Cigna Official Site - 2018 Cigna-HealthSpring ......• Talk with your doctor about whether a 90-day supply of your ongoing, stable medications may be appropriate. Taking these medications

Plans coveredCigna-HealthSpring Preferred (HMO)Cigna-HealthSpring Preferred (PPO)Cigna-HealthSpring Preferred AR (HMO)Cigna-HealthSpring Preferred KNX (HMO)Cigna-HealthSpring Preferred NGA (HMO)Cigna-HealthSpring Preferred SMS (HMO)Cigna-HealthSpring Preferred Plus (HMO)Cigna-HealthSpring Premier (HMO-POS)Cigna-HealthSpring PreventiveCare (HMO)

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

2018 Cigna-HealthSpring COMPREHENSIVE DRUG LIST (Formulary)

This drug list was updated in November 2018. For more recent information or other questions, please contact Cigna-HealthSpring Customer Service, at 1-800-668-3813 or, for TTY users, 711, 7 days a week, 8 a.m. - 8 p.m., or visit www.CignaHealthSpring.com. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal.HPMS Approved Formulary File Submission ID 18084, Version 16 Y0036_18_55624a_Final_1k Populated Template 08042017

1

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

Can the Drug List (formulary) change?Generally, if you are taking a drug on our 2018 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic equivalent of the drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of drug list changes, such as removing a drug from our drug list, will not affect customers who are currently taking the drug. It will remain available at the same cost-sharing for those customers taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the drugs that were available when you chose our plan, except for cases in which you can save additional money on the generic equivalent or we can ensure your safety. If we remove drugs from our drug list, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected customers of the change at least 60 days before the change becomes effective, or at the time the customer requests

a refill of the drug, at which time the customer will receive a 60-day supply of the drug. If the Food and Drug Administration (FDA) deems a drug on our drug list to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our drug list and provide notice to customers who take the drug. The enclosed drug list is current as of November 2018. To get updated information about the drugs covered by Cigna-HealthSpring, please contact us. Our contact information appears on the front and back cover pages. If there are significant changes made to the printed drug list within the covered year, you may be notified by mail identifying the changes. Drug lists located on our website are reviewed and updated on a monthly basis.

How do I use the Drug List? There are two ways to find your drug within the drug list:Medical ConditionThe drug list begins on page 14. The drugs in this drug list are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “CARDIOVASCULAR AGENTS”. If you know what your drug is used for, look for the category name in the list that begins on page 14. Then look under the category name for your drug. Covered Drug IndexIf you are not sure what category to look under, you should look for your drug in the Covered Drugs Index section that begins on page 58. The Covered Drugs Index provides a list of all of the drugs included in this document. Both brand name drugs and generic drugs are in the Drug List. Next to your drug, you will see the page number where you can find coverage information.

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

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Cigna-HealthSpring. When it refers to “plan” or “our plan,” it means Cigna-HealthSpring Preferred (HMO), Cigna-HealthSpring Preferred (PPO), Cigna-HealthSpring Preferred AR (HMO), Cigna-HealthSpring Preferred KNX (HMO), Cigna-HealthSpring Preferred NGA (HMO), Cigna-HealthSpring Preferred SMS (HMO), Cigna-HealthSpring Preferred Plus (HMO), Cigna-HealthSpring Premier (HMO-POS), Cigna-HealthSpring PreventiveCare (HMO).

This document includes a list of the drugs (formulary) for our plans, which is current as of November 2018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2019, and from time to time during the year.

2

Turn to the page listed in the Covered Drug Index and find the name of your drug in the drug name column of the list.

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

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

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

• Quantity Limits: For certain drugs, Cigna-HealthSpring limits the amount of the drug that Cigna-HealthSpring will cover. For example, Cigna-HealthSpring allows for 1 tablet per day for BYSTOLIC 10MG. This applies to a standard one-month supply (for total quantity of 30 per 30 days) or three-month supply (for total quantity of 90 per 90 days).

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

You can find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 14. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.You can ask Cigna-HealthSpring to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Cigna-HealthSpring Drug List?” on page 3 for information about how to request an exception.

Options for Maintenance MedicationsTaking the medications prescribed by your doctor (or other prescriber) is important to your health.

We are committed to helping you achieve control of chronic conditions by making it easy for you to receive your maintenance medications. As part of our commitment to coordinating your healthcare needs, we have set a goal of helping you take your medications at least 80% of the time. There are several ways we can work together to accomplish this goal:• Talk with your doctor about whether a 90-day supply of your

ongoing, stable medications may be appropriate. Taking these medications every day as prescribed is important for your overall health, and getting 90-day prescriptions of these medications can help ensure that you do not miss a dose.

• You can receive a 90-day supply at most retail pharmacies or through one of our mail-order pharmacies.

• Talk to your pharmacist if you are experiencing any new challenges with your maintenance medications.

How can I use my prescription drug coverage to save money on my medications?There may be opportunities for you to save money on your medications using your Cigna-HealthSpring coverage.• Ask your doctor (or other prescriber) if there are any lower-

cost generic alternatives available for any of your current medications.

• Explore whether the ‘CMS extra help’ program may offer additional financial support for your medications.

• If your medication is not covered on the Cigna-HealthSpring drug list, talk with your doctor about alternative medications which are covered in the drug list.

What if my drug is not in the Drug List?If your drug is not included in this drug list, you should first contact Customer Service and ask if your drug is covered. If you learn that Cigna-HealthSpring does not cover your drug, you have two options:• You can ask Customer Service for a list of similar drugs that

are covered by Cigna-HealthSpring. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Cigna-HealthSpring.

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

3

How do I request an exception to the Cigna-HealthSpring Drug List?You can ask Cigna-HealthSpring to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.• You can ask us to cover a drug even if it is not in our drug

list. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

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

• You can ask us to provide a tiering exception for a higher cost sharing drug to be covered at a lower cost-sharing tier. If your drug is contained in the Non-Preferred Drugs tier, you can ask us to cover it at the Preferred Brand Drugs tier, and if your drug is contained in the Generic Drugs tier, you can ask us to cover it at the Preferred Generic Drugs tier. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not in our drug list, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier.

Generally, Cigna-HealthSpring will only approve your request for an exception if the alternative drugs included on the plan’s drug list, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a drug list, tiering or utilization restriction exception. When you request a drug list, tiering or utilization restriction exception you should submit a statement from your prescriber or doctor supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or existing customer in our plan you may be taking drugs that are not in our drug list. Or, you may be taking a drug

that is on our drug list but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a drug list exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a customer of our plan.For each of your drugs that is not on our drug list or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs without a drug list exception, even if you have been a customer of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91- to 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a customer of our plan. If you need a drug that is not in our drug list or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a drug list exception. In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning, such as level-of-care changes due to discharge from a hospital to a nursing facility or to a home, Cigna-HealthSpring will allow a one-time 31-day supply (unless the prescription is written for fewer days). Cigna-HealthSpring’s Drug ListThe comprehensive drug list provides coverage information about all of the drugs covered by Cigna-HealthSpring. If you have trouble finding your drug in the list, turn to the Covered Drug Index that begins on page 58. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., BYSTOLIC) and generic drugs are listed in lower-case italics (e.g., simvastatin).The information in the Requirements/Limits column tells you if Cigna-HealthSpring has any special requirements for coverage of your drug. Some Cigna-HealthSpring plans offer additional prescription drug coverage in the coverage gap. Please refer to your

4

Evidence of Coverage to see if your plan has this coverage and for more information.We provide quantity limits on certain drugs which are indicated with a QL in the Covered Drugs by Category list on page 14 along with the amount dispensed per the days supplied. (For example: BYSTOLIC 10MG QL 30/30; this means the drug BYSTOLIC 10MG is limited to 30 tablets per 30 days. For 90-day supplies, this quantity limit would be expanded to 90 tablets per 90 days).

What is a preferred network pharmacy?If your plan has preferred network pharmacies, you will typically save money by using these pharmacies. Your prescription drug costs (like a copay or coinsurance) will typically be less at a preferred network pharmacy because it has a preferred agreement with your plan. You will receive a Pharmacy Directory in your Welcome Kit after you enroll, or you can visit www.CignaHealthSpring.com for the most current Pharmacy Directory.

For more information

For more detailed information about your Cigna-HealthSpring prescription drug coverage, please review your Evidence of Coverage and other plan materials.If you have questions about Cigna-HealthSpring, please contact us. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

Key:B/D – This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending on circumstances.

PA – This drug requires prior authorization

QL – This drug has quantity limits

ST – This drug has step therapy requirements

Generally all medications in the drug list are available through mail order, except when special circumstances or situations prohibit mailing a particular medication to your home.

Drug Tier and Cost-Share TableThe following table represents the plan name, plan service area, the drug tier number as it appears in the drug list, and the cost-share amount for that tier number. Tier 1 is for Preferred Generic drugs. Tier 2 is for Generic drugs. Tier 3 is for Preferred Brand drugs. Tier 4 is for Non-Preferred drugs. Tier 5 is for Specialty tier drugs. You may also refer to your Evidence of Coverage document for additional details.Cigna-HealthSpring is not always able to keep all generic medications in the Preferred Generic and Generic drug tiers, and some generic medications may be in Tier 3, Tier 4 or Tier 5.

Keep in mind that the name “Tier 3: Preferred Brand Drugs” is just a description of the majority of the drugs in the tier. It does not mean that there are only brand drugs in that tier.For customers receiving Extra Help: Your Low Income Subsidy (LIS) copay level will be based on how the Food and Drug Administration (FDA) classifies certain drugs. Due to this, a generic drug may receive a preferred brand copay, or a preferred brand drug may receive a generic drug copay. Please see your LIS Rider for additional information on these copay levels. Or call Customer Service for further clarification regarding a specific drug.

5

To locate your drug cost, please refer to the table(s) below to find your service area and the Medicare Advantage plan in which you are currently enrolled or would like to enroll.Cigna-HealthSpring has pharmacies with preferred cost-shares. See your Pharmacy Directory or visit www.CignaHealthSpring.com for information on which stores with preferred cost-shares are near you.

Service Area: Alabama H0150-024-001, H0150-024-002Cigna-HealthSpring Preferred (HMO) Autauga, Baldwin, Bibb, Blount, Cherokee, Chilton, Colbert, Cullman, Dallas, DeKalb, Elmore, Etowah, Jackson, Jefferson, Lauderdale, Lawrence, Limestone, Lowndes, Madison, Marshall, Mobile, Montgomery, Morgan, Shelby, St. Clair, Talladega, Tuscaloosa and Walker, Alabama

Preferred Retail Cost-Sharing

Standard Retail Cost-Sharing

Standard Mail Order Cost-Sharing

30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days

Tier 1: Preferred Generic Drugs $1 / $2 / $1 $6 / $12 / $6 $6 / $12 / $6

Tier 2: Generic Drugs $7 / $14 / $7 $12 / $24 / $12 $12 / $24 / $12

Tier 3: Preferred Brand Drugs $40 / $80 / $120 $45 / $90 / $135 $45 / $90 / $135

Tier 4: Non-Preferred Drugs 50% 50% 50%

Tier 5: Specialty Tier 29% (30-day supply only)

29% (30-day supply only)


Service Area: Arkansas H4454-033Cigna-HealthSpring Preferred AR (HMO) Craighead, Crittenden, Greene, Lawrence, Mississippi and Poinsett, Arkansas




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days

Tier 1: Preferred Generic Drugs $3 / $6 / $7.50 $10 / $20 / $30 $10 / $20 / $30

Tier 2: Generic Drugs $15 / $30 / $37.50 $20 / $40 / $60 $20 / $40 / $60






6

Service Area: Florida H5410-018Cigna-HealthSpring Premier (HMO-POS)Bay, Escambia, Okaloosa, Santa Rosa and Walton, Florida




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days








Service Area: GeorgiaH0439-003-001, H0439-003-002Cigna-HealthSpring Preferred (HMO) Banks, Barrow, Bartow, Butts, Chattooga, Cherokee, Clarke, Clayton, Cobb, Coweta, Dawson, DeKalb, Douglas, Fayette, Floyd, Forsyth, Franklin, Fulton, Gordon, Greene, Gwinnett, Habersham, Hall, Henry, Jackson, Lumpkin, Madison, Morgan, Newton, Oconee, Oglethorpe, Paulding, Pickens, Polk, Rockdale, Spalding, Stephens, Walton and White, Georgia




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days








Service Area: Illinois H1415-021Cigna-HealthSpring Premier (HMO-POS)Cook, DuPage, Kane and Will, Illinois




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days








7

Service Area: Kansas CityH9460-001Cigna-HealthSpring Preferred (HMO)Clay, Jackson, Platte and Ray, Missouri; Johnson and Wyandotte, Kansas




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days




Tier 4: Non-Preferred Drugs $95 / $190 / $285 $100 / $200 / $300 $100 / $200 / $300




Service Area: Maryland H2108-022Cigna-HealthSpring Preferred (HMO) Anne Arundel, Baltimore, Baltimore City and Harford, Maryland




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days








Service Area: Maryland H2108-033Cigna-HealthSpring PreventiveCare (HMO) Anne Arundel, Baltimore, Baltimore City and Harford, Maryland




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days








8

Service Area: Mid-Atlantic H2108-028Cigna-HealthSpring Preferred (HMO) District of Columbia; Kent, New Castle and Sussex, Delaware; Montgomery and Prince George’s, Maryland




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days








Service Area: Mid-Atlantic H2108-032Cigna-HealthSpring PreventiveCare (HMO) District of Columbia; Kent, New Castle and Sussex, Delaware; Montgomery and Prince George’s, Maryland




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days








Service Area: MississippiH4407-025-001, H4407-025-002Cigna-HealthSpring Preferred SMS (HMO)Covington, Forrest, George, Hancock, Harrison, Hinds, Jackson, Jones, Lamar, Madison, Marion, Pearl River, Perry, Rankin and Stone, Mississippi




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days








9

Service Area: North Carolina, South CarolinaH9725-001, H7020-004Cigna-HealthSpring Preferred (HMO) Alexander, Cabarrus, Catawba, Cleveland, Davidson, Davie, Forsyth, Gaston, Guilford, Iredell, Lincoln, Polk, Rowan, Stokes, Union and Yadkin, North Carolina; Cherokee, Chester, Greenville, Lancaster, Spartanburg, Union and York, South Carolina




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days








Service Area: North GeorgiaH4513-030Cigna-HealthSpring Preferred NGA (HMO) Catoosa, Dade and Walker, Georgia




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days








Service Area: Pennsylvania H3949-028Cigna-HealthSpring PreventiveCare (HMO)Bucks, Chester, Delaware, Lancaster, Montgomery and Philadelphia, Pennsylvania




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days








10

Service Area: Pennsylvania H3949-030Cigna-HealthSpring Preferred (HMO) Bucks, Chester, Delaware, Lancaster, Montgomery and Philadelphia, Pennsylvania




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days








Service Area: Pennsylvania H3949-013Cigna-HealthSpring Preferred Plus (HMO)Bucks, Chester, Delaware, Lancaster, Montgomery and Philadelphia, Pennsylvania




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days








11

Service Area: Tennessee H4454-037-001, H4454-037-002Cigna-HealthSpring Preferred (HMO)Bedford, Benton, Bledsoe, Bradley, Cannon, Carroll, Cheatham, Chester, Clay, Coffee, Crockett, Cumberland, Davidson, Decatur, DeKalb, Dickson, Fayette, Fentress, Gibson, Giles, Grundy, Hamilton, Hardeman, Hardin, Haywood, Henderson, Hickman, Houston, Humphreys, Jackson, Lauderdale, Lawrence, Lewis, Lincoln, Macon, Madison, Marion, Marshall, Maury, McNairy, Montgomery, Moore, Overton, Perry, Pickett, Polk, Putnam, Robertson, Rutherford, Sequatchie, Shelby, Smith, Stewart, Sumner, Tipton, Trousdale, Van Buren, Warren, Wayne, White, Williamson and Wilson, Tennessee




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days








Service Area: TennesseeH4454-030Cigna-HealthSpring Premier (HMO-POS)Bedford, Benton, Bledsoe, Bradley, Cannon, Carroll, Cheatham, Chester, Clay, Coffee, Crockett, Cumberland, Davidson, Decatur, DeKalb, Dickson, Fayette, Fentress, Gibson, Giles, Grundy, Hamilton, Hardeman, Hardin, Haywood, Henderson, Hickman, Houston, Humphreys, Jackson, Lauderdale, Lawrence, Lewis, Lincoln, Macon, Madison, Marion, Marshall, Maury, McNairy, Montgomery, Moore, Overton, Perry, Pickett, Polk, Putnam, Robertson, Rutherford, Sequatchie, Shelby, Smith, Stewart, Sumner, Tipton, Trousdale, Van Buren, Warren, Wayne, White, Williamson and Wilson, Tennessee




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days








12

Service Area: TennesseeH4454-031Cigna-HealthSpring Preferred KNX (HMO)Anderson, Blount, Cocke, Grainger, Hamblen, Jefferson, Knox, Loudon, Morgan, Sevier and Union, Tennessee




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days








Service Area: TexasH4513-025Cigna-HealthSpring Preferred (HMO)Angelina, Brazoria, Cameron, Chambers, El Paso, Fort Bend, Galveston (77510, 77511, 77517, 77518, 77539, 77546, 77549, 77563, 77565, 77568, 77573, 77574, 77590, 77591, and 77592), Hardin, Harris, Hidalgo, Jasper, Jefferson, Liberty, Montgomery, Nacogdoches, Newton, Orange, Polk, San Jacinto, Tyler, Walker, Waller, Webb and Willacy, Texas




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days








Service Area: Texas H4513-026, H4513-028Cigna-HealthSpring Preferred (HMO) Bexar, Collin, Dallas, Denton, El Paso, Henderson, Hood, Johnson, Parker, Rusk, Smith, Tarrant, Upshur, Van Zandt and Wise, Texas




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days

Tier 1: Preferred Generic Drugs $3 / $6 / $7.50 $8 / $16 / $20 $8 / $16 / $20

Tier 2: Generic Drugs $8 / $16 / $20 $13 / $26 / $32.50 $13 / $26 / $32.50






13

Service Area: TexasH7787-001Cigna-HealthSpring Preferred (PPO)Collin, Dallas, Denton, Johnson and Tarrant, Texas




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days

Tier 1: Preferred Generic Drugs $0 / $0 / $0 $5 / $10 / $12.50 $5 / $10 / $12.50

Tier 2: Generic Drugs $4 / $8 / $10 $9 / $18 / $22.50 $9 / $18 / $22.50






My MedicationsIn this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug list pages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before this page and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer Service at 1-800-668-3813, 7 days a week, 8 a.m. - 8 p.m. TTY users can call 711.

My Medications Page Number in the Drug List

Cost-Share through Cigna-HealthSpring

Generic Available?

Generic Cost-Share

14

Covered Drugs By Category

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Analgesics

Analgesicsbutalbital/acetaminophen/caffeine caps

3 PA QL(180/30)

butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg

3 PA QL(180/30)

butalbital/aspirin/caffeine caps 3 PA QL(180/30)esgic caps 3 PA QL(180/30)zebutal caps 325mg; 50mg; 40mg

3 PA QL(180/30)

Nonsteroidal Anti-inflammatory Drugscelecoxib caps 400mg 2 QL(30/30)celecoxib caps 100mg, 200mg, 50mg

2 QL(60/30)

diclofenac potassium 2diclofenac sodium dr tbec 25mg, 50mg

2

diclofenac sodium dr tbec 75mg 1diclofenac sodium er 2diflunisal 2etodolac 2etodolac er 2fenoprofen calcium caps 400mg

2

fenoprofen calcium tabs 2flurbiprofen 2ibu tabs 600mg, 800mg 1ibuprofen susp 1ibuprofen tabs 400mg, 600mg, 800mg

1

meclofenamate sodium 2meloxicam 1 QL(30/30)nabumetone 2naproxen dr 2naproxen sodium tabs 275mg, 550mg

2

naproxen susp 2naproxen tabs 250mg 2naproxen tabs 375mg, 500mg 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

oxaprozin 2piroxicam 2salsalate 2sulindac 2tolmetin sodium 2Opioid Analgesics, Long-actingbuprenorphine hcl inj 4 QL(150/30)DURAMORPH 4 QL(180/30)fentanyl 4 QL(10/30)INFUMORPH 200 4 QL(200/30)INFUMORPH 500 4 QL(200/30)levorphanol tartrate 5 QL(120/30)methadone hcl conc 2 QL(500/30)methadone hcl inj 4 QL(150/30)methadone hcl intensol 2 QL(500/30)methadone hcl oral soln 10mg/5ml

2 QL(450/30)

methadone hcl oral soln 5mg/5ml

2 QL(600/30)

methadone hcl tabs 10mg 2 QL(120/30)methadone hcl tabs 5mg 2 QL(180/30)mitigo 4 QL(200/30)morphine sulfate er tbcr 3 QL(90/30)morphine sulfate inj 0.5mg/ml, 1mg/ml

4 QL(180/30)

XTAMPZA ER 3 QL(60/30)Opioid Analgesics, Short-actingacetaminophen/codeine oral soln

2 QL(2700/30)

acetaminophen/codeine tabs 300mg; 60mg

2 QL(180/30)

acetaminophen/codeine tabs 300mg; 15mg, 300mg; 30mg

2 QL(360/30)

ascomp/codeine 3 PA QL(180/30)butalbital/acetaminophen/caffeine/codeine

3 PA QL(180/30)

butalbital/aspirin/caffeine/codeine

3 PA QL(180/30)

butorphanol tartrate inj 2mg/ml 4 QL(240/30)butorphanol tartrate inj 1mg/ml 4 QL(480/30)butorphanol tartrate nasal soln 2 QL(5/30)

15


CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drugQL = Quantity Limits listed as (qty/days) ST = Step Therapy rules applyPA = Prior Authorization may be required B/D = Drugs covered under Medicare Part B or Part DYou can find more information on the symbols by going to page 4.

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

endocet tabs 325mg; 10mg 3 QL(180/30)endocet tabs 325mg; 7.5mg 3 QL(240/30)endocet tabs 325mg; 2.5mg, 325mg; 5mg

3 QL(360/30)

fentanyl citrate inj 1000mcg/20ml, 100mcg/2ml, 2500mcg/50ml, 250mcg/5ml

4 B/D PA

fentanyl citrate oral transmucosal lpop 200mcg, 400mcg, 600mcg

4 PA QL(120/30)

fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 800mcg

5 PA QL(120/30)

hydrocodone bitartrate/acetaminophen oral soln

3 QL(2700/30)

hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg, 300mg; 7.5mg

3 QL(180/30)

hydrocodone bitartrate/acetaminophen tabs 300mg; 5mg, 325mg; 2.5mg

3 QL(360/30)

hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 7.5mg

3 QL(180/30)

hydrocodone/acetaminophen tabs 325mg; 5mg

3 QL(360/30)

hydrocodone/ibuprofen 3 QL(150/30)hydromorphone hcl dosette 4hydromorphone hcl inj 4hydromorphone hcl liqd 3 QL(1200/30)hydromorphone hcl tabs 8mg 3 QL(120/30)hydromorphone hcl tabs 2mg, 4mg

3 QL(180/30)

ibudone tabs 5mg; 200mg 3 QL(150/30)lorcet 3 QL(360/30)lorcet hd 3 QL(180/30)lorcet plus tabs 325mg; 7.5mg 3 QL(180/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MORPHINE SULFATE INJ 150MG/30ML, 50MG/ML

4

morphine sulfate inj 5mg/ml 4MORPHINE SULFATE INJ 1MG/ML

4 QL(180/30)

MORPHINE SULFATE INJ 10MG/ML

4 QL(200/30)

morphine sulfate inj 10mg/ml 4 QL(200/30)MORPHINE SULFATE INJ 8MG/ML

4 QL(250/30)

morphine sulfate inj 8mg/ml 4 QL(250/30)MORPHINE SULFATE INJ 4MG/ML

4 QL(630/30)

MORPHINE SULFATE INJ 2MG/ML

4 QL(1260/30)

morphine sulfate oral soln 100mg/5ml

2 QL(180/30)


2 QL(300/30)


2 QL(700/30)

MORPHINE SULFATE TABS 3 QL(120/30)nalbuphine hcl inj 20mg/ml 4 QL(90/30)nalbuphine hcl inj 10mg/ml 4 QL(180/30)oxycodone hcl caps 3 QL(120/30)oxycodone hcl conc 3 QL(120/30)oxycodone hcl oral soln 3 QL(1200/30)oxycodone hcl tabs 30mg 3 QL(90/30)oxycodone hcl tabs 10mg, 15mg, 20mg, 5mg

3 QL(120/30)

oxycodone/acetaminophen tabs 325mg; 10mg

3 QL(180/30)

oxycodone/acetaminophen tabs 325mg; 7.5mg

3 QL(240/30)

oxycodone/acetaminophen tabs 325mg; 2.5mg, 325mg; 5mg

3 QL(360/30)

oxycodone/aspirin 3 QL(180/30)

16


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Smoking Cessation Agentsbupropion hcl sr 3 QL(60/30)CHANTIX 3 QL(336/365)CHANTIX CONTINUING MONTH PAK

3 QL(336/365)

CHANTIX STARTING MONTH PAK

3 QL(336/365)

NICOTROL INHALER 4 QL(1008/90)NICOTROL NS 4 QL(30/30)

Antibacterials

Aminoglycosidesamikacin sulfate 4gentak 2gentamicin sulfate crea 2gentamicin sulfate inj 4gentamicin sulfate oint 2gentamicin sulfate ophthalmic soln

4

gentamicin sulfate pediatric 4gentamicin sulfate/0.9% sodium chloride

4

isotonic gentamicin 4neomycin sulfate 2neomycin/polymyxin b sulfates 4paromomycin sulfate 4streptomycin sulfate 4tobramycin ophthalmic soln 2tobramycin sulfate inj 1.2gm, 10mg/ml, 80mg/2ml

4

tobramycin sulfate ophthalmic soln

2

TOBREX OINT 3ZYLET 3Antibacterials, Otheralcohol prep pads 1baciim 4bacitracin inj 4bacitracin ophthalmic oint 2bacitracin/polymyxin b 2BACTROBAN NASAL 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

oxycodone/ibuprofen 3 QL(28/30)tramadol hcl 2 QL(240/30)tramadol hydrochloride/acetaminophen

3 QL(240/30)

vicodin es tabs 300mg; 7.5mg 3 QL(180/30)vicodin hp tabs 300mg; 10mg 3 QL(180/30)vicodin tabs 300mg; 5mg 3 QL(360/30)

Anesthetics

Local Anestheticsglydo 2lidocaine hcl external soln 2lidocaine hcl gel 2lidocaine hcl inj 4lidocaine hcl jelly 2lidocaine hcl mouth/throat soln 1lidocaine hcl viscous 1lidocaine oint 4 QL(120/30)lidocaine ptch 4 PA QL(90/30)lidocaine viscous 1lidocaine/prilocaine crea 4

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-cravingacamprosate calcium dr 2disulfiram 2Opioid Dependence Treatmentsbuprenorphine hcl subl 4 PA QL(90/30)buprenorphine hcl/naloxone hcl 3 PA QL(90/30)naltrexone hcl 2SUBOXONE 3 PA QL(90/30)ZUBSOLV SUBL 0.7MG; 0.18MG

3 PA QL(30/30)

ZUBSOLV SUBL 1.4MG; 0.36MG, 11.4MG; 2.9MG, 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG

3 PA QL(90/30)

Opioid Reversal Agentsnaloxone hcl 2NARCAN 3 QL(4/30)

17



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

neo-polycin 2neo-polycin hc 2neomycin/bacitracin/polymyxin 2neomycin/polymyxin/bacitracin/hydrocortisone

2

neomycin/polymyxin/gramicidin 2neomycin/polymyxin/hydrocortisone

2

nitrofurantoin 4nitrofurantoin macrocrystals 2nitrofurantoin monohydrate 2nitrofurantoin monohydrate/macrocrystals

2

polycin 2polymyxin b sulfate 4polymyxin b sulfate/trimethoprim sulfate

2

rosadan 2silver sulfadiazine 3ssd 3SYNERCID 5tigecycline 5trimethoprim 2trimethoprim sulfate/polymyxin b sulfate

2

TYGACIL 5vancomycin 4vancomycin hcl caps 125mg 4 QL(40/10)vancomycin hcl caps 250mg 4 QL(80/10)vancomycin hcl in dextrose 4vancomycin hcl inj 0.9%; 1gm/200ml, 10gm, 1gm, 500mg, 5gm, 750mg

4

VANCOMYCIN HYDROCHLORIDE INJ 250MG

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

chloramphenicol sodium succinate

1

clindacin etz pledgets 2clindacin-p 2clindamycin 4clindamycin hcl 2clindamycin hydrochloride 2clindamycin phosphate crea 2clindamycin phosphate external soln

2

clindamycin phosphate gel 2clindamycin phosphate in d5w 4clindamycin phosphate inj 150mg/ml, 300mg/2ml, 600mg/4ml, 900mg/6ml

4

clindamycin phosphate lotn 2clindamycin phosphate swab 2clindamycin/sodium chloride 4colistimethate sodium 4daptomycin inj 500mg 5 B/D PAlincomycin hcl 4linezolid inj 4linezolid susr 5 QL(1800/30)linezolid tabs 5 QL(60/30)methenamine hippurate 2metronidazole crea 2metronidazole gel 2metronidazole in nacl 0.79% 4metronidazole inj 500mg/100ml; 0.79%, 5mg/ml

4

metronidazole lotn 2metronidazole tabs 1metronidazole vaginal 2mupirocin crea 4mupirocin oint 2

18


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

AZACTAM IN ISO-OSMOTIC DEXTROSE

4

aztreonam inj 1gm 4AZTREONAM INJ 2GM 5cefotetan 4ertapenem 4ertapenem sodium 4imipenem/cilastatin inj 250mg; 250mg

2

imipenem/cilastatin inj 500mg; 500mg

4

INVANZ 4meropenem 4meropenem/sodium chloride 4Beta-lactam, Penicillinsamoxicillin caps 1amoxicillin chew 2amoxicillin susr 1amoxicillin tabs 2amoxicillin/clavulanate potassium

2

amoxicillin/clavulanate potassium er

2

ampicillin 2ampicillin sodium 4ampicillin-sulbactam 4AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML

3

BICILLIN L-A 4dicloxacillin sodium 2nafcillin sodium inj 10gm, 1gm, 2gm

4

nafcillin sodium inj 2gm 5oxacillin sodium 4penicillin g potassium 4penicillin v potassium oral soln 1penicillin v potassium tabs 250mg

1

penicillin v potassium tabs 500mg

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

vancomycin hydrochloride/sodium chloride inj 0.9%; 750mg/150ml

4

vandazole 2XIFAXAN TABS 200MG 4 PA QL(9/30)XIFAXAN TABS 550MG 5 PA QL(90/30)Beta-lactam, Cephalosporinscefaclor caps 2cefaclor er 2cefaclor susr 3cefadroxil 2CEFAZOLIN 4cefazolin sodium inj 10gm, 1gm, 1gm/50ml; 4%, 500mg

4

cefazolin sodium/dextrose inj 2gm; 3%

4

cefdinir 2cefepime 4cefepime/dextrose 4cefixime 4cefotaxime sodium 4cefoxitin sodium inj 10gm, 1gm, 2gm

4

cefpodoxime proxetil 2cefprozil 2ceftazidime 4ceftazidime/dextrose 4ceftriaxone in iso-osmotic dextrose

4

ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg

4

cefuroxime axetil 2cefuroxime sodium 4cephalexin caps 250mg, 500mg 1cephalexin susr 2cephalexin tabs 2SUPRAX SUSR 500MG/5ML 3tazicef inj 1gm, 2gm, 6gm 4TEFLARO 5Beta-lactam, OtherAZACTAM 4

19



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

BAXDELA 4BESIVANCE 4CILOXAN OINT 3CIPRO HC 3CIPRODEX 3ciprofloxacin er tb24 500mg; 0 2 QL(3/3)ciprofloxacin er tb24 1000mg; 0 2 QL(14/14)ciprofloxacin hcl ophthalmic soln

2

ciprofloxacin hcl tabs 100mg, 750mg

2

ciprofloxacin hcl tabs 250mg 1ciprofloxacin hydrochloride 1ciprofloxacin i.v.-in d5w 4ciprofloxacin susr 2levofloxacin in d5w 4levofloxacin inj 4levofloxacin oral soln 2levofloxacin tabs 2 QL(30/30)moxifloxacinhydrochloride/sodium hydrochloride

4

moxifloxacin hcl inj 4moxifloxacin hcl tabs 2 QL(30/30)moxifloxacin hydrochloride ophthalmic soln

3

ofloxacin 2VIGAMOX 3SulfonamidesBLEPHAMIDE 3BLEPHAMIDE S.O.P. 3sodium sulfacetamide ophthalmic soln

2

sulfacetamide sodium lotn 2sulfacetamide sodium ophthalmic soln

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

pfizerpen inj 20mu, 5000000unit

4

piperacillin sodium/tazobactam sodium

4

piperacillin/tazobactam 4ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML; 0.5GM/100ML

4

MacrolidesAZASITE 3azithromycin inj 4azithromycin pack 3azithromycin susr 200mg/5ml 2 QL(75/30)azithromycin susr 100mg/5ml 2 QL(150/30)azithromycin tabs 250mg, 500mg

2 QL(12/28)

azithromycin tabs 600mg 2 QL(60/30)clarithromycin er 2 QL(60/30)clarithromycin susr 2clarithromycin tabs 2 QL(42/14)e.e.s. 400 3ery 2ERY-TAB 3ERYPED 400 5ERYTHROCIN LACTOBIONATE

4

erythrocin stearate 2erythromycin base 4erythromycin ethylsuccinate 3erythromycin external soln 2erythromycin gel 2erythromycin oint 2erythromycin pads 2QuinolonesAVELOX INJ 4

20


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

FYCOMPA SUSP 4 QL(720/30)FYCOMPA TABS 4 QL(30/30)levetiracetam er tb24 750mg 2 QL(120/30)levetiracetam er tb24 500mg 2 QL(180/30)levetiracetam inj 4levetiracetam oral soln 2levetiracetam tabs 2magnesium sulfate in d5w 4 B/D PAroweepra 2roweepra xr tb24 750mg 2 QL(120/30)roweepra xr tb24 500mg 2 QL(180/30)SPRITAM TB3D 1000MG, 250MG, 500MG

4 QL(60/30)

SPRITAM TB3D 750MG 4 QL(120/30)Calcium Channel Modifying AgentsCELONTIN 3ethosuximide 2LYRICA CAPS 225MG, 300MG 3 QL(60/30)LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG

3 QL(90/30)

LYRICA ORAL SOLN 3 QL(900/30)zonisamide 2Gamma-aminobutyric Acid (GABA) Augmenting Agentsclonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg

2 QL(90/30)

clonazepam odt tbdp 1mg 2 QL(120/30)clonazepam odt tbdp 2mg 2 QL(300/30)clonazepam tabs 0.5mg 2 QL(90/30)clonazepam tabs 1mg 2 QL(120/30)clonazepam tabs 2mg 2 QL(300/30)DIASTAT ACUDIAL GEL 10MG 4 QL(20/30)DIASTAT ACUDIAL GEL 20MG 4 QL(40/30)DIASTAT PEDIATRIC 4 QL(5/30)diazepam rectal gel gel 2.5mg 3 QL(5/30)diazepam rectal gel gel 10mg 3 QL(20/30)diazepam rectal gel gel 20mg 3 QL(40/30)divalproex sodium 2divalproex sodium dr 2divalproex sodium er 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sulfacetamide sodium/prednisolone sodium phosphate

2

sulfadiazine 2sulfamethoxazole/trimethoprim ds

1

sulfamethoxazole/trimethoprim inj

4

sulfamethoxazole/trimethoprim susp

1

sulfamethoxazole/trimethoprim tabs

1

sulfatrim pediatric 1Tetracyclinesdemeclocycline hcl 2doxy 100 4doxycycline hyclate caps 1doxycycline hyclate tabs 100mg 1doxycycline hyclate tabs 20mg 2doxycycline monohydrate caps 100mg, 50mg

2 QL(60/30)

doxycycline monohydrate caps 75mg

3 QL(60/30)

doxycycline monohydrate tabs 2doxycycline susr 2minocycline hcl 2mondoxyne nl 2 QL(60/30)morgidox 1x100mg caps 1morgidox 1x50mg 1morgidox 2x100mg caps 1tetracycline hydrochloride 1

Anticonvulsants

Anticonvulsants, OtherAPTIOM TABS 200MG, 400MG, 800MG

5 QL(30/30)

APTIOM TABS 600MG 5 QL(60/30)BRIVIACT INJ 5 QL(600/30)BRIVIACT ORAL SOLN 5 QL(1200/30)BRIVIACT TABS 10MG, 25MG, 50MG, 75MG

5 QL(60/30)

BRIVIACT TABS 100MG 5 QL(120/30)

21



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TROKENDI XR CP24 100MG, 25MG, 50MG

4 QL(30/30)

Sodium Channel AgentsBANZEL SUSP 5 PA QL(2400/30)BANZEL TABS 200MG 5 PA QL(60/30)BANZEL TABS 400MG 5 PA QL(240/30)carbamazepine 2carbamazepine er 2DILANTIN CAPS 30MG 3epitol 2fosphenytoin sodium 4oxcarbazepine 2PEGANONE 3phenytoin 2phenytoin infatabs 2phenytoin sodium 4phenytoin sodium extended 2VIMPAT INJ 4 QL(1200/30)VIMPAT ORAL SOLN 4 QL(1200/30)VIMPAT TABS 4 QL(60/30)

Antidementia Agents

Antidementia Agents, Otherergoloid mesylates 2 PANAMZARIC C4PK 3 QL(56/365)NAMZARIC CP24 3 QL(30/30)Cholinesterase Inhibitorsdonepezil hcl tabs 23mg, 5mg 2 QL(30/30)donepezil hcl tabs 10mg 2 QL(60/30)donepezil hcl tbdp 5mg 2 QL(30/30)donepezil hcl tbdp 10mg 2 QL(60/30)donepezil hydrochloride tabs 5mg

