Individual & Family Plans Preferred Drug List

2021Individual & Family PlansPreferred Drug List

How to use the Preferred Drug List The Preferred Drug List (PDL) is a summary of prescription drugs covered under your plan. This contains the most commonly prescribed drugs with their dosing and forms. This list is not a complete list and additional drugs may be covered. Please note that the Preferred Drug List is subject to change as new drugs become available and therapeutic categories are reviewed and updated to provide the most effective and greatest value therapies available for our members. Your pharmacy benefit has four tiers and the tier is identified in the second column on the Preferred Drug List below. These tiers determine your out of pocket responsibility and correspond to the copays and/or coinsurance shown on your benefit summary. In most cases, the drugs on the lower tiers will cost less.

Tier 0: Preventive Drugs required by the Affordable Care Act (ACA) Tier 1: Preferred Generics

Tier 2: Non-Preferred Generics / Preferred Brands Tier 3: Non-Preferred Brands Tier 4: Specialty (Most specialty drugs require PA and must be filled at the Plan’s designated Specialty Pharmacy) If you have any questions about the Preferred Drug List or your pharmacy benefits please contact Pharmacy Customer Service at the number listed on the back of your ID Card. Pharmacy Customer Service is available 24 hours / 7 days a week / 365 days a year. You can also view additional information by logging into the pharmacy member portal. If you need assistance in registering for the portal, please contact Pharmacy Customer Service. The pharmacy member portal provides information such as how to find a pharmacy; look up drug information like benefit tier, limits, and drug interactions; shop for best price of a medication at different pharmacies; check the status of a prescription; print your drug fill history; and how to set up mail order. HOW DRUGS ARE CHOSEN FOR THE PDL Drugs approved by the United States (U.S.) Food and Drug Administration (FDA) are reviewed and considered for the PDL by the Pharmaceutical & Therapeutics (P&T) Committee utilizing the following criteria:

a) The drug is effective and medically necessary for the treatment, maintenance, and/or prevention of a specific medical condition

b) The PDL does not have other alternatives or similar drugs that could be used in its place c) The drug shows a strong therapeutic outcome d) The drug shows safety for medical use

As new drugs are approved by the FDA, they are reviewed within 180 days against similar drugs available on PDL before being considered for inclusion. New drugs with an FDA designation of 1P (FDA priority review – potential therapeutic gain) will automatically be reviewed for consideration for the Preferred Drug List. New drugs with an FDA designation of 1S (FDA standard review – no therapeutic gain) will not be reviewed for consideration until a provider/member requests or the next therapeutic class review is done. In addition, therapeutic classes are reviewed on a regular basis to ensure the Preferred Drug List includes the most clinically and cost-effective medications. Members will receive notices related to drug formulary changes at the point of sale when filling a prescription that is impacted by modifications to the PDL. Network pharmacies are required to inform the member of these messages regarding updates or changes to the program which may impact a member. In addition, members whose drugs have been removed from the PDL or have a negative change such as increased tier or new limits will receive written communication of change. PREVENTIVE DRUGS Certain medications are considered preventive under the Affordable Care Act (ACA). ACA preventive drugs are covered at 100 percent (no patient responsibility), although limits may apply. For more information about your preventive drug benefits, please contact Pharmacy Customer Service at the number listed on the back of your ID Card. PRIOR AUTHORIZATION (PA) To ensure appropriate utilization, some generic and brand medications and all specialty drugs require Prior Authorization to be eligible for coverage under the member’s prescription drug benefit. The P&T Committee establishes the Prior

Authorization criteria. In order for a member to receive coverage for a medication requiring Prior Authorization, the member or member’s provider should contact Pharmacy Customer Service at the number listed on the back of your ID Card. Your provider will be required to complete a prior authorization form and provide clinical documentation to show why this medication is needed for treatment of your disease state or medical condition. A letter of medical necessity is also recommended. Your provider should also include in his/her letter your diagnosis and previous therapies that have failed. If Prior Authorization is not received or if the medication is filled prior to approval, the cost of the medication will be full member responsibility. In addition, Prior Authorizations are not able to be back-dated. QUANTITY LIMIT (QL) Quantity Limit is a program that ensures members do not receive a prescription for a quantity that exceeds recommended Plan or safety limits. Limits are set because some medications have the potential to be abused, misused, shared, or have a manufacturer’s limit on the recommended maximum dose. Quantity limits are based on FDA approved dosing schedules, current medical practices, evidence-based clinical guidelines, and peer-reviewed medical literature related to a particular drug. Prior Authorization is required for any quantities that exceed Plan limits. STEP THERAPY (ST) Step Therapy is a program for prescription drugs that are taken on a regular basis to treat an ongoing medical condition. The program is developed around safety, cost, and a member’s health. In Step Therapy, the covered drugs are arranged in a series of “steps”. The program typically starts with generic drugs as the “first step.” These generics are rigorously tested and approved by the FDA and allow you to have safe, effective treatment with medication that is more affordable. More expensive brand-name drugs are usually considered in the “second step” if your provider determines the “second step” products are medically necessity for your treatment. Step Therapy is developed under the guidance and direction of independent, licensed doctors, pharmacists, and other medical experts. They review the most current research on thousands of drugs tested and approved by the FDA for safety and efficacy. The first time you submit a prescription that is not for a first-step drug, your pharmacist will receive a message to tell you that the Plan requires Step Therapy. This means if you don’t want to pay full price for your prescription drug, your doctor needs to write a new prescription for a “first-step” drug. With Step Therapy, if you’ve already tried and failed the “first-step” drug, can’t take the “first-step” drug (because of an allergy, etc.), and/or your provider can show medical necessity for the second step products, your provider can submit a request for Prior Authorization review. THERAPEUTIC INTERCHANGE (TI) Therapeutic interchange is the practice of replacing, with your physician’s approval, a prescription medication originally prescribed with a chemically different medication. Medications used in therapeutic interchange programs are expected to produce similar levels of effectiveness and results. Therapeutic interchange programs are based on scientific evidence. These programs are developed and administered by a team of physicians, pharmacists, and other medical practitioners who are experts in the diagnosis and treatment of disease. The program is designed to work along with other tools that medical professionals use to promote safe and effective drug therapy. If therapeutic interchange is required on a drug, your pharmacist will receive a message to request a therapeutic interchange from your provider. If you or your provider feel the interchange is not right for you and you do not want to pay full price for your prescription, your provider can submit a request for Prior Authorization review. AGE Some medications have a minimum or maximum age limit requirement under the Plan. Only members within those limits are able to fill those medications. BRAND-GENERIC CHARGE (Ancillary Charge) A Brand-Generic Charge is applied if you receive a brand name drug, regardless of reason or medical necessity, or if your provider prescribes a brand name drug when a generic is available. A Brand-Generic Charge is the difference in cost from the generic to the brand name drug. This penalty is in addition to the regular cost sharing outlined in your benefits summary. The Brand-Generic Charge does not apply towards Deductibles or Out-of-Pocket Maximum. GENERIC MANDATORY PLAN The Plan mandates generic drugs wherever available. If a brand-name drug is requested when a generic is available, the generic will be available without a Prior Authorization. If brand is still desired, Prior Authorization will be required, even if not indicated on the PDL below. If brand is approved through the PA process, the Brand-Generic penalty will still be applied.

MAIL ORDER Mail order is when a 90 day supply of a generic or brand name drug (Tier 0, 1, 2, and 3) is mailed directly to you through a designated Mail Order Pharmacy. Not all medications are available through Mail Order. Contact Pharmacy Customer Service at the number listed on the back of your ID Card for more information or to get started on the Mail Order program. SPECIALTY PHARMACY The Plan requires that all medications noted as Specialty drugs (Tier 4) be filled through the Plan’s designated Specialty Pharmacies. In cases where drugs are available only through a limited distribution channel from the manufacturer, these drugs may be filled at other designated specialty pharmacies as directed by the Plan. OFF-LABEL USE OF MEDICATIONS The FDA requires that drugs used in the U.S. be safe and effective. The label information of a medication outlines drug use for "approved" doses and specific conditions or disease states. The use of a drug for a disease state or condition not listed on the label, or in a dose or therapy not listed on the label, is considered to be a "non-approved" or "off-label" use of the drug. Off-label use of a medication is not covered unless it meets the Plan’s off-label use policy. A Prior Authorization is required when a medication is used outside of its FDA indication, dosage, or treatment. Coverage will be reviewed under the off-label use policy and subject to the same conditions and limitations as any other prescription drug. Therapies deemed investigational are not a covered benefit.

NON-FORMULARY (not covered) OR EXCEPTON REQUESTS FOR MEDICATIONS For drugs that are not covered by the Plan or non-formulary drugs, you or your provider can submit an exception request. Your provider will be required to complete a request for formulary exception form and provide clinical documentation to show why this medication is needed for treatment of your disease state or medical condition. A letter of medical necessity is also recommended. Your provider should also include in his/her letter your diagnosis and previous therapies that have failed. If exception request approval is not received or medication is filled prior to approval, the cost of the medication will be full member responsibility. Contact Pharmacy Customer Service at the number listed on the back of your ID Card for more information. PAPER CLAIMS FILING LIMITS Point-of-sale claims are generally submitted electronically at the time of dispensing. However, there may be mitigating reasons that require a claim to be submitted via a paper claim after being dispensed. The timely filing limit for paper claims submission is 90 days from the date of service for all original claims. Paper claims will be reimbursed off of what the contractual discount would have been if claim had processed through the system, so member will be responsible for any difference in paid cost.

TIER DESCRIPTION

1 Preferred Generics

2Preferred Brands/Non-

Preferred Generics

3 Non-Preferred Brands

4 Specialty

TYPE DESCRIPTION

QL Quantity LimitThere is a limit on the amount of this drug that is covered

per prescription, or within a specific time frame.

PA Prior Authorization

You (or your physician) are required to get prior

authorization before you fill your prescription for this drug.

Without prior approval, we may not cover this drug.

ST Step Therapy

In some cases, you may be required to first try certain drugs

to treat your medical condition before we will cover another

drug for that condition.

GL Gender LimitThis prescription drug may only be covered for a single

gender.

AL1 Age LimitThis prescription drug may only be covered if you meet the

minimum or maximum age limit.

MFL Max Fill LimitThere is a limit on the number of times this drug can be

refilled.

MDS Max Days Supply There is a limit on the amount of this drug that is covered.

S Specialty Drug

Specialty drugs are high-cost drugs used to treat complex or

rare conditions, such as multiple sclerosis, rheumatoid

arthritis, hepatitis C, and hemophilia.

PREV Preventative

Certain medications are considered preventive under the

Affordable Care Act (ACA). ACA preventive drugs are covered

at 100 percent (no patient responsibility), although limits

may apply. For more information about your preventive

drug benefits, please contact Pharmacy Customer Service at

the number listed on the back of your ID Card.

PAGE 1 LAST UPDATED 02/2022

LIST OF COVERED PRESCRIPTION MEDICATIONSPRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTSADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS

clonidine hcl er 0.1 mg tab er 12h 1

guanfacine hcl er 1 mg tab er 24h 1 QL 30 / 30 DAYS




ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR

atomoxetine hcl 10 mg cap 1 QL 60 / 30 DAYS







AMPHETAMINE MIXTURES

amphetamine-dextroamphet er 10 mg cap er 24h 1 QL 60 / 30 DAYS






amphetamine-dextroamphetamine 10 mg tab 1 QL 90 / 30 DAYS

amphetamine-dextroamphetamine 12.5 mg tab 1 QL 90 / 30 DAYS



PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS




amphetamine-dextroamphetamine 7.5 mg tab 1 QL 90 / 30 DAYS

AMPHETAMINESADZENYS ER 1.25 MG/ML SUSPamphetamine

3 PA

ADZENYS XR-ODT 12.5 MG TAB ER DISPamphetamine

3

QL 60 / 30 DAYS

PA

AL1 At least 6 yrs old


3

QL 60 / 30 DAYS

PA



3

QL 60 / 30 DAYS

PA



3

QL 60 / 30 DAYS

PA



3

QL 60 / 30 DAYS

PA



3

QL 60 / 30 DAYS

PA


AMPHETAMINE ER 1.25 MG/ML SUSPamphetamine

3 PA

amphetamine sulfate 10 mg tab 1 QL 60 / 30 DAYS

amphetamine sulfate 5 mg tab 1 QL 120 / 30 DAYS



dextroamphetamine sulfate 10 mg tab 1 QL 90 / 30 DAYS

dextroamphetamine sulfate 5 mg tab 1 QL 90 / 30 DAYS

dextroamphetamine sulfate er 10 mg cap er 24h 1 QL 60 / 30 DAYS



VYVANSE 10 MG CAPlisdexamfetamine dimesylate

2 QL 30 / 30 day(s)

VYVANSE 10 MG CHEW TABlisdexamfetamine dimesylate

2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)


2 QL 30 / 30 day(s)

DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS)SUNOSI 150 MG TABsolriamfetol hcl

3 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSSUNOSI 75 MG TABsolriamfetol hcl

3 PA

STIMULANTS - MISC.

armodafinil 150 mg tab 1 QL 30 / 30 DAYS




dexmethylphenidate hcl 10 mg tab 1 QL 90 / 30 DAYS

dexmethylphenidate hcl 2.5 mg tab 1 QL 90 / 30 DAYS

dexmethylphenidate hcl 5 mg tab 1 QL 90 / 30 DAYS

dexmethylphenidate hcl er 10 mg cap er 24h 1 QL 60 / 30 DAYS








metadate er 20 mg tab er 2 QL 60 / 30 DAYS

methylphenidate hcl 10 mg chew tab 1 QL 90 / 30 DAYS

methylphenidate hcl 10 mg tab 1 QL 90 / 30 DAYS

methylphenidate hcl 10 mg/5ml solution 1 QL 1350 / 30 DAYS

methylphenidate hcl 2.5 mg chew tab 1 QL 90 / 30 DAYS


methylphenidate hcl 5 mg chew tab 1 QL 90 / 30 DAYS




methylphenidate hcl 5 mg/5ml solution 1 QL 2700 / 30 DAYS

methylphenidate hcl er (cd) 10 mg cap er 2 QL 60 / 30 DAYS






methylphenidate hcl er (la) 20 mg cap er 24h 2 QL 60 / 30 DAYS



methylphenidate hcl er 10 mg tab er 2 QL 60 / 30 DAYS


METHYLPHENIDATE HCL ER 18 MG TAB ER 24Hmethylphenidate hcl

2 QL 30 / 30 DAYS



methylphenidate hcl er 27 mg tab er 24h 2 QL 30 / 30 DAYS

methylphenidate hcl er 36 mg tab er 2 QL 2 / 1 day(s)

methylphenidate hcl er 36 mg tab er 24h 2 QL 2 / 1 day(s)


methylphenidate hcl er 54 mg tab er 24h 2 QL 30 / 30 DAYS

METHYLPHENIDATE HCL ER 72 MG TAB ERmethylphenidate hcl

2 QL 30 / 30 DAYS

modafinil 100 mg tab 1 QL 30 / 30 DAYS



modafinil 200 mg tab 1 QL 30 / 30 DAYS

QUILLICHEW ER 20 MG CHERmethylphenidate hcl

3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA

QUILLIVANT XR 25 MG/5ML SRERmethylphenidate hcl

2QL 540 / 30 DAYS

AL1 Up to 8 yrs old

ALLERGENIC EXTRACTS/BIOLOGICALS MISCBIOLOGICALS MISC

ADAGEN 250 UNIT/ML SOLUTIONpegademase bovine

4PA

S

AMINOGLYCOSIDESneomycin sulfate 500 mg tab 1

TOBI PODHALER 28 MG CAPtobramycin

4PA

S

TOBRAMYCIN 300 MG/5ML NEBU SOLNtobramycin

4PA

S

tobramycin 300 mg/5ml nebu soln 4PA

S

tobramycin sulfate 1.2 gm recon soln 4PA

S

tobramycin sulfate 1.2 gm/30ml solution 4PA

S

TOBRAMYCIN SULFATE 10 MG/ML SOLUTIONtobramycin sulfate

4PA

S

TOBRAMYCIN SULFATE 2 GM/50ML SOLUTIONtobramycin sulfate

4PA

S



tobramycin sulfate 80 mg/2ml solution 4PA

S

ANALGESICS - ANTI-INFLAMMATORYANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES

HUMIRA 10 MG/0.1ML PREF SY KTadalimumab

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

HUMIRA 80 MG/0.8ML PEN KITadalimumab

4PA

S

HUMIRA PEDIATRIC CROHNS START 40 MG/0.8ML PREFSY KTadalimumab

4PA

S

HUMIRA PEDIATRIC CROHNS START 80 MG/0.8ML &40MG/0.4ML PREF SY KTadalimumab

4PA

S

HUMIRA PEDIATRIC CROHNS START 80 MG/0.8ML PREFSY KTadalimumab

4PA

S

HUMIRA PEN 40 MG/0.4ML PEN KITadalimumab

4PA

S

HUMIRA PEN 40 MG/0.8ML PEN KITadalimumab

4PA

S



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

4PA

S

HUMIRA PEN-CD/UC/HS STARTER 80 MG/0.8ML PEN KITadalimumab

4PA

S

HUMIRA PEN-PEDIATRIC UC START 80 MG/0.8ML PEN KITadalimumab

4PA

S

HUMIRA PEN-PS/UV/ADOL HS START 40 MG/0.8ML PENKITadalimumab

4PA

S

HUMIRA PEN-PSOR/UVEIT STARTER 80 MG/0.8ML &40MG/0.4ML PEN KITadalimumab

4PA

S

SIMPONI 100 MG/ML SOLN A-INJgolimumab

4PA

S

SIMPONI 100 MG/ML SOLN PRSYRgolimumab

4PA

S

SIMPONI 50 MG/0.5ML SOLN A-INJgolimumab

4PA

S

SIMPONI 50 MG/0.5ML SOLN PRSYRgolimumab

4PA

S

ANTIRHEUMATIC - JANUS KINASE (JAK) INHIBITORS

OLUMIANT 1 MG TABbaricitinib

4PA

S

OLUMIANT 2 MG TABbaricitinib

4PA

S

RINVOQ 15 MG TAB ER 24Hupadacitinib

4PA

S

XELJANZ 1 MG/ML SOLUTIONtofacitinib citrate

4PA

S

XELJANZ 10 MG TABtofacitinib citrate

4PA

S



XELJANZ 5 MG TABtofacitinib citrate

4PA

S

XELJANZ XR 11 MG TAB ER 24Htofacitinib citrate

4PA

S

XELJANZ XR 22 MG TAB ER 24Htofacitinib citrate

4PA

S

ANTIRHEUMATIC ANTIMETABOLITESOTREXUP 10 MG/0.4ML SOLN A-INJmethotrexate (antirheumatic)

3 PA

OTREXUP 12.5 MG/0.4ML SOLN A-INJmethotrexate (antirheumatic)

3 PA

OTREXUP 15 MG/0.4ML SOLN A-INJmethotrexate (antirheumatic)

3 PA


3 PA


3 PA


3 PA


3 PA

RASUVO 10 MG/0.2ML SOLN A-INJmethotrexate (antirheumatic)

2

RASUVO 12.5 MG/0.25ML SOLN A-INJmethotrexate (antirheumatic)

2


2


2


2


2


2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSRASUVO 30 MG/0.6ML SOLN A-INJmethotrexate (antirheumatic)

2


2

REDITREX 10 MG/0.4ML SOLN PRSYRmethotrexate (antirheumatic)

3 PA

REDITREX 12.5 MG/0.05ML SOLN PRSYRmethotrexate (antirheumatic)

3 PA


3 PA


3 PA


3 PA


3 PA

REDITREX 25 MG/ML SOLN PRSYRmethotrexate (antirheumatic)

3 PA


3 PA

CYCLOOXYGENASE 2 (COX-2) INHIBITORScelecoxib 100 mg cap 1

celecoxib 200 mg cap 1 QL 60 / 30 DAYS

celecoxib 400 mg cap 1 QL 60 / 30 DAYS

celecoxib 50 mg cap 1

GOLD COMPOUNDS

RIDAURA 3 MG CAPauranofin

4PA

S

INTERLEUKIN-1 RECEPTOR ANTAGONIST (IL-1RA)

KINERET 100 MG/0.67ML SOLN PRSYRanakinra

4PA

S

INTERLEUKIN-6 RECEPTOR INHIBITORS

ACTEMRA 162 MG/0.9ML SOLN PRSYRtocilizumab

4PA

S



ACTEMRA ACTPEN 162 MG/0.9ML SOLN A-INJtocilizumab

4PA

S

NONSTEROIDAL ANTI-INFLAMMATORY AGENT COMBINATIONSdiclofenac-misoprostol 50-0.2 mg tab dr 1

diclofenac-misoprostol 75-0.2 mg tab dr 1

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)cataflam 50 mg tab 1

diclofenac potassium 50 mg tab 1

diclofenac sodium 25 mg tab dr 1



diclofenac sodium er 100 mg tab er 24h 1

etodolac 200 mg cap 1

etodolac 300 mg cap 1

etodolac 400 mg tab 1

etodolac 500 mg tab 1

etodolac er 400 mg tab er 24h 1



FENOPROFEN CALCIUM 400 MG CAPfenoprofen calcium

1

fenoprofen calcium 600 mg tab 1

flurbiprofen 100 mg tab 1

FLURBIPROFEN 50 MG TABflurbiprofen

1

flurbiprofen 50 mg tab 1

ibu 400 mg tab 1

ibu 600 mg tab 1

ibu 800 mg tab 1



ibuprofen 400 mg tab 1



INDOCIN 25 MG/5ML SUSPENSIONindomethacin

3 AL1 Up to 8 yrs old

indomethacin 25 mg cap 1 QL 120 / 30 DAYS

indomethacin 50 mg cap 1

indomethacin er 75 mg cap er 1

KETOPROFEN 50 MG CAPketoprofen

1

KETOPROFEN 75 MG CAPketoprofen

1

ketorolac tromethamine 10 mg tab 1

QL 20 / 0 DAYS

MFL 1 / 30 day(s)MD 5 / 1 day(s)

ketorolac tromethamine 60 mg/2ml solution 1 QL 4 / 28 DAYS

MECLOFENAMATE SODIUM 100 MG CAPmeclofenamate sodium

1

MECLOFENAMATE SODIUM 50 MG CAPmeclofenamate sodium

1

mefenamic acid 250 mg cap 1

meloxicam 15 mg tab 1 QL 30 / 30 DAYS

meloxicam 7.5 mg tab 1 QL 30 / 30 DAYS

nabumetone 500 mg tab 1

nabumetone 750 mg tab 1

naproxen 125 mg/5ml suspension 1

naproxen 250 mg tab 1


naproxen 375 mg tab dr 1




naproxen 500 mg tab dr 1

naproxen sodium 275 mg tab 1

naproxen sodium 550 mg tab 1

oxaprozin 600 mg tab 1

piroxicam 10 mg cap 1

piroxicam 20 mg cap 1

relafen 500 mg tab 1

relafen 750 mg tab 1

sulindac 150 mg tab 1

sulindac 200 mg tab 1

TOLMETIN SODIUM 200 MG TABtolmetin sodium

2

TOLMETIN SODIUM 400 MG CAPtolmetin sodium

2

TOLMETIN SODIUM 600 MG TABtolmetin sodium

2

PHOSPHODIESTERASE 4 (PDE4) INHIBITORS

OTEZLA 10 & 20 & 30 MG TAB THPKapremilast

4PA

S

OTEZLA 30 MG TABapremilast

4PA

S

PYRIMIDINE SYNTHESIS INHIBITORS

leflunomide 10 mg tab 1 QL 30 / 30 DAYS

leflunomide 20 mg tab 1 QL 30 / 30 DAYS

SELECTIVE COSTIMULATION MODULATORS

ORENCIA 125 MG/ML SOLN PRSYRabatacept

4PA

S

ORENCIA 50 MG/0.4ML SOLN PRSYRabatacept

4PA

S

ORENCIA 87.5 MG/0.7ML SOLN PRSYRabatacept

4PA

S



ORENCIA CLICKJECT 125 MG/ML SOLN A-INJabatacept

4PA

S

SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS

ENBREL 25 MG RECON SOLNetanercept

4PA

S

ENBREL 25 MG/0.5ML SOLN PRSYRetanercept

4PA

S

ENBREL 25 MG/0.5ML SOLUTIONetanercept

4PA

S

ENBREL 50 MG/ML SOLN PRSYRetanercept

4PA

S

ENBREL MINI 50 MG/ML SOLN CARTetanercept

4PA

S

ENBREL SURECLICK 50 MG/ML SOLN A-INJetanercept

4PA

S

ANALGESICS - NONNARCOTICANALGESICS-SEDATIVES

bac 50-325-40 mg tab 1

butalbital-acetaminophen 50-325 mg tab 1

butalbital-apap 50-325 mg tab 1

butalbital-apap-caffeine 50-300-40 mg cap 1 QL 180 / 30 DAYS

butalbital-apap-caffeine 50-325-40 mg cap 1 QL 180 / 30 DAYS

butalbital-apap-caffeine 50-325-40 mg tab 1

butalbital-aspirin-caffeine 50-325-40 mg cap 1

BUTALBITAL-ASPIRIN-CAFFEINE 50-325-40 MG TABbutalbital-aspirin-caffeine

1

esgic 50-325-40 mg cap 1 QL 180 / 30 DAYS

phrenilin forte 50-300-40 mg cap 1 QL 180 / 30 DAYS



zebutal 50-325-40 mg cap 1 QL 180 / 30 DAYS

SALICYLATESdiflunisal 500 mg tab 1

salsalate 500 mg tab 1

ANALGESICS - OPIOIDCODEINE COMBINATIONS

acetaminophen-codeine #2 300-15 mg tab 1

QL 240 / 30 DAYS

MFL 1 / 60 DAYSMD 7 / 1 DAY

acetaminophen-codeine #3 300-30 mg tab 1QL 240 / 30 DAYS

MFL 1 / 60 DAYS

acetaminophen-codeine #4 300-60 mg tab 1QL 180 / 30 DAYS

MFL 1 / 60 DAYS

acetaminophen-codeine 120-12 mg/5ml solution 1

QL 450 / 30 DAYS


acetaminophen-codeine 300-15 mg tab 1QL 240 / 30 DAYSMD 7 / 1 DAY

acetaminophen-codeine 300-30 mg tab 1 QL 240 / 30 DAYS

acetaminophen-codeine 300-60 mg tab 1 QL 180 / 30 DAYS

ascomp-codeine 50-325-40-30 mg cap 1 QL 180 / 30 DAYS

butalbital-apap-caff-cod 50-300-40-30 mg cap 1 QL 180 / 30 DAYS

butalbital-apap-caff-cod 50-325-40-30 mg cap 1 QL 180 / 30 DAYS

butalbital-asa-caff-codeine 50-325-40-30 mg cap 1 QL 180 / 30 DAYS

HYDROCODONE COMBINATIONS

hydrocodone-acetaminophen 10-325 mg tab 1

QL 120 / 30 DAYS

MFL 1 / 60 DAYSMD 7 / 1 day(s)



hydrocodone-acetaminophen 10-325 mg/15ml solution 1QL 5400 / 30 DAYS

AL1 Up to 8 yrs old

hydrocodone-acetaminophen 2.5-108 mg/5ml solution 1QL 450 / 30 DAYSMD 7 / 1 DAY

hydrocodone-acetaminophen 2.5-325 mg tab 1

QL 120 / 30 DAYS


hydrocodone-acetaminophen 5-217 mg/10ml solution 1QL 450 / 30 DAYSMD 7 / 1 DAY

hydrocodone-acetaminophen 5-325 mg tab 1

QL 240 / 30 DAYS



QL 180 / 30 DAYS



QL 180 / 30 DAYS


hydrocodone-acetaminophen 7.5-325 mg/15ml solution 1

QL 450 / 30 DAYS


hydrocodone-ibuprofen 10-200 mg tab 1

QL 120 / 30 DAYS


HYDROCODONE-IBUPROFEN 5-200 MG TABhydrocodone-ibuprofen

1QL 120 / 30 DAYSMD 7 / 1 day(s)

hydrocodone-ibuprofen 5-200 mg tab 1

QL 120 / 30 DAYS




hydrocodone-ibuprofen 7.5-200 mg tab 1

QL 120 / 30 DAYS


ibudone 5-200 mg tab 1QL 120 / 30 DAYSMD 7 / 1 day(s)

lorcet 5-325 mg tab 1QL 240 / 30 DAYSMD 7 / 1 day(s)

lorcet hd 10-325 mg tab 1QL 120 / 30 DAYSMD 7 / 1 day(s)

lorcet plus 7.5-325 mg tab 1QL 180 / 30 DAYSMD 7 / 1 day(s)

OPIOID AGONISTS

ABSTRAL 100 MCG SL TABfentanyl citrate

4

PAMD 7 / 1 DAY

S


4

PAMD 7 / 1 DAY

S


4

PAMD 7 / 1 DAY

S


4

PAMD 7 / 1 DAY

S


4

PAMD 7 / 1 DAY

S


4

PAMD 7 / 1 DAY

S



alfentanil hcl 1000 mcg/2ml solution 2 PA

CODEINE SULFATE 15 MG TABcodeine sulfate

1

QL 180 / 30 DAYS



1

QL 180 / 30 DAYS


codeine sulfate 30 mg tab 1

QL 180 / 30 DAYS



1

QL 180 / 30 DAYS


codeine sulfate 60 mg tab 1

QL 180 / 30 DAYS


fentanyl 100 mcg/hr patch 72hr 1QL 15 / 30 DAYS

PA


PA


PA

fentanyl 37.5 mcg/hr patch 72hr 1QL 15 / 30 DAYS

PA


PA


PA


PA




PA

FENTANYL CITRATE 100 MCG TABfentanyl citrate

2

QL 112 / 28 DAYS

PA


fentanyl citrate 1200 mcg loz handle 2

QL 120 / 30 DAYS

PA



QL 30 / 30 DAYS

PA



QL 120 / 30 DAYS

PA



2

QL 112 / 28 DAYS

PA



QL 120 / 30 DAYS

PA



2

QL 112 / 28 DAYS

PA



QL 120 / 30 DAYS

PA





2

QL 112 / 28 DAYS

PA



QL 120 / 30 DAYS

PA



2

QL 112 / 28 DAYS

PA


hydrocodone bitartrate er 10 mg cap er 12h 2

HYDROCODONE BITARTRATE ER 10 MG CAP ER 12Hhydrocodone bitartrate

2

hydrocodone bitartrate er 100 mg tb24 deter 2 PA




2


2




2




2






2



hydromorphone hcl 1 mg/ml liquid 1

QL 120 / 30 DAYS


hydromorphone hcl 2 mg tab 1

QL 90 / 30 DAYS



QL 90 / 30 DAYS



QL 90 / 30 DAYS


hydromorphone hcl er 12 mg tab er 24h 2QL 30 / 30 DAYS

PA


PA


PA


PA

LAZANDA 100 MCG/ACT SOLUTIONfentanyl citrate

4

PAMD 7 / 1 DAY

S


4

PAMD 7 / 1 DAY

S




4

PAMD 7 / 1 DAY

S

methadone hcl 10 mg tab 1QL 60 / 30 DAYS

PA

METHADONE HCL 10 MG/5ML SOLUTIONmethadone hcl

2QL 240 / 30 DAYS

PA

methadone hcl 10 mg/5ml solution 2QL 240 / 30 DAYS

PA

methadone hcl 10 mg/ml conc 2QL 60 / 30 DAYS

PA

methadone hcl 5 mg tab 1QL 60 / 30 DAYS

PA

METHADONE HCL 5 MG/5ML SOLUTIONmethadone hcl

2QL 240 / 30 DAYS

PA

methadone hcl 5 mg/5ml solution 2QL 240 / 30 DAYS

PA

morphine sulfate (concentrate) 100 mg/5ml solution 1

QL 120 / 30 DAYS


morphine sulfate (concentrate) 20 mg/ml solution 1

QL 120 / 30 DAYS


MORPHINE SULFATE (PF) 2 MG/ML SOLUTIONmorphine sulfate

1

morphine sulfate 10 mg/5ml solution 1

QL 480 / 30 DAYS


MORPHINE SULFATE 15 MG TABmorphine sulfate

1

QL 180 / 30 DAYS

PA




morphine sulfate 15 mg tab 1

QL 180 / 30 DAYS

PAMD 7 / 1 DAY

morphine sulfate 20 mg/5ml solution 1

QL 480 / 30 DAYS

AL1 Up to 8 yrs old


MORPHINE SULFATE 30 MG TABmorphine sulfate

1

QL 90 / 30 DAYS

PA


morphine sulfate 30 mg tab 1

QL 90 / 30 DAYS

PAMD 7 / 1 DAY

morphine sulfate er 10 mg cap er 24h 2QL 60 / 30 DAYS

PA


PA

morphine sulfate er 15 mg tab er 1QL 90 / 30 DAYS

PA


PA


PA


PA


PA

MORPHINE SULFATE ER 40 MG CAP ER 24Hmorphine sulfate

2QL 60 / 30 DAYS

PA




PA


PA


PA

MORPHINE SULFATE ER BEADS 120 MG CAP ER 24Hmorphine sulfate beads

2QL 30 / 30 DAYS

PA


2QL 60 / 30 DAYS

PA


2QL 30 / 30 DAYS

PA


2QL 60 / 30 DAYS

PA


2QL 30 / 30 DAYS

PA


2QL 30 / 30 DAYS

PA

NUCYNTA 100 MG TABtapentadol hcl

3

QL 90 / 30 day(s)

PA



3

QL 90 / 30 day(s)

PA



3

QL 90 / 30 day(s)

PA




NUCYNTA ER 100 MG TAB ER 12Htapentadol hcl

3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA

oxycodone hcl 10 mg tab 1

QL 90 / 30 DAYS


oxycodone hcl 100 mg/5ml conc 1

QL 90 / 30 day(s)



QL 90 / 30 DAYS



QL 90 / 30 DAYS



QL 90 / 30 DAYS


oxycodone hcl 5 mg cap 1

QL 240 / 30 DAYS



QL 240 / 30 DAYS




oxycodone hcl 5 mg/5ml solution 1

QL 1800 / 30 DAYS


OXYCODONE HCL ER 10 MG TB12 DETERoxycodone hcl

1

QL 60 / 30 DAYS

PA

MFL 1 / 60 DAYS


1QL 60 / 30 DAYS

PA


1

QL 60 / 30 DAYS

PA

MFL 1 / 60 DAYS


1QL 60 / 30 DAYS

PA


1

QL 60 / 30 DAYS

PA

MFL 1 / 60 DAYS


1QL 60 / 30 DAYS

PA


1

QL 60 / 30 DAYS

PA

MFL 1 / 60 DAYS

OXYCONTIN 10 MG TB12 DETERoxycodone hcl

3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA




3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA

oxymorphone hcl 10 mg tab 1

QL 90 / 30 DAYS


oxymorphone hcl 5 mg tab 1

QL 60 / 30 DAYS


OXYMORPHONE HCL ER 10 MG TAB ER 12Hoxymorphone hcl

1QL 60 / 30 DAYS

PA


1QL 60 / 30 DAYS

PA


2QL 60 / 30 DAYS

PA


2QL 60 / 30 DAYS

PA


2QL 60 / 30 DAYS

PA


1QL 60 / 30 DAYS

PA

OXYMORPHONE HCL ER 7.5 MG TAB ER 12Hoxymorphone hcl

1QL 60 / 30 DAYS

PA

SUBSYS 100 MCG LIQUIDfentanyl

4

PA


S




4

PA


S


4

PA


S


4

PA


S


4

PA


S

tramadol hcl 50 mg tab 1 QL 240 / 30 DAYS

tramadol hcl er (biphasic) 100 mg tab er 24h 1QL 30 / 30 day(s)

PA

TRAMADOL HCL ER (BIPHASIC) 100 MG TAB ER 24Htramadol hcl

1QL 30 / 30 day(s)

PA


PA


1QL 30 / 30 day(s)

PA


PA


1QL 30 / 30 day(s)

PA



TRAMADOL HCL ER 100 MG CAP ER 24Htramadol hcl

1QL 30 / 30 DAYS

PA

tramadol hcl er 100 mg tab er 24h 1QL 30 / 30 DAYS

PA


1QL 30 / 30 DAYS

PA


1QL 30 / 30 DAYS

PA


PA


PA

OPIOID COMBINATIONS

endocet 10-325 mg tab 1QL 120 / 30 DAYSMD 7 / 1 day(s)

endocet 2.5-325 mg tab 1QL 240 / 30 DAYSMD 7 / 1 day(s)

endocet 5-325 mg tab 1QL 240 / 30 DAYSMD 7 / 1 day(s)

endocet 7.5-325 mg tab 1QL 180 / 30 DAYSMD 7 / 1 day(s)

oxycodone-acetaminophen 10-325 mg tab 1

QL 120 / 30 DAYS


oxycodone-acetaminophen 2.5-325 mg tab 1

QL 240 / 30 DAYS


oxycodone-acetaminophen 5-325 mg tab 1

QL 240 / 30 DAYS




oxycodone-acetaminophen 7.5-325 mg tab 1

QL 180 / 30 DAYS


OXYCODONE-IBUPROFEN 5-400 MG TABoxycodone-ibuprofen

2QL 120 / 30 DAYSMD 7 / 1 DAY

OPIOID PARTIAL AGONISTSBUPRENORPHINE 10 MCG/HR PATCH WKbuprenorphine

1 QL 4 / 28 DAYS

buprenorphine 10 mcg/hr patch wk 1 QL 4 / 28 DAYS

BUPRENORPHINE 15 MCG/HR PATCH WKbuprenorphine

1 QL 4 / 28 DAYS



1 QL 4 / 28 DAYS



1 QL 4 / 28 DAYS


buprenorphine 7.5 mcg/hr patch wk 1 QL 4 / 28 DAYS

buprenorphine hcl 2 mg sl tab 1 QL 90 / 30 DAYS

buprenorphine hcl 8 mg sl tab 1 QL 90 / 30 DAYS

buprenorphine hcl-naloxone hcl 12-3 mg film 1 QL 60 / 30 DAYS

buprenorphine hcl-naloxone hcl 2-0.5 mg film 1

buprenorphine hcl-naloxone hcl 2-0.5 mg sl tab 1 QL 90 / 30 DAYS



buprenorphine hcl-naloxone hcl 8-2 mg sl tab 1 QL 90 / 30 DAYS

butorphanol tartrate 10 mg/ml solution 1QL 2.5 / 30 DAYSMD 7 / 1 day(s)



nalbuphine hcl 10 mg/ml solution 2 PA

SUBLOCADE 100 MG/0.5ML SOLN PRSYRbuprenorphine

3 S

SUBLOCADE 300 MG/1.5ML SOLN PRSYRbuprenorphine

3 S

TRAMADOL COMBINATIONS

tramadol-acetaminophen 37.5-325 mg tab 1 QL 120 / 30 DAYS

ANDROGENS-ANABOLICANABOLIC STEROIDS

ANADROL-50 50 MG TABoxymetholone

4PA

S

oxandrolone 2.5 mg tab 1 PA

ANDROGENSdanazol 100 mg cap 2

danazol 200 mg cap 2

danazol 50 mg cap 2

DEPO-TESTOSTERONE 100 MG/ML SOLUTIONtestosterone cypionate

2

DEPO-TESTOSTERONE 200 MG/ML SOLUTIONtestosterone cypionate

2

METHITEST 10 MG TABmethyltestosterone

2 PA

METHYLTESTOSTERONE 10 MG CAPmethyltestosterone

2 PA

testosterone 1.62 % gel 1 QL 150 / 30 DAYS

TESTOSTERONE 12.5 MG/ACT (1%) GELtestosterone

1

testosterone 12.5 mg/act (1%) gel 1

testosterone 20.25 mg/1.25gm (1.62%) gel 1 QL 37.5 / 30 DAYS

testosterone 20.25 mg/act (1.62%) gel 1 QL 150 / 30 DAYS

TESTOSTERONE 25 MG/2.5GM (1%) GELtestosterone

1



testosterone 25 mg/2.5gm (1%) gel 1

testosterone 30 mg/act solution 1 QL 180 / 30 DAYS

TESTOSTERONE 50 MG/5GM (1%) GELtestosterone

1

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

TESTOSTERONE CYPIONATE 100 MG/ML SOLUTIONtestosterone cypionate

1

testosterone cypionate 100 mg/ml solution 1

TESTOSTERONE CYPIONATE 200 MG/ML SOLUTIONtestosterone cypionate

1

testosterone cypionate 200 mg/ml solution 2

TESTOSTERONE ENANTHATE 200 MG/ML SOLUTIONtestosterone enanthate

1

testosterone enanthate 200 mg/ml solution 1

ANORECTAL AND RELATED PRODUCTSINTRARECTAL STEROIDS

colocort 100 mg/60ml enema 1

hydrocortisone 100 mg/60ml enema 1

UCERIS 2 MG/ACT FOAMbudesonide (intrarectal)

3 QL 133.6 / 30 day(s)

NITRATE VASODILATING AGENTS

RECTIV 0.4 % OINTMENTnitroglycerin (intra-anal)

3QL 30 / 30 day(s)

PA

RECTAL ANESTHETIC/STEROIDSlidocaine-hydrocort (perianal) 3-0.5 % cream 1

lidocort 3-0.5 % cream 1

RECTAL STEROIDSanucort-hc 25 mg suppos 1

anusol-hc 25 mg suppos 1

hemmorex-hc 25 mg suppos 1

hemmorex-hc 30 mg suppos 1



hydrocortisone (perianal) 2.5 % cream 1

hydrocortisone acetate 25 mg suppos 1

hydrocortisone acetate 30 mg suppos 1

procto-med hc 2.5 % cream 1

proctosol hc 2.5 % cream 1

proctozone-hc 2.5 % cream 1

ANTHELMINTICS

albendazole 200 mg tab 2QL 120 / 30 DAYS

PA

EMVERM 100 MG CHEW TABmebendazole

3QL 6 / 3 DAYS

PA

ivermectin 3 mg tab 1

QL 6 / 1 day(s)

MFL 1 / 365 day(s)MD 2 / 1 day(s)

praziquantel 600 mg tab 2

ANTI-INFECTIVE AGENTS - MISC.metronidazole 250 mg tab 1

metronidazole 375 mg cap 1

metronidazole 500 mg tab 1

pentamidine isethionate 300 mg recon soln 1

PRIMSOL 50 MG/5ML SOLUTIONtrimethoprim hcl


tinidazole 500 mg tab 1

TRIMETHOPRIM 100 MG TABtrimethoprim

1

trimethoprim 100 mg tab 1

XIFAXAN 200 MG TABrifaximin

3QL 9 / 30 DAYS

PA

XIFAXAN 550 MG TABrifaximin

3QL 90 / 30 DAYS

PA



ANTI-INFECTIVE MISC. - COMBINATIONSsulfamethoxazole-trimethoprim 200-40 mg/5mlsuspension

1

sulfamethoxazole-trimethoprim 400-80 mg tab 1

sulfamethoxazole-trimethoprim 400-80 mg/5ml solution 1

sulfamethoxazole-trimethoprim 800-160 mg tab 1

sulfatrim pediatric 200-40 mg/5ml suspension 1

ANTIPROTOZOAL AGENTSALINIA 100 MG/5ML RECON SUSPnitazoxanide

3 PA

atovaquone 750 mg/5ml suspension 2

LAMPIT 120 MG TABnifurtimox

3

LAMPIT 30 MG TABnifurtimox

3

nitazoxanide 500 mg tab 2QL 20 / 10 day(s)

PA

CARBAPENEM COMBINATIONS

imipenem-cilastatin 250 mg recon soln 1 PA

GLYCOPEPTIDES

vancomycin hcl 125 mg cap 2 QL 56 / 14 DAYS

vancomycin hcl 250 mg cap 2 QL 56 / 14 DAYS

LEPROSTATICSdapsone 100 mg tab 1

dapsone 25 mg tab 1

LINCOSAMIDESclindamycin hcl 150 mg cap 1

clindamycin hcl 300 mg cap 1

clindamycin hcl 75 mg cap 1

clindamycin palmitate hcl 75 mg/5ml recon soln 1



MONOBACTAMS

CAYSTON 75 MG RECON SOLNaztreonam lysine

4PA

S

OXAZOLIDINONES

linezolid 600 mg tab 1 QL 56 / 28 DAYS

SIVEXTRO 200 MG TABtedizolid phosphate

4PA

S

URINARY ANTI-INFECTIVESfosfomycin tromethamine 3 gm packet 2

methenamine hippurate 1 gm tab 1

nitrofurantoin 25 mg/5ml suspension 1 AL1 Up to 8 yrs old

nitrofurantoin macrocrystal 100 mg cap 1



nitrofurantoin monohyd macro 100 mg cap 1

ANTIANGINAL AGENTSANTIANGINALS-OTHER

ranolazine er 1000 mg tab er 12h 1 QL 60 / 30 DAYS

ranolazine er 500 mg tab er 12h 1 QL 60 / 30 DAYS

NITRATESDILATRATE-SR 40 MG CAP ERisosorbide dinitrate

3 PA

isosorbide dinitrate 10 mg tab 1




ISOSORBIDE DINITRATE ER 40 MG TAB ERisosorbide dinitrate

1

isosorbide mononitrate 10 mg tab 1



isosorbide mononitrate 20 mg tab 1

isosorbide mononitrate er 120 mg tab er 24h 1



minitran 0.1 mg/hr patch 24hr 1




NITRO-BID 2 % OINTMENTnitroglycerin

2

nitroglycerin 0.1 mg/hr patch 24hr 1


nitroglycerin 0.3 mg sl tab 1

nitroglycerin 0.4 mg sl tab 1 QL 30 / 30 DAYS


nitroglycerin 0.4 mg/spray solution 1

nitroglycerin 0.6 mg sl tab 1 QL 30 / 30 DAYS


NITROGLYCERIN 400 MCG/SPRAY AERO SOLNnitroglycerin

1

nitroglycerin er 2.5 mg cap er 1

nitroglycerin er 6.5 mg cap er 1

nitroglycerin er 9 mg cap er 1

ANTIANXIETY AGENTSANTIANXIETY AGENTS - MISC.

buspirone hcl 10 mg tab 1






buspirone hcl 7.5 mg tab 1

hydroxyzine hcl 10 mg tab 1

hydroxyzine hcl 10 mg/5ml syrup 1



HYDROXYZINE PAMOATE 100 MG CAPhydroxyzine pamoate

1

hydroxyzine pamoate 25 mg cap 1

hydroxyzine pamoate 50 mg cap 1

meprobamate 200 mg tab 2

meprobamate 400 mg tab 2

BENZODIAZEPINES

alprazolam 0.25 mg tab 1 QL 90 / 30 DAYS

alprazolam 0.25 mg tab disp 1 QL 90 / 30 DAYS

alprazolam 0.5 mg tab 1 QL 5 / 1 day(s)

alprazolam 0.5 mg tab disp 1 QL 90 / 30 DAYS

alprazolam 1 mg tab 1 QL 5 / 1 day(s)

alprazolam 1 mg tab disp 1 QL 90 / 30 DAYS

alprazolam 2 mg tab 1 QL 90 / 30 DAYS

alprazolam 2 mg tab disp 1 QL 90 / 30 DAYS

alprazolam er 0.5 mg tab er 24h 1 QL 90 / 30 DAYS

alprazolam er 1 mg tab er 24h 1 QL 90 / 30 DAYS



ALPRAZOLAM INTENSOL 1 MG/ML CONCalprazolam


alprazolam xr 0.5 mg tab er 24h 1 QL 90 / 30 DAYS



alprazolam xr 1 mg tab er 24h 1 QL 90 / 30 DAYS



chlordiazepoxide hcl 10 mg cap 1



clorazepate dipotassium 15 mg tab 1

clorazepate dipotassium 3.75 mg tab 1

clorazepate dipotassium 7.5 mg tab 1

diazepam 10 mg tab 1 QL 60 / 30 DAYS



diazepam 5 mg/5ml solution 1QL 500 / 30 day(s)

AL1 Up to 8 yrs old

diazepam 5 mg/ml conc 1QL 90 / 30 DAYS

AL1 Up to 8 yrs old

diazepam intensol 5 mg/ml conc 1QL 90 / 30 DAYS

AL1 Up to 8 yrs old

lorazepam 0.5 mg tab 1 QL 5 / 1 day(s)

lorazepam 1 mg tab 1 QL 5 / 1 day(s)

lorazepam 2 mg tab 1 QL 90 / 30 DAYS

lorazepam 2 mg/ml conc 1

lorazepam intensol 2 mg/ml conc 1

oxazepam 10 mg cap 1 QL 90 / 30 day(s)





ANTIARRHYTHMICSANTIARRHYTHMICS TYPE I-A

disopyramide phosphate 100 mg cap 1

disopyramide phosphate 150 mg cap 1

NORPACE CR 100 MG CAP ER 12Hdisopyramide phosphate

3

NORPACE CR 150 MG CAP ER 12Hdisopyramide phosphate

3

quinidine gluconate er 324 mg tab er 1

quinidine sulfate 200 mg tab 1

quinidine sulfate 300 mg tab 1

ANTIARRHYTHMICS TYPE I-Bmexiletine hcl 150 mg cap 1

mexiletine hcl 200 mg cap 1

mexiletine hcl 250 mg cap 1

ANTIARRHYTHMICS TYPE I-Cflecainide acetate 100 mg tab 1

flecainide acetate 150 mg tab 1

flecainide acetate 50 mg tab 1

propafenone hcl 150 mg tab 1



propafenone hcl er 225 mg cap er 12h 1



ANTIARRHYTHMICS TYPE IIIamiodarone hcl 100 mg tab 1

amiodarone hcl 200 mg tab 1

amiodarone hcl 400 mg tab 1

dofetilide 125 mcg cap 2





MULTAQ 400 MG TABdronedarone hcl

3 QL 60 / 30 DAYS

pacerone 100 mg tab 1



ANTIASTHMATIC AND BRONCHODILATOR AGENTS5-LIPOXYGENASE INHIBITORS

zileuton er 600 mg tab er 12h 4PA

S

ADRENERGIC COMBINATIONSANORO ELLIPTA 62.5-25 MCG/INH AER POW BAumeclidinium-vilanterol

2 QL 60 / 30 DAYS

BREO ELLIPTA 100-25 MCG/INH AER POW BAfluticasone furoate-vilanterol

3QL 60 / 30 DAYS

ST

BREO ELLIPTA 200-25 MCG/INH AER POW BAfluticasone furoate-vilanterol

3QL 60 / 30 DAYS

ST

BREZTRI AEROSPHERE 160-9-4.8 MCG/ACT AEROSOLbudesonide-glycopyrrolate-formoterol fumarate

3 PA

COMBIVENT RESPIMAT 20-100 MCG/ACT AERO SOLNipratropium-albuterol

2 QL 4 / 30 DAYS

DULERA 100-5 MCG/ACT AEROSOLmometasone furoate-formoterol fumarate dihydrate

2 QL 13 / 30 day(s)


2 QL 13 / 30 day(s)


2 QL 13 / 30 day(s)

fluticasone-salmeterol 100-50 mcg/dose aer pow ba 2 QL 60 / 30 day(s)

FLUTICASONE-SALMETEROL 113-14 MCG/ACT AER POWBAfluticasone-salmeterol

1 QL 1 / 30 DAYS

FLUTICASONE-SALMETEROL 232-14 MCG/ACT AER POWBAfluticasone-salmeterol

1 QL 1 / 30 DAYS





FLUTICASONE-SALMETEROL 55-14 MCG/ACT AER POW BAfluticasone-salmeterol

1 QL 1 / 30 DAYS

ipratropium-albuterol 0.5-2.5 (3) mg/3ml solution 1

STIOLTO RESPIMAT 2.5-2.5 MCG/ACT AERO SOLNtiotropium bromide-olodaterol hcl

2 QL 4 / 30 day(s)

SYMBICORT 160-4.5 MCG/ACT AEROSOLbudesonide-formoterol fumarate dihydrate

2 QL 6 / 30 DAYS

SYMBICORT 80-4.5 MCG/ACT AEROSOLbudesonide-formoterol fumarate dihydrate

2 QL 6.9 / 30 DAYS

TRELEGY ELLIPTA 100-62.5-25 MCG/INH AER POW BAfluticasone-umeclidinium-vilanterol

2 QL 2 / 1 day(s)

TRELEGY ELLIPTA 200-62.5-25 MCG/INH AER POW BAfluticasone-umeclidinium-vilanterol

2 QL 2 / 1 day(s)

wixela inhub 100-50 mcg/dose aer pow ba 2 QL 60 / 30 day(s)



ANTI-IGE MONOCLONAL ANTIBODIES

XOLAIR 150 MG RECON SOLNomalizumab

4PA

S

XOLAIR 150 MG/ML SOLN PRSYRomalizumab

4PA

S

XOLAIR 75 MG/0.5ML SOLN PRSYRomalizumab

4PA

S

ANTI-INFLAMMATORY AGENTS

cromolyn sodium 20 mg/2ml nebu soln 1 QL 240 / 30 DAYS

BETA ADRENERGICS

albuterol sulfate (2.5 mg/3ml) 0.083% nebu soln 1 QL 360 / 30 DAYS

albuterol sulfate (5 mg/ml) 0.5% nebu soln 1



albuterol sulfate 0.63 mg/3ml nebu soln 1 QL 360 / 30 DAYS

albuterol sulfate 1.25 mg/3ml nebu soln 1 QL 360 / 30 DAYS

albuterol sulfate 2 mg tab 1

albuterol sulfate 2 mg/5ml syrup 1

albuterol sulfate 2.5 mg/0.5ml nebu soln 1

albuterol sulfate 4 mg tab 1

ALBUTEROL SULFATE ER 4 MG TAB ER 12Halbuterol sulfate

1

ALBUTEROL SULFATE ER 8 MG TAB ER 12Halbuterol sulfate

1

albuterol sulfate hfa 108 (90 base) mcg/act aero soln 1 QL 18 / 15 DAYS

ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT AEROSOLNalbuterol sulfate

1 QL 18 / 15 DAYS

ARCAPTA NEOHALER 75 MCG CAPindacaterol maleate

3 QL 30 / 30 DAYS

levalbuterol hcl 0.31 mg/3ml nebu soln 1 QL 270 / 30 DAYS

levalbuterol hcl 0.63 mg/3ml nebu soln 1 QL 270 / 30 day(s)

levalbuterol hcl 1.25 mg/0.5ml nebu soln 1

levalbuterol hcl 1.25 mg/3ml nebu soln 1 QL 270 / 30 DAYS

LEVALBUTEROL TARTRATE 45 MCG/ACT AEROSOLlevalbuterol tartrate

1 QL 30 / 30 DAYS

METAPROTERENOL SULFATE 10 MG TABmetaproterenol sulfate

1

METAPROTERENOL SULFATE 10 MG/5ML SYRUPmetaproterenol sulfate


METAPROTERENOL SULFATE 20 MG TABmetaproterenol sulfate

1

SEREVENT DISKUS 50 MCG/DOSE AER POW BAsalmeterol xinafoate

2 QL 60 / 30 DAYS

STRIVERDI RESPIMAT 2.5 MCG/ACT AERO SOLNolodaterol hcl

3 QL 4 / 30 DAYS



terbutaline sulfate 2.5 mg tab 1

terbutaline sulfate 5 mg tab 1

BRONCHODILATORS - ANTICHOLINERGICSATROVENT HFA 17 MCG/ACT AERO SOLNipratropium bromide hfa

