 160-12.5

mg................................................................................76valsartan-hydrochlorothiazide tab 160-25

mg................................................................................76valsartan-hydrochlorothiazide tab 320-12.5

mg................................................................................76valsartan-hydrochlorothiazide tab 320-25

mg................................................................................76valsartan-hydrochlorothiazide tab 80-12.5

mg................................................................................76valsartan tab 160 mg...................................................76valsartan tab 320 mg...................................................76valsartan tab 40 mg.....................................................76valsartan tab 80 mg.....................................................76vancomycin hcl cap 125 mg.......................................13vancomycin hcl cap 250 mg.......................................13vancomycin hcl for iv soln 100 gm............................ 13vancomycin hcl for iv soln 10 gm.............................. 13vancomycin hcl for iv soln 1 gm.................................13vancomycin hcl for iv soln 500 mg............................ 13vancomycin hcl for iv soln 5 gm.................................13vancomycin hcl for iv soln 750 mg............................ 13VANCOMYCIN HCL IN DEXTROSE.........................13VANCOMYCIN HCL IN DEXTROSE.........................13VANCOMYCIN HCL IN DEXTROSE.........................13VANCOMYCIN HYDROCHLORIDE..........................13VANCOMYCIN HYDROCHLORIDE..........................13VANCOMYCIN HYDROCHLORIDE..........................13VANISHPOINT INSULIN SYRINGE/0.5ML/30G X

1/2".............................................................................. 58VAQTA......................................................................... 102VAQTA......................................................................... 102VARIVAX..................................................................... 102VASCEPA...................................................................... 76VASCEPA...................................................................... 76VASERETIC.................................................................. 76VASOTEC......................................................................76VASOTEC......................................................................76VASOTEC......................................................................76VASOTEC......................................................................76VECTIBIX...................................................................... 37

VECTIBIX...................................................................... 37VELCADE......................................................................37VELPHORO.................................................................. 85VELTASSA.................................................................... 85VELTASSA.................................................................... 85VELTASSA.................................................................... 85VENCLEXTA.................................................................37VENCLEXTA.................................................................37VENCLEXTA.................................................................37VENCLEXTA STARTING PACK................................ 37venlafaxine hcl cap er 24hr 150 mg.......................... 22venlafaxine hcl cap er 24hr 37.5 mg......................... 22venlafaxine hcl cap er 24hr 75 mg............................ 22venlafaxine hcl tab 100 mg........................................ 22venlafaxine hcl tab 25 mg...........................................22venlafaxine hcl tab 37.5 mg....................................... 22venlafaxine hcl tab 50 mg...........................................22venlafaxine hcl tab 75 mg...........................................22venlafaxine hcl tab er 24hr 150 mg........................... 22venlafaxine hcl tab er 24hr 37.5 mg..........................22venlafaxine hcl tab er 24hr 75 mg............................. 22VENTAVIS................................................................... 111VENTAVIS................................................................... 111VENTOLIN HFA......................................................... 112verapamil hcl cap er 24hr 100 mg.............................77verapamil hcl cap er 24hr 120 mg.............................77verapamil hcl cap er 24hr 180 mg.............................77verapamil hcl cap er 24hr 200 mg.............................77verapamil hcl cap er 24hr 240 mg.............................77verapamil hcl cap er 24hr 300 mg.............................77verapamil hcl cap er 24hr 360 mg.............................77verapamil hcl tab 120 mg........................................... 77verapamil hcl tab 40 mg............................................. 77verapamil hcl tab 80 mg............................................. 77verapamil hcl tab er 120 mg.......................................77verapamil hcl tab er 180 mg.......................................77verapamil hcl tab er 240 mg.......................................77VERSACLOZ................................................................ 44VERZENIO....................................................................37VERZENIO....................................................................37VERZENIO....................................................................37VERZENIO....................................................................37VICTOZA....................................................................... 58VIDEX............................................................................ 49VIDEX............................................................................ 49VIDEX EC..................................................................... 49VIDEX EC..................................................................... 49VIDEX EC..................................................................... 49VIDEX EC..................................................................... 49VIEKIRA PAK................................................................49vigabatrin powd pack 500 mg.................................... 17vigabatrin tab 500 mg................................................. 17

