Providence Medicare Advantage Plans 2021 Formulary (List

Providence Medicare Advantage Plans 2021 Formulary (List of Covered Drugs)

PLEASE READ THIS DOCUMENT CONTAINS INFORMATION ABOUT

THE DRUGS WE COVER IN OUR BRIDGE 1 + Rx (HMO-POS) BRIDGE 2 + Rx (HMO-POS) CHOICE + Rx 001 (HMO-POS) CHOICE + Rx 002 (HMO-POS) COMPASS + Rx (HMO-POS) COTTONWOOD + Rx (HMO-POS) ENRICH + Rx (HMO) HARBOR + Rx (HMO) LATITUDE + Rx (HMO-POS) PINE + Rx (HMO) PRIME + Rx (HMO) SUMMIT +Rx (HMO-POS) AND TIMBER + Rx (HMO) PLANS

Formulary ID 00021075 Version

This formulary was updated on For more recent information or other questions please contact Providence Health Assurance Customer Service at 503-574-8000 or 1-800-603-2340 or for TTY users 711 seven days a week between 8 am and 8 pm (Pacific Time) or visit ProvidenceHealthAssurancecom

H9047_2021AM04_C

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31

H9047_2021AM04_C ii

Providence Medicare Advantage Plans

2021 Formulary(List of Covered Drugs)

Note to existing members

This formulary has changed since last year Please review this document to make sure that it still contains the drugs you take

When this drug list (formulary) refers to ldquowerdquo ldquousrdquo or ldquoourrdquo it means Providence Health Assurance When it refers to ldquoplanrdquo or ldquoour planrdquo it means Providence Medicare Advantage Plans

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

You must generally use network pharmacies to use your prescription drug benefit Benefits formulary pharmacy network andor copaymentscoinsurance may change on January 1 2022 and from time to time during the year

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112021

What is the Providence Medicare Advantage Plans Formulary

A formulary is a list of covered drugs selected by Providence Medicare Advantage Plans in consultation

with a team of health care providers which represents the prescription therapies believed to be a

necessary part of a quality treatment program Providence Medicare Advantage Plans will generally

cover the drugs listed in our formulary as long as the drug is medically necessary the prescription is

filled at a Providence Medicare Advantage Plans network pharmacy and other plan rules are followed

For more information on how to fill your prescriptions please review your Evidence of Coverage

Can the Formulary (drug list) change

Most changes in drug coverage happen on January 1 but Providence Medicare Advantage Plans may

add or remove drugs on the Drug List during the year move them to different cost-sharing tiers or add

new restrictions We must follow the Medicare rules in making these changes

Changes that can affect you this year In the below cases you will be affected by coverage changes

during the year

+ New generic drugs We may immediately remove a brand name drug on our Drug List if we are

replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with

the same or fewer restrictions Also when adding the new generic drug we may decide to keep the

brand name drug on our Drug List but immediately move it to a different cost-sharing tier or add new

restrictions If you are currently taking that brand name drug we may not tell you in advance before

we make that change but we will later provide you with information about the specific change(s) we

have made

+ If we make such a change you or your prescriber can ask us to make an exception and continue

to cover the brand name drug for you The notice we provide you will also include information on

how to request an exception and you can also find information in the section below entitled ldquoHow

do I request an exception to the Providence Medicare Advantage Plansrsquo Formularyrdquo

+ Drugs removed from the market If the Food and Drug Administration deems a drug on our

formulary to be unsafe or the drugrsquos manufacturer removes the drug from the market we will

immediately remove the drug from our formulary and provide notice to members who take the drug

+ Other changes We may make other changes that affect members currently taking a drug For

instance we may add a generic drug that is not new to market to replace a brand name drug

currently on the formulary or add new restrictions to the brand name drug or move it to a different

cost sharing tier or both Or we may make changes based on new clinical guidelines If we remove

drugs from our formulary add prior authorization quantity limits andor step therapy restrictions on

a drug or move a drug to a higher cost-sharing tier we must notify affected members of the change

at least 30 days before the change becomes effective or at the time the member requests a refill of

the drug at which time the member will receive a 30-day supply of the drug at retail or mail-order or

31-day supply of the drug at long-term care (LTC)

+ If we make these other changes you or your prescriber can ask us to make an exception and

continue to cover the brand name drug for you The notice we provide you will also include

information on how to request an exception and you can also find information in the section below

entitled ldquoHow do I request an exception to the Providence Medicare Advantage Plansrsquo Formularyrdquo

H9047_2021AM04_C iii 11222021

H9047_2021AM04_C iv

Changes that will not affect you if you are currently taking the drug Generally if you are taking a drug on our 2021 formulary that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above This means these drugs will remain available at the same cost sharing and with no new restrictions for those members taking them for the remainder of the coverage year You will not get direct notice this year about changes that do not affect you However on January 1 of the next year such changes would affect you and it is important to check the Drug List for the new benefit year for any changes to drugs

The enclosed formulary is current as of To get updated information about the drugs covered by Providence Medicare Advantage Plans please contact us Our contact information appears on the front and back cover pages In the event of mid-year non-maintenance formulary changes we will either notify you via the Explanation of Benefits (EOBs) or errata sheet to notify you of changes

How do I use the Formulary

There are two ways to find your drug within the formulary

Medical Condition Alphabetical Listing

If you are not sure what category to look under you should look for your drug in the Index that begins on page The Index provides an alphabetical list of all of the drugs included in this document Both brand name drugs and generic drugs are listed in the Index Look in the Index and find your drug Next to your drug you will see the page number where you can find coverage information Turn to the page listed in the Index and find the name of your drug in the first column of the list

The formulary begins on page 1 The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat For example drugs used to treat a heart condition are listed under the category ldquoCardiovascular Agentsrdquo If you know what your drug is used for look for the category name in the list that begins on page Then look under the category name for your drug

What are generic drugs Providence Medicare Advantage Plans covers both brand name drugs and generic drugs A generic drug is approved by the FDA as having the same active ingredient as the brand name drug Generally generic drugs cost less than brand name drugs

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

+ Prior Authorization Providence Medicare Advantage Plans requires you or your physician to get prior authorization for certain drugs This means that you will need to get approval from Providence Medicare Advantage Plans before you fill your prescriptions If you donrsquot get approval Providence Medicare Advantage Plans may not cover the drug

+ Quantity Limits For certain drugs Providence Medicare Advantage Plans limits the amount of the drug that Providence Medicare Advantage Plans will cover For example Providence Medicare Advantage Plans provides 2 tablets per day per prescription for Xtampza ERreg This may be in addition to a standard one-month or three-month supply

111

11222021

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134

H9047_2021AM04_C v

+ Step Therapy In some cases Providence Medicare Advantage Plans requires you to first try certaindrugs to treat your medical condition before we will cover another drug for that condition Forexample if Drug A and Drug B both treat your medical condition Providence Medicare AdvantagePlans may not cover Drug B unless you try Drug A first If Drug A does not work for you ProvidenceMedicare Advantage Plans will then cover Drug B

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1 You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site We have posted on line documents that explain our prior authorization and step therapy restrictions You may also ask us to send you a copy Our contact information along with the date we last updated the formulary appears on the front and back cover pages

You can ask Providence Medicare Advantage Plans to make an exception to these restrictions or limits or for a list of other similar drugs that may treat your health condition See the section ldquoHow do I request an exception to the Providence Medicare Advantage Plansrsquo formularyrdquo on page (v) for information about how to request an exception

What if my drug is not on the Formulary If your drug is not included in this formulary (list of covered drugs) you should first contact Customer Service and ask if your drug is covered If you learn that Providence Medicare Advantage Plans does not cover your drug you have two options

+ You can ask Customer Service for a list of similar drugs that are covered by Providence MedicareAdvantage Plans When you receive the list show it to your doctor and ask him or her to prescribe asimilar drug that is covered by Providence Medicare Advantage Plans

+ You can ask Providence Medicare Advantage Plans to make an exception and cover your drug Seebelow for information about how to request an exception

How do I request an exception to the Providence Medicare Advantage Plansrsquo FormularyYou can ask Providence Medicare Advantage Plans to make an exception to our coverage rules There are several types of exceptions that you can ask us to make

+ You can ask us to cover a drug even if it is not on our formulary If approved this drug will be coveredat a pre-determined cost-sharing level and you would not be able to ask us to provide the drug at alower cost-sharing level

+ You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on thespecialty tier If approved this would lower the amount you must pay for your drug

+ You can ask us to waive coverage restrictions or limits on your drug For example for certain drugsProvidence Medicare Advantage Plans limits the amount of the drug that we will cover If your drughas a quantity limit you can ask us to waive the limit and cover a greater amount

Generally Providence Medicare Advantage Plans will only approve your request for an exception if the alternative drugs included on the planrsquos formulary the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition andor would cause you to have adverse medical effects

11222021

H9047_2021AM04_C vi

Level of care change Day supply

For members transitioning from a SNF to LTC 31-day supply

SNF to Home (Retail) 30-day supply

LTC-LTC 31-day supply

Hospital to Home (Retail) 30-day supply

For more information For more detailed information about your Providence Medicare Advantage Plans prescription drug

coverage please review your Evidence of Coverage and other plan materials

If you have questions about Providence Medicare Advantage Plans please contact us Our contact

information along with the date we last updated the formulary appears on the front and back cover

pages

If you have general questions about Medicare prescription drug coverage please call Medicare at

1-800-MEDICARE (1-800-633-4227) 24 hours a day7 days a week TTY users should call

1-877-486-2048 Or visit httpwwwmedicaregov

You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction

exception When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request Generally we must make

our decision within 72 hours of getting your prescriberrsquos supporting statement You can request an

expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by

waiting up to 72 hours for a decision If your request to expedite is granted we must give you a decision

no later than 24 hours after we get a supporting statement from your doctor or other prescriber

What do I do before I can talk to my doctor about changing my drugs or requesting an exception As a new or continuing member in our plan you may be taking drugs that are not on our formulary

Or you may be taking a drug that is on our formulary but your ability to get it is limited For example

you may need a prior authorization from us before you can fill your prescription You should talk to

your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary

exception so that we will cover the drug you take While you talk to your doctor to determine the right

course of action for you we may cover your drug in certain cases during the first 90 days you are a member of our plan

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited we will

cover a temporary 30-day supply If your prescription is written for fewer days wersquoll allow refills to provide

up to a maximum 30 day supply of medication After your first 30-day supply we will not pay for these

drugs even if you have been a member of the plan less than 90 days

If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if

your ability to get your drugs is limited but you are past the first 90 days of membership in our plan we

will cover a 31-day emergency supply of that drug while you pursue a formulary exception

11222021

H9047_2021AM04_C vii

Providence Medicare Advantage Plansrsquo Formulary The formulary that begins on page 1 provides coverage information about some of the drugs covered by Providence Medicare Advantage Plans If you have trouble finding your drug in the list turn to the Index that begins on page The first column of the chart lists the drug name Brand name drugs are capitalized (eg JANUVIAreg) and generic drugs are listed in lower-case italics (eg lisinopril)

The second column of the chart lists the Drug Tier The Drug Tier name lets you know the amount you will pay at the pharmacy

+ Tier 1 is the lowest cost share tier and you will pay your preferred generic copay

+ Tier 2 you will pay your generic drug copay

+ Tier 3 you will pay your preferred brand name drug copay

+ Tier 4 you will pay your non-preferred drug copay

+ Tier 5 is the highest cost share tier and you will pay your specialty coinsurance

Please note that the brand and generic status of a drug may be different during the Coverage Gap and Catastrophic Coverage Phases as determined by the Food and Drug Administration (FDA) regulatory status

The information in the RequirementsLimits column tells you if Providence Medicare Advantage Plans has any special requirements for coverage of your drug

111

11222021

H9047_2021AM04_C viii

COVERAGE NOTES ABBREVIATIONS The following abbreviations may be found within the body of this document

ABBREVIATION DESCRIPTION EXPLANATION

Utilization Management Restrictions

PA Prior Authorization Restriction

You (or your physician) are required to get prior authorization from Providence Medicare Advantage Plans before you fill your prescription for this drug Without prior approval Providence Medicare Advantage Plans may not cover this drug

QL Quantity Limit Restriction

Providence Medicare Advantage Plans limits the amount of this drug that is covered per prescription or within a specific time frame

ST Step Therapy Restriction

Before Providence Medicare Advantage Plans will provide coverage for this drug you must first try another drug to treat your medical condition This drug may only be covered if the other drug does not work for you

Other Special Requirements for Coverage

LA Limited Access Drug

This prescription may be available only at certain pharmacies For more information consult your Provider and Pharmacy Directory or call Customer Service at 503-574-8000 or 1-800-603-2340 seven days a week between 8 am and 8 pm (Pacific Time) TTY users should call 711

11222021

Non‐discrimination Statement Providence Health Plan and Providence Health Assurance comply with applicable Federal civil rights laws and do not discriminate on the basis of race color national origin age disability sexual orientation religion gender identity marital status or sex Providence Health Plan and Providence Health Assurance donot exclude people or treat them differently because of race color national origin age disability sexual orientation religion gender identity marital status or sex Providence Health Plan and Providence HealthAssurance

Provide free aids and services to people with disabilities to communicate effectively with us suchaso Qualified sign language interpreterso Written information in other formats (large print audio accessible electronic formats other

formats)

Provide free language services to people whose primary language is not English such aso Qualified interpreterso Information written in other languages

If you are a Medicare member who needs these services call 503‐574‐8000 or 1‐800‐603‐2340 All other members can call 503‐574‐7500 or 1‐800‐878‐4445 Hearing impaired members may call our TTY line at 711

If you believe that Providence Health Plan or Providence Health Assurance has failed to provide these services or discriminated in another way on the basis of race color national origin age disability sexual orientation religion gender identity marital status or sex you can file a grievance with our Non‐discrimination Coordinator by mail

Providence Health Plan and Providence Health Assurance Attn Non‐discrimination Coordinator

PO Box 4158 Portland OR 97208‐4158

If you need help filing a grievance and you are a Medicare member call 503‐574‐8000 or 1‐800‐ 603‐2340 All other members can call 503‐574‐7500 or 1‐800‐878‐4445 (TTY line at 711) for assistance You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at

US Department of Health and Human Services 200 Independence Avenue SW ‐ Room 509F HHH Building Washington DC 20201 1‐800‐368‐1019 1‐800‐537‐7697 (TTY)

Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language Access Information

ATTENTION If you speak English language assistance services free of charge are available to you Call 1‐800‐603‐2340 (TTY 711)

Spanish ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1‐800‐603‐2340 (TTY 711)

Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1‐800‐603‐ 2340

(TTY 711）

Vietnamese CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1‐800‐603‐2340 (TTY 711)

Korean 주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다

1‐800‐603‐2340 (TTY 711) 번으로 전화해 주십시오

Russian ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните 1‐800‐603‐2340 (телетайп 711)

Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1‐800‐603‐2340 (TTY 711)

Ukrainian УВАГА Якщо ви розмовляєте українською мовою ви можете звернутися до безкоштовної служби мовної підтримки Телефонуйте за номером 1‐800‐603‐2340 (телетайп 711)

Mon-Khmer Cambodian បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន លគអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-800-603-2340 (TTY 711)

Japanese 注意事項日本語を話される場合無料の言語支援をご利用いただけます1‐800‐603‐2340

（TTY711）までお電話にてご連絡ください

Amharic ማስታወሻ የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው

ቁጥር ይደውሉ 1‐800‐603‐2340 (መስማት ለተሳናቸው 711)

Cushite (Oromo) XIYYEEFFANNAA Afaan dubbattu Oroomiffa tajaajila gargaarsa afaanii kanfaltiidhaan ala ni argama Bilbilaa 1‐800‐603‐2340 (TTY 711)

Arabic

2340-603-800-1 بالمجان اتصل برقمملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك

(TTY 711) )رقم هاتف الصم والبكم

Punjabi ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧਵਿ ਚ ਸਹਾਇਤਾ ਸਵਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-800-603-2340 (TTY 711) ਤ ਕਾਲ ਕਰ

German ACHTUNG Wenn Sie Deutsch sprechen stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfuumlgung Rufnummer 1-800-603-2340 (TTY 711)

Laotian ໂປດຊາບ ຖ າວ າ ທ ານເວ າພາສາ ລາວ ການບ ລການຊ ວຍເຫ ອດ ານພາສາ

ໂດຍ ບເສ ຽຄ າ ແມ ນມພ ອມໃຫ ທ ານ ໂທຣ 1-800-603-2340 (TTY 711)

Romanian ATENȚIE Dacă vorbiți limba romacircnă vă stau la dispoziție servicii de asistență lingvistică gratuit Sunați la 1-800-603-2340 (TTY 711)

French ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 1-800-603-2340 (ATS 711)

Thai เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-800-603-2340 (TTY 711)

Persian

شمای برا گانيرا بصورتی زبان لاتیتسه دیکنی م گفتگو فارسی زبان به اگر توجه

ديریبگ تماس

1-800-603-2340 (TTY 711) با باشدی م فراهم

(082021) H9047_2021RCGA03_C

PROVIDENCE MEDICARE ADVANTAGE PLANS 2021 FORMULARY (List ofCovered Drugs)

Drug Name Drug Tier RequirementsLimits

ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGScataflam 2-Generic

celecoxib 2-Generic

diclofenac potassium 50 mg tablet 2-Generic

diclofenac sodium (25 mg tablet dr 50mg tablet dr 75 mg tablet dr 100 mgtab er 24h)

3-Preferred Brand

diclofenac sodiummisoprostol 4-Non-PreferredDrug

diflunisal 3-Preferred Brand

etodolac (200 mg capsule 300 mgcapsule 400 mg tab er 24h 500 mg taber 24h 600 mg tab er 24h)

4-Non-PreferredDrug

etodolac (400 mg tablet 500 mg tablet) 3-Preferred Brand

flurbiprofen 3-Preferred Brand

ibu 2-Generic

ibuprofen (100 mg5ml oral susp 400mg tablet 600 mg tablet 800 mgtablet)

2-Generic

indomethacin (25 mg capsule 50 mgcapsule 75 mg capsule er)

2-Generic

ketoprofen (25 mg capsule 50 mgcapsule 75 mg capsule)

4-Non-PreferredDrug

KETOROLAC TROMETHAMINE 1575 MGSPRAY

5-Specialty PA QL (5 PER 30 OVER TIME)

meclofenamate sodium 4-Non-PreferredDrug

meloxicam 2-Generic

nabumetone 2-Generic

naproxen (250 mg tablet 375 mgtablet 375 mg tablet dr 500 mg tabletdr 500 mg tablet)

2-Generic

You can find information on what the symbols and abbreviationson this table mean by going to the Introduction

1


Drug Name Drug Tier RequirementsLimitsnaproxen 125 mg5ml oral susp 4-Non-Preferred

Drug

naproxen sodium 275 mg tablet 2-Generic

naproxen sodium 550 mg tablet 3-Preferred Brand

piroxicam 2-Generic

SPRIX 5-Specialty PA LA QL (5 PER 30 OVER TIME)

sulindac 2-Generic

tolmetin sodium 4-Non-PreferredDrug

OPIOID ANALGESICS LONG-ACTINGBELBUCA 4-Non-Preferred

DrugPA

buprenorphine 4-Non-PreferredDrug

PA QL (4 PER 28 OVER TIME)

buprenorphine hcl (75 mcg film 150mcg film 300 mcg film 450 mcg film600 mcg film 750 mcg film 900 mcgfilm)

4-Non-PreferredDrug

PA

fentanyl (12 mcghr patch td72 25mcghr patch td72 50mcghr patchtd72 75mcghr patch td72 100 mcghrpatch td72)

3-Preferred Brand PA QL (15 PER 30 OVER TIME)

hydrocodone bitartrate (10 mg cap er12h 15 mg cap er 12h 20 mg cap er12h 30 mg cap er 12h 40 mg cap er12h 50 mg cap er 12h)

4-Non-PreferredDrug

PA QL (2 PER 1 DAY)

levorphanol tartrate 2 mg tablet 4-Non-PreferredDrug

PA QL (4 PER 1 DAY)

methadone hcl (5 mg5 ml solution 5mg tablet 10 mg5 ml solution 10 mgtablet)

2-Generic PA

morphine sulfate (15 mg tablet er 30mg tablet er 60 mg tablet er)

2-Generic QL (3 PER 1 DAY)

morphine sulfate 100 mg tablet er 2-Generic QL (2 PER 1 DAY)


2


Drug Name Drug Tier RequirementsLimitstramadol hcl (100 mg tbmp 24hr 100mg tab er 24h 200 mg tab er 24h)

3-Preferred Brand

tramadol hcl (200 mg tbmp 24hr 300mg tab er 24h 300 mg tbmp 24hr)

4-Non-PreferredDrug

XTAMPZA ER 4-Non-PreferredDrug

PA QL (2 PER 1 DAY)

OPIOID ANALGESICS SHORT-ACTINGacetaminophen with codeine phosphate(120-12mg5 solution 300mg125solution 300mg-30mg tablet 300mg-60mg tablet 300mg-15mg tablet)

2-Generic

ascomp with codeine 4-Non-PreferredDrug

butalbitacetamincaffcodeine 50-325-30 capsule

4-Non-PreferredDrug

butalbitalaspirincaffeine 50-325-40capsule

3-Preferred Brand

butorphanol tartrate 10 mgml spray 4-Non-PreferredDrug

codeinephosphatebutalbitalaspirincaffeine

4-Non-PreferredDrug

codeine sulfate 4-Non-PreferredDrug

endocet 2-Generic

fentanyl citrate (200 mcg lozenge hd400 mcg lozenge hd 600 mcg lozengehd 800 mcg lozenge hd 1200 mcglozenge hd 1600 mcg lozenge hd)

4-Non-PreferredDrug

PA QL (4 PER 1 DAY)

hydrocodone bitartrateacetaminophen(25-1085 solution 5-217mg10solution 75-32515 solution)

3-Preferred Brand

hydrocodone bitartrateacetaminophen(5 mg-325mg tablet 75-325 mg tablet10mg-325mg tablet)

2-Generic

hydrocodoneibuprofen 75-200 mgtablet

2-Generic


3


Drug Name Drug Tier RequirementsLimitshydromorphone hcl (2 mg tablet 4 mgtablet 8 mg tablet)

2-Generic

hydromorphone hcl 1 mgml liquid 4-Non-PreferredDrug

hydromorphone hclpf (10 mgmlampul 10 mgml vial)

4-Non-PreferredDrug

lorcet 2-Generic

lorcet hd 2-Generic

morphine sulfate (10 mg5 ml solution15 mg tablet 20 mg5 ml solution 30mg tablet 100 mg5ml solution)

2-Generic

morphine sulfate (2 mgml cartridge 2mgml syringe 4 mgml syringe 4mgml cartridge)

4-Non-PreferredDrug

oxycodone hcl (5 mg capsule 5 mgtablet 10 mg tablet 15 mg tablet 20mg tablet 30 mg tablet)

2-Generic

oxycodone hcl (5 mg5 ml solution 20mgml oral conc)

4-Non-PreferredDrug

oxycodone hclacetaminophen (25-325mg tablet 5 mg-325mg tablet 75-325mg tablet 10mg-325mg tablet)

2-Generic

oxycodone hclaspirin 4-Non-PreferredDrug

oxymorphone hcl (5 mg tablet 10 mgtablet)

4-Non-PreferredDrug

tramadol hcl 50 mg tablet 2-Generic

tramadol hclacetaminophen 2-Generic

ANESTHETICS

LOCAL ANESTHETICSglydo 2-Generic

lidocaine 5 adh patch 4-Non-PreferredDrug

PA


4


Drug Name Drug Tier RequirementsLimitslidocaine 5 oint (g) 4-Non-Preferred

DrugPA TO CONFIRM PART D COVERAGE

lidocaine hcl (2 jelly(ml) 2 solution2 jelpf app 40 mgml solution)

2-Generic

lidocaine hcl (5 mgml vial 20 mgmlvial)

4-Non-PreferredDrug

lidocaine hclpf (5 mgml vial 20 mgmlvial)

4-Non-PreferredDrug

lidocaineprilocaine 4-Non-PreferredDrug

PA TO CONFIRM PART D COVERAGE

ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTSANTI-CRAVINGacamprosate calcium 2-Generic

disulfiram 2-Generic

naltrexone hcl 2-Generic

OPIOID DEPENDENCE TREATMENTSbuprenorphine hcl (03 mgml cartridge03 mgml vial)

4-Non-PreferredDrug

buprenorphine hcl 2 mg tab subl 1-PreferredGeneric

QL (4 PER 1 DAY)


QL (3 PER 1 DAY)

buprenorphine hclnaloxone hcl(naloxone 2 mg-05mg film naloxone4mg-1mg film naloxone 8 mg-2 mgfilm naloxone 12 mg-3 mg film)


buprenorphine hclnaloxone hcl 2 mg-05mg tab subl

1-PreferredGeneric

QL (4 PER 1 DAY)


1-PreferredGeneric

QL (3 PER 1 DAY)

LUCEMYRA 4-Non-PreferredDrug

ST QL (224 PER 90 OVER TIME)


5



OPIOID REVERSAL AGENTSKLOXXADO 3-Preferred Brand

naloxone hcl (04 mgml vial 04 mgmlcartridge 1 mgml syringe)

1-PreferredGeneric

naloxone hcl 2 mg04ml auto injct 3-Preferred Brand

NARCAN 3-Preferred Brand

SMOKING CESSATION AGENTSbupropion hcl 150 mg tab er 12h 2-Generic

CHANTIX STARTING MONTH BOX 3-Preferred Brand

NICOTROL 4-Non-PreferredDrug

NICOTROL NS 4-Non-PreferredDrug

varenicline tartrate 3-Preferred Brand

ANTIBACTERIALS

AMINOGLYCOSIDESgentak 2-Generic

gentamicin in nacl iso-osm 100mg100ml piggyback

4-Non-PreferredDrug

gentamicin sulfate (01 oint (g) 01 cream (g))

3-Preferred Brand

gentamicin sulfate (20 mg2 ml vial 40mgml vial)

4-Non-PreferredDrug

gentamicin sulfate 03 drops 2-Generic

gentamicin sulfatepf 4-Non-PreferredDrug

neomycin sulfate 2-Generic

paromomycin sulfate 4-Non-PreferredDrug

streptomycin sulfate 4-Non-PreferredDrug


6


Drug Name Drug Tier RequirementsLimitstobramycin 03 drops 2-Generic

tobramycin sulfate (12 g vial 10 mgmlvial 40 mgml vial)

4-Non-PreferredDrug

TOBREX 03 EYE OINTMENT 4-Non-PreferredDrug

ANTIBACTERIALS OTHERAEMCOLO 4-Non-Preferred

DrugPA QL (12 PER 28 OVER TIME)

bacitracin 500 unitg oint (g) 4-Non-PreferredDrug

chloramphenicol sod succinate 4-Non-PreferredDrug

cleocin phos 300 mg2ml addvan 4-Non-PreferredDrug

clindacin etz 4-Non-PreferredDrug

clindacin p 4-Non-PreferredDrug

clindamycin hcl (75 mg capsule 150 mgcapsule 300 mg capsule)

2-Generic

clindamycin palmitate hcl 4-Non-PreferredDrug

clindamycin phosphate (1 foam 1 lotion 1 med swab 1 gel (gram) 1 solution 2 creamappl 150 mgmlvial)

4-Non-PreferredDrug

CLINDAMYCIN PHOSPHATE IN 09 SODIUM CHLORIDE

4-Non-PreferredDrug

clindamycin phosphatedextrose 5 inwater

4-Non-PreferredDrug

colistin (as colistimethate sodium) 4-Non-PreferredDrug

daptomycin 5-Specialty

erythromycin basebenzoyl peroxide 4-Non-PreferredDrug


7


Drug Name Drug Tier RequirementsLimitsFIRVANQ 25 MGML SOLUTION 4-Non-Preferred

Drug

fosfomycin tromethamine 4-Non-PreferredDrug

linezolid (100 mg5ml susp recon 600mg tablet)

4-Non-PreferredDrug

linezolid in dextrose 5 in water 4-Non-PreferredDrug

methenamine hippurate 4-Non-PreferredDrug

metronidazole (075 gel wappl 375mg capsule)

4-Non-PreferredDrug

metronidazole (250 mg tablet 500 mgtablet)

2-Generic

metronidazole in sodium chloride 4-Non-PreferredDrug

mupirocin 2 ointment 2-Generic

nitrofurantoin 4-Non-PreferredDrug

nitrofurantoin macrocrystal (50 mgcapsule 100 mg capsule)

2-Generic

nitrofurantoin macrocrystal 25 mgcapsule

4-Non-PreferredDrug

nitrofurantoinmonohydratemacrocrystals

2-Generic

polymyxin b sulfate 4-Non-PreferredDrug

SIVEXTRO 200 MG TABLET 5-Specialty QL (6 PER 30 OVER TIME)

SULFAMYLON 85 CREAM 4-Non-PreferredDrug

tigecycline 4-Non-PreferredDrug

tinidazole 4-Non-PreferredDrug


8


Drug Name Drug Tier RequirementsLimitstrimethoprim 2-Generic

vancomycin hcl (1 g vial 1 g vial port125 g vial 15 g vial 5 g vial 10 g vial50 mgml soln recon 125 mg capsule250 mg capsule 250 mg vial 500 mgvial 500 mg vial port 750 mg vial port750 mg vial)

4-Non-PreferredDrug

VANCOMYCIN IN 09 SODIUMCHLORIDE

4-Non-PreferredDrug

VANCOMYCIN IN 5 DEXTROSE INWATER

4-Non-PreferredDrug

VANCOMYCINWATER FOR INJ (PEG)750MG15L PIGGYBACK

4-Non-PreferredDrug

VANDAZOLE 4-Non-PreferredDrug

XIFAXAN 200 MG TABLET 4-Non-PreferredDrug

PA QL (3 PER 1 DAY)

XIFAXAN 550 MG TABLET 5-Specialty PA QL (3 PER 1 DAY)

BETA-LACTAM CEPHALOSPORINSAVYCAZ 5-Specialty

cefaclor (125 mg5ml susp recon 250mg5ml susp recon 250 mg capsule375 mg5ml susp recon 500 mgcapsule)

4-Non-PreferredDrug

cefadroxil (1 g tablet 250 mg5ml susprecon 500 mg capsule 500 mg5mlsusp recon)

4-Non-PreferredDrug

cefazolin sodium 4-Non-PreferredDrug

cefdinir (125 mg5ml susp recon 250mg5ml susp recon)

4-Non-PreferredDrug

cefdinir 300 mg capsule 2-Generic

cefepime hcl (1 g vial 2 g vial) 4-Non-PreferredDrug

CEFEPIME HCL IN DEXTROSE 5 INWATER

4-Non-PreferredDrug


9


Drug Name Drug Tier RequirementsLimitscefixime (100 mg5ml susp recon 200mg5ml susp recon 400 mg capsule)

4-Non-PreferredDrug

cefotaxime sodium 4-Non-PreferredDrug

cefotetan disodium 4-Non-PreferredDrug

cefoxitin sodium 4-Non-PreferredDrug

cefpodoxime proxetil (50 mg5 ml susprecon 100 mg tablet 100 mg5ml susprecon 200 mg tablet)

4-Non-PreferredDrug

cefprozil (125 mg5ml susp recon 250mg tablet 250 mg5ml susp recon 500mg tablet)

4-Non-PreferredDrug

ceftazidime 4-Non-PreferredDrug

ceftriaxone sodium 4-Non-PreferredDrug

ceftriaxone sodium in iso-osmoticdextrose (in 1 g50 ml piggyback in 1g50 ml frozpiggy in 2 g50 mlpiggyback in 2 g50 ml frozpiggy)

4-Non-PreferredDrug

cefuroxime axetil 2-Generic

cefuroxime sodium 4-Non-PreferredDrug

cephalexin (125 mg5ml susp recon250 mg tablet 250 mg5ml susp recon500 mg tablet 750 mg capsule)

4-Non-PreferredDrug

cephalexin (250 mg capsule 500 mgcapsule)

2-Generic

suprax (100 mg tablet 200 mg tablet) 4-Non-PreferredDrug

tazicef 4-Non-PreferredDrug

TEFLARO 4-Non-PreferredDrug


10


Drug Name Drug Tier RequirementsLimitsZERBAXA 5-Specialty

BETA-LACTAM OTHERaztreonam 4-Non-Preferred

Drug

ertapenem sodium 4-Non-PreferredDrug

imipenemcilastatin sodium 4-Non-PreferredDrug

meropenem 4-Non-PreferredDrug

MEROPENEM IN 09 SODIUMCHLORIDE

4-Non-PreferredDrug

BETA-LACTAM PENICILLINSamoxicillin (125 mg tab chew 125mg5ml susp recon 200 mg5ml susprecon 250 mg capsule 250 mg tabchew 250 mg5ml susp recon 400mg5ml susp recon 500 mg tablet 500mg capsule 875 mg tablet)

2-Generic

amoxicillinpotassium clavulanate (200-2855 susp recon 250-6255 susprecon 400-57mg5 susp recon 500-125mg tablet 600-4295 susp recon 875-125 mg tablet)

2-Generic

amoxicillinpotassium clavulanate (200-285mg tab chew 250-125 mg tablet400-57mg tab chew 1000-625 tab er12h)

4-Non-PreferredDrug

ampicillin sodium 4-Non-PreferredDrug

ampicillin sodiumsulbactam sodium 4-Non-PreferredDrug

ampicillin trihydrate 2-Generic

BICILLIN C-R 4-Non-PreferredDrug


11


Drug Name Drug Tier RequirementsLimitsBICILLIN L-A 4-Non-Preferred

Drug

dicloxacillin sodium 3-Preferred Brand

nafcillin sodium (1 g vial port 1 g vial 2g vial 10 g vial)

4-Non-PreferredDrug

oxacillin sodium 4-Non-PreferredDrug

OXACILLIN SODIUM IN ISO-OSMOTICDEXTROSE

4-Non-PreferredDrug

penicillin g potassium 4-Non-PreferredDrug

penicillin g procaine 12mm2 mlsyringe

4-Non-PreferredDrug

penicillin g sodium 4-Non-PreferredDrug

penicillin v potassium (125 mg5ml solnrecon 250 mg tablet 250 mg5ml solnrecon 500 mg tablet)

2-Generic

pfizerpen 4-Non-PreferredDrug

piperacillin sodiumtazobactam sodium 4-Non-PreferredDrug

MACROLIDESAZASITE 4-Non-Preferred

Drug

azithromycin (100 mg5ml susp recon200 mg5ml susp recon 500 mg vialport 500 mg vial)

4-Non-PreferredDrug

azithromycin (250 mg tablet 500 mgtablet 600 mg tablet)

2-Generic

clarithromycin (125 mg5ml susp recon250 mg5ml susp recon 500 mg tab er24h)

4-Non-PreferredDrug

clarithromycin (250 mg tablet 500 mgtablet)

2-Generic


12


Drug Name Drug Tier RequirementsLimitsDIFICID (40 MGML SUSPENSION 200MG TABLET)

5-Specialty

ery 3-Preferred Brand

erythrocin lactobionate (lact 500 mgvial 500 mg addvan vial)

4-Non-PreferredDrug

erythrocin stearate 4-Non-PreferredDrug

erythromycin base (250 mg tablet 250mg capsule dr 250 mg tablet dr 333mg tablet dr 500 mg tablet 500 mgtablet dr)

4-Non-PreferredDrug

erythromycin base 5 mggram oint (g) 2-Generic

erythromycin base in ethanol 2 gel(gram)

4-Non-PreferredDrug

erythromycin base in ethanol 2 solution

3-Preferred Brand

erythromycin ethylsuccinate (200mg5ml susp recon 400 mg tablet 400mg5ml susp recon)

4-Non-PreferredDrug

QUINOLONESciprofloxacin 500 mg5ml sus mc rec 4-Non-Preferred

Drug

ciprofloxacin hcl (03 drops 100 mgtablet 250 mg tablet 500 mg tablet750 mg tablet)

2-Generic

ciprofloxacin hcl 02 droperette 4-Non-PreferredDrug

ciprofloxacin lactatedextrose 5 inwater

4-Non-PreferredDrug

gatifloxacin 4-Non-PreferredDrug

levofloxacin (05 drops 250 mgtablet 500 mg tablet 750 mg tablet)

