2021 Essential Plus Prescription Drug List - RMHP

2021 Essential Plus Prescription Drug List

Effective as of Jan. 1, 2021

Pharmacy | PDL

Colorado

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Understanding your Prescription Drug List

What is a Prescription Drug List (PDL)?A PDL is a list of prescribed medications or other pharmacy care products or supplies chosen for their safety, cost, and effectiveness. Medications are listed by categories or classes and are placed into cost levels known as tiers. It includes both brand and generic prescription medications.

To create the list, UnitedHealthcare® is guided by the Individual Exchange Pharmacy Management Committee. This group reviews which medications will be covered, how well the drugs work, and overall value. They also make sure there are safe and covered options.

How do I use my PDL?You and your provider can use the PDL to help you choose the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and if special rules apply. You can reference this list when you see your provider. Bring this list with you when you see your provider. If your medication is not listed here, please visit your health plan’s website or call the number on your health plan ID card.

Some medications on your PDL have extra requirements before they can be covered. A few of the most common coverage programs are prior authorization (PA), step therapy (ST) and quantity limits (QL). We use programs like these to help make sure the medication you take is safe and effective. Check your plan documents for more information. If you want to learn more about these programs or to see if you take a medication in one of these programs, please visit your health plan’s website or call the number on your health plan ID card.

What are tiers?Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by UnitedHealthcare. This is how much you will pay when you fill a prescription.

When does the PDL change?• Medications may move to a lower tier at any time.

• Medications may move to a higher tier or be removed from coverage when a generic equivalent becomes available.

• Medications may move to a higher tier or be removed from coverage up to monthly.

When a medication changes tiers, you may have to pay a different amount for that medication. Talk to your provider to learn about alternatives.

Why are some medications excluded from coverage?A medication may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription or over-the-counter (OTC) medication.

What if I don’t agree with a decision about an excluded medication?You, your authorized representative or your provider can ask for a coverage request by calling the number on your member ID card. Once the request is received, a decision will be provided within 72 hours,* unless there is are exigent circumstances and an expedited review is requested, in which case a decision will be provided in 24 hours. If the request is denied, information will be provided describing the process to appeal that decision and request an external review.

*A decision will be provided within 2 days in MD.

About this PDLWhere differences between this document and your benefit plan exist, the benefit plan documents rule. This may not be a complete list of medications that are covered by your plan. Please review your benefit plan for full details.

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Medication tips

What is the difference between brand-name and generic medications?Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less.

What if my doctor writes a brand-name prescription?If your provider gives you a prescription for a brand-name medication, ask if a generic or lower-cost option could be right for you. Generic medications are usually your lowest-cost option.

What if I am taking a specialty medication?Specialty medications are for rare or complex conditions and are usually higher-cost medications.

Please note, not all specialty medications may be available at a retail pharmacy. If you have question on how to access covered specialty medications, call the number on your ID card.

Over-the-counter medicationsAn over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your provider about available OTC options. Even though OTC medications may not be covered by your pharmacy benefit, they may cost less than a prescription medication.

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Reading your PDLThe PDL gives you choices so you and your provider can decide your best course of treatment. In this PDL, brand-name medications are shown in UPPERCASE (for example, CLOBEX) Generic medications are shown in lowercase (for example, clobetasol).

Tier informationUsing lower tier or preferred medications can help you pay your lowest out-of-pocket cost.

Drug Tier Cost Share Helpful Tips

Tier 1 $

Drugs in lower tiers will have lower cost shares. If you are prescribed a medication on a higher tier, you should discuss with your provider if a lower tier medication may be appropriate for your condition.

Tier 2 $$

Tier 3 $$$

Tier 4 $$$$

Tier 5 $$$$$

HCR $0 Copay $0 Preventive products listed in the HCR $0 Tier are available at zero cost.

Drug list informationIn this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan sets how these medications may be covered for you.

PA Prior Authorization – Your provider is required to give UnitedHealthcare more information to determine coverage.

QL Quantity Limit – Medication may be limited to a certain quantity.

ST Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered.

HCR $0 Copay HCR $0 Copay – These drugs may be available at zero cost if specific requirements are met.

For the most current list of covered medications or if you have questions:

Call the toll-free member phone number on your ID card.

Visit your health plan’s website listed on your ID card to:

• Find a participating retail pharmacy by ZIP code.

• Look up possible lower-cost medication alternatives.

• Compare medication pricing and options.

Questions

Table of Contents

Analgesics........................................................ 8Nonsteroidal Anti-inflammatory Drugs......... 8Opioid Analgesics, Long-acting................... 9Opioid Analgesics, Short-acting...................9

Anesthetics.....................................................10Local Anesthetics.......................................10

Anti-Addiction/Substance Abuse Treatment Agents.......................................................... 10

Alcohol Deterrents/Anti-craving................. 10Opioid Dependence Treatments................ 10Opioid Reversal Agents............................. 10Smoking Cessation Agents........................10

Antibacterials..................................................10Aminoglycosides........................................ 10Antibacterials, Other.................................. 11Beta-lactam, Cephalosporins.....................11Beta-lactam, Penicillins..............................11Macrolides..................................................11Quinolones.................................................12Sulfonamides............................................. 12Tetracyclines..............................................12

Anticonvulsants.............................................. 12Anticonvulsants, Other...............................12Calcium Channel Modifying Agents........... 12Gamma-aminobutyric Acid (GABA)

Augmenting Agents................................. 12Glutamate Reducing Agents...................... 12Sodium Channel Agents............................ 13

Antidementia Agents...................................... 13Cholinesterase Inhibitors........................... 13N-methyl-D-aspartate (NMDA) Receptor

Antagonist................................................13Antidepressants..............................................13

Antidepressants, Other.............................. 13Monoamine Oxidase Inhibitors.................. 13SSRI/SNRI (Selective Serotonin Reuptake

Inhibitor/ Serotonin and Norepinephrine Reuptake Inhibitor).................................. 13

Tricyclics.................................................... 14Antiemetics.....................................................14

Antiemetics, Other..................................... 14Emetogenic Therapy Adjuncts................... 14

Antifungals......................................................14Antigout Agents.............................................. 15Antimigraine Agents....................................... 15

Ergot Alkaloids........................................... 15Serotonin (5-HT) 1b/1d Receptor Agonists 15

Antimyasthenic Agents...................................15Parasympathomimetics..............................15

Antimycobacterials......................................... 15Antimycobacterials, Other..........................15

Antituberculars........................................... 15Antineoplastics............................................... 15

Alkylating Agents....................................... 15Antiandrogens............................................15Antiangiogenic Agents............................... 16Antiestrogens/Modifiers............................. 16Antimetabolites.......................................... 16Antineoplastics, Other................................16Aromatase Inhibitors, 3rd Generation........ 16Enzyme Inhibitors...................................... 16Molecular Target Inhibitors........................ 16Retinoids.................................................... 17

Antiparasitics.................................................. 17Anthelmintics..............................................17Antiprotozoals............................................ 17Pediculicides/Scabicides............................17

Antiparkinson Agents......................................17Anticholinergics..........................................17Antiparkinson Agents, Other...................... 17Dopamine Agonists....................................17Dopamine Precursors/L-Amino Acid

Decarboxylase Inhibitors......................... 17Monoamine Oxidase B (MAO-B) Inhibitors 17

Antipsychotics.................................................171st Generation/Typical............................... 172nd Generation/Atypical.............................17Treatment-Resistant.................................. 18

Antivirals.........................................................18Anti-cytomegalovirus (CMV) Agents.......... 18Anti-hepatitis B (HBV) Agents....................18Anti-hepatitis C (HCV) Agents................... 18Anti-hepatitis C (HCV) Agents, Other........ 18Antiherpetic Agents....................................18Anti-HIV Agents, Integrase Inhibitors

(INSTI)..................................................... 18Anti-HIV Agents, Non-nucleoside Reverse

Transcriptase Inhibitors (NNRTI)............. 18Anti-HIV Agents, Nucleoside And

Nucleotide Reverse Transcriptase Inhibitors (NRTI)...................................... 18

Anti-HIV Agents, Protease Inhibitors......... 19Anti-Influenza Agents.................................19

Anxiolytics.......................................................19Anxiolytics, Other....................................... 19Benzodiazepines........................................19

Bipolar Agents................................................ 20Mood Stabilizers........................................ 20

Blood Glucose Monitoring.............................. 20Blood Glucose Regulators..............................21

Antidiabetic Agents.................................... 21Glycemic Agents........................................ 21

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Insulins.......................................................21Blood Products/Modifiers/Volume Expanders 22

Anticoagulants........................................... 22Blood Formation Modifiers......................... 22Hemostasis Agents.................................... 22Platelet Modifying Agents.......................... 22

Cardiovascular Agents................................... 22Alpha-adrenergic Agonists.........................22Alpha-adrenergic Blocking Agents.............22Angiotensin II Receptor Antagonists..........22Angiotensin-converting Enzyme (ACE)

Inhibitors.................................................. 22Antiarrhythmics.......................................... 23Beta-adrenergic Blocking Agents...............23Calcium Channel Blocking Agents.............23Cardiovascular Agents, Other....................23Diuretics, Carbonic Anhydrase Inhibitors...24Diuretics, Loop........................................... 24Diuretics, Potassium-sparing..................... 24Diuretics, Thiazide..................................... 24Dyslipidemics, Fibric Acid Derivatives........24Dyslipidemics, HMG CoA Reductase

Inhibitors.................................................. 24Dyslipidemics, Other.................................. 24Vasodilators, Direct-acting Arterial.............24Vasodilators, Direct-acting Arterial/Venous25

Central Nervous System Agents.................... 25Attention Deficit Hyperactivity Disorder

Agents, Amphetamines............................25Attention Deficit Hyperactivity Disorder

Agents, Non-amphetamines.................... 25Central Nervous System, Other................. 25Fibromyalgia Agents.................................. 25Multiple Sclerosis Agents...........................25

Dental and Oral Agents.................................. 25Dermatological Agents................................... 25Electrolytes/Minerals/Metals/Vitamins............ 27

Electrolyte/Mineral Replacement............... 27Electrolyte/Mineral/Metal Modifiers............ 28Phosphate Binders.....................................28Vitamins..................................................... 28

Gastrointestinal Agents.................................. 29Antispasmodics, Gastrointestinal...............29Gastrointestinal Agents, Other...................29Histamine2 (H2) Receptor Antagonists......29Irritable Bowel Syndrome Agents...............29Laxatives....................................................30Protectants.................................................31Proton Pump Inhibitors.............................. 31

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment.................................... 31

Genitourinary Agents......................................31Antispasmodics, Urinary............................ 31

Benign Prostatic Hypertrophy Agents........ 31Genitourinary Agents, Other...................... 31

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) 31

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)33

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)........................................... 33

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)....................................33

Androgens..................................................33Estrogens...................................................33Progestins.................................................. 37Selective Estrogen Receptor Modifying

Agents......................................................38Hormonal Agents,

Stimulant/Replacement/Modifying (Thyroid) 38Hormonal Agents, Suppressant (Adrenal)......38Hormonal Agents, Suppressant (pituitary)......38Hormonal Agents, Suppressant (Thyroid)...... 38

Antithyroid Agents......................................38Immunological Agents.................................... 39

Angioedema Agents...................................39Immune Suppressants............................... 39Immunomodulators.................................... 39Vaccines.................................................... 39

Inflammatory Bowel Disease Agents..............40Aminosalicylates........................................ 40Glucocorticoids.......................................... 41Sulfonamides............................................. 41

Metabolic Bone Disease Agents.....................41Miscellaneous Therapeutic Agents.................41Ophthalmic Agents......................................... 42

Aminoglycosides........................................ 42Antibacterials, Other.................................. 42Antiherpetic Agents....................................42Macrolides..................................................42Ophthalmic Agents, Other..........................42Ophthalmic Anti-allergy Agents..................43Ophthalmic Antiglaucoma Agents..............43Ophthalmic Anti-inflammatories................. 43Ophthalmic Prostaglandin and Prostamide

Analogs....................................................43Quinolones.................................................43Sulfonamides............................................. 43

Otic Agents.....................................................43Respiratory Tract/Pulmonary Agents..............44

Antihistamines............................................44Anti-inflammatories, Inhaled

Corticosteroids.........................................44Antileukotrienes......................................... 44

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Bronchodilators, Anticholinergic.................44Bronchodilators, Sympathomimetic........... 44Cystic Fibrosis Agents............................... 45Mast Cell Stabilizers.................................. 45Phosphodiesterase Inhibitors, Airways

Disease....................................................45Pulmonary Antihypertensives.................... 45Pulmonary Fibrosis Agents........................ 45Respiratory Tract Agents, Other................ 45

Skeletal Muscle Relaxants............................. 45Sleep Disorder Agents....................................45

GABA Receptor Modulators.......................45Sleep Disorders, Other.............................. 46

Index of Drugs................................................ 47

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Drug NameDrug Tier

Requirements & Limits

Analgesics

butalbital-acetaminophen oral tablet 50-300 mg

3 QL

butalbital-apap-caffeine oral tablet

2 QL

butalbital-aspirin-caffeine 2 QL

Nonsteroidal Anti-inflammatory Drugs

adult aspirin regimen

HCR $0 Copay

HCR $0 copay for members between

ages of 12 to 79.

aspirin adult low strength oral tablet delayed release

HCR $0 Copay


ages of 12 to 79.

aspirin childrens

HCR $0 Copay


ages of 12 to 79.

aspirin ec low dose

HCR $0 Copay


ages of 12 to 79.

aspirin ec low strength

HCR $0 Copay


ages of 12 to 79.

aspirin low dose

HCR $0 Copay


ages of 12 to 79.

Drug NameDrug Tier


aspirin oral tablet delayed release 81 mg

HCR $0 Copay


ages of 12 to 79.

BAYER ASPIRIN EC LOW DOSE

HCR $0 Copay


ages of 12 to 79.

diclofenac-misoprostol 3

etodolac 2

gnp aspirin low dose

HCR $0 Copay


ages of 12 to 79.

goodsense aspirin low dose

HCR $0 Copay


ages of 12 to 79.

ibu 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

INDOCIN RECTAL 4

indomethacin oral capsule 25 mg, 50 mg

1

ketorolac tromethamine oral

2

meloxicam oral 1

naproxen oral tablet 1

qc aspirin low dose oral tablet delayed release

HCR $0 Copay


ages of 12 to 79.

salsalate oral 1

PA: Prior authorization; QL: Quantity Limit; ST: Step Therapy

8

Drug NameDrug Tier


ST JOSEPH LOW DOSE ORAL TABLET DELAYED RELEASE

HCR $0 Copay


ages of 12 to 79.

sulindac oral 2

Opioid Analgesics, Long-acting

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

3 PA; QL

hydrocodone bitartrate er 4 PA; QL

methadone hcl intensol 2 QL

methadone hcl oral concentrate

2 QL

methadone hcl oral solution

2 PA; QL

methadone hcl oral tablet 2 PA; QL

methadone hcl oral tablet soluble

2 PA; QL

methadose oral concentrate 10 mg/ml

2 QL

methadose oral tablet soluble

2 PA; QL

methadose sugar-free 2 QL

morphine sulfate er oral tablet extended release

4 PA; QL

Opioid Analgesics, Short-acting

acetaminophen-codeine 2 QL

acetaminophen-codeine #2

2 QL


2 QL


2 QL

ascomp-codeine 3 QL

butalbital-asa-caff-codeine

3 QL

Drug NameDrug Tier


butorphanol tartrate nasal

2 QL

carisoprodol-aspirin-codeine

1 QL

codeine sulfate oral tablet 30 mg, 60 mg

2 QL

endocet 2 QL

hydrocodone-acetaminophen oral solution 10-325 mg/15ml, 7.5-325 mg/15ml

2 QL

hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

2 QL

hydromorphone hcl oral liquid

3 QL

hydromorphone hcl oral tablet

2 QL

hydromorphone hcl rectal 3

LORTAB 4 QL

morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml

3 QL

morphine sulfate oral solution

3 QL

morphine sulfate oral tablet

2 QL

morphine sulfate rectal 3

oxycodone hcl oral capsule

2 QL

oxycodone hcl oral concentrate 100 mg/5ml

4 QL

oxycodone hcl oral solution

2 QL

oxycodone hcl oral tablet 2 QL

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

2 QL


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Drug NameDrug Tier


oxycodone-aspirin 3 QL

pentazocine-naloxone hcl 3 QL

tramadol hcl oral tablet 50 mg

2 QL

tramadol-acetaminophen 2 QL

Anesthetics

Local Anesthetics

lidocaine external ointment

2 QL

lidocaine external patch 5 %

3 PA; QL

lidocaine hcl external solution

3

lidocaine hcl mouth/throat

3

lidocaine hcl urethral/mucosal

1

lidocaine viscous hcl 1

lidocaine-prilocaine external cream

2

MEDI-DERM-RX 4

MEDROX-RX 4

premium lidocaine 2 QL

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-craving

acamprosate calcium 3

disulfiram oral 2

naltrexone hcl oralHCR $0 Copay

Opioid Dependence Treatments

buprenorphine hcl sublingual

HCR $0 Copay

QL

buprenorphine hcl-naloxone hcl sublingual film

4 QL

Drug NameDrug Tier


buprenorphine hcl-naloxone hcl sublingual tablet sublingual

HCR $0 Copay

QL

Opioid Reversal Agents

naloxone hcl injection solution

2

naloxone hcl injection solution cartridge

2

naloxone hcl injection solution prefilled syringe

2

NARCAN 3

Smoking Cessation Agents

bupropion hcl er (smoking det)

