2021 Comprehensive Formulary€¦ · Updated 10/01/20 3 Aetna Medicare is a HMO, PPO plan with a Medicare contract. Enrollment in our plans depends on contract renewal. Members who

2021 Comprehensive

FormularyAetna Medicare

(List of Covered Drugs) GRP B2 Plus

4 Tier

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

This formulary was updated on 10/01/2020. For more recent information or other questions, please contact Aetna Medicare Member Services at 1-888-267-2637

or for TTY users: 711, 8 a.m. to 9 p.m., E.S.T., Monday through Friday, or visit AetnaRetireePlans.com choose “Manage your prescription drugs”.

Formulary ID Number: 21115 Version 8

Updated 10/01/20

http://AetnaRetireePlans.com

2 Updated 10/01/20

Table of contents

Mail-order Pharmacy 3

What is the Aetna Medicare Comprehensive Formulary? 4

Can the Formulary (drug list) change? 4

How do I use the Formulary? 5

What are generic drugs? 5

Are there any restrictions on my coverage? 5

What if my drug is not on the Formulary? 6

How do I request an exception to the Aetna Medicare Formulary? 6

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? 7

For more information 7

Aetna Medicare Formulary 8

Drug tier copay levels 9

Formulary key 10

Drug list 10

Index of Drugs 90

Enhanced drug list 110

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Aetna Medicare is a HMO, PPO plan with a Medicare contract. Enrollment in our plans depends on contract renewal. Members who get “Extra Help” are not required to fill prescriptions at preferred network pharmacies in order to get Low Income Subsidy (LIS) copays.

See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area.

Mail-order PharmacyFor mail order, you can get prescription drugs shipped to your home through the network mail-order delivery program. Typically, mail-order drugs arrive within 10 days. You can call 1-888-267-2637 (TTY: 711) 8 a.m. to 9 p.m., E.S.T., Monday through Friday, if you do not receive your mail-order drugs within this timeframe. Members may have the option to sign up for automated mail-order delivery.

ATTENTION: If you speak Spanish or Chinese, language assistance services, free of charge, are available to you. Call the number on your ID card.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al número que figura en su tarjeta de identificación.

注意：如果您使用中文，您可以免費獲得語言援

助服務。請撥打您的會員身分卡上的電話號碼。

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

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Aetna Medicare. When it refers to “plan” or “our plan,” it means Aetna.

This document includes a list of the drugs (formulary) for our plan which is current as of 10/01/2020. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2022, and from time to time during the year. You will receive notice when necessary.

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

Can the Formulary (drug list) change?Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year, move them to different cost sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes.

Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:

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

° If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Aetna Medicare Formulary?”

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

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

° If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Aetna Medicare Formulary?”

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Changes that will not affect you if you are currently taking the drug.

Generally, if you are taking a drug on our 2021 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above. This means these drugs will remain available at the same cost sharing and with no new restrictions for those members taking them for the remainder of the coverage year. You will not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, such changes would affect you, and it is important to check the Drug List for the new benefit year for any changes to drugs.

The enclosed formulary is current as of 10/01/2020. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages.

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

Medical ConditionThe formulary begins on page 10. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular”. If you know what your drug is used for, look for the category name in the list that begins on page 10. Then look under the category name for your drug.

Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page 90. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

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

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

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

• Quantity Limits: For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 30 tablets per 30 days per prescription for rosuvastatin. This may be in addition to a standard one-month or three-month supply.

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

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 10. You can also get more information about the restrictions applied to specific covered drugs by visiting our Website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Aetna Medicare formulary?” on page 6 for information about how to request an exception.

What if my drug is not on the Formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered.

If you learn that our plan does not cover your drug, you have two options:

• You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan.

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

How do I request an exception to the Aetna Medicare Formulary?You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

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

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

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

Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request.

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Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30 day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 31-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

If you experience a change in your setting of care (such as being discharged or admitted to a long-term care facility), your physician or pharmacy can request a one-time prescription override. This one-time override will provide you with temporary coverage (up to a 30-day supply) for the applicable drug(s).

For more informationFor more detailed information about your plan's prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

http://www.medicare.gov

8 Updated 10/01/20

Aetna Medicare Formulary

The comprehensive formulary that begins on page 10 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 90.

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

The information in the Requirements/Limits column tells you if Aetna Medicare has any special requirements for coverage of your drug.

QL Quantity Limits

PA Prior Authorization

ST Step Therapy

LA Limited Access

MO Mail-order Delivery

B/D Part B vs. D Prior Authorization

QL: Quantity Limits. For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 30 tablets per 30 days per prescription for rosuvastatin.

PA: Prior Authorization. Our plan requires you or your provider to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don't get approval, we may not cover the drug.

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

LA: Limited Access. These prescriptions may be available only at certain pharmacies. For more Information, consult your Pharmacy Directory or call Aetna Member Services at 1-888-267-2637 (TTY: 711), 8 a.m. to 9 p.m., E.S.T., Monday through Friday.

MO: Mail Order. For certain kinds of drugs, you can use CVS Caremark® Mail Service Pharmacy. Generally, the drugs available through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs available through our plan’s mail-order service are marked as “MO” in our Drug List. For more information, consult your Pharmacy Directory or call Aetna Member Services at 1-888-267-2637 (TTY: 711), 8 a.m. to 9 p.m., E.S.T., Monday through Friday.

B/D: Part B versus Part D. This prescription drug has a Part B versus Part D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

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Drug tier copay levels

This 2021 comprehensive formulary is a listing of brand-name and generic drugs. Aetna Medicare’s 2021 formulary covers most drugs identified by Medicare as Part D drugs, and your copay may differ depending upon the tier at which the drug resides.

The copay tiers for covered prescription medications are listed below. Copay amounts and coinsurance percentages for each tier vary by Aetna Medicare plan. Look in the 2021 Prescription Drug Benefits Chart (The Prescription Drug Schedule of Cost Sharing) that was included in your Evidence of Coverage (EOC) packet.

Copay tier Type of drug

Tier 1 Generic Drugs

Tier 2 Preferred Brand Drugs

Tier 3 Non-Preferred Brand Drugs

Tier 4 Specialty Drugs

You may have drug coverage in the Coverage Gap StageThere are four “drug payment stages” of a Medicare Prescription Drug Plan. How much you pay for a Part D drug depends on which drug payment stage you are in. Your plan may include supplemental coverage for some drugs during the Coverage Gap stage of the plan. Look in the 2021 Prescription Drug Benefits Chart (Prescription Drug Schedule of Cost Sharing) that was included in your EOC packet. The Prescription Drug Benefits Chart will tell you if your plan provides coverage in the gap, and how much you will pay for covered drugs. If you need assistance finding this information, call the number on the back of your ID card.

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Key*Drug name

UPPERCASE = Brand-name prescription drugs

Lowercase italics = Generic medications

Drug tier

1, 2, 3, 4 = Copay tier level

Requirements/Limits

QL = Quantity Limit PA = Prior Authorization ST = Step Therapy LA = Limited Access MO = Mail-order Delivery B/D = Part B vs. Part D

Drug name Drug tier Requirements/LimitsANALGESICS

GOUT allopurinol tabs 1 MOcolchicine 1 QL (120 EA per 30 days) MOfebuxostat 1 ST MOMITIGARE 2 QL (60 EA per 30 days) MOprobenecid 1 MOprobenecid/colchicine 1 MO

NSAIDS celecoxib caps 400mg 1 QL (30 EA per 30 days) MOcelecoxib caps 100mg, 200mg, 50mg 1 QL (60 EA per 30 days) MOdiclofenac potassium 1 QL (120 EA per 30 days) MOdiclofenac sodium dr 1 MOdiclofenac sodium er 1 MOdiclofenac sodium/misoprostol 1 MOdiflunisal 1 MODUEXIS 4 MOetodolac 1 MOetodolac er 1 MOFENOPROFEN CALCIUM CAPS 400MG

3 MO

fenoprofen calcium tabs 1 MOflurbiprofen tabs 100mg 1 MOibu tabs 600mg, 800mg 1ibuprofen 1 MOketoprofen er 1 MOketoprofen caps 50mg 1ketoprofen caps 25mg 1 MO

* You can find information on what the symbols and abbreviations on this table mean by going to page 8.

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Drug name Drug tier Requirements/Limitsketorolac tromethamine inj 15mg/ml, 30mg/ml, 60mg/2ml

1 QL (20 ML per 30 days) PA MO

ketorolac tromethamine tabs 10mg 1 QL (20 EA per 30 days) PA MOmeclofenamate sodium 1 MOmeloxicam 1 MOnabumetone 1 MOnaproxen 1 MOnaproxen dr 1 MONAPROXEN SODIUM CR TABS 375MG

3 MO

naproxen sodium er tabs 500mg 1 MOnaproxen sodium tabs 275mg, 550mg

1 MO

naproxen/esomeprazole magnesium 4 MOoxaprozin 1 MOpiroxicam 1 MOsulindac 1 MOVIMOVO 4 MO

OPIOID ANALGESICS, LONG-ACTING buprenorphine transdermal patch 1 QL (4 EA per 28 days) PA MOfentanyl transdermal patch 1 QL (10 EA per 30 days) PA MOHYSINGLA ER 2 QL (30 EA per 30 days) PA MOMETHADONE HCL INJ 4 PAmethadone hcl oral soln 1 QL (450 ML per 30 days) PA MOmethadone hcl tabs 1 QL (90 EA per 30 days) PA MOmethadone hcl conc 1 QL (90 ML per 30 days) PA MOmorphine sulfate er cp24 (generic Avinza) 120mg, 30mg, 45mg, 60mg, 75mg, 90mg

1 QL (30 EA per 30 days) PA MO

morphine sulfate er cp24 (generic Kadian) 100mg, 10mg, 20mg, 30mg, 40mg, 50mg, 60mg, 80mg


morphine sulfate er tbcr 100mg, 200mg, 30mg, 60mg


morphine sulfate er tbcr 15mg 1 QL (90 EA per 30 days) PA MOTRAMADOL HCL ER CP24 3 QL (30 EA per 30 days) PA MOtramadol hcl er tb24 1 QL (30 EA per 30 days) PA MO

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Drug name Drug tier Requirements/LimitsOPIOID ANALGESICS, SHORT-ACTING

acetaminophen/codeine tabs 1 QL (180 EA per 30 days) MOacetaminophen/codeine soln 1 QL (2700 ML per 30 days) MObutorphanol tartrate nasal soln 1 QL (5 ML per 30 days) MObutorphanol tartrate inj 1mg/ml 1butorphanol tartrate inj 2mg/ml 1 MOCODEINE SULFATE TABS 30MG 3 QL (180 EA per 30 days)CODEINE SULFATE TABS 15MG, 60MG

3 QL (180 EA per 30 days) MO

endocet 1 QL (180 EA per 30 days)fentanyl citrate oral transmucosal lozenge


hydrocodone bitartrate/acetaminophen tabs


hydrocodone bitartrate/acetaminophen soln

1 QL (2700 ML per 30 days) MO

hydrocodone/acetaminophen 1 QL (180 EA per 30 days) MOhydrocodone/ibuprofen 1 QL (150 EA per 30 days) MOhydromorphone hcl tabs 1 QL (180 EA per 30 days) MOhydromorphone hcl liqd 1 QL (600 ML per 30 days) MOHYDROMORPHONE HCL INJ 1MG/ML, 4MG/ML

3 B/D MO

hydromorphone hcl inj 10mg/ml 1 B/Dhydromorphone hcl inj 2mg/ml 1 B/D MOHYDROMORPHONE HYDROCHLORIDE PF INJ 1MG/ML

3 B/D

HYDROMORPHONE HYDROCHLORIDE PF INJ 4MG/ML

3 B/D MO

hydromorphone hydrochloride pf inj 2mg/ml, 50mg/5ml

1 B/D

lorcet 1 QL (180 EA per 30 days)lorcet hd 1 QL (180 EA per 30 days)lorcet plus 1 QL (180 EA per 30 days)morphine sulfate tabs 1 QL (180 EA per 30 days) MOMORPHINE SULFATE INJ 10MG/ML PF, 25MG/ML PF, 2MG/ML PF, 4MG/ML PF, 50MG/ML, 5MG/ML PF, 8MG/ML PF

3 B/D

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Drug name Drug tier Requirements/Limitsmorphine sulfate iv inj 0.5mg/ml, 10mg/ml, 1mg/ml, 4mg/ml, 8mg/ml

1 B/D

morphine sulfate pf inj 1mg/ml 1 B/D MOmorphine sulfate oral soln 100mg/5ml


morphine sulfate oral soln 10mg/5ml, 20mg/5ml


nalbuphine hcl 1 MOoxycodone hcl 1 QL (180 EA per 30 days) MOoxycodone hydrochloride oral conc 1 QL (180 ML per 30 days) MOoxycodone hydrochloride soln 1 QL (900 ML per 30 days) MOoxycodone hydrochloride tabs 30mg 1 QL (120 EA per 30 days) MOoxycodone hydrochloride tabs 10mg, 15mg, 20mg, 5mg


oxycodone/acetaminophen 1 QL (180 EA per 30 days) MOoxycodone/aspirin 1 QL (180 EA per 30 days) MOoxymorphone hydrochloride immediate release tabs


tramadol hcl tabs 50mg 1 QL (240 EA per 30 days) MOtramadol hydrochloride tabs 100mg 1 QL (120 EA per 30 days) MOtramadol hydrochloride/acetaminophen


ANESTHETICSLOCAL ANESTHETICS

lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4%

1

lidocaine hydrochloride 1ANTI-INFECTIVES

ANTI-INFECTIVES - MISCELLANEOUS albendazole 4 MOALINIA 4 MOamikacin sulfate 1 MOatovaquone 1 PA MOaztreonam 1 MOCAYSTON 4 PA LAchloramphenicol inj 1gm 1clindamycin hcl caps 300mg, 75mg 1 MO

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Drug name Drug tier Requirements/Limitsclindamycin hydrochloride caps 150mg

1 MO

clindamycin palmitate hcl 1 MOclindamycin phosphate/dextrose 1clindamycin phosphate inj 300mg/2ml, 9000mg/60ml

1

clindamycin phosphate inj 600mg/4ml, 900mg/6ml

1 MO

CLINDAMYCIN/SODIUM CHLORIDE 3colistimethate inj 1 PA MOdapsone tabs 100mg, 25mg 1 MODAPTOMYCIN INJ 350MG 4daptomycin inj 500mg 4 MOEMVERM 4 QL (12 EA per 365 days) MOertapenem 1 MOgentamicin sulfate pediatric 1 MOgentamicin sulfate/0.9% sodium chloride inj 1.2mg/ml; 0.9%, 1mg/ml; 0.9%, 2mg/ml; 0.9%

1

gentamicin sulfate/0.9% sodium chloride inj 1.6mg/ml; 0.9%

1 MO

gentamicin sulfate inj 40mg/ml 1 MOimipenem/cilastatin 1 MOisotonic gentamicin 1 MOivermectin 1 MOlinezolid tabs 1 QL (56 EA per 28 days) PA MOlinezolid oral susp 4 QL (1800 ML per 28 days) PA MOLINEZOLID INJ 600MG/300ML; 0.9% 3 PAlinezolid inj 600mg/300ml 1 PAmeropenem inj 500mg 1meropenem inj 1gm 1 MOmethenamine hippurate 1 MOMETHENAMINE MANDELATE 3 MOmetronidazole in nacl 0.79% 1metronidazole caps 375mg 1 MOmetronidazole tabs 250mg, 500mg 1 MOneomycin tabs 1 MOnitrofurantoin macrocrystals 1 MO

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Drug name Drug tier Requirements/Limitsnitrofurantoin monohydrate 1 MOnitrofurantoin oral suspension 1 MOparomomycin caps 1 MOpentamidine isethionate inj 1pentamidine isethionate inhalation solr

1 B/D

praziquantel 1 MOSIVEXTRO INJ 4SIVEXTRO TABS 4 MOstreptomycin sulfate inj 1 MOSULFADIAZINE 3 MOsulfamethoxazole/trimethoprim 1 MOsulfamethoxazole/trimethoprim ds 1 MOSYNERCID 4tinidazole 1 MOtobramycin nebu 300mg/5ml 1 QL (280 ML per 56 days) PAtobramycin sulfate inj 1.2gm, 10mg/ml, 40mg/ml

1

tobramycin sulfate inj 1.2gm/30ml, 80mg/2ml

1 MO

trimethoprim tabs 1 MOVANCOMYCIN HCL INJ 0.9%; 1GM/200ML

3

vancomycin hcl inj 100gm, 10gm 1vancomycin hydrochloride caps 125mg


vancomycin hydrochloride caps 250mg


VANCOMYCIN HYDROCHLORIDE INJ 1.25GM, 1.5GM, 250MG, 500MG/100ML

3

vancomycin hydrochloride inj 1gm, 5gm, 750mg

1

vancomycin hydrochloride inj 500mg 1 MOVANCOMYCIN INJ 500MG/100ML, 750MG/150ML

3

ANTIFUNGALS ABELCET 3 B/D

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Drug name Drug tier Requirements/LimitsAMBISOME 4 B/Damphotericin b 1 B/D MOcaspofungin acetate inj 70mg 1caspofungin acetate inj 50mg 4fluconazole 1 MOfluconazole in nacl 200mg; 0.9% 1fluconazole in sodium chloride 400mg; 0.9%

1

flucytosine 4 MOgriseofulvin microsize 1 MOgriseofulvin ultramicrosize 1 MOitraconazole 1 PA MOketoconazole tabs 200mg 1 PA MOmicafungin inj 50mg 1micafungin inj 100mg 4MYCAMINE INJ 50MG 3 MOMYCAMINE INJ 100MG 4NOXAFIL 4 QL (630 ML per 30 days) MOnystatin tabs 500000unit 1 MOposaconazole dr 4 QL (93 EA per 30 days) MOterbinafine hcl tabs 1 QL (90 EA per 365 days) MOvoriconazole tabs 1 MOvoriconazole inj 1 PAvoriconazole oral susp 1 PA MO

ANTIMALARIALS atovaquone/proguanil hcl 1 MOchloroquine phosphate 1 MOCOARTEM 3 MOmefloquine hcl 1 MOprimaquine phosphate 1 MOquinine sulfate 1 PA MO

ANTIRETROVIRAL AGENTS abacavir 1 MOAPTIVUS SOLN 4APTIVUS CAPS 4 MOatazanavir sulfate caps 150mg, 300mg

1 MO

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Drug name Drug tier Requirements/Limitsatazanavir sulfate caps 200mg 4 MOCRIXIVAN 3 MOdidanosine caps 200mg, 250mg, 400mg

1 MO

EDURANT 4 MOefavirenz caps 1 MOefavirenz tabs 4 MOEMTRIVA 2 MOfosamprenavir calcium 4 MOFUZEON 4INTELENCE TABS 25MG 3INTELENCE TABS 100MG, 200MG 4 MOINVIRASE TABS 4 MOISENTRESS HD 4 MOISENTRESS PACK 2 MOISENTRESS TABS 4 MOISENTRESS CHEW 25MG 2 MOISENTRESS CHEW 100MG 4 MOlamivudine soln 10mg/ml 1 MOlamivudine tabs 150mg, 300mg 1 MOLEXIVA 3 MOnevirapine er tb24 100mg 1nevirapine er tb24 400mg 1 MOnevirapine susp 1nevirapine tabs 1 MONORVIR PACK, ORAL SOLN 3 MOPIFELTRO 4 MOPREZISTA SUSP 4 QL (400 ML per 30 days) MOPREZISTA TABS 75MG 3 QL (480 EA per 30 days) MOPREZISTA TABS 150MG 4 QL (240 EA per 30 days) MOPREZISTA TABS 800MG 4 QL (30 EA per 30 days) MOPREZISTA TABS 600MG 4 QL (60 EA per 30 days) MORESCRIPTOR TABS 200MG 3 MOREYATAZ CAPS 150MG,200 MG, PACK

4 MO

ritonavir 1 MORUKOBIA 4

18 Updated 10/01/20

Drug name Drug tier Requirements/LimitsSELZENTRY SOLN 4SELZENTRY TABS 25MG 2SELZENTRY TABS 75MG 4SELZENTRY TABS 150MG, 300MG 4 MOstavudine 1 MOtenofovir tabs 1 MOTIVICAY PD 3TIVICAY TABS 10MG 2 MOTIVICAY TABS 25MG, 50MG 4 MOTROGARZO 4 LATYBOST 3 MOVIDEX EC CAPS 125MG 3 MOVIDEX PEDIATRIC 3 MOVIRACEPT TABS 4 MOVIREAD 4 MOzidovudine 1 MO

ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate/lamivudine 1 MOabacavir sulfate/lamivudine/zidovudine

4 MO

ATRIPLA 4 MOBIKTARVY 4 MOCIMDUO 4 MOCOMPLERA 4 MODELSTRIGO 4 MODESCOVY 4 MODOVATO 4 MOEVOTAZ 4 MOGENVOYA 4 MOJULUCA 4 MOKALETRA TABS 100MG; 25MG 3 MOKALETRA TABS 200MG; 50MG 4 MOlamivudine/zidovudine 1 MOlopinavir/ritonavir 1 MOODEFSEY 4 MOPREZCOBIX 4 MOSTRIBILD 4 MO

19Updated 10/01/20

Drug name Drug tier Requirements/LimitsSYMFI 4 MOSYMFI LO 4 MOSYMTUZA 4 MOTEMIXYS 4 MOTRIUMEQ 4 MOTRUVADA 4 QL (30 EA per 30 days) MO

ANTITUBERCULAR AGENTS cycloserine 4 MOethambutol hydrochloride tabs 400mg

1 MO

isoniazid inj 1isoniazid syrp, tabs 1 MOPASER 3 MOPRETOMANID 3 QL (30 EA per 30 days) PAPRIFTIN 3 MOpyrazinamide 1 MOrifabutin 1 MOrifampin inj 1rifampin caps 1 MORIFATER 3 MOSIRTURO TABS 20MG 4 PASIRTURO TABS 100MG 4 PA LATRECATOR 3 MO

ANTIVIRALS acyclovir sodium inj 50mg/ml 1 B/Dacyclovir caps 200mg 1 MOacyclovir susp 200mg/5ml 1 MOacyclovir tabs 400mg, 800mg 1 MOadefovir dipivoxil 1 QL (30 EA per 30 days) MOBARACLUDE 3 MOentecavir 1 QL (30 EA per 30 days) MOEPCLUSA 4 PAEPIVIR HBV SOLN 3 MOfamciclovir tabs 500mg 1 QL (21 EA per 30 days) MOfamciclovir tabs 125mg, 250mg 1 QL (60 EA per 30 days) MOganciclovir inj 500mg/10ml, 500mg 1 B/DHARVONI TABS 4 PA

20 Updated 10/01/20

Drug name Drug tier Requirements/Limitslamivudine tabs 100mg 1 MOMAVYRET 4 PAoseltamivir phosphate caps 30mg 1 QL (168 EA per 365 days) MOoseltamivir phosphate caps 45mg, 75mg


oseltamivir phosphate oral susp 1 QL (1080 ML per 365 days) MOPEGASYS 4 PAPREVYMIS 4 QL (28 EA per 28 days) MORELENZA DISKHALER 2 QL (120 EA per 365 days) MOribavirin caps, tabs 1ribavirin inh 4rimantadine hydrochloride 1 MOvalacyclovir hcl tabs 1gm 1 MOvalacyclovir hydrochloride tabs 500mg

1 MO

valganciclovir hydrochloride oral soln 4 MOvalganciclovir tabs 4 MOVEMLIDY 4 MOVOSEVI 4 PA

CEPHALOSPORINS cefaclor 1 MOCEFACLOR ER 3 MOcefadroxil 1 MOCEFAZOLIN INJ 2GM/100ML; 4% 2CEFAZOLIN SODIUM INJ 1GM/50ML; 4%

2

CEFAZOLIN SODIUM INJ 100GM, 300GM

3

cefazolin sodium iv inj 1gm 1cefazolin sodium inj 10gm, 1gm, 500mg

1 MO

cefdinir 1 MOcefepime 1 MOcefixime 1 MOcefotetan 1cefoxitin sodium 1cefpodoxime proxetil 1 MO

21Updated 10/01/20

Drug name Drug tier Requirements/Limitscefprozil 1 MOCEFTAZIDIME/DEXTROSE 3ceftazidime inj 6gm 1ceftazidime inj 1gm, 2gm 1 MOceftriaxone in iso-osmotic dextrose 1CEFTRIAXONE SODIUM INJ 100GM 3ceftriaxone sodium iv inj 1gm 1ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg

1 MO

cefuroxime axetil tabs 1 MOcefuroxime sodium inj 1.5gm, 7.5gm 1cefuroxime sodium inj 750mg 1 MOcephalexin 1 MOSUPRAX ORAL SUSP 500MG/5ML 2SUPRAX CHEW 100MG 3SUPRAX CHEW 200MG 3 MOtazicef 1TEFLARO 4

ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK 2 MOazithromycin inj, oral susp, tabs 1 MOclarithromycin er 1 MOclarithromycin oral susp, tabs 1 MODIFICID 4 MOERYTHROCIN LACTOBIONATE INJ 500MG

3

erythrocin stearate tabs 250mg 1 MOerythromycin base 1 MOerythromycin dr 1 MOerythromycin ethylsuccinate tabs 1 MOerythromycin stearate 1 MOerythromycin cpep 250mg 1 MO

FLUOROQUINOLONES ciprofloxacin hcl tabs 100mg, 750mg 1 MOciprofloxacin hydrochloride tabs 250mg, 500mg

1 MO

22 Updated 10/01/20

Drug name Drug tier Requirements/Limitsciprofloxacin i.v.-in d5w inj 200mg/100ml; 5%

1

ciprofloxacin i.v.-in d5w inj 400mg/200ml; 5%

1 MO

levofloxacin in d5w 1levofloxacin inj 25mg/ml 1levofloxacin oral soln 25mg/ml 1 MOlevofloxacin tabs 250mg, 500mg, 750mg

1 MO

moxifloxacin hydrochloride/sodium hydrochloride inj

1

moxifloxacin hydrochloride inj 400mg/250ml

1

moxifloxacin hydrochloride tabs 400mg

1 MO

PENICILLINS amoxicillin 1 MOamoxicillin/clavulanate potassium 1 MOamoxicillin/clavulanate potassium er 1 MOampicillin caps 500mg 1 MOampicillin sodium inj 10gm, 125mg, 1gm iv, 250mg, 2gm iv

