2020 List of Covered Drugs/Formulary - Aetna...plan that contracts with Medicare and Michigan Medicaid to provide benefits of both programs to enrollees. For more recent information

2020 List of Covered

Drugs/Formulary

Aetna Better HealthSM Premier PlanAetna Better Health Premier Plan (Medicare-Medicaid Plan) is a health plan that contracts with Medicare and Michigan Medicaid to provide

benefits of both programs to enrollees.For more recent information or other questions, contact us at

1‑855‑676‑5772 (TTY: 711), 24 hours a day, 7 days a week or visit www.aetnabetterhealth.com/michigan.

92.05.300.1-MI U Updated on 11/01/2020 H8026_20DRUG LST R FINAL ACCEPTED

http://www.aetnabetterhealth.com/michigan

I

Aetna Better Health Premier Plan | 2020 List of Covered Drugs (Formulary)

IntroductionThis document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over-the-counter drugs and items are covered by Aetna Better Health Premier Plan. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by Aetna Better Health Premier Plan. Key terms and their definitions appear in the last chapter of the Member Handbook.

Table of ContentsA. Disclaimers ......................................................................................................................................................III

B. Frequently Asked Questions (FAQ) ..............................................................................................................IV

B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.) ............................................................IV

B2. Does the Drug List ever change? .........................................................................................................IV

B3. What happens when there is a change to the Drug List? .................................................................V

B4. Are there any restrictions or limits on drug coverage? Or are there any required actions to take to get certain drugs? ..................................................................................................VI

B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? ...........................................................................................................VI

B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)? ................................VI

B7. How can you find a drug on the Drug List? .......................................................................................VII

B8. What if the drug you want to take is not on the Drug List? ............................................................VII

B9. What if you are a new Aetna Better Health Premier Plan member and can’t find your drug on the Drug List or have a problem getting your drug? ........................................................VII

B10. Can you ask for an exception to cover your drug? ........................................................................ VIII

B11. How can you ask for an exception? ....................................................................................................IX

B12. How long does it take to get an exception? .......................................................................................IX

B13. What are generic drugs? ......................................................................................................................IX

B14. What are OTC drugs? ............................................................................................................................IX

B15. Does Aetna Better Health Premier Plan cover non-drug OTC products? .....................................IX

If you have questions, please call Aetna Better Health Premier Plan at 1‑855‑676‑5772 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/michigan.

II

If you have questions, please call Aetna Better Health Premier Plan at 1-855-676-5772 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/michigan.

B16. What is your copay? ..............................................................................................................................X

B17. What are drug tiers? ..............................................................................................................................X

C. List of Covered Drugs ....................................................................................................................................XI

D. List of Drugs by Medical Condition ..............................................................................................................1

E. Index of Covered Drugs ................................................................................................................................92

III


A. DisclaimersThis is a list of drugs that members can get in Aetna Better Health Premier Plan.

❖ Aetna Better Health Premier Plan is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees.

❖ ATTENTION: If you speak Spanish or Arabic, language assistance services, free of charge, are available to you. Call 1‑855‑676‑5772 (TTY: 711), 24 hours a day, 7 days a week. The call is free.

Si habla español o árabe, tiene a su disposición servicios de idiomas gratuitos. Llame al 1‑855‑676‑5772 (TTY: 711), las 24 horas del día, los 7 días de la semana. Esta llamada es gratuita.

يرجى االنتباه: إذا كنت تتكلم اإلسبانية أو العربية، فإن خدمات املساعدة اللغوية متاحة لك مجاناً. اتصل بالرقم 5772‑676‑855‑1 (الهاتف النيص: 711) عىل مدار الساعة، وطوال أيام األسبوع. االتصال بهذا الرقم مجاين.

❖ You can also get this document for free in other formats, such as large print, braille, or audio. Call 1‑855‑676‑5772 (TTY: 711), 24 hours a day, 7 days a week. The call is free.

❖ If you wish to make or change a standing request to receive materials in a language other than English or in an alternate format, you can call Member Services at 1‑855‑676‑5772 (TTY: 711), 24 hours a day, 7 days a week. To change your standing request for materials, please call Member Services at 1‑855‑676‑5772 (TTY: 711), 24 hours a day, 7 days a week.

IV


B. Frequently Asked Questions (FAQ)Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.

B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.)

The drugs on the List of Covered Drugs that starts on page 1 are the drugs covered by Aetna Better Health Premier Plan. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

• Aetna Better Health Premier Plan will cover all medically necessary drugs on the Drug List if:

° your doctor or other prescriber says you need them to get better or stay healthy, and

° you fill the prescription at a Aetna Better Health Premier Plan network pharmacy.

• Aetna Better Health Premier Plan may have additional steps to access certain drugs (see question B4 below).

You can also see an up-to-date list of drugs that we cover on our website at www.aetnabetterhealth.com/michigan or call Member Services toll-free at 1‑855‑676‑5772 (TTY: 711), 24 hours a day, 7 days a week.

B2. Does the Drug List ever change?Yes, and Aetna Better Health Premier Plan must follow Medicare and Medicaid rules when making changes. We may add or remove drugs on the Drug List during the year.

We may also change our rules about drugs. For example, we could:

• Decide to require or not require prior approval for a drug. (Prior approval is permission from Aetna Better Health Premier Plan before you can get a drug.)

• Add or change the amount of a drug you can get (called “quantity limits”).

• Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)

For more information on these drug rules, see question B4.

If you are taking a drug that was covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless:

• a new, cheaper drug comes on the market that works as well as a drug on the Drug List now, or

• we learn that a drug is not safe, or

• a drug is removed from the market.


V


Questions B3 and B6 below have more information on what happens when the Drug List changes.

• You can always check Aetna Better Health Premier Plan’s up to date Drug List online at www.aetnabetterhealth.com/michigan.

• You can also call Member Services to check the current Drug List at 1‑855‑676‑5772 (TTY: 711), 24 hours a day, 7 days a week.

B3. What happens when there is a change to the Drug List?Some changes to the Drug List will happen immediately. For example:

• A new generic drug becomes available. Sometimes, a new generic drug comes on the market that works as well as a brand name drug on the Drug List now. When that happens, we may remove the brand name drug and add the new generic drug, but your cost for the new drug will stay the same. When we add the new generic drug, we may also decide to keep the brand name drug on the list but change its coverage rules or limits.

° We may not tell you before we make this change, but we will send you information about the specific change we made once it happens.

° You or your provider can ask for an exception from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see question B10 for more information on exceptions.

• A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug’s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know.

° We will send you a letter telling you. We will also notify your doctor about this change, and will work with you to find another drug for your condition. Please contact your doctor if a drug you are taking is removed from the drug list.

We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if:

• The FDA provides new guidance or there are new clinical guidelines about a drug.

• We add a generic drug that is new to the market and

° Replace a brand name drug currently on the Drug List or

° Change the coverage rules or limits for the brand name drug.

• We add a generic drug that is not new to the market and

° Replace a brand name drug currently on the Drug List or

° Change the coverage rules or limits for the brand name drug.

When these changes happen, we will:

• Tell you at least 30 days before we make the change to the Drug List or

• Let you know and give you a 30-day supply of the drug in an outpatient setting and 31-day supply of the drug in a long-term care setting after you ask for a refill.


VI


This will give you time to talk to your doctor or other prescriber. He or she can help you decide:

• If there is a similar drug on the Drug List you can take instead or

• Whether to ask for an exception from these changes. To learn more about exceptions, see question B10.

B4. Are there any restrictions or limits on drug coverage? Or are there any required actions to take to get certain drugs?

Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example:

• Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Aetna Better Health Premier Plan before you fill your prescription. If you don’t get approval, Aetna Better Health Premier Plan may not cover the drug if you do not get approval.

• Quantity limits: Sometimes Aetna Better Health Premier Plan limits the amount of a drug you can get.

• Step therapy: Sometimes Aetna Better Health Premier Plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your prescriber thinks the first drug doesn’t work for you, then we will cover the second.

You can find out if your drug has any additional requirements or limits by looking in the tables on pages 1 - 91. You can also get more information by visiting our web site at www.aetnabetterhealth.com/michigan. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.

You can also ask for an exception from these limits. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see questions B10-B12 for more information about exceptions.

B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug?

The List of Covered Drugs on page 1 has a column labeled “Necessary actions, restrictions, or limits on use.”

B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)?

In some cases, we will tell you in advance if we add or change prior approval, quantity limits, and/or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change.


VII


B7. How can you find a drug on the Drug List?There are two ways to find a drug:

• You can search alphabetically (if you know how to spell the drug), or

• You can search by medical condition.

To search alphabetically, go to the Index of Covered Drugs section. You can find it on page 92. Both brand name drugs and generic drugs are listed in the index. Find your drug in the index. Next to your drug, you will see the page number where you can find coverage information.

To search by medical condition, find the section labeled “List of drugs by medical condition” on page 1. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular. That is where you will find drugs that treat heart conditions.

B8. What if the drug you want to take is not on the Drug List?If you don’t see your drug on the Drug List, call Member Services at 1‑855‑676‑5772 (TTY: 711), 24 hours a day, 7 days a week and ask about it. If you learn that Aetna Better Health Premier Plan will not cover the drug, you can do one of these things:

• Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or

• You can ask the health plan to make an exception to cover your drug. Please see questions B10-B12 for more information about exceptions.

B9. What if you are a new Aetna Better Health Premier Plan member and can’t find your drug on the Drug List or have a problem getting your drug?

We can help. We may cover a temporary 30-day supply of your drug in an outpatient setting and 31-day supply of your drug in a long-term care facility during the first 90 days you are a member of Aetna Better Health Premier Plan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception.

If your prescription is written for fewer days, we will allow multiple refills to provide up to a maximum of 30-day supply of medication in an outpatient setting and 31-day supply of medication in a long-term care facility.

We will cover a 30-day supply of your drug in an outpatient setting and 31-day supply of your drug in a long-term care facility if:

• you are taking a drug that is not on our Drug List, or

• health plan rules do not let you get the amount ordered by your prescriber, or

• the drug requires prior approval by Aetna Better Health Premier Plan, or

VIII


• you are taking a drug that is part of a step therapy restriction.

If you are in a nursing home or other long-term care facility, and need a drug that is not on the Drug List or if you cannot easily get the drug you need, we can help. If you have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away:

• We will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Aetna Better Health Premier Plan member.

• This is in addition to the temporary supply during the first 90 days you are a member of Aetna Better Health Premier Plan.

Current members with a change in level of care

• We will cover a one-time temporary 31-day supply if you move from a hospital or a long-term care facility to a home setting and:

° You need a drug that is not on our drug list, or

° Your ability to get the drug is limited

• We will cover a one-time temporary 31-day supply (see the note below for exceptions) if you move into or out of a long-term care setting and:

° You need a drug that is not on our drug list, or

° Your ability to get the drug is limited

Note: Oral brand name solid dosage forms such as tablets or capsules are limited to 14 day fills with exceptions as required by Medicare Part D rules. To ask for a temporary supply of a drug, call Member Services.

During the time when you are getting a temporary supply of a drug, you should talk to your provider to decide what to do when the temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. For example, you can ask the plan to cover a drug even though it is not on the Drug List. Or you can ask the plan to cover the drug without limits. If your provider says you have a good medical reason for an exception, he or she can help you ask for one.

B10. Can you ask for an exception to cover your drug?Yes. You can ask Aetna Better Health Premier Plan to make an exception to cover a drug that is not on the Drug List.

You can also ask us to change the rules on your drug.

• For example, Aetna Better Health Premier Plan may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.

• Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.

IX


B11. How can you ask for an exception?To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception. You can also read Chapter 9 of the Member Handbook to learn more about exceptions.

B12. How long does it take to get an exception?First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours.

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber’s supporting statement.

B13. What are generic drugs?Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA).

Aetna Better Health Premier Plan covers both brand name drugs and generic drugs.

B14. What are OTC drugs?OTC stands for “over-the-counter”. Aetna Better Health Premier Plan covers some OTC drugs when they are written as prescriptions by your provider.

You can read the Aetna Better Health Premier Plan Drug List to see what OTC drugs are covered.

Examples of OTC non-drug products include insulin syringes, alcohol swabs, and gauze pads. There is no cost sharing or copays.

B15. Does Aetna Better Health Premier Plan cover non‑drug OTC products? Aetna Better Health Premier Plan covers some non-drug OTC products when they are written as prescriptions by your provider.

Examples of non-drug OTC products include insulin syringes, alcohol swabs, and gauze pads. There is no cost sharing or copays.

You can read the Aetna Better Health Premier Plan Drug List to see what non-drug OTC products are covered.

X


B16. What is your copay? As an Aetna Better Health Premier Plan member, you have no copays for prescription and OTC drugs as long as you follow Aetna Better Health Premier Plan’s rules.

B17. What are drug tiers?Tiers are groups of drugs.

• Tier 1 drugs are Part D prescription brand name and generic drugs.

• Tier 2 drugs are Part D prescription brand name and generic drugs.

• Tier 3 drugs are Non-Part D prescription and over-the-counter drugs.

All tiers have no copay.

XI


C. List of Covered DrugsThe following list of covered drugs gives you information about the drugs covered by Aetna Better Health Premier Plan. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 92. The index alphabetically lists all drugs covered by Aetna Better Health Premier Plan.

The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., PRADAXA), and generic drugs are listed in lower-case italics (e.g., amoxicillin).

The information in the necessary actions, restrictions, or limits on use column tells you if Aetna Better Health Premier Plan has any rules for covering your drug.

Note: The asterisk * next to a drug means the drug is not a “Part D drug.”

• These drugs have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Michigan Medicaid.

• If you or your prescriber disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at 1‑855‑676‑5772 (TTY: 711), 24 hours a day, 7 days a week. You can also read Chapter 9, in the Member Handbook to learn how to appeal a decision.

1

D. List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular. That is where you will find drugs that treat heart conditions.

Here are the meanings of the codes used in the “Necessary actions, restrictions, or limits on use” column:

* = Non-Part D drugs or OTC items that are covered by Medicaid

PA = Prior Authorization QL = Quantity Limits ST = Step Therapy

NM = Not available at Mail-order

B/D = Covered under Medicare B or D LA = Limited Access

Name of drug

What the drug will cost

you (tier

level)

Necessary actions, restrictions,

or limits on useANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION

GOUT - DRUGS TO TREAT GOUTallopurinol tab $0(1)colchicine w/ probenecid $0(1)COLCRYS $0(2) QL (120 tabs / 30 days)MITIGARE $0(2) QL (60 caps / 30 days)probenecid $0(1)

MISCELLANEOUSacephen $0(3) NM; *acetaminophen LIQD; SOLN; SUPP; TABS; TBCR

$0(3) NM; *

acetaminophen extra stren $0(3) NM; *arthritis pain relief TBCR $0(3) NM; *aspir-low $0(3) NM; *aspirin CHEW; TABS; TBEC $0(3) NM; *ASPIRIN SUPP $0(3) NM; *aspirin 81 $0(3) NM; *

* - Non-Part D drugs or OTC items that are covered by Medicaid PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at Mail-order B/D - Covered under Medicare B or D LA - Limited AccessFormulary ID 00020352 v16

* - Non-Part D drugs or OTC items that are covered by Medicaid PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at Mail-order B/D - Covered under Medicare B or D LA - Limited AccessFormulary ID 00020352 v16 2

Name of drug


you (tier

level)


or limits on useaspirin adult low strengt $0(3) NM; *aspirin low dose $0(3) NM; *aspirin low strength $0(3) NM; *childrens acetaminophen SUSP $0(3) NM; *childrens aspirin low str $0(3) NM; *childrens silapap $0(3) NM; *ecpirin $0(3) NM; *ed-apap $0(3) NM; *feverall adults $0(3) NM; *feverall childrens $0(3) NM; *FEVERALL INFANTS $0(3) NM; *feverall junior strength $0(3) NM; *gnp 8 hour pain reliever $0(3) NM; *gnp adult aspirin low str $0(3) NM; *gnp arthritis pain relief $0(3) NM; *gnp aspirin $0(3) NM; *gnp aspirin low dose $0(3) NM; *gnp infants pain/fever $0(3) NM; *gnp pain & fever children $0(3) NM; *gnp pain relief TABS $0(3) NM; *gnp pain relief extra str $0(3) NM; *goodsense arthritis pain TBCR $0(3) NM; *goodsense aspirin $0(3) NM; *goodsense pain & fever ch $0(3) NM; *goodsense pain & fever in $0(3) NM; *goodsense pain relief $0(3) NM; *goodsense pain relief ext $0(3) NM; *HISTAFLEX $0(3) NM; *hm arthritis pain relief $0(3) NM; *hm aspirin $0(3) NM; *hm aspirin ec $0(3) NM; *hm aspirin ec low dose $0(3) NM; *


Name of drug


you (tier

level)


or limits on usehm pain & fever childrens $0(3) NM; *hm pain & fever infants $0(3) NM; *hm pain relief extra stre $0(3) NM; *hm pain reliever $0(3) NM; *mapap $0(3) NM; *mapap acetaminophen extra $0(3) NM; *mapap arthritis pain $0(3) NM; *mapap childrens 80mg $0(3) NM; *non-aspirin childrens $0(3) NM; *pain & fever $0(3) NM; *pain & fever childrens SOLN; SUSP $0(3) NM; *pain & fever extra streng $0(3) NM; *pain & fever infants $0(3) NM; *pain relief extra strengt $0(3) NM; *pharbetol $0(3) NM; *pharbetol extra strength $0(3) NM; *qc arthritis pain relief $0(3) NM; *qc aspirin $0(3) NM; *qc aspirin low dose $0(3) NM; *qc chewable aspirin low d $0(3) NM; *qc enteric aspirin $0(3) NM; *qc non-aspirin childrens SUSP $0(3) NM; *qc non-aspirin extra stre $0(3) NM; *qc non-aspirin jr strengt $0(3) NM; *sb aspirin $0(3) NM; *sb non-aspirin extra stre $0(3) NM; *sb pain reliever extra st $0(3) NM; *sm 8 hour pain relief $0(3) NM; *sm arthritis pain relief $0(3) NM; *sm aspirin $0(3) NM; *sm aspirin adult low stre $0(3) NM; *sm aspirin enteric coated $0(3) NM; *


Name of drug


you (tier

level)


or limits on usesm aspirin low dose $0(3) NM; *sm childrens aspirin $0(3) NM; *sm pain & fever childrens $0(3) NM; *sm pain & fever infants $0(3) NM; *sm pain reliever $0(3) NM; *sm pain reliever extra st $0(3) NM; *tactinal $0(3) NM; *tactinal extra strength $0(3) NM; *tri-buffered aspirin $0(3) NM; *

NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATIONall day pain relief $0(3) NM; *all day relief $0(3) NM; *celecoxib CAPS 50mg $0(1) QL (240 caps / 30 days)celecoxib CAPS 100mg $0(1) QL (120 caps / 30 days)celecoxib CAPS 200mg $0(1) QL (60 caps / 30 days)celecoxib CAPS 400mg $0(1) QL (30 caps / 30 days)childrens ibuprofen $0(3) NM; *diclofenac potassium $0(1) QL (120 tabs / 30 days)diclofenac sodium TB24; TBEC $0(1)diflunisal TABS $0(1)ec-naproxen $0(1)eq naproxen sodium $0(3) NM; *eql naproxen sodium $0(3) NM; *etodolac $0(1)etodolac er $0(1)flanax pain relief $0(3) NM; *flurbiprofen TABS 100mg $0(1)gnp all day pain relief $0(3) NM; *gnp childrens ibuprofen $0(3) NM; *gnp ibuprofen $0(3) NM; *gnp ibuprofen infants $0(3) NM; *gnp ibuprofen junior stre $0(3) NM; *


Name of drug


you (tier

level)


or limits on usegnp naproxen sodium $0(3) NM; *goodsense ibuprofen $0(3) NM; *goodsense ibuprofen child $0(3) NM; *goodsense ibuprofen infan $0(3) NM; *goodsense ibuprofen junio $0(3) NM; *goodsense naproxen sodium $0(3) NM; *hm ibuprofen $0(3) NM; *hm ibuprofen childrens $0(3) NM; *hm ibuprofen ib $0(3) NM; *hm ibuprofen infants $0(3) NM; *hm naproxen sodium $0(3) NM; *ibu tab 600mg $0(1)ibu tab 800mg $0(1)ibu-200 $0(3) NM; *ibuprofen SUSP $0(1)ibuprofen TABS 200mg $0(3) NM; *ibuprofen TABS 400mg, 600mg, 800mg $0(1)ibuprofen childrens $0(3) NM; *ibuprofen infants $0(3) NM; *ibuprofen junior strength $0(3) NM; *infants ibuprofen $0(3) NM; *kls naproxen sodium $0(3) NM; *mediproxen $0(3) NM; *meloxicam TABS $0(1)nabumetone TABS $0(1)naproxen TABS $0(1)naproxen dr $0(1)naproxen sodium CAPS $0(3) NM; *naproxen sodium TABS 220mg $0(3) NM; *naproxen sodium TABS 275mg, 550mg $0(1)piroxicam CAPS $0(1)provil $0(3) NM; *


Name of drug


you (tier

level)


or limits on usepx all day relief $0(3) NM; *qc ibuprofen ib $0(3) NM; *qc naproxen sodium $0(3) NM; *sb ibuprofen $0(3) NM; *sm childrens ibuprofen $0(3) NM; *sm ibuprofen $0(3) NM; *sm ibuprofen ib $0(3) NM; *sm infants ibuprofen $0(3) NM; *sm naproxen sodium $0(3) NM; *sulindac TABS $0(1)tgt naproxen sodium $0(3) NM; *

OPIOID ANALGESICS - DRUGS TO TREAT PAINacetaminophen w/ codeine 300-15mg $0(1) QL (400 tabs / 30 days)acetaminophen w/ codeine 300-30mg $0(1) QL (360 tabs / 30 days)acetaminophen w/ codeine 300-60mg $0(1) QL (180 tabs / 30 days)acetaminophen w/ codeine soln $0(1) QL (2700 mL / 30 days)buprenorphine patch $0(1) QL (4 patches / 28 days), PAbutorphanol tartrate SOLN 1mg/ml, 2mg/ml $0(2)nalbuphine hcl SOLN $0(2)tramadol hcl tab 50 mg $0(1) QL (240 tabs / 30 days)tramadol-acetaminophen $0(1) QL (240 tabs / 30 days)

OPIOID ANALGESICS, CII - DRUGS TO TREAT PAINendocet 2.5-325mg $0(1) QL (360 tabs / 30 days)endocet 5-325mg $0(1) QL (360 tabs / 30 days)endocet 7.5-325mg $0(1) QL (240 tabs / 30 days)endocet 10-325mg $0(1) QL (180 tabs / 30 days)fentanyl citrate LPOP $0(2) QL (120 lozenges / 30 days), PAfentanyl patch 12 mcg/hr $0(1) QL (10 patches / 30 days), PAfentanyl patch 25 mcg/hr $0(1) QL (10 patches / 30 days), PAfentanyl patch 50 mcg/hr $0(1) QL (10 patches / 30 days), PAfentanyl patch 75 mcg/hr $0(1) QL (10 patches / 30 days), PAfentanyl patch 100 mcg/hr $0(1) QL (10 patches / 30 days), PA


Name of drug


you (tier

level)


or limits on usehydroco/apap tab 5-325mg $0(1) QL (240 tabs / 30 days)hydroco/apap tab 7.5-325 $0(1) QL (180 tabs / 30 days)hydroco/apap tab 10-325mg $0(1) QL (180 tabs / 30 days)hydrocodone-acetaminophen 7.5-325 mg/15ml $0(1) QL (2700 mL / 30 days)hydrocodone-ibuprofen tab 7.5-200 mg $0(1) QL (150 tabs / 30 days)hydromorphone hcl LIQD $0(1) QL (600 mL / 30 days)hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml

$0(2) B/D

hydromorphone hcl TABS $0(1) QL (180 tabs / 30 days)HYSINGLA ER $0(2) QL (30 tabs / 30 days), PAmethadone hcl SOLN 5mg/5ml, 10mg/5ml $0(1) QL (450 mL / 30 days), PAmethadone hcl 5mg $0(1) QL (90 tabs / 30 days), PAmethadone hcl 10mg $0(1) QL (90 tabs / 30 days), PAmethadone hcl intensol $0(1) QL (90 mL / 30 days), PAmorphine ext-rel tab $0(1) QL (90 tabs / 30 days), PAmorphine sul inj 1mg/ml $0(2) B/DMORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml

$0(2) B/D

morphine sulfate SOLN 4mg/ml, 8mg/ml, 10mg/ml

$0(2) B/D

morphine sulfate TABS $0(1) QL (180 tabs / 30 days)morphine sulfate oral soln 10mg/5ml $0(1) QL (900 mL / 30 days)morphine sulfate oral soln 20mg/5ml $0(1) QL (900 mL / 30 days)morphine sulfate oral soln 100mg/5ml $0(1) QL (180 mL / 30 days)NUCYNTA ER $0(2) QL (60 tabs / 30 days), PAoxycodone hcl CAPS $0(1) QL (180 caps / 30 days)oxycodone hcl CONC $0(1) QL (180 mL / 30 days)oxycodone hcl SOLN $0(1) QL (900 mL / 30 days)oxycodone hcl TABS $0(1) QL (180 tabs / 30 days)oxycodone w/ acetaminophen 2.5-325mg $0(1) QL (360 tabs / 30 days)oxycodone w/ acetaminophen 5-325mg $0(1) QL (360 tabs / 30 days)oxycodone w/ acetaminophen 7.5-325mg $0(1) QL (240 tabs / 30 days)oxycodone w/ acetaminophen 10-325mg $0(1) QL (180 tabs / 30 days)


Name of drug


you (tier

level)


or limits on useOXYCONTIN $0(2) QL (60 tabs / 30 days), PA

ANESTHETICS - DRUGS FOR NUMBINGLOCAL ANESTHETICS

lidocaine hcl (local anesth.) $0(1) B/Dlidocaine inj 0.5% $0(1) B/Dlidocaine inj 1% $0(1) B/Dlidocaine inj 1.5% preservative free (pf) $0(1) B/D

ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONSANTI-BACTERIALS - MISCELLANEOUS

amikacin sulfate SOLN $0(1)gentamicin in saline $0(1)gentamicin sulfate SOLN $0(1)neomycin sulfate TABS $0(1)paromomycin sulfate CAPS $0(1)streptomycin sulfate SOLR $0(2)SULFADIAZINE TABS $0(2)tobramycin NEBU 300mg/5ml $0(2) NM, PAtobramycin inj 1.2 gm/30ml $0(1)tobramycin inj 1.2gm $0(2)tobramycin inj 10mg/ml $0(1)tobramycin inj 80mg/2ml $0(1)tobramycin sulfate SOLN $0(1)

ANTI-INFECTIVES - MISCELLANEOUSalbendazole TABS $0(2)ALINIA $0(2)atovaquone SUSP $0(2)aztreonam $0(1)CAYSTON $0(2) NM, LA, PAclindamycin cap 75mg $0(1)clindamycin cap 300mg $0(1)clindamycin hcl cap 150 mg $0(1)clindamycin phosphate in d5w $0(1)


Name of drug


you (tier

level)


or limits on useCLINDAMYCIN PHOSPHATE IN NACL $0(2)clindamycin phosphate inj $0(1)clindamycin soln 75mg/5ml $0(1)colistimethate sodium SOLR $0(1)dapsone TABS $0(1)daptomycin $0(2)EMVERM $0(2) QL (12 tabs / 365 days)ertapenem sodium $0(1)imipenem-cilastatin $0(1)ivermectin TABS $0(1)linezolid in sodium chloride $0(2)linezolid inj $0(1)linezolid susp $0(2)linezolid tab 600mg $0(1)meropenem $0(1)methenamine hippurate $0(1)metronidazole TABS $0(1)metronidazole in nacl $0(1)nitrofurantoin macrocrystal 50mg, 100mg $0(2)nitrofurantoin monohyd macro $0(2)pentamidine isethionate inh $0(1) B/Dpentamidine isethionate inj $0(1)praziquantel TABS $0(1)SIVEXTRO $0(2)sulfamethoxazole-trimethop ds $0(1)sulfamethoxazole-trimethoprim inj $0(1)sulfamethoxazole-trimethoprim susp $0(1)sulfamethoxazole-trimethoprim tab 400-80mg $0(1)SYNERCID $0(2)tigecycline $0(2)trimethoprim TABS $0(1)vancomycin hcl CAPS 125mg $0(1) QL (120 caps / 30 days)


Name of drug


you (tier

level)


or limits on usevancomycin hcl CAPS 250mg $0(2) QL (240 caps / 30 days)vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg

$0(1)

VANCOMYCIN IN NACL $0(2)ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS

ABELCET $0(2) B/DAMBISOME $0(2) B/Damphotericin b SOLR $0(1) B/Dcaspofungin acetate $0(2)fluconazole SUSR; TABS $0(1)fluconazole inj nacl 200 $0(1)fluconazole inj nacl 400 $0(1)flucytosine CAPS $0(2)griseofulvin microsize $0(1)griseofulvin ultramicrosize $0(1)itraconazole CAPS $0(1) PAketoconazole TABS $0(1) PAmicafungin sodium $0(2)MYCAMINE $0(2)NOXAFIL SUSP $0(2) QL (630 mL / 30 days)nystatin TABS $0(1)posaconazole $0(2) QL (93 tabs / 30 days)terbinafine hcl TABS $0(1) QL (90 tabs / year)voriconazole SOLR $0(2) PAvoriconazole SUSR $0(2) PAvoriconazole TABS 50mg $0(1)voriconazole TABS 200mg $0(2)

ANTIMALARIALS - DRUGS TO TREAT MALARIAatovaquone-proguanil hcl $0(1)chloroquine phosphate TABS $0(1)COARTEM $0(2)mefloquine hcl $0(1)primaquine phosphate 26.3mg $0(1)


Name of drug


you (tier

level)


or limits on usePRIMAQUINE PHOSPHATE 26.3mg $0(2)quinine sulfate CAPS $0(1) PA

ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTIONabacavir sulfate $0(1) NMAPTIVUS $0(2) NMatazanavir sulfate $0(1) NMCRIXIVAN $0(2) NMdidanosine $0(1) NMEDURANT $0(2) NMefavirenz CAPS 50mg $0(1) NMefavirenz CAPS 200mg $0(2) NMefavirenz TABS $0(2) NMemtricitabine $0(1) NMEMTRIVA $0(2) NMfosamprenavir tab 700 mg $0(2) NMFUZEON $0(2) NMINTELENCE $0(2) NMINVIRASE $0(2) NMISENTRESS $0(2) NMISENTRESS HD $0(2) NMlamivudine $0(1) NMLEXIVA SUSP $0(2) NMnevirapine susp 50 mg/5ml $0(1) NMnevirapine tab 100mg er $0(1) NMnevirapine tab 200mg $0(1) NMnevirapine tab 400mg er $0(1) NMNORVIR PACK $0(2) NMNORVIR SOLN $0(2) NMPIFELTRO $0(2) NMPREZISTA SUSP $0(2) QL (400 mL / 30 days), NMPREZISTA TABS 75mg $0(2) QL (480 tabs / 30 days), NMPREZISTA TABS 150mg $0(2) QL (240 tabs / 30 days), NM


Name of drug


you (tier

level)


or limits on usePREZISTA TABS 600mg $0(2) QL (60 tabs / 30 days), NMPREZISTA TABS 800mg $0(2) QL (30 tabs / 30 days), NMREYATAZ PACK $0(2) NMritonavir $0(1) NMRUKOBIA $0(2) NMSELZENTRY $0(2) NMstavudine $0(1) NMtenofovir disoproxil fumarate $0(1) NMTIVICAY $0(2) NMTIVICAY PD $0(2) NMTROGARZO $0(2) NM, LATYBOST $0(2) NMVIRACEPT $0(2) NMVIREAD POWD $0(2) NMVIREAD TABS 150mg, 200mg, 250mg $0(2) NMzidovudine cap 100mg $0(1) NMzidovudine syp 50mg/5ml $0(1) NMzidovudine tab 300mg $0(1) NM

ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTIONabacavir sulfate-lamivudine $0(1) NMabacavir sulfate-lamivudine-zidovudine $0(2) NMATRIPLA $0(2) NMBIKTARVY $0(2) NMCIMDUO $0(2) NMCOMPLERA $0(2) NMDELSTRIGO $0(2) NMDESCOVY $0(2) NMDOVATO $0(2) NMefavirenz-lamivudine-tenofovir disoproxil fumarate

