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UCare Individual & Family Plan members: 1-877-903-0070 toll free

UCare Individual & Family Plans with M Health Fairview members: 1-877-903-0069 toll free

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2020 Formulary (List of Covered Drugs)• UCare Individual & Family Plans• UCare Individual & Family Plans with M Health Fairview

This formulary may change throughout the year. Please visit ucare.org or call UCare Customer Service for the most current information.

PLEASE READ: This document contains information about the drugs we cover in these plans.

iv UCare Comprehensive Formulary

What is the UCare Formulary?The UCare formulary is a list of generic and brand drugs that are covered by this plan(s). To be covered, the drug must be on our formulary. The most current list of covered drugs can be found on the UCare Individual & Family Plans formulary at ucare.org.

To be covered, you must fill your prescription at a network pharmacy. The Provider Directory and Search Network tool at ucare.org includes in-network pharmacies. You can also visit ucare.org for the most current information.

Over-the-counter (OTC) drugs are usually not covered. They must be prescribed and on our formulary to be covered. This applies to drugs covered as part of the Essential Health Benefits, such as emergency contraception, tobacco cessation and diabetic supplies.

Can the formulary change?Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released.

How do I use the formulary? In the formulary, brand name drugs are capitalized (e.g. DILANTIN) and generic drugs are listed in lowercase italics (e.g. fenofibrate). UCare covers both brand name drugs and generic drugs. A generic drug is approved by the U.S. Food and Drug Administration (FDA) as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs, but work just as well and are equally as safe as the branded product.

How to find prescription drugs in the formulary?There are two ways to find your prescription drugs in the formulary. You can search by category of drug or by alphabetical listing.

Search by Drug CategoryDrugs listed by drug category begin on page 1. The drugs in this formulary are grouped into drug categories depending on the medical conditions they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovasuclar Agents,” If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Search by Alphabetical ListingIf you are not sure what class to look under, you can look for your drug in the Index. The Index gives an alphabetical list of all of the drugs included in the formulary. Both brand name and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information within the formulary.

UCare Comprehensive Formulary v

Tiers and limitations for prescription drugsThe numbers in the Tier column on the prescription drug formulary indicate the cost share for the medication.

Tier 1 Preferred generic drugs that have a Tier 1 copay.

Tier 2 Primarily non-preferred generic drugs that have a Tier 2 copay.

Tier 3 Preferred brand name drugs that have a Tier 3 copay.

Tier 4 Primarily non-preferred brand name drugs that have a Tier 4 copay.

Tier 5 Primarily specialty drugs that have a Tier 5 copay.

PV Preventive drugs that may be eligible for a zero dollar copay.

The abbreviations/symbols in the Limitations (Notes) column on the formulary tell you if UCare has any special requirements or limits on coverage for that drug. Use the key below to help understand the meaning of each abbreviation/symbol.

• PA = Prior authorization – Some drugs require you or your provider to get UCare’s approval before you fill your prescription in order for UCare to cover the drug.

• ST = Step therapy – Even if a drug is on the formulary, you may have to try one or more similar drugs on the formulary before this drug will be covered.

• QL = Quantity limits – There are limits to the amount of some covered drugs you can receive each time you fill a prescription, including limits on refills or dosages. An example of drugs with quantity limits are opioids.

• SP = Specialty drugs – Fairview Specialty Pharmacy (Fairview) is the only network provider of specialty drugs for plan members. Specialty drugs are injectable or oral drugs that often require special handling or monitoring by a pharmacist or nurse. If you use a specialty drug, you or your doctor must contact the specialty pharmacy to order the prescription. Your drug and any needed supplies will be shipped to your home, work or doctor’s office. Fairview also provides clinical support to you and your caregivers. A Fairview pharmacist is on call 24 hours a day if you have an urgent need related to your specialty drug. Call Fairview Specialty Pharmacy at 1-800-595-7140 toll free. TTY users may call the National Relay Center at 711 and ask for 1-800-595-7140.

• PV = May be considered a Preventive Medication with a zero copay.

Eligible Preventive Medication with no Copay

Aspirin For prevention or cardiovascular events

Men: 45 to 79 years old Women: 55 to 79 years old

Aspirin (for pregnant women who are at risk for preeclampsia)

Women under 55 years old

Oral Fluoride Children ages 6 months to 6 yearsFolic Acid Women under 51 years old

vi UCare Comprehensive Formulary

Eligible Preventive Medication with no Copay

Immunizations Recommended ages per the Advisory Committee on Immunization Practices

Tobacco Cessation Men and women age 18 and older who use tobacco products. Prescription products have $0 copay in pharmacy. OTC products available through smoking cessation program.

Bowel Preps Men and women between the ages of 49 and 76 - limit 2 per 365 daysBreast Cancer Prevention

High risk women age 35 and older with no previous diagnosis of breast cancer. Member must contact ESI for copay override.

Contraceptives Women under 51 years old: Please see Member Contract/SBCStatins Low-to Moderate-Dose Statins

Adults 40 -75 years

HIV Prevention All FDA-approved drugs for pre-exposure prophylaxis for HIV negative individuals.

What if my drug is not on the formulary?If your drug is not included in this formulary, you should first contact UCare Customer Service and confirm that your drug is not covered. If you learn that UCare does not cover your drug, you can:

• Ask your doctor to prescribe a similar drug that is covered by UCare.

• Ask UCare to make an exception to cover your drug

Requesting a formulary, step therapy or drug restriction exceptionYou or your doctor can ask UCare to make an exception and cover a non-formulary drug, or remove the step therapy requirements, drug restrictions or limits. For help requesting an exception, call Customer Service at the number on the inside front cover. Or log in to your UCare member account and complete the Exception Request form.

Your doctor must submit a statement supporting the request. If your request is approved, the drug will be covered at the copay or coinsurance amount, based on the drug’s level or tier in the plan formulary. Exception requests for lower cost sharing amounts for drugs on a higher tier will not be granted.

For more informationFor For more detailed information about your UCare prescription drug coverage, please review your Member Contract and other plan materials.

If you have questions, please call the UCare Customer Service number on the front cover or visit ucare.org.

This information is available in other forms to people with disabilities by calling: 612-676-0070 (voice) or toll free at 1-877-903-0070 (voice), 612-676-6810 (TTY) or toll free at 1-800-688-2534.

UCare Individual and Family Plans Comprehensive Formulary (List of Covered Drugs)

Drug Name Tier Limitations (Notes)ANTIHISTAMINE DRUGScarbinoxamine maleate oral liquid 4 mg/5 ml 2

carbinoxamine maleate oral tablet 4 mg 2cetirizine oral solution 1 mg/ml 2clemastine oral tablet 2.68 mg 2cyproheptadine oral syrup 2 mg/5 ml 4cyproheptadine oral tablet 4 mg 2desloratadine oral tablet 5 mg 2desloratadine oral tablet,disintegrating 2.5 mg, 5 mg 2 QL (30 EA per 30 days)

diphenhydramine hcl injection solution 50 mg/ml 2

diphenhydramine hcl oral capsule 50 mg 2hydroxyzine hcl intramuscular solution 25 mg/ml 2

hydroxyzine hcl oral solution 10 mg/5 ml 4hydroxyzine hcl oral solution 10 mg/5 ml (5 ml) 2

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 2

hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 2

levocetirizine oral solution 2.5 mg/5 ml 2levocetirizine oral tablet 5 mg 2meclizine oral tablet 12.5 mg, 25 mg 2promethazine injection solution 25 mg/ml, 50 mg/ml 2

promethazine oral syrup 6.25 mg/5 ml 2promethazine oral tablet 12.5 mg, 25 mg, 50 mg 2

promethazine rectal suppository 12.5 mg, 25 mg 2

ANTI-INFECTIVE AGENTSabacavir oral solution 20 mg/ml 5abacavir oral tablet 300 mg 2abacavir-lamivudine oral tablet 600-300 mg 2

Explanations of Limitations can be found on page v.Effective: March 1, 2020

1

Drug Name Tier Limitations (Notes)abacavir-lamivudine-zidovudine oral tablet300-150-300 mg 2

acyclovir oral capsule 200 mg 2acyclovir oral suspension 200 mg/5 ml 2acyclovir oral tablet 400 mg, 800 mg 2acyclovir sodium intravenous recon soln1,000 mg, 500 mg 5

adefovir oral tablet 10 mg 2 SPAEMCOLO ORAL TABLET,DELAYED RELEASE (DR/EC) 194 MG 4

albendazole oral tablet 200 mg 5ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML 5

amantadine hcl oral capsule 100 mg 2amantadine hcl oral solution 50 mg/5 ml 2amantadine hcl oral tablet 100 mg 2AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG 5

amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml 2

amoxicillin oral capsule 250 mg, 500 mg 1amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml

1

amoxicillin oral tablet 500 mg, 875 mg 1amoxicillin oral tablet,chewable 125 mg, 250 mg 1

amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml

1

amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg 1

amoxicillin-pot clavulanate oral tablet extended release 12 hr 1,000-62.5 mg 1

amoxicillin-pot clavulanate oral tablet,chewable 200-28.5 mg, 400-57 mg 1

amphotericin b injection recon soln 50 mg 2ampicillin oral capsule 250 mg 2ampicillin oral capsule 500 mg 1


Drug Name Tier Limitations (Notes)ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg, 2 gram, 250 mg, 500 mg

2

ampicillin sodium intravenous recon soln 2 gram 2

ampicillin-sulbactam injection recon soln1.5 gram, 15 gram 2

ampicillin-sulbactam intravenous recon soln 1.5 gram, 3 gram 2

APTIVUS (WITH VITAMIN E) ORAL SOLUTION 100 MG/ML 5

APTIVUS ORAL CAPSULE 250 MG 5ARIKAYCE INHALATION SUSPENSION FOR NEBULIZATION 590 MG/8.4 ML 5 PA

atazanavir oral capsule 150 mg, 200 mg, 300 mg 5

atovaquone oral suspension 750 mg/5 ml 2atovaquone-proguanil oral tablet 250-100 mg, 62.5-25 mg 2

ATRIPLA ORAL TABLET 600-200-300 MG 5azithromycin intravenous recon soln 500 mg 2

azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml 1

azithromycin oral tablet 250 mg, 500 mg, 600 mg 1

aztreonam injection recon soln 1 gram, 2 gram 2

bacitracin intramuscular recon soln 50,000 unit 2

BARACLUDE ORAL SOLUTION 0.05 MG/ML 5 SPbenznidazole oral tablet 100 mg, 12.5 mg 2BIKTARVY ORAL TABLET 50-200-25 MG 5CAPASTAT INJECTION RECON SOLN 1 GRAM 4

caspofungin intravenous recon soln 50 mg, 70 mg 5

CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 5 QL (84 ML per 28 days)

cefaclor oral capsule 250 mg, 500 mg 2cefaclor oral tablet extended release 12 hr500 mg 2


3

Drug Name Tier Limitations (Notes)cefadroxil oral capsule 500 mg 2cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml 2

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

cefazolin injection recon soln 1 gram, 10 gram, 100 gram, 20 gram, 300 g, 500 mg 2

cefazolin intravenous recon soln 1 gram 2cefdinir oral capsule 300 mg 2cefdinir oral suspension for reconstitution125 mg/5 ml, 250 mg/5 ml 2

cefditoren pivoxil oral tablet 200 mg 2cefepime injection recon soln 1 gram, 2 gram 2

cefotaxime injection recon soln 1 gram 2cefotetan injection recon soln 1 gram, 2 gram 2

cefotetan intravenous recon soln 10 gram 2cefoxitin in dextrose, iso-osm intravenous piggyback 1 gram/50 ml, 2 gram/50 ml 2

cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram 2

cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml 2

cefpodoxime oral tablet 100 mg, 200 mg 2cefprozil oral suspension for reconstitution125 mg/5 ml, 250 mg/5 ml 2

cefprozil oral tablet 250 mg, 500 mg 2ceftazidime injection recon soln 1 gram, 2 gram, 6 gram 2

ceftriaxone in dextrose,iso-os intravenous piggyback 1 gram/50 ml, 2 gram/50 ml 2

ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg 2

ceftriaxone intravenous recon soln 1 gram, 2 gram 2

cefuroxime axetil oral tablet 250 mg, 500 mg 2

cefuroxime sodium injection recon soln 750 mg 2


Drug Name Tier Limitations (Notes)cefuroxime sodium intravenous recon soln1.5 gram, 7.5 gram 2

cephalexin oral capsule 250 mg, 500 mg 2cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml 2

cephalexin oral tablet 250 mg, 500 mg 2chloramphenicol sod succinate intravenous recon soln 1 gram 2

chloroquine phosphate oral tablet 250 mg, 500 mg 2

cidofovir intravenous solution 75 mg/ml 5CIMDUO ORAL TABLET 300-300 MG 5ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg 1

ciprofloxacin hcl oral tablet 100 mg 2ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg 1

ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml 2

clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml 2

clarithromycin oral tablet 250 mg, 500 mg 2clarithromycin oral tablet extended release 24 hr 500 mg 2

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1

clindamycin phosphate injection solution150 mg/ml 2

clindamycin phosphate intravenous solution 300 mg/2 ml, 600 mg/4 ml, 900 mg/6 ml

2

COARTEM ORAL TABLET 20-120 MG 4colistin (colistimethate na) injection recon soln 150 mg 2

COMPLERA ORAL TABLET 200-25-300 MG 4CRIXIVAN ORAL CAPSULE 200 MG 5dapsone oral tablet 100 mg, 25 mg 2daptomycin intravenous recon soln 500 mg 5DELSTRIGO ORAL TABLET 100-300-300 MG 5

demeclocycline oral tablet 150 mg, 300 mg 2


5

Drug Name Tier Limitations (Notes)DESCOVY ORAL TABLET 200-25 MG 5dicloxacillin oral capsule 250 mg, 500 mg 2didanosine oral capsule,delayed release(dr/ec) 125 mg, 200 mg, 250 mg, 400 mg

5

DIFICID ORAL TABLET 200 MG 4DOVATO ORAL TABLET 50-300 MG 5DOXY-100 INTRAVENOUS RECON SOLN 100 MG 2

doxycycline hyclate oral capsule 100 mg, 50 mg 2

doxycycline hyclate oral tablet 100 mg 2doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg 2

doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg, 75 mg 2

doxycycline monohydrate oral tablet 150 mg, 50 mg, 75 mg 2

E.E.S. 400 ORAL TABLET 400 MG 2EDURANT ORAL TABLET 25 MG 5efavirenz oral capsule 200 mg, 50 mg 2efavirenz oral tablet 600 mg 2EMTRIVA ORAL CAPSULE 200 MG 4EMTRIVA ORAL SOLUTION 10 MG/ML 5entecavir oral tablet 0.5 mg, 1 mg 2ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 250 MG, 333 MG 2

ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG 2

ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG 4

erythromycin ethylsuccinate oral tablet 400 mg 2

erythromycin oral tablet 250 mg, 500 mg 2erythromycin oral tablet,delayed release (dr/ec) 250 mg, 500 mg 2

ethambutol oral tablet 100 mg, 400 mg 2EVOTAZ ORAL TABLET 300-150 MG 5FACTIVE ORAL TABLET 320 MG 4famciclovir oral tablet 125 mg, 500 mg 2 QL (21 EA per 30 days)famciclovir oral tablet 250 mg 2 QL (60 EA per 30 days)Explanations of Limitations can be found on page v.Effective: March 1, 20206

Drug Name Tier Limitations (Notes)fluconazole in dextrose(iso-o) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml 2

fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml 2

fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml 2

fluconazole oral tablet 100 mg, 200 mg, 50 mg 1

fluconazole oral tablet 150 mg 1 QL (6 EA Max Qty Per Fill Retail)

flucytosine oral capsule 250 mg, 500 mg 5fosamprenavir oral tablet 700 mg 2ganciclovir sodium intravenous recon soln500 mg 2

gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 120 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml

2

gentamicin injection solution 20 mg/2 ml, 40 mg/ml 2

gentamicin sulfate (ped) (pf) injection solution 20 mg/2 ml 2

gentamicin sulfate (pf) intravenous solution 60 mg/6 ml 2

GENVOYA ORAL TABLET 150-150-200-10 MG 5

griseofulvin microsize oral suspension 125 mg/5 ml 2

griseofulvin microsize oral tablet 500 mg 2griseofulvin ultramicrosize oral tablet 125 mg, 250 mg 2

hydroxychloroquine oral tablet 200 mg 2imipenem-cilastatin intravenous recon soln250 mg, 500 mg 2

INTELENCE ORAL TABLET 100 MG, 200 MG 4INTELENCE ORAL TABLET 25 MG 5INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)

5 SP

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML 5 SP

INVIRASE ORAL TABLET 500 MG 5


7

Drug Name Tier Limitations (Notes)ISENTRESS HD ORAL TABLET 600 MG 5ISENTRESS ORAL TABLET 400 MG 5ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG 5

isoniazid injection solution 100 mg/ml 2isoniazid oral solution 50 mg/5 ml 2isoniazid oral tablet 100 mg, 300 mg 1itraconazole oral capsule 100 mg 2 QL (30 EA per 30 days)ivermectin oral tablet 3 mg 2JULUCA ORAL TABLET 50-25 MG 5KALETRA ORAL TABLET 100-25 MG, 200-50 MG 5

KETEK ORAL TABLET 300 MG, 400 MG 4KETEK PAK ORAL TABLET 400 MG 4ketoconazole oral tablet 200 mg 2lamivudine oral solution 10 mg/ml 2lamivudine oral tablet 100 mg, 150 mg, 300 mg 2

lamivudine-zidovudine oral tablet 150-300 mg 2

ledipasvir-sofosbuvir oral tablet 90-400 mg 5 PA; SP; QL (28 EA per 28 days)

levofloxacin in d5w intravenous piggyback250 mg/50 ml, 500 mg/100 ml, 750 mg/150 ml

2

levofloxacin intravenous solution 25 mg/ml 2levofloxacin oral solution 250 mg/10 ml 2levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1

LEXIVA ORAL SUSPENSION 50 MG/ML 5linezolid in dextrose 5% intravenous piggyback 600 mg/300 ml 5

linezolid oral suspension for reconstitution100 mg/5 ml 5

linezolid oral tablet 600 mg 2linezolid-0.9% sodium chloride intravenous parenteral solution 600 mg/300 ml 5

lopinavir-ritonavir oral solution 400-100 mg/5 ml 5

MAVYRET ORAL TABLET 100-40 MG 5 PA; SP


Drug Name Tier Limitations (Notes)

MAVYRET ORAL TABLET 100-40 MG 5 PA; SP; QL (84 EA per 28 days)

mefloquine oral tablet 250 mg 2meropenem intravenous recon soln 1 gram, 500 mg 2

methenamine hippurate oral tablet 1 gram 2METRO I.V. INTRAVENOUS PIGGYBACK 500 MG/100 ML 2

metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml 2

metronidazole oral capsule 375 mg 2metronidazole oral tablet 250 mg, 500 mg 2minocycline oral capsule 100 mg, 50 mg, 75 mg 2

minocycline oral tablet 100 mg, 50 mg, 75 mg 2

moxifloxacin oral tablet 400 mg 2MYCAMINE INTRAVENOUS RECON SOLN 100 MG, 50 MG 5

nafcillin injection recon soln 1 gram, 2 gram 2

nafcillin injection recon soln 10 gram 5nafcillin intravenous recon soln 1 gram, 2 gram 2

neomycin oral tablet 500 mg 2nevirapine oral suspension 50 mg/5 ml 2nevirapine oral tablet 200 mg 2nitrofurantoin macrocrystal oral capsule100 mg, 50 mg 2

nitrofurantoin monohyd/m-cryst oral capsule 100 mg 2

nitrofurantoin oral suspension 25 mg/5 ml 2NORVIR ORAL CAPSULE 100 MG 5NORVIR ORAL SOLUTION 80 MG/ML 5NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) 5

NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG 5

nystatin oral suspension 100,000 unit/ml 2nystatin oral tablet 500,000 unit 2ODEFSEY ORAL TABLET 200-25-25 MG 5


9

Drug Name Tier Limitations (Notes)ofloxacin oral tablet 300 mg, 400 mg 2oseltamivir oral capsule 30 mg 2 QL (20 EA per 30 days)oseltamivir oral capsule 45 mg, 75 mg 2 QL (10 EA per 30 days)oseltamivir oral suspension for reconstitution 6 mg/ml 2 QL (180 ML per 30 days)

oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml 5

oxacillin injection recon soln 1 gram, 2 gram 2

oxacillin injection recon soln 10 gram 5oxacillin intravenous recon soln 1 gram, 2 gram 2

paromomycin oral capsule 250 mg 2PEGASYS CONVENIENCE PACK SUBCUTANEOUS KIT 180 MCG/0.5 ML 5

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML 5 SP; QL (4 ML per 21 days)

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML 5 SP; QL (4 EA per 21 days)

penicillin g potassium injection recon soln 5 million unit 2

penicillin g procaine intramuscular syringe1.2 million unit/2 ml 2

penicillin g sodium injection recon soln 5 million unit 2

penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml 2

penicillin v potassium oral tablet 250 mg, 500 mg 1

PIFELTRO ORAL TABLET 100 MG 5piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

2

polymyxin b sulfate injection recon soln500,000 unit 2

posaconazole oral tablet,delayed release (dr/ec) 100 mg 5

praziquantel oral tablet 600 mg 2PREVYMIS INTRAVENOUS SOLUTION 240 MG/12 ML, 480 MG/24 ML 5

PREVYMIS ORAL TABLET 240 MG, 480 MG 5PREZCOBIX ORAL TABLET 800-150 MG-MG 4


Drug Name Tier Limitations (Notes)PREZISTA ORAL SUSPENSION 100 MG/ML 4PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG 5

PRIFTIN ORAL TABLET 150 MG 4PYLERA ORAL CAPSULE 140-125-125 MG 4pyrazinamide oral tablet 500 mg 2quinidine gluconate oral tablet extended release 324 mg 2

quinidine sulfate oral tablet 200 mg, 300 mg 2

quinine sulfate oral capsule 324 mg 2RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION 3 QL (20 EA per 30 days)

RESCRIPTOR ORAL TABLET 200 MG 5RETROVIR INTRAVENOUS SOLUTION 10 MG/ML 5

ribavirin oral capsule 200 mg 2 SPribavirin oral tablet 200 mg 2 SPrifabutin oral capsule 150 mg 2rifampin intravenous recon soln 600 mg 2rifampin oral capsule 150 mg, 300 mg 2RIFATER ORAL TABLET 50-120-300 MG 4rimantadine oral tablet 100 mg 2ritonavir oral tablet 100 mg 2SELZENTRY ORAL SOLUTION 20 MG/ML 5SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG 5

SIRTURO ORAL TABLET 100 MG 5sofosbuvir-velpatasvir oral tablet 400-100 mg 5 PA; SP; QL (28 EA per 28

days)stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg 2

streptomycin intramuscular recon soln 1 gram 4

STRIBILD ORAL TABLET 150-150-200-300 MG 4

sulfadiazine oral tablet 500 mg 2sulfamethoxazole-trimethoprim intravenous solution 400-80 mg/5 ml 2

sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5 ml 2


11

Drug Name Tier Limitations (Notes)sulfamethoxazole-trimethoprim oral tablet400-80 mg, 800-160 mg 1

sulfasalazine oral tablet 500 mg 2sulfasalazine oral tablet,delayed release (dr/ec) 500 mg 2

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG 5 SP

SYMFI LO ORAL TABLET 400-300-300 MG 5SYMFI ORAL TABLET 600-300-300 MG 5SYMTUZA ORAL TABLET 800-150-200-10 MG 5

SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/0.5 ML 5

SYNERCID INTRAVENOUS RECON SOLN 500 MG 5

TEMIXYS ORAL TABLET 300-300 MG 5tenofovir disoproxil fumarate oral tablet300 mg 2

terbinafine hcl oral tablet 250 mg 2tetracycline oral capsule 250 mg, 500 mg 2tigecycline intravenous recon soln 50 mg 2tinidazole oral tablet 250 mg, 500 mg 2TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG 5

tobramycin in 0.225 % nacl inhalation solution for nebulization 300 mg/5 ml 5 SP; QL (280 ML per 23 days)

tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml 2

tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml 2

TRECATOR ORAL TABLET 250 MG 3trimethoprim oral tablet 100 mg 2TRIUMEQ ORAL TABLET 600-50-300 MG 5TROGARZO INTRAVENOUS SOLUTION 200 MG/1.33 ML (150 MG/ML) 5

TRUVADA ORAL TABLET 200-300 MG 5valacyclovir oral tablet 1 gram, 500 mg 2 QL (30 EA per 23 days)valganciclovir oral recon soln 50 mg/ml 2valganciclovir oral tablet 450 mg 2vancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram, 500 mg, 750 mg 2


Drug Name Tier Limitations (Notes)vancomycin oral capsule 125 mg, 250 mg 2VEMLIDY ORAL TABLET 25 MG 5 SPVIRACEPT ORAL TABLET 250 MG 5VIRACEPT ORAL TABLET 625 MG 4VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) 5 SP

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG 5 SP

voriconazole intravenous recon soln 200 mg 2

voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml) 5 PA

voriconazole oral tablet 200 mg, 50 mg 2 PA

VOSEVI ORAL TABLET 400-100-100 MG 5 PA; SP; QL (28 EA per 28 days)

XENLETA INTRAVENOUS SOLUTION 150 MG/15 ML 5 PA

XENLETA ORAL TABLET 600 MG 5 PAXOFLUZA ORAL TABLET 20 MG, 40 MG 3zidovudine oral capsule 100 mg 2zidovudine oral syrup 10 mg/ml 2zidovudine oral tablet 300 mg 2ANTINEOPLASTIC AGENTSabiraterone oral tablet 250 mg 5 PA; SPAFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG 5 PA; SP

ALECENSA ORAL CAPSULE 150 MG 5 PA; SPALUNBRIG ORAL TABLET 180 MG, 90 MG 5 PA; SP

ALUNBRIG ORAL TABLET 30 MG 5 PA; SP; QL (60 EA per 30 days)

ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG (23) 5 PA; SP

anastrozole oral tablet 1 mg 2azacitidine injection recon soln 100 mg 5BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG 5 PA

BELEODAQ INTRAVENOUS RECON SOLN 500 MG 5

bicalutamide oral tablet 50 mg 2bortezomib intravenous recon soln 3.5 mg 5


13

Drug Name Tier Limitations (Notes)BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG 5 PA

BRAFTOVI ORAL CAPSULE 50 MG, 75 MG 5 PACABOMETYX ORAL TABLET 20 MG 5 PA; QL (30 EA per 30 days)CABOMETYX ORAL TABLET 40 MG, 60 MG 5 PACALQUENCE ORAL CAPSULE 100 MG 5 PA; SPcapecitabine oral tablet 150 mg, 500 mg 5 SPCAPRELSA ORAL TABLET 100 MG, 300 MG 5 PACOMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY)

5 PA; SP

COPIKTRA ORAL CAPSULE 15 MG, 25 MG 5 PACOTELLIC ORAL TABLET 20 MG 5 PA; QL (63 EA per 28 days)cyclophosphamide oral capsule 25 mg, 50 mg 5

DAURISMO ORAL TABLET 100 MG, 25 MG 5 PAdiclofenac sodium topical gel 3 % 5 PA; QL (100 GM per 21 days)docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 mg/ml, 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)

5

doxorubicin intravenous recon soln 10 mg, 50 mg 5

doxorubicin intravenous solution 10 mg/5 ml, 2 mg/ml, 20 mg/10 ml, 50 mg/25 ml 5

EMCYT ORAL CAPSULE 140 MG 5ERIVEDGE ORAL CAPSULE 150 MG 5 PAERLEADA ORAL TABLET 60 MG 5 PAerlotinib oral tablet 100 mg, 150 mg, 25 mg 5 PA; SP

everolimus (antineoplastic) oral tablet 2.5 mg, 5 mg, 7.5 mg 5 PA; QL (30 EA per 30 days)

exemestane oral tablet 25 mg 2FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG 5 PA

FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML 5 SP

fluorouracil topical cream 5 % 2fluorouracil topical solution 2 %, 5 % 2


Drug Name Tier Limitations (Notes)flutamide oral capsule 125 mg 2fulvestrant intramuscular syringe 250 mg/5 ml 5 SP

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG 5 PA; SP; QL (30 EA per 30

days)HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG 5 PA; SPhydroxyurea oral capsule 500 mg 2IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG 5 PA