1

ampicillin sodium inj 1gm, 2gm, 500mg

1 MO

ampicillin-sulbactam 1BICILLIN L-A 3 MOdicloxacillin caps 1 MOnafcillin sodium inj 10gm, 1gm, 2gm iv

1

nafcillin sodium inj 2gm 1 MOnafcillin sodium inj 10gm iv 4oxacillin sodium inj 10gm, 1gm 1oxacillin sodium inj 2gm 1 MOpenicillin g potassium 1 MOPENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE

3

PENICILLIN G PROCAINE 3 MOpenicillin g sodium 1

23Updated 10/01/20

Drug name Drug tier Requirements/Limitspenicillin v potassium 1 MOpiperacillin sodium/tazobactam sodium

1

piperacillin/tazobactam 1TETRACYCLINES

doxy 100 inj 1 MOdoxycycline hyclate caps, tabs 1 MOdoxycycline hyclate dr 1 MOdoxycycline monohydrate 1 MOdoxycycline oral susp 25mg/5ml 1 MOdoxycycline tabs 50mg 1 MOminocycline hcl caps 75mg 1 MOminocycline hcl tabs 1 ST MOminocycline hydrochloride caps 100mg, 50mg

1 MO

minocycline hydrochloride er 1 ST MOmondoxyne nl caps 100mg, 75mg 1morgidox 1x100mg 1morgidox 2x100mg 1okebo 1tetracycline hydrochloride 1 MOtigecycline 4

ANTINEOPLASTIC AGENTSALKYLATING AGENTS

BENDEKA 4busulfan 4carboplatin 1carmustine 4cisplatin inj 100mg/100ml, 200mg/200ml, 50mg/50ml

1

cyclophosphamide inj 1cyclophosphamide caps 1 B/D MOGLEOSTINE CAPS 10MG 3 MOGLEOSTINE CAPS 100MG, 40MG 4 MOIFEX 3IFOSFAMIDE INJ 3GM 3

24 Updated 10/01/20

Drug name Drug tier Requirements/Limitsifosfamide inj 1gm/20ml, 1gm, 3gm/60ml

1

LEUKERAN 4 MOmelphalan hydrochloride inj 4melphalan tabs 1 B/D MOoxaliplatin 1paraplatin 1thiotepa 4

ANTIBIOTICS bleomycin sulfate 1 B/Ddactinomycin 4DAUNORUBICIN HYDROCHLORIDE INJ 50MG/10ML

3

daunorubicin hydrochloride inj 20mg/4ml

1

doxorubicin hcl liposome 2mg/ml 1doxorubicin hydrochloride liposomal 20mg/10ml, 50mg/25ml

1

epirubicin hcl 1idarubicin hcl 1mitomycin inj 20mg, 5mg 1mitomycin inj 40mg 4mutamycin inj 20mg, 5mg 1mutamycin inj 40mg 4

ANTIMETABOLITES adrucil 1 B/DALIMTA 4azacitidine 4cladribine 1 B/Dclofarabine 4cytarabine aqueous 1 B/Ddecitabine 1fludarabine phosphate 1fluorouracil inj 1gm/20ml, 2.5gm/50ml, 500mg/10ml, 5gm/100ml

1 B/D

gemcitabine hcl inj 1gm, 200mg, 2gm 1

25Updated 10/01/20

Drug name Drug tier Requirements/LimitsGEMCITABINE HYDROCHLORIDE INJ 1GM/10ML, 2GM/20ML

3

gemcitabine hydrochloride inj 200mg/2ml

1

gemcitabine inj 38mg/ml 1mercaptopurine 1 MOmethotrexate sodium inj 1gm/40ml, 1gm

1

methotrexate sodium inj 250mg/10ml, 50mg/2ml

1 MO

methotrexate pf inj 50mg/2ml 1 MOPURIXAN 4TABLOID 3 MO

HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate 4 PAanastrozole 1 MObicalutamide 1 MODEPO-PROVERA INJ 400MG/ML 3EMCYT 3 MOERLEADA 4 PA LAexemestane 1 MOflutamide 1 MOfulvestrant 4letrozole 1 MOleuprolide acetate 1 PALUPRON DEPOT (1-MONTH) INJ 3.75MG

4 PA

LUPRON DEPOT (3-MONTH) INJ 11.25MG

4 PA

LYSODREN 2megestrol acetate tabs 20mg, 40mg 1 MOnilutamide 4 MONUBEQA 4 PASOLTAMOX 4 MOtamoxifen citrate 1 MOtoremifene citrate 1 PA MOTRELSTAR MIXJECT 4 PAXTANDI 4 PA LA

26 Updated 10/01/20

Drug name Drug tier Requirements/LimitsZYTIGA 4 PA LA

IMMUNOMODULATORS POMALYST CAPS 1MG, 2MG 4 QL (21 EA per 21 days) PA LAPOMALYST CAPS 3MG, 4MG 4 QL (21 EA per 28 days) PA LAREVLIMID 4 QL (28 EA per 28 days) PA LATHALOMID CAPS 100MG, 50MG 4 QL (28 EA per 28 days) PATHALOMID CAPS 150MG, 200MG 4 QL (56 EA per 28 days) PA

MISCELLANEOUS arsenic trioxide 4bexarotene 4 PAdacarbazine 1hydroxyurea 1 MOIMLYGIC 4 PAINQOVI 4 QL (5 EA per 28 days) PAirinotecan hcl inj 100mg/5ml 1irinotecan hydrochloride inj 300mg/15ml, 40mg/2ml

1

irinotecan inj 500mg/25ml 1KISQALI FEMARA 200MG-2.5MG CO-PACK

4 PA

KISQALI FEMARA 400MG-2.5MG CO-PACK

4 PA

KISQALI FEMARA 600MG-2.5MG CO-PACK

4 PA

LONSURF 4 PAMATULANE 4 LAmitoxantrone hcl 1NIPENT 4SYLATRON KIT 200MCG, 300MCG 4 PASYNRIBO 4 PATOPOTECAN HCL INJ 4MG/4ML 4topotecan hcl inj 4mg 4tretinoin caps 10mg 4 MO

MITOTIC INHIBITORS ABRAXANE 4DOCETAXEL INJ 160MG/16ML 3

27Updated 10/01/20

Drug name Drug tier Requirements/LimitsDOCETAXEL INJ 160MG/8ML, 200MG/10ML, 20MG/2ML, 80MG/8ML

4

docetaxel inj 20mg/ml, 80mg/4ml 1etoposide inj 1paclitaxel inj 100mg/16.7ml, 150mg/25ml, 300mg/50ml, 30mg/5ml

1

toposar 1vinblastine sulfate 1 B/Dvincristine sulfate 1 B/Dvinorelbine tartrate 1

MOLECULAR TARGET AGENTS AFINITOR TABS 10MG 4 QL (30 EA per 30 days) PAAFINITOR DISPERZ TBSO 2MG 4 QL (150 EA per 30 days) PAAFINITOR DISPERZ TBSO 5MG 4 QL (60 EA per 30 days) PAAFINITOR DISPERZ TBSO 3MG 4 QL (90 EA per 30 days) PAALECENSA 4 PA LAALUNBRIG 4 PA LAAVASTIN 4 PA LAAYVAKIT 4 QL (30 EA per 30 days) PA MOBALVERSA TABS 5MG 4 QL (28 EA per 28 days) PA MOBALVERSA TABS 4MG 4 QL (56 EA per 28 days) PA MOBALVERSA TABS 3MG 4 QL (84 EA per 28 days) PA MOBELEODAQ 4 PABORTEZOMIB 4 PABOSULIF 4 PABRAFTOVI 4 PA LA MOBRUKINSA 4 QL (120 EA per 30 days) PA MOCABOMETYX 4 QL (30 EA per 30 days) PA LACALQUENCE 4 PA LA MOCAPRELSA 4 PA LA MOCOMETRIQ 4 PA LACOPIKTRA 4 PA LA MOCOTELLIC 4 PA LADAURISMO 4 PA LAENHERTU 4 PAERIVEDGE 4 PA LA

28 Updated 10/01/20

Drug name Drug tier Requirements/Limitserlotinib hydrochloride tabs 100mg, 150mg

4 QL (30 EA per 30 days) PA

erlotinib hydrochloride tabs 25mg 4 QL (90 EA per 30 days) PAeverolimus tabs 2.5mg, 5mg, 7.5mg 4 QL (30 EA per 30 days) PAFARYDAK CAPS 10MG, 20MG 4 PA LAGILOTRIF 4 PA LA MOHERCEPTIN 4 PAHERCEPTIN HYLECTA 4 PAIBRANCE TABS 4 QL (21 EA per 28 days) PAIBRANCE CAPS 4 QL (21 EA per 28 days) PA LAICLUSIG 4 PA LA MOIDHIFA 4 QL (30 EA per 30 days) PA LAimatinib mesylate tabs 400mg 4 QL (60 EA per 30 days) PAimatinib mesylate tabs 100mg 4 QL (90 EA per 30 days) PAIMBRUVICA 4 PA LA MOINLYTA TABS 5MG 4 QL (120 EA per 30 days) PA LAINLYTA TABS 1MG 4 QL (180 EA per 30 days) PA LAINREBIC 4 QL (120 EA per 30 days) PAIRESSA 4 PA LAJAKAFI 4 QL (60 EA per 30 days) PA LAKADCYLA 4KEYTRUDA 4 PAKISQALI 4 PALENVIMA 10 MG DAILY DOSE 4 PA LALENVIMA 12MG DAILY DOSE 4 PA LALENVIMA 14 MG DAILY DOSE 4 PA LALENVIMA 18 MG DAILY DOSE 4 PA LALENVIMA 20 MG DAILY DOSE 4 PA LALENVIMA 24 MG DAILY DOSE 4 PA LALENVIMA 4 MG DAILY DOSE 4 PA LALENVIMA 8 MG DAILY DOSE 4 PA LALIBTAYO 4 PALORBRENA 4 PA LALUMOXITI 4 PALYNPARZA 4 PA LAMEKINIST 4 PA LAMEKTOVI 4 PA LA

29Updated 10/01/20

Drug name Drug tier Requirements/LimitsMYLOTARG 4 PA LANERLYNX 4 PA LANEXAVAR 4 PA LANINLARO 4 PAODOMZO 4 PA LAPADCEV 4 PAPEMAZYRE 4 QL (14 EA per 21 days) PA MOPIQRAY 200MG DAILY DOSE 4 QL (28 EA per 28 days) PAPIQRAY 250MG DAILY DOSE 4 QL (56 EA per 28 days) PAPIQRAY 300MG DAILY DOSE 4 QL (56 EA per 28 days) PAPOLIVY 4 PAPOTELIGEO 4 PAQINLOCK 4 QL (90 EA per 30 days) PA MORETEVMO CAPS 80MG 4 QL (120 EA per 30 days) PARETEVMO CAPS 40MG 4 QL (180 EA per 30 days) PARITUXAN 4 PA LARITUXAN HYCELA 4 PA LAROMIDEPSIN 4ROZLYTREK CAPS 100MG 4 QL (150 EA per 30 days) PAROZLYTREK CAPS 200MG 4 QL (90 EA per 30 days) PARUBRACA 4 PA LARYDAPT 4 PASARCLISA 4 PASPRYCEL 4 PASTIVARGA 4 PA LASUTENT 4 QL (30 EA per 30 days) PATABRECTA 4 QL (112 EA per 28 days) PATAFINLAR 4 PA LATAGRISSO 4 QL (30 EA per 30 days) PA LATALZENNA 4 PA LATASIGNA 4 PATAZVERIK 4 QL (240 EA per 30 days) PA MOTECENTRIQ INJ 840MG/14ML 4 PATECENTRIQ INJ 1200MG/20ML 4 PA LAtemsirolimus 4TIBSOVO 4 PA LATUKYSA TABS 150MG 4 QL (120 EA per 30 days) PA MO

30 Updated 10/01/20

Drug name Drug tier Requirements/LimitsTUKYSA TABS 50MG 4 QL (240 EA per 30 days) PA MOTURALIO 4 QL (120 EA per 30 days) PA MOTYKERB 4 PA LAVELCADE 4 PAVENCLEXTA STARTING PACK 4 PA LA MOVENCLEXTA TABS 10MG 3 PA LA MOVENCLEXTA TABS 100MG, 50MG 4 PA LA MOVERZENIO 4 PA LAVITRAKVI 4 PA LAVIZIMPRO 4 PA LAVOTRIENT 4 PA LAXALKORI 4 PA LAXOSPATA 4 PA LA MOXPOVIO 100 MG ONCE WEEKLY 4 QL (20 EA per 28 days) PA MOXPOVIO 40 MG ONCE WEEKLY 4 QL (8 EA per 28 days) PAXPOVIO 40 MG TWICE WEEKLY 4 QL (16 EA per 28 days) PAXPOVIO 60 MG ONCE WEEKLY 4 QL (12 EA per 28 days) PA MOXPOVIO 60 MG TWICE WEEKLY 4 QL (24 EA per 28 days) PAXPOVIO 80 MG ONCE WEEKLY 4 QL (16 EA per 28 days) PA MOXPOVIO 80 MG TWICE WEEKLY 4 QL (32 EA per 28 days) PA MOYERVOY 4 PAZEJULA 4 PA LA MOZELBORAF 4 PA LAZOLINZA 4 PAZYDELIG 4 PA LAZYKADIA 4 PA

PROTECTIVE AGENTS dexrazoxane 1ELITEK 4KHAPZORY 4 B/Dleucovorin calcium inj 1leucovorin calcium tabs 1 MOlevoleucovorin calcium inj 175mg/17.5ml, 250mg/25ml

1

levoleucovorin inj 50mg 4mesna 1MESNEX 4 MO

31Updated 10/01/20

Drug name Drug tier Requirements/LimitsCARDIOVASCULAR

ACE INHIBITOR COMBINATIONS amlodipine besylate/benazepril hydrochloride


benazepril hcl/hydrochlorothiazide 1 MOcaptopril/hydrochlorothiazide 1 MOenalapril maleate/hydrochlorothiazide

1 MO

fosinopril sodium/hydrochlorothiazide

1 MO

lisinopril/hydrochlorothiazide 1 MOquinapril/hydrochlorothiazide 1 MOtrandolapril/verapamil hcl er 1 MO

ACE INHIBITORS benazepril hcl tabs 10mg, 50mg, 5mg 1 MObenazepril hydrochloride tabs 20mg 1 MOcaptopril 1 MOenalapril maleate 1 MOfosinopril sodium 1 MOlisinopril 1 MOmoexipril hcl 1 MOperindopril erbumine 1 MOquinapril hcl tabs 20mg, 40mg, 5mg 1 MOquinapril hydrochloride tabs 10mg 1 MOramipril 1 MOtrandolapril 1 MO

ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone 1 MOspironolactone 1 MO

ALPHA BLOCKERS doxazosin mesylate 1 MOprazosin hcl caps 1mg, 5mg 1 MOprazosin hydrochloride caps 2mg 1 MOterazosin hcl caps 10mg, 1mg, 5mg 1 MOterazosin hydrochloride caps 2mg 1 MO

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate/valsartan 1 QL (30 EA per 30 days) MO

32 Updated 10/01/20

Drug name Drug tier Requirements/Limitsamlodipine/olmesartan medoxomil 1 QL (30 EA per 30 days) MOamlodipine/valsartan/hctz tabs 10mg; 12.5mg; 160mg, 10mg; 25mg; 160mg, 10mg; 25mg; 320mg, 5mg; 25mg; 160mg


amlodipine/valsartan/hydrochlorothiazide tabs 5mg; 12.5mg; 160mg


candesartan cilexetil/hydrochlorothiazide tabs 32mg; 12.5mg, 32mg; 25mg


candesartan cilexetil/hydrochlorothiazide tabs 16mg; 12.5mg


EDARBYCLOR 3 QL (30 EA per 30 days) ST MOENTRESTO 2 MOirbesartan/hydrochlorothiazide 1 QL (30 EA per 30 days) MOlosartan potassium/hydrochlorothiazide


olmesartan medoxomil/amlodipine/hydrochlorothiazide


olmesartan medoxomil/hydrochlorothiazide


telmisartan/amlodipine 1 QL (30 EA per 30 days) MOtelmisartan/hydrochlorothiazide tabs 12.5mg; 40mg, 25mg; 80mg


telmisartan/hydrochlorothiazide tabs 12.5mg; 80mg


valsartan/hydrochlorothiazide 1 QL (30 EA per 30 days) MOANGIOTENSIN II RECEPTOR ANTAGONISTS

candesartan cilexetil 1 QL (30 EA per 30 days) MOEDARBI 3 QL (30 EA per 30 days) ST MOeprosartan mesylate 1 QL (30 EA per 30 days)irbesartan 1 QL (30 EA per 30 days) MOlosartan potassium tabs 100mg 1 QL (30 EA per 30 days) MOlosartan potassium tabs 25mg, 50mg 1 QL (60 EA per 30 days) MOolmesartan medoxomil 1 QL (30 EA per 30 days) MOtelmisartan 1 QL (30 EA per 30 days) MOvalsartan tabs 320mg 1 QL (30 EA per 30 days) MO

33Updated 10/01/20

Drug name Drug tier Requirements/Limitsvalsartan tabs 160mg, 40mg, 80mg 1 QL (60 EA per 30 days) MO

ANTIARRHYTHMICS amiodarone hcl inj 50mg/ml 1amiodarone hcl tabs 200mg, 400mg 1 MOamiodarone hydrochloride inj 150mg/3ml, 450mg/9ml, 900mg/18ml

1

amiodarone hydrochloride tabs 100mg

1 MO

disopyramide phosphate 1 PA MOdofetilide 1flecainide acetate 1 MOLIDOCAINE HCL IN D5W 3LIDOCAINE HCL INJ 100MG/5ML 3lidocaine hcl prefilled syringe inj 100mg/5ml, 50mg/5ml

1

MULTAQ 3 MONORPACE CR 3 MOpacerone 1propafenone hcl tabs 1 MOpropafenone hydrochloride er 1 MOquinidine sulfate 1 MOsorine 1sotalol hcl 1 MOsotalol hcl (af) 1 MO

ANTILIPEMICS, FIBRATES fenofibrate 1 MOfenofibrate micronized 1 MOfenofibric acid dr caps 1 MOgemfibrozil 1 MO

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium 1 QL (30 EA per 30 days) MOfluvastatin caps 1 QL (60 EA per 30 days) MOfluvastatin sodium er tabs 1 QL (30 EA per 30 days) MOlovastatin 1 MOpravastatin sodium 1 QL (30 EA per 30 days) MOrosuvastatin calcium 1 QL (30 EA per 30 days) MOsimvastatin 1 QL (30 EA per 30 days) MO

34 Updated 10/01/20

Drug name Drug tier Requirements/LimitsANTILIPEMICS, MISCELLANEOUS

cholestyramine 1 MOcholestyramine light 1 MOcolesevelam hydrochloride 1 MOcolestipol hcl 1 MOezetimibe 1 MOezetimibe/simvastatin 1 QL (30 EA per 30 days) MOFENOFIBRIC ACID TABS 2JUXTAPID 4 PA LA MOniacin er tbcr 1000mg, 750mg 1 MOniacin er tbcr 500mg 1 QL (60 EA per 30 days) MOniacin tabs 500mg 1 MOniacor 1 MOomega-3-acid ethyl esters 1 QL (120 EA per 30 days) MOPRALUENT 2 PA MOprevalite 1 MOVASCEPA 3 MO

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol/chlorthalidone 1 MObisoprolol fumarate/hydrochlorothiazide

1 MO

metoprolol/hydrochlorothiazide 1 MOpropranolol/hydrochlorothiazide 1 MO

BETA-BLOCKERS acebutolol hcl caps 200mg 1 MOacebutolol hydrochloride caps 400mg 1 MOatenolol 1 MObetaxolol hcl tabs 10mg, 20mg 1 MObisoprolol fumarate 1 MOBYSTOLIC TABS 10MG, 2.5MG, 5MG 3 QL (30 EA per 30 days) MOBYSTOLIC TABS 20MG 3 QL (60 EA per 30 days) MOcarvedilol phosphate er caps 1 QL (30 EA per 30 days) MOcarvedilol tabs 1 MOlabetalol hydrochloride 1 MOmetoprolol succinate er 1 MOmetoprolol tartrate tabs 1 MO

35Updated 10/01/20

Drug name Drug tier Requirements/Limitsmetoprolol tartrate cartridge 5mg/5ml

1

metoprolol tartrate vial 5mg/5ml 1 MOnadolol 1 MOpindolol 1 MOpropranolol hcl er caps 120mg, 160mg

1 MO

propranolol hcl inj 1propranolol hcl oral soln, tabs 40mg, 80mg

1 MO

propranolol hydrochloride er caps 60mg, 80mg

1 MO

propranolol hydrochloride tabs 10mg, 20mg, 60mg

1 MO

timolol maleate tabs 10mg, 20mg, 5mg

1 MO

CALCIUM CHANNEL BLOCKERS afeditab cr tb24 30mg 1amlodipine besylate 1 MOcartia xt 1dilt-xr 1 MOdiltiazem hcl cd 1 MOdiltiazem hcl er caps, tabs 1 MOdiltiazem hcl tabs 1 MODILTIAZEM HCL INJ 100MG 3diltiazem hcl inj 125mg/25ml, 50mg/10ml

1

diltiazem hydrochloride inj 25mg/5ml 1felodipine er 1 MOisradipine 1 MOmatzim la 1 MOnicardipine hcl 1 MOnifedical xl 1nifedipine er 1 MOnimodipine 1 MOnisoldipine er 1 MONYMALIZE ORAL SOLN 4taztia xt 1

36 Updated 10/01/20

Drug name Drug tier Requirements/Limitstiadylt er cp24 120mg, 180mg, 240mg, 300mg, 360mg

1

tiadylt er cp24 420mg 1 MOverapamil hcl 40mg, 80mg 1 MOverapamil hcl er caps, tabs 1 MOVERAPAMIL HCL SR CP24 360MG 2 MOverapamil hcl sr cp24 120mg, 180mg, 240mg

1 MO

verapamil hcl sr tbcr 240mg 1 MOverapamil hydrochloride 1 MOverapamil hydrochloride er caps 200mg

1 MO

DIURETICS acetazolamide er caps 1 MOacetazolamide tabs 1 MOamiloride hcl 1 MOamiloride/hydrochlorothiazide 1 MObumetanide 1 MOchlorthalidone 1 MOfurosemide 1 MOhydrochlorothiazide 1 MOindapamide 1 MOmethazolamide 1 MOmetolazone 1 MOspironolactone/hydrochlorothiazide 1 MOtorsemide 1 MOtriamterene/hydrochlorothiazide 1 MO

MISCELLANEOUS aliskiren 1 MOamlodipine besylate/atorvastatin calcium

1 MO

BIDIL 3 MOclonidine hcl weekly patch 1 QL (8 EA per 28 days) MOclonidine hydrochloride tabs 1 MOCORLANOR SOLN 3CORLANOR TABS 3 MODEMSER 4 PA MO

37Updated 10/01/20

Drug name Drug tier Requirements/Limitsdigitek 1 QL (30 EA per 30 days)digox 1 QL (30 EA per 30 days)digoxin inj, oral soln 1 MOdigoxin tabs 1 QL (30 EA per 30 days) MOguanfacine hcl 1 PA MOhydralazine hcl 1 MOhydralazine hydrochloride tabs 1 MOmethyldopa 1 PA MOmidodrine hcl 1 MOminoxidil 1 MONORTHERA CAPS 200MG, 300MG 4 QL (180 EA per 30 days) PA LANORTHERA CAPS 100MG 4 QL (90 EA per 30 days) PA LAranolazine er 1 MO

NITRATES isosorbide dinitrate immediate release tabs

1 MO

isosorbide mononitrate er tabs 1 MOisosorbide mononitrate immediate release tabs

1 MO

minitran 1NITRO-BID 2 MONITRO-DUR 3 MOnitroglycerin lingual spray 0.4mg 1 MOnitroglycerin patch 1 MONITROGLYCERIN INJ 3nitroglycerin subl 1 MO

PULMONARY ARTERIAL HYPERTENSION ADEMPAS 4 QL (90 EA per 30 days) PA LAalyq 4 PAambrisentan 4 QL (30 EA per 30 days) PAbosentan tabs 62.5mg 4 QL (120 EA per 30 days) PAbosentan tabs 125mg 4 QL (60 EA per 30 days) PAepoprostenol sodium 1 B/D LAOPSUMIT 4 QL (30 EA per 30 days) PA LAsildenafil inj 4 QL (1125 ML per 30 days) PAsildenafil citrate tabs 20mg 1 QL (90 EA per 30 days) PAtadalafil (generic adcirca) tabs 20mg 4 PA

38 Updated 10/01/20

Drug name Drug tier Requirements/LimitsTRACLEER 4 QL (120 EA per 30 days) PAtreprostinil 4 PAVENTAVIS 4 PA

CENTRAL NERVOUS SYSTEMANTIANXIETY

alprazolam er tb24 0.5mg, 1mg 1 QL (30 EA per 30 days) MOalprazolam er tb24 3mg 1 QL (60 EA per 30 days) MOalprazolam er tb24 2mg 1 QL (90 EA per 30 days) MOALPRAZOLAM INTENSOL 3 QL (300 ML per 30 days) MOalprazolam tabs 0.25mg, 0.5mg 1 QL (120 EA per 30 days) MOalprazolam tabs 1mg, 2mg 1 QL (150 EA per 30 days) MObuspirone hcl tabs 15mg, 30mg 1 MObuspirone hydrochloride tabs 10mg, 5mg, 7.5mg

1 MO

chlordiazepoxide hcl tabs 10mg, 5mg 1 QL (120 EA per 30 days) MOchlordiazepoxide hydrochloride tabs 25mg


fluvoxamine maleate er 1 QL (60 EA per 30 days) MOfluvoxamine maleate tabs 1 MOlorazepam conc, inj 1 QL (150 ML per 30 days) MOlorazepam tabs 0.5mg 1 QL (120 EA per 30 days) MOlorazepam tabs 1mg, 2mg 1 QL (150 EA per 30 days) MOmeprobamate 1 PA MOoxazepam 1 QL (120 EA per 30 days) MO

