2020 CIGNA COMPREHENSIVE DRUG LIST (Formulary) · 2020-06-01 · it means Cigna-HealthSpring Rx Secure-Extra (PDP). This document includes a list of the drugs (formulary) for our

This drug list was updated in July 2020. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-222-6700, or, for TTY users, 711, 8 a.m. – 8 p.m. local time, 7 days a week. Our automated phone system may answer your call during weekends from April 1 – September 30, or visit www.Cigna.com/part-d. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Cigna-HealthSpring® Rx is a Medicare Prescription Drug Plan (PDP) with a Medicare contract. Enrollment in Cigna-HealthSpring depends on contract renewal. HPMS Approved Formulary File Submission ID 20084, Version Number 13 INT_20_76977_C_Final_8g

Plan coveredCigna-HealthSpring Rx Secure-Extra (PDP)

Please read: This document contains information about all of the drugs we cover in this plan.

2020 CIGNA COMPREHENSIVE DRUG LIST (Formulary)

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

Can the Drug List (formulary) change?Most changes in drug coverage happen on January 1, but we may add or remove drugs on the drug list during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes.Changes that can affect you this year. In the below cases, you will be affected by coverage changes during the year:• 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. – 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 how to request an exception, and

you can also find information in the section entitled “How do I request an exception to the Cigna Drug List?”

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

• Other changes. We may make other changes that affect customers currently taking a drug. For instance, we may add a generic drug that is not new to the market to replace a brand name drug currently on the drug list 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 and/or studies. If we remove drugs from our drug list, add prior authorization, quantity limits, and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected customers of the change at least 30 days before the change becomes effective, or at the time the customer requests a refill of the drug, at which time the customer will receive a 30-day supply of the drug. – If we make these other changes, 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 how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Cigna’s Drug List?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with

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

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

This document includes a list of the drugs (formulary) for our plans, which is current as of July 2020. For an updated drug list, 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, 2021, and from time to time during the year.

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no new restrictions for those customers taking them for the remainder of the coverage year. The enclosed drug list is current as of July 2020. To get updated information about the drugs covered by Cigna, please contact us. Our contact information appears on the front and back cover pages. If there are significant changes made to the printed drug list within the covered year, you may be notified by mail identifying the changes. Drug lists located on our website are reviewed and updated on a monthly basis.

How do I use the Drug List? There are two ways to find your drug within the drug list:Medical ConditionThe drug list begins on page 19. The drugs in this drug list are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “CARDIOVASCULAR, HYPERTENSION / LIPIDS”. If you know what your drug is used for, look for the category name in the list that begins on page 19. Then look under the category name for your drug. Covered Drug IndexIf you are not sure what category to look under, you should look for your drug in the Covered Drugs Index that begins on page 65. The Covered Drugs 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 Covered Drug Index and find the name of your drug in the drug name column of the list.

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

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

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

• Quantity Limits: For certain drugs, Cigna limits the amount of the drug that Cigna will cover. For example, Cigna allows for 1 tablet per day for candesartan 32mg. This applies to a standard one-month supply (for total quantity of 30 per 30 days) or three-month supply (for total quantity of 90 per 90 days).

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

• Non-Extended Days Supply: For certain drugs, Cigna limits the amount of the drug that Cigna will cover to only a 30-day supply or less, at one time. For example, customers who have not had any recent fill of opioid pain medications within the past 120 days (referred to as “opioid naïve”) are limited to a maximum of 7 days’ supply of opioid pain medication. Customers who have received a recent fill of an opioid pain medication (not opioid naïve) are limited to up to a month’s supply of that medication at one time. Other high cost drugs may be subject to a non-extended day supply restriction, as well.

You can find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 19. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.You can ask Cigna to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Cigna drug list?” on page 3 for information about how to request an exception.

Options for Maintenance MedicationsTaking the medications prescribed by your doctor (or other prescriber) is important to your health. We are committed to helping you control your chronic conditions by making it easy for you to receive your maintenance medications. There are several ways we can work together to accomplish this goal:• Talk with your doctor about whether a 90-day supply of your

ongoing, stable medications may be appropriate. Taking these medications every day as prescribed is important for

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your overall health, and getting 90-day prescriptions of these medications can help ensure that you do not miss a dose.

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

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

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

cost generic alternatives available for any of your current medications.

• Some plans may offer a $0 copay for Tier 1 and 2 generic drugs filled at a preferred retail and/or mail-order pharmacies. Check the Drug Tier and Cost-share Tables on page 5 to see if your plan offers these savings.

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

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

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

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

• You can ask Cigna to make an exception and cover your drug. See the next section for information about how to request an exception.

How do I request an exception to the Cigna Drug List?You can ask Cigna 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 drug

list. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Cigna limits the

amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

• You can ask us to provide a tiering exception for a higher cost-sharing drug to be covered at a lower cost-sharing tier under following circumstances: – If the drug you’re taking is a brand name drug you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains brand name alternatives for treating your condition.

– If the drug you’re taking is a generic drug you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains either brand or generic alternatives for treating your condition.

– If the drug you’re taking is a biological product you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains biological product alternatives for treating your condition.

These exceptions would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not in our drug list, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier.

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

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or existing customer in our plan you may be taking drugs that are not on our drug list. Or, you may be taking a drug

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that is on our drug list but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a drug list exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug up to a 30-day supply, in certain cases during the first 90 days you are a customer of our plan.For each of your drugs that is not on our drug list or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs without a drug list exception, even if you have been a customer of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not on our drug list or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a drug list exception. In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning, such as level-of-care changes due to discharge from a hospital to a nursing facility or to a home, Cigna will allow a one-time 31-day supply (unless the prescription is written for fewer days). Cigna’s Drug ListThe comprehensive drug list that begins on page 19, provides coverage information about all of the drugs covered by Cigna. If you have trouble finding your drug in the list, turn to the Covered Drug Index that begins on page 65.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., TRELEGY ELLIPTA) and generic drugs are listed in lower-case italics (e.g., candesartan).The information in the Requirements/Limits column tells you if Cigna has any special requirements for coverage of your drug. We provide quantity limits on certain drugs which are indicated with a QL in the Covered Drugs by Category list on page 19 along with the amount dispensed per the days supplied. (For example: candesartan 32mg QL 30/30; this means the drug candesartan 32mg is limited to 30 tablets per 30 days. For 90-day supplies, this quantity limit would be expanded to 90 tablets per 90 days).

What is a preferred network pharmacy?If your plan has preferred network pharmacies, you will typically save money by using these pharmacies. Your prescription drug costs (like a copay or coinsurance) will typically be less at a preferred network pharmacy because it has a preferred agreement with your plan. If you need help finding a network pharmacy, please call Customer Service at 1-800-222-6700 (TTY 711), or you can visit www.Cigna.com/part-d for the most current Pharmacy Directory.

For more information

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

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Drug Tier and Cost-Share TableThe following table represents the plan name, plan service area, the drug tier number as it appears on the drug list, and the cost-share amount for that tier number. Tier 1 is for Preferred Generic drugs. Tier 2 is for Generic drugs. Tier 3 is for Preferred Brand drugs. Tier 4 is for Non-Preferred drugs. Tier 5 is for Specialty tier drugs. Tier 6 is for Select Care Drugs. Please refer to the following chart. You may also refer to your Evidence of Coverage document for additional details.Cigna is not always able to keep all generic medications in the Preferred Generic and Generic drug tiers, and some generic medications may be in Tier 3, Tier 4, Tier 5, or Tier 6. Keep in

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

Cigna Medicare Prescription Drug Secure-Extra (PDP)

Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing

Preferred Mail-Order

Cost-Sharing

Standard Mail-Order

Cost-Sharing

Long-term Care 31 days

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

ALABAMA

Tier 1: Preferred Generic Drugs $4 / $8 / $12 $15 / $30 / $45 $4 / $8 / $0 $15 / $30 / $45 $15

Tier 2: Generic Drugs $10 / $20 / $30 $20 / $40 / $60 $10 / $20 / $20 $20 / $40 / $60 $20

Tier 3: Preferred Brand Drugs $42 / $84 / $126 $47 / $94 / $141 $42 / $84 / $105 $47 / $94 / $141 $47

Tier 4: Non-Preferred Drugs 50% 50% 50% 50% 50%

Tier 5: Specialty Tier 31% (30 days) 31% (30 days) 31% (30 days) 31% (30 days) 31%

Tier 6: Select Care Drugs $2 / $4 / $6 $11 / $22 / $33 $2 / $4 / $4 $11 / $22 / $33 $11

ALASKA







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

To locate your drug cost, please refer to the table(s) below to find your service area and the Prescription Drug plan in which you are currently enrolled or would like to enroll. Cigna uses preferred network pharmacies. See your Pharmacy Directory or visit www.Cigna.com/part-d to search for a preferred retail or mail-order pharmacy near you.

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Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



ARIZONA







ARKANSAS







CALIFORNIA







COLORADO








7



Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



CONNECTICUT







DELAWARE







DISTRICT OF COLUMBIA







FLORIDA







8


Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



GEORGIA







HAWAII







IDAHO







ILLINOIS








9



Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



INDIANA







IOWA







KANSAS







KENTUCKY







10


Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



LOUISIANA







MAINE







MARYLAND







MASSACHUSETTS








11



Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



MICHIGAN







MINNESOTA







MISSISSIPPI







MISSOURI







12


Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



MONTANA







NEBRASKA







NEVADA







NEW HAMPSHIRE








13



Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



NEW JERSEY







NEW MEXICO







NEW YORK







NORTH CAROLINA







14


Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



NORTH DAKOTA







OHIO







OKLAHOMA







OREGON








15



Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



PENNSYLVANIA







RHODE ISLAND







SOUTH CAROLINA







SOUTH DAKOTA







16



Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



TENNESSEE







TEXAS







UTAH







VERMONT







17



Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



VIRGINIA







WASHINGTON







WEST VIRGINIA







WISCONSIN







18


Preferred Retail

Cost-Sharing

Standard Retail

Cost-Sharing


Cost-Sharing

Standard Mail-Order

Cost-Sharing



WYOMING







My MedicationsIn this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug list pages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before this page and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer Service at 1-800-222-6700, 8 a.m. – 8 p.m. local time, 7 days a week. Our automated phone system may answer your call during weekends from April 1 – September 30. TTY users can call 711.

My Medications Page Number in the Drug List Cost-Share through Cigna

Drug List Key:B/D – This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending on circumstances.NDS – Non-extended day supply medication. This drug is only available as a 30-day supply or less.PA – This drug requires prior authorization

QL – This drug has quantity limitsST – This drug has step therapy requirementsGenerally all medications in the drug list are available through mail-order, except when special circumstances or situations prohibit mailing a particular medication to your home.

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Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drugQL = Quantity Limits listed as (qty/days) ST = Step Therapy rules applyPA = Prior Authorization may be required B/D = Drugs covered under Medicare Part B or Part DNDS = Non-extended day supply medication You can find more information on the symbols by going to page 18.

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ANTI - INFECTIVES

ANTIFUNGAL AGENTSABELCET 5 PA; NDSAMBISOME 5 PA; NDSamphotericin b 4 PAcaspofungin 5 PA; NDSclotrimazole mucous membrane

2

CRESEMBA ORAL 4fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml

4

fluconazole oral suspension for reconstitution

3

fluconazole oral tablet 2flucytosine 5 NDSgriseofulvin microsize 4griseofulvin ultramicrosize 4itraconazole oral capsule 4 PA; QL (120/30)itraconazole oral solution 5 PA; NDSketoconazole oral 2NOXAFIL ORAL SUSPENSION 5 PA; QL (600/30);

NDSNOXAFIL ORAL TABLET, DELAYED RELEASE (DR/EC)

5 PA; QL (96/30); NDS

nystatin oral suspension 3nystatin oral tablet 2posaconazole oral tablet,delayed release (dr/ec)

5 PA; QL (96/30); NDS

terbinafine hcl oral 2voriconazole intravenous 4 PAvoriconazole oral suspension for reconstitution

5 PA; QL (300/30); NDS

voriconazole oral tablet 4 PAANTIVIRALSabacavir oral solution 3 QL (960/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

abacavir oral tablet 4 QL (60/30)abacavir-lamivudine 3 QL (30/30)abacavir-lamivudine-zidovudine 5 QL (60/30); NDSacyclovir oral capsule 2acyclovir oral suspension 200 mg/5 ml

4

acyclovir oral tablet 2acyclovir sodium intravenous solution

4 B/D PA

adefovir 5 QL (30/30); NDSamantadine hcl 3APTIVUS 4 QL (120/30)APTIVUS (WITH VITAMIN E) 4 QL (285/28)atazanavir oral capsule 150 mg 4 QL (30/30)atazanavir oral capsule 200 mg 5 QL (60/30); NDSatazanavir oral capsule 300 mg 5 QL (30/30); NDSATRIPLA 5 QL (30/30); NDSBARACLUDE ORAL SOLUTION

4 QL (630/30)

BIKTARVY 5 QL (30/30); NDSCIMDUO 5 QL (30/30); NDSCOMPLERA 4 QL (30/30)CRIXIVAN ORAL CAPSULE 200 MG

4 QL (270/30)

CRIXIVAN ORAL CAPSULE 400 MG

4 QL (180/30)

DELSTRIGO 5 QL (30/30); NDSDESCOVY 5 QL (30/30); NDSdidanosine oral capsule,delayed release(dr/ec) 200 mg, 250 mg, 400 mg

4 QL (30/30)

DOVATO 5 QL (30/30); NDSEDURANT 3 QL (30/30)efavirenz oral capsule 200 mg 3 QL (120/30)efavirenz oral capsule 50 mg 3 QL (180/30)efavirenz oral tablet 5 QL (30/30); NDS

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nevirapine oral tablet 3 QL (60/30)nevirapine oral tablet extended release 24 hr 100 mg

4 QL (90/30)

nevirapine oral tablet extended release 24 hr 400 mg

4 QL (30/30)

NORVIR ORAL POWDER IN PACKET

4 QL (360/30)

NORVIR ORAL SOLUTION 3 QL (480/30)ODEFSEY 5 QL (30/30); NDSoseltamivir oral capsule 3oseltamivir oral suspension for reconstitution

4

PIFELTRO 5 QL (30/30); NDSPREZCOBIX 4 QL (30/30)PREZISTA ORAL SUSPENSION

5 QL (400/30); NDS

PREZISTA ORAL TABLET 150 MG

4 QL (180/30)


5 QL (60/30); NDS


4 QL (210/30)


5 QL (30/30); NDS

RETROVIR INTRAVENOUS 4REYATAZ ORAL POWDER IN PACKET

5 QL (180/30); NDS

ribavirin oral capsule 3 QL (168/28)ribavirin oral tablet 200 mg 3rimantadine 2ritonavir 3 QL (360/30)SELZENTRY ORAL SOLUTION

5 QL (1610/26); NDS

SELZENTRY ORAL TABLET 150 MG, 75 MG

5 QL (60/30); NDS

SELZENTRY ORAL TABLET 25 MG

4 QL (240/30)

SELZENTRY ORAL TABLET 300 MG

5 QL (120/30); NDS

stavudine oral capsule 15 mg, 20 mg

3 QL (60/30)

stavudine oral capsule 30 mg, 40 mg

4 QL (60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

EMTRIVA ORAL CAPSULE 3 QL (30/30)EMTRIVA ORAL SOLUTION 3 QL (680/28)entecavir 4 QL (30/30)EPCLUSA 5 PA; QL (28/28);

NDSEPIVIR HBV ORAL SOLUTION 3EVOTAZ 4 QL (30/30)famciclovir 4 QL (60/30)fosamprenavir 5 QL (120/30); NDSFUZEON SUBCUTANEOUS RECON SOLN

5 QL (60/30); NDS

GENVOYA 5 QL (30/30); NDSHARVONI ORAL TABLET 5 PA; QL (28/28);

NDSINTELENCE ORAL TABLET 100 MG, 200 MG

5 QL (60/30); NDS

INTELENCE ORAL TABLET 25 MG

4 QL (120/30)

INVIRASE ORAL TABLET 5 QL (120/30); NDSISENTRESS HD 5 QL (60/30); NDSISENTRESS ORAL POWDER IN PACKET

5 QL (60/30); NDS

ISENTRESS ORAL TABLET 5 QL (120/30); NDSISENTRESS ORAL TABLET,CHEWABLE 100 MG

5 QL (180/30); NDS

ISENTRESS ORAL TABLET,CHEWABLE 25 MG

3 QL (180/30)

JULUCA 5 NDSKALETRA ORAL TABLET 100-25 MG

4 QL (300/30)

KALETRA ORAL TABLET 200-50 MG

5 QL (120/30); NDS

lamivudine oral solution 3 QL (900/30)lamivudine oral tablet 100 mg, 300 mg

3 QL (30/30)

lamivudine oral tablet 150 mg 3 QL (60/30)lamivudine-zidovudine 3 QL (60/30)LEXIVA ORAL SUSPENSION 4 QL (1575/28)lopinavir-ritonavir 4 QL (480/30)MAVYRET 5 PA; QL (84/28);

NDSnevirapine oral suspension 4 QL (1200/30)

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cefadroxil oral capsule 3cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

3

cefadroxil oral tablet 3cefazolin 4cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml

4

CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/100 ML

4

cefdinir 4CEFEPIME IN DEXTROSE 5% 4cefepime in dextrose,iso-osm 4cefepime injection 4cefixime oral capsule 4 QL (30/30)cefixime oral suspension for reconstitution

4

cefotetan 4CEFOTETAN IN DEXTROSE, ISO-OSM

4

cefoxitin 4cefoxitin in dextrose, iso-osm 4cefpodoxime 4cefprozil 3ceftazidime 4CEFTAZIDIME IN D5W 4ceftriaxone in dextrose,iso-os 4ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg

4

CEFTRIAXONE INJECTION RECON SOLN 100 GRAM

4

ceftriaxone intravenous 4cefuroxime axetil oral tablet 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

STRIBILD 5 QL (30/30); NDSSYMFI 5 QL (30/30); NDSSYMFI LO 5 QL (30/30); NDSSYMTUZA 5 QL (30/30); NDSSYNAGIS 5 PA; NDStenofovir disoproxil fumarate 4 QL (30/30)TIVICAY ORAL TABLET 10 MG 4 QL (60/30)TIVICAY ORAL TABLET 25 MG, 50 MG

5 QL (60/30); NDS

TRIUMEQ 5 QL (30/30); NDSTROGARZO 5 B/D PA; NDSTRUVADA 5 QL (30/30); NDSTYBOST 3 QL (30/30)valacyclovir oral tablet 1 gram 3 QL (120/30)valacyclovir oral tablet 500 mg 3 QL (60/30)valganciclovir 5 NDSVEMLIDY 4VIRACEPT ORAL TABLET 250 MG

4 QL (270/30)

VIRACEPT ORAL TABLET 625 MG

4 QL (120/30)

VIREAD ORAL POWDER 5 QL (240/30); NDSVIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

5 QL (30/30); NDS

VOSEVI 5 PA; QL (30/30); NDS

zidovudine oral capsule 4 QL (180/30)zidovudine oral syrup 4 QL (1680/28)zidovudine oral tablet 4 QL (60/30)CEPHALOSPORINScefaclor oral capsule 4cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

4

cefaclor oral tablet extended release 12 hr

4

22


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CAYSTON 5 PA; QL (84/56); NDS

chloramphenicol sod succinate 4chloroquine phosphate 2clindamycin hcl 2CLINDAMYCIN IN 0.9% SOD CHLOR

4

clindamycin in 5% dextrose 4clindamycin palmitate hcl 4clindamycin pediatric 4clindamycin phosphate injection 4clindamycin phosphate intravenous solution 600 mg/4 ml

4

COARTEM 4 QL (24/30)colistin (colistimethate na) 4CUBICIN 4 B/D PACUBICIN RF 4 B/D PACYCLOSERINE 4dapsone oral 3DAPTOMYCIN INTRAVENOUS RECON SOLN 350 MG

5 B/D PA; NDS

daptomycin intravenous recon soln 500 mg

5 B/D PA; NDS

DARAPRIM 5 QL (90/30); NDSEMVERM 4ertapenem 4ethambutol 4FIRVANQ 4gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml

4

GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML

4

gentamicin injection solution 40 mg/ml

4

gentamicin sulfate (ped) (pf) 4hydroxychloroquine 2imipenem-cilastatin 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cefuroxime sodium injection recon soln 750 mg

4

cefuroxime sodium intravenous 4cephalexin oral capsule 250 mg, 500 mg

2

cephalexin oral suspension for reconstitution

2

tazicef 4TEFLARO 4ERYTHROMYCINS / OTHER MACROLIDESazithromycin intravenous 4azithromycin oral packet 3azithromycin oral suspension for reconstitution

4

azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack)

2

azithromycin oral tablet 600 mg 2 QL (60/30)clarithromycin 4ERY-TAB 4erythrocin (as stearate) oral tablet 250 mg

4

ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG

4

erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml

4

erythromycin oral 4MISCELLANEOUS ANTIINFECTIVESalbendazole 5 NDSALINIA ORAL SUSPENSION FOR RECONSTITUTION

5 QL (180/30); NDS

ALINIA ORAL TABLET 5 QL (20/10); NDSamikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml

4

ARIKAYCE 4 PAatovaquone 4atovaquone-proguanil 4aztreonam 4bacitracin intramuscular 4CAPASTAT 4

23



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SIVEXTRO ORAL 5 QL (6/28); NDSstreptomycin 4SYNERCID 5 NDStigecycline 5 NDStobramycin in 0.225% nacl 5 B/D PA; QL

(280/28); NDStobramycin sulfate 4TRECATOR 3VANCOMYCIN IN 0.9% SODIUM CHL INTRAVENOUS PIGGYBACK

4

VANCOMYCIN IN DEXTROSE 5% INTRAVENOUS PIGGYBACK

4

VANCOMYCIN INJECTION 4vancomycin intravenous recon soln 1,000 mg, 10 gram, 250 mg, 5 gram, 500 mg, 750 mg

4

VANCOMYCIN INTRAVENOUS RECON SOLN 1.25 GRAM, 1.5 GRAM

4

vancomycin oral capsule 125 mg

4 QL (40/10)

vancomycin oral capsule 250 mg

4 QL (80/10)

vancomycin oral recon soln 2VANCOMYCIN-WATER INJECT (PEG)

4

XIFAXAN ORAL TABLET 550 MG

5 PA; QL (90/30); NDS

PENICILLINSamoxicillin oral capsule 2amoxicillin oral suspension for reconstitution

2

amoxicillin oral tablet 2amoxicillin oral tablet,chewable 125 mg, 250 mg

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

INVANZ INJECTION 4isoniazid oral solution 4isoniazid oral tablet 2ivermectin oral 3lincomycin 4linezolid in dextrose 5% 4linezolid oral suspension for reconstitution

5 QL (1800/30); NDS

linezolid oral tablet 3 QL (60/30)linezolid-0.9% sodium chloride 4mefloquine 2meropenem 4MEROPENEM-0.9% SODIUM CHLORIDE

4

metro i.v. 4metronidazole in nacl (iso-os) 4metronidazole oral tablet 2NEBUPENT 3 B/D PA; QL (1/28)neomycin 2paromomycin 4PASER 4PENTAM 4pentamidine inhalation 3 B/D PA; QL (1/28)pentamidine injection 4praziquantel 4PRIFTIN 4PRIMAQUINE 4pyrazinamide 4pyrimethamine 5 QL (90/30); NDSquinine sulfate 4 PA; QL (42/7)rifabutin 4rifampin 4SIRTURO 4 PA; QL (188/365)SIVEXTRO INTRAVENOUS 5 B/D PA; QL (6/28);

NDS

24


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

levofloxacin in d5w 4levofloxacin intravenous 4levofloxacin oral solution 4levofloxacin oral tablet 2moxifloxacin oral 4MOXIFLOXACIN-SOD.ACE,SUL-WATER

4

moxifloxacin-sod.chloride(iso) 4SULFAS / RELATED AGENTSsulfadiazine 4sulfamethoxazole-trimethoprim intravenous

4

sulfamethoxazole-trimethoprim oral suspension

4

sulfamethoxazole-trimethoprim oral tablet

2

sulfatrim 4TETRACYCLINESdoxy-100 4doxycycline hyclate intravenous 4doxycycline hyclate oral capsule

2

doxycycline hyclate oral tablet 100 mg, 20 mg

2

doxycycline monohydrate oral capsule 100 mg, 50 mg

3

doxycycline monohydrate oral suspension for reconstitution

4

doxycycline monohydrate oral tablet

3

minocycline oral capsule 2morgidox oral capsule 100 mg 2morgidox oral capsule 50 mg 4NUZYRA INTRAVENOUS 4 QL (15/14)NUZYRA ORAL 4 QL (30/14)tetracycline 4URINARY TRACT AGENTSmethenamine hippurate 4nitrofurantoin 4nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

amoxicillin-pot clavulanate oral suspension for reconstitution

2

amoxicillin-pot clavulanate oral tablet

2

amoxicillin-pot clavulanate oral tablet extended release 12 hr

4

amoxicillin-pot clavulanate oral tablet,chewable

2

ampicillin oral capsule 500 mg 2ampicillin sodium 4ampicillin-sulbactam 4AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 250-62.5 MG/5 ML

4

BICILLIN L-A 4dicloxacillin 2nafcillin 4nafcillin in dextrose iso-osm 4oxacillin injection 4penicillin g potassium 4penicillin v potassium 2pfizerpen-g 4PIPERACILLIN-TAZOBACTAM INTRAVENOUS RECON SOLN 13.5 GRAM

4

piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

4

ZOSYN IN DEXTROSE (ISO-OSM)

4

ZOSYN INTRAVENOUS RECON SOLN 2.25 GRAM, 3.375 GRAM

4

QUINOLONESBAXDELA 4 QL (28/14)ciprofloxacin 4ciprofloxacin hcl oral tablet 100 mg

4

ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg

2

ciprofloxacin in 5% dextrose 4

25



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ARSENIC TRIOXIDE INTRAVENOUS SOLUTION 1 MG/ML

4 B/D PA

arsenic trioxide intravenous solution 2 mg/ml

4 B/D PA

ASTAGRAF XL 4 PAAVASTIN 5 PA; NDSAYVAKIT 4 PA; QL (30/30)azathioprine 2 PAazathioprine sodium 4 PABALVERSA ORAL TABLET 3 MG

5 PA; QL (90/30); NDS

BALVERSA ORAL TABLET 4 MG

5 PA; QL (60/30); NDS

BALVERSA ORAL TABLET 5 MG

5 PA; QL (30/30); NDS

BAVENCIO 5 PA; NDSBENDEKA 5 B/D PA; QL (8/21);

NDSBESPONSA 5 PA; NDSbexarotene 5 PA; NDSbicalutamide 3BORTEZOMIB 5 PA; QL (14/21);

NDSBOSULIF 5 PA; NDSBRAFTOVI 5 PA; QL (180/30);

NDSBRUKINSA 4 PAbusulfan 5 B/D PA; NDSBUSULFEX 5 B/D PA; NDSCABOMETYX ORAL TABLET 20 MG, 60 MG

5 PA; QL (30/30); NDS

CABOMETYX ORAL TABLET 40 MG

5 PA; QL (60/30); NDS

CALQUENCE 5 PA; QL (60/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nitrofurantoin macrocrystal oral capsule 25 mg

4

nitrofurantoin monohyd/m-cryst 4trimethoprim 2

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTSleucovorin calcium injection recon soln

4

leucovorin calcium injection solution 10 mg/ml

4

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg

4

leucovorin calcium oral tablet 5 mg

3

mesna 4 B/D PAMESNEX ORAL 5 NDSXGEVA 5 PA; QL (1.7/28);

NDSANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGSabiraterone 4 PA; QL (120/30)ABRAXANE 5 PA; NDSAFINITOR 5 PA; QL (28/28);

NDSAFINITOR DISPERZ 5 PA; QL (56/28);

NDSALECENSA 5 PA; QL (240/30);

NDSALIMTA 5 PA; NDSALIQOPA 5 PA; QL (3/28); NDSALUNBRIG ORAL TABLET 180 MG, 90 MG

5 PA; QL (30/30); NDS

ALUNBRIG ORAL TABLET 30 MG

5 PA; QL (180/30); NDS

ALUNBRIG ORAL TABLETS,DOSE PACK

5 PA; QL (60/365); NDS

anastrozole 2

26


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

everolimus (immunosuppressive) oral tablet 0.25 mg

4 PA; QL (60/30)


5 PA; QL (120/30); NDS


5 PA; QL (60/30); NDS

EVOMELA 5 PA; NDSexemestane 4 QL (60/30)FARYDAK 5 PA; QL (6/21); NDSFASLODEX 5 B/D PA; QL (30/30);

NDSFIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG

4 B/D PA; QL (4/365)

FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG

4 B/D PA; QL (1/28)

fludarabine 4 B/D PAflutamide 4FOLOTYN 5 B/D PA; NDSfulvestrant 5 B/D PA; QL (30/30);

NDSGAZYVA 5 PA; NDSgemcitabine intravenous recon soln

4 B/D PA

gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml)

4 B/D PA

GEMCITABINE INTRAVENOUS SOLUTION 100 MG/ML

5 B/D PA; NDS

gengraf oral capsule 100 mg, 25 mg

4 PA

gengraf oral solution 4 PAGILOTRIF 5 PA; QL (30/30);

NDSGLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG

4

HALAVEN 5 PA; NDSHERCEPTIN HYLECTA 5 PA; NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CAPRELSA ORAL TABLET 100 MG

5 PA; QL (60/30); NDS

CAPRELSA ORAL TABLET 300 MG

5 PA; QL (30/30); NDS

COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1)

5 PA; QL (56/28); NDS

COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3)

5 PA; QL (112/28); NDS

COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY)

5 PA; QL (84/28); NDS

COPIKTRA 5 PA; QL (60/30); NDS

COTELLIC 5 PA; QL (63/28); NDS

cyclophosphamide intravenous 5 B/D PA; NDScyclophosphamide oral capsule 3 B/D PAcyclosporine intravenous 4 PAcyclosporine modified 4 PAcyclosporine oral capsule 4 PACYRAMZA 5 PA; NDSDARZALEX 5 PA; NDSdaunorubicin intravenous solution

4 B/D PA

DAURISMO ORAL TABLET 100 MG

5 PA; QL (30/30); NDS

DAURISMO ORAL TABLET 25 MG

5 PA; QL (60/30); NDS

DROXIA 4ELZONRIS 5 B/D PA; NDSEMCYT 4ENHERTU 5 PA; NDSERIVEDGE 5 PA; QL (28/28);

NDSERLEADA 4 PAerlotinib oral tablet 100 mg, 150 mg

5 PA; QL (30/30); NDS

erlotinib oral tablet 25 mg 5 PA; QL (60/30); NDS

etoposide intravenous 3 B/D PAeverolimus (antineoplastic) 5 PA; QL (28/28);

NDS

27



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

KEYTRUDA INTRAVENOUS SOLUTION

5 PA; NDS

KISQALI 5 PA; QL (63/28); NDS

KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG

5 PA; QL (49/28); NDS


5 PA; QL (70/28); NDS


5 PA; QL (91/28); NDS

KYPROLIS 5 B/D PA; NDSLENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 4 MG

5 PA; QL (30/30); NDS

LENVIMA ORAL CAPSULE 12 MG/DAY (4 MG X 3), 18 MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY(10 MG X 2-4 MG X 1)

5 PA; QL (90/30); NDS

LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2)

5 PA; QL (60/30); NDS

letrozole 2LEUKERAN 4leuprolide subcutaneous kit 4 PALIBTAYO 5 PA; QL (7/21); NDSLONSURF ORAL TABLET 15-6.14 MG

5 PA; QL (100/28); NDS

LONSURF ORAL TABLET 20-8.19 MG

5 PA; QL (80/28); NDS

LORBRENA ORAL TABLET 100 MG

5 PA; QL (30/30); NDS

LORBRENA ORAL TABLET 25 MG

5 PA; QL (90/30); NDS

LUMOXITI 5 PA; NDSLUPRON DEPOT 5 PA; QL (1/30); NDSLUPRON DEPOT (3 MONTH) 5 PA; QL (1/84); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HERCEPTIN INTRAVENOUS RECON SOLN 150 MG

5 PA; NDS

hydroxyurea 2IBRANCE 5 PA; QL (21/28);

NDSICLUSIG ORAL TABLET 15 MG

5 PA; QL (60/30); NDS

ICLUSIG ORAL TABLET 45 MG

5 PA; QL (30/30); NDS

IDHIFA 5 PA; QL (30/30); NDS

imatinib oral tablet 100 mg 5 PA; QL (180/30); NDS

imatinib oral tablet 400 mg 5 PA; QL (60/30); NDS

IMBRUVICA ORAL CAPSULE 140 MG

5 PA; QL (120/30); NDS

IMBRUVICA ORAL CAPSULE 70 MG

5 PA; QL (30/30); NDS

IMBRUVICA ORAL TABLET 5 PA; QL (30/30); NDS

IMFINZI 5 PA; NDSINFUGEM 5 B/D PA; NDSINLYTA ORAL TABLET 1 MG 5 PA; QL (180/30);

NDSINLYTA ORAL TABLET 5 MG 5 PA; QL (120/30);

NDSINREBIC 5 PA; QL (120/30);

NDSIRESSA 5 PA; QL (30/30);

NDSirinotecan 4 B/D PAISTODAX 5 PA; NDSJAKAFI 5 PA; QL (60/30);

NDSKADCYLA 5 PA; NDSKANJINTI 5 PA; NDS

28


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NEXAVAR 5 PA; QL (120/30); NDS

nilutamide 5 QL (60/30); NDSNINLARO 5 PA; QL (3/28); NDSNUBEQA 4 PA; QL (120/30)NULOJIX 5 PA; QL (26/28);

NDSoctreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml

4 PA

octreotide acetate injection solution 50 mcg/ml

3 PA

ODOMZO 5 PA; QL (30/30); NDS

OGIVRI 5 PA; NDSONTRUZANT 5 PA; NDSOPDIVO 5 PA; QL (80/28);

NDSpaclitaxel 4 B/D PAPADCEV 4 PAPEMAZYRE 4 PA; QL (14/21)PERJETA 5 PA; NDSPIQRAY ORAL TABLET 200 MG/DAY (200 MG X 1)

5 PA; QL (28/28); NDS

PIQRAY ORAL TABLET 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X 2)

5 PA; QL (56/28); NDS

POMALYST 5 PA; QL (21/28); NDS

POTELIGEO 5 PA; NDSPROGRAF INTRAVENOUS 4 PAPROGRAF ORAL GRANULES IN PACKET

4 PA

PURIXAN 5 PA; QL (300/30); NDS

RAPAMUNE ORAL SOLUTION 5 PA; NDSREVLIMID ORAL CAPSULE 10 MG, 2.5 MG, 5 MG

5 PA; QL (28/28); NDS

REVLIMID ORAL CAPSULE 15 MG, 20 MG, 25 MG

5 PA; QL (21/28); NDS

RITUXAN 5 PA; NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LUPRON DEPOT (4 MONTH) 5 PA; QL (1/112); NDS

LUPRON DEPOT (6 MONTH) 5 PA; QL (1/168); NDS

LUPRON DEPOT-PED 5 PA; QL (1/30); NDSLUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG

5 PA; QL (1/84); NDS

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG

5 PA; QL (1/112); NDS

LYNPARZA ORAL TABLET 5 PA; QL (120/30); NDS

LYSODREN 5 NDSMATULANE 5 NDSmegestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml)

4 PA

megestrol oral tablet 20 mg 4 PAmegestrol oral tablet 40 mg 3 PAMEKINIST ORAL TABLET 0.5 MG

5 PA; QL (90/30); NDS

MEKINIST ORAL TABLET 2 MG

5 PA; QL (30/30); NDS

MEKTOVI 5 PA; QL (180/30); NDS

melphalan hcl 5 B/D PA; NDSmercaptopurine 4methotrexate sodium (pf) 4methotrexate sodium injection 4methotrexate sodium oral 2MVASI 5 PA; NDSmycophenolate mofetil (hcl) 4 PAmycophenolate mofetil oral capsule

3 PA

mycophenolate mofetil oral suspension for reconstitution

5 PA; NDS

mycophenolate mofetil oral tablet

4 PA

mycophenolate sodium 4 PAMYLOTARG 5 PA; NDSNERLYNX 5 PA; QL (180/30);

NDS

29



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TABLOID 4tacrolimus oral 3 PATAFINLAR 5 PA; QL (120/30);

NDSTAGRISSO 5 PA; QL (30/30);

NDSTALZENNA 5 PA; QL (90/30);

NDStamoxifen 2TARGRETIN TOPICAL 5 PA; QL (60/30);