HCR $0 Copay

QL

CHANTIXHCR $0 Copay

PA; QL

CHANTIX CONTINUING MONTH PAK

HCR $0 Copay

PA; QL

CHANTIX STARTING MONTH PAK

HCR $0 Copay

PA; QL

NICORETTE MOUTH/THROAT GUM 2 MG

HCR $0 Copay

QL

nicotine polacrilex mouth/throat

HCR $0 Copay

QL

nicotine step 1HCR $0 Copay

QL


QL


QL

NICOTROLHCR $0 Copay

PA; QL

NICOTROL NSHCR $0 Copay

PA; QL

Antibacterials

Aminoglycosides

gentamicin sulfate external

3

neomycin sulfate oral 1


10

Drug NameDrug Tier


Antibacterials, Other

clindamycin hcl oral 1

clindamycin palmitate hcl 3

clindamycin phosphate vaginal

2

CLINDESSE 3

linezolid oral suspension reconstituted

4 QL

linezolid oral tablet 3 QL

methenamine mandelate oral

2

metronidazole oral tablet 1

metronidazole vaginal 2

mupirocin calcium 4 QL

mupirocin external 1 QL

nitrofurantoin 4

nitrofurantoin macrocrystal oral

3

nitrofurantoin monohydrate macrocrystals

2

silver nitrate external 1

silver sulfadiazine external

1

ssd 1

tinidazole oral 2

trimethoprim oral 1

vancomycin hcl oral capsule

1 QL

vancomycin hcl oral solution reconstituted

3

vandazole 2

Beta-lactam, Cephalosporins

cefdinir 2

cefuroxime axetil 1

cephalexin oral capsule 1

cephalexin oral suspension reconstituted

1

Drug NameDrug Tier


Beta-lactam, Penicillins

amoxicillin 1

amoxicillin-potassium clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml

2

amoxicillin-potassium clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

1

amoxicillin-potassium clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg

2

ampicillin 1

dicloxacillin sodium 2

penicillin v potassium 1

Macrolides

azithromycin oral 1

clarithromycin er 3

clarithromycin oral suspension reconstituted

4

clarithromycin oral tablet 1

E.E.S. GRANULES 4

ERYPED 200 4

ERYTHROCIN STEARATE

4

erythromycin base oral capsule delayed release particles

4

erythromycin base oral tablet

4

erythromycin base oral tablet delayed release

3

erythromycin ethylsuccinate oral

4

erythromycin oral 3


11

Drug NameDrug Tier


Quinolones

CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%)

4

ciprofloxacin hcl oral 1

levofloxacin oral solution 4

levofloxacin oral tablet 1

moxifloxacin hcl oral 2

Sulfonamides

sulfamethoxazole-trimethoprim oral suspension

2

sulfamethoxazole-trimethoprim oral tablet

1

sulfatrim pediatric 2

Tetracyclines

avidoxy 2

doxycycline hyclate oral capsule

2

doxycycline hyclate oral tablet 100 mg, 20 mg

2

doxycycline monohydrate oral capsule 100 mg, 50 mg

1

doxycycline monohydrate oral suspension reconstituted

3

doxycycline monohydrate oral tablet

2

minocycline hcl oral capsule

2

mondoxyne nl oral capsule 100 mg

1

tetracycline hcl oral 4

Anticonvulsants

Anticonvulsants, Other

levetiracetam er 2

levetiracetam oral 1

roweepra 1

Drug NameDrug Tier


roweepra xr 2

Calcium Channel Modifying Agents

CELONTIN 3

ethosuximide oral 3

zonisamide oral 2

Gamma-aminobutyric Acid (GABA) Augmenting Agents

diazepam rectal 4 QL

gabapentin oral capsule 1

gabapentin oral solution 250 mg/5ml

2

gabapentin oral tablet 1

phenobarbital oral 2

primidone oral 1

valproic acid oral 2

Glutamate Reducing Agents

felbamate 4

LAMICTAL ODT ORAL KIT

4 PA

lamotrigine oral kit 4 PA

lamotrigine oral tablet 1

lamotrigine oral tablet chewable

2

lamotrigine oral tablet dispersible

4 PA

lamotrigine starter kit-blue

4

lamotrigine starter kit-green

4

lamotrigine starter kit-orange

4

subvenite 1

subvenite starter kit-blue 4

subvenite starter kit-green

4

subvenite starter kit-orange

4


12

Drug NameDrug Tier


topiramate oral capsule sprinkle

3

topiramate oral tablet 1

Sodium Channel Agents

carbamazepine er 3

carbamazepine oral suspension

3

carbamazepine oral tablet

2

carbamazepine oral tablet chewable

2

DILANTIN ORAL CAPSULE 30 MG

4

epitol 2

oxcarbazepine oral suspension

4

oxcarbazepine oral tablet 2

phenytoin infatabs 2

phenytoin oral suspension 125 mg/5ml

2

phenytoin oral tablet chewable

2

phenytoin sodium extended

2

Antidementia Agents

Cholinesterase Inhibitors

donepezil hcl oral tablet 10 mg, 5 mg

1 QL

donepezil hcl oral tablet dispersible

1 QL

galantamine hydrobromide er

3 QL

galantamine hydrobromide oral solution

4 QL

galantamine hydrobromide oral tablet

3 QL

Drug NameDrug Tier


N-methyl-D-aspartate (NMDA) Receptor Antagonist

memantine hcl oral solution 2 mg/ml

4 QL

memantine hcl oral tablet 10 mg, 5 mg

2 QL

memantine hcl oral tablet 28 x 5 mg & 21 x 10 mg

2

Antidepressants

Antidepressants, Other

bupropion hcl er (sr) 1

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

2

bupropion hcl oral 1

chlordiazepoxide-amitriptyline

2

mirtazapine oral tablet 1

mirtazapine oral tablet dispersible

2

olanzapine-fluoxetine hcl 4 QL

perphenazine-amitriptyline

2

Monoamine Oxidase Inhibitors

phenelzine sulfate oral 2

tranylcypromine sulfate 4

SSRI/SNRI (Selective Serotonin Reuptake Inhibitor/ Serotonin and Norepinephrine Reuptake Inhibitor)

citalopram hydrobromide oral solution

3

citalopram hydrobromide oral tablet

1

escitalopram oxalate oral solution

3

escitalopram oxalate oral tablet

1


13

Drug NameDrug Tier


fluoxetine hcl (pmdd) 3 QL

fluoxetine hcl oral capsule

1

fluoxetine hcl oral capsule delayed release

3 QL

fluoxetine hcl oral solution

1

fluoxetine hcl oral tablet 10 mg, 20 mg

3 QL

fluvoxamine maleate er oral capsule extended release 24 hour 100 mg

4 QL

paroxetine hcl 1

sertraline hcl oral concentrate

2

sertraline hcl oral tablet 1

trazodone hcl oral 1

venlafaxine hcl 2

venlafaxine hcl er oral capsule extended release 24 hour

2

Tricyclics

amitriptyline hcl oral 1

desipramine hcl oral 3

doxepin hcl oral capsule 2

doxepin hcl oral concentrate

2

imipramine hcl oral 2

imipramine pamoate 4

nortriptyline hcl oral capsule

2

nortriptyline hcl oral solution

3

protriptyline hcl 3

Antiemetics

Antiemetics, Other

compro 3

metoclopramide hcl oral solution

1

Drug NameDrug Tier


metoclopramide hcl oral tablet

1

perphenazine oral 2

prochlorperazine 3

prochlorperazine maleate oral

1

scopolamine 3

Emetogenic Therapy Adjuncts

aprepitant 4 QL

dronabinol 4

EMEND ORAL SUSPENSION RECONSTITUTED

3 QL

ondansetron hcl oral solution

2

ondansetron hcl oral tablet

1

ondansetron odt 1

Antifungals

BIO-STATIN ORAL CAPSULE

4

clotrimazole mouth/throat 2

clotrimazole-betamethasone external cream

2 QL

clotrimazole-betamethasone external lotion

3

dermazene 2

exoderm external lotion 2

fluconazole oral suspension reconstituted

2

fluconazole oral tablet 1

flucytosine oral 4

griseofulvin microsize oral

3

griseofulvin ultramicrosize

3


14

Drug NameDrug Tier


hydrocortisone-iodoquinol

2

ketoconazole external cream

2 QL

ketoconazole external shampoo

1

ketoconazole oral 2

miconazole 3 vaginal suppository

2

nyamyc 2 QL

nystatin external cream 1

nystatin external ointment

1

nystatin external powder 2 QL

nystatin mouth/throat 2

nystatin oral 2

nystop 2 QL

posaconazole 3

SULCONAZOLE NITRATE

4

terbinafine hcl oral 2 QL

voriconazole oral suspension reconstituted

4

voriconazole oral tablet 4 QL

Antigout Agents

allopurinol oral 1

MITIGARE 3 QL

probenecid 2

Antimigraine Agents

Ergot Alkaloids

dihydroergotamine mesylate injection

4 QL

ergotamine-caffeine 4

MIGERGOT 4

Serotonin (5-HT) 1b/1d Receptor Agonists

naratriptan hcl 2 QL

rizatriptan benzoate 2 QL

sumatriptan nasal 4 QL

Drug NameDrug Tier


sumatriptan succinate oral

1 QL

sumatriptan succinate refill

4 QL

sumatriptan succinate subcutaneous

4 QL

Antimyasthenic Agents

Parasympathomimetics

pyridostigmine bromide er

4

pyridostigmine bromide oral solution

4

pyridostigmine bromide oral tablet 60 mg

1

Antimycobacterials

Antimycobacterials, Other

dapsone oral 2

Antituberculars

ethambutol hcl oral 2

isoniazid oral syrup 4

isoniazid oral tablet 1

pyrazinamide oral 3

rifampin oral 2

Antineoplastics

Alkylating Agents

cyclophosphamide oral 4

GLEOSTINE 5

LEUKERAN 4

melphalan 4

MYLERAN 4

temozolomide 5 PA

VALCHLOR 5 PA; QL

Antiandrogens

abiraterone acetate 5 PA; QL

bicalutamide 1

flutamide 3

nilutamide 4


15

Drug NameDrug Tier


ZYTIGA ORAL TABLET 500 MG

5 PA; QL

Antiangiogenic Agents

REVLIMID 4 PA; QL

THALOMID 4 PA; QL

Antiestrogens/Modifiers

EMCYT 4

tamoxifen citrate oral tablet 10 mg

1

tamoxifen citrate oral tablet 20 mg

1

HCR $0 Copay

after prior authorizati

on for members ages 35

and above who meet

breast cancer

prevention criteria.

Antimetabolites

capecitabine 5

DROXIA 4

hydroxyurea oral 2

mercaptopurine oral 2

Antineoplastics, Other

FLUOROURACIL EXTERNAL CREAM 0.5 %

4

fluorouracil external cream 5 %

2

fluorouracil external solution

2

leucovorin calcium oral 1

Drug NameDrug Tier


Aromatase Inhibitors, 3rd Generation

anastrozole oral

1

HCR $0 Copay



and above who meet

breast cancer


exemestane 4

letrozole oral

1

HCR $0 Copay



and above who meet

breast cancer


Enzyme Inhibitors

etoposide oral 3

Molecular Target Inhibitors

BOSULIF 5 PA; QL

CAPRELSA 5 PA; QL

COTELLIC 4 PA; QL

erlotinib hcl 5 PA; QL

everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg

5 PA; QL

IBRANCE 4 PA; QL

imatinib mesylate 4 PA; QL

IMBRUVICA 5 PA; QL

NEXAVAR 5 PA; QL


16

Drug NameDrug Tier


SPRYCEL 4 PA; QL

SUTENT 4 PA; QL

XALKORI 5 PA; QL

ZELBORAF 5 PA; QL

ZYKADIA 4 PA; QL

Retinoids

tretinoin oral 4 QL

Antiparasitics

Anthelmintics

ivermectin oral 2

praziquantel oral 4

Antiprotozoals

atovaquone oral 4

atovaquone-proguanil hcl 3

chloroquine phosphate oral

2 QL

hydroxychloroquine sulfate oral

2 QL

IMPAVIDO 3 PA; QL

mefloquine hcl 1

pentamidine isethionate inhalation

3 QL

primaquine phosphate 2

quinine sulfate oral 3

Pediculicides/Scabicides

permethrin external 2

Antiparkinson Agents

Anticholinergics

benztropine mesylate oral

2

trihexyphenidyl hcl 2

Antiparkinson Agents, Other

amantadine hcl oral 2

entacapone 3

Dopamine Agonists

bromocriptine mesylate oral capsule

4

Drug NameDrug Tier


bromocriptine mesylate oral tablet

3

pramipexole dihydrochloride

1

ropinirole hcl 1

Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors

carbidopa-levodopa er 2

carbidopa-levodopa oral tablet

2

carbidopa-levodopa-entacapone

4

Monoamine Oxidase B (MAO-B) Inhibitors

selegiline hcl oral 3

Antipsychotics

1st Generation/Typical

ADASUVE 4

chlorpromazine hcl oral 1

fluphenazine hcl oral concentrate

3

fluphenazine hcl oral elixir

3

fluphenazine hcl oral tablet

2

haloperidol lactate oral 2

haloperidol oral 2

loxapine succinate 1

molindone hcl 4

pimozide 3

thioridazine hcl oral 2

thiothixene 2

trifluoperazine hcl 2

2nd Generation/Atypical

aripiprazole oral tablet 2 QL

FANAPT 4 QL

FANAPT TITRATION PACK

4 QL


17

Drug NameDrug Tier


LATUDA 4 ST; QL

olanzapine oral tablet 1 QL

olanzapine oral tablet dispersible

2 QL

paliperidone er 4 QL

quetiapine fumarate 1 QL

quetiapine fumarate er 2 ST; QL

risperidone oral solution 2

risperidone oral tablet 1

risperidone oral tablet dispersible

3

SAPHRIS 4 ST; QL

ziprasidone hcl 2 QL

Treatment-Resistant

clozapine oral tablet 2

clozapine oral tablet dispersible

4 QL

Antivirals

Anti-cytomegalovirus (CMV) Agents

valganciclovir hcl 4 QL

Anti-hepatitis B (HBV) Agents

adefovir dipivoxil 4

entecavir 3

lamivudine oral tablet 100 mg

3

Anti-hepatitis C (HCV) Agents

MAVYRET 5 PA; QL

PEGASYS 4 PA; QL

PEGASYS PROCLICK 4 PA; QL

ribavirin oral 3

SOFOSBUVIR-VELPATASVIR

4 PA; QL

Anti-hepatitis C (HCV) Agents, Other

INTRON A 5 PA

Drug NameDrug Tier


Antiherpetic Agents

acyclovir oral capsule 1

acyclovir oral suspension 4

acyclovir oral tablet 1

famciclovir oral 2 QL

Anti-HIV Agents, Integrase Inhibitors (INSTI)

GENVOYA 4 QL

ISENTRESS 4 QL

ISENTRESS HD 4 QL

STRIBILD 4 QL

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)

COMPLERA 4 QL

EDURANT 4 QL

efavirenz 4 QL

INTELENCE 4 QL

nevirapine oral suspension

1 QL

nevirapine oral tablet 2 QL

ODEFSEY 4 QL

Anti-HIV Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (NRTI)

abacavir sulfate oral solution

4 QL

abacavir sulfate oral tablet

2 QL

abacavir sulfate-lamivudine

3 QL

abacavir-lamivudine-zidovudine

4 QL

didanosine 3 QL

lamivudine oral solution 2 QL


18

Drug NameDrug Tier


lamivudine oral tablet 150 mg, 300 mg

2 QL

lamivudine-zidovudine 3 QL

stavudine 3 QL

tenofovir disoproxil fumarate

2

QL; HCR $0 copay after prior authorizati

on to prevent

HIV (human

immunodeficiency virus)

infections in

individuals who are at high risk of

HIV acquisition.