IDHIFA ORAL TABLET 100 MG, 50 MG 5 PAimatinib oral tablet 100 mg, 400 mg 5 PA; SPIMBRUVICA ORAL CAPSULE 140 MG, 70 MG 5 PA

IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG 5 PA

INLYTA ORAL TABLET 1 MG, 5 MG 5 PAINREBIC ORAL CAPSULE 100 MG 5 PAINTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)

5 SP


IRESSA ORAL TABLET 250 MG 5 PA; SPirinotecan intravenous solution 100 mg/5 ml 2

irinotecan intravenous solution 40 mg/2 ml, 500 mg/25 ml 5

JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG 5 PA; SP

KADCYLA INTRAVENOUS RECON SOLN 100 MG, 160 MG 5 PA; SP

KEYTRUDA INTRAVENOUS RECON SOLN 50 MG 5 PA

KEYTRUDA INTRAVENOUS SOLUTION 25 MG/ML 5 PA

KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG

5 PA

KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3)

5 PA; SP


15

Drug Name Tier Limitations (Notes)LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 12 MG/DAY (4 MG X 3), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 4 MG, 8 MG/DAY (4 MG X 2)

5 PA; SP

letrozole oral tablet 2.5 mg 2LEUKERAN ORAL TABLET 2 MG 4leuprolide subcutaneous kit 1 mg/0.2 ml 5 SPLONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG 5 PA

LORBRENA ORAL TABLET 100 MG, 25 MG 5 PALUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 22.5 MG

5 PA; SP

LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG 5 PA; SP


LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG 5 PA; SP

LUPRON DEPOT-PED INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG (PED) 5 PA; SP

LYNPARZA ORAL TABLET 100 MG, 150 MG 5 PA; SPLYSODREN ORAL TABLET 500 MG 4MATULANE ORAL CAPSULE 50 MG 5megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml) 2 PA

megestrol oral tablet 20 mg, 40 mg 2 PAMEKINIST ORAL TABLET 0.5 MG, 2 MG 5 PA; SPMEKTOVI ORAL TABLET 15 MG 5 PAmelphalan oral tablet 2 mg 5mercaptopurine oral tablet 50 mg 2methotrexate sodium (pf) injection recon soln 1 gram 2

methotrexate sodium (pf) injection solution25 mg/ml 2

methotrexate sodium injection solution 25 mg/ml 2

methotrexate sodium oral tablet 2.5 mg 2MYLERAN ORAL TABLET 2 MG 4NERLYNX ORAL TABLET 40 MG 5 PA; SPExplanations of Limitations can be found on page v.Effective: March 1, 202016

Drug Name Tier Limitations (Notes)NEXAVAR ORAL TABLET 200 MG 5 PA; SPnilutamide oral tablet 150 mg 5NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG 5 PA; SP; QL (3 EA Max Qty Per

Fill Retail)NUBEQA ORAL TABLET 300 MG 5PIQRAY ORAL TABLET 200 MG/DAY (200 MG X 1), 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X 2)

5 PA; SP

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG 5 PA

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG 5 PA

RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG/11.7 ML (120 MG/ML), 1600 MG/13.4 ML (120 MG/ML)

5 PA

ROZLYTREK ORAL CAPSULE 100 MG 5 PA; QL (30 EA per 30 days)ROZLYTREK ORAL CAPSULE 200 MG 5 PA; QL (90 EA per 30 days)RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG 5 PA

RYDAPT ORAL CAPSULE 25 MG 5 PA; SPSIKLOS ORAL TABLET 1,000 MG, 100 MG 4SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG 5 PA; SP

STIVARGA ORAL TABLET 40 MG 5 PA; SPSUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG 5 PA

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG 5 SP

SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG 5 SP

TAFINLAR ORAL CAPSULE 50 MG, 75 MG 5 PA; SP; QL (120 EA per 23 days)

TAGRISSO ORAL TABLET 40 MG, 80 MG 5 PA; QL (30 EA Max Qty Per Fill Retail)

TALZENNA ORAL CAPSULE 0.25 MG, 1 MG 5 PAtamoxifen oral tablet 10 mg, 20 mg PVTARGRETIN TOPICAL GEL 1 % 5 PATASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG 5 PA; SP

temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg 5 SP

TIBSOVO ORAL TABLET 250 MG 5 PAExplanations of Limitations can be found on page v.Effective: March 1, 2020

17

Drug Name Tier Limitations (Notes)topotecan intravenous recon soln 4 mg 5topotecan intravenous solution 4 mg/4 ml (1 mg/ml) 5

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 11.25 MG, 22.5 MG, 3.75 MG

5 PA; SP

tretinoin (chemotherapy) oral capsule 10 mg 5

TRIPTODUR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG

5 PA; SP

TURALIO ORAL CAPSULE 200 MG 5 PATYKERB ORAL TABLET 250 MG 5 PA; SPVECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML)

5 SP

VELCADE INJECTION RECON SOLN 3.5 MG 5 SPVENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG 5 PA

VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG

5 PA

VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 5 PA; SP

VITRAKVI ORAL CAPSULE 100 MG, 25 MG 5 PAVITRAKVI ORAL SOLUTION 20 MG/ML 5 PAVIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG 5 PA

VOTRIENT ORAL TABLET 200 MG 5 PA; SPXALKORI ORAL CAPSULE 200 MG, 250 MG 5 PAXOSPATA ORAL TABLET 40 MG 5 PAXPOVIO ORAL TABLET 100 MG/WEEK (20 MG X 5), 160 MG/WEEK (20 MG X 8), 60 MG/WEEK (20 MG X 3), 80 MG/WEEK (20 MG X 4)

5 PA; SP

XTANDI ORAL CAPSULE 40 MG 5 PA; SPYONDELIS INTRAVENOUS RECON SOLN 1 MG 5 PA

ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML), 200 MG/8 ML (25 MG/ML)

5 SP

ZEJULA ORAL CAPSULE 100 MG 5 PA; QL (90 EA per 23 days)


Drug Name Tier Limitations (Notes)ZELBORAF ORAL TABLET 240 MG 5 PA; SPZOLINZA ORAL CAPSULE 100 MG 5 PA; SPZYDELIG ORAL TABLET 100 MG, 150 MG 5 PAZYKADIA ORAL CAPSULE 150 MG 5 PA; SPZYKADIA ORAL TABLET 150 MG 5 PA; SPZYTIGA ORAL TABLET 500 MG 5 PA; SPANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINESACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML PV

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML

PV

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML

PV

AFLURIA QD 2019-20(3YR UP)(PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

PV

AFLURIA QD 2019-20(6-35MO)(PF) INTRAMUSCULAR SYRINGE 30 MCG (7.5 MCG X 4)/0.25 ML

PV

AFLURIA QUAD 2019-20(6MO UP) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

PV

bcg vaccine, live (pf) percutaneous suspension for reconstitution 50 mg PV SP

BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG/0.5 ML PV

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 2.5-8-5 LF-MCG-LF/0.5ML PV

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML PV

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF/0.5ML

PV

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCG/ML PV

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML PV

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML PV


19

Drug Name Tier Limitations (Notes)FLUAD 2019-2020 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE 45 MCG (15 MCG X 3)/0.5 ML

PV

FLUARIX QUAD 2019-2020 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

PV

FLUBLOK QUAD 2019-2020 (PF) INTRAMUSCULAR SYRINGE 180 MCG (45 MCG X 4)/0.5 ML

PV

FLUCELVAX QUAD 2019-2020 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

PV

FLUCELVAX QUAD 2019-2020 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

PV

FLULAVAL QUAD 2019-2020 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

PV

FLULAVAL QUAD 2019-2020 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

PV

FLUMIST QUAD 2019-2020 NASAL NASAL SPRAY SYRINGE 10EXP6.5-7.5 FF UNIT/0.2 ML

PV

FLUZONE HIGH-DOSE 2019-20 (PF) INTRAMUSCULAR SYRINGE 180 MCG/0.5 ML

PV

FLUZONE QUAD 2019-2020 (PF) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

PV

FLUZONE QUAD 2019-2020 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

PV

FLUZONE QUAD 2019-2020 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

PV

FLUZONE QUAD PEDI 2019-20 (PF) INTRAMUSCULAR SYRINGE 30 MCG (7.5 MCG X 4)/0.25 ML

PV

GAMASTAN S/D INTRAMUSCULAR SOLUTION 15-18 % RANGE 5 SP

GAMMAGARD LIQUID INJECTION SOLUTION 10 % 5 PA; SP

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML PV


Drug Name Tier Limitations (Notes)GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML PV

HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML PV

HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML

PV

HEPLISAV-B (PF) INTRAMUSCULAR SOLUTION 20 MCG/0.5 ML PV

HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/0.5 ML PV

HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML PV

HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %)

5 PA; SP

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT PV

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 25-58-10 LF-MCG-LF/0.5ML PV

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF/0.5ML PV

IPOL INJECTION SUSPENSION 40-8-32 UNIT/0.5 ML PV

IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML PV

KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML PV

MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML PV

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML PV

M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML PV

ODACTRA SUBLINGUAL TABLET 12 SQ-HDM 4 PA

PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML PV

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PV

PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML PV


21

Drug Name Tier Limitations (Notes)PNEUMOVAX 23 INJECTION SOLUTION 25 MCG/0.5 ML PV

PNEUMOVAX 23 INJECTION SYRINGE 25 MCG/0.5 ML PV

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE 0.5 ML PV

PRIVIGEN INTRAVENOUS SOLUTION 10 % 5 PA; SPPROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-4.3-3- 3.99 TCID50/0.5

PV

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML

PV

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT

PV

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5 ML

PV

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML PV

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML PV

ROTATEQ VACCINE ORAL SOLUTION 2 ML PVSHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML

PV

SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG

PV

STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,000 UNIT/0.5 ML

PV

TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML PV

TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML PV

TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML PV

tetanus,diphtheria tox ped(pf) intramuscular suspension 5-25 lf unit/0.5 ml

PV

TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML PV


Drug Name Tier Limitations (Notes)TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCG/ML PV

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML PV

VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML PV

VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML PV

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML

PV

VAXCHORA ACTIVE COMPONENT ORAL SUSPENSION FOR RECONSTITUTION 4X10EXP8 TO 2X 10EXP9 CF UNIT

PV

VAXCHORA VACCINE ORAL SUSPENSION FOR RECONSTITUTION 4X10EXP8 TO 2X 10EXP9 CF UNIT

PV

VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC) 2 BILLION UNIT PV

XEMBIFY SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %)

5

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML

PV

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML

PV

AUTONOMIC DRUGSacebutolol oral capsule 200 mg, 400 mg 2albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml

2

albuterol sulfate oral syrup 2 mg/5 ml 2albuterol sulfate oral tablet 2 mg, 4 mg 2albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg 2

alfuzosin oral tablet extended release 24 hr10 mg 2

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION 3 QL (60 EA per 30 days)

atenolol oral tablet 100 mg, 25 mg, 50 mg 1


23

Drug Name Tier Limitations (Notes)atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1

atropine injection solution 0.4 mg/ml, 1 mg/ml 2

atropine injection syringe 0.05 mg/ml, 0.1 mg/ml 2

ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION 3 QL (26 GM per 30 days)

baclofen oral tablet 10 mg, 20 mg 2benztropine injection solution 2 mg/2 ml 2benztropine oral tablet 0.5 mg, 1 mg, 2 mg 2betaxolol oral tablet 10 mg, 20 mg 2bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg 2

bisoprolol fumarate oral tablet 10 mg, 5 mg 2

bisoprolol-hydrochlorothiazide oral tablet10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg 1

BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE

3

BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG/2 ML 3 QL (120 ML per 30 days)

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1

cevimeline oral capsule 30 mg 2CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG PV

CHANTIX ORAL TABLET 0.5 MG, 1 MG PVCHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42)

PV

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1

clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr 2 QL (4 EA per 21 days)

CLORPRES ORAL TABLET 0.1-15 MG, 0.2-15 MG 4

COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION 3 QL (8 GM per 30 days)

cyclobenzaprine oral tablet 10 mg, 5 mg, 7.5 mg 2


Drug Name Tier Limitations (Notes)dantrolene oral capsule 100 mg, 25 mg, 50 mg 2

dicyclomine oral capsule 10 mg 2dicyclomine oral solution 10 mg/5 ml 2dicyclomine oral tablet 20 mg 2dihydroergotamine injection solution 1 mg/ml 5

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml 2

diphenoxylate-atropine oral tablet 2.5-0.025 mg 2

donepezil oral tablet 10 mg, 5 mg 1donepezil oral tablet,disintegrating 10 mg, 5 mg 1

doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 QL (30 EA per 30 days)

DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION

3 QL (13 GM per 30 days)

dutasteride-tamsulosin oral capsule, er multiphase 24 hr 0.5-0.4 mg 2

DYSPORT INTRAMUSCULAR RECON SOLN 500 UNIT 5 PA; SP

epinephrine injection auto-injector 0.15 mg/0.15 ml 3 QL (2 EA per 30 days)

epinephrine injection auto-injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml 2 QL (2 EA per 30 days)

epinephrine injection solution 1 mg/ml, 1 mg/ml (1 ml) 2

epinephrine injection syringe 0.1 mg/ml 2ergoloid oral tablet 1 mg 2fluticasone propion-salmeterol inhalation aerosol powdr breath activated 113-14 mcg/actuation, 232-14 mcg/actuation, 55-14 mcg/actuation

3

galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg, 8 mg 2

galantamine oral solution 4 mg/ml 2galantamine oral tablet 12 mg, 4 mg, 8 mg 2glycopyrrolate oral tablet 1 mg, 2 mg 2guanidine oral tablet 125 mg 2


25

Drug Name Tier Limitations (Notes)INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION 3 QL (1 EA per 30 days)

ipratropium bromide inhalation solution0.02 % 2

ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml

2

labetalol intravenous solution 5 mg/ml 2labetalol oral tablet 100 mg, 200 mg, 300 mg 1

levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/3 ml

2

metaproterenol oral syrup 10 mg/5 ml 2metaproterenol oral tablet 10 mg, 20 mg 2methocarbamol oral tablet 500 mg, 750 mg 2

methscopolamine oral tablet 2.5 mg, 5 mg 2methyldopa oral tablet 250 mg, 500 mg 2methyldopa-hydrochlorothiazide oral tablet250-15 mg, 250-25 mg 2

methyldopate intravenous solution 250 mg/5 ml 2

metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg

1

metoprolol ta-hydrochlorothiaz oral tablet100-25 mg, 100-50 mg, 50-25 mg 2

metoprolol tartrate intravenous solution 5 mg/5 ml 2

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1

midodrine oral tablet 10 mg, 2.5 mg, 5 mg 2nicoderm cq transdermal patch 24 hour 14 mg/24 hr PV

NICODERM CQ TRANSDERMAL PATCH 24 HOUR 21 MG/24 HR, 7 MG/24 HR PV

nicorelief buccal gum 2 mg PVNICORELIEF BUCCAL GUM 4 MG PVnicorette buccal gum 2 mg PVNICORETTE BUCCAL GUM 4 MG PVNICORETTE BUCCAL LOZENGE 2 MG, 4 MG PV


Drug Name Tier Limitations (Notes)NICORETTE BUCCAL MINI LOZENGE 2 MG, 4 MG PV

nicotine (polacrilex) buccal gum 2 mg, 4 mg PV

nicotine (polacrilex) buccal mini lozenge 2 mg, 4 mg PV

nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr PV

nicotine transdermal patch, td daily, sequential 21-14-7 mg/24 hr PV

NICOTROL INHALATION CARTRIDGE 10 MG PV

NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML PV

orphenadrine citrate injection solution 30 mg/ml 2

phenoxybenzamine oral capsule 10 mg 5pilocarpine hcl oral tablet 5 mg, 7.5 mg 2pindolol oral tablet 10 mg, 5 mg 2prazosin oral capsule 1 mg, 2 mg, 5 mg 2propranolol intravenous solution 1 mg/ml 2propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 mg, 80 mg 2

propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) 2

propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1

propranolol-hydrochlorothiazid oral tablet40-25 mg, 80-25 mg 2

pyridostigmine bromide oral tablet 60 mg 2QUIT 2 BUCCAL GUM 2 MG PVQUIT 2 BUCCAL LOZENGE 2 MG PVQUIT 4 BUCCAL GUM 4 MG PVQUIT 4 BUCCAL LOZENGE 4 MG PVREGONOL INJECTION SOLUTION 5 MG/ML 2rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg 2

rivastigmine transdermal patch 24 hour13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr

2

sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg 2


27

Drug Name Tier Limitations (Notes)SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION


SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG 3 QL (30 EA per 30 days)

STIOLTO RESPIMAT INHALATION MIST 2.5-2.5 MCG/ACTUATION 3 QL (4 GM per 30 days)

STOP SMOKING AID BUCCAL LOZENGE 2 MG, 4 MG PV

SYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION


tamsulosin oral capsule 0.4 mg 1terazosin oral capsule 1 mg, 2 mg, 5 mg 1 QL (30 EA per 23 days)terazosin oral capsule 10 mg 1 QL (60 EA per 23 days)terbutaline oral tablet 2.5 mg, 5 mg 2terbutaline subcutaneous solution 1 mg/ml 2timolol maleate oral tablet 10 mg, 20 mg, 5 mg 2

tizanidine oral capsule 2 mg, 4 mg, 6 mg 2tizanidine oral tablet 2 mg, 4 mg 2TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG 3 QL (60 EA per 30 days)

trihexyphenidyl oral elixir 0.4 mg/ml 2trihexyphenidyl oral tablet 2 mg, 5 mg 2VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION 3 QL (8 GM per 30 days)

BLOOD FORMATION, COAGULATION, THROMBOSISADULT ASPIRIN REGIMEN ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG PV

ADULT LOW DOSE ASPIRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG PV

anagrelide oral capsule 0.5 mg, 1 mg 2ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

5 PA; SP

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML

5 PA; SP


Drug Name Tier Limitations (Notes)argatroban in 0.9 % sod chlor intravenous parenteral solution 250 mg/250 ml (1 mg/ml)

5

argatroban in 0.9 % sod chlor intravenous solution 1 mg/ml 5

argatroban in nacl (iso-os) intravenous solution 50 mg/50 ml (1 mg/ml) 4

argatroban intravenous solution 100 mg/ml 4

ASPIR-81 ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG PV

ASPIRIN CHILDRENS ORAL TABLET,CHEWABLE 81 MG PV

aspirin low dose oral tablet,delayed release (dr/ec) 81 mg PV

ASPIRIN LOW DOSE ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG PV

aspirin oral tablet 325 mg PVaspirin oral tablet,chewable 81 mg PVaspirin oral tablet,delayed release (dr/ec)325 mg, 81 mg PV

aspirin,buffd-calcium carb-mag oral tablet325 mg PV

aspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 mg 2

ASPIR-LOW ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG PV

ASPIR-TRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 325 MG PV

BAYER ASPIRIN ORAL TABLET 325 MG PVBRILINTA ORAL TABLET 60 MG, 90 MG 3BUFFERED ASPIRIN ORAL TABLET 325 MG PVCABLIVI INJECTION KIT 11 MG 5 PACABLIVI INJECTION RECON SOLN 11 MG 5 PACHILDREN'S ASPIRIN ORAL TABLET,CHEWABLE 81 MG PV

cilostazol oral tablet 100 mg, 50 mg 2CLASSIC PRENATAL ORAL TABLET 28 MG IRON- 800 MCG PV

clopidogrel oral tablet 300 mg 2clopidogrel oral tablet 75 mg 1


29

Drug Name Tier Limitations (Notes)DAILY PRENATAL ORAL COMBO PACK 28-800-440 MG-MCG-MG PV

desmopressin injection solution 4 mcg/ml 5desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml) 2

desmopressin oral tablet 0.1 mg, 0.2 mg 2dipyridamole oral tablet 25 mg, 50 mg, 75 mg 2

DOPTELET (10 TAB PACK) ORAL TABLET 20 MG 5 SP; QL (15 EA per 30 days)

DOPTELET (15 TAB PACK) ORAL TABLET 20 MG 5 SP

E.C. PRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 325 MG PV

ECOTRIN LOW STRENGTH ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG PV

ECOTRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 325 MG PV

ELIQUIS DVT-PE TREAT 30D START ORAL TABLETS,DOSE PACK 5 MG (74 TABS) 3

ELIQUIS ORAL TABLET 2.5 MG, 5 MG 3enoxaparin subcutaneous solution 300 mg/3 ml 2

enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml

2

ENTERIC COATED ASPIRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG PV

EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

5 PA; SP

fondaparinux subcutaneous syringe 10 mg/0.8 ml, 2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

5

FRAGMIN SUBCUTANEOUS SOLUTION 25,000 ANTI-XA UNIT/ML 5 SP

FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5 ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.72 ML, 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML, 7,500 ANTI-XA UNIT/0.3 ML

5 SP


Drug Name Tier Limitations (Notes)FULPHILA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML 5 PA; SP; QL (2 ML per 23

days)GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, 480 MCG/1.6 ML 5 SP; QL (2 ML per 22 days)

GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML 5 SP

HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7 ML, 150 MG/ML, 30 MG/ML, 60 MG/0.4 ML

5 PA; SP

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

2

heparin (porcine) in nacl (pf) intravenous parenteral solution 2,000 unit/1,000 ml 2

heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml 2

heparin, porcine (pf) injection solution1,000 unit/ml, 5,000 unit/0.5 ml 2

heparin, porcine (pf) injection syringe5,000 unit/0.5 ml 2

IXINITY INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT

5 SP

JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

1

JIVI INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

5 SP

LITE COAT ASPIRIN ORAL TABLET 325 MG PVMOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2 ML (20 MG/ML) 5 SP

NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML 5 PA; SP; QL (2 ML per 23

days)NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML 5 PA; SP; QL (2 ML per 23

days)NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML 5 PA; SP

NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML 5 PA; SP

NIVESTYM INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML 5 PA; SP


31

Drug Name Tier Limitations (Notes)NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML 5 PA; SP

NOVOEIGHT INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

5

OBIZUR INTRAVENOUS RECON SOLN 500 (+/-) UNIT RANGE 5

ONE DAILY PRENATAL ORAL COMBO PACK 28-800-440 MG-MCG-MG PV

pentoxifylline oral tablet extended release400 mg 2

PERRY PRENATAL ORAL CAPSULE 13.5-0.4 MG PV

pnv cmb#95-ferrous fumarate-fa oral tablet 28 mg iron- 800 mcg PV

PRENATAL COMPLETE ORAL TABLET 14 MG IRON- 400 MCG PV

PRENATAL MULTI-DHA (ALGAL OIL) ORAL CAPSULE 27MG IRON- 800 MCG-250 MG PV

PRENATAL ONE DAILY ORAL TABLET 27 MG IRON- 800 MCG PV

PRENATAL ORAL TABLET 28 MG IRON- 800 MCG PV

PRENATAL TABLET ORAL TABLET 28 MG IRON- 800 MCG PV

PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 0.8 MG PV

PRENATAL VITAMIN WITH MINERALS ORAL TABLET 28 MG IRON- 800 MCG PV

prenatal vit-iron fum-folic ac oral tablet 28 mg iron- 800 mcg PV

prenatal vits96-iron fum-folic oral tablet 27 mg iron- 800 mcg PV

PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML

5 PA; SP

PROMACTA ORAL POWDER IN PACKET 12.5 MG 5 PA; SP

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG 5 PA; SP


Drug Name Tier Limitations (Notes)REBINYN INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 500 (+/-) UNIT

5 SP

RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML

5 PA; SP

STRESS FORMULA WITH IRON ORAL TABLET 500 MG-400 MCG- 18 MG IRON PV

STRESS FORMULA WITH IRON(SULF) ORAL TABLET 500 MG-400 MCG- 27 MG IRON PV

tranexamic acid intravenous solution 1,000 mg/10 ml (100 mg/ml) 2

tranexamic acid oral tablet 650 mg 2TRI-BUFFERED ASPIRIN ORAL TABLET 325 MG PV

UDENYCA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML 5 PA; SP

warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg 1

XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG 3

XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) 3

ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML 5 PA; SP

CARDIOVASCULAR DRUGSacebutolol oral capsule 200 mg, 400 mg 2acetazolamide oral capsule, extended release 500 mg 2

acetazolamide oral tablet 125 mg, 250 mg 2acetazolamide sodium injection recon soln500 mg 2

ambrisentan oral tablet 10 mg, 5 mg 5 PAamiloride oral tablet 5 mg 2amiloride-hydrochlorothiazide oral tablet 5-50 mg 2

amiodarone intravenous solution 50 mg/ml 2amiodarone oral tablet 200 mg, 400 mg 2amlodipine oral tablet 10 mg, 2.5 mg, 5 mg 1


33

Drug Name Tier Limitations (Notes)amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

1


atenolol oral tablet 100 mg, 25 mg, 50 mg 1atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1

atorvastatin oral tablet 10 mg, 20 mg PVatorvastatin oral tablet 40 mg, 80 mg 1benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1

benazepril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

1

betaxolol oral tablet 10 mg, 20 mg 2bisoprolol fumarate oral tablet 10 mg, 5 mg 2


bosentan oral tablet 125 mg, 62.5 mg 5 PAbumetanide injection solution 0.25 mg/ml 2bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1

captopril-hydrochlorothiazide oral tablet25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg 1

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1

chlorothiazide oral tablet 250 mg, 500 mg 2chlorothiazide sodium intravenous recon soln 500 mg 2

chlorthalidone oral tablet 25 mg, 50 mg 1cholestyramine (with sugar) oral powder in packet 4 gram 2

CHOLESTYRAMINE LIGHT ORAL POWDER 4 GRAM 2

CHOLESTYRAMINE LIGHT ORAL POWDER IN PACKET 4 GRAM 2

cilostazol oral tablet 100 mg, 50 mg 2clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1


Drug Name Tier Limitations (Notes)clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr 2 QL (4 EA per 21 days)


colestipol oral packet 5 gram 2colestipol oral tablet 1 gram 2CORLANOR ORAL SOLUTION 5 MG/5 ML 4 PACORLANOR ORAL TABLET 5 MG, 7.5 MG 4 PAdigoxin injection solution 250 mcg/ml (0.25 mg/ml) 2

digoxin injection syringe 250 mcg/ml (0.25 mg/ml) 2

digoxin oral solution 50 mcg/ml (0.05 mg/ml) 2

digoxin oral tablet 125 mcg (0.125 mg), 250 mcg (0.25 mg) 1

DILANTIN ORAL CAPSULE 30 MG 4diltiazem hcl intravenous recon soln 100 mg 2

diltiazem hcl intravenous solution 5 mg/ml 2diltiazem hcl oral capsule,ext.rel 24h degradable 120 mg, 180 mg, 240 mg 1

diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg, 90 mg 1

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

1

diltiazem hcl oral capsule,extended release 24 hr 360 mg 2

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg 1

diltiazem hcl oral capsule,extended release 24hr 360 mg 2

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1

diltiazem hcl oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg 1

diltiazem hcl oral tablet extended release 24 hr 360 mg, 420 mg 2

dipyridamole oral tablet 25 mg, 50 mg, 75 mg 2


35

Drug Name Tier Limitations (Notes)disopyramide phosphate oral capsule 100 mg, 150 mg 2

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg 2

doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 QL (30 EA per 30 days)

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1

enalapril-hydrochlorothiazide oral tablet10-25 mg, 5-12.5 mg 1

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG 3 QL (60 EA per 30 days)

eplerenone oral tablet 25 mg, 50 mg 2ezetimibe oral tablet 10 mg 2 QL (30 EA per 22 days)felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg 2

fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg 2

fenofibrate nanocrystallized oral tablet 145 mg, 48 mg 2

fenofibrate oral tablet 160 mg, 54 mg 2fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg, 45 mg