NDSTASIGNA ORAL CAPSULE 150 MG, 200 MG

5 PA; QL (112/28); NDS

TASIGNA ORAL CAPSULE 50 MG

5 PA; QL (420/30); NDS

TAZVERIK 4 PATECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML)

5 PA; QL (20/21); NDS

TECENTRIQ INTRAVENOUS SOLUTION 840 MG/14 ML (60 MG/ML)

5 PA; QL (28/28); NDS

temsirolimus 5 B/D PA; QL (4/28); NDS

THALOMID ORAL CAPSULE 100 MG, 150 MG, 50 MG

5 PA; QL (28/28); NDS

THALOMID ORAL CAPSULE 200 MG

5 PA; QL (56/28); NDS

thiotepa 4 PATIBSOVO 5 PA; QL (60/30);

NDStoposar 3 B/D PAtopotecan intravenous recon soln

5 NDS

toremifene 5 QL (30/30); NDSTORISEL 5 B/D PA; QL (4/28);

NDSTRAZIMERA 5 PA; NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

RITUXAN HYCELA 5 PA; NDSROMIDEPSIN INTRAVENOUS RECON SOLN

5 PA; NDS

ROZLYTREK ORAL CAPSULE 100 MG

5 PA; QL (150/30); NDS

ROZLYTREK ORAL CAPSULE 200 MG

5 PA; QL (90/30); NDS

RUBRACA 5 PA; QL (120/30); NDS

RUXIENCE 5 B/D PA; NDSRYDAPT 5 PA; QL (224/28);

NDSSANDIMMUNE ORAL SOLUTION

4 PA

SARCLISA 4 PASIGNIFOR 5 PA; QL (60/30);

NDSSIMULECT 5 B/D PA; NDSsirolimus oral solution 5 PA; NDSsirolimus oral tablet 4 PASOLTAMOX 4SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML

5 PA; QL (0.5/28); NDS

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 60 MG/0.2 ML

5 PA; QL (0.2/28); NDS

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 90 MG/0.3 ML

5 PA; QL (0.3/28); NDS

SPRYCEL 5 PA; QL (30/30); NDS

STIVARGA 5 PA; QL (120/28); NDS

SUTENT 5 PA; QL (28/28); NDS

SYNRIBO 5 PA; QL (28/28); NDS

30


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VITRAKVI ORAL SOLUTION 5 PA; QL (300/30); NDS

VIZIMPRO 5 PA; QL (30/30); NDS

VOTRIENT 5 PA; QL (120/30); NDS

VYXEOS 5 B/D PA; NDSXALKORI 5 PA; QL (60/30);

NDSXATMEP 4 PAXOSPATA 5 PA; QL (90/30);

NDSXPOVIO ORAL TABLET 100 MG/WEEK (20 MG X 5)

5 PA; QL (20/28); NDS

XPOVIO ORAL TABLET 160 MG/WEEK (20 MG X 8)

5 PA; QL (32/28); NDS


5 PA; QL (12/28); NDS


5 PA; QL (16/28); NDS

XTANDI 4 PA; QL (120/30)YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML)

5 PA; QL (80/21); NDS

YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML)

5 PA; NDS

YONDELIS 5 PA; NDSZEJULA 5 PA; QL (90/30);

NDSZELBORAF 5 PA; QL (240/30);

NDSZIRABEV 5 PA; NDSZOLINZA 5 QL (120/30); NDSZORTRESS ORAL TABLET 0.25 MG

4 PA; QL (60/30)

ZORTRESS ORAL TABLET 0.5 MG

5 PA; QL (120/30); NDS

ZORTRESS ORAL TABLET 0.75 MG, 1 MG

5 PA; QL (60/30); NDS

ZYDELIG 5 PA; QL (60/30); NDS

ZYKADIA ORAL TABLET 5 PA; QL (140/28); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TREANDA INTRAVENOUS RECON SOLN 100 MG

5 B/D PA; NDS

TREANDA INTRAVENOUS RECON SOLN 25 MG

5 B/D PA; QL (8/21); NDS

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 11.25 MG

5 PA; QL (1/84); NDS


5 PA; QL (1/168); NDS


5 PA; QL (1/28); NDS

tretinoin (antineoplastic) 5 NDSTRIPTODUR 5 PA; QL (1/168);

NDSTRISENOX INTRAVENOUS SOLUTION 2 MG/ML

4 B/D PA

TRUXIMA 5 B/D PA; NDSTYKERB 5 PA; QL (180/30);

NDSUNITUXIN 5 PA; NDSVECTIBIX 5 PA; NDSVELCADE 5 PA; QL (14/21);

NDSVENCLEXTA ORAL TABLET 10 MG

3 PA; QL (60/30)

VENCLEXTA ORAL TABLET 100 MG

5 PA; QL (120/30); NDS

VENCLEXTA ORAL TABLET 50 MG

3 PA; QL (30/30); NDS

VENCLEXTA STARTING PACK 5 PA; QL (84/365); NDS

VERZENIO 5 PA; QL (60/30); NDS

vincasar pfs intravenous solution 1 mg/ml

4 B/D PA

vincristine 4 B/D PAvinorelbine 4 B/D PAVITRAKVI ORAL CAPSULE 100 MG

5 PA; QL (60/30); NDS

VITRAKVI ORAL CAPSULE 25 MG

5 PA; QL (180/30); NDS

31



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clonazepam oral tablet, disintegrating 1 mg

4 QL (120/30)

clonazepam oral tablet, disintegrating 2 mg

4 QL (300/30)

DIASTAT 4 QL (5/30)DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20 MG

4 QL (40/30)

DIASTAT ACUDIAL RECTAL KIT 5-7.5-10 MG

4 QL (20/30)

DIAZEPAM RECTAL KIT 12.5-15-17.5-20 MG

4 QL (40/30)

DIAZEPAM RECTAL KIT 2.5 MG

4 QL (5/30)

DIAZEPAM RECTAL KIT 5-7.5-10 MG

4 QL (20/30)

DILANTIN 30 MG 4divalproex oral capsule, delayed rel sprinkle

4

divalproex oral tablet extended release 24 hr

2

divalproex oral tablet,delayed release (dr/ec)

2

EPIDIOLEX 5 PA; NDSepitol 2ethosuximide 4felbamate 4FYCOMPA ORAL SUSPENSION

4 PA; QL (720/30)

FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG

4 PA; QL (30/30)

FYCOMPA ORAL TABLET 2 MG, 4 MG, 6 MG

4 PA; QL (60/30)

gabapentin oral capsule 100 mg, 400 mg

2 QL (270/30)

gabapentin oral capsule 300 mg

2 QL (360/30)

gabapentin oral solution 2 QL (2160/30)gabapentin oral tablet 600 mg 2 QL (180/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ZYTIGA ORAL TABLET 250 MG

4 PA; QL (120/30)

ZYTIGA ORAL TABLET 500 MG

4 PA; QL (60/30)

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTSAPTIOM ORAL TABLET 200 MG

4 ST; QL (180/30)

APTIOM ORAL TABLET 400 MG

4 ST; QL (90/30)

APTIOM ORAL TABLET 600 MG, 800 MG

4 ST; QL (60/30)

BANZEL ORAL SUSPENSION 5 PA; QL (2400/30); NDS

BANZEL ORAL TABLET 5 PA; NDSBRIVIACT ORAL SOLUTION 4 QL (600/30)BRIVIACT ORAL TABLET 4 QL (60/30)carbamazepine oral capsule, er multiphase 12 hr

4

carbamazepine oral suspension 100 mg/5 ml

2

carbamazepine oral tablet 2carbamazepine oral tablet extended release 12 hr

4

carbamazepine oral tablet,chewable

2

CELONTIN ORAL CAPSULE 300 MG

3

clobazam oral suspension 4 QL (480/30)clobazam oral tablet 4 QL (60/30)clonazepam oral tablet 0.5 mg, 1 mg

2 QL (120/30)

clonazepam oral tablet 2 mg 2 QL (300/30)clonazepam oral tablet, disintegrating 0.125 mg, 0.25 mg, 0.5 mg

4 QL (90/30)

32


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

primidone 2roweepra 2roweepra xr 4SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG

4 QL (60/30)

SPRITAM ORAL TABLET FOR SUSPENSION 750 MG

4 QL (120/30)

SYMPAZAN 5 PA; QL (60/30); NDS

tiagabine 4 STtopiramate oral capsule, sprinkle

2

topiramate oral tablet 2valproic acid 2valproic acid (as sodium salt) oral solution

2

VALTOCO 4 PA; QL (10/30)vigabatrin 5 PA; QL (180/30);

NDSvigadrone 5 PA; QL (180/30);

NDSVIMPAT INTRAVENOUS 4 QL (1200/30)VIMPAT ORAL SOLUTION 4 QL (1200/30)VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG

4 QL (60/30)

VIMPAT ORAL TABLET 50 MG 4 QL (120/30)XCOPRI 4 PAXCOPRI MAINTENANCE PACK

4 PA

XCOPRI TITRATION PACK 4 PAzonisamide 3ANTIPARKINSONISM AGENTSAPOKYN 5 PA; QL (60/30);

NDSbenztropine injection 4benztropine oral 2 PAbromocriptine 4carbidopa 5 NDScarbidopa-levodopa oral tablet 2carbidopa-levodopa oral tablet extended release

3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

gabapentin oral tablet 800 mg 2lamotrigine oral tablet 2lamotrigine oral tablet extended release 24hr

4

lamotrigine oral tablet, chewable dispersible

2

lamotrigine oral tablet,disintegrating

4

levetiracetam in nacl (iso-os) 4levetiracetam intravenous 4levetiracetam oral solution 2levetiracetam oral tablet 2levetiracetam oral tablet extended release 24 hr

4

LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG, 82.5 MG

3 QL (90/30)

LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 330 MG

3 QL (60/30)

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG

4 QL (90/30)

LYRICA ORAL CAPSULE 225 MG, 300 MG

4 QL (60/30)

LYRICA ORAL CAPSULE 75 MG

4 QL (120/30)

LYRICA ORAL SOLUTION 4 QL (900/30)NAYZILAM 4 PA; QL (10/30)oxcarbazepine 3PEGANONE 4phenobarbital oral elixir 4 QL (1500/30)phenobarbital oral tablet 3 QL (120/30)phenytoin oral suspension 2phenytoin oral tablet,chewable 2phenytoin sodium extended 2pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg

3 QL (90/30)

pregabalin oral capsule 225 mg, 300 mg

3 QL (60/30)

pregabalin oral capsule 75 mg 3 QL (120/30)pregabalin oral solution 3 QL (900/30)

33



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML

5 PA; QL (30/30); NDS

COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML

5 PA; QL (12/28); NDS

dalfampridine 3 PA; QL (60/30)donepezil oral tablet 10 mg 2 QL (60/30)donepezil oral tablet 5 mg 2 QL (30/30)donepezil oral tablet,disintegrating 10 mg

2 QL (60/30)

donepezil oral tablet,disintegrating 5 mg

2 QL (30/30)

galantamine oral capsule,ext rel. pellets 24 hr

4 QL (30/30)

galantamine oral solution 4 QL (200/30)galantamine oral tablet 4 QL (60/30)GILENYA ORAL CAPSULE 0.5 MG

5 PA; QL (30/30); NDS

memantine oral capsule,sprinkle,er 24hr

4 PA; QL (30/30)

memantine oral solution 4 PA; QL (300/30)memantine oral tablet 10 mg 3 PA; QL (60/30)memantine oral tablet 5 mg 3 PA; QL (90/30)memantine oral tablets,dose pack

3 PA; QL (98/365)

NAMZARIC ORAL CAP, SPRINKLE,ER 24HR DOSE PACK

4 PA; QL (56/365)

NAMZARIC ORAL CAPSULE, SPRINKLE,ER 24HR

4 PA

NUEDEXTA 4 PA; QL (60/30)OCREVUS 4 PArivastigmine 4 QL (30/30)rivastigmine tartrate 4 QL (60/30)TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG

5 PA; QL (14/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

carbidopa-levodopa oral tablet,disintegrating

2

carbidopa-levodopa-entacapone

4

entacapone 4 QL (240/30)NEUPRO 4pramipexole oral tablet 2rasagiline 4ropinirole oral tablet 2ropinirole oral tablet extended release 24 hr

4

RYTARY 4 STselegiline hcl 3MIGRAINE / CLUSTER HEADACHE THERAPYAIMOVIG AUTOINJECTOR 3 PA; QL (1/30)dihydroergotamine nasal 4 PA; QL (8/30)ergotamine-caffeine 3 QL (40/28)naratriptan 4 QL (18/28)rizatriptan oral tablet 2 QL (36/28)rizatriptan oral tablet,disintegrating

4 QL (36/28)

sumatriptan 4 QL (18/28)sumatriptan succinate oral 2 QL (18/28)sumatriptan succinate subcutaneous cartridge

4 QL (8/28)

sumatriptan succinate subcutaneous pen injector

4 QL (8/28)

sumatriptan succinate subcutaneous solution

4 QL (8/28)

sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml

4 QL (8/28)

MISCELLANEOUS NEUROLOGICAL THERAPYAUSTEDO ORAL TABLET 12 MG, 9 MG

5 PA; QL (120/30); NDS

AUSTEDO ORAL TABLET 6 MG

5 PA; QL (60/30); NDS

34


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

butalbital-acetaminophen-caff oral tablet 50-325-40 mg

4 PA; QL (180/30)

DURAMORPH (PF) 4 B/D PA; QL (180/30); NDS

endocet oral tablet 10-325 mg 4 QL (180/30); NDSendocet oral tablet 2.5-325 mg, 5-325 mg

4 QL (360/30); NDS

endocet oral tablet 7.5-325 mg 4 QL (240/30); NDSfentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 800 mcg

5 PA; QL (120/30); NDS

fentanyl citrate buccal lozenge on a handle 200 mcg, 400 mcg, 600 mcg

4 PA; QL (120/30); NDS

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

4 QL (10/30); NDS

hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml)

4 NDS

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml

4 QL (2700/30); NDS

hydrocodone-acetaminophen oral tablet 10-325 mg, 7.5-325 mg

3 QL (180/30); NDS

hydrocodone-acetaminophen oral tablet 5-325 mg

3 QL (360/30); NDS

hydrocodone-ibuprofen oral tablet 7.5-200 mg

4 QL (150/30); NDS

hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml, 2 mg/ml

4 NDS

hydromorphone injection solution 2 mg/ml

4 NDS

hydromorphone injection syringe 1 mg/ml, 2 mg/ml, 4 mg/ml

4 NDS

hydromorphone oral liquid 3 QL (1200/30); NDShydromorphone oral tablet 2 mg, 4 mg

4 QL (180/30); NDS

hydromorphone oral tablet 8 mg

4 QL (120/30); NDS

INFUMORPH P/F 4 B/D PA; QL (200/30); NDS

lorcet (hydrocodone) 4 QL (360/30); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46)

5 PA; QL (120/365); NDS

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 240 MG

5 PA; QL (60/30); NDS

tetrabenazine oral tablet 12.5 mg

5 PA; QL (90/30); NDS

tetrabenazine oral tablet 25 mg 5 PA; QL (120/30); NDS

TYSABRI 5 PA; QL (15/28); NDS

MUSCLE RELAXANTS / ANTISPASMODIC THERAPYbaclofen oral 2cyclobenzaprine oral tablet 10 mg, 5 mg

3 PA

dantrolene oral 4methocarbamol oral 2 PApyridostigmine bromide oral syrup

4

pyridostigmine bromide oral tablet 60 mg

3

pyridostigmine bromide oral tablet extended release

3

regonol 4tizanidine oral tablet 2NARCOTIC ANALGESICSacetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml

2 QL (2700/30); NDS

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg

2 QL (360/30); NDS

acetaminophen-codeine oral tablet 300-60 mg

2 QL (180/30); NDS

buprenorphine hcl injection solution

4 QL (150/30)

buprenorphine hcl injection syringe

4 QL (150/30); NDS

buprenorphine hcl sublingual 4 PA; QL (90/30)butalbital-acetaminophen-caff oral capsule

4 PA; QL (180/30)

35



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

morphine intravenous solution 10 mg/ml

4 B/D PA; QL (240/30); NDS

MORPHINE INTRAVENOUS SOLUTION 4 MG/ML

4 B/D PA; QL (480/30); NDS

MORPHINE INTRAVENOUS SOLUTION 8 MG/ML

4 B/D PA; QL (250/30); NDS

MORPHINE INTRAVENOUS SYRINGE 10 MG/ML

4 B/D PA; QL (240/30); NDS

morphine intravenous syringe 2 mg/ml

4 B/D PA; QL (1200/30); NDS

morphine intravenous syringe 4 mg/ml

4 B/D PA; QL (480/30); NDS

MORPHINE INTRAVENOUS SYRINGE 8 MG/ML

4 B/D PA; QL (250/30); NDS

morphine oral solution 10 mg/5 ml

2 QL (700/30); NDS

morphine oral solution 20 mg/5 ml (4 mg/ml)

2 QL (900/30); NDS

MORPHINE ORAL TABLET 3 QL (120/30); NDSmorphine oral tablet extended release

3 QL (90/30); NDS

oxycodone oral concentrate 4 QL (120/30); NDSoxycodone oral solution 4 QL (1200/30); NDSoxycodone oral tablet 3 QL (180/30); NDSoxycodone-acetaminophen oral tablet 10-325 mg

4 QL (180/30); NDS

oxycodone-acetaminophen oral tablet 2.5-300 mg

4 NDS

oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg

4 QL (360/30); NDS

oxycodone-acetaminophen oral tablet 7.5-325 mg

4 QL (240/30); NDS

oxycodone-aspirin 4 QL (180/30); NDSoxymorphone oral tablet extended release 12 hr

3 QL (90/30); NDS

XTAMPZA ER 3 QL (60/30); NDSzebutal oral capsule 50-325-40 mg

4 PA; QL (180/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lorcet hd 4 QL (180/30); NDSlorcet plus oral tablet 7.5-325 mg

4 QL (180/30); NDS

methadone injection solution 4 QL (150/30); NDSmethadone intensol 2 QL (500/30); NDSmethadone oral concentrate 2 QL (500/30); NDSmethadone oral solution 10 mg/5 ml

2 QL (450/30); NDS

methadone oral solution 5 mg/5 ml

2 QL (600/30); NDS

methadone oral tablet 10 mg 2 QL (120/30); NDSmethadone oral tablet 5 mg 2 QL (180/30); NDSMITIGO (PF) 4 QL (200/30); NDSmorphine (pf) injection solution 0.5 mg/ml, 1 mg/ml

4 B/D PA; QL (180/30); NDS

morphine concentrate oral solution

2 QL (240/30); NDS

MORPHINE INJECTION SOLUTION 10 MG/ML

4 B/D PA; QL (240/30); NDS


4 B/D PA; NDS


4 B/D PA; QL (480/30); NDS


4 B/D PA; QL (700/30); NDS

morphine injection solution 8 mg/ml

4 B/D PA; QL (250/30); NDS

morphine injection syringe 10 mg/ml

4 B/D PA; QL (240/30); NDS


4 B/D PA; QL (1200/30); NDS


4 B/D PA; QL (480/30); NDS


4 B/D PA; NDS


4 B/D PA; QL (250/30); NDS

36


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

naproxen sodium oral tablet 275 mg, 550 mg

4

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION

3 QL (4/30)

oxaprozin 4SUBOXONE SUBLINGUAL FILM 12-3 MG

3 QL (60/30)

SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG, 8-2 MG

3 QL (90/30)

sulindac 2tramadol oral tablet 50 mg 2 QL (240/30); NDStramadol-acetaminophen 4 QL (240/30); NDSVIVITROL 4 PAZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 11.4-2.9 MG

3 QL (30/30)

ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG

3 QL (90/30)

PSYCHOTHERAPEUTIC DRUGSABILIFY MAINTENA 4 QL (1/28)alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg

2 QL (120/30)

alprazolam oral tablet 2 mg 2 QL (150/30)alprazolam oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg

3 QL (90/30)

alprazolam oral tablet,disintegrating 2 mg

3 QL (150/30)

amitriptyline 2 PAamoxapine 4aripiprazole oral solution 4 QL (900/30)aripiprazole oral tablet 3 QL (30/30)aripiprazole oral tablet,disintegrating

5 QL (60/30); NDS

ARISTADA INITIO 4 QL (4.8/365)ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML

4 QL (3.9/56)

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML

4 QL (1.6/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NON-NARCOTIC ANALGESICSbuprenorphine-naloxone sublingual film 12-3 mg

4 QL (60/30)

buprenorphine-naloxone sublingual film 2-0.5 mg, 4-1 mg, 8-2 mg

4 QL (90/30)

buprenorphine-naloxone sublingual tablet

2 QL (90/30)

butorphanol tartrate injection solution 1 mg/ml

4 QL (480/30); NDS

butorphanol tartrate injection solution 2 mg/ml

4 QL (240/30); NDS

butorphanol tartrate nasal 4 QL (5/30); NDScelecoxib 3 QL (60/30)diclofenac potassium 2diclofenac sodium oral 2diclofenac sodium topical drops 4 QL (450/28)diclofenac sodium topical gel 1%

3 QL (1000/30)

diflunisal 2ec-naproxen 2etodolac 4flurbiprofen oral tablet 100 mg 2ibu 1ibuprofen oral suspension 2ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

meloxicam oral tablet 1nabumetone 2nalbuphine injection solution 10 mg/ml

4 QL (180/30); NDS

nalbuphine injection solution 20 mg/ml

4 QL (90/30); NDS

naloxone injection solution 2naloxone injection syringe 1 mg/ml

2

naltrexone 2naproxen oral suspension 4naproxen oral tablet 1naproxen oral tablet,delayed release (dr/ec)

2

37



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clorazepate dipotassium oral tablet 7.5 mg

4 QL (360/30)

clozapine oral tablet 100 mg, 200 mg

4

clozapine oral tablet 25 mg, 50 mg

3

clozapine oral tablet, disintegrating 100 mg

4 QL (270/30)

clozapine oral tablet, disintegrating 12.5 mg, 25 mg

4


4 QL (180/30)


4 QL (120/30)

desipramine 4desvenlafaxine succinate oral tablet extended release 24 hr 100 mg

4 QL (120/30)

desvenlafaxine succinate oral tablet extended release 24 hr 25 mg, 50 mg

4 QL (30/30)

dexmethylphenidate oral tablet 10 mg, 2.5 mg

3 QL (60/30)

dexmethylphenidate oral tablet 5 mg

3 QL (120/30)

dextroamphetamine oral capsule, extended release 10 mg

4 QL (180/30)


4 QL (120/30)


4 QL (60/30)

dextroamphetamine oral tablet 4 QL (180/30)dextroamphetamine-amphetamine oral capsule,extended release 24hr

4 QL (60/30)

dextroamphetamine-amphetamine oral tablet 10 mg

2 QL (180/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS


4 QL (2.4/28)


4 QL (3.2/28)

armodafinil 4 PA; QL (30/30)atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg

4 QL (60/30)

atomoxetine oral capsule 100 mg, 60 mg, 80 mg

4 QL (30/30)

BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG

3 QL (30/30)

BELSOMRA ORAL TABLET 5 MG

3 QL (60/30)

bupropion hcl oral tablet 100 mg

2 QL (120/30)

bupropion hcl oral tablet 75 mg 2 QL (180/30)bupropion hcl oral tablet extended release 24 hr 150 mg

2 QL (90/30)

bupropion hcl oral tablet extended release 24 hr 300 mg

2 QL (30/30)

bupropion hcl oral tablet sustained-release 12 hr 100 mg, 200 mg

2 QL (60/30)

bupropion hcl oral tablet sustained-release 12 hr 150 mg

2 QL (90/30)

buspirone 2CAPLYTA 4 ST; QL (30/30)chlorpromazine 4citalopram oral solution 4 QL (600/30)citalopram oral tablet 10 mg 1 QL (120/30)citalopram oral tablet 20 mg 1 QL (60/30)citalopram oral tablet 40 mg 1 QL (90/30)clomipramine 4 PAclorazepate dipotassium oral tablet 15 mg, 3.75 mg

4 QL (180/30)

38


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluphenazine decanoate 4fluphenazine hcl injection 4fluphenazine hcl oral concentrate

4

fluphenazine hcl oral elixir 4fluphenazine hcl oral tablet 2fluvoxamine oral tablet 3GEODON INTRAMUSCULAR 4 QL (6/30)haloperidol 2haloperidol decanoate 4haloperidol lactate injection 4haloperidol lactate oral 2HETLIOZ 5 PA; QL (30/30);

NDSimipramine hcl 3 PAINVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML

4 QL (0.75/28)

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML

4 QL (1/28)

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML

4 QL (1.5/28)


4 QL (0.25/28)


4 QL (0.5/28)

INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML

4 QL (0.88/90)


4 QL (1.32/90)


4 QL (1.75/90)


4 QL (2.63/90)

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG

4 QL (30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dextroamphetamine-amphetamine oral tablet 12.5 mg, 30 mg, 7.5 mg

2 QL (60/30)


2 QL (120/30)


2 QL (90/30)


2 QL (360/30)

diazepam injection syringe 2diazepam oral solution 5 mg/5 ml (1 mg/ml)

2 QL (1200/30)

diazepam oral tablet 2 QL (120/30)doxepin oral capsule 3 PAdoxepin oral concentrate 3 PAdoxepin oral tablet 3 QL (30/30)DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG

4 QL (180/30)

DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 30 MG, 40 MG

4 QL (90/30)

DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 60 MG

4 QL (60/30)

duloxetine oral capsule,delayed release(dr/ec) 20 mg

2 QL (180/30)


2 QL (90/30)


2 QL (60/30)

EMSAM 4 QL (30/30)escitalopram oxalate oral solution

4 QL (600/30)

escitalopram oxalate oral tablet 2FANAPT ORAL TABLET 4 ST; QL (60/30)FANAPT ORAL TABLETS,DOSE PACK

4 ST; QL (16/365)

FETZIMA ORAL CAPSULE, EXT REL 24HR DOSE PACK

4 ST; QL (56/365)

FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR

4 ST; QL (30/30)

fluoxetine oral capsule 2fluoxetine oral solution 2 QL (600/30)

39



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

olanzapine oral tablet 7.5 mg 3 QL (30/30)olanzapine oral tablet,disintegrating

4 QL (30/30)

olanzapine-fluoxetine 4 QL (30/30)oxazepam 2 QL (120/30)paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg

4 ST; QL (30/30)

paliperidone oral tablet extended release 24hr 6 mg

4 ST; QL (60/30)

paroxetine hcl oral tablet 10 mg, 30 mg, 40 mg

2 QL (60/30)

paroxetine hcl oral tablet 20 mg 2 QL (90/30)PAXIL ORAL SUSPENSION 4 ST; QL (900/30)perphenazine 4perphenazine-amitriptyline 4 PAPERSERIS 4 QL (1/30)phenelzine 3pimozide 4protriptyline 4quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

2 QL (90/30)

quetiapine oral tablet 300 mg, 400 mg

2 QL (60/30)

quetiapine oral tablet extended release 24 hr 150 mg, 200 mg

4 QL (30/30)

quetiapine oral tablet extended release 24 hr 300 mg, 400 mg, 50 mg

4 QL (60/30)

ramelteon 3REXULTI 4 QL (30/30)RISPERDAL CONSTA 4 QL (2/28)risperidone oral solution 4 QL (240/30)risperidone oral tablet 2risperidone oral tablet, disintegrating 0.25 mg, 1 mg, 2 mg, 3 mg

4 QL (60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LATUDA ORAL TABLET 80 MG 4 QL (60/30)lithium carbonate 2lorazepam injection 4lorazepam intensol 3 QL (150/30)lorazepam oral concentrate 3 QL (150/30)lorazepam oral tablet 0.5 mg, 1 mg

2 QL (120/30)

lorazepam oral tablet 2 mg 2 QL (150/30)loxapine succinate 4maprotiline 4MARPLAN 4 QL (180/30)methylphenidate hcl oral tablet 4 QL (90/30)methylphenidate hcl oral tablet extended release

4 QL (90/30)

methylphenidate hcl oral tablet extended release 24hr 18 mg, 18 mg (bx rating)

4 QL (120/30)

methylphenidate hcl oral tablet extended release 24hr 27 mg, 27 mg (bx rating), 54 mg, 54 mg (bx rating)

4 QL (30/30)

methylphenidate hcl oral tablet extended release 24hr 36 mg, 36 mg (bx rating)

4 QL (60/30)

mirtazapine oral tablet 2mirtazapine oral tablet,disintegrating

3 QL (30/30)

molindone 2nefazodone 4nortriptyline 2NUPLAZID ORAL CAPSULE 4 PA; QL (30/30)NUPLAZID ORAL TABLET 10 MG

4 PA; QL (30/30)

olanzapine intramuscular 4 QL (30/30)olanzapine oral tablet 10 mg, 2.5 mg, 5 mg

3 QL (120/30)

olanzapine oral tablet 15 mg, 20 mg

3 QL (60/30)

40


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ziprasidone hcl 4 QL (60/30)ziprasidone mesylate 4 QL (6/30)zolpidem oral tablet 2 QL (30/30)ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG

4 QL (2/28)

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG

4 QL (1/28)

CARDIOVASCULAR, HYPERTENSION / LIPIDS

ANTIARRHYTHMIC AGENTSamiodarone intravenous solution

4 B/D PA

amiodarone oral tablet 100 mg, 200 mg

2

amiodarone oral tablet 400 mg 4dofetilide 4flecainide 4lidocaine (pf) intravenous syringe

4

mexiletine 4MULTAQ 3 QL (60/30)pacerone oral tablet 100 mg, 200 mg, 400 mg

4

propafenone 4quinidine sulfate oral tablet 2sorine 2sotalol af 2sotalol oral 2SOTYLIZE 4ANTIHYPERTENSIVE THERAPYacebutolol 2aliskiren 4 QL (30/30)amiloride 2amiloride-hydrochlorothiazide 2amlodipine 1amlodipine-benazepril 2amlodipine-valsartan 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

risperidone oral tablet, disintegrating 0.5 mg, 4 mg

4 QL (120/30)

SAPHRIS 4 QL (60/30)SECUADO 4 QL (30/30)sertraline oral concentrate 2 QL (300/30)sertraline oral tablet 100 mg, 25 mg

2 QL (60/30)

sertraline oral tablet 50 mg 2 QL (120/30)SILENOR 3 QL (30/30)temazepam oral capsule 15 mg, 30 mg

2 QL (60/365)

temazepam oral capsule 22.5 mg, 7.5 mg

4 QL (60/365)

thioridazine 4thiothixene 4tranylcypromine 4trazodone oral tablet 100 mg, 150 mg, 50 mg

1

trazodone oral tablet 300 mg 2trifluoperazine oral tablet 1 mg 3trifluoperazine oral tablet 10 mg, 2 mg, 5 mg

4

trimipramine 4 PATRINTELLIX 4 ST; QL (30/30)venlafaxine oral capsule, extended release 24hr 150 mg, 37.5 mg

2 QL (60/30)

venlafaxine oral capsule, extended release 24hr 75 mg

2 QL (90/30)

venlafaxine oral tablet 2VERSACLOZ 4 QL (540/30)VIIBRYD ORAL TABLET 4 ST; QL (30/30)VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)

4 ST; QL (60/365)

VRAYLAR ORAL CAPSULE 4 ST; QL (30/30)VRAYLAR ORAL CAPSULE,DOSE PACK

4 ST; QL (14/365)

XYREM 5 PA; QL (540/30); NDS

zaleplon oral capsule 10 mg 3 QL (60/30)zaleplon oral capsule 5 mg 3 QL (30/30)

41



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

DEMSER 4 PAdiltiazem hcl intravenous 4diltiazem hcl oral capsule,extended release 12 hr

2

diltiazem hcl oral capsule, extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 420 mg

2

diltiazem hcl oral capsule, extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg

2

diltiazem hcl oral tablet 2diltiazem hcl oral tablet extended release 24 hr

2

dilt-xr 2doxazosin 2EDARBI 4 ST; QL (30/30)EDARBYCLOR 4 STenalapril maleate 1enalapril-hydrochlorothiazide 1ethacrynate sodium 4felodipine 2fosinopril 2 QL (60/30)fosinopril-hydrochlorothiazide 2 QL (120/30)furosemide injection 4furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

2

furosemide oral tablet 1hydralazine injection 4hydralazine oral 2hydrochlorothiazide 1indapamide 1irbesartan oral tablet 150 mg 1 QL (60/30)irbesartan oral tablet 300 mg, 75 mg

1 QL (30/30)

irbesartan-hydrochlorothiazide 1 QL (30/30)isradipine 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

amlodipine-valsartan-hcthiazid 2atenolol 1atenolol-chlorthalidone 2benazepril 1benazepril-hydrochlorothiazide 2betaxolol oral 3BIDIL 3 QL (180/30)bisoprolol fumarate 2bisoprolol-hydrochlorothiazide 1bumetanide injection 4bumetanide oral tablet 0.5 mg, 1 mg

2

bumetanide oral tablet 2 mg 3BYSTOLIC 4candesartan oral tablet 16 mg, 4 mg, 8 mg

2 QL (60/30)

candesartan oral tablet 32 mg 2 QL (30/30)candesartan-hydrochlorothiazid 2captopril 4captopril-hydrochlorothiazide 4cartia xt 2carvedilol 1carvedilol phosphate 4chlorothiazide oral tablet 500 mg

2

chlorothiazide sodium 4chlorthalidone oral tablet 25 mg, 50 mg

2

clonidine hcl oral tablet 0.1 mg, 0.2 mg

1

clonidine hcl oral tablet 0.3 mg 2clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr

3 QL (4/28)

clonidine transdermal patch weekly 0.3 mg/24 hr

3 QL (8/28)

42


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ramipril 1REMODULIN 5 B/D PA; NDSspironolactone 2spironolacton-hydrochlorothiaz 2taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg

2

TEKTURNA 4 QL (30/30)TEKTURNA HCT 4 QL (30/30)telmisartan oral tablet 20 mg, 40 mg

2 QL (30/30)

telmisartan oral tablet 80 mg 2 QL (60/30)telmisartan-amlodipine 2 QL (30/30)telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-25 mg

2 QL (30/30)

telmisartan-hydrochlorothiazid oral tablet 80-12.5 mg

2 QL (60/30)

terazosin 1tiadylt er 2timolol maleate oral 2torsemide oral 2trandolapril 2treprostinil sodium 5 B/D PA; NDStriamterene-hydrochlorothiazid oral capsule 37.5-25 mg

1

triamterene-hydrochlorothiazid oral tablet

1

UPTRAVI 5 PA; NDSvalsartan oral tablet 160 mg, 40 mg, 80 mg

2 QL (60/30)

valsartan oral tablet 320 mg 2 QL (30/30)valsartan-hydrochlorothiazide 2 QL (30/30)verapamil intravenous solution 4verapamil oral capsule, 24 hr er pellet ct

2

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg

2

VERAPAMIL ORAL CAPSULE,EXT REL. PELLETS 24 HR 360 MG

3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

labetalol oral 2lisinopril 1lisinopril-hydrochlorothiazide 1losartan 1 QL (60/30)losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg

1 QL (30/30)

losartan-hydrochlorothiazide oral tablet 50-12.5 mg

1 QL (60/30)

matzim la 2methyldopa 4metolazone 3metoprolol succinate 1metoprolol ta-hydrochlorothiaz 2metoprolol tartrate oral 1minoxidil oral 2moexipril 2nadolol 4nadolol-bendroflumethiazide oral tablet 80-5 mg

4

nicardipine intravenous solution 4nicardipine oral 4nifedipine oral tablet extended release

2 QL (60/30)

nifedipine oral tablet extended release 24hr

2 QL (60/30)

nimodipine 4nisoldipine 4olmesartan 2olmesartan-hydrochlorothiazide 3perindopril erbumine 2phenoxybenzamine 5 NDSpindolol 2prazosin 4propranolol oral capsule,extended release 24 hr

4

propranolol oral solution 4propranolol oral tablet 2propranolol-hydrochlorothiazid 3quinapril 1quinapril-hydrochlorothiazide 2

43



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

prasugrel 4 QL (30/30)PROMACTA ORAL POWDER IN PACKET 12.5 MG

5 PA; QL (360/30); NDS

PROMACTA ORAL POWDER IN PACKET 25 MG

5 PA; QL (180/30); NDS

PROMACTA ORAL TABLET 5 PA; QL (30/30); NDS

warfarin 1XARELTO 3LIPID/CHOLESTEROL LOWERING AGENTSatorvastatin oral tablet 10 mg, 20 mg, 80 mg