2 QL(30/30)

donepezil hydrochloride tabs 10mg

2 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

gabapentin caps 100mg 2 QL(180/30)gabapentin caps 300mg, 400mg

2 QL(270/30)

gabapentin oral soln 2 QL(2160/30)gabapentin tabs 800mg 2gabapentin tabs 600mg 2 QL(180/30)GABITRIL TABS 12MG 4 QL(120/30)GABITRIL TABS 16MG 4 QL(90/30)ONFI SUSP 5 QL(480/30)ONFI TABS 20MG 5 QL(60/30)ONFI TABS 10MG 3 QL(60/30)phenobarbital elix 2 QL(1500/30)phenobarbital tabs 2 QL(120/30)primidone 2SABRIL PACK 5 PA QL(200/30)SABRIL TABS 5 PA QL(180/30)tiagabine hydrochloride tabs 4mg

4

tiagabine hydrochloride tabs 16mg

4 QL(90/30)


4 QL(120/30)


4 QL(240/30)

valproate sodium 4valproic acid 2vigabatrin 5 PA QL(200/30)Glutamate Reducing Agentsfelbamate susp 5felbamate tabs 4lamotrigine 2lamotrigine er 2lamotrigine odt 2topiramate 2TROKENDI XR CP24 200MG 5 QL(60/30)

22


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tranylcypromine sulfate 2SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitorcitalopram hydrobromide oral soln

1 QL(600/30)

citalopram hydrobromide tabs 10mg

1


1 QL(30/30)


1 QL(60/30)

desvenlafaxine er 4 QL(30/30)duloxetine hcl cpep 20mg 2 QL(60/30)duloxetine hydrochloride cpep 60mg

2 QL(60/30)

duloxetine hydrochloride cpep 30mg

2 QL(90/30)

escitalopram oxalate oral soln 2 QL(600/30)escitalopram oxalate tabs 5mg 2 QL(30/30)escitalopram oxalate tabs 10mg 2 QL(60/30)escitalopram oxalate tabs 20mg 2 QL(90/30)FETZIMA 4 QL(30/30) STFETZIMA TITRATION PACK 4 QL(56/365) STfluoxetine caps 10mg 2 QL(30/30)fluoxetine caps 20mg 2 QL(120/30)fluoxetine dr 2 QL(4/28)fluoxetine hcl caps 10mg 2 QL(30/30)fluoxetine hcl caps 40mg 2 QL(60/30)fluoxetine hcl caps 20mg 2 QL(120/30)fluoxetine hcl oral soln 2 QL(600/30)fluoxetine hydrochloride tabs 10mg

2 QL(30/30)

fluoxetine hydrochloride tabs 20mg

2 QL(120/30)

fluvoxamine maleate er 2 QL(60/30)fluvoxamine maleate tabs 25mg, 50mg

2 QL(30/30)

fluvoxamine maleate tabs 100mg

2 QL(90/30)

olanzapine/fluoxetine 4 QL(30/30)paroxetine hcl er tb24 12.5mg 2 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

galantamine hydrobromide er 4 QL(30/30)galantamine hydrobromide oral soln

4 QL(200/30)

galantamine hydrobromide tabs 4 QL(60/30)rivastigmine tartrate 4 QL(60/30)rivastigmine transdermal system

4 QL(30/30)

N-methyl-D-aspartate (NMDA) Receptor Antagonistmemantine hcl tabs 10mg 2 PA QL(60/30)memantine hcl tabs 5mg 2 PA QL(90/30)memantine hcl titration pak 2 PA QL(49/28)memantine hydrochloride er 3 PA QL(30/30)memantine hydrochloride oral soln

2 PA QL(300/30)

NAMENDA XR 3 PA QL(30/30)NAMENDA XR TITRATION PACK

3 PA QL(56/365)

Antidepressants

Antidepressants, Otherbupropion hcl er tb12 100mg, 200mg

3 QL(60/30)

bupropion hcl sr 3 QL(60/30)bupropion hcl tabs 100mg 3 QL(120/30)bupropion hcl xl 3 QL(30/30)bupropion hydrochloride tabs 75mg

3 QL(180/30)

maprotiline hcl 4 QL(90/30)mirtazapine 2 QL(30/30)mirtazapine odt 2 QL(30/30)nefazodone hcl 3 QL(60/30)nefazodone hydrochloride 3 QL(60/30)trazodone hydrochloride tabs 100mg, 150mg, 50mg

1

trazodone hydrochloride tabs 300mg

2

TRINTELLIX 4 QL(30/30) STMonoamine Oxidase InhibitorsEMSAM 5 QL(30/30)MARPLAN 4 QL(180/30)phenelzine sulfate 2

23



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

promethazine hcl supp 2promethazine hcl syrp 2 PApromethazine hcl tabs 2 PApromethazine hydrochloride tabs 50mg

2 PA

promethegan 2scopolamine 4 QL(10/30)TRANSDERM-SCOP 4 QL(10/30)Emetogenic Therapy AdjunctsALOXI 5 B/D PAaprepitant caps 40mg 3 B/D PA QL(1/30)aprepitant caps 125mg 3 B/D PA QL(2/28)aprepitant caps 80mg 3 B/D PA QL(4/28)aprepitant caps 3 B/D PA QL(6/28)dronabinol 4 PA QL(60/30)EMEND SUSR 3 B/D PA QL(6/28)granisetron hcl inj 4 B/D PAgranisetron hcl tabs 2 B/D PA QL(30/30)ondansetron hcl inj 40mg/20ml, 4mg/2ml

4

ondansetron hcl oral soln 2 B/D PA QL(450/30)ondansetron hcl tabs 24mg 1 B/D PA QL(15/30)ondansetron hcl tabs 4mg, 8mg 1 B/D PA QL(90/30)ondansetron odt 1 B/D PA QL(90/30)PALONOSETRON HYDROCHLORIDE INJ 0.25MG/2ML

5 B/D PA

palonosetron hydrochloride inj 0.25mg/5ml

5 B/D PA

SANCUSO 5 QL(4/28)

Antifungals

AntifungalsABELCET 5 PAAMBISOME 5 PAamphotericin b 4 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

paroxetine hcl er tb24 25mg, 37.5mg

2 QL(60/30)

paroxetine hcl tabs 30mg, 40mg

2 QL(60/30)

paroxetine hcl tabs 10mg 1 QL(30/30)paroxetine hcl tabs 20mg 1 QL(90/30)PAXIL SUSP 3 QL(900/30) STPRISTIQ 4 QL(30/30)sertraline hcl conc 2 QL(300/30)sertraline hcl tabs 25mg 2 QL(30/30)sertraline hcl tabs 100mg 2 QL(60/30)sertraline hcl tabs 50mg 2 QL(120/30)venlafaxine hcl 2 QL(90/30)venlafaxine hcl er cp24 37.5mg 2 QL(30/30)venlafaxine hcl er cp24 150mg 2 QL(60/30)venlafaxine hcl er cp24 75mg 2 QL(90/30)VIIBRYD 4 QL(30/30) STVIIBRYD STARTER PACK 4 QL(30/30) STTricyclicsamitriptyline hcl 3 PAamoxapine 2clomipramine hcl 3 PAdesipramine hcl 2imipramine hcl tabs 25mg, 50mg

3 PA

imipramine hydrochloride 3 PAnortriptyline hcl 2perphenazine/amitriptyline 4 PAprotriptyline hcl 2trimipramine maleate 3 PA

Antiemetics

Antiemetics, Othermeclizine hcl tabs 2phenadoz 2

24


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

voriconazole inj 5 PAvoriconazole susr 5 PA QL(300/30)voriconazole tabs 4 PA QL(90/30)

Antigout Agents

Antigout Agentsallopurinol 1allopurinol sodium 4colchicine caps 3 QL(60/30)colchicine tabs 3 QL(120/30)MITIGARE 3 QL(60/30)probenecid 2probenecid/colchicine 2ULORIC 3 QL(30/30) ST

Antimigraine Agents

Ergot Alkaloidsdihydroergotamine mesylate inj 4 QL(30/28)ergotamine tartrate/caffeine 2 QL(40/28)migergot 5 QL(20/28)Serotonin (5-HT) 1b/1d Receptor Agonistsnaratriptan hcl 2 QL(9/30)rizatriptan benzoate 2 QL(12/30)rizatriptan benzoate odt 2 QL(12/30)sumatriptan 3 QL(12/30)sumatriptan succinate inj 6mg/0.5ml

2 QL(4/30)

sumatriptan succinate inj 4mg/0.5ml

2 QL(8/30)

sumatriptan succinate refill inj 6mg/0.5ml

2 QL(4/30)

sumatriptan succinate refill inj 4mg/0.5ml

2 QL(8/30)

sumatriptan succinate tabs 2 QL(9/30)

Antimyasthenic Agents

ParasympathomimeticsGUANIDINE HCL 3pyridostigmine bromide 2pyridostigmine bromide er 3REGONOL 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CANCIDAS 5 PAcaspofungin acetate 5 PAciclodan 2ciclopirox nail lacquer 2ciclopirox olamine 2ciclopirox sham 2ciclopirox susp 2clotrimazole external crea 2clotrimazole external soln 2clotrimazole lozg 2clotrimazole/betamethasone dipropionate

2

econazole nitrate 2fluconazole in nacl 4fluconazole susr 2fluconazole tabs 100mg, 200mg, 50mg

2

fluconazole tabs 150mg 1flucytosine 5griseofulvin microsize 4griseofulvin ultramicrosize 4itraconazole caps 4 PA QL(120/30)itraconazole oral soln 5 PAketoconazole crea 2ketoconazole sham 2ketoconazole tabs 2naftifine hcl 2naftifine hydrochloride 2NAFTIN GEL 3NATACYN 3NOXAFIL SUSP 5 PA QL(600/30)NOXAFIL TBEC 5 PA QL(96/30)nyamyc 2nystatin 2nystatin/triamcinolone 4nystop 2SPORANOX ORAL SOLN 5 PAterbinafine hcl tabs 1 QL(90/365)terconazole 2

25



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

GLEOSTINE 3HEXALEN 5ifosfamide inj 1gm, 3gm 4 B/D PAKISQALI FEMARA 200 DOSE 5 PA QL(49/28)KISQALI FEMARA 400 DOSE 5 PA QL(70/28)KISQALI FEMARA 600 DOSE 5 PA QL(91/28)LEUKERAN 3MATULANE 5melphalan hydrochloride 5 B/D PAMUSTARGEN 4 B/D PAthiotepa 4 PATREANDA INJ 100MG 5 B/D PATREANDA INJ 25MG 5 B/D PA QL(8/21)VALCHLOR 5 PA QL(60/30)YONDELIS 5 PAZANOSAR 4 B/D PAAntiandrogensbicalutamide 2 QL(30/30)ERLEADA 5 PA QL(120/30)flutamide 2nilutamide 5 QL(60/30)XTANDI 5 PA QL(120/30)YONSA 5 PA QL(120/30)ZYTIGA TABS 500MG 5 PA QL(60/30)ZYTIGA TABS 250MG 5 PA QL(120/30)Antiangiogenic AgentsPOMALYST 5 PA QL(21/28)REVLIMID CAPS 15MG, 20MG, 25MG

5 PA QL(21/28)

REVLIMID CAPS 10MG, 2.5MG, 5MG

5 PA QL(28/28)

THALOMID CAPS 100MG, 150MG, 50MG

5 PA QL(28/28)

THALOMID CAPS 200MG 5 PA QL(56/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antimycobacterials

Antimycobacterials, Otherdapsone tabs 3rifabutin 3AntitubercularsCAPASTAT SULFATE 4cycloserine 2ethambutol hcl 2isoniazid inj 4isoniazid syrp 2isoniazid tabs 100mg 2isoniazid tabs 300mg 1PASER 3PRIFTIN 4pyrazinamide 2rifampin caps 2rifampin inj 4RIFATER 3SIRTURO 4 PA QL(188/365)TRECATOR 3

Antineoplastics

Alkylating AgentsBENDEKA 5 B/D PA QL(8/21)BICNU 4 B/D PAbusulfan 5 B/D PABUSULFEX 5 B/D PAcarmustine 2 B/D PAcyclophosphamide caps 3 B/D PAcyclophosphamide inj 2gm 5 B/D PAcyclophosphamide inj 1gm, 500mg

4 B/D PA

dacarbazine 4 B/D PAEVOMELA 5 PA

26


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

BORTEZOMIB 5 PA QL(14/21)BRAFTOVI 5 PA QL(180/30)carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml

4 B/D PA

cisplatin 4 B/D PACOSMEGEN 5 B/D PAdactinomycin 5 B/D PAdaunorubicin hcl 4 B/D PAdaunorubicin hydrochloride 4 B/D PAdecitabine 5dexrazoxane 4 B/D PADOCETAXEL INJ 200MG/10ML 5 B/D PAdocetaxel inj 160mg/16ml, 160mg/8ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml

5 B/D PA

doxorubicin hcl 2 B/D PAdoxorubicin hcl liposome 5 B/D PAepirubicin hcl inj 200mg/100ml 4 B/D PAERWINAZE 5 B/D PA QL(60/28)ETHYOL 5 B/D PAfludarabine phosphate inj 50mg 4 B/D PAFUSILEV 5HALAVEN 5 PAidarubicin hcl inj 10mg/10ml 5 B/D PAirinotecan 4 B/D PAirinotecan hcl 4 B/D PAirinotecan hydrochloride inj 40mg/2ml

4 B/D PA

ISTODAX (OVERFILL) 5 PAJEVTANA 5 PAKISQALI 5 PA QL(63/28)LARTRUVO 5 PAleucovorin calcium inj 100mg, 350mg, 500mg, 50mg

4

leucovorin calcium tabs 2levoleucovorin calcium inj 175mg/17.5ml

5

levoleucovorin inj 175mg/17.5ml, 250mg/25ml, 50mg

5

lipodox 50 5 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antiestrogens/ModifiersEMCYT 3FARESTON 5 QL(30/30)FASLODEX 5 B/D PA QL(30/30)SOLTAMOX 5tamoxifen citrate 2Antimetabolitesadrucil 4 B/D PAALIMTA 5 PAARRANON 4cladribine 4 B/D PAclofarabine 4 B/D PAcytarabine 4 B/D PAcytarabine aqueous 4 B/D PADROXIA 3ELITEK 5 B/D PAfluorouracil inj 4 B/D PAFOLOTYN 5 B/D PAgemcitabine 4 B/D PAgemcitabine hcl inj 200mg, 2gm 4 B/D PAgemcitabine hcl inj 1gm 5 B/D PAgemcitabine hydrochloride inj 1.5gm/15ml, 1gm/10ml, 200mg/2ml, 2gm/20ml

5 B/D PA

hydroxyurea 2LONSURF TABS 8.19MG; 20MG

5 PA QL(80/28)

LONSURF TABS 6.14MG; 15MG

5 PA QL(100/28)

mercaptopurine 2NIPENT 5 B/D PAPURIXAN 5 PA QL(300/30)TABLOID 3VYXEOS 5 B/D PAAntineoplastics, OtherABRAXANE 5 PAadriamycin inj 2mg/ml 2 B/D PAazacitidine 5 B/D PABELEODAQ 5 PAbleomycin sulfate 4 B/D PA

27



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ZOLINZA 5 QL(120/30)Aromatase Inhibitors, 3rd Generationanastrozole 2 QL(30/30)exemestane 2 QL(60/30)letrozole 2 QL(30/30)Enzyme Inhibitorsetoposide inj 3 B/D PAKYPROLIS 5 B/D PAtoposar 3 B/D PAtopotecan hcl inj 4mg 5Molecular Target InhibitorsAFINITOR DISPERZ TBSO 2MG, 3MG

5 PA QL(56/28)

AFINITOR DISPERZ TBSO 5MG

5 PA QL(112/28)

AFINITOR TABS 2.5MG, 5MG, 7.5MG

5 PA QL(28/28)

AFINITOR TABS 10MG 5 PA QL(56/28)ALECENSA 5 PA QL(240/30)ALIQOPA 5 PA QL(3/28)ALUNBRIG TABS 180MG, 90MG

5 PA QL(30/30)

ALUNBRIG TABS 30MG 5 PA QL(180/30)ALUNBRIG TBPK 5 PA QL(60/365)BOSULIF TABS 400MG, 500MG

5 PA QL(30/30)

BOSULIF TABS 100MG 5 PA QL(120/30)CABOMETYX TABS 20MG, 60MG

5 PA QL(30/30)

CABOMETYX TABS 40MG 5 PA QL(60/30)CALQUENCE 5 PA QL(60/30)CAPRELSA TABS 300MG 5 PA QL(30/30)CAPRELSA TABS 100MG 5 PA QL(60/30)COMETRIQ KIT 5 PA QL(56/28)COMETRIQ KIT 20MG 5 PA QL(84/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LYNPARZA TABS 5 PA QL(120/30)MEKTOVI 5 PA QL(180/30)mesna 2 B/D PAMESNEX TABS 5mitomycin inj 40mg 5 B/D PAmitomycin inj 20mg, 5mg 4 B/D PAmitoxantrone hcl 2 B/D PANERLYNX 5 PA QL(180/30)NINLARO 5 PA QL(3/28)ODOMZO 5 PA QL(30/30)oxaliplatin inj 100mg 5 B/D PAoxaliplatin inj 100mg/20ml, 50mg/10ml

4 B/D PA

paclitaxel inj 100mg/16.7ml, 150mg/25ml, 300mg/50ml

4 B/D PA

PORTRAZZA 5 PA QL(100/21)PROLEUKIN 5 B/D PAromidepsin 5 PARUBRACA 5 PA QL(120/30)RYDAPT 5 PA QL(224/28)SYLATRON 5 PA QL(4/28)SYNRIBO 5 PA QL(28/28)TRISENOX 4 B/D PAVELCADE 5 PA QL(14/21)VENCLEXTA STARTING PACK 5 PA QL(84/365)VENCLEXTA TABS 100MG 5 PA QL(120/30)VENCLEXTA TABS 50MG 4 PA QL(30/30)VENCLEXTA TABS 10MG 4 PA QL(60/30)VERZENIO 5 PA QL(60/30)vinblastine sulfate 4 B/D PAvincasar pfs 4 B/D PAvincristine sulfate 4 B/D PAvinorelbine tartrate inj 50mg/5ml

4 B/D PA

ZEJULA 5 PA QL(90/30)

28


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

temsirolimus 5 B/D PA QL(4/28)TIBSOVO 5 PA QL(60/30)TYKERB 5 PA QL(180/30)VOTRIENT 5 PA QL(120/30)XALKORI 5 PA QL(60/30)ZALTRAP 5 PA QL(40/28)ZELBORAF 5 PA QL(240/30)ZYDELIG 5 PA QL(60/30)ZYKADIA 5 PA QL(140/28)Monoclonal Antibody/Antibody-Drug ConjugateAVASTIN 5 PABAVENCIO 5 PABESPONSA 5 PACYRAMZA 5 PADARZALEX 5 PAEMPLICITI 5 PAERBITUX 5 PAGAZYVA 5 PAHERCEPTIN INJ 440MG 5 PAHERCEPTIN INJ 150MG 5 B/D PAIMFINZI 5 PAKADCYLA 5 PAKEYTRUDA 5 PAMYLOTARG 5 PAOPDIVO INJ 240MG/24ML 5 PA QL(48/28)OPDIVO INJ 100MG/10ML, 40MG/4ML

5 PA QL(80/28)

PERJETA 5 PAPOTELIGEO 5 PARITUXAN 5 PARITUXAN HYCELA 5 PATECENTRIQ 5 PA QL(20/21)UNITUXIN 5 PAVECTIBIX 5 PAYERVOY INJ 50MG/10ML 5 PAYERVOY INJ 200MG/40ML 5 PA QL(80/21)Retinoidsbexarotene 5PANRETIN 5

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

COMETRIQ KIT 5 PA QL(112/28)COTELLIC 5 PA QL(63/28)ERIVEDGE 5 PA QL(28/28)FARYDAK 5 PA QL(6/21)GILOTRIF 5 PA QL(30/30)IBRANCE 5 PA QL(21/28)ICLUSIG TABS 45MG 5 PA QL(30/30)ICLUSIG TABS 15MG 5 PA QL(60/30)IDHIFA 5 PA QL(30/30)imatinib mesylate 5 PA QL(60/30)IMBRUVICA CAPS 70MG 5 PA QL(30/30)IMBRUVICA CAPS 140MG 5 PA QL(120/30)IMBRUVICA TABS 5 PA QL(30/30)INLYTA 5 PA QL(120/30)IRESSA 5 PA QL(30/30)JAKAFI 5 PA QL(60/30)LENVIMA 10 MG DAILY DOSE 5 PA QL(30/30)LENVIMA 12MG DAILY DOSE 5 PA QL(90/30)LENVIMA 14 MG DAILY DOSE 5 PA QL(60/30)LENVIMA 18 MG DAILY DOSE 5 PA QL(90/30)LENVIMA 20 MG DAILY DOSE 5 PA QL(60/30)LENVIMA 24 MG DAILY DOSE 5 PA QL(90/30)LENVIMA 4 MG DAILY DOSE 5 PA QL(30/30)LENVIMA 8 MG DAILY DOSE 5 PA QL(60/30)LYNPARZA CAPS 5 PA QL(448/28)MEKINIST TABS 2MG 5 PA QL(30/30)MEKINIST TABS 0.5MG 5 PA QL(90/30)NEXAVAR 5 PA QL(120/30)SPRYCEL 5 PA QL(30/30)STIVARGA 5 PASUTENT 5 PA QL(28/28)TAFINLAR 5 PA QL(120/30)TAGRISSO 5 PA QL(30/30)TARCEVA TABS 100MG, 150MG

5 PA QL(30/30)

TARCEVA TABS 25MG 5 PA QL(60/30)TASIGNA CAPS 150MG, 200MG

5 PA QL(112/28)

TASIGNA CAPS 50MG 5 PA QL(420/30)

29



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

entacapone 4 QL(240/30)tolcapone 5Dopamine AgonistsAPOKYN 5 PA QL(60/30)bromocriptine mesylate 2NEUPRO 4 QL(30/30)pramipexole dihydrochloride 2 QL(90/30)pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 3mg, 4.5mg

4 QL(30/30)

pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg

4 QL(90/30)

ropinirole hcl 2Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitorscarbidopa 2carbidopa/levodopa 2carbidopa/levodopa er 2carbidopa/levodopa odt 2carbidopa/levodopa/entacapone

3

RYTARY 4 STMonoamine Oxidase B (MAO-B) Inhibitorsrasagiline mesylate 3 QL(30/30)selegiline hcl 2

Antipsychotics

1st Generation/Typicalchlorpromazine hcl inj 4chlorpromazine hcl tabs 2compro 2fluphenazine decanoate 4fluphenazine hcl conc 2fluphenazine hcl elix 2fluphenazine hcl inj 4fluphenazine hcl tabs 1mg 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TARGRETIN GEL 5 QL(60/30)tretinoin caps 5

Antiparasitics

AnthelminticsALBENZA 4BILTRICIDE 4ivermectin 2praziquantel 4AntiprotozoalsALINIA SUSR 3 QL(150/30)ALINIA TABS 5 QL(20/30)atovaquone 4atovaquone/proguanil hcl 2chloroquine phosphate 2COARTEM 3 QL(24/30)DARAPRIM 5 QL(90/30)hydroxychloroquine sulfate 2mefloquine hcl 2NEBUPENT 3 B/D PA QL(6/28)PENTAM 300 3PRIMAQUINE PHOSPHATE 3quinine sulfate 4 QL(42/7)Pediculicides/Scabicideslindane 2malathion 4permethrin 2

Antiparkinson Agents

Anticholinergicsbenztropine mesylate inj 4benztropine mesylate tabs 2 PAtrihexyphenidyl hcl 2 PAAntiparkinson Agents, Otheramantadine hcl 2

30


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

FANAPT TITRATION PACK 4 QL(16/365) STGEODON INJ 4 QL(6/30)INVEGA SUSTENNA INJ 39MG/0.25ML

4 QL(0.25/28)

INVEGA SUSTENNA INJ 78MG/0.5ML

5 QL(0.5/28)


5 QL(0.75/28)

INVEGA SUSTENNA INJ 156MG/ML

5 QL(1/28)


5 QL(1.5/28)

INVEGA TRINZA INJ 273MG/0.875ML

5 QL(0.88/90)


5 QL(1.32/90)


5 QL(1.75/90)


5 QL(2.63/90)

LATUDA TABS 120MG, 20MG, 40MG, 60MG

5 QL(30/30) ST

LATUDA TABS 80MG 5 QL(60/30) STNUPLAZID CAPS 5 PA QL(30/30)NUPLAZID TABS 10MG 5 PA QL(30/30)NUPLAZID TABS 17MG 5 PA QL(60/30)olanzapine inj 4 QL(30/30)olanzapine odt 3 QL(30/30)olanzapine tabs 2 QL(30/30)paliperidone er tb24 1.5mg, 3mg

2 QL(30/30) ST

paliperidone er tb24 6mg 2 QL(60/30) STpaliperidone er tb24 9mg 5 QL(30/30) STquetiapine fumarate 2 QL(60/30)quetiapine fumarate er tb24 150mg, 200mg

3 QL(30/30)

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

3 QL(60/30)

REXULTI 5 QL(30/30)RISPERDAL CONSTA INJ 50MG

5 QL(2/28)

RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG

4 QL(2/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluphenazine hcl tabs 10mg, 2.5mg, 5mg

2

haloperidol conc 2haloperidol decanoate 4haloperidol lactate 4haloperidol tabs 10mg, 20mg 2haloperidol tabs 0.5mg, 1mg, 2mg, 5mg

1

loxapine caps 25mg, 50mg 2loxapine caps 10mg, 5mg 2 QL(120/30)loxapine succinate caps 25mg, 50mg

2

loxapine succinate caps 10mg, 5mg

2 QL(120/30)

perphenazine 2pimozide 2prochlorperazine 2prochlorperazine edisylate 4prochlorperazine maleate tabs 5mg

2

prochlorperazine maleate tabs 10mg

1

thioridazine hcl 2thiothixene caps 10mg, 1mg, 5mg

2

thiothixene caps 2mg 1trifluoperazine hcl 22nd Generation/AtypicalABILIFY MAINTENA 5 QL(1/28)aripiprazole odt 5 QL(60/30)aripiprazole oral soln 3 QL(900/30)aripiprazole tabs 3 QL(30/30)ARISTADA INITIO 5 QL(4.8/365)ARISTADA INJ 441MG/1.6ML 5 QL(1.6/30)ARISTADA INJ 662MG/2.4ML 5 QL(2.4/30)ARISTADA INJ 882MG/3.2ML 5 QL(3.2/30)ARISTADA INJ 1064MG/3.9ML 5 QL(3.9/60)FANAPT TABS 1MG, 2MG, 4MG

4 QL(60/30) ST

FANAPT TABS 10MG, 12MG, 6MG, 8MG

5 QL(60/30) ST

31



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antivirals

Anti-cytomegalovirus (CMV) Agentscidofovir 5FOSCAVIR 4ganciclovir inj 500mg, 500mg/10ml

4 B/D PA

valganciclovir 5valganciclovir hydrochlorde 5ZIRGAN 3Anti-hepatitis B (HBV) Agentsadefovir dipivoxil 5 QL(30/30)BARACLUDE ORAL SOLN 3 QL(630/30)entecavir 4 QL(30/30)EPIVIR HBV ORAL SOLN 3INTRON A INJ 10MU, 10MU/ML, 50MU

5

INTRON A INJ 18MU, 6000000UNIT/ML

4

lamivudine tabs 100mg 2Anti-hepatitis C (HCV) Agents, Direct Acting AgentsEPCLUSA 5 PA QL(28/28)HARVONI 5 PA QL(28/28)VOSEVI 5 PA QL(30/30)Anti-hepatitis C (HCV) Agents, OtherPEGASYS INJ 180MCG/0.5ML 5 PA QL(2/28)PEGASYS INJ 180MCG/ML 5 PA QL(4/28)PEGASYS PROCLICK 5 PA QL(2/28)ribavirin caps 4 QL(168/28)ribavirin tabs 4 QL(168/28)Anti-HIV Agents, Integrase Inhibitors (INSTI)BIKTARVY 5 QL(30/30)GENVOYA 5 QL(30/30)ISENTRESS CHEW 100MG 5 QL(180/30)ISENTRESS CHEW 25MG 3 QL(180/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

risperidone m-tab 3 QL(60/30)risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg

3 QL(60/30)

risperidone odt tbdp 4mg 3 QL(120/30)risperidone oral soln 2 QL(240/30)risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg

2 QL(60/30)

risperidone tabs 4mg 2 QL(120/30)SAPHRIS 4 QL(60/30)VRAYLAR CAPS 5 QL(30/30) STVRAYLAR CPPK 4 QL(14/365) STziprasidone hcl 3 QL(60/30)ZYPREXA RELPREVV INJ 210MG

4 QL(2/28)

ZYPREXA RELPREVV INJ 405MG

5 QL(1/28)

ZYPREXA RELPREVV INJ 300MG

5 QL(2/28)

Treatment-Resistantclozapine odt tbdp 12.5mg, 25mg

4

clozapine odt tbdp 150mg 4 QL(180/30)clozapine odt tbdp 100mg 4 QL(270/30)clozapine odt tbdp 200mg 5 QL(120/30)clozapine tabs 25mg, 50mg 3clozapine tabs 200mg 3 QL(120/30)clozapine tabs 100mg 3 QL(270/30)VERSACLOZ 4 QL(540/30)

Antispasticity Agents

Antispasticity Agentsbaclofen tabs 10mg 1baclofen tabs 20mg, 5mg 2dantrolene sodium 2tizanidine hcl 2

32


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lamivudine oral soln 2 QL(900/30)lamivudine tabs 300mg 2 QL(30/30)lamivudine tabs 150mg 2 QL(60/30)lamivudine/zidovudine 4 QL(60/30)RETROVIR IV INFUSION 4stavudine 2 QL(60/30)tenofovir disoproxil fumarate 5 QL(30/30)TRIUMEQ 5 QL(30/30)TRUVADA 5 QL(30/30)VIDEX EC CPDR 125MG 4 QL(30/30)VIDEX PEDIATRIC 3 QL(1200/30)VIREAD POWD 5 QL(240/30)VIREAD TABS 5 QL(30/30)ZERIT ORAL SOLN 3 QL(2400/30)ZIAGEN ORAL SOLN 3 QL(960/30)zidovudine caps 2 QL(180/30)zidovudine syrp 2 QL(1680/28)zidovudine tabs 2 QL(60/30)Anti-HIV Agents, OtherATRIPLA 5 QL(30/30)FUZEON 5 QL(60/30)ISENTRESS HD 5 QL(60/30)SELZENTRY ORAL SOLN 5 QL(1610/26)SELZENTRY TABS 150MG, 75MG

5 QL(60/30)

SELZENTRY TABS 300MG 5 QL(120/30)SELZENTRY TABS 25MG 4 QL(240/30)TROGARZO 5 B/D PATYBOST 3 QL(30/30)Anti-HIV Agents, Protease InhibitorsAPTIVUS CAPS 5 QL(120/30)APTIVUS ORAL SOLN 5 QL(285/28)atazanavir caps 300mg 5 QL(30/30)atazanavir caps 200mg 5 QL(60/30)atazanavir sulfate caps 300mg 5 QL(30/30)atazanavir sulfate caps 200mg 5 QL(60/30)atazanavir sulfate caps 150mg 4 QL(30/30)CRIXIVAN CAPS 400MG 3 QL(180/30)CRIXIVAN CAPS 200MG 3 QL(270/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ISENTRESS PACK 5 QL(180/30)ISENTRESS TABS 5 QL(60/30)JULUCA 5 QL(30/30)TIVICAY TABS 50MG 5 QL(60/30)TIVICAY TABS 10MG, 25MG 4 QL(60/30)Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)COMPLERA 5 QL(30/30)EDURANT 5 QL(30/30)efavirenz caps 200mg 3 QL(60/30)efavirenz caps 50mg 3 QL(90/30)efavirenz tabs 5 QL(30/30)INTELENCE TABS 100MG, 200MG

5 QL(60/30)

INTELENCE TABS 25MG 4 QL(120/30)nevirapine er tb24 400mg 2 QL(30/30)nevirapine er tb24 100mg 2 QL(90/30)nevirapine tabs 2 QL(60/30)ODEFSEY 5 QL(30/30)RESCRIPTOR TABS 200MG 3 QL(180/30)RESCRIPTOR TABS 100MG 3 QL(270/30)STRIBILD 5 QL(30/30)SUSTIVA CAPS 200MG 5 QL(60/30)SUSTIVA CAPS 50MG 3 QL(90/30)SUSTIVA TABS 5 QL(30/30)SYMFI 5 QL(30/30)SYMFI LO 5 QL(30/30)VIRAMUNE SUSP 4 QL(1200/30)Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)abacavir oral soln 3 QL(960/30)abacavir sulfate/lamivudine/zidovudine

5 QL(60/30)

abacavir tabs 4 QL(60/30)abacavir/lamivudine 5 QL(30/30)CIMDUO 5 QL(30/30)DESCOVY 5 QL(30/30)didanosine 2 QL(30/30)EMTRIVA CAPS 3 QL(30/30)EMTRIVA ORAL SOLN 3 QL(680/28)

33



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

oseltamivir phosphate susr 3 QL(700/365)rimantadine hcl 2TAMIFLU CAPS 45MG, 75MG 4 QL(56/365)TAMIFLU CAPS 30MG 4 QL(112/365)TAMIFLU SUSR 3 QL(700/365)Antiherpetic Agentsacyclovir caps 2acyclovir oint 4 QL(30/30)acyclovir sodium 4 B/D PAacyclovir susp 2acyclovir tabs 2DENAVIR 5 QL(5/30)famciclovir 2 QL(60/30)trifluridine 2valacyclovir hcl 2 QL(30/30)valacyclovir hydrochloride 2 QL(30/30)ZOVIRAX CREA 4 QL(5/30)

Anxiolytics

Anxiolytics, Otherbuspirone hcl tabs 10mg, 5mg 1buspirone hcl tabs 15mg, 30mg, 7.5mg

2

doxepin hcl 3 PABenzodiazepinesalprazolam odt tbdp 0.25mg, 0.5mg, 1mg

2 QL(90/30)

alprazolam odt tbdp 2mg 2 QL(150/30)alprazolam tabs 0.25mg, 0.5mg, 1mg

2 QL(90/30)

alprazolam tabs 2mg 2 QL(150/30)clorazepate dipotassium tabs 3.75mg, 7.5mg

3 QL(90/30)

clorazepate dipotassium tabs 15mg

3 QL(180/30)

diazepam inj 5mg/ml 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

EVOTAZ 5 QL(30/30)fosamprenavir calcium 5 QL(120/30)INVIRASE CAPS 5 QL(300/30)INVIRASE TABS 5 QL(120/30)KALETRA ORAL SOLN 4 QL(480/30)KALETRA TABS 100MG; 25MG

4 QL(300/30)

KALETRA TABS 200MG; 50MG

5 QL(120/30)

LEXIVA SUSP 4 QL(1575/28)LEXIVA TABS 5 QL(120/30)lopinavir/ritonavir 4 QL(480/30)NORVIR CAPS 4 QL(360/30)NORVIR ORAL SOLN 4 QL(480/30)NORVIR PACK 4 QL(360/30)NORVIR TABS 4 QL(360/30)PREZCOBIX 5 QL(30/30)PREZISTA SUSP 5 QL(400/30)PREZISTA TABS 800MG 5 QL(30/30)PREZISTA TABS 600MG 5 QL(60/30)PREZISTA TABS 150MG 4 QL(180/30)PREZISTA TABS 75MG 4 QL(210/30)REYATAZ CAPS 150MG, 300MG

5 QL(30/30)

REYATAZ CAPS 200MG 5 QL(60/30)REYATAZ PACK 5 QL(180/30)ritonavir 4 QL(360/30)SYMTUZA 5 QL(30/30)VIRACEPT TABS 625MG 5 QL(120/30)VIRACEPT TABS 250MG 5 QL(270/30)Anti-influenza Agentsoseltamivir phosphate caps 45mg, 75mg

3 QL(56/365)

oseltamivir phosphate caps 30mg

3 QL(112/365)

34


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

glipizide/metformin hcl tabs 2.5mg; 250mg

1 QL(240/30)

GLYXAMBI 4 QL(30/30)INVOKAMET 3 QL(60/30)INVOKAMET XR 3 QL(60/30)INVOKANA 3 QL(30/30)JANUMET 3 QL(60/30)JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG

3 QL(30/30)

JANUMET XR TB24 1000MG; 50MG

3 QL(60/30)

JANUVIA 3 QL(30/30)JARDIANCE 4 QL(30/30)JENTADUETO 3 QL(60/30)JENTADUETO XR TB24 5MG; 1000MG

3 QL(30/30)

JENTADUETO XR TB24 2.5MG; 1000MG

3 QL(60/30)

metformin hcl er tb24 1000mg, 500mg, (generic for Fortamet)

1 QL(60/30)

metformin hcl er tb24 750mg (generic for Glucophage XR)

1 QL(60/30)

metformin hcl er tb24 500mg (generic for Glucophage XR)

1 QL(120/30)

metformin hcl tabs 1000mg 1 QL(60/30)metformin hcl tabs 850mg 1 QL(90/30)metformin hydrochloride oral soln

3 QL(750/30)

metformin hydrochloride tabs 500mg

1 QL(150/30)

miglitol 4 QL(90/30)nateglinide 2 QL(90/30)OZEMPIC 3 QL(3/28)pioglitazone hcl 2 QL(30/30)pioglitazone hcl/metformin hcl 2 QL(90/30)repaglinide tabs 0.5mg, 1mg 2 QL(120/30)repaglinide tabs 2mg 2 QL(240/30)RIOMET 3 QL(750/30)SYMLINPEN 120 5 PA QL(10.8/28)SYMLINPEN 60 3 PA QL(6/30)SYNJARDY 4 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

diazepam oral soln 2 QL(1200/30)diazepam tabs 2 QL(120/30)lorazepam conc 2 QL(150/30)lorazepam inj 2mg/ml, 4mg/ml 4lorazepam intensol 2 QL(150/30)lorazepam tabs 0.5mg, 1mg 2 QL(90/30)lorazepam tabs 2mg 2 QL(150/30)oxazepam 2 QL(120/30)