2 QL 25.8 / 28 DAYS

INCRUSE ELLIPTA 62.5 MCG/INH AER POW BAumeclidinium bromide

2 QL 30 / 30 DAYS

ipratropium bromide 0.02 % solution 1

SPIRIVA HANDIHALER 18 MCG CAPtiotropium bromide monohydrate

2 QL 90 / DAYS

SPIRIVA RESPIMAT 1.25 MCG/ACT AERO SOLNtiotropium bromide monohydrate

2 QL 4 / 30 DAYS

SPIRIVA RESPIMAT 2.5 MCG/ACT AERO SOLNtiotropium bromide monohydrate

2 QL 4 / 30 DAYS

YUPELRI 175 MCG/3ML SOLUTIONrevefenacin

3QL 90 / 30 DAYS

PA

INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)

FASENRA 30 MG/ML SOLN PRSYRbenralizumab

4PA

S

FASENRA PEN 30 MG/ML SOLN A-INJbenralizumab

4PA

S

NUCALA 100 MG RECON SOLNmepolizumab

4PA

S

NUCALA 100 MG/ML SOLN A-INJmepolizumab

4PA

S

NUCALA 100 MG/ML SOLN PRSYRmepolizumab

4PA

S

LEUKOTRIENE RECEPTOR ANTAGONISTS

montelukast sodium 10 mg tab 1 QL 30 / 30 DAYS

montelukast sodium 4 mg chew tab 1 QL 30 / 30 DAYS

montelukast sodium 4 mg packet 1QL 30 / 30 DAYS

AL1 Up to 4 yrs old



montelukast sodium 5 mg chew tab 1 QL 30 / 30 DAYS

zafirlukast 10 mg tab 1 QL 60 / 30 DAYS

zafirlukast 20 mg tab 1 QL 60 / 30 DAYS

SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS

DALIRESP 250 MCG TABroflumilast

3QL 30 / 30 day(s)

PA

DALIRESP 500 MCG TABroflumilast

3QL 30 / 30 DAYS

PA

STEROID INHALANTSARNUITY ELLIPTA 100 MCG/ACT AER POW BAfluticasone furoate (inhalation)

2 QL 1 / 1 day(s)

ARNUITY ELLIPTA 200 MCG/ACT AER POW BAfluticasone furoate (inhalation)

2 QL 1 / 1 day(s)

ARNUITY ELLIPTA 50 MCG/ACT AER POW BAfluticasone furoate (inhalation)

2 QL 1 / 1 day(s)

ASMANEX (120 METERED DOSES) 220 MCG/INH AER POWBAmometasone furoate (inhalation)

3QL 1 / 30 day(s)

ST


3QL 1 / 30 day(s)

ST


3QL 1 / 30 day(s)

ST


3QL 1 / 30 day(s)

ST


3QL 1 / 30 day(s)

ST


3QL 1 / 30 day(s)

ST

ASMANEX HFA 100 MCG/ACT AEROSOLmometasone furoate (inhalation)

3QL 13 / 30 day(s)

ST




3QL 13 / 30 day(s)

ST


3QL 13 / 30 day(s)

ST

budesonide 0.25 mg/2ml suspension 1 QL 120 / 30 DAYS

budesonide 0.5 mg/2ml suspension 1 QL 120 / 30 DAYS

budesonide 1 mg/2ml suspension 1

FLOVENT DISKUS 100 MCG/BLIST AER POW BAfluticasone propionate (inhalation)

2 QL 60 / 30 DAYS


2 QL 60 / 30 DAYS


2 QL 60 / 30 DAYS

FLOVENT HFA 110 MCG/ACT AEROSOLfluticasone propionate hfa

2 QL 12 / 30 DAYS


2 QL 12 / 30 DAYS


2 QL 10.6 / 30 DAYS

PULMICORT FLEXHALER 180 MCG/ACT AER POW BAbudesonide (inhalation)

2 QL 2 / 30 DAYS

PULMICORT FLEXHALER 90 MCG/ACT AER POW BAbudesonide (inhalation)

2 QL 2 / 30 DAYS

QVAR 40 MCG/ACT AERO SOLNbeclomethasone dipropionate

2 QL 34.8 / 30 DAYS

QVAR 80 MCG/ACT AERO SOLNbeclomethasone dipropionate

2 QL 18 / 30 DAYS

QVAR REDIHALER 40 MCG/ACT AERO BAbeclomethasone dipropionate hfa

2 QL 10.6 / 30 DAYS

QVAR REDIHALER 80 MCG/ACT AERO BAbeclomethasone dipropionate hfa

2 QL 10.6 / 30 DAYS

XANTHINESELIXOPHYLLIN 80 MG/15ML ELIXIRtheophylline


THEO-24 100 MG CAP ER 24Htheophylline

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSTHEO-24 200 MG CAP ER 24Htheophylline

2


2


2

theophylline 80 mg/15ml solution 1 AL1 Up to 8 yrs old

theophylline er 100 mg tab er 12h 1



THEOPHYLLINE ER 300 MG TAB ER 12Htheophylline

1



THEOPHYLLINE ER 450 MG TAB ER 12Htheophylline

1


ANTICOAGULANTSCOUMARIN ANTICOAGULANTS

jantoven 1 mg tab 1

jantoven 10 mg tab 1

jantoven 2 mg tab 1

jantoven 2.5 mg tab 1

jantoven 3 mg tab 1

jantoven 4 mg tab 1

jantoven 5 mg tab 1

jantoven 6 mg tab 1

jantoven 7.5 mg tab 1

warfarin sodium 1 mg tab 1





warfarin sodium 2.5 mg tab 1





warfarin sodium 7.5 mg tab 1

DIRECT FACTOR XA INHIBITORSELIQUIS 2.5 MG TABapixaban

2 QL 2 / 1 day(s)

ELIQUIS 5 MG TABapixaban

2 QL 2.5 / 1 day(s)

ELIQUIS DVT/PE STARTER PACK 5 MG TAB THPKapixaban

2 QL 2.5 / 1 day(s)

SAVAYSA 15 MG TABedoxaban tosylate

3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST

XARELTO 1 MG/ML RECON SUSPrivaroxaban


XARELTO 10 MG TABrivaroxaban

2 QL 30 / 30 DAYS


2 QL 42 / 30 day(s)

XARELTO 2.5 MG TABrivaroxaban

2 QL 60 / 30 DAYS


2 QL 30 / 30 DAYS

XARELTO STARTER PACK 15 & 20 MG TAB THPKrivaroxaban

2 QL 51 / 30 DAYS



HEPARINS AND HEPARINOID-LIKE AGENTSheparin lock flush 10 unit/ml solution 1

heparin sodium (porcine) 1000 unit/ml solution 1



heparin sodium (porcine) pf 5000 unit/0.5ml solution 1

heparin sodium lock flush 100 unit/ml solution 1

LOW MOLECULAR WEIGHT HEPARINS

enoxaparin sodium 100 mg/ml solution 2 QL 2 / 1 day(s)

enoxaparin sodium 120 mg/0.8ml solution 2 QL 1.6 / 1 day(s)

enoxaparin sodium 150 mg/ml solution 2 QL 2 / 1 day(s)


enoxaparin sodium 300 mg/3ml solution 2 QL 3 / 1 day(s)






FRAGMIN 10000 UNIT/ML SOLUTIONdalteparin sodium

3 QL 2 / 1 day(s)

FRAGMIN 12500 UNIT/0.5ML SOLUTIONdalteparin sodium

3 QL 1 / 1 day(s)


3 QL 1.2 / 1 day(s)

FRAGMIN 18000 UNT/0.72ML SOLUTIONdalteparin sodium

3 QL 1.44 / 1 day(s)


3 QL 0.4 / 1 day(s)


3 QL 0.4 / 1 day(s)


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSFRAGMIN 7500 UNIT/0.3ML SOLUTIONdalteparin sodium

3 QL 0.6 / 1 day(s)


3 QL 7.6 / 1 day(s)

SYNTHETIC HEPARINOID-LIKE AGENTS

fondaparinux sodium 10 mg/0.8ml solution 2 QL 0.8 / 1 day(s)

fondaparinux sodium 2.5 mg/0.5ml solution 2 QL 0.5 / 1 day(s)

fondaparinux sodium 5 mg/0.4ml solution 2 QL 0.4 / 1 day(s)

fondaparinux sodium 7.5 mg/0.6ml solution 2 QL 0.6 / 1 day(s)

THROMBIN INHIBITORS - SELECTIVE DIRECT & REVERSIBLEPRADAXA 110 MG CAPdabigatran etexilate mesylate

2 QL 60 / 30 DAYS

PRADAXA 150 MG CAPdabigatran etexilate mesylate

2 QL 60 / 30 DAYS

PRADAXA 75 MG CAPdabigatran etexilate mesylate

2 QL 60 / 30 DAYS

ANTICONVULSANTSAMPA GLUTAMATE RECEPTOR ANTAGONISTS

FYCOMPA 0.5 MG/ML SUSPENSIONperampanel

3QL 30 / 30 day(s)

ST

FYCOMPA 10 MG TABperampanel

3QL 30 / 30 day(s)

ST


3QL 30 / 30 day(s)

ST


3QL 30 / 30 day(s)

ST


3QL 30 / 30 day(s)

ST


3QL 30 / 30 day(s)

ST


3QL 30 / 30 day(s)

ST



ANTICONVULSANTS - BENZODIAZEPINESclobazam 10 mg tab 1

clobazam 2.5 mg/ml suspension 1

clobazam 20 mg tab 1

clonazepam 0.125 mg tab disp 1


clonazepam 0.5 mg tab 1 QL 90 / 30 DAYS


clonazepam 1 mg tab 1 QL 90 / 30 DAYS

clonazepam 1 mg tab disp 1 QL 90 / 30 DAYS

clonazepam 2 mg tab 1 QL 90 / 30 DAYS

clonazepam 2 mg tab disp 1

NAYZILAM 5 MG/0.1ML SOLUTIONmidazolam (anticonvulsant)

3 PA

ONFI 10 MG TABclobazam

3

ONFI 20 MG TABclobazam

3

VALTOCO 10 MG DOSE 10 MG/0.1ML LIQUIDdiazepam (anticonvulsant)

3 PA

VALTOCO 15 MG DOSE 7.5 MG/0.1ML LIQD THPKdiazepam (anticonvulsant)

3 PA

VALTOCO 20 MG DOSE 10 MG/0.1ML LIQD THPKdiazepam (anticonvulsant)

3 PA

VALTOCO 5 MG DOSE 5 MG/0.1ML LIQUIDdiazepam (anticonvulsant)

3 PA

ANTICONVULSANTS - MISC.BRIVIACT 10 MG TABbrivaracetam

3 ST

BRIVIACT 10 MG/ML SOLUTIONbrivaracetam

3 ST

BRIVIACT 100 MG TABbrivaracetam

3 ST


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSBRIVIACT 25 MG TABbrivaracetam

3 ST


3 ST


3 ST

carbamazepine 100 mg chew tab 1

carbamazepine 100 mg/5ml suspension 1

carbamazepine 200 mg tab 1

carbamazepine er 100 mg cap er 12h 1

carbamazepine er 100 mg tab er 12h 1





EPIDIOLEX 100 MG/ML SOLUTIONcannabidiol

4PA

S

epitol 200 mg tab 1

EPRONTIA 25 MG/ML SOLUTIONtopiramate

2QL 16 / 1 day(s)

AL1 Up to 8 yrs old

gabapentin 100 mg cap 1

gabapentin 250 mg/5ml solution 1


gabapentin 300 mg/6ml solution 1


gabapentin 600 mg tab 1

gabapentin 800 mg tab 1

lamotrigine 100 mg tab 1





lamotrigine 25 mg chew tab 1


lamotrigine 5 mg chew tab 1

lamotrigine er 100 mg tab er 24h 1 QL 30 / 30 DAYS






lamotrigine starter kit-blue 35 x 25 mg kit 1

lamotrigine starter kit-green 84 x 25 mg & 14x100 mg kit 1

lamotrigine starter kit-orange 42 x 25 mg & 7 x 100 mg kit 1

levetiracetam 100 mg/ml solution 1

levetiracetam 1000 mg tab 1




levetiracetam er 500 mg tab er 24h 1 QL 180 / 30 DAYS

levetiracetam er 750 mg tab er 24h 1 QL 120 / 30 DAYS

LYRICA 20 MG/ML SOLUTIONpregabalin

3QL 900 / 30 DAYS

PA

oxcarbazepine 150 mg tab 1


oxcarbazepine 300 mg/5ml suspension 1


pregabalin 100 mg cap 1 QL 120 / 30 DAYS




pregabalin 20 mg/ml solution 1 QL 900 / 30 day(s)







primidone 250 mg tab 1

primidone 50 mg tab 1

roweepra 1000 mg tab 1



roweepra xr 500 mg tab er 24h 1 QL 180 / 30 DAYS

roweepra xr 750 mg tab er 24h 1 QL 120 / 30 DAYS

rufinamide 200 mg tab 2QL 240 / 30 day(s)

PA

rufinamide 40 mg/ml suspension 2 PA

rufinamide 400 mg tab 2QL 240 / 30 day(s)

PA

subvenite 100 mg tab 1




TEGRETOL 100 MG/5ML SUSPENSIONcarbamazepine

3 PA

TEGRETOL 200 MG TABcarbamazepine

3 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSTEGRETOL-XR 100 MG TAB ER 12Hcarbamazepine

3 PA

TEGRETOL-XR 200 MG TAB ER 12Hcarbamazepine

3 PA

TEGRETOL-XR 400 MG TAB ER 12Hcarbamazepine

3 PA

topiramate 100 mg tab 1 QL 120 / 30 DAYS

topiramate 15 mg cap sprink 1 QL 375 / 30 DAYS


topiramate 25 mg cap sprink 1 QL 480 / 30 DAYS



topiramate er 100 mg cp24 sprnk 2QL 120 / 30 DAYS

PA


PA


PA


PA


PA

VIMPAT 10 MG/ML SOLUTIONlacosamide

3QL 1200 / 30 DAYS

ST

VIMPAT 100 MG TABlacosamide

3QL 60 / 30 DAYS

ST


3QL 60 / 30 DAYS

ST


3QL 60 / 30 DAYS

ST




3QL 60 / 30 DAYS

ST

zonisamide 100 mg cap 1



CARBAMATESfelbamate 400 mg tab 2

felbamate 600 mg tab 2

felbamate 600 mg/5ml suspension 2

XCOPRI (250 MG DAILY DOSE) 100 & 150 MG TAB THPKcenobamate

3QL 1 / 1 day(s)

ST


3QL 1 / 1 day(s)

ST


3QL 1 / 1 day(s)

ST

XCOPRI 100 MG TABcenobamate

3QL 1 / 1 day(s)

ST

XCOPRI 14 X 12.5 MG & 14 X 25 MG TAB THPKcenobamate

3QL 1 / 1 day(s)

ST

XCOPRI 14 X 150 MG & 14 X200 MG TAB THPKcenobamate

3QL 1 / 1 day(s)

ST

XCOPRI 14 X 50 MG & 14 X100 MG TAB THPKcenobamate

3QL 1 / 1 day(s)

ST


3QL 1 / 1 day(s)

ST


3QL 1 / 1 day(s)

ST


3QL 1 / 1 day(s)

ST



GABA MODULATORStiagabine hcl 12 mg tab 1

tiagabine hcl 16 mg tab 1



vigabatrin 500 mg packet 2QL 180 / 30 DAYS

PA

vigabatrin 500 mg tab 2QL 180 / 30 DAYS

PA

HYDANTOINSDILANTIN 30 MG CAPphenytoin sodium extended

3

PEGANONE 250 MG TABethotoin

3

phenytoin 100 mg/4ml suspension 1

phenytoin 125 mg/5ml suspension 1

phenytoin 50 mg chew tab 1

phenytoin infatabs 50 mg chew tab 1

phenytoin sodium extended 100 mg cap 1



SUCCINIMIDESCELONTIN 300 MG CAPmethsuximide

3

ethosuximide 250 mg cap 1

ethosuximide 250 mg/5ml solution 1

VALPROIC ACIDdivalproex sodium 125 mg cap dr 1

divalproex sodium 125 mg tab dr 1





divalproex sodium er 250 mg tab er 24h 1

divalproex sodium er 500 mg tab er 24h 1

valproate sodium 250 mg/5ml solution 1

valproic acid 250 mg cap 1

valproic acid 250 mg/5ml solution 1

ANTIDEPRESSANTSALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)

mirtazapine 15 mg tab 1 QL 30 / 30 DAYS

mirtazapine 15 mg tab disp 1 QL 30 / 30 DAYS





mirtazapine 7.5 mg tab 1 QL 30 / 30 DAYS

ANTIDEPRESSANTS - MISC.

APLENZIN 174 MG TAB ER 24Hbupropion hydrobromide

3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST

bupropion hcl 100 mg tab 1 QL 60 / 30 DAYS

bupropion hcl 75 mg tab 1 QL 180 / 30 DAYS

bupropion hcl er (sr) 100 mg tab er 12h 1 QL 60 / 30 DAYS





bupropion hcl er (xl) 150 mg tab er 24h 1 QL 90 / 30 DAYS

bupropion hcl er (xl) 300 mg tab er 24h 1 QL 60 / 30 DAYS

BUPROPION HCL ER (XL) 450 MG TAB ER 24Hbupropion hcl

3QL 30 / 30 DAYS

ST

FORFIVO XL 450 MG TAB ER 24Hbupropion hcl

3QL 30 / 30 DAYS

ST

MAPROTILINE HCL 25 MG TABmaprotiline hcl

2 QL 270 / 30 DAYS


2 QL 135 / 30 DAYS


2

MONOAMINE OXIDASE INHIBITORS (MAOIS)EMSAM 12 MG/24HR PATCH 24HRselegiline

3 ST

EMSAM 6 MG/24HR PATCH 24HRselegiline

3 ST

EMSAM 9 MG/24HR PATCH 24HRselegiline

3 ST

MARPLAN 10 MG TABisocarboxazid

3

phenelzine sulfate 15 mg tab 1

tranylcypromine sulfate 10 mg tab 2

N-METHYL-D-ASPARTIC ACID (NMDA) RECEPTOR ANTAGONISTS

SPRAVATO (56 MG DOSE) 28 MG/DEVICE SOLN THPKesketamine hcl

3QL 16 / 28 DAYS

PA

SPRAVATO (84 MG DOSE) 28 MG/DEVICE SOLN THPKesketamine hcl

3QL 16 / 28 DAYS

PA

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)

citalopram hydrobromide 10 mg tab 1 QL 30 / 30 DAYS

citalopram hydrobromide 10 mg/5ml solution 1 QL 600 / 30 DAYS





escitalopram oxalate 10 mg tab 1 QL 60 / 30 DAYS



escitalopram oxalate 5 mg/5ml solution 1 QL 620 / 30 DAYS

fluoxetine hcl 10 mg cap 1 QL 90 / 30 DAYS

fluoxetine hcl 10 mg tab 1 QL 90 / 30 DAYS



fluoxetine hcl 20 mg/5ml solution 1 QL 600 / 30 DAYS


FLUOXETINE HCL 60 MG TABfluoxetine hcl

2 QL 30 / 30 DAYS


FLUOXETINE HCL 90 MG CAP DRfluoxetine hcl

1 QL 4 / 28 DAYS

fluvoxamine maleate 100 mg tab 1 QL 90 / 30 DAYS



paroxetine hcl 10 mg tab 1 QL 90 / 30 DAYS




paroxetine hcl er 12.5 mg tab er 24h 1 QL 60 / 30 DAYS



paroxetine hcl er 25 mg tab er 24h 1 QL 60 / 30 DAYS

paroxetine hcl er 37.5 mg tab er 24h 1 QL 60 / 30 DAYS

sertraline hcl 100 mg tab 1 QL 60 / 30 DAYS

sertraline hcl 20 mg/ml conc 1 QL 300 / 30 DAYS



SEROTONIN MODULATORSNEFAZODONE HCL 100 MG TABnefazodone hcl

1 QL 180 / 30 DAYS

NEFAZODONE HCL 150 MG TABnefazodone hcl

1 QL 120 / 30 DAYS


1 QL 90 / 30 DAYS


1 QL 72 / 30 DAYS

nefazodone hcl 250 mg tab 1 QL 72 / 30 DAYS


1 QL 360 / 30 DAYS

nefazodone hcl 50 mg tab 1 QL 360 / 30 DAYS

trazodone hcl 100 mg tab 1




TRINTELLIX 10 MG TABvortioxetine hbr

3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST



VIIBRYD 10 MG TABvilazodone hcl

3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST

VIIBRYD STARTER PACK 10 & 20 MG KITvilazodone hcl

3QL 30 / 30 DAYS

ST

SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)DESVENLAFAXINE ER 100 MG TAB ER 24Hdesvenlafaxine

1 QL 30 / 30 DAYS

DESVENLAFAXINE ER 50 MG TAB ER 24Hdesvenlafaxine

1 QL 30 / 30 DAYS

desvenlafaxine succinate er 100 mg tab er 24h 1 QL 30 / 30 DAYS



duloxetine hcl 20 mg cp dr part 1 QL 180 / 30 DAYS



FETZIMA 120 MG CAP ER 24Hlevomilnacipran hcl

3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST

venlafaxine hcl 100 mg tab 1 QL 30 / 30 DAYS




venlafaxine hcl 37.5 mg tab 1 QL 90 / 30 DAYS



venlafaxine hcl er 150 mg cap er 24h 1 QL 60 / 30 DAYS

venlafaxine hcl er 37.5 mg cap er 24h 1

venlafaxine hcl er 75 mg cap er 24h 1

TRICYCLIC AGENTSamitriptyline hcl 10 mg tab 1

amitriptyline hcl 100 mg tab 1





AMOXAPINE 100 MG TABamoxapine

2


2


2


2

clomipramine hcl 25 mg cap 1



desipramine hcl 10 mg tab 1








doxepin hcl 10 mg cap 1

doxepin hcl 10 mg/ml conc 1 AL1 Up to 8 yrs old


DOXEPIN HCL 150 MG CAPdoxepin hcl

1




imipramine hcl 10 mg tab 1



imipramine pamoate 100 mg cap 1




nortriptyline hcl 10 mg cap 1

NORTRIPTYLINE HCL 10 MG/5ML SOLUTIONnortriptyline hcl

1

nortriptyline hcl 10 mg/5ml solution 1




protriptyline hcl 10 mg tab 1

protriptyline hcl 5 mg tab 1

trimipramine maleate 100 mg cap 2





ANTIDIABETICSALPHA-GLUCOSIDASE INHIBITORS

acarbose 100 mg tab 1 QL 90 / 30 DAYS



miglitol 100 mg tab 1



ANTIDIABETIC - AMYLIN ANALOGS

SYMLINPEN 120 2700 MCG/2.7ML SOLN PENpramlintide acetate

3QL 10 / 30 DAYS

PA

SYMLINPEN 60 1500 MCG/1.5ML SOLN PENpramlintide acetate

3QL 10 / 30 DAYS

PA

BIGUANIDES

metformin hcl 1000 mg tab 1 QL 90 / 30 DAYS


metformin hcl 500 mg/5ml solution 2PA

AL1 0 to 8 yrs old


metformin hcl er 500 mg tab er 24h 1 QL 150 / 30 DAYS

metformin hcl er 750 mg tab er 24h 1 QL 90 / 30 DAYS

DIABETIC OTHERBAQSIMI ONE PACK 3 MG/DOSE POWDERglucagon

2 QL 2 / 60 day(s)

BAQSIMI TWO PACK 3 MG/DOSE POWDERglucagon

2 QL 2 / 60 day(s)

GLUCAGEN HYPOKIT 1 MG RECON SOLNglucagon hcl (rdna)

2 QL 2 / 60 day(s)

glucagon emergency 1 mg kit 2 QL 2 / 60 day(s)


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSGLUCAGON EMERGENCY 1 MG KITglucagon (rdna)

2 QL 2 / 60 day(s)

GVOKE HYPOPEN 1-PACK 0.5 MG/0.1ML SOLN A-INJglucagon

2 QL 0.2 / 60 day(s)

GVOKE HYPOPEN 1-PACK 1 MG/0.2ML SOLN A-INJglucagon

2 QL 0.4 / 60 day(s)

GVOKE HYPOPEN 2-PACK 0.5 MG/0.1ML SOLN A-INJglucagon

2 QL 0.2 / 60 day(s)

GVOKE HYPOPEN 2-PACK 1 MG/0.2ML SOLN A-INJglucagon

2 QL 0.4 / 60 day(s)

GVOKE KIT 1 MG/0.2ML SOLUTIONglucagon

2 QL 2 / 60 day(s)

GVOKE PFS 0.5 MG/0.1ML SOLN PRSYRglucagon

2 QL 0.2 / 60 day(s)

GVOKE PFS 1 MG/0.2ML SOLN PRSYRglucagon

2 QL 0.4 / 60 day(s)

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS

ALOGLIPTIN BENZOATE 12.5 MG TABalogliptin benzoate

3QL 30 / 30 DAYS

ST

ALOGLIPTIN BENZOATE 25 MG TABalogliptin benzoate

3QL 30 / 30 DAYS

ST

ALOGLIPTIN BENZOATE 6.25 MG TABalogliptin benzoate

3QL 30 / 30 DAYS

ST

JANUVIA 100 MG TABsitagliptin phosphate

2QL 1 / 1 day(s)

ST


2QL 1 / 1 day(s)

ST


2QL 1 / 1 day(s)

ST

TRADJENTA 5 MG TABlinagliptin

2QL 1 / 1 day(s)

ST



DIPEPTIDYL PEPTIDASE-4 INHIBITOR-BIGUANIDE COMBINATIONS

JANUMET 50-1000 MG TABsitagliptin-metformin hcl

2QL 2 / 1 day(s)

ST

JANUMET 50-500 MG TABsitagliptin-metformin hcl

2QL 2 / 1 day(s)

ST

JANUMET XR 100-1000 MG TAB ER 24Hsitagliptin-metformin hcl

2QL 1 / 1 day(s)

ST


2QL 2 / 1 day(s)

ST


2QL 30 / 30 DAYS

ST

JENTADUETO 2.5-1000 MG TABlinagliptin-metformin hcl

2QL 2 / 1 day(s)

ST


2QL 2 / 1 day(s)

ST


2QL 2 / 1 day(s)

ST

JENTADUETO XR 2.5-1000 MG TAB ER 24Hlinagliptin-metformin hcl

2QL 2 / 1 day(s)

ST

JENTADUETO XR 5-1000 MG TAB ER 24Hlinagliptin-metformin hcl

2QL 1 / 1 day(s)

ST

HUMAN INSULINBASAGLAR KWIKPEN 100 UNIT/ML SOLN PENinsulin glargine

2 QL 2 / 1 day(s)

HUMALOG 100 UNIT/ML SOLN CARTinsulin lispro

1 QL 2 / 1 day(s)

HUMALOG 100 UNIT/ML SOLUTIONinsulin lispro

1 QL 2 / 1 day(s)

HUMALOG JUNIOR KWIKPEN 100 UNIT/ML SOLN PENinsulin lispro

1 QL 2 / 1 day(s)


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSHUMALOG KWIKPEN 100 UNIT/ML SOLN PENinsulin lispro

1 QL 2 / 1 day(s)

HUMALOG KWIKPEN 200 UNIT/ML SOLN PENinsulin lispro

1 QL 1 / 1 day(s)

HUMALOG MIX 50/50 (50-50) 100 UNIT/ML SUSPENSIONinsulin lispro protamine & lispro

1 QL 2 / 1 day(s)

HUMALOG MIX 50/50 KWIKPEN (50-50) 100 UNIT/MLSUSP PENinsulin lispro protamine & lispro

1 QL 2 / 1 day(s)

HUMALOG MIX 75/25 (75-25) 100 UNIT/ML SUSPENSIONinsulin lispro protamine & lispro

1 QL 2 / 1 day(s)

HUMALOG MIX 75/25 KWIKPEN (75-25) 100 UNIT/MLSUSP PENinsulin lispro protamine & lispro

1 QL 2 / 1 day(s)

HUMULIN 70/30 (70-30) 100 UNIT/ML SUSPENSIONinsulin nph isophane & reg (human)

1 QL 2 / 1 day(s)

HUMULIN 70/30 KWIKPEN (70-30) 100 UNIT/ML SUSPPENinsulin nph isophane & reg (human)

1 QL 2 / 1 day(s)

HUMULIN N 100 UNIT/ML SUSPENSIONinsulin nph (human) (isophane)

1 QL 2 / 1 day(s)

HUMULIN N KWIKPEN 100 UNIT/ML SUSP PENinsulin nph (human) (isophane)

1 QL 2 / 1 day(s)

HUMULIN R 100 UNIT/ML SOLUTIONinsulin regular (human)

1 QL 2 / 1 day(s)

HUMULIN R U-500 (CONCENTRATED) 500 UNIT/MLSOLUTIONinsulin regular (human)

1 QL 2 / 1 day(s)

HUMULIN R U-500 KWIKPEN 500 UNIT/ML SOLN PENinsulin regular (human)

1 QL 1 / 1 day(s)

INSULIN LISPRO (1 UNIT DIAL) 100 UNIT/ML SOLN PENinsulin lispro

1 QL 2 / 1 day(s)

INSULIN LISPRO 100 UNIT/ML SOLUTIONinsulin lispro

1 QL 2 / 1 day(s)

INSULIN LISPRO JUNIOR KWIKPEN 100 UNIT/ML SOLNPENinsulin lispro

1 QL 2 / 1 day(s)

INSULIN LISPRO PROT & LISPRO (75-25) 100 UNIT/MLSUSP PENinsulin lispro protamine & lispro

1 QL 2 / 1 day(s)



LANTUS 100 UNIT/ML SOLUTIONinsulin glargine

3QL 2 / 1 day(s)

PA

LANTUS SOLOSTAR 100 UNIT/ML SOLN PENinsulin glargine

3QL 2 / 1 day(s)

PA

LEVEMIR 100 UNIT/ML SOLUTIONinsulin detemir

3QL 2 / 1 day(s)

PA

LEVEMIR FLEXTOUCH 100 UNIT/ML SOLN PENinsulin detemir

3QL 2 / 1 day(s)

PA

TRESIBA 100 UNIT/ML SOLUTIONinsulin degludec

3QL 2 / 1 day(s)

PA

TRESIBA FLEXTOUCH 100 UNIT/ML SOLN PENinsulin degludec

3QL 2 / 1 day(s)

PA

TRESIBA FLEXTOUCH 200 UNIT/ML SOLN PENinsulin degludec

3QL 0.9 / 1 day(s)

PA

INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)

BYDUREON 2 MG PENexenatide

2QL 4 / 28 DAYS

ST

BYDUREON 2 MG SRERexenatide

2QL 4 / 28 DAYS

ST

BYDUREON BCISE 2 MG/0.85ML A-INJexenatide

2QL 3.4 / 28 day(s)

ST

OZEMPIC (0.25 OR 0.5 MG/DOSE) 2 MG/1.5ML SOLN PENsemaglutide

2QL 1.5 / 28 day(s)

ST

OZEMPIC (1 MG/DOSE) 2 MG/1.5ML SOLN PENsemaglutide

2QL 3 / 28 day(s)

ST

OZEMPIC (1 MG/DOSE) 4 MG/3ML SOLN PENsemaglutide

2QL 3 / 28 day(s)

ST

RYBELSUS 14 MG TABsemaglutide

2QL 30 / 30 day(s)

ST




2QL 30 / 30 day(s)

ST


2QL 30 / 30 day(s)

ST

TRULICITY 0.75 MG/0.5ML SOLN PENdulaglutide

2QL 2 / 28 day(s)

ST


2QL 2 / 28 day(s)

ST

TRULICITY 3 MG/0.5ML SOLN PENdulaglutide

2QL 2 / 28 day(s)

ST


2QL 2 / 28 day(s)

ST

VICTOZA 18 MG/3ML SOLN PENliraglutide

2QL 9 / 30 DAYS

ST

INSULIN-INCRETIN MIMETIC COMBINATIONS

SOLIQUA 100-33 UNT-MCG/ML SOLN PENinsulin glargine-lixisenatide

2QL 0.6 / 1 day(s)

ST

XULTOPHY 100-3.6 UNIT-MG/ML SOLN PENinsulin degludec-liraglutide

3QL 0.5 / 1 day(s)

PA

MEGLITINIDE ANALOGUES

nateglinide 120 mg tab 1 QL 90 / 30 DAYS

nateglinide 60 mg tab 1 QL 90 / 30 DAYS

repaglinide 0.5 mg tab 1 QL 240 / 30 DAYS

repaglinide 1 mg tab 1 QL 240 / 30 DAYS

repaglinide 2 mg tab 1 QL 120 / 30 DAYS

SGLT2 INHIBITOR - DPP-4 INHIBITOR - BIGUANIDE COMB

TRIJARDY XR 10-5-1000 MG TAB ER 24Hempagliflozin-linagliptin-metformin

2QL 1 / 1 day(s)

ST



TRIJARDY XR 12.5-2.5-1000 MG TAB ER 24Hempagliflozin-linagliptin-metformin

2QL 2 / 1 day(s)

ST

TRIJARDY XR 25-5-1000 MG TAB ER 24Hempagliflozin-linagliptin-metformin

2QL 1 / 1 day(s)

ST

TRIJARDY XR 5-2.5-1000 MG TAB ER 24Hempagliflozin-linagliptin-metformin

2QL 2 / 1 day(s)

ST

SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS

GLYXAMBI 10-5 MG TABempagliflozin-linagliptin

2QL 30 / 30 day(s)

ST

GLYXAMBI 25-5 MG TABempagliflozin-linagliptin

2QL 30 / 30 day(s)

ST

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS

FARXIGA 10 MG TABdapagliflozin propanediol

2QL 30 / 30 days

ST

FARXIGA 5 MG TABdapagliflozin propanediol

2QL 30 / 30 days

ST

JARDIANCE 10 MG TABempagliflozin

2QL 30 / 30 DAYS

ST

JARDIANCE 25 MG TABempagliflozin

2QL 30 / 30 DAYS

ST

SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB

SYNJARDY 12.5-1000 MG TABempagliflozin-metformin hcl

2QL 60 / 30 DAYS

ST

SYNJARDY 12.5-500 MG TABempagliflozin-metformin hcl

2QL 60 / 30 DAYS

ST

SYNJARDY 5-1000 MG TABempagliflozin-metformin hcl

2QL 60 / 30 DAYS

ST

SYNJARDY 5-500 MG TABempagliflozin-metformin hcl

2QL 60 / 30 DAYS

ST



SYNJARDY XR 10-1000 MG TAB ER 24Hempagliflozin-metformin hcl

2QL 60 / 30 days

ST

SYNJARDY XR 12.5-1000 MG TAB ER 24Hempagliflozin-metformin hcl

2QL 60 / 30 days

ST


2QL 60 / 30 days

ST


2QL 60 / 30 days

ST

XIGDUO XR 10-1000 MG TAB ER 24Hdapagliflozin-metformin hcl

2QL 30 / 30 day(s)

ST


2QL 30 / 30 day(s)

ST

XIGDUO XR 2.5-1000 MG TAB ER 24Hdapagliflozin-metformin hcl

2QL 30 / 30 day(s)

ST


2QL 30 / 30 day(s)

ST


2QL 30 / 30 day(s)

ST

SULFONYLUREA-BIGUANIDE COMBINATIONSglipizide-metformin hcl 2.5-250 mg tab 1

glipizide-metformin hcl 2.5-500 mg tab 1

glipizide-metformin hcl 5-500 mg tab 1

glyburide-metformin 1.25-250 mg tab 1

glyburide-metformin 2.5-500 mg tab 1

glyburide-metformin 5-500 mg tab 1

SULFONYLUREAS

glimepiride 1 mg tab 1 QL 60 / 30 DAYS





glipizide 10 mg tab 1 QL 120 / 30 DAYS

glipizide 5 mg tab 1 QL 240 / 30 DAYS

glipizide er 10 mg tab er 24h 1 QL 60 / 30 DAYS

glipizide er 2.5 mg tab er 24h 1 QL 240 / 30 DAYS

glipizide er 5 mg tab er 24h 1 QL 60 / 30 DAYS

glipizide xl 10 mg tab er 24h 1 QL 60 / 30 DAYS

glipizide xl 2.5 mg tab er 24h 1 QL 240 / 30 DAYS

glipizide xl 5 mg tab er 24h 1 QL 60 / 30 DAYS

glyburide 1.25 mg tab 1 QL 480 / 30 DAYS

glyburide 2.5 mg tab 1 QL 240 / 30 DAYS

glyburide 5 mg tab 1 QL 120 / 30 DAYS

glyburide micronized 1.5 mg tab 1 QL 120 / 30 DAYS

glyburide micronized 3 mg tab 1 QL 60 / 30 DAYS

glyburide micronized 6 mg tab 1 QL 30 / 30 DAYS

THIAZOLIDINEDIONE-BIGUANIDE COMBINATIONSpioglitazone hcl-metformin hcl 15-500 mg tab 1

pioglitazone hcl-metformin hcl 15-850 mg tab 1 QL 90 / 30 DAYS

THIAZOLIDINEDIONES

pioglitazone hcl 15 mg tab 1 QL 30 / 30 DAYS





ANTIDIARRHEAL/PROBIOTIC AGENTSANTIPERISTALTIC AGENTS

diphenoxylate-atropine 2.5-0.025 mg tab 1 QL 80 / 10 DAYS

MOTOFEN 1-0.025 MG TABdifenoxin w/ atropine

3 QL 16 / 30 day(s)

opium 10 mg/ml (1%) tincture 1QL 15 / 5 DAYSMD 7 / 1 day(s)

ANTIDOTES AND SPECIFIC ANTAGONISTSANTIDOTES - CHELATING AGENTS

CHEMET 100 MG CAPsuccimer

3 PA

deferasirox 125 mg tab sol 4PA

S

deferasirox 180 mg packet 4PA

S

deferasirox 180 mg tab 4PA

S


S


S


S


S


S


S

deferasirox granules 180 mg packet 4PA

S




S


S

deferiprone 500 mg tab 4PA

S

FERRIPROX 100 MG/ML SOLUTIONdeferiprone

4PA

S

FERRIPROX 1000 MG TABdeferiprone

4PA

S

FERRIPROX TWICE-A-DAY 1000 MG TABdeferiprone

4PA

S

acetylcysteine 200 mg/ml solution 1

BRIDION 200 MG/2ML SOLUTIONsugammadex sodium

3 PA

BRIDION 500 MG/5ML SOLUTIONsugammadex sodium

3 PA

RADIOGARDASE 0.5 GM CAPprussian blue insoluble (ferric hexacyanoferrate ii)

2

OPIOID ANTAGONISTSKLOXXADO 8 MG/0.1ML LIQUIDnaloxone hcl

1 QL 2 / 30 day(s)

naloxone hcl 4 mg/0.1ml liquid 1 QL 2 / 30 day(s)

naltrexone hcl 50 mg tab 1 QL 60 / 30 DAYS

NARCAN 4 MG/0.1ML LIQUIDnaloxone hcl

1 QL 2 / 30 day(s)

VIVITROL 380 MG RECON SUSPnaltrexone

4QL 1 / DAYS

S



ANTIEMETICS5-HT3 RECEPTOR ANTAGONISTS

ANZEMET 100 MG TABdolasetron mesylate

3QL 7 / 30 DAYS

PA

ANZEMET 50 MG TABdolasetron mesylate

3QL 7 / 30 DAYS

PA

granisetron hcl 1 mg tab 1 QL 14 / 30 DAYS

ondansetron 4 mg tab disp 1 QL 180 / 30 DAYS

ondansetron 8 mg tab disp 1 QL 180 / 30 DAYS

ondansetron hcl 4 mg tab 1 QL 180 / 30 DAYS

ondansetron hcl 4 mg/2ml solution 2 PA

ondansetron hcl 4 mg/5ml solution 1 QL 100 / 30 DAYS

ondansetron hcl 8 mg tab 1 QL 180 / 30 DAYS

SANCUSO 3.1 MG/24HR PATCHgranisetron

3QL 1 / 7 DAYS

PA

SUSTOL 10 MG/0.4ML PRSYRgranisetron

3PA

S

ZUPLENZ 4 MG FILMondansetron

3 PA

ZUPLENZ 8 MG FILMondansetron

3 PA

ANTIEMETIC COMBINATIONS

AKYNZEO 300-0.5 MG CAPnetupitant-palonosetron

3QL 1 / 0 DAYS

PA

ANTIEMETICS - ANTICHOLINERGICmeclizine hcl 25 mg tab 1

scopolamine 1 mg/3days patch 72hr 1

trimethobenzamide hcl 300 mg cap 1



ANTIEMETICS - MISCELLANEOUS

CESAMET 1 MG CAPnabilone

3QL 30 / 5 DAYS

PA

dronabinol 10 mg cap 2 QL 60 / 30 DAYS

dronabinol 2.5 mg cap 2 QL 60 / 30 DAYS

dronabinol 5 mg cap 2 QL 60 / 30 DAYS

SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS

aprepitant 125 mg cap 1 QL 1 / 21 day(s)

aprepitant 80 & 125 mg cap 1 QL 3 / 21 day(s)

aprepitant 80 & 125 mg misc 1 QL 3 / 21 day(s)

aprepitant 80 mg cap 1 QL 2 / 21 day(s)

VARUBI (180 MG DOSE) 2 X 90 MG TAB THPKrolapitant hcl

3 PA

ANTIFUNGALSANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (TRITERPENOIDS)

BREXAFEMME 150 MG TABibrexafungerp citrate

3

QL 4 / 30 day(s)

ST

GL Female


flucytosine 250 mg cap 2

flucytosine 500 mg cap 2

griseofulvin microsize 125 mg/5ml suspension 1

griseofulvin microsize 500 mg tab 2 QL 30 / 30 DAYS

griseofulvin ultramicrosize 125 mg tab 2

griseofulvin ultramicrosize 250 mg tab 2

nystatin 500000 unit tab 1

terbinafine hcl 250 mg tab 1 QL 30 / 30 DAYS



IMIDAZOLESketoconazole 200 mg tab 1

TRIAZOLESfluconazole 10 mg/ml recon susp 1

fluconazole 100 mg tab 1

fluconazole 150 mg tab 1 QL 180 / 30 DAYS


fluconazole 40 mg/ml recon susp 1


itraconazole 100 mg cap 1

posaconazole 100 mg tab dr 4PA

S

voriconazole 200 mg tab 2 QL 60 / 30 DAYS

voriconazole 40 mg/ml recon susp 1 AL1 Up to 8 yrs old

voriconazole 50 mg tab 1 QL 120 / 30 DAYS

ANTIHISTAMINESANTIHISTAMINES - ETHANOLAMINES

carbinoxamine maleate 4 mg tab 1

CARBINOXAMINE MALEATE 4 MG/5ML SOLUTIONcarbinoxamine maleate

1

carbinoxamine maleate 4 mg/5ml solution 1

di-phen 12.5 mg/5ml elixir 1 AL1 Up to 8 yrs old

diphen 12.5 mg/5ml elixir 1 AL1 Up to 8 yrs old

diphenhydramine hcl 12.5 mg/5ml elixir 1 AL1 Up to 8 yrs old

diphenhydramine hcl 50 mg/ml solution 1

ANTIHISTAMINES - NON-SEDATINGDESLORATADINE 2.5 MG TAB DISPdesloratadine

1 QL 30 / 30 DAYS

desloratadine 5 mg tab 1 QL 30 / 30 DAYS


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSDESLORATADINE 5 MG TAB DISPdesloratadine

1 QL 30 / 30 DAYS

levocetirizine dihydrochloride 2.5 mg/5ml solution 1 QL 300 / 30 DAYS

levocetirizine dihydrochloride 5 mg tab 1 QL 30 / 30 DAYS

QUZYTTIR 10 MG/ML SOLUTIONcetirizine hcl

4PA

S

ANTIHISTAMINES - PHENOTHIAZINESphenadoz 12.5 mg suppos 1

phenadoz 25 mg suppos 1 QL 30 / 30 DAYS

phenergan 12.5 mg suppos 1

phenergan 25 mg suppos 1 QL 30 / 30 DAYS

promethazine hcl 12.5 mg suppos 1

promethazine hcl 12.5 mg tab 1

promethazine hcl 25 mg suppos 1 QL 30 / 30 DAYS

promethazine hcl 25 mg tab 1

promethazine hcl 50 mg tab 1

promethazine hcl 6.25 mg/5ml solution 1

promethazine hcl 6.25 mg/5ml syrup 1

promethegan 12.5 mg suppos 1

promethegan 25 mg suppos 1 QL 30 / 30 DAYS

ANTIHISTAMINES - PIPERIDINEScyproheptadine hcl 2 mg/5ml syrup 1

cyproheptadine hcl 4 mg tab 1

ANTIHYPERLIPIDEMICSACL INHIB-INTESTINAL CHOLESTEROL ABSORPTION INHIB COMB

NEXLIZET 180-10 MG TABbempedoic acid-ezetimibe

3 PA



ADENOSINE TRIPHOSPHATE-CITRATE LYASE (ACL) INHIBITORSNEXLETOL 180 MG TABbempedoic acid

3 PA

ANTIHYPERLIPIDEMICS - MISC.

icosapent ethyl 1 gm cap 2QL 4 / 1 day(s)

PA

omega-3-acid ethyl esters 1 gm cap 1

triklo 1 gm cap 1

VASCEPA 0.5 GM CAPicosapent ethyl

3QL 120 / 30 day(s)

PA

BILE ACID SEQUESTRANTScholestyramine 4 gm packet 1

cholestyramine 4 gm/dose powder 1

cholestyramine light 4 gm packet 1

cholestyramine light 4 gm/dose powder 1

colesevelam hcl 3.75 gm packet 2QL 30 / 30 day(s)

AL1 Up to 8 yrs old

colesevelam hcl 625 mg tab 2 QL 180 / 30 DAYS

colestipol hcl 1 gm tab 1

colestipol hcl 5 gm granules 1

colestipol hcl 5 gm packet 1

prevalite 4 gm packet 1

prevalite 4 gm/dose powder 1

FIBRIC ACID DERIVATIVES

fenofibrate 120 mg tab 1 QL 30 / 30 DAYS

fenofibrate 134 mg cap 1 QL 30 / 30 DAYS


FENOFIBRATE 150 MG CAPfenofibrate

3 QL 30 / 30 DAYS







FENOFIBRATE 50 MG CAPfenofibrate

3 QL 30 / 30 DAYS



fenofibrate micronized 130 mg cap 1 QL 30 / 30 DAYS





FENOFIBRIC ACID 105 MG TABfenofibric acid

1 QL 30 / 30 DAYS

fenofibric acid 135 mg cap dr 1 QL 30 / 30 DAYS

FENOFIBRIC ACID 35 MG TABfenofibric acid

1 QL 30 / 30 DAYS

fenofibric acid 45 mg cap dr 1 QL 30 / 30 DAYS

gemfibrozil 600 mg tab 1

LIPOFEN 150 MG CAPfenofibrate

3 QL 30 / 30 DAYS

LIPOFEN 50 MG CAPfenofibrate

3 QL 30 / 30 DAYS

HMG COA REDUCTASE INHIBITORS

atorvastatin calcium 10 mg tab 1QL 30 / 30 DAYS

PRE Preventative

atorvastatin calcium 20 mg tab 1QL 30 / 30 DAYS

PRE Preventative



atorvastatin calcium 40 mg tab 1 QL 30 / 30 DAYS

atorvastatin calcium 80 mg tab 1 QL 30 / 30 DAYS

fluvastatin sodium 20 mg cap 1QL 30 / 30 DAYS

PRE Preventative

fluvastatin sodium 40 mg cap 1QL 60 / 30 DAYS

PRE Preventative

fluvastatin sodium er 80 mg tab er 24h 1QL 30 / 30 DAYS

PRE Preventative

LIVALO 1 MG TABpitavastatin calcium

3QL 30 / 30 DAYS

PA


3QL 30 / 30 DAYS

PA


3QL 30 / 30 DAYS

PA

lovastatin 10 mg tab 1QL 30 / 30 DAYS

PRE Preventative


PRE Preventative


PRE Preventative

pravastatin sodium 10 mg tab 1QL 30 / 30 DAYS

PRE Preventative


PRE Preventative


PRE Preventative


PRE Preventative



rosuvastatin calcium 10 mg tab 1QL 30 / 30 DAYS

PRE Preventative

rosuvastatin calcium 20 mg tab 1 QL 30 / 30 DAYS

rosuvastatin calcium 40 mg tab 1 QL 30 / 30 DAYS

rosuvastatin calcium 5 mg tab 1QL 30 / 30 DAYS

PRE Preventative

simvastatin 10 mg tab 1QL 30 / 30 DAYS

PRE Preventative


PRE Preventative


PRE Preventative


PRE Preventative

simvastatin 80 mg tab 1 QL 30 / 30 DAYS

INTEST CHOLEST ABSORP INHIB-HMG COA REDUCTASE INHIB COMBEZETIMIBE-ROSUVASTATIN 10-10 MG TABezetimibe-rosuvastatin calcium

1 QL 1 / 1 day(s)

EZETIMIBE-ROSUVASTATIN 10-20 MG TABezetimibe-rosuvastatin calcium

1 QL 1 / 1 day(s)


1 QL 1 / 1 day(s)


1 QL 1 / 1 day(s)

ezetimibe-simvastatin 10-10 mg tab 1 QL 30 / 30 DAYS






INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS

ezetimibe 10 mg tab 1 QL 30 / 30 DAYS

NICOTINIC ACID DERIVATIVESniacin er (antihyperlipidemic) 1000 mg tab er 1

niacin er (antihyperlipidemic) 500 mg tab er 1

niacin er (antihyperlipidemic) 750 mg tab er 1

NIACOR 500 MG TABniacin (antihyperlipidemic)