ANTICONVULSANTS APTIOM 4 MOBANZEL 4 PA MOBRIVIACT INJ 4 PABRIVIACT ORAL SOLN, TABS 4 PA MOcarbamazepine chew, susp, tabs 1 MOcarbamazepine er 1 MOCELONTIN 3 MOclobazam tabs 1 PA MOclobazam susp 4 PA MOclonazepam odt tbdp 2mg 1 QL (300 EA per 30 days) MOclonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg


39Updated 10/01/20

Drug name Drug tier Requirements/Limitsclonazepam tabs 2mg 1 QL (300 EA per 30 days) MOclonazepam tabs 0.5mg, 1mg 1 QL (90 EA per 30 days) MOclorazepate dipotassium tabs 15mg 1 QL (180 EA per 30 days) PA MOclorazepate dipotassium tabs 3.75mg, 7.5mg


DIAZEPAM RECTAL GEL 3 MOdiazepam tabs 1 QL (120 EA per 30 days) PA MOdiazepam oral soln 1 QL (1200 ML per 30 days) PA MOdiazepam oral conc, inj 1 QL (240 ML per 30 days) PA MODILANTIN 3 MODILANTIN INFATABS 3 MODILANTIN-125 3 MOdivalproex sodium dr 1 MOdivalproex sodium er 1 MOdivalproex sodium sprinkle caps 1 MOEPIDIOLEX 4 QL (600 ML per 30 days) PA LAepitol 1ethosuximide 1 MOfelbamate 1 MOFINTEPLA 4 QL (360 ML per 30 days) PAfosphenytoin sodium inj 100mg pe/2ml

1

fosphenytoin sodium inj 500mg pe/10ml

1 MO

FYCOMPA SUSP 4 QL (720 ML per 30 days) PA MOFYCOMPA TABS 2MG 3 QL (60 EA per 30 days) PA MOFYCOMPA TABS 10MG, 12MG, 8MG 4 QL (30 EA per 30 days) PA MOFYCOMPA TABS 4MG, 6MG 4 QL (60 EA per 30 days) PA MOgabapentin caps 300mg 1 QL (360 EA per 30 days) MOgabapentin caps 100mg, 400mg 1 QL (90 EA per 30 days) MOgabapentin soln 1 QL (2160 ML per 30 days) MOgabapentin tabs 600mg 1 QL (180 EA per 30 days) MOgabapentin tabs 800mg 1 QL (90 EA per 30 days) MOlamotrigine chew, tabs 1 MOlamotrigine er 1 MOlamotrigine odt 1 MOlamotrigine starter kit/blue 1 MO

40 Updated 10/01/20

Drug name Drug tier Requirements/Limitslamotrigine starter kit/green 1 MOlamotrigine starter kit/orange 1 MOlevetiracetam er 1 MOlevetiracetam/sodium chloride 1levetiracetam inj 1levetiracetam oral soln, tabs 1 MONAYZILAM 3 QL (10 EA per 30 days) PA MOoxcarbazepine 1 MOPEGANONE 3 MOPHENOBARBITAL SODIUM INJ 3 PAPHENOBARBITAL TABS 3 QL (120 EA per 30 days) PA MOPHENOBARBITAL ELIX 3 QL (1500 ML per 30 days) PA MOPHENYTEK 3 MOphenytoin chew, susp 1 MOphenytoin sodium er caps 1 MOphenytoin sodium inj 1pregabalin caps 100mg, 150mg, 25mg, 50mg, 75mg


pregabalin caps 225mg, 300mg 1 QL (60 EA per 30 days) PA MOpregabalin caps 200mg 1 QL (90 EA per 30 days) PA MOpregabalin soln 1 QL (900 ML per 30 days) PA MOprimidone 1 MOroweepra 1roweepra xr 1SPRITAM 3 PA MOsubvenite 1subvenite starter kit/blue 1subvenite starter kit/green 1subvenite starter kit/orange 1SYMPAZAN FILM 5MG 3 PA MOSYMPAZAN FILM 10MG, 20MG 4 PA MOtiagabine hydrochloride tabs 1 MOTOPIRAMATE ER 3 MOtopiramate sprinkle caps, tabs 1 MOvalproate sodium inj 100mg/ml 1valproic acid caps, soln 1 MOVALTOCO 3 QL (10 EA per 30 days) PA

41Updated 10/01/20

Drug name Drug tier Requirements/Limitsvigabatrin 4 QL (180 EA per 30 days) PAvigadrone 1 QL (180 EA per 30 days) PAVIMPAT INJ 4VIMPAT ORAL SOLN 4 MOVIMPAT TABS 50MG 3 MOVIMPAT TABS 100MG, 150MG, 200MG

4 MO

XCOPRI TABS 150MG 4XCOPRI TABS 100MG, 200MG, 50MG

4 MO

XCOPRI TITRATION PACK 12.5MG-25MG

3 MO

XCOPRI MAINTENACE PACK 4XCOPRI TITRATION PACK 50MG-100MG, 150MG-200MG

4 MO

zonisamide 1 MOANTIDEMENTIA

donepezil hcl odt tabs 5mg, 10mg 1 QL (30 EA per 30 days) MOdonepezil hcl tabs 23mg 1 QL (30 EA per 30 days) MOdonepezil hcl tabs 10mg 1 QL (60 EA per 30 days) MOdonepezil hydrochloride tabs 5mg 1 QL (30 EA per 30 days) MOgalantamine hydrobromide er 1 QL (30 EA per 30 days) MOgalantamine hydrobromide soln 1 QL (200 ML per 30 days) MOgalantamine hydrobromide tabs 1 QL (60 EA per 30 days) MOMEMANTINE HCL TITRATION PAK 2 QL (98 EA per 365 days) PA MOmemantine hydrochloride er 1 PA MOmemantine hydrochloride soln 1 QL (360 ML per 30 days) PA MOmemantine hydrochloride tabs 1 QL (60 EA per 30 days) PA MONAMZARIC 3 MOrivastigmine tartrate caps 1 QL (60 EA per 30 days) MOrivastigmine patch 1 QL (30 EA per 30 days) MO

ANTIDEPRESSANTS amitriptyline hcl tabs 100mg, 10mg, 150mg, 25mg, 75mg

1 PA MO

amitriptyline hydrochloride tabs 50mg

1 PA MO

amoxapine 1 MObupropion hcl tabs 100mg 1 QL (180 EA per 30 days) MO

42 Updated 10/01/20

Drug name Drug tier Requirements/Limitsbupropion hydrochloride er (sr) tb12 100mg, 150mg, 200mg


bupropion hydrochloride er (xl) 1 QL (30 EA per 30 days) MObupropion hydrochloride tabs 75mg 1 QL (180 EA per 30 days) MOcitalopram hydrobromide soln 1 QL (600 ML per 30 days) MOcitalopram hydrobromide tabs 10mg 1 QL (120 EA per 30 days) MOcitalopram hydrobromide tabs 40mg 1 QL (30 EA per 30 days) MOcitalopram hydrobromide tabs 20mg 1 QL (60 EA per 30 days) MOclomipramine hcl caps 1 PA MOdesipramine hcl tabs 1 MODESVENLAFAXINE ER (GENERIC KHEDEZLA) TB24 100MG, 50MG


desvenlafaxine er (generic Pristiq) tb24 100mg, 25mg, 50mg


doxepin hcl caps 10mg, 50mg, 75mg, 100mg, 150mg, oral conc 10mg/ml

1 PA MO

doxepin hydrochloride caps 25mg 1 PA MODRIZALMA SPRINKLE CSDR 20MG, 30MG, 60MG


DRIZALMA SPRINKLE CSDR 40MG 3 QL (90 EA per 30 days) PA MOduloxetine hydrochloride caps 20mg, 30mg, 60mg


EMSAM 4 QL (30 EA per 30 days) PA MOescitalopram oxalate soln 1 QL (600 ML per 30 days) MOescitalopram oxalate tabs 20mg 1 QL (30 EA per 30 days) MOescitalopram oxalate tabs 10mg, 5mg 1 QL (45 EA per 30 days) MOFETZIMA TITRATION PACK 3 PA MOFETZIMA CP24 120MG, 80MG 3 QL (30 EA per 30 days) PA MOFETZIMA CP24 20MG, 40MG 3 QL (60 EA per 30 days) PA MOfluoxetine dr caps 90mg 1 QL (4 EA per 28 days) MOfluoxetine hcl caps 20mg 1 QL (120 EA per 30 days) MOfluoxetine hydrochloride caps 10mg 1 QL (30 EA per 30 days) MOfluoxetine hydrochloride caps 40mg 1 QL (60 EA per 30 days) MOfluoxetine hydrochloride (generic Prozac) oral soln, tabs

1 MO

imipramine hcl tabs 25mg, 50mg 1 PA MOimipramine hydrochloride tabs 10mg 1 PA MOimipramine pamoate 1 PA MO

43Updated 10/01/20

Drug name Drug tier Requirements/Limitsmaprotiline hcl 1 MOMARPLAN 3 QL (180 EA per 30 days) MOmirtazapine odt 1 QL (30 EA per 30 days) MOmirtazapine tabs 1 QL (30 EA per 30 days) MOnefazodone hcl tabs 100mg, 150mg 1 MOnefazodone hydrochloride tabs 200mg, 250mg, 50mg

1 MO

nortriptyline hcl caps 25mg, 75mg, soln 10mg/5ml

1 MO

nortriptyline hydrochloride caps 10mg, 50mg

1 MO

paroxetine hcl immediate release tabs 30mg, 40mg


paroxetine hcl er tb24 37.5mg 1 QL (60 EA per 30 days) MOparoxetine hcl er tb24 12.5mg, 25mg 1 QL (90 EA per 30 days) MOparoxetine hydrochloride immediate release tabs 10mg, 20mg


PAXIL 3 QL (900 ML per 30 days) MOperphenazine/amitriptyline 1 PA MOphenelzine sulfate 1 MOprotriptyline hcl 1 MOsertraline hcl oral conc 1 QL (300 ML per 30 days) MOsertraline hcl tabs 25mg 1 QL (30 EA per 30 days) MOsertraline hcl tabs 50mg 1 QL (60 EA per 30 days) MOsertraline hydrochloride tabs 100mg 1 QL (60 EA per 30 days) MOtranylcypromine sulfate 1 MOtrazodone hydrochloride tabs 1 MOtrimipramine maleate caps 50mg 1 QL (120 EA per 30 days) PA MOtrimipramine maleate caps 25mg 1 QL (240 EA per 30 days) PA MOtrimipramine maleate caps 100mg 1 QL (60 EA per 30 days) PA MOTRINTELLIX TABS 5MG 3 QL (120 EA per 30 days) MOTRINTELLIX TABS 20MG 3 QL (30 EA per 30 days) MOTRINTELLIX TABS 10MG 3 QL (60 EA per 30 days) MOvenlafaxine hcl er cp24 37.5mg 1 QL (30 EA per 30 days) MOvenlafaxine hcl er cp24 150mg 1 QL (60 EA per 30 days) MOvenlafaxine hcl er tb24 37.5mg 1 QL (30 EA per 30 days) MOvenlafaxine hcl tabs 25mg, 37.5mg, 50mg, 75mg, 100mg

1 MO

44 Updated 10/01/20

Drug name Drug tier Requirements/Limitsvenlafaxine hydrochloride er cp24 75mg


venlafaxine hydrochloride er tb24 225mg, 75mg


venlafaxine hydrochloride er tb24 150mg


VIIBRYD 3 QL (30 EA per 30 days) MOVIIBRYD STARTER PACK 3 MOZOLOFT ORAL CONC 3 QL (300 ML per 30 days) MO

ANTIPARKINSONIAN AGENTS amantadine hcl syrp, tabs 1 MOamantadine hcl caps 1 QL (120 EA per 30 days) MOAPOKYN 4 QL (60 ML per 30 days) PA LAbenztropine mesylate inj 1 MObenztropine mesylate tabs 1 PA MObromocriptine mesylate tabs, caps 1 MOcarbidopa tabs 4 MOcarbidopa/levodopa 1 MOcarbidopa/levodopa er 1 MOcarbidopa/levodopa odt 1 MOCARBIDOPA/LEVODOPA/ENTACAPONE

3 MO

entacapone 1 MONEUPRO 3 MOpramipexole dihydrochloride er 1 QL (30 EA per 30 days) MOpramipexole dihydrochloride immediate release tabs

1 MO

rasagiline mesylate 1 MOropinirole er tb24 6mg 1 QL (120 EA per 30 days) MOropinirole er tb24 4mg 1 QL (150 EA per 30 days) MOropinirole er tb24 2mg 1 QL (30 EA per 30 days) MOropinirole er tb24 12mg 1 QL (60 EA per 30 days) MOropinirole er tb24 8mg 1 QL (90 EA per 30 days) MOropinirole hcl immediate release tabs 0.5mg, 1mg, 2mg, 4mg, 5mg

1 MO

ropinirole hydrochloride immediate release tabs 0.25mg, 3mg

1 MO

selegiline hcl tabs, caps 1 MO

45Updated 10/01/20

Drug name Drug tier Requirements/Limitstrihexyphenidyl hcl oral soln 1 PA MOtrihexyphenidyl hydrochloride tabs 1 PA MO

ANTIPSYCHOTICS ABILIFY MAINTENA 4 QL (1 EA per 28 days) MOaripiprazole odt 4 QL (60 EA per 30 days) MOaripiprazole tabs 1 QL (30 EA per 30 days) MOaripiprazole soln 1 QL (900 ML per 30 days) MOARISTADA INITIO 4ARISTADA INJ 441MG/1.6ML 4 QL (1.6 ML per 28 days)ARISTADA INJ 662MG/2.4ML 4 QL (2.4 ML per 28 days)ARISTADA INJ 882MG/3.2ML 4 QL (3.2 ML per 28 days)ARISTADA INJ 1064MG/3.9ML 4 QL (3.9 ML per 56 days)CAPLYTA 4 QL (30 EA per 30 days) PA MOchlorpromazine hcl tabs 1 MOCHLORPROMAZINE HCL INJ 50MG/2ML

3

CHLORPROMAZINE HCL INJ 25MG/ML

3 MO

CLOZAPINE ODT TBDP 200MG 3 QL (135 EA per 30 days) PACLOZAPINE ODT TBDP 150MG 3 QL (180 EA per 30 days) PAclozapine odt tbdp 12.5mg, 25mg 1 PAclozapine odt tbdp 100mg 1 QL (270 EA per 30 days) PAclozapine tabs 1FANAPT TITRATION PACK 3 PA MOFANAPT TABS 1MG 3 QL (60 EA per 30 days) PA MOFANAPT TABS 10MG, 12MG, 2MG, 4MG, 6MG, 8MG


fluphenazine decanoate inj 1 MOfluphenazine hcl 1 MOfluphenazine hydrochloride oral elixir 1 MOGEODON 3 QL (6 EA per 3 days) MOhaloperidol 1 MOhaloperidol decanoate inj 1 MOhaloperidol lactate inj 1 MOINVEGA SUSTENNA INJ 39MG/0.25ML

3 QL (0.25 ML per 28 days) MO

INVEGA SUSTENNA INJ 78MG/0.5ML 4 QL (0.5 ML per 28 days) MO

46 Updated 10/01/20

Drug name Drug tier Requirements/LimitsINVEGA SUSTENNA INJ 117MG/0.75ML


INVEGA SUSTENNA INJ 156MG/ML 4 QL (1 ML per 28 days) MOINVEGA SUSTENNA INJ 234MG/1.5ML


INVEGA TRINZA INJ 273MG/0.875ML 4 QL (0.88 ML per 90 days)INVEGA TRINZA INJ 410MG/1.315ML 4 QL (1.32 ML per 90 days)INVEGA TRINZA INJ 546MG/1.75ML 4 QL (1.75 ML per 90 days)INVEGA TRINZA INJ 819MG/2.625ML 4 QL (2.63 ML per 90 days)LATUDA TABS 120MG, 20MG, 40MG, 60MG


LATUDA TABS 80MG 4 QL (60 EA per 30 days) MOloxapine caps 10mg 1 MOloxapine succinate caps 25mg, 50mg, 5mg

1 MO

molindone hydrochloride 1NUPLAZID 4 QL (30 EA per 30 days) PA LAolanzapine odt 1 QL (30 EA per 30 days) MOolanzapine inj 1 QL (3 EA per 1 days) MOolanzapine tabs 10mg, 15mg, 20mg, 5mg, 7.5mg


olanzapine tabs 2.5mg 1 QL (60 EA per 30 days) MOpaliperidone er tb24 1.5mg, 3mg 1 QL (30 EA per 30 days) MOpaliperidone er tb24 6mg 1 QL (60 EA per 30 days) MOpaliperidone er tb24 9mg 4 QL (30 EA per 30 days) MOperphenazine 1 MOPERSERIS 4 QL (1 EA per 30 days)pimozide 1 MOquetiapine fumarate er tb24 150mg, 200mg


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


quetiapine fumarate tabs 200mg 1 QL (120 EA per 30 days) MOquetiapine fumarate tabs 25mg 1 QL (180 EA per 30 days) MOquetiapine fumarate tabs 300mg, 400mg


quetiapine fumarate tabs 100mg, 50mg


47Updated 10/01/20

Drug name Drug tier Requirements/LimitsREXULTI TABS 3MG, 4MG 4 QL (30 EA per 30 days) MOREXULTI TABS 0.25MG, 0.5MG, 1MG, 2MG


RISPERDAL CONSTA INJ 12.5MG, 25MG


RISPERDAL CONSTA INJ 37.5MG, 50MG


risperidone odt tbdp 1mg, 2mg, 3mg, 4mg


risperidone odt tbdp 0.25mg, 0.5mg 1 QL (90 EA per 30 days) MOrisperidone soln 1 MOrisperidone tabs 4mg 1 QL (120 EA per 30 days) MOrisperidone tabs 1mg, 2mg 1 QL (60 EA per 30 days) MOrisperidone tabs 0.25mg, 0.5mg, 3mg 1 QL (90 EA per 30 days) MOSAPHRIS 4 QL (60 EA per 30 days) MOSECUADO 4 QL (30 EA per 30 days)thioridazine hcl tabs 1 PA MOthiothixene 1 MOtrifluoperazine hcl 1 MOVERSACLOZ 4 QL (600 ML per 30 days) PAVRAYLAR CAP THERAPY PACK 3 PA MOVRAYLAR CAPS 3MG, 4.5MG, 6MG 4 QL (30 EA per 30 days) PA MOVRAYLAR CAPS 1.5MG 4 QL (60 EA per 30 days) PA MOziprasidone hcl caps 1 QL (60 EA per 30 days) MOziprasidone mesylate inj 1 QL (6 EA per 3 days)ZYPREXA RELPREVV INJ 210MG 3 QL (2 EA per 28 days) PAZYPREXA RELPREVV INJ 405MG 4 QL (1 EA per 28 days) PAZYPREXA RELPREVV INJ 300MG 4 QL (2 EA per 28 days) PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine/dextroamphetamine er cp24


amphetamine/dextroamphetamine tabs 5mg, 7.5mg, 10mg, 12.5mg, 15mg, 30mg


amphetamine/dextroamphetamine tabs 20mg


atomoxetine caps 10mg, 18mg, 25mg 1 QL (120 EA per 30 days) MO

48 Updated 10/01/20

Drug name Drug tier Requirements/Limitsatomoxetine caps 100mg, 60mg, 80mg


atomoxetine caps 40mg 1 QL (60 EA per 30 days) MOdexmethylphenidate hcl er caps 1 QL (30 EA per 30 days) MOdexmethylphenidate hcl tabs 5mg, 10mg


dexmethylphenidate hydrochloride tabs 2.5mg


dextroamphetamine sulfate er 1 QL (120 EA per 30 days) MOdextroamphetamine sulfate tabs 1 QL (180 EA per 30 days) MOdextroamphetamine sulfate soln 1 QL (1800 ML per 30 days) MOguanfacine er 1 QL (30 EA per 30 days) PA MOmetadate er 1 QL (90 EA per 30 days)methylphenidate hydrochloride cd er caps 10mg, 20mg, 50mg, 60mg


methylphenidate hydrochloride er cp24 (generic ritalin la) 60mg


methylphenidate hydrochloride er cp24 10mg, 15mg, 50mg, 60mg

1 QL (30 EA per 30 days)

methylphenidate hydrochloride er cp24 (generic Ritalin LA) 10mg, 20mg, 40mg


methylphenidate hydrochloride er cp24 (generic Ritalin LA) 30mg


methylphenidate hydrochloride er tb24 18mg, 27mg, 36mg, 54mg

1 QL (30 EA per 30 days)

methylphenidate hydrochloride cd er caps 30mg, 40mg


METHYLPHENIDATE HYDROCHLORIDE ER TBCR 72MG


methylphenidate hydrochloride er tbcr (generic Concerta) 18mg, 27mg, 36mg, 54mg


methylphenidate hydrochloride er tbcr 10mg, 20mg


methylphenidate hydrochloride chewable tablet


methylphenidate hydrochloride tabs 5mg, 10mg, 20mg


49Updated 10/01/20

Drug name Drug tier Requirements/Limitsmethylphenidate hydrochloride oral soln 5mg/5ml


methylphenidate hydrochloride oral soln 10mg/5ml


VYVANSE 3 QL (30 EA per 30 days) MOzenzedi 1 QL (180 EA per 30 days)

HYPNOTICS BELSOMRA 3 QL (30 EA per 30 days) MOdoxepin hydrochloride tabs 3mg, 6mg 1 QL (30 EA per 30 days) MOeszopiclone 1 QL (30 EA per 30 days) PA MOHETLIOZ 4 PA LA MOtemazepam 1 QL (30 EA per 30 days) PA MOtriazolam 1 QL (60 EA per 30 days) MOzaleplon caps 5mg 1 QL (30 EA per 30 days) PA MOzaleplon caps 10mg 1 QL (60 EA per 30 days) PA MOzolpidem tartrate immediate release tabs, subl


MIGRAINE AIMOVIG 2 QL (1 ML per 30 days) PAalmotriptan malate 1 QL (8 EA per 30 days) MOdihydroergotamine mesylate inj 1 PA MOdihydroergotamine mesylate nasal soln

4 QL (8 ML per 30 days) PA MO

eletriptan hydrobromide 1 QL (12 EA per 30 days) MOergotamine tartrate/caffeine 1 MOfrovatriptan succinate 1 QL (12 EA per 30 days) MOnaratriptan hcl 1 QL (9 EA per 30 days) MOrizatriptan benzoate odt 1 QL (12 EA per 30 days) MOrizatriptan benzoate tabs 1 QL (12 EA per 30 days) MOsumatriptan nasal spray 1 QL (12 EA per 30 days) MOsumatriptan succinate refill 1 QL (4 ML per 30 days) MOsumatriptan succinate tabs 1 QL (9 EA per 30 days) MOsumatriptan succinate prefilled syringe 6mg/0.5ml

1 QL (4 ML per 30 days)

sumatriptan succinate inj 4mg/0.5ml, 6mg/0.5ml


sumatriptan/naproxen sodium 1 QL (9 EA per 30 days) MOzolmitriptan odt 1 QL (6 EA per 30 days) MO

50 Updated 10/01/20

Drug name Drug tier Requirements/Limitszolmitriptan tabs 1 QL (6 EA per 30 days) MO

MISCELLANEOUS AUSTEDO TABS 12MG, 9MG 4 QL (120 EA per 30 days) PA LAAUSTEDO TABS 6MG 4 QL (60 EA per 30 days) PA LAGUANIDINE HCL 3lithium carbonate caps, tabs 1 MOlithium carbonate er 1 MOLITHIUM ORAL SOLN 3 MOLYRICA CR 2 QL (60 EA per 30 days) PA MONUEDEXTA 4 QL (60 EA per 30 days) PA MOpyridostigmine bromide 1 MOpyridostigmine bromide er 1 MOriluzole 1 MOtetrabenazine tabs 25mg 4 QL (120 EA per 30 days) PAtetrabenazine tabs 12.5mg 4 QL (90 EA per 30 days) PA

MULTIPLE SCLEROSIS AGENTS BETASERON 4 QL (14 EA per 28 days) PACOPAXONE INJ 40MG/ML 4 QL (12 ML per 28 days) PACOPAXONE INJ 20MG/ML 4 QL (30 ML per 30 days) PAdalfampridine er 4 PAGILENYA CAPS 0.5MG 4 QL (28 EA per 28 days) PAREBIF 4 QL (6 ML per 28 days) PAREBIF REBIDOSE 4 QL (6 ML per 28 days) PAREBIF REBIDOSE TITRATION PACK 4 QL (8.4 ML per 365 days) PAREBIF TITRATION PACK 4 QL (8.4 ML per 365 days) PA

MUSCULOSKELETAL THERAPY AGENTS baclofen 1 MOCHLORZOXAZONE TABS 250MG 2 QL (180 EA per 30 days) PAchlorzoxazone tabs 500mg 1 QL (180 EA per 30 days) PA MOcyclobenzaprine hydrochloride tabs 10mg, 5mg


dantrolene sodium caps 25mg, 50mg, 100mg

1 MO

tizanidine hcl 1 MOtizanidine hydrochloride tabs 4mg 1 MO

NARCOLEPSY/CATAPLEXY armodafinil 1 QL (30 EA per 30 days) PA MO

51Updated 10/01/20

Drug name Drug tier Requirements/Limitsmodafinil tabs 100mg 1 QL (30 EA per 30 days) PA MOmodafinil tabs 200mg 1 QL (60 EA per 30 days) PA MOXYREM 4 QL (540 ML per 30 days) PA LA

MOPSYCHOTHERAPEUTIC-MISC

acamprosate calcium dr 1 MObuprenorphine hcl 1 QL (90 EA per 30 days) PA MObuprenorphine hcl/naloxone hcl subl tabs


buprenorphine hydrochloride/naloxone hydrochloride film 12mg; 3mg


buprenorphine hydrochloride/naloxone hydrochloride film 2mg; 0.5mg, 4mg; 1mg, 8mg; 2mg


bupropion hydrochloride er (sr) tb12 150mg


CHANTIX 3 PA MOCHANTIX CONTINUING MONTH PAK 3 PA MOCHANTIX STARTING MONTH PAK 3 PA MOdisulfiram tabs 1 MOnaloxone hcl inj 0.4mg/ml cartridge, 2mg/2ml

1

naloxone hcl inj 4mg/10ml 1 MOnaloxone hydrochloride vial 0.4mg/ml

1 MO

naltrexone hcl tabs 1 MONARCAN 2 MONICOTROL INHALER 3 MONICOTROL NASAL SPRAY 3 MOVIVITROL 4