Bipolar Agents

Mood Stabilizerslithium carbonate caps 300mg 1lithium carbonate caps 150mg, 600mg

2

lithium carbonate er 2lithium carbonate tabs 2

Blood Glucose Regulators

Antidiabetic Agentsacarbose 2 QL(90/30)BYDUREON 3 QL(4/28)BYDUREON BCISE 3 QL(4/28)BYDUREON PEN 3 QL(4/28)BYETTA INJ 5MCG/0.02ML 3 QL(1.2/30)BYETTA INJ 10MCG/0.04ML 3 QL(2.4/30)CYCLOSET 4 QL(180/30)FARXIGA 3 QL(30/30)glimepiride tabs 4mg 1 QL(60/30)glimepiride tabs 2mg 1 QL(120/30)glimepiride tabs 1mg 1 QL(240/30)glipizide er tb24 10mg 1 QL(60/30)glipizide er tb24 5mg 1 QL(120/30)glipizide er tb24 2.5mg 1 QL(240/30)glipizide tabs 5mg 1 QL(60/30)glipizide tabs 10mg 1 QL(120/30)glipizide xl tb24 10mg 1 QL(60/30)glipizide xl tb24 5mg 1 QL(120/30)glipizide xl tb24 2.5mg 1 QL(240/30)glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg

1 QL(120/30)

35



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LANTUS SOLOSTAR 3LEVEMIR 3LEVEMIR FLEXTOUCH 3SOLIQUA 100/33 3 QL(18/30) STTOUJEO MAX SOLOSTAR 3TOUJEO SOLOSTAR 3TRESIBA FLEXTOUCH 3XULTOPHY 100/3.6 3 QL(15/30) ST

Blood Products/Modifiers/Volume Expanders

AnticoagulantsCOUMADIN 4ELIQUIS STARTER PACK 4 QL(74/30)ELIQUIS TABS 2.5MG 4 QL(60/30)ELIQUIS TABS 5MG 4 QL(74/30)enoxaparin sodium inj 30mg/0.3ml

4 QL(9/90)

enoxaparin sodium inj 40mg/0.4ml

4 QL(12/90)

enoxaparin sodium inj 60mg/0.6ml

4 QL(18/90)

enoxaparin sodium inj 120mg/0.8ml, 80mg/0.8ml

4 QL(24/90)

enoxaparin sodium inj 100mg/ml, 150mg/ml, 300mg/3ml

4 QL(30/90)

fondaparinux sodium inj 2.5mg/0.5ml

4 QL(15/90)

fondaparinux sodium inj 5mg/0.4ml

5 QL(12/90)

fondaparinux sodium inj 7.5mg/0.6ml

5 QL(18/90)

fondaparinux sodium inj 10mg/0.8ml

5 QL(24/90)

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

4

heparin sodium/d5w 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG

4 QL(30/30)

SYNJARDY XR TB24 12.5MG; 1000MG, 5MG; 1000MG

4 QL(60/30)

TRADJENTA 3 QL(30/30)TRULICITY 3 QL(2/28)VICTOZA 3 QL(9/30)XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, 2.5MG; 1000MG, 5MG; 500MG

3 QL(30/30)

XIGDUO XR TB24 5MG; 1000MG

3 QL(60/30)

Glycemic AgentsGLUCAGEN HYPOKIT 3 QL(4/30)GLUCAGON EMERGENCY KIT

3 QL(4/30)

PROGLYCEM 4InsulinsHUMALOG 3HUMALOG JUNIOR KWIKPEN 3HUMALOG KWIKPEN 3HUMALOG MIX 50/50 3HUMALOG MIX 50/50 KWIKPEN

3

HUMALOG MIX 75/25 3HUMALOG MIX 75/25 KWIKPEN

3

HUMULIN 70/30 3HUMULIN 70/30 KWIKPEN 3HUMULIN N 3HUMULIN N KWIKPEN 3HUMULIN R 3HUMULIN R U-500 (CONCENTRATED)

3

HUMULIN R U-500 KWIKPEN 3LANTUS 3

36


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

4 PA QL(12/28)

PROMACTA 5 PA QL(30/30)ZARXIO 5 PAHemostasis Agentstranexamic acid inj 2tranexamic acid tabs 2 QL(30/28)Platelet Modifying Agentsaspirin/dipyridamole 4 QL(60/30)BRILINTA 3 QL(60/30)cilostazol 2clopidogrel tabs 300mg 2 QL(2/365)clopidogrel tabs 75mg 2 QL(30/30)prasugrel 4 QL(30/30)

Cardiovascular Agents

Alpha-adrenergic Agonistsclonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr

2 QL(4/28)

clonidine hcl ptwk 0.3mg/24hr 2 QL(8/28)clonidine hcl tabs 0.3mg 2clonidine hcl tabs 0.1mg, 0.2mg 1midodrine hcl 2Alpha-adrenergic Blocking Agentsphenoxybenzamine hydrochloride

5

prazosin hcl 2Angiotensin II Receptor AntagonistsBENICAR 4 QL(30/30) STBENICAR HCT 4 QL(30/30) STcandesartan cilexetil 2 QL(30/30)candesartan cilexetil/hydrochlorothiazide

2 QL(30/30)

EDARBI 4 STEDARBYCLOR 4 STENTRESTO 3 QL(60/30)irbesartan 1 QL(30/30)irbesartan/hydrochlorothiazide 1 QL(30/30)losartan potassium tabs 100mg 1 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

heparin sodium/nacl 0.45% inj 50unit/ml; 0.45%

4

heparin sodium/nacl 0.9% 4heparin sodium/sodium chloride 0.9%

4

heparin sodium/sodium chloride 0.9% premix

4

jantoven 1PRADAXA 3 QL(60/30)SAVAYSA 4 QL(30/30)warfarin sodium 1XARELTO STARTER PACK 3 QL(102/365)XARELTO TABS 20MG 3 QL(30/30)XARELTO TABS 15MG 3 QL(60/30)XARELTO TABS 10MG 3 QL(90/90)Blood Formation Modifiersanagrelide hydrochloride 2ARANESP ALBUMIN FREE INJ 60MCG/0.3ML

4 PA QL(1.2/28)

ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML

4 PA QL(1.6/28)

ARANESP ALBUMIN FREE INJ 25MCG/0.42ML

4 PA QL(1.68/28)

ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML

4 PA QL(4/28)

ARANESP ALBUMIN FREE INJ 500MCG/ML

5 PA QL(1/21)


5 PA QL(1.2/28)


5 PA QL(1.6/28)


5 PA QL(2/28)


5 PA QL(2.4/28)

ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML, 60MCG/ML

5 PA QL(4/28)

LEUKINE INJ 250MCG 5 PAMOZOBIL 5 QL(9.6/30)PROCRIT INJ 40000UNIT/ML 5 PA QL(6/28)PROCRIT INJ 20000UNIT/ML 5 PA QL(12/28)

37



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg

1 QL(120/30)

moexipril hcl 2moexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg

2 QL(30/30)

moexipril/hydrochlorothiazide tabs 12.5mg; 15mg, 25mg; 15mg

2 QL(60/30)

perindopril erbumine 1 QL(60/30)quinapril hcl 1 QL(60/30)quinapril/hydrochlorothiazide tabs 12.5mg; 10mg

2 QL(30/30)

quinapril/hydrochlorothiazide tabs 12.5mg; 20mg, 25mg; 20mg

2 QL(60/30)

ramipril 1 QL(60/30)trandolapril tabs 1mg 2 QL(30/30)trandolapril tabs 2mg, 4mg 2 QL(60/30)Antiarrhythmicsamiodarone hcl inj 4amiodarone hcl tabs 2dofetilide 3 QL(60/30)flecainide acetate 2lidocaine hcl inj 4mexiletine hcl 2MULTAQ 3 QL(60/30)pacerone 2propafenone hcl 2propafenone hcl er cp12 225mg, 325mg

4

propafenone hydrochloride er cp12 425mg

4

quinidine sulfate 2sorine 2sotalol hcl 2sotalol hcl (af) 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

losartan potassium tabs 25mg, 50mg

1 QL(60/30)

losartan potassium/hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg

1 QL(30/30)

losartan potassium/hydrochlorothiazide tabs 12.5mg; 50mg

1 QL(60/30)

olmesartan medoxomil 4 QL(30/30)olmesartan medoxomil/hydrochlorothiazide

4 QL(30/30)

telmisartan 2 QL(30/30)telmisartan/amlodipine 2 QL(30/30)telmisartan/hydrochlorothiazide 2 QL(30/30)valsartan 2 QL(30/30)valsartan/hydrochlorothiazide 2 QL(30/30)Angiotensin-converting Enzyme (ACE) Inhibitorsbenazepril hcl 1 QL(60/30)benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg, 20mg; 25mg, 5mg; 6.25mg

2 QL(30/30)

benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg

2 QL(60/30)

captopril tabs 100mg, 50mg 2captopril tabs 12.5mg, 25mg 2 QL(90/30)captopril/hydrochlorothiazide 2enalapril maleate 2 QL(60/30)enalapril maleate/hydrochlorothiazide

2 QL(60/30)

fosinopril sodium 2 QL(60/30)fosinopril sodium/hydrochlorothiazide

2 QL(120/30)

lisinopril 1 QL(60/30)lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg, 25mg; 20mg

1 QL(60/30)

38


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Calcium Channel Blocking Agentsafeditab cr 3 QL(60/30)amlodipine besylate tabs 10mg 1 QL(30/30)amlodipine besylate tabs 5mg 1 QL(60/30)amlodipine besylate tabs 2.5mg 1 QL(120/30)amlodipine besylate/benazepril hydrochloride caps 10mg; 20mg, 10mg; 40mg

2 QL(30/30)

amlodipine besylate/benazepril hydrochloride caps 2.5mg; 10mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg

2 QL(60/30)

amlodipine besylate/valsartan 2 QL(30/30)amlodipine/olmesartan medoxomil

4 QL(30/30)

amlodipine/valsartan/hctz 2 QL(30/30)AZOR 4 QL(30/30) STcartia xt 2dilt-xr 2diltiazem hcl er cp12 2diltiazem hcl er cp24 120mg, 180mg, 240mg, 300mg, 420mg

2

diltiazem hcl er tb24 2diltiazem hcl inj 4diltiazem hcl tabs 2felodipine er 2 QL(60/30)isradipine 2matzim la 2nicardipine hcl caps 2nicardipine hcl inj 4nifedipine er tb24 90mg 3 QL(30/30)nifedipine er tb24 30mg, 60mg 3 QL(60/30)nimodipine 4nisoldipine er tb24 20mg, 30mg, 40mg

2

nisoldipine er tb24 17mg, 25.5mg, 34mg, 8.5mg

2 QL(30/30)

taztia xt cp24 120mg, 180mg, 240mg, 300mg

2

verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg

2 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sotalol hcl af 2sotalol hydrochloride (af) tabs 80mg

2

sotalol hydrochloride tabs 120mg

2

Beta-adrenergic Blocking Agentsacebutolol hcl 2atenolol 1atenolol/chlorthalidone 1betaxolol hcl 2bisoprolol fumarate 2bisoprolol fumarate/hydrochlorothiazide

1

BYSTOLIC TABS 10MG, 2.5MG, 5MG

3 QL(30/30)

BYSTOLIC TABS 20MG 3 QL(60/30)BYVALSON 3 QL(30/30)carvedilol 1carvedilol phosphate 3 QL(30/30)COREG CR 3 QL(30/30)labetalol hcl inj 4labetalol hcl tabs 2metoprolol succinate er 1 QL(60/30)metoprolol tartrate inj 4metoprolol tartrate tabs 1metoprolol/hydrochlorothiazide 2nadolol 3nadolol/bendroflumethiazide 3 QL(30/30)pindolol 1propranolol hcl er 3propranolol hcl inj 4propranolol hcl oral soln 2propranolol hcl tabs 60mg 2propranolol hcl tabs 10mg, 20mg, 40mg, 80mg

1

propranolol hydrochloride tabs 60mg

2

propranolol/hydrochlorothiazide 2timolol maleate tabs 4

39



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

furosemide inj 2furosemide oral soln 2furosemide tabs 1torsemide 2Diuretics, Potassium-sparingamiloride hcl 2amiloride/hydrochlorothiazide 1spironolactone tabs 25mg 1spironolactone tabs 100mg, 50mg

2

spironolactone/hydrochlorothiazide

2

triamterene/hydrochlorothiazide 1Diuretics, Thiazidechlorothiazide 2chlorothiazide sodium 4chlorthalidone 2hydrochlorothiazide 1indapamide 1metolazone 2Dyslipidemics, Fibric Acid Derivativesfenofibrate caps 130mg, 150mg 4 QL(30/30)fenofibrate caps 43mg, 50mg 4 QL(60/30)fenofibrate micronized caps 134mg, 200mg

2 QL(30/30)

fenofibrate micronized caps 67mg

2 QL(60/30)

fenofibrate tabs 145mg, 160mg 4 QL(30/30)fenofibrate tabs 48mg, 54mg 4 QL(60/30)fenofibric acid dr cpdr 135mg 4 QL(30/30)fenofibric acid dr cpdr 45mg 4 QL(60/30)gemfibrozil 2 QL(60/30)Dyslipidemics, HMG CoA Reductase Inhibitorsatorvastatin calcium 1 QL(30/30)CRESTOR 4 QL(30/30) ST

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

verapamil hcl er cp24 200mg 2 QL(60/30)verapamil hcl er tbcr 2verapamil hcl inj 4verapamil hcl sr cp24 360mg 2 QL(30/30)verapamil hcl tabs 40mg 2verapamil hcl tabs 120mg, 80mg

1

Cardiovascular Agents, Otheratropine sulfate inj 0.5mg/5ml 4CORLANOR 4 PA QL(60/30)DEMSER 5digitek tabs 0.125mg 2 QL(30/30)digitek tabs 0.25mg 2 PAdigox tabs 125mcg 2 QL(30/30)digox tabs 250mcg 2 PAdigoxin inj 4 PAdigoxin tabs 125mcg 2 QL(30/30)digoxin tabs 250mcg 2 PANORTHERA CAPS 100MG 5 PA QL(90/30)NORTHERA CAPS 200MG, 300MG

5 PA QL(180/30)

pentoxifylline er 2PRALUENT 5 PARANEXA 3 QL(60/30)TEKTURNA 3 QL(30/30)TEKTURNA HCT 3 QL(30/30)Diuretics, Carbonic Anhydrase Inhibitorsacetazolamide 2acetazolamide sodium 4methazolamide 4Diuretics, Loopbumetanide inj 4bumetanide tabs 0.5mg, 1mg 1bumetanide tabs 2mg 2ethacrynate sodium 4

40


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nitroglycerin transdermal 2 QL(30/30)

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetaminesamphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 5mg; 5mg; 5mg; 5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg

3 QL(30/30)

amphetamine/dextroamphetamine cp24 1.25mg; 1.25mg; 1.25mg; 1.25mg, 6.25mg; 6.25mg; 6.25mg; 6.25mg

3 QL(60/30)

amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg

2 QL(60/30)

amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg

2 QL(90/30)

dextroamphetamine sulfate er cp24 5mg

2 QL(60/30)


2 QL(90/30)


2 QL(120/30)

dextroamphetamine sulfate oral soln

2 QL(1800/30)

dextroamphetamine sulfate tabs 5mg

2 QL(60/30)

dextroamphetamine sulfate tabs 10mg

2 QL(180/30)

Attention Deficit Hyperactivity Disorder Agents, Non-amphetaminesatomoxetine caps 100mg, 60mg, 80mg

4 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LIVALO 3 QL(30/30) STlovastatin tabs 40mg 2 QL(60/30)lovastatin tabs 10mg, 20mg 1 QL(30/30)pravastatin sodium 1 QL(30/30)rosuvastatin calcium 2 QL(30/30)simvastatin 1 QL(30/30)Dyslipidemics, Othercholestyramine 2cholestyramine light 2colestipol hcl 2ezetimibe 3 QL(30/30)ezetimibe/simvastatin 4 QL(30/30)niacin er tbcr 500mg 2 QL(30/30)niacin er tbcr 1000mg, 750mg 2 QL(60/30)niacor 2omega-3-acid ethyl esters 4 QL(120/30)prevalite 2REPATHA 5 PA QL(3/30)REPATHA PUSHTRONEX SYSTEM

5 PA QL(3.5/30)

REPATHA SURECLICK 5 PA QL(3/30)VASCEPA CAPS 1GM 4 QL(120/30)VASCEPA CAPS 0.5GM 4 QL(240/30)WELCHOL 3ZETIA 4 QL(30/30) STVasodilators, Direct-acting Arterialhydralazine hcl inj 4hydralazine hcl tabs 2minoxidil 2Vasodilators, Direct-acting Arterial/VenousBIDIL 3 QL(180/30)isosorbide dinitrate er 2isosorbide dinitrate tabs 2isosorbide mononitrate 2isosorbide mononitrate er 2minitran 2 QL(30/30)nitroglycerin inj 4nitroglycerin lingual 4nitroglycerin subl 2

41



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

COPAXONE INJ 40MG/ML 5 PA QL(12/28)COPAXONE INJ 20MG/ML 5 PA QL(30/30)GILENYA 5 PA QL(30/30)REBIF 5 PA QL(6/28)REBIF REBIDOSE 5 PA QL(6/28)REBIF REBIDOSE TITRATION PACK

5 PA QL(4.2/28)

REBIF TITRATION PACK 5 PA QL(4.2/28)TECFIDERA CPDR 120MG 5 PA QL(14/30)TECFIDERA CPDR 240MG 5 PA QL(60/30)TECFIDERA STARTER PACK 5 PA QL(120/365)TYSABRI 5 PA QL(15/28)

Dental and Oral Agents

Dental and Oral Agentschlorhexidine gluconate mouth/throat soln

1

oralone dental paste 2paroex 1periogard 1pilocarpine hcl tabs 2pilocarpine hydrochloride 2triamcinolone acetonide dental paste

2

Dermatological Agents

Dermatological Agentsacitretin 4 PAammonium lactate 2amnesteem 2avita 2 PA QL(45/30)calcipotriene crea 4 QL(120/30)calcipotriene external soln 4 QL(60/30)calcipotriene oint 4 QL(120/30)calcitrene 4 QL(120/30)calcitriol oint 3 QL(800/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

atomoxetine caps 10mg, 18mg, 25mg, 40mg

4 QL(60/30)

clonidine hcl er 4 QL(120/30)dexmethylphenidate hcl 2 QL(60/30)metadate er 3 QL(90/30)methylphenidate hydrochloride er tb24 27mg, 54mg

3 QL(30/30)

methylphenidate hydrochloride er tb24 36mg

3 QL(60/30)

methylphenidate hydrochloride er tb24 18mg

3 QL(120/30)

methylphenidate hydrochloride er tbcr 10mg, 27mg, 54mg

3 QL(30/30)

methylphenidate hydrochloride er tbcr 36mg

3 QL(60/30)


3 QL(90/30)


3 QL(120/30)

methylphenidate hydrochloride tabs

3 QL(90/30)

Central Nervous System, OtherHETLIOZ 5 PA QL(30/30)NUEDEXTA 3 QL(60/30)riluzole 4tetrabenazine tabs 12.5mg 5 PA QL(90/30)tetrabenazine tabs 25mg 5 PA QL(120/30)Fibromyalgia AgentsLYRICA CR TB24 330MG 3 QL(60/30)LYRICA CR TB24 165MG, 82.5MG

3 QL(90/30)

Multiple Sclerosis AgentsAMPYRA 5 PA QL(60/30)AVONEX 5 PA QL(4/28)AVONEX PEN 5 PA QL(4/28)BETASERON 5 PA QL(14/28)

42


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

AMINOSYN 7%/ELECTROLYTES

4 B/D PA

AMINOSYN 8.5%/ELECTROLYTES

4 B/D PA

AMINOSYN II 4 B/D PAAMINOSYN II 8.5%/ELECTROLYTES

4 B/D PA

AMINOSYN M 4 B/D PAAMINOSYN-HBC 4 B/D PAAMINOSYN-PF 4 B/D PAAMINOSYN-PF 7% 4 B/D PAAMINOSYN-RF 4 B/D PACARBAGLU 5 PACLINIMIX 2.75%/DEXTROSE 5%

4 B/D PA

CLINIMIX 4.25%/DEXTROSE 10%

4 B/D PA


4 B/D PA


4 B/D PA


4 B/D PA

CLINIMIX 5%/DEXTROSE 15% 4 B/D PACLINIMIX 5%/DEXTROSE 20% 4 B/D PACLINIMIX 5%/DEXTROSE 25% 4 B/D PACLINIMIX E 2.75%/DEXTROSE 10%

4 B/D PA

CLINIMIX E 4.25%/DEXTROSE 10%

4 B/D PA

CLINIMIX E 4.25%/DEXTROSE 25%

4 B/D PA

CLINIMIX E 5%/DEXTROSE 25%

4 B/D PA

CLINIMIX N14G30E 4 B/D PACLINIMIX N9G15E 4 B/D PACLINISOL SF 15% 4 B/D PAdextrose10%/nacl 0.45% 4 B/D PAdextrose5% /electrolyte #48 viaflex

4 B/D PA

DEXTROSE 10% 4 B/D PAdextrose 10%/nacl 0.2% 4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

claravis 2curity gauze pads 2”x2” 2diclofenac sodium gel 1% 3 QL(1000/30)diclofenac sodium transdermal soln

4 QL(1050/30)

doxepin hydrochloride 2ELIDEL 3 QL(100/90)erythromycin/benzoyl peroxide 2fluorouracil crea 5% 3fluorouracil crea 0.5% 5fluorouracil external soln 2imiquimod 2 QL(12/30)imiquimod pump 5 QL(56/30)isotretinoin 2methoxsalen 5myorisan 2PICATO GEL 0.05% 4 QL(2/56)PICATO GEL 0.015% 4 QL(3/56)podofilox 2REGRANEX 5 PA QL(15/30)SANTYL 3selenium sulfide lotn 1tacrolimus oint 2 QL(100/90)tazarotene 4 QL(120/30)TAZORAC CREA 4 QL(120/30)TAZORAC GEL 4 QL(100/30)tretinoin crea 2 PA QL(45/30)tretinoin gel 2 PA QL(45/30)tretinoin microsphere 4 PAtretinoin microsphere pump gel 0.1%

4 PA

zenatane 2ZYCLARA 5 QL(56/30)ZYCLARA PUMP CREA 2.5% 5 QL(15/30)ZYCLARA PUMP CREA 3.75% 5 QL(56/30)

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral ReplacementAMINOSYN 4 B/D PA

43



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

kcl 0.3%/d5w/nacl 0.45% 4 B/D PAkcl 0.3%/d5w/nacl 0.9% 4 B/D PAklor-con 2klor-con 10 1klor-con 8 1klor-con m10 1klor-con m20 1klor-con sprinkle 2LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L

4 B/D PA

LACTATED RINGERS VIAFLEX

4 B/D PA

ludent 1MAGNESIUM SULFATE INJ 20GM/500ML, 2GM/50ML, 40GM/1000ML, 4GM/100ML, 4GM/50ML

4 B/D PA

magnesium sulfate inj 20gm/500ml, 2gm/50ml, 40gm/1000ml, 4gm/100ml, 4gm/50ml, 50%

4 B/D PA

NEPHRAMINE 4 B/D PANORMOSOL -R 4 B/D PANORMOSOL-M IN D5W 4 B/D PANORMOSOL-R 4 B/D PANORMOSOL-R IN D5W 4 B/D PAPERIKABIVEN 4 B/D PAPLENAMINE 4 B/D PApotassium chloride cr 1potassium chloride er cpcr 2potassium chloride er tbcr 1potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml

4 B/D PA

potassium chloride oral soln 2potassium chloride sr 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dextrose 2.5%/nacl 0.45% 4 B/D PADEXTROSE 20% 4 B/D PADEXTROSE 25% 4 B/D PADEXTROSE 30% 4 B/D PADEXTROSE 40% 4 B/D PADEXTROSE 5% 4dextrose 5%/lactated ringers 4 B/D PAdextrose 5%/nacl 0.2% 4dextrose 5%/nacl 0.225% 4DEXTROSE 5%/NACL 0.3% 4dextrose 5%/nacl 0.33% 4dextrose 5%/nacl 0.45% 4dextrose 5%/nacl 0.9% 4DEXTROSE 50% 4 B/D PADEXTROSE 70% 4fluoride chew 0.25mg 1fluoritab chew 0.5mg, 1mg 1FREAMINE HBC 6.9% 4 B/D PAFREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML

4 B/D PA

HEPATAMINE 4 B/D PAKABIVEN 4 B/D PAkcl 0.075%/d5w/nacl 0.45% 4 B/D PAkcl 0.15%/d5w/nacl 0.2% 4 B/D PAkcl 0.15%/d5w/nacl 0.225% 4 B/D PAkcl 0.15%/d5w/nacl 0.45% 4 B/D PAkcl 0.15%/d5w/nacl 0.9% 4 B/D PA

44


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5%

4

sodium fluoride chew 0.5mg, 1mg

1

SODIUM LACTATE INJ 5MEQ/ML

4 B/D PA

TPN ELECTROLYTES 4 B/D PATRAVASOL 4 B/D PATROPHAMINE 4 B/D PAElectrolyte/Mineral/Metal ModifiersCHEMET 5CUPRIMINE 5DEPEN TITRATABS 5JADENU 5JADENU SPRINKLE 5kionex 3SAMSCA TABS 15MG 5 PA QL(30/30)SAMSCA TABS 30MG 5 PA QL(60/30)sodium polystyrene sulfonate powd

3

sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml

3

sps 3SYPRINE 5trientine hydrochloride 5VELTASSA 3Phosphate BindersAURYXIA 4 QL(360/30)calcium acetate caps 2calcium acetate tabs 667mg 2PHOSLYRA 4RENVELA PACK 3 QL(180/30)RENVELA TABS 3 QL(540/30)VELPHORO 4 QL(180/30)Vitaminsmultivitamin with fluoride chew 2VP-PNV-DHA 3

Gastrointestinal Agents

Antispasmodics, Gastrointestinalanaspaz 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

potassium chloride/dextrose inj 5%; 20meq/l, 5%; 40meq/l

4 B/D PA

POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS INJ 3MEQ/L; 149MEQ/L; 5%; 28MEQ/L; 44MEQ/L; 130MEQ/L

4 B/D PA

potassium chloride/dextrose/lactated ringers inj 3meq/l; 149meq/l; 5%; 28meq/l; 24meq/l; 130meq/l

4 B/D PA

potassium chloride/dextrose/sodium chloride

4 B/D PA

potassium chloride/sodium chloride inj 20meq/l; 0.45%, 20meq/l; 0.9%, 40meq/l; 0.9%

4 B/D PA

potassium citrate er 2PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML

4 B/D PA

premasol inj 56meq/l; 320mg/100ml; 730mg/100ml; 190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml; 220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml; 490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml; 230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml

4 B/D PA

PROCALAMINE 4 B/D PAPROSOL 4 B/D PAringers injection 4 B/D PAsodium bicarbonate inj 4sodium bicarbonate partial fill 4sodium chloride 0.45% 4

45



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

famotidine premixed 4famotidine tabs 20mg, 40mg 2nizatidine caps 2ranitidine hcl caps 2ranitidine hcl inj 4ranitidine hcl syrp 2ranitidine hcl tabs 1Irritable Bowel Syndrome Agentsalosetron hydrochloride tabs 0.5mg

4 PA QL(60/30)

alosetron hydrochloride tabs 1mg

5 PA QL(60/30)

AMITIZA 3 QL(60/30)LINZESS 3 QL(30/30)VIBERZI 4 PA QL(60/30)Laxativesconstulose 2enulose 2gavilyte-c 2gavilyte-g 2gavilyte-n/flavor pack 2generlac 2lactulose oral soln 2MOVIPREP 3peg 3350/electrolytes 2peg-3350/electrolytes 2peg-3350/nacl/na bicarbonate/kcl

2

polyethylene glycol 3350 powd 2SUPREP BOWEL PREP KIT 3trilyte 2ProtectantsCARAFATE SUSP 4misoprostol 3sucralfate 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

atropine sulfate inj 0.25mg/5ml, 1mg/ml, 8mg/20ml

4

dicyclomine hcl caps 1dicyclomine hcl oral soln 2dicyclomine hydrochloride 1ed-spaz 2glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml

4

glycopyrrolate tabs 2hyoscyamine sulfate elix 2hyoscyamine sulfate odt 2hyoscyamine sulfate subl 2hyoscyamine sulfate tabs 2hyoscyamine sulfate tbdp 2methscopolamine bromide 2nulev 2oscimin 2propantheline bromide 2Gastrointestinal Agents, Othercromolyn sodium conc 2diphenoxylate/atropine 2GATTEX 5 PA QL(30/30)loperamide hcl caps 2metoclopramide hcl inj 4metoclopramide hcl oral soln 2metoclopramide hcl tabs 2OSMOPREP 3RELISTOR INJ 8MG/0.4ML 5 PA QL(11.2/28)RELISTOR INJ 12MG/0.6ML 5 PA QL(16.8/28)TRULANCE 4 QL(30/30)ursodiol 3Histamine2 (H2) Receptor Antagonistscimetidine 2cimetidine hcl 2famotidine inj 4

46


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tolterodine tartrate 3 QL(60/30)tolterodine tartrate er 3 QL(30/30)VESICARE 4 QL(30/30)Benign Prostatic Hypertrophy Agentsalfuzosin hcl er 2 QL(30/30)doxazosin mesylate tabs 1mg, 2mg, 4mg

2 QL(30/30)

doxazosin mesylate tabs 8mg 2 QL(60/30)dutasteride 2 QL(30/30)dutasteride/tamsulosin hydrochloride

4 QL(30/30)

finasteride tabs 5mg 2 QL(30/30)tamsulosin hcl 2 QL(60/30)terazosin hcl caps 1mg, 2mg, 5mg

1

terazosin hcl caps 10mg 1 QL(60/30)Genitourinary Agents, Otherbethanechol chloride 2ELMIRON 4phenazopyridine hydrochloride 2phenazopyridine hydrocholride 2

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)a-methapred 4ala-cort crea 1% 1alclometasone dipropionate 2augmented betamethasone dipropionate

2

betamethasone dipropionate 3betamethasone valerate crea 2betamethasone valerate foam 3betamethasone valerate lotn 2betamethasone valerate oint 2clobetasol propionate crea 2clobetasol propionate emollient crea

2

clobetasol propionate emollient foam

4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Proton Pump Inhibitorsesomeprazole magnesium 3 QL(60/30)esomeprazole sodium 4omeprazole cpdr 2 QL(60/30)pantoprazole sodium tbec 1 QL(60/30)

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

Genetic or Enzyme Disorder: Replacement, Modifiers, TreatmentADAGEN 5 PAALDURAZYME 5 PABUPHENYL TABS 5 PACEREZYME 5 B/D PACREON 3CYSTADANE 5CYSTAGON 3ELAPRASE 5 PAFABRAZYME 5 B/D PAKUVAN 5 PALUMIZYME 5 PAmiglustat 5 QL(90/30)NAGLAZYME 5 PAORFADIN 5sodium phenylbutyrate 5 PAVPRIV 5 PAZAVESCA 5 QL(90/30)ZENPEP 3

Genitourinary Agents

Antispasmodics, Urinarydarifenacin hydrobromide er 4 QL(30/30)ENABLEX 4 QL(30/30) STflavoxate hcl 2MYRBETRIQ 3 QL(30/30)oxybutynin chloride er tb24 10mg, 5mg

2 QL(30/30)

oxybutynin chloride er tb24 15mg

2 QL(60/30)

oxybutynin chloride syrp 1 QL(600/30)oxybutynin chloride tabs 1 QL(120/30)

47



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluocinonide oint 2fluticasone propionate crea 2fluticasone propionate oint 2halobetasol propionate 2hydrocortisone butyrate (lipid) 2hydrocortisone butyrate (lipophilic)

2

hydrocortisone butyrate crea 2hydrocortisone butyrate external soln

2

hydrocortisone butyrate oint 2hydrocortisone external crea 1hydrocortisone lotn 2.5% 2hydrocortisone oint 1%, 2.5% 2hydrocortisone rectal crea 1hydrocortisone tabs 2hydrocortisone valerate 2MEDROL TABS 2MG 3methylprednisolone acetate inj 40mg/ml, 80mg/ml

4

methylprednisolone dose pack 2methylprednisolone sodiumsuccinate inj 125mg, 40mg

4

methylprednisolone tabs 2mometasone furoate crea 2mometasone furoate external soln

2

mometasone furoate oint 2prednicarbate oint 2prednisolone 2prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml

2

prednisone intensol 2prednisone oral soln 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clobetasol propionate external soln

2

clobetasol propionate foam 4clobetasol propionate gel 2clobetasol propionate oint 2clobetasol propionate sham 2clodan 2cortisone acetate 4DEPO-MEDROL INJ 20MG/ML 4desonide lotn 2desonide oint 2desoximetasone crea 4desoximetasone gel 4desoximetasone oint 4dexamethasone elix 2dexamethasone intensol 2dexamethasone oral soln 2dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml

4

dexamethasone tabs 1.5mg, 1mg, 2mg, 6mg

2

dexamethasone tabs 0.5mg, 0.75mg, 4mg

1

fludrocortisone acetate 2fluocinolone acetonide body 2fluocinolone acetonide crea 2fluocinolone acetonide external soln

1

fluocinolone acetonide oint 2fluocinolone acetonide scalp 2fluocinonide crea 0.05% 2fluocinonide crea 0.1% 4fluocinonide external soln 2fluocinonide gel 2

48


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

STIMATE 3

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

Anabolic SteroidsANADROL-50 5 PAoxandrolone tabs 10mg 5 PA QL(60/30)oxandrolone tabs 2.5mg 3 PA QL(120/30)Androgensdanazol caps 100mg, 200mg 4danazol caps 50mg 3testosterone cypionate 4testosterone enanthate 4 QL(5/30)testosterone gel 25mg/2.5gm, 50mg/5gm

4 PA QL(300/30)

testosterone pump 4 PA QL(300/30)EstrogensALORA 3 PA QL(8/28)altavera 2alyacen 1/35 2alyacen 7/7/7 2amethia 2 QL(91/91)amethia lo 2 QL(91/91)apri 2aranelle 2ashlyna 2 QL(91/91)aubra 2aviane 2balziva 2bekyree 2blisovi fe 1.5/30 2blisovi fe 1/20 2briellyn 2camrese 2 QL(91/91)camrese lo 2 QL(91/91)caziant 2cesia 2chateal 2cryselle-28 2cyclafem 1/35 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

prednisone tabs 50mg 2prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg

1

prednisone tbpk 1procto-med hc 1procto-pak 1proctosol hc 1proctozone-hc 1SOLU-CORTEF 4texacort 3triamcinolone acetonide crea 0.1%

1

triamcinolone acetonide crea 0.025%, 0.5%

2

triamcinolone acetonide inj 40mg/ml

2

triamcinolone acetonide lotn 2triamcinolone acetonide oint 2trianex 5triderm crea 0.1% 1TRIPTODUR 5 PA QL(1/168)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)chorionic gonadotropin 4 PAdesmopressin acetate inj 4desmopressin acetate nasal soln

4 QL(15/30)

desmopressin acetate tabs 2GENOTROPIN 5 PAGENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG

5 PA

GENOTROPIN MINIQUICK INJ 0.2MG

4 PA

INCRELEX 4 PANOVAREL 4 PAPREGNYL W/DILUENT BENZYL ALCOHOL/NACL

4 PA

49



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

junel fe 1.5/30 2junel fe 1/20 2kariva 2kelnor 1/35 2kelnor 1/50 2kimidess 2kurvelo 2larin 1.5/30 2larin 1/20 2larin fe 1.5/30 2larin fe 1/20 2larissia 2lessina 2levonest 2levonorgestrel and ethinyl estradiol tabs 0; 0

2 QL(91/91)

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, 20mcg; 0.1mg

2

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0

2 QL(91/91)

levora 0.15/30-28 2low-ogestrel 2lutera 2marlissa 2melodetta 24 fe 2MENEST 3 PAMENOSTAR 3 PA QL(4/28)mibelas 24 fe 2microgestin 1.5/30 2microgestin 1/20 2microgestin fe 2microgestin fe 1.5/30 2mili 2MINIVELLE 3 PA QL(8/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

cyclafem 7/7/7 2cyred 2dasetta 1/35 2dasetta 7/7/7 2daysee 2 QL(91/91)DELESTROGEN INJ 10MG/ML 4delyla 2DEPO-ESTRADIOL 4desogestrel/ethinyl estradiol 2elinest 2emoquette 2enpresse-28 2enskyce 2estarylla 2estradiol crea 4estradiol pttw 2 PA QL(8/28)estradiol ptwk 2 PA QL(4/28)estradiol tabs 0.5mg, 1mg, 2mg 2 PAestradiol tabs 10mcg 4 QL(18/28)estradiol valerate 4ESTRING 3 QL(1/90)ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg

2

falmina 2FEMRING 3 QL(1/90)femynor 2fyavolv tabs 2.5mcg; 0.5mg 3 PAintrovale 2 QL(91/91)isibloom 2jevantique lo 3 PAjolessa 2 QL(91/91)juleber 2junel 1.5/30 2junel 1/20 2

50


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tydemy 2velivet 2vienva 2viorele 2vyfemla 2vylibra 2wera 2yuvafem 4 QL(18/28)zenchent 2zovia 1/35e 2Progesterone Agonists/AntagonistsELLA 3MAKENA 5 PAProgestinscamila 2deblitane 2DEPO-PROVERA 4 QL(10/28)errin 2heather 2hydroxyprogesterone caproate 5 PAincassia 2jencycla 2jolivette 2lyza 2MAKENA 5 PAmedroxyprogesterone acetate inj 150mg/ml

4 QL(1/90)

medroxyprogesterone acetate inj 150mg/ml

2 QL(1/90)

medroxyprogesterone acetate tabs

1

megestrol acetate susp 40mg/ml

3 PA

megestrol acetate tabs 3 PAnora-be 2norethindrone 2norethindrone acetate 2norlyroc 2progesterone caps 2sharobel 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

mono-linyah 2myzilra 2necon 0.5/35-28 2necon 7/7/7 2norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg

2

norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg

3 PA

norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs

2

norgestimate/ethinyl estradiol 2nortrel 0.5/35 (28) 2nortrel 1/35 2nortrel 7/7/7 2ogestrel 2orsythia 2philith 2pimtrea 2pirmella 1/35 2pirmella 7/7/7 2portia-28 2PREMARIN CREA 3PREMARIN INJ 4PREMARIN TABS 3 PA QL(30/30)previfem 2quasense 2 QL(91/91)reclipsen 2setlakin 2 QL(91/91)sprintec 28 2sronyx 2tarina fe 1/20 2tri-estarylla 2tri-legest fe 2tri-linyah 2tri-mili 2tri-previfem 2tri-sprintec 2tri-vylibra 2trinessa 2trivora-28 2

51



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

leuprolide acetate 4 PALUPRON DEPOT (1-MONTH) 5 PA QL(1/30)LUPRON DEPOT (3-MONTH) 5 PA QL(1/84)LUPRON DEPOT (4-MONTH) 5 PA QL(1/112)LUPRON DEPOT (6-MONTH) 5 PA QL(1/168)LUPRON DEPOT-PED (1-MONTH)

5 PA QL(1/30)

LUPRON DEPOT-PED (3-MONTH)

5 PA QL(1/84)

octreotide acetate inj 500mcg/ml

5 PA

octreotide acetate inj 1000mcg/ml, 100mcg/ml, 200mcg/ml, 50mcg/ml

4 PA

SANDOSTATIN LAR DEPOT 5 PASIGNIFOR 5 PA QL(60/30)SOMATULINE DEPOT INJ 60MG/0.2ML

5 PA QL(0.2/28)

SOMATULINE DEPOT INJ 90MG/0.3ML

5 PA QL(0.3/28)

SOMATULINE DEPOT INJ 120MG/0.5ML

5 PA QL(0.5/28)

SOMAVERT 5 PA QL(30/30)SYNAREL 5 PATRELSTAR MIXJECT INJ 22.5MG

5 PA QL(1/168)

TRELSTAR MIXJECT INJ 3.75MG

5 PA QL(1/28)

TRELSTAR MIXJECT INJ 11.25MG

5 PA QL(1/84)

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agentsmethimazole 2propylthiouracil 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Selective Estrogen Receptor Modifying Agentsraloxifene hydrochloride 2 QL(30/30)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium tabs 1LEVOXYL TABS 125MCG, 137MCG, 150MCG, 200MCG, 25MCG, 50MCG, 75MCG, 88MCG

3

levoxyl tabs 100mcg, 112mcg, 175mcg

3

liothyronine sodium inj 4liothyronine sodium tabs 2SYNTHROID 3THYROLAR-1 3THYROLAR-1/2 3THYROLAR-1/4 3THYROLAR-2 3THYROLAR-3 3UNITHROID 3

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)LYSODREN 5

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)cabergoline 2 QL(16/28)ELIGARD INJ 30MG 4 PA QL(1/120)ELIGARD INJ 45MG 4 PA QL(1/180)ELIGARD INJ 7.5MG 4 PA QL(1/30)ELIGARD INJ 22.5MG 4 PA QL(1/90)FIRMAGON INJ 80MG 4 B/D PA QL(1/28)FIRMAGON INJ 120MG 5 B/D PA QL(4/365)

52


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

KINERET 5 PA QL(20.1/30)methotrexate sodium 4methotrexate tabs 2mycophenolate mofetil caps 2 PAmycophenolate mofetil inj 4 PAmycophenolate mofetil susr 5 PAmycophenolate mofetil tabs 2 PAmycophenolic acid dr 2 PANULOJIX 5 PA QL(150/30)PROGRAF INJ 4 PARAPAMUNE ORAL SOLN 5 PAREMICADE 5 PARENFLEXIS 5 PASANDIMMUNE ORAL SOLN 4 PAsirolimus 4 PAtacrolimus caps 2 PATORISEL 5 B/D PA QL(4/28)XATMEP 4 PAZORTRESS TABS 0.25MG, 0.75MG

5 PA QL(60/30)

ZORTRESS TABS 0.5MG 5 PA QL(120/30)Immunizing Agents, PassiveATGAM 4 PAGAMMAKED INJ 1GM/10ML 4 B/D PAGAMMAKED INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 5GM/50ML

5 B/D PA

GAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 40GM/400ML, 5GM/50ML

5 B/D PA

GAMUNEX-C INJ 1GM/10ML 4 B/D PATHYMOGLOBULIN 3 B/D PAImmunomodulatorsACTEMRA INJ 162MG/0.9ML 5 PA QL(3.6/28)ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML

5 PA QL(40/28)

ACTIMMUNE 5 PAARCALYST 5 PABENLYSTA INJ 400MG 5 PA QL(9/28)BENLYSTA INJ 120MG 5 PA QL(30/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Immunological Agents

Angioedema AgentsCINRYZE 5 PA QL(100/30)FIRAZYR 5 PA QL(18/30)RUCONEST 5 PA QL(8/30)Immune SuppressantsASTAGRAF XL CP24 0.5MG, 1MG

4 PA

ASTAGRAF XL CP24 5MG 5 PAAZASAN 3 PAazathioprine inj 4 PAazathioprine tabs 2 PAcyclosporine 4 PAcyclosporine modified 4 PAENBREL INJ 25MG/0.5ML 5 PA QL(4.08/28)ENBREL INJ 25MG, 50MG/ML 5 PA QL(8/28)ENBREL MINI 5 PA QL(8/28)ENBREL SURECLICK 5 PA QL(8/28)ENVARSUS XR TB24 4MG 5 PAENVARSUS XR TB24 0.75MG, 1MG

4 PA

gengraf 4 PAHUMIRA INJ 10MG/0.1ML, 10MG/0.2ML, 20MG/0.2ML, 20MG/0.4ML

5 PA QL(2/28)

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

5 PA QL(4/28)

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ

5 PA QL(4/365)

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML, 80MG/0.8ML

5 PA QL(6/365)

HUMIRA PEN 5 PA QL(4/28)HUMIRA PEN-CD/UC/HS STARTER INJ 80MG/0.8ML

5 PA QL(6/365)

HUMIRA PEN-CD/UC/HS STARTER INJ 40MG/0.8ML

5 PA QL(12/365)

HUMIRA PEN-PS/UV STARTER INJ

5 PA QL(6/365)

HUMIRA PEN-PS/UV STARTER INJ 40MG/0.8ML

5 PA QL(8/365)

53



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ROTARIX 3ROTATEQ 3SHINGRIX 4 QL(2/999)STAMARIL 4 QL(1/999)TENIVAC 4 QL(0.5/28)TETANUS/DIPHTHERIA TOXOIDS-ADSORBED

4

TRUMENBA 4TWINRIX 4TYPHIM VI 4VAQTA 4VARIVAX 4 QL(1/365)VARIZIG 4 QL(12/30)VAXCHORA 4YF-VAX 4ZOSTAVAX 4 QL(1/999)

Inflammatory Bowel Disease Agents

AminosalicylatesAPRISO 3 QL(120/30)balsalazide disodium 2LIALDA 3 QL(120/30)mesalamine 4Glucocorticoidsbudesonide cpep 4colocort 2hydrocortisone enem 2Sulfonamidessulfasalazine 2

Metabolic Bone Disease Agents

Metabolic Bone Disease Agentsalendronate sodium tabs 35mg, 70mg

1 QL(4/28)

alendronate sodium tabs 10mg, 40mg, 5mg

1 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ILARIS 5 PA QL(2/28)leflunomide 2 QL(30/30)RIDAURA 4SIMULECT 5 B/D PASYNAGIS 5 PAVaccinesACTHIB 4ADACEL 4 QL(0.5/365)BCG VACCINE 4BEXSERO 4BOOSTRIX 4 QL(0.5/365)DAPTACEL 4DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC

4

ENGERIX-B INJ 10MCG/0.5ML 4 B/D PA QL(3/365)ENGERIX-B INJ 20MCG/ML 4 B/D PA QL(8/365)GARDASIL 9 4 QL(1.5/365)HAVRIX 4HEPLISAV-B 4 B/D PA QL(3/365)HIBERIX 4IMOVAX RABIES (H.D.C.V.) 4 B/D PAINFANRIX 4IPOL INACTIVATED IPV 4IXIARO 4KINRIX 4M-M-R II 4 QL(2/365)MENACTRA 4MENVEO 4PEDIARIX 4PEDVAX HIB 4PROQUAD 4 QL(2/365)QUADRACEL 4RABAVERT 4 B/D PARECOMBIVAX HB 4 B/D PA QL(3/365)

54


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

bd pen needle/nano/ultra fine/32g x 4mm

2 QL(200/30)

bd pen needle/ultrafine/29g x 12.7mm

2 QL(200/30)

bd safetyglide 27g x 5/8” 2 QL(200/30)CARNITOR INJ 4 B/D PAFERRIPROX 5 PAfomepizole 5INTRALIPID 4 B/D PAKORLYM 5 PA QL(120/30)LACTATED RINGERS IRRIGATION

4

levocarnitine 2LIPOSYN III 4 B/D PANATPARA 5 PA QL(2/28)novofine 31 2 QL(200/30)novofine 32gx6mm 2 QL(200/30)novofine autocover 30gx8mm 2 QL(200/30)novotwist 32gx5mm 2 QL(200/30)NUTRILIPID 4 B/D PAOMNIPOD 5 PACK 3 QL(30/30)OMNIPOD DASH 5 PACK 3 QL(30/30)OMNIPOD DASH SYSTEM 3 QL(1/365)OMNIPOD STARTER KIT 3 QL(1/365)PHYSIOLYTE 4physiosol irrigation 4RINGERS IRRIGATION 4sodium chloride0.9% 4sodium chloride 0.9% 4sterile water irrigation 4sterile water irrigation plastic bottle

4

techlite pen needles/31g x 6 mm

2 QL(200/30)

techlite pen needles/31g x 8mm 2 QL(200/30)techlite pen needles/32g x 4mm 2 QL(200/30)techlite pen needles/32g x 6mm 2 QL(200/30)techlite pen needles/32g x 8mm 2 QL(200/30)TIS-U-SOL 4V-GO 20 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

BINOSTO 4calcitonin-salmon 2 QL(3.7/30)calcitriol caps 2calcitriol inj 4calcitriol oral soln 2doxercalciferol caps 0.5mcg 4 QL(90/30)doxercalciferol caps 1mcg 4 QL(240/30)doxercalciferol caps 2.5mcg 5 QL(120/30)doxercalciferol inj 4etidronate disodium 2FORTEO 5 PA QL(2.4/28)ibandronate sodium tabs 3 QL(1/28)MIACALCIN 5pamidronate disodium 4 B/D PAparicalcitol caps 4mcg 4 QL(60/30)paricalcitol caps 1mcg, 2mcg 2 QL(90/30)PROLIA 4 QL(1/180)risedronate sodium tabs 150mg 3 QL(1/30)risedronate sodium tabs 35mg 3 QL(4/28)risedronate sodium tabs 30mg, 5mg

3 QL(30/30)

SENSIPAR TABS 30MG 3 QL(60/30)SENSIPAR TABS 60MG 5 QL(60/30)SENSIPAR TABS 90MG 5 QL(120/30)XGEVA 5 PA QL(1.7/28)zoledronic acid inj 4mg/5ml 4 B/D PA QL(15/21)zoledronic acid inj 5mg/100ml 4 B/D PA QL(100/365)

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic Agentsbd eclipse syringe/1ml/30gx1/2” 2 QL(200/30)bd insulin syringe safetyglide/1ml/29g x 1/2”

2 QL(200/30)

bd insulin syringe ultrafine/0.3ml/31g x 5/16”

2 QL(200/30)

bd insulin syringe ultrafine/0.5ml/30g x 1/2”

2 QL(200/30)

bd insulin syringe ultrafine/1ml/31g x 5/16”

2 QL(200/30)

bd pen needle/mini/ultrafine/31g x 3/16”

2 QL(200/30)

55



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluorometholone 3flurbiprofen sodium 2ILEVRO 3ketorolac tromethamine ophthalmic soln

2

LOTEMAX 4neomycin/polymyxin/dexamethasone

2

PRED MILD 3PRED-G 3PRED-G S.O.P. 3prednisolone acetate 3prednisolone sodium phosphate ophthalmic soln

1

PROLENSA 3TOBRADEX OINT 3tobramycin/dexamethasone 3Ophthalmic Antiglaucoma Agentsacetazolamide er 2apraclonidine 2AZOPT 3betaxolol hcl 2brimonidine tartrate ophthalmic soln 0.2%

2

brimonidine tartrate ophthalmic soln 0.15%

3

carteolol hcl 2dorzolamide hcl 2 QL(10/30)dorzolamide hcl/timolol maleate 2 QL(10/30)levobunolol hcl 1metipranolol 2PHOSPHOLINE IODIDE 4pilocarpine hcl ophthalmic soln 3SIMBRINZA 4timolol maleate ophthalmic soln 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

V-GO 30 3V-GO 40 3

Ophthalmic Agents

Ophthalmic Prostaglandin and Prostamide Analogsbimatoprost ophthalmic soln 2 QL(5/30)COMBIGAN 3latanoprost 2 QL(5/30)LUMIGAN 4 QL(5/30) STTRAVATAN Z 3 QL(5/30)ZIOPTAN 4 QL(30/30)Ophthalmic Agents, Otheratropine sulfate ophthalmic soln 2CYSTARAN 5 PA QL(60/28)LACRISERT 3proparacaine hcl 2RESTASIS 3 QL(60/30)tropicamide 2Ophthalmic Anti-allergy AgentsALOCRIL 3azelastine hcl ophthalmic soln 2cromolyn sodium ophthalmic soln

2

epinastine hcl 2olopatadine hcl ophthalmic soln 2 QL(5/30)olopatadine hydrochloride ophthalmic soln 0.2%

2 QL(2.5/30)

PAZEO 3 QL(2.5/30)Ophthalmic Anti-inflammatoriesbromfenac 4dexamethasone sodium phosphate ophthalmic soln

2

diclofenac sodium ophthalmic soln

2

DUREZOL 3

56


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

zafirlukast 2 QL(60/30)Bronchodilators, AnticholinergicATROVENT HFA 3 QL(25.8/30)COMBIVENT RESPIMAT 3 QL(8/30)INCRUSE ELLIPTA 3 QL(30/30)ipratropium bromide inhalation soln

2 B/D PA QL(300/30)

ipratropium bromide nasal soln 2 QL(30/30)ipratropium bromide/albuterol sulfate

2 B/D PA QL(540/30)

Bronchodilators, Sympathomimeticalbuterol sulfate er 2albuterol sulfate nebu 0.5% 2 B/D PA QL(180/30)albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml

2 B/D PA QL(360/30)

albuterol sulfate syrp 1albuterol sulfate tabs 1ANORO ELLIPTA 3 QL(60/30)epinephrine hcl inj 1mg/10ml, 1mg/ml, 30mg/30ml

4

epinephrine inj 0.15mg/0.15ml, 0.15mg/0.3ml, 0.3mg/0.3ml

2 QL(2/30)

EPIPEN 2-PAK 3 QL(2/30)EPIPEN-JR 2-PAK 3 QL(2/30)levalbuterol tartrate hfa 3 QL(30/30)metaproterenol sulfate 2PERFOROMIST 3 B/D PA QL(120/30)PROAIR HFA 3 QL(17/30)PROAIR RESPICLICK 3 QL(2/30)SEREVENT DISKUS 3 QL(60/30)terbutaline sulfate 4VENTOLIN HFA 4 QL(36/30)Cystic Fibrosis AgentsCAYSTON 5 PA QL(84/56)KALYDECO 5 PA QL(60/30)ORKAMBI PACK 5 PA QL(56/28)ORKAMBI TABS 5 PA QL(120/30)PULMOZYME 5 B/D PA QL(150/30)TOBI PODHALER 5 QL(1568/365)tobramycin nebu 5 B/D PA QL(280/56)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Otic Agents

Otic Agentsacetic acid 2COLY-MYCIN S 4fluocinolone acetonide oil 4hydrocortisone/acetic acid 2neomycin/polymyxin/hc 2neomycin/polymyxin/hydrocortisone

2

Respiratory Tract/Pulmonary Agents

Anti-inflammatories, Inhaled CorticosteroidsADVAIR DISKUS 3 QL(60/30)ADVAIR HFA 3 QL(12/30)ARNUITY ELLIPTA 3 QL(30/30)BREO ELLIPTA 3 QL(60/30)budesonide susp 4 B/D PA QL(120/30)FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST

3 QL(60/30)

FLOVENT DISKUS AEPB 250MCG/BLIST

3 QL(240/30)

FLOVENT HFA AERO 44MCG/ACT

3 QL(10.6/30)


3 QL(12/30)


3 QL(24/30)

flunisolide 1 QL(50/30)fluticasone propionate susp 2 QL(16/30)mometasone furoate susp 2 QL(34/30)NASONEX 4 QL(34/30) STAntihistaminesazelastine hcl nasal soln 2 QL(30/25)desloratadine 2 QL(30/30)diphenhydramine hcl inj 4levocetirizine dihydrochloride oral soln

2 QL(300/30)

levocetirizine dihydrochloride tabs

2 QL(30/30)

Antileukotrienesmontelukast sodium 2 QL(30/30)

57



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Skeletal Muscle Relaxants

Skeletal Muscle Relaxantscyclobenzaprine hcl tabs 10mg, 5mg

3 PA QL(90/30)

methocarbamol tabs 2 PAorphenadrine citrate er 2 PA QL(60/30)

Sleep Disorder Agents

GABA Receptor Modulatorstemazepam 2 QL(60/365)zaleplon 2 QL(30/30)zolpidem tartrate tabs 3 PA QL(30/30)Sleep Disorders, Otherarmodafinil 4 PA QL(30/30)modafinil 4 PA QL(30/30)ROZEREM 3 QL(30/30)SILENOR 3 QL(30/30)XYREM 5 PA QL(540/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Mast Cell Stabilizerscromolyn sodium nebu 2 B/D PA QL(240/30)Phosphodiesterase Inhibitors, Airways Diseaseaminophylline 4DALIRESP TABS 500MCG 4 PA QL(30/30)DALIRESP TABS 250MCG 4 PA QL(60/365)THEO-24 3theophylline cr 2theophylline er tb12 300mg, 450mg

2

theophylline er tb24 2Pulmonary AntihypertensivesADEMPAS 5 PA QL(90/30)LETAIRIS 5 PA QL(30/30)OPSUMIT 5 PA QL(30/30)REMODULIN 5 B/D PAsildenafil tabs 20mg 3 PA QL(90/30)TRACLEER 5 PA QL(60/30)VENTAVIS 5 PA QL(270/30)Pulmonary Fibrosis AgentsESBRIET CAPS 5 PA QL(270/30)ESBRIET TABS 801MG 5 PA QL(90/30)ESBRIET TABS 267MG 5 PA QL(270/30)OFEV 5 PA QL(60/30)Respiratory Tract Agents, Otheracetylcysteine inhalation soln 2 B/D PAARALAST NP 4 B/D PAPROLASTIN-C 5 B/D PAribavirin inhalation soln 5 B/D PATRELEGY ELLIPTA 3 QL(60/30)XOLAIR 5 PA QL(6/28)ZEMAIRA 5 B/D PA

58

DRUG PAGE DRUG PAGE DRUG PAGE

Covered Drugs Index

Aabacavir/lamivudine . . . . . . . . . . . . . . . 32abacavir oral soln . . . . . . . . . . . . . . . . . 32abacavir sulfate/ lamivudine/zidovudine . . . . . . . . . . . . . 32abacavir tabs . . . . . . . . . . . . . . . . . . . . . 32ABELCET . . . . . . . . . . . . . . . . . . . . . . . . . 23ABILIFY MAINTENA . . . . . . . . . . . . . . . 30ABRAXANE . . . . . . . . . . . . . . . . . . . . . . . 26acamprosate calcium dr . . . . . . . . . . . . 16acarbose . . . . . . . . . . . . . . . . . . . . . . . . . . 34acebutolol hcl . . . . . . . . . . . . . . . . . . . . . 38acetaminophen/codeine oral soln . . . 14acetaminophen/codeine tabs 300mg; 15mg, 300mg; 30mg . . . . . . . 14acetaminophen/codeine tabs 300mg; 60mg . . . . . . . . . . . . . . . . . . . . . 14acetazolamide . . . . . . . . . . . . . . . . . . . . . 39acetazolamide er . . . . . . . . . . . . . . . . . . 55acetazolamide sodium . . . . . . . . . . . . . 39acetic acid . . . . . . . . . . . . . . . . . . . . . . . . 56acetylcysteine inhalation soln . . . . . . 57acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . . 41ACTEMRA INJ 162MG/0.9ML . . . . . . 52ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML . . . . . . . . . . 52ACTHIB . . . . . . . . . . . . . . . . . . . . . . . . . . . 53ACTIMMUNE . . . . . . . . . . . . . . . . . . . . . 52acyclovir caps . . . . . . . . . . . . . . . . . . . . 33acyclovir oint . . . . . . . . . . . . . . . . . . . . . 33acyclovir sodium . . . . . . . . . . . . . . . . . . . 33acyclovir susp . . . . . . . . . . . . . . . . . . . . 33acyclovir tabs . . . . . . . . . . . . . . . . . . . . . 33ADACEL . . . . . . . . . . . . . . . . . . . . . . . . . . 53ADAGEN . . . . . . . . . . . . . . . . . . . . . . . . . 46adefovir dipivoxil . . . . . . . . . . . . . . . . . . . 31ADEMPAS . . . . . . . . . . . . . . . . . . . . . . . . 57adriamycin inj 2mg/ml . . . . . . . . . . . . . . 26adrucil . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26ADVAIR DISKUS . . . . . . . . . . . . . . . . . . 56

ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . . 56afeditab cr . . . . . . . . . . . . . . . . . . . . . . . . 38AFINITOR DISPERZ TBSO 2MG, 3MG . . . . . . . . . . . . . . . . . . . . . . . . 27AFINITOR DISPERZ TBSO 5MG . . . 27AFINITOR TABS 2.5MG, 5MG, 7.5MG . . . . . . . . . . . . . . 27AFINITOR TABS 10MG . . . . . . . . . . . . 27ala-cort crea 1% . . . . . . . . . . . . . . . . . . . 46ALBENZA . . . . . . . . . . . . . . . . . . . . . . . . . 29albuterol sulfate er . . . . . . . . . . . . . . . . . 56albuterol sulfate nebu 0.5% . . . . . . . . 56albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml . . . . . . . . . . . 56albuterol sulfate syrp . . . . . . . . . . . . . . 56albuterol sulfate tabs . . . . . . . . . . . . . . 56alclometasone dipropionate . . . . . . . . 46alcohol prep pads . . . . . . . . . . . . . . . . . 16ALDURAZYME . . . . . . . . . . . . . . . . . . . . 46ALECENSA . . . . . . . . . . . . . . . . . . . . . . . 27alendronate sodium tabs 10mg, 40mg, 5mg . . . . . . . . . . . . . . . . . 53alendronate sodium tabs 35mg, 70mg . . . . . . . . . . . . . . . . . . . . . . . 53alfuzosin hcl er . . . . . . . . . . . . . . . . . . . . 46ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 26ALINIA SUSR . . . . . . . . . . . . . . . . . . . . . 29ALINIA TABS . . . . . . . . . . . . . . . . . . . . . 29ALIQOPA . . . . . . . . . . . . . . . . . . . . . . . . . 27allopurinol . . . . . . . . . . . . . . . . . . . . . . . . . 24allopurinol sodium . . . . . . . . . . . . . . . . . 24ALOCRIL . . . . . . . . . . . . . . . . . . . . . . . . . 55ALORA . . . . . . . . . . . . . . . . . . . . . . . . . . . 48alosetron hydrochloride tabs 0.5mg . . 45alosetron hydrochloride tabs 1mg . . . 45ALOXI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23alprazolam odt tbdp 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 33alprazolam odt tbdp 2mg . . . . . . . . . . . 33alprazolam tabs 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 33

alprazolam tabs 2mg . . . . . . . . . . . . . . 33altavera . . . . . . . . . . . . . . . . . . . . . . . . . . . 48ALUNBRIG TABS 30MG . . . . . . . . . . . 27ALUNBRIG TABS 180MG, 90MG . . . 27ALUNBRIG TBPK . . . . . . . . . . . . . . . . . 27alyacen 1/35 . . . . . . . . . . . . . . . . . . . . . . 48alyacen 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 48amantadine hcl . . . . . . . . . . . . . . . . . . . . 29AMBISOME . . . . . . . . . . . . . . . . . . . . . . . 23a-methapred . . . . . . . . . . . . . . . . . . . . . . 46amethia . . . . . . . . . . . . . . . . . . . . . . . . . . . 48amethia lo . . . . . . . . . . . . . . . . . . . . . . . . . 48amikacin sulfate . . . . . . . . . . . . . . . . . . . 16amiloride hcl . . . . . . . . . . . . . . . . . . . . . . 39amiloride/hydrochlorothiazide . . . . . . 39aminophylline . . . . . . . . . . . . . . . . . . . . . 57AMINOSYN . . . . . . . . . . . . . . . . . . . . . . . 42AMINOSYN 7%/ELECTROLYTES . . 42AMINOSYN 8.5%/ ELECTROLYTES . . . . . . . . . . . . . . . . . . 42AMINOSYN-HBC . . . . . . . . . . . . . . . . . . 42AMINOSYN II . . . . . . . . . . . . . . . . . . . . . 42AMINOSYN II 8.5%/ ELECTROLYTES . . . . . . . . . . . . . . . . . . 42AMINOSYN M . . . . . . . . . . . . . . . . . . . . . 42AMINOSYN-PF . . . . . . . . . . . . . . . . . . . . 42AMINOSYN-PF 7% . . . . . . . . . . . . . . . . 42AMINOSYN-RF . . . . . . . . . . . . . . . . . . . 42amiodarone hcl inj . . . . . . . . . . . . . . . . 37amiodarone hcl tabs . . . . . . . . . . . . . . 37AMITIZA . . . . . . . . . . . . . . . . . . . . . . . . . . 45amitriptyline hcl . . . . . . . . . . . . . . . . . . . . 23amlodipine besylate/benazepril hydrochloride caps 2.5mg; 10mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg . . . . . . . . . . . . . . . . . 38amlodipine besylate/benazepril hydrochloride caps 10mg; 20mg, 10mg; 40mg . . . . . . . . . . . . . . . . 38amlodipine besylate tabs 2.5mg . . . . 38amlodipine besylate tabs 5mg . . . . . . 38

59


Covered Drugs Index

ARISTADA INJ 662MG/2.4ML . . . . . . 30ARISTADA INJ 882MG/3.2ML . . . . . . 30ARISTADA INJ 1064MG/3.9ML . . . . . 30armodafinil . . . . . . . . . . . . . . . . . . . . . . . . 57ARNUITY ELLIPTA . . . . . . . . . . . . . . . . 56ARRANON . . . . . . . . . . . . . . . . . . . . . . . . 26ascomp/codeine . . . . . . . . . . . . . . . . . . . 14ashlyna . . . . . . . . . . . . . . . . . . . . . . . . . . . 48aspirin/dipyridamole . . . . . . . . . . . . . . . 36ASTAGRAF XL CP24 0.5MG, 1MG . . 52ASTAGRAF XL CP24 5MG . . . . . . . . . 52atazanavir caps 200mg . . . . . . . . . . . . 32atazanavir caps 300mg . . . . . . . . . . . . 32atazanavir sulfate caps 150mg . . . . . 32atazanavir sulfate caps 200mg . . . . . 32atazanavir sulfate caps 300mg . . . . . 32atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 38atenolol/chlorthalidone . . . . . . . . . . . . . 38ATGAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 52atomoxetine caps 10mg, 18mg, 25mg, 40mg . . . . . . . . . 41atomoxetine caps 100mg, 60mg, 80mg . . . . . . . . . . . . . . . 40atorvastatin calcium . . . . . . . . . . . . . . . 39atovaquone . . . . . . . . . . . . . . . . . . . . . . . 29atovaquone/proguanil hcl . . . . . . . . . . 29ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . . 32atropine sulfate inj 0.5mg/5ml . . . . . . 39atropine sulfate inj 0.25mg/5ml, 1mg/ml, 8mg/20ml . . . . 45atropine sulfate ophthalmic soln . . . . 55ATROVENT HFA . . . . . . . . . . . . . . . . . . 56aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48augmented betamethasone dipropionate . . . . . . . . . . . . . . . . . . . . . . . 46AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML . . . . . . . . 18AURYXIA . . . . . . . . . . . . . . . . . . . . . . . . . 44AVASTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 28AVELOX INJ . . . . . . . . . . . . . . . . . . . . . . 19aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

APOKYN . . . . . . . . . . . . . . . . . . . . . . . . . . 29apraclonidine . . . . . . . . . . . . . . . . . . . . . . 55aprepitant caps . . . . . . . . . . . . . . . . . . . 23aprepitant caps 40mg . . . . . . . . . . . . . . 23aprepitant caps 80mg . . . . . . . . . . . . . . 23aprepitant caps 125mg . . . . . . . . . . . . . 23apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48APRISO . . . . . . . . . . . . . . . . . . . . . . . . . . 53APTIOM TABS 200MG, 400MG, 800MG . . . . . . . . . . . 20APTIOM TABS 600MG . . . . . . . . . . . . . 20APTIVUS CAPS . . . . . . . . . . . . . . . . . . 32APTIVUS ORAL SOLN . . . . . . . . . . . . 32ARALAST NP . . . . . . . . . . . . . . . . . . . . . 57aranelle . . . . . . . . . . . . . . . . . . . . . . . . . . . 48ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML . . . . . 36ARANESP ALBUMIN FREE INJ 25MCG/0.42ML . . . . . . . . . . . . . . . . . . . 36ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML . . . . . . . . . . . 36ARANESP ALBUMIN FREE INJ 60MCG/0.3ML . . . . . . . . . . . . . . . . . . . . 36ARANESP ALBUMIN FREE INJ 100MCG/0.5ML . . . . . . . . . . . . . . . . . . . 36ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML, 60MCG/ML . . . . . . . . . . 36ARANESP ALBUMIN FREE INJ 150MCG/0.3ML . . . . . . . . . . . . . . . . . . . 36ARANESP ALBUMIN FREE INJ 200MCG/0.4ML . . . . . . . . . . . . . . . . . . . 36ARANESP ALBUMIN FREE INJ 300MCG/0.6ML . . . . . . . . . . . . . . . . . . . 36ARANESP ALBUMIN FREE INJ 500MCG/ML . . . . . . . . . . . . . . . . . . . . . . 36ARCALYST . . . . . . . . . . . . . . . . . . . . . . . 52aripiprazole odt . . . . . . . . . . . . . . . . . . . . 30aripiprazole oral soln . . . . . . . . . . . . . . 30aripiprazole tabs . . . . . . . . . . . . . . . . . . 30ARISTADA INITIO . . . . . . . . . . . . . . . . . 30ARISTADA INJ 441MG/1.6ML . . . . . . 30

amlodipine besylate tabs 10mg . . . . . 38amlodipine besylate/valsartan . . . . . . 38amlodipine/olmesartan medoxomil . . 38amlodipine/valsartan/hctz . . . . . . . . . . 38ammonium lactate . . . . . . . . . . . . . . . . . 41amnesteem . . . . . . . . . . . . . . . . . . . . . . . 41amoxapine . . . . . . . . . . . . . . . . . . . . . . . . 23amoxicillin caps . . . . . . . . . . . . . . . . . . . 18amoxicillin chew . . . . . . . . . . . . . . . . . . 18amoxicillin/clavulanate potassium . . . 18amoxicillin/clavulanate potassium er . . . . . . . . . . . . . . . . . . . . . . 18amoxicillin susr . . . . . . . . . . . . . . . . . . . 18amoxicillin tabs . . . . . . . . . . . . . . . . . . . 18amphetamine/dextroamphetamine cp24 1.25mg; 1.25mg; 1.25mg; 1.25mg, 6.25mg; 6.25mg; 6.25mg; 6.25mg . . . . . . . . . . . . . . . . . . . 40amphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 5mg; 5mg; 5mg; 5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg . . . . . . . 40amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg . . . . . . . 40amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg . . . . . . . . . 40amphotericin b . . . . . . . . . . . . . . . . . . . . 23ampicillin . . . . . . . . . . . . . . . . . . . . . . . . . . 18ampicillin sodium . . . . . . . . . . . . . . . . . . 18ampicillin-sulbactam . . . . . . . . . . . . . . . 18AMPYRA . . . . . . . . . . . . . . . . . . . . . . . . . 41ANADROL-50 . . . . . . . . . . . . . . . . . . . . . 48anagrelide hydrochloride . . . . . . . . . . . 36anaspaz . . . . . . . . . . . . . . . . . . . . . . . . . . 44anastrozole . . . . . . . . . . . . . . . . . . . . . . . 27ANORO ELLIPTA . . . . . . . . . . . . . . . . . . 56

60


Covered Drugs Index

betaxolol hcl . . . . . . . . . . . . . . . . . . . . . . . 55bethanechol chloride . . . . . . . . . . . . . . . 46bexarotene . . . . . . . . . . . . . . . . . . . . . . . . 28BEXSERO . . . . . . . . . . . . . . . . . . . . . . . . 53bicalutamide . . . . . . . . . . . . . . . . . . . . . . 25BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . . 18BICNU . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40BIKTARVY . . . . . . . . . . . . . . . . . . . . . . . . 31BILTRICIDE . . . . . . . . . . . . . . . . . . . . . . . 29bimatoprost ophthalmic soln . . . . . . . 55BINOSTO . . . . . . . . . . . . . . . . . . . . . . . . . 54bisoprolol fumarate . . . . . . . . . . . . . . . . 38bisoprolol fumarate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 38bleomycin sulfate . . . . . . . . . . . . . . . . . . 26BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . . 19BLEPHAMIDE S.O.P. . . . . . . . . . . . . . . 19blisovi fe 1.5/30 . . . . . . . . . . . . . . . . . . . . 48blisovi fe 1/20 . . . . . . . . . . . . . . . . . . . . . 48BOOSTRIX . . . . . . . . . . . . . . . . . . . . . . . 53BORTEZOMIB . . . . . . . . . . . . . . . . . . . . 26BOSULIF TABS 100MG . . . . . . . . . . . . 27BOSULIF TABS 400MG, 500MG . . . 27BRAFTOVI . . . . . . . . . . . . . . . . . . . . . . . . 26BREO ELLIPTA . . . . . . . . . . . . . . . . . . . 56briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . . 36brimonidine tartrate ophthalmic soln 0.2% . . . . . . . . . . . . . . 55brimonidine tartrate ophthalmic soln 0.15% . . . . . . . . . . . . . 55BRIVIACT INJ . . . . . . . . . . . . . . . . . . . . 20BRIVIACT ORAL SOLN . . . . . . . . . . . 20BRIVIACT TABS 10MG, 25MG, 50MG, 75MG . . . . . . . 20BRIVIACT TABS 100MG . . . . . . . . . . . 20bromfenac . . . . . . . . . . . . . . . . . . . . . . . . 55bromocriptine mesylate . . . . . . . . . . . . 29budesonide cpep . . . . . . . . . . . . . . . . . 53

BAXDELA . . . . . . . . . . . . . . . . . . . . . . . . . 19BCG VACCINE . . . . . . . . . . . . . . . . . . . . 53bd eclipse syringe/1ml/30gx1/2” . . . . 54bd insulin syringe safetyglide/ 1ml/29g x 1/2” . . . . . . . . . . . . . . . . . . . . . 54bd insulin syringe ultrafine/ 0.3ml/31g x 5/16” . . . . . . . . . . . . . . . . . . 54bd insulin syringe ultrafine/ 0.5ml/30g x 1/2” . . . . . . . . . . . . . . . . . . . 54bd insulin syringe ultrafine/ 1ml/31g x 5/16” . . . . . . . . . . . . . . . . . . . . 54bd pen needle/mini/ultrafine/ 31g x 3/16” . . . . . . . . . . . . . . . . . . . . . . . . 54bd pen needle/nano/ultra fine/ 32g x 4mm . . . . . . . . . . . . . . . . . . . . . . . . 54bd pen needle/ultrafine/ 29g x 12.7mm . . . . . . . . . . . . . . . . . . . . . 54bd safetyglide 27g x 5/8” . . . . . . . . . . . 54bekyree . . . . . . . . . . . . . . . . . . . . . . . . . . . 48BELEODAQ . . . . . . . . . . . . . . . . . . . . . . . 26benazepril hcl . . . . . . . . . . . . . . . . . . . . . 37benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg, 20mg; 25mg, 5mg; 6.25mg . . . . . . . . . . . . . . . 37benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg . . . . . . . . . . . . . . . . 37BENDEKA . . . . . . . . . . . . . . . . . . . . . . . . 25BENICAR . . . . . . . . . . . . . . . . . . . . . . . . . 36BENICAR HCT . . . . . . . . . . . . . . . . . . . . 36BENLYSTA INJ 120MG . . . . . . . . . . . . 52BENLYSTA INJ 400MG . . . . . . . . . . . . 52benztropine mesylate inj . . . . . . . . . . . 29benztropine mesylate tabs . . . . . . . . . 29BESIVANCE . . . . . . . . . . . . . . . . . . . . . . 19BESPONSA . . . . . . . . . . . . . . . . . . . . . . . 28betamethasone dipropionate . . . . . . . 46betamethasone valerate crea . . . . . . 46betamethasone valerate foam . . . . . 46betamethasone valerate lotn . . . . . . . 46betamethasone valerate oint . . . . . . . 46BETASERON . . . . . . . . . . . . . . . . . . . . . 41betaxolol hcl . . . . . . . . . . . . . . . . . . . . . . . 38

avita . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41AVONEX . . . . . . . . . . . . . . . . . . . . . . . . . . 41AVONEX PEN . . . . . . . . . . . . . . . . . . . . . 41azacitidine . . . . . . . . . . . . . . . . . . . . . . . . 26AZACTAM . . . . . . . . . . . . . . . . . . . . . . . . 18AZACTAM IN ISO-OSMOTIC DEXTROSE . . . . . . . . . . . . . . . . . . . . . . . 18AZASAN . . . . . . . . . . . . . . . . . . . . . . . . . . 52AZASITE . . . . . . . . . . . . . . . . . . . . . . . . . . 19azathioprine inj . . . . . . . . . . . . . . . . . . . 52azathioprine tabs . . . . . . . . . . . . . . . . . 52azelastine hcl nasal soln . . . . . . . . . . . 56azelastine hcl ophthalmic soln . . . . . 55azithromycin inj . . . . . . . . . . . . . . . . . . . 19azithromycin pack . . . . . . . . . . . . . . . . . 19azithromycin susr 100mg/5ml . . . . . . 19azithromycin susr 200mg/5ml . . . . . . 19azithromycin tabs 250mg, 500mg . . . 19azithromycin tabs 600mg . . . . . . . . . . . 19AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . . 55AZOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38aztreonam inj 1gm . . . . . . . . . . . . . . . . . 18AZTREONAM INJ 2GM . . . . . . . . . . . . 18