3

PCSK9 INHIBITORSREPATHA 140 MG/ML SOLN PRSYRevolocumab

2 ST

REPATHA PUSHTRONEX SYSTEM 420 MG/3.5ML SOLNCARTevolocumab

2 ST

REPATHA SURECLICK 140 MG/ML SOLN A-INJevolocumab

2 ST

ANTIHYPERTENSIVESACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine besy-benazepril hcl 10-20 mg cap 1


amlodipine besy-benazepril hcl 2.5-10 mg cap 1 QL 30 / 30 DAYS




trandolapril-verapamil hcl er 1-240 mg tab er 1

TRANDOLAPRIL-VERAPAMIL HCL ER 1-240 MG TAB ERtrandolapril-verapamil hcl

1



1



1 QL 30 / 30 day(s)





1

ACE INHIBITORSbenazepril hcl 10 mg tab 1

benazepril hcl 20 mg tab 1



captopril 100 mg tab 1

captopril 12.5 mg tab 1



enalapril maleate 1 mg/ml solution 2 AL1 Up to 8 yrs old

enalapril maleate 10 mg tab 1

enalapril maleate 2.5 mg tab 1



fosinopril sodium 10 mg tab 1



lisinopril 10 mg tab 1

lisinopril 2.5 mg tab 1





moexipril hcl 15 mg tab 1

moexipril hcl 7.5 mg tab 1

perindopril erbumine 2 mg tab 1





QBRELIS 1 MG/ML SOLUTIONlisinopril


quinapril hcl 10 mg tab 1




ramipril 1.25 mg cap 1 QL 30 / 30 DAYS

ramipril 10 mg cap 1 QL 60 / 30 DAYS

ramipril 2.5 mg cap 1 QL 30 / 30 DAYS

ramipril 5 mg cap 1 QL 30 / 30 DAYS

trandolapril 1 mg tab 1 QL 30 / 30 DAYS



ACE INHIBITORS & THIAZIDE/THIAZIDE-LIKEbenazepril-hydrochlorothiazide 10-12.5 mg tab 1

benazepril-hydrochlorothiazide 20-12.5 mg tab 1

benazepril-hydrochlorothiazide 20-25 mg tab 1

benazepril-hydrochlorothiazide 5-6.25 mg tab 1

BENAZEPRIL-HYDROCHLOROTHIAZIDE 5-6.25 MG TABbenazepril & hydrochlorothiazide

1

CAPTOPRIL-HYDROCHLOROTHIAZIDE 25-15 MG TABcaptopril & hydrochlorothiazide

1


1


1


1



enalapril-hydrochlorothiazide 10-25 mg tab 1

enalapril-hydrochlorothiazide 5-12.5 mg tab 1

fosinopril sodium-hctz 10-12.5 mg tab 1

fosinopril sodium-hctz 20-12.5 mg tab 1

lisinopril-hydrochlorothiazide 10-12.5 mg tab 1

lisinopril-hydrochlorothiazide 20-12.5 mg tab 1

lisinopril-hydrochlorothiazide 20-25 mg tab 1

moexipril-hydrochlorothiazide 15-12.5 mg tab 1

moexipril-hydrochlorothiazide 15-25 mg tab 1

moexipril-hydrochlorothiazide 7.5-12.5 mg tab 1

quinapril-hydrochlorothiazide 10-12.5 mg tab 1

quinapril-hydrochlorothiazide 20-12.5 mg tab 1

quinapril-hydrochlorothiazide 20-25 mg tab 1

AGENTS FOR PHEOCHROMOCYTOMA

phenoxybenzamine hcl 10 mg cap 4PA

S

ANGIOTENSIN II RECEPTOR ANT-CA CHANNEL BLOCKER-THIAZIDES

amlodipine-valsartan-hctz 10-160-12.5 mg tab 1 QL 30 / 30 day(s)

amlodipine-valsartan-hctz 10-160-25 mg tab 1 QL 30 / 30 day(s)


amlodipine-valsartan-hctz 5-160-12.5 mg tab 1 QL 30 / 30 day(s)


olmesartan-amlodipine-hctz 20-5-12.5 mg tab 1


olmesartan-amlodipine-hctz 40-10-25 mg tab 1


olmesartan-amlodipine-hctz 40-5-25 mg tab 1



ANGIOTENSIN II RECEPTOR ANTAG & CA CHANNEL BLOCKER COMBamlodipine besylate-valsartan 10-160 mg tab 1

amlodipine besylate-valsartan 10-320 mg tab 1

amlodipine besylate-valsartan 5-160 mg tab 1 QL 30 / 30 DAYS

amlodipine besylate-valsartan 5-320 mg tab 1 QL 30 / 30 DAYS

amlodipine-olmesartan 10-20 mg tab 1




telmisartan-amlodipine 40-10 mg tab 1 QL 30 / 30 DAYS




ANGIOTENSIN II RECEPTOR ANTAG & THIAZIDE/THIAZIDE-LIKEcandesartan cilexetil-hctz 16-12.5 mg tab 1

candesartan cilexetil-hctz 32-12.5 mg tab 1

candesartan cilexetil-hctz 32-25 mg tab 1

irbesartan-hydrochlorothiazide 150-12.5 mg tab 1

irbesartan-hydrochlorothiazide 300-12.5 mg tab 1

losartan potassium-hctz 100-12.5 mg tab 1

losartan potassium-hctz 100-25 mg tab 1

losartan potassium-hctz 50-12.5 mg tab 1

olmesartan medoxomil-hctz 20-12.5 mg tab 1 QL 30 / 30 DAYS

olmesartan medoxomil-hctz 40-12.5 mg tab 1 QL 30 / 30 DAYS

olmesartan medoxomil-hctz 40-25 mg tab 1

telmisartan-hctz 40-12.5 mg tab 1 QL 30 / 30 DAYS

telmisartan-hctz 80-12.5 mg tab 1 QL 30 / 30 DAYS



telmisartan-hctz 80-25 mg tab 1 QL 30 / 30 DAYS

valsartan-hydrochlorothiazide 160-12.5 mg tab 1

valsartan-hydrochlorothiazide 160-25 mg tab 1


valsartan-hydrochlorothiazide 320-25 mg tab 1


ANGIOTENSIN II RECEPTOR ANTAGONISTS

candesartan cilexetil 16 mg tab 1 QL 30 / 30 DAYS




EDARBI 40 MG TABazilsartan medoxomil

3 QL 30 / 30 DAYS

EDARBI 80 MG TABazilsartan medoxomil

3 QL 30 / 30 DAYS

EPROSARTAN MESYLATE 600 MG TABeprosartan mesylate

1 QL 30 / 30 DAYS

irbesartan 150 mg tab 1 QL 30 / 30 DAYS



losartan potassium 100 mg tab 1 QL 60 / 30 DAYS



olmesartan medoxomil 20 mg tab 1



telmisartan 20 mg tab 1





valsartan 160 mg tab 1 QL 30 / 30 DAYS




ANTIADRENERGICS - CENTRALLY ACTINGclonidine 0.1 mg/24hr patch wk 1

clonidine 0.2 mg/24hr patch wk 1

clonidine 0.3 mg/24hr patch wk 1

clonidine hcl 0.1 mg tab 1



guanfacine hcl 1 mg tab 1

guanfacine hcl 2 mg tab 1

METHYLDOPA 250 MG TABmethyldopa

1

methyldopa 250 mg tab 1

METHYLDOPA 500 MG TABmethyldopa

1

methyldopa 500 mg tab 1

ANTIADRENERGICS - PERIPHERALLY ACTING

doxazosin mesylate 1 mg tab 1 QL 30 / 30 DAYS




prazosin hcl 1 mg cap 1





terazosin hcl 1 mg cap 1 QL 30 / 30 DAYS




BETA BLOCKER & DIURETIC COMBINATIONSatenolol-chlorthalidone 100-25 mg tab 1

atenolol-chlorthalidone 50-25 mg tab 1

bisoprolol-hydrochlorothiazide 10-6.25 mg tab 1

bisoprolol-hydrochlorothiazide 2.5-6.25 mg tab 1

bisoprolol-hydrochlorothiazide 5-6.25 mg tab 1

metoprolol-hydrochlorothiazide 100-25 mg tab 1

METOPROLOL-HYDROCHLOROTHIAZIDE 100-50 MG TABmetoprolol & hydrochlorothiazide

1

metoprolol-hydrochlorothiazide 50-25 mg tab 1

PROPRANOLOL-HCTZ 40-25 MG TABpropranolol & hydrochlorothiazide

1

PROPRANOLOL-HCTZ 80-25 MG TABpropranolol & hydrochlorothiazide

1

DIRECT RENIN INHIBITORSaliskiren fumarate 150 mg tab 2

aliskiren fumarate 300 mg tab 2

DOPAMINE D1 RECEPTOR AGONISTSCORLOPAM 20 MG/2ML SOLUTIONfenoldopam mesylate

3 PA

SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)

eplerenone 25 mg tab 1 QL 60 / 30 DAYS

eplerenone 50 mg tab 1 QL 60 / 30 DAYS

VASODILATORShydralazine hcl 10 mg tab 1

hydralazine hcl 100 mg tab 1





minoxidil 10 mg tab 1

minoxidil 2.5 mg tab 1

ANTIMALARIALSANTIMALARIAL COMBINATIONS

atovaquone-proguanil hcl 250-100 mg tab 1

atovaquone-proguanil hcl 62.5-25 mg tab 1

COARTEM 20-120 MG TABartemether-lumefantrine

2

chloroquine phosphate 250 mg tab 1

CHLOROQUINE PHOSPHATE 500 MG TABchloroquine phosphate

1

chloroquine phosphate 500 mg tab 1

HYDROXYCHLOROQUINE SULFATE 100 MG TABhydroxychloroquine sulfate

1

hydroxychloroquine sulfate 200 mg tab 1


1


1

mefloquine hcl 250 mg tab 1

PRIMAQUINE PHOSPHATE 26.3 (15 BASE) MG TABprimaquine phosphate

1

primaquine phosphate 26.3 (15 base) mg tab 1

pyrimethamine 25 mg tab 4PA

S

quinine sulfate 324 mg cap 1

ANTIMYASTHENIC/CHOLINERGIC AGENTSGUANIDINE HCL 125 MG TABguanidine hcl

2

pyridostigmine bromide 60 mg tab 1



pyridostigmine bromide 60 mg/5ml solution 2 PA

RUZURGI 10 MG TABamifampridine

4PA

S

ANTIMYCOBACTERIAL AGENTSANTI TB COMBINATIONS

RIFATER 50-120-300 MG TABisoniazid-rifampin w/ pyrazinamide

3

CYCLOSERINE 250 MG CAPcycloserine

2

cycloserine 250 mg cap 2

ethambutol hcl 100 mg tab 1

ethambutol hcl 400 mg tab 1

ISONIAZID 100 MG TABisoniazid

1

isoniazid 100 mg tab 1

isoniazid 300 mg tab 1

ISONIAZID 50 MG/5ML SYRUPisoniazid

1

PRETOMANID 200 MG TABpretomanid

3

PRIFTIN 150 MG TABrifapentine

3

pyrazinamide 500 mg tab 2

rifabutin 150 mg cap 2

rifampin 150 mg cap 1

rifampin 300 mg cap 1

SIRTURO 100 MG TABbedaquiline fumarate

4PA

S

SIRTURO 20 MG TABbedaquiline fumarate

4PA

S

TRECATOR 250 MG TABethionamide

3



ANTINEOPLASTICS AND ADJUNCTIVE THERAPIESALKYLATING AGENTS

HEXALEN 50 MG CAPaltretamine

4PA

S

MYLERAN 2 MG TABbusulfan

4PA

S

ANDROGEN BIOSYNTHESIS INHIBITORSabiraterone acetate 250 mg tab 2

ANTIADRENALS

LYSODREN 500 MG TABmitotane

4PA

S

ANTIANDROGENS

bicalutamide 50 mg tab 1 QL 30 / 30 DAYS

ERLEADA 60 MG TABapalutamide

4PA

S

FLUTAMIDE 125 MG CAPflutamide

1

flutamide 125 mg cap 1

nilutamide 150 mg tab 2QL 60 / 30 DAYS

PA

XTANDI 40 MG CAPenzalutamide

4PA

S

XTANDI 40 MG TABenzalutamide

4PA

S

XTANDI 80 MG TABenzalutamide

4PA

S

ANTIESTROGENS

tamoxifen citrate 10 mg tab 1 PRE Preventative

tamoxifen citrate 20 mg tab 1 PRE Preventative



toremifene citrate 60 mg tab 2 QL 30 / 30 DAYS

ANTIMETABOLITEScapecitabine 150 mg tab 2

capecitabine 500 mg tab 2

mercaptopurine 50 mg tab 1

methotrexate 2.5 mg tab 1

methotrexate sodium (pf) 1 gm/40ml solution 1

methotrexate sodium (pf) 250 mg/10ml solution 1

methotrexate sodium (pf) 50 mg/2ml solution 1

methotrexate sodium 1 gm recon soln 1

methotrexate sodium 2.5 mg tab 1

METHOTREXATE SODIUM 250 MG/10ML SOLUTIONmethotrexate sodium

1

methotrexate sodium 50 mg/2ml solution 1

PURIXAN 2000 MG/100ML SUSPENSIONmercaptopurine

4PA

S

TABLOID 40 MG TABthioguanine

4PA

S

TREXALL 10 MG TABmethotrexate sodium

4PA

S


4PA

S


4PA

S

TREXALL 7.5 MG TABmethotrexate sodium

4PA

S

ANTINEOPLASTIC - ALK INHIBITORS

ALECENSA 150 MG CAPalectinib hcl

4PA

S



XALKORI 200 MG CAPcrizotinib

4PA

S

XALKORI 250 MG CAPcrizotinib

4PA

S

ZYKADIA 150 MG CAPceritinib

4PA

S

ZYKADIA 150 MG TABceritinib

4PA

S

ANTINEOPLASTIC - ANTI-HER2 AGENTS

TUKYSA 150 MG TABtucatinib

4PA

S

TUKYSA 50 MG TABtucatinib

4PA

S

ANTINEOPLASTIC - BCL-2 INHIBITORS

VENCLEXTA 10 MG TABvenetoclax

4PA

S


4PA

S


4PA

S

ANTINEOPLASTIC - BCR-ABL KINASE INHIBITORS

BOSULIF 100 MG TABbosutinib

4PA

S


4PA

S


4PA

S

ICLUSIG 10 MG TABponatinib hcl

4PA

S




4PA

S


4PA

S


4PA

S

imatinib mesylate 100 mg tab 2 QL 90 / 30 DAYS

imatinib mesylate 400 mg tab 2 QL 60 / 30 DAYS

SCEMBLIX 20 MG TABasciminib hcl

4PA

S

SCEMBLIX 40 MG TABasciminib hcl

4PA

S

SPRYCEL 100 MG TABdasatinib

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

TASIGNA 150 MG CAPnilotinib hcl

4PA

S


4PA

S




4PA

S

ANTINEOPLASTIC - BRAF KINASE INHIBITORS

BRAFTOVI 50 MG CAPencorafenib

4PA

S

BRAFTOVI 75 MG CAPencorafenib

4PA

S

TAFINLAR 50 MG CAPdabrafenib mesylate

4PA

S

TAFINLAR 75 MG CAPdabrafenib mesylate

4PA

S

ZELBORAF 240 MG TABvemurafenib

4PA

S

ANTINEOPLASTIC - BTK INHIBITORS

BRUKINSA 80 MG CAPzanubrutinib

4PA

S

CALQUENCE 100 MG CAPacalabrutinib

4PA

S

IMBRUVICA 140 MG CAPibrutinib

4PA

S

IMBRUVICA 420 MG TABibrutinib

4PA

S

IMBRUVICA 560 MG TABibrutinib

4PA

S

IMBRUVICA 70 MG CAPibrutinib

4PA

S

ANTINEOPLASTIC - EGFR INHIBITORS

erlotinib hcl 100 mg tab 4 PA





EXKIVITY 40 MG CAPmobocertinib succinate

4PA

S

GILOTRIF 20 MG TABafatinib dimaleate

4PA

S


4PA

S


4PA

S

TAGRISSO 40 MG TABosimertinib mesylate

4PA

S

TAGRISSO 80 MG TABosimertinib mesylate

4PA

S

VIZIMPRO 15 MG TABdacomitinib

4PA

S


4PA

S


4PA

S

ANTINEOPLASTIC - FGFR KINASE INHIBITORS

BALVERSA 3 MG TABerdafitinib

4PA

S


4PA

S


4PA

S

PEMAZYRE 13.5 MG TABpemigatinib

4PA

S



PEMAZYRE 4.5 MG TABpemigatinib

4PA

S

PEMAZYRE 9 MG TABpemigatinib

4PA

S

TRUSELTIQ (100MG DAILY DOSE) 100 MG CAP THPKinfigratinib phosphate

4PA

S

TRUSELTIQ (125MG DAILY DOSE) 100 & 25 MG CAP THPKinfigratinib phosphate

4PA

S


4PA

S


4PA

S

ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS

ERIVEDGE 150 MG CAPvismodegib

4PA

S

ODOMZO 200 MG CAPsonidegib phosphate

4PA

S

ANTINEOPLASTIC - HIF-2-ALPHA INHIBITORS

WELIREG 40 MG TABbelzutifan

4PA

S

ANTINEOPLASTIC - HISTONE DEACETYLASE INHIBITORS

FARYDAK 10 MG CAPpanobinostat lactate

4PA

S


4PA

S


4PA

S

ZOLINZA 100 MG CAPvorinostat

4PA

S



ANTINEOPLASTIC - IMMUNOMODULATORS

POMALYST 1 MG CAPpomalidomide

4PA

S


4PA

S


4PA

S


4PA

S

ANTINEOPLASTIC - KRAS INHIBITORS

LUMAKRAS 120 MG TABsotorasib

4PA

S

ANTINEOPLASTIC - MEK INHIBITORS

COTELLIC 20 MG TABcobimetinib fumarate

4PA

S

KOSELUGO 10 MG CAPselumetinib sulfate

4PA

S

KOSELUGO 25 MG CAPselumetinib sulfate

4PA

S

MEKINIST 0.5 MG TABtrametinib dimethyl sulfoxide

4PA

S

MEKINIST 2 MG TABtrametinib dimethyl sulfoxide

4PA

S

MEKTOVI 15 MG TABbinimetinib

4PA

S

ANTINEOPLASTIC - MET INHIBITORS

TABRECTA 150 MG TABcapmatinib hcl

4PA

S

TABRECTA 200 MG TABcapmatinib hcl

4PA

S



TEPMETKO 225 MG TABtepotinib hcl

4PA

S

ANTINEOPLASTIC - METHYLTRANSFERASE INHIBITORS

TAZVERIK 200 MG TABtazemetostat hbr

4PA

S

ANTINEOPLASTIC - MTOR KINASE INHIBITORS

everolimus 10 mg tab 4PA

S

everolimus 2 mg tab sol 4PA

S

everolimus 2.5 mg tab 4

QL 30 / 30 day(s)

PA

S


S

everolimus 5 mg tab 4

QL 30 / 30 day(s)

PA

S


S

everolimus 7.5 mg tab 4

QL 30 / 30 day(s)

PA

S

ANTINEOPLASTIC - MULTIKINASE INHIBITORS

CABOMETYX 20 MG TABcabozantinib s-malate

4PA

S


4PA

S


4PA

S



CAPRELSA 100 MG TABvandetanib

4PA

S

CAPRELSA 300 MG TABvandetanib

4PA

S

COMETRIQ (100 MG DAILY DOSE) 80 & 20 MG KITcabozantinib s-malate

4PA

S

COMETRIQ (140 MG DAILY DOSE) 3 X 20 MG & 80 MG KITcabozantinib s-malate

4PA

S

COMETRIQ (60 MG DAILY DOSE) 20 MG KITcabozantinib s-malate

4PA

S

FOTIVDA 0.89 MG CAPtivozanib hcl

4PA

S

FOTIVDA 1.34 MG CAPtivozanib hcl

4PA

S

lapatinib ditosylate 250 mg tab 4PA

S

NERLYNX 40 MG TABneratinib maleate

4PA

S

NEXAVAR 200 MG TABsorafenib tosylate

4PA

S

QINLOCK 50 MG TABripretinib

4PA

S

STIVARGA 40 MG TABregorafenib

4PA

S

sunitinib malate 12.5 mg cap 4PA

S

sunitinib malate 25 mg cap 4PA

S



sunitinib malate 37.5 mg cap 4PA

S

sunitinib malate 50 mg cap 4PA

S

TURALIO 200 MG CAPpexidartinib hcl

4PA

S

UKONIQ 200 MG TABumbralisib tosylate

4PA

S

VOTRIENT 200 MG TABpazopanib hcl

4PA

S

ANTINEOPLASTIC - PDGFR-ALPHA INHIBITORS

AYVAKIT 100 MG TABavapritinib

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

ANTINEOPLASTIC - PROTEASOME INHIBITORS

NINLARO 2.3 MG CAPixazomib citrate

4PA

S

NINLARO 3 MG CAPixazomib citrate

4PA

S

NINLARO 4 MG CAPixazomib citrate

4PA

S



ANTINEOPLASTIC - RET INHIBITORS

GAVRETO 100 MG CAPpralsetinib

4PA

S

RETEVMO 40 MG CAPselpercatinib

4PA

S

RETEVMO 80 MG CAPselpercatinib

4PA

S

ANTINEOPLASTIC - TROPOMYOSIN RECEPTOR KINASE INHIBITORS

ROZLYTREK 100 MG CAPentrectinib

4PA

S

ROZLYTREK 200 MG CAPentrectinib

4PA

S

ANTINEOPLASTIC - XPO1 INHIBITORS

XPOVIO (100 MG ONCE WEEKLY) 20 MG TAB THPKselinexor

4PA

S


4PA

S


4PA

S


4PA

S

XPOVIO (40 MG TWICE WEEKLY) 20 MG TAB THPKselinexor

4PA

S


4PA

S


4PA

S


4PA

S




4PA

S


4PA

S


4PA

S


4PA

S

ANTINEOPLASTIC COMBINATIONS

INQOVI 35-100 MG TABdecitabine-cedazuridine

4PA

S

LONSURF 15-6.14 MG TABtrifluridine-tipiracil

4PA

S

LONSURF 20-8.19 MG TABtrifluridine-tipiracil

4PA

S

ANTINEOPLASTICS MISC.

ACTIMMUNE 2000000 UNIT/0.5ML SOLUTIONinterferon gamma-1b

4PA

S

hydroxyurea 500 mg cap 1

INTRON A 10000000 UNIT RECON SOLNinterferon alfa-2b

4PA

S

INTRON A 10000000 UNIT/ML SOLUTIONinterferon alfa-2b

4PA

S


4PA

S


4PA

S

INTRON A 6000000 UNIT/ML SOLUTIONinterferon alfa-2b

4PA

S



MATULANE 50 MG CAPprocarbazine hcl

4PA

S

AROMATASE INHIBITORS

anastrozole 1 mg tab 1

QL 30 / 30 DAYS

GL FemalePRE Preventative

exemestane 25 mg tab 1QL 60 / 30 DAYS

GL Female

letrozole 2.5 mg tab 1QL 30 / 30 DAYS

GL Female

CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS

IBRANCE 100 MG CAPpalbociclib

4PA

S

IBRANCE 100 MG TABpalbociclib

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

VERZENIO 100 MG TABabemaciclib

4PA

S


4PA

S


4PA

S




4PA

S

ESTROGENS-ANTINEOPLASTIC

EMCYT 140 MG CAPestramustine phosphate sodium

4PA

S

FOLIC ACID ANTAGONISTS RESCUE AGENTSleucovorin calcium 10 mg tab 2

leucovorin calcium 15 mg tab 2



IMIDAZOTETRAZINES

temozolomide 100 mg cap 2 QL 2 / 1 day(s)






JANUS ASSOCIATED KINASE (JAK) INHIBITORS

JAKAFI 10 MG TABruxolitinib phosphate

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S



LHRH ANALOGS

ELIGARD 22.5 MG KITleuprolide acetate (3 month)

4PA

S

ELIGARD 30 MG KITleuprolide acetate (4 month)

4PA

S

ELIGARD 45 MG KITleuprolide acetate (6 month)

4PA

S

ELIGARD 7.5 MG KITleuprolide acetate

4PA

S

leuprolide acetate 1 mg/0.2ml kit 1 PA

LUPRON DEPOT (1-MONTH) 3.75 MG KITleuprolide acetate

4PA

S

LUPRON DEPOT (1-MONTH) 7.5 MG KITleuprolide acetate

4PA

S

LUPRON DEPOT (3-MONTH) 11.25 MG KITleuprolide acetate (3 month)

4PA

S

LUPRON DEPOT (3-MONTH) 22.5 MG KITleuprolide acetate (3 month)

4PA

S

LUPRON DEPOT (4-MONTH) 30 MG KITleuprolide acetate (4 month)

4PA

S

LUPRON DEPOT (6-MONTH) 45 MG KITleuprolide acetate (6 month)

4PA

S

VANTAS 50 MG KIThistrelin acetate

4PA

S

ZOLADEX 10.8 MG IMPLANTgoserelin acetate

4PA

S

ZOLADEX 3.6 MG IMPLANTgoserelin acetate

4PA

S



MITOTIC INHIBITORS

ETOPOSIDE 50 MG CAPetoposide

4PA

S

NITROGEN MUSTARDS AND RELATED ANALOGUESCYCLOPHOSPHAMIDE 25 MG CAPcyclophosphamide

1

cyclophosphamide 25 mg cap 1

CYCLOPHOSPHAMIDE 50 MG CAPcyclophosphamide

1

cyclophosphamide 50 mg cap 1

LEUKERAN 2 MG TABchlorambucil

4PA

S

melphalan 2 mg tab 1

NITROSOUREAS

GLEOSTINE 10 MG CAPlomustine

4PA

S


4PA

S


4PA

S

PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS

COPIKTRA 15 MG CAPduvelisib

4PA

S

COPIKTRA 25 MG CAPduvelisib

4PA

S

PIQRAY (200 MG DAILY DOSE) 200 MG TAB THPKalpelisib

4PA

S

PIQRAY (250 MG DAILY DOSE) 200 & 50 MG TAB THPKalpelisib

4PA

S

PIQRAY (300 MG DAILY DOSE) 2 X 150 MG TAB THPKalpelisib

4PA

S



ZYDELIG 100 MG TABidelalisib

4PA

S

ZYDELIG 150 MG TABidelalisib

4PA

S

POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS

LYNPARZA 100 MG TABolaparib

4PA

S

LYNPARZA 150 MG TABolaparib

4PA

S

LYNPARZA 50 MG CAPolaparib

4PA

S

TALZENNA 0.5 MG CAPtalazoparib tosylate

4PA

S

TALZENNA 0.75 MG CAPtalazoparib tosylate

4PA

S

PROGESTINS-ANTINEOPLASTICHYDROXYPROGESTERONE CAPROATE 1.25 GM/5MLSOLUTIONhydroxyprogesterone caproate (antineoplastic)

2 PA

megestrol acetate 20 mg tab 1

megestrol acetate 40 mg tab 1

megestrol acetate 40 mg/ml suspension 1

megestrol acetate 400 mg/10ml suspension 1

RETINOIDS

tretinoin 10 mg cap 1 PA

SELECTIVE RETINOID X RECEPTOR AGONISTS

bexarotene 75 mg cap 2 PA

VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) INHIBITORS

INLYTA 1 MG TABaxitinib

4PA

S



INLYTA 5 MG TABaxitinib

4PA

S

LENVIMA (10 MG DAILY DOSE) 10 MG CAP THPKlenvatinib mesylate

4PA

S

LENVIMA (14 MG DAILY DOSE) 10 & 4 MG CAP THPKlenvatinib mesylate

4PA

S

LENVIMA (20 MG DAILY DOSE) 2 X 10 MG CAP THPKlenvatinib mesylate

4PA

S

LENVIMA (24 MG DAILY DOSE) 2 X 10 MG & 4 MG CAPTHPKlenvatinib mesylate

4PA

S

ANTIPARKINSON AND RELATED THERAPY AGENTSANTIPARKINSON ANTICHOLINERGICS

benztropine mesylate 0.5 mg tab 1

benztropine mesylate 1 mg tab 1

benztropine mesylate 2 mg tab 1

trihexyphenidyl hcl 0.4 mg/ml solution 1 AL1 Up to 8 yrs old

trihexyphenidyl hcl 2 mg tab 1

trihexyphenidyl hcl 5 mg tab 1

ANTIPARKINSON DOPAMINERGICSamantadine hcl 100 mg cap 1

amantadine hcl 100 mg tab 1

amantadine hcl 50 mg/5ml solution 1

amantadine hcl 50 mg/5ml syrup 1

bromocriptine mesylate 2.5 mg tab 1

bromocriptine mesylate 5 mg cap 1

ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS

rasagiline mesylate 0.5 mg tab 2 QL 30 / 30 DAYS

rasagiline mesylate 1 mg tab 2 QL 30 / 30 DAYS



selegiline hcl 5 mg cap 1

selegiline hcl 5 mg tab 1

ZELAPAR 1.25 MG TAB DISPselegiline hcl

3 PA

CENTRAL/PERIPHERAL COMT INHIBITORS

tolcapone 100 mg tab 2 PA

DECARBOXYLASE INHIBITORScarbidopa 25 mg tab 1

LEVODOPA COMBINATIONScarbidopa-levodopa 10-100 mg tab 1

carbidopa-levodopa 10-100 mg tab disp 1

CARBIDOPA-LEVODOPA 10-100 MG TAB DISPcarbidopa-levodopa

1

carbidopa-levodopa 25-100 mg tab 1



1

carbidopa-levodopa 25-250 mg tab 1



1

carbidopa-levodopa er 25-100 mg tab er 1

carbidopa-levodopa er 50-200 mg tab er 1

CARBIDOPA-LEVODOPA-ENTACAPONE 12.5-50-200 MGTABcarbidopa-levodopa-entacapone

1


1

CARBIDOPA-LEVODOPA-ENTACAPONE 25-100-200 MGTABcarbidopa-levodopa-entacapone

1


1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSCARBIDOPA-LEVODOPA-ENTACAPONE 37.5-150-200 MGTABcarbidopa-levodopa-entacapone

1

CARBIDOPA-LEVODOPA-ENTACAPONE 50-200-200 MGTABcarbidopa-levodopa-entacapone

1

NONERGOLINE DOPAMINE RECEPTOR AGONISTS

KYNMOBI 10 MG FILMapomorphine hydrochloride

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

KYNMOBI TITRATION KIT 10/15/20/25/30 MG KITapomorphine hydrochloride

4PA

S

NEUPRO 1 MG/24HR PATCH 24HRrotigotine

3 PA


3 PA


3 PA


3 PA


3 PA


3 PA

pramipexole dihydrochloride 0.125 mg tab 1 QL 90 / 30 DAYS






pramipexole dihydrochloride 1 mg tab 1 QL 90 / 30 DAYS


pramipexole dihydrochloride er 0.375 mg tab er 24h 2 QL 30 / 30 DAYS




pramipexole dihydrochloride er 3 mg tab er 24h 2 QL 30 / 30 DAYS



ropinirole hcl 0.25 mg tab 1

ropinirole hcl 0.5 mg tab 1

ropinirole hcl 1 mg tab 1





ropinirole hcl er 12 mg tab er 24h 1 QL 30 / 30 DAYS





PERIPHERAL COMT INHIBITORS

entacapone 200 mg tab 1 QL 270 / 30 DAYS


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSONGENTYS 25 MG CAPopicapone

3 PA

ONGENTYS 50 MG CAPopicapone

3 PA

ANTIPSYCHOTICS/ANTIMANIC AGENTSANTIMANIC AGENTS

LITHIUM 8 MEQ/5ML SOLUTIONlithium


LITHIUM CARBONATE 150 MG CAPlithium carbonate

1

lithium carbonate 150 mg cap 1


1


lithium carbonate 300 mg tab 1


1


lithium carbonate er 300 mg tab er 1

lithium carbonate er 450 mg tab er 1

ANTIPSYCHOTICS - MISC.EQUETRO 100 MG CAP ER 12Hcarbamazepine (antipsychotic)

3 QL 480 / 30 DAYS

EQUETRO 200 MG CAP ER 12Hcarbamazepine (antipsychotic)

3 QL 240 / 30 DAYS

EQUETRO 300 MG CAP ER 12Hcarbamazepine (antipsychotic)

3 QL 180 / 30 DAYS

LATUDA 120 MG TABlurasidone hcl

3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST




3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST

VRAYLAR 1.5 & 3 MG CAP THPKcariprazine hcl

3QL 30 / 30 day(s)

ST

VRAYLAR 1.5 MG CAPcariprazine hcl

3QL 30 / 30 DAYS

ST

VRAYLAR 3 MG CAPcariprazine hcl

3QL 30 / 30 DAYS

ST

VRAYLAR 4.5 MG CAPcariprazine hcl

3QL 30 / 30 DAYS

ST

VRAYLAR 6 MG CAPcariprazine hcl

3QL 30 / 30 DAYS

ST

ziprasidone hcl 20 mg cap 1 QL 240 / 30 DAYS




BENZISOXAZOLES

FANAPT 1 MG TABiloperidone

3QL 60 / 30 day(s)

ST


3QL 60 / 30 day(s)

ST


3QL 60 / 30 day(s)

ST


3QL 60 / 30 day(s)

ST


3QL 60 / 30 day(s)

ST




3QL 60 / 30 day(s)

ST


3QL 60 / 30 day(s)

ST

FANAPT TITRATION PACK 1 & 2 & 4 & 6 MG TABiloperidone

3QL 60 / 30 day(s)

ST

INVEGA HAFYERA 1092 MG/3.5ML SUSP PRSYRpaliperidone palmitate

3 ST

INVEGA HAFYERA 1560 MG/5ML SUSP PRSYRpaliperidone palmitate

3 ST

INVEGA SUSTENNA 117 MG/0.75ML SUSP PRSYRpaliperidone palmitate

3 ST

INVEGA SUSTENNA 156 MG/ML SUSP PRSYRpaliperidone palmitate

3 ST


3 ST


3 ST


3 ST

INVEGA TRINZA 273 MG/0.88ML SUSP PRSYRpaliperidone palmitate

3 ST


3 ST


3 ST


3 ST

paliperidone er 1.5 mg tab er 24h 2QL 30 / 30 DAYS

ST

paliperidone er 3 mg tab er 24h 2QL 30 / 30 DAYS

ST


ST




ST

RISPERDAL CONSTA 12.5 MG SRERrisperidone microspheres

3 ST

RISPERDAL CONSTA 25 MG SRERrisperidone microspheres

3 ST

RISPERDAL CONSTA 37.5 MG SRERrisperidone microspheres

3 ST

RISPERDAL CONSTA 50 MG SRERrisperidone microspheres

3 ST

risperidone 0.25 mg tab 1 QL 60 / 30 DAYS

RISPERIDONE 0.25 MG TAB DISPrisperidone

1 QL 1920 / 30 DAYS

risperidone 0.5 mg tab 1 QL 60 / 30 DAYS

risperidone 0.5 mg tab disp 1 QL 960 / 30 DAYS

risperidone 1 mg tab 1 QL 480 / 30 DAYS

risperidone 1 mg tab disp 1 QL 60 / 30 DAYS

risperidone 1 mg/ml solution 1 AL1 Up to 8 yrs old







risperidone m-tab 0.5 mg tab disp 1 QL 960 / 30 DAYS

risperidone m-tab 1 mg tab disp 1 QL 60 / 30 DAYS

risperidone m-tab 2 mg tab disp 1 QL 60 / 30 DAYS



BUTYROPHENONEShaloperidol 0.5 mg tab 1

haloperidol 1 mg tab 1





haloperidol lactate 2 mg/ml conc 1

DIBENZO-OXEPINO PYRROLES

asenapine maleate 10 mg sl tab 2 ST

asenapine maleate 2.5 mg sl tab 2 ST

asenapine maleate 5 mg sl tab 2 ST

DIBENZODIAZEPINES

clozapine 100 mg tab 1 QL 120 / 30 DAYS

clozapine 100 mg tab disp 1

CLOZAPINE 12.5 MG TAB DISPclozapine

1

CLOZAPINE 150 MG TAB DISPclozapine

1


CLOZAPINE 200 MG TAB DISPclozapine

1


clozapine 25 mg tab disp 1 QL 1080 / 30 DAYS


DIBENZOTHIAZEPINES

quetiapine fumarate 100 mg tab 1 QL 90 / 30 DAYS








quetiapine fumarate er 150 mg tab er 24h 1 QL 60 / 30 DAYS





DIBENZOXAZEPINESloxapine succinate 10 mg cap 1

loxapine succinate 25 mg cap 1



PHENOTHIAZINESchlorpromazine hcl 10 mg tab 1

chlorpromazine hcl 100 mg tab 1




compro 25 mg suppos 1 QL 30 / 30 DAYS

fluphenazine hcl 1 mg tab 1


fluphenazine hcl 2.5 mg tab 1

FLUPHENAZINE HCL 2.5 MG/5ML ELIXIRfluphenazine hcl




PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSFLUPHENAZINE HCL 5 MG/ML CONCfluphenazine hcl


perphenazine 16 mg tab 1




prochlorperazine 25 mg suppos 1 QL 30 / 30 DAYS

prochlorperazine maleate 10 mg tab 1

prochlorperazine maleate 5 mg tab 1

thioridazine hcl 10 mg tab 1




trifluoperazine hcl 1 mg tab 1




QUINOLINONE DERIVATIVESABILIFY MAINTENA 300 MG PRSYRaripiprazole

3 ST

ABILIFY MAINTENA 300 MG SRERaripiprazole

3 ST

ABILIFY MAINTENA 400 MG PRSYRaripiprazole

3 ST

ABILIFY MAINTENA 400 MG SRERaripiprazole

3 ST

aripiprazole 1 mg/ml solution 2 QL 30 / 30 DAYS

aripiprazole 10 mg tab 1 QL 30 / 30 DAYS


aripiprazole 2 mg tab 1 QL 60 / 30 day(s)






REXULTI 0.25 MG TABbrexpiprazole

3QL 30 / 30 DAYS

ST

REXULTI 0.5 MG TABbrexpiprazole

3QL 30 / 30 DAYS

ST

REXULTI 1 MG TABbrexpiprazole

3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST


3QL 30 / 30 DAYS

ST

THIENBENZODIAZEPINES

olanzapine 10 mg tab 1 QL 30 / 30 DAYS

olanzapine 10 mg tab disp 1 QL 30 / 30 DAYS



olanzapine 2.5 mg tab 1 QL 30 / 30 DAYS





olanzapine 7.5 mg tab 1 QL 30 / 30 DAYS


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSZYPREXA RELPREVV 210 MG RECON SUSPolanzapine pamoate

3 ST

ZYPREXA RELPREVV 300 MG RECON SUSPolanzapine pamoate

3 ST

ZYPREXA RELPREVV 405 MG RECON SUSPolanzapine pamoate

3 ST

THIOXANTHENESthiothixene 1 mg cap 1

thiothixene 10 mg cap 1



ANTIVIRALSANTIRETROVIRAL COMBINATIONS

abacavir sulfate-lamivudine 600-300 mg tab 1 QL 30 / 30 DAYS

abacavir-lamivudine-zidovudine 300-150-300 mg tab 2 QL 60 / 30 DAYS

BIKTARVY 30-120-15 MG TABbictegravir-emtricitabine-tenofovir alafenamide fumarate

4QL 30 / 30 day(s)

S

BIKTARVY 50-200-25 MG TABbictegravir-emtricitabine-tenofovir alafenamide fumarate

4QL 30 / 30 DAYS

S

CIMDUO 300-300 MG TABlamivudine-tenofovir disoproxil fumarate

4 S

COMPLERA 200-25-300 MG TABemtricitabine-rilpivirine-tenofovir disoproxil fumarate

4QL 30 / 30 DAYS

S

DESCOVY 200-25 MG TABemtricitabine-tenofovir alafenamide fumarate

4

QL 30 / 30 DAYS

PA

S

DOVATO 50-300 MG TABdolutegravir sodium-lamivudine

4PA

S

efavirenz-emtricitab-tenofovir 600-200-300 mg tab 4

efavirenz-lamivudine-tenofovir 400-300-300 mg tab 4 S



efavirenz-lamivudine-tenofovir 600-300-300 mg tab 4 S

emtricitabine-tenofovir df 100-150 mg tab 4QL 30 / 30 day(s)

S


S


S


PRE Preventative

EVOTAZ 300-150 MG TABatazanavir sulfate-cobicistat

4QL 30 / 30 DAYS

S

GENVOYA 150-150-200-10 MG TABelvitegravir-cobicistat-emtricitabine-tenofoviralafenamide

4QL 30 / 30 DAYS

S

JULUCA 50-25 MG TABdolutegravir sodium-rilpivirine hcl

4 S

lamivudine-zidovudine 150-300 mg tab 1 QL 60 / 30 DAYS

lopinavir-ritonavir 100-25 mg tab 4 S

lopinavir-ritonavir 200-50 mg tab 4 S

lopinavir-ritonavir 400-100 mg/5ml solution 1

ODEFSEY 200-25-25 MG TABemtricitabine-rilpivirine-tenofovir alafenamide fumarate

4QL 30 / 30 DAYS

S

PREZCOBIX 800-150 MG TABdarunavir-cobicistat

4QL 30 / 30 DAYS

S

STRIBILD 150-150-200-300 MG TABelvitegravir-cobicistat-emtricitabine-tenofovir df

4QL 30 / 30 DAYS

S

SYMTUZA 800-150-200-10 MG TABdarunavir-cobicistat-emtricitabine-tenofovir alafenamide

4 S

TEMIXYS 300-300 MG TABlamivudine-tenofovir disoproxil fumarate

4 S



TRIUMEQ 600-50-300 MG TABabacavir-dolutegravir-lamivudine

4QL 30 / 30 DAYS

S

ANTIRETROVIRALS - CCR5 ANTAGONISTS (ENTRY INHIBITOR)

SELZENTRY 150 MG TABmaraviroc

4PA

S

SELZENTRY 20 MG/ML SOLUTIONmaraviroc

4PA

S


4PA

S


4PA

S


4PA

S

ANTIRETROVIRALS - FUSION INHIBITORS

FUZEON 90 MG RECON SOLNenfuvirtide

4PA

S

ANTIRETROVIRALS - GP120-DIRECTED ATTACHMENT INHIBITOR

RUKOBIA 600 MG TAB ER 12Hfostemsavir tromethamine

4PA

S

ANTIRETROVIRALS - INTEGRASE INHIBITORS

ISENTRESS 100 MG CHEW TABraltegravir potassium

4QL 180 / 30 DAYS

S

ISENTRESS 100 MG PACKETraltegravir potassium

4QL 240 / 30 DAYS

S

ISENTRESS 25 MG CHEW TABraltegravir potassium

4QL 720 / 30 DAYS

S

ISENTRESS 400 MG TABraltegravir potassium

4QL 60 / 30 DAYS

S

ISENTRESS HD 600 MG TABraltegravir potassium

4QL 60 / 30 DAYS

S



TIVICAY 10 MG TABdolutegravir sodium

4QL 30 / 30 DAYS

S


4QL 30 / 30 DAYS

S


4QL 60 / 30 DAYS

S

TIVICAY PD 5 MG TAB SOLdolutegravir sodium

4PA

S

ANTIRETROVIRALS - PROTEASE INHIBITORS

APTIVUS 100 MG/ML SOLUTIONtipranavir

4

QL 300 / 30 DAYS

AL1 Up to 8 yrs old

S

APTIVUS 250 MG CAPtipranavir

4QL 120 / 30 DAYS

S

atazanavir sulfate 150 mg cap 2



CRIXIVAN 200 MG CAPindinavir sulfate

4QL 360 / 30 DAYS

S

CRIXIVAN 400 MG CAPindinavir sulfate

4QL 180 / 30 DAYS

S

fosamprenavir calcium 700 mg tab 2

INVIRASE 200 MG CAPsaquinavir mesylate

4QL 300 / 30 DAYS

S

INVIRASE 500 MG TABsaquinavir mesylate

4QL 120 / 30 DAYS

S

LEXIVA 50 MG/ML SUSPENSIONfosamprenavir calcium

4QL 1800 / 30 DAYS

S



NORVIR 100 MG CAPritonavir

4QL 360 / 30 DAYS

S

NORVIR 80 MG/ML SOLUTIONritonavir

4

QL 480 / 30 DAYS

AL1 Up to 8 yrs old

S

PREZISTA 100 MG/ML SUSPENSIONdarunavir ethanolate

4QL 400 / 30 DAYS

S

PREZISTA 150 MG TABdarunavir ethanolate

4QL 180 / 30 DAYS

S


4QL 60 / 30 DAYS

S


4QL 300 / 30 DAYS

S


4 S

REYATAZ 50 MG PACKETatazanavir sulfate

4AL1 Up to 8 yrs old

S

ritonavir 100 mg tab 1

ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE ANALOGUES

EDURANT 25 MG TABrilpivirine hcl

4QL 30 / 30 DAYS

S

efavirenz 200 mg cap 2

efavirenz 50 mg cap 2

efavirenz 600 mg tab 2

etravirine 100 mg tab 4QL 120 / 30 day(s)

S

etravirine 200 mg tab 4QL 60 / 30 day(s)

S

INTELENCE 25 MG TABetravirine

4 S



nevirapine 200 mg tab 1 QL 60 / 30 DAYS

NEVIRAPINE 50 MG/5ML SUSPENSIONnevirapine

1QL 1200 / 30 day(s)

AL1 Up to 8 yrs old

nevirapine er 100 mg tab er 24h 1 QL 90 / 30 DAYS

NEVIRAPINE ER 100 MG TAB ER 24Hnevirapine

1 QL 90 / 30 DAYS

nevirapine er 400 mg tab er 24h 1 QL 30 / 30 DAYS

PIFELTRO 100 MG TABdoravirine

4 S

RESCRIPTOR 100 MG TABdelavirdine mesylate

4QL 360 / 30 DAYS

S

RESCRIPTOR 200 MG TABdelavirdine mesylate

4QL 180 / 30 DAYS

S

ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PURINES

abacavir sulfate 20 mg/ml solution 1 AL1 Up to 8 yrs old

abacavir sulfate 300 mg tab 1 QL 60 / 30 DAYS

DIDANOSINE 200 MG CAP DRdidanosine

1 QL 60 / 30 DAYS

didanosine 200 mg cap dr 1 QL 60 / 30 DAYS


1 QL 30 / 30 DAYS



1 QL 30 / 30 DAYS


ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PYRIMIDINESemtricitabine 200 mg cap 2

EMTRIVA 10 MG/ML SOLUTIONemtricitabine

4QL 850 / 30 DAYS

S

lamivudine 10 mg/ml solution 1



lamivudine 150 mg tab 1 QL 60 / 30 DAYS


ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-THYMIDINESSTAVUDINE 15 MG CAPstavudine

1 QL 120 / 30 DAYS

stavudine 15 mg cap 1 QL 120 / 30 DAYS

STAVUDINE 20 MG CAPstavudine

1 QL 120 / 30 DAYS



1 QL 60 / 30 DAYS



1 QL 60 / 30 DAYS


zidovudine 100 mg cap 1 QL 180 / 30 DAYS

zidovudine 300 mg tab 1 QL 60 / 30 DAYS

zidovudine 50 mg/5ml syrup 1 QL 1920 / 30 DAYS

ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES

tenofovir disoproxil fumarate 300 mg tab 1 QL 30 / 30 DAYS

VIREAD 150 MG TABtenofovir disoproxil fumarate

4QL 30 / 30 DAYS

S


4QL 30 / 30 DAYS

S


4QL 30 / 30 DAYS

S

VIREAD 40 MG/GM POWDERtenofovir disoproxil fumarate

4

QL 240 / 30 DAYS

AL1 Up to 8 yrs old

S



ANTIRETROVIRALS ADJUVANTS

TYBOST 150 MG TABcobicistat

4QL 30 / 30 DAYS

S

ANTIVIRAL COMBINATIONSPAXLOVID 20 X 150 MG & 10 X 100MG TAB THPKnirmatrelvir-ritonavir

2 QL 30 / 180 day(s)

CMV AGENTS

LIVTENCITY 200 MG TABmaribavir

4PA

S

valganciclovir hcl 450 mg tab 2

valganciclovir hcl 50 mg/ml recon soln 2 AL1 Up to 8 yrs old

HEPATITIS B AGENTS

adefovir dipivoxil 10 mg tab 4PA

S

BARACLUDE 0.05 MG/ML SOLUTIONentecavir

4PA

S

entecavir 0.5 mg tab 1 QL 30 / 30 DAYS

entecavir 1 mg tab 1 QL 30 / 30 DAYS


HEPATITIS C AGENT - COMBINATIONS

LEDIPASVIR-SOFOSBUVIR 90-400 MG TABledipasvir-sofosbuvir

4PA

S

MAVYRET 100-40 MG TABglecaprevir-pibrentasvir

4PA

S

MAVYRET 50-20 MG PACKETglecaprevir-pibrentasvir

4PA

S

SOFOSBUVIR-VELPATASVIR 400-100 MG TABsofosbuvir-velpatasvir

4PA

S



HEPATITIS C AGENTSmoderiba 200 mg tab 1

PEGASYS 180 MCG/0.5ML SOLN PRSYRpeginterferon alfa-2a

4PA

S

PEGASYS PROCLICK 135 MCG/0.5ML SOLN A-INJpeginterferon alfa-2a

4PA

S

PEGASYS PROCLICK 180 MCG/0.5ML SOLN A-INJpeginterferon alfa-2a

4PA

S

PEGINTRON 50 MCG/0.5ML KITpeginterferon alfa-2b

4PA

S

ribasphere 200 mg cap 1

ribasphere 200 mg tab 1

RIBASPHERE 400 MG TABribavirin (hepatitis c)

4PA

S

RIBASPHERE 600 MG TABribavirin (hepatitis c)

4PA

S

RIBASPHERE RIBAPAK (1000 PACK) 400 & 600 MG TABTHPKribavirin (hepatitis c)

4PA

S

RIBASPHERE RIBAPAK (1200 PACK) 600 MG TAB THPKribavirin (hepatitis c)

4PA

S

RIBASPHERE RIBAPAK (800 PACK) 400 MG TAB THPKribavirin (hepatitis c)

4PA

S

ribavirin 200 mg cap 1

ribavirin 200 mg tab 1

HERPES AGENTS - PURINE ANALOGUESacyclovir 200 mg cap 1

acyclovir 200 mg/5ml suspension 1

acyclovir 400 mg tab 1



acyclovir 800 mg tab 1

valacyclovir hcl 1 gm tab 1

valacyclovir hcl 500 mg tab 1

HERPES AGENTS - THYMIDINE ANALOGUES

famciclovir 125 mg tab 1 QL 60 / 30 DAYS



INFLUENZA AGENTSRIMANTADINE HCL 100 MG TABrimantadine hydrochloride

1

MISC. ANTIVIRALSMOLNUPIRAVIR 200 MG CAPmolnupiravir

2 QL 40 / 180 day(s)

NEURAMINIDASE INHIBITORS

oseltamivir phosphate 30 mg cap 1 QL 10 / 5 DAYS


oseltamivir phosphate 6 mg/ml recon susp 1QL 180 / 5 DAYS

MFL 1 / 180 DAYS


RELENZA DISKHALER 5 MG/BLISTER AER POW BAzanamivir

3 QL 20 / 10 DAYS

PA ENDONUCLEASE INHIBITORS

XOFLUZA (40 MG DOSE) 1 X 40 MG TAB THPKbaloxavir marboxil

3QL 1 / 0 day(s)

MFL 1 / 180 day(s)


3 QL 2 / 180 DAYS


3QL 1 / 0 day(s)

MFL 1 / 180 day(s)


3 QL 2 / 180 DAYS



BETA BLOCKERSALPHA-BETA BLOCKERS

carvedilol 12.5 mg tab 1 QL 4 / 1 day(s)

carvedilol 25 mg tab 1 QL 4 / 1 day(s)



carvedilol phosphate er 10 mg cap er 24h 2 QL 30 / 30 DAYS




labetalol hcl 100 mg tab 1



BETA BLOCKERS CARDIO-SELECTIVEacebutolol hcl 200 mg cap 1

acebutolol hcl 400 mg cap 1

atenolol 100 mg tab 1



betaxolol hcl 10 mg tab 1

betaxolol hcl 20 mg tab 1

bisoprolol fumarate 10 mg tab 1

bisoprolol fumarate 5 mg tab 1

metoprolol succinate er 100 mg tab er 24h 1 QL 60 / 30 day(s)






metoprolol tartrate 100 mg tab 1


metoprolol tartrate 37.5 mg tab 1



nebivolol hcl 10 mg tab 2 QL 60 / 30 day(s)

nebivolol hcl 2.5 mg tab 2 QL 60 / 30 day(s)



BETA BLOCKERS NON-SELECTIVEINDERAL XL 120 MG CAP ER 24Hpropranolol hcl sustained-release beads

3

INDERAL XL 80 MG CAP ER 24Hpropranolol hcl sustained-release beads

3

INNOPRAN XL 80 MG CAP ER 24Hpropranolol hcl sustained-release beads

3

nadolol 20 mg tab 1

nadolol 40 mg tab 1

nadolol 80 mg tab 1

pindolol 10 mg tab 1

pindolol 5 mg tab 1

propranolol hcl 10 mg tab 1


propranolol hcl 20 mg/5ml solution 1 AL1 Up to 8 yrs old


PROPRANOLOL HCL 40 MG/5ML SOLUTIONpropranolol hcl






propranolol hcl er 120 mg cap er 24h 1




sorine 120 mg tab 1

sorine 160 mg tab 1

sorine 240 mg tab 1

sorine 80 mg tab 1

sotalol hcl (af) 120 mg tab 1



sotalol hcl 120 mg tab 1




SOTYLIZE 5 MG/ML SOLUTIONsotalol hcl

4QL 1920 / 30 day(s)

PA

TIMOLOL MALEATE 10 MG TABtimolol maleate

1

TIMOLOL MALEATE 20 MG TABtimolol maleate

1

timolol maleate 20 mg tab 1

timolol maleate 5 mg tab 1

CALCIUM CHANNEL BLOCKERSafeditab cr 30 mg tab er 24h 1

afeditab cr 60 mg tab er 24h 1

amlodipine besylate 10 mg tab 1 QL 30 / 30 DAYS

amlodipine besylate 2.5 mg tab 1 QL 30 / 30 DAYS

amlodipine besylate 5 mg tab 1 QL 30 / 30 DAYS



cartia xt 120 mg cap er 24h 1




dilt-xr 120 mg cap er 24h 1



diltiazem cd 120 mg cap er 24h 1




diltiazem hcl 120 mg tab 1




diltiazem hcl er 120 mg cap er 12h 1






diltiazem hcl er beads 120 mg cap er 24h 1






diltiazem hcl er coated beads 120 mg cap er 24h 1




diltiazem hcl er coated beads 180 mg tab er 24h 1








felodipine er 10 mg tab er 24h 1

felodipine er 2.5 mg tab er 24h 1

felodipine er 5 mg tab er 24h 1

isradipine 2.5 mg cap 1

isradipine 5 mg cap 1

KATERZIA 1 MG/ML SUSPENSIONamlodipine benzoate


matzim la 180 mg tab er 24h 1





nicardipine hcl 20 mg cap 1

nicardipine hcl 30 mg cap 1

nifedipine 10 mg cap 1

nifedipine 20 mg cap 1

nifedipine er 30 mg tab er 24h 1



nifedipine er osmotic release 30 mg tab er 24h 1





nimodipine 30 mg cap 2

nisoldipine er 17 mg tab er 24h 1

NISOLDIPINE ER 20 MG TAB ER 24Hnisoldipine

1

NISOLDIPINE ER 25.5 MG TAB ER 24Hnisoldipine

1


1

nisoldipine er 34 mg tab er 24h 1


1

nisoldipine er 8.5 mg tab er 24h 1

taztia xt 120 mg cap er 24h 1





tiadylt er 120 mg cap er 24h 1






verapamil hcl 120 mg tab 1



verapamil hcl er 120 mg cap er 24h 1

verapamil hcl er 120 mg tab er 1







CARDIOTONICSCARDIAC GLYCOSIDES

digitek 125 mcg tab 1

digitek 250 mcg tab 1

digox 125 mcg tab 1

digox 250 mcg tab 1

DIGOXIN 0.05 MG/ML SOLUTIONdigoxin

1

digoxin 0.05 mg/ml solution 1

digoxin 125 mcg tab 1

digoxin 250 mcg tab 1

LANOXIN 125 MCG TABdigoxin

3

LANOXIN 187.5 MCG TABdigoxin

3

LANOXIN 250 MCG TABdigoxin

3

LANOXIN 62.5 MCG TABdigoxin

3

CARDIOVASCULAR AGENTS - MISC.CALCIUM CHANNEL BLOCKER & HMG COA REDUCTASE INHIBIT COMB

amlodipine-atorvastatin 10-10 mg tab 1




amlodipine-atorvastatin 2.5-10 mg tab 1









NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMBENTRESTO 24-26 MG TABsacubitril-valsartan