2-Generic

levofloxacin (25 mgml vial250mg10ml solution)

4-Non-PreferredDrug


13


Drug Name Drug Tier RequirementsLimitslevofloxacindextrose 5 in water 4-Non-Preferred

Drug

moxifloxacin hcl 05 drops 2-Generic

moxifloxacin hcl 400 mg tablet 4-Non-PreferredDrug

MOXIFLOXACIN HCL IN SODIUMACETATE AND SULFATEWATERISO-OSM

4-Non-PreferredDrug

moxifloxacin hcl in sodium chloride iso-osmotic

4-Non-PreferredDrug

ofloxacin (300 mg tablet 400 mgtablet)

4-Non-PreferredDrug

ofloxacin 03 drops 2-Generic

SULFONAMIDESSILVADENE 2-Generic

SILVER SULFADIAZINE 2-Generic

SSD 2-Generic

sulfacetamide sodium (10 drops 10 suspension 10 oint (g))

4-Non-PreferredDrug

sulfadiazine 4-Non-PreferredDrug

sulfamethoxazoletrimethoprim(400mg-80mg tablet 800-160 mgtablet)

2-Generic

sulfamethoxazoletrimethoprim (80-16mgml vial 200-40mg5 oral susp800-16020 oral susp)

4-Non-PreferredDrug

TETRACYCLINESavidoxy 2-Generic

demeclocycline hcl 4-Non-PreferredDrug

doxy 100 4-Non-PreferredDrug


14


Drug Name Drug Tier RequirementsLimitsdoxycycline hyclate (20 mg tablet 50mg capsule 100 mg capsule 100 mgtablet)

2-Generic

doxycycline monohydrate (25 mg5 mlsusp recon 50 mg capsule 50 mgtablet 75 mg tablet 100 mg tablet 100mg capsule 150 mg tablet)

2-Generic

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

2-Generic

minocycline hcl (50 mg tablet 75 mgtablet 100 mg tablet)

4-Non-PreferredDrug

mondoxyne nl 100 mg capsule 2-Generic

morgidox 2-Generic

tetracycline hcl 4-Non-PreferredDrug

ANTICONVULSANTS

ANTICONVULSANTS OTHERBRIVIACT (10 MGML ORAL SOLN 10MG TABLET 25 MG TABLET 50 MGTABLET 75 MG TABLET 100 MGTABLET)

5-Specialty PA FOR NEW STARTS ONLY

DIACOMIT 5-Specialty PA FOR NEW STARTS ONLY LA

EPIDIOLEX 5-Specialty PA FOR NEW STARTS ONLY LA

FINTEPLA 5-Specialty PA FOR NEW STARTS ONLY

levetiracetam (100 mgml solution 250mg tablet 500 mg tab er 24h 500mg5ml solution 500 mg tablet 750mg tab er 24h 750 mg tablet 1000 mgtablet)

2-Generic

levetiracetam in sodium chloride iso-osmotic

4-Non-PreferredDrug

NAYZILAM 4-Non-PreferredDrug

PA FOR NEW STARTS ONLY QL (10 PER30 OVER TIME)

roweepra 2-Generic


15


Drug Name Drug Tier RequirementsLimitsroweepra xr 2-Generic

SPRITAM 4-Non-PreferredDrug

PA FOR NEW STARTS ONLY

XCOPRI (50 MG TABLET 50-100 MGTITRATION PAK 100 MG TABLET 150-200 MG TITRATION PK 150 MG TABLET200 MG TABLET 250 MG DAILY DOSEPACK 350 MG DAILY DOSE PACK)


XCOPRI 125-25 MG TITRATION PK 4-Non-PreferredDrug


CALCIUM CHANNEL MODIFYING AGENTSCELONTIN 4-Non-Preferred

Drug

ethosuximide (250 mg5ml solution250 mg capsule)

3-Preferred Brand

zonisamide 2-Generic

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTSclobazam (25 mgml oral susp 10 mgtablet 20 mg tablet)

4-Non-PreferredDrug

DIASTAT 4-Non-PreferredDrug

DIASTAT ACUDIAL 4-Non-PreferredDrug

DIAZEPAM (25 MG KIT 5-75-10MGKIT 125-15-20 KIT)

4-Non-PreferredDrug

divalproex sodium (125 mg tablet dr125 mg cap dr spr 250 mg tab er 24h250 mg tablet dr 500 mg tablet dr 500mg tab er 24h)

2-Generic

gabapentin (100 mg capsule 300 mgcapsule 400 mg capsule 600 mg tablet800 mg tablet)

2-Generic

gabapentin (250 mg5ml solution 300mg6ml solution)

4-Non-PreferredDrug


16


Drug Name Drug Tier RequirementsLimitsphenobarbital (15 mg tablet 162 mgtablet 30 mg tablet 324 mg tablet 60mg tablet 648 mg tablet 972mgtablet 100 mg tablet)

3-Preferred Brand

phenobarbital 20 mg5 ml elixir 4-Non-PreferredDrug

primidone 2-Generic

SYMPAZAN 5-Specialty PA FOR NEW STARTS ONLY

tiagabine hcl 4-Non-PreferredDrug

valproic acid 2-Generic

valproic acid (as sodium salt) (valproatesodium) (salt) 250 mg5ml solutionsalt) 500mg10ml solution)

2-Generic

VALTOCO 4-Non-PreferredDrug


vigabatrin 5-Specialty PA FOR NEW STARTS ONLY LA

vigadrone 5-Specialty PA FOR NEW STARTS ONLY LA

GLUTAMATE REDUCING AGENTSfelbamate (400 mg tablet 600 mgtablet 600 mg5ml oral susp)

4-Non-PreferredDrug

FYCOMPA (05 MGML ORAL SUSP 2MG TABLET 4 MG TABLET 6 MGTABLET 8 MG TABLET 10 MG TABLET12 MG TABLET)


lamotrigine (25 mg tab er 24 50 mg taber 24 100 mg tab er 24 200 mg tab er24 250 mg tab er 24 300 mg tab er 24)

4-Non-PreferredDrug

lamotrigine (5 mg tb chw dsp 25 mgtablet 25 mg tb chw dsp 100 mgtablet 150 mg tablet 200 mg tablet)

2-Generic

topiramate (15 mg cap sprink 25 mgcap sprink 25 mg tablet 50 mg tablet100 mg tablet 200 mg tablet)

2-Generic


17


Drug Name Drug Tier RequirementsLimitstopiramate (25 mg cap spr 24 50 mgcap spr 24 100 mg cap spr 24 150 mgcap spr 24 200 mg cap spr 24)

4-Non-PreferredDrug


SODIUM CHANNEL AGENTSAPTIOM 5-Specialty PA FOR NEW STARTS ONLY

carbamazepine (100 mg tab chew 200mg tablet)

3-Preferred Brand

carbamazepine (100 mg tab er 12h 100mg cpmp 12hr 100 mg5ml oral susp200mg10ml oral susp 200 mg tab er12h 200 mg cpmp 12hr 300 mg cpmp12hr 400 mg tab er 12h)

4-Non-PreferredDrug

dilantin 30 mg capsule 4-Non-PreferredDrug

epitol 3-Preferred Brand

fosphenytoin sodium 4-Non-PreferredDrug

oxcarbazepine (150 mg tablet 300 mgtablet 300 mg5ml oral susp 600 mgtablet)

2-Generic

PEGANONE 4-Non-PreferredDrug

phenytoin (50 mg tab chew 100mg4ml oral susp 125 mg5ml oralsusp)

2-Generic

phenytoin sodium extended 2-Generic

rufinamide (40 mgml oral susp 200 mgtablet 400 mg tablet)

4-Non-PreferredDrug


VIMPAT (10 MGML SOLUTION 100MG TABLET 150 MG TABLET 200 MGTABLET)


VIMPAT 50 MG TABLET 4-Non-PreferredDrug



18



ANTIDEMENTIA AGENTS

CHOLINESTERASE INHIBITORSdonepezil hcl 2-Generic

galantamine hbr (4 mg tablet 4 mgmlsolution 8 mg cap24h pel 8 mg tablet12 mg tablet 16 mg cap24h pel 24 mgcap24h pel)

3-Preferred Brand

rivastigmine 4-Non-PreferredDrug

rivastigmine tartrate 2-Generic

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine hcl (2 mgml solution 5 mg-10 mg tab ds pk 7 mg cap spr 24 14mg cap spr 24 21 mg cap spr 24 28 mgcap spr 24)

4-Non-PreferredDrug

memantine hcl (5 mg tablet 10 mgtablet)

2-Generic

NAMENDA XR TITRATION PACK 4-Non-PreferredDrug

ANTIDEPRESSANTS

ANTIDEPRESSANTS OTHERbupropion hcl (75 mg tablet 100 mgtab sr 12h 100 mg tablet 150 mg taber 24h 150 mg tab sr 12h 200 mg tabsr 12h 300 mg tab er 24h)

2-Generic

mirtazapine (15 mg tablet 15 mg tabrapdis 30 mg tablet 30 mg tab rapdis45 mg tablet 45 mg tab rapdis)

2-Generic

mirtazapine 75 mg tablet 3-Preferred Brand

olanzapinefluoxetine hcl 4-Non-PreferredDrug

perphenazineamitriptyline hcl 4-Non-PreferredDrug


19



MONOAMINE OXIDASE INHIBITORSEMSAM 5-Specialty

marplan 4-Non-PreferredDrug

phenelzine sulfate 3-Preferred Brand

tranylcypromine sulfate 4-Non-PreferredDrug

SSRISSNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORSEROTONIN ANDNOREPINEPHRINE REUPTAKE INHIBITOR)

citalopram hydrobromide (10 mg tablet20 mg tablet 40 mg tablet)

1-PreferredGeneric

citalopram hydrobromide (10 mg5 mlsolution 20 mg10ml solution)

3-Preferred Brand

desvenlafaxine succinate 2-Generic

escitalopram oxalate (5 mg tablet 10mg tablet 20 mg tablet)

1-PreferredGeneric

escitalopram oxalate 5 mg5 mlsolution

3-Preferred Brand

FETZIMA 4-Non-PreferredDrug

ST

fluoxetine hcl (10 mg capsule 20 mg5ml solution 20 mg capsule 40 mgcapsule)

2-Generic

fluoxetine hcl (10 mg tablet 20 mgtablet 60 mg tablet 90 mg capsule dr)

4-Non-PreferredDrug

fluvoxamine maleate (100 mg cap er24h 150 mg cap er 24h)

4-Non-PreferredDrug

fluvoxamine maleate (25 mg tablet 50mg tablet 100 mg tablet)

2-Generic

maprotiline hcl 4-Non-PreferredDrug

nefazodone hcl 4-Non-PreferredDrug


20


Drug Name Drug Tier RequirementsLimitsparoxetine hcl (10 mg tablet 20 mgtablet 30 mg tablet 40 mg tablet)

2-Generic

paroxetine hcl (10 mg5 ml oral susp125 mg tab er 24h 25 mg tab er 24h375 mg tab er 24h)

4-Non-PreferredDrug

PAXIL 10 MG5 ML SUSPENSION 4-Non-PreferredDrug

sertraline hcl (20 mgml oral conc 25mg tablet 50 mg tablet 100 mg tablet)

1-PreferredGeneric

trazodone hcl 2-Generic

TRINTELLIX 4-Non-PreferredDrug

ST

venlafaxine hcl (25 mg tablet 375 mgcap er 24h 375 mg tablet 50 mgtablet 75 mg cap er 24h 75 mg tablet100 mg tablet 150 mg cap er 24h)

2-Generic

venlafaxine hcl (375 mg tab er 24 75mg tab er 24 150 mg tab er 24 225 mgtab er 24)

4-Non-PreferredDrug

QL (1 PER 1 DAY)

VIIBRYD 4-Non-PreferredDrug

ST

TRICYCLICSamitriptyline hcl 2-Generic

amoxapine 2-Generic

clomipramine hcl 4-Non-PreferredDrug

desipramine hcl 4-Non-PreferredDrug

imipramine hcl 2-Generic

imipramine pamoate 4-Non-PreferredDrug

nortriptyline hcl (10 mg5 ml solution10 mg capsule 25 mg capsule 50 mgcapsule 75 mg capsule)

2-Generic


21


Drug Name Drug Tier RequirementsLimitsprotriptyline hcl 4-Non-Preferred

Drug

trimipramine maleate 4-Non-PreferredDrug

ANTIEMETICS

ANTIEMETICS OTHERcompro 4-Non-Preferred

Drug

meclizine hcl (125 mg tablet 25 mgtablet)

2-Generic

metoclopramide hcl (5 mg tablet 5mg5 ml solution 10 mg tablet 10mg10ml solution)

2-Generic

perphenazine 4-Non-PreferredDrug

prochlorperazine 4-Non-PreferredDrug

prochlorperazine edisylate 4-Non-PreferredDrug

prochlorperazine maleate 2-Generic

promethazine hcl (125 mg supprect125 mg tablet 25 mg tablet 25 mgsupprect 50 mg tablet)

4-Non-PreferredDrug

EMETOGENIC THERAPY ADJUNCTSAKYNZEO 300-05 MG CAPSULE 4-Non-Preferred

DrugQL (4 PER 28 OVER TIME)

aprepitant 125 mg capsule 4-Non-PreferredDrug

QL (2 PER 30 OVER TIME)

aprepitant 125mg-80mg cap ds pk 4-Non-PreferredDrug







22


Drug Name Drug Tier RequirementsLimitsdronabinol 4-Non-Preferred

DrugPA

EMEND 125 MG POWDER PACKET 4-Non-PreferredDrug


granisetron hcl 1 mg tablet 4-Non-PreferredDrug

QL (2 PER 1 DAY)

ondansetron hcl (2 mgml vial 4 mg5ml solution)

4-Non-PreferredDrug

ondansetron hcl (4 mg tablet 8 mgtablet 24 mg tablet)

2-Generic

ondansetron hclpf 4-Non-PreferredDrug

ondansetron odt (4 mg tablet 8 mgtablet)

3-Preferred Brand

VARUBI 180 MG DOSE(2X 90MG TB) 4-Non-PreferredDrug


ANTIFUNGALS

ANTIFUNGALSABELCET 4-Non-Preferred


AMBISOME 4-Non-PreferredDrug


amphotericin b 4-Non-PreferredDrug


caspofungin acetate 5-Specialty

ciclodan (077 cream 8 solution) 2-Generic

ciclopirox (077 gel (gram) 1 shampoo)

3-Preferred Brand

ciclopirox 8 solution 2-Generic

ciclopirox olamine 077 cream (g) 2-Generic

ciclopirox olamine 077 suspension 3-Preferred Brand

clotrimazole (1 solution 10 mgtroche)

3-Preferred Brand


23


Drug Name Drug Tier RequirementsLimitsclotrimazole 1 cream (g) 2-Generic

CRESEMBA 186 MG CAPSULE 5-Specialty PA

econazole nitrate 3-Preferred Brand

ERAXIS(WATER DIL) 100 MG VIAL 5-Specialty

fluconazole (10 mgml susp recon 40mgml susp recon)

3-Preferred Brand

fluconazole (50 mg tablet 100 mgtablet 150 mg tablet 200 mg tablet)

2-Generic

fluconazole in sodium chloride iso-osmotic

4-Non-PreferredDrug

flucytosine 5-Specialty

griseofulvin ultramicrosize 4-Non-PreferredDrug

griseofulvin microsize (125 mg5ml oralsusp 500 mg tablet)

4-Non-PreferredDrug

itraconazole 10 mgml solution 5-Specialty PA

itraconazole 100 mg capsule 4-Non-PreferredDrug

ketoconazole (2 cream (g) 2 foam200 mg tablet)

4-Non-PreferredDrug

ketoconazole 2 shampoo 2-Generic

ketodan 4-Non-PreferredDrug

micafungin sodium 5-Specialty

miconazole nitrate 200 mg suppvag 3-Preferred Brand

naftifine hcl (1 gel (gram) 1 cream(g))

4-Non-PreferredDrug

NAFTIN 1 GEL 4-Non-PreferredDrug

NATACYN 4-Non-PreferredDrug

NOXAFIL 40 MGML SUSPENSION 4-Non-PreferredDrug

PA


24


Drug Name Drug Tier RequirementsLimitsnyamyc 2-Generic

nystatin (100000ml oral susp100000g powder 100000g cream (g)100000g oint (g))

2-Generic

nystatin 500k unit tablet 3-Preferred Brand

nystatintriamcinolone acetonide 4-Non-PreferredDrug

nystop 2-Generic

oxiconazole nitrate 4-Non-PreferredDrug

posaconazole 5-Specialty PA

terbinafine hcl 250 mg tablet 2-Generic

terconazole (04 creamappl 08 creamappl 80 mg suppvag)

4-Non-PreferredDrug

voriconazole (50 mg tablet 200 mgtablet 200 mg vial 200 mg5ml susprecon)

4-Non-PreferredDrug

PA

ANTIGOUT AGENTS

ANTIGOUT AGENTSallopurinol 2-Generic

colchicine 3-Preferred Brand

febuxostat 4-Non-PreferredDrug

probenecid 2-Generic

probenecidcolchicine 2-Generic

ANTIMIGRAINE AGENTS

ANTIMIGRAINE AGENTS OTHERaimovig autoinjector 3-Preferred Brand PA

emgality pen 3-Preferred Brand PA


25


Drug Name Drug Tier RequirementsLimitsemgality syringe 3-Preferred Brand PA

ERGOT ALKALOIDScafergot 3-Preferred Brand QL (40 PER 28 OVER TIME)

dihydroergotamine mesylate05mgspry spraypump

5-Specialty QL (8 ML PER 30 OVER TIME)

ergotamine tartratecaffeine 3-Preferred Brand QL (40 PER 28 OVER TIME)

migergot 4-Non-PreferredDrug


SEROTONIN (5-HT) 1B1D RECEPTOR AGONISTSalmotriptan malate 4-Non-Preferred

DrugST QL (12 PER 30 OVER TIME)

frovatriptan succinate 4-Non-PreferredDrug


naratriptan hcl 3-Preferred Brand QL (9 PER 30 OVER TIME)

rizatriptan benzoate 2-Generic QL (12 PER 30 OVER TIME)

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

2-Generic QL (9 PER 30 OVER TIME)

sumatriptan succinate (4 mg05ml peninjctr 4 mg05ml cartridge 6mg05ml pen injctr 6 mg05mlsyringe 6 mg05ml cartridge 6mg05ml vial)

4-Non-PreferredDrug

QL (4 ML PER 30 OVER TIME)

zolmitriptan (25 mg tab rapdis 25 mgtablet 5 mg tab rapdis 5 mg tablet)

3-Preferred Brand ST QL (9 PER 30 OVER TIME)

ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICSGUANIDINE HCL 2-Generic

pyridostigmine bromide (60 mg5 mlsolution 180 mg tablet er)

4-Non-PreferredDrug

pyridostigmine bromide 60 mg tablet 3-Preferred Brand


26



ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS OTHERdapsone (25 mg tablet 100 mg tablet) 3-Preferred Brand

rifabutin 4-Non-PreferredDrug

ANTITUBERCULARSCAPASTAT SULFATE 4-Non-Preferred

Drug

cycloserine 2-Generic

ethambutol hcl 2-Generic

isoniazid (50 mg5 ml solution 100 mgtablet 300 mg tablet)

2-Generic

isoniazid 100 mgml vial 4-Non-PreferredDrug

paser 4-Non-PreferredDrug

PRIFTIN 4-Non-PreferredDrug

pyrazinamide 4-Non-PreferredDrug

rifampin (150 mg capsule 300 mgcapsule)

3-Preferred Brand

rifampin 600 mg vial 4-Non-PreferredDrug

RIFATER 4-Non-PreferredDrug

SIRTURO 5-Specialty LA

TRECATOR 4-Non-PreferredDrug


27



ANTINEOPLASTICS

ALKYLATING AGENTScyclophosphamide (25 mg tablet 25 mgcapsule 50 mg tablet 50 mg capsule)

4-Non-PreferredDrug


LEUKERAN 3-Preferred Brand

MATULANE 5-Specialty LA

VALCHLOR 5-Specialty LA

ANTIANDROGENSabiraterone acetate (250 mg tablet 500mg tablet)


bicalutamide 2-Generic

ERLEADA 5-Specialty PA FOR NEW STARTS ONLY LA

flutamide 2-Generic

nilutamide 5-Specialty

NUBEQA 5-Specialty PA FOR NEW STARTS ONLY LA

XTANDI 5-Specialty PA FOR NEW STARTS ONLY LA

YONSA 5-Specialty PA FOR NEW STARTS ONLY

ANTIANGIOGENIC AGENTSPOMALYST 5-Specialty PA FOR NEW STARTS ONLY LA

REVLIMID 5-Specialty PA FOR NEW STARTS ONLY LA

THALOMID 5-Specialty LA

ANTIESTROGENSMODIFIERSEMCYT 5-Specialty

soltamox 4-Non-PreferredDrug

tamoxifen citrate 2-Generic

toremifene citrate 5-Specialty


28



ANTIMETABOLITESDROXIA 3-Preferred Brand

fluorouracil (2 solution 5 solution5 cream (g))

4-Non-PreferredDrug

hydroxyurea 2-Generic

mercaptopurine 3-Preferred Brand

PURIXAN 4-Non-PreferredDrug

LA

TABLOID 4-Non-PreferredDrug

ANTINEOPLASTICS OTHERALUNBRIG 5-Specialty PA FOR NEW STARTS ONLY LA

amifostine crystalline 4-Non-PreferredDrug

arsenic trioxide 4-Non-PreferredDrug

AYVAKIT 5-Specialty PA FOR NEW STARTS ONLY

BALVERSA 5-Specialty PA FOR NEW STARTS ONLY LA

BRUKINSA 5-Specialty PA FOR NEW STARTS ONLY LA

COPIKTRA 5-Specialty PA FOR NEW STARTS ONLY

GAVRETO 5-Specialty PA FOR NEW STARTS ONLY

IDHIFA 5-Specialty PA FOR NEW STARTS ONLY LA QL (1PER 1 DAY)

INQOVI 5-Specialty PA FOR NEW STARTS ONLY

INREBIC 5-Specialty PA FOR NEW STARTS ONLY LA

leucovorin calcium (350 mg vial 500 mgvial)

4-Non-PreferredDrug

leucovorin calcium (5 mg tablet 10 mgtablet 15 mg tablet 25 mg tablet)

2-Generic

LONSURF 5-Specialty PA FOR NEW STARTS ONLY LA

LYSODREN 3-Preferred Brand


29


Drug Name Drug Tier RequirementsLimitsmitoxantrone hcl 2-Generic

NINLARO 5-Specialty PA FOR NEW STARTS ONLY

ONUREG 5-Specialty PA FOR NEW STARTS ONLY

QINLOCK 5-Specialty PA FOR NEW STARTS ONLY

RETEVMO 40 MG CAPSULE 5-Specialty PA FOR NEW STARTS ONLY QL (2 PER1 DAYS)

RETEVMO 80 MG CAPSULE 5-Specialty PA FOR NEW STARTS ONLY

ROZLYTREK 5-Specialty PA FOR NEW STARTS ONLY LA

RUBRACA 5-Specialty PA FOR NEW STARTS ONLY LA

RYDAPT 5-Specialty PA FOR NEW STARTS ONLY

sylatron 5-Specialty PA FOR NEW STARTS ONLY

SYNRIBO 5-Specialty PA FOR NEW STARTS ONLY

TABRECTA 5-Specialty PA FOR NEW STARTS ONLY

TAZVERIK 5-Specialty PA FOR NEW STARTS ONLY

TIBSOVO 5-Specialty PA FOR NEW STARTS ONLY LA

TUKYSA 5-Specialty PA FOR NEW STARTS ONLY

TURALIO 5-Specialty PA FOR NEW STARTS ONLY LA

VITRAKVI (20 MGML SOLUTION 25MG CAPSULE 100 MG CAPSULE)


VIZIMPRO 5-Specialty PA FOR NEW STARTS ONLY LA

WELIREG 5-Specialty PA FOR NEW STARTS ONLY LA

XOSPATA 5-Specialty PA FOR NEW STARTS ONLY LA

XPOVIO 5-Specialty PA FOR NEW STARTS ONLY LA

ZOLINZA 5-Specialty PA FOR NEW STARTS ONLY

AROMATASE INHIBITORS 3RD GENERATIONanastrozole 2-Generic

exemestane 4-Non-PreferredDrug

letrozole 2-Generic


30



ENZYME INHIBITORSetoposide 20 mgml vial 2-Generic

LORBRENA 5-Specialty PA FOR NEW STARTS ONLY LA

PIQRAY 5-Specialty PA FOR NEW STARTS ONLY

toposar 2-Generic

topotecan hcl 4 mg vial 4-Non-PreferredDrug

MOLECULAR TARGET INHIBITORSAFINITOR 10 MG TABLET 5-Specialty PA FOR NEW STARTS ONLY

AFINITOR DISPERZ 5-Specialty PA FOR NEW STARTS ONLY

ALECENSA 5-Specialty PA FOR NEW STARTS ONLY LA

BOSULIF 5-Specialty PA FOR NEW STARTS ONLY LA

BRAFTOVI 75 MG CAPSULE 5-Specialty PA FOR NEW STARTS ONLY LA

CABOMETYX 5-Specialty PA FOR NEW STARTS ONLY LA

CALQUENCE 5-Specialty PA FOR NEW STARTS ONLY LA

CAPRELSA 5-Specialty PA FOR NEW STARTS ONLY LA

COMETRIQ 5-Specialty PA FOR NEW STARTS ONLY LA

COTELLIC 5-Specialty PA FOR NEW STARTS ONLY LA QL (63PER 28 OVER TIME)

DAURISMO 5-Specialty PA FOR NEW STARTS ONLY

ERIVEDGE 5-Specialty PA FOR NEW STARTS ONLY LA

erlotinib hcl 5-Specialty PA FOR NEW STARTS ONLY

everolimus (2 mg tab susp 25 mgtablet 3 mg tab susp 5 mg tab susp 5mg tablet 75 mg tablet 10 mg tablet)


FARYDAK 5-Specialty PA FOR NEW STARTS ONLY QL (6 PER21 OVER TIME)

FOTIVDA 5-Specialty PA FOR NEW STARTS ONLY

GILOTRIF 5-Specialty PA FOR NEW STARTS ONLY LA


31


Drug Name Drug Tier RequirementsLimitsIBRANCE 5-Specialty PA FOR NEW STARTS ONLY LA

ICLUSIG 5-Specialty PA FOR NEW STARTS ONLY LA

imatinib mesylate 4-Non-PreferredDrug


IMBRUVICA 5-Specialty PA FOR NEW STARTS ONLY LA

INLYTA 5-Specialty PA FOR NEW STARTS ONLY LA

IRESSA 5-Specialty PA FOR NEW STARTS ONLY LA QL (1PER 1 DAY)

JAKAFI 5-Specialty PA FOR NEW STARTS ONLY LA

KISQALI 5-Specialty PA FOR NEW STARTS ONLY

KISQALI FEMARA CO-PACK 5-Specialty PA FOR NEW STARTS ONLY

KOSELUGO 5-Specialty PA FOR NEW STARTS ONLY

lapatinib ditosylate 5-Specialty PA FOR NEW STARTS ONLY

LENVIMA 5-Specialty PA FOR NEW STARTS ONLY LA

LUMAKRAS 5-Specialty PA FOR NEW STARTS ONLY LA

LYNPARZA 5-Specialty PA FOR NEW STARTS ONLY LA

MEKINIST 5-Specialty PA FOR NEW STARTS ONLY LA

MEKTOVI 5-Specialty PA FOR NEW STARTS ONLY LA

NERLYNX 5-Specialty PA FOR NEW STARTS ONLY LA

NEXAVAR 5-Specialty PA FOR NEW STARTS ONLY LA

ODOMZO 5-Specialty PA FOR NEW STARTS ONLY

PEMAZYRE 5-Specialty PA FOR NEW STARTS ONLY

SPRYCEL 5-Specialty PA FOR NEW STARTS ONLY

STIVARGA 5-Specialty PA FOR NEW STARTS ONLY LA

sunitinib malate 5-Specialty PA FOR NEW STARTS ONLY

TAFINLAR 5-Specialty PA FOR NEW STARTS ONLY LA

TAGRISSO 5-Specialty PA FOR NEW STARTS ONLY LA

TALZENNA 5-Specialty PA FOR NEW STARTS ONLY LA

TASIGNA 5-Specialty PA FOR NEW STARTS ONLY


32


Drug Name Drug Tier RequirementsLimitsTEPMETKO 5-Specialty PA FOR NEW STARTS ONLY

truseltiq 5-Specialty PA FOR NEW STARTS ONLY

UKONIQ 5-Specialty PA FOR NEW STARTS ONLY

VENCLEXTA (10 MG TABLET 10 MG TAB(10MG X 2) 50 MG TABLET)

3-Preferred Brand PA FOR NEW STARTS ONLY LA

VENCLEXTA 100 MG TABLET 5-Specialty PA FOR NEW STARTS ONLY LA

VENCLEXTA STARTING PACK 5-Specialty PA FOR NEW STARTS ONLY LA

VERZENIO 5-Specialty PA FOR NEW STARTS ONLY LA

VOTRIENT 5-Specialty PA FOR NEW STARTS ONLY LA

XALKORI 5-Specialty PA FOR NEW STARTS ONLY LA

ZEJULA 5-Specialty PA FOR NEW STARTS ONLY LA

ZELBORAF 5-Specialty PA FOR NEW STARTS ONLY LA

ZYDELIG 5-Specialty PA FOR NEW STARTS ONLY LA QL (2PER 1 DAY)

ZYKADIA 5-Specialty PA FOR NEW STARTS ONLY LA

RETINOIDSbexarotene 5-Specialty PA FOR NEW STARTS ONLY

PANRETIN 5-Specialty

TARGRETIN 1 GEL 5-Specialty PA FOR NEW STARTS ONLY

tretinoin 10 mg capsule 5-Specialty PA FOR NEW STARTS ONLY

TREATMENT ADJUNCTSMESNEX 400 MG TABLET 5-Specialty

ANTIPARASITICS

ANTIHELMINTHICSalbendazole 4-Non-Preferred

DrugPA

emverm 4-Non-PreferredDrug

PA


33


Drug Name Drug Tier RequirementsLimitsivermectin 3 mg tablet 3-Preferred Brand PA

ANTIPROTOZOALSatovaquone 4-Non-Preferred

Drug

atovaquoneproguanil hcl (625-25 mgtablet 250-100 mg tablet)

3-Preferred Brand

BENZNIDAZOLE 3-Preferred Brand LA

chloroquine phosphate 4-Non-PreferredDrug

COARTEM 4-Non-PreferredDrug

hydroxychloroquine sulfate 200 mgtablet

2-Generic

mefloquine hcl 2-Generic

nitazoxanide 5-Specialty QL (6 PER 30 OVER TIME)

pentamidine isethionate 300 mg vial 4-Non-PreferredDrug

pentamidine isethionate 300 mg vial-neb

4-Non-PreferredDrug


primaquine phosphate 3-Preferred Brand

pyrimethamine 5-Specialty

PEDICULICIDESSCABICIDESlindane 4-Non-Preferred

Drug

permethrin 3-Preferred Brand

ANTIPARKINSON AGENTS

ANTICHOLINERGICSbenztropine mesylate (05 mg tablet 1mg tablet 2 mg tablet)

2-Generic

trihexyphenidyl hcl (2 mg tablet 2 mg5ml solution 5 mg tablet)

2-Generic


34



ANTIPARKINSON AGENTS OTHERamantadine hcl (50 mg5 ml solution100 mg capsule)

3-Preferred Brand

amantadine hcl 100 mg tablet 4-Non-PreferredDrug

CARBIDOPALEVODOPAENTACAPONE 4-Non-PreferredDrug

entacapone 4-Non-PreferredDrug

NOURIANZ 5-Specialty PA LA QL (1 PER 1 DAY)

ONGENTYS 4-Non-PreferredDrug

ST

OSMOLEX ER 4-Non-PreferredDrug

PA LA

DOPAMINE AGONISTSAPOKYN 5-Specialty LA

bromocriptine mesylate 4-Non-PreferredDrug

INBRIJA 5-Specialty LA

KYNMOBI 5-Specialty

NEUPRO 4-Non-PreferredDrug

QL (1 PER 1 DAY)

pramipexole di-hcl (0125 mg tablet025 mg tablet 05 mg tablet 075 mgtablet 1 mg tablet 15 mg tablet)

2-Generic

ropinirole hcl (025 mg tablet 05 mgtablet 1 mg tablet 2 mg tablet 3 mgtablet 4 mg tablet 5 mg tablet)

2-Generic

ropinirole hcl (2 mg tab er 24h 4 mgtab er 24h 6 mg tab er 24h 8 mg tab er24h 12 mg tab er 24h)

3-Preferred Brand


35



DOPAMINE PRECURSORSL-AMINO ACID DECARBOXYLASE INHIBITORScarbidopa 4-Non-Preferred

Drug

carbidopalevodopa (10mg-100mg tabrapdis 25mg-250mg tab rapdis 25mg-100mg tab rapdis)

4-Non-PreferredDrug

carbidopalevodopa (10mg-100mgtablet 25mg-250mg tablet 25mg-100mg tablet er 25mg-100mg tablet50mg-200mg tablet er)

2-Generic

MONOAMINE OXIDASE B (MAO-B) INHIBITORSrasagiline mesylate 4-Non-Preferred

Drug

selegiline hcl 3-Preferred Brand

ANTIPSYCHOTICS

1ST GENERATIONTYPICALchlorpromazine hcl (10 mg tablet 25mg tablet 30 mgml oral conc 50 mgtablet 100 mg tablet 100 mgml oralconc 200 mg tablet)

4-Non-PreferredDrug

fluphenazine decanoate 4-Non-PreferredDrug

fluphenazine hcl (1 mg tablet 25mg5ml elixir 25 mg tablet 5 mgtablet 10 mg tablet)

3-Preferred Brand

fluphenazine hcl (25 mgml vial 5mgml oral conc)

4-Non-PreferredDrug

haloperidol 2-Generic

haloperidol decanoate (50 mgml vial50 mgml ampul 100 mgml ampul100 mgml vial)

4-Non-PreferredDrug

haloperidol lactate (5 mgml vial 5mgml ampul)

4-Non-PreferredDrug


36


Drug Name Drug Tier RequirementsLimitshaloperidol lactate 2 mgml oral conc 2-Generic

loxapine succinate 3-Preferred Brand

molindone hcl 4-Non-PreferredDrug

pimozide 2-Generic

thioridazine hcl 3-Preferred Brand

thiothixene 4-Non-PreferredDrug

trifluoperazine hcl 3-Preferred Brand

2ND GENERATIONATYPICALABILIFY MAINTENA 5-Specialty

ABILIFY MYCITE 5-Specialty PA FOR NEW STARTS ONLY

aripiprazole (1 mgml solution 10 mgtab rapdis 15 mg tab rapdis)

4-Non-PreferredDrug

aripiprazole (2 mg tablet 5 mg tablet10 mg tablet 15 mg tablet 20 mgtablet 30 mg tablet)

2-Generic

ARISTADA 5-Specialty

ARISTADA INITIO 5-Specialty

asenapine maleate 4-Non-PreferredDrug


CAPLYTA 4-Non-PreferredDrug


FANAPT 4-Non-PreferredDrug

INVEGA SUSTENNA 117 MG075 ML 5-Specialty QL (075 ML PER 28 OVER TIME)

INVEGA SUSTENNA 156 MGML SYRG 5-Specialty QL (1 ML PER 28 OVER TIME)


INVEGA SUSTENNA 39 MG025 ML 4-Non-PreferredDrug




37


Drug Name Drug Tier RequirementsLimitsINVEGA TRINZA 5-Specialty

LATUDA 5-Specialty PA FOR NEW STARTS ONLY QL (1 PER1 DAY)

NUPLAZID 5-Specialty PA FOR NEW STARTS ONLY LA QL (1PER 1 DAY)

olanzapine (25 mg tablet 5 mg tablet75 mg tablet 10 mg tablet 15 mgtablet 20 mg tablet)

2-Generic

olanzapine (5 mg tab rapdis 10 mg tabrapdis 15 mg tab rapdis 20 mg tabrapdis)