2

flecainide oral tablet 100 mg, 150 mg, 50 mg 2

fluvastatin oral capsule 20 mg, 40 mg PV QL (60 EA per 23 days)fluvastatin oral tablet extended release 24 hr 80 mg PV QL (30 EA per 23 days)

fosinopril oral tablet 10 mg, 20 mg, 40 mg 1fosinopril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg 2

furosemide injection solution 10 mg/ml 2furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) 2

furosemide oral tablet 20 mg, 40 mg, 80 mg 1

gemfibrozil oral tablet 600 mg 1guanfacine oral tablet 1 mg, 2 mg 2guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg 2

hydralazine injection solution 20 mg/ml 2


Drug Name Tier Limitations (Notes)hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1

hydrochlorothiazide oral capsule 12.5 mg 1hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1

indapamide oral tablet 1.25 mg, 2.5 mg 2irbesartan oral tablet 150 mg, 300 mg, 75 mg 1

irbesartan-hydrochlorothiazide oral tablet150-12.5 mg, 300-12.5 mg 1

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg 1

isosorbide dinitrate oral tablet extended release 40 mg 2

isosorbide mononitrate oral tablet 10 mg, 20 mg 1

isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg

1

isradipine oral capsule 2.5 mg, 5 mg 2labetalol intravenous solution 5 mg/ml 2labetalol oral tablet 100 mg, 200 mg, 300 mg 1

lidocaine (pf) intravenous solution 20 mg/ml (2 %) 2

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg 1

lisinopril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg, 20-25 mg 1

losartan oral tablet 100 mg, 25 mg, 50 mg 1losartan-hydrochlorothiazide oral tablet100-12.5 mg, 100-25 mg, 50-12.5 mg 1

lovastatin oral tablet 10 mg PV QL (30 EA per 23 days)lovastatin oral tablet 20 mg, 40 mg PV QL (60 EA per 23 days)magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %)

2

magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/100 ml (4 %), 4 gram/50 ml (8 %)

2

magnesium sulfate injection syringe 4 meq/ml 2


37

Drug Name Tier Limitations (Notes)methyclothiazide oral tablet 5 mg 2methyldopa oral tablet 250 mg, 500 mg 2methyldopa-hydrochlorothiazide oral tablet250-15 mg, 250-25 mg 2

methyldopate intravenous solution 250 mg/5 ml 2

metolazone oral tablet 10 mg, 2.5 mg, 5 mg 2

metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg

1


metoprolol tartrate intravenous solution 5 mg/5 ml 2

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1

mexiletine oral capsule 150 mg, 200 mg, 250 mg 2

minoxidil oral tablet 10 mg, 2.5 mg 2moexipril oral tablet 15 mg, 7.5 mg 1MULTAQ ORAL TABLET 400 MG 4niacin oral tablet 500 mg 2niacin oral tablet extended release 24 hr1,000 mg, 500 mg, 750 mg 2

nicardipine intravenous solution 25 mg/10 ml 2

nicardipine oral capsule 20 mg, 30 mg 2nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg 2

nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg 2

nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg

2

NITRO-BID TRANSDERMAL OINTMENT 2 % 2nitroglycerin intravenous solution 50 mg/10 ml (5 mg/ml) 2

nitroglycerin oral capsule, extended release2.5 mg, 6.5 mg, 9 mg 2

nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg 1


Drug Name Tier Limitations (Notes)nitroglycerin transdermal patch 24 hour0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

2

omega-3 acid ethyl esters oral capsule 1 gram 2

OPSUMIT ORAL TABLET 10 MG 5 PAperindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1

phenoxybenzamine oral capsule 10 mg 5phenytoin oral suspension 125 mg/5 ml 2phenytoin oral tablet,chewable 50 mg 2phenytoin sodium extended oral capsule100 mg, 200 mg, 300 mg 2

phenytoin sodium intravenous solution 50 mg/ml 2

pindolol oral tablet 10 mg, 5 mg 2PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML 4 PA; SP; QL (2 ML per 21

days)pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg PV

prazosin oral capsule 1 mg, 2 mg, 5 mg 2PREVALITE ORAL POWDER 4 GRAM 2procainamide injection solution 100 mg/ml, 500 mg/ml 2

propafenone oral capsule,extended release 12 hr 225 mg, 325 mg, 425 mg 2

propafenone oral tablet 150 mg, 225 mg, 300 mg 2

propranolol intravenous solution 1 mg/ml 2propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 mg, 80 mg 2




quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1

quinapril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg, 20-25 mg 2


39

Drug Name Tier Limitations (Notes)quinidine gluconate oral tablet extended release 324 mg 2

quinidine sulfate oral tablet 200 mg, 300 mg 2

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1

ranolazine oral tablet extended release 12 hr 1,000 mg, 500 mg 2

REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML 4 SP; QL (3.5 ML per 21 days)

REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML 4 PA; SP; QL (2 ML per 21

days)REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML 4 PA; SP; QL (2 ML per 21

days)rosuvastatin oral tablet 10 mg, 5 mg PV QL (30 EA per 23 days)rosuvastatin oral tablet 20 mg, 40 mg 1 QL (30 EA per 23 days)sildenafil (pulm.hypertension) intravenous solution 10 mg/12.5 ml 5 PA; SP

sildenafil (pulm.hypertension) oral tablet20 mg 5 PA; SP; QL (90 EA per 23

days)simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg PV

simvastatin oral tablet 80 mg 1sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg 2

spironolactone oral tablet 100 mg, 25 mg, 50 mg 1

spironolacton-hydrochlorothiaz oral tablet25-25 mg 2

tadalafil (pulm. hypertension) oral tablet20 mg 5 PA; SP; QL (60 EA per 23

days)terazosin oral capsule 1 mg, 2 mg, 5 mg 1 QL (30 EA per 23 days)terazosin oral capsule 10 mg 1 QL (60 EA per 23 days)theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg 2

theophylline oral tablet extended release 24 hr 400 mg, 600 mg 2

timolol maleate oral tablet 10 mg, 20 mg, 5 mg 2

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 2

trandolapril oral tablet 1 mg, 2 mg, 4 mg 1


Drug Name Tier Limitations (Notes)triamterene-hydrochlorothiazid oral capsule 37.5-25 mg, 50-25 mg 1

triamterene-hydrochlorothiazid oral tablet37.5-25 mg, 75-50 mg 1

UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

5 PA

UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60) 5 PA

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg 1

valsartan-hydrochlorothiazide oral tablet160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

1

VASCEPA ORAL CAPSULE 0.5 GRAM, 1 GRAM 4 PA

verapamil intravenous solution 2.5 mg/ml 2verapamil oral capsule, 24 hr er pellet ct100 mg, 200 mg, 300 mg 2

verapamil oral capsule,ext rel. pellets 24 hr120 mg, 180 mg, 240 mg, 360 mg 1

verapamil oral tablet 120 mg, 40 mg, 80 mg 1

verapamil oral tablet extended release 120 mg, 180 mg, 240 mg 1

VYNDAMAX ORAL CAPSULE 61 MG 5 PA; SPVYNDAQEL ORAL CAPSULE 20 MG 5 PA; SPCENTRAL NERVOUS SYSTEM AGENTSacamprosate oral tablet,delayed release (dr/ec) 333 mg 2

acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml 2

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg 2 QL (360 EA per 30 days)

acetaminophen-codeine oral tablet 300-60 mg 2 QL (180 EA per 30 days)

ADULT ASPIRIN REGIMEN ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG PV

ADULT LOW DOSE ASPIRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG PV

AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MG/ML 4 PA; QL (1 ML per 23 days)


41

Drug Name Tier Limitations (Notes)AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML 4 PA; QL (2 ML per 23 days)

AJOVY SUBCUTANEOUS SYRINGE 225 MG/1.5 ML 4 PA

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg 2

alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg, 3 mg 2

amantadine hcl oral capsule 100 mg 2amantadine hcl oral solution 50 mg/5 ml 2amantadine hcl oral tablet 100 mg 2amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 1

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg 2

amphetamine sulfate oral tablet 10 mg, 5 mg 2

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg 2 ST; QL (30 EA per 30 days)

ASPIR-81 ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG PV

ASPIRIN CHILDRENS ORAL TABLET,CHEWABLE 81 MG PV

ASPIRIN LOW DOSE ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG PV

aspirin oral tablet 325 mg PVaspirin oral tablet,chewable 81 mg PVaspirin oral tablet,delayed release (dr/ec)325 mg, 81 mg PV

aspirin,buffd-calcium carb-mag oral tablet325 mg PV


ASPIR-LOW ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG PV

ASPIR-TRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 325 MG PV

atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg 2

AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG 5 PA; SP

BANZEL ORAL SUSPENSION 40 MG/ML 5


Drug Name Tier Limitations (Notes)BANZEL ORAL TABLET 200 MG, 400 MG 5BAYER ASPIRIN ORAL TABLET 325 MG PVbenztropine injection solution 2 mg/2 ml 2benztropine oral tablet 0.5 mg, 1 mg, 2 mg 2BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML 4

BRIVIACT ORAL SOLUTION 10 MG/ML 4BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG 4

bromocriptine oral capsule 5 mg 2bromocriptine oral tablet 2.5 mg 2BUFFERED ASPIRIN ORAL TABLET 325 MG PVbuprenorphine hcl injection syringe 0.3 mg/ml 2

buprenorphine hcl sublingual tablet 2 mg, 8 mg 2 QL (90 EA per 30 days)

buprenorphine transdermal patch weekly10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour

2 QL (4 EA per 28 days)

buprenorphine-naloxone sublingual film12-3 mg, 2-0.5 mg, 8-2 mg 2

buprenorphine-naloxone sublingual film 4-1 mg 2 QL (180 EA per 30 days)

buprenorphine-naloxone sublingual tablet2-0.5 mg 2 QL (360 EA per 30 days)

buprenorphine-naloxone sublingual tablet8-2 mg 2 QL (90 EA per 28 days)

bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg PV QL (60 EA per 30 days)

bupropion hcl oral tablet 100 mg, 75 mg 1bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg 1 QL (30 EA per 30 days)

bupropion hcl oral tablet sustained-release 12 hr 100 mg, 200 mg 1 QL (60 EA per 30 days)

bupropion hcl oral tablet sustained-release 12 hr 150 mg PV QL (60 EA per 30 days)

buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg 1

cabergoline oral tablet 0.5 mg 2carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg 2


43

Drug Name Tier Limitations (Notes)carbamazepine oral suspension 100 mg/5 ml 1

carbamazepine oral tablet 200 mg 1carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 mg 2

carbamazepine oral tablet,chewable 100 mg 1

carbidopa oral tablet 25 mg 2carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg 1

carbidopa-levodopa oral tablet extended release 25-100 mg, 50-200 mg 1

carbidopa-levodopa oral tablet,disintegrating 10-100 mg 2

carbidopa-levodopa oral tablet,disintegrating 25-100 mg, 25-250 mg

1

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg 2

CHILDREN'S ASPIRIN ORAL TABLET,CHEWABLE 81 MG PV

chlorpromazine injection solution 25 mg/ml 2chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg 2

citalopram oral solution 10 mg/5 ml 2citalopram oral tablet 10 mg, 20 mg, 40 mg 1 QL (30 EA per 30 days)

clomipramine oral capsule 25 mg, 50 mg, 75 mg 2

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 2clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg 2

clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg 2

clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg 2 ST

desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 2

desvenlafaxine succinate oral tablet extended release 24 hr 100 mg, 50 mg 2 QL (30 EA per 30 days)


Drug Name Tier Limitations (Notes)desvenlafaxine succinate oral tablet extended release 24 hr 25 mg 2

dexmethylphenidate oral capsule,er biphasic 50-50 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg

2

dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg 2

dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg 2

dextroamphetamine oral tablet 10 mg, 5 mg 2

dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg

2

dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

2

DIACOMIT ORAL CAPSULE 250 MG, 500 MG 5 PA

DIACOMIT ORAL POWDER IN PACKET 250 MG, 500 MG 5 PA

diazepam injection solution 5 mg/ml 2diazepam injection syringe 5 mg/ml 2DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML 2

diazepam oral solution 5 mg/5 ml (1 mg/ml), 5 mg/5 ml (1 mg/ml, 5 ml) 2

diazepam oral tablet 10 mg, 2 mg, 5 mg 2diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg, 5-7.5-10 mg 2

diclofenac potassium oral tablet 50 mg 2diclofenac sodium oral tablet extended release 24 hr 100 mg 2

diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg 2

diclofenac sodium topical gel 1 % 2 QL (500 GM per 21 days)diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic 50-200 mg-mcg, 75-200 mg-mcg

2

diflunisal oral tablet 500 mg 2dihydroergotamine injection solution 1 mg/ml 5

DILANTIN ORAL CAPSULE 30 MG 4Explanations of Limitations can be found on page v.Effective: March 1, 2020

45

Drug Name Tier Limitations (Notes)divalproex oral capsule, delayed rel sprinkle 125 mg 1

divalproex oral tablet extended release 24 hr 250 mg, 500 mg 1

divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 mg 1

doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 2

doxepin oral concentrate 10 mg/ml 2duloxetine oral capsule,delayed release(dr/ec) 20 mg, 60 mg 2 QL (60 EA per 30 days)

duloxetine oral capsule,delayed release(dr/ec) 30 mg 2 QL (30 EA per 30 days)

duloxetine oral capsule,delayed release(dr/ec) 40 mg 2

E.C. PRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 325 MG PV

ECOTRIN LOW STRENGTH ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG PV

ECOTRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 325 MG PV

EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MG/ML 4 PA

EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MG/ML, 300 MG/3 ML (100 MG/ML X 3)

4 PA

entacapone oral tablet 200 mg 2ENTERIC COATED ASPIRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 81 MG PV

EPIDIOLEX ORAL SOLUTION 100 MG/ML 5 PA; SPescitalopram oxalate oral solution 5 mg/5 ml 2

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg 1 QL (30 EA per 30 days)

ethosuximide oral capsule 250 mg 2ethosuximide oral solution 250 mg/5 ml 2etodolac oral capsule 200 mg, 300 mg 2etodolac oral tablet 400 mg, 500 mg 2etodolac oral tablet extended release 24 hr400 mg, 500 mg, 600 mg 2

felbamate oral suspension 600 mg/5 ml 2felbamate oral tablet 400 mg, 600 mg 2


Drug Name Tier Limitations (Notes)fenoprofen oral tablet 600 mg 2fentanyl citrate buccal lozenge on a handle1,200 mcg, 1,600 mcg, 400 mcg, 600 mcg, 800 mcg

5 PA; QL (30 EA per 23 days)

fentanyl citrate buccal lozenge on a handle200 mcg 5 PA; QL (90 EA per 23 days)

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr 2 PA; QL (10 EA per 23 days)

fentanyl transdermal patch 72 hour 25 mcg/hr, 50 mcg/hr, 75 mcg/hr 2 PA; QL (10 EA per 30 days)

fluoxetine oral capsule 10 mg 1 QL (30 EA per 30 days)fluoxetine oral capsule 20 mg 1fluoxetine oral capsule 40 mg 1 QL (60 EA per 30 days)fluoxetine oral solution 20 mg/5 ml (4 mg/ml) 2

fluoxetine oral tablet 10 mg 1 QL (30 EA per 30 days)fluoxetine oral tablet 20 mg 1fluphenazine decanoate injection solution25 mg/ml 2

fluphenazine hcl injection solution 2.5 mg/ml 2

fluphenazine hcl oral concentrate 5 mg/ml 2fluphenazine hcl oral elixir 2.5 mg/5 ml 2fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg 2

flurbiprofen oral tablet 100 mg, 50 mg 2fluvoxamine oral capsule,extended release 24hr 100 mg, 150 mg 2 QL (60 EA per 30 days)

fluvoxamine oral tablet 100 mg 2 QL (90 EA per 30 days)fluvoxamine oral tablet 25 mg 2 QL (30 EA per 30 days)fluvoxamine oral tablet 50 mg 2 QL (60 EA per 30 days)fosphenytoin injection solution 500 mg pe/10 ml 2

gabapentin oral capsule 100 mg, 300 mg, 400 mg 2

gabapentin oral solution 250 mg/5 ml, 250 mg/5 ml (5 ml) 2

gabapentin oral tablet 600 mg, 800 mg 2guanfacine oral tablet 1 mg, 2 mg 2guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg 2


47

Drug Name Tier Limitations (Notes)haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml 2

haloperidol lactate injection solution 5 mg/ml 2

haloperidol lactate oral concentrate 2 mg/ml 2

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg 1

hydrocodone-acetaminophen oral solution7.5-325 mg/15 ml 2 QL (5400 ML per 23 days)

hydrocodone-acetaminophen oral tablet10-300 mg, 10-325 mg 2 QL (270 EA per 23 days)

hydrocodone-acetaminophen oral tablet2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg


hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg 2 QL (150 EA per 23 days)

hydromorphone (pf) injection solution 10 mg/ml 2 QL (120 ML per 23 days)

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

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

hydromorphone oral liquid 1 mg/ml 2 QL (675 ML per 23 days)hydromorphone oral tablet 2 mg 2 QL (180 EA per 23 days)hydromorphone oral tablet 4 mg 2 QL (150 EA per 23 days)hydromorphone oral tablet 8 mg 2 QL (60 EA per 23 days)hydroxyzine hcl intramuscular solution 25 mg/ml 2

hydroxyzine hcl oral solution 10 mg/5 ml 4hydroxyzine hcl oral solution 10 mg/5 ml (5 ml) 2

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 2

hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 2

ibuprofen oral suspension 100 mg/5 ml 2ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1

ibuprofen-oxycodone oral tablet 400-5 mg 2imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 2


Drug Name Tier Limitations (Notes)indomethacin oral capsule 25 mg, 50 mg 2indomethacin oral capsule, extended release 75 mg 2

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML

4

ketoprofen oral capsule 50 mg, 75 mg 2ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg 2

ketorolac injection cartridge 30 mg/ml 2ketorolac injection solution 15 mg/ml, 30 mg/ml (1 ml) 2

ketorolac intramuscular solution 60 mg/2 ml 2

ketorolac oral tablet 10 mg 2 QL (20 EA per 30 days)lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1

lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg

2

lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg 2

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG 4 ST; QL (30 EA per 30 days)

LATUDA ORAL TABLET 80 MG 4 ST; QL (60 EA per 30 days)LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 400 MCG/SPRAY 5 PA

levetiracetam intravenous solution 500 mg/5 ml 2

levetiracetam oral solution 100 mg/ml 1levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg 1

levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg 2

LITE COAT ASPIRIN ORAL TABLET 325 MG PVlithium carbonate oral capsule 150 mg, 300 mg, 600 mg 1

lithium carbonate oral tablet 300 mg 1lithium carbonate oral tablet extended release 300 mg, 450 mg 2

lithium citrate oral solution 8 meq/5 ml 2


49

Drug Name Tier Limitations (Notes)LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML 2

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 2loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg 2

magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %)

2


2


maprotiline oral tablet 25 mg, 50 mg, 75 mg 2

mefenamic acid oral capsule 250 mg 5meloxicam oral suspension 7.5 mg/5 ml 2meloxicam oral tablet 15 mg 1meloxicam oral tablet 7.5 mg 1 QL (30 EA per 30 days)memantine oral capsule,sprinkle,er 24hr14 mg, 21 mg, 28 mg, 7 mg 2

memantine oral solution 2 mg/ml 2memantine oral tablet 10 mg, 5 mg 2memantine oral tablets,dose pack 5-10 mg 4methadone oral concentrate 10 mg/ml 2 PA; QL (60 ML per 23 days)methadone oral solution 10 mg/5 ml 2 PA; QL (300 ML per 23 days)methadone oral solution 5 mg/5 ml 2 PA; QL (600 ML per 23 days)methadone oral tablet 10 mg 2 PA; QL (60 EA per 23 days)methadone oral tablet 5 mg 2 PA; QL (120 EA per 23 days)methylphenidate hcl oral capsule, er biphasic 30-70 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

2

methylphenidate hcl oral capsule,er biphasic 50-50 10 mg, 20 mg, 30 mg, 40 mg, 60 mg

2

methylphenidate hcl oral solution 10 mg/5 ml, 5 mg/5 ml 2

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg 2

methylphenidate hcl oral tablet extended release 10 mg, 20 mg 2


Drug Name Tier Limitations (Notes)methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg 2

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg 1

mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg 2

modafinil oral tablet 100 mg, 200 mg 2morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml, 30 mg/30 ml

2

morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) 2 QL (135 ML per 23 days)

morphine injection solution 4 mg/ml, 8 mg/ml 2

morphine injection syringe 10 mg/ml, 2 mg/ml, 8 mg/ml 2

morphine injection syringe 4 mg/ml 2 QL (500 ML per 23 days)morphine intravenous pt controlled analgesia syring 30 mg/30 ml (1 mg/ml) 2

morphine intravenous solution 10 mg/ml, 100 mg/4 ml, 25 mg/ml, 250 mg/10 ml, 4 mg/ml, 50 mg/ml

2

morphine intravenous syringe 2 mg/ml 2morphine intravenous syringe 4 mg/ml 2 QL (500 ML per 23 days)morphine oral capsule,extend.release pellets 100 mg, 50 mg, 60 mg, 80 mg 2 PA; QL (30 EA per 23 days)

morphine oral capsule,extend.release pellets 20 mg 2 PA; QL (120 EA per 23 days)

morphine oral capsule,extend.release pellets 30 mg 2 PA; QL (90 EA per 23 days)

morphine oral solution 10 mg/5 ml 2 QL (900 ML per 23 days)morphine oral solution 20 mg/5 ml (4 mg/ml) 2 QL (675 ML per 23 days)

morphine oral tablet 15 mg 2 QL (180 EA per 23 days)morphine oral tablet 30 mg 2 QL (90 EA per 23 days)morphine oral tablet extended release 100 mg, 200 mg, 60 mg 2 PA; QL (30 EA per 23 days)

morphine oral tablet extended release 15 mg 2 PA; QL (120 EA per 23 days)

morphine oral tablet extended release 30 mg 2 PA; QL (90 EA per 23 days)

nabumetone oral tablet 500 mg, 750 mg 2


51

Drug Name Tier Limitations (Notes)nalbuphine injection solution 10 mg/ml, 20 mg/ml 2

naloxone injection auto-injector 2 mg/0.4 ml 3

naloxone injection solution 0.4 mg/ml 1naloxone injection syringe 0.4 mg/ml, 1 mg/ml 1

naltrexone oral tablet 50 mg 2naproxen oral suspension 125 mg/5 ml 2naproxen oral tablet 250 mg, 375 mg, 500 mg 1

naproxen sodium oral tablet 275 mg, 550 mg 2

naratriptan oral tablet 1 mg, 2.5 mg 2NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION 3

NAYZILAM NASAL SPRAY,NON-AEROSOL 5 MG/SPRAY (0.1 ML) 5

nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg 2

nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg 1

NUEDEXTA ORAL CAPSULE 20-10 MG 4 PA; QL (60 EA per 22 days)olanzapine intramuscular recon soln 10 mg 2olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg 1 QL (30 EA per 23 days)

olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 mg 2 ST; QL (30 EA per 23 days)

opium tincture oral tincture 10 mg/ml (morphine) 2

oxaprozin oral tablet 600 mg 2oxazepam oral capsule 10 mg, 15 mg, 30 mg 2

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 2

oxycodone oral concentrate 20 mg/ml 2 QL (90 ML per 23 days)oxycodone oral solution 5 mg/5 ml 2 QL (1200 ML per 23 days)oxycodone oral tablet 10 mg 2 QL (180 EA per 23 days)oxycodone oral tablet 15 mg 2 QL (120 EA per 23 days)oxycodone oral tablet 20 mg 2 QL (90 EA per 23 days)oxycodone oral tablet 30 mg 2 QL (60 EA per 23 days)


Drug Name Tier Limitations (Notes)oxycodone oral tablet 5 mg 2 QL (360 EA per 23 days)oxycodone-acetaminophen oral tablet 10-325 mg 2 QL (180 EA per 23 days)

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

2

oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg 2 QL (360 EA per 23 days)

oxycodone-acetaminophen oral tablet 7.5-325 mg 2 QL (240 EA per 23 days)

oxycodone-aspirin oral tablet 4.8355-325 mg 2

oxycodone-aspirin oral tablet 4.8355-325 mg 2 QL (360 EA per 23 days)

paroxetine hcl oral tablet 10 mg, 40 mg 1 QL (30 EA per 23 days)paroxetine hcl oral tablet 20 mg, 30 mg 1 QL (60 EA per 23 days)paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg 2 QL (60 EA per 23 days)

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 2

perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg 2

phenelzine oral tablet 15 mg 2phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) 2

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

2

phenytoin oral suspension 125 mg/5 ml 2phenytoin oral tablet,chewable 50 mg 2phenytoin sodium extended oral capsule100 mg, 200 mg, 300 mg 2

phenytoin sodium intravenous solution 50 mg/ml 2

piroxicam oral capsule 10 mg, 20 mg 2pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg 1

pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 300 mg, 50 mg, 75 mg


pregabalin oral solution 20 mg/ml 2primidone oral tablet 250 mg, 50 mg 2


53

Drug Name Tier Limitations (Notes)prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) 2

prochlorperazine maleate oral tablet 10 mg, 5 mg 1

prochlorperazine rectal suppository 25 mg 2promethazine injection solution 25 mg/ml, 50 mg/ml 2


promethazine rectal suppository 12.5 mg, 25 mg 2

propranolol intravenous solution 1 mg/ml 2propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 mg, 80 mg 2



protriptyline oral tablet 10 mg, 5 mg 2quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 QL (90 EA per 23 days)

quetiapine oral tablet 300 mg, 400 mg 1 QL (60 EA per 23 days)quetiapine oral tablet extended release 24 hr 150 mg, 200 mg 2 ST; QL (30 EA per 23 days)

quetiapine oral tablet extended release 24 hr 300 mg, 400 mg, 50 mg 2 ST; QL (60 EA per 23 days)

ramelteon oral tablet 8 mg 2riluzole oral tablet 50 mg 5RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML

4

risperidone oral solution 1 mg/ml 2risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg 1 QL (60 EA per 23 days)

risperidone oral tablet,disintegrating 0.25 mg 2 QL (60 EA per 23 days)

risperidone oral tablet,disintegrating 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg 2 ST; QL (60 EA per 23 days)

rizatriptan oral tablet 10 mg, 5 mg 2rizatriptan oral tablet,disintegrating 10 mg, 5 mg 2


Drug Name Tier Limitations (Notes)ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg 1

ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg 2

salsalate oral tablet 500 mg, 750 mg 2SAPHRIS SUBLINGUAL TABLET 10 MG, 5 MG 4 ST; QL (60 EA per 23 days)

SAPHRIS SUBLINGUAL TABLET 2.5 MG 4 STselegiline hcl oral capsule 5 mg 2selegiline hcl oral tablet 5 mg 2sertraline oral concentrate 20 mg/ml 2sertraline oral tablet 100 mg, 50 mg 1 QL (60 EA per 23 days)sertraline oral tablet 25 mg 1 QL (45 EA per 23 days)SPRAVATO NASAL SPRAY,NON-AEROSOL 28 MG 5 PA

SPRAVATO NASAL SPRAY,NON-AEROSOL 56 MG (28 MG X 2), 84 MG (28 MG X 3) 5 PA; SP

sulindac oral tablet 150 mg, 200 mg 2sumatriptan nasal spray,non-aerosol 20 mg/actuation 2

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg 2

sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml 2

sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml 2

sumatriptan succinate subcutaneous solution 6 mg/0.5 ml 2

temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg 2

tetrabenazine oral tablet 12.5 mg, 25 mg 5 PA; SPthioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg 2

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 2

tiagabine oral tablet 12 mg, 16 mg, 2 mg, 4 mg 2

timolol maleate oral tablet 10 mg, 20 mg, 5 mg 2

tolcapone oral tablet 100 mg 5tolmetin oral capsule 400 mg 2


55

Drug Name Tier Limitations (Notes)tolmetin oral tablet 200 mg, 600 mg 2topiramate oral capsule, sprinkle 15 mg, 25 mg 2

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1

tramadol oral tablet 50 mg 2 QL (240 EA per 30 days)tramadol oral tablet extended release 24 hr100 mg, 200 mg, 300 mg 2 QL (30 EA per 30 days)

tramadol-acetaminophen oral tablet 37.5-325 mg 2 QL (240 EA per 30 days)

tranylcypromine oral tablet 10 mg 2trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg 1

TRI-BUFFERED ASPIRIN ORAL TABLET 325 MG PV

trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg 2

trihexyphenidyl oral elixir 0.4 mg/ml 2trihexyphenidyl oral tablet 2 mg, 5 mg 2TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG 4

valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml) 2

valproic acid (as sodium salt) oral solution250 mg/5 ml, 250 mg/5 ml (5 ml) 2

valproic acid oral capsule 250 mg 2venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 mg 2 QL (30 EA per 23 days)

venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg 1 QL (90 EA per 23 days)

venlafaxine oral tablet extended release 24hr 150 mg, 225 mg, 37.5 mg, 75 mg 2 QL (30 EA per 23 days)

