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Zero Dollar Copay Age Limit Maintenance 90 drug Prior Authorization Quantity Limit Specialty Drug Step Therapy Preferred DrugBrand Name PreferredAvailable on the medical benefit only Available on medical and pharmacy benefitIndicates a brand name drug Indicates a generic drug
$0 AL M90 PA QL SP STPDBPMBDualCAPITALIZED lowercase
NOTICE The information contained in this document is proprietary. The information may not be copied in
whole or in part without written permission. ©2019 All rights reserved. This document contains
references to brand-name prescription drugs that are trademarks or registered trademarks of
pharmaceutical manufacturers.
When viewing the document via the Internet, please be advised that the document is updated
periodically, and changes may appear prior to their effective date to allow for client notification.
This list is subject to change at any time.
AllWays Health Partners complies with applicable federal civil rights laws and does not discriminate
or exclude people on the basis of race, color, national origin, age, disability, or sex.
399 Revolution Drive, Suite 810, Somerville, MA 02145 | allwayshealthpartners.org
AllWays Health Partners includes AllWays Health Partners, Inc. and AllWays Health Partners Insurance Company
2021MassHealth Pharmacy Formulary
INTRODUCTION
AllWays Health Partners covers a wide variety of safe and effective medications for treating our
members' medical needs. This list of AllWays Health Partners’ covered medications shows the tier in
which medications are placed. You can use this list to find out if your drug is covered and at which tier.
Check the plan documents such as the schedule of benefits, the summary of benefits and coverage, or the
benefit handbook for details on coverage and cost sharing. If you are a member, you also can view your
prescription drug coverage information by logging in to allwaysmember.org. This list of covered
medications is continually updated based on recommendations by AllWays Health Partners’ Pharmacy
& Therapeutics Committee.
It is always a good idea to discuss your medication options with your doctor to decide which is the most
appropriate to treat your specific medical condition.
LEGEND
Covered Product Reference Tier Status Notes1st Tier Unifine Pentips 29G X 12MM , 31G X 6 MM
CareFine Pen Needles $0 M90
1st Tier Unifine Pentips 31G X 5 MM , 31G X 8 MM
Advocate Insulin Pen Needles
$0 M90
1st Tier Unifine Pentips 32G X 4 MM BD Pen Needle Nano U/F $0 M90
1st Tier Unifine Pentips Plus 29G X 12MM , 31G X 6 MM
CareFine Pen Needles $0 M90
1st Tier Unifine Pentips Plus 31G X 5 MM , 31G X 8 MM
Advocate Insulin Pen Needles
$0 M90
1st Tier Unifine Pentips Plus 32G X 4 MM
BD Pen Needle Nano U/F $0 M90
3 Day Vaginal Gyne-Lotrimin 3 Tier 2 M90
50+ Adult Eye Health DEKAs Plus Tier 2 M90
7 Series BP Monitor/Upper Arm $0M90; QL (QL Flag); QL (1 EA per 3 YEARs)
8 Hour Pain Relief Midol Tier 2 M90
8 Hour Pain Reliever Midol Tier 2 M90
A + D Personal Care Lotion Tier 2 M90
A Thru Z Advanced ABC Plus Senior Tier 2 M90
A Thru Z High Potency ABC Plus Senior Tier 2 M90
A Thru Z Select 50+ Advanced ABC Plus Senior Tier 2 M90
A Thru Z Select 50+ Mens ABC Plus Senior Tier 2 M90
A Thru Z Select Advanced ABC Plus Senior Tier 2 M90
A Thru Z Select Oral Tablet ABC Plus Senior Tier 2 M90
A Thru Z Select Ultimate Women ABC Plus Senior Tier 2 M90
A Thru Z Ultimate Mens ABC Plus Senior Tier 2 M90
Abacavir Sulfate Oral Solution Ziagen Tier 2
Abacavir Sulfate Oral Tablet Ziagen Tier 2 M90
Abacavir Sulfate-lamiVUDine Epzicom Tier 2 M90
Abacavir-Lamivudine-Zidovudine Trizivir Tier 2 M90
Abatron AF Tier 2 M90
ABC Plus ABC Plus Senior Tier 2 M90
Abilify Maintena Intramuscular Prefilled Syringe
Tier 2PA; QL (Quantity Limit Applies); QL (1 INJ per 30 days)
Abilify Maintena Intramuscular Suspension Reconstituted ER
Tier 2PA; QL (Quantity Limit Applies); QL (1 INJ per 30 days)
Abilify MyCite Oral Tablet 10 MG, 2 MG, 5 MG
Tier 2PA; QL (60 EA per 30 days)
1
Covered Product Reference Tier Status NotesAbilify MyCite Oral Tablet 15 MG, 20 MG, 30 MG
Tier 2PA; QL (30 EA per 90 days)
Abiraterone Acetate Oral Tablet 250 MG Zytiga $0 SP; QL (QL Applies)
Abiraterone Acetate Oral Tablet 500 MG Zytiga $0QL (60 EA per 30 days)
Abraxane $0 M90
Acamprosate Calcium Tier 2 M90
Acarbose Oral Precose Tier 1 M90
Acebutolol HCl Oral Tier 1 M90
Acephen Rectal Suppository 120 MG, 325 MG
Tier 2 M90
Acetaminophen ER Midol Tier 2 M90
Acetaminophen Extra Strength Oral Liquid
Mapap Acetaminophen Extra Str
Tier 2 M90
Acetaminophen Extra Strength Oral Tablet
Healthy Mama Shake That Ache
Tier 2 M90
Acetaminophen Oral Liquid Little Remedies for Fever Tier 2 M90
Acetaminophen Oral Solution 160 MG/5ML
Tier 2 M90
Acetaminophen Oral Tablet Aphen Tier 2 M90
Acetaminophen Oral Tablet Chewable 80 MG
Childrens Medi-Tabs Tier 2 M90
Acetaminophen Rectal Suppository 120 MG
FeverAll Childrens Tier 2 M90
Acetaminophen-Codeine #2 Tier 2QL (400 tablets per 30 days. Click;HERE)
Acetaminophen-Codeine #3 Tier 2QL (360 tablets per 30 days. Click;HERE)
Acetaminophen-Codeine #4 Tier 2QL (180 EA per 30 days)
Acetaminophen-Codeine Oral Solution Tier 2M90; QL (2700 mL per 30 days. Click;HERE)
Acetaminophen-Codeine Oral Tablet 300-15 MG
Tier 2M90; QL (400 tablets per 30 days. Click;HERE)
Acetaminophen-Codeine Oral Tablet 300-30 MG
Tier 2 M90
Acetaminophen-Codeine Oral Tablet 300-60 MG
Tier 2M90; QL (180 EA per 30 days)
Acetasol HC Tier 2 M90
acetaZOLAMIDE ER Tier 1 M90
2
Covered Product Reference Tier Status NotesacetaZOLAMIDE Oral Tier 1 M90
Acetic Acid Otic Tier 2 M90
Acetic Acid-Aluminum Acetate Tier 2 M90
Acetylcysteine Inhalation Tier 2 M90
Acid Control Tier 2 M90
Acid Control Maximum Strength Oral Tablet 20 MG
MM Acid-Pep Maximum Strength
Tier 2 M90
Acid Controller Pepcid AC Tier 2 M90
Acid Controller Max StMM Acid-Pep Maximum Strength
Tier 2 M90
Acid Reducer Maximum StrengthMM Acid-Pep Maximum Strength
Tier 2 M90
Acid Reducer Oral Tablet 10 MG Pepcid AC Tier 2 M90
Acid Reducer Oral Tablet 150 MG, 75 MG
Tier 2 M90
AcipHex Sprinkle Oral Capsule Sprinkle 5 MG
Tier 2M90; QL (30 EA per 90 days)
Acitretin Soriatane Tier 2 M90
Acne Foaming Wash PanOxyl Foaming Wash Tier 2 M90
Acne Medication 10 External GelClean & Clear Persa-Gel Max St
Tier 2 M90
Acne Medication 5 External Gel Tier 2 M90
Acne-ClearClean & Clear Persa-Gel Max St
Tier 2 M90
Actemra ACTPen Tier 2PA; SP; Dual; QL (4 PENS per 28 days)
Actemra Intravenous Solution 200 MG/10ML
Tier 2PA; SP; Dual; QL (4 VIALS per 14 days)
Actemra Intravenous Solution 400 MG/20ML
Tier 2PA; SP; Dual; QL (2 VIALS per 14 days)
Actemra Intravenous Solution 80 MG/4ML
Tier 2PA; SP; Dual; QL (10 VIALS per 28 days)
Actemra Subcutaneous Tier 2PA; SP; Dual; QL (4 SYR per 28 days)
Acthar Tier 2PA; SP; QL (35 ml per 21 days)
ActHIB $0 M90
Actical DEKAs Plus Tier 2 M90
Actimmune $0 SP
Activite EC Tier 2 M90
Actoplus met XR Tier 2 ST; M90
3
Covered Product Reference Tier Status Notes
Acuvail Tier 2ST; M90; QL (60ml per 25 days)
Acyclovir External Ointment Zovirax Tier 2 M90
Acyclovir Oral Tier 2 M90
Acyclovir Sodium Intravenous Solution Tier 2 M90
Adacel Intramuscular Suspension 5-2-15.5 LF-MCG/0.5
$0 M90
Adagen MB PA
Adakveo MB PA
Adapalene External Cream Differin Tier 2 ST; M90
Adapalene External Gel 0.3 % Differin Tier 2 ST; M90
Adapalene External Lotion Differin Tier 2 ST; M90
Adcetris $0 SP
Addaprin Tier 2 M90
Adderall XR Tier 2PD; BP; QL (60 EA per 30 days)
Adefovir Dipivoxil Hepsera Tier 2SP; QL (30 EA per 90 days)
Adempas Tier 2 PA; SP
Adenosine Intravenous Solution 12 MG/4ML, 6 MG/2ML
Tier 2 M90
Admelog Tier 1 PA
Admelog SoloStar Tier 1 PA
Adrenalin Nasal Tier 2
Adrucil $0 M90
Advair Diskus Tier 2 BP
Advair HFA Tier 2 M90
Advanced Diabetic Multivitamin ABC Plus Senior Tier 2 M90
Advate Tier 2 PA; SP; Dual
Advil Junior Strength Tier 2 M90
Advocate Insulin Pen Needles 29G X 12.7MM , 31G X 5 MM , 31G X 8 MM
$0 M90
Adynovate Tier 2 PA; SP; Dual
Adzenys XR-ODT Oral Tablet Extended Release Dispersible 12.5 MG, 15.7 MG, 18.8 MG, 6.3 MG, 9.4 MG
Tier 2QL (30 EA per 90 days)
Adzenys XR-ODT Oral Tablet Extended Release Dispersible 3.1 MG
Tier 2PA; QL (30 EA per 90 days)
Aerospan Tier 2 M90
Afeditab CR Tier 1 M90
4
Covered Product Reference Tier Status Notes
Afinitor Oral Tablet 10 MG $0PA; SP; BP; QL (30 EA per 30 days)
Afinitor Oral Tablet 2.5 MG, 5 MG, 7.5 MG
$0PA; BP; QL (30 EA per 30 days)
Afluria $0 M90
Afluria Preservative Free Intramuscular Suspension Prefilled Syringe
$0 M90
Afluria Quadrivalent Intramuscular Suspension
$0
Afluria Quadrivalent Intramuscular Suspension Prefilled Syringe 0.25 ML
$0
Afluria Quadrivalent Intramuscular Suspension Prefilled Syringe 0.5 ML
$0 M90
Afrin Saline Nasal Mist Tier 1 M90
Afstyla Tier 2 PA; SP; Dual
Aftera $0 M90
Aimovig Tier 2PA; QL (1 PEN per 30 days)
AirDuo RespiClick 113/14 Tier 2 PA
AirDuo RespiClick 232/14 Tier 2 PA
AirDuo RespiClick 55/14 Tier 2 PA
Ajovy Tier 2PA; PD; QL (3 PENS per 90 days)
Akten Tier 2 M90
AL12 Tier 2 M90
Ala-Cort External Cream 1 % Aveeno Anti-Itch Max St Tier 2 M90
Ala-Quin Tier 2 M90
Alavert Oral Tablet Tier 2 M90; QL (QL Flag)
Alavert Oral Tablet Dispersible Tier 2 M90
Alaway Tier 2 M90; QL (QL Flag)
Alaway Childrens Allergy Tier 2 M90; QL (QL Flag)
Albendazole Oral Albenza Tier 2
Albuterol Sulfate ER Tier 2 M90
Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083%, (5 MG/ML) 0.5%, 0.63 MG/3ML, 1.25 MG/3ML
Tier 2 M90
Albuterol Sulfate Oral Tier 2 M90
Alclometasone Dipropionate External Cream
Tier 2ST; M90; QL (QL Applies)
5
Covered Product Reference Tier Status NotesAlclometasone Dipropionate External Ointment
Tier 2 M90
Aldactazide Oral Tablet 50-50 MG Tier 2 M90
Aldurazyme Tier 2 PA; SP; Dual
Alecensa $0SP; QL (240 EA per 30 days)
Alendronate Sodium Oral Solution Tier 2 M90
Alendronate Sodium Oral Tablet 10 MG, 40 MG, 5 MG
Tier 2M90; QL (30 EA per 90 days)
Alendronate Sodium Oral Tablet 35 MG Tier 2M90; QL (4 tablets per 28 days; 13 tablets per 90 days)
Alendronate Sodium Oral Tablet 70 MG Fosamax Tier 2M90; QL (4 tablets per 28 days; 13 tablets per 90 days)
Aler-Cap Banophen Tier 2 M90
AlerTab Alka-Seltzer Plus Allergy Tier 2 M90
Alferon N $0 SP
Alfuzosin HCl ER Uroxatral Tier 2M90; QL (30 EA per 90 days)
Alimta MB PA
Alinia Oral Suspension Reconstituted Tier 2 M90
Aliqopa $0 PA
Alka-Seltzer Plus Allergy Tier 2 M90
Alkeran Oral Tier 1 M90
All Day Allergy Childrens Oral Solution KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)
All Day Allergy Childrens Oral Tablet Chewable 10 MG
Wal-Zyr Childrens Tier 2 M90; QL (QL Flag)
All Day Allergy Oral Tablet KLS Aller-Tec Tier 2 M90; QL (QL Flag)
All Day Pain Relief Mediproxen Tier 2 M90
All Day Relief Mediproxen Tier 2 M90
Allegra Allergy Childrens Oral Tablet Dispersible
Tier 2 M90; QL (QL Flag)
Aller-Chlor Diabetic Tussin Allergy Tier 2 M90
Aller-Ease Oral Tablet 60 MG Wal-Fex Allergy Tier 2M90; QL (60 EA per 30 days)
Allergy 24-HR KLS Aller-Fex Tier 2 M90; QL (QL Flag)
Allergy 4 Hour Wal-finate Tier 2 M90
Allergy Childrens Oral Liquid Banophen Tier 2 M90
Allergy Eye Naphcon-A Tier 2 M90
Allergy Eye Drops Alaway Tier 2 M90; QL (QL Flag)
6
Covered Product Reference Tier Status NotesAllergy Medication Banophen Tier 2 M90
Allergy Medication Childrens Banophen Tier 2 M90
Allergy Oral Capsule Banophen Tier 2 M90
Allergy Oral Tablet 10 MG KLS AllerClear Tier 2 M90; QL (QL Flag)
Allergy Oral Tablet 25 MG Alka-Seltzer Plus Allergy Tier 2 M90
Allergy Oral Tablet 4 MG Wal-finate Tier 2 M90
Allergy Oral Tablet Dispersible Alavert Tier 2 M90
Allergy Oral Tablet Extended Release Chlor-Trimeton Allergy Tier 2 M90
Allergy Relief Child Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
Allergy Relief Childrens Oral Liquid Banophen Tier 2 M90
Allergy Relief Childrens Oral Solution 5 MG/5ML
Claritin Allergy Childrens Tier 2 M90; QL (QL Flag)
Allergy Relief Childrens Oral Syrup Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
Allergy Relief Childrens Oral Tablet Chewable
Wal-Zyr Childrens Tier 2 M90; QL (QL Flag)
Allergy Relief Childrens Oral Tablet Dispersible 10 MG
Alavert Tier 2 M90
Allergy Relief Nighttime Alka-Seltzer Plus Allergy Tier 2 M90
Allergy Spray 24 Hour Nasal Suspension ClariSpray Tier 2 M90
Allergy-Time Wal-finate Tier 2 M90
Allopurinol Oral Zyloprim Tier 2 M90
Almotriptan Malate Tier 2M90; QL (12 tablets per month)
Alocril Tier 2 M90
Aloe Aftersun External Lotion Tier 2 M90
Alogliptin Benzoate Nesina Tier 1PA; M90; QL (30 EA per 90 days)
Alogliptin-Metformin HCl Kazano Tier 2ST; M90; QL (60 EA per 30 days)
Alogliptin-Pioglitazone Oseni Tier 1PA; M90; QL (30 EA per 90 days)
Alomide Tier 2 M90
Alophen Tier 2 M90
Alora Tier 2 M90
Alosetron HCl Lotronex Tier 2 M90
Alphagan P Ophthalmic Solution 0.1 % Tier 2 M90
Alphanate/VWF Complex/Human Tier 2 PA; SP; Dual
AlphaNine SD Tier 2 PA; SP; Dual
7
Covered Product Reference Tier Status NotesALPRAZolam Intensol Tier 2
ALPRAZolam Oral Tablet Xanax Tier 2
Alprolix Tier 2 PA; SP; Dual
Alrex Tier 2 M90
Altabax Tier 2 PA; M90
Altacaine Tier 2 M90
Altafluor Tier 2 M90
Altafrin Ophthalmic Solution 10 %, 2.5 % Tier 2 M90
Altamist Spray Afrin Saline Nasal Mist Tier 1 M90
Altaryl Tier 2 M90
Altavera $0 M90
Alunbrig Oral Tablet 180 MG, 90 MG $0SP; QL (30 EA per 30 days)
Alunbrig Oral Tablet 30 MG $0SP; QL (120 EA per 30 days)
Alunbrig Oral Tablet Therapy Pack $0SP; QL (30 EA per 30 days)
Alvesco Tier 2 PA; M90
Alyacen 1/35 Cyclafem 1/35 $0 M90
Alyacen 7/7/7 Cyclafem 7/7/7 $0 M90
Amabelz Tier 2 M90
Amantadine HCl Oral Capsule Tier 2 M90
Amantadine HCl Oral Syrup Tier 2 M90
Amantadine HCl Oral Tablet Tier 2 M90
Ambrisentan Letairis Tier 2PA; SP; QL (30 EA per 90 days)
Amethia $0 M90
Amethia Lo $0 M90
Amethyst $0 M90
Amifostine Ethyol Tier 1 M90
aMILoride HCl Oral Tier 1 M90
Amiloride-Hydrochlorothiazide Tier 1 M90
Aminoacetic Acid Tier 2 M90
Aminobenzoate Potassium Oral Packet Tier 2 M90
Aminocaproic Acid Intravenous Tier 2 M90
Aminocaproic Acid Oral Solution Amicar Tier 2
Aminocaproic Acid Oral Tablet Amicar Tier 2
Aminofen Aphen Tier 2 M90
8
Covered Product Reference Tier Status NotesAmiodarone HCl Intravenous Solution 150 MG/3ML, 450 MG/9ML
Tier 2 M90
Amiodarone HCl Oral Pacerone Tier 2 M90
Amitriptyline HCl Oral Tier 2 M90
AmLactin Cerapeutic Tier 2 M90
AmLactin External Lotion Tier 2 M90
Amlodipine Besy-Benazepril HCl Tier 1 M90
AmLODIPine Besylate Oral Norvasc Tier 1 M90
Amlodipine-Olmesartan Azor Tier 2 PA; ST; M90
Amlodipine-Valsartan-HCTZ Exforge HCT Tier 1 ST; M90
Ammonium Lactate External AL12 Tier 2 M90
Amondys 45 MB PA
Amoxapine Tier 2 M90
Amoxicill-Clarithro-Lansopraz Tier 2 M90
Amoxicillin Oral Capsule Tier 2 M90
Amoxicillin Oral Suspension Reconstituted
Tier 2 M90
Amoxicillin Oral Tablet Tier 2 M90
Amoxicillin Oral Tablet Chewable 125 MG, 250 MG
Tier 2 M90
Amoxicillin-Pot Clavulanate ER Tier 2 M90
Amoxicillin-Pot Clavulanate Oral Tier 2 M90
Amphadase Tier 2 M90
Amphetamine ER Tier 2 PA
Amphetamine Sulfate Evekeo Tier 2
Amphetamine-Dextroamphetamine Adderall Tier 2QL (90 EA per 30 days)
Ampicillin Tier 2 M90
Anagrelide HCl Agrylin Tier 2 M90
Anastrozole Oral Arimidex $0 M90
Androderm Transdermal Patch 24 Hour Tier 2 ST
AndroGel Transdermal Gel 50 MG/5GM (1%)
Tier 2
Androxy Tier 2
Angeliq Tier 2 M90
Animal Chews Oral Tablet Chewable Bounty Bears/C Tier 2 M90
Animal Shapes Tier 2 M90
Animal Shapes Plus IronLand Before Time Multivitamin
Tier 2 M90
Anoro Ellipta Tier 2 M90
9
Covered Product Reference Tier Status NotesAntacid Calcium Cal-Gest Antacid Tier 2 M90
Antacid Calcium Extra StrengthCVS Chewy Not Chalky Flavor
Tier 2 M90
Antacid Extra Strength Oral Tablet Chewable 750 MG
CVS Chewy Not Chalky Flavor
Tier 2 M90
Antacid Maximum Tums Ultra 1000 Tier 2 M90
Antacid Oral Tablet Chewable 500 MG Cal-Gest Antacid Tier 2 M90
Antacid Ultra Strength Oral Tablet Chewable 1000 MG
Tums Ultra 1000 Tier 2 M90
Antara Oral Capsule 30 MG, 90 MG Tier 2 M90
Anti-Diarrheal Oral Capsule Imodium A-D Tier 2 M90
Antifungal (Tolnaftate) Tinactin Tier 2 M90
Anti-Fungal External Cream 1 % Desenex Tier 2 M90
Anti-Hist Allergy Alka-Seltzer Plus Allergy Tier 2 M90
Anti-Itch Maximum Strength External Cream 1 %
Aveeno Anti-Itch Max St Tier 2 M90
Antioxidant A/C/E/Selenium ABC Plus Senior Tier 2 M90
Anti-Oxidant Formula DEKAs Plus Tier 2 M90
Antioxidant Formula Oral Tablet ABC Plus Senior Tier 2 M90
Antioxidant Formula/Minerals DEKAs Plus Tier 2 M90
AntiOxidant Forte ABC Plus Senior Tier 2 M90
Antioxidant Oral Capsule DEKAs Plus Tier 2 M90
Antioxidant Protection Formula ABC Plus Senior Tier 2 M90
Antioxidant Vitamins ABC Plus Senior Tier 2 M90
Anzemet Oral Tier 2M90; QL (1 EA per 30 days)
APAP Extra StrengthHealthy Mama Shake That Ache
Tier 2 M90
APAP Oral Tablet 325 MG Aphen Tier 2 M90
APAP Oral Tablet Chewable Childrens Medi-Tabs Tier 2 M90
APAP-Caff-Dihydrocodeine Oral Capsule Trezix Tier 2QL (300 Capsules per 30 days. Click;HERE)
Apatate Forte Tier 2 M90
Aphen Tier 2 M90
Apidra Tier 1 M90
Apidra SoloStar Subcutaneous Solution Pen-Injector
Tier 1 M90
Apokyn Subcutaneous Solution Cartridge Tier 2SP; QL (20 EA per 30 days)
Apra Medi-Tabs Childrens Tier 2 M90
10
Covered Product Reference Tier Status NotesApraclonidine HCl Tier 2 M90
Aprepitant Oral Capsule 125 MG Tier 2M90; QL (4 capsules per 25 days)
Aprepitant Oral Capsule 40 MG Tier 2M90; QL (1 capsule per 25 days)
Aprepitant Oral Capsule 80 MG Emend Tier 2M90; QL (8 capsules per 25 days)
Apri $0 M90
Aptiom Tier 2 M90
Aptivus Oral Capsule Tier 2QL (120 EA per 30 days)
Aptivus Oral Solution Tier 2 QL (300 ml/30 days)
AP-Zel ABC Plus Senior Tier 2 M90
Aqua Glycolic Hand/Body Tier 2 M90
Aqua Lacten Tier 2 M90
Aquaderm Treatment/Moisturizer Tier 2 M90
Aquamed Tier 2 M90
Aralast NP Intravenous Solution Reconstituted 1000 MG, 500 MG
Tier 2 PA; SP; Dual
Aranelle $0 M90
Aranesp (Albumin Free) Injection Solution 10 MCG/0.4ML
Tier 2 PA; SP
Aranesp (Albumin Free) Injection Solution 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML
Tier 2 PA; SP; Dual
Aranesp (Albumin Free) Injection Solution Prefilled Syringe
Tier 2 PA; SP; Dual
Arbinoxa Oral Tablet Tier 2 M90
Arcalyst Tier 2PA; SP; Dual; QL (8 VIALS per 28 days)
Arcapta Neohaler Tier 2 M90
Arformoterol Tartrate Brovana Tier 2PA; QL (60 ML per 30 days)
Argyle Sterile Saline Tier 2 M90
ARIPiprazole Oral Solution Tier 2M90; QL (150ml per month)
ARIPiprazole Oral Tablet 10 MG, 2 MG, 5 MG
Abilify Tier 2M90; QL (60 EA per 30 days)
ARIPiprazole Oral Tablet 15 MG, 20 MG, 30 MG
Abilify Tier 2M90; QL (30 EA per 90 days)
11
Covered Product Reference Tier Status Notes
ARIPiprazole Oral Tablet Dispersible Tier 2M90; QL (30 EA per 90 days)
Aristada Initio Tier 2PD; QL (1 SYR per 30 days)
Aristada Intramuscular Prefilled Syringe 1064 MG/3.9ML
Tier 2PD; QL (1 SYR per 60 days)
Aristada Intramuscular Prefilled Syringe 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML
Tier 2PD; QL (1 SYR per 30 days)
Armodafinil Oral Tablet 150 MG, 200 MG, 250 MG
Nuvigil Tier 2PA; QL (30 EA per 90 days)
Armodafinil Oral Tablet 50 MG Nuvigil Tier 2PA; QL (60 EA per 30 days)
Armour Thyroid Oral Tablet 120 MG, 180 MG, 240 MG, 300 MG
Tier 2 M90
Arnuity Ellipta Inhalation Aerosol Powder Breath Activated 100 MCG/ACT, 50 MCG/ACT
Tier 2 PA
Arnuity Ellipta Inhalation Aerosol Powder Breath Activated 200 MCG/ACT
Tier 2 PA; M90
Arranon $0 M90
Arsenic Trioxide Intravenous Solution 12 MG/6ML
Trisenox $0
Arthritis Pain Midol Tier 2 M90
Arthritis Pain Relief Oral Midol Tier 2 M90
Arthritis Pain Reliever Oral Midol Tier 2 M90
Artificial Tears Ophthalmic Solution 1.4 %
Tier 2 M90
Arzerra $0 SP
Asceniv Tier 2 PA; SP; Dual
Ascomp-Codeine Tier 2 M90
Asenapine Maleate Saphris Tier 2QL (60 EA per 30 days)
Ashlyna $0 M90
Asmanex (120 Metered Doses) Tier 2 M90
Asmanex (14 Metered Doses) Tier 2 M90
Asmanex (30 Metered Doses) Tier 2 M90
Asmanex (60 Metered Doses) Tier 2 M90
Asmanex (7 Metered Doses) Tier 2 M90
Asmanex HFA Inhalation Aerosol 100 MCG/ACT, 200 MCG/ACT
Tier 2 M90
12
Covered Product Reference Tier Status NotesAsmanex HFA Inhalation Aerosol 50 MCG/ACT
Tier 2
Aspirin-Caff-Dihydrocodeine Tier 2M90; QL (300 capsules per 30 days. Click;HERE)
Aspirin-Dipyridamole ER Tier 2 M90
Aspirtab Maximum StrengthBayer Advanced Aspirin Ex St
Tier 2 M90
Astagraf XL Tier 2 SP
Atazanavir Sulfate Reyataz Tier 2 SP
Atenolol Oral Tenormin Tier 1 M90
Atenolol-Chlorthalidone Tenoretic 100 Tier 1 M90
Athletes Foot Spray External Aerosol Tinactin Tier 2 M90
Atomoxetine HCl Strattera Tier 2 ST
Atorvastatin Calcium Oral Lipitor Tier 2M90; QL (30 EA per 90 days)
Atovaquone Oral Mepron Tier 2 M90
Atovaquone-Proguanil HCl Malarone Tier 2 M90
Atropine Sulfate Injection Solution 0.4 MG/ML, 1 MG/ML
Tier 2 M90
Atropine Sulfate Ophthalmic Ointment Tier 2 M90
Atropine Sulfate Ophthalmic Solution 1 % Isopto Atropine Tier 2 M90
Atrovent HFA Tier 2 M90
Aubagio Tier 2PA; SP; QL (30 EA per 90 days)
Aubra $0 M90
Augmentin Oral Suspension Reconstituted 125-31.25 MG/5ML
Tier 2 M90
Auraphene-B Murine Ear Tier 2 M90
Aurora Pen Needles CareFine Pen Needles $0 M90
Aurora Unifine PentipsAdvocate Insulin Pen Needles
$0 M90
Austedo Tier 2 PA
Avandia Oral Tablet 2 MG, 4 MG Tier 2 ST; M90
Avastin $0 PA; SP; Dual
AVC Vaginal Tier 2 M90
Aveed MB PA
Aveeno Active Naturals Daily Tier 2 M90
Aveeno Anti-Itch Max St Tier 2 M90
Aveeno Daily Moisturizing External Lotion
Tier 2 M90
13
Covered Product Reference Tier Status NotesAveeno Positively Ageless Body Tier 2 M90
Aveeno Stress Relief Tier 2 M90
Aviane $0 M90
Avidoxy Tier 2 M90
Avita External Cream Tier 2 M90
Avita External Gel Tier 2 ST; M90
Avonex Tier 2SP; QL (4 SYR per 28 days)
Avonex Pen Intramuscular Auto-Injector Kit
Tier 2SP; QL (1 KIT per 28 days)
Avonex Prefilled Intramuscular Prefilled Syringe Kit
Tier 2SP; QL (1 KIT per 28 days)
Av-Phos 250 Neutral Phospha 250 Neutral Tier 2 M90
Avsola Tier 2PA; SP; Dual; QL (5 VIALS per 42 days)
Ayr Nasal Tier 1 M90
Ayvakit Oral Tablet 100 MG, 200 MG, 300 MG
$0QL (30 EA per 30 days)
Ayvakit Oral Tablet 25 MG $0QL (120 EA per 30 days)
Ayvakit Oral Tablet 50 MG $0QL (60 EA per 30 days)
AzaCITIDine Vidaza $0 SP; QL (QL Flag)
Azasan Tier 2 M90
AzaSite Tier 2 M90
azaTHIOprine Oral Tablet 50 MG Imuran Tier 2 M90
Azelaic Acid External Finacea Tier 2 ST
Azelastine HCl Nasal Solution 0.1 %, 0.15 %
Tier 2 M90
Azelastine HCl Ophthalmic Tier 2ST; M90; QL (6ml per 25 days)
Azelex Tier 2 ST; M90
Azilect Tier 2 M90; QL (QL Flag)
Azithromycin Oral Suspension Reconstituted
Zithromax Tier 2 M90
Azithromycin Oral Tablet 250 MG, 500 MG
Zithromax Tier 2 M90
Azithromycin Oral Tablet 600 MG Tier 2 M90
B-6 (pyridoxine) TABLET 500 MG ORAL
Tier 2 M90
B6 Natural Tier 2 M90
14
Covered Product Reference Tier Status NotesBaby Ayr Saline Tier 1 M90
Baby Ease Tier 2 M90
Baby Super Daily D3 Oral Liquid 400 UT/0.028ML
Baby Ddrops Tier 2 M90
Baby Vitamin D3 Oral Liquid 400 UT/0.028ML
Baby Ddrops Tier 2 M90
Bacitracin External Bacitraycin Plus Tier 2 M90
Bacitracin Ophthalmic Tier 2 M90
Bacitracin-Polymyxin B Ophthalmic Ointment 500-10000 UNIT/GM
Polycin Tier 2 M90
Bacitra-Neomycin-Polymyxin-HC Neo-Polycin HC Tier 2 M90
Bacitraycin Plus External Ointment 500 UNIT/GM
Tier 2 M90
Baclofen Oral Tablet 10 MG, 20 MG Tier 2 M90
Bactroban Nasal Tier 2 PA; M90
Bafiertam Tier 2PA; SP; QL (120 EA per 30 days)
Balcoltra $0
Balsalazide Disodium Colazal Tier 2 M90
Balversa Oral Tablet 3 MG $0PA; SP; QL (84 EA per 28 days)
Balversa Oral Tablet 4 MG $0PA; SP; QL (56 EA per 28 days)
Balversa Oral Tablet 5 MG $0PA; SP; QL (28 EA per 28 days)
Balziva $0 M90
Banophen Oral Tier 2 M90
Banzel Oral Tablet 200 MG Tier 2M90; QL (120 EA per 30 days)
Banzel Oral Tablet 400 MG Tier 2M90; QL (240 tablets per month)
Baqsimi One Pack Tier 2 PD
Baqsimi Two Pack Tier 2 PD
Baraclude Oral Solution Tier 2 SP; QL (QL Flag)
Basaglar KwikPen Tier 1 PA
Basic AM ABC Plus Senior Tier 2 M90
Basic PM ABC Plus Senior Tier 2 M90
Bavencio MB PA
Baxdela Oral Tier 2
Bayer Advanced Aspirin Ex St Tier 2 M90
Bayer Aspirin Extra Strength Tier 2 M90
15
Covered Product Reference Tier Status NotesBayer Low Dose Oral Tablet Chewable Tier 2 M90
Baza Antifungal Tineacide Tier 2 M90
BCG Vaccine $0 M90
BD AutoShield 29G X 5MM , 29G X 8MM
Tier 1 M90
BD AutoShield Duo $0 M90
BD Pen Needle Mini U/F $0 M90
BD Pen Needle Original U/F $0 M90
BD PosiFlush Intravenous Tier 2 M90
Beauty LotionA + D Personal Care Lotion
Tier 2 M90
Bebulin Tier 2 PA; SP
Bedding Spray Lice Treatment RID Tier 2 M90
Bekyree $0 M90
Beleodaq $0 SP
Belladonna Alkaloids-Opium Rectal Suppository 16.2-60 MG
Tier 2
Belsomra Tier 2PA; QL (30 EA per 30 days)
Benazepril HCl Oral Lotensin Tier 1 M90
Benazepril-hydroCHLOROthiazide Tier 1 M90
Bendeka $0 SP
BeneFIX Intravenous Kit Tier 2 PA; SP; PD; Dual
Benlysta Intravenous MB PA
Benlysta Subcutaneous Solution Auto-Injector
MBPA; QL (4 PENS per 28 days)
Benlysta Subcutaneous Solution Prefilled Syringe
MBPA; QL (4 SYR per 28 days)
Bensal HP Tier 2 M90
BenzePrO Creamy Wash Tier 2 M90
Benznidazole Tier 2
Benzoyl Peroxide Cleanser External Lotion 6 %
Tier 2 M90
Benzoyl Peroxide External Gel 10 %Clean & Clear Persa-Gel Max St
Tier 2 M90
Benzoyl Peroxide External Gel 2.5 %, 5 % Tier 2 M90
Benzoyl Peroxide Wash External Liquid 10 %
PanOxyl Foaming Wash Tier 2 M90
Benzoyl Peroxide Wash Liquid 10 % External External Liquid 10 %
PanOxyl Foaming Wash Tier 2 M90
Benztropine Mesylate Oral Tier 2 M90
16
Covered Product Reference Tier Status NotesBeovu Tier 2 PA; SP; Dual
Bepreve Tier 2ST; M90; QL (5ml per 25 days)
Berinert Tier 2PA; SP; QL (QL Flag); Dual
Besivance Tier 2 M90
Besponsa MB PA
Beta Care External LotionA + D Personal Care Lotion
Tier 2 M90
Betadine Ophthalmic Prep Tier 2 M90
Betamethasone Dipropionate Aug External Cream
Diprolene AF Tier 2 M90
Betamethasone Dipropionate Aug External Gel
Tier 2ST; M90; QL (QL Applies)
Betamethasone Dipropionate Aug External Lotion
Tier 2ST; M90; QL (QL Applies)
Betamethasone Dipropionate Aug External Ointment
Diprolene Tier 2 M90
Betamethasone Dipropionate External Cream
Tier 2 M90
Betamethasone Dipropionate External Lotion
Tier 2 M90
Betamethasone Dipropionate External Ointment
Tier 2ST; M90; QL (QL Applies)
Betamethasone Valerate External Cream Tier 2 M90
Betamethasone Valerate External Foam Luxiq Tier 2 ST; QL (QL Applies)
Betamethasone Valerate External Lotion Tier 2 M90
Betamethasone Valerate External Ointment
Tier 2 M90
Betaseron Subcutaneous Kit Tier 2SP; QL (14 per 28 days)
BetaTemp Childrens PediaCare Children Tier 2 M90
Betaxolol HCl Ophthalmic Tier 2 M90
Betaxolol HCl Oral Tier 1 M90
Bethanechol Chloride Oral Tier 2 M90
Betimol Tier 2 M90
Betoptic-S Tier 2 M90
Bevacizumab Intraocular Tier 2 PA; SP
Bevespi Aerosphere Tier 2
Bexarotene Targretin $0 SP; QL (QL Flag)
Bexsero $0 M90
17
Covered Product Reference Tier Status NotesBicalutamide Casodex $0 M90
Bicarsim Oral Tablet 80 MG Tier 2 M90
BiCNU $0 M90
Bijuva Tier 2 PA
Biktarvy Tier 2PD; QL (30 EA per 30 days)
Bimatoprost External Latisse Tier 2 M90
Bimatoprost Ophthalmic Tier 2 M90
Bio Glo Tier 2 M90
Biocal DEKAs Plus Tier 2 M90
Biocel ABC Plus Senior Tier 2 M90
Bio-Statin Tier 2 M90
Biosupp BProtected Multi-Vite Tier 2 M90
Biotect Plus Oral Liquid Tier 2 M90
BioThrax $0 M90
Biotin Plus/Calcium/Vit D3 ABC Plus Senior Tier 2 M90
Bisac-Evac Rectal Tier 2 M90
Bisacodyl EC Alophen Tier 2 M90
Bisacodyl Laxative Rectal The Magic Bullet Tier 2 M90
Bisacodyl Rectal The Magic Bullet Tier 2 M90
Biscolax The Magic Bullet Tier 2 M90
Bismatrol Oral Suspension Kaopectate Tier 2 M90
Bisoprolol Fumarate Oral Tier 1 M90
Bisoprolol-Hydrochlorothiazide Ziac Tier 1 M90
Bite-A-Mins Bounty Bears/C Tier 2 M90
Bite-A-Mins/IronLand Before Time Multivitamin
Tier 2 M90
Bivigam Tier 2 PA; SP; Dual
Blenrep MB PA
Bleo 15K Tier 1 M90
Bleomycin Sulfate $0 M90
Blephamide Tier 2 M90
Blephamide S.O.P. Tier 2 M90
Blincyto $0 SP
Blisovi 24 Fe $0 M90
Blisovi Fe 1.5/30 $0 M90
Blisovi FE 1/20 $0 M90
Blis-To-Sol External Liquid Tier 2 M90
18
Covered Product Reference Tier Status Notes
Blood Pressure Monitor 7 $0M90; QL (QL Flag); QL (1 EA per 3 YEARs)
Body/Hair/Skin/Nails DEKAs Plus Tier 2 M90
Bonjesta Tier 2PA; QL (60 EA per 30 days)
Boostrix Intramuscular Suspension 5-2.5-18.5
$0 M90
Boric Acid External Granules Tier 2 M90
Bosentan Tracleer Tier 2PA; SP; QL (60 EA per 30 days)
Bosulif Oral Tablet 100 MG $0SP; PD; QL (90 EA per 30 days)
Bosulif Oral Tablet 400 MG, 500 MG $0SP; PD; QL (30 EA per 30 days)
Botox Tier 2PA; QL (QL Flag); Dual
Boudreauxs Butt Paste Tier 2 M90
Bounty Bears/C Tier 2 M90
BP 10-1 Tier 2 M90
BP Foaming Wash PanOxyl Foaming Wash Tier 2 M90
BP Gel External Gel 10 %Clean & Clear Persa-Gel Max St
Tier 2 M90
BP Gel External Gel 5 % Tier 2 M90
BP Wash External Liquid 10 % PanOxyl Foaming Wash Tier 2 M90
BP Wash External Liquid 2.5 % PanOxyl Tier 2 M90
BP Wash External Liquid 7 % BenzePrO Creamy Wash Tier 2 M90
B-Plex Plus ABC Plus Senior Tier 2 M90
BPO-10 Wash PanOxyl Foaming Wash Tier 2 M90
BProtected Multi-Vite Tier 2 M90
BProtected Pedia Iron $0 M90
BProtected Pedia Poly-Vite/Fe Tier 2 M90
Braftovi Oral Capsule 75 MG $0SP; QL (180 EA per 30 days)
B-Redi/Red Hearts/Red Roosters ABC Plus Senior Tier 2 M90
Breo Ellipta Tier 2PA; M90; QL (1 EA per 30 days)
Briellyn Balziva $0 M90
Brilinta Tier 2M90; QL (60 EA per 30 days)
Brimonidine Tartrate Ophthalmic Tier 2 M90
19
Covered Product Reference Tier Status NotesBrineura MB PA
Brinzolamide Azopt Tier 2
Bromfenac Sodium (Once-Daily) Tier 2ST; M90; QL (1.7ml per 25 days)
Bromfenac Sodium Ophthalmic Tier 2ST; M90; QL (5ml per 25 days)
Bromocriptine Mesylate Oral Parlodel Tier 2 M90
Brompheniramine Tannate Oral Tablet Chewable
Tier 2 M90
Bronchitol Tier 2PA; QL (600 EA per 30 days)
Brukinsa $0PA; SP; QL (120 EA per 30 days)
Bucalsep Tier 2 M90
Budesonide ER Oral Tablet Extended Release 24 Hour
Uceris Tier 2QL (112 tablets per year (a rolling 365 days))
Budesonide Inhalation Pulmicort Tier 2 M90
Budesonide Nasal Tier 2 ST; M90
Budesonide Oral Entocort EC Tier 2 M90
Bumetanide Injection Tier 1 M90
Bumetanide Oral Bumex Tier 1 M90
Bunavail Tier 2PA; QL (60 EA per 30 days)
Buphenyl Oral Tablet Tier 2 SP; QL (QL Flag)
Bupivacaine HCl (PF) Injection Solution 0.75 %
Sensorcaine-MPF Tier 2 M90
Bupivacaine HCl Injection Solution 0.25 %, 0.5 %
Sensorcaine Tier 2 M90
Bupivacaine-Epinephrine Injection Solution 0.25% -1:200000, 0.5% -1:200000
Sensorcaine/EPINEPHrine
Tier 2 M90
Buprenex Tier 2 PA; M90
Buprenorphine HCl Injection Solution 0.3 MG/ML
Buprenex Tier 2 PA
Buprenorphine HCl Sublingual Tier 2PA; QL (90 EA per 30 days)
Buprenorphine HCl-Naloxone HCl Sublingual Tablet Sublingual
Tier 2PA; QL (60 EA per 30 days)
Buprenorphine Transdermal Butrans Tier 2ST; QL (4 patches per 30 days)
BuPROPion HCl ER (Smoking Det) $0 M90
20
Covered Product Reference Tier Status NotesbuPROPion HCl ER (SR) Wellbutrin SR Tier 2 M90
BuPROPion HCl ER (XL) Oral Tablet Extended Release 24 Hour 150 MG, 300 MG
Wellbutrin XL Tier 2 M90
buPROPion HCl Oral Tier 2 M90
Buried Treasure Active 55 Plus Tier 2 M90
busPIRone HCl Oral Tier 2 M90
Busulfex Tier 1 M90
Butalbital-Acetaminophen Oral Tablet 50-325 MG
Tencon Tier 2 M90
Butalbital-APAP-Caff-Cod Oral Capsule 50-300-40-30 MG
Fioricet/Codeine Tier 2
Butalbital-APAP-Caff-Cod Oral Capsule 50-325-40-30 MG
Tier 2 M90
Butalbital-APAP-Caffeine Oral Capsule Esgic Tier 2 M90
Butalbital-APAP-Caffeine Oral Tablet 50-325-40 MG
Bac Tier 2 M90
Butalbital-ASA-Caff-Codeine Ascomp-Codeine Tier 2
Butalbital-ASA-Caffeine Tier 2 M90
Butalbital-Aspirin-Caffeine Oral Capsule Tier 2
Butisol Sodium Oral Tablet 30 MG Tier 2
Butorphanol Tartrate Injection Tier 2
Butorphanol Tartrate Nasal Tier 2
Bydureon BCise Tier 2 PA
Bydureon Subcutaneous Pen-Injector Tier 2QL (4 pens per 28 days)
Byetta 10 MCG Pen Subcutaneous Solution Pen-Injector
Tier 2BP; QL (2 pens per 28 days)
Byetta 5 MCG Pen Subcutaneous Solution Pen-Injector
Tier 2BP; QL (1 pen per 28 days)
Bynfezia Pen Tier 2PA; SP; Dual; QL (6 PENS per 30 days)
Cabenuva MB PD
Cabergoline Tier 2 M90
Cablivi Tier 2 PA; SP; Dual
Cabometyx $0PA; SP; QL (30 EA per 30 days)
Caffeine Citrate Oral Tier 2 M90
Calamine External Lotion Tier 2 M90
Calamine-Zinc Oxide External Lotion Tier 2 M90
Calcidol Oral Solution 8000 UNIT/ML Tier 2 M90
21
Covered Product Reference Tier Status NotesCalciferol Oral Solution 8000 UNIT/ML Tier 2 M90
CalciFol Tier 2 M90
Calcipotriene External Cream Dovonex Tier 2PA; M90; QL (60 GM per 30 days)
Calcipotriene External Ointment Calcitrene Tier 2 PA; M90
Calcipotriene External Solution Tier 2PA; M90; QL (60 ML per 30 days)
Calcipotriene-Betameth Diprop External Ointment
Taclonex Tier 2PA; M90; QL (60 GM per 30 days)
Calcitonin (Salmon) Nasal Miacalcin Tier 2 M90
Calcitrate Oral Tablet 315-250 MG-UNIT, 950 MG
Tier 2 M90
Calcitrate Plus D Tier 2 M90
Cal-Citrate Plus Vitamin D Tier 2 M90
Calcitrene Tier 2 PA; M90
Calcitriol External Vectical Tier 2PA; M90; QL (60 GM per 30 days)
Calcitriol Oral Rocaltrol Tier 2 M90
Calcium + D Oral Tablet 315-200 MG-UNIT
Tier 2 M90
Calcium + D3 Oral Tablet 600-200 MG-UNIT
Tier 2 M90
Calcium 1000 + D Tier 2 M90
Calcium 1200 Tier 2 M90
Calcium 500 + D Oral Tablet 500-125 MG-UNIT
Tier 2 M90
Calcium 500 + D3 Oral Tablet 500-600 MG-UNIT
Os-Cal Extra D3 Tier 2 M90
Calcium 500 +D Oystercal-D Tier 2 M90
Calcium 500/D Os-Cal Calcium + D3 Tier 2 M90
Calcium 500/Vitamin D Tier 2 M90
Calcium 500+D Oystercal-D Tier 2 M90
Calcium 500+D High Potency Oystercal-D Tier 2 M90
Calcium 500+D3 Oral Tablet 500-400 MG-UNIT
Oystercal-D Tier 2 M90
Calcium 600 Tier 2 M90
Calcium 600 + D Tier 2 M90
Calcium 600 + Minerals Tier 2 M90
Calcium 600 High Potency Tier 2 M90
Calcium 600/Vitamin D Oral Tablet Tier 2 M90
Calcium 600/Vitamin D3 Pronutrients Calcium+D3 Tier 2 M90
22
Covered Product Reference Tier Status NotesCalcium 600+D Tier 2 M90
Calcium 600+D High Potency Tier 2 M90
Calcium 600+D Plus Minerals Tier 2 M90
Calcium 600+D3 Tier 2 M90
Calcium 600+D3 Plus MineralsCaltrate 600+D Plus Minerals
Tier 2 M90
Calcium 600-D Tier 2 M90
Calcium Acetate (Phos Binder) Calphron Tier 2 M90
Calcium Antacid Cal-Gest Antacid Tier 2 M90
Calcium Antacid Extra StrengthCVS Chewy Not Chalky Flavor
Tier 2 M90
Calcium Antacid Ultra Tums Ultra 1000 Tier 2 M90
Calcium Antacid Ultra Max St Tums Ultra 1000 Tier 2 M90
Calcium Antacid Ultra Strength Tums Ultra 1000 Tier 2 M90
Calcium Carb-Cholecalciferol Oral Tablet 500-125 MG-UNIT
Tier 2 M90
Calcium Carbonate Antacid Oral Tablet Chewable
Cal-Gest Antacid Tier 2 M90
Calcium Carbonate Oral Tablet 1500 (600 Ca) MG, 600 MG
Tier 2 M90
Calcium Carbonate-Vitamin D Oral Capsule
Tier 2 M90
Calcium Carbonate-Vitamin D Oral Tablet 500-400 MG-UNIT, 600-400 MG-UNIT
Tier 2 M90
Calcium Carbonate-Vitamin D3 Tier 2 M90
Calcium Citrate + D Oral Tablet 250-200 MG-UNIT, 315-200 MG-UNIT
Tier 2 M90
Calcium Citrate + D Oral Tablet 315-250 MG-UNIT
Calcitrate Tier 2 M90
Calcium Citrate + D3 Maximum Calcitrate Tier 2 M90
Calcium Citrate + D3 Oral Tablet 200-250 MG-UNIT
Citracal Petites/Vitamin D
Tier 2 M90
Calcium Citrate + D3 Oral Tablet 250-200 MG-UNIT
Tier 2 M90
Calcium Citrate + Oral Tablet 315-200 MG-UNIT
Tier 2 M90
Calcium Citrate +D Calcitrate Tier 2 M90
Calcium Citrate Maximum/Vit D Calcitrate Tier 2 M90
Calcium Citrate Oral Tablet 1040 MG, 200 MG, 250 MG, 950 (200 Ca) MG
Tier 2 M90
Calcium Citrate Petite/Vit DCitracal Petites/Vitamin D
Tier 2 M90
23
Covered Product Reference Tier Status NotesCalcium Citrate+D3 Calcitrate Tier 2 M90
Calcium Citrate+D3 PetitesCitracal Petites/Vitamin D
Tier 2 M90
Calcium Citrate-Vitamin D Oral Tablet 200-125 MG-UNIT, 250-50 MG-UNIT, 315-200 MG-UNIT
Tier 2 M90
Calcium Citrate-Vitamin D Oral Tablet 315-250 MG-UNIT
Calcitrate Tier 2 M90
Calcium Citrate-Vitamin D3 Calcitrate Tier 2 M90
Calcium High Potency Tier 2 M90
Calcium High Potency/Vitamin D Tier 2 M90
Calcium Oral Tablet 500-125 MG-UNIT, 600-200 MG-UNIT
Tier 2 M90
Calcium Oral Tablet Chewable 500-100 MG-UNIT, 600-400 MG-UNIT
Tier 2 M90
Calcium Oyster Shell Oral Tablet 500 MG Oystercal Tier 2 M90
Calcium Plus Vitamin D Oral Capsule Tier 2 M90
Calcium Plus Vitamin D3 Tier 2 M90
Calcium+D3 Oral Tablet 600-800 MG-UNIT
Pronutrients Calcium+D3 Tier 2 M90
Calcium-Carb 600 Tier 2 M90
Calcium-Carb 600 + D Tier 2 M90
Calcium-Vitamin D Oral Tablet 500-125 MG-UNIT, 600-125 MG-UNIT, 600-200 MG-UNIT, 600-400 MG-UNIT
Tier 2 M90
Calcium-Vitamin D Oral Tablet 500-200 MG-UNIT
Os-Cal Calcium + D3 Tier 2 M90
Calcium-Vitamin D Oral Tablet 500-400 MG-UNIT
Oystercal-D Tier 2 M90
Calcium-Vitamin D3 Oral Capsule 600-500 MG-UNIT
Tier 2 M90
Calcium-Vitamin D3 Oral Tablet 500-400 MG-UNIT
Oystercal-D Tier 2 M90
Calcium-Vitamin D3 Oral Tablet 600-125 MG-UNIT, 600-400 MG-UNIT
Tier 2 M90
Calcium-Vitamin D-Minerals Oral Tablet Chewable 600-400 MG-UNIT
Tier 2 M90
Cal-Gest Antacid Tier 2 M90
Calquence $0SP; QL (120 EA per 30 days)
Cal-Quick Tier 2 M90
Caltrate 600+D3 Soft Tier 2 M90
24
Covered Product Reference Tier Status NotesCam Tier 2 M90
Camila $0 M90
Camrese $0 M90
Camrese Lo $0 M90
Candesartan Cilexetil Atacand Tier 1 ST; M90
Candesartan Cilexetil-HCTZ Atacand HCT Tier 1 ST; M90
Capacet Tier 2 M90
Capecitabine Oral Tablet 150 MG Xeloda $0SP; QL (120 EA per 30 days)
Capecitabine Oral Tablet 500 MG Xeloda $0SP; QL (300 tablets per 30 days)
Capex Tier 2 ST; QL (QL Applies)
Caplyta Tier 2PA; QL (30 EA per 30 days)
Caprelsa Oral Tablet 100 MG $0QL (60 EA per 30 days)
Caprelsa Oral Tablet 300 MG $0QL (30 EA per 30 days)
Capsaicin External Cream 0.025 % DermacinRx Penetral Tier 2 M90
Capsaicin External Cream 0.1 % Capzasin-HP Tier 2 M90
Capsaicin HP Capzasin-HP Tier 2 M90
Captopril Oral Tier 1 M90
Captopril-hydroCHLOROthiazide Tier 1 M90
Capzasin-P Tier 2 M90