1 QL (30/30)

atorvastatin oral tablet 40 mg 1 QL (60/30)cholestyramine (with sugar) 4cholestyramine light 4colesevelam 3colestipol 4ezetimibe 3 QL (30/30)ezetimibe-simvastatin 4 QL (30/30)fenofibrate micronized oral capsule 130 mg, 43 mg

4

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

3

fenofibrate nanocrystallized oral tablet 145 mg, 48 mg

3

fenofibrate oral capsule 4fenofibrate oral tablet 160 mg, 54 mg

3

fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg

4 QL (30/30)

fenofibric acid (choline) oral capsule,delayed release(dr/ec) 45 mg

4 QL (60/30)

gemfibrozil 2LIVALO 4 QL (30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

verapamil oral tablet 1verapamil oral tablet extended release

2

COAGULATION THERAPYaminocaproic acid oral 4aspirin-dipyridamole 4 QL (60/30)BRILINTA 3 QL (60/30)cilostazol 2clopidogrel oral tablet 300 mg 2 QL (2/365)clopidogrel oral tablet 75 mg 2COUMADIN ORAL 4dipyridamole oral 3 PAELIQUIS 3ELIQUIS DVT-PE TREAT 30D START

3

enoxaparin 4fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

5 NDS

fondaparinux subcutaneous syringe 2.5 mg/0.5 ml

4

heparin (porcine) in 5% dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)

4

heparin (porcine) in nacl (pf) 4heparin (porcine) injection solution

3

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml

4

heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml

4

jantoven 1pentoxifylline 2PRADAXA 4 QL (60/30)

44


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nitroglycerin translingual spray,non-aerosol

4

DERMATOLOGICALS/TOPICAL THERAPY

ANTIPSORIATIC / ANTISEBORRHEICacitretin 4 PAcalcipotriene scalp 3calcipotriene topical cream 4 QL (120/30)calcipotriene topical ointment 4 QL (120/30)selenium sulfide topical lotion 2SKYRIZI SUBCUTANEOUS SYRINGE KIT

5 PA; QL (2/28); NDS

STELARA INTRAVENOUS 5 PA; NDSSTELARA SUBCUTANEOUS SOLUTION

5 PA; QL (0.5/28); NDS

STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML

5 PA; QL (0.5/28); NDS

STELARA SUBCUTANEOUS SYRINGE 90 MG/ML

5 PA; QL (1/28); NDS

MISCELLANEOUS DERMATOLOGICALSacyclovir topical cream 5 QL (5/30); NDSacyclovir topical ointment 4 QL (30/30)ammonium lactate 2DUPIXENT 4 PAfluorouracil topical cream 0.5% 5 NDSfluorouracil topical cream 5% 3fluorouracil topical solution 3glydo 3 QL (60/30)imiquimod topical cream in packet

3

lidocaine (pf) injection solution 4lidocaine hcl injection solution 4lidocaine hcl laryngotracheal 3lidocaine hcl mucous membrane jelly

3 QL (60/30)

lidocaine hcl mucous membrane jelly in applicator

3 QL (60/30)

lidocaine hcl mucous membrane solution 4% (40 mg/ml)

3

lidocaine topical adhesive patch,medicated 5%

4 PA; QL (90/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lovastatin 1 QL (60/30)niacin oral tablet extended release 24 hr

3

pravastatin oral tablet 10 mg, 20 mg, 80 mg

1 QL (30/30)

pravastatin oral tablet 40 mg 1 QL (60/30)prevalite 4REPATHA 3 PA; QL (3/28)REPATHA PUSHTRONEX 3 PA; QL (3.5/28)REPATHA SURECLICK 3 PA; QL (3/28)rosuvastatin 2 QL (30/30)simvastatin oral tablet 1 QL (30/30)VASCEPA ORAL CAPSULE 0.5 GRAM

4 QL (240/30)

VASCEPA ORAL CAPSULE 1 GRAM

4 QL (120/30)

MISCELLANEOUS CARDIOVASCULAR AGENTSCORLANOR ORAL TABLET 4 PA; QL (60/30)digitek oral tablet 125 mcg (0.125 mg)

2

digitek oral tablet 250 mcg (0.25 mg)

3

digox oral tablet 125 mcg (0.125 mg)

2

digox oral tablet 250 mcg (0.25 mg)

3

digoxin oral solution 50 mcg/ml (0.05 mg/ml)

3 QL (150/30)

digoxin oral tablet 125 mcg (0.125 mg)

2

digoxin oral tablet 250 mcg (0.25 mg)

3

ENTRESTO 3 QL (60/30)ranolazine 4 QL (60/30)NITRATESisosorbide dinitrate oral tablet 4isosorbide mononitrate 2minitran 3nitroglycerin intravenous 4 B/D PAnitroglycerin sublingual 2nitroglycerin transdermal patch 24 hour

2

45



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

isotretinoin 4metronidazole topical 3rosadan topical cream 3rosadan topical gel 3tazarotene 4TAZORAC TOPICAL CREAM 0.05%

4

TAZORAC TOPICAL GEL 4 QL (100/30)tretinoin microspheres topical gel 0.1%

4 PA

tretinoin microspheres topical gel with pump 0.1%

4 PA

tretinoin topical cream 0.025%, 0.05%, 0.1%

4 PA

tretinoin topical topical gel 0.01%

3 PA

tretinoin topical topical gel 0.025%, 0.05%

4 PA

TOPICAL ANTIBACTERIALSgentamicin topical cream 4gentamicin topical ointment 3mupirocin 2mupirocin calcium 4sulfacetamide sodium (acne) 4TOPICAL ANTIFUNGALSciclodan topical solution 4ciclopirox topical cream 4 QL (90/28)ciclopirox topical shampoo 4 QL (120/28)ciclopirox topical solution 4ciclopirox topical suspension 4clotrimazole topical cream 2clotrimazole topical solution 3 QL (30/28)clotrimazole-betamethasone topical cream

4 QL (45/28)

clotrimazole-betamethasone topical lotion

4 QL (60/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lidocaine topical ointment 4 QL (50/30)lidocaine viscous 2lidocaine-prilocaine topical cream

4 QL (30/30)

methoxsalen 4PANRETIN 5 NDSPICATO TOPICAL GEL 0.015% 4 QL (3/56)PICATO TOPICAL GEL 0.05% 4 QL (2/56)pimecrolimus 4 QL (100/90)podofilox 4REGRANEX 5 PA; NDSSANTYL 3silver sulfadiazine 4SSD 4tacrolimus topical 4 QL (100/90)VALCHLOR 5 PA; QL (60/30);

NDSZTLIDO 4 PA; QL (90/30)THERAPY FOR ACNEavita 4 PAclaravis 4clindamycin phosphate topical gel

4

CLINDAMYCIN PHOSPHATE TOPICAL GEL, ONCE DAILY

4

clindamycin phosphate topical lotion

4

clindamycin phosphate topical solution

4

clindamycin phosphate topical swab

2

ery pads 4erythromycin with ethanol topical gel

4

erythromycin with ethanol topical solution

2

erythromycin-benzoyl peroxide 4

46


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CLOBEX TOPICAL SPRAY,NON-AEROSOL

4 QL (125/28)

CLOCORTOLONE PIVALATE 4CLODAN 4 QL (236/28)DESONATE 4desonide topical lotion 4desonide topical ointment 4desowen topical cream 4DESOWEN TOPICAL LOTION 4desoximetasone topical cream 4desoximetasone topical gel 4desoximetasone topical ointment

4

fluocinolone 4fluocinolone and shower cap 4fluocinonide topical cream 0.05%

3

fluocinonide topical gel 4 QL (120/30)fluocinonide topical ointment 4 QL (120/30)fluocinonide topical solution 4 QL (120/30)fluticasone propionate topical cream

2

fluticasone propionate topical ointment

3

halobetasol propionate topical cream

4

halobetasol propionate topical ointment

4

hydrocortisone butyrate topical cream

4

hydrocortisone butyrate topical ointment

4

hydrocortisone butyr-emollient 4hydrocortisone topical cream 1%, 2.5%

2

hydrocortisone topical lotion 2.5%

2

hydrocortisone topical ointment 1%, 2.5%

2

hydrocortisone valerate 4IMPOYZ 4 QL (120/28)mometasone topical 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

econazole 4 QL (85/28)ketoconazole topical cream 2 QL (60/28)ketoconazole topical shampoo 2 QL (120/28)nyamyc 4nystatin topical cream 2 QL (30/28)nystatin topical ointment 2 QL (30/28)nystatin topical powder 3nystatin-triamcinolone 4 QL (60/28)nystop 4TOPICAL CORTICOSTEROIDSala-cort topical cream 1% 2alclometasone topical cream 3alclometasone topical ointment 2betamethasone dipropionate 4betamethasone valerate topical cream

2

betamethasone valerate topical lotion

4

betamethasone valerate topical ointment

2

betamethasone, augmented topical cream

2

betamethasone, augmented topical gel

4

betamethasone, augmented topical lotion

4

betamethasone, augmented topical ointment

4

clobetasol scalp 2 QL (100/28)clobetasol topical cream 2 QL (120/28)clobetasol topical foam 4 QL (100/28)clobetasol topical gel 2 QL (120/28)clobetasol topical lotion 4 QL (118/28)clobetasol topical ointment 2 QL (120/28)clobetasol topical shampoo 4 QL (236/28)clobetasol topical spray,non-aerosol

4 QL (125/28)

clobetasol-emollient topical cream

2 QL (120/28)

CLOBEX TOPICAL LOTION 4 QL (118/28)CLOBEX TOPICAL SHAMPOO 4 QL (236/28)

47



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

d5%-0.45% sodium chloride 4dextrose 10% and 0.2% nacl 4 B/D PADEXTROSE 10% IN WATER (D10W)

4 B/D PA

dextrose 20% in water (d20w) 4 B/D PAdextrose 25% in water (d25w) 4 B/D PAdextrose 30% in water (d30w) 4 B/D PAdextrose 40% in water (d40w) 4 B/D PADEXTROSE 5% IN WATER (D5W) INTRAVENOUS PARENTERAL SOLUTION

4

dextrose 5% in water (d5w) intravenous piggyback

4

dextrose 5%-lactated ringers 4 B/D PAdextrose 5%-0.2% sod chloride 4dextrose 5%-0.3% sod.chloride 4dextrose 50% in water (d50w) 4 B/D PAdextrose 70% in water (d70w) 4dextrose with sodium chloride 4disulfiram 4EXJADE 5 PA; NDSINCRELEX 4 PAkionex (with sorbitol) 3levocarnitine (with sugar) 2levocarnitine oral solution 100 mg/ml

2

levocarnitine oral tablet 2midodrine 3nitisinone 5 NDSNORTHERA ORAL CAPSULE 100 MG

5 PA; QL (90/30); NDS

NORTHERA ORAL CAPSULE 200 MG, 300 MG

5 PA; QL (180/30); NDS

ORFADIN 5 NDSpilocarpine hcl oral 4PROLASTIN-C 5 B/D PA; NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

OLUX 4 QL (100/28)prednicarbate topical ointment 2triamcinolone acetonide topical cream 0.025%, 0.5%

2

triamcinolone acetonide topical cream 0.1%

1

triamcinolone acetonide topical lotion

3

triamcinolone acetonide topical ointment

2

triderm topical cream 0.1% 2tridesilon 4TOPICAL SCABICIDES / PEDICULICIDESlindane topical shampoo 4malathion 4permethrin topical cream 3

DIAGNOSTICS / MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONSlactated ringers irrigation 4neomycin-polymyxin b gu 4PHYSIOLYTE 4PHYSIOSOL IRRIGATION 4ringer’s irrigation 4tis-u-sol pentalyte 4MISCELLANEOUS AGENTSacamprosate 4anagrelide 3AURYXIA 4 PA; QL (360/30)CARBAGLU 5 PA; NDSCHEMET 4CLINIMIX 4.25%/D5W SULFIT FREE

4 B/D PA

d10%-0.45% sodium chloride 4 B/D PAd2.5%-0.45% sodium chloride 4 B/D PAd5% and 0.9% sodium chloride 4

48


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ipratropium bromide nasal spray,non-aerosol 42 mcg (0.06%)

2 QL (45/30)

oralone 4paroex oral rinse 2triamcinolone acetonide dental 4MISCELLANEOUS OTIC PREPARATIONSacetic acid otic (ear) 2flac otic oil 4fluocinolone acetonide oil 4hydrocortisone-acetic acid 4OTIC STEROID / ANTIBIOTICCIPRO HC 4CIPRODEX 3neomycin-polymyxin-hc otic (ear)

4

ENDOCRINE/DIABETES

ADRENAL HORMONEScortisone 4DEPO-MEDROL 4dexamethasone intensol 4dexamethasone oral elixir 2dexamethasone oral solution 2dexamethasone oral tablet 0.5 mg, 0.75 mg, 4 mg

1

dexamethasone oral tablet 1 mg, 1.5 mg, 2 mg, 6 mg

2

dexamethasone sodium phos (pf) injection solution

4

dexamethasone sodium phosphate injection solution

4

fludrocortisone 2hydrocortisone oral 3MEDROL ORAL TABLET 2 MG 3methylprednisolone 2methylprednisolone acetate 4methylprednisolone sodium succ injection recon soln 125 mg, 40 mg

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

RENVELA ORAL POWDER IN PACKET

3 QL (180/30)

RENVELA ORAL TABLET 3 QL (540/30)riluzole 3sevelamer carbonate oral powder in packet

4 QL (180/30)

sevelamer carbonate oral tablet 4 QL (540/30)sodium chloride 0.9% intravenous

4

sodium chloride irrigation 4sodium phenylbutyrate 5 PA; NDSsodium polystyrene (sorb free) 3sodium polystyrene sulfonate oral powder

3

sps (with sorbitol) 3trientine 5 QL (240/30); NDSVELPHORO 4 QL (180/30)VELTASSA 3water for irrigation, sterile 4XIAFLEX 4 PAzoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml

4 B/D PA; QL (100/365)

SMOKING DETERRENTSbupropion hcl (smoking deter) 2 QL (60/30)CHANTIX 3CHANTIX CONTINUING MONTH BOX

3

CHANTIX STARTING MONTH BOX

3

NICOTROL 4NICOTROL NS 4 QL (30/30)

EAR, NOSE / THROAT MEDICATIONS

MISCELLANEOUS AGENTSazelastine nasal 3 QL (30/25)chlorhexidine gluconate mucous membrane

2

ipratropium bromide nasal spray,non-aerosol 0.03%

2 QL (30/30)

49



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML

4 QL (2.4/30)

BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML

4 QL (1.2/30)

CYCLOSET 4 QL (180/30)diazoxide 4FARXIGA ORAL TABLET 10 MG

4 QL (30/30)

FARXIGA ORAL TABLET 5 MG 4 QL (60/30)GAUZE PADS 2 X 2 6glimepiride oral tablet 1 mg 1 QL (240/30)glimepiride oral tablet 2 mg 1 QL (120/30)glimepiride oral tablet 4 mg 1 QL (60/30)glipizide oral tablet 10 mg 1 QL (120/30)glipizide oral tablet 5 mg 1 QL (240/30)glipizide oral tablet extended release 24hr 10 mg

2 QL (60/30)

glipizide oral tablet extended release 24hr 2.5 mg

2 QL (240/30)

glipizide oral tablet extended release 24hr 5 mg

2 QL (120/30)

glipizide-metformin oral tablet 2.5-250 mg

1 QL (240/30)

glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg

1 QL (120/30)

GLUCAGEN HYPOKIT 3GLUCAGON (HCL) EMERGENCY KIT

3

GLUCAGON EMERGENCY KIT (HUMAN)

3

GLYXAMBI 3 QL (30/30)GVOKE PFS 1-PACK SYRINGE

3

GVOKE PFS 2-PACK SYRINGE

3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

methylprednisolone sodium succ intravenous recon soln 1,000 mg

4 QL (8/30)

methylprednisolone sodium succ intravenous recon soln 500 mg

4 QL (12/30)

prednisolone oral solution 15 mg/5 ml

4

prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 15 mg/5 ml (5 ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

4

prednisone intensol 4prednisone oral solution 2prednisone oral tablet 2 B/D PAprednisone oral tablets,dose pack

1

SOLU-CORTEF ACT-O-VIAL (PF)

4

triamcinolone acetonide injection

4

ANTITHYROID AGENTSmethimazole oral tablet 10 mg, 5 mg

2

propylthiouracil 3DIABETES THERAPYacarbose oral tablet 100 mg, 25 mg

2 QL (90/30)

acarbose oral tablet 50 mg 2 QL (180/30)ALCOHOL PADS 6BAQSIMI 3BD PEN NEEDLE 6 QL(200/30)BYDUREON BCISE 4 QL (4/28)BYDUREON SUBCUTANEOUS PEN INJECTOR

4 QL (4/28)

50


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG

3 QL (60/30)

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG

3 QL (30/30)

LANTUS SOLOSTAR U-100 INSULIN

6

LANTUS U-100 INSULIN 6LEVEMIR FLEXTOUCH U-100 INSULN

6

LEVEMIR U-100 INSULIN 6metformin oral solution 4 QL (750/30)metformin oral tablet 1,000 mg 1 QL (75/30)metformin oral tablet 500 mg 1 QL (150/30)metformin oral tablet 850 mg 1 QL (90/30)metformin oral tablet extended release 24 hr 500 mg (generic for glucophage xr)

1 QL (120/30)

metformin oral tablet extended release 24 hr 750 mg (generic for glucophage xr)

1 QL (60/30)

metformin oral tablet extended release (osm) 24 hr 1000mg, 500mg (generic for fortamet)

4 QL (60/30)

metformin oral tablet,er gast.retention 24 hr 1,000 mg

4 ST; QL (60/30)

metformin oral tablet,er gast.retention 24 hr 500 mg

4 ST; QL (120/30)

nateglinide oral tablet 120 mg 2 QL (90/30)nateglinide oral tablet 60 mg 2 QL (180/30)NEEDLES, INSULIN DISP.,SAFETY

6 QL (200/30)

NOVOFINE PEN NEEDLE 6 QL(200/30)NOVOTWIST PEN NEEDLE 6 QL(200/30)OMNIPOD 5 PACK 3 QL(30/30)OMNIPOD DASH 5 PACK 3 QL(30/30)OMNIPOD STARTER KIT 3 QL(1/365)OZEMPIC 3 QL (3/28)pioglitazone oral tablet 15 mg 1 QL (90/30)pioglitazone oral tablet 30 mg, 45 mg

1 QL (30/30)

pioglitazone-metformin 2 QL (90/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HUMALOG JUNIOR KWIKPEN U-100

6

HUMALOG KWIKPEN INSULIN

6

HUMALOG MIX 50-50 INSULN U-100

6

HUMALOG MIX 50-50 KWIKPEN

6

HUMALOG MIX 75-25 KWIKPEN

6

HUMALOG MIX 75-25(U-100)INSULN

6

HUMALOG U-100 INSULIN 6HUMULIN 70/30 U-100 INSULIN

6

HUMULIN 70/30 U-100 KWIKPEN

6

HUMULIN N NPH INSULIN KWIKPEN

6

HUMULIN N NPH U-100 INSULIN

6

HUMULIN R REGULAR U-100 INSULN

6

HUMULIN R U-500 (CONC) INSULIN

4 B/D PA

HUMULIN R U-500 (CONC) KWIKPEN

4

INSULIN PEN NEEDLE 6 QL (200/30)INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML

6 QL (200/30)

INVOKAMET 3 QL (60/30)INVOKAMET XR 3 QL (60/30)INVOKANA 3 QL (30/30)JANUMET 3 QL (60/30)JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG

3 QL (30/30)

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG

3 QL (60/30)

JANUVIA 3 QL (30/30)JARDIANCE 3 QL (30/30)JENTADUETO 3 QL (60/30)

51



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG

4 QL (30/30)

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG, 5-500 MG

4 QL (60/30)

XULTOPHY 100/3.6 3 ST; QL (15/30)MISCELLANEOUS HORMONESALDURAZYME 5 PA; NDSANADROL-50 4 PAcabergoline 4calcitonin (salmon) 3calcitriol intravenous solution 1 mcg/ml

4

calcitriol oral 2CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

5 B/D PA; NDS

CHORIONIC GONADOTROPIN, HUMAN INTRAMUSCULAR

4 PA

cinacalcet oral tablet 30 mg, 60 mg

4 QL (60/30)

cinacalcet oral tablet 90 mg 4 QL (120/30)danazol 4desmopressin injection 4desmopressin nasal spray with pump

4

desmopressin nasal spray,non-aerosol

4

desmopressin oral 3doxercalciferol intravenous 4doxercalciferol oral capsule 0.5 mcg

4 QL (90/30)

doxercalciferol oral capsule 1 mcg

4 QL (240/30)

doxercalciferol oral capsule 2.5 mcg

4 QL (120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PROGLYCEM 4repaglinide oral tablet 0.5 mg, 1 mg

4 QL (120/30)

repaglinide oral tablet 2 mg 4 QL (240/30)RIOMET 4 QL (750/30)SOLIQUA 100/33 3 ST; QL (18/30)SYMLINPEN 120 4 PA; QL (10.8/28)SYMLINPEN 60 4 PA; QL (6/30)SYNJARDY 3 QL (60/30)SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG

3 QL (60/30)

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 25-1,000 MG

3 QL (30/30)

TECHLITE PEN NEEDLE 6 QL(200/30)TOUJEO MAX U-300 SOLOSTAR

6

TOUJEO SOLOSTAR U-300 INSULIN

6

TRADJENTA 3 QL (30/30)TRESIBA FLEXTOUCH U-100 6TRESIBA FLEXTOUCH U-200 6TRESIBA U-100 INSULIN 6TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-5-1,000 MG, 25-5-1,000 MG

3 QL (30/30)

TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 12.5-2.5-1,000 MG, 5-2.5-1,000 MG

3 QL (60/30)

TRULICITY 3 QL (2/28)V-GO 20 3V-GO 30 3V-GO 40 3VICTOZA 2-PAK 3 QL (9/30)VICTOZA 3-PAK 3 QL (9/30)

52


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

4

liothyronine oral 2SYNTHROID 4THYROLAR-1 3THYROLAR-1/2 3THYROLAR-1/4 3THYROLAR-2 3THYROLAR-3 3UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

4

unithroid oral tablet 137 mcg 4

GASTROENTEROLOGY

ANTIDIARRHEALS / ANTISPASMODICSdicyclomine oral capsule 2dicyclomine oral solution 4dicyclomine oral tablet 2diphenoxylate-atropine 4GLYCOPYRROLATE (PF) IN WATER INJECTION

4

glycopyrrolate (pf) in water intravenous syringe 0.4 mg/2 ml (0.2 mg/ml)

4

glycopyrrolate oral 4loperamide oral capsule 2propantheline 4MISCELLANEOUS GASTROINTESTINAL AGENTSalosetron oral tablet 0.5 mg 4 PA; QL (60/30)alosetron oral tablet 1 mg 5 PA; QL (60/30);

NDSAMITIZA 4 QL (60/30)aprepitant 4 B/D PAAPRISO 3 QL (120/30)balsalazide 4budesonide oral 4compro 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ELAPRASE 5 PA; NDSFABRAZYME 5 B/D PA; NDSKORLYM 5 PA; QL (120/30);

NDSKUVAN 5 PA; NDSLUMIZYME 5 PA; NDSmiglustat 5 QL (90/30); NDSNAGLAZYME 5 PA; NDSNATPARA 5 PA; QL (2/28); NDSoxandrolone oral tablet 10 mg 4 PA; QL (60/30)oxandrolone oral tablet 2.5 mg 3 PA; QL (120/30)pamidronate 4 B/D PAparicalcitol oral 4SAMSCA ORAL TABLET 15 MG

5 PA; QL (30/30); NDS

SAMSCA ORAL TABLET 30 MG

5 PA; QL (60/30); NDS

SENSIPAR ORAL TABLET 30 MG, 60 MG

4 QL (60/30)

SENSIPAR ORAL TABLET 90 MG

4 QL (120/30)

SOMAVERT 5 PA; QL (30/30); NDS

STIMATE 5 NDSSYNAREL 4 PAtestosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml, 200 mg/ml (1 ml)

3

testosterone enanthate 4testosterone transdermal gel 4 PA; QL (300/30)testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1%)

4 PA; QL (300/30)

testosterone transdermal gel in packet 1% (25 mg/2.5gram), 1% (50 mg/5 gram)

4 PA; QL (300/30)

zoledronic acid intravenous solution

4 B/D PA; QL (15/21)

THYROID HORMONESlevothyroxine oral 2

53



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ondansetron hcl oral solution 4 B/D PA; QL (450/30)

ondansetron hcl oral tablet 2 B/D PApeg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram

2

peg-electrolyte 2PENTASA 3PLENVU 4prochlorperazine 4prochlorperazine edisylate 4prochlorperazine maleate oral 2procto-med hc 2procto-pak 2proctosol hc topical 2proctozone-hc 2RECTIV 4 QL (30/30)RELISTOR SUBCUTANEOUS SOLUTION

5 PA; NDS

RELISTOR SUBCUTANEOUS SYRINGE

5 PA; NDS

RENFLEXIS 5 PA; NDSSANCUSO 5 QL (4/28); NDSscopolamine base 4 QL (10/30)sulfasalazine 2SUPREP BOWEL PREP KIT 4trilyte with flavor packets 2TRULANCE 4ursodiol oral capsule 4ursodiol oral tablet 3VIBERZI 4 PA; QL (60/30)VIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT

4

VIOKACE ORAL TABLET 20,880-78,300- 78,300 UNIT

4 NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

constulose 2CREON 3cromolyn oral 3CYSTADANE 5 NDSdronabinol 4 PA; QL (60/30)EMEND ORAL SUSPENSION FOR RECONSTITUTION

4 B/D PA

enulose 2GATTEX 30-VIAL 5 PA; NDSGATTEX ONE-VIAL 5 PA; NDSgavilyte-c 2gavilyte-g 2gavilyte-n 2generlac 2granisetron hcl oral 4 B/D PA; QL (30/30)hydrocortisone rectal 3hydrocortisone topical cream with perineal applicator

2

lactulose oral solution 2LINZESS 3 QL (30/30)meclizine oral tablet 12.5 mg, 25 mg

2

mesalamine oral capsule,extended release 24hr

3 QL (120/30)

mesalamine oral tablet,delayed release (dr/ec) 1.2 gram

4 QL (120/30)

mesalamine rectal enema 4mesalamine with cleansing wipe

4

metoclopramide hcl oral solution

2

metoclopramide hcl oral tablet 2OCALIVA 4 PA; QL (30/30)ondansetron 2 B/D PAondansetron hcl (pf) 4ondansetron hcl intravenous 4

54


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 40 MCG/0.4 ML

4 PA; QL (1.6/28)

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML

5 PA; QL (2/28); NDS


5 PA; QL (1.2/28); NDS


5 PA; QL (1.6/28); NDS


4 PA; QL (1.68/28)


5 PA; QL (2.4/28); NDS

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 500 MCG/ML

5 PA; QL (1/21); NDS


4 PA; QL (1.2/28)

ARCALYST 5 PA; NDSAVONEX INTRAMUSCULAR PEN INJECTOR KIT

5 PA; QL (1/28); NDS

AVONEX INTRAMUSCULAR SYRINGE KIT

5 PA; QL (1/28); NDS

BETASERON SUBCUTANEOUS KIT

5 PA; QL (14/28); NDS

GENOTROPIN 5 PA; NDSGENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML

4 PA

GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML

5 PA; NDS

INTRON A INJECTION RECON SOLN

5 NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT

3

ULCER THERAPYCARAFATE ORAL SUSPENSION

4

DEXILANT 4 QL (30/30)esomeprazole magnesium oral capsule,delayed release(dr/ec)

4 QL (60/30)

famotidine oral suspension 4famotidine oral tablet 20 mg, 40 mg

2

lansoprazole oral capsule,delayed release(dr/ec)

3 QL (60/30)

misoprostol 3omeprazole oral capsule,delayed release(dr/ec)

2 QL (60/30)

pantoprazole oral 2 QL (60/30)ranitidine hcl oral syrup 3ranitidine hcl oral tablet 150 mg, 300 mg

1

sucralfate oral suspension 4sucralfate oral tablet 2

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGSACTIMMUNE 5 PA; NDSARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 300 MCG/ML, 60 MCG/ML

5 PA; QL (4/28); NDS

ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML

4 PA; QL (4/28)

55



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

3 B/D PA; QL (8/365)

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

3 B/D PA; QL (3/365)

fomepizole 5 NDSGAMUNEX-C 5 B/D PA; NDSGARDASIL 9 (PF) 4 QL (1.5/365)HAVRIX (PF) 3HIBERIX (PF) 3HIZENTRA SUBCUTANEOUS SOLUTION

4 B/D PA

IMOVAX RABIES VACCINE (PF)

4 B/D PA

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

3

IPOL 3IXIARO (PF) 4KINRIX (PF) 3MENACTRA (PF) INTRAMUSCULAR SOLUTION

3

MENVEO A-C-Y-W-135-DIP (PF)

3

M-M-R II (PF) 3 QL (2/365)PEDIARIX (PF) 3PEDVAX HIB (PF) 3PROQUAD (PF) 3 QL (2/365)QUADRACEL (PF) 3RABAVERT (PF) 3 B/D PARECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML

3 B/D PA; QL (3/365)

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 5 MCG/0.5 ML

3 B/D PA

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE

3 B/D PA; QL (3/365)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML

5 NDS

INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML

4

MOZOBIL 5 QL (9.6/30); NDSNEULASTA 4 PAREBIF (WITH ALBUMIN) 5 PA; QL (6/28); NDSREBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML

5 PA; QL (6/28); NDS

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6)

5 PA; QL (8.4/365); NDS

REBIF TITRATION PACK 5 PA; QL (8.4/365); NDS

RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

4 PA; QL (12/28)

RETACRIT INJECTION SOLUTION 40,000 UNIT/ML

5 PA; QL (6/28); NDS

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG

5 PA; QL (4/28); NDS

ZARXIO 5 PA; NDSZIEXTENZO 4 PAVACCINES / MISCELLANEOUS IMMUNOLOGICALSACTHIB (PF) 3ADACEL(TDAP ADOLESN/ADULT)(PF)

3 QL (0.5/365)

BCG VACCINE, LIVE (PF) 3BEXSERO 3BOOSTRIX TDAP 3 QL (0.5/365)BOTOX 4 PADAPTACEL (DTAP PEDIATRIC) (PF)

3

56


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TYMLOS 5 PA; QL (1.56/30); NDS

OTHER RHEUMATOLOGICALSBENLYSTA INTRAVENOUS RECON SOLN 120 MG

5 PA; QL (30/28); NDS

BENLYSTA INTRAVENOUS RECON SOLN 400 MG

5 PA; QL (9/28); NDS

DEPEN TITRATABS 5 NDSENBREL MINI 5 PA; QL (8/28); NDSENBREL SUBCUTANEOUS RECON SOLN

5 PA; QL (8/28); NDS

ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5)

5 PA; QL (4.08/28); NDS

ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML)

5 PA; QL (8/28); NDS

ENBREL SURECLICK 5 PA; QL (8/28); NDSHUMIRA PEN 5 PA; QL (4/28); NDSHUMIRA PEN CROHNS-UC-HS START

5 PA; QL (12/365); NDS

HUMIRA PEN PSOR-UVEITS-ADOL HS

5 PA; QL (8/365); NDS

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML

5 PA; QL (2/28); NDS

HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML

5 PA; QL (4/28); NDS

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML

5 PA; QL (6/365); NDS

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML

5 PA; QL (4/365); NDS

HUMIRA(CF) PEN CROHNS-UC-HS

5 PA; QL (6/365); NDS

HUMIRA(CF) PEN PSOR-UV-ADOL HS

5 PA; QL (6/365); NDS

HUMIRA(CF) PEN SUBCUTANEOUS INJECTOR KIT 40 MG/0.4 ML

5 PA; QL (4/28); NDS

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML

5 PA; QL (2/28); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ROTARIX 3ROTATEQ VACCINE 3SHINGRIX (PF) 4 QL (2/999)STAMARIL (PF) 4 QL (1/999)TDVAX 3TENIVAC (PF) INTRAMUSCULAR SYRINGE

3 QL (0.5/28)

TETANUS,DIPHTHERIA TOX PED(PF)

3

TRUMENBA 3TWINRIX (PF) INTRAMUSCULAR SYRINGE

3

TYPHIM VI 3VAQTA (PF) 3VARIVAX (PF) 3 QL (1/365)VARIZIG INTRAMUSCULAR SOLUTION

4 QL (12/30)

YF-VAX (PF) 3ZOSTAVAX (PF) 4 QL (1/999)

MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPYallopurinol 1colchicine oral capsule 3 QL (60/30)colchicine oral tablet 4 QL (120/30)febuxostat 4 ST; QL (30/30)MITIGARE 3 QL (60/30)probenecid 3probenecid-colchicine 3OSTEOPOROSIS THERAPYalendronate oral tablet 10 mg, 5 mg

1 QL (30/30)

alendronate oral tablet 35 mg, 70 mg

1 QL (4/28)

BINOSTO 4FORTEO 5 PA; QL (2.4/28);

NDSibandronate oral 3 QL (1/28)PROLIA 4 QL (1/180)raloxifene 2 QL (30/30)

57



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nora-be 3norethindrone (contraceptive) 3norethindrone acetate 2PREMARIN INJECTION 4PREMARIN ORAL 4 PAPREMARIN VAGINAL 3PREMPRO ORAL TABLET 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG

3

progesterone micronized 2sharobel 3yuvafem 4 QL (18/28)MISCELLANEOUS OB/GYNclindamycin phosphate vaginal 4metronidazole vaginal 4terconazole 4tranexamic acid oral 3vandazole 4ORAL CONTRACEPTIVES / RELATED AGENTSafirmelle 2altavera (28) 2alyacen 1/35 (28) 2alyacen 7/7/7 (28) 2amethia 2amethia lo 2amethyst (28) 2apri 2aranelle (28) 2ashlyna 2aubra 2aubra eq 2aurovela 1.5/30 (21) 2aurovela 1/20 (21) 2aurovela 24 fe 2aurovela fe 1.5/30 (28) 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 40 MG/0.4 ML

5 PA; QL (4/28); NDS

leflunomide 3ORENCIA 5 PA; QL (4/28); NDSORENCIA CLICKJECT 5 PA; QL (4/28); NDSpenicillamine 5 NDSRINVOQ 5 PA; QL (30/30);

NDSXELJANZ 5 PA; QL (60/30);

NDSXELJANZ XR 5 PA; QL (30/30);

NDS

OBSTETRICS / GYNECOLOGY

ESTROGENS / PROGESTINSALORA 4 PA; QL (8/28)camila 3deblitane 3dotti 4 PA; QL (8/28)DUAVEE 4 PA; QL (30/30)errin 3estradiol oral 3 PAestradiol transdermal patch semiweekly

4 PA; QL (8/28)

estradiol transdermal patch weekly

4 PA; QL (4/28)

estradiol vaginal tablet 4 QL (18/28)estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml

4

fyavolv 4 PAheather 2hydroxyprogesterone caproate 5 PA; NDSincassia 3jencycla 2lyza 2medroxyprogesterone 2

58


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

hailey fe 1/20 (28) 3introvale 2isibloom 2jaimiess 2jasmiel (28) 2jolessa 2juleber 2junel 1.5/30 (21) 2junel 1/20 (21) 2junel fe 1.5/30 (28) 2junel fe 1/20 (28) 2junel fe 24 2kaitlib fe 2kalliga 2kariva (28) 2kelnor 1/35 (28) 2kelnor 1-50 2kurvelo (28) 2l norgest/e.estradiol-e.estrad 2larin 1.5/30 (21) 2larin 1/20 (21) 2larin 24 fe 2larin fe 1.5/30 (28) 2larin fe 1/20 (28) 2larissia 2layolis fe 2leena 28 2lessina 2levonest (28) 2levonorgestrel-ethinyl estrad 2levonorg-eth estrad triphasic 2levora-28 2lillow (28) 2lojaimiess 2loryna (28) 2low-ogestrel (28) 2lo-zumandimine (28) 2lutera (28) 2marlissa (28) 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

aurovela fe 1-20 (28) 2aviane 2ayuna 2azurette (28) 2balziva (28) 2bekyree (28) 2blisovi 24 fe 2blisovi fe 1.5/30 (28) 2blisovi fe 1/20 (28) 2briellyn 2camrese 2camrese lo 2caziant (28) 2chateal (28) 2chateal eq (28) 2cryselle (28) 2cyclafem 1/35 (28) 2cyclafem 7/7/7 (28) 2cyred 3cyred eq 3dasetta 1/35 (28) 2dasetta 7/7/7 (28) 2daysee 2desog-e.estradiol/e.estradiol 2desogestrel-ethinyl estradiol 2drospirenone-e.estradiol-lm.fa 2drospirenone-ethinyl estradiol 2elinest 2emoquette 2enpresse 2enskyce 2estarylla 2ethynodiol diac-eth estradiol 2falmina (28) 2fayosim 2femynor 2gianvi (28) 2hailey 2hailey 24 fe 3