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG 4 QL (30 EA per 23 days)

VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) 4 QL (30 EA per 23 days)

VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML 4

VIMPAT ORAL SOLUTION 10 MG/ML 4VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 4


Drug Name Tier Limitations (Notes)VIVITROL INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 380 MG

5 SP

VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG 4

zaleplon oral capsule 10 mg 2 QL (60 EA per 23 days)zaleplon oral capsule 5 mg 2 QL (30 EA per 23 days)ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg 2 QL (60 EA per 23 days)

zolmitriptan oral tablet 2.5 mg, 5 mg 2zolpidem oral tablet 10 mg 2 QL (30 EA per 23 days)zolpidem oral tablet 5 mg 2zolpidem oral tablet,ext release multiphase12.5 mg, 6.25 mg 2 QL (30 EA per 23 days)

ZOMIG NASAL SPRAY,NON-AEROSOL 2.5 MG, 5 MG 4

zonisamide oral capsule 100 mg, 25 mg, 50 mg 2

CONTRACEPTIVES (E.G. FOAMS, DEVICES)CAYA CONTOURED VAGINAL DIAPHRAGM 65-80 MM PV

FC2 FEMALE CONDOM PVFEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM PV

GYNOL II VAGINAL GEL 3 % PVTODAY CONTRACEPTIVE SPONGE VAGINAL CONTRACEPTIVE SPONGE 1,000 MG PV

VAGINAL CONTRACEPTIVE FILM VAGINAL FILM 28 % PV

VAGINAL CONTRACEPTIVE FOAM VAGINAL FOAM 12.5 % PV

WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 MM PV






57

Drug Name Tier Limitations (Notes)WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM 85 MM PV



DEVICES1ST TIER UNIFINE PENTIPS NEEDLE 29 GAUGE X 1/2" 3

BD PRE-FILLED NORMAL SALINE INJECTION SYRINGE 2

DEXCOM G4 RECEIVER 3 PADEXCOM G4 RECEIVER PEDIATRIC 3 PADEXCOM G4 RECEIVER-SHARE (PED) 3 PADEXCOM G4 RECEIVER-SHARE KIT 3 PADEXCOM G4 TRANSMITTER DEVICE 3 PADEXCOM G5 RECEIVER 3 PADEXCOM G5 TRANSMITTER DEVICE 3 PADEXCOM G5-G4 SENSOR DEVICE 3 PADEXCOM G6 RECEIVER 3 PADEXCOM G6 SENSOR DEVICE 3 PADEXCOM G6 TRANSMITTER DEVICE 3 PADEXCOM RECEIVER 3 PAFEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM PV

FREESTYLE LIBRE 10 DAY READER 3 PAFREESTYLE LIBRE 10 DAY SENSOR KIT 3 PAFREESTYLE LIBRE 14 DAY READER 3 PAFREESTYLE LIBRE 14 DAY SENSOR KIT 3 PAheparin (porcine) in nacl (pf) intravenous parenteral solution 2,000 unit/1,000 ml 2

ONETOUCH ULTRA2 METER KIT 3ONETOUCH ULTRAMINI KIT 3ONETOUCH VERIO FLEX 3ONETOUCH VERIO FLEX START KIT 3ONETOUCH VERIO IQ METER 3REJUVENESS TOPICAL COMBO PACK 4RESTORE WOUND CLEANSER TOPICAL CLEANSER 4


Drug Name Tier Limitations (Notes)DIAGNOSTIC AGENTSDIASTIX STRIP 3glucagon hcl injection recon soln 1 mg/ml 3ONETOUCH ULTRA BLUE TEST STRIP STRIP 3ONETOUCH VERIO STRIP 3ELECTROLYTIC, CALORIC, AND WATER BALANCEacetazolamide oral capsule, extended release 500 mg 2


amiloride oral tablet 5 mg 2amiloride-hydrochlorothiazide oral tablet 5-50 mg 2

AMINOSYN 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % 4

AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 %

4

AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % 4

AMINOSYN 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 %

4

AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % 4

AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % 4

AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % 4

AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % 4

AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % 4

AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 7 %

4

ammonium chloride intravenous solution 5 meq/ml 4

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1


59

Drug Name Tier Limitations (Notes)BD PRE-FILLED NORMAL SALINE INJECTION SYRINGE 2

benazepril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

1


bumetanide injection solution 0.25 mg/ml 2bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1calcium acetate(phosphat bind) oral capsule 667 mg 2

calcium acetate(phosphat bind) oral tablet667 mg 2

captopril-hydrochlorothiazide oral tablet25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg 1

chlorothiazide oral tablet 250 mg, 500 mg 2chlorothiazide sodium intravenous recon soln 500 mg 2

chlorthalidone oral tablet 25 mg, 50 mg 1CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 %

4

CLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION 5 %

4

CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

4

CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

4

CLINIMIX 4.25%-D20W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

4

CLINIMIX 4.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

4

CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5 %

4

CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 %

4


Drug Name Tier Limitations (Notes)CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 %

4


4


4

CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %

4

CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 %

4


4


4

CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % 4


CRYSVITA SUBCUTANEOUS SOLUTION 10 MG/ML, 20 MG/ML, 30 MG/ML 5 PA

d10 %-0.45 % sodium chloride intravenous parenteral solution 2

d2.5 %-0.45 % sodium chloride intravenous parenteral solution 2

d5 % and 0.9 % sodium chloride intravenous parenteral solution 2

d5 %-0.45 % sodium chloride intravenous parenteral solution 2

DAILY PRENATAL ORAL COMBO PACK 28-800-440 MG-MCG-MG PV

dextrose 10 % and 0.2 % nacl intravenous parenteral solution 2

dextrose 10 % in water (d10w) intravenous parenteral solution 10 % 2

dextrose 25 % in water (d25w) intravenous syringe 2


61

Drug Name Tier Limitations (Notes)dextrose 30 % in water (d30w) intravenous parenteral solution 2

dextrose 40 % in water (d40w) intravenous parenteral solution 40 % 2

dextrose 5 % in water (d5w) intravenous parenteral solution 2

dextrose 5 %-lactated ringers intravenous parenteral solution 2

dextrose 5%-0.2 % sod chloride intravenous parenteral solution 2

dextrose 5%-0.3 % sod.chloride intravenous parenteral solution 2


dextrose 50 % in water (d50w) intravenous syringe 2


enalapril-hydrochlorothiazide oral tablet10-25 mg, 5-12.5 mg 1

fosinopril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg 2

FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % 4

furosemide injection solution 10 mg/ml 2furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) 2

furosemide oral tablet 20 mg, 40 mg, 80 mg 1

generlac oral solution 10 gram/15 ml 2HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % 4

hydrochlorothiazide oral capsule 12.5 mg 1hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1

indapamide oral tablet 1.25 mg, 2.5 mg 2INTRALIPID INTRAVENOUS EMULSION 20 % 2

IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % 4

IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % 4


Drug Name Tier Limitations (Notes)irbesartan-hydrochlorothiazide oral tablet150-12.5 mg, 300-12.5 mg 1

ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 %

4

ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION 4

JYNARQUE ORAL TABLET 15 MG, 30 MG 5 PAJYNARQUE ORAL TABLETS, SEQUENTIAL 45 MG (AM)/ 15 MG (PM), 60 MG (AM)/ 30 MG (PM), 90 MG (AM)/ 30 MG (PM)

5 PA

KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ 2

KLOR-CON 8 ORAL TABLET EXTENDED RELEASE 8 MEQ 2

KLOR-CON M15 ORAL TABLET,ER PARTICLES/CRYSTALS 15 MEQ 2

KLOR-CON M20 ORAL TABLET,ER PARTICLES/CRYSTALS 20 MEQ 2

lactated ringers intravenous parenteral solution 2

lactated ringers irrigation solution 2lactulose oral solution 10 gram/15 ml, 10 gram/15 ml (15 ml) 2

LIPOSYN III INTRAVENOUS EMULSION 10 %, 30 % 4

lisinopril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg, 20-25 mg 1

losartan-hydrochlorothiazide oral tablet100-12.5 mg, 100-25 mg, 50-12.5 mg 1

methyclothiazide oral tablet 5 mg 2methyldopa-hydrochlorothiazide oral tablet250-15 mg, 250-25 mg 2

metolazone oral tablet 10 mg, 2.5 mg, 5 mg 2


MONOJECT 0.9% SODIUM CHLORIDE INJECTION SYRINGE 2

NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % 4

NORMAL SALINE FLUSH INJECTION SYRINGE 2


63

Drug Name Tier Limitations (Notes)NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 4

NORMOSOL-R IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 %

4

NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION 4

NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION 4



PHYSIOLYTE IRRIGATION SOLUTION 140-5-3-98 MEQ/L 4

PHYSIOSOL IRRIGATION IRRIGATION SOLUTION 140-5-3-98 MEQ/L 4

PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION 4

PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION 4

potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l

2

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

2

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

2

potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l, 40 meq/l 2

potassium chloride in water intravenous piggyback 10 meq/100 ml, 10 meq/50 ml, 20 meq/100 ml, 20 meq/50 ml, 30 meq/100 ml, 40 meq/100 ml

2

potassium chloride intravenous solution 2 meq/ml 2

potassium chloride oral capsule, extended release 10 meq, 8 meq 2

potassium chloride oral packet 20 meq 2potassium chloride oral tablet extended release 10 meq, 20 meq, 8 meq 2


Drug Name Tier Limitations (Notes)potassium chloride oral tablet,er particles/crystals 10 meq, 20 meq 2

potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l 2

potassium chloride-d5-0.2%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 40 meq/l

2

potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l 2

potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

2

potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg)

2

PREMASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % 2

PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 % 4








probenecid oral tablet 500 mg 2probenecid-colchicine oral tablet 500-0.5 mg 2

PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION 3 % 4


PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION 4


65

Drug Name Tier Limitations (Notes)quinapril-hydrochlorothiazide oral tablet10-12.5 mg, 20-12.5 mg, 20-25 mg 2

ringer's intravenous parenteral solution 2ringer's irrigation solution 2SAMSCA ORAL TABLET 15 MG 5 PA; QL (30 EA per 23 days)SAMSCA ORAL TABLET 30 MG 5 PA; QL (60 EA per 23 days)sevelamer carbonate oral powder in packet0.8 gram, 2.4 gram 5

sevelamer carbonate oral tablet 800 mg 2sevelamer hcl oral tablet 400 mg, 800 mg 2sodium chlor 0.9% bacteriostat injection solution 0.9 % 2

sodium chloride 0.45 % intravenous parenteral solution 0.45 % 2

sodium chloride 0.9 % (flush) injection syringe 2

sodium chloride 0.9 % injection solution 2sodium chloride 0.9 % intravenous piggyback 2

sodium chloride 3 % intravenous parenteral solution 3 % 2

sodium chloride 5 % intravenous parenteral solution 5 % 2

sodium chloride intravenous parenteral solution 2.5 meq/ml, 4 meq/ml 2

sodium chloride irrigation solution 0.9 % 2sodium citrate-citric acid oral solution 500-334 mg/5 ml 2

sodium lactate intravenous solution 5 meq/ml 2

sodium phenylbutyrate oral powder 0.94 gram/gram 5 PA

sodium phenylbutyrate oral tablet 500 mg 5 PAsodium polystyrene sulfonate rectal enema30 gram/120 ml 2

spironolactone oral tablet 100 mg, 25 mg, 50 mg 1

spironolacton-hydrochlorothiaz oral tablet25-25 mg 2

SPS (WITH SORBITOL) RECTAL ENEMA 30-40 GRAM/120 ML 2


Drug Name Tier Limitations (Notes)theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg 2


torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 2

TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % 2

triamterene-hydrochlorothiazid oral capsule 37.5-25 mg, 50-25 mg 1

triamterene-hydrochlorothiazid oral tablet37.5-25 mg, 75-50 mg 1

TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % 4

TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 % 4

valsartan-hydrochlorothiazide oral tablet160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

1

VELTASSA ORAL POWDER IN PACKET 16.8 GRAM, 25.2 GRAM, 8.4 GRAM 5 SP

water for irrigation, sterile irrigation solution 2

ENZYMESALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML 5 PA; SP

CEREZYME INTRAVENOUS RECON SOLN 400 UNIT 5 PA; SP

ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML 5 PA; SP

ELELYSO INTRAVENOUS RECON SOLN 200 UNIT 5 PA

FABRAZYME INTRAVENOUS RECON SOLN 35 MG, 5 MG 5 PA; SP

LUMIZYME INTRAVENOUS RECON SOLN 50 MG 5 PA; SP

PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG/0.5 ML, 2.5 MG/0.5 ML, 20 MG/ML 5 PA; SP

PULMOZYME INHALATION SOLUTION 1 MG/ML 5 SP

REVCOVI INTRAMUSCULAR SOLUTION 2.4 MG/1.5 ML (1.6 MG/ML) 5 PA


67

Drug Name Tier Limitations (Notes)STRENSIQ SUBCUTANEOUS SOLUTION 18 MG/0.45 ML, 28 MG/0.7 ML, 40 MG/ML, 80 MG/0.8 ML

5 PA

VIMIZIM INTRAVENOUS SOLUTION 5 MG/5 ML (1 MG/ML) 5 PA; SP

VORAXAZE INTRAVENOUS RECON SOLN 1,000 UNIT 4

VPRIV INTRAVENOUS RECON SOLN 400 UNIT 5 PA; SP

EYE, EAR, NOSE AND THROAT (EENT) PREPS.acetazolamide oral capsule, extended release 500 mg 2


acetic acid otic (ear) solution 2 % 2apraclonidine ophthalmic (eye) drops 0.5 % 2

atropine ophthalmic (eye) drops 1 % 2azelastine nasal aerosol,spray 137 mcg (0.1 %) 2 QL (60 ML per 22 days)

azelastine nasal spray,non-aerosol 0.15 % (205.5 mcg) 2 QL (60 ML per 22 days)

azelastine ophthalmic (eye) drops 0.05 % 2bacitracin ophthalmic (eye) ointment 500 unit/gram 2

bacitracin-polymyxin b ophthalmic (eye) ointment 500-10,000 unit/gram 2

betaxolol ophthalmic (eye) drops 0.5 % 2bimatoprost base of the eyelashes drops with applicator 0.03 % 2

bimatoprost ophthalmic (eye) drops 0.03 % 2

brimonidine ophthalmic (eye) drops 0.15 %, 0.2 % 2

carteolol ophthalmic (eye) drops 1 % 2chlorhexidine gluconate mucous membrane mouthwash 0.12 % 2

CIPRODEX OTIC (EAR) DROPS,SUSPENSION 0.3-0.1 % 4


Drug Name Tier Limitations (Notes)ciprofloxacin hcl ophthalmic (eye) drops0.3 % 2

ciprofloxacin hcl otic (ear) dropperette 0.2 % 2

ciprofloxacin-fluocinolone otic (ear) solution 0.3-0.025 % (0.25 ml) 3

cromolyn ophthalmic (eye) drops 4 % 2dexamethasone sodium phosphate ophthalmic (eye) drops 0.1 % 2

diclofenac sodium ophthalmic (eye) drops0.1 % 2

dorzolamide ophthalmic (eye) drops 2 % 2dorzolamide-timolol ophthalmic (eye) drops 22.3-6.8 mg/ml 2

doxycycline hyclate oral tablet 20 mg 2erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %) 2

fluocinolone acetonide oil otic (ear) drops0.01 % 2

fluorometholone ophthalmic (eye) drops,suspension 0.1 % 2

flurbiprofen sodium ophthalmic (eye) drops0.03 % 2

fluticasone propionate nasal spray,suspension 50 mcg/actuation 2 QL (16 GM per 30 days)

gatifloxacin ophthalmic (eye) drops 0.5 % 2gentamicin ophthalmic (eye) drops 0.3 % 2hydrocortisone-acetic acid otic (ear) drops1-2 % 2

ipratropium bromide nasal spray,non-aerosol 0.03 %, 42 mcg (0.06 %) 2 QL (30 ML per 30 days)

ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % 2

latanoprost ophthalmic (eye) drops 0.005 % 2

levobunolol ophthalmic (eye) drops 0.5 % 2levofloxacin ophthalmic (eye) drops 0.5 % 2lidocaine hcl mucous membrane jelly 2 % 2lidocaine hcl mucous membrane jelly in applicator 2 % 2

lidocaine hcl mucous membrane solution 4 % (40 mg/ml) 2


69

Drug Name Tier Limitations (Notes)LIDOCAINE VISCOUS MUCOUS MEMBRANE SOLUTION 2 % 2

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % 4

methazolamide oral tablet 25 mg, 50 mg 2metipranolol ophthalmic (eye) drops 0.3 % 2moxifloxacin ophthalmic (eye) drops 0.5 % 2NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 % 4

neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 3.5-400-10,000 mg-unit/g-1%

2

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 3.5-400-10,000 mg-unit-unit/g

2

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension3.5mg/ml-10,000 unit/ml-0.1 %

2

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 %

2

neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg-10,000 unit-0.025mg/ml

2

neomycin-polymyxin-hc ophthalmic (eye) drops,suspension 3.5-10,000-10 mg-unit-mg/ml

2

neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-10,000-1 mg/ml-unit/ml-%

2

neomycin-polymyxin-hc otic (ear) solution3.5-10,000-1 mg/ml-unit/ml-% 2

ofloxacin ophthalmic (eye) drops 0.3 % 2ofloxacin otic (ear) drops 0.3 % 2olopatadine ophthalmic (eye) drops 0.1 %, 0.2 % 2

OXERVATE OPHTHALMIC (EYE) DROPS 0.002 % 5 PA

PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS 0.125 % 4

polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml 2


Drug Name Tier Limitations (Notes)prednisolone acetate ophthalmic (eye) drops,suspension 1 % 2

prednisolone sodium phosphate ophthalmic (eye) drops 1 % 2

proparacaine ophthalmic (eye) drops 0.5 % 2

sulfacetamide sodium ophthalmic (eye) drops 10 % 2

sulfacetamide sodium ophthalmic (eye) ointment 10 % 2

sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0.23 % (0.25 %) 2

tetracaine hcl ophthalmic (eye) drops 0.5 % 2

timolol maleate ophthalmic (eye) drops0.25 %, 0.5 % 1

timolol maleate ophthalmic (eye) gel forming solution 0.25 %, 0.5 % 2

TOBRADEX OPHTHALMIC (EYE) OINTMENT 0.3-0.1 % 4

tobramycin ophthalmic (eye) drops 0.3 % 2tobramycin-dexamethasone ophthalmic (eye) drops,suspension 0.3-0.1 % 2

TRAVATAN Z OPHTHALMIC (EYE) DROPS 0.004 % 4

triamcinolone acetonide nasal aerosol,spray 55 mcg 2

trifluridine ophthalmic (eye) drops 1 % 2TYZINE NASAL DROPS 0.05 %, 0.1 % 4XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 % 4 QL (60 EA per 30 days)

ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % 4ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3-0.5 % 4

GASTROINTESTINAL DRUGSadvanced antacid-antigas oral suspension400-400-40 mg/5 ml 2

ALOPHEN (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) 5 MG PV

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG 4aprepitant oral capsule 125 mg, 40 mg 2 QL (1 EA per 23 days)aprepitant oral capsule 80 mg 2


71

Drug Name Tier Limitations (Notes)aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2) 2 QL (3 EA per 23 days)

balsalazide oral capsule 750 mg 2bisacodyl oral tablet,delayed release (dr/ec) 5 mg PV

BISA-LAX (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) 5 MG PV

BISMATROL ORAL SUSPENSION 262 MG/15 ML 2

BISMATROL ORAL TABLET,CHEWABLE 262 MG 2

CHENODAL ORAL TABLET 250 MG 5 PAcimetidine hcl oral solution 300 mg/5 ml 2cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg 2

CITRATE OF MAGNESIA ORAL SOLUTION PVCITROMA ORAL SOLUTION PVCLEARLAX ORAL POWDER 17 GRAM/DOSE PVCLEARLAX ORAL POWDER IN PACKET 17 GRAM PV

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 6,000-19,000 -30,000 UNIT

5

diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic 50-200 mg-mcg, 75-200 mg-mcg

2

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml 2


dronabinol oral capsule 10 mg, 2.5 mg, 5 mg 2

DUCODYL (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) 5 MG PV

esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg 2 QL (30 EA per 30 days)

esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg 2

famotidine (pf)-nacl (iso-os) intravenous piggyback 20 mg/50 ml 2

famotidine intravenous solution 10 mg/ml 2Explanations of Limitations can be found on page v.Effective: March 1, 202072

Drug Name Tier Limitations (Notes)famotidine oral suspension 40 mg/5 ml (8 mg/ml) 2

famotidine oral tablet 20 mg, 40 mg 1FLEET LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) 5 MG PV

GAVILAX ORAL POWDER 17 GRAM/DOSE PVGAVILAX ORAL POWDER IN PACKET 17 GRAM, 8.5 GRAM PV

GAVILYTE-C ORAL RECON SOLN 240-22.72-6.72 -5.84 GRAM PV

GAVILYTE-G ORAL RECON SOLN 236-22.74-6.74 -5.86 GRAM PV

GAVILYTE-N ORAL RECON SOLN 420 GRAM PVGENTLE LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) 5 MG PV

GENTLELAX ORAL POWDER 17 GRAM/DOSE PV

GLYCOLAX ORAL POWDER 17 GRAM/DOSE PVgranisetron (pf) intravenous solution 100 mcg/ml 2

granisetron hcl intravenous solution 1 mg/ml, 1 mg/ml (1 ml) 2

granisetron hcl oral tablet 1 mg 2 QL (6 EA per 30 days)HEALTHYLAX ORAL POWDER IN PACKET 17 GRAM PV

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML

5 PA; SP; QL (2 EA per 21 days)

HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML


HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML


HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML 5 PA; SP; QL (2 EA per 21 days)

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML 5 PA; SP; QL (2 EA per 21 days)

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



73

Drug Name Tier Limitations (Notes)HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML


HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML


HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML, 80 MG/0.8 ML


HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML, 40 MG/0.4 ML


lansoprazole oral capsule,delayed release(dr/ec) 15 mg, 30 mg 2 QL (30 EA per 30 days)

LAXACLEAR ORAL POWDER 17 GRAM/DOSE PV

LAXATIVE (BISACODYL) ORAL TABLET 5 MG PV

LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) 5 MG PV

LAXATIVE FEMININE ORAL TABLET 5 MG PVLINZESS ORAL CAPSULE 145 MCG, 290 MCG 4

loperamide oral capsule 2 mg 2loperamide oral liquid 1 mg/7.5 ml 2loperamide oral tablet 2 mg 2magnesium citrate oral solution PVmeclizine oral tablet 12.5 mg, 25 mg 2mesalamine oral capsule (with del rel tablets) 400 mg 2

mesalamine oral tablet,delayed release (dr/ec) 1.2 gram, 800 mg 2

mesalamine rectal enema 4 gram/60 ml 2mesalamine rectal suppository 1,000 mg 2mesalamine with cleansing wipe rectal enema kit 4 gram/60 ml 2

metoclopramide hcl injection solution 5 mg/ml 2

metoclopramide hcl oral solution 5 mg/5 ml 2

metoclopramide hcl oral tablet 10 mg, 5 mg 1


Drug Name Tier Limitations (Notes)MILK OF MAGNESIA CONCENTRATED ORAL SUSPENSION 2,400 MG/10 ML PV

MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5 ML PV

MIRALAX ORAL POWDER IN PACKET 17 GRAM PV

misoprostol oral tablet 100 mcg, 200 mcg 2MOTOFEN ORAL TABLET 1-0.025 MG 4nizatidine oral capsule 150 mg, 300 mg 2nizatidine oral solution 150 mg/10 ml 2OCALIVA ORAL TABLET 10 MG, 5 MG 5 PAomeprazole oral capsule,delayed release(dr/ec) 10 mg 2 QL (30 EA per 30 days)

omeprazole oral capsule,delayed release(dr/ec) 20 mg, 40 mg 2

ondansetron hcl (pf) injection solution 4 mg/2 ml 2

ondansetron hcl intravenous solution 2 mg/ml 2

ondansetron hcl oral solution 4 mg/5 ml 2ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg 2

ondansetron oral tablet,disintegrating 4 mg, 8 mg 2

opium tincture oral tincture 10 mg/ml (morphine) 2

ORAL SALINE LAXATIVE ORAL LIQUID 7.2-2.7 GRAM/15 ML PV

ORAL SALINE LAXATIVE ORAL SOLUTION PVOSMOPREP ORAL TABLET 1.5 GRAM 4palonosetron intravenous solution 0.25 mg/2 ml, 0.25 mg/5 ml 4

pantoprazole intravenous recon soln 40 mg 2pantoprazole oral tablet,delayed release (dr/ec) 20 mg 2 QL (30 EA per 30 days)

pantoprazole oral tablet,delayed release (dr/ec) 40 mg 2

paregoric oral liquid 2 mg/5 ml 2peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram, 240-22.72-6.72 -5.84 gram

PV


75

Drug Name Tier Limitations (Notes)PEG-3350 WITH FLAVOR PACKS ORAL RECON SOLN 420 GRAM PV

peg-electrolyte soln oral recon soln 420 gram PV

PEG-PREP ORAL KIT 5-210 MG-GRAM PVPENTASA ORAL CAPSULE, EXTENDED RELEASE 250 MG, 500 MG 4

PHOSPHATE LAXATIVE ORAL LIQUID 7.2-2.7 GRAM/15 ML PV

polyethylene glycol 3350 oral powder 17 gram/dose PV

polyethylene glycol 3350 oral powder in packet 17 gram PV

POWDERLAX ORAL POWDER 17 GRAM/DOSE PV

prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) 2

prochlorperazine maleate oral tablet 10 mg, 5 mg 1

prochlorperazine rectal suppository 25 mg 2PURELAX ORAL POWDER IN PACKET 17 GRAM PV

PYLERA ORAL CAPSULE 140-125-125 MG 4ranitidine hcl injection solution 25 mg/ml 2ranitidine hcl oral capsule 150 mg, 300 mg 1ranitidine hcl oral syrup 15 mg/ml 2ranitidine hcl oral tablet 150 mg, 300 mg 1RENFLEXIS INTRAVENOUS RECON SOLN 100 MG 5

SMOOTHLAX ORAL POWDER 17 GRAM/DOSE PV

SMOOTHLAX ORAL POWDER IN PACKET 17 GRAM PV

sucralfate oral tablet 1 gram 2sulfasalazine oral tablet 500 mg 2sulfasalazine oral tablet,delayed release (dr/ec) 500 mg 2

TRILYTE WITH FLAVOR PACKETS ORAL RECON SOLN 420 GRAM PV

trimethobenzamide oral capsule 300 mg 2ursodiol oral capsule 300 mg 2


Drug Name Tier Limitations (Notes)ursodiol oral tablet 250 mg, 500 mg 2VIBERZI ORAL TABLET 100 MG, 75 MG 4WOMAN'S LAXATIVE (BISACODYL) ORAL TABLET 5 MG PV

WOMAN'S LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) 5 MG PV

WOMEN'S GENTLE LAXATIVE(BISAC) ORAL TABLET,DELAYED RELEASE (DR/EC) 5 MG PV

WOMEN'S LAXATIVE (BISACODYL) ORAL TABLET 5 MG PV

XERMELO ORAL TABLET 250 MG 5 PAHEAVY METAL ANTAGONISTSdeferasirox oral tablet 360 mg, 90 mg 5 PA; SPdeferasirox oral tablet, dispersible 125 mg, 250 mg, 500 mg 5 PA; SP

FERRIPROX ORAL SOLUTION 100 MG/ML 5 PAFERRIPROX ORAL TABLET 1,000 MG, 500 MG 5 PA

trientine oral capsule 250 mg 5 SPHORMONES AND SYNTHETIC SUBSTITUTESacarbose oral tablet 100 mg, 25 mg, 50 mg 2

AFTERA ORAL TABLET 1.5 MG PV QL (1 EA per 30 days)A-HYDROCORT INJECTION RECON SOLN 100 MG 2

ALTAVERA (28) ORAL TABLET 0.15-0.03 MG PV

ALYACEN 1/35 (28) ORAL TABLET 1-35 MG-MCG PV

ALYACEN 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG PV

AMETHIA LO ORAL TABLETS,DOSE PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7) PV