Carbaglu Tier 2 PA; M90
CarBAMazepine ER Carbatrol Tier 2 M90
carBAMazepine Oral Tier 2 M90
Carbidopa Oral Lodosyn Tier 2 M90
Carbidopa-Levodopa Sinemet Tier 2 M90
Carbidopa-Levodopa ER Oral Tablet Extended Release 25-100 MG, 50-200 MG
Tier 2 M90
Carbidopa-Levodopa-Entacapone Stalevo 50 Tier 2 M90
Carbinoxamine Maleate Oral Solution Tier 2 M90
Carbinoxamine Maleate Oral Tablet 4 MG Tier 2 M90
CARBOplatin Intravenous Solution Paraplatin $0 M90
Cardizem LA Oral Tablet Extended Release 24 Hour 120 MG
Tier 2 M90
CareFine Pen Needles $0 M90
CareOne Unifine Pentips CareFine Pen Needles $0 M90
25
Covered Product Reference Tier Status NotesCareOne Unifine Pentips Plus 29G X 12MM , 31G X 6 MM
CareFine Pen Needles $0 M90
CareOne Unifine Pentips Plus 31G X 5 MM , 31G X 8 MM
Advocate Insulin Pen Needles
$0 M90
CareOne Unifine Pentips Plus 32G X 4 MM
BD Pen Needle Nano U/F $0 M90
Carimune NF Intravenous Solution Reconstituted 12 GM, 6 GM
Tier 2 PA; SP; Dual
Carisoprodol Oral Tablet 350 MG Soma Tier 2M90; QL (90 EA per 30 days)
Carisoprodol-Aspirin Tier 2 ST
Carisoprodol-Aspirin-Codeine Tier 2 ST
Carrington Antifungal Tier 2 M90
Carteolol HCl Tier 2 M90
Carters Little Pills Tier 2 M90
Cartia XT Tier 1 M90
Carvedilol Coreg Tier 1 M90
Carvedilol Phosphate ER Coreg CR Tier 2
Cavarest Tier 2 M90
Caya Tier 2 M90; QL (QL Flag)
Cayston Tier 2 QL (84 per 28 days)
Caziant $0 M90
Cefaclor Tier 2 M90
Cefadroxil Tier 2 M90
Cefdinir Tier 2 M90
Cefditoren Pivoxil Tier 2 M90
Cefixime Oral Capsule Suprax Tier 2
Cefixime Oral Suspension Reconstituted Suprax Tier 2 M90
Cefpodoxime Proxetil Tier 2 M90
Cefprozil Tier 2 M90
Ceftibuten Tier 2 M90
Ceftin Oral Suspension Reconstituted Tier 2 M90
CefTRIAXone Sodium Injection Tier 2 M90
CefTRIAXone Sodium Intravenous Tier 2 M90
Cefuroxime Axetil Oral Tablet Tier 2 M90
Celecoxib Oral CeleBREX Tier 2 PA; M90
Cellular Security DEKAs Plus Tier 2 M90
Celontin Tier 2 M90
Centamin BProtected Multi-Vite Tier 2 M90
26
Covered Product Reference Tier Status NotesCentaVite BProtected Multi-Vite Tier 2 M90
Centavite A-Z Complete-Mineral ABC Plus Senior Tier 2 M90
Centravites ABC Plus Senior Tier 2 M90
Centravites 50 Plus ABC Plus Senior Tier 2 M90
Century Mature ABC Plus Senior Tier 2 M90
Cephalexin Oral Capsule 250 MG, 500 MG
Tier 2 M90
Cephalexin Oral Suspension Reconstituted Tier 2 M90
CeraLyte 70 Oral Solution Tier 2 M90
CeraSport EX1 Oral Solution Tier 2 M90
CeraSport Oral Solution Tier 2 M90
CeraVe AM SPF 30 Tier 2 M90
CeraVe External Lotion Tier 2 M90
CeraVe PM Tier 2 M90
CeraVe SA Renewing External Lotion Tier 2 M90
Cerdelga Tier 2PA; SP; QL (60 EA per 30 days)
Cerezyme MB PA
Cerisa Wash Tier 2 M90
Cerovel External Gel Tier 2 M90
Cerovel External Lotion Tier 2 M90
Cerovite Advanced Formula Oral Liquid Tier 2 M90
Certa Plus ABC Plus Senior Tier 2 M90
Certagen Oral Tablet ABC Plus Senior Tier 2 M90
CertaVite/Antioxidants Oral Liquid Tier 2 M90
Cervarix Tier 1 M90
Cervidil Tier 2 M90
Cesamet Tier 2QL (60 EA per 30 days)
Cetaphil Daily Advance Tier 2 M90
Cetaphil Daily Facial Moist Tier 2 M90
Cetaphil DermaControl/SPF 30 Tier 2 M90
Cetaphil Moisturizing External Lotion Tier 2 M90
Cetaphil RestoraDerm External Lotion Tier 2 M90
Cetirizine HCl Allergy Child KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)
Cetirizine HCl Childrens Alrgy Oral Syrup 1 MG/ML
KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)
Cetirizine HCl Childrens Oral Solution 1 MG/ML
KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)
27
Covered Product Reference Tier Status NotesCetirizine HCl Hives Relief KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)
Cetirizine HCl Oral Solution 1 MG/ML KLS Aller-Tec Childrens Tier 2 M90
Cetirizine HCl Oral Syrup 1 MG/ML KLS Aller-Tec Childrens Tier 2 M90
Cetirizine HCl Oral Tablet KLS Aller-Tec Tier 2 M90; QL (QL Flag)
Cetirizine HCl Oral Tablet Chewable Wal-Zyr Childrens Tier 2 M90; QL (QL Flag)
Cevimeline HCl Evoxac Tier 2 M90
Chantix $0 M90; QL (QL Flag)
Chantix Continuing Month Pak $0 M90; QL (QL Flag)
Chantix Starting Month Pak $0 M90; QL (QL Flag)
Chateal $0 M90
Chelated Zinc IS-ZC 50 Tier 2 M90
Chemet Tier 2 M90
Chenodal Tier 2 M90
Chewable Vite Childrens Bounty Bears/C Tier 2 M90
Chewable Vite/Iron ChildrensLand Before Time Multivitamin
Tier 2 M90
Child Chewable Vitamins/IronLand Before Time Multivitamin
Tier 2 M90
Childrens Acetaminophen Oral Suspension 160 MG/5ML
PediaCare Children Tier 2 M90
Childrens Allergy Banophen Tier 2 M90
Childrens APAP Childrens Medi-Tabs Tier 2 M90
Childrens Aspirin Free PediaCare Children Tier 2 M90
Childrens Chewable Multi Vits Bounty Bears/C Tier 2 M90
Childrens Chewable Vitamins Bounty Bears/C Tier 2 M90
Childrens Ibuprofen Childrens Medi-Profen Tier 2 M90
Childrens Ibuprofen 100 Childrens Medi-Profen Tier 2 M90
Childrens Loratadine Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
Childrens Medi-Profen Tier 2 M90
Childrens Medi-Tabs Tier 2 M90
Childrens Multivitamin/IronLand Before Time Multivitamin
Tier 2 M90
Childrens Non-ASA Pain Relief Childrens Medi-Tabs Tier 2 M90
Childrens Non-Aspirin Oral Suspension PediaCare Children Tier 2 M90
Childrens Non-Aspirin Oral Tablet Chewable
Childrens Medi-Tabs Tier 2 M90
Childrens Pain Reliever Oral Suspension PediaCare Children Tier 2 M90
Childrens Pain Reliever Oral Tablet Chewable
Childrens Medi-Tabs Tier 2 M90
28
Covered Product Reference Tier Status NotesChildrens Silapap Little Remedies for Fever Tier 2 M90
Childrens Silfedrine Sudafed Childrens Tier 2 M90
Childrens Tactinal Childrens Medi-Tabs Tier 2 M90
Childrens Vitamins/IronLand Before Time Multivitamin
Tier 2 M90
Childs Ibuprofen Childrens Medi-Profen Tier 2 M90
Chloraseptic Sore Throat Oral Tier 2 M90
ChlordiazePOXIDE HCl Tier 2 M90
Chlordiazepoxide-Amitriptyline Tier 2
chlordiazePOXIDE-Clidinium Librax Tier 2 M90
Chlorhexidine Gluconate Mouth/Throat Paroex Tier 2 M90
ChlorHist Wal-finate Tier 2 M90
Chloromag Tier 2 M90
Chloroquine Phosphate Oral Tier 2
Chlorothiazide Oral Tier 1 M90
Chlorphen SR Tier 2 M90
Chlorpheniramine Maleate ER Chlor-Trimeton Allergy Tier 2 M90
Chlorpheniramine Maleate Oral Wal-finate Tier 2 M90
Chlorpheniramine Maleate Syrup 2 MG/5ML
Diabetic Tussin Allergy Tier 2 M90
chlorproMAZINE HCl Injection Tier 2 M90
chlorproMAZINE HCl Oral Tablet Tier 2 M90
chlorproPAMIDE Tier 1 M90
Chlorthalidone Oral Tablet 100 MG, 25 MG
Tier 1 M90
Chlorthalidone Oral Tablet 50 MG Tier 2 M90
Chlorzoxazone Oral Tablet 500 MG Tier 2 M90
Cholestyramine Light Prevalite Tier 1 M90
Cholestyramine Oral Questran Tier 1 M90
Choline & Mag Trisalicylate Oral Tablet 1000 MG
Tier 2 M90
Choline-Mag Trisalicylate Tier 2 M90
Ciclodan External Cream Tier 2 M90
Ciclodan External Solution Tier 2 M90; QL (QL Flag)
Ciclopirox External Gel Tier 2 PA; M90
Ciclopirox External Shampoo Loprox Tier 2 PA; M90
Ciclopirox External Solution Ciclodan Tier 2PA; M90; QL (6.6ml per 90 days)
Ciclopirox Olamine External Loprox Tier 2 PA; M90
29
Covered Product Reference Tier Status NotesCilostazol Tier 2 M90
Cimduo Tier 2
Cimetidine 200 Tagamet HB Tier 2 M90
Cimetidine Acid Reducer Tagamet HB Tier 2 M90
Cimetidine HCl Oral Solution 300 MG/5ML
Tier 2 M90
Cimetidine Oral Tagamet HB Tier 2 M90
Cimzia Prefilled Tier 2PA; SP; QL (4 SYR per 28 days)
Cimzia Starter Kit Tier 2PA; SP; QL (1 KIT per 28 days)
Cimzia Subcutaneous Kit 2 X 200 MG Tier 2PA; SP; QL (4 SYR per 28 days)
Cinacalcet HCl Oral Tablet 30 MG, 60 MG
Sensipar Tier 2PA; SP; QL (60 EA per 30 days)
Cinacalcet HCl Oral Tablet 90 MG Sensipar Tier 2PA; SP; QL (120 EA per 30 days)
Cinqair MBPA; QL (3 VIALS per 28 days)
Cinryze Tier 2PA; SP; QL (QL Flag); Dual
Cinvanti Tier 2
Cipro HC Tier 2 M90
Ciprofloxacin HCl Ophthalmic Ciloxan Tier 2 M90
Ciprofloxacin HCl Oral Tier 2 M90
Ciprofloxacin HCl Otic Cetraxal Tier 2 M90
Ciprofloxacin Oral Cipro Tier 2 M90
Ciprofloxacin-Ciproflox HCl ER Tier 2 M90
Ciprofloxacin-Dexamethasone Ciprodex Tier 2
CISplatin Intravenous Solution 100 MG/100ML, 200 MG/200ML, 50 MG/50ML
$0 M90
Citalopram Hydrobromide Oral Solution Tier 2 M90
Citalopram Hydrobromide Oral Tablet 10 MG
CeleXA Tier 2M90; QL (90 EA per 30 days)
Citalopram Hydrobromide Oral Tablet 20 MG
CeleXA Tier 2M90; QL (75 tablets per month)
Citalopram Hydrobromide Oral Tablet 40 MG
CeleXA Tier 2M90; QL (45 tablets per month)
Citric Acid-Sodium Citrate Tier 2 M90
Citroma Tier 2 M90
30
Covered Product Reference Tier Status NotesCitrus Calcium +D Calcitrate Tier 2 M90
Citrus Calcium/Vitamin D Oral Tablet 200-250 MG-UNIT
Citracal Petites/Vitamin D
Tier 2 M90
Cladribine Intravenous Solution 10 MG/10ML
$0 M90
Claravis Tier 2 M90
Clarinex Oral Syrup Tier 2 QL (300ml per month)
Clarinex-D 12 Hour Tier 2M90; QL (60 EA per 30 days)
ClariSpray Tier 2 M90
Clarithromycin ER Tier 2 M90
Clarithromycin Oral Tier 2 M90
Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
Claritin Eye Tier 2 M90; QL (QL Flag)
Classic Prenatal Tier 1 M90
Clean & Clear Persa-Gel Max St Tier 2 M90
ClearLax Oral Powder Tier 2 M90
Clearplex V Tier 2 M90
Clearplex X Tier 2 M90
Clemastine Fumarate Oral Tablet 2.68 MG
Tier 2 M90
Clever Choice Comfort EZ 29G X 12MM $0 M90
Clever Choice Comfort EZ 33G X 4 MM Tier 1 M90
Clickfine Pen Needles 31G X 6 MM CareFine Pen Needles $0 M90
Clickfine Pen Needles 31G X 8 MMAdvocate Insulin Pen Needles
$0 M90
Clickfine Pen Needles 32G X 4 MM BD Pen Needle Nano U/F $0 M90
Climara Pro Tier 2 M90
Clindacin ETZ External Swab Tier 2 M90
Clindacin-P Tier 2 M90
ClindaMax External Gel Tier 2 M90
Clindamycin HCl Oral Cleocin Tier 2 M90
Clindamycin Palmitate HCl Cleocin Tier 2 M90
Clindamycin Phosphate External Gel Clindagel Tier 2 M90
Clindamycin Phosphate External Lotion Cleocin-T Tier 2 M90
Clindamycin Phosphate External Solution Tier 2 M90
Clindamycin Phosphate External Swab Clindacin ETZ Tier 2 M90
Clindamycin Phosphate Vaginal Cleocin Tier 2 M90
CLn Facial Moisturizer Nourish Tier 2 M90
31
Covered Product Reference Tier Status NotesCloBAZam Oral Suspension Onfi Tier 2 QL (480ml per month)
CloBAZam Oral Tablet 10 MG Onfi Tier 2QL (90 EA per 30 days)
CloBAZam Oral Tablet 20 MG Onfi Tier 2QL (60 EA per 30 days)
Clobetasol Propionate E Tier 2 PA; M90
Clobetasol Propionate Emulsion Olux-E Tier 2 PA; M90
Clobetasol Propionate External Cream Temovate Tier 2ST; M90; QL (QL Applies)
Clobetasol Propionate External Foam Olux Tier 2 PA; M90
Clobetasol Propionate External Gel Tier 2ST; M90; QL (QL Applies)
Clobetasol Propionate External Liquid Clobex Spray Tier 2 ST; QL (QL Applies)
Clobetasol Propionate External Lotion Clobex Tier 2 ST; QL (QL Applies)
Clobetasol Propionate External Ointment Temovate Tier 2ST; M90; QL (QL Applies)
Clobetasol Propionate External Shampoo Clobex Tier 2ST; M90; QL (QL Applies)
Clobetasol Propionate External Solution Tier 2 PA; M90
Clocortolone Pivalate Cloderm Tier 2 QL (QL Applies)
Clocortolone Pivalate Pump Cloderm Tier 2 PA; M90
Clolar Tier 1 M90
ClomiPRAMINE HCl Oral Anafranil Tier 2 M90
clonazePAM Oral Tablet KlonoPIN Tier 2
CloNIDine Catapres-TTS-3 Tier 2
cloNIDine HCl ER Kapvay Tier 2 PA; ST; M90
cloNIDine HCl Oral Tier 1 M90
Clopidogrel Bisulfate Oral Plavix Tier 2 M90
Clorazepate Dipotassium Tier 2
Clorpres Tier 1 M90
Clotrimazole 3 Gyne-Lotrimin 3 Tier 2 M90
Clotrimazole AF Desenex Tier 2 M90
Clotrimazole Anti-Fungal Desenex Tier 2 M90
Clotrimazole External Cream Desenex Tier 2 M90
Clotrimazole External Solution Tier 2 M90
Clotrimazole GRx Tier 2 M90
Clotrimazole Mouth/Throat Tier 2 M90
Clotrimazole Soln 1% Tier 2 M90
Clotrimazole Vaginal Cream 1 % Gyne-Lotrimin Tier 2 M90
Clotrimazole-7 Gyne-Lotrimin Tier 2 M90
32
Covered Product Reference Tier Status NotesClotrimazole-Betamethasone Tier 2 PA; M90
cloZAPine Oral Tablet 100 MG Clozaril Tier 2M90; QL (270 tablets per month)
cloZAPine Oral Tablet 25 MG Clozaril Tier 2M90; QL (90 EA per 30 days)
CloZAPine Oral Tablet 50 MG Clozaril Tier 2M90; QL (135 tablets per month)
Coagadex Tier 2 PA; SP; Dual
Coal Tar External Solution Tier 2 M90
Coartem Tier 2 M90
Cocoa Butter ExternalA + D Personal Care Lotion
Tier 2 M90
Cocoa Butter Hand & BodyA + D Personal Care Lotion
Tier 2 M90
Codeine Sulfate Oral Tablet Tier 2QL (42 tablets per 30 days. Click;HERE)
Colchicine Oral Colcrys Tier 2 M90
Colchicine-Probenecid Tier 2 M90
Colesevelam HCl Oral Packet Welchol Tier 1
Colesevelam HCl Oral Tablet Welchol Tier 2
Colestipol HCl Colestid Tier 1 M90
Colocort Tier 2 M90
Coly-Mycin S Tier 2 M90
Combigan Tier 2 M90
CombiPatch Tier 2 M90
Combivent Respimat Tier 2 M90
Cometriq (100 MG Daily Dose) Oral Kit 80 & 20 MG
$0SP; QL (56 EA per 28 days)
Cometriq (140 MG Daily Dose) Oral Kit 3 x 20 MG & 80 MG
$0SP; QL (112 EA per 28 days)
Cometriq (60 MG Daily Dose) $0SP; QL (84 EA per 28 days)
Comfort EZ Pen Needles 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 MM
$0 M90
Comfort EZ Pen Needles 32G X 8 MM , 33G X 4 MM , 33G X 5 MM , 33G X 6 MM , 33G X 8 MM
Tier 1 M90
Companion ABC Plus Senior Tier 2 M90
Complera Tier 2
Complere ABC Plus Senior Tier 2 M90
33
Covered Product Reference Tier Status NotesComplete ABC Plus Senior Tier 2 M90
Complete Allergy Medication Alka-Seltzer Plus Allergy Tier 2 M90
Complete Allergy Medicine Alka-Seltzer Plus Allergy Tier 2 M90
Complete Allergy Relief Alka-Seltzer Plus Allergy Tier 2 M90
Complete Daily/Lutein ABC Plus Senior Tier 2 M90
Complete Energy ABC Plus Senior Tier 2 M90
Complete MoistureA + D Personal Care Lotion
Tier 2 M90
Complete Multivitamin/Mineral BProtected Multi-Vite Tier 2 M90
Complete PMS Support Complex DEKAs Plus Tier 2 M90
Complete Senior ABC Plus Senior Tier 2 M90
Complete Womens ABC Plus Senior Tier 2 M90
CompleteNate $0 M90
Compro Tier 2 M90
Concept OB $0 M90
Concerta Tier 2BP; QL (60 EA per 30 days)
Condylox External Gel Tier 2 M90
Constulose Tier 2 M90
ControlRx Dental Cream Tier 2 M90
Copaxone Subcutaneous Solution Prefilled Syringe 20 MG/ML
Tier 2SP; BP; QL (30 SYR per 30 days)
Copaxone Subcutaneous Solution Prefilled Syringe 40 MG/ML
Tier 2SP; BP; QL (12 SYR per 28 days)
Copiktra $0
Coral Calcium Plus Oral Capsule DEKAs Plus Tier 2 M90
Cordran External Ointment Tier 2 M90
Corifact Tier 2 PA; SP; Dual
Corlanor Tier 2 PA
Cormax Scalp Application Tier 2 PA; M90
Correct Alophen Tier 2 M90
Correctol Tier 2 M90
Correctol Extra Gentle Tier 2 M90
Cortaid Maximum Strength External Cream
Tier 2 M90
Cortane-B Aqueous Tier 2 M90
Cortane-B External Tier 2 M90
Cortic-ND Tier 2 M90
Cortisone Acetate Oral Tier 2 M90
34
Covered Product Reference Tier Status NotesCortisporin External Tier 2 M90
Cortizone-10 External Ointment Tier 2 M90
Corvite 150 Oral Tablet Tier 2 M90
Corvite Fe Corvite 150 Tier 2 M90
Cosentyx (300 MG Dose) Tier 2 PA; SP
Cosentyx Sensoready (300 MG) Tier 2PA; SP; QL (300 mg (2 ml) per 28 days.)
Cosentyx Sensoready Pen Subcutaneous Solution Auto-Injector 150 MG/ML
Tier 2PA; SP; QL (150 mg ( 1 ml) per 28 days.)
Cosentyx Subcutaneous Solution Prefilled Syringe 150 MG/ML
Tier 2PA; SP; QL (2 SYR per 28 days)
Cosentyx Subcutaneous Solution Prefilled Syringe 75 MG/0.5ML
Tier 2 PA; SP
Cosmegen Tier 1 M90
Cotellic $0SP; QL (63 EA per 21 days)
Cotempla XR-ODT Tier 2PA; QL (30 EA per 30 days)
Cottontails Diaper Rash Tier 2 M90
Covaryx Tier 2 M90
Covaryx HS Tier 2 M90
Creon Tier 2 M90
Cresemba Oral Tier 2 PA; M90
Crixivan Oral Capsule 200 MG Tier 2 QL (450 per 30 days)
Crixivan Oral Capsule 400 MG Tier 2QL (180 EA per 30 days)
Cromolyn Sodium Inhalation Tier 2 M90
Cromolyn Sodium Nasal NasalCrom Tier 2 M90
Cromolyn Sodium Ophthalmic Tier 2 M90
Cromolyn Sodium Oral Gastrocrom Tier 2 M90
Cryselle-28 $0 M90
Crysvita Subcutaneous Solution 10 MG/ML
MB PA
Crysvita Subcutaneous Solution 20 MG/ML
MBPA; QL (9 VIALS per 14 days)
Crysvita Subcutaneous Solution 30 MG/ML
MBPA; QL (6 VIALS per 14 days)
Curity Sterile Saline Tier 2 M90
Cutaquig Tier 2 PA; SP; Dual
Cuvitru Tier 2 PA; SP; Dual
Cuvposa Tier 2 M90
35
Covered Product Reference Tier Status NotesCVS 3-Day Vaginal Gyne-Lotrimin 3 Tier 2 M90
CVS 8 Hour Pain Relief Midol Tier 2 M90
CVS Acetaminophen Oral Tablet Aphen Tier 2 M90
CVS Acid Controller Max StMM Acid-Pep Maximum Strength
Tier 2 M90
CVS Acid Reducer Max St Tier 2 M90
CVS Acid Reducer Oral Tablet 10 MG Pepcid AC Tier 2 M90
CVS Acne Foaming Face Wash PanOxyl Foaming Wash Tier 2 M90
CVS Acne TreatmentClean & Clear Persa-Gel Max St
Tier 2 M90
CVS All Day Pain Relief Mediproxen Tier 2 M90
CVS Allergy Eye Drops Alaway Tier 2 M90; QL (QL Flag)
CVS Allergy Oral Capsule Banophen Tier 2 M90
CVS Allergy Oral Liquid Banophen Tier 2 M90
CVS Allergy Oral Tablet 25 MG Alka-Seltzer Plus Allergy Tier 2 M90
CVS Allergy Relief Adult Banophen Tier 2 M90
CVS Allergy Relief Childrens Oral Solution
KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)
CVS Allergy Relief Childrens Oral Suspension
Allegra Allergy Childrens Tier 2M90; QL (300ml per month)
CVS Allergy Relief Childrens Oral Syrup Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
CVS Allergy Relief D Oral Tablet Extended Release 12 Hour
Wal-Fex D Allergy & Congestion
Tier 2 M90; QL (QL Flag)
CVS Allergy Relief Nighttime Alka-Seltzer Plus Allergy Tier 2 M90
CVS Allergy Relief Oral Liquid Banophen Tier 2 M90
CVS Allergy Relief Oral Tablet 10 MG KLS AllerClear Tier 2 M90; QL (QL Flag)
CVS Allergy Relief Oral Tablet 180 MG KLS Aller-Fex Tier 2 M90; QL (QL Flag)
CVS Allergy Relief Oral Tablet 4 MG Wal-finate Tier 2 M90
CVS Allergy Relief Oral Tablet 60 MG Wal-Fex Allergy Tier 2 M90; QL (QL Flag)
CVS Allergy Relief Oral Tablet Dispersible
Alavert Tier 2 M90
CVS Allergy Relief Oral Tablet Extended Release
Chlor-Trimeton Allergy Tier 2 M90
CVS Antacid ExtraCVS Chewy Not Chalky Flavor
Tier 2 M90
CVS Antacid Extra Strength Oral Tablet Chewable 750 MG
CVS Chewy Not Chalky Flavor
Tier 2 M90
CVS Antacid KidsCVS Chewy Not Chalky Flavor
Tier 2 M90
CVS Antacid Maximum Strength Tums Ultra 1000 Tier 2 M90
36
Covered Product Reference Tier Status NotesCVS Antacid Ultra Strength Tums Ultra 1000 Tier 2 M90
CVS Anti-Diarrheal Oral Capsule Imodium A-D Tier 2 M90
CVS Anti-Diarrheal Oral Suspension Kaopectate Tier 2 M90
CVS Antifungal Tinactin Tier 2 M90
CVS Anti-Itch Maximum Strength Aveeno Anti-Itch Max St Tier 2 M90
CVS Arthritis Pain Relief Oral Midol Tier 2 M90
CVS B-6 Tier 2 M90
CVS Bedding Spray Lice Treat RID Tier 2 M90
CVS Bisacodyl Alophen Tier 2 M90
CVS Bismuth Oral Suspension Kaopectate Tier 2 M90
CVS Calcium 600 & Vitamin D3 Pronutrients Calcium+D3 Tier 2 M90
CVS Calcium 600 + D/Minerals Oral Tablet 600-800 MG-UNIT
Caltrate 600+D Plus Minerals
Tier 2 M90
CVS Calcium 600+D Oral Tablet 600-800 MG-UNIT
Pronutrients Calcium+D3 Tier 2 M90
CVS Calcium Citrate +D Calcitrate Tier 2 M90
CVS Calcium Citrate +D3 MiniCitracal Petites/Vitamin D
Tier 2 M90
CVS Capsaicin HP Capzasin-HP Tier 2 M90
CVS Chewy Not Chalky Flavor Tier 2 M90
CVS Children Multivitamin/IronLand Before Time Multivitamin
Tier 2 M90
CVS Childrens Allergy Banophen Tier 2 M90
CVS Childrens Ibuprofen Childrens Medi-Profen Tier 2 M90
CVS Childs Non-Aspirin Childrens Medi-Tabs Tier 2 M90
CVS Citrate of Magnesia Citroma Tier 2 M90
CVS Clotrimazole External Cream Desenex Tier 2 M90
CVS Cortisone Intense Healing Aveeno Anti-Itch Max St Tier 2 M90
CVS Cortisone Maximum Strength External Cream
Aveeno Anti-Itch Max St Tier 2 M90
CVS Cortisone Maximum Strength External Ointment
Cortizone-10 Tier 2 M90
CVS D3 Oral Capsule 125 MCG (5000 UT)
Dialyvite Vitamin D 5000 Tier 2 M90
CVS D3 Oral Capsule 50 MCG (2000 UT)
Tier 2 M90
CVS D3 Oral Tablet ChewableVitaJoy Daily D Gummies
Tier 2 M90
CVS Daily Multiple FE/CA/ZN ABC Plus Senior Tier 2 M90
CVS Daily Multiple For Men ABC Plus Senior Tier 2 M90
37
Covered Product Reference Tier Status NotesCVS Daily Multiple For Men 50+ ABC Plus Senior Tier 2 M90
CVS Daily Multiple For Women ABC Plus Senior Tier 2 M90
CVS Daily Multiple Women 50+ ABC Plus Senior Tier 2 M90
CVS Daily Ultra MoistureA + D Personal Care Lotion
Tier 2 M90
CVS Diaper Rash External Ointment 40 % Boudreauxs Butt Paste Tier 2 M90
CVS Dry Skin CareA + D Personal Care Lotion
Tier 2 M90
CVS Dye-Free Allergy Alka-Seltzer Plus Allergy Tier 2 M90
CVS Ear Drops Murine Ear Tier 2 M90
CVS Ear Wax Removal System Murine Ear Tier 2 M90
CVS Eczema Anti-Itch Aveeno Anti-Itch Max St Tier 2 M90
CVS Electrolyte Solution CeraLyte 70 Tier 2 M90
CVS Enema Disposable Fleet Enema Tier 2 M90
CVS Extra MoisturizingA + D Personal Care Lotion
Tier 2 M90
CVS Eye Allergy Relief Ophthalmic Solution 0.025-0.3 %
Naphcon-A Tier 2 M90
CVS Eye Itch Relief Alaway Tier 2 M90; QL (QL Flag)
CVS Fever Reducing Childrens FeverAll Childrens Tier 2 M90
CVS Fluticasone Propionate ClariSpray Tier 2 M90
CVS Foaming Acne Face Wash PanOxyl Foaming Wash Tier 2 M90
CVS Gas Relief Drops Ex St Gas-X Infant Drops Tier 2 M90
CVS Gas Relief Oral Tablet Chewable Tier 2 M90
CVS Gentle Laxative Alophen Tier 2 M90
CVS Gentle Laxative Womens Alophen Tier 2 M90
CVS Gentle Skin CleanserA + D Personal Care Lotion
Tier 2 M90
CVS Heartburn Relief Oral Tablet Tagamet HB Tier 2 M90
CVS Hydrocortisone Anti-Itch External Cream 1 %
Aveeno Anti-Itch Max St Tier 2 M90
CVS Hydrocortisone Max St Aveeno Anti-Itch Max St Tier 2 M90
CVS Ibuprofen IB Medi-Profen Tier 2 M90
CVS Ibuprofen Infants Medi-Profen Tier 2 M90
CVS Ibuprofen Junior Strength Advil Junior Strength Tier 2 M90
CVS Ibuprofen Oral Tablet Medi-Profen Tier 2 M90
CVS Indoor/Outdoor Allergy Rlf KLS Aller-Tec Tier 2 M90; QL (QL Flag)
CVS Infants Gas ReliefLittle Remedies for Tummys
Tier 2 M90
38
Covered Product Reference Tier Status NotesCVS Infants Pain Relief Drops Oral Suspension 160 MG/5ML
PediaCare Children Tier 2 M90
CVS Iron Oral Tablet 240 (27 Fe) MG Ferate Tier 2 M90
CVS Itch Relief External Cream 1 % Desenex Tier 2 M90
CVS Laxative Pills Tier 2 M90
CVS Loratadine Oral Tablet KLS AllerClear Tier 2 M90; QL (QL Flag)
CVS Lubricant Drops Ophthalmic Gel 0.25-0.3 %
Tier 2
CVS Lubricant Drops Ophthalmic Solution
Systane Complete Tier 2 M90
CVS Magnesium Citrate Oral Solution Citroma Tier 2 M90
CVS Miconazole 1 Combo Pack Monistat 1 Combo Pack Tier 2 M90
CVS Miconazole 3 Combo PackMonistat 3 Combo Pack App
Tier 2 M90
CVS Miconazole 3-Day Combo AppMonistat 3 Combo Pack App
Tier 2 M90
CVS Miconazole 7 Monistat 7 Simply Cure Tier 2 M90
CVS Milk of MagnesiaDulcolax Milk of Magnesia
Tier 2 M90
CVS Mineral Oil Tier 2 M90
CVS Moisturizing External LotionA + D Personal Care Lotion
Tier 2 M90
CVS Motion Sickness II Wal-Dram II Tier 2 M90
CVS Naproxen Sodium Oral Tablet Mediproxen Tier 2 M90
CVS Nasal Allergy Spray KLS Aller-Cort Tier 2ST; M90; QL (QL Flag)
CVS Nasal Decongestant Oral Tablet SudoGest Tier 2 M90
CVS Nicotine Mouth/Throat Lozenge KLS Quit2 $0 M90
CVS Nicotine Polacrilex KLS Quit2 $0 M90
CVS Nicotine Transdermal Patch 24 Hour 14 MG/24HR, 7 MG/24HR
Nicoderm CQ $0 M90
CVS Non-Aspirin Childrens Childrens Medi-Tabs Tier 2 M90
CVS Non-Aspirin Extra StrengthHealthy Mama Shake That Ache
Tier 2 M90
CVS NTS Step 1 Habitrol Tier 1 M90
CVS Oyster Shell Calcium+Vit D Tier 2 M90
CVS Pain & Fever Childrens PediaCare Children Tier 2 M90
CVS Pain & Fever Infants PediaCare Children Tier 2 M90
CVS Pain Relief AdultMapap Acetaminophen Extra Str
Tier 2 M90
39
Covered Product Reference Tier Status NotesCVS Pain Relief Childrens Oral Suspension
PediaCare Children Tier 2 M90
CVS Pain Relief Extra StrengthHealthy Mama Shake That Ache
Tier 2 M90
CVS Ped Electrolyte Freeze Pop CeraLyte 70 Tier 2 M90
CVS Pediatric Electrolyte Oral Solution CeraLyte 70 Tier 2 M90
CVS Permethrin Tier 2 M90
CVS Prenatal Oral Tablet 28-0.8 MG Tier 1 M90
CVS Purelax Tier 2 M90
CVS Ringworm Desenex Tier 2 M90
CVS Saline Nasal Spray Afrin Saline Nasal Mist Tier 1 M90
CVS Saline Nose Spray Afrin Saline Nasal Mist Tier 1 M90
CVS Senna Evac-U-Gen Tier 2 M90
CVS Senna-Extra Senokot Extra Strength Tier 2 M90
CVS Skin Treatment AL12 Tier 2 M90
CVS Special CareA + D Personal Care Lotion
Tier 2 M90
CVS Spectravite Adult 50+ Oral Tablet ABC Plus Senior Tier 2 M90
CVS Spectravite Advanced Oral Tablet ABC Plus Senior Tier 2 M90
CVS Spectravite Senior ABC Plus Senior Tier 2 M90
CVS Spectravite Ultra Men 50+ ABC Plus Senior Tier 2 M90
CVS Spectravite Ultra Mens ABC Plus Senior Tier 2 M90
CVS Spectravite Ultra Women ABC Plus Senior Tier 2 M90
CVS Spectravite Womens Senior ABC Plus Senior Tier 2 M90
CVS Stool Softener Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90
CVS Vision Formula ABC Plus Senior Tier 2 M90
CVS Vitamin B-6 Oral Tablet 100 MG Tier 2 M90
CVS Vitamin D Child GummiesVitaJoy Daily D Gummies
Tier 2 M90
CVS Vitamin D3 Oral Tablet Chewable 25 MCG (1000 UT)
VitaJoy Daily D Gummies
Tier 2 M90
CVS Womens Active Daily ABC Plus Senior Tier 2 M90
CVS Zinc Oral Tier 2 M90
CVS Zinc Oxide Tier 2 M90
Cyanocobalamin Injection Solution 1000 MCG/ML
Tier 2 M90
Cyclafem 1/35 $0 M90
Cyclafem 7/7/7 $0 M90
Cyclobenzaprine HCl Oral Tier 2 M90
Cyclomydril Tier 2 M90
40
Covered Product Reference Tier Status NotesCyclopentolate HCl Ophthalmic Cyclogyl Tier 2 M90
Cyclophosphamide Injection $0 M90
Cyclophosphamide Intravenous $0
Cyclophosphamide Oral Capsule $0 M90
Cyclosporine in Klarity Tier 2
CycloSPORINE Intravenous SandIMMUNE Tier 2 SP
CycloSPORINE Modified Gengraf Tier 2 SP
CycloSPORINE Oral Capsule SandIMMUNE Tier 2 SP
Cyotic Tier 2 M90
Cyproheptadine HCl Oral Tier 2 M90
Cyred $0 M90
Cystadane Tier 2 M90
Cystagon Tier 2 SP; QL (QL Flag)
Cystaran Tier 2 M90
Cytarabine (PF) $0 M90
Cytarabine Injection Solution $0 M90
Cytogam MB PA
Cytra K Crystals Tier 2 M90
D 1000 Pronutrients Vitamin D3 Tier 2 M90
D 10000 Decara Tier 2 M90
D 5000Radiance Platinum Vitamin D3
Tier 2 M90
D-1000 Vitamin D-1000 Max St Tier 2 M90
D-1000 Extra Strength Vitamin D-1000 Max St Tier 2 M90
D-2000 Maximum Strength Thera-D 2000 Tier 2 M90
D2000 Ultra Strength Tier 2 M90
D3 Thera-D 2000 Tier 2 M90
D3 (cholecalciferol) Capsule 125 MCG (5000 UT) Oral Oral Capsule
Dialyvite Vitamin D 5000 Tier 2 M90
D3 (cholecalciferol) Capsule 125 MCG (5000 UT) Oral Oral Liquid 5000 UNIT/ML
Tier 2 M90
D3 AdultVitaJoy Daily D Gummies
Tier 2 M90
D3 High Potency Oral Capsule 25 MCG (1000 UT)
Pronutrients Vitamin D3 Tier 2 M90
D3 Super Strength Tier 2 M90
D3-1000 Pronutrients Vitamin D3 Tier 2 M90
D-3-5 Dialyvite Vitamin D 5000 Tier 2 M90
D3-50 Tier 2 M90
41
Covered Product Reference Tier Status Notes
D-5000Radiance Platinum Vitamin D3
Tier 2 M90
Dacarbazine Intravenous $0 M90
Daily Betic ABC Plus Senior Tier 2 M90
Daily Combo Multi Vitamins ABC Plus Senior Tier 2 M90
Daily Mens Health Formula ABC Plus Senior Tier 2 M90
Daily Multi ABC Plus Senior Tier 2 M90
Daily Multi 50+ ABC Plus Senior Tier 2 M90
Daily Multiple Vitamins/IronTab-A-Vite/Iron/Beta Carotene
Tier 2 M90
Daily Multiple Vitamins/Min ABC Plus Senior Tier 2 M90
Daily Multivitamin DEKAs Plus Tier 2 M90
Daily Vitamin Formula+IronTab-A-Vite/Iron/Beta Carotene
Tier 2 M90
Daily Vitamin Formula+Minerals ABC Plus Senior Tier 2 M90
Daily Vitamin Plus DEKAs Plus Tier 2 M90
Daily Womens Health Formula ABC Plus Senior Tier 2 M90
Daily-Vitamin Maximum Formula ABC Plus Senior Tier 2 M90
Daily-Vitamin/IronTab-A-Vite/Iron/Beta Carotene
Tier 2 M90
Daily-Vite/Iron/Beta-CaroteneTab-A-Vite/Iron/Beta Carotene
Tier 2 M90
Dairy Digest Extra Tier 2
Dalfampridine ER Ampyra Tier 2PA; SP; QL (60 EA per 30 days)
Daliresp Oral Tablet 250 MCG Tier 2 PA
Daliresp Oral Tablet 500 MCG Tier 2 PA; M90
Danazol Oral Tier 2 M90
Dantrolene Sodium Oral Tier 2 M90
Danyelza MB PA
Dapsone External Aczone Tier 2 ST
Dapsone Oral Tier 2 M90
Daptacel Intramuscular Suspension 10-15-5
Tier 2 M90
Darifenacin Hydrobromide ER Enablex Tier 2ST; M90; QL (30 EA per 90 days)
Darzalex $0 SP
Dasetta 1/35 $0 M90
Dasetta 7/7/7 $0 M90
42
Covered Product Reference Tier Status NotesDAUNOrubicin HCl Intravenous Injectable
$0 M90
Daurismo Oral Tablet 100 MG $0PA; SP; QL (30 EA per 90 days)
Daurismo Oral Tablet 25 MG $0PA; SP; QL (60 EA per 30 days)
Daysee $0 M90
Daytrana Tier 2PA; ST; M90; QL (30 EA per 90 days)
DayVigo Tier 2PA; QL (30 EA per 30 days)
Deblitane $0 M90
Decara Oral Capsule 1.25 MG (50000 UT)
Tier 2 M90
Decitabine Dacogen $0 SP
Decon-A Oral Elixir Tier 2 M90
Decon-G Tier 2 M90
Decongestant Oral Tablet 30 MG SudoGest Tier 2 M90
Deep Sea Nasal Spray Afrin Saline Nasal Mist Tier 1 M90
Deferasirox Granules Jadenu Sprinkle Tier 2 PA; SP
Deferasirox Oral Tablet Jadenu Tier 2 PA; SP
Deferasirox Oral Tablet Soluble Exjade Tier 2 PA; SP
Deferiprone Ferriprox Tier 2 PA
DEKAs Plus Ocean Tier 2 M90
DEKAs Plus Oral Capsule Tier 2 M90
Delazinc Tier 2 M90
Delestrogen Intramuscular Oil 10 MG/ML Tier 2 M90
Delstrigo Tier 2PD; QL (30 EA per 30 days)
Deltasone Tier 2 M90
Delyla $0 M90
Demeclocycline HCl Oral Tier 2 M90
Demser Tier 2 M90
Denavir Tier 2 M90
Denta 5000 Plus Tier 2 M90
DentaGel Tier 2 M90
DepoCyt Tier 1 M90
Depo-Estradiol Tier 2 M90
Depo-Medrol Injection Suspension 20 MG/ML
Tier 2 M90
43
Covered Product Reference Tier Status NotesDepo-Provera Intramuscular Suspension 400 MG/ML
$0 M90
Depo-SubQ Provera 104 Subcutaneous Suspension Prefilled Syringe
$0M90; QL (4 syringes every 300 days)
DermaDaily Tier 2 M90
Dermal Therapy Extra Strength Tier 2 M90
Dermal Therapy Face Care Tier 2 M90
Dermal Therapy Foot Massage Tier 2 M90
Dermal Therapy Hand/Elbow Tier 2 M90
Dermal Therapy Heel Care Tier 2 M90
Dermasorb AF Tier 2 M90
Dermasorb XM Tier 2 M90
DermaVantage Tier 2 M90
Descovy $0PD; QL (30 EA per 30 days)
Desenex External Cream Tier 2 M90
Desipramine HCl Oral Norpramin Tier 2 M90
Desloratadine Clarinex Tier 2M90; QL (30 EA per 90 days)
Desmopressin Ace Rhinal Tube Tier 2 M90
Desmopressin Ace Spray Refrig Tier 2 M90
Desmopressin Acetate Injection DDAVP Tier 2 M90
Desmopressin Acetate Oral DDAVP Tier 2 M90
Desmopressin Acetate PF DDAVP PF Tier 2 M90
Desmopressin Acetate Spray Tier 2 M90
Desogestrel-Ethinyl Estradiol Kariva $0 M90
Desonide External Cream DesOwen Tier 2ST; M90; QL (QL Applies)
Desonide External Lotion Tier 2ST; M90; QL (QL Applies)
Desonide External Ointment Tier 2ST; M90; QL (QL Applies)
Desoximetasone External Cream 0.05 % Topicort Tier 2 M90
Desoximetasone External Cream 0.25 % Topicort Tier 2ST; M90; QL (QL Applies)
Desoximetasone External Gel Topicort Tier 2ST; M90; QL (QL Applies)
Desoximetasone External Ointment 0.05 %
Topicort Tier 2 M90
Desoximetasone External Ointment 0.25 %
Topicort Tier 2ST; M90; QL (QL Applies)
44
Covered Product Reference Tier Status Notes
Desvenlafaxine ER Tier 2ST; M90; QL (30 EA per 90 days)
Desvenlafaxine Fumarate ER Tier 2 ST; M90
Dex LA 16 Tier 2 M90
Dexamethasone Intensol Tier 2 M90
Dexamethasone Oral Elixir Tier 2 M90
Dexamethasone Oral Solution Tier 2 M90
Dexamethasone Oral Tablet Decadron Tier 2 M90
Dexamethasone Oral Tablet Therapy Pack HiDex 6-Day Tier 2
Dexamethasone Sodium Phosphate Injection Solution 10 MG/ML, 100 MG/10ML, 120 MG/30ML, 20 MG/5ML
Tier 2 M90
Dexamethasone Sodium Phosphate Ophthalmic
Tier 2 M90
Dexcom G6 Receiver Tier 2PA; PD; QL (1 EA per 365 days)
Dexcom G6 Sensor Tier 2PA; PD; QL (3 EA per 30 days)
Dexcom G6 Transmitter Tier 2PA; PD; QL (1 EA per 90 days)
Dexedrine Oral Tablet Tier 2 M90; QL (QL Flag)
Dexilant Tier 2ST; M90; QL (30 EA per 90 days)
Dexmethylphenidate HCl Focalin Tier 2QL (90 EA per 30 days)
Dexrazoxane $0 M90
Dextroamphetamine Sulfate ER Dexedrine Tier 2QL (90 EA per 30 days)
Dextroamphetamine Sulfate Oral Solution ProCentra Tier 2QL (900 ML per 30 days)
Dextroamphetamine Sulfate Oral Tablet 10 MG, 5 MG
Zenzedi Tier 2QL (90 EA per 30 days)
Diabetes Health Formula ABC Plus Senior Tier 2 M90
Diabetic Tussin Allergy Tier 2 M90
DiabetiDerm External Lotion Tier 2 M90
DiabetiDerm Hand & Body Tier 2 M90
Diacomit Oral Capsule 250 MG Tier 2PA; SP; QL (360 capsules per month)
Diacomit Oral Capsule 500 MG Tier 2PA; SP; QL (180 EA per 30 days)
Diacomit Oral Packet 250 MG Tier 2PA; SP; QL (360 per month)
45
Covered Product Reference Tier Status Notes
Diacomit Oral Packet 500 MG Tier 2PA; SP; QL (180 EA per 30 days)
Dialyvite 800/Ultra D ABC Plus Senior Tier 2 M90
Dialyvite Supreme D Tier 2 M90
Dialyvite Vitamin D 5000 Tier 2 M90
Dialyvite Vitamin D3 Max Tier 2 M90
Diaper Rash External Ointment Boudreauxs Butt Paste Tier 2 M90
Diarrhea Kaopectate Tier 2 M90
diazePAM Injection Tier 2
Diazepam Intensol Tier 2
Diazepam Oral Concentrate Diazepam Intensol Tier 2
diazePAM Oral Solution 1 MG/ML Tier 2
diazePAM Oral Tablet Valium Tier 2
DiazePAM Rectal Diastat Pediatric Tier 2
Diazoxide Oral Proglycem Tier 2
Diclofenac Potassium Oral Tablet 50 MG Cataflam Tier 2 M90
Diclofenac Sodium ER Tier 2 M90
Diclofenac Sodium Ophthalmic Tier 2 M90
Diclofenac Sodium Oral Tier 2 M90
Diclofenac Sodium Transdermal Gel 1 % Aspercreme Arthritis Pain Tier 2M90; QL (100gm per month)
Diclofenac Sodium Transdermal Gel 3 % Tier 2 PA; M90
Diclofex DC Combination Therapy Pack 1.5 & 0.025 %
Tier 2 M90
Diclofex DC External Therapy Pack 1.5 & 0.025 %
Tier 2 M90
Diclotral Tier 2 M90
Dicloxacillin Sodium Tier 2 M90
Dicyclomine HCl Oral Tier 2 M90
Didanosine Tier 2 M90
Differin External Gel 0.1 % Tier 2
Dificid Oral Suspension Reconstituted Tier 2PA; QL (136 ML per 8 days)
Dificid Oral Tablet Tier 2PA; M90; QL (180 EA per 30 days)
Difil-G Forte Tier 2 M90
Diflunisal Oral Tier 2 M90
Difluprednate Durezol Tier 2ST; QL (5 ML per 30 days)
Digitek Tier 2 M90
46
Covered Product Reference Tier Status NotesDigox Tier 2 M90
Digoxin Oral Digitek Tier 2 M90
Dihydroergotamine Mesylate Nasal Migranal Tier 2 PA; M90
Dilantin Oral Capsule 30 MG Tier 2 M90
Dilatrate-SR Tier 2 M90
DilTIAZem CD Cartia XT Tier 1 M90
Diltiazem HCl ER Beads Taztia XT Tier 1 M90
Diltiazem HCl ER Coated Beads Cartia XT Tier 1 M90
dilTIAZem HCl ER Oral Capsule Extended Release 12 Hour
Tier 1 M90
dilTIAZem HCl ER Oral Capsule Extended Release 24 Hour 120 MG, 180 MG, 240 MG
Tier 1 M90
Diltiazem HCl Oral Cardizem Tier 1 M90
Dilt-XR Tier 1 M90
Dino-Life Tier 2 M90
Diocto Oral Liquid Docu Liquid Tier 2 M90
Diocto Oral Syrup Tier 2 M90
Dipentum Tier 2 M90
Diphen Oral Tablet Alka-Seltzer Plus Allergy Tier 2 M90
Diphenhydramine HCl Cap 25 MG Banophen Tier 2 M90
Diphenhydramine HCl Cap 50 MG Banophen Tier 2 M90
Diphenhydramine HCl Elixir 12.5 MG/5ML Oral Elixir 12.5 MG/5ML
Tier 2 M90
Diphenhydramine HCl Elixir 12.5 MG/5ML Oral Liquid 12.5 MG/5ML
Banophen Tier 2 M90
Diphenhydramine HCl Elixir 12.5 MG/5ML Oral Solution 5 MG/5ML
KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)
Diphenhydramine HCl Elixir 12.5 MG/5ML Oral Syrup 5 MG/5ML
Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
DiphenhydrAMINE HCl Injection Tier 2 M90
Diphenhydramine HCl Liquid 12.5 MG/5ML
Banophen Tier 2 M90
DiphenhydrAMINE HCl Oral Capsule Banophen Tier 2 M90
DiphenhydrAMINE HCl Oral Elixir Tier 2 M90
DiphenhydrAMINE HCl Oral Liquid 12.5 MG/5ML
Banophen Tier 2 M90
DiphenhydrAMINE HCl Oral Tablet 25 MG
Alka-Seltzer Plus Allergy Tier 2 M90
Diphenoxylate-Atropine Oral Liquid Tier 2 M90
47
Covered Product Reference Tier Status NotesDiphenoxylate-Atropine Oral Tablet 2.5-0.025 MG
Lomotil Tier 2 M90
Diphtheria-Tetanus Toxoids DT $0 M90
Dipyridamole Intravenous Tier 2 M90
Dipyridamole Oral Tier 2 M90
Disopyramide Phosphate Oral Norpace Tier 2 M90
Disulfiram Oral Tier 2 M90
Diuril Tier 2 M90
Divalproex Sodium ER Oral Tablet Extended Release 24 Hour
Depakote ER Tier 2 M90
Divalproex Sodium Oral Capsule Delayed Release Sprinkle
Depakote Sprinkles Tier 2 M90
Divalproex Sodium Oral Tablet Delayed Release
Depakote Tier 2 M90
Divigel Transdermal Gel 0.25 MG/0.25GM, 0.5 MG/0.5GM, 1 MG/GM
Tier 2 M90
Divigel Transdermal Gel 0.75 MG/0.75GM
Tier 2
DML Tier 2 M90
DocQLace Correctol Extra Gentle Tier 2 M90
Docu Oral Liquid Docu Liquid Tier 2 M90
Docu Soft Correctol Extra Gentle Tier 2 M90
Docuprene DOK Tier 2 M90
Docusate Sodium Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90
Docusate Sodium Oral Liquid 50 MG/5ML
Docu Liquid Tier 2 M90
Docusate Sodium Oral Tablet DOK Tier 2 M90
Docusil Tier 2 M90
Dofetilide Tikosyn Tier 2 SP; QL (QL Flag)
Dojolvi Tier 2 PA; SP
DOK Oral Capsule 100 MG Tier 2 M90
DOK Oral Tablet Tier 2 M90
Dologesic Oral Tablet 30-500 MG Tier 2 M90
Donepezil HCl Aricept Tier 2 M90
Donnatal Oral Elixir Tier 2 M90
Doptelet Oral Tablet 20 MG Tier 2 PA; SP
Dorzolamide HCl Ophthalmic Trusopt Tier 2 M90
Dorzolamide HCl-Timolol Mal Cosopt Tier 2 M90
Dovato Tier 2PD; QL (30 EA per 30 days)
48
Covered Product Reference Tier Status NotesDoxazosin Mesylate Oral Cardura Tier 1 M90
Doxepin HCl External Prudoxin Tier 2
ST; M90; QL (45 grams with a maximum fill of 30 days)
Doxepin HCl Oral Capsule Tier 2 M90
Doxepin HCl Oral Concentrate Tier 2 M90
Doxercalciferol Oral Tier 2 M90
DOXOrubicin HCl Adriamycin $0 M90
DOXOrubicin HCl Liposomal Doxil $0 M90
Doxycycline Hyclate Oral Capsule Vibramycin Tier 2 M90
Doxycycline Hyclate Oral Tablet 100 MG Lymepak Tier 2 M90
Doxycycline Hyclate Oral Tablet 150 MG, 75 MG
Acticlate Tier 2 M90
Doxycycline Hyclate Oral Tablet 20 MG Tier 2 M90
Doxycycline Monohydrate Oral Capsule 100 MG
Mondoxyne NL Tier 2 M90
Doxycycline Monohydrate Oral Capsule 50 MG
Tier 2 M90
Doxycycline Monohydrate Oral Suspension Reconstituted
Vibramycin Tier 2 M90
Doxycycline Monohydrate Oral Tablet Tier 2 M90
Doxylamine-Pyridoxine Diclegis Tier 2PA; QL (120 EA per 30 days)
Dr Edwards Olive Laxative Tier 2 M90
Dr Gs Clear Nail Tier 2 M90
Dr Smiths Diaper Tier 2
Dramamine Less Drowsy Tier 2 M90
Drihep Arterial Line Syringe Tier 2 M90
Drihep Plus Prefilled Syringe Tier 2 M90
Dritho-Creme HP Tier 2 M90
Dronabinol Marinol Tier 2QL (60 capsules per month)
Droplet Pen Needles 29G X 10MM Tier 2 M90
Droplet Pen Needles 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 MM
$0 M90
Droplet Pen Needles 32G X 8 MM Tier 1 M90
Drospiren-Eth Estrad-Levomefol Oral Tablet 3-0.02-0.451 MG
Beyaz $0 M90
49
