Atlas $3000 HSA Atlas $6750 HSA Atlas Catastrophic

Atlas $3000 HSA Atlas $6750 HSA

Atlas Catastrophic

2021 Formulary

(List of covered drugs)

For current information on the GenericsAdvantageRx Drug List, visit healthpartners.com/pharmacy.

Effective: October 1, 2021

©2021 HealthPartners

What’s the GenericsAdvantageRx drug list?

This is the list of medicines (sometimes called a formulary) covered by your health plan. The drug list is reviewed by a

team of experts every three months for new medicines, safety alerts and other updates.

Who decides what’s on the drug list?

The HealthPartners Pharmacy and Therapeutics Committee manage the list. This team of experts focuses on safety,

effectiveness and affordability. Visit healthpartners.com/pharmacy for more information.

How do you use the drug list?

The medicines are listed in alphabetical order by type of medicine starting on page 4.

Generic medicines are in lowercase italics (e.g., cephalexin). These medicines are safe and effective but cost less than brand

medicines.

Brand medicines are in ALL CAPS (e.g., KEFLEX) and are more costly than generic medicines.

The Tier is used to determine how much a medicine will cost you. For exact cost information,

• Find the tier status for your medicine.

• Review your Summary of Plan Benefits or contract for the copay or coinsurance for that Tier Status. Or,

• Log on to your myHealthPartners account to check your pharmacy benefits.

o Tier 1 – Formulary Generics o Tier 2 – Formulary Brands

o Tier 3 – Non-Formulary Generics &Brands

(Non-Formulary medicines are not listed in this document)

o Tier 4 – Specialty Generics & Brands

What’s a Specialty Medicine?

Specialty medicines are usually prescribed by doctors whose focus is on the treatment of chronic and complex diseases.

These medicines usually require more management, have a high price and aren’t always stocked at retail pharmacies.

Prescriptions for these medicines must be filled at a specialty pharmacy and are often covered at a different benefit than

non-specialty medicines. Log on to your myHealthPartners account and click on My plan benefits on the Medical Plan

tab to check your benefits for specialty medicines.

What do the abbreviations under Limits & Restrictions mean?

Special information about the medicine you’re searching for. The abbreviations let you know there might be a special program

or rule for the medicine. Use this key to help you navigate the drug list:

• PA - Prior Authorization Required

• ST - Step Therapy Required

• AL1 - Age Limit

• AQ1 – Age Quantity Limit

• QL - Quantity Limit

• SC - Smoking Cessation Benefit

• WL - Weight Loss Benefit

• ONC - Oncology Benefit

• TD - Trial Drug Program

• S – Specialty

Why do you need prior authorization (PA) for some medicines? Even though some medicines are on the drug list, they

need to meet the HealthPartners prior authorization criteria in order for the medicine to be covered by your

pharmacy benefits.

What’s Step Therapy (ST)? Some medicines are on the drug list, but you need to try

one or more other medicines first. HealthPartners

covers a medicine with step therapy, if you've already

tried the other medicine(s). If you haven't, you or your doctor will need to get approval from HealthPartners

before the medicine will be covered by your lowest

brand, generic or specialty copay or coinsurance.

What’s an Age Limit (AL1)? An age edit means some medicines are only covered if

you’re within a specific age range. If you're not in the

approved age range, you or your doctor will need to

request approval from HealthPartners for your

medicine to be covered.

What’s an Age Quantity Limit (AQ1)?

An age quantity limit means some medicines have a quantity limit that only applies to a specific age range. If

you're not in the approved age range, you or your

doctor will need to request approval from

HealthPartners for your medicine to be covered.

What’s a Quantity Limit (QL)? This means HealthPartners limits the amount of the

medicine you'll get each time you fill your prescription.

The quantity limit may be less than the day supply listed in your contract or Summary Plan Description.

What’s the Trial Drug Program (TD)? The trial drug program is for new prescriptions for

certain medicines that may not be well tolerated due

to:

• Side effects

• High cost

• High potential for waste

Your first 6 fills of a trial drug may be limited to less

than a month supply. If the medicine works well, you’ll

get the rest of your month supply. If a copay applies to

the medicine, you’ll pay no more than one copay for

each one month supply.

What’s the Weight Loss Benefit (WL)? This type of medicine may have limits on the amount

you get or may not be covered under all plans. Log on to

your myHealthPartners account and click on My plan

benefits on the Medical Plan tab to check your benefits

for weight loss. Weight Loss medicines are listed on the

drug list under the Weight Loss medicine category.

What’s the Oncology Benefit (ONC)? These are oncology (cancer) medicines that must be filled at a specialty pharmacy, but you’re only responsible for your regular generic or brand pharmacy copay or coinsurance.

The HealthPartners family of health plans is underwritten and/or administered by HealthPartners, Inc., Group Health, Inc., HealthPartners Insurance Company or HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. (10/21) ©2021 HealthPartners

LIST OF COVERED PRESCRIPTION MEDICATIONSPRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS

ergoloid mesylates 1 PA

phenoxybenzamine hcl 1 PA

SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENTalfuzosin hcl er 1

tamsulosin hcl 1

ANALGESICS AND ANTIPYRETICSANALGESICS AND ANTIPYRETICS, MISC.

butalb-acetamin-caff 50-325-40 1 QL 6 TABS / 1 DAY

butalbital-acetaminophn 50-325 1 QL 6 TABS / 1 DAY

TENCON 1 QL 6 TABS / 1 DAY

ZEBUTAL 1 QL 6 CAPS / 1 DAY

OPIATE AGONISTS

acetamin-codein 300-30 mg/12.5 1 AQ1 At least 12 yrs old;60 / 1 DAY

acetaminop-codeine 120-12 mg/5 1 AQ1 At least 12 yrs old;60 / 1 day(s)

acetaminophen-codeine (#2 tablet, #3 tablet, #4 tablet) 1 AQ1 At least 12 yrs old; 8/ 1 DAY

codeine sulfate 1 AQ1 At least 12 yrs old; 8/ 1 DAY

ENDOCET 10-325 MG TABLET 1 QL 5 TABS / 1 DAY

ENDOCET 5-325 TABLET 1 QL 8 TABS / 1 DAY

ENDOCET 7.5-325 MG TABLET 1 QL 7 TABS / 1 DAY

fentanyl (12 mcg/hr patch, 25 mcg/hr patch, 50 mcg/hrpatch, 75 mcg/hr patch, 100 mcg/hr patch)

1 PA

hydrocodone-acetaminophen (5-325 mg, 7.5-325, 10-325mg)

1 QL 8 TABS / 1 DAY

PAGE 1 LAST UPDATED 10/2021

PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONShydrocodone-acetaminophen (hydrocodone-acetamin2.5-108/5, hydrocodone-acetamin 5-217/10,hydrocodone-acetamn 7.5-325/15)

1 QL 120 ML / 1 DAY

hydrocodone-ibuprofen 7.5-200 1 QL 8 TABS / 1 DAY

hydromorphone 2 mg tablet 1 QL 8 TABS / 1 DAY

hydromorphone 3 mg suppos 1 QL 8 SUPP / 1 DAY



hydromorphone hcl (1 mg/ml solution, 5 mg/5 ml soln) 1 QL 20 ML / 1 DAY

LORCET 1 QL 8 TABS / 1 DAY

LORCET HD 1 QL 8 TABS / 1 DAY

LORCET PLUS 1 QL 8 TABS / 1 DAY

methadone hcl (5 mg/5 ml solution, hcl 5 mg tablet, 10mg/5 ml solution, 10 mg/ml oral conc, hcl 10 mg tablet,40 mg tablet dispr)

1 PA

METHADONE INTENSOL 1 PA

METHADOSE 40 MG TABLET DISPR 1 PA

morphine sulf 10 mg/5 ml soln 1 QL 30 ML / 1 DAY

morphine sulf 100 mg/5 ml conc 1 QL 4 ML / 1 DAY

morphine sulf 20 mg/5 ml soln 1 QL 20 ML / 1 DAY

morphine sulfate (5 mg suppos, 10 mg suppos, 20 mgsuppos, 30 mg suppos)

1 QL 8 SUPP / 1 DAY

morphine sulfate er (er 15 mg tablet, er 30 mg tablet, er60 mg tablet, er 100 mg tablet, er 200 mg tablet)

1 PA

morphine sulfate ir 15 mg tab 1 QL 5 TABS / 1 DAY

MORPHINE SULFATE IR 15 MG TAB (BRAND) 2 QL 5 TABS / 1 DAY

morphine sulfate ir 30 mg tab 1 QL 2 TABS / 1 DAY

MORPHINE SULFATE IR 30 MG TAB (BRAND) 2 QL 2 TABS / 1 DAY


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

oxycodone hcl 10 mg tablet 1 QL 5 TABS / 1 DAY

oxycodone hcl 100 mg/5 ml conc 1 QL 2 ML / 1 DAY



oxycodone hcl 30 mg tablet 1 PA

oxycodone hcl 5 mg capsule 1 QL 8 CAPS / 1 DAY


oxycodone hcl 5 mg/5 ml soln 1 QL 40 ML / 1 DAY

oxycodone hcl er 1 PA

oxycodone hcl-aspirin 1 QL 8 TABS / 1 DAY

oxycodone-acetaminophen 10-325 1 QL 5 TABS / 1 DAY

oxycodone-acetaminophen 5-325 1 QL 8 TABS / 1 DAY

oxycodone-acetaminophn 7.5-325 1 QL 7 TABS / 1 DAY

OXYCONTIN 2 PA

tramadol hcl 50 mg tablet 1 AQ1 At least 12 yrs old; 8/ 1 DAY

tramadol hcl-acetaminophen 1PA

AQ1 At least 12 yrs old; 8/ 1 DAY

OPIATE PARTIAL AGONISTS

buprenorphine 1 PA

buprenorphine-nalox 12-3mg flm 1 QL 2 FILMS / 1 DAY

buprenorphine-naloxone (2-0.5mg fm, 4-1mg film, 8-2mgfilm)

1 QL 3 FILMS / 1 DAY

buprenorphine-naloxone (2-0.5mg tb, 8-2 mg tab) 1 QL 3 TABS / 1 DAY



ANOREXIGENIC AGENTSAMPHETAMINE DERIVATIVES

LOMAIRA 1QL 3 TABS / 1 DAY

WL Weight Loss

phentermine 15 mg capsule 1QL 2 CAPS / 1 DAY

WL Weight Loss

phentermine 37.5 mg tablet 1QL 1 TAB / 1 DAY

WL Weight Loss

phentermine hcl (30 mg capsule, 37.5 mg capsule) 1QL 1 CAP / 1 DAY

WL Weight Loss

ANOREXIGENICS;RESPIRATORY,CNS STIMULANTSAMPHETAMINES

ADDERALL XR 1 QL 2 CAPS / 1 DAY

dextroamp-amphetamin 15 mg tab (generic adderall) 1 QL 3 TABS / 1 DAY

dextroamp-amphetamin 20 mg tab (generic adderall) 1 QL 3 TABS / 1 DAY

dextroamp-amphetamin 30 mg tab 1 QL 2 TABS / 1 DAY

dextroamphetamine sulfate (5 mg tab, 10 mg tab) 1 QL 4 TABS / 1 DAY

dextroamphetamine sulfate er 1 QL 4 CAPS / 1 DAY

dextroamphetamine-amphetamine (dextroamp-amphetam 7.5 mg tab, dextroamp-amphetam 12.5 mgtab, dextroamp-amphetamin 10 mg tab, dextroamp-amphetamine 5 mg tab)

1 QL 3 TABS / 1 DAY

VYVANSE (10 MG CAPSULE, 20 MG CAPSULE, 30 MGCAPSULE)

2 QL 2 CAPS / 1 DAY

VYVANSE (10 MG TABLET, 20 MG TABLET, 30 MG TABLET) 2 QL 2 CHEW TABS / 1DAY

VYVANSE (40 MG CAPSULE, 50 MG CAPSULE, 60 MGCAPSULE, 70 MG CAPSULE)

2 QL 1 CAP / 1 DAY

VYVANSE (40 MG TABLET, 50 MG TABLET, 60 MG TABLET) 2 QL 1 CHEW TAB / 1 DAY

ZENZEDI (5 MG TABLET, 10 MG TABLET) 1 QL 4 TABS / 1 DAY



RESPIRATORY AND CNS STIMULANTSCONCERTA (ER 18 MG TABLET, ER 27 MG TABLET, ER 36MG TABLET)

1 QL 2 TABS / 1 DAY

CONCERTA ER 54 MG TABLET 1 QL 1 TAB / 1 DAY

dexmethylphenidate hcl 1 QL 2 TABS / 1 DAY

dexmethylphenidate hcl er (er 25 mg cp, er 30 mg cp, er35 mg cp, er 40 mg cp)

1 QL 1 CAP / 1 DAY

dexmethylphenidate hcl er (er 5 mg cap, er 10 mg cp, er15 mg cp, er 20 mg cp)

1 QL 2 CAPS / 1 DAY

METADATE ER 1 QL 3 TABS / 1 DAY

methylphenidate er (la) (10mg cp, 20mg cp, 30mg cp) 1 QL 2 CAPS / 1 DAY

methylphenidate er 10 mg tab 1 QL 4 TABS / 1 DAY

methylphenidate er 20 mg tab 1 QL 3 TABS / 1 DAY

methylphenidate er(la) 40mg cp 1 QL 1 CAP / 1 DAY

methylphenidate hcl (5 mg tablet, 10 mg tablet, 20 mgtablet)

1 QL 3 TABS / 1 DAY

methylphenidate hcl cd (10 mg cap, 20 mg cap, 30 mgcap)

1 QL 2 CAPS / 1 DAY

methylphenidate hcl cd (40 mg cap, 50 mg cap, 60 mgcap)

1 QL 1 CAP / 1 DAY

methylphenidate hcl er (cd) (10mg cp, 20mg cp, 30mg cp) 1 QL 2 CAPS / 1 DAY

methylphenidate hcl er (cd) (40mg cp, 50mg cp, 60mg cp) 1 QL 1 CAP / 1 DAY

methylphenidate la (10 mg cap, 20 mg cap, 30 mg cap) 1 QL 2 CAPS / 1 DAY

methylphenidate la (40 mg cap, 60 mg cap) 1 QL 1 CAP / 1 DAY

QUILLICHEW ER 20 MG CHEW TAB 2 QL 3 CHEW TABS / 1DAY

QUILLICHEW ER 30 MG CHEW TAB 2 QL 2 CHEW TABS / 1DAY

QUILLICHEW ER 40 MG CHEW TAB 2 QL 1 CHEW TAB / 1 DAY

QUILLIVANT XR 2 QL 6 ML / 1 DAY



WAKEFULNESS-PROMOTING AGENTS

armodafinil (150 mg tablet, 200 mg tablet, 250 mg tablet) 1 QL 1 TAB / 1 DAY

armodafinil 50 mg tablet 1 QL 2 TABS / 1 DAY

modafinil 1 QL 2 TABS / 1 DAY

SUNOSI 2QL 1 TAB / 1 DAY

PA

WAKIX 4PA

S

ANTI-INFECTIVE AGENTSANTHELMINTICS

albendazole 1 PA

ivermectin 3 mg tablet 1

praziquantel 1

URINARY ANTI-INFECTIVES

fosfomycin tromethamine 1 QL 1 PACKET / RX

nitrofurantoin (25 mg/5 ml susp, mcr 25 mg cap) 1 AL1 Up to 12 yrs old

nitrofurantoin (50 mg cap, 100 mg cap) 1

nitrofurantoin mono-macro 1

trimethoprim 1

ANTI-INFECTIVES (EENT)ANTIBACTERIALS (EENT)

bacitracin 500 unit/gm ophth 1

bacitracin-polymyxin 1

BESIVANCE 2 PA

BLEPHAMIDE S.O.P. 2

CILOXAN 0.3% OINTMENT 2

CIPRO HC 2

ciprofloxacin 0.3% eye drop 1



ciprofloxacin-dexamethasone 1

doxycycline hyclate 20 mg tab 1

erythromycin 0.5% eye ointment 1

moxifloxacin 0.5% eye drops 1

neomyc-polym-dexamet eye ointm 1

neomycin-bacitracin-polymyxin 1

neomycin-polymyxin-gramicidin 1

neomycin-polymyxin-hc ear susp 1

neomycin-polymyxin-hydrocort 1

ofloxacin (ear drops, eye drops) 1

polymyxin b sul-trimethoprim 1

sulfacetamide sodium (drops, ointment) 1

sulfacetamide-prednisolone 1

TOBRADEX EYE OINTMENT 2

tobramycin 0.3% eye drop 1

tobramycin-dexamethasone 1

TOBREX 0.3% EYE OINTMENT 2

ANTIVIRALS (EENT)trifluridine 1

ZIRGAN 2

EENT ANTI-INFECTIVES, MISCELLANEOUSacetic acid 2% ear solution 1

chlorhexidine gluconate 1

PAROEX 1

PERIOGARD 1

ANTI-INFECTIVES (SKIN, MUCOUS MEMBRANE)ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)

CLEOCIN 100 MG VAGINAL OVULE 2

clind ph-benzoyl perox 1.2-5% 1



clindamycin ph 1% gel (generic for cleocin t) 1

clindamycin ph 1% solution 1 QL 60 ML / 30 DAYS

clindamycin phosphate (phos 1% pledget, phosp 1%lotion, 2% vaginal cream)

1

clindamycin-benzoyl peroxide 1

erythromycin 2% gel 1

erythromycin 2% solution 1 QL 60 ML / 30 DAYS

erythromycin-benzoyl peroxide 1

gentamicin 0.1% cream 1 QL 30 GM / 30 DAYS

gentamicin 0.1% ointment 1

metronidazole (cream, lotion, topical gl, vaginal gl) 1

mupirocin 2% cream 1QL 30 GM / 30 DAYS

PA

mupirocin 2% ointment 1 QL 44 GM / RX

ROSADAN 0.75% CREAM 1

LOCAL ANTI-INFECTIVES, MISCELLANEOUSdermazene cream 1

hydrocortisone-iodoquinol 1

selenium sulfide 2.5% lotion 1

silver sulfadiazine 1

sodium sulf-sulfur cleanser 1

SSD 1

sulfacetamide sodium (sod top susp, sodium lotn) 1

SCABICIDES AND PEDICULICIDESmalathion 1

permethrin 1



ANTI-INFLAMMATORY AGENTS (EENT)CORTICOSTEROIDS (EENT)

dexamethasone 0.1% eye drop 1

flunisolide 1

fluocinolone acetonide oil 1

fluorometholone 1

fluticasone prop 50 mcg spray 1

FML S.O.P. 2

loteprednol etabonate 0.5% drp 1

prednisolone ac 1% eye drop (generic pred forte) 1

prednisolone sod 1% eye drop 1

EENT ANTI-INFLAMMATORY AGENTS, MISC.RESTASIS 2

RESTASIS MULTIDOSE 2

EENT NONSTEROIDAL ANTI-INFLAM. AGENTSbromfenac sodium 1

diclofenac 0.1% eye drops 1

flurbiprofen sodium 1

ketorolac tromethamine (0.4% solution, 0.5% solution) 1

ANTI-INFLAMMATORY AGENTS (RESPIRATORY)INTERLEUKIN ANTAGONISTS

DUPIXENT 200 MG/1.14 ML PEN 4

QL 2 PENS / 28 day(s)

PA

S

DUPIXENT 200 MG/1.14 ML SYRING 4

QL 2.28 ML / 28 DAYS

PA

S

FASENRA PEN 4PA

S



NUCALA (100 MG/ML AUTO-INJECTOR, 100 MG/MLSYRINGE)

4PA

S

LEUKOTRIENE MODIFIERSmontelukast sodium 1

MAST-CELL STABILIZERS

cromolyn 20 mg/2 ml neb soln 1 PA

cromolyn 4% eye drops 1

ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)ANTI-INFLAMMATORY AGENTS, MISC (SKIN)

EUCRISA 2QL 60 GM / 30 DAYS

ST

CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE)alclometasone dipropionate 1

anucort-hc 1

betamethasone diprop augmented (crm, gel, lot, oin) 1

betamethasone dipropionate (crm, lot, oint) 1

betamethasone valerate (va cream, va lotion, valer ointm) 1

clobetasol emollient 0.05% crm 1

clobetasol propionate (cream, gel, ointment, solution) 1

desonide (cream, lotion, ointment) 1

desoximetasone (0.05% cream, 0.05% gel, 0.25% cream,0.25% ointment)

1

fluocinolone 0.01% solution 1 QL 60 ML / 30 DAYS

fluocinolone acetonide (0.01% body oil, 0.01% cream,0.01% scalp oil, 0.025% cream, 0.025% ointment)

1

fluocinonide (0.05% cream, 0.05% gel, 0.05% ointment,0.05% solution, 0.1% cream)

1

fluocinonide-e 1

fluticasone propionate (0.005% oint, 0.05% cream) 1

hydrocortisone (2.5% cream, 2.5% lotion, 2.5% ointment,100 mg/60 ml)