$0(2) NM

EVOTAZ $0(2) NMGENVOYA $0(2) NMJULUCA $0(2) NM


Name of drug


you (tier

level)


or limits on useKALETRA TAB 100-25MG $0(2) NMKALETRA TAB 200-50MG $0(2) NMlamivudine-zidovudine $0(1) NMlopinavir-ritonavir $0(1) NMODEFSEY $0(2) NMPREZCOBIX $0(2) NMSTRIBILD $0(2) NMSYMFI $0(2) NMSYMFI LO $0(2) NMSYMTUZA $0(2) NMTEMIXYS $0(2) NMTRIUMEQ $0(2) NMTRUVADA TAB 100-150 $0(2) QL (30 tabs / 30 days), NMTRUVADA TAB 133-200 $0(2) QL (30 tabs / 30 days), NMTRUVADA TAB 167-250 $0(2) QL (30 tabs / 30 days), NMTRUVADA TAB 200-300 $0(2) QL (30 tabs / 30 days), NM

ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIScycloserine CAPS $0(2)ethambutol hcl TABS $0(1)isoniazid TABS $0(1)isoniazid syp 50mg/5ml $0(1)PASER D/R $0(2)PRIFTIN $0(2)pyrazinamide TABS $0(1)rifabutin $0(1)rifampin CAPS; SOLR $0(1)SIRTURO $0(2) LA, PATRECATOR $0(2)

ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONSacyclovir CAPS; SUSP; TABS $0(1)acyclovir sodium $0(1) B/Dadefovir dipivoxil $0(2) NM


Name of drug


you (tier

level)


or limits on useBARACLUDE SOLN $0(2) NMentecavir $0(1) NMEPCLUSA $0(2) NM, PAEPIVIR HBV SOLN $0(2) NMfamciclovir TABS $0(1)ganciclovir sodium $0(1) B/DHARVONI $0(2) NM, PAlamivudine (hbv) $0(1) NMMAVYRET $0(2) NM, PAoseltamivir phosphate CAPS 30mg $0(1) QL (168 caps / year)oseltamivir phosphate CAPS 45mg, 75mg $0(1) QL (84 caps / year)oseltamivir phosphate SUSR $0(1) QL (1080 mL / year)PEGASYS $0(2) NM, PAPEGASYS PROCLICK $0(2) NM, PARELENZA DISKHALER $0(2) QL (6 inhalers / year)ribavirin 200mg $0(1) NMrimantadine hydrochloride $0(1)valacyclovir hcl TABS $0(1)valganciclovir hcl $0(2)VEMLIDY $0(2) NMVOSEVI $0(2) NM, PA

CEPHALOSPORINS - DRUGS TO TREAT INFECTIONScefaclor $0(1)CEFACLOR MONOHYDRATE ER $0(2)cefadroxil $0(1)CEFAZOLIN IN DEXTROSE 2GM/100ML-4% $0(2)cefazolin inj $0(1)cefazolin sodium SOLR 1gm $0(1)CEFAZOLIN SODIUM 1 GM/50ML $0(2)cefdinir $0(1)cefepime hcl $0(1)cefixime SUSR $0(1)


Name of drug


you (tier

level)


or limits on usecefoxitin sodium $0(1)cefpodoxime proxetil $0(1)cefprozil $0(1)ceftazidime SOLR $0(1)CEFTAZIDIME/DEXTROSE $0(2)ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg

$0(1)

cefuroxime axetil $0(1)cefuroxime sodium $0(1)cephalexin CAPS 250mg, 500mg $0(1)cephalexin SUSR $0(1)tazicef SOLR $0(1)TEFLARO $0(2)

ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONSazithromycin PACK; SOLR; SUSR; TABS $0(1)clarithromycin TABS $0(1)clarithromycin er $0(1)clarithromycin for susp $0(1)DIFICID $0(2)ery-tab $0(1)ERYTHROCIN LACTOBIONATE $0(2)erythrocin stearate $0(1)erythromycin base $0(1)erythromycin cap 250mg ec $0(1)erythromycin ethylsuccinate TABS $0(1)erythromycin tab ec $0(1)

FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONSCIPRO SUSR 500mg/5ml $0(2)ciprofloxacin hcl tab $0(1)ciprofloxacin in d5w $0(1)levofloxacin TABS $0(1)levofloxacin in d5w $0(1)levofloxacin inj 25mg/ml $0(1)


Name of drug


you (tier

level)


or limits on uselevofloxacin oral soln 25 mg/ml $0(1)moxifloxacin hcl TABS $0(1)

PENICILLINS - DRUGS TO TREAT INFECTIONSamoxicillin $0(1)amoxicillin & pot clavulanate 200-28.5 chw tabs $0(1)amoxicillin & pot clavulanate 200/5ml susr $0(1)amoxicillin & pot clavulanate 250-125 tabs $0(1)amoxicillin & pot clavulanate 250/5ml susr $0(1)amoxicillin & pot clavulanate 400-57 chw tabs $0(1)amoxicillin & pot clavulanate 400/5ml susr $0(1)amoxicillin & pot clavulanate 500-125 tabs $0(1)amoxicillin & pot clavulanate 600/5ml susr $0(1)amoxicillin & pot clavulanate 875-125 tabs $0(1)amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs

$0(1)

ampicillin & sulbactam sodium $0(1)ampicillin cap 500mg $0(1)ampicillin inj $0(1)ampicillin sodium $0(1)BICILLIN L-A $0(2)dicloxacillin sodium $0(1)nafcillin sodium 1gm, 2gm $0(1)nafcillin sodium 10gm $0(2)NAFCILLIN SODIUM FOR INJ 10GM $0(2)oxacillin sodium SOLR 1gm, 2gm $0(1)oxacillin sodium SOLR 10gm $0(2)PENICILLIN G POT IN DEXTROSE 2MU $0(2)PENICILLIN G POT IN DEXTROSE 3MU $0(2)PENICILLIN G PROCAINE $0(2)penicillin g sodium $0(1)penicillin v potassium $0(1)penicilln gk inj 5mu $0(1)penicilln gk inj 20mu $0(1)


Name of drug


you (tier

level)


or limits on usepfizerpen-g inj 5mu $0(1)pfizerpen-g inj 20mu $0(1)piper/tazoba inj 2-0.25gm $0(1)piper/tazoba inj 3-0.375gm $0(1)piper/tazoba inj 4-0.5gm $0(1)piper/tazoba inj 12-1.5gm $0(1)piper/tazoba inj 36-4.5gm $0(1)

TETRACYCLINES - DRUGS TO TREAT INFECTIONSdoxy 100 $0(1)doxycycline (monohydrate) CAPS 50mg, 100mg

$0(1)

doxycycline (monohydrate) TABS 50mg, 75mg, 100mg

$0(1)

doxycycline hyclate CAPS $0(1)doxycycline hyclate SOLR $0(1)doxycycline hyclate TABS 20mg, 100mg $0(1)minocycline hcl CAPS $0(1)mondoxyne nl cap 100mg $0(1)tetracycline hcl CAPS $0(1)

ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCERALKYLATING AGENTS

BENDEKA $0(2) B/D, NMcyclophosphamide CAPS $0(1) B/DCYCLOPHOSPHAMIDE SOLN $0(2) B/Dcyclophosphamide SOLR $0(2) B/DEMCYT $0(2)GLEOSTINE $0(2)LEUKERAN $0(2)

ANTHRACYCLINESadriamycin SOLN $0(1) B/Ddoxorubicin hcl $0(1) B/Ddoxorubicin hcl liposomal $0(2) B/Depirubicin hcl $0(1) B/D


Name of drug


you (tier

level)


or limits on useANTIMETABOLITES

ALIMTA $0(2) B/Dazacitidine $0(2) B/D, NMcytarabine 20mg/ml $0(1) B/Dfluorouracil SOLN $0(1) B/Dgemcitabine inj soln $0(1) B/Dgemcitabine inj solr $0(1) B/Dmercaptopurine TABS $0(1)methotrexate sodium inj soln $0(1) B/Dmethotrexate sodium inj solr $0(1) B/DPURIXAN $0(2) NMTABLOID $0(2)

ANTIMITOTIC, TAXOIDSABRAXANE $0(2) B/Ddocetaxel CONC 20mg/ml, 80mg/4ml, 160mg/8ml

$0(2) B/D

DOCETAXEL CONC 80mg/4ml, 160mg/8ml, 200mg/10ml

$0(2) B/D

docetaxel SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

$0(2) B/D

DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

$0(2) B/D

paclitaxel 30mg/5ml, 100mg/16.7ml, 150mg/25ml, 300mg/50ml

$0(1) B/D

TAXOTERE $0(2) B/DANTIMITOTIC, VINCA ALKALOIDS

vincristine sulfate $0(1) B/Dvinorelbine tartrate $0(1) B/D

BIOLOGIC RESPONSE MODIFIERSAVASTIN $0(2) NM, LA, PABORTEZOMIB $0(2) NM, PADAURISMO $0(2) NM, LA, PAERIVEDGE $0(2) NM, LA, PA


Name of drug


you (tier

level)


or limits on useFARYDAK $0(2) NM, LA, PAHERCEPTIN $0(2) NM, PAHERCEPTIN HYLECTA $0(2) NM, PAHERZUMA $0(2) NM, PAIBRANCE CAPS $0(2) QL (21 caps / 28 days), NM, LA,

PAIBRANCE TABS $0(2) QL (21 tabs / 28 days), NM, LA,

PAIDHIFA $0(2) QL (30 tabs / 30 days), NM, LA,

PAKADCYLA $0(2) B/D, NMKANJINTI $0(2) NM, PAKEYTRUDA $0(2) NM, PAKISQALI $0(2) NM, PAKISQALI FEMARA 200 DOSE $0(2) NM, PAKISQALI FEMARA 400 DOSE $0(2) NM, PAKISQALI FEMARA 600 DOSE $0(2) NM, PALYNPARZA $0(2) NM, LA, PAMVASI $0(2) NM, LA, PANINLARO $0(2) NM, PAODOMZO $0(2) NM, LA, PAOGIVRI $0(2) NM, PAONTRUZANT $0(2) NM, PAPHESGO $0(2) NM, LA, PARITUXAN $0(2) NM, LA, PARITUXAN HYCELA $0(2) NM, LA, PARUBRACA $0(2) NM, LA, PARUXIENCE $0(2) NM, PATALZENNA $0(2) NM, LA, PATECENTRIQ $0(2) NM, LA, PATIBSOVO $0(2) NM, LA, PATRAZIMERA $0(2) NM, PATRUXIMA $0(2) NM, PA


Name of drug


you (tier

level)


or limits on useVELCADE $0(2) NM, PAVENCLEXTA $0(2) NM, LA, PAVENCLEXTA STARTING PACK $0(2) NM, LA, PAVERZENIO $0(2) NM, LA, PAZEJULA $0(2) NM, LA, PAZIRABEV $0(2) NM, PAZOLINZA $0(2) NM, PA

HORMONAL ANTINEOPLASTIC AGENTSabiraterone acetate $0(2) NM, PAanastrozole TABS $0(1)bicalutamide $0(1)DEPO-PROVERA INJ 400/ML $0(2) B/DERLEADA $0(2) NM, LA, PAexemestane $0(1)flutamide $0(1)fulvestrant $0(2) B/Dletrozole TABS $0(1)leuprolide inj 1mg/0.2 $0(1) NM, PALUPRON DEPOT (1-MONTH) 3.75mg $0(2) NM, PALUPRON DEPOT INJ 11.25MG (3-MONTH) $0(2) NM, PALYSODREN $0(2)megestrol ac sus 40mg/ml $0(2)megestrol ac tab 20mg $0(2)megestrol ac tab 40mg $0(2)megestrol sus 625mg/5ml $0(2) PAnilutamide $0(2)NUBEQA $0(2) NM, LA, PASOLTAMOX $0(2)tamoxifen citrate TABS $0(1)toremifene citrate $0(2)TRELSTAR DEP INJ 3.75MG $0(2) NM, PATRELSTAR LA INJ 11.25MG $0(2) NM, PA


Name of drug


you (tier

level)


or limits on useXTANDI $0(2) NM, LA, PAZYTIGA 500mg $0(2) NM, LA, PA

IMMUNOMODULATORSPOMALYST CAP 1MG $0(2) QL (21 caps / 21 days), NM, LA,

PAPOMALYST CAP 2MG $0(2) QL (21 caps / 21 days), NM, LA,



PAREVLIMID $0(2) QL (28 caps / 28 days), NM, LA,

PATHALOMID 50mg, 100mg $0(2) QL (28 caps / 28 days), NM, PATHALOMID 150mg, 200mg $0(2) QL (56 caps / 28 days), NM, PA

KINASE INHIBITORSAFINITOR 10mg $0(2) QL (30 tabs / 30 days), NM, PAAFINITOR DISPERZ 2mg $0(2) QL (150 tabs / 30 days), NM, PAAFINITOR DISPERZ 3mg $0(2) QL (90 tabs / 30 days), NM, PAAFINITOR DISPERZ 5mg $0(2) QL (60 tabs / 30 days), NM, PAALECENSA $0(2) NM, LA, PAALUNBRIG $0(2) NM, LA, PAAYVAKIT $0(2) QL (30 tabs / 30 days), NM, LA,

PABALVERSA $0(2) NM, LA, PABOSULIF $0(2) NM, PABRAFTOVI $0(2) NM, LA, PABRUKINSA $0(2) NM, LA, PACABOMETYX $0(2) QL (30 tabs / 30 days), NM, LA,

PACALQUENCE $0(2) NM, LA, PACAPRELSA $0(2) NM, LA, PACOMETRIQ $0(2) NM, LA, PACOPIKTRA $0(2) NM, LA, PA


Name of drug


you (tier

level)


or limits on useCOTELLIC $0(2) NM, LA, PAerlotinib hcl 25mg $0(2) QL (90 tabs / 30 days), NM, PAerlotinib hcl 100mg, 150mg $0(2) QL (30 tabs / 30 days), NM, PAeverolimus $0(2) QL (30 tabs / 30 days), NM, PAGILOTRIF TAB 20MG $0(2) NM, LA, PAGILOTRIF TAB 30MG $0(2) NM, LA, PAGILOTRIF TAB 40MG $0(2) NM, LA, PAICLUSIG $0(2) NM, LA, PAimatinib mesylate 100mg $0(2) QL (90 tabs / 30 days), NM, PAimatinib mesylate 400mg $0(2) QL (60 tabs / 30 days), NM, PAIMBRUVICA $0(2) NM, LA, PAINLYTA 1mg $0(2) QL (180 tabs / 30 days), NM, LA,

PAINLYTA 5mg $0(2) QL (120 tabs / 30 days), NM, LA,

PAINREBIC $0(2) NM, LA, PAIRESSA $0(2) NM, LA, PAJAKAFI $0(2) QL (60 tabs / 30 days), NM, LA,

PALENVIMA 4 MG DAILY DOSE $0(2) NM, LA, PALENVIMA 8 MG DAILY DOSE $0(2) NM, LA, PALENVIMA 10 MG DAILY DOSE $0(2) NM, LA, PALENVIMA 12MG DAILY DOSE $0(2) NM, LA, PALENVIMA 14 MG DAILY DOSE $0(2) NM, LA, PALENVIMA 18 MG DAILY DOSE $0(2) NM, LA, PALENVIMA 20 MG DAILY DOSE $0(2) NM, LA, PALENVIMA 24 MG DAILY DOSE $0(2) NM, LA, PALORBRENA $0(2) NM, LA, PAMEKINIST $0(2) NM, LA, PAMEKTOVI $0(2) NM, LA, PANERLYNX $0(2) NM, LA, PANEXAVAR $0(2) NM, LA, PAPEMAZYRE $0(2) NM, LA, PA


Name of drug


you (tier

level)


or limits on usePIQRAY 200MG DAILY DOSE $0(2) NM, PAPIQRAY 250MG DAILY DOSE $0(2) NM, PAPIQRAY 300MG DAILY DOSE $0(2) NM, PAQINLOCK $0(2) NM, LA, PARETEVMO $0(2) NM, LA, PAROZLYTREK $0(2) NM, LA, PARYDAPT $0(2) NM, PASPRYCEL $0(2) NM, PASTIVARGA $0(2) NM, LA, PASUTENT $0(2) QL (30 caps / 30 days), NM, PATABRECTA $0(2) NM, PATAFINLAR $0(2) NM, LA, PATAGRISSO $0(2) QL (30 tabs / 30 days), NM, LA,

PATASIGNA $0(2) NM, PATUKYSA $0(2) NM, LA, PATURALIO $0(2) NM, LA, PATYKERB $0(2) NM, LA, PAVITRAKVI $0(2) NM, LA, PAVIZIMPRO $0(2) NM, LA, PAVOTRIENT $0(2) NM, LA, PAXALKORI $0(2) NM, LA, PAXOSPATA $0(2) NM, LA, PAZELBORAF $0(2) NM, LA, PAZYDELIG $0(2) NM, LA, PAZYKADIA $0(2) NM, LA, PA

MISCELLANEOUSbexarotene $0(2) NM, PAhydroxyurea CAPS $0(1)INQOVI $0(2) NM, LA, PALONSURF $0(2) NM, PAMATULANE $0(2) LASYLATRON $0(2) NM, PA


Name of drug


you (tier

level)


or limits on useSYNRIBO $0(2) NM, PATAZVERIK $0(2) NM, LA, PAtretinoin (chemotherapy) $0(2)XPOVIO 40 MG ONCE WEEKLY $0(2) NM, LA, PAXPOVIO 40 MG TWICE WEEKLY $0(2) NM, LA, PAXPOVIO 60 MG ONCE WEEKLY $0(2) NM, LA, PAXPOVIO 60 MG TWICE WEEKLY $0(2) NM, LA, PAXPOVIO 80 MG ONCE WEEKLY $0(2) NM, LA, PAXPOVIO 80 MG TWICE WEEKLY $0(2) NM, LA, PAXPOVIO 100 MG ONCE WEEKLY $0(2) NM, LA, PA

PLATINUM-BASED AGENTScarboplatin $0(1) B/Dcisplatin SOLN $0(1) B/Doxaliplatin inj 50mg $0(2) B/Doxaliplatin inj 50mg/10ml $0(1) B/Doxaliplatin inj 100mg $0(2) B/Doxaliplatin inj 100mg/20ml $0(1) B/D

PROTECTIVE AGENTSleucovorin calcium SOLN 500mg/50ml $0(1) B/Dleucovorin calcium SOLR $0(1) B/Dleucovorin calcium TABS $0(1)MESNEX TABS $0(2)

TOPOISOMERASE INHIBITORSetoposide SOLN $0(1) B/Dirinotecan hcl $0(1) B/Dtoposar $0(1) B/D

CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONSACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE

amlodipine--benazepril hcl cap 10-20 mg $0(1)amlodipine-benazepril hcl cap 2.5-10 mg $0(1)amlodipine-benazepril hcl cap 5-10 mg $0(1)amlodipine-benazepril hcl cap 5-20 mg $0(1)


Name of drug


you (tier

level)


or limits on useamlodipine-benazepril hcl cap 5-40 mg $0(1)amlodipine-benazepril hcl cap 10-40mg $0(1)benazepril & hydrochlorothiazide $0(1)captopril & hydrochlorothiazide $0(1)enalapril maleate & hydrochlorothiazide $0(1)fosinopril sodium & hydrochlorothiazide $0(1)lisinopril & hydrochlorothiazide $0(1)quinapril-hydrochlorothiazide $0(1)

ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSUREbenazepril hcl TABS $0(1)captopril TABS $0(1)enalapril maleate TABS $0(1)fosinopril sodium $0(1)lisinopril TABS $0(1)moexipril hcl $0(1)perindopril erbumine $0(1)quinapril hcl $0(1)ramipril $0(1)trandolapril $0(1)

ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSUREeplerenone $0(1)spironolactone TABS $0(1)

ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSUREdoxazosin mesylate TABS $0(1)prazosin hcl $0(1)terazosin hcl $0(1)

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE

amlodipine besylate-olmesartan medoxomil $0(1)amlodipine besylate-valsartan tab 5-160 mg $0(1)amlodipine besylate-valsartan tab 5-320 mg $0(1)amlodipine besylate-valsartan tab 10-160 mg $0(1)amlodipine besylate-valsartan tab 10-320 mg $0(1)


Name of drug


you (tier

level)


or limits on useamlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg

$0(1)

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg

$0(1)

amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg

$0(1)


$0(1)


$0(1)

candesartan cilexetil-hydrochlorothiazide $0(1)ENTRESTO $0(2)irbesartan-hydrochlorothiazide $0(1)losartan-hydrochlorothiazide $0(1)olmesartan medoxomil-amlodipine-hydrochlorothiazide

$0(1)

olmesartan medoxomil-hydrochlorothiazide $0(1)telmisartan-amlodipine $0(1)telmisartan-hydrochlorothiazide $0(1)valsartan-hydrochlorothiazide $0(1)

ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSUREcandesartan cilexetil $0(1)irbesartan $0(1)losartan potassium TABS $0(1)olmesartan medoxomil TABS $0(1)telmisartan $0(1)valsartan $0(1)

ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHMamiodarone hcl soln $0(1)amiodarone tab 100mg $0(1)amiodarone tab 200mg $0(1)amiodarone tab 400mg $0(1)disopyramide phosphate $0(2)


Name of drug


you (tier

level)


or limits on usedofetilide $0(1) NMflecainide acetate $0(1)MULTAQ $0(2)NORPACE CR $0(2)pacerone $0(1)propafenone hcl $0(1)propafenone hcl 12hr $0(1)quinidine sulfate $0(1)sorine $0(1)sotalol hcl $0(1)sotalol hcl (afib/afl) $0(1)

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - DRUGS TO TREAT HIGH CHOLESTEROLatorvastatin calcium TABS $0(1)lovastatin $0(1)pravastatin sodium $0(1)rosuvastatin calcium $0(1) QL (30 tabs / 30 days)simvastatin TABS 5mg, 10mg, 20mg, 40mg $0(1)simvastatin TABS 80mg $0(1) QL (30 tabs / 30 days)

ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH CHOLESTEROLcholestyramine $0(1)cholestyramine light pack $0(1)cholestyramine light powd $0(1)colesevelam hcl $0(1)colestipol hcl gran $0(1)colestipol hcl pack $0(1)colestipol hcl tabs $0(1)ezetimibe $0(1)ezetimibe-simvastatin $0(1)fenofibrate TABS 48mg, 54mg, 145mg, 160mg

$0(1)

fenofibrate micronized 67mg, 134mg, 200mg $0(1)gemfibrozil TABS $0(1)JUXTAPID $0(2) NM, LA, PA


Name of drug


you (tier

level)


or limits on useniacin (antihyperlipidemic) $0(1)niacin er (antihyperlipidemic) 500mg $0(1) QL (60 tabs / 30 days)niacin er (antihyperlipidemic) 750mg, 1000mg $0(1)niacor $0(1)PRALUENT $0(2) NM, PAprevalite $0(1)VASCEPA $0(2)

BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS

atenolol & chlorthalidone $0(1)bisoprolol & hydrochlorothiazide $0(1)metoprolol & hctz tab 50-25mg $0(1)metoprolol & hctz tab 100-25mg $0(1)metoprolol & hctz tab 100-50mg $0(1)propranolol & hydrochlorothiazide $0(1)

BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONSacebutolol hcl CAPS $0(1)atenolol TABS $0(1)betaxolol hcl $0(1)bisoprolol fumarate $0(1)BYSTOLIC 2.5mg, 5mg, 10mg $0(2) QL (30 tabs / 30 days)BYSTOLIC 20mg $0(2) QL (60 tabs / 30 days)carvedilol $0(1)labetalol hcl TABS $0(1)metoprolol succinate $0(1)metoprolol tartrate SOCT $0(1)metoprolol tartrate SOLN $0(1)metoprolol tartrate TABS 25mg, 50mg, 100mg $0(1)nadolol TABS $0(1)pindolol $0(1)propranolol cap er $0(1)propranolol hcl TABS $0(1)propranolol oral sol $0(1)


Name of drug


you (tier

level)


or limits on usetimolol maleate TABS $0(1)

CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS

amlodipine besylate TABS $0(1)cartia xt cap 120/24hr $0(1)cartia xt cap 180/24hr $0(1)cartia xt cap 240/24hr $0(1)cartia xt cap 300/24hr $0(1)dilt-xr cap $0(1)diltiazem cap 240mg cd $0(1)diltiazem cap 360mg cd $0(1)diltiazem cap er/12hr $0(1)diltiazem hcl TABS $0(1)diltiazem hcl coated beads CP24 $0(1)diltiazem hcl coated beads cap sr 24hr $0(1)diltiazem hcl extended release beads cap sr $0(1)diltiazem inj $0(1)felodipine $0(1)isradipine $0(1)nicardipine hcl CAPS $0(1)nifedipine TB24 $0(1)nifedipine er $0(1)nimodipine CAPS $0(2)NYMALIZE $0(2)taztia xt $0(1)tiadylt er $0(1)verapamil cap er $0(1)verapamil hcl SOLN; TABS $0(1)verapamil hcl tab er $0(1)

DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONSdigitek .25mg $0(1) PA; PA if 70 years and olderdigitek .125mg $0(1) QL (30 tabs / 30 days)digox 125mcg $0(1) QL (30 tabs / 30 days)


Name of drug


you (tier

level)


or limits on usedigox 250mcg $0(1) PA; PA if 70 years and olderdigoxin TABS 125mcg $0(1) QL (30 tabs / 30 days)digoxin TABS 250mcg $0(1) PA; PA if 70 years and olderdigoxin inj $0(1)digoxin sol 50mcg/ml $0(1) PA; PA if 70 years and older

DIURETICS - DRUGS TO TREAT HEART CONDITIONSacetazolamide CP12; TABS $0(1)amiloride & hydrochlorothiazide $0(1)amiloride hcl TABS $0(1)bumetanide $0(1)chlorothiazide TABS $0(1)chlorthalidone $0(1)furosemide SOLN; TABS $0(1)furosemide inj $0(1)hydrochlorothiazide CAPS; TABS $0(1)indapamide $0(1)methazolamide TABS $0(1)metolazone $0(1)spironolactone & hydrochlorothiazide $0(1)torsemide tabs $0(1)triamterene & hydrochlorothiazide cap 37.5-25 mg

$0(1)

triamterene & hydrochlorothiazide tabs $0(1)MISCELLANEOUS

aliskiren fumarate $0(1)clonidine hcl TABS $0(1)clonidine hcl ptwk $0(1)CORLANOR $0(2)DEMSER $0(2) PAhydralazine hcl SOLN; TABS $0(1)metyrosine $0(2) PAmidodrine hcl $0(1)minoxidil TABS $0(1)


Name of drug


you (tier

level)


or limits on useNORTHERA 100mg $0(2) QL (90 caps / 30 days), NM, LA,

PANORTHERA 200mg, 300mg $0(2) QL (180 caps / 30 days), NM, LA,

PAranolazine $0(1)

NITRATES - DRUGS TO TREAT HEART CONDITIONSisosorb mononitrate tab $0(1)isosorbide dinitrate 5mg, 10mg, 20mg, 30mg $0(1)isosorbide mononitrate er $0(1)minitran $0(1)NITRO-BID $0(2)NITRO-DUR DIS 0.3MG/HR $0(2)NITRO-DUR DIS 0.8MG/HR $0(2)nitroglycerin SOLN .4mg/spray $0(1)nitroglycerin SUBL $0(1)nitroglycerin td patch $0(1)

PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT PULMONARY HYPERTENSIONADEMPAS $0(2) QL (90 tabs / 30 days), NM, LA,

PAambrisentan $0(2) QL (30 tabs / 30 days), NM, LA,

PAbosentan 62.5mg $0(2) QL (120 tabs / 30 days), NM, LA,

PAbosentan 125mg $0(2) QL (60 tabs / 30 days), NM, LA,

PAOPSUMIT $0(2) QL (30 tabs / 30 days), NM, LA,

PAsildenafil citrate tab 20 mg (pulmonary hypertension)

$0(1) QL (90 tabs / 30 days), NM, PA

treprostinil $0(2) NM, LA, PAVENTAVIS $0(2) NM, PA

CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERSANTIANXIETY - DRUGS TO TREAT ANXIETY

alprazolam tab 0.5mg $0(1) QL (150 tabs / 30 days)


Name of drug


you (tier

level)


or limits on usealprazolam tab 0.25mg $0(1) QL (150 tabs / 30 days)alprazolam tab 1mg $0(1) QL (150 tabs / 30 days)alprazolam tab 2mg $0(1) QL (150 tabs / 30 days)buspirone hcl TABS $0(1)fluvoxamine maleate TABS $0(1)lorazepam SOLN $0(1)lorazepam TABS $0(1) QL (150 tabs / 30 days)lorazepam intensol $0(1) QL (150 mL / 30 days)

ANTICONVULSANTS - DRUGS TO TREAT SEIZURESAPTIOM $0(2) QL (60 tabs / 30 days)BANZEL SUS 40MG/ML $0(2) PABANZEL TAB 200MG $0(2) PABANZEL TAB 400MG $0(2) PABRIVIACT INJ 50MG/5ML $0(2) PABRIVIACT SOL 10MG/ML $0(2) PABRIVIACT TAB 10MG $0(2) PABRIVIACT TAB 25MG $0(2) PABRIVIACT TAB 50MG $0(2) PABRIVIACT TAB 75MG $0(2) PABRIVIACT TAB 100MG $0(2) PAcarbamazepine CHEW; CP12; SUSP; TABS; TB12

$0(1)

CELONTIN $0(2)clobazam $0(1) PAclonazepam TABS 2mg $0(1) QL (300 tabs / 30 days)clonazepam TABS .5mg, 1mg $0(1) QL (90 tabs / 30 days)clonazepam TBDP 2mg $0(1) QL (300 tabs / 30 days)clonazepam TBDP .125mg, .25mg, .5mg, 1mg $0(1) QL (90 tabs / 30 days)clorazepate dipotassium $0(1) QL (180 tabs / 30 days), PA; PA if

65 years and olderDIASTAT ACUDIAL $0(2)DIASTAT PEDIATRIC $0(2)


Name of drug


you (tier

level)


or limits on usediazepam TABS $0(1) QL (120 tabs / 30 days), PA; PA if

65 years and olderdiazepam gel $0(1)diazepam inj $0(1)diazepam intensol $0(1) QL (240 mL / 30 days), PA; PA if

65 years and olderdiazepam oral soln 1 mg/ml $0(1) QL (1200 mL / 30 days), PA; PA if

65 years and olderDILANTIN CAP 30MG $0(2)DILANTIN CAP 100MG $0(2)DILANTIN CHEW TAB 50MG $0(2)DILANTIN-125 SUSP $0(2)divalproex sodium CSDR; TB24; TBEC $0(1)EPIDIOLEX $0(2) QL (600 mL / 30 days), NM, LA,

PAepitol $0(1)ethosuximide CAPS; SOLN $0(1)felbamate SUSP $0(2)felbamate TABS $0(1)FINTEPLA $0(2) QL (360 mL / 30 days), NM, LA,

PAFYCOMPA SUSP $0(2) QL (720 mL / 30 days), PAFYCOMPA TABS 2mg, 4mg, 6mg $0(2) QL (60 tabs / 30 days), PAFYCOMPA TABS 8mg, 10mg, 12mg $0(2) QL (30 tabs / 30 days), PAgabapentin CAPS 100mg $0(1) QL (1080 caps / 30 days)gabapentin CAPS 300mg $0(1) QL (360 caps / 30 days)gabapentin CAPS 400mg $0(1) QL (270 caps / 30 days)gabapentin SOLN $0(1) QL (2160 mL / 30 days)gabapentin TABS 600mg $0(1) QL (180 tabs / 30 days)gabapentin TABS 800mg $0(1) QL (120 tabs / 30 days)lamotrigine CHEW; TABS; TB24 $0(1)levetiracetam SOLN; TABS; TB24 $0(1)levetiracetam in sodium chloride $0(1)levetiracetam oral soln 100 mg/ml $0(1)


Name of drug


you (tier

level)


or limits on useNAYZILAM $0(2)oxcarbazepine $0(1)PEGANONE $0(2)phenobarbital ELIX; TABS $0(2) PA; PA if 70 years and olderphenobarbital sodium SOLN $0(2) PA; PA if 70 years and olderPHENYTEK $0(2)phenytoin CHEW; SUSP $0(1)phenytoin sodium extended $0(1)phenytoin sodium inj 50mg/ml $0(1)pregabalin CAPS 25mg, 50mg, 75mg, 100mg, 150mg

$0(1) QL (120 caps / 30 days), PA

pregabalin CAPS 200mg $0(1) QL (90 caps / 30 days), PApregabalin CAPS 225mg, 300mg $0(1) QL (60 caps / 30 days), PApregabalin SOLN $0(1) QL (900 mL / 30 days), PAprimidone TABS $0(1)roweepra $0(1)roweepra xr $0(1)SPRITAM $0(2)subvenite tab $0(1)SYMPAZAN $0(2) PAtiagabine hcl $0(1)topiramate CPSP; TABS $0(1)valproate sodium SOLN $0(1)valproic acid CAPS $0(1)VALTOCO $0(2) NMvigabatrin powd pack 500mg $0(2) QL (180 packets / 30 days), NM,