Covered Product Reference Tier Status NotesDrospirenone-Ethinyl Estradiol Ocella $0 M90
Droxia Tier 2 M90
Drug Mart Unifine Pentips CareFine Pen Needles $0 M90
Drug Mart Unifine Pentips Plus BD Pen Needle Nano U/F $0 M90
Drysol Tier 2 M90
DSS Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90
Duavee Tier 2M90; QL (30 EA per 90 days)
Ducodyl Alophen Tier 2 M90
Dulcolax Balance Tier 2 M90
Dulcolax Milk of Magnesia Tier 2 M90
Dulcolax Stool Softener Tier 2 M90
Dulera Inhalation Aerosol 100-5 MCG/ACT, 200-5 MCG/ACT
Tier 2 M90
Dulera Inhalation Aerosol 50-5 MCG/ACT
Tier 2
DULoxetine HCl Oral Capsule Delayed Release Particles 20 MG
Cymbalta Tier 2M90; QL (60 EA per 30 days)
DULoxetine HCl Oral Capsule Delayed Release Particles 30 MG, 60 MG
Cymbalta Tier 2M90; QL (30 EA per 90 days)
Dupixent Subcutaneous Solution Pen-Injector
Tier 2PA; SP; QL (2 PENS per 28 days)
Dupixent Subcutaneous Solution Prefilled Syringe
Tier 2PA; SP; QL (2 SYR per 28 days)
Duraxin Tier 2 M90
Durolane Intra-Articular Tier 2PA; SP; Dual; QL (1 SYR per 1 APPROVAL)
Durysta MB PA
Dutasteride Oral Avodart Tier 2 M90
Dutoprol Tier 2 M90
Dyanavel XR Tier 2 PA
Dyspel Medi-Profen Tier 2 M90
Dysport Tier 2PA; SP; QL (QL Flag); Dual
Ear Drops Murine Ear Tier 2 M90
Ear Wax Removal Drops Murine Ear Tier 2 M90
Ear Wax Removal Kit Murine Ear Tier 2 M90
Ear Wax Removal System Otic Solution Murine Ear Tier 2 M90
Earwax Treatment Drops Murine Ear Tier 2 M90
50
Covered Product Reference Tier Status NotesEasy Comfort Pen Needles 31G X 5 MM , 31G X 8 MM
Advocate Insulin Pen Needles
$0 M90
Easy Comfort Pen Needles 31G X 6 MM CareFine Pen Needles $0 M90
Easy Comfort Pen Needles 32G X 4 MM BD Pen Needle Nano U/F $0 M90
Easy Touch Pen Needles 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 MM
$0 M90
Easygel Dental Tier 2 M90
Easy-Lax Correctol Extra Gentle Tier 2 M90
Ecolovit ABC Plus Senior Tier 2 M90
Econazole Nitrate External Tier 2 PA; M90
EContra EZ $0 M90
EContra One-Step $0
ED Cyte F Tier 2 M90
Ed-APAP Little Remedies for Fever Tier 2 M90
Edarbi Tier 2 ST; M90
Ed-Chlortan Wal-finate Tier 2 M90
Ed-Flex Tier 2 M90
Ed-Spaz NuLev Tier 2 M90
Edurant Tier 2QL (60 EA per 30 days)
EEMT Tier 2 M90
EEMT HS Tier 2 M90
Efavirenz Oral Capsule Sustiva Tier 2 SP
Efavirenz-Emtricitab-Tenofovir Atripla Tier 2QL (30 EA per 30 days)
Efavirenz-lamiVUDine-Tenofovir Symfi Tier 2QL (30 EA per 30 days)
Effer-K Tier 2 M90
Effervescent Pot Chloride Tier 2 M90
Effient Tier 2 M90
Elaprase MB PA
Elelyso MB PA
Elestrin Tier 2 M90
Eletriptan Hydrobromide Relpax Tier 2M90; QL (12 tablets per month)
Elidel Tier 2BP; QL (60 GM per 30 days)
Eligard $0 PA; SP; Dual
51
Covered Product Reference Tier Status NotesElinest $0 M90
Eliquis Tier 2 PD
Eliquis DVT/PE Starter Pack Oral Tablet Therapy Pack
Tier 2 PD
Elite Zinc Tier 2 M90
Elitek $0 M90
Elixophyllin Tier 2 M90
Ella $0 M90
Elmiron Tier 2 M90
Eloctate Tier 2 PA; SP; Dual
Elta External Lotion Tier 2 M90
Emadine Tier 2ST; M90; QL (10ml per 25 days)
Embeda Oral Capsule Extended Release 100-4 MG
Tier 2ST; QL (QL applies. Click;HERE)
Embeda Oral Capsule Extended Release 20-0.8 MG, 30-1.2 MG
Tier 2ST; QL (60 EA per 30 days)
Embeda Oral Capsule Extended Release 50-2 MG, 60-2.4 MG, 80-3.2 MG
Tier 2ST; QL (30 EA per 90 days)
Emcyt $0 M90
Emend Oral Capsule Tier 2 M90; QL (QL Flag)
Emflaza Tier 2 PA; SP
Emgality Tier 2PA; QL (1 PEN per 30 days)
Emgality (300 MG Dose) Tier 2PA; PD; QL (3 PENS per 30 days)
Emollia-Lotion Tier 2 M90
Emoquette $0 M90
Empliciti $0 SP
Emsam Tier 2PA; M90; QL (30 EA per 90 days)
Emtricitabine Emtriva Tier 2QL (30 EA per 30 days)
Emtricitabine-Tenofovir DF Truvada $0QL (30 EA per 30 days)
Emtriva Oral Solution Tier 2SP; QL (680 ml per 28 days)
Enalapril Maleate Oral Solution Epaned Tier 1
Enalapril Maleate Oral Tablet Vasotec Tier 1 M90
Enalapril-Hydrochlorothiazide Vaseretic Tier 1 M90
52
Covered Product Reference Tier Status Notes
Enbrel Mini Tier 2PA; SP; PD; QL (4 EA per 28 days)
Enbrel Subcutaneous Solution 25 MG/0.5ML
Tier 2PA; SP; PD; QL (4 VIALS per 28 days)
Enbrel Subcutaneous Solution Prefilled Syringe
Tier 2PA; SP; PD; QL (4 SYR per 28 days)
Enbrel Subcutaneous Solution Reconstituted
Tier 2PA; SP; PD; QL (4 VIALS per 28 days)
Enbrel SureClick Subcutaneous Solution Auto-Injector
Tier 2PA; SP; PD; QL (4 PENS per 28 days)
Encare Vaginal Suppository $0 M90
Endocet Oral Tablet 10-325 MG Tier 2M90; QL (180 EA per 30 days)
Endocet Oral Tablet 2.5-325 MG, 5-325 MG
Tier 2M90; QL (360 tablets per 30 days. Click;HERE)
Endocet Oral Tablet 7.5-325 MG Tier 2M90; QL (240 tablets per 30 days. Click;HERE)
Endometrin Tier 2 M90
Endur-Acin Oral Tablet Extended Release 250 MG, 500 MG
Tier 1 M90
Enema Fleet Enema Tier 2 M90
Enema Disposable Rectal Fleet Enema Tier 2 M90
Enema Pediatric Fleet Pediatric Tier 2 M90
Enfamil Enfalyte Tier 2 M90
Engerix-B Injection Suspension 10 MCG/0.5ML, 20 MCG/ML
$0 M90
Engerix-B Intramuscular $0 M90
Enlon Tier 2 M90
Enoxaparin Sodium Lovenox Tier 2 M90
Enpresse-28 $0 M90
Enskyce Oral Tablet 0.15-30 MG-MCG $0 M90
Enspryng Tier 2PA; SP; QL (1 SYR per 28 days)
Entacapone Comtan Tier 2 M90
Entecavir Baraclude Tier 2SP; QL (30 EA per 90 days)
Entresto Tier 2PA; QL (60 EA per 30 days)
Entyvio Tier 2PA; SP; QL (Quantity Limit Applies); Dual
53
Covered Product Reference Tier Status NotesEnulose Tier 2 M90
Envarsus XR Tier 2 SP; QL (QL Flag)
Epaned Oral Solution Reconstituted Tier 2 M90
Epclusa Oral Tablet 200-50 MG Tier 2PA; SP; QL (28 EA per 28 days)
Epidiolex Tier 2 PA; SP
Epifoam Tier 2 ST; M90
Epilyt Tier 2 M90
Epinastine HCl Tier 2ST; M90; QL (5ml per 25 days)
EPINEPHrine HCl Injection Solution 1 MG/ML
Tier 2 M90
EPINEPHrine Injection Solution Auto-Injector 0.15 MG/0.15ML
Auvi-Q Tier 2QL (2 pens per fill, 1 fill per day)
EPINEPHrine Injection Solution Auto-Injector 0.15 MG/0.3ML
EpiPen Jr 2-Pak Tier 2QL (2 pens per fill, 1 fill per day)
EPINEPHrine Injection Solution Auto-Injector 0.3 MG/0.3ML
Auvi-Q Tier 2QL (2 PENS per 28 days)
EPINEPHrine Intravenous Solution Prefilled Syringe 0.1 MG/10ML
Tier 2 QL (2 PENS per 1 Fill)
EpiRUBicin HCl Intravenous Solution 200 MG/100ML, 50 MG/25ML
Ellence $0 M90
Epitol Tier 2 M90
Epivir HBV Oral Solution Tier 2 QL (600ml per month)
Eplerenone Inspra Tier 1 M90
Epogen Injection Solution 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML
Tier 2 PA; SP; Dual
Epoprostenol Sodium Flolan Tier 2 PA; SP; Dual
Eprosartan Mesylate Tier 1 ST; M90
EQ AcetaminophenHealthy Mama Shake That Ache
Tier 2 M90
EQ Acetaminophen Childrens Oral Suspension
PediaCare Children Tier 2 M90
EQ Acid Reducer Tier 2 M90
EQ Acid Reducer Max StMM Acid-Pep Maximum Strength
Tier 2 M90
EQ Allergy Banophen Tier 2 M90
EQ Allergy Relief (Cetirizine) KLS Aller-Tec Tier 2 M90; QL (QL Flag)
EQ Allergy Relief Nasal ClariSpray Tier 2 M90
EQ Allergy Relief Oral Capsule Banophen Tier 2 M90
54
Covered Product Reference Tier Status NotesEQ Allergy Relief Oral Tablet 10 MG KLS AllerClear Tier 2 M90; QL (QL Flag)
EQ Allergy Relief Oral Tablet 180 MG KLS Aller-Fex Tier 2 M90; QL (QL Flag)
EQ Allergy Relief Oral Tablet 25 MG Alka-Seltzer Plus Allergy Tier 2 M90
EQ Antacid Extra Strength Oral Tablet Chewable 750 MG
CVS Chewy Not Chalky Flavor
Tier 2 M90
EQ Antacid Oral Tablet Chewable Cal-Gest Antacid Tier 2 M90
EQ Antacid Ultra Strength Tums Ultra 1000 Tier 2 M90
EQ Anti-Diarrheal Oral Capsule Imodium A-D Tier 2 M90
EQ Antifungal Desenex Tier 2 M90
EQ Anti-Itch Max Strength Aveeno Anti-Itch Max St Tier 2 M90
EQ Arthritis Pain Midol Tier 2 M90
EQ Aspirin Oral Tablet Delayed Release 500 MG
Tier 2 M90
EQ Athletes Foot (tolnaftate) Tinactin Tier 2 M90
EQ Athletes Foot External Cream Desenex Tier 2 M90
EQ Calcium 500+D Os-Cal Calcium + D3 Tier 2 M90
EQ Calcium 600+D Oral Tablet 600-800 MG-UNIT
Pronutrients Calcium+D3 Tier 2 M90
EQ Calcium 600+D+MineralsCaltrate 600+D Plus Minerals
Tier 2 M90
EQ Calcium Citrate+D Calcitrate Tier 2 M90
EQ Childrens Loratadine Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
EQ Childrens Pain Reliever PediaCare Children Tier 2 M90
EQ Chlortabs Wal-finate Tier 2 M90
EQ ClearLax Tier 2 M90
EQ Complete Multivit Adult 50+ ABC Plus Senior Tier 2 M90
EQ Complete Multivitamin-Adult ABC Plus Senior Tier 2 M90
EQ Ear Wax Removal Aid Murine Ear Tier 2 M90
EQ Enema Fleet Enema Tier 2 M90
EQ Eye Itch Relief Alaway Tier 2 M90; QL (QL Flag)
EQ Gentle Laxative Alophen Tier 2 M90
EQ Heartburn Relief Tagamet HB Tier 2 M90
EQ Hydrocortisone Max St Aveeno Anti-Itch Max St Tier 2 M90
EQ Hydrocortisone Plus Aveeno Anti-Itch Max St Tier 2 M90
EQ Ibuprofen Childrens Childrens Medi-Profen Tier 2 M90
EQ Ibuprofen Infants Medi-Profen Tier 2 M90
EQ Ibuprofen Junior Advil Junior Strength Tier 2 M90
EQ Ibuprofen Oral Tablet Medi-Profen Tier 2 M90
55
Covered Product Reference Tier Status Notes
EQ Infants Gas ReliefLittle Remedies for Tummys
Tier 2 M90
EQ Itchy Eye Drops Alaway Tier 2 M90; QL (QL Flag)
EQ Jock Itch Desenex Tier 2 M90
EQ Laxative Maximum Strength Tier 2 M90
EQ Loratadine Oral Tablet KLS AllerClear Tier 2 M90; QL (QL Flag)
EQ Magnesium Citrate Citroma Tier 2 M90
EQ Miconazole 1 Monistat 1 Combo Pack Tier 2 M90
EQ Miconazole 3 Combo Pack Vagistat-3 Tier 2 M90
EQ Miconazole 7 Monistat 7 Simply Cure Tier 2 M90
EQ Miconazole 7 Day Treatment Monistat 7 Simply Cure Tier 2 M90
EQ Milk of Magnesia Oral Suspension 1200 MG/15ML
Dulcolax Milk of Magnesia
Tier 2 M90
EQ Mineral Oil Tier 2 M90
EQ Motion Sickness Relief Oral Tablet 25 MG
Wal-Dram II Tier 2 M90
EQ Naproxen Sodium Oral Tablet Mediproxen Tier 2 M90
EQ Natural Laxative Evac-U-Gen Tier 2 M90
EQ Natural Vegetable Laxative Evac-U-Gen Tier 2 M90
EQ Nicotine Mouth/Throat Gum 4 MG KLS Quit4 $0 M90
EQ Nicotine Mouth/Throat Lozenge KLS Quit4 $0 M90
EQ Nicotine Polacrilex KLS Quit2 $0 M90
EQ Nicotine Step 3 Nicoderm CQ $0 M90
EQ Nicotine Transdermal Nicoderm CQ $0 M90
EQ One Daily Mens Health ABC Plus Senior Tier 2 M90
EQ One Daily Womens Health ABC Plus Senior Tier 2 M90
EQ Pain & Fever Childrens Oral Suspension
PediaCare Children Tier 2 M90
EQ Pain & Fever Infants PediaCare Children Tier 2 M90
EQ Pain Reliever Oral Tablet 325 MG Aphen Tier 2 M90
EQ raNITIdine Oral Tablet 75 MG Tier 2 M90
EQ Saline Nasal Spray Afrin Saline Nasal Mist Tier 1 M90
EQ Stomach Relief Oral Suspension Kaopectate Tier 2 M90
EQ Stool Softener Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90
EQ Suphedrine Oral Tablet SudoGest Tier 2 M90
EQ Tolnaftate Tinactin Tier 2 M90
EQ Vegetable Laxative Evac-U-Gen Tier 2 M90
EQ Womans Laxative Alophen Tier 2 M90
EQ Womens Laxative Alophen Tier 2 M90
56
Covered Product Reference Tier Status Notes
EQL Absolute Moisture Dry SkinA + D Personal Care Lotion
Tier 2 M90
EQL Acetaminophen Childrens PediaCare Children Tier 2 M90
EQL Acetaminophen Ex StHealthy Mama Shake That Ache
Tier 2 M90
EQL Acetaminophen Oral Tablet Aphen Tier 2 M90
EQL Acid Reducer Oral Tablet 150 MG, 75 MG
Tier 2 M90
EQL All Day Allergy KLS Aller-Tec Tier 2 M90; QL (QL Flag)
EQL All Day Allergy Childrens KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)
EQL Aller-ease KLS Aller-Fex Tier 2 M90; QL (QL Flag)
EQL Allergy Oral Tablet 25 MG Alka-Seltzer Plus Allergy Tier 2 M90
EQL Allergy Relief Oral Capsule Banophen Tier 2 M90
EQL Allergy Relief Oral Tablet 10 MG KLS AllerClear Tier 2 M90; QL (QL Flag)
EQL Allergy Relief Oral Tablet 25 MG Alka-Seltzer Plus Allergy Tier 2 M90
EQL Antacid Ultra Strength Tums Ultra 1000 Tier 2 M90
EQL Antifungal Desenex Tier 2 M90
EQL Antifungal (Tolnaftate) Tinactin Tier 2 M90
EQL Anti-Itch Intensive Heal Aveeno Anti-Itch Max St Tier 2 M90
EQL Anti-Itch Maximum Strength Aveeno Anti-Itch Max St Tier 2 M90
EQL Arthritis Pain Relief Midol Tier 2 M90
EQL Athletes Foot External Cream Desenex Tier 2 M90
EQL B-6 Tier 2 M90
EQL Baby Basics Diaper Rash Boudreauxs Butt Paste Tier 2 M90
EQL Calcium Citrate/Vitamin D Calcitrate Tier 2 M90
EQL Calcium Citrate/Vitamin D3 Calcitrate Tier 2 M90
EQL Calcium/Vitamin D Tier 2 M90
EQL Calcium/Vitamin D3 Pronutrients Calcium+D3 Tier 2 M90
EQL Century ABC Plus Senior Tier 2 M90
EQL Century Mature ABC Plus Senior Tier 2 M90
EQL Century Mature Adults 50+ ABC Plus Senior Tier 2 M90
EQL Century Mature Men 50+ ABC Plus Senior Tier 2 M90
EQL Century Mature Women 50+ ABC Plus Senior Tier 2 M90
EQL Century Mens ABC Plus Senior Tier 2 M90
EQL Century Womens ABC Plus Senior Tier 2 M90
EQL Childrens Allergy Banophen Tier 2 M90
EQL Childrens Ibuprofen Childrens Medi-Profen Tier 2 M90
EQL ClearLax Tier 2 M90
EQL Fluticasone Propionate ClariSpray Tier 2 M90
57
Covered Product Reference Tier Status NotesEQL Gentle Laxative Alophen Tier 2 M90
EQL Heartburn Prevention Pepcid AC Tier 2 M90
EQL Ibuprofen Infants Medi-Profen Tier 2 M90
EQL Ibuprofen Junior Strength Advil Junior Strength Tier 2 M90
EQL Ibuprofen Oral Tablet Medi-Profen Tier 2 M90
EQL Infants Gas ReliefLittle Remedies for Tummys
Tier 2 M90
EQL Laxative Maximum Strength Tier 2 M90
EQL Laxative Oral Tablet Tier 2 M90
EQL Laxative Oral Tablet Delayed Release
Alophen Tier 2 M90
EQL Miconazole 1 Monistat 1 Combo Pack Tier 2 M90
EQL Miconazole 3 Vagistat-3 Tier 2 M90
EQL Miconazole 7 Monistat 7 Simply Cure Tier 2 M90
EQL Milk of MagnesiaDulcolax Milk of Magnesia
Tier 2 M90
EQL Naproxen Sodium Oral Tablet Mediproxen Tier 2 M90
EQL Nasal Decongestant SudoGest Tier 2 M90
EQL Natural Zinc IS-ZC 50 Tier 2 M90
EQL Nicotine Mouth/Throat KLS Quit4 Tier 1 M90
EQL Nicotine Polacrilex KLS Quit4 $0 M90
EQL One Daily Mens ABC Plus Senior Tier 2 M90
EQL One Daily Mens 50+ Advance ABC Plus Senior Tier 2 M90
EQL One Daily Mens Health ABC Plus Senior Tier 2 M90
EQL One Daily Womens 50+ Adv ABC Plus Senior Tier 2 M90
EQL Pain & Fever Infants PediaCare Children Tier 2 M90
EQL Prenatal Formula Tier 1 M90
EQL Ready-to-Use Enema Rectal Enema 7-19 GM/118ML
Fleet Enema Tier 2 M90
EQL Saline Nasal Spray Afrin Saline Nasal Mist Tier 1 M90
EQL Senna Laxative Evac-U-Gen Tier 2 M90
EQL Stomach Relief Oral Suspension Kaopectate Tier 2 M90
EQL Stool Softener Correctol Extra Gentle Tier 2 M90
EQL Ultra Moisturizing DailyA + D Personal Care Lotion
Tier 2 M90
EQL Vision Formula ABC Plus Senior Tier 2 M90
EQL Vitamin D3 GummiesVitaJoy Daily D Gummies
Tier 2 M90
EQL Vitamin D3 Oral Capsule 125 MCG (5000 UT)
Dialyvite Vitamin D 5000 Tier 2 M90
58
Covered Product Reference Tier Status NotesEQL Vitamin D3 Oral Capsule 25 MCG (1000 UT)
Pronutrients Vitamin D3 Tier 2 M90
EQL Vitamin D3 Oral Capsule 50 MCG (2000 UT)
Tier 2 M90
Equetro Tier 2 M90
Erbitux MB PA
Ergocalciferol Oral Solution 8000 UNIT/ML
Calcidol Tier 2 M90
Ergoloid Mesylates Oral Tier 2 M90
Ergomar Tier 2 M90
Erivedge $0SP; QL (30 EA per 90 days)
Erleada $0QL (120 EA per 30 days)
Erlotinib HCl Tarceva $0
E-R-O Ear Drops Tier 2 M90
E-R-O Ear Wax Removal System Tier 2 M90
Errin $0 M90
Ertaczo Tier 2 ST; M90
Ery Tier 2 M90
Ery-Tab Tier 2 M90
Erythrocin Stearate Oral Tablet 250 MG Tier 2 M90
Erythromycin Base Oral Capsule Delayed Release Particles
Tier 2 M90
Erythromycin Base Oral Tablet Tier 2 M90
Erythromycin Ethylsuccinate Oral Suspension Reconstituted 200 MG/5ML
E.E.S. Granules Tier 2 M90
Erythromycin Ethylsuccinate Oral Suspension Reconstituted 400 MG/5ML
EryPed 400 Tier 2
Erythromycin Ethylsuccinate Oral Tablet E.E.S. 400 Tier 2 M90
Erythromycin External Erygel Tier 2 M90
Erythromycin Ophthalmic Tier 2 M90
Esbriet Oral Capsule Tier 2PA; SP; QL (270 capsules per 30 days)
Esbriet Oral Tablet 267 MG Tier 2PA; SP; QL (QL Applies)
Esbriet Oral Tablet 801 MG Tier 2PA; SP; QL (90 EA per 30 days)
Escitalopram Oxalate Oral Solution Tier 2 M90
Escitalopram Oxalate Oral Tablet 10 MG, 5 MG
Lexapro Tier 2QL (30 EA per 90 days)
59
Covered Product Reference Tier Status Notes
Escitalopram Oxalate Oral Tablet 20 MG Lexapro Tier 2QL (60 EA per 30 days)
Esgic Oral Capsule Tier 2 M90
Esomeprazole Magnesium Oral Packet NexIUM Tier 2ST; QL (30 EA per 30 days)
Esperoct Tier 2 PA; SP; Dual
Essential Balance ABC Plus Senior Tier 2 M90
Est Estrogens-Methyltest DS Covaryx Tier 2 M90
Est Estrogens-Methyltest HS Covaryx HS Tier 2 M90
Est Estrogens-Methyltest Oral Tablet 1.25-2.5 MG
Covaryx Tier 2 M90
Estarylla $0 M90
Estazolam Oral Tablet 1 MG Tier 2
Estazolam Oral Tablet 2 MG Tier 2 M90
Estradiol Oral Estrace Tier 2 M90
Estradiol Transdermal Alora Tier 2 M90
Estradiol Vaginal Cream Estrace Tier 2
Estradiol Valerate Intramuscular Oil 20 MG/ML, 40 MG/ML
Delestrogen Tier 2 M90
Estradiol-Norethindrone Acet Amabelz Tier 2 M90
Estring Tier 2 M90
Estrogel Tier 2 M90
Estropipate Oral Tier 2 M90
Eszopiclone Lunesta Tier 2ST; QL (30 EA per 30 days)
Ethacrynic Acid Oral Edecrin Tier 1 M90
Ethambutol HCl Oral Tier 2 M90
Ethosuximide Oral Zarontin Tier 2 M90
Ethynodiol Diac-Eth Estradiol Kelnor 1/35 $0
Etidronate Disodium Tier 2 M90
Etodolac ER Tier 2 M90
Etodolac Oral Tier 2 M90
Etonogestrel-Ethinyl Estradiol EluRyng $0
Etopophos $0 M90
Etoposide Intravenous Solution 1 GM/50ML, 100 MG/5ML, 500 MG/25ML
Toposar $0 M90
Etoposide Oral $0 M90
Etravirine Oral Tablet 100 MG Intelence Tier 2QL (120 EA per 30 days)
60
Covered Product Reference Tier Status Notes
Etravirine Oral Tablet 200 MG Intelence Tier 2QL (60 EA per 30 days)
Eucerin Daily Protection/SPF30 Tier 2 M90
Eucerin External Lotion Tier 2 M90
Eucerin Intensive Repair Tier 2 M90
Eucerin Original Healing Tier 2 M90
Eucerin Plus External Lotion Tier 2 M90
Eucerin Smoothing Repair Tier 2 M90
Eucrisa Tier 2PA; PD; QL (60 GM per 30 days)
Euflexxa Intra-Articular Solution Prefilled Syringe
Tier 2PA; SP; QL (QL Applies); Dual
Eurax Tier 2 M90
Evac-U-Gen Oral Tablet Tier 2 M90
Evamist Tier 2 M90
Everolimus Oral Tablet 0.25 MG, 0.5 MG, 0.75 MG
Zortress Tier 2 QL (QL Applies)
Everolimus Oral Tablet Soluble 2 MG Afinitor Disperz $0PA; QL (60 EA per 30 days)
Everolimus Oral Tablet Soluble 3 MG Afinitor Disperz $0PA; QL (90 EA per 30 days)
Everolimus Oral Tablet Soluble 5 MG Afinitor Disperz $0PA; QL (30 EA per 30 days)
Evkeeza MB PA
Evomela $0 SP
Evotaz Tier 2QL (30 EA per 90 days)
Evrysdi Tier 2PA; SP; QL (2 BOTTLES per 24 Days)
Evzio Tier 2PA; QL (1 FILL per 365 days)
Exel Comfort Point Pen Needle 29G X 12MM , 31G X 6 MM , 31G X 8 MM
$0 M90
Exel Comfort Point Pen Needle 31G X 4 MM
Tier 1 M90
Exemestane Aromasin $0 M90
Ex-Lax Ultra Tier 2 M90
Exoderm External Lotion Tier 2 M90
Exondys 51 MB PA
Exotic-HC Cortic-ND Tier 2 M90
61
Covered Product Reference Tier Status Notes
Extavia Subcutaneous Kit Tier 2SP; QL (15 per 30 days)
Extra Strength Pain ReliefHealthy Mama Shake That Ache
Tier 2 M90
Eye Allergy Relief Ophthalmic Solution 0.025-0.3 %
Naphcon-A Tier 2 M90
Eye Itch Relief Alaway Tier 2 M90; QL (QL Flag)
Eye Vitamins & Minerals ABC Plus Senior Tier 2 M90
EyeProtect ABC Plus Senior Tier 2 M90
Eylea Intraocular Tier 2 PA; SP; QL (QL Flag)
Eylea Intravitreal Tier 2 PA; SP; Dual
E-Z-Cat Dry Tier 2 M90
Ezetimibe Zetia Tier 2ST; QL (30 EA per 90 days)
Fabior Tier 2 ST; M90
Fabrazyme Tier 2 PA; SP; Dual
Factive Tier 2 M90
FaLessa Oral Kit 20-1-0.1 MCG-MG $0 M90
Fallback Solo $0 M90
Falmina $0 M90
Famciclovir Oral Tier 2 M90
Famotidine OralMM Acid-Pep Maximum Strength
Tier 2 M90
Famotidine Tab 20 MGMM Acid-Pep Maximum Strength
Tier 2 M90
Fanapt Tier 2M90; QL (60 EA per 30 days)
Fanapt Titration Pack Tier 2M90; QL (1 PACK per 28 days)
Farxiga Tier 2M90; QL (30 EA per 30 days)
Farydak $0 SP; QL (QL Flag)
Fasenra Tier 2PA; SP; Dual; QL (1 SYR per 56 days)
Fasenra Pen Tier 2PA; SP; Dual; QL (1 PEN per 56 days)
FC Female Condom Tier 1M90; QL (4 EA per 30 days)
FE C Tab Plus Icar-C Plus Tier 2 M90
FE Plus Protein Tier 2 M90
Fe Tabs Tier 2 M90
62
Covered Product Reference Tier Status NotesFebrol Tier 2 M90
Febuxostat Uloric Tier 2ST; QL (30 EA per 90 days)
Feenamint Tier 2 M90
Feiba Tier 2 PA; SP; Dual
Feiba NF Tier 2 PA; SP; Dual
Feiba VH Immuno Tier 2 PA; SP; Dual
Felbamate Felbatol Tier 2 M90
Felodipine ER Tier 1 M90
FemCap Tier 2 M90
Femring Tier 2 M90
Femynor $0 M90
Fenofibrate Micronized Oral Capsule 130 MG, 134 MG, 200 MG, 43 MG, 67 MG
Tier 1 M90
Fenofibrate Oral Capsule 150 MG, 50 MG Lipofen Tier 1 M90
Fenofibrate Oral Tablet 145 MG, 48 MG Tricor Tier 1 M90
Fenofibrate Oral Tablet 160 MG, 54 MG Tier 1 M90
Fenofibrate Oral Tablet 40 MG Fenoglide Tier 1 M90
Fenofibric Acid Fibricor Tier 1 M90
Fenoprofen Calcium Oral Tablet Nalfon Tier 2
Fensolvi (6 Month) Tier 2PA; SP; Dual; QL (1 KIT per 180 Days)
FentaNYL Citrate Buccal Lozenge On A Handle
Actiq Tier 2 PA
fentaNYL Citrate Buccal Tablet Fentora Tier 2 PA; QL (QL Applies)
FentaNYL Transdermal Patch 72 Hour 100 MCG/HR, 50 MCG/HR, 75 MCG/HR
Tier 2 ST; QL (QL applies)
FentaNYL Transdermal Patch 72 Hour 12 MCG/HR, 25 MCG/HR
Tier 2ST; QL (10 EA per 30 days)
Ferate Oral Tablet 240 (27 Fe) MG Tier 2 M90
Fergon Tier 2 M90
Fer-Iron BProtected Pedia Iron Tier 2 M90
Ferocon Tricon Tier 2 M90
FeroSul Oral Elixir $0 M90
Ferotrinsic Tricon Tier 2 M90
Ferrex 150 Forte Oral Capsule 150-25-1 MG-MCG-MG
iFerex 150 Forte Tier 2 M90
Ferriprox Oral Tablet 1000 MG Tier 2 PA; SP
Ferriprox Twice-A-Day Tier 2 PA; SP
Ferrotabs Ferate Tier 2 M90
63
Covered Product Reference Tier Status NotesFerrous Aspartate Tier 2 M90
Ferrous Gluconate Oral Tablet 240 (27 Fe) MG
Ferate Tier 2 M90
Ferrous Gluconate Oral Tablet 324 (38 Fe) MG, 325 (36 Fe) MG
Tier 2 M90
Ferrous Sulfate Oral Elixir $0 M90
Ferrous Sulfate Oral Liquid $0 M90
Ferrous Sulfate Oral Solution 75 (15 Fe) MG/ML
BProtected Pedia Iron $0 M90
Ferrous Sulfate Oral Syrup Tier 1 M90
Ferrous Sulfate Oral Tablet 27 MG Tier 2 M90
Ferrous Sulfate Oral Tablet Delayed Release 324 (65 Fe) MG, 325 (65 Fe) MG
Tier 2 M90
Fetzima Tier 2ST; M90; QL (30 EA per 90 days)
Fetzima Titration Tier 2ST; M90; QL (1 PACK per 28 days)
Fever Reducer Childrens FeverAll Childrens Tier 2 M90
FeverAll Childrens Tier 2 M90
FeverAll Junior Strength Tier 2 M90
Fexofenadine HCl Childrens Allegra Allergy Childrens Tier 2M90; QL (300ml per month)
Fexofenadine HCl Oral Tablet 180 MG KLS Aller-Fex Tier 2 M90; QL (QL Flag)
Fexofenadine HCl Oral Tablet 60 MG Wal-Fex Allergy Tier 2 M90; QL (QL Flag)
Fexofenadine-Pseudoephed ER Oral Tablet Extended Release 12 Hour
Wal-Fex D Allergy & Congestion
Tier 2M90; QL (60 EA per 30 days)
Fexofenadine-Pseudoephed ER Oral Tablet Extended Release 24 Hour
Wal-Fex D Allergy & Congestion
Tier 2 M90; QL (QL Flag)
Fibryga Tier 2 PA; SP; Dual
Fifty50 Pen Needles $0 M90
Finacea External Foam Tier 2 M90
Finasteride Oral Tablet 5 MG Proscar Tier 2 M90
Fintepla Tier 2PA; SP; QL (360 ML per 30 days)
Firdapse Tier 2PA; SP; QL (240 EA per 30 days)
Firmagon $0 PA; SP; Dual
First-Omeprazole Tier 2
First-Testosterone Tier 2 M90
First-Testosterone MC Tier 2 M90
64
Covered Product Reference Tier Status NotesFirvanq Oral Solution Reconstituted 25 MG/ML
Tier 2
Flanax Pain Relief Oral Tier 2 M90
Flarex Tier 2 M90
FlavoxATE HCl Tier 2 M90
Flebogamma DIF Tier 2 PA; SP; Dual
Flecainide Acetate Tier 2 M90
Fleet Laxative Oral Tier 2 M90
Flinstones Gummies Omega-3 DHA Tier 2 M90
Flintstones Plus Calcium Tier 2 M90
Flintstones Plus Iron Tier 2 M90
Flintstones/My First Tier 2 M90
Floriva Plus Tier 2 M90
Flovent Diskus Tier 2 M90
Flovent HFA Tier 2 M90
Floxuridine Injection $0 M90
Fluad $0 M90
Fluad Quadrivalent $0
Fluarix Quadrivalent Intramuscular Suspension Prefilled Syringe
$0 M90
Flublok $0 M90
Flublok Quadrivalent $0
Flucaine Tier 2 M90
Flucelvax Intramuscular Suspension Prefilled Syringe
Tier 1 M90
Flucelvax Quadrivalent Intramuscular Suspension
$0
Flucelvax Quadrivalent Intramuscular Suspension Prefilled Syringe
$0 M90
Fluconazole in Sodium Chloride Tier 2 M90
Fluconazole Oral Diflucan Tier 2 M90
Flucytosine Oral Ancobon Tier 2 M90
Fludarabine Phosphate $0 M90
Fludrocortisone Acetate Oral Tier 2 M90
Flulaval Quadrivalent Intramuscular Suspension
$0 M90
Flulaval Quadrivalent Intramuscular Suspension Prefilled Syringe
$0 M90
FluMist Quadrivalent $0 M90
65
Covered Product Reference Tier Status NotesFlunisolide Nasal Solution 25 MCG/ACT (0.025%)
Tier 2 M90
Fluocinolone Acetonide Body Derma-Smoothe/FS Body Tier 2ST; M90; QL (QL Applies)
Fluocinolone Acetonide External Cream 0.01 %
Tier 2ST; M90; QL (QL Applies)
Fluocinolone Acetonide External Cream 0.025 %
Synalar Tier 2 M90
Fluocinolone Acetonide External Ointment
Synalar Tier 2 M90
Fluocinolone Acetonide External Solution Synalar Tier 2ST; M90; QL (QL Applies)
Fluocinolone Acetonide Otic DermOtic Tier 2 M90
Fluocinolone Acetonide Scalp Derma-Smoothe/FS Scalp Tier 2 M90
Fluocinonide Emulsified Base Tier 2ST; QL (120 GM per 30 days)
Fluocinonide External Cream 0.05 % Tier 2 PA; M90
Fluocinonide External Gel Tier 2ST; M90; QL (QL Applies)
Fluocinonide External Ointment Tier 2ST; M90; QL (QL Applies)
Fluocinonide External Solution Tier 2 PA; M90
Fluorabon Tier 1 M90
Fluor-a-day Oral Solution Tier 1 M90
Fluorescein-Benoxinate Tier 2 M90
Fluoridex Daily Defense Tier 2 M90
Fluoridex Enhanced Whitening Dental Gel Tier 2 M90
Fluoridex Sensitivity Relief Dental Paste Tier 2 M90
Fluor-I-Strips A.T. Tier 2 M90
Fluoritab Oral Solution NaFrinse Drops Tier 1 M90
Fluoritab Oral Tablet Chewable 0.55 (0.25 F) MG, 1.1 (0.5 F) MG
Tier 1 M90
Fluoritab Oral Tablet Chewable 2.2 (1 F) MG
NaFrinse Tier 2 M90
Fluorometholone Ophthalmic FML Liquifilm Tier 2 M90
Fluoroplex Tier 2 PA; M90
Fluorouracil External Efudex Tier 2 PA; M90
Fluorouracil Intravenous $0 M90
FLUoxetine HCl Oral Capsule 10 MG PROzac Tier 2M90; QL (90 EA per 30 days)
66
Covered Product Reference Tier Status Notes
FLUoxetine HCl Oral Capsule 20 MG PROzac Tier 2M90; QL (150 EA per 30 days)
FLUoxetine HCl Oral Solution Tier 2 M90
FLUoxetine HCl Oral Tablet 10 MG Tier 2M90; QL (90 EA per 30 days)
FluPHENAZine Decanoate Injection Tier 2 M90
FluPHENAZine HCl Injection Tier 2 M90
FluPHENAZine HCl Oral Tier 2 M90
Flura-Drops Tier 1 M90
Flurazepam HCl Tier 2
Flurbiprofen Oral Tier 2 M90
Flurbiprofen Sodium Tier 2 M90
Flurox Tier 2 M90
Flutamide $0 M90
Fluticasone Propionate External Cream Tier 2 PA; M90
Fluticasone Propionate External Ointment Tier 2 PA; M90
Fluticasone Propionate Nasal ClariSpray Tier 2 M90
Fluticasone Propionate Nasal Susp 50 MCG/ACT
ClariSpray Tier 2 M90
Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE
Advair Diskus Tier 2PA; QL (60 EA per 30 days)
Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 113-14 MCG/ACT
AirDuo RespiClick 113/14
Tier 2 PA
Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 232-14 MCG/ACT
AirDuo RespiClick 232/14
Tier 2 PA
Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 55-14 MCG/ACT
AirDuo RespiClick 55/14 Tier 2 PA
Fluvastatin Sodium Tier 2ST; M90; QL (30 EA per 90 days)
Fluvastatin Sodium ER Lescol XL Tier 1ST; M90; QL (30 EA per 90 days)
Fluvirin Intramuscular Suspension $0 M90
Fluvirin Intramuscular Suspension Prefilled Syringe
$0 M90
Fluvirin Preservative Free Intramuscular Suspension Prefilled Syringe
Tier 1 M90
67
Covered Product Reference Tier Status NotesFluvoxaMINE Maleate Oral Tablet 100 MG
Tier 2M90; QL (90 EA per 30 days)
FluvoxaMINE Maleate Oral Tablet 25 MG
Tier 2M90; QL (45 tablets per month)
FluvoxaMINE Maleate Oral Tablet 50 MG
Tier 2M90; QL (75 tablets per month)
Fluzone High-Dose Intramuscular Suspension Prefilled Syringe
$0 M90
Fluzone High-Dose Quadrivalent $0
Fluzone Quadrivalent Intradermal $0 M90
Fluzone Quadrivalent Intramuscular Suspension , 0.5 ML
$0 M90
Fluzone Quadrivalent Intramuscular Suspension Prefilled Syringe
$0 M90
FML Tier 2 M90
FML Forte Tier 2 M90
Focalin XR Tier 2PD; BP; QL (60 EA per 30 days)
Folic Acid Injection $0 M90
Folic Acid Oral Capsule 20 MG $0 M90
Folic Acid Oral Capsule 5 MG Tier 2 M90
Folic Acid Oral Tablet 1 MG Tier 2 M90
Folivane-OB Oral Capsule 130-92.4-1 MG
$0 M90
Folotyn $0 SP
Foltrin Tricon Tier 2 M90
Formoterol Fumarate Inhalation Perforomist Tier 2 PA
Formula 3 The Treatment Tier 2 M90
Formula 405 Body Smoothing Tier 2 M90
Formula 405 Moisturizing Tier 2 M90
Fortamet Tier 1 PA
Fortavit Oral Liquid Tier 2 M90
Fosamprenavir Calcium Lexiva Tier 2
Fosaprepitant Dimeglumine Emend Tier 2
Fosinopril Sodium Tier 1 M90
Fosinopril Sodium-HCTZ Tier 1 M90
Fosrenol Oral Packet Tier 2 M90
Fosrenol Oral Tablet Chewable 1000 MG, 500 MG, 750 MG
Tier 2 M90
68
Covered Product Reference Tier Status NotesFragmin Subcutaneous Solution 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML
Tier 2 M90
Freds Pharmacy Unifine Pentip+Advocate Insulin Pen Needles
$0 M90
Freds Pharmacy Unifine Pentips BD Pen Needle Nano U/F $0 M90
Freedavite ABC Plus Senior Tier 2 M90
FreeStyle Freedom Lite $0M90; QL (1 EA per 365 days)
FreeStyle InsuLinx System $0M90; QL (1 EA per 365 days)
FreeStyle InsuLinx Test $0M90; PD; QL (100 EA per 30 days)
FreeStyle Libre 14 Day Reader Tier 2PA; PD; QL (1 EA per 365 days)
FreeStyle Libre 14 Day Sensor Tier 2PA; PD; QL (3 EA per 30 days)
FreeStyle Libre 2 Reader Tier 2PA; PD; QL (1 EA per 365 days)
FreeStyle Libre 2 Sensor Tier 2PA; PD; QL (3 EA per 30 days)
FreeStyle Libre Reader Tier 2PA; PD; QL (1 EA per 365 days)
FreeStyle Libre Sensor System Tier 2PA; PD; QL (1 EA per 365 days)
FreeStyle Lite Device $0M90; QL (1 EA per 365 days)
FreeStyle Lite Test $0M90; PD; QL (100 EA per 30 days)
FreeStyle Precision Neo System $0PA; QL (1 EA per 365 days)
FreeStyle Precision Neo Test $0PA; PD; QL (100 EA per 30 days)
FreeStyle Test $0M90; PD; QL (100 EA per 30 days)
Frovatriptan Succinate Frova Tier 2M90; QL (12 tablets per month)
Fruity Chews Bounty Bears/C Tier 2 M90
Fruity Chews/IronLand Before Time Multivitamin
Tier 2 M90
Ful-Glo Tier 2 M90
69
Covered Product Reference Tier Status Notes
Fulphila Tier 2SP; Dual; QL (2 SYR per 28 days)
Fulvestrant Faslodex $0 QL (QL Applies)
Fungi-Guard Tinactin Tier 2 M90
Fungoid-D Tier 2 M90
Furosemide Injection Solution 10 MG/ML Tier 1 M90
Furosemide Oral Solution 10 MG/ML, 8 MG/ML
Tier 1 M90
Furosemide Oral Tablet Lasix Tier 1 M90
Fusion Plus Tier 2 M90
Fuzeon Subcutaneous Solution Reconstituted
Tier 2QL (60 VIALS per 30 days)
Fyavolv Tier 2 M90
Fycompa Oral Suspension Tier 2 M90
Fycompa Oral Tablet 10 MG, 12 MG, 2 MG, 4 MG
Tier 2M90; QL (60 EA per 30 days)
Fycompa Oral Tablet 6 MG, 8 MG Tier 2M90; QL (30 EA per 90 days)
Gabapentin Oral Neurontin Tier 2 M90
Galafold Tier 2 PA; SP
Galantamine Hydrobromide Tier 2 M90
Galantamine Hydrobromide ER Razadyne ER Tier 2 M90
Galzin Tier 2 M90
Gammagard Tier 2 PA; SP; Dual
Gammagard S/D Less IgA Tier 2 PA; SP; Dual
Gammaked Tier 2 PA; SP; Dual
Gammaplex Intravenous Solution 10 GM/100ML, 10 GM/200ML, 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML
Tier 2 PA; SP; Dual
Gamunex-C Tier 2 PA; SP; Dual
Ganciclovir Sodium Intravenous Solution Reconstituted
Tier 2 M90
Gardasil 9 $0 M90
Gas Relief Oral Liquid Gas-X Infant Drops Tier 2 M90
Gas Relief Oral SuspensionLittle Remedies for Tummys
Tier 2 M90
Gas Relief Oral Tablet Chewable Tier 2 M90
Gas-X Infant Drops Tier 2 M90
Gatifloxacin Ophthalmic Zymaxid Tier 2 M90
70
Covered Product Reference Tier Status Notes
Gattex Tier 2SP; QL (1 KIT per 30 Days)
GaviLAX Oral Powder ClearLax Tier 2 M90
GaviLyte-C Tier 2 M90
GaviLyte-G Tier 2 M90
GaviLyte-H $0 M90
GaviLyte-N with Flavor Pack Tier 2 M90
Gavreto Tier 2PA; SP; QL (120 EA per 30 days)
Gazyva $0 SP
Gelfilm Ophthalmic Tier 2 M90
Gelnique Transdermal Gel 10 % Tier 2 ST; M90
Gel-One Intra-Articular Prefilled Syringe Tier 2PA; SP; QL (QL Flag); Dual; QL (1 SYR per 1 APPROVAL)
Gelsyn-3 Tier 2PA; SP; QL (QL Applies); Dual
Gel-Tin Dental Tier 2 M90
Gemcitabine HCl Intravenous Solution 1 GM/10ML
$0
Gemcitabine HCl Intravenous Solution 1 GM/26.3ML, 2 GM/52.6ML, 200 MG/5.26ML
$0 M90
Gemcitabine HCl Intravenous Solution Reconstituted
$0 M90
Gemfibrozil Oral Lopid Tier 1 M90
Genahist Oral Capsule Banophen Tier 2 M90
Genaphed SudoGest Tier 2 M90
Generlac Tier 2 M90
Gengraf Oral Capsule 100 MG, 25 MG Tier 2 SP
Gengraf Oral Solution Tier 2 SP
Genotropin Tier 2 PA; SP; PD
Genotropin MiniQuick Tier 2 PA; SP; PD
Genpril Medi-Profen Tier 2 M90
Gentak Ophthalmic Ointment Tier 2 M90
Gentamicin Sulfate External Tier 2 M90
Gentamicin Sulfate Ophthalmic Gentak Tier 2 M90
Gentle Laxative Alophen Tier 2 M90
Gentle Laxative For Women Alophen Tier 2 M90
GenVisc 850 Tier 2PA; SP; QL (QL Applies); Dual
71
Covered Product Reference Tier Status Notes
Genvoya Tier 2PD; QL (30 EA per 30 days)
Geri-Dryl Oral Capsule Banophen Tier 2 M90
Geri-Dryl Oral Tablet Alka-Seltzer Plus Allergy Tier 2 M90
Geri-Freeda Senior Formula ABC Plus Senior Tier 2 M90
Geri-Hydrolac 12 Tier 2 M90
Geri-kot Evac-U-Gen Tier 2 M90
Geri-Pectate Kaopectate Tier 2 M90
Gerivite Complete ABC Plus Senior Tier 2 M90
Gianvi $0 M90
Giazo Tier 2 M90
Gildagia Tier 2 M90
Gilenya Tier 2PA; SP; BP; QL (28 EA per 28 days)
Gilotrif $0SP; QL (30 EA per 30 days)
Gimoti Tier 2PA; QL (9.8 ML per 28 days)
Givlaari MB PA; PD
Glass Syringe 3 ML Tier 2 M90
Glass Syringe 5 ML Tier 2 M90
Glassia Tier 2 PA; SP; Dual
Gleostine $0 M90
Gliadel Wafer $0 M90
Glimepiride Amaryl Tier 1 M90
glipiZIDE ER Glucotrol XL Tier 1 M90
glipiZIDE Oral Tier 1 M90
GlipiZIDE XL Glucotrol XL Tier 1 M90
glipiZIDE-metFORMIN HCl Tier 1 M90
Global Ease Inject Pen Needles CareFine Pen Needles $0 M90
Global Easy Glide Pen Needles BD Pen Needle Nano U/F $0 M90
Glucagon Emergency Injection Kit Tier 2 M90
Glucagon Emergency Injection Solution Reconstituted
Tier 2
Glucoten DEKAs Plus Tier 2 M90
Glumetza Tier 1 PA
GlyBURIDE Micronized Glynase Tier 1 M90
GlyBURIDE Oral Tier 1 M90
GlyBURIDE-MetFORMIN Tier 1 M90
72
Covered Product Reference Tier Status NotesGlycine Irrigation Tier 2 M90
Glycine Urologic Tier 2 M90
GlycoLax Tier 2 M90
Glycopyrrolate Oral Tablet 1 MG, 2 MG Tier 2 M90
Glydo External Gel Tier 2 M90
Glyxambi Tier 2PA; ST; M90; QL (30 EA per 90 days)
GNP 8 Hour Pain Relief Midol Tier 2 M90
GNP 8 Hour Pain Reliever Midol Tier 2 M90
GNP Acid Control 150 Max St Tier 2 M90
GNP Acid Control 75 Tier 2 M90
GNP Acid Reducer Pepcid AC Tier 2 M90
GNP Acid Reducer Max StMM Acid-Pep Maximum Strength
Tier 2 M90
GNP Advanced RecoveryA + D Personal Care Lotion
Tier 2 M90
GNP All Day Allergy KLS Aller-Tec Tier 2 M90; QL (QL Flag)
GNP All Day Allergy Childrens KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)
GNP All Day Pain Relief Mediproxen Tier 2 M90
GNP Allergy Wal-finate Tier 2 M90
GNP Allergy Relief Oral Tablet 180 MG KLS Aller-Fex Tier 2 M90; QL (QL Flag)
GNP Allergy Relief Oral Tablet Dispersible
Alavert Tier 2 M90
GNP Allergy-D Allergy & CongesWal-Fex D Allergy & Congestion
Tier 2 M90; QL (QL Flag)
GNP Animal Shapes Bounty Bears/C Tier 2 M90
GNP Animal Shapes Plus IronLand Before Time Multivitamin
Tier 2 M90
GNP Antacid Extra Strength Oral Tablet Chewable 750 MG
CVS Chewy Not Chalky Flavor
Tier 2 M90
GNP Antacid Oral Tablet Chewable 500 MG
Cal-Gest Antacid Tier 2 M90
GNP Antacid Ultra Strength Tums Ultra 1000 Tier 2 M90
GNP Anti-Diarrheal Oral Capsule Imodium A-D Tier 2 M90
GNP Arthritis Pain Relief Oral Midol Tier 2 M90
GNP Athletes Foot External Cream Desenex Tier 2 M90
GNP Bisa-Lax Oral Tier 2 M90
GNP Calcium Tier 2 M90
GNP Calcium 1200 Tier 2 M90
GNP Calcium 500 +D3 Os-Cal Extra D3 Tier 2 M90
73
Covered Product Reference Tier Status NotesGNP Calcium 500/D Os-Cal Calcium + D3 Tier 2 M90
GNP Calcium 600 +D/Minerals Tier 2 M90
GNP Calcium 600 +D3 Pronutrients Calcium+D3 Tier 2 M90
GNP Calcium 600 +D3/MineralsCaltrate 600+D Plus Minerals
Tier 2 M90
GNP Calcium 600 Plus D/Mineral Tier 2 M90
GNP Calcium 600/D Tier 2 M90
GNP Calcium Citrate +D3 Calcitrate Tier 2 M90
GNP Calcium Citrate+D Maximum Calcitrate Tier 2 M90
GNP Calcium Plus 600 +D Tier 2 M90
GNP Calcium/Vitamin D/Minerals Tier 2 M90
GNP Capsaicin External Cream Capzasin-HP Tier 2 M90
GNP Century ABC Plus Senior Tier 2 M90
GNP Century Active Performance ABC Plus Senior Tier 2 M90
GNP Century Adults 50+ Senior ABC Plus Senior Tier 2 M90
GNP Century Cardio Health ABC Plus Senior Tier 2 M90
GNP Century Mature ABC Plus Senior Tier 2 M90
GNP Century Ultimate Mens ABC Plus Senior Tier 2 M90
GNP Century Ultimate Womens ABC Plus Senior Tier 2 M90
GNP Childrens Allergy Banophen Tier 2 M90
GNP Childrens Chewables/IronLand Before Time Multivitamin
Tier 2 M90
GNP Childrens Ibuprofen Childrens Medi-Profen Tier 2 M90
GNP Childrens Pain Relief Oral Suspension
PediaCare Children Tier 2 M90
GNP ClearLax Oral Powder Tier 2 M90
GNP Clickfine Pen NeedlesAdvocate Insulin Pen Needles
$0 M90
GNP Clotrimazole 3 Gyne-Lotrimin 3 Tier 2 M90
GNP D 2000VitaJoy Daily D Gummies
Tier 2 M90
GNP Diabetic Support Formula ABC Plus Senior Tier 2 M90
GNP Ear Drops Murine Ear Tier 2 M90
GNP Ear Systems Murine Ear Tier 2 M90
GNP Enema Rectal Enema 7-19 GM/118ML
Fleet Enema Tier 2 M90
GNP Eye Itch Relief Alaway Tier 2 M90; QL (QL Flag)
GNP Gas Relief Tier 2 M90
GNP Hair/Skin/Nails ABC Plus Senior Tier 2 M90
GNP Healthy Eyes ABC Plus Senior Tier 2 M90
74
Covered Product Reference Tier Status NotesGNP Healthy Eyes SuperVision DEKAs Plus Tier 2 M90
GNP Heartburn Relief Tagamet HB Tier 2 M90
GNP Heartburn Relief 200 Tagamet HB Tier 2 M90
GNP Hydrocortisone Max St Cortizone-10 Tier 2 M90
GNP Hydrocortisone Plus Aveeno Anti-Itch Max St Tier 2 M90
GNP Ibuprofen Infants Medi-Profen Tier 2 M90
GNP Ibuprofen Junior Strength Advil Junior Strength Tier 2 M90
GNP Ibuprofen Oral Tablet Medi-Profen Tier 2 M90
GNP Infants Gas ReliefLittle Remedies for Tummys
Tier 2 M90
GNP Infants Pain Relief Oral Suspension PediaCare Children Tier 2 M90
GNP Infants Pain/Fever PediaCare Children Tier 2 M90
GNP Iodides Tier 2 M90
GNP Iodine Tier 2 M90
GNP Itchy Eye Alaway Tier 2 M90; QL (QL Flag)
GNP K-Pec Kaopectate Tier 2 M90
GNP Laxative The Magic Bullet Tier 2 M90
GNP Laxative Pills Tier 2 M90
GNP Lice Bedding RID Tier 2 M90
GNP Lice Treatment External Liquid Nix Creme Rinse Tier 2 M90
GNP Little Ones Childrens Bounty Bears/C Tier 2 M90