Bbaciim . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16bacitracin inj . . . . . . . . . . . . . . . . . . . . . . 16bacitracin ophthalmic oint . . . . . . . . . . 16bacitracin/polymyxin b . . . . . . . . . . . . . 16baclofen tabs 10mg . . . . . . . . . . . . . . . . 31baclofen tabs 20mg, 5mg . . . . . . . . . . 31BACTROBAN NASAL . . . . . . . . . . . . . 16balsalazide disodium . . . . . . . . . . . . . . 53balziva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48BANZEL SUSP . . . . . . . . . . . . . . . . . . . 21BANZEL TABS 200MG . . . . . . . . . . . . 21BANZEL TABS 400MG . . . . . . . . . . . . 21BARACLUDE ORAL SOLN . . . . . . . . 31BAVENCIO . . . . . . . . . . . . . . . . . . . . . . . . 28

61


Covered Drugs Index

carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml . . . . . . . . . . . . 26carmustine . . . . . . . . . . . . . . . . . . . . . . . . 25CARNITOR INJ . . . . . . . . . . . . . . . . . . . 54carteolol hcl . . . . . . . . . . . . . . . . . . . . . . . 55cartia xt . . . . . . . . . . . . . . . . . . . . . . . . . . . 38carvedilol . . . . . . . . . . . . . . . . . . . . . . . . . 38carvedilol phosphate . . . . . . . . . . . . . . . 38caspofungin acetate . . . . . . . . . . . . . . . 24CAYSTON . . . . . . . . . . . . . . . . . . . . . . . . 56caziant . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48cefaclor caps . . . . . . . . . . . . . . . . . . . . . 18cefaclor er . . . . . . . . . . . . . . . . . . . . . . . . 18cefaclor susr . . . . . . . . . . . . . . . . . . . . . . 18cefadroxil . . . . . . . . . . . . . . . . . . . . . . . . . 18CEFAZOLIN . . . . . . . . . . . . . . . . . . . . . . . 18cefazolin sodium/ dextrose inj 2gm; 3% . . . . . . . . . . . . . . 18cefazolin sodium inj 10gm, 1gm, 1gm/50ml; 4%, 500mg . . . . . . . . 18cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18cefepime . . . . . . . . . . . . . . . . . . . . . . . . . . 18cefepime/dextrose . . . . . . . . . . . . . . . . . 18cefixime . . . . . . . . . . . . . . . . . . . . . . . . . . . 18cefotaxime sodium . . . . . . . . . . . . . . . . . 18cefotetan . . . . . . . . . . . . . . . . . . . . . . . . . . 18cefoxitin sodium inj 10gm, 1gm, 2gm . . . . . . . . . . . . . . . . . . 18cefpodoxime proxetil . . . . . . . . . . . . . . . 18cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . 18ceftazidime . . . . . . . . . . . . . . . . . . . . . . . . 18ceftazidime/dextrose . . . . . . . . . . . . . . . 18ceftriaxone in iso-osmotic dextrose . . 18ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg . . . . . . . . . 18cefuroxime axetil . . . . . . . . . . . . . . . . . . 18cefuroxime sodium . . . . . . . . . . . . . . . . 18celecoxib caps 100mg, 200mg, 50mg . . . . . . . . . . . . . . 14celecoxib caps 400mg . . . . . . . . . . . . . 14CELONTIN . . . . . . . . . . . . . . . . . . . . . . . . 20

Ccabergoline . . . . . . . . . . . . . . . . . . . . . . . 51CABOMETYX TABS 20MG, 60MG . . . . . . . . . . . . . . . . . . . . . . 27CABOMETYX TABS 40MG . . . . . . . . 27calcipotriene crea . . . . . . . . . . . . . . . . . 41calcipotriene external soln . . . . . . . . . 41calcipotriene oint . . . . . . . . . . . . . . . . . . 41calcitonin-salmon . . . . . . . . . . . . . . . . . . 54calcitrene . . . . . . . . . . . . . . . . . . . . . . . . . 41calcitriol caps . . . . . . . . . . . . . . . . . . . . . 54calcitriol inj . . . . . . . . . . . . . . . . . . . . . . . 54calcitriol oint . . . . . . . . . . . . . . . . . . . . . . 41calcitriol oral soln . . . . . . . . . . . . . . . . . 54calcium acetate caps . . . . . . . . . . . . . . 44calcium acetate tabs 667mg . . . . . . . . 44CALQUENCE . . . . . . . . . . . . . . . . . . . . . 27camila . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50camrese . . . . . . . . . . . . . . . . . . . . . . . . . . 48camrese lo . . . . . . . . . . . . . . . . . . . . . . . . 48CANCIDAS . . . . . . . . . . . . . . . . . . . . . . . 24candesartan cilexetil . . . . . . . . . . . . . . . 36candesartan cilexetil/ hydrochlorothiazide . . . . . . . . . . . . . . . . 36CAPASTAT SULFATE . . . . . . . . . . . . . . 25CAPRELSA TABS 100MG . . . . . . . . . 27CAPRELSA TABS 300MG . . . . . . . . . 27captopril/hydrochlorothiazide . . . . . . . 37captopril tabs 12.5mg, 25mg . . . . . . . 37captopril tabs 100mg, 50mg . . . . . . . . 37CARAFATE SUSP . . . . . . . . . . . . . . . . 45CARBAGLU . . . . . . . . . . . . . . . . . . . . . . . 42carbamazepine . . . . . . . . . . . . . . . . . . . . 21carbamazepine er . . . . . . . . . . . . . . . . . 21carbidopa . . . . . . . . . . . . . . . . . . . . . . . . . 29carbidopa/levodopa . . . . . . . . . . . . . . . . 29carbidopa/levodopa/entacapone . . . . 29carbidopa/levodopa er . . . . . . . . . . . . . 29carbidopa/levodopa odt . . . . . . . . . . . . 29

budesonide susp . . . . . . . . . . . . . . . . . . 56bumetanide inj . . . . . . . . . . . . . . . . . . . . 39bumetanide tabs 0.5mg, 1mg . . . . . . . 39bumetanide tabs 2mg . . . . . . . . . . . . . . 39BUPHENYL TABS . . . . . . . . . . . . . . . . 46buprenorphine hcl inj . . . . . . . . . . . . . . 14buprenorphine hcl/naloxone hcl . . . . . 16buprenorphine hcl subl . . . . . . . . . . . . 16bupropion hcl er tb12 100mg, 200mg . . . . . . . . . . . . . . . . . . . . 22bupropion hcl sr . . . . . . . . . . . . . . . . . . . 16bupropion hcl sr . . . . . . . . . . . . . . . . . . . 22bupropion hcl tabs 100mg . . . . . . . . . . 22bupropion hcl xl . . . . . . . . . . . . . . . . . . . 22bupropion hydrochloride tabs 75mg . . . . . . . . . . . . . . . . . . . . . . . . 22buspirone hcl tabs 10mg, 5mg . . . . . . 33buspirone hcl tabs 15mg, 30mg, 7.5mg . . . . . . . . . . . . . . . 33busulfan . . . . . . . . . . . . . . . . . . . . . . . . . . 25BUSULFEX . . . . . . . . . . . . . . . . . . . . . . . 25butalbital/acetaminophen/ caffeine caps . . . . . . . . . . . . . . . . . . . . . 14butalbital/acetaminophen/ caffeine/codeine . . . . . . . . . . . . . . . . . . . 14butalbital/acetaminophen/ caffeine tabs 325mg; 50mg; 40mg . . 14butalbital/aspirin/caffeine caps . . . . . 14butalbital/aspirin/caffeine/codeine . . . 14butorphanol tartrate inj 1mg/ml . . . . . 14butorphanol tartrate inj 2mg/ml . . . . . 14butorphanol tartrate nasal soln . . . . . 14BYDUREON . . . . . . . . . . . . . . . . . . . . . . 34BYDUREON BCISE . . . . . . . . . . . . . . . 34BYDUREON PEN . . . . . . . . . . . . . . . . . 34BYETTA INJ 5MCG/0.02ML . . . . . . . . 34BYETTA INJ 10MCG/0.04ML . . . . . . . 34BYSTOLIC TABS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 38BYSTOLIC TABS 20MG . . . . . . . . . . . 38BYVALSON . . . . . . . . . . . . . . . . . . . . . . . 38

62


Covered Drugs Index

CLINIMIX 5%/DEXTROSE 15% . . . . 42CLINIMIX 5%/DEXTROSE 20% . . . . 42CLINIMIX 5%/DEXTROSE 25% . . . . 42CLINIMIX E 2.75%/ DEXTROSE 10% . . . . . . . . . . . . . . . . . . 42CLINIMIX E 4.25%/ DEXTROSE 10% . . . . . . . . . . . . . . . . . . 42CLINIMIX E 4.25%/ DEXTROSE 25% . . . . . . . . . . . . . . . . . . 42CLINIMIX E 5%/DEXTROSE 25% . . . 42CLINIMIX N9G15E . . . . . . . . . . . . . . . . 42CLINIMIX N14G30E . . . . . . . . . . . . . . . 42CLINISOL SF 15% . . . . . . . . . . . . . . . . 42clobetasol propionate crea . . . . . . . . . 46clobetasol propionate emollient crea . . . . . . . . . . . . . . . . . . . . 46clobetasol propionate emollient foam . . . . . . . . . . . . . . . . . . . . 46clobetasol propionate external soln . . . . . . . . . . . . . . . . . . . . . . 47clobetasol propionate foam . . . . . . . . 47clobetasol propionate gel . . . . . . . . . . 47clobetasol propionate oint . . . . . . . . . 47clobetasol propionate sham . . . . . . . . 47clodan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47clofarabine . . . . . . . . . . . . . . . . . . . . . . . . 26clomipramine hcl . . . . . . . . . . . . . . . . . . 23clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg . . . . . . . . . . . 20clonazepam odt tbdp 1mg . . . . . . . . . . 20clonazepam odt tbdp 2mg . . . . . . . . . . 20clonazepam tabs 0.5mg . . . . . . . . . . . . 20clonazepam tabs 1mg . . . . . . . . . . . . . 20clonazepam tabs 2mg . . . . . . . . . . . . . 20clonidine hcl er . . . . . . . . . . . . . . . . . . . . 41clonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr . . . . . . . . . . . . 36clonidine hcl ptwk 0.3mg/24hr . . . . . . 36clonidine hcl tabs 0.1mg, 0.2mg . . . . 36clonidine hcl tabs 0.3mg . . . . . . . . . . . 36clopidogrel tabs 75mg . . . . . . . . . . . . . 36

ciprofloxacin hcl tabs 100mg, 750mg . . . . . . . . . . . . . . . . . . . . 19ciprofloxacin hcl tabs 250mg . . . . . . . 19ciprofloxacin hydrochloride . . . . . . . . . 19ciprofloxacin i.v.-in d5w . . . . . . . . . . . . 19ciprofloxacin susr . . . . . . . . . . . . . . . . . 19CIPRO HC . . . . . . . . . . . . . . . . . . . . . . . . 19cisplatin . . . . . . . . . . . . . . . . . . . . . . . . . . . 26citalopram hydrobromide oral soln . . 22citalopram hydrobromide tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 22citalopram hydrobromide tabs 20mg . . . . . . . . . . . . . . . . . . . . . . . . 22citalopram hydrobromide tabs 40mg . . . . . . . . . . . . . . . . . . . . . . . . 22cladribine . . . . . . . . . . . . . . . . . . . . . . . . . 26claravis . . . . . . . . . . . . . . . . . . . . . . . . . . . 42clarithromycin er . . . . . . . . . . . . . . . . . . . 19clarithromycin susr . . . . . . . . . . . . . . . . 19clarithromycin tabs . . . . . . . . . . . . . . . . 19clindacin etz pledgets . . . . . . . . . . . . . . 17clindacin-p . . . . . . . . . . . . . . . . . . . . . . . . 17clindamycin . . . . . . . . . . . . . . . . . . . . . . . 17clindamycin hcl . . . . . . . . . . . . . . . . . . . . 17clindamycin hydrochloride . . . . . . . . . . 17clindamycin phosphate crea . . . . . . . 17clindamycin phosphate external soln . . . . . . . . . . . . . . . . . . . . . . 17clindamycin phosphate gel . . . . . . . . 17clindamycin phosphate in d5w . . . . . . 17clindamycin phosphate inj 150mg/ml, 300mg/2ml, 600mg/4ml, 900mg/6ml . . . . . . . . . . . . 17clindamycin phosphate lotn . . . . . . . . 17clindamycin phosphate swab . . . . . . 17clindamycin/sodium chloride . . . . . . . . 17CLINIMIX 2.75%/DEXTROSE 5% . . 42CLINIMIX 4.25%/DEXTROSE 5% . . 42CLINIMIX 4.25%/DEXTROSE 10% . . 42CLINIMIX 4.25%/DEXTROSE 20% . . 42CLINIMIX 4.25%/DEXTROSE 25% . . 42

cephalexin caps 250mg, 500mg . . . . 18cephalexin susr . . . . . . . . . . . . . . . . . . . 18cephalexin tabs . . . . . . . . . . . . . . . . . . . 18CEREZYME . . . . . . . . . . . . . . . . . . . . . . . 46cesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . . 16CHANTIX CONTINUING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . 16CHANTIX STARTING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . 16chateal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48CHEMET . . . . . . . . . . . . . . . . . . . . . . . . . 44chloramphenicol sodium succinate . . 17chlorhexidine gluconate mouth/throat soln . . . . . . . . . . . . . . . . . 41chloroquine phosphate . . . . . . . . . . . . . 29chlorothiazide . . . . . . . . . . . . . . . . . . . . . 39chlorothiazide sodium . . . . . . . . . . . . . . 39chlorpromazine hcl inj . . . . . . . . . . . . . 29chlorpromazine hcl tabs . . . . . . . . . . . 29chlorthalidone . . . . . . . . . . . . . . . . . . . . . 39cholestyramine . . . . . . . . . . . . . . . . . . . . 40cholestyramine light . . . . . . . . . . . . . . . 40chorionic gonadotropin . . . . . . . . . . . . . 48ciclodan . . . . . . . . . . . . . . . . . . . . . . . . . . . 24ciclopirox nail lacquer . . . . . . . . . . . . . . 24ciclopirox olamine . . . . . . . . . . . . . . . . . 24ciclopirox sham . . . . . . . . . . . . . . . . . . . 24ciclopirox susp . . . . . . . . . . . . . . . . . . . . 24cidofovir . . . . . . . . . . . . . . . . . . . . . . . . . . 31cilostazol . . . . . . . . . . . . . . . . . . . . . . . . . . 36CILOXAN OINT . . . . . . . . . . . . . . . . . . . 19CIMDUO . . . . . . . . . . . . . . . . . . . . . . . . . . 32cimetidine . . . . . . . . . . . . . . . . . . . . . . . . . 45cimetidine hcl . . . . . . . . . . . . . . . . . . . . . 45CINRYZE . . . . . . . . . . . . . . . . . . . . . . . . . 52CIPRODEX . . . . . . . . . . . . . . . . . . . . . . . 19ciprofloxacin er tb24 500mg; 0 . . . . . . 19ciprofloxacin er tb24 1000mg; 0 . . . . 19ciprofloxacin hcl ophthalmic soln . . . 19

63


Covered Drugs Index

daptomycin inj 500mg . . . . . . . . . . . . . . 17DARAPRIM . . . . . . . . . . . . . . . . . . . . . . . 29darifenacin hydrobromide er . . . . . . . . 46DARZALEX . . . . . . . . . . . . . . . . . . . . . . . 28dasetta 1/35 . . . . . . . . . . . . . . . . . . . . . . . 49dasetta 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 49daunorubicin hcl . . . . . . . . . . . . . . . . . . . 26daunorubicin hydrochloride . . . . . . . . . 26daysee . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49deblitane . . . . . . . . . . . . . . . . . . . . . . . . . . 50decitabine . . . . . . . . . . . . . . . . . . . . . . . . . 26DELESTROGEN INJ 10MG/ML . . . . 49delyla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49demeclocycline hcl . . . . . . . . . . . . . . . . 20DEMSER . . . . . . . . . . . . . . . . . . . . . . . . . 39DENAVIR . . . . . . . . . . . . . . . . . . . . . . . . . 33DEPEN TITRATABS . . . . . . . . . . . . . . . 44DEPO-ESTRADIOL . . . . . . . . . . . . . . . 49DEPO-MEDROL INJ 20MG/ML . . . . . 47DEPO-PROVERA . . . . . . . . . . . . . . . . . 50DESCOVY . . . . . . . . . . . . . . . . . . . . . . . . 32desipramine hcl . . . . . . . . . . . . . . . . . . . 23desloratadine . . . . . . . . . . . . . . . . . . . . . . 56desmopressin acetate inj . . . . . . . . . . 48desmopressin acetate nasal soln . . . 48desmopressin acetate tabs . . . . . . . . 48desogestrel/ethinyl estradiol . . . . . . . . 49desonide lotn . . . . . . . . . . . . . . . . . . . . . 47desonide oint . . . . . . . . . . . . . . . . . . . . . 47desoximetasone crea . . . . . . . . . . . . . 47desoximetasone gel . . . . . . . . . . . . . . . 47desoximetasone oint . . . . . . . . . . . . . . 47desvenlafaxine er . . . . . . . . . . . . . . . . . . 22dexamethasone elix . . . . . . . . . . . . . . . 47dexamethasone intensol . . . . . . . . . . . 47dexamethasone oral soln . . . . . . . . . . 47dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml . . . . 47

CREON . . . . . . . . . . . . . . . . . . . . . . . . . . . 46CRESTOR . . . . . . . . . . . . . . . . . . . . . . . . 39CRIXIVAN CAPS 200MG . . . . . . . . . . 32CRIXIVAN CAPS 400MG . . . . . . . . . . 32cromolyn sodium conc . . . . . . . . . . . . 45cromolyn sodium nebu . . . . . . . . . . . . 57cromolyn sodium ophthalmic soln . . . 55cryselle-28 . . . . . . . . . . . . . . . . . . . . . . . . 48CUPRIMINE . . . . . . . . . . . . . . . . . . . . . . 44curity gauze pads 2”x2” . . . . . . . . . . . . 42cyclafem 1/35 . . . . . . . . . . . . . . . . . . . . . 48cyclafem 7/7/7 . . . . . . . . . . . . . . . . . . . . . 49cyclobenzaprine hcl tabs 10mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 57cyclophosphamide caps . . . . . . . . . . . 25cyclophosphamide inj 1gm, 500mg . . . . . . . . . . . . . . . . . . . . . . . 25cyclophosphamide inj 2gm . . . . . . . . . 25cycloserine . . . . . . . . . . . . . . . . . . . . . . . . 25CYCLOSET . . . . . . . . . . . . . . . . . . . . . . . 34cyclosporine . . . . . . . . . . . . . . . . . . . . . . . 52cyclosporine modified . . . . . . . . . . . . . . 52CYRAMZA . . . . . . . . . . . . . . . . . . . . . . . . 28cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49CYSTADANE . . . . . . . . . . . . . . . . . . . . . 46CYSTAGON . . . . . . . . . . . . . . . . . . . . . . . 46CYSTARAN . . . . . . . . . . . . . . . . . . . . . . . 55cytarabine . . . . . . . . . . . . . . . . . . . . . . . . . 26cytarabine aqueous . . . . . . . . . . . . . . . . 26

Ddacarbazine . . . . . . . . . . . . . . . . . . . . . . . 25dactinomycin . . . . . . . . . . . . . . . . . . . . . . 26DALIRESP TABS 250MCG . . . . . . . . . 57DALIRESP TABS 500MCG . . . . . . . . . 57danazol caps 50mg . . . . . . . . . . . . . . . . 48danazol caps 100mg, 200mg . . . . . . . 48dantrolene sodium . . . . . . . . . . . . . . . . . 31dapsone tabs . . . . . . . . . . . . . . . . . . . . . 25DAPTACEL . . . . . . . . . . . . . . . . . . . . . . . 53

clopidogrel tabs 300mg . . . . . . . . . . . . 36clorazepate dipotassium tabs 3.75mg, 7.5mg . . . . . . . . . . . . . . . 33clorazepate dipotassium tabs 15mg . . . . . . . . . . . . . . . . . . . . . . . . 33clotrimazole/betamethasone dipropionate . . . . . . . . . . . . . . . . . . . . . . . 24clotrimazole external crea . . . . . . . . . 24clotrimazole external soln . . . . . . . . . . 24clotrimazole lozg . . . . . . . . . . . . . . . . . . 24clozapine odt tbdp 12.5mg, 25mg . . . 31clozapine odt tbdp 100mg . . . . . . . . . . 31clozapine odt tbdp 150mg . . . . . . . . . . 31clozapine odt tbdp 200mg . . . . . . . . . . 31clozapine tabs 25mg, 50mg . . . . . . . . 31clozapine tabs 100mg . . . . . . . . . . . . . . 31clozapine tabs 200mg . . . . . . . . . . . . . . 31COARTEM . . . . . . . . . . . . . . . . . . . . . . . . 29colchicine caps . . . . . . . . . . . . . . . . . . . 24colchicine tabs . . . . . . . . . . . . . . . . . . . . 24colestipol hcl . . . . . . . . . . . . . . . . . . . . . . 40colistimethate sodium . . . . . . . . . . . . . . 17colocort . . . . . . . . . . . . . . . . . . . . . . . . . . . 53COLY-MYCIN S . . . . . . . . . . . . . . . . . . . 56COMBIGAN . . . . . . . . . . . . . . . . . . . . . . . 55COMBIVENT RESPIMAT . . . . . . . . . . 56COMETRIQ KIT . . . . . . . . . . . . . . . . . . 27COMETRIQ KIT . . . . . . . . . . . . . . . . . . 28COMETRIQ KIT 20MG . . . . . . . . . . . . 27COMPLERA . . . . . . . . . . . . . . . . . . . . . . 32compro . . . . . . . . . . . . . . . . . . . . . . . . . . . 29constulose . . . . . . . . . . . . . . . . . . . . . . . . 45COPAXONE INJ 20MG/ML . . . . . . . . . 41COPAXONE INJ 40MG/ML . . . . . . . . . 41COREG CR . . . . . . . . . . . . . . . . . . . . . . . 38CORLANOR . . . . . . . . . . . . . . . . . . . . . . 39cortisone acetate . . . . . . . . . . . . . . . . . . 47COSMEGEN . . . . . . . . . . . . . . . . . . . . . . 26COTELLIC . . . . . . . . . . . . . . . . . . . . . . . . 28COUMADIN . . . . . . . . . . . . . . . . . . . . . . . 35

64


Covered Drugs Index

DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC . . . . . . . . . . . . . . . . . . . . . . . 53disulfiram . . . . . . . . . . . . . . . . . . . . . . . . . 16divalproex sodium . . . . . . . . . . . . . . . . . 20divalproex sodium dr . . . . . . . . . . . . . . . 20divalproex sodium er . . . . . . . . . . . . . . . 20docetaxel inj 160mg/16ml, 160mg/8ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml . . . . . . . . . . . . . . 26DOCETAXEL INJ 200MG/10ML . . . . 26dofetilide . . . . . . . . . . . . . . . . . . . . . . . . . . 37donepezil hcl tabs 10mg . . . . . . . . . . . 21donepezil hcl tabs 23mg, 5mg . . . . . . 21donepezil hcl tbdp 5mg . . . . . . . . . . . . 21donepezil hcl tbdp 10mg . . . . . . . . . . . 21donepezil hydrochloride tabs 5mg . . 21donepezil hydrochloride tabs 10mg . . 21dorzolamide hcl . . . . . . . . . . . . . . . . . . . 55dorzolamide hcl/timolol maleate . . . . 55doxazosin mesylate tabs 1mg, 2mg, 4mg . . . . . . . . . . . . . . . . . . . . 46doxazosin mesylate tabs 8mg . . . . . . 46doxepin hcl . . . . . . . . . . . . . . . . . . . . . . . . 33doxepin hydrochloride . . . . . . . . . . . . . 42doxercalciferol caps 0.5mcg . . . . . . . . 54doxercalciferol caps 1mcg . . . . . . . . . . 54doxercalciferol caps 2.5mcg . . . . . . . . 54doxercalciferol inj . . . . . . . . . . . . . . . . . 54doxorubicin hcl . . . . . . . . . . . . . . . . . . . . 26doxorubicin hcl liposome . . . . . . . . . . . 26doxy 100 . . . . . . . . . . . . . . . . . . . . . . . . . . 20doxycycline hyclate caps . . . . . . . . . . 20doxycycline hyclate tabs 20mg . . . . . 20doxycycline hyclate tabs 100mg . . . . 20doxycycline monohydrate caps 75mg . . . . . . . . . . . . . . . . . . . . . . . . 20doxycycline monohydrate caps 100mg, 50mg . . . . . . . . . . . . . . . . 20doxycycline monohydrate tabs . . . . . 20doxycycline susr . . . . . . . . . . . . . . . . . . 20

diazepam inj 5mg/ml . . . . . . . . . . . . . . . 33diazepam oral soln . . . . . . . . . . . . . . . . 34diazepam rectal gel gel 2.5mg . . . . . . 20diazepam rectal gel gel 10mg . . . . . . 20diazepam rectal gel gel 20mg . . . . . . 20diazepam tabs . . . . . . . . . . . . . . . . . . . . 34diclofenac potassium . . . . . . . . . . . . . . 14diclofenac sodium dr tbec 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 14diclofenac sodium dr tbec 75mg . . . . 14diclofenac sodium er . . . . . . . . . . . . . . . 14diclofenac sodium gel 1% . . . . . . . . . . 42diclofenac sodium ophthalmic soln . . . . . . . . . . . . . . . . . . . 55diclofenac sodium transdermal soln . . . . . . . . . . . . . . . . . . 42dicloxacillin sodium . . . . . . . . . . . . . . . . 18dicyclomine hcl caps . . . . . . . . . . . . . . 45dicyclomine hcl oral soln . . . . . . . . . . . 45dicyclomine hydrochloride . . . . . . . . . . 45didanosine . . . . . . . . . . . . . . . . . . . . . . . . 32diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . . 14digitek tabs 0.25mg . . . . . . . . . . . . . . . . 39digitek tabs 0.125mg . . . . . . . . . . . . . . . 39digoxin inj . . . . . . . . . . . . . . . . . . . . . . . . 39digoxin tabs 125mcg . . . . . . . . . . . . . . . 39digoxin tabs 250mcg . . . . . . . . . . . . . . . 39digox tabs 125mcg . . . . . . . . . . . . . . . . 39digox tabs 250mcg . . . . . . . . . . . . . . . . 39dihydroergotamine mesylate inj . . . . 24DILANTIN CAPS 30MG . . . . . . . . . . . . 21diltiazem hcl er cp12 . . . . . . . . . . . . . . 38diltiazem hcl er cp24 120mg, 180mg, 240mg, 300mg, 420mg . . . . . 38diltiazem hcl er tb24 . . . . . . . . . . . . . . . 38diltiazem hcl inj . . . . . . . . . . . . . . . . . . . 38diltiazem hcl tabs . . . . . . . . . . . . . . . . . 38dilt-xr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38diphenhydramine hcl inj . . . . . . . . . . . 56diphenoxylate/atropine . . . . . . . . . . . . . 45

dexamethasone sodium phosphate ophthalmic soln . . . . . . . . 55dexamethasone tabs 0.5mg, 0.75mg, 4mg . . . . . . . . . . . . . . . 47dexamethasone tabs 1.5mg, 1mg, 2mg, 6mg . . . . . . . . . . . . 47dexmethylphenidate hcl . . . . . . . . . . . . 41dexrazoxane . . . . . . . . . . . . . . . . . . . . . . 26dextroamphetamine sulfate er cp24 5mg . . . . . . . . . . . . . . . . . . . . . . . 40dextroamphetamine sulfate er cp24 10mg . . . . . . . . . . . . . . . . . . . . . 40dextroamphetamine sulfate er cp24 15mg . . . . . . . . . . . . . . . . . . . . . 40dextroamphetamine sulfate oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 40dextroamphetamine sulfate tabs 5mg . . . . . . . . . . . . . . . . . . . . . . . . . . 40dextroamphetamine sulfate tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 40dextrose 2.5%/nacl 0.45% . . . . . . . . . 43DEXTROSE 5% . . . . . . . . . . . . . . . . . . . 43dextrose5% /electrolyte #48 viaflex . . 42dextrose 5%/lactated ringers . . . . . . . 43dextrose 5%/nacl 0.2% . . . . . . . . . . . . 43DEXTROSE 5%/NACL 0.3% . . . . . . . 43dextrose 5%/nacl 0.9% . . . . . . . . . . . . 43dextrose 5%/nacl 0.33% . . . . . . . . . . . 43dextrose 5%/nacl 0.45% . . . . . . . . . . . 43dextrose 5%/nacl 0.225% . . . . . . . . . . 43DEXTROSE 10% . . . . . . . . . . . . . . . . . . 42dextrose 10%/nacl 0.2% . . . . . . . . . . . 42dextrose10%/nacl 0.45% . . . . . . . . . . . 42DEXTROSE 20% . . . . . . . . . . . . . . . . . . 43DEXTROSE 25% . . . . . . . . . . . . . . . . . . 43DEXTROSE 30% . . . . . . . . . . . . . . . . . . 43DEXTROSE 40% . . . . . . . . . . . . . . . . . . 43DEXTROSE 50% . . . . . . . . . . . . . . . . . . 43DEXTROSE 70% . . . . . . . . . . . . . . . . . . 43DIASTAT ACUDIAL GEL 10MG . . . . . 20DIASTAT ACUDIAL GEL 20MG . . . . . 20DIASTAT PEDIATRIC . . . . . . . . . . . . . . 20

65


Covered Drugs Index

epirubicin hcl inj 200mg/100ml . . . . . 26epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21EPIVIR HBV ORAL SOLN . . . . . . . . . 31ERBITUX . . . . . . . . . . . . . . . . . . . . . . . . . 28ergoloid mesylates . . . . . . . . . . . . . . . . . 21ergotamine tartrate/caffeine . . . . . . . . 24ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . . 28ERLEADA . . . . . . . . . . . . . . . . . . . . . . . . 25errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50ertapenem . . . . . . . . . . . . . . . . . . . . . . . . 18ertapenem sodium . . . . . . . . . . . . . . . . . 18ERWINAZE . . . . . . . . . . . . . . . . . . . . . . . 26ery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19ERYPED 400 . . . . . . . . . . . . . . . . . . . . . 19ERY-TAB . . . . . . . . . . . . . . . . . . . . . . . . . . 19ERYTHROCIN LACTOBIONATE . . . 19erythrocin stearate . . . . . . . . . . . . . . . . . 19erythromycin base . . . . . . . . . . . . . . . . . 19erythromycin/benzoyl peroxide . . . . . 42erythromycin ethylsuccinate . . . . . . . . 19erythromycin external soln . . . . . . . . . 19erythromycin gel . . . . . . . . . . . . . . . . . . 19erythromycin oint . . . . . . . . . . . . . . . . . 19erythromycin pads . . . . . . . . . . . . . . . . 19ESBRIET CAPS . . . . . . . . . . . . . . . . . . 57ESBRIET TABS 267MG . . . . . . . . . . . . 57ESBRIET TABS 801MG . . . . . . . . . . . . 57escitalopram oxalate oral soln . . . . . 22escitalopram oxalate tabs 5mg . . . . . 22escitalopram oxalate tabs 10mg . . . . 22escitalopram oxalate tabs 20mg . . . . 22esgic caps . . . . . . . . . . . . . . . . . . . . . . . . 14esomeprazole magnesium . . . . . . . . . 46esomeprazole sodium . . . . . . . . . . . . . 46estarylla . . . . . . . . . . . . . . . . . . . . . . . . . . 49estradiol crea . . . . . . . . . . . . . . . . . . . . . 49estradiol pttw . . . . . . . . . . . . . . . . . . . . . 49estradiol ptwk . . . . . . . . . . . . . . . . . . . . . 49estradiol tabs 0.5mg, 1mg, 2mg . . . . 49estradiol tabs 10mcg . . . . . . . . . . . . . . . 49

EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 22EMTRIVA CAPS . . . . . . . . . . . . . . . . . . 32EMTRIVA ORAL SOLN . . . . . . . . . . . . 32ENABLEX . . . . . . . . . . . . . . . . . . . . . . . . . 46enalapril maleate . . . . . . . . . . . . . . . . . . 37enalapril maleate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 37ENBREL INJ 25MG/0.5ML . . . . . . . . . 52ENBREL INJ 25MG, 50MG/ML . . . . . 52ENBREL MINI . . . . . . . . . . . . . . . . . . . . . 52ENBREL SURECLICK . . . . . . . . . . . . . 52endocet tabs 325mg; 2.5mg, 325mg; 5mg . . . . . . . . 15endocet tabs 325mg; 7.5mg . . . . . . . . 15endocet tabs 325mg; 10mg . . . . . . . . 15ENGERIX-B INJ 10MCG/0.5ML . . . . 53ENGERIX-B INJ 20MCG/ML . . . . . . . 53enoxaparin sodium inj 30mg/0.3ml . . 35enoxaparin sodium inj 40mg/0.4ml . . 35enoxaparin sodium inj 60mg/0.6ml . . 35enoxaparin sodium inj 100mg/ml, 150mg/ml, 300mg/3ml . . 35enoxaparin sodium inj 120mg/0.8ml, 80mg/0.8ml . . . . . . . . . . 35enpresse-28 . . . . . . . . . . . . . . . . . . . . . . . 49enskyce . . . . . . . . . . . . . . . . . . . . . . . . . . . 49entacapone . . . . . . . . . . . . . . . . . . . . . . . 29entecavir . . . . . . . . . . . . . . . . . . . . . . . . . . 31ENTRESTO . . . . . . . . . . . . . . . . . . . . . . . 36enulose . . . . . . . . . . . . . . . . . . . . . . . . . . . 45ENVARSUS XR TB24 0.75MG, 1MG . . . . . . . . . . . . . . . . . . . . . 52ENVARSUS XR TB24 4MG . . . . . . . . 52EPCLUSA . . . . . . . . . . . . . . . . . . . . . . . . 31epinastine hcl . . . . . . . . . . . . . . . . . . . . . 55epinephrine hcl inj 1mg/10ml, 1mg/ml, 30mg/30ml . . . . . 56epinephrine inj 0.15mg/0.15ml, 0.15mg/0.3ml, 0.3mg/0.3ml . . . . . . . . 56EPIPEN 2-PAK . . . . . . . . . . . . . . . . . . . . 56EPIPEN-JR 2-PAK . . . . . . . . . . . . . . . . . 56

dronabinol . . . . . . . . . . . . . . . . . . . . . . . . 23DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . . 26duloxetine hcl cpep 20mg . . . . . . . . . . 22duloxetine hydrochloride cpep 30mg . . . . . . . . . . . . . . . . . . . . . . . . 22duloxetine hydrochloride cpep 60mg . . . . . . . . . . . . . . . . . . . . . . . . 22DURAMORPH . . . . . . . . . . . . . . . . . . . . 14DUREZOL . . . . . . . . . . . . . . . . . . . . . . . . 55dutasteride . . . . . . . . . . . . . . . . . . . . . . . . 46dutasteride/tamsulosin hydrochloride . . . . . . . . . . . . . . . . . . . . . . 46

Eeconazole nitrate . . . . . . . . . . . . . . . . . . 24EDARBI . . . . . . . . . . . . . . . . . . . . . . . . . . 36EDARBYCLOR . . . . . . . . . . . . . . . . . . . . 36ed-spaz . . . . . . . . . . . . . . . . . . . . . . . . . . . 45EDURANT . . . . . . . . . . . . . . . . . . . . . . . . 32e.e.s. 400 . . . . . . . . . . . . . . . . . . . . . . . . . 19efavirenz caps 50mg . . . . . . . . . . . . . . . 32efavirenz caps 200mg . . . . . . . . . . . . . 32efavirenz tabs . . . . . . . . . . . . . . . . . . . . 32ELAPRASE . . . . . . . . . . . . . . . . . . . . . . . 46ELIDEL . . . . . . . . . . . . . . . . . . . . . . . . . . . 42ELIGARD INJ 7.5MG . . . . . . . . . . . . . . 51ELIGARD INJ 22.5MG . . . . . . . . . . . . . 51ELIGARD INJ 30MG . . . . . . . . . . . . . . . 51ELIGARD INJ 45MG . . . . . . . . . . . . . . . 51elinest . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49ELIQUIS STARTER PACK . . . . . . . . . 35ELIQUIS TABS 2.5MG . . . . . . . . . . . . . 35ELIQUIS TABS 5MG . . . . . . . . . . . . . . . 35ELITEK . . . . . . . . . . . . . . . . . . . . . . . . . . . 26ELLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50ELMIRON . . . . . . . . . . . . . . . . . . . . . . . . . 46EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . . 26EMEND SUSR . . . . . . . . . . . . . . . . . . . . 23emoquette . . . . . . . . . . . . . . . . . . . . . . . . 49EMPLICITI . . . . . . . . . . . . . . . . . . . . . . . . 28