LA, PAvigabatrin tab 500mg $0(2) QL (180 tabs / 30 days), NM, LA,

PAvigadrone $0(2) QL (180 packets / 30 days), NM,

LA, PAVIMPAT 50mg $0(2) QL (120 tabs / 30 days)VIMPAT 100mg, 150mg, 200mg $0(2) QL (60 tabs / 30 days)


Name of drug


you (tier

level)


or limits on useVIMPAT INJ 200MG/20ML $0(2)VIMPAT SOL 10MG/ML $0(2) QL (1200 mL / 30 days)XCOPRI MAINTENANCE PAK 150-200MG $0(2) QL (56 tabs / 28 days)XCOPRI PAK 12.5-25MG $0(2) QL (28 tabs / 28 days)XCOPRI PAK 50-100MG $0(2) QL (28 tabs / 28 days)XCOPRI PAK 50-200MG $0(2) QL (56 tabs / 28 days)XCOPRI TABS 50mg $0(2) QL (90 tabs / 30 days)XCOPRI TABS 100mg, 150mg, 200mg $0(2) QL (60 tabs / 30 days)XCOPRI TITRATION PAK 150-200MG $0(2) QL (28 tabs / 28 days)zonisamide CAPS $0(1)

ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSSdonepezil hydrochloride TABS 5mg $0(1) QL (30 tabs / 30 days)donepezil hydrochloride TABS 10mg $0(1)donepezil hydrochloride TBDP 5mg $0(1) QL (30 tabs / 30 days)donepezil hydrochloride TBDP 10mg $0(1)galantamine hydrobromide SOLN $0(1)galantamine hydrobromide TABS $0(1) QL (60 tabs / 30 days)galantamine hydrobromide er $0(1) QL (30 caps / 30 days)memantine hcl cp24 $0(1) PA; PA if < 30 yrsmemantine soln $0(1) PA; PA if < 30 yrsmemantine tabs $0(1) PA; PA if < 30 yrsmemantine titration pak $0(2) PA; PA if < 30 yrsNAMZARIC $0(2)rivastigmine tartrate 1.5mg, 3mg $0(1) QL (90 caps / 30 days)rivastigmine tartrate 4.5mg, 6mg $0(1) QL (60 caps / 30 days)rivastigmine td patch 24hr 4.6 mg/24hr $0(1) QL (30 patches / 30 days)rivastigmine td patch 24hr 9.5 mg/24hr $0(1) QL (30 patches / 30 days)rivastigmine td patch 24hr 13.3 mg/24hr $0(1) QL (30 patches / 30 days)

ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSIONamitriptyline hcl TABS $0(2)amoxapine tab 25mg $0(2)amoxapine tab 50mg $0(2)


Name of drug


you (tier

level)


or limits on useamoxapine tab 100mg $0(2)amoxapine tab 150mg $0(2)bupropion hcl TABS $0(1)bupropion hcl TB12 $0(1)bupropion hcl TB24 150mg, 300mg $0(1)citalopram hydrobromide $0(1)clomipramine hcl CAPS $0(2) PAdesipramine hcl TABS $0(2)desvenlafaxine succinate $0(1) QL (30 tabs / 30 days), PAdoxepin hcl CAPS; CONC $0(2)DRIZALMA SPRINKLE 20mg, 30mg, 60mg $0(2) QL (60 caps / 30 days), PADRIZALMA SPRINKLE 40mg $0(2) QL (90 caps / 30 days), PAduloxetine hcl CPEP 20mg, 30mg, 60mg $0(1) QL (60 caps / 30 days)EMSAM $0(2) QL (30 patches / 30 days), PAescitalopram oxalate $0(1)FETZIMA 20mg, 40mg $0(2) QL (60 caps / 30 days), PAFETZIMA 80mg, 120mg $0(2) QL (30 caps / 30 days), PAFETZIMA TITRATION PACK $0(2) PAfluoxetine cap 10mg $0(1)fluoxetine cap 20mg $0(1)fluoxetine cap 40mg $0(1)fluoxetine hcl SOLN $0(1)imipramine hcl TABS $0(2)maprotiline hcl $0(1)MARPLAN TAB 10MG $0(2) QL (180 tabs / 30 days)mirtazapine TABS; TBDP $0(1)nefazodone hcl $0(1)nortriptyline hcl CAPS; SOLN $0(2)paroxetine hcl tabs $0(2)PAXIL SUSP $0(2) QL (900 mL / 30 days)phenelzine sulfate TABS $0(1)protriptyline hcl $0(2)


Name of drug


you (tier

level)


or limits on usesertraline hcl CONC; TABS $0(1)tranylcypromine sulfate $0(1)trazodone hcl TABS 50mg, 100mg, 150mg $0(1)trimipramine maleate CAPS 25mg $0(2) QL (240 caps / 30 days)trimipramine maleate CAPS 50mg $0(2) QL (120 caps / 30 days)trimipramine maleate CAPS 100mg $0(2) QL (60 caps / 30 days)TRINTELLIX 5mg $0(2) QL (120 tabs / 30 days)TRINTELLIX 10mg $0(2) QL (60 tabs / 30 days)TRINTELLIX 20mg $0(2) QL (30 tabs / 30 days)venlafaxine hcl CP24; TABS $0(1)VIIBRYD STARTER PACK $0(2)VIIBRYD TAB $0(2) QL (30 tabs / 30 days)

ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS DISEASEamantadine hcl CAPS $0(1) QL (120 caps / 30 days)amantadine hcl SYRP; TABS $0(1)APOKYN $0(2) QL (20 cartridges / 30 days),

NM, LA, PAbenztropine mesylate inj $0(1)benztropine mesylate tab 0.5mg $0(2) PA; PA if 70 years and olderbenztropine mesylate tab 1mg $0(2) PA; PA if 70 years and olderbenztropine mesylate tab 2mg $0(2) PA; PA if 70 years and olderbromocriptine mesylate CAPS; TABS $0(1)carbidopa-levodopa $0(1)carbidopa/levodopa/entacapone $0(1)entacapone $0(1)NEUPRO $0(2)pramipexole tab 0.5mg $0(1)pramipexole tab 0.25mg $0(1)pramipexole tab 0.75mg $0(1)pramipexole tab 0.125mg $0(1)pramipexole tab 1.5mg $0(1)pramipexole tab 1mg $0(1)rasagiline mesylate TABS $0(1)


Name of drug


you (tier

level)


or limits on useropinirole tab 0.5mg $0(1)ropinirole tab 0.25mg $0(1)ropinirole tab 1mg $0(1)ropinirole tab 2mg $0(1)ropinirole tab 3mg $0(1)ropinirole tab 4mg $0(1)ropinirole tab 5mg $0(1)selegiline hcl CAPS; TABS $0(1)trihexyphenidyl hcl $0(2) PA; PA if 70 years and older

ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSESABILIFY MAINTENA $0(2) QL (1 injection / 28 days)aripiprazole odt $0(2) QL (60 tabs / 30 days)aripiprazole oral solution 1 mg/ml $0(2) QL (900 mL / 30 days)aripiprazole tab $0(1) QL (30 tabs / 30 days)ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml

$0(2) QL (1 injection / 28 days)

ARISTADA 1064mg/3.9ml $0(2) QL (1 injection / 56 days)ARISTADA INITIO $0(2)CAPLYTA $0(2) QL (30 caps / 30 days)chlorpromazine hcl TABS $0(1)chlorpromazine inj $0(1)clozapine odt 12.5mg, 25mg $0(1) PAclozapine odt 100mg $0(1) QL (270 tabs / 30 days), PAclozapine odt 150mg $0(1) QL (180 tabs / 30 days), PAclozapine odt 200mg $0(1) QL (135 tabs / 30 days), PAclozapine tab 25mg $0(1)clozapine tab 50mg $0(1)clozapine tab 100mg $0(1) QL (270 tabs / 30 days)clozapine tab 200mg $0(1) QL (135 tabs / 30 days)FANAPT $0(2) QL (60 tabs / 30 days), PAFANAPT TITRATION PACK $0(2) PAfluphenazine decanoate SOLN $0(1)fluphenazine hcl $0(1)


Name of drug


you (tier

level)


or limits on useGEODON SOLR $0(2) QL (6 mL / 3 days)haloperidol TABS $0(1)haloperidol conc 2mg/ml $0(1)haloperidol decanoate SOLN $0(1)haloperidol lactate inj 5mg/ml $0(1)INVEGA SUST INJ 39 MG/0.25 ML $0(2) QL (1 injection / 28 days)INVEGA SUST INJ 78 MG/0.5 ML $0(2) QL (1 injection / 28 days)INVEGA SUST INJ 117 MG/0.75 ML $0(2) QL (1 injection / 28 days)INVEGA SUST INJ 156MG/ML $0(2) QL (1 injection / 28 days)INVEGA SUST INJ 234 MG/1.5 ML $0(2) QL (1 injection / 28 days)INVEGA TRINZA $0(2) QL (1 injection / 90 days)LATUDA 20mg, 40mg, 60mg, 120mg $0(2) QL (30 tabs / 30 days)LATUDA 80mg $0(2) QL (60 tabs / 30 days)loxapine succinate $0(1)molindone hcl $0(1)NUPLAZID CAPS $0(2) QL (30 caps / 30 days), NM, LA,

PANUPLAZID TABS 10MG $0(2) QL (30 tabs / 30 days), NM, LA,

PAolanzapine SOLR $0(1) QL (3 vials / 1 day)olanzapine TABS 2.5mg, 5mg, 10mg $0(1) QL (60 tabs / 30 days)olanzapine TABS 7.5mg, 15mg, 20mg $0(1) QL (30 tabs / 30 days)olanzapine TBDP 5mg, 15mg, 20mg $0(1) QL (30 tabs / 30 days)olanzapine TBDP 10mg $0(1) QL (60 tabs / 30 days)paliperidone 1.5mg, 3mg, 9mg $0(1) QL (30 tabs / 30 days)paliperidone 6mg $0(1) QL (60 tabs / 30 days)perphenazine TABS $0(1)PERSERIS $0(2) QL (1 injection / 30 days)pimozide $0(1)quetiapine fumarate TABS $0(1)quetiapine fumarate TB24 50mg, 300mg, 400mg

$0(1) QL (60 tabs / 30 days), PA

quetiapine fumarate TB24 150mg, 200mg $0(1) QL (30 tabs / 30 days), PA


Name of drug


you (tier

level)


or limits on useREXULTI 3mg, 4mg $0(2) QL (30 tabs / 30 days)REXULTI .25mg, .5mg, 1mg, 2mg $0(2) QL (60 tabs / 30 days)RISPERDAL INJ 12.5MG $0(2) QL (2 injections / 28 days)RISPERDAL INJ 25MG $0(2) QL (2 injections / 28 days)RISPERDAL INJ 37.5MG $0(2) QL (2 injections / 28 days)RISPERDAL INJ 50MG $0(2) QL (2 injections / 28 days)risperidone SOLN $0(1) QL (240 mL / 30 days)risperidone TABS $0(1)risperidone TBDP 1mg, 2mg, 3mg, 4mg $0(1) QL (60 tabs / 30 days)risperidone TBDP .25mg, .5mg $0(1) QL (90 tabs / 30 days)SAPHRIS $0(2) QL (60 tabs / 30 days)SECUADO $0(2) QL (30 patches / 30 days)thioridazine hcl TABS $0(1)thiothixene $0(1)trifluoperazine hcl $0(1)VERSACLOZ $0(2) QL (600 mL / 30 days), PAVRAYLAR 1.5mg $0(2) QL (60 caps / 30 days), PAVRAYLAR 3mg, 4.5mg, 6mg $0(2) QL (30 caps / 30 days), PAVRAYLAR THERAPY PACK $0(2) PAziprasidone hcl $0(1) QL (60 caps / 30 days)ziprasidone mesylate $0(1) QL (6 injections / 3 days)ZYPREXA RELPREVV 300mg $0(2) QL (2 vials / 28 days), PAZYPREXA RELPREVV 405mg $0(2) QL (1 vial / 28 days), PAZYPREXA RELPREVV INJ 210MG $0(2) QL (2 vials / 28 days), PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER - DRUGS TO TREAT ADHDamphetamine-dextroamphetamine cap sr 24hr 5 mg

$0(1) QL (90 caps / 30 days)

amphetamine-dextroamphetamine cap sr 24hr 10 mg

$0(1) QL (90 caps / 30 days)


$0(1) QL (30 caps / 30 days)


$0(1) QL (30 caps / 30 days)


Name of drug


you (tier

level)


or limits on useamphetamine-dextroamphetamine cap sr 24hr 25 mg

$0(1) QL (30 caps / 30 days)


$0(1) QL (30 caps / 30 days)

amphetamine-dextroamphetamine tab 5 mg $0(1) QL (120 tabs / 30 days)amphetamine-dextroamphetamine tab 7.5 mg $0(1) QL (120 tabs / 30 days)amphetamine-dextroamphetamine tab 10 mg $0(1) QL (120 tabs / 30 days)amphetamine-dextroamphetamine tab 12.5 mg $0(1) QL (120 tabs / 30 days)amphetamine-dextroamphetamine tab 15 mg $0(1) QL (90 tabs / 30 days)amphetamine-dextroamphetamine tab 20 mg $0(1) QL (90 tabs / 30 days)amphetamine-dextroamphetamine tab 30 mg $0(1) QL (60 tabs / 30 days)atomoxetine hcl 10mg, 18mg, 25mg $0(1) QL (120 caps / 30 days)atomoxetine hcl 40mg $0(1) QL (60 caps / 30 days)atomoxetine hcl 60mg, 80mg, 100mg $0(1) QL (30 caps / 30 days)dexmethylphenidate hcl TABS 2.5mg, 5mg $0(1) QL (120 tabs / 30 days)dexmethylphenidate hcl TABS 10mg $0(1) QL (60 tabs / 30 days)guanfacine er (adhd) $0(2) PA; PA if 70 years and oldermetadate er tab 20mg $0(1) QL (90 tabs / 30 days)methylphenidate hcl TABS 5mg, 10mg $0(1) QL (180 tabs / 30 days)methylphenidate hcl TABS 20mg $0(1) QL (90 tabs / 30 days)methylphenidate hcl oral soln 5mg/5ml $0(1) QL (1800 mL / 30 days)methylphenidate hcl oral soln 10mg/5ml $0(1) QL (900 mL / 30 days)methylphenidate hcl tbcr 10 mg $0(1) QL (90 tabs / 30 days)methylphenidate hcl tbcr 20mg $0(1) QL (90 tabs / 30 days)

HYPNOTICS - DRUGS TO TREAT INSOMNIABELSOMRA $0(2) QL (30 tabs / 30 days)doxepin hcl (sleep) $0(1) QL (30 tabs / 30 days)eszopiclone $0(2) QL (30 tabs / 30 days), PA; PA

applies if 70 years and older after a 90 day supply in a

calendar yearHETLIOZ $0(2) NM, LA, PA


Name of drug


you (tier

level)


or limits on usetemazepam 7.5mg $0(1) QL (30 caps / 30 days), PA; PA


calendar yeartemazepam 15mg $0(1) QL (60 caps / 30 days), PA; PA


calendar yearzaleplon $0(2) QL (60 caps / 30 days), PA; PA


calendar yearzolpidem tartrate TABS $0(2) QL (30 tabs / 30 days), PA; PA


calendar yearMIGRAINE - DRUGS TO TREAT SEVERE HEADACHES

AIMOVIG $0(2) QL (1 pen / 30 days), NM, PAdihydroergotamine mesylate inj 1 mg/ml $0(2)dihydroergotamine mesylate nasal spr 4 mg/ml $0(2) QL (8 mL / 30 days), PAeletriptan hydrobromide $0(1) QL (12 tabs / 30 days)EMGALITY SOAJ $0(2) QL (2 pens / 30 days), NM, PAEMGALITY SOSY 120mg/ml $0(2) QL (2 syringes / 30 days), NM,

PAergotamine w/ caffeine TABS $0(1)naratriptan hcl $0(1) QL (12 tabs / 30 days)rizatriptan benzoate $0(1) QL (18 tabs / 30 days)rizatriptan benzoate odt $0(1) QL (18 tabs / 30 days)sumatriptan SOLN 5mg/act $0(1) QL (24 inhalers / 30 days)sumatriptan SOLN 20mg/act $0(1) QL (12 inhalers / 30 days)sumatriptan inj 4mg/0.5ml $0(1) QL (18 injections / 30 days)sumatriptan inj 6mg/0.5ml $0(1) QL (12 injections / 30 days)sumatriptan succinate TABS $0(1) QL (12 tabs / 30 days)zolmitriptan TABS $0(1) QL (12 tabs / 30 days)zolmitriptan odt $0(1) QL (12 tabs / 30 days)


Name of drug


you (tier

level)


or limits on useMISCELLANEOUS

AUSTEDO 6mg $0(2) QL (60 tabs / 30 days), NM, PAAUSTEDO 9mg, 12mg $0(2) QL (120 tabs / 30 days), NM, PAINGREZZA CAPS $0(2) QL (30 caps / 30 days), NM, PAINGREZZA CPPK $0(2) QL (28 caps / 28 days), NM, PAlithium carbonate CAPS; TABS $0(1)lithium carbonate er $0(1)LITHIUM SOLN 8MEQ/5ML $0(2)LYRICA CR $0(2) QL (60 tabs / 30 days), PANUEDEXTA $0(2) QL (60 caps / 30 days), PApyridostigmine tab 60mg $0(1)riluzole $0(1)tetrabenazine 12.5mg $0(2) QL (240 tabs / 30 days), NM, PAtetrabenazine 25mg $0(2) QL (120 tabs / 30 days), NM, PA

MULTIPLE SCLEROSIS AGENTS - DRUGS TO TREAT MULTIPLE SCLEROSISBETASERON $0(2) QL (14 syringes / 28 days), NM,

PAdalfampridine TB12 $0(2) NM, PAGILENYA CAP 0.5MG $0(2) QL (28 caps / 28 days), NM, PAglatiramer acetate 20mg/ml $0(2) QL (30 syringes / 30 days), NM,

PAglatiramer acetate 40mg/ml $0(2) QL (12 syringes / 28 days), NM,

PAglatopa 20mg/ml $0(2) QL (30 syringes / 30 days), NM,

PAglatopa 40mg/ml $0(2) QL (12 syringes / 28 days), NM,

PAMUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE SPASMS

baclofen TABS 10mg, 20mg $0(1)carisoprodol TABS 350mg $0(2) QL (120 tabs / 30 days), PA; PA if

70 years and oldercyclobenzaprine hcl TABS 5mg, 10mg $0(2) PA; PA if 70 years and olderdantrolene sodium CAPS $0(1)methocarbamol TABS $0(2) PA; PA if 70 years and older


Name of drug


you (tier

level)


or limits on usetizanidine hcl TABS $0(1)vanadom $0(2) QL (120 tabs / 30 days), PA; PA if

70 years and olderNARCOLEPSY/CATAPLEXY - DRUGS FOR SLEEP DISORDERS

armodafinil 50mg $0(1) QL (90 tabs / 30 days), PAarmodafinil 150mg, 200mg, 250mg $0(1) QL (30 tabs / 30 days), PAXYREM $0(2) QL (540 mL / 30 days), NM, LA,

PAPSYCHOTHERAPEUTIC-MISC

acamprosate calcium $0(1)buprenorphine hcl SUBL $0(1) QL (90 tabs / 30 days), PAbuprenorphine hcl-naloxone hcl dihydrate 2-0.5mg

$0(1) QL (90 films / 30 days)

buprenorphine hcl-naloxone hcl dihydrate 4-1mg

$0(1) QL (90 films / 30 days)


$0(1) QL (90 films / 30 days)


$0(1) QL (60 films / 30 days)

buprenorphine hcl-naloxone hcl sl $0(1) QL (90 tabs / 30 days)bupropion hcl (smoking deterrent) $0(1)CHANTIX $0(2) PACHANTIX CONTINUING MONTH $0(2) PACHANTIX STARTER PACK $0(2) PAdisulfiram TABS $0(1)gnp nicotine gum $0(3) NM; *gnp nicotine mini lozenge $0(3) NM; *gnp nicotine polacrilex $0(3) NM; *gnp nicotine polacrilex m $0(3) NM; *goodsense nicotine gum $0(3) NM; *goodsense nicotine polacr $0(3) NM; *hm nicotine polacrilex $0(3) NM; *hm nicotine transdermal s $0(3) NM; *naloxone inj 0.4mg/ml $0(1)


Name of drug


you (tier

level)


or limits on usenaloxone inj 1mg/ml $0(1)naltrexone hcl TABS $0(1)NARCAN $0(2)NICODERM CQ $0(3) NM; *nicorelief $0(3) NM; *NICORETTE $0(3) NM; *NICORETTE MINI $0(3) NM; *NICORETTE STARTER KIT $0(3) NM; *nicotine $0(3) NM; *nicotine polacrilex GUM; LOZG $0(3) NM; *NICOTINE TRANSDERMAL SYST KIT $0(3) NM; *nicotine transdermal syst PT24 $0(3) NM; *NICOTROL INHALER $0(2)NICOTROL NS $0(2)sm nicotine $0(3) NM; *sm nicotine polacrilex $0(3) NM; *sm nicotine transdermal s $0(3) NM; *VIVITROL $0(2) NM

ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE HORMONESANDROGENS - DRUGS TO REGULATE MALE HORMONES

ANADROL-50 $0(2) PAANDRODERM $0(2) QL (30 patches / 30 days), PAoxandrolone TABS $0(1) PAtestosterone GEL 1%, 25mg/2.5gm, 50mg/5gm

$0(1) QL (300 grams / 30 days), PA

testosterone cypionate SOLN $0(1) PAtestosterone enanthate SOLN $0(1) PA

ANTIDIABETICS, INJECTABLE - DRUGS TO TREAT DIABETESBASAGLAR KWIKPEN $0(2)BD ALCOHOL SWABS $0(2)BD ULTRAFINE INSULIN SYRINGE $0(2)BD ULTRAFINE/NANO PEN NEEDLES $0(2)BYDUREON BCISE $0(2) QL (4 pens / 28 days)


Name of drug


you (tier

level)


or limits on useBYDUREON PEN $0(2) QL (4 pens / 28 days)BYETTA $0(2) QL (1 pen / 30 days)FIASP $0(2)FIASP FLEXTOUCH $0(2)FIASP PENFILL $0(2)GAUZE PADS 2” X 2” $0(2)HUMULIN R INJ U-500 $0(2) B/DHUMULIN R U-500 KWIKPEN $0(2)INSULIN PEN NEEDLE $0(2)INSULIN SAFETY NEEDLES $0(2)INSULIN SYRINGE $0(2)LEVEMIR $0(2)LEVEMIR FLEXTOUCH $0(2)NOVOLIN 70/30 $0(2) (brand RELION not covered)NOVOLIN 70/30 FLEXPEN $0(2) (brand RELION not covered)NOVOLIN N $0(2) (brand RELION not covered)NOVOLIN N FLEXPEN $0(2) (brand RELION not covered)NOVOLIN R $0(2) (brand RELION not covered)NOVOLIN R FLEXPEN $0(2) (brand RELION not covered)NOVOLOG $0(2)NOVOLOG 70/30 FLEXPEN $0(2)NOVOLOG FLEXPEN $0(2)NOVOLOG MIX 70/30 $0(2)NOVOLOG PENFILL $0(2)OZEMPIC INJ 0.25 OR 0.5MG/DOSE $0(2) QL (1 pen / 28 days)OZEMPIC INJ 1MG/DOSE $0(2) QL (2 pens / 28 days)SOLIQUA 100/33 $0(2) QL (10 pens / 30 days)TRESIBA FLEXTOUCH $0(2)TRESIBA INJ $0(2)TRULICITY $0(2) QL (4 pens / 28 days)VICTOZA $0(2) QL (3 pens / 30 days)XULTOPHY 100/3.6 $0(2) QL (5 pens / 30 days)


Name of drug


you (tier

level)


or limits on useANTIDIABETICS, ORAL - DRUGS TO TREAT DIABETES

acarbose TABS $0(1)FARXIGA $0(2) QL (30 tabs / 30 days)glimepiride 1mg, 2mg $0(2) QL (90 tabs / 30 days)glimepiride 4mg $0(2) QL (60 tabs / 30 days)glip/metform tab 2.5-250mg $0(1) QL (240 tabs / 30 days)glip/metform tab 2.5-500mg $0(1) QL (120 tabs / 30 days)glip/metform tab 5-500mg $0(1) QL (120 tabs / 30 days)glipizide TABS 5mg $0(1) QL (240 tabs / 30 days)glipizide TABS 10mg $0(1) QL (120 tabs / 30 days)glipizide TB24 2.5mg, 5mg $0(1) QL (90 tabs / 30 days)glipizide TB24 10mg $0(1) QL (60 tabs / 30 days)glipizide xl 2.5mg, 5mg $0(1) QL (90 tabs / 30 days)glipizide xl 10mg $0(1) QL (60 tabs / 30 days)glyburide TABS 1.25mg $0(2) QL (480 tabs / 30 days), PA; PA if

70 years and olderglyburide TABS 2.5mg $0(2) QL (240 tabs / 30 days), PA; PA if

70 years and olderglyburide TABS 5mg $0(2) QL (120 tabs / 30 days), PA; PA if

70 years and olderglyburide micronized 1.5mg $0(2) QL (240 tabs / 30 days), PA; PA if

70 years and olderglyburide micronized 3mg $0(2) QL (120 tabs / 30 days), PA; PA if

70 years and olderglyburide micronized 6mg $0(2) QL (60 tabs / 30 days), PA; PA if

70 years and olderglyburide-metformin tab 1.25-250 mg $0(2) QL (240 tabs / 30 days), PA; PA if

70 years and olderglyburide-metformin tab 2.5-500 mg $0(2) QL (120 tabs / 30 days), PA; PA if

70 years and olderglyburide-metformin tab 5-500mg $0(2) QL (120 tabs / 30 days), PA; PA if

70 years and olderGLYXAMBI $0(2) QL (30 tabs / 30 days)JANUMET $0(2) QL (60 tabs / 30 days)JANUMET XR TAB 50-500MG $0(2) QL (60 tabs / 30 days)


Name of drug


you (tier

level)


or limits on useJANUMET XR TAB 50-1000 $0(2) QL (60 tabs / 30 days)JANUMET XR TAB 100-1000 $0(2) QL (30 tabs / 30 days)JANUVIA $0(2) QL (30 tabs / 30 days)JARDIANCE 10mg $0(2) QL (60 tabs / 30 days)JARDIANCE 25mg $0(2) QL (30 tabs / 30 days)JENTADUETO $0(2) QL (60 tabs / 30 days)JENTADUETO TAB XR 2.5-1000 MG $0(2) QL (60 tabs / 30 days)JENTADUETO TAB XR 5-1000 MG $0(2) QL (30 tabs / 30 days)metformin er 500mg $0(1) QL (120 tabs / 30 days); (generic

of GLUCOPHAGE XR)metformin er 750mg $0(1) QL (60 tabs / 30 days); (generic

of GLUCOPHAGE XR)metformin hcl TABS 500mg $0(1) QL (150 tabs / 30 days)metformin hcl TABS 850mg $0(1) QL (90 tabs / 30 days)metformin hcl TABS 1000mg $0(1) QL (75 tabs / 30 days)nateglinide $0(1) QL (90 tabs / 30 days)pioglitazone hcl $0(1) QL (30 tabs / 30 days)repaglinide 2mg $0(1) QL (240 tabs / 30 days)repaglinide .5mg, 1mg $0(1) QL (120 tabs / 30 days)RYBELSUS $0(2) QL (30 tabs / 30 days)SYNJARDY TAB 5-500MG $0(2) QL (120 tabs / 30 days)SYNJARDY TAB 5-1000MG $0(2) QL (60 tabs / 30 days)SYNJARDY TAB 12.5-500MG $0(2) QL (60 tabs / 30 days)SYNJARDY TAB 12.5-1000MG $0(2) QL (60 tabs / 30 days)SYNJARDY XR TAB 5-1000MG $0(2) QL (60 tabs / 30 days)SYNJARDY XR TAB 10-1000MG $0(2) QL (60 tabs / 30 days)SYNJARDY XR TAB 12.5-1000MG $0(2) QL (60 tabs / 30 days)SYNJARDY XR TAB 25-1000MG $0(2) QL (30 tabs / 30 days)TRADJENTA $0(2) QL (30 tabs / 30 days)TRIJARDY XR TAB ER 24HR 5-2.5-1000MG $0(2) QL (60 tabs / 30 days)TRIJARDY XR TAB ER 24HR 10-5-1000 MG $0(2) QL (30 tabs / 30 days)TRIJARDY XR TAB ER 24HR 12.5-2.5-1000MG $0(2) QL (60 tabs / 30 days)TRIJARDY XR TAB ER 24HR 25-5-1000 MG $0(2) QL (30 tabs / 30 days)


Name of drug


you (tier

level)


or limits on useXIGDUO XR TAB 2.5-1000MG $0(2) QL (60 tabs / 30 days)XIGDUO XR TAB 5-500MG $0(2) QL (60 tabs / 30 days)XIGDUO XR TAB 5-1000MG $0(2) QL (60 tabs / 30 days)XIGDUO XR TAB 10-500MG $0(2) QL (30 tabs / 30 days)XIGDUO XR TAB 10-1000MG $0(2) QL (30 tabs / 30 days)

BISPHOSPHONATES - DRUGS TO TREAT BONE LOSSalendronate sodium soln 70mg/75ml $0(1)alendronate sodium tab 5 mg $0(1)alendronate sodium tab 10 mg $0(1)alendronate sodium tab 35 mg $0(1)alendronate sodium tab 40 mg $0(1)alendronate sodium tab 70 mg $0(1)ibandronate sodium tabs $0(1) B/DPAMIDRONATE DISODIUM 6mg/ml $0(2) B/Dpamidronate disodium 30mg/10ml, 90mg/10ml

$0(1) B/D

pamidronate inj 30mg $0(1) B/Dpamidronate inj 90mg $0(1) B/Drisedronate sodium TABS 5mg, 35mg, 150mg $0(1)risedronate sodium TBEC $0(1)zoledronic acid inj 4mg/100ml $0(1) B/D, NMzoledronic acid inj 5mg/100ml $0(1) B/D, NMzoledronic inj 4mg/5ml $0(1) B/D, NM

CHELATING AGENTSCHEMET $0(2)clovique $0(2) PAdeferasirox granules $0(2) NM, PAdeferasirox tab $0(2) NM, PAJADENU 180mg $0(2) NM, LA, PAJADENU SPRINKLE $0(2) NM, LA, PAkionex sus 15gm/60ml $0(1)LOKELMA $0(2)penicillamine TABS $0(2)


Name of drug


you (tier

level)


or limits on usesodium polystyrene sulfonate powder $0(1)sodium polystyrene sulfonate susp $0(1)sps susp 15gm/60ml $0(1)trientine hcl $0(2) PAVELTASSA $0(2) LA, PA

CONTRACEPTIVES - DRUGS FOR BIRTH CONTROLaftera $0(3) NM; *altavera tab $0(1)alyacen 1/35 $0(1)amethia $0(1)amethia lo $0(1)apri $0(1)aranelle $0(1)ashlyna $0(1)aubra $0(1)aviane $0(1)balziva $0(1)bekyree $0(1)blisovi 24 fe $0(1)blisovi fe 1.5/30 $0(1)briellyn $0(1)camila $0(1)camrese lo $0(1)caziant pak $0(1)cryselle-28 $0(1)cyclafem 1/35 $0(1)cyclafem 7/7/7 $0(1)cyred tab $0(1)dasetta 1/35 $0(1)dasetta 7/7/7 $0(1)deblitane $0(1)desogestrel-ethinyl estradiol (biphasic) $0(1)


Name of drug


you (tier

level)


or limits on usedrospirenone-ethinyl estradiol $0(1)drospirenone-ethinyl estradiol-levomefolate calcium

$0(1)

econtra ez $0(3) NM; *ELLA $0(2)eluryng $0(1)emoquette $0(1)enpresse-28 $0(1)enskyce $0(1)errin $0(1)estarylla tab 0.25-35 $0(1)ethynodiol diacet & eth estrad $0(1)ethynodiol tab 1-50 $0(1)etonogestrel-ethinyl estradiol $0(1)falmina $0(1)fayosim $0(1)femynor $0(1)gianvi $0(1)hailey 24 fe $0(1)heather $0(1)incassia $0(1)introvale $0(1)isibloom $0(1)jasmiel $0(1)jolessa tab 0.15-0.03 mg $0(1)jolivette $0(1)juleber $0(1)junel 1.5/30 $0(1)junel 1/20 $0(1)junel fe 1.5/30 $0(1)junel fe 1/20 $0(1)junel fe 24 $0(1)kaitlib fe $0(1)