TRUVADA

4

QL; HCR $0 copay after prior authorizati

on to prevent

HIV (human

immunodeficiency virus)

infections in

individuals who are at high risk of

HIV acquisition.

zidovudine oral capsule 3 QL

zidovudine oral syrup 3 QL

zidovudine oral tablet 2 QL

Drug NameDrug Tier


Anti-HIV Agents, Protease Inhibitors

APTIVUS 4 QL

atazanavir sulfate 4 QL

CRIXIVAN 4 QL

fosamprenavir calcium 4 QL

INVIRASE 4 QL

KALETRA ORAL TABLET

4 QL

LEXIVA ORAL SUSPENSION

4 QL

lopinavir-ritonavir 4 QL

NORVIR ORAL PACKET 4 QL

NORVIR ORAL SOLUTION

4 QL

PREZISTA 4 QL

REYATAZ ORAL PACKET

4 QL

ritonavir 4 QL

VIRACEPT 4 QL

Anti-Influenza Agents

oseltamivir phosphate oral

3 QL

rimantadine hcl 1

Anxiolytics

Anxiolytics, Other

buspirone hcl oral 2

hydroxyzine hcl oral 2

Benzodiazepines

alprazolam oral tablet 1 QL

chlordiazepoxide hcl 1

clonazepam oral tablet 1 QL

diazepam intensol 1 QL

diazepam oral concentrate

1 QL

diazepam oral solution 2

diazepam oral tablet 1 QL

lorazepam intensol 1 QL


19

Drug NameDrug Tier


lorazepam oral concentrate 2 mg/ml

1 QL

lorazepam oral tablet 1 QL

oxazepam 2

triazolam 2 QL

Bipolar Agents

Mood Stabilizers

divalproex sodium er 2

divalproex sodium oral capsule delayed release sprinkle

2

divalproex sodium oral tablet delayed release

1

lithium 2

lithium carbonate er 1

lithium carbonate oral 1

Blood Glucose Monitoring

ACCU-CHEK AVIVA DEVICE

3 QL

ACCU-CHEK AVIVA CONNECT KIT W/DEVICE

3 QL

ACCU-CHEK AVIVA PLUS KIT W/DEVICE

3 QL

ACCU-CHEK COMPACT PLUS CARE KIT

3 QL

ACCU-CHEK COMPACT PLUS CONTROL

3 QL

ACCU-CHEK COMPACT PLUS TEST STRIPS

3 QL

ACCU-CHEK FASTCLIX LANCET KIT

3 QL

ACCU-CHEK GUIDE KIT W/DEVICE

3 QL

ACCU-CHEK GUIDE CONTROL

3 QL

ACCU-CHEK MULTICLIX LANCET DEVICE KIT

3 QL

Drug NameDrug Tier


ACCU-CHEK NANO SMARTVIEW KIT W/DEVICE

3 QL

ACCU-CHEK SMARTVIEW CONTROL

3 QL

ACCU-CHEK SMARTVIEW TEST STRIPS

3 QL

ACCU-CHEK SOFTCLIX LANCET DEVICE KIT

3 QL

AUTOLET II CLINISAFE 3 QL

AUTOLET LANCING DEVICE

3 QL

CARETOUCH CONTROL SOL LEVEL 2

3 QL

CARETOUCH LANCING/EJECTOR

3 QL

CEQUR SIMPLICITY 2U 3

CONTOUR CONTROL 3 QL

CONTOUR NEXT CONTROL

3 QL

EASYMAX 15 LEVEL 2-3 CONTROL

3 QL

EASYMAX CONTROL 3 QL

EASYMAX CONTROL NORMAL/HIGH

3 QL

FORTISCARE CONTROL

3 QL

LANCETS 3

MICROLET NEXT LANCING DEVICE

3 QL

NOVOPEN ECHO 3

ONETOUCH DELICA LANCING DEV

3 QL

ONETOUCH DELICA PLUS LANCING

3 QL

ONETOUCH ULTRA 3 QL

ONETOUCH ULTRA 2 KIT W/DEVICE

3 QL


20

Drug NameDrug Tier


ONETOUCH ULTRA MINI KIT W/DEVICE

3 QL

ONETOUCH VERIO KIT W/DEVICE

3 QL

ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE

3 QL

ONETOUCH VERIO IN VITRO SOLUTION HIGH

3 QL

ONETOUCH VERIO TEST STRIPS

3 QL

ONETOUCH VERIO IQ SYSTEM

3 QL

ONETOUCH VERIO REFLECT

3 QL

ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE

3 QL

SURESTEP PRO HIGH GLUCOSE

3 QL

SURESTEP PRO LOW GLUCOSE

3 QL

SURESTEP PRO NORMAL GLUCOSE

3 QL

TRUE METRIX LEVEL 1 3 QL



UNISTRIP CONTROL IN VITRO SOLUTION LOW

3 QL

Blood Glucose Regulators

Antidiabetic Agents

acarbose oral 2 QL

BYDUREON 3 QL

BYDUREON BCISE AUTOINJECTOR

3 QL

glimepiride 1 QL

glipizide er 1 QL

glipizide ir 1 QL

glipizide xl 1 QL

Drug NameDrug Tier


INVOKANA 3 ST; QL

JARDIANCE 3 ST; QL

metformin hcl er 1 QL

metformin hcl oral solution

4 QL

metformin hcl oral tablet 1 QL

ONGLYZA 3 QL

pioglitazone hcl 1 QL

repaglinide oral tablet 1 mg, 2 mg

2 QL

TRADJENTA 3 QL

TRULICITY 4 QL

Glycemic Agents

diazoxide oral 4

GLUCAGEN HYPOKIT 3 QL

GLUCAGON EMERGENCY KIT

3 QL

Insulins

HUMALOG KWIKPEN 3 QL

HUMALOG MIX 50/50 KWIKPEN

3 QL

HUMALOG MIX 50/50 VIAL

3 QL

HUMALOG MIX 75/25 KWIKPEN

3 QL

HUMALOG MIX 75/25 VIAL

3 QL

HUMALOG U-100 JUNIOR KWIKPEN

3 QL

HUMALOG VIAL 3 QL

HUMULIN 70/30 KWIKPEN

3 QL

HUMULIN 70/30 VIAL 3 QL

HUMULIN N KWIKPEN 3 QL

HUMULIN N VIAL 3 QL

HUMULIN R U-500 KWIKPEN

3 QL

HUMULIN R U-500 VIAL 3 QL

HUMULIN R VIAL 3 QL


21

Drug NameDrug Tier


INSULIN ASPART PROT & ASPART

3 QL

INSULIN LISPRO 3 QL

INSULIN LISPRO (1 UNIT DIAL)

3 QL

INSULIN LISPRO JUNIOR KWIKPEN

3 QL

INSULIN LISPRO PROT & LISPRO

3 QL

Blood Products/Modifiers/Volume Expanders

Anticoagulants

fondaparinux sodium 4 QL

heparin sodium (porcine) 2

heparin sodium (porcine) pf

2

jantoven 1

PRADAXA 3 QL

warfarin sodium oral 1

Blood Formation Modifiers

anagrelide hcl 4

MOZOBIL 5

PROMACTA 5 PA; QL

RETACRIT 4 QL

ZARXIO 5

Hemostasis Agents

aminocaproic acid oral 4

RECOTHROM 4

RECOTHROM SPRAY KIT

4

THROMBIN-JMI EPISTAXIS

4

THROMBIN-JMI EXTERNAL KIT

4

THROMBOGEN 4

tranexamic acid oral 3 QL

Drug NameDrug Tier


Platelet Modifying Agents

aspirin-dipyridamole er 4 QL

BRILINTA 4 QL

clopidogrel bisulfate oral 1 QL

dipyridamole oral 2

prasugrel hcl 2 QL

Cardiovascular Agents

Alpha-adrenergic Agonists

clonidine hcl oral 1

methyldopa 1

methyldopa-hydrochlorothiazide

2

midodrine hcl 1

Alpha-adrenergic Blocking Agents

doxazosin mesylate oral 1

phenoxybenzamine hcl oral

4

prazosin hcl oral 2

Angiotensin II Receptor Antagonists

amlodipine besylate-valsartan

2 QL

candesartan cilexetil-hctz 3 QL

EDARBYCLOR 4 QL

irbesartan-hydrochlorothiazide

1 QL

losartan potassium oral 1 QL

losartan potassium-hctz 1 QL

telmisartan-hctz 3 QL

valsartan-hydrochlorothiazide

1 QL

Angiotensin-converting Enzyme (ACE) Inhibitors

amlodipine besylate-benazepril hcl

1 QL

benazepril hcl oral 1 QL


22

Drug NameDrug Tier


benazepril-hydrochlorothiazide

2 QL

captopril-hydrochlorothiazide

3 QL

enalapril-hydrochlorothiazide

1 QL

fosinopril sodium-hctz 2 QL

lisinopril oral 1 QL

lisinopril-hydrochlorothiazide

1 QL

quinapril-hydrochlorothiazide

2 QL

trandolapril-verapamil hcl er

3 QL

Antiarrhythmics

amiodarone hcl oral 1

disopyramide phosphate 3

dofetilide 4

flecainide acetate 2

NORPACE CR 3

pacerone oral tablet 200 mg

1

propafenone hcl 2

propafenone hcl er 4

quinidine gluconate er 1

quinidine sulfate 1

sotalol hcl (af) 2

sotalol hcl oral 2

SOTYLIZE 4 PA

Beta-adrenergic Blocking Agents

atenolol oral 1

atenolol-chlorthalidone 2

bisoprolol fumarate 2

bisoprolol-hydrochlorothiazide

1 QL

carvedilol 1

labetalol hcl oral 1

metoprolol succinate er 1

Drug NameDrug Tier


metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

1

propranolol hcl oral solution

2

propranolol hcl oral tablet 1

propranolol-hctz 2

Calcium Channel Blocking Agents

amlodipine besylate oral 1

cartia xt 2

diltiazem hcl er 2

diltiazem hcl er beads 2

diltiazem hcl er coated beads oral capsule extended release 24 hour

2

diltiazem hcl er coated beads oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg

2

diltiazem hcl oral 2

dilt-xr 2

felodipine er 1

matzim la 2

nimodipine oral 4

NYMALIZE 3

taztia xt 2

tiadylt er 2

verapamil hcl er oral capsule extended release 24 hour

3

verapamil hcl er oral tablet extended release

1

verapamil hcl oral 1

Cardiovascular Agents, Other

ALDACTAZIDE ORAL TABLET 50-50 MG

3


23

Drug NameDrug Tier


amiloride-hydrochlorothiazide

1

BIDIL 3 QL

digitek oral tablet 125 mcg

1

digitek oral tablet 250 mcg

2

digox oral tablet 125 mcg 1

digox oral tablet 250 mcg 2

digoxin oral solution 3

digoxin oral tablet 125 mcg

1

digoxin oral tablet 250 mcg

2

ENTRESTO 4 PA; QL

isoxsuprine hcl oral 1

pentoxifylline er 2

spironolactone-hctz 2

triamterene-hctz 1

Diuretics, Carbonic Anhydrase Inhibitors

acetazolamide er 3

acetazolamide oral 3

methazolamide oral 4

Diuretics, Loop

bumetanide oral 2

furosemide oral 1

torsemide 1

Diuretics, Potassium-sparing

amiloride hcl oral 1

CAROSPIR 4 PA

spironolactone oral 1

triamterene oral 3

Diuretics, Thiazide

chlorthalidone 1

DIURIL 3

hydrochlorothiazide oral 1

Drug NameDrug Tier


metolazone 2

Dyslipidemics, Fibric Acid Derivatives

fenofibrate oral tablet 160 mg, 54 mg

4

gemfibrozil oral 1

Dyslipidemics, HMG CoA Reductase Inhibitors

atorvastatin calcium oral tablet 10 mg, 20 mg

1

QL; HCR $0 Copay

for members between

ages 40 to 75.

atorvastatin calcium oral tablet 40 mg, 80 mg

1 QL

lovastatin

1

QL; HCR $0 Copay

for members between

ages 40 to 75.

pravastatin sodium 1 QL

rosuvastatin calcium 1 QL

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg

1

QL; HCR $0 Copay

for members between

ages 40 to 75.

simvastatin oral tablet 80 mg

1 QL

Dyslipidemics, Other

cholestyramine light 3

cholestyramine oral 3

colesevelam hcl 3

prevalite 3

Vasodilators, Direct-acting Arterial

hydralazine hcl oral 1


24

Drug NameDrug Tier


minoxidil oral 1

Vasodilators, Direct-acting Arterial/Venous

isosorbide dinitrate 2

isosorbide mononitrate 1

isosorbide mononitrate er 1

minitran 2

NITRO-BID 3

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR

4

nitroglycerin sublingual 1

nitroglycerin transdermal 2

NITROMIST 4 QL

nitro-time 1

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetamines

amphetamine-dextroamphetamine

2 PA; QL

amphetamine-dextroamphetamine er

3 QL

dextroamphetamine sulfate er

3 PA; QL

dextroamphetamine sulfate oral solution

3 PA

dextroamphetamine sulfate oral tablet

2 PA; QL

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines

atomoxetine hcl 3 QL

methylphenidate hcl oral tablet 10 mg, 20 mg

2 PA; QL

Central Nervous System, Other

caffeine citrate oral 1

Drug NameDrug Tier


riluzole 4

tetrabenazine 5 PA; QL

Fibromyalgia Agents

duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg

1 QL

duloxetine hcl oral capsule delayed release particles 30 mg

2 QL

SAVELLA TITRATION PACK

4 QL

Multiple Sclerosis Agents

AVONEX PEN 5 PA; QL

AVONEX PREFILLED 5 PA; QL

BETASERON 5 PA; QL

dalfampridine er 4 PA; QL

glatiramer acetate 4 PA; QL

glatopa 4 PA; QL

Dental and Oral Agents

chlorhexidine gluconate mouth/throat

1

DEBACTEROL 3

oralone 2

paroex 1

periogard 1

TOPEX TOPICAL ANESTHETIC

4

triamcinolone acetonide mouth/throat

2

Dermatological Agents

acitretin 4

arzol silver nit applicators 1

avar cleanser 1

azelaic acid external 4

benzoyl peroxide-erythromycin

3 QL

bp 10-1 1

bp cleansing wash 1


25

Drug NameDrug Tier


calcipotriene external cream

4 QL

calcipotriene external ointment

4

calcipotriene external solution

3 QL

calcitriol external 4 QL

cerovel 2

clindacin etz external swab

2

clindacin-p 2

clindamycin phos-benzoyl perox external gel 1.2-5 %

4 QL

clindamycin phosphate external lotion

3

clindamycin phosphate external solution

2 QL

clindamycin phosphate external swab

2

COAL TAR EXTERNAL 4

EPIFOAM 3

ery 2

erythromycin external 3

GORDOFILM 3

grafco silver nit applicator 1

hydrocortisone ace-pramoxine external cream 2.5-1 %

3

imiquimod external 2 QL

INOVA 4/1 ACNE CONTROL THERAPY

4

INOVA 8/2 ACNE CONTROL THERAPY

4

isotretinoin oral 4

metronidazole external cream

3

metronidazole external gel 0.75 %

3

Drug NameDrug Tier


metronidazole external lotion

3

podocon 2

podofilox external 2

pramosone external cream 1-1 %

2

PRAMOSONE EXTERNAL CREAM 1-2.5 %

4

PRAMOSONE EXTERNAL LOTION

3

PRAMOSONE EXTERNAL OINTMENT 1-1 %

3

pramox 1

PYROGALLIC ACID 3

rosadan external cream 3

rosadan external gel 3

salicylic acid external solution

1

SALVAX DUO PLUS 4

SCALACORT DK 4

selenium sulfide external lotion

1

selenium sulfide external shampoo 2.25 %

1

sodium sulfacetamide 1

sodium sulfacetamide wash liquid 10 % external

3

SODIUM SULFACETAMIDE WASH LIQUID 10 % EXTERNAL

3

sss 10-5 1

sulfacetamide sodium (acne)

1

sulfacetamide sodium external

3

sulfacetamide sodium-sulfur external cream 10-2 %, 10-5 %

1


26

Drug NameDrug Tier


sulfacetamide sodium-sulfur external emulsion

1

sulfacetamide sodium-sulfur external liquid 9-4 %

1

sulfacetamide sodium-sulfur external lotion 10-5 %

1

sulfacetamide sodium-sulfur external pad

1

sulfamez wash 1

SUMAXIN WASH 4

tacrolimus external ointment

4 ST; QL

tazarotene external 4 PA; QL

TAZORAC EXTERNAL CREAM 0.05 %

4 PA; QL

TAZORAC EXTERNAL GEL

4 PA; QL

TRI-CHLOR 3

urea external cream 40 %, 45 %

2

urea external lotion 2

urea external suspension 2

urea nail 2

urea-c40 2

uremez-40 2

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral Replacement

cytra k crystals 1

EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ

3

effer-k oral tablet effervescent 25 meq

1

Drug NameDrug Tier


FLORIVA ORAL LIQUID

HCR $0 Copay

HCR $0 copay for members ages 0 to 16 years.