2 QL 60 / 30 DAYS

ENTRESTO 49-51 MG TABsacubitril-valsartan

2 QL 60 / 30 DAYS

ENTRESTO 97-103 MG TABsacubitril-valsartan

2 QL 60 / 30 DAYS

PROSTAGLANDIN VASODILATORS

VENTAVIS 10 MCG/ML SOLUTIONiloprost

4PA

S

VENTAVIS 20 MCG/ML SOLUTIONiloprost

4PA

S

PULM HYPERTEN-SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC)

ADEMPAS 0.5 MG TABriociguat

4PA

S

ADEMPAS 1 MG TABriociguat

4PA

S


4PA

S

ADEMPAS 2 MG TABriociguat

4PA

S


4PA

S

PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS

ambrisentan 10 mg tab 4

QL 30 / 30 DAYS

PA

S



ambrisentan 5 mg tab 4

QL 30 / 30 DAYS

PA

S

bosentan 125 mg tab 2QL 60 / 30 DAYS

PA

bosentan 62.5 mg tab 2QL 60 / 30 DAYS

PA

OPSUMIT 10 MG TABmacitentan

4PA

S

PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS

sildenafil citrate 10 mg/ml recon susp 2PA

S

sildenafil citrate 20 mg tab 1QL 90 / 30 DAYS

PA

tadalafil (pah) 20 mg tab 2QL 60 / 30 DAYS

PA

PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST

UPTRAVI 1000 MCG TABselexipag

4PA

S


4PA

S


4PA

S


4PA

S

UPTRAVI 200 & 800 MCG TAB THPKselexipag

4PA

S


4PA

S




4PA

S


4PA

S


4PA

S

SELECTIVE CGMP PHOSPHODIESTERASE TYPE 5 INHIBITORS

tadalafil 2.5 mg tab 1QL 30 / 30 DAYS

PA

tadalafil 20 mg tab 2QL 60 / 30 DAYS

PA

tadalafil 5 mg tab 1QL 30 / 30 DAYS

PA

SINUS NODE INHIBITORSCORLANOR 5 MG TABivabradine hcl

2 QL 60 / 30 day(s)

CORLANOR 7.5 MG TABivabradine hcl

2 QL 60 / 30 day(s)

CEPHALOSPORINSCEPHALOSPORINS - 1ST GENERATION

CEFADROXIL 1 GM TABcefadroxil

1

cefadroxil 1 gm tab 1

cefadroxil 250 mg/5ml recon susp 1

cefadroxil 500 mg cap 1

cefadroxil 500 mg/5ml recon susp 1

cephalexin 125 mg/5ml recon susp 1

cephalexin 250 mg cap 1

CEPHALEXIN 250 MG TABcephalexin

1

cephalexin 250 mg/5ml recon susp 1




CEPHALEXIN 500 MG TABcephalexin

1

CEPHALEXIN 750 MG CAPcephalexin

1


CEPHALOSPORINS - 2ND GENERATIONCEFACLOR 125 MG/5ML RECON SUSPcefaclor


CEFACLOR 250 MG CAPcefaclor

1 QL 30 / 10 DAYS

cefaclor 250 mg cap 1 QL 30 / 10 DAYS

CEFACLOR 250 MG/5ML RECON SUSPcefaclor


CEFACLOR 375 MG/5ML RECON SUSPcefaclor


CEFACLOR 500 MG CAPcefaclor

1 QL 30 / 10 DAYS

cefaclor 500 mg cap 1 QL 30 / 10 DAYS

CEFACLOR ER 500 MG TAB ER 12Hcefaclor monohydrate

1 QL 20 / 10 DAYS

cefprozil 125 mg/5ml recon susp 1

cefprozil 250 mg tab 1

cefprozil 250 mg/5ml recon susp 1

cefprozil 500 mg tab 1

cefuroxime axetil 250 mg tab 1

cefuroxime axetil 500 mg tab 1

CEPHALOSPORINS - 3RD GENERATIONcefdinir 125 mg/5ml recon susp 1

cefdinir 250 mg/5ml recon susp 1

cefdinir 300 mg cap 1

CEFDITOREN PIVOXIL 200 MG TABcefditoren pivoxil

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSCEFDITOREN PIVOXIL 400 MG TABcefditoren pivoxil

2

cefixime 100 mg/5ml recon susp 2

cefixime 200 mg/5ml recon susp 2 AL1 Up to 8 yrs old

cefixime 400 mg cap 2 QL 14 / 30 DAYS

cefpodoxime proxetil 100 mg tab 1

cefpodoxime proxetil 100 mg/5ml recon susp 1 AL1 Up to 8 yrs old

cefpodoxime proxetil 200 mg tab 1

cefpodoxime proxetil 50 mg/5ml recon susp 1 AL1 Up to 8 yrs old

CONTRACEPTIVESBIPHASIC CONTRACEPTIVES - ORAL

azurette 0.15-0.02/0.01 mg (21/5) tab 1 PRE Preventative

bekyree 0.15-0.02/0.01 mg (21/5) tab 1 PRE Preventative

desogestrel-ethinyl estradiol 0.15-0.02/0.01 mg (21/5) tab 1 PRE Preventative

kariva 0.15-0.02/0.01 mg (21/5) tab 1 PRE Preventative

kimidess 0.15-0.02/0.01 mg (21/5) tab 1 PRE Preventative

LO LOESTRIN FE 1 MG-10 MCG / 10 MCG TABnorethindrone acetate-ethinyl estradiol-fe fum (biphasic)

3 QL 30 / 30 day(s)

MIRCETTE 0.15-0.02/0.01 MG (21/5) TABdesogestrel-ethinyl estradiol (biphasic)

3

pimtrea 0.15-0.02/0.01 mg (21/5) tab 1 PRE Preventative

simliya 0.15-0.02/0.01 mg (21/5) tab 1 PRE Preventative

viorele 0.15-0.02/0.01 mg (21/5) tab 1 PRE Preventative

volnea 0.15-0.02/0.01 mg (21/5) tab 1 PRE Preventative

COMBINATION CONTRACEPTIVES - ORAL

afirmelle 0.1-20 mg-mcg tab 1 PRE Preventative

altavera 0.15-30 mg-mcg tab 1 PRE Preventative



alyacen 1/35 1-35 mg-mcg tab 1 PRE Preventative

apri 0.15-30 mg-mcg tab 1 PRE Preventative

aubra 0.1-20 mg-mcg tab 1 PRE Preventative

aubra eq 0.1-20 mg-mcg tab 1 PRE Preventative

aurovela 1.5/30 1.5-30 mg-mcg tab 1 PRE Preventative

aurovela 1/20 1-20 mg-mcg tab 1 PRE Preventative

aurovela 24 fe 1-20 mg-mcg(24) tab 1 PRE Preventative

aurovela fe 1.5/30 1.5-30 mg-mcg tab 1 PRE Preventative

aurovela fe 1/20 1-20 mg-mcg tab 1 PRE Preventative

aviane 0.1-20 mg-mcg tab 1 PRE Preventative

ayuna 0.15-30 mg-mcg tab 1 PRE Preventative

BALCOLTRA 0.1-20 MG-MCG(21) TABlevonorgestrel-ethinyl estradiol-ferrous bisglycinate

3

balziva 0.4-35 mg-mcg tab 1 PRE Preventative

BEYAZ 3-0.02-0.451 MG TABdrospirenone-ethinyl estradiol-levomefolate calcium

3

blisovi 24 fe 1-20 mg-mcg(24) tab 1 PRE Preventative

blisovi fe 1.5/30 1.5-30 mg-mcg tab 1 PRE Preventative

blisovi fe 1/20 1-20 mg-mcg tab 1 PRE Preventative

briellyn 0.4-35 mg-mcg tab 1 PRE Preventative

charlotte 24 fe 1-20 mg-mcg(24) chew tab 1 PRE Preventative

chateal 0.15-30 mg-mcg tab 1 PRE Preventative

chateal eq 0.15-30 mg-mcg tab 1 PRE Preventative

cryselle-28 0.3-30 mg-mcg tab 1 PRE Preventative

cyclafem 1/35 1-35 mg-mcg tab 1 PRE Preventative



cyred 0.15-30 mg-mcg tab 1 PRE Preventative

cyred eq 0.15-30 mg-mcg tab 1 PRE Preventative

dasetta 1/35 1-35 mg-mcg tab 1 PRE Preventative

delyla 0.1-20 mg-mcg tab 1 PRE Preventative

desogestrel-ethinyl estradiol 0.15-30 mg-mcg tab 1 PRE Preventative

drospiren-eth estrad-levomefol 3-0.02-0.451 mg tab 3

drospiren-eth estrad-levomefol 3-0.03-0.451 mg tab 1 PRE Preventative

drospirenone-ethinyl estradiol 3-0.02 mg tab 1 PRE Preventative

drospirenone-ethinyl estradiol 3-0.03 mg tab 1 PRE Preventative

elinest 0.3-30 mg-mcg tab 1 PRE Preventative

emoquette 0.15-30 mg-mcg tab 1 PRE Preventative

enskyce 0.15-30 mg-mcg tab 1 PRE Preventative

estarylla 0.25-35 mg-mcg tab 1 PRE Preventative

ethynodiol diac-eth estradiol 1-35 mg-mcg tab 1 PRE Preventative

ethynodiol diac-eth estradiol 1-50 mg-mcg tab 1 PRE Preventative

falmina 0.1-20 mg-mcg tab 1 PRE Preventative

femynor 0.25-35 mg-mcg tab 1 PRE Preventative

gemmily 1-20 mg-mcg(24) cap 2

GENERESS FE 0.8-25 MG-MCG CHEW TABnorethindrone & ethinyl estradiol-fe

3

gianvi 3-0.02 mg tab 1 PRE Preventative

hailey 1.5/30 1.5-30 mg-mcg tab 1 PRE Preventative

hailey 24 fe 1-20 mg-mcg(24) tab 1 PRE Preventative

hailey fe 1.5/30 1.5-30 mg-mcg tab 1 PRE Preventative

hailey fe 1/20 1-20 mg-mcg tab 1 PRE Preventative



isibloom 0.15-30 mg-mcg tab 1 PRE Preventative

jasmiel 3-0.02 mg tab 1 PRE Preventative

juleber 0.15-30 mg-mcg tab 1 PRE Preventative

junel 1.5/30 1.5-30 mg-mcg tab 1 PRE Preventative

junel 1/20 1-20 mg-mcg tab 1 PRE Preventative

junel fe 1.5/30 1.5-30 mg-mcg tab 1 PRE Preventative

junel fe 1/20 1-20 mg-mcg tab 1 PRE Preventative

junel fe 24 1-20 mg-mcg(24) tab 1 PRE Preventative

kaitlib fe 0.8-25 mg-mcg chew tab 1 PRE Preventative

kalliga 0.15-30 mg-mcg tab 1 PRE Preventative

kelnor 1/35 1-35 mg-mcg tab 1 PRE Preventative

kelnor 1/50 1-50 mg-mcg tab 1 PRE Preventative

kurvelo 0.15-30 mg-mcg tab 1 PRE Preventative

larin 1.5/30 1.5-30 mg-mcg tab 1 PRE Preventative

larin 1/20 1-20 mg-mcg tab 1 PRE Preventative

larin 24 fe 1-20 mg-mcg(24) tab 1 PRE Preventative

larin fe 1.5/30 1.5-30 mg-mcg tab 1 PRE Preventative

larin fe 1/20 1-20 mg-mcg tab 1 PRE Preventative

larissia 0.1-20 mg-mcg tab 1 PRE Preventative

layolis fe 0.8-25 mg-mcg chew tab 1 PRE Preventative

lessina 0.1-20 mg-mcg tab 1 PRE Preventative

levonorgestrel-ethinyl estrad 0.1-20 mg-mcg tab 1 PRE Preventative

levonorgestrel-ethinyl estrad 0.15-30 mg-mcg tab 1 PRE Preventative

levora 0.15/30 (28) 0.15-30 mg-mcg tab 1 PRE Preventative



lillow 0.15-30 mg-mcg tab 1 PRE Preventative

lo-zumandimine 3-0.02 mg tab 1 PRE Preventative

loestrin 1.5/30 (21) 1.5-30 mg-mcg tab 1 PRE Preventative

loestrin 1/20 (21) 1-20 mg-mcg tab 1 PRE Preventative

loestrin fe 1.5/30 1.5-30 mg-mcg tab 1 PRE Preventative

loestrin fe 1/20 1-20 mg-mcg tab 1 PRE Preventative

loryna 3-0.02 mg tab 1 PRE Preventative

low-ogestrel 0.3-30 mg-mcg tab 1 PRE Preventative

lutera 0.1-20 mg-mcg tab 1 PRE Preventative

marlissa 0.15-30 mg-mcg tab 1 PRE Preventative

melodetta 24 fe 1-20 mg-mcg(24) chew tab 1 PRE Preventative

merzee 1-20 mg-mcg(24) cap 2

mibelas 24 fe 1-20 mg-mcg(24) chew tab 1 PRE Preventative

microgestin 1.5/30 1.5-30 mg-mcg tab 1 PRE Preventative

microgestin 1/20 1-20 mg-mcg tab 1 PRE Preventative

microgestin 24 fe 1-20 mg-mcg tab 1 PRE Preventative

microgestin fe 1.5/30 1.5-30 mg-mcg tab 1 PRE Preventative

microgestin fe 1/20 1-20 mg-mcg tab 1 PRE Preventative

mili 0.25-35 mg-mcg tab 1 PRE Preventative

MINASTRIN 24 FE 1-20 MG-MCG(24) CHEW TABnorethin acet & estrad-fe

3

mono-linyah 0.25-35 mg-mcg tab 1 PRE Preventative

mononessa 0.25-35 mg-mcg tab 1 PRE Preventative

necon 0.5/35 (28) 0.5-35 mg-mcg tab 1 PRE Preventative

NEXTSTELLIS 3-14.2 MG TABdrospirenone-estetrol

3



nikki 3-0.02 mg tab 1 PRE Preventative

norethin ace-eth estrad-fe 1-20 mg-mcg tab 1 PRE Preventative

norethin ace-eth estrad-fe 1-20 mg-mcg(24) cap 2

norethin ace-eth estrad-fe 1-20 mg-mcg(24) chew tab 1 PRE Preventative

norethin ace-eth estrad-fe 1-20 mg-mcg(24) tab 1 PRE Preventative

norethin ace-eth estrad-fe 1.5-30 mg-mcg tab 1 PRE Preventative

norethin-eth estradiol-fe 0.4-35 mg-mcg chew tab 1 PRE Preventative

norethin-eth estradiol-fe 0.8-25 mg-mcg chew tab 1 PRE Preventative

norethindrone acet-ethinyl est 1-20 mg-mcg tab 1 PRE Preventative

norethindrone acet-ethinyl est 1-20 mg-mcg(24) chew tab 1 PRE Preventative

norethindrone acet-ethinyl est 1.5-30 mg-mcg tab 1 PRE Preventative

norgestimate-eth estradiol 0.25-35 mg-mcg tab 1 PRE Preventative

nortrel 0.5/35 (28) 0.5-35 mg-mcg tab 1 PRE Preventative

nortrel 1/35 (21) 1-35 mg-mcg tab 1 PRE Preventative

nortrel 1/35 (28) 1-35 mg-mcg tab 1 PRE Preventative

nylia 1/35 1-35 mg-mcg tab 1 PRE Preventative

nymyo 0.25-35 mg-mcg tab 1 PRE Preventative

ocella 3-0.03 mg tab 1 PRE Preventative

OGESTREL 0.5-50 MG-MCG TABnorgestrel & ethinyl estradiol

2 PRE Preventative

orsythia 0.1-20 mg-mcg tab 1 PRE Preventative

ORTHO-CYCLEN (28) 0.25-35 MG-MCG TABnorgestimate-ethinyl estradiol

3

ORTHO-NOVUM 1/35 (28) 1-35 MG-MCG TABnorethindrone & eth estradiol

3

philith 0.4-35 mg-mcg tab 1 PRE Preventative



pirmella 1/35 1-35 mg-mcg tab 1 PRE Preventative

portia-28 0.15-30 mg-mcg tab 1 PRE Preventative

previfem 0.25-35 mg-mcg tab 1 PRE Preventative

rajani 3-0.02-0.451 mg tab 3

reclipsen 0.15-30 mg-mcg tab 1 PRE Preventative

SAFYRAL 3-0.03-0.451 MG TABdrospirenone-ethinyl estradiol-levomefolate calcium

3

sprintec 28 0.25-35 mg-mcg tab 1 PRE Preventative

sronyx 0.1-20 mg-mcg tab 1 PRE Preventative

syeda 3-0.03 mg tab 1 PRE Preventative

tarina 24 fe 1-20 mg-mcg(24) tab 1 PRE Preventative

tarina fe 1/20 1-20 mg-mcg tab 1 PRE Preventative

tarina fe 1/20 eq 1-20 mg-mcg tab 1 PRE Preventative

taysofy 1-20 mg-mcg(24) cap 2

TAYTULLA 1-20 MG-MCG(24) CAPnorethin acet & estrad-fe

3

TYBLUME 0.1-20 MG-MCG CHEW TABlevonorgestrel & eth estradiol

1 PRE Preventative

tydemy 3-0.03-0.451 mg tab 1 PRE Preventative

vestura 3-0.02 mg tab 1 PRE Preventative

vienva 0.1-20 mg-mcg tab 1 PRE Preventative

vyfemla 0.4-35 mg-mcg tab 1 PRE Preventative

vylibra 0.25-35 mg-mcg tab 1 PRE Preventative

wera 0.5-35 mg-mcg tab 1 PRE Preventative

wymzya fe 0.4-35 mg-mcg chew tab 1 PRE Preventative

YASMIN 28 3-0.03 MG TABdrospirenone-ethinyl estradiol

3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSYAZ 3-0.02 MG TABdrospirenone-ethinyl estradiol

3

zarah 3-0.03 mg tab 1 PRE Preventative

zenchent 0.4-35 mg-mcg tab 1 PRE Preventative

zovia 1/35 (28) 1-35 mg-mcg tab 1 PRE Preventative

zovia 1/35e (28) 1-35 mg-mcg tab 1 PRE Preventative

zovia 1/50e (28) 1-50 mg-mcg tab 1 PRE Preventative

zumandimine 3-0.03 mg tab 1 PRE Preventative

COMBINATION CONTRACEPTIVES - TRANSDERMAL

TWIRLA 120-30 MCG/24HR PATCH WKlevonorgestrel-ethinyl estradiol

2QL 3 / 21 day(s)

PRE Preventative

xulane 150-35 mcg/24hr patch wk 1QL 3 / 21 day(s)

PRE Preventative

zafemy 150-35 mcg/24hr patch wk 1QL 3 / 21 day(s)

PRE Preventative

COMBINATION CONTRACEPTIVES - VAGINAL

ANNOVERA 0.013-0.15 MG/24HR RINGsegesterone acetate-ethinyl estradiol

2QL 1 / 365 day(s)

PRE Preventative

eluryng 0.12-0.015 mg/24hr ring 1 PRE Preventative

etonogestrel-ethinyl estradiol 0.12-0.015 mg/24hr ring 1 PRE Preventative

CONTINUOUS CONTRACEPTIVES - ORAL

amethyst 90-20 mcg tab 1 PRE Preventative

dolishale 90-20 mcg tab 1 PRE Preventative

levonorgestrel-ethinyl estrad 90-20 mcg tab 1 PRE Preventative

COPPER CONTRACEPTIVES - IUDPARAGARD INTRAUTERINE COPPER IUDcopper (iud)

2 PRE Preventative



EMERGENCY CONTRACEPTIVES

ELLA 30 MG TABulipristal acetate

2QL 1 / 30 DAYS

PRE Preventative

EXTENDED-CYCLE CONTRACEPTIVES - ORAL

amethia 0.15-0.03 &0.01 mg tab 1QL 91 / 91 DAYS

PRE Preventative

amethia lo 0.1-0.02 & 0.01 mg tab 1QL 91 / 91 DAYS

PRE Preventative

ashlyna 0.15-0.03 &0.01 mg tab 1QL 91 / 91 DAYS

PRE Preventative

camrese 0.15-0.03 &0.01 mg tab 1QL 91 / 91 DAYS

PRE Preventative

camrese lo 0.1-0.02 & 0.01 mg tab 1QL 91 / 91 DAYS

PRE Preventative

daysee 0.15-0.03 &0.01 mg tab 1QL 91 / 91 DAYS

PRE Preventative

fayosim 42-21-21-7 days tab 1 PRE Preventative

iclevia 0.15-0.03 mg tab 1QL 91 / 91 DAYS

PRE Preventative

introvale 0.15-0.03 mg tab 1QL 91 / 91 DAYS

PRE Preventative

jaimiess 0.15-0.03 &0.01 mg tab 1QL 91 / 91 DAYS

PRE Preventative

jolessa 0.15-0.03 mg tab 1QL 91 / 91 DAYS

PRE Preventative

levonorgest-eth est & eth est 42-21-21-7 days tab 1 PRE Preventative

levonorgest-eth estrad 91-day 0.1-0.02 & 0.01 mg tab 1QL 91 / 91 DAYS

PRE Preventative



levonorgest-eth estrad 91-day 0.15-0.03 &0.01 mg tab 1QL 91 / 91 DAYS

PRE Preventative

levonorgest-eth estrad 91-day 0.15-0.03 mg tab 1QL 91 / 91 DAYS

PRE Preventative

lojaimiess 0.1-0.02 & 0.01 mg tab 1QL 91 / 91 DAYS

PRE Preventative

LOSEASONIQUE 0.1-0.02 & 0.01 MG TABlevonorgestrel-ethinyl estradiol (91-day)

3

QUARTETTE 42-21-21-7 DAYS TABlevonorgestrel-ethinyl estradiol (91-day)

3

quasense 0.15-0.03 mg tab 1QL 91 / 91 DAYS

PRE Preventative

rivelsa 42-21-21-7 days tab 1 PRE Preventative

SEASONIQUE 0.15-0.03 &0.01 MG TABlevonorgestrel-ethinyl estradiol (91-day)

3

setlakin 0.15-0.03 mg tab 1QL 91 / 91 DAYS

PRE Preventative

simpesse 0.15-0.03 &0.01 mg tab 1QL 91 / 91 DAYS

PRE Preventative

FOUR PHASE CONTRACEPTIVES - ORALNATAZIA 3/2-2/2-3/1 MG TABestradiol valerate-dienogest

3

PROGESTIN CONTRACEPTIVES - IMPLANTSNEXPLANON 68 MG IMPLANTetonogestrel

2 PRE Preventative

PROGESTIN CONTRACEPTIVES - INJECTABLEDEPO-PROVERA 150 MG/ML SUSP PRSYRmedroxyprogesterone acetate (contraceptive)

3

DEPO-PROVERA 150 MG/ML SUSPENSIONmedroxyprogesterone acetate (contraceptive)

3

DEPO-SUBQ PROVERA 104 104 MG/0.65ML SUSP PRSYRmedroxyprogesterone acetate (contraceptive)

2 PRE Preventative



medroxyprogesterone acetate 150 mg/ml susp prsyr 1 PRE Preventative

medroxyprogesterone acetate 150 mg/ml suspension 1 PRE Preventative

PROGESTIN CONTRACEPTIVES - IUDKYLEENA 19.5 MG IUDlevonorgestrel (iud)

2 PRE Preventative

LILETTA (52 MG) 19.5 MCG/DAY IUDlevonorgestrel (iud)

2 PRE Preventative

MIRENA (52 MG) 20 MCG/24HR IUDlevonorgestrel (iud)

2 PRE Preventative

SKYLA 13.5 MG IUDlevonorgestrel (iud)

2 PRE Preventative

PROGESTIN CONTRACEPTIVES - ORAL

camila 0.35 mg tab 1 PRE Preventative

deblitane 0.35 mg tab 1 PRE Preventative

errin 0.35 mg tab 1 PRE Preventative

heather 0.35 mg tab 1 PRE Preventative

incassia 0.35 mg tab 1 PRE Preventative

jencycla 0.35 mg tab 1 PRE Preventative

jolivette 0.35 mg tab 1 PRE Preventative

lyleq 0.35 mg tab 1 PRE Preventative

lyza 0.35 mg tab 1 PRE Preventative

nora-be 0.35 mg tab 1 PRE Preventative

norethindrone 0.35 mg tab 1 PRE Preventative

norlyda 0.35 mg tab 1 PRE Preventative

norlyroc 0.35 mg tab 1 PRE Preventative

ORTHO MICRONOR 0.35 MG TABnorethindrone (contraceptive)

3

sharobel 0.35 mg tab 1 PRE Preventative


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSSLYND 4 MG TABdrospirenone

3

tulana 0.35 mg tab 1 PRE Preventative

TRIPHASIC CONTRACEPTIVES - ORAL

alyacen 7/7/7 0.5/0.75/1-35 mg-mcg tab 1 PRE Preventative

aranelle 0.5/1/0.5-35 mg-mcg tab 1 PRE Preventative

caziant 0.1/0.125/0.15 -0.025 mg tab 1 PRE Preventative

cyclafem 7/7/7 0.5/0.75/1-35 mg-mcg tab 1 PRE Preventative

dasetta 7/7/7 0.5/0.75/1-35 mg-mcg tab 1 PRE Preventative

enpresse-28 50-30/75-40/ 125-30 mcg tab 1 PRE Preventative

ESTROSTEP FE 1-20/1-30/1-35 MG-MCG TABnorethindrone acetate-ethinyl estradiol-fe

3

leena 0.5/1/0.5-35 mg-mcg tab 1 PRE Preventative

levonest 50-30/75-40/ 125-30 mcg tab 1 PRE Preventative

levonorg-eth estrad triphasic 50-30/75-40/ 125-30 mcgtab

1 PRE Preventative

myzilra 50-30/75-40/ 125-30 mcg tab 1 PRE Preventative

necon 7/7/7 0.5/0.75/1-35 mg-mcg tab 1 PRE Preventative

norgestim-eth estrad triphasic 0.18/0.215/0.25 mg-25mcg tab

1 PRE Preventative

norgestim-eth estrad triphasic 0.18/0.215/0.25 mg-35mcg tab

1 PRE Preventative

nortrel 7/7/7 0.5/0.75/1-35 mg-mcg tab 1 PRE Preventative

nylia 7/7/7 0.5/0.75/1-35 mg-mcg tab 1 PRE Preventative

ORTHO TRI-CYCLEN (28) 0.18/0.215/0.25 MG-35 MCGTABnorgestimate-ethinyl estradiol (triphasic)

3

ORTHO TRI-CYCLEN LO 0.18/0.215/0.25 MG-25 MCG TABnorgestimate-ethinyl estradiol (triphasic)

3

ORTHO-NOVUM 7/7/7 (28) 0.5/0.75/1-35 MG-MCG TABnorethindrone-eth estradiol (triphasic)

3



pirmella 7/7/7 0.5/0.75/1-35 mg-mcg tab 1 PRE Preventative

tilia fe 1-20/1-30/1-35 mg-mcg tab 1 PRE Preventative

tri femynor 0.18/0.215/0.25 mg-35 mcg tab 1 PRE Preventative

tri-estarylla 0.18/0.215/0.25 mg-35 mcg tab 1 PRE Preventative

tri-legest fe 1-20/1-30/1-35 mg-mcg tab 1 PRE Preventative

tri-linyah 0.18/0.215/0.25 mg-35 mcg tab 1 PRE Preventative

tri-lo-estarylla 0.18/0.215/0.25 mg-25 mcg tab 1 PRE Preventative

tri-lo-marzia 0.18/0.215/0.25 mg-25 mcg tab 1 PRE Preventative

tri-lo-mili 0.18/0.215/0.25 mg-25 mcg tab 1 PRE Preventative

tri-lo-sprintec 0.18/0.215/0.25 mg-25 mcg tab 1 PRE Preventative

tri-mili 0.18/0.215/0.25 mg-35 mcg tab 1 PRE Preventative

TRI-NORINYL (28) 0.5/1/0.5-35 MG-MCG TABnorethindrone-eth estradiol (triphasic)

1

tri-nymyo 0.18/0.215/0.25 mg-35 mcg tab 1 PRE Preventative

tri-previfem 0.18/0.215/0.25 mg-35 mcg tab 1 PRE Preventative

tri-sprintec 0.18/0.215/0.25 mg-35 mcg tab 1 PRE Preventative

tri-vylibra 0.18/0.215/0.25 mg-35 mcg tab 1 PRE Preventative

tri-vylibra lo 0.18/0.215/0.25 mg-25 mcg tab 1 PRE Preventative

trinessa (28) 0.18/0.215/0.25 mg-35 mcg tab 1 PRE Preventative

trinessa lo 0.18/0.215/0.25 mg-25 mcg tab 1 PRE Preventative

trivora (28) 50-30/75-40/ 125-30 mcg tab 1 PRE Preventative

velivet 0.1/0.125/0.15 -0.025 mg tab 1 PRE Preventative



CORTICOSTEROIDSGLUCOCORTICOSTEROIDS

ALKINDI SPRINKLE 0.5 MG CAP SPRINKhydrocortisone

3QL 2 / 1 day(s)

AL1 Up to 8 yrs old

ALKINDI SPRINKLE 1 MG CAP SPRINKhydrocortisone

3QL 2 / 1 day(s)

AL1 Up to 8 yrs old


3QL 2 / 1 day(s)

AL1 Up to 8 yrs old


3QL 2 / 1 day(s)

AL1 Up to 8 yrs old

budesonide 3 mg cp dr part 2 QL 90 / 30 DAYS

budesonide er 9 mg tab er 24h 2

CORTISONE ACETATE 25 MG TABcortisone acetate

1

decadron 0.5 mg tab 1

decadron 0.5 mg/5ml elixir 1

decadron 0.75 mg tab 1

decadron 4 mg tab 1

decadron 6 mg tab 1

dexamethasone 0.5 mg tab 1

dexamethasone 0.5 mg/5ml elixir 1

DEXAMETHASONE 0.5 MG/5ML SOLUTIONdexamethasone

1


DEXAMETHASONE 1 MG TABdexamethasone

1

DEXAMETHASONE 1.5 MG (35) TAB THPKdexamethasone

1

DEXAMETHASONE 1.5 MG (51) TAB THPKdexamethasone

1



PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSDEXAMETHASONE 2 MG TABdexamethasone

1

dexamethasone 4 mg tab 1

dexamethasone 6 mg tab 1

DEXAMETHASONE INTENSOL 1 MG/ML CONCdexamethasone


hydrocortisone 10 mg tab 1



KENALOG-80 80 MG/ML SUSPENSIONtriamcinolone acetonide

3 PA

methylprednisolone 16 mg tab 1



methylprednisolone 4 mg tab thpk 1


PREDNISOLONE 15 MG/5ML SOLUTIONprednisolone

1

prednisolone 15 mg/5ml solution 1

prednisolone 15 mg/5ml syrup 1

prednisolone sodium phosphate 10 mg/5ml solution 1

prednisolone sodium phosphate 15 mg/5ml solution 1

prednisolone sodium phosphate 20 mg/5ml solution 1 AL1 Up to 8 yrs old

PREDNISOLONE SODIUM PHOSPHATE 25 MG/5MLSOLUTIONprednisolone sodium phosphate


prednisolone sodium phosphate 6.7 (5 base) mg/5mlsolution

1

prednisone 1 mg tab 1

prednisone 10 mg (21) tab thpk 1





prednisone 2.5 mg tab 1





PREDNISONE 5 MG/5ML SOLUTIONprednisone

1


PREDNISONE INTENSOL 5 MG/ML CONCprednisone


UCERIS 9 MG TAB ER 24Hbudesonide

2QL 30 / 30 DAYS

PA

MINERALOCORTICOIDSfludrocortisone acetate 0.1 mg tab 1

COUGH/COLD/ALLERGYANTITUSSIVE - NONNARCOTIC

benzonatate 100 mg cap 1

benzonatate 200 mg cap 1

ANTITUSSIVE - OPIOID

HYCODAN 5-1.5 MG/5ML SYRUPhydrocodone w/ homatropine

1

QL 30 / 1 day(s)


hydrocodone-homatropine 5-1.5 mg tab 1 QL 6 / 1 day(s)

hydrocodone-homatropine 5-1.5 mg/5ml syrup 1

QL 30 / 1 day(s)


hydromet 5-1.5 mg/5ml syrup 1

QL 30 / 1 day(s)




tussigon 5-1.5 mg tab 1 QL 6 / 1 day(s)

ANTITUSSIVE-EXPECTORANT

cheratussin ac 100-10 mg/5ml syrup 1 AL1 Up to 8 yrs old

g tussin ac 100-10 mg/5ml solution 1 AL1 Up to 8 yrs old

guaiatussin ac 100-10 mg/5ml syrup 1 AL1 Up to 8 yrs old

guaifenesin ac 100-10 mg/5ml syrup 1 AL1 Up to 8 yrs old

guaifenesin-codeine 100-10 mg/5ml solution 1 AL1 Up to 8 yrs old

maxi-tuss ac 100-10 mg/5ml solution 1 AL1 Up to 8 yrs old

robafen ac 100-10 mg/5ml solution 1 AL1 Up to 8 yrs old

virtussin a/c 100-10 mg/5ml solution 1 AL1 Up to 8 yrs old

virtussin ac w/alc 100-10 mg/5ml liquid 1 AL1 Up to 8 yrs old

MISC. RESPIRATORY INHALANTSsodium chloride 7 % nebu soln 1

MUCOLYTICSacetylcysteine 10 % solution 1

acetylcysteine 20 % solution 1

NON-NARC ANTITUSSIVE-ANTIHISTAMINEPROMETHAZINE-DM 6.25-15 MG/5ML SOLUTIONpromethazine-dm

1

promethazine-dm 6.25-15 mg/5ml syrup 1

NON-NARC ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINEpseudoeph-bromphen-dm 30-2-10 mg/5ml syrup 1

OPIOID ANTITUSSIVE-ANTIHISTAMINE

hydrocod polst-cpm polst er 10-8 mg/5ml susp 1 QL 50 / 5 DAYS

promethazine-codeine 6.25-10 mg/5ml solution 1QL 150 / 5 DAYS

MFL 3 / 180 DAYS

promethazine-codeine 6.25-10 mg/5ml syrup 1QL 150 / 5 DAYS

MFL 3 / 180 DAYS



DERMATOLOGICALSACNE ANTIBIOTICS

clindacin etz 1 % swab 3

clindamycin phosphate 1 % foam 1

clindamycin phosphate 1 % gel 1

clindamycin phosphate 1 % gel 1

clindamycin phosphate 1 % lotion 1

clindamycin phosphate 1 % solution 1

clindamycin phosphate 1 % swab 1

dapsone 5 % gel 1

DAPSONE 7.5 % GELdapsone (topical)

1

dapsone 7.5 % gel 1

erythromycin 2 % gel 1

erythromycin 2 % pad 1

erythromycin 2 % solution 1

sulfacetamide sodium (acne) 10 % lotion 1

ACNE COMBINATIONS

adapalene-benzoyl peroxide 0.1-2.5 % gel 1 QL 90 / 30 DAYS

avar cleanser 10-5 % liquid 1

benzoyl peroxide-erythromycin 5-3 % gel 1

CLINDACIN ETZ 1 % KITclindamycin phosphate & cleanser

3

CLINDACIN PAC 1 % KITclindamycin phosphate & cleanser

3

clindamycin phos-benzoyl perox 1-5 % gel 2

clindamycin phos-benzoyl perox 1.2-2.5 % gel 1

clindamycin phos-benzoyl perox 1.2-5 % gel 1

clindamycin-tretinoin 1.2-0.025 % gel 1 QL 30 / 30 DAYS

neuac 1.2-5 % gel 1



rosanil cleanser 10-5 % liquid 1

sulfacetamide sodium-sulfur 10-5 % liquid 1

ACNE PRODUCTS

accutane 10 mg cap 2 QL 60 / 30 DAYS




adapalene 0.1 % cream 1

adapalene 0.1 % gel 1

adapalene 0.3 % gel 1

amnesteem 10 mg cap 2 QL 60 / 30 DAYS



avita 0.025 % cream 1 QL 45 / 30 DAYS

avita 0.025 % gel 1 QL 45 / 30 DAYS

AZELEX 20 % CREAMazelaic acid (acne)

3 ST

claravis 10 mg cap 2 QL 60 / 30 DAYS




isotretinoin 10 mg cap 2 QL 60 / 30 DAYS




myorisan 10 mg cap 2 QL 60 / 30 DAYS






TRETIN-X 0.075 % CREAMtretinoin

2 QL 45 / 30 DAYS

tretinoin 0.01 % gel 1 QL 45 / 30 DAYS

tretinoin 0.025 % cream 1 QL 45 / 30 DAYS

tretinoin 0.025 % gel 1 QL 45 / 30 DAYS


tretinoin 0.05 % gel 1


tretinoin microsphere 0.1 % gel 1

tretinoin microsphere pump 0.1 % gel 1

zenatane 10 mg cap 2 QL 60 / 30 DAYS




AGENTS FOR EXTERNAL GENITAL AND PERIANAL WARTSVEREGEN 15 % OINTMENTsinecatechins

3 PA

AGENTS FOR FACIAL WRINKLES - RETINOIDSTRETINOIN (EMOLLIENT) 0.05 % CREAMtretinoin (facial wrinkles)

1

ANTI-INFLAMMATORY AGENTS - TOPICAL

DICLOFENAC EPOLAMINE 1.3 % PATCHdiclofenac epolamine

2QL 60 / 30 DAYS

PA

diclofenac sodium 1 % gel 1 QL 500 / 30 DAYS

diclofenac sodium 1.5 % solution 1 QL 150 / 30 DAYS



klofensaid ii 1.5 % solution 1 QL 150 / 30 DAYS

ANTIBIOTIC STEROID COMBINATIONS - TOPICALCORTISPORIN 1 % OINTMENTbacitracin-polymyxin-neomycin hc

3

CORTISPORIN 3.5-10000-0.5 CREAMneomycin-polymyxin-hc

3

ANTIBIOTICS - TOPICALALTABAX 1 % OINTMENTretapamulin

3

gentamicin sulfate 0.1 % cream 1

gentamicin sulfate 0.1 % ointment 1

mupirocin 2 % ointment 1

ANTIFUNGALS - TOPICALciclodan 0.77 % cream 1

ciclodan 8 % solution 1

CICLODAN CREAM 0.77 % KITciclopirox olamine & cleanser

2

ciclopirox 0.77 % gel 1

ciclopirox 1 % shampoo 1

ciclopirox 8 % solution 1

ciclopirox olamine 0.77 % cream 1

ciclopirox olamine 0.77 % suspension 1

CICLOPIROX TREATMENT 8 % KITciclopirox

2

LOPROX 0.77 % CREAMciclopirox olamine

3

LOPROX 0.77 % KITciclopirox olamine & cleanser

3

nyamyc 100000 unit/gm powder 1

nystatin 100000 unit/gm cream 1

nystatin 100000 unit/gm ointment 1

nystatin 100000 unit/gm powder 1



nystop 100000 unit/gm powder 1

ANTIFUNGALS - TOPICAL COMBINATIONSclotrimazole-betamethasone 1-0.05 % cream 1

nystatin-triamcinolone 100000-0.1 unit/gm-% cream 1

nystatin-triamcinolone 100000-0.1 unit/gm-% ointment 1

ANTINEOPLASTIC ALKYLATING AGENTS - TOPICAL

VALCHLOR 0.016 % GELmechlorethamine hcl (topical)

4PA

S

ANTINEOPLASTIC ANTIMETABOLITES - TOPICALFLUOROPLEX 1 % CREAMfluorouracil (topical)

2 PA

FLUOROURACIL 2 % SOLUTIONfluorouracil (topical)

1

fluorouracil 5 % cream 1

FLUOROURACIL 5 % SOLUTIONfluorouracil (topical)

1

ANTINEOPLASTIC OR PREMALIGNANT LESIONS - TOPICAL NSAID'S

diclofenac sodium 3 % gel 1 QL 500 / 30 DAYS

ANTIPRURITICS - TOPICALDOXEPIN HCL 5 % CREAMdoxepin hcl (antipruritic)

2 PA

PRUDOXIN 5 % CREAMdoxepin hcl (antipruritic)

2 PA

ZONALON 5 % CREAMdoxepin hcl (antipruritic)

2 PA

ANTIPSORIATICS

calcipotriene 0.005 % cream 1 QL 120 / 30 DAYS

calcipotriene 0.005 % solution 1 QL 60 / 30 DAYS

CALCITRIOL 3 MCG/GM OINTMENTcalcitriol (topical)

2

tazarotene 0.1 % cream 1

TAZORAC 0.05 % CREAMtazarotene

3 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSTAZORAC 0.05 % GELtazarotene

3 PA

TAZORAC 0.1 % GELtazarotene

3 PA

ANTIPSORIATICS - SYSTEMIC

acitretin 10 mg cap 2 QL 30 / 30 DAYS

acitretin 17.5 mg cap 2 QL 30 / 30 DAYS

acitretin 25 mg cap 2 QL 30 / 30 DAYS

COSENTYX (300 MG DOSE) 150 MG/ML SOLN PRSYRsecukinumab

4PA

S

COSENTYX 150 MG/ML SOLN PRSYRsecukinumab

4PA

S

COSENTYX 75 MG/0.5ML SOLN PRSYRsecukinumab

4PA

S

COSENTYX SENSOREADY (300 MG) 150 MG/ML SOLN A-INJsecukinumab

4PA

S

COSENTYX SENSOREADY PEN 150 MG/ML SOLN A-INJsecukinumab

4PA

S

METHOXSALEN RAPID 10 MG CAPmethoxsalen rapid

2 PA

methoxsalen rapid 10 mg cap 2 PA

SKYRIZI (150 MG DOSE) 75 MG/0.83ML PREF SY KTrisankizumab-rzaa

4PA

S

SKYRIZI 150 MG/ML SOLN A-INJrisankizumab-rzaa

4PA

S

SKYRIZI 150 MG/ML SOLN PRSYRrisankizumab-rzaa

4PA

S

STELARA 45 MG/0.5ML SOLN PRSYRustekinumab

4PA

S



STELARA 45 MG/0.5ML SOLUTIONustekinumab

4PA

S

STELARA 90 MG/ML SOLN PRSYRustekinumab

4PA

S

TALTZ 80 MG/ML SOLN A-INJixekizumab

4PA

S

TALTZ 80 MG/ML SOLN PRSYRixekizumab

4PA

S

TREMFYA 100 MG/ML SOLN PENguselkumab

4PA

S

TREMFYA 100 MG/ML SOLN PRSYRguselkumab

4PA

S

ANTISEBORRHEIC PRODUCTSselenium sulfide 2.25 % shampoo 1

selenium sulfide 2.5 % lotion 1

ANTIVIRALS - TOPICAL

acyclovir 5 % ointment 1 QL 30 / 30 DAYS

DENAVIR 1 % CREAMpenciclovir

3QL 5 / 30 DAYS

PA

ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES

DUPIXENT 100 MG/0.67ML SOLN PRSYRdupilumab

4PA

S

DUPIXENT 200 MG/1.14ML SOLN PENdupilumab

4PA

S

DUPIXENT 200 MG/1.14ML SOLN PRSYRdupilumab

4PA

S

DUPIXENT 300 MG/2ML SOLN PENdupilumab

4PA

S



DUPIXENT 300 MG/2ML SOLN PRSYRdupilumab

4PA

S

BURN PRODUCTSmafenide acetate 5 % packet 1

silver sulfadiazine 1 % cream 1

ssd 1 % cream 1

SULFAMYLON 85 MG/GM CREAMmafenide acetate

3

CORTICOSTEROIDS - TOPICALala-cort 1 % cream 1

ala-cort 2.5 % cream 1

alclometasone dipropionate 0.05 % cream 1

alclometasone dipropionate 0.05 % ointment 1

AMCINONIDE 0.1 % CREAMamcinonide

1

AMCINONIDE 0.1 % LOTIONamcinonide

1

AMCINONIDE 0.1 % OINTMENTamcinonide

2

betamethasone dipropionate 0.05 % cream 1

betamethasone dipropionate 0.05 % lotion 1

betamethasone dipropionate 0.05 % ointment 1

betamethasone dipropionate aug 0.05 % cream 1

BETAMETHASONE DIPROPIONATE AUG 0.05 % GELbetamethasone dipropionate augmented

1

betamethasone dipropionate aug 0.05 % lotion 1

betamethasone dipropionate aug 0.05 % ointment 1

betamethasone valerate 0.1 % cream 1

betamethasone valerate 0.1 % lotion 1

betamethasone valerate 0.1 % ointment 1

clobetasol prop emollient base 0.05 % cream 1



clobetasol propionate 0.05 % cream 1

clobetasol propionate 0.05 % foam 1

clobetasol propionate 0.05 % gel 1

clobetasol propionate 0.05 % liquid 1

clobetasol propionate 0.05 % lotion 1

clobetasol propionate 0.05 % ointment 1

clobetasol propionate 0.05 % shampoo 1

clobetasol propionate 0.05 % solution 1

clobetasol propionate e 0.05 % cream 1

clobetasol propionate emulsion 0.05 % foam 1

CLOCORTOLONE PIVALATE 0.1 % CREAMclocortolone pivalate

1

clocortolone pivalate 0.1 % cream 1

CLOCORTOLONE PIVALATE PUMP 0.1 % CREAMclocortolone pivalate

1

CORDRAN 4 MCG/SQCM TAPEflurandrenolide

3 QL 1 / 30 DAYS

desonide 0.05 % cream 1

desonide 0.05 % lotion 1

desonide 0.05 % ointment 1

desoximetasone 0.05 % cream 1

desoximetasone 0.05 % gel 1

desoximetasone 0.05 % ointment 1

desoximetasone 0.25 % cream 1

desoximetasone 0.25 % ointment 1

DIFLORASONE DIACETATE 0.05 % CREAMdiflorasone diacetate

2

diflorasone diacetate 0.05 % ointment 2 QL 60 / 30 DAYS

fluocinolone acetonide 0.01 % cream 1

fluocinolone acetonide 0.01 % solution 1



fluocinolone acetonide 0.025 % cream 1

fluocinolone acetonide 0.025 % ointment 1

fluocinolone acetonide body 0.01 % oil 1

fluocinolone acetonide scalp 0.01 % oil 1

fluocinonide 0.05 % cream 1

fluocinonide 0.05 % gel 1

fluocinonide 0.05 % ointment 1

fluocinonide 0.05 % solution 1

fluocinonide 0.1 % cream 2

fluocinonide emulsified base 0.05 % cream 1

flurandrenolide 0.05 % lotion 1

fluticasone propionate 0.005 % ointment 1

fluticasone propionate 0.05 % cream 1

fluticasone propionate 0.05 % lotion 2

halobetasol propionate 0.05 % cream 1

halobetasol propionate 0.05 % ointment 1

hydrocortisone 1 % cream 1

hydrocortisone 1 % ointment 1

hydrocortisone 2.5 % cream 1

hydrocortisone 2.5 % lotion 1

hydrocortisone 2.5 % ointment 1

hydrocortisone butyr lipo base 0.1 % cream 2

HYDROCORTISONE BUTYRATE 0.1 % CREAMhydrocortisone butyrate

1

hydrocortisone butyrate 0.1 % cream 1

hydrocortisone butyrate 0.1 % ointment 1

HYDROCORTISONE BUTYRATE 0.1 % SOLUTIONhydrocortisone butyrate

2

hydrocortisone butyrate 0.1 % solution 2



hydrocortisone valerate 0.2 % cream 1

hydrocortisone valerate 0.2 % ointment 1

mometasone furoate 0.1 % cream 1

mometasone furoate 0.1 % ointment 1

mometasone furoate 0.1 % solution 1

PREDNICARBATE 0.1 % CREAMprednicarbate

1

PREDNICARBATE 0.1 % OINTMENTprednicarbate

1

tovet 0.05 % foam 1

triamcinolone acetonide 0.025 % cream 1

triamcinolone acetonide 0.025 % lotion 1

triamcinolone acetonide 0.025 % ointment 1


triamcinolone acetonide 0.1 % lotion 1




ENZYMES - TOPICALSANTYL 250 UNIT/GM OINTMENTcollagenase

3 QL 30 / 30 DAYS

IMIDAZOLE-RELATED ANTIFUNGALS - TOPICALclotrimazole 1 % solution 1

econazole nitrate 1 % cream 1

ERTACZO 2 % CREAMsertaconazole nitrate

3 PA

EXELDERM 1 % CREAMsulconazole nitrate

3

EXELDERM 1 % SOLUTIONsulconazole nitrate

3

JUBLIA 10 % SOLUTIONefinaconazole

3QL 4 / 30 DAYS

ST



ketoconazole 2 % cream 1

ketoconazole 2 % foam 1

ketoconazole 2 % shampoo 1

ketodan 2 % foam 2

LULICONAZOLE 1 % CREAMluliconazole

2 QL 60 / 30 day(s)

XOLEGEL 2 % GELketoconazole (topical)

3

IMMUNOMODULATORS IMIDAZOQUINOLINAMINES - TOPICALimiquimod 5 % cream 1

KERATOLYTIC/ANTIMITOTIC AGENTSkeralyt 6 % shampoo 1

podofilox 0.5 % solution 1

salicylic acid 6 % cream 1

salicylic acid 6 % shampoo 1

LOCAL ANESTHETICS - TOPICALlidocaine 5 % ointment 1

lidocaine 5 % patch 1 QL 90 / 30 DAYS

lidocaine hcl urethral/mucosal 2 % gel 1

LIDOCAINE HCL URETHRAL/MUCOSAL 2 % GELlidocaine hcl

1

lidocaine hcl urethral/mucosal 2 % prsyr 1

lidocaine pak 5 % ointment 1

LIDOTREX 2 % GELlidocaine

2

premium lidocaine 5 % ointment 1

MACROLIDE IMMUNOSUPPRESSANTS - TOPICAL

pimecrolimus 1 % cream 2 QL 60 / 30 DAYS

tacrolimus 0.03 % ointment 2

tacrolimus 0.1 % ointment 2



MISC. TOPICALDRYSOL 20 % SOLUTIONaluminum chloride

2

OXABOROLE-RELATED ANTIFUNGALS - TOPICAL

tavaborole 5 % solution 2QL 10 / 30 day(s)

ST

PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICALEUCRISA 2 % OINTMENTcrisaborole

3 PA

ROSACEA AGENTS

azelaic acid 15 % gel 1 QL 50 / 30 DAYS

ivermectin 1 % cream 1 QL 1 / 1 day(s)

metronidazole 0.75 % cream 1

metronidazole 0.75 % gel 1

metronidazole 0.75 % lotion 1

metronidazole 1 % gel 1

rosadan 0.75 % cream 1

rosadan 0.75 % gel 1

SCABICIDES & PEDICULICIDESEURAX 10 % CREAMcrotamiton

3

EURAX 10 % LOTIONcrotamiton

3

IVERMECTIN 0.5 % LOTIONivermectin (pediculicide)

3 QL 117 / 30 DAYS

LINDANE 1 % SHAMPOOlindane

1

malathion 0.5 % lotion 1

permethrin 5 % cream 1

SPINOSAD 0.9 % SUSPENSIONspinosad

1

ULESFIA 5 % LOTIONbenzyl alcohol (pediculicide)

3



TOPICAL ANESTHETIC COMBINATIONSlidocaine-prilocaine 2.5-2.5 % cream 1

SYNERA 70-70 MG PATCHlidocaine-tetracaine

3

TOPICAL SELECTIVE RETINOID X RECEPTOR AGONISTS

TARGRETIN 1 % GELbexarotene (topical)

4PA

S

WOUND CARE - GROWTH FACTOR AGENTSREGRANEX 0.01 % GELbecaplermin

3 PA

DIAGNOSTIC PRODUCTSDIAGNOSTIC DRUGS

GLUCAGEN DIAGNOSTIC 1 MG RECON SOLNglucagon hcl rdna (diagnostic)

2

GLUCAGON HCL (DIAGNOSTIC) 1 MG RECON SOLNglucagon hcl (diagnostic)

1

DIAGNOSTIC TESTSFREESTYLE INSULINX TEST STRIPglucose blood

2 QL 150 / 30 DAYS

FREESTYLE LITE TEST STRIPglucose blood

2 QL 150 / 30 DAYS

FREESTYLE TEST STRIPglucose blood

2 QL 150 / 30 DAYS

ONETOUCH ULTRA STRIPglucose blood

2 QL 150 / 30 DAYS

ONETOUCH VERIO STRIPglucose blood

2 QL 150 / 30 DAYS

INFECTION TESTS

BD VERITOR SYSTEM SARS-COV-2 KITcovid-19 antigen test

2QL 8 / 30 day(s)

PRE Preventative

BINAXNOW COVID-19 AG CARD KITcovid-19 antigen test

2QL 8 / 30 day(s)

PRE Preventative

BINAXNOW COVID-19 AG HOME TEST KITcovid-19 at home test

2QL 8 / 30 day(s)

PRE Preventative



CLINITEST RAPID COVID-19 TEST KITcovid-19 at home test

2QL 8 / 30 day(s)

PRE Preventative

COBAS LIAT SARS-COV-2 ASSAY KITcovid-19 test

2QL 8 / 30 day(s)

PRE Preventative

COVID-19 AT-HOME TEST KITcovid-19 at home test

2QL 8 / 30 day(s)

PRE Preventative

COVID-19 OTC ANTIGEN 1-PACK KITcovid-19 at home test

2QL 8 / 30 day(s)

PRE Preventative

COVID-19 OTC ANTIGEN 2-PACK KITcovid-19 at home test

2QL 8 / 30 day(s)

PRE Preventative

DXTERITY COVID-19 HOME TEST KITcovid-19 home collection test

2QL 8 / 30 day(s)

PRE Preventative

ELLUME COVID-19 HOME TEST KITcovid-19 at home test

2QL 8 / 30 day(s)

PRE Preventative

FLOWFLEX COVID-19 AG HOME TEST KITcovid-19 at home test

2QL 8 / 30 day(s)

PRE Preventative

ID NOW COVID-19 KITcovid-19 test

2QL 8 / 30 day(s)

PRE Preventative

IHEALTH COVID-19 RAPID TEST KITcovid-19 at home test

2QL 8 / 30 day(s)

PRE Preventative

INTELISWAB COVID-19 RAPID TEST KITcovid-19 at home test

2QL 8 / 30 day(s)