66


Covered Drugs Index

fludarabine phosphate inj 50mg . . . . 26fludrocortisone acetate . . . . . . . . . . . . . 47flunisolide . . . . . . . . . . . . . . . . . . . . . . . . . 56fluocinolone acetonide body . . . . . . . . 47fluocinolone acetonide crea . . . . . . . . 47fluocinolone acetonide external soln . . . . . . . . . . . . . . . . . . . . . . 47fluocinolone acetonide oil . . . . . . . . . . 56fluocinolone acetonide oint . . . . . . . . 47fluocinolone acetonide scalp . . . . . . . 47fluocinonide crea 0.1% . . . . . . . . . . . . . 47fluocinonide crea 0.05% . . . . . . . . . . . 47fluocinonide external soln . . . . . . . . . . 47fluocinonide gel . . . . . . . . . . . . . . . . . . . 47fluocinonide oint . . . . . . . . . . . . . . . . . . 47fluoride chew 0.25mg . . . . . . . . . . . . . . 43fluoritab chew 0.5mg, 1mg . . . . . . . . . 43fluorometholone . . . . . . . . . . . . . . . . . . . 55fluorouracil crea 0.5% . . . . . . . . . . . . . . 42fluorouracil crea 5% . . . . . . . . . . . . . . . 42fluorouracil external soln . . . . . . . . . . . 42fluorouracil inj . . . . . . . . . . . . . . . . . . . . . 26fluoxetine caps 10mg . . . . . . . . . . . . . . 22fluoxetine caps 20mg . . . . . . . . . . . . . . 22fluoxetine dr . . . . . . . . . . . . . . . . . . . . . . . 22fluoxetine hcl caps 10mg . . . . . . . . . . . 22fluoxetine hcl caps 20mg . . . . . . . . . . . 22fluoxetine hcl caps 40mg . . . . . . . . . . . 22fluoxetine hcl oral soln . . . . . . . . . . . . . 22fluoxetine hydrochloride tabs 10mg . . 22fluoxetine hydrochloride tabs 20mg . . 22fluphenazine decanoate . . . . . . . . . . . . 29fluphenazine hcl conc . . . . . . . . . . . . . 29fluphenazine hcl elix . . . . . . . . . . . . . . 29fluphenazine hcl inj . . . . . . . . . . . . . . . . 29fluphenazine hcl tabs 1mg . . . . . . . . . 29fluphenazine hcl tabs 10mg, 2.5mg, 5mg . . . . . . . . . . . . . . . . . 30flurbiprofen . . . . . . . . . . . . . . . . . . . . . . . . 14flurbiprofen sodium . . . . . . . . . . . . . . . . 55

fenofibrate micronized caps 67mg . . 39fenofibrate micronized caps 134mg, 200mg . . . . . . . . . . . . . . . . . . . . 39fenofibrate tabs 48mg, 54mg . . . . . . . 39fenofibrate tabs 145mg, 160mg . . . . . 39fenofibric acid dr cpdr 45mg . . . . . . . . 39fenofibric acid dr cpdr 135mg . . . . . . . 39fenoprofen calcium caps 400mg . . . . 14fenoprofen calcium tabs . . . . . . . . . . . 14fentanyl . . . . . . . . . . . . . . . . . . . . . . . . . . . 14fentanyl citrate inj 1000mcg/20ml, 100mcg/2ml, 2500mcg/50ml, 250mcg/5ml . . . . . . . 15fentanyl citrate oral transmucosal lpop 200mcg, 400mcg, 600mcg . . . . 15fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 800mcg . . 15FERRIPROX . . . . . . . . . . . . . . . . . . . . . . 54FETZIMA . . . . . . . . . . . . . . . . . . . . . . . . . 22FETZIMA TITRATION PACK . . . . . . . 22finasteride tabs 5mg . . . . . . . . . . . . . . . 46FIRAZYR . . . . . . . . . . . . . . . . . . . . . . . . . 52FIRMAGON INJ 80MG . . . . . . . . . . . . . 51FIRMAGON INJ 120MG . . . . . . . . . . . 51flavoxate hcl . . . . . . . . . . . . . . . . . . . . . . . 46flecainide acetate . . . . . . . . . . . . . . . . . . 37FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST . . . . 56FLOVENT DISKUS AEPB 250MCG/BLIST . . . . . . . . . . . . . . . . . . . 56FLOVENT HFA AERO 44MCG/ACT . . . . . . . . . . . . . . . . . . . . . . 56FLOVENT HFA AERO 110MCG/ACT . . . . . . . . . . . . . . . . . . . . . 56FLOVENT HFA AERO 220MCG/ACT . . . . . . . . . . . . . . . . . . . . . 56fluconazole in nacl . . . . . . . . . . . . . . . . . 24fluconazole susr . . . . . . . . . . . . . . . . . . 24fluconazole tabs 100mg, 200mg, 50mg . . . . . . . . . . . . . . 24fluconazole tabs 150mg . . . . . . . . . . . . 24flucytosine . . . . . . . . . . . . . . . . . . . . . . . . 24

estradiol valerate . . . . . . . . . . . . . . . . . . 49ESTRING . . . . . . . . . . . . . . . . . . . . . . . . . 49ethacrynate sodium . . . . . . . . . . . . . . . . 39ethambutol hcl . . . . . . . . . . . . . . . . . . . . 25ethosuximide . . . . . . . . . . . . . . . . . . . . . . 20ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg . . . . . . . . . 49ETHYOL . . . . . . . . . . . . . . . . . . . . . . . . . . 26etidronate disodium . . . . . . . . . . . . . . . . 54etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . 14etodolac er . . . . . . . . . . . . . . . . . . . . . . . . 14etoposide inj . . . . . . . . . . . . . . . . . . . . . . 27EVOMELA . . . . . . . . . . . . . . . . . . . . . . . . 25EVOTAZ . . . . . . . . . . . . . . . . . . . . . . . . . . 33exemestane . . . . . . . . . . . . . . . . . . . . . . . 27ezetimibe . . . . . . . . . . . . . . . . . . . . . . . . . 40ezetimibe/simvastatin . . . . . . . . . . . . . . 40

FFABRAZYME . . . . . . . . . . . . . . . . . . . . . 46falmina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49famciclovir . . . . . . . . . . . . . . . . . . . . . . . . 33famotidine inj . . . . . . . . . . . . . . . . . . . . . 45famotidine premixed . . . . . . . . . . . . . . . 45famotidine tabs 20mg, 40mg . . . . . . . 45FANAPT TABS 1MG, 2MG, 4MG . . . 30FANAPT TABS 10MG, 12MG, 6MG, 8MG . . . . . . . . . . 30FANAPT TITRATION PACK . . . . . . . . 30FARESTON . . . . . . . . . . . . . . . . . . . . . . . 26FARXIGA . . . . . . . . . . . . . . . . . . . . . . . . . 34FARYDAK . . . . . . . . . . . . . . . . . . . . . . . . 28FASLODEX . . . . . . . . . . . . . . . . . . . . . . . 26felbamate susp . . . . . . . . . . . . . . . . . . . 21felbamate tabs . . . . . . . . . . . . . . . . . . . . 21felodipine er . . . . . . . . . . . . . . . . . . . . . . . 38FEMRING . . . . . . . . . . . . . . . . . . . . . . . . . 49femynor . . . . . . . . . . . . . . . . . . . . . . . . . . . 49fenofibrate caps 43mg, 50mg . . . . . . . 39fenofibrate caps 130mg, 150mg . . . . 39

67


Covered Drugs Index

GENOTROPIN MINIQUICK INJ 0.2MG . . . . . . . . . . . . . . . . . . . . . . . . 48GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG . . 48gentak . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16gentamicin sulfate/ 0.9% sodium chloride . . . . . . . . . . . . . . 16gentamicin sulfate crea . . . . . . . . . . . . 16gentamicin sulfate inj . . . . . . . . . . . . . . 16gentamicin sulfate oint . . . . . . . . . . . . 16gentamicin sulfate ophthalmic soln . . 16gentamicin sulfate pediatric . . . . . . . . 16GENVOYA . . . . . . . . . . . . . . . . . . . . . . . . 31GEODON INJ . . . . . . . . . . . . . . . . . . . . 30GILENYA . . . . . . . . . . . . . . . . . . . . . . . . . 41GILOTRIF . . . . . . . . . . . . . . . . . . . . . . . . . 28GLEOSTINE . . . . . . . . . . . . . . . . . . . . . . 25glimepiride tabs 1mg . . . . . . . . . . . . . . . 34glimepiride tabs 2mg . . . . . . . . . . . . . . . 34glimepiride tabs 4mg . . . . . . . . . . . . . . . 34glipizide er tb24 2.5mg . . . . . . . . . . . . . 34glipizide er tb24 5mg . . . . . . . . . . . . . . . 34glipizide er tb24 10mg . . . . . . . . . . . . . 34glipizide/metformin hcl tabs 2.5mg; 250mg . . . . . . . . . . . . . . . . . . . . . 34glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg . . . . . . . . 34glipizide tabs 5mg . . . . . . . . . . . . . . . . . 34glipizide tabs 10mg . . . . . . . . . . . . . . . . 34glipizide xl tb24 2.5mg . . . . . . . . . . . . . 34glipizide xl tb24 5mg . . . . . . . . . . . . . . . 34glipizide xl tb24 10mg . . . . . . . . . . . . . . 34GLUCAGEN HYPOKIT . . . . . . . . . . . . 35GLUCAGON EMERGENCY KIT . . . . 35glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml . . . . 45glycopyrrolate tabs . . . . . . . . . . . . . . . . 45glydo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16GLYXAMBI . . . . . . . . . . . . . . . . . . . . . . . . 34granisetron hcl inj . . . . . . . . . . . . . . . . . 23

FYCOMPA SUSP . . . . . . . . . . . . . . . . . 20FYCOMPA TABS . . . . . . . . . . . . . . . . . 20

Ggabapentin caps 100mg . . . . . . . . . . . 21gabapentin caps 300mg, 400mg . . . . 21gabapentin oral soln . . . . . . . . . . . . . . 21gabapentin tabs 600mg . . . . . . . . . . . . 21gabapentin tabs 800mg . . . . . . . . . . . . 21GABITRIL TABS 12MG . . . . . . . . . . . . 21GABITRIL TABS 16MG . . . . . . . . . . . . 21galantamine hydrobromide er . . . . . . 22galantamine hydrobromide oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 22galantamine hydrobromide tabs . . . . 22GAMMAKED INJ 1GM/10ML . . . . . . . 52GAMMAKED INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 5GM/50ML . . . . . . . . . . 52GAMUNEX-C INJ 1GM/10ML . . . . . . 52GAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 40GM/400ML, 5GM/50ML . . . . . . . . . . 52ganciclovir inj 500mg, 500mg/10ml . . . . . . . . . . . . . . . 31GARDASIL 9 . . . . . . . . . . . . . . . . . . . . . . 53GATTEX . . . . . . . . . . . . . . . . . . . . . . . . . . 45gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . . 45gavilyte-g . . . . . . . . . . . . . . . . . . . . . . . . . 45gavilyte-n/flavor pack . . . . . . . . . . . . . . 45GAZYVA . . . . . . . . . . . . . . . . . . . . . . . . . . 28gemcitabine . . . . . . . . . . . . . . . . . . . . . . . 26gemcitabine hcl inj 1gm . . . . . . . . . . . . 26gemcitabine hcl inj 200mg, 2gm . . . . 26gemcitabine hydrochloride inj 1.5gm/15ml, 1gm/10ml, 200mg/2ml, 2gm/20ml . . . . . . . . . . . . . 26gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . . 39generlac . . . . . . . . . . . . . . . . . . . . . . . . . . 45gengraf . . . . . . . . . . . . . . . . . . . . . . . . . . . 52GENOTROPIN . . . . . . . . . . . . . . . . . . . . 48

flutamide . . . . . . . . . . . . . . . . . . . . . . . . . . 25fluticasone propionate crea . . . . . . . . 47fluticasone propionate oint . . . . . . . . . 47fluticasone propionate susp . . . . . . . . 56fluvoxamine maleate er . . . . . . . . . . . . 22fluvoxamine maleate tabs 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 22fluvoxamine maleate tabs 100mg . . . 22FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . . 26fomepizole . . . . . . . . . . . . . . . . . . . . . . . . 54fondaparinux sodium inj 2.5mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . 35fondaparinux sodium inj 5mg/0.4ml . . . . . . . . . . . . . . . . . . . . . . . . 35fondaparinux sodium inj 7.5mg/0.6ml . . . . . . . . . . . . . . . . . . . . . . . 35fondaparinux sodium inj 10mg/0.8ml . . . . . . . . . . . . . . . . . . . . . . . 35FORTEO . . . . . . . . . . . . . . . . . . . . . . . . . . 54fosamprenavir calcium . . . . . . . . . . . . . 33FOSCAVIR . . . . . . . . . . . . . . . . . . . . . . . . 31fosinopril sodium . . . . . . . . . . . . . . . . . . 37fosinopril sodium/ hydrochlorothiazide . . . . . . . . . . . . . . . . 37fosphenytoin sodium . . . . . . . . . . . . . . . 21FREAMINE HBC 6.9% . . . . . . . . . . . . . 43FREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML . . . . . 43furosemide inj . . . . . . . . . . . . . . . . . . . . 39furosemide oral soln . . . . . . . . . . . . . . 39furosemide tabs . . . . . . . . . . . . . . . . . . . 39FUSILEV . . . . . . . . . . . . . . . . . . . . . . . . . . 26FUZEON . . . . . . . . . . . . . . . . . . . . . . . . . . 32fyavolv tabs 2.5mcg; 0.5mg . . . . . . . . 49

68


Covered Drugs Index

hydrocodone/ibuprofen . . . . . . . . . . . . 15hydrocortisone/acetic acid . . . . . . . . . . 56hydrocortisone butyrate crea . . . . . . . 47hydrocortisone butyrate external soln . . . . . . . . . . . . . . . . . . . . . . 47hydrocortisone butyrate (lipid) . . . . . . 47hydrocortisone butyrate (lipophilic) . . 47hydrocortisone butyrate oint . . . . . . . 47hydrocortisone enem . . . . . . . . . . . . . . 53hydrocortisone external crea . . . . . . . 47hydrocortisone lotn 2.5% . . . . . . . . . . . 47hydrocortisone oint 1%, 2.5% . . . . . . 47hydrocortisone rectal crea . . . . . . . . . 47hydrocortisone tabs . . . . . . . . . . . . . . . 47hydrocortisone valerate . . . . . . . . . . . . 47hydromorphone hcl dosette . . . . . . . . 15hydromorphone hcl inj . . . . . . . . . . . . . 15hydromorphone hcl liqd . . . . . . . . . . . 15hydromorphone hcl tabs 2mg, 4mg . . . . . . . . . . . . . . . . . . . . . . . . . 15hydromorphone hcl tabs 8mg . . . . . . . 15hydroxychloroquine sulfate . . . . . . . . . 29hydroxyprogesterone caproate . . . . . 50hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . 26hyoscyamine sulfate elix . . . . . . . . . . . 45hyoscyamine sulfate odt . . . . . . . . . . . 45hyoscyamine sulfate subl . . . . . . . . . . 45hyoscyamine sulfate tabs . . . . . . . . . . 45hyoscyamine sulfate tbdp . . . . . . . . . . 45

Iibandronate sodium tabs . . . . . . . . . . 54IBRANCE . . . . . . . . . . . . . . . . . . . . . . . . . 28ibudone tabs 5mg; 200mg . . . . . . . . . . 15ibuprofen susp . . . . . . . . . . . . . . . . . . . . 14ibuprofen tabs 400mg, 600mg, 800mg . . . . . . . . . . . . 14ibu tabs 600mg, 800mg . . . . . . . . . . . . 14ICLUSIG TABS 15MG . . . . . . . . . . . . . 28ICLUSIG TABS 45MG . . . . . . . . . . . . . 28

HUMALOG MIX 75/25 KWIKPEN . . . 35HUMIRA INJ 10MG/0.1ML, 10MG/0.2ML, 20MG/0.2ML, 20MG/0.4ML . . . . . . . . 52HUMIRA INJ 40MG/0.4ML, 40MG/0.8ML . . . . . . . . 52HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ . . . . 52HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML, 80MG/0.8ML . . . . . . . . 52HUMIRA PEN . . . . . . . . . . . . . . . . . . . . . 52HUMIRA PEN-CD/UC/HS STARTER INJ 40MG/0.8ML . . . . . . . . 52HUMIRA PEN-CD/UC/HS STARTER INJ 80MG/0.8ML . . . . . . . . 52HUMIRA PEN-PS/UV STARTER INJ . . . . . . . . . . . . . . . . . . . . 52HUMIRA PEN-PS/UV STARTER INJ 40MG/0.8ML . . . . . . . . 52HUMULIN 70/30 . . . . . . . . . . . . . . . . . . . 35HUMULIN 70/30 KWIKPEN . . . . . . . . 35HUMULIN N . . . . . . . . . . . . . . . . . . . . . . . 35HUMULIN N KWIKPEN . . . . . . . . . . . . 35HUMULIN R . . . . . . . . . . . . . . . . . . . . . . . 35HUMULIN R U-500 (CONCENTRATED) . . . . . . . . . . . . . . . 35HUMULIN R U-500 KWIKPEN. . . . . . 35hydralazine hcl inj . . . . . . . . . . . . . . . . . 40hydralazine hcl tabs . . . . . . . . . . . . . . . 40hydrochlorothiazide . . . . . . . . . . . . . . . . 39hydrocodone/acetaminophen tabs 325mg; 5mg . . . . . . . . . . . . . . . . . . . . . . . 15hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 7.5mg . . . . . . 15hydrocodone bitartrate/ acetaminophen oral soln . . . . . . . . . . 15hydrocodone bitartrate/ acetaminophen tabs 300mg; 5mg, 325mg; 2.5mg . . . . . . . . . . . . . . . 15hydrocodone bitartrate/ acetaminophen tabs 300mg; 10mg, 300mg; 7.5mg . . . . . . . . . . . . . . 15

granisetron hcl tabs . . . . . . . . . . . . . . . 23griseofulvin microsize . . . . . . . . . . . . . . 24griseofulvin ultramicrosize . . . . . . . . . . 24GUANIDINE HCL . . . . . . . . . . . . . . . . . . 24

HHALAVEN . . . . . . . . . . . . . . . . . . . . . . . . . 26halobetasol propionate . . . . . . . . . . . . . 47haloperidol conc . . . . . . . . . . . . . . . . . . 30haloperidol decanoate . . . . . . . . . . . . . 30haloperidol lactate . . . . . . . . . . . . . . . . . 30haloperidol tabs 0.5mg, 1mg, 2mg, 5mg . . . . . . . . . . . . 30haloperidol tabs 10mg, 20mg . . . . . . . 30HARVONI . . . . . . . . . . . . . . . . . . . . . . . . . 31HAVRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 53heather . . . . . . . . . . . . . . . . . . . . . . . . . . . 50heparin sodium/d5w . . . . . . . . . . . . . . . 35heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml . . . . . . . . 35heparin sodium/nacl 0.9% . . . . . . . . . . 36heparin sodium/ nacl 0.45% inj 50unit/ml; 0.45% . . . . 36heparin sodium/ sodium chloride 0.9% . . . . . . . . . . . . . . 36heparin sodium/ sodium chloride 0.9% premix . . . . . . . 36HEPATAMINE . . . . . . . . . . . . . . . . . . . . . 43HEPLISAV-B . . . . . . . . . . . . . . . . . . . . . . 53HERCEPTIN INJ 150MG . . . . . . . . . . . 28HERCEPTIN INJ 440MG . . . . . . . . . . . 28HETLIOZ . . . . . . . . . . . . . . . . . . . . . . . . . 41HEXALEN . . . . . . . . . . . . . . . . . . . . . . . . 25HIBERIX . . . . . . . . . . . . . . . . . . . . . . . . . . 53HUMALOG . . . . . . . . . . . . . . . . . . . . . . . . 35HUMALOG JUNIOR KWIKPEN . . . . 35HUMALOG KWIKPEN . . . . . . . . . . . . . 35HUMALOG MIX 50/50 . . . . . . . . . . . . . 35HUMALOG MIX 50/50 KWIKPEN . . . 35HUMALOG MIX 75/25 . . . . . . . . . . . . . 35

69


Covered Drugs Index

isosorbide dinitrate er . . . . . . . . . . . . . . 40isosorbide dinitrate tabs . . . . . . . . . . . 40isosorbide mononitrate . . . . . . . . . . . . . 40isosorbide mononitrate er . . . . . . . . . . 40isotonic gentamicin . . . . . . . . . . . . . . . . 16isotretinoin . . . . . . . . . . . . . . . . . . . . . . . . 42isradipine . . . . . . . . . . . . . . . . . . . . . . . . . 38ISTODAX (OVERFILL) . . . . . . . . . . . . . 26itraconazole caps . . . . . . . . . . . . . . . . . 24itraconazole oral soln . . . . . . . . . . . . . . 24ivermectin . . . . . . . . . . . . . . . . . . . . . . . . . 29IXIARO . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

JJADENU . . . . . . . . . . . . . . . . . . . . . . . . . . 44JADENU SPRINKLE . . . . . . . . . . . . . . . 44JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . . 28jantoven . . . . . . . . . . . . . . . . . . . . . . . . . . 36JANUMET . . . . . . . . . . . . . . . . . . . . . . . . 34JANUMET XR TB24 1000MG; 50MG . . . . . . . . . . . . . . . . . . . 34JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG . . . 34JANUVIA . . . . . . . . . . . . . . . . . . . . . . . . . 34JARDIANCE . . . . . . . . . . . . . . . . . . . . . . 34jencycla . . . . . . . . . . . . . . . . . . . . . . . . . . . 50JENTADUETO . . . . . . . . . . . . . . . . . . . . 34JENTADUETO XR TB24 2.5MG; 1000MG . . . . . . . . . . . . . . . . . . . 34JENTADUETO XR TB24 5MG; 1000MG . . . . . . . . . . . . . . . . . . . . 34jevantique lo . . . . . . . . . . . . . . . . . . . . . . 49JEVTANA . . . . . . . . . . . . . . . . . . . . . . . . . 26jolessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49jolivette . . . . . . . . . . . . . . . . . . . . . . . . . . . 50juleber . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49JULUCA . . . . . . . . . . . . . . . . . . . . . . . . . . 32junel 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . 49junel 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . 49junel fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 49

INVEGA SUSTENNA INJ 117MG/0.75ML . . . . . . . . . . . . . . . . . . . . 30INVEGA SUSTENNA INJ 156MG/ML . . . . . . . . . . . . . . . . . . . . . . . . 30INVEGA SUSTENNA INJ 234MG/1.5ML . . . . . . . . . . . . . . . . . . . . . 30INVEGA TRINZA INJ 273MG/0.875ML . . . . . . . . . . . . . . . . . . 30INVEGA TRINZA INJ 410MG/1.315ML . . . . . . . . . . . . . . . . . . 30INVEGA TRINZA INJ 546MG/1.75ML . . . . . . . . . . . . . . . . . . . . 30INVEGA TRINZA INJ 819MG/2.625ML . . . . . . . . . . . . . . . . . . 30INVIRASE CAPS . . . . . . . . . . . . . . . . . 33INVIRASE TABS . . . . . . . . . . . . . . . . . . 33INVOKAMET . . . . . . . . . . . . . . . . . . . . . . 34INVOKAMET XR . . . . . . . . . . . . . . . . . . 34INVOKANA . . . . . . . . . . . . . . . . . . . . . . . 34IPOL INACTIVATED IPV . . . . . . . . . . . 53ipratropium bromide/ albuterol sulfate . . . . . . . . . . . . . . . . . . . 56ipratropium bromide inhalation soln . . . . . . . . . . . . . . . . . . . . 56ipratropium bromide nasal soln . . . . . 56irbesartan . . . . . . . . . . . . . . . . . . . . . . . . . 36irbesartan/hydrochlorothiazide . . . . . . 36IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 28irinotecan . . . . . . . . . . . . . . . . . . . . . . . . . 26irinotecan hcl . . . . . . . . . . . . . . . . . . . . . . 26irinotecan hydrochloride inj 40mg/2ml . . . . . . . . . . . . . . . . . . . . . . 26ISENTRESS CHEW 25MG . . . . . . . . . 31ISENTRESS CHEW 100MG . . . . . . . 31ISENTRESS HD . . . . . . . . . . . . . . . . . . . 32ISENTRESS PACK . . . . . . . . . . . . . . . 32ISENTRESS TABS . . . . . . . . . . . . . . . . 32isibloom . . . . . . . . . . . . . . . . . . . . . . . . . . . 49isoniazid inj . . . . . . . . . . . . . . . . . . . . . . . 25isoniazid syrp . . . . . . . . . . . . . . . . . . . . . 25isoniazid tabs 100mg . . . . . . . . . . . . . . 25isoniazid tabs 300mg . . . . . . . . . . . . . . 25

idarubicin hcl inj 10mg/10ml . . . . . . . . 26IDHIFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28ifosfamide inj 1gm, 3gm . . . . . . . . . . . . 25ILARIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53ILEVRO . . . . . . . . . . . . . . . . . . . . . . . . . . . 55imatinib mesylate . . . . . . . . . . . . . . . . . . 28IMBRUVICA CAPS 70MG . . . . . . . . . . 28IMBRUVICA CAPS 140MG. . . . . . . . . 28IMBRUVICA TABS . . . . . . . . . . . . . . . . 28IMFINZI . . . . . . . . . . . . . . . . . . . . . . . . . . . 28imipenem/cilastatin inj 250mg; 250mg . . . . . . . . . . . . . . . . . . . . 18imipenem/cilastatin inj 500mg; 500mg . . . . . . . . . . . . . . . . . . . . 18imipramine hcl tabs 25mg, 50mg . . . 23imipramine hydrochloride . . . . . . . . . . 23imiquimod . . . . . . . . . . . . . . . . . . . . . . . . . 42imiquimod pump . . . . . . . . . . . . . . . . . . . 42IMOVAX RABIES (H.D.C.V.) . . . . . . . 53incassia . . . . . . . . . . . . . . . . . . . . . . . . . . . 50INCRELEX . . . . . . . . . . . . . . . . . . . . . . . . 48INCRUSE ELLIPTA . . . . . . . . . . . . . . . . 56indapamide . . . . . . . . . . . . . . . . . . . . . . . 39INFANRIX . . . . . . . . . . . . . . . . . . . . . . . . . 53INFUMORPH 200 . . . . . . . . . . . . . . . . . 14INFUMORPH 500 . . . . . . . . . . . . . . . . . 14INLYTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 28INTELENCE TABS 25MG . . . . . . . . . . 32INTELENCE TABS 100MG, 200MG . . . . . . . . . . . . . . . . . . . 32INTRALIPID . . . . . . . . . . . . . . . . . . . . . . . 54INTRON A INJ 10MU, 10MU/ML, 50MU . . . . . . . . . . . 31INTRON A INJ 18MU, 6000000UNIT/ML . . . . . . . . . . . 31introvale . . . . . . . . . . . . . . . . . . . . . . . . . . 49INVANZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 18INVEGA SUSTENNA INJ 39MG/0.25ML . . . . . . . . . . . . . . . . . . . . . 30INVEGA SUSTENNA INJ 78MG/0.5ML . . . . . . . . . . . . . . . . . . . . . . 30

70


Covered Drugs Index

LENVIMA 12MG DAILY DOSE . . . . . 28LENVIMA 14 MG DAILY DOSE . . . . . 28LENVIMA 18 MG DAILY DOSE . . . . . 28LENVIMA 20 MG DAILY DOSE . . . . . 28LENVIMA 24 MG DAILY DOSE . . . . . 28lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49LETAIRIS . . . . . . . . . . . . . . . . . . . . . . . . . 57letrozole . . . . . . . . . . . . . . . . . . . . . . . . . . 27leucovorin calcium inj 100mg, 350mg, 500mg, 50mg . . . . . . 26leucovorin calcium tabs . . . . . . . . . . . 26LEUKERAN . . . . . . . . . . . . . . . . . . . . . . . 25LEUKINE INJ 250MCG . . . . . . . . . . . . 36leuprolide acetate . . . . . . . . . . . . . . . . . 51levalbuterol tartrate hfa . . . . . . . . . . . . 56LEVEMIR . . . . . . . . . . . . . . . . . . . . . . . . . 35LEVEMIR FLEXTOUCH . . . . . . . . . . . 35levetiracetam er tb24 500mg . . . . . . . 20levetiracetam er tb24 750mg . . . . . . . 20levetiracetam inj . . . . . . . . . . . . . . . . . . 20levetiracetam oral soln . . . . . . . . . . . . 20levetiracetam tabs . . . . . . . . . . . . . . . . 20levobunolol hcl . . . . . . . . . . . . . . . . . . . . 55levocarnitine . . . . . . . . . . . . . . . . . . . . . . 54levocetirizine dihydrochloride oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 56levocetirizine dihydrochloride tabs . . 56levofloxacin in d5w . . . . . . . . . . . . . . . . 19levofloxacin inj . . . . . . . . . . . . . . . . . . . . 19levofloxacin oral soln . . . . . . . . . . . . . . 19levofloxacin tabs . . . . . . . . . . . . . . . . . . 19levoleucovorin calcium inj 175mg/17.5ml . . . . . . . . . . . . . . . . . . . . . 26levoleucovorin inj 175mg/17.5ml, 250mg/25ml, 50mg . . . . . . . . . . . . . . . . 26levonest . . . . . . . . . . . . . . . . . . . . . . . . . . 49levonorgestrel and ethinyl estradiol tabs 0; 0 . . . . . . . . . . . . . . . . . 49levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0 . . . . . . . . . 49

KORLYM . . . . . . . . . . . . . . . . . . . . . . . . . . 54kurvelo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49KUVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . 46KYPROLIS . . . . . . . . . . . . . . . . . . . . . . . . 27

Llabetalol hcl inj . . . . . . . . . . . . . . . . . . . . 38labetalol hcl tabs . . . . . . . . . . . . . . . . . . 38LACRISERT . . . . . . . . . . . . . . . . . . . . . . 55LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L . . . . . . . . . . . . . . . 43LACTATED RINGERS IRRIGATION . . . . . . . . . . . . . . . . . . . . . . 54LACTATED RINGERS VIAFLEX . . . . 43lactulose oral soln . . . . . . . . . . . . . . . . . 45lamivudine oral soln . . . . . . . . . . . . . . . 32lamivudine tabs 100mg . . . . . . . . . . . . 31lamivudine tabs 150mg . . . . . . . . . . . . 32lamivudine tabs 300mg . . . . . . . . . . . . 32lamivudine/zidovudine . . . . . . . . . . . . . 32lamotrigine . . . . . . . . . . . . . . . . . . . . . . . . 21lamotrigine er . . . . . . . . . . . . . . . . . . . . . 21lamotrigine odt . . . . . . . . . . . . . . . . . . . . 21LANTUS . . . . . . . . . . . . . . . . . . . . . . . . . . 35LANTUS SOLOSTAR . . . . . . . . . . . . . . 35larin 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . . 49larin 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . . 49larin fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 49larin fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 49larissia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49LARTRUVO . . . . . . . . . . . . . . . . . . . . . . . 26latanoprost . . . . . . . . . . . . . . . . . . . . . . . . 55LATUDA TABS 80MG . . . . . . . . . . . . . . 30LATUDA TABS 120MG, 20MG, 40MG, 60MG . . . . . . 30leflunomide . . . . . . . . . . . . . . . . . . . . . . . 53LENVIMA 4 MG DAILY DOSE . . . . . . 28LENVIMA 8 MG DAILY DOSE . . . . . . 28LENVIMA 10 MG DAILY DOSE . . . . . 28

junel fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 49

KKABIVEN . . . . . . . . . . . . . . . . . . . . . . . . . 43KADCYLA . . . . . . . . . . . . . . . . . . . . . . . . 28KALETRA ORAL SOLN . . . . . . . . . . . 33KALETRA TABS 100MG; 25MG . . . . 33KALETRA TABS 200MG; 50MG . . . . 33KALYDECO . . . . . . . . . . . . . . . . . . . . . . . 56kariva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49kcl 0.3%/d5w/nacl 0.9% . . . . . . . . . . . . 43kcl 0.3%/d5w/nacl 0.45% . . . . . . . . . . . 43kcl 0.15%/d5w/nacl 0.2% . . . . . . . . . . . 43kcl 0.15%/d5w/nacl 0.9% . . . . . . . . . . . 43kcl 0.15%/d5w/nacl 0.45% . . . . . . . . . 43kcl 0.15%/d5w/nacl 0.225% . . . . . . . . 43kcl 0.075%/d5w/nacl 0.45% . . . . . . . . 43kelnor 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 49kelnor 1/50 . . . . . . . . . . . . . . . . . . . . . . . . 49ketoconazole crea . . . . . . . . . . . . . . . . 24ketoconazole sham . . . . . . . . . . . . . . . 24ketoconazole tabs . . . . . . . . . . . . . . . . . 24ketorolac tromethamine ophthalmic soln . . . . . . . . . . . . . . . . . . . 55KEYTRUDA . . . . . . . . . . . . . . . . . . . . . . . 28kimidess . . . . . . . . . . . . . . . . . . . . . . . . . . 49KINERET . . . . . . . . . . . . . . . . . . . . . . . . . 52KINRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 53kionex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44KISQALI . . . . . . . . . . . . . . . . . . . . . . . . . . 26KISQALI FEMARA 200 DOSE . . . . . . 25KISQALI FEMARA 400 DOSE . . . . . . 25KISQALI FEMARA 600 DOSE . . . . . . 25klor-con . . . . . . . . . . . . . . . . . . . . . . . . . . . 43klor-con 8 . . . . . . . . . . . . . . . . . . . . . . . . . 43klor-con 10 . . . . . . . . . . . . . . . . . . . . . . . . 43klor-con m10 . . . . . . . . . . . . . . . . . . . . . . 43klor-con m20 . . . . . . . . . . . . . . . . . . . . . . 43klor-con sprinkle . . . . . . . . . . . . . . . . . . . 43

71


Covered Drugs Index

LUPRON DEPOT (3-MONTH) . . . . . . 51LUPRON DEPOT (4-MONTH) . . . . . . 51LUPRON DEPOT (6-MONTH) . . . . . . 51LUPRON DEPOT-PED (1-MONTH) . . . . . . . . . . . . . . . . . . . . . . . 51LUPRON DEPOT-PED (3-MONTH) . . . . . . . . . . . . . . . . . . . . . . . 51lutera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49LYNPARZA CAPS . . . . . . . . . . . . . . . . 28LYNPARZA TABS . . . . . . . . . . . . . . . . . 27LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG . . . . . . 20LYRICA CAPS 225MG, 300MG . . . . . 20LYRICA CR TB24 165MG, 82.5MG . . 41LYRICA CR TB24 330MG . . . . . . . . . . 41LYRICA ORAL SOLN . . . . . . . . . . . . . . 20LYSODREN . . . . . . . . . . . . . . . . . . . . . . . 51lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Mmagnesium sulfate in d5w . . . . . . . . . . 20MAGNESIUM SULFATE INJ 20GM/500ML, 2GM/50ML, 40GM/1000ML, 4GM/100ML, 4GM/50ML . . . . . . . . . . . . . . . . . . . . . . . . 43magnesium sulfate inj 20gm/500ml, 2gm/50ml, 40gm/1000ml, 4gm/100ml, 4gm/50ml, 50% . . . . . . . . . . . . . . . . . . . . 43MAKENA . . . . . . . . . . . . . . . . . . . . . . . . . 50MAKENA . . . . . . . . . . . . . . . . . . . . . . . . . 50malathion . . . . . . . . . . . . . . . . . . . . . . . . . 29maprotiline hcl . . . . . . . . . . . . . . . . . . . . . 22marlissa . . . . . . . . . . . . . . . . . . . . . . . . . . 49MARPLAN . . . . . . . . . . . . . . . . . . . . . . . . 22MATULANE . . . . . . . . . . . . . . . . . . . . . . . 25matzim la . . . . . . . . . . . . . . . . . . . . . . . . . 38meclizine hcl tabs . . . . . . . . . . . . . . . . . 23meclofenamate sodium . . . . . . . . . . . . 14MEDROL TABS 2MG . . . . . . . . . . . . . . 47

lithium carbonate caps 150mg, 600mg . . . . . . . . . . . . . . . . . . . . 34lithium carbonate caps 300mg . . . . . . 34lithium carbonate er . . . . . . . . . . . . . . . . 34lithium carbonate tabs . . . . . . . . . . . . . 34LIVALO . . . . . . . . . . . . . . . . . . . . . . . . . . . 40LONSURF TABS 6.14MG; 15MG . . . 26LONSURF TABS 8.19MG; 20MG . . . 26loperamide hcl caps . . . . . . . . . . . . . . . 45lopinavir/ritonavir . . . . . . . . . . . . . . . . . . 33lorazepam conc . . . . . . . . . . . . . . . . . . . 34lorazepam inj 2mg/ml, 4mg/ml . . . . . . 34lorazepam intensol . . . . . . . . . . . . . . . . 34lorazepam tabs 0.5mg, 1mg . . . . . . . . 34lorazepam tabs 2mg . . . . . . . . . . . . . . . 34lorcet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15lorcet hd . . . . . . . . . . . . . . . . . . . . . . . . . . 15lorcet plus tabs 325mg; 7.5mg . . . . . . 15losartan potassium/ hydrochlorothiazide tabs 12.5mg; 50mg . . . . . . . . . . . . . . . . . . . . . 37losartan potassium/ hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg . . . . . 37losartan potassium tabs 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 37losartan potassium tabs 100mg . . . . . 36LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . . 55lovastatin tabs 10mg, 20mg . . . . . . . . 40lovastatin tabs 40mg . . . . . . . . . . . . . . . 40low-ogestrel . . . . . . . . . . . . . . . . . . . . . . . 49loxapine caps 10mg, 5mg . . . . . . . . . . 30loxapine caps 25mg, 50mg . . . . . . . . . 30loxapine succinate caps 10mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 30loxapine succinate caps 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 30ludent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43LUMIGAN . . . . . . . . . . . . . . . . . . . . . . . . . 55LUMIZYME . . . . . . . . . . . . . . . . . . . . . . . 46LUPRON DEPOT (1-MONTH) . . . . . . 51