1



hydrocortisone ac 25 mg supp 1

hydrocortisone butyrate (buty cream, butyr oint) 1

hydrocortisone valerate 1

hydrocortisone-pramoxine (1%-1% crm, 2.5-1% crm) 1

mometasone furoate (cream, oint, soln) 1

PROCTO-MED HC 1

PROCTOSOL-HC 1

PROCTOZONE-HC 1

triamcinolone acetonide (0.025% cream, 0.025% lotion,0.025% oint, 0.1% cream, 0.1% lotion, 0.1% ointment,0.1% paste, 0.5% cream, 0.5% ointment)

1

TRIDERM 1

ANTIARRHYTHMIC AGENTSCLASS IA ANTIARRHYTHMICS

disopyramide phosphate 1

NORPACE CR 2

quinidine sulfate 1

CLASS IB ANTIARRHYTHMICSmexiletine hcl 1

CLASS IC ANTIARRHYTHMICSflecainide acetate 1

propafenone hcl 1

CLASS III ANTIARRHYTHMICSamiodarone hcl (100 mg tablet, 200 mg tablet, 400 mgtablet)

1

dofetilide 1

MULTAQ 2 PA

PACERONE (100 MG TABLET, 400 MG TABLET) 1



ANTIBACTERIALSAMINOGLYCOSIDE ANTIBIOTICS

neomycin sulfate 1

tobramycin 300 mg/5 ml ampule 4PA

S

QUINOLONE ANTIBIOTICS

CIPRO (5% SUSPENSION, 10% SUSPENSION) 2 AL1 Up to 12 yrs old

ciprofloxacin 1 AL1 Up to 12 yrs old

ciprofloxacin hcl (100 mg tab, 250 mg tab, 500 mg tab,750 mg tab)

1

levofloxacin (250 mg tablet, 500 mg tablet, 750 mgtablet)

1

levofloxacin 25 mg/ml solution 1 AL1 Up to 12 yrs old

moxifloxacin hcl 1

SULFONAMIDE ANTIBIOTICS (SYSTEMIC)sulfamethoxazole-trimethoprim (ds tablet, ss tablet, susp) 1

sulfasalazine 1

sulfasalazine dr 1

SULFATRIM 1

TETRACYCLINE ANTIBIOTICSdemeclocycline hcl 1

doxycycline 25 mg/5 ml susp 1 AL1 Up to 12 yrs old

doxycycline hyclate (50 mg cap, 100 mg cap, 100 mg tab) 1

doxycycline monohydrate (50 mg cap, 50 mg tablet, 100mg cap, 100 mg tablet)

1

minocycline hcl (50 mg capsule, 75 mg capsule, 100 mgcapsule)

1

MONDOXYNE NL 100 MG CAPSULE 1



ANTIBACTERIALS, MISCELLANEOUSGLYCOPEPTIDE ANTIBIOTICS

vancomycin hcl (125 mg capsule, 250 mg capsule) 1

LINCOMYCIN ANTIBIOTICS

clindamycin (pediatric) 1 AL1 Up to 12 yrs old

clindamycin hcl 1

OXAZOLIDINONE ANTIBIOTICS

linezolid 100 mg/5 ml susp 1 PA

linezolid 600 mg tablet 1 QL 28 TABS / RX

SIVEXTRO 200 MG TABLET 2 PA

PLEUROMUTILINS

XENLETA 600 MG TABLET 2QL 10 TABS / RX

PA

RIFAMYCIN ANTIBIOTICS

XIFAXAN 2 PA

ANTICHOLINERGIC AGENTSANTIMUSCARINICS/ANTISPASMODICS

ANORO ELLIPTA 2

ATROVENT HFA 2 QL 1 INHALER / 25 DAYS

COMBIVENT RESPIMAT 2 QL 1 INHALER / 30 DAYS

CUVPOSA 2 PA

dicyclomine hcl (10 mg capsule, 10 mg/5 ml soln, 20 mgtablet)

1

ed-spaz 1

glycopyrrolate (1 mg tablet, 2 mg tablet) 1

hyoscyamine sulfate (0.125 mg odt, 0.125 mg tab sl,0.125 mg/5 ml elix, 0.125 mg/ml drop, sulf 0.125 mg tab)

1

hyoscyamine sulfate er 1

hyoscyamine sulfate sr 1



hyosyne 1

INCRUSE ELLIPTA 2

ipratropium br 0.02% soln 1

ipratropium-albuterol 1

oscimin 1

oscimin sl 1

oscimin sr 1

propantheline bromide 1

symax-sr 1

ANTICOAGULANTSANTICOAGULANTS, MISCELLANEOUS

fondaparinux sodium 1QL 1 SYRINGE / 1 DAY

PA

COUMARIN DERIVATIVESjantoven 1

warfarin sodium 1

DIRECT FACTOR XA INHIBITORS

ELIQUIS (2.5 MG TABLET, 5 MG TABLET) 2 QL 2 TABS / 1 DAY

ELIQUIS DVT-PE TREAT START 5MG 2 QL 1 RX / 30 DAYS

XARELTO (10 MG TABLET, 20 MG TABLET) 2 QL 1 TAB / 1 DAY

XARELTO (2.5 MG TABLET, 15 MG TABLET) 2 QL 2 TABS / 1 DAY

XARELTO DVT-PE TREAT START 30D 2 QL 51 TABS / 30 DAYS

DIRECT THROMBIN INHIBITORS

PRADAXA 2 PA

HEPARINS

enoxaparin 300 mg/3 ml vial 1 QL 2 VIALS / 1 DAY


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSenoxaparin sodium (30 mg/0.3 ml syr, 40 mg/0.4 ml syr,60 mg/0.6 ml syr, 80 mg/0.8 ml syr, 100 mg/ml syringe,120 mg/0.8 ml syr, 150 mg/ml syringe)

1 QL 2 SYRINGES / 1 DAY

heparin sodium (sod 1,000 unit/ml vial, 5,000 unit/mlcarpujct, sod 5,000 unit/0.5 ml, sod 5,000 unit/ml syrg,sod 5,000 unit/ml vial, 10,000 unit/10 ml vial, sod 10,000unit/ml vl, sod 20,000 unit/ml vl, 30,000 unit/30 ml vial,40,000 unit/4 ml vial, 50,000 unit/10 ml vial, 50,000unit/5 ml vial)

1

ANTICONVULSANTSANTICONVULSANTS, MISCELLANEOUS

APTIOM 2 PA

BANZEL 200 MG TABLET 2QL 16 TABS / 1 DAY

PA

BANZEL 400 MG TABLET 2QL 8 TABS / 1 DAY

PA

BRIVIACT (10 MG TABLET, 10 MG/ML ORAL SOLN, 25 MGTABLET, 50 MG TABLET, 75 MG TABLET, 100 MG TABLET)

2 PA

carbamazepine (100 mg tab chew, 100 mg/5 ml susp, 200mg tablet)

1

carbamazepine er 1

DIACOMIT 250 MG CAPSULE 4

QL 12 CAPS / 1 DAY

PA

S

DIACOMIT 250 MG POWDER PACKET 4

QL 12 PACKETS / 1 DAY

PA

S

DIACOMIT 500 MG CAPSULE 4

QL 6 CAPS / 1 DAY

PA

S

DIACOMIT 500 MG POWDER PACKET 4


PA

S



divalproex sodium 1

divalproex sodium er 1

EPIDIOLEX 4

QL 20 ML / 1 DAY

PA

S

felbamate (400 mg tablet, 600 mg tablet, 600 mg/5 mlsusp)

1

FINTEPLA 4PA

S

FYCOMPA (0.5 MG/ML ORAL SUSP, 2 MG TABLET, 4 MGTABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12MG TABLET)

2 PA

gabapentin (100 mg capsule, 300 mg capsule) 1 QL 12 CAPS / 1 DAY

gabapentin (250 mg/5 ml soln, 300 mg/6 ml soln) 1 QL 72 ML / 1 DAY

gabapentin 400 mg capsule 1 QL 9 CAPS / 1 DAY

gabapentin 600 mg tablet 1 QL 6 TABS / 1 DAY

gabapentin 800 mg tablet 1 QL 4 TABS / 1 DAY

lamotrigine 1

levetiracetam (100 mg/ml soln, 250 mg tablet, 500 mgtablet, 750 mg tablet, 1,000 mg tablet, 1000 mg/10 ml)

1

levetiracetam er 1

oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml susp, 600 mg tablet)

1

pregabalin (225 mg capsule, 300 mg capsule) 1 QL 2 CAPS / 1 DAY

pregabalin (25 mg capsule, 50 mg capsule, 75 mg capsule,100 mg capsule, 150 mg capsule, 200 mg capsule)

1 QL 3 CAPS / 1 DAY

pregabalin 20 mg/ml solution 1 QL 30 ML / 1 DAY

rufinamide 200 mg tablet 1QL 16 TABS / 1 DAY

PA

rufinamide 40 mg/ml suspension 1QL 80 ML / 1 DAY

PA



rufinamide 400 mg tablet 1QL 8 TABS / 1 DAY

PA

SUBVENITE 1

tiagabine hcl 1

topiramate 1

valproic acid (250 mg capsule, 250 mg/5 ml soln, 500mg/10 ml sol)

1

vigabatrin 4PA

S

VIGADRONE 4PA

S

VIMPAT (150 MG TABLET, 200 MG TABLET) 2 QL 2 TABS / 1 DAY

VIMPAT 10 MG/ML SOLUTION 2 QL 40 ML / 1 DAY

VIMPAT 100 MG TABLET 2 QL 4 TABS / 1 DAY

VIMPAT 50 MG TABLET 2 QL 8 TABS / 1 DAY

zonisamide 1

BARBITURATES (ANTICONVULSANTS)primidone 1

BENZODIAZEPINES (ANTICONVULSANTS)

clobazam 10 mg tablet 1 QL 4 TABS / 1 DAY

clobazam 2.5 mg/ml suspension 1 QL 16 ML / 1 DAY

clobazam 20 mg tablet 1 QL 2 TABS / 1 DAY

clonazepam (0.125 mg dis tab, 0.125 mg odt, 0.25 mgodt, 0.5 mg dis tablet, 0.5 mg odt, 0.5 mg tablet)

1 QL 6 TABS / 1 DAY

clonazepam (1 mg dis tablet, 1 mg odt, 1 mg tablet) 1 QL 4 TABS / 1 DAY

clonazepam (2 mg odt, 2 mg tablet) 1 QL 2 TABS / 1 DAY

NAYZILAM 2QL 2 BOTTLES / RX

PA



HYDANTOINSDILANTIN 30 MG CAPSULE 2

phenytoin (50 mg infatab, 50 mg tablet chew, 100 mg/4ml susp, 125 mg/5 ml susp)

1

phenytoin sodium extended 1

SUCCINIMIDESethosuximide (250 mg capsule, 250 mg/5 ml soln) 1

ANTIDEPRESSANTSANTIDEPRESSANTS, MISCELLANEOUS

bupropion hcl 1

bupropion hcl sr 1

bupropion xl (150 mg tablet, 300 mg tablet) 1

mirtazapine (7.5 mg tablet, 15 mg tablet, 30 mg tablet, 45mg tablet)

1

MONOAMINE OXIDASE INHIBITORSphenelzine sulfate 1

tranylcypromine sulfate 1

SEL.SEROTONIN,NOREPI REUPTAKE INHIBITORdesvenlafaxine suc er 100 mg tablet (generic for pristiq) 1

desvenlafaxine suc er 25 mg tablet (generic for pristiq) 1

desvenlafaxine suc er 50 mg tablet (generic for pristiq) 1

duloxetine hcl (dr 20 mg cap, dr 30 mg cap, dr 60 mg cap) 1

FETZIMA 2 PA

venlafaxine hcl 1

venlafaxine hcl er (er 37.5 mg cap, er 75 mg cap, er 150mg cap)

1

SELECTIVE-SEROTONIN REUPTAKE INHIBITORScitalopram hbr (10 mg tablet, 10 mg/5 ml soln, 20 mgtablet, 20 mg/10 ml sol, 40 mg tablet)

1

escitalopram oxalate (5 mg tablet, oxalate 5 mg/5 ml, 10mg tablet, 20 mg tablet)

1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSfluoxetine hcl (hcl 10 mg capsule, 20 mg/5 ml solution, hcl20 mg capsule, hcl 40 mg capsule)

1

fluvoxamine maleate 1

paroxetine hcl (10 mg tablet, 10 mg/5 ml susp, 20 mgtablet, 30 mg tablet, 40 mg tablet)

1

sertraline hcl (20 mg/ml oral conc, hcl 25 mg tablet, hcl 50mg tablet, hcl 100 mg tablet)

1

SEROTONIN MODULATORSnefazodone hcl 1

trazodone hcl 1

TRINTELLIX 2 PA

VIIBRYD 2 PA

TRICYCLICS, OTHER NOREPI-RU INHIBITORSamitriptyline hcl 1

clomipramine hcl 1

desipramine hcl 1

doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 25 mgcapsule, 50 mg capsule, 75 mg capsule, 100 mg capsule,150 mg capsule)

1

imipramine hcl 1

nortriptyline hcl (10 mg/5 ml soln, hcl 10 mg cap, hcl 25mg cap, hcl 50 mg cap, hcl 75 mg cap)

1

ANTIDIABETIC AGENTSALPHA-GLUCOSIDASE INHIBITORS

acarbose 1

miglitol 1

BIGUANIDESmetformin hcl 1,000 mg tablet (generic for glucophage) 1

metformin hcl 500 mg tablet (generic for glucophage) 1

metformin hcl 850 mg tablet 1

metformin hcl er 1



DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS

alogliptin 1 QL 1 TAB / 1 DAY

alogliptin-metformin 1 QL 2 TABS / 1 DAY

alogliptin-pioglitazone 1 QL 1 TAB / 1 DAY

JENTADUETO 2 QL 2 TABS / 1 DAY

JENTADUETO XR 2 QL 2 TABS / 1 DAY

TRADJENTA 2 QL 1 TAB / 1 DAY

INCRETIN MIMETICS

BYDUREON BCISE 2 QL 3.4 ML / 28 DAYS

BYDUREON PEN 2 QL 4 PEN / 28 DAYS

BYETTA 10 MCG DOSE PEN INJ 2 QL 2.4 ML / 30 DAYS

BYETTA 5 MCG DOSE PEN INJ 2 QL 1.2 ML / 30 DAYS

OZEMPIC (1 MG/DOSE (2 MG/1.5ML), 1 MG/DOSE (4MG/3 ML))

2 QL 3 ML / 28 DAYS

OZEMPIC 0.25-0.5 MG/DOSE PEN 2 QL 1.5 ML / 28 DAYS

RYBELSUS 2 QL 1 TAB / 1 DAY

TRULICITY 2 QL 2 ML / 28 DAYS

VICTOZA 2-PAK 2 QL 9 ML / 30 DAYS

VICTOZA 3-PAK 2 QL 9 ML / 30 DAYS

MEGLITINIDESnateglinide 1

repaglinide 1

SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB

GLYXAMBI 2 QL 1 TAB / 1 DAY

INVOKAMET 2 QL 2 TABS / 1 DAY

INVOKAMET XR 2 QL 2 TABS / 1 DAY



INVOKANA 2 QL 1 TAB / 1 DAY

JARDIANCE 2 QL 1 TAB / 1 DAY

SYNJARDY 2 QL 2 TABS / 1 DAY

SYNJARDY XR (10-1,000 MG TABLET, 25-1,000 MGTABLET)

2 QL 1 TAB / 1 DAY

SYNJARDY XR (5-1,000 MG TABLET, 12.5-1,000 MG TAB) 2 QL 2 TABS / 1 DAY

TRIJARDY XR (10-5-1,000 MG TAB, 25-5-1,000 MG TAB) 2 QL 1 TAB / 1 DAY

TRIJARDY XR (5-2.5-1,000 MG TAB, 12.5-2.5-1,000 MG) 2 QL 2 TABS / 1 DAY

SULFONYLUREASglimepiride 1

glipizide 1

glipizide er 1

glipizide xl 1

glipizide-metformin 1

glyburide 1 PA

glyburide micronized 1 PA

glyburide-metformin hcl 1 PA

THIAZOLIDINEDIONESpioglitazone hcl 1

pioglitazone-glimepiride 1

pioglitazone-metformin 1

ANTIEMETICS5-HT3 RECEPTOR ANTAGONISTS

ondansetron hcl (4 mg/5 ml solution, hcl 4 mg tablet, hcl 8mg tablet, hcl 24 mg tablet)

1

ondansetron odt 1

ANTIEMETICS, MISCELLANEOUS

dronabinol (2.5 mg capsule, 5 mg capsule) 1 QL 6 CAPS / 1 DAY



dronabinol 10 mg capsule 1 QL 4 CAPS / 1 DAY

scopolamine 1

ANTIHISTAMINES (GI DRUGS)prochlorperazine 1

prochlorperazine maleate 1

trimethobenzamide hcl 1

NEUROKININ-1 RECEPTOR ANTAGONISTSaprepitant 1

EMEND 125 MG POWDER PACKET 2

ANTIFUNGAL (SYSTEMIC)ALLYLAMINE ANTIFUNGALS

terbinafine hcl 1

ANTIFUNGALS, MISCELLANEOUSgriseofulvin (125 mg/5 ml susp, micro 500 mg tab) 1

griseofulvin ultramicrosize 1

AZOLE ANTIFUNGALS

CRESEMBA 186 MG CAPSULE 2 PA

fluconazole (10 mg/ml susp, 40 mg/ml susp, 50 mg tablet,100 mg tablet, 150 mg tablet, 200 mg tablet)

1

itraconazole 100 mg capsule 1

ketoconazole 200 mg tablet 1

posaconazole 1 PA

voriconazole (40 mg/ml susp, 50 mg tablet, 200 mgtablet)

1 PA

POLYENE ANTIFUNGALS

nystatin (100,000 unit/ml susp, 500,000 unit/5 ml sus) 1 QL 480 ML / RX

nystatin 500,000 unit oral tab 1



ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE)AZOLES (SKIN AND MUCOUS MEMBRANE)

clotrimazole 10 mg troche 1

clotrimazole-betamethasone crm 1

econazole nitrate 1 QL 85 GM / 30 DAYS

ketoconazole 2% cream 1 QL 60 GM / 30 DAYS

ketoconazole 2% shampoo 1

terconazole (0.4% cream, 0.8% cream, 80 mg suppository) 1

HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)ciclopirox (0.77% cream, 0.77% gel, 1% shampoo, 8%solution)

1

ciclopirox 0.77% topical susp 1 QL 60 ML / 30 DAYS

POLYENES (SKIN AND MUCOUS MEMBRANE)nystatin (unit/gm cream, unit/gm oint) 1

nystatin 100,000 unit/gm powd 1 QL 240 GM / RX

ANTIGLAUCOMA AGENTSALPHA-ADRENERGIC AGONISTS (EENT)

brimonidine tartrate 1

BETA-ADRENERGIC BLOCKING AGENTS (EENT)betaxolol hcl 0.5% eye drop 1

carteolol hcl 1

levobunolol hcl 1

timolol maleate (0.25%, 0.25% gfs, 0.5%, 0.5% gfs) 1

timolol maleate 0.25% eye drop (generic for timoptic) 1

timolol maleate 0.5% eye drops (generic for timoptic) 1

CARBONIC ANHYDRASE INHIBITORS (EENT)acetazolamide 1

acetazolamide er 1

dorzolamide hcl 1



dorzolamide-timolol (2%-0.5%, eye drops) 1

methazolamide 1

MIOTICSpilocarpine hcl (1% drops, 2% drops, 4% drops) 1

PROSTAGLANDIN ANALOGSbimatoprost 0.03% eye drops 1

latanoprost 1

LUMIGAN 2

travoprost 1

ZIOPTAN 2 PA

RHO KINASE INHIBITORSRHOPRESSA 2

ROCKLATAN 2

ANTIHEMORRHAGIC AGENTSHEMOSTATICS

ADVATE 4PA

S

ADYNOVATE 4PA

S

AFSTYLA 4PA

S

ALPHANATE 4PA

S

ALPHANINE SD 4PA

S

ALPROLIX 4PA

S

BENEFIX 4PA

S



COAGADEX 4PA

S

CORIFACT 4PA

S

ELOCTATE 4PA

S

ESPEROCT 4PA

S

FEIBA NF 4PA

S

HEMLIBRA 4PA

S

HEMOFIL M 4PA

S

HUMATE-P 4PA

S

IDELVION 4PA

S

IXINITY 4PA

S

JIVI 4PA

S

KOATE 4PA

S

KOGENATE FS 4PA

S

KOVALTRY 4PA

S



MONONINE 4 S

NOVOEIGHT 4PA

S

NOVOSEVEN RT 4PA

S

NUWIQ 4PA

S

OBIZUR 4PA

S

PROFILNINE 4PA

S

REBINYN 4PA

S

RECOMBINATE 4PA

S

RIXUBIS 4PA

S

SEVENFACT 4PA

S

tranexamic acid 650 mg tablet 1 QL 30 TABS / RX

TRETTEN 4PA

S

VONVENDI 4PA

S

WILATE 4PA

S

XYNTHA 4PA

S



XYNTHA SOLOFUSE 4PA

S

ANTIHYPOGLYCEMIC AGENTSGLYCOGENOLYTIC AGENTS

BAQSIMI 2

glucagon 1 mg emergency kit 1

glucagon 1 mg emergency kit (generic glucagen) 1

GLUCAGON 1 MG EMERGENCY KIT (LILLY) 2

GLUCAGON 1 MG VIAL 2

GVOKE HYPOPEN 1-PACK 2

GVOKE HYPOPEN 2-PACK 2

GVOKE PFS 1-PACK SYRINGE 2

GVOKE PFS 2-PACK SYRINGE 2

ZEGALOGUE AUTOINJECTOR 2

ZEGALOGUE SYRINGE 2

ANTILIPEMIC AGENTSANTILIPEMIC AGENTS, MISCELLANEOUS

icosapent ethyl 1 PA

JUXTAPID 4PA

S

omega-3 acid ethyl esters 1

TRIKLO 1

VASCEPA 2 PA

BILE ACID SEQUESTRANTScholestyramine (packet, powder) 1

cholestyramine light (packet, powder) 1

colestipol hcl 1 gm tablet 1

PREVALITE (PACKET, POWDER) 1



CHOLESTEROL ABSORPTION INHIBITORSezetimibe 1

FIBRIC ACID DERIVATIVESfenofibrate (48 mg tablet, 54 mg tablet, 67 mg capsule,134 mg capsule, 145 mg tablet, 160 mg tablet, 200 mgcapsule)

1

gemfibrozil 1

HMG-COA REDUCTASE INHIBITORS

atorvastatin calcium (10 mg tablet, 20 mg tablet) 1 ACA Affordable Care Act

atorvastatin calcium (40 mg tablet, 80 mg tablet) 1

lovastatin (20 mg tablet, 40 mg tablet) 1 ACA Affordable Care Act

lovastatin 10 mg tablet 1

pravastatin sodium 1 ACA Affordable Care Act

rosuvastatin calcium (20 mg tab, 40 mg tab) 1

rosuvastatin calcium (5 mg tab, 10 mg tab) 1 ACA Affordable Care Act

simvastatin (10 mg tablet, 20 mg tablet, 40 mg tablet) 1 ACA Affordable Care Act

simvastatin (5 mg tablet, 80 mg tablet) 1

PCSK9 INHIBITORS

REPATHA PUSHTRONEX 2QL 1 PEN / 28 DAYS

PA

REPATHA SURECLICK 2QL 2 PENS / 28 DAYS

PA

REPATHA SYRINGE 2QL 2 PENS / 28 DAYS

PA

ANTIMIGRAINE AGENTSCALCITONIN GENE-RELATED PEPTIDE ANTAG.