59



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

simliya (28) 2simpesse 2sprintec (28) 2sronyx 2syeda 2tarina 24 fe 2tarina fe 1/20 (28) 2tarina fe 1-20 eq (28) 2tilia fe 2tri femynor 2tri-estarylla 2tri-legest fe 2tri-linyah 2tri-lo-estarylla 2tri-lo-marzia 2tri-lo-mili 2tri-lo-sprintec 2tri-mili 2tri-previfem (28) 2tri-sprintec (28) 2trivora (28) 2tri-vylibra 2tri-vylibra lo 2tydemy 2velivet triphasic regimen (28) 2vienva 2viorele (28) 2volnea (28) 2vyfemla (28) 2vylibra 2wera (28) 2wymzya fe 2zarah 2zovia 1/35e (28) 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

melodetta 24 fe 2mibelas 24 fe 2microgestin 1.5/30 (21) 2microgestin 1/20 (21) 2microgestin fe 1.5/30 (28) 2microgestin fe 1/20 (28) 2mili 2mono-linyah 2necon 0.5/35 (28) 2nikki (28) 2noreth-ethinyl estradiol-iron 2norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg

2

norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1.5 mg-30 mcg (21)/75 mg (7)

2

norethindrone-e.estradiol-iron oral tablet,chewable

2

norgestimate-ethinyl estradiol 2nortrel 0.5/35 (28) 2nortrel 1/35 (21) 2nortrel 1/35 (28) 2nortrel 7/7/7 (28) 2ocella 2ogestrel (28) 2orsythia 2philith 2pimtrea (28) 2pirmella 2portia 28 2previfem 2reclipsen (28) 2rivelsa 2setlakin 2

60


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MISCELLANEOUS OPHTHALMOLOGICSatropine ophthalmic (eye) drops 3azelastine ophthalmic (eye) 4BLEPHAMIDE 4BLEPHAMIDE S.O.P. 4cromolyn ophthalmic (eye) 2CYSTARAN 5 PA; QL (60/28);

NDSepinastine 4EYLEA 4 PAolopatadine ophthalmic (eye) 4PAZEO 3PHOSPHOLINE IODIDE 4pilocarpine hcl ophthalmic (eye) drops 1%, 2%, 4%

4

RESTASIS 3 QL (60/30)RESTASIS MULTIDOSE 3 QL (11/30)sulfacetamide sodium ophthalmic (eye) drops

2

sulfacetamide-prednisolone 2NON-STEROIDAL ANTI-INFLAMMATORY AGENTSbromfenac 4diclofenac sodium ophthalmic (eye)

2

flurbiprofen sodium 2ketorolac ophthalmic (eye) 2PROLENSA 3ORAL DRUGS FOR GLAUCOMAacetazolamide 3acetazolamide sodium 4methazolamide 4OTHER GLAUCOMA DRUGSAZOPT 3bimatoprost ophthalmic (eye) 2 QL (5/30)COMBIGAN 3dorzolamide 2dorzolamide-timolol 2latanoprost 2LUMIGAN OPHTHALMIC (EYE) DROPS 0.01%

3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

zumandimine (28) 2

OPHTHALMOLOGY

ANTIBIOTICSak-poly-bac 2AZASITE 4bacitracin ophthalmic (eye) 4bacitracin-polymyxin b ophthalmic (eye)

2

BESIVANCE 4CILOXAN OPHTHALMIC (EYE) OINTMENT

3

ciprofloxacin hcl ophthalmic (eye)

2

erythromycin ophthalmic (eye) 2gentak ophthalmic (eye) ointment

2

gentamicin ophthalmic (eye) drops

3

moxifloxacin ophthalmic (eye) drops

3

NATACYN 4neomycin-bacitracin-polymyxin 2neomycin-polymyxin-gramicidin 3neo-polycin 2ofloxacin ophthalmic (eye) 2polycin 2polymyxin b sulf-trimethoprim 2tobramycin 2ANTIVIRALStrifluridine 4ZIRGAN 3BETA-BLOCKERSbetaxolol ophthalmic (eye) 4carteolol 2levobunolol ophthalmic (eye) drops 0.5%

2

timolol maleate ophthalmic (eye) drops

1

timolol maleate ophthalmic (eye) gel forming solution

4

61



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

RESPIRATORY AND ALLERGY

ANTIHISTAMINE / ANTIALLERGENIC AGENTSdesloratadine oral tablet 3diphenhydramine hcl injection solution 50 mg/ml

4

epinephrine injection auto-injector

3 QL (2/30)

epinephrine injection solution 1 mg/ml

4

EPIPEN 3 QL (2/30)EPIPEN 2-PAK 3 QL (2/30)EPIPEN JR 3 QL (2/30)EPIPEN JR 2-PAK 3 QL (2/30)hydroxyzine hcl oral tablet 3 PAlevocetirizine oral solution 4 QL (300/30)levocetirizine oral tablet 2 QL (120/30)promethazine oral 2 PAPULMONARY AGENTSacetylcysteine 4 B/D PAADEMPAS 5 PA; QL (90/30);

NDSADVAIR DISKUS 3 QL (60/30)ADVAIR HFA 3 QL (12/30)albuterol sulfate inhalation solution for nebulization

2 B/D PA

albuterol sulfate oral syrup 2albuterol sulfate oral tablet 4albuterol sulfate oral tablet extended release 12 hr

4

AMBRISENTAN 5 PA; QL (30/30); NDS

ANORO ELLIPTA 3 QL (60/30)ARNUITY ELLIPTA 3 QL (30/30)ATROVENT HFA 4 QL (25.8/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

RHOPRESSA 4 STROCKLATAN 4 STSIMBRINZA 4travoprost 3ZIOPTAN (PF) 4 QL (30/30)STEROID-ANTIBIOTIC COMBINATIONSneomycin-bacitracin-poly-hc 4neomycin-polymyxin b-dexameth

2

neomycin-polymyxin-hc ophthalmic (eye)

4

neo-polycin hc 4TOBRADEX OPHTHALMIC (EYE) OINTMENT

3

tobramycin-dexamethasone 3STEROIDSdexamethasone sodium phosphate ophthalmic (eye)

2

DUREZOL 3fluorometholone 3INVELTYS 4LOTEMAX 4LOTEMAX SM 4PRED MILD 3prednisolone acetate 3prednisolone sodium phosphate ophthalmic (eye)

2

SYMPATHOMIMETICSALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1%

4

apraclonidine 4brimonidine ophthalmic (eye) drops 0.15%

3

brimonidine ophthalmic (eye) drops 0.2%

2

62


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LETAIRIS 5 PA; QL (30/30); NDS

levalbuterol tartrate 4 QL (30/30)metaproterenol oral syrup 4mometasone nasal 4 ST; QL (34/30)montelukast oral granules in packet

3 QL (30/30)

montelukast oral tablet 2 QL (30/30)montelukast oral tablet,chewable

2 QL (30/30)

nasonex 4 ST; QL (34/30)OFEV 5 PA; QL (60/30);

NDSOPSUMIT 5 PA; QL (30/30);

NDSORKAMBI ORAL GRANULES IN PACKET

5 PA; QL (56/28); NDS

ORKAMBI ORAL TABLET 5 PA; QL (120/30); NDS

PERFOROMIST 4 B/D PA; QL (120/30)

PROAIR HFA 3 QL (17/30)PROAIR RESPICLICK 3 QL (2/30)PULMOZYME 5 B/D PA; QL

(150/30); NDSRUCONEST 5 PA; QL (8/30); NDSSEREVENT DISKUS 3 QL (60/30)sildenafil (pulmonary arterial hypertension) oral tablet

3 PA; QL (90/30)

terbutaline 4THEO-24 4theophylline oral tablet extended release 12 hr

2

theophylline oral tablet extended release 24 hr

2

TRACLEER ORAL TABLET FOR SUSPENSION

5 PA; NDS

TRELEGY ELLIPTA 3 QL (60/30)VENTAVIS 4 PA; QL (270/30)VENTOLIN HFA 4 QL (36/30)XOLAIR SUBCUTANEOUS RECON SOLN

5 PA; QL (6/28); NDS

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

bosentan 5 PA; QL (60/30); NDS

BREO ELLIPTA 3 QL (60/30)budesonide inhalation 4 B/D PACINRYZE 5 PA; QL (20/30);

NDSCOMBIVENT RESPIMAT 4 QL (8/30)cromolyn inhalation 2 B/D PA; QL

(240/30)DALIRESP 4 PA; QL (30/30)ESBRIET ORAL CAPSULE 5 PA; QL (270/30);

NDSESBRIET ORAL TABLET 267 MG

5 PA; QL (270/30); NDS

ESBRIET ORAL TABLET 801 MG

5 PA; QL (90/30); NDS

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION

3 QL (60/30)

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION

3 QL (240/30)

FLOVENT HFA AEROSOL INHALER 110 MCG/ACTUATION

3 QL (12/30)


3 QL (24/30)


3 QL (10.6/30)

flunisolide nasal spray,non-aerosol 25 mcg (0.025%)

3 QL (50/30)

fluticasone propionate nasal 2 QL (16/30)icatibant 5 PA; QL (18/30);

NDSINCRUSE ELLIPTA 3 QL (30/30)ipratropium bromide inhalation 2 B/D PAipratropium-albuterol 2 B/D PAKALYDECO 5 PA; QL (60/30);

NDS

63



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTEScalcium acetate(phosphat bind) 3klor-con 2KLOR-CON 10 3KLOR-CON 8 3klor-con m10 1klor-con m20 1lactated ringers intravenous 4 B/D PAMAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/100 ML

4 B/D PA

magnesium sulfate in water 4 B/D PAmagnesium sulfate injection 4 B/D PANORMOSOL-R 4 B/D PANORMOSOL-R IN 5% DEXTROSE

4 B/D PA

PHOSLYRA 4POTASSIUM CHLORID-D5-0.45%NACL INTRAVENOUS PARENTERAL SOLUTION 10 MEQ/L, 20 MEQ/L, 40 MEQ/L

4 B/D PA

potassium chlorid-d5-0.45%nacl intravenous parenteral solution 30 meq/l

4 B/D PA

potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

4 B/D PA

potassium chloride in 5% dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l

4 B/D PA

potassium chloride in lr-d5 4 B/D PApotassium chloride in water intravenous piggyback

4 B/D PA

potassium chloride intravenous 4 B/D PApotassium chloride oral capsule, extended release

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

XOLAIR SUBCUTANEOUS SYRINGE

5 PA; QL (5/28); NDS

zafirlukast 4 QL (60/30)

UROLOGICALS

ANTICHOLINERGICS / ANTISPASMODICSMYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG

4 QL (60/30)

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG

4 QL (30/30)

oxybutynin chloride oral syrup 2 QL (600/30)oxybutynin chloride oral tablet 2oxybutynin chloride oral tablet extended release 24hr

2 QL (60/30)

solifenacin 3 QL (30/30)tolterodine oral capsule,extended release 24hr

4 QL (30/30)

tolterodine oral tablet 4TOVIAZ 4 QL (30/30)BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPYalfuzosin 2 QL (30/30)dutasteride 2 QL (30/30)finasteride oral tablet 5 mg 2 QL (30/30)tamsulosin 2 QL (60/30)MISCELLANEOUS UROLOGICALSbethanechol chloride 3CYSTAGON 4ELMIRON 4K-PHOS ORIGINAL 4potassium citrate 4RENACIDIN IRRIGATION SOLUTION 1980.6 MG-59.4 MG-980.4MG/30ML

4

64


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CLINIMIX E 4.25%/D10W SUL FREE

4 B/D PA

CLINISOL SF 15% 4 B/D PAelectrolyte-48 in d5w 4 B/D PAFREAMINE HBC 6.9% 4 B/D PAfreamine iii 10% 4 B/D PAHEPATAMINE 8% 4 B/D PAINTRALIPID INTRAVENOUS EMULSION 20%, 30%

4 B/D PA

KABIVEN 4 B/D PANEPHRAMINE 5.4% 4 B/D PANORMOSOL-M IN 5% DEXTROSE

4 B/D PA

NORMOSOL-R PH 7.4 4 B/D PANUTRILIPID 4 B/D PAPERIKABIVEN 4 B/D PAPLENAMINE 4 B/D PAPREMASOL 10% 4 B/D PAPROCALAMINE 3% 4 B/D PAPROSOL 20% 4 B/D PATRAVASOL 10% 4 B/D PATROPHAMINE 10% 4 B/D PATROPHAMINE 6% 4 B/D PAVITAMINS / HEMATINICSfluoride (sodium) oral tablet 1fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

1

PRENATAL VITAMIN ORAL TABLET

3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

potassium chloride oral liquid 4potassium chloride oral packet 2potassium chloride oral tablet extended release

1

potassium chloride oral tablet,er particles/crystals

1

potassium chloride-0.45% nacl 4 B/D PAPOTASSIUM CHLORIDE-D5-0.2%NACL INTRAVENOUS PARENTERAL SOLUTION 20 MEQ/L

4 B/D PA

potassium chloride-d5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l

4 B/D PA

potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l

4 B/D PA

POTASSIUM CHLORIDE-D5-0.9%NACL

4 B/D PA

ringer’s intravenous 4 B/D PAsodium bicarbonate intravenous syringe 10 meq/10 ml (8.4%), 7.5% (0.9 meq/ml), 8.4% (1 meq/ml)

4

sodium chloride 0.45% intravenous parenteral solution

4

sodium chloride 3% 4sodium chloride 5% 4sodium chloride intravenous 4TPN ELECTROLYTES 4 B/D PAMISCELLANEOUS NUTRITION PRODUCTSAMINOSYN II 10% 4 B/D PAAMINOSYN II 15% 4 B/D PAAMINOSYN-PF 10% 4 B/D PAAMINOSYN-PF 7% (SULFITE-FREE)

4 B/D PA

CLINIMIX 5%/D15W SULFITE FREE

4 B/D PA

CLINIMIX 4.25%/D10W SULF FREE

4 B/D PA

CLINIMIX 5%-D20W(SULFITE-FREE)

4 B/D PA

65

DRUG PAGE DRUG PAGE DRUG PAGE

Covered Drugs Index

Aabacavir-lamivudine . . . . . . . . . . . . . . . 19abacavir-lamivudine-zidovudine . . . . 19abacavir oral solution . . . . . . . . . . . . . . 19abacavir oral tablet . . . . . . . . . . . . . . . . 19ABELCET . . . . . . . . . . . . . . . . . . . . . . . . . 19ABILIFY MAINTENA . . . . . . . . . . . . . . . 36abiraterone . . . . . . . . . . . . . . . . . . . . . . . . 25ABRAXANE . . . . . . . . . . . . . . . . . . . . . . . 25acamprosate . . . . . . . . . . . . . . . . . . . . . . 47acarbose oral tablet 50 mg . . . . . . . . . 49acarbose oral tablet 100 mg, 25 mg . 49acebutolol . . . . . . . . . . . . . . . . . . . . . . . . . 40acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml . . . . . . . . . . . . 34acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg . . . . . . . 34acetaminophen-codeine oral tablet 300-60 mg . . . . . . . . . . . . . . . . . . 34acetazolamide . . . . . . . . . . . . . . . . . . . . . 60acetazolamide sodium . . . . . . . . . . . . . 60acetic acid otic (ear) . . . . . . . . . . . . . . . 48acetylcysteine . . . . . . . . . . . . . . . . . . . . . 61acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . . 44ACTHIB (PF) . . . . . . . . . . . . . . . . . . . . . . 55ACTIMMUNE . . . . . . . . . . . . . . . . . . . . . 54acyclovir oral capsule . . . . . . . . . . . . . . 19acyclovir oral suspension 200 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . 19acyclovir oral tablet . . . . . . . . . . . . . . . . 19acyclovir sodium intravenous solution . . . . . . . . . . . . . . . 19acyclovir topical cream . . . . . . . . . . . . . 44acyclovir topical ointment . . . . . . . . . . 44ADACEL (TDAP ADOLESN/ADULT)(PF) . . . . . 55adefovir . . . . . . . . . . . . . . . . . . . . . . . . . . . 19ADEMPAS . . . . . . . . . . . . . . . . . . . . . . . . 61ADVAIR DISKUS . . . . . . . . . . . . . . . . . . 61

ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . . 61AFINITOR . . . . . . . . . . . . . . . . . . . . . . . . 25AFINITOR DISPERZ . . . . . . . . . . . . . . . 25afirmelle . . . . . . . . . . . . . . . . . . . . . . . . . . 57AIMOVIG AUTOINJECTOR . . . . . . . . 33ak-poly-bac . . . . . . . . . . . . . . . . . . . . . . . 60ala-cort topical cream 1% . . . . . . . . . . 46albendazole . . . . . . . . . . . . . . . . . . . . . . . 22albuterol sulfate inhalation solution for nebulization . . . . . . . . . . . . 61albuterol sulfate oral syrup . . . . . . . . . 61albuterol sulfate oral tablet . . . . . . . . . 61albuterol sulfate oral tablet extended release 12 hr . . . . . . . . . . . . 61alclometasone topical cream . . . . . . . 46alclometasone topical ointment . . . . . 46ALCOHOL PADS . . . . . . . . . . . . . . . . . . 49ALDURAZYME . . . . . . . . . . . . . . . . . . . . 51ALECENSA . . . . . . . . . . . . . . . . . . . . . . . 25alendronate oral tablet 10 mg, 5 mg . 56alendronate oral tablet 35 mg, 70 mg . 56alfuzosin . . . . . . . . . . . . . . . . . . . . . . . . . . 63ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 25ALINIA ORAL SUSPENSION FOR RECONSTITUTION . . . . . . . . . . 22ALINIA ORAL TABLET . . . . . . . . . . . . . 22ALIQOPA . . . . . . . . . . . . . . . . . . . . . . . . . 25aliskiren . . . . . . . . . . . . . . . . . . . . . . . . . . . 40allopurinol . . . . . . . . . . . . . . . . . . . . . . . . . 56ALORA . . . . . . . . . . . . . . . . . . . . . . . . . . . 57alosetron oral tablet 0.5 mg . . . . . . . . 52alosetron oral tablet 1 mg . . . . . . . . . . 52ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1% . . . . . . . . . . . . . . . 61alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg . . . . . . . . . . . . . 36alprazolam oral tablet 2 mg . . . . . . . . 36alprazolam oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg . . . . . . . . . . . . . 36alprazolam oral tablet, disintegrating 2 mg . . . . . . . . . . . . . . . . 36

altavera (28) . . . . . . . . . . . . . . . . . . . . . . 57ALUNBRIG ORAL TABLET 30 MG . 25ALUNBRIG ORAL TABLET 180 MG, 90 MG . . . . . . . . . . . . . . . . . . . 25ALUNBRIG ORAL TABLETS, DOSE PACK . . . . . . . . . . . . . . . . . . . . . . 25alyacen 1/35 (28) . . . . . . . . . . . . . . . . . . 57alyacen 7/7/7 (28) . . . . . . . . . . . . . . . . . 57amantadine hcl . . . . . . . . . . . . . . . . . . . . 19AMBISOME . . . . . . . . . . . . . . . . . . . . . . . 19AMBRISENTAN . . . . . . . . . . . . . . . . . . . 61amethia . . . . . . . . . . . . . . . . . . . . . . . . . . . 57amethia lo . . . . . . . . . . . . . . . . . . . . . . . . . 57amethyst (28) . . . . . . . . . . . . . . . . . . . . . 57amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml . . . . . . . . 22amiloride . . . . . . . . . . . . . . . . . . . . . . . . . . 40amiloride-hydrochlorothiazide . . . . . . 40aminocaproic acid oral . . . . . . . . . . . . . 43AMINOSYN II 10% . . . . . . . . . . . . . . . . 64AMINOSYN II 15% . . . . . . . . . . . . . . . . 64AMINOSYN-PF 7% (SULFITE-FREE) . . . . . . . . . . . . . . . . . . 64AMINOSYN-PF 10% . . . . . . . . . . . . . . . 64amiodarone intravenous solution . . . 40amiodarone oral tablet 100 mg, 200 mg . . . . . . . . . . . . . . . . . . . 40amiodarone oral tablet 400 mg . . . . . 40AMITIZA . . . . . . . . . . . . . . . . . . . . . . . . . . 52amitriptyline . . . . . . . . . . . . . . . . . . . . . . . 36amlodipine . . . . . . . . . . . . . . . . . . . . . . . . 40amlodipine-benazepril . . . . . . . . . . . . . 40amlodipine-valsartan . . . . . . . . . . . . . . . 40amlodipine-valsartan-hcthiazid . . . . . 41ammonium lactate . . . . . . . . . . . . . . . . . 44amoxapine . . . . . . . . . . . . . . . . . . . . . . . . 36amoxicillin oral capsule . . . . . . . . . . . . 23amoxicillin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 23amoxicillin oral tablet . . . . . . . . . . . . . . 23

66


Covered Drugs Index

ASTAGRAF XL . . . . . . . . . . . . . . . . . . . . 25atazanavir oral capsule 150 mg . . . . . 19atazanavir oral capsule 200 mg . . . . . 19atazanavir oral capsule 300 mg . . . . . 19atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 41atenolol-chlorthalidone . . . . . . . . . . . . . 41atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg . . . . . . . 37atomoxetine oral capsule 100 mg, 60 mg, 80 mg . . . . . . . . . . . . . 37atorvastatin oral tablet 10 mg, 20 mg, 80 mg . . . . . . . . . . . . . . 43atorvastatin oral tablet 40 mg . . . . . . . 43atovaquone . . . . . . . . . . . . . . . . . . . . . . . 22atovaquone-proguanil . . . . . . . . . . . . . . 22ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . . 19atropine ophthalmic (eye) drops . . . . 60ATROVENT HFA . . . . . . . . . . . . . . . . . . 61aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57aubra eq . . . . . . . . . . . . . . . . . . . . . . . . . . 57AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 250-62.5 MG/5 ML . . . . . . . . . . . . . . . . . 24aurovela 1.5/30 (21) . . . . . . . . . . . . . . . 57aurovela 1/20 (21) . . . . . . . . . . . . . . . . . 57aurovela 24 fe . . . . . . . . . . . . . . . . . . . . . 57aurovela fe 1.5/30 (28) . . . . . . . . . . . . . 57aurovela fe 1-20 (28) . . . . . . . . . . . . . . 58AURYXIA . . . . . . . . . . . . . . . . . . . . . . . . . 47AUSTEDO ORAL TABLET 6 MG . . . 33AUSTEDO ORAL TABLET 12 MG, 9 MG . . . . . . . . . . . . . . . . . . . . . . 33AVASTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 25aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58avita . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45AVONEX INTRAMUSCULAR PEN INJECTOR KIT . . . . . . . . . . . . . . . 54AVONEX INTRAMUSCULAR SYRINGE KIT . . . . . . . . . . . . . . . . . . . . . 54ayuna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58AYVAKIT . . . . . . . . . . . . . . . . . . . . . . . . . . 25

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 60 MCG/0.3 ML . . . . . . . . . . . . . . . . . . . 54ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML . . . . . . . . . . . . . . . . . . 54ARANESP (IN POLYSORBATE) INJECTION SYRINGE 150 MCG/0.3 ML . . . . . . . . . . . . . . . . . . 54ARANESP (IN POLYSORBATE) INJECTION SYRINGE 200 MCG/0.4 ML . . . . . . . . . . . . . . . . . . 54ARANESP (IN POLYSORBATE) INJECTION SYRINGE 300 MCG/0.6 ML . . . . . . . . . . . . . . . . . . 54ARANESP (IN POLYSORBATE) INJECTION SYRINGE 500 MCG/ML . . . . . . . . . . . . . . . . . . . . . . 54ARCALYST . . . . . . . . . . . . . . . . . . . . . . . 54ARIKAYCE . . . . . . . . . . . . . . . . . . . . . . . . 22aripiprazole oral solution . . . . . . . . . . . 36aripiprazole oral tablet . . . . . . . . . . . . . 36aripiprazole oral tablet, disintegrating . . . . . . . . . . . . . . . . . . . . . . 36ARISTADA INITIO . . . . . . . . . . . . . . . . . 36ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML . . . . . . . . . 36ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML . . . . . . . . . . . 36ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML . . . . . . . . . . . 37ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML . . . . . . . . . . . 37armodafinil . . . . . . . . . . . . . . . . . . . . . . . . 37ARNUITY ELLIPTA . . . . . . . . . . . . . . . . 61ARSENIC TRIOXIDE INTRAVENOUS SOLUTION 1 MG/ML . . . . . . . . . . . . . . 25arsenic trioxide intravenous solution 2 mg/ml . . . . . . . . . . . . . . . . . . . 25ashlyna . . . . . . . . . . . . . . . . . . . . . . . . . . . 57aspirin-dipyridamole . . . . . . . . . . . . . . . 43

amoxicillin oral tablet, chewable 125 mg, 250 mg . . . . . . . . . 23amoxicillin-pot clavulanate oral suspension for reconstitution . . . . . . . 24amoxicillin-pot clavulanate oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 24amoxicillin-pot clavulanate oral tablet,chewable . . . . . . . . . . . . . . . 24amoxicillin-pot clavulanate oral tablet extended release 12 hr . . . . . . . 24amphotericin b . . . . . . . . . . . . . . . . . . . . 19ampicillin oral capsule 500 mg . . . . . . 24ampicillin sodium . . . . . . . . . . . . . . . . . . 24ampicillin-sulbactam . . . . . . . . . . . . . . . 24ANADROL-50 . . . . . . . . . . . . . . . . . . . . . 51anagrelide . . . . . . . . . . . . . . . . . . . . . . . . 47anastrozole . . . . . . . . . . . . . . . . . . . . . . . 25ANORO ELLIPTA . . . . . . . . . . . . . . . . . . 61APOKYN . . . . . . . . . . . . . . . . . . . . . . . . . . 32apraclonidine . . . . . . . . . . . . . . . . . . . . . . 61aprepitant . . . . . . . . . . . . . . . . . . . . . . . . . 52apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57APRISO . . . . . . . . . . . . . . . . . . . . . . . . . . 52APTIOM ORAL TABLET 200 MG . . . 31APTIOM ORAL TABLET 400 MG . . . 31APTIOM ORAL TABLET 600 MG, 800 MG . . . . . . . . . . . . . . . . . . 31APTIVUS . . . . . . . . . . . . . . . . . . . . . . . . . 19APTIVUS (WITH VITAMIN E). . . . . . . 19aranelle (28) . . . . . . . . . . . . . . . . . . . . . . 57ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML . . . . . . . . . . 54ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 300 MCG/ML, 60 MCG/ML . . . . . . . . . 54ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 40 MCG/0.4 ML . . . 54ARANESP (IN POLYSORBATE) INJECTION SYRINGE 25 MCG/0.42 ML . . . . . . . . . . . . . . . . . . 54

67


Covered Drugs Index

blisovi 24 fe . . . . . . . . . . . . . . . . . . . . . . . 58blisovi fe 1.5/30 (28) . . . . . . . . . . . . . . . 58blisovi fe 1/20 (28) . . . . . . . . . . . . . . . . . 58BOOSTRIX TDAP . . . . . . . . . . . . . . . . . 55BORTEZOMIB . . . . . . . . . . . . . . . . . . . . 25bosentan . . . . . . . . . . . . . . . . . . . . . . . . . . 62BOSULIF . . . . . . . . . . . . . . . . . . . . . . . . . 25BOTOX . . . . . . . . . . . . . . . . . . . . . . . . . . . 55BRAFTOVI . . . . . . . . . . . . . . . . . . . . . . . . 25BREO ELLIPTA . . . . . . . . . . . . . . . . . . . 62briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . . 43brimonidine ophthalmic (eye) drops 0.2% . . . . . . . . . . . . . . . . . . 61brimonidine ophthalmic (eye) drops 0.15% . . . . . . . . . . . . . . . . . 61BRIVIACT ORAL SOLUTION . . . . . . . 31BRIVIACT ORAL TABLET . . . . . . . . . . 31bromfenac . . . . . . . . . . . . . . . . . . . . . . . . 60bromocriptine . . . . . . . . . . . . . . . . . . . . . 32BRUKINSA . . . . . . . . . . . . . . . . . . . . . . . 25budesonide inhalation . . . . . . . . . . . . . . 62budesonide oral . . . . . . . . . . . . . . . . . . . 52bumetanide injection . . . . . . . . . . . . . . . 41bumetanide oral tablet 0.5 mg, 1 mg . 41bumetanide oral tablet 2 mg . . . . . . . . 41buprenorphine hcl injection solution . . 34buprenorphine hcl injection syringe . 34buprenorphine hcl sublingual . . . . . . . 34buprenorphine-naloxone sublingual film 2-0.5 mg, 4-1 mg, 8-2 mg . . . . . . 36buprenorphine-naloxone sublingual film 12-3 mg . . . . . . . . . . . . 36buprenorphine-naloxone sublingual tablet . . . . . . . . . . . . . . . . . . . 36bupropion hcl oral tablet 75 mg . . . . . 37bupropion hcl oral tablet 100 mg . . . . 37bupropion hcl oral tablet extended release 24 hr 150 mg . . . . . 37bupropion hcl oral tablet extended release 24 hr 300 mg . . . . . 37

benazepril . . . . . . . . . . . . . . . . . . . . . . . . . 41benazepril-hydrochlorothiazide . . . . . 41BENDEKA . . . . . . . . . . . . . . . . . . . . . . . . 25BENLYSTA INTRAVENOUS RECON SOLN 120 MG . . . . . . . . . . . . 56BENLYSTA INTRAVENOUS RECON SOLN 400 MG . . . . . . . . . . . . 56benztropine injection . . . . . . . . . . . . . . . 32benztropine oral . . . . . . . . . . . . . . . . . . . 32BESIVANCE . . . . . . . . . . . . . . . . . . . . . . 60BESPONSA . . . . . . . . . . . . . . . . . . . . . . . 25betamethasone, augmented topical cream . . . . . . . . . . 46betamethasone, augmented topical gel . . . . . . . . . . . . . 46betamethasone, augmented topical lotion . . . . . . . . . . . 46betamethasone, augmented topical ointment . . . . . . . . 46betamethasone dipropionate . . . . . . . 46betamethasone valerate topical cream . . . . . . . . . . . . . . . . . . . . . . 46betamethasone valerate topical lotion . . . . . . . . . . . . . . . . . . . . . . . 46betamethasone valerate topical ointment . . . . . . . . . . . . . . . . . . . 46BETASERON SUBCUTANEOUS KIT . 54betaxolol ophthalmic (eye) . . . . . . . . . 60betaxolol oral . . . . . . . . . . . . . . . . . . . . . . 41bethanechol chloride . . . . . . . . . . . . . . . 63bexarotene . . . . . . . . . . . . . . . . . . . . . . . . 25BEXSERO . . . . . . . . . . . . . . . . . . . . . . . . 55bicalutamide . . . . . . . . . . . . . . . . . . . . . . 25BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . . 24BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41BIKTARVY . . . . . . . . . . . . . . . . . . . . . . . . 19bimatoprost ophthalmic (eye) . . . . . . . 60BINOSTO . . . . . . . . . . . . . . . . . . . . . . . . . 56bisoprolol fumarate . . . . . . . . . . . . . . . . 41bisoprolol-hydrochlorothiazide . . . . . . 41BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . . 60BLEPHAMIDE S.O.P. . . . . . . . . . . . . . . 60

AZASITE . . . . . . . . . . . . . . . . . . . . . . . . . . 60azathioprine . . . . . . . . . . . . . . . . . . . . . . . 25azathioprine sodium . . . . . . . . . . . . . . . 25azelastine nasal . . . . . . . . . . . . . . . . . . . 48azelastine ophthalmic (eye) . . . . . . . . 60azithromycin intravenous . . . . . . . . . . . 22azithromycin oral packet . . . . . . . . . . . 22azithromycin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 22azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack) . . . . . . . . . . . 22azithromycin oral tablet 600 mg . . . . . 22AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . . 60aztreonam . . . . . . . . . . . . . . . . . . . . . . . . 22azurette (28) . . . . . . . . . . . . . . . . . . . . . . 58

Bbacitracin intramuscular . . . . . . . . . . . . 22bacitracin ophthalmic (eye) . . . . . . . . . 60bacitracin-polymyxin b ophthalmic (eye) . . . . . . . . . . . . . . . . . . . 60baclofen oral . . . . . . . . . . . . . . . . . . . . . . 34balsalazide . . . . . . . . . . . . . . . . . . . . . . . . 52BALVERSA ORAL TABLET 3 MG . . . 25BALVERSA ORAL TABLET 4 MG . . . 25BALVERSA ORAL TABLET 5 MG . . . 25balziva (28) . . . . . . . . . . . . . . . . . . . . . . . 58BANZEL ORAL SUSPENSION . . . . . 31BANZEL ORAL TABLET . . . . . . . . . . . 31BAQSIMI . . . . . . . . . . . . . . . . . . . . . . . . . . 49BARACLUDE ORAL SOLUTION . . . 19BAVENCIO . . . . . . . . . . . . . . . . . . . . . . . . 25BAXDELA . . . . . . . . . . . . . . . . . . . . . . . . . 24BCG VACCINE, LIVE (PF) . . . . . . . . . 55BD PEN NEEDLE . . . . . . . . . . . . . . . . . 49bekyree (28) . . . . . . . . . . . . . . . . . . . . . . 58BELSOMRA ORAL TABLET 5 MG . . 37BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG . . . . . . . . . . . . . 37

68


Covered Drugs Index

cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml . . . . . . . . . . 21cefaclor oral tablet extended release 12 hr . . . . . . . . . . . . 21cefadroxil oral capsule . . . . . . . . . . . . . 21cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . 21cefadroxil oral tablet . . . . . . . . . . . . . . . 21cefazolin . . . . . . . . . . . . . . . . . . . . . . . . . . 21cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml . . . . . . . . 21CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/100 ML . . . . . 21cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21CEFEPIME IN DEXTROSE 5% . . . . . 21cefepime in dextrose,iso-osm . . . . . . 21cefepime injection . . . . . . . . . . . . . . . . . 21cefixime oral capsule . . . . . . . . . . . . . . 21cefixime oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 21cefotetan . . . . . . . . . . . . . . . . . . . . . . . . . . 21CEFOTETAN IN DEXTROSE, ISO-OSM . . . . . . . . . . . . . . . . . . . . . . . . . 21cefoxitin . . . . . . . . . . . . . . . . . . . . . . . . . . . 21cefoxitin in dextrose, iso-osm . . . . . . . 21cefpodoxime . . . . . . . . . . . . . . . . . . . . . . 21cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . 21ceftazidime . . . . . . . . . . . . . . . . . . . . . . . . 21CEFTAZIDIME IN D5W . . . . . . . . . . . . 21ceftriaxone in dextrose,iso-os . . . . . . 21ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg . . . . . . . . . . . 21CEFTRIAXONE INJECTION RECON SOLN 100 GRAM . . . . . . . . . 21ceftriaxone intravenous . . . . . . . . . . . . 21cefuroxime axetil oral tablet . . . . . . . . 21cefuroxime sodium injection r econ soln 750 mg . . . . . . . . . . . . . . . . . 22