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, 20mcg; 0.1mg . . . . . . . . . . . . . . . . . . 49levora 0.15/30-28 . . . . . . . . . . . . . . . . . . 49levorphanol tartrate . . . . . . . . . . . . . . . . 14levothyroxine sodium tabs . . . . . . . . . 51levoxyl tabs 100mcg, 112mcg, 175mcg . . . . . . . . . 51LEVOXYL TABS 125MCG, 137MCG, 150MCG, 200MCG, 25MCG, 50MCG, 75MCG, 88MCG . . . 51LEXIVA SUSP . . . . . . . . . . . . . . . . . . . . 33LEXIVA TABS . . . . . . . . . . . . . . . . . . . . . 33LIALDA . . . . . . . . . . . . . . . . . . . . . . . . . . . 53lidocaine hcl external soln . . . . . . . . . 16lidocaine hcl gel . . . . . . . . . . . . . . . . . . . 16lidocaine hcl inj . . . . . . . . . . . . . . . . . . . 16lidocaine hcl inj . . . . . . . . . . . . . . . . . . . 37lidocaine hcl jelly . . . . . . . . . . . . . . . . . . 16lidocaine hcl mouth/throat soln . . . . . 16lidocaine hcl viscous . . . . . . . . . . . . . . . 16lidocaine oint . . . . . . . . . . . . . . . . . . . . . 16lidocaine/prilocaine crea . . . . . . . . . . . 16lidocaine ptch . . . . . . . . . . . . . . . . . . . . . 16lidocaine viscous . . . . . . . . . . . . . . . . . . 16lincomycin hcl . . . . . . . . . . . . . . . . . . . . . 17lindane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29linezolid inj . . . . . . . . . . . . . . . . . . . . . . . 17linezolid susr . . . . . . . . . . . . . . . . . . . . . 17linezolid tabs . . . . . . . . . . . . . . . . . . . . . 17LINZESS . . . . . . . . . . . . . . . . . . . . . . . . . . 45liothyronine sodium inj . . . . . . . . . . . . . 51liothyronine sodium tabs . . . . . . . . . . . 51lipodox 50 . . . . . . . . . . . . . . . . . . . . . . . . . 26LIPOSYN III . . . . . . . . . . . . . . . . . . . . . . . 54lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . 37lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg, 25mg; 20mg . . . . . . . . 37lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg . . . . . . . . . . . . . . . . . . . . . 37

72


Covered Drugs Index

metoclopramide hcl oral soln . . . . . . 45metoclopramide hcl tabs . . . . . . . . . . . 45metolazone . . . . . . . . . . . . . . . . . . . . . . . 39metoprolol/hydrochlorothiazide . . . . . 38metoprolol succinate er . . . . . . . . . . . . 38metoprolol tartrate inj . . . . . . . . . . . . . . 38metoprolol tartrate tabs . . . . . . . . . . . . 38metronidazole crea . . . . . . . . . . . . . . . . 17metronidazole gel . . . . . . . . . . . . . . . . . 17metronidazole inj 500mg/100ml; 0.79%, 5mg/ml . . . . . . 17metronidazole in nacl 0.79% . . . . . . . 17metronidazole lotn . . . . . . . . . . . . . . . . 17metronidazole tabs . . . . . . . . . . . . . . . . 17metronidazole vaginal . . . . . . . . . . . . . . 17mexiletine hcl . . . . . . . . . . . . . . . . . . . . . 37MIACALCIN . . . . . . . . . . . . . . . . . . . . . . . 54mibelas 24 fe . . . . . . . . . . . . . . . . . . . . . . 49microgestin 1.5/30 . . . . . . . . . . . . . . . . . 49microgestin 1/20 . . . . . . . . . . . . . . . . . . . 49microgestin fe . . . . . . . . . . . . . . . . . . . . . 49microgestin fe 1.5/30 . . . . . . . . . . . . . . 49midodrine hcl . . . . . . . . . . . . . . . . . . . . . . 36migergot . . . . . . . . . . . . . . . . . . . . . . . . . . 24miglitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34miglustat . . . . . . . . . . . . . . . . . . . . . . . . . . 46mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49minitran . . . . . . . . . . . . . . . . . . . . . . . . . . . 40MINIVELLE . . . . . . . . . . . . . . . . . . . . . . . 49minocycline hcl . . . . . . . . . . . . . . . . . . . . 20minoxidil . . . . . . . . . . . . . . . . . . . . . . . . . . 40mirtazapine . . . . . . . . . . . . . . . . . . . . . . . 22mirtazapine odt . . . . . . . . . . . . . . . . . . . . 22misoprostol . . . . . . . . . . . . . . . . . . . . . . . 45MITIGARE . . . . . . . . . . . . . . . . . . . . . . . . 24mitigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14mitomycin inj 20mg, 5mg . . . . . . . . . . . 27mitomycin inj 40mg . . . . . . . . . . . . . . . . 27mitoxantrone hcl . . . . . . . . . . . . . . . . . . . 27M-M-R II . . . . . . . . . . . . . . . . . . . . . . . . . . 53

metformin hydrochloride oral soln . . . 34metformin hydrochloride tabs 500mg . . . . . . . . . . . . . . . . . . . . . . . 34methadone hcl conc . . . . . . . . . . . . . . . 14methadone hcl inj . . . . . . . . . . . . . . . . . 14methadone hcl intensol . . . . . . . . . . . . 14methadone hcl oral soln 5mg/5ml . . . 14methadone hcl oral soln 10mg/5ml . . 14methadone hcl tabs 5mg . . . . . . . . . . . 14methadone hcl tabs 10mg . . . . . . . . . . 14methazolamide . . . . . . . . . . . . . . . . . . . . 39methenamine hippurate . . . . . . . . . . . . 17methimazole . . . . . . . . . . . . . . . . . . . . . . 51methocarbamol tabs . . . . . . . . . . . . . . 57methotrexate sodium . . . . . . . . . . . . . . 52methotrexate tabs . . . . . . . . . . . . . . . . . 52methoxsalen . . . . . . . . . . . . . . . . . . . . . . 42methscopolamine bromide . . . . . . . . . 45methylphenidate hydrochloride er tb24 18mg . . . . . . . . . . . . . . . . . . . . . . 41methylphenidate hydrochloride er tb24 27mg, 54mg . . . . . . . . . . . . . . . 41methylphenidate hydrochloride er tb24 36mg . . . . . . . . . . . . . . . . . . . . . . 41methylphenidate hydrochloride er tbcr 10mg, 27mg, 54mg . . . . . . . . . 41methylphenidate hydrochloride er tbcr 18mg . . . . . . . . . . . . . . . . . . . . . . 41methylphenidate hydrochloride er tbcr 20mg . . . . . . . . . . . . . . . . . . . . . . 41methylphenidate hydrochloride er tbcr 36mg . . . . . . . . . . . . . . . . . . . . . . 41methylphenidate hydrochloride tabs . . . . . . . . . . . . . . . . 41methylprednisolone acetate inj 40mg/ml, 80mg/ml . . . . . . . . . . . . . . 47methylprednisolone dose pack . . . . . 47methylprednisolone sodiumsuccinate inj 125mg, 40mg . . 47methylprednisolone tabs . . . . . . . . . . . 47metipranolol . . . . . . . . . . . . . . . . . . . . . . . 55metoclopramide hcl inj . . . . . . . . . . . . 45

medroxyprogesterone acetate inj 150mg/ml . . . . . . . . . . . . . . . 50medroxyprogesterone acetate inj 150mg/ml . . . . . . . . . . . . . . . 50medroxyprogesterone acetate tabs . . . . . . . . . . . . . . . . . . . . . . 50mefloquine hcl . . . . . . . . . . . . . . . . . . . . . 29megestrol acetate susp 40mg/ml . . . 50megestrol acetate tabs . . . . . . . . . . . . 50MEKINIST TABS 0.5MG . . . . . . . . . . . 28MEKINIST TABS 2MG . . . . . . . . . . . . . 28MEKTOVI . . . . . . . . . . . . . . . . . . . . . . . . . 27melodetta 24 fe . . . . . . . . . . . . . . . . . . . . 49meloxicam . . . . . . . . . . . . . . . . . . . . . . . . 14melphalan hydrochloride . . . . . . . . . . . 25memantine hcl tabs 5mg . . . . . . . . . . . 22memantine hcl tabs 10mg . . . . . . . . . . 22memantine hcl titration pak . . . . . . . . . 22memantine hydrochloride er . . . . . . . . 22memantine hydrochloride oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 22MENACTRA . . . . . . . . . . . . . . . . . . . . . . 53MENEST . . . . . . . . . . . . . . . . . . . . . . . . . . 49MENOSTAR . . . . . . . . . . . . . . . . . . . . . . 49MENVEO . . . . . . . . . . . . . . . . . . . . . . . . . 53mercaptopurine . . . . . . . . . . . . . . . . . . . . 26meropenem . . . . . . . . . . . . . . . . . . . . . . . 18meropenem/sodium chloride . . . . . . . 18mesalamine . . . . . . . . . . . . . . . . . . . . . . . 53mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27MESNEX TABS . . . . . . . . . . . . . . . . . . . 27metadate er . . . . . . . . . . . . . . . . . . . . . . . 41metaproterenol sulfate . . . . . . . . . . . . . 56metformin hcl er tb24 500mg (generic for Glucophage XR) . . . . . . . 34metformin hcl er tb24 750mg (generic for Glucophage XR) . . . . . . . 34metformin hcl er tb24 1000mg, 500mg, (generic for Fortamet) . . . . . . 34metformin hcl tabs 850mg . . . . . . . . . . 34metformin hcl tabs 1000mg . . . . . . . . 34

73


Covered Drugs Index

naproxen susp . . . . . . . . . . . . . . . . . . . . 14naproxen tabs 250mg . . . . . . . . . . . . . . 14naproxen tabs 375mg, 500mg . . . . . . 14naratriptan hcl . . . . . . . . . . . . . . . . . . . . . 24NARCAN . . . . . . . . . . . . . . . . . . . . . . . . . 16NASONEX . . . . . . . . . . . . . . . . . . . . . . . . 56NATACYN . . . . . . . . . . . . . . . . . . . . . . . . . 24nateglinide . . . . . . . . . . . . . . . . . . . . . . . . 34NATPARA . . . . . . . . . . . . . . . . . . . . . . . . . 54NEBUPENT . . . . . . . . . . . . . . . . . . . . . . . 29necon 0.5/35-28 . . . . . . . . . . . . . . . . . . . 50necon 7/7/7 . . . . . . . . . . . . . . . . . . . . . . . 50nefazodone hcl . . . . . . . . . . . . . . . . . . . . 22nefazodone hydrochloride . . . . . . . . . . 22neomycin/bacitracin/polymyxin . . . . . 17neomycin/polymyxin/ bacitracin/hydrocortisone . . . . . . . . . . . 17neomycin/polymyxin b sulfates . . . . . 16neomycin/polymyxin/ dexamethasone . . . . . . . . . . . . . . . . . . . 55neomycin/polymyxin/gramicidin . . . . . 17neomycin/polymyxin/hc . . . . . . . . . . . . 56neomycin/polymyxin/ hydrocortisone . . . . . . . . . . . . . . . . . . . . 17neomycin/polymyxin/ hydrocortisone . . . . . . . . . . . . . . . . . . . . 56neomycin sulfate . . . . . . . . . . . . . . . . . . 16neo-polycin . . . . . . . . . . . . . . . . . . . . . . . 17neo-polycin hc . . . . . . . . . . . . . . . . . . . . . 17NEPHRAMINE . . . . . . . . . . . . . . . . . . . . 43NERLYNX . . . . . . . . . . . . . . . . . . . . . . . . 27NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . . 29nevirapine er tb24 100mg . . . . . . . . . . 32nevirapine er tb24 400mg . . . . . . . . . . 32nevirapine tabs . . . . . . . . . . . . . . . . . . . 32NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . . . 28niacin er tbcr 500mg . . . . . . . . . . . . . . . 40niacin er tbcr 1000mg, 750mg . . . . . . 40niacor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40nicardipine hcl caps . . . . . . . . . . . . . . . 38

moxifloxacinhydrochloride/ sodium hydrochloride . . . . . . . . . . . . . . 19MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . . 36MULTAQ . . . . . . . . . . . . . . . . . . . . . . . . . . 37multivitamin with fluoride chew . . . . . 44mupirocin crea . . . . . . . . . . . . . . . . . . . . 17mupirocin oint . . . . . . . . . . . . . . . . . . . . 17MUSTARGEN . . . . . . . . . . . . . . . . . . . . . 25mycophenolate mofetil caps . . . . . . . 52mycophenolate mofetil inj . . . . . . . . . . 52mycophenolate mofetil susr . . . . . . . . 52mycophenolate mofetil tabs . . . . . . . . 52mycophenolic acid dr . . . . . . . . . . . . . . 52MYLOTARG . . . . . . . . . . . . . . . . . . . . . . . 28myorisan . . . . . . . . . . . . . . . . . . . . . . . . . . 42MYRBETRIQ . . . . . . . . . . . . . . . . . . . . . . 46myzilra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Nnabumetone . . . . . . . . . . . . . . . . . . . . . . . 14nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38nadolol/bendroflumethiazide . . . . . . . . 38nafcillin sodium inj 2gm . . . . . . . . . . . . 18nafcillin sodium inj 10gm, 1gm, 2gm . . . . . . . . . . . . . . . . . . 18naftifine hcl . . . . . . . . . . . . . . . . . . . . . . . . 24naftifine hydrochloride . . . . . . . . . . . . . 24NAFTIN GEL . . . . . . . . . . . . . . . . . . . . . 24NAGLAZYME . . . . . . . . . . . . . . . . . . . . . 46nalbuphine hcl inj 10mg/ml . . . . . . . . . 15nalbuphine hcl inj 20mg/ml . . . . . . . . . 15naloxone hcl . . . . . . . . . . . . . . . . . . . . . . 16naltrexone hcl . . . . . . . . . . . . . . . . . . . . . 16NAMENDA XR . . . . . . . . . . . . . . . . . . . . 22NAMENDA XR TITRATION PACK . . 22NAMZARIC C4PK . . . . . . . . . . . . . . . . 21NAMZARIC CP24 . . . . . . . . . . . . . . . . . 21naproxen dr . . . . . . . . . . . . . . . . . . . . . . . 14naproxen sodium tabs 275mg, 550mg . . . . . . . . . . . . . . . . . . . . 14

modafinil . . . . . . . . . . . . . . . . . . . . . . . . . . 57moexipril hcl . . . . . . . . . . . . . . . . . . . . . . . 37moexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg . . . . . . . . . . . . . . . . . . . . 37moexipril/hydrochlorothiazide tabs 12.5mg; 15mg, 25mg; 15mg . . . . . . . . 37mometasone furoate crea . . . . . . . . . 47mometasone furoate external soln . . 47mometasone furoate oint . . . . . . . . . . 47mometasone furoate susp . . . . . . . . . 56mondoxyne nl . . . . . . . . . . . . . . . . . . . . . 20mono-linyah . . . . . . . . . . . . . . . . . . . . . . . 50montelukast sodium . . . . . . . . . . . . . . . 56morgidox 1x50mg . . . . . . . . . . . . . . . . . 20morgidox 1x100mg caps . . . . . . . . . . 20morgidox 2x100mg caps . . . . . . . . . . 20morphine sulfate er tbcr . . . . . . . . . . . 14morphine sulfate inj 0.5mg/ml, 1mg/ml . . . . . . . . . . . . . . . . . 14MORPHINE SULFATE INJ 1MG/ML . . 15MORPHINE SULFATE INJ 2MG/ML . . 15MORPHINE SULFATE INJ 4MG/ML . . 15morphine sulfate inj 5mg/ml . . . . . . . . 15MORPHINE SULFATE INJ 8MG/ML . . 15morphine sulfate inj 8mg/ml . . . . . . . . 15MORPHINE SULFATE INJ 10MG/ML . . . . . . . . . . . . . . . . . . . . . . . . . 15morphine sulfate inj 10mg/ml . . . . . . . 15MORPHINE SULFATE INJ 150MG/30ML, 50MG/ML . . . . . . . . . . . 15morphine sulfate oral soln 10mg/5ml . . . . . . . . . . . . . . . . 15morphine sulfate oral soln 20mg/5ml . . . . . . . . . . . . . . . . 15morphine sulfate oral soln 100mg/5ml . . . . . . . . . . . . . . . 15MORPHINE SULFATE TABS . . . . . . 15MOVIPREP . . . . . . . . . . . . . . . . . . . . . . . 45moxifloxacin hcl inj . . . . . . . . . . . . . . . . 19moxifloxacin hcl tabs . . . . . . . . . . . . . . 19moxifloxacin hydrochloride ophthalmic soln . . . . . . . . . . . . . . . . . . . 19

74


Covered Drugs Index

olanzapine tabs . . . . . . . . . . . . . . . . . . . 30olmesartan medoxomil . . . . . . . . . . . . . 37olmesartan medoxomil/hydrochlorothiazide . . . . . . . . . . . . . . . . 37olopatadine hcl ophthalmic soln . . . . 55olopatadine hydrochloride ophthalmic soln 0.2% . . . . . . . . . . . . . . 55omega-3-acid ethyl esters . . . . . . . . . . 40omeprazole cpdr . . . . . . . . . . . . . . . . . . 46OMNIPOD 5 PACK . . . . . . . . . . . . . . . . 54OMNIPOD DASH 5 PACK. . . . . . . . . . 54OMNIPOD DASH SYSTEM . . . . . . . . 54OMNIPOD STARTER KIT . . . . . . . . . . 54ondansetron hcl inj 40mg/20ml, 4mg/2ml . . . . . . . . . . . . . . 23ondansetron hcl oral soln . . . . . . . . . . 23ondansetron hcl tabs 4mg, 8mg . . . . 23ondansetron hcl tabs 24mg . . . . . . . . 23ondansetron odt . . . . . . . . . . . . . . . . . . . 23ONFI SUSP . . . . . . . . . . . . . . . . . . . . . . 21ONFI TABS 10MG . . . . . . . . . . . . . . . . . 21ONFI TABS 20MG . . . . . . . . . . . . . . . . . 21OPDIVO INJ 100MG/10ML, 40MG/4ML . . . . . . . . . . 28OPDIVO INJ 240MG/24ML . . . . . . . . . 28OPSUMIT . . . . . . . . . . . . . . . . . . . . . . . . . 57oralone dental paste . . . . . . . . . . . . . . . 41ORFADIN . . . . . . . . . . . . . . . . . . . . . . . . . 46ORKAMBI PACK . . . . . . . . . . . . . . . . . . 56ORKAMBI TABS . . . . . . . . . . . . . . . . . . 56orphenadrine citrate er . . . . . . . . . . . . . 57orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . . 50oscimin . . . . . . . . . . . . . . . . . . . . . . . . . . . 45oseltamivir phosphate caps 30mg . . 33oseltamivir phosphate caps 45mg, 75mg . . . . . . . . . . . . . . . . . . . . . . . 33oseltamivir phosphate susr . . . . . . . . 33OSMOPREP . . . . . . . . . . . . . . . . . . . . . . 45oxacillin sodium . . . . . . . . . . . . . . . . . . . 18oxaliplatin inj 100mg . . . . . . . . . . . . . . . 27

nortrel 0.5/35 (28) . . . . . . . . . . . . . . . . . 50nortrel 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 50nortrel 7/7/7 . . . . . . . . . . . . . . . . . . . . . . . 50nortriptyline hcl . . . . . . . . . . . . . . . . . . . . 23NORVIR CAPS . . . . . . . . . . . . . . . . . . . 33NORVIR ORAL SOLN . . . . . . . . . . . . . 33NORVIR PACK . . . . . . . . . . . . . . . . . . . 33NORVIR TABS . . . . . . . . . . . . . . . . . . . . 33NOVAREL . . . . . . . . . . . . . . . . . . . . . . . . 48novofine 31 . . . . . . . . . . . . . . . . . . . . . . . 54novofine 32gx6mm . . . . . . . . . . . . . . . . 54novofine autocover 30gx8mm . . . . . . 54novotwist 32gx5mm . . . . . . . . . . . . . . . 54NOXAFIL SUSP . . . . . . . . . . . . . . . . . . 24NOXAFIL TBEC . . . . . . . . . . . . . . . . . . 24NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . . 41nulev . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . . 52NUPLAZID CAPS . . . . . . . . . . . . . . . . . 30NUPLAZID TABS 10MG . . . . . . . . . . . 30NUPLAZID TABS 17MG . . . . . . . . . . . 30NUTRILIPID . . . . . . . . . . . . . . . . . . . . . . . 54nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . . 24nystatin . . . . . . . . . . . . . . . . . . . . . . . . . . . 24nystatin/triamcinolone . . . . . . . . . . . . . . 24nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Ooctreotide acetate inj 500mcg/ml . . . 51octreotide acetate inj 1000mcg/ml, 100mcg/ml, 200mcg/ml, 50mcg/ml . . . . . . . . . . . . . 51ODEFSEY . . . . . . . . . . . . . . . . . . . . . . . . 32ODOMZO . . . . . . . . . . . . . . . . . . . . . . . . . 27OFEV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57ofloxacin . . . . . . . . . . . . . . . . . . . . . . . . . . 19ogestrel . . . . . . . . . . . . . . . . . . . . . . . . . . . 50olanzapine/fluoxetine . . . . . . . . . . . . . . 22olanzapine inj . . . . . . . . . . . . . . . . . . . . . 30olanzapine odt . . . . . . . . . . . . . . . . . . . . 30

nicardipine hcl inj . . . . . . . . . . . . . . . . . 38NICOTROL INHALER. . . . . . . . . . . . . . 16NICOTROL NS . . . . . . . . . . . . . . . . . . . . 16nifedipine er tb24 30mg, 60mg . . . . . 38nifedipine er tb24 90mg . . . . . . . . . . . . 38nilutamide . . . . . . . . . . . . . . . . . . . . . . . . . 25nimodipine . . . . . . . . . . . . . . . . . . . . . . . . 38NINLARO . . . . . . . . . . . . . . . . . . . . . . . . . 27NIPENT . . . . . . . . . . . . . . . . . . . . . . . . . . . 26nisoldipine er tb24 17mg, 25.5mg, 34mg, 8.5mg . . . . . . . 38nisoldipine er tb24 20mg, 30mg, 40mg . . . . . . . . . . . . . . . . 38nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . 17nitrofurantoin macrocrystals . . . . . . . . 17nitrofurantoin monohydrate . . . . . . . . . 17nitrofurantoin monohydrate/macrocrystals . . . . . . . . . . . . . . . . . . . . . 17nitroglycerin inj . . . . . . . . . . . . . . . . . . . . 40nitroglycerin lingual . . . . . . . . . . . . . . . . 40nitroglycerin subl . . . . . . . . . . . . . . . . . . 40nitroglycerin transdermal . . . . . . . . . . . 40nizatidine caps . . . . . . . . . . . . . . . . . . . . 45nora-be . . . . . . . . . . . . . . . . . . . . . . . . . . . 50norethindrone . . . . . . . . . . . . . . . . . . . . . 50norethindrone acetate . . . . . . . . . . . . . . 50norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs . . . . . 50norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg . . . . . . . 50norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg . . . . . . . . . 50norgestimate/ethinyl estradiol . . . . . . 50norlyroc . . . . . . . . . . . . . . . . . . . . . . . . . . . 50NORMOSOL-M IN D5W . . . . . . . . . . . 43NORMOSOL -R . . . . . . . . . . . . . . . . . . . 43NORMOSOL-R . . . . . . . . . . . . . . . . . . . . 43NORMOSOL-R IN D5W. . . . . . . . . . . . 43NORTHERA CAPS 100MG . . . . . . . . 39NORTHERA CAPS 200MG, 300MG . . . . . . . . . . . . . . . . . . . 39

75


Covered Drugs Index

phenazopyridine hydrochloride . . . . . 46phenazopyridine hydrocholride . . . . . 46phenelzine sulfate . . . . . . . . . . . . . . . . . 22phenobarbital elix . . . . . . . . . . . . . . . . . 21phenobarbital tabs . . . . . . . . . . . . . . . . 21phenoxybenzamine hydrochloride . . 36phenytoin . . . . . . . . . . . . . . . . . . . . . . . . . 21phenytoin infatabs . . . . . . . . . . . . . . . . . 21phenytoin sodium . . . . . . . . . . . . . . . . . . 21phenytoin sodium extended . . . . . . . . 21philith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50PHOSLYRA . . . . . . . . . . . . . . . . . . . . . . . 44PHOSPHOLINE IODIDE . . . . . . . . . . . 55PHYSIOLYTE . . . . . . . . . . . . . . . . . . . . . 54physiosol irrigation . . . . . . . . . . . . . . . . . 54PICATO GEL 0.05% . . . . . . . . . . . . . . . 42PICATO GEL 0.015% . . . . . . . . . . . . . . 42pilocarpine hcl ophthalmic soln . . . . . 55pilocarpine hcl tabs . . . . . . . . . . . . . . . 41pilocarpine hydrochloride . . . . . . . . . . . 41pimozide . . . . . . . . . . . . . . . . . . . . . . . . . . 30pimtrea . . . . . . . . . . . . . . . . . . . . . . . . . . . 50pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 38pioglitazone hcl . . . . . . . . . . . . . . . . . . . . 34pioglitazone hcl/metformin hcl . . . . . . 34piperacillin sodium/ tazobactam sodium . . . . . . . . . . . . . . . . 19piperacillin/tazobactam . . . . . . . . . . . . . 19pirmella 1/35 . . . . . . . . . . . . . . . . . . . . . . 50pirmella 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 50piroxicam . . . . . . . . . . . . . . . . . . . . . . . . . 14PLENAMINE . . . . . . . . . . . . . . . . . . . . . . 43podofilox . . . . . . . . . . . . . . . . . . . . . . . . . . 42polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17polyethylene glycol 3350 powd . . . . . 45polymyxin b sulfate . . . . . . . . . . . . . . . . 17polymyxin b sulfate/ trimethoprim sulfate . . . . . . . . . . . . . . . . 17POMALYST . . . . . . . . . . . . . . . . . . . . . . . 25portia-28 . . . . . . . . . . . . . . . . . . . . . . . . . . 50

PANRETIN . . . . . . . . . . . . . . . . . . . . . . . . 28pantoprazole sodium tbec . . . . . . . . . 46paricalcitol caps 1mcg, 2mcg . . . . . . . 54paricalcitol caps 4mcg . . . . . . . . . . . . . 54paroex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41paromomycin sulfate . . . . . . . . . . . . . . . 16paroxetine hcl er tb24 12.5mg . . . . . . 22paroxetine hcl er tb24 25mg, 37.5mg . . . . . . . . . . . . . . . . . . . . . 23paroxetine hcl tabs 10mg . . . . . . . . . . 23paroxetine hcl tabs 20mg . . . . . . . . . . 23paroxetine hcl tabs 30mg, 40mg . . . . 23PASER . . . . . . . . . . . . . . . . . . . . . . . . . . . 25PAXIL SUSP . . . . . . . . . . . . . . . . . . . . . . 23PAZEO . . . . . . . . . . . . . . . . . . . . . . . . . . . 55PEDIARIX . . . . . . . . . . . . . . . . . . . . . . . . 53PEDVAX HIB . . . . . . . . . . . . . . . . . . . . . . 53peg 3350/electrolytes . . . . . . . . . . . . . . 45peg-3350/electrolytes . . . . . . . . . . . . . . 45peg-3350/nacl/na bicarbonate/kcl . . . 45PEGANONE . . . . . . . . . . . . . . . . . . . . . . 21PEGASYS INJ 180MCG/0.5ML . . . . . 31PEGASYS INJ 180MCG/ML . . . . . . . . 31PEGASYS PROCLICK . . . . . . . . . . . . . 31penicillin g potassium . . . . . . . . . . . . . . 18penicillin v potassium oral soln . . . . . 18penicillin v potassium tabs 250mg . . 18penicillin v potassium tabs 500mg . . 18PENTAM 300 . . . . . . . . . . . . . . . . . . . . . 29pentoxifylline er . . . . . . . . . . . . . . . . . . . . 39PERFOROMIST . . . . . . . . . . . . . . . . . . . 56PERIKABIVEN . . . . . . . . . . . . . . . . . . . . 43perindopril erbumine . . . . . . . . . . . . . . . 37periogard . . . . . . . . . . . . . . . . . . . . . . . . . 41PERJETA . . . . . . . . . . . . . . . . . . . . . . . . . 28permethrin . . . . . . . . . . . . . . . . . . . . . . . . 29perphenazine . . . . . . . . . . . . . . . . . . . . . 30perphenazine/amitriptyline . . . . . . . . . 23pfizerpen inj 20mu, 5000000unit . . . . 19phenadoz . . . . . . . . . . . . . . . . . . . . . . . . . 23

oxaliplatin inj 100mg/20ml, 50mg/10ml . . . . . . . . . . . 27oxandrolone tabs 2.5mg . . . . . . . . . . . 48oxandrolone tabs 10mg . . . . . . . . . . . . 48oxaprozin . . . . . . . . . . . . . . . . . . . . . . . . . 14oxazepam . . . . . . . . . . . . . . . . . . . . . . . . . 34oxcarbazepine . . . . . . . . . . . . . . . . . . . . 21oxybutynin chloride er tb24 10mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 46oxybutynin chloride er tb24 15mg . . . 46oxybutynin chloride syrp . . . . . . . . . . . 46oxybutynin chloride tabs . . . . . . . . . . . 46oxycodone/acetaminophen tabs 325mg; 2.5mg, 325mg; 5mg . . . 15oxycodone/acetaminophen tabs 325mg; 7.5mg . . . . . . . . . . . . . . . . 15oxycodone/acetaminophen tabs 325mg; 10mg . . . . . . . . . . . . . . . . . 15oxycodone/aspirin . . . . . . . . . . . . . . . . . 15oxycodone hcl caps . . . . . . . . . . . . . . . 15oxycodone hcl conc . . . . . . . . . . . . . . . 15oxycodone hcl oral soln . . . . . . . . . . . 15oxycodone hcl tabs 10mg, 15mg, 20mg, 5mg . . . . . . . . . . . 15oxycodone hcl tabs 30mg . . . . . . . . . . 15oxycodone/ibuprofen . . . . . . . . . . . . . . 16OZEMPIC . . . . . . . . . . . . . . . . . . . . . . . . . 34

Ppacerone . . . . . . . . . . . . . . . . . . . . . . . . . . 37paclitaxel inj 100mg/16.7ml, 150mg/25ml, 300mg/50ml . . . . . . . . . . 27paliperidone er tb24 1.5mg, 3mg . . . 30paliperidone er tb24 6mg . . . . . . . . . . . 30paliperidone er tb24 9mg . . . . . . . . . . . 30PALONOSETRON HYDROCHLORIDE INJ 0.25MG/2ML . . . . . . . . . . . . . . . . . . . . . . 23palonosetron hydrochloride inj 0.25mg/5ml . . . . . . . . . . . . . . . . . . . . . . . 23pamidronate disodium . . . . . . . . . . . . . 54

76


Covered Drugs Index

PRIMAQUINE PHOSPHATE . . . . . . . 29primidone . . . . . . . . . . . . . . . . . . . . . . . . . 21PRISTIQ . . . . . . . . . . . . . . . . . . . . . . . . . . 23PROAIR HFA . . . . . . . . . . . . . . . . . . . . . 56PROAIR RESPICLICK . . . . . . . . . . . . . 56probenecid . . . . . . . . . . . . . . . . . . . . . . . . 24probenecid/colchicine . . . . . . . . . . . . . . 24PROCALAMINE . . . . . . . . . . . . . . . . . . . 44prochlorperazine . . . . . . . . . . . . . . . . . . 30prochlorperazine edisylate . . . . . . . . . 30prochlorperazine maleate tabs 5mg . . . . . . . . . . . . . . . . . . . . . . . . . . 30prochlorperazine maleate tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 30PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML . . . . . . 36PROCRIT INJ 20000UNIT/ML . . . . . . 36PROCRIT INJ 40000UNIT/ML . . . . . . 36procto-med hc . . . . . . . . . . . . . . . . . . . . . 48procto-pak . . . . . . . . . . . . . . . . . . . . . . . . 48proctosol hc . . . . . . . . . . . . . . . . . . . . . . . 48proctozone-hc . . . . . . . . . . . . . . . . . . . . . 48progesterone caps . . . . . . . . . . . . . . . . 50PROGLYCEM . . . . . . . . . . . . . . . . . . . . . 35PROGRAF INJ . . . . . . . . . . . . . . . . . . . 52PROLASTIN-C . . . . . . . . . . . . . . . . . . . . 57PROLENSA . . . . . . . . . . . . . . . . . . . . . . . 55PROLEUKIN . . . . . . . . . . . . . . . . . . . . . . 27PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 54PROMACTA . . . . . . . . . . . . . . . . . . . . . . 36promethazine hcl supp . . . . . . . . . . . . 23promethazine hcl syrp . . . . . . . . . . . . . 23promethazine hcl tabs . . . . . . . . . . . . . 23promethazine hydrochloride tabs 50mg . . . . . . . . . . . . . . . . . . . . . . . . 23promethegan . . . . . . . . . . . . . . . . . . . . . . 23propafenone hcl . . . . . . . . . . . . . . . . . . . 37propafenone hcl er cp12 225mg, 325mg . . . . . . . . . . . . . . . . . . . . 37

prednisolone sodium phosphate ophthalmic soln . . . . . . . . 55prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml . . . . . . . . . . . . . . . . 47prednisone intensol . . . . . . . . . . . . . . . . 47prednisone oral soln . . . . . . . . . . . . . . 47prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg . . . . . 48prednisone tabs 50mg . . . . . . . . . . . . . 48prednisone tbpk . . . . . . . . . . . . . . . . . . . 48PREGNYL W/DILUENT BENZYL ALCOHOL/NACL . . . . . . . . . 48PREMARIN CREA . . . . . . . . . . . . . . . . 50PREMARIN INJ . . . . . . . . . . . . . . . . . . . 50PREMARIN TABS . . . . . . . . . . . . . . . . 50PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML . . . . . . 44premasol inj 56meq/l; 320mg/100ml; 730mg/100ml; 190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml; 220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml; 490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml; 230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml . . . . . . . 44prevalite . . . . . . . . . . . . . . . . . . . . . . . . . . 40previfem . . . . . . . . . . . . . . . . . . . . . . . . . . 50PREZCOBIX . . . . . . . . . . . . . . . . . . . . . . 33PREZISTA SUSP . . . . . . . . . . . . . . . . . 33PREZISTA TABS 75MG . . . . . . . . . . . . 33PREZISTA TABS 150MG . . . . . . . . . . . 33PREZISTA TABS 600MG . . . . . . . . . . . 33PREZISTA TABS 800MG . . . . . . . . . . . 33PRIFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 25

PORTRAZZA . . . . . . . . . . . . . . . . . . . . . 27potassium chloride cr . . . . . . . . . . . . . . 43potassium chloride/dextrose inj 5%; 20meq/l, 5%; 40meq/l . . . . . . . . . 44potassium chloride/dextrose/ lactated ringers inj 3meq/l; 149meq/l; 5%; 28meq/l; 24meq/l; 130meq/l . . . . . . . . . . . . . . . . . 44POTASSIUM CHLORIDE/ DEXTROSE/LACTATED RINGERS INJ 3MEQ/L; 149MEQ/L; 5%; 28MEQ/L; 44MEQ/L; 130MEQ/L . . . . 44potassium chloride/ dextrose/sodium chloride . . . . . . . . . . . 44potassium chloride er cpcr . . . . . . . . . 43potassium chloride er tbcr . . . . . . . . . 43potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml . . . . . . . . . . . . 43potassium chloride oral soln . . . . . . . 43potassium chloride/sodium chloride inj 20meq/l; 0.45%, 20meq/l; 0.9%, 40meq/l; 0.9% . . . . . . 44potassium chloride sr . . . . . . . . . . . . . . 43potassium citrate er . . . . . . . . . . . . . . . . 44POTELIGEO . . . . . . . . . . . . . . . . . . . . . . 28PRADAXA . . . . . . . . . . . . . . . . . . . . . . . . 36PRALUENT . . . . . . . . . . . . . . . . . . . . . . . 39pramipexole dihydrochloride . . . . . . . . 29pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg . . . . . . 29pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 3mg, 4.5mg . . 29prasugrel . . . . . . . . . . . . . . . . . . . . . . . . . . 36pravastatin sodium . . . . . . . . . . . . . . . . 40praziquantel . . . . . . . . . . . . . . . . . . . . . . . 29prazosin hcl . . . . . . . . . . . . . . . . . . . . . . . 36PRED-G . . . . . . . . . . . . . . . . . . . . . . . . . . 55PRED-G S.O.P. . . . . . . . . . . . . . . . . . . . 55PRED MILD . . . . . . . . . . . . . . . . . . . . . . . 55prednicarbate oint . . . . . . . . . . . . . . . . . 47prednisolone . . . . . . . . . . . . . . . . . . . . . . 47prednisolone acetate . . . . . . . . . . . . . . 55

77


Covered Drugs Index

REVLIMID CAPS 15MG, 20MG, 25MG . . . . . . . . . . . . . . 25REXULTI . . . . . . . . . . . . . . . . . . . . . . . . . . 30REYATAZ CAPS 150MG, 300MG . . . 33REYATAZ CAPS 200MG . . . . . . . . . . . 33REYATAZ PACK . . . . . . . . . . . . . . . . . . 33ribavirin caps . . . . . . . . . . . . . . . . . . . . . 31ribavirin inhalation soln . . . . . . . . . . . . 57ribavirin tabs . . . . . . . . . . . . . . . . . . . . . . 31RIDAURA . . . . . . . . . . . . . . . . . . . . . . . . . 53rifabutin . . . . . . . . . . . . . . . . . . . . . . . . . . . 25rifampin caps . . . . . . . . . . . . . . . . . . . . . 25rifampin inj . . . . . . . . . . . . . . . . . . . . . . . 25RIFATER . . . . . . . . . . . . . . . . . . . . . . . . . . 25riluzole . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41rimantadine hcl . . . . . . . . . . . . . . . . . . . . 33ringers injection . . . . . . . . . . . . . . . . . . . 44RINGERS IRRIGATION . . . . . . . . . . . . 54RIOMET . . . . . . . . . . . . . . . . . . . . . . . . . . 34risedronate sodium tabs 30mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 54risedronate sodium tabs 35mg . . . . . 54risedronate sodium tabs 150mg . . . . 54RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG . . . . . . . . . . . 30RISPERDAL CONSTA INJ 50MG . . . 30risperidone m-tab . . . . . . . . . . . . . . . . . . 31risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 31risperidone odt tbdp 4mg . . . . . . . . . . . 31risperidone oral soln . . . . . . . . . . . . . . 31risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 31risperidone tabs 4mg . . . . . . . . . . . . . . 31ritonavir . . . . . . . . . . . . . . . . . . . . . . . . . . . 33RITUXAN . . . . . . . . . . . . . . . . . . . . . . . . . 28RITUXAN HYCELA . . . . . . . . . . . . . . . . 28rivastigmine tartrate . . . . . . . . . . . . . . . . 22rivastigmine transdermal system . . . . 22rizatriptan benzoate . . . . . . . . . . . . . . . . 24rizatriptan benzoate odt . . . . . . . . . . . . 24