AJOVY AUTOINJECTOR 4

QL 1.5 ML / 30 DAYS

PA

S



AJOVY SYRINGE 4

QL 1.5 ML / 30 DAYS

PA

S

EMGALITY 120 MG/ML SYRINGE 4

QL 1 ML / 30 DAYS

PA

S

EMGALITY PEN 4

QL 1 ML / 30 DAYS

PA

S

EMGALITY SYRINGE (100 MG/ML SYR(1 OF 3), 300 MG(100 MG X3SYR))

4

QL 3 ML / 30 DAYS

PA

S

NURTEC ODT 2QL 8 TABS / 30 DAYS

PA

SELECTIVE SEROTONIN AGONISTS

eletriptan hbr 1QL 12 TABS / 28 DAYS

PA

naratriptan hcl 1 QL 12 TABS / 30 DAYS

REYVOW 2QL 8 TABS / 30 DAYS

PA

rizatriptan 1 QL 12 TABS / 28 DAYS

sumatriptan 1 QL 12 ML / 30 DAYS

sumatriptan succinate (25 mg tablet, 50 mg tablet, 100mg tablet)

1 QL 12 TABS / 28 DAYS

sumatriptan succinate (4 mg/0.5 ml cart, 4 mg/0.5 mlinject, 6 mg/0.5 ml cart, 6 mg/0.5 ml inject, 6 mg/0.5 mlsyrng, 6 mg/0.5 ml vial)

1 QL 5 ML / 30 DAYS

zolmitriptan (2.5 mg tablet, 5 mg tablet) 1 QL 12 TABS / 28 DAYS

zolmitriptan odt 1 QL 12 TABS / 28 DAYS



ANTIMYCOBACTERIALSANTIMYCOBACTERIALS, MISCELLANEOUS

dapsone (25 mg tablet, 100 mg tablet) 1

ANTITUBERCULOSIS AGENTS

cycloserine 1 PA

ethambutol hcl 1

isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mgtablet)

1

pretomanid 1 PA

PRIFTIN 2

pyrazinamide 1

rifabutin 1

rifampin (150 mg capsule, 300 mg capsule) 1

SIRTURO 2 PA

TRECATOR 2 PA

ANTINEOPLASTIC AGENTS

abiraterone 500 mg tablet 1

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

abiraterone acetate 250 mg tab 1

QL 4 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

AFINITOR 10 MG TABLET 2

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

TD Trial Drug



AFINITOR DISPERZ (2 MG TABLET, 5 MG TABLET) 2

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

AFINITOR DISPERZ 3 MG TABLET 2

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

ALECENSA 2

QL 8 CAPS / 30 DAYS

PA

S

ONC Oncology

anastrozole 1 ACA Affordable Care Act

AYVAKIT 2

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

BALVERSA 2PA

S

bicalutamide 1

BOSULIF (400 MG TABLET, 500 MG TABLET) 2

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

BOSULIF 100 MG TABLET 2

QL 4 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug



BRAFTOVI 50 MG CAPSULE 2

QL 2 CAPS / 1 DAY

PA

S

BRAFTOVI 75 MG CAPSULE 2

QL 6 CAPS / 1 DAY

PA

S

BRUKINSA 4

PA

S

ONC Oncology

CABOMETYX 2

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

capecitabine 1S

ONC Oncology

CAPRELSA 100 MG TABLET 2

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

CAPRELSA 300 MG TABLET 2

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

COMETRIQ 100 MG DAILY-DOSE PK 2

QL 2 CAPS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

COMETRIQ 140 MG DAILY-DOSE PK 2

QL 4 CAPS / 1 DAY

PA

S

ONC Oncology

TD Trial DrugPAGE 32 LAST UPDATED 10/2021


COMETRIQ 60 MG DAILY-DOSE PACK 2

QL 3 CAPS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

COPIKTRA 2

QL 2 CAPS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

COTELLIC 2

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

CYCLOPHOSPHAMIDE (25 MG CAPSULE, 25 MG TABLET,50 MG CAPSULE, 50 MG TABLET)

1

DAURISMO 100 MG TABLET 2

QL 1 TAB / 1 DAY

PA

S

TD Trial Drug

DAURISMO 25 MG TABLET 2

QL 3 TABS / 1 DAY

PA

S

TD Trial Drug

EMCYT 2

ERIVEDGE 2

QL 1 CAP / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

ERLEADA 2

PA

S

ONC Oncology



erlotinib hcl (100 mg tablet, 150 mg tablet) 1

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

erlotinib hcl 25 mg tablet 1

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

etoposide 50 mg capsule 1

everolimus (2 mg tab susp, 5 mg tab susp) 1

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

everolimus (2.5 mg tablet, 5 mg tablet, 7.5 mg tablet, 10mg tablet)

1

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

everolimus 3 mg tab for susp 1

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

exemestane 1 ACA Affordable Care Act

EXKIVITY 2

QL 4 CAPS / DAY

PA

S

ONC Oncology



fluorouracil (2% topical soln, 5% cream, 5% topical soln) 1

flutamide 1

FOTIVDA 2

QL 21 CAPS / 28 DAYS

PA

S

ONC Oncology

GAVRETO 2

PA

S

ONC Oncology

GILOTRIF 2

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

GLEOSTINE 2

HYCAMTIN 2S

ONC Oncology

hydroxyurea 1

IBRANCE (75 MG CAPSULE, 100 MG CAPSULE, 125 MGCAPSULE)

2


PA

S

ONC Oncology

IBRANCE (75 MG TABLET, 100 MG TABLET, 125 MGTABLET)

2

QL 21 TABS / 28 DAYS

PA

S

ONC Oncology

ICLUSIG (10 MG TABLET, 15 MG TABLET) 2

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug



ICLUSIG (30 MG TABLET, 45 MG TABLET) 2

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

IDHIFA 2

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

imatinib mesylate 1

S

ONC Oncology

TD Trial Drug

IMBRUVICA (420 MG TABLET, 560 MG TABLET) 2

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

IMBRUVICA 140 MG CAPSULE 2

QL 4 CAPS / 1 DAY

PA

S

ONC Oncology

IMBRUVICA 70 MG CAPSULE 2

QL 1 CAP / 1 DAY

PA

S

ONC Oncology

INLYTA 1 MG TABLET 2

QL 6 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

INLYTA 5 MG TABLET 2

QL 4 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug



INQOVI 2

QL 5 TABS / 28 DAYS

PA

S

ONC Oncology

INREBIC 2

PA

S

ONC Oncology

IRESSA 2

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

JAKAFI 2

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

KISQALI 200 MG DAILY DOSE 2


PA

S

ONC Oncology



PA

S

ONC Oncology



PA

S

ONC Oncology

KISQALI FEMARA 200 MG CO-PACK 2


PA

S

ONC Oncology





PA

S

ONC Oncology



PA

S

ONC Oncology

KOSELUGO 10 MG CAPSULE 2

QL 8 CAPS / 1 DAY

PA

S

ONC Oncology

KOSELUGO 25 MG CAPSULE 2

QL 4 CAPS / 1 DAY

PA

S

ONC Oncology

lapatinib 1

QL 6 TABS / 1 DAY

PA

S

ONC Oncology

letrozole 1 ACA Affordable Care Act

LEUKERAN 2

LONSURF 15 MG-6.14 MG TABLET 2

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

LONSURF 20 MG-8.19 MG TABLET 2

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

LORBRENA 100 MG TABLET 2

QL 1 TAB / 1 DAY

PA

S

TD Trial DrugPAGE 38 LAST UPDATED 10/2021


LORBRENA 25 MG TABLET 2

QL 3 TABS / 1 DAY

PA

S

TD Trial Drug

LUMAKRAS 2

PA

S

ONC Oncology

LYNPARZA 2

QL 4 TABS / 1 DAY

PA

S

TD Trial Drug

LYSODREN 2PA

S

MATULANE 2

QL 2 CAPS / 1 DAY

PA

S

ONC Oncology

MEKINIST 0.5 MG TABLET 2

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

MEKINIST 2 MG TABLET 2

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

MEKTOVI 2

QL 6 TABS / 1 DAY

PA

S

melphalan 1

mercaptopurine 1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSmethotrexate (2.5 mg tablet, 50 mg/2 ml vial, 250 mg/10ml vial)

1

methotrexate sodium 1

MYLERAN 2

NERLYNX 2

QL 6 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

NEXAVAR 2

QL 4 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

NINLARO 2

QL 3 CAPS / 28 DAYS

PA

S

ONC Oncology

NUBEQA 2PA

S

ODOMZO 2

QL 1 CAP / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

ONUREG 2


PA

S

ONC Oncology

PEMAZYRE 2


PA

S

ONC Oncology



PICATO 2 PA

POMALYST 2

QL 1 CAP / 1 DAY

PA

S

ONC Oncology

QINLOCK 2

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

RASUVO 2 PA

RETEVMO 40 MG CAPSULE 2

QL 6 CAPS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

RETEVMO 80 MG CAPSULE 2

QL 4 CAPS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

REVLIMID 2

QL 1 CAP / 1 DAY

S

ONC Oncology

ROZLYTREK 2

PA

S

ONC Oncology

RYDAPT 2

PA

S

ONC Oncology

SPRYCEL 2

PA

S

ONC Oncology

TD Trial Drug



STIVARGA 2

PA

S

ONC Oncology

sunitinib malate 1

QL 1 CAP / 1 DAY

PA

S

ONC Oncology

TABLOID 2

TABRECTA 2

QL 4 TABS / 1 DAY

PA

S

ONC Oncology

TAFINLAR 2

QL 4 CAPS / 1 DAY

PA

S

ONC Oncology

TAGRISSO 2

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

TASIGNA 2

PA

S

ONC Oncology

TD Trial Drug

TAZVERIK 2

QL 8 TABS / 1 DAY

PA

S

ONC Oncology

temozolomide 1S

ONC Oncology



TEPMETKO 2

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

TIBSOVO 2

QL 2 TABS / 1 DAY

PA

S

ONC Oncology

tretinoin 10 mg capsule 1S

ONC Oncology

TRUSELTIQ 2

PA

S

ONC Oncology

TURALIO 2PA

S

UKONIQ 2

QL 4 TABS / 1 DAY

PA

S

ONC Oncology

VALCHLOR 2

QL 120 GM / 30 DAYS

PA

S

ONC Oncology

VERZENIO 2


PA

S

ONC Oncology

VITRAKVI 100 MG CAPSULE 2

QL 2 CAPS / 1 DAY

PA

S

TD Trial Drug



VITRAKVI 20 MG/ML SOLUTION 2

QL 300 ML / 30 DAYS

PA

S

TD Trial Drug

VITRAKVI 25 MG CAPSULE 2

QL 6 CAPS / 1 DAY

PA

S

TD Trial Drug

VIZIMPRO 2

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

VOTRIENT 2

QL 4 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

WELIREG 2

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

XALKORI 2

QL 2 CAPS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

XOSPATA 2

QL 3 TABS / 1 DAY

PA

S

XPOVIO 2

PA

S

ONC Oncology



XTANDI 2

PA

S

ONC Oncology

TD Trial Drug

ZEJULA 2

QL 3 CAPS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

ZELBORAF 2

QL 8 TABS / 30 DAYS

PA

S

ONC Oncology

ZOLINZA 2

QL 4 CAPS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

ZYKADIA 2

QL 3 TABS / 1 DAY

PA

S

ONC Oncology

TD Trial Drug

ANTIPARKINSONIAN AGENTS (CNS)ADAMANTANES (CNS)

amantadine (50 mg/5 ml solution, 100 mg capsule, 100mg tablet, 100 mg/10 ml soln)

1

ANTICHOLINERGIC AGENTS (CNS)benztropine mesylate (0.5 mg tab, 1 mg tablet, 2 mgtablet)

1

trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml soln, 5 mgtablet)

1



CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.entacapone 1

DOPAMINE PRECURSORScarbidopa-levodopa 1

carbidopa-levodopa er 1

carbidopa-levodopa-entacapone 1

INBRIJA 4PA

S

RYTARY 2 ST

MONOAMINE OXIDASE B INHIBITORS

rasagiline mesylate 1 PA

selegiline hcl 1

ANTIPROTOZOALSANTIMALARIALS

atovaquone-proguanil hcl 1

chloroquine phosphate 1

hydroxychloroquine 200 mg tab 1

mefloquine hcl 1

ANTIPROTOZOALS, MISCELLANEOUS

ALINIA 100 MG/5 ML SUSPENSION 2 PA

atovaquone 1

benznidazole 1 PA

LAMPIT 2 PA

metronidazole (250 mg tablet, 500 mg tablet) 1

nitazoxanide 1 PA



ANTIPSYCHOTIC AGENTSANTIPSYCHOTICS, MISCELLANEOUS

loxapine 1 AL1 At least 13 yrs old

ATYPICAL ANTIPSYCHOTICSaripiprazole (1 mg/ml solution, 2 mg tablet, 5 mg tablet,10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet)

1 AL1 At least 13 yrs old

aripiprazole odt 1PA

AL1 At least 13 yrs old

asenapine maleate 1 PA

CAPLYTA 2QL 1 CAP / 1 DAY

PA

clozapine 1 AL1 At least 13 yrs old

clozapine odt 1PA


FANAPT 2 PA

LATUDA 2QL 1 TAB / 1 DAY

PA

LYBALVI 2QL 1 TAB / DAY

PA

NUPLAZID 4

PA

S

TD Trial Drug

olanzapine (2.5 mg tablet, 5 mg tablet, 7.5 mg tablet, 10mg tablet, 15 mg tablet, 20 mg tablet)


olanzapine odt 1PA


paliperidone er 1 PA

quetiapine fumarate 1 AL1 At least 13 yrs old

quetiapine fumarate er 1 AL1 At least 13 yrs old



REXULTI 2 PA

risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 1mg/ml solution, 2 mg tablet, 3 mg tablet, 4 mg tablet)


risperidone odt 1PA


SECUADO 2 PA

VERSACLOZ 2PA


VRAYLAR (1.5 MG CAPSULE, 1.5 MG-3 MG PACK) 2QL 2 CAPS / 1 DAY

PA

VRAYLAR (3 MG CAPSULE, 4.5 MG CAPSULE, 6 MGCAPSULE)

2QL 1 CAP / 1 DAY

PA

ziprasidone hcl 1 AL1 At least 13 yrs old

BUTYROPHENONES

haloperidol 1 AL1 At least 13 yrs old

haloperidol lactate (2 mg/ml conc, 10 mg/5 ml cup) 1 AL1 At least 13 yrs old

PHENOTHIAZINESchlorpromazine hcl (10 mg tablet, 25 mg tablet, 30 mg/mlconc, 50 mg tablet, 100 mg tablet, 100 mg/ml conc, 200mg tablet)

1 PA

fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5 mlelix, 5 mg tablet, 5 mg/ml conc, 10 mg tablet)


perphenazine 1

thioridazine hcl 1 AL1 At least 13 yrs old

trifluoperazine hcl 1 AL1 At least 13 yrs old

THIOXANTHENES

thiothixene 1 AL1 At least 13 yrs old



ANTIRETROVIRALSHIV ENTRY AND FUSION INHIBITORS

FUZEON 4 S

RUKOBIA 2 PA

SELZENTRY (20 MG/ML ORAL SOLN, 25 MG TABLET, 75MG TABLET, 150 MG TABLET, 300 MG TABLET)

2

HIV INTEGRASE INHIBITOR ANTIRETROVIRALSISENTRESS 2

ISENTRESS HD 2

JULUCA 2

TIVICAY 2

TIVICAY PD 2

VOCABRIA 2

HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.EDURANT 2

efavirenz 1

etravirine 1

INTELENCE 25 MG TABLET 2

nevirapine (50 mg/5 ml susp, 200 mg tablet) 1

nevirapine er 1

HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORSabacavir (20 mg/ml solution, 300 mg tablet) 1

abacavir-lamivudine 1

abacavir-lamivudine-zidovudine 1

BIKTARVY 2

COMPLERA 2

DESCOVY 2 ACA Affordable Care Act

efavirenz-emtric-tenofov disop 1

emtricitabine 1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSemtricitabine-tenofovir disop (100-150mg, 133-200mg,167-250mg)

1

emtricitabine-tenofv 200-300mg 1 ACA Affordable Care Act

EPIVIR HBV 25 MG/5 ML SOLN 2

GENVOYA 2

lamivudine (10 mg/ml oral soln, 150 mg tablet, 300 mgtablet)

1

lamivudine hbv 1

lamivudine-zidovudine 1

ODEFSEY 2

STRIBILD 2

tenofovir disoproxil fumarate 1

TRIUMEQ 2

TRUVADA (100 MG-150 MG TABLET, 133 MG-200 MGTABLET, 167 MG-250 MG TABLET)

2

VIREAD (150 MG TABLET, 200 MG TABLET, 250 MGTABLET, POWDER)

2

zidovudine (50 mg/5 ml syrup, 100 mg capsule, 300 mgtablet)

1

HIV PROTEASE INHIBITOR ANTIRETROVIRALSAPTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 2

atazanavir sulfate 1

EVOTAZ 2

fosamprenavir calcium 1

INVIRASE 2

KALETRA (100-25 MG TABLET, 200-50 MG TABLET) 2

LEXIVA 50 MG/ML SUSPENSION 2

lopinavir-ritonavir (lopinavir-ritonavir 80-20mg/ml,lopinavir-ritonavr 100-25mg tb, lopinavir-ritonavr 200-50mg tb)

1

NORVIR 80 MG/ML SOLUTION 2



PREZCOBIX 2

PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150MG TABLET, 600 MG TABLET, 800 MG TABLET)

2

REYATAZ 50 MG POWDER PACKET 2

ritonavir 1

SYMTUZA 2

ANTITHROMBOTIC AGENTSANTITHROMBOTIC AGENTS, MISCELLANEOUS

CABLIVI 11 MG KIT 4PA

S

PLATELET-AGGREGATION INHIBITORSBRILINTA 2

cilostazol 1

clopidogrel 75 mg tablet 1

prasugrel hcl 1

ZONTIVITY 2 PA

PLATELET-REDUCING AGENTSanagrelide hcl 1

ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINESALLERGENIC EXTRACTS (THERAPEUTIC)