3-Preferred Brand

olanzapine 10 mg vial 4-Non-PreferredDrug

paliperidone 4-Non-PreferredDrug

PERSERIS 5-Specialty

quetiapine fumarate 2-Generic

REXULTI 5-Specialty PA FOR NEW STARTS ONLY

RISPERDAL CONSTA (25 MG VIAL 375MG VIAL 50 MG VIAL)

5-Specialty

RISPERDAL CONSTA 125 MG VIAL 4-Non-PreferredDrug

risperidone (025 mg tab rapdis 05 mgtab rapdis 1 mg tab rapdis 2 mg tabrapdis 3 mg tab rapdis 4 mg tabrapdis)

4-Non-PreferredDrug

risperidone (025 mg tablet 05 mgtablet 1 mgml solution 1 mg tablet 2mg tablet 3 mg tablet 4 mg tablet)

2-Generic

SECUADO 5-Specialty PA FOR NEW STARTS ONLY

VRAYLAR (15 MG CAPSULE 3 MGCAPSULE 45 MG CAPSULE 6 MGCAPSULE)


VRAYLAR 15 MG-3 MG PACK 4-Non-PreferredDrug



38


Drug Name Drug Tier RequirementsLimitsziprasidone hcl 2-Generic

ziprasidone mesylate 4-Non-PreferredDrug

TREATMENT-RESISTANTclozapine (125 mg tab rapdis 25 mgtab rapdis 100 mg tab rapdis 150 mgtab rapdis 200 mg tab rapdis)

4-Non-PreferredDrug

clozapine (25 mg tablet 50 mg tablet100 mg tablet 200 mg tablet)

3-Preferred Brand

VERSACLOZ 4-Non-PreferredDrug

ANTISPASTICITY AGENTS

ANTISPASTICITY AGENTSbaclofen (5 mg tablet 10 mg tablet 20mg tablet)

2-Generic

dantrolene sodium (25 mg capsule 50mg capsule 100 mg capsule)

3-Preferred Brand

tizanidine hcl (2 mg capsule 4 mgcapsule 6 mg capsule)

4-Non-PreferredDrug

tizanidine hcl (2 mg tablet 4 mg tablet) 2-Generic

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTSPREVYMIS (240 MG TABLET 480 MGTABLET)

5-Specialty PA QL (1 PER 1 DAY)

valganciclovir hcl 450 mg tablet 3-Preferred Brand

valganciclovir hcl 50 mgml soln recon 5-Specialty

ZIRGAN 4-Non-PreferredDrug


39



ANTI-HEPATITIS B (HBV) AGENTSadefovir dipivoxil 4-Non-Preferred

Drug

BARACLUDE 005 MGML SOLUTION 4-Non-PreferredDrug

entecavir 4-Non-PreferredDrug

EPIVIR HBV 25 MG5 ML SOLN 3-Preferred Brand

lamivudine 100 mg tablet 3-Preferred Brand

VEMLIDY 5-Specialty

ANTI-HEPATITIS C (HCV) AGENTS DIRECT ACTING AGENTSLEDIPASVIRSOFOSBUVIR 5-Specialty PA

SOFOSBUVIRVELPATASVIR 5-Specialty PA

VOSEVI 5-Specialty PA

ANTI-HEPATITIS C (HCV) AGENTS OTHERintron a (10 million units vil 18 millionunit3 ml 18 million units vil 25 millionunit25ml 50 million units vil)

5-Specialty LA

pegasys 5-Specialty

pegintron 5-Specialty

ribavirin (200 mg capsule 200 mgtablet)

3-Preferred Brand

ANTI-HIV AGENTS INTEGRASE INHIBITORS (INSTI)BIKTARVY 5-Specialty

GENVOYA 5-Specialty

ISENTRESS (100 MG TABLET CHEW 400MG TABLET)

5-Specialty

ISENTRESS (25 MG TABLET CHEW 100MG POWDER PACKET)

3-Preferred Brand

ISENTRESS HD 5-Specialty


40


Drug Name Drug Tier RequirementsLimitsSTRIBILD 5-Specialty

TIVICAY (25 MG TABLET 50 MGTABLET)

5-Specialty

TIVICAY 10 MG TABLET 3-Preferred Brand

TIVICAY PD 4-Non-PreferredDrug

ANTI-HIV AGENTS NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)COMPLERA 5-Specialty

DELSTRIGO 5-Specialty

EDURANT 5-Specialty

efavirenz 2-Generic

efavirenzemtricitabinetenofovirdisoproxil fumarate

5-Specialty

efavirenzlamivudinetenofovirdisoproxil fumarate

5-Specialty

etravirine 4-Non-PreferredDrug

INTELENCE 25 MG TABLET 3-Preferred Brand

nevirapine (50 mg5 ml oral susp 100mg tab er 24h 400 mg tab er 24h)

4-Non-PreferredDrug

nevirapine 200 mg tablet 2-Generic

ODEFSEY 5-Specialty

PIFELTRO 5-Specialty

ANTI-HIV AGENTS NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS(NRTI)

abacavir sulfate 20 mgml solution 3-Preferred Brand

abacavir sulfate 300 mg tablet 4-Non-PreferredDrug

abacavir sulfatelamivudine 4-Non-PreferredDrug

abacavir sulfatelamivudinezidovudine 4-Non-PreferredDrug


41


Drug Name Drug Tier RequirementsLimitsDESCOVY 5-Specialty

didanosine 2-Generic

emtricitabine 2-Generic

emtricitabinetenofovir disoproxilfumarate

5-Specialty

EMTRIVA 10 MGML SOLUTION 3-Preferred Brand

lamivudine (10 mgml solution 150 mgtablet 300 mg tablet)

4-Non-PreferredDrug

lamivudinezidovudine 4-Non-PreferredDrug

RETROVIR 200 MG20 ML VIAL 4-Non-PreferredDrug

stavudine 2-Generic

tenofovir disoproxil fumarate 3-Preferred Brand

VIDEX 3-Preferred Brand

VIDEX EC 125 MG CAPSULE 4-Non-PreferredDrug

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

5-Specialty

zidovudine (10 mgml syrup 100 mgcapsule 300 mg tablet)

2-Generic

ANTI-HIV AGENTS OTHERCIMDUO 4-Non-Preferred

Drug

DOVATO 5-Specialty

FUZEON 5-Specialty

JULUCA 5-Specialty

RUKOBIA 5-Specialty

SELZENTRY (20 MGML ORAL SOLN 75MG TABLET 150 MG TABLET 300 MGTABLET)

5-Specialty

SELZENTRY 25 MG TABLET 3-Preferred Brand


42


Drug Name Drug Tier RequirementsLimitsTEMIXYS 4-Non-Preferred

Drug

TRIUMEQ 5-Specialty

TYBOST 3-Preferred Brand

ANTI-HIV AGENTS PROTEASE INHIBITORSAPTIVUS (100 MGML SOLUTION 250MG CAPSULE)

5-Specialty

atazanavir sulfate 4-Non-PreferredDrug

CRIXIVAN 3-Preferred Brand

EVOTAZ 5-Specialty

fosamprenavir calcium 5-Specialty

INVIRASE 5-Specialty

LEXIVA 50 MGML SUSPENSION 3-Preferred Brand

lopinavirritonavir 100mg-25mg tablet 3-Preferred Brand

lopinavirritonavir 200mg-50mg tablet 5-Specialty

lopinavirritonavir 400-1005 solution 2-Generic

NORVIR (80 MGML SOLUTION 100 MGPOWDER PACKET)

3-Preferred Brand

PREZCOBIX 5-Specialty

PREZISTA (100 MGML SUSPENSION600 MG TABLET 800 MG TABLET)

5-Specialty

PREZISTA (75 MG TABLET 150 MGTABLET)

3-Preferred Brand

REYATAZ 50 MG POWDER PACKET 5-Specialty

ritonavir 3-Preferred Brand

SYMTUZA 5-Specialty

VIRACEPT 3-Preferred Brand


43



ANTI-INFLUENZA AGENTSoseltamivir phosphate (6 mgml susprecon 30 mg capsule 45 mg capsule75 mg capsule)

3-Preferred Brand

RELENZA 3-Preferred Brand

rimantadine hcl 3-Preferred Brand

XOFLUZA 4-Non-PreferredDrug

ANTIHERPETIC AGENTSacyclovir (200 mg capsule 400 mgtablet 800 mg tablet)

2-Generic

acyclovir (5 oint (g) 200 mg5ml oralsusp)

4-Non-PreferredDrug

acyclovir sodium 50 mgml vial 4-Non-PreferredDrug


famciclovir 2-Generic

trifluridine 3-Preferred Brand

valacyclovir hcl 2-Generic

ANXIOLYTICS

ANXIOLYTICS OTHERbuspirone hcl 2-Generic

doxepin hcl (10 mgml oral conc 10 mgcapsule 25 mg capsule 50 mg capsule75 mg capsule 100 mg capsule 150 mgcapsule)

3-Preferred Brand

BENZODIAZEPINESalprazolam (025 mg tablet 05 mgtablet 1 mg tablet 2 mg tablet)

4-Non-PreferredDrug

clonazepam (0125 mg tab rapdis 025mg tab rapdis 05 mg tab rapdis 1 mgtab rapdis 2 mg tab rapdis)

3-Preferred Brand


44


Drug Name Drug Tier RequirementsLimitsclonazepam (05 mg tablet 1 mg tablet2 mg tablet)

2-Generic

clorazepate dipotassium 4-Non-PreferredDrug

diazepam (2 mg tablet 5 mg5 mlsolution 5 mg tablet 5 mgml oralconc 10 mg tablet)

2-Generic

lorazepam (05 mg tablet 1 mg tablet2 mgml oral conc 2 mg tablet)

2-Generic

lorazepam intensol 2-Generic

oxazepam 3-Preferred Brand

BIPOLAR AGENTS

MOOD STABILIZERSlithium carbonate (150 mg capsule 300mg tablet er 300 mg tablet 300 mgcapsule 450 mg tablet er 600 mgcapsule)

2-Generic

LITHIUM CITRATE 4-Non-PreferredDrug

BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTSacarbose 2-Generic

ALOGLIPTIN BENZOATE 3-Preferred Brand PA

ALOGLIPTIN BENZOATEMETFORMINHCL

4-Non-PreferredDrug

PA

ALOGLIPTIN BENZOATEPIOGLITAZONEHCL

4-Non-PreferredDrug

PA

BYDUREON BCISE 3-Preferred Brand

BYDUREON PEN 3-Preferred Brand

CYCLOSET 4-Non-PreferredDrug


45


Drug Name Drug Tier RequirementsLimitsFARXIGA 4-Non-Preferred

DrugST

glimepiride 1-PreferredGeneric

glipizide (25 mg tab er 24 5 mg tab er24 10 mg tab er 24)

2-Generic

glipizide (5 mg tablet 10 mg tablet) 1-PreferredGeneric

glipizidemetformin hcl 2-Generic

GLYXAMBI 4-Non-PreferredDrug

PA

INVOKAMET 4-Non-PreferredDrug

ST

INVOKAMET XR 4-Non-PreferredDrug

ST

INVOKANA 4-Non-PreferredDrug

ST

JANUMET 3-Preferred Brand

JANUMET XR 3-Preferred Brand

JANUVIA 3-Preferred Brand

JARDIANCE 3-Preferred Brand

JENTADUETO 4-Non-PreferredDrug

PA

JENTADUETO XR 4-Non-PreferredDrug

PA

KOMBIGLYZE XR 4-Non-PreferredDrug

PA

metformin hcl (500 mg osm tablet er24h 1000 mg osm tablet er 24h)

4-Non-PreferredDrug

metformin hcl (500 mg tablet er 24h750 mg tablet er 24h)

1-PreferredGeneric

metformin hcl (500 mg tablet 850 mgtablet 1000 mg tablet)

1-PreferredGeneric


46


Drug Name Drug Tier RequirementsLimitsmetformin hcl 500 mg5ml solution 4-Non-Preferred

Drug

miglitol 4-Non-PreferredDrug

nateglinide 3-Preferred Brand

ONGLYZA 4-Non-PreferredDrug

PA

OZEMPIC 3-Preferred Brand

pioglitazone hcl 1-PreferredGeneric

PIOGLITAZONE HCLGLIMEPIRIDE 4-Non-PreferredDrug

pioglitazone hclmetformin hcl 3-Preferred Brand

repaglinide 2-Generic

repaglinidemetformin hcl 4-Non-PreferredDrug

RYBELSUS 3-Preferred Brand

SEGLUROMET 4-Non-PreferredDrug

ST

STEGLATRO 4-Non-PreferredDrug

ST

STEGLUJAN 4-Non-PreferredDrug

PA

SYNJARDY 3-Preferred Brand

SYNJARDY XR 3-Preferred Brand

TRADJENTA 4-Non-PreferredDrug

PA

trulicity 3-Preferred Brand

VICTOZA 2-PAK 3-Preferred Brand


XIGDUO XR 4-Non-PreferredDrug

ST


47



GLYCEMIC AGENTSBAQSIMI 3-Preferred Brand

diazoxide 4-Non-PreferredDrug

GLUCAGEN 3-Preferred Brand

glucagon emergency kit 3-Preferred Brand

GVOKE HYPOPEN 1-PACK 3-Preferred Brand


GVOKE PFS 1-PACK SYRINGE 3-Preferred Brand


INSULINShumalog 3-Preferred Brand

humalog junior kwikpen 3-Preferred Brand

humalog kwikpen u-100 3-Preferred Brand


humalog mix 50-50 3-Preferred Brand

humalog mix 50-50 kwikpen 3-Preferred Brand



humulin 70-30 2-Generic

humulin 7030 kwikpen 3-Preferred Brand

humulin n 2-Generic

humulin n kwikpen 3-Preferred Brand

humulin r 2-Generic

humulin r u-500 3-Preferred Brand

humulin r u-500 kwikpen 3-Preferred Brand

lantus 3-Preferred Brand

lantus solostar 3-Preferred Brand


48


Drug Name Drug Tier RequirementsLimitstoujeo max solostar 3-Preferred Brand

toujeo solostar 3-Preferred Brand

BLOOD PRODUCTSMODIFIERSVOLUME EXPANDERS

ANTICOAGULANTSELIQUIS 3-Preferred Brand

enoxaparin sodium (30mg03mlsyringe 40mg04ml syringe60mg06ml syringe 80mg08mlsyringe 100 mgml syringe120mg8ml syringe 150 mgmlsyringe)

4-Non-PreferredDrug

fondaparinux sodium (5mg04mlsyringe 75mg06 syringe 10mg08mlsyringe)

5-Specialty

fondaparinux sodium 25 mg05syringe

4-Non-PreferredDrug

FRAGMIN (2500 UNIT02 ML SYR5000 UNIT02 ML SYR)

4-Non-PreferredDrug

FRAGMIN (7500 UNIT03 ML SYR10000 UNITML SYRINGE 12500UNIT05 ML SYR 15000 UNIT06 MLSYR 18000 UNIT072 ML 95000UNIT38 ML VL)

5-Specialty

heparin sodiumporcine (5000mlsyringe 5000ml vial 5000ml(1)cartridge 10000ml vial 20000ml vial)

3-Preferred Brand

heparin sodiumporcine 1000ml vial 3-Preferred Brand PA TO CONFIRM PART D COVERAGE

HEPARIN SODIUMPORCINE IN 045 SODIUM CHLORIDE

4-Non-PreferredDrug

HEPARIN SODIUMPORCINEDEXTROSE5 IN WATER

4-Non-PreferredDrug

heparin sodiumporcinepf (500005mlsyringe 5000ml syringe 500005mlvial)

3-Preferred Brand


49


Drug Name Drug Tier RequirementsLimitsheparin sodiumporcinepf 1000ml vial 3-Preferred Brand PA TO CONFIRM PART D COVERAGE

jantoven 2-Generic

PRADAXA 4-Non-PreferredDrug

SAVAYSA 4-Non-PreferredDrug

warfarin sodium 2-Generic

XARELTO 3-Preferred Brand

BLOOD FORMATION MODIFIERSanagrelide hcl 3-Preferred Brand

aranesp (10 mcg04 ml syringe 25mcg042 ml syring 25 mcgml vial 40mcgml vial 40 mcg04 ml syringe 60mcg03 ml syringe 60 mcgml vial 100mcg05 ml syringe)

4-Non-PreferredDrug

PA

aranesp (100 mcgml vial 150 mcg03ml syringe 200 mcg04 ml syringe 200mcgml vial 300 mcg06 ml syringe300 mcgml vial 500 mcg1 ml syringe)

5-Specialty PA

cablivi 5-Specialty PA LA QL (1 PER 1 DAY)

DOPTELET 5-Specialty PA LA

epogen (2000 unitsml vial 3000unitsml vial 4000 unitsml vial 10000unitsml vial 20000 units2 ml vial)

4-Non-PreferredDrug

PA

epogen 20000 unitsml vial 5-Specialty PA

fulphila 5-Specialty

granix 5-Specialty

leukine 5-Specialty

MOZOBIL 5-Specialty

neulasta 5-Specialty

neulasta onpro 5-Specialty

neupogen 5-Specialty


50


Drug Name Drug Tier RequirementsLimitsnivestym 5-Specialty

nyvepria 5-Specialty

procrit (2000 vial 3000 vial 4000 vial10000 vial)

4-Non-PreferredDrug

PA

procrit (20000 vial 40000 vial) 5-Specialty PA

PROMACTA 5-Specialty PA LA

retacrit (2000 unitml vial 3000unitml vial 4000 unitml vial 10000unitml vial 20000 unit2 ml vial20000 unitml vial)

4-Non-PreferredDrug

PA

retacrit 40000 unitml vial 5-Specialty PA

TAVALISSE 5-Specialty PA LA QL (2 PER 1 DAY)

udenyca 5-Specialty

zarxio 5-Specialty

ziextenzo 5-Specialty

HEMOSTASIS AGENTStranexamic acid (1000 mg10 vial 1000mg10 ampul)

4-Non-PreferredDrug

tranexamic acid 650 mg tablet 3-Preferred Brand

PLATELET MODIFYING AGENTSaspirindipyridamole 4-Non-Preferred

Drug

BRILINTA 3-Preferred Brand

cilostazol 2-Generic

clopidogrel bisulfate 75 mg tablet 1-PreferredGeneric

prasugrel hcl 4-Non-PreferredDrug


51



CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTSclonidine (01 mgday patch 02mgday patch 03 mgday patch)

4-Non-PreferredDrug

clonidine hcl (01 mg tablet 02 mgtablet 03 mg tablet)

1-PreferredGeneric

droxidopa 5-Specialty PA

midodrine hcl 4-Non-PreferredDrug

ALPHA-ADRENERGIC BLOCKING AGENTSdoxazosin mesylate 2-Generic

phenoxybenzamine hcl 5-Specialty

prazosin hcl 3-Preferred Brand

terazosin hcl 2-Generic

ANGIOTENSIN II RECEPTOR ANTAGONISTScandesartan cilexetil 3-Preferred Brand

irbesartan 1-PreferredGeneric

losartan potassium 1-PreferredGeneric

olmesartan medoxomil 2-Generic

telmisartan 2-Generic

valsartan 2-Generic

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORSbenazepril hcl 1-Preferred

Generic

captopril 3-Preferred Brand

enalapril maleate (25 mg tablet 5 mgtablet 10 mg tablet 20 mg tablet)

2-Generic


52


Drug Name Drug Tier RequirementsLimitsenalapril maleate 1 mgml solution 4-Non-Preferred

Drug

fosinopril sodium 2-Generic

lisinopril 1-PreferredGeneric

moexipril hcl 2-Generic

perindopril erbumine 2-Generic

quinapril hcl 1-PreferredGeneric

ramipril 1-PreferredGeneric

trandolapril 2-Generic

ANTIARRHYTHMICSamiodarone hcl (100 mg tablet 400 mgtablet)

4-Non-PreferredDrug

amiodarone hcl 200 mg tablet 2-Generic

disopyramide phosphate 4-Non-PreferredDrug

dofetilide 3-Preferred Brand

flecainide acetate 2-Generic

mexiletine hcl 4-Non-PreferredDrug

MULTAQ 4-Non-PreferredDrug

NORPACE CR 4-Non-PreferredDrug

propafenone hcl (150 mg tablet 225mg tablet 300 mg tablet)

3-Preferred Brand

propafenone hcl (225 mg cap er 12h325 mg cap er 12h 425 mg cap er 12h)

4-Non-PreferredDrug

quinidine gluconate 4-Non-PreferredDrug


53


Drug Name Drug Tier RequirementsLimitsquinidine sulfate 4-Non-Preferred

Drug

sorine 2-Generic

sotalol af 2-Generic

sotalol hcl 2-Generic

BETA-ADRENERGIC BLOCKING AGENTSacebutolol hcl 2-Generic

atenolol 1-PreferredGeneric

betaxolol hcl (10 mg tablet 20 mgtablet)

2-Generic

bisoprolol fumarate 2-Generic

carvedilol 1-PreferredGeneric

carvedilol phosphate 4-Non-PreferredDrug

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

2-Generic

labetalol hcl 5 mgml vial 4-Non-PreferredDrug

metoprolol succinate 2-Generic

metoprolol tartrate (25 mg tablet 50mg tablet 100 mg tablet)

1-PreferredGeneric

metoprolol tartrate (375 mg tablet 75mg tablet)

2-Generic

nadolol 4-Non-PreferredDrug

nebivolol hcl 4-Non-PreferredDrug

ST

pindolol 2-Generic


54


Drug Name Drug Tier RequirementsLimitspropranolol hcl (10 mg tablet 20 mg5ml solution 20 mg tablet 40 mg tablet40mg5ml solution 60 mg cap sa 24h60 mg tablet 80 mg tablet 80 mg capsa 24h 120 mg cap sa 24h 160 mg capsa 24h)

2-Generic

timolol maleate (5 mg tablet 10 mgtablet 20 mg tablet)

4-Non-PreferredDrug

CALCIUM CHANNEL BLOCKING AGENTSamlodipine besylate 1-Preferred

Generic

CARDIZEM LA 120 MG TABLET 4-Non-PreferredDrug

cartia xt 2-Generic

dilt-xr 2-Generic

diltiazem hcl (30 mg tablet 60 mgtablet 90 mg tablet 120 mg cap sa24h 120 mg cap er 24h 120 mg cap erdeg 120 mg tablet 180 mg cap er 24h180 mg cap sa 24h 180 mg cap er deg240 mg cap sa 24h 240 mg cap er deg240 mg cap er 24h 300 mg cap sa 24h300 mg cap er 24h 360 mg cap er 24h360 mg cap sa 24h 420 mg cap sa 24h)

2-Generic

diltiazem hcl (60 mg cap er 12h 90 mgcap er 12h 120 mg cap er 12h 180 mgtab er 24h 240 mg tab er 24h 300 mgtab er 24h 360 mg tab er 24h 420 mgtab er 24h)

4-Non-PreferredDrug

felodipine 2-Generic

isradipine 4-Non-PreferredDrug

matzim la 4-Non-PreferredDrug

nicardipine hcl (20 mg capsule 30 mgcapsule)

4-Non-PreferredDrug


55


Drug Name Drug Tier RequirementsLimitsnifedipine (10 mg capsule 20 mgcapsule 30 mg tab er 24 30 mg tableter 60 mg tablet er 60 mg tab er 24 90mg tab er 24 90 mg tablet er)

2-Generic

nimodipine 4-Non-PreferredDrug

taztia xt 2-Generic

tiadylt er 2-Generic

verapamil hcl (100 mg cap24h pct 120mg cap24h pel 180 mg cap24h pel 200mg cap24h pct 240 mg cap24h pel 300mg cap24h pct 360 mg cap24h pel)

4-Non-PreferredDrug

verapamil hcl (40 mg tablet 80 mgtablet 120 mg tablet 120 mg tablet er180 mg tablet er 240 mg tablet er)

2-Generic

CARDIOVASCULAR AGENTS OTHERaliskiren hemifumarate 4-Non-Preferred

Drug

amiloride hclhydrochlorothiazide 2-Generic

amlodipine besylatebenazepril hcl 2-Generic

amlodipine besylateolmesartanmedoxomil

2-Generic

amlodipine besylatevalsartan 2-Generic

amlodipinebesylatevalsartanhydrochlorothiazide

3-Preferred Brand

atenololchlorthalidone 2-Generic

benazepril hclhydrochlorothiazide (5-625mg tablet 10-125mg tablet 20-125 mg tablet 20 mg-25mg tablet)

2-Generic

bisoprololfumaratehydrochlorothiazide

2-Generic

candesartancilexetilhydrochlorothiazide

4-Non-PreferredDrug

captoprilhydrochlorothiazide 4-Non-PreferredDrug


56


Drug Name Drug Tier RequirementsLimitsCORLANOR (5 MG5 ML ORAL SOLN 5MG TABLET 75 MG TABLET)

4-Non-PreferredDrug

PA

digitek 2-Generic

digox 2-Generic

digoxin (125 mcg tablet 250 mcgtablet)

2-Generic

digoxin (250 mcgml ampul 250mcgml syringe)

4-Non-PreferredDrug

digoxin 50 mcgml solution 3-Preferred Brand

enalapril maleatehydrochlorothiazide 2-Generic

ENTRESTO 3-Preferred Brand

fosinopril sodiumhydrochlorothiazide 3-Preferred Brand

irbesartanhydrochlorothiazide 2-Generic

lisinoprilhydrochlorothiazide 1-PreferredGeneric

losartan potassiumhydrochlorothiazide 2-Generic

metoprololtartratehydrochlorothiazide

2-Generic

NEXLETOL 4-Non-PreferredDrug

PA

olmesartan medoxomilamlodipinebesylatehydrochlorothiazide

4-Non-PreferredDrug

olmesartanmedoxomilhydrochlorothiazide

2-Generic

pentoxifylline 2-Generic

propranolol hclhydrochlorothiazide 3-Preferred Brand

quinapril hclhydrochlorothiazide 2-Generic

ranolazine 4-Non-PreferredDrug

spironolactonehydrochlorothiazide 2-Generic

telmisartanamlodipine besylate 4-Non-PreferredDrug


57


Drug Name Drug Tier RequirementsLimitstelmisartanhydrochlorothiazide 4-Non-Preferred

Drug

trandolaprilverapamil hcl 4-Non-PreferredDrug

triamterenehydrochlorothiazide 2-Generic

valsartanhydrochlorothiazide 2-Generic

verquvo 4-Non-PreferredDrug

PA

VYNDAMAX 5-Specialty PA LA QL (1 PER 1 DAY)

VYNDAQEL 5-Specialty PA LA QL (4 PER 1 DAY)

DIURETICS CARBONIC ANHYDRASE INHIBITORSacetazolamide (125 mg tablet 250 mgtablet)

4-Non-PreferredDrug

acetazolamide 500 mg capsule er 3-Preferred Brand

methazolamide 4-Non-PreferredDrug

DIURETICS LOOPbumetanide (05 mg tablet 1 mg tablet2 mg tablet)

3-Preferred Brand

ethacrynic acid 4-Non-PreferredDrug

furosemide (10 mgml solution 20 mgtablet 40 mg tablet 40mg5mlsolution 80 mg tablet)

1-PreferredGeneric

furosemide (10 mgml syringe 10mgml vial)

4-Non-PreferredDrug

torsemide 2-Generic

DIURETICS POTASSIUM-SPARINGamiloride hcl 2-Generic

eplerenone 3-Preferred Brand

spironolactone 2-Generic


58


Drug Name Drug Tier RequirementsLimitstriamterene 4-Non-Preferred

Drug

DIURETICS THIAZIDEchlorthalidone 2-Generic

hydrochlorothiazide (125 mg capsule125 mg tablet 25 mg tablet 50 mgtablet)

2-Generic

indapamide 2-Generic

metolazone 3-Preferred Brand

DYSLIPIDEMICS FIBRIC ACID DERIVATIVESfenofibrate (54 mg tablet 160 mgtablet)

2-Generic

fenofibrate nanocrystallized 2-Generic

fenofibratemicronized (43 mg capsule67 mg capsule 130 mg capsule 134 mgcapsule 200 mg capsule)

2-Generic

FENOFIBRIC ACID 2-Generic

fenofibric acid (choline) 2-Generic

gemfibrozil 2-Generic

DYSLIPIDEMICS HMG COA REDUCTASE INHIBITORSatorvastatin calcium 1-Preferred

Generic

fluvastatin sodium 4-Non-PreferredDrug

lovastatin 1-PreferredGeneric

pravastatin sodium 2-Generic

rosuvastatin calcium 1-PreferredGeneric

simvastatin 1-PreferredGeneric


59



DYSLIPIDEMICS OTHERcholestyramine (with sugar) (sugar) 4 gpowder sugar) 4 g powd pack)

4-Non-PreferredDrug

cholestyramineaspartame (4 g powdpack 4 g powder)

4-Non-PreferredDrug

colesevelam hcl 4-Non-PreferredDrug

colestipol hcl (1 g tablet 5 g packet 5 ggranules)

4-Non-PreferredDrug

ezetimibe 2-Generic

ezetimibesimvastatin 3-Preferred Brand

icosapent ethyl 3-Preferred Brand PA

JUXTAPID 5-Specialty PA LA

NEXLIZET 4-Non-PreferredDrug

PA

niacin (500 mg tab er 24h 750 mg taber 24h 1000 mg tab er 24h)

2-Generic

omega-3 acid ethyl esters 2-Generic

prevalite (packet powder) 4-Non-PreferredDrug

repatha pushtronex 3-Preferred Brand PA

repatha sureclick 3-Preferred Brand PA

repatha syringe 3-Preferred Brand PA

triklo 2-Generic

VASCEPA 05 GM CAPSULE 3-Preferred Brand PA

VASODILATORS DIRECT-ACTING ARTERIALhydralazine hcl (10 mg tablet 25 mgtablet 50 mg tablet 100 mg tablet)

2-Generic

minoxidil 2-Generic


60



VASODILATORS DIRECT-ACTING ARTERIALVENOUSisosorbide dinitrate (5 mg tablet 10 mgtablet 20 mg tablet 30 mg tablet)

3-Preferred Brand

isosorbide mononitrate (10 mg tablet20 mg tablet 30 mg tab er 24h 60 mgtab er 24h 120 mg tab er 24h)

2-Generic

minitran 2-Generic

NITRO-DUR (03 PATCH 08 PATCH) 3-Preferred Brand

nitroglycerin (01mghr patch td2402mghr patch td24 03 mg tab subl04 mg tab subl 04mghr patch td2406mghr patch td24 06 mg tab subl)

2-Generic

NITROSTAT 4-Non-PreferredDrug

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS AMPHETAMINESdextroamphetamine sulf-saccharateamphetamine sulf-aspartate (5 mg cap er 24h 10 mg caper 24h 15 mg cap er 24h 25 mg cap er24h 30 mg cap er 24h)

3-Preferred Brand QL (1 PER 1 DAY)

dextroamphetamine sulf-saccharateamphetamine sulf-aspartate (5 mg tablet 75 mg tablet10 mg tablet 125 mg tablet 15 mgtablet 20 mg tablet 30 mg tablet)

2-Generic

dextroamphetamine sulfate (5 mgtablet 5 mg capsule er 10 mg tablet10 mg capsule er 15 mg capsule er)

4-Non-PreferredDrug

dextroamphetamineamphetamine 20mg cap er 24h


VYVANSE 4-Non-PreferredDrug

QL (1 PER 1 DAY)

zenzedi (5 mg tablet 10 mg tablet) 4-Non-PreferredDrug


61



ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS NON-AMPHETAMINESatomoxetine hcl 4-Non-Preferred

Drug

clonidine hcl 01 mg tab er 12h 4-Non-PreferredDrug

DAYTRANA 4-Non-PreferredDrug

QL (1 PER 1 DAY)

dexmethylphenidate hcl (25 mg tablet5 mg tablet 10 mg tablet)

2-Generic

dexmethylphenidate hcl (5 mg cpbp 50-50 10 mg cpbp 50-50 15 mg cpbp 50-50 20 mg cpbp 50-50 25 mg cpbp 50-50 30 mg cpbp 50-50 35 mg cpbp 50-50 40 mg cpbp 50-50)

4-Non-PreferredDrug

QL (1 PER 1 DAY)

guanfacine hcl (1 mg tab er 24h 2 mgtab er 24h 3 mg tab er 24h 4 mg tab er24h)

2-Generic

metadate er 4-Non-PreferredDrug

methylphenidate hcl (10 mg tablet er10 mg cpbp 30-70 18 mg tab er 24 20mg cpbp 30-70 20 mg cpbp 50-50 27mg tab er 24 30 mg cpbp 50-50 30 mgcpbp 30-70 40 mg cpbp 50-50 40 mgcpbp 30-70 50 mg cpbp 30-70 54 mgtab er 24 60 mg cpbp 30-70 60 mgcpbp 50-50 72 mg tab er 24)

4-Non-PreferredDrug

QL (1 PER 1 DAY)

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

2-Generic

methylphenidate hcl 10 mg cpbp 50-50 4-Non-PreferredDrug

QL (6 PER 1 DAY)

methylphenidate hcl 20 mg tablet er 4-Non-PreferredDrug

methylphenidate hcl 36 mg tab er 24 4-Non-PreferredDrug

QL (2 PER 1 DAY)

relexxii 4-Non-PreferredDrug

QL (1 PER 1 DAY)


62



CENTRAL NERVOUS SYSTEM OTHERAUSTEDO 5-Specialty PA

butalb-acetamin-caff 50-325-40 (tablet) 4-Non-PreferredDrug

FIRDAPSE 5-Specialty PA LA

INGREZZA (40 MG CAPSULE 80 MGCAPSULE)

5-Specialty PA LA QL (1 PER 1 DAY)

INGREZZA 60 MG CAPSULE 5-Specialty PA LA QL (1 PER 1 DAYS)

INGREZZA INITIATION PACK 5-Specialty PA LA

NUEDEXTA 5-Specialty PA QL (2 PER 1 DAY)

riluzole 2-Generic

RUZURGI 5-Specialty PA LA

TEGSEDI 5-Specialty PA LA QL (6 ML PER 28 OVER TIME)

tetrabenazine 5-Specialty PA

FIBROMYALGIA AGENTSDRIZALMA SPRINKLE 4-Non-Preferred

Drug

duloxetine hcl (20 mg capsule dr 30 mgcapsule dr 60 mg capsule dr)

2-Generic

pregabalin (20 mgml solution 25 mgcapsule 50 mg capsule 75 mg capsule100 mg capsule 150 mg capsule 200mg capsule 225 mg capsule 300 mgcapsule)

2-Generic

SAVELLA (125 MG TABLET 25 MGTABLET 50 MG TABLET 100 MGTABLET)

4-Non-PreferredDrug

QL (2 PER 1 DAY)

SAVELLA TITRATION PACK 4-Non-PreferredDrug


MULTIPLE SCLEROSIS AGENTSAUBAGIO 5-Specialty LA

avonex 5-Specialty


63


Drug Name Drug Tier RequirementsLimitsavonex pen 5-Specialty

betaseron 5-Specialty

COPAXONE 5-Specialty

dalfampridine 3-Preferred Brand QL (2 PER 1 DAY)

dimethyl fumarate (120 mg capsule dr120-240 mg capsule dr 240 mg capsuledr)

5-Specialty

extavia 5-Specialty PA

GILENYA 5-Specialty

glatiramer acetate 5-Specialty

glatopa 5-Specialty

kesimpta pen 5-Specialty

MAVENCLAD 5-Specialty PA LA

MAYZENT (025 MG STARTER PACK 2MG TABLET)

5-Specialty LA

MAYZENT 025 MG TABLET 5-Specialty LA QL (4 PER 1 DAY)

plegridy 5-Specialty

plegridy pen 5-Specialty

rebif 5-Specialty

rebif rebidose 5-Specialty

VUMERITY 5-Specialty

ZEPOSIA 5-Specialty

DENTAL AND ORAL AGENTS

DENTAL AND ORAL AGENTSchlorhexidine gluconate 012 mouthwash

2-Generic

paroex 2-Generic

periogard 2-Generic


64


Drug Name Drug Tier RequirementsLimitspilocarpine hcl (5 mg tablet 75 mgtablet)

4-Non-PreferredDrug

triamcinolone acetonide 01 paste (g) 2-Generic

DERMATOLOGICAL AGENTS

DERMATOLOGICAL AGENTSaccutane 4-Non-Preferred

Drug

acitretin (10 mg capsule 175 mgcapsule 25 mg capsule)