CALQUENCE . . . . . . . . . . . . . . . . . . . . . 25camila . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57camrese . . . . . . . . . . . . . . . . . . . . . . . . . . 58camrese lo . . . . . . . . . . . . . . . . . . . . . . . . 58candesartan-hydrochlorothiazid . . . . 41candesartan oral tablet 16 mg, 4 mg, 8 mg . . . . . . . . . . . . . . . . . 41candesartan oral tablet 32 mg . . . . . . 41CAPASTAT . . . . . . . . . . . . . . . . . . . . . . . . 22CAPLYTA . . . . . . . . . . . . . . . . . . . . . . . . . 37CAPRELSA ORAL TABLET 100 MG . . 26CAPRELSA ORAL TABLET 300 MG . . 26captopril . . . . . . . . . . . . . . . . . . . . . . . . . . 41captopril-hydrochlorothiazide . . . . . . . 41CARAFATE ORAL SUSPENSION . . 54CARBAGLU . . . . . . . . . . . . . . . . . . . . . . . 47carbamazepine oral capsule, er multiphase 12 hr . . . . . . . . . . . . . . . . 31carbamazepine oral suspension 100 mg/5 ml . . . . . . . . . . . 31carbamazepine oral tablet . . . . . . . . . . 31carbamazepine oral tablet, chewable . . . . . . . . . . . . . . . . . . . . . . . . . 31carbamazepine oral tablet extended release 12 hr . . . . . . . . . . . . 31carbidopa . . . . . . . . . . . . . . . . . . . . . . . . . 32carbidopa-levodopa-entacapone . . . . 33carbidopa-levodopa oral tablet . . . . . 32carbidopa-levodopa oral tablet,disintegrating . . . . . . . . . . . . . . . . 33carbidopa-levodopa oral tablet extended release . . . . . . . . . . . . 32carteolol . . . . . . . . . . . . . . . . . . . . . . . . . . 60cartia xt . . . . . . . . . . . . . . . . . . . . . . . . . . . 41carvedilol . . . . . . . . . . . . . . . . . . . . . . . . . 41carvedilol phosphate . . . . . . . . . . . . . . . 41caspofungin . . . . . . . . . . . . . . . . . . . . . . . 19CAYSTON . . . . . . . . . . . . . . . . . . . . . . . . 22caziant (28) . . . . . . . . . . . . . . . . . . . . . . . 58cefaclor oral capsule . . . . . . . . . . . . . . . 21

bupropion hcl oral tablet sustained-release 12 hr 100 mg, 200 mg . . . . . . 37bupropion hcl oral tablet sustained-release 12 hr 150 mg . . . . . . . . . . . . . . 37bupropion hcl (smoking deter) . . . . . . 48buspirone . . . . . . . . . . . . . . . . . . . . . . . . . 37busulfan . . . . . . . . . . . . . . . . . . . . . . . . . . 25BUSULFEX . . . . . . . . . . . . . . . . . . . . . . . 25butalbital-acetaminophen-caff oral capsule . . . . . . . . . . . . . . . . . . . . . . . 34butalbital-acetaminophen-caff oral tablet 50-325-40 mg . . . . . . . . . . . 34butorphanol tartrate injection solution 1 mg/ml . . . . . . . . . . . . . . . . . . . 36butorphanol tartrate injection solution 2 mg/ml . . . . . . . . . . . . . . . . . . . 36butorphanol tartrate nasal . . . . . . . . . . 36BYDUREON BCISE . . . . . . . . . . . . . . . 49BYDUREON SUBCUTANEOUS PEN INJECTOR . . . . . . . . . . . . . . . . . . . 49BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML . . . . . . . . . . . . . 49BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE (250 MCG/ML) 2.4 ML . . . . . . . . . . . . . 49BYSTOLIC . . . . . . . . . . . . . . . . . . . . . . . . 41

Ccabergoline . . . . . . . . . . . . . . . . . . . . . . . 51CABOMETYX ORAL TABLET 20 MG, 60 MG . . . . . . . . . . . . 25CABOMETYX ORAL TABLET 40 MG . . . . . . . . . . . . . . . . . . . 25calcipotriene scalp . . . . . . . . . . . . . . . . . 44calcipotriene topical cream . . . . . . . . . 44calcipotriene topical ointment . . . . . . . 44calcitonin (salmon) . . . . . . . . . . . . . . . . . 51calcitriol intravenous solution 1 mcg/ml . . . . . . . . . . . . . . . . . . 51calcitriol oral . . . . . . . . . . . . . . . . . . . . . . . 51calcium acetate(phosphat bind) . . . . . 63

69


Covered Drugs Index

CLINIMIX E 4.25%/D10W SUL FREE . . . . . . . . . . . . . . . . . . . . . . . . 64CLINISOL SF 15% . . . . . . . . . . . . . . . . 64clobazam oral suspension . . . . . . . . . . 31clobazam oral tablet . . . . . . . . . . . . . . . 31clobetasol-emollient topical cream . . 46clobetasol scalp . . . . . . . . . . . . . . . . . . . 46clobetasol topical cream . . . . . . . . . . . 46clobetasol topical foam . . . . . . . . . . . . . 46clobetasol topical gel . . . . . . . . . . . . . . 46clobetasol topical lotion . . . . . . . . . . . . 46clobetasol topical ointment . . . . . . . . . 46clobetasol topical shampoo . . . . . . . . 46clobetasol topical spray,non-aerosol . . 46CLOBEX TOPICAL LOTION . . . . . . . 46CLOBEX TOPICAL SHAMPOO . . . . 46CLOBEX TOPICAL SPRAY,NON-AEROSOL . . . . . . . . . . . . . . . . . . . . . . . . 46CLOCORTOLONE PIVALATE . . . . . . 46CLODAN . . . . . . . . . . . . . . . . . . . . . . . . . . 46clomipramine . . . . . . . . . . . . . . . . . . . . . . 37clonazepam oral tablet 0.5 mg, 1 mg . . . . . . . . . . . . . . . . . . . . . . 31clonazepam oral tablet 2 mg . . . . . . . 31clonazepam oral tablet, disintegrating 0.125 mg, 0.25 mg, 0.5 mg . . . . . . . . . . . . . . . . . . . 31clonazepam oral tablet, disintegrating 1 mg . . . . . . . . . . . . . . . . 31clonazepam oral tablet, disintegrating 2 mg . . . . . . . . . . . . . . . . 31clonidine hcl oral tablet 0.1 mg, 0.2 mg . . . . . . . . . . . . . . . . . . . . 41clonidine hcl oral tablet 0.3 mg . . . . . 41clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr . . 41clonidine transdermal patch weekly 0.3 mg/24 hr . . . . . . . . . . . . . . . 41clopidogrel oral tablet 75 mg . . . . . . . 43clopidogrel oral tablet 300 mg . . . . . . 43clorazepate dipotassium oral tablet 7.5 mg . . . . . . . . . . . . . . . . . . 37

CIPRODEX . . . . . . . . . . . . . . . . . . . . . . . 48ciprofloxacin . . . . . . . . . . . . . . . . . . . . . . . 24ciprofloxacin hcl ophthalmic (eye) . . . 60ciprofloxacin hcl oral tablet 100 mg . . . . . . . . . . . . . . . . . . . . . . . . . . . 24ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg . . . . . . . . . . . 24ciprofloxacin in 5% dextrose . . . . . . . . 24CIPRO HC . . . . . . . . . . . . . . . . . . . . . . . . 48citalopram oral solution . . . . . . . . . . . . 37citalopram oral tablet 10 mg . . . . . . . . 37citalopram oral tablet 20 mg . . . . . . . . 37citalopram oral tablet 40 mg . . . . . . . . 37claravis . . . . . . . . . . . . . . . . . . . . . . . . . . . 45clarithromycin . . . . . . . . . . . . . . . . . . . . . 22clindamycin hcl . . . . . . . . . . . . . . . . . . . . 22CLINDAMYCIN IN 0.9% SOD CHLOR . . . . . . . . . . . . . . . . 22clindamycin in 5% dextrose . . . . . . . . 22clindamycin palmitate hcl . . . . . . . . . . . 22clindamycin pediatric . . . . . . . . . . . . . . 22clindamycin phosphate injection . . . . 22clindamycin phosphate intravenous solution 600 mg/4 ml . . . 22clindamycin phosphate topical gel . . 45CLINDAMYCIN PHOSPHATE TOPICAL GEL, ONCE DAILY . . . . . . 45clindamycin phosphate topical lotion . . . . . . . . . . . . . . . . . . . . . . . 45clindamycin phosphate topical solution . . . . . . . . . . . . . . . . . . . . 45clindamycin phosphate topical swab . . . . . . . . . . . . . . . . . . . . . . . 45clindamycin phosphate vaginal . . . . . 57CLINIMIX 4.25%/D5W SULFIT FREE . . . . . . . . . . . . . . . . . . . . . 47CLINIMIX 4.25%/D10W SULF FREE . . . . . . . . . . . . . . . . . . . . . . . 64CLINIMIX 5%/D15W SULFITE FREE . . . . . . . . . . . . . . . . . . . 64CLINIMIX 5%-D20W (SULFITE-FREE) . . . . . . . . . . . . . . . . . . 64

cefuroxime sodium intravenous . . . . . 22celecoxib . . . . . . . . . . . . . . . . . . . . . . . . . . 36CELONTIN ORAL CAPSULE 300 MG . . . . . . . . . . . . . . . . 31cephalexin oral capsule 250 mg, 500 mg . . . . . . . . . . . . . . . . . . . 22cephalexin oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 22CEREZYME INTRAVENOUS RECON SOLN 400 UNIT . . . . . . . . . . 51CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . . 48CHANTIX CONTINUING MONTH BOX . . . . . . . . . . . . . . . . . . . . . 48CHANTIX STARTING MONTH BOX . . 48chateal (28) . . . . . . . . . . . . . . . . . . . . . . . 58chateal eq (28) . . . . . . . . . . . . . . . . . . . . 58CHEMET . . . . . . . . . . . . . . . . . . . . . . . . . 47chloramphenicol sod succinate . . . . . 22chlorhexidine gluconate mucous membrane . . . . . . . . . . . . . . . . 48chloroquine phosphate . . . . . . . . . . . . . 22chlorothiazide oral tablet 500 mg . . . 41chlorothiazide sodium . . . . . . . . . . . . . . 41chlorpromazine . . . . . . . . . . . . . . . . . . . . 37chlorthalidone oral tablet 25 mg, 50 mg . . . . . . . . . . . . . . . . . . . . . 41cholestyramine light . . . . . . . . . . . . . . . 43cholestyramine (with sugar) . . . . . . . . 43CHORIONIC GONADOTROPIN, HUMAN INTRAMUSCULAR . . . . . . . 51ciclodan topical solution . . . . . . . . . . . . 45ciclopirox topical cream . . . . . . . . . . . . 45ciclopirox topical shampoo . . . . . . . . . 45ciclopirox topical solution . . . . . . . . . . . 45ciclopirox topical suspension . . . . . . . 45cilostazol . . . . . . . . . . . . . . . . . . . . . . . . . . 43CILOXAN OPHTHALMIC (EYE) OINTMENT . . . . . . . . . . . . . . . . . 60CIMDUO . . . . . . . . . . . . . . . . . . . . . . . . . . 19cinacalcet oral tablet 30 mg, 60 mg . 51cinacalcet oral tablet 90 mg . . . . . . . . 51CINRYZE . . . . . . . . . . . . . . . . . . . . . . . . . 62

70


Covered Drugs Index

DALIRESP . . . . . . . . . . . . . . . . . . . . . . . . 62danazol . . . . . . . . . . . . . . . . . . . . . . . . . . . 51dantrolene oral . . . . . . . . . . . . . . . . . . . . 34dapsone oral . . . . . . . . . . . . . . . . . . . . . . 22DAPTACEL (DTAP PEDIATRIC) (PF) . . . . . . . . . . . 55DAPTOMYCIN INTRAVENOUS RECON SOLN 350 MG . . . . . . . . . . . . 22daptomycin intravenous recon soln 500 mg . . . . . . . . . . . . . . . . . 22DARAPRIM . . . . . . . . . . . . . . . . . . . . . . . 22DARZALEX . . . . . . . . . . . . . . . . . . . . . . . 26dasetta 1/35 (28) . . . . . . . . . . . . . . . . . . 58dasetta 7/7/7 (28) . . . . . . . . . . . . . . . . . . 58daunorubicin intravenous solution . . 26DAURISMO ORAL TABLET 25 MG . . 26DAURISMO ORAL TABLET 100 MG . 26daysee . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58deblitane . . . . . . . . . . . . . . . . . . . . . . . . . . 57DELSTRIGO . . . . . . . . . . . . . . . . . . . . . . 19DEMSER . . . . . . . . . . . . . . . . . . . . . . . . . 41DEPEN TITRATABS . . . . . . . . . . . . . . . 56DEPO-MEDROL . . . . . . . . . . . . . . . . . . 48DESCOVY . . . . . . . . . . . . . . . . . . . . . . . . 19desipramine . . . . . . . . . . . . . . . . . . . . . . . 37desloratadine oral tablet . . . . . . . . . . . 61desmopressin injection . . . . . . . . . . . . . 51desmopressin nasal spray, non-aerosol . . . . . . . . . . . . . . . . . . . . . . . 51desmopressin nasal spray with pump . . . . . . . . . . . . . . . . . . . . . . . . . 51desmopressin oral . . . . . . . . . . . . . . . . . 51desog-e.estradiol/e.estradiol . . . . . . . 58desogestrel-ethinyl estradiol . . . . . . . . 58DESONATE . . . . . . . . . . . . . . . . . . . . . . . 46desonide topical lotion . . . . . . . . . . . . . 46desonide topical ointment . . . . . . . . . . 46desowen topical cream . . . . . . . . . . . . 46DESOWEN TOPICAL LOTION . . . . . 46desoximetasone topical cream . . . . . 46desoximetasone topical gel . . . . . . . . 46

CORLANOR ORAL TABLET . . . . . . . 44cortisone . . . . . . . . . . . . . . . . . . . . . . . . . . 48COTELLIC . . . . . . . . . . . . . . . . . . . . . . . . 26COUMADIN ORAL . . . . . . . . . . . . . . . . 43CREON . . . . . . . . . . . . . . . . . . . . . . . . . . . 53CRESEMBA ORAL . . . . . . . . . . . . . . . . 19CRIXIVAN ORAL CAPSULE 200 MG . . . . . . . . . . . . . . . . 19CRIXIVAN ORAL CAPSULE 400 MG . . . . . . . . . . . . . . . . 19cromolyn inhalation . . . . . . . . . . . . . . . . 62cromolyn ophthalmic (eye) . . . . . . . . . 60cromolyn oral . . . . . . . . . . . . . . . . . . . . . . 53cryselle (28) . . . . . . . . . . . . . . . . . . . . . . . 58CUBICIN . . . . . . . . . . . . . . . . . . . . . . . . . . 22CUBICIN RF . . . . . . . . . . . . . . . . . . . . . . 22cyclafem 1/35 (28) . . . . . . . . . . . . . . . . . 58cyclafem 7/7/7 (28) . . . . . . . . . . . . . . . . 58cyclobenzaprine oral tablet 10 mg, 5 mg . . . . . . . . . . . . . . . . . . . . . . . 34cyclophosphamide intravenous . . . . . 26cyclophosphamide oral capsule . . . . 26CYCLOSERINE . . . . . . . . . . . . . . . . . . . 22CYCLOSET . . . . . . . . . . . . . . . . . . . . . . . 49cyclosporine intravenous . . . . . . . . . . . 26cyclosporine modified . . . . . . . . . . . . . . 26cyclosporine oral capsule . . . . . . . . . . 26CYRAMZA . . . . . . . . . . . . . . . . . . . . . . . . 26cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58cyred eq . . . . . . . . . . . . . . . . . . . . . . . . . . 58CYSTADANE . . . . . . . . . . . . . . . . . . . . . 53CYSTAGON . . . . . . . . . . . . . . . . . . . . . . . 63CYSTARAN . . . . . . . . . . . . . . . . . . . . . . . 60

Dd2.5%-0.45% sodium chloride . . . . . . 47d5%-0.45% sodium chloride . . . . . . . . 47d5% and 0.9% sodium chloride . . . . . 47d10%-0.45% sodium chloride . . . . . . 47dalfampridine . . . . . . . . . . . . . . . . . . . . . . 33

clorazepate dipotassium oral tablet 15 mg, 3.75 mg . . . . . . . . . 37clotrimazole-betamethasone topical cream . . . . . . . . . . . . . . . . . . . . . . 45clotrimazole-betamethasone topical lotion . . . . . . . . . . . . . . . . . . . . . . . 45clotrimazole mucous membrane . . . . 19clotrimazole topical cream . . . . . . . . . . 45clotrimazole topical solution . . . . . . . . 45clozapine oral tablet 25 mg, 50 mg . . 37clozapine oral tablet 100 mg, 200 mg . . . . . . . . . . . . . . . . . . . 37clozapine oral tablet, disintegrating 12.5 mg, 25 mg . . . . . . 37clozapine oral tablet, disintegrating 100 mg . . . . . . . . . . . . . . 37clozapine oral tablet, disintegrating 150 mg . . . . . . . . . . . . . . 37clozapine oral tablet, disintegrating 200 mg . . . . . . . . . . . . . . 37COARTEM . . . . . . . . . . . . . . . . . . . . . . . . 22colchicine oral capsule . . . . . . . . . . . . . 56colchicine oral tablet . . . . . . . . . . . . . . . 56colesevelam . . . . . . . . . . . . . . . . . . . . . . . 43colestipol . . . . . . . . . . . . . . . . . . . . . . . . . . 43colistin (colistimethate na) . . . . . . . . . . 22COMBIGAN . . . . . . . . . . . . . . . . . . . . . . . 60COMBIVENT RESPIMAT . . . . . . . . . . 62COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) . . . . . . 26COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) . . 26COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3) . . 26COMPLERA . . . . . . . . . . . . . . . . . . . . . . 19compro . . . . . . . . . . . . . . . . . . . . . . . . . . . 52constulose . . . . . . . . . . . . . . . . . . . . . . . . 53COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML . . . . . . . . . . . . . . 33COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML . . . . . . . . . . . . . . 33COPIKTRA . . . . . . . . . . . . . . . . . . . . . . . 26

71


Covered Drugs Index

didanosine oral capsule, delayed release(dr/ec) 200 mg, 250 mg, 400 mg . . . . . . . . . . . 19diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . . 36digitek oral tablet 125 mcg (0.125 mg) . . . . . . . . . . . . . . . 44digitek oral tablet 250 mcg (0.25 mg) . . . . . . . . . . . . . . . . 44digoxin oral solution 50 mcg/ml (0.05 mg/ml) . . . . . . . . . . . . 44digoxin oral tablet 125 mcg (0.125 mg) . . . . . . . . . . . . . . . 44digoxin oral tablet 250 mcg (0.25 mg) . . . . . . . . . . . . . . . . 44digox oral tablet 125 mcg (0.125 mg) . . . . . . . . . . . . . . . 44digox oral tablet 250 mcg (0.25 mg) . . . . . . . . . . . . . . . . 44dihydroergotamine nasal . . . . . . . . . . . 33DILANTIN 30 MG . . . . . . . . . . . . . . . . . . 31diltiazem hcl intravenous . . . . . . . . . . . 41diltiazem hcl oral capsule, extended release 12 hr . . . . . . . . . . . . 41diltiazem hcl oral capsule, extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg . . . . . . . . . . . 41diltiazem hcl oral capsule, extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 420 mg . . 41diltiazem hcl oral tablet . . . . . . . . . . . . . 41diltiazem hcl oral tablet extended release 24 hr . . . . . . . . . . . . 41dilt-xr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41diphenhydramine hcl injection solution 50 mg/ml . . . . . . . . . 61diphenoxylate-atropine . . . . . . . . . . . . . 52dipyridamole oral . . . . . . . . . . . . . . . . . . 43disulfiram . . . . . . . . . . . . . . . . . . . . . . . . . 47divalproex oral capsule, delayed rel sprinkle . . . . . . . . . . . . . . . . 31divalproex oral tablet, delayed release (dr/ec) . . . . . . . . . . . . 31divalproex oral tablet extended release 24 hr . . . . . . . . . . . . 31

dextrose 5%-0.3% sod.chloride . . . . . 47DEXTROSE 5% IN WATER (D5W) INTRAVENOUS PARENTERAL SOLUTION . . . . . . . . . 47dextrose 5% in water (d5w) intravenous piggyback . . . . . . . . . . . . . 47dextrose 5%-lactated ringers . . . . . . . 47dextrose 10% and 0.2% nacl . . . . . . . 47DEXTROSE 10% IN WATER (D10W) . . . . . . . . . . . . . . . . 47dextrose 20% in water (d20w) . . . . . . 47dextrose 25% in water (d25w) . . . . . . 47dextrose 30% in water (d30w) . . . . . . 47dextrose 40% in water (d40w) . . . . . . 47dextrose 50% in water (d50w) . . . . . . 47dextrose 70% in water (d70w) . . . . . . 47dextrose with sodium chloride . . . . . . 47DIASTAT . . . . . . . . . . . . . . . . . . . . . . . . . . 31DIASTAT ACUDIAL RECTAL KIT 5-7.5-10 MG . . . . . . . . . . 31DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20 MG . . . . . . . . . . . 31diazepam injection syringe . . . . . . . . . 38diazepam oral solution 5 mg/5 ml (1 mg/ml) . . . . . . . . . . . . . . . 38diazepam oral tablet . . . . . . . . . . . . . . . 38DIAZEPAM RECTAL KIT 2.5 MG . . . 31DIAZEPAM RECTAL KIT 5-7.5-10 MG . . . . . . . . . . . . . . . . . . 31DIAZEPAM RECTAL KIT 12.5-15-17.5-20 MG . . . . . . . . . . . 31diazoxide . . . . . . . . . . . . . . . . . . . . . . . . . 49diclofenac potassium . . . . . . . . . . . . . . 36diclofenac sodium ophthalmic (eye) . . . . . . . . . . . . . . . . . . . 60diclofenac sodium oral . . . . . . . . . . . . . 36diclofenac sodium topical drops . . . . 36diclofenac sodium topical gel 1% . . . 36dicloxacillin . . . . . . . . . . . . . . . . . . . . . . . . 24dicyclomine oral capsule . . . . . . . . . . . 52dicyclomine oral solution . . . . . . . . . . . 52dicyclomine oral tablet . . . . . . . . . . . . . 52

desoximetasone topical ointment . . . 46desvenlafaxine succinate oral tablet extended release 24 hr 25 mg, 50 mg . . . . . . . . . . . . . . . . 37desvenlafaxine succinate oral tablet extended release 24 hr 100 mg . . . . . 37dexamethasone intensol . . . . . . . . . . . 48dexamethasone oral elixir . . . . . . . . . . 48dexamethasone oral solution . . . . . . . 48dexamethasone oral tablet 0.5 mg, 0.75 mg, 4 mg . . . . . . . . . . . . . 48dexamethasone oral tablet 1 mg, 1.5 mg, 2 mg, 6 mg . . . . . . . . . . 48dexamethasone sodium phos (pf) injection solution . . . . . . . . . . . . . . . 48dexamethasone sodium phosphate injection solution . . . . . . . . 48dexamethasone sodium phosphate ophthalmic (eye) . . . . . . . . 61DEXILANT . . . . . . . . . . . . . . . . . . . . . . . . 54dexmethylphenidate oral tablet 5 mg . . . . . . . . . . . . . . . . . . . . . . . . 37dexmethylphenidate oral tablet 10 mg, 2.5 mg . . . . . . . . . . . . . . . 37dextroamphetamine-amphetamine oral capsule,extended release 24hr . . 37dextroamphetamine-amphetamine oral tablet 5 mg . . . . . . . . . . . . . . . . . . . . 38dextroamphetamine-amphetamine oral tablet 10 mg . . . . . . . . . . . . . . . . . . 37dextroamphetamine-amphetamine oral tablet 12.5 mg, 30 mg, 7.5 mg . . 38dextroamphetamine-amphetamine oral tablet 15 mg . . . . . . . . . . . . . . . . . . 38dextroamphetamine-amphetamine oral tablet 20 mg . . . . . . . . . . . . . . . . . . 38dextroamphetamine oral capsule, extended release 5 mg . . . . . . . . . . . . . 37dextroamphetamine oral capsule, extended release 10 mg . . . . . . . . . . . 37dextroamphetamine oral capsule, extended release 15 mg . . . . . . . . . . . 37dextroamphetamine oral tablet . . . . . 37dextrose 5%-0.2% sod chloride . . . . . 47

72


Covered Drugs Index

ENBREL SUBCUTANEOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . 56ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5) . . . . . . 56ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML) . . . . . . . 56ENBREL SURECLICK . . . . . . . . . . . . . 56endocet oral tablet 2.5-325 mg, 5-325 mg . . . . . . . . . . . . . 34endocet oral tablet 7.5-325 mg . . . . . 34endocet oral tablet 10-325 mg . . . . . . 34ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE . . . . . . 55ENGERIX-B (PF) INTRAMUSCULAR SYRINGE . . . . . . 55ENHERTU . . . . . . . . . . . . . . . . . . . . . . . . 26enoxaparin . . . . . . . . . . . . . . . . . . . . . . . . 43enpresse . . . . . . . . . . . . . . . . . . . . . . . . . . 58enskyce . . . . . . . . . . . . . . . . . . . . . . . . . . . 58entacapone . . . . . . . . . . . . . . . . . . . . . . . 33entecavir . . . . . . . . . . . . . . . . . . . . . . . . . . 20ENTRESTO . . . . . . . . . . . . . . . . . . . . . . . 44enulose . . . . . . . . . . . . . . . . . . . . . . . . . . . 53EPCLUSA . . . . . . . . . . . . . . . . . . . . . . . . 20EPIDIOLEX . . . . . . . . . . . . . . . . . . . . . . . 31epinastine . . . . . . . . . . . . . . . . . . . . . . . . . 60epinephrine injection auto-injector . . 61epinephrine injection solution 1 mg/ml . . . . . . . . . . . . . . . . . . . 61EPIPEN . . . . . . . . . . . . . . . . . . . . . . . . . . . 61EPIPEN 2-PAK . . . . . . . . . . . . . . . . . . . . 61EPIPEN JR . . . . . . . . . . . . . . . . . . . . . . . 61EPIPEN JR 2-PAK . . . . . . . . . . . . . . . . . 61epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31EPIVIR HBV ORAL SOLUTION . . . . 20ergotamine-caffeine . . . . . . . . . . . . . . . 33ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . . 26ERLEADA . . . . . . . . . . . . . . . . . . . . . . . . 26erlotinib oral tablet 25 mg . . . . . . . . . . 26erlotinib oral tablet 100 mg, 150 mg . . 26errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

DUAVEE . . . . . . . . . . . . . . . . . . . . . . . . . . 57duloxetine oral capsule,delayed release(dr/ec) 20 mg . . . . . . . . . . . . . . . 38duloxetine oral capsule,delayed release(dr/ec) 30 mg . . . . . . . . . . . . . . . 38duloxetine oral capsule,delayed release(dr/ec) 60 mg . . . . . . . . . . . . . . . 38DUPIXENT . . . . . . . . . . . . . . . . . . . . . . . . 44DURAMORPH (PF) . . . . . . . . . . . . . . . . 34DUREZOL . . . . . . . . . . . . . . . . . . . . . . . . 61dutasteride . . . . . . . . . . . . . . . . . . . . . . . . 63

Eec-naproxen . . . . . . . . . . . . . . . . . . . . . . . 36econazole . . . . . . . . . . . . . . . . . . . . . . . . . 46EDARBI . . . . . . . . . . . . . . . . . . . . . . . . . . 41EDARBYCLOR . . . . . . . . . . . . . . . . . . . . 41EDURANT . . . . . . . . . . . . . . . . . . . . . . . . 19efavirenz oral capsule 50 mg . . . . . . . 19efavirenz oral capsule 200 mg . . . . . . 19efavirenz oral tablet . . . . . . . . . . . . . . . . 19ELAPRASE . . . . . . . . . . . . . . . . . . . . . . . 52electrolyte-48 in d5w . . . . . . . . . . . . . . . 64elinest . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58ELIQUIS . . . . . . . . . . . . . . . . . . . . . . . . . . 43ELIQUIS DVT-PE TREAT 30D START . . . . . . . . . . . . . . . . 43ELMIRON . . . . . . . . . . . . . . . . . . . . . . . . . 63ELZONRIS . . . . . . . . . . . . . . . . . . . . . . . . 26EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . . 26EMEND ORAL SUSPENSION FOR RECONSTITUTION . . . . . . . . . . 53emoquette . . . . . . . . . . . . . . . . . . . . . . . . 58EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 38EMTRIVA ORAL CAPSULE . . . . . . . . 20EMTRIVA ORAL SOLUTION . . . . . . . 20EMVERM . . . . . . . . . . . . . . . . . . . . . . . . . 22enalapril-hydrochlorothiazide . . . . . . . 41enalapril maleate . . . . . . . . . . . . . . . . . . 41ENBREL MINI . . . . . . . . . . . . . . . . . . . . . 56

dofetilide . . . . . . . . . . . . . . . . . . . . . . . . . . 40donepezil oral tablet 5 mg . . . . . . . . . . 33donepezil oral tablet 10 mg . . . . . . . . . 33donepezil oral tablet, disintegrating 5 mg . . . . . . . . . . . . . . . . 33donepezil oral tablet, disintegrating 10 mg . . . . . . . . . . . . . . . 33dorzolamide . . . . . . . . . . . . . . . . . . . . . . . 60dorzolamide-timolol . . . . . . . . . . . . . . . . 60dotti . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57DOVATO . . . . . . . . . . . . . . . . . . . . . . . . . . 19doxazosin . . . . . . . . . . . . . . . . . . . . . . . . . 41doxepin oral capsule . . . . . . . . . . . . . . . 38doxepin oral concentrate . . . . . . . . . . . 38doxepin oral tablet . . . . . . . . . . . . . . . . . 38doxercalciferol intravenous . . . . . . . . . 51doxercalciferol oral capsule 0.5 mcg. . 51doxercalciferol oral capsule 1 mcg . . 51doxercalciferol oral capsule 2.5 mcg. . 51doxy-100 . . . . . . . . . . . . . . . . . . . . . . . . . . 24doxycycline hyclate intravenous . . . . 24doxycycline hyclate oral capsule . . . . 24doxycycline hyclate oral tablet 100 mg, 20 mg . . . . . . . . . . . . . . 24doxycycline monohydrate oral capsule 100 mg, 50 mg . . . . . . . . 24doxycycline monohydrate oral suspension for reconstitution . . . . . . . 24doxycycline monohydrate oral tablet . 24DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG . . . . . . . . . . . . . . . . . 38DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 30 MG, 40 MG . . . . . . . . . 38DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 60 MG . . . . . . . . . . . . . . . . . 38dronabinol . . . . . . . . . . . . . . . . . . . . . . . . 53drospirenone-e.estradiol-lm.fa . . . . . . 58drospirenone-ethinyl estradiol . . . . . . 58DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . . 26

73


Covered Drugs Index

fenofibric acid (choline) oral capsule,delayed release (dr/ec) 45 mg . . . . . . . . . . . . . . . . . . . . . . 43fenofibric acid (choline) oral capsule,delayed release (dr/ec) 135 mg . . . . . . . . . . . . . . . . . . . . 43fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 800 mcg . . . . . . . . . . . . . . . 34fentanyl citrate buccal lozenge on a handle 200 mcg, 400 mcg, 600 mcg . . . . . . . . . . . . . . . . . 34fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr . . . . 34FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR. . . . . . 38FETZIMA ORAL CAPSULE, EXT REL 24HR DOSE PACK. . . . . . . 38finasteride oral tablet 5 mg . . . . . . . . . 63FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG . . . . . . . . . . . . . 26FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG . . . . . . . . . . . . 26FIRVANQ . . . . . . . . . . . . . . . . . . . . . . . . . 22flac otic oil . . . . . . . . . . . . . . . . . . . . . . . . 48flecainide . . . . . . . . . . . . . . . . . . . . . . . . . 40FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION . . . . . . . . . . . . . . 62FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION . . . . . . . . . . . . 62FLOVENT HFA AEROSOL INHALER 44 MCG/ACTUATION . . . . 62FLOVENT HFA AEROSOL INHALER 110 MCG/ACTUATION . . . 62FLOVENT HFA AEROSOL INHALER 220 MCG/ACTUATION . . 62fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml . . . . . 19

everolimus (immunosuppressive) oral tablet 0.25 mg . . . . . . . . . . . . . . . . . 26everolimus (immunosuppressive) oral tablet 0.75 mg . . . . . . . . . . . . . . . . . 26EVOMELA . . . . . . . . . . . . . . . . . . . . . . . . 26EVOTAZ . . . . . . . . . . . . . . . . . . . . . . . . . . 20exemestane . . . . . . . . . . . . . . . . . . . . . . . 26EXJADE . . . . . . . . . . . . . . . . . . . . . . . . . . 47EYLEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60ezetimibe . . . . . . . . . . . . . . . . . . . . . . . . . 43ezetimibe-simvastatin . . . . . . . . . . . . . . 43

FFABRAZYME . . . . . . . . . . . . . . . . . . . . . 52falmina (28) . . . . . . . . . . . . . . . . . . . . . . . 58famciclovir . . . . . . . . . . . . . . . . . . . . . . . . 20famotidine oral suspension . . . . . . . . . 54famotidine oral tablet 20 mg, 40 mg . . . . . . . . . . . . . . . . . . . . . 54FANAPT ORAL TABLET . . . . . . . . . . . 38FANAPT ORAL TABLETS, DOSE PACK . . . . . . . . . . . . . . . . . . . . . . 38FARXIGA ORAL TABLET 5 MG . . . . 49FARXIGA ORAL TABLET 10 MG . . . 49FARYDAK . . . . . . . . . . . . . . . . . . . . . . . . 26FASLODEX . . . . . . . . . . . . . . . . . . . . . . . 26fayosim . . . . . . . . . . . . . . . . . . . . . . . . . . . 58febuxostat . . . . . . . . . . . . . . . . . . . . . . . . . 56felbamate . . . . . . . . . . . . . . . . . . . . . . . . . 31felodipine . . . . . . . . . . . . . . . . . . . . . . . . . 41femynor . . . . . . . . . . . . . . . . . . . . . . . . . . . 58fenofibrate micronized oral capsule 130 mg, 43 mg . . . . . . . . . . . . 43fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg . . . . 43fenofibrate nanocrystallized oral tablet 145 mg, 48 mg . . . . . . . . . . 43fenofibrate oral capsule . . . . . . . . . . . . 43fenofibrate oral tablet 160 mg, 54 mg . . . . . . . . . . . . . . . . . . . . 43

ertapenem . . . . . . . . . . . . . . . . . . . . . . . . 22ery pads . . . . . . . . . . . . . . . . . . . . . . . . . . 45ERY-TAB . . . . . . . . . . . . . . . . . . . . . . . . . . 22erythrocin (as stearate) oral tablet 250 mg . . . . . . . . . . . . . . . . . 22ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG . . . . . . . . . . . . 22erythromycin-benzoyl peroxide . . . . . 45erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml . . . . . . . . . 22erythromycin ophthalmic (eye) . . . . . . 60erythromycin oral . . . . . . . . . . . . . . . . . . 22erythromycin with ethanol topical gel . . . . . . . . . . . . . . . . . . . . . . . . . 45erythromycin with ethanol topical solution . . . . . . . . . . . . . . . . . . . . 45ESBRIET ORAL CAPSULE . . . . . . . . 62ESBRIET ORAL TABLET 267 MG . . 62ESBRIET ORAL TABLET 801 MG . . 62escitalopram oxalate oral solution . . 38escitalopram oxalate oral tablet . . . . . 38esomeprazole magnesium oral capsule,delayed release(dr/ec) . . . . . 54estarylla . . . . . . . . . . . . . . . . . . . . . . . . . . 58estradiol oral . . . . . . . . . . . . . . . . . . . . . . 57estradiol transdermal patch semiweekly . . . . . . . . . . . . . . . . . . . . . . . 57estradiol transdermal patch weekly . 57estradiol vaginal tablet . . . . . . . . . . . . . 57estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml . . . . . . . . . . . . . 57ethacrynate sodium . . . . . . . . . . . . . . . . 41ethambutol . . . . . . . . . . . . . . . . . . . . . . . . 22ethosuximide . . . . . . . . . . . . . . . . . . . . . . 31ethynodiol diac-eth estradiol . . . . . . . . 58etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . 36etoposide intravenous . . . . . . . . . . . . . 26everolimus (antineoplastic) . . . . . . . . . 26everolimus (immunosuppressive) oral tablet 0.5 mg . . . . . . . . . . . . . . . . . . 26