GRASTEK 2 PA

ODACTRA 2 PA

PALFORZIA 4PA

S

RAGWITEK 2 PA

TOXOIDSADACEL TDAP 2

BOOSTRIX TDAP 2

DAPTACEL DTAP 2



diphtheria-tetanus toxoids-ped 2

INFANRIX DTAP 2

tdvax 2

TENIVAC SYRINGE 2

VAXELIS 2

VACCINESACTHIB 2

adenovirus type 4 2

adenovirus type 4 and type 7 2

adenovirus type 7 2

AFLURIA QUAD 2019-20 (3YR UP) 2 ACA Affordable Care Act

AFLURIA QUAD 2019-20 (6-35MO) 2 ACA Affordable Care Act

AFLURIA QUAD 2019-2020 2 ACA Affordable Care Act







ASTRAZENECA COVID19 VAC(UNAPP) 2

BEXSERO 2

COMIRNATY 2

DENGVAXIA 2

ENGERIX-B ADULT 2

ENGERIX-B PEDIATRIC-ADOLESCENT 2

FLUAD 2019-2020 2 ACA Affordable Care Act



FLUAD 2020-2021 2 ACA Affordable Care Act

FLUAD QUAD 2020-2021 2 ACA Affordable Care Act

FLUAD QUAD 2021-2022 2 ACA Affordable Care Act

FLUARIX QUAD 2019-2020 2 ACA Affordable Care Act



FLUBLOK QUAD 2019-2020 2 ACA Affordable Care Act



FLUCELVAX QUAD 2019-2020 (SYR, VIAL) 2 ACA Affordable Care Act



FLULAVAL QUAD 2019-2020 (SYR, VIAL) 2 ACA Affordable Care Act

FLULAVAL QUAD 2020-2021 2 ACA Affordable Care Act

FLULAVAL QUAD 2021-2022 2 ACA Affordable Care Act

FLUMIST QUAD 2019-2020 2 ACA Affordable Care Act



FLUZONE HIGH-DOSE 2019-2020 2 ACA Affordable Care Act

FLUZONE HIGH-DOSE QUAD 2020-21 2 ACA Affordable Care Act

FLUZONE HIGH-DOSE QUAD 2021-22 2 ACA Affordable Care Act

FLUZONE QUAD 2019-2020 2 ACA Affordable Care Act





FLUZONE QUAD PEDI 2019-2020 2 ACA Affordable Care Act

FLUZONE QUAD SOUTHERN HEM 2020 (HEM2020 SYR,HEM 2020 VL)

2 ACA Affordable Care Act

FLUZONE QUAD SOUTHERN HEM 2021 (HEM2021 SYR,HEM 2021 VL)


GARDASIL 9 2

HAVRIX 2

HEPLISAV-B 2

HIBERIX 2

IPOL 2 ACA Affordable Care Act

JANSSEN COVID-19 VACCINE (EUA) 2

KINRIX 2

M-M-R II VACCINE 2 ACA Affordable Care Act

MENACTRA 2

MENQUADFI 2 ACA Affordable Care Act

MENVEO A-C-Y-W-135-DIP 2

MENVEO MENA COMPONENT 2 ACA Affordable Care Act

MENVEO MENCYW-135 COMPONENT 2 ACA Affordable Care Act

MODERNA COVID-19 VACCINE (EUA) 2

NOVAVAX COVID19 VAC,ADJ(UNAPP) 2

PEDIARIX 2

PEDVAXHIB 2

PENTACEL 2

PENTACEL ACTHIB COMPONENT 2

PENTACEL DTAP-IPV COMPONENT 2

PFIZER COVID(12Y UP) VAC(UNAP) 2

PFIZER COVID(5-11Y) VAC(UNAPP) 2

PFIZER COVID-19 VACCINE (EUA) 2



PNEUMOVAX 23 2

PREVNAR 13 2

PREVNAR 20 2

PROQUAD 2

QUADRACEL DTAP-IPV 2 ACA Affordable Care Act

RECOMBIVAX HB (5 MCG/0.5 ML SYR, 10 MCG/ML SYR,40 MCG/ML VIAL)

2

RECOMBIVAX HB (5 MCG/0.5 ML VL, 10 MCG/ML VIAL) 2 ACA Affordable Care Act

ROTARIX 2

ROTATEQ 2

SHINGRIX 2 QL 1 KIT / RX

SHINGRIX GE ANTIGEN COMPONENT 2 QL 1 KIT / RX

TRUMENBA 2

TWINRIX 2

VAQTA (25 UNITS/0.5 ML SYRINGE, 50 UNITS/MLSYRINGE, 50 UNITS/ML VIAL)

2

VAQTA 25 UNITS/0.5 ML VIAL 2 ACA Affordable Care Act

VARIVAX VACCINE 2

VAXCHORA ACTIVE COMPONENT 2

VAXCHORA VACCINE 2

VAXNEUVANCE 2

VIVOTIF 2

ZOSTAVAX 2

ANTIULCER AGENTS AND ACID SUPPRESSANTSANTIULCER AGENTS AND ACID SUPPRESS.,MISC

TALICIA 2 PA

HISTAMINE H2-ANTAGONISTScimetidine (300 mg tablet, 300 mg/5 ml soln, 400 mgtablet, 400 mg/6.67 ml soln, 800 mg tablet)

1



famotidine (20 mg tablet, 40 mg tablet) 1

famotidine 40 mg/5 ml susp 1 AL1 Up to 12 yrs old

PROSTAGLANDINSmisoprostol 1

PROTECTANTSsucralfate 1 gm tablet 1

sucralfate 1 gm/10 ml susp 1 PA

PROTON-PUMP INHIBITORSesomeprazole magnesium (cvs 20 mg cap, dr 20 mg cap,dr 40 mg cap, gnp dr 20 mg, gs dr 20 mg, hm dr 20 mg, qcdr 20 mg, ra dr 20 mg, sm dr 20 mg)

1

lansoprazole (dr 15 mg capsule, dr 30 mg capsule) 1

lansoprazole (odt 15 mg tablet, odt 30 mg tablet) 1 AL1 Up to 9 yrs old

omeprazole (dr 10 mg capsule, dr 20 mg capsule, dr 40mg capsule)

1

pantoprazole sodium (dr 20 mg tab, dr 40 mg tab) 1

rabeprazole sod dr 20 mg tab 1

ANTIVIRALS (SYSTEMIC)ADAMANTANE ANTIVIRALS

rimantadine hcl 1

ANTIVIRALS, MISCELLANEOUSPREVYMIS (240 MG TABLET, 480 MG TABLET) 2

TPOXX (NATIONAL STOCKPILE) 2 PA

INTERFERON ANTIVIRALS

ALFERON N 4 S

INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML,18 MILLION UNITS VIL, 25 MILLION UNIT/2.5ML, 50MILLION UNITS VIL)

4 S

PEGASYS 4PA

S



PEGASYS PROCLICK 4PA

S

PEGINTRON 4PA

S

SYLATRON 2S

ONC Oncology

NEURAMINIDASE INHIBITOR ANTIVIRALS

oseltamivir 6 mg/ml suspension 1 QL 180 ML / 1 FILL

oseltamivir phos 30 mg capsule 1 QL 20 CAPS / 1 FILL

oseltamivir phosphate (45 mg capsule, 75 mg capsule) 1 QL 10 CAPS / 1 FILL

RELENZA 2 QL 20 CAPS / 1 FILL

NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALSacyclovir (200 mg capsule, 400 mg tablet, 800 mg tablet) 1

acyclovir 200 mg/5 ml susp 1 AL1 Up to 12 yrs old

adefovir dipivoxil 1

BARACLUDE 0.05 MG/ML SOLUTION 2

entecavir 1

famciclovir 1

ribavirin (200 mg capsule, 200 mg tablet) 4 S

valacyclovir 1

valganciclovir hcl (hcl 50 mg/ml, 450 mg tablet) 1

VEMLIDY 2

ANXIOLYTICS, SEDATIVES AND HYPNOTICSANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC

buspirone hcl 1

eszopiclone 1

hydroxyzine hcl (10 mg/5 ml soln, 10 mg/5 ml syrup, hcl10 mg tablet, hcl 25 mg tablet, 50 mg/25 ml syrup, hcl 50mg tablet)

1



hydroxyzine pamoate 1

ramelteon 1 QL 1 TAB / 1 DAY

zaleplon 1

zolpidem tartrate (5 mg tablet, 10 mg tablet) 1

BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 mlelix, 20 mg/5 ml soln, 30 mg tablet, 60 mg tablet, 100 mgtablet)

1

BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)

alprazolam (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet) 1 QL 6 TABS / 1 DAY

alprazolam 2 mg tablet 1 QL 3 TABS / 1 DAY

alprazolam er (er 0.5 mg tablet, er 1 mg tablet) 1 QL 6 TABS / 1 DAY

alprazolam er 2 mg tablet 1 QL 3 TABS / 1 DAY

alprazolam er 3 mg tablet 1 QL 2 TABS / 1 DAY

alprazolam xr (0.5 mg tablet, 1 mg tablet) 1 QL 6 TABS / 1 DAY

alprazolam xr 2 mg tablet 1 QL 3 TABS / 1 DAY

alprazolam xr 3 mg tablet 1 QL 2 TABS / 1 DAY

chlordiazepoxide 25 mg capsule 1 QL 4 CAPS / 1 DAY

chlordiazepoxide hcl (5 mg capsule, 10 mg capsule) 1 QL 6 CAPS / 1 DAY

diazepam (2 mg tablet, 5 mg tablet) 1 QL 6 TABS / 1 DAY

diazepam (2.5 mg rectal gel sys, 10 mg rectal gel syst, 20mg rectal gel syst)

1 QL 4 KIT / 30 DAYS

diazepam 10 mg tablet 1 QL 4 TABS / 1 DAY

diazepam 5 mg/5 ml solution 1 QL 40 ML / 1 DAY

diazepam 5 mg/ml oral conc 1 QL 8 ML / 1 DAY

lorazepam (0.5 mg tablet, 1 mg tablet) 1 QL 6 TABS / 1 DAY

lorazepam 2 mg tablet 1 QL 5 TABS / 1 DAY



lorazepam 2 mg/ml oral concent 1 QL 5 ML / 1 DAY

LORAZEPAM INTENSOL 1 QL 5 ML / 1 DAY

temazepam 15 mg capsule 1 QL 2 CAPS / 1 DAY

temazepam 30 mg capsule 1 QL 1 CAP / 1 DAY

VALTOCO 2QL 1 CARTON / RX

PA

AUTONOMIC DRUGSAUTONOMIC DRUGS, MISCELLANEOUS

CHANTIX 2QL 2 TABS / 1 DAY

SC Smoking Cessation

nicotine gum 1 SC Smoking Cessation

nicotine lozenge (2 mg lozenge, 2 mg mini lozenge, cvs 2mg lozenge, eq 2 mg lozenge, eql 2 mg lozenge, gnp 2 mglozenge, hm 2 mg lozenge, kro 2 mg lozenge, ra 2 mglozenge, sm 2 mg lozenge, sw 2 mg lozenge, 4 mglozenge, 4 mg mini lozenge, cvs 4 mg lozenge, eq 4 mglozenge, eql 4 mg lozenge, gnp 4 mg lozenge, gs 4 mglozenge, hm 4 mg lozenge, kro 4 mg lozenge, ra 4 mglozenge, sm 4 mg lozenge, sw 4 mg lozenge)

1 SC Smoking Cessation


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSnicotine patch (7 mg/24hr patch, cvs 7 mg/24hr patch, eq7 mg/24hr patch, hm 7 mg/24hr patch, kro 7 mg/24hrpatch, ra 7 mg/24hr patch, sm 7 mg/24hr patch, 14mg/24hr patch, cvs 14 mg/24hr patch, gnp 7 mg/24hrpatch, hm 14 mg/24hr patch, qc 14 mg/24hr patch, ra 14mg/24hr patch, 21 mg/24hr patch, cvs 21 mg/24hr patch,eq 14 mg/24hr patch, eq 21 mg/24hr patch, gnp 14mg/24hr patch, gnp 21 mg/24hr patch, hm 21 mg/24hrpatch, kro 14 mg/24hr patch, kro 21 mg/24hr patch, qc 21mg/24hr patch, ra 21 mg/24hr patch, sm 14 mg/24hrpatch, sm 21 mg/24hr patch)

1 SC Smoking Cessation

NICOTROL 2 SC Smoking Cessation

NICOTROL NS 2 SC Smoking Cessation

varenicline tartrate 1

QL 2 TABS / 1 DAY

ACA Affordable Care Act

SC Smoking Cessation

PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)bethanechol chloride 1

cevimeline hcl 1

donepezil hcl (5 mg tablet, 10 mg tablet) 1

donepezil hcl odt 1

galantamine er 1

galantamine hbr 1

galantamine hydrobromide 1

pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1

pyridostigmine br 30 mg tablet 1 QL 1 TAB / 1 DAY

pyridostigmine br 60 mg tablet 1

pyridostigmine bromide er 1 PA

rivastigmine (1.5 mg capsule, 3 mg capsule, 4.5 mgcapsule, 4.6 mg/24hr patch, 6 mg capsule, 9.5 mg/24hrpatch, 13.3 mg/24hr ptch)

1



BETA-3-ADRENERGIC AGONISTSSELECTIVE BETA-3-ADRENERGIC AGONISTS

MYRBETRIQ (ER 25 MG TABLET, ER 50 MG TABLET) 2

BETA-ADRENERGIC AGONISTSSELECTIVE BETA-2-ADRENERGIC AGONISTS

albuterol sulfate (sul 0.63 mg/3 ml sol, sul 1.25 mg/3 mlsol, 2.5 mg/0.5 ml sol, sul 2.5 mg/3 ml soln, sulf 2 mg/5ml syrup, 5 mg/ml solution, 100 mg/20 ml soln)

1

levalbuterol tartrate hfa 1

SEREVENT DISKUS 2

STRIVERDI RESPIMAT 2

VENTOLIN HFA 1

BLOOD FORMATION, COAGULATION, THROMBOSISBLOOD FORM.,COAG,THROMBOSIS AGENTS MISC.

OXBRYTA 4

QL 3 TABS / 1 DAY

PA

S

HEMATOPOIETIC AGENTS

ARANESP 4 S

FULPHILA 2

GRANIX 2 S

NYVEPRIA 2

PROMACTA (12.5 MG TABLET, 25 MG TABLET, 50 MGTABLET, 75 MG TABLET)

4PA

S

PROMACTA 12.5 MG SUSPEN PACKET 4

QL 1 PACKET / 1 DAY

PA

S

PROMACTA 25 MG SUSPENSION PCKT 4


PA

S


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSRETACRIT (2,000 UNIT/ML VIAL, 3,000 UNIT/ML VIAL,4,000 UNIT/ML VIAL, 10,000 UNIT/ML VIAL, 20,000UNIT/ML VIAL, 40,000 UNIT/ML VIAL)

4 S

UDENYCA 2

ZIEXTENZO 2

HEMORRHEOLOGIC AGENTSpentoxifylline 1

CALCIUM-CHANNEL BLOCKING AGENTSCALCIUM-CHANNEL BLOCKING AGENTS, MISC.

CARTIA XT 1

DILT-XR 1

diltiazem 24hr er 1

diltiazem 24hr er (cd) (24h 120 mg cp, 24h 180 mg cp, 24h240 mg cp, 24h 300 mg cp)

1

diltiazem 24hr er (xr) 1

diltiazem hcl (30 mg tablet, 60 mg tablet, 90 mg tablet,120 mg tablet)

1

MATZIM LA 240 MG TABLET 1

TAZTIA XT 1

TIADYLT ER (ER 180 MG CAPSULE, ER 420 MG CAPSULE) 1

verapamil er 1

verapamil hcl (40 mg tablet, 80 mg tablet, 120 mg tablet,360 mg cap pellet)

1

verapamil sr 1

DIHYDROPYRIDINESamlodipine besylate 1

amlodipine besylate-benazepril 1

amlodipine-olmesartan 1

amlodipine-valsartan 1

amlodipine-valsartan-hctz 1

felodipine er 1



nifedipine 1 AL1 Up to 45 yrs old

nifedipine er 1

nimodipine 1

CARDIAC DRUGSCARDIAC DRUGS, MISCELLANEOUS

CORLANOR (5 MG TABLET, 5 MG/5 ML ORAL SOLN, 7.5MG TABLET)

2 PA

VYNDAMAX 4PA

S

VYNDAQEL 4PA

S

CARDIOTONIC AGENTSDIGITEK 125 MCG TABLET 1

DIGITEK 250 MCG TABLET 1 AL1 Up to 64 yrs old

DIGOX 125 MCG TABLET 1

DIGOX 250 MCG TABLET 1 AL1 Up to 64 yrs old

digoxin (0.125 mg tablet, 125 mcg tablet) 1

digoxin (0.25 mg tablet, 250 mcg tablet) 1 AL1 Up to 64 yrs old

digoxin 0.05 mg/ml solution 2

CARDIOVASCULAR DRUGSALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate 1

prazosin hcl 1

terazosin hcl 1

BETA-ADRENERGIC BLOCKING AGENTSacebutolol hcl 1

atenolol 1

atenolol-chlorthalidone 1

betaxolol hcl (10 mg tablet, 20 mg tablet) 1



bisoprolol fumarate 1

bisoprolol-hydrochlorothiazide 1

carvedilol 1

labetalol hcl (100 mg tablet, 200 mg tablet, 300 mgtablet)

1

metoprolol succinate 1

metoprolol tartrate (25 mg tab, 50 mg tab, 100 mg tab) 1

metoprolol-hydrochlorothiazide 1

nadolol 1

propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 mlsoln, 40 mg tablet, 40 mg/5 ml soln, 60 mg tablet, 80 mgtablet)

1

propranolol hcl er 1

propranolol-hydrochlorothiazid 1

sotalol 1

SOTALOL AF 1

timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 1

CENTRAL NERVOUS SYSTEM AGENTSANTIMANIC AGENTS

lithium 1

lithium carbonate 1

lithium carbonate er 1

CENTRAL NERVOUS SYSTEM AGENTS, MISC.acamprosate calcium 1

atomoxetine hcl (10 mg capsule, 18 mg capsule, 25 mgcapsule, 40 mg capsule)

1 QL 2 CAPS / 1 DAY

atomoxetine hcl (60 mg capsule, 80 mg capsule, 100 mgcapsule)

1 QL 1 CAP / 1 DAY

guanfacine hcl er (er 3 mg tablet, er 4 mg tablet) 1 QL 1 TAB / 1 DAY

guanfacine hcl er 1 mg tablet 1 QL 3 TABS / 1 DAY

guanfacine hcl er 2 mg tablet 1 QL 2 TABS / 1 DAY


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSmemantine hcl (hcl 2 mg/ml solution, 5-10 mg titrationpk, hcl 5 mg tablet, hcl 10 mg tablet)

1

NOURIANZ 4PA

S

riluzole 1

XYREM 4

QL 18 ML / 1 DAY

PA

S

XYWAV 4

QL 18 ML / 1 DAY

PA

S

OPIATE ANTAGONISTSKLOXXADO 2

naloxone 2 mg/2 ml syringe 1

naltrexone hcl 1

NARCAN 2

VESICULAR MONOAMINE TRANSPORT2 INHIBITOR

AUSTEDO 4PA

S

INGREZZA 4PA

S

INGREZZA INITIATION PACK 4PA

S

tetrabenazine 4PA

S

CEPHALOSPORIN ANTIBIOTICS1ST GENERATION CEPHALOSPORIN ANTIBIOTICS

cefadroxil (1 gm tablet, 250 mg/5 ml susp, 500 mgcapsule, 500 mg/5 ml susp)

1

cephalexin (125 mg/5 ml susp, 250 mg capsule, 250 mg/5ml susp, 500 mg capsule)

1



2ND GENERATION CEPHALOSPORIN ANTIBIOTICScefprozil (125 mg/5 ml susp, 250 mg tablet, 250 mg/5 mlsusp, 500 mg tablet)

1

cefuroxime 1

3RD GENERATION CEPHALOSPORIN ANTIBIOTICScefdinir (125 mg/5 ml susp, 250 mg/5 ml susp, 300 mgcapsule)

1

cefixime 400 mg capsule 1 QL 1 CAP / 30 DAYS

cefpodoxime proxetil (100 mg tablet, 200 mg tablet) 1QL 14 TABS / RX

PA

cefpodoxime proxetil (50 mg/5 ml susp, 100 mg/5 mlsusp)

1QL 100 ML / RX

PA

CORTICOSTEROIDS (RESPIRATORY TRACT)ORALLY INHALED PREPARATIONS (STEROIDS)

ADVAIR DISKUS 1

ADVAIR HFA 2

ARNUITY ELLIPTA 2

ASMANEX (TWISTHALER 110 MCG #30, TWISTHALER 220MCG #30, TWISTHALER 220 MCG #60, TWISTHALR 220MCG #120)

2

ASMANEX HFA 2

BREO ELLIPTA 2

budesonide (0.25 mg/2 ml susp, 0.5 mg/2 ml susp, 1 mg/2ml inh susp)

1

budesonide-formoterol fumarate 1

DULERA 2 PA

FLOVENT DISKUS 2

FLOVENT HFA 2

fluticasone-salmeterol 113-14 (generic for airduorespiclick)

1

fluticasone-salmeterol 232-14 (generic for airduorespiclick)

1



fluticasone-salmeterol 55-14 (generic for airduo respiclick) 1

PULMICORT FLEXHALER 2

QVAR REDIHALER 2

TRELEGY ELLIPTA 2

CYSTIC FIBROSIS (CFTR) MODULATORSCYSTIC FIBROSIS (CFTR) CORRECTORS

SYMDEKO 4PA

S

TRIKAFTA 4PA

S

CYSTIC FIBROSIS (CFTR) POTENTIATORS

KALYDECO 4PA

S

ORKAMBI 4PA

S

DIAGNOSTIC AGENTSADRENOCORTICAL INSUFFICIENCY

ACTHAR 4PA

S

DIURETICSLOOP DIURETICS

bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1

furosemide (10 mg/ml solution, 20 mg tablet, 40 mgtablet, 40 mg/5 ml soln, 80 mg tablet)