4-Non-PreferredDrug

adapalene (01 gel (gram) 01 cream (g))

4-Non-PreferredDrug

ALTRENO 4-Non-PreferredDrug

ammonium lactate 2-Generic

amnesteem 4-Non-PreferredDrug

AVITA 0025 CREAM 4-Non-PreferredDrug

azelaic acid 4-Non-PreferredDrug

calcipotriene (0005 cream (g) 0005 oint (g) 0005 solution)

4-Non-PreferredDrug

CALCITRIOL 3 MCGG OINT (G) 4-Non-PreferredDrug

claravis 4-Non-PreferredDrug

clindamycin phosphatebenzoylperoxide (1 -5 gel (gram) 1 -5 gel wpump)

4-Non-PreferredDrug

clotrimazolebetamethasone dip 1 -005 cream (g)

2-Generic

clotrimazolebetamethasone dip 1 -005 lotion

4-Non-PreferredDrug


65


Drug Name Drug Tier RequirementsLimitsCORTISPORIN OINTMENT 4-Non-Preferred

Drug

cosentyx (2 syringes) 5-Specialty PA LA

cosentyx 150 mgml syringe 5-Specialty PA LA

cosentyx 75 mg05 ml syringe 5-Specialty PA

cosentyx pen 5-Specialty PA LA

cosentyx pen (2 pens) 5-Specialty PA LA

diclofenac sodium (1 gel (gram) 3 gel (gram))

3-Preferred Brand

diclofenac sodium 15 drops 4-Non-PreferredDrug

dupixent pen 5-Specialty PA

dupixent syringe 5-Specialty PA

epifoam 4-Non-PreferredDrug

FINACEA 15 FOAM 4-Non-PreferredDrug

FLUOROURACIL 05 CREAM (G) 5-Specialty PA

imiquimod 5 cream pack 2-Generic

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

4-Non-PreferredDrug

ivermectin 1 cream (g) 4-Non-PreferredDrug

ST

KLISYRI 5-Specialty PA

methoxsalen 5-Specialty

metronidazole (075 gel (gram) 075 cream (g) 075 lotion)

3-Preferred Brand

metronidazole (1 gel wpump 1 gel(gram))

4-Non-PreferredDrug

myorisan 4-Non-PreferredDrug

PICATO 5-Specialty PA


66


Drug Name Drug Tier RequirementsLimitspimecrolimus 4-Non-Preferred

DrugST

podofilox 3-Preferred Brand

proctofoam-hc 4-Non-PreferredDrug

RECTIV 4-Non-PreferredDrug

regranex 5-Specialty PA

rosadan 3-Preferred Brand

santyl 4-Non-PreferredDrug

QL (30 GM PER 30 OVER TIME)

selenium sulfide 2-Generic

skyrizi 5-Specialty PA

skyrizi (2 syringes) kit 5-Specialty PA

skyrizi pen 5-Specialty PA

SOOLANTRA 4-Non-PreferredDrug

ST

stelara (45 mg05 ml vial 45 mg05ml syringe 90 mgml syringe)

5-Specialty PA

tacrolimus (003 oint (g) 01 oint(g))

4-Non-PreferredDrug

tazarotene 01 cream (g) 3-Preferred Brand

TAZORAC (005 CREAM 005 GEL01 GEL)

4-Non-PreferredDrug

tremfya 5-Specialty PA

tretinoin (001 gel (gram) 0025 gel (gram) 0025 cream (g) 005 cream (g) 005 gel (gram) 01 cream (g))

4-Non-PreferredDrug

tretinoin microspheres 4-Non-PreferredDrug

zenatane 4-Non-PreferredDrug


67



ELECTROLYTESMINERALSMETALSVITAMINS

ELECTROLYTEMINERAL REPLACEMENT09 sodium chloride (09 09 ivsoln 09 pggybk prt 09 pgy vlprt)

4-Non-PreferredDrug

AMINOSYN II 15 IV SOLUTION 4-Non-PreferredDrug


CLINOLIPID 4-Non-PreferredDrug


dextrose 10 in water 4-Non-PreferredDrug

dextrose 25 and 045 sodiumchloride

4-Non-PreferredDrug

dextrose 5 and 02 sodium chloride 4-Non-PreferredDrug



4-Non-PreferredDrug


DEXTROSE 5 IN LACTATED RINGERS 4-Non-PreferredDrug


INTRALIPID 4-Non-PreferredDrug


K-TAB ER (8 MEG TABLET 10 MEQTABLET)

2-Generic

KLOR-CON 10 2-Generic


klor-con m10 2-Generic


68


Drug Name Drug Tier RequirementsLimitsklor-con m15 2-Generic


levocarnitine (with sugar) 3-Preferred Brand PA TO CONFIRM PART D COVERAGE

LEVOCARNITINE 330 MG TABLET 3-Preferred Brand PA TO CONFIRM PART D COVERAGE

magnesium sulfate 4 meqml vial 4-Non-PreferredDrug

NUTRILIPID 4-Non-PreferredDrug


OMEGAVEN 4-Non-PreferredDrug


plenamine 4-Non-PreferredDrug


potassium chloride (2 meqml vial 2meqml ampul 20meq15ml liquid40meq15ml liquid)

4-Non-PreferredDrug

potassium chloride (8 capsule er 8tablet er 10 tablet er 10 tab er prt 10capsule er 15 tab er prt 20 tablet er 20tab er prt)

2-Generic

POTASSIUM CHLORIDE IN DEXTROSE 5 AND 09 SODIUM CHLORIDE

4-Non-PreferredDrug

POTASSIUM CHLORIDE IN DEXTROSE 5-045 SODIUM CHLORIDE(CHLORIDED5-045NACL 10 IV SOLNCHLORIDED5-045NACL 20 IV SOLNCHLORIDED5-045NACL 30 IV SOLN)

4-Non-PreferredDrug

POTASSIUM CHLORIDE IN LACTATEDRINGERS AND 5 DEXTROSE

4-Non-PreferredDrug

potassium chloride in water forinjection sterile

4-Non-PreferredDrug

POTASSIUM CHLORIDED5-02NACL20 MEQL IV SOLN

4-Non-PreferredDrug

ringers solutionlactated iv soln 4-Non-PreferredDrug

SMOFLIPID 4-Non-PreferredDrug



69


Drug Name Drug Tier RequirementsLimitssodium chloride 045 4-Non-Preferred

Drug

SODIUM CHLORIDE IRRIGATINGSOLUTION

2-Generic

TPN ELECTROLYTES 4-Non-PreferredDrug

ELECTROLYTEMINERALMETAL MODIFIERSCHEMET 5-Specialty

clovique 5-Specialty PA

deferasirox 5-Specialty

JYNARQUE (15 MG TABLET 30 MGTABLET 45 MG-15 MG TABLET 60 MG-30 MG TABLET 90 MG-30 MG TABLET)

5-Specialty PA LA

JYNARQUE (15 MG-15 MG TABLET 30MG-15 MG TABLET)

5-Specialty PA

kionex 2-Generic

SAMSCA 15 MG TABLET 5-Specialty PA LA

sodium polystyrene sulfonate (15 g60ml oral susp powder)

2-Generic

sps 15 gm60 ml suspension 2-Generic

tolvaptan 5-Specialty PA

trientine hcl 5-Specialty PA

PHOSPHATE BINDERSAURYXIA 4-Non-Preferred

Drug

calcium acetate (667 mg capsule 667mg tablet)

3-Preferred Brand

FOSRENOL (750 MG POWDER PACKET1000 MG POWDER PACK)

5-Specialty

lanthanum carbonate 4-Non-PreferredDrug

PHOSLYRA 4-Non-PreferredDrug


70


Drug Name Drug Tier RequirementsLimitssevelamer carbonate (08 g powd pack24 g powd pack)

5-Specialty

sevelamer carbonate 800 mg tablet 4-Non-PreferredDrug

VITAMINSconcept ob 2-Generic

folivane-ob 2-Generic

multivitamin combination no51ferrousfumaratefolic acid

2-Generic

o-cal fa 2-Generic

ob complete 2-Generic

prenatal vitamins (no dha) 2-Generic

prenate am 2-Generic

prenate chewable 2-Generic

purefe ob plus 2-Generic

zingiber 2-Generic

GASTROINTESTINAL AGENTS

ANTISPASMODICS GASTROINTESTINALdicyclomine hcl (10 mg capsule 20 mgtablet)

2-Generic

glycopyrrolate (1 mg tablet 2 mgtablet)

2-Generic

glycopyrrolate 02 mgml vial 4-Non-PreferredDrug

methscopolamine bromide 2-Generic

GASTROINTESTINAL AGENTS OTHERchenodal 5-Specialty PA LA

cromolyn sodium 20 mgml oral conc 4-Non-PreferredDrug


71


Drug Name Drug Tier RequirementsLimitsdiphenoxylate hclatropine 25-025mgtablet

3-Preferred Brand

GATTEX 5-Specialty PA LA

lansoprazoleamoxicillintrihydrateclarithromycin

4-Non-PreferredDrug

loperamide hcl 2 mg capsule 2-Generic

MOVANTIK 4-Non-PreferredDrug

myalept 5-Specialty PA LA

MYTESI 4-Non-PreferredDrug

PYLERA 5-Specialty

RELISTOR (8 MG04 ML SYRINGE 150MG TABLET)

5-Specialty PA

RELISTOR 12 MG06 ML (KIT SYRINGEVIAL)

5-Specialty PA

SYMPROIC 4-Non-PreferredDrug

TALICIA 4-Non-PreferredDrug

ursodiol (250 mg tablet 300 mgcapsule 500 mg tablet)

3-Preferred Brand

XERMELO 5-Specialty PA LA

HISTAMINE2 (H2) RECEPTOR ANTAGONISTScimetidine 3-Preferred Brand

cimetidine hcl 3-Preferred Brand

famotidine (20 mg tablet 40mg5mlsusp recon 40 mg tablet)

2-Generic

famotidinepf 4-Non-PreferredDrug

nizatidine (150mg10ml solution 150mg capsule 300 mg capsule)

2-Generic


72



IRRITABLE BOWEL SYNDROME AGENTSalosetron hcl 4-Non-Preferred

Drug

AMITIZA 3-Preferred Brand

LINZESS 3-Preferred Brand

LUBIPROSTONE 3-Preferred Brand

VIBERZI 5-Specialty PA

LAXATIVESconstulose 2-Generic

enulose 2-Generic

gavilyte-c 2-Generic

gavilyte-g 2-Generic

gavilyte-n 2-Generic

generlac 2-Generic

lactulose (10 g15 ml solution 20 g30ml solution)

2-Generic

peg 3350sod sulfsod bicarbsodchloridepotassium chloride

2-Generic

peg 3350sodium sulfatesodchloridekclascorbate sodvit c

4-Non-PreferredDrug

PLENVU 4-Non-PreferredDrug

sodium chloridesodiumbicarbonatepotassium chloridepeg

2-Generic

SUPREP 4-Non-PreferredDrug

SUTAB 4-Non-PreferredDrug

trilyte with flavor packets 2-Generic


73



PROTECTANTSmisoprostol 2-Generic

sucralfate (1 g tablet 1 g10 ml oralsusp)

2-Generic

PROTON PUMP INHIBITORSDEXILANT 4-Non-Preferred

DrugST

esomeprazole magnesium (10 mgsuspdr pkt 20 mg suspdr pkt 40 mgsuspdr pkt)

4-Non-PreferredDrug

ST

esomeprazole magnesium (20 mgcapsule dr 40 mg capsule dr)

2-Generic

lansoprazole (15 mg capsule dr 30 mgcapsule dr)

2-Generic

NEXIUM (DR 25 MG PACKET DR 5 MGPACKET)

4-Non-PreferredDrug

ST

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

2-Generic

pantoprazole sodium (20 mg tablet dr40 mg tablet dr)

2-Generic

pantoprazole sodium (40 mg granpktdr 40 mg vial)

4-Non-PreferredDrug

rabeprazole sodium 20 mg tablet dr 2-Generic

GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERS TREATMENT

GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERS TREATMENTaralast np 5-Specialty PA LA

CARBAGLU 5-Specialty PA LA

CERDELGA 5-Specialty PA

CHOLBAM 5-Specialty PA

creon 3-Preferred Brand


74


Drug Name Drug Tier RequirementsLimitscystadane 5-Specialty LA

CYSTAGON 4-Non-PreferredDrug

LA

EVRYSDI 5-Specialty PA

GALAFOLD 5-Specialty PA LA QL (05 PER 1 DAY)

glassia 5-Specialty PA LA

miglustat 5-Specialty PA LA

nitisinone 5-Specialty

NITYR 5-Specialty LA

OCALIVA 5-Specialty PA LA QL (1 PER 1 DAY)

ORFADIN (4 MGML SUSPENSION 20MG CAPSULE)

5-Specialty LA

palynziq 10 mg05 ml syringe 5-Specialty PA LA QL (1 ML PER 1 DAY)

palynziq 25 mg05 ml syringe 5-Specialty PA LA QL (8 ML PER 28 OVER TIME)

palynziq 20 mgml syringe 5-Specialty PA LA

PROCYSBI (DR 75 MG GRANULE PKT DR300 MG GRANULE PKT)

5-Specialty PA LA

prolastin c 5-Specialty PA LA

RAVICTI 5-Specialty PA LA

sapropterin dihydrochloride 5-Specialty PA

sodium phenylbutyrate (094 ggpowder 500 mg tablet)

5-Specialty PA

sucraid 5-Specialty LA

zemaira 5-Specialty PA LA

zenpep 3-Preferred Brand

GENITOURINARY AGENTS

ANTISPASMODICS URINARYflavoxate hcl 2-Generic


75


Drug Name Drug Tier RequirementsLimitsMYRBETRIQ (ER 8 MGML SUSP ER 25MG TABLET ER 50 MG TABLET)

3-Preferred Brand

oxybutynin chloride (5 mg tablet 5 mgtab er 24 10 mg tab er 24 15 mg tab er24)

2-Generic

solifenacin succinate 2-Generic

tolterodine tartrate 3-Preferred Brand

TOVIAZ 3-Preferred Brand

trospium chloride 20 mg tablet 2-Generic

trospium chloride 60 mg cap er 24h 4-Non-PreferredDrug

BENIGN PROSTATIC HYPERTROPHY AGENTSalfuzosin hcl 2-Generic

dutasteride 2-Generic

finasteride 2-Generic

silodosin 3-Preferred Brand

tadalafil (25 mg tablet 5 mg tablet) 2-Generic PA QL (1 PER 1 DAY)

tamsulosin hcl 2-Generic

GENITOURINARY AGENTS OTHERbethanechol chloride 3-Preferred Brand

ELMIRON 5-Specialty QL (3 PER 1 DAY)

penicillamine 250 mg tablet 5-Specialty

potassium citrate 4-Non-PreferredDrug

RENACIDIN 4-Non-PreferredDrug

THIOLA EC 5-Specialty PA LA

tiopronin 5-Specialty PA


76



HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (ADRENAL)

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (ADRENAL)alclometasone dipropionate 005 cream (g)

4-Non-PreferredDrug

alclometasone dipropionate 005 oint (g)

2-Generic

amcinonide (01 cream (g) 01 lotion 01 oint (g))

4-Non-PreferredDrug

beser 4-Non-PreferredDrug

betamethasone dipropionate (005 lotion 005 gel (gram) 005 cream(g))

3-Preferred Brand

betamethasone dipropionate 005 oint (g)

4-Non-PreferredDrug

betamethasone dipropionatepropyleneglycol (005 oint (g) 005 lotion)

4-Non-PreferredDrug

betamethasone valerate (01 cream(g) 01 lotion)

3-Preferred Brand

betamethasone valerate 01 oint (g) 2-Generic

betamethasone valerate 012 foam 4-Non-PreferredDrug

betamethasonepropylene glyc 005 cream (g)

2-Generic

clobetasol propionate (005 lotion005 shampoo 005 oint (g) 005 gel (gram))

4-Non-PreferredDrug

clobetasol propionate (005 solution005 cream (g))

3-Preferred Brand

clobetasol propionateemoll 005 cream (g)

4-Non-PreferredDrug

clodan 4-Non-PreferredDrug


77


Drug Name Drug Tier RequirementsLimitscormax 3-Preferred Brand

cortisone acetate 4-Non-PreferredDrug

decadron 2-Generic

desonide (005 cream (g) 005 oint(g))

3-Preferred Brand

desonide 005 lotion 4-Non-PreferredDrug

desoximetasone (005 cream (g) 005 gel (gram) 005 oint (g) 025 oint (g) 025 cream (g))

4-Non-PreferredDrug

dexamethasone (05 mg tablet 075 mgtablet 1 mg tablet 15 mg tablet 2 mgtablet 4 mg tablet 6 mg tablet)

2-Generic

dexamethasone (05 mg5ml elixir 05mg5ml solution)

3-Preferred Brand

dexamethasone sodium phosppf 10mgml vial

4-Non-PreferredDrug

dexamethasone sodium phosphate (4mgml syringe 4 mgml vial 10 mgmlvial)

4-Non-PreferredDrug

diflorasone diacetate 4-Non-PreferredDrug

EMFLAZA (2275 MGML ORAL SUSP 30MG TABLET 36 MG TABLET)

5-Specialty PA LA

EMFLAZA 18 MG TABLET 5-Specialty PA LA QL (1 PER 1 DAY)


fludrocortisone acetate 2-Generic

fluocinolone 001 scalp oil 4-Non-PreferredDrug

fluocinolone acetonide (001 cream(g) 001 oil 001 solution 0025 oint (g) 0025 cream (g))

3-Preferred Brand

fluocinonide (005 gel (gram) 005 solution 005 cream (g) 005 oint(g))

3-Preferred Brand


78


Drug Name Drug Tier RequirementsLimitsfluocinonide 01 cream (g) 2-Generic

fluocinonideemollient base 3-Preferred Brand

fluticasone propionate (0005 oint(g) 005 cream (g))

2-Generic

fluticasone propionate 005 lotion 4-Non-PreferredDrug

halobetasol propionate (005 oint(g) 005 cream (g))

4-Non-PreferredDrug

hydrocortisone (1 oint (g) 1 cream(g) 1 crmpe app 25 lotion 25 oint (g) 5 mg tablet 10 mg tablet 20mg tablet)

2-Generic

hydrocortisone (25 cream (g) 25 crmpe app)

3-Preferred Brand

hydrocortisone butyrate (01 oint (g)01 solution 01 cream (g))

4-Non-PreferredDrug

hydrocortisone butyrateemollient base 4-Non-PreferredDrug

hydrocortisone valerate 4-Non-PreferredDrug

ISTURISA 5-Specialty PA

KORLYM 5-Specialty PA LA

methylprednisolone (4 mg tablet 4 mgtab ds pk)

2-Generic

methylprednisolone (8 mg tablet 16 mgtablet 32 mg tablet)

3-Preferred Brand

methylprednisolone acetate 4-Non-PreferredDrug

methylprednisolone sodium succinate 4-Non-PreferredDrug

mometasone furoate (01 cream (g)01 oint (g) 01 solution)

2-Generic

PREDNICARBATE 01 CREAM (G) 4-Non-PreferredDrug


79


Drug Name Drug Tier RequirementsLimitsprednisolone 2-Generic

prednisolone sodium phosphate (10 mgtab rapdis 15 mg tab rapdis)

4-Non-PreferredDrug

prednisolone sodium phosphate (5mg5 ml solution 15 mg5 ml solution25 mg5 ml solution)

2-Generic

prednisone (1 mg tablet 25 mg tablet5 mg tablet 5 mg tab ds pk 10 mg tabds pk 10 mg tablet 20 mg tablet 50mg tablet)

2-Generic

prednisone 5 mg5 ml solution 4-Non-PreferredDrug

prednisone intensol 4-Non-PreferredDrug

psorcon 4-Non-PreferredDrug

SOLU-CORTEF (100 MG ACT-O-VIAL250 MG ACT-O-VIAL 500 MG ACT-O-VIAL 1000 MG ACT-O-VL)

3-Preferred Brand

triamcinolone acetonide (0025 cream (g) 0025 oint (g) 01 oint(g) 01 cream (g) 05 oint (g) 05 cream (g))

2-Generic

triamcinolone acetonide (0025 lotion 01 lotion)

3-Preferred Brand

triderm 2-Generic

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (PITUITARY)

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (PITUITARY)desmopressin acetate (01 mg tablet02 mg tablet)

2-Generic

desmopressin acetate (non-refrigerated)

4-Non-PreferredDrug

desmopressin acetate 10sprayspraypump

4-Non-PreferredDrug


80


Drug Name Drug Tier RequirementsLimitsegrifta sv 5-Specialty PA LA

increlex 5-Specialty PA LA

omnitrope (5 mg15 ml crtg 58 mgvial 10 mg15 ml crtg)

5-Specialty PA

ORIAHNN 4-Non-PreferredDrug

PA

ORILISSA 4-Non-PreferredDrug

PA

STIMATE 5-Specialty

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEXHORMONESMODIFIERS)

ANABOLIC STEROIDSANADROL-50 5-Specialty

oxandrolone 2-Generic

ANDROGENSANDRODERM 4-Non-Preferred

DrugPA

danazol 3-Preferred Brand

testosterone (125g-162 gel packet25g-162 gel packet 2025125 gelmd pmp)

4-Non-PreferredDrug

PA

testosterone (125125g gel md pmp25mg(1) gel packet 50 mg (1) gel(gram) 50 mg (1) gel packet)

4-Non-PreferredDrug

testosterone cypionate 4-Non-PreferredDrug

testosterone enanthate 4-Non-PreferredDrug

ESTROGENSafirmelle 2-Generic

altavera 2-Generic


81


Drug Name Drug Tier RequirementsLimitsalyacen 2-Generic

amabelz 4-Non-PreferredDrug

amethyst 2-Generic

apri 2-Generic

aranelle 2-Generic

aubra 2-Generic

aubra eq 2-Generic

aurovela 1 mg-20 mcg tablet 4-Non-PreferredDrug

aurovela 21 15-30 tablet 2-Generic

aurovela 24 fe 3-Preferred Brand

aurovela fe 2-Generic

aviane 2-Generic

ayuna 3-Preferred Brand

azurette 2-Generic

balziva 2-Generic

bekyree 2-Generic

blisovi 24 fe 3-Preferred Brand

blisovi fe 2-Generic

briellyn 2-Generic

caziant 2-Generic

charlotte 24 fe 4-Non-PreferredDrug

chateal 3-Preferred Brand

chateal eq 3-Preferred Brand

COMBIPATCH 4-Non-PreferredDrug

cryselle 2-Generic


82


Drug Name Drug Tier RequirementsLimitscyclafem 2-Generic

cyred 2-Generic

cyred eq 2-Generic

dasetta 2-Generic

desogestrel-ethinyl estradiol 2-Generic

desogestrel-ethinyl estradiolethinylestradiol

2-Generic

dolishale 2-Generic

dotti 4-Non-PreferredDrug

elinest 2-Generic

eluryng 4-Non-PreferredDrug

emoquette 2-Generic

enpresse 2-Generic

enskyce 2-Generic

estarylla 2-Generic

estradiol (025mg24h patch tdsw025mg24h patch tdwk 0375mg24patch tdwk 0375mg24 patch tdsw005mg24h patch tdsw 005mg24hpatch tdwk 006mg24h patch tdwk075mg24h patch tdwk 075mg24hpatch tdsw 01mg24hr patch tdwk01mg24hr patch tdsw 10 mcg tablet)

4-Non-PreferredDrug

estradiol (05 mg tablet 1 mg tablet 2mg tablet)

2-Generic

estradiol 001 creamappl 3-Preferred Brand

estradiol valerate 4-Non-PreferredDrug

estradiolnorethindrone acetate 4-Non-PreferredDrug

ESTRING 3-Preferred Brand


83


Drug Name Drug Tier RequirementsLimitsethinyl estradioldrospirenone 2-Generic

ethynodiol diacetate-ethinyl estradiol 2-Generic

etonogestrelethinyl estradiol 4-Non-PreferredDrug

falmina 2-Generic

FEMRING 4-Non-PreferredDrug

femynor 2-Generic

fyavolv 4-Non-PreferredDrug

gemmily 4-Non-PreferredDrug

GIANVI 2-Generic

hailey 2-Generic

hailey 24 fe 3-Preferred Brand

hailey fe 2-Generic

iclevia 2-Generic

introvale 2-Generic

isibloom 2-Generic

jasmiel 2-Generic

jinteli 4-Non-PreferredDrug

JOLESSA 2-Generic

juleber 2-Generic

junel 1 mg-20 mcg tablet 4-Non-PreferredDrug

junel 15 mg-30 mcg tablet 2-Generic

junel fe 2-Generic

junel fe 24 3-Preferred Brand

kaitlib fe 4-Non-PreferredDrug


84


Drug Name Drug Tier RequirementsLimitskalliga 2-Generic

kariva 2-Generic

kelnor 1-35 2-Generic


kurvelo 2-Generic

larin 15 mg-30 mcg tablet 2-Generic

larin 21 1-20 tablet 4-Non-PreferredDrug

larin 24 fe 3-Preferred Brand

larin fe 2-Generic

larissia 2-Generic

LEENA 2-Generic

lessina 2-Generic

levonest 2-Generic

levonorgestrelethinyl estradiol 2-Generic

levora-28 2-Generic

lillow 2-Generic

lo-zumandimine 2-Generic

LOPREEZA 4-Non-PreferredDrug

loryna 2-Generic

low-ogestrel 2-Generic

lutera 2-Generic

lyllana 4-Non-PreferredDrug

marlissa 2-Generic

melodetta 24 fe 4-Non-PreferredDrug

menest 4-Non-PreferredDrug


85


Drug Name Drug Tier RequirementsLimitsmerzee 4-Non-Preferred

Drug

mibelas 24 fe 4-Non-PreferredDrug

microgestin 21 1-20 tablet 4-Non-PreferredDrug

microgestin 21 15-30 tab 2-Generic

microgestin 24 fe 3-Preferred Brand

microgestin fe 2-Generic

mili 2-Generic

mimvey 4-Non-PreferredDrug

mono-linyah 2-Generic

necon 2-Generic

nikki 2-Generic

noreth-ethinyl estradioliron 08-25(24)tab chew

4-Non-PreferredDrug

norethindrone ac-eth estradiol 1mg-5mcg tablet

4-Non-PreferredDrug

norethindrone acetate-ethinyl estradiol(05mg-25 tablet 1mg-20mcg tablet15-003mg tablet)

2-Generic

norethindrone acetate-ethinylestradiolferrous fumarate (1mg-20(21)tablet 15-30(21) tablet)

2-Generic

norethindrone acetate-ethinylestradiolferrous fumarate (1mg-20(24)capsule 1mg-20(24) tab chew)

4-Non-PreferredDrug

norgestimate-ethinyl estradiol 2-Generic

nortrel 2-Generic

nylia 2-Generic

nymyo 2-Generic

OCELLA 2-Generic


86


Drug Name Drug Tier RequirementsLimitsogestrel 2-Generic

orsythia 2-Generic

philith 2-Generic

pimtrea 2-Generic

pirmella 2-Generic

portia 2-Generic

PREMARIN (03 MG TABLET 045 MGTABLET 0625 MG TABLET 09 MGTABLET 125 MG TABLET VAGINALCREAM-APPL)

3-Preferred Brand

PREMPHASE 4-Non-PreferredDrug

PREMPRO 4-Non-PreferredDrug

previfem 2-Generic

reclipsen 2-Generic

setlakin 2-Generic

simliya 2-Generic

sprintec 2-Generic

sronyx 2-Generic

syeda 2-Generic

tarina 24 fe 3-Preferred Brand

tarina fe 2-Generic

tarina fe 1-20 eq 2-Generic

taysofy 4-Non-PreferredDrug

tilia fe 3-Preferred Brand

tri femynor 2-Generic

tri-estarylla 2-Generic

tri-legest fe 3-Preferred Brand


87


Drug Name Drug Tier RequirementsLimitstri-linyah 2-Generic

tri-lo-estarylla 2-Generic

tri-lo-marzia 2-Generic

tri-lo-mili 2-Generic

tri-lo-sprintec 2-Generic

tri-mili 2-Generic

tri-nymyo 2-Generic

tri-previfem 2-Generic

tri-sprintec 2-Generic

tri-vylibra 2-Generic

tri-vylibra lo 2-Generic

trivora-28 2-Generic

TYBLUME 2-Generic

velivet 2-Generic

vestura 2-Generic

vienva 2-Generic

viorele 2-Generic

volnea 2-Generic

vyfemla 2-Generic

vylibra 2-Generic

wera 2-Generic

xulane 2-Generic

yuvafem (10 mcg insert 10 mcg tablet) 4-Non-PreferredDrug

zafemy 2-Generic

zarah 2-Generic

zovia 1-35 2-Generic

zovia 1-35e 2-Generic


88


Drug Name Drug Tier RequirementsLimitszumandimine 2-Generic

PROGESTERONE AGONISTSANTAGONISTSELLA 4-Non-Preferred

Drug

PROGESTINScamila 2-Generic

deblitane 2-Generic

DEPO-PROVERA 400 MGML VIAL 4-Non-PreferredDrug

DEPO-SUBQ PROVERA 104 4-Non-PreferredDrug

errin 2-Generic

heather 2-Generic

incassia 2-Generic

jencycla 2-Generic

lyleq 2-Generic

lyza 2-Generic

medroxyprogesterone acetate (150mgml vial 150 mgml syringe)

4-Non-PreferredDrug

medroxyprogesterone acetate (25 mgtablet 5 mg tablet 10 mg tablet)

2-Generic

megestrol acetate (20 mg tablet 40 mgtablet 400mg10ml oral susp)

2-Generic

megestrol acetate 625mg5ml oral susp 4-Non-PreferredDrug

NORA-BE 2-Generic

norethindrone 2-Generic

norethindrone acetate 2-Generic

norlyda 2-Generic

progesterone micronized 2-Generic


89


Drug Name Drug Tier RequirementsLimitssharobel 2-Generic

tulana 2-Generic

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTSDUAVEE 4-Non-Preferred

Drug

raloxifene hcl 2-Generic

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (THYROID)

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (THYROID)armour thyroid 4-Non-Preferred

Drug

EUTHYROX 3-Preferred Brand

LEVO-T 3-Preferred Brand

levothyroxine sodium (100 mcg vial100mcg5ml vial 200 mcg vial200mcg5ml vial 500 mcg vial500mcg5ml vial)

4-Non-PreferredDrug

levothyroxine sodium (25 mcg tablet 50mcg tablet 75 mcg tablet 88 mcgtablet 100 mcg tablet 112 mcg tablet125 mcg tablet 137 mcg tablet 150mcg tablet 175 mcg tablet 200 mcgtablet 300 mcg tablet)

2-Generic

LEVOXYL 3-Preferred Brand

liothyronine sodium (5 mcg tablet 25mcg tablet 50 mcg tablet)

2-Generic

liothyronine sodium 10 mcgml vial 4-Non-PreferredDrug

np thyroid 4-Non-PreferredDrug

SYNTHROID 3-Preferred Brand

thyroid 4-Non-PreferredDrug


90


Drug Name Drug Tier RequirementsLimitsthyroidpork 4-Non-Preferred

Drug

UNITHROID 3-Preferred Brand

HORMONAL AGENTS SUPPRESSANT (PITUITARY)

HORMONAL AGENTS SUPPRESSANT (PITUITARY)cabergoline 2-Generic

ELIGARD 4-Non-PreferredDrug

FIRMAGON 4-Non-PreferredDrug

leuprolide acetate 4-Non-PreferredDrug

LUPANETA PACK 5-Specialty

LUPRON DEPOT 5-Specialty

LUPRON DEPOT-PED (75 MG KIT 1125MG 3MO)

5-Specialty

MYCAPSSA 4-Non-PreferredDrug

PA

octreotide acetate 4-Non-PreferredDrug

ORGOVYX 5-Specialty PA FOR NEW STARTS ONLY

SIGNIFOR 5-Specialty PA LA

SOMATULINE DEPOT 5-Specialty

somavert 5-Specialty PA LA

SYNAREL 5-Specialty PA

trelstar 5-Specialty

HORMONAL AGENTS SUPPRESSANT (THYROID)

ANTITHYROID AGENTSmethimazole 2-Generic


91


Drug Name Drug Tier RequirementsLimitspropylthiouracil 3-Preferred Brand

IMMUNOLOGICAL AGENTS

ANGIOEDEMA AGENTScinryze 5-Specialty PA LA

haegarda 5-Specialty PA LA

icatibant acetate 5-Specialty PA QL (18 ML PER 30 OVER TIME)

ORLADEYO 5-Specialty PA LA QL (1 PER 1 DAYS)

sajazir 5-Specialty PA QL (18 ML PER 30 OVER TIME)

takhzyro 5-Specialty PA LA

IMMUNE SUPPRESSANTSASTAGRAF XL 4-Non-Preferred


azathioprine 50 mg tablet 2-Generic PA TO CONFIRM PART D COVERAGE

azathioprine sodium 4-Non-PreferredDrug


cyclosporine (25 mg capsule 100 mgcapsule)

4-Non-PreferredDrug


cyclosporine modified (25 mg capsule50 mg capsule 100 mgml solution 100mg capsule)

4-Non-PreferredDrug


enbrel (25 mg05 ml vial 25 mg kit 25mg05 ml syringe 50 mgml syringe)

5-Specialty PA

enbrel mini 5-Specialty PA

enbrel sureclick 5-Specialty PA

everolimus (05 mg tablet 075 mgtablet)

5-Specialty PA TO CONFIRM PART D COVERAGEQL (2 PER 1 DAY)

everolimus 025 mg tablet 4-Non-PreferredDrug

PA TO CONFIRM PART D COVERAGEQL (2 PER 1 DAY)

gengraf (25 mg capsule 100 mgmlsolution 100 mg capsule)

4-Non-PreferredDrug



92


Drug Name Drug Tier RequirementsLimitshumira 5-Specialty PA

humira pen 5-Specialty PA

humira pen crohns-uc-hs 5-Specialty PA

humira pen psor-uveits-adol hs 5-Specialty PA

humira(cf) 5-Specialty PA

humira(cf) pediatric crohns 5-Specialty PA

humira(cf) pen 5-Specialty PA

humira(cf) pen crohns-uc-hs 5-Specialty PA

humira(cf) pen pediatric uc 5-Specialty PA

humira(cf) pen psor-uv-adol hs 5-Specialty PA

LUPKYNIS 5-Specialty PA

methotrexate sodium (25 mg tablet 25mgml vial)

2-Generic

methotrexate sodiumpf (1 g vial 25mgml vial)

2-Generic

mycophenolate mofetil (250 mgcapsule 500 mg tablet)

2-Generic PA TO CONFIRM PART D COVERAGE

mycophenolate mofetil 200 mgml susprecon

5-Specialty PA TO CONFIRM PART D COVERAGE

mycophenolate sodium 4-Non-PreferredDrug


orencia (50 mg04 ml syringe 875mg07 ml syringe 125 mgml syringe)

5-Specialty PA

orencia clickject 5-Specialty PA

PROGRAF (02 MG GRANULE PACKET 5MGML AMPULE)

4-Non-PreferredDrug


PROGRAF 1 MG GRANULE PACKET 5-Specialty PA TO CONFIRM PART D COVERAGE

REZUROCK 5-Specialty PA FOR NEW STARTS ONLY QL (1 PER1 DAYS)

RINVOQ 5-Specialty PA

sirolimus (05 mg tablet 1 mg tablet 2mg tablet)

4-Non-PreferredDrug



93


Drug Name Drug Tier RequirementsLimitssirolimus 1 mgml solution 5-Specialty PA TO CONFIRM PART D COVERAGE

tacrolimus (05 mg capsule 1 mgcapsule)


tacrolimus 5 mg capsule 4-Non-PreferredDrug


trexall 4-Non-PreferredDrug

XATMEP 4-Non-PreferredDrug

XELJANZ (1 MGML SOLUTION 5 MGTABLET 10 MG TABLET)

5-Specialty PA

XELJANZ XR 5-Specialty PA

ZORTRESS 1 MG TABLET 5-Specialty PA TO CONFIRM PART D COVERAGEQL (2 PER 1 DAY)