74


Covered Drugs Index

gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . . 53gavilyte-g . . . . . . . . . . . . . . . . . . . . . . . . . 53gavilyte-n . . . . . . . . . . . . . . . . . . . . . . . . . 53GAZYVA . . . . . . . . . . . . . . . . . . . . . . . . . . 26gemcitabine intravenous recon soln . . 26gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) . . . . . . . . . 26GEMCITABINE INTRAVENOUS SOLUTION 100 MG/ML . . . . . . . . . . . . 26gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . . 43generlac . . . . . . . . . . . . . . . . . . . . . . . . . . 53gengraf oral capsule 100 mg, 25 mg . . . . . . . . . . . . . . . . . . . . 26gengraf oral solution . . . . . . . . . . . . . . . 26GENOTROPIN . . . . . . . . . . . . . . . . . . . . 54GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML . . . . . . . . . . . . . . . . . . . 54GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML . . . . . . . . . . . . . . . . . . . . . 54gentak ophthalmic (eye) ointment . . . 60gentamicin injection solution 40 mg/ml . . . . . . . . . . . . . . . . . . 22GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML . . . . 22gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml . . . . . . . . 22gentamicin ophthalmic (eye) drops . . 60gentamicin sulfate (ped) (pf) . . . . . . . . 22gentamicin topical cream . . . . . . . . . . . 45gentamicin topical ointment . . . . . . . . 45GENVOYA . . . . . . . . . . . . . . . . . . . . . . . . 20GEODON INTRAMUSCULAR . . . . . . 38gianvi (28) . . . . . . . . . . . . . . . . . . . . . . . . 58

fondaparinux subcutaneous syringe 2.5 mg/0.5 ml . . . . . . . . . . . . . . 43fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml . . . . . . . . . 43FORTEO . . . . . . . . . . . . . . . . . . . . . . . . . . 56fosamprenavir . . . . . . . . . . . . . . . . . . . . . 20fosinopril . . . . . . . . . . . . . . . . . . . . . . . . . . 41fosinopril-hydrochlorothiazide . . . . . . 41FREAMINE HBC 6.9% . . . . . . . . . . . . . 64freamine iii 10% . . . . . . . . . . . . . . . . . . . 64fulvestrant . . . . . . . . . . . . . . . . . . . . . . . . . 26furosemide injection . . . . . . . . . . . . . . . 41furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) . . . . 41furosemide oral tablet . . . . . . . . . . . . . . 41FUZEON SUBCUTANEOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . 20fyavolv . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57FYCOMPA ORAL SUSPENSION . . . 31FYCOMPA ORAL TABLET 2 MG, 4 MG, 6 MG . . . . . . . . . . . . . . . . 31FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG . . . . . . . . . . . . . . 31

Ggabapentin oral capsule 100 mg, 400 mg . . . . . . . . . . . . . . . . . . . 31gabapentin oral capsule 300 mg . . . . 31gabapentin oral solution . . . . . . . . . . . . 31gabapentin oral tablet 600 mg . . . . . . 31gabapentin oral tablet 800 mg . . . . . . 32galantamine oral capsule, ext rel. pellets 24 hr . . . . . . . . . . . . . . . . 33galantamine oral solution . . . . . . . . . . . 33galantamine oral tablet . . . . . . . . . . . . . 33GAMUNEX-C . . . . . . . . . . . . . . . . . . . . . 55GARDASIL 9 (PF) . . . . . . . . . . . . . . . . . 55GATTEX 30-VIAL . . . . . . . . . . . . . . . . . . 53GATTEX ONE-VIAL . . . . . . . . . . . . . . . 53GAUZE PADS 2 X 2 . . . . . . . . . . . . . . . 49

fluconazole oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 19fluconazole oral tablet . . . . . . . . . . . . . . 19flucytosine . . . . . . . . . . . . . . . . . . . . . . . . 19fludarabine . . . . . . . . . . . . . . . . . . . . . . . . 26fludrocortisone . . . . . . . . . . . . . . . . . . . . 48flunisolide nasal spray, non-aerosol 25 mcg (0.025%) . . . . . . 62fluocinolone . . . . . . . . . . . . . . . . . . . . . . . 46fluocinolone acetonide oil . . . . . . . . . . 48fluocinolone and shower cap . . . . . . . 46fluocinonide topical cream 0.05% . . . 46fluocinonide topical gel . . . . . . . . . . . . . 46fluocinonide topical ointment . . . . . . . 46fluocinonide topical solution . . . . . . . . 46fluoride (sodium) oral tablet . . . . . . . . 64fluoride (sodium) oral tablet, chewable 1 mg (2.2 mg sod. fluoride) . . . . . . . . . . . . . . 64fluorometholone . . . . . . . . . . . . . . . . . . . 61fluorouracil topical cream 0.5% . . . . . 44fluorouracil topical cream 5% . . . . . . . 44fluorouracil topical solution . . . . . . . . . 44fluoxetine oral capsule . . . . . . . . . . . . . 38fluoxetine oral solution . . . . . . . . . . . . . 38fluphenazine decanoate . . . . . . . . . . . . 38fluphenazine hcl injection . . . . . . . . . . 38fluphenazine hcl oral concentrate . . . 38fluphenazine hcl oral elixir . . . . . . . . . . 38fluphenazine hcl oral tablet . . . . . . . . . 38flurbiprofen oral tablet 100 mg . . . . . . 36flurbiprofen sodium . . . . . . . . . . . . . . . . 60flutamide . . . . . . . . . . . . . . . . . . . . . . . . . . 26fluticasone propionate nasal . . . . . . . . 62fluticasone propionate topical cream . . . . . . . . . . . . . . . . . . . . . . 46fluticasone propionate topical ointment . . . . . . . . . . . . . . . . . . . 46fluvoxamine oral tablet . . . . . . . . . . . . . 38FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . . 26fomepizole . . . . . . . . . . . . . . . . . . . . . . . . 55

75


Covered Drugs Index

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML . . . . . . . 56HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML- 40 MG/0.4 ML . . . . . . . . . . . . . . . . . . . . . 56HUMIRA(CF) PEN CROHNS-UC-HS . . . . . . . . . . . . . . . . . . 56HUMIRA(CF) PEN PSOR-UV-ADOL HS . . . . . . . . . . . . . . . 56HUMIRA(CF) PEN SUBCUTANEOUS INJECTOR KIT 40 MG/0.4 ML . . . . . . . . . . . . . . . . . 56HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/ 0.1 ML, 20 MG/0.2 ML . . . . . . . . . . . . . 56HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 40 MG/0.4 ML . . . . . . . 57HUMIRA PEN . . . . . . . . . . . . . . . . . . . . . 56HUMIRA PEN CROHNS- UC-HS START . . . . . . . . . . . . . . . . . . . . 56HUMIRA PEN PSOR- UVEITS-ADOL HS . . . . . . . . . . . . . . . . . 56HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML . . . . . . . . . . . . . . . . . . . . . 56HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML . . . . . . . 56HUMULIN 70/30 U-100 INSULIN . . . 50HUMULIN 70/30 U-100 KWIKPEN . . 50HUMULIN N NPH INSULIN KWIKPEN . . . . . . . . . . . . . . . 50HUMULIN N NPH U-100 INSULIN . . 50HUMULIN R REGULAR U-100 INSULN . . . . . . . . . . . . . . . . . . . . 50HUMULIN R U-500 (CONC) INSULIN . . . . . . . . . . . . . . . . . . 50HUMULIN R U-500 (CONC) KWIKPEN . . . . . . . . . . . . . . . . 50hydralazine injection . . . . . . . . . . . . . . . 41hydralazine oral . . . . . . . . . . . . . . . . . . . 41hydrochlorothiazide . . . . . . . . . . . . . . . . 41

HALAVEN . . . . . . . . . . . . . . . . . . . . . . . . . 26halobetasol propionate topical cream . . . . . . . . . . . . . . . . . . . . . . 46halobetasol propionate topical ointment . . . . . . . . . . . . . . . . . . . 46haloperidol . . . . . . . . . . . . . . . . . . . . . . . . 38haloperidol decanoate . . . . . . . . . . . . . 38haloperidol lactate injection . . . . . . . . 38haloperidol lactate oral . . . . . . . . . . . . . 38HARVONI ORAL TABLET . . . . . . . . . . 20HAVRIX (PF) . . . . . . . . . . . . . . . . . . . . . . 55heather . . . . . . . . . . . . . . . . . . . . . . . . . . . 57heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml . . . . . . . . . . . . . . . . . 43heparin (porcine) in 5% dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) . . . . . 43heparin (porcine) injection solution . . 43heparin (porcine) in nacl (pf) . . . . . . . . 43heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml . . . . . . . . . . . 43HEPATAMINE 8% . . . . . . . . . . . . . . . . . 64HERCEPTIN HYLECTA . . . . . . . . . . . . 26HERCEPTIN INTRAVENOUS RECON SOLN 150 MG . . . . . . . . . . . . 27HETLIOZ . . . . . . . . . . . . . . . . . . . . . . . . . 38HIBERIX (PF) . . . . . . . . . . . . . . . . . . . . . 55HIZENTRA SUBCUTANEOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 55HUMALOG JUNIOR KWIKPEN U-100 . . . . . . . . . . . . . . . . . . 50HUMALOG KWIKPEN INSULIN . . . . 50HUMALOG MIX 50-50 INSULN U-100 . . . . . . . . . . . . . . . . . . . . 50HUMALOG MIX 50-50 KWIKPEN. . . 50HUMALOG MIX 75-25 KWIKPEN. . . 50HUMALOG MIX 75-25 (U-100)INSULN . . . . . . . . . . . . . . . . . . . 50HUMALOG U-100 INSULIN . . . . . . . . 50

GILENYA ORAL CAPSULE 0.5 MG . . 33GILOTRIF . . . . . . . . . . . . . . . . . . . . . . . . . 26GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG . . . . . . . . . . . 26glimepiride oral tablet 1 mg . . . . . . . . . 49glimepiride oral tablet 2 mg . . . . . . . . . 49glimepiride oral tablet 4 mg . . . . . . . . . 49glipizide-metformin oral tablet 2.5-250 mg . . . . . . . . . . . . . . . . . . . . . . . . 49glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg . . . . . . . . . . . . . 49glipizide oral tablet 5 mg . . . . . . . . . . . 49glipizide oral tablet 10 mg . . . . . . . . . . 49glipizide oral tablet extended release 24hr 2.5 mg . . . . . . . . . . . . . . . 49glipizide oral tablet extended release 24hr 5 mg . . . . . . . . . . . . . . . . . 49glipizide oral tablet extended release 24hr 10 mg . . . . . . . . . . . . . . . . 49GLUCAGEN HYPOKIT . . . . . . . . . . . . 49GLUCAGON EMERGENCY KIT (HUMAN) . . . . . . . . . . . . . . . . . . . . . 49GLUCAGON (HCL) EMERGENCY KIT . . . . . . . . . . . . . . . . . 49glycopyrrolate oral . . . . . . . . . . . . . . . . . 52GLYCOPYRROLATE (PF) IN WATER INJECTION . . . . . . . . . . . . 52glycopyrrolate (pf) in water intravenous syringe 0.4 mg/2 ml (0.2 mg/ml) . . . . . . . . . . . . 52glydo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44GLYXAMBI . . . . . . . . . . . . . . . . . . . . . . . . 49granisetron hcl oral . . . . . . . . . . . . . . . . 53griseofulvin microsize . . . . . . . . . . . . . . 19griseofulvin ultramicrosize . . . . . . . . . . 19GVOKE PFS 1-PACK SYRINGE. . . . 49GVOKE PFS 2-PACK SYRINGE. . . . 49

Hhailey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58hailey 24 fe . . . . . . . . . . . . . . . . . . . . . . . 58hailey fe 1/20 (28) . . . . . . . . . . . . . . . . . 58

76


Covered Drugs Index

INTELENCE ORAL TABLET 100 MG, 200 MG . . . . . . . . . 20INTRALIPID INTRAVENOUS EMULSION 20%, 30% . . . . . . . . . . . . . 64INTRON A INJECTION RECON SOLN . . . . . . . . . . . . . . . . . . . . 54INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML . . . . . . . . . . . . . . . 55INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML . . . . . . . . . . . . . . 55introvale . . . . . . . . . . . . . . . . . . . . . . . . . . 58INVANZ INJECTION . . . . . . . . . . . . . . . 23INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML . . . . . . . . . . . . . . . . . . . . 38INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML . . . . . . . . . . . . . . . . . . . . . 38INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML . . . . . . . . . . . . . . . . . . . 38INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML . . . . . . . . . . . . . . . . . . . . . . . 38INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML . . . . . . . . . . . . . . . . . . . . 38INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML . . . . . . . 38INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML . . . . . . . 38INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML . . . . . . . . 38INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML . . . . . . . 38INVELTYS . . . . . . . . . . . . . . . . . . . . . . . . 61INVIRASE ORAL TABLET . . . . . . . . . 20INVOKAMET . . . . . . . . . . . . . . . . . . . . . . 50INVOKAMET XR . . . . . . . . . . . . . . . . . . 50INVOKANA . . . . . . . . . . . . . . . . . . . . . . . 50IPOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55ipratropium-albuterol . . . . . . . . . . . . . . . 62ipratropium bromide inhalation . . . . . 62

Iibandronate oral . . . . . . . . . . . . . . . . . . . 56IBRANCE . . . . . . . . . . . . . . . . . . . . . . . . . 27ibu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36ibuprofen oral suspension . . . . . . . . . . 36ibuprofen oral tablet 400 mg, 600 mg, 800 mg . . . . . . . . . . . 36icatibant . . . . . . . . . . . . . . . . . . . . . . . . . . 62ICLUSIG ORAL TABLET 15 MG . . . . 27ICLUSIG ORAL TABLET 45 MG . . . . 27IDHIFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27imatinib oral tablet 100 mg . . . . . . . . . 27imatinib oral tablet 400 mg . . . . . . . . . 27IMBRUVICA ORAL CAPSULE 70 MG . . . . . . . . . . . . . . . . . 27IMBRUVICA ORAL CAPSULE 140 MG . . . . . . . . . . . . . . . . 27IMBRUVICA ORAL TABLET . . . . . . . . 27IMFINZI . . . . . . . . . . . . . . . . . . . . . . . . . . . 27imipenem-cilastatin . . . . . . . . . . . . . . . . 22imipramine hcl . . . . . . . . . . . . . . . . . . . . . 38imiquimod topical cream in packet . . 44IMOVAX RABIES VACCINE (PF) . . . 55IMPOYZ . . . . . . . . . . . . . . . . . . . . . . . . . . 46incassia . . . . . . . . . . . . . . . . . . . . . . . . . . . 57INCRELEX . . . . . . . . . . . . . . . . . . . . . . . . 47INCRUSE ELLIPTA . . . . . . . . . . . . . . . . 62indapamide . . . . . . . . . . . . . . . . . . . . . . . 41INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION . 55INFUGEM . . . . . . . . . . . . . . . . . . . . . . . . . 27INFUMORPH P/F. . . . . . . . . . . . . . . . . . 34INLYTA ORAL TABLET 1 MG . . . . . . . 27INLYTA ORAL TABLET 5 MG . . . . . . . 27INREBIC . . . . . . . . . . . . . . . . . . . . . . . . . . 27INSULIN PEN NEEDLE . . . . . . . . . . . . 50INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML . . . . . . . . 50INTELENCE ORAL TABLET 25 MG . . . . . . . . . . . . . . . . . . . 20

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml . . . . . 34hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml) . . . . 34hydrocodone-acetaminophen oral tablet 5-325 mg . . . . . . . . . . . . . . . 34hydrocodone-acetaminophen oral tablet 10-325 mg, 7.5-325 mg . . 34hydrocodone-ibuprofen oral tablet 7.5-200 mg . . . . . . . . . . . . . . 34hydrocortisone-acetic acid . . . . . . . . . 48hydrocortisone butyrate topical cream . . . . . . . . . . . . . . . . . . . . . . 46hydrocortisone butyrate topical ointment . . . . . . . . . . . . . . . . . . . 46hydrocortisone butyr-emollient . . . . . . 46hydrocortisone oral . . . . . . . . . . . . . . . . 48hydrocortisone rectal . . . . . . . . . . . . . . 53hydrocortisone topical cream 1%, 2.5% . . . . . . . . . . . . . . . . . . . . . . . . . 46hydrocortisone topical cream with perineal applicator . . . . . . . . . . . . 53hydrocortisone topical lotion 2.5% . . 46hydrocortisone topical ointment 1%, 2.5% . . . . . . . . . . . . . . . . 46hydrocortisone valerate . . . . . . . . . . . . 46hydromorphone injection solution 2 mg/ml . . . . . . . . . . . . . . . . . . . 34hydromorphone injection syringe 1 mg/ml, 2 mg/ml, 4 mg/ml . . . . . . . . . 34hydromorphone oral liquid . . . . . . . . . . 34hydromorphone oral tablet 2 mg, 4 mg . . . . . . . . . . . . . . . . . . . . . . . . 34hydromorphone oral tablet 8 mg . . . . 34hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml, 2 mg/ml . . . . . . . . . . . . . . . . . 34hydroxychloroquine . . . . . . . . . . . . . . . . 22hydroxyprogesterone caproate . . . . . 57hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . 27hydroxyzine hcl oral tablet . . . . . . . . . . 61

77


Covered Drugs Index

kionex (with sorbitol) . . . . . . . . . . . . . . . 47KISQALI . . . . . . . . . . . . . . . . . . . . . . . . . . 27KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY (200 MG X 1)-2.5 MG . . . . . . . . . . . . . . 27KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY (200 MG X 2)-2.5 MG . . . . . . . . . . . . . . 27KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY (200 MG X 3)-2.5 MG . . . . . . . . . . . . . . 27klor-con . . . . . . . . . . . . . . . . . . . . . . . . . . . 63KLOR-CON 8 . . . . . . . . . . . . . . . . . . . . . 63KLOR-CON 10 . . . . . . . . . . . . . . . . . . . . 63klor-con m10 . . . . . . . . . . . . . . . . . . . . . . 63klor-con m20 . . . . . . . . . . . . . . . . . . . . . . 63KORLYM . . . . . . . . . . . . . . . . . . . . . . . . . . 52K-PHOS ORIGINAL . . . . . . . . . . . . . . . 63kurvelo (28) . . . . . . . . . . . . . . . . . . . . . . . 58KUVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . 52KYPROLIS . . . . . . . . . . . . . . . . . . . . . . . . 27

Llabetalol oral . . . . . . . . . . . . . . . . . . . . . . 42lactated ringers intravenous . . . . . . . . 63lactated ringers irrigation . . . . . . . . . . . 47lactulose oral solution . . . . . . . . . . . . . . 53lamivudine oral solution . . . . . . . . . . . . 20lamivudine oral tablet 100 mg, 300 mg . . . . . . . . . . . . . . . . . . . 20lamivudine oral tablet 150 mg . . . . . . 20lamivudine-zidovudine . . . . . . . . . . . . . 20lamotrigine oral tablet . . . . . . . . . . . . . . 32lamotrigine oral tablet, chewable dispersible . . . . . . . . . . . . . . 32lamotrigine oral tablet,disintegrating . . 32lamotrigine oral tablet extended release 24hr . . . . . . . . . . . . . 32lansoprazole oral capsule, delayed release(dr/ec) . . . . . . . . . . . . . 54LANTUS SOLOSTAR U-100 INSULIN . . . . . . . . . . . . . . . . . . . . 50

JANUVIA . . . . . . . . . . . . . . . . . . . . . . . . . 50JARDIANCE . . . . . . . . . . . . . . . . . . . . . . 50jasmiel (28) . . . . . . . . . . . . . . . . . . . . . . . 58jencycla . . . . . . . . . . . . . . . . . . . . . . . . . . . 57JENTADUETO . . . . . . . . . . . . . . . . . . . . 50JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG . . . . . . . . . . . . . . . 50JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG . . . . . . . . . . . . . . . . . 50jolessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58juleber . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58JULUCA . . . . . . . . . . . . . . . . . . . . . . . . . . 20junel 1.5/30 (21) . . . . . . . . . . . . . . . . . . . 58junel 1/20 (21) . . . . . . . . . . . . . . . . . . . . . 58junel fe 1.5/30 (28) . . . . . . . . . . . . . . . . . 58junel fe 1/20 (28) . . . . . . . . . . . . . . . . . . 58junel fe 24 . . . . . . . . . . . . . . . . . . . . . . . . . 58

KKABIVEN . . . . . . . . . . . . . . . . . . . . . . . . . 64KADCYLA . . . . . . . . . . . . . . . . . . . . . . . . 27kaitlib fe . . . . . . . . . . . . . . . . . . . . . . . . . . . 58KALETRA ORAL TABLET 100-25 MG . . . . . . . . . . . . . . . 20KALETRA ORAL TABLET 200-50 MG . . . . . . . . . . . . . . . 20kalliga . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58KALYDECO . . . . . . . . . . . . . . . . . . . . . . . 62KANJINTI . . . . . . . . . . . . . . . . . . . . . . . . . 27kariva (28) . . . . . . . . . . . . . . . . . . . . . . . . 58kelnor 1/35 (28) . . . . . . . . . . . . . . . . . . . 58kelnor 1-50 . . . . . . . . . . . . . . . . . . . . . . . . 58ketoconazole oral . . . . . . . . . . . . . . . . . . 19ketoconazole topical cream . . . . . . . . 46ketoconazole topical shampoo . . . . . 46ketorolac ophthalmic (eye) . . . . . . . . . 60KEYTRUDA INTRAVENOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 27KINRIX (PF) . . . . . . . . . . . . . . . . . . . . . . . 55

ipratropium bromide nasal spray,non-aerosol 0.03% . . . . . . . . . . . 48ipratropium bromide nasal spray, non-aerosol 42 mcg (0.06%) . . . . . . . 48irbesartan-hydrochlorothiazide . . . . . 41irbesartan oral tablet 150 mg . . . . . . . 41irbesartan oral tablet 300 mg, 75 mg . . . . . . . . . . . . . . . . . . . . 41IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 27irinotecan . . . . . . . . . . . . . . . . . . . . . . . . . 27ISENTRESS HD . . . . . . . . . . . . . . . . . . . 20ISENTRESS ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 20ISENTRESS ORAL TABLET . . . . . . . 20ISENTRESS ORAL TABLET, CHEWABLE 25 MG . . . . . . . . . . . . . . . 20ISENTRESS ORAL TABLET, CHEWABLE 100 MG . . . . . . . . . . . . . . 20isibloom . . . . . . . . . . . . . . . . . . . . . . . . . . . 58isoniazid oral solution . . . . . . . . . . . . . . 23isoniazid oral tablet . . . . . . . . . . . . . . . . 23isosorbide dinitrate oral tablet . . . . . . 44isosorbide mononitrate . . . . . . . . . . . . . 44isotretinoin . . . . . . . . . . . . . . . . . . . . . . . . 45isradipine . . . . . . . . . . . . . . . . . . . . . . . . . 41ISTODAX . . . . . . . . . . . . . . . . . . . . . . . . . 27itraconazole oral capsule . . . . . . . . . . . 19itraconazole oral solution . . . . . . . . . . . 19ivermectin oral . . . . . . . . . . . . . . . . . . . . 23IXIARO (PF) . . . . . . . . . . . . . . . . . . . . . . 55

Jjaimiess . . . . . . . . . . . . . . . . . . . . . . . . . . . 58JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . . 27jantoven . . . . . . . . . . . . . . . . . . . . . . . . . . 43JANUMET . . . . . . . . . . . . . . . . . . . . . . . . 50JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG . . . . . . . . . . . . . . . . . . . . . . . . 50JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG . . 50

78


Covered Drugs Index

lillow (28) . . . . . . . . . . . . . . . . . . . . . . . . . 58lincomycin . . . . . . . . . . . . . . . . . . . . . . . . 23lindane topical shampoo . . . . . . . . . . . 47linezolid-0.9% sodium chloride . . . . . 23linezolid in dextrose 5% . . . . . . . . . . . . 23linezolid oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 23linezolid oral tablet . . . . . . . . . . . . . . . . . 23LINZESS . . . . . . . . . . . . . . . . . . . . . . . . . . 53liothyronine oral . . . . . . . . . . . . . . . . . . . 52lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . 42lisinopril-hydrochlorothiazide . . . . . . . 42lithium carbonate . . . . . . . . . . . . . . . . . . 39LIVALO . . . . . . . . . . . . . . . . . . . . . . . . . . . 43l norgest/e.estradiol-e.estrad . . . . . . . 58lojaimiess . . . . . . . . . . . . . . . . . . . . . . . . . 58LONSURF ORAL TABLET 15-6.14 MG . . . . . . . . . . . . . . . 27LONSURF ORAL TABLET 20-8.19 MG . . . . . . . . . . . . . . . 27loperamide oral capsule . . . . . . . . . . . . 52lopinavir-ritonavir . . . . . . . . . . . . . . . . . . 20lorazepam injection . . . . . . . . . . . . . . . . 39lorazepam intensol . . . . . . . . . . . . . . . . 39lorazepam oral concentrate . . . . . . . . 39lorazepam oral tablet 0.5 mg, 1 mg . . 39lorazepam oral tablet 2 mg . . . . . . . . . 39LORBRENA ORAL TABLET 25 MG . 27LORBRENA ORAL TABLET 100 MG . 27lorcet hd . . . . . . . . . . . . . . . . . . . . . . . . . . 35lorcet (hydrocodone) . . . . . . . . . . . . . . . 34lorcet plus oral tablet 7.5-325 mg . . . 35loryna (28) . . . . . . . . . . . . . . . . . . . . . . . . 58losartan . . . . . . . . . . . . . . . . . . . . . . . . . . . 42losartan-hydrochlorothiazide oral tablet 50-12.5 mg . . . . . . . . . . . . . . 42losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg . . . . . 42LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . . 61LOTEMAX SM . . . . . . . . . . . . . . . . . . . . 61lovastatin . . . . . . . . . . . . . . . . . . . . . . . . . 44

levetiracetam oral solution . . . . . . . . . 32levetiracetam oral tablet . . . . . . . . . . . . 32levetiracetam oral tablet extended release 24 hr . . . . . . . . . . . . 32levobunolol ophthalmic (eye) drops 0.5% . . . . . . . . . . . . . . . . . . 60levocarnitine oral solution 100 mg/ml . . . . . . . . . . . . . . . . . . . . . . . . 47levocarnitine oral tablet . . . . . . . . . . . . 47levocarnitine (with sugar) . . . . . . . . . . . 47levocetirizine oral solution . . . . . . . . . . 61levocetirizine oral tablet . . . . . . . . . . . . 61levofloxacin in d5w . . . . . . . . . . . . . . . . 24levofloxacin intravenous . . . . . . . . . . . 24levofloxacin oral solution . . . . . . . . . . . 24levofloxacin oral tablet . . . . . . . . . . . . . 24levonest (28) . . . . . . . . . . . . . . . . . . . . . . 58levonorgestrel-ethinyl estrad . . . . . . . 58levonorg-eth estrad triphasic . . . . . . . 58levora-28 . . . . . . . . . . . . . . . . . . . . . . . . . . 58levothyroxine oral . . . . . . . . . . . . . . . . . . 52levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg . . . 52LEXIVA ORAL SUSPENSION . . . . . . 20LIBTAYO . . . . . . . . . . . . . . . . . . . . . . . . . . 27lidocaine hcl injection solution . . . . . . 44lidocaine hcl laryngotracheal . . . . . . . 44lidocaine hcl mucous membrane jelly . . . . . . . . . . . . . . . . . . . . 44lidocaine hcl mucous membrane jelly in applicator . . . . . . . . 44lidocaine hcl mucous membrane solution 4% (40 mg/ml) . . 44lidocaine (pf) injection solution . . . . . . 44lidocaine (pf) intravenous syringe . . . 40lidocaine-prilocaine topical cream . . . 45lidocaine topical adhesive patch,medicated 5% . . . . . . . . . . . . . . . 44lidocaine topical ointment . . . . . . . . . . 45lidocaine viscous . . . . . . . . . . . . . . . . . . 45

LANTUS U-100 INSULIN . . . . . . . . . . 50larin 1.5/30 (21) . . . . . . . . . . . . . . . . . . . 58larin 1/20 (21) . . . . . . . . . . . . . . . . . . . . . 58larin 24 fe . . . . . . . . . . . . . . . . . . . . . . . . . 58larin fe 1.5/30 (28) . . . . . . . . . . . . . . . . . 58larin fe 1/20 (28) . . . . . . . . . . . . . . . . . . . 58larissia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58latanoprost . . . . . . . . . . . . . . . . . . . . . . . . 60LATUDA ORAL TABLET 80 MG . . . . 39LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG . . . . 38layolis fe . . . . . . . . . . . . . . . . . . . . . . . . . . 58leena 28 . . . . . . . . . . . . . . . . . . . . . . . . . . 58leflunomide . . . . . . . . . . . . . . . . . . . . . . . 57LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 4 MG . . . . 27LENVIMA ORAL CAPSULE 12 MG/DAY (4 MG X 3), 18 MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY (10 MG X 2-4 MG X 1) . . . . . . . . . . . . . 27LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2) . . . . . . . . . . . . . 27lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58LETAIRIS . . . . . . . . . . . . . . . . . . . . . . . . . 62letrozole . . . . . . . . . . . . . . . . . . . . . . . . . . 27leucovorin calcium injection recon soln . . . . . . . . . . . . . . . . . . . . . . . . . 25leucovorin calcium injection solution 10 mg/ml . . . . . . . . . . . . . . . . . . 25leucovorin calcium oral tablet 5 mg . . 25leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg . . . . . . . . . . . . . . 25LEUKERAN . . . . . . . . . . . . . . . . . . . . . . . 27leuprolide subcutaneous kit . . . . . . . . 27levalbuterol tartrate . . . . . . . . . . . . . . . . 62LEVEMIR FLEXTOUCH U-100 INSULN . . . . . . . . . . . . . . . . . . . . 50LEVEMIR U-100 INSULIN . . . . . . . . . 50levetiracetam in nacl (iso-os) . . . . . . . 32levetiracetam intravenous . . . . . . . . . . 32

79


Covered Drugs Index

mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25MESNEX ORAL . . . . . . . . . . . . . . . . . . . 25metaproterenol oral syrup . . . . . . . . . . 62metformin oral solution . . . . . . . . . . . . . 50metformin oral tablet 1,000 mg . . . . . 50metformin oral tablet 500 mg . . . . . . . 50metformin oral tablet 850 mg . . . . . . . 50metformin oral tablet,er gast.retention 24 hr 1,000 mg . . . . . . 50metformin oral tablet,er gast.retention 24 hr 500 mg . . . . . . . . 50metformin oral tablet extended release 24 hr 500 mg (generic for glucophage xr) . . . . . . . . . 50metformin oral tablet extended release 24 hr 750 mg (generic for glucophage xr) . . . . . . . . . 50metformin oral tablet extended release (osm) 24 hr 1000mg, 500mg (generic for fortamet) . . . . . . . 50methadone injection solution . . . . . . . 35methadone intensol . . . . . . . . . . . . . . . . 35methadone oral concentrate . . . . . . . . 35methadone oral solution 5 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . . . 35methadone oral solution 10 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . . 35methadone oral tablet 5 mg . . . . . . . . 35methadone oral tablet 10 mg . . . . . . . 35methazolamide . . . . . . . . . . . . . . . . . . . . 60methenamine hippurate . . . . . . . . . . . . 24methimazole oral tablet 10 mg, 5 mg . . . . . . . . . . . . . . . . . . . . . . . 49methocarbamol oral . . . . . . . . . . . . . . . 34methotrexate sodium injection . . . . . . 28methotrexate sodium oral . . . . . . . . . . 28methotrexate sodium (pf) . . . . . . . . . . . 28methoxsalen . . . . . . . . . . . . . . . . . . . . . . 45methyldopa . . . . . . . . . . . . . . . . . . . . . . . 42methylphenidate hcl oral tablet . . . . . 39methylphenidate hcl oral tablet extended release . . . . . . . . . . . . . . . . . . 39

maprotiline . . . . . . . . . . . . . . . . . . . . . . . . 39marlissa (28) . . . . . . . . . . . . . . . . . . . . . . 58MARPLAN . . . . . . . . . . . . . . . . . . . . . . . . 39MATULANE . . . . . . . . . . . . . . . . . . . . . . . 28matzim la . . . . . . . . . . . . . . . . . . . . . . . . . 42MAVYRET . . . . . . . . . . . . . . . . . . . . . . . . 20meclizine oral tablet 12.5 mg, 25 mg . . . . . . . . . . . . . . . . . . . . 53MEDROL ORAL TABLET 2 MG . . . . . 48medroxyprogesterone . . . . . . . . . . . . . . 57mefloquine . . . . . . . . . . . . . . . . . . . . . . . . 23megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml) . . . . . . . . . . . 28megestrol oral tablet 20 mg . . . . . . . . 28megestrol oral tablet 40 mg . . . . . . . . 28MEKINIST ORAL TABLET 0.5 MG . . 28MEKINIST ORAL TABLET 2 MG . . . . 28MEKTOVI . . . . . . . . . . . . . . . . . . . . . . . . . 28melodetta 24 fe . . . . . . . . . . . . . . . . . . . . 59meloxicam oral tablet . . . . . . . . . . . . . . 36melphalan hcl . . . . . . . . . . . . . . . . . . . . . 28memantine oral capsule, sprinkle,er 24hr . . . . . . . . . . . . . . . . . . . . 33memantine oral solution . . . . . . . . . . . . 33memantine oral tablet 5 mg . . . . . . . . 33memantine oral tablet 10 mg . . . . . . . 33memantine oral tablets,dose pack . . 33MENACTRA (PF) INTRAMUSCULAR SOLUTION . . . . 55MENVEO A-C-Y-W-135-DIP (PF) . . . 55mercaptopurine . . . . . . . . . . . . . . . . . . . . 28meropenem . . . . . . . . . . . . . . . . . . . . . . . 23MEROPENEM- 0.9% SODIUM CHLORIDE . . . . . . . . . 23mesalamine oral capsule, extended release 24hr . . . . . . . . . . . . . 53mesalamine oral tablet, delayed release (dr/ec) 1.2 gram . . . 53mesalamine rectal enema . . . . . . . . . . 53mesalamine with cleansing wipe . . . . 53

low-ogestrel (28) . . . . . . . . . . . . . . . . . . 58loxapine succinate . . . . . . . . . . . . . . . . . 39lo-zumandimine (28) . . . . . . . . . . . . . . . 58LUMIGAN OPHTHALMIC (EYE) DROPS 0.01% . . . . . . . . . . . . . . 60LUMIZYME . . . . . . . . . . . . . . . . . . . . . . . 52LUMOXITI . . . . . . . . . . . . . . . . . . . . . . . . 27LUPRON DEPOT . . . . . . . . . . . . . . . . . 27LUPRON DEPOT (3 MONTH) . . . . . . 27LUPRON DEPOT (4 MONTH) . . . . . . 28LUPRON DEPOT (6 MONTH) . . . . . . 28LUPRON DEPOT-PED . . . . . . . . . . . . 28LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG . . . . . . . . . . . 28LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG . . . . . . . . . . . . . . 28lutera (28) . . . . . . . . . . . . . . . . . . . . . . . . . 58LYNPARZA ORAL TABLET . . . . . . . . . 28LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 165 MG, 82.5 MG . . . . . . . . . . . 32LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR 330 MG . . . . . . . . . . . . . . . . . . . . 32LYRICA ORAL CAPSULE 75 MG . . . 32LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG . . . 32LYRICA ORAL CAPSULE 225 MG, 300 MG . . . . . . . . . . . . . . . . . . 32LYRICA ORAL SOLUTION . . . . . . . . . 32LYSODREN . . . . . . . . . . . . . . . . . . . . . . . 28lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

MMAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/100 ML . . . . . . . . . . . . . . . . . . 63magnesium sulfate injection . . . . . . . . 63magnesium sulfate in water . . . . . . . . 63malathion . . . . . . . . . . . . . . . . . . . . . . . . . 47

80


Covered Drugs Index

MORPHINE INTRAVENOUS SYRINGE 8 MG/ML . . . . . . . . . . . . . . . 35MORPHINE INTRAVENOUS SYRINGE 10 MG/ML . . . . . . . . . . . . . . 35morphine oral solution 10 mg/5 ml . . 35morphine oral solution 20 mg/5 ml (4 mg/ml) . . . . . . . . . . . . . . 35MORPHINE ORAL TABLET . . . . . . . . 35morphine oral tablet extended release . . . . . . . . . . . . . . . . . . 35morphine (pf) injection solution 0.5 mg/ml, 1 mg/ml . . . . . . . . 35moxifloxacin ophthalmic (eye) drops . . . . . . . . . . . . . . . . . . . . . . . . 60moxifloxacin oral . . . . . . . . . . . . . . . . . . 24MOXIFLOXACIN-SOD.ACE, SUL-WATER . . . . . . . . . . . . . . . . . . . . . . 24moxifloxacin-sod.chloride(iso) . . . . . . 24MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . . 55MULTAQ . . . . . . . . . . . . . . . . . . . . . . . . . . 40mupirocin . . . . . . . . . . . . . . . . . . . . . . . . . 45mupirocin calcium . . . . . . . . . . . . . . . . . 45MVASI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28mycophenolate mofetil (hcl) . . . . . . . . 28mycophenolate mofetil oral capsule . . 28mycophenolate mofetil oral suspension for reconstitution . . . . . . . 28mycophenolate mofetil oral tablet . . . 28mycophenolate sodium . . . . . . . . . . . . 28MYLOTARG . . . . . . . . . . . . . . . . . . . . . . . 28MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG . . . . . . . . . . . . . . . . . . . . . 63MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG . . . . . . . . . . . . . . . . . . . . . 63