1

torsemide 1

POTASSIUM-SPARING DIURETICSamiloride hcl 1

amiloride-hydrochlorothiazide 1

triamterene-hydrochlorothiazid 1



THIAZIDE DIURETICShydrochlorothiazide 1

THIAZIDE-LIKE DIURETICSchlorthalidone 1

indapamide 1

metolazone 1

DOPAMINE RECEPTOR AGONISTSERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS

bromocriptine mesylate 1

cabergoline 1

CYCLOSET 2 PA

NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST

NEUPRO 2 PA

pramipexole dihydrochloride 1

ropinirole hcl 1

ELECTROLYTIC, CALORIC, AND WATER BALANCEALKALINIZING AGENTS

potassium citrate er 1

AMMONIA DETOXICANTS

CARBAGLU 4PA

S

ENULOSE 1

GENERLAC 1

lactulose 10 gm/15 ml solution 1

sodium phenylbutyrate powder 1 PA

CALORIC AGENTS

DOJOLVI 4PA

S

levocarnitine 330 mg tablet 1



REPLACEMENT PREPARATIONSKLOR-CON M10 1

KLOR-CON M15 1

KLOR-CON M20 1

potassium chloride (er 8 meq capsule, er 8 meq tablet,10% (20 meq/15ml), 10% (40 meq/30ml), er 10 meqcapsule, er 10 meq tablet, 20 meq packet, 20% (40meq/15ml), er 20 meq tablet)

1

URICOSURIC AGENTSprobenecid 1

probenecid-colchicine 1

EMOLLIENTS, DEMULCENTS, AND PROTECTANTSBASIC LOTIONS AND LINIMENTS

ammonium lactate 12% lotion 1

BASIC OINTMENTS AND PROTECTANTSammonium lactate 12% cream 1

ENZYMES

REVCOVI 4PA

S

STRENSIQ 4PA

S

SUCRAID 4PA

S

ESTROGENS AND ANTIESTROGENSESTROGEN AGONIST-ANTAGONISTS

raloxifene hcl 1 ACA Affordable Care Act

SOLTAMOX 2

tamoxifen citrate 1 ACA Affordable Care Act

ESTROGENSAMABELZ 0.5 MG-0.1 MG TABLET 1



DOTTI 1

estradiol (0.01% cream, 0.5 mg tablet, 1 mg tablet, 2 mgtablet, 10 mcg vaginal insrt)

1

estradiol (once weekly) 1

estradiol (twice weekly) 1

estradiol-noreth 0.5-0.1 mg tb 1

FYAVOLV 1 MG-5 MCG TABLET 1

JINTELI 1

LOPREEZA 0.5 MG-0.1 MG TABLET 1

MIMVEY LO 1

norethin-eth estrad 1 mg-5 mcg 1

PREMARIN VAGINAL CREAM-APPL 2

PREMPRO 2

YUVAFEM 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS.ANTIALLERGIC AGENTS

azelastine hcl (hcl 0.05% drops, 0.1% (137 mcg) spry) 1

epinastine hcl 1

olopatadine hcl 0.1% eye drops 1

EENT DRUGS, MISCELLANEOUS

CYSTADROPS 4

QL 5 ML / RX

PA

S

CYSTARAN 4

QL 15 ML / RX

PA

S

ipratropium bromide (0.03% spray, 0.06% spray) 1

OXERVATE 4

QL 1 ML / 1 DAY

PA

S



LOCAL ANESTHETICS (EENT)lidocaine hcl (2% jel urojet ac, 2% jelly, 2% jelly uro-jet, 4%solution)

1

lidocaine hcl viscous 1

MYDRIATICSatropine sulfate (drops, ointment) 1

cyclopentolate hcl (drop, drops) 1

homatropaire 1

homatropine hydrobromide 1

VASOCONSTRICTORSphenylephrine hcl (2.5% drop, 10% drops) 1

FIRST GENERATION ANTIHISTAMINESFIRST GEN. ANTIHIST. DERIVATIVES, MISC.

cyproheptadine hcl (2 mg/5 ml soln, 2 mg/5 ml syrup, 4mg tablet, 4 mg/10 ml syrp)

1

PHENOTHIAZINE DERIVATIVESPHENADOZ 1

promethazine hcl (12.5 mg suppos, 25 mg suppository, 50mg suppository)

1

promethazine hcl (12.5 mg tablet, 25 mg tablet, 50 mgtablet)

1 AQ1 Up to 64 yrs old; 30 /1 FILL

promethazine hcl (6.25 mg/5 ml soln, 6.25 mg/5 ml syrp) 1 AQ1 Up to 64 yrs old; 300/ 1 FILL

promethazine vc 1

promethazine-phenylephrine 1

PROMETHEGAN 1

GASTROINTESTINAL DRUGSANTI-INFLAMMATORY AGENTS (GI DRUGS)

alosetron hcl 1 PA

balsalazide disodium 1

mesalamine (dr 1.2 gm tablet, 4 gm/60 ml enema, 800mg dr tablet, 1,000 mg supp)

1



mesalamine dr 1

mesalamine er 1

ANTIDIARRHEA AGENTS

diphenoxylat-atrop 2.5-0.025/5 1 QL 40 ML / 1 DAY

diphenoxylate-atrop 2.5-0.025 1 QL 8 TABS / 1 DAY

paregoric 1 QL 40 ML / 1 DAY

XERMELO 4PA

S

CATHARTICS AND LAXATIVESGAVILYTE-C 1

GAVILYTE-G 1 ACA Affordable Care Act

GAVILYTE-N 1

lubiprostone 1 QL 2 CAPS / 1 DAY

peg 3350-electrolyte (3350 electrolyte soln, 3350-electrolyte solution)

1

SUPREP 2 ACA Affordable Care Act

TRILYTE WITH FLAVOR PACKETS 1

CHOLELITHOLYTIC AGENTSursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) 1

DIGESTANTSCREON 2

GI DRUGS, MISCELLANEOUS

ALLI 2PA

WL Weight Loss

CHOLBAM 4PA

S

ENDARI 4PA

S



HUMIRA(CF) PEDI CROHN 80-40 MG 4

QL 2 SYRINGES / 28DAYS

PA

S

LINZESS 2 QL 1 CAP / 1 DAY

MOVANTIK 2QL 1 TAB / 1 DAY

PA

SYMPROIC 2 PA

XENICAL 2PA

WL Weight Loss

PROKINETIC AGENTS

GIMOTI 2 PA

metoclopramide hcl (5 mg tablet, 5 mg/5 ml soln, 10 mgtablet, 10 mg/10 ml sol)

1

metoclopramide hcl odt 1 PA

GENITOURINARY SMOOTH MUSCLE RELAXANTSANTIMUSCARINICS

oxybutynin chloride (5 mg tablet, 5 mg/5 ml syrup) 1

oxybutynin chloride er 1

solifenacin succinate 1

tolterodine tartrate 1

tolterodine tartrate er 1

trospium chloride 1

GOLD COMPOUNDSRIDAURA 2

GONADOTROPINS AND ANTIGONADOTROPINSANTIGONADTROPINS

MYFEMBREE 4


PA

S



ORGOVYX 2PA

S

ORIAHNN 4

QL 2 CAPS / 1 DAY

PA

S

ORILISSA 150 MG TABLET 4

QL 1 TAB / 1 DAY

PA

S

ORILISSA 200 MG TABLET 4


PA

S

HCV ANTIVIRALSHCV POLYMERASE INHIBITOR ANTIVIRALS

EPCLUSA 200 MG-50 MG TABLET 4PA

S

HARVONI (33.75-150 MG PELLET PK, 45-200 MG PELLETPACKT, 45-200 MG TABLET)

4PA

S

ledipasvir-sofosbuvir 4PA

S

sofosbuvir-velpatasvir 4PA

S

SOVALDI (150 MG PELLET PACKET, 200 MG PELLETPACKET, 200 MG TABLET)

4PA

S

VOSEVI 4PA

S

HCV PROTEASE INHIBITOR ANTIVIRALS

MAVYRET 4PA

S



HEAVY METAL ANTAGONISTSCHEMET 2

D-PENAMINE 1 PA

deferasirox (90 mg tablet, 125 mg tb for susp, 180 mgtablet, 250 mg tb for susp, 500 mg tb for susp)

4

PA

S

TD Trial Drug

deferiprone 4PA

S

FERRIPROX (100 MG/ML SOLUTION, 1,000 MG TABLET) 4PA

S

FERRIPROX (2 TIMES A DAY) 4PA

S

FERRIPROX (3 TIMES A DAY) 4PA

S

penicillamine 250 mg tablet 4PA

S

HORMONES AND SYNTHETIC SUBSTITUTESADRENALS

budesonide ec 1

dexamethasone (0.5 mg tablet, 0.5 mg/5 ml elx, 0.5 mg/5ml liq, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mgtablet, 4 mg tablet, 6 mg tablet)

1

DEXAMETHASONE INTENSOL 2

dexamethasone sodium phosphate (4 mg/ml vial, 10mg/ml syring, 10 mg/ml vial, 20 mg/5 ml vial, 100 mg/10ml vl, 120 mg/30 ml vl)

1

fludrocortisone acetate 1

hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet) 1

MEDROL 2 MG TABLET 2

methylprednisolone 1



MILLIPRED 2

prednisolone 1

prednisolone sodium phosphate (5 mg/5 ml soln, 15 mg/5ml soln, sod ph 25 mg/5 ml)

1

prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab dosepack, 5 mg tablet, 5 mg/5 ml solution, 10 mg tab dosepack, 10 mg tablet, 20 mg tablet, 50 mg tablet)

1

PREDNISONE INTENSOL 2

SOLU-CORTEF 100 MG ACT-O-VIAL 2

ANDROGENSdanazol 1

methyltestosterone 1QL 5 CAPS / 1 DAY

PA

oxandrolone 10 mg tablet 1QL 2 TABS / 1 DAY

PA

oxandrolone 2.5 mg tablet 1QL 4 TABS / 1 DAY

PA

testosterone (1% (25mg/2.5g) pk, 1% (50 mg/5 g) pk,1.62% (2.5 g) pkt, 1.62% gel pump, 1.62%(1.25 g) pkt, 10mg gel pump, 12.5 mg/1.25 gram, 50 mg/5 gram gel, 50mg/5 gram pkt)

1 PA

testosterone cypionate (testosteron 1,000 mg/10 ml,testosteron 2,000 mg/10 ml, testosterone 100 mg/ml,testosterone 200 mg/ml, testosterone 500 mg/2.5 ml,testosterone 500 mg/5 ml, testosterone 1,000 mg/5 ml,testosterone 6,000 mg/30ml)

1 PA

testosterone enanthate 1 PA

testosterone propionate 1 PA

CONTRACEPTIVES

AFIRMELLE 1 ACA Affordable Care Act

ALTAVERA 1 ACA Affordable Care Act

ALYACEN 1 ACA Affordable Care Act



AMETHIA 1 ACA Affordable Care Act

AMETHIA LO 1 ACA Affordable Care Act

APRI 1 ACA Affordable Care Act

ARANELLE 1 ACA Affordable Care Act

ASHLYNA 1 ACA Affordable Care Act

AUBRA 1 ACA Affordable Care Act

AUBRA EQ 1 ACA Affordable Care Act

AUROVELA 1 ACA Affordable Care Act

AUROVELA 24 FE 1 ACA Affordable Care Act

AUROVELA FE 1 ACA Affordable Care Act

AVIANE 1 ACA Affordable Care Act

AYUNA 1 ACA Affordable Care Act

AZURETTE 1 ACA Affordable Care Act

BALZIVA 1 ACA Affordable Care Act

BEKYREE 1 ACA Affordable Care Act

BLISOVI 24 FE 2 ACA Affordable Care Act

BLISOVI FE 1 ACA Affordable Care Act

BRIELLYN 1 ACA Affordable Care Act

CAMILA 1 ACA Affordable Care Act

CAMRESE 1 ACA Affordable Care Act

CAMRESE LO 1 ACA Affordable Care Act

CAZIANT 1 ACA Affordable Care Act

CHATEAL 1 ACA Affordable Care Act

CHATEAL EQ 1 ACA Affordable Care Act



CRYSELLE 1 ACA Affordable Care Act

CYCLAFEM 1 ACA Affordable Care Act

CYRED 1 ACA Affordable Care Act

CYRED EQ 1 ACA Affordable Care Act

DASETTA 1 ACA Affordable Care Act

DAYSEE 1 ACA Affordable Care Act

DEBLITANE 1 ACA Affordable Care Act

desogestr-eth estrad eth estra 1 ACA Affordable Care Act

desogestrel-ethinyl estradiol 1 ACA Affordable Care Act

drospirenone-ethinyl estradiol 1 ACA Affordable Care Act

ELINEST 1 ACA Affordable Care Act

ELLA 2 ACA Affordable Care Act

ELURYNG 1 ACA Affordable Care Act

EMOQUETTE 1 ACA Affordable Care Act

ENPRESSE 1 ACA Affordable Care Act

ENSKYCE 1 ACA Affordable Care Act

ERRIN 1 ACA Affordable Care Act

ESTARYLLA 1 ACA Affordable Care Act

ethynodiol-ethinyl estradiol 1 ACA Affordable Care Act

etonogestrel-ethinyl estradiol 1 ACA Affordable Care Act

FALMINA 1 ACA Affordable Care Act

FEMYNOR 1 ACA Affordable Care Act

GIANVI 1 ACA Affordable Care Act

HAILEY 1 ACA Affordable Care Act



HAILEY FE 1 ACA Affordable Care Act

HEATHER 1 ACA Affordable Care Act

ICLEVIA 1 ACA Affordable Care Act

INCASSIA 1 ACA Affordable Care Act

INTROVALE 1 ACA Affordable Care Act

ISIBLOOM 1 ACA Affordable Care Act

JAIMIESS 1 ACA Affordable Care Act

JASMIEL 1 ACA Affordable Care Act

JENCYCLA 1 ACA Affordable Care Act

JOLESSA 1 ACA Affordable Care Act

JULEBER 1 ACA Affordable Care Act

JUNEL 1 ACA Affordable Care Act

JUNEL FE 1 ACA Affordable Care Act

KALLIGA 1 ACA Affordable Care Act

KARIVA 1 ACA Affordable Care Act

KELNOR 1-35 1 ACA Affordable Care Act

KELNOR 1-50 1 ACA Affordable Care Act

KURVELO 1 ACA Affordable Care Act

LARIN 1 ACA Affordable Care Act

LARIN FE 1 ACA Affordable Care Act

LARISSIA 1 ACA Affordable Care Act

LEENA 1 ACA Affordable Care Act

LESSINA 1 ACA Affordable Care Act

LEVONEST 1 ACA Affordable Care Act


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSlevonorg-eth estrad eth estrad (levono-e 0.15-0.03-0.01,levonor-e 0.1-0.02-0.01)


levonorgestrel 1 ACA Affordable Care Act

levonorgestrel-eth estradiol (0.1-0.02 mg, 0.15-0.03,triphasic)


LEVORA-28 1 ACA Affordable Care Act

LILLOW 1 ACA Affordable Care Act

LO-ZUMANDIMINE 1 ACA Affordable Care Act

LOJAIMIESS 1 ACA Affordable Care Act

LORYNA 1 ACA Affordable Care Act

LOW-OGESTREL 1 ACA Affordable Care Act

LUTERA 1 ACA Affordable Care Act

LYZA 1 ACA Affordable Care Act

MARLISSA 1 ACA Affordable Care Act

MICROGESTIN 1 ACA Affordable Care Act

MICROGESTIN FE 1 ACA Affordable Care Act

MILI 1 ACA Affordable Care Act

MONO-LINYAH 1 ACA Affordable Care Act

MY WAY 1 ACA Affordable Care Act

NECON 1 ACA Affordable Care Act

NIKKI 1 ACA Affordable Care Act

NORA-BE 1 ACA Affordable Care Act

norethindron-ethinyl estradiol (norethin-ee 1.5-0.03mg(21) tb, norethind-eth estrad 1-0.02 mg)


norethindrone 1 ACA Affordable Care Act

norethindrone-e.estradiol-iron (1-0.02(21)-75 tab, 1.5-0.03mg(21)-75)




norgestimate-ethinyl estradiol 1 ACA Affordable Care Act

NORLYDA 1 ACA Affordable Care Act

NORTREL 1 ACA Affordable Care Act

NYMYO 1 ACA Affordable Care Act

OCELLA 1 ACA Affordable Care Act

OGESTREL 1 ACA Affordable Care Act

ORSYTHIA 1 ACA Affordable Care Act

PHILITH 1 ACA Affordable Care Act

PIMTREA 1 ACA Affordable Care Act

PIRMELLA 1 ACA Affordable Care Act

PORTIA 1 ACA Affordable Care Act

PREVIFEM 1 ACA Affordable Care Act

RECLIPSEN 1 ACA Affordable Care Act

SETLAKIN 1 ACA Affordable Care Act

SHAROBEL 1 ACA Affordable Care Act

SIMLIYA 1 ACA Affordable Care Act

SIMPESSE 1 ACA Affordable Care Act

SPRINTEC 1 ACA Affordable Care Act

SRONYX 1 ACA Affordable Care Act

SYEDA 1 ACA Affordable Care Act

TARINA 24 FE 1 ACA Affordable Care Act

TARINA FE 1 ACA Affordable Care Act

TARINA FE 1-20 EQ 1 ACA Affordable Care Act

TILIA FE 1 ACA Affordable Care Act



TRI FEMYNOR 1 ACA Affordable Care Act

TRI-ESTARYLLA 1 ACA Affordable Care Act

TRI-LEGEST FE 1 ACA Affordable Care Act

TRI-LINYAH 1 ACA Affordable Care Act

TRI-LO-ESTARYLLA 1 ACA Affordable Care Act

TRI-LO-MARZIA 1 ACA Affordable Care Act

TRI-LO-MILI 1 ACA Affordable Care Act

TRI-LO-SPRINTEC 1 ACA Affordable Care Act

TRI-MILI 1 ACA Affordable Care Act

TRI-PREVIFEM 1 ACA Affordable Care Act

TRI-SPRINTEC 1 ACA Affordable Care Act

TRI-VYLIBRA 1 ACA Affordable Care Act

TRI-VYLIBRA LO 1 ACA Affordable Care Act

TRIVORA-28 1 ACA Affordable Care Act

TULANA 1 ACA Affordable Care Act

TYBLUME 1 ACA Affordable Care Act

VELIVET 1 ACA Affordable Care Act

VESTURA 1

VIENVA 1 ACA Affordable Care Act

VIORELE 1 ACA Affordable Care Act

VOLNEA 1 ACA Affordable Care Act

VYFEMLA 1 ACA Affordable Care Act

VYLIBRA 1 ACA Affordable Care Act

WERA 1 ACA Affordable Care Act



XULANE 1 ACA Affordable Care Act

ZARAH 1 ACA Affordable Care Act

ZOVIA 1-35 1 ACA Affordable Care Act

ZOVIA 1-35E 1 ACA Affordable Care Act

ZUMANDIMINE 1 ACA Affordable Care Act

PITUITARY

desmopressin acetate (0.01% solution, 10 mcg/0.1 ml spr) 1 PA

desmopressin acetate (0.1 mg tb, 0.2 mg tb) 1 AL1 At least 8 yrs old

STIMATE 2 PA

PROGESTINS

hydroxyprogest 250 mg/ml vial 4QL 2 ML / 1 FILL

S

MAKENA 250 MG/ML VIAL 4QL 2 ML / 1 FILL

S

MAKENA 275 MG/1.1 ML AUTOINJCT 4QL 2.2 ML / 1 FILL

S

medroxyprogesterone acetate (2.5 mg tab, 5 mg tab, 10mg tab)

1

megestrol acetate (20 mg tablet, 40 mg tablet, acet 40mg/ml susp)

1

norethindrone ac (lupaneta) 1

norethindrone acetate 1

progesterone (100 mg capsule, 200 mg capsule) 1

HYPOTENSIVE AGENTSCENTRAL ALPHA-AGONISTS

clonidine 1

clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1

guanfacine hcl 1



methyldopa 1

DIRECT VASODILATORShydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet,100 mg tablet)