PRE Preventative

LUCIRA COVID-19 ALL-IN-ONE KITcovid-19 at home test

2QL 8 / 30 day(s)

PRE Preventative

LYRA DIRECT SARS-COV-2 ASSAY KITcovid-19 test

2QL 8 / 30 day(s)

PRE Preventative

LYRA SARS-COV-2 ASSAY KITcovid-19 test

2QL 8 / 30 day(s)

PRE Preventative



MYLAB BOX COVID-19 TESTING KITcovid-19 home test

2QL 8 / 30 day(s)

PRE Preventative

ON/GO COVID-19 ANTIGEN TEST KITcovid-19 at home test

2QL 8 / 30 day(s)

PRE Preventative

PIXEL COVID-19 PCR HOME TEST KITcovid-19 home test

2QL 8 / 30 day(s)

PRE Preventative

QUICKVUE AT-HOME COVID-19 TEST KITcovid-19 at home test

2QL 8 / 30 day(s)

PRE Preventative

QUICKVUE SARS ANTIGEN TEST KITcovid-19 antigen test

2QL 8 / 30 day(s)

PRE Preventative

SIMPLICITY COVID-19 AT-HOME KITcovid-19 home collection test

2QL 8 / 30 day(s)

PRE Preventative

SOFIA SARS ANTIGEN FIA KITcovid-19 antigen test

2QL 8 / 30 day(s)

PRE Preventative

SOFIA2 SARS ANTIGEN FIA KITcovid-19 antigen test

2QL 8 / 30 day(s)

PRE Preventative

XPERT XPRESS SARS-COV-2 KITcovid-19 test

2QL 8 / 30 day(s)

PRE Preventative

DIGESTIVE AIDSDIGESTIVE ENZYMES

CREON 12000 UNIT CP DR PARTpancrelipase (lipase-protease-amylase)

2 PA

CREON 24000-76000 UNIT CP DR PARTpancrelipase (lipase-protease-amylase)

2 PA

CREON 3000-9500 UNIT CP DR PARTpancrelipase (lipase-protease-amylase)

2 PA


2 PA


2 PA

PANCREAZE 10500 UNIT CP DR PARTpancrelipase (lipase-protease-amylase)

3 PA


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSPANCREAZE 16800 UNIT CP DR PARTpancrelipase (lipase-protease-amylase)

3 PA


3 PA


3 PA

PANCREAZE 2600-8800 UNIT CP DR PARTpancrelipase (lipase-protease-amylase)

3 PA

PANCREAZE 37000-97300 UNIT CP DR PARTpancrelipase (lipase-protease-amylase)

3 PA


3 PA

ZENPEP 10000-32000 UNIT CP DR PARTpancrelipase (lipase-protease-amylase)

2 PA


2 PA


2 PA


2 PA


2 PA


2 PA


2 PA


2 PA

DIURETICSCARBONIC ANHYDRASE INHIBITORS

acetazolamide 125 mg tab 1

acetazolamide 250 mg tab 1

acetazolamide er 500 mg cap er 12h 1

methazolamide 25 mg tab 1 QL 3 / 1 day(s)

methazolamide 50 mg tab 1



DIURETIC COMBINATIONSamiloride-hydrochlorothiazide 5-50 mg tab 1

spironolactone-hctz 25-25 mg tab 1

triamterene-hctz 37.5-25 mg cap 1

triamterene-hctz 37.5-25 mg tab 1

triamterene-hctz 75-50 mg tab 1

LOOP DIURETICSbumetanide 0.5 mg tab 1

bumetanide 1 mg tab 1

bumetanide 2 mg tab 1

ethacrynic acid 25 mg tab 1

furosemide 10 mg/ml solution 1

furosemide 20 mg tab 1


FUROSEMIDE 8 MG/ML SOLUTIONfurosemide



torsemide 10 mg tab 1




POTASSIUM SPARING DIURETICSamiloride hcl 5 mg tab 1

spironolactone 100 mg tab 1



triamterene 100 mg cap 1

triamterene 50 mg cap 1



THIAZIDES AND THIAZIDE-LIKE DIURETICSCHLOROTHIAZIDE 250 MG TABchlorothiazide

1

CHLOROTHIAZIDE 500 MG TABchlorothiazide

1

chlorothiazide 500 mg tab 1

chlorthalidone 25 mg tab 1

chlorthalidone 50 mg tab 1

DIURIL 250 MG/5ML SUSPENSIONchlorothiazide


hydrochlorothiazide 12.5 mg cap 1

hydrochlorothiazide 12.5 mg tab 1

hydrochlorothiazide 25 mg tab 1

hydrochlorothiazide 50 mg tab 1

indapamide 1.25 mg tab 1

indapamide 2.5 mg tab 1

METHYCLOTHIAZIDE 5 MG TABmethyclothiazide

1

metolazone 10 mg tab 1

metolazone 2.5 mg tab 1

metolazone 5 mg tab 1

ENDOCRINE AND METABOLIC AGENTS - MISC.BISPHOSPHONATES

alendronate sodium 10 mg tab 1 QL 30 / 28 DAYS


ALENDRONATE SODIUM 40 MG TABalendronate sodium

1 QL 30 / 28 DAYS



ETIDRONATE DISODIUM 200 MG TABetidronate disodium

1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSETIDRONATE DISODIUM 400 MG TABetidronate disodium

1

FOSAMAX PLUS D 70-2800 MG-UNIT TABalendronate sodium-cholecalciferol

3 QL 4 / 28 DAYS

FOSAMAX PLUS D 70-5600 MG-UNIT TABalendronate sodium-cholecalciferol

3 QL 4 / 28 DAYS

ibandronate sodium 150 mg tab 1 QL 1 / 28 DAYS

risedronate sodium 150 mg tab 1 QL 1 / 30 DAYS



risedronate sodium 35 mg tab dr 1 QL 4 / 28 DAYS


CALCIMIMETIC AGENTS

cinacalcet hcl 30 mg tab 1 QL 120 / 30 day(s)



CALCITONINScalcitonin (salmon) 200 unit/act solution 1

calcitonin (salmon) 200 unit/ml solution 4PA

S

CARNITINE REPLENISHER - AGENTSlevocarnitine 1 gm/10ml solution 1

levocarnitine sf 1 gm/10ml solution 1

CORTISOL SYNTHESIS INHIBITORS

ISTURISA 1 MG TABosilodrostat phosphate

4PA

S


4PA

S


4PA

S



DOPAMINE RECEPTOR AGONISTScabergoline 0.5 mg tab 1

GNRH/LHRH ANTAGONISTS

ORILISSA 150 MG TABelagolix sodium

4PA

S

ORILISSA 200 MG TABelagolix sodium

4PA

S

GROWTH HORMONE RECEPTOR ANTAGONISTS

SOMAVERT 10 MG RECON SOLNpegvisomant

4PA

S


4PA

S


4PA

S

GROWTH HORMONES

NORDITROPIN FLEXPRO 10 MG/1.5ML SOLN PENsomatropin

4PA

S


4PA

S

NORDITROPIN FLEXPRO 30 MG/3ML SOLN PENsomatropin

4PA

S


4PA

S

NUTROPIN AQ NUSPIN 10 10 MG/2ML SOLN PENsomatropin

4PA

S


4PA

S


4PA

S



OMNITROPE 10 MG/1.5ML SOLN CARTsomatropin

4PA

S

OMNITROPE 5 MG/1.5ML SOLN CARTsomatropin

4PA

S

OMNITROPE 5.8 MG RECON SOLNsomatropin

4PA

S

HYPERAMMONEMIA TREATMENT - AGENTS

carglumic acid 200 mg tab 4PA

S

HYPERPARATHYROID TREATMENT - VITAMIN D ANALOGScalcitriol 0.25 mcg cap 1

calcitriol 0.5 mcg cap 1

calcitriol 1 mcg/ml solution 1 AL1 Up to 8 yrs old

doxercalciferol 0.5 mcg cap 2

doxercalciferol 1 mcg cap 2

doxercalciferol 2.5 mcg cap 2

paricalcitol 1 mcg cap 1



INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)

INCRELEX 40 MG/4ML SOLUTIONmecasermin

4PA

S

LEPTIN ANALOGUES

MYALEPT 11.3 MG RECON SOLNmetreleptin

4PA

S

LHRH/GNRH AGONIST ANALOG COMBINATIONS

LUPANETA PACK 11.25 & 5 MG KITleuprolide acetate & norethindrone acetate

4PA

S

LUPANETA PACK 3.75 & 5 MG KITleuprolide acetate & norethindrone acetate

4PA

S



LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS

LUPRON DEPOT-PED (1-MONTH) 11.25 MG KITleuprolide acetate (cpp)

4PA

S

LUPRON DEPOT-PED (1-MONTH) 15 MG KITleuprolide acetate (cpp)

4PA

S

LUPRON DEPOT-PED (1-MONTH) 7.5 MG KITleuprolide acetate (cpp)

4PA

S

LUPRON DEPOT-PED (3-MONTH) 11.25 MG (PED) KITleuprolide acetate (cpp) (3 month)

4PA

S

LUPRON DEPOT-PED (3-MONTH) 30 MG (PED) KITleuprolide acetate (cpp) (3 month)

4PA

S

PARATHYROID HORMONE AND DERIVATIVES

FORTEO 620 MCG/2.48ML SOLN PENteriparatide (recombinant)

4PA

S

TERIPARATIDE (RECOMBINANT) 620 MCG/2.48ML SOLNPENteriparatide (recombinant)

4PA

S

TYMLOS 3120 MCG/1.56ML SOLN PENabaloparatide

4PA

S

PHENYLKETONURIA TREATMENT - AGENTS

PALYNZIQ 10 MG/0.5ML SOLN PRSYRpegvaliase-pqpz

4PA

S

PALYNZIQ 2.5 MG/0.5ML SOLN PRSYRpegvaliase-pqpz

4PA

S

PALYNZIQ 20 MG/ML SOLN PRSYRpegvaliase-pqpz

4PA

S

sapropterin dihydrochloride 100 mg packet 4PA

S

sapropterin dihydrochloride 100 mg tab 4PA

S



sapropterin dihydrochloride 500 mg packet 4PA

S

SCLEROSTIN INHIBITORS

EVENITY 105 MG/1.17ML SOLN PRSYRromosozumab-aqqg

4PA

S

SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)OSPHENA 60 MG TABospemifene

3

raloxifene hcl 60 mg tab 1QL 30 / 30 DAYS

PRE Preventative

SELECTIVE VASOPRESSIN V2-RECEPTOR ANTAGONISTS

JYNARQUE 15 MG TAB THPKtolvaptan

4PA

S

JYNARQUE 30 & 15 MG TAB THPKtolvaptan

4PA

S


4PA

S


4PA

S


4PA

S

TOLVAPTAN 15 MG TABtolvaptan

4PA

S

tolvaptan 30 mg tab 4PA

S

SOMATOSTATIC AGENTSOCTREOTIDE ACETATE 100 MCG/ML SOLN PRSYRoctreotide acetate

2

octreotide acetate 100 mcg/ml solution 2





OCTREOTIDE ACETATE 50 MCG/ML SOLN PRSYRoctreotide acetate

2


OCTREOTIDE ACETATE 500 MCG/ML SOLN PRSYRoctreotide acetate

2


SIGNIFOR 0.3 MG/ML SOLUTIONpasireotide diaspartate

4PA

S


4PA

S


4PA

S

SIGNIFOR LAR 10 MG SRERpasireotide pamoate

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

VASOPRESSINdesmopressin ace spray refrig 0.01 % solution 1

desmopressin acetate 0.1 mg tab 1

desmopressin acetate 0.2 mg tab 1

DESMOPRESSIN ACETATE 1.5 MG/ML SOLUTIONdesmopressin acetate

2 QL 1 / 90 day(s)

desmopressin acetate 4 mcg/ml solution 1



desmopressin acetate pf 4 mcg/ml solution 1

desmopressin acetate spray 0.01 % solution 1

STIMATE 1.5 MG/ML SOLUTIONdesmopressin acetate

2 QL 1 / 180 day(s)

ESTROGENSESTROGEN & ANDROGEN

covaryx 1.25-2.5 mg tab 1

covaryx hs 0.625-1.25 mg tab 1

eemt 1.25-2.5 mg tab 1

eemt hs 0.625-1.25 mg tab 1

est estrogens-methyltest 0.625-1.25 mg tab 1

est estrogens-methyltest 1.25-2.5 mg tab 1

est estrogens-methyltest ds 1.25-2.5 mg tab 1

est estrogens-methyltest hs 0.625-1.25 mg tab 1

ESTROGEN & PROGESTINamabelz 0.5-0.1 mg tab 1

amabelz 1-0.5 mg tab 1

estradiol-norethindrone acet 0.5-0.1 mg tab 1

estradiol-norethindrone acet 1-0.5 mg tab 1

fyavolv 0.5-2.5 mg-mcg tab 1

fyavolv 1-5 mg-mcg tab 1

jevantique lo 0.5-2.5 mg-mcg tab 1

jinteli 1-5 mg-mcg tab 1

lopreeza 0.5-0.1 mg tab 1

lopreeza 1-0.5 mg tab 1

mimvey 1-0.5 mg tab 1

mimvey lo 0.5-0.1 mg tab 1

norethindrone-eth estradiol 0.5-2.5 mg-mcg tab 1

norethindrone-eth estradiol 1-5 mg-mcg tab 1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSPREMPRO 0.3-1.5 MG TABconjugated estrogens-medroxyprogesterone acetate

3

PREMPRO 0.45-1.5 MG TABconjugated estrogens-medroxyprogesterone acetate

3

PREMPRO 0.625-2.5 MG TABconjugated estrogens-medroxyprogesterone acetate

3

PREMPRO 0.625-5 MG TABconjugated estrogens-medroxyprogesterone acetate

3

ESTROGEN-PROGESTIN-GNRH ANTAGONIST

ORIAHNN 300-1-0.5 & 300 MG CAP THPKelagolix sodium-estradiol-norethindrone acetate

4PA

S

ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBDUAVEE 0.45-20 MG TABconjugated estrogens-bazedoxifene

2 QL 30 / 30 DAYS

DIVIGEL 0.25 MG/0.25GM GELestradiol

3 QL 30 / 30 DAYS


3 QL 30 / 30 DAYS


3

DIVIGEL 1 MG/GM GELestradiol

3 QL 30 / 30 DAYS


3

dotti 0.025 mg/24hr patch tw 1 QL 8 / 28 DAYS





ELESTRIN 0.52 MG/0.87 GM (0.06%) GELestradiol

3 QL 26 / 30 DAYS

estradiol 0.025 mg/24hr patch tw 1 QL 8 / 28 DAYS

estradiol 0.025 mg/24hr patch wk 1 QL 4 / 28 DAYS












estradiol 0.5 mg tab 1

estradiol 1 mg tab 1

estradiol 2 mg tab 1

estradiol valerate 20 mg/ml oil 1

estradiol valerate 40 mg/ml oil 1

ESTROPIPATE 0.75 MG TABestropipate

1

ESTROPIPATE 1.5 MG TABestropipate

1

ESTROPIPATE 3 MG TABestropipate

2

EVAMIST 1.53 MG/SPRAY SOLUTIONestradiol

3 QL 16.2 / 30 DAYS

lyllana 0.025 mg/24hr patch tw 1 QL 8 / 28 DAYS





MENEST 0.3 MG TABesterified estrogens

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSMENEST 0.625 MG TABesterified estrogens

2


2


2

MENOSTAR 14 MCG/24HR PATCH WKestradiol

3 QL 4 / 28 DAYS

PREMARIN 0.3 MG TABestrogens, conjugated

2


2


2


2


2

FLUOROQUINOLONES

ciprofloxacin 500 mg/5ml (10%) recon susp 1 AL1 Up to 8 yrs old

CIPROFLOXACIN HCL 100 MG TABciprofloxacin hcl

1

ciprofloxacin hcl 250 mg tab 1



CIPROFLOXACIN-CIPROFLOX HCL ER 1000 MG TAB ER 24Hciprofloxacin-ciprofloxacin hcl

1

levofloxacin 25 mg/ml solution 1 AL1 At least 8 yrs old

levofloxacin 25 mg/ml solution 1 AL1 At least 8 yrs old

levofloxacin 250 mg tab 1 QL 14 / 14 DAYS



moxifloxacin hcl 400 mg tab 1 QL 14 / 0 DAYS


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSOFLOXACIN 300 MG TABofloxacin

2

ofloxacin 400 mg tab 2

GASTROINTESTINAL AGENTS - MISC.5-HT4 RECEPTOR AGONISTS

MOTEGRITY 1 MG TABprucalopride succinate

3QL 30 / 30 DAYS

PA

MOTEGRITY 2 MG TABprucalopride succinate

3QL 30 / 30 DAYS

PA

CIC AGENTS - GUANYLATE CYCLASE-C (GC-C) AGONISTS

TRULANCE 3 MG TABplecanatide

3QL 30 / 30 DAYS

PA

FARNESOID X RECEPTOR (FXR) AGONISTS

OCALIVA 10 MG TABobeticholic acid

4PA

S

OCALIVA 5 MG TABobeticholic acid

4PA

S

GALLSTONE SOLUBILIZING AGENTSursodiol 250 mg tab 1

ursodiol 300 mg cap 1

ursodiol 500 mg tab 1

GASTROINTESTINAL ANTIALLERGY AGENTScromolyn sodium 100 mg/5ml conc 1

GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS

AMITIZA 24 MCG CAPlubiprostone

3QL 60 / 30 day(s)

PA

AMITIZA 8 MCG CAPlubiprostone

3QL 60 / 30 day(s)

PA

LUBIPROSTONE 24 MCG CAPlubiprostone

3QL 60 / 30 day(s)

PA



LUBIPROSTONE 8 MCG CAPlubiprostone

3QL 60 / 30 day(s)

PA

GASTROINTESTINAL STIMULANTSmetoclopramide hcl 10 mg tab 1

metoclopramide hcl 10 mg/10ml solution 1

metoclopramide hcl 5 mg tab 1

METOCLOPRAMIDE HCL 5 MG TAB DISPmetoclopramide hcl

1 QL 120 / 30 DAYS

metoclopramide hcl 5 mg/5ml solution 1

IBS AGENT - GUANYLATE CYCLASE-C (GC-C) AGONISTS

LINZESS 145 MCG CAPlinaclotide

2QL 30 / 30 DAYS

PA


2QL 30 / 30 DAYS

PA


2QL 30 / 30 DAYS

PA

IBS AGENT - MU-OPIOID RECEPTOR AGONISTSVIBERZI 100 MG TABeluxadoline

3 PA

VIBERZI 75 MG TABeluxadoline

3 PA

IBS AGENT - SELECTIVE 5-HT3 RECEPTOR ANTAGONISTS

alosetron hcl 0.5 mg tab 2QL 60 / 30 DAYS

PA

alosetron hcl 1 mg tab 2QL 60 / 30 DAYS

PA

ILEAL BILE ACID TRANSPORTER (IBAT) INHIBITORS

BYLVAY (PELLETS) 200 MCG CAP SPRINKodevixibat

4PA

S

BYLVAY (PELLETS) 600 MCG CAP SPRINKodevixibat

4PA

S



BYLVAY 1200 MCG CAPodevixibat

4PA

S

BYLVAY 400 MCG CAPodevixibat

4PA

S

INFLAMMATORY BOWEL AGENTSbalsalazide disodium 750 mg cap 1

DIPENTUM 250 MG CAPolsalazine sodium

3 PA

GIAZO 1.1 GM TABbalsalazide disodium

3QL 180 / 30 DAYS

PA

mesalamine 1.2 gm tab dr 2 QL 120 / 30 DAYS

mesalamine 1000 mg suppos 2 QL 30 / 30 DAYS

mesalamine 4 gm enema 1 QL 1680 / 28 DAYS

mesalamine 400 mg cap dr 1 QL 6 / 1 day(s)

mesalamine 800 mg tab dr 2 QL 180 / 30 DAYS

mesalamine er 0.375 gm cap er 24h 2 QL 4 / 1 day(s)

mesalamine-cleanser 4 gm kit 1 QL 1680 / 28 DAYS

PENTASA 250 MG CAP ERmesalamine

2 QL 90 / 30 DAYS

PENTASA 500 MG CAP ERmesalamine

2 QL 240 / 30 DAYS

sulfasalazine 500 mg tab 1

sulfasalazine 500 mg tab dr 1

INTESTINAL ACIDIFIERSenulose 10 gm/15ml solution 1

generlac 10 gm/15ml solution 1

lactulose encephalopathy 10 gm/15ml solution 1



PERIPHERAL OPIOID RECEPTOR ANTAGONISTS

MOVANTIK 12.5 MG TABnaloxegol oxalate

2QL 30 / 30 DAYS

PA

MOVANTIK 25 MG TABnaloxegol oxalate

2QL 30 / 30 DAYS

PA

SYMPROIC 0.2 MG TABnaldemedine tosylate

3QL 30 / 30 DAYS

PA

PHOSPHATE BINDER AGENTScalcium acetate (phos binder) 667 mg cap 1

calcium acetate (phos binder) 667 mg tab 1

calcium acetate 667 mg tab 1

lanthanum carbonate 1000 mg chew tab 2



PHOSLYRA 667 MG/5ML SOLUTIONcalcium acetate (phosphate binder)


sevelamer carbonate 0.8 gm packet 1 AL1 Up to 8 yrs old

sevelamer carbonate 2.4 gm packet 1 AL1 Up to 8 yrs old

sevelamer carbonate 800 mg tab 1

TUMOR NECROSIS FACTOR ALPHA BLOCKERS

CIMZIA 2 X 200 MG KITcertolizumab pegol

4PA

S

CIMZIA PREFILLED 2 X 200 MG/ML KITcertolizumab pegol

4PA

S

CIMZIA STARTER KIT 6 X 200 MG/ML KITcertolizumab pegol

4PA

S



GENITOURINARY AGENTS - MISCELLANEOUS5-ALPHA REDUCTASE INHIBITORS

dutasteride 0.5 mg cap 1 QL 30 / 30 DAYS

finasteride 5 mg tab 1QL 30 / 30 DAYS

GL Male

ALPHA 1-ADRENOCEPTOR ANTAGONISTS

alfuzosin hcl er 10 mg tab er 24h 1 QL 60 / 30 DAYS

CARDURA XL 4 MG TAB ER 24Hdoxazosin mesylate (bph)

3

CARDURA XL 8 MG TAB ER 24Hdoxazosin mesylate (bph)

3

silodosin 4 mg cap 1 QL 60 / 30 DAYS

silodosin 8 mg cap 1 QL 30 / 30 DAYS

tamsulosin hcl 0.4 mg cap 1 QL 60 / 30 DAYS

CITRATESpotassium citrate er 10 meq (1080 mg) tab er 1

potassium citrate er 15 meq (1620 mg) tab er 1

potassium citrate er 5 meq (540 mg) tab er 1

CYSTINOSIS AGENTS

CYSTAGON 150 MG CAPcysteamine bitartrate

4PA

S

CYSTAGON 50 MG CAPcysteamine bitartrate

4PA

S

INTERSTITIAL CYSTITIS AGENTSELMIRON 100 MG CAPpentosan polysulfate sodium

3 PA

PHOSPHATESK-PHOS NO 2 305-700 MG TABpotassium & sodium acid phosphates

2



URINARY ANALGESICSphenazo 200 mg tab 1

phenazopyridine hcl 100 mg tab 1

phenazopyridine hcl 200 mg tab 1

GOUT AGENTSGOUT AGENT COMBINATIONS

colchicine-probenecid 0.5-500 mg tab 1

allopurinol 100 mg tab 1

allopurinol 300 mg tab 1

COLCHICINE 0.6 MG CAPcolchicine

2 QL 60 / 30 DAYS

colchicine 0.6 mg tab 2 QL 60 / 30 DAYS

febuxostat 40 mg tab 1 QL 3 / 1 day(s)

febuxostat 80 mg tab 1 QL 1.5 / 1 day(s)

URICOSURICSprobenecid 500 mg tab 1

HEMATOLOGICAL AGENTS - MISC.ANTI-VON WILLEBRAND FACTOR AGENTS

CABLIVI 11 MG KITcaplacizumab-yhdp

4PA

S

ANTIHEMOPHILIC PRODUCTSADVATE 1000 UNIT RECON SOLNantihemophilic factor (rcmb) plasma/albumin free (rahf-pfm)

4PA

S

ADVATE 1500 UNIT RECON SOLNantihemophilic factor (rcmb) plasma/albumin free (rahf-pfm)

4PA

S


4PA

S


4PA

S


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSADVATE 3000 UNIT RECON SOLNantihemophilic factor (rcmb) plasma/albumin free (rahf-pfm)

4PA

S


4PA

S


4PA

S

ADYNOVATE 1000 UNIT RECON SOLNantihemophilic factor (recombinant) pegylated

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

AFSTYLA 1000 UNIT KITantihemophilic factor (recombinant) single chain

4PA

S


4PA

S


4PA

S


4PA

S




4PA

S


4PA

S


4PA

S

ALPHANATE 1000 UNIT RECON SOLNantihemophilic factor/von willebrand factor complex(human)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

ALPHANATE/VWF COMPLEX/HUMAN 1000 UNIT RECONSOLNantihemophilic factor/von willebrand factor complex(human)

4PA

S


4PA

S


4PA

S


4PA

S


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSALPHANATE/VWF COMPLEX/HUMAN 500 UNIT RECONSOLNantihemophilic factor/von willebrand factor complex(human)

4PA

S

ALPHANINE SD 1000 UNIT RECON SOLNcoagulation factor ix

4PA

S


4PA

S


4PA

S

ALPROLIX 1000 UNIT RECON SOLNcoagulation factor ix (recomb) fc fusion protein (rfixfc)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

BENEFIX 1000 UNIT KITcoagulation factor ix (recombinant)

4PA

S


4PA

S


4PA

S


4PA

S




4PA

S

ELOCTATE 1000 UNIT RECON SOLNantihemophilic factor (rcmb) fc fusion protein(bdd-rfviiifc)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

ESPEROCT 1000 UNIT RECON SOLNantihemophilic factor (recombinant) glycopegylated-exei

4PA

S


4PA

S


4PA

S




4PA

S


4PA

S

HELIXATE FS 1000 UNIT KITantihemophilic factor (recombinant)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

HEMOFIL M 1000 UNIT RECON SOLNantihemophilic factor (human)

4PA

S


4PA

S


4PA

S


4PA

S

HUMATE-P 1000-2400 UNIT RECON SOLNantihemophilic factor/von willebrand factor complex(human)

4PA

S


4PA

S


4PA

S


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSIDELVION 1000 UNIT RECON SOLNcoagulation factor ix recomb albumin fusion protein (rix-fp)

4PA

S

IDELVION 2000 UNIT RECON SOLNcoagulation factor ix recomb albumin fusion protein (rix-fp)

4PA

S


4PA

S


4PA

S


4PA

S

IXINITY 1000 UNIT RECON SOLNcoagulation factor ix (recombinant)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

JIVI 1000 UNIT RECON SOLNantihemophil fact(rcmb) pegylated-aucl (bdd-rfviii peg-aucl)

4PA

S


4PA

S


4PA

S


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSJIVI 500 UNIT RECON SOLNantihemophil fact(rcmb) pegylated-aucl (bdd-rfviii peg-aucl)

4PA

S

KOATE 1000 UNIT RECON SOLNantihemophilic factor (human)

4PA

S


4PA

S


4PA

S

KOATE-DVI 1000 UNIT RECON SOLNantihemophilic factor (human)

4PA

S


4PA

S


4PA

S

KOGENATE FS 1000 UNIT KITantihemophilic factor (recombinant)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

KOGENATE FS BIO-SET 1000 UNIT KITantihemophilic factor (recombinant)

4PA

S


4PA

S




4PA

S


4PA

S


4PA

S

KOVALTRY 1000 UNIT RECON SOLNantihemophilic factor (rcmb) plasma/albumin free (rahf-pfm)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

MONOCLATE-P 1000 UNIT KITantihemophilic factor (human)

4PA

S

MONOCLATE-P 1500 UNIT KITantihemophilic factor (human)

4PA

S

MONONINE 1000 UNIT RECON SOLNcoagulation factor ix

4PA

S

NOVOEIGHT 1000 UNIT RECON SOLNantihemophilic factor (rcmb) bd truncated (bd trunc-rfviii)

4PA

S


4PA

S


4PA

S




4PA

S


4PA

S


4PA

S

NUWIQ 1000 UNIT KITantihemophilic factor (rcmb) simoctocog alfa(bdd-rfviii,sim)

4PA

S

NUWIQ 1000 UNIT RECON SOLNantihemophilic factor (rcmb) simoctocog alfa(bdd-rfviii,sim)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSNUWIQ 4000 UNIT RECON SOLNantihemophilic factor (rcmb) simoctocog alfa(bdd-rfviii,sim)

4PA

S


4PA

S


4PA

S

OBIZUR 500 UNIT RECON SOLNantihemophilic factor (recombinant porcine) (rpfviii)

4PA

S

REBINYN 1000 UNIT RECON SOLNcoagulation factor ix (recombinant) glycopegylated

4PA

S


4PA

S


4PA

S

RECOMBINATE 1241-1800 UNIT RECON SOLNantihemophilic factor (recombinant)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

RIXUBIS 1000 UNIT RECON SOLNcoagulation factor ix (recombinant)

4PA

S


4PA

S




4PA

S


4PA

S


4PA

S

WILATE 1000-1000 UNIT KITantihemophilic factor/von willebrand factor complex(human)

4PA

S

WILATE 500-500 UNIT KITantihemophilic factor/von willebrand factor complex(human)

4PA

S

XYNTHA 1000 UNIT KITantihemophilic factor (rcmb) moroctocog alfa(bdd-rfviii,mor)

4PA

S


4PA

S


4PA

S


4PA

S

XYNTHA SOLOFUSE 1000 UNIT KITantihemophilic factor (rcmb) moroctocog alfa(bdd-rfviii,mor)

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S



ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES

HEMLIBRA 105 MG/0.7ML SOLUTIONemicizumab-kxwh

4PA

S

HEMLIBRA 150 MG/ML SOLUTIONemicizumab-kxwh

4PA

S

HEMLIBRA 30 MG/ML SOLUTIONemicizumab-kxwh

4PA

S

HEMLIBRA 60 MG/0.4ML SOLUTIONemicizumab-kxwh

4PA

S

BRADYKININ B2 RECEPTOR ANTAGONISTS

icatibant acetate 30 mg/3ml solution 4PA

S

sajazir 30 mg/3ml solution 4PA

S

C1 INHIBITORS

BERINERT 500 UNIT KITc1 esterase inhibitor (human)

4PA

S

HAEGARDA 2000 UNIT RECON SOLNc1 esterase inhibitor (human)

4PA

S

HAEGARDA 3000 UNIT RECON SOLNc1 esterase inhibitor (human)

4PA

S

DIRECT-ACTING P2Y12 INHIBITORSBRILINTA 60 MG TABticagrelor

2 QL 60 / 30 DAYS

BRILINTA 90 MG TABticagrelor

2 QL 60 / 30 DAYS

HEMATORHEOLOGIC AGENTSpentoxifylline er 400 mg tab er 1



PHOSPHODIESTERASE III INHIBITORScilostazol 100 mg tab 1

cilostazol 50 mg tab 1

PLATELET AGGREGATION INHIBITOR COMBINATIONSaspirin-dipyridamole er 25-200 mg cap er 12h 2

PLATELET AGGREGATION INHIBITORSdipyridamole 25 mg tab 1

dipyridamole 50 mg tab 1

dipyridamole 75 mg tab 1

PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS

ZONTIVITY 2.08 MG TABvorapaxar sulfate

3QL 30 / 30 DAYS

PA

QUINAZOLINE AGENTSanagrelide hcl 0.5 mg cap 1

anagrelide hcl 1 mg cap 1

THIENOPYRIDINE DERIVATIVESclopidogrel bisulfate 300 mg tab 1

clopidogrel bisulfate 75 mg tab 1

prasugrel hcl 10 mg tab 1

prasugrel hcl 5 mg tab 1

HEMATOPOIETIC AGENTSAGENTS FOR GAUCHER DISEASE

CERDELGA 84 MG CAPeliglustat tartrate

4PA

S

COBALAMINScyanocobalamin 1000 mcg/ml solution 1

CYTOTOXIC AGENTSDROXIA 200 MG CAPhydroxyurea (sickle cell anemia)

2

DROXIA 300 MG CAPhydroxyurea (sickle cell anemia)

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSDROXIA 400 MG CAPhydroxyurea (sickle cell anemia)

2

ERYTHROPOIESIS-STIMULATING AGENTS (ESAS)

ARANESP (ALBUMIN FREE) 10 MCG/0.4ML SOLN PRSYRdarbepoetin alfa

4PA

S


4PA

S

ARANESP (ALBUMIN FREE) 100 MCG/ML SOLUTIONdarbepoetin alfa

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

ARANESP (ALBUMIN FREE) 500 MCG/ML SOLN PRSYRdarbepoetin alfa

4PA

S




4PA

S


4PA

S

MIRCERA 100 MCG/0.3ML SOLN PRSYRmethoxy polyethylene glycol-epoetin beta

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

PROCRIT 10000 UNIT/ML SOLUTIONepoetin alfa

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

RETACRIT 10000 UNIT/ML SOLUTIONepoetin alfa-epbx

4PA

S




4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

FOLIC ACID/FOLATESfolic acid 1 mg tab 1

GRANULOCYTE COLONY-STIMULATING FACTORS (G-CSF)

FULPHILA 6 MG/0.6ML SOLN PRSYRpegfilgrastim-jmdb

3

QL 1.2 / 28 day(s)

PA

S

GRANIX 300 MCG/0.5ML SOLN PRSYRtbo-filgrastim

3

QL 10 / 28 day(s)

PA

S

GRANIX 300 MCG/ML SOLUTIONtbo-filgrastim

3

QL 20 / 28 day(s)

PA

S

GRANIX 480 MCG/0.8ML SOLN PRSYRtbo-filgrastim

3

QL 16 / 28 day(s)

PA

S

GRANIX 480 MCG/1.6ML SOLUTIONtbo-filgrastim

3

QL 32 / 28 day(s)

PA

S

NIVESTYM 300 MCG/0.5ML SOLN PRSYRfilgrastim-aafi

2QL 10 / 28 day(s)

S



NIVESTYM 300 MCG/ML SOLUTIONfilgrastim-aafi

2QL 20 / 28 day(s)

S

NIVESTYM 480 MCG/0.8ML SOLN PRSYRfilgrastim-aafi

2QL 16 / 28 day(s)

S

NIVESTYM 480 MCG/1.6ML SOLUTIONfilgrastim-aafi

2QL 32 / 28 day(s)

S

NYVEPRIA 6 MG/0.6ML SOLN PRSYRpegfilgrastim-apgf

2QL 1.2 / 28 day(s)

S

UDENYCA 6 MG/0.6ML SOLN PRSYRpegfilgrastim-cbqv

3

QL 1.2 / 28 day(s)

PA

S

ZARXIO 300 MCG/0.5ML SOLN PRSYRfilgrastim-sndz

2QL 10 / 28 day(s)

S

ZARXIO 480 MCG/0.8ML SOLN PRSYRfilgrastim-sndz

2QL 16 / 28 day(s)

S

ZIEXTENZO 6 MG/0.6ML SOLN PRSYRpegfilgrastim-bmez

2QL 1.2 / 28 day(s)

S

THROMBOPOIETIN (TPO) RECEPTOR AGONISTS

PROMACTA 12.5 MG PACKETeltrombopag olamine

4PA

S

PROMACTA 12.5 MG TABeltrombopag olamine

4PA

S

PROMACTA 25 MG PACKETeltrombopag olamine

4PA

S

PROMACTA 25 MG TABeltrombopag olamine

4PA

S


4PA

S




4PA

S

HEMOSTATICSHEMOSTATICS - SYSTEMIC

aminocaproic acid 0.25 gm/ml solution 2

aminocaproic acid 1000 mg tab 2

aminocaproic acid 500 mg tab 2

tranexamic acid 650 mg tab 1

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTSBARBITURATE HYPNOTICS

phenobarbital 100 mg tab 1


phenobarbital 16.2 mg tab 1

phenobarbital 20 mg/5ml elixir 1

phenobarbital 20 mg/5ml solution 1






BENZODIAZEPINE HYPNOTICSFLURAZEPAM HCL 15 MG CAPflurazepam hcl

1 QL 30 / 30 day(s)

FLURAZEPAM HCL 30 MG CAPflurazepam hcl

1 QL 30 / 30 day(s)

midazolam hcl (pf) 10 mg/2ml solution 1

midazolam hcl (pf) 5 mg/ml solution 1

temazepam 15 mg cap 1 QL 30 / 30 DAYS

temazepam 22.5 mg cap 2 QL 30 / 30 DAYS



temazepam 30 mg cap 1 QL 30 / 30 DAYS

temazepam 7.5 mg cap 1 QL 30 / 30 DAYS

triazolam 0.125 mg tab 1 QL 30 / 30 DAYS

triazolam 0.25 mg tab 1 QL 30 / 30 DAYS

NON-BENZODIAZEPINE - GABA-RECEPTOR MODULATORS

eszopiclone 1 mg tab 1 QL 30 / 30 DAYS



zaleplon 10 mg cap 1 QL 60 / 30 DAYS

zaleplon 5 mg cap 1 QL 30 / 30 DAYS

zolpidem tartrate 10 mg tab 1 QL 30 / 30 DAYS

zolpidem tartrate 5 mg tab 1 QL 30 / 30 DAYS

zolpidem tartrate er 12.5 mg tab er 1 QL 30 / 30 DAYS

zolpidem tartrate er 6.25 mg tab er 1 QL 30 / 30 DAYS

OREXIN RECEPTOR ANTAGONISTS

BELSOMRA 10 MG TABsuvorexant

3QL 30 / 30 DAYS

PA


3QL 30 / 30 DAYS

PA


3QL 30 / 30 DAYS

PA


3QL 30 / 30 DAYS

PA

DAYVIGO 10 MG TABlemborexant

3 PA

DAYVIGO 5 MG TABlemborexant

3 PA



SELECTIVE MELATONIN RECEPTOR AGONISTS

ramelteon 8 mg tab 1 QL 30 / 30 DAYS

LAXATIVESBOWEL EVACUANT COMBINATIONS

GAVILYTE-C 240 GM RECON SOLNpeg 3350-kcl-sod bicarb-sod chloride-sod sulfate

2

gavilyte-g 236 gm recon soln 1 PRE Preventative

gavilyte-n with flavor pack 420 gm recon soln 1 PRE Preventative

GOLYTELY 227.1 GM RECON SOLNpeg 3350-kcl-sod bicarb-sod chloride-sod sulfate

2 PRE Preventative

GOLYTELY 236 GM RECON SOLNpeg 3350-kcl-sod bicarb-sod chloride-sod sulfate

2

peg 3350-kcl-na bicarb-nacl 420 gm recon soln 1 PRE Preventative

peg 3350/electrolytes 240 gm recon soln 1 PRE Preventative

peg-3350/electrolytes 236 gm recon soln 1 PRE Preventative

PREPOPIK 10-3.5-12 MG-GM-GM PACKETsodium picosulfate-magnesium oxide-anhydrous citricacid

2

SUPREP BOWEL PREP KIT 17.5-3.13-1.6 GM/177MLSOLUTIONsodium sulfate-potassium sulfate-magnesium sulfate

2 QL 354 / 30 day(s)

trilyte 420 gm recon soln 1 PRE Preventative

LAXATIVES - MISCELLANEOUSconstulose 10 gm/15ml solution 1

lactulose 10 gm/15ml solution 1

lactulose 20 gm/30ml solution 1

pegylax 17 gm/scoop powder 1

polyethylene glycol 3350 17 gm packet 1

polyethylene glycol 3350 17 gm/scoop powder 1



MACROLIDESAZITHROMYCIN

AZITHROMYCIN 1 GM PACKETazithromycin


azithromycin 100 mg/5ml recon susp 1 QL 30 / 5 DAYS

azithromycin 200 mg/5ml recon susp 1 QL 90 / 5 DAYS

azithromycin 250 mg tab 1 QL 30 / 30 day(s)

azithromycin 500 mg tab 1 QL 30 / 30 DAYS

azithromycin 600 mg tab 1 QL 30 / 30 DAYS

CLARITHROMYCINCLARITHROMYCIN 125 MG/5ML RECON SUSPclarithromycin

1

clarithromycin 250 mg tab 1

CLARITHROMYCIN 250 MG/5ML RECON SUSPclarithromycin

1

clarithromycin 500 mg tab 1 QL 28 / 14 DAYS

clarithromycin er 500 mg tab er 24h 1 QL 28 / 14 DAYS

ERYTHROMYCINSery-tab 250 mg tab dr 3

ery-tab 333 mg tab dr 3

ery-tab 500 mg tab dr 3

ERYTHROCIN STEARATE 250 MG TABerythromycin stearate

3 PA

erythromycin 250 mg tab dr 1



erythromycin base 250 mg tab 1

erythromycin base 250 mg tab dr 1




erythromycin base 500 mg tab 1


erythromycin ethylsuccinate 200 mg/5ml recon susp 1

ERYTHROMYCIN ETHYLSUCCINATE 400 MG TABerythromycin ethylsuccinate

1

erythromycin ethylsuccinate 400 mg/5ml recon susp 2 AL1 Up to 8 yrs old

FIDAXOMICIN

DIFICID 200 MG TABfidaxomicin

4PA

S

DIFICID 40 MG/ML RECON SUSPfidaxomicin

4PA

S

MEDICAL DEVICES AND SUPPLIESCERVICAL CAPS

FEMCAP 22 MM DEVICEcervical caps

2 PRE Preventative


2 PRE Preventative


2 PRE Preventative

DIAPHRAGMSCAYA DIAPHRAGMdiaphragm arc-spring

2 PRE Preventative

OMNIFLEX DIAPHRAGM DIAPHRAGMdiaphragms

2 PRE Preventative

WIDE-SEAL DIAPHRAGM 60 2 % DIAPHRAGMdiaphragm wide seal

2 PRE Preventative


2 PRE Preventative


2 PRE Preventative


2 PRE Preventative


2 PRE Preventative


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSWIDE-SEAL DIAPHRAGM 85 2 % DIAPHRAGMdiaphragm wide seal

2 PRE Preventative


2 PRE Preventative


2 PRE Preventative

GLUCOSE MONITORING TEST SUPPLIES

DEXCOM G6 RECEIVER DEVICEcontinuous blood glucose system receiver

2QL 1 / 365 day(s)

PA

DEXCOM G6 SENSOR MISCcontinuous blood glucose system sensor

2QL 3 / 30 day(s)

PA

DEXCOM G6 TRANSMITTER MISCcontinuous blood glucose system transmitter

2QL 1 / 90 day(s)

PA

EASY TOUCH LANCETS 30G/TWIST MISClancets

1

EASY TOUCH LANCETS 33G/TWIST MISClancets

1

FREESTYLE FLASH SYSTEM KITblood glucose monitoring supplies

2

FREESTYLE FREEDOM KITblood glucose monitoring supplies

2

FREESTYLE FREEDOM LITE W/DEVICE KITblood glucose monitoring supplies

2

FREESTYLE INSULINX SYSTEM W/DEVICE KITblood glucose monitoring supplies

2

FREESTYLE LANCETS MISClancets

1

FREESTYLE LIBRE 14 DAY READER DEVICEcontinuous blood glucose system receiver

2QL 1 / 365 day(s)

PA

FREESTYLE LIBRE 14 DAY SENSOR MISCcontinuous blood glucose system sensor

2QL 2 / 28 day(s)

PA

FREESTYLE LIBRE 2 READER DEVICEcontinuous blood glucose system receiver

2QL 1 / 365 day(s)

PA



FREESTYLE LIBRE 2 SENSOR MISCcontinuous blood glucose system sensor

2QL 2 / 28 day(s)

PA

FREESTYLE LIBRE READER DEVICEcontinuous blood glucose system receiver

2QL 1 / 365 day(s)

PA

FREESTYLE LIBRE SENSOR SYSTEM MISCcontinuous blood glucose system sensor

2QL 2 / 28 day(s)

PA

FREESTYLE LITE DEVICEblood glucose monitoring supplies

2

FREESTYLE LITE W/DEVICE KITblood glucose monitoring supplies

2

FREESTYLE SIDEKICK II KITblood glucose monitoring supplies

2

FREESTYLE SYSTEM KITblood glucose monitoring supplies

2

FREESTYLE UNISTICK II LANCETS MISClancets

1

KROGER HEALTHPRO LANCET 26G MISClancets

1

KROGER LANCETS MISClancets

1

KROGER LANCETS 21G MISClancets

1

KROGER LANCETS MICRO THIN 33G MISClancets

1

KROGER LANCETS SUPER THIN MISClancets

1

KROGER LANCETS THIN MISClancets

1

KROGER LANCETS THIN 26G MISClancets

1

KROGER LANCETS ULTRATHIN 30G MISClancets

1

MICROLET LANCETS MISClancets

1

ONETOUCH CLUB LANCETS FINE PT MISClancets

1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSONETOUCH DELICA LANCETS 30G MISClancets

1

ONETOUCH DELICA LANCETS 33G MISClancets

1

ONETOUCH DELICA LANCING DEV MISClancet devices

2

ONETOUCH DELICA PLUS LANCET30G MISClancets

1

ONETOUCH DELICA PLUS LANCET33G MISClancets

1

ONETOUCH DELICA PLUS LANCING MISClancet devices

2

ONETOUCH FINEPOINT LANCETS MISClancets

1

ONETOUCH PING METER REMOTE SUPPLIES MISCblood glucose monitoring supplies

2

ONETOUCH SURESOFT LANCING DEV MISClancets misc.

2

ONETOUCH ULTRA 2 W/DEVICE KITblood glucose monitoring supplies

2

ONETOUCH ULTRA MINI W/DEVICE KITblood glucose monitoring supplies

2

ONETOUCH ULTRALINK W/DEVICE KITblood glucose monitoring supplies

2

ONETOUCH ULTRASOFT LANCETS MISClancets

1

ONETOUCH VERIO FLEX SYSTEM W/DEVICE KITblood glucose monitoring supplies

2

ONETOUCH VERIO IQ SYSTEM W/DEVICE KITblood glucose monitoring supplies

2

ONETOUCH VERIO REFLECT W/DEVICE KITblood glucose monitoring supplies

2

ONETOUCH VERIO SYNC SYSTEM W/DEVICE KITblood glucose monitoring supplies

2

ONETOUCH VERIO W/DEVICE KITblood glucose monitoring supplies

2

PHARMACIST CHOICE LANCETS MISClancets

1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSTRUEPLUS LANCETS 26G MISClancets

1

TRUEPLUS LANCETS 28G MISClancets

1


1


1

TRUEPLUS SAFETY LANCETS 28G MISClancets

1

INSULIN ADMINISTRATION SUPPLIESOMNIPOD 5 PACK MISCinsulin infusion disposable pump

3 PA

OMNIPOD DASH 5 PACK PODS MISCinsulin infusion disposable pump

3 PA

OMNIPOD DASH SYSTEM KITinsulin infusion disposable pump

3 PA

OMNIPOD STARTER KITinsulin infusion disposable pump

3 PA

NEEDLES & SYRINGESASSURE ID INSULIN SAFETY SYR 29G X 1/2" 0.5 ML MISCinsulin syringe/needle u-100

1

ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML MISCinsulin syringe/needle u-100

1

BD INSULIN SYRINGE U-500 31G X 6MM 0.5 ML MISCinsulin syringe/needle u-500

1

BD KLATSKIN BIOPSY NEEDLE 16G X 4" MISCneedle (disp) 16 g

2

BD OSGOOD BIOPSY NEEDLE 16G X 1-5/16" MISCneedle (disp) 16 g

2

BD OSGOOD BIOPSY NEEDLE 18G X 1" MISCneedle (reusable) 18 g

2

BD PEN NEEDLE NANO U/F 32G X 4 MM MISCinsulin pen needle

1

BD ROSENTHAL BIOPSY NEEDLE 16G X 1-5/16" MISCneedle (disp) 16 g

2

BD SAFETYGLIDE INSULIN SYRINGE 31G X 15/64" 0.3 MLMISCinsulin syringe/needle u-100

1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSCEQUR SIMPLICITY INSERTER MISCinjection device for insulin

2

CEQUR SIMPLICITY STARTER KITinjection device for insulin

2

J-TIP KIT W/VIAL ADAPTERS KITinjection device

2

MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML MISCinsulin syringe/needle u-100

1


1

MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 1 ML MISCinsulin syringe/needle u-100

1


1


1

MAGELLAN INSULIN SAFETY SYR 30G X 5/16" 1 ML MISCinsulin syringe/needle u-100

1

MARATHON MEDICAL PENTIPS 29G X 12MM MISCinsulin pen needle

1

MARATHON MEDICAL PENTIPS 31G X 5 MM MISCinsulin pen needle

1


1


1

MONOJECT INSULIN SYRINGE 27G X 1/2" 1 ML MISCinsulin syringe/needle u-100

1

MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML MISCinsulin syringe/needle u-100

1


1


1


1


1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSMONOJECT INSULIN SYRINGE 30G X 5/16" 0.3 ML MISCinsulin syringe/needle u-100

1


1


1

MONOJECT INSULIN SYRINGE U-100 1 ML MISCinsulin syringes (disposable)

1

MONOJECT INTRODUCER NEEDLE 18G X 1-1/4" MISCneedle (reusable) 18 g

2

MONOJECT MAGELLAN SAFETY NDL 21G X 5/8" MISCneedle (disp) 21 g

2

MONOJECT MAGELLAN SAFETY NDL 23G X 5/8" MISCneedle (disp) 23 g

2

MONOJECT MAGELLAN SYRINGE 18G X 1" 6 ML MISCsyringe/needle (disp) 6 ml

2

MONOJECT MAGELLAN SYRINGE 21G X 1" 12 ML MISCsyringe/needle (disp) 12 ml

2

MONOJECT MAGELLAN SYRINGE 22G X 1-1/2" 12 MLMISCsyringe/needle (disp) 12 ml

2

MONOJECT SYRINGE 21G X 1" 12 ML MISCsyringe/needle (disp) 12 ml

2

MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 MLMISCinsulin syringe/needle u-100

1

MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 1 MLMISCinsulin syringe/needle u-100

1

MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" 0.3ML MISCinsulin syringe/needle u-100

1

MONOJECT ULTRA COMFORT SYRINGE 30G X 5/16" 0.5ML MISCinsulin syringe/needle u-100

1

NORDIPEN 5 INJECTION DEVICE MISCinjection device

2

OMNITROPE PEN 5 INJ DEVICE MISCinjection device

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSPENTIPS 29G X 12MM MISCinsulin pen needle

1

PENTIPS 31G X 5 MM MISCinsulin pen needle

1


1


1

PRO COMFORT PEN NEEDLES 31G X 8 MM MISCinsulin pen needle

1


1


1

ULTICARE INSULIN SAFETY SYR 29G X 1/2" 0.5 ML MISCinsulin syringe/needle u-100

1

ULTICARE INSULIN SAFETY SYR 29G X 1/2" 1 ML MISCinsulin syringe/needle u-100

1

ULTILET INSULIN SYRINGE 31G X 15/64" 0.3 ML MISCinsulin syringe/needle u-100

1

SPACER/AEROSOL-HOLDING CHAMBERS & SUPPLIESAEROCHAMBER MINI CHAMBER DEVICEspacer/aerosol-holding chambers

2

AEROCHAMBER MV MISCspacer/aerosol-holding chambers

2

AEROCHAMBER PLUS FLO-VU MISCspacer/aerosol-holding chambers

2

AEROCHAMBER PLUS FLO-VU LARGE MISCspacer/aerosol-holding chambers

2

AEROCHAMBER PLUS FLO-VU MEDIUM MISCspacer/aerosol-holding chambers

2

AEROCHAMBER PLUS FLO-VU SMALL MISCspacer/aerosol-holding chambers

2

AEROCHAMBER PLUS FLO-VU W/MASK MISCspacer/aerosol-holding chambers

2

AEROCHAMBER PLUS FLOW VU MISCspacer/aerosol-holding chambers

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSAEROCHAMBER W/FLOWSIGNAL MISCspacer/aerosol-holding chambers

2

AEROCHAMBER Z-STAT PLUS MISCspacer/aerosol-holding chambers

2

AEROCHAMBER Z-STAT PLUS CHAMBR MISCspacer/aerosol-holding chambers

2

AEROCHAMBER Z-STAT PLUS/LARGE MISCspacer/aerosol-holding chambers

2

AEROCHAMBER Z-STAT PLUS/MEDIUM MISCspacer/aerosol-holding chambers

2

AEROCHAMBER Z-STAT PLUS/SMALL MISCspacer/aerosol-holding chambers

2

COMPACT SPACE CHAMBER DEVICEspacer/aerosol-holding chambers

2

COMPACT SPACE CHAMBER/LG MASK DEVICEspacer/aerosol-holding chambers

2

COMPACT SPACE CHAMBER/MED MASK DEVICEspacer/aerosol-holding chambers

2

COMPACT SPACE CHAMBER/SM MASK DEVICEspacer/aerosol-holding chambers

2

EASIVENT MISCspacer/aerosol-holding chambers

2

EASIVENT MASK LARGE MISCspacer/aerosol-holding chambers

2

EASIVENT MASK MEDIUM MISCspacer/aerosol-holding chambers

2

EASIVENT MASK SMALL MISCspacer/aerosol-holding chambers

2

MICROCHAMBER MISCspacer/aerosol-holding chambers

2

MICROSPACER MISCspacer/aerosol-holding chambers

2

OPTICHAMBER ADVANTAGE-LG MASK MISCspacer/aerosol-holding chambers

2

OPTICHAMBER ADVANTAGE-MED MASK MISCspacer/aerosol-holding chambers

2

OPTICHAMBER ADVANTAGE-SM MASK MISCspacer/aerosol-holding chambers

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSOPTICHAMBER DIAMOND MISCspacer/aerosol-holding chambers