Nnabumetone . . . . . . . . . . . . . . . . . . . . . . . 36nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42nadolol-bendroflumethiazide oral tablet 80-5 mg . . . . . . . . . . . . . . . . . 42

mirtazapine oral tablet, disintegrating . . . . . . . . . . . . . . . . . . . . . . 39misoprostol . . . . . . . . . . . . . . . . . . . . . . . 54MITIGARE . . . . . . . . . . . . . . . . . . . . . . . . 56MITIGO (PF) . . . . . . . . . . . . . . . . . . . . . . 35M-M-R II (PF) . . . . . . . . . . . . . . . . . . . . . 55moexipril . . . . . . . . . . . . . . . . . . . . . . . . . . 42molindone . . . . . . . . . . . . . . . . . . . . . . . . . 39mometasone nasal . . . . . . . . . . . . . . . . 62mometasone topical . . . . . . . . . . . . . . . 46mono-linyah . . . . . . . . . . . . . . . . . . . . . . . 59montelukast oral granules in packet . . . . . . . . . . . . . . . . . . . . . . . . . . 62montelukast oral tablet . . . . . . . . . . . . . 62montelukast oral tablet,chewable . . . 62morgidox oral capsule 50 mg . . . . . . . 24morgidox oral capsule 100 mg . . . . . . 24morphine concentrate oral solution . 35MORPHINE INJECTION SOLUTION 2 MG/ML . . . . . . . . . . . . . . 35MORPHINE INJECTION SOLUTION 4 MG/ML . . . . . . . . . . . . . . 35MORPHINE INJECTION SOLUTION 5 MG/ML . . . . . . . . . . . . . . 35morphine injection solution 8 mg/ml . 35MORPHINE INJECTION SOLUTION 10 MG/ML . . . . . . . . . . . . . 35morphine injection syringe 2 mg/ml . 35morphine injection syringe 4 mg/ml . 35morphine injection syringe 5 mg/ml . 35morphine injection syringe 8 mg/ml . 35morphine injection syringe 10 mg/ml 35MORPHINE INTRAVENOUS SOLUTION 4 MG/ML . . . . . . . . . . . . . . 35MORPHINE INTRAVENOUS SOLUTION 8 MG/ML . . . . . . . . . . . . . . 35morphine intravenous solution 10 mg/ml . . . . . . . . . . . . . . . . . . 35morphine intravenous syringe 2 mg/ml . . . . . . . . . . . . . . . . . . . 35morphine intravenous syringe 4 mg/ml . . . . . . . . . . . . . . . . . . . 35

methylphenidate hcl oral tablet extended release 24hr 18 mg, 18 mg (bx rating) . . . . . . 39methylphenidate hcl oral tablet extended release 24hr 27 mg, 27 mg (bx rating), 54 mg, 54 mg (bx rating) . . . . . . . . . . . 39methylphenidate hcl oral tablet extended release 24hr 36 mg, 36 mg (bx rating) . . . . . . 39methylprednisolone . . . . . . . . . . . . . . . . 48methylprednisolone acetate . . . . . . . . 48methylprednisolone sodium succ injection recon soln 125 mg, 40 mg . . 48methylprednisolone sodium succ intravenous recon soln 1,000 mg . . . 49methylprednisolone sodium succ intravenous recon soln 500 mg . . . . . 49metoclopramide hcl oral solution . . . . 53metoclopramide hcl oral tablet . . . . . . 53metolazone . . . . . . . . . . . . . . . . . . . . . . . 42metoprolol succinate . . . . . . . . . . . . . . . 42metoprolol ta-hydrochlorothiaz . . . . . 42metoprolol tartrate oral . . . . . . . . . . . . . 42metro i.v. . . . . . . . . . . . . . . . . . . . . . . . . . . 23metronidazole in nacl (iso-os) . . . . . . 23metronidazole oral tablet . . . . . . . . . . . 23metronidazole topical . . . . . . . . . . . . . . 45metronidazole vaginal . . . . . . . . . . . . . . 57mexiletine . . . . . . . . . . . . . . . . . . . . . . . . . 40mibelas 24 fe . . . . . . . . . . . . . . . . . . . . . . 59microgestin 1.5/30 (21) . . . . . . . . . . . . 59microgestin 1/20 (21) . . . . . . . . . . . . . . 59microgestin fe 1.5/30 (28) . . . . . . . . . . 59microgestin fe 1/20 (28) . . . . . . . . . . . . 59midodrine . . . . . . . . . . . . . . . . . . . . . . . . . 47miglustat . . . . . . . . . . . . . . . . . . . . . . . . . . 52mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59minitran . . . . . . . . . . . . . . . . . . . . . . . . . . . 44minocycline oral capsule . . . . . . . . . . . 24minoxidil oral . . . . . . . . . . . . . . . . . . . . . . 42mirtazapine oral tablet . . . . . . . . . . . . . 39

81


Covered Drugs Index

nora-be . . . . . . . . . . . . . . . . . . . . . . . . . . . 57noreth-ethinyl estradiol-iron . . . . . . . . 59norethindrone acetate . . . . . . . . . . . . . . 57norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg . . . . . . . . . . . . . . . . . . . . 59norethindrone (contraceptive) . . . . . . 57norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1.5 mg-30 mcg (21)/75 mg (7) . . 59norethindrone-e.estradiol-iron oral tablet,chewable . . . . . . . . . . . . . . . 59norgestimate-ethinyl estradiol . . . . . . 59NORMOSOL-M IN 5% DEXTROSE . 64NORMOSOL-R . . . . . . . . . . . . . . . . . . . . 63NORMOSOL-R IN 5% DEXTROSE . 63NORMOSOL-R PH 7.4 . . . . . . . . . . . . 64NORTHERA ORAL CAPSULE 100 MG . . . . . . . . . . . . . . . . 47NORTHERA ORAL CAPSULE 200 MG, 300 MG . . . . . . . 47nortrel 0.5/35 (28) . . . . . . . . . . . . . . . . . 59nortrel 1/35 (21) . . . . . . . . . . . . . . . . . . . 59nortrel 1/35 (28) . . . . . . . . . . . . . . . . . . . 59nortrel 7/7/7 (28) . . . . . . . . . . . . . . . . . . . 59nortriptyline . . . . . . . . . . . . . . . . . . . . . . . 39NORVIR ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 20NORVIR ORAL SOLUTION . . . . . . . . 20NOVOFINE PEN NEEDLE . . . . . . . . . 50NOVOTWIST PEN NEEDLE . . . . . . . 50NOXAFIL ORAL SUSPENSION . . . . 19NOXAFIL ORAL TABLET, DELAYED RELEASE (DR/EC) . . . . . 19NUBEQA . . . . . . . . . . . . . . . . . . . . . . . . . 28NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . . 33NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . . 28NUPLAZID ORAL CAPSULE . . . . . . . 39NUPLAZID ORAL TABLET 10 MG . . 39NUTRILIPID . . . . . . . . . . . . . . . . . . . . . . . 64NUZYRA INTRAVENOUS . . . . . . . . . . 24NUZYRA ORAL . . . . . . . . . . . . . . . . . . . 24

neomycin-polymyxin-hc otic (ear) . . . 48neo-polycin . . . . . . . . . . . . . . . . . . . . . . . 60neo-polycin hc . . . . . . . . . . . . . . . . . . . . . 61NEPHRAMINE 5.4% . . . . . . . . . . . . . . . 64NERLYNX . . . . . . . . . . . . . . . . . . . . . . . . 28NEULASTA . . . . . . . . . . . . . . . . . . . . . . . 55NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . . 33nevirapine oral suspension . . . . . . . . . 20nevirapine oral tablet . . . . . . . . . . . . . . 20nevirapine oral tablet extended release 24 hr 100 mg . . . . . 20nevirapine oral tablet extended release 24 hr 400 mg . . . . . 20NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . . . 28niacin oral tablet extended release 24 hr . . . . . . . . . . . . 44nicardipine intravenous solution . . . . 42nicardipine oral . . . . . . . . . . . . . . . . . . . . 42NICOTROL . . . . . . . . . . . . . . . . . . . . . . . 48NICOTROL NS . . . . . . . . . . . . . . . . . . . . 48nifedipine oral tablet extended release . . . . . . . . . . . . . . . . . . 42nifedipine oral tablet extended release 24hr . . . . . . . . . . . . . 42nikki (28) . . . . . . . . . . . . . . . . . . . . . . . . . . 59nilutamide . . . . . . . . . . . . . . . . . . . . . . . . . 28nimodipine . . . . . . . . . . . . . . . . . . . . . . . . 42NINLARO . . . . . . . . . . . . . . . . . . . . . . . . . 28nisoldipine . . . . . . . . . . . . . . . . . . . . . . . . 42nitisinone . . . . . . . . . . . . . . . . . . . . . . . . . 47nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . 24nitrofurantoin macrocrystal oral capsule 25 mg . . . . . . . . . . . . . . . . 25nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg . . . . . . . . 24nitrofurantoin monohyd/m-cryst . . . . . 25nitroglycerin intravenous . . . . . . . . . . . 44nitroglycerin sublingual . . . . . . . . . . . . . 44nitroglycerin transdermal patch 24 hour . . . . . . . . . . . . . . . . . . . . . 44nitroglycerin translingual spray,non-aerosol . . . . . . . . . . . . . . . . . 44

nafcillin . . . . . . . . . . . . . . . . . . . . . . . . . . . 24nafcillin in dextrose iso-osm . . . . . . . . 24NAGLAZYME . . . . . . . . . . . . . . . . . . . . . 52nalbuphine injection solution 10 mg/ml . . . . . . . . . . . . . . . . . . 36nalbuphine injection solution 20 mg/ml . . . . . . . . . . . . . . . . . . 36naloxone injection solution . . . . . . . . . 36naloxone injection syringe 1 mg/ml . 36naltrexone . . . . . . . . . . . . . . . . . . . . . . . . 36NAMZARIC ORAL CAP, SPRINKLE,ER 24HR DOSE PACK . 33NAMZARIC ORAL CAPSULE, SPRINKLE,ER 24HR . . . . . . . . . . . . . . 33naproxen oral suspension . . . . . . . . . . 36naproxen oral tablet . . . . . . . . . . . . . . . 36naproxen oral tablet, delayed release (dr/ec) . . . . . . . . . . . . 36naproxen sodium oral tablet 275 mg, 550 mg . . . . . . . . . . . . . 36naratriptan . . . . . . . . . . . . . . . . . . . . . . . . 33NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION . . . . . 36nasonex . . . . . . . . . . . . . . . . . . . . . . . . . . 62NATACYN . . . . . . . . . . . . . . . . . . . . . . . . . 60nateglinide oral tablet 60 mg . . . . . . . 50nateglinide oral tablet 120 mg . . . . . . 50NATPARA . . . . . . . . . . . . . . . . . . . . . . . . . 52NAYZILAM . . . . . . . . . . . . . . . . . . . . . . . . 32NEBUPENT . . . . . . . . . . . . . . . . . . . . . . . 23necon 0.5/35 (28) . . . . . . . . . . . . . . . . . . 59NEEDLES, INSULIN DISP.,SAFETY . . . . . . . . . . . . . . . . . . . . 50nefazodone . . . . . . . . . . . . . . . . . . . . . . . 39neomycin . . . . . . . . . . . . . . . . . . . . . . . . . 23neomycin-bacitracin-poly-hc . . . . . . . . 61neomycin-bacitracin-polymyxin . . . . . 60neomycin-polymyxin b-dexameth . . . 61neomycin-polymyxin b gu . . . . . . . . . . 47neomycin-polymyxin-gramicidin . . . . 60neomycin-polymyxin-hc ophthalmic (eye) . . . . . . . . . . . . . . . . . . . 61

82


Covered Drugs Index

oxymorphone oral tablet extended release 12 hr . . . . . . . . . . . . 35OZEMPIC . . . . . . . . . . . . . . . . . . . . . . . . . 50

Ppacerone oral tablet 100 mg, 200 mg, 400 mg . . . . . . . . . . . 40paclitaxel . . . . . . . . . . . . . . . . . . . . . . . . . . 28PADCEV . . . . . . . . . . . . . . . . . . . . . . . . . . 28paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg . . . 39paliperidone oral tablet extended release 24hr 6 mg . . . . . . . . 39pamidronate . . . . . . . . . . . . . . . . . . . . . . . 52PANRETIN . . . . . . . . . . . . . . . . . . . . . . . . 45pantoprazole oral . . . . . . . . . . . . . . . . . . 54paricalcitol oral . . . . . . . . . . . . . . . . . . . . 52paroex oral rinse . . . . . . . . . . . . . . . . . . 48paromomycin . . . . . . . . . . . . . . . . . . . . . . 23paroxetine hcl oral tablet 10 mg, 30 mg, 40 mg . . . . . . . . . . . . . . 39paroxetine hcl oral tablet 20 mg . . . . 39PASER . . . . . . . . . . . . . . . . . . . . . . . . . . . 23PAXIL ORAL SUSPENSION . . . . . . . 39PAZEO . . . . . . . . . . . . . . . . . . . . . . . . . . . 60PEDIARIX (PF) . . . . . . . . . . . . . . . . . . . . 55PEDVAX HIB (PF) . . . . . . . . . . . . . . . . . 55peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram . . . . 53PEGANONE . . . . . . . . . . . . . . . . . . . . . . 32peg-electrolyte . . . . . . . . . . . . . . . . . . . . 53PEMAZYRE . . . . . . . . . . . . . . . . . . . . . . . 28penicillamine . . . . . . . . . . . . . . . . . . . . . . 57penicillin g potassium . . . . . . . . . . . . . . 24penicillin v potassium . . . . . . . . . . . . . . 24PENTAM . . . . . . . . . . . . . . . . . . . . . . . . . . 23pentamidine inhalation . . . . . . . . . . . . . 23pentamidine injection . . . . . . . . . . . . . . 23PENTASA . . . . . . . . . . . . . . . . . . . . . . . . . 53pentoxifylline . . . . . . . . . . . . . . . . . . . . . . 43PERFOROMIST . . . . . . . . . . . . . . . . . . . 62

ondansetron . . . . . . . . . . . . . . . . . . . . . . . 53ondansetron hcl intravenous . . . . . . . 53ondansetron hcl oral solution . . . . . . . 53ondansetron hcl oral tablet . . . . . . . . . 53ondansetron hcl (pf) . . . . . . . . . . . . . . . 53ONTRUZANT . . . . . . . . . . . . . . . . . . . . . 28OPDIVO . . . . . . . . . . . . . . . . . . . . . . . . . . 28OPSUMIT . . . . . . . . . . . . . . . . . . . . . . . . . 62oralone . . . . . . . . . . . . . . . . . . . . . . . . . . . 48ORENCIA . . . . . . . . . . . . . . . . . . . . . . . . . 57ORENCIA CLICKJECT . . . . . . . . . . . . 57ORFADIN . . . . . . . . . . . . . . . . . . . . . . . . . 47ORKAMBI ORAL GRANULES IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 62ORKAMBI ORAL TABLET . . . . . . . . . . 62orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . . 59oseltamivir oral capsule . . . . . . . . . . . . 20oseltamivir oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 20oxacillin injection . . . . . . . . . . . . . . . . . . 24oxandrolone oral tablet 2.5 mg . . . . . 52oxandrolone oral tablet 10 mg . . . . . . 52oxaprozin . . . . . . . . . . . . . . . . . . . . . . . . . 36oxazepam . . . . . . . . . . . . . . . . . . . . . . . . . 39oxcarbazepine . . . . . . . . . . . . . . . . . . . . 32oxybutynin chloride oral syrup . . . . . . 63oxybutynin chloride oral tablet . . . . . . 63oxybutynin chloride oral tablet extended release 24hr . . . . . . . 63oxycodone-acetaminophen oral tablet 2.5-300 mg . . . . . . . . . . . . . . 35oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg . . . 35oxycodone-acetaminophen oral tablet 7.5-325 mg . . . . . . . . . . . . . . 35oxycodone-acetaminophen oral tablet 10-325 mg . . . . . . . . . . . . . . 35oxycodone-aspirin . . . . . . . . . . . . . . . . . 35oxycodone oral concentrate . . . . . . . . 35oxycodone oral solution . . . . . . . . . . . . 35oxycodone oral tablet . . . . . . . . . . . . . . 35

nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . . 46nystatin oral suspension . . . . . . . . . . . 19nystatin oral tablet . . . . . . . . . . . . . . . . . 19nystatin topical cream . . . . . . . . . . . . . . 46nystatin topical ointment . . . . . . . . . . . 46nystatin topical powder . . . . . . . . . . . . . 46nystatin-triamcinolone . . . . . . . . . . . . . . 46nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

OOCALIVA . . . . . . . . . . . . . . . . . . . . . . . . . 53ocella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59OCREVUS . . . . . . . . . . . . . . . . . . . . . . . . 33octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml . . . . . . . . . . . 28octreotide acetate injection solution 50 mcg/ml . . . . . . . . . . . . . . . . . 28ODEFSEY . . . . . . . . . . . . . . . . . . . . . . . . 20ODOMZO . . . . . . . . . . . . . . . . . . . . . . . . . 28OFEV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62ofloxacin ophthalmic (eye) . . . . . . . . . 60ogestrel (28) . . . . . . . . . . . . . . . . . . . . . . 59OGIVRI . . . . . . . . . . . . . . . . . . . . . . . . . . . 28olanzapine-fluoxetine . . . . . . . . . . . . . . 39olanzapine intramuscular . . . . . . . . . . . 39olanzapine oral tablet 7.5 mg . . . . . . . 39olanzapine oral tablet 10 mg, 2.5 mg, 5 mg . . . . . . . . . . . . . . . 39olanzapine oral tablet 15 mg, 20 mg . . . . . . . . . . . . . . . . . . . . . 39olanzapine oral tablet,disintegrating . . 39olmesartan . . . . . . . . . . . . . . . . . . . . . . . . 42olmesartan-hydrochlorothiazide . . . . 42olopatadine ophthalmic (eye) . . . . . . . 60OLUX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47omeprazole oral capsule, delayed release(dr/ec) . . . . . . . . . . . . . 54OMNIPOD 5 PACK . . . . . . . . . . . . . . . . 50OMNIPOD DASH 5 PACK. . . . . . . . . . 50OMNIPOD STARTER KIT . . . . . . . . . . 50

83


Covered Drugs Index

potassium chloride oral capsule, extended release . . . . . . . . . 63potassium chloride oral liquid . . . . . . . 64potassium chloride oral packet . . . . . 64potassium chloride oral tablet, er particles/crystals . . . . . . . . . . . . . . . . 64potassium chloride oral tablet extended release . . . . . . . . . . . . 64potassium citrate . . . . . . . . . . . . . . . . . . 63POTELIGEO . . . . . . . . . . . . . . . . . . . . . . 28PRADAXA . . . . . . . . . . . . . . . . . . . . . . . . 43pramipexole oral tablet . . . . . . . . . . . . . 33prasugrel . . . . . . . . . . . . . . . . . . . . . . . . . . 43pravastatin oral tablet 10 mg, 20 mg, 80 mg . . . . . . . . . . . . . . 44pravastatin oral tablet 40 mg . . . . . . . 44praziquantel . . . . . . . . . . . . . . . . . . . . . . . 23prazosin . . . . . . . . . . . . . . . . . . . . . . . . . . 42PRED MILD . . . . . . . . . . . . . . . . . . . . . . . 61prednicarbate topical ointment . . . . . . 47prednisolone acetate . . . . . . . . . . . . . . 61prednisolone oral solution 15 mg/5 ml . . . . . . . . . . . . . . . . . . . . . . . . 49prednisolone sodium phosphate ophthalmic (eye) . . . . . . . . . . . . . . . . . . . 61prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 15 mg/5 ml (5 ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) . . . . . . 49prednisone intensol . . . . . . . . . . . . . . . . 49prednisone oral solution . . . . . . . . . . . . 49prednisone oral tablet . . . . . . . . . . . . . . 49prednisone oral tablets,dose pack . . 49pregabalin oral capsule 75 mg . . . . . . 32pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg . . . . . 32pregabalin oral capsule 225 mg, 300 mg . . . . . . . . . . . . . . . . . . . 32pregabalin oral solution . . . . . . . . . . . . 32PREMARIN INJECTION . . . . . . . . . . . 57PREMARIN ORAL . . . . . . . . . . . . . . . . . 57

PIQRAY ORAL TABLET 200 MG/DAY (200 MG X 1) . . . . . . . . 28PIQRAY ORAL TABLET 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X 2) . . . . . . . . . . . . . 28pirmella . . . . . . . . . . . . . . . . . . . . . . . . . . . 59PLENAMINE . . . . . . . . . . . . . . . . . . . . . . 64PLENVU . . . . . . . . . . . . . . . . . . . . . . . . . . 53podofilox . . . . . . . . . . . . . . . . . . . . . . . . . . 45polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60polymyxin b sulf-trimethoprim . . . . . . 60POMALYST . . . . . . . . . . . . . . . . . . . . . . . 28portia 28 . . . . . . . . . . . . . . . . . . . . . . . . . . 59posaconazole oral tablet, delayed release (dr/ec) . . . . . . . . . . . . 19POTASSIUM CHLORID-D5- 0.45%NACL INTRAVENOUS PARENTERAL SOLUTION 10 MEQ/L, 20 MEQ/L, 40 MEQ/L . . . 63potassium chlorid-d5- 0.45%nacl intravenous parenteral solution 30 meq/l . . . . . . . . 63potassium chloride-0.45% nacl . . . . . 64POTASSIUM CHLORIDE-D5-0.2% NACL INTRAVENOUS PARENTERAL SOLUTION 20 MEQ/L . . . . . . . . . . . . . 64potassium chloride-d5- 0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l . . . . . . . . . 64potassium chloride-d5- 0.3%nacl intravenous parenteral solution 20 meq/l . . . . . . . . 64POTASSIUM CHLORIDE- D5-0.9%NACL . . . . . . . . . . . . . . . . . . . . 64potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l . . . . . . . . . . . . . . . . . 63potassium chloride in 5% dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l . . . . . . . 63potassium chloride in lr-d5 . . . . . . . . . 63potassium chloride intravenous . . . . . 63potassium chloride in water intravenous piggyback . . . . . . . 63

PERIKABIVEN . . . . . . . . . . . . . . . . . . . . 64perindopril erbumine . . . . . . . . . . . . . . . 42PERJETA . . . . . . . . . . . . . . . . . . . . . . . . . 28permethrin topical cream . . . . . . . . . . . 47perphenazine . . . . . . . . . . . . . . . . . . . . . 39perphenazine-amitriptyline . . . . . . . . . 39PERSERIS . . . . . . . . . . . . . . . . . . . . . . . . 39pfizerpen-g . . . . . . . . . . . . . . . . . . . . . . . . 24phenelzine . . . . . . . . . . . . . . . . . . . . . . . . 39phenobarbital oral elixir . . . . . . . . . . . . 32phenobarbital oral tablet . . . . . . . . . . . 32phenoxybenzamine . . . . . . . . . . . . . . . . 42phenytoin oral suspension . . . . . . . . . 32phenytoin oral tablet,chewable . . . . . 32phenytoin sodium extended . . . . . . . . 32philith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59PHOSLYRA . . . . . . . . . . . . . . . . . . . . . . . 63PHOSPHOLINE IODIDE . . . . . . . . . . . 60PHYSIOLYTE . . . . . . . . . . . . . . . . . . . . . 47PHYSIOSOL IRRIGATION . . . . . . . . . 47PICATO TOPICAL GEL 0.05% . . . . . 45PICATO TOPICAL GEL 0.015% . . . . 45PIFELTRO . . . . . . . . . . . . . . . . . . . . . . . . 20pilocarpine hcl ophthalmic (eye) drops 1%, 2%, 4% . . . . . . . . . . . 60pilocarpine hcl oral . . . . . . . . . . . . . . . . . 47pimecrolimus . . . . . . . . . . . . . . . . . . . . . . 45pimozide . . . . . . . . . . . . . . . . . . . . . . . . . . 39pimtrea (28) . . . . . . . . . . . . . . . . . . . . . . . 59pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 42pioglitazone-metformin . . . . . . . . . . . . . 50pioglitazone oral tablet 15 mg . . . . . . 50pioglitazone oral tablet 30 mg, 45 mg . . . . . . . . . . . . . . . . . . . . . 50piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram . . . . . . . . . . . . . . . 24PIPERACILLIN-TAZOBACTAM INTRAVENOUS RECON SOLN 13.5 GRAM . . . . . . . . . . . . . . . . . . . . . . . 24

84


Covered Drugs Index

raloxifene . . . . . . . . . . . . . . . . . . . . . . . . . 56ramelteon . . . . . . . . . . . . . . . . . . . . . . . . . 39ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . . 42ranitidine hcl oral syrup . . . . . . . . . . . . 54ranitidine hcl oral tablet 150 mg, 300 mg . . . . . . . . . . . . . . . . . . . 54ranolazine . . . . . . . . . . . . . . . . . . . . . . . . . 44RAPAMUNE ORAL SOLUTION . . . . 28rasagiline . . . . . . . . . . . . . . . . . . . . . . . . . 33REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/ 0.2ML-22 MCG/0.5ML (6) . . . . . . . . . . 55REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML . . . 55REBIF TITRATION PACK . . . . . . . . . . 55REBIF (WITH ALBUMIN) . . . . . . . . . . . 55reclipsen (28) . . . . . . . . . . . . . . . . . . . . . 59RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 5 MCG/0.5 ML . . . . . . . . . . . . . . . . . . . . 55RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML . . . . . . . . . . 55RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE . . . . . . 55RECTIV . . . . . . . . . . . . . . . . . . . . . . . . . . . 53regonol . . . . . . . . . . . . . . . . . . . . . . . . . . . 34REGRANEX . . . . . . . . . . . . . . . . . . . . . . 45RELISTOR SUBCUTANEOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 53RELISTOR SUBCUTANEOUS SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . . 53REMODULIN . . . . . . . . . . . . . . . . . . . . . . 42RENACIDIN IRRIGATION SOLUTION 1980.6 MG- 59.4 MG-980.4MG/30ML . . . . . . . . . . . 63RENFLEXIS . . . . . . . . . . . . . . . . . . . . . . . 53RENVELA ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 48RENVELA ORAL TABLET . . . . . . . . . . 48repaglinide oral tablet 0.5 mg, 1 mg . . 51repaglinide oral tablet 2 mg . . . . . . . . 51

PROMACTA ORAL TABLET . . . . . . . . 43promethazine oral . . . . . . . . . . . . . . . . . 61propafenone . . . . . . . . . . . . . . . . . . . . . . 40propantheline . . . . . . . . . . . . . . . . . . . . . 52propranolol-hydrochlorothiazid . . . . . 42propranolol oral capsule, extended release 24 hr . . . . . . . . . . . . 42propranolol oral solution . . . . . . . . . . . 42propranolol oral tablet . . . . . . . . . . . . . . 42propylthiouracil . . . . . . . . . . . . . . . . . . . . 49PROQUAD (PF) . . . . . . . . . . . . . . . . . . . 55PROSOL 20% . . . . . . . . . . . . . . . . . . . . . 64protriptyline . . . . . . . . . . . . . . . . . . . . . . . 39PULMOZYME . . . . . . . . . . . . . . . . . . . . . 62PURIXAN . . . . . . . . . . . . . . . . . . . . . . . . . 28pyrazinamide . . . . . . . . . . . . . . . . . . . . . . 23pyridostigmine bromide oral syrup . . 34pyridostigmine bromide oral tablet 60 mg . . . . . . . . . . . . . . . . . . 34pyridostigmine bromide oral tablet extended release . . . . . . . . 34pyrimethamine . . . . . . . . . . . . . . . . . . . . 23

QQUADRACEL (PF) . . . . . . . . . . . . . . . . 55quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg . . . . . 39quetiapine oral tablet 300 mg, 400 mg . . . . . . . . . . . . . . . . . . . 39quetiapine oral tablet extended release 24 hr 150 mg, 200 mg . . . . . . 39quetiapine oral tablet extended release 24 hr 300 mg, 400 mg, 50 mg . . . . . . . . . . . . 39quinapril . . . . . . . . . . . . . . . . . . . . . . . . . . 42quinapril-hydrochlorothiazide . . . . . . . 42quinidine sulfate oral tablet . . . . . . . . . 40quinine sulfate . . . . . . . . . . . . . . . . . . . . . 23

RRABAVERT (PF) . . . . . . . . . . . . . . . . . . 55

PREMARIN VAGINAL . . . . . . . . . . . . . 57PREMASOL 10% . . . . . . . . . . . . . . . . . . 64PREMPRO ORAL TABLET 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG . . . . . . . . . . . . . . . . . . . . . . . 57PRENATAL VITAMIN ORAL TABLET . 64prevalite . . . . . . . . . . . . . . . . . . . . . . . . . . 44previfem . . . . . . . . . . . . . . . . . . . . . . . . . . 59PREZCOBIX . . . . . . . . . . . . . . . . . . . . . . 20PREZISTA ORAL SUSPENSION . . . 20PREZISTA ORAL TABLET 75 MG . . 20PREZISTA ORAL TABLET 150 MG . 20PREZISTA ORAL TABLET 600 MG . 20PREZISTA ORAL TABLET 800 MG . 20PRIFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 23PRIMAQUINE . . . . . . . . . . . . . . . . . . . . . 23primidone . . . . . . . . . . . . . . . . . . . . . . . . . 32PROAIR HFA . . . . . . . . . . . . . . . . . . . . . 62PROAIR RESPICLICK . . . . . . . . . . . . . 62probenecid . . . . . . . . . . . . . . . . . . . . . . . . 56probenecid-colchicine . . . . . . . . . . . . . . 56PROCALAMINE 3% . . . . . . . . . . . . . . . 64prochlorperazine . . . . . . . . . . . . . . . . . . 53prochlorperazine edisylate . . . . . . . . . 53prochlorperazine maleate oral . . . . . . 53procto-med hc . . . . . . . . . . . . . . . . . . . . . 53procto-pak . . . . . . . . . . . . . . . . . . . . . . . . 53proctosol hc topical . . . . . . . . . . . . . . . . 53proctozone-hc . . . . . . . . . . . . . . . . . . . . . 53progesterone micronized . . . . . . . . . . . 57PROGLYCEM . . . . . . . . . . . . . . . . . . . . . 51PROGRAF INTRAVENOUS . . . . . . . . 28PROGRAF ORAL GRANULES IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 28PROLASTIN-C . . . . . . . . . . . . . . . . . . . . 47PROLENSA . . . . . . . . . . . . . . . . . . . . . . . 60PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 56PROMACTA ORAL POWDER IN PACKET 12.5 MG . . . . . . . . . . . . . . 43PROMACTA ORAL POWDER IN PACKET 25 MG . . . . . . . . . . . . . . . . 43

85


Covered Drugs Index

SELZENTRY ORAL TABLET 150 MG, 75 MG . . . . . . . . . . . 20SELZENTRY ORAL TABLET 300 MG . . . . . . . . . . . . . . . . . . 20SENSIPAR ORAL TABLET 30 MG, 60 MG . . . . . . . . . . . . 52SENSIPAR ORAL TABLET 90 MG . . 52SEREVENT DISKUS . . . . . . . . . . . . . . 62sertraline oral concentrate . . . . . . . . . . 40sertraline oral tablet 50 mg . . . . . . . . . 40sertraline oral tablet 100 mg, 25 mg . . 40setlakin . . . . . . . . . . . . . . . . . . . . . . . . . . . 59sevelamer carbonate oral powder in packet . . . . . . . . . . . . . . 48sevelamer carbonate oral tablet . . . . 48sharobel . . . . . . . . . . . . . . . . . . . . . . . . . . 57SHINGRIX (PF) . . . . . . . . . . . . . . . . . . . 56SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . . 29sildenafil (pulmonary arterial hypertension) oral tablet . . . . . . . . . . . 62SILENOR . . . . . . . . . . . . . . . . . . . . . . . . . 40silver sulfadiazine . . . . . . . . . . . . . . . . . 45SIMBRINZA . . . . . . . . . . . . . . . . . . . . . . . 61simliya (28) . . . . . . . . . . . . . . . . . . . . . . . 59simpesse . . . . . . . . . . . . . . . . . . . . . . . . . 59SIMULECT . . . . . . . . . . . . . . . . . . . . . . . . 29simvastatin oral tablet . . . . . . . . . . . . . . 44sirolimus oral solution . . . . . . . . . . . . . . 29sirolimus oral tablet . . . . . . . . . . . . . . . . 29SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . . 23SIVEXTRO INTRAVENOUS . . . . . . . . 23SIVEXTRO ORAL . . . . . . . . . . . . . . . . . 23SKYRIZI SUBCUTANEOUS SYRINGE KIT . . . . . . . . . . . . . . . . . . . . . 44sodium bicarbonate intravenous syringe 10 meq/10 ml (8.4%), 7.5% (0.9 meq/ml), 8.4% (1 meq/ml) . . . . . 64sodium chloride 0.9% intravenous . . 48sodium chloride 0.45% intravenous parenteral solution . . . . . 64sodium chloride 3% . . . . . . . . . . . . . . . . 64sodium chloride 5% . . . . . . . . . . . . . . . . 64

rivelsa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59rizatriptan oral tablet . . . . . . . . . . . . . . . 33rizatriptan oral tablet,disintegrating . . 33ROCKLATAN . . . . . . . . . . . . . . . . . . . . . . 61ROMIDEPSIN INTRAVENOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . 29ropinirole oral tablet . . . . . . . . . . . . . . . . 33ropinirole oral tablet extended release 24 hr . . . . . . . . . . . . 33rosadan topical cream . . . . . . . . . . . . . 45rosadan topical gel . . . . . . . . . . . . . . . . 45rosuvastatin . . . . . . . . . . . . . . . . . . . . . . . 44ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . . 56ROTATEQ VACCINE . . . . . . . . . . . . . . 56roweepra . . . . . . . . . . . . . . . . . . . . . . . . . . 32roweepra xr . . . . . . . . . . . . . . . . . . . . . . . 32ROZLYTREK ORAL CAPSULE 100 MG . . . . . . . . . . . . . . . . 29ROZLYTREK ORAL CAPSULE 200 MG . . . . . . . . . . . . . . . . 29RUBRACA . . . . . . . . . . . . . . . . . . . . . . . . 29RUCONEST . . . . . . . . . . . . . . . . . . . . . . 62RUXIENCE . . . . . . . . . . . . . . . . . . . . . . . 29RYDAPT . . . . . . . . . . . . . . . . . . . . . . . . . . 29RYTARY . . . . . . . . . . . . . . . . . . . . . . . . . . 33

SSAMSCA ORAL TABLET 15 MG . . . . 52SAMSCA ORAL TABLET 30 MG . . . . 52SANCUSO . . . . . . . . . . . . . . . . . . . . . . . . 53SANDIMMUNE ORAL SOLUTION . . 29SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . . 45SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . . 40SARCLISA . . . . . . . . . . . . . . . . . . . . . . . . 29scopolamine base . . . . . . . . . . . . . . . . . 53SECUADO . . . . . . . . . . . . . . . . . . . . . . . . 40selegiline hcl . . . . . . . . . . . . . . . . . . . . . . 33selenium sulfide topical lotion . . . . . . 44SELZENTRY ORAL SOLUTION . . . . 20SELZENTRY ORAL TABLET 25 MG . . 20