1

minoxidil 1

INSULINSINTERMEDIATE-ACTING INSULINS

HUMULIN 70-30 2

HUMULIN 70/30 KWIKPEN 2

HUMULIN N 2

HUMULIN N KWIKPEN 2

relion novolin 70-30 flexpen 2

relion novolin 70-30 vial 2

relion novolin n 100 unit/ml 2

relion novolin n u-100 flexpen 2

LONG-ACTING INSULINSLANTUS 2

LANTUS SOLOSTAR 2

LEVEMIR 2 PA

LEVEMIR FLEXTOUCH 2 PA

SOLIQUA 100-33 2

TOUJEO MAX SOLOSTAR 2

TOUJEO SOLOSTAR 2

XULTOPHY 100-3.6 2

RAPID-ACTING INSULINSHUMALOG 2

HUMALOG JUNIOR KWIKPEN 2

HUMALOG KWIKPEN U-100 2

HUMALOG KWIKPEN U-200 2



HUMALOG MIX 50-50 2

HUMALOG MIX 50-50 KWIKPEN 2

HUMALOG MIX 75-25 2

HUMALOG MIX 75-25 KWIKPEN 2

insulin lispro 1

insulin lispro junior kwikpen 1

insulin lispro kwikpen u-100 1

insulin lispro protamine mix 1

SHORT-ACTING INSULINSHUMULIN R 2

HUMULIN R U-500 2

HUMULIN R U-500 KWIKPEN 2

relion novolin r 100 unit/ml 2

relion novolin r u-100 flexpen 2

ION-REMOVING AGENTSPHOSPHATE-REMOVING AGENTS

calcium acetate (667 mg capsule, 667 mg gelcap) 1

PHOSLYRA 2

sevelamer carbonate 1

POTASSIUM-REMOVING AGENTSsodium polystyrene sulfonate (sod polystyren 15 g/60 ml,sodium polystyrene powder)

1

MACROLIDE ANTIBIOTICSOTHER MACROLIDE ANTIBIOTICS

azithromycin (100 mg/5 ml susp, 200 mg/5 ml susp, 250mg tablet, 500 mg tablet, 600 mg tablet)

1

clarithromycin (125 mg/5 ml sus, 250 mg/5 ml sus) 1 AL1 Up to 12 yrs old

clarithromycin (250 mg tablet, 500 mg tablet) 1

DIFICID (40 MG/ML SUSPENSION, 200 MG TABLET) 2 PA



MISC. BETA-LACTAM ANTIBIOTICSMONOBACTAM ANTIBIOTICS

CAYSTON 4PA

S

MISCELLANEOUS THERAPEUTIC AGENTS5-ALPHA-REDUCTASE INHIBITORS

dutasteride 1

finasteride 5 mg tablet 1

ALCOHOL DETERRENTSdisulfiram 1

ANTIDOTESleucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab, 25mg tab)

1

VISTOGARD 4PA

S

ANTIGOUT AGENTSallopurinol 1

colchicine 1

febuxostat 1 ST

BONE RESORPTION INHIBITORS

alendronate sod 70 mg/75 ml 1 PA

alendronate sodium (5 mg tablet, 10 mg tab, 35 mg tab,40 mg tab, 70 mg tab)

1

etidronate disodium 1

ibandronate sodium 150 mg tab 1

CARIOSTATIC AGENTSdenta 5000 plus 1

dentagel 1

fluoride 1AL1 Up to 5 yrs old




fluoritab (0.5 mg tablet chew, 1 mg tablet chew) 1AL1 Up to 5 yrs old


flura-drops 1AL1 Up to 5 yrs old


ludent fluoride 1AL1 Up to 5 yrs old


sf 1

sf 5000 plus 1

sodium fluoride (0.25 (0.55) mg, 0.5 mg(1.1 mg), 0.5mg/ml drop, 1 mg (2.2 mg))

1AL1 Up to 5 yrs old


COMPLEMENT INHIBITORS

BERINERT 4PA

S

CINRYZE 4PA

S

FIRAZYR 4

QL 9 ML / 1 FILL

PA

S

HAEGARDA 4PA

S

KALBITOR 4PA

S

ORLADEYO 4

QL 1 CAP / 1 DAY

PA

S

RUCONEST 4PA

S

TAKHZYRO 4

QL 4 ML / 28 DAYS

PA

S



DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

ACTEMRA 162 MG/0.9 ML SYRINGE 4


PA

S

ACTEMRA ACTPEN 4PA

S

CIMZIA (MG/ML SYRINGE KIT, MG/ML(X3)START KT) 4


PA

S

ENBREL (25 MG/0.5 ML SYRINGE, 25 MG/0.5 ML VIAL) 4

QL 4 ML (8 DOSES) / 28DAYS

PA

S

ENBREL 25 MG KIT 4

QL 8 VIALS (8 ML) / 28DAYS

PA

S

ENBREL 50 MG/ML SYRINGE 4


PA

S

ENBREL MINI 4


PA

S

ENBREL SURECLICK 4


PA

S

HUMIRA 4


PA

S



HUMIRA PEN 4

QL 2 PENS / 28 DAYS

PA

S

HUMIRA PEN CROHN'S-UC-HS 4

QL 2 PENS / 28 DAYS

PA

S

HUMIRA PEN PSOR-UVEITS-ADOL HS 4

QL 2 PENS / 28 DAYS

PA

S

HUMIRA(CF) 4


PA

S

HUMIRA(CF) PEDI CROHN 80MG/0.8 4

QL 3 PENS / 28 DAYS

PA

S

HUMIRA(CF) PEN 40 MG/0.4 ML 4

QL 2 PENS / 28 DAYS

PA

S

HUMIRA(CF) PEN 80 MG/0.8 ML 4

QL 3 PENS / 28 DAYS

PA

S

HUMIRA(CF) PEN CROHN'S-UC-HS 4

QL 3 PENS / 28 DAYS

PA

S

HUMIRA(CF) PEN PEDIATRIC UC 4

QL 3 PENS / 28 DAYS

PA

S

HUMIRA(CF) PEN PSOR-UV-ADOL HS 4

QL 2 PENS / 28 DAYS

PA

S



KINERET 4


PA

S

leflunomide 1

OLUMIANT 4

QL 1 TAB / 1 DAY

PA

S

ORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 MLSYRINGE, 125 MG/ML SYRINGE)

4


PA

S

ORENCIA CLICKJECT 4

QL 4 ML / 28 DAYS

PA

S

OTEZLA 28 DAY STARTER PACK 4


PA

S

OTEZLA 30 MG TABLET 4

QL 2 TABS / 1 DAY

PA

S

OTEZLA STARTER PACK 4

QL 2 PACKS / 28 DAYS

PA

S

RINVOQ 4

QL 1 TAB / 1 DAY

PA

S

IMMUNOMODULATORY AGENTS

AUBAGIO 4QL 1 TAB / 1 DAY

S

AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG KT) 4QL 1 KIT / 28 DAYS

S



AVONEX 30 MCG/0.5 ML SYRINGE 4QL 4 SYRINGES / 28

DAYSS

AVONEX PEN 4QL 1 KIT / 28 DAYS

S

BAFIERTAM 4QL 4 CAPS / 1 DAY

S

BETASERON 0.3 MG KIT 4QL 15 ML / 28 DAYS

S

BETASERON 0.3 MG VIAL 4QL 15 ML / 30 DAYS

S

dimethyl fumarate 4QL 2 CAPS / 1 DAY

S

ENSPRYNG 4PA

S

GILENYA 4QL 1 CAP / 1 DAY

S

glatiramer 20 mg/ml syringe 4QL 30 ML / 30 DAYS

S

glatiramer 40 mg/ml syringe 4QL 12 ML / 28 DAYS

S

GLATOPA 20 MG/ML SYRINGE 4QL 30 ML / 30 DAYS

S

GLATOPA 40 MG/ML SYRINGE 4QL 12 ML / 28 DAYS

S

KESIMPTA PEN 4QL 1 PEN / 28 DAYS

S

MAYZENT 0.25 MG STARTER PACK 4QL 12 TABS / 4 DAYS

S



MAYZENT 0.25 MG TABLET 4QL 4 TABS / 1 DAY

S

MAYZENT 2 MG TABLET 4QL 1 TAB / 1 DAY

S

PLEGRIDY 4QL 1 ML / 28 DAYS

S

PLEGRIDY PEN 4QL 1 ML / 28 DAYS

S

REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 MLSYRINGE)

4QL 6 ML / 28 DAYS

S

REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML) 4QL 6 ML / 28 DAYS

S

REBIF REBIDOSE TITRATION PACK 4QL 4.2 ML / 28 DAYS

S

REBIF TITRATION PACK 4QL 4.2 ML / 28 DAYS

S

REDITREX 2 PA

THALOMID 2S

ONC Oncology

VUMERITY 4QL 4 CAPS / 1 DAY

S

ZEPOSIA 0.23-0.46 MG START PCK 4QL 7 CAPS / 180 DAYS

S

ZEPOSIA 0.23-0.46-0.92 MG KIT 4QL 37 CAPS / 180 DAYS

S

ZEPOSIA 0.92 MG CAPSULE 4QL 1 CAP / 1 DAY

S



IMMUNOSUPPRESSIVE AGENTSazathioprine 50 mg tablet 1

cyclosporine (25 mg capsule, 100 mg capsule) 1

cyclosporine modified (25 mg, 50 mg, 100 mg, 100mg/ml) 1

GENGRAF (25 MG CAPSULE, 100 MG CAPSULE, 100MG/ML SOLUTION)

1

MAVENCLAD 4PA

S

mycophenolate mofetil (200 mg/ml susp, 250 mg capsule,500 mg tablet)

1

mycophenolic acid 1

sirolimus (0.5 mg tablet, 1 mg tablet, 1 mg/ml solution, 2mg tablet)

1

tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule) 1

OTHER MISCELLANEOUS THERAPEUTIC AGENTS

ARCALYST 4PA

S

CERDELGA 4PA

S

CYSTAGON 2

dalfampridine er 4

QL 2 TABS / 1 DAY

PA

S

EVRYSDI 4PA

S

GALAFOLD 4


PA

S

ILARIS 4

QL 2 ML / 28 DAYS

PA

S



ISTURISA 4PA

S

levocarnitine 1 g/10 ml soln 1

levocarnitine sf 1

miglustat 4PA

S

REZUROCK 2

QL 1 TAB / 1 DAY

PA

S

ONC Oncology

RUZURGI 4

QL 10 TABS / 1 DAY

PA

S

sapropterin dihydrochloride 4PA

S

THIOLA 4PA

S

THIOLA EC 4PA

S

tiopronin 4PA

S

TYBOST 2

ZOKINVY 4PA

S

PROTECTIVE AGENTSELMIRON 2

NONHORMONAL CONTRACEPTIVES

TODAY CONTRACEPTIVE SPONGE 2 ACA Affordable Care Act

vcf 1 ACA Affordable Care Act



NONSTEROIDAL ANTI-INFLAMMATORY AGENTSCYCLOOXYGENASE-2 (COX-2) INHIBITORS

celecoxib 1

OTHER NONSTEROIDAL ANTI-INFLAM. AGENTSdiclofenac pot 50 mg tablet 1

diclofenac sodium (sod dr 25 mg tab, sod dr 50 mg tab,sod dr 75 mg tab, sod ec 25 mg tab, sod ec 50 mg tab, sodec 75 mg tab, sodium 1% gel)

1

diclofenac sodium er 1

etodolac 1

etodolac er 1

flurbiprofen 1

ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) 1

indomethacin (25 mg capsule, 50 mg capsule) 1 AQ1 Up to 64 yrs old; 20 /1 FILL

ketorolac 10 mg tablet 1 QL 20 TABS / RX

meloxicam (7.5 mg tablet, 15 mg tablet) 1

nabumetone 1

naproxen (250 mg tablet, 375 mg tablet, dr 375 mgtablet, 500 mg kit, 500 mg tablet, dr 500 mg tablet)

1

piroxicam 1

sulindac 1

tolmetin sodium 1 PA

SALICYLATES

butalbital-asa-caffeine cap 1 QL 6 CAPS / 1 DAY

salsalate 1

OXYTOCICSmethylergonovine 0.2 mg tablet 1



PARATHYROID AND ANTIPARATHYROID AGENTSANTIPARATHYROID AGENTS

calcitonin-salmon 200 units sp 1

cinacalcet hcl 1

SENSIPAR 2

PARATHYROID AGENTS

FORTEO 4PA

S

teriparatide 4PA

S

TYMLOS 4PA

S

PENICILLIN ANTIBIOTICSAMINOPENICILLIN ANTIBIOTICS

amoxicillin (125 mg tab chew, 125 mg/5 ml susp, 200mg/5 ml susp, 250 mg capsule, 250 mg tab chew, 250mg/5 ml susp, 400 mg/5 ml susp, 500 mg capsule, 500 mgtablet, 875 mg tablet)

1

amoxicillin-clavulanate potass (200-28.5 mg tab chew,200-28.5 mg/5 ml sus, 250-125 mg tablet, 250-62.5 mg/5ml sus, 400-57 mg tab chew, 400-57 mg/5 ml susp, 500-125 mg tablet, 600-42.9 mg/5 ml sus, 875-125 mg tablet)

1

ampicillin trihydrate 1

NATURAL PENICILLIN ANTIBIOTICSpenicillin v potassium (125 mg/5 ml soln, 250 mg tablet,250 mg/5 ml soln, 500 mg tablet)

1

PENICILLINASE-RESISTANT PENICILLINSdicloxacillin sodium 1

PHARMACEUTICAL AIDS

SHINGRIX ADJUVANT COMPONENT 2 QL 1 KIT / RX

VAXCHORA BUFFER COMPONENT 2



RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIBANGIOTENSIN II RECEPTOR ANTAGONISTS

candesartan cilexetil 1

ENTRESTO 2

irbesartan 1

irbesartan-hydrochlorothiazide 1

losartan potassium 1

losartan-hydrochlorothiazide 1

olmesartan medoxomil 1

olmesartan-hydrochlorothiazide 1

telmisartan 1

telmisartan-hydrochlorothiazid 1

valsartan 1

valsartan-hydrochlorothiazide 1

ANGIOTENSIN-CONVERTING ENZYME INHIBITORSbenazepril hcl 1

benazepril-hydrochlorothiazide 1

captopril 1

captopril-hydrochlorothiazide 1

enalapril maleate (2.5 mg tab, 5 mg tablet, 10 mg tab, 20mg tab)

1

enalapril-hydrochlorothiazide 1

fosinopril sodium 1

fosinopril-hydrochlorothiazide 1

lisinopril 1

lisinopril-hydrochlorothiazide 1

moexipril hcl 1

perindopril erbumine 1

quinapril hcl 1



quinapril-hydrochlorothiazide 1

ramipril 1

trandolapril 1

MINERALOCORTICOID (ALDOSTERONE) ANTAGNTSeplerenone 1

spironolactone 1

spironolactone-hctz 1

RESPIRATORY TRACT AGENTSANTIFIBROTIC AGENTS

ESBRIET 4PA

S

OFEV 4PA

S

ANTITUSSIVESbenzonatate (100 mg capsule, perle 100 mg cap, 200 mgcapsule)

1

codeine-guaifenesin 1

QL 60 ML / 1 DAY


AQ1 At least 18 yrs old;60 / 1 day(s)

guaifenesin-codeine 1 AQ1 At least 18 yrs old;60 / 1 day(s)

promethazine-dm 1

MUCOLYTIC AGENTSacetylcysteine (10% vial, 20% vial) 1

PULMOZYME 4

QL 150 ML / 30 DAYS

PA

S

PHOSPHODIESTERASE TYPE 4 INHIBITORS

DALIRESP 2 PA



VASODILATING AGENTS (RESPIRATORY TRACT)

ADEMPAS 4PA

S

ambrisentan 4PA

S

bosentan 4PA

S

epoprostenol sodium 4PA

S

FLOLAN 1.5 MG VIAL 4PA

S

OPSUMIT 4PA

S

TRACLEER 32 MG TABLET FOR SUSP 4PA

S

treprostinil 4PA

S

TYVASO 4PA

S

TYVASO REFILL KIT 4PA

S

TYVASO STARTER KIT 4PA

S

UPTRAVI (200 MCG TABLET, 200-800 TITRATION PACK,400 MCG TABLET, 600 MCG TABLET, 800 MCG TABLET,1,000 MCG TABLET, 1,200 MCG TABLET, 1,400 MCGTABLET, 1,600 MCG TABLET)

4PA

S

VENTAVIS 4PA

S



SKELETAL MUSCLE RELAXANTSCENTRALLY ACTING SKELETAL MUSCLE RELAXNT

chlorzoxazone 500 mg tablet 1

cyclobenzaprine hcl (5 mg tablet, 10 mg tablet) 1

methocarbamol (500 mg tablet, 750 mg tablet) 1

tizanidine hcl (2 mg tablet, 4 mg tablet) 1

DIRECT-ACTING SKELETAL MUSCLE RELAXANTSdantrolene sodium (25 mg cap, 50 mg cap, 100 mg cap) 1

GABA-DERIVATIVE SKELETAL MUSCLE RELAXANTbaclofen (5 mg tablet, 10 mg tablet, 20 mg tablet) 1

SKIN AND MUCOUS MEMBRANE AGENTSANTIPRURITICS AND LOCAL ANESTHETICS

lidocaine-prilocaine 1 QL 60 GM / 1 FILL

phenazopyridine hcl 1

ASTRINGENTSDRYSOL 2

CELL STIMULANTS AND PROLIFERANTSAVITA 1

tretinoin (0.01% gel, 0.025% cream, 0.025% gel, 0.05%cream, 0.1% cream)

1

KERATOLYTIC AGENTS

sod sulfacet-sulfur 10-5% clsr 1 QL 12 ML / 1 DAY

sodium sulfacetamide-sulfur (10-5% crm, sod lotn) 1

sss 10-5 cream 1

urea (cream, lotion) 1

SKIN AND MUCOUS MEMBRANE AGENTS, MISC.acitretin 1

adapalene (0.1% cream, 0.3% gel, 0.3% gel pump) 1 PA

adapalene 0.1% gel 1



AMNESTEEM 1

azelaic acid 1

calcipotriene (cream, ointment, solution) 1 QL 120 GM / 30 DAYS

CLARAVIS 1

COSENTYX (2 SYRINGES) 4PA

S

COSENTYX PEN 4PA

S

COSENTYX PEN (2 PENS) 4PA

S

COSENTYX SYRINGE 4PA

S

DIFFERIN 0.1% GEL 2

DUPIXENT 300 MG/2 ML PEN 4

QL 2 PENS / 28 DAYS

PA

S

DUPIXENT 300 MG/2 ML SYRINGE 4

QL 4 ML / 28 DAYS

PA

S

imiquimod 5% cream packet 1

isotretinoin (10 mg capsule, 20 mg capsule, 30 mgcapsule, 40 mg capsule)

1

MYORISAN 1

pimecrolimus 1

podofilox 1

SKYRIZI 4PA

S

SKYRIZI (2 SYRINGES) KIT 4PA

S



SKYRIZI PEN 4PA

S

tacrolimus (0.03% ointment, 0.1% ointment) 1

tazarotene 0.1% cream 1 QL 30 GM / 30 DAYS

ZENATANE 1

SMOOTH MUSCLE RELAXANTSRESPIRATORY SMOOTH MUSCLE RELAXANTS

theophylline (er 400 mg tablet, er 600 mg tablet) 1

theophylline anhydrous 1

SOMATOSTATIN AGONISTS AND ANTAGONISTSSOMATOSTATIN AGONISTS

BYNFEZIA 4PA

S

octreotide acetate (0.05 mg/ml vl, 50 mcg/ml amp, 50mcg/ml vial)

4QL 3 ML / 1 DAY

S

octreotide acetate (1,000 mcg/ml vial, 5,000 mcg/5 mlvial)

4QL 9 VIALS / 30 DAYS

S

octreotide acetate (100 mcg/ml amp, 100 mcg/ml vl) 4QL 5 ML / 1 DAY

S

octreotide acetate (50 mcg/ml syr, 100 mcg/ml syr, 500mcg/ml syr)

4 S

octreotide acetate (500 mcg/ml amp, 500 mcg/ml vl) 4QL 7 ML / DAY

S

octreotide acetate (acet 200 mcg/ml vl, 1,000 mcg/5 mlvial)

4QL 7.5 ML / 1 DAY

S

SANDOSTATIN LAR DEPOT (10 MG KT, 10 MG VL) 4QL 1 KIT / 28 DAYS

S

SANDOSTATIN LAR DEPOT (20 MG KT, 20 MG VL) 4QL 2 KITS / 28 DAYS

S



SANDOSTATIN LAR DEPOT (30 MG KT, 30 MG VL) 4QL 3 KITS / 28 DAYS

S

SIGNIFOR 4PA

S

SYMPATHOMIMETIC (ADRENERGIC) AGENTSALPHA- AND BETA-ADRENERGIC AGONISTS

epinephrine 0.15 mg auto-injct (teva) 1

epinephrine 0.15 mg auto-inject (generic for epi-pen jr /mylan)

1

epinephrine 0.3 mg auto-inject (generic for adrenaclick) 1

epinephrine 0.3 mg auto-inject (generic for epi-pen /mylan)

1

epinephrine 0.3 mg auto-inject (teva) 1

SYMJEPI 2

ALPHA-ADRENERGIC AGONISTSmidodrine hcl 1

TETRACYCLINE ANTIBIOTICSAMINOMETHYLCYCLINES

NUZYRA (150 MG TABLET, 150 MG TABLET-7 DAY, 150MG-7 DAY WITH LOAD)

2 PA

THYROID AND ANTITHYROID AGENTSANTITHYROID AGENTS

methimazole 1

propylthiouracil 1

THYROID AGENTSeuthyrox 1

levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcgtablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet,175 mcg tablet, 200 mcg tablet, 300 mcg tablet)