2

OPTICHAMBER DIAMOND-LG MASK DEVICEspacer/aerosol-holding chambers

2

OPTICHAMBER DIAMOND-MD MASK MISCspacer/aerosol-holding chambers

2

OPTICHAMBER DIAMOND-SM MASK MISCspacer/aerosol-holding chambers

2

VALVED HOLDING CHAMBER DEVICEspacer/aerosol-holding chambers

2

MIGRAINE PRODUCTSCALCITONIN GENE-RELATED PEPTIDE RECEPTOR ANTAG (CGRP)

NURTEC 75 MG TAB DISPrimegepant sulfate

3QL 8 / 30 day(s)

PA

QULIPTA 10 MG TABatogepant

3 PA


3 PA


3 PA

UBRELVY 100 MG TABubrogepant

2QL 12 / 30 day(s)

PA

UBRELVY 50 MG TABubrogepant

2QL 12 / 30 day(s)

PA

CGRP RECEPTOR ANTAGONISTS - MONOCOLONAL ANTIBODIES

AIMOVIG (140 MG DOSE) 70 MG/ML SOLN A-INJerenumab-aooe

3QL 2 / 30 DAYS

PA

AIMOVIG 140 MG/ML SOLN A-INJerenumab-aooe

3 PA

AIMOVIG 70 MG/ML SOLN A-INJerenumab-aooe

3QL 1 / 30 DAYS

PA

AJOVY 225 MG/1.5ML SOLN A-INJfremanezumab-vfrm

2QL 1.5 / 30 day(s)

PA



AJOVY 225 MG/1.5ML SOLN PRSYRfremanezumab-vfrm

2QL 1.5 / 30 DAYS

PA

EMGALITY (300 MG DOSE) 100 MG/ML SOLN PRSYRgalcanezumab-gnlm

2QL 1 / 30 DAYS

PA

EMGALITY 120 MG/ML SOLN A-INJgalcanezumab-gnlm

2QL 1 / 30 DAYS

PA

EMGALITY 120 MG/ML SOLN PRSYRgalcanezumab-gnlm

2QL 1 / 30 DAYS

PA

ERGOT COMBINATIONSergotamine-caffeine 1-100 mg tab 1

dihydroergotamine mesylate 1 mg/ml solution 2 QL 24 / 30 DAYS

dihydroergotamine mesylate 4 mg/ml solution 2QL 16 / 30 DAYS

PA

SELECTIVE SEROTONIN AGONISTS 5-HT(1)

almotriptan malate 12.5 mg tab 1 QL 9 / 28 DAYS

almotriptan malate 6.25 mg tab 1 QL 9 / 28 DAYS

eletriptan hydrobromide 20 mg tab 1 QL 9 / 28 DAYS

eletriptan hydrobromide 40 mg tab 1 QL 9 / 28 DAYS

frovatriptan succinate 2.5 mg tab 2 QL 9 / 28 DAYS

naratriptan hcl 1 mg tab 1 QL 9 / 30 DAYS

naratriptan hcl 2.5 mg tab 1 QL 9 / 30 DAYS

rizatriptan benzoate 10 mg tab 1 QL 9 / 28 DAYS

rizatriptan benzoate 10 mg tab disp 1 QL 9 / 28 DAYS

rizatriptan benzoate 5 mg tab 1 QL 9 / 28 DAYS

rizatriptan benzoate 5 mg tab disp 1 QL 9 / 28 DAYS

sumatriptan 20 mg/act solution 1 QL 6 / 28 DAYS



sumatriptan 5 mg/act solution 1 QL 6 / 28 DAYS

sumatriptan succinate 100 mg tab 1 QL 9 / 30 DAYS


sumatriptan succinate 4 mg/0.5ml soln a-inj 2 QL 2 / 28 day(s)


sumatriptan succinate 6 mg/0.5ml soln a-inj 2 QL 2 / 28 day(s)

SUMATRIPTAN SUCCINATE 6 MG/0.5ML SOLN PRSYRsumatriptan succinate

2

sumatriptan succinate 6 mg/0.5ml solution 2 QL 5 / 28 day(s)

zolmitriptan 2.5 mg tab 1 QL 12 / 30 DAYS

zolmitriptan 2.5 mg tab disp 1 QL 9 / 30 DAYS

zolmitriptan 5 mg tab 1 QL 9 / 30 DAYS

zolmitriptan 5 mg tab disp 1 QL 9 / 30 DAYS

SELECTIVE SEROTONIN AGONISTS 5-HT(1F)

REYVOW 100 MG TABlasmiditan succinate

3QL 4 / 30 day(s)

PA

REYVOW 50 MG TABlasmiditan succinate

3QL 4 / 30 day(s)

PA

MINERALS & ELECTROLYTESFLUORIDE

fluoritab 0.55 (0.25 f) mg chew tab 1 PRE Preventative

fluoritab 1.1 (0.5 f) mg chew tab 1 PRE Preventative

fluoritab 2.2 (1 f) mg chew tab 1 PRE Preventative

FLURA-DROPS 0.55 (0.25 F) MG/DROP SOLUTIONsodium fluoride

2AL1 Up to 8 yrs oldPRE Preventative

ludent 0.55 (0.25 f) mg chew tab 1 PRE Preventative



ludent 1.1 (0.5 f) mg chew tab 1 PRE Preventative

ludent 2.2 (1 f) mg chew tab 1 PRE Preventative

nafrinse 2.2 (1 f) mg chew tab 1 PRE Preventative

sodium fluoride 0.55 (0.25 f) mg chew tab 1 PRE Preventative

sodium fluoride 1.1 (0.5 f) mg chew tab 1 PRE Preventative

sodium fluoride 1.1 (0.5 f) mg/ml solution 1 PRE Preventative

sodium fluoride 2.2 (1 f) mg chew tab 1 PRE Preventative

PHOSPHATEK-PHOS 500 MG TABpotassium phosphate monobasic

2

phospha 250 neutral 155-852-130 mg tab 1

phospho-trin 250 neutral 155-852-130 mg tab 1

phosphorous 155-852-130 mg tab 1

virt-phos 250 neutral 155-852-130 mg tab 1

POTASSIUMeffer-k 25 meq effer tab 1

k-effervescent 25 meq effer tab 1

k-prime 25 meq effer tab 1

k-vescent 25 meq effer tab 1

klor-con 10 10 meq tab er 2

klor-con 20 meq packet 2

klor-con 8 meq tab er 1

klor-con m10 10 meq tab er 1



klor-con sprinkle 10 meq cap er 1

klor-con sprinkle 8 meq cap er 1

klor-con/ef 25 meq effer tab 1



potassium bicarbonate 25 meq effer tab 1

potassium chloride 10 % solution 1

potassium chloride 20 meq packet 2

potassium chloride 20 meq/15ml (10%) solution 1

potassium chloride crys er 10 meq tab er 1



potassium chloride er 10 meq cap er 1

potassium chloride er 10 meq tab er 1


POTASSIUM CHLORIDE ER 20 MEQ TAB ERpotassium chloride

1

potassium chloride er 8 meq cap er 1


POTASSIUM CHLORIDE ER 8 MEQ TAB ERpotassium chloride

1

MISCELLANEOUS THERAPEUTIC CLASSESANTILEPROTICS

THALOMID 100 MG CAPthalidomide

4PA

S


4PA

S


4PA

S


4PA

S

B-LYMPHOCYTE STIMULATOR (BLYS)-SPECIFIC INHIBITORS

BENLYSTA 200 MG/ML SOLN A-INJbelimumab

4PA

S

BENLYSTA 200 MG/ML SOLN PRSYRbelimumab

4PA

S



CHELATING AGENTS

clovique 250 mg cap 4PA

S

penicillamine 250 mg cap 4PA

S

penicillamine 250 mg tab 4PA

S

trientine hcl 250 mg cap 4PA

S

CYCLOSPORINE ANALOGScyclosporine 100 mg cap 2

cyclosporine 25 mg cap 1 QL 90 / 30 DAYS

cyclosporine modified 100 mg cap 1 QL 4 / 1 day(s)

cyclosporine modified 100 mg/ml solution 1 QL 90 / 30 DAYS

cyclosporine modified 25 mg cap 1 QL 4 / 1 day(s)

cyclosporine modified 50 mg cap 1 QL 120 / 30 DAYS

gengraf 100 mg cap 1 QL 4 / 1 day(s)

gengraf 100 mg/ml solution 1 QL 90 / 30 DAYS

gengraf 25 mg cap 1 QL 4 / 1 day(s)

LUPKYNIS 7.9 MG CAPvoclosporin

4PA

S

NEORAL 100 MG CAPcyclosporine modified (for microemulsion)

4

QL 4 / 1 day(s)

PA

S

NEORAL 100 MG/ML SOLUTIONcyclosporine modified (for microemulsion)

4PA

S

NEORAL 25 MG CAPcyclosporine modified (for microemulsion)

4

QL 4 / 1 day(s)

PA

S



ENZYMES

XIAFLEX 0.9 MG RECON SOLNcollagenase clostridium histolyticum

4PA

S

IMMUNOMODULATORS FOR MYELODYSPLASTIC SYNDROMES

REVLIMID 10 MG CAPlenalidomide

4PA

S


4PA

S

REVLIMID 2.5 MG CAPlenalidomide

4PA

S


4PA

S


4PA

S


4PA

S

INOSINE MONOPHOSPHATE DEHYDROGENASE INHIBITORS

mycophenolate mofetil 200 mg/ml recon susp 2PA

AL1 Up to 8 yrs old

mycophenolate mofetil 250 mg cap 1

mycophenolate mofetil 500 mg tab 1

mycophenolate sodium 180 mg tab dr 2

mycophenolate sodium 360 mg tab dr 2

IRRIGATION SOLUTIONSphysiolyte solution 3

physiosol irrigation solution 3

MACROLIDE IMMUNOSUPPRESSANTS

ASTAGRAF XL 0.5 MG CAP ER 24Htacrolimus

3QL 45 / 30 DAYS

PA



ASTAGRAF XL 1 MG CAP ER 24Htacrolimus

3QL 45 / 30 DAYS

PA

ASTAGRAF XL 5 MG CAP ER 24Htacrolimus

3QL 45 / 30 DAYS

PA

ENVARSUS XR 0.75 MG TAB ER 24Htacrolimus

3 PA

ENVARSUS XR 1 MG TAB ER 24Htacrolimus

3 PA

ENVARSUS XR 4 MG TAB ER 24Htacrolimus

3 PA

everolimus 0.25 mg tab 2 QL 120 / 30 day(s)



everolimus 1 mg tab 2 QL 60 / 30 day(s)

sirolimus 0.5 mg tab 2

sirolimus 1 mg tab 2

sirolimus 1 mg/ml solution 4

PA

AL1 0 to 8 yrs old

S

sirolimus 2 mg tab 2

tacrolimus 0.5 mg cap 1

tacrolimus 1 mg cap 1

tacrolimus 5 mg cap 1

MONOCLONAL ANTIBODIES

ENSPRYNG 120 MG/ML SOLN PRSYRsatralizumab-mwge

4PA

S

POTASSIUM REMOVING AGENTSkionex powder 1

kionex 15 gm/60ml suspension 1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSLOKELMA 10 GM PACKETsodium zirconium cyclosilicate

3 PA

LOKELMA 5 GM PACKETsodium zirconium cyclosilicate

3 PA

sodium polystyrene sulfonate powder 1

sodium polystyrene sulfonate 15 gm/60ml suspension 1



SPS 15 GM/60ML SUSPENSIONsodium polystyrene sulfonate

2

VELTASSA 16.8 GM PACKETpatiromer sorbitex calcium

3QL 30 / 30 DAYS

PA


3QL 30 / 30 DAYS

PA


3QL 60 / 28 DAYS

PA

PURINE ANALOGSazathioprine 50 mg tab 1

ROCK INHIBITORS

REZUROCK 200 MG TABbelumosudil mesylate

4PA

S

MOUTH/THROAT/DENTAL AGENTSANESTHETICS TOPICAL ORAL

lidocaine viscous hcl 2 % solution 1

ANTI-INFECTIVES - THROATclotrimazole 10 mg troche 1

nystatin 100000 unit/ml suspension 1

ORAVIG 50 MG TABmiconazole (mouth-throat)

3QL 14 / 14 DAYS

PA



ANTISEPTICS - MOUTH/THROATchlorhexidine gluconate 0.12 % solution 1

paroex 0.12 % solution 1

periogard 0.12 % solution 1

SALIVA STIMULANTScevimeline hcl 30 mg cap 1

pilocarpine hcl 5 mg tab 1

pilocarpine hcl 7.5 mg tab 1

STEROIDS - MOUTH/THROAT/DENTALtriamcinolone acetonide 0.1 % paste 1

MULTIVITAMINSPRENATAL MV & MIN W/FE-FA

CO-NATAL FA TABprenatal vit w/ ferrous fumarate-folic acid

1 PRE Preventative

COMPLETENATE 29-1 MG CHEW TABprenatal vit w/ ferrous fumarate-folic acid

2

M-VIT TABprenatal vit w/ ferrous fumarate-folic acid

1

NEONATAL COMPLETE 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

1

NEONATAL COMPLETE 29-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

1 PRE Preventative

NEONATAL PLUS 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

1

OB COMPLETE/DHA 30-10-1-200 MG CAPprenat vit w/ iron carbonyl-fe asp glyc-fa-omega fattyacid

2

PNV FOLIC ACID + IRON 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

1

PNV PRENATAL PLUS MULTIVITAMIN 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

1

PNV TABS 29-1 29-1 MG TABprenatal vit w/ iron carbonyl-folic acid

2

PRENATA 29-1 MG CHEW TABprenatal without a vit w/ fe fumarate-folic acid

2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSPRENATABS RX 29-1 MG TABprenatal vit w/ iron carbonyl-folic acid

2

PRENATAL 19 29-1 MG CHEW TABprenatal vit w/ ferrous fumarate-folic acid

2

PRENATAL 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

1

PRENATAL PLUS IRON 29-1 MG TABprenatal vit w/ iron carbonyl-folic acid

1

PRENATAL VITAMIN PLUS LOW IRON 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

1

PRETAB 29-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

1 PRE Preventative

TRINATAL RX 1 60-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

2

VINATE ONE 60-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

2

VITATHELY WITH GINGER 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

1

WESTAB PLUS 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid

1

PRENATAL MV & MIN W/FE-FA-CA-OMEGA 3 FISH OILCOMPLETE NATAL DHA 29-1-200 & 200 MG MISCprenatal mv & min w/fe bisglyc-fe prot succ-fa-ca-omega3

2

TRIVEEN-DUO DHA 29-1-200 & 300 MG MISCprenatal mv & min w/fe bisglyc-fe prot succ-fa-ca-omega3

2

PRENATAL MV & MIN W/FE-FA-DHAPNV-DHA+DOCUSATE 27-1.25-300 MG CAPprenatal w/o vit a w/ fe fumarate-dss-fa-dha

2

VITAFOL-OB+DHA 65-1 & 250 MG MISCprenatal mv & min w/fe fumarate-fa-dha

2

VITAMEDMD ONE RX/QUATREFOLIC 30-0.6-0.4-200 MGCAPprenatal without a w/ fe fumarate-l methylfolate-fa-dha

2

PRENATAL VITAMINSVITAMEDMD REDICHEW RX 1.4 MG CHEW TABprenatal w/ vit b2-b6-b12-cholecalciferol-folic acid

2



MUSCULOSKELETAL THERAPY AGENTSCENTRAL MUSCLE RELAXANTS

baclofen 10 mg tab 1 QL 90 / 30 DAYS

baclofen 20 mg tab 1 QL 6 / 1 day(s)

baclofen 5 mg tab 1 QL 90 / 30 DAYS

chlorzoxazone 500 mg tab 1

chlorzoxazone 750 mg tab 1

cyclobenzaprine hcl 10 mg tab 1

cyclobenzaprine hcl 5 mg tab 1

cyclobenzaprine hcl 7.5 mg tab 1

lorzone 750 mg tab 1

metaxalone 800 mg tab 1 QL 90 / 30 DAYS

methocarbamol 500 mg tab 1

methocarbamol 750 mg tab 1

orphenadrine citrate er 100 mg tab er 12h 1

tizanidine hcl 2 mg cap 1

tizanidine hcl 2 mg tab 1


tizanidine hcl 4 mg tab 1


DIRECT MUSCLE RELAXANTSdantrolene sodium 100 mg cap 1

dantrolene sodium 25 mg cap 1

dantrolene sodium 50 mg cap 1

MUSCLE RELAXANT COMBINATIONS

carisoprodol-aspirin-codeine 200-325-16 mg tab 2 PA

orphenadrine-asa-caffeine 50-770-60 mg tab 2 PA

orphengesic forte 50-770-60 mg tab 2 PA



NASAL AGENTS - SYSTEMIC AND TOPICALANTIHISTAMINE-STEROID

azelastine-fluticasone 137-50 mcg/act suspension 2

NASAL ANTIBIOTICSBACTROBAN NASAL 2 % OINTMENTmupirocin calcium

3

NASAL ANTICHOLINERGICS

ipratropium bromide 0.03 % solution 1 QL 30 / 28 DAYS

ipratropium bromide 0.06 % solution 1 QL 15 / 14 DAYS

NASAL ANTIHISTAMINES

azelastine hcl 0.1 % solution 1 QL 30 / 25 DAYS

azelastine hcl 0.15 % solution 1 QL 30 / 25 DAYS

azelastine hcl 137 mcg/spray solution 1 QL 30 / 25 DAYS

olopatadine hcl 0.6 % solution 1 QL 30.5 / 30 DAYS

NASAL STEROIDSFLUNISOLIDE 25 MCG/ACT (0.025%) SOLUTIONflunisolide (nasal)

1 QL 25 / 25 DAYS

fluticasone propionate 50 mcg/act suspension 1 QL 16 / 30 DAYS

mometasone furoate 50 mcg/act suspension 1 QL 34 / 30 DAYS

XHANCE 93 MCG/ACT EXHUfluticasone propionate (nasal)

2 PA

NEUROMUSCULAR AGENTSBENZATHIAZOLES

riluzole 50 mg tab 1

NONDEPOLARIZING MUSCLE RELAXANTS

atracurium besylate 50 mg/5ml solution 2 PA

SPINAL MUSCULAR ATROPHY-SMN2 SPLICING MODIFIERS

EVRYSDI 0.75 MG/ML RECON SOLNrisdiplam

4PA

S



NUTRIENTSLIPIDS

DOJOLVI 100 % LIQUIDtriheptanoin

4PA

S

OPHTHALMIC AGENTSALPHA ADRENERGIC AGONIST & CARBONIC ANHYDRASE INHIB COMB

SIMBRINZA 1-0.2 % SUSPENSIONbrinzolamide-brimonidine tartrate

3

ARTIFICIAL TEAR INSERTSLACRISERT 5 MG INSERTartificial tear insert

3 PA

BETA-BLOCKERS - OPHTHALMICbetaxolol hcl 0.5 % solution 1

BETIMOL 0.25 % SOLUTIONtimolol

3

BETIMOL 0.5 % SOLUTIONtimolol

3

BETOPTIC-S 0.25 % SUSPENSIONbetaxolol hcl (ophth)

3

CARTEOLOL HCL 1 % SOLUTIONcarteolol hcl (ophth)

1

carteolol hcl 1 % solution 1

LEVOBUNOLOL HCL 0.5 % SOLUTIONlevobunolol hcl

1

levobunolol hcl 0.5 % solution 1

METIPRANOLOL 0.3 % SOLUTIONmetipranolol

1

timolol maleate 0.25 % gel f soln 1

timolol maleate 0.25 % solution 1

timolol maleate 0.5 % gel f soln 1

timolol maleate 0.5 % solution 1

BETA-BLOCKERS - OPHTHALMIC COMBINATIONSCOMBIGAN 0.2-0.5 % SOLUTIONbrimonidine tartrate-timolol maleate

3



dorzolamide hcl-timolol mal 22.3-6.8 mg/ml solution 1

dorzolamide hcl-timolol mal pf 2-0.5 % solution 1

CYCLOPLEGIC MYDRIATICSatropine sulfate 1 % solution 1

cyclopentolate hcl 0.5 % solution 1

cyclopentolate hcl 1 % solution 1

cyclopentolate hcl 2 % solution 1

homatropine hbr 5 % solution 1

tropicamide 0.5 % solution 1

tropicamide 1 % solution 1

LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAGXIIDRA 5 % SOLUTIONlifitegrast

2

MIOTICS - CHOLINESTERASE INHIBITORSPHOSPHOLINE IODIDE 0.125 % RECON SOLNechothiophate iodide

2

MIOTICS - DIRECT ACTINGpilocarpine hcl 1 % solution 1

pilocarpine hcl 2 % solution 1

pilocarpine hcl 4 % solution 1

OPHTHALMIC ANTI-INFECTIVE COMBINATIONSak-poly-bac 500-10000 unit/gm ointment 1

bacitracin-polymyxin b 500-10000 unit/gm ointment 1

neo-polycin 3.5-400-10000 ointment 1

neomycin-bacitracin zn-polymyx 3.5-400-10000 ointment 1

neomycin-bacitracin zn-polymyx 5-400-10000 ointment 1

NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75-10000-.025SOLUTIONneomycin-polymyxin-gramicidin

1

polycin 500-10000 unit/gm ointment 1

polymyxin b-trimethoprim 10000-0.1 unit/ml-% solution 1



OPHTHALMIC ANTIALLERGICALOCRIL 2 % SOLUTIONnedocromil sodium (ophth)

2

ALOMIDE 0.1 % SOLUTIONlodoxamide tromethamine

2

azelastine hcl 0.05 % solution 1

bepotastine besilate 1.5 % solution 2 QL 10 / 30 day(s)

BEPREVE 1.5 % SOLUTIONbepotastine besilate

3 QL 10 / 30 day(s)

cromolyn sodium 4 % solution 1

EMADINE 0.05 % SOLUTIONemedastine difumarate

2

epinastine hcl 0.05 % solution 1

LASTACAFT 0.25 % SOLUTIONalcaftadine

3

olopatadine hcl 0.1 % solution 1

olopatadine hcl 0.2 % solution 1

OPHTHALMIC ANTIBIOTICSAZASITE 1 % SOLUTIONazithromycin (ophth)

3

BACITRACIN 500 UNIT/GM OINTMENTbacitracin (ophthalmic)

1

BESIVANCE 0.6 % SUSPENSIONbesifloxacin hcl

3

ciprofloxacin hcl 0.3 % solution 1

erythromycin 5 mg/gm ointment 1

gatifloxacin 0.5 % solution 1 QL 2.5 / 30 DAYS

gentamicin sulfate 0.3 % solution 1

levofloxacin 0.5 % solution 1

MOXEZA 0.5 % SOLUTIONmoxifloxacin hcl (ophth)

3 QL 3 / 30 DAYS

moxifloxacin hcl (2x day) 0.5 % solution 1

moxifloxacin hcl 0.5 % solution 1



ofloxacin 0.3 % solution 1

tobramycin 0.3 % solution 1

OPHTHALMIC ANTIFUNGALNATACYN 5 % SUSPENSIONnatamycin

3

OPHTHALMIC ANTIVIRALSTRIFLURIDINE 1 % SOLUTIONtrifluridine

1

ZIRGAN 0.15 % GELganciclovir ophthalmic

3

OPHTHALMIC CARBONIC ANHYDRASE INHIBITORSbrinzolamide 1 % suspension 2

dorzolamide hcl 2 % solution 1

OPHTHALMIC IMMUNOMODULATORSRESTASIS 0.05 % EMULSIONcyclosporine (ophth)

2

RESTASIS MULTIDOSE 0.05 % EMULSIONcyclosporine (ophth)

2

OPHTHALMIC KINASE INHIBITORS - COMBINATIONSROCKLATAN 0.02-0.005 % SOLUTIONnetarsudil dimesylate-latanoprost

3 PA

OPHTHALMIC NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

bromfenac sodium (once-daily) 0.09 % solution 1 QL 3.4 / 30 DAYS

diclofenac sodium 0.1 % solution 1

FLURBIPROFEN SODIUM 0.03 % SOLUTIONflurbiprofen sodium

1

flurbiprofen sodium 0.03 % solution 1

ILEVRO 0.3 % SUSPENSIONnepafenac

3

ketorolac tromethamine 0.4 % solution 1

ketorolac tromethamine 0.5 % solution 1

NEVANAC 0.1 % SUSPENSIONnepafenac

3



OPHTHALMIC RHO KINASE INHIBITORSRHOPRESSA 0.02 % SOLUTIONnetarsudil dimesylate

3 PA

OPHTHALMIC SELECTIVE ALPHA ADRENERGIC AGONISTSALPHAGAN P 0.1 % SOLUTIONbrimonidine tartrate

3

apraclonidine hcl 0.5 % solution 1

brimonidine tartrate 0.15 % solution 1

brimonidine tartrate 0.2 % solution 1

OPHTHALMIC STEROID COMBINATIONSBLEPHAMIDE S.O.P. 10-0.2 % OINTMENTsulfacetamide sod-prednisolone

3

neomycin-polymyxin-dexameth 3.5-10000-0.1 ointment 1

neomycin-polymyxin-dexameth 3.5-10000-0.1 suspension 1

SULFACETAMIDE-PREDNISOLONE 10-0.23 % SOLUTIONsulfacetamide sod-prednisolone

1

TOBRADEX 0.3-0.1 % OINTMENTtobramycin-dexamethasone

2

tobramycin-dexamethasone 0.3-0.1 % suspension 1

OPHTHALMIC STEROIDSALREX 0.2 % SUSPENSIONloteprednol etabonate

3 ST

DEXAMETHASONE SODIUM PHOSPHATE 0.1 % SOLUTIONdexamethasone sodium phosphate (ophth)

1

difluprednate 0.05 % emulsion 1 QL 5 / 30 day(s)

FLAREX 0.1 % SUSPENSIONfluorometholone acetate

3

fluorometholone 0.1 % suspension 1

FML 0.1 % OINTMENTfluorometholone (ophth)

2

FML FORTE 0.25 % SUSPENSIONfluorometholone (ophth)

2

LOTEMAX 0.5 % OINTMENTloteprednol etabonate

3 ST



loteprednol etabonate 0.5 % gel 1

loteprednol etabonate 0.5 % suspension 1 QL 15 / 30 DAYS

MAXIDEX 0.1 % SUSPENSIONdexamethasone (ophth)

3

OMNIPRED 1 % SUSPENSIONprednisolone acetate (ophth)

2 QL 10 / 30 DAYS

PRED MILD 0.12 % SUSPENSIONprednisolone acetate (ophth)

2

PREDNISOLONE ACETATE 1 % SUSPENSIONprednisolone acetate (ophth)

1

PREDNISOLONE ACETATE P-F 1 % SUSPENSIONprednisolone acetate (ophth)

1

PREDNISOLONE SODIUM PHOSPHATE 1 % SOLUTIONprednisolone sodium phosphate (ophth)

1

OPHTHALMIC SULFONAMIDESsulfacetamide sodium 10 % solution 1

OPHTHALMICS - CYSTINOSIS AGENTS

CYSTADROPS 0.37 % SOLUTIONcysteamine hcl

4PA

S

CYSTARAN 0.44 % SOLUTIONcysteamine hcl

4PA

S

PROSTAGLANDINS - OPHTHALMIC

latanoprost 0.005 % solution 1 QL 5 / 30 DAYS

LUMIGAN 0.01 % SOLUTIONbimatoprost

2 QL 7 / 30 DAYS

travoprost (bak free) 0.004 % solution 2

ZIOPTAN 0.0015 % SOLUTIONtafluprost

3 PA

OTIC AGENTSOTIC AGENTS - MISCELLANEOUS

acetic acid 2 % solution 1



OTIC ANTI-INFECTIVESCIPROFLOXACIN HCL 0.2 % SOLUTIONciprofloxacin hcl (otic)

1

ofloxacin 0.3 % solution 1

OTIPRIO 6 % SUSPENSIONciprofloxacin (otic)

3 PA

OTIC STEROID-ANTI-INFECTIVE COMBINATIONSCIPRO HC 0.2-1 % SUSPENSIONciprofloxacin-hydrocortisone

2

ciprofloxacin-dexamethasone 0.3-0.1 % suspension 1

COLY-MYCIN S 3.3-3-10-0.5 MG/ML SUSPENSIONneomycin-colistin-hc-thonzonium

3

neomycin-polymyxin-hc 1 % solution 1

neomycin-polymyxin-hc 3.5-10000-1 solution 1

neomycin-polymyxin-hc 3.5-10000-1 suspension 1

OTOVEL 0.3-0.025 % SOLUTIONciprofloxacin-fluocinolone acetonide

3 ST

OTIC STEROIDSacetasol hc 2-1 % solution 1

flac 0.01 % oil 1

fluocinolone acetonide 0.01 % oil 1

hydrocortisone-acetic acid 1-2 % solution 1

OXYTOCICS

methergine 0.2 mg tab 2 QL 28 / 30 DAYS

methylergonovine maleate 0.2 mg tab 2 QL 28 / 30 DAYS

PASSIVE IMMUNIZING AND TREATMENT AGENTSANTIVIRAL MONOCLONAL ANTIBODIES

SYNAGIS 100 MG/ML SOLUTIONpalivizumab

4PA

S

SYNAGIS 50 MG/0.5ML SOLUTIONpalivizumab

4PA

S



IMMUNE SERUMS

CUVITRU 1 GM/5ML SOLUTIONimmune globulin (human) subcutaneous

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

HIZENTRA 1 GM/5ML SOLN PRSYRimmune globulin (human) subcutaneous

4PA

S

HIZENTRA 1 GM/5ML SOLUTIONimmune globulin (human) subcutaneous

4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

PASSIVE IMMUNIZING AGENTS - COMBINATIONSHYQVIA 10 GM/100ML KITimmune globulin (human)-hyaluronidase (humanrecombinant)

4PA

S


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSHYQVIA 2.5 GM/25ML KITimmune globulin (human)-hyaluronidase (humanrecombinant)

4PA

S

HYQVIA 20 GM/200ML KITimmune globulin (human)-hyaluronidase (humanrecombinant)

4PA

S


4PA

S


4PA

S

PENICILLINSAMINOPENICILLINS

AMOXICILLIN 125 MG CHEW TABamoxicillin

1

amoxicillin 125 mg/5ml recon susp 1


amoxicillin 250 mg cap 1

AMOXICILLIN 250 MG CHEW TABamoxicillin

1



amoxicillin 500 mg cap 1

amoxicillin 500 mg tab 1

amoxicillin 875 mg tab 1

AMPICILLIN 500 MG CAPampicillin

1

NATURAL PENICILLINSPENICILLIN V POTASSIUM 125 MG/5ML RECON SOLNpenicillin v potassium

1

penicillin v potassium 250 mg tab 1

PENICILLIN V POTASSIUM 250 MG/5ML RECON SOLNpenicillin v potassium

1

penicillin v potassium 500 mg tab 1



PENICILLIN COMBINATIONSAMOXICILLIN-POT CLAVULANATE 200-28.5 MG CHEWTABamoxicillin & pot clavulanate

1

amoxicillin-pot clavulanate 200-28.5 mg/5ml recon susp 1

amoxicillin-pot clavulanate 250-125 mg tab 1


AMOXICILLIN-POT CLAVULANATE 400-57 MG CHEW TABamoxicillin & pot clavulanate

1

amoxicillin-pot clavulanate 400-57 mg/5ml recon susp 1




amoxicillin-pot clavulanate er 1000-62.5 mg tab er 12h 1

AMOXICILLIN-POT CLAVULANATE ER 1000-62.5 MG TABER 12Hamoxicillin & pot clavulanate

1

PENICILLINASE-RESISTANT PENICILLINSdicloxacillin sodium 250 mg cap 1

dicloxacillin sodium 500 mg cap 1

nafcillin sodium 1 gm recon soln 2 PA

PROGESTINS

hydroxyprogesterone caproate 250 mg/ml oil 2 PA

medroxyprogesterone acetate 10 mg tab 1

medroxyprogesterone acetate 2.5 mg tab 1

medroxyprogesterone acetate 5 mg tab 1

megestrol acetate 625 mg/5ml suspension 1

norethindrone acetate 5 mg tab 1

progesterone 100 mg cap 1

progesterone 200 mg cap 1



PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.ALCOHOL DETERRENTS

acamprosate calcium 333 mg tab dr 1

disulfiram 250 mg tab 1

disulfiram 500 mg tab 1

BENZODIAZEPINES & TRICYCLIC AGENTSCHLORDIAZEPOXIDE-AMITRIPTYLINE 5-12.5 MG TABchlordiazepoxide-amitriptyline

1

CHOLINOMIMETICS - ACHE INHIBITORS

donepezil hcl 10 mg tab 1 QL 30 / 30 DAYS

donepezil hcl 10 mg tab disp 1 QL 30 / 30 DAYS



donepezil hcl 5 mg tab disp 1 QL 30 / 30 DAYS

galantamine hydrobromide 12 mg tab 1 QL 60 / 30 DAYS


GALANTAMINE HYDROBROMIDE 4 MG/ML SOLUTIONgalantamine hydrobromide

1 QL 180 / 30 DAYS


galantamine hydrobromide er 16 mg cap er 24h 1 QL 30 / 30 DAYS



rivastigmine 13.3 mg/24hr patch 24hr 1 QL 30 / 30 DAYS



rivastigmine tartrate 1.5 mg cap 1 QL 60 / 30 DAYS

rivastigmine tartrate 3 mg cap 1 QL 60 / 30 DAYS



rivastigmine tartrate 4.5 mg cap 1 QL 60 / 30 DAYS

rivastigmine tartrate 6 mg cap 1 QL 60 / 30 DAYS

FIBROMYALGIA AGENT - SNRIS

SAVELLA 100 MG TABmilnacipran hcl

3QL 60 / 30 DAYS

PA

SAVELLA 12.5 MG TABmilnacipran hcl

3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA


3QL 60 / 30 DAYS

PA

SAVELLA TITRATION PACK 12.5 & 25 & 50 MG MISCmilnacipran hcl

3 PA

MOVEMENT DISORDER DRUG THERAPY

tetrabenazine 12.5 mg tab 2 PA

tetrabenazine 25 mg tab 2 PA

MS AGENTS - PYRIMIDINE SYNTHESIS INHIBITORS

AUBAGIO 14 MG TABteriflunomide

4PA

S

AUBAGIO 7 MG TABteriflunomide

4PA

S

MULTIPLE SCLEROSIS AGENTS

glatiramer acetate 20 mg/ml soln prsyr 4PA

S

glatiramer acetate 40 mg/ml soln prsyr 4PA

S

MULTIPLE SCLEROSIS AGENTS - ANTIMETABOLITES

MAVENCLAD (10 TABS) 10 MG TAB THPKcladribine (multiple sclerosis)

4PA

S




4PA

S


4PA

S


4PA

S


4PA

S


4PA

S


4PA

S

MULTIPLE SCLEROSIS AGENTS - INTERFERONS

AVONEX 30 MCG KITinterferon beta-1a

4PA

S

AVONEX PEN 30 MCG/0.5ML AUT-IJ KITinterferon beta-1a

4PA

S

AVONEX PREFILLED 30 MCG/0.5ML PREF SY KTinterferon beta-1a

4PA

S

BETASERON 0.3 MG KITinterferon beta-1b

4PA

S

EXTAVIA 0.3 MG KITinterferon beta-1b

4PA

S

PLEGRIDY 125 MCG/0.5ML SOLN PENpeginterferon beta-1a

4PA

S

PLEGRIDY 125 MCG/0.5ML SOLN PRSYRpeginterferon beta-1a

4PA

S

PLEGRIDY STARTER PACK 63 & 94 MCG/0.5ML SOLN PENpeginterferon beta-1a

4PA

S


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSPLEGRIDY STARTER PACK 63 & 94 MCG/0.5ML SOLNPRSYRpeginterferon beta-1a

4PA

S

REBIF 22 MCG/0.5ML SOLN PRSYRinterferon beta-1a

4PA

S

REBIF 44 MCG/0.5ML SOLN PRSYRinterferon beta-1a

4PA

S

REBIF REBIDOSE 22 MCG/0.5ML SOLN A-INJinterferon beta-1a

4PA

S

REBIF REBIDOSE 44 MCG/0.5ML SOLN A-INJinterferon beta-1a

4PA

S

REBIF REBIDOSE TITRATION PACK 6X8.8 & 6X22 MCGSOLN A-INJinterferon beta-1a

4PA

S

REBIF TITRATION PACK 6X8.8 & 6X22 MCG SOLN PRSYRinterferon beta-1a

4PA

S

MULTIPLE SCLEROSIS AGENTS - MONOCLONAL ANTIBODIES

KESIMPTA 20 MG/0.4ML SOLN A-INJofatumumab (ms)

4PA

S

MULTIPLE SCLEROSIS AGENTS - NRF2 PATHWAY ACTIVATORS

BAFIERTAM 95 MG CAP DRmonomethyl fumarate

4PA

S

dimethyl fumarate 120 mg cap dr 4

dimethyl fumarate 240 mg cap dr 4

dimethyl fumarate starter pack 120 & 240 mg misc 4

VUMERITY (STARTER) 231 MG CAP DRdiroximel fumarate

4PA

S

VUMERITY 231 MG CAP DRdiroximel fumarate

4PA

S



MULTIPLE SCLEROSIS AGENTS - POTASSIUM CHANNEL BLOCKERS

dalfampridine er 10 mg tab er 12h 2 QL 60 / 30 DAYS

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTS

memantine hcl 10 mg tab 1 QL 60 / 30 DAYS

memantine hcl 10 mg/5ml solution 1 QL 30 / 30 DAYS

memantine hcl 2 mg/ml solution 1 QL 30 / 30 DAYS

memantine hcl 28 x 5 mg & 21 x 10 mg tab 1 QL 49 / 30 day(s)

memantine hcl 5 mg tab 1 QL 120 / 30 DAYS

memantine hcl er 14 mg cap er 24h 1 QL 30 / 30 DAYS




PHENOTHIAZINES & TRICYCLIC AGENTSPERPHENAZINE-AMITRIPTYLINE 2-10 MG TABperphenazine-amitriptyline

1

PERPHENAZINE-AMITRIPTYLINE 2-25 MG TABperphenazine-amitriptyline

1


1


1


1

POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS

pregabalin er 165 mg tab er 24h 2 PA

pregabalin er 330 mg tab er 24h 2 PA

pregabalin er 82.5 mg tab er 24h 2 PA

PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS - SSRISFLUOXETINE HCL (PMDD) 10 MG CAPfluoxetine hcl (pmdd)

1 QL 90 / 30 DAYS


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSFLUOXETINE HCL (PMDD) 10 MG TABfluoxetine hcl (pmdd)

1 QL 90 / 30 DAYS

FLUOXETINE HCL (PMDD) 20 MG CAPfluoxetine hcl (pmdd)

1 QL 90 / 30 DAYS

FLUOXETINE HCL (PMDD) 20 MG TABfluoxetine hcl (pmdd)

1 QL 90 / 30 DAYS

ERGOLOID MESYLATES 1 MG TABergoloid mesylates

1

PIMOZIDE 1 MG TABpimozide

1 QL 30 / 30 DAYS

PIMOZIDE 2 MG TABpimozide

1 QL 60 / 30 DAYS

SMOKING DETERRENTS

APO-VARENICLINE 0.5 MG TABvarenicline tartrate

2QL 60 / 30 day(s)

PRE Preventative

APO-VARENICLINE 1 MG TABvarenicline tartrate

2QL 60 / 30 day(s)

PRE Preventative

bupropion hcl er (smoking det) 150 mg tab er 12h 1 PRE Preventative

CHANTIX 0.5 MG TABvarenicline tartrate

2QL 60 / 30 day(s)

PRE Preventative

CHANTIX 1 MG TABvarenicline tartrate

2QL 60 / 30 day(s)

PRE Preventative

CHANTIX CONTINUING MONTH PAK 1 MG TABvarenicline tartrate

2QL 60 / 30 day(s)

PRE Preventative

CHANTIX STARTING MONTH PAK 0.5 MG X 11 & 1 MG X42 TABvarenicline tartrate

2QL 53 / 0 DAYS

PRE Preventative

NICOTROL 10 MG INHALERnicotine

2QL 672 / 30 DAYS

PRE Preventative

NICOTROL NS 10 MG/ML SOLUTIONnicotine

2QL 120 / 30 DAYS

PRE Preventative

VARENICLINE TARTRATE 0.5 MG TABvarenicline tartrate

2QL 60 / 30 day(s)

PRE Preventative



VARENICLINE TARTRATE 1 MG TABvarenicline tartrate

2QL 60 / 30 day(s)

PRE Preventative

ZYBAN 150 MG TAB ER 12Hbupropion hcl (smoking deterrent)

2 PRE Preventative

SPHINGOSINE 1-PHOSPHATE (S1P) RECEPTOR MODULATORS

GILENYA 0.25 MG CAPfingolimod hcl

4PA

S

GILENYA 0.5 MG CAPfingolimod hcl

4PA

S

MAYZENT 0.25 MG TABsiponimod fumarate

4PA

S

MAYZENT 2 MG TABsiponimod fumarate

4PA

S

MAYZENT STARTER PACK 12 X 0.25 MG TAB THPKsiponimod fumarate

4PA

S

PONVORY 20 MG TABponesimod

4PA

S

PONVORY STARTER PACK 2,3,4,5,6,7,8,9 & 10 MG TABTHPKponesimod

4PA

S

ZEPOSIA 0.92 MG CAPozanimod hcl

4PA

S

ZEPOSIA 7-DAY STARTER PACK 4 X 0.23MG & 3 X 0.46MGCAP THPKozanimod hcl

4PA

S

ZEPOSIA STARTER KIT 0.23MG & 0.46MG & 0.92MG CAPTHPKozanimod hcl

4PA

S

VASOMOTOR SYMPTOM AGENTS - SSRIS

paroxetine mesylate 7.5 mg cap 1 QL 30 / 30 DAYS



RESPIRATORY AGENTS - MISC.ALPHA-PROTEINASE INHIBITOR (HUMAN)

ARALAST NP 1000 MG RECON SOLNalpha1-proteinase inhibitor (human)

4PA

S

ARALAST NP 500 MG RECON SOLNalpha1-proteinase inhibitor (human)

4PA

S

GLASSIA 1000 MG/50ML SOLUTIONalpha1-proteinase inhibitor (human)

4PA

S

PROLASTIN-C 1000 MG RECON SOLNalpha1-proteinase inhibitor (human)

4PA

S

PROLASTIN-C 1000 MG/20ML SOLUTIONalpha1-proteinase inhibitor (human)

4PA

S

ZEMAIRA 1000 MG RECON SOLNalpha1-proteinase inhibitor (human)

4PA

S

CFTR POTENTIATORS

KALYDECO 150 MG TABivacaftor

4PA

S

KALYDECO 25 MG PACKETivacaftor

4PA

S


4PA

S


4PA

S

CYSTIC FIBROSIS AGENT - COMBINATIONS

ORKAMBI 100-125 MG PACKETlumacaftor-ivacaftor

4PA

S

ORKAMBI 100-125 MG TABlumacaftor-ivacaftor

4PA

S

ORKAMBI 150-188 MG PACKETlumacaftor-ivacaftor

4PA

S



ORKAMBI 200-125 MG TABlumacaftor-ivacaftor

4PA

S

SYMDEKO 100-150 & 150 MG TAB THPKtezacaftor-ivacaftor

4PA

S

SYMDEKO 50-75 & 75 MG TAB THPKtezacaftor-ivacaftor

4PA

S

TRIKAFTA 100-50-75 & 150 MG TAB THPKelexacaftor-tezacaftor-ivacaftor

4PA

S

TRIKAFTA 50-25-37.5 & 75 MG TAB THPKelexacaftor-tezacaftor-ivacaftor

4PA

S

HYDROLYTIC ENZYMES

PULMOZYME 2.5 MG/2.5ML SOLUTIONdornase alfa

4PA

S

PULMONARY FIBROSIS AGENTS

ESBRIET 267 MG CAPpirfenidone

4PA

S

ESBRIET 267 MG TABpirfenidone

4PA

S

ESBRIET 801 MG TABpirfenidone

4PA

S

PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS

OFEV 100 MG CAPnintedanib esylate

4PA

S

OFEV 150 MG CAPnintedanib esylate

4PA

S

SULFONAMIDESsulfadiazine 500 mg tab 1



TETRACYCLINESavidoxy 100 mg tab 1

coremino 90 mg tab er 24h 2 QL 30 / 30 DAYS

demeclocycline hcl 150 mg tab 2

demeclocycline hcl 300 mg tab 2

doxycycline hyclate 100 mg cap 1

doxycycline hyclate 100 mg tab 1

doxycycline hyclate 100 mg tab dr 2


doxycycline hyclate 20 mg tab 1

doxycycline hyclate 50 mg cap 1



doxycycline monohydrate 100 mg cap 1

doxycycline monohydrate 100 mg tab 1


doxycycline monohydrate 25 mg/5ml recon susp 1 AL1 Up to 8 yrs old

doxycycline monohydrate 50 mg cap 1



lymepak 100 mg tab 1

minocycline hcl 100 mg cap 1

minocycline hcl 100 mg tab 1





minocycline hcl er 105 mg tab er 24h 2 QL 30 / 30 DAYS










mondoxyne nl 50 mg cap 1

morgidox 100 mg cap 1

morgidox 50 mg cap 1

tetracycline hcl 250 mg cap 1

tetracycline hcl 500 mg cap 1

THYROID AGENTSANTITHYROID AGENTS

methimazole 10 mg tab 1

methimazole 5 mg tab 1

propylthiouracil 50 mg tab 1

THYROID HORMONESARMOUR THYROID 120 MG TABthyroid

2

ARMOUR THYROID 15 MG TABthyroid

2


2


2


2


2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSARMOUR THYROID 60 MG TABthyroid

2


2

euthyrox 100 mcg tab 1











levo-t 100 mcg tab 1







levo-t 25 mcg tab 1


levo-t 50 mcg tab 1

levo-t 75 mcg tab 1

levo-t 88 mcg tab 1

LEVOTHYROXINE SODIUM 100 MCG CAPlevothyroxine sodium

2

levothyroxine sodium 100 mcg tab 1


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSLEVOTHYROXINE SODIUM 112 MCG CAPlevothyroxine sodium

2



2



2


2



2



2



2



2




2



2



2


levoxyl 100 mcg tab 1













liothyronine sodium 25 mcg tab 1



NATURE-THROID 113.75 MG TABthyroid

2

NATURE-THROID 130 MG TABthyroid

2


2


2


2


2


2


2


2


2


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSNATURE-THROID 65 MG TABthyroid

2


2


2

np thyroid 120 mg tab 1





SYNTHROID 100 MCG TABlevothyroxine sodium

2


2


2


2


2


2


2


2


2


2


2


2

thyroid 120 mg tab 1



thyroid 15 mg tab 1

thyroid 30 mg tab 1

thyroid 60 mg tab 1

thyroid 90 mg tab 1

THYROLAR-1 60 (12.5-50) MG (MCG) TABliotrix (t3-t4)

3

THYROLAR-1/2 30 (6.25-25) MG (MCG) TABliotrix (t3-t4)

3

THYROLAR-1/4 15 (3.1-12.5) MG (MCG) TABliotrix (t3-t4)

3

THYROLAR-2 120 (25-100) MG (MCG) TABliotrix (t3-t4)

3

THYROLAR-3 180 (37.5-150) MG (MCG) TABliotrix (t3-t4)

3

unithroid 100 mcg tab 1












WESTHROID 130 MG TABthyroid

3

WESTHROID 195 MG TABthyroid

3

WESTHROID 32.5 MG TABthyroid

3


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSWESTHROID 65 MG TABthyroid

3

WESTHROID 97.5 MG TABthyroid

3

WP THYROID 113.75 MG TABthyroid

3

WP THYROID 130 MG TABthyroid

3


3


3


3

WP THYROID 65 MG TABthyroid

3


3


3

TOXOIDSTOXOID COMBINATIONS

ADACEL 5-2-15.5 LF-MCG/0.5 SUSPENSIONtetanus toxoid-diphtheria-acellular pertussis adsorb(tdap)

2 PRE Preventative

BOOSTRIX 5-2.5-18.5 LF-MCG/0.5 SUSP PRSYRtetanus toxoid-diphtheria-acellular pertussis adsorb(tdap)

2 PRE Preventative

BOOSTRIX 5-2.5-18.5 LF-MCG/0.5 SUSPENSIONtetanus toxoid-diphtheria-acellular pertussis adsorb(tdap)

2 PRE Preventative

DAPTACEL 23-15-5 SUSPENSIONdiphtheria, acellular pertussis & tetanus toxoids

2 PRE Preventative

DIPHTHERIA-TETANUS TOXOIDS DT 25-5 LFU/0.5MLSUSPENSIONdiphtheria-tetanus toxoids (dt)

2 PRE Preventative

INFANRIX 25-58-10 SUSPENSIONdiphtheria, acellular pertussis & tetanus toxoids

2 PRE Preventative


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSKINRIX SUSPENSIONdiph-tetanus tox ad-acell pertussis & polio virus, ipv vac

2 PRE Preventative

KINRIX 0.5 ML SUSP PRSYRdiph-tetanus tox ad-acell pertussis & polio virus, ipv vac

2 PRE Preventative

PEDIARIX SUSPENSIONdiph-tetanus tox-acell pert-hepatitis b recomb-polio ipvvac

2 PRE Preventative

PENTACEL RECON SUSPdiph-ac pert-tet tox ad-polio ipv-haemophil b poly vac

2 PRE Preventative

QUADRACEL SUSPENSIONdiph-tetanus tox ad-acell pertussis & polio virus, ipv vac

2 PRE Preventative

TDVAX 2-2 LF/0.5ML SUSPENSIONtetanus-diphtheria toxoids (td)

2 PRE Preventative

TENIVAC 5-2 LFU INJECTABLEtetanus-diphtheria toxoids (td)

2 PRE Preventative

TETANUS-DIPHTHERIA TOXOIDS TD 2-2 LF/0.5MLSUSPENSIONtetanus-diphtheria toxoids (td)

2 PRE Preventative

VAXELIS SUSP PRSYRdiph-tet tox-acell pert ad-polio ipv-hib-hepatitis b recomb

2 PRE Preventative

VAXELIS SUSPENSIONdiph-tet tox-acell pert ad-polio ipv-hib-hepatitis b recomb

2 PRE Preventative

ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICSANTICHOLINERGIC COMBINATIONS

BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG SUPPOSbelladonna alkaloids & opium

2

ANTISPASMODICSdicyclomine hcl 10 mg cap 1

dicyclomine hcl 10 mg/5ml solution 1 AL1 Up to 8 yrs old

dicyclomine hcl 20 mg tab 1

BELLADONNA ALKALOIDShyoscyamine sulfate 0.125 mg sl tab 1

hyoscyamine sulfate 0.125 mg tab 1

hyoscyamine sulfate er 0.375 mg tab er 12h 1

hyoscyamine sulfate sl 0.125 mg sl tab 1



oscimin 0.125 mg sl tab 1

oscimin sr 0.375 mg tab er 12h 1

SYMAX DUOTAB 0.375 MG TAB ERhyoscyamine sulfate

3 PA

symax-sl 0.125 mg sl tab 1

symax-sr 0.375 mg tab er 12h 1

H-2 ANTAGONISTSCIMETIDINE HCL 300 MG/5ML SOLUTIONcimetidine hcl


cimetidine hcl 300 mg/5ml solution 1 AL1 Up to 8 yrs old

cimetidine hcl 400 mg/6.67ml solution 1 AL1 Up to 8 yrs old

famotidine 20 mg tab 1

famotidine 40 mg tab 1

famotidine 40 mg/5ml recon susp 1

NIZATIDINE 150 MG CAPnizatidine

1

nizatidine 150 mg cap 1

NIZATIDINE 300 MG CAPnizatidine

1

nizatidine 300 mg cap 1

ranitidine hcl 15 mg/ml syrup 1 AL1 Up to 8 yrs old

ranitidine hcl 150 mg cap 1

ranitidine hcl 150 mg tab 1

ranitidine hcl 150 mg/10ml syrup 1 AL1 Up to 8 yrs old

ranitidine hcl 300 mg cap 1

ranitidine hcl 300 mg tab 1

ranitidine hcl 75 mg/5ml syrup 1 AL1 Up to 8 yrs old

MISC. ANTI-ULCERsucralfate 1 gm tab 1

sucralfate 1 gm/10ml suspension 1



PROTON PUMP INHIBITORS

DEXILANT 30 MG CAP DRdexlansoprazole

3QL 30 / 30 day(s)

PA

DEXILANT 60 MG CAP DRdexlansoprazole

3QL 30 / 30 day(s)

PA

DEXLANSOPRAZOLE 30 MG CAP DRdexlansoprazole

2QL 30 / 30 day(s)

PA

DEXLANSOPRAZOLE 60 MG CAP DRdexlansoprazole

2QL 30 / 30 day(s)

PA

esomeprazole magnesium 10 mg packet 2 AL1 Up to 8 yrs old

esomeprazole magnesium 20 mg cap dr 1


esomeprazole magnesium 40 mg cap dr 1 QL 60 / 30 DAYS


FIRST-LANSOPRAZOLE 3 MG/ML SUSPENSIONlansoprazole

1QL 10 / 1 day(s)

AL1 Up to 8 yrs old

FIRST-OMEPRAZOLE 2 MG/ML SUSPENSIONomeprazole

1QL 10 / 1 day(s)