Name of drug


you (tier

level)


or limits on usekariva $0(1)kelnor 1/35 $0(1)kelnor 1/50 $0(1)kurvelo $0(1)larin 1.5/30 $0(1)larin 1/20 $0(1)larin fe 1.5/30 $0(1)larin fe 1/20 $0(1)larissia tab $0(1)layolis fe $0(1)leena $0(1)lessina $0(1)levonest $0(1)levonor/ethi tab $0(1)levonorgestrel & eth estradiol $0(1)levonorgestrel-ethinyl estradiol (91-day) $0(1)levora 0.15/30-28 $0(1)loryna $0(1)low-ogestrel $0(1)lutera $0(1)lyza $0(1)marlissa $0(1)medroxyprogesterone acetate (contraceptive) $0(1)melodetta 24 fe $0(1)mibelas 24 fe $0(1)microgestin 1.5/30 $0(1)microgestin 1/20 $0(1)microgestin fe 1.5/30 $0(1)microgestin fe 1/20 $0(1)mili $0(1)mono-linyah tab 0.25-35 $0(1)necon 0.5/35-28 $0(1)


Name of drug


you (tier

level)


or limits on usenikki $0(1)nora-be tab $0(1)nore/eth/fer chw 0.4mg-35 $0(1)noreth/ethin chw fe $0(1)norethin acet & estrad-fe $0(1)norethindrone (contraceptive) $0(1)norethindrone acet & eth estra $0(1)norgest/ethi tab 0.25/35 $0(1)norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg

$0(1)

norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg

$0(1)

nortrel 0.5/35 (28) $0(1)nortrel 1/35 $0(1)nortrel 7/7/7 $0(1)ocella tab 3-0.03mg $0(1)opcicon one-step $0(3) NM; *option 2 $0(3) NM; *orsythia $0(1)philith $0(1)pimtrea $0(1)pirmella 1/35 $0(1)PLAN B ONE-STEP $0(3) NM; *portia-28 $0(1)previfem $0(1)reclipsen $0(1)rivelsa $0(1)setlakin tab $0(1)sharobel $0(1)sprintec 28 $0(1)sronyx $0(1)syeda $0(1)take action $0(3) NM; *


Name of drug


you (tier

level)


or limits on usetarina 24 fe $0(1)tarina fe 1/20 $0(1)tilia fe $0(1)tri-estarylla $0(1)tri-legest fe $0(1)tri-linyah $0(1)tri-lo marzia $0(1)tri-lo-estarylla $0(1)tri-lo-sprintec $0(1)tri-mili $0(1)tri-previfem $0(1)tri-sprintec $0(1)tri-vylibra $0(1)tri-vylibra lo $0(1)trivora-28 $0(1)tulana $0(1)tydemy $0(1)velivet $0(1)vienva $0(1)viorele $0(1)vyfemla $0(1)vylibra $0(1)wymzya fe $0(1)xulane $0(1)zarah $0(1)zovia 1/35e $0(1)

ENDOMETRIOSISdanazol CAPS $0(1)SYNAREL $0(2)

ENZYME REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIESALDURAZYME $0(2) NM, LA, PACARBAGLU $0(2) NM, LA, PA


Name of drug


you (tier

level)


or limits on useCERDELGA $0(2) NM, PACEREZYME $0(2) NM, LA, PACYSTADANE $0(2) NM, LACYSTAGON $0(2) NM, LA, PAFABRAZYME $0(2) NM, LA, PAKUVAN $0(2) NM, LA, PAlevocarnitine (metabolic modifiers) $0(1) B/DLUMIZYME $0(2) NM, LA, PAmiglustat $0(2) NM, PANAGLAZYME $0(2) NM, LA, PAnitisinone $0(2) NM, PANITYR $0(2) NM, LA, PAORFADIN $0(2) NM, LA, PAsodium phenylbutyrate $0(2) NM, PA

ESTROGENS - DRUGS TO REGULATE FEMALE HORMONESDELESTROGEN 10mg/ml $0(2)estradiol PTWK; TABS $0(2)estradiol vaginal cream $0(1)estradiol vaginal tab $0(1)estradiol valerate OIL $0(1)fyavolv $0(2)jinteli $0(2)norethindrone acetate-ethinyl estradiol $0(2)yuvafem vaginal tablet 10 mcg $0(1)

GLUCOCORTICOIDS - DRUGS TO TREAT INFLAMMATORY RESPONSEcortisone acetate TABS $0(1)dexamethasone ELIX; SOLN; TABS $0(1)DEXAMETHASONE INTENSOL $0(2)dexamethasone sodium phosphate $0(1)fludrocortisone acetate TABS $0(1)hydrocortisone TABS $0(1)methylpr ss inj $0(1) B/D


Name of drug


you (tier

level)


or limits on usemethylpred pak 4mg $0(1)methylpred tab 4mg $0(1) B/Dmethylpred tab 8mg $0(1) B/Dmethylpred tab 16mg $0(1) B/Dmethylpred tab 32mg $0(1) B/Dmethylprednisolone acetate $0(1) B/Dpred sod pho sol 5mg/5ml $0(1) B/Dprednisolone sodium phosphate SOLN 15mg/5ml

$0(1) B/D

prednisolone sol 15mg/5ml $0(1) B/Dprednisolone sol 25mg/5ml $0(1) B/DPREDNISONE CON 5MG/ML $0(2) B/Dprednisone pak 5mg $0(1)prednisone pak 10mg $0(1)prednisone sol 5mg/5ml $0(1) B/Dprednisone tab 1mg $0(1) B/Dprednisone tab 2.5mg $0(1) B/Dprednisone tab 5mg $0(1) B/Dprednisone tab 10mg $0(1) B/Dprednisone tab 20mg $0(1) B/Dprednisone tab 50mg $0(1) B/DSOLU-CORTEF $0(2)

GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOOD SUGARdiazoxide SUSP $0(1)GLUCAGEN HYPOKIT $0(2)GLUCAGON EMERGENCY KIT $0(2)GVOKE HYPOPEN 2-PACK $0(2)GVOKE PFS $0(2)PROGLYCEM SUS 50MG/ML $0(2)

MISCELLANEOUScabergoline $0(1)calcitonin (salmon) $0(1) B/Dcinacalcet hcl 30mg, 90mg $0(2) B/D, QL (120 tabs / 30 days), NM


Name of drug


you (tier

level)


or limits on usecinacalcet hcl 60mg $0(2) B/D, QL (60 tabs / 30 days), NMFORTEO $0(2) NM, PAGENOTROPIN $0(2) NM, PAGENOTROPIN MINIQUICK $0(2) NM, PAINCRELEX $0(2) NM, LA, PAKORLYM $0(2) NM, LA, PALUPRON DEP-PED INJ 7.5MG $0(2) NM, PALUPRON DEP-PED INJ 11.25MG (3-MONTH) $0(2) NM, PALUPRON DEPOT-PED (1-MONTH $0(2) NM, PALUPRON DEPOT-PED (3-MONTH $0(2) NM, PANATPARA $0(2) NM, PAoctreotide acetate 50mcg/ml, 100mcg/ml, 200mcg/ml

$0(1) NM, PA

octreotide acetate 500mcg/ml, 1000mcg/ml $0(2) NM, PAOSPHENA $0(2) PAPROLIA $0(2) QL (1 injection / 180 days), NMraloxifene hcl $0(1)SIGNIFOR $0(2) NM, LA, PASOMATULINE DEPOT $0(2) NM, PASOMAVERT $0(2) NM, LA, PATYMLOS $0(2) NM, PAXENICAL $0(3) NM; *XGEVA $0(2) NM, PA

PHOSPHATE BINDER AGENTS - DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELSAURYXIA $0(2) QL (360 tabs / 30 days), PAcalcium acetate (phosphate binder) CAPS $0(1) QL (360 caps / 30 days)calcium acetate (phosphate binder) TABS $0(1) QL (360 tabs / 30 days)sevelamer carbonate PACK 2.4gm $0(2) QL (180 packets / 30 days)sevelamer carbonate PACK .8gm $0(2) QL (540 packets / 30 days)sevelamer carbonate TABS $0(1) QL (540 tabs / 30 days)

PROGESTINS - DRUGS TO REGULATE FEMALE HORMONESmedroxyprogesterone acetate tab $0(1)norethindrone acetate TABS $0(1)


Name of drug


you (tier

level)


or limits on useTHYROID AGENTS - DRUGS TO REGULATE THYROID LEVELS

euthyrox $0(1)levo-t $0(1)levothyroxine sodium TABS $0(1)levoxyl $0(1)liothyronine sodium TABS $0(1)methimazole TABS $0(1)propylthiouracil TABS $0(1)SYNTHROID $0(2)unithroid $0(1)

VASOPRESSINS - DRUGS TO REGULATE PITUITARY HORMONESdesmopressin acetate spray $0(1)desmopressin acetate spray refrigerated $0(1)desmopressin acetate tabs $0(1)desmopressin inj 4mcg/ml $0(1)STIMATE $0(2) NM

GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERSANTACIDS

acid gone SUSP $0(3) NM; *almacone $0(3) NM; *almacone double strength $0(3) NM; *ALUMINUM HYDROXIDE $0(3) NM; *antacid CHEW 500mg $0(3) NM; *antacid SUSP $0(3) NM; *antacid anti-gas maximum $0(3) NM; *antacid calcium extra str $0(3) NM; *antacid calcium regular s $0(3) NM; *antacid extra strength $0(3) NM; *antacid fast acting $0(3) NM; *antacid fast relief $0(3) NM; *antacid maximum strength $0(3) NM; *antacid plus anti-gas fas $0(3) NM; *


Name of drug


you (tier

level)


or limits on useantacid plus anti-gas rel $0(3) NM; *antacid regular strength $0(3) NM; *cal-gest antacid $0(3) NM; *calcium antacid $0(3) NM; *calcium antacid extra str $0(3) NM; *calcium antacid ultra max $0(3) NM; *calcium antacid ultra str $0(3) NM; *CALCIUM CARBONATE TABS 648mg $0(3) NM; *GAVISCON SUSP $0(3) NM; *GAVISCON EXTRA STRENGTH SUSP $0(3) NM; *GAVISCON EXTRA STRENGTH R $0(3) NM; *gnp antacid anti-gas $0(3) NM; *gnp antacid extra strengt $0(3) NM; *hm advanced antacid maxim $0(3) NM; *hm antacid $0(3) NM; *hm antacid anti-gas extra $0(3) NM; *hm antacid/antigas $0(3) NM; *hm calcium antacid extra $0(3) NM; *hm calcium antacid smooth $0(3) NM; *hm calcium antacid ultra $0(3) NM; *MAG-AL $0(3) NM; *mag-al plus $0(3) NM; *mag-al plus xs $0(3) NM; *magnesium oxide TABS 400mg $0(3) NM; *mi-acid $0(3) NM; *mi-acid maximum strength $0(3) NM; *mintox $0(3) NM; *mintox maximum strength $0(3) NM; *qc antacid $0(3) NM; *qc antacid/anti-gas $0(3) NM; *rulox $0(3) NM; *sm antacid advanced $0(3) NM; *


Name of drug


you (tier

level)


or limits on usesm antacid advanced maxi $0(3) NM; *sm antacid maximum streng $0(3) NM; *sm antacid/antigas $0(3) NM; *sm calcium antacid $0(3) NM; *sm calcium antacid extra $0(3) NM; *sodium bicarbonate (antacid) $0(3) NM; *TUMS $0(3) NM; *TUMS CHEWY DELIGHTS $0(3) NM; *TUMS E-X 750 $0(3) NM; *TUMS EXTRA STRENGTH 750 $0(3) NM; *tums smoothies 750mg $0(3) NM; *TUMS SMOOTHIES 750mg $0(3) NM; *TUMS ULTRA 1000 $0(3) NM; *

ANTI-DIARRHEALanti-diarrheal TABS $0(3) NM; *bismatrol $0(3) NM; *bismatrol maximum strengt $0(3) NM; *gnp anti-diarrheal $0(3) NM; *gnp loperamide hcl $0(3) NM; *gnp pink bismuth $0(3) NM; *hm anti-diarrheal $0(3) NM; *hm loperamide hcl $0(3) NM; *hm stomach relief $0(3) NM; *hm stomach relief maximum $0(3) NM; *kao-tin SUSP $0(3) NM; *loperamide hcl SUSP $0(3) NM; *peptic relief $0(3) NM; *qc anti-diarrheal $0(3) NM; *sm anti-diarrheal $0(3) NM; *sm loperamide hcl $0(3) NM; *sm stomach relief $0(3) NM; *stomach relief $0(3) NM; *


Name of drug


you (tier

level)


or limits on usestomach relief maximum st $0(3) NM; *

ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITINGaprepitant $0(1) B/Daprepitant pak 80mg & 125mg $0(1) B/Dcompro $0(1)dronabinol $0(1) B/D, QL (60 caps / 30 days)EMEND SUSR $0(2) B/Dgranisetron hcl SOLN $0(1)granisetron hcl TABS $0(1) B/Dmeclizine hcl TABS $0(2)metoclopramide hcl SOLN; TABS $0(1)metoclopramide hcl inj $0(1)ondansetron hcl TABS $0(1) B/Dondansetron hcl inj $0(1)ondansetron hcl oral soln $0(1) B/Dondansetron odt $0(1) B/Dprochlorperazine inj $0(1)prochlorperazine maleate TABS $0(1)prochlorperazine supp $0(1)promethazine hcl SYRP; TABS $0(2) PA; PA if 70 years and olderpromethazine hcl inj $0(2) PA; PA if 70 years and olderscopolamine $0(2) QL (10 patches / 30 days), PA;

PA if 70 years and olderANTISPASMODICS - DRUGS FOR STOMACH SPASMS

dicyclomine hcl cap 10mg $0(2)dicyclomine hcl soln 10mg/5ml $0(2)dicyclomine hcl tab 20mg $0(2)glycopyrrolate tab 1mg $0(1)glycopyrrolate tab 2mg $0(1)

H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACH ACIDacid reducer TABS $0(3) NM; *acid reducer maximum stre $0(3) NM; *famotidine SUSR $0(1)


Name of drug


you (tier

level)


or limits on usefamotidine TABS 10mg $0(3) NM; *famotidine TABS 20mg, 40mg $0(1)famotidine in nacl $0(1)famotidine inj $0(1)gnp acid control 150 maxi $0(3) NM; *gnp acid reducer $0(3) NM; *gnp acid reducer maximum $0(3) NM; *gnp heartburn relief $0(3) NM; *heartburn relief $0(3) NM; *heartburn relief 150 maxi $0(3) NM; *heartburn relief maximum $0(3) NM; *hm acid reducer $0(3) NM; *hm famotidine $0(3) NM; *nizatidine CAPS $0(1)qc acid controller $0(3) NM; *qc acid controller maximu $0(3) NM; *ranitidine hcl $0(3) NM; *sm acid reducer $0(3) NM; *sm acid reducer maximum s $0(3) NM; *

INFLAMMATORY BOWEL DISEASEbalsalazide disodium $0(1)budesonide ec $0(1)hydrocortisone (enema) $0(1)mesalamine CPDR $0(1)mesalamine ENEM $0(1)mesalamine SUPP $0(2)mesalamine TBEC 1.2gm $0(1)mesalamine w/ cleanser $0(1)sulfasalazine TABS $0(1)sulfasalazine ec $0(1)

LAXATIVESbisac-evac $0(3) NM; *


Name of drug


you (tier

level)


or limits on usebisacodyl SUPP $0(3) NM; *bisacodyl ec $0(3) NM; *biscolax $0(3) NM; *COLACE $0(3) NM; *constulose $0(1)docu $0(3) NM; *docusate sodium CAPS; LIQD $0(3) NM; *docusil $0(3) NM; *dok CAPS $0(3) NM; *ducodyl $0(3) NM; *ENEMEEZ MINI $0(3) NM; *ENEMEEZ PLUS $0(3) NM; *enulose $0(1)FLEET ENEMA $0(3) NM; *FLEET PEDIATRIC $0(3) NM; *gavilyte-c $0(1)gavilyte-g $0(1)gavilyte-n/flavor pack $0(1)generlac $0(1)gnp enema $0(3) NM; *gnp laxative $0(3) NM; *gnp stool softener $0(3) NM; *GOLYTELY $0(2)hm enema ready-to-use $0(3) NM; *hm enema saline laxative $0(3) NM; *hm laxative $0(3) NM; *hm stool softener CAPS $0(3) NM; *hm stool softener maximum $0(3) NM; *kao-tin CAPS $0(3) NM; *lactulose SOLN $0(1)lactulose (encephalopathy) $0(1)laxative $0(3) NM; *


Name of drug


you (tier

level)


or limits on usenatural fiber therapy $0(3) NM; *NULYTELY/FLAVOR PACKS $0(2)pediatric enema $0(3) NM; *peg 3350-kcl-sod bicarb-sod chloride-sod sulfate

$0(1)

peg 3350-potassium chloride-sod bicarbonate-sod chloride

$0(1)

PLENVU $0(2)qc enema $0(3) NM; *qc gentle laxative $0(3) NM; *reguloid POWD 28.3%, 48.57%, 58.6% $0(3) NM; *silace $0(3) NM; *sm fiber POWD 28.3%, 48.57%, 58.6% $0(3) NM; *sm gentle laxative $0(3) NM; *sm stool softener CAPS $0(3) NM; *sodium phosphates $0(3) NM; *stimulant laxative TBEC $0(3) NM; *stool softener CAPS $0(3) NM; *stool softener extra stre $0(3) NM; *SUPREP BOWEL PREP KIT $0(2)trilyte $0(1)

MISCELLANEOUSalosetron hcl $0(2) PAAMITIZA CAP 8MCG $0(2) QL (180 caps / 30 days)AMITIZA CAP 24MCG $0(2) QL (60 caps / 30 days)cromolyn sodium (mastocytosis) $0(2)diphenoxylate w/ atropine $0(2)GATTEX $0(2) NM, LA, PALINZESS $0(2) QL (30 caps / 30 days)loperamide hcl CAPS $0(1)misoprostol TABS $0(1)MOVANTIK 12.5mg $0(2) QL (60 tabs / 30 days)MOVANTIK 25mg $0(2) QL (30 tabs / 30 days)


Name of drug


you (tier

level)


or limits on useRELISTOR SOLN $0(2) PAsucralfate TABS $0(1)ursodiol CAPS; TABS $0(1)XIFAXAN 550mg $0(2) PA

PANCREATIC ENZYMESCREON $0(2)ZENPEP $0(2)

PROTON PUMP INHIBITORS - DRUGS FOR ULCERS AND STOMACH ACIDDEXILANT $0(2) QL (30 caps / 30 days)esomeprazole magnesium CPDR $0(1) QL (30 caps / 30 days), STgnp lansoprazole $0(3) NM; *GNP OMEPRAZOLE $0(3) NM, PA; *goodsense lansoprazole $0(3) NM; *heartburn treatment 24 ho $0(3) NM; *hm lansoprazole $0(3) NM; *HM OMEPRAZOLE $0(3) NM, PA; *lansoprazole CPDR 15mg $0(3) NM; *lansoprazole CPDR 15mg, 30mg $0(1) QL (30 caps / 30 days)OMEPRAZOLE TBEC $0(3) NM, PA; *omeprazole cap 10mg $0(1)omeprazole cap 20mg $0(1)omeprazole cap 40mg $0(1)pantoprazole sodium SOLR $0(1)pantoprazole sodium tbec $0(1)PREVACID 24HR $0(3) NM; *rabeprazole sodium $0(1) QL (30 tabs / 30 days)sm lansoprazole $0(3) NM; *SM OMEPRAZOLE $0(3) NM, PA; *

GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONSBENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGED PROSTATE

alfuzosin hcl $0(1) QL (30 tabs / 30 days)dutasteride CAPS $0(1) QL (30 caps / 30 days)


Name of drug


you (tier

level)


or limits on usedutasteride-tamsulosin hcl $0(1) QL (30 caps / 30 days)finasteride TABS 5mg $0(1)tamsulosin hcl $0(1)

MISCELLANEOUSbethanechol chloride TABS $0(1)potassium citrate (alkalinizer) er tabs $0(1)

URINARY ANTISPASMODICS - DRUGS TO TREAT URINARY INCONTINENCEMYRBETRIQ $0(2) QL (30 tabs / 30 days)oxybutynin chloride SYRP $0(1)oxybutynin chloride TABS $0(1)oxybutynin chloride TB24 5mg $0(1) QL (30 tabs / 30 days)oxybutynin chloride TB24 10mg, 15mg $0(1) QL (60 tabs / 30 days)tolterodine tartrate cap er $0(1) QL (30 caps / 30 days), STtolterodine tartrate tabs $0(1) STTOVIAZ $0(2) QL (30 tabs / 30 days)trospium chloride TABS $0(1) QL (60 tabs / 30 days)

VAGINAL ANTI-INFECTIVESclindamycin phosphate vaginal $0(1)clotrimazole vaginal $0(3) NM; *3 day vaginal $0(3) NM; *gnp clotrimazole 3 $0(3) NM; *gnp miconazole 3 $0(3) NM; *gnp miconazole 7 $0(3) NM; *gnp tioconazole 1 $0(3) NM; *metronidazole vaginal $0(1)miconazole 3 combo pack $0(3) NM; *miconazole 7 $0(3) NM; *miconazole nitrate vaginal CREA $0(3) NM; *miconazole nitrate vaginal KIT $0(3) NM; *miconazole nitrate vaginal SUPP 100mg $0(3) NM; *qc 3 day vaginal cream $0(3) NM; *qc miconazole 7 $0(3) NM; *


Name of drug


you (tier

level)


or limits on usesm 3-day vaginal $0(3) NM; *sm clotrimazole vaginal $0(3) NM; *sm miconazole 3 $0(3) NM; *sm miconazole 7 $0(3) NM; *sm tioconazole-1 $0(3) NM; *terconazole vaginal $0(1)vandazole $0(1)

HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERSANTICOAGULANTS - BLOOD THINNERS

COUMADIN 1MG $0(2)ELIQUIS 2.5mg $0(2) QL (60 tabs / 30 days)ELIQUIS 5mg $0(2) QL (74 tabs / 30 days)ELIQUIS STARTER PACK $0(2) QL (74 tabs / 30 days)enoxaparin sodium $0(1)fondaparinux sodium 2.5mg/0.5ml $0(1)fondaparinux sodium 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml

$0(2)

heparin sod (porcine) in d5w $0(2)heparin sod inj 1000/ml $0(1) B/Dheparin sod inj 5000/ml $0(1) B/Dheparin sod inj 10000/ml $0(1) B/Dheparin sod inj 20000/ml $0(1) B/DHEPARIN SODIUM/NACL 0.45% $0(2)jantoven $0(1)PRADAXA $0(2) QL (60 caps / 30 days)warfarin sodium $0(1)XARELTO 2.5mg $0(2) QL (60 tabs / 30 days)XARELTO 10mg, 15mg, 20mg $0(2) QL (30 tabs / 30 days)XARELTO STARTER PACK $0(2) QL (51 tabs / 30 days)

HEMATOPOIETIC GROWTH FACTORSPROCRIT $0(2) NM, PAZARXIO $0(2) NM, PA


Name of drug


you (tier

level)


or limits on useIRON

FERROUS GLUCONATE TABS 324mg $0(3) NM; *ferrous sulfate SOLN $0(3) NM; *ferrous sulfate TABS 325mg $0(3) NM; *FERROUS SULFATE TBEC 324mg $0(3) NM; *wee care $0(3) NM; *

MISCELLANEOUSanagrelide hcl $0(1)BERINERT $0(2) QL (24 boxes / 30 days), NM, LA,

PAcilostazol $0(1)DROXIA $0(2)ENDARI $0(2) NM, LA, PAHAEGARDA 2000unit $0(2) QL (30 vials / 30 days), NM, LA,

PAHAEGARDA 3000unit $0(2) QL (20 vials / 30 days), NM, LA,

PAicatibant acetate $0(2) QL (9 syringes / 30 days), NM,

PApentoxifylline TBCR $0(1)PROMACTA PACK 12.5mg $0(2) QL (360 packets / 30 days), NM,

LA, PAPROMACTA PACK 25mg $0(2) QL (180 packets / 30 days), NM,

LA, PAPROMACTA TABS 12.5mg, 25mg $0(2) QL (30 tabs / 30 days), NM, LA,

PAPROMACTA TABS 50mg, 75mg $0(2) QL (60 tabs / 30 days), NM, LA,

PAtranexamic acid SOLN; TABS $0(1)

PLATELET AGGREGATION INHIBITORSaspirin-dipyridamole $0(1)BRILINTA $0(2)clopidogrel tab 75mg $0(1)prasugrel hcl $0(1)


Name of drug


you (tier

level)


or limits on useIMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM

DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGS TO TREAT RHEUMATOID ARTHRITIS

ENBREL SOLN $0(2) QL (16 vials / 28 days), NM, PAENBREL SOLR $0(2) QL (16 vials / 28 days), NM, PAENBREL SOSY 25mg/0.5ml $0(2) QL (16 syringes / 28 days), NM,

PAENBREL SOSY 50mg/ml $0(2) QL (8 syringes / 28 days), NM,

PAENBREL MINI $0(2) QL (8 injections / 28 days), NM,

PAENBREL SURECLICK $0(2) QL (8 injections / 28 days), NM,

PAHUMIRA 10mg/0.1ml, 20mg/0.2ml $0(2) QL (2 injections / 28 days), NM,

PAHUMIRA 40mg/0.4ml $0(2) QL (6 injections / 28 days), NM,

PAHUMIRA INJ 10MG/0.2ML $0(2) QL (2 syringes / 28 days), NM,

PAHUMIRA KIT 20MG/0.4ML $0(2) QL (2 syringes / 28 days), NM,

PAHUMIRA KIT 40MG/0.8ML $0(2) QL (6 syringes / 28 days), NM,

PAHUMIRA PEDIATRIC CROHNS DISEASE $0(2) NM, PAHUMIRA PEN $0(2) QL (6 pens / 28 days), NM, PAHUMIRA PEN CD/UC/HS STARTER $0(2) NM, PAHUMIRA PEN INJ CD/UC/HS STARTER $0(2) NM, PAHUMIRA PEN INJ PS/UV STARTER $0(2) NM, PAHUMIRA PEN-PS/UV STARTER $0(2) NM, PAhydroxychloroquine sulfate $0(1)leflunomide TABS $0(1) QL (30 tabs / 30 days)methotrexate sodium tabs $0(1)REMICADE $0(2) NM, PARENFLEXIS $0(2) NM, LA, PARINVOQ $0(2) QL (30 tabs / 30 days), NM, PA


Name of drug


you (tier

level)


or limits on useSKYRIZI $0(2) QL (7 kits / year), NM, PASTELARA SOLN 45mg/0.5ml $0(2) QL (1 vial / 28 days), NM, LA, PASTELARA SOSY $0(2) QL (1 syringe / 28 days), NM, PAXATMEP $0(2) B/DXELJANZ $0(2) QL (60 tabs / 30 days), NM, PAXELJANZ XR $0(2) QL (30 tabs / 30 days), NM, PA

IMMUNOGLOBULINSBIVIGAM $0(2) NM, PAFLEBOGAMMA DIF 2.5gm/50ml, 5gm/100ml, 5gm/50ml, 10gm/100ml, 10gm/200ml, 20gm/200ml, 20gm/400ml

$0(2) NM, PA

GAMASTAN $0(2) B/D, NMGAMMAGARD LIQUID $0(2) NM, PAGAMMAGARD S/D $0(2) NM, PAGAMMAKED $0(2) NM, PAGAMMAPLEX $0(2) NM, PAGAMMAPLEX 10GM/100ML $0(2) NM, PAGAMUNEX-C $0(2) NM, PAOCTAGAM $0(2) NM, PAPANZYGA $0(2) NM, PAPRIVIGEN $0(2) NM, PA

IMMUNOMODULATORSACTIMMUNE $0(2) NM, LA, PAARCALYST $0(2) NM, PAINTRON-A INJ 10MU $0(2) B/D, NMINTRON-A INJ 18MU $0(2) B/D, NMINTRON-A INJ 25MU $0(2) B/D, NMINTRON-A INJ 50MU $0(2) B/D, NM

IMMUNOSUPPRESSANTSazathioprine TABS $0(1) B/DBENLYSTA $0(2) NM, PAcyclosporine CAPS; SOLN $0(1) B/D, NMcyclosporine modified (for microemulsion) $0(1) B/D, NM


Name of drug


you (tier

level)


or limits on useeverolimus (immunosuppressant) .5mg, .75mg $0(2) B/D, NMeverolimus (immunosuppressant) .25mg $0(1) B/D, NMgengraf $0(1) B/D, NMmycophenolate mofetil CAPS; TABS $0(1) B/D, NMmycophenolate mofetil SUSR $0(2) B/D, NMmycophenolate sodium tbec $0(1) B/D, NMNULOJIX $0(2) B/D, NMPROGRAF PACK $0(2) B/D, NMSANDIMMUNE SOLN 100mg/ml $0(2) B/D, NMsirolimus SOLN $0(2) B/D, NMsirolimus TABS 2mg $0(2) B/D, NMsirolimus TABS .5mg, 1mg $0(1) B/D, NMtacrolimus CAPS $0(1) B/D, NMZORTRESS TAB 0.5MG $0(2) B/D, NMZORTRESS TAB 0.25MG $0(2) B/D, NMZORTRESS TAB 0.75MG $0(2) B/D, NMZORTRESS TAB 1MG $0(2) B/D, NM

VACCINESACTHIB $0(2)ADACEL $0(2)BCG VACCINE $0(2)BEXSERO $0(2)BOOSTRIX $0(2)DAPTACEL $0(2)DIPHTHERIA/TETANUS TOXOID $0(2) B/DENGERIX-B $0(2) B/DGARDASIL 9 $0(2)HAVRIX $0(2)HIBERIX $0(2)IMOVAX RABIES (H.D.C.V.) $0(2) B/DINFANRIX $0(2)IPOL INACTIVATED IPV $0(2)


Name of drug


you (tier

level)


or limits on useIXIARO $0(2)KINRIX $0(2)M-M-R II $0(2)MENACTRA $0(2)MENVEO $0(2)PEDIARIX $0(2)PEDVAX HIB $0(2)PENTACEL $0(2)PROQUAD $0(2)QUADRACEL $0(2)RABAVERT $0(2) B/DRECOMBIVAX HB $0(2) B/DROTARIX $0(2)ROTATEQ $0(2)SHINGRIX $0(2) QL (2 vials per lifetime)TDVAX $0(2) B/DTENIVAC $0(2) B/DTRUMENBA $0(2)TWINRIX INJ $0(2)TYPHIM VI $0(2)VAQTA $0(2)VARIVAX $0(2)YF-VAX $0(2)ZOSTAVAX $0(2) QL (1 vial per lifetime)

NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTSELECTROLYTES

klor-con 8 $0(1)klor-con 10 $0(1)klor-con m10 $0(1)klor-con m15 $0(1)klor-con m20 $0(1)klor-con pak 20meq $0(1)


Name of drug


you (tier

level)


or limits on useklor-con spr cap 8meq $0(1)klor-con spr cap 10meq $0(1)MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

$0(2)

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

$0(2)

MAGNESIUM SULFATE IN D5W $0(2)magnesium sulfate in dextrose $0(2)magnesium sulfate inj 50% $0(2)potassium chloride CPCR $0(1)potassium chloride PACK $0(1)potassium chloride SOLN 10%, 20% $0(1)potassium chloride TBCR $0(1)potassium chloride microencapsulated crystals er

$0(1)

sodium chloride SOLN 2.5meq/ml $0(1)sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln

$0(1)

TPN ELECTROLYTES $0(2) B/DIV NUTRITION

AMINOSYN II INJ 10% $0(2) B/DAMINOSYN-PF 7% $0(2) B/Dchromic chloride SOLN $0(3) NM; *CLINIMIX 4.25%/DEXTROSE 5% $0(2) B/DCLINIMIX 5%/DEXTROSE 15% $0(2) B/DCLINIMIX 5%/DEXTROSE 20% $0(2) B/DCLINIMIX INJ 4.25/D10 $0(2) B/Dclinisol sf 15% $0(1) B/DCLINOLIPID $0(2) B/Dcupric chloride $0(3) NM; *FREAMINE HBC 6.9% $0(2) B/D


Name of drug


you (tier

level)


or limits on useFREAMINE III $0(2) B/Dhepatamine $0(2) B/DINTRALIPID 30% $0(2) B/DINTRALIPID INJ 20% $0(2) B/DNEPHRAMINE $0(2) B/DNUTRILIPID INJ 20% $0(2) B/Dplenamine $0(1) B/DPREMASOL SOL 10% $0(2) B/DPROCALAMINE $0(2) B/DPROSOL $0(2) B/DTRAVASOL $0(2) B/DTROPHAMINE INJ 10% $0(2) B/D