AMETHIA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) PV

AMETHYST (28) ORAL TABLET 90-20 MCG (28) PV

anastrozole oral tablet 1 mg 2ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR 4 PA; QL (30 EA per 30 days)

ANDROXY ORAL TABLET 10 MG 4Explanations of Limitations can be found on page v.Effective: March 1, 2020

77

Drug Name Tier Limitations (Notes)APRI ORAL TABLET 0.15-0.03 MG PVARANELLE (28) ORAL TABLET 0.5/1/0.5-35 MG-MCG PV

ASHLYNA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) PV

ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION

3 ST; QL (13 GM per 30 days)

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (120), 220 MCG/ ACTUATION (14), 220 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (60)

3 ST; QL (1 EA per 30 days)

AUBRA EQ ORAL TABLET 0.1-20 MG-MCG PVAUBRA ORAL TABLET 0.1-20 MG-MCG PVAVIANE ORAL TABLET 0.1-20 MG-MCG PVAZURETTE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 PV

BALZIVA (28) ORAL TABLET 0.4-35 MG-MCG PV

BAQSIMI NASAL SPRAY,NON-AEROSOL 3 MG/ACTUATION 3

BASAGLAR KWIKPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

3

BEKYREE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 PV

BEYAZ ORAL TABLET 3-0.02-0.451 MG (24) (4) PV

BLISOVI 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4) PV

BLISOVI FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) PV

BLISOVI FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) PV

BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE

3

BREVICON (28) ORAL TABLET 0.5-35 MG-MCG PV

BRIELLYN ORAL TABLET 0.4-35 MG-MCG PV


Drug Name Tier Limitations (Notes)budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml 2 QL (120 ML per 30 days)

budesonide inhalation suspension for nebulization 1 mg/2 ml 2 QL (60 ML per 30 days)

budesonide oral capsule,delayed,extend.release 3 mg 2

BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85 ML 3 PA; QL (4 ML per 30 days)

BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML 3 PA; QL (4 EA per 30 days)

BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML 3 PA; QL (3 ML per 30 days)

BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML 3 PA; QL (2 ML per 30 days)

calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation 2

CAMILA ORAL TABLET 0.35 MG PVCAMRESE LO ORAL TABLETS,DOSE PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7) PV

CAMRESE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) PV

CAZIANT (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG PV

CHATEAL (28) ORAL TABLET 0.15-0.03 MG PVCHATEAL EQ (28) ORAL TABLET 0.15-0.03 MG PV

cinacalcet oral tablet 30 mg, 60 mg, 90 mg 5 SPcortisone oral tablet 25 mg 2CRYSELLE (28) ORAL TABLET 0.3-30 MG-MCG PV

CYCLAFEM 1/35 (28) ORAL TABLET 1-35 MG-MCG PV

CYCLAFEM 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG PV

CYCLESSA (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG PV

CYRED EQ ORAL TABLET 0.15-0.03 MG PVCYRED ORAL TABLET 0.15-0.03 MG PVdanazol oral capsule 100 mg, 200 mg, 50 mg 2

DASETTA 1/35 (28) ORAL TABLET 1-35 MG-MCG PV


79

Drug Name Tier Limitations (Notes)DASETTA 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG PV

DAYSEE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) PV

DEBLITANE ORAL TABLET 0.35 MG PVDELYLA (28) ORAL TABLET 0.1-20 MG-MCG PV

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML PV

DEPO-PROVERA INTRAMUSCULAR SYRINGE 150 MG/ML PV

desmopressin injection solution 4 mcg/ml 5desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml) 2

desmopressin oral tablet 0.1 mg, 0.2 mg 2desog-e.estradiol/e.estradiol oral tablet0.15-0.02 mgx21 /0.01 mg x 5 PV

desogestrel-ethinyl estradiol oral tablet0.15-0.03 mg PV

DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML 2

dexamethasone oral solution 0.5 mg/5 ml 2dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg 1

dexamethasone sodium phos (pf) injection solution 10 mg/ml 2

dexamethasone sodium phosphate injection solution 10 mg/ml, 4 mg/ml 2

drospirenone-e.estradiol-lm.fa oral tablet3-0.02-0.451 mg (24) (4), 3-0.03-0.451 mg (21) (7)

PV

drospirenone-ethinyl estradiol oral tablet3-0.02 mg, 3-0.03 mg PV



ECONTRA EZ ORAL TABLET 1.5 MG PV QL (1 EA per 30 days)ELINEST ORAL TABLET 0.3-30 MG-MCG PVELLA ORAL TABLET 30 MG PV QL (1 EA per 30 days)ELURYNG VAGINAL RING 0.12-0.015 MG/24 HR PV

EMOQUETTE ORAL TABLET 0.15-0.03 MG PV


Drug Name Tier Limitations (Notes)ENPRESSE ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10) PV

ENSKYCE ORAL TABLET 0.15-0.03 MG PVERRIN ORAL TABLET 0.35 MG PVESTARYLLA ORAL TABLET 0.25-35 MG-MCG PV

estradiol oral tablet 0.5 mg, 1 mg, 2 mg 2estradiol transdermal patch semiweekly0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

2

estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

2

estradiol vaginal cream 0.01 % (0.1 mg/gram) 2

estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml 2

estradiol-norethindrone acet oral tablet0.5-0.1 mg, 1-0.5 mg 2

ESTROSTEP FE-28 ORAL TABLET 1-20(5)/1-30(7) /1MG-35MCG (9) PV

ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg-mcg PV

etonogestrel-ethinyl estradiol vaginal ring0.12-0.015 mg/24 hr PV

exemestane oral tablet 25 mg 2FALMINA (28) ORAL TABLET 0.1-20 MG-MCG PV

FARXIGA ORAL TABLET 10 MG, 5 MG 3 QL (30 EA per 30 days)FAYOSIM ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-20 MCG/ 0.15 MG-25 MCG

PV

FEMYNOR ORAL TABLET 0.25-35 MG-MCG PVFLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION 3 QL (1 EA per 30 days)

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION 3 QL (4 EA per 30 days)


FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION 3 QL (12 GM per 30 days)


81

Drug Name Tier Limitations (Notes)FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION 3 QL (24 GM per 30 days)


fludrocortisone oral tablet 0.1 mg 2fluticasone propion-salmeterol inhalation aerosol powdr breath activated 113-14 mcg/actuation, 232-14 mcg/actuation, 55-14 mcg/actuation

3

GENERESS FE ORAL TABLET,CHEWABLE 0.8MG-25MCG(24) AND 75 MG (4) PV

GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML

5 PA; SP

GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML)

5 PA; SP

GIANVI (28) ORAL TABLET 3-0.02 MG PVglimepiride oral tablet 1 mg 1 QL (240 EA per 22 days)glimepiride oral tablet 2 mg 1 QL (120 EA per 22 days)glimepiride oral tablet 4 mg 1 QL (60 EA per 22 days)glipizide oral tablet 10 mg 1 QL (120 EA per 22 days)glipizide oral tablet 5 mg 1 QL (240 EA per 22 days)glipizide oral tablet extended release 24hr10 mg 1

glipizide oral tablet extended release 24hr2.5 mg 1 QL (240 EA per 22 days)

glipizide oral tablet extended release 24hr5 mg 1 QL (60 EA per 22 days)

glipizide-metformin oral tablet 2.5-250 mg 1 QL (240 EA per 22 days)glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg 1 QL (120 EA per 22 days)

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION RECON SOLN 1 MG 3

glucagon hcl injection recon soln 1 mg/ml 3glyburide micronized oral tablet 1.5 mg 1 QL (240 EA per 22 days)glyburide micronized oral tablet 3 mg 1 QL (120 EA per 22 days)glyburide micronized oral tablet 6 mg 1 QL (60 EA per 22 days)glyburide oral tablet 1.25 mg 1


Drug Name Tier Limitations (Notes)glyburide oral tablet 2.5 mg 1 QL (240 EA per 22 days)glyburide oral tablet 5 mg 1 QL (120 EA per 22 days)glyburide-metformin oral tablet 1.25-250 mg 1 QL (240 EA per 22 days)

glyburide-metformin oral tablet 2.5-500 mg, 5-500 mg 1

GVOKE SYRINGE SUBCUTANEOUS SYRINGE 0.5 MG/0.1 ML, 1 MG/0.2 ML 3

HAILEY 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4) PV

HEATHER ORAL TABLET 0.35 MG PVhydrocortisone oral tablet 10 mg, 20 mg, 5 mg 2

hydroxyprogest(pf)(preg presv) intramuscular oil 250 mg/ml (1 ml) 5 PA; SP

hydroxyprogesterone cap(ppres) intramuscular oil 250 mg/ml 5 PA; SP

hydroxyprogesterone capr(bulk) powder100 % 5 PA; SP

hydroxyprogesterone caproate intramuscular oil 250 mg/ml 5 PA; SP

INTROVALE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (91) PV

ISIBLOOM ORAL TABLET 0.15-0.03 MG PVJANUMET ORAL TABLET 50-1,000 MG, 50-500 MG 3 QL (60 EA per 30 days)

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-500 MG


JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG 3 QL (60 EA per 30 days)

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG 3 QL (30 EA per 30 days)

JARDIANCE ORAL TABLET 10 MG, 25 MG 3 QL (30 EA per 30 days)JENCYCLA ORAL TABLET 0.35 MG PVJINTELI ORAL TABLET 1-5 MG-MCG 2JOLESSA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (91) PV

JOLIVETTE ORAL TABLET 0.35 MG PVJULEBER ORAL TABLET 0.15-0.03 MG PVJUNEL 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG PV


83

Drug Name Tier Limitations (Notes)JUNEL 1/20 (21) ORAL TABLET 1-20 MG-MCG PV

JUNEL FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) PV

JUNEL FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) PV

JUNEL FE 24 ORAL TABLET 1 MG-20 MCG (24)/75 MG (4) PV

KAITLIB FE ORAL TABLET,CHEWABLE 0.8MG-25MCG(24) AND 75 MG (4) PV

KARIVA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 PV

KELNOR 1/35 (28) ORAL TABLET 1-35 MG-MCG PV

KELNOR 1-50 ORAL TABLET 1-50 MG-MCG PVKISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG

5 PA

KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 MG 3 QL (60 EA per 30 days)

KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG 3 QL (30 EA per 30 days)

KURVELO (28) ORAL TABLET 0.15-0.03 MG PVl norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7), 0.15 mg-20 mcg/ 0.15 mg-25 mcg, 0.15 mg-30 mcg (84)/10 mcg (7)

PV

LARIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG PV

LARIN 1/20 (21) ORAL TABLET 1-20 MG-MCG PV

LARIN 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4) PV

LARIN FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) PV

LARIN FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) PV

LARISSIA ORAL TABLET 0.1-20 MG-MCG PVLAYOLIS FE ORAL TABLET,CHEWABLE 0.8MG-25MCG(24) AND 75 MG (4) PV


Drug Name Tier Limitations (Notes)LEENA 28 ORAL TABLET 0.5/1/0.5-35 MG-MCG PV

LESSINA ORAL TABLET 0.1-20 MG-MCG PVletrozole oral tablet 2.5 mg 2leuprolide subcutaneous kit 1 mg/0.2 ml 5 SPLEVONEST (28) ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10) PV

levonorgestrel oral tablet 1.5 mg PV QL (1 EA per 30 days)levonorgestrel-ethinyl estrad oral tablet0.1-20 mg-mcg, 0.15-0.03 mg, 90-20 mcg (28)

PV

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (91)

PV

levonorg-eth estrad triphasic oral tablet50-30 (6)/75-40 (5)/125-30(10) PV

LEVORA-28 ORAL TABLET 0.15-0.03 MG PVlevothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

1

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

1

LILETTA INTRAUTERINE INTRAUTERINE DEVICE 20.1 MCG/24 HRS (6 YRS) 52 MG 5

LILLOW (28) ORAL TABLET 0.15-0.03 MG PVliothyronine intravenous solution 10 mcg/ml 2

liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg 2

LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG PV

LOESTRIN 1/20 (21) ORAL TABLET 1-20 MG-MCG PV

LOESTRIN FE 1.5/30 (28-DAY) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) PV

LOESTRIN FE 1/20 (28-DAY) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) PV

LORYNA (28) ORAL TABLET 3-0.02 MG PV


85

Drug Name Tier Limitations (Notes)LOSEASONIQUE ORAL TABLETS,DOSE PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7)

PV

LOW-OGESTREL (28) ORAL TABLET 0.3-30 MG-MCG PV

LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 22.5 MG

5 PA; SP



LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG 5 PA; SP

LUPRON DEPOT-PED INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG (PED) 5 PA; SP

LUTERA (28) ORAL TABLET 0.1-20 MG-MCG PV

LYZA ORAL TABLET 0.35 MG PVMARLISSA (28) ORAL TABLET 0.15-0.03 MG PV

medroxyprogesterone intramuscular suspension 150 mg/ml PV

medroxyprogesterone intramuscular syringe 150 mg/ml PV

medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg 2

megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml) 2 PA

megestrol oral tablet 20 mg, 40 mg 2 PAMELODETTA 24 FE ORAL TABLET,CHEWABLE 1 MG-20 MCG(24) /75 MG (4)

PV

metformin oral tablet 1,000 mg 1metformin oral tablet 500 mg 1 QL (150 EA per 22 days)metformin oral tablet 850 mg 1 QL (90 EA per 22 days)metformin oral tablet extended release 24 hr 500 mg 2 QL (150 EA per 22 days)

metformin oral tablet extended release 24 hr 750 mg 1

metformin oral tablet extended release 24hr 500 mg 2 QL (150 EA per 30 days)

methimazole oral tablet 10 mg, 5 mg 2Explanations of Limitations can be found on page v.Effective: March 1, 202086

Drug Name Tier Limitations (Notes)methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml 2

methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1

methylprednisolone oral tablets,dose pack4 mg 1

methylprednisolone sodium succ injection recon soln 125 mg, 40 mg 2

methylprednisolone sodium succ intravenous recon soln 1,000 mg, 500 mg 2

methyltestosterone oral tablet 10 mg 2MIBELAS 24 FE ORAL TABLET,CHEWABLE 1 MG-20 MCG(24) /75 MG (4) PV

MICROGESTIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG PV

MICROGESTIN 1/20 (21) ORAL TABLET 1-20 MG-MCG PV

MICROGESTIN 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4) PV

MICROGESTIN FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) PV

MICROGESTIN FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) PV

MILI ORAL TABLET 0.25-35 MG-MCG PVMIRCETTE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 PV

MIRENA INTRAUTERINE INTRAUTERINE DEVICE 20 MCG/24 HOURS (5 YRS) 52 MG PV

MONO-LINYAH ORAL TABLET 0.25-35 MG-MCG PV

MONONESSA (28) ORAL TABLET 0.25-35 MG-MCG PV

MY CHOICE ORAL TABLET 1.5 MG PV QL (1 EA per 23 days)MY WAY ORAL TABLET 1.5 MG PV QL (1 EA per 23 days)nateglinide oral tablet 120 mg, 60 mg 2NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE

5 PA

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG PV

NEW DAY ORAL TABLET 1.5 MG PV QL (1 EA per 23 days)NEXPLANON SUBDERMAL IMPLANT 68 MG PV SP


87

Drug Name Tier Limitations (Notes)NEXT CHOICE ONE DOSE ORAL TABLET 1.5 MG PV QL (1 EA per 23 days)

NIKKI (28) ORAL TABLET 3-0.02 MG PVNORA-BE ORAL TABLET 0.35 MG PVNORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML)

5 PA; SP

noreth-ethinyl estradiol-iron oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7), 0.8mg-25mcg(24) and 75 mg (4)

PV

norethindrone (contraceptive) oral tablet0.35 mg PV

norethindrone acetate oral tablet 5 mg 2norethindrone ac-eth estradiol oral tablet0.5-2.5 mg-mcg 2

norethindrone ac-eth estradiol oral tablet1-20 mg-mcg PV

norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1 mg-20 mcg (24)/75 mg (4)

PV

norethindrone-e.estradiol-iron oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4)

PV

norgestimate-ethinyl estradiol oral tablet0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg

PV

norgestrel-ethinyl estradiol oral tablet 0.5-50 mg-mcg PV

NORLYDA ORAL TABLET 0.35 MG PVNORLYROC ORAL TABLET 0.35 MG PVNORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG PV

NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG (21) PV

NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG PV

NORTREL 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG PV

NOVAREL INTRAMUSCULAR RECON SOLN 10,000 UNIT 5


Drug Name Tier Limitations (Notes)NOVAREL INTRAMUSCULAR RECON SOLN 5,000 UNIT 5 QL (6 EA per 30 days)

NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)

3

NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)

3

NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML

3

NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML 3

NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

3

NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30)

3

NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)

3

NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML 3

NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML 3

NP THYROID ORAL TABLET 15 MG, 30 MG, 60 MG, 90 MG 2

OCELLA ORAL TABLET 3-0.03 MG PVoctreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

5 SP

octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml)

5 SP

OGESTREL (28) ORAL TABLET 0.5-50 MG-MCG PV

ONGLYZA ORAL TABLET 2.5 MG, 5 MG 3 QL (30 EA per 30 days)OPCICON ONE-STEP ORAL TABLET 1.5 MG PV QL (1 EA per 23 days)OPTION-2 ORAL TABLET 1.5 MG PV QL (1 EA per 23 days)ORILISSA ORAL TABLET 150 MG, 200 MG 5 PAORSYTHIA ORAL TABLET 0.1-20 MG-MCG PV


89

Drug Name Tier Limitations (Notes)ORTHO TRI-CYCLEN (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) PV

ORTHO TRI-CYCLEN LO (28) ORAL TABLET 0.18/0.215/0.25 MG-25 MCG PV

ORTHO-CYCLEN (28) ORAL TABLET 0.25-35 MG-MCG PV

ORTHO-NOVUM 1/35 (28) ORAL TABLET 1-35 MG-MCG PV

oxandrolone oral tablet 10 mg, 2.5 mg 2 PAOZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML) 3 PA; QL (1 ML per 30 days)

OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MG/DOSE (2 MG/1.5 ML) 3 PA; QL (2 ML per 30 days)

PARAGARD T 380A INTRAUTERINE INTRAUTERINE DEVICE 380 SQUARE MM PV

PHILITH ORAL TABLET 0.4-35 MG-MCG PVPIMTREA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 PV

pioglitazone oral tablet 15 mg 1 QL (90 EA per 23 days)pioglitazone oral tablet 30 mg, 45 mg 1 QL (30 EA per 23 days)pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg 1 QL (30 EA per 23 days)

pioglitazone-metformin oral tablet 15-500 mg, 15-850 mg 1 QL (90 EA per 23 days)

PIRMELLA ORAL TABLET 0.5/0.75/1 MG- 35 MCG, 1-35 MG-MCG PV

PLAN B ONE-STEP ORAL TABLET 1.5 MG PVPORTIA 28 ORAL TABLET 0.15-0.03 MG PVprednisolone oral solution 15 mg/5 ml 2prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

2

PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML 2

prednisone oral solution 5 mg/5 ml 2prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg 1

PREMPHASE ORAL TABLET 0.625 MG (14)/ 0.625MG-5MG(14) 4

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG 4


Drug Name Tier Limitations (Notes)PREVIFEM ORAL TABLET 0.25-35 MG-MCG PVprogesterone micronized oral capsule 100 mg, 200 mg 2

propylthiouracil oral tablet 50 mg 2QUARTETTE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-20 MCG/ 0.15 MG-25 MCG

PV

QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION




RAJANI ORAL TABLET 3-0.02-0.451 MG (24) (4) PV

raloxifene oral tablet 60 mg PVRECLIPSEN (28) ORAL TABLET 0.15-0.03 MG PV

RIVELSA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-20 MCG/ 0.15 MG-25 MCG

PV

SAFYRAL ORAL TABLET 3-0.03-0.451 MG (21) (7) PV

SEASONIQUE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) PV

SETLAKIN ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (91) PV

SHAROBEL ORAL TABLET 0.35 MG PVSOLIQUA 100/33 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCG/ML 3 PA; QL (15 ML per 30 days)

SOMAVERT SUBCUTANEOUS RECON SOLN 15 MG, 20 MG 5

SPRINTEC (28) ORAL TABLET 0.25-35 MG-MCG PV

SRONYX ORAL TABLET 0.1-20 MG-MCG PVSYEDA ORAL TABLET 3-0.03 MG PVSYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION


SYNJARDY ORAL TABLET 12.5-1,000 MG, 12.5-500 MG, 5-1,000 MG, 5-500 MG 3 QL (60 EA per 30 days)


91

Drug Name Tier Limitations (Notes)SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG


SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 25-1,000 MG 3 QL (30 EA per 30 days)

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

4

TAKE ACTION ORAL TABLET 1.5 MG PV QL (1 EA per 23 days)tamoxifen oral tablet 10 mg, 20 mg PVTARINA FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) PV

TARINA FE 1-20 EQ (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) PV

testosterone cypionate intramuscular oil100 mg/ml, 200 mg/ml 2 PA

testosterone enanthate intramuscular oil200 mg/ml 2 PA

testosterone transdermal gel 50 mg/5 gram (1 %) 2 PA

testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation, 12.5 mg/ 1.25 gram (1 %), 20.25 mg/1.25 gram (1.62 %)

2 PA

testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram) 2 PA

TILIA FE ORAL TABLET 1-20(5)/1-30(7) /1MG-35MCG (9) PV

tolazamide oral tablet 250 mg 2 QL (120 EA per 23 days)tolazamide oral tablet 500 mg 2 QL (60 EA per 23 days)tolbutamide oral tablet 500 mg 2TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG 3 QL (60 EA per 30 days)

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 11.25 MG, 22.5 MG, 3.75 MG

5 PA; SP

TRI FEMYNOR ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) PV

TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) PV

TRI-LEGEST FE ORAL TABLET 1-20(5)/1-30(7) /1MG-35MCG (9) PV


Drug Name Tier Limitations (Notes)TRI-LINYAH ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) PV

TRI-LO-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-25 MCG PV

TRI-LO-MARZIA ORAL TABLET 0.18/0.215/0.25 MG-25 MCG PV

TRI-LO-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-25 MCG PV

TRI-MILI ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) PV

TRI-PREVIFEM (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) PV

TRIPTODUR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG

5 PA; SP

TRI-SPRINTEC (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) PV

TRIVORA (28) ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10) PV

TRI-VYLIBRA LO ORAL TABLET 0.18/0.215/0.25 MG-25 MCG PV

TRI-VYLIBRA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) PV

TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML 3 PA; QL (2 ML per 30 days)

TYDEMY ORAL TABLET 3-0.03-0.451 MG (21) (7) PV

TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML) 5 PA; SP; QL (1 ML per 30

days)UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

1

VELIVET TRIPHASIC REGIMEN (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG PV

VERIPRED 20 ORAL SOLUTION 20 MG/5 ML (4 MG/ML) 2

VIENVA ORAL TABLET 0.1-20 MG-MCG PVVIORELE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 PV

VYFEMLA (28) ORAL TABLET 0.4-35 MG-MCG PV

VYLIBRA ORAL TABLET 0.25-35 MG-MCG PV


93

Drug Name Tier Limitations (Notes)WERA (28) ORAL TABLET 0.5-35 MG-MCG PVWYMZYA FE ORAL TABLET,CHEWABLE 0.4MG-35MCG(21) AND 75 MG (7) PV

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 5-500 MG


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


XULANE TRANSDERMAL PATCH WEEKLY 150-35 MCG/24 HR PV

YASMIN (28) ORAL TABLET 3-0.03 MG PVYAZ (28) ORAL TABLET 3-0.02 MG PVYUVAFEM VAGINAL TABLET 10 MCG 2ZARAH ORAL TABLET 3-0.03 MG PVZENCHENT (28) ORAL TABLET 0.4-35 MG-MCG PV

ZORBTIVE SUBCUTANEOUS RECON SOLN 8.8 MG 5 PA; SP

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG PV

LOCAL ANESTHETICS (PARENTERAL)lidocaine (pf) injection solution 10 mg/ml (1 %), 15 mg/ml (1.5 %), 20 mg/ml (2 %), 40 mg/ml (4 %)

2

lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %) 2

MISCELLANEOUS THERAPEUTIC AGENTSacetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) 2

ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG/0.9 ML 5 PA

ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML 5 PA; SP

ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML 5 SP

alendronate oral solution 70 mg/75 ml 2 QL (300 ML per 21 days)alendronate oral tablet 10 mg, 40 mg, 5 mg 1 QL (30 EA per 30 days)

alendronate oral tablet 35 mg, 70 mg 1 QL (4 EA per 21 days)allopurinol oral tablet 100 mg, 300 mg 1


Drug Name Tier Limitations (Notes)allopurinol sodium intravenous recon soln500 mg 2

amifostine crystalline intravenous recon soln 500 mg 2

ARCALYST SUBCUTANEOUS RECON SOLN 220 MG 5 PA

AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG 5 PA; SP; QL (4 EA per 21 days)

AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML 5 PA; SP; QL (1 EA per 21 days)

AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML 5 PA; SP; QL (1 EA per 21 days)

azathioprine oral tablet 50 mg 2azathioprine sodium injection recon soln100 mg 2

BAQSIMI NASAL SPRAY,NON-AEROSOL 3 MG/ACTUATION 3

calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation 2

cinacalcet oral tablet 30 mg, 60 mg, 90 mg 5 SPcolchicine oral capsule 0.6 mg 2colchicine oral tablet 0.6 mg 2cyclophosphamide oral capsule 25 mg, 50 mg 5

cyclosporine intravenous solution 250 mg/5 ml 2

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 2

cyclosporine modified oral solution 100 mg/ml 2

cyclosporine oral capsule 100 mg, 25 mg 2CYSTAGON ORAL CAPSULE 150 MG, 50 MG 5 PAdalfampridine oral tablet extended release 12 hr 10 mg 5 PA; SP

disulfiram oral tablet 250 mg, 500 mg 2dutasteride oral capsule 0.5 mg 2dutasteride-tamsulosin oral capsule, er multiphase 24 hr 0.5-0.4 mg 2

ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML (1 ML) 5 PA; SP

ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) 5 PA; SP


95

Drug Name Tier Limitations (Notes)ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5), 50 MG/ML (1 ML) 5 PA; SP

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (1 ML) 5 PA; SP

etidronate disodium oral tablet 200 mg, 400 mg 2

EVOTAZ ORAL TABLET 300-150 MG 5febuxostat oral tablet 40 mg, 80 mg 2finasteride oral tablet 5 mg 2FIRDAPSE ORAL TABLET 10 MG 5 PAfluoride (sodium) dental gel 1.1 % 2fluoride (sodium) oral drops 0.5 mg (1.1 mg sod.fluorid)/ml PV

fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid), 1 mg (2.2 mg sod. fluoride)

PV

FLUORITAB ORAL TABLET,CHEWABLE 0.5 MG (1.1 MG SODIUM FLUORID), 1 MG (2.2 MG SOD. FLUORIDE)

PV

fomepizole intravenous solution 1 gram/ml 2GILENYA ORAL CAPSULE 0.5 MG 5 PA; SP

glatiramer subcutaneous syringe 20 mg/ml 5 PA; SP; QL (30 ML per 23 days)

glatiramer subcutaneous syringe 40 mg/ml 5 PA; SP; QL (12 ML per 23 days)

GLATOPA SUBCUTANEOUS SYRINGE 20 MG/ML, 40 MG/ML 5 PA; SP

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION RECON SOLN 1 MG 3

GVOKE SYRINGE SUBCUTANEOUS SYRINGE 0.5 MG/0.1 ML, 1 MG/0.2 ML 3

HAEGARDA SUBCUTANEOUS RECON SOLN 2,000 UNIT, 3,000 UNIT 5 PA

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML







Drug Name Tier Limitations (Notes)HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML 5 PA; SP; QL (2 EA per 21 days)


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


HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML








hydroxychloroquine oral tablet 200 mg 2ibandronate intravenous solution 3 mg/3 ml 5 PA; SP

ibandronate intravenous syringe 3 mg/3 ml 5 PA; SP

icatibant subcutaneous syringe 30 mg/3 ml 5 PA; SP; QL (9 ML Max Qty Per Fill Retail)

indomethacin oral capsule 25 mg, 50 mg 2indomethacin oral capsule, extended release 75 mg 2

INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)

5 SP


leflunomide oral tablet 10 mg, 20 mg 2 QL (30 EA per 30 days)leflunomide oral tablet 20 mg 2LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2 ML 5 PA

leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg, 500 mg 5 SP

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg 5

levocarnitine (with sugar) oral solution 100 mg/ml 2


97

Drug Name Tier Limitations (Notes)levocarnitine oral tablet 330 mg 2LUDENT FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG(0.55 MG SOD. FLUORIDE), 0.5 MG (1.1 MG SODIUM FLUORID), 1 MG (2.2 MG SOD. FLUORIDE)

PV

magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %)

2


2


MAYZENT ORAL TABLET 0.25 MG, 2 MG 5 PA; SPMAYZENT STARTER PACK ORAL TABLETS,DOSE PACK 0.25 MG (12 TABS) 5 PA

mercaptopurine oral tablet 50 mg 2mesna intravenous solution 100 mg/ml 2methotrexate sodium (pf) injection recon soln 1 gram 2

methotrexate sodium (pf) injection solution25 mg/ml 2

methotrexate sodium injection solution 25 mg/ml 2

methotrexate sodium oral tablet 2.5 mg 2MITIGARE ORAL CAPSULE 0.6 MG 3MULTI-VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG/ML, 0.5 MG/ML PV

MULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 0.5 MG, 1 MG

PV

MULTIVITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG PV

MULTIVITAMINS WITH FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 0.5 MG, 1 MG

PV

MVC-FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 0.5 MG, 1 MG PV

mycophenolate mofetil (hcl) intravenous recon soln 500 mg 2

mycophenolate mofetil oral capsule 250 mg 2


Drug Name Tier Limitations (Notes)mycophenolate mofetil oral suspension for reconstitution 200 mg/ml 2

mycophenolate mofetil oral tablet 500 mg 2mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg, 360 mg 2 SP

naloxone injection auto-injector 2 mg/0.4 ml 3

naloxone injection solution 0.4 mg/ml 1naloxone injection syringe 0.4 mg/ml, 1 mg/ml 1

naltrexone oral tablet 50 mg 2naproxen oral suspension 125 mg/5 ml 2naproxen oral tablet 250 mg, 375 mg, 500 mg 1

naproxen sodium oral tablet 275 mg, 550 mg 2

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION 3

NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE

5 PA

nitisinone oral capsule 10 mg, 2 mg, 5 mg 5NULOJIX INTRAVENOUS RECON SOLN 250 MG 5 SP

OCREVUS INTRAVENOUS SOLUTION 30 MG/ML 5 PA

octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

5 SP

octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml)

5 SP

OTEZLA ORAL TABLET 30 MG 5 PA; SP; QL (60 EA per 23 days)

OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47) 5 PA; SP; QL (55 EA per 273

days)OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG(19) 5 PA; SP; QL (27 EA per 273

days)pamidronate intravenous solution 30 mg/10 ml (3 mg/ml), 60 mg/10 ml (6 mg/ml), 90 mg/10 ml (9 mg/ml)

2

phytonadione (vitamin k1) oral tablet 5 mg 2pimecrolimus topical cream 1 % 2Explanations of Limitations can be found on page v.Effective: March 1, 2020

99

Drug Name Tier Limitations (Notes)PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML 5 PA; SP; QL (1 ML per 21

days)PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG/0.5 ML- 94 MCG/0.5 ML 5 PA; SP

PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML

5 PA; SP

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG 5 PA

PREZCOBIX ORAL TABLET 800-150 MG-MG 4probenecid oral tablet 500 mg 2probenecid-colchicine oral tablet 500-0.5 mg 2

raloxifene oral tablet 60 mg PVREBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML 5 PA; SP; QL (6 ML per 21

days)REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6)

5 PA; SP; QL (6 ML per 21 days)

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6)

5 PA; SP; QL (5 ML per 21 days)

RENFLEXIS INTRAVENOUS RECON SOLN 100 MG 5

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG 5 PA

RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 MG 5

RUZURGI ORAL TABLET 10 MG 5 PAsevelamer carbonate oral powder in packet0.8 gram, 2.4 gram 5

sevelamer carbonate oral tablet 800 mg 2sevelamer hcl oral tablet 400 mg, 800 mg 2sirolimus oral solution 1 mg/ml 5sirolimus oral tablet 0.5 mg, 1 mg, 2 mg 2sodium polystyrene sulfonate rectal enema30 gram/120 ml 2

SPS (WITH SORBITOL) RECTAL ENEMA 30-40 GRAM/120 ML 2

STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML 5 PA; SP


Drug Name Tier Limitations (Notes)STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML 5 PA; SP

sulfasalazine oral tablet 500 mg 2sulfasalazine oral tablet,delayed release (dr/ec) 500 mg 2

SYMTUZA ORAL TABLET 800-150-200-10 MG 5

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 2

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

5 PA; SP

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG 5 PA

THYMOGLOBULIN INTRAVENOUS RECON SOLN 25 MG 5 SP

TRIPLE VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML PV

TRI-VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML, 0.5 MG FLUORIDE (1.1 MG)/ML

PV

TRI-VITE WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML, 0.5 MG FLUORIDE (1.1 MG)/ML

PV

TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML) 5 PA; SP; QL (1 ML per 30

days)TYSABRI INTRAVENOUS SOLUTION 300 MG/15 ML 5 PA

VITAMINS A,C,D AND FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML, 0.5 MG FLUORIDE (1.1 MG)/ML

PV

VIVITROL INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 380 MG

5 SP

VORAXAZE INTRAVENOUS RECON SOLN 1,000 UNIT 4

XELJANZ ORAL TABLET 10 MG 5 PA; SP

XELJANZ ORAL TABLET 5 MG 5 PA; SP; QL (60 EA per 30 days)

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG 5 PA; SP; QL (30 EA per 30

days)zoledronic acid intravenous recon soln 4 mg 5 PA; SP


101

Drug Name Tier Limitations (Notes)zoledronic acid intravenous solution 4 mg/5 ml 5 PA; SP

zoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml 5 PA; SP

zoledronic ac-mannitol-0.9nacl intravenous piggyback 4 mg/100 ml 5 PA; SP

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG, 1 MG 5 PA; SP

OXYTOCICSmethylergonovine oral tablet 0.2 mg 5mifepristone oral tablet 200 mg 2PHARMACEUTICAL AIDSM9 ODOR ELIMINATOR LIQUID 4water (bulk) liquid 2RESPIRATORY TRACT AGENTSacetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) 2

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml

2

albuterol sulfate oral syrup 2 mg/5 ml 2albuterol sulfate oral tablet 2 mg, 4 mg 2albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg 2

ambrisentan oral tablet 10 mg, 5 mg 5 PAaminophylline intravenous solution 250 mg/10 ml, 500 mg/20 ml 2

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION 3 QL (60 EA per 30 days)

ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION

3 ST; QL (13 GM per 30 days)

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (120), 220 MCG/ ACTUATION (14), 220 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (60)

3 ST; QL (1 EA per 30 days)

atropine injection solution 0.4 mg/ml, 1 mg/ml 2

atropine injection syringe 0.05 mg/ml, 0.1 mg/ml 2


Drug Name Tier Limitations (Notes)ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION 3 QL (26 GM per 30 days)

bosentan oral tablet 125 mg, 62.5 mg 5 PABREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE

3

BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG/2 ML 3 QL (120 ML per 30 days)

budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml 2 QL (120 ML per 30 days)

budesonide inhalation suspension for nebulization 1 mg/2 ml 2 QL (60 ML per 30 days)

carbinoxamine maleate oral liquid 4 mg/5 ml 2

carbinoxamine maleate oral tablet 4 mg 2cetirizine oral solution 1 mg/ml 2clemastine oral tablet 2.68 mg 2COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION 3 QL (8 GM per 30 days)

cromolyn inhalation solution for nebulization 20 mg/2 ml 2

cromolyn ophthalmic (eye) drops 4 % 2cromolyn oral concentrate 100 mg/5 ml 2cyproheptadine oral syrup 2 mg/5 ml 4cyproheptadine oral tablet 4 mg 2DALIRESP ORAL TABLET 250 MCG 4 PA; QL (30 EA per 30 days)DALIRESP ORAL TABLET 500 MCG 4 PAdesloratadine oral tablet 5 mg 2desloratadine oral tablet,disintegrating 2.5 mg, 5 mg 2 QL (30 EA per 30 days)

diphenhydramine hcl injection solution 50 mg/ml 2

diphenhydramine hcl oral capsule 50 mg 2diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml 2




DUPIXENT SUBCUTANEOUS SYRINGE 200 MG/1.14 ML 5 PA; SP


103

Drug Name Tier Limitations (Notes)DUPIXENT SUBCUTANEOUS SYRINGE 300 MG/2 ML 5 PA; SP; QL (4 ML per 30

days)epinephrine injection auto-injector 0.15 mg/0.15 ml 3 QL (2 EA per 30 days)

epinephrine injection auto-injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml 2 QL (2 EA per 30 days)

epinephrine injection solution 1 mg/ml, 1 mg/ml (1 ml) 2

epinephrine injection syringe 0.1 mg/ml 2

ESBRIET ORAL CAPSULE 267 MG 5 PA; SP; QL (270 EA per 30 days)

ESBRIET ORAL TABLET 267 MG 5 PA; SP; QL (270 EA per 30 days)

ESBRIET ORAL TABLET 801 MG 5 PA; SP; QL (90 EA per 30 days)

FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MG/ML 5 PA

FASENRA SUBCUTANEOUS SYRINGE 30 MG/ML 5 PA







fluticasone propionate nasal spray,suspension 50 mcg/actuation 2 QL (16 GM per 30 days)

fluticasone propion-salmeterol inhalation aerosol powdr breath activated 113-14 mcg/actuation, 232-14 mcg/actuation, 55-14 mcg/actuation

3

ipratropium bromide inhalation solution0.02 % 2

ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml

2


Drug Name Tier Limitations (Notes)KALYDECO ORAL GRANULES IN PACKET 25 MG 5

KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG 5 PA; QL (56 EA per 28 days)

KALYDECO ORAL TABLET 150 MG 5 PA; SP; QL (60 EA per 30 days)

levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/3 ml

2

levocetirizine oral solution 2.5 mg/5 ml 2levocetirizine oral tablet 5 mg 2metaproterenol oral syrup 10 mg/5 ml 2metaproterenol oral tablet 10 mg, 20 mg 2montelukast oral tablet 10 mg 2montelukast oral tablet,chewable 4 mg, 5 mg 2

NUCALA SUBCUTANEOUS AUTO-INJECTOR 100 MG/ML 5 PA; SP; QL (1 ML per 21

days)NUCALA SUBCUTANEOUS RECON SOLN 100 MG 5 PA; SP; QL (1 EA per 21 days)

NUCALA SUBCUTANEOUS SYRINGE 100 MG/ML 5 PA; SP; QL (1 ML per 21

days)NUEDEXTA ORAL CAPSULE 20-10 MG 4 PAOFEV ORAL CAPSULE 100 MG, 150 MG 5 QL (60 EA per 30 days)OPSUMIT ORAL TABLET 10 MG 5 PAORKAMBI ORAL GRANULES IN PACKET 100-125 MG, 150-188 MG 5 PA; SP; QL (56 EA per 28

days)ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG 5 PA; SP; QL (112 EA per 28

days)PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG 5 PA

PROLASTIN-C INTRAVENOUS SOLUTION 1,000 MG (+/-)/20 ML 5 PA

promethazine injection solution 25 mg/ml, 50 mg/ml 2


PULMOZYME INHALATION SOLUTION 1 MG/ML 5 SP


105

Drug Name Tier Limitations (Notes)QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION




sildenafil (pulm.hypertension) intravenous solution 10 mg/12.5 ml 5 PA; SP

sildenafil (pulm.hypertension) oral tablet20 mg 5 PA; SP; QL (90 EA per 23

days)SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION


SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG 3 QL (30 EA per 30 days)

SYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION


SYMDEKO ORAL TABLETS, SEQUENTIAL 100-150 MG (D)/ 150 MG (N) 5 PA; SP; QL (56 EA per 28

days)SYMDEKO ORAL TABLETS, SEQUENTIAL 50-75 MG (D)/ 75 MG (N) 5 PA; QL (56 EA per 28 days)

tadalafil (pulm. hypertension) oral tablet20 mg 5 PA; SP

terbutaline oral tablet 2.5 mg, 5 mg 2terbutaline subcutaneous solution 1 mg/ml 2theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg 2


TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG 3 QL (60 EA per 30 days)

triamcinolone acetonide nasal aerosol,spray 55 mcg 2

TRIKAFTA ORAL TABLETS, SEQUENTIAL 100-50-75 MG(D) /150 MG (N) 5 PA; QL (84 EA per 28 days)

UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

5 PA

UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60) 5 PA

VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION 3 QL (8 GM per 30 days)


Drug Name Tier Limitations (Notes)XOLAIR SUBCUTANEOUS RECON SOLN 150 MG 5 PA; SP; QL (6 EA per 21 days)

XOLAIR SUBCUTANEOUS SYRINGE 150 MG/ML 5 PA; SP; QL (4 ML per 21

days)XOLAIR SUBCUTANEOUS SYRINGE 75 MG/0.5 ML 5 PA; SP; QL (2 ML per 21

days)SKIN AND MUCOUS MEMBRANE AGENTSacitretin oral capsule 10 mg, 17.5 mg, 25 mg 5 SP

adapalene topical cream 0.1 % 2adapalene topical gel 0.1 %, 0.3 % 2adapalene topical gel with pump 0.3 % 2alclometasone topical cream 0.05 % 2alclometasone topical ointment 0.05 % 2ALCOHOL PREP PADS TOPICAL PADS, MEDICATED 3

amcinonide topical cream 0.1 % 2amcinonide topical lotion 0.1 % 2amcinonide topical ointment 0.1 % 2ammonium lactate topical cream 12 % 2ammonium lactate topical lotion 12 % 2betamethasone dipropionate topical cream0.05 % 2

betamethasone dipropionate topical lotion0.05 % 2

betamethasone dipropionate topical ointment 0.05 % 2

betamethasone valerate topical cream 0.1 % 2

betamethasone valerate topical foam 0.12 % 2

betamethasone valerate topical lotion 0.1 % 2

betamethasone valerate topical ointment0.1 % 2

betamethasone, augmented topical cream0.05 % 2

betamethasone, augmented topical lotion0.05 % 2

betamethasone, augmented topical ointment 0.05 % 2


107

Drug Name Tier Limitations (Notes)calcipotriene scalp solution 0.005 % 2ciclopirox topical cream 0.77 % 2ciclopirox topical gel 0.77 % 2ciclopirox topical shampoo 1 % 2ciclopirox topical solution 8 % 2ciclopirox topical suspension 0.77 % 2CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG 2

clindamycin phosphate topical foam 1 % 2clindamycin phosphate topical gel 1 % 2clindamycin phosphate topical lotion 1 % 2clindamycin phosphate topical solution 1 % 2clindamycin phosphate topical swab 1 % 2clindamycin phosphate vaginal cream 2 % 2clindamycin-benzoyl peroxide topical gel 1-5 % 2

clindamycin-tretinoin topical gel 1.2-0.025 % 2

clobetasol-emollient topical cream 0.05 % 2 QL (120 GM per 23 days)clotrimazole mucous membrane troche 10 mg 2

clotrimazole topical solution 1 % 2clotrimazole vaginal cream 1 % 2clotrimazole-betamethasone topical cream1-0.05 % 2

clotrimazole-betamethasone topical lotion1-0.05 % 2

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MG/ML 5 PA; SP

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MG/ML 5 PA; SP

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML 5 PA; SP

COSENTYX SUBCUTANEOUS SYRINGE 150 MG/ML 5 PA; SP

desonide topical cream 0.05 % 2desonide topical lotion 0.05 % 2desonide topical ointment 0.05 % 2desoximetasone topical cream 0.05 % 2


Drug Name Tier Limitations (Notes)desoximetasone topical ointment 0.05 %, 0.25 % 2

diclofenac sodium topical gel 1 % 2 QL (500 GM per 21 days)diclofenac sodium topical gel 3 % 5 PADRYSOL TOPICAL SOLUTION 20 % 4DUPIXENT SUBCUTANEOUS SYRINGE 200 MG/1.14 ML 5 PA; SP

DUPIXENT SUBCUTANEOUS SYRINGE 300 MG/2 ML 5 PA; SP; QL (4 ML per 30

days)econazole topical cream 1 % 2ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML (1 ML) 5 PA; SP

ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) 5 PA; SP

ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5), 50 MG/ML (1 ML) 5 PA; SP

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (1 ML) 5 PA; SP

ERY PADS TOPICAL SWAB 2 % 2erythromycin with ethanol topical gel 2 % 2erythromycin with ethanol topical solution2 % 2

erythromycin-benzoyl peroxide topical gel3-5 % 2

fluocinolone and shower cap scalp oil 0.01 % 2

fluocinolone topical cream 0.01 %, 0.025 % 2

fluocinolone topical oil 0.01 % 2fluocinolone topical ointment 0.025 % 2fluocinolone topical solution 0.01 % 2fluocinonide topical cream 0.05 % 2 QL (120 GM per 23 days)fluocinonide topical gel 0.05 % 2fluocinonide topical ointment 0.05 % 2fluocinonide topical solution 0.05 % 2FLUOCINONIDE-E TOPICAL CREAM 0.05 % 2fluorouracil topical cream 5 % 2fluorouracil topical solution 2 %, 5 % 2fluticasone propionate topical cream 0.05 % 2

fluticasone propionate topical lotion 0.05 % 2Explanations of Limitations can be found on page v.Effective: March 1, 2020

109

Drug Name Tier Limitations (Notes)fluticasone propionate topical ointment0.005 % 2

FRESHNET TOPICAL LIQUID 4gentamicin topical cream 0.1 % 2gentamicin topical ointment 0.1 % 2halobetasol propionate topical cream 0.05 % 2

halobetasol propionate topical ointment0.05 % 2

HEX-ON LIGHT ODOR TOPICAL LIQUID 4HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML






HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML 5 PA; SP; QL (2 EA per 21 days)


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


HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML








hydrocortisone butyrate topical cream 0.1 % 2

hydrocortisone butyrate topical solution0.1 % 2

hydrocortisone rectal enema 100 mg/60 ml 2


Drug Name Tier Limitations (Notes)hydrocortisone topical cream 1 %, 2.5 % 2hydrocortisone topical lotion 2.5 % 2hydrocortisone topical ointment 2.5 % 2hydrocortisone valerate topical cream 0.2 % 2

hydrocortisone valerate topical ointment0.2 % 2

hydrocortisone-pramoxine topical cream2.5-1 % 2

imiquimod topical cream in packet 5 % 2ketoconazole topical cream 2 % 2ketoconazole topical foam 2 % 2ketoconazole topical shampoo 2 % 2lidocaine topical ointment 5 % 2 QL (50 GM per 21 days)lidocaine-prilocaine topical cream 2.5-2.5 % 2 QL (30 GM per 30 days)

lindane topical shampoo 1 % 2malathion topical lotion 0.5 % 2metronidazole topical cream 0.75 % 2metronidazole topical gel 0.75 % 2metronidazole topical lotion 0.75 % 2metronidazole vaginal gel 0.75 % 2MICONAZOLE-3 VAGINAL SUPPOSITORY 200 MG 2 QL (3 EA per 2 days)

mometasone topical cream 0.1 % 2mometasone topical ointment 0.1 % 2mometasone topical solution 0.1 % 2mupirocin topical ointment 2 % 2neomycin-polymyxin b gu irrigation solution 40 mg-200,000 unit/ml 2

nystatin (bulk) powder 10 billion unit 4nystatin topical cream 100,000 unit/gram 2nystatin topical ointment 100,000 unit/gram 2

nystatin topical powder 100,000 unit/gram 2nystatin-triamcinolone topical cream100,000-0.1 unit/g-% 2

nystatin-triamcinolone topical ointment100,000-0.1 unit/gram-% 2


111

Drug Name Tier Limitations (Notes)

OTEZLA ORAL TABLET 30 MG 5 PA; SP; QL (60 EA per 23 days)

OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47) 5 PA; SP; QL (55 EA per 273

days)OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG(19) 5 PA; SP; QL (27 EA per 273

days)permethrin topical cream 5 % 2pimecrolimus topical cream 1 % 2podofilox topical solution 0.5 % 2prednicarbate topical ointment 0.1 % 2PROCTO-PAK TOPICAL CREAM WITH PERINEAL APPLICATOR 1 % 2

PROCTOZONE-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 % 2

RECTIV RECTAL OINTMENT 0.4 % (W/W) 4RENFLEXIS INTRAVENOUS RECON SOLN 100 MG 5

RESTORE SKIN CLEANSER TOPICAL CLEANSER 4

silver sulfadiazine topical cream 1 % 2SKYRIZI SUBCUTANEOUS SYRINGE 75 MG/0.83 ML 5 PA

SKYRIZI SUBCUTANEOUS SYRINGE KIT 150MG/1.66ML(75 MG/0.83 ML X2) 5 PA; SP

STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML 5 PA; SP; QL (0.5 ML per 63

days)STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML 5 PA; SP; QL (0.5 ML per 63

days)STELARA SUBCUTANEOUS SYRINGE 90 MG/ML 5 PA; SP; QL (1 ML per 42

days)sulfacetamide sodium (acne) topical suspension 10 % 2

tacrolimus topical ointment 0.03 %, 0.1 % 2 QL (100 GM per 23 days)TARGRETIN TOPICAL GEL 1 % 5 PAtazarotene topical cream 0.1 % 2terconazole vaginal cream 0.4 % 2 QL (45 GM per 5 days)terconazole vaginal cream 0.8 % 2terconazole vaginal suppository 80 mg 2 QL (3 EA per 2 days)TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 MG/ML 5 PA; SP


Drug Name Tier Limitations (Notes)TREMFYA SUBCUTANEOUS SYRINGE 100 MG/ML 5 PA; SP

tretinoin topical cream 0.025 %, 0.05 %, 0.1 % 2

tretinoin topical gel 0.01 %, 0.025 % 2triamcinolone acetonide dental paste 0.1 % 2triamcinolone acetonide topical cream0.025 %, 0.1 %, 0.5 % 2

triamcinolone acetonide topical lotion0.025 %, 0.1 % 2

triamcinolone acetonide topical ointment0.025 %, 0.1 %, 0.5 % 2

XERESE TOPICAL CREAM 5-1 % 4SMOOTH MUSCLE RELAXANTSaminophylline intravenous solution 250 mg/10 ml, 500 mg/20 ml 2

flavoxate oral tablet 100 mg 2MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG 4

oxybutynin chloride oral syrup 5 mg/5 ml 2oxybutynin chloride oral tablet 5 mg 2oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg, 5 mg 2

theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg 2


tolterodine oral capsule,extended release 24hr 2 mg, 4 mg 2

tolterodine oral tablet 1 mg, 2 mg 2trospium oral capsule,extended release 24hr 60 mg 2

trospium oral tablet 20 mg 2VITAMINSB COMPLEX 1 ORAL TABLET PVB COMPLEX 100 ORAL TABLET 0.4 MG PVB COMPLEX-VITAMIN B12 ORAL TABLET PVb complex-vitamin c-folic acid oral tablet400 mcg PV

B-100 COMPLEX ORAL TABLET EXTENDED RELEASE 100 MG PV


113

Drug Name Tier Limitations (Notes)BALANCE B-100 ORAL TABLET PVBALANCE B-50 ORAL TABLET PVBALANCED B-100 COMPLEX ORAL TABLET EXTENDED RELEASE 100 MG PV

BALANCED B-100 ORAL TABLET 0.4 MG PVBALANCED B-50 COMPLEX ORAL TABLET PVBALANCED B-50 ORAL TABLET PVB-COMPLEX ORAL TABLET PVb-complex with vitamin c oral tablet PVB-COMPLEX WITH VITAMIN C ORAL TABLET 400-500 MCG-MG PV

calcitriol intravenous solution 1 mcg/ml 2calcitriol oral capsule 0.25 mcg, 0.5 mcg 2calcitriol oral solution 1 mcg/ml 2cholecalciferol (vitamin d3) oral capsule1,250 mcg (50,000 unit) 2

cholecalciferol (vitamin d3) oral tablet 25 mcg (1,000 unit) 2

CLASSIC PRENATAL ORAL TABLET 28 MG IRON- 800 MCG PV

COMPLEX B-100 ORAL TABLET EXTENDED RELEASE PV

cyanocobalamin (vitamin b-12) injection solution 1,000 mcg/ml 2

DAILY PRENATAL ORAL COMBO PACK 28-800-440 MG-MCG-MG PV

DIALYVITE 800 ORAL TABLET 0.8 MG PVfolic acid oral tablet 1 mg, 400 mcg, 800 mcg PV

FOLTABS 800 ORAL TABLET 0.8-10-115 MG-MG-MCG PV

FULL SPECTRUM B-VITAMIN C ORAL TABLET 0.8 MG PV

KOBEE ORAL TABLET 0.4 MG PVKPN ORAL TABLET PVMULTI-VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG/ML, 0.5 MG/ML PV

MULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 0.5 MG, 1 MG

PV


Drug Name Tier Limitations (Notes)MULTIVITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG PV

MULTIVITAMINS WITH FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 0.5 MG, 1 MG

PV

MVC-FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 0.5 MG, 1 MG PV

NATURAL B-100 COMPLEX ORAL TABLET 100 MG PV


P D NATAL VITAMINS-FOLIC ACID ORAL TABLET PV


phytonadione (vitamin k1) oral tablet 5 mg 2pnv cmb#95-ferrous fumarate-fa oral tablet 28 mg iron- 800 mcg PV


PRENATAL MULTI-DHA (ALGAL OIL) ORAL CAPSULE 27MG IRON- 800 MCG-250 MG PV


PRENATAL ORAL TABLET 28 MG IRON- 800 MCG PV






RENA-VITE ORAL TABLET 0.8 MG PVSTRESS FORMULA 600 C ORAL TABLET PVSTRESS FORMULA ORAL TABLET PVSTRESS FORMULA WITH IRON ORAL TABLET 500 MG-400 MCG- 18 MG IRON PV

STRESS FORMULA WITH IRON(SULF) ORAL TABLET 500 MG-400 MCG- 27 MG IRON PV


115

Drug Name Tier Limitations (Notes)SUPER B COMPLEX-VITAMIN C ORAL TABLET PV

SUPER B MAXI COMPLEX ORAL TABLET 0.4 MG PV

SUPER B-50 COMPLEX PLUS ORAL TABLET PVSUPER QUINTS B-50 ORAL TABLET PVSUPER QUINTS ORAL TABLET 0.4 MG PVSUPERPLEX-T ORAL TABLET PVTOTAL B/C ORAL TABLET PVTRIPLE VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML PV

TRI-VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML, 0.5 MG FLUORIDE (1.1 MG)/ML

PV

TRI-VITE WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML, 0.5 MG FLUORIDE (1.1 MG)/ML

PV

ULTRA B-100 COMPLEX ORAL TABLET PVULTRA B-100 COMPLEX ORAL TABLET EXTENDED RELEASE PV

vitamin b complex oral tablet PVvitamin b complex-folic acid oral tablet 0.4 mg PV

VITAMINS A,C,D AND FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML, 0.5 MG FLUORIDE (1.1 MG)/ML