IMMUNIZING AGENTS PASSIVEbivigam 5-Specialty PA

flebogamma dif 5-Specialty PA

gammagard liquid 5-Specialty PA

gammagard s-d 5-Specialty PA

gammaked 5-Specialty PA

gammaplex 5-Specialty PA

gamunex-c (25 gram25 ml vial 5gram50 ml vial 10 gram100 ml vial20 gram200 ml vial 40 gram400 mlvial)

5-Specialty PA LA

gamunex-c 1 gram10 ml vial 5-Specialty PA

octagam 5-Specialty PA

panzyga 5-Specialty PA

privigen 5-Specialty PA

IMMUNOLOGICAL AGENTS OTHERenspryng 5-Specialty PA


94



IMMUNOMODULATORSactimmune 5-Specialty PA FOR NEW STARTS ONLY LA

arcalyst 5-Specialty PA LA

benlysta (200 mgml syringe 200mgml autoinject)

5-Specialty PA LA QL (4 ML PER 28 OVER TIME)

grastek 4-Non-PreferredDrug

PA

leflunomide 3-Preferred Brand

odactra 4-Non-PreferredDrug

PA

oralair 4-Non-PreferredDrug

PA LA

OTEZLA 5-Specialty PA

ragwitek 4-Non-PreferredDrug

PA

VACCINESacthib 3-Preferred Brand

adacel tdap 3-Preferred Brand

bcg vaccine livepf 3-Preferred Brand

bexsero 3-Preferred Brand

boostrix tdap 3-Preferred Brand

daptacel dtap 3-Preferred Brand

engerix-b adult 3-Preferred Brand PA TO CONFIRM PART D COVERAGE

engerix-b pediatric-adolescent 3-Preferred Brand PA TO CONFIRM PART D COVERAGE

gardasil 9 3-Preferred Brand

havrix (720 unit05 ml syringe 1440unitsml vial 1440 unitsml syringe)

3-Preferred Brand

hiberix 3-Preferred Brand

imovax rabies vaccine 3-Preferred Brand

infanrix dtap 3-Preferred Brand


95


Drug Name Drug Tier RequirementsLimitsipol 3-Preferred Brand

ixiaro 3-Preferred Brand

kinrix 3-Preferred Brand

m-m-r ii vaccine 3-Preferred Brand

menactra 3-Preferred Brand

menquadfi 3-Preferred Brand

menveo a-c-y-w-135-dip 3-Preferred Brand

pediarix 3-Preferred Brand

pedvaxhib 3-Preferred Brand

pentacel acthib component 3-Preferred Brand

pentacel dtap-ipv component 3-Preferred Brand

proquad 3-Preferred Brand

quadracel dtap-ipv 3-Preferred Brand

rabavert 3-Preferred Brand

recombivax hb 3-Preferred Brand PA TO CONFIRM PART D COVERAGE

rotarix 3-Preferred Brand

rotateq 3-Preferred Brand

shingrix 3-Preferred Brand

tenivac 3-Preferred Brand

tetanus and diphtheria toxoids adult 3-Preferred Brand

tetanusdiphtheria toxoid pedpf 3-Preferred Brand

trumenba 3-Preferred Brand

twinrix 3-Preferred Brand

typhim vi 3-Preferred Brand

vaqta 3-Preferred Brand

varivax vaccine 3-Preferred Brand

yf-vax 3-Preferred Brand


96



INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATESbalsalazide disodium 3-Preferred Brand

DIPENTUM 5-Specialty

mesalamine (12 g tablet dr 4 g60 mlenema 400 mg cap(drtab) 800 mgtablet dr 1000 mg supprect)

4-Non-PreferredDrug

mesalamine 0375g cap er 24h 3-Preferred Brand

mesalamine with cleansing wipes 4-Non-PreferredDrug

PENTASA 5-Specialty

GLUCOCORTICOIDSanusol-hc 3-Preferred Brand

budesonide 3 mg capdr - er 4-Non-PreferredDrug

budesonide 9 mg tabdr - er 5-Specialty PA

colocort 2-Generic

hydrocortisone 100mg60ml enema 2-Generic

procto-med hc 3-Preferred Brand

proctosol-hc 3-Preferred Brand

proctozone-hc 3-Preferred Brand

SULFONAMIDESsulfasalazine 500 mg tablet 2-Generic

sulfasalazine 500 mg tablet dr 3-Preferred Brand

METABOLIC BONE DISEASE AGENTS

METABOLIC BONE DISEASE AGENTSalendronate sodium (5 mg tablet 10mg tablet 35 mg tablet 70 mg tablet)

2-Generic


97


Drug Name Drug Tier RequirementsLimitsalendronate sodium 70 mg75mlsolution

4-Non-PreferredDrug

BINOSTO 4-Non-PreferredDrug

calcitoninsalmonsynthetic 200sprayspraypump

3-Preferred Brand PA TO CONFIRM PART D COVERAGE

calcitriol (025 mcg capsule 05 mcgcapsule 1 mcgml solution)


cinacalcet hcl 30 mg tablet 4-Non-PreferredDrug


cinacalcet hcl 60 mg tablet 5-Specialty PA TO CONFIRM PART D COVERAGEQL (2 PER 1 DAY)


doxercalciferol (05 mcg capsule 1 mcgcapsule 25 mcg capsule)

2-Generic PA TO CONFIRM PART D COVERAGEST

etidronate disodium 2-Generic

ibandronate sodium (3 mg3 ml syringe3 mg3 ml vial)

4-Non-PreferredDrug


ibandronate sodium 150 mg tablet 2-Generic

natpara 5-Specialty PA LA QL (2 PER 28 OVER TIME)

pamidronate disodium (30 mg vial30mg10ml vial 60 mg10ml vial 90mg vial 90 mg10ml vial)

4-Non-PreferredDrug


paricalcitol (1 mcg capsule 2 mcgcapsule 4 mcg capsule)

4-Non-PreferredDrug

PA TO CONFIRM PART D COVERAGEST

paricalcitol (2 mcgml vial 5 mcgmlvial)

4-Non-PreferredDrug


prolia 4-Non-PreferredDrug

risedronate sodium (35 mg tablet 150mg tablet)

2-Generic

risedronate sodium (5 mg tablet 30 mgtablet 35 mg tablet dr)

4-Non-PreferredDrug


98


Drug Name Drug Tier RequirementsLimitsTYMLOS 5-Specialty PA

xgeva 5-Specialty

zoledronic acid (4 mg5 ml vial 4 mgvial)

4-Non-PreferredDrug


ZOLEDRONIC ACID IN MANNITOL AND09 SODIUM CHLORIDE

4-Non-PreferredDrug

zoledronic acid in mannitol and waterfor injection

4-Non-PreferredDrug


MISCELLANEOUS THERAPEUTIC AGENTS

MISCELLANEOUS THERAPEUTIC AGENTSalcohol antiseptic pads 2-Generic

gauze bandage 2 x 2 bandage 2-Generic

insulin pen needles 2-Generic

insulin syringes 2-Generic

methergine 4-Non-PreferredDrug

methylergonovine maleate 02 mgtablet

4-Non-PreferredDrug

pen needle diabetic (pen 29 g x12 disneedle pen 31 g x14 dis needle pen31 gx316 dis needle pen 31 gx516dis needle pen 31gx1564 dis needlepen 31g x532 dis needle pen 32gx516 dis needle pen 32 gx316 disneedle pen 32 gx 14 dis needle pen32gx 532 dis needle pen 33 gx532dis needle pen 33 g x14 dis needlepen 33 gx316 dis needle)

2-Generic

pen needle diabetic remover anddisposal unit

2-Generic


99


Drug Name Drug Tier RequirementsLimitspen needle diabetic safety (pen 29gx516 dis needle pen 30 gx516 disneedle pen 30 gx316 dis needle pen30 g x14 dis needle pen 31 g x14 disneedle pen 32gx 532 dis needle)

2-Generic

syringe with needle insulin1 ml andsharps container

2-Generic

syringe with needledisposableinsulin 1ml (syringe needleinsulin1ml 27gx58disp syrin syringe needleinsulin1ml 29g x12 disp syrin syringeneedleinsulin1ml 27gx12 disp syrinsyringe needleinsulin1ml 28gx12disp syrin)

2-Generic

syringe without needleinsulindisposible 1 ml

2-Generic

syringe insulin u-500 with needledisposable 05 ml

2-Generic

syringe-needleinsulin05mlcontainerempty

2-Generic

OPHTHALMIC AGENTS

OPHTHALMIC AGENTS OTHERak-poly-bac 4-Non-Preferred

Drug

ATROPINE SULFATE 1 DROPS 4-Non-PreferredDrug

bacitracinpolymyxin b sulfate 4-Non-PreferredDrug

BLEPHAMIDE 3-Preferred Brand

blephamide sop 3-Preferred Brand

CYSTADROPS 5-Specialty LA QL (20 ML PER 28 OVER TIME)

CYSTARAN 5-Specialty LA QL (60 ML PER 30 OVER TIME)

LACRISERT 4-Non-PreferredDrug


100


Drug Name Drug Tier RequirementsLimitsneo-polycin 4-Non-Preferred

Drug

neo-polycin hc 4-Non-PreferredDrug

neomycin sulfatebacitracinzincpolymyxin bhydrocortisone

4-Non-PreferredDrug

neomycin sulfatebacitracinpolymyxinb

4-Non-PreferredDrug

neomycin sulfatepolymyxin bsulfategramicidin d

4-Non-PreferredDrug

neomycinpolymyxin bsulfatedexamethasone (01 dropssusp 35-10k-1 oint (g))

2-Generic

neomycinpolymyxin bhydrocort 35-10k-10 drops susp

4-Non-PreferredDrug

oxervate 5-Specialty PA QL (1 ML PER 1 DAY)

polycin 4-Non-PreferredDrug

polymyxin b sulfatetrimethoprim 2-Generic

RESTASIS 3-Preferred Brand QL (2 PER 1 DAY)

RESTASIS MULTIDOSE 3-Preferred Brand QL (55 ML PER 28 OVER TIME)

sulfacetamide sodiumprednisolonesodium phosphate

4-Non-PreferredDrug

TOBRADEX EYE OINTMENT 4-Non-PreferredDrug

tobramycindexamethasone 4-Non-PreferredDrug

tropicamide 4-Non-PreferredDrug

ZYLET 3-Preferred Brand

OPHTHALMIC ANTI-ALLERGY AGENTSALOMIDE 4-Non-Preferred

Drug


101


Drug Name Drug Tier RequirementsLimitsazelastine hcl 005 drops 2-Generic

cromolyn sodium 4 drops 2-Generic

epinastine hcl 3-Preferred Brand

olopatadine hcl 01 drops 2-Generic

olopatadine hcl 02 drops 4-Non-PreferredDrug

PAZEO 3-Preferred Brand

OPHTHALMIC ANTI-INFLAMMATORIESALREX 3-Preferred Brand

bromfenac sodium 4-Non-PreferredDrug

dexamethasone sodium phosphate 01 drops

3-Preferred Brand

diclofenac sodium 01 drops 2-Generic

difluprednate 4-Non-PreferredDrug

FLAREX 3-Preferred Brand

FLUOROMETHOLONE 3-Preferred Brand

flurbiprofen sodium 2-Generic

FML FORTE 3-Preferred Brand

FML SOP 3-Preferred Brand

ILEVRO 3-Preferred Brand

INVELTYS 4-Non-PreferredDrug

ketorolac tromethamine 04 drops 3-Preferred Brand

ketorolac tromethamine 05 drops 2-Generic

LOTEMAX 05 EYE OINTMENT 3-Preferred Brand

LOTEMAX SM 3-Preferred Brand

loteprednol etabonate (05 dropssusp 05 drops gel)

3-Preferred Brand


102


Drug Name Drug Tier RequirementsLimitsPRED MILD 4-Non-Preferred

Drug

PREDNISOLONE ACETATE 3-Preferred Brand

prednisolone sodium phosphate 1 drops

2-Generic

PROLENSA 4-Non-PreferredDrug

OPHTHALMIC ANTIGLAUCOMA AGENTSALPHAGAN P 01 DROPS 3-Preferred Brand

apraclonidine hcl 4-Non-PreferredDrug

betaxolol hcl 05 drops 3-Preferred Brand

BETIMOL 4-Non-PreferredDrug

brimonidine tartrate 015 drops 4-Non-PreferredDrug

brimonidine tartrate 02 drops 2-Generic

brinzolamide 4-Non-PreferredDrug

carteolol hcl 2-Generic

COMBIGAN 4-Non-PreferredDrug

dorzolamide hcl 2-Generic

dorzolamide hcltimolol maleate 2-Generic

dorzolamide hcltimolol maleatepf 4-Non-PreferredDrug

levobunolol hcl 1-PreferredGeneric

PHOSPHOLINE IODIDE 4-Non-PreferredDrug

pilocarpine hcl (1 drops 2 drops 4 drops)

3-Preferred Brand


103


Drug Name Drug Tier RequirementsLimitsRHOPRESSA 3-Preferred Brand ST

SIMBRINZA 3-Preferred Brand

timolol maleate (025 drops 05 drops)

1-PreferredGeneric

timolol maleate (025 sol-gel 05 sol-gel)

4-Non-PreferredDrug

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGSbimatoprost 3-Preferred Brand

latanoprost 2-Generic

LUMIGAN 3-Preferred Brand

travoprost 2-Generic

VYZULTA 4-Non-PreferredDrug

ST

XELPROS 4-Non-PreferredDrug

OTIC AGENTS

OTIC AGENTSacetic acid 2 solution 2-Generic

ciprofloxacin hcldexamethasone 3-Preferred Brand

fluocinolone acetonide oil 4-Non-PreferredDrug

hydrocortisoneacetic acid 4-Non-PreferredDrug

neomycin sulfatepolymyxin bsulfatehydrocortisone (35-10k-1 dropssusp 35-10k-1 solution)

4-Non-PreferredDrug

RESPIRATORY TRACTPULMONARY AGENTS

ANTI-INFLAMMATORIES INHALED CORTICOSTEROIDSARNUITY ELLIPTA 3-Preferred Brand


104


Drug Name Drug Tier RequirementsLimitsASMANEX (TWISTHALER 110 MCG 30TWISTHALER 220 MCG 60TWISTHALER 220 MCG 30 TWISTHALR220 MCG 120)

3-Preferred Brand

ASMANEX HFA 3-Preferred Brand

budesonide (025mg2ml ampul-neb05 mg2ml ampul-neb 1 mg2 mlampul-neb)

4-Non-PreferredDrug


FLOVENT DISKUS 3-Preferred Brand

FLOVENT HFA 3-Preferred Brand

flunisolide 3-Preferred Brand

fluticasone propionate 50 mcg spraysusp

2-Generic

mometasone furoate 50 mcgspraypump

3-Preferred Brand

QVAR REDIHALER 3-Preferred Brand

ANTIHISTAMINESazelastine hcl 137 mcg spraypump 2-Generic

azelastine hcl 2055 mcg spraypump 3-Preferred Brand

clemastine fumarate 268 mg tablet 4-Non-PreferredDrug

cyproheptadine hcl (2 mg5 ml syrup 4mg10 ml syrup 4 mg tablet)

2-Generic

diphenhydramine hcl 50 mgml vial 4-Non-PreferredDrug

hydroxyzine hcl (10 mg tablet 25 mgtablet 50 mg tablet)

4-Non-PreferredDrug

hydroxyzine pamoate (25 mg capsule50 mg capsule)

4-Non-PreferredDrug

levocetirizine dihydrochloride 25mg5ml solution

4-Non-PreferredDrug

levocetirizine dihydrochloride 5 mgtablet

2-Generic


105


Drug Name Drug Tier RequirementsLimitsolopatadine hcl 06 spraypump 4-Non-Preferred

Drug

ANTILEUKOTRIENESmontelukast sodium 2-Generic

zafirlukast 4-Non-PreferredDrug

BRONCHODILATORS ANTICHOLINERGICATROVENT HFA 3-Preferred Brand

INCRUSE ELLIPTA 3-Preferred Brand

ipratropium bromide (21 mcg spray 42mcg spray)

2-Generic

ipratropium bromide 02 mgmlsolution


SPIRIVA 3-Preferred Brand

SPIRIVA RESPIMAT 3-Preferred Brand

BRONCHODILATORS SYMPATHOMIMETICalbuterol sulfate (063mg3ml vial-neb125mg3ml vial-neb 25 mg05 vial-neb 5 mgml solution)


albuterol sulfate (2 mg tablet 4 mg taber 12h 4 mg tablet 8 mg tab er 12h)

4-Non-PreferredDrug

albuterol sulfate 2 mg5 ml syrup 2-Generic

albuterol sulfate 25 mg3ml vial-neb 2-Generic PA TO CONFIRM PART D COVERAGE

albuterol sulfate 90 mcg hfa (generic forproair)

2-Generic QL (17 GM PER 30 OVER TIME)

albuterol sulfate 90 mcg hfa (generic forproventil)


albuterol sulfate 90 mcg hfa (generic forventolin)


AUVI-Q 01 MG AUTO-INJECTOR 4-Non-PreferredDrug

epinephrine (015mg03 auto injct015015 auto injct 03mg03 autoinjct)

2-Generic


106


Drug Name Drug Tier RequirementsLimitsepinephrine 1 mgml vial 4-Non-Preferred

Drug

formoterol fumarate 5-Specialty

levalbuterol hcl (031mg3ml vial-neb063mg3ml vial-neb 125mg05 vial-neb 125mg3ml vial-neb)

4-Non-PreferredDrug

LEVALBUTEROL TARTRATE 4-Non-PreferredDrug

metaproterenol sulfate 2-Generic

PERFOROMIST 5-Specialty

PROAIR RESPICLICK 4-Non-PreferredDrug


SEREVENT DISKUS 3-Preferred Brand

terbutaline sulfate (25 mg tablet 5 mgtablet)

4-Non-PreferredDrug

CYSTIC FIBROSIS AGENTSCAYSTON 5-Specialty LA

KALYDECO 5-Specialty PA LA QL (2 PER 1 DAY)

ORKAMBI (100 MG-125 MG TABLET200 MG-125 MG TABLET)


ORKAMBI (100-125 MG GRANULE PKT150-188 MG GRANULE PKT)


pulmozyme 5-Specialty PA TO CONFIRM PART D COVERAGE

SYMDEKO 5-Specialty PA LA QL (2 PER 1 DAY)

tobi podhaler 5-Specialty LA

tobramycin in 0225 sodium chloride 5-Specialty PA TO CONFIRM PART D COVERAGE

TRIKAFTA 100-50-75 MG150 MG 5-Specialty PA LA QL (3 PER 1 DAY)

TRIKAFTA 50-25-375 MG75 MG 5-Specialty PA LA QL (3 PER 1 DAYS)

MAST CELL STABILIZERScromolyn sodium 20 mg2 ml ampul-neb

4-Non-PreferredDrug



107



PHOSPHODIESTERASE INHIBITORS AIRWAYS DISEASEDALIRESP 4-Non-Preferred

DrugPA

theophylline anhydrous (100 mg tab er12h 200 mg tab er 12h 300 mg tab er12h 400 mg tab er 24h 450 mg tab er12h 600 mg tab er 24h)

2-Generic

PULMONARY ANTIHYPERTENSIVESADEMPAS 5-Specialty PA LA

alyq 2-Generic PA QL (2 PER 1 DAY)

ambrisentan 5-Specialty PA LA

bosentan 5-Specialty PA LA

OPSUMIT 5-Specialty PA LA

sildenafil citrate 20 mg tablet 2-Generic PA

tadalafil 20 mg tablet 2-Generic PA QL (2 PER 1 DAY)

TRACLEER 32 MG TABLET FOR SUSP 5-Specialty PA LA

UPTRAVI (200 MCG TABLET 200-800TITRATION PACK 400 MCG TABLET 600MCG TABLET 800 MCG TABLET 1000MCG TABLET 1200 MCG TABLET 1400MCG TABLET 1600 MCG TABLET)

5-Specialty PA LA

PULMONARY FIBROSIS AGENTSESBRIET 5-Specialty PA LA

OFEV 5-Specialty PA LA

RESPIRATORY TRACT AGENTS OTHERacetylcysteine 2-Generic PA TO CONFIRM PART D COVERAGE

ADVAIR DISKUS 2-Generic

ADVAIR HFA 2-Generic

ANORO ELLIPTA 3-Preferred Brand

BREO ELLIPTA 3-Preferred Brand


108


Drug Name Drug Tier RequirementsLimitsCOMBIVENT RESPIMAT 3-Preferred Brand QL (8 GM PER 30 OVER TIME)

DULERA 3-Preferred Brand

fasenra pen 5-Specialty PA LA QL (1 ML PER 28 OVER TIME)

FLUTICASONEPROPIONATESALMETEROL XINAFOATE(55-14 MCG AER POW BA 113-14 MCGAER POW BA 232-14 MCG AER POWBA)

2-Generic

ipratropium bromidealbuterol sulfate 2-Generic PA TO CONFIRM PART D COVERAGE

nucala (100 mgml powder vial 100mgml auto-injector 100 mgmlsyringe)

5-Specialty PA LA QL (3 PER 28 OVER TIME)

STIOLTO RESPIMAT 3-Preferred Brand

SYMBICORT 3-Preferred Brand

TRELEGY ELLIPTA 3-Preferred Brand

xolair (75 mg05 ml syringe 150mgml syringe)

5-Specialty PA LA

xolair 150 mg12 ml powder vl 5-Specialty PA LA

SKELETAL MUSCLE RELAXANTS

SKELETAL MUSCLE RELAXANTScyclobenzaprine hcl (5 mg tablet 75mg tablet 10 mg tablet)

2-Generic

methocarbamol (500 mg tablet 750 mgtablet)

2-Generic

SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORSeszopiclone 2-Generic

temazepam (15 mg capsule 30 mgcapsule)

2-Generic

temazepam 75 mg capsule 3-Preferred Brand


109


Drug Name Drug Tier RequirementsLimitszaleplon 2-Generic

zolpidem tartrate (5 mg tablet 10 mgtablet)

2-Generic

SLEEP DISORDERS OTHERarmodafinil 4-Non-Preferred

Drug

HETLIOZ 5-Specialty PA LA QL (1 PER 1 DAY)

HETLIOZ LQ 5-Specialty PA LA QL (5 ML PER 1 DAYS)

modafinil 3-Preferred Brand

SUNOSI 4-Non-PreferredDrug

PA QL (1 PER 1 DAY)

WAKIX 5-Specialty PA LA QL (2 PER 1 DAY)

XYREM 5-Specialty PA LA QL (18 ML PER 1 DAY)

XYWAV 5-Specialty PA LA QL (18 ML PER 1 DAYS)

MISCELLANEOUS

Diabetes Testing Suppliesaccu chek (meters amp test strips) PART B BENEFIT QL (150 STRIPS PER 30 DAYS)

lifescan (meters amp test strips) PART B BENEFIT QL (150 STRIPS PER 30 DAYS)