1

liothyronine sodium (5 mcg tab, 25 mcg tab, 50 mcg tab) 1

SYNTHROID 2



VASODILATING AGENTSNITRATES AND NITRITES

isosorbide dinitrate (5 mg tab, 10 mg tab, 20 mg tab, 30mg tab)

1

isosorbide mononitrate 1

isosorbide mononitrate er 1

NITRO-BID 2

nitroglycerin (0.3 mg tablet, 0.4 mg tablet, 0.6 mg tablet) 1

nitroglycerin patch 1

PHOSPHODIESTERASE TYPE 5 INHIBITORS

sildenafil 20 mg tablet (generic for revatio) 1 QL 1 TAB / 1 DAY

tadalafil (2.5 mg tablet, 5 mg tablet) 1QL 1 TAB / 1 DAY

PA

tadalafil 20 mg tablet (generic for adcirca) 1QL 2 TABS / 1 DAY

PA

VASODILATING AGENTS, MISCELLANEOUSaspirin-dipyridamole er 1

dipyridamole 1

VERQUVO 2 PA

VITAMINSMULTIVITAMIN PREPARATIONS

completenate 1

m-natal plus 1

mynatal plus 1

mynatal-z 1

O-CAL PRENATAL 1

pnv 29-1 1

PRENATA 2

PRENATABS FA 1



PRENATABS RX 1

prenatal plus (iron tablet, pnv multivit tab) 1

prenatal vitamin plus low iron 1

prenatal-u 1 PA

PRENATE ELITE 2 PA

preplus 1

PUREFE OB PLUS 1

se-natal 19 1

TRINATE 1

VINATE CARE 1

vinate one 1

vinate-m 1

VITAMIN B COMPLEXcyanocobalamin injection 1

folic acid 1 mg tablet 1

VITAMIN Dcalcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/mlsolution)

1

vitamin d2 1.25mg(50,000 unit) 1

VITAMIN K ACTIVITY

phytonadione 5 mg tablet 1 QL 3 TABS / 1 FILL


Index of Covered Drugs

Aabacavir 49abacavir-lamivudine 49abacavir-lamivudine-zidovudine 49abiraterone acetate 30acamprosate calcium 64acarbose 19acebutolol hcl 63acetaminophen-codeine 1acetazolamide 23acetazolamide er 23acetic acid 7acetylcysteine 98acitretin 100ACTEMRA 88ACTEMRA ACTPEN 88ACTHAR 67ACTHIB 52acyclovir 57ADACEL TDAP 51adapalene 100ADDERALL XR 4adefovir dipivoxil 57ADEMPAS 99adenovirus type 4 52adenovirus type 4 and type 7 52adenovirus type 7 52ADVAIR DISKUS 66ADVAIR HFA 66ADVATE 24ADYNOVATE 24AFINITOR 30AFINITOR DISPERZ 31AFIRMELLE 76AFLURIA QUAD 2019-20 (3YR UP) 52AFLURIA QUAD 2019-20 (6-35MO) 52AFLURIA QUAD 2019-2020 52AFLURIA QUAD 2020-2021 52AFLURIA QUAD 2020-21 (3YR UP) 52AFLURIA QUAD 2020-21 (6-35MO) 52

AFLURIA QUAD 2021-2022 52AFLURIA QUAD 2021-22 (3YR UP) 52AFLURIA QUAD 2021-22 (6-35MO) 52AFSTYLA 24AJOVY AUTOINJECTOR 28AJOVY SYRINGE 29albendazole 6albuterol sulfate 61alclometasone dipropionate 10ALECENSA 31alendronate sodium 86ALFERON N 56alfuzosin hcl er 1ALINIA 46ALLI 72allopurinol 86alogliptin 20alogliptin-metformin 20alogliptin-pioglitazone 20alosetron hcl 71ALPHANATE 24ALPHANINE SD 24alprazolam 58alprazolam er 58alprazolam xr 58ALPROLIX 24ALTAVERA 76ALYACEN 76AMABELZ 69amantadine 45ambrisentan 99AMETHIA 77AMETHIA LO 77amiloride hcl 67amiloride-hydrochlorothiazide 67amiodarone hcl 11amitriptyline hcl 19amlodipine besylate 62amlodipine besylate-benazepril 62amlodipine-olmesartan 62amlodipine-valsartan 62

amlodipine-valsartan-hctz 62ammonium lactate 69AMNESTEEM 101amoxicillin 96amoxicillin-clavulanate potass 96ampicillin trihydrate 96anagrelide hcl 51anastrozole 31ANORO ELLIPTA 13anucort-hc 10aprepitant 22APRI 77APTIOM 15APTIVUS 50ARANELLE 77ARANESP 61ARCALYST 93aripiprazole 47aripiprazole odt 47armodafinil 6ARNUITY ELLIPTA 66asenapine maleate 47ASHLYNA 77ASMANEX 66ASMANEX HFA 66aspirin-dipyridamole er 104ASTRAZENECA COVID19 VAC(UNAPP) 52atazanavir sulfate 50atenolol 63atenolol-chlorthalidone 63atomoxetine hcl 64atorvastatin calcium 28atovaquone 46atovaquone-proguanil hcl 46atropine sulfate 71ATROVENT HFA 13AUBAGIO 90AUBRA 77AUBRA EQ 77AUROVELA 77AUROVELA 24 FE 77

AUROVELA FE 77AUSTEDO 65AVIANE 77AVITA 100AVONEX 90,91AVONEX PEN 91AYUNA 77AYVAKIT 31azathioprine 93azelaic acid 101azelastine hcl 70azithromycin 85AZURETTE 77

Bbacitracin 6bacitracin-polymyxin 6baclofen 100BAFIERTAM 91balsalazide disodium 71BALVERSA 31BALZIVA 77BANZEL 15BAQSIMI 27BARACLUDE 57BEKYREE 77benazepril hcl 97benazepril-hydrochlorothiazide 97BENEFIX 24benznidazole 46benzonatate 98benztropine mesylate 45BERINERT 87BESIVANCE 6betamethasone diprop augmented 10betamethasone dipropionate 10betamethasone valerate 10BETASERON 91betaxolol hcl 23,63bethanechol chloride 60BEXSERO 52

bicalutamide 31BIKTARVY 49bimatoprost 24bisoprolol fumarate 64bisoprolol-hydrochlorothiazide 64BLEPHAMIDE S.O.P. 6BLISOVI 24 FE 77BLISOVI FE 77BOOSTRIX TDAP 51bosentan 99BOSULIF 31BRAFTOVI 32BREO ELLIPTA 66BRIELLYN 77BRILINTA 51brimonidine tartrate 23BRIVIACT 15bromfenac sodium 9bromocriptine mesylate 68BRUKINSA 32budesonide 66budesonide ec 75budesonide-formoterol fumarate 66bumetanide 67buprenorphine 3buprenorphine-naloxone 3bupropion hcl 18bupropion hcl sr 18bupropion xl 18buspirone hcl 57butalbital-acetaminophen 1butalbital-acetaminophen-caffe 1butalbital-aspirin-caffeine 95BYDUREON BCISE 20BYDUREON PEN 20BYETTA 20BYNFEZIA 102

Ccabergoline 68CABLIVI 51

CABOMETYX 32calcipotriene 101calcitonin-salmon 96calcitriol 105calcium acetate 85CAMILA 77CAMRESE 77CAMRESE LO 77candesartan cilexetil 97capecitabine 32CAPLYTA 47CAPRELSA 32captopril 97captopril-hydrochlorothiazide 97CARBAGLU 68carbamazepine 15carbamazepine er 15carbidopa-levodopa 46carbidopa-levodopa er 46carbidopa-levodopa-entacapone 46carteolol hcl 23CARTIA XT 62carvedilol 64CAYSTON 86CAZIANT 77cefadroxil 65cefdinir 66cefixime 66cefpodoxime proxetil 66cefprozil 66cefuroxime 66celecoxib 95cephalexin 65CERDELGA 93cevimeline hcl 60CHANTIX 59CHATEAL 77CHATEAL EQ 77CHEMET 75chlordiazepoxide hcl 58chlorhexidine gluconate 7

chloroquine phosphate 46chlorpromazine hcl 48chlorthalidone 68chlorzoxazone 100CHOLBAM 72cholestyramine 27cholestyramine light 27ciclopirox 23cilostazol 51CILOXAN 6cimetidine 55CIMZIA 88cinacalcet hcl 96CINRYZE 87CIPRO 12CIPRO HC 6ciprofloxacin 12ciprofloxacin hcl 6,12ciprofloxacin-dexamethasone 7citalopram hbr 18CLARAVIS 101clarithromycin 85CLEOCIN 7clindamycin (pediatric) 13clindamycin hcl 13clindamycin ph 1% gel (generic for cleocin t) 8clindamycin phos-benzoyl perox 7clindamycin phosphate 8clindamycin-benzoyl peroxide 8clobazam 17clobetasol emollient 10clobetasol propionate 10clomipramine hcl 19clonazepam 17clonidine 83clonidine hcl 83clopidogrel 51clotrimazole 23clotrimazole-betamethasone 23clozapine 47clozapine odt 47

COAGADEX 25codeine sulfate 1codeine-guaifenesin 98colchicine 86colestipol hcl 27COMBIVENT RESPIMAT 13COMETRIQ 32,33COMIRNATY 52COMPLERA 49completenate 104CONCERTA 5COPIKTRA 33CORIFACT 25CORLANOR 63COSENTYX (2 SYRINGES) 101COSENTYX PEN 101COSENTYX PEN (2 PENS) 101COSENTYX SYRINGE 101COTELLIC 33CREON 72CRESEMBA 22cromolyn sodium 10CRYSELLE 78CUVPOSA 13cyanocobalamin injection 105CYCLAFEM 78cyclobenzaprine hcl 100cyclopentolate hcl 71CYCLOPHOSPHAMIDE 33cycloserine 30CYCLOSET 68cyclosporine 93cyclosporine modified 93cyproheptadine hcl 71CYRED 78CYRED EQ 78CYSTADROPS 70CYSTAGON 93CYSTARAN 70

DD-PENAMINE 75dalfampridine er 93DALIRESP 98danazol 76dantrolene sodium 100dapsone 30DAPTACEL DTAP 51DASETTA 78DAURISMO 33DAYSEE 78DEBLITANE 78deferasirox 75deferiprone 75demeclocycline hcl 12DENGVAXIA 52denta 5000 plus 86dentagel 86dermazene 8DESCOVY 49desipramine hcl 19desmopressin acetate 83desogestr-eth estrad eth estra 78desogestrel-ethinyl estradiol 78desonide 10desoximetasone 10desvenlafaxine suc er 100 mg tablet (generic forpristiq) 18desvenlafaxine suc er 25 mg tablet (generic forpristiq) 18desvenlafaxine suc er 50 mg tablet (generic forpristiq) 18dexamethasone 75DEXAMETHASONE INTENSOL 75dexamethasone sodium phosphate 9,75dexmethylphenidate hcl 5dexmethylphenidate hcl er 5dextroamp-amphetamin 15 mg tab (genericadderall) 4

dextroamp-amphetamin 20 mg tab (genericadderall) 4dextroamphetamine sulfate 4dextroamphetamine sulfate er 4dextroamphetamine-amphetamine 4DIACOMIT 15diazepam 58diclofenac potassium 95diclofenac sodium 9,95diclofenac sodium er 95dicloxacillin sodium 96dicyclomine hcl 13DIFFERIN 101DIFICID 85DIGITEK 63DIGOX 63digoxin 63DILANTIN 18DILT-XR 62diltiazem 24hr er 62diltiazem 24hr er (cd) 62diltiazem 24hr er (xr) 62diltiazem hcl 62dimethyl fumarate 91diphenoxylate-atropine 72diphtheria-tetanus toxoids-ped 52dipyridamole 104disopyramide phosphate 11disulfiram 86divalproex sodium 16divalproex sodium er 16dofetilide 11DOJOLVI 68donepezil hcl 60donepezil hcl odt 60dorzolamide hcl 23dorzolamide-timolol 24DOTTI 70doxazosin mesylate 63doxepin hcl 19doxycycline hyclate 7,12

doxycycline monohydrate 12dronabinol 21,22drospirenone-ethinyl estradiol 78DRYSOL 100DULERA 66duloxetine hcl 18DUPIXENT PEN 9,101DUPIXENT SYRINGE 9,101dutasteride 86

Eeconazole nitrate 23ed-spaz 13EDURANT 49efavirenz 49efavirenz-emtric-tenofov disop 49eletriptan hbr 29ELINEST 78ELIQUIS 14ELLA 78ELMIRON 94ELOCTATE 25ELURYNG 78EMCYT 33EMEND 22EMGALITY PEN 29EMGALITY SYRINGE 29EMOQUETTE 78emtricitabine 49emtricitabine-tenofovir disop 50enalapril maleate 97enalapril-hydrochlorothiazide 97ENBREL 88ENBREL MINI 88ENBREL SURECLICK 88ENDARI 72ENDOCET 1ENGERIX-B ADULT 52ENGERIX-B PEDIATRIC-ADOLESCENT 52enoxaparin sodium 14,15ENPRESSE 78

ENSKYCE 78ENSPRYNG 91entacapone 46entecavir 57ENTRESTO 97ENULOSE 68EPCLUSA 74EPIDIOLEX 16epinastine hcl 70epinephrine 0.15 mg auto-injct (teva) 103epinephrine 0.15 mg auto-inject (generic for epi-pen jr / mylan) 103epinephrine 0.3 mg auto-inject (generic foradrenaclick) 103epinephrine 0.3 mg auto-inject (generic for epi-pen / mylan) 103epinephrine 0.3 mg auto-inject (teva) 103EPIVIR HBV 50eplerenone 98epoprostenol sodium 99ergoloid mesylates 1ERIVEDGE 33ERLEADA 33erlotinib hcl 34ERRIN 78erythromycin 7,8erythromycin-benzoyl peroxide 8ESBRIET 98escitalopram oxalate 18esomeprazole magnesium 56ESPEROCT 25ESTARYLLA 78estradiol 70estradiol (once weekly) 70estradiol (twice weekly) 70estradiol-norethindrone acetat 70eszopiclone 57ethambutol hcl 30ethosuximide 18ethynodiol-ethinyl estradiol 78etidronate disodium 86

etodolac 95etodolac er 95etonogestrel-ethinyl estradiol 78etoposide 34etravirine 49EUCRISA 10euthyrox 103everolimus 34EVOTAZ 50EVRYSDI 93exemestane 34EXKIVITY 34ezetimibe 28

FFALMINA 78famciclovir 57famotidine 56FANAPT 47FASENRA PEN 9febuxostat 86FEIBA NF 25felbamate 16felodipine er 62FEMYNOR 78fenofibrate 28fentanyl 1FERRIPROX 75FERRIPROX (2 TIMES A DAY) 75FERRIPROX (3 TIMES A DAY) 75FETZIMA 18finasteride 86FINTEPLA 16FIRAZYR 87flecainide acetate 11FLOLAN 99FLOVENT DISKUS 66FLOVENT HFA 66FLUAD 2019-2020 52FLUAD 2020-2021 53FLUAD QUAD 2020-2021 53

FLUAD QUAD 2021-2022 53FLUARIX QUAD 2019-2020 53FLUARIX QUAD 2020-2021 53FLUARIX QUAD 2021-2022 53FLUBLOK QUAD 2019-2020 53FLUBLOK QUAD 2020-2021 53FLUBLOK QUAD 2021-2022 53FLUCELVAX QUAD 2019-2020 53FLUCELVAX QUAD 2020-2021 53FLUCELVAX QUAD 2021-2022 53fluconazole 22fludrocortisone acetate 75FLULAVAL QUAD 2019-2020 53FLULAVAL QUAD 2020-2021 53FLULAVAL QUAD 2021-2022 53FLUMIST QUAD 2019-2020 53FLUMIST QUAD 2020-2021 53FLUMIST QUAD 2021-2022 53flunisolide 9fluocinolone acetonide 10fluocinolone acetonide oil 9fluocinonide 10fluocinonide-e 10fluoride 86fluoritab 87fluorometholone 9fluorouracil 35fluoxetine hcl 19fluphenazine hcl 48flura-drops 87flurbiprofen 95flurbiprofen sodium 9flutamide 35fluticasone propionate 9,10fluticasone-salmeterol 113-14 (generic for airduorespiclick) 66fluticasone-salmeterol 232-14 (generic for airduorespiclick) 66fluticasone-salmeterol 55-14 (generic for airduorespiclick) 67fluvoxamine maleate 19

FLUZONE HIGH-DOSE 2019-2020 53FLUZONE HIGH-DOSE QUAD 2020-21 53FLUZONE HIGH-DOSE QUAD 2021-22 53FLUZONE QUAD 2019-2020 53FLUZONE QUAD 2020-2021 53FLUZONE QUAD 2021-2022 53FLUZONE QUAD PEDI 2019-2020 54FLUZONE QUAD SOUTHERN HEM 2020 54FLUZONE QUAD SOUTHERN HEM 2021 54FML S.O.P. 9folic acid 105fondaparinux sodium 14FORTEO 96fosamprenavir calcium 50fosfomycin tromethamine 6fosinopril sodium 97fosinopril-hydrochlorothiazide 97FOTIVDA 35FULPHILA 61furosemide 67FUZEON 49FYAVOLV 70FYCOMPA 16

Ggabapentin 16GALAFOLD 93galantamine er 60galantamine hbr 60galantamine hydrobromide 60GARDASIL 9 54GAVILYTE-C 72GAVILYTE-G 72GAVILYTE-N 72GAVRETO 35gemfibrozil 28GENERLAC 68GENGRAF 93gentamicin sulfate 8GENVOYA 50GIANVI 78

GILENYA 91GILOTRIF 35GIMOTI 73glatiramer acetate 91GLATOPA 91GLEOSTINE 35glimepiride 21glipizide 21glipizide er 21glipizide xl 21glipizide-metformin 21glucagon 1 mg emergency kit 27glucagon 1 mg emergency kit (genericglucagen) 27glucagon 1 mg emergency kit (Lilly) 27GLUCAGON 1 MG VIAL 27glyburide 21glyburide micronized 21glyburide-metformin hcl 21glycopyrrolate 13GLYXAMBI 20GRANIX 61GRASTEK 51griseofulvin 22griseofulvin ultramicrosize 22guaifenesin-codeine 98guanfacine hcl 83guanfacine hcl er 64GVOKE HYPOPEN 1-PACK 27GVOKE HYPOPEN 2-PACK 27GVOKE PFS 1-PACK SYRINGE 27GVOKE PFS 2-PACK SYRINGE 27

HHAEGARDA 87HAILEY 78HAILEY FE 79haloperidol 48haloperidol lactate 48HARVONI 74HAVRIX 54

HEATHER 79HEMLIBRA 25HEMOFIL M 25heparin sodium 15HEPLISAV-B 54HIBERIX 54homatropaire 71homatropine hydrobromide 71HUMALOG 84HUMALOG JUNIOR KWIKPEN 84HUMALOG KWIKPEN U-100 84HUMALOG KWIKPEN U-200 84HUMALOG MIX 50-50 85HUMALOG MIX 50-50 KWIKPEN 85HUMALOG MIX 75-25 85HUMALOG MIX 75-25 KWIKPEN 85HUMATE-P 25HUMIRA 88HUMIRA PEN 89HUMIRA PEN CROHN'S-UC-HS 89HUMIRA PEN PSOR-UVEITS-ADOL HS 89HUMIRA(CF) 89HUMIRA(CF) PEDIATRIC CROHN'S 73,89HUMIRA(CF) PEN 89HUMIRA(CF) PEN CROHN'S-UC-HS 89HUMIRA(CF) PEN PEDIATRIC UC 89HUMIRA(CF) PEN PSOR-UV-ADOL HS 89HUMULIN 70-30 84HUMULIN 70/30 KWIKPEN 84HUMULIN N 84HUMULIN N KWIKPEN 84HUMULIN R 85HUMULIN R U-500 85HUMULIN R U-500 KWIKPEN 85HYCAMTIN 35hydralazine hcl 84hydrochlorothiazide 68hydrocodone-acetaminophen 1,2hydrocodone-ibuprofen 2hydrocortisone 10,75hydrocortisone acetate 11

hydrocortisone butyrate 11hydrocortisone valerate 11hydrocortisone-iodoquinol 8hydrocortisone-pramoxine 11hydromorphone hcl 2hydroxychloroquine sulfate 46hydroxyprogesterone caproate 83hydroxyurea 35hydroxyzine hcl 57hydroxyzine pamoate 58hyoscyamine sulfate 13hyoscyamine sulfate er 13hyoscyamine sulfate sr 13hyosyne 14