RRABAVERT . . . . . . . . . . . . . . . . . . . . . . . 53raloxifene hydrochloride . . . . . . . . . . . . 51ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . . 37RANEXA . . . . . . . . . . . . . . . . . . . . . . . . . . 39ranitidine hcl caps . . . . . . . . . . . . . . . . . 45ranitidine hcl inj . . . . . . . . . . . . . . . . . . . 45ranitidine hcl syrp . . . . . . . . . . . . . . . . . 45ranitidine hcl tabs . . . . . . . . . . . . . . . . . 45RAPAMUNE ORAL SOLN . . . . . . . . . 52rasagiline mesylate . . . . . . . . . . . . . . . . 29REBIF . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41REBIF REBIDOSE . . . . . . . . . . . . . . . . 41REBIF REBIDOSE TITRATION PACK . . . . . . . . . . . . . . . . . 41REBIF TITRATION PACK . . . . . . . . . . 41reclipsen . . . . . . . . . . . . . . . . . . . . . . . . . . 50RECOMBIVAX HB . . . . . . . . . . . . . . . . . 53REGONOL . . . . . . . . . . . . . . . . . . . . . . . . 24REGRANEX . . . . . . . . . . . . . . . . . . . . . . 42RELISTOR INJ 8MG/0.4ML . . . . . . . . 45RELISTOR INJ 12MG/0.6ML . . . . . . . 45REMICADE . . . . . . . . . . . . . . . . . . . . . . . 52REMODULIN . . . . . . . . . . . . . . . . . . . . . . 57RENFLEXIS . . . . . . . . . . . . . . . . . . . . . . . 52RENVELA PACK . . . . . . . . . . . . . . . . . . 44RENVELA TABS . . . . . . . . . . . . . . . . . . 44repaglinide tabs 0.5mg, 1mg . . . . . . . 34repaglinide tabs 2mg . . . . . . . . . . . . . . 34REPATHA . . . . . . . . . . . . . . . . . . . . . . . . . 40REPATHA PUSHTRONEX SYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . 40REPATHA SURECLICK . . . . . . . . . . . . 40RESCRIPTOR TABS 100MG . . . . . . . 32RESCRIPTOR TABS 200MG . . . . . . . 32RESTASIS . . . . . . . . . . . . . . . . . . . . . . . . 55RETROVIR IV INFUSION . . . . . . . . . . 32REVLIMID CAPS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 25

propafenone hydrochloride er cp12 425mg . . . . . . . . . . . . . . . . . . . . 37propantheline bromide . . . . . . . . . . . . . 45proparacaine hcl . . . . . . . . . . . . . . . . . . . 55propranolol hcl er . . . . . . . . . . . . . . . . . . 38propranolol hcl inj . . . . . . . . . . . . . . . . . 38propranolol hcl oral soln . . . . . . . . . . . 38propranolol hcl tabs 10mg, 20mg, 40mg, 80mg . . . . . . . . . 38propranolol hcl tabs 60mg . . . . . . . . . . 38propranolol hydrochloride tabs 60mg . . . . . . . . . . . . . . . . . . . . . . . . 38propranolol/hydrochlorothiazide . . . . 38propylthiouracil . . . . . . . . . . . . . . . . . . . . 51PROQUAD . . . . . . . . . . . . . . . . . . . . . . . . 53PROSOL . . . . . . . . . . . . . . . . . . . . . . . . . . 44protriptyline hcl . . . . . . . . . . . . . . . . . . . . 23PULMOZYME . . . . . . . . . . . . . . . . . . . . . 56PURIXAN . . . . . . . . . . . . . . . . . . . . . . . . . 26pyrazinamide . . . . . . . . . . . . . . . . . . . . . . 25pyridostigmine bromide . . . . . . . . . . . . 24pyridostigmine bromide er . . . . . . . . . . 24

QQUADRACEL . . . . . . . . . . . . . . . . . . . . . 53quasense . . . . . . . . . . . . . . . . . . . . . . . . . 50quetiapine fumarate . . . . . . . . . . . . . . . 30quetiapine fumarate er tb24 150mg, 200mg . . . . . . . . . . . . . . . 30quetiapine fumarate er tb24 300mg, 400mg, 50mg . . . . . . . . . 30quinapril hcl . . . . . . . . . . . . . . . . . . . . . . . 37quinapril/hydrochlorothiazide tabs 12.5mg; 10mg . . . . . . . . . . . . . . . . . . . . . 37quinapril/hydrochlorothiazide tabs 12.5mg; 20mg, 25mg; 20mg . . . . . . . . 37quinidine sulfate . . . . . . . . . . . . . . . . . . . 37quinine sulfate . . . . . . . . . . . . . . . . . . . . . 29

78


Covered Drugs Index

sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37sotalol hcl . . . . . . . . . . . . . . . . . . . . . . . . . 37sotalol hcl (af) . . . . . . . . . . . . . . . . . . . . . 37sotalol hcl af . . . . . . . . . . . . . . . . . . . . . . . 38sotalol hydrochloride (af) tabs 80mg . . . . . . . . . . . . . . . . . . . . . . . . 38sotalol hydrochloride tabs 120mg . . . 38spironolactone/hydrochlorothiazide . . 39spironolactone tabs 25mg . . . . . . . . . . 39spironolactone tabs 100mg, 50mg . . 39SPORANOX ORAL SOLN . . . . . . . . . 24sprintec 28 . . . . . . . . . . . . . . . . . . . . . . . . 50SPRITAM TB3D 750MG . . . . . . . . . . . 20SPRITAM TB3D 1000MG, 250MG, 500MG . . . . . . . . . . 20SPRYCEL . . . . . . . . . . . . . . . . . . . . . . . . 28sps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50ssd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17STAMARIL . . . . . . . . . . . . . . . . . . . . . . . . 53stavudine . . . . . . . . . . . . . . . . . . . . . . . . . 32sterile water irrigation . . . . . . . . . . . . . . 54sterile water irrigation plastic bottle . . 54STIMATE . . . . . . . . . . . . . . . . . . . . . . . . . 48STIVARGA . . . . . . . . . . . . . . . . . . . . . . . . 28streptomycin sulfate . . . . . . . . . . . . . . . 16STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . . 32SUBOXONE . . . . . . . . . . . . . . . . . . . . . . 16sucralfate . . . . . . . . . . . . . . . . . . . . . . . . . 45sulfacetamide sodium lotn . . . . . . . . . 19sulfacetamide sodium ophthalmic soln . . . . . . . . . . . . . . . . . . . 19sulfacetamide sodium/ prednisolone sodium phosphate . . . . 20sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . 20sulfamethoxazole/trimethoprim ds . . 20sulfamethoxazole/trimethoprim inj . . 20sulfamethoxazole/ trimethoprim susp . . . . . . . . . . . . . . . . . 20sulfamethoxazole/ trimethoprim tabs . . . . . . . . . . . . . . . . . 20

sertraline hcl tabs 25mg . . . . . . . . . . . . 23sertraline hcl tabs 50mg . . . . . . . . . . . . 23sertraline hcl tabs 100mg . . . . . . . . . . 23setlakin . . . . . . . . . . . . . . . . . . . . . . . . . . . 50sharobel . . . . . . . . . . . . . . . . . . . . . . . . . . 50SHINGRIX . . . . . . . . . . . . . . . . . . . . . . . . 53SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . . 51sildenafil tabs 20mg . . . . . . . . . . . . . . . 57SILENOR . . . . . . . . . . . . . . . . . . . . . . . . . 57silver sulfadiazine . . . . . . . . . . . . . . . . . 17SIMBRINZA . . . . . . . . . . . . . . . . . . . . . . . 55SIMULECT . . . . . . . . . . . . . . . . . . . . . . . . 53simvastatin . . . . . . . . . . . . . . . . . . . . . . . . 40sirolimus . . . . . . . . . . . . . . . . . . . . . . . . . . 52SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . . 25sodium bicarbonate inj . . . . . . . . . . . . 44sodium bicarbonate partial fill . . . . . . . 44sodium chloride 0.9% . . . . . . . . . . . . . . 54sodium chloride0.9% . . . . . . . . . . . . . . 54sodium chloride 0.45% . . . . . . . . . . . . . 44sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5% . . . . . . . . . . 44sodium fluoride chew 0.5mg, 1mg . . 44SODIUM LACTATE INJ 5MEQ/ML . . 44sodium phenylbutyrate . . . . . . . . . . . . . 46sodium polystyrene sulfonate powd . . . . . . . . . . . . . . . . . . . 44sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml . . . . . . 44sodium sulfacetamide ophthalmic soln . . . . . . . . . . . . . . . . . . . 19SOLIQUA 100/33 . . . . . . . . . . . . . . . . . . 35SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . . 26SOLU-CORTEF . . . . . . . . . . . . . . . . . . . 48SOMATULINE DEPOT INJ 60MG/0.2ML . . . . . . . . . . . . . . . . . . . . . . 51SOMATULINE DEPOT INJ 90MG/0.3ML . . . . . . . . . . . . . . . . . . . . . . 51SOMATULINE DEPOT INJ 120MG/0.5ML . . . . . . . . . . . . . . . . . . . . . 51SOMAVERT . . . . . . . . . . . . . . . . . . . . . . . 51

romidepsin . . . . . . . . . . . . . . . . . . . . . . . . 27ropinirole hcl . . . . . . . . . . . . . . . . . . . . . . 29rosadan . . . . . . . . . . . . . . . . . . . . . . . . . . . 17rosuvastatin calcium . . . . . . . . . . . . . . . 40ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . . 53ROTATEQ . . . . . . . . . . . . . . . . . . . . . . . . 53roweepra . . . . . . . . . . . . . . . . . . . . . . . . . . 20roweepra xr tb24 500mg . . . . . . . . . . . 20roweepra xr tb24 750mg . . . . . . . . . . . 20ROZEREM . . . . . . . . . . . . . . . . . . . . . . . . 57RUBRACA . . . . . . . . . . . . . . . . . . . . . . . . 27RUCONEST . . . . . . . . . . . . . . . . . . . . . . 52RYDAPT . . . . . . . . . . . . . . . . . . . . . . . . . . 27RYTARY . . . . . . . . . . . . . . . . . . . . . . . . . . 29

SSABRIL PACK . . . . . . . . . . . . . . . . . . . . 21SABRIL TABS . . . . . . . . . . . . . . . . . . . . 21salsalate . . . . . . . . . . . . . . . . . . . . . . . . . . 14SAMSCA TABS 15MG . . . . . . . . . . . . . 44SAMSCA TABS 30MG . . . . . . . . . . . . . 44SANCUSO . . . . . . . . . . . . . . . . . . . . . . . . 23SANDIMMUNE ORAL SOLN . . . . . . 52SANDOSTATIN LAR DEPOT . . . . . . . 51SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . . 42SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . . 31SAVAYSA . . . . . . . . . . . . . . . . . . . . . . . . . 36scopolamine . . . . . . . . . . . . . . . . . . . . . . 23selegiline hcl . . . . . . . . . . . . . . . . . . . . . . 29selenium sulfide lotn . . . . . . . . . . . . . . 42SELZENTRY ORAL SOLN . . . . . . . . 32SELZENTRY TABS 25MG . . . . . . . . . 32SELZENTRY TABS 150MG, 75MG . . 32SELZENTRY TABS 300MG . . . . . . . . 32SENSIPAR TABS 30MG . . . . . . . . . . . 54SENSIPAR TABS 60MG . . . . . . . . . . . 54SENSIPAR TABS 90MG . . . . . . . . . . . 54SEREVENT DISKUS . . . . . . . . . . . . . . 56sertraline hcl conc . . . . . . . . . . . . . . . . . 23

79


Covered Drugs Index

terbinafine hcl tabs . . . . . . . . . . . . . . . . 24terbutaline sulfate . . . . . . . . . . . . . . . . . 56terconazole . . . . . . . . . . . . . . . . . . . . . . . 24testosterone cypionate . . . . . . . . . . . . . 48testosterone enanthate . . . . . . . . . . . . 48testosterone gel 25mg/2.5gm, 50mg/5gm . . . . . . . . . . . 48testosterone pump . . . . . . . . . . . . . . . . . 48TETANUS/DIPHTHERIA TOXOIDS-ADSORBED . . . . . . . . . . . . 53tetrabenazine tabs 12.5mg . . . . . . . . . 41tetrabenazine tabs 25mg . . . . . . . . . . . 41tetracycline hydrochloride . . . . . . . . . . 20texacort . . . . . . . . . . . . . . . . . . . . . . . . . . . 48THALOMID CAPS 100MG, 150MG, 50MG . . . . . . . . . . . . 25THALOMID CAPS 200MG . . . . . . . . . 25THEO-24 . . . . . . . . . . . . . . . . . . . . . . . . . 57theophylline cr . . . . . . . . . . . . . . . . . . . . . 57theophylline er tb12 300mg, 450mg . . . . . . . . . . . . . . . . . . . . 57theophylline er tb24 . . . . . . . . . . . . . . . 57thioridazine hcl . . . . . . . . . . . . . . . . . . . . 30thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . . 25thiothixene caps 2mg . . . . . . . . . . . . . . 30thiothixene caps 10mg, 1mg, 5mg . . 30THYMOGLOBULIN . . . . . . . . . . . . . . . . 52THYROLAR-1 . . . . . . . . . . . . . . . . . . . . . 51THYROLAR-1/2 . . . . . . . . . . . . . . . . . . . 51THYROLAR-1/4 . . . . . . . . . . . . . . . . . . . 51THYROLAR-2 . . . . . . . . . . . . . . . . . . . . . 51THYROLAR-3 . . . . . . . . . . . . . . . . . . . . . 51tiagabine hydrochloride tabs 2mg . . . 21tiagabine hydrochloride tabs 4mg . . . 21tiagabine hydrochloride tabs 12mg . . 21tiagabine hydrochloride tabs 16mg . . 21TIBSOVO . . . . . . . . . . . . . . . . . . . . . . . . . 28tigecycline . . . . . . . . . . . . . . . . . . . . . . . . 17timolol maleate ophthalmic soln . . . . 55timolol maleate tabs . . . . . . . . . . . . . . . 38

TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . . 28TAGRISSO . . . . . . . . . . . . . . . . . . . . . . . . 28TAMIFLU CAPS 30MG . . . . . . . . . . . . 33TAMIFLU CAPS 45MG, 75MG . . . . . 33TAMIFLU SUSR . . . . . . . . . . . . . . . . . . 33tamoxifen citrate . . . . . . . . . . . . . . . . . . . 26tamsulosin hcl . . . . . . . . . . . . . . . . . . . . . 46TARCEVA TABS 25MG . . . . . . . . . . . . 28TARCEVA TABS 100MG, 150MG . . . 28TARGRETIN GEL . . . . . . . . . . . . . . . . . 29tarina fe 1/20 . . . . . . . . . . . . . . . . . . . . . . 50TASIGNA CAPS 50MG . . . . . . . . . . . . 28TASIGNA CAPS 150MG, 200MG . . . 28tazarotene . . . . . . . . . . . . . . . . . . . . . . . . 42tazicef inj 1gm, 2gm, 6gm . . . . . . . . . . 18TAZORAC CREA . . . . . . . . . . . . . . . . . 42TAZORAC GEL . . . . . . . . . . . . . . . . . . . 42taztia xt cp24 120mg, 180mg, 240mg, 300mg . . . . . 38TECENTRIQ . . . . . . . . . . . . . . . . . . . . . . 28TECFIDERA CPDR 120MG . . . . . . . . 41TECFIDERA CPDR 240MG . . . . . . . . 41TECFIDERA STARTER PACK . . . . . . 41techlite pen needles/31g x 6 mm . . . 54techlite pen needles/31g x 8mm . . . . 54techlite pen needles/32g x 4mm . . . . 54techlite pen needles/32g x 6mm . . . . 54techlite pen needles/32g x 8mm . . . . 54TEFLARO . . . . . . . . . . . . . . . . . . . . . . . . . 18TEKTURNA . . . . . . . . . . . . . . . . . . . . . . . 39TEKTURNA HCT . . . . . . . . . . . . . . . . . . 39telmisartan . . . . . . . . . . . . . . . . . . . . . . . . 37telmisartan/amlodipine . . . . . . . . . . . . . 37telmisartan/hydrochlorothiazide . . . . . 37temazepam . . . . . . . . . . . . . . . . . . . . . . . 57temsirolimus . . . . . . . . . . . . . . . . . . . . . . 28TENIVAC . . . . . . . . . . . . . . . . . . . . . . . . . 53tenofovir disoproxil fumarate . . . . . . . 32terazosin hcl caps 1mg, 2mg, 5mg . . 46terazosin hcl caps 10mg . . . . . . . . . . . 46

sulfasalazine . . . . . . . . . . . . . . . . . . . . . . 53sulfatrim pediatric . . . . . . . . . . . . . . . . . . 20sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . 14sumatriptan . . . . . . . . . . . . . . . . . . . . . . . 24sumatriptan succinate inj 4mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . 24sumatriptan succinate inj 6mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . 24sumatriptan succinate refill inj 4mg/0.5ml . . . . . . . . . . . . . . . . . 24sumatriptan succinate refill inj 6mg/0.5ml . . . . . . . . . . . . . . . . . 24sumatriptan succinate tabs . . . . . . . . 24SUPRAX SUSR 500MG/5ML . . . . . . . 18SUPREP BOWEL PREP KIT . . . . . . . 45SUSTIVA CAPS 50MG . . . . . . . . . . . . . 32SUSTIVA CAPS 200MG . . . . . . . . . . . 32SUSTIVA TABS . . . . . . . . . . . . . . . . . . . 32SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . . 28SYLATRON . . . . . . . . . . . . . . . . . . . . . . . 27SYMFI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32SYMFI LO . . . . . . . . . . . . . . . . . . . . . . . . 32SYMLINPEN 60 . . . . . . . . . . . . . . . . . . . 34SYMLINPEN 120 . . . . . . . . . . . . . . . . . . 34SYMTUZA . . . . . . . . . . . . . . . . . . . . . . . . 33SYNAGIS . . . . . . . . . . . . . . . . . . . . . . . . . 53SYNAREL . . . . . . . . . . . . . . . . . . . . . . . . 51SYNERCID . . . . . . . . . . . . . . . . . . . . . . . 17SYNJARDY . . . . . . . . . . . . . . . . . . . . . . . 34SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG . . . 35SYNJARDY XR TB24 12.5MG; 1000MG, 5MG; 1000MG . . 35SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . . 27SYNTHROID . . . . . . . . . . . . . . . . . . . . . . 51SYPRINE . . . . . . . . . . . . . . . . . . . . . . . . . 44

TTABLOID . . . . . . . . . . . . . . . . . . . . . . . . . 26tacrolimus caps . . . . . . . . . . . . . . . . . . . 52tacrolimus oint . . . . . . . . . . . . . . . . . . . . 42

80


Covered Drugs Index

trimethoprim sulfate/ polymyxin b sulfate . . . . . . . . . . . . . . . . 17tri-mili . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50trimipramine maleate . . . . . . . . . . . . . . 23trinessa . . . . . . . . . . . . . . . . . . . . . . . . . . . 50TRINTELLIX . . . . . . . . . . . . . . . . . . . . . . 22tri-previfem . . . . . . . . . . . . . . . . . . . . . . . . 50TRIPTODUR . . . . . . . . . . . . . . . . . . . . . . 48TRISENOX . . . . . . . . . . . . . . . . . . . . . . . 27tri-sprintec . . . . . . . . . . . . . . . . . . . . . . . . 50TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . . . 32trivora-28 . . . . . . . . . . . . . . . . . . . . . . . . . 50tri-vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . 50TROGARZO . . . . . . . . . . . . . . . . . . . . . . 32TROKENDI XR CP24 100MG, 25MG, 50MG . . . . . . . . . . . . . 21TROKENDI XR CP24 200MG . . . . . . 21TROPHAMINE . . . . . . . . . . . . . . . . . . . . 44tropicamide . . . . . . . . . . . . . . . . . . . . . . . 55TRULANCE . . . . . . . . . . . . . . . . . . . . . . . 45TRULICITY . . . . . . . . . . . . . . . . . . . . . . . 35TRUMENBA . . . . . . . . . . . . . . . . . . . . . . 53TRUVADA . . . . . . . . . . . . . . . . . . . . . . . . 32TWINRIX . . . . . . . . . . . . . . . . . . . . . . . . . 53TYBOST . . . . . . . . . . . . . . . . . . . . . . . . . . 32tydemy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50TYGACIL . . . . . . . . . . . . . . . . . . . . . . . . . 17TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . . 28TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . . 53TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . . 41

UULORIC . . . . . . . . . . . . . . . . . . . . . . . . . . 24UNITHROID . . . . . . . . . . . . . . . . . . . . . . . 51UNITUXIN . . . . . . . . . . . . . . . . . . . . . . . . 28ursodiol . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Vvalacyclovir hcl . . . . . . . . . . . . . . . . . . . . 33

trazodone hydrochloride tabs 100mg, 150mg, 50mg . . . . . . . . . 22trazodone hydrochloride tabs 300mg . . . . . . . . . . . . . . . . . . . . . . . 22TREANDA INJ 25MG . . . . . . . . . . . . . . 25TREANDA INJ 100MG . . . . . . . . . . . . . 25TRECATOR . . . . . . . . . . . . . . . . . . . . . . . 25TRELEGY ELLIPTA . . . . . . . . . . . . . . . 57TRELSTAR MIXJECT INJ 3.75MG . . 51TRELSTAR MIXJECT INJ 11.25MG . . 51TRELSTAR MIXJECT INJ 22.5MG . . 51TRESIBA FLEXTOUCH . . . . . . . . . . . . 35tretinoin caps . . . . . . . . . . . . . . . . . . . . . 29tretinoin crea . . . . . . . . . . . . . . . . . . . . . 42tretinoin gel . . . . . . . . . . . . . . . . . . . . . . . 42tretinoin microsphere . . . . . . . . . . . . . . 42tretinoin microsphere pump gel 0.1% . . . . . . . . . . . . . . . . . . . . 42triamcinolone acetonide crea 0.1% . . . . . . . . . . . . . . . . . . . . . . . . . 48triamcinolone acetonide crea 0.025%, 0.5% . . . . . . . . . . . . . . . . 48triamcinolone acetonide dental paste . . . . . . . . . . . . . . . . . . . . . . . 41triamcinolone acetonide inj 40mg/ml . . . . . . . . . . . . . . . . . . . . . . . . . . 48triamcinolone acetonide lotn . . . . . . . 48triamcinolone acetonide oint . . . . . . . 48triamterene/hydrochlorothiazide . . . . 39trianex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48triderm crea 0.1% . . . . . . . . . . . . . . . . . 48trientine hydrochloride . . . . . . . . . . . . . 44tri-estarylla . . . . . . . . . . . . . . . . . . . . . . . . 50trifluoperazine hcl . . . . . . . . . . . . . . . . . . 30trifluridine . . . . . . . . . . . . . . . . . . . . . . . . . 33trihexyphenidyl hcl . . . . . . . . . . . . . . . . . 29tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . . 50tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . . . 50trilyte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45trimethoprim . . . . . . . . . . . . . . . . . . . . . . . 17

TIS-U-SOL . . . . . . . . . . . . . . . . . . . . . . . . 54TIVICAY TABS 10MG, 25MG . . . . . . . 32TIVICAY TABS 50MG . . . . . . . . . . . . . . 32tizanidine hcl . . . . . . . . . . . . . . . . . . . . . . 31TOBI PODHALER . . . . . . . . . . . . . . . . . 56TOBRADEX OINT . . . . . . . . . . . . . . . . 55tobramycin/dexamethasone . . . . . . . . 55tobramycin nebu . . . . . . . . . . . . . . . . . . 56tobramycin ophthalmic soln . . . . . . . . 16tobramycin sulfate inj 1.2gm, 10mg/ml, 80mg/2ml . . . . . . . . 16tobramycin sulfate ophthalmic soln . . . . . . . . . . . . . . . . . . . . 16TOBREX OINT . . . . . . . . . . . . . . . . . . . 16tolcapone . . . . . . . . . . . . . . . . . . . . . . . . . 29tolmetin sodium . . . . . . . . . . . . . . . . . . . 14tolterodine tartrate . . . . . . . . . . . . . . . . . 46tolterodine tartrate er . . . . . . . . . . . . . . 46topiramate . . . . . . . . . . . . . . . . . . . . . . . . 21toposar . . . . . . . . . . . . . . . . . . . . . . . . . . . 27topotecan hcl inj 4mg . . . . . . . . . . . . . . 27TORISEL . . . . . . . . . . . . . . . . . . . . . . . . . 52torsemide . . . . . . . . . . . . . . . . . . . . . . . . . 39TOUJEO MAX SOLOSTAR . . . . . . . . 35TOUJEO SOLOSTAR . . . . . . . . . . . . . . 35TPN ELECTROLYTES . . . . . . . . . . . . . 44TRACLEER . . . . . . . . . . . . . . . . . . . . . . . 57TRADJENTA . . . . . . . . . . . . . . . . . . . . . . 35tramadol hcl . . . . . . . . . . . . . . . . . . . . . . . 16tramadol hydrochloride/ acetaminophen . . . . . . . . . . . . . . . . . . . . 16trandolapril tabs 1mg . . . . . . . . . . . . . . 37trandolapril tabs 2mg, 4mg . . . . . . . . . 37tranexamic acid inj . . . . . . . . . . . . . . . . 36tranexamic acid tabs . . . . . . . . . . . . . . 36TRANSDERM-SCOP . . . . . . . . . . . . . . 23tranylcypromine sulfate . . . . . . . . . . . . 22TRAVASOL . . . . . . . . . . . . . . . . . . . . . . . 44TRAVATAN Z . . . . . . . . . . . . . . . . . . . . . . 55

81


Covered Drugs Index

VIREAD TABS . . . . . . . . . . . . . . . . . . . . 32voriconazole inj . . . . . . . . . . . . . . . . . . . 24voriconazole susr . . . . . . . . . . . . . . . . . 24voriconazole tabs . . . . . . . . . . . . . . . . . 24VOSEVI . . . . . . . . . . . . . . . . . . . . . . . . . . 31VOTRIENT . . . . . . . . . . . . . . . . . . . . . . . . 28VP-PNV-DHA . . . . . . . . . . . . . . . . . . . . . 44VPRIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46VRAYLAR CAPS . . . . . . . . . . . . . . . . . . 31VRAYLAR CPPK . . . . . . . . . . . . . . . . . . 31vyfemla . . . . . . . . . . . . . . . . . . . . . . . . . . . 50vylibra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50VYXEOS . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Wwarfarin sodium . . . . . . . . . . . . . . . . . . . 36WELCHOL . . . . . . . . . . . . . . . . . . . . . . . . 40wera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

XXALKORI . . . . . . . . . . . . . . . . . . . . . . . . . 28XARELTO STARTER PACK . . . . . . . . 36XARELTO TABS 10MG . . . . . . . . . . . . 36XARELTO TABS 15MG . . . . . . . . . . . . 36XARELTO TABS 20MG . . . . . . . . . . . . 36XATMEP . . . . . . . . . . . . . . . . . . . . . . . . . . 52XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . 54XIFAXAN TABS 200MG . . . . . . . . . . . . 18XIFAXAN TABS 550MG . . . . . . . . . . . . 18XIGDUO XR TB24 5MG; 1000MG . . . . . . . . . . . . . . . . . . . . 35XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, 2.5MG; 1000MG, 5MG; 500MG . . . . 35XOLAIR . . . . . . . . . . . . . . . . . . . . . . . . . . . 57XTAMPZA ER . . . . . . . . . . . . . . . . . . . . . 14XTANDI . . . . . . . . . . . . . . . . . . . . . . . . . . . 25XULTOPHY 100/3.6 . . . . . . . . . . . . . . . 35XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

VENTOLIN HFA . . . . . . . . . . . . . . . . . . . 56verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg . . . . . . . . . . . . . . . . . . . . 38verapamil hcl er cp24 200mg . . . . . . . 39verapamil hcl er tbcr . . . . . . . . . . . . . . 39verapamil hcl inj . . . . . . . . . . . . . . . . . . 39verapamil hcl sr cp24 360mg . . . . . . . 39verapamil hcl tabs 40mg . . . . . . . . . . . 39verapamil hcl tabs 120mg, 80mg . . . 39VERSACLOZ . . . . . . . . . . . . . . . . . . . . . 31VERZENIO . . . . . . . . . . . . . . . . . . . . . . . 27VESICARE . . . . . . . . . . . . . . . . . . . . . . . . 46V-GO 20 . . . . . . . . . . . . . . . . . . . . . . . . . . 54V-GO 30 . . . . . . . . . . . . . . . . . . . . . . . . . . 55V-GO 40 . . . . . . . . . . . . . . . . . . . . . . . . . . 55VIBERZI . . . . . . . . . . . . . . . . . . . . . . . . . . 45vicodin es tabs 300mg; 7.5mg . . . . . . 16vicodin hp tabs 300mg; 10mg . . . . . . 16vicodin tabs 300mg; 5mg . . . . . . . . . . . 16VICTOZA . . . . . . . . . . . . . . . . . . . . . . . . . 35VIDEX EC CPDR 125MG . . . . . . . . . . 32VIDEX PEDIATRIC . . . . . . . . . . . . . . . . 32vienva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50vigabatrin . . . . . . . . . . . . . . . . . . . . . . . . . 21VIGAMOX . . . . . . . . . . . . . . . . . . . . . . . . 19VIIBRYD . . . . . . . . . . . . . . . . . . . . . . . . . . 23VIIBRYD STARTER PACK . . . . . . . . . 23VIMPAT INJ . . . . . . . . . . . . . . . . . . . . . . 21VIMPAT ORAL SOLN . . . . . . . . . . . . . 21VIMPAT TABS . . . . . . . . . . . . . . . . . . . . 21vinblastine sulfate . . . . . . . . . . . . . . . . . 27vincasar pfs . . . . . . . . . . . . . . . . . . . . . . . 27vincristine sulfate . . . . . . . . . . . . . . . . . . 27vinorelbine tartrate inj 50mg/5ml . . . . 27viorele . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50VIRACEPT TABS 250MG . . . . . . . . . . 33VIRACEPT TABS 625MG . . . . . . . . . . 33VIRAMUNE SUSP . . . . . . . . . . . . . . . . 32VIREAD POWD . . . . . . . . . . . . . . . . . . . 32

valacyclovir hydrochloride . . . . . . . . . . 33VALCHLOR . . . . . . . . . . . . . . . . . . . . . . . 25valganciclovir . . . . . . . . . . . . . . . . . . . . . . 31valganciclovir hydrochlorde . . . . . . . . 31valproate sodium . . . . . . . . . . . . . . . . . . 21valproic acid . . . . . . . . . . . . . . . . . . . . . . . 21valsartan . . . . . . . . . . . . . . . . . . . . . . . . . . 37valsartan/hydrochlorothiazide . . . . . . 37vancomycin . . . . . . . . . . . . . . . . . . . . . . . 17vancomycin hcl caps 125mg . . . . . . . 17vancomycin hcl caps 250mg . . . . . . . 17vancomycin hcl in dextrose . . . . . . . . . 17vancomycin hcl inj 0.9%; 1gm/200ml, 10gm, 1gm, 500mg, 5gm, 750mg . . . . . . . . . 17VANCOMYCIN HYDROCHLORIDE INJ 250MG . . . . 17vancomycin hydrochloride/sodium chloride inj 0.9%; 750mg/150ml . . . . 18vandazole . . . . . . . . . . . . . . . . . . . . . . . . . 18VAQTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53VARIVAX . . . . . . . . . . . . . . . . . . . . . . . . . 53VARIZIG . . . . . . . . . . . . . . . . . . . . . . . . . . 53VASCEPA CAPS 0.5GM . . . . . . . . . . . 40VASCEPA CAPS 1GM . . . . . . . . . . . . . 40VAXCHORA . . . . . . . . . . . . . . . . . . . . . . . 53VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . . . 28VELCADE . . . . . . . . . . . . . . . . . . . . . . . . 27velivet . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50VELPHORO . . . . . . . . . . . . . . . . . . . . . . . 44VELTASSA . . . . . . . . . . . . . . . . . . . . . . . . 44VENCLEXTA STARTING PACK . . . . 27VENCLEXTA TABS 10MG . . . . . . . . . 27VENCLEXTA TABS 50MG . . . . . . . . . 27VENCLEXTA TABS 100MG . . . . . . . . 27venlafaxine hcl . . . . . . . . . . . . . . . . . . . . 23venlafaxine hcl er cp24 37.5mg . . . . . 23venlafaxine hcl er cp24 75mg . . . . . . 23venlafaxine hcl er cp24 150mg . . . . . 23VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . . 57

82


Covered Drugs Index

ZOSTAVAX . . . . . . . . . . . . . . . . . . . . . . . 53ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML; 0.5GM/100ML . . . 19zovia 1/35e . . . . . . . . . . . . . . . . . . . . . . . 50ZOVIRAX CREA . . . . . . . . . . . . . . . . . . 33ZUBSOLV SUBL 0.7MG; 0.18MG . . 16ZUBSOLV SUBL 1.4MG; 0.36MG, 11.4MG; 2.9MG, 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG . . . . . 16ZYCLARA . . . . . . . . . . . . . . . . . . . . . . . . . 42ZYCLARA PUMP CREA 2.5% . . . . . . 42ZYCLARA PUMP CREA 3.75% . . . . . 42ZYDELIG . . . . . . . . . . . . . . . . . . . . . . . . . 28ZYKADIA . . . . . . . . . . . . . . . . . . . . . . . . . 28ZYLET . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16ZYPREXA RELPREVV INJ 210MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 31ZYPREXA RELPREVV INJ 300MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 31ZYPREXA RELPREVV INJ 405MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 31ZYTIGA TABS 250MG . . . . . . . . . . . . . 25ZYTIGA TABS 500MG . . . . . . . . . . . . . 25

YYERVOY INJ 50MG/10ML . . . . . . . . . 28YERVOY INJ 200MG/40ML . . . . . . . . 28YF-VAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 53YONDELIS . . . . . . . . . . . . . . . . . . . . . . . . 25YONSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 25yuvafem . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Zzafirlukast . . . . . . . . . . . . . . . . . . . . . . . . . 56zaleplon . . . . . . . . . . . . . . . . . . . . . . . . . . 57ZALTRAP . . . . . . . . . . . . . . . . . . . . . . . . . 28ZANOSAR . . . . . . . . . . . . . . . . . . . . . . . . 25ZARXIO . . . . . . . . . . . . . . . . . . . . . . . . . . 36ZAVESCA . . . . . . . . . . . . . . . . . . . . . . . . . 46zebutal caps 325mg; 50mg; 40mg . . 14ZEJULA . . . . . . . . . . . . . . . . . . . . . . . . . . 27ZELBORAF . . . . . . . . . . . . . . . . . . . . . . . 28ZEMAIRA . . . . . . . . . . . . . . . . . . . . . . . . . 57zenatane . . . . . . . . . . . . . . . . . . . . . . . . . . 42zenchent . . . . . . . . . . . . . . . . . . . . . . . . . . 50ZENPEP . . . . . . . . . . . . . . . . . . . . . . . . . . 46ZERIT ORAL SOLN . . . . . . . . . . . . . . . 32ZETIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40ZIAGEN ORAL SOLN . . . . . . . . . . . . . 32zidovudine caps . . . . . . . . . . . . . . . . . . 32zidovudine syrp . . . . . . . . . . . . . . . . . . . 32zidovudine tabs . . . . . . . . . . . . . . . . . . . 32ZIOPTAN . . . . . . . . . . . . . . . . . . . . . . . . . 55ziprasidone hcl . . . . . . . . . . . . . . . . . . . . 31ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . . 31zoledronic acid inj 4mg/5ml . . . . . . . . 54zoledronic acid inj 5mg/100ml . . . . . . 54ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . . 27zolpidem tartrate tabs . . . . . . . . . . . . . 57zonisamide . . . . . . . . . . . . . . . . . . . . . . . . 20ZORTRESS TABS 0.5MG . . . . . . . . . . 52ZORTRESS TABS 0.25MG, 0.75MG . . . . . . . . . . . . . . . . . . 52

This drug list was updated in November 2018. For more recent information or other questions, please contact Cigna-HealthSpring Customer Service, at 1-800-668-3813 or, for TTY users, 711, 7 days a week, 8 a.m. - 8 p.m., or visit www.CignaHealthSpring.com. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-668-3813 (TTY 711), 7 days a week, 8 a.m. - 8 p.m. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-668-3813 (TTY 711). 注意：如果您使用繁體/中文，您可以免費獲得語言援助服務請致電 1-800-668-3813 (TTY 711). Cigna-HealthSpring complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna-HealthSpring cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2017 Cigna

1-800-668-3813 (TTY 711) October 1 – February 14, 8 a.m. – 8 p.m. local time, 7 days a week. From February 15 – September 30, Monday – Friday, 8 a.m. – 8 p.m. local time, Saturday, 8 a.m. – 6 p.m. local time. Messaging service used weekends, after hours, and on federal holidays.

CignaHealthSpring.com

Documents

Cigna Official Site - 2018 Cigna-HealthSpring ......• Talk with your doctor about whether a 90-day supply of your ongoing, stable medications may be appropriate. Taking these medications