110

Alphabetical Listing

009 sodium chloride 68

Aabacavir sulfate 41

abacavir sulfatelamivudine 41

abacavir sulfatelamivudinezidovudine 41

ABELCET 23

ABILIFY MAINTENA 37

ABILIFY MYCITE 37

abiraterone acetate 28

acamprosate calcium 5

acarbose 45

accutane 65

acebutolol hcl 54

acetaminophen with codeine phosphate 3

acetazolamide 58

acetic acid 104

acetylcysteine 108

acitretin 65

acthib 95

actimmune 95

acyclovir 44

acyclovir sodium 44

adacel tdap 95

adapalene 65

adefovir dipivoxil 40

ADEMPAS 108

ADVAIR DISKUS 108

ADVAIR HFA 108

AEMCOLO 7

AFINITOR 31

AFINITOR DISPERZ 31

afirmelle 81

aimovig autoinjector 25

ak-poly-bac 100

AKYNZEO 22

albendazole 33

albuterol sulfate 106

albuterol sulfate 90 mcg hfa (generic for proair) 106

albuterol sulfate 90 mcg hfa (generic for proventil) 106

albuterol sulfate 90 mcg hfa (generic for ventolin) 106

alclometasone dipropionate 77

alcohol antiseptic pads 99

ALECENSA 31

alendronate sodium 97

alfuzosin hcl 76

aliskiren hemifumarate 56

allopurinol 25

almotriptan malate 26

ALOGLIPTIN BENZOATE 45

ALOGLIPTIN BENZOATEMETFORMIN HCL 45

ALOGLIPTIN BENZOATEPIOGLITAZONE HCL 45

ALOMIDE 101

alosetron hcl 73

ALPHAGAN P 103

alprazolam 44

ALREX 102

altavera 81

ALTRENO 65

ALUNBRIG 29

alyacen 82

alyq 108

amabelz 82

amantadine hcl 35

AMBISOME 23

ambrisentan 108

amcinonide 77

amethyst 82

amifostine crystalline 29

amiloride hcl 58

amiloride hclhydrochlorothiazide 56

AMINOSYN II 68

amiodarone hcl 53

AMITIZA 73

amitriptyline hcl 21

amlodipine besylate 55

amlodipine besylatebenazepril hcl 56

amlodipine besylateolmesartan medoxomil 56

amlodipine besylatevalsartan 56

amlodipine besylatevalsartanhydrochlorothiazide 56

111

ammonium lactate 65

amnesteem 65

amoxapine 21

amoxicillin 11

amoxicillinpotassium clavulanate 11

amphotericin b 23

ampicillin sodium 11

ampicillin sodiumsulbactam sodium 11

ampicillin trihydrate 11

ANADROL-50 81

anagrelide hcl 50

anastrozole 30

ANDRODERM 81

ANORO ELLIPTA 108

anusol-hc 97

APOKYN 35

apraclonidine hcl 103

aprepitant 22

apri 82

APTIOM 18

APTIVUS 43

aralast np 74

aranelle 82

aranesp 50

arcalyst 95

aripiprazole 37

ARISTADA 37

ARISTADA INITIO 37

armodafinil 110

armour thyroid 90

ARNUITY ELLIPTA 104

arsenic trioxide 29

ascomp with codeine 3

asenapine maleate 37

ASMANEX 105

ASMANEX HFA 105

aspirindipyridamole 51

ASTAGRAF XL 92

atazanavir sulfate 43

atenolol 54

atenololchlorthalidone 56

atomoxetine hcl 62

atorvastatin calcium 59

atovaquone 34

atovaquoneproguanil hcl 34

ATROPINE SULFATE 100

ATROVENT HFA 106

AUBAGIO 63

aubra 82

aubra eq 82

aurovela 82

aurovela 24 fe 82

aurovela fe 82

AURYXIA 70

AUSTEDO 63

AUVI-Q 106

aviane 82

avidoxy 14

AVITA 65

avonex 63

avonex pen 64

AVYCAZ 9

ayuna 82

AYVAKIT 29

AZASITE 12

azathioprine 92

azathioprine sodium 92

azelaic acid 65

azelastine hcl 102

azithromycin 12

aztreonam 11

azurette 82

Bbacitracin 7

bacitracinpolymyxin b sulfate 100

baclofen 39

balsalazide disodium 97

BALVERSA 29

balziva 82

BAQSIMI 48

BARACLUDE 40

112

bcg vaccine livepf 95

bekyree 82

BELBUCA 2

benazepril hcl 52

benazepril hclhydrochlorothiazide 56

benlysta 95

BENZNIDAZOLE 34

benztropine mesylate 34

beser 77

betamethasone dipropionate 77

betamethasone dipropionatepropylene glycol 77

betamethasone valerate 77

betaseron 64

betaxolol hcl 54

bethanechol chloride 76

BETIMOL 103

bexarotene 33

bexsero 95

bicalutamide 28

BICILLIN C-R 11

BICILLIN L-A 12

BIKTARVY 40

bimatoprost 104

BINOSTO 98

bisoprolol fumarate 54

bisoprolol fumaratehydrochlorothiazide 56

bivigam 94

BLEPHAMIDE 100

blephamide sop 100

blisovi 24 fe 82

blisovi fe 82

blood sugar diagnostic 110

boostrix tdap 95

bosentan 108

BOSULIF 31

BRAFTOVI 31

BREO ELLIPTA 108

briellyn 82

BRILINTA 51

brimonidine tartrate 103

brinzolamide 103

BRIVIACT 15

bromfenac sodium 102

bromocriptine mesylate 35

BRUKINSA 29

budesonide 97

bumetanide 58

buprenorphine 2

buprenorphine hcl 2

buprenorphine hclnaloxone hcl 5

bupropion hcl 6

buspirone hcl 44

butalb-acetamin-caff 50-325-40 (tablet) 63

butalbitalacetaminophencaffeinecodeine phosphate 3

butalbitalaspirincaffeine 3

butorphanol tartrate 3

BYDUREON BCISE 45

BYDUREON PEN 45

Ccabergoline 91

cablivi 50

CABOMETYX 31

cafergot 26

calcipotriene 65

calcitoninsalmonsynthetic 98

CALCITRIOL 65

calcitriol 98

calcium acetate 70

CALQUENCE 31

camila 89

candesartan cilexetil 52

candesartan cilexetilhydrochlorothiazide 56

CAPASTAT SULFATE 27

CAPLYTA 37

CAPRELSA 31

captopril 52

captoprilhydrochlorothiazide 56

CARBAGLU 74

carbamazepine 18

carbidopa 36

carbidopalevodopa 36

113

CARBIDOPALEVODOPAENTACAPONE 35

CARDIZEM LA 55

carteolol hcl 103

cartia xt 55

carvedilol 54

carvedilol phosphate 54

caspofungin acetate 23

cataflam 1

CAYSTON 107

caziant 82

cefaclor 9

cefadroxil 9

cefazolin sodium 9

cefdinir 9

cefepime hcl 9

CEFEPIME HCL IN DEXTROSE 5 IN WATER 9

cefixime 10

cefotaxime sodium 10

cefotetan disodium 10

cefoxitin sodium 10

cefpodoxime proxetil 10

cefprozil 10

ceftazidime 10

ceftriaxone sodium 10

ceftriaxone sodium in iso-osmotic dextrose 10

cefuroxime axetil 10

cefuroxime sodium 10

celecoxib 1

CELONTIN 16

cephalexin 10

CERDELGA 74

CHANTIX 6

charlotte 24 fe 82

chateal 82

chateal eq 82

CHEMET 70

chenodal 71

chloramphenicol sod succinate 7

chlorhexidine gluconate 64

chloroquine phosphate 34

chlorpromazine hcl 36

chlorthalidone 59

CHOLBAM 74

cholestyramine (with sugar) 60

cholestyramineaspartame 60

ciclodan 23

ciclopirox 23

ciclopirox olamine 23

cilostazol 51

CIMDUO 42

cimetidine 72

cimetidine hcl 72

cinacalcet hcl 98

cinryze 92

ciprofloxacin 13

ciprofloxacin hcl 13

ciprofloxacin hcldexamethasone 104

ciprofloxacin lactatedextrose 5 in water 13

citalopram hydrobromide 20

claravis 65

clarithromycin 12

clemastine fumarate 105

cleocin phosphate 7

clindacin etz 7

clindacin p 7

clindamycin hcl 7

clindamycin palmitate hcl 7

clindamycin phosphate 7

CLINDAMYCIN PHOSPHATE IN 09 SODIUM

CHLORIDE 7

clindamycin phosphatebenzoyl peroxide 65

clindamycin phosphatedextrose 5 in water 7

CLINOLIPID 68

clobazam 16

clobetasol propionate 77

clobetasol propionateemollient base 77

clodan 77

clomipramine hcl 21

clonazepam 44

clonidine (01 mgday patch 02 mgday patch 03

mgday patch) 52

clonidine hcl 52

114

clopidogrel bisulfate 51

clorazepate dipotassium 45

clotrimazole 23

clotrimazolebetamethasone dipropionate 65

clovique 70

clozapine 39

COARTEM 34

codeine phosphatebutalbitalaspirincaffeine 3

codeine sulfate 3

colchicine 25

colesevelam hcl 60

colestipol hcl 60

colistin (as colistimethate sodium) 7

colocort 97

COMBIGAN 103

COMBIPATCH 82

COMBIVENT RESPIMAT 109

COMETRIQ 31

COMPLERA 41

compro 22

concept ob 71

constulose 73

COPAXONE 64

COPIKTRA 29

CORLANOR 57

cormax 78

cortisone acetate 78

CORTISPORIN 66

cosentyx (2 syringes) 66

cosentyx pen 66

cosentyx pen (2 pens) 66

cosentyx syringe 66

COTELLIC 31

creon 74

CRESEMBA 24

CRIXIVAN 43

cromolyn sodium 71

cryselle 82

cyclafem 83

cyclobenzaprine hcl 109

cyclophosphamide 28

cycloserine 27

CYCLOSET 45

cyclosporine 92

cyclosporine modified 92

cyproheptadine hcl 105

cyred 83

cyred eq 83

cystadane 75

CYSTADROPS 100

CYSTAGON 75

CYSTARAN 100

Ddalfampridine 64

DALIRESP 108

danazol 81

dantrolene sodium 39

dapsone 27

daptacel dtap 95

daptomycin 7

dasetta 83

DAURISMO 31

DAYTRANA 62

deblitane 89

decadron 78

deferasirox 70

DELSTRIGO 41

demeclocycline hcl 14

DEPO-PROVERA 89

DEPO-SUBQ PROVERA 104 89

DESCOVY 42

desipramine hcl 21

desmopressin acetate 80

desmopressin acetate (non-refrigerated) 80

desogestrel-ethinyl estradiol 83

desogestrel-ethinyl estradiolethinyl estradiol 83

desonide 78

desoximetasone 78

desvenlafaxine succinate 20

dexamethasone 78

dexamethasone sodium phosphate 78

115

dexamethasone sodium phosphatepf 78

DEXILANT 74

dexmethylphenidate hcl 62

dextroamphetamine sulf-saccharateamphetamine sulf-

aspartate 61

dextroamphetamine sulfate 61

dextrose 10 in water 68

dextrose 25 and 045 sodium chloride 68





DEXTROSE 5 IN LACTATED RINGERS 68


DIACOMIT 15

DIASTAT 16

DIASTAT ACUDIAL 16

DIAZEPAM 16

diazepam 45

diazoxide 48

diclofenac potassium 1

diclofenac sodium 1

diclofenac sodiummisoprostol 1

dicloxacillin sodium 12

dicyclomine hcl 71

didanosine 42

DIFICID 13

diflorasone diacetate 78

diflunisal 1

difluprednate 102

digitek 57

digox 57

digoxin 57

dihydroergotamine mesylate 26

dilantin 18

dilt-xr 55

diltiazem hcl 55

dimethyl fumarate 64

DIPENTUM 97

diphenhydramine hcl 105

diphenoxylate hclatropine sulfate 72

disopyramide phosphate 53

disulfiram 5

divalproex sodium 16

dofetilide 53

dolishale 83

donepezil hcl 19

DOPTELET 50

dorzolamide hcl 103

dorzolamide hcltimolol maleate 103

dorzolamide hcltimolol maleatepf 103

dotti 83

DOVATO 42

doxazosin mesylate 52

doxepin hcl 44

doxercalciferol 98

doxy 100 14

doxycycline hyclate 15

doxycycline monohydrate 15

DRIZALMA SPRINKLE 63

dronabinol 23

DROXIA 29

droxidopa 52

DUAVEE 90

DULERA 109

duloxetine hcl 63

dupixent pen 66

dupixent syringe 66

dutasteride 76

Eeconazole nitrate 24

EDURANT 41

efavirenz 41

efavirenzemtricitabinetenofovir disoproxil fumarate 41

efavirenzlamivudinetenofovir disoproxil fumarate 41

egrifta sv 81

ELIGARD 91

elinest 83

ELIQUIS 49

ELLA 89

ELMIRON 76

116

eluryng 83

EMCYT 28

EMEND 23

EMFLAZA 78

emgality pen 25

emgality syringe 26

emoquette 83

EMSAM 20

emtricitabine 42

emtricitabinetenofovir disoproxil fumarate 42

EMTRIVA 42

emverm 33

enalapril maleate 52

enalapril maleatehydrochlorothiazide 57

enbrel 92

enbrel mini 92

enbrel sureclick 92

endocet 3

engerix-b adult 95

engerix-b pediatric-adolescent 95

enoxaparin sodium 49

enpresse 83

enskyce 83

enspryng 94

entacapone 35

entecavir 40

ENTRESTO 57

enulose 73

EPIDIOLEX 15

epifoam 66

epinastine hcl 102

epinephrine 106

epitol 18

EPIVIR HBV 40

eplerenone 58

epogen 50

ERAXIS (WATER DILUENT) 24

ergotamine tartratecaffeine 26

ERIVEDGE 31

ERLEADA 28

erlotinib hcl 31

errin 89

ertapenem sodium 11

ery 13

erythrocin lactobionate 13

erythrocin stearate 13

erythromycin base 13

erythromycin base in ethanol 13

erythromycin basebenzoyl peroxide 7

erythromycin ethylsuccinate 13

ESBRIET 108

escitalopram oxalate 20

esomeprazole magnesium 74

estarylla 83

estradiol 83

estradiol valerate 83

estradiolnorethindrone acetate 83

ESTRING 83

eszopiclone 109

ethacrynic acid 58

ethambutol hcl 27

ethinyl estradioldrospirenone 84

ethosuximide 16

ethynodiol diacetate-ethinyl estradiol 84

etidronate disodium 98

etodolac 1

etonogestrelethinyl estradiol 84

etoposide 31

etravirine 41

EUTHYROX 90

everolimus 31

EVOTAZ 43

EVRYSDI 75

exemestane 30

extavia 64

ezetimibe 60

ezetimibesimvastatin 60

Ffalmina 84

famciclovir 44

famotidine 72

117

famotidinepf 72

FANAPT 37

FARXIGA 46

FARYDAK 31

fasenra pen 109

febuxostat 25

felbamate 17

felodipine 55

FEMRING 84

femynor 84

fenofibrate 59

fenofibrate nanocrystallized 59

fenofibratemicronized 59

FENOFIBRIC ACID 59

fenofibric acid (choline) 59

fentanyl 2

fentanyl citrate 3

FETZIMA 20

FINACEA 66

finasteride 76

FINTEPLA 15

FIRDAPSE 63

FIRMAGON 91

FIRVANQ 8

FLAREX 102

flavoxate hcl 75

flebogamma dif 94

flecainide acetate 53

FLOVENT DISKUS 105

FLOVENT HFA 105

fluconazole 24

fluconazole in sodium chloride iso-osmotic 24

flucytosine 24

fludrocortisone acetate 78

flunisolide 105

fluocinolone 001 scalp oil 78

fluocinolone acetonide 78

fluocinolone acetonide oil 104

fluocinonide 78

fluocinonideemollient base 79

FLUOROMETHOLONE 102

fluorouracil 29

FLUOROURACIL 66

fluoxetine hcl 20

fluphenazine decanoate 36

fluphenazine hcl 36

flurbiprofen 1

flurbiprofen sodium 102

flutamide 28

fluticasone propionate 79

FLUTICASONE PROPIONATESALMETEROL

XINAFOATE 109

fluvastatin sodium 59

fluvoxamine maleate 20

FML FORTE 102

FML SOP 102

folivane-ob 71

fondaparinux sodium 49

formoterol fumarate 107

fosamprenavir calcium 43

fosfomycin tromethamine 8

fosinopril sodium 53

fosinopril sodiumhydrochlorothiazide 57

fosphenytoin sodium 18

FOSRENOL 70

FOTIVDA 31

FRAGMIN 49

frovatriptan succinate 26

fulphila 50

furosemide 58

FUZEON 42

fyavolv 84

FYCOMPA 17

Ggabapentin 16

GALAFOLD 75

galantamine hbr 19

gammagard liquid 94

gammagard s-d 94

gammaked 94

gammaplex 94

118

gamunex-c 94

gardasil 9 95

gatifloxacin 13

GATTEX 72

gauze bandage 99

gavilyte-c 73

gavilyte-g 73

gavilyte-n 73

GAVRETO 29

gemfibrozil 59

gemmily 84

generlac 73

gengraf 92

gentak 6

gentamicin sulfate 6

gentamicin sulfate in sodium chloride iso-osmotic 6

gentamicin sulfatepf 6

GENVOYA 40

GIANVI 84

GILENYA 64

GILOTRIF 31

glassia 75

glatiramer acetate 64

glatopa 64

glimepiride 46

glipizide 46

glipizidemetformin hcl 46

GLUCAGEN 48

glucagon emergency kit 48

glycopyrrolate 71

glydo 4

GLYXAMBI 46

granisetron hcl 23

granix 50

grastek 95

griseofulvin ultramicrosize 24

griseofulvin microsize 24

guanfacine hcl 62

GUANIDINE HCL 26

GVOKE HYPOPEN 1-PACK 48


GVOKE PFS 1-PACK SYRINGE 48


Hhaegarda 92

hailey 84

hailey 24 fe 84

hailey fe 84

halobetasol propionate 79

haloperidol 36

haloperidol decanoate 36

haloperidol lactate 36

havrix 95

heather 89

heparin sodiumporcine 49

HEPARIN SODIUMPORCINE IN 045 SODIUM

CHLORIDE 49

HEPARIN SODIUMPORCINEDEXTROSE 5 IN

WATER 49

heparin sodiumporcinepf 49

HETLIOZ 110

HETLIOZ LQ 110

hiberix 95

humalog 48

humalog junior kwikpen 48

humalog kwikpen u-100 48


humalog mix 50-50 48

humalog mix 50-50 kwikpen 48



humira 93

humira pen 93

humira pen crohns-uc-hs 93

humira pen psor-uveits-adol hs 93

humira(cf) 93

humira(cf) pediatric crohns 93

humira(cf) pen 93

humira(cf) pen crohns-uc-hs 93

humira(cf) pen pediatric uc 93

humira(cf) pen psor-uv-adol hs 93

119

humulin 70-30 48

humulin 7030 kwikpen 48

humulin n 48

humulin n kwikpen 48

humulin r 48

humulin r u-500 48

humulin r u-500 kwikpen 48

hydralazine hcl 60

hydrochlorothiazide 59

hydrocodone bitartrate 2

hydrocodone bitartrateacetaminophen 3

hydrocodoneibuprofen 3

hydrocortisone 79

hydrocortisone butyrate 79

hydrocortisone butyrateemollient base 79

hydrocortisone valerate 79

hydrocortisoneacetic acid 104

hydromorphone hcl 4

hydromorphone hclpf 4

hydroxychloroquine sulfate 34

hydroxyurea 29

hydroxyzine hcl 105

hydroxyzine pamoate 105

Iibandronate sodium 98

IBRANCE 32

ibu 1

ibuprofen 1

icatibant acetate 92

iclevia 84

ICLUSIG 32

icosapent ethyl 60

IDHIFA 29

ILEVRO 102

imatinib mesylate 32

IMBRUVICA 32

imipenemcilastatin sodium 11

imipramine hcl 21

imipramine pamoate 21

imiquimod 66

imovax rabies vaccine 95

INBRIJA 35

incassia 89

increlex 81

INCRUSE ELLIPTA 106

indapamide 59

indomethacin 1

infanrix dtap 95

INGREZZA 63

INGREZZA INITIATION PACK 63

INLYTA 32

INQOVI 29

INREBIC 29

insulin pen needles 99

insulin syringes 99

INTELENCE 41

INTRALIPID 68

intron a 40

introvale 84

INVEGA SUSTENNA 37

INVEGA TRINZA 38

INVELTYS 102

INVIRASE 43

INVOKAMET 46

INVOKAMET XR 46

INVOKANA 46

ipol 96

ipratropium bromide 106

ipratropium bromidealbuterol sulfate 109

irbesartan 52

irbesartanhydrochlorothiazide 57

IRESSA 32

ISENTRESS 40

ISENTRESS HD 40

isibloom 84

isoniazid 27

isosorbide dinitrate 61

isosorbide mononitrate 61

isotretinoin 66

isradipine 55

ISTURISA 79

120

itraconazole 24

ivermectin 34

ixiaro 96

JJAKAFI 32

jantoven 50

JANUMET 46

JANUMET XR 46

JANUVIA 46

JARDIANCE 46

jasmiel 84

jencycla 89

JENTADUETO 46

JENTADUETO XR 46

jinteli 84

JOLESSA 84

juleber 84

JULUCA 42

junel 84

junel fe 84

junel fe 24 84

JUXTAPID 60

JYNARQUE 70

KK-TAB ER (8 MEG TABLET 10 MEQ TABLET) 68

kaitlib fe 84

kalliga 85

KALYDECO 107

kariva 85

kelnor 1-35 85

kelnor 1-50 85

kesimpta pen 64

ketoconazole 24

ketodan 24

ketoprofen 1

KETOROLAC TROMETHAMINE 1

ketorolac tromethamine 102

kinrix 96

kionex 70

KISQALI 32

KISQALI FEMARA CO-PACK 32

KLISYRI 66

KLOR-CON 10 68

KLOR-CON 8 68

klor-con m10 68

klor-con m15 69

klor-con m20 69

KLOXXADO 6

KOMBIGLYZE XR 46

KORLYM 79

KOSELUGO 32

kurvelo 85

KYNMOBI 35

Llabetalol hcl 54

LACRISERT 100

lactulose 73

lamivudine 40

lamivudinezidovudine 42

lamotrigine 17

lansoprazole 74

lansoprazoleamoxicillin trihydrateclarithromycin 72

lanthanum carbonate 70

lantus 48

lantus solostar 48

lapatinib ditosylate 32

larin 85

larin 24 fe 85

larin fe 85

larissia 85

latanoprost 104

LATUDA 38

LEDIPASVIRSOFOSBUVIR 40

LEENA 85

leflunomide 95

LENVIMA 32

lessina 85

letrozole 30

leucovorin calcium 29

121

LEUKERAN 28

leukine 50

leuprolide acetate 91

levalbuterol hcl 107

LEVALBUTEROL TARTRATE 107

levetiracetam 15

levetiracetam in sodium chloride iso-osmotic 15

LEVO-T 90

levobunolol hcl 103

LEVOCARNITINE 69

levocarnitine (with sugar) 69

levocetirizine dihydrochloride 105

levofloxacin 13

levofloxacindextrose 5 in water 14

levonest 85

levonorgestrelethinyl estradiol 85

levora-28 85

levorphanol tartrate 2

levothyroxine sodium 90

LEVOXYL 90

LEXIVA 43

lidocaine 4

lidocaine hcl 5

lidocaine hclpf 5

lidocaineprilocaine 5

lillow 85

lindane 34

linezolid 8

linezolid in dextrose 5 in water 8

LINZESS 73

liothyronine sodium 90

lisinopril 53

lisinoprilhydrochlorothiazide 57

lithium carbonate 45

LITHIUM CITRATE 45

lo-zumandimine 85

LONSURF 29

loperamide hcl 72

lopinavirritonavir 43

LOPREEZA 85

lorazepam 45

lorazepam intensol 45

LORBRENA 31

lorcet 4

lorcet hd 4

loryna 85

losartan potassium 52

losartan potassiumhydrochlorothiazide 57

LOTEMAX 102

LOTEMAX SM 102

loteprednol etabonate 102

lovastatin 59

low-ogestrel 85

loxapine succinate 37

LUBIPROSTONE 73

LUCEMYRA 5

LUMAKRAS 32

LUMIGAN 104

LUPANETA PACK 91

LUPKYNIS 93

LUPRON DEPOT 91

LUPRON DEPOT-PED 91

lutera 85

lyleq 89

lyllana 85

LYNPARZA 32

LYSODREN 29

lyza 89

Mm-m-r ii vaccine 96

magnesium sulfate 69

maprotiline hcl 20

marlissa 85

marplan 20

MATULANE 28

matzim la 55

MAVENCLAD 64

MAYZENT 64

meclizine hcl 22

meclofenamate sodium 1

medroxyprogesterone acetate 89

122

mefloquine hcl 34

megestrol acetate 89

MEKINIST 32

MEKTOVI 32

melodetta 24 fe 85

meloxicam 1

memantine hcl 19

menactra 96

menest 85

menquadfi 96

menveo a-c-y-w-135-dip 96

mercaptopurine 29

meropenem 11

MEROPENEM IN 09 SODIUM CHLORIDE 11

merzee 86

mesalamine 97

mesalamine with cleansing wipes 97

MESNEX 33

metadate er 62

metaproterenol sulfate 107

metformin hcl 46

metformin hcl (500 mg osm tablet er 24h 1000 mg

osm tablet er 24h) 46

metformin hcl (500 mg tablet er 24h 750 mg tablet er

24h) 46

methadone hcl 2

methazolamide 58

methenamine hippurate 8

methergine 99

methimazole 91

methocarbamol 109

methotrexate sodium 93

methotrexate sodiumpf 93

methoxsalen 66

methscopolamine bromide 71

methylergonovine maleate 99

methylphenidate hcl 62

methylprednisolone 79

methylprednisolone acetate 79

methylprednisolone sodium succinate 79

metoclopramide hcl 22

metolazone 59

metoprolol succinate 54

metoprolol tartrate 54

metoprolol tartratehydrochlorothiazide 57

metronidazole 8

metronidazole in sodium chloride 8

mexiletine hcl 53

mibelas 24 fe 86

micafungin sodium 24

miconazole nitrate 24

microgestin 86

microgestin 24 fe 86

microgestin fe 86

midodrine hcl 52

migergot 26

miglitol 47

miglustat 75

mili 86

mimvey 86

minitran 61

minocycline hcl 15

minoxidil 60

mirtazapine 19

misoprostol 74

mitoxantrone hcl 30

modafinil 110

moexipril hcl 53

molindone hcl 37

mometasone furoate 79

mondoxyne nl 15

mono-linyah 86

montelukast sodium 106

morgidox 15

morphine sulfate 2

MOVANTIK 72

moxifloxacin hcl 14

MOXIFLOXACIN HCL IN SODIUM ACETATE AND

SULFATEWATERISO-OSM 14

moxifloxacin hcl in sodium chloride iso-osmotic 14

MOZOBIL 50

MULTAQ 53

123

multivitamin combination no51ferrous fumaratefolic

acid 71

mupirocin 2 ointment 8

myalept 72

MYCAPSSA 91

mycophenolate mofetil 93

mycophenolate sodium 93

myorisan 66

MYRBETRIQ 76

MYTESI 72

Nnabumetone 1

nadolol 54

nafcillin sodium 12

naftifine hcl 24

NAFTIN 24

naloxone hcl 6

naltrexone hcl 5

NAMENDA XR 19

naproxen 1

naproxen sodium 2

naratriptan hcl 26

NARCAN 6

NATACYN 24

nateglinide 47

natpara 98

NAYZILAM 15

nebivolol hcl 54

necon 86

nefazodone hcl 20

neo-polycin 101

neo-polycin hc 101

neomycin sulfate 6

neomycin sulfatebacitracin zincpolymyxin

bhydrocortisone 101

neomycin sulfatebacitracinpolymyxin b 101

neomycin sulfatepolymyxin b sulfategramicidin d 101

neomycin sulfatepolymyxin b

sulfatehydrocortisone 101

neomycinpolymyxin b sulfatedexamethasone 101

NERLYNX 32

neulasta 50

neulasta onpro 50

neupogen 50

NEUPRO 35

nevirapine 41

NEXAVAR 32

NEXIUM 74

NEXLETOL 57

NEXLIZET 60

niacin 60

nicardipine hcl 55

NICOTROL 6

NICOTROL NS 6

nifedipine 56

nikki 86

nilutamide 28

nimodipine 56

NINLARO 30

nitazoxanide 34

nitisinone 75

NITRO-DUR 61

nitrofurantoin 8

nitrofurantoin macrocrystal 8

nitrofurantoin monohydratemacrocrystals 8

nitroglycerin 61

NITROSTAT 61

NITYR 75

nivestym 51

nizatidine 72

NORA-BE 89

norethindrone 89

norethindrone acetate 89

norethindrone acetate-ethinyl estradiol 86

norethindrone acetate-ethinyl estradiolferrous

fumarate 86

norethindrone-ethinyl estradiolferrous fumarate 86

norgestimate-ethinyl estradiol 86

norlyda 89

NORPACE CR 53

nortrel 86

124

nortriptyline hcl 21

NORVIR 43

NOURIANZ 35

NOXAFIL 24

np thyroid 90

NUBEQA 28

nucala 109

NUEDEXTA 63

NUPLAZID 38

NUTRILIPID 69

nyamyc 25

nylia 86

nymyo 86

nystatin 25

nystatintriamcinolone acetonide 25

nystop 25

nyvepria 51

Oo-cal fa 71

ob complete 71

OCALIVA 75

OCELLA 86

octagam 94

octreotide acetate 91

odactra 95

ODEFSEY 41

ODOMZO 32

OFEV 108

ofloxacin 14

ogestrel 87

olanzapine 38

olanzapinefluoxetine hcl 19

olmesartan medoxomil 52

olmesartan medoxomilamlodipine

besylatehydrochlorothiazide 57

olmesartan medoxomilhydrochlorothiazide 57

olopatadine hcl 102

omega-3 acid ethyl esters 60

OMEGAVEN 69

omeprazole 74

omnitrope 81

ondansetron hcl 23

ondansetron hclpf 23

ondansetron odt (4 mg tablet 8 mg tablet) 23

ONGENTYS 35

ONGLYZA 47

ONUREG 30

OPSUMIT 108

oralair 95

orencia 93

orencia clickject 93

ORFADIN 75

ORGOVYX 91

ORIAHNN 81

ORILISSA 81

ORKAMBI 107

ORLADEYO 92

orsythia 87

oseltamivir phosphate 44

OSMOLEX ER 35

OTEZLA 95

oxacillin sodium 12

OXACILLIN SODIUM IN ISO-OSMOTIC

DEXTROSE 12

oxandrolone 81

oxazepam 45

oxcarbazepine 18

oxervate 101

oxiconazole nitrate 25

oxybutynin chloride 76

oxycodone hcl 4

oxycodone hclacetaminophen 4

oxycodone hclaspirin 4

oxymorphone hcl 4

OZEMPIC 47

Ppaliperidone 38

palynziq 75

pamidronate disodium 98

PANRETIN 33

125

pantoprazole sodium 74

panzyga 94

paricalcitol 98

paroex 64

paromomycin sulfate 6

paroxetine hcl 21

paser 27

PAXIL 21

PAZEO 102

pediarix 96

pedvaxhib 96

peg 3350sod sulfsod bicarbsod chloridepotassium

chloride 73

peg 3350sodium sulfatesod chloridekclascorbate

sodvit c 73

PEGANONE 18

pegasys 40

pegintron 40

PEMAZYRE 32

pen needle diabetic 99

pen needle diabetic remover and disposal unit 99

pen needle diabetic safety 100

penicillamine 76

penicillin g potassium 12

penicillin g procaine 12

penicillin g sodium 12

penicillin v potassium 12

pentacel acthib component 96

pentacel dtap-ipv component 96

pentamidine isethionate 34

PENTASA 97

pentoxifylline 57

PERFOROMIST 107

perindopril erbumine 53

periogard 64

permethrin 34

perphenazine 22

perphenazineamitriptyline hcl 19

PERSERIS 38

pfizerpen 12

phenelzine sulfate 20

phenobarbital 17

phenoxybenzamine hcl 52

phenytoin 18

phenytoin sodium extended 18

philith 87

PHOSLYRA 70

PHOSPHOLINE IODIDE 103

PICATO 66

PIFELTRO 41

pilocarpine hcl 65

pimecrolimus 67

pimozide 37

pimtrea 87

pindolol 54

pioglitazone hcl 47

PIOGLITAZONE HCLGLIMEPIRIDE 47

pioglitazone hclmetformin hcl 47

piperacillin sodiumtazobactam sodium 12

PIQRAY 31

pirmella 87

piroxicam 2

plegridy 64

plegridy pen 64

plenamine 69

PLENVU 73

podofilox 67

polycin 101

polymyxin b sulfate 8

polymyxin b sulfatetrimethoprim 101

POMALYST 28

portia 87

posaconazole 25

potassium chloride 69

POTASSIUM CHLORIDE IN DEXTROSE 5 AND 09

SODIUM CHLORIDE 69

POTASSIUM CHLORIDE IN DEXTROSE 5 -02

SODIUM CHLORIDE 69


SODIUM CHLORIDE 69

POTASSIUM CHLORIDE IN LACTATED RINGERS

AND 5 DEXTROSE 69

126

potassium chloride in water for injection sterile 69

potassium citrate 76

PRADAXA 50

pramipexole di-hcl 35

prasugrel hcl 51

pravastatin sodium 59

prazosin hcl 52

PRED MILD 103

PREDNICARBATE 79

prednisolone 80

PREDNISOLONE ACETATE 103

prednisolone sodium phosphate 80

prednisone 80

prednisone intensol 80

pregabalin 63

PREMARIN 87

PREMPHASE 87

PREMPRO 87

prenatal vitamins (no dha) 71

prenate am 71

prenate chewable 71

prevalite 60

previfem 87

PREVYMIS 39

PREZCOBIX 43

PREZISTA 43

PRIFTIN 27

primaquine phosphate 34

primidone 17

privigen 94

PROAIR RESPICLICK 107

probenecid 25

probenecidcolchicine 25

prochlorperazine 22

prochlorperazine edisylate 22

prochlorperazine maleate 22

procrit 51

procto-med hc 97

proctofoam-hc 67

proctosol-hc 97

proctozone-hc 97

PROCYSBI 75

progesterone micronized 89

PROGRAF 93

prolastin c 75

PROLENSA 103

prolia 98

PROMACTA 51

promethazine hcl 22

propafenone hcl 53

propranolol hcl 55

propranolol hclhydrochlorothiazide 57

propylthiouracil 92

proquad 96

protriptyline hcl 22

psorcon 80

pulmozyme 107

purefe ob plus 71

PURIXAN 29

PYLERA 72

pyrazinamide 27

pyridostigmine bromide 26

pyrimethamine 34

QQINLOCK 30

quadracel dtap-ipv 96

quetiapine fumarate 38

quinapril hcl 53

quinapril hclhydrochlorothiazide 57

quinidine gluconate 53

quinidine sulfate 54

QVAR REDIHALER 105

Rrabavert 96

rabeprazole sodium 74

ragwitek 95

raloxifene hcl 90

ramipril 53

ranolazine 57

rasagiline mesylate 36

127

RAVICTI 75

rebif 64

rebif rebidose 64

reclipsen 87

recombivax hb 96

RECTIV 67

regranex 67

RELENZA 44

relexxii 62

RELISTOR 72

RELISTOR 12 MG06 ML (KIT SYRINGE VIAL) 72

RENACIDIN 76

repaglinide 47

repaglinidemetformin hcl 47

repatha pushtronex 60

repatha sureclick 60

repatha syringe 60

RESTASIS 101

RESTASIS MULTIDOSE 101

retacrit 51

RETEVMO 30

RETROVIR 42

REVLIMID 28

REXULTI 38

REYATAZ 43

REZUROCK 93

RHOPRESSA 104

ribavirin 40

rifabutin 27

rifampin 27

RIFATER 27

riluzole 63

rimantadine hcl 44

ringers solutionlactated 69

RINVOQ 93

risedronate sodium 98

RISPERDAL CONSTA 38

risperidone 38

ritonavir 43

rivastigmine 19

rivastigmine tartrate 19

rizatriptan benzoate 26

ropinirole hcl 35

rosadan 67

rosuvastatin calcium 59

rotarix 96

rotateq 96

roweepra 15

roweepra xr 16

ROZLYTREK 30

RUBRACA 30

rufinamide 18

RUKOBIA 42

RUZURGI 63

RYBELSUS 47

RYDAPT 30

Ssajazir 92

SAMSCA 70

santyl 67

sapropterin dihydrochloride 75

SAVAYSA 50

SAVELLA 63

SECUADO 38

SEGLUROMET 47

selegiline hcl 36

selenium sulfide 67

SELZENTRY 42

SEREVENT DISKUS 107

sertraline hcl 21

setlakin 87

sevelamer carbonate 71

sharobel 90

shingrix 96

SIGNIFOR 91

sildenafil citrate 108

silodosin 76

SILVADENE 14

SILVER SULFADIAZINE 14

SIMBRINZA 104

simliya 87

128

simvastatin 59

sirolimus 93

SIRTURO 27

SIVEXTRO 8

skyrizi 67

skyrizi (2 syringes) kit 67

skyrizi pen 67

SMOFLIPID 69

sodium chloride 045 70

SODIUM CHLORIDE IRRIGATING SOLUTION 70

sodium chloridesodium bicarbonatepotassium

chloridepeg 73

sodium phenylbutyrate 75

sodium polystyrene sulfonate 70

SOFOSBUVIRVELPATASVIR 40

solifenacin succinate 76

soltamox 28

SOLU-CORTEF 80

SOMATULINE DEPOT 91

somavert 91

SOOLANTRA 67

sorine 54

sotalol af 54

sotalol hcl 54

SPIRIVA 106

SPIRIVA RESPIMAT 106

spironolactone 58

spironolactonehydrochlorothiazide 57

sprintec 87

SPRITAM 16

SPRIX 2

SPRYCEL 32

sps 70

sronyx 87

SSD 14

stavudine 42

STEGLATRO 47

STEGLUJAN 47

stelara 67

STIMATE 81

STIOLTO RESPIMAT 109

STIVARGA 32

streptomycin sulfate 6

STRIBILD 41

sucraid 75

sucralfate 74

sulfacetamide sodium 14

sulfacetamide sodiumprednisolone sodium

phosphate 101

sulfadiazine 14

sulfamethoxazoletrimethoprim 14

SULFAMYLON 8

sulfasalazine 97

sulindac 2

sumatriptan succinate 26

sunitinib malate 32

SUNOSI 110

suprax 10

SUPREP 73

SUTAB 73

syeda 87

sylatron 30

SYMBICORT 109

SYMDEKO 107

SYMPAZAN 17

SYMPROIC 72

SYMTUZA 43

SYNAREL 91

SYNJARDY 47

SYNJARDY XR 47

SYNRIBO 30

SYNTHROID 90

syringe with needle insulin1 ml and sharps

container 100

syringe with needledisposableinsulin 1 ml 100

syringe without needleinsulin disposible 1 ml 100

syringe insulin u-500 with needle disposable 05

ml 100

syringe-needleinsulin05 mlcontainerempty 100

TTABLOID 29

129

TABRECTA 30

tacrolimus 67

tadalafil 76

TAFINLAR 32

TAGRISSO 32

takhzyro 92

TALICIA 72

TALZENNA 32

tamoxifen citrate 28

tamsulosin hcl 76

TARGRETIN 33

tarina 24 fe 87

tarina fe 87

tarina fe 1-20 eq 87

TASIGNA 32

TAVALISSE 51

taysofy 87

tazarotene 67

tazicef 10

TAZORAC 67

taztia xt 56

TAZVERIK 30

TEFLARO 10

TEGSEDI 63

telmisartan 52

telmisartanamlodipine besylate 57

telmisartanhydrochlorothiazide 58

temazepam 109

TEMIXYS 43

tenivac 96

tenofovir disoproxil fumarate 42

TEPMETKO 33

terazosin hcl 52

terbinafine hcl 25

terbutaline sulfate 107

terconazole 25

testosterone 81

testosterone cypionate 81

testosterone enanthate 81

tetanus and diphtheria toxoids adult 96

tetanusdiphtheria toxoid pedpf 96

tetrabenazine 63

tetracycline hcl 15

THALOMID 28

theophylline anhydrous 108

THIOLA EC 76

thioridazine hcl 37

thiothixene 37

thyroid 90

thyroidpork 91

tiadylt er 56

tiagabine hcl 17

TIBSOVO 30

tigecycline 8

tilia fe 87

timolol maleate 55

tinidazole 8

tiopronin 76

TIVICAY 41

TIVICAY PD 41

tizanidine hcl 39

tobi podhaler 107

TOBRADEX 101

tobramycin 7

tobramycin in 0225 sodium chloride 107

tobramycin sulfate 7

tobramycindexamethasone 101

TOBREX 7

tolmetin sodium 2

tolterodine tartrate 76

tolvaptan 70

topiramate 17

toposar 31

topotecan hcl 31

toremifene citrate 28

torsemide 58

toujeo max solostar 49

toujeo solostar 49

TOVIAZ 76

TPN ELECTROLYTES 70

TRACLEER 108

TRADJENTA 47

130

tramadol hcl 3

tramadol hclacetaminophen 4

trandolapril 53

trandolaprilverapamil hcl 58

tranexamic acid 51

tranylcypromine sulfate 20

travoprost 104

trazodone hcl 21

TRECATOR 27

TRELEGY ELLIPTA 109

trelstar 91

tremfya 67

tretinoin 33

tretinoin microspheres 67

trexall 94

tri femynor 87

tri-estarylla 87

tri-legest fe 87

tri-linyah 88

tri-lo-estarylla 88

tri-lo-marzia 88

tri-lo-mili 88

tri-lo-sprintec 88

tri-mili 88

tri-nymyo 88

tri-previfem 88

tri-sprintec 88

tri-vylibra 88

tri-vylibra lo 88

triamcinolone acetonide 65

triamterene 59

triamterenehydrochlorothiazide 58

triderm 80

trientine hcl 70

trifluoperazine hcl 37

trifluridine 44

trihexyphenidyl hcl 34

TRIKAFTA 107

triklo 60

trilyte with flavor packets 73

trimethoprim 9

trimipramine maleate 22

TRINTELLIX 21

TRIUMEQ 43

trivora-28 88

tropicamide 101

trospium chloride 76

trulicity 47

trumenba 96

truseltiq 33

TUKYSA 30

tulana 90

TURALIO 30

twinrix 96

TYBLUME 88

TYBOST 43

TYMLOS 99

typhim vi 96

Uudenyca 51

UKONIQ 33

UNITHROID 91

UPTRAVI 108

ursodiol 72

Vvalacyclovir hcl 44

VALCHLOR 28

valganciclovir hcl 39

valproic acid 17

valproic acid (as sodium salt) (valproate sodium) 17

valsartan 52

valsartanhydrochlorothiazide 58

VALTOCO 17

vancomycin hcl 9

VANCOMYCIN HCL IN WATER FOR INJECTION

(PEG-400 NADA) 9

VANCOMYCIN IN 09 SODIUM CHLORIDE 9

VANCOMYCIN IN 5 DEXTROSE IN WATER 9

VANDAZOLE 9

vaqta 96

131

varenicline tartrate 6

varivax vaccine 96

VARUBI 23

VASCEPA 60

velivet 88

VEMLIDY 40

VENCLEXTA 33

VENCLEXTA STARTING PACK 33

venlafaxine hcl 21

verapamil hcl 56

verquvo 58

VERSACLOZ 39

VERZENIO 33

vestura 88

VIBERZI 73

VICTOZA 2-PAK 47

VICTOZA 3-PAK 47

VIDEX 42

VIDEX EC 42

vienva 88

vigabatrin 17

vigadrone 17

VIIBRYD 21

VIMPAT 18

viorele 88

VIRACEPT 43

VIREAD 42

VITRAKVI 30

VIZIMPRO 30

volnea 88

voriconazole 25

VOSEVI 40

VOTRIENT 33

VRAYLAR 38

VUMERITY 64

vyfemla 88

vylibra 88

VYNDAMAX 58

VYNDAQEL 58

VYVANSE 61

VYZULTA 104

WWAKIX 110

warfarin sodium 50

WELIREG 30

wera 88

XXALKORI 33

XARELTO 50

XATMEP 94

XCOPRI 16

XELJANZ 94

XELJANZ XR 94

XELPROS 104

XERMELO 72

xgeva 99

XIFAXAN 9

XIGDUO XR 47

XOFLUZA 44

xolair 109

XOSPATA 30

XPOVIO 30

XTAMPZA ER 3

XTANDI 28

xulane 88

XYREM 110

XYWAV 110

Yyf-vax 96

YONSA 28

yuvafem 88

Zzafemy 88

zafirlukast 106

zaleplon 110

zarah 88

zarxio 51

ZEJULA 33

132

ZELBORAF 33

zemaira 75

zenatane 67

zenpep 75

zenzedi 61

ZEPOSIA 64

ZERBAXA 11

zidovudine 42

ziextenzo 51

zingiber 71

ziprasidone hcl 39

ziprasidone mesylate 39

ZIRGAN 39

zoledronic acid 99

ZOLEDRONIC ACID IN MANNITOL AND 09

SODIUM CHLORIDE 99

zoledronic acid in mannitol and water for injection 99

ZOLINZA 30

zolmitriptan 26

zolpidem tartrate 110

zonisamide 16

ZORTRESS 94

zovia 1-35 88

zovia 1-35e 88

zumandimine 89

ZYDELIG 33

ZYKADIA 33

ZYLET 101

133

Category ListingANALGESICS 1

ANESTHETICS 4

ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS 5

ANTIBACTERIALS 6

ANTICONVULSANTS 15

ANTIDEMENTIA AGENTS 19

ANTIDEPRESSANTS 19

ANTIEMETICS 22

ANTIFUNGALS 23

ANTIGOUT AGENTS 25

ANTIMIGRAINE AGENTS 25

ANTIMYASTHENIC AGENTS 26

ANTIMYCOBACTERIALS 27

ANTINEOPLASTICS 28

ANTIPARASITICS 33

ANTIPARKINSON AGENTS 34

ANTIPSYCHOTICS 36

ANTISPASTICITY AGENTS 39

ANTIVIRALS 39

ANXIOLYTICS 44

BIPOLAR AGENTS 45

BLOOD GLUCOSE REGULATORS 45

BLOOD PRODUCTSMODIFIERSVOLUME EXPANDERS 49

CARDIOVASCULAR AGENTS 52

CENTRAL NERVOUS SYSTEM AGENTS 61

DENTAL AND ORAL AGENTS 64

DERMATOLOGICAL AGENTS 65

ELECTROLYTESMINERALSMETALSVITAMINS 68

GASTROINTESTINAL AGENTS 71

GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERS TREATMENT 74

GENITOURINARY AGENTS 75

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (ADRENAL) 77

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (PITUITARY) 80

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEX HORMONESMODIFIERS) 81

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (THYROID) 90

HORMONAL AGENTS SUPPRESSANT (PITUITARY) 91

HORMONAL AGENTS SUPPRESSANT (THYROID) 91

IMMUNOLOGICAL AGENTS 92

INFLAMMATORY BOWEL DISEASE AGENTS 97

METABOLIC BONE DISEASE AGENTS 97

MISCELLANEOUS 110

MISCELLANEOUS THERAPEUTIC AGENTS 99

OPHTHALMIC AGENTS 100

OTIC AGENTS 104

RESPIRATORY TRACTPULMONARY AGENTS 104

134

SKELETAL MUSCLE RELAXANTS 109

SLEEP DISORDER AGENTS 109

135

copy2020 Providence Health Assurance All rights reserved

Our MissionAs expressions of Godrsquos healing love witnessed through the ministry of Jesus we are steadfast in serving all especially those who are poor and vulnerable

Our ValuesCompassion | Dignity | Justice | Excellence | Integrity

Wersquore here to help


MDC-455

11222021

11222021

H9047_2021AM04_C ii

Providence Medicare Advantage Plans

2021 Formulary(List of Covered Drugs)

Note to existing members

This formulary has changed since last year Please review this document to make sure that it still contains the drugs you take

When this drug list (formulary) refers to ldquowerdquo ldquousrdquo or ldquoourrdquo it means Providence Health Assurance When it refers to ldquoplanrdquo or ldquoour planrdquo it means Providence Medicare Advantage Plans

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

You must generally use network pharmacies to use your prescription drug benefit Benefits formulary pharmacy network andor copaymentscoinsurance may change on January 1 2022 and from time to time during the year

11222021

112021













during the year







have made





















H9047_2021AM04_C iii 11222021

H9047_2021AM04_C iv












111

11222021

112021

134

H9047_2021AM04_C v












11222021

H9047_2021AM04_C vi










pages























11222021

H9047_2021AM04_C vii










111

11222021

H9047_2021AM04_C viii













11222021



formats)













(TTY 711）



1‐800‐603‐2340 (TTY 711) 번으로 전화해 주십시오










Arabic










Persian




(082021) H9047_2021RCGA03_C



ANALGESICS


celecoxib 2-Generic



3-Preferred Brand




4-Non-PreferredDrug



ibu 2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug




meloxicam 2-Generic



2-Generic


1



Drug



piroxicam 2-Generic


sulindac 2-Generic



DrugPA




4-Non-PreferredDrug

PA




4-Non-PreferredDrug

PA QL (2 PER 1 DAY)


PA QL (4 PER 1 DAY)


2-Generic PA





2



3-Preferred Brand


4-Non-PreferredDrug


PA QL (2 PER 1 DAY)