GNP Loratadine Childrens Oral Syrup Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
GNP Loratadine Oral Syrup Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
GNP Loratadine Oral Tablet KLS AllerClear Tier 2 M90; QL (QL Flag)
GNP Magnesium Citrate Citroma Tier 2 M90
GNP Magnesium Oxide Tier 2 M90
GNP Maximum One Daily ABC Plus Senior Tier 2 M90
GNP Mega Multi for Men ABC Plus Senior Tier 2 M90
GNP Mega Multi for Women ABC Plus Senior Tier 2 M90
GNP Miconazole 1 Monistat 1 Combo Pack Tier 2 M90
GNP Miconazole 3 Vagistat-3 Tier 2 M90
GNP Miconazole 3 ApplicatorMonistat 3 Combo Pack App
Tier 2 M90
GNP Miconazole 7 Monistat 7 Simply Cure Tier 2 M90
GNP Milk of MagnesiaDulcolax Milk of Magnesia
Tier 2 M90
GNP Mineral Oil Heavy Tier 2 M90
75
Covered Product Reference Tier Status NotesGNP Motion Sickness Relief Oral Tablet 25 MG
Wal-Dram II Tier 2 M90
GNP Naproxen Sodium Oral Tablet Mediproxen Tier 2 M90
GNP Nasal Decongestant SudoGest Tier 2 M90
GNP Nasal Moisturizing Afrin Saline Nasal Mist Tier 1 M90
GNP Niacin Tier 1 M90
GNP Niacin TR Endur-Acin Tier 1 M90
GNP Nicotine Mini Mouth/Throat Lozenge 2 MG
KLS Quit2 $0 M90
GNP Nicotine Polacrilex KLS Quit2 $0 M90
GNP One Daily Maximum ABC Plus Senior Tier 2 M90
GNP One Daily Mens 50+Advanced ABC Plus Senior Tier 2 M90
GNP One Daily Mens Health 50+ ABC Plus Senior Tier 2 M90
GNP One Daily Mens/Lycopene ABC Plus Senior Tier 2 M90
GNP One Daily Plus IronTab-A-Vite/Iron/Beta Carotene
Tier 2 M90
GNP One Daily Womens ABC Plus Senior Tier 2 M90
GNP One Daily Womens 50+ ABC Plus Senior Tier 2 M90
GNP Opti-Vitamins ABC Plus Senior Tier 2 M90
GNP Pain & Fever Childrens Oral Suspension 160 MG/5ML
PediaCare Children Tier 2 M90
GNP Pain Relief Aphen Tier 2 M90
GNP Pain Relief Extra Strength Oral Tablet
Healthy Mama Shake That Ache
Tier 2 M90
GNP Pain Reliever Ex StHealthy Mama Shake That Ache
Tier 2 M90
GNP Pediatric Electrolyte Oral Solution CeraLyte 70 Tier 2 M90
GNP PreNatal Tier 1 M90
GNP Senna-Lax Evac-U-Gen Tier 2 M90
GNP Stomach Relief Kaopectate Tier 2 M90
GNP Stool Softener Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90
GNP Stool Softener Oral Liquid Docu Liquid Tier 2 M90
GNP Stool Softener Oral Syrup Tier 2 M90
GNP Therapeutic-M ABC Plus Senior Tier 2 M90
GNP Tolnaftate Tinactin Tier 2 M90
GNP Vitamin B-6 Oral Tablet 100 MG Tier 2 M90
GNP Vitamin D Maximum Strength Thera-D 2000 Tier 2 M90
GNP Vitamin D Oral Tablet 25 MCG (1000 UT)
Vitamin D-1000 Max St Tier 2 M90
76
Covered Product Reference Tier Status Notes
GNP Vitamin D Super StrengthRadiance Platinum Vitamin D3
Tier 2 M90
GNP Vitamin D3 Extra Strength Vitamin D-1000 Max St Tier 2 M90
GNP Womens Laxative Alophen Tier 2 M90
GNP Womens One Daily ABC Plus Senior Tier 2 M90
GNP Zinc Chelated IS-ZC 50 Tier 2 M90
GNP Zinc Oxide Tier 2 M90
Gold Bond Medicated Body Tier 2 M90
Gold Bond Medicated Body Ex St Tier 2 M90
Gold Bond Ult Sheer Ribbons Tier 2 M90
Gold Bond Ultimate External Lotion Tier 2 M90
Gold Bond Ultimate Healing External Lotion
Tier 2 M90
Gold Bond Ultimate Protection Tier 2 M90
Gold Bond Ultimate Restoring Tier 2 M90
Gold Bond Ultimate Softening Tier 2 M90
Gold Bond Ultimate Soothing External Lotion
Tier 2 M90
Golytely Oral Solution Reconstituted 227.1 GM
Tier 2 M90
GoodSense Acid Reducer Tier 2 M90
GoodSense All Day Allergy Oral Tablet KLS Aller-Tec Tier 2 M90; QL (QL Flag)
GoodSense Aller-Ease KLS Aller-Fex Tier 2M90; QL (30 EA per 90 days)
GoodSense Allergy Relief Oral Capsule 25 MG
Banophen Tier 2 M90
GoodSense Magnesium Citrate Citroma Tier 2 M90
GoodSense Mineral Oil Tier 2 M90
GoodSense Nasoflow ClariSpray Tier 2 M90
GoodSense Nicotine Mouth/Throat Gum 4 MG
KLS Quit4 $0 M90
GoodSense Pain & Fever Child PediaCare Children Tier 2 M90
GoodSense Pain & Fever Infants PediaCare Children Tier 2 M90
GoodSense Pain Relief Oral Tablet Aphen Tier 2 M90
GoodSense Prenatal Vitamins Tier 1 M90
GoodSense Senna Laxative Oral Tablet 8.6 MG
Evac-U-Gen Tier 2 M90
Gordofilm Tier 2 M90
Gordomatic External LotionA + D Personal Care Lotion
Tier 2 M90
77
Covered Product Reference Tier Status NotesGranisetron HCl Intravenous Solution 4 MG/4ML
Tier 2 M90
Granisetron HCl Oral Tier 2M90; QL (2 EA per 28 days)
Granix Tier 2 PA; SP; Dual
Grastek Tier 2 PA; M90
Griseofulvin Microsize Oral Tier 2 M90
Griseofulvin Ultramicrosize Tier 2 M90
GRX Vitamin E External Lotion Tier 2 M90
GuanFACINE HCl ER Intuniv Tier 2 ST; M90
guanFACINE HCl Oral Tier 1 M90
Guanidine HCl Oral Tier 2 M90
Gvoke HypoPen 1-Pack Tier 2 PA
Gvoke HypoPen 2-Pack Tier 2 PA
Gvoke PFS Tier 2 PA
Gynazole-1 Tier 2 M90
Haegarda Tier 2 PA; SP; Dual
Hair Formula Extra Strength ABC Plus Senior Tier 2 M90
Hair Skin and Nails Formula ABC Plus Senior Tier 2 M90
Hair Vitamins ABC Plus Senior Tier 2 M90
Hair/Skin/Nails Oral Tablet ABC Plus Senior Tier 2 M90
Hair/Skin/Nails/Biotin ABC Plus Senior Tier 2 M90
Hair-Vites ABC Plus Senior Tier 2 M90
Halaven $0 SP
Halobetasol Propionate External Cream Tier 2ST; M90; QL (QL Applies)
Halobetasol Propionate External Ointment Tier 2ST; M90; QL (QL Applies)
Haloperidol Decanoate Intramuscular Solution 100 MG/ML, 50 MG/ML
Haldol Decanoate Tier 2 M90
Haloperidol Lactate Injection Solution 5 MG/ML
Tier 2 M90
Haloperidol Lactate Oral Tier 2 M90
Haloperidol Oral Tier 2 M90
Halotin Tier 2 ST; M90
Harvoni Oral Packet Tier 2PA; SP; QL (28 EA per 28 days)
Harvoni Oral Tablet 45-200 MG Tier 2PA; SP; QL (28 tablets per 28 days)
78
Covered Product Reference Tier Status NotesHavrix Intramuscular Suspension 1440 EL U/ML, 720 EL U/0.5ML
$0 M90
HealthWise Mini Pen Needles CareFine Pen Needles $0 M90
HealthWise Pen Needles CareFine Pen Needles $0 M90
HealthWise Short Pen Needles 31G X 8 MM
Advocate Insulin Pen Needles
$0 M90
HealthWise Unifine Pentips BD Pen Needle Nano U/F $0 M90
Healthy Accents Unifine PentipAdvocate Insulin Pen Needles
$0 M90
Healthy Eyes ABC Plus Senior Tier 2 M90
Healthy Mama Move It Along Tier 2 M90
Healthy Mama Shake That Ache Tier 2 M90
Healthy Mama Tame the Flame Tier 2 M90
HealthyLax Tier 2 M90
Heartburn Relief Pepcid AC Tier 2 M90
Heartburn Relief 150 Max St Tier 2 M90
Heather $0 M90
H-E-B inControl Pen Needles CareFine Pen Needles $0 M90
H-E-B inControl Unifine Pentip 32G X 4 MM
$0 M90
H-E-B Oral Electrolyte CeraLyte 70 Tier 2 M90
Helixate FS Tier 2 PA; SP; Dual
Hemangeol Tier 2 M90
Hemax Oral Tablet Tier 2 M90
Hemlibra Tier 2 PA; SP; Dual
Hemmorex-HC Rectal Suppository 30 MG
Tier 2 M90
Hemocyte-F Oral Elixir Tier 2 M90
Hemofil M Intravenous Solution Reconstituted 1000 UNIT, 1700 UNIT, 250 UNIT, 500 UNIT
Tier 2 PA; SP; Dual
Heparin Lock Flush Intravenous Solution 10 UNIT/ML, 100 UNIT/ML
Tier 2 M90
Heparin Sodium (Porcine) Injection Solution 1000 UNIT/ML, 10000 UNIT/ML, 20000 UNIT/ML, 5000 UNIT/ML
Tier 2 M90
Heparin Sodium Flush Tier 2 M90
Heparin Sodium Lock Flush Intravenous Solution 100 UNIT/ML
Tier 2 M90
Heplisav-B Intramuscular Solution $0
79
Covered Product Reference Tier Status NotesHetastarch-NaCl Hespan Tier 2 M90
Hetlioz Tier 2PA; SP; QL (30 EA per 90 days)
Hetlioz LQ Tier 2PA; SP; QL (150 ML per 30 days)
Hexalen $0 M90
Hiberix Injection $0 M90
High Potency Calcium Oral Tablet 600 MG
Tier 2 M90
High Potency Iron Oral Tablet 134 MG Tier 2 M90
Hi-Kovite 2-Part Formula ABC Plus Senior Tier 2 M90
Hi-Potency Multi-Vitamin ABC Plus Senior Tier 2 M90
Hizentra Subcutaneous Solution 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML
Tier 2 PA; SP; Dual
Hizentra Subcutaneous Solution Prefilled Syringe
Tier 2 PA; SP; Dual
HM Acid Reducer Tier 2 M90
HM Acid Reducer Max Strength Tier 2 M90
HM All Day Allergy Oral Tablet KLS Aller-Tec Tier 2 M90; QL (QL Flag)
HM Allergy Alka-Seltzer Plus Allergy Tier 2 M90
HM Allergy Childrens Banophen Tier 2 M90
HM Allergy Complete Childrens KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)
HM Allergy Multi Symptom Banophen Tier 2 M90
HM Allergy Relief (Loratadine) KLS AllerClear Tier 2 M90; QL (QL Flag)
HM Allergy Relief Childrens Banophen Tier 2 M90
HM Allergy Relief Nasal ClariSpray Tier 2 M90
HM Allergy Relief Oral Capsule Banophen Tier 2 M90
HM Allergy Relief Oral Tablet 4 MG Wal-finate Tier 2 M90
HM Allergy Relief Oral Tablet Dispersible
Alavert Tier 2 M90
HM Antioxidant Vitamins ABC Plus Senior Tier 2 M90
HM Arthritis Pain Relief Midol Tier 2 M90
HM Bacitracin Bacitraycin Plus Tier 2 M90
HM Calcium 600+D Plus MineralsCaltrate 600+D Plus Minerals
Tier 2 M90
HM Calcium Antacid Cal-Gest Antacid Tier 2 M90
HM Calcium Antacid Ex StCVS Chewy Not Chalky Flavor
Tier 2 M90
HM Calcium Antacid Ultra St Tums Ultra 1000 Tier 2 M90
80
Covered Product Reference Tier Status Notes
HM Calcium Citrate+D3 PetiteCitracal Petites/Vitamin D
Tier 2 M90
HM Calcium Citrate+Vitamin D Calcitrate Tier 2 M90
HM Calcium-Vitamin D Oral Tablet 500-200 MG-UNIT
Os-Cal Calcium + D3 Tier 2 M90
HM Calcium-Vitamin D Oral Tablet 600-400 MG-UNIT
Tier 2 M90
HM Calcium-Vitamin D-Minerals Tier 2 M90
HM Cetirizine HCl Childrens KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)
HM ClearLax Oral Powder Tier 2 M90
HM Complete ABC Plus Senior Tier 2 M90
HM Complete 50+ ABC Plus Senior Tier 2 M90
HM Complete 50+ Mens Ultimate ABC Plus Senior Tier 2 M90
HM Complete 50+ Women Ultimate ABC Plus Senior Tier 2 M90
HM Earwax Removal Aid Murine Ear Tier 2 M90
HM Earwax Removal Kit Murine Ear Tier 2 M90
HM Enema Fleet Enema Tier 2 M90
HM Eye Itch Relief Alaway Tier 2 M90; QL (QL Flag)
HM Famotidine Pepcid AC Tier 2 M90
HM Fexofenadine HCl KLS Aller-Fex Tier 2 M90; QL (QL Flag)
HM Gas Relief Infants DropsLittle Remedies for Tummys
Tier 2 M90
HM Gas Relief Oral Tablet Chewable 80 MG
Tier 2 M90
HM Hair/Skin/Nails ABC Plus Senior Tier 2 M90
HM Ibuprofen Childrens Childrens Medi-Profen Tier 2 M90
HM Ibuprofen IB Oral Tablet Medi-Profen Tier 2 M90
HM Ibuprofen Infants Medi-Profen Tier 2 M90
HM Ibuprofen Oral Tablet Medi-Profen Tier 2 M90
HM Iodides Tier 2 M90
HM Iodine Tier 2 M90
HM Laxative The Magic Bullet Tier 2 M90
HM Lice Treatment Tier 2 M90
HM Loperamide HCl Oral Capsule Imodium A-D Tier 2 M90
HM Loratadine KLS AllerClear Tier 2 M90; QL (QL Flag)
HM Loratadine Childrens Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
HM Magnesium Citrate Citroma Tier 2 M90
HM Magnesium Oral Tablet 250 MG Tier 2 M90
81
Covered Product Reference Tier Status Notes
HM Milk of MagnesiaDulcolax Milk of Magnesia
Tier 2 M90
HM Mineral Oil Tier 2 M90
HM Motion Relief Wal-Dram II Tier 2 M90
HM Naproxen Sodium Oral Tablet Mediproxen Tier 2 M90
HM Nasal Decongestant SudoGest Tier 2 M90
HM Niacin Endur-Acin Tier 1 M90
HM Nicotine Nicoderm CQ $0 M90
HM Nicotine Polacrilex KLS Quit2 $0 M90
HM One Daily Mens ABC Plus Senior Tier 2 M90
HM One Daily Womens ABC Plus Senior Tier 2 M90
HM One Daily/IronTab-A-Vite/Iron/Beta Carotene
Tier 2 M90
HM Pain & Fever Childrens PediaCare Children Tier 2 M90
HM Pain & Fever Infants PediaCare Children Tier 2 M90
HM Pain Relief Childrens PediaCare Children Tier 2 M90
HM Pain Relief Extra StrengthHealthy Mama Shake That Ache
Tier 2 M90
HM Pain Reliever Aphen Tier 2 M90
HM Pediatric Electrolyte CeraLyte 70 Tier 2 M90
HM Prenatal Tier 1 M90
HM Saline Nasal Spray Afrin Saline Nasal Mist Tier 1 M90
HM Senna Evac-U-Gen Tier 2 M90
HM Stomach Relief Oral Suspension Kaopectate Tier 2 M90
HM Stool Softener Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90
HM Stool Softener Oral Tablet DOK Tier 2 M90
HM Vitamin B6 Tier 2 M90
HM Vitamin D Oral Tablet 25 MCG (1000 UT)
Vitamin D-1000 Max St Tier 2 M90
HM Vitamin D3 Oral Capsule 50 MCG (2000 UT)
Tier 2 M90
HM Zinc IS-ZC 50 Tier 2 M90
Homatropaire Tier 2 M90
Homatropine HBr Ophthalmic Homatropaire Tier 2 M90
HumaLOG Junior KwikPen Tier 1 BP
HumaLOG KwikPen Subcutaneous Solution Pen-Injector 100 UNIT/ML, 200 UNIT/ML
Tier 1 BP
HumaLOG Mix 50/50 Tier 1 M90; BP
82
Covered Product Reference Tier Status NotesHumaLOG Mix 50/50 KwikPen Subcutaneous Suspension Pen-Injector
Tier 1 M90; BP
HumaLOG Mix 75/25 Tier 1 M90; BP
HumaLOG Mix 75/25 KwikPen Subcutaneous Suspension Pen-Injector
Tier 1 BP
HumaLOG Subcutaneous Solution Tier 2 BP
HumaLOG Subcutaneous Solution Cartridge
Tier 1 BP
Humate-P Intravenous Solution Reconstituted 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT
Tier 2 PA; SP; Dual
Humatrope Tier 2 PA; SP
Humira Pediatric Crohns Start Subcutaneous Prefilled Syringe Kit 40 MG/0.8ML
Tier 2PA; SP; PD; QL (4 SYR per 28 days)
Humira Pediatric Crohns Start Subcutaneous Prefilled Syringe Kit 80 MG/0.8ML
Tier 2PA; SP; PD; QL (3 SYR per 28 days)
Humira Pediatric Crohns Start Subcutaneous Prefilled Syringe Kit 80 MG/0.8ML & 40MG/0.4ML
Tier 2PA; SP; PD; QL (2 SYR per 28 days)
Humira Pen Subcutaneous Pen-Injector Kit 40 MG/0.4ML, 40 MG/0.8ML
Tier 2PA; SP; PD; QL (4 SYR per 28 days)
Humira Pen-CD/UC/HS Starter Subcutaneous Pen-Injector Kit 40 MG/0.8ML
Tier 2PA; SP; PD; QL (4 PENS per 28 days)
Humira Pen-Ps/UV/Adol HS Start Subcutaneous Pen-Injector Kit 40 MG/0.8ML
Tier 2PA; SP; PD; QL (4 PENS per 28 days)
Humira Subcutaneous Prefilled Syringe Kit 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML
Tier 2PA; SP; PD; QL (2 SYR per 28 days)
Humira Subcutaneous Prefilled Syringe Kit 40 MG/0.4ML, 40 MG/0.8ML
Tier 2PA; SP; PD; QL (4 SYR per 28 days)
Humist Tier 1 M90
HumuLIN 70/30 Tier 1 M90
HumuLIN 70/30 KwikPen Subcutaneous Suspension Pen-Injector
Tier 1 M90
HumuLIN N Tier 1 M90
HumuLIN N KwikPen Subcutaneous Suspension Pen-Injector
Tier 1 M90
HumuLIN R Tier 1 M90
HumuLIN R U-500 (CONCENTRATED) Tier 1 M90
83
Covered Product Reference Tier Status NotesHumuLIN R U-500 KwikPen Subcutaneous Solution Pen-Injector
Tier 1 M90
Hyalgan Intra-Articular Solution Tier 2PA; SP; QL (QL Flag); Dual
Hyalgan Intra-Articular Solution Prefilled Syringe
Tier 2PA; SP; QL (QL Applies); Dual
Hycamtin Oral $0 SP; QL (QL Flag)
HydrALAZINE HCl Oral Tier 1 M90
HydroCHLOROthiazide Oral Tier 1 M90
HYDROcodone Bitartrate ER Oral Tablet ER 24 Hour Abuse-Deterrent
Hysingla ER Tier 2ST; QL (30 EA per 90 days)
HYDROcodone-Acetaminophen Oral Solution 10-325 MG/15ML, 2.5-108 MG/5ML, 5-217 MG/10ML, 7.5-325 MG/15ML
Tier 2PA; QL (2700 ML per 30 days)
HYDROcodone-Acetaminophen Oral Tablet 10-300 MG, 10-325 MG, 7.5-300 MG, 7.5-325 MG
Tier 2QL (180 EA per 30 days)
HYDROcodone-Acetaminophen Oral Tablet 5-300 MG
Xodol Tier 2QL (240 tablets per 30 days. Click;HERE)
HYDROcodone-Acetaminophen Oral Tablet 5-325 MG
Tier 2QL (240 tablets per 30 days. Click;HERE)
HYDROcodone-Ibuprofen Oral Tablet 10-200 MG, 5-200 MG, 7.5-200 MG
Tier 2QL (50 tablets per 30 days. Click;HERE)
Hydrocortisone Ace-Pramoxine External Cream 2.5-1 %
Pramosone Tier 2 M90
Hydrocortisone Acetate Rectal Anusol-HC Tier 2 M90
Hydrocortisone Butyrate External Cream Tier 2ST; M90; QL (QL Applies)
Hydrocortisone Butyrate External Ointment
Tier 2ST; M90; QL (QL Applies)
Hydrocortisone Butyrate External Solution
Tier 2 M90
Hydrocortisone External Cream 1 % Aveeno Anti-Itch Max St Tier 2 M90
Hydrocortisone External Cream 2.5 % Tier 2 M90
Hydrocortisone External Lotion 2.5 % Tier 2 M90
Hydrocortisone External Ointment 1 % Cortizone-10 Tier 2 M90
Hydrocortisone External Ointment 2.5 % Tier 2 M90
Hydrocortisone in Absorbase Tier 2 M90
Hydrocortisone Intensive Heal Aveeno Anti-Itch Max St Tier 2 M90
Hydrocortisone Max St External Cream Aveeno Anti-Itch Max St Tier 2 M90
Hydrocortisone Max St/12 Moist Aveeno Anti-Itch Max St Tier 2 M90
84
Covered Product Reference Tier Status NotesHydrocortisone Oint 1% Cortizone-10 Tier 2 M90
Hydrocortisone Oral Cortef Tier 2 M90
Hydrocortisone Plus Aveeno Anti-Itch Max St Tier 2 M90
Hydrocortisone Rectal Enema Cortenema Tier 2 M90
Hydrocortisone Valerate Tier 2ST; M90; QL (QL Applies)
Hydrocortisone-Acetic Acid Acetasol HC Tier 2 M90
HYDROmorphone HCl ER Oral Tablet ER 24 Hour Abuse-Deterrent
Tier 2ST; QL (30 EA per 30 days)
HYDROmorphone HCl Oral Liquid Dilaudid Tier 2QL (600 mL per 30 days. Click;HERE)
HYDROmorphone HCl Oral Tablet 2 MG Dilaudid Tier 2QL (180 EA per 30 days)
HYDROmorphone HCl Oral Tablet 4 MG Dilaudid Tier 2QL (150 EA per 30 days)
HYDROmorphone HCl Oral Tablet 8 MG Dilaudid Tier 2QL (60 EA per 30 days)
HYDROmorphone HCl Rectal Tier 2QL (120 EA per 30 days)
HydroSKIN External Cream Tier 2 M90
Hydroxocobalamin Intramuscular Tier 2 M90
Hydroxychloroquine Sulfate Oral Plaquenil Tier 2
HYDROXYprogesterone Caproate Intramuscular Oil
Makena Tier 2 PA; SP; Dual
Hydroxyprogesterone Caproate Intramuscular Solution
$0 PA; SP; M90; Dual
Hydroxyurea Oral Hydrea $0 M90
hydrOXYzine HCl Intramuscular Solution 50 MG/ML
Tier 2 M90
HydrOXYzine HCl Oral Syrup Tier 2 M90
hydrOXYzine HCl Oral Tablet Tier 2 M90
HydrOXYzine Pamoate Oral Tier 2 M90
Hymovis Tier 2PA; SP; Dual; QL (2 SYR per 14 days)
Hyoscyamine Sulfate ER Oral Tablet Extended Release 12 Hour
Levbid Tier 2 M90
Hyoscyamine Sulfate Oral Tier 2 M90
Hyoscyamine Sulfate Sublingual Levsin/SL Tier 2 M90
Hyosyne Tier 2 M90
Hyqvia Tier 2 PA; SP; Dual
Hy-Vee All Day Relief Mediproxen Tier 2 M90
85
Covered Product Reference Tier Status NotesHyVee Ibuprofen Childrens Tier 2 M90
I.L.X. B-12 Oral Elixir Tier 2 M90
Ibandronate Sodium Intravenous Solution 3 MG/3ML
Tier 2 M90
Ibandronate Sodium Oral Boniva Tier 2M90; QL (1 tablet per 28 days; 13 tablets per 365 days)
Ibrance $0SP; PD; QL (21 EA per 28 days)
IBU-200 Medi-Profen Tier 2 M90
Ibudone Tier 2M90; QL (50 tablets per 30 days. Click;HERE)
Ibu-Drops Medi-Profen Tier 2 M90
Ibuprofen Childrens Childrens Medi-Profen Tier 2 M90
Ibuprofen Junior Strength Oral Tablet Chewable
Advil Junior Strength Tier 2 M90
Ibuprofen Oral Suspension Childrens Medi-Profen Tier 2 M90
Ibuprofen Oral Tablet Medi-Profen Tier 2 M90
Icar Oral Suspension Tier 1 M90
Icar-C Plus Tier 2 M90
Icatibant Acetate Firazyr Tier 2PA; SP; QL (QL Applies); Dual
Iclusig Oral Tablet 10 MG, 30 MG $0 PA; SP
Iclusig Oral Tablet 15 MG $0PA; SP; QL (60 EA per 30 days)
Iclusig Oral Tablet 45 MG $0PA; SP; QL (30 EA per 30 days)
Icosapent Ethyl Vascepa Tier 2PA; QL (120 EA per 30 days)
IDArubicin HCl Idamycin PFS $0 M90
Idelvion Tier 2 PA; SP; Dual
iFerex 150 Forte Tier 2 M90
Ifex Intravenous Solution Reconstituted 3 GM
$0 M90
Ifosfamide Ifex $0 M90
Ilaris (150mg Delivered) Tier 2 PA; SP
Ilaris Subcutaneous Solution Tier 2 PA; SP; Dual
Ilevro Tier 2ST; M90; QL (1.7ml per 25 days)
Ilotycin Tier 2 M90
86
Covered Product Reference Tier Status Notes
Ilumya Tier 2PA; Dual; QL (1 SYR per 12 Weeks)
Iluvien Intraocular Tier 2 SP
Imatinib Mesylate Oral Tablet 100 MG Gleevec $0SP; QL (90 EA per 30 days)
Imatinib Mesylate Oral Tablet 400 MG Gleevec $0SP; QL (60 EA per 30 days)
Imbruvica Oral Capsule 140 MG $0QL (90 EA per 30 days)
Imbruvica Oral Capsule 70 MG $0QL (30 EA per 30 days)
Imbruvica Oral Tablet 420 MG, 560 MG $0QL (30 EA per 30 days)
Imcivree Tier 2PA; SP; QL (10 ML per 30 days)
Imfinzi MB PA
Imipramine HCl Oral Tier 2 M90
Imipramine Pamoate Tier 2 M90
Imiquimod External Cream 5 % Aldara Tier 2 PA; M90
Imiquimod Pump Zyclara Tier 2 ST
Inbrija Tier 2PA; SP; QL (300 capsules per month)
Increlex Tier 2 PA; SP; QL (QL Flag)
Incruse Ellipta Tier 2
Indapamide Oral Tier 1 M90
Inderal XL Tier 2 M90
Indocin Oral Tier 2 M90
Indomethacin Oral Capsule 25 MG, 50 MG
Tier 2 M90
Infanrix $0 M90
Infants Gas ReliefLittle Remedies for Tummys
Tier 2 M90
Infants Ibuprofen Medi-Profen Tier 2 M90
Infants Pain & Fever PediaCare Children Tier 2 M90
Infants Pain Reliever Tier 2 M90
Infants Silapap Tier 2 M90
Infants Simethicone Oral Suspension 20 MG/0.3ML
Little Remedies for Tummys
Tier 2 M90
Infed Tier 2M90; QL (1 FILL per 365 days)
87
Covered Product Reference Tier Status Notes
Inflectra Tier 2
PA; SP; QL (Quantity Limit Applies); Dual; QL (5 VIALS per 28 days)
Ingrezza Oral Capsule Tier 2PA; SP; QL (30 EA per 30 days)
Inlyta Oral Tablet 1 MG $0PA; SP; PD; QL (240 EA per 30 days)
Inlyta Oral Tablet 5 MG $0PA; SP; PD; QL (120 EA per 30 days)
InnoPran XL Tier 2 M90
Inqovi $0
Inrebic $0PA; SP; QL (120 EA per 30 days)
Insulin Pen Needle 29 G X 12 MM (1/2") $0 M90
Insulin Pen Needle 31 G X 5 MM (1/5" or 3/16")
$0 M90
Insulin Pen Needle 31 G X 8 MM (1/3" or 5/16")
$0 M90
Insulin Pen Needle 32 G X 4 MM (1/6" or 5/32")
$0 M90
Insulin Pen Needle 32 G X 5 MM (1/5" or 3/16") 32G X 5 MM
$0 M90
Insupen Pen Needles 32G X 4 MM BD Pen Needle Nano U/F $0 M90
Insupen Pen Needles 33G X 4 MMClever Choice Comfort EZ
Tier 1 M90
Insupen Sensitive 32G X 6 MM $0 M90
Insupen Sensitive 32G X 8 MM Tier 1 M90
Insupen Ultrafin $0 M90
Intelence Oral Tablet 25 MG Tier 2QL (120 EA per 30 days)
Intralipid Intravenous Emulsion 20 % Tier 2 M90
Intron A $0 SP
Introvale $0 M90
Inulin Tier 2 M90
Invega Sustenna Intramuscular Suspension Prefilled Syringe
Tier 2PD; QL (1 SYR per 28 days)
Invega Trinza Intramuscular Suspension Prefilled Syringe
Tier 2PD; QL (1 SYR per 28 days)
Invirase Oral Capsule Tier 2SP; QL (300 per 30 days)
88
Covered Product Reference Tier Status Notes
Invirase Oral Tablet Tier 2QL (120 EA per 30 days)
Invokamet Tier 2M90; QL (60 EA per 30 days)
Invokamet XR Tier 2
Invokana Tier 2M90; QL (30 EA per 30 days)
Iodides Tincture Tier 2 M90
Iodine External Tincture , 2 %, 2-2.4 % Tier 2 M90
Iodine Tincture External Tincture Tier 2 M90
Ipol Injection Injectable $0 M90
Ipratropium Bromide Inhalation Tier 2 M90
Ipratropium Bromide Nasal Tier 2 M90
Ipratropium-Albuterol Tier 2 M90
I-Prin Medi-Profen Tier 2 M90
Irbesartan Avapro Tier 1 M90
Irbesartan-Hydrochlorothiazide Avalide Tier 1 M90
Iressa $0SP; QL (30 EA per 30 days)
Irinotecan HCl Intravenous Solution 100 MG/5ML, 40 MG/2ML
Camptosar $0 M90
Irinotecan HCl Intravenous Solution 300 MG/15ML
Camptosar $0
Irinotecan HCl Intravenous Solution 500 MG/25ML
$0 M90
Iron 100 Plus Icar-C Plus Tier 2 M90
Iron Oral Tablet 240 (27 Fe) MG Ferate Tier 2 M90
Iron Oral Tablet 28 MG, 90 (18 Fe) MG Tier 2 M90
Iron Supplement Childrens BProtected Pedia Iron $0 M90
Isentress Oral Packet Tier 2QL (60 EA per 30 days)
Isentress Oral Tablet Tier 2QL (120 EA per 30 days)
Isentress Oral Tablet Chewable Tier 2QL (180 EA per 30 days)
Isometheptene-Caffeine-APAP Oral Tablet 65-20-325 MG
Tier 2 M90
Isometheptene-Dichloral-APAP Tier 2 M90
Isoniazid Injection Tier 2 M90
Isoniazid Oral Tier 2 M90
Isosorbide Dinitrate ER Tier 2 M90
89
Covered Product Reference Tier Status NotesIsosorbide Dinitrate Oral Tablet 10 MG, 20 MG, 30 MG
Tier 2 M90
Isosorbide Dinitrate Oral Tablet 40 MG Isordil Titradose Tier 2
Isosorbide Dinitrate Oral Tablet 5 MG Isordil Titradose Tier 2 M90
Isosorbide Mononitrate Tier 2 M90
Isosorbide Mononitrate ER Tier 2 M90
Isoxsuprine HCl Oral Tier 2 M90
Isradipine Tier 1 M90
Istodax Tier 1 SP
Istodax (Overfill) $0 SP
Isturisa Oral Tablet 1 MG Tier 2PA; SP; QL (240 EA per 30 Days)
Isturisa Oral Tablet 10 MG Tier 2PA; SP; QL (360 EA per 30 Days)
Isturisa Oral Tablet 5 MG Tier 2PA; SP; QL (180 EA per 30 Days)
Itraconazole Oral Capsule Sporanox Tier 2PA; M90; QL (60 EA per 30 days)
Itraconazole Oral Solution Sporanox Tier 2PA; SP; QL (450ml per 21 days)
Ivermectin External Cream Soolantra Tier 2 PA
Ivermectin External Lotion Tier 2
Ivermectin Oral Stromectol Tier 2M90; QL (20 EA per 90 days)
I-Vite ABC Plus Senior Tier 2 M90
I-Vite Protect ABC Plus Senior Tier 2 M90
Ixempra Kit $0 SP
Ixiaro $0 M90
Ixinity Tier 2 PA; SP; Dual
Jakafi $0SP; QL (60 EA per 30 days)
Jantoven Tier 2 M90
Janumet Tier 2M90; QL (60 EA per 60 days)
Janumet XR Tier 2M90; QL (30 EA per 30 days)
Januvia Tier 2M90; QL (30 EA per 30 days)
Jardiance Tier 2M90; QL (30 EA per 30 days)
Jatenzo Tier 2 ST
90
Covered Product Reference Tier Status NotesJencycla $0 M90
Jentadueto Tier 2QL (30 EA per 30 days)
Jentadueto XR Tier 2
Jevantique Lo Fyavolv Tier 2 M90
Jevtana $0 SP
Jinteli Tier 2 M90
Jivi Tier 2 PA; SP; Dual
Jock Itch Desenex Tier 2 M90
Jock Itch Relief Desenex Tier 2 M90
Jolessa $0 M90
Jolivette $0 M90
Juleber $0 M90
Juluca Tier 2PD; QL (30 EA per 30 days)
Junel 1.5/30 $0 M90
Junel 1/20 $0 M90
Junel FE 1.5/30 $0 M90
Junel FE 1/20 $0 M90
Junel Fe 24 $0 M90
Just for Kids Dental Tier 2 M90
Juxtapid Tier 2PA; QL (30 EA per 90 days)
Jynarque Oral Tablet Tier 2 SP
Jynarque Oral Tablet Therapy Pack 15 MG, 30 & 15 MG
Tier 2SP; QL (56 EA per 28 days)
Jynarque Oral Tablet Therapy Pack 45 & 15 MG, 60 & 30 MG, 90 & 30 MG
Tier 2SP; QL (56 tablets per month); QL (56 EA per 28 days)
Kadcyla $0 SP
Kadian Oral Capsule Extended Release 24 Hour 200 MG
Tier 2ST; M90; QL (QL applies)
Kaitlib Fe $0 M90
Kalbitor Tier 2PA; SP; QL (QL Flag); Dual
Kaletra Oral Solution Tier 2SP; QL (390 per 30 days)
Kalydeco Oral Packet 25 MG Tier 2 PA; PD
Kalydeco Oral Packet 50 MG, 75 MG Tier 2PA; SP; PD; QL (60 PACKS per 30 days)
91
Covered Product Reference Tier Status Notes
Kalydeco Oral Tablet Tier 2PA; SP; PD; QL (60 EA per 30 days)
Kanuma MB PA
Kaopectate Oral Suspension Tier 2 M90
Kao-Tin Oral Suspension Tier 2 M90
Karbinal ER Oral Suspension Extended Release
Tier 2 M90
Karidium Tier 1 M90
Karigel Tier 2 M90
Karigel-N Tier 2 M90
Kariva $0 M90
Kaz HealthMist Humidifier $0 QL (1 EA per 1 Year)
Kaz Vicks Vaporizer V150 $0M90; QL (QL Flag); QL (1 EA per 1 Year)
Kazano Tier 2PA; QL (30 EA per 30 days)
K-Effervescent Effer-K Tier 2 M90
Kelnor 1/35 $0 M90
Kenalog Injection Tier 2 M90
Kendall Sodium Chloride Flush Tier 2 M90
Kepivance $0 M90
Keri Advanced Moisture Therapy Tier 2 M90
Keri Basic Essentials Tier 2 M90
Keri Nourishing Shea Butter Tier 2 M90
Keri Original Tier 2 M90
Keri Overnight Tier 2 M90
Keri Renewal Milk Body Tier 2 M90
Keri Renewal Skin Firming Tier 2 M90
Keri Renewal Stretch Mark Tier 2 M90
Keri Sensitive Skin Tier 2 M90
KeriCort 10 Tier 2 M90
Ketoconazole External Cream Tier 2 PA; M90
Ketoconazole External Shampoo 2 % Tier 2 PA; M90
Ketoconazole Oral Tier 2 PA; M90
Ketoprofen ER Tier 2 M90
Ketoprofen Oral Capsule 50 MG, 75 MG Tier 2 M90
Ketorolac Tromethamine Injection Solution 15 MG/ML, 30 MG/ML, 60 MG/2ML
Tier 2 M90
92
Covered Product Reference Tier Status NotesKetorolac Tromethamine Ophthalmic Solution 0.4 %
Acular LS Tier 2M90; QL (5ml per 25 days)
Ketorolac Tromethamine Ophthalmic Solution 0.5 %
Acular Tier 2M90; QL (10ml per 25 days)
Ketorolac Tromethamine Oral Tier 2M90; QL (30 EA per 90 days)
Ketotifen Fumarate Ophthalmic Alaway Tier 2 M90; QL (QL Flag)
Kevzara Subcutaneous Solution Auto-Injector
Tier 2PA; SP; QL (2 ML per 28 PENSs)
Kevzara Subcutaneous Solution Prefilled Syringe
Tier 2PA; SP; QL (2 ML per 28 SYRs)
Keytruda Intravenous Solution MB PA
Khedezla Oral Tablet Extended Release 24 Hour 50 MG
Tier 2 ST; M90
Kimidess $0 M90
Kineret Subcutaneous Solution Prefilled Syringe
Tier 2PA; SP; QL (30 SYR per 30 days)
Kinrix Intramuscular Suspension $0 M90
Kionex Tier 2 M90
Kisqali 200 Dose $0SP; QL (63 EA per 28 days)
Kisqali 400 Dose $0 SP
Kisqali 600 Dose $0 SP
Kisqali Femara (400 MG Dose) $0 SP
Kisqali Femara (600 MG Dose) $0 SP
Kisqali Femara(200 MG Dose) $0 SP
Klor-Con Tier 2 M90
Klor-Con 10 Tier 2 M90
Klor-Con M10 Tier 2 M90
Klor-Con M15 Tier 2 M90
Klor-Con M20 Tier 2 M90
Klor-Con Sprinkle Tier 2 M90
Klor-Con/EF Tier 2 M90
KLS Acetaminophen Ex StHealthy Mama Shake That Ache
Tier 2 M90
KLS Acid Controller Max StMM Acid-Pep Maximum Strength
Tier 2 M90
KLS Acid Reducer Tier 2 M90
KLS Acid Reducer Max St Tier 2 M90
KLS AllerClear Tier 2 M90; QL (QL Flag)
KLS Aller-Fex Tier 2 M90; QL (QL Flag)
93
Covered Product Reference Tier Status NotesKLS Aller-Flo Tier 2 M90
KLS Allergy Medicine Alka-Seltzer Plus Allergy Tier 2 M90
KLS Aller-Tec Tier 2M90; QL (30 EA per 90 days)
KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)
KLS Antacid Cal-Gest Antacid Tier 2 M90
KLS Arthritis Pain Midol Tier 2 M90
KLS Ibuprofen Medi-Profen Tier 2 M90
KLS Ibuprofen IB Medi-Profen Tier 2 M90
KLS LaxaClear Tier 2 M90
KLS Naproxen Sodium Mediproxen Tier 2 M90
KLS Non AspirinHealthy Mama Shake That Ache
Tier 2 M90
KLS Pain & Fever Infants PediaCare Children Tier 2 M90
KLS Pain Relief Childrens PediaCare Children Tier 2 M90
KLS Quit2 $0 M90
KLS Quit4 $0 M90
KLS Rapid Release PainHealthy Mama Shake That Ache
Tier 2 M90
KLS Stool Softener Correctol Extra Gentle Tier 2 M90
Koate Tier 2 PA; SP; Dual
Koate-DVI Tier 2 PA; SP; Dual
Kogenate FS Tier 2 PA; SP; Dual
Kogenate FS Bio-Set Tier 2 PA; SP
Kombiglyze XR Oral Tablet Extended Release 24 Hour 2.5-1000 MG
Tier 2M90; QL (60 EA per 60 days)
Kombiglyze XR Oral Tablet Extended Release 24 Hour 5-1000 MG, 5-500 MG
Tier 2M90; QL (30 EA per 30 days)
Korlym Tier 2PA; QL (120 EA per 30 days)
Koselugo $0
Kovaltry Tier 2 PA; SP; Dual
KP Adults 50+ Daily Formula ABC Plus Senior Tier 2 M90
KP Adults Daily Formula ABC Plus Senior Tier 2 M90
KP Benzoyl Peroxide Tier 2 M90
KP Bisacodyl Alophen Tier 2 M90
KP Calcium 600+D Oral Capsule Tier 2 M90
KP Calcium 600+D Oral Tablet 600-400 MG-UNIT
Tier 2 M90
KP Cetirizine HCl Oral Tablet 10 MG KLS Aller-Tec Tier 2 M90; QL (QL Flag)
94
Covered Product Reference Tier Status Notes
KP Cetirizine HCl Oral Tablet 5 MG Tier 2M90; QL (30 EA per 90 days)
KP Clotrimazole Desenex Tier 2 M90
KP Fexofenadine HCl Wal-Fex Allergy Tier 2 M90; QL (QL Flag)
KP Hydrocortisone Aveeno Anti-Itch Max St Tier 2 M90
KP Hydrocortisone Max St Cortizone-10 Tier 2 M90
KP Ketotifen Fumarate Alaway Tier 2M90; QL (10ml per 25 days)
KP Loratadine KLS AllerClear Tier 2 M90; QL (QL Flag)
KP Mens 50+ Daily Formula ABC Plus Senior Tier 2 M90
KP Mens Daily Formula ABC Plus Senior Tier 2 M90
KP Miconazole Nitrate Tineacide Tier 2 M90
KP Prenatal Multivitamins Tier 1 M90
KP Vitamin D Oral Capsule 25 MCG (1000 UT)
Pronutrients Vitamin D3 Tier 2 M90
KP Womens 50+ Daily Formula ABC Plus Senior Tier 2 M90
KP Womens Daily Formula ABC Plus Senior Tier 2 M90
K-Phos Tier 2 M90
K-Phos No 2 Tier 2 M90
K-Prime Tier 2 M90
Krintafel Tier 2PA; QL (2 tablets per request)
Kroger Pen Needles 29G X 12MM , 31G X 6 MM
CareFine Pen Needles $0 M90
Kroger Pen Needles 31G X 8 MMAdvocate Insulin Pen Needles
$0 M90
Krystexxa MB PA
KS Stool Softener Correctol Extra Gentle Tier 2 M90
Kurvelo $0 M90
K-Vescent Oral Tablet Effervescent Effer-K Tier 2 M90
Kyleena $0SP; QL (1 FILL per 365 days)
Kynamro Subcutaneous Solution Prefilled Syringe
Tier 2PA; SP; QL (4 per 28 days)
Kynmobi Tier 2PA; SP; QL (150 EA per 30 days)
Labetalol HCl Intravenous Solution Tier 1 M90
Labetalol HCl Oral Tier 1 M90
Lacrisert Tier 2 M90
Lactaid Oral Tablet Tier 2
95
Covered Product Reference Tier Status NotesLactase Fast Acting Lactaid Fast Act Tier 2
Lactated Ringers Irrigation Tier 2 M90
Lactic Acid (Ammonium Lactate) Lotion 12%
AL12 Tier 2 M90
Lactic Acid E Tier 2 M90
Lactic Acid External Lotion Tier 2 M90
Lactulose Encephalopathy Tier 2 M90
Lactulose Oral Solution Tier 2 M90
LamiVUDine Oral Solution Epivir Tier 2 SP; M90
LamiVUDine Oral Tablet 100 MG Epivir HBV Tier 2M90; QL (30 EA per 90 days)
LamiVUDine Oral Tablet 150 MG, 300 MG
Epivir Tier 2 SP; M90
lamiVUDine-Zidovudine Combivir Tier 2 M90
LamoTRIgine ER LaMICtal XR Tier 2 M90
lamoTRIgine Oral Tablet LaMICtal Tier 2 M90
LamoTRIgine Oral Tablet Chewable LaMICtal Tier 2 M90
LamoTRIgine Oral Tablet Dispersible LaMICtal ODT Tier 2 M90
Lampit Tier 2
Lancets $0
Land Before Time Multivitamin Oral Tablet Chewable 15 MG
Tier 2 M90
Lan-O-Soothe External Cream Tier 2 M90
Lansoprazole Oral Capsule Delayed Release 15 MG
Prevacid 24HR Tier 2ST; M90; QL (120 EA per 30 days)
Lansoprazole Oral Capsule Delayed Release 30 MG
Prevacid Tier 2 ST
Lanthanum Carbonate Fosrenol Tier 2
Lantus Tier 1
Lantus SoloStar Subcutaneous Solution Pen-Injector
Tier 1
Larin 1.5/30 $0 M90
Larin 1/20 $0 M90
Larin 24 FE $0 M90
Larin Fe 1.5/30 $0 M90
Larin Fe 1/20 $0 M90
Larissia $0 M90
Lastacaft Tier 2ST; M90; QL (3ml per 25 days)
Latanoprost Ophthalmic Xalatan Tier 2 M90
96
Covered Product Reference Tier Status NotesLatuda Oral Tablet 120 MG, 20 MG, 40 MG, 60 MG
Tier 2M90; QL (30 EA per 90 days)
Latuda Oral Tablet 80 MG Tier 2M90; QL (60 EA per 30 days)
Laxa Basic Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90
Laxative Feminine Alophen Tier 2 M90
Laxative Oral Tablet 25 MG Tier 2 M90
Laxative Oral Tablet Delayed Release Alophen Tier 2 M90
Laxative Pills Tier 2 M90
Laxative Rectal The Magic Bullet Tier 2 M90
Layolis FE $0 M90
Lazanda Nasal Solution 100 MCG/ACT, 400 MCG/ACT
Tier 2 PA; M90
L-Cysteine HCl Intravenous Elcys Tier 2 M90
Leader Unifine Pentips $0 M90
Leader Unifine Pentips Plus $0 M90
Lecithin Oral Granules Tier 2 M90
Ledipasvir-Sofosbuvir Harvoni Tier 2PA; SP; PD; QL (28 EA per 28 days)
Leena $0 M90
Leflunomide Oral Arava Tier 2 M90
Lemtrada MB PA
Lenvima (10 MG Daily Dose) $0PA; SP; QL (30 EA per 30 days)
Lenvima (12 MG Daily Dose) $0PA; SP; QL (90 EA per 30 days)
Lenvima (14 MG Daily Dose) $0PA; SP; QL (60 EA per 30 days)
Lenvima (18 MG Daily Dose) $0PA; SP; QL (90 EA per 30 days)
Lenvima (20 MG Daily Dose) $0PA; SP; QL (60 EA per 30 days)
Lenvima (24 MG Daily Dose) $0PA; SP; QL (90 EA per 30 days)
Lenvima (4 MG Daily Dose) $0PA; SP; QL (30 EA per 30 days)
Lenvima (8 MG Daily Dose) $0PA; SP; QL (60 EA per 30 days)
Lessina $0 M90
Letrozole Oral Femara $0 M90
97
Covered Product Reference Tier Status NotesLeucovorin Calcium Injection Solution 100 MG/10ML
$0
Leucovorin Calcium Injection Solution Reconstituted
$0 M90
Leucovorin Calcium Oral $0 M90
Leukeran $0 M90
Leukine Injection Solution Reconstituted Tier 2 SP; Dual
Leuprolide Acetate Injection $0 PA; SP
Levacet Tier 2 M90
Levalbuterol HCl Inhalation Nebulization Solution 0.31 MG/3ML, 0.63 MG/3ML, 1.25 MG/3ML
Xopenex Tier 2PA; M90; QL (4 PACKS per 30 days)
Levalbuterol HCl Inhalation Nebulization Solution 1.25 MG/0.5ML
Xopenex Concentrate Tier 2PA; M90; QL (3 PACKS per 30 days)
Levalbuterol Tartrate Xopenex HFA Tier 2 PA
LevETIRAcetam ER Keppra XR Tier 2 M90
levETIRAcetam Oral Keppra Tier 2 M90
Levobunolol HCl Ophthalmic Solution 0.5 %
Tier 2 M90
levOCARNitine Intravenous Carnitor Tier 2 M90
levOCARNitine Oral Solution Carnitor Tier 2 M90
levOCARNitine Oral Tablet Carnitor Tier 2 M90
Levocetirizine Dihydrochloride Oral Solution
Xyzal Allergy 24HR Childrens
Tier 2M90; QL (300ml per month)
Levocetirizine Dihydrochloride Oral Tablet
Xyzal Allergy 24HR Tier 2M90; QL (30 EA per 90 days)
LevoFLOXacin Intravenous Tier 2 M90
Levofloxacin Ophthalmic Tier 2 M90
Levofloxacin Oral Levaquin Tier 2 M90
Levoleucovorin Calcium Intravenous Solution
$0 SP
LEVOleucovorin Calcium Intravenous Solution Reconstituted 50 MG
$0 SP
LEVOleucovorin Calcium PF Intravenous Solution 250 MG/25ML
$0 SP
Levonest $0 M90
Levonorgest-Eth Estrad 91-Day Introvale $0 M90
Levonorgestrel Oral Tablet 1.5 MG Aftera $0 M90
Levonorgestrel-Ethinyl Estrad Altavera $0 M90
Levonorg-Eth Estrad Triphasic Oral Tablet
Enpresse-28 $0 M90
98
Covered Product Reference Tier Status NotesLevora 0.15/30 (28) $0 M90
Levorphanol Tartrate Oral Tablet 2 MG Tier 2
Levo-T Tier 2 M90
Levothyroxine Sodium Oral Capsule Tirosint Tier 2
Levothyroxine Sodium Oral Tablet Levo-T Tier 2 M90
Levoxyl Tier 2 M90
Levulan Kerastick Tier 2 M90
Lexiva Oral Suspension Tier 2QL (1680 ml per 30 days)
Lexiva Oral Tablet Tier 2QL (120 EA per 30 days)
Lexuss 210 Tier 2 M90
Libtayo MBPA; QL (1 VIAL per 21 days)
Lice Treatment External Liquid RID Tier 2 M90
Lice Treatment External Lotion Tier 2 M90
Licide Tier 2 M90
Licide Maximum Strength Tier 2 M90
Lidocaine External Ointment 5 % Tier 2 M90
Lidocaine External Patch 5 % Lidoderm Tier 2QL (90 EA per 30 days)
Lidocaine HCl External Gel 2 % Regenecare HA Tier 2 M90
Lidocaine HCl External Solution Tier 2 M90
Lidocaine HCl Injection Solution 0.5 %, 1 %, 2 %
Xylocaine Tier 2 M90
Lidocaine HCl Mouth/Throat Tier 2 M90
Lidocaine PAK Tier 2 M90
Lidocaine Viscous Tier 2 M90
Lidocaine-Epinephrine Injection Solution 0.5 %-1:200000
Xylocaine/EPINEPHrine Tier 2 M90
Lidocaine-Epinephrine Injection Solution 1 %-1:100000, 2 %-1:100000
Xylocaine/Epinephrine Tier 2 M90
Lidocaine-Epinephrine Injection Solution 1.5 %-1:200000
Xylocaine-MPF/Epinephrine
Tier 2 M90
Lidocaine-Hydrocortisone Ace Rectal Gel Tier 2 M90
Lidocaine-Hydrocortisone Ace Rectal Kit 3-0.5 %, 3-1 %
Tier 2 M90
Lidocaine-Prilocaine External Cream Tier 2 M90
LifEMS Naloxone $0
Liletta (52 MG) Intrauterine Intrauterine Device 18.6 MCG/DAY
$0SP; QL (1 FILL per 365 days)
99
Covered Product Reference Tier Status NotesLiletta (52 MG) Intrauterine Intrauterine Device 19.5 MCG/DAY
$0
Lincomycin HCl Injection Lincocin Tier 2 M90
Lindane External Shampoo Tier 2 M90
Linezolid Oral Suspension Reconstituted Zyvox Tier 2PA; M90; QL (1800ml per 75 days)
Linezolid Oral Tablet Zyvox Tier 2PA; M90; QL (56 tablets per 75 days)
Linzess Oral Capsule 145 MCG, 290 MCG
Tier 2PA; QL (30 EA per 90 days)
Linzess Oral Capsule 72 MCG Tier 2PA; QL (30 EA per 30 days)
Liothyronine Sodium Oral Cytomel Tier 2 M90
Lipodox 50 $0 M90
Liquid Calcium with D3 Tier 2 M90
Liquid Calcium/Vitamin D Tier 2 M90
Liquid Pain Relief Little Remedies for Fever Tier 2 M90
Liquihep II Prefilled Syringe Tier 2 M90
Liquihep Prefilled Syringe Tier 2 M90
LiquiTears Tier 2 M90
Lisinopril Oral Prinivil Tier 1 M90
Lisinopril-hydroCHLOROthiazide Zestoretic Tier 1 M90
Litetouch Pen Needles 29G X 12.7MM , 31G X 6 MM , 31G X 8 MM
$0 M90
Lithium Tier 2 M90
Lithium Carbonate ER Lithobid Tier 2 M90
Lithium Carbonate Oral Tier 2 M90
Lithium Heparin Prefilled Syr Tier 2 M90
Lithostat Tier 2 M90
Little Animals Bounty Bears/C Tier 2 M90
Little Animals Plus IronLand Before Time Multivitamin
Tier 2 M90
Little Fevers Fever-Pain Rel Oral Solution 160 MG/5ML
Tier 2 M90
Little Noses Saline Tier 1 M90
Little Noses Stuffy Nose Kit Tier 1 M90
Little Remedies for Fever Oral Liquid Tier 2 M90
Little Remedies for Tummys Oral Suspension
Tier 2 M90
Little Tummys Gas Relief Tier 2 M90
100
Covered Product Reference Tier Status NotesLo Loestrin Fe $0 M90
Lomedia 24 FE Tier 2 M90
Long Lasting Antacid Cal-Gest Antacid Tier 2 M90
Lonhala Magnair Refill Kit Tier 2 PA
Lonhala Magnair Starter Kit Tier 2 PA