IV REPLACEMENT SOLUTIONSdextrose 2.5%/nacl 0.45% $0(1)dextrose 5% $0(1)DEXTROSE 5% /ELECTROLYTE $0(2)dextrose 5%/nacl 0.2% $0(1)DEXTROSE 5%/NACL 0.3% $0(2)dextrose 5%/nacl 0.9% $0(1)dextrose 5%/nacl 0.45% $0(1)dextrose 5%/potassium chl $0(1)dextrose 10% flex contain $0(1)DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% $0(2)dextrose 10%/nacl 0.45% $0(1)dextrose 50% $0(1)dextrose in lactated ringers $0(1)dextrose inj 70% $0(1)ISOLYTE P $0(2)ISOLYTE S $0(2)kcl0.15%/d5w/nacl0.2% $0(1)KCL 0.3%/D5W/NACL 0.9% $0(2)kcl 0.3%/d5w/nacl 0.45% $0(1)


Name of drug


you (tier

level)


or limits on usekcl 0.15%/d5w/nacl 0.9% $0(1)KCL 0.15%/D5W/NACL 0.225% $0(2)kcl 0.075%/d5w/nacl 0.45% $0(1)kcl/d5w/nacl inj 0.22%/0.45% $0(1)kcl/d5w/nacl inj .15/.45% $0(1)kcl/nacl inj 0.3-0.9 $0(1)kcl/nacl inj 0.15%-0.9% $0(1)lactated ringer’s $0(1)NORMOSOL-M IN D5W $0(2)PLASMA-LYTE A $0(2)PLASMA-LYTE-148 $0(2)pot chloride inj 2meq/ml $0(1)potassium chloride SOLN 2meq/ml $0(1)POTASSIUM CHLORIDE SOLN .4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml

$0(1)

potassium chloride in nacl $0(1)sodium chloride SOLN 3%, 5% $0(1)sodium chloride 0.45% $0(1)sodium chloride inj 0.9% $0(1)

MINERALScalcium carbonate TABS 600mg $0(3) NM; *calcium carbonate (antacid) $0(3) NM; *calcium carbonate-cholecalciferol $0(3) NM; *calcium carbonate-vitamin d $0(3) NM; *manganese chloride $0(3) NM; *NU-MAG $0(3) NM; *oysco 500+d TABS $0(3) NM; *

VITAMINSAQUASOL A PARENTERAL $0(3) NM; *aqueous vitamin d infants $0(3) NM; *calcitriol CAPS $0(1) B/Dcalcitriol inj $0(1) B/D


Name of drug


you (tier

level)


or limits on usecalcitriol oral soln 1 mcg/ml $0(1) B/Dcholecalciferol CAPS; TABS $0(3) NM; *CORVITE $0(3) NM; *corvite free $0(3) NM; *cyanocobalamin SOLN 1000mcg/ml $0(3) NM; *d3 super strength $0(3) NM; *d2000 ultra strength $0(3) NM; *DECARA 25000unit $0(3) NM; *decara 50000unit $0(3) NM; *DEKAS ESSENTIAL $0(3) NM; *DEKAS PLUS $0(3) NM; *ENLYTE $0(3) NM; *ergocalciferol CAPS; SOLN $0(3) NM; *ESCAVITE $0(3) NM; *folic acid SOLN $0(3) NM; *folic acid TABS 1mg $0(3) NM; *FOLTRATE $0(3) NM; *hydroxocobalamin acetate $0(3) NM; *INFUVITE ADULT $0(3) NM; *INFUVITE PEDIATRIC $0(3) NM; *M-NATAL PLUS $0(2)M.V.I. PEDIATRIC $0(3) NM; *melatonin LIQD 1mg/ml $0(3) NM; *MEPHYTON $0(3) NM; *multi-vit/iron/fluoride $0(3) NM; *multivitamin with fluorid SOLN $0(3) NM; *multivitamin/fluoride $0(3) NM; *NASCOBAL $0(3) NM; *NEPHPLEX RX $0(3) NM; *niacin CPCR 500mg $0(3) NM; *paricalcitol CAPS $0(1) B/Dphytonadione SOLN; TABS $0(3) NM; *


Name of drug


you (tier

level)


or limits on usePNV FOLIC ACID + IRON MUL $0(2)PRENATAL $0(2)PRENATAL PLUS $0(2)PRENATAL PLUS LOW IRON $0(2)pyridoxine hcl SOLN $0(3) NM; *RAYALDEE $0(2)renal caps $0(3) NM; *thiamine hcl SOLN $0(3) NM; *TRICARE $0(2)virt-caps $0(3) NM; *VITAL-D RX $0(3) NM; *

OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONSANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREAT INFECTIONS AND INFLAMMATION

bacitracin-poly-neomycin-hc $0(1)BLEPHAMIDE OINT $0(2)neomycin-polymy-dexameth $0(1)neomycin-polymyxin-hc (ophth) $0(1)sulfacetamide sod-prednisolone $0(1)TOBRADEX OINT $0(2)TOBRADEX ST $0(2)tobramycin-dexamethasone $0(1)ZYLET $0(2)

ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONSAZASITE $0(2)bacitracin (ophthalmic) $0(1)bacitracin-polymyxin b (ophth) $0(1)BESIVANCE $0(2)CILOXAN OINT $0(2)ciprofloxacin hcl (ophth) $0(1)erythromycin (ophth) $0(1)gatifloxacin (ophth) $0(1)gentak $0(1)


Name of drug


you (tier

level)


or limits on usegentamicin sulfate soln (ophth) $0(1)MOXEZA $0(2)moxifloxacin hcl (ophth) $0(1)NATACYN $0(2)neomycin-bacitracin zn-polymyxin $0(1)neomycin-polymyxin-gramicidin $0(1)ofloxacin (ophth) $0(1)polymyxin b-trimethoprim $0(1)sulfacetamide sodium (ophth) $0(1)tobramycin (ophth) $0(1)trifluridine $0(1)ZIRGAN $0(2)

ANTI-INFLAMMATORIES - DRUGS TO TREAT INFLAMMATIONALREX $0(2)bromfenac sodium (ophth) $0(1)BROMSITE $0(2)dexamethasone sodium phosphate (ophth) $0(1)diclofenac sodium (ophth) $0(1)DUREZOL $0(2)FLAREX $0(2)fluorometholone $0(1)flurbiprofen sodium $0(1)ILEVRO $0(2)ketorolac tromethamine (ophth) $0(1)LOTEMAX GEL; OINT $0(2)loteprednol etabonate $0(1)prednisolone acetate (ophth) $0(1)PREDNISOLONE SODIUM PHOSPHATE (OPHTH)

$0(2)

PROLENSA $0(2)ANTIALLERGICS - DRUGS TO TREAT ALLERGIES

alaway $0(3) NM; *alaway childrens allergy $0(3) NM; *


Name of drug


you (tier

level)


or limits on useazelastine drop 0.05% $0(1)BEPREVE $0(2)cromolyn sodium (ophth) $0(1)eye itch relief $0(3) NM; *hm eye itch relief $0(3) NM; *ketotifen fumarate (ophth) $0(3) NM; *LASTACAFT $0(2)olopatadine hcl 0.2% $0(1)PAZEO $0(2)sm eye itch relief $0(3) NM; *ZADITOR $0(3) NM; *ZERVIATE $0(2)

ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMAALPHAGAN P SOL 0.1% $0(2)AZOPT $0(2)betaxolol hcl (ophth) $0(1)BETOPTIC-S $0(2)brimonidine sol 0.2% $0(1)brimonidine sol 0.15% $0(1)carteolol hcl (ophth) $0(1)COMBIGAN $0(2)dorzolamide hcl $0(1)dorzolamide hcl-timolol maleate $0(1)latanoprost SOLN $0(1)levobunolol hcl $0(1)LUMIGAN $0(2)PHOSPHOLINE IODIDE $0(2)pilocarpine hcl SOLN $0(1)RHOPRESSA $0(2)SIMBRINZA $0(2)timolol maleate (ophth) soln $0(1)timolol maleate gel $0(1)


Name of drug


you (tier

level)


or limits on usetimolol maleate ophth soln 0.5% (once-daily) $0(1)travoprost $0(1)

MISCELLANEOUSakwa tears $0(3) NM; *artificial tears 1.4% $0(3) NM; *ATROPINE SULFATE SOLN 1% $0(2)CYSTARAN $0(2) NM, LA, PAGENTEAL SEVERE $0(3) NM; *genteal tears mild $0(3) NM; *gnp artificial tears $0(3) NM; *gnp lubricant pm $0(3) NM; *gnp lubricating plus eye $0(3) NM; *GONAK $0(3) NM; *goodsense lubricating plu $0(3) NM; *hm lubricating plus $0(3) NM; *ISOPTO TEARS $0(3) NM; *liquitears $0(3) NM; *lubricating plus eye drop $0(3) NM; *natural balance tears $0(3) NM; *natures tears $0(3) NM; *proparacaine hcl SOLN $0(1)puralube $0(3) NM; *ra lubricant eye drops .5% $0(3) NM; *refresh celluvisc $0(3) NM; *refresh lacri-lube $0(3) NM; *REFRESH LIQUIGEL $0(3) NM; *refresh p.m. $0(3) NM; *REFRESH PLUS $0(3) NM; *REFRESH TEARS $0(3) NM; *RESTASIS $0(2) QL (60 single use vials / 30 days)RESTASIS MULTIDOSE $0(2) QL (1 bottle / 30 days)systane nighttime $0(3) NM; *


Name of drug


you (tier

level)


or limits on useSYSTANE OVERNIGHT THERAPY $0(3) NM; *

RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERSANTICHOLINERGIC/BETA AGONIST COMBINATIONS - DRUGS TO TREAT COPD

ANORO ELLIPTA $0(2) QL (60 blisters / 30 days)BEVESPI AEROSPHERE $0(2) QL (1 inhaler / 30 days)COMBIVENT RESPIMAT $0(2) QL (2 inhalers / 30 days)ipratropium-albuterol nebu $0(1) B/DTRELEGY ELLIPTA $0(2) QL (60 blisters / 30 days)

ANTICHOLINERGICS - DRUGS TO TREAT COPDATROVENT HFA $0(2) QL (2 inhalers / 30 days)INCRUSE ELLIPTA $0(2) QL (30 blisters / 30 days)ipratropium bromide SOLN $0(1) B/Dipratropium bromide (nasal) $0(1)

ANTIHISTAMINES - DRUGS TO TREAT ALLERGIESAHIST $0(3) NM; *ALA-HIST IR $0(3) NM; *all day allergy $0(3) NM; *all day allergy childrens $0(3) NM; *aller-chlor $0(3) NM; *aller-ease $0(3) NM; *allergy $0(3) NM; *allergy 24-hr $0(3) NM; *allergy childrens $0(3) NM; *allergy relief CAPS 25mg $0(3) NM; *allergy relief TABS $0(3) NM; *allergy relief TBDP $0(3) NM; *allergy relief childrens LIQD $0(3) NM; *allergy-time $0(3) NM; *azelastine spr 0.1% $0(1)azelastine spr 0.15% $0(1)banophen CAPS; LIQD; TABS $0(3) NM; *cetirizine hcl $0(3) NM; *


Name of drug


you (tier

level)


or limits on usecetirizine hcl allergy ch $0(3) NM; *cetirizine hcl childrens $0(3) NM; *cetirizine hcl hives reli $0(3) NM; *cetirizine syrup $0(1)childrens loratadine $0(3) NM; *chlorphen sr $0(3) NM; *complete allergy medicine $0(3) NM; *cyproheptadine hcl SYRP; TABS $0(2) PA; PA if 70 years and olderdiphenhist $0(3) NM; *diphenhydramine hcl CAPS $0(3) NM; *diphenhydramine hcl TABS 25mg $0(3) NM; *diphenhydramine hcl inj 50mg/ml $0(1)ed chlorped jr $0(3) NM; *fexofenadine hcl TABS $0(3) NM; *gnp all day allergy $0(3) NM; *gnp all day allergy child $0(3) NM; *gnp allergy $0(3) NM; *gnp allergy relief TABS; TBDP $0(3) NM; *gnp childrens allergy $0(3) NM; *gnp dayhist allergy $0(3) NM; *gnp loratadine $0(3) NM; *gnp loratadine childrens SYRP $0(3) NM; *goodsense all day allergy $0(3) NM; *HISTEX $0(3) NM; *HISTEX PD $0(3) NM; *hm all day allergy $0(3) NM; *hm allergy $0(3) NM; *hm allergy relief $0(3) NM; *hm cetirizine hcl childre $0(3) NM; *hm fexofenadine hydrochlo $0(3) NM; *hm loratadine childrens $0(3) NM; *hydroxyzine hcl SYRP; TABS $0(2) PA; PA if 70 years and older


Name of drug


you (tier

level)


or limits on usehydroxyzine hcl inj $0(2) PA; PA if 70 years and olderhydroxyzine pamoate CAPS 25mg, 50mg $0(2) PA; PA if 70 years and olderlevocetirizine dihydrochloride $0(1)loratadine TABS $0(3) NM; *loratadine childrens SYRP $0(3) NM; *m-hist pd $0(3) NM; *PEDIAVENT $0(3) NM; *pharbedryl $0(3) NM; *qc all day allergy $0(3) NM; *qc loratadine allergy rel $0(3) NM; *siladryl allergy $0(3) NM; *sm all day allergy $0(3) NM; *sm all day allergy childr $0(3) NM; *sm allergy 4 hour $0(3) NM; *sm allergy relief $0(3) NM; *sm childrens loratadine $0(3) NM; *sm fexofenadine hydrochlo $0(3) NM; *sm loratadine $0(3) NM; *triprolidine hcl LIQD $0(3) NM; *VANACLEAR PD $0(3) NM; *VANAHIST PD $0(3) NM; *VANAMINE PD $0(3) NM; *

BETA AGONISTS - DRUGS TO TREAT ASTHMA AND COPDalbuterol sulfate AERS 108mcg/act $0(1) QL (2 inhalers / 30 days);

(generic of Proair HFA)albuterol sulfate AERS 108mcg/act $0(1) QL (2 inhalers / 30 days);

(generic of Ventolin HFA)albuterol sulfate NEBU .083%, .63mg/3ml, 1.25mg/3ml, 2.5mg/0.5ml

$0(1) B/D

albuterol sulfate SYRP $0(1)albuterol sulfate TABS $0(1)albuterol sulfate TB12 $0(1)levalbuterol hcl NEBU $0(1) B/D


Name of drug


you (tier

level)


or limits on uselevalbuterol hcl soln nebu conc 1.25 mg/0.5ml $0(1) B/Dlevalbuterol tartrate hfa $0(1) QL (2 inhalers / 30 days)SEREVENT DISKUS $0(2) QL (60 inhalations / 30 days)terbutaline sulfate TABS $0(1)VENTOLIN HFA $0(2) QL (2 inhalers / 30 days)

COUGH AND COLDcromolyn sodium (nasal) $0(3) NM; *

LEUKOTRIENE MODULATORSmontelukast sodium CHEW; PACK; TABS $0(1)zafirlukast $0(1)

MAST CELL STABILIZERS - DRUGS TO TREAT ALLERGIEScromolyn sodium nebu $0(1) B/D

MISCELLANEOUSacetylcysteine SOLN 10%, 20% $0(1) B/DARALAST NP $0(2) NM, LA, PADALIRESP $0(2)epinephrine (anaphylaxis) .15mg/0.3ml, .3mg/0.3ml

$0(1) (generic of EpiPen)

epinephrine (anaphylaxis) .15mg/0.15ml, .3mg/0.3ml

$0(1) (generic of Adrenaclick)

ESBRIET $0(2) NM, PAFASENRA $0(2) NM, LA, PAFASENRA PEN $0(2) NM, LA, PAKALYDECO $0(2) NM, PANUCALA $0(2) NM, LA, PAOFEV $0(2) NM, PAORKAMBI $0(2) NM, PAPROLASTIN-C $0(2) NM, LA, PAPULMOZYME $0(2) NM, PASYMDEKO $0(2) NM, LA, PASYMJEPI $0(2)THEO-24 $0(2)theophylline $0(1)


Name of drug


you (tier

level)


or limits on usetheophylline tab er 12hr 300 mg $0(1)theophylline tab er 12hr 450 mg $0(1)theophylline tab sr 24hr $0(1)TRIKAFTA $0(2) NM, LA, PAXOLAIR $0(2) NM, LA, PAZEMAIRA $0(2) NM, LA, PA

NASAL STEROIDS - DRUGS TO TREAT ALLERGIESbudesonide (nasal) $0(3) NM; *FLONASE ALLERGY RELIEF $0(3) NM; *FLONASE ALLERGY RELIEF CH $0(3) NM; *FLONASE SENSIMIST $0(3) NM; *flunisolide (nasal) $0(1) QL (3 bottles / 30 days)fluticasone propionate (nasal) 50mcg/act $0(1) QL (1 bottle / 30 days)fluticasone propionate (nasal) 50mcg/act $0(3) NM; *sm allergy relief nasal s $0(3) NM; *

STEROID INHALANTS - DRUGS TO TREAT ASTHMAARNUITY ELLIPTA $0(2) QL (30 inhalations / 30 days)budesonide (inhalation) .25mg/2ml, .5mg/2ml $0(1) B/DFLOVENT DISKUS 50mcg/blist, 100mcg/blist $0(2) QL (120 inhalations / 30 days)FLOVENT DISKUS 250mcg/blist $0(2) QL (240 inhalations / 30 days)FLOVENT HFA $0(2) QL (2 inhalers / 30 days)PULMICORT FLEXHALER $0(2) QL (2 inhalers / 30 days)

STEROID/BETA-AGONIST COMBINATIONS - DRUGS TO TREAT ASTHMA AND COPDADVAIR DISKUS $0(2) QL (60 inhalations / 30 days)ADVAIR HFA $0(2) QL (1 inhaler / 30 days)BREO ELLIPTA $0(2) QL (60 blisters / 30 days)SYMBICORT $0(2) QL (1 inhaler / 30 days)

TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONSDERMATOLOGY, ACNE

acne medication 10 GEL $0(3) NM; *ACNE MEDICATION 10 LOTN $0(3) NM; *amnesteem $0(1) PA


Name of drug


you (tier

level)


or limits on useavita $0(1) QL (45 grams / 30 days), PABENZOYL PEROXIDE GEL 2.5% $0(3) NM; *benzoyl peroxide GEL 5%, 10% $0(3) NM; *benzoyl peroxide wash 5% $0(3) NM; *benzoyl peroxide-erythromycin $0(1)claravis $0(1) PAclindamycin phosphate (topical) GEL $0(1) QL (75 grams / 30 days)clindamycin phosphate (topical) LOTN $0(1)clindamycin phosphate (topical) SOLN $0(1) QL (60 mL / 30 days)DIFFERIN GEL .1% $0(3) NM; *ery pad 2% $0(1)erythromycin (acne aid) $0(1)isotretinoin CAPS $0(1) PAmyorisan $0(1) PAsulfacetamide sodium (acne) $0(1)tretinoin CREA $0(1) QL (45 grams / 30 days), PAtretinoin GEL .01%, .025% $0(1) QL (45 grams / 30 days), PAzenatane $0(1) PA

DERMATOLOGY, ANTIBIOTICSgentamicin sulfate (topical) $0(1)hm triple antibiotic $0(3) NM; *mupirocin OINT $0(1) QL (220 grams / 30 days)silver sulfadiazine CREA $0(1)sm triple antibiotic $0(3) NM; *ssd $0(1)SULFAMYLON CREA $0(2)triple antibiotic $0(3) NM; *

DERMATOLOGY, ANTIFUNGALSanti-fungal powder $0(3) NM; *antifungal $0(3) NM; *baza antifungal $0(3) NM; *carrington antifungal $0(3) NM; *


Name of drug


you (tier

level)


or limits on useciclopirox CREA $0(1) QL (90 grams / 30 days)ciclopirox SUSP $0(1) QL (60 mL / 30 days)clotrimazole (topical) CREA 1% $0(1)clotrimazole (topical) CREA 1% $0(3) NM; *clotrimazole (topical) SOLN $0(1) QL (30 mL / 30 days)clotrimazole anti-fungal $0(3) NM; *clotrimazole antifungal $0(3) NM; *clotrimazole w/ betamethasone CREA $0(1)FUNGOID TINCTURE $0(3) NM; *fungoid-d $0(3) NM; *gnp athletes foot $0(3) NM; *gnp tolnaftate $0(3) NM; *ketoconazole cream $0(1) QL (60 grams / 30 days)miconazole nitrate (topical) $0(3) NM; *nyamyc $0(1) QL (60 grams / 30 days)nystatin (topical) $0(1)nystatin pow 100000 $0(1) QL (60 grams / 30 days)nystop $0(1) QL (60 grams / 30 days)qc tolnaftate $0(3) NM; *sm antifungal clotrimazol $0(3) NM; *sm antifungal miconazole $0(3) NM; *sm antifungal tolnaftate $0(3) NM; *soothe & cool inzo antifu $0(3) NM; *tolnaftate CREA; POWD $0(3) NM; *

DERMATOLOGY, ANTIPSORIATICSacitretin $0(1) PAcalcipotriene CREA; OINT $0(1) QL (120 grams / 30 days), PAcalcipotriene SOLN $0(1) QL (120 mL / 30 days), PAcalcitrene $0(1) QL (120 grams / 30 days), PAtazarotene CREA $0(1) QL (60 grams / 30 days), PATAZORAC CREA .05% $0(2) QL (60 grams / 30 days), PA


Name of drug


you (tier

level)


or limits on useDERMATOLOGY, ANTISEBORRHEICS

ketoconazole shampoo $0(1)selenium sulfide LOTN $0(1)

DERMATOLOGY, CORTICOSTEROIDSala-cort $0(1)alclometasone dipropionate $0(1)anti-itch maximum strengt $0(3) NM; *betamethasone dipropionate (topical) $0(1)betamethasone dipropionate augmented $0(1)betamethasone valerate CREA; LOTN; OINT $0(1)curad hydrocortisone $0(3) NM; *ENSTILAR $0(2) QL (120 grams / 30 days), PAfluocinolone acetonide CREA; OIL; OINT $0(1)fluocinolone acetonide SOLN $0(1) QL (90 mL / 30 days)fluocinolone acetonide oil body $0(1)fluocinonide CREA .05% $0(1) QL (120 grams / 30 days)fluocinonide GEL $0(1) QL (60 grams / 30 days)fluocinonide OINT $0(1) QL (60 grams / 30 days)fluocinonide SOLN $0(1) QL (60 mL / 30 days)fluocinonide emulsified base $0(1) QL (120 grams / 30 days)fluticasone propionate CREA; OINT $0(1)gnp hydrocortisone $0(3) NM; *gnp hydrocortisone maximu $0(3) NM; *gnp hydrocortisone plus $0(3) NM; *gnp hydrocortisone/aloe $0(3) NM; *halobetasol propionate CREA; OINT $0(1) QL (50 grams / 30 days)hm hydrocortisone plus $0(3) NM; *hm hydrocortisone/aloe ma $0(3) NM; *hydrocortisone (topical) $0(3) NM; *hydrocortisone (topical) cream 1% $0(1)hydrocortisone (topical) cream 2.5% $0(1)hydrocortisone (topical) lotion 2.5% $0(1)


Name of drug


you (tier

level)


or limits on usehydrocortisone (topical) oint 2.5% $0(1)hydrocortisone butyrate cream 0.1% $0(1) QL (45 grams / 30 days)hydrocortisone butyrate oint 0.1% $0(1) QL (45 grams / 30 days)hydrocortisone maximum st $0(3) NM; *hydrocortisone-aloe vera $0(3) NM; *mometasone furoate CREA; OINT; SOLN $0(1)scalpicin maximum strengt $0(3) NM; *sm hydrocortisone $0(3) NM; *sm hydrocortisone maximum $0(3) NM; *sm hydrocortisone plus $0(3) NM; *TEXACORT SOLN 2.5% $0(2)triamcinolone acetonide (topical) CREA .1% $0(1) QL (454 grams / 30 days)triamcinolone acetonide (topical) CREA .025%, .5%

$0(1)

triamcinolone acetonide (topical) LOTN $0(1)triamcinolone acetonide (topical) OINT .025%, .1%, .5%

$0(1)

DERMATOLOGY, LOCAL ANESTHETICSglydo $0(1) QL (30 mL / 30 days), PAlidocaine PTCH 5% $0(1) QL (3 patches / 1 day), PAlidocaine hcl GEL $0(1) QL (30 mL / 30 days), PAlidocaine hcl SOLN 4% $0(1) QL (50 mL / 30 days), PAlidocaine oint 5% $0(1) QL (50 grams / 30 days), PAlidocaine-prilocaine $0(1) QL (30 grams / 30 days), PA

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANEammonium lactate CREA; LOTN $0(1)AVAGE $0(3) NM; *BETADINE 10% $0(3) NM; *diclofenac sodium (topical) 1% gel $0(1) QL (1000 grams / 30 days), PAfluorouracil (topical) crea 5% $0(1) QL (40 grams / 30 days)fluorouracil (topical) soln $0(1) QL (10 mL / 30 days)hm povidone-iodine $0(3) NM; *imiquimod CREA 5% $0(1) QL (24 packets / 30 days)


Name of drug


you (tier

level)


or limits on uselactic acid (ammonium lactate) $0(3) NM; *metronidazole (topical) CREA; LOTN $0(1)metronidazole gel 0.75% $0(1)PANRETIN $0(2) QL (60 grams / 30 days)PICATO .05% $0(2) QL (2 tubes / 30 days)PICATO .015% $0(2) QL (3 tubes / 30 days)podofilox SOLN $0(1)povidone-iodine OINT; SOLN $0(3) NM; *procto-med hc $0(1)procto-pak $0(1)proctosol hc cre 2.5% $0(1)proctozone-hc $0(1)qc povidone iodine $0(3) NM; *RECTIV $0(2) QL (30 grams / 30 days)RENOVA $0(3) NM; *RENOVA PUMP $0(3) NM; *rosadan $0(1)sm povidone-iodine $0(3) NM; *tacrolimus (topical) $0(1) QL (100 grams / 30 days)TARGRETIN GEL $0(2) QL (60 grams / 30 days), NM, PAVALCHLOR $0(2) QL (60 grams / 30 days), NM, LA,

PADERMATOLOGY, SCABICIDES AND PEDICULIDES

gnp lice treatment $0(3) NM; *hm lice killing maximum s $0(3) NM; *hm lice treatment $0(3) NM; *lice killing maximum stre $0(3) NM; *malathion $0(1)permethrin cre 5% $0(1)sb lice killing maximum s $0(3) NM; *sm lice killing maximum s $0(3) NM; *sm lice treatment $0(3) NM; *


Name of drug


you (tier

level)


or limits on useDERMATOLOGY, WOUND CARE AGENTS

acetic acid .25% $0(1)REGRANEX $0(2) QL (30 grams / 30 days), PASANTYL $0(2)sodium chlor sol 0.9% irr $0(1)water for irrigation, sterile $0(1)

MOUTH/THROAT/DENTAL AGENTScevimeline hcl $0(1)chlorhexidine gluconate (mouth-throat) $0(1)clotrimazole TROC $0(1)lidocaine hcl (mouth-throat) $0(1)nystatin (mouth-throat) $0(1)paroex sol 0.12% $0(1)periogard $0(1)pilocarpine hcl (oral) $0(1)triamcinolone acetonide (mouth) $0(1)

OTIC - DRUGS TO TREAT CONDITIONS OF THE EARacetic acid (otic) $0(1)CIPRODEX $0(2)ciprofloxacin-dexamethasone $0(1)flac $0(1)fluocinolone acetonide (otic) $0(1)neomycin-polymyxin-hc (otic) $0(1)ofloxacin (otic) $0(1)

92

Drug Name Page #

E. Index of Covered DrugsDrug Name Page #3

3 day vaginal ........................................................... 66

A

abacavir sulfate ...................................................... 11abacavir sulfate-lamivudine................................... 12abacavir sulfate-lamivudine-zidovudine ............... 12ABELCET ................................................................. 10ABILIFY MAINTENA ................................................ 38abiraterone acetate ................................................ 20ABRAXANE .............................................................. 18acamprosate calcium ............................................. 44acarbose ................................................................. 47acebutolol hcl ......................................................... 28acephen..................................................................... 1acetaminophen ......................................................... 1acetaminophen extra stren ...................................... 1acetaminophen w/ codeine 300-15mg .................... 6acetaminophen w/ codeine 300-30mg .................... 6acetaminophen w/ codeine 300-60mg .................... 6acetaminophen w/ codeine soln .............................. 6acetazolamide ........................................................ 30acetic acid ............................................................... 91acetic acid (otic) ...................................................... 91acetylcysteine .......................................................... 84acid gone ................................................................. 58acid reducer ............................................................ 61acid reducer maximum stre ................................... 61acitretin ................................................................... 87acne medication 10 ................................................ 85ACNE MEDICATION 10 .......................................... 85ACTHIB ................................................................... 71ACTIMMUNE .......................................................... 70acyclovir .................................................................. 13acyclovir sodium ..................................................... 13ADACEL ................................................................... 71adefovir dipivoxil .................................................... 13ADEMPAS ............................................................... 31adriamycin .............................................................. 17ADVAIR DISKUS...................................................... 85ADVAIR HFA ........................................................... 85AFINITOR ................................................................ 21AFINITOR DISPERZ ................................................ 21aftera ....................................................................... 50AHIST ...................................................................... 81

AIMOVIG ................................................................. 42akwa tears .............................................................. 80ala-cort .................................................................... 88ALA-HIST IR ............................................................ 81alaway ..................................................................... 78alaway childrens allergy ......................................... 78albendazole .............................................................. 8albuterol sulfate ..................................................... 83alclometasone dipropionate .................................. 88ALDURAZYME ........................................................ 54ALECENSA .............................................................. 21alendronate sodium soln 70mg/75ml ................... 49alendronate sodium tab 5 mg ............................... 49alendronate sodium tab 10 mg ............................. 49alendronate sodium tab 35 mg ............................. 49alendronate sodium tab 40 mg ............................. 49alendronate sodium tab 70 mg ............................. 49alfuzosin hcl ............................................................ 65ALIMTA ................................................................... 18ALINIA ....................................................................... 8aliskiren fumarate .................................................. 30all day allergy.......................................................... 81all day allergy childrens ......................................... 81all day pain relief ...................................................... 4all day relief .............................................................. 4aller-chlor ................................................................ 81aller-ease ................................................................. 81allergy ...................................................................... 81allergy 24-hr ............................................................ 81allergy childrens...................................................... 81allergy relief ............................................................ 81allergy relief childrens ............................................ 81allergy-time ............................................................. 81allopurinol tab .......................................................... 1almacone ................................................................ 58almacone double strength ..................................... 58alosetron hcl ........................................................... 64ALPHAGAN P SOL 0.1% ........................................ 79alprazolam tab 0.5mg ............................................ 31alprazolam tab 0.25mg .......................................... 32alprazolam tab 1mg ............................................... 32alprazolam tab 2mg ............................................... 32ALREX ...................................................................... 78altavera tab ............................................................ 50ALUMINUM HYDROXIDE ...................................... 58ALUNBRIG .............................................................. 21

93

Drug Name Page # Drug Name Page #alyacen 1/35 ........................................................... 50amantadine hcl ....................................................... 37AMBISOME ............................................................. 10ambrisentan ........................................................... 31amethia ................................................................... 50amethia lo ............................................................... 50amikacin sulfate ....................................................... 8amiloride hcl ........................................................... 30amiloride & hydrochlorothiazide ........................... 30AMINOSYN II INJ 10% ............................................ 73AMINOSYN-PF 7% ................................................. 73amiodarone hcl soln ............................................... 26amiodarone tab 100mg ......................................... 26amiodarone tab 200mg ......................................... 26amiodarone tab 400mg ......................................... 26AMITIZA CAP 8MCG .............................................. 64AMITIZA CAP 24MCG ............................................ 64amitriptyline hcl ...................................................... 35amlodipine-benazepril hcl cap 2.5-10 mg ............. 24amlodipine-benazepril hcl cap 5-10 mg ................ 24amlodipine-benazepril hcl cap 5-20 mg ................ 24amlodipine-benazepril hcl cap 5-40 mg ................ 25amlodipine--benazepril hcl cap 10-20 mg ............. 24amlodipine-benazepril hcl cap 10-40mg ............... 25amlodipine besylate ............................................... 29amlodipine besylate-olmesartan medoxomil ........ 25amlodipine besylate-valsartan tab 5-160 mg ........ 25amlodipine besylate-valsartan tab 5-320 mg ........ 25amlodipine besylate-valsartan tab 10-160 mg ..... 25amlodipine besylate-valsartan tab 10-320 mg ..... 25amlodipine-valsartan-hydrochlorothiazide 5-160-

12.5mg ................................................................ 26amlodipine-valsartan-hydrochlorothiazide 5-160-

25mg ................................................................... 26amlodipine-valsartan-hydrochlorothiazide 10-

160-12.5mg ......................................................... 26amlodipine-valsartan-hydrochlorothiazide 10-

160-25mg ............................................................ 26amlodipine-valsartan-hydrochlorothiazide 10-