ENDOCRINE AND METABOLICANDROGENS

ANADROL-50 4 PA MOANDRODERM 3 QL (30 EA per 30 days) PA MOoxandrolone tabs 2.5mg 1 QL (120 EA per 30 days) PA MOoxandrolone tabs 10mg 4 QL (60 EA per 30 days) PA MOtestosterone cypionate inj 1 PA MO

52 Updated 10/01/20

Drug name Drug tier Requirements/Limitstestosterone enanthate inj 1 PA MOtestosterone pump gel 1% (12.5mg/act)

1 QL (300 GM per 30 days) PA MO

testosterone pump gel 2% (10mg/act) 1 QL (120 GM per 30 days) PA MOtestosterone gel 1% (25mg/2.5gm, 50mg/5gm)


testosterone topical soln 30mg/act 1 QL (180 ML per 30 days) PA MOANTIDIABETICS, INSULINS

BD ALCOHOL SWABS 2 MOBD/ULTIMED/ALLISON/TRIVIDIA/MHC INSULIN SYRINGE ULTRAFINE II/0.3ML/31G X 5/16”

2 MO

BASAGLAR KWIKPEN 2 MOBD/ULTIMED/ALLISON/TRIVIDIA/MHC INSULIN SYRINGE SAFETYGLIDE/1ML/ 29G X 1/2”

2 MO

BD/ULTIMED/ALLISON/TRIVIDIA/MHC INSULIN SYRINGE ULTRA-FINE/0.5ML/30G X 1/2”

2 MO

BD/ULTIMED/ALLISON/TRIVIDIA/MHC INSULIN SYRINGE ULTRA-FINE/1ML/31G X 5/16”

2 MO

NOVO/BD/ULTIMED/OWEN/TRIVIDIA PEN NEEDLE/ORIGINAL/ULTRA-FINE

2 MO

BD/ULTIMED/ALLISON/TRIVIDIA/MHC INSULIN SYRINGE ULTRA-AFINE/0.3ML/31G X 6MM

2 MO

CURITY GAUZE PADS 2”X2” 2 MOFIASP 2 MOFIASP FLEXTOUCH 2 MOFIASP PENFILL 2 MOHUMULIN R U-500 (CONCENTRATED)

4 B/D MO

HUMULIN R U-500 KWIKPEN 4 MOLEVEMIR 2 MOLEVEMIR FLEXTOUCH 2 MONOVOLIN 70/30 (BRAND RELION NOT COVERED)

2 MO

53Updated 10/01/20

Drug name Drug tier Requirements/LimitsNOVOLIN 70/30 FLEXPEN (BRAND RELION NOT COVERED)

2 MO

NOVOLIN N (BRAND RELION NOT COVERED)

2 MO

NOVOLIN N FLEXPEN (BRAND RELION NOT COVERED)

2 MO

NOVOLIN R (BRAND RELION NOT COVERED)

2 MO

NOVOLIN R FLEXPEN (BRAND RELION NOT COVERED)

2 MO

NOVOLOG 2 MONOVOLOG FLEXPEN 2 MONOVOLOG MIX 70/30 2 MONOVOLOG MIX 70/30 PREFILLED FLEXPEN

2 MO

NOVOLOG PENFILL 2 MOSOLIQUA 100/33 2 QL (30 ML per 30 days) MOTRESIBA 2 MOTRESIBA FLEXTOUCH 2 MOXULTOPHY 100/3.6 2 QL (15 ML per 30 days) MO

ANTIDIABETICS acarbose tabs 1 QL (90 EA per 30 days) MOBYDUREON BCISE 2 QL (3.4 ML per 28 days) MOBYDUREON PEN 2 QL (4 EA per 28 days) MOBYETTA INJ 5MCG/0.02ML 3 QL (1.2 ML per 30 days) MOBYETTA INJ 10MCG/0.04ML 3 QL (2.4 ML per 30 days) MOFARXIGA 2 QL (30 EA per 30 days) MOglimepiride tabs 4mg 1 QL (60 EA per 30 days) MOglimepiride tabs 1mg, 2mg 1 QL (90 EA per 30 days) MOglipizide er tb24 10mg 1 QL (60 EA per 30 days) MOglipizide er tb24 2.5mg, 5mg 1 QL (90 EA per 30 days) MOglipizide xl tb24 10mg 1 QL (60 EA per 30 days) MOglipizide xl tb24 2.5mg, 5mg 1 QL (90 EA per 30 days) MOglipizide/metformin hydrochloride tabs 2.5mg; 500mg, 5mg; 500mg


glipizide/metformin hydrochloride tabs 2.5mg; 250mg


glipizide tabs 10mg 1 QL (120 EA per 30 days) MO

54 Updated 10/01/20

Drug name Drug tier Requirements/Limitsglipizide tabs 5mg 1 QL (240 EA per 30 days) MOGLYXAMBI 2 QL (30 EA per 30 days) MOJANUMET 2 QL (60 EA per 30 days) MOJANUMET XR TB24 1000MG; 100MG 2 QL (30 EA per 30 days) MOJANUMET XR TB24 1000MG; 50MG, 500MG; 50MG


JANUVIA 2 QL (30 EA per 30 days) MOJARDIANCE TABS 25MG 2 QL (30 EA per 30 days) MOJARDIANCE TABS 10MG 2 QL (60 EA per 30 days) MOJENTADUETO 2 QL (60 EA per 30 days) MOJENTADUETO XR TB24 5MG; 1000MG


JENTADUETO XR TB24 2.5MG; 1000MG


metformin hydrochloride er tb24 (generic Glucophage XR) 500mg


metformin hydrochloride er tb24 (generic Glumetza and Fortamet) 500mg


metformin hydrochloride er tb24 (generic Glucophage XR) 750mg


metformin hydrochloride tabs 500mg 1 QL (150 EA per 30 days) MOmetformin hydrochloride tabs 1000mg


metformin hydrochloride tabs 850mg 1 QL (90 EA per 30 days) MOmiglitol 1 QL (90 EA per 30 days) MOnateglinide 1 QL (90 EA per 30 days) MOOZEMPIC INJ 2MG/1.5ML (0.25MG AND 0.5MG DOSE)


OZEMPIC INJ 2MG/1.5ML (1MG DOSE)


pioglitazone hcl tabs 45mg 1 QL (30 EA per 30 days) MOpioglitazone hcl-glimepiride 1 QL (30 EA per 30 days) MOpioglitazone hcl/metformin hcl 1 QL (90 EA per 30 days) MOpioglitazone hydrochloride tabs 15mg, 30mg


repaglinide tabs 0.5mg, 1mg 1 QL (120 EA per 30 days) MOrepaglinide tabs 2mg 1 QL (240 EA per 30 days) MO

55Updated 10/01/20

Drug name Drug tier Requirements/LimitsSYMLINPEN 120 4 QL (10.8 ML per 30 days) PA MOSYMLINPEN 60 4 QL (12 ML per 30 days) PA MOSYNJARDY XR TB24 25MG; 1000MG 2 QL (30 EA per 30 days) MOSYNJARDY XR TB24 10MG; 1000MG, 12.5MG; 1000MG, 5MG; 1000MG


SYNJARDY TABS 5MG; 500MG 2 QL (120 EA per 30 days) MOSYNJARDY TABS 12.5MG; 1000MG, 12.5MG; 500MG, 5MG; 1000MG


TRADJENTA 2 QL (30 EA per 30 days) MOTRULICITY 2 QL (2 ML per 28 days) MOVICTOZA 2 QL (9 ML per 30 days) MOXIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG


XIGDUO XR TB24 2.5MG; 1000MG, 5MG; 1000MG, 5MG; 500MG


CALCIUM REGULATORS alendronate sodium oral soln 1 MOalendronate sodium tabs 10mg 1 QL (30 EA per 30 days) MOalendronate sodium tabs 35mg, 70mg


calcitonin-salmon 1 MOFORTEO 4 PAibandronate sodium tabs 1 QL (1 EA per 30 days) MOibandronate sodium inj 1 QL (3 ML per 90 days) MONATPARA 4 PAPAMIDRONATE DISODIUM INJ 6MG/ML

3

pamidronate disodium inj 30mg/10ml, 30mg, 90mg/10ml, 90mg

1

PROLIA 3 QL (1 ML per 180 days)risedronate sodium dr tab 35mg 1 QL (4 EA per 28 days) MOrisedronate sodium tabs 150mg 1 QL (1 EA per 28 days) MOrisedronate sodium tabs 35mg 1 QL (12 EA per 84 days) MOrisedronate sodium tabs 30mg, 5mg 1 QL (30 EA per 30 days) MOTYMLOS 4 PAXGEVA 4 PAZOLEDRONIC ACID INJ 4MG/100ML 3

56 Updated 10/01/20

Drug name Drug tier Requirements/Limitszoledronic acid inj 4mg/5ml, 5mg/100ml

1

CHELATING AGENTS CHEMET 4 MOclovique 4 PAdeferasirox 4 PAkionex 1LOKELMA 2 MOpenicillamine tabs 4 MOsodium polystyrene sulfonate rectal susp

1

sodium polystyrene sulfonate powd, oral susp

1 MO

sps oral susp 15gm/60ml 1 MOtrientine hydrochloride 4 PA MOVELTASSA PACK 16.8GM, 25.2GM 3 QL (30 EA per 30 days) PA MOVELTASSA PACK 8.4GM 3 QL (90 EA per 30 days) PA MO

CONTRACEPTIVES afirmelle 1altavera 1alyacen 1/35 1alyacen 7/7/7 1amethia 1AMETHIA LO 2amethyst 1apri 1aranelle 1ashlyna 1aubra 1aubra eq 1aurovela 1.5/30 1aurovela 24 fe 1aurovela fe 1.5/30 1aurovela fe 1/20 1aviane 1ayuna 1azurette 1

57Updated 10/01/20

Drug name Drug tier Requirements/Limitsbalziva 1bekyree 1blisovi 24 fe 1 MOblisovi fe 1.5/30 1blisovi fe 1/20 1briellyn 1camila 1 MOCAMRESE 2CAMRESE LO 2caziant 1chateal 1chateal eq 1cryselle-28 1 MOcyclafem 1/35 1cyclafem 7/7/7 1cyred 1cyred eq 1dasetta 1/35 1dasetta 7/7/7 1daysee 1 MOdeblitane 1desogestrel/ethinyl estradiol 1 MOdrospirenone/ethinyl estradiol 1 MOdrospirenone/ethinyl estradiol/levomefolate calcium

1 MO

elinest 1eluryng 1emoquette 1enpresse-28 1enskyce 1 MOerrin 1 MOestarylla 1ethynodiol diacetate/ethinyl estradiol 1 MOETONOGESTREL/ETHINYL ESTRADIOL

3 MO

falmina 1fayosim 1

58 Updated 10/01/20

Drug name Drug tier Requirements/Limitsfemynor 1GIANVI 2 MOhailey 1.5/30 1 MOhailey 24 fe 1heather 1incassia 1introvale 1isibloom 1jaimiess 1jasmiel 1jencycla 1JOLESSA 2JOLIVETTE 2juleber 1junel 1.5/30 1junel 1/20 1junel fe 1.5/30 1 MOjunel fe 1/20 1 MOjunel fe 24 1kaitlib fe 1 MOkalliga 1kariva 1kelnor 1/35 1 MOkelnor 1/50 1 MOkurvelo 1larin 1.5/30 1larin 1/20 1larin 24 fe 1larin fe 1.5/30 1larin fe 1/20 1larissia 1LEENA 2 MOlessina 1levonest 1levonorgestrel/ethinyl estradiol 1 MOlevora 0.15/30-28 1lillow 1

59Updated 10/01/20

Drug name Drug tier Requirements/Limitslo-zumandimine 1lojaimiess 1loryna 1low-ogestrel 1lutera 1lyza 1marlissa 1 MOmedroxyprogesterone acetate inj 150mg/ml

1 MO

melodetta 24 fe 1mibelas 24 fe 1 MOMICROGESTIN 1.5/30 2MICROGESTIN 1/20 2MICROGESTIN FE 1.5/30 2MICROGESTIN FE 1/20 2mili 1mono-linyah 1necon 0.5/35-28 1nikki 1NORA-BE 2norethindrone acetate/ethinyl estradiol/ferrous fumarate

1 MO

norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg, 30mcg; 1.5mg

1 MO

norethindrone tabs 0.35mg 1 MOnorethindrone/ethinyl estradiol/ferrous fumarate

1 MO

norgestimate/ethinyl estradiol 1 MOnorlyda 1nortrel 0.5/35 (28) 1 MOnortrel 1/35 1nortrel 7/7/7 1OCELLA 2orsythia 1philith 1pimtrea 1

60 Updated 10/01/20

Drug name Drug tier Requirements/Limitspirmella 1/35 1 MOpirmella 7/7/7 1 MOportia-28 1previfem 1 MOreclipsen 1RIVELSA 2setlakin 1sharobel 1simliya 1simpesse 1sprintec 28 1sronyx 1 MOsyeda 1tarina fe 1/20 1tarina fe 1/20 eq 1TILIA FE 2tri femynor 1tri-estarylla 1 MOtri-legest fe 1 MOtri-linyah 1tri-lo-estarylla 1tri-lo-marzia 1tri-lo-mili 1tri-lo-sprintec 1 MOtri-mili 1tri-previfem 1tri-sprintec 1tri-vylibra 1tri-vylibra lo 1trivora-28 1tulana 1tydemy 1velivet 1 MOvienva 1viorele 1 MOvolnea 1vyfemla 1 MO

61Updated 10/01/20

Drug name Drug tier Requirements/Limitsvylibra 1wera 1wymzya fe 1zarah 1zovia 1/35e 1zumandimine 1

ENDOMETRIOSIS danazol caps 1 MOSYNAREL 4 MO

ESTROGENS amabelz 1 MODELESTROGEN INJ 10MG/ML 3 MOdotti 1 QL (8 EA per 28 days)DUAVEE 3 MOestradiol valerate inj 1 MOestradiol/norethindrone acetate tabs 1mg/0.5mg, 0.5mg/0.1mg

1 MO

estradiol vaginal crea, oral tabs, vaginal tabs

1 MO

estradiol patch weekly 1 QL (4 EA per 28 days) MOestradiol patch twice weekly 1 QL (8 EA per 28 days) MOESTRING 3 QL (1 EA per 90 days) MOfyavolv 1 MOjinteli 1LOPREEZA 2mimvey 1norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg, 5mcg; 1mg

1 MO

PREMARIN 3 MOPREMPRO 3 MOyuvafem 1

GLUCOCORTICOIDS cortisone acetate tabs 1 MODEXAMETHASONE INTENSOL 3 MOdexamethasone sodium phosphate inj 10mg/ml

1

62 Updated 10/01/20

Drug name Drug tier Requirements/Limitsdexamethasone sodium phosphate inj 100mg/10ml, 120mg/30ml, 20mg/5ml, 4mg/ml

1 MO

dexamethasone tabs, oral soln, oral elixir

1 MO

fludrocortisone acetate tabs 1 MOhydrocortisone tabs 10mg, 20mg, 5mg

1 MO

methylprednisolone acetate inj 1 B/D MOmethylprednisolone dose pack 1 MOmethylprednisolone sodium succinate inj 125mg, 1000mg, 40mg

1 B/D MO

methylprednisolone sodium succinate inj 500mg

1 B/D

methylprednisolone tabs 1 B/D MOprednisolone oral soln 15mg/5ml 1 B/D MOprednisolone sodium phosphate odt 1 B/D MOprednisolone sodium phosphate oral soln 10mg/5ml, 15mg/5ml, 20mg/5ml, 25mg/5ml, 5mg/5ml

1 B/D MO

PREDNISONE INTENSOL 3 B/D MOprednisone soln, tabs 1 B/D MOprednisone tab therapy pack 1 MOSOLU-CORTEF INJ 1000MG 3SOLU-CORTEF INJ 100MG, 250MG, 500MG

3 MO

triamcinolone acetonide inj 40mg/ml 1 MOGLUCOSE ELEVATING AGENTS

diazoxide oral susp 1 MOGVOKE HYPOPEN 1-PACK 2 MOGVOKE HYPOPEN 2-PACK 2 MOGVOKE PFS 2 MO

MISCELLANEOUS acetylcysteine inj 200mg/ml 1ALDURAZYME 4 PA LAcabergoline 1 MOCARBAGLU 4 PA LA MOCERDELGA 4 PA

63Updated 10/01/20

Drug name Drug tier Requirements/LimitsCEREZYME 4 PA LAcinacalcet hydrochloride tabs 30mg 1 QL (120 EA per 30 days)cinacalcet hydrochloride tabs 90mg 4 QL (120 EA per 30 days)cinacalcet hydrochloride tabs 60mg 4 QL (60 EA per 30 days)CYSTADANE 4 LA MOCYSTAGON 3 PA LAdesmopressin acetate 1 MOFABRAZYME 4 PA LAfomepizole 4GENOTROPIN 4 PAGENOTROPIN MINIQUICK INJ 0.2MG

2 PA

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

4 PA

INCRELEX 4 PA LAKORLYM 4 PA LA MOKUVAN 4 PA LALEVOCARNITINE TABS 3 MOlevocarnitine soln 1 MOLUMIZYME 4 PA LALUPRON DEPOT-PED (1-MONTH) INJ 11.25MG, 15MG, 7.5MG

4 PA

LUPRON DEPOT-PED (3-MONTH) INJ 11.25MG, 30MG

4 PA

methergine 1methylergonovine maleate tabs 1 MOmiglustat 4 PANAGLAZYME 4 PA LAnitisinone 4 PA MONITYR 4 PA LA MOoctreotide acetate 1 PAORFADIN 4 PA LA MOraloxifene hydrochloride 1 MOSIGNIFOR INJ 0.3MG/ML, 0.6MG/ML, 0.9MG/ML

4 PA LA MO

sodium phenylbutyrate tabs, oral powder

4 PA

64 Updated 10/01/20

Drug name Drug tier Requirements/LimitsSOMATULINE DEPOT 4 PASOMAVERT INJ 4 PA LASTIMATE 4

PHOSPHATE BINDER AGENTS AURYXIA 4 QL (360 EA per 30 days) PA MOcalcium acetate caps, tabs 667mg 1 QL (360 EA per 30 days) MO

PROGESTINS medroxyprogesterone acetate tabs 10mg, 2.5mg, 5mg

1 MO

megestrol acetate susp 40mg/ml, 625mg/5ml

1 MO

norethindrone acetate tabs 5mg 1 MOprogesterone 1 MO

THYROID AGENTS euthyrox 1 MOLEVO-T 3levothyroxine sodium tabs 1 MOLEVOTHYROXINE SODIUM INJ SOLN 100MCG/5ML, 200MCG/5ML, 500MCG/5ML

3

levothyroxine sodium inj powder 100mcg, 200mcg, 500mcg

1 MO

LEVOXYL 2 MOliothyronine sodium tabs 1 MOliothyronine sodium inj 4methimazole tabs 1 MOpropylthiouracil tabs 1 MOSYNTHROID 3 MOUNITHROID 2

VITAMIN D ANALOGS calcitriol caps 0.25mcg, 0.5mcg 1 MOcalcitriol inj 1mcg/ml 1calcitriol oral soln 1mcg/ml 1 MOdoxercalciferol 1paricalcitol 1 MO

65Updated 10/01/20

Drug name Drug tier Requirements/LimitsGASTROINTESTINAL

ANTIEMETICS aprepitant 1 B/D MOcompro 1 MODIMENHYDRINATE INJ 3dronabinol 1 QL (60 EA per 30 days) PA MOEMEND 3 B/D MOgranisetron hcl 1 QL (60 EA per 30 days) B/D MOmeclizine hcl tabs 1 MOmetoclopramide hcl tabs 5mg 1 MOmetoclopramide hydrochloride tabs 10mg

1 MO

METOCLOPRAMIDE ODT TBDP 10MG

2 MO

metoclopramide odt tbdp 5mg 1 MOondansetron hcl tabs 24mg 1 B/Dondansetron hcl oral soln 1 QL (900 ML per 30 days) B/D MOondansetron hydrochloride tabs 4mg, 8mg

1 B/D MO

ondansetron hydrochloride inj 1 MOondansetron odt 1 B/D MOphenadoz supp 25mg 1 PAphenadoz supp 12.5mg 1 PA MOprochlorperazine edisylate inj 50mg/10ml

1

prochlorperazine edisylate inj 10mg/2ml

1 MO

prochlorperazine maleate tabs 1 MOprochlorperazine supp 1 MOpromethazine hcl inj, supp 1 PA MOpromethazine hcl plain syrp 6.25mg/5ml

1 PA MO

promethazine hydrochloride tabs 1 PA MOpromethegan supp 12.5mg, 25mg 1 PApromethegan supp 50mg 1 PA MOSANCUSO 4 QL (4 EA per 28 days) MOscopolamine patch 1 QL (10 EA per 30 days) PA MO

66 Updated 10/01/20

Drug name Drug tier Requirements/Limitstrimethobenzamide hydrochloride caps

1 PA MO

ANTISPASMODICS dicyclomine hcl oral soln 1 MOdicyclomine hydrochloride 1 MOglycopyrrolate tabs 1mg, 2mg 1 MOglycopyrrolate inj 0.2mg/ml, 0.4mg/2ml

1

glycopyrrolate inj 1mg/5ml, 4mg/20ml

1 MO

methscopolamine bromide tabs 1 PA MOH2-RECEPTOR ANTAGONISTS

cimetidine hcl oral soln 1 MOcimetidine tabs 1 MOfamotidine premixed inj 20mg/50ml 1famotidine inj 1famotidine oral susp, tabs 1 MOnizatidine 1 MO

INFLAMMATORY BOWEL DISEASE balsalazide disodium 1 MObudesonide er tab 9mg 4 MObudesonide cpep 3mg 1 MOcolocort 1hydrocortisone enem 100mg/60ml 1 MOmesalamine dr caps, tabs 1 MOmesalamine kit, supp 1 MOmesalamine enem 1 QL (1680 ML per 28 days) MOSULFASALAZINE DELAYED RELEASE TABS

2 MO

sulfasalazine tabs 1 MOLAXATIVES

constulose 1enulose 1 MOgavilyte-c 1 MOgavilyte-g 1 MOgavilyte-n/flavor pack 1 MOgenerlac 1

67Updated 10/01/20

Drug name Drug tier Requirements/LimitsGOLYTELY 2 MOlactulose 1 MONULYTELY/FLAVOR PACKS 2 MOOSMOPREP 3 MOpeg-3350/electrolytes 1 MOpeg-3350/nacl/na bicarbonate/kcl 1 MOPLENVU 3 MOSUPREP BOWEL PREP KIT 3 MOtrilyte 1

MISCELLANEOUS alosetron hydrochloride 4 QL (60 EA per 30 days) PA MOCARAFATE 3 MOcromolyn sodium oral conc 100mg/5ml

1 MO

diphenoxylate/atropine 1 MOGATTEX 4 PA LAlansoprazole/amoxicillin/clarithromycin


LINZESS 3 QL (30 EA per 30 days) MOloperamide hcl caps 1 MOmisoprostol tabs 1 MOMOVANTIK TABS 25MG 2 QL (30 EA per 30 days) MOMOVANTIK TABS 12.5MG 2 QL (60 EA per 30 days) MORELISTOR 4 PA MOSUCRALFATE SUSP 3 MOsucralfate tabs 1 MOursodiol 1 MOXIFAXAN TABS 550MG 4 PA MO

PANCREATIC ENZYMES CREON 2 MOZENPEP 3 MO

PROTON PUMP INHIBITORS DEXILANT 3 QL (30 EA per 30 days) MOesomeprazole magnesium caps 1 QL (30 EA per 30 days) MOesomeprazole sodium inj 1lansoprazole dr caps, odt 1 QL (30 EA per 30 days) MOomeprazole caps 1 QL (30 EA per 30 days) MO

68 Updated 10/01/20

Drug name Drug tier Requirements/Limitspantoprazole sodium dr tabs 20mg 1 QL (30 EA per 30 days) MOpantoprazole sodium inj 1pantoprazole sodium tbec 20mg 1 QL (30 EA per 30 days) MOpantoprazole sodium tbec 40mg 1 QL (60 EA per 30 days) MOrabeprazole sodium dr tabs 20mg 1 QL (30 EA per 30 days) MO

GENITOURINARYBENIGN PROSTATIC HYPERPLASIA

alfuzosin hcl er 1 QL (30 EA per 30 days) MOdutasteride 1 QL (30 EA per 30 days) MOdutasteride/tamsulosin hcl 1 QL (30 EA per 30 days) MOfinasteride tabs 5mg 1 QL (30 EA per 30 days) MOsilodosin 1 QL (30 EA per 30 days) MOtamsulosin hydrochloride 1 QL (60 EA per 30 days) MO

MISCELLANEOUS ACETIC ACID 0.25% IRRIGATION SOLN

2 MO

bethanechol chloride 1 MOELMIRON 3 MOflavoxate hcl 1 MOpotassium citrate er 1 MO

URINARY ANTISPASMODICS darifenacin hydrobromide er 1 QL (30 EA per 30 days) MOMYRBETRIQ 3 QL (30 EA per 30 days) MOoxybutynin chloride er tb24 5mg 1 QL (30 EA per 30 days) MOoxybutynin chloride er tb24 10mg, 15mg


oxybutynin chloride tabs 1 QL (120 EA per 30 days) MOoxybutynin chloride syrp 1 QL (600 ML per 30 days) MOsolifenacin succinate 1 QL (30 EA per 30 days) ST MOtolterodine tartrate 1 QL (60 EA per 30 days) ST MOtolterodine tartrate er 1 QL (30 EA per 30 days) ST MOTOVIAZ 3 QL (30 EA per 30 days) MOtrospium chloride 1 QL (60 EA per 30 days) MOtrospium chloride er 1 QL (30 EA per 30 days) MO

VAGINAL ANTI-INFECTIVES clindamycin phosphate crea 2% 1 MOmetronidazole vaginal 1 MO

69Updated 10/01/20

Drug name Drug tier Requirements/Limitsmiconazole 3 1 MOterconazole 1 MO

HEMATOLOGICANTICOAGULANTS

ELIQUIS STARTER PACK 2 QL (74 EA per 30 days) MOELIQUIS TABS 2.5MG 2 QL (60 EA per 30 days) MOELIQUIS TABS 5MG 2 QL (74 EA per 30 days) MOenoxaparin sodium 1 MOfondaparinux sodium 1 MOFRAGMIN 3 MOHEPARIN SODIUM/D5W INJ 20000UNIT/500ML, 25000UNIT/500ML