AL1 Up to 8 yrs old

lansoprazole 15 mg cap dr 1 QL 60 / 30 DAYS

lansoprazole 30 mg cap dr 1 QL 60 / 30 DAYS

omeprazole 10 mg cap dr 1 QL 60 / 30 DAYS



pantoprazole sodium 20 mg tab dr 1 QL 60 / 30 DAYS

pantoprazole sodium 40 mg tab dr 1 QL 60 / 30 DAYS

rabeprazole sodium 20 mg tab dr 1 QL 60 / 30 DAYS



QUATERNARY ANTICHOLINERGICS

CUVPOSA 1 MG/5ML SOLUTIONglycopyrrolate

3PA

AL1 Up to 8 yrs old

glycopyrrolate 1 mg tab 1

glycopyrrolate 2 mg tab 1

methscopolamine bromide 2.5 mg tab 1

methscopolamine bromide 5 mg tab 1

ULCER DRUGS - PROSTAGLANDINSmisoprostol 100 mcg tab 1

misoprostol 200 mcg tab 1

URINARY ANTISPASMODICSURINARY ANTISPASMODIC - ANTIMUSCARINIC (ANTICHOLINERGIC)

darifenacin hydrobromide er 15 mg tab er 24h 1 QL 30 / 30 DAYS

darifenacin hydrobromide er 7.5 mg tab er 24h 1

GELNIQUE 10 % GELoxybutynin chloride

3 QL 30 / 30 DAYS

GELNIQUE PUMP 10 % GELoxybutynin chloride

3 QL 30 / 30 DAYS

oxybutynin chloride 5 mg tab 1 QL 120 / 30 DAYS

oxybutynin chloride 5 mg/5ml syrup 1 QL 600 / 30 DAYS

oxybutynin chloride er 10 mg tab er 24h 1



solifenacin succinate 10 mg tab 2 QL 30 / 30 DAYS

solifenacin succinate 5 mg tab 2 QL 30 / 30 DAYS

tolterodine tartrate 1 mg tab 1 QL 60 / 30 DAYS

tolterodine tartrate 2 mg tab 1 QL 60 / 30 DAYS

tolterodine tartrate er 2 mg cap er 24h 1 QL 30 / 30 DAYS



tolterodine tartrate er 4 mg cap er 24h 1 QL 30 / 30 DAYS

TOVIAZ 4 MG TAB ER 24Hfesoterodine fumarate

3QL 30 / 30 DAYS

ST

TOVIAZ 8 MG TAB ER 24Hfesoterodine fumarate

3QL 30 / 30 DAYS

ST

trospium chloride 20 mg tab 1 QL 60 / 30 DAYS

trospium chloride er 60 mg cap er 24h 1

VESICARE LS 5 MG/5ML SUSPENSIONsolifenacin succinate


URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS

MYRBETRIQ 25 MG TAB ER 24Hmirabegron

3QL 30 / 30 DAYS

ST

MYRBETRIQ 50 MG TAB ER 24Hmirabegron

3QL 30 / 30 DAYS

ST

MYRBETRIQ 8 MG/ML SRERmirabegron

3

QL 10 / 1 day(s)

ST

AL1 Up to 8 yrs old

URINARY ANTISPASMODICS - CHOLINERGIC AGONISTSbethanechol chloride 10 mg tab 1

bethanechol chloride 25 mg tab 1



URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTSflavoxate hcl 100 mg tab 1

VACCINESBACTERIAL VACCINES

ACTHIB RECON SOLNhaemophilus b polysac conj vac

2 PRE Preventative

BEXSERO SUSP PRSYRmeningococcal vac group b (recombant omv adjuvanted)

2 PRE Preventative


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSHIBERIX 10 MCG RECON SOLNhaemophilus b polysac conj vac

2 PRE Preventative

MENACTRA SOLUTIONmeningococcal (a,c,y&w-135) polysacch diphth conjvaccine

2 PRE Preventative

MENQUADFI SOLUTIONmeningococcal (a,c,y&w-135) polysacch tetanus conjvaccine

2 PRE Preventative

MENVEO RECON SOLNmeningococcal (a,c,y&w-135) oligosaccharide conjugatevac

2 PRE Preventative

PEDVAX HIB 7.5 MCG/0.5ML SUSPENSIONhaemophilus b polysac conj vac

2 PRE Preventative

PNEUMOVAX 23 25 MCG/0.5ML INJECTABLEpneumococcal vac polyvalent

2 PRE Preventative

PREVNAR 13 SUSPENSIONpneumococcal 13-valent conjugate vaccine

2 PRE Preventative

PREVNAR 20 0.5 ML SUSP PRSYRpneumococcal 20-valent conjugate vaccine

2 PRE Preventative

TRUMENBA SUSP PRSYRmeningococcal group b vaccine (recombinant)

2 PRE Preventative

VAXNEUVANCE 0.5 ML SUSP PRSYRpneumococcal 15-valent conjugate vaccine

2 PRE Preventative

VIVOTIF CAP DRtyphoid vaccine

3

VIRAL VACCINE COMBINATIONS

M-M-R II RECON SOLNmeasles, mumps & rubella virus vaccines


PROQUAD RECON SUSPmeasles-mumps-rubella-varicella virus vaccines


TWINRIX 720-20 ELU-MCG/ML SUSP PRSYRhepatitis a (inactivated)-hepatitis b (recombinant)vaccines

2 PRE Preventative

VIRAL VACCINES

AFLURIA SUSPENSIONinfluenza virus vaccine split

2QL 0.5 / 0 DAYS

PRE Preventative



AFLURIA PRESERVATIVE FREE 0.5 ML SUSP PRSYRinfluenza virus vaccine split preservative free

2QL 0.5 / 0 DAYS

PRE Preventative

AFLURIA QUADRIVALENT SUSPENSIONinfluenza virus vaccine split quadrivalent

2QL 0.5 / 0 DAYS

PRE Preventative

AFLURIA QUADRIVALENT 0.25 ML SUSP PRSYRinfluenza virus vaccine split quadrivalent

2QL 0.5 / 0 DAYS

PRE Preventative

AFLURIA QUADRIVALENT 0.5 ML SUSP PRSYRinfluenza virus vaccine split quadrivalent

2QL 0.5 / 0 DAYS

PRE Preventative

ASTRAZENECA COVID-19 VACCINE 0.5 ML SUSPENSIONcovid-19 (sars-cov-2) adenovirus vaccine

2MFL 3 / 1 year(s)PRE Preventative

ENGERIX-B 10 MCG/0.5ML INJECTABLEhepatitis b vaccine (recomb)

2 PRE Preventative

ENGERIX-B 10 MCG/0.5ML SUSPENSIONhepatitis b vaccine (recomb)

2 PRE Preventative

ENGERIX-B 20 MCG/ML INJECTABLEhepatitis b vaccine (recomb)

2 PRE Preventative

ENGERIX-B 20 MCG/ML SUSPENSIONhepatitis b vaccine (recomb)

2 PRE Preventative

FLUAD 0.5 ML SUSP PRSYRinfluenza virus vaccine types a & b surface antigenadjuvant

2QL 0.5 / 0 DAYS

PRE Preventative

FLUAD QUADRIVALENT 0.5 ML PRSYRinfluenza virus vacc types a & b surf antigen adjuvantquad

2MFL 1 / 365 day(s)PRE Preventative

FLUARIX QUADRIVALENT 0.5 ML SUSP PRSYRinfluenza virus vaccine split quadrivalent

2QL 0.5 / 0 DAYS

PRE Preventative

FLUBLOK SOLUTIONinfluenza virus vaccine recombinant hemagglutinin (ha)

2QL 0.5 / 0 DAYS

PRE Preventative

FLUBLOK QUADRIVALENT 0.5 ML SOLN PRSYRinfluenza virus vac recomb hemagglutinin (ha)quadrivalent

2QL 0.5 / 0 DAYS

PRE Preventative

FLUCELVAX QUADRIVALENT SUSPENSIONinfluenza virus vaccine tissue-cultured subunitquadrivalent

2QL 0.5 / 0 DAYS

PRE Preventative


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSFLUCELVAX QUADRIVALENT 0.5 ML SUSP PRSYRinfluenza virus vaccine tissue-cultured subunitquadrivalent

2QL 0.5 / 0 DAYS

PRE Preventative

FLULAVAL QUADRIVALENT SUSPENSIONinfluenza virus vaccine split quadrivalent

2QL 0.5 / 0 DAYS

PRE Preventative

FLULAVAL QUADRIVALENT 0.5 ML SUSP PRSYRinfluenza virus vaccine split quadrivalent

2QL 0.5 / 0 DAYS

PRE Preventative

FLUMIST QUADRIVALENT SUSPENSIONinfluenza virus vaccine live quadrivalent

2QL 0.5 / 0 DAYS

PRE Preventative

FLUVIRIN SUSPENSIONinfluenza virus vaccine types a & b surface antigen

2QL 0.5 / 0 DAYS

PRE Preventative

FLUVIRIN 0.5 ML SUSP PRSYRinfluenza virus vaccine types a & b surface antigen

2QL 0.5 / 0 DAYS

PRE Preventative

FLUZONE HIGH-DOSE 0.5 ML SUSP PRSYRinfluenza virus vaccine split high-dose preservative free

2QL 0.5 / 0 DAYS

PRE Preventative

FLUZONE HIGH-DOSE QUADRIVALENT 0.7 ML SUSP PRSYRinfluenza virus vac split high-dose quad preservative free

2 PRE Preventative

FLUZONE QUADRIVALENT SUSPENSIONinfluenza virus vaccine split quadrivalent

2QL 0.5 / 0 DAYS

PRE Preventative

FLUZONE QUADRIVALENT 0.25 ML SUSP PRSYRinfluenza virus vaccine split quadrivalent

2QL 0.5 / 0 DAYS

PRE Preventative

FLUZONE QUADRIVALENT 0.5 ML SUSP PRSYRinfluenza virus vaccine split quadrivalent

2QL 0.5 / 0 DAYS

PRE Preventative

FLUZONE QUADRIVALENT 0.5 ML SUSPENSIONinfluenza virus vaccine split quadrivalent

2QL 0.5 / 0 DAYS

PRE Preventative

FLUZONE QUADRIVALENT 9 MCG/STRAIN SUSP PENinfluenza virus vaccine split quadrivalent

2QL 0.5 / 0 DAYS

PRE Preventative

GARDASIL 9 SUSP PRSYRhuman papillomavirus (hpv) 9-valent recombinant vaccine

2AL1 9 to 45 yrs oldPRE Preventative

GARDASIL 9 SUSPENSIONhuman papillomavirus (hpv) 9-valent recombinant vaccine

2AL1 9 to 45 yrs oldPRE Preventative


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSHAVRIX 1440 EL U/ML SUSPENSIONhepatitis a vaccine

2 PRE Preventative

HAVRIX 720 EL U/0.5ML SUSPENSIONhepatitis a vaccine

2 PRE Preventative

HEPLISAV-B 20 MCG/0.5ML SOLN PRSYRhepatitis b vaccine recombinant adjuvanted

2 PRE Preventative

HEPLISAV-B 20 MCG/0.5ML SOLUTIONhepatitis b vaccine recombinant adjuvanted

2 PRE Preventative

IPOL INJECTABLEpoliovirus vaccine, ipv

2 PRE Preventative

JANSSEN COVID-19 VACCINE 0.5 ML SUSPENSIONcovid-19 (sars-cov-2) adenovirus vaccine


MODERNA COVID-19 VACCINE 100 MCG/0.5MLSUSPENSIONcovid-19 (sars-cov-2) mrna virus vaccine


NOVAVAX COVID-19 VACCINE 5 MCG/0.5ML SUSPENSIONcovid-19 (sars-cov-2) subunit (spike) protein virus vaccine


PFIZER COVID-19 VAC-TRIS 5-11Y 10 MCG/0.2MLSUSPENSIONcovid-19 (sars-cov-2) mrna virus vaccine


PFIZER COVID-19 VAC-TRIS 6M-4Y 3 MCG/0.2MLSUSPENSIONcovid-19 (sars-cov-2) mrna virus vaccine

2MFL 3 / 365 day(s)PRE Preventative

PFIZER-BIONT COVID-19 VAC-TRIS 30 MCG/0.3MLSUSPENSIONcovid-19 (sars-cov-2) mrna virus vaccine


PFIZER-BIONTECH COVID-19 VACC 30 MCG/0.3MLSUSPENSIONcovid-19 (sars-cov-2) mrna virus vaccine


PREHEVBRIO 10 MCG/ML SUSPENSIONhepatitis b vaccine 3-antigen recombinant

2 PRE Preventative

RECOMBIVAX HB 10 MCG/ML SUSPENSIONhepatitis b vaccine (recomb)

2 PRE Preventative

RECOMBIVAX HB 40 MCG/ML SUSPENSIONhepatitis b vaccine (recomb)

2 PRE Preventative

RECOMBIVAX HB 5 MCG/0.5ML SUSPENSIONhepatitis b vaccine (recomb)

2 PRE Preventative



ROTARIX RECON SUSProtavirus vaccine, live oral


ROTATEQ SOLUTIONrotavirus vaccine, live oral pentavalent


SHINGRIX 50 MCG/0.5ML RECON SUSPzoster vaccine recombinant adjuvanted

2 PRE Preventative

VAQTA 25 UNIT/0.5ML SUSPENSIONhepatitis a vaccine

2 PRE Preventative

VAQTA 50 UNIT/ML SUSPENSIONhepatitis a vaccine

2 PRE Preventative

VARIVAX 1350 PFU/0.5ML INJECTABLEvaricella virus vaccine live

2 PRE Preventative

ZOSTAVAX 19400 UNT/0.65ML RECON SUSPzoster vaccine live

2AL1 At least 50 yrs oldPRE Preventative

VAGINAL AND RELATED PRODUCTSIMIDAZOLE-RELATED ANTIFUNGALS

terconazole 0.4 % cream 1 QL 450 / 30 DAYS

terconazole 0.8 % cream 1 QL 450 / 30 DAYS

terconazole 80 mg suppos 1 QL 3 / 3 DAYS

VAGINAL ANTI-INFECTIVESclindamycin phosphate 2 % cream 1

metronidazole 0.75 % gel 1

VANDAZOLE 0.75 % GELmetronidazole vaginal

1

VAGINAL ESTROGENSestradiol 0.1 mg/gm cream 2

estradiol 10 mcg tab 1

ESTRING 2 MG RINGestradiol vaginal

2 QL 1 / 90 DAYS

FEMRING 0.05 MG/24HR RINGestradiol acetate vaginal

3 QL 1 / 84 DAYS

FEMRING 0.1 MG/24HR RINGestradiol acetate vaginal

3 QL 1 / 84 DAYS


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSPREMARIN 0.625 MG/GM CREAMestrogens, conjugated vaginal

2

yuvafem 10 mcg tab 1

VAGINAL PROGESTINS

CRINONE 4 % GELprogesterone (vaginal)

4PA

S

CRINONE 8 % GELprogesterone (vaginal)

4PA

S

ENDOMETRIN 100 MG INSERTprogesterone (vaginal)

3

VASOPRESSORSANAPHYLAXIS THERAPY AGENTS

EPINEPHRINE 0.15 MG/0.15ML SOLN A-INJepinephrine (anaphylaxis)

1 QL 4 / 365 day(s)

epinephrine 0.15 mg/0.3ml soln a-inj 1 QL 4 / 365 day(s)

EPINEPHRINE 0.3 MG/0.3ML SOLN A-INJepinephrine (anaphylaxis)

1 QL 4 / 365 day(s)

epinephrine 0.3 mg/0.3ml soln a-inj 1 QL 4 / 365 day(s)

SYMJEPI 0.15 MG/0.3ML SOLN PRSYRepinephrine (anaphylaxis)

2 QL 4 / 365 day(s)

midodrine hcl 10 mg tab 1

midodrine hcl 2.5 mg tab 1

midodrine hcl 5 mg tab 1

VITAMINSVITAMIN D

DRISDOL 1.25 MG (50000 UT) CAPergocalciferol

1

ergocalciferol 1.25 mg (50000 ut) cap 1 QL 4 / 28 DAYS

vitamin d (ergocalciferol) 1.25 mg (50000 ut) cap 1 QL 4 / 28 DAYS

VITAMIN K

phytonadione 5 mg tab 2 QL 5 / 30 DAYS


Index of Covered Drugs

AABACAVIR SULFATE 129ABACAVIR SULFATE-LAMIVUDINE 124ABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE 124ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE 126ABALOPARATIDE 184ABATACEPT 14,15ABEMACICLIB 107,108Abilify Maintena 122ABIRATERONE ACETATE 94Abstral 18ACALABRUTINIB 98ACAMPROSATE CALCIUM 250ACARBOSE 65ACEBUTOLOL HCL 134ACETAMINOPHEN W/ CODEINE 16ACETAZOLAMIDE 178ACETIC ACID (OTIC) 245ACETYLCYSTEINE 161ACETYLCYSTEINE (ANTIDOTE) 75ACITRETIN 167Actemra 11Actemra ACTPen 12ActHIB 271Actimmune 106ACYCLOVIR 132,133ACYCLOVIR TOPICAL 168Adacel 266Adagen 7ADALIMUMAB 8,9ADAPALENE 163ADAPALENE-BENZOYL PEROXIDE 162ADEFOVIR DIPIVOXIL 131Adempas 141Advate 196,197Adynovate 197Adzenys ER 3Adzenys XR-ODT 3AeroChamber Mini Chamber 225

AeroChamber MV 225AeroChamber Plus Flo-Vu 225AeroChamber Plus Flo-Vu Large 225AeroChamber Plus Flo-Vu Medium 225AeroChamber Plus Flo-Vu Small 225AeroChamber Plus Flo-Vu w/Mask 225AeroChamber Plus Flow VU 225AeroChamber w/FLOWSIGnal 226AeroChamber Z-Stat Plus 226AeroChamber Z-Stat Plus Chambr 226AeroChamber Z-Stat Plus/Large 226AeroChamber Z-Stat Plus/Medium 226AeroChamber Z-Stat Plus/Small 226AFATINIB DIMALEATE 99Afluria 272Afluria Preservative Free 273Afluria Quadrivalent 273Afstyla 197,198Aimovig 227Aimovig (140 MG Dose) 227Ajovy 227,228Akynzeo 76ALBENDAZOLE 34ALBUTEROL SULFATE 42,43Albuterol Sulfate ER 43Albuterol Sulfate HFA 43ALCAFTADINE 242ALCLOMETASONE DIPROPIONATE 169Alecensa 95ALECTINIB HCL 95ALENDRONATE SODIUM 180Alendronate Sodium 180ALENDRONATE SODIUM-CHOLECALCIFEROL 181ALFENTANIL HCL 19ALFUZOSIN HCL 195Alinia 35ALISKIREN FUMARATE 91Alkindi Sprinkle 158ALLOPURINOL 196ALMOTRIPTAN MALATE 228Alocril 242

ALOGLIPTIN BENZOATE 66Alogliptin Benzoate 66Alomide 242ALOSETRON HCL 192ALPELISIB 110ALPHA1-PROTEINASE INHIBITOR (HUMAN) 257Alphagan P 244Alphanate 198Alphanate/VWF Complex/Human 198,199AlphaNine SD 199ALPRAZOLAM 38,39ALPRAZolam Intensol 38Alprolix 199Alrex 244Altabax 165ALTRETAMINE 94ALUMINUM CHLORIDE 174AMANTADINE HCL 112AMBRISENTAN 141,142AMCINONIDE 169Amcinonide 169AMIFAMPRIDINE 93AMILORIDE & HYDROCHLOROTHIAZIDE 179AMILORIDE HCL 179AMINOCAPROIC ACID 214AMIODARONE HCL 40,41Amitiza 191AMITRIPTYLINE HCL 63AMLODIPINE BENZOATE 138AMLODIPINE BESYLATE 136AMLODIPINE BESYLATE-ATORVASTATINCALCIUM 140,141AMLODIPINE BESYLATE-BENAZEPRIL HCL 84AMLODIPINE BESYLATE-OLMESARTANMEDOXOMIL 88AMLODIPINE BESYLATE-VALSARTAN 88AMLODIPINE-VALSARTAN-HYDROCHLOROTHIAZIDE 87AMOXAPINE 63Amoxapine 63AMOXICILLIN 248

Amoxicillin 248AMOXICILLIN & POT CLAVULANATE 249Amoxicillin-Pot Clavulanate 249Amoxicillin-Pot Clavulanate ER 249AMPHETAMINE 3Amphetamine ER 3AMPHETAMINE SULFATE 3AMPHETAMINE-DEXTROAMPHETAMINE 2,3AMPICILLIN 248Ampicillin 248Anadrol-50 32ANAGRELIDE HCL 209ANAKINRA 11ANASTROZOLE 107Annovera 152Anoro Ellipta 41ANTIHEMOPHIL FACT(RCMB) PEGYLATED-AUCL(BDD-RFVIII PEG-AUCL) 202,203ANTIHEMOPHILIC FACTOR (HUMAN) 201,203,204ANTIHEMOPHILIC FACTOR (RCMB) BDTRUNCATED (BD TRUNC-RFVIII) 204,205ANTIHEMOPHILIC FACTOR (RCMB) FC FUSIONPROTEIN(BDD-RFVIIIFC) 200ANTIHEMOPHILIC FACTOR (RCMB)MOROCTOCOG ALFA(BDD-RFVIII,MOR) 207ANTIHEMOPHILIC FACTOR (RCMB)PLASMA/ALBUMIN FREE (RAHF-PFM) 196,197,204ANTIHEMOPHILIC FACTOR (RCMB) SIMOCTOCOGALFA(BDD-RFVIII,SIM) 205,206ANTIHEMOPHILIC FACTOR (RECOMBINANTPORCINE) (RPFVIII) 206ANTIHEMOPHILIC FACTOR(RECOMBINANT) 201,203,204,206ANTIHEMOPHILIC FACTOR (RECOMBINANT)GLYCOPEGYLATED-EXEI 200,201ANTIHEMOPHILIC FACTOR (RECOMBINANT)PEGYLATED 197ANTIHEMOPHILIC FACTOR (RECOMBINANT)SINGLE CHAIN 197,198ANTIHEMOPHILIC FACTOR/VON WILLEBRANDFACTOR COMPLEX (HUMAN) 198,199,201,207

Anzemet 76APALUTAMIDE 94APIXABAN 48Aplenzin 58APO-Varenicline 255APOMORPHINE HYDROCHLORIDE 114APRACLONIDINE HCL 244APREMILAST 14APREPITANT 77Aptivus 127Aralast NP 257Aranesp (Albumin Free) 210,211Arcapta Neohaler 43ARIPIPRAZOLE 122,123ARMODAFINIL 5Armour Thyroid 260,261Arnuity Ellipta 45ARTEMETHER-LUMEFANTRINE 92ARTIFICIAL TEAR INSERT 240ASCIMINIB HCL 97ASENAPINE MALEATE 120Asmanex (120 Metered Doses) 45Asmanex (14 Metered Doses) 45Asmanex (30 Metered Doses) 45Asmanex (60 Metered Doses) 45Asmanex (7 Metered Doses) 45Asmanex HFA 45,46ASPIRIN-DIPYRIDAMOLE 209Assure ID Insulin Safety Syr 222Astagraf XL 233,234AstraZeneca COVID-19 Vaccine 273ATAZANAVIR SULFATE 127,128ATAZANAVIR SULFATE-COBICISTAT 125ATENOLOL 134ATENOLOL & CHLORTHALIDONE 91ATOGEPANT 227ATOMOXETINE HCL 2ATORVASTATIN CALCIUM 81,82ATOVAQUONE 35ATOVAQUONE-PROGUANIL HCL 92ATRACURIUM BESYLATE 239

ATROPINE SULFATE (OPHTHALMIC) 241Atrovent HFA 44Aubagio 251AURANOFIN 11AVAPRITINIB 104Avonex 252Avonex Pen 252Avonex Prefilled 252AXITINIB 111,112Ayvakit 104AzaSite 242AZATHIOPRINE 235AZELAIC ACID 174AZELAIC ACID (ACNE) 163AZELASTINE HCL 239AZELASTINE HCL (OPHTH) 242AZELASTINE HCL-FLUTICASONE PROPIONATE 239Azelex 163AZILSARTAN MEDOXOMIL 89AZITHROMYCIN 217Azithromycin 217AZITHROMYCIN (OPHTH) 242AZTREONAM LYSINE 36

BBacitracin 242BACITRACIN (OPHTHALMIC) 242BACITRACIN-POLYMYXIN B (OPHTH) 241BACITRACIN-POLYMYXIN-NEOMYCIN HC 165BACLOFEN 238Bactroban Nasal 239Bafiertam 253Balcoltra 146BALOXAVIR MARBOXIL 133BALSALAZIDE DISODIUM 193Balversa 99Baqsimi One Pack 65Baqsimi Two Pack 65Baraclude 131BARICITINIB 9Basaglar KwikPen 67

BD Insulin Syringe U-500 222BD Klatskin Biopsy Needle 222BD Osgood Biopsy Needle 222BD Pen Needle Nano U/F 222BD Rosenthal Biopsy Needle 222BD SafetyGlide Insulin Syringe 222BD Veritor System SARS-CoV-2 175BECAPLERMIN 175BECLOMETHASONE DIPROPIONATE 46BECLOMETHASONE DIPROPIONATE HFA 46BEDAQUILINE FUMARATE 93BELIMUMAB 231BELLADONNA ALKALOIDS & OPIUM 267Belladonna Alkaloids-Opium 267Belsomra 215BELUMOSUDIL MESYLATE 235BELZUTIFAN 100BEMPEDOIC ACID 80BEMPEDOIC ACID-EZETIMIBE 79BENAZEPRIL & HYDROCHLOROTHIAZIDE 86BENAZEPRIL HCL 85Benazepril-Hydrochlorothiazide 86BeneFIX 199,200Benlysta 231BENRALIZUMAB 44BENZONATATE 160BENZOYL PEROXIDE-ERYTHROMYCIN 162BENZTROPINE MESYLATE 112BENZYL ALCOHOL (PEDICULICIDE) 174BEPOTASTINE BESILATE 242Bepreve 242Berinert 208BESIFLOXACIN HCL 242Besivance 242BETAMETHASONE DIPROPIONATE (TOPICAL) 169Betamethasone Dipropionate Aug 169BETAMETHASONE DIPROPIONATEAUGMENTED 169BETAMETHASONE VALERATE 169Betaseron 252BETAXOLOL HCL 134

BETAXOLOL HCL (OPHTH) 240BETHANECHOL CHLORIDE 271Betimol 240Betoptic-S 240BEXAROTENE 111BEXAROTENE (TOPICAL) 175Bexsero 271Beyaz 146BICALUTAMIDE 94BICTEGRAVIR-EMTRICITABINE-TENOFOVIRALAFENAMIDE FUMARATE 124Biktarvy 124BIMATOPROST 245BinaxNOW COVID-19 Ag Card 175BinaxNOW COVID-19 Ag Home Test 175BINIMETINIB 101BISOPROLOL & HYDROCHLOROTHIAZIDE 91BISOPROLOL FUMARATE 134Blephamide S.O.P. 244BLOOD GLUCOSE MONITORINGSUPPLIES 219,220,221Boostrix 266BOSENTAN 142Bosulif 96BOSUTINIB 96Braftovi 98Breo Ellipta 41Brexafemme 77BREXPIPRAZOLE 123Breztri Aerosphere 41Bridion 75Brilinta 208BRIMONIDINE TARTRATE 244BRIMONIDINE TARTRATE-TIMOLOL MALEATE 240BRINZOLAMIDE 243BRINZOLAMIDE-BRIMONIDINE TARTRATE 240BRIVARACETAM 51,52Briviact 51,52BROMFENAC SODIUM (OPHTH) 243BROMOCRIPTINE MESYLATE 112Brukinsa 98

BUDESONIDE 158,160BUDESONIDE (INHALATION) 46BUDESONIDE (INTRARECTAL) 33BUDESONIDE-FORMOTEROL FUMARATEDIHYDRATE 42BUDESONIDE-GLYCOPYRROLATE-FORMOTEROLFUMARATE 41BUMETANIDE 179BUPRENORPHINE 31,32Buprenorphine 31BUPRENORPHINE HCL 31BUPRENORPHINE HCL-NALOXONE HCLDIHYDRATE 31BUPROPION HCL 58,59BUPROPION HCL (SMOKING DETERRENT) 255,256BuPROPion HCl ER (XL) 59BUPROPION HYDROBROMIDE 58BUSPIRONE HCL 37,38BUSULFAN 94BUTALBITAL-ACETAMINOPHEN 15BUTALBITAL-ACETAMINOPHEN-CAFFEINE 15,16BUTALBITAL-ACETAMINOPHEN-CAFFEINE W/CODEINE 16BUTALBITAL-ASPIRIN-CAFFEINE 15Butalbital-Aspirin-Caffeine 15BUTALBITAL-ASPIRIN-CAFFEINE W/COD 16BUTORPHANOL TARTRATE 31Bydureon 69Bydureon BCise 69Bylvay 193Bylvay (Pellets) 192

CC1 ESTERASE INHIBITOR (HUMAN) 208CABERGOLINE 182Cablivi 196Cabometyx 102CABOZANTINIB S-MALATE 102,103CALCIPOTRIENE 166CALCITONIN (SALMON) 181Calcitriol 166

CALCITRIOL 183CALCITRIOL (TOPICAL) 166CALCIUM ACETATE (PHOSPHATE BINDER) 194Calquence 98CANDESARTAN CILEXETIL 89CANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDE 88CANNABIDIOL 52CAPECITABINE 95CAPLACIZUMAB-YHDP 196CAPMATINIB HCL 101Caprelsa 103CAPTOPRIL 85CAPTOPRIL & HYDROCHLOROTHIAZIDE 86Captopril-Hydrochlorothiazide 86CARBAMAZEPINE 52,54,55CARBAMAZEPINE (ANTIPSYCHOTIC) 116CARBIDOPA 113CARBIDOPA-LEVODOPA 113Carbidopa-Levodopa 113CARBIDOPA-LEVODOPA-ENTACAPONE 113,114Carbidopa-Levodopa-Entacapone 113,114CARBINOXAMINE MALEATE 78Carbinoxamine Maleate 78Cardura XL 195CARGLUMIC ACID 183CARIPRAZINE HCL 117CARISOPRODOL W/ ASPIRIN & CODEINE 238Carteolol HCl 240CARTEOLOL HCL (OPHTH) 240CARVEDILOL 134CARVEDILOL PHOSPHATE 134Caya 218Cayston 36CEFACLOR 144Cefaclor 144Cefaclor ER 144CEFACLOR MONOHYDRATE 144CEFADROXIL 143Cefadroxil 143CEFDINIR 144

CEFDITOREN PIVOXIL 144,145Cefditoren Pivoxil 144,145CEFIXIME 145CEFPODOXIME PROXETIL 145CEFPROZIL 144CEFUROXIME AXETIL 144CELECOXIB 11Celontin 57CENOBAMATE 56CEPHALEXIN 143,144Cephalexin 143,144CeQur Simplicity Inserter 223CeQur Simplicity Starter 223Cerdelga 209CERITINIB 96CERTOLIZUMAB PEGOL 194CERVICAL CAPS 218Cesamet 77CETIRIZINE HCL 79CEVIMELINE HCL 236Chantix 255Chantix Continuing Month Pak 255Chantix Starting Month Pak 255Chemet 74CHLORAMBUCIL 110CHLORDIAZEPOXIDE HCL 39CHLORDIAZEPOXIDE-AMITRIPTYLINE 250Chlordiazepoxide-Amitriptyline 250CHLORHEXIDINE GLUCONATE (MOUTH-THROAT) 236CHLOROQUINE PHOSPHATE 92Chloroquine Phosphate 92CHLOROTHIAZIDE 180Chlorothiazide 180CHLORPROMAZINE HCL 121CHLORTHALIDONE 180CHLORZOXAZONE 238CHOLESTYRAMINE 80CHOLESTYRAMINE LIGHT 80CHOLINE FENOFIBRATE 81Ciclodan Cream 165

CICLOPIROX 165CICLOPIROX OLAMINE 165CICLOPIROX OLAMINE & CLEANSER 165Ciclopirox Treatment 165CILOSTAZOL 209Cimduo 124CIMETIDINE HCL 268Cimetidine HCl 268Cimzia 194Cimzia Prefilled 194Cimzia Starter Kit 194CINACALCET HCL 181Cipro HC 246CIPROFLOXACIN 190CIPROFLOXACIN (OTIC) 246CIPROFLOXACIN HCL 190Ciprofloxacin HCl 190,246CIPROFLOXACIN HCL (OPHTH) 242CIPROFLOXACIN HCL (OTIC) 246Ciprofloxacin-Ciproflox HCl ER 190CIPROFLOXACIN-CIPROFLOXACIN HCL 190CIPROFLOXACIN-DEXAMETHASONE 246CIPROFLOXACIN-FLUOCINOLONE ACETONIDE 246CIPROFLOXACIN-HYDROCORTISONE 246CITALOPRAM HYDROBROMIDE 59,60CLADRIBINE (MULTIPLE SCLEROSIS) 251,252CLARITHROMYCIN 217Clarithromycin 217Clindacin ETZ 162Clindacin Pac 162CLINDAMYCIN HCL 35CLINDAMYCIN PALMITATE HYDROCHLORIDE 35CLINDAMYCIN PHOSPHATE & CLEANSER 162CLINDAMYCIN PHOSPHATE (TOPICAL) 162CLINDAMYCIN PHOSPHATE VAGINAL 276CLINDAMYCIN PHOSPHATE-BENZOYLPEROXIDE 162CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE(REFRIGERATE) 162CLINDAMYCIN PHOSPHATE-TRETINOIN 162Clinitest Rapid COVID-19 Test 176

CLOBAZAM 51CLOBETASOL PROPIONATE 170CLOBETASOL PROPIONATE EMOLLIENTBASE 169,170CLOBETASOL PROPIONATE EMULSION 170,172CLOCORTOLONE PIVALATE 170Clocortolone Pivalate 170Clocortolone Pivalate Pump 170CLOMIPRAMINE HCL 63CLONAZEPAM 51CLONIDINE 90CLONIDINE HCL 90CLONIDINE HCL (ADHD) 2CLOPIDOGREL BISULFATE 209CLORAZEPATE DIPOTASSIUM 39CLOTRIMAZOLE 235CLOTRIMAZOLE (TOPICAL) 172CLOTRIMAZOLE W/ BETAMETHASONE 166CLOZAPINE 120CloZAPine 120Co-Natal FA 236COAGULATION FACTOR IX 199,204COAGULATION FACTOR IX (RECOMB) FC FUSIONPROTEIN (RFIXFC) 199COAGULATION FACTOR IX(RECOMBINANT) 199,200,202,206,207COAGULATION FACTOR IX (RECOMBINANT)GLYCOPEGYLATED 206COAGULATION FACTOR IX RECOMB ALBUMINFUSION PROTEIN (RIX-FP) 202Coartem 92Cobas Liat SARS-CoV-2 Assay 176COBICISTAT 131COBIMETINIB FUMARATE 101CODEINE SULFATE 19Codeine Sulfate 19COLCHICINE 196Colchicine 196COLCHICINE W/ PROBENECID 196COLESEVELAM HCL 80COLESTIPOL HCL 80

COLLAGENASE 172COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 233Coly-Mycin S 246Combigan 240Combivent Respimat 41Cometriq (100 mg Daily Dose) 103Cometriq (140 mg Daily Dose) 103Cometriq (60 mg Daily Dose) 103Compact Space Chamber 226Compact Space Chamber/Lg Mask 226Compact Space Chamber/Med Mask 226Compact Space Chamber/Sm Mask 226Complera 124Complete Natal DHA 237CompleteNate 236CONJUGATED ESTROGENS-BAZEDOXIFENE 188CONJUGATED ESTROGENS-MEDROXYPROGESTERONE ACETATE 188CONTINUOUS BLOOD GLUCOSE SYSTEMRECEIVER 219,220CONTINUOUS BLOOD GLUCOSE SYSTEMSENSOR 219,220CONTINUOUS BLOOD GLUCOSE SYSTEMTRANSMITTER 219Copiktra 110COPPER (IUD) 152Cordran 170Corlanor 143Corlopam 91CORTISONE ACETATE 158Cortisone Acetate 158Cortisporin 165Cosentyx 167Cosentyx (300 MG Dose) 167Cosentyx Sensoready (300 MG) 167Cosentyx Sensoready Pen 167Cotellic 101COVID-19 (SARS-COV-2) ADENOVIRUSVACCINE 273,275COVID-19 (SARS-COV-2) MRNA VIRUSVACCINE 275

COVID-19 (SARS-COV-2) SUBUNIT (SPIKE)PROTEIN VIRUS VACCINE 275COVID-19 ANTIGEN TEST 175,177COVID-19 AT HOME TEST 175,176,177COVID-19 At-Home Test 176COVID-19 HOME COLLECTION TEST 176,177COVID-19 HOME TEST 177COVID-19 OTC Antigen 1-Pack 176COVID-19 OTC Antigen 2-Pack 176COVID-19 TEST 176,177Creon 177Crinone 277CRISABOROLE 174Crixivan 127CRIZOTINIB 96CROMOLYN SODIUM 42CROMOLYN SODIUM (MASTOCYTOSIS) 191CROMOLYN SODIUM (OPHTH) 242CROTAMITON 174Cuvitru 247Cuvposa 270CYANOCOBALAMIN 209CYCLOBENZAPRINE HCL 238CYCLOPENTOLATE HCL 241CYCLOPHOSPHAMIDE 110Cyclophosphamide 110CYCLOSERINE 93CycloSERINE 93CYCLOSPORINE 232CYCLOSPORINE (OPHTH) 243CYCLOSPORINE MODIFIED (FORMICROEMULSION) 232CYPROHEPTADINE HCL 79Cystadrops 245Cystagon 195Cystaran 245CYSTEAMINE BITARTRATE 195CYSTEAMINE HCL 245

DDABIGATRAN ETEXILATE MESYLATE 50

DABRAFENIB MESYLATE 98DACOMITINIB 99DALFAMPRIDINE 254Daliresp 45DALTEPARIN SODIUM 49,50DANAZOL 32DANTROLENE SODIUM 238DAPAGLIFLOZIN PROPANEDIOL 71DAPAGLIFLOZIN-METFORMIN HCL 72DAPSONE 35Dapsone 162DAPSONE (TOPICAL) 162Daptacel 266DARBEPOETIN ALFA 210,211DARIFENACIN HYDROBROMIDE 270DARUNAVIR ETHANOLATE 128DARUNAVIR-COBICISTAT 125DARUNAVIR-COBICISTAT-EMTRICITABINE-TENOFOVIR ALAFENAMIDE 125DASATINIB 97DayVigo 215DECITABINE-CEDAZURIDINE 106DEFERASIROX 74,75DEFERIPRONE 75DELAVIRDINE MESYLATE 129DEMECLOCYCLINE HCL 259Denavir 168Depo-Provera 154Depo-SubQ Provera 104 154Depo-Testosterone 32Descovy 124DESIPRAMINE HCL 63,64DESLORATADINE 78,79Desloratadine 78,79DESMOPRESSIN ACETATE 186,187Desmopressin Acetate 186DESMOPRESSIN ACETATE SPRAY 187DESMOPRESSIN ACETATE SPRAYREFRIGERATED 186DESOGESTREL & ETHINYLESTRADIOL 146,147,148,151

DESOGESTREL-ETHINYL ESTRADIOL (BIPHASIC) 145DESOGESTREL-ETHINYL ESTRADIOL(TRIPHASIC) 156,157DESONIDE 170DESOXIMETASONE 170DESVENLAFAXINE 62Desvenlafaxine ER 62DESVENLAFAXINE SUCCINATE 62DEXAMETHASONE 158,159Dexamethasone 158,159DEXAMETHASONE (OPHTH) 245Dexamethasone Intensol 159Dexamethasone Sodium Phosphate 244DEXAMETHASONE SODIUM PHOSPHATE(OPHTH) 244Dexcom G6 Receiver 219Dexcom G6 Sensor 219Dexcom G6 Transmitter 219Dexilant 269DEXLANSOPRAZOLE 269Dexlansoprazole 269DEXMETHYLPHENIDATE HCL 5DEXTROAMPHETAMINE SULFATE 4DIAPHRAGM ARC-SPRING 218DIAPHRAGM WIDE SEAL 218,219DIAPHRAGMS 218DIAZEPAM 39DIAZEPAM (ANTICONVULSANT) 51DICLOFENAC EPOLAMINE 164Diclofenac Epolamine 164DICLOFENAC POTASSIUM 12DICLOFENAC SODIUM 12DICLOFENAC SODIUM (ACTINIC KERATOSES) 166DICLOFENAC SODIUM (OPHTH) 243DICLOFENAC SODIUM (TOPICAL) 164,165DICLOFENAC W/ MISOPROSTOL 12DICLOXACILLIN SODIUM 249DICYCLOMINE HCL 267DIDANOSINE 129Didanosine 129DIFENOXIN W/ ATROPINE 74

Dificid 218DIFLORASONE DIACETATE 170Diflorasone Diacetate 170DIFLUNISAL 16DIFLUPREDNATE 244DIGOXIN 140Digoxin 140DIHYDROERGOTAMINE MESYLATE 228Dilantin 57Dilatrate-SR 36DILTIAZEM HCL 137DILTIAZEM HCL COATED BEADS 137,138DILTIAZEM HCL EXTENDED RELEASEBEADS 137,139DIMETHYL FUMARATE 253Dipentum 193DIPH-AC PERT-TET TOX AD-POLIO IPV-HAEMOPHIL B POLY VAC 267DIPH-TET TOX-ACELL PERT AD-POLIO IPV-HIB-HEPATITIS B RECOMB 267DIPH-TETANUS TOX AD-ACELL PERTUSSIS & POLIOVIRUS, IPV VAC 267DIPH-TETANUS TOX-ACELL PERT-HEPATITIS BRECOMB-POLIO IPV VAC 267DIPHENHYDRAMINE HCL 78DIPHENOXYLATE W/ ATROPINE 74DIPHTHERIA, ACELLULAR PERTUSSIS & TETANUSTOXOIDS 266DIPHTHERIA-TETANUS TOXOIDS (DT) 266Diphtheria-Tetanus Toxoids DT 266DIPYRIDAMOLE 209DIROXIMEL FUMARATE 253DISOPYRAMIDE PHOSPHATE 40DISULFIRAM 250Diuril 180DIVALPROEX SODIUM 57,58Divigel 188DOFETILIDE 40,41Dojolvi 240DOLASETRON MESYLATE 76DOLUTEGRAVIR SODIUM 127

DOLUTEGRAVIR SODIUM-LAMIVUDINE 124DOLUTEGRAVIR SODIUM-RILPIVIRINE HCL 125DONEPEZIL HYDROCHLORIDE 250DORAVIRINE 129DORNASE ALFA 258DORZOLAMIDE HCL 243DORZOLAMIDE HCL-TIMOLOL MALEATE 241Dovato 124DOXAZOSIN MESYLATE 90DOXAZOSIN MESYLATE (BPH) 195DOXEPIN HCL 64Doxepin HCl 64,166DOXEPIN HCL (ANTIPRURITIC) 166DOXERCALCIFEROL 183DOXYCYCLINE (MONOHYDRATE) 259,260DOXYCYCLINE HYCLATE 259,260Drisdol 277DRONABINOL 77DRONEDARONE HCL 41DROSPIRENONE 156DROSPIRENONE-ESTETROL 149DROSPIRENONE-ETHINYLESTRADIOL 147,148,149,150,151,152DROSPIRENONE-ETHINYL ESTRADIOL-LEVOMEFOLATE CALCIUM 146,147,151Droxia 209,210Drysol 174Duavee 188DULAGLUTIDE 70Dulera 41DULOXETINE HCL 62DUPILUMAB 168,169Dupixent 168,169DUTASTERIDE 195DUVELISIB 110DxTerity COVID-19 Home Test 176

EEasiVent 226EasiVent Mask Large 226EasiVent Mask Medium 226

EasiVent Mask Small 226Easy Touch Lancets 30G/Twist 219Easy Touch Lancets 33G/Twist 219ECHOTHIOPHATE IODIDE 241ECONAZOLE NITRATE 172Edarbi 89EDOXABAN TOSYLATE 48Edurant 128EFAVIRENZ 128EFAVIRENZ-EMTRICITABINE-TENOFOVIRDISOPROXIL FUMARATE 124EFAVIRENZ-LAMIVUDINE-TENOFOVIR DISOPROXILFUMARATE 124,125EFINACONAZOLE 172ELAGOLIX SODIUM 182ELAGOLIX SODIUM-ESTRADIOL-NORETHINDRONEACETATE 188Elestrin 188ELETRIPTAN HYDROBROMIDE 228ELEXACAFTOR-TEZACAFTOR-IVACAFTOR 258Eligard 109ELIGLUSTAT TARTRATE 209Eliquis 48Eliquis DVT/PE Starter Pack 48Elixophyllin 46Ella 153Ellume Covid-19 Home Test 176Elmiron 195Eloctate 200ELTROMBOPAG OLAMINE 213,214ELUXADOLINE 192ELVITEGRAVIR-COBICISTAT-EMTRICITABINE-TENOFOVIR ALAFENAMIDE 125ELVITEGRAVIR-COBICISTAT-EMTRICITABINE-TENOFOVIR DF 125Emadine 242Emcyt 108EMEDASTINE DIFUMARATE 242Emgality 228Emgality (300 MG Dose) 228EMICIZUMAB-KXWH 208

EMPAGLIFLOZIN 71EMPAGLIFLOZIN-LINAGLIPTIN 71EMPAGLIFLOZIN-LINAGLIPTIN-METFORMIN 70,71EMPAGLIFLOZIN-METFORMIN HCL 71,72Emsam 59EMTRICITABINE 129EMTRICITABINE-RILPIVIRINE-TENOFOVIRALAFENAMIDE FUMARATE 125EMTRICITABINE-RILPIVIRINE-TENOFOVIRDISOPROXIL FUMARATE 124EMTRICITABINE-TENOFOVIR ALAFENAMIDEFUMARATE 124EMTRICITABINE-TENOFOVIR DISOPROXILFUMARATE 125Emtriva 129Emverm 34ENALAPRIL MALEATE 85ENALAPRIL MALEATE &HYDROCHLOROTHIAZIDE 87Enbrel 15Enbrel Mini 15Enbrel SureClick 15ENCORAFENIB 98Endometrin 277ENFUVIRTIDE 126Engerix-B 273ENOXAPARIN SODIUM 49Enspryng 234ENTACAPONE 115ENTECAVIR 131ENTRECTINIB 105Entresto 141Envarsus XR 234ENZALUTAMIDE 94Epidiolex 52EPINASTINE HCL (OPHTH) 242EPINEPHrine 277EPINEPHRINE (ANAPHYLAXIS) 277EPLERENONE 91EPOETIN ALFA 211EPOETIN ALFA-EPBX 211,212

Eprontia 52EPROSARTAN MESYLATE 89Eprosartan Mesylate 89Equetro 116ERDAFITINIB 99ERENUMAB-AOOE 227ERGOCALCIFEROL 277ERGOLOID MESYLATES 255Ergoloid Mesylates 255ERGOTAMINE W/ CAFFEINE 228Erivedge 100Erleada 94ERLOTINIB HCL 98,99Ertaczo 172Erythrocin Stearate 217ERYTHROMYCIN (ACNE AID) 162ERYTHROMYCIN (OPHTH) 242ERYTHROMYCIN BASE 217,218ERYTHROMYCIN ETHYLSUCCINATE 218Erythromycin Ethylsuccinate 218ERYTHROMYCIN STEARATE 217Esbriet 258ESCITALOPRAM OXALATE 60ESKETAMINE HCL 59ESOMEPRAZOLE MAGNESIUM 269Esperoct 200,201ESTERIFIED ESTROGENS 189,190ESTERIFIED ESTROGENS &METHYLTESTOSTERONE 187ESTRADIOL 188,189,190ESTRADIOL & NORETHINDRONE ACETATE 187ESTRADIOL ACETATE VAGINAL 276ESTRADIOL VAGINAL 276,277ESTRADIOL VALERATE 189ESTRADIOL VALERATE-DIENOGEST 154ESTRAMUSTINE PHOSPHATE SODIUM 108Estring 276ESTROGENS, CONJUGATED 190ESTROGENS, CONJUGATED VAGINAL 277ESTROPIPATE 189Estropipate 189

Estrostep Fe 156ESZOPICLONE 215ETANERCEPT 15ETHACRYNIC ACID 179ETHAMBUTOL HCL 93ETHIONAMIDE 93ETHOSUXIMIDE 57ETHOTOIN 57ETHYNODIOL DIACET & ETH ESTRAD 147,148,152ETIDRONATE DISODIUM 180,181Etidronate Disodium 180,181ETODOLAC 12ETONOGESTREL 154ETONOGESTREL-ETHINYL ESTRADIOL 152ETOPOSIDE 110Etoposide 110ETRAVIRINE 128Eucrisa 174Eurax 174Evamist 189Evenity 185EVEROLIMUS 102EVEROLIMUS (IMMUNOSUPPRESSANT) 234EVOLOCUMAB 84Evotaz 125Evrysdi 239Exelderm 172EXEMESTANE 107EXENATIDE 69Exkivity 99Extavia 252EZETIMIBE 84Ezetimibe-Rosuvastatin 83EZETIMIBE-ROSUVASTATIN CALCIUM 83EZETIMIBE-SIMVASTATIN 83

FFAMCICLOVIR 133FAMOTIDINE 268Fanapt 117,118Fanapt Titration Pack 118

Farxiga 71Farydak 100Fasenra 44Fasenra Pen 44FEBUXOSTAT 196FELBAMATE 56FELODIPINE 138FemCap 218Femring 276FENOFIBRATE 80,81Fenofibrate 80,81FENOFIBRATE MICRONIZED 80,81FENOFIBRIC ACID 81Fenofibric Acid 81FENOLDOPAM MESYLATE 91FENOPROFEN CALCIUM 12Fenoprofen Calcium 12FENTANYL 19,20,28,29FENTANYL CITRATE 18,20,21,22,23fentaNYL Citrate 20,21Ferriprox 75Ferriprox Twice-A-Day 75FESOTERODINE FUMARATE 271Fetzima 62FIDAXOMICIN 218FILGRASTIM-AAFI 212,213FILGRASTIM-SNDZ 213FINASTERIDE 195FINGOLIMOD HCL 256First-Lansoprazole 269First-Omeprazole 269Flarex 244FLAVOXATE HCL 271FLECAINIDE ACETATE 40Flovent Diskus 46Flovent HFA 46Flowflex COVID-19 Ag Home Test 176Fluad 273Fluad Quadrivalent 273Fluarix Quadrivalent 273Flublok 273

Flublok Quadrivalent 273Flucelvax Quadrivalent 273,274FLUCONAZOLE 78FLUCYTOSINE 77FLUDROCORTISONE ACETATE 160Flulaval Quadrivalent 274FluMist Quadrivalent 274Flunisolide 239FLUNISOLIDE (NASAL) 239FLUOCINOLONE ACETONIDE 170,171FLUOCINOLONE ACETONIDE (OTIC) 246FLUOCINONIDE 171FLUOCINONIDE EMULSIFIED BASE 171FLUOROMETHOLONE (OPHTH) 244FLUOROMETHOLONE ACETATE 244Fluoroplex 166Fluorouracil 166FLUOROURACIL (TOPICAL) 166FLUOXETINE HCL 60FLUoxetine HCl 60FLUOXETINE HCL (PMDD) 254,255FLUoxetine HCl (PMDD) 254,255FLUPHENAZINE HCL 121,122FluPHENAZine HCl 121,122Flura-Drops 229FLURANDRENOLIDE 170,171FLURAZEPAM HCL 214Flurazepam HCl 214FLURBIPROFEN 12Flurbiprofen 12FLURBIPROFEN SODIUM 243Flurbiprofen Sodium 243FLUTAMIDE 94Flutamide 94FLUTICASONE FUROATE (INHALATION) 45FLUTICASONE FUROATE-VILANTEROL 41FLUTICASONE PROPIONATE 171FLUTICASONE PROPIONATE (INHALATION) 46FLUTICASONE PROPIONATE (NASAL) 239FLUTICASONE PROPIONATE HFA 46FLUTICASONE-SALMETEROL 41,42

Fluticasone-Salmeterol 41,42FLUTICASONE-UMECLIDINIUM-VILANTEROL 42FLUVASTATIN SODIUM 82Fluvirin 274FLUVOXAMINE MALEATE 60Fluzone High-Dose 274Fluzone High-Dose Quadrivalent 274Fluzone Quadrivalent 274FML 244FML Forte 244FOLIC ACID 212FONDAPARINUX SODIUM 50Forfivo XL 59Forteo 184Fosamax Plus D 181FOSAMPRENAVIR CALCIUM 127FOSFOMYCIN TROMETHAMINE 36FOSINOPRIL SODIUM 85FOSINOPRIL SODIUM &HYDROCHLOROTHIAZIDE 87FOSTEMSAVIR TROMETHAMINE 126Fotivda 103Fragmin 49,50FreeStyle Flash System 219FreeStyle Freedom 219FreeStyle Freedom Lite 219FreeStyle InsuLinx System 219FreeStyle InsuLinx Test 175FreeStyle Lancets 219FreeStyle Libre 14 Day Reader 219FreeStyle Libre 14 Day Sensor 219FreeStyle Libre 2 Reader 219FreeStyle Libre 2 Sensor 220FreeStyle Libre Reader 220FreeStyle Libre Sensor System 220FreeStyle Lite 220FreeStyle Lite Test 175FreeStyle Sidekick II 220FreeStyle System 220FreeStyle Test 175FreeStyle Unistick II Lancets 220

FREMANEZUMAB-VFRM 227,228FROVATRIPTAN SUCCINATE 228Fulphila 212FUROSEMIDE 179Furosemide 179Fuzeon 126Fycompa 50

GGABAPENTIN 52GALANTAMINE HYDROBROMIDE 250Galantamine Hydrobromide 250GALCANEZUMAB-GNLM 228GANCICLOVIR OPHTHALMIC 243Gardasil 9 274GATIFLOXACIN (OPHTH) 242GaviLyte-C 216Gavreto 105Gelnique 270Gelnique Pump 270GEMFIBROZIL 81Generess FE 147GENTAMICIN SULFATE (OPHTH) 242GENTAMICIN SULFATE (TOPICAL) 165Genvoya 125Giazo 193Gilenya 256Gilotrif 99Glassia 257GLATIRAMER ACETATE 251GLECAPREVIR-PIBRENTASVIR 131Gleostine 110GLIMEPIRIDE 72,73GLIPIZIDE 73GLIPIZIDE-METFORMIN HCL 72GlucaGen Diagnostic 175GlucaGen HypoKit 65GLUCAGON 65,66GLUCAGON (RDNA) 65,66Glucagon Emergency 66GLUCAGON HCL (DIAGNOSTIC) 175