REPATHA . . . . . . . . . . . . . . . . . . . . . . . . . 44REPATHA PUSHTRONEX . . . . . . . . . 44REPATHA SURECLICK . . . . . . . . . . . . 44RESTASIS . . . . . . . . . . . . . . . . . . . . . . . . 60RESTASIS MULTIDOSE . . . . . . . . . . . 60RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML . . . . 55RETACRIT INJECTION SOLUTION 40,000 UNIT/ML . . . . . . . 55RETROVIR INTRAVENOUS . . . . . . . 20REVLIMID ORAL CAPSULE 10 MG, 2.5 MG, 5 MG . . . . . . . . . . . . . 28REVLIMID ORAL CAPSULE 15 MG, 20 MG, 25 MG . . . . . . . . . . . . . 28REXULTI . . . . . . . . . . . . . . . . . . . . . . . . . . 39REYATAZ ORAL POWDER IN PACKET . . . . . . . . . . . . . . . . . . . . . . . 20RHOPRESSA . . . . . . . . . . . . . . . . . . . . . 61ribavirin oral capsule . . . . . . . . . . . . . . . 20ribavirin oral tablet 200 mg . . . . . . . . . 20rifabutin . . . . . . . . . . . . . . . . . . . . . . . . . . . 23rifampin . . . . . . . . . . . . . . . . . . . . . . . . . . . 23riluzole . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48rimantadine . . . . . . . . . . . . . . . . . . . . . . . 20ringer’s intravenous . . . . . . . . . . . . . . . . 64ringer’s irrigation . . . . . . . . . . . . . . . . . . . 47RINVOQ . . . . . . . . . . . . . . . . . . . . . . . . . . 57RIOMET . . . . . . . . . . . . . . . . . . . . . . . . . . 51RISPERDAL CONSTA . . . . . . . . . . . . . 39risperidone oral solution . . . . . . . . . . . . 39risperidone oral tablet . . . . . . . . . . . . . . 39risperidone oral tablet, disintegrating 0.5 mg, 4 mg . . . . . . . . 40risperidone oral tablet, disintegrating 0.25 mg, 1 mg, 2 mg, 3 mg . . . . . . . . . . . . . . . . . . 39ritonavir . . . . . . . . . . . . . . . . . . . . . . . . . . . 20RITUXAN . . . . . . . . . . . . . . . . . . . . . . . . . 28RITUXAN HYCELA . . . . . . . . . . . . . . . . 29rivastigmine . . . . . . . . . . . . . . . . . . . . . . . 33rivastigmine tartrate . . . . . . . . . . . . . . . . 33

86


Covered Drugs Index

syeda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG . . . . . . . . . . . 55SYMFI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21SYMFI LO . . . . . . . . . . . . . . . . . . . . . . . . 21SYMLINPEN 60 . . . . . . . . . . . . . . . . . . . 51SYMLINPEN 120 . . . . . . . . . . . . . . . . . . 51SYMPAZAN . . . . . . . . . . . . . . . . . . . . . . . 32SYMTUZA . . . . . . . . . . . . . . . . . . . . . . . . 21SYNAGIS . . . . . . . . . . . . . . . . . . . . . . . . . 21SYNAREL . . . . . . . . . . . . . . . . . . . . . . . . 52SYNERCID . . . . . . . . . . . . . . . . . . . . . . . 23SYNJARDY . . . . . . . . . . . . . . . . . . . . . . . 51SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG . . . . . . . . 51SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 25-1,000 MG . 51SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . . 29SYNTHROID . . . . . . . . . . . . . . . . . . . . . . 52

TTABLOID . . . . . . . . . . . . . . . . . . . . . . . . . 29tacrolimus oral . . . . . . . . . . . . . . . . . . . . 29tacrolimus topical . . . . . . . . . . . . . . . . . . 45TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . . 29TAGRISSO . . . . . . . . . . . . . . . . . . . . . . . . 29TALZENNA . . . . . . . . . . . . . . . . . . . . . . . 29tamoxifen . . . . . . . . . . . . . . . . . . . . . . . . . 29tamsulosin . . . . . . . . . . . . . . . . . . . . . . . . 63TARGRETIN TOPICAL . . . . . . . . . . . . 29tarina 24 fe . . . . . . . . . . . . . . . . . . . . . . . . 59tarina fe 1/20 (28) . . . . . . . . . . . . . . . . . 59tarina fe 1-20 eq (28) . . . . . . . . . . . . . . 59TASIGNA ORAL CAPSULE 50 MG . 29TASIGNA ORAL CAPSULE 150 MG, 200 MG . . . . . . . . . . . . . . . . . . 29tazarotene . . . . . . . . . . . . . . . . . . . . . . . . 45tazicef . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22TAZORAC TOPICAL CREAM 0.05% . . . . . . . . . . . . . . . . . . . . 45

STELARA SUBCUTANEOUS SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 44STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML . . . . . . . . . . . 44STELARA SUBCUTANEOUS SYRINGE 90 MG/ML . . . . . . . . . . . . . . 44STIMATE . . . . . . . . . . . . . . . . . . . . . . . . . 52STIVARGA . . . . . . . . . . . . . . . . . . . . . . . . 29streptomycin . . . . . . . . . . . . . . . . . . . . . . 23STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . . 21SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG, 8-2 MG . . . 36SUBOXONE SUBLINGUAL FILM 12-3 MG . . . . . . . . . . . . . . . . . . . . . 36sucralfate oral suspension . . . . . . . . . 54sucralfate oral tablet . . . . . . . . . . . . . . . 54sulfacetamide-prednisolone . . . . . . . . 60sulfacetamide sodium (acne) . . . . . . . 45sulfacetamide sodium ophthalmic (eye) drops . . . . . . . . . . . . . 60sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . 24sulfamethoxazole-trimethoprim intravenous . . . . . . . . . . . . . . . . . . . . . . . 24sulfamethoxazole-trimethoprim oral suspension . . . . . . . . . . . . . . . . . . . 24sulfamethoxazole-trimethoprim oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 24sulfasalazine . . . . . . . . . . . . . . . . . . . . . . 53sulfatrim . . . . . . . . . . . . . . . . . . . . . . . . . . 24sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . 36sumatriptan . . . . . . . . . . . . . . . . . . . . . . . 33sumatriptan succinate oral . . . . . . . . . 33sumatriptan succinate subcutaneous cartridge . . . . . . . . . . . . 33sumatriptan succinate subcutaneous pen injector . . . . . . . . . 33sumatriptan succinate subcutaneous solution . . . . . . . . . . . . . 33sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml . . 33SUPREP BOWEL PREP KIT . . . . . . . 53SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . . 29

sodium chloride intravenous . . . . . . . . 64sodium chloride irrigation . . . . . . . . . . . 48sodium phenylbutyrate . . . . . . . . . . . . . 48sodium polystyrene (sorb free) . . . . . 48sodium polystyrene sulfonate oral powder . . . . . . . . . . . . . . 48solifenacin . . . . . . . . . . . . . . . . . . . . . . . . 63SOLIQUA 100/33 . . . . . . . . . . . . . . . . . . 51SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . . 29SOLU-CORTEF ACT-O-VIAL (PF) . . 49SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 60 MG/0.2 ML . . . . . . . . . . . . . . . . . . . . . 29SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 90 MG/0.3 ML . . . . . . . . . . . . . . . . . . . . . 29SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML . . . . . . . . . . . . . . . . . . . . 29SOMAVERT . . . . . . . . . . . . . . . . . . . . . . . 52sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40sotalol af . . . . . . . . . . . . . . . . . . . . . . . . . . 40sotalol oral . . . . . . . . . . . . . . . . . . . . . . . . 40SOTYLIZE . . . . . . . . . . . . . . . . . . . . . . . . 40spironolactone . . . . . . . . . . . . . . . . . . . . 42spironolacton-hydrochlorothiaz . . . . . 42sprintec (28) . . . . . . . . . . . . . . . . . . . . . . . 59SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG . . . . . . . . . . . . . . . . . . 32SPRITAM ORAL TABLET FOR SUSPENSION 750 MG . . . . . . . 32SPRYCEL . . . . . . . . . . . . . . . . . . . . . . . . 29sps (with sorbitol) . . . . . . . . . . . . . . . . . . 48sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59SSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45STAMARIL (PF) . . . . . . . . . . . . . . . . . . . 56stavudine oral capsule 15 mg, 20 mg . . . . . . . . . . . . . . . . . . . . . 20stavudine oral capsule 30 mg, 40 mg . . . . . . . . . . . . . . . . . . . . . 20STELARA INTRAVENOUS . . . . . . . . . 44

87


Covered Drugs Index

timolol maleate ophthalmic (eye) gel forming solution . . . . . . . . . . 60timolol maleate oral . . . . . . . . . . . . . . . . 42tis-u-sol pentalyte . . . . . . . . . . . . . . . . . . 47TIVICAY ORAL TABLET 10 MG . . . . 21TIVICAY ORAL TABLET 25 MG, 50 MG . . . . . . . . . . . . . . . . . . . . 21tizanidine oral tablet . . . . . . . . . . . . . . . 34TOBRADEX OPHTHALMIC (EYE) OINTMENT . . . . . . . . . . . . . . . . . 61tobramycin . . . . . . . . . . . . . . . . . . . . . . . . 60tobramycin-dexamethasone . . . . . . . . 61tobramycin in 0.225% nacl . . . . . . . . . 23tobramycin sulfate . . . . . . . . . . . . . . . . . 23tolterodine oral capsule, extended release 24hr . . . . . . . . . . . . . 63tolterodine oral tablet . . . . . . . . . . . . . . 63topiramate oral capsule, sprinkle . . . 32topiramate oral tablet . . . . . . . . . . . . . . 32toposar . . . . . . . . . . . . . . . . . . . . . . . . . . . 29topotecan intravenous recon soln . . . 29toremifene . . . . . . . . . . . . . . . . . . . . . . . . 29TORISEL . . . . . . . . . . . . . . . . . . . . . . . . . 29torsemide oral . . . . . . . . . . . . . . . . . . . . . 42TOUJEO MAX U-300 SOLOSTAR . . 51TOUJEO SOLOSTAR U-300 INSULIN . . . . . . . . . . . . . . . . . . . . 51TOVIAZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 63TPN ELECTROLYTES . . . . . . . . . . . . . 64TRACLEER ORAL TABLET FOR SUSPENSION . . . . . . . . . . . . . . . 62TRADJENTA . . . . . . . . . . . . . . . . . . . . . . 51tramadol-acetaminophen . . . . . . . . . . . 36tramadol oral tablet 50 mg . . . . . . . . . 36trandolapril . . . . . . . . . . . . . . . . . . . . . . . . 42tranexamic acid oral . . . . . . . . . . . . . . . 57tranylcypromine . . . . . . . . . . . . . . . . . . . 40TRAVASOL 10% . . . . . . . . . . . . . . . . . . 64travoprost . . . . . . . . . . . . . . . . . . . . . . . . . 61TRAZIMERA . . . . . . . . . . . . . . . . . . . . . . 29

terbutaline . . . . . . . . . . . . . . . . . . . . . . . . 62terconazole . . . . . . . . . . . . . . . . . . . . . . . 57testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml, 200 mg/ml (1 ml) . . . . . . . 52testosterone enanthate . . . . . . . . . . . . 52testosterone transdermal gel . . . . . . . 52testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1%) . . . . . . . . . . . 52testosterone transdermal gel in packet 1% (25 mg/2.5gram), 1% (50 mg/5 gram) . . . . . . . . . . . . . . . . 52TETANUS,DIPHTHERIA TOX PED(PF) . . . . . . . . . . . . . . . . . . . . . 56tetrabenazine oral tablet 12.5 mg . . . 34tetrabenazine oral tablet 25 mg . . . . . 34tetracycline . . . . . . . . . . . . . . . . . . . . . . . . 24THALOMID ORAL CAPSULE 100 MG, 150 MG, 50 MG . . . . . . . . . . 29THALOMID ORAL CAPSULE 200 MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 29THEO-24 . . . . . . . . . . . . . . . . . . . . . . . . . 62theophylline oral tablet extended release 12 hr . . . . . . . . . . . . 62theophylline oral tablet extended release 24 hr . . . . . . . . . . . . 62thioridazine . . . . . . . . . . . . . . . . . . . . . . . 40thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . . 29thiothixene . . . . . . . . . . . . . . . . . . . . . . . . 40THYROLAR-1 . . . . . . . . . . . . . . . . . . . . . 52THYROLAR-1/2 . . . . . . . . . . . . . . . . . . . 52THYROLAR-1/4 . . . . . . . . . . . . . . . . . . . 52THYROLAR-2 . . . . . . . . . . . . . . . . . . . . . 52THYROLAR-3 . . . . . . . . . . . . . . . . . . . . . 52tiadylt er . . . . . . . . . . . . . . . . . . . . . . . . . . 42tiagabine . . . . . . . . . . . . . . . . . . . . . . . . . . 32TIBSOVO . . . . . . . . . . . . . . . . . . . . . . . . . 29tigecycline . . . . . . . . . . . . . . . . . . . . . . . . 23tilia fe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59timolol maleate ophthalmic (eye) drops . . . . . . . . . . . . . . . . . . . . . . . . 60

TAZORAC TOPICAL GEL . . . . . . . . . . 45taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg . . . . . . . . . . . . . . . . . . . 42TAZVERIK . . . . . . . . . . . . . . . . . . . . . . . . 29TDVAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 56TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) . . . . . . . . . . . . . . . . . . . . . . . 29TECENTRIQ INTRAVENOUS SOLUTION 840 MG/14 ML (60 MG/ML) . . . . . . . . . . . . . . . . . . . . . . . 29TECFIDERA ORAL CAPSULE,DELAYED RELEASE (DR/EC) 120 MG . . . . . . . . . . . . . . . . . . 33TECFIDERA ORAL CAPSULE,DELAYED RELEASE (DR/EC) 120 MG (14)- 240 MG (46) . 34TECFIDERA ORAL CAPSULE,DELAYED RELEASE (DR/EC) 240 MG . . . . . . . . . . . . . . . . . . 34TECHLITE PEN NEEDLE . . . . . . . . . . 51TEFLARO . . . . . . . . . . . . . . . . . . . . . . . . . 22TEKTURNA . . . . . . . . . . . . . . . . . . . . . . . 42TEKTURNA HCT . . . . . . . . . . . . . . . . . . 42telmisartan-amlodipine . . . . . . . . . . . . . 42telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-25 mg . . . 42telmisartan-hydrochlorothiazid oral tablet 80-12.5 mg . . . . . . . . . . . . . . 42telmisartan oral tablet 20 mg, 40 mg . . . . . . . . . . . . . . . . . . . . . 42telmisartan oral tablet 80 mg . . . . . . . 42temazepam oral capsule 15 mg, 30 mg . . . . . . . . . . . . . . . . . . . . . 40temazepam oral capsule 22.5 mg, 7.5 mg . . . . . . . . . . . . . . . . . . . 40temsirolimus . . . . . . . . . . . . . . . . . . . . . . 29TENIVAC (PF) INTRAMUSCULAR SYRINGE . . . . . . 56tenofovir disoproxil fumarate . . . . . . . 21terazosin . . . . . . . . . . . . . . . . . . . . . . . . . . 42terbinafine hcl oral . . . . . . . . . . . . . . . . . 19

88


Covered Drugs Index

TROPHAMINE 10% . . . . . . . . . . . . . . . 64TRULANCE . . . . . . . . . . . . . . . . . . . . . . . 53TRULICITY . . . . . . . . . . . . . . . . . . . . . . . 51TRUMENBA . . . . . . . . . . . . . . . . . . . . . . 56TRUVADA . . . . . . . . . . . . . . . . . . . . . . . . 21TRUXIMA . . . . . . . . . . . . . . . . . . . . . . . . . 30TWINRIX (PF) INTRAMUSCULAR SYRINGE . . . . . . 56TYBOST . . . . . . . . . . . . . . . . . . . . . . . . . . 21tydemy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . . 30TYMLOS . . . . . . . . . . . . . . . . . . . . . . . . . . 56TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . . 56TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . . 34

UUNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG . . . . . . . . . . . . . . . . . 52unithroid oral tablet 137 mcg . . . . . . . 52UNITUXIN . . . . . . . . . . . . . . . . . . . . . . . . 30UPTRAVI . . . . . . . . . . . . . . . . . . . . . . . . . 42ursodiol oral capsule . . . . . . . . . . . . . . . 53ursodiol oral tablet . . . . . . . . . . . . . . . . . 53

Vvalacyclovir oral tablet 1 gram . . . . . . 21valacyclovir oral tablet 500 mg . . . . . 21VALCHLOR . . . . . . . . . . . . . . . . . . . . . . . 45valganciclovir . . . . . . . . . . . . . . . . . . . . . . 21valproic acid . . . . . . . . . . . . . . . . . . . . . . . 32valproic acid (as sodium salt) oral solution . . . . . . . . . . . . . . . . . . . . . . . 32valsartan-hydrochlorothiazide . . . . . . 42valsartan oral tablet 160 mg, 40 mg, 80 mg . . . . . . . . . . . . . 42valsartan oral tablet 320 mg . . . . . . . . 42VALTOCO . . . . . . . . . . . . . . . . . . . . . . . . . 32

triamterene-hydrochlorothiazid oral capsule 37.5-25 mg . . . . . . . . . . . 42triamterene-hydrochlorothiazid oral tablet . . . . . . . . . . . . . . . . . . . . . . . . . 42triderm topical cream 0.1% . . . . . . . . . 47tridesilon . . . . . . . . . . . . . . . . . . . . . . . . . . 47trientine . . . . . . . . . . . . . . . . . . . . . . . . . . . 48tri-estarylla . . . . . . . . . . . . . . . . . . . . . . . . 59tri femynor . . . . . . . . . . . . . . . . . . . . . . . . 59trifluoperazine oral tablet 1 mg . . . . . 40trifluoperazine oral tablet 10 mg, 2 mg, 5 mg . . . . . . . . . . . . . . . . . 40trifluridine . . . . . . . . . . . . . . . . . . . . . . . . . 60TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-5-1,000 MG, 25-5-1,000 MG . . . . 51TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 12.5-2.5-1,000 MG, 5-2.5-1,000 MG . . 51tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . . 59tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . . . 59tri-lo-estarylla . . . . . . . . . . . . . . . . . . . . . . 59tri-lo-marzia . . . . . . . . . . . . . . . . . . . . . . . 59tri-lo-mili . . . . . . . . . . . . . . . . . . . . . . . . . . 59tri-lo-sprintec . . . . . . . . . . . . . . . . . . . . . . 59trilyte with flavor packets . . . . . . . . . . . 53trimethoprim . . . . . . . . . . . . . . . . . . . . . . . 25tri-mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59trimipramine . . . . . . . . . . . . . . . . . . . . . . . 40TRINTELLIX . . . . . . . . . . . . . . . . . . . . . . 40tri-previfem (28) . . . . . . . . . . . . . . . . . . . 59TRIPTODUR . . . . . . . . . . . . . . . . . . . . . . 30TRISENOX INTRAVENOUS SOLUTION 2 MG/ML . . . . . . . . . . . . . . 30tri-sprintec (28) . . . . . . . . . . . . . . . . . . . . 59TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . . . 21trivora (28) . . . . . . . . . . . . . . . . . . . . . . . . 59tri-vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . 59tri-vylibra lo . . . . . . . . . . . . . . . . . . . . . . . 59TROGARZO . . . . . . . . . . . . . . . . . . . . . . 21TROPHAMINE 6% . . . . . . . . . . . . . . . . 64

trazodone oral tablet 100 mg, 150 mg, 50 mg . . . . . . . . . . . . 40trazodone oral tablet 300 mg . . . . . . . 40TREANDA INTRAVENOUS RECON SOLN 25 MG . . . . . . . . . . . . . 30TREANDA INTRAVENOUS RECON SOLN 100 MG . . . . . . . . . . . . 30TRECATOR . . . . . . . . . . . . . . . . . . . . . . . 23TRELEGY ELLIPTA . . . . . . . . . . . . . . . 62TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 3.75 MG . . . . . . 30TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 11.25 MG . . . . . 30TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG . . . . . . 30treprostinil sodium . . . . . . . . . . . . . . . . . 42TRESIBA FLEXTOUCH U-100 . . . . . 51TRESIBA FLEXTOUCH U-200 . . . . . 51TRESIBA U-100 INSULIN . . . . . . . . . . 51tretinoin (antineoplastic) . . . . . . . . . . . . 30tretinoin microspheres topical gel 0.1% . . . . . . . . . . . . . . . . . . . 45tretinoin microspheres topical gel with pump 0.1% . . . . . . . . . 45tretinoin topical cream 0.025%, 0.05%, 0.1% . . . . . . . . . . . . . . 45tretinoin topical topical gel 0.01% . . . 45tretinoin topical topical gel 0.025%, 0.05% . . . . . . . . . . . . . . . . . . . . 45triamcinolone acetonide dental . . . . . 48triamcinolone acetonide injection . . . 49triamcinolone acetonide topical cream 0.1% . . . . . . . . . . . . . . . . 47triamcinolone acetonide topical cream 0.025%, 0.5% . . . . . . . . 47triamcinolone acetonide topical lotion . . . . . . . . . . . . . . . . . . . . . . . 47triamcinolone acetonide topical ointment . . . . . . . . . . . . . . . . . . . 47

89


Covered Drugs Index

VIRACEPT ORAL TABLET 625 MG . . 21VIREAD ORAL POWDER . . . . . . . . . . 21VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG . . . . . . . . . 21VITRAKVI ORAL CAPSULE 25 MG . . . . . . . . . . . . . . . . . 30VITRAKVI ORAL CAPSULE 100 MG . . . . . . . . . . . . . . . . 30VITRAKVI ORAL SOLUTION . . . . . . . 30VIVITROL . . . . . . . . . . . . . . . . . . . . . . . . . 36VIZIMPRO . . . . . . . . . . . . . . . . . . . . . . . . 30volnea (28) . . . . . . . . . . . . . . . . . . . . . . . . 59voriconazole intravenous . . . . . . . . . . . 19voriconazole oral suspension for reconstitution . . . . . . . . . . . . . . . . . . . 19voriconazole oral tablet . . . . . . . . . . . . 19VOSEVI . . . . . . . . . . . . . . . . . . . . . . . . . . 21VOTRIENT . . . . . . . . . . . . . . . . . . . . . . . . 30VRAYLAR ORAL CAPSULE . . . . . . . . 40VRAYLAR ORAL CAPSULE, DOSE PACK . . . . . . . . . . . . . . . . . . . . . . 40vyfemla (28) . . . . . . . . . . . . . . . . . . . . . . . 59vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59VYXEOS . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Wwarfarin . . . . . . . . . . . . . . . . . . . . . . . . . . . 43water for irrigation, sterile . . . . . . . . . . 48wera (28) . . . . . . . . . . . . . . . . . . . . . . . . . 59wymzya fe . . . . . . . . . . . . . . . . . . . . . . . . 59

XXALKORI . . . . . . . . . . . . . . . . . . . . . . . . . 30XARELTO . . . . . . . . . . . . . . . . . . . . . . . . . 43XATMEP . . . . . . . . . . . . . . . . . . . . . . . . . . 30XCOPRI . . . . . . . . . . . . . . . . . . . . . . . . . . 32XCOPRI MAINTENANCE PACK . . . . 32XCOPRI TITRATION PACK . . . . . . . . 32XELJANZ . . . . . . . . . . . . . . . . . . . . . . . . . 57XELJANZ XR . . . . . . . . . . . . . . . . . . . . . 57

VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . . 62VENTOLIN HFA . . . . . . . . . . . . . . . . . . . 62verapamil intravenous solution . . . . . 42verapamil oral capsule, 24 hr er pellet ct . . . . . . . . . . . . . . . . . . . 42verapamil oral capsule, ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg . . . . . . . . . . . 42VERAPAMIL ORAL CAPSULE,EXT REL. PELLETS 24 HR 360 MG . . . . . 42verapamil oral tablet . . . . . . . . . . . . . . . 43verapamil oral tablet extended release . . . . . . . . . . . . . . . . . . 43VERSACLOZ . . . . . . . . . . . . . . . . . . . . . 40VERZENIO . . . . . . . . . . . . . . . . . . . . . . . 30V-GO 20 . . . . . . . . . . . . . . . . . . . . . . . . . . 51V-GO 30 . . . . . . . . . . . . . . . . . . . . . . . . . . 51V-GO 40 . . . . . . . . . . . . . . . . . . . . . . . . . . 51VIBERZI . . . . . . . . . . . . . . . . . . . . . . . . . . 53VICTOZA 2-PAK . . . . . . . . . . . . . . . . . . . 51VICTOZA 3-PAK . . . . . . . . . . . . . . . . . . . 51vienva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59vigabatrin . . . . . . . . . . . . . . . . . . . . . . . . . 32vigadrone . . . . . . . . . . . . . . . . . . . . . . . . . 32VIIBRYD ORAL TABLET . . . . . . . . . . . 40VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) . . . . . . 40VIMPAT INTRAVENOUS . . . . . . . . . . . 32VIMPAT ORAL SOLUTION . . . . . . . . . 32VIMPAT ORAL TABLET 50 MG . . . . . 32VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG . . . . . . . . . 32vincasar pfs intravenous solution 1 mg/ml . . . . . . . . . . . . . . . . . . . 30vincristine . . . . . . . . . . . . . . . . . . . . . . . . . 30vinorelbine . . . . . . . . . . . . . . . . . . . . . . . . 30VIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT . . . . . . . 53VIOKACE ORAL TABLET 20,880-78,300- 78,300 UNIT . . . . . . . 53viorele (28) . . . . . . . . . . . . . . . . . . . . . . . . 59VIRACEPT ORAL TABLET 250 MG . . 21

VANCOMYCIN IN 0.9% SODIUM CHL INTRAVENOUS PIGGYBACK . 23VANCOMYCIN IN DEXTROSE 5% INTRAVENOUS PIGGYBACK . . 23VANCOMYCIN INJECTION . . . . . . . . 23vancomycin intravenous recon soln 1,000 mg, 10 gram, 250 mg, 5 gram, 500 mg, 750 mg . . . . . . . . . . . 23VANCOMYCIN INTRAVENOUS RECON SOLN 1.25 GRAM, 1.5 GRAM . . . . . . . . . . . . . . . . . . . . . . . . 23vancomycin oral capsule 125 mg . . . 23vancomycin oral capsule 250 mg . . . 23vancomycin oral recon soln . . . . . . . . 23VANCOMYCIN-WATER INJECT (PEG) . . . . . . . . . . . . . . . . . . . . 23vandazole . . . . . . . . . . . . . . . . . . . . . . . . . 57VAQTA (PF) . . . . . . . . . . . . . . . . . . . . . . . 56VARIVAX (PF) . . . . . . . . . . . . . . . . . . . . . 56VARIZIG INTRAMUSCULAR SOLUTION . . . . . . . . . . . . . . . . . . . . . . . 56VASCEPA ORAL CAPSULE 0.5 GRAM . . . . . . . . . . . . . . . . . . . . . . . . 44VASCEPA ORAL CAPSULE 1 GRAM . . . . . . . . . . . . . . . . . . . . . . . . . . 44VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . . . 30VELCADE . . . . . . . . . . . . . . . . . . . . . . . . 30velivet triphasic regimen (28) . . . . . . . 59VELPHORO . . . . . . . . . . . . . . . . . . . . . . . 48VELTASSA . . . . . . . . . . . . . . . . . . . . . . . . 48VEMLIDY . . . . . . . . . . . . . . . . . . . . . . . . . 21VENCLEXTA ORAL TABLET 10 MG . . . . . . . . . . . . . . . . . . . 30VENCLEXTA ORAL TABLET 50 MG . . . . . . . . . . . . . . . . . . . 30VENCLEXTA ORAL TABLET 100 MG . . . . . . . . . . . . . . . . . . 30VENCLEXTA STARTING PACK . . . . 30venlafaxine oral capsule, extended release 24hr 75 mg . . . . . . 40venlafaxine oral capsule, extended release 24hr 150 mg, 37.5 mg . . . . . . 40venlafaxine oral tablet . . . . . . . . . . . . . . 40

90


Covered Drugs Index

ZTLIDO . . . . . . . . . . . . . . . . . . . . . . . . . . . 45ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 11.4-2.9 MG . . . . . . . . . 36ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG . . . . . . . . . . . . 36zumandimine (28) . . . . . . . . . . . . . . . . . 60ZYDELIG . . . . . . . . . . . . . . . . . . . . . . . . . 30ZYKADIA ORAL TABLET . . . . . . . . . . 30ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG . . . . . . . . . . . . . . . . . . 40ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 40ZYTIGA ORAL TABLET 250 MG . . . . 31ZYTIGA ORAL TABLET 500 MG . . . . 31

zarah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59ZARXIO . . . . . . . . . . . . . . . . . . . . . . . . . . 55zebutal oral capsule 50-325-40 mg . . . . . . . . . . . . . . . . . . . . . 35ZEJULA . . . . . . . . . . . . . . . . . . . . . . . . . . 30ZELBORAF . . . . . . . . . . . . . . . . . . . . . . . 30ZENPEP ORAL CAPSULE, DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT . . . . . . . . 54zidovudine oral capsule . . . . . . . . . . . . 21zidovudine oral syrup . . . . . . . . . . . . . . 21zidovudine oral tablet . . . . . . . . . . . . . . 21ZIEXTENZO . . . . . . . . . . . . . . . . . . . . . . 55ZIOPTAN (PF) . . . . . . . . . . . . . . . . . . . . . 61ziprasidone hcl . . . . . . . . . . . . . . . . . . . . 40ziprasidone mesylate . . . . . . . . . . . . . . 40ZIRABEV . . . . . . . . . . . . . . . . . . . . . . . . . 30ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . . 60zoledronic acid intravenous solution . . . . . . . . . . . . . . . 52zoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml . . . . . . . . . . . . . . . . . . . . . . . 48ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . . 30zolpidem oral tablet . . . . . . . . . . . . . . . . 40zonisamide . . . . . . . . . . . . . . . . . . . . . . . . 32ZORTRESS ORAL TABLET 0.5 MG . . . . . . . . . . . . . . . . . . . 30ZORTRESS ORAL TABLET 0.25 MG . . . . . . . . . . . . . . . . . . 30ZORTRESS ORAL TABLET 0.75 MG, 1 MG . . . . . . . . . . . 30ZOSTAVAX (PF) . . . . . . . . . . . . . . . . . . . 56ZOSYN IN DEXTROSE (ISO-OSM) . . 24ZOSYN INTRAVENOUS RECON SOLN 2.25 GRAM, 3.375 GRAM . . . 24zovia 1/35e (28) . . . . . . . . . . . . . . . . . . . 59

XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . 25XIAFLEX . . . . . . . . . . . . . . . . . . . . . . . . . . 48XIFAXAN ORAL TABLET 550 MG . . 23XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG, 5-500 MG . . . . . . . . . . . . 51XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG . . . . . . . . . . 51XOLAIR SUBCUTANEOUS RECON SOLN . . . . . . . . . . . . . . . . . . . . 62XOLAIR SUBCUTANEOUS SYRINGE . . . . . . . . . . . . . . . . . . . . . . . . . 63XOSPATA . . . . . . . . . . . . . . . . . . . . . . . . . 30XPOVIO ORAL TABLET 60 MG/WEEK (20 MG X 3) . . . . . . . . . 30XPOVIO ORAL TABLET 80 MG/WEEK (20 MG X 4) . . . . . . . . . 30XPOVIO ORAL TABLET 100 MG/WEEK (20 MG X 5) . . . . . . . . 30XPOVIO ORAL TABLET 160 MG/WEEK (20 MG X 8) . . . . . . . . 30XTAMPZA ER . . . . . . . . . . . . . . . . . . . . . 35XTANDI . . . . . . . . . . . . . . . . . . . . . . . . . . . 30XULTOPHY 100/3.6 . . . . . . . . . . . . . . . 51XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

YYERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) . . . . . . . . . . . . . . . . . . . . . . . . 30YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML) . . . . . . . . . . . . . . . . . . . . . . . . 30YF-VAX (PF) . . . . . . . . . . . . . . . . . . . . . . 56YONDELIS . . . . . . . . . . . . . . . . . . . . . . . . 30yuvafem . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Zzafirlukast . . . . . . . . . . . . . . . . . . . . . . . . . 63zaleplon oral capsule 5 mg . . . . . . . . . 40zaleplon oral capsule 10 mg . . . . . . . . 40

91

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Notice of Nondiscrimination: Discrimination is Against the Law

Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Cigna: Provides free aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreterso 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:o Qualified interpreterso Information written in other languages

If you need these services, contact Customer Service at 1-800-222-6700 (TTY 711), 8 am – 8 pm local time, 7 days a week. Our automated phone system may answer your call during weekends from April 1 - September 30.

If you believe that Cigna 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:

Cigna - Grievance PO Box 269005 Weston, FL 33326-9927 Phone: 1-800-222-6700 (TTY 711), Fax: 1-800-735-1469

You can file a grievance in writing by mail or fax. If you need help filing a grievance, Customer Service 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.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. Call 1-800-222-6700 (TTY 711), 8 am – 8 pm, 7 days a week. ATENCIÓN: si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-222-6700 (TTY 711), 8 a.m. – 8 p.m, 7 días de la semana. Cigna HealthSpring® Rx (PDP) is a Medicare Prescription Drug plan (PDP) with a Medicare contract. Enrollment in Cigna-HealthSpring depends on contract renewal.

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Notificación Contra la Discriminación: La Discriminación es Contra la Ley

Cigna cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Cigna no excluye a las personas ni las trata de forma diferente debido a su origen étnico, color, nacionalidad, edad, discapacidad o sexo.

Cigna: • Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera

eficaz con nosotros, como los siguientes:o Intérpretes de lenguaje de señas capacitados.o Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos).

• Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes:o Intérpretes capacitados.o Información escrita en otros idiomas.

Si necesita recibir estos servicios, comuníquese con Customer Service, al 1-800-222-6700 (TTY 711), de 8 a.m. a 8 p.m., hora local, los siete días de la semana. Puede que nuestro sistema telefónico automático conteste sus llamadas durante los fines de semana del 1 de abril al 30 de septiembre.

Si considera que Cigna no le proporcionó estos servicios o lo discriminó de otra manera por motivos de origen étnico, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a la siguiente persona:

Cigna – Grievance PO Box 269005 Weston, FL 33326-9927 Teléfono: 1-800-222-6700 (TTY 711) Fax: 1-800-735-1469.

Puede presentar el reclamo escrito por correo postal o fax. Si necesita ayuda para hacerlo, Customer Service está a su disposición para brindársela.

También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles) del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera electrónica a través de Office for Civil Rights Complaint Portal (Oficina de Derechos Civiles portal de quejas), disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, por correo postal a la siguiente dirección o por teléfono a los números que figuran a continuación:

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)Puede obtener los formularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html.

Todos los productos y servicios de Cigna se brindan exclusivamente por o a través de subsidiarias operativas de Cigna Corporation. El nombre de Cigna, los logotipos, y otras marcas de Cigna son propiedad de Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. Call 1-800-222-6700 (TTY 711), 8 am – 8 pm, 7 days a week. ATENCIÓN: si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-222-6700 (TTY 711), 8 a.m.– 8 p.m , 7 días de la semana. Cigna-HealthSpring® Rx (PDP) es un plan de medicamentos con receta (PDP, por sus siglas en inglés) de Medicare con un contrato con Medicare. La inscripción en Cigna-HealthSpring depende de la renovación de los contratos.

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S5617_17_50212 ACCEPTED 17_MLI_PDP

English – ATTENTION: If you speak English, language assistance services, free of charge are available to you. Call 1-800-222-6700 (TTY 711).

Spanish – ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-222-6700 (TTY 711).

Chinese – 1-800-222-6700 (TTY 711)

Vietnamese – CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-222-6700 (TTY 711).

French Creole – ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-222-6700 (TTY 711).

Korean – 1-800-222-6700 (TTY 711)

Polish – UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-222-6700 (TTY 711).

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Arabic – 1-800-222-6700 اتصل برقم. ، فإن خدمات المساعدة اللغویة تتوافر لك بالمجاناللغة العربیةإذا كنت تتحدث : ملحوظة)TTY 711.(

Russian – ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-222-6700 (телетайп 711).

Tagalog – PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-222-6700 (TTY 711).

Farsi/Persian – . توجھ: اگر بھ زبان فارسی گفتگو می کنید، تسھیالت زبانی بصورت رایگان برای شما فراھم می باشد . تماس بگیرید (711 :TTY) 1-800-222-6700 با

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Portuguese – ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-222-6700 (TTY 711).

Italian – ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-222-6700 (TTY 711).

Japanese – 1-800-222-6700 (TTY 711)

Navajo – D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1-800-222-6700 (TTY 711).

Gujarati – �યાન આપો: જો તમે�જુરાતી બોલતા હો તો િન:��ુક ભાષા સહાય સેવાઓ તમારા માટ� �પલ�� છે. ફોન કરો 1-800-222-6700 (TTY 711).

Urdu توجہ دیں: اگرآپ اردو زبان بولتے ہیں تو آپ کےلئے زبان معاون خدمات مفت میں دستیاب ہیں۔ کال کریں 1-800-222-6700 (TTY 711)

This drug list was updated in July 2020. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-222-6700 or, for TTY users, 711, 8 a.m. – 8 p.m. local time, 7 days a week. Our automated phone system may answer your call during weekends from April 1 – September 30, or visit www.Cigna.com/part-d. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2019 Cigna 929084 g

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

Cigna.com/part-d

Documents

2020 CIGNA COMPREHENSIVE DRUG LIST (Formulary) · 2020-06-01 · it means Cigna-HealthSpring Rx Secure-Extra (PDP). This document includes a list of the drugs (formulary) for our