Lonsurf $0 SP; QL (QL Flag)
Loperamide HCl Oral Capsule Imodium A-D Tier 2 M90
Lopinavir-Ritonavir Oral Tablet 100-25 MG
Kaletra Tier 2QL (240 EA per 30 days)
Lopinavir-Ritonavir Oral Tablet 200-50 MG
Kaletra Tier 2QL (120 EA per 30 days)
Loradamed KLS AllerClear Tier 2 M90; QL (QL Flag)
Loratadine Allergy Relief Oral Tablet Dispersible
Alavert Tier 2 M90
Loratadine Childrens Oral Solution Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
Loratadine Childrens Oral Syrup Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
Loratadine Oral Tablet KLS AllerClear Tier 2M90; QL (30 EA per 90 days)
Loratadine Rapidly-Disintegrating Tab 10 MG Oral Capsule 25 MG
Banophen Tier 2 M90
Loratadine Rapidly-Disintegrating Tab 10 MG Oral Tablet 10 MG
KLS AllerClear Tier 2 M90; QL (QL Flag)
Loratadine Rapidly-Disintegrating Tab 10 MG Oral Tablet 25 MG
Alka-Seltzer Plus Allergy Tier 2 M90
Loratadine Rapidly-Disintegrating Tab 10 MG Oral Tablet 4 MG
Wal-finate Tier 2 M90
Loratadine Rapidly-Disintegrating Tab 10 MG Oral Tablet 60 MG
Wal-Fex Allergy Tier 2 M90; QL (QL Flag)
Loratadine Rapidly-Disintegrating Tab 10 MG Oral Tablet Dispersible 10 MG
Alavert Tier 2 M90
LORazepam Injection Ativan Tier 2
LORazepam Intensol Tier 2
LORazepam Oral Concentrate 2 MG/ML LORazepam Intensol Tier 2
LORazepam Oral Tablet Ativan Tier 2
Lorbrena Oral Tablet 100 MG $0PA; SP; QL (30 EA per 30 days)
Lorbrena Oral Tablet 25 MG $0PA; SP; QL (90 EA per 30 days)
101
Covered Product Reference Tier Status Notes
Lorcet Tier 2M90; QL (240 tablets per 30 days. Click;HERE)
Lorcet HD Tier 2M90; QL (180 EA per 30 days)
Lorcet Plus Oral Tablet 7.5-325 MG Tier 2M90; QL (180 EA per 30 days)
Lortab Oral Elixir 10-300 MG/15ML Tier 2PA; M90; QL (2025 ML per 30 days)
Lortab Oral Tablet 10-325 MG, 7.5-325 MG
Tier 2M90; QL (180 EA per 30 days)
Lortab Oral Tablet 5-325 MG Tier 2M90; QL (240 tablets per 30 days. Click;HERE)
Loryna $0 M90
Losartan Potassium Oral Cozaar Tier 1 M90
Losartan Potassium-HCTZ Hyzaar Tier 1 M90
Lotemax Ophthalmic Ointment Tier 2 ST; M90
Lotemax SM Tier 2 ST
Loteprednol Etabonate Lotemax Tier 2 ST
Lovastatin Oral Tier 2M90; QL (30 EA per 90 days)
Low-Ogestrel $0 M90
Loxapine Succinate Oral Tier 2 M90
Lubiprostone Amitiza Tier 2PA; QL (60 EA per 30 days)
Lubricant Eye Drops Ophthalmic Solution 0.6 %
Systane Complete Tier 2 M90
Lubricating LotionA + D Personal Care Lotion
Tier 2 M90
Lubriderm Tier 2 M90
Lubriderm Advanced Therapy External Lotion
Tier 2 M90
Lubriderm Daily Moisture Tier 2 M90
Lubriderm Intense Skin Repair External Lotion
Tier 2 M90
Lubriderm Mens 3-in-1 Tier 2 M90
Lubriderm Seriously Sensitive Tier 2 M90
Lubriderm Skin Nourishing Tier 2 M90
LubriSilk Tier 2 M90
Lubriskin Tier 2 M90
LubriSoft Tier 2 M90
102
Covered Product Reference Tier Status NotesLucemyra Tier 2 PA
Lucentis Intravitreal Tier 2 PA; SP; Dual
Ludent Oral Tablet Chewable 0.55 (0.25 F) MG, 1.1 (0.5 F) MG
Tier 1 M90
Ludent Oral Tablet Chewable 2.2 (1 F) MG
Tier 2 M90
Lugols External Tier 2 M90
Lumigan Ophthalmic Solution 0.01 % Tier 2 ST
Lumizyme MB PA
Lumoxiti MB PA
Lupaneta Pack MB PA
Lupkynis Tier 2PA; SP; QL (180 EA per 30 days)
Lupron Depot (1-Month) $0 PA; SP; Dual
Lupron Depot (3-Month) $0 PA; SP; Dual
Lupron Depot (4-Month) $0 PA; SP; Dual
Lupron Depot (6-Month) $0 PA; SP; Dual
Lupron Depot-Ped (1-Month) Tier 2 PA; SP; Dual
Lupron Depot-Ped (3-Month) Tier 2 PA; SP; Dual
Luride Oral Solution Tier 1 M90
Lutera $0 M90
Lynparza Oral Capsule $0PA; SP; QL (480 capsules per 30 days)
Lynparza Oral Tablet Tier 2 PA; SP
Lyophil Lith Hep Prefilled Syr Tier 2 M90
Lysiplex Plus Oral Liquid Tier 2 M90
Lysodren $0 SP; M90
Lyza $0 M90
M2 Zinc-50 Tier 2 M90
Maalox Tier 2 M90
Macular Vitamin Benefit ABC Plus Senior Tier 2 M90
MagneBind 400 Tier 2 M90
Magnesium Chloride Injection Tier 2 M90
Magnesium Citrate Oral Solution 1.745 GM/30ML
Citroma Tier 2 M90
Magnesium Citrate SOLUTION 1.745 GM/30ML Oral
Citroma Tier 2 M90
Magnesium Oxide -Mg Supplement Oral Tablet
Tier 2 M90
Magnesium Oxide Oral Capsule 400 MG Tier 2 M90
103
Covered Product Reference Tier Status NotesMagnesium Oxide Oral Tablet 250 MG, 400 (240 Mg) MG, 400 MG
Tier 2 M90
Magnesium Oxide Oral Tablet 400 (241.3 Mg) MG
MAGnesium-Oxide Tier 2 M90
Magnesium Oxide Oral Tablet 420 MG Maox Tier 2
Magnesium Sulfate Injection Solution 50 %
Tier 2 M90
MAGnesium-Oxide Tier 2 M90
Malathion External Ovide Tier 2 M90
Mapap Acetaminophen Extra Str Tier 2 M90
Mapap Arthritis Pain Midol Tier 2 M90
Mapap Childrens Oral Suspension Tier 2 M90
Mapap Extra Strength Tier 2 M90
Mapap Oral Liquid Little Remedies for Fever Tier 2 M90
Mapap Oral Tablet Aphen Tier 2 M90
Mapap Oral Tablet Chewable Childrens Medi-Tabs Tier 2 M90
Maprotiline HCl Tier 2 M90
Margenza MB PA
Margesic Esgic Tier 2 M90
Marlissa Altavera $0 M90
Marplan Tier 2 M90
Marqibo $0 M90
Matulane $0 M90
Matzim LA Tier 1 M90
Mavenclad (10 Tabs) Tier 2 PA; SP
Mavenclad (4 Tabs) Tier 2 PA; SP
Mavenclad (5 Tabs) Tier 2 PA; SP
Mavenclad (6 Tabs) Tier 2 PA; SP
Mavenclad (7 Tabs) Tier 2 PA; SP
Mavenclad (8 Tabs) Tier 2 PA; SP
Mavenclad (9 Tabs) Tier 2 PA; SP
Mavyret Oral Tablet Tier 2PA; SP; PD; QL (84 EA per 28 days)
Maxam Tier 2 M90
Maxapap Maximum StrengthHealthy Mama Shake That Ache
Tier 2 M90
Maxapap Regular Strength Aphen Tier 2 M90
Maxidex Tier 2 M90
Maximum D3 Oral Capsule 10000 UNIT Tier 2 M90
104
Covered Product Reference Tier Status NotesMaximum Daily Green ABC Plus Senior Tier 2 M90
Mayzent Tier 2 PA; SP
Mayzent Starter Pack Tier 2PA; SP; QL (12 EA per 1 Fill)
McCarnitine Tier 2 M90
Meclizine HCl Oral Tablet 12.5 MG Tier 2 M90
Meclofenamate Sodium Oral Tier 2 M90
Med-Derm Hydrocortisone External Cream 1 %
Aveeno Anti-Itch Max St Tier 2 M90
Medical Provider EZ Afluria PF Tier 1 M90
Medical Provider EZ Flu PF Intramuscular Prefilled Syringe Kit
Tier 1 M90
Medical Provider EZ Flu Shot Intramuscular Prefilled Syringe Kit 0.25 ML
Tier 1 M90
Medical Provider EZ Fluvirin Tier 1 M90
Medicated Anti-Fungal Blis-To-Sol Tier 2 M90
Medicine Shoppe Pen Needles CareFine Pen Needles $0 M90
Medi-First Anti-Fungal Tier 2 M90
Medi-Lax Tier 2 M90
Medi-Natural Evac-U-Gen Tier 2 M90
Medi-Phedryl Oral Capsule Tier 2 M90
Medi-Profen Oral Suspension Tier 2 M90
Medi-Profen Oral Tablet Tier 2 M90
Mediproxen Tier 2 M90
Medi-Tabs Childrens Tier 2 M90
Medi-Tabs Extra Strength Tier 2 M90
Medrol Oral Tablet 2 MG Tier 2 M90
MedroxyPROGESTERone Acetate Intramuscular
Depo-Provera $0 M90
MedroxyPROGESTERone Acetate Oral Provera Tier 2 M90
Mefloquine HCl Tier 2 M90
Mega Multivitamin for Men ABC Plus Senior Tier 2 M90
Mega Multivitamin for Women ABC Plus Senior Tier 2 M90
Mega VM-80 ABC Plus Senior Tier 2 M90
Megavite Fruits & Veggies ABC Plus Senior Tier 2 M90
Megavite Golden Years 55+ ABC Plus Senior Tier 2 M90
Megestrol Acetate Oral Suspension 40 MG/ML, 400 MG/10ML
$0 M90
105
Covered Product Reference Tier Status NotesMegestrol Acetate Oral Suspension 625 MG/5ML
Tier 2 M90
Megestrol Acetate Oral Tablet $0 M90
Meijer Advanced Formula ABC Plus Senior Tier 2 M90
Meijer Allergy Relief Oral Tablet KLS AllerClear Tier 2 M90; QL (QL Flag)
Meijer Allergy Relief Oral Tablet Dispersible
Alavert Tier 2 M90
Meijer Antihistamine Allergy Banophen Tier 2 M90
Meijer Aspirin Free Aphen Tier 2 M90
Meijer Calamine Tier 2 M90
Meijer Hydrocortisone Aveeno Anti-Itch Max St Tier 2 M90
Meijer Ibuprofen Medi-Profen Tier 2 M90
Meijer Loratadine Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
Meijer Nasal Decongestant SudoGest Tier 2 M90
Meijer Pen Needles CareFine Pen Needles $0 M90
Meijer Saline Nasal Spray Afrin Saline Nasal Mist Tier 1 M90
Meijer Zinc Oxide Tier 2 M90
Mekinist Oral Tablet 0.5 MG $0SP; QL (90 EA per 30 days)
Mekinist Oral Tablet 2 MG $0SP; QL (30 EA per 90 days)
Mektovi $0SP; QL (180 EA per 30 days)
Meloxicam Oral Tablet Mobic Tier 2 M90
Melphalan HCl Alkeran $0 M90
Memantine HCl ER Namenda XR Tier 2
Memantine HCl Oral Solution 2 MG/ML Tier 2 M90
Memantine HCl Oral Tablet Tier 2 M90
Menactra Intramuscular Injectable $0 M90
Menest Tier 2 M90
Menomune Subcutaneous Injectable Tier 1 M90
Menostar Tier 2 M90
Mens 50+ Advanced DEKAs Plus Tier 2 M90
Mens 50+ Multi Vitamin/Min ABC Plus Senior Tier 2 M90
Mens Daily Formula/Lycopene DEKAs Plus Tier 2 M90
Mens Multi Vitamin & Mineral ABC Plus Senior Tier 2 M90
Menveo $0 M90
Meperidine HCl Oral Solution Tier 2QL (90 mL per 30 days. Click;HERE)
106
Covered Product Reference Tier Status NotesMeperidine HCl Oral Tablet Tier 2
Meperidine-Promethazine Tier 2 M90
Meprobamate Tier 2 M90
Mepsevii MB PA
Mercaptopurine Oral $0 M90
Mesalamine ER Apriso Tier 2
Mesalamine Oral Capsule Delayed Release
Delzicol Tier 2
Mesalamine Oral Tablet Delayed Release 1.2 GM
Lialda Tier 2
Mesalamine Oral Tablet Delayed Release 800 MG
Asacol HD Tier 2 M90
Mesalamine Rectal Tier 2
Mesna Mesnex $0 M90
Mesnex Oral $0 M90
Mestinon Oral Syrup Tier 2 M90
Metaproterenol Sulfate Oral Tier 2 M90
Metaxall Tier 2 ST; M90
Metaxalone Tier 2 ST; M90
metFORMIN HCl ER Tier 1 M90
MetFORMIN HCl ER (MOD) Glumetza Tier 1 PA; M90
MetFORMIN HCl ER (OSM) Oral Tablet Extended Release 24 Hour 1000 MG, 500 MG
Tier 1 PA; M90
MetFORMIN HCl Oral Tablet Tier 1 M90
Methadone HCl Injection Tier 2ST; M90; QL (20 mL per 30 days. Click;HERE)
Methadone HCl Intensol Tier 2ST; QL (90 mL per 30 days. Click;HERE)
Methadone HCl Oral Concentrate Methadone HCl Intensol Tier 2 ST
Methadone HCl Oral Solution Tier 2ST; QL (450 mL per 30 days. Click;HERE)
Methadone HCl Oral Tablet Tier 2ST; QL (90 EA per 30 days)
Methadone HCl Oral Tablet Soluble Methadose Tier 2 ST
Methadose Oral Tablet Soluble Tier 2 ST
Methamphetamine HCl Desoxyn Tier 2 PA
methazolAMIDE Oral Tier 1 M90
Methenamine Hippurate Hiprex Tier 2 M90
107
Covered Product Reference Tier Status NotesMethenamine Mandelate Oral Tablet 0.5 GM
Tier 2 M90
methIMAzole Oral Tier 2 M90
Methitest Tier 2
Methocarbamol Oral Tier 2 M90
Methotrexate Sodium (PF) Injection Solution 1 GM/40ML, 100 MG/4ML, 200 MG/8ML, 250 MG/10ML, 50 MG/2ML
$0 M90
Methotrexate Sodium Injection Solution 250 MG/10ML, 50 MG/2ML
$0 M90
Methotrexate Sodium Injection Solution Reconstituted
$0 M90
Methotrexate Sodium Oral $0
Methoxsalen Oral Tier 2 M90
Methoxsalen Rapid Tier 2 M90
Methscopolamine Bromide Oral Tier 2 M90
Methyclothiazide Oral Tier 1 M90
Methyldopa Oral Tier 1 M90
Methyldopa-hydroCHLOROthiazide Tier 1 M90
Methylergonovine Maleate Oral Methergine Tier 2 M90
Methylphenidate HCl ER (CD) Tier 2PA; QL (60 EA per 30 days)
Methylphenidate HCl ER (LA) Oral Capsule Extended Release 24 Hour 10 MG
Ritalin LA Tier 2
Methylphenidate HCl ER (LA) Oral Capsule Extended Release 24 Hour 20 MG, 30 MG, 40 MG
Ritalin LA Tier 2QL (60 EA per 30 days)
Methylphenidate HCl ER (LA) Oral Capsule Extended Release 24 Hour 60 MG
Tier 2QL (60 EA per 30 days)
Methylphenidate HCl ER (XR) Oral Capsule Extended Release 24 Hour 10 MG
Aptensio XR Tier 2PA; QL (30 EA per 30 days)
Methylphenidate HCl ER (XR) Oral Capsule Extended Release 24 Hour 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG
Aptensio XR Tier 2PA; QL (30 EA per 30 Days)
Methylphenidate HCl ER Oral Tablet Extended Release 10 MG
Tier 2QL (90 EA per 30 days)
Methylphenidate HCl ER Oral Tablet Extended Release 20 MG
Tier 2 QL (QL Flag)
108
Covered Product Reference Tier Status NotesMethylphenidate HCl ER Oral Tablet Extended Release 24 Hour 18 MG
Tier 2M90; QL (30 EA per 90 days)
Methylphenidate HCl ER Oral Tablet Extended Release 24 Hour 27 MG, 54 MG
Tier 2QL (30 EA per 90 days)
Methylphenidate HCl ER Oral Tablet Extended Release 24 Hour 36 MG
Tier 2QL (60 EA per 30 days)
Methylphenidate HCl Oral Solution Methylin Tier 2QL (900 ML per 30 days)
Methylphenidate HCl Oral Tablet Ritalin Tier 2QL (90 EA per 30 days)
Methylphenidate HCl Oral Tablet Chewable
Tier 2M90; QL (90 EA per 30 days)
MethylPREDNISolone Acetate Injection Suspension 40 MG/ML
Depo-Medrol Tier 2 M90
MethylPREDNISolone Acetate Injection Suspension 80 MG/ML
DEPO-Medrol Tier 2 M90
MethylPREDNISolone Oral Medrol Tier 2 M90
MethylPREDNISolone Sodium Succ Injection Solution Reconstituted 1000 MG
Solu-MEDROL Tier 2 M90
MethylPREDNISolone Sodium Succ Injection Solution Reconstituted 125 MG, 40 MG
SOLU-medrol Tier 2 M90
MethylTESTOSTERone Oral Tier 2
Metipranolol Tier 2 M90
Metoclopramide HCl Oral Solution 10 MG/10ML, 5 MG/5ML
Tier 2 M90
Metoclopramide HCl Oral Tablet Reglan Tier 2 M90
Metolazone Tier 1 M90
Metoprolol Succinate ER Toprol XL Tier 1 M90
Metoprolol Tartrate Oral Tablet 100 MG, 50 MG
Lopressor Tier 1 M90
Metoprolol Tartrate Oral Tablet 25 MG Tier 1 M90
Metoprolol-HCTZ ER Oral Tablet Extended Release 24 Hour 25-12.5 MG
Dutoprol Tier 2 M90
Metoprolol-Hydrochlorothiazide Tier 1 M90
MetroNIDAZOLE External Cream Rosadan Tier 2 M90
MetroNIDAZOLE External Gel 0.75 % Rosadan Tier 2 M90
MetroNIDAZOLE External Gel 1 % Metrogel Tier 2 ST; M90
MetroNIDAZOLE External Lotion MetroLotion Tier 2 M90
metroNIDAZOLE Oral Tier 2 M90
MetroNIDAZOLE Vaginal Vandazole Tier 2 M90
Mexiletine HCl Oral Tier 2 M90
109
Covered Product Reference Tier Status NotesMgO MAGnesium-Oxide Tier 2 M90
Miacalcin Injection Tier 2 M90
Mi-Acid Gas Relief Tier 2 M90
Micaderm Tineacide Tier 2 M90
Miconazole 1 Monistat 1 Combo Pack Tier 2 M90
Miconazole 3 ApplicatorMonistat 3 Combo Pack App
Tier 2 M90
Miconazole 3 Combo PackMonistat 3 Combo Pack App
Tier 2 M90
Miconazole 3 Combo Pack AppMonistat 3 Combo Pack App
Tier 2 M90
Miconazole 3 Vaginal Cream Monistat 3 Tier 2 M90
Miconazole 3 Vaginal Suppository Tier 2 M90
Miconazole 7 Monistat 7 Simply Cure Tier 2 M90
Miconazole Nitrate Cream 2 % External External Aerosol
Tinactin Tier 2 M90
Miconazole Nitrate Cream 2 % External External Cream
Tinactin Tier 2 M90
Miconazole Nitrate External Cream Tineacide Tier 2 M90
Miconazole Nitrate Vaginal Monistat 7 Simply Cure Tier 2 M90
Microgestin 1.5/30 $0 M90
Microgestin 1/20 $0 M90
Microgestin 24 Fe Tier 2 M90
Microgestin FE 1.5/30 $0 M90
Microgestin FE 1/20 $0 M90
Midazolam HCl Oral Tier 2
Midodrine HCl Tier 2 M90
miFEPRIStone Mifeprex Tier 2
Migergot Tier 2 M90
Miglitol Tier 1 M90
Miglustat Zavesca Tier 2
Milk of Magnesia Concentrate Tier 2 M90
Milk of Magnesia Oral Suspension 1200 MG/15ML, 400 MG/5ML, 7.75 %
Dulcolax Milk of Magnesia
Tier 2 M90
Millipred Tier 2 M90
Mimvey Tier 2 M90
Mimvey Lo Tier 2 M90
Mineral Oil Heavy Oral Tier 2 M90
Mineral Oil Oral Oil Tier 2 M90
Minerin Tier 2 M90
110
Covered Product Reference Tier Status NotesMinitran Tier 2 M90
Minivelle Transdermal Patch Twice Weekly 0.025 MG/24HR
Tier 2 M90
Minocycline HCl Oral Minocin Tier 2 M90
Minoxidil Oral Tier 1 M90
Mircera Injection Solution Prefilled Syringe
MB PA
Mirena (52 MG) $0SP; QL (1 FILL per 365 days)
Mirtazapine Oral Remeron Tier 2 M90
miSOPROStol Oral Cytotec Tier 2 M90
Mitomycin Intravenous Mutamycin $0 M90
Mitoxantrone HCl $0 SP
M-M-R II Subcutaneous $0 M90
Modafinil Provigil Tier 2PA; QL (30 EA per 90 days)
Moderiba 1200 Dose Pack Tier 2 SP
Moderiba Oral Tier 2 PA; SP
Moderiba Oral Tablet 200 MG Tier 2 SP
Moexipril HCl Tier 1 M90
Moexipril-hydroCHLOROthiazide Tier 1 M90
Moisture External LotionA + D Personal Care Lotion
Tier 2 M90
Moisture RecoveryA + D Personal Care Lotion
Tier 2 M90
Moisturel External Lotion Tier 2 M90
Moisturizing LotionA + D Personal Care Lotion
Tier 2 M90
Moisturizing Sensitive SkinA + D Personal Care Lotion
Tier 2 M90
Moisturizing Vitamin E/AloeA + D Personal Care Lotion
Tier 2 M90
Mometasone Furoate External Tier 2 M90
Mometasone Furoate Nasal Nasonex Tier 2ST; M90; QL (17ml per 25 days)
Mondoxyne NL Oral Capsule 100 MG, 50 MG
Tier 2 M90
Monistat 7 Combo Pack App Tier 2 M90
Monjuvi MB PA
Monoclate-P Intravenous Kit 1000 UNIT, 1500 UNIT
Tier 2 PA; SP; Dual
111
Covered Product Reference Tier Status NotesMonoject Flush Syringe Intravenous Tier 2 M90
Monoject Sodium Chloride Flush Intravenous
Tier 2 M90
Mono-Linyah $0 M90
MonoNessa $0 M90
Mononine Intravenous Solution Reconstituted 1000 UNIT
Tier 2 PA; SP; Dual
Monovisc Tier 2PA; SP; QL (QL Flag); Dual; QL (1 SYR per 1 APPROVAL)
Monsels Ferric Subsulfate External Tier 2 M90
Montelukast Sodium Oral Packet Singulair Tier 2ST; M90; QL (30 EA per 90 days)
Montelukast Sodium Oral Tablet Singulair Tier 2M90; QL (30 EA per 90 days)
Montelukast Sodium Oral Tablet Chewable
Singulair Tier 2M90; QL (30 EA per 90 days)
Morgidox Oral Tier 2 M90
MorphaBond ER Oral Tablet ER 12 Hour Abuse-Deterrent 100 MG, 60 MG
Tier 2 ST; QL (QL applies)
MorphaBond ER Oral Tablet ER 12 Hour Abuse-Deterrent 15 MG, 30 MG
Tier 2ST; QL (60 EA per 30 days)
Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML
Tier 2QL (135 mL per 30 days. Click;HERE)
Morphine Sulfate ER Beads Oral Capsule Extended Release 24 Hour 120 MG
Tier 2 ST; QL (QL applies)
Morphine Sulfate ER Beads Oral Capsule Extended Release 24 Hour 30 MG, 45 MG, 60 MG, 75 MG, 90 MG
Tier 2ST; QL (30 EA per 90 days)
Morphine Sulfate ER Oral Capsule Extended Release 24 Hour 10 MG, 20 MG, 30 MG
Tier 2ST; QL (60 EA per 30 days)
Morphine Sulfate ER Oral Capsule Extended Release 24 Hour 100 MG
Tier 2 ST; QL (QL applies)
Morphine Sulfate ER Oral Capsule Extended Release 24 Hour 40 MG
Tier 1ST; M90; QL (180 EA per 30 days)
Morphine Sulfate ER Oral Capsule Extended Release 24 Hour 50 MG, 60 MG, 80 MG
Tier 2ST; QL (30 EA per 90 days)
Morphine Sulfate ER Oral Tablet Extended Release 100 MG, 200 MG, 60 MG
MS Contin Tier 2ST; QL (QL applies. Click;HERE)
Morphine Sulfate ER Oral Tablet Extended Release 15 MG, 30 MG
MS Contin Tier 2ST; QL (90 EA per 30 days)
112
Covered Product Reference Tier Status NotesMorphine Sulfate Oral Solution 10 MG/5ML
Tier 2QL (900 mL per 30 days. Click;HERE)
Morphine Sulfate Oral Solution 20 MG/5ML
Tier 2QL (675 mL per 30 days. Click;HERE)
Morphine Sulfate Oral Tablet 15 MG Tier 2QL (180 EA per 30 days)
Morphine Sulfate Oral Tablet 30 MG Tier 2QL (90 EA per 30 days)
Morphine Sulfate Rectal Suppository 10 MG, 5 MG
Tier 2QL (180 EA per 30 days)
Morphine Sulfate Rectal Suppository 20 MG
Tier 2QL (120 EA per 30 days)
Morphine Sulfate Rectal Suppository 30 MG
Tier 2QL (90 EA per 30 days)
Motegrity Tier 2PA; QL (30 EA per 30 days)
Mothers Friend External Lotion Tier 2 M90
Motrin IB Oral Tablet Tier 2 M90
Movantik Tier 2PA; M90; QL (30 EA per 90 days)
Moxifloxacin HCl (2X Day) Moxeza Tier 2
Moxifloxacin HCl Ophthalmic Solution Vigamox Tier 2
Moxifloxacin HCl Oral Tier 2 M90
Mozobil Tier 2 SP; QL (QL Flag)
MSM SkinA + D Personal Care Lotion
Tier 2 M90
Mulpleta Tier 2 PA; SP
Multaq Tier 2 M90
Multi Complete/Iron ABC Plus Senior Tier 2 M90
Multi For Her 50+ ABC Plus Senior Tier 2 M90
Multi For Her Oral Capsule DEKAs Plus Tier 2 M90
Multi For Her Oral Tablet ABC Plus Senior Tier 2 M90
Multi For Him 50+ ABC Plus Senior Tier 2 M90
Multi Prenatal Right Step Prenatal Tier 1 M90
Multi Vitamin/Minerals ABC Plus Senior Tier 2 M90
Multi-Day Plus IronTab-A-Vite/Iron/Beta Carotene
Tier 2 M90
Multi-Day Plus Minerals ABC Plus Senior Tier 2 M90
Multigen Folic Tier 2 M90
Multilex ABC Plus Senior Tier 2 M90
Multilex-T ABC Plus Senior Tier 2 M90
113
Covered Product Reference Tier Status NotesMultimineral Plus ABC Plus Senior Tier 2 M90
Multiple Vit/Minerals/No Iron ABC Plus Senior Tier 2 M90
Multiple Vitamins/IronTab-A-Vite/Iron/Beta Carotene
Tier 2 M90
Multiple Vitamins/Womens ABC Plus Senior Tier 2 M90
Multi-Symptom Allergy Banophen Tier 2 M90
Multi-Vit/Fluoride Oral Solution Quflora Pediatric Tier 2 M90
Multi-Vit/Fluoride/Iron Tier 2 M90
Multivitamin ABC Plus Senior Tier 2 M90
Multivitamin & Mineral BProtected Multi-Vite Tier 2 M90
Multivitamin Adult Oral Tablet EstroFactors Tier 2 M90
Multivitamin Adults 50+ ABC Plus Senior Tier 2 M90
Multivitamin Childrens Culturelle Kids Complete Tier 2
Multivitamin Men ABC Plus Senior Tier 2 M90
Multi-Vitamin Menopausal ABC Plus Senior Tier 2 M90
Multi-Vitamin Monocaps ABC Plus Senior Tier 2 M90
Multivitamin Oral Liquid BProtected Multi-Vite Tier 2 M90
Multivitamin Women ABC Plus Senior Tier 2 M90
Multivitamin Women 50+ ABC Plus Senior Tier 2 M90
Multivitamin/Fluoride Oral Tablet Chewable 0.25 MG, 0.5 MG, 1 MG
Quflora Pediatric Tier 2 M90
Multi-Vitamin/Fluoride/Iron Tier 2 M90
Multi-Vitamin/IronTab-A-Vite/Iron/Beta Carotene
Tier 2 M90
Multi-Vitamin/Minerals ABC Plus Senior Tier 2 M90
Multivitamins/Fluoride Quflora Pediatric Tier 2 M90
Mupirocin Calcium Tier 2 PA; M90
Mupirocin External Centany Tier 2 M90
Murine Ear Tier 2 M90
Murine Ear Wax Removal System Tier 2 M90
Mustargen $0 M90
Mvasi Tier 2 PA; SP; Dual
MVC-Fluoride Tier 2 M90
M-Vit Tier 1 M90
My Choice $0
My Way $0 M90
Myamulti ABC Plus Senior Tier 2 M90
Mycapssa Tier 2PA; SP; QL (120 EA per 30 days)
114
Covered Product Reference Tier Status NotesMycocide Clinical NS Tier 2 M90
Mycophenolate Mofetil Oral CellCept Tier 2 SP; QL (QL Flag)
Mycophenolate Sodium Myfortic Tier 2 SP; QL (QL Flag)
Mydayis Tier 2PA; QL (30 EA per 90 days)
Myferon 150 Forte iFerex 150 Forte Tier 2 M90
MyKidz Iron 10 Tier 1 M90
Myleran $0 M90
Myobloc Tier 2PA; SP; QL (QL Flag); Dual
Myorisan Tier 2 M90
Myrbetriq Oral Tablet Extended Release 24 Hour
Tier 2ST; M90; QL (30 EA per 90 days)
Mytab Gas Tier 2 M90
Mytesi Tier 2PA; M90; QL (60 EA per 30 days)
My-Vitalife DEKAs Plus Tier 2 M90
Myzilra $0 M90
Na Ferric Gluc Cplx in Sucrose Ferrlecit Tier 2 M90
Nabumetone Oral Relafen Tier 2 M90
Nadolol Oral Tablet 20 MG, 40 MG, 80 MG
Corgard Tier 1 M90
Nadolol-Bendroflumethiazide Tier 1 M90
NaFrinse Tier 2 M90
NaFrinse Drops Tier 1 M90
Naftifine HCl External Cream Tier 2 ST; M90
Naftifine HCl External Gel Naftin Tier 2 ST
Naftin External Gel 2 % Tier 2 ST; M90
Nalbuphine HCl Injection Tier 2 M90
Naloxone HCl Injection Solution 0.4 MG/ML, 4 MG/10ML
Tier 2 M90
Naloxone HCl Injection Solution Cartridge
Tier 2 M90
Naloxone HCl Injection Solution Prefilled Syringe
$0 M90
Naltrexone HCl Oral Tier 2 M90
Namenda XR Titration Pack Tier 2 M90
Namzaric Oral Capsule Extended Release 24 Hour 14-10 MG, 28-10 MG
Tier 2 M90
Naproxen DR EC-Naprosyn Tier 2 M90
115
Covered Product Reference Tier Status NotesNaproxen Oral Suspension Naprosyn Tier 2 M90
Naproxen Oral Tablet Tier 2 M90
Naproxen Sodium Oral Tablet 220 MG Mediproxen Tier 2 M90
Naproxen Sodium Oral Tablet 275 MG Tier 2 M90
Naproxen Sodium Oral Tablet 550 MG Anaprox DS Tier 2
Naramin Tier 2 M90
Naratriptan HCl Amerge Tier 2M90; QL (12 tablets per month)
Narcan Tier 2 M90
Nasal Allergy 24 Hour KLS Aller-Cort Tier 2ST; M90; QL (QL Flag)
Nasal Decongestant Oral Syrup Tier 2 M90
Nasal Decongestant Oral Tablet 30 MG SudoGest Tier 2 M90
Nasal Moist Nasal Solution Tier 1 M90
Nasal Moisturizing Spray Afrin Saline Nasal Mist Tier 1 M90
Nascobal Tier 2 PA; QL (4 per 28 days)
Natacyn Tier 2 M90
Natazia $0 M90
Nateglinide Tier 1 M90
Nat-Rul Prenatal Vitamins Tier 1 M90
Nat-Rul Vitamin D Vitamin D-1000 Max St Tier 2 M90
Natrul-Mega-75 ABC Plus Senior Tier 2 M90
Natrul-Vites ABC Plus Senior Tier 2 M90
Natural Vitamin D-3Radiance Platinum Vitamin D3
Tier 2 M90
Naturalyte Tier 2 M90
Nature-Throid Tier 2 M90
Nayzilam Tier 2PA; QL (10 EA per 30 days)
Na-Zone Afrin Saline Nasal Mist Tier 1 M90
Nebivolol HCl Bystolic Tier 2
Nebusal Inhalation Nebulization Solution 3 %
Tier 2 M90
Necon 0.5/35 (28) $0 M90
Necon 1/35 (28) $0 M90
Necon 1/50 (28) Tier 2 M90
Necon 10/11 (28) Tier 2 M90
Necon 7/7/7 $0 M90
Nefazodone HCl Tier 2 M90
116
Covered Product Reference Tier Status NotesNembutal Tier 2 M90
Neomycin Sulfate Oral Tier 2 M90
Neomycin-Bacitracin Zn-Polymyx Ophthalmic Ointment 5-400-10000
Neo-Polycin Tier 2 M90
Neomycin-Polymyxin B GU Tier 2 M90
Neomycin-Polymyxin-Dexameth Ophthalmic Ointment
Maxitrol Tier 2 M90
Neomycin-Polymyxin-Dexameth Ophthalmic Suspension 3.5-10000-0.1
Maxitrol Tier 2 M90
Neomycin-Polymyxin-Gramicidin Ophthalmic Solution 1.75-10000-.025
Tier 2 M90
Neomycin-Polymyxin-HC Ophthalmic Suspension 3.5-10000-1
Tier 2 M90
Neomycin-Polymyxin-HC Otic Tier 2 M90
Neo-Polycin Tier 2 M90
Neo-Polycin HC Tier 2 M90
Neosalus External Lotion Tier 2 M90
Neosporin Eczema Essent Max St Tier 2 M90
Neostigmine Methylsulfate Injection Tier 2 M90
Neostigmine Methylsulfate Intravenous Solution 10 MG/10ML, 5 MG/10ML
Bloxiverz Tier 2 M90
Neo-Synalar External Cream Tier 2 M90
Nerlynx $0 PA; SP
Nesina Tier 2 PA
Neulasta Onpro Tier 2SP; Dual; QL (2 SYR per 28 days)
Neulasta Subcutaneous Solution Prefilled Syringe
Tier 2SP; Dual; QL (2 SYR per 28 days)
Neupogen Injection Solution 300 MCG/ML, 480 MCG/1.6ML
Tier 2 SP; Dual
Neupogen Injection Solution Prefilled Syringe
Tier 2 SP; Dual
Neupro Tier 2 PA; M90
Neuro-K-250 Vitamin B6 Tier 2 M90
Neuro-K-50 Tier 2 M90
NeutraGard Advanced Tier 2 M90
Neutrogena Body External Lotion Tier 2 M90
Neutrogena Healthy Skin Face Tier 2 M90
Neutrogena Moisture Sens Skin Tier 2 M90
Nevanac Tier 2ST; M90; QL (3ml per 25 days)
117
Covered Product Reference Tier Status NotesNevirapine Tier 2 M90
Nevirapine ER Viramune XR Tier 2 M90
New Day $0
NexAVAR $0PA; SP; QL (120 EA per 30 days)
NexIUM Oral Packet 2.5 MG, 5 MG Tier 2ST; QL (30 EA per 30 days)
Nexletol Tier 2PA; QL (30 EA per 30 days)
Nexlizet Tier 2PA; QL (30 EA per 30 days)
Nexplanon $0SP; QL (1 FILL per 365 days)
Next Choice One Dose $0 M90
Niacin ER (Antihyperlipidemic) Niaspan Tier 1 M90
Niacin ER Oral Capsule Extended Release Tier 1 M90
Niacin ER Oral Tablet Extended Release 1000 MG
Tier 2 M90
Niacin ER Oral Tablet Extended Release 250 MG, 500 MG, 750 MG
Endur-Acin Tier 1 M90
Niacin Oral Tablet Tier 1 M90
Niacin-50 Tier 1 M90
Niacor Tier 1 M90
NiCARdipine HCl Oral Tier 1 M90
Nicorelief Mouth/Throat Gum $0 M90
Nicotine Mini KLS Quit2 $0 M90
Nicotine Polacrilex Mouth/Throat KLS Quit2 $0 M90
Nicotine Step 1 Habitrol $0 M90
Nicotine Step 2 Nicoderm CQ $0 M90
Nicotine Step 3 Nicoderm CQ $0 M90
Nicotine Transdermal Kit Tier 1 M90
Nicotine Transdermal Patch 24 Hour Nicoderm CQ $0 M90
Nicotrol $0 M90
Nicotrol NS Tier 2 M90
Nifedical XL Tier 1 M90
NIFEdipine ER Afeditab CR Tier 1 M90
NIFEdipine ER Osmotic Release Procardia XL Tier 1 M90
NIFEdipine Oral Tier 1 M90
Nikki $0 M90
Nilutamide Nilandron $0 M90
118
Covered Product Reference Tier Status NotesNiMODipine Oral Tier 1 M90
Ninlaro $0 SP; QL (QL Flag)
Nipent $0 M90
Nisoldipine ER Tier 1 M90
Nitazoxanide Oral Alinia Tier 2
Nitro-Bid Tier 2 M90
Nitro-Dur Transdermal Patch 24 Hour 0.3 MG/HR, 0.8 MG/HR
Tier 2 M90
Nitrofurantoin Macrocrystal Oral Macrodantin Tier 2 M90
Nitrofurantoin Monohyd Macro Macrobid Tier 2 M90
Nitroglycerin ER Nitro-Time Tier 2 M90
Nitroglycerin Transdermal Patch 24 Hour Nitro-Dur Tier 2 M90
Nitroglycerin Translingual Nitrolingual Tier 2 M90
Nitro-Time Tier 2 M90
Niva-Plus Tier 1 M90
Nivea External Lotion Tier 2 M90
Nivea Original Moisture Tier 2 M90
Nivea Visage External Lotion Tier 2 M90
Nivestym Injection Solution Prefilled Syringe
Tier 2 PA; SP; Dual
Nizatidine Tier 2 M90
No Iron Mult Vitamin-Minerals ABC Plus Senior Tier 2 M90
Noble Formula HC External Cream Tier 2 M90
Noctiva Tier 2 PA
Nodolor Tier 2 M90
Non-Aspirin Childrens Oral Suspension PediaCare Children Tier 2 M90
Non-Aspirin Extra Strength Oral TabletHealthy Mama Shake That Ache
Tier 2 M90
Non-Aspirin Oral Tablet 325 MG Aphen Tier 2 M90
Non-Aspirin Pain Relief Aphen Tier 2 M90
Nora-BE $0 M90
Norepinephrine Bitartrate Intravenous Levophed Tier 2 M90
Norethin Ace-Eth Estrad-FE Oral Tablet 1-20 MG-MCG
Blisovi FE 1/20 $0 M90
Norethin Ace-Eth Estrad-FE Oral Tablet 1-20 MG-MCG(24)
Microgestin 24 Fe $0 M90
Norethin Ace-Eth Estrad-FE Oral Tablet Chewable
Charlotte 24 Fe $0
Norethindrone Acetate Oral Aygestin Tier 2 M90
119
Covered Product Reference Tier Status NotesNorethindrone Acet-Ethinyl Est Oral Tablet 1.5-30 MG-MCG
Junel 1.5/30 $0
Norethindrone Acet-Ethinyl Est Oral Tablet 1-20 MG-MCG
Junel 1/20 $0 M90
Norethindrone Oral Camila $0 M90
Norethindrone-Eth Estradiol Fyavolv Tier 2 M90
Norethin-Eth Estradiol-Fe Wymzya Fe $0 M90
Norgestimate-Eth Estradiol Oral Tablet 0.25-35 MG-MCG
Estarylla $0 M90
Norgestim-Eth Estrad Triphasic Tri-Lo-Estarylla $0 M90
Noritate Tier 2 ST; M90
Norlyroc $0 M90
Normal Saline Flush Intravenous Monoject Flush Syringe Tier 2 M90
Norpace CR Tier 2 M90
Nortemp Infants Tier 2 M90
Nortemp Oral Suspension Tier 2 M90
Nortrel 0.5/35 (28) $0 M90
Nortrel 1/35 (21) $0 M90
Nortrel 1/35 (28) $0 M90
Nortrel 7/7/7 $0 M90
Nortriptyline HCl Oral Pamelor Tier 2 M90
Norvir Oral Capsule Tier 2 QL (360 per 30 days)
Norvir Oral Packet Tier 2
Norvir Oral Solution Tier 2QL (450 ml per 30 days)
Norvir Oral Tablet Tier 2PD; BP; QL (360 EA per 30 days)
Nourianz Tier 2PA; QL (30 EA per 30 days)
Novavax COVID-19 Vaccine $0
Novoeight Tier 2 PA; SP; Dual
NovoFine $0 M90
NovoFine Autocover $0 M90
NovoFine Autocover Pen Needle $0 M90
Novofine Pen Needle $0 M90
NovoFine Plus $0 M90
NovoFine Plus Pen Needle $0 M90
NovoLIN 70/30 Tier 1 M90
NovoLIN 70/30 ReliOn Tier 1 M90
NovoLIN N Tier 1 M90
120
Covered Product Reference Tier Status NotesNovoLIN N ReliOn Tier 1 M90
NovoLIN R Tier 1 M90
NovoLIN R ReliOn Tier 1 M90
NovoLOG Tier 1 BP
NovoLOG FlexPen Subcutaneous Solution Pen-Injector
Tier 1 BP
NovoLOG Mix 70/30 Tier 1 M90; BP
NovoLOG Mix 70/30 FlexPen Subcutaneous Suspension Pen-Injector
Tier 1 M90; BP
NovoLOG PenFill Subcutaneous Solution Cartridge
Tier 1 BP
NovoSeven RT Tier 2 PA; SP; Dual
NovoTwist Pen Needle $0 M90
Noxafil Oral Suspension Tier 2 PA; M90
NP Thyroid Oral Tablet 15 MG, 30 MG, 60 MG, 90 MG
Armour Thyroid Tier 2 M90
Nplate MB PA
Nubeqa $0PA; SP; QL (120 EA per 30 days)
Nucala Subcutaneous Solution Auto-Injector
Tier 2PA; QL (3 PENS per 28 days)
Nucala Subcutaneous Solution Prefilled Syringe
Tier 2PA; QL (3 SYR per 28 days)
Nucala Subcutaneous Solution Reconstituted
Tier 2PA; SP; Dual; QL (3 VIALS per 28 days)
Nucynta ER Oral Tablet Extended Release 12 Hour 100 MG, 50 MG
Tier 2ST; M90; QL (60 EA per 30 days)
Nucynta ER Oral Tablet Extended Release 12 Hour 150 MG, 200 MG, 250 MG
Tier 2ST; M90; QL (QL applies. Click;HERE)
NuDiclo SoluPak Tier 2 M90
Nuedexta Tier 2PA; M90; QL (60 EA per 30 days)
NuFera Tier 2 M90
NuLev Tier 2 M90
Nulibry MB PA
Nutraderm Advanced Formula Tier 2 M90
Nutraderm External Lotion Tier 2 M90
Nutrilipid Intravenous Emulsion 20 % Tier 2 M90
Nutrilyte Hyperlyte-CR Tier 2 M90
Nutropin AQ NuSpin 10 Subcutaneous Solution
Tier 2 PA; SP
121
Covered Product Reference Tier Status NotesNutropin AQ NuSpin 20 Subcutaneous Solution
Tier 2 PA; SP
Nutropin AQ NuSpin 5 Subcutaneous Solution
Tier 2 PA; SP
Nutropin AQ Pen Subcutaneous Solution 10 MG/2ML
Tier 2 PA; SP
Nuwiq Tier 2 PA; SP; Dual
Nuzyra Oral Tablet 150 MG Tier 2PA; QL (30 EA per 90 days)
Nyamyc Tier 2 M90
Nystatin External Tier 2 M90
Nystatin Mouth/Throat Tier 2 M90
Nystatin Oral Tier 2 M90
Nystatin-Triamcinolone Tier 2 M90
Nystop Tier 2 M90
Nyvepria Tier 2SP; Dual; QL (2 SYR per 28 days)
Obizur Tier 2 PA; SP; Dual
O-Cal FA Tier 1 M90
O-Cal Prenatal $0 M90
Ocaliva Tier 2PA; SP; QL (30 EA per 90 days)
Ocean for Kids Tier 1 M90
Ocella $0 M90
Ocrevus MB PA
Octagam Tier 2 PA; SP; Dual
Octaplas Blood Group A Tier 2 M90
Octaplas Blood Group AB Tier 2 M90
Octaplas Blood Group B Tier 2 M90
Octaplas Blood Group O Tier 2 M90
Octreotide Acetate Injection Solution 100 MCG/ML, 50 MCG/ML, 500 MCG/ML
SandoSTATIN Tier 2PA; SP; QL (QL Flag); Dual
Octreotide Acetate Injection Solution 1000 MCG/ML, 200 MCG/ML
Tier 2PA; SP; QL (QL Flag); Dual
Ocutabs ABC Plus Senior Tier 2 M90
Ocutabs-Lutein ABC Plus Senior Tier 2 M90
Odactra Tier 2 PA; SP
Odefsey Tier 2PD; QL (30 EA per 30 days)
Odomzo $0SP; QL (30 EA per 90 days)
122
Covered Product Reference Tier Status Notes
Ofev Tier 2PA; SP; QL (60 EA per 30 days)
Ofloxacin Ophthalmic Ocuflox Tier 2 M90
Ofloxacin Oral Tablet 400 MG Tier 2 M90
Ofloxacin Otic Tier 2 M90
Ogestrel $0 M90
OLANZapine Intramuscular ZyPREXA Tier 2 M90
OLANZapine Oral Tablet 10 MG, 15 MG, 20 MG, 7.5 MG
ZyPREXA Tier 2M90; QL (30 EA per 90 days)
OLANZapine Oral Tablet 2.5 MG, 5 MG ZyPREXA Tier 2M90; QL (60 EA per 30 days)
OLANZapine Oral Tablet Dispersible ZyPREXA Zydis Tier 2M90; QL (30 EA per 90 days)
Olmesartan Medoxomil Oral Benicar Tier 1 ST; M90
Olmesartan Medoxomil-HCTZ Benicar HCT Tier 1 ST; M90
Olopatadine HCl Nasal Patanase Tier 2 M90
Olopatadine HCl Ophthalmic Solution 0.1 %
Pataday Tier 2ST; M90; QL (5ml per 25 days)
Olopatadine HCl Ophthalmic Solution 0.2 %
Pataday Tier 2ST; QL (2.5ml per 25 days)
Olumiant Tier 2 PA; SP
Omeclamox-Pak Tier 2 M90
Omega-3-acid Ethyl Esters Lovaza Tier 1PA; M90; QL (120 EA per 30 days)
Omeprazole Magnesium Oral Tablet Delayed Release
PriLOSEC OTC Tier 2
Omeprazole Oral Capsule Delayed Release 10 MG
Tier 2M90; QL (30 EA per 90 days)
Omeprazole Oral Capsule Delayed Release 20 MG
Tier 2M90; QL (120 EA per 30 days)
Omeprazole Oral Capsule Delayed Release 40 MG
Tier 2M90; QL (60 EA per 30 days)
Omeprazole-Sodium Bicarbonate Cap 20-1100 MG
Zegerid Tier 2ST; M90; QL (QL Flag)
Omniflex Diaphragm Tier 2 M90
OmniPod 5 Pack Tier 2PA; PD; QL (10 EA per 30 days)
OmniPod Dash 5 Pack Pods Tier 2PA; PD; QL (10 EA per 30 days)
OmniPod Starter Tier 2PA; PD; QL (1 EA per 5 Years)
Omnitrope Subcutaneous Solution Tier 2 PA; SP
123
Covered Product Reference Tier Status NotesOmnitrope Subcutaneous Solution Reconstituted
Tier 2 PA
Omron 3 Series BP Monitor $0QL (1 EA per 3 YEARs)
Omron 5 Series BP Monitor $0QL (1 EA per 3 YEARs)
Oncaspar Injection $0 SP; QL (QL Flag)
Once Daily/IronTab-A-Vite/Iron/Beta Carotene
Tier 2 M90
Ondansetron Tier 2M90; QL (60 EA per 30 days)
Ondansetron HCl Oral Tablet 4 MG Zofran Tier 2M90; QL (60 EA per 30 days)
Ondansetron HCl Oral Tablet 8 MG Tier 2M90; QL (60 EA per 30 days)
One Daily 50 Plus ABC Plus Senior Tier 2 M90
One Daily Adults 50+ ABC Plus Senior Tier 2 M90
One Daily Calcium/Iron ABC Plus Senior Tier 2 M90
One Daily Complete ABC Plus Senior Tier 2 M90
One Daily Complete for Men ABC Plus Senior Tier 2 M90
One Daily For Men 50+ Advanced ABC Plus Senior Tier 2 M90
One Daily For Men/Lycopene ABC Plus Senior Tier 2 M90
One Daily For Women ABC Plus Senior Tier 2 M90
One Daily For Women 50+ Adv ABC Plus Senior Tier 2 M90
One Daily Healthy Weight ABC Plus Senior Tier 2 M90
One Daily Healthy Weight Adv ABC Plus Senior Tier 2 M90
One Daily Maximum ABC Plus Senior Tier 2 M90
One Daily Men Formula w/o Iron ABC Plus Senior Tier 2 M90
One Daily Mens ABC Plus Senior Tier 2 M90
One Daily Mens Health ABC Plus Senior Tier 2 M90
One Daily Multivit/Iron-Free ABC Plus Senior Tier 2 M90
One Daily Multivitamin Men ABC Plus Senior Tier 2 M90
One Daily Multivitamin Women ABC Plus Senior Tier 2 M90
One Daily Multivitamin/IronTab-A-Vite/Iron/Beta Carotene
Tier 2 M90
One Daily Plus Minerals ABC Plus Senior Tier 2 M90
One Daily Womens ABC Plus Senior Tier 2 M90
One Daily Womens 50 Plus ABC Plus Senior Tier 2 M90
One Daily Womens 50+ ABC Plus Senior Tier 2 M90
One Daily/Minerals ABC Plus Senior Tier 2 M90
124
Covered Product Reference Tier Status Notes
One-Daily/IronTab-A-Vite/Iron/Beta Carotene
Tier 2 M90
Onglyza Tier 2M90; QL (30 EA per 30 days)
Onmel Tier 2 M90
Onpattro MB PA; PD
Onureg $0QL (14 EA per 28 days)
Opcicon One-Step $0 M90
Opdivo MB PA
Opium Tier 2
Opsumit Tier 2PA; SP; QL (30 EA per 90 days)
Optic-Vites ABC Plus Senior Tier 2 M90
Optic-Vites with Lutein ABC Plus Senior Tier 2 M90
Optimal-D Tier 2 M90
Optimum PMS ABC Plus Senior Tier 2 M90
Option 2 $0 M90
Options Gynol II Contraceptive $0 M90
Opti-Woman ABC Plus Senior Tier 2 M90
Opurity Vitamin D Tier 2 M90
Oracit Tier 2 M90
Oralair Tier 2PA; SP; QL (Quantity Limit Applies)
Oralone Tier 2 M90
Oralyte Tier 2 M90
Oralyte Freezer Pops Tier 2 M90
Orazinc Oral Capsule Tier 2 M90
Orencia ClickJect Tier 2PA; SP; Dual; QL (4 PENS per 28 days)
Orencia Intravenous Tier 2PA; SP; Dual; QL (4 VIALS per 28 days)
Orencia Subcutaneous Solution Prefilled Syringe
Tier 2PA; SP; Dual; QL (4 SYR per 28 days)
Orenitram Tier 2 PA; SP
Orgovyx $0PA; SP; QL (30 EA per 30 days)
Oriahnn Tier 2 PA
Orilissa Tier 2 PA
Orkambi Oral Packet Tier 2PA; PD; QL (56 EA per 28 days)
125
Covered Product Reference Tier Status Notes
Orkambi Oral Tablet Tier 2PA; PD; QL (112 EA per 28 days)
Orladeyo Tier 2PA; SP; QL (30 EA per 30 days)
Ormir Unisom Sleepgels Tier 2 M90
Orphenadrine Citrate ER Tier 2 M90
Orsythia $0 M90
Ortho-CS 250 Tier 2 M90
OrthoVisc Intra-Articular Solution Prefilled Syringe
Tier 2PA; SP; QL (QL Flag); Dual
Oscal 500/200 D-3 Tier 2 M90
Os-Cal Calcium + D3 Tier 2 M90
Os-Cal Extra D3 Tier 2 M90
Os-Cal Oral Tablet Chewable 500-600 MG-UNIT
Tier 2 M90
Oscimin Levsin Tier 2 M90
Oscimin SR Levbid Tier 2 M90
Oscion Cleanser External Lotion 6 % Tier 2 M90
Oseltamivir Phosphate Oral Capsule 30 MG
Tamiflu Tier 2QL (28 EA per 90 days)
Oseltamivir Phosphate Oral Capsule 45 MG, 75 MG
Tamiflu Tier 2QL (14 EA per 90 days)
Oseltamivir Phosphate Oral Suspension Reconstituted
Tamiflu Tier 2QL (180ml per 25 days)
Osmolex ER Oral Tablet Extended Release 24 Hour
Tier 2PA; QL (30 EA per 30 days)
OsmoPrep Tier 2 M90
Otezla Oral Tablet Tier 2PA; SP; QL (60 EA per 30 days)
Otezla Oral Tablet Therapy Pack Tier 2PA; SP; QL (55 EA per 28 days)
Otix Tier 2 M90
Otomax-HC Cortic-ND Tier 2 M90
Oxaliplatin Intravenous Solution 100 MG/20ML, 50 MG/10ML
$0 M90
Oxaliplatin Intravenous Solution 200 MG/40ML
$0
Oxaliplatin Intravenous Solution Reconstituted
$0 M90
Oxaprozin Daypro Tier 2 M90
Oxaydo Oral Tablet Abuse-Deterrent Tier 2ST; QL (180 EA per 30 days)
126
Covered Product Reference Tier Status NotesOxazepam Tier 2
Oxbryta Tier 2PA; SP; QL (90 EA per 30 days)
OXcarbazepine Trileptal Tier 2 M90
Oxervate Tier 2PA; SP; QL (56 ML per 30 days)
Oxiconazole Nitrate Oxistat Tier 2 ST; M90
Oxistat External Lotion Tier 2 ST; M90
Oxlumo MB PA
Oxtellar XR Tier 2 PA; M90
Oxybutynin Chloride ER Oral Tablet Extended Release 24 Hour 10 MG
Ditropan XL Tier 2M90; QL (60 EA per 30 days)
Oxybutynin Chloride ER Oral Tablet Extended Release 24 Hour 15 MG