320-25mg ............................................................ 26ammonium lactate ................................................. 89amnesteem ............................................................. 85amoxapine tab 25mg ............................................. 35amoxapine tab 50mg ............................................. 35amoxapine tab 100mg ........................................... 36amoxapine tab 150mg ........................................... 36amoxicillin ............................................................... 16

amoxicillin & pot clavulanate 200/5ml susr .......... 16amoxicillin & pot clavulanate 200-28.5 chw tabs . 16amoxicillin & pot clavulanate 250/5ml susr .......... 16amoxicillin & pot clavulanate 250-125 tabs .......... 16amoxicillin & pot clavulanate 400/5ml susr .......... 16amoxicillin & pot clavulanate 400-57 chw tabs .... 16amoxicillin & pot clavulanate 500-125 tabs .......... 16amoxicillin & pot clavulanate 600/5ml susr .......... 16amoxicillin & pot clavulanate 875-125 tabs .......... 16amoxicillin & pot clavulanate er 12hr 1000-62.5

tabs ..................................................................... 16amphetamine-dextroamphetamine cap sr 24hr

5 mg .................................................................... 40amphetamine-dextroamphetamine cap sr 24hr

10 mg .................................................................. 40amphetamine-dextroamphetamine cap sr 24hr




30 mg .................................................................. 41amphetamine-dextroamphetamine tab 5 mg ....... 41amphetamine-dextroamphetamine tab 7.5 mg .... 41amphetamine-dextroamphetamine tab 10 mg ..... 41amphetamine-dextroamphetamine tab 12.5 mg .. 41amphetamine-dextroamphetamine tab 15 mg ..... 41amphetamine-dextroamphetamine tab 20 mg ..... 41amphetamine-dextroamphetamine tab 30 mg ..... 41amphotericin b ....................................................... 10ampicillin cap 500mg ............................................. 16ampicillin inj ........................................................... 16ampicillin sodium ................................................... 16ampicillin & sulbactam sodium ............................. 16ANADROL-50 ......................................................... 45anagrelide hcl ......................................................... 68anastrozole ............................................................. 20ANDRODERM ......................................................... 45ANORO ELLIPTA .................................................... 81antacid .................................................................... 58antacid anti-gas maximum .................................... 58antacid calcium extra str........................................ 58antacid calcium regular s ....................................... 58antacid extra strength ............................................ 58antacid fast acting .................................................. 58antacid fast relief .................................................... 58

94

Drug Name Page # Drug Name Page #antacid maximum strength .................................... 58antacid plus anti-gas fas ........................................ 58antacid plus anti-gas rel ......................................... 59antacid regular strength ......................................... 59anti-diarrheal .......................................................... 60antifungal ................................................................ 86anti-fungal powder ................................................. 86anti-itch maximum strengt ..................................... 88APOKYN .................................................................. 37aprepitant ............................................................... 61aprepitant pak 80mg & 125mg .............................. 61apri .......................................................................... 50APTIOM .................................................................. 32APTIVUS .................................................................. 11AQUASOL A PARENTERAL .................................... 75aqueous vitamin d infants ..................................... 75ARALAST NP ........................................................... 84aranelle ................................................................... 50ARCALYST ............................................................... 70aripiprazole odt ...................................................... 38aripiprazole oral solution 1 mg/ml ........................ 38aripiprazole tab ...................................................... 38ARISTADA ............................................................... 38ARISTADA INITIO ................................................... 38armodafinil ............................................................. 44ARNUITY ELLIPTA .................................................. 85arthritis pain relief .................................................... 1artificial tears .......................................................... 80ashlyna .................................................................... 50aspirin ....................................................................... 1ASPIRIN ..................................................................... 1aspirin 81 .................................................................. 1aspirin adult low strengt .......................................... 2aspirin-dipyridamole .............................................. 68aspirin low dose ........................................................ 2aspirin low strength .................................................. 2aspir-low ................................................................... 1atazanavir sulfate ................................................... 11atenolol ................................................................... 28atenolol & chlorthalidone ...................................... 28atomoxetine hcl ...................................................... 41atorvastatin calcium ............................................... 27atovaquone ............................................................... 8atovaquone-proguanil hcl ...................................... 10ATRIPLA .................................................................. 12ATROPINE SULFATE .............................................. 80ATROVENT HFA...................................................... 81

aubra ...................................................................... 50AURYXIA ................................................................. 57AUSTEDO................................................................ 43AVAGE ..................................................................... 89AVASTIN.................................................................. 18aviane ...................................................................... 50avita ........................................................................ 86AYVAKIT .................................................................. 21azacitidine ............................................................... 18AZASITE .................................................................. 77azathioprine ............................................................ 70azelastine drop 0.05% ............................................ 79azelastine spr 0.1% ................................................. 81azelastine spr 0.15% ............................................... 81azithromycin ........................................................... 15AZOPT ..................................................................... 79aztreonam................................................................. 8

B

bacitracin (ophthalmic) .......................................... 77bacitracin-polymyxin b (ophth) .............................. 77bacitracin-poly-neomycin-hc .................................. 77baclofen .................................................................. 43balsalazide disodium ............................................. 62BALVERSA ............................................................... 21balziva ..................................................................... 50banophen ................................................................ 81BANZEL SUS 40MG/ML ......................................... 32BANZEL TAB 200MG ............................................. 32BANZEL TAB 400MG ............................................. 32BARACLUDE ........................................................... 14BASAGLAR KWIKPEN ............................................. 45baza antifungal ....................................................... 86BCG VACCINE ......................................................... 71BD ALCOHOL SWABS ............................................ 45BD ULTRAFINE INSULIN SYRINGE ....................... 45BD ULTRAFINE/NANO PEN NEEDLES .................. 45bekyree .................................................................... 50BELSOMRA ............................................................. 41benazepril hcl ......................................................... 25benazepril & hydrochlorothiazide ......................... 25BENDEKA ................................................................ 17BENLYSTA ............................................................... 70benzoyl peroxide..................................................... 86BENZOYL PEROXIDE ............................................. 86benzoyl peroxide-erythromycin ............................. 86benzoyl peroxide wash ........................................... 86

95

Drug Name Page # Drug Name Page #benztropine mesylate inj ........................................ 37benztropine mesylate tab 0.5mg ........................... 37benztropine mesylate tab 1mg .............................. 37benztropine mesylate tab 2mg .............................. 37BEPREVE ................................................................. 79BERINERT ............................................................... 68BESIVANCE ............................................................. 77BETADINE ............................................................... 89betamethasone dipropionate augmented ............. 88betamethasone dipropionate (topical) .................. 88betamethasone valerate ........................................ 88BETASERON ........................................................... 43betaxolol hcl ........................................................... 28betaxolol hcl (ophth)............................................... 79bethanechol chloride .............................................. 66BETOPTIC-S ............................................................ 79BEVESPI AEROSPHERE .......................................... 81bexarotene .............................................................. 23BEXSERO ................................................................ 71bicalutamide ........................................................... 20BICILLIN L-A ........................................................... 16BIKTARVY ................................................................ 12bisac-evac ............................................................... 62bisacodyl ................................................................. 63bisacodyl ec ............................................................ 63biscolax ................................................................... 63bismatrol ................................................................. 60bismatrol maximum strengt .................................. 60bisoprolol fumarate................................................ 28bisoprolol & hydrochlorothiazide .......................... 28BIVIGAM ................................................................. 70BLEPHAMIDE ......................................................... 77blisovi 24 fe ............................................................. 50blisovi fe 1.5/30....................................................... 50BOOSTRIX ............................................................... 71BORTEZOMIB ......................................................... 18bosentan ................................................................. 31BOSULIF ................................................................. 21BRAFTOVI ............................................................... 21BREO ELLIPTA ........................................................ 85briellyn .................................................................... 50BRILINTA ................................................................ 68brimonidine sol 0.2% .............................................. 79brimonidine sol 0.15%............................................ 79BRIVIACT INJ 50MG/5ML ...................................... 32BRIVIACT SOL 10MG/ML ....................................... 32BRIVIACT TAB 10MG ............................................. 32

BRIVIACT TAB 25MG ............................................. 32BRIVIACT TAB 50MG ............................................. 32BRIVIACT TAB 75MG ............................................. 32BRIVIACT TAB 100MG ........................................... 32bromfenac sodium (ophth) .................................... 78bromocriptine mesylate ......................................... 37BROMSITE .............................................................. 78BRUKINSA .............................................................. 21budesonide ec ......................................................... 62budesonide (inhalation) ......................................... 85budesonide (nasal) ................................................. 85bumetanide ............................................................. 30buprenorphine hcl .................................................. 44buprenorphine hcl-naloxone hcl dihydrate

2-0.5mg ............................................................... 44buprenorphine hcl-naloxone hcl dihydrate 4-1mg 44buprenorphine hcl-naloxone hcl dihydrate 8-2mg 44buprenorphine hcl-naloxone hcl dihydrate 12-

3mg ..................................................................... 44buprenorphine hcl-naloxone hcl sl ........................ 44buprenorphine patch ............................................... 6bupropion hcl ......................................................... 36bupropion hcl (smoking deterrent) ........................ 44buspirone hcl .......................................................... 32butorphanol tartrate ................................................ 6BYDUREON BCISE ................................................. 45BYDUREON PEN .................................................... 46BYETTA ................................................................... 46BYSTOLIC ................................................................ 28

C

cabergoline ............................................................. 56CABOMETYX ........................................................... 21calcipotriene ........................................................... 87calcitonin (salmon) ................................................. 56calcitrene ................................................................. 87calcitriol .................................................................. 75calcitriol inj ............................................................. 75calcitriol oral soln 1 mcg/ml................................... 76calcium acetate (phosphate binder) ...................... 57calcium antacid ...................................................... 59calcium antacid extra str........................................ 59calcium antacid ultra max ..................................... 59calcium antacid ultra str ........................................ 59calcium carbonate .................................................. 75CALCIUM CARBONATE ......................................... 59calcium carbonate (antacid) .................................. 75

96

Drug Name Page # Drug Name Page #calcium carbonate-cholecalciferol ......................... 75calcium carbonate-vitamin d ................................. 75cal-gest antacid ....................................................... 59CALQUENCE ........................................................... 21camila ..................................................................... 50camrese lo ............................................................... 50candesartan cilexetil ............................................... 26candesartan cilexetil-hydrochlorothiazide ............ 26CAPLYTA ................................................................. 38CAPRELSA ............................................................... 21captopril .................................................................. 25captopril & hydrochlorothiazide ............................ 25CARBAGLU ............................................................. 54carbamazepine ....................................................... 32carbidopa-levodopa ............................................... 37carbidopa/levodopa/entacapone .......................... 37carboplatin ............................................................. 24carisoprodol ............................................................ 43carrington antifungal ............................................. 86carteolol hcl (ophth) ............................................... 79cartia xt cap 120/24hr ............................................ 29cartia xt cap 180/24hr ............................................ 29cartia xt cap 240/24hr ............................................ 29cartia xt cap 300/24hr ............................................ 29carvedilol................................................................. 28caspofungin acetate ............................................... 10CAYSTON .................................................................. 8caziant pak ............................................................. 50cefaclor ................................................................... 14CEFACLOR MONOHYDRATE ER ........................... 14cefadroxil ................................................................ 14CEFAZOLIN IN DEXTROSE 2GM/100ML-4% ........ 14cefazolin inj ............................................................. 14cefazolin sodium ..................................................... 14CEFAZOLIN SODIUM 1 GM/50ML ........................ 14cefdinir .................................................................... 14cefepime hcl ............................................................ 14cefixime ................................................................... 14cefoxitin sodium ..................................................... 15cefpodoxime proxetil .............................................. 15cefprozil .................................................................. 15ceftazidime .............................................................. 15CEFTAZIDIME/DEXTROSE ..................................... 15ceftriaxone sodium ................................................. 15cefuroxime axetil .................................................... 15cefuroxime sodium ................................................. 15celecoxib ................................................................... 4

CELONTIN .............................................................. 32cephalexin ............................................................... 15CERDELGA .............................................................. 55CEREZYME .............................................................. 55cetirizine hcl ............................................................ 81cetirizine hcl allergy ch ........................................... 82cetirizine hcl childrens ............................................ 82cetirizine hcl hives reli ............................................ 82cetirizine syrup ........................................................ 82cevimeline hcl ......................................................... 91CHANTIX ................................................................. 44CHANTIX CONTINUING MONTH ......................... 44CHANTIX STARTER PACK ...................................... 44CHEMET .................................................................. 49childrens acetaminophen ......................................... 2childrens aspirin low str ........................................... 2childrens ibuprofen .................................................. 4childrens loratadine ............................................... 82childrens silapap ...................................................... 2chlorhexidine gluconate (mouth-throat)................ 91chloroquine phosphate .......................................... 10chlorothiazide ......................................................... 30chlorphen sr ............................................................ 82chlorpromazine hcl................................................. 38chlorpromazine inj ................................................. 38chlorthalidone ........................................................ 30cholecalciferol ......................................................... 76cholestyramine ....................................................... 27cholestyramine light pack ...................................... 27cholestyramine light powd ..................................... 27chromic chloride ..................................................... 73ciclopirox ................................................................. 87cilostazol ................................................................. 68CILOXAN ................................................................. 77CIMDUO ................................................................. 12cinacalcet hcl .................................................... 56, 57CIPRO ...................................................................... 15CIPRODEX ............................................................... 91ciprofloxacin-dexamethasone ................................ 91ciprofloxacin hcl (ophth) ........................................ 77ciprofloxacin hcl tab ............................................... 15ciprofloxacin in d5w ............................................... 15cisplatin ................................................................... 24citalopram hydrobromide ...................................... 36claravis .................................................................... 86clarithromycin......................................................... 15clarithromycin er .................................................... 15

97

Drug Name Page # Drug Name Page #clarithromycin for susp .......................................... 15clindamycin cap 75mg ............................................. 8clindamycin cap 300mg ........................................... 8clindamycin hcl cap 150 mg ..................................... 8clindamycin phosphate in d5w ................................ 8clindamycin phosphate inj ....................................... 9CLINDAMYCIN PHOSPHATE IN NACL.................... 9clindamycin phosphate (topical) ............................ 86clindamycin phosphate vaginal ............................. 66clindamycin soln 75mg/5ml ..................................... 9CLINIMIX 4.25%/DEXTROSE 5% ........................... 73CLINIMIX 5%/DEXTROSE 15% .............................. 73CLINIMIX 5%/DEXTROSE 20% .............................. 73CLINIMIX INJ 4.25/D10 .......................................... 73clinisol sf 15% ......................................................... 73CLINOLIPID ............................................................ 73clobazam ................................................................ 32clomipramine hcl .................................................... 36clonazepam ............................................................ 32clonidine hcl ............................................................ 30clonidine hcl ptwk ................................................... 30clopidogrel tab 75mg ............................................. 68clorazepate dipotassium ........................................ 32clotrimazole ............................................................ 91clotrimazole anti-fungal ......................................... 87clotrimazole antifungal .......................................... 87clotrimazole (topical) .............................................. 87clotrimazole vaginal ............................................... 66clotrimazole w/ betamethasone ............................ 87clovique ................................................................... 49clozapine odt .......................................................... 38clozapine tab 25mg ................................................ 38clozapine tab 50mg ................................................ 38clozapine tab 100mg .............................................. 38clozapine tab 200mg .............................................. 38COARTEM ............................................................... 10COLACE .................................................................. 63colchicine w/ probenecid .......................................... 1COLCRYS .................................................................. 1colesevelam hcl ....................................................... 27colestipol hcl gran .................................................. 27colestipol hcl pack .................................................. 27colestipol hcl tabs ................................................... 27colistimethate sodium .............................................. 9COMBIGAN ............................................................ 79COMBIVENT RESPIMAT......................................... 81COMETRIQ ............................................................. 21

COMPLERA ............................................................. 12complete allergy medicine ...................................... 82compro .................................................................... 61constulose ............................................................... 63COPIKTRA ............................................................... 21CORLANOR............................................................. 30cortisone acetate .................................................... 55CORVITE ................................................................. 76corvite free .............................................................. 76COTELLIC ................................................................ 22COUMADIN 1MG ................................................... 67CREON .................................................................... 65CRIXIVAN ................................................................ 11cromolyn sodium (mastocytosis) ........................... 64cromolyn sodium (nasal) ........................................ 84cromolyn sodium nebu .......................................... 84cromolyn sodium (ophth) ....................................... 79cryselle-28 ............................................................... 50cupric chloride ........................................................ 73curad hydrocortisone ............................................. 88cyanocobalamin ..................................................... 76cyclafem 1/35.......................................................... 50cyclafem 7/7/7 ........................................................ 50cyclobenzaprine hcl ................................................ 43cyclophosphamide .................................................. 17CYCLOPHOSPHAMIDE .......................................... 17cycloserine .............................................................. 13cyclosporine ............................................................ 70cyclosporine modified (for microemulsion) ........... 70cyproheptadine hcl ................................................. 82cyred tab ................................................................. 50CYSTADANE ........................................................... 55CYSTAGON ............................................................. 55CYSTARAN .............................................................. 80cytarabine ............................................................... 18

D

d3 super strength ................................................... 76d2000 ultra strength ............................................... 76dalfampridine ......................................................... 43DALIRESP ................................................................ 84danazol ................................................................... 54dantrolene sodium ................................................. 43dapsone .................................................................... 9DAPTACEL .............................................................. 71daptomycin ............................................................... 9dasetta 1/35 ............................................................ 50

98

Drug Name Page # Drug Name Page #dasetta 7/7/7 .......................................................... 50DAURISMO ............................................................. 18deblitane ................................................................. 50decara ..................................................................... 76DECARA .................................................................. 76deferasirox granules ............................................... 49deferasirox tab ....................................................... 49DEKAS ESSENTIAL ................................................. 76DEKAS PLUS ........................................................... 76DELESTROGEN ....................................................... 55DELSTRIGO ............................................................. 12DEMSER .................................................................. 30DEPO-PROVERA INJ 400/ML ................................. 20DESCOVY ................................................................ 12desipramine hcl ...................................................... 36desmopressin acetate spray................................... 58desmopressin acetate spray refrigerated .............. 58desmopressin acetate tabs..................................... 58desmopressin inj 4mcg/ml ..................................... 58desogestrel-ethinyl estradiol (biphasic) ................. 50desvenlafaxine succinate ........................................ 36dexamethasone ...................................................... 55DEXAMETHASONE INTENSOL .............................. 55dexamethasone sodium phosphate ...................... 55dexamethasone sodium phosphate (ophth) ......... 78DEXILANT ............................................................... 65dexmethylphenidate hcl ......................................... 41dextrose 2.5%/nacl 0.45% ...................................... 74dextrose 5% ............................................................ 74DEXTROSE 5% /ELECTROLYTE ............................. 74dextrose 5%/nacl 0.2% ........................................... 74DEXTROSE 5%/NACL 0.3% .................................... 74dextrose 5%/nacl 0.9% ........................................... 74dextrose 5%/nacl 0.45% ......................................... 74dextrose 5%/potassium chl .................................... 74dextrose 10% flex contain ...................................... 74dextrose 10%/nacl 0.45% ....................................... 74DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% ... 74dextrose 50% .......................................................... 74dextrose inj 70% ..................................................... 74dextrose in lactated ringers .................................... 74DIASTAT ACUDIAL ................................................. 32DIASTAT PEDIATRIC .............................................. 32diazepam ................................................................ 33diazepam gel........................................................... 33diazepam inj ........................................................... 33diazepam intensol .................................................. 33

diazepam oral soln 1 mg/ml .................................. 33diazoxide ................................................................. 56diclofenac potassium ............................................... 4diclofenac sodium .................................................... 4diclofenac sodium (ophth) ..................................... 78diclofenac sodium (topical) 1% gel ........................ 89dicloxacillin sodium ................................................ 16dicyclomine hcl cap 10mg ...................................... 61dicyclomine hcl soln 10mg/5ml ............................. 61dicyclomine hcl tab 20mg ...................................... 61didanosine .............................................................. 11DIFFERIN ................................................................. 86DIFICID .................................................................... 15diflunisal ................................................................... 4digitek ...................................................................... 29digox .................................................................. 29, 30digoxin..................................................................... 30digoxin inj ............................................................... 30digoxin sol 50mcg/ml ............................................. 30dihydroergotamine mesylate inj 1 mg/ml ............. 42dihydroergotamine mesylate nasal spr 4 mg/ml .. 42DILANTIN-125 SUSP .............................................. 33DILANTIN CAP 30MG ............................................ 33DILANTIN CAP 100MG .......................................... 33DILANTIN CHEW TAB 50MG ................................. 33diltiazem cap 240mg cd ......................................... 29diltiazem cap 360mg cd ......................................... 29diltiazem cap er/12hr ............................................. 29diltiazem hcl ............................................................ 29diltiazem hcl coated beads..................................... 29diltiazem hcl coated beads cap sr 24hr ................. 29diltiazem hcl extended release beads cap sr ......... 29diltiazem inj ............................................................ 29dilt-xr cap ................................................................ 29diphenhist ............................................................... 82diphenhydramine hcl ............................................. 82diphenhydramine hcl inj 50mg/ml ........................ 82diphenoxylate w/ atropine ..................................... 64DIPHTHERIA/TETANUS TOXOID........................... 71disopyramide phosphate ....................................... 26disulfiram ................................................................ 44divalproex sodium .................................................. 33docetaxel ................................................................. 18DOCETAXEL ............................................................ 18docu ........................................................................ 63docusate sodium .................................................... 63docusil ..................................................................... 63

99

Drug Name Page # Drug Name Page #dofetilide ................................................................. 27dok .......................................................................... 63donepezil hydrochloride ......................................... 35dorzolamide hcl ...................................................... 79dorzolamide hcl-timolol maleate ........................... 79DOVATO ................................................................. 12doxazosin mesylate ................................................ 25doxepin hcl.............................................................. 36doxepin hcl (sleep) .................................................. 41doxorubicin hcl ....................................................... 17doxorubicin hcl liposomal ...................................... 17doxy 100 .................................................................. 17doxycycline hyclate ................................................. 17doxycycline (monohydrate) .................................... 17DRIZALMA SPRINKLE ............................................ 36dronabinol .............................................................. 61drospirenone-ethinyl estradiol ............................... 51drospirenone-ethinyl estradiol-levomefolate

calcium ................................................................ 51DROXIA ................................................................... 68ducodyl .................................................................... 63duloxetine hcl ......................................................... 36DUREZOL ................................................................ 78dutasteride .............................................................. 65dutasteride-tamsulosin hcl ..................................... 66

E

ec-naproxen .............................................................. 4econtra ez ............................................................... 51ecpirin ....................................................................... 2ed-apap ..................................................................... 2ed chlorped jr.......................................................... 82EDURANT ............................................................... 11efavirenz.................................................................. 11efavirenz-lamivudine-tenofovir disoproxil

fumarate ............................................................. 12eletriptan hydrobromide ........................................ 42ELIQUIS ................................................................... 67ELIQUIS STARTER PACK ........................................ 67ELLA ........................................................................ 51eluryng .................................................................... 51EMCYT .................................................................... 17EMEND ................................................................... 61EMGALITY ............................................................... 42emoquette ............................................................... 51EMSAM ................................................................... 36emtricitabine ........................................................... 11

EMTRIVA ................................................................. 11EMVERM ................................................................... 9enalapril maleate ................................................... 25enalapril maleate & hydrochlorothiazide .............. 25ENBREL ................................................................... 69ENBREL MINI.......................................................... 69ENBREL SURECLICK ............................................... 69ENDARI ................................................................... 68endocet 2.5-325mg ................................................... 6endocet 5-325mg ...................................................... 6endocet 7.5-325mg ................................................... 6endocet 10-325mg .................................................... 6ENEMEEZ MINI....................................................... 63ENEMEEZ PLUS ...................................................... 63ENGERIX-B .............................................................. 71ENLYTE ................................................................... 76enoxaparin sodium ................................................ 67enpresse-28 ............................................................. 51enskyce .................................................................... 51ENSTILAR ................................................................ 88entacapone ............................................................. 37entecavir ................................................................. 14ENTRESTO .............................................................. 26enulose .................................................................... 63EPCLUSA ................................................................. 14EPIDIOLEX .............................................................. 33epinephrine (anaphylaxis) ...................................... 84epirubicin hcl .......................................................... 17epitol ....................................................................... 33EPIVIR HBV ............................................................. 14eplerenone .............................................................. 25eql naproxen sodium ............................................... 4eq naproxen sodium ................................................ 4ergocalciferol .......................................................... 76ergotamine w/ caffeine ........................................... 42ERIVEDGE ............................................................... 18ERLEADA ................................................................. 20erlotinib hcl ............................................................. 22errin ......................................................................... 51ertapenem sodium ................................................... 9ery pad 2% .............................................................. 86ery-tab ..................................................................... 15ERYTHROCIN LACTOBIONATE ............................. 15erythrocin stearate ................................................. 15erythromycin (acne aid) ......................................... 86erythromycin base .................................................. 15erythromycin cap 250mg ec ................................... 15

100

Drug Name Page # Drug Name Page #erythromycin ethylsuccinate .................................. 15erythromycin (ophth) .............................................. 77erythromycin tab ec ................................................ 15ESBRIET .................................................................. 84ESCAVITE ................................................................ 76escitalopram oxalate .............................................. 36esomeprazole magnesium ..................................... 65estarylla tab 0.25-35 ............................................... 51estradiol .................................................................. 55estradiol vaginal cream .......................................... 55estradiol vaginal tab ............................................... 55estradiol valerate .................................................... 55eszopiclone ............................................................. 41ethambutol hcl ....................................................... 13ethosuximide .......................................................... 33ethynodiol diacet & eth estrad ............................... 51ethynodiol tab 1-50 ................................................ 51etodolac .................................................................... 4etodolac er ................................................................ 4etonogestrel-ethinyl estradiol ................................. 51etoposide ................................................................ 24euthyrox .................................................................. 58everolimus............................................................... 22everolimus (immunosuppressant) ......................... 71EVOTAZ ................................................................... 12exemestane ............................................................. 20eye itch relief ........................................................... 79ezetimibe ................................................................. 27ezetimibe-simvastatin ............................................. 27

F

FABRAZYME ........................................................... 55falmina .................................................................... 51famciclovir .............................................................. 14famotidine......................................................... 61, 62famotidine inj ......................................................... 62famotidine in nacl................................................... 62FANAPT ................................................................... 38FANAPT TITRATION PACK ..................................... 38FARXIGA .................................................................. 47FARYDAK ................................................................ 19FASENRA................................................................. 84FASENRA PEN ........................................................ 84fayosim .................................................................... 51felbamate ................................................................ 33felodipine ................................................................ 29femynor ................................................................... 51

fenofibrate .............................................................. 27fenofibrate micronized ........................................... 27fentanyl citrate .......................................................... 6fentanyl patch 12 mcg/hr ......................................... 6fentanyl patch 25 mcg/hr ......................................... 6fentanyl patch 50 mcg/hr ......................................... 6fentanyl patch 75 mcg/hr ......................................... 6fentanyl patch 100 mcg/hr ....................................... 6FERROUS GLUCONATE ......................................... 68ferrous sulfate ......................................................... 68FERROUS SULFATE ................................................ 68FETZIMA ................................................................. 36FETZIMA TITRATION PACK ................................... 36feverall adults ........................................................... 2feverall childrens ...................................................... 2FEVERALL INFANTS ................................................. 2feverall junior strength ............................................. 2fexofenadine hcl ..................................................... 82FIASP ....................................................................... 46FIASP FLEXTOUCH ................................................. 46FIASP PENFILL ........................................................ 46finasteride ............................................................... 66FINTEPLA ................................................................ 33flac ........................................................................... 91flanax pain relief ....................................................... 4FLAREX .................................................................... 78FLEBOGAMMA DIF ................................................ 70flecainide acetate .................................................... 27FLEET ENEMA ......................................................... 63FLEET PEDIATRIC ................................................... 63FLONASE ALLERGY RELIEF ................................... 85FLONASE ALLERGY RELIEF CH ............................. 85FLONASE SENSIMIST ............................................. 85FLOVENT DISKUS ................................................... 85FLOVENT HFA ........................................................ 85fluconazole .............................................................. 10fluconazole inj nacl 200 ......................................... 10fluconazole inj nacl 400 ......................................... 10flucytosine ............................................................... 10fludrocortisone acetate .......................................... 55flunisolide (nasal) ................................................... 85fluocinolone acetonide ........................................... 88fluocinolone acetonide oil body ............................. 88fluocinolone acetonide (otic) .................................. 91fluocinonide ............................................................ 88fluocinonide emulsified base ................................. 88fluorometholone ..................................................... 78

101

Drug Name Page # Drug Name Page #fluorouracil ............................................................. 18fluorouracil (topical) crea 5% ................................. 89fluorouracil (topical) soln ....................................... 89fluoxetine cap 10mg ............................................... 36fluoxetine cap 20mg ............................................... 36fluoxetine cap 40mg ............................................... 36fluoxetine hcl .......................................................... 36fluphenazine decanoate ......................................... 38fluphenazine hcl ..................................................... 38flurbiprofen ............................................................... 4flurbiprofen sodium ............................................... 78flutamide ................................................................. 20fluticasone propionate ........................................... 88fluticasone propionate (nasal) ............................... 85fluvoxamine maleate .............................................. 32folic acid .................................................................. 76FOLTRATE ............................................................... 76fondaparinux sodium ............................................. 67FORTEO .................................................................. 57fosamprenavir tab 700 mg .................................... 11fosinopril sodium .................................................... 25fosinopril sodium & hydrochlorothiazide .............. 25FREAMINE HBC 6.9%............................................. 73FREAMINE III .......................................................... 74fulvestrant ............................................................... 20fungoid-d ................................................................. 87FUNGOID TINCTURE ............................................. 87furosemide .............................................................. 30furosemide inj ......................................................... 30FUZEON .................................................................. 11fyavolv ..................................................................... 55FYCOMPA ............................................................... 33

G

gabapentin .............................................................. 33galantamine hydrobromide ................................... 35galantamine hydrobromide er ............................... 35GAMASTAN ............................................................ 70GAMMAGARD LIQUID ........................................... 70GAMMAGARD S/D ................................................. 70GAMMAKED ........................................................... 70GAMMAPLEX .......................................................... 70GAMMAPLEX 10GM/100ML ................................. 70GAMUNEX-C ........................................................... 70ganciclovir sodium.................................................. 14GARDASIL 9 ............................................................ 71gatifloxacin (ophth) ................................................ 77

GATTEX ................................................................... 64GAUZE PADS 2 ....................................................... 46gavilyte-c ................................................................. 63gavilyte-g ................................................................. 63gavilyte-n/flavor pack ............................................. 63GAVISCON .............................................................. 59GAVISCON EXTRA STRENGTH .............................. 59GAVISCON EXTRA STRENGTH R ........................... 59gemcitabine inj soln................................................ 18gemcitabine inj solr ................................................ 18gemfibrozil .............................................................. 27generlac................................................................... 63gengraf .................................................................... 71GENOTROPIN ........................................................ 57GENOTROPIN MINIQUICK .................................... 57gentak ..................................................................... 77gentamicin in saline.................................................. 8gentamicin sulfate .................................................... 8gentamicin sulfate soln (ophth) ............................. 78gentamicin sulfate (topical) .................................... 86GENTEAL SEVERE................................................... 80genteal tears mild ................................................... 80GENVOYA ............................................................... 12GEODON ................................................................ 39gianvi ....................................................................... 51GILENYA CAP 0.5MG ............................................. 43GILOTRIF TAB 20MG ............................................. 22GILOTRIF TAB 30MG ............................................. 22GILOTRIF TAB 40MG ............................................. 22glatiramer acetate 20mg/ml .................................. 43glatiramer acetate 40mg/ml .................................. 43glatopa .................................................................... 43GLEOSTINE ............................................................. 17glimepiride .............................................................. 47glipizide ................................................................... 47glipizide xl ............................................................... 47glip/metform tab 2.5-250mg .................................. 47glip/metform tab 2.5-500mg .................................. 47glip/metform tab 5-500mg ..................................... 47GLUCAGEN HYPOKIT ............................................ 56GLUCAGON EMERGENCY KIT .............................. 56glyburide ................................................................. 47glyburide-metformin tab 1.25-250 mg .................. 47glyburide-metformin tab 2.5-500 mg .................... 47glyburide-metformin tab 5-500mg ........................ 47glyburide micronized .............................................. 47glycopyrrolate tab 1mg .......................................... 61