FLUORABON

HCR $0 Copay


fluoritab

HCR $0 Copay


FLURA-DROPS

HCR $0 Copay


GALZIN 4

hematinic/folic acid 1

hemocyte-f 1

klor-con 10 1

klor-con m10 1

KLOR-CON M15 4

klor-con m20 1

klor-con oral packet 4

klor-con oral tablet extended release

1

klor-con sprinkle 1

klor-con/ef 1

K-PHOS 3

K-PHOS NO 2 3

K-PHOS-NEUTRAL 3

k-prime 1

levocarnitine oral solution 3

levocarnitine oral tablet 2

levocarnitine sf 3

MAGNEBIND 400 3


27

Drug NameDrug Tier


nafrinse

HCR $0 Copay


nafrinse drops

HCR $0 Copay


ORACIT 3

phospha 250 neutral 1

phosphorous 1

phospho-trin 250 neutral 1

pot bicarb-pot chloride 1

potassium bicarbonate oral

1

potassium chloride crys er

1

potassium chloride er 1

potassium chloride oral packet

4

potassium chloride oral solution

1

potassium citrate er 3

potassium citrate-citric acid

1

sod citrate-citric acid 1

sodium fluoride oral

HCR $0 Copay


taron-crystals 1

tricitrates 1

virt-phos 250 neutral 1

Electrolyte/Mineral/Metal Modifiers

CHEMET 3

deferasirox oral tablet 5 PA

Drug NameDrug Tier


deferasirox oral tablet soluble

4 PA

kionex 2

sodium polystyrene sulfonate oral

2

sps 2

Phosphate Binders

AURYXIA 4

calcium acetate (phos binder)

2

calcium acetate oral tablet 667 mg

2

sevelamer carbonate 4

sevelamer hcl 4

Vitamins

aminobenzoate potassium

3

ATABEX OB 3

CITRANATAL BLOOM 3

CITRANATAL MEDLEY 3

ELITE-OB 3

ENBRACE HR 3

ergocalciferol oral capsule

1

folic acid oral tablet 1 mg 1

folic acid oral tablet 800 mcg

HCR $0 Copay

M-NATAL PLUS 3

NEONATAL COMPLETE 3

NEONATAL PLUS 3

NESTABS 3

ONE VITE WOMENS PLUS

3

ONEVITE 3

phytonadione oral 4 QL

PREMESISRX 3

PRENAISSANCE 3

prenatal oral tablet 27-1 mg

1


28

Drug NameDrug Tier


prenatal plus iron 1

PRENATE 3

PRENATE DHA 3

PRENATE ELITE 3

PRENATE ENHANCE 3

PRENATE ESSENTIAL 3

PRENATE MINI 3

PRENATE PIXIE 3

PRENATE RESTORE 3

PRENATRIX 3

PRIMACARE 3

RELNATE DHA 3

TRICARE PRENATAL DHA ONE

3

trinate 1

TRISTART ONE 3

UDAMIN SP 3

VITAFOL FE+ 3

VITAFOL STRIPS 3

VITAFOL-OB+DHA 3

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

1

VITATHELY WITH GINGER

3

vp-pnv-dha 1

WESTAB PLUS 3

WESTGEL DHA 3

Gastrointestinal Agents

Antispasmodics, Gastrointestinal

belladonna alkaloids-opium

1

dicyclomine hcl oral capsule

1

dicyclomine hcl oral solution

3

dicyclomine hcl oral tablet

1

Drug NameDrug Tier


ed-spaz 1

glycopyrrolate oral tablet 1 mg, 2 mg

2

hyoscyamine sulfate er 1

hyoscyamine sulfate oral 1

hyoscyamine sulfate sl 1

hyoscyamine sulfate sublingual

1

hyosyne 1

oscimin 1

oscimin sr 1

propantheline bromide oral

3

symax-sl 1

symax-sr 1

Gastrointestinal Agents, Other

cromolyn sodium oral 4

diphenoxylate-atropine oral tablet

2

ENTEREG 4

GATTEX 5 PA; QL

loperamide hcl oral capsule

1

opium 4 QL

ursodiol oral capsule 4

ursodiol oral tablet 3

Histamine2 (H2) Receptor Antagonists

cimetidine hcl 2

cimetidine oral tablet 300 mg, 400 mg, 800 mg

2

famotidine oral suspension reconstituted

3

Irritable Bowel Syndrome Agents

LINZESS 3 PA; QL


29

Drug NameDrug Tier


Laxatives

bisacodyl ecHCR $0 Copay

QL

citromaHCR $0 Copay

QL

clearlaxHCR $0 Copay

QL

constulose 2

enulose 2

EX-LAX ULTRAHCR $0 Copay

QL

gavilax oral powderHCR $0 Copay

QL

gavilyte-c

1

QL; HCR $0 Copay after prior authorization if taken to prepare

for a preventive colonoscop

y.

gavilyte-g

1



y.

gavilyte-h

1

HCR $0 Copay

after prior authorization if taken to prepare


y.

Drug NameDrug Tier


gavilyte-n with flavor pack

1



y.

generlac 2

gentle laxative oralHCR $0 Copay

QL

glycolaxHCR $0 Copay

QL

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM

3 QL

lactulose encephalopathy 2

lactulose oral solution 2

magnesium citrate oral solution

HCR $0 Copay

QL

peg 3350-kcl-na bicarb-nacl

1



y.

peg-3350/electrolytes

1



y.


30

Drug NameDrug Tier


peg-prep

1

HCR $0 Copay

after prior authorization if taken to prepare


y.

qc magnesium citrateHCR $0 Copay

QL

trilyte

1



y.

Protectants

misoprostol oral 2

sucralfate oral suspension

4

sucralfate oral tablet 2

Proton Pump Inhibitors

omeprazole oral capsule delayed release 10 mg

1 QL

omeprazole oral capsule delayed release 40 mg

1

pantoprazole sodium oral tablet delayed release

1 QL

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

CYSTAGON 5

SUCRAID 5 PA

Genitourinary Agents

Antispasmodics, Urinary

hyophen 1

oxybutynin chloride er 2 QL

Drug NameDrug Tier


oxybutynin chloride oral 1

tolterodine tartrate 2 ST

URIMAR-T 3

uro-mp 1

ustell 1

uticap 1

vilamit mb 1

Benign Prostatic Hypertrophy Agents

finasteride oral tablet 5 mg

1

tamsulosin hcl 1

terazosin hcl 1

Genitourinary Agents, Other

bethanechol chloride oral 2

ELMIRON 3

LITHOSTAT 4

OPTIONS CONCEPTROL

HCR $0 Copay

phenazo oral tablet 200 mg

1

phenazopyridine hcl oral tablet 100 mg, 200 mg

1

PYRIDIUM 4

VCF VAGINAL CONTRACEPTIVE VAGINAL FILM

HCR $0 Copay

vcf vaginal contraceptive vaginal gel

HCR $0 Copay

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

ALA SCALP 4

ala-cort external cream 2.5 %

2

alclometasone dipropionate

2

betamethasone dipropionate aug

3


31

Drug NameDrug Tier


betamethasone dipropionate external

3

betamethasone valerate external cream

2

betamethasone valerate external lotion

2

betamethasone valerate external ointment

2

CAPEX 3

clobetasol prop emollient base

4 QL

clobetasol propionate e 4 QL

clobetasol propionate external cream

3 QL

clobetasol propionate external gel

3 QL

clobetasol propionate external ointment

3 QL

clobetasol propionate external solution

2 QL

cortisone acetate oral 2

desonide external cream 2 QL

desonide external lotion 3 QL

desonide external ointment

2 QL

desoximetasone external cream

3 QL

desoximetasone external gel

4 QL

desoximetasone external ointment

3 QL

dexamethasone intensol 2

dexamethasone oral elixir

2

dexamethasone oral tablet

1

dexamethasone oral tablet therapy pack

2

fludrocortisone acetate oral

1

Drug NameDrug Tier


fluocinolone acetonide body

3 QL

fluocinolone acetonide external cream

2 QL

fluocinolone acetonide external ointment

2 QL

fluocinolone acetonide external solution

3 QL

fluocinolone acetonide scalp

3 QL

fluocinonide emulsified base

3

fluocinonide external cream 0.05 %

3

fluocinonide external gel 3

fluocinonide external ointment

3

fluocinonide external solution

3

flurandrenolide external ointment

4 ST

halobetasol propionate external cream

3 QL

halobetasol propionate external ointment

3 QL

hydrocortisone butyrate external ointment

4

hydrocortisone butyrate external solution

4

hydrocortisone external cream 2.5 %

2

hydrocortisone external lotion 2.5 %

2

hydrocortisone external ointment 1 %, 2.5 %

2

hydrocortisone oral 2

hydrocortisone valerate 3 QL

methylprednisolone oral 1

mometasone furoate external

2

NUCORT 4


32

Drug NameDrug Tier


prednisolone sodium phosphate oral solution

2

prednisone intensol 3

prednisone oral solution 3

prednisone oral tablet 1

prednisone oral tablet therapy pack

1

TEXACORT 3

triamcinolone acetonide external cream 0.025 %, 0.1 %

1

triamcinolone acetonide external cream 0.5 %

1 QL

triamcinolone acetonide external lotion

2

triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %

1

triderm external cream 0.1 %

1

triderm external cream 0.5 %

1 QL

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

cabergoline 3

desmopressin acetate injection

4

desmopressin acetate oral

2

desmopressin acetate spray

3

INCRELEX 5 PA; QL

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

PREPIDIL 4

PROSTIN E2 4

Drug NameDrug Tier


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

Androgens

ANDRODERM 3 PA; QL

danazol oral 3

METHITEST 3

methyltestosterone oral 4

oxandrolone oral 4 QL

TESTOSTERONE CYPIONATE INJECTION

2

testosterone cypionate intramuscular

2

testosterone enanthate intramuscular

2

testosterone transdermal gel 50 mg/5gm (1%)