Tier 2M90; QL (60 EA per 30 days)
Oxybutynin Chloride ER Oral Tablet Extended Release 24 Hour 5 MG
Ditropan XL Tier 2M90; QL (30 EA per 90 days)
Oxybutynin Chloride Oral Tier 2 M90
oxyCODONE HCl ER Oral Tablet ER 12 Hour Abuse-Deterrent
OxyCONTIN Tier 2ST; QL (Quantity Limit)
OxyCODONE HCl Oral Capsule Tier 2QL (180 EA per 30 days)
OxyCODONE HCl Oral Concentrate 100 MG/5ML
Tier 2QL (90 mL per 30 days. Click;HERE)
OxyCODONE HCl Oral Solution Tier 2QL (900 mL per 30 days. Click;HERE)
oxyCODONE HCl Oral Tablet 10 MG Tier 2QL (180 EA per 30 days)
oxyCODONE HCl Oral Tablet 15 MG Roxicodone Tier 2QL (120 EA per 30 days)
oxyCODONE HCl Oral Tablet 20 MG Tier 2QL (90 EA per 30 days)
oxyCODONE HCl Oral Tablet 30 MG Roxicodone Tier 2QL (60 EA per 30 days)
oxyCODONE HCl Oral Tablet 5 MG Oxaydo Tier 2QL (180 EA per 30 days)
Oxycodone-Acetaminophen Oral Solution 5-325 MG/5ML
Tier 2QL (1800 mL per 30 days. Click;HERE)
oxyCODONE-Acetaminophen Oral Tablet 10-325 MG
Endocet Tier 2QL (180 EA per 30 days)
Oxycodone-Acetaminophen Oral Tablet 2.5-325 MG, 5-325 MG
Endocet Tier 2QL (360 tablets per 30 days. Click;HERE)
oxyCODONE-Acetaminophen Oral Tablet 7.5-325 MG
Endocet Tier 2QL (240 tablets per 30 days. Click;HERE)
127
Covered Product Reference Tier Status NotesoxyCODONE-Aspirin Oral Tablet 4.8355-325 MG
Tier 2QL (360 tablets per 30 days. Click;HERE)
OxyCONTIN Oral Tablet ER 12 Hour Abuse-Deterrent 10 MG, 15 MG, 20 MG, 30 MG
Tier 2ST; M90; QL (60 EA per 30 days)
OxyCONTIN Oral Tablet ER 12 Hour Abuse-Deterrent 40 MG, 60 MG, 80 MG
Tier 2ST; M90; QL (QL applies)
oxyMORphone HCl ER Oral Tablet Extended Release 12 Hour 10 MG, 15 MG, 5 MG, 7.5 MG
Tier 2ST; QL (60 EA per 30 days)
OxyMORphone HCl ER Oral Tablet Extended Release 12 Hour 20 MG, 30 MG, 40 MG
Tier 2 ST; QL (QL applies)
Oxytrol For Women Tier 2M90; QL (8 patches per 28 days)
Oysco 500 Oral Tablet 500 MG Tier 2 M90
Oysco 500+D Tier 2 M90
Oysco D Tier 2 M90
Oyst-Cal D Tier 2 M90
Oyster Calcium + D Tier 2 M90
Oyster Shell Calcium + D Os-Cal Calcium + D3 Tier 2 M90
Oyster Shell Calcium + D3 Oystercal-D Tier 2 M90
Oyster Shell Calcium 250+D Tier 2 M90
Oyster Shell Calcium 500 + D Oral Tablet 500-125 MG-UNIT
Tier 2 M90
Oyster Shell Calcium 500+D Tier 2 M90
Oyster Shell Calcium Oral Tablet 500 MG Oystercal Tier 2 M90
Oyster Shell Calcium Oral Tablet 500-400 MG-UNIT
Oystercal-D Tier 2 M90
Oyster Shell Calcium Plus D Tier 2 M90
Oyster Shell Calcium/D Oral Tablet 250-125 MG-UNIT, 250-250 MG-UNIT, 500-200 MG-UNIT
Tier 2 M90
Oyster Shell Calcium/D Oral Tablet 500-400 MG-UNIT
Oystercal-D Tier 2 M90
Oyster Shell Calcium/D3 Oystercal-D Tier 2 M90
Oyster Shell Calcium/Vitamin D Oral Tablet
Os-Cal Calcium + D3 Tier 2 M90
Oyster Shell/Vitamin D Tier 2 M90
Oystercal Tier 2 M90
Oyster-Cal 250 + D Tier 2 M90
Oyster-Cal 500 + D Tier 2 M90
128
Covered Product Reference Tier Status NotesOystercal-D Tier 2 M90
Ozempic (0.25 or 0.5 MG/DOSE) Tier 1PA; QL (3 mL per 28 days); QL (2 PENS per 30 days)
Ozempic (1 MG/DOSE) Subcutaneous Solution Pen-Injector 2 MG/1.5ML
Tier 1PA; QL (3 mL per 28 days); QL (2 PENS per 30 days)
Ozempic (1 MG/DOSE) Subcutaneous Solution Pen-Injector 4 MG/3ML
Tier 1PA; QL (3 PENS per 28 days)
PA Calcium/Vitamin D Tier 2 M90
PA Oyster Shell Calcium Tier 2 M90
PA Vitamin D-3 Tier 2 M90
Pacerone Oral Tablet 100 MG, 200 MG, 400 MG
Tier 2 M90
PACLitaxel Intravenous Concentrate 100 MG/16.7ML, 150 MG/25ML, 30 MG/5ML, 300 MG/50ML
$0 M90
Pain & Fever Aphen Tier 2 M90
Pain & Fever Childrens Oral Solution Tier 2 M90
Pain & Fever Childrens Oral Suspension PediaCare Children Tier 2 M90
Pain & Fever Childrens Oral Tablet Chewable 80 MG
Childrens Medi-Tabs Tier 2 M90
Pain & Fever Extra StrengthHealthy Mama Shake That Ache
Tier 2 M90
Pain & Fever Infants PediaCare Children Tier 2 M90
Pain Relief 8 Hour Midol Tier 2 M90
Pain Relief Childrens Oral Suspension PediaCare Children Tier 2 M90
Pain Relief Extra Strength Oral Tablet 500 MG
Healthy Mama Shake That Ache
Tier 2 M90
Pain Relief Oral Tablet 325 MG Aphen Tier 2 M90
Pain Relief Oral Tablet 500 MGHealthy Mama Shake That Ache
Tier 2 M90
Pain Relief Regular Strength Aphen Tier 2 M90
Pain Reliever Extra Strength Oral Tablet 500 MG
Healthy Mama Shake That Ache
Tier 2 M90
Pain Reliever Oral Tablet Aphen Tier 2 M90
Pain Reliever/Fever Reducer FeverAll Childrens Tier 2 M90
Palforzia (12 MG Daily Dose) Tier 2 PA
Palforzia (120 MG Daily Dose) Tier 2 PA
Palforzia (160 MG Daily Dose) Tier 2 PA
Palforzia (20 MG Daily Dose) Tier 2 PA
129
Covered Product Reference Tier Status NotesPalforzia (200 MG Daily Dose) Tier 2 PA
Palforzia (240 MG Daily Dose) Tier 2 PA
Palforzia (3 MG Daily Dose) Tier 2 PA
Palforzia (40 MG Daily Dose) Tier 2 PA
Palforzia (6 MG Daily Dose) Tier 2 PA
Palforzia (80 MG Daily Dose) Tier 2 PA
Palforzia Initial Escalation Tier 2 PA
Paliperidone ER Oral Tablet Extended Release 24 Hour 1.5 MG, 3 MG, 6 MG
Invega Tier 2M90; QL (30 EA per 90 days)
Paliperidone ER Oral Tablet Extended Release 24 Hour 9 MG
Invega Tier 2M90; QL (60 EA per 30 days)
Palynziq Subcutaneous Solution Prefilled Syringe 10 MG/0.5ML
Tier 2PA; SP; QL (30 SYR per 30 days)
Palynziq Subcutaneous Solution Prefilled Syringe 2.5 MG/0.5ML, 20 MG/ML
Tier 2PA; SP; QL (90 SYR per 30 days)
Pamidronate Disodium Intravenous Solution 30 MG/10ML, 90 MG/10ML
Tier 2 M90
Pamidronate Disodium Intravenous Solution Reconstituted
Tier 2 M90
Pamprin All Day Relief Max St Tier 2 M90
Pancreaze Oral Capsule Delayed Release Particles 10500-35500 UNIT, 16800-56800 UNIT, 21000-54700 UNIT, 4200-14200 UNIT
Tier 2 PA; M90
Pancreaze Oral Capsule Delayed Release Particles 2600-6200 UNIT, 2600-8800 UNIT, 37000-97300 UNIT
Tier 2 PA
Pancuronium Bromide Intravenous Tier 2 M90
PanOxyl Wash Tier 2 M90
Panretin Tier 2 M90
Pantoprazole Sodium Oral Packet Protonix Tier 2 ST
Pantoprazole Sodium Oral Tablet Delayed Release
Protonix Tier 2M90; QL (60 EA per 30 days)
Panzyga Tier 2 PA; SP; Dual
Papaverine HCl Injection Tier 2 M90
Paragard Intrauterine Copper $0 M90
Paregoric Tier 2 M90
Paremyd Tier 2 M90
Paricalcitol Oral Zemplar Tier 2 M90
Paroex Tier 2 M90
Paromomycin Sulfate Oral Humatin Tier 2 M90
130
Covered Product Reference Tier Status NotesPARoxetine HCl ER Oral Tablet Extended Release 24 Hour 12.5 MG
Paxil CR Tier 2M90; QL (30 EA per 90 days)
PARoxetine HCl ER Oral Tablet Extended Release 24 Hour 25 MG, 37.5 MG
Paxil CR Tier 2M90; QL (60 EA per 30 days)
PARoxetine HCl Oral Tablet 10 MG, 20 MG
Paxil Tier 2M90; QL (45 tablets per month)
PARoxetine HCl Oral Tablet 30 MG Paxil Tier 2M90; QL (75 tablets per month)
PARoxetine HCl Oral Tablet 40 MG Paxil Tier 2M90; QL (60 EA per 30 days)
Parvlex ABC Plus Senior Tier 2 M90
Pazeo Tier 2 ST
PC Pediatric Electrolyte CeraLyte 70 Tier 2 M90
PC Unifine Pentips CareFine Pen Needles $0 M90
PCE Tier 2 M90
Ped Electrolyte Freeze Pops CeraLyte 70 Tier 2 M90
Ped Electrolyte Freezer Pops CeraLyte 70 Tier 2 M90
Pedia Vance Tier 2 M90
PediaCare Children Tier 2 M90
PediaCare Childrens Allergy Tier 2 M90
PediaCare Infants Tier 2 M90
PediaCare Infants Gas Relief Tier 2 M90
Pedia-Lax Oral Liquid Tier 2 M90
Pediarix $0 M90
Pediatric Electrolyte Oral Solution CeraLyte 70 Tier 2 M90
Pediatric Electrolyte-Zinc CeraLyte 70 Tier 2 M90
Pedvax HIB Intramuscular Suspension $0 M90
PEG 3350/Electrolytes GaviLyte-C Tier 2 M90
PEG 3350-KCl-Na Bicarb-NaClGaviLyte-N with Flavor Pack
Tier 2 M90
PEG-3350/Electrolytes GaviLyte-G Tier 2 M90
PEG-3350/Electrolytes/Ascorbat MoviPrep Tier 2
Peganone Tier 2 M90
Pegasys ProClick Subcutaneous Solution 135 MCG/0.5ML
Tier 2PA; SP; QL (4 per 28 days)
Pegasys ProClick Subcutaneous Solution 180 MCG/0.5ML
Tier 2 PA; SP
Pegasys Subcutaneous Solution Tier 2 PA; SP
PegIntron Tier 2 PA; SP
131
Covered Product Reference Tier Status NotesPeg-Intron Redipen Tier 2 PA; SP
Peg-Intron Redipen Pak 4 Subcutaneous Kit 120 MCG/0.5ML
Tier 2 PA; SP
PEG-Prep $0 M90
PEGyLAX Tier 2 M90
Pen Needles 1/2" CareFine Pen Needles $0 M90
Pen Needles 29G X 12MM , 31G X 6 MM CareFine Pen Needles $0 M90
Pen Needles 3/16"Advocate Insulin Pen Needles
$0 M90
Pen Needles 31G X 5 MM , 31G X 8 MMAdvocate Insulin Pen Needles
$0 M90
Pen Needles 32G X 4 MM BD Pen Needle Nano U/F $0 M90
Pen Needles 5/16"Advocate Insulin Pen Needles
$0 M90
penicillAMINE Oral Cuprimine Tier 2
Penicillin V Potassium Tier 2 M90
Pentacel $0 M90
Pentasa Tier 2 M90
Pentazocine-Naloxone HCl Tier 2QL (120 EA per 30 days)
Pentoxifylline ER Tier 2 M90
Peptic Relief Oral Suspension Kaopectate Tier 2 M90
Perdiem Overnight Relief Tier 2 M90
Perindopril Erbumine Tier 1 M90
Periogard Tier 2 M90
PerioMed Tier 2 M90
Perjeta MB PA
Permethrin External Cream Tier 2 M90
Perphenazine Oral Tier 2 M90
Perphenazine-Amitriptyline Tier 2 M90
Perseris Tier 2
Pertzye Oral Capsule Delayed Release Particles 16000-57500 UNIT, 4000-14375 UNIT, 8000-28750 UNIT
Tier 2 PA; M90
Pharbechlor Wal-finate Tier 2 M90
Pharbedryl Banophen Tier 2 M90
Pharbetol Extra Strength Tier 2 M90
Pharbetol Oral Tablet 325 MG Tier 2 M90
Pharmabase Barrier Tier 2 M90
Phenadoz Tier 2 M90
132
Covered Product Reference Tier Status NotesPhenazopyridine HCl Oral Tablet 200 MG Phenazo Tier 2 M90
Phenelzine Sulfate Oral Nardil Tier 2 M90
Phenergan Rectal Tier 2 M90
PHENobarbital Oral Elixir Tier 2
PHENobarbital Oral Solution Tier 2 M90
PHENobarbital Oral Tablet Tier 2
PHENobarbital Sodium Injection Solution 130 MG/ML
Tier 2
Phenohytro Oral Tablet Tier 2 M90
Phenoxybenzamine HCl Oral Dibenzyline Tier 2 M90
Phenylephrine HCl Injection Tier 2 M90
Phenylephrine HCl Ophthalmic Solution 10 %, 2.5 %
Altafrin Tier 2 M90
Phenylephrine-guaiFENesin Oral Liquid Tier 2 M90
Phenytoin Infatabs Tier 2 M90
Phenytoin Oral Suspension 125 MG/5ML Dilantin Tier 2 M90
Phenytoin Oral Tablet Chewable Phenytoin Infatabs Tier 2 M90
Phenytoin Sodium Extended Dilantin Tier 2 M90
Phexxi Tier 2QL (60 GM per 30 days)
Philith $0 M90
Phillips Milk of Magnesia Oral Suspension 400 MG/5ML
Tier 2 M90
Phillips Stool Softener Tier 2 M90
Phos-Flur Tier 2 M90
Phoslyra Tier 2 M90
Phos-NaK Tier 2 M90
Phospha 250 Neutral Tier 2 M90
Phospholine Iodide Tier 2 M90
Photofrin $0 M90
Phytonadione Oral Mephyton Tier 2
Picato Tier 2PA; M90; QL (QL Flag)
Pifeltro Tier 2PD; QL (60 EA per 30 days)
Pilocarpine HCl Ophthalmic Solution 1 %, 2 %
Isopto Carpine Tier 2 M90
Pilocarpine HCl Ophthalmic Solution 4 % Tier 2 M90
Pilocarpine HCl Oral Salagen Tier 2 M90
Pimozide Tier 2 M90
133
Covered Product Reference Tier Status NotesPimtrea $0 M90
Pindolol Tier 1 M90
Pink Bismuth Oral Suspension 262 MG/15ML
Kaopectate Tier 2 M90
Pin-X Oral Suspension Tier 2 M90
Pinxav External Ointment 30 % Tier 2 M90
Pioglitazone HCl Actos Tier 1 ST; M90
Pioglitazone HCl-Glimepiride Duetact Tier 1 ST; M90
Pioglitazone HCl-Metformin HCl Actoplus Met Tier 1 ST; M90
Piqray (200 MG Daily Dose) $0SP; QL (28 EA per 28 days)
Piqray (250 MG Daily Dose) $0SP; QL (56 EA per 28 days)
Piqray (300 MG Daily Dose) $0SP; QL (56 EA per 28 days)
Pirmella 1/35 $0 M90
Pirmella 7/7/7 $0 M90
Piroxicam Oral Feldene Tier 2 M90
Plan B One-Step $0
Plasmanate Tier 2 M90
Plegridy Intramuscular Tier 2SP; QL (2 SYR per 28 days)
Plegridy Starter Pack Subcutaneous Solution Pen-Injector
Tier 2 SP; QL (QL Flag)
Plegridy Starter Pack Subcutaneous Solution Prefilled Syringe
Tier 2SP; QL (2 SYR per 28 days)
Plegridy Subcutaneous Solution Pen-Injector
Tier 2SP; QL (1 PEN per 28 days)
Plegridy Subcutaneous Solution Prefilled Syringe
Tier 2SP; QL (2 SYR per 28 days)
Plenvu Tier 2
Pneumovax 23 $0 M90
PNV Folic Acid + Iron Niva-Plus Tier 1 M90
PNV Prenatal Plus Multivitamin Niva-Plus Tier 1 M90
PNV Tabs 29-1 Prenatabs Rx $0 M90
Podactin External Cream Tineacide Tier 2 M90
Podofilox External Tier 2 M90
Polivy Intravenous Solution Reconstituted 140 MG
MB PA; SP
Polivy Intravenous Solution Reconstituted 30 MG
MB PA
134
Covered Product Reference Tier Status NotesPolocaine Tier 2 M90
Poly Vitamin Bounty Bears/C Tier 2 M90
Polycin Tier 2 M90
Polyethylene Glycol 3350 Oral Packet 17 GM
CVS Purelax Tier 2 M90
Polyethylene Glycol 3350 Oral Packet 17 GM
ClearLax Tier 2 M90
Polyethylene Glycol 3350 Oral Powder ClearLax Tier 2 M90
Polyethylene Glycol 3350 Oral Powder 17 GM/SCOOP Oral Powder
ClearLax Tier 2 M90
Poly-Iron 150 Forte iFerex 150 Forte Tier 2 M90
Polymyxin B-Trimethoprim Polytrim Tier 2 M90
Polysaccharide Iron Forte iFerex 150 Forte Tier 2 M90
Poly-Vi-Flor Oral Tablet Chewable Tier 2 M90
Poly-Vi-Flor/Iron Oral Tablet Chewable Tier 2 M90
Polyvinyl Alcohol Ophthalmic Tier 2 M90
Poly-Vita/IronBProtected Pedia Poly-Vite/Fe
Tier 2 M90
Polyvitamin/Iron Oral SolutionBProtected Pedia Poly-Vite/Fe
Tier 2 M90
Pomalyst $0SP; QL (21 per 21 days)
Portia-28 $0 M90
Posaconazole Noxafil Tier 2 PA
Pot Bicarb-Pot Chloride Tier 2 M90
Potaba Oral Capsule Tier 2 M90
Potassium Bicarbonate Oral Effer-K Tier 2 M90
Potassium Chloride Crys ER Oral Tablet Extended Release 10 MEQ
Klor-Con M10 Tier 2 M90
Potassium Chloride Crys ER Oral Tablet Extended Release 20 MEQ
Klor-Con M20 Tier 2 M90
Potassium Chloride ER Klor-Con 10 Tier 2 M90
Potassium Chloride Oral Packet Klor-Con Tier 2 M90
Potassium Chloride Oral Solution 20 MEQ/15ML (10%), 40 MEQ/15ML (20%)
Tier 2 M90
Potassium Citrate ER Urocit-K 10 Tier 2 M90
Potassium Citrate-Citric Acid Tier 2 M90
Potassium Phosphates Intravenous Solution 150 MMOLE/50ML
Tier 2 M90
Poteligeo MB PA
135
Covered Product Reference Tier Status NotesPotiga Tier 2 M90
PR Benzoyl Peroxide Wash Tier 2 M90
Pradaxa Oral Capsule 110 MG Tier 2PA; QL (70 EA per 365 days)
Pradaxa Oral Capsule 150 MG, 75 MG Tier 2 PA
Praluent Subcutaneous Solution Auto-Injector
Tier 2PA; QL (2 PENS per 28 days)
PrameGel Tier 2 M90
Pramipexole Dihydrochloride Tier 2 M90
Pramipexole Dihydrochloride ER Mirapex ER Tier 2 M90
Pramosone E Tier 2 M90
Pramosone External Cream 1-1 % Tier 2 M90
Pramosone External Lotion 1-1 % Tier 2 M90
Pramosone External Lotion 1-2.5 % Tier 2 ST; M90
Pramosone External Ointment Tier 2 M90
PramOtic Tier 2 M90
Pravastatin Sodium Tier 2M90; QL (30 EA per 90 days)
Praziquantel Oral Biltricide Tier 2
Prazosin HCl Oral Minipress Tier 1 M90
Precision Xtra Blood Glucose $0PD; QL (100 EA per 30 days)
Precision Xtra Device $0M90; PD; QL (1 EA per 365 days)
Precision Xtra Ketone $0M90; PD; QL (100 EA per 30 days)
Pred Mild Tier 2 M90
Pred-G Tier 2 M90
Pred-G S.O.P. Tier 2 M90
Prednicarbate Tier 2 M90
prednisoLONE Acetate Ophthalmic Pred Forte Tier 2 M90
PrednisoLONE Oral Solution Tier 2 M90
PrednisoLONE Oral Syrup 15 MG/5ML Tier 2 M90
PrednisoLONE Sodium Phosphate Ophthalmic
Tier 2 M90
PrednisoLONE Sodium Phosphate Oral Solution 15 MG/5ML, 25 MG/5ML
Tier 2 M90
PrednisoLONE Sodium Phosphate Oral Solution 6.7 (5 Base) MG/5ML
Pediapred Tier 2 M90
prednisoLONE Sodium Phosphate Oral Tablet Dispersible
Orapred ODT Tier 2 M90
136
Covered Product Reference Tier Status NotesPredniSONE Intensol Tier 2 M90
PredniSONE Oral Tier 2 M90
Preferred Plus Unifine PentipsAdvocate Insulin Pen Needles
$0 M90
Prefest Tier 2 M90
Pregabalin Oral Lyrica Tier 2 ST
Premarin Oral Tier 2 M90
Premarin Vaginal Tier 2 M90
Premium Lidocaine Tier 2 M90
Premphase Tier 2 M90
Prempro Tier 2 M90
Prenatabs FA Oral Tablet 29-1 MG Co-Natal FA $0
Prenatabs Rx $0 M90
Prenatal (w/Iron & FA) Tier 1 M90
Prenatal 19 Oral Tablet Chewable $0 M90
Prenatal Low Iron Oral Tablet 27-0.8 MG Right Step Prenatal Tier 1 M90
Prenatal One Daily Right Step Prenatal Tier 1 M90
Prenatal Oral Tablet 27-0.8 MG Right Step Prenatal Tier 1 M90
Prenatal Oral Tablet 27-1 MG Niva-Plus Tier 1 M90
Prenatal Oral Tablet 28-0.8 MG Tier 1 M90
Prenatal Plus Niva-Plus Tier 1 M90
Prenatal Plus Iron Prenatabs Rx $0 M90
Prenatal Vitamin Right Step Prenatal Tier 1 M90
Prenatal Vitamin Plus Low Iron Niva-Plus Tier 1 M90
Prenatal Vitamins Oral Tablet 28-0.8 MG Tier 1 M90
Prenatal/Iron Oral Tablet 28-0.8 MG Tier 1 M90
Preparation H External Cream 1 % Tier 2 M90
PrePLUS Niva-Plus Tier 1 M90
Pretomanid Tier 2 PA
Prevalite Tier 1 M90
Prevent DEKAs Plus Tier 2 M90
Preventeza $0
Previfem $0 M90
Prevnar 13 $0 M90
Prevymis Intravenous Tier 2 PA; SP
Prevymis Oral Tier 2 PA
Prezcobix Tier 2PD; QL (30 EA per 30 days)
137
Covered Product Reference Tier Status Notes
Prezista Oral Suspension Tier 2PD; BP; QL (400 ML per 30 days)
Prezista Oral Tablet 150 MG Tier 2PD; BP; QL (180 EA per 30 days)
Prezista Oral Tablet 600 MG Tier 2PD; BP; QL (60 EA per 30 days)
Prezista Oral Tablet 75 MG Tier 2PD; BP; QL (300 EA per 30 days)
Prezista Oral Tablet 800 MG Tier 2PD; BP; QL (30 EA per 30 days)
Priftin Tier 2 M90
PriLOSEC Oral Packet Tier 2ST; M90; QL (60 PACKS per 30 days)
Primaquine Phosphate Oral Tier 2 M90
Primidone Oral Mysoline Tier 2 M90
Primsol Tier 2 M90
Pristiq Oral Tablet Extended Release 24 Hour 100 MG, 50 MG
Tier 2 ST; M90
Pristiq Oral Tablet Extended Release 24 Hour 25 MG
Tier 2ST; M90; QL (QL Flag)
Privigen Tier 2 PA; SP; Dual
ProAir Digihaler Tier 2 PA
ProAir HFA Tier 2 BP
ProAir RespiClick Tier 2
Probenecid Oral Tier 2 M90
Probuphine Implant Kit MB PA
Prochlorperazine Compro Tier 2 M90
Prochlorperazine Edisylate Injection Solution 5 MG/ML
Tier 2 M90
Prochlorperazine Maleate Oral Tier 2 M90
Procrit Tier 2 PA; SP; Dual
Procysbi Oral Capsule Delayed Release Tier 2 SP; QL (QL Flag)
Procysbi Oral Packet Tier 2
Pro-Ex Antifungal Desenex Tier 2 M90
Proferrin-Forte Tier 2 M90
Profilnine Tier 2 PA; SP; Dual
Profilnine SD Tier 2 PA; SP; Dual
Progesterone Intramuscular Tier 2 M90
Progesterone Micronized Oral Tier 2 M90
Progesterone Micronized Transdermal Tier 2 M90
138
Covered Product Reference Tier Status NotesProgesterone Oral Prometrium Tier 2 M90
Prograf Oral Packet Tier 2 SP
Prolastin-C Intravenous Solution Tier 2 PA; SP; Dual
Prolastin-C Intravenous Solution Reconstituted 1000 MG
Tier 2 PA; SP; Dual
Prolensa Tier 2 ST; M90
Proleukin $0 SP
Prolia Subcutaneous Solution Prefilled Syringe
Tier 2PA; SP; Dual; QL (1 SYR per 168 days)
Promacta Oral Packet Tier 2 PA; SP
Promacta Oral Tablet 12.5 MG, 25 MG Tier 2PA; SP; QL (30 EA per 90 days)
Promacta Oral Tablet 50 MG, 75 MG Tier 2PA; SP; QL (60 EA per 30 days)
Promethazine HCl Oral Tier 2 M90
Promethazine HCl Rectal Promethegan Tier 2 M90
Promethazine VC Plain Oral Syrup Tier 2 M90
Promethazine-Phenylephrine Tier 2 M90
Promethegan Tier 2 M90
Promolaxin Tier 2 M90
Pronutrients Calcium+D3 Tier 2 M90
Pronutrients Vitamin D3 Tier 2 M90
Propafenone HCl Tier 2 M90
Propafenone HCl ER Rythmol SR Tier 2 M90
Propantheline Bromide Oral Tier 2 M90
Proparacaine HCl Ophthalmic Alcaine Tier 2 M90
Proparacaine-Fluorescein Flucaine Tier 2 M90
Propranolol HCl ER Inderal LA Tier 1 M90
Propranolol HCl Intravenous Tier 1 M90
Propranolol HCl Oral Tier 1 M90
Propranolol-HCTZ Tier 1 M90
Propylthiouracil Oral Tier 2 M90
ProQuad Subcutaneous Injectable $0 M90
Prostin E2 Tier 2 M90
Protect Plus NF Tier 2 M90
ProtectIron Tier 2 M90
Protopic Tier 2BP; QL (60 GM per 30 days)
Protriptyline HCl Tier 2 M90
139
Covered Product Reference Tier Status NotesProvil Tier 2 M90
Pseudoephedrine HCl Liq 15 MG/5ML Oral Liquid
Sudafed Childrens Tier 2 M90
Pseudoephedrine HCl Oral Tablet SudoGest Tier 2 M90
Pseudoephedrine HCl Tab 60 MG SudoGest Tier 2 M90
Psorcon Tier 2 M90
Psudatabs SudoGest Tier 2 M90
Pulmicort Flexhaler Tier 2 M90
Pulmicort Inhalation Suspension 0.25 MG/2ML
Tier 2
Pulmozyme Inhalation Solution 1 MG/ML Tier 2SP; QL (150 ml per 30 days)
Purixan $0 SP; QL (QL Flag)
PX Acid Reducer Pepcid AC Tier 2 M90
PX Acid Reducer Max St Tier 2 M90
PX Advanced Formula Multivits ABC Plus Senior Tier 2 M90
PX All Day Relief Mediproxen Tier 2 M90
PX Allergy Banophen Tier 2 M90
PX Allergy Relief Cetirizine KLS Aller-Tec Tier 2 M90; QL (QL Flag)
PX Allergy Relief Loratadine KLS AllerClear Tier 2 M90; QL (QL Flag)
PX Allergy Relief Oral Tablet KLS Aller-Fex Tier 2 M90; QL (QL Flag)
PX Allergy Relief Oral Tablet Dispersible Alavert Tier 2 M90
PX Antacid Extra StrengthCVS Chewy Not Chalky Flavor
Tier 2 M90
PX Antacid Maximum Strength Oral Tablet Chewable
Tums Ultra 1000 Tier 2 M90
PX Arthritis Pain Relief Midol Tier 2 M90
PX Athletic Foot Desenex Tier 2 M90
PX Calcium Antacid Cal-Gest Antacid Tier 2 M90
PX Calcium Tier 2 M90
PX Childrens Allergy KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)
PX Childrens Pain Relief PediaCare Children Tier 2 M90
PX Childrens Profen IB Childrens Medi-Profen Tier 2 M90
PX Complete Senior Multivits ABC Plus Senior Tier 2 M90
PX Docusate Sodium Correctol Extra Gentle Tier 2 M90
PX Extra Short Pen Needles CareFine Pen Needles $0 M90
PX Gas Relief InfantsLittle Remedies for Tummys
Tier 2 M90
PX Hydrocream Aveeno Anti-Itch Max St Tier 2 M90
PX Ibuprofen Medi-Profen Tier 2 M90
140
Covered Product Reference Tier Status NotesPX Ibuprofen Junior Strength Advil Junior Strength Tier 2 M90
PX Infants Profen IB Medi-Profen Tier 2 M90
PX Iron Oral Tablet 27 MG Tier 2 M90
PX Laxative Alophen Tier 2 M90
PX Mens Multivitamins ABC Plus Senior Tier 2 M90
PX Miconazole 3-Day Combo Vagistat-3 Tier 2 M90
PX Milk of MagnesiaDulcolax Milk of Magnesia
Tier 2 M90
PX Mini Pen NeedlesAdvocate Insulin Pen Needles
$0 M90
PX Nasal Decongestant Oral Tablet SudoGest Tier 2 M90
PX Niacin Tier 1 M90
PX Pain Relief Extra StrengthHealthy Mama Shake That Ache
Tier 2 M90
PX Pen NeedleAdvocate Insulin Pen Needles
$0 M90
PX Prenatal Multivitamins Tier 1 M90
PX raNITIdine Tier 2 M90
PX Saline Nasal Spray Afrin Saline Nasal Mist Tier 1 M90
PX Shortlength Pen NeedlesAdvocate Insulin Pen Needles
$0 M90
PX Stomach Relief Oral Suspension Kaopectate Tier 2 M90
PX Stop Smoking Aid KLS Quit4 $0 M90
PX Vegetable Laxative Evac-U-Gen Tier 2 M90
Pylera Tier 2 M90
Pyrazinamide Oral Tier 2 M90
Pyridostigmine Bromide ER Mestinon Tier 2 M90
Pyridostigmine Bromide Oral Tablet 60 MG
Mestinon Tier 2 M90
Pyridoxine HCl Injection Tier 2 M90
Pyridoxine HCl Oral Tier 2 M90
Pyrimethamine Oral Daraprim Tier 2
Pyrogallic Acid Tier 2 M90
QC 3 Day Monistat 3 Tier 2 M90
QC Acetaminophen 8 Hours Midol Tier 2 M90
QC Acid Controller Pepcid AC Tier 2 M90
QC Acid Controller Max StMM Acid-Pep Maximum Strength
Tier 2 M90
QC All Day Allergy KLS Aller-Tec Tier 2 M90; QL (QL Flag)
141
Covered Product Reference Tier Status NotesQC Allergy Relief Childrens Oral Syrup 1 MG/ML
KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)
QC Allergy Relief Childrens Oral Syrup 5 MG/5ML
Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
QC Allergy Relief Oral Tablet Dispersible Alavert Tier 2 M90
QC Antacid Extra StrengthCVS Chewy Not Chalky Flavor
Tier 2 M90
QC Antacid Oral Tablet Chewable Cal-Gest Antacid Tier 2 M90
QC Arthritis Pain Relief Midol Tier 2 M90
QC Bacitracin Bacitraycin Plus Tier 2 M90
QC Calamine Tier 2 M90
QC Calcium Fast Dissolution Tier 2 M90
QC Calcium/Minerals/Vitamin D Tier 2 M90
QC Childrens Ibuprofen Childrens Medi-Profen Tier 2 M90
QC Childrens Vitamins/IronLand Before Time Multivitamin
Tier 2 M90
QC Chlor-Pheniramine Wal-finate Tier 2 M90
QC Clotrimazole Desenex Tier 2 M90
QC Complete Allergy Medicine Oral Tablet
Alka-Seltzer Plus Allergy Tier 2 M90
QC Daily Multivit/Multimineral ABC Plus Senior Tier 2 M90
QC Daily Multivitamins/IronTab-A-Vite/Iron/Beta Carotene
Tier 2 M90
QC Diarrhea Relief Kaopectate Tier 2 M90
QC Ear Wax Removal Murine Ear Tier 2 M90
QC Enema Fleet Enema Tier 2 M90
QC Gas Relief Oral Tablet Chewable Tier 2 M90
QC Gentle Laxative Alophen Tier 2 M90
QC Hydrocortisone Aveeno Anti-Itch Max St Tier 2 M90
QC Hydrocortisone Max St Aveeno Anti-Itch Max St Tier 2 M90
QC Ibuprofen IB Medi-Profen Tier 2 M90
QC Ibuprofen Infants Medi-Profen Tier 2 M90
QC Ibuprofen Oral Tablet Medi-Profen Tier 2 M90
QC Iodides Tier 2 M90
QC Iodine Tincture Tier 2 M90
QC Laxative Tier 2 M90
QC Loratadine Allergy Relief KLS AllerClear Tier 2 M90; QL (QL Flag)
QC Magnesium Citrate Citroma Tier 2 M90
QC Mens Daily Multivitamin ABC Plus Senior Tier 2 M90
QC Miconazole 7 Vaginal Cream Monistat 7 Simply Cure Tier 2 M90
142
Covered Product Reference Tier Status Notes
QC Milk of MagnesiaDulcolax Milk of Magnesia
Tier 2 M90
QC Mineral Oil Heavy Tier 2 M90
QC Multi-Vite ABC Plus Senior Tier 2 M90
QC Multi-Vite 50 & Over ABC Plus Senior Tier 2 M90
QC Multi-Vite Plus ABC Plus Senior Tier 2 M90
QC Naproxen Sodium Mediproxen Tier 2 M90
QC Natural Vegetable Laxative Evac-U-Gen Tier 2 M90
QC Natura-LAX ClearLax Tier 2 M90
QC Nicotine Polacrilex KLS Quit4 $0 M90
QC Non-Aspirin 8 Hour Midol Tier 2 M90
QC Non-Aspirin Childrens Oral Suspension
PediaCare Children Tier 2 M90
QC Non-Aspirin Extra StrengthHealthy Mama Shake That Ache
Tier 2 M90
QC Pain Relief Aphen Tier 2 M90
QC Pain Relief Childrens PediaCare Children Tier 2 M90
QC Pain Relief Infants PediaCare Children Tier 2 M90
QC Pen Needles CareFine Pen Needles $0 M90
QC Pink Bismuth Oral Suspension Kaopectate Tier 2 M90
QC Prenatal Tier 1 M90
QC Saline Nasal Relief Afrin Saline Nasal Mist Tier 1 M90
QC Senna Evac-U-Gen Tier 2 M90
QC Stool Softener Correctol Extra Gentle Tier 2 M90
QC Suphedrine SudoGest Tier 2 M90
QC Therin-M ABC Plus Senior Tier 2 M90
QC Tolnaftate Tinactin Tier 2 M90
QC Unifine Pentips BD Pen Needle Nano U/F $0 M90
QC Womens Daily Multivitamin ABC Plus Senior Tier 2 M90
Q-Dryl Banophen Tier 2 M90
Q-PAP Childrens PediaCare Children Tier 2 M90
Q-PAP Extra StrengthHealthy Mama Shake That Ache
Tier 2 M90
Q-PAP Oral Tablet Aphen Tier 2 M90
Quadracel $0 M90
Quartette $0 M90
Quasense $0 M90
Quazepam Doral Tier 2ST; QL (30 EA per 30 days)
143
Covered Product Reference Tier Status NotesQuench ABC Plus Senior Tier 2 M90
QUEtiapine Fumarate ER Oral Tablet Extended Release 24 Hour 150 MG, 200 MG
SEROquel XR Tier 2M90; QL (30 EA per 90 days)
QUEtiapine Fumarate ER Oral Tablet Extended Release 24 Hour 300 MG, 400 MG, 50 MG
SEROquel XR Tier 2M90; QL (60 EA per 30 days)
QUEtiapine Fumarate Oral Tablet 100 MG, 200 MG, 50 MG
SEROquel Tier 2M90; QL (90 EA per 30 days)
QUEtiapine Fumarate Oral Tablet 25 MG SEROquel Tier 2M90; QL (120 EA per 30 days)
QUEtiapine Fumarate Oral Tablet 300 MG, 400 MG
SEROquel Tier 2M90; QL (60 EA per 30 days)
Quflora Pediatric Tier 2 M90
QuilliChew ER Tier 2PA; QL (60 EA per 30 days)
Quillivant XR Oral Suspension Reconstituted
Tier 2 PA; ST
Quin B Strong ABC Plus Senior Tier 2 M90
Quinapril HCl Accupril Tier 1 M90
Quinapril-Hydrochlorothiazide Accuretic Tier 1 M90
quiNIDine Gluconate ER Tier 2 M90
QuiNIDine Sulfate Oral Tier 2 M90
QuiNINE Sulfate Oral Qualaquin Tier 2 M90
Quintabs-M ABC Plus Senior Tier 2 M90
Qvar Inhalation Aerosol Solution Tier 2 M90
Qvar RediHaler Tier 2 PA
RA 8 Hour Pain Relief Midol Tier 2 M90
RA Acetaminophen Aphen Tier 2 M90
RA Acetaminophen Ex StHealthy Mama Shake That Ache
Tier 2 M90
RA Acid Reducer Pepcid AC Tier 2 M90
RA Acid Reducer Max StMM Acid-Pep Maximum Strength
Tier 2 M90
RA Advanced RecoveryA + D Personal Care Lotion
Tier 2 M90
RA Allergy Medication Banophen Tier 2 M90
RA Allergy Oral Alka-Seltzer Plus Allergy Tier 2 M90
RA Allergy Relief Childrens Oral Liquid Banophen Tier 2 M90
RA Allergy Relief Childrens Oral Syrup KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)
RA Allergy Relief Oral Tablet 10 MG KLS Aller-Tec Tier 2 M90; QL (QL Flag)
144
Covered Product Reference Tier Status NotesRA Allergy Relief Oral Tablet 180 MG KLS Aller-Fex Tier 2 M90; QL (QL Flag)
RA Allergy Relief Oral Tablet 25 MG Alka-Seltzer Plus Allergy Tier 2 M90
RA Allergy Relief Oral Tablet Dispersible Alavert Tier 2 M90
RA Allergy Relief-DWal-Fex D Allergy & Congestion
Tier 2 M90; QL (QL Flag)
RA Antacid Cal-Gest Antacid Tier 2 M90
RA Antacid Extra StrengthCVS Chewy Not Chalky Flavor
Tier 2 M90
RA Antacid Ultra Strength Tums Ultra 1000 Tier 2 M90
RA Anti-Diarrheal Oral Capsule Imodium A-D Tier 2 M90
RA Antifungal Tineacide Tier 2 M90
RA Antihistamine Eye Drops Alaway Tier 2 M90; QL (QL Flag)
RA Anti-Itch Maximum Strength Aveeno Anti-Itch Max St Tier 2 M90
RA Arthritis Pain Relief Midol Tier 2 M90
RA Aspirin Oral Tablet 500 MGBayer Advanced Aspirin Ex St
Tier 2 M90
RA Athletes Foot Desenex Tier 2 M90
RA Athletes Foot (Tolnaftate) Tinactin Tier 2 M90
RA Calcium 600 Tier 2 M90
RA Calcium 600/Vit D/Minerals Tier 2 M90
RA Calcium 600/Vitamin D-3 Tier 2 M90
RA Calcium Cit Plus Vit D-3 Calcitrate Tier 2 M90
RA Calcium Citrate Plus Vit D Tier 2 M90
RA Calcium Cit-Vit D-3 PetitesCitracal Petites/Vitamin D
Tier 2 M90
RA Calcium Plus Vitamin D Oral Tablet 600-200 MG-UNIT, 600-400 MG-UNIT
Tier 2 M90
RA Calcium Plus Vitamin D3 Tier 2 M90
RA Calcium/Vitamin D/Minerals Tier 2 M90
RA Central-Vite Energy ABC Plus Senior Tier 2 M90
RA Central-Vite Mens Mature ABC Plus Senior Tier 2 M90
RA Central-Vite Senior ABC Plus Senior Tier 2 M90
RA Central-Vite Under 50 Mens ABC Plus Senior Tier 2 M90
RA Central-Vite Under 50 Women ABC Plus Senior Tier 2 M90
RA Central-Vite Womens Mature ABC Plus Senior Tier 2 M90
RA Cetirizine KLS Aller-Tec Tier 2 M90; QL (QL Flag)
RA Cetirizine Childrens Wal-Zyr Childrens Tier 2 M90; QL (QL Flag)
RA Cetirizine HCl Child Allrgy Oral Syrup
KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)
145
Covered Product Reference Tier Status Notes
RA Childrens Chewable Vit/IronLand Before Time Multivitamin
Tier 2 M90
RA Childrens Non-Aspirin PediaCare Children Tier 2 M90
RA Chlorpheniramine Maleate Wal-finate Tier 2 M90
RA Clotrimazole Desenex Tier 2 M90
RA Clotrimazole 3 Gyne-Lotrimin 3 Tier 2 M90
RA Clotrimazole 7 Gyne-Lotrimin Tier 2 M90
RA Col-Rite Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90
RA Complete Allergy Alka-Seltzer Plus Allergy Tier 2 M90
RA DermaA + D Personal Care Lotion
Tier 2 M90
RA Diaper Rash Boudreauxs Butt Paste Tier 2 M90
RA Diphedryl Allergy Tier 2 M90
RA Ear Drops Murine Ear Tier 2 M90
RA Earwax Removal Kit Murine Ear Tier 2 M90
RA Enema Fleet Enema Tier 2 M90
RA Esomeprazole Magnesium GoodSense Esomeprazole Tier 2 ST; QL (QL)
RA Eye Itch Relief Alaway Tier 2 M90; QL (QL Flag)
RA Fast Relief Laxative The Magic Bullet Tier 2 M90
RA Fever Reducer/Pain Reliever PediaCare Children Tier 2 M90
RA First Aid Iodine Tier 2 M90
RA Gas Relief Oral SuspensionLittle Remedies for Tummys
Tier 2 M90
RA Gas Relief Oral Tablet Chewable Tier 2 M90
RA Gas Relief/InfantsLittle Remedies for Tummys
Tier 2 M90
RA Gentle Skin External LotionA + D Personal Care Lotion
Tier 2 M90
RA Hair/Skin/Nails ABC Plus Senior Tier 2 M90
RA Hi Cal Tier 2 M90
RA Hi-Cal Tier 2 M90
RA Hi-Cal Plus Vitamin D Tier 2 M90
RA High Potency Iron Tier 2 M90
RA Hydrocortisone Max St Aveeno Anti-Itch Max St Tier 2 M90
RA Hydrocortisone Plus 12 Aveeno Anti-Itch Max St Tier 2 M90
RA Ibuprofen Childrens Childrens Medi-Profen Tier 2 M90
RA Ibuprofen Infants Medi-Profen Tier 2 M90
RA Ibuprofen Junior Strength Advil Junior Strength Tier 2 M90
RA Ibuprofen Oral Suspension Childrens Medi-Profen Tier 2 M90
146
Covered Product Reference Tier Status NotesRA Ibuprofen Oral Tablet Medi-Profen Tier 2 M90
RA Iron Oral Tablet 27 MG Tier 2 M90
RA Jock Itch Desenex Tier 2 M90
RA K-Pec Kaopectate Tier 2 M90
RA Laxative Extra Strength Senokot Extra Strength Tier 2 M90
RA Laxative Maximum Strength Tier 2 M90
RA Laxative Oral Powder ClearLax Tier 2 M90
RA Laxative Oral Tablet Tier 2 M90
RA Laxative Oral Tablet Delayed Release Alophen Tier 2 M90
RA Lice Bedding RID Tier 2 M90
RA Lice Maximum Strength External Liquid
RID Tier 2 M90
RA Loratadine Childrens Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
RA Loratadine Oral Syrup Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
RA Loratadine Oral Tablet KLS AllerClear Tier 2 M90; QL (QL Flag)
RA Loratadine Oral Tablet Dispersible Alavert Tier 2 M90
RA Magnesium Citrate Citroma Tier 2 M90
RA Mature Womens Dietary Supp ABC Plus Senior Tier 2 M90
RA Miconazole 3 Combo Pack Vagistat-3 Tier 2 M90
RA Miconazole 3 Combo Pack AppMonistat 3 Combo Pack App
Tier 2 M90
RA Miconazole 7 Monistat 7 Simply Cure Tier 2 M90
RA Milk of Magnesia Oral SuspensionDulcolax Milk of Magnesia
Tier 2 M90
RA Mineral Oil Tier 2 M90
RA Mini Nicotine KLS Quit2 $0 M90
RA Moisturizing OatmealA + D Personal Care Lotion
Tier 2 M90
RA Motion Sickness Relief Oral Tablet 25 MG
Wal-Dram II Tier 2 M90
RA Naproxen Sodium Oral Tablet Mediproxen Tier 2 M90
RA Niacin Tier 1 M90
RA Nicotine Nicoderm CQ $0 M90
RA Nicotine Polacrilex KLS Quit2 $0 M90
RA No Flush Niacin Tier 1 M90
RA One Daily Energy Formula ABC Plus Senior Tier 2 M90
RA One Daily Maximum ABC Plus Senior Tier 2 M90
RA One Daily Mens 50+ w/Vit D3 ABC Plus Senior Tier 2 M90
147
Covered Product Reference Tier Status NotesRA One Daily Mens Multi ABC Plus Senior Tier 2 M90
RA One Daily Mens/Vit D-3 ABC Plus Senior Tier 2 M90
RA One Daily Multi-Vit Plus FeTab-A-Vite/Iron/Beta Carotene
Tier 2 M90
RA One Daily Womens ABC Plus Senior Tier 2 M90
RA Oyster Shell Calcium Oystercal Tier 2 M90
RA Oyster Shell Calcium/D Tier 2 M90
RA Ped Electrolyte Freezer Pop CeraLyte 70 Tier 2 M90
RA Pediatric Electrolyte CeraLyte 70 Tier 2 M90
RA Pen NeedlesAdvocate Insulin Pen Needles
$0 M90
RA Prenatal Tier 1 M90
RA Prenatal Formula Tier 1 M90
RA Renewal Acne Treatment Tier 2 M90
RA Renewal Cocoa Butter Tier 2 M90
RA Renewal Dry Skin TherapyA + D Personal Care Lotion
Tier 2 M90
RA Saline Enema Fleet Enema Tier 2 M90
RA Saline Nasal Spray Afrin Saline Nasal Mist Tier 1 M90
RA Senna Oral Tablet Evac-U-Gen Tier 2 M90
RA Smooth Antacid Ex StCVS Chewy Not Chalky Flavor
Tier 2 M90
RA Stimulant Laxative The Magic Bullet Tier 2 M90
RA Stomach Relief Oral Suspension Kaopectate Tier 2 M90
RA Stool Softener Correctol Extra Gentle Tier 2 M90
RA Stress Formula Advanced ABC Plus Senior Tier 2 M90
RA Stress Formula Energy ABC Plus Senior Tier 2 M90
RA Suphedrine Oral Tablet 30 MG SudoGest Tier 2 M90
RA Therapeutic M Plus Beta Car ABC Plus Senior Tier 2 M90
RA Total MoistureA + D Personal Care Lotion
Tier 2 M90
RA Vision Vite Plus Zinc ABC Plus Senior Tier 2 M90
RA Vitamin B-6 Tier 2 M90
RA Vitamin D-3 Tier 2 M90
RA Womens Laxative Alophen Tier 2 M90
RA Zinc Oxide Tier 2 M90
RABEprazole Sodium Oral Capsule Sprinkle
AcipHex Sprinkle Tier 2 ST; QL (QL)
RABEprazole Sodium Oral Tablet Delayed Release
Aciphex Tier 2ST; M90; QL (30 EA per 90 days)
148
Covered Product Reference Tier Status Notes
RadiaGuard Advanced External LotionA + D Personal Care Lotion
Tier 2 M90
Radicava MB PA
Ragwitek Tier 2 PA
Rajani $0 M90
Ramelteon Rozerem Tier 2ST; QL (30 EA per 30 days)
Ramipril Altace Tier 1 M90
raNITIdine Acid Reducer Tier 2 M90
raNITIdine HCl Injection Solution 1000 MG/40ML
Tier 2QL (1 FILL per 365 days)
raNITIdine HCl Oral Syrup Tier 2 M90
raNITIdine HCl Oral Tablet Tier 2 M90
Ranitidine HCl Tab 150 MGMM Acid-Pep Maximum Strength
Tier 2 M90
Ranitidine HCl Tab 75 MG Tier 2 M90
Ranolazine ER Oral Tablet Extended Release 12 Hour 1000 MG
Ranexa Tier 2PA; QL (60 EA per 30 days)
Ranolazine ER Oral Tablet Extended Release 12 Hour 500 MG
Ranexa Tier 2PA; QL (120 EA per 30 days)
Rasagiline Mesylate Oral Azilect Tier 2PA; QL (30 EA per 90 days)
Rea Lo 39 Tier 2 M90
React $0 M90
Rebetol Oral Solution Tier 2 SP
Rebif Rebidose Subcutaneous Solution Auto-Injector
Tier 2 SP; QL (QL Flag)
Rebif Rebidose Titration Pack Subcutaneous Solution Auto-Injector
Tier 2SP; QL (12 (4.2 ml) per 28 days)
Rebif Subcutaneous Solution Prefilled Syringe
Tier 2SP; QL (12 (6 ml)per 28 days)
Rebif Titration Pack Subcutaneous Solution Prefilled Syringe
Tier 2 SP; QL (QL Flag)
Rebinyn Tier 2 PA; SP; Dual
Reblozyl MB PA
Reclipsen $0 M90
Recombinate Tier 2 PA; SP; Dual
Recombivax HB Injection Suspension 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML
$0 M90
Recort Plus Aveeno Anti-Itch Max St Tier 2 M90
Rectiv Tier 2 M90
149
Covered Product Reference Tier Status NotesReeses Pinworm Medicine Oral Suspension
Tier 2 M90
Refreshing AloeA + D Personal Care Lotion
Tier 2 M90
Regenecare HA External Gel Tier 2 M90
Regranex Tier 2M90; QL (15gm per month)
Rehydralyte Tier 2 M90
Relagard Tier 2 M90
Relenza Diskhaler Tier 2PA; M90; QL (40 EA per 90 days)
ReliOn Mini Pen Needles $0 M90
ReliOn Pen Needles $0 M90
ReliOn Short Pen Needles $0 M90
Relistor Oral Tier 2 PA; M90
Relistor Subcutaneous Solution 12 MG/0.6ML, 8 MG/0.4ML
Tier 2 PA; M90
Remedy Antifungal External Cream Tier 2 M90
Remeven Tier 2 M90
Remicade Tier 2PA; SP; Dual; QL (5 VIALS per 42 days)
Remodulin Injection Solution 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML
Tier 2 PA; SP
Renacidin Tier 2 M90
Renagel Oral Tablet 400 MG Tier 2 M90
Renagel Oral Tablet 800 MG Tier 2
Renflexis Tier 2PA; SP; Dual; QL (5 VIALS per 28 days)
Renvela Tier 2 M90
Repaglinide Tier 1 M90
Repaglinide-metFORMIN HCl Tier 1 M90
Repatha Tier 2 PA; QL (2 per 28 days)
Repatha Pushtronex System Tier 2PA; QL (1 EA per 28 days)
Repatha SureClick Tier 2PA; QL (2 PENS per 28 days)
Replace DEKAs Plus Tier 2 M90
Reprexain Oral Tablet 10-200 MG Tier 2M90; QL (50 tablets per 30 days. Click;HERE)
Rescriptor Oral Tablet 100 MG Tier 2 SP
150
Covered Product Reference Tier Status Notes
Rescriptor Oral Tablet 200 MG Tier 2SP; QL (450 per 30 days)
Rescula Tier 2 M90
Reserpine Tier 2
Restasis Tier 2 PA; M90
Restasis Multidose Ophthalmic Emulsion 0.05 %
Tier 2 PA; M90
Retacrit Injection Solution 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML
Tier 2 PA; SP; Dual
Retevmo Oral Capsule 40 MG $0SP; QL (160 EA per 30 days)
Retevmo Oral Capsule 80 MG $0SP; QL (120 EA per 30 days)
Retisert Intraocular Tier 2 SP
Retrovir Intravenous Tier 2 M90
Revcovi Tier 2 PA; SP; Dual
ReVital Freezer Pops CeraLyte 70 Tier 2 M90
ReVital Jell Cups CeraLyte 70 Tier 2 M90
ReVital Liquid Squeezers CeraLyte 70 Tier 2 M90
Revlimid Oral Capsule 10 MG, 2.5 MG, 5 MG
$0SP; QL (28 per 28 days)
Revlimid Oral Capsule 15 MG, 20 MG, 25 MG
$0SP; QL (21 per 28 days)
Rexulti Oral Tablet 0.25 MG, 0.5 MG, 1 MG
Tier 2M90; QL (30 EA per 90 days)
Rexulti Oral Tablet 2 MG, 3 MG, 4 MG Tier 2M90; QL (60 EA per 30 days)