102

Drug Name Page # Drug Name Page #glycopyrrolate tab 2mg .......................................... 61glydo ........................................................................ 89GLYXAMBI .............................................................. 47gnp 8 hour pain reliever ........................................... 2gnp acid control 150 maxi ..................................... 62gnp acid reducer ..................................................... 62gnp acid reducer maximum ................................... 62gnp adult aspirin low str .......................................... 2gnp all day allergy .................................................. 82gnp all day allergy child ......................................... 82gnp all day pain relief ............................................... 4gnp allergy .............................................................. 82gnp allergy relief ..................................................... 82gnp antacid anti-gas ............................................... 59gnp antacid extra strengt ....................................... 59gnp anti-diarrheal .................................................. 60gnp arthritis pain relief ............................................ 2gnp artificial tears .................................................. 80gnp aspirin ................................................................ 2gnp aspirin low dose ................................................ 2gnp athletes foot ..................................................... 87gnp childrens allergy .............................................. 82gnp childrens ibuprofen ........................................... 4gnp clotrimazole 3 .................................................. 66gnp dayhist allergy ................................................. 82gnp enema .............................................................. 63gnp heartburn relief ............................................... 62gnp hydrocortisone ................................................ 88gnp hydrocortisone/aloe ........................................ 88gnp hydrocortisone maximu .................................. 88gnp hydrocortisone plus ......................................... 88gnp ibuprofen ........................................................... 4gnp ibuprofen infants ............................................... 4gnp ibuprofen junior stre ......................................... 4gnp infants pain/fever .............................................. 2gnp lansoprazole .................................................... 65gnp laxative ............................................................. 63gnp lice treatment .................................................. 90gnp loperamide hcl ................................................. 60gnp loratadine ........................................................ 82gnp loratadine childrens ........................................ 82gnp lubricant pm .................................................... 80gnp lubricating plus eye ......................................... 80gnp miconazole 3 ................................................... 66gnp miconazole 7 ................................................... 66gnp naproxen sodium .............................................. 5gnp nicotine gum .................................................... 44

gnp nicotine mini lozenge ...................................... 44gnp nicotine polacrilex ........................................... 44gnp nicotine polacrilex m ....................................... 44GNP OMEPRAZOLE ............................................... 65gnp pain & fever children ......................................... 2gnp pain relief ........................................................... 2gnp pain relief extra str ............................................ 2gnp pink bismuth .................................................... 60gnp stool softener ................................................... 63gnp tioconazole 1 ................................................... 66gnp tolnaftate ......................................................... 87GOLYTELY ............................................................... 63GONAK ................................................................... 80goodsense all day allergy ....................................... 82goodsense arthritis pain ........................................... 2goodsense aspirin ..................................................... 2goodsense ibuprofen ................................................ 5goodsense ibuprofen child ....................................... 5goodsense ibuprofen infan ...................................... 5goodsense ibuprofen junio ....................................... 5goodsense lansoprazole ......................................... 65goodsense lubricating plu ...................................... 80goodsense naproxen sodium ................................... 5goodsense nicotine gum ......................................... 44goodsense nicotine polacr ...................................... 44goodsense pain & fever ch ....................................... 2goodsense pain & fever in ........................................ 2goodsense pain relief................................................ 2goodsense pain relief ext .......................................... 2granisetron hcl ........................................................ 61griseofulvin microsize ............................................. 10griseofulvin ultramicrosize ..................................... 10guanfacine er (adhd) .............................................. 41GVOKE HYPOPEN 2-PACK .................................... 56GVOKE PFS ............................................................. 56

H

HAEGARDA ............................................................. 68hailey 24 fe .............................................................. 51halobetasol propionate .......................................... 88haloperidol ............................................................. 39haloperidol conc 2mg/ml ....................................... 39haloperidol decanoate ........................................... 39haloperidol lactate inj 5mg/ml............................... 39HARVONI ................................................................ 14HAVRIX .................................................................... 71heartburn relief ...................................................... 62

103

Drug Name Page # Drug Name Page #heartburn relief 150 maxi ...................................... 62heartburn relief maximum ..................................... 62heartburn treatment 24 ho .................................... 65heather .................................................................... 51heparin sod inj 1000/ml ......................................... 67heparin sod inj 5000/ml ......................................... 67heparin sod inj 10000/ml ....................................... 67heparin sod inj 20000/ml ....................................... 67HEPARIN SODIUM/NACL 0.45%........................... 67heparin sod (porcine) in d5w ................................. 67hepatamine ............................................................. 74HERCEPTIN ............................................................. 19HERCEPTIN HYLECTA ............................................ 19HERZUMA ............................................................... 19HETLIOZ.................................................................. 41HIBERIX ................................................................... 71HISTAFLEX ................................................................ 2HISTEX .................................................................... 82HISTEX PD .............................................................. 82hm acid reducer ..................................................... 62hm advanced antacid maxim ................................ 59hm all day allergy ................................................... 82hm allergy ............................................................... 82hm allergy relief ...................................................... 82hm antacid .............................................................. 59hm antacid/antigas ................................................ 59hm antacid anti-gas extra ...................................... 59hm anti-diarrheal ................................................... 60hm arthritis pain relief ............................................. 2hm aspirin ................................................................. 2hm aspirin ec ............................................................ 2hm aspirin ec low dose ............................................. 2hm calcium antacid extra ...................................... 59hm calcium antacid smooth .................................. 59hm calcium antacid ultra ....................................... 59hm cetirizine hcl childre ......................................... 82hm enema ready-to-use ......................................... 63hm enema saline laxative ...................................... 63hm eye itch relief .................................................... 79hm famotidine ........................................................ 62hm fexofenadine hydrochlo ................................... 82hm hydrocortisone/aloe ma................................... 88hm hydrocortisone plus ......................................... 88hm ibuprofen ............................................................ 5hm ibuprofen childrens ............................................ 5hm ibuprofen ib ........................................................ 5hm ibuprofen infants ............................................... 5

hm lansoprazole ..................................................... 65hm laxative ............................................................. 63hm lice killing maximum s ...................................... 90hm lice treatment ................................................... 90hm loperamide hcl ................................................. 60hm loratadine childrens ......................................... 82hm lubricating plus ................................................ 80hm naproxen sodium ............................................... 5hm nicotine polacrilex ............................................ 44hm nicotine transdermal s ..................................... 44HM OMEPRAZOLE ................................................. 65hm pain & fever childrens ........................................ 3hm pain & fever infants ............................................ 3hm pain relief extra stre ........................................... 3hm pain reliever ........................................................ 3hm povidone-iodine ............................................... 89hm stomach relief ................................................... 60hm stomach relief maximum ................................. 60hm stool softener .................................................... 63hm stool softener maximum .................................. 63hm triple antibiotic ................................................. 86HUMIRA .................................................................. 69HUMIRA INJ 10MG/0.2ML ..................................... 69HUMIRA KIT 20MG/0.4ML .................................... 69HUMIRA KIT 40MG/0.8ML .................................... 69HUMIRA PEDIATRIC CROHNS DISEASE ............... 69HUMIRA PEN .......................................................... 69HUMIRA PEN CD/UC/HS STARTER ....................... 69HUMIRA PEN INJ CD/UC/HS STARTER ................. 69HUMIRA PEN INJ PS/UV STARTER ........................ 69HUMIRA PEN-PS/UV STARTER.............................. 69HUMULIN R INJ U-500 ........................................... 46HUMULIN R U-500 KWIKPEN ............................... 46hydralazine hcl ....................................................... 30hydrochlorothiazide ............................................... 30hydroco/apap tab 5-325mg ..................................... 7hydroco/apap tab 7.5-325 ....................................... 7hydroco/apap tab 10-325mg ................................... 7hydrocodone-acetaminophen 7.5-325 mg/15ml .... 7hydrocodone-ibuprofen tab 7.5-200 mg ................. 7hydrocortisone ........................................................ 55hydrocortisone-aloe vera ....................................... 89hydrocortisone butyrate cream 0.1% .................... 89hydrocortisone butyrate oint 0.1% ........................ 89hydrocortisone (enema) ......................................... 62hydrocortisone maximum st .................................. 89hydrocortisone (topical) ......................................... 88

104

Drug Name Page # Drug Name Page #hydrocortisone (topical) cream 1% ........................ 88hydrocortisone (topical) cream 2.5% ..................... 88hydrocortisone (topical) lotion 2.5% ...................... 88hydrocortisone (topical) oint 2.5% ......................... 89hydromorphone hcl .................................................. 7hydroxocobalamin acetate .................................... 76hydroxychloroquine sulfate ................................... 69hydroxyurea ............................................................ 23hydroxyzine hcl ....................................................... 82hydroxyzine hcl inj .................................................. 83hydroxyzine pamoate ............................................. 83HYSINGLA ER ........................................................... 7

I

ibandronate sodium tabs ....................................... 49IBRANCE ................................................................. 19ibu-200 ...................................................................... 5ibuprofen .................................................................. 5ibuprofen childrens .................................................. 5ibuprofen infants ...................................................... 5ibuprofen junior strength ......................................... 5ibu tab 600mg .......................................................... 5ibu tab 800mg .......................................................... 5icatibant acetate ..................................................... 68ICLUSIG ................................................................... 22IDHIFA ..................................................................... 19ILEVRO .................................................................... 78imatinib mesylate ................................................... 22IMBRUVICA ............................................................. 22imipenem-cilastatin .................................................. 9imipramine hcl........................................................ 36imiquimod............................................................... 89IMOVAX RABIES (H.D.C.V.) .................................... 71incassia ................................................................... 51INCRELEX ................................................................ 57INCRUSE ELLIPTA .................................................. 81indapamide ............................................................. 30INFANRIX ................................................................ 71infants ibuprofen ...................................................... 5INFUVITE ADULT .................................................... 76INFUVITE PEDIATRIC ............................................. 76INGREZZA ............................................................... 43INLYTA .................................................................... 22INQOVI.................................................................... 23INREBIC .................................................................. 22INSULIN PEN NEEDLE ........................................... 46INSULIN SAFETY NEEDLES .................................... 46

INSULIN SYRINGE .................................................. 46INTELENCE ............................................................. 11INTRALIPID 30% .................................................... 74INTRALIPID INJ 20% ............................................... 74INTRON-A INJ 10MU .............................................. 70INTRON-A INJ 18MU .............................................. 70INTRON-A INJ 25MU .............................................. 70INTRON-A INJ 50MU .............................................. 70introvale .................................................................. 51INVEGA SUST INJ 39 MG/0.25 ML ........................ 39INVEGA SUST INJ 78 MG/0.5 ML .......................... 39INVEGA SUST INJ 117 MG/0.75 ML ...................... 39INVEGA SUST INJ 156MG/ML ............................... 39INVEGA SUST INJ 234 MG/1.5 ML ........................ 39INVEGA TRINZA ..................................................... 39INVIRASE................................................................. 11IPOL INACTIVATED IPV .......................................... 71ipratropium-albuterol nebu ................................... 81ipratropium bromide ............................................. 81ipratropium bromide (nasal) ................................. 81irbesartan ............................................................... 26irbesartan-hydrochlorothiazide ............................. 26IRESSA ..................................................................... 22irinotecan hcl .......................................................... 24ISENTRESS .............................................................. 11ISENTRESS HD ....................................................... 11isibloom .................................................................. 51ISOLYTE P ............................................................... 74ISOLYTE S ............................................................... 74isoniazid .................................................................. 13isoniazid syp 50mg/5ml ......................................... 13ISOPTO TEARS ....................................................... 80isosorbide dinitrate ................................................ 31isosorbide mononitrate er...................................... 31isosorb mononitrate tab ........................................ 31isotretinoin .............................................................. 86isradipine ................................................................ 29itraconazole ............................................................ 10ivermectin ................................................................. 9IXIARO ..................................................................... 72

J

JADENU ................................................................... 49JADENU SPRINKLE ................................................. 49JAKAFI ..................................................................... 22jantoven .................................................................. 67JANUMET ................................................................ 47

105

Drug Name Page # Drug Name Page #JANUMET XR TAB 50-500MG ................................ 47JANUMET XR TAB 50-1000 .................................... 48JANUMET XR TAB 100-1000 ................................. 48JANUVIA .................................................................. 48JARDIANCE ............................................................. 48jasmiel ..................................................................... 51JENTADUETO .......................................................... 48JENTADUETO TAB XR 2.5-1000 MG ..................... 48JENTADUETO TAB XR 5-1000 MG ........................ 48jinteli ....................................................................... 55jolessa tab 0.15-0.03 mg ........................................ 51jolivette .................................................................... 51juleber ..................................................................... 51JULUCA ................................................................... 12junel 1.5/30 ............................................................. 51junel 1/20 ................................................................ 51junel fe 1.5/30 ......................................................... 51junel fe 1/20 ............................................................ 51junel fe 24 ............................................................... 51JUXTAPID ................................................................ 27

K

KADCYLA ................................................................ 19kaitlib fe .................................................................. 51KALETRA TAB 100-25MG ...................................... 13KALETRA TAB 200-50MG ...................................... 13KALYDECO .............................................................. 84KANJINTI ................................................................. 19kao-tin ............................................................... 60, 63kariva ...................................................................... 52KCL 0.3%/D5W/NACL 0.9%................................... 74kcl 0.3%/d5w/nacl 0.45% ....................................... 74kcl0.15%/d5w/nacl0.2% ......................................... 74kcl 0.15%/d5w/nacl 0.9% ....................................... 75KCL 0.15%/D5W/NACL 0.225% ............................ 75kcl 0.075%/d5w/nacl 0.45% ................................... 75kcl/d5w/nacl inj 0.22%/0.45% ................................ 75kcl/d5w/nacl inj .15/.45% ....................................... 75kcl/nacl inj 0.3-0.9 .................................................. 75kcl/nacl inj 0.15%-0.9% .......................................... 75kelnor 1/35 .............................................................. 52kelnor 1/50 .............................................................. 52ketoconazole ........................................................... 10ketoconazole cream ............................................... 87ketoconazole shampoo .......................................... 88ketorolac tromethamine (ophth)............................ 78ketotifen fumarate (ophth) ..................................... 79

KEYTRUDA .............................................................. 19KINRIX ..................................................................... 72kionex sus 15gm/60ml ........................................... 49KISQALI ................................................................... 19KISQALI FEMARA 200 DOSE ................................. 19KISQALI FEMARA 400 DOSE ................................. 19KISQALI FEMARA 600 DOSE ................................. 19klor-con 8 ................................................................ 72klor-con 10 .............................................................. 72klor-con m10 ........................................................... 72klor-con m15 ........................................................... 72klor-con m20 ........................................................... 72klor-con pak 20meq ............................................... 72klor-con spr cap 8meq ........................................... 73klor-con spr cap 10meq ......................................... 73kls naproxen sodium ................................................ 5KORLYM.................................................................. 57kurvelo .................................................................... 52KUVAN .................................................................... 55

L

labetalol hcl ............................................................ 28lactated ringer’s ...................................................... 75lactic acid (ammonium lactate) ............................. 90lactulose .................................................................. 63lactulose (encephalopathy) .................................... 63lamivudine .............................................................. 11lamivudine (hbv) ..................................................... 14lamivudine-zidovudine ........................................... 13lamotrigine .............................................................. 33lansoprazole ........................................................... 65larin 1.5/30 ............................................................. 52larin 1/20 ................................................................ 52larin fe 1.5/30 ......................................................... 52larin fe 1/20 ............................................................ 52larissia tab .............................................................. 52LASTACAFT ............................................................. 79latanoprost ............................................................. 79LATUDA .................................................................. 39laxative .................................................................... 63layolis fe .................................................................. 52leena ........................................................................ 52leflunomide ............................................................. 69LENVIMA 4 MG DAILY DOSE ................................ 22LENVIMA 8 MG DAILY DOSE ................................ 22LENVIMA 10 MG DAILY DOSE .............................. 22LENVIMA 12MG DAILY DOSE ............................... 22

106

Drug Name Page # Drug Name Page #LENVIMA 14 MG DAILY DOSE .............................. 22LENVIMA 18 MG DAILY DOSE .............................. 22LENVIMA 20 MG DAILY DOSE .............................. 22LENVIMA 24 MG DAILY DOSE .............................. 22lessina ..................................................................... 52letrozole .................................................................. 20leucovorin calcium ................................................. 24LEUKERAN .............................................................. 17leuprolide inj 1mg/0.2 ............................................ 20levalbuterol hcl ....................................................... 83levalbuterol hcl soln nebu conc 1.25 mg/0.5ml .... 84levalbuterol tartrate hfa ......................................... 84LEVEMIR ................................................................. 46LEVEMIR FLEXTOUCH ........................................... 46levetiracetam .......................................................... 33levetiracetam in sodium chloride .......................... 33levetiracetam oral soln 100 mg/ml ........................ 33levobunolol hcl ....................................................... 79levocarnitine (metabolic modifiers) ....................... 55levocetirizine dihydrochloride ................................ 83levofloxacin ............................................................. 15levofloxacin in d5w ................................................. 15levofloxacin inj 25mg/ml ........................................ 15levofloxacin oral soln 25 mg/ml ............................. 16levonest ................................................................... 52levonor/ethi tab ...................................................... 52levonorgestrel & eth estradiol ................................ 52levonorgestrel-ethinyl estradiol (91-day) ............... 52levora 0.15/30-28 ................................................... 52levo-t ....................................................................... 58levothyroxine sodium ............................................. 58levoxyl ..................................................................... 58LEXIVA ..................................................................... 11lice killing maximum stre ....................................... 90lidocaine .................................................................. 89lidocaine hcl ............................................................ 89lidocaine hcl (local anesth.) ...................................... 8lidocaine hcl (mouth-throat) .................................. 91lidocaine inj 0.5% ..................................................... 8lidocaine inj 1% ........................................................ 8lidocaine inj 1.5% preservative free (pf) ................... 8lidocaine oint 5% .................................................... 89lidocaine-prilocaine ................................................ 89linezolid inj ................................................................ 9linezolid in sodium chloride ..................................... 9linezolid susp ............................................................ 9linezolid tab 600mg .................................................. 9

LINZESS .................................................................. 64liothyronine sodium ............................................... 58liquitears ................................................................. 80lisinopril .................................................................. 25lisinopril & hydrochlorothiazide ............................ 25lithium carbonate ................................................... 43lithium carbonate er ............................................... 43LITHIUM SOLN 8MEQ/5ML .................................. 43LOKELMA ................................................................ 49LONSURF ................................................................ 23loperamide hcl .................................................. 60, 64lopinavir-ritonavir .................................................. 13loratadine ............................................................... 83loratadine childrens ............................................... 83lorazepam ............................................................... 32lorazepam intensol ................................................. 32LORBRENA ............................................................. 22loryna ...................................................................... 52losartan-hydrochlorothiazide ................................ 26losartan potassium................................................. 26LOTEMAX ................................................................ 78loteprednol etabonate ............................................ 78lovastatin ................................................................ 27low-ogestrel ............................................................. 52loxapine succinate .................................................. 39lubricating plus eye drop ........................................ 80LUMIGAN ............................................................... 79LUMIZYME .............................................................. 55LUPRON DEPOT (1-MONTH) ................................ 20LUPRON DEPOT INJ 11.25MG (3-MONTH) ......... 20LUPRON DEPOT-PED (1-MONTH ......................... 57LUPRON DEPOT-PED (3-MONTH ......................... 57LUPRON DEP-PED INJ 7.5MG ............................... 57LUPRON DEP-PED INJ 11.25MG (3-MONTH) ...... 57lutera ....................................................................... 52LYNPARZA .............................................................. 19LYRICA CR ............................................................... 43LYSODREN.............................................................. 20lyza .......................................................................... 52

M

MAG-AL .................................................................. 59mag-al plus ............................................................. 59mag-al plus xs ......................................................... 59magnesium oxide ................................................... 59magnesium sulfate ................................................. 73MAGNESIUM SULFATE .......................................... 73

107

Drug Name Page # Drug Name Page #MAGNESIUM SULFATE IN D5W ........................... 73magnesium sulfate in dextrose .............................. 73magnesium sulfate inj 50% .................................... 73malathion ............................................................... 90manganese chloride ............................................... 75mapap ....................................................................... 3mapap acetaminophen extra .................................. 3mapap arthritis pain ................................................ 3mapap childrens ....................................................... 3maprotiline hcl ....................................................... 36marlissa .................................................................. 52MARPLAN TAB 10MG ............................................ 36MATULANE ............................................................. 23MAVYRET ................................................................ 14meclizine hcl ........................................................... 61mediproxen ............................................................... 5medroxyprogesterone acetate (contraceptive) ...... 52medroxyprogesterone acetate tab ......................... 57mefloquine hcl ........................................................ 10megestrol ac sus 40mg/ml ..................................... 20megestrol ac tab 20mg ........................................... 20megestrol ac tab 40mg ........................................... 20megestrol sus 625mg/5ml ...................................... 20MEKINIST ................................................................ 22MEKTOVI ................................................................ 22melatonin ................................................................ 76melodetta 24 fe ....................................................... 52meloxicam ................................................................ 5memantine hcl cp24 ............................................... 35memantine soln ...................................................... 35memantine tabs ...................................................... 35memantine titration pak ........................................ 35MENACTRA ............................................................. 72MENVEO ................................................................. 72MEPHYTON ............................................................ 76mercaptopurine ...................................................... 18meropenem .............................................................. 9mesalamine ............................................................ 62mesalamine w/ cleanser ......................................... 62MESNEX .................................................................. 24metadate er tab 20mg ............................................ 41metformin er ........................................................... 48metformin hcl ......................................................... 48methadone hcl .......................................................... 7methadone hcl 5mg .................................................. 7methadone hcl 10mg................................................ 7methadone hcl intensol ............................................ 7

methazolamide ....................................................... 30methenamine hippurate .......................................... 9methimazole ........................................................... 58methocarbamol ...................................................... 43methotrexate sodium inj soln ................................ 18methotrexate sodium inj solr ................................. 18methotrexate sodium tabs ..................................... 69methylphenidate hcl ............................................... 41methylphenidate hcl oral soln ............................... 41methylphenidate hcl tbcr 10 mg ............................ 41methylphenidate hcl tbcr 20mg ............................. 41methylprednisolone acetate ................................... 56methylpred pak 4mg .............................................. 56methylpred tab 4mg ............................................... 56methylpred tab 8mg ............................................... 56methylpred tab 16mg ............................................. 56methylpred tab 32mg ............................................. 56methylpr ss inj ........................................................ 55metoclopramide hcl ............................................... 61metoclopramide hcl inj .......................................... 61metolazone ............................................................. 30metoprolol & hctz tab 50-25mg ............................. 28metoprolol & hctz tab 100-25mg ........................... 28metoprolol & hctz tab 100-50mg ........................... 28metoprolol succinate .............................................. 28metoprolol tartrate ................................................. 28metronidazole ........................................................... 9metronidazole gel 0.75% ........................................ 90metronidazole in nacl ............................................... 9metronidazole (topical) .......................................... 90metronidazole vaginal ............................................ 66metyrosine .............................................................. 30m-hist pd ................................................................. 83mi-acid .................................................................... 59mi-acid maximum strength .................................... 59mibelas 24 fe .......................................................... 52micafungin sodium ................................................. 10miconazole 3 combo pack ..................................... 66miconazole 7 ........................................................... 66miconazole nitrate (topical) ................................... 87miconazole nitrate vaginal ..................................... 66microgestin 1.5/30 .................................................. 52microgestin 1/20 ..................................................... 52microgestin fe 1.5/30 .............................................. 52microgestin fe 1/20 ................................................. 52midodrine hcl .......................................................... 30miglustat ................................................................. 55

108

Drug Name Page # Drug Name Page #mili .......................................................................... 52minitran .................................................................. 31minocycline hcl ....................................................... 17minoxidil ................................................................. 30mintox ..................................................................... 59mintox maximum strength ..................................... 59mirtazapine ............................................................. 36misoprostol ............................................................. 64MITIGARE ................................................................. 1M-M-R II .................................................................. 72M-NATAL PLUS ...................................................... 76moexipril hcl ........................................................... 25molindone hcl ......................................................... 39mometasone furoate .............................................. 89mondoxyne nl cap 100mg ...................................... 17mono-linyah tab 0.25-35 ........................................ 52montelukast sodium ............................................... 84morphine ext-rel tab ................................................. 7morphine sulfate ...................................................... 7MORPHINE SULFATE ............................................... 7morphine sulfate oral soln 10mg/5ml ..................... 7morphine sulfate oral soln 20mg/5ml ..................... 7morphine sulfate oral soln 100mg/5ml ................... 7morphine sul inj 1mg/ml .......................................... 7MOVANTIK ............................................................. 64MOXEZA ................................................................. 78moxifloxacin hcl ...................................................... 16moxifloxacin hcl (ophth) ......................................... 78MULTAQ ................................................................. 27multivitamin/fluoride ............................................. 76multivitamin with fluorid........................................ 76multi-vit/iron/fluoride ............................................. 76mupirocin ................................................................ 86MVASI ..................................................................... 19M.V.I. PEDIATRIC .................................................... 76MYCAMINE ............................................................. 10mycophenolate mofetil ........................................... 71mycophenolate sodium tbec .................................. 71myorisan ................................................................. 86MYRBETRIQ ............................................................ 66

N

nabumetone ............................................................. 5nadolol .................................................................... 28nafcillin sodium ...................................................... 16NAFCILLIN SODIUM FOR INJ 10GM ..................... 16NAGLAZYME........................................................... 55

nalbuphine hcl .......................................................... 6naloxone inj 0.4mg/ml ........................................... 44naloxone inj 1mg/ml .............................................. 45naltrexone hcl ......................................................... 45NAMZARIC .............................................................. 35naproxen ................................................................... 5naproxen dr .............................................................. 5naproxen sodium ..................................................... 5naratriptan hcl........................................................ 42NARCAN ................................................................. 45NASCOBAL ............................................................. 76NATACYN ................................................................ 78nateglinide .............................................................. 48NATPARA ................................................................ 57natural balance tears ............................................. 80natural fiber therapy .............................................. 64natures tears ........................................................... 80NAYZILAM .............................................................. 34necon 0.5/35-28 ...................................................... 52nefazodone hcl ....................................................... 36neomycin-bacitracin zn-polymyxin ........................ 78neomycin-polymy-dexameth .................................. 77neomycin-polymyxin-gramicidin ............................ 78neomycin-polymyxin-hc (ophth)............................. 77neomycin-polymyxin-hc (otic) ................................ 91neomycin sulfate ...................................................... 8NEPHPLEX RX ......................................................... 76NEPHRAMINE......................................................... 74NERLYNX ................................................................ 22NEUPRO ................................................................. 37nevirapine susp 50 mg/5ml .................................... 11nevirapine tab 100mg er ........................................ 11nevirapine tab 200mg ............................................ 11nevirapine tab 400mg er ........................................ 11NEXAVAR ................................................................ 22niacin ...................................................................... 76niacin (antihyperlipidemic) .................................... 28niacin er (antihyperlipidemic) ................................ 28niacor ...................................................................... 28nicardipine hcl ........................................................ 29NICODERM CQ ....................................................... 45nicorelief ................................................................. 45NICORETTE ............................................................. 45NICORETTE MINI ................................................... 45NICORETTE STARTER KIT ...................................... 45nicotine ................................................................... 45nicotine polacrilex .................................................. 45

109

Drug Name Page # Drug Name Page #nicotine transdermal syst ....................................... 45NICOTINE TRANSDERMAL SYST .......................... 45NICOTROL INHALER .............................................. 45NICOTROL NS ........................................................ 45nifedipine ................................................................ 29nifedipine er ............................................................ 29nikki ......................................................................... 53nilutamide ............................................................... 20nimodipine .............................................................. 29NINLARO ................................................................ 19nitisinone ................................................................ 55NITRO-BID .............................................................. 31NITRO-DUR DIS 0.3MG/HR ................................... 31NITRO-DUR DIS 0.8MG/HR ................................... 31nitrofurantoin macrocrystal ..................................... 9nitrofurantoin monohyd macro ............................... 9nitroglycerin ............................................................ 31nitroglycerin td patch ............................................. 31NITYR ...................................................................... 55nizatidine ................................................................ 62non-aspirin childrens ............................................... 3nora-be tab ............................................................. 53nore/eth/fer chw 0.4mg-35 .................................... 53noreth/ethin chw fe ................................................ 53norethin acet & estrad-fe ....................................... 53norethindrone acetate ............................................ 57norethindrone acetate-ethinyl estradiol ................ 55norethindrone acet & eth estra .............................. 53norethindrone (contraceptive) ............................... 53norgest/ethi tab 0.25/35 ......................................... 53norgestimate-ethinyl estradiol (triphasic) 0.18-

25/0.215-25/0.25-25 mg-mcg ............................ 53norgestimate-ethinyl estradiol (triphasic) 0.18-

35/0.215-35/0.25-35 mg-mcg ............................ 53NORMOSOL-M IN D5W ........................................ 75NORPACE CR .......................................................... 27NORTHERA ............................................................. 31nortrel 0.5/35 (28) .................................................. 53nortrel 1/35 ............................................................. 53nortrel 7/7/7 ........................................................... 53nortriptyline hcl ...................................................... 36NORVIR PACK ......................................................... 11NORVIR SOLN ........................................................ 11NOVOLIN 70/30 ..................................................... 46NOVOLIN 70/30 FLEXPEN..................................... 46NOVOLIN N ............................................................ 46NOVOLIN N FLEXPEN ............................................ 46

NOVOLIN R ............................................................ 46NOVOLIN R FLEXPEN ............................................ 46NOVOLOG .............................................................. 46NOVOLOG 70/30 FLEXPEN ................................... 46NOVOLOG FLEXPEN .............................................. 46NOVOLOG MIX 70/30 ........................................... 46NOVOLOG PENFILL ............................................... 46NOXAFIL ................................................................. 10NUBEQA ................................................................. 20NUCALA .................................................................. 84NUCYNTA ER ............................................................ 7NUEDEXTA ............................................................. 43NULOJIX .................................................................. 71NULYTELY/FLAVOR PACKS ................................... 64NU-MAG ................................................................. 75NUPLAZID CAPS .................................................... 39NUPLAZID TABS 10MG ......................................... 39NUTRILIPID INJ 20% .............................................. 74nyamyc .................................................................... 87NYMALIZE ............................................................... 29nystatin ................................................................... 10nystatin (mouth-throat) .......................................... 91nystatin pow 100000 .............................................. 87nystatin (topical) ..................................................... 87nystop...................................................................... 87

O

ocella tab 3-0.03mg ................................................ 53OCTAGAM .............................................................. 70octreotide acetate ................................................... 57ODEFSEY ................................................................. 13ODOMZO ............................................................... 19OFEV ....................................................................... 84ofloxacin (ophth) .................................................... 78ofloxacin (otic) ........................................................ 91OGIVRI .................................................................... 19olanzapine .............................................................. 39olmesartan medoxomil .......................................... 26olmesartan medoxomil-amlodipine-

hydrochlorothiazide ........................................... 26olmesartan medoxomil-hydrochlorothiazide ........ 26olopatadine hcl 0.2% .............................................. 79OMEPRAZOLE ........................................................ 65omeprazole cap 10mg ............................................ 65omeprazole cap 20mg ............................................ 65omeprazole cap 40mg ............................................ 65ondansetron hcl ...................................................... 61

110

Drug Name Page # Drug Name Page #ondansetron hcl inj................................................. 61ondansetron hcl oral soln ...................................... 61ondansetron odt ..................................................... 61ONTRUZANT .......................................................... 19opcicon one-step..................................................... 53OPSUMIT ................................................................ 31option 2 ................................................................... 53ORFADIN ................................................................ 55ORKAMBI ................................................................ 84orsythia ................................................................... 53oseltamivir phosphate ............................................ 14OSPHENA ............................................................... 57oxacillin sodium ...................................................... 16oxaliplatin inj 50mg ................................................ 24oxaliplatin inj 50mg/10ml ...................................... 24oxaliplatin inj 100mg .............................................. 24oxaliplatin inj 100mg/20ml .................................... 24oxandrolone ........................................................... 45oxcarbazepine ........................................................ 34oxybutynin chloride ................................................ 66oxycodone hcl ........................................................... 7oxycodone w/ acetaminophen 2.5-325mg .............. 7oxycodone w/ acetaminophen 5-325mg ................. 7oxycodone w/ acetaminophen 7.5-325mg .............. 7oxycodone w/ acetaminophen 10-325mg ............... 7OXYCONTIN ............................................................. 8oysco 500+d ............................................................ 75OZEMPIC INJ 0.25 OR 0.5MG/DOSE .................... 46OZEMPIC INJ 1MG/DOSE ...................................... 46