3 PA; QL

Estrogens

afirmelleHCR $0 Copay

altaveraHCR $0 Copay

alyacen 1/35HCR $0 Copay

alyacen 7/7/7HCR $0 Copay

amabelz 3

amethia loHCR $0 Copay

ANGELIQ 4

apriHCR $0 Copay

aranelleHCR $0 Copay

aubraHCR $0 Copay

aubra eqHCR $0 Copay

aurovela 1.5/30HCR $0 Copay


33

Drug NameDrug Tier


aurovela 24 feHCR $0 Copay

aurovela fe 1.5/30HCR $0 Copay

aurovela fe 1/20HCR $0 Copay

avianeHCR $0 Copay

ayunaHCR $0 Copay

azuretteHCR $0 Copay

balzivaHCR $0 Copay

bekyreeHCR $0 Copay

blisovi 24 feHCR $0 Copay

blisovi fe 1.5/30HCR $0 Copay

blisovi fe 1/20HCR $0 Copay

briellynHCR $0 Copay

camrese loHCR $0 Copay

caziantHCR $0 Copay

chatealHCR $0 Copay

chateal eqHCR $0 Copay

CLIMARA PRO 4 QL

COMBIPATCH 4 QL

covaryx 1

covaryx hs 1

cryselle-28HCR $0 Copay

cyclafem 1/35HCR $0 Copay

Drug NameDrug Tier


cyclafem 7/7/7HCR $0 Copay

cyredHCR $0 Copay

cyred eqHCR $0 Copay

dasetta 1/35HCR $0 Copay

dasetta 7/7/7HCR $0 Copay

delylaHCR $0 Copay

DEPO-ESTRADIOL 4

desogestrel-ethinyl estradiol

HCR $0 Copay

drospirenone-ethinyl estradiol

HCR $0 Copay

eemt 1

eemt hs 1

elinestHCR $0 Copay

eluryngHCR $0 Copay

emoquetteHCR $0 Copay

enpresse-28HCR $0 Copay

enskyceHCR $0 Copay

est estrogens-methyltest 1

est estrogens-methyltest ds

1

est estrogens-methyltest hs

1

estaryllaHCR $0 Copay

estradiol oral 1

estradiol transdermal patch weekly

2 QL

estradiol vaginal tablet 3 QL


34

Drug NameDrug Tier


estradiol valerate intramuscular

2

estradiol-norethindrone acet

3

ethynodiol diac-eth estradiol

HCR $0 Copay

etonogestrel-ethinyl estradiol

HCR $0 Copay

falminaHCR $0 Copay

femynorHCR $0 Copay

fyavolv 3

gianviHCR $0 Copay

hailey 1.5/30HCR $0 Copay

hailey 24 feHCR $0 Copay

hailey fe 1.5/30HCR $0 Copay

hailey fe 1/20HCR $0 Copay

introvaleHCR $0 Copay

isibloomHCR $0 Copay

jasmielHCR $0 Copay

jinteli 3

jolessaHCR $0 Copay

juleberHCR $0 Copay

junel 1.5/30HCR $0 Copay

junel fe 1.5/30HCR $0 Copay

junel fe 1/20HCR $0 Copay

Drug NameDrug Tier


junel fe 24HCR $0 Copay

kalligaHCR $0 Copay

karivaHCR $0 Copay

kelnor 1/35HCR $0 Copay

kelnor 1/50HCR $0 Copay

kurveloHCR $0 Copay

larin 1.5/30HCR $0 Copay

larin 24 feHCR $0 Copay

larin fe 1.5/30HCR $0 Copay

larin fe 1/20HCR $0 Copay

larissiaHCR $0 Copay

leenaHCR $0 Copay

lessinaHCR $0 Copay

levonestHCR $0 Copay

levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 0.15-0.03 mg

HCR $0 Copay

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg

HCR $0 Copay

levonorg-eth estrad triphasic

HCR $0 Copay

levora 0.15/30 (28)HCR $0 Copay

lillowHCR $0 Copay


35

Drug NameDrug Tier


lojaimiessHCR $0 Copay

lorynaHCR $0 Copay

low-ogestrelHCR $0 Copay

lo-zumandimineHCR $0 Copay

luteraHCR $0 Copay

marlissaHCR $0 Copay

microgestin 1.5/30HCR $0 Copay

microgestin fe 1.5/30HCR $0 Copay

microgestin fe 1/20HCR $0 Copay

miliHCR $0 Copay

mimvey 3

mono-linyahHCR $0 Copay

NATAZIAHCR $0 Copay

necon 0.5/35 (28)HCR $0 Copay

nikkiHCR $0 Copay

norethin ace-eth estrad-fe oral tablet

HCR $0 Copay

norethindrone acet-ethinyl est oral tablet 1.5-30 mg-mcg

HCR $0 Copay

norethindrone-eth estradiol

3

norgestimate-eth estradiol

HCR $0 Copay

norgestimate-ethinyl estradiol triphasic

HCR $0 Copay

nortrel 0.5/35 (28)HCR $0 Copay

Drug NameDrug Tier


nortrel 1/35 (21)HCR $0 Copay

nortrel 1/35 (28)HCR $0 Copay

nortrel 7/7/7HCR $0 Copay

ocellaHCR $0 Copay

orsythiaHCR $0 Copay

philithHCR $0 Copay

pimtreaHCR $0 Copay

pirmella 1/35HCR $0 Copay

pirmella 7/7/7HCR $0 Copay

portia-28HCR $0 Copay

PREFEST 3

PREMPHASE 4 QL

previfemHCR $0 Copay

reclipsenHCR $0 Copay

setlakinHCR $0 Copay

simliyaHCR $0 Copay

sprintec 28HCR $0 Copay

sronyxHCR $0 Copay

syedaHCR $0 Copay

tarina 24 feHCR $0 Copay

tarina fe 1/20HCR $0 Copay


36

Drug NameDrug Tier


tarina fe 1/20 eqHCR $0 Copay

tilia feHCR $0 Copay

tri femynorHCR $0 Copay

tri-estaryllaHCR $0 Copay

tri-legest feHCR $0 Copay

tri-linyahHCR $0 Copay

tri-lo-estaryllaHCR $0 Copay

tri-lo-marziaHCR $0 Copay

tri-lo-miliHCR $0 Copay

tri-lo-sprintecHCR $0 Copay

tri-miliHCR $0 Copay

tri-previfemHCR $0 Copay

tri-sprintecHCR $0 Copay

trivora (28)HCR $0 Copay

tri-vylibraHCR $0 Copay

tri-vylibra loHCR $0 Copay

TWIRLAHCR $0 Copay

velivetHCR $0 Copay

vienvaHCR $0 Copay

vioreleHCR $0 Copay

volneaHCR $0 Copay

Drug NameDrug Tier


vyfemlaHCR $0 Copay

vylibraHCR $0 Copay

weraHCR $0 Copay

xulaneHCR $0 Copay

yuvafem 3 QL

zarahHCR $0 Copay

zovia 1/35e (28)HCR $0 Copay

zumandimineHCR $0 Copay

Progestins

camilaHCR $0 Copay

deblitaneHCR $0 Copay

DEPO-SUBQ PROVERA 104

HCR $0 Copay

QL

ELLAHCR $0 Copay

QL

errinHCR $0 Copay

heatherHCR $0 Copay

incassiaHCR $0 Copay

jencyclaHCR $0 Copay

KYLEENAHCR $0 Copay

levonorgestrelHCR $0 Copay

lyzaHCR $0 Copay

medroxyprogesterone acetate intramuscular suspension

HCR $0 Copay

QL


37

Drug NameDrug Tier


medroxyprogesterone acetate intramuscular suspension prefilled syringe

HCR $0 Copay

medroxyprogesterone acetate oral

1

megestrol acetate oral suspension 40 mg/ml

2

megestrol acetate oral suspension 625 mg/5ml

4

megestrol acetate oral tablet

2

NEXPLANONHCR $0 Copay

QL

nora-beHCR $0 Copay

norethindrone acetate oral

2

norethindrone oralHCR $0 Copay

norlydaHCR $0 Copay

norlyrocHCR $0 Copay

PLAN B ONE-STEPHCR $0 Copay

progesterone intramuscular

2

sharobelHCR $0 Copay

tulanaHCR $0 Copay

Selective Estrogen Receptor Modifying Agents

OSPHENA 4 PA; QL

Drug NameDrug Tier


raloxifene hcl

2

QL; HCR $0 Copay after prior authorizati


and above who meet

breast cancer


Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

ARMOUR THYROID 4

euthyrox 1

levo-t 1

levothyroxine sodium oral 1

levoxyl 1

liothyronine sodium oral 2

NATURE-THROID 4

np thyroid 1

unithroid 1

WESTHROID 4

WP THYROID 4

Hormonal Agents, Suppressant (Adrenal)

LYSODREN 4

Hormonal Agents, Suppressant (pituitary)

leuprolide acetate injection

5 PA

octreotide acetate 4 PA

SYNAREL 3

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agents

methimazole oral 1

propylthiouracil oral 2


38

Drug NameDrug Tier


Immunological Agents

Angioedema Agents

BERINERT 4 PA; QL

Immune Suppressants

azathioprine oral 2

CIMZIA 5 PA; QL

CIMZIA PREFILLED KIT 5 PA; QL

CIMZIA STARTER KIT 5 PA; QL

cyclosporine modified 4

cyclosporine oral 4

gengraf 4

HUMIRA 5 PA; QL

HUMIRA PEDIATRIC CROHNS START

5 PA; QL

HUMIRA PEN 5 PA; QL

HUMIRA PEN-CD/UC/HS STARTER

5 PA; QL

HUMIRA PEN-PS/UV/ADOL HS START

5 PA; QL

methotrexate oral 2

methotrexate sodium oral 2

mycophenolate mofetil oral capsule

3

mycophenolate mofetil oral tablet

3

mycophenolate sodium 4

SANDIMMUNE ORAL SOLUTION

4

SIMPONI 5 PA; QL

sirolimus oral 4

SKYRIZI (150 MG DOSE)

5 PA; QL

tacrolimus oral 2

XELJANZ 5 PA; QL

XELJANZ XR 5 PA; QL

Immunomodulators

ACTEMRA ACTPEN 5 PA; QL

ACTEMRA SUBCUTANEOUS

5 PA; QL

Drug NameDrug Tier


ALFERON N 5

leflunomide oral 4

RINVOQ 5 PA; QL

Vaccines

ACTHIBHCR $0 Copay

QL

ADACEL

HCR $0 Copay

QL; HCR $ 0 copay for members 7

years of age or older.

AFLURIA QUADRIVALENT

HCR $0 Copay

QL

BEXSERO

HCR $0 Copay



BOOSTRIX

HCR $0 Copay



ENGERIX-BHCR $0 Copay

QL

FLUAD

HCR $0 Copay

QL; HCR $ 0 copay for members

65 years of age or older.

FLUAD QUADRIVALENT

HCR $0 Copay



FLUARIX QUADRIVALENT

HCR $0 Copay

QL


39

Drug NameDrug Tier


FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

HCR $0 Copay

QL

FLULAVAL QUADRIVALENT

HCR $0 Copay

QL

FLUMIST QUADRIVALENT

HCR $0 Copay

QL; HCR $ 0 copay for members between

age of 2 to 49.

FLUZONE QUADRIVALENT

HCR $0 Copay

QL

GARDASIL 9

HCR $0 Copay

QL; HCR $ 0 copay for members between

ages of 9 to 45.

HAVRIXHCR $0 Copay

QL

HEPLISAV-B

HCR $0 Copay



HIBERIXHCR $0 Copay

QL

IPOLHCR $0 Copay

QL

MENACTRAHCR $0 Copay

QL

MENQUADFIHCR $0 Copay

QL

MENVEOHCR $0 Copay

QL

M-M-R IIHCR $0 Copay

QL

PEDVAX HIBHCR $0 Copay

QL

Drug NameDrug Tier


PNEUMOVAX 23

HCR $0 Copay



PREVNAR 13HCR $0 Copay

QL

RECOMBIVAX HBHCR $0 Copay

QL

SHINGRIX

HCR $0 Copay



TENIVAC

HCR $0 Copay



TRUMENBA

HCR $0 Copay



TWINRIX

HCR $0 Copay



VAQTAHCR $0 Copay

QL

VARIVAXHCR $0 Copay

QL

Inflammatory Bowel Disease Agents

Aminosalicylates

balsalazide disodium 3

mesalamine er 3 QL


40

Drug NameDrug Tier


mesalamine rectal suppository

4 QL

Glucocorticoids

ANALPRAM-HC EXTERNAL LOTION

4

anucort-hc 2

budesonide oral 4

CORTIFOAM 3

hemmorex-hc 2

hemorrhoidal-hc rectal suppository 25 mg

2

hydrocortisone (perianal) external cream 2.5 %

2

hydrocortisone ace-pramoxine external cream 1-1 %

3

hydrocortisone acetate rectal

2

hydrocortisone rectal 3

hydrocort-pramoxine (perianal)

3

PROCTOFOAM HC 3

procto-med hc 2

proctozone-hc 2

UCERIS RECTAL 3

Sulfonamides

sulfasalazine oral tablet 1

sulfasalazine oral tablet delayed release

2

Metabolic Bone Disease Agents

alendronate sodium oral solution

3

alendronate sodium oral tablet

1 QL

calcitonin (salmon) 2 QL

calcitriol oral capsule 1

FOSAMAX PLUS D 4 QL

MIACALCIN INJECTION 4

NATPARA 5 PA; QL

Drug NameDrug Tier


paricalcitol oral capsule 4 mcg

3

Miscellaneous Therapeutic Agents

ALCOHOL PREP PADS PAD

3

ALCOHOL PREP PADS PAD 70 %

3

ARTISS 4

ASTRINGYN 4

BENZOIN 4

CAYAHCR $0 Copay

ergoloid mesylates oral 4

INSULIN PEN NEEDLES 3

INSULIN SYRINGES 3

MAXICOMFORT SYR 27G X 1/2"

3

methergine 4 QL

methylergonovine maleate oral

4 QL

monsels ferric subsulfate 1

n-acetyl-l-cysteine oral 1

NOVOFINE AUTOCOVER PEN NEEDLE

3

NOVOFINE PEN NEEDLE

3

NOVOFINE PLUS PEN NEEDLE

3

NOVOTWIST PEN NEEDLE

3

PARAGARD INTRAUTERINE COPPER

HCR $0 Copay

SSKI 4

TISSEEL EXTERNAL KIT 10 ML

4

TISSEEL EXTERNAL SOLUTION

4


41

Drug NameDrug Tier


WIDE-SEAL DIAPHRAGM 60

HCR $0 Copay


HCR $0 Copay


HCR $0 Copay


HCR $0 Copay


HCR $0 Copay


HCR $0 Copay


HCR $0 Copay


HCR $0 Copay

Ophthalmic Agents

Aminoglycosides

gentak 1

gentamicin sulfate ophthalmic

1

neomycin-polymyxin-gramicidin

2

tobramycin ophthalmic 1

tobramycin-dexamethasone

3

Antibacterials, Other

ak-poly-bac 1

bacitracin ophthalmic 3

bacitracin-polymyxin b ophthalmic

1

bacitra-neomycin-polymyxin-hc

3

BETADINE OPHTHALMIC PREP

4

neomycin-bacitracin zn-polymyx

2

neomycin-polymyxin-dexameth ophthalmic ointment

1

Drug NameDrug Tier


neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

1

neomycin-polymyxin-hc ophthalmic

3

neo-polycin 2

neo-polycin hc 3

polycin 1

polymyxin b-trimethoprim 1

POVIDONE-IODINE OPHTHALMIC

4

Antiherpetic Agents

trifluridine 3

Macrolides

erythromycin ophthalmic 1

Ophthalmic Agents, Other

AKTEN 4

altacaine 2

atropine sulfate ophthalmic ointment

2

atropine sulfate ophthalmic solution 1 %

2

BLEPHAMIDE 4

BLEPHAMIDE S.O.P. 3

cyclopentolate hcl ophthalmic

1

homatropaire 1

ISOPTO ATROPINE 4

MITOSOL 4

PRED-G 4

PRED-G S.O.P. 4

proparacaine hcl ophthalmic

2

sulfacetamide-prednisolone ophthalmic solution

1

tetracaine hcl ophthalmic 2

ZYLET 4


42

Drug NameDrug Tier


Ophthalmic Anti-allergy Agents

altafrin 1

azelastine hcl ophthalmic 1

CYCLOMYDRIL 4

phenylephrine hcl ophthalmic

1

Ophthalmic Antiglaucoma Agents

betaxolol hcl ophthalmic 2

brimonidine tartrate ophthalmic solution 0.15 %

3 QL

brimonidine tartrate ophthalmic solution 0.2 %

3

COMBIGAN 3 QL

dorzolamide hcl ophthalmic

1

dorzolamide hcl-timolol mal

2

levobunolol hcl 1

pilocarpine hcl ophthalmic

1

SIMBRINZA 4 QL

timolol maleate ophthalmic gel forming solution

3

timolol maleate ophthalmic solution

1

TIMOPTIC OCUDOSE 3

Ophthalmic Anti-inflammatories

diclofenac sodium ophthalmic

1

fluorometholone 2

flurbiprofen sodium 1

ketorolac tromethamine ophthalmic

2

Drug NameDrug Tier


LOTEMAX OPHTHALMIC OINTMENT

4

LOTEMAX SM 4 QL

loteprednol etabonate 4 QL

Ophthalmic Prostaglandin and Prostamide Analogs

latanoprost ophthalmic 1

Quinolones

ciprofloxacin hcl ophthalmic

1

levofloxacin ophthalmic 2

moxifloxacin hcl (2x day) 2

moxifloxacin hcl ophthalmic

2

ofloxacin ophthalmic 1

Sulfonamides

sulfacetamide sodium ophthalmic ointment

2

sulfacetamide sodium ophthalmic solution

1

Otic Agents

acetic acid otic 1

ciprofloxacin hcl otic 3

cortic-nd 2

exotic-hc 2

flac 3

fluocinolone acetonide otic

3

hydrocortisone-acetic acid

3

neomycin-polymyxin-hc otic

2

ofloxacin otic 2


43

Drug NameDrug Tier


Respiratory Tract/Pulmonary Agents

Antihistamines

azelastine hcl nasal solution 0.1 %, 137 mcg/spray

2

clemastine fumarate oral tablet 2.68 mg

2

cyproheptadine hcl oral 1

promethazine hcl oral 1

promethazine hcl rectal 3

promethazine-phenylephrine

2

promethegan 3

Anti-inflammatories, Inhaled Corticosteroids

ARNUITY ELLIPTA 3 QL

BEVESPI AEROSPHERE

3 QL

BREO ELLIPTA 4 QL

budesonide inhalation 3 QL

BUDESONIDE-FORMOTEROL FUMARATE

4 QL

FLOVENT DISKUS 3 QL

FLOVENT HFA 3 QL

flunisolide nasal 2

fluticasone propionate nasal

1 QL

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

3 QL

Drug NameDrug Tier


FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT

3 QL

PULMICORT FLEXHALER

3 QL

SYMBICORT 4 QL

wixela inhub 3 QL

Antileukotrienes

montelukast sodium oral packet

2 QL

montelukast sodium oral tablet

1 QL

montelukast sodium oral tablet chewable

1 QL

Bronchodilators, Anticholinergic

ATROVENT HFA 4 QL

ipratropium bromide inhalation

1

ipratropium bromide nasal

2

SPIRIVA HANDIHALER 3 QL

SPIRIVA RESPIMAT 3 QL

Bronchodilators, Sympathomimetic

albuterol sulfate hfa 3 QL

albuterol sulfate inhalation

1

albuterol sulfate oral 3

epinephrine injection solution auto-injector 0.15 mg/0.3ml, 0.3 mg/0.3ml

4 QL

metaproterenol sulfate oral

3

STRIVERDI RESPIMAT 3 QL


44

Drug NameDrug Tier


SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE 0.15 MG/0.3ML

3 QL

terbutaline sulfate oral 4

VENTOLIN HFA 3 QL

Cystic Fibrosis Agents

CAYSTON 4 PA; QL

PULMOZYME 5 PA; QL

tobramycin nebulization solution 300 mg/5ml inhalation

4 PA; QL

Mast Cell Stabilizers

cromolyn sodium inhalation

3

Phosphodiesterase Inhibitors, Airways Disease

theophylline 3

theophylline er 2

Pulmonary Antihypertensives

ambrisentan 5 PA; QL

bosentan 5 PA; QL

ORENITRAM 4 PA; QL

sildenafil citrate oral suspension reconstituted

3 PA; QL

sildenafil citrate oral tablet 20 mg

3 PA; QL

TRACLEER 32 MG 5 PA; QL

TYVASO 5 PA; QL

TYVASO REFILL 5 PA; QL

TYVASO STARTER 5 PA; QL

VENTAVIS 5 PA; QL

Pulmonary Fibrosis Agents

ESBRIET 4 PA; QL

Respiratory Tract Agents, Other

acetylcysteine inhalation 2

Drug NameDrug Tier


ADRENALIN NASAL 3

benzonatate oral capsule 100 mg, 200 mg

1

bromfed dm 1

epinephrine hcl (nasal) 3

GILPHEX TR 4

GILTUSS TR 4

guaiatussin ac 1 QL

guaifenesin ac 1 QL

hydrocodone-homatropine

1 PA; QL

hydromet 1 PA; QL

HYPERSAL 3

maxi-tuss ac 1 QL

promethazine-codeine 2 PA; QL

promethazine-dm 1

promethazine-phenyleph-codeine

2 PA; QL

pseudoephedrine-bromphen-dm

1

sodium chloride inhalation

2

virtussin ac w/alc 1 QL

Skeletal Muscle Relaxants

baclofen oral 1

cyclobenzaprine hcl oral 1

metaxalone oral tablet 400 mg

3

methocarbamol oral 1

tizanidine hcl oral capsule

3

tizanidine hcl oral tablet 1

Sleep Disorder Agents

GABA Receptor Modulators

temazepam 1 QL

zolpidem tartrate oral 1 QL


45

Drug NameDrug Tier


Sleep Disorders, Other

armodafinil 2 PA; QL

doxepin hcl oral tablet 1 QL


46

Index of Drugs

abacavir sulfate...................18abacavir sulfate-lamivudine 18abacavir-lamivudine-zidovudine...........................18abiraterone acetate.............15acamprosate calcium..........10acarbose............................. 21ACCU-CHEK AVIVA CONNECT KIT W/DEVICE.20ACCU-CHEK AVIVA DEVICE.............................. 20ACCU-CHEK AVIVA PLUS KIT W/DEVICE................... 20ACCU-CHEK COMPACT PLUS CARE KIT.................20ACCU-CHEK COMPACT PLUS CONTROL................20ACCU-CHEK COMPACT PLUS TEST STRIPS.......... 20ACCU-CHEK FASTCLIX LANCET KIT....................... 20ACCU-CHEK GUIDE CONTROL.......................... 20ACCU-CHEK GUIDE KIT W/DEVICE.......................... 20ACCU-CHEK MULTICLIX LANCET DEVICE KIT.........20ACCU-CHEK NANO SMARTVIEW KIT W/DEVICE.......................... 20ACCU-CHEK SMARTVIEW CONTROL... 20ACCU-CHEK SMARTVIEW TEST STRIPS...............................20ACCU-CHEK SOFTCLIX LANCET DEVICE KIT.........20acetaminophen-codeine....... 9acetaminophen-codeine #2.. 9acetaminophen-codeine #3.. 9acetaminophen-codeine #4.. 9acetazolamide.....................24acetazolamide er................ 24acetic acid...........................43acetylcysteine..................... 45acitretin............................... 25ACTEMRA.......................... 39ACTEMRA ACTPEN...........39ACTHIB...............................39acyclovir..............................18ADACEL............................. 39ADASUVE...........................17adefovir dipivoxil ................. 18