3

HEPARIN SODIUM/DEXTROSE 100UNIT/ML

3

HEPARIN SODIUM/NACL 0.45% INJ 25000UNIT/250ML, 25000UNIT/500ML

2

HEPARIN SODIUM/SODIUM CHLORIDE 25000UNIT/250ML; 0.45%

2

HEPARIN SODIUM INJ 5000UNIT/0.5ML, 5000UNIT/ML

2

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

1 MO

jantoven 1 MOPRADAXA 3 QL (60 EA per 30 days) MOwarfarin sodium 1 MOXARELTO STARTER PACK 2 QL (51 EA per 30 days) MOXARELTO TABS 10MG, 15MG, 20MG 2 QL (30 EA per 30 days) MOXARELTO TABS 2.5MG 2 QL (60 EA per 30 days) MO

HEMATOPOIETIC GROWTH FACTORS PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

2 PA

PROCRIT INJ 20000UNIT/ML, 40000UNIT/ML

4 PA

ZARXIO 4 PA

70 Updated 10/01/20

Drug name Drug tier Requirements/LimitsMISCELLANEOUS

anagrelide hydrochloride 1 MOcilostazol 1 MODROXIA 2 MOENDARI 4 PA LA MOHAEGARDA INJ 3000UNIT 4 QL (20 EA per 30 days) PA LAHAEGARDA INJ 2000UNIT 4 QL (30 EA per 30 days) PA LAicatibant acetate 4 QL (27 ML per 30 days) PApentoxifylline er 1 MOPROMACTA POWDER PACK 25MG 4 QL (180 EA per 30 days) PAPROMACTA POWDER PACK 12.5MG 4 QL (360 EA per 30 days) PA LAPROMACTA TABS 12.5MG, 25MG 4 QL (30 EA per 30 days) PA LAPROMACTA TABS 50MG, 75MG 4 QL (60 EA per 30 days) PA LAtranexamic acid inj 1tranexamic acid tabs 1 QL (30 EA per 30 days) MO

PLATELET AGGREGATION INHIBITORS aspirin/dipyridamole 1 QL (60 EA per 30 days) MOBRILINTA 3 MOclopidogrel tabs 300mg 1 QL (2 EA per 365 days) MOclopidogrel tabs 75mg 1 QL (30 EA per 30 days) MOdipyridamole 1 PA MOprasugrel 1 MO

IMMUNOLOGIC AGENTSAUTOIMMUNE AGENTS

ENBREL MINI 4 QL (8 ML per 28 days) PAENBREL SURECLICK 4 QL (8 ML per 28 days) PAENBREL INJ 25MG/VIAL 4 QL (8 EA per 28 days) PAENBREL INJ 25MG/0.5ML VIAL, 50MG/ML

4 QL (8 ML per 28 days) PA

ENBREL INJ 25MG/0.5ML PREFILLED SYRINGE

4 QL (8.16 ML per 28 days) PA

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK

4 PA

HUMIRA PEN 4 QL (6 EA per 28 days) PAHUMIRA PEN-CD/UC/HS STARTER 4 PAHUMIRA PEN-PS/UV STARTER 4 PA

71Updated 10/01/20

Drug name Drug tier Requirements/LimitsHUMIRA INJ 10MG/0.1ML, 10MG/0.2ML, 20MG/0.2ML, 20MG/0.4ML


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


RENFLEXIS 4 PARINVOQ 4 QL (30 EA per 30 days) PASKYRIZI 4 QL (7 EA per 365 days) PASTELARA INJ 45MG/0.5ML 4 QL (0.5 ML per 28 days) PASTELARA INJ 90MG/ML 4 QL (1 ML per 28 days) PATALTZ 4 QL (3 ML per 28 days) PAXELJANZ 4 QL (60 EA per 30 days) PAXELJANZ XR 4 QL (30 EA per 30 days) PA

DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) hydroxychloroquine sulfate 1 MOleflunomide 1 QL (30 EA per 30 days) MOmethotrexate tabs 2.5mg 1 MOXATMEP 3 MO

IMMUNOGLOBULINS BIVIGAM 4 PAFLEBOGAMMA DIF INJ 5% (5GM/100ML)

3 PA

FLEBOGAMMA DIF INJ 5% (0.5GM/10ML, 10GM/200ML, 2.5GM/50ML, 20GM/400ML), 10% (10GM/100ML, 20GM/200ML, 5GM/50ML)

4 PA

GAMASTAN 2 B/DGAMMAGARD LIQUID 4 PAGAMMAGARD S/D INJ 5GM, 10GM 4 PAGAMMAKED 4 PAGAMMAPLEX 4 PAGAMUNEX-C 4 PAOCTAGAM 4 PAPANZYGA 4 PAPRIVIGEN 4 PA

IMMUNOMODULATORS ACTIMMUNE 4 PA LA

72 Updated 10/01/20

Drug name Drug tier Requirements/LimitsARCALYST 4 PAINTRON A INJ 10MU 3INTRON A INJ 10MU/ML, 18MU, 50MU, 6000000UNIT/ML

4

IMMUNOSUPPRESSANTS AZATHIOPRINE INJ 3 B/Dazathioprine tabs 1 B/D MOBENLYSTA 4 PAcyclosporine 1 B/D MOcyclosporine modified caps, soln 1 B/D MOeverolimus tabs 0.25mg, 0.5mg, 0.75mg

4 B/D MO

gengraf caps 1 B/Dgengraf soln 1 B/D MOmycophenolate mofetil inj 1 B/Dmycophenolate mofetil caps, tabs 1 B/D MOmycophenolate mofetil oral susp 4 B/D MOmycophenolic acid dr 1 B/D MONULOJIX 4 B/DPROGRAF 3 B/D MOSANDIMMUNE 2 B/D MOsirolimus tabs 1 B/D MOsirolimus soln 4 B/D MOtacrolimus caps 0.5mg, 1mg, 5mg 1 B/D MOZORTRESS 4 B/D MO

VACCINES ACTHIB 2ADACEL 2BCG VACCINE 2BEXSERO 2BOOSTRIX 2DAPTACEL 2DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC

2 B/D

ENGERIX-B 2 B/DGARDASIL 9 2HAVRIX 2

73Updated 10/01/20

Drug name Drug tier Requirements/LimitsHIBERIX 2IMOVAX RABIES (H.D.C.V.) 2 B/DINFANRIX 2IPOL INACTIVATED IPV 2IXIARO 2KINRIX 2M-M-R II 2MENACTRA 2MENVEO 2PEDIARIX 2PEDVAX HIB 2PENTACEL 2PROQUAD 2QUADRACEL 2RABAVERT 2 B/DRECOMBIVAX HB 2 B/DROTARIX 2ROTATEQ 2SHINGRIX 2 QL (2 EA per 999 days)TDVAX 2 B/DTENIVAC 2 B/DTRUMENBA 2TWINRIX 2TYPHIM VI 2VAQTA 2VARIVAX 2YF-VAX 2ZOSTAVAX 2 QL (1 EA per 999 days)

NUTRITIONAL/SUPPLEMENTSELECTROLYTES/MINERALS, INJECTABLE

DEXTROSE 10%/NACL 0.45% 3DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX

2

DEXTROSE 10%/NACL 0.2% 3DEXTROSE 2.5%/NACL 0.45% 3DEXTROSE 5%/LACTATED RINGERS 3DEXTROSE 5%/NACL 0.2% 3

74 Updated 10/01/20

Drug name Drug tier Requirements/LimitsDEXTROSE 5%/NACL 0.225% 3DEXTROSE 5%/NACL 0.3% 3DEXTROSE 5%/NACL 0.33% 3DEXTROSE 5%/NACL 0.45% 3DEXTROSE 5%/NACL 0.9% 3 MOIONOSOL-MB/DEXTROSE 5% 3ISOLYTE-P/DEXTROSE 5% 3ISOLYTE-S 3KCL 0.075%/D5W/NACL 0.45% 3KCL 0.15%/D5W/NACL 0.2% 3KCL 0.15%/D5W/NACL 0.225% 3KCL 0.15%/D5W/NACL 0.45% 3KCL 0.15%/D5W/NACL 0.9% 3KCL 0.3%/D5W/NACL 0.45% 3KCL 0.3%/D5W/NACL 0.9% 3lactated ringers viaflex inj 1MAGNESIUM SULFATE INJ 20GM/500ML, 40GM/1000ML, 4GM/50ML

3

magnesium sulfate inj 2gm/50ml, 4gm/100ml, 50%

1

NORMOSOL-M IN D5W 3NORMOSOL-R INJ PH 7.4 3PLASMA-LYTE A 3PLASMA-LYTE-148 3POTASSIUM CHLORIDE/DEXTROSE 3POTASSIUM CHLORIDE/DEXTROSE/SODIUM CHLORIDE

3

POTASSIUM CHLORIDE/SODIUM CHLORIDE INJ 40MEQ/L; 0.9%

3

potassium chloride/sodium chloride inj 20meq/l; 0.45%

1

potassium chloride/sodium chloride inj 20meq/l; 0.9%

1 MO

POTASSIUM CHLORIDE INJ 0.4MEQ/ML, 10MEQ/100ML, 10MEQ/50ML, 20MEQ/100ML, 40MEQ/100ML

3

potassium chloride inj 2meq/ml 1 MO

75Updated 10/01/20

Drug name Drug tier Requirements/LimitsRINGERS INJECTION 2SODIUM BICARBONATE INJ 7.5% 3 MOsodium bicarbonate inj 4.2% 1sodium bicarbonate inj 8.4% 1 MOSODIUM CHLORIDE INJ 2.5MEQ/ML, 4MEQ/ML, 5%

3 MO

sodium chloride inj 0.45% 1sodium chloride inj 0.9% (flex cont), 3%

1 MO

TPN ELECTROLYTES 3 B/DELECTROLYTES/MINERALS/VITAMINS, ORAL

ADC/FLUORIDE 3 MOEFFER-K TAB 25MEQ 2 MOEFFERVESCENT POTASSIUM 2 MOFLUORIDE 3 MOFLUORITAB 3KLOR-CON 10 2KLOR-CON 8 2 MOklor-con m10 1 MOklor-con m15 1 MOklor-con m20 1 MOklor-con pow 20meq 1KLOR-CON/EF 2 MOLUDENT 3 MOM-NATAL PLUS 2 MOMULTI VITAMIN/FLUORIDE 3 MOMULTI-VITAMIN/FLUORIDE DROPS 3 MOMULTI-VITAMIN/FLUORIDE/IRON DROPS

3 MO

MULTIVITAMIN/FLUORIDE CHEW 0.5MG

3

MULTIVITAMIN/FLUORIDE CHEW 0.25MG, 0.5MG

3 MO

NEONATAL PLUS 2 MONIVA-PLUS 2 MOPNV FOLIC ACID + IRON MULTIVITAMIN

2 MO

76 Updated 10/01/20

Drug name Drug tier Requirements/LimitsPNV PRENATAL PLUS MULTIVITAMIN

2 MO

POLY-VITAMIN/FLUORIDE 3potassium chloride cr 1 MOpotassium chloride er 1 MOpotassium chloride sr 1 MOpotassium chloride pack 20meq 1 MOpotassium chloride oral soln 10%, 20%

1 MO

PRENATAL 2 MOPRENATAL PLUS 2 MOPRENATAL VITAMINS PLUS LOW IRON

2 MO

PREPLUS 2 MOSODIUM FLUORIDE CHEW 0.25MG, 0.5MG, 1MG

3 MO

SODIUM FLUORIDE SOLN 0.5MG/ML

3 MO

TRI-VITE/FLUORIDE 3 MOTRICARE PRENATAL TABS 2 MOVOL-PLUS 2 MOVP-PNV-DHA 2 MO

IV NUTRITION AMINOSYN II INJ 10% 3 B/DAMINOSYN-PF 10% 3 B/DAMINOSYN-PF 7% 3 B/DCLINIMIX 4.25%/DEXTROSE 10% 3 B/DCLINIMIX 4.25%/DEXTROSE 5% 3 B/DCLINIMIX 5%/DEXTROSE 15% 3 B/DCLINIMIX 5%/DEXTROSE 20% 3 B/Dclinisol sf 15% 1 B/D MOCLINOLIPID 2 B/Ddextrose 10% 1dextrose 5% 1 MODEXTROSE 50% 2 B/DDEXTROSE 70% 2 B/DFREAMINE HBC 6.9% 3 B/D

77Updated 10/01/20

Drug name Drug tier Requirements/LimitsFREAMINE III 3 B/DHEPATAMINE 3 B/DNEPHRAMINE 3 B/DNUTRILIPID 2 B/Dplenamine 1 B/DPREMASOL 10% 3 B/DPROCALAMINE 3 B/DPROSOL 3 B/DTRAVASOL 3 B/DTROPHAMINE 10 % 3 B/D

OPHTHALMICANTI-INFECTIVE/ANTI-INFLAMMATORY

BLEPHAMIDE S.O.P. OINT 3 MOneomycin/polymyxin/bacitracin/hydrocortisone ophthalmic oint

1 MO

neomycin/polymyxin/dexamethasone 1 MOneomycin/polymyxin/hydrocortisone ophthalmic susp 1%; 3.5mg/ml; 10000unit/ml

1 MO

sulfacetamide sodium/prednisolone sodium phosphate

1 MO

TOBRADEX 2 MOTOBRADEX ST 2 MOtobramycin/dexamethasone ophthalmic susp

1 MO

ZYLET 2 MOANTI-INFECTIVES

AZASITE 3 MObacitracin 1 MObacitracin/polymyxin ophthalmic oint 1 MOBESIVANCE 2 MOCILOXAN 2 QL (42 GM per 30 days) MOciprofloxacin hydrochloride ophthalmic soln 0.3%


erythromycin oint 5mg/gm 1 QL (42 GM per 30 days) MOgatifloxacin soln 1 QL (20 ML per 30 days) MOgentak 1 QL (42 GM per 30 days) MO

78 Updated 10/01/20

Drug name Drug tier Requirements/Limitsgentamicin sulfate ophthalmic soln 0.3%


levofloxacin ophthalmic soln 0.5% 1 QL (30 ML per 30 days) MOmoxifloxacin hydrochloride ophthalmic soln 0.5%


NATACYN 3 MOneo-polycin 1neomycin/bacitracin/polymyxin topical ointment

1 MO

neomycin/polymyxin/gramicidin 1 MOofloxacin ophthalmic soln 0.3% 1 QL (60 ML per 30 days) MOpolycin 1polymyxin b sulfate/trimethoprim sulfate

1 MO

sodium sulfacetamide ophthalmic soln


sulfacetamide sodium oint 10% 1 QL (42 GM per 30 days) MOsulfacetamide sodium soln 10% 1 QL (90 ML per 30 days) MOtobramycin sulfate ophthalmic soln 0.3%


trifluridine 1 MOtrimethoprim sulfate/polymyxin b sulfate

1 MO

ZIRGAN 3 MOANTI-INFLAMMATORIES

ALREX 2 MObromfenac 1 MOBROMSITE 3 MOdexamethasone sodium phosphate ophthalmic soln 0.1%

1 MO

diclofenac sodium soln 0.1% 1 QL (10 ML per 30 days) MODUREZOL 2 MOFLUOROMETHOLONE 2 MOflurbiprofen sodium ophthalmic soln 0.03%

1 MO

ILEVRO 2 MOketorolac tromethamine ophthalmic soln 0.4%, 0.5%

1 MO

79Updated 10/01/20

Drug name Drug tier Requirements/LimitsLOTEMAX 2 MOLOTEMAX SM 2 MOloteprednol etabonate 1 MOprednisolone acetate ophthalmic soln 1 MOPREDNISOLONE SODIUM PHOSPHATE OPHTHALMIC SOLN 1%

2 MO

PROLENSA 2 MOANTIALLERGICS

azelastine hcl nasal soln 0.15% (137mcg/spray) ophthalmic soln 0.05%

1 MO

BEPREVE 2 MOcromolyn sodium ophthalmic soln 4% 1 MOepinastine hcl 1 MOLASTACAFT 3 MOolopatadine hcl ophthalmic soln 0.2% 1 MOolopatadine hcl ophthalmic soln 0.1% 1 MOPAZEO 2 MO

ANTIGLAUCOMA ALPHAGAN P SOLN 0.1% 2 MOAZOPT 2 MObetaxolol hcl soln 0.5% 1 MOBETOPTIC-S 2 MOBRIMONIDINE TARTRATE SOLN 0.15%

2 MO

brimonidine tartrate soln 0.2% 1 MOcarteolol hcl 1 MOCOMBIGAN 2 MOdorzolamide hcl 1 MOdorzolamide hcl/timolol maleate 1 MOdorzolamide hydrochloride/timolol maleate pf

1 MO

latanoprost 1 MOlevobunolol hcl 1 MOLUMIGAN 2 MOPHOSPHOLINE IODIDE 3pilocarpine hcl ophthalmic soln 1 MO

80 Updated 10/01/20

Drug name Drug tier Requirements/LimitsRHOPRESSA 2 MOSIMBRINZA 2 MOTIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLN

3 MO

timolol maleate soln 0.25%, 0.5% 1 MOtravoprost 1 MO

MISCELLANEOUS ATROPINE SULFATE OPHTHALMIC SOLN 1%

2 MO

CYSTARAN 4 PA LA MOproparacaine hcl 1 MORESTASIS 2 QL (60 EA per 30 days) MORESTASIS MULTIDOSE 2 QL (5.5 ML per 30 days) MO

RESPIRATORYANTICHOLINERGIC/BETA AGONIST COMBINATIONS

ANORO ELLIPTA 2 QL (60 EA per 30 days) MOBEVESPI AEROSPHERE 2 QL (10.7 GM per 30 days) MOCOMBIVENT RESPIMAT 3 QL (8 GM per 30 days) MOipratropium bromide/albuterol sulfate neb

1 B/D MO

TRELEGY ELLIPTA 2 QL (60 EA per 30 days) MOANTICHOLINERGICS

ATROVENT HFA 3 QL (25.8 GM per 30 days) MOINCRUSE ELLIPTA 2 QL (30 EA per 30 days) MOipratropium bromide inhalation soln 1 B/D MOipratropium bromide nasal soln 0.03%


ipratropium bromide nasal soln 0.06%


ANTIHISTAMINES azelastine hcl nasal soln 0.15% (137mcg/spray) nasal soln 0.15%


azelastine hydrochloride nasal spray 0.15% (205.5mcg/spray)


carbinoxamine maleate soln 1 PA MOCARBINOXAMINE MALEATE TABS 6MG

4 PA MO

carbinoxamine maleate tabs 4mg 1 PA MO

81Updated 10/01/20

Drug name Drug tier Requirements/Limitscetirizine hydrochloride oral soln 1mg/ml


clemastine fumarate tab 2.68mg 1 PA MOcyproheptadine hcl syrp 2mg/5ml 1 PA MOcyproheptadine hydrochloride tab 4mg

1 PA MO

desloratadine 1 QL (30 EA per 30 days) MOdesloratadine odt 1 QL (30 EA per 30 days) MOdiphenhydramine hcl inj 1 PA MOhydroxyzine hcl inj, syrp 1 PA MOhydroxyzine hydrochloride tabs 1 PA MOhydroxyzine pamoate 1 PA MOlevocetirizine dihydrochloride soln 1 MOlevocetirizine dihydrochloride tabs 1 QL (30 EA per 30 days) MOolopatadine hcl nasal soln 0.6% 1 QL (30.5 GM per 30 days) MO

BETA AGONISTS albuterol sulfate er tabs 1 MOalbuterol sulfate hfa (generic Proventil HFA) aers 108mcg/act

1 QL (13.4 GM per 30 days) MO

albuterol sulfate hfa (generic Proair HFA) aers 108mcg/act

1 QL (17 GM per 30 days) MO

albuterol sulfate hfa (generic Ventolin HFA) aers 108mcg/act


albuterol sulfate nebu 1 B/D MOalbuterol sulfate syrp, tabs 1 MOlevalbuterol hcl neb 1.25mg/0.5ml 1 B/D MOlevalbuterol hydrochloride nebu 0.31mg/3ml, 0.63mg/3ml, 1.25mg/3ml

1 B/D MO

LEVALBUTEROL TARTRATE HFA 2 QL (30 GM per 30 days) MOmetaproterenol sulfate 1SEREVENT DISKUS 2 QL (60 EA per 30 days) MOterbutaline sulfate 1 MOVENTOLIN HFA 2 QL (36 GM per 30 days) MO

LEUKOTRIENE MODULATORS montelukast sodium 1 QL (30 EA per 30 days) MOzafirlukast 1 QL (60 EA per 30 days) MO

82 Updated 10/01/20

Drug name Drug tier Requirements/LimitsMISCELLANEOUS

acetylcysteine inhalation soln 10%, 20%

1 B/D MO

aminophylline 1ARALAST NP 4 PA LAcromolyn sodium nebu 20mg/2ml 1 B/D MODALIRESP 3 MOepinephrine hcl inj soln 1 QL (2 EA per 30 days) MOEPIPEN 2-PAK 3 QL (2 EA per 30 days) MOEPIPEN-JR 2-PAK 3 QL (2 EA per 30 days) MOESBRIET 4 PAFASENRA 4 QL (1 ML per 28 days) PAFASENRA PEN 4 QL (1 ML per 28 days) PAKALYDECO 4 PA MOOFEV 4 PAORKAMBI 4 PA MOPROLASTIN-C 4 PA LA MOPULMOZYME 4 PASYMDEKO TBPK 75MG; 50MG 4 PASYMDEKO TBPK 150MG; 100MG 4 PA LATHEO-24 3 MOtheophylline er 1 MOtheophylline soln 80 mg/15ml 1 MOXOLAIR 4 PA LAZEMAIRA 4 PA LA

NASAL STEROIDS flunisolide 1 QL (75 ML per 30 days) MOfluticasone propionate susp 50mcg/act


mometasone furoate susp 50mcg/act 1 QL (34 GM per 30 days) MOSTEROID INHALANTS

ARNUITY ELLIPTA 2 QL (30 EA per 30 days) MObudesonide susp 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml

1 B/D MO

FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST


83Updated 10/01/20

Drug name Drug tier Requirements/LimitsFLOVENT DISKUS AEPB 250MCG/BLIST


FLOVENT HFA AERO 44MCG/ACT 2 QL (21.2 GM per 30 days) MOFLOVENT HFA AERO 110MCG/ACT, 220MCG/ACT


PULMICORT FLEXHALER 3 QL (2 EA per 30 days) MOSTEROID/BETA-AGONIST COMBINATIONS

ADVAIR DISKUS 2 QL (60 EA per 30 days) MOADVAIR HFA 2 QL (12 GM per 30 days) MOBREO ELLIPTA 2 QL (60 EA per 30 days) MOSYMBICORT 2 QL (10.2 GM per 30 days) MO

TOPICALDERMATOLOGY, ACNE

amnesteem 1 PAAVITA CREA 3 QL (45 GM per 30 days) PAAVITA GEL 3 QL (45 GM per 30 days) PA MOclaravis 1 PAclindacin etz pledgets 1 MOclindacin-p pad 1% 1 MOclindamycin phosphate/benzoyl peroxide

1 MO

clindamycin phosphate foam 1% 1 QL (100 GM per 30 days) MOclindamycin phosphate gel 1% 1 QL (75 GM per 30 days) MOCLINDAMYCIN PHOSPHATE LOTN 1%


clindamycin phosphate external soln 1%


clindamycin phosphate swab 1% 1 MOclindamycin/benzoyl peroxide gel 5%;1%

1 MO

dapsone gel 5%, 7.5% 1 QL (90 GM per 30 days) MOery pad 2% 1 MOerythromycin/benzoyl peroxide gel 5%; 3%

1 MO

erythromycin gel 2% 1 QL (60 GM per 30 days) MOerythromycin soln 2% 1 QL (60 ML per 30 days) MOisotretinoin 1 PAmyorisan 1 PA

84 Updated 10/01/20

Drug name Drug tier Requirements/Limitsneuac gel 1 MOsulfacetamide sodium lotn 10% 1 MOTRETINOIN MICROSPHERE GEL 3 QL (50 GM per 30 days) PA MOTRETINOIN MICROSPHERE PUMP GEL


tretinoin crea 0.025%, 0.05%, 0.1% 1 QL (45 GM per 30 days) PA MOtretinoin gel 0.01%, 0.025%, 0.05% 1 QL (45 GM per 30 days) PA MOzenatane 1 PA

DERMATOLOGY, ANTIBIOTICS gentamicin sulfate crea 0.1% 1 QL (60 GM per 30 days) MOgentamicin sulfate oint 0.1% 1 QL (60 GM per 30 days) MOmafenide acetate 1 MOmupirocin 1 QL (30 GM per 30 days) MOSILVER SULFADIAZINE 2 MOSSD 2SULFAMYLON CREA 3 MO

DERMATOLOGY, ANTIFUNGALS ciclopirox olamine cream 1 QL (90 GM per 30 days) MOciclopirox gel 1 QL (100 GM per 30 days) MOciclopirox sham 1 QL (120 ML per 30 days) MOciclopirox susp 1 QL (60 ML per 30 days) MOclotrimazole/betamethasone dipropionate


clotrimazole crea 1% 1 QL (45 GM per 30 days) MOclotrimazole soln 1% 1 QL (30 ML per 30 days) MOeconazole nitrate 1 QL (85 GM per 30 days) MOERTACZO 4 QL (60 GM per 30 days) MOketoconazole crea 2% 1 QL (60 GM per 30 days) MOketoconazole foam 2% 1 QL (100 GM per 30 days) MOnaftifine hcl crea 1% 1 QL (90 GM per 30 days) MOnaftifine hydrochloride crea 2% 1 QL (60 GM per 30 days) MOnyamyc 1 QL (60 GM per 30 days)nystatin crea 100000unit/gm 1 QL (30 GM per 30 days) MOnystatin oint 100000unit/gm 1 QL (30 GM per 30 days) MOnystatin powd 100000unit/gm 1 QL (60 GM per 30 days) MOnystop 1 QL (60 GM per 30 days) MOoxiconazole nitrate 1 QL (90 GM per 30 days) MO