P

pacerone ................................................................. 27paclitaxel ................................................................. 18pain & fever ............................................................... 3pain & fever childrens............................................... 3pain & fever extra streng .......................................... 3pain & fever infants .................................................. 3pain relief extra strengt ............................................ 3paliperidone ............................................................ 39pamidronate disodium .......................................... 49PAMIDRONATE DISODIUM .................................. 49pamidronate inj 30mg ............................................ 49pamidronate inj 90mg ............................................ 49PANRETIN ............................................................... 90pantoprazole sodium ............................................. 65pantoprazole sodium tbec ..................................... 65PANZYGA ................................................................ 70

paricalcitol .............................................................. 76paroex sol 0.12% .................................................... 91paromomycin sulfate ............................................... 8paroxetine hcl tabs ................................................. 36PASER D/R .............................................................. 13PAXIL ....................................................................... 36PAZEO ..................................................................... 79PEDIARIX ................................................................ 72pediatric enema ...................................................... 64PEDIAVENT ............................................................. 83PEDVAX HIB ........................................................... 72peg 3350-kcl-sod bicarb-sod chloride-sod sulfate. 64peg 3350-potassium chloride-sod bicarbonate-

sod chloride ........................................................ 64PEGANONE ............................................................ 34PEGASYS ................................................................. 14PEGASYS PROCLICK .............................................. 14PEMAZYRE .............................................................. 22penicillamine .......................................................... 49PENICILLIN G POT IN DEXTROSE 2MU ................ 16PENICILLIN G POT IN DEXTROSE 3MU ................ 16PENICILLIN G PROCAINE ...................................... 16penicillin g sodium .................................................. 16penicillin v potassium ............................................. 16penicilln gk inj 5mu ................................................ 16penicilln gk inj 20mu .............................................. 16PENTACEL .............................................................. 72pentamidine isethionate inh .................................... 9pentamidine isethionate inj ..................................... 9pentoxifylline .......................................................... 68peptic relief ............................................................. 60perindopril erbumine ............................................. 25periogard ................................................................ 91permethrin cre 5% .................................................. 90perphenazine .......................................................... 39PERSERIS ................................................................ 39pfizerpen-g inj 5mu ................................................ 17pfizerpen-g inj 20mu .............................................. 17pharbedryl .............................................................. 83pharbetol .................................................................. 3pharbetol extra strength .......................................... 3phenelzine sulfate ................................................... 36phenobarbital ......................................................... 34phenobarbital sodium ............................................ 34PHENYTEK .............................................................. 34phenytoin ................................................................ 34phenytoin sodium extended ................................... 34

111

Drug Name Page # Drug Name Page #phenytoin sodium inj 50mg/ml .............................. 34PHESGO .................................................................. 19philith ...................................................................... 53PHOSPHOLINE IODIDE ......................................... 79phytonadione .......................................................... 76PICATO ................................................................... 90PIFELTRO ................................................................ 11pilocarpine hcl ........................................................ 79pilocarpine hcl (oral) .............................................. 91pimozide ................................................................. 39pimtrea ................................................................... 53pindolol ................................................................... 28pioglitazone hcl ....................................................... 48piper/tazoba inj 2-0.25gm ...................................... 17piper/tazoba inj 3-0.375gm.................................... 17piper/tazoba inj 4-0.5gm ........................................ 17piper/tazoba inj 12-1.5gm ...................................... 17piper/tazoba inj 36-4.5gm ...................................... 17PIQRAY 200MG DAILY DOSE ................................ 23PIQRAY 250MG DAILY DOSE ................................ 23PIQRAY 300MG DAILY DOSE ................................ 23pirmella 1/35 .......................................................... 53piroxicam .................................................................. 5PLAN B ONE-STEP ................................................. 53PLASMA-LYTE-148 ................................................. 75PLASMA-LYTE A ..................................................... 75plenamine ............................................................... 74PLENVU .................................................................. 64PNV FOLIC ACID + IRON MUL .............................. 77podofilox ................................................................. 90polymyxin b-trimethoprim ..................................... 78POMALYST CAP 1MG ............................................ 21POMALYST CAP 2MG ............................................ 21POMALYST CAP 3MG ............................................ 21POMALYST CAP 4MG ............................................ 21portia-28 ................................................................. 53posaconazole .......................................................... 10potassium chloride ........................................... 73, 75POTASSIUM CHLORIDE ........................................ 75potassium chloride in nacl ..................................... 75potassium chloride microencapsulated crystals

er ......................................................................... 73potassium citrate (alkalinizer) er tabs ................... 66pot chloride inj 2meq/ml ........................................ 75povidone-iodine ...................................................... 90PRADAXA ................................................................ 67PRALUENT .............................................................. 28

pramipexole tab 0.5mg .......................................... 37pramipexole tab 0.25mg ........................................ 37pramipexole tab 0.75mg ........................................ 37pramipexole tab 0.125mg ...................................... 37pramipexole tab 1.5mg .......................................... 37pramipexole tab 1mg ............................................. 37prasugrel hcl ........................................................... 68pravastatin sodium ................................................ 27praziquantel ............................................................. 9prazosin hcl ............................................................ 25prednisolone acetate (ophth) ................................. 78prednisolone sodium phosphate ........................... 56PREDNISOLONE SODIUM PHOSPHATE

(OPHTH) ............................................................. 78prednisolone sol 15mg/5ml ................................... 56prednisolone sol 25mg/5ml ................................... 56PREDNISONE CON 5MG/ML ................................ 56prednisone pak 5mg ............................................... 56prednisone pak 10mg ............................................. 56prednisone sol 5mg/5ml......................................... 56prednisone tab 1mg ............................................... 56prednisone tab 2.5mg ............................................ 56prednisone tab 5mg ............................................... 56prednisone tab 10mg ............................................. 56prednisone tab 20mg ............................................. 56prednisone tab 50mg ............................................. 56pred sod pho sol 5mg/5ml ..................................... 56pregabalin ............................................................... 34PREMASOL SOL 10% ............................................. 74PRENATAL .............................................................. 77PRENATAL PLUS .................................................... 77PRENATAL PLUS LOW IRON ................................. 77PREVACID 24HR ..................................................... 65prevalite .................................................................. 28previfem .................................................................. 53PREZCOBIX ............................................................. 13PREZISTA .......................................................... 11, 12PRIFTIN ................................................................... 13primaquine phosphate ........................................... 10PRIMAQUINE PHOSPHATE ................................... 11primidone ............................................................... 34PRIVIGEN ................................................................ 70probenecid ................................................................ 1PROCALAMINE ....................................................... 74prochlorperazine inj ............................................... 61prochlorperazine maleate ...................................... 61prochlorperazine supp ........................................... 61

112

Drug Name Page # Drug Name Page #PROCRIT ................................................................. 67procto-med hc ........................................................ 90procto-pak .............................................................. 90proctosol hc cre 2.5% ............................................. 90proctozone-hc ......................................................... 90PROGLYCEM SUS 50MG/ML ................................ 56PROGRAF ................................................................ 71PROLASTIN-C ......................................................... 84PROLENSA .............................................................. 78PROLIA .................................................................... 57PROMACTA ............................................................ 68promethazine hcl .................................................... 61promethazine hcl inj ............................................... 61propafenone hcl ..................................................... 27propafenone hcl 12hr ............................................. 27proparacaine hcl .................................................... 80propranolol cap er ................................................. 28propranolol hcl ....................................................... 28propranolol & hydrochlorothiazide ....................... 28propranolol oral sol ............................................... 28propylthiouracil ...................................................... 58PROQUAD .............................................................. 72PROSOL .................................................................. 74protriptyline hcl ...................................................... 36provil ......................................................................... 5PULMICORT FLEXHALER ....................................... 85PULMOZYME.......................................................... 84puralube ................................................................. 80PURIXAN ................................................................. 18px all day relief ......................................................... 6pyrazinamide .......................................................... 13pyridostigmine tab 60mg ....................................... 43pyridoxine hcl ......................................................... 77

Q

qc 3 day vaginal cream .......................................... 66qc acid controller .................................................... 62qc acid controller maximu ..................................... 62qc all day allergy ..................................................... 83qc antacid ............................................................... 59qc antacid/anti-gas ................................................. 59qc anti-diarrheal ..................................................... 60qc arthritis pain relief ............................................... 3qc aspirin .................................................................. 3qc aspirin low dose ................................................... 3qc chewable aspirin low d ........................................ 3qc enema ................................................................ 64

qc enteric aspirin ...................................................... 3qc gentle laxative .................................................... 64qc ibuprofen ib ......................................................... 6qc loratadine allergy rel ......................................... 83qc miconazole 7 ...................................................... 66qc naproxen sodium ................................................. 6qc non-aspirin childrens ........................................... 3qc non-aspirin extra stre .......................................... 3qc non-aspirin jr strengt ........................................... 3qc povidone iodine ................................................. 90qc tolnaftate ............................................................ 87QINLOCK ................................................................ 23QUADRACEL ........................................................... 72quetiapine fumarate .............................................. 39quinapril hcl ............................................................ 25quinapril-hydrochlorothiazide ............................... 25quinidine sulfate ..................................................... 27quinine sulfate ........................................................ 11

R

RABAVERT .............................................................. 72rabeprazole sodium ............................................... 65raloxifene hcl .......................................................... 57ra lubricant eye drops ............................................ 80ramipril ................................................................... 25ranitidine hcl ........................................................... 62ranolazine ............................................................... 31rasagiline mesylate ................................................. 37RAYALDEE .............................................................. 77reclipsen .................................................................. 53RECOMBIVAX HB ................................................... 72RECTIV .................................................................... 90refresh celluvisc ...................................................... 80refresh lacri-lube .................................................... 80REFRESH LIQUIGEL ............................................... 80REFRESH PLUS ....................................................... 80refresh p.m. ............................................................. 80REFRESH TEARS ..................................................... 80REGRANEX .............................................................. 91reguloid ................................................................... 64RELENZA DISKHALER ............................................ 14RELISTOR ................................................................ 65REMICADE .............................................................. 69renal caps ............................................................... 77RENFLEXIS .............................................................. 69RENOVA .................................................................. 90RENOVA PUMP ...................................................... 90

113

Drug Name Page # Drug Name Page #repaglinide .............................................................. 48RESTASIS ................................................................ 80RESTASIS MULTIDOSE .......................................... 80RETEVMO ............................................................... 23REVLIMID ................................................................ 21REXULTI .................................................................. 40REYATAZ ................................................................. 12RHOPRESSA ........................................................... 79ribavirin 200mg ...................................................... 14rifabutin .................................................................. 13rifampin .................................................................. 13riluzole .................................................................... 43rimantadine hydrochloride .................................... 14RINVOQ .................................................................. 69risedronate sodium ................................................ 49RISPERDAL INJ 12.5MG ......................................... 40RISPERDAL INJ 25MG ............................................ 40RISPERDAL INJ 37.5MG ......................................... 40RISPERDAL INJ 50MG ............................................ 40risperidone .............................................................. 40ritonavir .................................................................. 12RITUXAN ................................................................. 19RITUXAN HYCELA .................................................. 19rivastigmine tartrate ............................................... 35rivastigmine td patch 24hr 4.6 mg/24hr................ 35rivastigmine td patch 24hr 9.5 mg/24hr................ 35rivastigmine td patch 24hr 13.3 mg/24hr ............. 35rivelsa ...................................................................... 53rizatriptan benzoate ............................................... 42rizatriptan benzoate odt ........................................ 42ropinirole tab 0.5mg ............................................... 38ropinirole tab 0.25mg............................................. 38ropinirole tab 1mg .................................................. 38ropinirole tab 2mg .................................................. 38ropinirole tab 3mg .................................................. 38ropinirole tab 4mg .................................................. 38ropinirole tab 5mg .................................................. 38rosadan ................................................................... 90rosuvastatin calcium .............................................. 27ROTARIX ................................................................. 72ROTATEQ ................................................................ 72roweepra ................................................................. 34roweepra xr ............................................................ 34ROZLYTREK ............................................................ 23RUBRACA ................................................................ 19RUKOBIA ................................................................ 12rulox ........................................................................ 59

RUXIENCE ............................................................... 19RYBELSUS ............................................................... 48RYDAPT ................................................................... 23

S

SANDIMMUNE ....................................................... 71SANTYL ................................................................... 91SAPHRIS .................................................................. 40sb aspirin .................................................................. 3sb ibuprofen.............................................................. 6sb lice killing maximum s ....................................... 90sb non-aspirin extra stre .......................................... 3sb pain reliever extra st ............................................ 3scalpicin maximum strengt .................................... 89scopolamine............................................................ 61SECUADO ............................................................... 40selegiline hcl ............................................................ 38selenium sulfide ...................................................... 88SELZENTRY ............................................................. 12SEREVENT DISKUS ................................................. 84sertraline hcl ........................................................... 37setlakin tab ............................................................. 53sevelamer carbonate .............................................. 57sharobel .................................................................. 53SHINGRIX ................................................................ 72SIGNIFOR ................................................................ 57silace ....................................................................... 64siladryl allergy ......................................................... 83sildenafil citrate tab 20 mg (pulmonary

hypertension) ...................................................... 31silver sulfadiazine ................................................... 86SIMBRINZA ............................................................. 79simvastatin .............................................................. 27sirolimus ................................................................. 71SIRTURO ................................................................. 13SIVEXTRO .................................................................. 9SKYRIZI ................................................................... 70sm 3-day vaginal .................................................... 67sm 8 hour pain relief ................................................ 3sm acid reducer ...................................................... 62sm acid reducer maximum s .................................. 62sm all day allergy .................................................... 83sm all day allergy childr ......................................... 83sm allergy 4 hour .................................................... 83sm allergy relief ...................................................... 83sm allergy relief nasal s .......................................... 85sm antacid advanced ............................................. 59

114

Drug Name Page # Drug Name Page #sm antacid advanced maxi .................................... 60sm antacid/antigas ................................................. 60sm antacid maximum streng ................................. 60sm anti-diarrheal .................................................... 60sm antifungal clotrimazol ...................................... 87sm antifungal miconazole ...................................... 87sm antifungal tolnaftate ......................................... 87sm arthritis pain relief .............................................. 3sm aspirin ................................................................. 3sm aspirin adult low stre .......................................... 3sm aspirin enteric coated ......................................... 3sm aspirin low dose .................................................. 4sm calcium antacid ................................................ 60sm calcium antacid extra ....................................... 60sm childrens aspirin ................................................. 4sm childrens ibuprofen ............................................ 6sm childrens loratadine ......................................... 83sm clotrimazole vaginal ......................................... 67sm eye itch relief ..................................................... 79sm fexofenadine hydrochlo .................................... 83sm fiber ................................................................... 64sm gentle laxative ................................................... 64sm hydrocortisone .................................................. 89sm hydrocortisone maximum ................................ 89sm hydrocortisone plus .......................................... 89sm ibuprofen ............................................................ 6sm ibuprofen ib ........................................................ 6sm infants ibuprofen ................................................ 6sm lansoprazole ..................................................... 65sm lice killing maximum s ...................................... 90sm lice treatment .................................................... 90sm loperamide hcl .................................................. 60sm loratadine.......................................................... 83sm miconazole 3 ..................................................... 67sm miconazole 7 ..................................................... 67sm naproxen sodium................................................ 6sm nicotine .............................................................. 45sm nicotine polacrilex ............................................ 45sm nicotine transdermal s...................................... 45SM OMEPRAZOLE .................................................. 65sm pain & fever childrens ......................................... 4sm pain & fever infants ............................................ 4sm pain reliever ........................................................ 4sm pain reliever extra st ........................................... 4sm povidone-iodine ................................................ 90sm stomach relief ................................................... 60sm stool softener .................................................... 64

sm tioconazole-1 .................................................... 67sm triple antibiotic ................................................. 86sodium bicarbonate (antacid) ................................ 60sodium chloride ................................................ 73, 75sodium chloride 0.45% ........................................... 75sodium chloride inj 0.9% ........................................ 75sodium chlor sol 0.9% irr ....................................... 91sodium fluoride chew\; tab\; 1.1 (0.5 f) mg/ml

soln ...................................................................... 73sodium phenylbutyrate .......................................... 55sodium phosphates ................................................ 64sodium polystyrene sulfonate powder ................... 50sodium polystyrene sulfonate susp ....................... 50SOLIQUA 100/33 ................................................... 46SOLTAMOX ............................................................. 20SOLU-CORTEF ........................................................ 56SOMATULINE DEPOT ............................................ 57SOMAVERT ............................................................. 57soothe & cool inzo antifu ....................................... 87sorine ...................................................................... 27sotalol hcl ................................................................ 27sotalol hcl (afib/afl) ................................................. 27spironolactone ........................................................ 25spironolactone & hydrochlorothiazide .................. 30sprintec 28 .............................................................. 53SPRITAM ................................................................. 34SPRYCEL ................................................................. 23sps susp 15gm/60ml ............................................... 50sronyx ...................................................................... 53ssd ........................................................................... 86stavudine................................................................. 12STELARA ................................................................. 70STIMATE ................................................................. 58stimulant laxative ................................................... 64STIVARGA ............................................................... 23stomach relief ......................................................... 60stomach relief maximum st ................................... 61stool softener .......................................................... 64stool softener extra stre ......................................... 64streptomycin sulfate ................................................. 8STRIBILD ................................................................. 13subvenite tab .......................................................... 34sucralfate ................................................................ 65sulfacetamide sodium (acne) ................................. 86sulfacetamide sodium (ophth) ............................... 78sulfacetamide sod-prednisolone ............................ 77SULFADIAZINE ......................................................... 8

115

Drug Name Page # Drug Name Page #sulfamethoxazole-trimethop ds ............................... 9sulfamethoxazole-trimethoprim inj ......................... 9sulfamethoxazole-trimethoprim susp ..................... 9sulfamethoxazole-trimethoprim tab 400-80mg ...... 9SULFAMYLON ........................................................ 86sulfasalazine ........................................................... 62sulfasalazine ec....................................................... 62sulindac ..................................................................... 6sumatriptan ............................................................ 42sumatriptan inj 4mg/0.5ml .................................... 42sumatriptan inj 6mg/0.5ml .................................... 42sumatriptan succinate ............................................ 42SUPREP BOWEL PREP KIT ..................................... 64SUTENT ................................................................... 23syeda ....................................................................... 53SYLATRON .............................................................. 23SYMBICORT ............................................................ 85SYMDEKO ............................................................... 84SYMFI ...................................................................... 13SYMFI LO ................................................................ 13SYMJEPI ................................................................... 84SYMPAZAN ............................................................. 34SYMTUZA ................................................................ 13SYNAREL ................................................................. 54SYNERCID ................................................................. 9SYNJARDY TAB 5-500MG ...................................... 48SYNJARDY TAB 5-1000MG .................................... 48SYNJARDY TAB 12.5-500MG ................................. 48SYNJARDY TAB 12.5-1000MG ............................... 48SYNJARDY XR TAB 5-1000MG ............................... 48SYNJARDY XR TAB 10-1000MG ............................ 48SYNJARDY XR TAB 12.5-1000MG ......................... 48SYNJARDY XR TAB 25-1000MG ............................ 48SYNRIBO ................................................................. 24SYNTHROID ............................................................ 58systane nighttime .................................................... 80SYSTANE OVERNIGHT THERAPY .......................... 81

T

TABLOID ................................................................. 18TABRECTA .............................................................. 23tacrolimus ............................................................... 71tacrolimus (topical) ................................................. 90tactinal ...................................................................... 4tactinal extra strength .............................................. 4TAFINLAR ................................................................ 23TAGRISSO ............................................................... 23

take action .............................................................. 53TALZENNA .............................................................. 19tamoxifen citrate .................................................... 20tamsulosin hcl ......................................................... 66TARGRETIN ............................................................. 90tarina 24 fe ............................................................. 54tarina fe 1/20 .......................................................... 54TASIGNA ................................................................. 23TAXOTERE .............................................................. 18tazarotene ............................................................... 87tazicef ...................................................................... 15TAZORAC ................................................................ 87taztia xt ................................................................... 29TAZVERIK ................................................................ 24TDVAX ..................................................................... 72TECENTRIQ ............................................................. 19TEFLARO ................................................................. 15telmisartan .............................................................. 26telmisartan-amlodipine .......................................... 26telmisartan-hydrochlorothiazide ........................... 26temazepam ............................................................. 42TEMIXYS .................................................................. 13TENIVAC ................................................................. 72tenofovir disoproxil fumarate ................................ 12terazosin hcl ............................................................ 25terbinafine hcl ......................................................... 10terbutaline sulfate .................................................. 84terconazole vaginal ................................................ 67testosterone ............................................................ 45testosterone cypionate ........................................... 45testosterone enanthate .......................................... 45tetrabenazine .......................................................... 43tetracycline hcl ........................................................ 17TEXACORT SOLN 2.5% .......................................... 89tgt naproxen sodium ................................................ 6THALOMID ............................................................. 21THEO-24 ................................................................. 84theophylline ............................................................ 84theophylline tab er 12hr 300 mg ........................... 85theophylline tab er 12hr 450 mg ........................... 85theophylline tab sr 24hr ......................................... 85thiamine hcl ............................................................ 77thioridazine hcl ....................................................... 40thiothixene .............................................................. 40tiadylt er .................................................................. 29tiagabine hcl ........................................................... 34TIBSOVO ................................................................. 19

116

Drug Name Page # Drug Name Page #tigecycline .................................................................. 9tilia fe ...................................................................... 54timolol maleate ....................................................... 29timolol maleate gel ................................................. 79timolol maleate (ophth) soln .................................. 79timolol maleate ophth soln 0.5% (once-daily) ....... 80TIVICAY ................................................................... 12TIVICAY PD ............................................................. 12tizanidine hcl........................................................... 44TOBRADEX ............................................................. 77TOBRADEX ST ........................................................ 77tobramycin ................................................................ 8tobramycin-dexamethasone .................................. 77tobramycin inj 1.2gm ............................................... 8tobramycin inj 1.2 gm/30ml ..................................... 8tobramycin inj 10mg/ml ........................................... 8tobramycin inj 80mg/2ml ......................................... 8tobramycin (ophth) ................................................. 78tobramycin sulfate.................................................... 8tolnaftate ................................................................ 87tolterodine tartrate cap er ..................................... 66tolterodine tartrate tabs ......................................... 66topiramate .............................................................. 34toposar .................................................................... 24toremifene citrate ................................................... 20torsemide tabs ........................................................ 30TOVIAZ .................................................................... 66TPN ELECTROLYTES .............................................. 73TRADJENTA ............................................................. 48tramadol-acetaminophen ........................................ 6tramadol hcl tab 50 mg ............................................ 6trandolapril ............................................................. 25tranexamic acid ...................................................... 68tranylcypromine sulfate ......................................... 37TRAVASOL .............................................................. 74travoprost ............................................................... 80TRAZIMERA ............................................................ 19trazodone hcl .......................................................... 37TRECATOR .............................................................. 13TRELEGY ELLIPTA .................................................. 81TRELSTAR DEP INJ 3.75MG ................................... 20TRELSTAR LA INJ 11.25MG ................................... 20treprostinil .............................................................. 31TRESIBA FLEXTOUCH ............................................ 46TRESIBA INJ ............................................................ 46tretinoin .................................................................. 86tretinoin (chemotherapy) ....................................... 24

triamcinolone acetonide (mouth) .......................... 91triamcinolone acetonide (topical) .......................... 89triamterene & hydrochlorothiazide cap 37.5-

25 mg .................................................................. 30triamterene & hydrochlorothiazide tabs ............... 30tri-buffered aspirin ................................................... 4TRICARE .................................................................. 77trientine hcl ............................................................. 50tri-estarylla .............................................................. 54trifluoperazine hcl .................................................. 40trifluridine ............................................................... 78trihexyphenidyl hcl ................................................. 38TRIJARDY XR TAB ER 24HR 5-2.5-1000MG .......... 48TRIJARDY XR TAB ER 24HR 10-5-1000 MG .......... 48TRIJARDY XR TAB ER 24HR 12.5-2.5-1000MG ..... 48TRIJARDY XR TAB ER 24HR 25-5-1000 MG .......... 48TRIKAFTA ................................................................ 85tri-legest fe .............................................................. 54tri-linyah .................................................................. 54tri-lo-estarylla ......................................................... 54tri-lo marzia ............................................................ 54tri-lo-sprintec .......................................................... 54trilyte ....................................................................... 64trimethoprim ............................................................ 9tri-mili ...................................................................... 54trimipramine maleate ............................................ 37TRINTELLIX ............................................................. 37triple antibiotic ....................................................... 86tri-previfem ............................................................. 54triprolidine hcl ........................................................ 83tri-sprintec ............................................................... 54TRIUMEQ ................................................................ 13trivora-28 ................................................................ 54tri-vylibra ................................................................. 54tri-vylibra lo............................................................. 54TROGARZO ............................................................. 12TROPHAMINE INJ 10% .......................................... 74trospium chloride ................................................... 66TRULICITY ............................................................... 46TRUMENBA ............................................................ 72TRUVADA TAB 100-150 ......................................... 13TRUVADA TAB 133-200 ......................................... 13TRUVADA TAB 167-250 ......................................... 13TRUVADA TAB 200-300 ......................................... 13TRUXIMA ................................................................ 19TUKYSA ................................................................... 23tulana ...................................................................... 54

117

Drug Name Page # Drug Name Page #TUMS ...................................................................... 60TUMS CHEWY DELIGHTS ...................................... 60TUMS E-X 750 ........................................................ 60TUMS EXTRA STRENGTH 750 ............................... 60tums smoothies ...................................................... 60TUMS SMOOTHIES ................................................ 60TUMS ULTRA 1000 ................................................ 60TURALIO ................................................................. 23TWINRIX INJ ............................................................ 72TYBOST ................................................................... 12tydemy ..................................................................... 54TYKERB ................................................................... 23TYMLOS .................................................................. 57TYPHIM VI ............................................................... 72

U

unithroid ................................................................. 58ursodiol ................................................................... 65

V

valacyclovir hcl ....................................................... 14VALCHLOR .............................................................. 90valganciclovir hcl .................................................... 14valproate sodium ................................................... 34valproic acid ........................................................... 34valsartan ................................................................. 26valsartan-hydrochlorothiazide............................... 26VALTOCO ................................................................ 34VANACLEAR PD ...................................................... 83vanadom ................................................................. 44VANAHIST PD ......................................................... 83VANAMINE PD ....................................................... 83vancomycin hcl ................................................... 9, 10VANCOMYCIN IN NACL ......................................... 10vandazole ................................................................ 67VAQTA ..................................................................... 72VARIVAX .................................................................. 72VASCEPA ................................................................. 28VELCADE ................................................................. 20velivet ...................................................................... 54VELTASSA ............................................................... 50VEMLIDY ................................................................. 14VENCLEXTA ............................................................ 20VENCLEXTA STARTING PACK................................ 20venlafaxine hcl ........................................................ 37VENTAVIS ................................................................ 31VENTOLIN HFA ...................................................... 84

verapamil cap er ..................................................... 29verapamil hcl .......................................................... 29verapamil hcl tab er ............................................... 29VERSACLOZ ............................................................ 40VERZENIO ............................................................... 20VICTOZA ................................................................. 46vienva ...................................................................... 54vigabatrin powd pack 500mg ................................ 34vigabatrin tab 500mg ............................................. 34vigadrone ................................................................ 34VIIBRYD STARTER PACK ........................................ 37VIIBRYD TAB ........................................................... 37VIMPAT ................................................................... 34VIMPAT INJ 200MG/20ML ..................................... 35VIMPAT SOL 10MG/ML ......................................... 35vincristine sulfate .................................................... 18vinorelbine tartrate ................................................ 18viorele ...................................................................... 54VIRACEPT ................................................................ 12VIREAD .................................................................... 12virt-caps .................................................................. 77VITAL-D RX ............................................................. 77VITRAKVI ................................................................. 23VIVITROL ................................................................. 45VIZIMPRO ............................................................... 23voriconazole ............................................................ 10VOSEVI .................................................................... 14VOTRIENT ............................................................... 23VRAYLAR ................................................................. 40VRAYLAR THERAPY PACK ...................................... 40vyfemla .................................................................... 54vylibra ..................................................................... 54

W

warfarin sodium ..................................................... 67water for irrigation, sterile .................................... 91wee care .................................................................. 68wymzya fe ............................................................... 54

X

XALKORI ................................................................. 23XARELTO ................................................................. 67XARELTO STARTER PACK ...................................... 67XATMEP .................................................................. 70XCOPRI MAINTENANCE PAK 150-200MG ........... 35XCOPRI PAK 12.5-25MG ....................................... 35XCOPRI PAK 50-100MG ........................................ 35

118

Drug Name Page # Drug Name Page #XCOPRI PAK 50-200MG ........................................ 35XCOPRI TABS.......................................................... 35XCOPRI TITRATION PAK 150-200MG ................... 35XELJANZ .................................................................. 70XELJANZ XR ............................................................ 70XENICAL .................................................................. 57XGEVA ..................................................................... 57XIFAXAN .................................................................. 65XIGDUO XR TAB 2.5-1000MG ............................... 49XIGDUO XR TAB 5-500MG .................................... 49XIGDUO XR TAB 5-1000MG .................................. 49XIGDUO XR TAB 10-500MG .................................. 49XIGDUO XR TAB 10-1000MG ................................ 49XOLAIR .................................................................... 85XOSPATA ................................................................ 23XPOVIO 40 MG ONCE WEEKLY ............................ 24XPOVIO 40 MG TWICE WEEKLY ............................ 24XPOVIO 60 MG ONCE WEEKLY ............................ 24XPOVIO 60 MG TWICE WEEKLY ............................ 24XPOVIO 80 MG ONCE WEEKLY ............................ 24XPOVIO 80 MG TWICE WEEKLY ............................ 24XPOVIO 100 MG ONCE WEEKLY .......................... 24XTANDI ................................................................... 21xulane ..................................................................... 54XULTOPHY 100/3.6 ............................................... 46XYREM .................................................................... 44

Y

YF-VAX .................................................................... 72yuvafem vaginal tablet 10 mcg .............................. 55

Z

ZADITOR ................................................................. 79zafirlukast ............................................................... 84zaleplon ................................................................... 42zarah ....................................................................... 54ZARXIO .................................................................... 67ZEJULA .................................................................... 20ZELBORAF .............................................................. 23ZEMAIRA ................................................................. 85zenatane ................................................................. 86ZENPEP ................................................................... 65ZERVIATE ................................................................ 79zidovudine cap 100mg ........................................... 12zidovudine syp 50mg/5ml ...................................... 12zidovudine tab 300mg ............................................ 12ziprasidone hcl ....................................................... 40

ziprasidone mesylate .............................................. 40ZIRABEV .................................................................. 20ZIRGAN ................................................................... 78zoledronic acid inj 4mg/100ml .............................. 49zoledronic acid inj 5mg/100ml .............................. 49zoledronic inj 4mg/5ml .......................................... 49ZOLINZA ................................................................. 20zolmitriptan ............................................................ 42zolmitriptan odt ...................................................... 42zolpidem tartrate .................................................... 42zonisamide .............................................................. 35ZORTRESS TAB 0.5MG .......................................... 71ZORTRESS TAB 0.25MG ........................................ 71ZORTRESS TAB 0.75MG ........................................ 71ZORTRESS TAB 1MG ............................................. 71ZOSTAVAX .............................................................. 72zovia 1/35e .............................................................. 54ZYDELIG .................................................................. 23ZYKADIA ................................................................. 23ZYLET ...................................................................... 77ZYPREXA RELPREVV ............................................... 40ZYPREXA RELPREVV INJ 210MG ........................... 40ZYTIGA .................................................................... 21

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

Aetna, Inc.: • 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 Aetna Medicaid Civil Rights Coordinator

If you believe that Aetna, Inc. 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: Aetna Medicaid Civil Rights Coordinator, 4500 East Cotton Center Boulevard, Phoenix, AZ 85040, 1-888-234-7358, TTY 711, 860-900-7667 (fax), [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Aetna Medicaid Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

MI-18-12-01

http://www.hhs.gov/ocr/office/file/index.html

mailto:[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Multi-language Interpreter ServicesEnglish: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-385-4104 (TTY: 711).

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-385-4104 (TTY: 711).

Arabic:

Chinese: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-385-4104 (TTY: 711)。

Syriac:

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-385-4104 (TTY: 711).

Albanian: KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-800-385-4104 (TTY: 711).

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-385-4104 (TTY: 711) 번으로 전화해 주십시오.

Bengali: লক্ষ্য করুনঃ যদি আপনি বাংলা, কথা বলতে পারেন, তাহলে নিঃখরচায় ভাষা সহায়তা পরিষেবা উপলব্ধ আছে। ফোন করুন 1-800-385-4104 (TTY: 711)।

Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-385-4104 (TTY: 711).

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-385-4104 (TTY: 711).

Italian: ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-385-4104 (TTY: 711).

Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-385-4104 (TTY: 711) まで、お電話にてご連絡ください。

Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-385-4104 (телетайп: 711).

Serbo-Croatian (Serbian): OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-800-385-4104 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711).

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-385-4104 (TTY: 711).

MI-18-12-01

Helpful information

Aetna Better Health Premier Plan1333 Gratiot Avenue, Suite 400Detroit, MI 48207

Member Services1-855-676-5772 (TTY: 711)

For more recent information or other questions, contact us at 1-855-676-5772 (TTY: 711), 24 hours a day, 7 days a week or visit aetnabetterhealth.com/michigan

©2020 Aetna Inc. 92.05.300.1-MI U (11/20)Updated on 11/01/2020


Documents

2020 List of Covered Drugs/Formulary - Aetna...plan that contracts with Medicare and Michigan Medicaid to provide benefits of both programs to enrollees. For more recent information