ADRENALIN....................... 45adult aspirin regimen............ 8afirmelle.............................. 33AFLURIA QUADRIVALENT................39ak-poly-bac......................... 42AKTEN................................42ALA SCALP........................ 31ala-cort................................31albuterol sulfate.................. 44albuterol sulfate hfa............ 44alclometasone dipropionate........................ 31ALCOHOL PREP PADS..... 41ALDACTAZIDE................... 23alendronate sodium............ 41ALFERON N....................... 39allopurinol........................... 15alprazolam.......................... 19altacaine............................. 42altafrin................................. 43altavera............................... 33alyacen 1/35....................... 33alyacen 7/7/7...................... 33amabelz.............................. 33amantadine hcl................... 17ambrisentan........................ 45amethia lo........................... 33amiloride hcl........................24amiloride-hydrochlorothiazide.............24aminobenzoate potassium..28aminocaproic acid...............22amiodarone hcl................... 23amitriptyline hcl................... 14amlodipine besylate............ 23amlodipine besylate-benazepril hcl......................22amlodipine besylate-valsartan............................. 22amoxicillin........................... 11amoxicillin-potassium clavulanate..........................11amphetamine-dextroamphetamine............ 25amphetamine-dextroamphetamine er........25ampicillin............................. 11anagrelide hcl..................... 22ANALPRAM-HC..................41anastrozole......................... 16ANDRODERM.................... 33ANGELIQ............................33

anucort-hc...........................41aprepitant............................14apri......................................33APTIVUS............................ 19aranelle............................... 33aripiprazole......................... 17armodafinil .......................... 46ARMOUR THYROID...........38ARNUITY ELLIPTA.............44ARTISS...............................41arzol silver nit applicators... 25ascomp-codeine................... 9aspirin................................... 8aspirin adult low strength...... 8aspirin childrens....................8aspirin ec low dose............... 8aspirin ec low strength.......... 8aspirin low dose.................... 8aspirin-dipyridamole er....... 22ASTRINGYN.......................41ATABEX OB....................... 28atazanavir sulfate................19atenolol............................... 23atenolol-chlorthalidone........23atomoxetine hcl...................25atorvastatin calcium............ 24atovaquone......................... 17atovaquone-proguanil hcl... 17atropine sulfate................... 42ATROVENT HFA................ 44aubra...................................33aubra eq..............................33aurovela 1.5/30................... 33aurovela 24 fe..................... 34aurovela fe 1.5/30............... 34aurovela fe 1/20.................. 34AURYXIA............................ 28AUTOLET II CLINISAFE.....20AUTOLET LANCING DEVICE.............................. 20avar cleanser...................... 25aviane................................. 34avidoxy................................12AVONEX PEN.................... 25AVONEX PREFILLED........ 25ayuna.................................. 34azathioprine........................ 39azelaic acid......................... 25azelastine hcl................ 43, 44azithromycin........................11azurette...............................34bacitracin............................ 42bacitracin-polymyxin b........ 42

47

bacitra-neomycin-polymyxin-hc.......................42baclofen.............................. 45balsalazide disodium.......... 40balziva.................................34BAYER ASPIRIN EC LOW DOSE....................................8bekyree............................... 34belladonna alkaloids-opium 29benazepril hcl......................22benazepril-hydrochlorothiazide.............23BENZOIN............................41benzonatate........................ 45benzoyl peroxide-erythromycin....................... 25benztropine mesylate..........17BERINERT..........................39BETADINE OPHTHALMIC PREP.................................. 42betamethasone dipropionate........................ 32betamethasone dipropionate aug................. 31betamethasone valerate..... 32BETASERON......................25betaxolol hcl........................43bethanechol chloride...........31BEVESPI AEROSPHERE.. 44BEXSERO.......................... 39bicalutamide........................15BIDIL...................................24BIO-STATIN........................14bisacodyl ec........................ 30bisoprolol fumarate............. 23bisoprolol-hydrochlorothiazide.............23BLEPHAMIDE.....................42BLEPHAMIDE S.O.P.......... 42blisovi 24 fe.........................34blisovi fe 1.5/30...................34blisovi fe 1/20......................34BOOSTRIX......................... 39bosentan............................. 45BOSULIF............................ 16bp 10-1................................25bp cleansing wash.............. 25BREO ELLIPTA.................. 44briellyn................................ 34BRILINTA............................22brimonidine tartrate.............43bromfed dm.........................45bromocriptine mesylate.......17

budesonide................... 41, 44BUDESONIDE-FORMOTEROL FUMARATE........................ 44bumetanide......................... 24buprenorphine hcl............... 10buprenorphine hcl-naloxone hcl........................10bupropion hcl...................... 13bupropion hcl er (smoking det)......................................10bupropion hcl er (sr)............13bupropion hcl er (xl)............ 13buspirone hcl...................... 19butalbital-acetaminophen......8butalbital-apap-caffeine........ 8butalbital-asa-caff-codeine....9butalbital-aspirin-caffeine......8butorphanol tartrate.............. 9BYDUREON....................... 21BYDUREON BCISE AUTOINJECTOR................21cabergoline......................... 33caffeine citrate.................... 25calcipotriene........................26calcitonin (salmon)..............41calcitriol.........................26, 41calcium acetate...................28calcium acetate (phos binder).................................28camila................................. 37camrese lo.......................... 34candesartan cilexetil-hctz... 22capecitabine........................16CAPEX................................32CAPRELSA.........................16captopril-hydrochlorothiazide.............23carbamazepine................... 13carbamazepine er............... 13carbidopa-levodopa............ 17carbidopa-levodopa er........ 17carbidopa-levodopa-entacapone......................... 17CARETOUCH CONTROL SOL LEVEL 2..................... 20CARETOUCH LANCING/EJECTOR.......... 20carisoprodol-aspirin-codeine................................. 9CAROSPIR......................... 24cartia xt............................... 23carvedilol.............................23

CAYA.................................. 41CAYSTON.......................... 45caziant................................ 34cefdinir................................ 11cefuroxime axetil .................11CELONTIN..........................12cephalexin...........................11CEQUR SIMPLICITY 2U.... 20cerovel................................ 26CHANTIX............................ 10CHANTIX CONTINUING MONTH PAK...................... 10CHANTIX STARTING MONTH PAK...................... 10chateal................................ 34chateal eq........................... 34CHEMET.............................28chlordiazepoxide hcl........... 19chlordiazepoxide-amitriptyline.........................13chlorhexidine gluconate...... 25chloroquine phosphate....... 17chlorpromazine hcl..............17chlorthalidone..................... 24cholestyramine....................24cholestyramine light............ 24cimetidine............................29cimetidine hcl...................... 29CIMZIA................................39CIMZIA PREFILLED KIT.... 39CIMZIA STARTER KIT....... 39CIPRO................................ 12ciprofloxacin hcl............ 12, 43citalopram hydrobromide.... 13CITRANATAL BLOOM....... 28CITRANATAL MEDLEY......28citroma................................ 30clarithromycin......................11clarithromycin er................. 11clearlax............................... 30clemastine fumarate........... 44CLIMARA PRO................... 34clindacin etz........................ 26clindacin-p...........................26clindamycin hcl................... 11clindamycin palmitate hcl....11clindamycin phosphate. 11, 26clindamycin phosphate-benzoyl peroxide.................26CLINDESSE....................... 11clobetasol prop emollient base.................................... 32clobetasol propionate..........32

48

clobetasol propionate e.......32clonazepam........................ 19clonidine hcl........................ 22clopidogrel bisulfate............ 22clotrimazole.........................14clotrimazole-betamethasone................... 14clozapine.............................18COAL TAR..........................26codeine sulfate......................9colesevelam hcl.................. 24COMBIGAN........................ 43COMBIPATCH....................34COMPLERA........................18compro................................14constulose...........................30CONTOUR CONTROL....... 20CONTOUR NEXT CONTROL.......................... 20cortic-nd.............................. 43CORTIFOAM...................... 41cortisone acetate................ 32COTELLIC.......................... 16covaryx............................... 34covaryx hs...........................34CRIXIVAN...........................19cromolyn sodium...........29, 45cryselle-28.......................... 34cyclafem 1/35......................34cyclafem 7/7/7.....................34cyclobenzaprine hcl............ 45CYCLOMYDRIL..................43cyclopentolate hcl............... 42cyclophosphamide.............. 15cyclosporine........................39cyclosporine modified......... 39cyproheptadine hcl..............44cyred................................... 34cyred eq.............................. 34CYSTAGON........................31cytra k crystals.................... 27dalfampridine er.................. 25danazol............................... 33dapsone.............................. 15dasetta 1/35........................ 34dasetta 7/7/7....................... 34DEBACTEROL................... 25deblitane............................. 37deferasirox.......................... 28delyla.................................. 34DEPO-ESTRADIOL............ 34DEPO-SUBQ PROVERA 104......................................37

dermazene..........................14desipramine hcl...................14desmopressin acetate.........33desmopressin acetate spray................................... 33desogestrel-ethinyl estradiol.............................. 34desonide............................. 32desoximetasone..................32dexamethasone.................. 32dexamethasone intensol.....32dextroamphetamine sulfate 25dextroamphetamine sulfate er.........................................25diazepam...................... 12, 19diazepam intensol...............19diazoxide.............................21diclofenac sodium............... 43diclofenac-misoprostol.......... 8dicloxacillin sodium............. 11dicyclomine hcl................... 29didanosine.......................... 18digitek................................. 24digox................................... 24digoxin................................ 24dihydroergotamine mesylate............................. 15DILANTIN........................... 13diltiazem hcl........................ 23diltiazem hcl er....................23diltiazem hcl er beads......... 23diltiazem hcl er coated beads.................................. 23dilt-xr................................... 23diphenoxylate-atropine....... 29dipyridamole....................... 22disopyramide phosphate.....23disulfiram............................ 10DIURIL................................ 24divalproex sodium...............20divalproex sodium er...........20dofetilide............................. 23donepezil hcl.......................13dorzolamide hcl...................43dorzolamide hcl-timolol mal 43doxazosin mesylate............ 22doxepin hcl....................14, 46doxycycline hyclate.............12doxycycline monohydrate... 12dronabinol........................... 14drospirenone-ethinyl estradiol.............................. 34DROXIA.............................. 16

duloxetine hcl......................25E.E.S. GRANULES.............11EASYMAX 15 LEVEL 2-3 CONTROL.......................... 20EASYMAX CONTROL........20EASYMAX CONTROL NORMAL/HIGH.................. 20EDARBYCLOR................... 22ed-spaz............................... 29EDURANT.......................... 18eemt....................................34eemt hs............................... 34efavirenz............................. 18EFFER-K............................ 27effer-k..................................27elinest................................. 34ELITE-OB........................... 28ELLA................................... 37ELMIRON........................... 31eluryng................................ 34EMCYT............................... 16EMEND...............................14emoquette...........................34enalapril-hydrochlorothiazide.............23ENBRACE HR.................... 28endocet................................. 9ENGERIX-B........................ 39enpresse-28........................34enskyce...............................34entacapone......................... 17entecavir............................. 18ENTEREG.......................... 29ENTRESTO........................ 24enulose............................... 30EPIFOAM............................26epinephrine......................... 44epinephrine hcl (nasal)....... 45epitol................................... 13ergocalciferol...................... 28ergoloid mesylates..............41ergotamine-caffeine............ 15erlotinib hcl..........................16errin.....................................37ery.......................................26ERYPED 200...................... 11ERYTHROCIN STEARATE.........................11erythromycin........... 11, 26, 42erythromycin base.............. 11erythromycin ethylsuccinate..................... 11ESBRIET............................ 45

49

escitalopram oxalate...........13est estrogens-methyltest.....34est estrogens-methyltest ds........................................ 34est estrogens-methyltest hs........................................ 34estarylla.............................. 34estradiol.............................. 34estradiol valerate................ 35estradiol-norethindrone acet..................................... 35ethambutol hcl.................... 15ethosuximide.......................12ethynodiol diac-eth estradiol.............................. 35etodolac................................ 8etonogestrel-ethinyl estradiol.............................. 35etoposide............................ 16euthyrox.............................. 38everolimus.......................... 16exemestane........................ 16EX-LAX ULTRA.................. 30exoderm..............................14exotic-hc............................. 43falmina................................ 35famciclovir...........................18famotidine........................... 29FANAPT..............................17FANAPT TITRATION PACK.................................. 17felbamate............................ 12felodipine er........................ 23femynor...............................35fenofibrate...........................24fentanyl................................. 9finasteride........................... 31flac...................................... 43flecainide acetate................23FLORIVA............................ 27FLOVENT DISKUS.............44FLOVENT HFA................... 44FLUAD................................ 39FLUAD QUADRIVALENT... 39FLUARIX QUADRIVALENT................39FLUCELVAX QUADRIVALENT................40fluconazole..........................14flucytosine...........................14fludrocortisone acetate....... 32FLULAVAL QUADRIVALENT................40