85Updated 10/01/20

Drug name Drug tier Requirements/LimitsDERMATOLOGY, ANTIPSORIATICS

acitretin 1 PA MOcalcipotriene crea, oint 1 QL (120 GM per 30 days) PA MOcalcipotriene soln 1 QL (60 ML per 30 days) PA MOCALCITRIOL OINT 3MCG/GM 3 QL (100 GM per 30 days) MOmethoxsalen 4 MOtazarotene crea 0.1% 1 QL (60 GM per 30 days) PA MOTAZORAC CREAM 0.05% 3 QL (60 GM per 30 days) PA MO

DERMATOLOGY, ANTISEBORRHEICS ketoconazole sham 2% 1 QL (120 ML per 30 days) MOselenium sulfide 1 MO

DERMATOLOGY, CORTICOSTEROIDS ala-cort crea 1% 1ala-cort crea 2.5% 1 QL (30 GM per 30 days)alclometasone dipropionate 1 MOaugmented betamethasone dipropionate

1 MO

beser lotn 0.05% 1 QL (120 ML per 30 days)betamethasone dipropionate 1 MObetamethasone valerate 1 MOcalcipotriene/betamethasone dipropionate


clobetasol propionate emollient foam 1 QL (100 GM per 30 days) MOclobetasol propionate emollient crea 1 QL (60 GM per 30 days) MOclobetasol propionate foam 1 QL (100 GM per 30 days) MOclobetasol propionate lotn, sham 1 QL (118 ML per 30 days) MOclobetasol propionate spray 1 QL (125 ML per 30 days) MOclobetasol propionate soln 1 QL (50 ML per 30 days) MOclobetasol propionate crea, gel, oint 1 QL (60 GM per 30 days) MOclodan shampoo 1 QL (118 ML per 30 days)desonide lotn 1 QL (118 ML per 30 days) MOdesonide crea, oint 1 QL (60 GM per 30 days) MOdesoximetasone crea, oint 1 QL (100 GM per 30 days) MOdesoximetasone gel 1 QL (60 GM per 30 days) MOdiflorasone diacetate 1 QL (60 GM per 30 days) MOENSTILAR 3 QL (120 GM per 30 days) PA MOfluocinolone acetonide body oil 1 QL (118.28 ML per 30 days) MO

86 Updated 10/01/20

Drug name Drug tier Requirements/Limitsfluocinolone acetonide scalp oil 1 QL (118.28 ML per 30 days) MOfluocinolone acetonide crea 0.025% 1 QL (120 GM per 30 days) MOfluocinolone acetonide crea 0.01% 1 QL (60 GM per 30 days) MOfluocinolone acetonide oint 0.025% 1 QL (120 GM per 30 days) MOfluocinolone acetonide soln 0.01% 1 QL (90 ML per 30 days) MOfluocinonide emulsified cream 1 QL (120 GM per 30 days) MOfluocinonide crea 1 QL (120 GM per 30 days) MOfluocinonide gel, oint 1 QL (60 GM per 30 days) MOfluocinonide soln 1 QL (60 ML per 30 days) MOflurandrenolide cream 1 QL (120 GM per 30 days) MOfluticasone propionate crea 0.05% 1 MOfluticasone propionate lotn 0.05% 1 QL (120 ML per 30 days) MOfluticasone propionate oint 0.005% 1 MOhalobetasol propionate crea, oint 1 QL (50 GM per 30 days) MOhydrocortisone butyrate (lipophilic) crea


hydrocortisone butyrate lotn 1 QL (118 ML per 30 days) MOhydrocortisone butyrate crea, oint 1 QL (45 GM per 30 days) MOhydrocortisone butyrate soln 1 QL (60 ML per 30 days) MOhydrocortisone valerate crea, oint 1 QL (60 GM per 30 days) MOhydrocortisone (generic Ala-Cort) crea 2.5%


hydrocortisone crea 1% 1 QL (90 GM per 30 days) MOhydrocortisone lotn 2.5% 1 MOhydrocortisone oint 2.5% 1 QL (30 GM per 30 days) MOmometasone furoate crea 0.1% 1 MOmometasone furoate oint 0.1% 1 MOmometasone furoate soln 0.1% 1 MOnolix cream 1 QL (120 GM per 30 days) MOPREDNICARBATE CREA 3 QL (60 GM per 30 days) MOprednicarbate oint 1 QL (60 GM per 30 days) MOTEXACORT 3 MOtovet foam 1 QL (100 GM per 30 days)triamcinolone acetonide aers spray 1 MOtriamcinolone acetonide crea 0.025%, 0.5%

1 MO

triamcinolone acetonide crea 0.1% 1 QL (454 GM per 30 days) MO

87Updated 10/01/20

Drug name Drug tier Requirements/Limitstriamcinolone acetonide lotn 0.025%, 0.1%

1 MO

triamcinolone acetonide oint 0.025%, 0.1%, 0.5%

1 MO

triderm crea 0.5% 1triderm crea 0.1% 1 QL (454 GM per 30 days)

DERMATOLOGY, LOCAL ANESTHETICS lidocaine hcl external soln 4% 1 QL (50 ML per 30 days) PA MOlidocaine/prilocaine 1 QL (30 GM per 30 days) PA MOlidocaine ptch 1 QL (3 EA per 1 days) PA MOlidocaine oint 1 QL (35.44 GM per 30 days) PA

MODERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE

acyclovir oint 5% 1 QL (30 GM per 30 days) MOammonium lactate 1 MOazelaic acid 1 QL (50 GM per 30 days) MOdiclofenac sodium gel 1% 1 QL (1000 GM per 30 days) PA

MODOXEPIN HYDROCHLORIDE CREA 5%


DOXYCYCLINE CPDR 40MG 3 QL (30 EA per 30 days) PA MOFINACEA FOAM 3 QL (50 GM per 30 days) MOFLUOROURACIL CREA 0.5% 3 QL (30 GM per 30 days) PA MOfluorouracil crea 5% 1 QL (40 GM per 30 days) PA MOfluorouracil external soln 2%, 5% 1 QL (10 ML per 30 days) MOhydrocortisone (generic Proctosol HC) crea 2.5%

1 MO

imiquimod 1 QL (24 EA per 30 days) MOIMIQUIMOD PUMP 4 QL (7.5 GM per 30 days) MOmetronidazole crea 0.75% 1 QL (45 GM per 30 days) MOmetronidazole gel 0.75%, 1% 1 MOmetronidazole lotn 0.75% 1 MONORITATE 4 QL (60 GM per 30 days) MOORACEA 3 QL (30 EA per 30 days) PA MOPANRETIN 4 QL (60 GM per 30 days)PENNSAID 4 QL (224 GM per 28 days) PA MOPICATO GEL 0.05% 4 QL (2 EA per 30 days) MOPICATO GEL 0.015% 4 QL (3 EA per 30 days) MO

88 Updated 10/01/20

Drug name Drug tier Requirements/Limitspodofilox 1 MOprocto-med hc 1procto-pak 1 MOproctosol hc 1 MOproctozone-hc 1RECTIV 3 QL (30 GM per 30 days) MOrosadan gel 1rosadan crea 1 QL (45 GM per 30 days)tacrolimus oint 0.03%, 0.1% 1 QL (60 GM per 30 days) MOTARGRETIN 4 QL (60 GM per 30 days) PAVALCHLOR 4 QL (60 GM per 30 days) PA LA

MOZYCLARA PUMP 2.5% 4 QL (15 GM per 30 days) MO

DERMATOLOGY, SCABICIDES AND PEDICULIDES malathion 1 MOpermethrin 1 MO

DERMATOLOGY, WOUND CARE AGENTS REGRANEX 4 QL (30 GM per 30 days) PA MOSANTYL 3 MOSODIUM CHLORIDE 0.9% IRRIGATION SOLN

2 MO

STERILE WATER IRRIGATION PLASTIC BOTTLE

2 MO

MOUTH/THROAT/DENTAL AGENTS cevimeline hydrochloride 1 MOchlorhexidine gluconate oral soln 1 MOCLINPRO 5000 3 MOclotrimazole troc 10mg 1 MODENTAGEL 3 QL (56 GM per 30 days) MOFLUORIDEX 3FLUORIDEX SENSITIVITY RELIEF/SLS FREE

3

lidocaine viscous 1 MOnystatin susp 100000unit/ml 1 MOoralone dental paste 1paroex oral soln 1periogard oral soln 1

89Updated 10/01/20

Drug name Drug tier Requirements/Limitspilocarpine hydrochloride tabs 1 MOSF GEL 3 QL (56 GM per 30 days) MOSODIUM FLUORIDE GEL 1.1% 3 QL (56 GM per 30 days) MOtriamcinolone acetonide dental paste 1 MO

OTIC acetic acid otic soln 1 MOCIPRO HC OTIC SUSP 3 MOCIPRODEX 2 MOCIPROFLOXACIN OTIC SOLN 0.2% 2 MOflac otic oil 1 QL (20 ML per 30 days)fluocinolone acetonide otic oil 0.01% 1 QL (20 ML per 30 days) MOhydrocortisone/acetic acid otic soln 1 MOneomycin/polymyxin/hydrocortisone otic soln

1 MO

neomycin/polymyxin/hydrocortisone otic susp 1%; 3.5mg/ml; 10000unit/ml

1 MO

ofloxacin otic soln 0.3% 1 MO

90 Updated 10/01/20

Drug name PageDrug name Page

Index of Drugs

Drug name Page

abacavir sulfate/lamivudine

18

abacavir sulfate/lamivudine/zidovudine

18

ABELCET 15ABILIFY MAINTENA 45abiraterone acetate 25

ABRAXANE 26acamprosate calcium dr 51

acarbose 53acebutolol hcl 34

acebutolol hydrochloride

34

acetaminophen/codeine soln

12

acetaminophen/codeine tabs

12

acetazolamide 36acetazolamide er 36

acetic acid 89ACETIC ACID 0.25% 68

acetylcysteine 62, 82

acitretin 85ACTHIB 72

ACTIMMUNE 71acyclovir 19,

87acyclovir sodium 19

ADACEL 72ADC/FLUORIDE 75

adefovir dipivoxil 19ADEMPAS 37

adrucil 24ADVAIR DISKUS 83

ADVAIR HFA 83

afeditab cr 35AFINITOR 27

AFINITOR DISPERZ 27afirmelle 56

AIMOVIG 49ala-cort 85

albendazole 13albuterol sulfate 81

albuterol sulfate er 81albuterol sulfate hfa 81

alclometasone dipropionate

85

ALDURAZYME 62ALECENSA 27

alendronate sodium 55alfuzosin hcl er 68

ALIMTA 24ALINIA 13

aliskiren 36allopurinol 10

almotriptan malate 49alosetron hydrochloride 67

ALPHAGAN P 79alprazolam 38

alprazolam er 38ALPRAZOLAM

INTENSOL38

ALREX 78altavera 56

ALUNBRIG 27alyacen 1/35 56

alyacen 7/7/7 56alyq 37

amabelz 61amantadine hcl 44

AMBISOME 16

ambrisentan 37amethia 56

AMETHIA LO 56amethyst 56

amikacin sulfate 13amiloride hcl 36

amiloride/hydrochlorothiazide

36

aminophylline 82AMINOSYN II 76

AMINOSYN-PF 76amiodarone hcl 33

amiodarone hydrochloride

33

amitriptyline hcl 41amitriptyline

hydrochloride41

amlodipine besylate 31, 35, 36

amlodipine besylate/atorvastatin calcium

36

amlodipine besylate/benazepril

hydrochloride

31

amlodipine besylate/valsartan

31

amlodipine/olmesartan medoxomil

32

amlodipine/valsartan/hctz

32

amlodipine/valsartan/hydrochlorothiazide

32

ammonium lactate 87amnesteem 83amoxapine 41amoxicillin 22

91Updated 10/01/20

Drug name Page Drug name Page Drug name Page

amoxicillin/clavulanate potassium

22

amoxicillin/clavulanate potassium er

22

amphetamine/dextroamphetamine

47

amphetamine/dextroamphetamine er

47

amphotericin b 16ampicillin 22

ampicillin sodium 22ampicillin-sulbactam 22

ANADROL-50 51anagrelide

hydrochloride70

anastrozole 25ANDRODERM 51

ANORO ELLIPTA 80APOKYN 44

aprepitant 65apri 56

APTIOM 38APTIVUS 16

ARALAST NP 82aranelle 56

ARCALYST 72aripiprazole odt 45

aripiprazole soln 45aripiprazole tabs 45

ARISTADA 45ARISTADA INITIO 45

armodafinil 50ARNUITY ELLIPTA 82

arsenic trioxide 26ashlyna 56

aspirin/dipyridamole 70atazanavir sulfate 16,

17atenolol 34

atenolol/chlorthalidone 34

atomoxetine 47, 48

atorvastatin calcium 33atovaquone 13,

16atovaquone/proguanil

hcl16

ATRIPLA 18ATROPINE SULFATE 80

ATROVENT HFA 80aubra 56

aubra eq 56augmented

betamethasone dipropionate

85

aurovela 1.5/30 56aurovela 24 fe 56

aurovela fe 1.5/30 56aurovela fe 1/20 56

AURYXIA 64AUSTEDO 50

AVASTIN 27aviane 56AVITA 83ayuna 56

AYVAKIT 27azacitidine 24

AZASITE 77azathioprine 72azelaic acid 87

azelastine hcl 79, 80

azelastine hydrochloride 80azithromycin 21

AZITHROMYCIN PACK 21AZOPT 79

aztreonam 13azurette 56

bacitracin 77bacitracin/polymyxin 77

baclofen 50

balsalazide disodium 66BALVERSA 27

balziva 57BANZEL 38

BARACLUDE 19BASAGLAR KWIKPEN 52

BCG 72BD ALCOHOL SWABS 52

BD/ULTIMED/ALLISON/TRIVIDIA/

MHC INSULIN SYRINGE SAFETYGLIDE/1ML/

29G X 1/2

52


MHC INSULIN SYRINGE ULTRA-

AFINE/0.3ML/31G X 6MM

52



FINE/0.5ML/30G X 1/2

52



FINE/1ML/31G X 5/16

52


MHC INSULIN SYRINGE ULTRAFINE II/0.3ML/31G X 5/16

52

bekyree 57BELEODAQ 27BELSOMRA 49

benazepril hcl 31benazepril hcl/

hydrochlorothiazide31

benazepril hydrochloride

31

BENDEKA 23

92 Updated 10/01/20


BENLYSTA 72benztropine mesylate 44

BEPREVE 79beser 85

BESIVANCE 77betamethasone

dipropionate85

betamethasone valerate 85BETASERON 50betaxolol hcl 34,

79bethanechol chloride 68

BETOPTIC-S 79BEVESPI AEROSPHERE 80

bexarotene 26BEXSERO 72

bicalutamide 25BICILLIN L-A 22

BIDIL 36BIKTARVY 18

bisoprolol fumarate 34bisoprolol fumarate/hydrochlorothiazide

34

BIVIGAM 71bleomycin sulfate 24

BLEPHAMIDE S.O.P. 77blisovi 24 fe 57

blisovi fe 1.5/30 57blisovi fe 1/20 57

BOOSTRIX 72BORTEZOMIB 27

bosentan 37BOSULIF 27

BRAFTOVI 27BREO ELLIPTA 83

briellyn 57BRILINTA 70

brimonidine tartrate 79BRIMONIDINE

TARTRATE79

BRIVIACT 38

bromfenac 78bromocriptine mesylate 44

BROMSITE 78BRUKINSA 27budesonide 66,

82budesonide er 66

bumetanide 36buprenorphine 11

buprenorphine hcl 51buprenorphine hcl/

naloxone hcl51

buprenorphine hydrochloride/naloxone

hydrochloride

51

bupropion hcl 41bupropion

hydrochloride42

bupropion hydrochloride er (sr)

42, 51

bupropion hydrochloride er (xl)