Reyataz Oral Packet Tier 2QL (180 packets per 30 days)
Rezira Tier 2 M90
Rhinocort Allergy Tier 2 ST; M90
Rhopressa Tier 2 ST
Riabni $0 PA; Dual
RiaSTAP Tier 2 PA; SP; Dual
Ribasphere Oral Capsule Tier 2 SP
Ribasphere Oral Tablet 200 MG, 600 MG Tier 2 SP
Ribasphere RibaPak Oral Tablet 200 & 400 MG, 400 & 600 MG
Tier 2 PA; SP
Ribasphere RibaPak Oral Tablet 600 MG Tier 2 SP
151
Covered Product Reference Tier Status NotesRibavirin Oral Capsule Tier 2 SP
Ribavirin Oral Tablet 200 MG, 400 MG Tier 2 SP
Ridaura Tier 2 M90
Rifabutin Mycobutin Tier 2 M90
Rifamate Tier 2 M90
rifAMPin Oral Tier 2 M90
Rifater Tier 2 M90
Right Step Prenatal Tier 1 M90
Riluzole Rilutek Tier 2 M90
riMANTAdine HCl Tier 2 M90
Rimso-50 Tier 2 M90
Rinvoq Tier 2PA; SP; QL (QL Applies)
Riomet Tier 1 M90; BP
Riomet ER Tier 1 PA
Risedronate Sodium Oral Tablet 150 MG Actonel Tier 2ST; M90; QL (1 tablet per 28 days; 13 tablets per 365 days)
Risedronate Sodium Oral Tablet 30 MG, 5 MG
Tier 2ST; M90; QL (30 EA per 90 days)
Risedronate Sodium Oral Tablet 35 MG Actonel Tier 2ST; M90; QL (4 tablets per 28 days; 13 tablets per 90 days)
Risedronate Sodium Oral Tablet Delayed Release
Atelvia Tier 2ST; M90; QL (QL Flag)
RisperDAL Consta Intramuscular Suspension Reconstituted
Tier 2M90; QL (2 KITS per 28 days)
risperiDONE M-TAB Tier 2 M90; QL (QL Flag)
risperiDONE Oral Solution RisperDAL Tier 2M90; QL (60ml per month)
risperiDONE Oral Tablet 0.25 MG Tier 2M90; QL (90 EA per 30 days)
RisperiDONE Oral Tablet 0.5 MG, 1 MG RisperDAL Tier 2M90; QL (90 EA per 30 days)
RisperiDONE Oral Tablet 2 MG, 3 MG, 4 MG
RisperDAL Tier 2M90; QL (60 EA per 30 days)
RisperiDONE Oral Tablet Dispersible 0.25 MG, 0.5 MG, 1 MG
Tier 2M90; QL (90 EA per 30 days)
RisperiDONE Oral Tablet Dispersible 2 MG, 3 MG, 4 MG
Tier 2M90; QL (60 EA per 30 days)
Rituxan Hycela $0 PA; SP; Dual
Rituxan Intravenous Solution $0 PA; SP; Dual
152
Covered Product Reference Tier Status NotesRivastigmine Exelon Tier 2 M90
Rivastigmine Tartrate Tier 2 M90
Rixubis Ixinity Tier 2 PA; SP; Dual
Rizatriptan Benzoate Tier 2M90; QL (12 tablets per month)
RoC Deep Wrinkle Serum Tier 2 M90
rocklatan Tier 2 ST
rOPINIRole HCl Tier 2 M90
ROPINIRole HCl ER Tier 2 M90
Rosadan External Cream Tier 2 M90
Rosadan External Gel Tier 2 M90
Rose Milk Tier 2 M90
Rosuvastatin Calcium Crestor Tier 2ST; M90; QL (30 EA per 90 days)
Rotarix $0 M90
RotaTeq Oral Solution $0 M90
Roweepra Oral Tablet 500 MG Tier 2 M90
Rozlytrek Oral Capsule 100 MG $0PA; SP; QL (60 EA per 30 days)
Rozlytrek Oral Capsule 200 MG $0PA; SP; QL (90 EA per 30 days)
Rubraca $0 PA; SP
Ruconest Tier 2PA; SP; QL (QL Flag); Dual
Rufinamide Oral Suspension Banzel Tier 2QL (2400 ML per 30 days)
Rukobia Tier 2PA; SP; PD; QL (60 EA per 30 days)
Ruxience $0 PA; SP; Dual
Ruzurgi Tier 2PA; SP; QL (300 EA per 30 days)
Rybelsus Tier 2 PA
Rydapt $0 PA
Rytary Oral Capsule Extended Release 23.75-95 MG, 36.25-145 MG
Tier 2 PA; M90
Sabril Tier 2PA; SP; BP; QL (180 EA per 30 days)
Safyral $0 M90
Saizen Tier 2PA; SP; QL (Quantity Limit Applies)
Saizen Click.Easy Tier 2 PA; SP
153
Covered Product Reference Tier Status NotesSalacyn External Lotion Tier 2 M90
Salicylic Acid External Lotion Tier 2 M90
Salicylic Acid External Shampoo Keralyt Tier 2 M90
Salimez Tier 2
Saline Flush Intravenous Monoject Flush Syringe Tier 2 M90
Saline Flush ZR Tier 2 M90
Saline Mist Spray Afrin Saline Nasal Mist Tier 1 M90
Saline Nasal Spray Afrin Saline Nasal Mist Tier 1 M90
Salsalate Oral Tier 2 M90
SandoSTATIN LAR Depot Intramuscular Kit 10 MG, 30 MG
Tier 2PA; SP; Dual; QL (1 KIT per 28 days)
SandoSTATIN LAR Depot Intramuscular Kit 20 MG
Tier 2PA; SP; Dual; QL (2 KITS per 28 days)
Santyl Tier 2 M90
Sapropterin Dihydrochloride Tier 2 SP
Sash Kit Tier 2 M90
Savaysa Tier 2PA; QL (Quantity Limit Applies)
Savella Tier 2PA; M90; QL (60 EA per 30 days)
Savella Titration Pack Tier 2PA; M90; QL (60 EA per 30 days)
SB Acid Controller Pepcid AC Tier 2 M90
SB Acid Controller Max StMM Acid-Pep Maximum Strength
Tier 2 M90
SB Acid Reducer Pepcid AC Tier 2 M90
SB Acid Reducer raNITIdine Tier 2 M90
SB Allergy Medicine Alka-Seltzer Plus Allergy Tier 2 M90
SB Allergy Oral Capsule Banophen Tier 2 M90
SB Allergy Oral Tablet KLS Aller-Tec Tier 2 M90; QL (QL Flag)
SB Allergy Relief Alavert Tier 2 M90
SB Antacid Cal-Gest Antacid Tier 2 M90
SB Antacid Extra StrengthCVS Chewy Not Chalky Flavor
Tier 2 M90
SB Anti-Fungal Tinactin Tier 2 M90
SB Arthritis Pain Relief Midol Tier 2 M90
SB Bacitracin Bacitraycin Plus Tier 2 M90
SB Bisacodyl Laxative EC Alophen Tier 2 M90
SB Bismuth Oral Suspension Kaopectate Tier 2 M90
SB Calcium + D Tier 2 M90
154
Covered Product Reference Tier Status NotesSB Cetirizine HCl Childrens Oral Syrup KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)
SB Childrens Ibuprofen Childrens Medi-Profen Tier 2 M90
SB Chlorpheniramine Wal-finate Tier 2 M90
SB Cimetidine Tagamet HB Tier 2 M90
SB Clotrimazole Foot Desenex Tier 2 M90
SB Docusate Sodium Correctol Extra Gentle Tier 2 M90
SB Ear Wax Remover Murine Ear Tier 2 M90
SB Gas Relief Oral SuspensionLittle Remedies for Tummys
Tier 2 M90
SB Gentle Laxative Womens Alophen Tier 2 M90
SB Gentle Lax-Women Alophen Tier 2 M90
SB Hydrocortisone Aveeno Anti-Itch Max St Tier 2 M90
SB Hydrocortisone Max St Cortizone-10 Tier 2 M90
SB Hydrocortisone Plus Aveeno Anti-Itch Max St Tier 2 M90
SB Ibuprofen Medi-Profen Tier 2 M90
SB Infants Ibuprofen Medi-Profen Tier 2 M90
SB Laxative The Magic Bullet Tier 2 M90
SB Lice Treatment Tier 2 M90
SB Loratadine Allergy Relief KLS AllerClear Tier 2 M90; QL (QL Flag)
SB Loratadine Oral Syrup Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
SB Loratadine Oral Tablet KLS AllerClear Tier 2 M90; QL (QL Flag)
SB Magnesium Citrate Citroma Tier 2 M90
SB Milk of MagnesiaDulcolax Milk of Magnesia
Tier 2 M90
SB Naproxen Sodium Mediproxen Tier 2 M90
SB Non-Aspirin Extra StrengthHealthy Mama Shake That Ache
Tier 2 M90
SB Non-Aspirin Oral Tablet Aphen Tier 2 M90
SB Non-Aspirin Oral Tablet Chewable 80 MG
Childrens Medi-Tabs Tier 2 M90
SB Oyster Shell Calcium Oystercal Tier 2 M90
SB Pain Reliever Childrens PediaCare Children Tier 2 M90
SB Pain Reliever Ex StHealthy Mama Shake That Ache
Tier 2 M90
SB Pediatric Electrolyte CeraLyte 70 Tier 2 M90
SB Peptic Relief Kaopectate Tier 2 M90
SB Polyethylene Glycol 3350 ClearLax Tier 2 M90
SB Saline Nose Afrin Saline Nasal Mist Tier 1 M90
SB Senna-Lax Evac-U-Gen Tier 2 M90
155
Covered Product Reference Tier Status Notes
Scalacort Ala Scalp Tier 2ST; M90; QL (QL Applies)
Scenesse MB PA
ScopolamineTransderm-Scop (1.5 MG)
Tier 2
Scot-Tussin Allergy Relief Tier 2 M90
Sea Soft Nasal Mist Afrin Saline Nasal Mist Tier 1 M90
Seb-Prev Wash Tier 2 M90
Seconal Tier 2
Secuado Tier 2 ST
Secura Antifungal Tier 2 M90
Secura Antifungal Extra Thick Tier 2 M90
Seebri Neohaler Tier 2
Segluromet Tier 2 PA
Selegiline HCl Oral Tier 2 M90
Selenium Sulfide External Lotion Tier 2 M90
Selenium Sulfide External Shampoo 2.25 %
Tier 2 M90
Selenium Sulf-Pyrithione-Urea Tier 2 M90
Selzentry Oral Solution Tier 2 PA
Selzentry Oral Tablet 150 MG, 75 MG Tier 2PA; QL (60 EA per 30 days)
Selzentry Oral Tablet 25 MG Tier 2PA; QL (240 per 30 days)
Selzentry Oral Tablet 300 MG Tier 2PA; QL (120 EA per 30 days)
Semglee Tier 1 PA
Semprex-D Tier 2 M90
Se-Natal 19 Oral Tablet Chewable $0 M90
Senexon Evac-U-Gen Tier 2 M90
Senior Tabs ABC Plus Senior Tier 2 M90
Senna Lax Evac-U-Gen Tier 2 M90
Senna Laxative Evac-U-Gen Tier 2 M90
Senna Oral Syrup 8.8 MG/5ML Tier 2 M90
Senna Oral Tablet 8.6 MG Evac-U-Gen Tier 2 M90
Senna Smooth Tier 2 M90
SennaCon Tier 2 M90
Senna-GRX Tier 2 M90
Senna-Lax Evac-U-Gen Tier 2 M90
Senna-Tabs Evac-U-Gen Tier 2 M90
156
Covered Product Reference Tier Status NotesSenna-Time Evac-U-Gen Tier 2 M90
Sennazon Tier 2 M90
Senno Tier 2 M90
Sensorcaine Tier 2 M90
Sensorcaine/EPINEPHrine Tier 2 M90
Sensorcaine-MPF Injection Solution 0.75 %
Tier 2 M90
Sentry ABC Plus Senior Tier 2 M90
Sentry Adult ABC Plus Senior Tier 2 M90
Sentry Senior ABC Plus Senior Tier 2 M90
Sentry Senior/Lutein ABC Plus Senior Tier 2 M90
Serevent Diskus Tier 2 M90
Serostim Subcutaneous Solution Reconstituted 4 MG, 5 MG, 6 MG
Tier 2 PA; SP; QL (QL Flag)
Sertraline HCl Oral Concentrate Zoloft Tier 2 M90
Sertraline HCl Oral Tablet 100 MG Zoloft Tier 2M90; QL (90 EA per 30 days)
Sertraline HCl Oral Tablet 25 MG, 50 MG Zoloft Tier 2M90; QL (75 tablets per month)
Setlakin $0 M90
Sevelamer Carbonate Oral Packet Renvela Tier 2
Sevenfact Tier 2 PA; SP; Dual
SF Cavarest Tier 2 M90
SF 5000 Plus Denta 5000 Plus Tier 2 M90
SfRowasa Tier 2 M90
Sharobel $0 M90
Shingrix Intramuscular Suspension Reconstituted 50 MCG
$0
Shopko Athletes Foot Tier 2 M90
Shopko Nasal Decongestant Max Tier 2 M90
Shopko Unifine Pentips $0 M90
Shopko Unifine Pentips Plus $0 M90
Shur-Seal Contraceptive $0 M90
Signifor LAR Intramuscular Suspension Reconstituted ER
MB PA
Silace Tier 2 M90
Siladryl Allergy Banophen Tier 2 M90
Sildenafil Citrate Oral Suspension Reconstituted
Revatio Tier 2PA; SP; QL (224 ml per 30 days)
157
Covered Product Reference Tier Status Notes
Sildenafil Citrate Oral Tablet 20 MG Revatio Tier 2PA; SP; QL (90 EA per 30 days)
Siliq Tier 2PA; QL (2 ML per 28 SYRs)
Silodosin Rapaflo Tier 2PA; QL (30 EA per 90 days)
Silphen Cough Tier 2 M90
Silver Sulfadiazine External SSD Tier 2 M90
Simbrinza Tier 2 M90
SimepedLittle Remedies for Tummys
Tier 2 M90
Simethicone Oral SuspensionLittle Remedies for Tummys
Tier 2 M90
Simethicone Oral Tablet Chewable 80 MG
Tier 2 M90
Simponi Aria Tier 2PA; SP; QL (200 mg every 8 weeks; Based on 100 kg pt); Dual
Simponi Subcutaneous Solution Auto-Injector 100 MG/ML
Tier 2PA; SP; QL (1 PEN per 28 days)
Simponi Subcutaneous Solution Auto-Injector 50 MG/0.5ML
Tier 2PA; SP; QL (Quantity Limit Applies)
Simponi Subcutaneous Solution Prefilled Syringe 100 MG/ML
Tier 2PA; SP; QL (Quantity Limit Applies)
Simponi Subcutaneous Solution Prefilled Syringe 50 MG/0.5ML
Tier 2PA; SP; QL (1 SYR per 28 days)
Simvastatin Oral Tablet Zocor Tier 2M90; QL (30 EA per 90 days)
Sirolimus Oral Solution Rapamune Tier 2 SP; QL (QL Applies)
Sirolimus Oral Tablet Rapamune Tier 2 SP; QL (QL Flag)
Sirturo Oral Tablet 100 MG Tier 2 M90
Sirturo Oral Tablet 20 MG Tier 2
Sitavig Tier 2 PA; M90
Sivextro Oral Tier 2PA; M90; QL (QL Flag)
Skin Repair Tier 2 M90
Skyla $0SP; QL (1 FILL per 365 days)
Skyrizi Tier 2PA; SP; QL (2 SYR per 84 days)
Skyrizi (150 MG Dose) Tier 2PA; SP; QL (2 SYR per 12 Weeks)
158
Covered Product Reference Tier Status NotesSlo-Niacin Oral Tablet Extended Release 250 MG
Tier 1 M90
Slynd $0
SM 3-Day Vaginal Gyne-Lotrimin 3 Tier 2 M90
SM 8 Hour Pain Relief Midol Tier 2 M90
SM Acid Reducer Tier 2 M90
SM All Day Allergy KLS Aller-Tec Tier 2 M90; QL (QL Flag)
SM All Day Allergy Childrens KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)
SM All Day Pain Relief Mediproxen Tier 2 M90
SM Allergy 4 Hour Wal-finate Tier 2 M90
SM Allergy Relief Childrens Banophen Tier 2 M90
SM Allergy Relief Loratadine KLS AllerClear Tier 2 M90; QL (QL Flag)
SM Allergy Relief Nasal ClariSpray Tier 2 M90
SM Allergy Relief Oral Capsule Banophen Tier 2 M90
SM Allergy Relief Oral Liquid Banophen Tier 2 M90
SM Allergy Relief Oral Tablet 25 MG Alka-Seltzer Plus Allergy Tier 2 M90
SM Allergy Relief Oral Tablet Dispersible Alavert Tier 2 M90
SM Animal Shapes Kids First Bounty Bears/C Tier 2 M90
SM Anti-Diarrheal Oral Capsule Imodium A-D Tier 2 M90
SM Antifungal Clotrimazole Desenex Tier 2 M90
SM Antifungal Miconazole Tineacide Tier 2 M90
SM Antifungal Tolnaftate Tinactin Tier 2 M90
SM Antioxidant Vitamins ABC Plus Senior Tier 2 M90
SM Arthritis Pain Relief Midol Tier 2 M90
SM Athletes Foot External Aerosol Tinactin Tier 2 M90
SM Bedding Lice Treatment RID Tier 2 M90
SM Calamine Tier 2 M90
SM Calcium 500/Vitamin D3 Oystercal-D Tier 2 M90
SM Calcium 600/Vitamin D Tier 2 M90
SM Calcium 600+D Plus MineralsCaltrate 600+D Plus Minerals
Tier 2 M90
SM Calcium 600+D3 Pronutrients Calcium+D3 Tier 2 M90
SM Calcium Antacid Cal-Gest Antacid Tier 2 M90
SM Calcium Antacid Ex StCVS Chewy Not Chalky Flavor
Tier 2 M90
SM Calcium Antacid Ultra St Tums Ultra 1000 Tier 2 M90
SM Calcium Citrate w/Vit D3 Calcitrate Tier 2 M90
SM Calcium Citrate+/Vit D3 Calcitrate Tier 2 M90
159
Covered Product Reference Tier Status Notes
SM Calcium Citrate+D3 PetiteCitracal Petites/Vitamin D
Tier 2 M90
SM Calcium Citrate-Vit D Tier 2 M90
SM Calcium/Vitamin D Os-Cal Calcium + D3 Tier 2 M90
SM Calcium/Vitamin D3Caltrate 600+D Plus Minerals
Tier 2 M90
SM Calcium-Vitamin D Tier 2 M90
SM Childrens Ibuprofen Childrens Medi-Profen Tier 2 M90
SM Childrens Loratadine Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
SM ClearLax Tier 2 M90
SM Clotrimazole Vaginal Gyne-Lotrimin Tier 2 M90
SM Complete ABC Plus Senior Tier 2 M90
SM Complete 50+ ABC Plus Senior Tier 2 M90
SM Complete 50+ Ultimate Mens ABC Plus Senior Tier 2 M90
SM Complete 50+ Ultimate Women ABC Plus Senior Tier 2 M90
SM Complete Advanced Formula ABC Plus Senior Tier 2 M90
SM Complete Senior Formula ABC Plus Senior Tier 2 M90
SM Daily Diet Support ABC Plus Senior Tier 2 M90
SM Dry Skin TherapyA + D Personal Care Lotion
Tier 2 M90
SM Ear Drops Murine Ear Tier 2 M90
SM Enema Fleet Enema Tier 2 M90
SM Eye Itch Relief Alaway Tier 2 M90; QL (QL Flag)
SM Fexofenadine HCl KLS Aller-Fex Tier 2 M90; QL (QL Flag)
SM First Aid Antibiotic Bacitraycin Plus Tier 2 M90
SM Gas Relief InfantsLittle Remedies for Tummys
Tier 2 M90
SM Gas Relief Infants DropsLittle Remedies for Tummys
Tier 2 M90
SM Gas Relief Oral Tablet Chewable 80 MG
Tier 2 M90
SM Gentle Laxative Alophen Tier 2 M90
SM Hair/Skin/Nails ABC Plus Senior Tier 2 M90
SM Hydrocortisone External Cream 1 % Aveeno Anti-Itch Max St Tier 2 M90
SM Ibuprofen IB Advil Junior Strength Tier 2 M90
SM Ibuprofen Jr Advil Junior Strength Tier 2 M90
SM Ibuprofen Oral Tablet Medi-Profen Tier 2 M90
SM Infants Ibuprofen Medi-Profen Tier 2 M90
SM Infants Pain Reliever PediaCare Children Tier 2 M90
160
Covered Product Reference Tier Status NotesSM Iodides Tier 2 M90
SM Iodine Tincture Tier 2 M90
SM Iron Oral Tablet 134 MG Tier 2 M90
SM Laxative Maximum Strength Tier 2 M90
SM Laxative Rectal The Magic Bullet Tier 2 M90
SM Lice Killing RID Tier 2 M90
SM Lice Treatment Tier 2 M90
SM Loratadine Allergy Relief Alavert Tier 2 M90
SM Loratadine Oral Syrup Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
SM Loratadine Oral Tablet KLS AllerClear Tier 2 M90; QL (QL Flag)
SM Loratadine Oral Tablet Dispersible Alavert Tier 2 M90
SM Magnesium Citrate Citroma Tier 2 M90
SM Miconazole 3 Vagistat-3 Tier 2 M90
SM Miconazole 3 ApplicatorMonistat 3 Combo Pack App
Tier 2 M90
SM Miconazole 7 Tier 2 M90
SM Milk of MagnesiaDulcolax Milk of Magnesia
Tier 2 M90
SM Mineral Oil Oral Tier 2 M90
SM Motion Sickness Oral Tablet 25 MG Wal-Dram II Tier 2 M90
SM Multiple Vitamins/IronTab-A-Vite/Iron/Beta Carotene
Tier 2 M90
SM Naproxen Sodium Oral Tablet Mediproxen Tier 2 M90
SM Nasal Decongestant Max St SudoGest Tier 2 M90
SM Nasal Spray Saline Afrin Saline Nasal Mist Tier 1 M90
SM Niacin CR Endur-Acin Tier 1 M90
SM Nicotine Habitrol $0 M90
SM Nicotine Polacrilex Mouth/Throat Gum
KLS Quit2 $0 M90
SM Nicotine Polacrilex Mouth/Throat Lozenge 4 MG
KLS Quit4 $0 M90
SM One Daily Mens ABC Plus Senior Tier 2 M90
SM One Daily Womens ABC Plus Senior Tier 2 M90
SM Opti-Vitamins ABC Plus Senior Tier 2 M90
SM Oyster Shell Calcium/Vit D Oystercal-D Tier 2 M90
SM Oyster Shell Calcium/Vit D3 Oystercal-D Tier 2 M90
SM Pain & Fever Childrens PediaCare Children Tier 2 M90
SM Pain & Fever Infants PediaCare Children Tier 2 M90
161
Covered Product Reference Tier Status Notes
SM Pain Relief Extra StrengthHealthy Mama Shake That Ache
Tier 2 M90
SM Pain Reliever 8 Hour Ex St Midol Tier 2 M90
SM Pain Reliever Childrens PediaCare Children Tier 2 M90
SM Pain Reliever Ex St Oral TabletHealthy Mama Shake That Ache
Tier 2 M90
SM Pain Reliever Oral Tablet 325 MG Aphen Tier 2 M90
SM Pediatric Electrolyte CeraLyte 70 Tier 2 M90
SM Prenatal Vitamins Tier 1 M90
SM Senna Laxative Evac-U-Gen Tier 2 M90
SM Senna Laxative Max St Tier 2 M90
SM Smooth Antacid Ex StCVS Chewy Not Chalky Flavor
Tier 2 M90
SM Stomach Relief Oral Suspension Kaopectate Tier 2 M90
SM Stool Softener Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90
SM Vitamin B-6 Tier 2 M90
SM Vitamin D3 Oral Capsule 50 MCG (2000 UT)
Tier 2 M90
SM Vitamin D3 Oral Tablet Vitamin D-1000 Max St Tier 2 M90
SM Womans Laxative Alophen Tier 2 M90
Smooth LAX Tier 2 M90
Sodium Acetate Intravenous Solution 2 MEQ/ML
Tier 2
Sodium Ascorbate Injection Solution 250 MG/ML
Tier 2 M90
Sodium Chloride Flush Monoject Flush Syringe Tier 2 M90
Sodium Chloride Inhalation Nebulization Solution 0.9 %, 3 %
Tier 2 M90
Sodium Chloride Intravenous Solution 0.9 %
Tier 2 M90
Sodium Chloride Irrigation Solution 0.9 % Argyle Sterile Saline Tier 2 M90
Sodium Fluoride Mouth/Throat PreviDent Tier 2
Sodium Fluoride Oral Solution 1.1 (0.5 F) MG/ML
Tier 1 M90
Sodium Fluoride Oral Tablet 1.1 (0.5 F) MG
Tier 1 M90
Sodium Fluoride Oral Tablet Chewable 0.55 (0.25 F) MG, 1.1 (0.5 F) MG
Tier 1 M90
Sodium Fluoride Oral Tablet Chewable 2.2 (1 F) MG
NaFrinse Tier 2 M90
Sodium Hyaluronate External Gel Tier 2 M90
162
Covered Product Reference Tier Status Notes
Sodium Hyaluronate Intra-Articular Euflexxa Tier 2PA; SP; QL (QL Applies); Dual
Sodium Phenylbutyrate Oral Powder 3 GM/TSP
Buphenyl Tier 2 SP; QL (QL Flag)
Sodium Phenylbutyrate Oral Tablet Buphenyl Tier 2
Sodium Polystyrene Sulfonate Oral Tier 2 M90
Sodium Polystyrene Sulfonate Rectal Tier 2 M90
Sodium Sulfacetamide External Shampoo 10 %
Ovace Plus Tier 2 M90
Sodium Sulfacetamide External Shampoo 9.8 %
Plexion NS Tier 2
Sof-Lax Tier 2 M90
Sofosbuvir-Velpatasvir Epclusa Tier 2PA; SP; PD; QL (28 EA per 28 days)
Softden Tier 2 M90
Solifenacin Succinate VESIcare Tier 2ST; QL (30 EA per 90 days)
Soliqua Tier 2 PA
Soliris Tier 2 PA; SP; Dual
Solo ABC Plus Senior Tier 2 M90
Soltamox $0 M90
Solu-CORTEF Tier 2 M90
Solu-MEDROL Injection Solution Reconstituted 2 GM
Tier 2 M90
Somatuline Depot Subcutaneous Solution 120 MG/0.5ML
Tier 2PA; SP; Dual; QL (120 ML per 28 days)
Somatuline Depot Subcutaneous Solution 60 MG/0.2ML
Tier 2PA; SP; Dual; QL (1 SYR per 28 days)
Somatuline Depot Subcutaneous Solution 90 MG/0.3ML
Tier 2PA; SP; QL (90 mg per 28 days); Dual
Somavert MB PA
Soothe & Cool INZO Antifungal Tier 2 M90
Soothe & Cool Moisturizing Tier 2 M90
Soothe Oral Suspension 262 MG/15ML Tier 2 M90
Sorilux Tier 2PA; M90; QL (120 GM per 30 days)
Sorine Tier 1 M90
Sotalol HCl (AF) Betapace AF Tier 1 M90
Sotalol HCl Oral Sorine Tier 1 M90
Sotylize Tier 2 M90
163
Covered Product Reference Tier Status Notes
Sovaldi Oral Packet Tier 2PA; SP; QL (28 EA per 28 days)
Spinosad Natroba Tier 2
Spinraza MB PA
Spiriva HandiHaler Tier 2 M90
Spiriva Respimat Inhalation Aerosol Solution 1.25 MCG/ACT, 2.5 MCG/ACT
Tier 2 M90
Spironolactone Oral Aldactone Tier 1 M90
Spironolactone-HCTZ Aldactazide Tier 1 M90
Spravato (56 MG Dose) MB PA
Spravato (84 MG Dose) MB PA
Sprintec 28 $0 M90
Sprycel Oral Tablet 100 MG, 140 MG, 50 MG, 70 MG, 80 MG
$0SP; QL (30 EA per 30 days)
Sprycel Oral Tablet 20 MG $0SP; QL (90 EA per 30 days)
SPS Tier 2 M90
SR Nicotine KLS Quit2 $0 M90
Sronyx $0 M90
SSD Tier 2 M90
SSD (silver sulfADIAZINE) Tier 2 M90
SSKI Tier 2 M90
St Ives Swiss Formula Moisture Tier 2 M90
St Joseph Adult Tier 1 M90
St Joseph Adult Low Dose Tier 1 M90
Stavudine Tier 2 M90
Steglatro Tier 2 PA
Stelara Intravenous Tier 2PA; SP; Dual; QL (4 VIALS per 56 days)
Stelara Subcutaneous Solution 45 MG/0.5ML
Tier 2PA; SP; PD; Dual; QL (1 VIAL per 84 days)
Stelara Subcutaneous Solution Prefilled Syringe
Tier 2PA; SP; PD; QL (1 SYR per 84 days)
Stimate Tier 2 SP; QL (QL Flag)
Stimulant Laxative Oral Tablet Delayed Release
Alophen Tier 2 M90
Stiolto Respimat Inhalation Aerosol Solution 2.5-2.5 MCG/ACT
Tier 2M90; QL (1 EA per 30 days)
Stivarga $0PA; SP; QL (112 EA per 28 days)
164
Covered Product Reference Tier Status NotesStomach Relief Oral Suspension 262 MG/15ML, 527 MG/30ML
Kaopectate Tier 2 M90
Stool Softener Oral Capsule 100 MG Correctol Extra Gentle Tier 2 M90
Stool Softener Oral Tablet DOK Tier 2 M90
Stop Lice RID Tier 2 M90
Stop Lice Maximum Strength External Liquid
RID Tier 2 M90
Stop Lice Step 3 RID Tier 2 M90
Stress B Complex/IronTab-A-Vite/Iron/Beta Carotene
Tier 2 M90
Stress B-Complex/C/Zinc ABC Plus Senior Tier 2 M90
Stress Formula EstroFactors Tier 2 M90
Stress Formula (Folic Acid) Tier 2 M90
Stress Formula/IronTab-A-Vite/Iron/Beta Carotene
Tier 2 M90
Stress Formula/Zinc ABC Plus Senior Tier 2 M90
Stress Formula/Zinc (B-Compl) Tier 2 M90
Stribild Tier 2
Striverdi Respimat Tier 2 M90
Strovite Forte Oral Syrup Tier 2 M90
Sublocade MB PD
Suboxone Sublingual Film 12-3 MG Tier 2PD; BP; QL (60 EA per 30 days)
Suboxone Sublingual Film 2-0.5 MG Tier 2PD; BP; QL (360 EA per 30 days)
Suboxone Sublingual Film 4-1 MG Tier 2PD; BP; QL (180 EA per 30 days)
Suboxone Sublingual Film 8-2 MG Tier 2PD; BP; QL (90 EA per 30 days)
Sucraid Tier 2 M90
Sucralfate Oral Tablet Carafate Tier 2 M90
SudoGest Tier 2 M90
SUFentanil Citrate Intravenous Solution 100 MCG/2ML, 50 MCG/ML
Tier 2
Sulconazole Nitrate Exelderm Tier 2 ST
Sulfacetamide Sodium (Acne) Klaron Tier 2 M90
Sulfacetamide Sodium External Gel Ovace Plus Wash Tier 2 M90
Sulfacetamide Sodium External Liquid Ovace Plus Wash Tier 2 M90
Sulfacetamide Sodium External Suspension
Klaron Tier 2 M90
165
Covered Product Reference Tier Status NotesSulfacetamide Sodium Ophthalmic Solution
Bleph-10 Tier 2 M90
Sulfacetamide Sodium-Sulfur External Emulsion
Tier 2
Sulfacetamide Sodium-Sulfur External Lotion 10-5 %
Tier 2 M90
Sulfacetamide-Prednisolone Ophthalmic Solution
Tier 2 M90
SulfADIAZINE Oral Tier 2 M90
Sulfamethoxazole-Trimethoprim Intravenous
Tier 2 M90
Sulfamethoxazole-Trimethoprim Oral Suspension 200-40 MG/5ML
Sulfatrim Pediatric Tier 2 M90
Sulfamethoxazole-Trimethoprim Oral Tablet
Bactrim Tier 2 M90
Sulfamylon External Cream Tier 2 M90
SulfaSALAzine Oral Azulfidine Tier 2 M90
Sulfatrim Pediatric Tier 2 M90
Sulfoam Tier 2 M90
Sulindac Oral Tier 2 M90
SUMAtriptan Nasal Solution 20 MG/ACT Imitrex Tier 2M90; QL (12ml (2 nasal sprays) per 25 days)
SUMAtriptan Succinate Oral Imitrex Tier 2M90; QL (12 tablets per month)
SUMAtriptan Succinate Refill Subcutaneous Solution Cartridge 6 MG/0.5ML
Imitrex STATdose Refill Tier 2 M90; QL (QL Flag)
SUMAtriptan Succinate Subcutaneous Solution 6 MG/0.5ML
Imitrex Tier 2 M90
SUMAtriptan Succinate Subcutaneous Solution Auto-Injector 6 MG/0.5ML
Imitrex STATdose System
Tier 2 M90
SUMAtriptan Succinate Subcutaneous Solution Prefilled Syringe 6 MG/0.5ML
Tier 2M90; QL (6 kits (12 syringes) per month)
Sunosi Tier 2 PA
Supartz FX Tier 2PA; SP; QL (QL Applies); Dual
Super 28 Formula ABC Plus Senior Tier 2 M90
Super Antioxidant Oral Capsule DEKAs Plus Tier 2 M90
Super Antioxidants Protector DEKAs Plus Tier 2 M90
Super Aytinal ABC Plus Senior Tier 2 M90
Super Aytinal 50 Plus ABC Plus Senior Tier 2 M90
166
Covered Product Reference Tier Status NotesSuper Calcium 600 + D 400 Tier 2 M90
Super Calcium 600 + D3 Tier 2 M90
Super Calcium Oral Tablet 1500 (600 Ca) MG, 600 MG
Tier 2 M90
Super Daily D3 Oral Liquid 1000 UNT/0.03ML
Ddrops Tier 2
Super Multiple ABC Plus Senior Tier 2 M90
Super Nu-Thera Oral Liquid Tier 2 M90
Super Thera Vite M ABC Plus Senior Tier 2 M90
Super Vikaps ABC Plus Senior Tier 2 M90
Super Vita-Mins ABC Plus Senior Tier 2 M90
Superb Nails ABC Plus Senior Tier 2 M90
Suphedrine SudoGest Tier 2 M90
Support BProtected Multi-Vite Tier 2 M90
Supprelin LA Tier 2 PA; SP; Dual
Suprax Oral Suspension Reconstituted 500 MG/5ML
Tier 2 M90
Suprep Bowel Prep Kit $0
Sure Comfort Pen NeedlesAdvocate Insulin Pen Needles
$0 M90
Sure Guard Anti-Oxidant Plus ABC Plus Senior Tier 2 M90
Sure Guard Multi Vit/Mineral ABC Plus Senior Tier 2 M90
Sure Result DSS Premium Pack NuDiclo SoluPak Tier 2 M90
Sure-Fine Pen Needles $0 M90
Surgilube Tier 2 PA; SP
Surmontil Oral Capsule 25 MG, 50 MG Tier 2 M90
Sustiva Oral Tablet Tier 2QL (30 EA per 90 days)
Sutab $0
Sutent $0PA; SP; PD; QL (30 EA per 30 days)
SW Acid Reducer 150 Max St Tier 2 M90
SW Allergy Relief KLS Aller-Tec Tier 2 M90; QL (QL Flag)
SW ClearLax Tier 2 M90
SW Nasal Decongestant Max St SudoGest Tier 2 M90
SW Nicotine Polacrilex KLS Quit4 Tier 1 M90
SwabFlush Saline Flush Tier 2 M90
Syeda $0 M90
Sylatron Subcutaneous Kit 200 MCG, 300 MCG, 600 MCG
$0 SP; QL (4 per 28 days)
167
Covered Product Reference Tier Status NotesSymax Duotab Tier 2 M90
Symax-SL Tier 2 M90
Symax-SR Tier 2 M90
Symbicort Tier 2 BP
Symdeko Tier 2PA; PD; QL (60 EA per 30 days)
Symjepi Injection Solution Prefilled Syringe 0.15 MG/0.3ML
Tier 2
QL (1 pack (2 pens) per fill with a maximum of 1 fill per day)
Symjepi Injection Solution Prefilled Syringe 0.3 MG/0.3ML
Tier 2QL (2 pens per fill, 1 fill per day)
SymlinPen 120 Subcutaneous Solution Pen-Injector
Tier 2 PA; M90
SymlinPen 60 Subcutaneous Solution Pen-Injector
Tier 2 PA; M90
Symtuza Tier 2PD; QL (30 EA per 30 days)
Synagex Tier 2 M90
Synagis $0PA; SP; QL (5 DOSES per 1 RSV SEASON)
Synarel Tier 2 M90
SynaTek Tier 2 M90
Synercid Tier 2 M90
Synjardy Tier 2QL (60 EA per 30 days)
Synjardy XR Tier 2QL (60 EA per 30 days)
Synthroid Tier 2
Synvisc Intra-Articular Solution Prefilled Syringe
Tier 2PA; SP; QL (QL Flag); Dual
Synvisc One Intra-Articular Solution Prefilled Syringe
Tier 2PA; SP; QL (QL Flag); Dual; QL (1 SYR per 1 APPROVAL)
T.R.U.E. Test Tier 2 M90
Tab-A-Vite/IronTab-A-Vite/Iron/Beta Carotene
Tier 2 M90
Tabloid $0 M90
Tabrecta $0SP; QL (112 EA per 28 days)
Tacrolimus Oral Prograf Tier 2 SP; QL (QL Flag)
168
Covered Product Reference Tier Status NotesTactinal Aphen Tier 2 M90
Tactinal Extra StrengthHealthy Mama Shake That Ache
Tier 2 M90
Tadalafil (PAH) Adcirca Tier 2PA; SP; QL (60 EA per 30 days)
Tadalafil Oral Tablet 5 MG Cialis Tier 1PA; M90; QL (QL Applies)
Tafinlar $0SP; QL (120 EA per 30 days)
Tagrisso $0PA; SP; QL (30 EA per 30 days)
Take Action $0 M90
Takhzyro Tier 2PA; SP; QL (2 VIALS per 28 days)
Taltz Subcutaneous Solution Auto-Injector
Tier 2PA; SP; PD; QL (1 INJ per 28 days)
Taltz Subcutaneous Solution Prefilled Syringe
Tier 2PA; SP; PD; QL (1 SYR per 28 days)
Talwin Tier 2
Talzenna $0 SP
Tamsulosin HCl Flomax Tier 2M90; QL (60 EA per 30 days)
TargaDOX Tier 2 M90
Targretin External Tier 2 SP; QL (QL Flag)
Tarina FE 1/20 $0 M90
Taron Forte Tier 2 M90
Taron-Crystals Tier 2 M90
Tasigna $0SP; QL (120 EA per 30 days)
Tavalisse Oral Tablet 100 MG Tier 2 PA; SP
Taytulla $0 M90
Tazarotene External Cream Tazorac Tier 2 ST; M90
Tazorac External Cream 0.05 % Tier 2 ST; M90
Tazorac External Gel Tier 2 ST; M90
Taztia XT Tier 1 M90
Tazverik $0SP; QL (240 EA per 30 days)
TBC Tier 2 M90
Tecentriq Intravenous Solution 1200 MG/20ML
$0 PA; SP
169
Covered Product Reference Tier Status NotesTecentriq Intravenous Solution 840 MG/14ML
$0 PA; SP; Dual
Tecfidera Oral Tier 2PA; SP; PD; BP; QL (60 EA per 30 days)
Tecfidera Oral Capsule Delayed Release 120 MG
Tier 2PA; SP; PD; BP; QL (14 EA per 30 days)
Tecfidera Oral Capsule Delayed Release 240 MG
Tier 2PA; SP; PD; BP; QL (60 EA per 30 days)
TechLite Pen Needles 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM
$0 M90
TechLite Pen Needles 32G X 8 MM Tier 1 M90
Telmisartan Micardis Tier 1 ST; M90
Telmisartan-HCTZ Micardis HCT Tier 1 ST; M90
Temazepam Restoril Tier 2
Temodar Intravenous $0 SP
Temozolomide $0 SP
Temsirolimus Torisel $0 SP
Teniposide $0 M90
Tenivac $0 M90
Tenofovir Disoproxil Fumarate Viread Tier 2QL (30 EA per 90 days)
Tepadina Tier 2 SP
Tepezza MB PA
Tepmetko $0PA; SP; QL (60 EA per 30 days)
Terazosin HCl Oral Tier 1 M90
Terbinafine HCl Oral Tier 2M90; QL (30 EA per 90 days)
Terbutaline Sulfate Oral Tier 2 M90
Terconazole Tier 2 M90
Tersaseptic Tier 2 M90
Tersi Tier 2 M90
Testopel MB PA
Testosterone Cypionate Intramuscular Solution 100 MG/ML, 200 MG/ML
Depo-Testosterone Tier 2
Testosterone Enanthate Intramuscular Solution
Tier 2
Testosterone Transdermal Gel 10 MG/ACT (2%)
Fortesta Tier 2
170
Covered Product Reference Tier Status NotesTestosterone Transdermal Gel 12.5 MG/ACT (1%)
Vogelxo Pump Tier 2
Testosterone Transdermal Gel 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%)
AndroGel Tier 2 ST
Testosterone Transdermal Gel 20.25 MG/ACT (1.62%)
AndroGel Pump Tier 2 ST
Testosterone Transdermal Gel 25 MG/2.5GM (1%), 50 MG/5GM (1%)
AndroGel Tier 2
Testosterone Transdermal Solution Tier 2 ST
Tetanus-Diphtheria Toxoids Td TDVAX $0 M90
Tetcaine Tier 2 M90
Tetrabenazine Xenazine Tier 2 PA; SP; QL (QL Flag)
Tetracaine HCl Ophthalmic Altacaine Tier 2 M90
Tetracycline HCl Oral Tier 2 M90
TetraVisc Tier 2 M90
TetraVisc Forte Tier 2 M90
TexaVite LQ Tier 2 M90
TGT Acetaminophen Childrens PediaCare Children Tier 2 M90
TGT Acetaminophen Ex StHealthy Mama Shake That Ache
Tier 2 M90
TGT Acetaminophen Infants Tier 2 M90
TGT Acid Reducer Pepcid AC Tier 2 M90
TGT All Day Allergy Childrens KLS Aller-Tec Childrens Tier 2 M90; QL (QL Flag)
TGT All Day Allergy Relief KLS Aller-Tec Tier 2 M90; QL (QL Flag)
TGT Allergy Childrens Banophen Tier 2 M90
TGT Allergy Relief Childrens Banophen Tier 2 M90
TGT Allergy Relief Oral Capsule Banophen Tier 2 M90
TGT Allergy Relief Oral Tablet 10 MG KLS AllerClear Tier 2 M90; QL (QL Flag)
TGT Allergy Relief Oral Tablet 180 MG KLS Aller-Fex Tier 2 M90; QL (QL Flag)
TGT Allergy Relief Oral Tablet 25 MG Alka-Seltzer Plus Allergy Tier 2 M90
TGT Allergy Relief Oral Tablet Dispersible
Alavert Tier 2 M90
TGT Allergy+ Congestion Relief Oral Tablet Extended Release 12 Hour 60-120 MG
Wal-Fex D Allergy & Congestion
Tier 2 M90; QL (QL Flag)
TGT Antacid Tums Ultra 1000 Tier 2 M90
TGT Antacid Extra Strength Oral Tablet Chewable 750 MG
CVS Chewy Not Chalky Flavor
Tier 2 M90
TGT Antifungal Tinactin Tier 2 M90
TGT Anti-Itch Maximum Strength Cortizone-10 Tier 2 M90
171
Covered Product Reference Tier Status NotesTGT Anti-Itch Plus Oatmeal Aveeno Anti-Itch Max St Tier 2 M90
TGT Anti-Itch/Aloe/Vit E Aveeno Anti-Itch Max St Tier 2 M90
TGT Arthritis Pain Relief Midol Tier 2 M90
TGT Bacitracin Bacitraycin Plus Tier 2 M90
TGT Calcium + Vitamin D3 Pronutrients Calcium+D3 Tier 2 M90
TGT Childrens Acetaminophen PediaCare Children Tier 2 M90
TGT Childrens Ibuprofen Childrens Medi-Profen Tier 2 M90
TGT Clotrimazole Desenex Tier 2 M90
TGT Eye Itch Relief Alaway Tier 2 M90; QL (QL Flag)
TGT Gas Relief Infants Gas-X Infant Drops Tier 2 M90
TGT Gentle Laxative Alophen Tier 2 M90
TGT Ibuprofen Childrens Childrens Medi-Profen Tier 2 M90
TGT Ibuprofen Junior Strength Advil Junior Strength Tier 2 M90
TGT Ibuprofen Oral Tablet Medi-Profen Tier 2 M90
TGT Infants Ibuprofen Medi-Profen Tier 2 M90
TGT Laxative Pills Max St Tier 2 M90
TGT Loperamide HCl Imodium A-D Tier 2 M90
TGT Loratadine Childrens Claritin Allergy Childrens Tier 2M90; QL (300ml per month)
TGT Miconazole 1 Monistat 1 Combo Pack Tier 2 M90
TGT Miconazole 3 Combo Pack Vagistat-3 Tier 2 M90
TGT Miconazole 7 Monistat 7 Simply Cure Tier 2 M90
TGT Multivitamin/Multimineral ABC Plus Senior Tier 2 M90
TGT Naproxen Sodium Oral Tablet Mediproxen Tier 2 M90
TGT Nasal Decongestant SudoGest Tier 2 M90
TGT Nasal Spray Nasal Solution 0.65 % Afrin Saline Nasal Mist Tier 1 M90
TGT Natural Laxative Pills Tier 2 M90
TGT Nicotine KLS Quit2 $0 M90
TGT Nicotine Polacrilex KLS Quit4 $0 M90
TGT Nicotine Step One Habitrol $0 M90
TGT Nicotine Step Three Nicoderm CQ $0 M90
TGT Nicotine Step Two Nicoderm CQ $0 M90
TGT Pain/Fever Acetaminophen PediaCare Children Tier 2 M90
TGT Powderlax Oral Powder Tier 2 M90
TGT Saline Laxative Fleet Enema Tier 2 M90
TGT Saline Nasal Spray Afrin Saline Nasal Mist Tier 1 M90
TGT Senna Evac-U-Gen Tier 2 M90
TGT Senna Laxative Oral Tablet 8.6 MG Evac-U-Gen Tier 2 M90
172
Covered Product Reference Tier Status NotesTGT Stool Softener Correctol Extra Gentle Tier 2 M90
TGT Womens Laxative Alophen Tier 2 M90
Thalomid Oral Capsule 100 MG, 50 MG Tier 2SP; QL (30 EA per 90 days)
Thalomid Oral Capsule 150 MG, 200 MG Tier 2SP; QL (60 EA per 30 days)
The Magic Bullet Tier 2 M90
The Treatment Formula 3 Tier 2 M90
Theo-24 Tier 2 M90
Theophylline Tier 2 M90
Theophylline ER Oral Tablet Extended Release 12 Hour 300 MG, 450 MG
Tier 2 M90
Theophylline ER Oral Tablet Extended Release 24 Hour
Tier 2 M90
Thera Vital M ABC Plus Senior Tier 2 M90
Thera vital-M ABC Plus Senior Tier 2 M90
Therabasic-M ABC Plus Senior Tier 2 M90
TheraBetic Skin Care Tier 2 M90
TheraCys $0 M90
Thera-D 2000 Tier 2 M90
Thera-D Rapid Repletion Tier 2 M90
Thera-DermA + D Personal Care Lotion
Tier 2 M90
Thera-M ABC Plus Senior Tier 2 M90
TheraNatal Core Nutrition Tier 1 M90
Therapeutic Formula/Hematinics ABC Plus Senior Tier 2 M90
Therapeutic Liquid BProtected Multi-Vite Tier 2 M90
Therapeutic M ABC Plus Senior Tier 2 M90
Therapeutic-M ABC Plus Senior Tier 2 M90
Therapeutic-M/Lutein ABC Plus Senior Tier 2 M90
Theraplex Hydrolotion Tier 2 M90
Thera-Tabs M ABC Plus Senior Tier 2 M90
TheraTears Allergy Tier 2 M90; QL (QL Flag)
Theravim-M ABC Plus Senior Tier 2 M90
Thiamine HCl Injection Tier 2 M90
Thiola Tier 2 M90
Thiola EC Tier 2
Thioridazine HCl Oral Tier 2 M90
Thiothixene Oral Tier 2 M90
173
Covered Product Reference Tier Status NotesThrive Mouth/Throat Gum 2 MG $0 M90
Thrivite Rx Prenatabs Rx $0 M90
Thrombogen Tier 2 M90
Thyrogen Intramuscular Solution Reconstituted 1.1 MG
Tier 2 SP; QL (QL Flag)
Thyrolar-1 Oral Tablet 60 (12.5-50) MG (MCG)
Tier 2 M90
Thyrolar-1/2 Oral Tablet 30 (6.25-25) MG (MCG)
Tier 2 M90
Thyrolar-1/4 Oral Tablet 15 (3.1-12.5) MG (MCG)
Tier 2 M90
Thyrolar-2 Oral Tablet 120 (25-100) MG (MCG)
Tier 2 M90
Thyrolar-3 Oral Tablet 180 (37.5-150) MG (MCG)
Tier 2 M90
TiaGABine HCl Oral Tablet 12 MG, 16 MG
Gabitril Tier 2
TiaGABine HCl Oral Tablet 2 MG, 4 MG Gabitril Tier 2 M90
Tibsovo $0 PA; SP
Tice BCG $0 M90
Tigan Intramuscular Tier 2 M90
Tiglutik Tier 2 PA
Tilia Fe $0 M90
Timolol Maleate Ophthalmic Gel Forming Solution
Timoptic-XE Tier 2 M90
Timolol Maleate Ophthalmic Solution 0.25 %, 0.5 %
Timoptic Tier 2 M90
Timolol Maleate Ophthalmic Solution 0.5 % (DAILY)
Istalol Tier 2
Timolol Maleate Oral Tier 1 M90
Timolol Maleate PF Timoptic Ocudose Tier 2
Timoptic Ocudose Ophthalmic Solution 0.25 %
Tier 2 M90
Tinaspore Blis-To-Sol Tier 2 M90
Tineacide External Cream 2 % Tier 2 M90
Tinidazole Oral Tier 2 M90
Tivicay Tier 2QL (30 EA per 90 days)
Tivicay PD Tier 2QL (300 EA per 30 days)
tiZANidine HCl Oral Tier 2 M90
174
Covered Product Reference Tier Status NotesTL Icon Tricon Tier 2 M90
TL-Hem 150 Abatron AF Tier 2 M90
Tobi Podhaler Tier 2SP; QL (224 caps per 28 days)
TobraDex ST Tier 2 M90
Tobramycin Inhalation Nebulization Solution 300 MG/5ML
Kitabis Pak Tier 2SP; QL (280 per 28 days)
Tobramycin Ophthalmic Tobrex Tier 2 M90
Tobramycin Sulfate Injection Tier 2 M90
Tobramycin-Dexamethasone TobraDex Tier 2 M90
Tobrex Ophthalmic Ointment Tier 2 M90
Today Sponge $0 M90
Todays Health Mini Pen Needles CareFine Pen Needles $0 M90
Todays Health Pen Needles CareFine Pen Needles $0 M90
Todays Health Short Pen NeedleAdvocate Insulin Pen Needles
$0 M90
TOLAZamide Tier 1 M90
TOLBUTamide Tier 1 M90
Tolcapone Tasmar Tier 2 M90
Tolmetin Sodium Tier 2 M90
Tolnaftate Aerosol 1% External Aerosol Tinactin Tier 2 M90
Tolnaftate Aerosol 1% External Cream Tinactin Tier 2 M90
Tolnaftate Antifungal Tinactin Tier 2 M90
Tolnaftate External Cream Tinactin Tier 2 M90
Tolnaftate External Solution Blis-To-Sol Tier 2 M90
Tolterodine Tartrate Detrol Tier 2 M90
Tolterodine Tartrate ER Detrol LA Tier 2ST; M90; QL (30 EA per 90 days)
Tolvaptan Oral Tablet 15 MG Jynarque Tier 2 QL (QL Flag)
Tolvaptan Oral Tablet 30 MG Jynarque Tier 2 SP; QL (QL)
TopCare Clickfine Pen NeedlesAdvocate Insulin Pen Needles
$0 M90
Topiramate ER Qudexy XR Tier 2 ST
Topiramate Oral Topamax Tier 2 M90
Toposar Intravenous Solution 1 GM/50ML, 100 MG/5ML, 500 MG/25ML
$0 M90
Topotecan HCl Hycamtin $0 M90
Toprol XL Oral Tablet Extended Release 24 Hour 100 MG, 25 MG
Tier 1 M90
175
Covered Product Reference Tier Status NotesToremifene Citrate Fareston $0
Torsemide Oral Tier 1 M90
Total Allergy Alka-Seltzer Plus Allergy Tier 2 M90
Total Allergy Medicine Tier 2 M90
Toviaz Tier 2ST; M90; QL (30 EA per 90 days)
TPN Electrolytes Intravenous Solution Tier 2 M90
Tradjenta Tier 2M90; QL (30 EA per 30 days)
traMADol HCl Oral Tablet 50 MG Ultram Tier 2QL (180 EA per 30 days)
Tramadol-Acetaminophen Ultracet Tier 2QL (40 tablets per 30 days. Click;HERE)
Trandolapril Tier 1 M90
Trandolapril-Verapamil HCl ER Oral Tablet Extended Release 1-240 MG, 2-240 MG, 4-240 MG
Tier 1 M90
Trandolapril-Verapamil HCl ER Oral Tablet Extended Release 2-180 MG
Tier 1
Tranexamic Acid Intravenous Solution 1000 MG/10ML
Cyklokapron Tier 2 M90
Tranexamic Acid Oral Lysteda Tier 2M90; QL (30 EA per 90 days)
Transderm-Scop (1.5 MG) Tier 2
Tranylcypromine Sulfate Parnate Tier 2 M90
Travoprost (BAK Free) Travatan Z Tier 2 ST
traZODone HCl Oral Tier 2 M90
Treanda Intravenous Solution Reconstituted
$0 SP
Trecator Tier 2 M90
Trelstar Tier 1 SP
Trelstar Mixject $0 SP
Tremfya Subcutaneous Solution Pen-Injector
Tier 2PA; SP; QL (1 PEN per 28 days)
Tremfya Subcutaneous Solution Prefilled Syringe
Tier 2PA; SP; QL (1 SYR per 28 days)
Treprostinil Remodulin Tier 2 PA; SP; Dual
Tresiba Tier 1
Tresiba FlexTouch Tier 1 M90
Tretinoin External Cream Avita Tier 2 M90
Tretinoin External Gel 0.01 % Retin-A Tier 2 M90
176
Covered Product Reference Tier Status NotesTretinoin External Gel 0.025 % Avita Tier 2 M90
Tretinoin External Gel 0.05 % Atralin Tier 2 ST; M90
Tretinoin Microsphere Retin-A Micro Tier 2 ST; M90
Tretinoin Microsphere Pump Retin-A Micro Tier 2 ST; M90
Tretinoin Oral $0 M90
Tretten Tier 2 PA; SP; Dual
Trexall $0 M90
TriAdvance Inatal GT Tier 1 M90