2019

157

VIIBRYD.........................................................................22VIIBRYD.........................................................................22VIIBRYD.........................................................................22VIIBRYD STARTER PACK......................................... 22VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VINBLASTINE SULFATE............................................37vincristine sulfate iv soln 1 mg/ml..............................37vinorelbine tartrate inj 10 mg/ml.................................37vinorelbine tartrate inj 50 mg/5ml (10 mg/

ml)................................................................................37VIRACEPT.................................................................... 49VIRACEPT.................................................................... 49VIRAMUNE................................................................... 49VIREAD..........................................................................49VIREAD..........................................................................49VIREAD..........................................................................50VIREAD..........................................................................50VIREAD..........................................................................50VITRAKVI...................................................................... 37VITRAKVI...................................................................... 37VITRAKVI...................................................................... 37VIVITROL........................................................................ 5VIZIMPRO..................................................................... 37VIZIMPRO..................................................................... 38VIZIMPRO..................................................................... 38voriconazole for inj 200 mg........................................ 25voriconazole for susp 40 mg/ml.................................25voriconazole tab 200 mg............................................ 25voriconazole tab 50 mg...............................................25VOSEVI..........................................................................50VOTRIENT.................................................................... 38VPRIV............................................................................ 89VRAYLAR...................................................................... 44VRAYLAR...................................................................... 44VRAYLAR...................................................................... 45VRAYLAR...................................................................... 45VYNDAMAX.................................................................. 77VYNDAQEL...................................................................77VYXEOS........................................................................38Wwarfarin sodium tab 10 mg.........................................61warfarin sodium tab 1 mg...........................................61warfarin sodium tab 2.5 mg........................................61warfarin sodium tab 2 mg...........................................61warfarin sodium tab 3 mg...........................................61warfarin sodium tab 4 mg...........................................61warfarin sodium tab 5 mg...........................................61

warfarin sodium tab 6 mg...........................................61warfarin sodium tab 7.5 mg........................................61water for irrigation, sterile irrigation

soln..............................................................................85XXALKORI....................................................................... 38XALKORI....................................................................... 38XARELTO...................................................................... 61XARELTO...................................................................... 61XARELTO...................................................................... 61XARELTO...................................................................... 61XARELTO STARTER PACK.......................................62XATMEP...................................................................... 102XGEVA.........................................................................104XIFAXAN........................................................................87XOFLUZA......................................................................50XOFLUZA......................................................................50XOLAIR........................................................................103XOLAIR........................................................................103XOLAIR........................................................................103XOPENEX HFA..........................................................112XOSPATA...................................................................... 38XPOVIO 100 MG ONCE WEEKLY............................38XPOVIO 60 MG ONCE WEEKLY..............................38XPOVIO 80 MG ONCE WEEKLY..............................38XPOVIO 80 MG TWICE WEEKLY.............................38XTANDI.......................................................................... 38XYREM........................................................................112YYERVOY........................................................................38YERVOY........................................................................38YF-VAX........................................................................ 103YONDELIS.................................................................... 38YONSA.......................................................................... 38Zzafirlukast tab 10 mg.................................................112zafirlukast tab 20 mg.................................................112zaleplon cap 10 mg...................................................112zaleplon cap 5 mg..................................................... 112ZALTRAP.......................................................................38ZALTRAP.......................................................................38ZANOSAR..................................................................... 38ZEJULA..........................................................................38ZELBORAF................................................................... 38ZENPEP........................................................................ 89ZENPEP........................................................................ 89ZENPEP........................................................................ 89ZENPEP........................................................................ 89ZENPEP........................................................................ 89ZENPEP........................................................................ 89