PV

VITAMINS B COMPLEX ORAL TABLET PV


Index1ST TIER UNIFINE PENTIPS 58abacavir............................ 1abacavir-lamivudine............ 1abacavir-lamivudine-zidovudine......................... 2abiraterone.......................13acamprosate.....................41acarbose.......................... 77acebutolol...................23, 33acetaminophen-codeine..... 41acetazolamide........33, 59, 68acetazolamide sodium............................33, 59, 68acetic acid........................68acetylcysteine............94, 102acitretin......................... 107ACTEMRA......................... 94ACTEMRA ACTPEN............. 94ACTHIB (PF)..................... 19ACTIMMUNE..................... 94acyclovir............................ 2acyclovir sodium................. 2ADACEL(TDAP ADOLESN/ADULT)(PF)........19adapalene...................... 107adefovir............................. 2ADULT ASPIRIN REGIMEN................................. 28, 41ADULT LOW DOSE ASPIRIN................................. 28, 41advanced antacid-antigas... 71AEMCOLO.......................... 2AFINITOR.........................13AFLURIA QD 2019-20(3YR UP)(PF)............................19AFLURIA QD 2019-20(6-35MO)(PF)....................... 19AFLURIA QUAD 2019-20(6MO UP)......................19AFTERA............................77A-HYDROCORT..................77AIMOVIG AUTOINJECTOR................................. 41, 42AJOVY..............................42albendazole........................2albuterol sulfate.........23, 102alclometasone.................107ALCOHOL PREP PADS....... 107ALDURAZYME................... 67ALECENSA........................13alendronate...................... 94

alfuzosin.......................... 23ALINIA.............................. 2allopurinol........................ 94allopurinol sodium............. 95ALOPHEN (BISACODYL)......71alprazolam....................... 42ALTAVERA (28)................. 77ALUNBRIG........................13ALYACEN 1/35 (28)........... 77ALYACEN 7/7/7 (28).......... 77amantadine hcl............. 2, 42AMBISOME.........................2ambrisentan.............. 33, 102amcinonide.....................107AMETHIA..........................77AMETHIA LO..................... 77AMETHYST (28)................ 77amifostine crystalline......... 95amikacin............................2amiloride.................... 33, 59amiloride-hydrochlorothiazide......33, 59aminophylline.......... 102, 113AMINOSYN 3.5 %..............59AMINOSYN 7 % WITH ELECTROLYTES................. 59AMINOSYN 8.5 %..............59AMINOSYN 8.5 %-ELECTROLYTES................. 59AMINOSYN II 10 %............59AMINOSYN II 15 %............59AMINOSYN M 3.5 %...........59AMINOSYN-HBC 7%.......... 59AMINOSYN-PF 10 %.......... 59AMINOSYN-PF 7 % (SULFITE-FREE)................ 59amiodarone...................... 33AMITIZA.......................... 71amitriptyline..................... 42amlodipine....................... 33amlodipine-benazepril........34ammonium chloride........... 59ammonium lactate...........107amoxapine....................... 42amoxicillin..........................2amoxicillin-pot clavulanate... 2amphetamine sulfate......... 42amphotericin b................... 2ampicillin........................... 2ampicillin sodium................ 3ampicillin-sulbactam............3

anagrelide........................ 28anastrozole................. 13, 77ANDRODERM.................... 77ANDROXY.........................77ANORO ELLIPTA.........23, 102apraclonidine.................... 68aprepitant...................71, 72APRI................................78APTIVUS............................ 3APTIVUS (WITH VITAMIN E)..................................... 3ARANELLE (28)................. 78ARANESP (IN POLYSORBATE)................. 28ARCALYST........................ 95argatroban....................... 29argatroban in 0.9 % sod chlor................................29argatroban in nacl (iso-os)..29ARIKAYCE.......................... 3aripiprazole...................... 42ASHLYNA......................... 78ASMANEX HFA........... 78, 102ASMANEX TWISTHALER............................... 78, 102ASPIR-81....................29, 42aspirin........................29, 42ASPIRIN CHILDRENS....29, 42aspirin low dose................ 29ASPIRIN LOW DOSE..... 29, 42aspirin,buffd-calcium carb-mag...........................29, 42aspirin-dipyridamole............................29, 34, 42ASPIR-LOW.................29, 42ASPIR-TRIN................ 29, 42atazanavir..........................3atenolol...................... 23, 34atenolol-chlorthalidone............................24, 34, 59atomoxetine..................... 42atorvastatin......................34atovaquone........................ 3atovaquone-proguanil..........3ATRIPLA............................ 3atropine.............. 24, 68, 102ATROVENT HFA..........24, 103AUBRA.............................78AUBRA EQ........................ 78AUSTEDO.........................42AVIANE............................78


117

AVONEX...........................95AVONEX (WITH ALBUMIN)..95azacitidine........................13azathioprine..................... 95azathioprine sodium.......... 95azelastine.........................68azithromycin...................... 3aztreonam......................... 3AZURETTE (28).................78B COMPLEX 1..................113B COMPLEX 100.............. 113B COMPLEX-VITAMIN B12.113b complex-vitamin c-folic acid............................... 113B-100 COMPLEX.............. 113bacitracin..................... 3, 68bacitracin-polymyxin b.......68baclofen...........................24BALANCE B-100.............. 114BALANCE B-50................ 114BALANCED B-100............ 114BALANCED B-100 COMPLEX....................... 114BALANCED B-50.............. 114BALANCED B-50 COMPLEX 114balsalazide....................... 72BALVERSA........................13BALZIVA (28)................... 78BANZEL...................... 42, 43BAQSIMI.................... 78, 95BARACLUDE....................... 3BASAGLAR KWIKPEN U-100 INSULIN.................... 78BAYER ASPIRIN........... 29, 43bcg vaccine, live (pf)......... 19B-COMPLEX.................... 114b-complex with vitamin c..114B-COMPLEX WITH VITAMIN C...................................114BD PRE-FILLED NORMAL SALINE.......................58, 60BEKYREE (28)...................78BELEODAQ....................... 13benazepril........................ 34benazepril-hydrochlorothiazide......34, 60benznidazole...................... 3benztropine.................24, 43betamethasone dipropionate................... 107betamethasone valerate... 107

betamethasone, augmented..................... 107betaxolol...............24, 34, 68bethanechol chloride..........24BEXSERO......................... 19BEYAZ............................. 78bicalutamide.....................13BIKTARVY.......................... 3bimatoprost......................68bisacodyl..........................72BISA-LAX (BISACODYL)..... 72BISMATROL...................... 72bisoprolol fumarate...... 24, 34bisoprolol-hydrochlorothiazide 24, 34, 60BLISOVI 24 FE.................. 78BLISOVI FE 1.5/30 (28)..... 78BLISOVI FE 1/20 (28)........ 78BOOSTRIX TDAP............... 19bortezomib.......................13bosentan...................34, 103BOSULIF.......................... 14BRAFTOVI........................ 14BREO ELLIPTA......24, 78, 103BREVICON (28).................78BRIELLYN.........................78BRILINTA......................... 29brimonidine...................... 68BRIVIACT.........................43bromocriptine................... 43BROVANA..................24, 103budesonide............... 79, 103BUFFERED ASPIRIN......29, 43bumetanide.................34, 60buprenorphine.................. 43buprenorphine hcl............. 43buprenorphine-naloxone.....43bupropion hcl....................43bupropion hcl (smoking deter)..............................43buspirone.........................43BYDUREON.......................79BYDUREON BCISE............. 79BYETTA............................79cabergoline.......................43CABLIVI........................... 29CABOMETYX..................... 14calcipotriene................... 108calcitonin (salmon).......79, 95calcitriol......................... 114calcium acetate(phosphat bind)............................... 60

CALQUENCE..................... 14CAMILA............................79CAMRESE......................... 79CAMRESE LO.................... 79CAPASTAT..........................3capecitabine..................... 14CAPRELSA........................ 14captopril.......................... 34captopril-hydrochlorothiazide......34, 60carbamazepine............ 43, 44carbidopa......................... 44carbidopa-levodopa........... 44carbinoxamine maleate.1, 103carteolol...........................68carvedilol....................24, 34caspofungin........................3CAYA CONTOURED............ 57CAYSTON...........................3CAZIANT (28)................... 79cefaclor............................. 3cefadroxil...........................4cefazolin............................ 4cefazolin in dextrose (iso-os)....................................4cefdinir.............................. 4cefditoren pivoxil................ 4cefepime............................4cefotaxime......................... 4cefotetan........................... 4cefoxitin............................ 4cefoxitin in dextrose, iso-osm.................................. 4cefpodoxime.......................4cefprozil.............................4ceftazidime........................ 4ceftriaxone.........................4ceftriaxone in dextrose,iso-os..................................... 4cefuroxime axetil................ 4cefuroxime sodium.......... 4, 5celecoxib..........................44cephalexin......................... 5CEREZYME....................... 67cetirizine.....................1, 103cevimeline........................24CHANTIX..........................24CHANTIX CONTINUING MONTH BOX..................... 24CHANTIX STARTING MONTH BOX..................... 24CHATEAL (28)...................79


CHATEAL EQ (28)..............79CHENODAL....................... 72CHILDREN'S ASPIRIN... 29, 44chloramphenicol sod succinate........................... 5chlorhexidine gluconate......68chloroquine phosphate.........5chlorothiazide..............34, 60chlorothiazide sodium...34, 60chlorpromazine................. 44chlorthalidone............. 34, 60cholecalciferol (vitamin d3).....................................114cholestyramine (with sugar)............................. 34CHOLESTYRAMINE LIGHT... 34ciclopirox........................108cidofovir............................ 5cilostazol.................... 29, 34CIMDUO............................ 5cimetidine........................ 72cimetidine hcl................... 72cinacalcet................... 79, 95CIPRODEX........................68ciprofloxacin.......................5ciprofloxacin (mixture).........5ciprofloxacin hcl............ 5, 69ciprofloxacin-fluocinolone... 69citalopram........................44CITRATE OF MAGNESIA......72CITROMA......................... 72CLARAVIS.......................108clarithromycin.................... 5CLASSIC PRENATAL....29, 114CLEARLAX........................ 72clemastine.................. 1, 103clindamycin hcl................... 5clindamycin phosphate. 5, 108clindamycin-benzoyl peroxide.........................108clindamycin-tretinoin....... 108CLINIMIX 5%/D15W SULFITE FREE...................60CLINIMIX 5%/D25W SULFITE-FREE...................60CLINIMIX 4.25%/D10W SULF FREE....................... 60CLINIMIX 4.25%/D5W SULFIT FREE.....................60CLINIMIX 4.25%-D20W SULF-FREE....................... 60

CLINIMIX 4.25%-D25W SULF-FREE....................... 60CLINIMIX 5%-D20W(SULFITE-FREE)........60CLINIMIX E 2.75%/D10W SUL FREE......................... 60CLINIMIX E 2.75%/D5W SULF FREE....................... 61CLINIMIX E 4.25%/D10W SUL FREE......................... 61CLINIMIX E 4.25%/D25W SUL FREE......................... 61CLINIMIX E 4.25%/D5W SULF FREE....................... 61CLINIMIX E 5%/D15W SULFIT FREE.....................61CLINIMIX E 5%/D20W SULFIT FREE.....................61CLINIMIX E 5%/D25W SULFIT FREE.....................61CLINISOL SF 15 %............ 61clobetasol-emollient.........108clomipramine....................44clonazepam...................... 44clonidine.....................24, 35clonidine hcl................24, 34clopidogrel....................... 29clorazepate dipotassium..... 44CLORPRES.............24, 35, 61clotrimazole.................... 108clotrimazole-betamethasone............... 108clozapine..........................44COARTEM...........................5colchicine......................... 95colestipol......................... 35colistin (colistimethate na)... 5COMBIVENT RESPIMAT............................... 24, 103COMETRIQ....................... 14COMPLERA......................... 5COMPLEX B-100.............. 114COPIKTRA........................ 14CORLANOR.......................35cortisone..........................79COSENTYX......................108COSENTYX (2 SYRINGES). 108COSENTYX PEN............... 108COSENTYX PEN (2 PENS)..108COTELLIC.........................14CREON.............................72CRIXIVAN.......................... 5

cromolyn.................. 69, 103CRYSELLE (28)................. 79CRYSVITA........................ 61cyanocobalamin (vitamin b-12)............................. 114CYCLAFEM 1/35 (28)......... 79CYCLAFEM 7/7/7 (28)........ 79CYCLESSA (28)................. 79cyclobenzaprine................ 24cyclophosphamide........14, 95cyclosporine..................... 95cyclosporine modified.........95cyproheptadine............1, 103CYRED............................. 79CYRED EQ........................ 79CYSTAGON....................... 95d10 %-0.45 % sodium chloride............................61d2.5 %-0.45 % sodium chloride............................61d5 % and 0.9 % sodium chloride............................61d5 %-0.45 % sodium chloride............................61DAILY PRENATAL.. 30, 61, 114dalfampridine................... 95DALIRESP.......................103danazol............................79dantrolene........................25dapsone.............................5DAPTACEL (DTAP PEDIATRIC) (PF)............... 19daptomycin........................ 5DASETTA 1/35 (28)........... 79DASETTA 7/7/7 (28)..........80DAURISMO....................... 14DAYSEE........................... 80DEBLITANE.......................80deferasirox....................... 77DELSTRIGO........................5DELYLA (28)..................... 80demeclocycline................... 5DEPO-PROVERA................ 80DESCOVY...........................6desipramine......................44desloratadine.............. 1, 103desmopressin.............. 30, 80desog-e.estradiol/e.estradiol........ 80desogestrel-ethinyl estradiol...........................80desonide........................ 108


119

desoximetasone....... 108, 109desvenlafaxine succinate................................. 44, 45dexamethasone................ 80DEXAMETHASONE INTENSOL........................ 80dexamethasone sodium phos (pf)..........................80dexamethasone sodium phosphate...................69, 80DEXCOM G4 RECEIVER...... 58DEXCOM G4 RECEIVER PEDIATRIC....................... 58DEXCOM G4 RECEIVER-SHARE (PED).................... 58DEXCOM G4 RECEIVER-SHARE KIT....................... 58DEXCOM G4 TRANSMITTER.58DEXCOM G5 RECEIVER...... 58DEXCOM G5 TRANSMITTER.58DEXCOM G5-G4 SENSOR....58DEXCOM G6 RECEIVER...... 58DEXCOM G6 SENSOR.........58DEXCOM G6 TRANSMITTER.58DEXCOM RECEIVER........... 58dexmethylphenidate.......... 45dextroamphetamine...........45dextroamphetamine-amphetamine................... 45dextrose 10 % and 0.2 % nacl.................................61dextrose 10 % in water (d10w)............................ 61dextrose 25 % in water (d25w)............................ 61dextrose 30 % in water (d30w)............................ 62dextrose 40 % in water (d40w)............................ 62dextrose 5 % in water (d5w).............................. 62dextrose 5 %-lactated ringers.............................62dextrose 5%-0.2 % sod chloride............................62dextrose 5%-0.3 % sod.chloride......................62dextrose 50 % in water (d50w)............................ 62dextrose 70 % in water (d70w)............................ 62DIACOMIT........................ 45

DIALYVITE 800................114DIASTIX...........................59diazepam......................... 45DIAZEPAM INTENSOL.........45diclofenac potassium..........45diclofenac sodium.................... 14, 45, 69, 109diclofenac-misoprostol.. 45, 72dicloxacillin........................ 6dicyclomine...................... 25didanosine......................... 6DIFICID............................. 6diflunisal.......................... 45digoxin............................ 35dihydroergotamine.......25, 45DILANTIN................... 35, 45diltiazem hcl..................... 35diphenhydramine hcl.... 1, 103diphenoxylate-atropine.......................... 25, 72, 103dipyridamole............... 30, 35disopyramide phosphate.....36disulfiram.........................95divalproex........................ 46docetaxel......................... 14dofetilide..........................36donepezil......................... 25DOPTELET (10 TAB PACK).. 30DOPTELET (15 TAB PACK).. 30dorzolamide......................69dorzolamide-timolol........... 69DOVATO............................ 6doxazosin................... 25, 36doxepin............................46doxorubicin...................... 14DOXY-100..........................6doxycycline hyclate........6, 69doxycycline monohydrate.....6dronabinol........................72drospirenone-e.estradiol-lm.fa............................... 80drospirenone-ethinyl estradiol...........................80DRYSOL......................... 109DUCODYL (BISACODYL)..... 72DULERA...............25, 80, 103duloxetine........................ 46DUPIXENT........103, 104, 109dutasteride.......................95dutasteride-tamsulosin. 25, 95DYSPORT......................... 25E.C. PRIN....................30, 46

E.E.S. 400..........................6econazole....................... 109ECONTRA EZ.................... 80ECOTRIN.................... 30, 46ECOTRIN LOW STRENGTH................................. 30, 46EDURANT...........................6efavirenz............................6ELAPRASE........................ 67ELELYSO.......................... 67ELINEST...........................80ELIQUIS...........................30ELIQUIS DVT-PE TREAT 30D START.......................30ELLA................................80ELURYNG......................... 80EMCYT............................. 14EMGALITY PEN..................46EMGALITY SYRINGE...........46EMOQUETTE..................... 80EMTRIVA............................6enalapril maleate...............36enalapril-hydrochlorothiazide......36, 62ENBREL...............95, 96, 109ENBREL MINI.............95, 109ENBREL SURECLICK... 96, 109ENGERIX-B (PF)................ 19ENGERIX-B PEDIATRIC (PF).................................19enoxaparin....................... 30ENPRESSE........................81ENSKYCE......................... 81entacapone...................... 46entecavir........................... 6ENTERIC COATED ASPIRIN................................. 30, 46ENTRESTO........................36EPIDIOLEX....................... 46epinephrine............... 25, 104eplerenone....................... 36EPOGEN...........................30ergoloid........................... 25ERIVEDGE........................ 14ERLEADA..........................14erlotinib........................... 14ERRIN..............................81ERY PADS.......................109ERY-TAB............................ 6ERYTHROCIN......................6ERYTHROCIN (AS STEARATE)........................ 6


erythromycin................ 6, 69erythromycin ethylsuccinate.................... 6erythromycin with ethanol 109erythromycin-benzoyl peroxide.........................109ESBRIET.........................104escitalopram oxalate..........46esomeprazole magnesium.. 72ESTARYLLA.......................81estradiol...........................81estradiol valerate.............. 81estradiol-norethindrone acet.................................81ESTROSTEP FE-28............. 81ethambutol........................ 6ethosuximide.................... 46ethynodiol diac-eth estradiol...........................81etidronate disodium...........96etodolac...........................46etonogestrel-ethinyl estradiol...........................81everolimus (antineoplastic).14EVOTAZ....................... 6, 96exemestane................ 14, 81ezetimibe......................... 36FABRAZYME......................67FACTIVE............................ 6FALMINA (28)................... 81famciclovir......................... 6famotidine.................. 72, 73famotidine (pf)-nacl (iso-os).................................. 72FARXIGA.......................... 81FARYDAK......................... 14FASENRA........................104FASENRA PEN................. 104FASLODEX........................14FAYOSIM..........................81FC2 FEMALE CONDOM........57febuxostat........................96felbamate.........................46felodipine......................... 36FEMCAP......................57, 58FEMYNOR......................... 81fenofibrate....................... 36fenofibrate micronized....... 36fenofibrate nanocrystallized 36fenofibric acid (choline)......36fenoprofen....................... 47fentanyl........................... 47

fentanyl citrate................. 47FERRIPROX...................... 77finasteride........................96FIRDAPSE........................ 96flavoxate........................ 113flecainide......................... 36FLEET LAXATIVE (BISACODYL)....................73FLOVENT DISKUS.......81, 104FLOVENT HFA.......81, 82, 104FLUAD 2019-2020 (65 YR UP)(PF)............................20FLUARIX QUAD 2019-2020 (PF).................................20FLUBLOK QUAD 2019-2020 (PF).................................20FLUCELVAX QUAD 2019-2020............................... 20FLUCELVAX QUAD 2019-2020 (PF).........................20fluconazole.........................7fluconazole in dextrose(iso-o)..................................... 7fluconazole in nacl (iso-osm)................................. 7flucytosine......................... 7fludrocortisone..................82FLULAVAL QUAD 2019-2020............................... 20FLULAVAL QUAD 2019-2020 (PF).........................20FLUMIST QUAD 2019-2020.20fluocinolone.................... 109fluocinolone acetonide oil... 69fluocinolone and shower cap................................109fluocinonide.................... 109FLUOCINONIDE-E............ 109fluoride (sodium)...............96FLUORITAB.......................96fluorometholone................69fluorouracil................14, 109fluoxetine.........................47fluphenazine decanoate......47fluphenazine hcl................ 47flurbiprofen...................... 47flurbiprofen sodium........... 69flutamide......................... 15fluticasone propionate................. 69, 104, 109, 110fluticasone propion-salmeterol........... 25, 82, 104

fluvastatin........................36fluvoxamine......................47FLUZONE HIGH-DOSE 2019-20 (PF).................... 20FLUZONE QUAD 2019-2020 20FLUZONE QUAD 2019-2020 (PF).................................20FLUZONE QUAD PEDI 2019-20 (PF).................... 20folic acid.........................114FOLTABS 800..................114fomepizole....................... 96fondaparinux.................... 30fosamprenavir.................... 7fosinopril..........................36fosinopril-hydrochlorothiazide......36, 62fosphenytoin.....................47FRAGMIN......................... 30FREAMINE HBC 6.9 %........62FREESTYLE LIBRE 10 DAY READER........................... 58FREESTYLE LIBRE 10 DAY SENSOR...........................58FREESTYLE LIBRE 14 DAY READER........................... 58FREESTYLE LIBRE 14 DAY SENSOR...........................58FRESHNET...................... 110FULL SPECTRUM B-VITAMIN C......................114FULPHILA......................... 31fulvestrant....................... 15furosemide..................36, 62gabapentin....................... 47galantamine..................... 25GAMASTAN S/D................ 20GAMMAGARD LIQUID.........20ganciclovir sodium.............. 7GARDASIL 9 (PF)......... 20, 21gatifloxacin.......................69GAVILAX.......................... 73GAVILYTE-C......................73GAVILYTE-G..................... 73GAVILYTE-N..................... 73gemfibrozil....................... 36GENERESS FE................... 82generlac...........................62GENOTROPIN....................82GENOTROPIN MINIQUICK...82gentamicin............ 7, 69, 110


121

gentamicin in nacl (iso-osm)................................. 7gentamicin sulfate (ped) (pf)................................... 7gentamicin sulfate (pf).........7GENTLE LAXATIVE (BISACODYL)....................73GENTLELAX...................... 73GENVOYA...........................7GIANVI (28)..................... 82GILENYA.......................... 96GILOTRIF......................... 15glatiramer........................ 96GLATOPA......................... 96glimepiride....................... 82glipizide........................... 82glipizide-metformin............82GLUCAGON EMERGENCY KIT (HUMAN).............. 82, 96glucagon hcl................59, 82glyburide.................... 82, 83glyburide micronized..........82glyburide-metformin.......... 83GLYCOLAX........................73glycopyrrolate...................25granisetron (pf)................ 73granisetron hcl..................73GRANIX........................... 31griseofulvin microsize.......... 7griseofulvin ultramicrosize....7guanfacine..................36, 47guanidine......................... 25GVOKE SYRINGE..........83, 96GYNOL II..........................57HAEGARDA.......................96HAILEY 24 FE....................83halobetasol propionate..... 110haloperidol....................... 48haloperidol decanoate........ 48haloperidol lactate.............48HAVRIX (PF).....................21HEALTHYLAX.................... 73HEATHER......................... 83HEMLIBRA........................31heparin (porcine).............. 31heparin (porcine) in 5 % dex................................. 31heparin (porcine) in nacl (pf)............................31, 58heparin, porcine (pf)..........31HEPATAMINE 8%...............62HEPLISAV-B (PF)...............21

HEX-ON LIGHT ODOR.......110HIBERIX (PF)....................21HUMIRA.............. 73, 97, 110HUMIRA PEDIATRIC CROHNS START....73, 96, 110HUMIRA PEN........ 73, 97, 110HUMIRA PEN CROHNS-UC-HS START............73, 96, 110HUMIRA PEN PSOR-UVEITS-ADOL HS..73, 96, 110HUMIRA(CF)........ 74, 97, 110HUMIRA(CF) PEDI CROHNS STARTER............. 73, 97, 110HUMIRA(CF) PEN.. 74, 97, 110HUMIRA(CF) PEN CROHNS-UC-HS.................74, 97, 110HUMIRA(CF) PEN PSOR-UV-ADOL HS........ 74, 97, 110HYCAMTIN........................15hydralazine................. 36, 37hydrochlorothiazide......37, 62hydrocodone-acetaminophen................. 48hydrocodone-ibuprofen...... 48hydrocortisone... 83, 110, 111hydrocortisone butyrate... 110hydrocortisone valerate.... 111hydrocortisone-acetic acid.. 69hydrocortisone-pramoxine 111hydromorphone................ 48hydromorphone (pf).......... 48hydroxychloroquine....... 7, 97hydroxyprogest(pf)(preg presv)..............................83hydroxyprogesterone cap(ppres)....................... 83hydroxyprogesterone capr(bulk)........................ 83hydroxyprogesterone caproate.......................... 83hydroxyurea..................... 15hydroxyzine hcl............. 1, 48hydroxyzine pamoate.....1, 48HYQVIA............................21ibandronate......................97IBRANCE..........................15ibuprofen......................... 48ibuprofen-oxycodone......... 48icatibant...........................97IDHIFA............................ 15imatinib........................... 15IMBRUVICA...................... 15

imipenem-cilastatin............. 7imipramine hcl.................. 48imiquimod...................... 111IMOVAX RABIES VACCINE (PF).................................21INCRUSE ELLIPTA..............26indapamide................. 37, 62indomethacin.............. 49, 97INFANRIX (DTAP) (PF)....... 21INLYTA............................ 15INREBIC...........................15INTELENCE.........................7INTRALIPID...................... 62INTRON A............... 7, 15, 97INTROVALE...................... 83INVEGA SUSTENNA........... 49INVIRASE.......................... 7IONOSOL-B IN D5W.......... 62IONOSOL-MB IN D5W........ 62IPOL................................21ipratropium bromide.......................... 26, 69, 104ipratropium-albuterol..26, 104irbesartan........................ 37irbesartan-hydrochlorothiazide......37, 63IRESSA............................ 15irinotecan.........................15ISENTRESS........................ 8ISENTRESS HD................... 8ISIBLOOM........................ 83ISOLYTE-P IN 5 % DEXTROSE....................... 63ISOLYTE-S....................... 63isoniazid............................ 8isosorbide dinitrate............37isosorbide mononitrate.......37isradipine......................... 37itraconazole....................... 8ivermectin..........................8IXIARO (PF)......................21IXINITY............................31JAKAFI.............................15JANTOVEN........................31JANUMET......................... 83JANUMET XR.....................83JANUVIA.......................... 83JARDIANCE...................... 83JENCYCLA........................ 83JINTELI............................83JIVI................................. 31JOLESSA.......................... 83


JOLIVETTE........................83JULEBER.......................... 83JULUCA..............................8JUNEL 1.5/30 (21).............83JUNEL 1/20 (21)............... 84JUNEL FE 1.5/30 (28)........ 84JUNEL FE 1/20 (28)........... 84JUNEL FE 24..................... 84JYNARQUE........................63KADCYLA......................... 15KAITLIB FE.......................84KALETRA............................8KALYDECO......................105KARIVA (28).....................84KELNOR 1/35 (28).............84KELNOR 1-50....................84KETEK............................... 8KETEK PAK.........................8ketoconazole............... 8, 111ketoprofen....................... 49ketorolac.................... 49, 69KEYTRUDA....................... 15KINRIX (PF)......................21KISQALI...........................15KISQALI FEMARA CO-PACK................................. 15, 84KLOR-CON 10................... 63KLOR-CON 8.....................63KLOR-CON M15.................63KLOR-CON M20.................63KOBEE........................... 114KOMBIGLYZE XR............... 84KPN............................... 114KURVELO (28).................. 84l norgest/e.estradiol-e.estrad........................... 84labetalol..................... 26, 37lactated ringers.................63lactulose.......................... 63lamivudine......................... 8lamivudine-zidovudine......... 8lamotrigine.......................49lansoprazole..................... 74LARIN 1.5/30 (21).............84LARIN 1/20 (21)............... 84LARIN 24 FE..................... 84LARIN FE 1.5/30 (28)........ 84LARIN FE 1/20 (28)........... 84LARISSIA......................... 84latanoprost.......................69LATUDA........................... 49LAXACLEAR...................... 74