Iibandronate sodium 86IBRANCE 35ibuprofen 95ICLEVIA 79ICLUSIG 35,36icosapent ethyl 27IDELVION 25IDHIFA 36ILARIS 93imatinib mesylate 36IMBRUVICA 36imipramine hcl 19imiquimod 101INBRIJA 46INCASSIA 79INCRUSE ELLIPTA 14indapamide 68indomethacin 95INFANRIX DTAP 52INGREZZA 65INGREZZA INITIATION PACK 65INLYTA 36INQOVI 37INREBIC 37insulin lispro 85

insulin lispro junior kwikpen 85insulin lispro kwikpen u-100 85insulin lispro protamine mix 85INTELENCE 49INTRON A 56INTROVALE 79INVIRASE 50INVOKAMET 20INVOKAMET XR 20INVOKANA 21IPOL 54ipratropium bromide 14,70ipratropium-albuterol 14irbesartan 97irbesartan-hydrochlorothiazide 97IRESSA 37ISENTRESS 49ISENTRESS HD 49ISIBLOOM 79isoniazid 30isosorbide dinitrate 104isosorbide mononitrate 104isosorbide mononitrate er 104isotretinoin 101ISTURISA 94itraconazole 22ivermectin 6IXINITY 25

JJAIMIESS 79JAKAFI 37JANSSEN COVID-19 VACCINE (EUA) 54jantoven 14JARDIANCE 21JASMIEL 79JENCYCLA 79JENTADUETO 20JENTADUETO XR 20JINTELI 70JIVI 25

JOLESSA 79JULEBER 79JULUCA 49JUNEL 79JUNEL FE 79JUXTAPID 27

KKALBITOR 87KALETRA 50KALLIGA 79KALYDECO 67KARIVA 79KELNOR 1-35 79KELNOR 1-50 79KESIMPTA PEN 91ketoconazole 22,23ketorolac tromethamine 9,95KINERET 90KINRIX 54KISQALI 37KISQALI FEMARA CO-PACK 37,38KLOR-CON M10 69KLOR-CON M15 69KLOR-CON M20 69KLOXXADO 65KOATE 25KOGENATE FS 25KOSELUGO 38KOVALTRY 25KURVELO 79

Llabetalol hcl 64lactulose 68lamivudine 50lamivudine hbv 50lamivudine-zidovudine 50lamotrigine 16LAMPIT 46lansoprazole 56

LANTUS 84LANTUS SOLOSTAR 84lapatinib 38LARIN 79LARIN FE 79LARISSIA 79latanoprost 24LATUDA 47ledipasvir-sofosbuvir 74LEENA 79leflunomide 90LESSINA 79letrozole 38leucovorin calcium 86LEUKERAN 38levalbuterol tartrate hfa 61LEVEMIR 84LEVEMIR FLEXTOUCH 84levetiracetam 16levetiracetam er 16levobunolol hcl 23levocarnitine 68,94levocarnitine sf 94levofloxacin 12LEVONEST 79levonorg-eth estrad eth estrad 80levonorgestrel 80levonorgestrel-eth estradiol 80LEVORA-28 80levothyroxine sodium 103LEXIVA 50lidocaine hcl 71lidocaine hcl viscous 71lidocaine-prilocaine 100LILLOW 80linezolid 13LINZESS 73liothyronine sodium 103lisinopril 97lisinopril-hydrochlorothiazide 97lithium 64

lithium carbonate 64lithium carbonate er 64LO-ZUMANDIMINE 80LOJAIMIESS 80LOMAIRA 4LONSURF 38lopinavir-ritonavir 50LOPREEZA 70lorazepam 58,59LORAZEPAM INTENSOL 59LORBRENA 38,39LORCET 2LORCET HD 2LORCET PLUS 2LORYNA 80losartan potassium 97losartan-hydrochlorothiazide 97loteprednol etabonate 9lovastatin 28LOW-OGESTREL 80loxapine 47lubiprostone 72ludent fluoride 87LUMAKRAS 39LUMIGAN 24LUTERA 80LYBALVI 47LYNPARZA 39LYSODREN 39LYZA 80

MM-M-R II VACCINE 54m-natal plus 104MAKENA 83malathion 8MARLISSA 80MATULANE 39MATZIM LA 62MAVENCLAD 93MAVYRET 74

MAYZENT 91,92MEDROL 75medroxyprogesterone acetate 83mefloquine hcl 46megestrol acetate 83MEKINIST 39MEKTOVI 39meloxicam 95melphalan 39memantine hcl 65MENACTRA 54MENQUADFI 54MENVEO A-C-Y-W-135-DIP 54MENVEO MENA COMPONENT 54MENVEO MENCYW-135 COMPONENT 54mercaptopurine 39mesalamine 71mesalamine dr 72mesalamine er 72METADATE ER 5metformin hcl 19metformin hcl 1,000 mg tablet (generic forglucophage) 19metformin hcl 500 mg tablet (generic forglucophage) 19metformin hcl er 19methadone hcl 2METHADONE INTENSOL 2METHADOSE 2methazolamide 24methimazole 103methocarbamol 100methotrexate 40methotrexate sodium 40methyldopa 84methylergonovine maleate 95methylphenidate er 5methylphenidate er (la) 5methylphenidate hcl 5methylphenidate hcl cd 5methylphenidate hcl er (cd) 5

methylphenidate la 5methylprednisolone 75methyltestosterone 76metoclopramide hcl 73metoclopramide hcl odt 73metolazone 68metoprolol succinate 64metoprolol tartrate 64metoprolol-hydrochlorothiazide 64metronidazole 8,46mexiletine hcl 11MICROGESTIN 80MICROGESTIN FE 80midodrine hcl 103miglitol 19miglustat 94MILI 80MILLIPRED 76MIMVEY LO 70minocycline hcl 12minoxidil 84mirtazapine 18misoprostol 56modafinil 6MODERNA COVID-19 VACCINE (EUA) 54moexipril hcl 97mometasone furoate 11MONDOXYNE NL 12MONO-LINYAH 80MONONINE 26montelukast sodium 10morphine sulfate 2morphine sulfate er 2MORPHINE SULFATE IR 15 MG TAB (BRAND) 2MORPHINE SULFATE IR 30 MG TAB (BRAND) 2MOVANTIK 73moxifloxacin 7moxifloxacin hcl 12MULTAQ 11mupirocin 8MY WAY 80

mycophenolate mofetil 93mycophenolic acid 93MYFEMBREE 73MYLERAN 40mynatal plus 104mynatal-z 104MYORISAN 101MYRBETRIQ 61

Nnabumetone 95nadolol 64naloxone hcl 65naltrexone hcl 65naproxen 95naratriptan hcl 29NARCAN 65nateglinide 20NAYZILAM 17NECON 80nefazodone hcl 19neomycin sulfate 12neomycin-bacitracin-polymyxin 7neomycin-polymyxin-dexameth 7neomycin-polymyxin-gramicidin 7neomycin-polymyxin-hc 7neomycin-polymyxin-hydrocort 7NERLYNX 40NEUPRO 68nevirapine 49nevirapine er 49NEXAVAR 40nicotine gum 59nicotine lozenge 59nicotine patch 60NICOTROL 60NICOTROL NS 60nifedipine 63nifedipine er 63NIKKI 80nimodipine 63

NINLARO 40nitazoxanide 46NITRO-BID 104nitrofurantoin 6nitrofurantoin mono-macro 6nitroglycerin 104nitroglycerin patch 104NORA-BE 80norethindron-ethinyl estradiol 70,80norethindrone 80norethindrone ac (lupaneta) 83norethindrone acetate 83norethindrone-e.estradiol-iron 80norgestimate-ethinyl estradiol 81NORLYDA 81NORPACE CR 11NORTREL 81nortriptyline hcl 19NORVIR 50NOURIANZ 65NOVAVAX COVID19 VAC,ADJ(UNAPP) 54NOVOEIGHT 26novolin 70-30 flexpen 84NOVOSEVEN RT 26NUBEQA 40NUCALA 10NUPLAZID 47NURTEC ODT 29NUWIQ 26NUZYRA 103NYMYO 81nystatin 22,23NYVEPRIA 61

OO-CAL PRENATAL 104OBIZUR 26OCELLA 81octreotide acetate 102ODACTRA 51ODEFSEY 50

ODOMZO 40OFEV 98ofloxacin 7OGESTREL 81olanzapine 47olanzapine odt 47olmesartan medoxomil 97olmesartan-hydrochlorothiazide 97olopatadine hcl 70OLUMIANT 90omega-3 acid ethyl esters 27omeprazole 56ondansetron hcl 21ondansetron odt 21ONUREG 40OPSUMIT 99ORENCIA 90ORENCIA CLICKJECT 90ORGOVYX 74ORIAHNN 74ORILISSA 74ORKAMBI 67ORLADEYO 87ORSYTHIA 81oscimin 14oscimin sl 14oscimin sr 14oseltamivir phosphate 57OTEZLA 90oxandrolone 76OXBRYTA 61oxcarbazepine 16OXERVATE 70oxybutynin chloride 73oxybutynin chloride er 73oxycodone hcl 3oxycodone hcl er 3oxycodone hcl-aspirin 3oxycodone-acetaminophen 3OXYCONTIN 3OZEMPIC 20

PPACERONE 11PALFORZIA 51paliperidone er 47pantoprazole sodium 56paregoric 72PAROEX 7paroxetine hcl 19PEDIARIX 54PEDVAXHIB 54peg 3350-electrolyte 72PEGASYS 56PEGASYS PROCLICK 57PEGINTRON 57PEMAZYRE 40penicillamine 75penicillin v potassium 96PENTACEL 54PENTACEL ACTHIB COMPONENT 54PENTACEL DTAP-IPV COMPONENT 54pentoxifylline 62perindopril erbumine 97PERIOGARD 7permethrin 8perphenazine 48PFIZER COVID(12Y UP) VAC(UNAP) 54PFIZER COVID(5-11Y) VAC(UNAPP) 54PFIZER COVID-19 VACCINE (EUA) 54PHENADOZ 71phenazopyridine hcl 100phenelzine sulfate 18phenobarbital 58phenoxybenzamine hcl 1phentermine hcl 4phenylephrine hcl 71phenytoin 18phenytoin sodium extended 18PHILITH 81PHOSLYRA 85phytonadione 105

PICATO 41pilocarpine hcl 24,60pimecrolimus 101PIMTREA 81pioglitazone hcl 21pioglitazone-glimepiride 21pioglitazone-metformin 21PIRMELLA 81piroxicam 95PLEGRIDY 92PLEGRIDY PEN 92PNEUMOVAX 23 55pnv 29-1 104podofilox 101polymyxin b sul-trimethoprim 7POMALYST 41PORTIA 81posaconazole 22potassium chloride 69potassium citrate er 68PRADAXA 14pramipexole dihydrochloride 68prasugrel hcl 51pravastatin sodium 28praziquantel 6prazosin hcl 63prednisolone 76prednisolone ac 1% eye drop (generic predforte) 9prednisolone sodium phosphate 9,76prednisone 76PREDNISONE INTENSOL 76pregabalin 16PREMARIN 70PREMPRO 70PRENATA 104PRENATABS FA 104PRENATABS RX 105prenatal plus 105prenatal vitamin plus low iron 105prenatal-u 105

PRENATE ELITE 105preplus 105pretomanid 30PREVALITE 27PREVIFEM 81PREVNAR 13 55PREVNAR 20 55PREVYMIS 56PREZCOBIX 51PREZISTA 51PRIFTIN 30primidone 17probenecid 69probenecid-colchicine 69prochlorperazine 22prochlorperazine maleate 22PROCTO-MED HC 11PROCTOSOL-HC 11PROCTOZONE-HC 11PROFILNINE 26progesterone 83PROMACTA 61promethazine hcl 71promethazine vc 71promethazine-dm 98promethazine-phenylephrine 71PROMETHEGAN 71propafenone hcl 11propantheline bromide 14propranolol hcl 64propranolol hcl er 64propranolol-hydrochlorothiazid 64propylthiouracil 103PROQUAD 55PULMICORT FLEXHALER 67PULMOZYME 98PUREFE OB PLUS 105pyrazinamide 30pyridostigmine bromide 60pyridostigmine bromide er 60

QQINLOCK 41QUADRACEL DTAP-IPV 55quetiapine fumarate 47quetiapine fumarate er 47QUILLICHEW ER 5QUILLIVANT XR 5quinapril hcl 97quinapril-hydrochlorothiazide 98quinidine sulfate 11QVAR REDIHALER 67

Rrabeprazole sodium 56RAGWITEK 51raloxifene hcl 69ramelteon 58ramipril 98rasagiline mesylate 46RASUVO 41REBIF 92REBIF REBIDOSE 92REBINYN 26RECLIPSEN 81RECOMBINATE 26RECOMBIVAX HB 55REDITREX 92RELENZA 57relion novolin 70-30 vial 84relion novolin n 100 unit/ml 84relion novolin n u-100 flexpen 84relion novolin r 100 unit/ml 85relion novolin r u-100 flexpen 85repaglinide 20REPATHA PUSHTRONEX 28REPATHA SURECLICK 28REPATHA SYRINGE 28RESTASIS 9RESTASIS MULTIDOSE 9RETACRIT 62

RETEVMO 41REVCOVI 69REVLIMID 41REXULTI 48REYATAZ 51REYVOW 29REZUROCK 94RHOPRESSA 24ribavirin 57RIDAURA 73rifabutin 30rifampin 30riluzole 65rimantadine hcl 56RINVOQ 90risperidone 48risperidone odt 48ritonavir 51rivastigmine 60RIXUBIS 26rizatriptan 29ROCKLATAN 24ropinirole hcl 68ROSADAN 8rosuvastatin calcium 28ROTARIX 55ROTATEQ 55ROZLYTREK 41RUCONEST 87rufinamide 16,17RUKOBIA 49RUZURGI 94RYBELSUS 20RYDAPT 41RYTARY 46

Ssalsalate 95SANDOSTATIN LAR DEPOT 102,103sapropterin dihydrochloride 94scopolamine 22

se-natal 19 105SECUADO 48selegiline hcl 46selenium sulfide 8SELZENTRY 49SENSIPAR 96SEREVENT DISKUS 61sertraline hcl 19SETLAKIN 81sevelamer carbonate 85SEVENFACT 26sf 87sf 5000 plus 87SHAROBEL 81SHINGRIX 55SHINGRIX ADJUVANT COMPONENT 96SHINGRIX GE ANTIGEN COMPONENT 55SIGNIFOR 103sildenafil 20 mg tablet (generic for revatio) 104silver sulfadiazine 8SIMLIYA 81SIMPESSE 81simvastatin 28sirolimus 93SIRTURO 30SIVEXTRO 13SKYRIZI 101SKYRIZI (2 SYRINGES) KIT 101SKYRIZI PEN 102sodium fluoride 87sodium phenylbutyrate 68sodium polystyrene sulfonate 85sodium sulfacetamide-sulfur 8,100sofosbuvir-velpatasvir 74solifenacin succinate 73SOLIQUA 100-33 84SOLTAMOX 69SOLU-CORTEF 76sotalol 64SOTALOL AF 64SOVALDI 74

spironolactone 98spironolactone-hctz 98SPRINTEC 81SPRYCEL 41SRONYX 81SSD 8sss 10-5 100STIMATE 83STIVARGA 42STRENSIQ 69STRIBILD 50STRIVERDI RESPIMAT 61SUBVENITE 17SUCRAID 69sucralfate 56sulfacetamide sodium 7,8sulfacetamide-prednisolone 7sulfamethoxazole-trimethoprim 12sulfasalazine 12sulfasalazine dr 12SULFATRIM 12sulindac 95sumatriptan 29sumatriptan succinate 29sunitinib malate 42SUNOSI 6SUPREP 72SYEDA 81SYLATRON 57symax-sr 14SYMDEKO 67SYMJEPI 103SYMPROIC 73SYMTUZA 51SYNJARDY 21SYNJARDY XR 21SYNTHROID 103

TTABLOID 42TABRECTA 42

tacrolimus 93,102tadalafil 104tadalafil 20 mg tablet (generic for adcirca) 104TAFINLAR 42TAGRISSO 42TAKHZYRO 87TALICIA 55tamoxifen citrate 69tamsulosin hcl 1TARINA 24 FE 81TARINA FE 81TARINA FE 1-20 EQ 81TASIGNA 42tazarotene 102TAZTIA XT 62TAZVERIK 42tdvax 52telmisartan 97telmisartan-hydrochlorothiazid 97temazepam 59temozolomide 42TENCON 1TENIVAC 52tenofovir disoproxil fumarate 50TEPMETKO 43terazosin hcl 63terbinafine hcl 22terconazole 23teriparatide 96testosterone 76testosterone cypionate 76testosterone enanthate 76testosterone propionate 76tetrabenazine 65THALOMID 92theophylline 102theophylline anhydrous 102THIOLA 94THIOLA EC 94thioridazine hcl 48thiothixene 48

TIADYLT ER 62tiagabine hcl 17TIBSOVO 43TILIA FE 81timolol maleate 23,64timolol maleate 0.25% eye drop (generic fortimoptic) 23timolol maleate 0.5% eye drops (generic fortimoptic) 23tiopronin 94TIVICAY 49TIVICAY PD 49tizanidine hcl 100TOBRADEX 7tobramycin 7,12tobramycin-dexamethasone 7TOBREX 7TODAY CONTRACEPTIVE SPONGE 94tolmetin sodium 95tolterodine tartrate 73tolterodine tartrate er 73topiramate 17torsemide 67TOUJEO MAX SOLOSTAR 84TOUJEO SOLOSTAR 84TPOXX (NATIONAL STOCKPILE) 56TRACLEER 99TRADJENTA 20tramadol hcl 3tramadol hcl-acetaminophen 3trandolapril 98tranexamic acid 26tranylcypromine sulfate 18travoprost 24trazodone hcl 19TRECATOR 30TRELEGY ELLIPTA 67treprostinil 99tretinoin 43,100TRETTEN 26TRI FEMYNOR 82

TRI-ESTARYLLA 82TRI-LEGEST FE 82TRI-LINYAH 82TRI-LO-ESTARYLLA 82TRI-LO-MARZIA 82TRI-LO-MILI 82TRI-LO-SPRINTEC 82TRI-MILI 82TRI-PREVIFEM 82TRI-SPRINTEC 82TRI-VYLIBRA 82TRI-VYLIBRA LO 82triamcinolone acetonide 11triamterene-hydrochlorothiazid 67TRIDERM 11trifluoperazine hcl 48trifluridine 7trihexyphenidyl hcl 45TRIJARDY XR 21TRIKAFTA 67TRIKLO 27TRILYTE WITH FLAVOR PACKETS 72trimethobenzamide hcl 22trimethoprim 6TRINATE 105TRINTELLIX 19TRIUMEQ 50TRIVORA-28 82trospium chloride 73TRULICITY 20TRUMENBA 55TRUSELTIQ 43TRUVADA 50TULANA 82TURALIO 43TWINRIX 55TYBLUME 82TYBOST 94TYMLOS 96TYVASO 99TYVASO REFILL KIT 99

TYVASO STARTER KIT 99

UUDENYCA 62UKONIQ 43UPTRAVI 99urea 100ursodiol 72

Vvalacyclovir 57VALCHLOR 43valganciclovir hcl 57valproic acid 17valsartan 97valsartan-hydrochlorothiazide 97VALTOCO 59vancomycin hcl 13VAQTA 55varenicline tartrate 60VARIVAX VACCINE 55VASCEPA 27VAXCHORA ACTIVE COMPONENT 55VAXCHORA BUFFER COMPONENT 96VAXCHORA VACCINE 55VAXELIS 52VAXNEUVANCE 55vcf 94VELIVET 82VEMLIDY 57venlafaxine hcl 18venlafaxine hcl er 18VENTAVIS 99VENTOLIN HFA 61verapamil er 62verapamil hcl 62verapamil sr 62VERQUVO 104VERSACLOZ 48VERZENIO 43VESTURA 82

VICTOZA 2-PAK 20VICTOZA 3-PAK 20VIENVA 82vigabatrin 17VIGADRONE 17VIIBRYD 19VIMPAT 17VINATE CARE 105vinate one 105vinate-m 105VIORELE 82VIREAD 50VISTOGARD 86vitamin d2 105VITRAKVI 43,44VIVOTIF 55VIZIMPRO 44VOCABRIA 49VOLNEA 82VONVENDI 26voriconazole 22VOSEVI 74VOTRIENT 44VRAYLAR 48VUMERITY 92VYFEMLA 82VYLIBRA 82VYNDAMAX 63VYNDAQEL 63VYVANSE 4

WWAKIX 6warfarin sodium 14WELIREG 44WERA 82WILATE 26

XXALKORI 44XARELTO 14

XENICAL 73XENLETA 13XERMELO 72XIFAXAN 13XOSPATA 44XPOVIO 44XTANDI 45XULANE 83XULTOPHY 100-3.6 84XYNTHA 26XYNTHA SOLOFUSE 27XYREM 65XYWAV 65

YYUVAFEM 70

Zzaleplon 58ZARAH 83ZEBUTAL 1ZEGALOGUE AUTOINJECTOR 27ZEGALOGUE SYRINGE 27ZEJULA 45ZELBORAF 45ZENATANE 102ZENZEDI 4ZEPOSIA 92zidovudine 50ZIEXTENZO 62ZIOPTAN 24ziprasidone hcl 48ZIRGAN 7ZOKINVY 94ZOLINZA 45zolmitriptan 29zolmitriptan odt 29zolpidem tartrate 58zonisamide 17ZONTIVITY 51ZOSTAVAX 55

ZOVIA 1-35 83ZOVIA 1-35E 83ZUMANDIMINE 83ZYKADIA 45

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