2019

158

ZENPEP........................................................................ 89ZEPATIER..................................................................... 50ZESTORETIC............................................................... 77ZESTORETIC............................................................... 77ZESTORETIC............................................................... 77ZESTRIL........................................................................77ZESTRIL........................................................................77ZESTRIL........................................................................77ZESTRIL........................................................................77ZESTRIL........................................................................77ZESTRIL........................................................................77ZIAGEN..........................................................................50zidovudine cap 100 mg...............................................50zidovudine syrup 10 mg/ml.........................................50zidovudine tab 300 mg................................................50ziprasidone hcl cap 20 mg..........................................45ziprasidone hcl cap 40 mg..........................................45ziprasidone hcl cap 60 mg..........................................45ziprasidone hcl cap 80 mg..........................................45ZOCOR..........................................................................77ZOCOR..........................................................................77ZOCOR..........................................................................77ZOCOR..........................................................................77zoledronic acid inj conc for iv infusion 4

mg/5ml......................................................................104zoledronic acid iv soln 5 mg/100ml......................... 104ZOLINZA........................................................................38ZOLOFT.........................................................................22ZOLOFT.........................................................................22ZOLOFT.........................................................................22zolpidem tartrate tab 10 mg..................................... 112zolpidem tartrate tab 5 mg....................................... 112zonisamide cap 100 mg..............................................17zonisamide cap 25 mg................................................17zonisamide cap 50 mg................................................17ZONTIVITY....................................................................62ZORTRESS.................................................................103ZORTRESS.................................................................103ZORTRESS.................................................................103ZORTRESS.................................................................103ZOSTAVAX..................................................................103ZOSYN...........................................................................13ZOSYN...........................................................................13ZOSYN...........................................................................13ZYDELIG....................................................................... 38ZYDELIG....................................................................... 38ZYKADIA....................................................................... 38ZYKADIA....................................................................... 38ZYLOPRIM....................................................................25ZYLOPRIM....................................................................25ZYPREXA RELPREVV............................................... 45ZYPREXA RELPREVV............................................... 45

ZYPREXA RELPREVV............................................... 45ZYTIGA..........................................................................38ZYTIGA..........................................................................38

Blue Cross and Blue Shield of Illinois complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of Illinois does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Blue Cross and Blue Shield of Illinois:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

○ Qualified sign language interpreters

○ Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

○ Qualified interpreters

○ Information written in other languages

If you need these services, contact Civil Rights Coordinator

If you believe that Blue Cross and Blue Shield of Illinois has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, Office of Civil Rights Coordinator, 300 E. Randolph St., 35th floor, Chicago, Illinois 60601, 1-855-664-7270, TTY/TDD: 1-855-661-6965, Fax: 1-855-661-6960, [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW

Room 509F, HHH Building Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

mailto:[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

A T NT ON If yo peak E g ish anguage ass stance servi es free o harge a e ava able to yoal

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-888-285-2249 (TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-285-2249 (TTY: 711).

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-888-285-2249 (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1-888-285-2249 (TTY: 711).

주의: 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 .

1-888-285-2249 (TTY: 711) 번으로 전화해 주십시오 .

PAUNAWA: Kung nagsasa ita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-285-2249 (TTY: 711).

2249-285-888-1رقم ل تصا .نبالمجاك فر لتتواة يعدة اللغوات المسان خدمفإ، ةيبلعرة اغحدث اللتتت نا كإذ :ظحومل

.( 711:كمبواللصم افتهام قر)

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-285-2249 (телетайп: 711).

સુચના: જો તમે ગુજરાતી બોલતા હો, તો નિ:શુલક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-888-285-2249 (TTY: 711)

2249-285-888-1ں ريک.(TTY: 711)

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-285-2249 (TTY: 711).

ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-888-285-2249 (TTY: 711).