42

buspirone hcl 38buspirone

hydrochloride38

busulfan 23butorphanol tartrate 12

BYDUREON BCISE 53BYDUREON PEN 53

BYETTA 53BYSTOLIC 34

cabergoline 62CABOMETYX 27calcipotriene 85

calcipotriene/betamethasone

dipropionate

85

calcitonin-salmon 55calcitriol 64

CALCITRIOL 85calcium acetate 64

CALQUENCE 27camila 57

CAMRESE 57CAMRESE LO 57

candesartan cilexetil 32candesartan cilexetil/


CAPLYTA 45CAPRELSA 27

captopril 31captopril/


CARAFATE 67CARBAGLU 62

carbamazepine 38carbamazepine er 38

carbidopa 44carbidopa/levodopa 44

CARBIDOPA/LEVODOPA/

ENTACAPONE

44

carbidopa/levodopa er 44carbidopa/levodopa odt 44carbinoxamine maleate 80

CARBINOXAMINE MALEATE

80

carboplatin 23carmustine 23

carteolol hcl 79cartia xt 35

carvedilol 34carvedilol phosphate er 34

caspofungin acetate 16CAYSTON 13

caziant 57cefaclor 20

CEFACLOR ER 20cefadroxil 20

CEFAZOLIN 20cefazolin sodium 20

CEFAZOLIN SODIUM 20

93Updated 10/01/20


cefdinir 20cefepime 20cefixime 20

cefotetan 20cefoxitin sodium 20

cefpodoxime proxetil 20cefprozil 21

ceftazidime 21CEFTAZIDIME/

DEXTROSE21

ceftriaxone in iso-osmotic dextrose

21

ceftriaxone sodium 21CEFTRIAXONE

SODIUM21

cefuroxime axetil 21cefuroxime sodium 21

celecoxib 10CELONTIN 38cephalexin 21CERDELGA 62CEREZYME 63

cetirizine hydrochloride 81cevimeline

hydrochloride88

CHANTIX 51CHANTIX CONTINUING

MONTH PAK51

CHANTIX STARTING MONTH PAK

51

chateal 57chateal eq 57

CHEMET 56chloramphenicol 13

chlordiazepoxide hcl 38chlordiazepoxide

hydrochloride38

chlorhexidine gluconate 88chloroquine phosphate 16

chlorpromazine 45

CHLORPROMAZINE HCL INJ

45

chlorthalidone 36chlorzoxazone 50

CHLORZOXAZONE 50cholestyramine 34

cholestyramine light 34ciclopirox 84

ciclopirox gel 84ciclopirox olamine 84

cilostazol 70CILOXAN 77CIMDUO 18

cimetidine 66cimetidine hcl 66

cinacalcet hydrochloride 63CIPRODEX 89

CIPROFLOXACIN 89ciprofloxacin hcl 21

ciprofloxacin hydrochloride

21, 77

ciprofloxacin i.v.-in d5w 22CIPRO HC 89

cisplatin 23citalopram

hydrobromide42

cladribine 24claravis 83

clarithromycin 21clarithromycin er 21

clemastine fumarate 81clindacin etz pledgets 83

clindacin-p 83clindamycin/benzoyl

peroxide83

clindamycin hcl 13clindamycin

hydrochloride14

clindamycin palmitate hcl

14

clindamycin phosphat 14

clindamycin phosphate 14, 68, 83

CLINDAMYCIN PHOSPHATE

83

clindamycin phosphate/benzoyl peroxide

83

clindamycin phosphate/dextrose

14

CLINDAMYCIN/SODIUM CHLORIDE

14

CLINIMIX 4.25%/DEXTROSE 5%

76

CLINIMIX 4.25%/DEXTROSE 10%

76

CLINIMIX 5%/DEXTROSE 15%

76

CLINIMIX 5%/DEXTROSE 20%

76

clinisol sf 76CLINOLIPID 76

CLINPRO 5000 88clobazam 38

clobetasol propionate 85clodan shampoo 85

clofarabine 24clomipramine hcl 42

clonazepam 39clonazepam odt 38

clonidine hcl 36clonidine hydrochloride 36

clopidogrel 70clorazepate

dipotassium39

clotrimazole 84clotrimazole/

betamethasone dipropionate

84

clotrimazole troc 88clovique 56

clozapine 45clozapine odt 45

94 Updated 10/01/20


CLOZAPINE ODT 45COARTEM 16

CODEINE SULFATE 12colchicine 10

colesevelam hydrochloride

34

colestipol hcl 34colistimethate 14

colocort 66COMBIGAN 79

COMBIVENT RESPIMAT 80COMETRIQ 27COMPLERA 18

compro 65constulose 66

COPAXONE 50COPIKTRA 27

CORLANOR 36cortisone acetate 61

COTELLIC 27CREON 67

CRIXIVAN 17cromolyn sodium 67,

79, 82

cryselle-28 57cyclafem 1/35 57

cyclafem 7/7/7 57cyclobenzaprine

hydrochloride50

cyclophosphamide 23cycloserine 19

cyclosporine 72cyclosporine modified 72

cyproheptadine hcl 81cyproheptadine

hydrochloride81

cyred 57cyred eq 57

CYSTADANE 63CYSTAGON 63

CYSTARAN 80cytarabine aqueous 24

dacarbazine 26dactinomycin 24

dalfampridine er 50DALIRESP 82

danazol 61dantrolene sodium 50

dapsone 14, 83

DAPTACEL 72daptomycin 14

DAPTOMYCIN 14darifenacin

hydrobromide er68

dasetta 1/35 57dasetta 7/7/7 57daunorubicin hydrochloride

24

DAUNORUBICIN HYDROCHLORIDE

24

DAURISMO 27daysee 57

deblitane 57decitabine 24

deferasirox 56DELESTROGEN 61

DELSTRIGO 18DEMSER 36

DENTAGEL 88DEPO-PROVERA 25

DESCOVY 18desipramine hcl 42

desloratadine 81desloratadine odt 81

desmopressin acetate 63desogestrel/ethinyl

estradiol57

desonide 85desoximetasone 85

desvenlafaxine er 42

DESVENLAFAXINE ER 42dexamethasone 62

DEXAMETHASONE INTENSOL

61

dexamethasone sodium phosphate

61, 62, 78

DEXILANT 67dexmethylphenidate hcl 48

dexmethylphenidate hcl er

48

dexmethylphenidate hydrochloride

48

dexrazoxane 30dextroamphetamine

sulfate48

dextroamphetamine sulfate er

48

DEXTROSE 2.5%/NACL 0.45%

73

dextrose 5% 73, 74, 76

DEXTROSE 5% /ELECTROLYTE #48

VIAFLEX

73

DEXTROSE 5%/LACTATED RINGERS

73

DEXTROSE 5%/NACL 0.2%

73


74


74


74


74


74

dextrose 10% 73, 76

95Updated 10/01/20



73


73

DEXTROSE 50% 76DEXTROSE 70% 76

diazepam 39DIAZEPAM RECTAL

GEL39

diazoxide 62diclofenac potassium 10

diclofenac sodium 78, 87

diclofenac sodium dr 10diclofenac sodium er 10

diclofenac sodium/misoprostol

10

dicloxacillin 22dicyclomine hcl 66

dicyclomine hydrochloride

66

didanosine 17DIFICID 21

diflorasone diacetate 85diflunisal 10

digitek 37digox 37

digoxin 37dihydroergotamine

mesylate49

DILANTIN 39DILANTIN-125 39

DILANTIN INFATABS 39diltiazem hcl 35

DILTIAZEM HCL 35diltiazem hcl cd 35diltiazem hcl er 35diltiazem hcl inj 35

diltiazem hydrochloride 35dilt-xr 35

DIMENHYDRINATE 65

diphenhydramine hcl 81diphenoxylate/atropine 67DIPHTHERIA/TETANUS

TOXOIDS ADSORBED PEDIATRIC

72

dipyridamole 70disopyramide

phosphate33

disulfiram 51divalproex sodium 39

divalproex sodium dr 39divalproex sodium er 39

docetaxel 27DOCETAXEL 26,

27dofetilide 33

donepezil hc 41donepezil hcl 41

donepezil hydrochloride 41dorzolamide hcl 79

dorzolamide hcl/timolol maleate

79

dorzolamide hydrochloride/timolol

maleate pf

79

dotti 61DOVATO 18

doxazosin mesylate 31DOXEPINE

HYDROCHLORIDE87

doxepin hcl 42doxepin hydrochloride 42,

49doxercalciferol 64

doxorubicin hcl liposome

24

doxorubicin hydrochloride liposomal

24

doxy 100 23doxycycline 23

DOXYCYCLINE 87

doxycycline hyclate 23doxycycline hyclate dr 23

doxycycline monohydrate

23

DRIZALMA 42dronabinol 65

drospirenone/ethinyl estradiol

57

drospirenone/ethinyl estradiol/levomefolate

calcium

57

DROXIA 70DUAVEE 61DUEXIS 10

duloxetine hydrochloride

42

DUREZOL 78dutasteride 68

dutasteride/tamsulosin hcl

68

econazole nitrate 84EDARBI 32

EDARBYCLOR 32EDURANT 17

efavirenz 17EFFER-K 75

EFFERVESCENT POTASSIUM

75

eletriptan hydrobromide

49

elinest 57ELIQUIS 69

ELIQUIS STARTER PACK 69ELITEK 30

ELMIRON 68eluryng 57EMBRE; 70EMCYT 25EMEND 65

emoquette 57EMSAM 42

96 Updated 10/01/20


EMTRIVA 17EMVERM 14

enalapril maleate 31enalapril maleate/


ENBREL 70ENBREL MINI 70

ENBREL SURECLICK 70ENDARI 70endocet 12

ENGERIX-B 72ENHERTU 27

enoxaparin sodium 69enpresse-28 57

enskyce 57ENSTILAR 85

entacapone 44entecavir 19

ENTRESTO 32enulose 66

EPCLUSA 19EPIDIOLEX 39

epinastine hcl 79epinephrine hcl 82

EPIPEN 82EPIPEN-JR 82

epirubicin hcl 24epitol 39

EPIVIR HBV 19eplerenone 31

epoprostenol sodium 37eprosartan mesylate 32ergotamine tartrate/

caffeine49

ERIVEDGE 27ERLEADA 25

erlotinib hydrochloride 28errin 57

ERTACZO 84ertapenem 14

ery pad 83ERYTHROCIN

LACTOBIONATE21

erythrocin stearate 21erythromycin 21,

77, 83

erythromycin base 21erythromycin/benzoyl

peroxide83

erythromycin dr 21erythromycin

ethylsuccinate21

erythromycin stearate 21ESBRIET 82

escitalopram oxalate 42esomeprazole

magnesium67

esomeprazole sodium 67estarylla 57estradiol 61

estradiol/norethindrone acetatemg

61

estradiol valerate 61ESTRING 61

eszopiclone 49ethambutol

hydrochloride19

ethosuximide 39ethynodiol diacetate/

ethinyl estradiol57

etodolac 10etodolac er 10

ETONOGESTREL/ETHINYL ESTRADIOL

57

etoposide 27euthyrox 64

everolimus 28, 72

EVOTAZ 18exemestane 25

ezetimibe 34ezetimibe/simvastatin 34

FABRAZYME 63falmina 57

famciclovir 19famotidine 66

famotidine premixedl 66FANAPT 45

FANAPT TITRATION PACK

45

FARXIGA 53FARYDAK 28FASENRA 82

FASENRA PEN 82fayosim 57

febuxostat 10felbamate 39

felodipine er 35femynor 58

fenofibrate 33fenofibrate micronized 33

FENOFIBRIC ACID 34fenofibric acid dr 33

fenoprofen calcium 10FENOPROFEN

CALCIUM10

fentanyl 11fentanyl citrate oral

transmucosal12

FETZIMA 42FETZIMA TITRATION

PACK42

FIASP 52FIASP FLEXTOUCH 52

FIASP PENFILL 52FINACEA 87

finasteride 68FINTEPLA 39

flac 89flavoxate hcl 68

FLEBOGAMMA DIF 71

97Updated 10/01/20


flecainide acetate 33FLOVENT DISKUS 82,

83FLOVENT HFA 83

fluconazole 16fluconazole in nacl 16

fluconazole in sodium chloride

16

flucytosine 16fludarabine phosphate 24fludrocortisone acetate 62

flunisolide 82fluocinolone acetonide 86,

89fluocinolone acetonide

body oil85

fluocinolone acetonide scalp oil

86

fluocinonide 86fluocinonide emulsified 86

FLUORIDE 75FLUORIDEX 88FLUORIDEX

SENSITIVITY RELIEF/SLS FREE

88

FLUORITAB 75FLUOROMETHOLONE 78

fluorouracil 24, 87

FLUOROURACIL CREA 0.5%

87

fluoxetine dr 42fluoxetine hcl 42

fluoxetine hydrochloride 42fluphenazine decanoate 45

fluphenazine hcl 45fluphenazine

hydrochloride45

flurandrenolide 86flurbiprofen 10

flurbiprofen sodium 78

flutamide 25fluticasone propionate 82,

86fluvastatin 33

fluvastatin sodium er 33fluvoxamine maleate 38

fluvoxamine maleate er 38fomepizole 63

fondaparinux sodium 69FORTEO 55

fosamprenavir calcium 17fosinopril sodium 31

fosinopril sodium/hydrochlorothiazide

31

fosphenytoin sodium 39FRAGMIN 69

FREAMINE HBC 76FREAMINE III 77

frovatriptan succinate 49fulvestrant 25furosemide 36

FUZEON 17fyavolv 61

FYCOMPA 39gabapentin 39

galantamine hydrobromide

41

galantamine hydrobromide er

41

GAMASTAN 71GAMMAGARD 71

GAMMAKED 71GAMMAPLEX 71GAMUNEX-C 71

ganciclovir 19GARDASIL 9 72gatifloxacin 77

GATTEX 67GAUZE PADS 52

gavilyte-c 66gavilyte-g 66

gavilyte-n/flavor pack 66gemcitabine 25

gemcitabine hcl 24gemcitabine

hydrochloride25

GEMCITABINE HYDROCHLORIDE

25

gemfibrozil 33generlac 66gengraf 72

GENOTROPIN 63GENOTROPIN

MINIQUICK63

gentak 77gentamicin sulfate 14,

78, 84

gentamicin sulfate pediatric

14

gentamicin sulfate/sodium chloride

14

GENVOYA 18GEODON 45

GIANVI 58GILENYA 50

GILOTRIF 28GLEOSTINE 23glimepiride 53

glipizide 53, 54

glipizide er 53glipizide/metformin

hydrochloride53

glipizide xl 53glycopyrrolate 66

GLYXAMBI 54GOLYTELY 67

granisetron hcl 65griseofulvin microsize 16

griseofulvin ultramicrosize

16

98 Updated 10/01/20


guanfacine er 48guanfacine hcl 37

GUANIDINE HCL 50GVOKE HYPOPEN 62

GVOKE PFS 62HAEGARDA 70

hailey 1.5/30 58hailey 24 fe 58

halobetasol propionate 86haloperidol 45

haloperidol decanoate 45haloperidol lactate 45

HARVONI 19HAVRIX 72heather 58

heparin sodium 69HEPARIN SODIUM 69

HEPARIN SODIUM/D5W

69

HEPARIN SODIUM/DEXTROSE

69

HEPARIN SODIUM/NACL 0.45%

69

HEPARIN SODIUM/SODIUM CHLORIDE

69

HEPATAMINE 77HERCEPTIN 28

HERCEPTIN HYLECTA 28HETLIOZ 49HIBERIX 73HUMIRA 71

HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK

70

HUMIRA PEN 70HUMIRA PEN-CD/UC/

HS STARTER70

HUMIRA PEN-PS/UV STARTER

70

HUMULIN R U-500 52hydralazine hcl 37

hydralazine hydrochloride

37

hydrochlorothiazide 36hydrocodone/

acetaminophen12

hydrocodone bitartrate/acetaminophen

12

hydrocodone/ibuprofen 12hydrocortisone 62,

66, 86, 87

hydrocortisone/acetic acid

89

hydrocortisone butyrate 86hydrocortisone butyrate

(lipophilic)86

hydrocortisone valerate 86hydromorphone hcl 12

HYDROMORPHONE HCL

12

hydromorphone hydrochloride

12

HYDROMORPHONE HYDROCHLORIDE

12

hydroxychloroquine sulfate

71

hydroxyurea 26hydroxyzine hcl 81

hydroxyzine hydrochloride

81

hydroxyzine pamoate 81HYSINGLA ER 11

ibandronate sodium 55IBRANCE 28

ibu 10ibuprofen 10

icatibant acetate 70ICLUSIG 28

idarubicin hcl 24IDHIFA 28

IFEX 23

ifosfamide 24IFOSFAMIDE 23

ILEVRO 78imatinib mesylate 28

IMBRUVICA 28imipenem/cilastatin 14

imipramine hcl 42imipramine

hydrochloride42

imipramine pamoate 42imiquimod 87

IMIQUIMOD PUMP 87IMLYGIC 26

IMOVAX RABIES (H.D.C.V.)

73

incassia 58INCRELEX 63

INCRUSE ELLIPTA 80indapamide 36

INFANRIX 73INLYTA 28INQOVI 26

INREBIC 28INTELENCE 17

INTRON A 72introvale 58

INVEGA SUSTENNA 45, 46

INVEGA TRINZA 46INVIRASE 17

IONOSOL-MB/DEXTROSE 5%

74

IPOL INACTIVATED IPV 73ipratropium bromide 80

ipratropium bromide/albuterol sulfate

80

irbesartan 32irbesartan/


IRESSA 28irinotecan 26

99Updated 10/01/20


irinotecan hcl 26irinotecan

hydrochloride26

ISENTRESS 17ISENTRESS HD 17

isibloom 58ISOLYTE-P/DEXTROSE

5%74

ISOLYTE-S 74isoniazid 19

isosorbide dinitrate immediate release

37

isosorbide mononitrate 37isosorbide mononitrate

er37

isotonic gentamicin 14isotretinoin 83

isradipine 35itraconazole 16

ivermectin 14IXIARO 73

jaimiess 58JAKAFI 28

jantoven 69JANUMET 54

JANUMET XR 54JANUVIA 54

JARDIANCE 54jasmiel 58

jencycla 58JENTADUETO 54

JENTADUETO XR 54jinteli 61

JOLESSA 58JOLIVETTE 58

juleber 58JULUCA 18

junel 1.5/30 58junel 1/20 58

junel fe 1.5/30 58junel fe 1/20 58

junel fe 24 58JUXTAPID 34KADCYLA 28

kaitlib fe 58KALETRA 18

kalliga 58KALTETRA 18KALYDECO 82

kariva 58KCL 0.3%/D5W/NACL

0.9%74

KCL 0.3%/D5W/NACL 0.45%

74

KCL 0.15%/D5W/NACL 0.2%

74

KCL 0.15%/D5W/NACL 0.9%

74

KCL 0.15%/D5W/NACL 0.45%

74

KCL 0.15%/D5W/NACL 0.225%

74

KCL 0.075%/D5W/NACL 0.45%

74

kelnor 1/35 58kelnor 1/50 58

ketoconazole 16, 84, 85

ketoprofen 10ketoprofen er 10

ketorolac tromethamine 11, 78

KEYTRUDA 28KHAPZORY 30

KINRIX 73kionex 56

KISQALI 26, 28

KISQALI FEMARA CO-PACK

26

klor-con 75KLOR-CON 8 75

KLOR-CON 10 75KLOR-CON/EF 75

klor-con m10 75klor-con m15 75klor-con m20 75

KORLYM 63kurvelo 58KUVAN 63

labetalol hydrochloride 34lactated ringers viaflex 74

lactulose 67lamivudine 17,

20lamivudine/zidovudine 18

lamotrigine 39lamotrigine er 39

lamotrigine odt 39lamotrigine starter kit/

blue39

lamotrigine starter kit/green

40

lamotrigine starter kit/orange

40

lansoprazole/amoxicillin/

clarithromycin

67

lansoprazole dr 67larin 1.5/30 58

larin 1/20 58larin 24 fe 58

larin fe 1.5/30 58larin fe 1/20 58

larissia 58LASTACAFT 79latanoprost 79

LATUDA 46LEENA 58

leflunomide 71LENVIMA 4 MG DAILY

DOSE28

100 Updated 10/01/20


LENVIMA 8 MG DAILY DOSE

28


28

LENVIMA 12MG DAILY DOSE

28


28


28


28


28

lessina 58letrozole 25

leucovorin calcium 30LEUKERAN 24

leuprolide acetate 25levalbuterol hcl 81

levalbuterol hydrochloride

81

LEVALBUTEROL TARTRATE HFA

81

LEVEMIR 52LEVEMIR FLEXTOUCH 52

levetiracetam 40levetiracetam er 40

levetiracetam/sodium chloride

40

levobunolol hcl 79levocarnitine 63

LEVOCARNITINE 63levocetirizine

dihydrochloride81

levofloxacin 22, 78

levofloxacin in d5w 22levoleucovorin 30

levoleucovorin calcium 30levonest 58

levonorgestrel/ethinyl estradiol

58

levora 0.15/30-28 58LEVO-T 64

levothyroxine sodium 64LEVOTHYROXINE

SODIUM64

LEVOXYL 64LEXIVA 17

LIBTAYO 28lidocaine 87

lidocaine hcl 13, 87

LIDOCAINE HCL 33LIDOCAINE HCL IN

D5W33

lidocaine hcl prefilled syringe

33

lidocaine hydrochloride 13lidocaine/prilocaine 87

lidocaine viscous 88lillow 58

linezolid 14LINEZOLID 14

LINZESS 67liothyronine sodium 64

lisinopril 31lisinopril/


LITHIUM 50lithium carbonate 50

lithium carbonate er 50lojaimiess 59LOKELMA 56LONSURF 26

loperamide hcl 67lopinavir/ritonavir 18

LOPREEZA 61lorazepam 38

LORBRENA 28lorcet 12

lorcet hd 12lorcet plus 12

loryna 59losartan potassium 32

losartan potassium/hydrochlorothiazide

32

LOTEMAX 79LOTEMAX SM 79

loteprednol etabonate 79lovastatin 33

low-ogestrel 59loxapine 46

loxapine succinate 46lo-zumandimine 59

LUDENT 75LUMIGAN 79

LUMIZYME 63LUMOXITI 28

LUPRON DEPOT (1-MONTH)

25

LUPRON DEPOT (3-MONTH)

25

LUPRON DEPOT-PED (1-MONTH)

63

LUPRON DEPOT-PED (3-MONTH)