LAXATIVE (BISACODYL)..... 74LAXATIVE FEMININE.......... 74LAYOLIS FE...................... 84LAZANDA......................... 49ledipasvir-sofosbuvir............8LEENA 28......................... 85leflunomide...................... 97LEMTRADA....................... 97LENVIMA..........................16LESSINA.......................... 85letrozole..................... 16, 85leucovorin calcium.............97LEUKERAN........................16leuprolide................... 16, 85levalbuterol hcl.......... 26, 105levetiracetam....................49levobunolol.......................69levocarnitine.....................98levocarnitine (with sugar)...97levocetirizine...............1, 105levofloxacin.................. 8, 69levofloxacin in d5w..............8LEVONEST (28).................85levonorgestrel...................85levonorgestrel-ethinyl estrad..............................85levonorg-eth estrad triphasic...........................85LEVORA-28.......................85levothyroxine....................85LEVOXYL.......................... 85LEXIVA.............................. 8lidocaine.........................111lidocaine (pf)...............37, 94lidocaine hcl................ 69, 94LIDOCAINE VISCOUS.........70lidocaine-prilocaine.......... 111LILETTA........................... 85LILLOW (28).....................85lindane...........................111linezolid............................. 8linezolid in dextrose 5%.......8linezolid-0.9% sodium chloride............................. 8LINZESS.......................... 74liothyronine...................... 85LIPOSYN III......................63lisinopril...........................37lisinopril-hydrochlorothiazide......37, 63LITE COAT ASPIRIN......31, 49lithium carbonate.............. 49

lithium citrate................... 49LOESTRIN 1.5/30 (21)....... 85LOESTRIN 1/20 (21)..........85LOESTRIN FE 1.5/30 (28-DAY)............................... 85LOESTRIN FE 1/20 (28-DAY)............................... 85LONSURF......................... 16loperamide....................... 74lopinavir-ritonavir............... 8lorazepam........................ 50LORAZEPAM INTENSOL...... 50LORBRENA....................... 16LORYNA (28).................... 85losartan........................... 37losartan-hydrochlorothiazide......37, 63LOSEASONIQUE................ 86lovastatin......................... 37LOW-OGESTREL (28)......... 86loxapine succinate............. 50LUDENT FLUORIDE............ 98LUMIGAN......................... 70LUMIZYME........................67LUPRON DEPOT........... 16, 86LUPRON DEPOT (3 MONTH)................................. 16, 86LUPRON DEPOT (4 MONTH)................................. 16, 86LUPRON DEPOT (6 MONTH)................................. 16, 86LUPRON DEPOT-PED.....16, 86LUTERA (28).....................86LYNPARZA........................16LYSODREN....................... 16LYZA............................... 86M9 ODOR ELIMINATOR.....102magnesium citrate.............74magnesium sulfate. 37, 50, 98magnesium sulfate in water....................37, 50, 98malathion....................... 111maprotiline.......................50MARLISSA (28)................. 86MATULANE....................... 16MAVYRET....................... 8, 9MAYZENT......................... 98MAYZENT STARTER PACK... 98meclizine......................1, 74medroxyprogesterone........ 86mefenamic acid.................50mefloquine.........................9


123

megestrol................... 16, 86MEKINIST........................ 16MEKTOVI..........................16MELODETTA 24 FE.............86meloxicam........................50melphalan........................ 16memantine.......................50MENACTRA (PF)................ 21MENVEO A-C-Y-W-135-DIP (PF).................................21mercaptopurine........... 16, 98meropenem........................9mesalamine......................74mesalamine with cleansing wipe................................ 74mesna............................. 98metaproterenol..........26, 105metformin........................ 86methadone.......................50methazolamide................. 70methenamine hippurate....... 9methimazole.....................86methocarbamol.................26methotrexate sodium... 16, 98methotrexate sodium (pf)................................. 16, 98methscopolamine.............. 26methyclothiazide..........38, 63methyldopa.................26, 38methyldopa-hydrochlorothiazide 26, 38, 63methyldopate.............. 26, 38methylergonovine............102methylphenidate hcl.....50, 51methylprednisolone........... 87methylprednisolone acetate 87methylprednisolone sodium succ................................ 87methyltestosterone............87metipranolol..................... 70metoclopramide hcl........... 74metolazone................. 38, 63metoprolol succinate.... 26, 38metoprolol ta-hydrochlorothiaz.... 26, 38, 63metoprolol tartrate.......26, 38METRO I.V......................... 9metronidazole............. 9, 111metronidazole in nacl (iso-os)....................................9mexiletine........................ 38MIBELAS 24 FE................. 87

MICONAZOLE-3...............111MICROGESTIN 1.5/30 (21). 87MICROGESTIN 1/20 (21)....87MICROGESTIN 24 FE..........87MICROGESTIN FE 1.5/30 (28)................................ 87MICROGESTIN FE 1/20 (28)................................ 87midodrine.........................26mifepristone................... 102MILI................................ 87MILK OF MAGNESIA...........75MILK OF MAGNESIA CONCENTRATED................75minocycline........................ 9minoxidil.......................... 38MIRALAX..........................75MIRCETTE (28)................. 87MIRENA........................... 87mirtazapine...................... 51misoprostol...................... 75MITIGARE........................ 98M-M-R II (PF)................... 21modafinil..........................51moexipril..........................38mometasone...................111MONOJECT 0.9% SODIUM CHLORIDE........................63MONO-LINYAH.................. 87MONONESSA (28)............. 87montelukast....................105morphine......................... 51morphine (pf)................... 51morphine concentrate........ 51MOTOFEN.........................75moxifloxacin................. 9, 70MOZOBIL......................... 31MULTAQ...........................38MULTIVITAMIN WITH FLUORIDE................. 98, 115MULTI-VITAMIN WITH FLUORIDE................. 98, 114MULTIVITAMINS WITH FLUORIDE................. 98, 115mupirocin....................... 111MVC-FLUORIDE..........98, 115MY CHOICE...................... 87MY WAY........................... 87MYCAMINE......................... 9mycophenolate mofetil. 98, 99mycophenolate mofetil (hcl)................................ 98

mycophenolate sodium...... 99MYLERAN......................... 16MYRBETRIQ.................... 113nabumetone..................... 51nafcillin..............................9nalbuphine....................... 52naloxone.................... 52, 99naltrexone.................. 52, 99naproxen.................... 52, 99naproxen sodium......... 52, 99naratriptan....................... 52NARCAN..................... 52, 99NATACYN......................... 70nateglinide....................... 87NATPARA.................... 87, 99NATURAL B-100 COMPLEX 115NAYZILAM........................ 52NECON 0.5/35 (28)........... 87nefazodone.......................52neomycin...........................9neomycin-bacitracin-poly-hc................................... 70neomycin-bacitracin-polymyxin........................ 70neomycin-polymyxin b gu.111neomycin-polymyxin b-dexameth.........................70neomycin-polymyxin-gramicidin........................ 70neomycin-polymyxin-hc..... 70NEPHRAMINE 5.4 %.......... 63NERLYNX..........................16NEULASTA........................31NEUPOGEN.......................31nevirapine..........................9NEW DAY......................... 87NEXAVAR......................... 17NEXPLANON..................... 87NEXT CHOICE ONE DOSE... 88niacin.............................. 38nicardipine....................... 38nicoderm cq..................... 26NICODERM CQ.................. 26nicorelief..........................26NICORELIEF..................... 26nicorette.......................... 26NICORETTE.................26, 27nicotine............................27nicotine (polacrilex)........... 27NICOTROL........................27NICOTROL NS...................27nifedipine......................... 38


NIKKI (28)....................... 88nilutamide........................17NINLARO..........................17nisoldipine........................38nitisinone......................... 99NITRO-BID....................... 38nitrofurantoin..................... 9nitrofurantoin macrocrystal.. 9nitrofurantoin monohyd/m-cryst................................. 9nitroglycerin................38, 39NIVESTYM...................31, 32nizatidine......................... 75NORA-BE..........................88NORDITROPIN FLEXPRO..... 88noreth-ethinyl estradiol-iron................................. 88norethindrone (contraceptive)................. 88norethindrone acetate........88norethindrone ac-eth estradiol...........................88norethindrone-e.estradiol-iron................................. 88norgestimate-ethinyl estradiol...........................88norgestrel-ethinyl estradiol. 88NORLYDA......................... 88NORLYROC....................... 88NORMAL SALINE FLUSH..... 63NORMOSOL-M IN 5 % DEXTROSE....................... 64NORMOSOL-R................... 64NORMOSOL-R IN 5 % DEXTROSE....................... 64NORMOSOL-R PH 7.4.........64NORTREL 0.5/35 (28)........ 88NORTREL 1/35 (21)........... 88NORTREL 1/35 (28)........... 88NORTREL 7/7/7 (28)..........88nortriptyline..................... 52NORVIR............................. 9NOVAREL....................88, 89NOVOEIGHT..................... 32NOVOLIN 70/30 U-100 INSULIN...........................89NOVOLIN 70-30 FLEXPEN U-100..............................89NOVOLIN N NPH U-100 INSULIN...........................89NOVOLIN R REGULAR U-100 INSULN..................... 89

NOVOLOG FLEXPEN U-100 INSULIN...........................89NOVOLOG MIX 70-30 U-100 INSULN..................... 89NOVOLOG MIX 70-30FLEXPEN U-100............. 89NOVOLOG PENFILL U-100 INSULIN...........................89NOVOLOG U-100 INSULIN ASPART........................... 89NOXAFIL............................9NP THYROID.....................89NUBEQA...........................17NUCALA......................... 105NUEDEXTA................ 52, 105NULOJIX.......................... 99nystatin......................9, 111nystatin (bulk)................ 111nystatin-triamcinolone......111OBIZUR........................... 32OCALIVA.......................... 75OCELLA............................89OCREVUS.........................99octreotide acetate........ 89, 99ODACTRA.........................21ODEFSEY........................... 9OFEV............................. 105ofloxacin.....................10, 70OGESTREL (28).................89olanzapine........................52olopatadine...................... 70omega-3 acid ethyl esters.. 39omeprazole...................... 75ondansetron..................... 75ondansetron hcl................ 75ondansetron hcl (pf).......... 75ONE DAILY PRENATAL.......................... 32, 64, 115ONETOUCH ULTRA BLUE TEST STRIP...................... 59ONETOUCH ULTRA2 METER 58ONETOUCH ULTRAMINI......58ONETOUCH VERIO.............59ONETOUCH VERIO FLEX..... 58ONETOUCH VERIO FLEX START............................. 58ONETOUCH VERIO IQ METER............................. 58ONGLYZA......................... 89OPCICON ONE-STEP.......... 89opium tincture.............52, 75OPSUMIT.................. 39, 105

OPTION-2........................ 89ORAL SALINE LAXATIVE..... 75ORILISSA.........................89ORKAMBI....................... 105orphenadrine citrate.......... 27ORSYTHIA........................ 89ORTHO TRI-CYCLEN (28)....90ORTHO TRI-CYCLEN LO (28)................................ 90ORTHO-CYCLEN (28)......... 90ORTHO-NOVUM 1/35 (28).. 90oseltamivir....................... 10OSMOPREP.......................75OTEZLA.................... 99, 112OTEZLA STARTER.......99, 112oxacillin........................... 10oxacillin in dextrose(iso-osm)............................... 10oxandrolone..................... 90oxaprozin......................... 52oxazepam........................ 52oxcarbazepine...................52OXERVATE........................70oxybutynin chloride......... 113oxycodone.................. 52, 53oxycodone-acetaminophen. 53oxycodone-aspirin............. 53OZEMPIC..........................90P D NATAL VITAMINS-FOLIC ACID.................... 115palonosetron.................... 75PALYNZIQ........................ 67pamidronate..................... 99pantoprazole.................... 75PARAGARD T 380A............ 90paregoric......................... 75paromomycin....................10paroxetine hcl...................53PEDIARIX (PF).................. 21PEDVAX HIB (PF).............. 21peg 3350-electrolytes........ 75PEG-3350 WITH FLAVOR PACKS............................. 76PEGASYS..........................10PEGASYS CONVENIENCE PACK............................... 10peg-electrolyte soln........... 76PEGINTRON......................10PEG-PREP.........................76penicillin g potassium.........10penicillin g procaine........... 10penicillin g sodium.............10


125

penicillin v potassium.........10PENTACEL (PF)................. 21PENTASA..........................76pentoxifylline.................... 32perindopril erbumine..........39permethrin..................... 112perphenazine....................53perphenazine-amitriptyline. 53PERRY PRENATAL..32, 64, 115phenelzine........................53phenobarbital................... 53phenoxybenzamine...... 27, 39phenytoin................... 39, 53phenytoin sodium........ 39, 53phenytoin sodium extended.................... 39, 53PHILITH........................... 90PHOSPHATE LAXATIVE....... 76PHOSPHOLINE IODIDE.......70PHYSIOLYTE..................... 64PHYSIOSOL IRRIGATION.... 64phytonadione (vitamin k1)............................... 99, 115PIFELTRO......................... 10pilocarpine hcl...................27pimecrolimus.............99, 112PIMTREA (28)................... 90pindolol...................... 27, 39pioglitazone......................90pioglitazone-glimepiride..... 90pioglitazone-metformin...... 90piperacillin-tazobactam...... 10PIQRAY............................ 17PIRMELLA.........................90piroxicam......................... 53PLAN B ONE-STEP............. 90PLASMA-LYTE 148............. 64PLASMA-LYTE A................ 64PLEGRIDY.......................100PNEUMOVAX 23................ 22pnv cmb#95-ferrous fumarate-fa...............32, 115podofilox........................ 112polyethylene glycol 3350.... 76polymyxin b sulfate........... 10polymyxin b sulf-trimethoprim.................... 70POMALYST................ 17, 100PORTIA 28....................... 90posaconazole.................... 10potassium chlorid-d5-0.45%nacl........................64

potassium chloride....... 64, 65potassium chloride in 0.9%nacl......................... 64potassium chloride in 5 % dex................................. 64potassium chloride in lr-d5. 64potassium chloride in water 64potassium chloride-0.45 % nacl.................................65potassium chloride-d5-0.2%nacl......................... 65potassium chloride-d5-0.3%nacl......................... 65potassium chloride-d5-0.9%nacl......................... 65potassium citrate.............. 65POWDERLAX.....................76PRALUENT PEN................. 39pramipexole..................... 53pravastatin.......................39praziquantel..................... 10prazosin..................... 27, 39prednicarbate..................112prednisolone.....................90prednisolone acetate..........71prednisolone sodium phosphate...................71, 90prednisone....................... 90PREDNISONE INTENSOL.....90pregabalin........................53PREMASOL 10 %............... 65PREMASOL 6 %.................65PREMPHASE......................90PREMPRO......................... 90PRENATAL.................32, 115PRENATAL COMPLETE.......................... 32, 65, 115PRENATAL MULTI-DHA (ALGAL OIL).............. 32, 115PRENATAL ONE DAILY.......................... 32, 65, 115PRENATAL TABLET 32, 65, 115PRENATAL VITAMIN.......................... 32, 65, 115PRENATAL VITAMIN WITH MINERALS........... 32, 65, 115prenatal vit-iron fum-folic ac.......................32, 65, 115prenatal vits96-iron fum-folic.................... 32, 65, 115PREVALITE....................... 39PREVIFEM........................ 91

PREVNAR 13 (PF).............. 22PREVYMIS........................ 10PREZCOBIX............... 10, 100PREZISTA.........................11PRIFTIN........................... 11primidone.........................53PRIVIGEN.........................22probenecid................ 65, 100probenecid-colchicine. 65, 100procainamide....................39PROCALAMINE 3%.............65prochlorperazine..........54, 76prochlorperazine edisylate................................. 54, 76prochlorperazine maleate................................. 54, 76PROCRIT.......................... 32PROCTO-PAK.................. 112PROCTOZONE-HC............ 112progesterone micronized.... 91PROLASTIN-C..................105PROMACTA....................... 32promethazine.........1, 54, 105propafenone..................... 39proparacaine.................... 71propranolol............27, 39, 54propranolol-hydrochlorothiazid.. 27, 39, 65propylthiouracil................. 91PROQUAD (PF)..................22PROSOL 20 %...................65protriptyline......................54PULMOZYME..............67, 105PURELAX..........................76PYLERA.......................11, 76pyrazinamide....................11pyridostigmine bromide......27QUADRACEL (PF)...............22QUARTETTE......................91quetiapine........................ 54quinapril.......................... 39quinapril-hydrochlorothiazide......39, 66quinidine gluconate...... 11, 40quinidine sulfate.......... 11, 40quinine sulfate.................. 11QUIT 2.............................27QUIT 4.............................27QVAR REDIHALER...... 91, 106RABAVERT (PF)................. 22RAJANI............................ 91raloxifene..................91, 100


ramelteon........................ 54ramipril............................40ranitidine hcl.................... 76ranolazine........................ 40REBIF (WITH ALBUMIN)... 100REBIF REBIDOSE.............100REBIF TITRATION PACK....100REBINYN..........................33RECLIPSEN (28)................91RECOMBIVAX HB (PF)........ 22RECTIV.......................... 112REGONOL.........................27REJUVENESS.................... 58RELENZA DISKHALER.........11RENA-VITE..................... 115RENFLEXIS........ 76, 100, 112REPATHA PUSHTRONEX......40REPATHA SURECLICK.........40REPATHA SYRINGE............ 40RESCRIPTOR.................... 11RESTORE SKIN CLEANSER 112RESTORE WOUND CLEANSER........................58RETACRIT........................ 33RETROVIR........................ 11REVCOVI..........................67REVLIMID................. 17, 100ribavirin........................... 11rifabutin...........................11rifampin........................... 11RIFATER...........................11riluzole............................ 54rimantadine......................11ringer's............................ 66RINVOQ......................... 100RISPERDAL CONSTA.......... 54risperidone....................... 54ritonavir...........................11RITUXAN HYCELA.............. 17rivastigmine..................... 27rivastigmine tartrate..........27RIVELSA.......................... 91rizatriptan........................ 54ropinirole......................... 55rosuvastatin..................... 40ROTARIX..........................22ROTATEQ VACCINE............22ROZLYTREK...................... 17RUBRACA......................... 17RUZURGI........................100RYDAPT........................... 17SAFYRAL.......................... 91

salsalate.......................... 55SAMSCA...........................66SAPHRIS.......................... 55SEASONIQUE....................91selegiline hcl.....................55SELZENTRY...................... 11sertraline......................... 55SETLAKIN.........................91sevelamer carbonate.. 66, 100sevelamer hcl............ 66, 100SHAROBEL....................... 91SHINGRIX (PF)................. 22SHINGRIX GE ANTIGEN COMPONENT.....................22SIKLOS............................17sildenafil (pulm.hypertension)...40, 106silver sulfadiazine............ 112simvastatin.......................40sirolimus........................ 100SIRTURO..........................11SKYRIZI......................... 112SMOOTHLAX.....................76sodium chlor 0.9% bacteriostat...................... 66sodium chloride.................66sodium chloride 0.45 %..... 66sodium chloride 0.9 %....... 66sodium chloride 0.9 % (flush)............................. 66sodium chloride 3 %.......... 66sodium chloride 5 %.......... 66sodium citrate-citric acid.... 66sodium lactate.................. 66sodium phenylbutyrate.......66sodium polystyrene sulfonate...................66, 100sofosbuvir-velpatasvir........11SOLIQUA 100/33...............91SOMAVERT....................... 91sotalol........................27, 40SPIRIVA RESPIMAT.... 28, 106SPIRIVA WITH HANDIHALER.............28, 106spironolactone.............40, 66spironolacton-hydrochlorothiaz..........40, 66SPRAVATO....................... 55SPRINTEC (28)................. 91SPRYCEL.......................... 17SPS (WITH SORBITOL)66, 100SRONYX...........................91

STAMARIL (PF)................. 22stavudine......................... 11STELARA..........100, 101, 112STIOLTO RESPIMAT...........28STIVARGA........................ 17STOP SMOKING AID.......... 28STRENSIQ........................68streptomycin.................... 11STRESS FORMULA........... 115STRESS FORMULA 600 C.. 115STRESS FORMULA WITH IRON........................33, 115STRESS FORMULA WITH IRON(SULF).............. 33, 115STRIBILD......................... 11sucralfate.........................76sulfacetamide sodium........ 71sulfacetamide sodium (acne)............................112sulfacetamide-prednisolone 71sulfadiazine...................... 11sulfamethoxazole-trimethoprim...............11, 12sulfasalazine........ 12, 76, 101sulindac........................... 55sumatriptan......................55sumatriptan succinate........55SUPER B COMPLEX-VITAMIN C......................116SUPER B MAXI COMPLEX.. 116SUPER B-50 COMPLEX PLUS..............................116SUPER QUINTS................116SUPER QUINTS B-50........ 116SUPERPLEX-T..................116SUTENT........................... 17SYEDA............................. 91SYLATRON.................. 12, 17SYMBICORT......... 28, 91, 106SYMDEKO.......................106SYMFI..............................12SYMFI LO......................... 12SYMTUZA..................12, 101SYNAGIS..........................12SYNERCID........................ 12SYNJARDY........................91SYNJARDY XR................... 92SYNRIBO..........................17SYNTHROID......................92tacrolimus............... 101, 112tadalafil (pulm. hypertension)............ 40, 106


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TAFINLAR.........................17TAGRISSO........................17TAKE ACTION................... 92TALZENNA........................17tamoxifen................... 17, 92tamsulosin....................... 28TARGRETIN............... 17, 112TARINA FE 1/20 (28)......... 92TARINA FE 1-20 EQ (28).... 92TASIGNA..........................17tazarotene......................112TDVAX............................. 22TECFIDERA.....................101temazepam...................... 55TEMIXYS.......................... 12temozolomide................... 17TENIVAC (PF)................... 22tenofovir disoproxil fumarate..........................12terazosin.................... 28, 40terbinafine hcl...................12terbutaline................ 28, 106terconazole.....................112testosterone..................... 92testosterone cypionate.......92testosterone enanthate...... 92tetanus,diphtheria tox ped(pf)............................ 22tetrabenazine................... 55tetracaine hcl....................71tetracycline...................... 12THALOMID......................101theophylline..40, 67, 106, 113thioridazine...................... 55thiothixene....................... 55THYMOGLOBULIN............ 101tiagabine..........................55TIBSOVO..........................17tigecycline........................12TILIA FE...........................92timolol maleate.28, 40, 55, 71tinidazole......................... 12TIVICAY........................... 12tizanidine......................... 28TOBRADEX....................... 71tobramycin.......................71tobramycin in 0.225 % nacl.................................12tobramycin in 0.9 % nacl... 12tobramycin sulfate.............12tobramycin-dexamethasone................ 71

TODAY CONTRACEPTIVE SPONGE...........................57tolazamide....................... 92tolbutamide...................... 92tolcapone......................... 55tolmetin......................55, 56tolterodine......................113topiramate....................... 56topotecan.........................18torsemide................... 40, 67TOTAL B/C......................116tramadol.......................... 56tramadol-acetaminophen....56trandolapril.......................40tranexamic acid................ 33tranylcypromine................ 56TRAVASOL 10 %............... 67TRAVATAN Z.....................71trazodone.........................56TRECATOR....................... 12TRELEGY ELLIPTA. 28, 92, 106TRELSTAR...................18, 92TREMFYA.................112, 113tretinoin......................... 113tretinoin (chemotherapy)....18TRI FEMYNOR................... 92triamcinolone acetonide........................ 71, 106, 113triamterene-hydrochlorothiazid....... 41, 67TRI-BUFFERED ASPIRIN33, 56trientine...........................77TRI-ESTARYLLA.................92trifluoperazine.................. 56trifluridine........................ 71trihexyphenidyl............28, 56TRIKAFTA....................... 106TRI-LEGEST FE................. 92TRI-LINYAH...................... 93TRI-LO-ESTARYLLA............93TRI-LO-MARZIA................ 93TRI-LO-SPRINTEC............. 93TRILYTE WITH FLAVOR PACKETS..........................76trimethobenzamide............76trimethoprim.................... 12TRI-MILI.......................... 93TRINTELLIX...................... 56TRIPLE VITAMIN WITH FLUORIDE............... 101, 116TRI-PREVIFEM (28)........... 93TRIPTODUR.................18, 93

TRI-SPRINTEC (28)........... 93TRIUMEQ......................... 12TRI-VITAMIN WITH FLUORIDE............... 101, 116TRI-VITE WITH FLUORIDE..............................101, 116TRIVORA (28)...................93TRI-VYLIBRA.................... 93TRI-VYLIBRA LO................93TROGARZO.......................12TROPHAMINE 10 %........... 67TROPHAMINE 6%.............. 67trospium........................ 113TRULICITY........................93TRUMENBA.......................22TRUVADA......................... 12TURALIO.......................... 18TWINRIX (PF)................... 23TYDEMY........................... 93TYKERB............................18TYMLOS....................93, 101TYPHIM VI........................23TYSABRI.........................101TYZINE............................ 71UDENYCA......................... 33ULTRA B-100 COMPLEX.... 116UNITHROID...................... 93UPTRAVI................... 41, 106ursodiol...................... 76, 77VAGINAL CONTRACEPTIVE FILM................................57VAGINAL CONTRACEPTIVE FOAM.............................. 57valacyclovir...................... 12valganciclovir....................12valproate sodium.............. 56valproic acid..................... 56valproic acid (as sodium salt)................................ 56valsartan..........................41valsartan-hydrochlorothiazide......41, 67vancomycin.................12, 13VAQTA (PF)...................... 23VARIVAX (PF)................... 23VASCEPA..........................41VAXCHORA ACTIVE COMPONENT.....................23VAXCHORA VACCINE......... 23VECTIBIX......................... 18VELCADE..........................18


VELIVET TRIPHASIC REGIMEN (28).................. 93VELTASSA........................ 67VEMLIDY.......................... 13VENCLEXTA...................... 18VENCLEXTA STARTING PACK............................... 18venlafaxine.......................56VENTOLIN HFA.......... 28, 106verapamil.........................41VERIPRED 20....................93VERZENIO........................18VIBERZI...........................77VIENVA............................93VIIBRYD...........................56VIMIZIM...........................68VIMPAT............................56VIORELE (28)................... 93VIRACEPT.........................13VIREAD............................13vitamin b complex........... 116vitamin b complex-folic acid............................... 116VITAMINS A,C,D AND FLUORIDE............... 101, 116VITAMINS B COMPLEX......116VITRAKVI......................... 18VIVITROL..................57, 101VIVOTIF...........................23VIZIMPRO........................ 18VORAXAZE................ 68, 101voriconazole..................... 13VOSEVI............................13VOTRIENT........................ 18VPRIV..............................68VYFEMLA (28)...................93VYLIBRA.......................... 93VYNDAMAX.......................41VYNDAQEL....................... 41VYVANSE......................... 57warfarin........................... 33water (bulk)....................102water for irrigation, sterile.. 67WERA (28)....................... 94WIDE-SEAL DIAPHRAGM 60...................................57WIDE-SEAL DIAPHRAGM 65...................................57WIDE-SEAL DIAPHRAGM 70...................................57WIDE-SEAL DIAPHRAGM 75...................................57

WIDE-SEAL DIAPHRAGM 80...................................57WIDE-SEAL DIAPHRAGM 85...................................58WIDE-SEAL DIAPHRAGM 90...................................58WIDE-SEAL DIAPHRAGM 95...................................58WOMAN'S LAXATIVE (BISACODYL)....................77WOMEN'S GENTLE LAXATIVE(BISAC)..............77WOMEN'S LAXATIVE (BISACODYL)....................77WYMZYA FE...................... 94XALKORI.......................... 18XARELTO..........................33XELJANZ........................ 101XELJANZ XR....................101XEMBIFY.......................... 23XENLETA..........................13XERESE..........................113XERMELO......................... 77XIGDUO XR...................... 94XIIDRA............................ 71XOFLUZA......................... 13XOLAIR.......................... 107XOSPATA......................... 18XPOVIO........................... 18XTANDI............................18XULANE........................... 94YASMIN (28).................... 94YAZ (28).......................... 94YF-VAX (PF)......................23YONDELIS........................ 18YUVAFEM......................... 94zaleplon........................... 57ZALTRAP.......................... 18ZARAH.............................94ZARXIO............................33ZEJULA............................ 18ZELBORAF........................19ZENCHENT (28)................ 94zidovudine........................13ziprasidone hcl..................57ZIRGAN........................... 71zoledronic acid......... 101, 102zoledronic acid-mannitol-water.............................102zoledronic ac-mannitol-0.9nacl...........................102ZOLINZA..........................19

zolmitriptan......................57zolpidem.......................... 57ZOMIG.............................57zonisamide....................... 57ZORBTIVE........................ 94ZORTRESS......................102ZOSTAVAX (PF).................23ZOVIA 1/35E (28)............. 94ZYDELIG.......................... 19ZYKADIA..........................19ZYLET..............................71ZYTIGA............................ 19


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› filer_public › files › u5434_ifp... 2020 Formulary (List of Covered Drugs)amoxicillin-pot clavulanate oral tablet extended release 12 hr 1,000-62.5 mg 1 amoxicillin-pot clavulanate