Triamcinolone Acetonide External Aerosol Solution
Kenalog Tier 2ST; M90; QL (QL Applies)
Triamcinolone Acetonide External Cream Tier 2 M90
Triamcinolone Acetonide External Lotion Tier 2 M90
Triamcinolone Acetonide External Ointment 0.025 %, 0.1 %, 0.5 %
Tier 2 M90
Triamcinolone Acetonide Mouth/Throat Oralone Tier 2 M90
Triamcinolone Acetonide Nasal Aerosol KLS Aller-Cort Tier 2ST; M90; QL (QL Flag)
Triamcinolone Diacetate Injection Suspension 40 MG/ML
Tier 2 M90
Triaminic Allerchews Tier 2 M90
Triamterene Oral Dyrenium Tier 2
Triamterene-HCTZ Maxzide-25 Tier 1 M90
Triazolam Tier 2 M90
TriCare Tier 1 M90
TriCitrasol Tier 2 M90
Tricitrates Tier 2 M90
Tricon Tier 2 M90
Triderm External Cream 0.1 % Tier 2 M90
Trientine HCl Syprine Tier 2 SP
Tri-Estarylla $0 M90
Trifluoperazine HCl Oral Tier 2 M90
Trifluridine Ophthalmic Tier 2 M90
Trihexyphenidyl HCl Oral Tablet Tier 2 M90
Trijardy XR Tier 2 PA
Trikafta Tier 2PA; PD; QL (84 EA per 28 days)
Tri-Legest Fe $0 M90
Tri-Linyah $0 M90
Tri-Lo-Estarylla $0 M90
177
Covered Product Reference Tier Status NotesTri-Lo-Marzia $0 M90
Tri-Lo-Sprintec $0 M90
Triluron Tier 2PA; SP; QL (QL Applies); Dual
TriLyte Tier 2 M90
Trimethobenzamide HCl Oral Tier 2 M90
Trimethoprim Oral Tier 2 M90
Trimipramine Maleate Oral Tier 2 M90
Trinatal GT Inatal GT Tier 1 M90
Trinatal Rx 1 Vinate One $0 M90
Trinate $0 M90
TriNessa (28) $0 M90
TriNessa Lo $0 M90
Trintellix Tier 2ST; M90; QL (30 EA per 90 days)
Tri-Previfem $0 M90
Triptodur MB PA
Trisenox Intravenous Solution 10 MG/10ML
Tier 1 M90
Tri-Sprintec $0 M90
Triumeq Tier 2PD; QL (30 EA per 30 days)
TriVisc Tier 2PA; SP; QL (QL Applies); Dual
Tri-Vit/Fluoride Tier 2 M90
Tri-Vit/Fluoride/Iron Tier 2 M90
Tri-Vitamin/Fluoride Tier 2 M90
Trivora (28) $0 M90
Trogarzo MB PA
Trokendi XR Tier 2 ST; M90
Tropical Liquid Nutrition BProtected Multi-Vite Tier 2 M90
Tropicamide Ophthalmic Tier 2 M90
Trospium Chloride Tier 2M90; QL (60 EA per 30 days)
Trospium Chloride ER Tier 2M90; QL (30 EA per 90 days)
Trulance Tier 2PA; QL (30 EA per 30 days)
Trulicity Subcutaneous Solution Pen-Injector 0.75 MG/0.5ML, 1.5 MG/0.5ML
Tier 2PD; QL (4 pens per 28 days)
178
Covered Product Reference Tier Status NotesTrumenba $0 M90
Truxima $0 PA; SP; Dual
Tudorza Pressair Inhalation Aerosol Powder Breath Activated 400 MCG/ACT
Tier 2 M90
Tukysa $0SP; QL (120 EA per 30 days)
Tums Freshers Tier 2 M90
Tums Smoothies Tier 2 M90
Turalio $0 PA
Tusnel Oral Capsule Tier 2 M90
T-Vites ABC Plus Senior Tier 2 M90
Twinrix Intramuscular Suspension 720-20 $0 M90
Tybost Tier 2QL (30 EA per 90 days)
Tykerb $0SP; BP; QL (180 EA per 30 days)
Tymlos Tier 2 PA
Typhim VI Intramuscular Solution 25 MCG/0.5ML
$0 M90
Tysabri Tier 2PA; SP; QL (300 mg/15 ml per 28 days); Dual
Tyvaso Tier 2PA; SP; QL (81.2 ml (28 amps) per 28 days)
Tyvaso Refill Tier 2 PA; SP; QL (QL Flag)
Tyvaso Starter Tier 2 PA; SP; QL (QL Flag)
Tyzine Nasal Solution 0.05 % Tier 2 M90
Uceris Rectal Tier 2 M90; QL (QL Flag)
Udamin SP Tier 2 M90
Udenyca Tier 2SP; Dual; QL (2 SYR per 28 days)
Ulesfia Tier 2 M90
UltiCare Micro Pen Needles 31G X 8 MM , 32G X 4 MM
$0 M90
UltiCare Mini Pen Needles 31G X 6 MM $0 M90
UltiCare Pen Needles 29G X 12.7MM $0 M90
UltiCare Short Pen Needles 31G X 8 MM $0 M90
UltiGuard SafePack Pen Needle 32G X 4 MM
BD Pen Needle Nano U/F $0 M90
Ultilet Pen Needle 31G X 5 MM , 31G X 8 MM , 32G X 4 MM
$0 M90
179
Covered Product Reference Tier Status NotesUltomiris MB PA
Ultra Antioxidant Formula ABC Plus Senior Tier 2 M90
Ultra Freeda ABC Plus Senior Tier 2 M90
Ultra Freeda/Iron ABC Plus Senior Tier 2 M90
Ultra Multi Formula/Iron DEKAs Plus Tier 2 M90
Ultra-Thin II Mini Pen Needle $0 M90
Ultra-Thin II Pen Needle Short $0 M90
Ultra-Thin II Pen Needles $0 M90
Unicomplex-M ABC Plus Senior Tier 2 M90
Unifine Pentips 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM
$0 M90
Unifine Pentips Plus 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM
$0 M90
Unithroid Tier 2 M90
Unithroid Direct Tier 2 M90
UPCal D Oral Packet 500-500 MG-UNIT Tier 2 M90
UPCal D Oral Powder 500-500 MG-UNT/5GM
Tier 2 M90
Uplizna Tier 2PA; SP; Dual; QL (30 ML per 180 days)
Uptravi Oral Tier 2 PA; SP; QL (QL Flag)
Urea External Cream 39 % Uredeb Tier 2 M90
Urea External Cream 40 %, 45 %, 50 % Tier 2 M90
Urea External Cream 47 % Keralac Tier 2 M90
Urea External Gel Tier 2 M90
Urea External Suspension 40 % Tier 2 M90
Urea Nail Film Tier 2 M90
Ure-K Tier 2 M90
Uretron D/S Oral Tablet Tier 2 M90
Urin DS Oral Tablet Tier 2 M90
Uro-Mag Tier 2 M90
Ursodiol Oral Capsule 300 MG Tier 2 M90
Ursodiol Oral Tablet Urso 250 Tier 2 M90
Utibron Neohaler Tier 2QL (60 EA per 30 days)
Uvadex Tier 1 M90
Vagistat-3 Tier 2 M90
valACYclovir HCl Oral Valtrex Tier 2 M90
180
Covered Product Reference Tier Status NotesValchlor $0 M90
ValGANciclovir HCl Valcyte Tier 2 M90
Valproate Sodium Intravenous Tier 2 M90
Valproate Sodium Oral Syrup Tier 2 M90
Valproic Acid Oral Capsule Tier 2 M90
Valproic Acid Oral Solution Tier 2 M90
Valrubicin Valstar $0 SP
Valsartan Diovan Tier 1 M90
Valsartan-Hydrochlorothiazide Diovan HCT Tier 1 M90
Valtoco 10 MG Dose Tier 2PA; QL (5 BOXES per 30 days)
Valtoco 15 MG Dose Tier 2PA; QL (5 BOXES per 30 days)
Valtoco 20 MG Dose Tier 2PA; QL (5 BOXES per 30 days)
Valtoco 5 MG Dose Tier 2PA; QL (5 BOXES per 30 days)
ValuMark Pen Needles CareFine Pen Needles $0 M90
Vancomycin HCl Intravenous Solution Reconstituted 5000 MG
Tier 2 M90
Vancomycin HCl Oral Capsule Vancocin HCl Tier 2 M90
Vanicream External Lotion Tier 2 M90
Vantas $0 SP; QL (QL Flag)
Vaqta Intramuscular Suspension 25 UNIT/0.5ML, 50 UNIT/ML
$0 M90
Varivax $0 M90
Varubi Intravenous Tier 2
Varubi Oral Tier 2 M90; QL (QL Flag)
Vascepa Oral Capsule 0.5 GM Tier 2PA; QL (120 EA per 30 days)
Vaxchora $0 M90
V-C Forte DEKAs Plus Tier 2 M90
VCF Vaginal Contraceptive $0 M90
Vectibix Intravenous Solution 100 MG/5ML, 400 MG/20ML
$0 SP
Velcade Injection $0PA; SP; QL (QL Flag); Dual
Velivet $0 M90
Venclexta $0 M90
Venclexta Starting Pack $0 M90
181
Covered Product Reference Tier Status Notes
Venlafaxine HCl Tier 2M90; QL (90 EA per 30 days)
Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour
Effexor XR Tier 2M90; QL (60 EA per 30 days)
Venlafaxine HCl ER Oral Tablet Extended Release 24 Hour 150 MG, 37.5 MG, 75 MG
Tier 2M90; QL (60 EA per 30 days)
Venlafaxine HCl ER Oral Tablet Extended Release 24 Hour 225 MG
Tier 2 QL (QL Applies)
Ventavis Tier 2PA; SP; QL (270 per 30 days)
Ventolin HFA Tier 2 PA
Veracolate Alophen Tier 2 M90
Verapamil HCl ER Oral Capsule Extended Release 24 Hour
Verelan Tier 1 M90
Verapamil HCl ER Oral Tablet Extended Release 120 MG, 180 MG, 240 MG
Calan SR Tier 1 M90
Verapamil HCl Oral Tier 1 M90
Veripred 20 Tier 2 M90
Verquvo Tier 2PA; QL (30 EA per 30 days)
Verzenio $0 SP; QL (QL Applies)
Vestura $0 M90
V-Go 20 Tier 2PA; PD; QL (30 EA per 30 days)
V-Go 30 Tier 2PA; PD; QL (30 EA per 30 days)
V-Go 40 Tier 2PA; PD; QL (30 EA per 30 days)
Viberzi Tier 2PA; M90; QL (60 EA per 30 days)
Vibramycin Oral Syrup Tier 2 M90
Vicks Humidifier Tier 1 M90
Vicks Warm Mist Humidifier $0M90; QL (QL Flag); QL (1 EA per 1 Year)
Vicodin ES Oral Tablet 7.5-300 MG Tier 2QL (180 EA per 30 days)
Vicodin HP Oral Tablet 10-300 MG Tier 2QL (180 EA per 30 days)
Vicodin Oral Tablet 5-300 MG Tier 2QL (240 tablets per 30 days. Click;HERE)
Victoza Subcutaneous Solution Pen-Injector
Tier 2QL (3 pens per 28 days)
182
Covered Product Reference Tier Status NotesVida Mia Unifine Pentips $0 M90
Videx Tier 2QL (1200 ml per 30 days)
Vienva $0 M90
Vigabatrin Sabril Tier 2PA; SP; QL (180 EA per 30 days)
Vigamox Tier 2 M90
Viibryd Oral Tablet Tier 2ST; M90; QL (30 EA per 90 days)
Viibryd Starter Pack Tier 2 ST; M90
Viltepso MB PA
Vimizim MB PA
Vimpat Oral Solution Tier 2M90; QL (60ml per month)
Vimpat Oral Tablet Tier 2M90; QL (60 EA per 30 days)
Vinate M $0 M90
Vinate One $0 M90
VinBLAStine Sulfate Intravenous Solution
$0 M90
Vincasar PFS $0 M90
vinCRIStine Sulfate Intravenous $0 M90
Vinorelbine Tartrate Navelbine $0 M90
Viokace Tier 2 M90
Viorele Kariva $0 M90
Viracept Oral Tablet 250 MG Tier 2 QL (300 per 30 days)
Viracept Oral Tablet 625 MG Tier 2QL (120 EA per 30 days)
Viread Oral Powder Tier 2 QL (QL Applies)
Viread Oral Tablet 150 MG, 200 MG, 250 MG
Tier 2QL (30 EA per 90 days)
Virt Nate Trinate $0 M90
Virt-Advance Inatal GT Tier 1 M90
Virt-Phos 250 Neutral Phospha 250 Neutral Tier 2 M90
Virtrate-2 Tier 2 M90
Virtrate-3 Tier 2 M90
Virtrate-K Tier 2 M90
Virt-Vite GT Inatal GT Tier 1 M90
Visco-3 Intra-Articular Solution Prefilled Syringe
Tier 2PA; SP; QL (QL Applies); Dual
183
Covered Product Reference Tier Status NotesVisine-A Tier 2 M90
Vision Formula/Lutein ABC Plus Senior Tier 2 M90
Vision Plus DEKAs Plus Tier 2 M90
Vision Vitamins ABC Plus Senior Tier 2 M90
VisiVites ABC Plus Senior Tier 2 M90
VisiVites/Lutein ABC Plus Senior Tier 2 M90
Vit B3-AzelAc-Turm-FA-B6-Zn-CU ABC Plus Senior Tier 2 M90
Vita Hair ABC Plus Senior Tier 2 M90
Vitabasic Complete ABC Plus Senior Tier 2 M90
Vitabasic Senior ABC Plus Senior Tier 2 M90
Vitabex DEKAs Plus Tier 2 M90
VitaJoy Daily D Gummies Tier 2 M90
Vita-Min DEKAs Plus Tier 2 M90
Vitamin B-6 (pyridoxine) Tablet 100 MG Oral Oral Tablet 100 MG, 25 MG, 250 MG, 50 MG
Tier 2 M90
Vitamin B-6 (pyridoxine) Tablet 25 MG Oral Oral Tablet 100 MG, 25 MG, 250 MG, 50 MG
Tier 2 M90
Vitamin B6 (pyridoxine) TABLET 250 MG ORAL Oral Tablet 200 MG, 250 MG
Tier 2 M90
Vitamin B-6 (pyridoxine) Tablet 50 MG Oral Oral Tablet 100 MG, 25 MG, 250 MG, 50 MG
Tier 2 M90
Vitamin D (Cholecalciferol) Oral Capsule 25 MCG (1000 UT)
Pronutrients Vitamin D3 Tier 2 M90
Vitamin D (Cholecalciferol) Oral Tablet 25 MCG (1000 UT)
Vitamin D-1000 Max St Tier 2 M90
Vitamin D (cholecalciferol) Tablet 50 MCG (2000 UT) Oral Oral Capsule 50 MCG (2000 UT)
Tier 2 M90
Vitamin D (cholecalciferol) Tablet 50 MCG (2000 UT) Oral Oral Tablet 1000 UNIT
Vitamin D-1000 Max St Tier 2 M90
Vitamin D (cholecalciferol) Tablet 50 MCG (2000 UT) Oral Oral Tablet 50 MCG (2000 UT)
Thera-D 2000 Tier 2 M90
Vitamin D-1000 Max St Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Capsule 1.25 MG (50000 UT)
D3-50 Tier 2 M90
184
Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Capsule 125 MCG (5000 UT)
Dialyvite Vitamin D 5000 Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Capsule 25 MCG (1000 UT)
Pronutrients Vitamin D3 Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Capsule 250 MCG (10000 UT)
Decara Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Capsule 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Liquid 5000 UNIT/ML
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Tablet 1.25 MG (50000 UT)
Dialyvite Vitamin D3 Max
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Tablet 125 MCG (5000 UT)
Radiance Platinum Vitamin D3
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Tablet 25 MCG (1000 UT)
Vitamin D-1000 Max St Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Tablet 50 MCG (2000 UT)
Thera-D 2000 Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Tablet Chewable 125 MCG (5000 UT)
Opurity Vitamin D Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Tablet Chewable 25 MCG (1000 UT)
VitaJoy Daily D Gummies
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 1.25 MG (50000 UT) Oral Oral Tablet Chewable 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Capsule 1.25 MG (50000 UT)
D3-50 Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Capsule 125 MCG (5000 UT)
Dialyvite Vitamin D 5000 Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Capsule 25 MCG (1000 UT)
Pronutrients Vitamin D3 Tier 2 M90
185
Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Capsule 250 MCG (10000 UT)
Decara Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Capsule 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Liquid 5000 UNIT/ML
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Tablet 1.25 MG (50000 UT)
Dialyvite Vitamin D3 Max
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Tablet 125 MCG (5000 UT)
Radiance Platinum Vitamin D3
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Tablet 25 MCG (1000 UT)
Vitamin D-1000 Max St Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Tablet 50 MCG (2000 UT)
Thera-D 2000 Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Tablet Chewable 125 MCG (5000 UT)
Opurity Vitamin D Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Tablet Chewable 25 MCG (1000 UT)
VitaJoy Daily D Gummies
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 10 MCG (400 UNIT) Oral Oral Tablet Chewable 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 25 MCG (1000 UT) Oral Oral Capsule 1.25 MG (50000 UT)
D3-50 Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 25 MCG (1000 UT) Oral Oral Capsule 125 MCG (5000 UT)
Dialyvite Vitamin D 5000 Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 25 MCG (1000 UT) Oral Oral Capsule 25 MCG (1000 UT)
Pronutrients Vitamin D3 Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 25 MCG (1000 UT) Oral Oral Capsule 250 MCG (10000 UT)
Decara Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 25 MCG (1000 UT) Oral Oral Capsule 50 MCG (2000 UT)
Tier 2 M90
186
Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Capsule 25 MCG (1000 UT) Oral Oral Liquid 5000 UNIT/ML
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 25 MCG (1000 UT) Oral Oral Tablet 1.25 MG (50000 UT)
Dialyvite Vitamin D3 Max
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 25 MCG (1000 UT) Oral Oral Tablet 125 MCG (5000 UT)
Radiance Platinum Vitamin D3
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 25 MCG (1000 UT) Oral Oral Tablet 25 MCG (1000 UT)
Vitamin D-1000 Max St Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 25 MCG (1000 UT) Oral Oral Tablet 50 MCG (2000 UT)
Thera-D 2000 Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 25 MCG (1000 UT) Oral Oral Tablet Chewable 125 MCG (5000 UT)
Opurity Vitamin D Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 25 MCG (1000 UT) Oral Oral Tablet Chewable 25 MCG (1000 UT)
VitaJoy Daily D Gummies
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 25 MCG (1000 UT) Oral Oral Tablet Chewable 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 250 MCG (10000 UT) Oral Oral Capsule 1.25 MG (50000 UT)
D3-50 Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 250 MCG (10000 UT) Oral Oral Capsule 125 MCG (5000 UT)
Dialyvite Vitamin D 5000 Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 250 MCG (10000 UT) Oral Oral Capsule 25 MCG (1000 UT)
Pronutrients Vitamin D3 Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 250 MCG (10000 UT) Oral Oral Capsule 250 MCG (10000 UT)
Decara Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 250 MCG (10000 UT) Oral Oral Capsule 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 250 MCG (10000 UT) Oral Oral Liquid 5000 UNIT/ML
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 250 MCG (10000 UT) Oral Oral Tablet 1.25 MG (50000 UT)
Dialyvite Vitamin D3 Max
Tier 2 M90
187
Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Capsule 250 MCG (10000 UT) Oral Oral Tablet 125 MCG (5000 UT)
Radiance Platinum Vitamin D3
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 250 MCG (10000 UT) Oral Oral Tablet 25 MCG (1000 UT)
Vitamin D-1000 Max St Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 250 MCG (10000 UT) Oral Oral Tablet 50 MCG (2000 UT)
Thera-D 2000 Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 250 MCG (10000 UT) Oral Oral Tablet Chewable 125 MCG (5000 UT)
Opurity Vitamin D Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 250 MCG (10000 UT) Oral Oral Tablet Chewable 25 MCG (1000 UT)
VitaJoy Daily D Gummies
Tier 2 M90
Vitamin D3 (cholecalciferol) Capsule 250 MCG (10000 UT) Oral Oral Tablet Chewable 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Capsule 1.25 MG (50000 UT)
D3-50 Tier 2 M90
Vitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Capsule 125 MCG (5000 UT)
Dialyvite Vitamin D 5000 Tier 2 M90
Vitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Capsule 25 MCG (1000 UT)
Pronutrients Vitamin D3 Tier 2 M90
Vitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Capsule 250 MCG (10000 UT)
Decara Tier 2 M90
Vitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Capsule 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Liquid 5000 UNIT/ML
Tier 2 M90
Vitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Tablet 1.25 MG (50000 UT)
Dialyvite Vitamin D3 Max
Tier 2 M90
Vitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Tablet 125 MCG (5000 UT)
Radiance Platinum Vitamin D3
Tier 2 M90
Vitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Tablet 25 MCG (1000 UT)
Vitamin D-1000 Max St Tier 2 M90
188
Covered Product Reference Tier Status NotesVitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Tablet 50 MCG (2000 UT)
Thera-D 2000 Tier 2 M90
Vitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Tablet Chewable 125 MCG (5000 UT)
Opurity Vitamin D Tier 2 M90
Vitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Tablet Chewable 25 MCG (1000 UT)
VitaJoy Daily D Gummies
Tier 2 M90
Vitamin D3 (Cholecalciferol) Capsule 50 MCG (2000 UT) Oral Oral Tablet Chewable 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Capsule 1.25 MG (50000 UT)
D3-50 Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Capsule 125 MCG (5000 UT)
Dialyvite Vitamin D 5000 Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Capsule 25 MCG (1000 UT)
Pronutrients Vitamin D3 Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Capsule 250 MCG (10000 UT)
Decara Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Capsule 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Liquid 5000 UNIT/ML
Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Tablet 1.25 MG (50000 UT)
Dialyvite Vitamin D3 Max
Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Tablet 125 MCG (5000 UT)
Radiance Platinum Vitamin D3
Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Tablet 25 MCG (1000 UT)
Vitamin D-1000 Max St Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Tablet 50 MCG (2000 UT)
Thera-D 2000 Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Tablet Chewable 125 MCG (5000 UT)
Opurity Vitamin D Tier 2 M90
189
Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Tablet Chewable 25 MCG (1000 UT)
VitaJoy Daily D Gummies
Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 400 UNIT/ML Oral Oral Tablet Chewable 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 5000 UNIT/ML Oral Oral Capsule 1.25 MG (50000 UT)
D3-50 Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 5000 UNIT/ML Oral Oral Capsule 125 MCG (5000 UT)
Dialyvite Vitamin D 5000 Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 5000 UNIT/ML Oral Oral Capsule 25 MCG (1000 UT)
Pronutrients Vitamin D3 Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 5000 UNIT/ML Oral Oral Capsule 250 MCG (10000 UT)
Decara Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 5000 UNIT/ML Oral Oral Capsule 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 5000 UNIT/ML Oral Oral Liquid 5000 UNIT/ML
Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 5000 UNIT/ML Oral Oral Tablet 1.25 MG (50000 UT)
Dialyvite Vitamin D3 Max
Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 5000 UNIT/ML Oral Oral Tablet 125 MCG (5000 UT)
Radiance Platinum Vitamin D3
Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 5000 UNIT/ML Oral Oral Tablet 25 MCG (1000 UT)
Vitamin D-1000 Max St Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 5000 UNIT/ML Oral Oral Tablet 50 MCG (2000 UT)
Thera-D 2000 Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 5000 UNIT/ML Oral Oral Tablet Chewable 125 MCG (5000 UT)
Opurity Vitamin D Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 5000 UNIT/ML Oral Oral Tablet Chewable 25 MCG (1000 UT)
VitaJoy Daily D Gummies
Tier 2 M90
Vitamin D3 (cholecalciferol) Liquid 5000 UNIT/ML Oral Oral Tablet Chewable 50 MCG (2000 UT)
Tier 2 M90
190
Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Tablet 1.25 MG (50000 UT) Oral Oral Capsule 1.25 MG (50000 UT)
D3-50 Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 1.25 MG (50000 UT) Oral Oral Capsule 125 MCG (5000 UT)
Dialyvite Vitamin D 5000 Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 1.25 MG (50000 UT) Oral Oral Capsule 25 MCG (1000 UT)
Pronutrients Vitamin D3 Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 1.25 MG (50000 UT) Oral Oral Capsule 250 MCG (10000 UT)
Decara Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 1.25 MG (50000 UT) Oral Oral Capsule 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 1.25 MG (50000 UT) Oral Oral Liquid 5000 UNIT/ML
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 1.25 MG (50000 UT) Oral Oral Tablet 1.25 MG (50000 UT)
Dialyvite Vitamin D3 Max
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 1.25 MG (50000 UT) Oral Oral Tablet 125 MCG (5000 UT)
Radiance Platinum Vitamin D3
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 1.25 MG (50000 UT) Oral Oral Tablet 25 MCG (1000 UT)
Vitamin D-1000 Max St Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 1.25 MG (50000 UT) Oral Oral Tablet 50 MCG (2000 UT)
Thera-D 2000 Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 1.25 MG (50000 UT) Oral Oral Tablet Chewable 125 MCG (5000 UT)
Opurity Vitamin D Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 1.25 MG (50000 UT) Oral Oral Tablet Chewable 25 MCG (1000 UT)
VitaJoy Daily D Gummies
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 1.25 MG (50000 UT) Oral Oral Tablet Chewable 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Capsule 1.25 MG (50000 UT)
D3-50 Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Capsule 125 MCG (5000 UT)
Dialyvite Vitamin D 5000 Tier 2 M90
191
Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Capsule 25 MCG (1000 UT)
Pronutrients Vitamin D3 Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Capsule 250 MCG (10000 UT)
Decara Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Capsule 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Liquid 5000 UNIT/ML
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Tablet 1.25 MG (50000 UT)
Dialyvite Vitamin D3 Max
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Tablet 125 MCG (5000 UT)
Radiance Platinum Vitamin D3
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Tablet 25 MCG (1000 UT)
Vitamin D-1000 Max St Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Tablet 50 MCG (2000 UT)
Thera-D 2000 Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Tablet Chewable 125 MCG (5000 UT)
Opurity Vitamin D Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Tablet Chewable 25 MCG (1000 UT)
VitaJoy Daily D Gummies
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 10 MCG (400 UNIT) Oral Oral Tablet Chewable 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Capsule 1.25 MG (50000 UT)
D3-50 Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Capsule 125 MCG (5000 UT)
Dialyvite Vitamin D 5000 Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Capsule 25 MCG (1000 UT)
Pronutrients Vitamin D3 Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Capsule 250 MCG (10000 UT)
Decara Tier 2 M90
192
Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Capsule 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Liquid 5000 UNIT/ML
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Tablet 1.25 MG (50000 UT)
Dialyvite Vitamin D3 Max
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Tablet 125 MCG (5000 UT)
Radiance Platinum Vitamin D3
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Tablet 25 MCG (1000 UT)
Vitamin D-1000 Max St Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Tablet 50 MCG (2000 UT)
Thera-D 2000 Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Tablet Chewable 125 MCG (5000 UT)
Opurity Vitamin D Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Tablet Chewable 25 MCG (1000 UT)
VitaJoy Daily D Gummies
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 125 MCG (5000 UT) Oral Oral Tablet Chewable 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 25 MCG (1000 UT) Oral Oral Capsule 1.25 MG (50000 UT)
D3-50 Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 25 MCG (1000 UT) Oral Oral Capsule 125 MCG (5000 UT)
Dialyvite Vitamin D 5000 Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 25 MCG (1000 UT) Oral Oral Capsule 25 MCG (1000 UT)
Pronutrients Vitamin D3 Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 25 MCG (1000 UT) Oral Oral Capsule 250 MCG (10000 UT)
Decara Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 25 MCG (1000 UT) Oral Oral Capsule 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 25 MCG (1000 UT) Oral Oral Liquid 5000 UNIT/ML
Tier 2 M90
193
Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Tablet 25 MCG (1000 UT) Oral Oral Tablet 1.25 MG (50000 UT)
Dialyvite Vitamin D3 Max
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 25 MCG (1000 UT) Oral Oral Tablet 125 MCG (5000 UT)
Radiance Platinum Vitamin D3
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 25 MCG (1000 UT) Oral Oral Tablet 25 MCG (1000 UT)
Vitamin D-1000 Max St Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 25 MCG (1000 UT) Oral Oral Tablet 50 MCG (2000 UT)
Thera-D 2000 Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 25 MCG (1000 UT) Oral Oral Tablet Chewable 125 MCG (5000 UT)
Opurity Vitamin D Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 25 MCG (1000 UT) Oral Oral Tablet Chewable 25 MCG (1000 UT)
VitaJoy Daily D Gummies
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet 25 MCG (1000 UT) Oral Oral Tablet Chewable 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Capsule 1.25 MG (50000 UT)
D3-50 Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Capsule 125 MCG (5000 UT)
Dialyvite Vitamin D 5000 Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Capsule 25 MCG (1000 UT)
Pronutrients Vitamin D3 Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Capsule 250 MCG (10000 UT)
Decara Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Capsule 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Liquid 5000 UNIT/ML
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Tablet 1.25 MG (50000 UT)
Dialyvite Vitamin D3 Max
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Tablet 125 MCG (5000 UT)
Radiance Platinum Vitamin D3
Tier 2 M90
194
Covered Product Reference Tier Status NotesVitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Tablet 25 MCG (1000 UT)
Vitamin D-1000 Max St Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Tablet 50 MCG (2000 UT)
Thera-D 2000 Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Tablet Chewable 125 MCG (5000 UT)
Opurity Vitamin D Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Tablet Chewable 25 MCG (1000 UT)
VitaJoy Daily D Gummies
Tier 2 M90
Vitamin D3 (cholecalciferol) Tablet Chewable 25 MCG (1000 UT) Oral Oral Tablet Chewable 50 MCG (2000 UT)
Tier 2 M90
Vitamin D3 Adult GummiesVitaJoy Daily D Gummies
Tier 2 M90
Vitamin D3 Complete ABC Plus Senior Tier 2 M90
Vitamin D3 Maximum Strength Dialyvite Vitamin D 5000 Tier 2 M90
Vitamin D-3 Oral Capsule Pronutrients Vitamin D3 Tier 2 M90
Vitamins A-D-E/Selenium ABC Plus Senior Tier 2 M90
Vitamins/Minerals ABC Plus Senior Tier 2 M90
VitaTRUM Oral Tablet ABC Plus Senior Tier 2 M90
Vitekta Tier 2QL (30 EA per 90 days)
Vitrakvi Oral Capsule $0 PA; SP
Vitrakvi Oral Solution $0 PA
VITRUM 50+ Senior Multi ABC Plus Senior Tier 2 M90
Vivitrol Tier 2QL (1 VIAL per 28 days)
Vivotif $0 M90
Vizimpro $0PA; SP; QL (30 EA per 30 days)
Vol-Nate Trinate $0 M90
Vol-Plus Niva-Plus Tier 1 M90
Vol-Tab Rx Prenatabs Rx $0 M90
Vonvendi Tier 2 PA; SP; Dual
Voriconazole Oral Vfend Tier 2 M90
Vosevi Tier 2PA; SP; QL (28 EA per 28 days)
Votrient $0PA; SP; QL (120 EA per 30 days)
195
Covered Product Reference Tier Status NotesVpriv MB PA
VP-ZEL ABC Plus Senior Tier 2 M90
Vraylar Oral Capsule 1.5 MG Tier 2M90; QL (60 EA per 30 days)
Vraylar Oral Capsule 3 MG, 4.5 MG, 6 MG
Tier 2M90; QL (30 EA per 90 days)
Vumerity Tier 2PA; SP; QL (120 EA per 30 days)
Vumerity (Starter) Tier 2PA; SP; QL (120 EA per 30 days)
Vyepti MB PA
Vyfemla $0 M90
Vyndamax Tier 2PA; SP; QL (30 EA per 30 days)
Vyndaqel Tier 2PA; SP; QL (120 EA per 30 days)
Vyondys 53 MB PA
Vyvanse Tier 2PD; QL (60 EA per 30 days)
Wal-Dram II Tier 2 M90
Wal-Dryl Allergy Tier 2 M90
Wal-Dryl Allergy Childrens Tier 2 M90
Wal-Fex Allergy Tier 2 M90; QL (QL Flag)
Wal-Fex Childrens Tier 2M90; QL (300ml per month)
Wal-Fex D Allergy & Congestion Oral Tablet Extended Release 12 Hour
Tier 2 M90; QL (QL Flag)
Wal-Fex D Allergy & Congestion Oral Tablet Extended Release 24 Hour
Tier 2M90; QL (30 EA per 90 days)
Wal-finate Tier 2 M90
Wal-itin Allergy Reditabs Tier 2 M90
Wal-itin Aller-Melts Tier 2 M90
Wal-itin Childrens Tier 2M90; QL (300ml per month)
Wal-itin Oral Syrup Tier 2M90; QL (300ml per month)
Wal-itin Oral Tablet Tier 2 M90; QL (QL Flag)
Wal-itin Oral Tablet Dispersible Tier 2 M90
Wal-phed Tier 2 M90
Wal-Profen Oral Tablet Tier 2 M90
Wal-Tap Childrens Tier 2 M90; QL (QL Flag)
196
Covered Product Reference Tier Status NotesWal-Tussin Pediatric Cgh/Cold Tier 2 M90
Wal-vert Tier 2 M90
Wal-Zan 150 Maximum Strength Tier 2 M90
Wal-Zan 75 Tier 2 M90
Wal-Zyr All Day Allergy Child Tier 2 M90; QL (QL Flag)
Wal-Zyr Childrens Oral Solution Tier 2 M90; QL (QL Flag)
Wal-Zyr Childrens Oral Tablet Chewable 10 MG
Tier 2 M90; QL (QL Flag)
Wal-Zyr Childrens Oral Tablet Chewable 5 MG
Tier 2M90; QL (30 EA per 90 days)
Wal-Zyr Ophthalmic Tier 2 M90; QL (QL Flag)
Wal-Zyr Oral Tablet Tier 2 M90; QL (QL Flag)
Warfarin Sodium Oral Jantoven Tier 2 M90
Wee Care Icar Tier 1 M90
Wegmans Unifine Pentips PlusAdvocate Insulin Pen Needles
$0 M90
Wera $0 M90
Westhroid Oral Tablet 130 MG, 195 MG, 32.5 MG, 65 MG, 97.5 MG
Tier 2 M90
Whole Food Multivitamin ABC Plus Senior Tier 2 M90
Wibi Tier 2 M90
Wide-Seal Diaphragm 60 Tier 2 M90
Wide-Seal Diaphragm 65 Tier 2 M90
Wide-Seal Diaphragm 70 Tier 2 M90
Wide-Seal Diaphragm 75 Tier 2 M90
Wide-Seal Diaphragm 80 Tier 2 M90
Wide-Seal Diaphragm 85 Tier 2 M90
Wide-Seal Diaphragm 90 Tier 2 M90
Wide-Seal Diaphragm 95 Tier 2 M90
Wilate Intravenous Kit Tier 2 PA; SP; Dual
Wixela Inhub Tier 2
Womans Laxative Oral Tablet Delayed Release
Alophen Tier 2 M90
Womens 50+ Advanced DEKAs Plus Tier 2 M90
Womens 50+ Multi Vitamin/Min ABC Plus Senior Tier 2 M90
Womens Biomultiple ABC Plus Senior Tier 2 M90
Womens Daily Form/FA/Ca/Fe ABC Plus Senior Tier 2 M90
Womens Daily Formula ABC Plus Senior Tier 2 M90
Womens Laxative Alophen Tier 2 M90
197
Covered Product Reference Tier Status NotesWomens Multi DEKAs Plus Tier 2 M90
Womens Multi Vitamin & Mineral ABC Plus Senior Tier 2 M90
Womens One Daily ABC Plus Senior Tier 2 M90
WP Thyroid Tier 2 M90
Wymzya Fe $0 M90
Xadago Tier 2 PA
Xalkori $0SP; QL (60 EA per 30 days)
Xarelto Oral Tablet 10 MG, 15 MG, 20 MG
Tier 2
Xarelto Oral Tablet 2.5 MG Tier 2 PA
Xarelto Starter Pack Tier 2QL (51 EA per 28 days)
Xatmep $0PA; QL (60 ML per 30 days)
Xcopri Tier 2
Xcopri (250 MG Daily Dose) Tier 2
Xcopri (350 MG Daily Dose) Tier 2
Xelitral Tier 2 M90
Xeljanz Oral Solution Tier 2PA; SP; QL (300 ML per 30 days)
Xeljanz Oral Tablet Tier 2PA; SP; PD; QL (60 EA per 30 days)
Xeljanz XR Tier 2PA; SP; PD; QL (30 EA per 30 days)
Xembify Tier 2 PA; SP; Dual
Xenleta Oral Tier 2PA; SP; QL (10 EA per 5 days)
Xeomin Tier 2PA; SP; QL (QL Flag); Dual
Xermelo Tier 2 PA
Xgeva Tier 2PA; SP; QL (QL Flag); Dual
Xiaflex Tier 2 PA; SP; QL (QL Flag)
Xifaxan Oral Tablet 200 MG Tier 2M90; QL (9 tablets per 3 days)
Xifaxan Oral Tablet 550 MG Tier 2 PA; M90
Xigduo XR Oral Tablet Extended Release 24 Hour 10-1000 MG, 10-500 MG, 5-500 MG
Tier 2M90; QL (30 EA per 30 days)
Xigduo XR Oral Tablet Extended Release 24 Hour 2.5-1000 MG
Tier 2QL (30 EA per 30 days)
198
Covered Product Reference Tier Status NotesXigduo XR Oral Tablet Extended Release 24 Hour 5-1000 MG
Tier 2M90; QL (60 EA per 60 days)
Xiidra Tier 2 PA; M90
Xofigo Intravenous Solution 30 MCCI/ML
$0 M90
Xofluza (40 MG Dose) Oral Tablet Therapy Pack 2 x 20 MG
Tier 2
Xofluza (80 MG Dose) Oral Tablet Therapy Pack 2 x 40 MG
Tier 2
Xolair Subcutaneous Solution Prefilled Syringe 150 MG/ML
Tier 2PA; SP; Dual; QL (8 SYR per 28 days)
Xolair Subcutaneous Solution Prefilled Syringe 75 MG/0.5ML
Tier 2PA; SP; Dual; QL (2 SYR per 28 days)
Xolair Subcutaneous Solution Reconstituted
Tier 2PA; SP; Dual; QL (8 VIALS per 28 days)
Xolegel Tier 2 ST; M90
Xopenex HFA Tier 2 BP
Xospata $0PA; SP; QL (90 EA per 30 days)
Xpovio (100 MG Once Weekly) Oral Tablet Therapy Pack 20 MG
$0 SP
Xpovio (60 MG Once Weekly) Oral Tablet Therapy Pack 20 MG
$0 SP
Xpovio (80 MG Once Weekly) Oral Tablet Therapy Pack 20 MG
$0 SP
Xpovio (80 MG Twice Weekly) $0 SP
Xtandi Oral Capsule $0SP; QL (120 EA per 30 days)
Xtandi Oral Tablet 40 MG Tier 2SP; QL (120 EA per 30 days)
Xtandi Oral Tablet 80 MG Tier 2SP; QL (60 EA per 30 days)
Xulane $0 M90
Xultophy Tier 2 PA
Xylocaine Dental Injection Solution 2 %-1:100000
Tier 2 M90
Xylon Tier 2M90; QL (50 tablets per 30 days. Click;HERE)
Xyntha Intravenous Kit 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT
Tier 2 PA; SP; PD; Dual
Xyntha Solofuse Tier 2 PA; SP; PD; Dual
Xyrem Tier 2 PA; SP
199
Covered Product Reference Tier Status Notes
Xywav Tier 2PA; QL (540 ML per 30 days)
Yervoy MB PA
YF-VAX $0 M90
YL Vitamin B-6 Tier 2 M90
Yondelis $0 SP
Yupelri Tier 2 PA
Yuvafem Tier 2 M90
Zaclir Cleansing External Lotion 8 % Tier 2 M90
Zafirlukast Accolate Tier 2ST; M90; QL (60 EA per 30 days)
Zaleplon Tier 2QL (30 EA per 90 days)
Zaltrap $0 SP
Zanosar $0 M90
Zantac Injection Solution 150 MG/6ML Tier 2 M90; QL (QL Flag)
Zantac Injection Solution 50 MG/2ML Tier 2 M90
Zarah $0 M90
Zarxio Tier 2 PA; SP; Dual
Zebutal Oral Capsule 50-325-40 MG Tier 2 M90
Zejula Tier 2 PA; SP
Zelapar Tier 2ST; M90; QL (60 EA per 30 days)
Zelboraf $0SP; QL (240 per 30 days)
Zemaira Tier 2 PA; SP; Dual
Zenatane Tier 2 M90
Zenchent $0 M90
Zenchent FE Tier 2 M90
Zenpep Oral Capsule Delayed Release Particles 10000 UNIT, 15000-51000 UNIT, 20000-68000 UNIT, 25000 UNIT, 3000-10000 UNIT, 40000-136000 UNIT, 5000 UNIT
Tier 2 PA; M90
Zenpep Oral Capsule Delayed Release Particles 10000-32000 UNIT, 25000-79000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT
Tier 2
Zenzedi Oral Tablet 10 MG, 5 MG Tier 2 M90; QL (QL Flag)
Zenzedi Oral Tablet 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG
Tier 2PA; QL (90 EA per 30 days)
200
Covered Product Reference Tier Status Notes
Zepatier Tier 2PA; SP; QL (28 EA per 28 days)
Zeposia Tier 2PA; SP; QL (30 EA per 30 days)
Zeposia 7-Day Starter Pack Tier 2PA; SP; QL (7 EA per 7 days)
Zeposia Starter Kit Tier 2PA; SP; QL (30 EA per 30 days)
Zerviate Tier 2ST; QL (30 EA per 5 days)
Zevalin Y-90 $0 M90
Ziagen Oral Solution Tier 2 QL (900 per 30 days)
Zidovudine Retrovir Tier 2 SP; M90
Ziextenzo Tier 2SP; Dual; QL (2 SYR per 28 days)
Zileuton ER Tier 2
Zinc Aspartate Tier 2 M90
Zinc Chelated Tier 2 M90
Zinc Methionate Tier 2 M90
Zinc Oral Capsule 30 MG Tier 2 M90
Zinc Oral Tablet 100 MG, 25 MG Tier 2 M90
Zinc Oral Tablet 50 MG IS-ZC 50 Tier 2 M90
Zinc Oxide External Ointment 20 % Tier 2 M90
Zinc Oxide External Ointment 40 % Boudreauxs Butt Paste Tier 2 M90
Zinc Picolinate Oral Tablet 25 MG Tier 2 M90
Zinc Sulfate Oral Capsule 220 (50 Zn) MG
Orazinc Tier 2 M90
Zinc Sulfate Oral Tablet 220 (50 Zn) MG Tier 2 M90
Zinc-220 Orazinc Tier 2 M90
Zinplava Tier 2 SP
Zioptan Tier 2 ST
Ziprasidone HCl Oral Capsule 20 MG Geodon Tier 2M90; QL (90 EA per 30 days)
Ziprasidone HCl Oral Capsule 40 MG, 60 MG, 80 MG
Geodon Tier 2M90; QL (60 EA per 30 days)
Ziprasidone Mesylate Geodon Tier 2
Zirabev $0 PA; SP; Dual
Zirgan Tier 2 M90
Zithranol Tier 2 M90
Zithranol-RR Tier 2 M90
201
Covered Product Reference Tier Status NotesZodex 12-Day Tier 2
Zokinvy Tier 2PA; SP; QL (120 EA per 30 days)
Zoladex $0 PA; SP; Dual
Zoledronic Acid Intravenous Concentrate Tier 2 PA; SP; Dual
Zoledronic Acid Intravenous Solution Reclast Tier 2 PA; SP; Dual
Zolgensma 10.1-10.5 kg MB PA; PD
Zolgensma 10.6-11.0 kg MB PA; PD
Zolgensma 11.1-11.5 kg MB PA; PD
Zolgensma 11.6-12.0 kg MB PA; PD
Zolgensma 12.1-12.5 kg MB PA; PD
Zolgensma 12.6-13.0 kg MB PA; PD
Zolgensma 13.1-13.5 kg MB PA; PD
Zolgensma 2.6-3.0 kg MB PA; PD
Zolgensma 3.1-3.5 kg MB PA; PD
Zolgensma 3.6-4.0 kg MB PA; PD
Zolgensma 4.1-4.5 kg MB PA; PD
Zolgensma 4.6-5.0 kg MB PA; PD
Zolgensma 5.1-5.5 kg MB PA; PD
Zolgensma 5.6-6.0 kg MB PA; PD
Zolgensma 6.1-6.5 kg MB PA; PD
Zolgensma 6.6-7.0 kg MB PA; PD
Zolgensma 7.1-7.5 kg MB PA; PD
Zolgensma 7.6-8.0 kg MB PA; PD
Zolgensma 8.1-8.5 kg MB PA; PD
Zolgensma 8.6-9.0 kg MB PA; PD
Zolgensma 9.1-9.5 kg MB PA; PD
Zolgensma 9.6-10.0 kg MB PA; PD
Zolinza $0PA; SP; QL (120 EA per 30 days)
ZOLMitriptan Nasal Zomig Tier 2QL (12 EA per 30 days)
ZOLMitriptan Oral Zomig Tier 2M90; QL (12 tablets per month)
Zolpidem Tartrate ER Ambien CR Tier 2ST; QL (30 EA per 30 days)
Zolpidem Tartrate Oral Ambien Tier 2QL (30 EA per 90 days)
Zomacton Tier 2 PA; SP
Zonisamide Oral Zonegran Tier 2 M90
202
Covered Product Reference Tier Status Notes
Zoo Friends Plus IronLand Before Time Multivitamin
Tier 2 M90
Zorbtive Tier 2 PA; SP; QL (QL Flag)
Zortress Tier 2
Zostavax Subcutaneous Solution Reconstituted
Tier 1 M90
Zostrix HP External Cream 0.075 % Tier 2 M90
Zovia 1/35E (28) $0 M90
Zovia 1/50E (28) Tier 2 M90
Zubsolv Tier 2PA; M90; QL (60 EA per 30 days)
Zulresso MB PA
Zyclara Pump External Cream 2.5 % Tier 2ST; M90; QL (1 pump (7.5mg) per 28 days)
Zydelig $0QL (60 EA per 30 days)
Zyflo Tier 2ST; M90; QL (120 EA per 30 days)
Zyflo CR Tier 2ST; M90; QL (QL Flag)
Zykadia $0SP; QL (90 EA per 30 days)
Zylet Tier 2 M90
ZyPREXA Relprevv Tier 2M90; QL (2 VIALS per 28 days)
203
204