Glucagon HCl (Diagnostic) 175GLUCAGON HCL (RDNA) 65GLUCAGON HCL RDNA (DIAGNOSTIC) 175GLUCOSE BLOOD 175GLYBURIDE 73GLYBURIDE MICRONIZED 73GLYBURIDE-METFORMIN 72GLYCOPYRROLATE 270Glyxambi 71GOLIMUMAB 9Golytely 216GOSERELIN ACETATE 109GRANISETRON 76GRANISETRON HCL 76Granix 212GRISEOFULVIN MICROSIZE 77GRISEOFULVIN ULTRAMICROSIZE 77GUAIFENESIN-CODEINE 161GUANFACINE HCL 90GUANFACINE HCL (ADHD) 2GUANIDINE HCL 92Guanidine HCl 92GUSELKUMAB 168Gvoke HypoPen 1-Pack 66Gvoke HypoPen 2-Pack 66Gvoke Kit 66Gvoke PFS 66

HHaegarda 208HAEMOPHILUS B POLYSAC CONJ VAC 271,272HALOBETASOL PROPIONATE 171HALOPERIDOL 120HALOPERIDOL LACTATE 120Havrix 275Helixate FS 201Hemlibra 208Hemofil M 201HEPARIN SODIUM (PORCINE) 49HEPARIN SODIUM (PORCINE) LOCK FLUSH 49

HEPATITIS A (INACTIVATED)-HEPATITIS B(RECOMBINANT) VACCINES 272HEPATITIS A VACCINE 275,276HEPATITIS B VACCINE (RECOMB) 273,275HEPATITIS B VACCINE 3-ANTIGENRECOMBINANT 275HEPATITIS B VACCINE RECOMBINANTADJUVANTED 275Heplisav-B 275Hexalen 94Hiberix 272HISTRELIN ACETATE 109Hizentra 247HOMATROPINE HBR 241HumaLOG 67HumaLOG Junior KwikPen 67HumaLOG KwikPen 68HumaLOG Mix 50/50 68HumaLOG Mix 50/50 KwikPen 68HumaLOG Mix 75/25 68HumaLOG Mix 75/25 KwikPen 68HUMAN PAPILLOMAVIRUS (HPV) 9-VALENTRECOMBINANT VACCINE 274Humate-P 201Humira 8Humira Pediatric Crohns Start 8Humira Pen 8Humira Pen-CD/UC/HS Starter 9Humira Pen-Pediatric UC Start 9Humira Pen-Ps/UV/Adol HS Start 9Humira Pen-Psor/Uveit Starter 9HumuLIN 70/30 68HumuLIN 70/30 KwikPen 68HumuLIN N 68HumuLIN N KwikPen 68HumuLIN R 68HumuLIN R U-500 (CONCENTRATED) 68HumuLIN R U-500 KwikPen 68Hycodan 160HYDRALAZINE HCL 91,92HYDROCHLOROTHIAZIDE 180

HYDROCODONE BITARTRATE 21,22HYDROcodone Bitartrate ER 21,22HYDROCODONE POLISTIREX-CHLORPHENIRAMINEPOLISTIREX 161HYDROCODONE W/ HOMATROPINE 160,161HYDROCODONE-ACETAMINOPHEN 16,17,18HYDROCODONE-IBUPROFEN 17,18Hydrocodone-Ibuprofen 17HYDROCORTISONE 158,159HYDROCORTISONE (INTRARECTAL) 33HYDROCORTISONE (RECTAL) 34HYDROCORTISONE (TOPICAL) 169,171HYDROCORTISONE ACETATE (RECTAL) 33,34HYDROCORTISONE BUTYRATE 171Hydrocortisone Butyrate 171HYDROCORTISONE BUTYRATE HYDROPHILIC LIPOBASE 171HYDROCORTISONE VALERATE 172HYDROCORTISONE W/ACETIC ACID 246HYDROMORPHONE HCL 22HYDROXYCHLOROQUINE SULFATE 92Hydroxychloroquine Sulfate 92HYDROXYprogesterone Caproate 111HYDROXYPROGESTERONE CAPROATE 249HYDROXYPROGESTERONE CAPROATE(ANTINEOPLASTIC) 111HYDROXYUREA 106HYDROXYUREA (SICKLE CELL ANEMIA) 209,210HYDROXYZINE HCL 38HYDROXYZINE PAMOATE 38HydrOXYzine Pamoate 38HYOSCYAMINE SULFATE 267,268Hyqvia 247,248

IIBANDRONATE SODIUM 181Ibrance 107IBREXAFUNGERP CITRATE 77IBRUTINIB 98IBUPROFEN 12,13ICATIBANT ACETATE 208

Iclusig 96,97ICOSAPENT ETHYL 80ID NOW COVID-19 176IDELALISIB 111Idelvion 202IHealth COVID-19 Rapid Test 176Ilevro 243ILOPERIDONE 117,118ILOPROST 141IMATINIB MESYLATE 97Imbruvica 98IMIPENEM-CILASTATIN 35IMIPRAMINE HCL 64IMIPRAMINE PAMOATE 64IMIQUIMOD 173IMMUNE GLOBULIN (HUMAN)SUBCUTANEOUS 247IMMUNE GLOBULIN (HUMAN)-HYALURONIDASE(HUMAN RECOMBINANT) 247,248Increlex 183Incruse Ellipta 44INDACATEROL MALEATE 43INDAPAMIDE 180Inderal XL 135INDINAVIR SULFATE 127Indocin 13INDOMETHACIN 13Infanrix 266INFIGRATINIB PHOSPHATE 100INFLUENZA VIRUS VAC RECOMB HEMAGGLUTININ(HA) QUADRIVALENT 273INFLUENZA VIRUS VAC SPLIT HIGH-DOSE QUADPRESERVATIVE FREE 274INFLUENZA VIRUS VACC TYPES A & B SURFANTIGEN ADJUVANT QUAD 273INFLUENZA VIRUS VACCINE LIVEQUADRIVALENT 274INFLUENZA VIRUS VACCINE RECOMBINANTHEMAGGLUTININ (HA) 273INFLUENZA VIRUS VACCINE SPLIT 272

INFLUENZA VIRUS VACCINE SPLIT HIGH-DOSEPRESERVATIVE FREE 274INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVEFREE 273INFLUENZA VIRUS VACCINE SPLITQUADRIVALENT 273,274INFLUENZA VIRUS VACCINE TISSUE-CULTUREDSUBUNIT QUADRIVALENT 273,274INFLUENZA VIRUS VACCINE TYPES A & B SURFACEANTIGEN 274INFLUENZA VIRUS VACCINE TYPES A & B SURFACEANTIGEN ADJUVANT 273INJECTION DEVICE 223,224INJECTION DEVICE FOR INSULIN 223Inlyta 111,112InnoPran XL 135Inqovi 106INSULIN DEGLUDEC 69INSULIN DEGLUDEC-LIRAGLUTIDE 70INSULIN DETEMIR 69INSULIN GLARGINE 67,69INSULIN GLARGINE-LIXISENATIDE 70INSULIN INFUSION DISPOSABLE PUMP 222INSULIN LISPRO 67,68Insulin Lispro 68Insulin Lispro (1 Unit Dial) 68Insulin Lispro Junior KwikPen 68Insulin Lispro Prot & Lispro 68INSULIN LISPRO PROTAMINE & LISPRO 68INSULIN NPH (HUMAN) (ISOPHANE) 68INSULIN NPH ISOPHANE & REG (HUMAN) 68INSULIN PEN NEEDLE 222,223,225INSULIN REGULAR (HUMAN) 68INSULIN SYRINGE/NEEDLE U-100 222,223,224,225INSULIN SYRINGE/NEEDLE U-500 222INSULIN SYRINGES (DISPOSABLE) 224Intelence 128InteliSwab COVID-19 Rapid Test 176INTERFERON ALFA-2B 106INTERFERON BETA-1A 252,253INTERFERON BETA-1B 252

INTERFERON GAMMA-1B 106Intron A 106Invega Hafyera 118Invega Sustenna 118Invega Trinza 118Invirase 127Ipol 275IPRATROPIUM BROMIDE 44IPRATROPIUM BROMIDE (NASAL) 239IPRATROPIUM BROMIDE HFA 44IPRATROPIUM-ALBUTEROL 41,42IRBESARTAN 89IRBESARTAN-HYDROCHLOROTHIAZIDE 88IRRIGATION SOLUTIONS, PHYSIOLOGICAL 233Isentress 126Isentress HD 126ISOCARBOXAZID 59ISONIAZID 93Isoniazid 93ISONIAZID-RIFAMPIN W/ PYRAZINAMIDE 93ISOSORBIDE DINITRATE 36Isosorbide Dinitrate ER 36ISOSORBIDE MONONITRATE 36,37ISOTRETINOIN 163,164ISRADIPINE 138Isturisa 181ITRACONAZOLE 78IVABRADINE HCL 143IVACAFTOR 257IVERMECTIN 34Ivermectin 174IVERMECTIN (PEDICULICIDE) 174IVERMECTIN (ROSACEA) 174IXAZOMIB CITRATE 104IXEKIZUMAB 168Ixinity 202

JJ-Tip Kit w/Vial Adapters 223Jakafi 108Janssen COVID-19 Vaccine 275

Janumet 67Janumet XR 67Januvia 66Jardiance 71Jentadueto 67Jentadueto XR 67Jivi 202,203Jublia 172Juluca 125Jynarque 185

KK-Phos 230K-Phos No 2 195Kalydeco 257Katerzia 138Kenalog-80 159Kesimpta 253KETOCONAZOLE 78KETOCONAZOLE (TOPICAL) 173KETOPROFEN 13Ketoprofen 13KETOROLAC TROMETHAMINE 13KETOROLAC TROMETHAMINE (OPHTH) 243Kineret 11Kinrix 267Kloxxado 75Koate 203Koate-DVI 203Kogenate FS 203Kogenate FS Bio-Set 203,204Koselugo 101Kovaltry 204Kroger HealthPro Lancet 26G 220Kroger Lancets 220Kroger Lancets 21G 220Kroger Lancets Micro Thin 33G 220Kroger Lancets Super Thin 220Kroger Lancets Thin 220Kroger Lancets Thin 26G 220Kroger Lancets UltraThin 30G 220

Kyleena 155Kynmobi 114Kynmobi Titration Kit 114

LLABETALOL HCL 134LACOSAMIDE 55,56Lacrisert 240LACTULOSE 216LACTULOSE (ENCEPHALOPATHY) 193LAMIVUDINE 129,130LAMIVUDINE (HBV) 131LAMIVUDINE-TENOFOVIR DISOPROXILFUMARATE 124,125LAMIVUDINE-ZIDOVUDINE 125LAMOTRIGINE 52,53,54Lampit 35LANCET DEVICES 221LANCETS 219,220,221,222LANCETS MISC. 221Lanoxin 140LANSOPRAZOLE 269LANTHANUM CARBONATE 194Lantus 69Lantus SoloStar 69LAPATINIB DITOSYLATE 103LASMIDITAN SUCCINATE 229Lastacaft 242LATANOPROST 245Latuda 116,117Lazanda 22,23LEDIPASVIR-SOFOSBUVIR 131Ledipasvir-Sofosbuvir 131LEFLUNOMIDE 14LEMBOREXANT 215LENALIDOMIDE 233LENVATINIB MESYLATE 112Lenvima (10 MG Daily Dose) 112Lenvima (14 MG Daily Dose) 112Lenvima (20 MG Daily Dose) 112Lenvima (24 MG Daily Dose) 112

LETROZOLE 107LEUCOVORIN CALCIUM 108Leukeran 110LEUPROLIDE ACETATE 109LEUPROLIDE ACETATE & NORETHINDRONEACETATE 183LEUPROLIDE ACETATE (3 MONTH) 109LEUPROLIDE ACETATE (4 MONTH) 109LEUPROLIDE ACETATE (6 MONTH) 109LEUPROLIDE ACETATE (CPP) 184LEUPROLIDE ACETATE (CPP) (3 MONTH) 184LEVALBUTEROL HCL 43LEVALBUTEROL TARTRATE 43Levalbuterol Tartrate 43Levemir 69Levemir FlexTouch 69LEVETIRACETAM 53,54LEVOBUNOLOL HCL 240Levobunolol HCl 240LEVOCARNITINE (METABOLIC MODIFIERS) 181LEVOCETIRIZINE DIHYDROCHLORIDE 79LEVOFLOXACIN 190LEVOFLOXACIN (OPHTH) 242LEVOMILNACIPRAN HCL 62LEVONORGESTREL & ETHESTRADIOL 145,146,147,148,149,150,151LEVONORGESTREL (IUD) 155LEVONORGESTREL-ETH ESTRADIOL(TRIPHASIC) 156,157LEVONORGESTREL-ETHINYL ESTRADIOL 152LEVONORGESTREL-ETHINYL ESTRADIOL (91-DAY) 153,154LEVONORGESTREL-ETHINYL ESTRADIOL(CONTINUOUS) 152LEVONORGESTREL-ETHINYL ESTRADIOL-FERROUSBISGLYCINATE 146LEVOTHYROXINE SODIUM 261,262,263,264,265Levothyroxine Sodium 261,262Lexiva 127LIDOCAINE 173LIDOCAINE HCL 173

LIDOCAINE HCL (MOUTH-THROAT) 235Lidocaine HCl Urethral/Mucosal 173LIDOCAINE-HYDROCORTISONE ACETATE(RECTAL) 33LIDOCAINE-PRILOCAINE 175LIDOCAINE-TETRACAINE 175Lidotrex 173LIFITEGRAST 241Liletta (52 MG) 155LINACLOTIDE 192LINAGLIPTIN 66LINAGLIPTIN-METFORMIN HCL 67LINDANE 174Lindane 174LINEZOLID 36Linzess 192LIOTHYRONINE SODIUM 263LIOTRIX (T3-T4) 265Lipofen 81LIRAGLUTIDE 70LISDEXAMFETAMINE DIMESYLATE 4LISINOPRIL 85,86LISINOPRIL & HYDROCHLOROTHIAZIDE 87LITHIUM 116Lithium 116LITHIUM CARBONATE 116Lithium Carbonate 116Livalo 82Livtencity 131Lo Loestrin Fe 145LODOXAMIDE TROMETHAMINE 242Lokelma 235LOMUSTINE 110Lonsurf 106LOPINAVIR-RITONAVIR 125Loprox 165LORAZEPAM 39LOSARTAN POTASSIUM 89LOSARTAN POTASSIUM &HYDROCHLOROTHIAZIDE 88LoSeasonique 154

Lotemax 244LOTEPREDNOL ETABONATE 244,245LOVASTATIN 82LOXAPINE SUCCINATE 121LUBIPROSTONE 191,192Lubiprostone 191,192Lucira COVID-19 All-In-One 176LULICONAZOLE 173Luliconazole 173LUMACAFTOR-IVACAFTOR 257,258Lumakras 101Lumigan 245Lupaneta Pack 183Lupkynis 232Lupron Depot (1-Month) 109Lupron Depot (3-Month) 109Lupron Depot (4-Month) 109Lupron Depot (6-Month) 109Lupron Depot-Ped (1-Month) 184Lupron Depot-Ped (3-Month) 184LURASIDONE HCL 116,117Lynparza 111Lyra Direct SARS-CoV-2 Assay 176Lyra SARS-CoV-2 Assay 176Lyrica 53Lysodren 94

MM-M-R II 272M-Vit 236MACITENTAN 142MAFENIDE ACETATE 169Magellan Insulin Safety Syr 223MALATHION 174MAPROTILINE HCL 59Maprotiline HCl 59Marathon Medical Pentips 223MARAVIROC 126MARIBAVIR 131Marplan 59Matulane 107

Mavenclad (10 Tabs) 251Mavenclad (4 Tabs) 252Mavenclad (5 Tabs) 252Mavenclad (6 Tabs) 252Mavenclad (7 Tabs) 252Mavenclad (8 Tabs) 252Mavenclad (9 Tabs) 252Mavyret 131Maxidex 245Mayzent 256Mayzent Starter Pack 256MEASLES, MUMPS & RUBELLA VIRUSVACCINES 272MEASLES-MUMPS-RUBELLA-VARICELLA VIRUSVACCINES 272MEBENDAZOLE 34MECASERMIN 183MECHLORETHAMINE HCL (TOPICAL) 166MECLIZINE HCL 76MECLOFENAMATE SODIUM 13Meclofenamate Sodium 13MEDROXYPROGESTERONE ACETATE 249MEDROXYPROGESTERONE ACETATE(CONTRACEPTIVE) 154,155MEFENAMIC ACID 13MEFLOQUINE HCL 92MEGESTROL ACETATE 111MEGESTROL ACETATE (APPETITE) 249Mekinist 101Mektovi 101MELOXICAM 13MELPHALAN 110MEMANTINE HCL 254Menactra 272Menest 189,190MENINGOCOCCAL (A,C,Y&W-135)OLIGOSACCHARIDE CONJUGATE VAC 272MENINGOCOCCAL (A,C,Y&W-135) POLYSACCHDIPHTH CONJ VACCINE 272MENINGOCOCCAL (A,C,Y&W-135) POLYSACCHTETANUS CONJ VACCINE 272

MENINGOCOCCAL GROUP B VACCINE(RECOMBINANT) 272MENINGOCOCCAL VAC GROUP B (RECOMBANTOMV ADJUVANTED) 271Menostar 190MenQuadfi 272Menveo 272MEPOLIZUMAB 44MEPROBAMATE 38MERCAPTOPURINE 95MESALAMINE 193MESALAMINE W/ CLEANSER 193METAPROTERENOL SULFATE 43Metaproterenol Sulfate 43METAXALONE 238METFORMIN HCL 65METHADONE HCL 23Methadone HCl 23METHAZOLAMIDE 178METHENAMINE HIPPURATE 36METHIMAZOLE 260Methitest 32METHOCARBAMOL 238METHOTREXATE (ANTIRHEUMATIC) 10,11METHOTREXATE SODIUM 95Methotrexate Sodium 95METHOXSALEN RAPID 167Methoxsalen Rapid 167METHOXY POLYETHYLENE GLYCOL-EPOETINBETA 211METHSCOPOLAMINE BROMIDE 270METHSUXIMIDE 57METHYCLOTHIAZIDE 180Methyclothiazide 180METHYLDOPA 90Methyldopa 90METHYLERGONOVINE MALEATE 246METHYLPHENIDATE HCL 5,6,7Methylphenidate HCl ER 6METHYLPREDNISOLONE 159METHYLTESTOSTERONE 32

MethylTESTOSTERone 32METIPRANOLOL 240Metipranolol 240METOCLOPRAMIDE HCL 192Metoclopramide HCl 192METOLAZONE 180METOPROLOL & HYDROCHLOROTHIAZIDE 91METOPROLOL SUCCINATE 134METOPROLOL TARTRATE 135Metoprolol-Hydrochlorothiazide 91METRELEPTIN 183METRONIDAZOLE 34METRONIDAZOLE (TOPICAL) 174METRONIDAZOLE VAGINAL 276MEXILETINE HCL 40MICONAZOLE (MOUTH-THROAT) 235Microchamber 226Microlet Lancets 220Microspacer 226MIDAZOLAM (ANTICONVULSANT) 51MIDAZOLAM HCL 214MIDODRINE HCL 277MIGLITOL 65MILNACIPRAN HCL 251Minastrin 24 Fe 149MINOCYCLINE HCL 259,260MINOXIDIL 92MIRABEGRON 271Mircera 211Mircette 145Mirena (52 MG) 155MIRTAZAPINE 58MISOPROSTOL 270MITOTANE 94MOBOCERTINIB SUCCINATE 99MODAFINIL 6,7Moderna COVID-19 Vaccine 275MOEXIPRIL HCL 85MOEXIPRIL-HYDROCHLOROTHIAZIDE 87MOLNUPIRAVIR 133Molnupiravir 133

MOMETASONE FUROATE 172MOMETASONE FUROATE (INHALATION) 45,46MOMETASONE FUROATE (NASAL) 239MOMETASONE FUROATE-FORMOTEROLFUMARATE DIHYDRATE 41Monoclate-P 204Monoject Insulin Syringe 223,224Monoject Introducer Needle 224Monoject Magellan Safety Ndl 224Monoject Magellan Syringe 224Monoject Syringe 224Monoject Ultra Comfort Syringe 224MONOMETHYL FUMARATE 253Mononine 204MONTELUKAST SODIUM 44,45MORPHINE SULFATE 23,24,25Morphine Sulfate 23,24Morphine Sulfate (PF) 23MORPHINE SULFATE BEADS 25Morphine Sulfate ER 24Morphine Sulfate ER Beads 25Motegrity 191Motofen 74Movantik 194Moxeza 242MOXIFLOXACIN HCL 190MOXIFLOXACIN HCL (OPHTH) 242Multaq 41MUPIROCIN 165MUPIROCIN CALCIUM 239Myalept 183MYCOPHENOLATE MOFETIL 233MYCOPHENOLATE SODIUM 233MyLab Box Covid-19 Testing 177Myleran 94Myrbetriq 271

NNABILONE 77NABUMETONE 13,14NADOLOL 135

NAFCILLIN SODIUM 249NALBUPHINE HCL 32NALDEMEDINE TOSYLATE 194NALOXEGOL OXALATE 194NALOXONE HCL 75NALTREXONE 75NALTREXONE HCL 75NAPROXEN 13,14NAPROXEN SODIUM 14NARATRIPTAN HCL 228Narcan 75Natacyn 243NATAMYCIN 243Natazia 154NATEGLINIDE 70Nature-Throid 263,264Nayzilam 51NEBIVOLOL HCL 135NEDOCROMIL SODIUM (OPHTH) 242NEEDLE (DISP) 16 G 222NEEDLE (DISP) 21 G 224NEEDLE (DISP) 23 G 224NEEDLE (REUSABLE) 18 G 222,224NEFAZODONE HCL 61Nefazodone HCl 61NEOMYCIN SULFATE 7NEOMYCIN-BACITRACIN ZN-POLYMYXIN 241NEOMYCIN-COLISTIN-HC-THONZONIUM 246NEOMYCIN-POLYMY-DEXAMETH 244NEOMYCIN-POLYMYXIN-GRAMICIDIN 241Neomycin-Polymyxin-Gramicidin 241NEOMYCIN-POLYMYXIN-HC 165NEOMYCIN-POLYMYXIN-HC (OTIC) 246Neonatal Complete 236NeoNatal Plus 236Neoral 232NEPAFENAC 243NERATINIB MALEATE 103Nerlynx 103NETARSUDIL DIMESYLATE 244NETARSUDIL DIMESYLATE-LATANOPROST 243

NETUPITANT-PALONOSETRON 76Neupro 114Nevanac 243NEVIRAPINE 129Nevirapine 129Nevirapine ER 129NexAVAR 103Nexletol 80Nexlizet 79Nexplanon 154Nextstellis 149NIACIN (ANTIHYPERLIPIDEMIC) 84Niacor 84NICARDIPINE HCL 138NICOTINE 255Nicotrol 255Nicotrol NS 255NIFEDIPINE 136,138,139NIFURTIMOX 35NILOTINIB HCL 97,98NILUTAMIDE 94NIMODIPINE 139Ninlaro 104NINTEDANIB ESYLATE 258NIRMATRELVIR-RITONAVIR 131NISOLDIPINE 139Nisoldipine ER 139NITAZOXANIDE 35Nitro-Bid 37NITROFURANTOIN 36NITROFURANTOIN MACROCRYSTAL 36NITROFURANTOIN MONOHYD MACRO 36NITROGLYCERIN 37Nitroglycerin 37NITROGLYCERIN (INTRA-ANAL) 33Nivestym 212,213NIZATIDINE 268Nizatidine 268Nordipen 5 Injection Device 224Norditropin FlexPro 182NORELGESTROMIN-ETHINYL ESTRADIOL 152

NORETHIN ACET & ESTRAD-FE 146,147,148,149,150,151NORETHINDRONE & ETHESTRADIOL 146,147,149,150,151,152NORETHINDRONE & ETHINYL ESTRADIOL-FE 147,148,150,151NORETHINDRONE (CONTRACEPTIVE) 155,156NORETHINDRONE ACET & ETHESTRA 146,147,148,149,150NORETHINDRONE ACETATE 249NORETHINDRONE ACETATE-ETHINYLESTRADIOL 187NORETHINDRONE ACETATE-ETHINYL ESTRADIOL-FE 156,157NORETHINDRONE ACETATE-ETHINYL ESTRADIOL-FE FUM (BIPHASIC) 145NORETHINDRONE-ETH ESTRADIOL(TRIPHASIC) 156,157NORGESTIMATE-ETHINYLESTRADIOL 147,149,150,151NORGESTIMATE-ETHINYL ESTRADIOL(TRIPHASIC) 156,157NORGESTREL & ETHINYLESTRADIOL 146,147,149,150Norpace CR 40NORTRIPTYLINE HCL 64Nortriptyline HCl 64Norvir 128Novavax COVID-19 Vaccine 275Novoeight 204,205Nucala 44Nucynta 25Nucynta ER 26Nurtec 227Nutropin AQ NuSpin 10 182Nutropin AQ NuSpin 20 182Nutropin AQ NuSpin 5 182Nuwiq 205,206NYSTATIN 77NYSTATIN (MOUTH-THROAT) 235NYSTATIN (TOPICAL) 165,166

NYSTATIN-TRIAMCINOLONE 166Nyvepria 213

OOB Complete/DHA 236OBETICHOLIC ACID 191Obizur 206Ocaliva 191OCTREOTIDE ACETATE 185,186Octreotide Acetate 185,186Odefsey 125ODEVIXIBAT 192,193Odomzo 100OFATUMUMAB (MS) 253Ofev 258OFLOXACIN 191Ofloxacin 191OFLOXACIN (OPHTH) 243OFLOXACIN (OTIC) 246Ogestrel 150OLANZAPINE 123OLANZAPINE PAMOATE 124OLAPARIB 111OLMESARTAN MEDOXOMIL 89OLMESARTAN MEDOXOMIL-AMLODIPINE-HYDROCHLOROTHIAZIDE 87OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE 88OLODATEROL HCL 43OLOPATADINE HCL 242OLOPATADINE HCL (NASAL) 239OLSALAZINE SODIUM 193Olumiant 9OMALIZUMAB 42OMEGA-3-ACID ETHYL ESTERS 80OMEPRAZOLE 269Omniflex Diaphragm 218OmniPod 5 Pack 222OmniPod Dash 5 Pack Pods 222OmniPod Dash System 222OmniPod Starter 222

Omnipred 245Omnitrope 183Omnitrope Pen 5 Inj Device 224On/Go Covid-19 Antigen Test 177ONDANSETRON 76ONDANSETRON HCL 76OneTouch Club Lancets Fine Pt 220OneTouch Delica Lancets 30G 221OneTouch Delica Lancets 33G 221OneTouch Delica Lancing Dev 221OneTouch Delica Plus Lancet30G 221OneTouch Delica Plus Lancet33G 221OneTouch Delica Plus Lancing 221OneTouch FinePoint Lancets 221OneTouch Ping Meter Remote 221OneTouch SureSoft Lancing Dev 221OneTouch Ultra 175OneTouch Ultra 2 221OneTouch Ultra Mini 221OneTouch UltraLink 221OneTouch UltraSoft Lancets 221OneTouch Verio 175,221OneTouch Verio Flex System 221OneTouch Verio IQ System 221OneTouch Verio Reflect 221OneTouch Verio Sync System 221Onfi 51Ongentys 116OPICAPONE 116OPIUM TINCTURE 74Opsumit 142OptiChamber Advantage-Lg Mask 226OptiChamber Advantage-Med Mask 226OptiChamber Advantage-Sm Mask 226OptiChamber Diamond 227OptiChamber Diamond-Lg Mask 227OptiChamber Diamond-Md Mask 227OptiChamber Diamond-Sm Mask 227Oravig 235Orencia 14Orencia ClickJect 15

Oriahnn 188Orilissa 182Orkambi 257,258ORPHENADRINE CITRATE 238ORPHENADRINE W/ ASPIRIN & CAFF 238Ortho Micronor 155Ortho Tri-Cyclen (28) 156Ortho Tri-Cyclen Lo 156Ortho-Cyclen (28) 150Ortho-Novum 1/35 (28) 150Ortho-Novum 7/7/7 (28) 156OSELTAMIVIR PHOSPHATE 133OSILODROSTAT PHOSPHATE 181OSIMERTINIB MESYLATE 99OSPEMIFENE 185Osphena 185Otezla 14Otiprio 246Otovel 246Otrexup 10OXANDROLONE 32OXAPROZIN 14OXAZEPAM 39OXCARBAZEPINE 53OXYBUTYNIN CHLORIDE 270OXYCODONE HCL 26,27,28OxyCODONE HCl ER 27OXYCODONE W/ ACETAMINOPHEN 30,31OXYCODONE-IBUPROFEN 31Oxycodone-Ibuprofen 31OxyCONTIN 27,28OXYMETHOLONE 32OXYMORPHONE HCL 28OxyMORphone HCl ER 28OZANIMOD HCL 256Ozempic (0.25 or 0.5 MG/DOSE) 69Ozempic (1 MG/DOSE) 69

PPALBOCICLIB 107PALIPERIDONE 118,119

PALIPERIDONE PALMITATE 118PALIVIZUMAB 246Palynziq 184Pancreaze 177,178PANCRELIPASE (LIPASE-PROTEASE-AMYLASE) 177,178PANOBINOSTAT LACTATE 100PANTOPRAZOLE SODIUM 269Paragard Intrauterine Copper 152PARICALCITOL 183PAROXETINE HCL 60,61PAROXETINE MESYLATE (VASOMOTOR) 256PASIREOTIDE DIASPARTATE 186PASIREOTIDE PAMOATE 186PATIROMER SORBITEX CALCIUM 235Paxlovid 131PAZOPANIB HCL 104Pediarix 267Pedvax HIB 272PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SODSULFATE 216PEG 3350-POTASSIUM CHLORIDE-SODBICARBONATE-SOD CHLORIDE 216PEGADEMASE BOVINE 7Peganone 57Pegasys 132Pegasys ProClick 132PEGFILGRASTIM-APGF 213PEGFILGRASTIM-BMEZ 213PEGFILGRASTIM-CBQV 213PEGFILGRASTIM-JMDB 212PEGINTERFERON ALFA-2A 132PEGINTERFERON ALFA-2B 132PEGINTERFERON BETA-1A 252,253PegIntron 132PEGVALIASE-PQPZ 184PEGVISOMANT 182Pemazyre 99,100PEMIGATINIB 99,100PENCICLOVIR 168PENICILLAMINE 232

PENICILLIN V POTASSIUM 248Penicillin V Potassium 248Pentacel 267PENTAMIDINE ISETHIONATE 34Pentasa 193PenTips 225PENTOSAN POLYSULFATE SODIUM 195PENTOXIFYLLINE 208PERAMPANEL 50PERINDOPRIL ERBUMINE 85,86PERMETHRIN 174PERPHENAZINE 122PERPHENAZINE-AMITRIPTYLINE 254Perphenazine-Amitriptyline 254PEXIDARTINIB HCL 104Pfizer COVID-19 Vac-TriS 5-11y 275Pfizer COVID-19 Vac-TriS 6m-4y 275Pfizer-BioNT COVID-19 Vac-TriS 275Pfizer-BioNTech COVID-19 Vacc 275Pharmacist Choice Lancets 221PHENAZOPYRIDINE HCL 196PHENELZINE SULFATE 59PHENOBARBITAL 214PHENOXYBENZAMINE HCL 87PHENYTOIN 57PHENYTOIN SODIUM EXTENDED 57Phoslyra 194Phospholine Iodide 241PHYTONADIONE 277Pifeltro 129PILOCARPINE HCL 241PILOCARPINE HCL (ORAL) 236PIMECROLIMUS 173PIMOZIDE 255Pimozide 255PINDOLOL 135PIOGLITAZONE HCL 73PIOGLITAZONE HCL-METFORMIN HCL 73Piqray (200 MG Daily Dose) 110Piqray (250 MG Daily Dose) 110Piqray (300 MG Daily Dose) 110

PIRFENIDONE 258PIROXICAM 14PITAVASTATIN CALCIUM 82Pixel COVID-19 PCR Home Test 177PLECANATIDE 191Plegridy 252Plegridy Starter Pack 252,253PNEUMOCOCCAL 13-VALENT CONJUGATEVACCINE 272PNEUMOCOCCAL 15-VALENT CONJUGATEVACCINE 272PNEUMOCOCCAL 20-VALENT CONJUGATEVACCINE 272PNEUMOCOCCAL VAC POLYVALENT 272Pneumovax 23 272PNV Folic Acid + Iron 236PNV Prenatal Plus Multivitamin 236PNV Tabs 29-1 236PNV-DHA+Docusate 237PODOFILOX 173POLIOVIRUS VACCINE, IPV 275POLYETHYLENE GLYCOL 3350 216POLYMYXIN B-TRIMETHOPRIM 241POMALIDOMIDE 101Pomalyst 101PONATINIB HCL 96,97PONESIMOD 256Ponvory 256Ponvory Starter Pack 256POSACONAZOLE 78POT PHOSPHATE MONOBASIC W/ SODPHOSPHATE DIBASIC & MONOBASIC 230POTASSIUM & SODIUM ACID PHOSPHATES 195POTASSIUM BICARBONATE 230,231POTASSIUM CHLORIDE 230,231Potassium Chloride ER 231POTASSIUM CHLORIDE MICROENCAPSULATEDCRYSTALS ER 230,231POTASSIUM CITRATE (ALKALINIZER) 195POTASSIUM PHOSPHATE MONOBASIC 230Pradaxa 50

PRALSETINIB 105PRAMIPEXOLE DIHYDROCHLORIDE 114,115PRAMLINTIDE ACETATE 65PRASUGREL HCL 209PRAVASTATIN SODIUM 82PRAZIQUANTEL 34PRAZOSIN HCL 90Pred Mild 245PREDNICARBATE 172Prednicarbate 172PREDNISOLONE 159PrednisoLONE 159PrednisoLONE Acetate 245PREDNISOLONE ACETATE (OPHTH) 245PrednisoLONE Acetate P-F 245PREDNISOLONE SODIUM PHOSPHATE 159PrednisoLONE Sodium Phosphate 159,245PREDNISOLONE SODIUM PHOSPHATE(OPHTH) 245PREDNISONE 159,160PredniSONE 160PredniSONE Intensol 160PREGABALIN 53,54PREGABALIN (ONCE-DAILY) 254PreHevbrio 275Premarin 190,277Prempro 188PRENAT VIT W/ IRON CARBONYL-FE ASP GLYC-FA-OMEGA FATTY ACID 236PreNata 236Prenatabs Rx 237Prenatal 237Prenatal 19 237PRENATAL MV & MIN W/FE BISGLYC-FE PROTSUCC-FA-CA-OMEGA 3 237PRENATAL MV & MIN W/FE FUMARATE-FA-DHA 237Prenatal Plus Iron 237PRENATAL VIT W/ FERROUS FUMARATE-FOLICACID 236,237

PRENATAL VIT W/ IRON CARBONYL-FOLICACID 236,237Prenatal Vitamin Plus Low Iron 237PRENATAL W/ VIT B2-B6-B12-CHOLECALCIFEROL-FOLIC ACID 237PRENATAL W/O VIT A W/ FE FUMARATE-DSS-FA-DHA 237PRENATAL WITHOUT A VIT W/ FE FUMARATE-FOLIC ACID 236PRENATAL WITHOUT A W/ FE FUMARATE-LMETHYLFOLATE-FA-DHA 237Prepopik 216PreTAB 237PRETOMANID 93Pretomanid 93Prevnar 13 272Prevnar 20 272Prezcobix 125Prezista 128Priftin 93PRIMAQUINE PHOSPHATE 92Primaquine Phosphate 92PRIMIDONE 54Primsol 34Pro Comfort Pen Needles 225PROBENECID 196PROCARBAZINE HCL 107PROCHLORPERAZINE 121,122PROCHLORPERAZINE MALEATE 122Procrit 211PROGESTERONE 249PROGESTERONE (VAGINAL) 277Prolastin-C 257Promacta 213,214PROMETHAZINE HCL 79PROMETHAZINE W/CODEINE 161PROMETHAZINE-DM 161Promethazine-DM 161PROPAFENONE HCL 40PROPRANOLOL & HYDROCHLOROTHIAZIDE 91PROPRANOLOL HCL 135,136

Propranolol HCl 135PROPRANOLOL HCL SUSTAINED-RELEASEBEADS 135Propranolol-HCTZ 91PROPYLTHIOURACIL 260ProQuad 272PROTRIPTYLINE HCL 64PRUCALOPRIDE SUCCINATE 191Prudoxin 166PRUSSIAN BLUE INSOLUBLE (FERRICHEXACYANOFERRATE II) 75PSEUDOEPHED-BROMPHEN-DM 161Pulmicort Flexhaler 46Pulmozyme 258Purixan 95PYRAZINAMIDE 93PYRIDOSTIGMINE BROMIDE 92,93PYRIMETHAMINE 92

QQbrelis 86Qinlock 103Quadracel 267Quartette 154QUETIAPINE FUMARATE 120,121QuickVue At-Home Covid-19 Test 177QuickVue SARS Antigen Test 177QuilliChew ER 7Quillivant XR 7QUINAPRIL HCL 86QUINAPRIL-HYDROCHLOROTHIAZIDE 87QUINIDINE GLUCONATE 40QUINIDINE SULFATE 40QUININE SULFATE 92Qulipta 227Quzyttir 79Qvar 46Qvar RediHaler 46

RRABEPRAZOLE SODIUM 269

Radiogardase 75RALOXIFENE HCL 185RALTEGRAVIR POTASSIUM 126RAMELTEON 216RAMIPRIL 86RANITIDINE HCL 268RANOLAZINE 36RASAGILINE MESYLATE 112Rasuvo 10,11Rebif 253Rebif Rebidose 253Rebif Rebidose Titration Pack 253Rebif Titration Pack 253Rebinyn 206Recombinate 206Recombivax HB 275Rectiv 33RediTrex 11REGORAFENIB 103Regranex 175Relenza Diskhaler 133REPAGLINIDE 70Repatha 84Repatha Pushtronex System 84Repatha SureClick 84Rescriptor 129Restasis 243Restasis Multidose 243Retacrit 211,212RETAPAMULIN 165Retevmo 105REVEFENACIN 44Revlimid 233Rexulti 123Reyataz 128Reyvow 229Rezurock 235Rhopressa 244Ribasphere 132Ribasphere RibaPak (1000 Pack) 132Ribasphere Ribapak (1200 Pack) 132

Ribasphere RibaPak (800 Pack) 132RIBAVIRIN (HEPATITIS C) 132Ridaura 11RIFABUTIN 93RIFAMPIN 93RIFAPENTINE 93Rifater 93RIFAXIMIN 34RILPIVIRINE HCL 128RILUZOLE 239RiMANTAdine HCl 133RIMANTADINE HYDROCHLORIDE 133RIMEGEPANT SULFATE 227Rinvoq 9RIOCIGUAT 141RIPRETINIB 103RISANKIZUMAB-RZAA 167RISDIPLAM 239RISEDRONATE SODIUM 181RisperDAL Consta 119RISPERIDONE 119RisperiDONE 119RISPERIDONE MICROSPHERES 119RITONAVIR 128RIVAROXABAN 48RIVASTIGMINE 250RIVASTIGMINE TARTRATE 250,251Rixubis 206,207RIZATRIPTAN BENZOATE 228rocklatan 243ROFLUMILAST 45ROLAPITANT HCL 77ROMOSOZUMAB-AQQG 185ROPINIROLE HYDROCHLORIDE 115ROSUVASTATIN CALCIUM 83Rotarix 276RotaTeq 276ROTAVIRUS VACCINE, LIVE ORAL 276ROTAVIRUS VACCINE, LIVE ORALPENTAVALENT 276ROTIGOTINE 114

Rozlytrek 105RUFINAMIDE 54Rukobia 126RUXOLITINIB PHOSPHATE 108Ruzurgi 93Rybelsus 69,70

SSACUBITRIL-VALSARTAN 141Safyral 151SALICYLIC ACID 173SALMETEROL XINAFOATE 43SALSALATE 16Sancuso 76Santyl 172SAPROPTERIN DIHYDROCHLORIDE 184,185SAQUINAVIR MESYLATE 127SATRALIZUMAB-MWGE 234Savaysa 48Savella 251Savella Titration Pack 251Scemblix 97SCOPOLAMINE 76Seasonique 154SECUKINUMAB 167SEGESTERONE ACETATE-ETHINYL ESTRADIOL 152SELEGILINE 59SELEGILINE HCL 113SELENIUM SULFIDE 168SELEXIPAG 142,143SELINEXOR 105,106SELPERCATINIB 105SELUMETINIB SULFATE 101Selzentry 126SEMAGLUTIDE 69,70Serevent Diskus 43SERTACONAZOLE NITRATE 172SERTRALINE HCL 61SEVELAMER CARBONATE 194Shingrix 276Signifor 186

Signifor LAR 186SILDENAFIL CITRATE (PULMONARYHYPERTENSION) 142SILODOSIN 195SILVER SULFADIAZINE 169Simbrinza 240Simplicity COVID-19 At-Home 177Simponi 9SIMVASTATIN 83SINECATECHINS 164SIPONIMOD FUMARATE 256SIROLIMUS 234Sirturo 93SITAGLIPTIN PHOSPHATE 66SITAGLIPTIN-METFORMIN HCL 67Sivextro 36Skyla 155Skyrizi 167Skyrizi (150 MG Dose) 167Slynd 156SODIUM CHLORIDE (INHALANT) 161SODIUM FLUORIDE 229,230SODIUM PICOSULFATE-MAGNESIUM OXIDE-ANHYDROUS CITRIC ACID 216SODIUM POLYSTYRENE SULFONATE 234,235SODIUM SULFATE-POTASSIUM SULFATE-MAGNESIUM SULFATE 216SODIUM ZIRCONIUM CYCLOSILICATE 235Sofia SARS Antigen FIA 177Sofia2 SARS Antigen FIA 177SOFOSBUVIR-VELPATASVIR 131Sofosbuvir-Velpatasvir 131SOLIFENACIN SUCCINATE 270,271Soliqua 70SOLRIAMFETOL HCL 4,5SOMATROPIN 182,183Somavert 182SONIDEGIB PHOSPHATE 100SORAFENIB TOSYLATE 103SOTALOL HCL 136SOTALOL HCL (AFIB/AFL) 136

SOTORASIB 101Sotylize 136SPACER/AEROSOL-HOLDINGCHAMBERS 225,226,227SPINOSAD 174Spinosad 174Spiriva HandiHaler 44Spiriva Respimat 44SPIRONOLACTONE 179SPIRONOLACTONE & HYDROCHLOROTHIAZIDE179Spravato (56 MG Dose) 59Spravato (84 MG Dose) 59Sprycel 97SPS 235STAVUDINE 130Stavudine 130Stelara 167,168Stimate 187Stiolto Respimat 42Stivarga 103Stribild 125Striverdi Respimat 43Sublocade 32Subsys 28,29SUCCIMER 74SUCRALFATE 268SUGAMMADEX SODIUM 75SULCONAZOLE NITRATE 172SULFACETAMIDE SOD-PREDNISOLONE 244SULFACETAMIDE SODIUM (ACNE) 162SULFACETAMIDE SODIUM (OPHTH) 245SULFACETAMIDE SODIUM W/ SULFUR 162,163Sulfacetamide-Prednisolone 244SULFADIAZINE 258SULFAMETHOXAZOLE-TRIMETHOPRIM 35Sulfamylon 169SULFASALAZINE 193SULINDAC 14SUMATRIPTAN 228,229SUMATRIPTAN SUCCINATE 229SUMAtriptan Succinate 229

SUNITINIB MALATE 103,104Sunosi 4,5Suprep Bowel Prep Kit 216Sustol 76SUVOREXANT 215Symax Duotab 268Symbicort 42Symdeko 258Symjepi 277SymlinPen 120 65SymlinPen 60 65Symproic 194Symtuza 125Synagis 246Synera 175Synjardy 71Synjardy XR 72Synthroid 264SYRINGE/NEEDLE (DISP) 12 ML 224SYRINGE/NEEDLE (DISP) 6 ML 224

TTabloid 95Tabrecta 101TACROLIMUS 233,234TACROLIMUS (TOPICAL) 173TADALAFIL 143TADALAFIL (PULMONARY HYPERTENSION) 142Tafinlar 98TAFLUPROST 245Tagrisso 99TALAZOPARIB TOSYLATE 111Taltz 168Talzenna 111TAMOXIFEN CITRATE 94TAMSULOSIN HCL 195TAPENTADOL HCL 25,26Targretin 175Tasigna 97,98TAVABOROLE 174Taytulla 151

TAZAROTENE 166,167TAZEMETOSTAT HBR 102Tazorac 166,167Tazverik 102TBO-FILGRASTIM 212TDVAX 267TEDIZOLID PHOSPHATE 36TEGretol 54TEGretol-XR 55TELMISARTAN 89,90TELMISARTAN-AMLODIPINE 88TELMISARTAN-HYDROCHLOROTHIAZIDE 88,89TEMAZEPAM 214,215Temixys 125TEMOZOLOMIDE 108Tenivac 267TENOFOVIR DISOPROXIL FUMARATE 130Tepmetko 102TEPOTINIB HCL 102TERAZOSIN HCL 91TERBINAFINE HCL 77TERBUTALINE SULFATE 44TERCONAZOLE VAGINAL 276TERIFLUNOMIDE 251TERIPARATIDE (RECOMBINANT) 184Teriparatide (Recombinant) 184TESTOSTERONE 32,33Testosterone 32,33TESTOSTERONE CYPIONATE 32,33Testosterone Cypionate 33TESTOSTERONE ENANTHATE 33Testosterone Enanthate 33TETANUS TOXOID-DIPHTHERIA-ACELLULARPERTUSSIS ADSORB (TDAP) 266TETANUS-DIPHTHERIA TOXOIDS (TD) 267Tetanus-Diphtheria Toxoids Td 267TETRABENAZINE 251TETRACYCLINE HCL 260TEZACAFTOR-IVACAFTOR 258THALIDOMIDE 231Thalomid 231

Theo-24 46,47THEOPHYLLINE 46,47Theophylline ER 47THIOGUANINE 95THIORIDAZINE HCL 122THIOTHIXENE 124THYROID 260,261,263,264,265,266Thyrolar-1 265Thyrolar-1/2 265Thyrolar-1/4 265Thyrolar-2 265Thyrolar-3 265TIAGABINE HCL 57TICAGRELOR 208TIMOLOL 240TIMOLOL MALEATE 136Timolol Maleate 136TIMOLOL MALEATE (OPHTH) 240TINIDAZOLE 34TIOTROPIUM BROMIDE MONOHYDRATE 44TIOTROPIUM BROMIDE-OLODATEROL HCL 42TIPRANAVIR 127Tivicay 127Tivicay PD 127TIVOZANIB HCL 103TIZANIDINE HCL 238Tobi Podhaler 7TobraDex 244TOBRAMYCIN 7Tobramycin 7TOBRAMYCIN (OPHTH) 243TOBRAMYCIN SULFATE 7,8Tobramycin Sulfate 7TOBRAMYCIN-DEXAMETHASONE 244TOCILIZUMAB 11,12TOFACITINIB CITRATE 9,10TOLCAPONE 113TOLMETIN SODIUM 14Tolmetin Sodium 14TOLTERODINE TARTRATE 270,271TOLVAPTAN 185

Tolvaptan 185TOPIRAMATE 52,55TOREMIFENE CITRATE 95TORSEMIDE 179Toviaz 271Tradjenta 66TRAMADOL HCL 29,30TraMADol HCl ER 30TraMADol HCl ER (Biphasic) 29TRAMADOL-ACETAMINOPHEN 32TRAMETINIB DIMETHYL SULFOXIDE 101TRANDOLAPRIL 86TRANDOLAPRIL-VERAPAMIL HCL 84,85Trandolapril-Verapamil HCl ER 84,85TRANEXAMIC ACID 214TRANYLCYPROMINE SULFATE 59TRAVOPROST 245TRAZODONE HCL 61Trecator 93Trelegy Ellipta 42Tremfya 168Tresiba 69Tresiba FlexTouch 69Tretin-X 164TRETINOIN 163,164TRETINOIN (CHEMOTHERAPY) 111Tretinoin (Emollient) 164TRETINOIN (FACIAL WRINKLES) 164TRETINOIN MICROSPHERE 164Trexall 95Tri-Norinyl (28) 157TRIAMCINOLONE ACETONIDE 159TRIAMCINOLONE ACETONIDE (MOUTH) 236TRIAMCINOLONE ACETONIDE (TOPICAL) 172TRIAMTERENE 179TRIAMTERENE & HYDROCHLOROTHIAZIDE 179TRIAZOLAM 215TRIENTINE HCL 232TRIFLUOPERAZINE HCL 122TRIFLURIDINE 243Trifluridine 243

TRIFLURIDINE-TIPIRACIL 106TRIHEPTANOIN 240TRIHEXYPHENIDYL HCL 112Trijardy XR 70,71Trikafta 258TRIMETHOBENZAMIDE HCL 76TRIMETHOPRIM 34Trimethoprim 34TRIMETHOPRIM HCL 34TRIMIPRAMINE MALEATE 64Trinatal Rx 1 237Trintellix 61Triumeq 126Triveen-Duo DHA 237TROPICAMIDE 241TROSPIUM CHLORIDE 271TRUEplus Lancets 26G 222TRUEplus Lancets 28G 222TRUEplus Lancets 30G 222TRUEplus Lancets 33G 222TRUEplus Safety Lancets 28G 222Trulance 191Trulicity 70Trumenba 272Truseltiq (100MG Daily Dose) 100Truseltiq (125MG Daily Dose) 100Truseltiq (50MG Daily Dose) 100Truseltiq (75MG Daily Dose) 100TUCATINIB 96Tukysa 96Turalio 104Twinrix 272Twirla 152Tyblume 151Tybost 131Tymlos 184TYPHOID VACCINE 272

UUbrelvy 227UBROGEPANT 227

Uceris 33,160Udenyca 213Ukoniq 104Ulesfia 174ULIPRISTAL ACETATE 153UltiCare Insulin Safety Syr 225Ultilet Insulin Syringe 225UMBRALISIB TOSYLATE 104UMECLIDINIUM BROMIDE 44UMECLIDINIUM-VILANTEROL 41UPADACITINIB 9Uptravi 142,143URSODIOL 191USTEKINUMAB 167,168

VVALACYCLOVIR HCL 133Valchlor 166VALGANCICLOVIR HCL 131VALPROATE SODIUM 58VALPROIC ACID 58VALSARTAN 90VALSARTAN-HYDROCHLOROTHIAZIDE 89Valtoco 10 MG Dose 51Valtoco 15 MG Dose 51Valtoco 20 MG Dose 51Valtoco 5 MG Dose 51Valved Holding Chamber 227VANCOMYCIN HCL 35Vandazole 276VANDETANIB 103Vantas 109Vaqta 276VARENICLINE TARTRATE 255,256Varenicline Tartrate 255,256VARICELLA VIRUS VACCINE LIVE 276Varivax 276Varubi (180 MG Dose) 77Vascepa 80Vaxelis 267Vaxneuvance 272

Veltassa 235VEMURAFENIB 98Venclexta 96VENETOCLAX 96VENLAFAXINE HCL 62,63Ventavis 141VERAPAMIL HCL 139,140Veregen 164Verzenio 107,108VESIcare LS 271Viberzi 192Victoza 70VIGABATRIN 57Viibryd 62Viibryd Starter Pack 62VILAZODONE HCL 62Vimpat 55,56Vinate One 237Viread 130VISMODEGIB 100Vitafol-OB+DHA 237VitaMedMD One Rx/Quatrefolic 237VitaMedMD RediChew Rx 237Vitathely with Ginger 237Vivitrol 75Vivotif 272Vizimpro 99VOCLOSPORIN 232VORAPAXAR SULFATE 209VORICONAZOLE 78VORINOSTAT 100VORTIOXETINE HBR 61Votrient 104Vraylar 117Vumerity 253Vumerity (Starter) 253Vyvanse 4

WWARFARIN SODIUM 47,48Welireg 100

WesTab Plus 237Westhroid 265,266Wide-Seal Diaphragm 60 218Wide-Seal Diaphragm 65 218Wide-Seal Diaphragm 70 218Wide-Seal Diaphragm 75 218Wide-Seal Diaphragm 80 218Wide-Seal Diaphragm 85 219Wide-Seal Diaphragm 90 219Wide-Seal Diaphragm 95 219Wilate 207WP Thyroid 266

XXalkori 96Xarelto 48Xarelto Starter Pack 48Xcopri 56Xcopri (250 MG Daily Dose) 56Xcopri (350 MG Daily Dose) 56Xeljanz 9,10Xeljanz XR 10Xhance 239Xiaflex 233Xifaxan 34Xigduo XR 72Xiidra 241Xofluza (40 MG Dose) 133Xofluza (80 MG Dose) 133Xolair 42Xolegel 173Xpert Xpress SARS-CoV-2 177Xpovio (100 MG Once Weekly) 105Xpovio (40 MG Once Weekly) 105Xpovio (40 MG Twice Weekly) 105Xpovio (60 MG Once Weekly) 105Xpovio (60 MG Twice Weekly) 106Xpovio (80 MG Once Weekly) 106Xpovio (80 MG Twice Weekly) 106Xtandi 94Xultophy 70

Xyntha 207Xyntha Solofuse 207

YYasmin 28 151YAZ 152Yupelri 44

ZZAFIRLUKAST 45ZALEPLON 215ZANAMIVIR 133ZANUBRUTINIB 98Zarxio 213Zelapar 113Zelboraf 98Zemaira 257Zenpep 178Zeposia 256Zeposia 7-Day Starter Pack 256Zeposia Starter Kit 256ZIDOVUDINE 130Ziextenzo 213ZILEUTON 41Zioptan 245ZIPRASIDONE HCL 117Zirgan 243Zoladex 109Zolinza 100ZOLMITRIPTAN 229ZOLPIDEM TARTRATE 215Zonalon 166ZONISAMIDE 56Zontivity 209Zostavax 276ZOSTER VACCINE LIVE 276ZOSTER VACCINE RECOMBINANTADJUVANTED 276Zuplenz 76Zyban 256Zydelig 111

Zykadia 96ZyPREXA Relprevv 124

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Individual & Family Plans Preferred Drug List