FLUMIST QUADRIVALENT................40flunisolide............................44fluocinolone acetonide.. 32, 43fluocinolone acetonide body.................................... 32fluocinolone acetonide scalp................................... 32fluocinonide.........................32fluocinonide emulsified base.................................... 32FLUORABON..................... 27fluoritab............................... 27fluorometholone.................. 43FLUOROURACIL................16fluorouracil .......................... 16fluoxetine hcl.......................14fluoxetine hcl (pmdd).......... 14fluphenazine hcl..................17FLURA-DROPS.................. 27flurandrenolide.................... 32flurbiprofen sodium............. 43flutamide............................. 15fluticasone propionate.........44fluticasone-salmeterol.........44FLUTICASONE-SALMETEROL....................44fluvoxamine maleate er.......14FLUZONE QUADRIVALENT................40folic acid..............................28fondaparinux sodium.......... 22FORTISCARE CONTROL.. 20FOSAMAX PLUS D............ 41fosamprenavir calcium........19fosinopril sodium-hctz......... 23furosemide.......................... 24fyavolv.................................35gabapentin.......................... 12galantamine hydrobromide. 13galantamine hydrobromide er.........................................13GALZIN...............................27GARDASIL 9.......................40GATTEX............................. 29gavilax.................................30gavilyte-c.............................30gavilyte-g............................ 30gavilyte-h............................ 30gavilyte-n with flavor pack...30gemfibrozil .......................... 24generlac.............................. 30gengraf................................39

gentak................................. 42gentamicin sulfate.........10, 42gentle laxative.....................30GENVOYA.......................... 18gianvi.................................. 35GILPHEX TR...................... 45GILTUSS TR.......................45glatiramer acetate............... 25glatopa................................ 25GLEOSTINE....................... 15glimepiride.......................... 21glipizide er...........................21glipizide ir............................21glipizide xl........................... 21GLUCAGEN HYPOKIT.......21GLUCAGON EMERGENCY KIT.............. 21glycolax...............................30glycopyrrolate..................... 29gnp aspirin low dose............. 8GOLYTELY.........................30goodsense aspirin low dose...................................... 8GORDOFILM...................... 26grafco silver nit applicator... 26griseofulvin microsize......... 14griseofulvin ultramicrosize.. 14guaiatussin ac.....................45guaifenesin ac.....................45hailey 1.5/30....................... 35hailey 24 fe......................... 35hailey fe 1.5/30................... 35hailey fe 1/20...................... 35halobetasol propionate....... 32haloperidol.......................... 17haloperidol lactate...............17HAVRIX.............................. 40heather................................37hematinic/folic acid............. 27hemmorex-hc......................41hemocyte-f.......................... 27hemorrhoidal-hc..................41heparin sodium (porcine).... 22heparin sodium (porcine) pf.........................................22HEPLISAV-B.......................40HIBERIX............................. 40homatropaire.......................42HUMALOG KWIKPEN........ 21HUMALOG MIX 50/50 KWIKPEN........................... 21HUMALOG MIX 50/50 VIAL.................................... 21

50

HUMALOG MIX 75/25 KWIKPEN........................... 21HUMALOG MIX 75/25 VIAL.................................... 21HUMALOG U-100 JUNIOR KWIKPEN........................... 21HUMALOG VIAL.................21HUMIRA..............................39HUMIRA PEDIATRIC CROHNS START............... 39HUMIRA PEN..................... 39HUMIRA PEN-CD/UC/HS STARTER........................... 39HUMIRA PEN-PS/UV/ADOL HS START... 39HUMULIN 70/30 KWIKPEN........................... 21HUMULIN 70/30 VIAL.........21HUMULIN N KWIKPEN...... 21HUMULIN N VIAL............... 21HUMULIN R U-500 KWIKPEN........................... 21HUMULIN R U-500 VIAL.... 21HUMULIN R VIAL............... 21hydralazine hcl....................24hydrochlorothiazide.............24hydrocodone bitartrate er......9hydrocodone-acetaminophen..................... 9hydrocodone-homatropine..45hydrocortisone.............. 32, 41hydrocortisone (perianal).... 41hydrocortisone ace-pramoxine..................... 26, 41hydrocortisone acetate....... 41hydrocortisone butyrate...... 32hydrocortisone valerate...... 32hydrocortisone-acetic acid.. 43hydrocortisone-iodoquinol...15hydrocort-pramoxine (perianal).............................41hydromet.............................45hydromorphone hcl............... 9hydroxychloroquine sulfate. 17hydroxyurea........................ 16hydroxyzine hcl................... 19hyophen.............................. 31hyoscyamine sulfate........... 29hyoscyamine sulfate er....... 29hyoscyamine sulfate sl........29hyosyne.............................. 29HYPERSAL.........................45IBRANCE............................16

ibu......................................... 8ibuprofen...............................8imatinib mesylate................ 16IMBRUVICA........................16imipramine hcl.....................14imipramine pamoate........... 14imiquimod........................... 26IMPAVIDO.......................... 17incassia...............................37INCRELEX..........................33INDOCIN...............................8indomethacin........................ 8INOVA 4/1 ACNE CONTROL THERAPY........ 26INOVA 8/2 ACNE CONTROL THERAPY........ 26INSULIN ASPART PROT & ASPART.......................... 22INSULIN LISPRO............... 22INSULIN LISPRO (1 UNIT DIAL)...................................22INSULIN LISPRO JUNIOR KWIKPEN........................... 22INSULIN LISPRO PROT & LISPRO...............................22INSULIN PEN NEEDLES... 41INSULIN SYRINGES.......... 41INTELENCE........................18INTRON A...........................18introvale.............................. 35INVIRASE........................... 19INVOKANA......................... 21IPOL....................................40ipratropium bromide............44irbesartan-hydrochlorothiazide.............22ISENTRESS....................... 18ISENTRESS HD................. 18isibloom...............................35isoniazid..............................15ISOPTO ATROPINE...........42isosorbide dinitrate..............25isosorbide mononitrate....... 25isosorbide mononitrate er... 25isotretinoin.......................... 26isoxsuprine hcl.................... 24ivermectin........................... 17jantoven.............................. 22JARDIANCE....................... 21jasmiel.................................35jencycla...............................37jinteli ....................................35jolessa.................................35

juleber................................. 35junel 1.5/30......................... 35junel fe 1.5/30..................... 35junel fe 1/20........................ 35junel fe 24........................... 35KALETRA........................... 19kalliga..................................35kariva.................................. 35kelnor 1/35.......................... 35kelnor 1/50.......................... 35ketoconazole.......................15ketorolac tromethamine.. 8, 43kionex................................. 28klor-con............................... 27klor-con 10.......................... 27klor-con m10....................... 27KLOR-CON M15.................27klor-con m20....................... 27klor-con sprinkle..................27klor-con/ef........................... 27K-PHOS.............................. 27K-PHOS NO 2.....................27K-PHOS-NEUTRAL............ 27k-prime................................27kurvelo................................ 35KYLEENA........................... 37labetalol hcl.........................23lactulose..............................30lactulose encephalopathy... 30LAMICTAL ODT..................12lamivudine.....................18, 19lamivudine-zidovudine........ 19lamotrigine.......................... 12lamotrigine starter kit-blue.. 12lamotrigine starter kit-green...................................12lamotrigine starter kit-orange.................................12LANCETS........................... 20larin 1.5/30.......................... 35larin 24 fe............................ 35larin fe 1.5/30...................... 35larin fe 1/20......................... 35larissia.................................35latanoprost.......................... 43LATUDA..............................18leena................................... 35leflunomide......................... 39lessina.................................35letrozole.............................. 16leucovorin calcium.............. 16LEUKERAN........................ 15leuprolide acetate............... 38

51

levetiracetam...................... 12levetiracetam er.................. 12levobunolol hcl.................... 43levocarnitine........................27levocarnitine sf....................27levofloxacin................... 12, 43levonest.............................. 35levonorgest-eth estrad 91-day...................................... 35levonorgestrel..................... 37levonorgestrel-ethinyl estrad..................................35levonorg-eth estrad triphasic.............................. 35levora 0.15/30 (28)..............35levo-t................................... 38levothyroxine sodium.......... 38levoxyl.................................38LEXIVA............................... 19lidocaine..............................10lidocaine hcl........................ 10lidocaine hcl urethral/mucosal................. 10lidocaine viscous hcl........... 10lidocaine-prilocaine............. 10lillow.................................... 35linezolid...............................11LINZESS.............................29liothyronine sodium.............38lisinopril ...............................23lisinopril-hydrochlorothiazide.............23lithium................................. 20lithium carbonate................ 20lithium carbonate er............ 20LITHOSTAT........................ 31lojaimiess............................ 36loperamide hcl.................... 29lopinavir-ritonavir................ 19lorazepam........................... 20lorazepam intensol..............19LORTAB............................... 9loryna.................................. 36losartan potassium..............22losartan potassium-hctz......22LOTEMAX...........................43LOTEMAX SM.................... 43loteprednol etabonate......... 43lovastatin.............................24low-ogestrel........................ 36loxapine succinate.............. 17lo-zumandimine.................. 36lutera...................................36

LYSODREN........................ 38lyza..................................... 37MAGNEBIND 400............... 27magnesium citrate.............. 30marlissa.............................. 36matzim la............................ 23MAVYRET.......................... 18MAXICOMFORT SYR 27G X 1/2".................................. 41maxi-tuss ac........................45MEDI-DERM-RX.................10MEDROX-RX......................10medroxyprogesterone acetate.......................... 37, 38mefloquine hcl.....................17megestrol acetate............... 38meloxicam.............................8melphalan........................... 15memantine hcl.................... 13MENACTRA........................40MENQUADFI...................... 40MENVEO............................ 40mercaptopurine...................16mesalamine........................ 41mesalamine er.................... 40metaproterenol sulfate........ 44metaxalone......................... 45metformin hcl er.................. 21metformin hcl ir ................... 21methadone hcl...................... 9methadone hcl intensol.........9methadose............................ 9methadose sugar-free...........9methazolamide................... 24methenamine mandelate.... 11methergine..........................41methimazole....................... 38METHITEST....................... 33methocarbamol................... 45methotrexate.......................39methotrexate sodium.......... 39methyldopa......................... 22methyldopa-hydrochlorothiazide.............22methylergonovine maleate..41methylphenidate hcl............25methylprednisolone.............32methyltestosterone............. 33metoclopramide hcl.............14metolazone......................... 24metoprolol succinate er.......23metoprolol tartrate...............23metronidazole............... 11, 26

MIACALCIN........................ 41miconazole 3.......................15microgestin 1.5/30.............. 36microgestin fe 1.5/30.......... 36microgestin fe 1/20............. 36MICROLET NEXT LANCING DEVICE............. 20midodrine hcl...................... 22MIGERGOT........................ 15mili ...................................... 36mimvey............................... 36minitran............................... 25minocycline hcl................... 12minoxidil ..............................25mirtazapine......................... 13misoprostol......................... 31MITIGARE.......................... 15MITOSOL............................42M-M-R II..............................40M-NATAL PLUS..................28molindone hcl......................17mometasone furoate...........32mondoxyne nl..................... 12mono-linyah........................ 36monsels ferric subsulfate.... 41montelukast sodium............44morphine sulfate................... 9morphine sulfate (concentrate).........................9morphine sulfate er............... 9moxifloxacin hcl............ 12, 43moxifloxacin hcl (2x day).... 43MOZOBIL............................22mupirocin............................ 11mupirocin calcium............... 11mycophenolate mofetil ........39mycophenolate sodium.......39MYLERAN.......................... 15n-acetyl-l-cysteine...............41nafrinse............................... 28nafrinse drops..................... 28naloxone hcl........................10naltrexone hcl..................... 10naproxen...............................8naratriptan hcl..................... 15NARCAN.............................10NATAZIA.............................36NATPARA...........................41NATURE-THROID.............. 38necon 0.5/35 (28)................36neomycin sulfate.................10neomycin-bacitracin zn-polymyx...............................42

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neomycin-polymyxin-dexameth............................ 42neomycin-polymyxin-gramicidin........................... 42neomycin-polymyxin-hc 42, 43NEONATAL COMPLETE....28NEONATAL PLUS.............. 28neo-polycin......................... 42neo-polycin hc.....................42NESTABS........................... 28nevirapine........................... 18NEXAVAR...........................16NEXPLANON......................38NICORETTE....................... 10nicotine polacrilex............... 10nicotine step 1.....................10nicotine step 2.....................10nicotine step 3.....................10NICOTROL......................... 10NICOTROL NS................... 10nikki.....................................36nilutamide........................... 15nimodipine.......................... 23NITRO-BID......................... 25NITRO-DUR........................25nitrofurantoin.......................11nitrofurantoin macrocrystal. 11nitrofurantoin monohydrate macrocrystals......................11nitroglycerin........................ 25NITROMIST........................ 25nitro-time.............................25nora-be............................... 38norethin ace-eth estrad-fe...36norethindrone......................38norethindrone acetate.........38norethindrone acet-ethinyl est....................................... 36norethindrone-eth estradiol.36norgestimate-eth estradiol.. 36norgestimate-ethinyl estradiol triphasic................36norlyda................................ 38norlyroc............................... 38NORPACE CR....................23nortrel 0.5/35 (28)............... 36nortrel 1/35 (21).................. 36nortrel 1/35 (28).................. 36nortrel 7/7/7.........................36nortriptyline hcl....................14NORVIR..............................19NOVOFINE AUTOCOVER PEN NEEDLE..................... 41

NOVOFINE PEN NEEDLE. 41NOVOFINE PLUS PEN NEEDLE............................. 41NOVOPEN ECHO.............. 20NOVOTWIST PEN NEEDLE............................. 41np thyroid............................ 38NUCORT............................ 32nyamyc............................... 15NYMALIZE..........................23nystatin............................... 15nystop................................. 15ocella.................................. 36octreotide acetate............... 38ODEFSEY...........................18ofloxacin..............................43olanzapine.......................... 18olanzapine-fluoxetine hcl.... 13omeprazole......................... 31ondansetron hcl.................. 14ondansetron odt..................14ONE VITE WOMENS PLUS.................................. 28ONETOUCH DELICA LANCING DEV................... 20ONETOUCH DELICA PLUS LANCING................. 20ONETOUCH ULTRA.......... 20ONETOUCH ULTRA 2 KIT W/DEVICE.......................... 20ONETOUCH ULTRA MINI KIT W/DEVICE................... 21ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE....21ONETOUCH VERIO IQ SYSTEM............................. 21ONETOUCH VERIO KIT W/DEVICE.......................... 21ONETOUCH VERIO REFLECT........................... 21ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE.......................... 21ONEVITE............................ 28ONGLYZA...........................21opium.................................. 29OPTIONS CONCEPTROL..31ORACIT.............................. 28oralone................................25ORENITRAM...................... 45orsythia............................... 36oscimin................................29oscimin sr............................29

oseltamivir phosphate.........19OSPHENA.......................... 38oxandrolone........................ 33oxazepam........................... 20oxcarbazepine.................... 13oxybutynin chloride............. 31oxybutynin chloride er.........31oxycodone hcl.......................9oxycodone-acetaminophen...9oxycodone-aspirin...............10pacerone.............................23paliperidone er.................... 18pantoprazole sodium.......... 31PARAGARD INTRAUTERINE COPPER. 41paricalcitol...........................41paroex.................................25paroxetine hcl..................... 14PEDVAX HIB...................... 40peg 3350-kcl-na bicarb-nacl..................................... 30peg-3350/electrolytes......... 30PEGASYS...........................18PEGASYS PROCLICK....... 18peg-prep............................. 31penicillin v potassium..........11pentamidine isethionate......17pentazocine-naloxone hcl... 10pentoxifylline er...................24periogard.............................25permethrin...........................17perphenazine...................... 14perphenazine-amitriptyline..13phenazo.............................. 31phenazopyridine hcl............31phenelzine sulfate...............13phenobarbital...................... 12phenoxybenzamine hcl....... 22phenylephrine hcl................43phenytoin............................ 13phenytoin infatabs...............13phenytoin sodium extended............................. 13philith.................................. 36phospha 250 neutral........... 28phosphorous....................... 28phospho-trin 250 neutral.....28phytonadione...................... 28pilocarpine hcl.....................43pimozide............................. 17pimtrea................................36pioglitazone hcl................... 21pirmella 1/35....................... 36

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pirmella 7/7/7...................... 36PLAN B ONE-STEP............38PNEUMOVAX 23................40podocon.............................. 26podofilox............................. 26polycin.................................42polymyxin b-trimethoprim....42portia-28..............................36posaconazole......................15pot bicarb-pot chloride........ 28potassium bicarbonate........28potassium chloride..............28potassium chloride crys er.. 28potassium chloride er..........28potassium citrate er............ 28potassium citrate-citric acid 28POVIDONE-IODINE........... 42PRADAXA...........................22pramipexole dihydrochloride................... 17pramosone..........................26PRAMOSONE.................... 26pramox................................26prasugrel hcl....................... 22pravastatin sodium..............24praziquantel........................ 17prazosin hcl.........................22PRED-G..............................42PRED-G S.O.P................... 42prednisolone sodium phosphate........................... 33prednisone.......................... 33prednisone intensol.............33PREFEST........................... 36PREMESISRX.................... 28premium lidocaine...............10PREMPHASE..................... 36PRENAISSANCE................28prenatal...............................28prenatal plus iron................ 29PRENATE...........................29PRENATE DHA.................. 29PRENATE ELITE................29PRENATE ENHANCE........ 29PRENATE ESSENTIAL...... 29PRENATE MINI.................. 29PRENATE PIXIE.................29PRENATE RESTORE........ 29PRENATRIX....................... 29PREPIDIL........................... 33prevalite.............................. 24previfem.............................. 36PREVNAR 13..................... 40