2-Generic



4-Non-PreferredDrug


3-Preferred Brand



4-Non-PreferredDrug


endocet 2-Generic


4-Non-PreferredDrug

PA QL (4 PER 1 DAY)


3-Preferred Brand


2-Generic


2-Generic


3



2-Generic



4-Non-PreferredDrug

lorcet 2-Generic

lorcet hd 2-Generic


2-Generic


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


2-Generic



4-Non-PreferredDrug



ANESTHETICS



PA


4





2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug








4-Non-PreferredDrug


QL (4 PER 1 DAY)


QL (3 PER 1 DAY)




1-PreferredGeneric

QL (4 PER 1 DAY)


1-PreferredGeneric

QL (3 PER 1 DAY)




5





1-PreferredGeneric








ANTIBACTERIALS



4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug







6




4-Non-PreferredDrug










2-Generic



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug





7



Drug



4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic





2-Generic


4-Non-PreferredDrug


2-Generic







8




4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug



PA QL (3 PER 1 DAY)




4-Non-PreferredDrug


4-Non-PreferredDrug



4-Non-PreferredDrug




4-Non-PreferredDrug


9



4-Non-PreferredDrug





4-Non-PreferredDrug


4-Non-PreferredDrug




4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic





10




Drug





4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug






11



Drug



4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug



2-Generic




Drug


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


2-Generic


12



5-Specialty



4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug


Drug


2-Generic



4-Non-PreferredDrug



2-Generic


4-Non-PreferredDrug


13



Drug




4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug




SSD 2-Generic


4-Non-PreferredDrug



2-Generic


4-Non-PreferredDrug





14



2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug


morgidox 2-Generic


ANTICONVULSANTS







2-Generic


4-Non-PreferredDrug



roweepra 2-Generic


15










Drug


3-Preferred Brand



4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug


16



3-Preferred Brand


primidone 2-Generic





2-Generic






4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


2-Generic


17



4-Non-PreferredDrug




3-Preferred Brand


4-Non-PreferredDrug





2-Generic



2-Generic



4-Non-PreferredDrug







18



ANTIDEMENTIA AGENTS



3-Preferred Brand




4-Non-PreferredDrug


2-Generic


ANTIDEPRESSANTS


2-Generic


2-Generic





19









1-PreferredGeneric


3-Preferred Brand



1-PreferredGeneric


3-Preferred Brand


ST


2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic




20



2-Generic


4-Non-PreferredDrug



1-PreferredGeneric



ST


2-Generic


4-Non-PreferredDrug

QL (1 PER 1 DAY)


ST


amoxapine 2-Generic






2-Generic


21



Drug


ANTIEMETICS


Drug


2-Generic


2-Generic






4-Non-PreferredDrug












22



DrugPA




QL (2 PER 1 DAY)


4-Non-PreferredDrug


2-Generic



3-Preferred Brand



ANTIFUNGALS










3-Preferred Brand





3-Preferred Brand


23







3-Preferred Brand


2-Generic


4-Non-PreferredDrug




4-Non-PreferredDrug




4-Non-PreferredDrug






4-Non-PreferredDrug




PA


24




2-Generic



nystop 2-Generic





4-Non-PreferredDrug


4-Non-PreferredDrug

PA

ANTIGOUT AGENTS






ANTIMIGRAINE AGENTS




25


















4-Non-PreferredDrug







4-Non-PreferredDrug



26



ANTIMYCOBACTERIALS




Drug




2-Generic






3-Preferred Brand






27



ANTINEOPLASTICS


4-Non-PreferredDrug









flutamide 2-Generic













28





4-Non-PreferredDrug




LA














4-Non-PreferredDrug


2-Generic




29



























letrozole 2-Generic


30






toposar 2-Generic





















31































32





















ANTIPARASITICS


DrugPA


PA


33




Drug


3-Preferred Brand





2-Generic





4-Non-PreferredDrug





Drug




2-Generic


2-Generic


34




3-Preferred Brand






ST


PA LA




KYNMOBI 5-Specialty


QL (1 PER 1 DAY)


2-Generic


2-Generic


3-Preferred Brand


35




Drug


4-Non-PreferredDrug


2-Generic


Drug


ANTIPSYCHOTICS


4-Non-PreferredDrug



3-Preferred Brand


4-Non-PreferredDrug



4-Non-PreferredDrug


4-Non-PreferredDrug


36





pimozide 2-Generic







4-Non-PreferredDrug


2-Generic















37






2-Generic


3-Preferred Brand







5-Specialty



4-Non-PreferredDrug


2-Generic







38





4-Non-PreferredDrug


3-Preferred Brand




2-Generic


3-Preferred Brand


4-Non-PreferredDrug


ANTIVIRALS







39




Drug





VEMLIDY 5-Specialty





5-Specialty LA

pegasys 5-Specialty



3-Preferred Brand


GENVOYA 5-Specialty


5-Specialty


3-Preferred Brand



40




5-Specialty





EDURANT 5-Specialty

efavirenz 2-Generic


5-Specialty


5-Specialty




4-Non-PreferredDrug


ODEFSEY 5-Specialty








41






5-Specialty



4-Non-PreferredDrug



stavudine 2-Generic





5-Specialty


2-Generic


Drug

DOVATO 5-Specialty

FUZEON 5-Specialty

JULUCA 5-Specialty

RUKOBIA 5-Specialty


5-Specialty



42



Drug

TRIUMEQ 5-Specialty



5-Specialty



EVOTAZ 5-Specialty








3-Preferred Brand



5-Specialty


3-Preferred Brand



SYMTUZA 5-Specialty



43




3-Preferred Brand





2-Generic


4-Non-PreferredDrug






ANXIOLYTICS



3-Preferred Brand


4-Non-PreferredDrug


3-Preferred Brand


44



2-Generic



2-Generic


2-Generic



BIPOLAR AGENTS


2-Generic






4-Non-PreferredDrug

PA


4-Non-PreferredDrug

PA





45



DrugST



2-Generic




PA


ST


ST


ST






PA


PA


PA


4-Non-PreferredDrug


1-PreferredGeneric


1-PreferredGeneric


46



Drug




PA









ST


ST


PA




PA





ST


47





















humulin n 2-Generic


humulin r 2-Generic






48







4-Non-PreferredDrug


5-Specialty


4-Non-PreferredDrug


4-Non-PreferredDrug


5-Specialty


3-Preferred Brand



4-Non-PreferredDrug


4-Non-PreferredDrug


3-Preferred Brand


49



jantoven 2-Generic







4-Non-PreferredDrug

PA


5-Specialty PA




4-Non-PreferredDrug

PA



granix 5-Specialty

leukine 5-Specialty

MOZOBIL 5-Specialty





50





4-Non-PreferredDrug

PA




4-Non-PreferredDrug

PA



udenyca 5-Specialty

zarxio 5-Specialty



4-Non-PreferredDrug



Drug






51





4-Non-PreferredDrug


1-PreferredGeneric












valsartan 2-Generic


Generic



2-Generic


52



Drug









4-Non-PreferredDrug









3-Preferred Brand


4-Non-PreferredDrug



53



Drug

sorine 2-Generic






2-Generic





2-Generic




1-PreferredGeneric


2-Generic



ST

pindolol 2-Generic


54



2-Generic


4-Non-PreferredDrug


Generic


cartia xt 2-Generic

dilt-xr 2-Generic


2-Generic


4-Non-PreferredDrug





4-Non-PreferredDrug


55



2-Generic


taztia xt 2-Generic



4-Non-PreferredDrug


2-Generic


Drug




2-Generic



3-Preferred Brand



2-Generic


2-Generic


4-Non-PreferredDrug



56



4-Non-PreferredDrug

PA

digitek 2-Generic

digox 2-Generic


2-Generic


4-Non-PreferredDrug









2-Generic


PA


4-Non-PreferredDrug


2-Generic








57



Drug





PA




4-Non-PreferredDrug




3-Preferred Brand



1-PreferredGeneric


4-Non-PreferredDrug

torsemide 2-Generic





58



Drug



2-Generic




2-Generic



2-Generic





Generic







59




4-Non-PreferredDrug


4-Non-PreferredDrug



4-Non-PreferredDrug

ezetimibe 2-Generic





PA


2-Generic






triklo 2-Generic



2-Generic

minoxidil 2-Generic


60




3-Preferred Brand


2-Generic

minitran 2-Generic



2-Generic






2-Generic


4-Non-PreferredDrug




QL (1 PER 1 DAY)



61




Drug



QL (1 PER 1 DAY)


2-Generic


4-Non-PreferredDrug

QL (1 PER 1 DAY)


2-Generic



4-Non-PreferredDrug

QL (1 PER 1 DAY)


2-Generic


QL (6 PER 1 DAY)



QL (2 PER 1 DAY)


QL (1 PER 1 DAY)


62











riluzole 2-Generic





Drug


2-Generic


2-Generic


4-Non-PreferredDrug

QL (2 PER 1 DAY)




avonex 5-Specialty


63







5-Specialty


GILENYA 5-Specialty


glatopa 5-Specialty




5-Specialty LA




rebif 5-Specialty



ZEPOSIA 5-Specialty



2-Generic

paroex 2-Generic

periogard 2-Generic


64



4-Non-PreferredDrug




Drug


4-Non-PreferredDrug


4-Non-PreferredDrug







4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


65



Drug







3-Preferred Brand









4-Non-PreferredDrug


ST




3-Preferred Brand


4-Non-PreferredDrug




66



DrugST













ST


5-Specialty PA


4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug




67





4-Non-PreferredDrug







4-Non-PreferredDrug




4-Non-PreferredDrug







2-Generic





68














4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug





69



Drug


2-Generic






5-Specialty PA LA


5-Specialty PA

kionex 2-Generic



2-Generic





Drug


3-Preferred Brand


5-Specialty




70



5-Specialty





2-Generic

o-cal fa 2-Generic






zingiber 2-Generic



2-Generic


2-Generic






71



3-Preferred Brand



4-Non-PreferredDrug





PYLERA 5-Specialty


5-Specialty PA


5-Specialty PA




3-Preferred Brand





2-Generic



2-Generic


72




Drug






enulose 2-Generic




generlac 2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug



2-Generic





73





2-Generic


DrugST


4-Non-PreferredDrug

ST


2-Generic


2-Generic


4-Non-PreferredDrug

ST


2-Generic


2-Generic


4-Non-PreferredDrug









74




LA









5-Specialty LA





5-Specialty PA LA





5-Specialty PA







75



3-Preferred Brand


2-Generic




















76





4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug



3-Preferred Brand


4-Non-PreferredDrug


4-Non-PreferredDrug


3-Preferred Brand




2-Generic


4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug



77




decadron 2-Generic


3-Preferred Brand



4-Non-PreferredDrug


2-Generic


3-Preferred Brand


4-Non-PreferredDrug


4-Non-PreferredDrug



5-Specialty PA LA






3-Preferred Brand


3-Preferred Brand


78





2-Generic



4-Non-PreferredDrug


2-Generic


3-Preferred Brand


4-Non-PreferredDrug






2-Generic


3-Preferred Brand




2-Generic



79




4-Non-PreferredDrug


2-Generic


2-Generic





3-Preferred Brand


2-Generic


3-Preferred Brand

triderm 2-Generic



2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


80





5-Specialty PA


PA


PA

STIMATE 5-Specialty





DrugPA



4-Non-PreferredDrug

PA


4-Non-PreferredDrug




altavera 2-Generic


81




amethyst 2-Generic

apri 2-Generic

aranelle 2-Generic

aubra 2-Generic

aubra eq 2-Generic





aviane 2-Generic


azurette 2-Generic

balziva 2-Generic

bekyree 2-Generic



briellyn 2-Generic

caziant 2-Generic





cryselle 2-Generic


82



cyred 2-Generic

cyred eq 2-Generic

dasetta 2-Generic



2-Generic

dolishale 2-Generic


elinest 2-Generic


emoquette 2-Generic

enpresse 2-Generic

enskyce 2-Generic

estarylla 2-Generic


4-Non-PreferredDrug


2-Generic






83





falmina 2-Generic


femynor 2-Generic



GIANVI 2-Generic

hailey 2-Generic


hailey fe 2-Generic

iclevia 2-Generic

introvale 2-Generic

isibloom 2-Generic

jasmiel 2-Generic


JOLESSA 2-Generic

juleber 2-Generic



junel fe 2-Generic




84



kariva 2-Generic



kurvelo 2-Generic




larin fe 2-Generic

larissia 2-Generic

LEENA 2-Generic

lessina 2-Generic

levonest 2-Generic


levora-28 2-Generic

lillow 2-Generic



loryna 2-Generic


lutera 2-Generic


marlissa 2-Generic




85



Drug






mili 2-Generic



necon 2-Generic

nikki 2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug


nortrel 2-Generic

nylia 2-Generic

nymyo 2-Generic

OCELLA 2-Generic


86



orsythia 2-Generic

philith 2-Generic

pimtrea 2-Generic

pirmella 2-Generic

portia 2-Generic


3-Preferred Brand



previfem 2-Generic

reclipsen 2-Generic

setlakin 2-Generic

simliya 2-Generic

sprintec 2-Generic

sronyx 2-Generic

syeda 2-Generic


tarina fe 2-Generic








87







tri-mili 2-Generic

tri-nymyo 2-Generic






TYBLUME 2-Generic

velivet 2-Generic

vestura 2-Generic

vienva 2-Generic

viorele 2-Generic

volnea 2-Generic

vyfemla 2-Generic

vylibra 2-Generic

wera 2-Generic

xulane 2-Generic


zafemy 2-Generic

zarah 2-Generic




88




Drug


deblitane 2-Generic



errin 2-Generic

heather 2-Generic

incassia 2-Generic

jencycla 2-Generic

lyleq 2-Generic

lyza 2-Generic


4-Non-PreferredDrug


2-Generic


2-Generic


NORA-BE 2-Generic



norlyda 2-Generic



89



tulana 2-Generic


Drug




Drug




4-Non-PreferredDrug


2-Generic



2-Generic






90



Drug










5-Specialty


PA











91
















4-Non-PreferredDrug



4-Non-PreferredDrug



5-Specialty PA








4-Non-PreferredDrug



92














2-Generic


2-Generic








5-Specialty PA



4-Non-PreferredDrug






4-Non-PreferredDrug



93










5-Specialty PA










5-Specialty PA LA







94








PA



PA


PA LA



PA











3-Preferred Brand





95






























96







4-Non-PreferredDrug



PENTASA 5-Specialty




colocort 2-Generic









2-Generic


97



4-Non-PreferredDrug














4-Non-PreferredDrug





4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug




2-Generic


4-Non-PreferredDrug


98



xgeva 5-Specialty


4-Non-PreferredDrug



4-Non-PreferredDrug


4-Non-PreferredDrug









4-Non-PreferredDrug


2-Generic


2-Generic


99



2-Generic


2-Generic


2-Generic


2-Generic


2-Generic


2-Generic

OPHTHALMIC AGENTS


Drug









100



Drug



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug







4-Non-PreferredDrug






Drug


101











3-Preferred Brand















3-Preferred Brand


102



Drug



2-Generic

















3-Preferred Brand


103





1-PreferredGeneric


4-Non-PreferredDrug






ST


OTIC AGENTS






4-Non-PreferredDrug




104



3-Preferred Brand



4-Non-PreferredDrug






2-Generic


3-Preferred Brand






2-Generic



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


105



Drug






2-Generic








4-Non-PreferredDrug











2-Generic


106



Drug



4-Non-PreferredDrug








4-Non-PreferredDrug














4-Non-PreferredDrug



107




DrugPA


2-Generic










5-Specialty PA LA









108






2-Generic








5-Specialty PA LA




2-Generic


2-Generic




2-Generic



109




2-Generic


Drug





PA QL (1 PER 1 DAY)