ध्यान दें: यदद आप दह ललए म भाषा सहायता सेवाएदी बोलत हैं तो आपक फ्त म उपलब्ध हैं। 1-888-285-2249 (TTY: 711) पर कॉल कर। ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-888-285-2249 (ATS: 711).

ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίεςπαρέχονται δωρεάν. Καλέστε 1-888-285-2249 (TTY: 711).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-285-2249 (TTY: 711).

ل کا۔ ںہیب استيدں میت مفت ادمخی کدمدی کنزب و کپآوت،ہي ے تولبو ارد پ آراگ :بردارخ اں

Ca l <1-877 7 -8592> ( TY: 7 >)

Llame al 1 877-774-8592> (TTY 711>)

Zadzwoń pod numer < -877-774 8592> (TTY: <711>).

如您使繁體文您獲請致電 9

<1-877-7 4 5 2> (TTY < 11>) 번으로 전화해 주십시오

.

ث م ت

م

A T NTIO If you ea E ish, l gu g assista ce erv c s, free o arge, are a aila le o all <

N I : si abla e pa o ie a su dis ici n se ios gra u s a s e ll me al < 8 4

WA A Jeżeli mówisz po olsku, możesz skorzystać z be płatnej

注意如果您使用繁體中您可費獲得言援助服務致電 < 877 7 4 8592

TTY: <711> 번으로 전화해 주십

مقرب لصت

В МА Е Ес и в говорите а русс о яз е то ва ос упн бес ат е с и ерев даво е е е й

مد یک دد یک نابز پ وت ،ںی م ت م ت ک ںیہ بایتسد ں ںیرک ل

Ý ếu bạ ó iếng iệ ó cá ịc ỗ rợ gô g ễn à họ số

A E Z O E caso a g a parla a sia ita a o sono dispo bil ser i di assisten a nguis ica ra uiti.

धयान : द प ह दी बो त ह त आपक ल ए मुफ्त म भाषा ह त स ाए उपल ध ह। <1-877-774

A E O S o s pa le ra ça s des ser ces d a de i g stiq e o s son proposés gra uitemenAppe e e

ΡΟΣΟΧ Α ιλά ε ελλ ι ά σ δ άθεσή σας ρ σ ο τα ηρεσίες λωσσι ής οσ ήριξης οι ο οίεςαρέ ο τα δωρεά αλέσ ε

A G Wenn Sie e tsch sp eche ste e e kostenlos sp achl che i fsdienstleistungen uV ü

िं े े ु ें िंें

This formulary was updated on 11/18/2019. For more recent information or other questions, please contact Blue Cross MedicareRx Customer Service at 1-888-285-2249 or, for TTY users, 711, 8:00 a.m. – 8:00 p.m., local time, 7 days a week. If you are calling from April 1 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays, or visit www.getblueil.com/pdp/druglist.

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-888-285-2249 (TTY: 711) We are open between 8:00 a.m. and 8:00 p.m., local time, 7 days a week. If you are calling from April 1 through September 30, alternate technologies (for example, voicemail) will be used on the weekends and holidays. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-285-2249 (TTY: 711). Nuestro horario es de 8:00 a.m. a 8:00 p.m., hora local, los 7 días de la semana. Si usted llama del 1 de abril al 30 de septiembre, durante los fines de semana y feriados, se usarán tecnologías alternas (por ejemplo, correo de voz).

Blue Cross MedicareRx is a prescription drug plan provided by HCSC Insurance Services Company (HISC), an Independent Licensee of the Blue Cross and Blue Shield Association. A Medicare-approved Part D sponsor. Enrollment in HISC’s plan depends on contract renewal.

http://www.getblueil.com/pdp/druglist

Documents

2019 IL PDP Value - bcbsil.comi | Blue Cross MedicareRx (PDP) 2019 Formulary (List of Covered Drugs) Note to existing members: This formulary has changed since last year. Please review