PREZISTA.......................... 19PRIMACARE...................... 29primaquine phosphate........ 17primidone............................ 12probenecid.......................... 15prochlorperazine................. 14prochlorperazine maleate... 14PROCTOFOAM HC............41procto-med hc.....................41proctozone-hc..................... 41progesterone.......................38PROMACTA....................... 22promethazine hcl................ 44promethazine-codeine........ 45promethazine-dm................45promethazine-phenyleph-codeine............................... 45promethazine-phenylephrine..................... 44promethegan.......................44propafenone hcl.................. 23propafenone hcl er..............23propantheline bromide........ 29proparacaine hcl................. 42propranolol hcl.................... 23propranolol-hctz.................. 23propylthiouracil ....................38PROSTIN E2...................... 33protriptyline hcl....................14pseudoephedrine-bromphen-dm..................... 45PULMICORT FLEXHALER.44PULMOZYME..................... 45pyrazinamide...................... 15PYRIDIUM.......................... 31pyridostigmine bromide.......15pyridostigmine bromide er.. 15PYROGALLIC ACID........... 26qc aspirin low dose............... 8qc magnesium citrate..........31quetiapine fumarate............ 18quetiapine fumarate er........18quinapril-hydrochlorothiazide.............23quinidine gluconate er.........23quinidine sulfate..................23quinine sulfate.....................17raloxifene hcl.......................38reclipsen............................. 36RECOMBIVAX HB..............40RECOTHROM.................... 22RECOTHROM SPRAY KIT 22RELNATE DHA...................29

repaglinide.......................... 21RETACRIT..........................22REVLIMID...........................16REYATAZ........................... 19ribavirin............................... 18rifampin............................... 15riluzole................................ 25rimantadine hcl................... 19RINVOQ..............................39risperidone.......................... 18ritonavir............................... 19rizatriptan benzoate............ 15ropinirole hcl....................... 17rosadan...............................26rosuvastatin calcium........... 24roweepra.............................12roweepra xr.........................12salicylic acid........................26salsalate................................8SALVAX DUO PLUS.......... 26SANDIMMUNE................... 39SAPHRIS............................ 18SAVELLA TITRATION PACK.................................. 25SCALACORT DK................26scopolamine........................14selegiline hcl....................... 17selenium sulfide.................. 26sertraline hcl....................... 14setlakin................................36sevelamer carbonate.......... 28sevelamer hcl......................28sharobel.............................. 38SHINGRIX.......................... 40sildenafil citrate................... 45silver nitrate........................ 11silver sulfadiazine............... 11SIMBRINZA........................ 43simliya.................................36SIMPONI.............................39simvastatin..........................24sirolimus..............................39SKYRIZI (150 MG DOSE).. 39sod citrate-citric acid........... 28sodium chloride...................45sodium fluoride................... 28sodium polystyrene sulfonate............................. 28sodium sulfacetamide......... 26sodium sulfacetamide wash................................... 26SODIUM SULFACETAMIDE WASH..26

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SOFOSBUVIR-VELPATASVIR................... 18sotalol hcl............................23sotalol hcl (af)..................... 23SOTYLIZE.......................... 23SPIRIVA HANDIHALER..... 44SPIRIVA RESPIMAT.......... 44spironolactone.................... 24spironolactone-hctz.............24sprintec 28.......................... 36SPRYCEL........................... 17sps...................................... 28sronyx................................. 36ssd...................................... 11SSKI....................................41sss 10-5.............................. 26ST JOSEPH LOW DOSE..... 9stavudine............................ 19STRIBILD............................18STRIVERDI RESPIMAT..... 44subvenite............................ 12subvenite starter kit-blue.....12subvenite starter kit-green.. 12subvenite starter kit-orange 12SUCRAID............................31sucralfate............................ 31SULCONAZOLE NITRATE.15sulfacetamide sodium... 26, 43sulfacetamide sodium (acne)..................................26sulfacetamide sodium-sulfur............................. 26, 27sulfacetamide-prednisolone....................... 42sulfamethoxazole-trimethoprim........................12sulfamez wash.................... 27sulfasalazine....................... 41sulfatrim pediatric................12sulindac.................................9sumatriptan......................... 15sumatriptan succinate.........15sumatriptan succinate refill . 15SUMAXIN WASH................27SURESTEP PRO HIGH GLUCOSE.......................... 21SURESTEP PRO LOW GLUCOSE.......................... 21SURESTEP PRO NORMAL GLUCOSE..........21SUTENT............................. 17syeda.................................. 36symax-sl..............................29

symax-sr............................. 29SYMBICORT...................... 44SYMJEPI............................ 45SYNAREL........................... 38tacrolimus..................... 27, 39tamoxifen citrate................. 16tamsulosin hcl..................... 31tarina 24 fe..........................36tarina fe 1/20.......................36tarina fe 1/20 eq..................37taron-crystals...................... 28tazarotene...........................27TAZORAC...........................27taztia xt............................... 23telmisartan-hctz.................. 22temazepam......................... 45temozolomide..................... 15TENIVAC............................ 40tenofovir disoproxil fumarate..............................19terazosin hcl........................31terbinafine hcl..................... 15terbutaline sulfate............... 45testosterone........................ 33TESTOSTERONE CYPIONATE....................... 33testosterone cypionate........33testosterone enanthate....... 33tetrabenazine...................... 25tetracaine hcl...................... 42tetracycline hcl.................... 12TEXACORT........................ 33THALOMID......................... 16theophylline.........................45theophylline er.................... 45thioridazine hcl....................17thiothixene.......................... 17THROMBIN-JMI..................22THROMBIN-JMI EPISTAXIS......................... 22THROMBOGEN..................22tiadylt er.............................. 23tilia fe.................................. 37timolol maleate....................43TIMOPTIC OCUDOSE....... 43tinidazole.............................11TISSEEL............................. 41tizanidine hcl....................... 45tobramycin.................... 42, 45tobramycin-dexamethasone.................. 42tolterodine tartrate...............31

TOPEX TOPICAL ANESTHETIC..................... 25topiramate...........................13torsemide............................ 24TRACLEER.........................45TRADJENTA.......................21tramadol hcl ir ..................... 10tramadol-acetaminophen.... 10trandolapril-verapamil hcl er.........................................23tranexamic acid...................22tranylcypromine sulfate.......13trazodone hcl...................... 14tretinoin............................... 17tri femynor...........................37triamcinolone acetonide 25, 33triamterene..........................24triamterene-hctz..................24triazolam............................. 20TRICARE PRENATAL DHA ONE........................... 29TRI-CHLOR........................ 27tricitrates............................. 28triderm.................................33tri-estarylla.......................... 37trifluoperazine hcl................17trifluridine............................ 42trihexyphenidyl hcl.............. 17tri-legest fe.......................... 37tri-linyah.............................. 37tri-lo-estarylla...................... 37tri-lo-marzia.........................37tri-lo-mili .............................. 37tri-lo-sprintec....................... 37trilyte................................... 31trimethoprim........................11tri-mili .................................. 37trinate..................................29tri-previfem..........................37tri-sprintec........................... 37TRISTART ONE................. 29trivora (28).......................... 37tri-vylibra............................. 37tri-vylibra lo......................... 37TRUE METRIX LEVEL 1.... 21TRUE METRIX LEVEL 2.... 21TRUE METRIX LEVEL 3.... 21TRULICITY......................... 21TRUMENBA........................40TRUVADA...........................19tulana.................................. 38TWINRIX.............................40TWIRLA.............................. 37

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TYVASO............................. 45TYVASO REFILL................ 45TYVASO STARTER........... 45UCERIS.............................. 41UDAMIN SP........................29UNISTRIP CONTROL........ 21unithroid.............................. 38urea.....................................27urea nail .............................. 27urea-c40..............................27uremez-40...........................27URIMAR-T.......................... 31uro-mp................................ 31ursodiol............................... 29ustell ................................... 31uticap.................................. 31VALCHLOR........................ 15valganciclovir hcl.................18valproic acid........................12valsartan-hydrochlorothiazide.............22vancomycin hcl................... 11vandazole........................... 11VAQTA................................40VARIVAX............................ 40VCF VAGINAL CONTRACEPTIVE............. 31vcf vaginal contraceptive.... 31velivet..................................37venlafaxine hcl.................... 14venlafaxine hcl er................14VENTAVIS.......................... 45VENTOLIN HFA..................45verapamil hcl.......................23verapamil hcl er.................. 23vienva................................. 37vilamit mb............................31viorele................................. 37VIRACEPT..........................19virt-phos 250 neutral........... 28virtussin ac w/alc.................45VITAFOL FE+..................... 29VITAFOL STRIPS...............29VITAFOL-OB+DHA.............29vitamin d (ergocalciferol).....29VITATHELY WITH GINGER..............................29volnea................................. 37voriconazole........................15vp-pnv-dha..........................29vyfemla............................... 37vylibra................................. 37warfarin sodium.................. 22

wera.................................... 37WESTAB PLUS.................. 29WESTGEL DHA..................29WESTHROID......................38WIDE-SEAL DIAPHRAGM 60........................................42WIDE-SEAL DIAPHRAGM 65........................................42WIDE-SEAL DIAPHRAGM 70........................................42WIDE-SEAL DIAPHRAGM 75........................................42WIDE-SEAL DIAPHRAGM 80........................................42WIDE-SEAL DIAPHRAGM 85........................................42WIDE-SEAL DIAPHRAGM 90........................................42WIDE-SEAL DIAPHRAGM 95........................................42wixela inhub........................ 44WP THYROID.....................38XALKORI............................ 17XELJANZ............................ 39XELJANZ XR...................... 39xulane................................. 37yuvafem.............................. 37zarah...................................37ZARXIO.............................. 22ZELBORAF.........................17zidovudine...........................19ziprasidone hcl....................18zolpidem tartrate................. 45zonisamide..........................12zovia 1/35e (28).................. 37zumandimine...................... 37ZYKADIA............................ 17ZYLET.................................42ZYTIGA...............................16

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English If you need help in another language or you need another format, like large print, please call the member number on your health plan ID card, TTY / RTT 711. Translation services and interpreters are available at no cost to you. Español Si necesita ayuda en otro idioma o en otro formato, como letra grande, llame al número para miembros en su tarjeta de ID del plan de salud, TTY/RTT 711. Los servicios de traducción y de interpretación están disponibles sin costo para usted. 中文如果您需要以其他語言提供的協助，或您需要其他形式版本，例如大字體，請撥健保計劃會員卡上的會員電話，聽力語言殘障服務專線 / 即時訊息 (TTY / RTT) 711。可免費向您提供翻譯服務和口譯員服務。 Tiếng Việt Nếu quý vị cần trợ giúp bằng ngôn ngữ khác hoặc quý vị cần định dạng khác, như bản in cỡ lớn, vui lòng gọi đê n số điê n thoa i danh cho hôi viên trên thẻ ID chương tri nh hiêm y tê cu a quy vi , TTY/RTT 711. Có sẵn các dịch vụ dịch thuật và thông dịch viên miễn phí cho quý vị. 한국어 귀하가 다른 언어로 도움이 필요하거나 큰 활자와 같은 다른 형식으로 필요한 경우 귀하의 건강보험 ID 카드에 기재된 회원 번호, TTY / RTT 711 번으로 전화하십시오. 귀하는 번역 서비스 및 통역사를 무료로 이용하실 수 있습니다. Tagalog Kung kailangan ninyo ng tulong sa ibang wika o kailangan ninyo ng ibang format, tulad ng malalaking titik, pakitawagan ang numero para sa miyembro na makikita sa inyong ID card sa planong pangkalusugan, para sa gumagamit ng TTY / RTT, tumawag sa 711. Available para sa inyo ang mga serbisyo sa pagsasalin at interpreter nang wala kayong babayaran. Русский Если Вам нужна помощь на другом языке или Вы хотели бы получить этот документ в другом формате (например, крупным шрифтом), позвоните по телефону, указанному на Вашей идентификационной карте участника плана медицинского страхования, линия TTY/RTT: 711. Услуги устного и письменного перевода предоставляются бесплатно.

اللغة العربيةإذا كنت بحاجة إلى مساعدة بلغة أخرى أو تحتاج إلى تنسيق آخر مثل الطباعة بأحرف كبيرة، فيرجى الاتصال برقم ھاتف الأعضاء

. تتوفر خدمات الترجمة التحريرية والمترجمين TTY/RTT 711المدرج على بطاقة معرف العضوية الخاص بخطتك الصحية، الفوريين دون أن تتحمل أي تكلفة.

Français Si vous avez besoin d’aide dans une autre langue ou souhaitez un autre format, par exemple en gros caractères, veuillez appeler le numéro d’assuré figurant sur votre carte d’assurance, ATS / RTT (texte en temps réel) 711. Des services de traduction et des interprètes sont disponibles gratuitement. ኢንግሊዝኛ በሌላ ቋንቋ እርዳታ የሚፈልጉ ከሆነ ወይም በሌላ ፎርማት የተዘጋጀ ካስፈለግዎት፣ ለምሳሌ በትልቅ የተጻፈ፣ እባክዎን በኢንሽራንስ ካርድዎ ላይ ባለው የአባል አገልግሎት መስጫ ስልክ ቁጥር ይደውሉ፣ መስማት ለተሳናቸው (TTY/RTT) በ 711። የጽሑፍ ትርጉም ኣገልግሎት እንዲሁም የቃል አስተርጓሚዎች ምንም ሳይከፍሉ መጠቀም ይችላሉ።

Access to communication services If you need help in another language please call the number on your member health plan ID card.

Multi-language interpreter services

UHEX20PO4780325_000 07/2020

Diné Ła’ nááná saad bee shika’a’doowoł nínízingo doodago t’áá łahgo át’éego anályaago, nitsaago bee bik’e’ashchįigo da, t’áá shoodí nits’íís nánel’i ih naaltsoos bee ha’dít’éhígíí bił ninaaltsoos nitł’izí bee nééhizinígíí béésh bee hane’í biká’ígíí bee hodíilnih, TTY / RTT 711. T’áá ni nizaad bee ha’dilyaago dóó atah hane’ígíí t’áá jiik’eh bee ná’agot’i.

فارسی اگر به زبان ديگری به کمک نياز داريد يا به فرمت متفاوتی از قبيل چاپ درشت نياز داريد، لطفا با شماره مرقوم شده بر روی

تماس بگيريد. خدمات ترجمه و مترجمين شفاھی بدون اخذ ھزينه در TTY / RTT 711کارت شناسايی برنامه درمانی خود، اختيار شما می باشند.

اردو کو کسی دوسری زبان ميں معاونت کی ضرورت ہے يا آپ کو کسی اور فارميٹ کی ضرورت ہے جيسے بڑے پرنٹ اگر آپ

۔ آپ کے لئے ترجمہ TTY / RTT 711کارڈ پر دئے گئے ممبر نمبر پر کال کريں، IDکی ، تو براه کرم اپنے ہيلتھ پلان خدمات اور ترجمان بغير کسی معاوضہ کے دستياب ہيں۔

Deutsch Wenn Sie Hilfe in einer anderen Sprache oder ein anderes Format benötigen, z. B. Großdruck, rufen Sie bitte die Telefonnummer für Mitglieder an, die auf Ihrer Versicherungskarte angegeben ist, TTY / RTT 711. Übersetzer- und Dolmetscherdienste stehen Ihnen kostenlos zur Verfügung. 日本語他の言語でのお手伝いや他の形式（大きな文字など）が必要な場合は、医療保険プラン ID カードに記載されている電話番号（TTY／RTT は 711）にお電話ください。翻訳サービスと

通訳は無料でご利用いただけます。 ភាសាែខមរ េបើសនអនករតវការជនយ ជាភាសាមយេទៀត ឬអនករតវការទរងមយេទៀត ដចជាអកសរពមពធៗ សមទរសពទេទៅេលខសមាជក មានេនៅេលើបណណ ID គេរាងសខភាពរបសអនក, TTY / RTT 711។ េសវាការបកែរប នងអនកបកែរប គមានផដលជនេដាយ ឥតអសៃថលដលអនក។

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Documents

2021 Essential Plus Prescription Drug List - RMHP