63

lutera 59LYNPARZA 28LYRICA CR 50

LYSODREN 25lyza 59

mafenide acetate 84magnesium sulfate 74

MAGNESIUM SULFATE 74malathion 88

maprotiline hcl 43marlissa 59

MARPLAN 43MATULANE 26

matzim la 35MAVYRET 20

101Updated 10/01/20


meclizine hcl 65meclofenamate sodium 11

medroxyprogesterone acetate

59, 64

mefloquine hcl 16megestrol acetate 25,

64MEKINIST 28MEKTOVI 28

melodetta 24 fe 59meloxicam 11melphalan 24melphalan

hydrochloride24

MEMANTINE HCL TITRATION PAK

41

memantine hydrochloride

41

memantine hydrochloride er

41

MENACTRA 73MENVEO 73

meprobamate 38mercaptopurine 25

meropenem 14mesalamine 66

mesalamine dr 66mesna 30

MESNEX 30metadate er 48

metaproterenol sulfate 81metformin

hydrochloride54

metformin hydrochloride er

54

methadone hcl 11METHADONE HCL INJ 11

methazolamide 36methenamine hippurate 14

METHENAMINE MANDELATE

14

methergine 63methimazole 64methotrexate 25,

71methotrexate sodium 25

methoxsalen 85methscopolamine

bromide66

methyldopa 37methylergonovine

maleate63

methylphenidate hydrochloride

48

methylphenidate hydrochloride/5ml

49

methylphenidate hydrochloride cd er

48

methylphenidate hydrochloride er

48

METHYLPHENIDATE HYDROCHLORIDE ER

48

methylprednisolone 62methylprednisolone

acetate62

methylprednisolone sodium succinate

62

metoclopramide hcl 65metoclopramide

hydrochloride65

metoclopramide odt 65METOCLOPRAMIDE

ODT65

metolazone 36metoprolol/


metoprolol succinate er 34metoprolol tartrate 34,

35metronidazole 14,

68, 87

metronidazole in nacl 14

mibelas 24 fe 59micafungin 16

miconazole 3 69MICROGESTIN 1.5/30 59

MICROGESTIN 1/20 59MICROGESTIN FE

1.5/3059

MICROGESTIN FE 1/20 59midodrine hcl 37

miglitol 54miglustat 63

mili 59mimvey 61

minitran 37minocycline hcl 23

minocycline hydrochloride

23

minocycline hydrochloride er

23

minoxidil 37mirtazapine 43misoprostol 67

MITIGARE 10mitomycin 24

mitoxantrone hcl 26M-M-R II 73

M-NATAL PLUS 75modafinil 51

moexipril hcl 31molindone

hydrochloride46

mometasone furoate 82, 86

mondoxyne nl 23mono-linyah 59

montelukast sodium 81morgidox 1x100mg 23morgidox 2x100mg 23

morphine sulfate 12, 13

MORPHINE SULFATE 12

102 Updated 10/01/20


morphine sulfate er 11MOVANTIK 67

moxifloxacin hydrochloride

22, 78

moxifloxacin hydrochloride/sodium

hydrochloride

22

MULTAQ 33MULTI VITAMIN/

FLUORIDE75

MULTIVITAMIN/FLUORIDE

75

MULTI-VITAMIN/FLUORIDE DROPS

75

MULTI-VITAMIN/FLUORIDE/IRON

75

mupirocin 84mutamycin 24

MYCAMINE 16mycophenolate mofetil 72

mycophenolic acid dr 72MYLOTARG 29

myorisan 83MYRBETRIQ 68nabumetone 11

nadolol 35nafcillin sodium 22

naftifine hcl 84naftifine hydrochloride 84

NAGLAZYME 63nalbuphine hcl 13

naloxone hcl 51naloxone hydrochloride 51

naltrexone hcl 51NAMZARIC 41

naproxen 11naproxen dr 11

naproxen/esomeprazole magnesium

11

naproxen sodium 11

NAPROXEN SODIUM CR

11

naproxen sodium er 11naratriptan hcl 49

NARCAN 51NATACYN 78

nateglinide 54NATPARA 55

NAYZILAM 40necon 0.5/35-28 59nefazodone hcl 43

nefazodone hydrochloride

43

neomycin 14neomycin/bacitracin/

polymyxin78

neomycin/polymyxin/bacitracin/

hydrocortisone

77

neomycin/polymyxin/dexamethasone

77

neomycin/polymyxin/gramicidin

78

neomycin/polymyxin/hydrocortisone

77, 89

NEONATAL PLUS 75neo-polycin 78

NEPHRAMINE 77NERLYNX 29

neuac 84NEUPRO 44

nevirapine 17nevirapine er 17

NEXAVAR 29niacin 34

niacin er 34niacor 34

nicardipine hcl 35NICOTROL 51

NICOTROL INHALER 51nifedical xl 35

nifedipine er 35nikki 59

nilutamide 25nimodipine 35

NINLARO 29NIPENT 26

nisoldipine er 35nitisinone 63

NITRO-BID 37NITRO-DUR 37

nitrofurantoin 15nitrofurantoin macrocrystals

14

nitrofurantoin monohydrate

15

nitroglycerin 37NITROGLYCERIN INJ 37nitroglycerin lingual 37

nitroglycerin subl 37NITYR 63

NIVA-PLUS 75nizatidine 66

nolix 86NORA-BE 59

norethindrone 59norethindrone acetate 64

norethindrone acetate/ethinyl estradiol

59, 61

norethindrone acetate/ethinyl estradiol/ferrous

fumarate

59

norethindrone/ethinyl estradiol/ferrous

fumarate

59

norgestimate/ethinyl estradiol

59

NORITATE 87norlyda 59

NORMOSOL-M IN D5W 74NORMOSOL-R PH 7.4 74

NORPACE CR 33

103Updated 10/01/20


NORTHERA 37nortrel 0.5/35 (28) 59

nortrel 1/35 59nortrel 7/7/7 59

nortriptyline hcl 43nortriptyline

hydrochloride43

NORVIR 17NOVO/BD/ULTIMED/OWEN/TRIVIDIA PEN

NEEDLE/ORIGINAL/ULTRA-FINE

52

NOVOLIN 70/30 52NOVOLIN 70/30

FLEXPEN53

NOVOLIN N 53NOVOLIN N FLEXPEN 53

NOVOLIN R 53NOVOLIN R FLEXPEN 53

NOVOLOG 53NOVOLOG FLEXPEN 53

NOVOLOG MIX 70/30 53NOVOLOG MIX 70/30

PREFILLED FLEXPEN53

NOVOLOG PENFILL 53NOXAFIL 16NUBEQA 25

NUEDEXTA 50NULOJIX 72

NULYTELY/FLAVOR PACKS

67

NUPLAZID 46NUTRILIPID 77

nyamyc 84NYMALIZE 35

nystatin 16, 84, 88

nystop 84OCELLA 59

OCTAGAM 71

octreotide acetate 63ODEFSEY 18ODOMZO 29

OFEV 82ofloxacin 78,

89okebo 23

olanzapine 46olanzapine odt 46

olmesartan medoxomil 32olmesartan medoxomil/

amlodipine/hydrochlorothiazide

32

olmesartan medoxomil/hydrochlorothiazide

32

olopatadine hcl 79, 81

omega-3-acid ethyl esters

34

omeprazole 67ondansetron hcl 65

ondansetron hydrochloride

65

ondansetron odt 65OPSUMIT 37ORACEA 87

oralone dental paste 88ORFADIN 63ORKAMBI 82

orsythia 59oseltamivir phosphate 20

OSMOPREP 67oxacillin sodium 22

oxaliplatin 24oxandrolone 51

oxaprozin 11oxazepam 38

oxcarbazepine 40oxiconazole nitrate 84

oxybutynin chloride 68oxybutynin chloride er 68

oxycodone/acetaminophen

13

oxycodone/aspirin 13oxycodone hcl 13

oxycodone hydrochloride

13

oxymorphone hydrochloride

13

OZEMPIC 54pacerone 33paclitaxel 27PADCEV 29

paliperidone er 46pamidronate disodium 55

PAMIDRONATE DISODIUM

55

PANRETIN 87pantoprazole sodium 68

pantoprazole sodium dr 68PANZYGA 71paraplatin 24paricalcitol 64

paroex 88paromomycin 15paroxetine hcl 43

paroxetine hcl er 43paroxetine

hydrochloride43

PASER 19PAXIL 43

PAZEO 79PEDIARIX 73

PEDVAX HIB 73peg-3350/electrolytes 67

peg-3350/nacl/na bicarbonate/kcl

67

PEGANONE 40PEGASYS 20

PEMAZYRE 29penicillamine 56

penicillin g potassium 22

104 Updated 10/01/20


PENICILLIN G POTASSIUM IN ISO-

OSMOTIC DEXTROSE

22

PENICILLIN G PROCAINE

22

penicillin g sodium 22penicillin v potassium 23

PENNSAID 87PENTACEL 73

pentamidine isethionate 15pentoxifylline er 70

perindopril erbumine 31periogard 88

permethrin 88perphenazine 43,

46perphenazine/

amitriptyline43

PERSERIS 46phenadoz 65

phenelzine sulfate 43PHENOBARBITAL ELIX 40

PHENOBARBITAL SODIUM

40

PHENOBARBITAL TABS 40PHENYTEK 40

phenytoin 40phenytoin sodium 40

phenytoin sodium er 40philith 59

PHOSPHOLINE IODIDE 79PICATO 87

PIFELTRO 17pilocarpine hcl 79

pilocarpine hydrochloride

89

pimozide 46pimtrea 59pindolol 35

pioglitazone hcl 54

pioglitazone hcl-glimepiride

54

pioglitazone hcl/metformin hcl

54

pioglitazone hydrochloride

54

piperacillin sodium/tazobactam sodium

23

piperacillin/tazobactam 23PIQRAY 200MG DAILY

DOSE29

PIQRAY 250MG DAILY DOSE

29

PIQRAY 300MG DAILY DOSE

29

pirmella 1/35 60pirmella 7/7/7 60

piroxicam 11PLASMA-LYTE-148 74

PLASMA-LYTE A 74plenamine 77

PLENVU 67PNV FOLIC ACID +

IRON MULTIVITAMIN75

PNV PRENATAL PLUS MULTIVITAMIN

76

podofilox 88POLIVY 29polycin 78

polymyxin b sulfate/trimethoprim sulfate

78

POLY-VITAMIN/FLUORIDE

76

POMALYST 26portia-28 60

posaconazole dr 16potassium chloride 74,

76POTASSIUM CHLORIDE 74

potassium chloride cr 76POTASSIUM

CHLORIDE/DEXTROSE74

POTASSIUM CHLORIDE/DEXTROSE/

SODIUM CHLORIDE

74

potassium chloride er 76potassium chloride/

sodium chloride74

POTASSIUM CHLORIDE/SODIUM

CHLORIDE

74

potassium chloride sr 76potassium citrate er 68

POTELIGEO 29PRADAXA 69

PRALUENT 34pramipexole

dihydrochloride44

pramipexole dihydrochloride er

44

prasugrel 70pravastatin sodium 33

praziquantel 15prazosin hcl 31

prazosin hydrochloride 31prednicarbate 86

PREDNICARBATE 86prednisolone 62

prednisolone acetate 79prednisolone sodium

phosphate62

prednisolone sodium phosphate odt

62

PREDNISOLONE SODIUM PHOSPHATE

OPHTHALMIC SOLN 1%

79

prednisone 62PREDNISONE

INTENSOL62

pregabalin 40PREMARIN 61PREMASOL 77

PREMPRO 61

105Updated 10/01/20


PRENATAL 76PRENATAL PLUS 76

PRENATAL VITAMINS PLUS LOW IRON

76

PREPLUS 76PRETOMANID 19

prevalite 34previfem 60

PREVYMIS 20PREZCOBIX 18

PREZISTA 17PRIFTIN 19

primaquine phosphate 16primidone 40PRIVIGEN 71

probenecid 10probenecid/colchicine 10

PROCALAMINE 77prochlorperazine 65prochlorperazine

edisylate65

prochlorperazine maleate

65

PROCRIT 69procto-med hc 88

procto-pak 88proctosol hc 88

proctozone-hc 88progesterone 64

PROGRAF 72PROLASTIN-C 82

PROLENSA 79PROLIA 55

PROMACTA 70promethazine hcl 65

promethazine hcl plain 65promethazine hydrochloride

65

promethegan 65propafenone hcl 33

propafenone hydrochloride er

33

proparacaine hcl 80propranolol hcl 35

propranolol hcl er 35propranolol

hydrochloride35

propranolol hydrochloride er

35

propranolol/hydrochlorothiazide

34

propylthiouracil 64PROQUAD 73

PROSOL 77protriptyline hcl 43

PULMICORT FLEXHALER

83

PULMOZYME 82PURIXAN 25

pyrazinamide 19pyridostigmine bromide 50pyridostigmine bromide

er50

QINLOCK 29QUADRACEL 73

quetiapine fumarate 46quetiapine fumarate er 46

quinapril hcl 31quinapril hydrochloride 31

quinapril/hydrochlorothiazide

31

quinidine sulfate 33quinine sulfate 16

RABAVERT 73rabeprazole sodium dr 68

raloxifene hydrochloride 63ramipril 31

ranolazine er 37rasagiline mesylate 44

REBIF 50REBIF REBIDOSE 50

REBIF REBIDOSE TITRATION PACK

50

REBIF TITRATION PACK 50reclipsen 60

RECOMBIVAX HB 73RECTIV 88

REGRANEX 88RELENZA DISKHALER 20

RELISTOR 67RENFLEXIS 71repaglinide 54

RESCRIPTOR 17RESTASIS 80

RESTASIS MULTIDOSE 80RETEVMO 29REVLIMID 26

REXULTI 47REYATAZ 17

RHOPRESSA 80ribavirin 20rifabutin 19rifampin 19RIFATER 19

riluzole 50rimantadine

hydrochloride20

RINGERS INJECTION 75RINVOQ 71

risedronate sodium 55risedronate sodium dr 55

RISPERDAL CONSTA 47risperidone 47

risperidone odt 47ritonavir 17

RITUXAN 29RITUXAN HYCELA 29

rivastigmine 41rivastigmine tartrate 41

RIVELSA 60rizatriptan benzoate 49

106 Updated 10/01/20


rizatriptan benzoate odt 49ROMIDEPSIN 29

ropinirole er 44ropinirole hcl 44

ropinirole hydrochloride 44rosadan 88

rosuvastatin calcium 33ROTARIX 73

ROTATEQ 73roweepra 40

roweepra xr 40ROZYLTREK 29

RUBRACA 29RUKOBIA 17

RYDAPT 29SANCUSO 65

SANDIMMUNE 72SANTYL 88

SAPHRIS 47SARCLISA 29

scopolamine 65SECUADO 47

selegiline hcl 44selenium sulfide 85

SELZENTRY 18SEREVENT DISKUS 81

sertraline hcl 43sertraline hydrochloride 43

setlakin 60SF 89

sharobel 60SHINGRIX 73SIGNIFOR 63

sildenafil 37sildenafil citrate 37

silodosin 68SILVER SULFADIAZINE 84

SIMBRINZA 80simliya 60

simpesse 60

simvastatin 33sirolimus 72SIRTURO 19

SIVEXTRO 15SIVEXTRO TABS 15

SKYRIZI 71sodium bicarbonate 75

SODIUM BICARBONATE

75

sodium chloride 75SODIUM CHLORIDE

0.9% IRRIGATION SOLN

88

sodium chloride inj 75SODIUM CHLORIDE INJ 75

SODIUM FLUORIDE 76, 89

sodium phenylbutyrate 63sodium polystyrene

sulfonate56

sodium sulfacetamide 78solifenacin succinate 68

SOLIQUA 100/33 53SOLTAMOX 25

SOLU-CORTEF INJ 62SOMATULINE DEPOT 64

SOMAVERT 64sorine 33

sotalol hcl 33sotalol hcl (af) 33

spironolactone 31, 36

spironolactone/hydrochlorothiazide

36

sprintec 28 60SPRITAM 40SPRYCEL 29

sps 56sronyx 60

SSD 84stavudine 18

STELARA 71STERILE WATER

IRRIGATION PLASTIC BOTTLE

88

STIMATE 64STIVARGA 29

streptomycin sulfate 15STRIBILD 18subvenite 40

subvenite starter kit/blue

40

subvenite starter kit/green

40

subvenite starter kit/orange

40

SUCRALFATE SUSP 67sucralfate tabs 67

sulfacetamide sodium 78, 84

sulfacetamide sodium/prednisolone sodium

phosphate

77

SULFADIAZINE 15sulfamethoxazole/

trimethoprim15

sulfamethoxazole/trimethoprim ds

15

SULFAMYLON 84sulfasalazine 66

SULFASALAZINE 66sulindac 11

sumatriptan 49sumatriptan/naproxen

sodium49

sumatriptan succinate 49SUPRAX 21

SUPREP BOWEL PREP KIT

67

SUTENT 29syeda 60

SYLATRON 26SYMBICORT 83

107Updated 10/01/20


SYMDEKO 82SYMFI 19

SYMFI LO 19SYMLINPEN 60 55

SYMLINPEN 120 55SYMPAZAN 40

SYMTUZA 19SYNAREL 61

SYNERCID 15SYNJARDY 55

SYNJARDY XR 55SYNRIBO 26

SYNTHROID 64TABLOID 25

TABRECTA 29tacrolimus 72,

88tadalafil 37

TAFINLAR 29TAGRISSO 29

TALTZ 71TALZENNA 29

tamoxifen citrate 25tamsulosin

hydrochloride68

TARGRETIN 88tarina fe 1/20 60

tarina fe 1/20 eq 60TASIGNA 29

tazarotene 85tazicef 21

TAZORAC 85taztia xt 35

TAZVERIK 29TDVAX 73

TECENTRIQ 29TEFLARO 21

telmisartan 32telmisartan/amlodipine 32

telmisartan/hydrochlorothiazide

32

temazepam 49TEMIXYS 19

temsirolimus 29TENIVAC 73tenofovir 18

terazosin hcl 31terazosin hydrochloride 31

terbinafine hcl 16terbutaline sulfate 81

terconazole 69testosterone cypionate 51testosterone enanthate 52

testosterone gel 52testosterone pump gel 52

testosterone topical 52tetrabenazine 50

tetracycline hydrochloride

23

TEXACORT 86THALOMID 26

THEO-24 82theophylline 82

theophylline er 82thioridazine hcl 47

thiotepa 24thiothixene 47

tiadylt er 36tiagabine hydrochloride 40

TIBSOVO 29tigecycline 23

TILIA FE 60TIMOLOL MALEATE

OPHTHALMIC80

timolol maleate soln 80timolol maleate tabs 35

tinidazole 15TIVICAY 18

TIVICAY PD 18

tizanidine hcl 50tizanidine hydrochloride 50

TOBRADEX 77TOBRADEX ST 77

tobramycin 15tobramycin/

dexamethasone77

tobramycin sulfate 15, 78

tolterodine tartrate 68tolterodine tartrate er 68

topiramate 40TOPIRAMATE ER 40

toposar 27topotecan 26

TOPOTECAN 26toremifene citrate 25

torsemide 36tovet foam 86

TOVIAZ 68TPN ELECTROLYTES 75

TRACLEER 38TRADJENTA 55

tramadol hcl 13TRAMADOL HCL ER 11tramadol hcl er tabs 11

tramadol hydrochloride 13tramadol

hydrochloride/acetaminophen

13

trandolapril 31trandolapril/verapamil

hcl er31

tranexamic acid 70tranylcypromine sulfate 43

TRAVASOL 77travoprost 80trazodone

hydrochloride43

TRECATOR 19TRELEGY ELLIPTA 80

108 Updated 10/01/20


TRELSTAR MIXJECT 25treprostinil 38

TRESIBA 53TRESIBA FLEXTOUCH 53

tretinoin 26, 84

TRETINOIN MICROSPHERE

84

triamcinolone acetonide 86, 87

triamcinolone acetonide dental paste

89

triamcinolone acetonide inj

62

triamterene/hydrochlorothiazide

36

triazolam 49TRICARE PRENATAL 76

triderm 87trientine hydrochloride 56

tri-estarylla 60tri femynor 60

trifluoperazine hcl 47trifluridine 78

trihexyphenidyl hcl 45trihexyphenidyl

hydrochloride45

tri-legest fe 60tri-linyah 60

tri-lo-estarylla 60tri-lo-marzia 60

tri-lo-mili 60tri-lo-sprintec 60

trilyte 67trimethobenzamide

hydrochloride66

trimethoprim 15trimethoprim sulfate/

polymyxin b sulfate78

tri-mili 60trimipramine maleate 43

TRINTELLIX 43tri-previfem 60tri-sprintec 60TRIUMEQ 19

TRI-VITE/FLUORIDE 76trivora-28 60tri-vylibra 60

tri-vylibra lo 60TROGARZO 18

TROPHAMINE 77trospium chloride 68

trospium chloride er 68TRULICITY 55

TRUMENBA 73TRUVADA 19

TUKYSA 29, 30

tulana 60TURALIO 30TWINRIX 73TYBOST 18

tydemy 60TYKERB 30

TYMLOS 55TYPHIM VI 73

UNITHROID 64ursodiol 67

valacyclovir hcl 20valacyclovir

hydrochloride20

VALCHLOR 88valganciclovir 20valganciclovir hydrochloride

20

valproate sodium 40valproic acid 40

valsartan 32, 33

valsartan/hydrochlorothiazide

32

VALTOCO 40

VANCOMYCIN 15vancomycin hcl 15

VANCOMYCIN HLC 15vancomycin

hydrochloride15

VANCOMYCIN HYDROCHLORIDE

15

VAQTA 73VARIVAX 73VASCEPA 34VELCADE 30

velivet 60VELTASSA PACK 56

VEMLIDY 20VENCLEXTA 30

VENCLEXTA STARTING PACK

30

venlafaxine hcl 43venlafaxine hcl er 43

venlafaxine hydrochloride er

44

VENTAVIS 38VENTOLIN HFA 81

verapamil hcl 36verapamil hcl er 36verapamil hcl sr 36

VERAPAMIL HCL SR CP24 360MG

36

verapamil hydrochloride

36

verapamil hydrochloride er

36

VERSACLOZ 47VERZENIO 30

VICTOZA 55VIDEX EC 18

VIDEX PEDIATRIC 18vienva 60

vigabatrin 41vigadrone 41

VIIBRYD 44

109Updated 10/01/20


VIIBRYD STARTER PACK

44

VIMOVO 11VIMPAT 41

vinblastine sulfate 27vincristine sulfate 27

vinorelbine tartrate 27viorele 60

VIRACEP 18VIREAD 18

VITRAKVI 30VIVITROL 51

VIZIMPRO 30volnea 60

VOL-PLUS 76voriconazole 16

VOSEVI 20VOTRIENT 30

VP-PNV-DHA 76VRAYLAR 47

VRAYLAR CAP THERAPY PACK

47

vyfemla 60vylibra 61

VYVANSE 49warfarin sodium 69

wera 61wymzya fe 61

XALKORI 30XARELTO 69

XARELTO STARTER PACK

69

XATMEP 71XCOPRI 41

XCOPRI MAINTENACE PACK

41

XCOPRI TITRATION PACK

41

XELJANZ 71XELJANZ XR 71

XGEVA 55

XIFAXAN 67XIGDUO XR 55

XOLAIR 82XOSPATA 30XPOVIO 30

XPOVIO 60 MG ONCE WEEKLY

30


30

XPOVIO 80 MG TWICE WEEKLY

30


30

XTANDI 25XULTOPHY 53

XYREM 51YERVOY 30YF-VAX 73

yuvafem 61zafirlukast 81

zaleplon 49zarah 61

ZARXIO 69ZEJULA 30

ZELBORAF 30ZEMAIRA 82zenatane 84ZENPEP 67zenzedi 49

zidovudine 18ziprasidone hcl 47

ziprasidone mesylate 47ZIRGAN 78

zoledronic acid 56ZOLEDRONIC ACID 55

ZOLINZA 30zolmitriptan 50

zolmitriptan odt 49ZOLOFT 44

zolpidem tartrate 49zonisamide 41

ZORTRESS 72ZOSTAVAX 73zovia 1/35e 61

zumandimine 61ZYCLARA PUMP 88

ZYDELIG 30ZYKADIA 30

ZYLET 77ZYPREXA RELPREVV 47

ZYTIGA 26

110 Updated 10/01/20

Enhanced Drug Benefit List*Please check your Prescription Drug Schedule of Cost Sharing to find out if your plan includes an “Enhanced Drug Benefit.” The enhanced drugs are listed in this guide by Enhanced Drug Benefit Categories. If your plan includes enhanced drug benefits, look for the Enhanced Drug Benefit Category in the following pages to determine which drugs are covered. For example, if your Prescription Drug Schedule of Cost Sharing says that your plan includes coverage for “Vitamins and Minerals” and “Erectile Dysfunction”, find the lists titled “Vitamins and Minerals” and “Erectile Dysfunction” to find which drugs are covered. For more information, call the toll-free telephone number on your Aetna identification card or our member service center at 1-888-267-2637. Representatives are available to assist you 8 a.m. to 9 p.m., E.S.T., Monday through Friday. For TTY assistance please dial 711.

Key**Drug name

UPPERCASE = Brand-name prescription drugs

Lowercase italics = Generic medications

Drug tier

1, 2, 3, 4 = Copay tier level

Requirements/Limits

QL = Quantity Limit PA = Prior Authorization

Drug name Drug tier Requirements/LimitsCOSMETIC

ACUICYN ANTIMICROBIAL EY ELID & EYELASH HYGIENE

2

alphaquin hp 1ARNICA FLOWER 2AVENOVA 2BENZOIN TINCTURE 2BETAMETHASONE DIPROPIONATE/MINOXIDIL

2

bimatoprost 1blanche 1BORIC ACID 2BOTOX COSMETIC 2DRYSOL 2EPICYN 2

* These prescription drugs are not normally covered in a Medicare Prescription Drug Plan. Check your Prescription Drug Schedule of Cost Sharing to find out if you have coverage for these drugs. The amount you pay when you fill a prescription for these drugs does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs.

** You can find information on what the symbols and abbreviations on this table mean by going to page 8.

111Updated 10/01/20

Drug name Drug tier Requirements/LimitsEPIQUIN MICRO 2finasteride 1FINASTERIDE/MINOXIDIL 2HYALURONIC ACID SODIUM/HYDROQUINONE

2

HYCLODEX 2HYDROCORTISONE/HYDROQUINONE

2

HYDROCORTISONE/HYDROQUINONE/TRETINOIN

2

hydroquinone time release 1HYDROQUINONE EMUL 2hydroquinone crea 1HYPOCYN 2KYBELLA 2LACTIC ACID/NIACINAMIDE 2LATISSE 2LUSTRA 2LUSTRA-AF 2LUSTRA-ULTRA 2melpaque hp 1melquin hp 1MINOXIDIL/PROGESTERONE 2MINOXIDIL/PROGESTERONE/TRETINOIN

2

nuquin hp 1PROPECIA 2REFISSA 2remergent hq 1RENOVA 2RENOVA PUMP 2skin bleaching 1

112 Updated 10/01/20

Drug name Drug tier Requirements/Limitsskin bleaching/sunscreen 1tl hydroquinone 1tretinoin emollient 1TRI-LUMA 2VANIQA 2XERAC AC 2

COUGH AND COLDbenzonatate 1biotuss 1biotuss pediatric 1bromfed dm 1CARBAPHEN 12 2CARBAPHEN 12 PED 2centergy dm 1CODAR AR 2CPB WC 2DECON-G 2dextromethorphan hbr/phenylephrine hcl/chlorpheniramine

1

EXACTUSS 2exefen-ir 1FLOWTUSS 2GILPHEX TR 2GILTUSS 2giltuss pediatric 1GILTUSS TR 2guaifenesin/dextromethorphan sr 1HDC DM 2HYCOFENIX 2hydrocodone bitartrate/chlorpheniramine maleate/pse

1

113Updated 10/01/20

Drug name Drug tier Requirements/Limitshydrocodone bitartrate/homatropine methylbromide

1

hydrocodone polistirex/chlorpheniramine polistirex

1

hydromet 1lexuss 210 1MUCINEX DM 2NARIZ 2NASOTUSS 2NEOTUSS PLUS 2nohist-dm 1nortuss-de 1NORTUSS-EX 2OBREDON 2phenylephrine/guaifenesin 1PROHIST CD 2PROHIST CF 2PROMETHAZINE VC/CODEINE 2promethazine/codeine 1promethazine/dextromethorphan 1RELHIST 2RHINOLAR 2TESSALON PERLES 2TGQ 15DM/5PEH/2CPM 2TGQ 30PSE/150GFN/15DM 2TGQ 30PSE/3BRM/15DM 2TUSNEL PED-C 2TUSSICAPS 2tussigon 1TUSSIONEX PENNKINETIC EXTENDED RELEASE

2

TUXARIN ER 2

114 Updated 10/01/20

Drug name Drug tier Requirements/LimitsTUZISTRA XR 2VAZOTAN 2VIRAVAN-DM 2VITUZ 2ZONATUSS 2zotex-12d 1ZOTEX-C 2ZUTRIPRO 2

ERECTILE DYSFUNCTIONBI-MIX 2 QL (6 EA per 30 days)CAVERJECT 2 QL (6 EA per 30 days)CAVERJECT IMPULSE 2 QL (6 EA per 30 days)CIALIS 2 QL (6 EA per 30 days)EDEX 2 QL (6 EA per 30 days)LEVITRA 2 QL (6 EA per 30 days)MUSE 2 QL (6 EA per 30 days)papaverine-phentolamine mesylate 1 QL (5 ML per 30 days)QUAD-MIX 2 QL (6 EA per 30 days)STAXYN 2 QL (6 EA per 30 days)STENDRA 2 QL (6 EA per 30 days)SUPER BI-MIX 2 QL (6 EA per 30 days)SUPER QUAD-MIX 2 QL (6 EA per 30 days)SUPER TRI-MIX 2 QL (6 EA per 30 days)tadalafil 1 QL (6 EA per 30 days)TRI-MIX 2 QL (6 EA per 30 days)vardenafil hydrochloride 1 QL (6 EA per 30 days)VIAGRA 2 QL (6 EA per 30 days)

FERTILITYCETROTIDE 2clomiphene citrate 1ENDOMETRIN 2

115Updated 10/01/20

Drug name Drug tier Requirements/LimitsFIRST-PROGESTERONE VGS 100 COMPOUNDING KIT

2

FIRST-PROGESTERONE VGS 200 COMPOUNDING KIT

2

FOLLISTIM AQ 2ganirelix acetate 1GONAL-F 2GONAL-F RFF 2GONAL-F RFF REDIJECT 2MENOPUR 2OVIDREL 2

MISCELLANEOUSaero otic hc 1ALA-QUIN 2ALCORTIN A 2ALOQUIN 2aminobenzoate potassium 1ANALPRAM-HC 2ANALPRAM-HC SINGLES 2anucort-hc 1ANUSOL-HC 2arzol silver nitrate app licators 1ASCOR 2ascorbic acid 1benzoyl peroxide 8% 1bpm/pse/dm 1bromfed dm 1CETACAINE 2CORTANE-B 2CORTANE-B-OTIC 2cortic-nd 1covaryx 1

116 Updated 10/01/20

Drug name Drug tier Requirements/Limitscovaryx hs 1cyotic 1dermazene 1DONNATAL 2DRYSOL 2eemt 1eemt hs 1esterified estrogens/methyltestosterone

1

exactacain 1exotic-hc 1FIRST-MOUTHWASH BLM 2GILPHEX TR 2GILTUSS TR 2grx hicort 25 1hemorrhoidal-hc 1hydrocodone polistirex/chlorpheniramine polistirex

1

hydrocortisone acetate 1hydrocortisone acetate/pramoxine 1hydrocortisone/iodoquinol 1HYOPHEN 2hyoscyamine sulfate er 1hyosyne 1iodoquinol/hydrocortisone acetate/aloe polysaccharides

1

IODOSORB 2isoxsuprine hcl 1K-PHOS 2K-PHOS NEUTRAL 2LEVBID 2lidocaine hcl/hydrocortisone acetate 1

117Updated 10/01/20

Drug name Drug tier Requirements/Limitsme/naphos/mb/hyo 1 1MEZPAROX-HC FORTE 2NATURE-THROID 2NEOTUSS PLUS 2NITRO-TIME 2nohist-dm 1NOVACORT 2OTICIN HC NR 2oto-end 10 1otomax-hc 1phenazopyridine hcl 1phenazopyridine hydrochloride 1phospha 250 neutral 1POTABA 2PRAMOSONE 2PROCORT 2PROCTOCORT 2promethazine hydrochloride/dextromethorphan hydrobromide

1

promethazine vc/codeine 1promethazine/codeine 1promethazine/dextromethorphan 1promethazine/phenylephrine/codeine 1pyridoxine hcl 1QUINJA 2rectacort-hc 1RHINOLAR 2sodium chloride 1sodium sulfacetamide/sulfur 1thiamine hcl 1TUSSICAPS 2

118 Updated 10/01/20

Drug name Drug tier Requirements/LimitsTUXARIN ER 2TUZISTRA XR 2urea 1uribel 1uro-458 1uro-mp 1ustell 1vilamit mb 1vilevev mb 1VIRATAN-DM 2VYTONE 2WP THYROID 2

VITAMINS AND MINERALSACTIVE FE 2ADRENAL C FORMULA 2airavite 1ALBAFORT 2aminobenzoate potassium 1ANIMI-3 2ANIMI-3/VITAMIN D 2AP-ZEL 2AQUASOL A PARENTERAL 2ASCOR 2ASCORBIC ACID INJ 15000MG/30ML 2ascorbic acid inj 500mg/ml 1ASTAMED MYO 2AVAILNEX 2AXONA 2b-6 folic acid 1b-complex 100 1b-plex 1

119Updated 10/01/20

Drug name Drug tier Requirements/Limitsb-plex plus 1BACMIN 2biocel 1BP VIT 3 2CENFOL 2CENTRATEX 2CEREFOLIN 2CEREFOLIN NAC 2CHOLECAL DF 2CIFEREX 2cod liver oil 1corvita 1corvita 150 1CORVITE 2CORVITE 150 2CORVITE FE 2corvite free 1CYANOCOBALAMIN INJ 2000MCG/ML

2

cyanocobalamin inj 1000mcg/ml 1DEPLIN 15 2DEPLIN 7.5 2dialyvite 1DIALYVITE 3000 2DIALYVITE 5000 2DIALYVITE SUPREME D 2DIALYVITE/ZINC 2DRISDOL 2DURACHOL 2ELFOLATE PLUS 2ENLYTE 2

120 Updated 10/01/20

Drug name Drug tier Requirements/LimitsENTERAGAM 2ERGOCAL 2ergocalciferol 1fabb 1FE 90 PLUS 2FERAHEME 2FERIVA 21/7 2FERIVAFA 2ferocon 1ferotrinsic 1FERRALET 90 2FERRAPLUS 90 2FERRO-PLEX HEMATINIC 2ferrocite plus 1ferrogels forte 1FERROTRIN 2FIBRIK 2folbee 1folbee plus 1folbee plus cz 1folbic 1FOLBIC RF 2FOLGARD RX 2FOLI-D 2folic acid 1folic acid/cyanocobalamin/pyridoxine hydrochloride

1

folic acid/vitamin b-6/vitamin b-12 1FOLIKA-V 2FOLITE 2FOLIVANE-F 2

121Updated 10/01/20

Drug name Drug tier Requirements/LimitsFOLIVANE-PLUS 2FOLIXAPURE 2folplex 2.2 1FOLTANX 2FOLTANX RF 2FOLTRATE 2foltrin 1FOLTX 2FOLVITE FE 2FORTAVIT 2FOSTEUM 2FOSTEUM PLUS 2FOVEX 2FUSION PLUS 2FUSION SPRINKLES 2GABADONE 2GENICIN VITA-D 2hematinic plus complex 1hematinic plus vitamins/minerals 1hematinic/folic acid 1hematogen 1HEMATOGEN FA 2hematogen forte 1HEMATRON-AF 2HEMENATAL OB + DHA 2HEMOCYTE PLUS 2hemocyte-f 1hemocyte-plus 1hydroxocobalamin 1HYPERTENSA 2ICAR-C PLUS 2

122 Updated 10/01/20

Drug name Drug tier Requirements/Limitsiferex 150 forte 1infed 1infuvite adult 1infuvite pediatric 1INJECTAFER 2INTEGRA F 2INTEGRA PLUS 2IROSPAN 24/6 2l-methyl-b6-b12 1L-METHYL-MC 2L-METHYL-MC NAC 2l-methylfolate 1L-METHYLFOLATE CA ME-CBL NAC 2l-methylfolate ca/p-5-p/me-cbl 1l-methylfolate calcium 1L-METHYLFOLATE FORMULA 15 2L-METHYLFOLATE FORMULA 7.5 2L-METHYLFOLATE FORTE 2LIMBREL 2LIPICHOL 540 2LISTER-V 2lmthf/pyridoxine hcl/cyanocobalamin 1lysiplex plus 1M.V.I. ADULT 2M.V.I. PEDIATRIC 2M.V.I.-12 WITHOUT VITAMIN K 2MEPHYTON 2METAFOLBIC 2METAFOLBIC PLUS 2METAFOLBIC PLUS RF 2METANX 2

123Updated 10/01/20

Drug name Drug tier Requirements/Limitsmethionine/inositol/choline/cyanocobalamin

1

METHYLCOBALAMIN 2multi-b-plus 1MULTIGEN 2MULTIGEN FOLIC 2MULTIGEN PLUS 2myferon 150 forte 1mynephrocaps 1NASCOBAL 2NATALVIRT FLT 2NEPHPLEX RX 2NEPHRO-VITE RX 2NEPHROCAPS 2NEPHRON FA 2nephronex 1NEUREPA 2NEURIN-SL 2niacin 1NICADAN 2NICAZEL 2NICAZEL FORTE 2NICOMIDE 2nufol 1NUTRICAP 2nutrifac zx 1NUTRIVIT 2OCUVEL 2ORTHO-FOLIC 2PERCURA 2PHYSICIANS EZ USE B-12 COMPLIANCE KIT

2

124 Updated 10/01/20

Drug name Drug tier Requirements/LimitsPHYTONADIONE 1PNV-VP-U 2PODIAPN 2poly-iron 150 forte 1polysaccharide iron forte 1POTABA 2PROTECT PLUS 2PROTECTIRON 2PROTEOLIN 2PULMONA 2PUREFE PLUS 2purevit dualfe plus 1PYRIDOXAL-5-PHOSPHATE 2pyridoxine hcl 1renal caps 1RENATABS 2RENATABS WITH IRON 2reno caps 1REQ 49+ 2REVESTA 2RHEUMATE 2se-tan plus 1SENTRA AM 2SENTRA PM 2SIDEROL 2sodium ferric gluconate complex/sucrose

1

STROVITE FORTE 2STROVITE ONE 2SUPERVITE 2SUPPORT 2

125Updated 10/01/20

Drug name Drug tier Requirements/LimitsSUPPORT-500 2SYNAGEX 2SYNATEK 2TANDEM PLUS 2TARON FORTE 2THERAMINE 2thiamine hcl 1tl gard rx 1tl icon 1tl-hem 150 1TL-ICARE 2TOZAL 2TREPADONE 2tricon 1TRIFERIC 2trigels-f forte 1triphrocaps 1UDAMIN SP 2v-c forte 1VASCAZEN 2VASCULERA 2VENOFER 2vic-forte 1vicap forte 1virt-caps 1virt-vite 1virt-vite forte 1virt-vite plus 1vita s forte 1vita-min 1vitacel 1

126 Updated 10/01/20

Drug name Drug tier Requirements/LimitsVITAL-D RX 2vitamax pediatric 1vitamin b-complex 100 1vitamin d 1VITAMIN K1 1VITAROCA PLUS 2vol-care rx 1VP-GSTN 2VP-ZEL 2wheat germ 1XAQUIL XR 2xyzbac 1

WEIGHT LOSSADIPEX-P 2 PAAPPTRIM 2 PAAPPTRIM-D 2 PAbenzphetamine hcl 1 PACONTRAVE 2 PAdiethylpropion hcl 1 PAdiethylpropion hcl er 1 PALOMAIRA 2 PAMEDACTIV 2 PAphendimetrazine tartrate 1 PAphendimetrazine tartrate er 1 PAphentermine hcl 1 PAphentermine hydrochloride 1 PAQSYMIA 2 PASAXENDA 2 PAXENICAL 2 PA

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This formulary was updated on 10/01/2020. For more recent information or other questions, please contact Aetna Medicare Member Services at 1-888-267-2637 or for TTY users: 711, 8 a.m. to 9 p.m., E.S.T., Monday through Friday, or visit AetnaRetireePlans.com choose “Manage your prescription drugs”.

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2021 Comprehensive Formulary€¦ · Updated 10/01/20 3 Aetna Medicare is a HMO, PPO plan with a Medicare contract. Enrollment in our plans depends on contract renewal. Members who