MISCELLANEOUS




110






ABELCET 23

ABILIFY MAINTENA 37

ABILIFY MYCITE 37



acarbose 45

accutane 65

acebutolol hcl 54


acetazolamide 58

acetic acid 104

acetylcysteine 108

acitretin 65

acthib 95

actimmune 95

acyclovir 44

acyclovir sodium 44

adacel tdap 95

adapalene 65


ADEMPAS 108

ADVAIR DISKUS 108

ADVAIR HFA 108

AEMCOLO 7

AFINITOR 31

AFINITOR DISPERZ 31

afirmelle 81


ak-poly-bac 100

AKYNZEO 22

albendazole 33







ALECENSA 31


alfuzosin hcl 76


allopurinol 25





ALOMIDE 101

alosetron hcl 73

ALPHAGAN P 103

alprazolam 44

ALREX 102

altavera 81

ALTRENO 65

ALUNBRIG 29

alyacen 82

alyq 108

amabelz 82

amantadine hcl 35

AMBISOME 23

ambrisentan 108

amcinonide 77

amethyst 82


amiloride hcl 58


AMINOSYN II 68

amiodarone hcl 53

AMITIZA 73







111

ammonium lactate 65

amnesteem 65

amoxapine 21

amoxicillin 11


amphotericin b 23




ANADROL-50 81

anagrelide hcl 50

anastrozole 30

ANDRODERM 81

ANORO ELLIPTA 108

anusol-hc 97

APOKYN 35


aprepitant 22

apri 82

APTIOM 18

APTIVUS 43

aralast np 74

aranelle 82

aranesp 50

arcalyst 95

aripiprazole 37

ARISTADA 37

ARISTADA INITIO 37

armodafinil 110

armour thyroid 90

ARNUITY ELLIPTA 104

arsenic trioxide 29



ASMANEX 105

ASMANEX HFA 105


ASTAGRAF XL 92


atenolol 54


atomoxetine hcl 62


atovaquone 34



ATROVENT HFA 106

AUBAGIO 63

aubra 82

aubra eq 82

aurovela 82

aurovela 24 fe 82

aurovela fe 82

AURYXIA 70

AUSTEDO 63

AUVI-Q 106

aviane 82

avidoxy 14

AVITA 65

avonex 63

avonex pen 64

AVYCAZ 9

ayuna 82

AYVAKIT 29

AZASITE 12

azathioprine 92


azelaic acid 65

azelastine hcl 102

azithromycin 12

aztreonam 11

azurette 82

Bbacitracin 7


baclofen 39


BALVERSA 29

balziva 82

BAQSIMI 48

BARACLUDE 40

112


bekyree 82

BELBUCA 2

benazepril hcl 52


benlysta 95

BENZNIDAZOLE 34


beser 77




betaseron 64

betaxolol hcl 54


BETIMOL 103

bexarotene 33

bexsero 95

bicalutamide 28

BICILLIN C-R 11

BICILLIN L-A 12

BIKTARVY 40

bimatoprost 104

BINOSTO 98



bivigam 94

BLEPHAMIDE 100

blephamide sop 100

blisovi 24 fe 82

blisovi fe 82


boostrix tdap 95

bosentan 108

BOSULIF 31

BRAFTOVI 31

BREO ELLIPTA 108

briellyn 82

BRILINTA 51


brinzolamide 103

BRIVIACT 15



BRUKINSA 29

budesonide 97

bumetanide 58

buprenorphine 2

buprenorphine hcl 2


bupropion hcl 6

buspirone hcl 44





BYDUREON BCISE 45

BYDUREON PEN 45

Ccabergoline 91

cablivi 50

CABOMETYX 31

cafergot 26

calcipotriene 65


CALCITRIOL 65

calcitriol 98

calcium acetate 70

CALQUENCE 31

camila 89



CAPASTAT SULFATE 27

CAPLYTA 37

CAPRELSA 31

captopril 52


CARBAGLU 74

carbamazepine 18

carbidopa 36


113


CARDIZEM LA 55

carteolol hcl 103

cartia xt 55

carvedilol 54



cataflam 1

CAYSTON 107

caziant 82

cefaclor 9

cefadroxil 9

cefazolin sodium 9

cefdinir 9

cefepime hcl 9


cefixime 10



cefoxitin sodium 10


cefprozil 10

ceftazidime 10





celecoxib 1

CELONTIN 16

cephalexin 10

CERDELGA 74

CHANTIX 6

charlotte 24 fe 82

chateal 82

chateal eq 82

CHEMET 70

chenodal 71





chlorthalidone 59

CHOLBAM 74



ciclodan 23

ciclopirox 23


cilostazol 51

CIMDUO 42

cimetidine 72

cimetidine hcl 72

cinacalcet hcl 98

cinryze 92

ciprofloxacin 13





claravis 65

clarithromycin 12


cleocin phosphate 7

clindacin etz 7

clindacin p 7

clindamycin hcl 7




CHLORIDE 7



CLINOLIPID 68

clobazam 16



clodan 77

clomipramine hcl 21

clonazepam 44


mgday patch) 52

clonidine hcl 52

114



clotrimazole 23


clovique 70

clozapine 39

COARTEM 34


codeine sulfate 3

colchicine 25

colesevelam hcl 60

colestipol hcl 60


colocort 97

COMBIGAN 103

COMBIPATCH 82


COMETRIQ 31

COMPLERA 41

compro 22

concept ob 71

constulose 73

COPAXONE 64

COPIKTRA 29

CORLANOR 57

cormax 78


CORTISPORIN 66


cosentyx pen 66


cosentyx syringe 66

COTELLIC 31

creon 74

CRESEMBA 24

CRIXIVAN 43

cromolyn sodium 71

cryselle 82

cyclafem 83


cyclophosphamide 28

cycloserine 27

CYCLOSET 45

cyclosporine 92



cyred 83

cyred eq 83

cystadane 75

CYSTADROPS 100

CYSTAGON 75

CYSTARAN 100

Ddalfampridine 64

DALIRESP 108

danazol 81


dapsone 27

daptacel dtap 95

daptomycin 7

dasetta 83

DAURISMO 31

DAYTRANA 62

deblitane 89

decadron 78

deferasirox 70

DELSTRIGO 41


DEPO-PROVERA 89


DESCOVY 42

desipramine hcl 21





desonide 78

desoximetasone 78


dexamethasone 78


115


DEXILANT 74



aspartate 61










DIACOMIT 15

DIASTAT 16

DIASTAT ACUDIAL 16

DIAZEPAM 16

diazepam 45

diazoxide 48


diclofenac sodium 1



dicyclomine hcl 71

didanosine 42

DIFICID 13


diflunisal 1

difluprednate 102

digitek 57

digox 57

digoxin 57


dilantin 18

dilt-xr 55

diltiazem hcl 55


DIPENTUM 97




disulfiram 5


dofetilide 53

dolishale 83

donepezil hcl 19

DOPTELET 50

dorzolamide hcl 103



dotti 83

DOVATO 42


doxepin hcl 44

doxercalciferol 98

doxy 100 14




dronabinol 23

DROXIA 29

droxidopa 52

DUAVEE 90

DULERA 109

duloxetine hcl 63

dupixent pen 66

dupixent syringe 66

dutasteride 76


EDURANT 41

efavirenz 41



egrifta sv 81

ELIGARD 91

elinest 83

ELIQUIS 49

ELLA 89

ELMIRON 76

116

eluryng 83

EMCYT 28

EMEND 23

EMFLAZA 78

emgality pen 25

emgality syringe 26

emoquette 83

EMSAM 20

emtricitabine 42


EMTRIVA 42

emverm 33



enbrel 92

enbrel mini 92

enbrel sureclick 92

endocet 3

engerix-b adult 95



enpresse 83

enskyce 83

enspryng 94

entacapone 35

entecavir 40

ENTRESTO 57

enulose 73

EPIDIOLEX 15

epifoam 66

epinastine hcl 102

epinephrine 106

epitol 18

EPIVIR HBV 40

eplerenone 58

epogen 50



ERIVEDGE 31

ERLEADA 28

erlotinib hcl 31

errin 89

ertapenem sodium 11

ery 13







ESBRIET 108



estarylla 83

estradiol 83



ESTRING 83

eszopiclone 109

ethacrynic acid 58

ethambutol hcl 27


ethosuximide 16



etodolac 1


etoposide 31

etravirine 41

EUTHYROX 90

everolimus 31

EVOTAZ 43

EVRYSDI 75

exemestane 30

extavia 64

ezetimibe 60


Ffalmina 84

famciclovir 44

famotidine 72

117

famotidinepf 72

FANAPT 37

FARXIGA 46

FARYDAK 31

fasenra pen 109

febuxostat 25

felbamate 17

felodipine 55

FEMRING 84

femynor 84

fenofibrate 59



FENOFIBRIC ACID 59


fentanyl 2

fentanyl citrate 3

FETZIMA 20

FINACEA 66

finasteride 76

FINTEPLA 15

FIRDAPSE 63

FIRMAGON 91

FIRVANQ 8

FLAREX 102

flavoxate hcl 75

flebogamma dif 94


FLOVENT DISKUS 105

FLOVENT HFA 105

fluconazole 24


flucytosine 24


flunisolide 105




fluocinonide 78


FLUOROMETHOLONE 102

fluorouracil 29

FLUOROURACIL 66

fluoxetine hcl 20


fluphenazine hcl 36

flurbiprofen 1


flutamide 28



XINAFOATE 109



FML FORTE 102

FML SOP 102

folivane-ob 71








FOSRENOL 70

FOTIVDA 31

FRAGMIN 49


fulphila 50

furosemide 58

FUZEON 42

fyavolv 84

FYCOMPA 17

Ggabapentin 16

GALAFOLD 75

galantamine hbr 19

gammagard liquid 94

gammagard s-d 94

gammaked 94

gammaplex 94

118

gamunex-c 94

gardasil 9 95

gatifloxacin 13

GATTEX 72

gauze bandage 99

gavilyte-c 73

gavilyte-g 73

gavilyte-n 73

GAVRETO 29

gemfibrozil 59

gemmily 84

generlac 73

gengraf 92

gentak 6




GENVOYA 40

GIANVI 84

GILENYA 64

GILOTRIF 31

glassia 75


glatopa 64

glimepiride 46

glipizide 46


GLUCAGEN 48


glycopyrrolate 71

glydo 4

GLYXAMBI 46

granisetron hcl 23

granix 50

grastek 95



guanfacine hcl 62

GUANIDINE HCL 26





Hhaegarda 92

hailey 84

hailey 24 fe 84

hailey fe 84


haloperidol 36



havrix 95

heather 89



CHLORIDE 49


WATER 49


HETLIOZ 110

HETLIOZ LQ 110

hiberix 95

humalog 48








humira 93

humira pen 93



humira(cf) 93


humira(cf) pen 93




119

humulin 70-30 48


humulin n 48


humulin r 48

humulin r u-500 48


hydralazine hcl 60





hydrocortisone 79





hydromorphone hcl 4



hydroxyurea 29

hydroxyzine hcl 105



IBRANCE 32

ibu 1

ibuprofen 1


iclevia 84

ICLUSIG 32

icosapent ethyl 60

IDHIFA 29

ILEVRO 102


IMBRUVICA 32


imipramine hcl 21


imiquimod 66


INBRIJA 35

incassia 89

increlex 81

INCRUSE ELLIPTA 106

indapamide 59

indomethacin 1

infanrix dtap 95

INGREZZA 63


INLYTA 32

INQOVI 29

INREBIC 29


insulin syringes 99

INTELENCE 41

INTRALIPID 68

intron a 40

introvale 84

INVEGA SUSTENNA 37

INVEGA TRINZA 38

INVELTYS 102

INVIRASE 43

INVOKAMET 46

INVOKAMET XR 46

INVOKANA 46

ipol 96



irbesartan 52


IRESSA 32

ISENTRESS 40

ISENTRESS HD 40

isibloom 84

isoniazid 27



isotretinoin 66

isradipine 55

ISTURISA 79

120

itraconazole 24

ivermectin 34

ixiaro 96

JJAKAFI 32

jantoven 50

JANUMET 46

JANUMET XR 46

JANUVIA 46

JARDIANCE 46

jasmiel 84

jencycla 89

JENTADUETO 46

JENTADUETO XR 46

jinteli 84

JOLESSA 84

juleber 84

JULUCA 42

junel 84

junel fe 84

junel fe 24 84

JUXTAPID 60

JYNARQUE 70


kaitlib fe 84

kalliga 85

KALYDECO 107

kariva 85

kelnor 1-35 85

kelnor 1-50 85

kesimpta pen 64

ketoconazole 24

ketodan 24

ketoprofen 1



kinrix 96

kionex 70

KISQALI 32


KLISYRI 66

KLOR-CON 10 68

KLOR-CON 8 68

klor-con m10 68

klor-con m15 69

klor-con m20 69

KLOXXADO 6

KOMBIGLYZE XR 46

KORLYM 79

KOSELUGO 32

kurvelo 85

KYNMOBI 35

Llabetalol hcl 54

LACRISERT 100

lactulose 73

lamivudine 40


lamotrigine 17

lansoprazole 74



lantus 48

lantus solostar 48


larin 85

larin 24 fe 85

larin fe 85

larissia 85

latanoprost 104

LATUDA 38


LEENA 85

leflunomide 95

LENVIMA 32

lessina 85

letrozole 30


121

LEUKERAN 28

leukine 50




levetiracetam 15


LEVO-T 90

levobunolol hcl 103

LEVOCARNITINE 69



levofloxacin 13


levonest 85


levora-28 85



LEVOXYL 90

LEXIVA 43

lidocaine 4

lidocaine hcl 5

lidocaine hclpf 5


lillow 85

lindane 34

linezolid 8


LINZESS 73


lisinopril 53



LITHIUM CITRATE 45

lo-zumandimine 85

LONSURF 29

loperamide hcl 72


LOPREEZA 85

lorazepam 45


LORBRENA 31

lorcet 4

lorcet hd 4

loryna 85



LOTEMAX 102

LOTEMAX SM 102


lovastatin 59

low-ogestrel 85


LUBIPROSTONE 73

LUCEMYRA 5

LUMAKRAS 32

LUMIGAN 104

LUPANETA PACK 91

LUPKYNIS 93

LUPRON DEPOT 91

LUPRON DEPOT-PED 91

lutera 85

lyleq 89

lyllana 85

LYNPARZA 32

LYSODREN 29

lyza 89



maprotiline hcl 20

marlissa 85

marplan 20

MATULANE 28

matzim la 55

MAVENCLAD 64

MAYZENT 64

meclizine hcl 22



122

mefloquine hcl 34


MEKINIST 32

MEKTOVI 32

melodetta 24 fe 85

meloxicam 1

memantine hcl 19

menactra 96

menest 85

menquadfi 96


mercaptopurine 29

meropenem 11


merzee 86

mesalamine 97


MESNEX 33

metadate er 62


metformin hcl 46




24h) 46

methadone hcl 2

methazolamide 58


methergine 99

methimazole 91

methocarbamol 109



methoxsalen 66








metolazone 59




metronidazole 8


mexiletine hcl 53

mibelas 24 fe 86



microgestin 86


microgestin fe 86

midodrine hcl 52

migergot 26

miglitol 47

miglustat 75

mili 86

mimvey 86

minitran 61

minocycline hcl 15

minoxidil 60

mirtazapine 19

misoprostol 74

mitoxantrone hcl 30

modafinil 110

moexipril hcl 53

molindone hcl 37


mondoxyne nl 15

mono-linyah 86


morgidox 15

morphine sulfate 2

MOVANTIK 72

moxifloxacin hcl 14




MOZOBIL 50

MULTAQ 53

123


acid 71


myalept 72

MYCAPSSA 91



myorisan 66

MYRBETRIQ 76

MYTESI 72

Nnabumetone 1

nadolol 54

nafcillin sodium 12

naftifine hcl 24

NAFTIN 24

naloxone hcl 6

naltrexone hcl 5

NAMENDA XR 19

naproxen 1

naproxen sodium 2

naratriptan hcl 26

NARCAN 6

NATACYN 24

nateglinide 47

natpara 98

NAYZILAM 15

nebivolol hcl 54

necon 86

nefazodone hcl 20

neo-polycin 101

neo-polycin hc 101

neomycin sulfate 6


bhydrocortisone 101






NERLYNX 32

neulasta 50

neulasta onpro 50

neupogen 50

NEUPRO 35

nevirapine 41

NEXAVAR 32

NEXIUM 74

NEXLETOL 57

NEXLIZET 60

niacin 60

nicardipine hcl 55

NICOTROL 6

NICOTROL NS 6

nifedipine 56

nikki 86

nilutamide 28

nimodipine 56

NINLARO 30

nitazoxanide 34

nitisinone 75

NITRO-DUR 61

nitrofurantoin 8



nitroglycerin 61

NITROSTAT 61

NITYR 75

nivestym 51

nizatidine 72

NORA-BE 89

norethindrone 89




fumarate 86



norlyda 89

NORPACE CR 53

nortrel 86

124


NORVIR 43

NOURIANZ 35

NOXAFIL 24

np thyroid 90

NUBEQA 28

nucala 109

NUEDEXTA 63

NUPLAZID 38

NUTRILIPID 69

nyamyc 25

nylia 86

nymyo 86

nystatin 25


nystop 25

nyvepria 51

Oo-cal fa 71

ob complete 71

OCALIVA 75

OCELLA 86

octagam 94


odactra 95

ODEFSEY 41

ODOMZO 32

OFEV 108

ofloxacin 14

ogestrel 87

olanzapine 38






olopatadine hcl 102


OMEGAVEN 69

omeprazole 74

omnitrope 81

ondansetron hcl 23



ONGENTYS 35

ONGLYZA 47

ONUREG 30

OPSUMIT 108

oralair 95

orencia 93


ORFADIN 75

ORGOVYX 91

ORIAHNN 81

ORILISSA 81

ORKAMBI 107

ORLADEYO 92

orsythia 87


OSMOLEX ER 35

OTEZLA 95

oxacillin sodium 12


DEXTROSE 12

oxandrolone 81

oxazepam 45

oxcarbazepine 18

oxervate 101



oxycodone hcl 4



oxymorphone hcl 4

OZEMPIC 47

Ppaliperidone 38

palynziq 75


PANRETIN 33

125


panzyga 94

paricalcitol 98

paroex 64


paroxetine hcl 21

paser 27

PAXIL 21

PAZEO 102

pediarix 96

pedvaxhib 96


chloride 73


sodvit c 73

PEGANONE 18

pegasys 40

pegintron 40

PEMAZYRE 32




penicillamine 76








PENTASA 97

pentoxifylline 57

PERFOROMIST 107


periogard 64

permethrin 34

perphenazine 22


PERSERIS 38

pfizerpen 12


phenobarbital 17


phenytoin 18


philith 87

PHOSLYRA 70


PICATO 66

PIFELTRO 41

pilocarpine hcl 65

pimecrolimus 67

pimozide 37

pimtrea 87

pindolol 54

pioglitazone hcl 47




PIQRAY 31

pirmella 87

piroxicam 2

plegridy 64

plegridy pen 64

plenamine 69

PLENVU 73

podofilox 67

polycin 101



POMALYST 28

portia 87

posaconazole 25



SODIUM CHLORIDE 69


SODIUM CHLORIDE 69


SODIUM CHLORIDE 69


AND 5 DEXTROSE 69

126



PRADAXA 50


prasugrel hcl 51


prazosin hcl 52

PRED MILD 103

PREDNICARBATE 79

prednisolone 80



prednisone 80


pregabalin 63

PREMARIN 87

PREMPHASE 87

PREMPRO 87


prenate am 71

prenate chewable 71

prevalite 60

previfem 87

PREVYMIS 39

PREZCOBIX 43

PREZISTA 43

PRIFTIN 27


primidone 17

privigen 94


probenecid 25


prochlorperazine 22



procrit 51

procto-med hc 97

proctofoam-hc 67

proctosol-hc 97

proctozone-hc 97

PROCYSBI 75


PROGRAF 93

prolastin c 75

PROLENSA 103

prolia 98

PROMACTA 51

promethazine hcl 22

propafenone hcl 53

propranolol hcl 55


propylthiouracil 92

proquad 96


psorcon 80

pulmozyme 107

purefe ob plus 71

PURIXAN 29

PYLERA 72

pyrazinamide 27


pyrimethamine 34

QQINLOCK 30



quinapril hcl 53




QVAR REDIHALER 105

Rrabavert 96


ragwitek 95

raloxifene hcl 90

ramipril 53

ranolazine 57


127

RAVICTI 75

rebif 64

rebif rebidose 64

reclipsen 87

recombivax hb 96

RECTIV 67

regranex 67

RELENZA 44

relexxii 62

RELISTOR 72


RENACIDIN 76

repaglinide 47




repatha syringe 60

RESTASIS 101


retacrit 51

RETEVMO 30

RETROVIR 42

REVLIMID 28

REXULTI 38

REYATAZ 43

REZUROCK 93

RHOPRESSA 104

ribavirin 40

rifabutin 27

rifampin 27

RIFATER 27

riluzole 63

rimantadine hcl 44


RINVOQ 93


RISPERDAL CONSTA 38

risperidone 38

ritonavir 43

rivastigmine 19



ropinirole hcl 35

rosadan 67


rotarix 96

rotateq 96

roweepra 15

roweepra xr 16

ROZLYTREK 30

RUBRACA 30

rufinamide 18

RUKOBIA 42

RUZURGI 63

RYBELSUS 47

RYDAPT 30

Ssajazir 92

SAMSCA 70

santyl 67


SAVAYSA 50

SAVELLA 63

SECUADO 38

SEGLUROMET 47

selegiline hcl 36

selenium sulfide 67

SELZENTRY 42

SEREVENT DISKUS 107

sertraline hcl 21

setlakin 87


sharobel 90

shingrix 96

SIGNIFOR 91


silodosin 76

SILVADENE 14


SIMBRINZA 104

simliya 87

128

simvastatin 59

sirolimus 93

SIRTURO 27

SIVEXTRO 8

skyrizi 67


skyrizi pen 67

SMOFLIPID 69




chloridepeg 73





soltamox 28

SOLU-CORTEF 80

SOMATULINE DEPOT 91

somavert 91

SOOLANTRA 67

sorine 54

sotalol af 54

sotalol hcl 54

SPIRIVA 106


spironolactone 58


sprintec 87

SPRITAM 16

SPRIX 2

SPRYCEL 32

sps 70

sronyx 87

SSD 14

stavudine 42

STEGLATRO 47

STEGLUJAN 47

stelara 67

STIMATE 81


STIVARGA 32


STRIBILD 41

sucraid 75

sucralfate 74



phosphate 101

sulfadiazine 14


SULFAMYLON 8

sulfasalazine 97

sulindac 2


sunitinib malate 32

SUNOSI 110

suprax 10

SUPREP 73

SUTAB 73

syeda 87

sylatron 30

SYMBICORT 109

SYMDEKO 107

SYMPAZAN 17

SYMPROIC 72

SYMTUZA 43

SYNAREL 91

SYNJARDY 47

SYNJARDY XR 47

SYNRIBO 30

SYNTHROID 90


container 100




ml 100


TTABLOID 29

129

TABRECTA 30

tacrolimus 67

tadalafil 76

TAFINLAR 32

TAGRISSO 32

takhzyro 92

TALICIA 72

TALZENNA 32


tamsulosin hcl 76

TARGRETIN 33

tarina 24 fe 87

tarina fe 87


TASIGNA 32

TAVALISSE 51

taysofy 87

tazarotene 67

tazicef 10

TAZORAC 67

taztia xt 56

TAZVERIK 30

TEFLARO 10

TEGSEDI 63

telmisartan 52



temazepam 109

TEMIXYS 43

tenivac 96


TEPMETKO 33

terazosin hcl 52

terbinafine hcl 25


terconazole 25

testosterone 81





tetrabenazine 63

tetracycline hcl 15

THALOMID 28


THIOLA EC 76

thioridazine hcl 37

thiothixene 37

thyroid 90

thyroidpork 91

tiadylt er 56

tiagabine hcl 17

TIBSOVO 30

tigecycline 8

tilia fe 87

timolol maleate 55

tinidazole 8

tiopronin 76

TIVICAY 41

TIVICAY PD 41

tizanidine hcl 39

tobi podhaler 107

TOBRADEX 101

tobramycin 7




TOBREX 7

tolmetin sodium 2


tolvaptan 70

topiramate 17

toposar 31

topotecan hcl 31


torsemide 58


toujeo solostar 49

TOVIAZ 76

TPN ELECTROLYTES 70

TRACLEER 108

TRADJENTA 47

130

tramadol hcl 3


trandolapril 53


tranexamic acid 51


travoprost 104

trazodone hcl 21

TRECATOR 27

TRELEGY ELLIPTA 109

trelstar 91

tremfya 67

tretinoin 33


trexall 94

tri femynor 87

tri-estarylla 87

tri-legest fe 87

tri-linyah 88

tri-lo-estarylla 88

tri-lo-marzia 88

tri-lo-mili 88

tri-lo-sprintec 88

tri-mili 88

tri-nymyo 88

tri-previfem 88

tri-sprintec 88

tri-vylibra 88

tri-vylibra lo 88


triamterene 59


triderm 80

trientine hcl 70


trifluridine 44


TRIKAFTA 107

triklo 60


trimethoprim 9


TRINTELLIX 21

TRIUMEQ 43

trivora-28 88

tropicamide 101


trulicity 47

trumenba 96

truseltiq 33

TUKYSA 30

tulana 90

TURALIO 30

twinrix 96

TYBLUME 88

TYBOST 43

TYMLOS 99

typhim vi 96

Uudenyca 51

UKONIQ 33

UNITHROID 91

UPTRAVI 108

ursodiol 72


VALCHLOR 28


valproic acid 17


valsartan 52


VALTOCO 17

vancomycin hcl 9


(PEG-400 NADA) 9



VANDAZOLE 9

vaqta 96

131


varivax vaccine 96

VARUBI 23

VASCEPA 60

velivet 88

VEMLIDY 40

VENCLEXTA 33


venlafaxine hcl 21

verapamil hcl 56

verquvo 58

VERSACLOZ 39

VERZENIO 33

vestura 88

VIBERZI 73

VICTOZA 2-PAK 47

VICTOZA 3-PAK 47

VIDEX 42

VIDEX EC 42

vienva 88

vigabatrin 17

vigadrone 17

VIIBRYD 21

VIMPAT 18

viorele 88

VIRACEPT 43

VIREAD 42

VITRAKVI 30

VIZIMPRO 30

volnea 88

voriconazole 25

VOSEVI 40

VOTRIENT 33

VRAYLAR 38

VUMERITY 64

vyfemla 88

vylibra 88

VYNDAMAX 58

VYNDAQEL 58

VYVANSE 61

VYZULTA 104

WWAKIX 110

warfarin sodium 50

WELIREG 30

wera 88

XXALKORI 33

XARELTO 50

XATMEP 94

XCOPRI 16

XELJANZ 94

XELJANZ XR 94

XELPROS 104

XERMELO 72

xgeva 99

XIFAXAN 9

XIGDUO XR 47

XOFLUZA 44

xolair 109

XOSPATA 30

XPOVIO 30

XTAMPZA ER 3

XTANDI 28

xulane 88

XYREM 110

XYWAV 110

Yyf-vax 96

YONSA 28

yuvafem 88

Zzafemy 88

zafirlukast 106

zaleplon 110

zarah 88

zarxio 51

ZEJULA 33

132

ZELBORAF 33

zemaira 75

zenatane 67

zenpep 75

zenzedi 61

ZEPOSIA 64

ZERBAXA 11

zidovudine 42

ziextenzo 51

zingiber 71

ziprasidone hcl 39


ZIRGAN 39

zoledronic acid 99


SODIUM CHLORIDE 99


ZOLINZA 30

zolmitriptan 26


zonisamide 16

ZORTRESS 94

zovia 1-35 88

zovia 1-35e 88

zumandimine 89

ZYDELIG 33

ZYKADIA 33

ZYLET 101

133


ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 15


ANTIDEPRESSANTS 19

ANTIEMETICS 22

ANTIFUNGALS 23

ANTIGOUT AGENTS 25




ANTINEOPLASTICS 28

ANTIPARASITICS 33


ANTIPSYCHOTICS 36


ANTIVIRALS 39

ANXIOLYTICS 44

BIPOLAR AGENTS 45




















MISCELLANEOUS 110



OTIC AGENTS 104


134



135






MDC-455

11222021

11222021













during the year







have made





















H9047_2021AM04_C iii 11222021

H9047_2021AM04_C iv












111

11222021

112021

134

H9047_2021AM04_C v












11222021

H9047_2021AM04_C vi










pages























11222021

H9047_2021AM04_C vii










111

11222021

H9047_2021AM04_C viii













11222021



formats)













(TTY 711）



1‐800‐603‐2340 (TTY 711) 번으로 전화해 주십시오










Arabic










Persian




(082021) H9047_2021RCGA03_C



ANALGESICS


celecoxib 2-Generic



3-Preferred Brand




4-Non-PreferredDrug



ibu 2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug




meloxicam 2-Generic



2-Generic


1



Drug



piroxicam 2-Generic


sulindac 2-Generic



DrugPA




4-Non-PreferredDrug

PA




4-Non-PreferredDrug

PA QL (2 PER 1 DAY)


PA QL (4 PER 1 DAY)


2-Generic PA





2



3-Preferred Brand


4-Non-PreferredDrug


PA QL (2 PER 1 DAY)


2-Generic



4-Non-PreferredDrug


3-Preferred Brand



4-Non-PreferredDrug


endocet 2-Generic


4-Non-PreferredDrug

PA QL (4 PER 1 DAY)


3-Preferred Brand


2-Generic


2-Generic


3



2-Generic



4-Non-PreferredDrug

lorcet 2-Generic

lorcet hd 2-Generic


2-Generic


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


2-Generic



4-Non-PreferredDrug



ANESTHETICS



PA


4





2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug








4-Non-PreferredDrug


QL (4 PER 1 DAY)


QL (3 PER 1 DAY)




1-PreferredGeneric

QL (4 PER 1 DAY)


1-PreferredGeneric

QL (3 PER 1 DAY)




5





1-PreferredGeneric








ANTIBACTERIALS



4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug







6




4-Non-PreferredDrug










2-Generic



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug





7



Drug



4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic





2-Generic


4-Non-PreferredDrug


2-Generic







8




4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug



PA QL (3 PER 1 DAY)




4-Non-PreferredDrug


4-Non-PreferredDrug



4-Non-PreferredDrug




4-Non-PreferredDrug


9



4-Non-PreferredDrug





4-Non-PreferredDrug


4-Non-PreferredDrug




4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic





10




Drug





4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug






11



Drug



4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug



2-Generic




Drug


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


2-Generic


12



5-Specialty



4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug


Drug


2-Generic



4-Non-PreferredDrug



2-Generic


4-Non-PreferredDrug


13



Drug




4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug




SSD 2-Generic


4-Non-PreferredDrug



2-Generic


4-Non-PreferredDrug





14



2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug


morgidox 2-Generic


ANTICONVULSANTS







2-Generic


4-Non-PreferredDrug



roweepra 2-Generic


15










Drug


3-Preferred Brand



4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug


16



3-Preferred Brand


primidone 2-Generic





2-Generic






4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


2-Generic


17



4-Non-PreferredDrug




3-Preferred Brand


4-Non-PreferredDrug





2-Generic



2-Generic



4-Non-PreferredDrug







18



ANTIDEMENTIA AGENTS



3-Preferred Brand




4-Non-PreferredDrug


2-Generic


ANTIDEPRESSANTS


2-Generic


2-Generic





19









1-PreferredGeneric


3-Preferred Brand



1-PreferredGeneric


3-Preferred Brand


ST


2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic




20



2-Generic


4-Non-PreferredDrug



1-PreferredGeneric



ST


2-Generic


4-Non-PreferredDrug

QL (1 PER 1 DAY)


ST


amoxapine 2-Generic






2-Generic


21



Drug


ANTIEMETICS


Drug


2-Generic


2-Generic






4-Non-PreferredDrug












22



DrugPA




QL (2 PER 1 DAY)


4-Non-PreferredDrug


2-Generic



3-Preferred Brand



ANTIFUNGALS










3-Preferred Brand





3-Preferred Brand


23







3-Preferred Brand


2-Generic


4-Non-PreferredDrug




4-Non-PreferredDrug




4-Non-PreferredDrug






4-Non-PreferredDrug




PA


24




2-Generic



nystop 2-Generic





4-Non-PreferredDrug


4-Non-PreferredDrug

PA

ANTIGOUT AGENTS






ANTIMIGRAINE AGENTS




25


















4-Non-PreferredDrug







4-Non-PreferredDrug



26



ANTIMYCOBACTERIALS




Drug




2-Generic






3-Preferred Brand






27



ANTINEOPLASTICS


4-Non-PreferredDrug









flutamide 2-Generic













28





4-Non-PreferredDrug




LA














4-Non-PreferredDrug


2-Generic




29



























letrozole 2-Generic


30






toposar 2-Generic





















31































32





















ANTIPARASITICS


DrugPA


PA


33




Drug


3-Preferred Brand





2-Generic





4-Non-PreferredDrug





Drug




2-Generic


2-Generic


34




3-Preferred Brand






ST


PA LA




KYNMOBI 5-Specialty


QL (1 PER 1 DAY)


2-Generic


2-Generic


3-Preferred Brand


35




Drug


4-Non-PreferredDrug


2-Generic


Drug


ANTIPSYCHOTICS


4-Non-PreferredDrug



3-Preferred Brand


4-Non-PreferredDrug



4-Non-PreferredDrug


4-Non-PreferredDrug


36





pimozide 2-Generic







4-Non-PreferredDrug


2-Generic















37






2-Generic


3-Preferred Brand







5-Specialty



4-Non-PreferredDrug


2-Generic







38





4-Non-PreferredDrug


3-Preferred Brand




2-Generic


3-Preferred Brand


4-Non-PreferredDrug


ANTIVIRALS







39




Drug





VEMLIDY 5-Specialty





5-Specialty LA

pegasys 5-Specialty



3-Preferred Brand


GENVOYA 5-Specialty


5-Specialty


3-Preferred Brand



40




5-Specialty





EDURANT 5-Specialty

efavirenz 2-Generic


5-Specialty


5-Specialty




4-Non-PreferredDrug


ODEFSEY 5-Specialty








41






5-Specialty



4-Non-PreferredDrug



stavudine 2-Generic





5-Specialty


2-Generic


Drug

DOVATO 5-Specialty

FUZEON 5-Specialty

JULUCA 5-Specialty

RUKOBIA 5-Specialty


5-Specialty



42



Drug

TRIUMEQ 5-Specialty



5-Specialty



EVOTAZ 5-Specialty








3-Preferred Brand



5-Specialty


3-Preferred Brand



SYMTUZA 5-Specialty



43




3-Preferred Brand





2-Generic


4-Non-PreferredDrug






ANXIOLYTICS



3-Preferred Brand


4-Non-PreferredDrug


3-Preferred Brand


44



2-Generic



2-Generic


2-Generic



BIPOLAR AGENTS


2-Generic






4-Non-PreferredDrug

PA


4-Non-PreferredDrug

PA





45



DrugST



2-Generic




PA


ST


ST


ST






PA


PA


PA


4-Non-PreferredDrug


1-PreferredGeneric


1-PreferredGeneric


46



Drug




PA









ST


ST


PA




PA





ST


47





















humulin n 2-Generic


humulin r 2-Generic






48







4-Non-PreferredDrug


5-Specialty


4-Non-PreferredDrug


4-Non-PreferredDrug


5-Specialty


3-Preferred Brand



4-Non-PreferredDrug


4-Non-PreferredDrug


3-Preferred Brand


49



jantoven 2-Generic







4-Non-PreferredDrug

PA


5-Specialty PA




4-Non-PreferredDrug

PA



granix 5-Specialty

leukine 5-Specialty

MOZOBIL 5-Specialty





50





4-Non-PreferredDrug

PA




4-Non-PreferredDrug

PA



udenyca 5-Specialty

zarxio 5-Specialty



4-Non-PreferredDrug



Drug






51





4-Non-PreferredDrug


1-PreferredGeneric












valsartan 2-Generic


Generic



2-Generic


52



Drug









4-Non-PreferredDrug









3-Preferred Brand


4-Non-PreferredDrug



53



Drug

sorine 2-Generic






2-Generic





2-Generic




1-PreferredGeneric


2-Generic



ST

pindolol 2-Generic


54



2-Generic


4-Non-PreferredDrug


Generic


cartia xt 2-Generic

dilt-xr 2-Generic


2-Generic


4-Non-PreferredDrug





4-Non-PreferredDrug


55



2-Generic


taztia xt 2-Generic



4-Non-PreferredDrug


2-Generic


Drug




2-Generic



3-Preferred Brand



2-Generic


2-Generic


4-Non-PreferredDrug



56



4-Non-PreferredDrug

PA

digitek 2-Generic

digox 2-Generic


2-Generic


4-Non-PreferredDrug









2-Generic


PA


4-Non-PreferredDrug


2-Generic








57



Drug





PA




4-Non-PreferredDrug




3-Preferred Brand



1-PreferredGeneric


4-Non-PreferredDrug

torsemide 2-Generic





58



Drug



2-Generic




2-Generic



2-Generic





Generic







59




4-Non-PreferredDrug


4-Non-PreferredDrug



4-Non-PreferredDrug

ezetimibe 2-Generic





PA


2-Generic






triklo 2-Generic



2-Generic

minoxidil 2-Generic


60




3-Preferred Brand


2-Generic

minitran 2-Generic



2-Generic






2-Generic


4-Non-PreferredDrug




QL (1 PER 1 DAY)



61




Drug



QL (1 PER 1 DAY)


2-Generic


4-Non-PreferredDrug

QL (1 PER 1 DAY)


2-Generic



4-Non-PreferredDrug

QL (1 PER 1 DAY)


2-Generic


QL (6 PER 1 DAY)



QL (2 PER 1 DAY)


QL (1 PER 1 DAY)


62











riluzole 2-Generic





Drug


2-Generic


2-Generic


4-Non-PreferredDrug

QL (2 PER 1 DAY)




avonex 5-Specialty


63







5-Specialty


GILENYA 5-Specialty


glatopa 5-Specialty




5-Specialty LA




rebif 5-Specialty



ZEPOSIA 5-Specialty



2-Generic

paroex 2-Generic

periogard 2-Generic


64



4-Non-PreferredDrug




Drug


4-Non-PreferredDrug


4-Non-PreferredDrug







4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


65



Drug







3-Preferred Brand









4-Non-PreferredDrug


ST




3-Preferred Brand


4-Non-PreferredDrug




66



DrugST













ST


5-Specialty PA


4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug




67





4-Non-PreferredDrug







4-Non-PreferredDrug




4-Non-PreferredDrug







2-Generic





68














4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug





69



Drug


2-Generic






5-Specialty PA LA


5-Specialty PA

kionex 2-Generic



2-Generic





Drug


3-Preferred Brand


5-Specialty




70



5-Specialty





2-Generic

o-cal fa 2-Generic






zingiber 2-Generic



2-Generic


2-Generic






71



3-Preferred Brand



4-Non-PreferredDrug





PYLERA 5-Specialty


5-Specialty PA


5-Specialty PA




3-Preferred Brand





2-Generic



2-Generic


72




Drug






enulose 2-Generic




generlac 2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug



2-Generic





73





2-Generic


DrugST


4-Non-PreferredDrug

ST


2-Generic


2-Generic


4-Non-PreferredDrug

ST


2-Generic


2-Generic


4-Non-PreferredDrug









74




LA









5-Specialty LA





5-Specialty PA LA





5-Specialty PA







75



3-Preferred Brand


2-Generic




















76





4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug



3-Preferred Brand


4-Non-PreferredDrug


4-Non-PreferredDrug


3-Preferred Brand




2-Generic


4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug



77




decadron 2-Generic


3-Preferred Brand



4-Non-PreferredDrug


2-Generic


3-Preferred Brand


4-Non-PreferredDrug


4-Non-PreferredDrug



5-Specialty PA LA






3-Preferred Brand


3-Preferred Brand


78





2-Generic



4-Non-PreferredDrug


2-Generic


3-Preferred Brand


4-Non-PreferredDrug






2-Generic


3-Preferred Brand




2-Generic



79




4-Non-PreferredDrug


2-Generic


2-Generic





3-Preferred Brand


2-Generic


3-Preferred Brand

triderm 2-Generic



2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


80





5-Specialty PA


PA


PA

STIMATE 5-Specialty





DrugPA



4-Non-PreferredDrug

PA


4-Non-PreferredDrug




altavera 2-Generic


81




amethyst 2-Generic

apri 2-Generic

aranelle 2-Generic

aubra 2-Generic

aubra eq 2-Generic





aviane 2-Generic


azurette 2-Generic

balziva 2-Generic

bekyree 2-Generic



briellyn 2-Generic

caziant 2-Generic





cryselle 2-Generic


82



cyred 2-Generic

cyred eq 2-Generic

dasetta 2-Generic



2-Generic

dolishale 2-Generic


elinest 2-Generic


emoquette 2-Generic

enpresse 2-Generic

enskyce 2-Generic

estarylla 2-Generic


4-Non-PreferredDrug


2-Generic






83





falmina 2-Generic


femynor 2-Generic



GIANVI 2-Generic

hailey 2-Generic


hailey fe 2-Generic

iclevia 2-Generic

introvale 2-Generic

isibloom 2-Generic

jasmiel 2-Generic


JOLESSA 2-Generic

juleber 2-Generic



junel fe 2-Generic




84



kariva 2-Generic



kurvelo 2-Generic




larin fe 2-Generic

larissia 2-Generic

LEENA 2-Generic

lessina 2-Generic

levonest 2-Generic


levora-28 2-Generic

lillow 2-Generic



loryna 2-Generic


lutera 2-Generic


marlissa 2-Generic




85



Drug






mili 2-Generic



necon 2-Generic

nikki 2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug


nortrel 2-Generic

nylia 2-Generic

nymyo 2-Generic

OCELLA 2-Generic


86



orsythia 2-Generic

philith 2-Generic

pimtrea 2-Generic

pirmella 2-Generic

portia 2-Generic


3-Preferred Brand



previfem 2-Generic

reclipsen 2-Generic

setlakin 2-Generic

simliya 2-Generic

sprintec 2-Generic

sronyx 2-Generic

syeda 2-Generic


tarina fe 2-Generic








87







tri-mili 2-Generic

tri-nymyo 2-Generic






TYBLUME 2-Generic

velivet 2-Generic

vestura 2-Generic

vienva 2-Generic

viorele 2-Generic

volnea 2-Generic

vyfemla 2-Generic

vylibra 2-Generic

wera 2-Generic

xulane 2-Generic


zafemy 2-Generic

zarah 2-Generic




88




Drug


deblitane 2-Generic



errin 2-Generic

heather 2-Generic

incassia 2-Generic

jencycla 2-Generic

lyleq 2-Generic

lyza 2-Generic


4-Non-PreferredDrug


2-Generic


2-Generic


NORA-BE 2-Generic



norlyda 2-Generic



89



tulana 2-Generic


Drug




Drug




4-Non-PreferredDrug


2-Generic



2-Generic






90



Drug










5-Specialty


PA











91
















4-Non-PreferredDrug



4-Non-PreferredDrug



5-Specialty PA








4-Non-PreferredDrug



92














2-Generic


2-Generic








5-Specialty PA



4-Non-PreferredDrug






4-Non-PreferredDrug



93










5-Specialty PA










5-Specialty PA LA







94








PA



PA


PA LA



PA











3-Preferred Brand





95






























96







4-Non-PreferredDrug



PENTASA 5-Specialty




colocort 2-Generic









2-Generic


97



4-Non-PreferredDrug














4-Non-PreferredDrug





4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug




2-Generic


4-Non-PreferredDrug


98



xgeva 5-Specialty


4-Non-PreferredDrug



4-Non-PreferredDrug


4-Non-PreferredDrug









4-Non-PreferredDrug


2-Generic


2-Generic


99



2-Generic


2-Generic


2-Generic


2-Generic


2-Generic


2-Generic

OPHTHALMIC AGENTS


Drug









100



Drug



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug







4-Non-PreferredDrug






Drug


101











3-Preferred Brand















3-Preferred Brand


102



Drug



2-Generic

















3-Preferred Brand


103





1-PreferredGeneric


4-Non-PreferredDrug






ST


OTIC AGENTS






4-Non-PreferredDrug




104



3-Preferred Brand



4-Non-PreferredDrug






2-Generic


3-Preferred Brand






2-Generic



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


105



Drug






2-Generic








4-Non-PreferredDrug











2-Generic


106



Drug



4-Non-PreferredDrug








4-Non-PreferredDrug














4-Non-PreferredDrug



107




DrugPA


2-Generic










5-Specialty PA LA









108






2-Generic








5-Specialty PA LA




2-Generic


2-Generic




2-Generic



109




2-Generic


Drug





PA QL (1 PER 1 DAY)




MISCELLANEOUS




110






ABELCET 23

ABILIFY MAINTENA 37

ABILIFY MYCITE 37



acarbose 45

accutane 65

acebutolol hcl 54


acetazolamide 58

acetic acid 104

acetylcysteine 108

acitretin 65

acthib 95

actimmune 95

acyclovir 44

acyclovir sodium 44

adacel tdap 95

adapalene 65


ADEMPAS 108

ADVAIR DISKUS 108

ADVAIR HFA 108

AEMCOLO 7

AFINITOR 31

AFINITOR DISPERZ 31

afirmelle 81


ak-poly-bac 100

AKYNZEO 22

albendazole 33







ALECENSA 31


alfuzosin hcl 76


allopurinol 25





ALOMIDE 101

alosetron hcl 73

ALPHAGAN P 103

alprazolam 44

ALREX 102

altavera 81

ALTRENO 65

ALUNBRIG 29

alyacen 82

alyq 108

amabelz 82

amantadine hcl 35

AMBISOME 23

ambrisentan 108

amcinonide 77

amethyst 82


amiloride hcl 58


AMINOSYN II 68

amiodarone hcl 53

AMITIZA 73







111

ammonium lactate 65

amnesteem 65

amoxapine 21

amoxicillin 11


amphotericin b 23




ANADROL-50 81

anagrelide hcl 50

anastrozole 30

ANDRODERM 81

ANORO ELLIPTA 108

anusol-hc 97

APOKYN 35


aprepitant 22

apri 82

APTIOM 18

APTIVUS 43

aralast np 74

aranelle 82

aranesp 50

arcalyst 95

aripiprazole 37

ARISTADA 37

ARISTADA INITIO 37

armodafinil 110

armour thyroid 90

ARNUITY ELLIPTA 104

arsenic trioxide 29



ASMANEX 105

ASMANEX HFA 105


ASTAGRAF XL 92


atenolol 54


atomoxetine hcl 62


atovaquone 34



ATROVENT HFA 106

AUBAGIO 63

aubra 82

aubra eq 82

aurovela 82

aurovela 24 fe 82

aurovela fe 82

AURYXIA 70

AUSTEDO 63

AUVI-Q 106

aviane 82

avidoxy 14

AVITA 65

avonex 63

avonex pen 64

AVYCAZ 9

ayuna 82

AYVAKIT 29

AZASITE 12

azathioprine 92


azelaic acid 65

azelastine hcl 102

azithromycin 12

aztreonam 11

azurette 82

Bbacitracin 7


baclofen 39


BALVERSA 29

balziva 82

BAQSIMI 48

BARACLUDE 40

112


bekyree 82

BELBUCA 2

benazepril hcl 52


benlysta 95

BENZNIDAZOLE 34


beser 77




betaseron 64

betaxolol hcl 54


BETIMOL 103

bexarotene 33

bexsero 95

bicalutamide 28

BICILLIN C-R 11

BICILLIN L-A 12

BIKTARVY 40

bimatoprost 104

BINOSTO 98



bivigam 94

BLEPHAMIDE 100

blephamide sop 100

blisovi 24 fe 82

blisovi fe 82


boostrix tdap 95

bosentan 108

BOSULIF 31

BRAFTOVI 31

BREO ELLIPTA 108

briellyn 82

BRILINTA 51


brinzolamide 103

BRIVIACT 15



BRUKINSA 29

budesonide 97

bumetanide 58

buprenorphine 2

buprenorphine hcl 2


bupropion hcl 6

buspirone hcl 44





BYDUREON BCISE 45

BYDUREON PEN 45

Ccabergoline 91

cablivi 50

CABOMETYX 31

cafergot 26

calcipotriene 65


CALCITRIOL 65

calcitriol 98

calcium acetate 70

CALQUENCE 31

camila 89



CAPASTAT SULFATE 27

CAPLYTA 37

CAPRELSA 31

captopril 52


CARBAGLU 74

carbamazepine 18

carbidopa 36


113


CARDIZEM LA 55

carteolol hcl 103

cartia xt 55

carvedilol 54



cataflam 1

CAYSTON 107

caziant 82

cefaclor 9

cefadroxil 9

cefazolin sodium 9

cefdinir 9

cefepime hcl 9


cefixime 10



cefoxitin sodium 10


cefprozil 10

ceftazidime 10





celecoxib 1

CELONTIN 16

cephalexin 10

CERDELGA 74

CHANTIX 6

charlotte 24 fe 82

chateal 82

chateal eq 82

CHEMET 70

chenodal 71





chlorthalidone 59

CHOLBAM 74



ciclodan 23

ciclopirox 23


cilostazol 51

CIMDUO 42

cimetidine 72

cimetidine hcl 72

cinacalcet hcl 98

cinryze 92

ciprofloxacin 13





claravis 65

clarithromycin 12


cleocin phosphate 7

clindacin etz 7

clindacin p 7

clindamycin hcl 7




CHLORIDE 7



CLINOLIPID 68

clobazam 16



clodan 77

clomipramine hcl 21

clonazepam 44


mgday patch) 52

clonidine hcl 52

114



clotrimazole 23


clovique 70

clozapine 39

COARTEM 34


codeine sulfate 3

colchicine 25

colesevelam hcl 60

colestipol hcl 60


colocort 97

COMBIGAN 103

COMBIPATCH 82


COMETRIQ 31

COMPLERA 41

compro 22

concept ob 71

constulose 73

COPAXONE 64

COPIKTRA 29

CORLANOR 57

cormax 78


CORTISPORIN 66


cosentyx pen 66


cosentyx syringe 66

COTELLIC 31

creon 74

CRESEMBA 24

CRIXIVAN 43

cromolyn sodium 71

cryselle 82

cyclafem 83


cyclophosphamide 28

cycloserine 27

CYCLOSET 45

cyclosporine 92



cyred 83

cyred eq 83

cystadane 75

CYSTADROPS 100

CYSTAGON 75

CYSTARAN 100

Ddalfampridine 64

DALIRESP 108

danazol 81


dapsone 27

daptacel dtap 95

daptomycin 7

dasetta 83

DAURISMO 31

DAYTRANA 62

deblitane 89

decadron 78

deferasirox 70

DELSTRIGO 41


DEPO-PROVERA 89


DESCOVY 42

desipramine hcl 21





desonide 78

desoximetasone 78


dexamethasone 78


115


DEXILANT 74



aspartate 61










DIACOMIT 15

DIASTAT 16

DIASTAT ACUDIAL 16

DIAZEPAM 16

diazepam 45

diazoxide 48


diclofenac sodium 1



dicyclomine hcl 71

didanosine 42

DIFICID 13


diflunisal 1

difluprednate 102

digitek 57

digox 57

digoxin 57


dilantin 18

dilt-xr 55

diltiazem hcl 55


DIPENTUM 97




disulfiram 5


dofetilide 53

dolishale 83

donepezil hcl 19

DOPTELET 50

dorzolamide hcl 103



dotti 83

DOVATO 42


doxepin hcl 44

doxercalciferol 98

doxy 100 14




dronabinol 23

DROXIA 29

droxidopa 52

DUAVEE 90

DULERA 109

duloxetine hcl 63

dupixent pen 66

dupixent syringe 66

dutasteride 76


EDURANT 41

efavirenz 41



egrifta sv 81

ELIGARD 91

elinest 83

ELIQUIS 49

ELLA 89

ELMIRON 76

116

eluryng 83

EMCYT 28

EMEND 23

EMFLAZA 78

emgality pen 25

emgality syringe 26

emoquette 83

EMSAM 20

emtricitabine 42


EMTRIVA 42

emverm 33



enbrel 92

enbrel mini 92

enbrel sureclick 92

endocet 3

engerix-b adult 95



enpresse 83

enskyce 83

enspryng 94

entacapone 35

entecavir 40

ENTRESTO 57

enulose 73

EPIDIOLEX 15

epifoam 66

epinastine hcl 102

epinephrine 106

epitol 18

EPIVIR HBV 40

eplerenone 58

epogen 50



ERIVEDGE 31

ERLEADA 28

erlotinib hcl 31

errin 89

ertapenem sodium 11

ery 13







ESBRIET 108



estarylla 83

estradiol 83



ESTRING 83

eszopiclone 109

ethacrynic acid 58

ethambutol hcl 27


ethosuximide 16



etodolac 1


etoposide 31

etravirine 41

EUTHYROX 90

everolimus 31

EVOTAZ 43

EVRYSDI 75

exemestane 30

extavia 64

ezetimibe 60


Ffalmina 84

famciclovir 44

famotidine 72

117

famotidinepf 72

FANAPT 37

FARXIGA 46

FARYDAK 31

fasenra pen 109

febuxostat 25

felbamate 17

felodipine 55

FEMRING 84

femynor 84

fenofibrate 59



FENOFIBRIC ACID 59


fentanyl 2

fentanyl citrate 3

FETZIMA 20

FINACEA 66

finasteride 76

FINTEPLA 15

FIRDAPSE 63

FIRMAGON 91

FIRVANQ 8

FLAREX 102

flavoxate hcl 75

flebogamma dif 94


FLOVENT DISKUS 105

FLOVENT HFA 105

fluconazole 24


flucytosine 24


flunisolide 105




fluocinonide 78


FLUOROMETHOLONE 102

fluorouracil 29

FLUOROURACIL 66

fluoxetine hcl 20


fluphenazine hcl 36

flurbiprofen 1


flutamide 28



XINAFOATE 109



FML FORTE 102

FML SOP 102

folivane-ob 71








FOSRENOL 70

FOTIVDA 31

FRAGMIN 49


fulphila 50

furosemide 58

FUZEON 42

fyavolv 84

FYCOMPA 17

Ggabapentin 16

GALAFOLD 75

galantamine hbr 19

gammagard liquid 94

gammagard s-d 94

gammaked 94

gammaplex 94

118

gamunex-c 94

gardasil 9 95

gatifloxacin 13

GATTEX 72

gauze bandage 99

gavilyte-c 73

gavilyte-g 73

gavilyte-n 73

GAVRETO 29

gemfibrozil 59

gemmily 84

generlac 73

gengraf 92

gentak 6




GENVOYA 40

GIANVI 84

GILENYA 64

GILOTRIF 31

glassia 75


glatopa 64

glimepiride 46

glipizide 46


GLUCAGEN 48


glycopyrrolate 71

glydo 4

GLYXAMBI 46

granisetron hcl 23

granix 50

grastek 95



guanfacine hcl 62

GUANIDINE HCL 26





Hhaegarda 92

hailey 84

hailey 24 fe 84

hailey fe 84


haloperidol 36



havrix 95

heather 89



CHLORIDE 49


WATER 49


HETLIOZ 110

HETLIOZ LQ 110

hiberix 95

humalog 48








humira 93

humira pen 93



humira(cf) 93


humira(cf) pen 93




119

humulin 70-30 48


humulin n 48


humulin r 48

humulin r u-500 48


hydralazine hcl 60





hydrocortisone 79





hydromorphone hcl 4



hydroxyurea 29

hydroxyzine hcl 105



IBRANCE 32

ibu 1

ibuprofen 1


iclevia 84

ICLUSIG 32

icosapent ethyl 60

IDHIFA 29

ILEVRO 102


IMBRUVICA 32


imipramine hcl 21


imiquimod 66


INBRIJA 35

incassia 89

increlex 81

INCRUSE ELLIPTA 106

indapamide 59

indomethacin 1

infanrix dtap 95

INGREZZA 63


INLYTA 32

INQOVI 29

INREBIC 29


insulin syringes 99

INTELENCE 41

INTRALIPID 68

intron a 40

introvale 84

INVEGA SUSTENNA 37

INVEGA TRINZA 38

INVELTYS 102

INVIRASE 43

INVOKAMET 46

INVOKAMET XR 46

INVOKANA 46

ipol 96



irbesartan 52


IRESSA 32

ISENTRESS 40

ISENTRESS HD 40

isibloom 84

isoniazid 27



isotretinoin 66

isradipine 55

ISTURISA 79

120

itraconazole 24

ivermectin 34

ixiaro 96

JJAKAFI 32

jantoven 50

JANUMET 46

JANUMET XR 46

JANUVIA 46

JARDIANCE 46

jasmiel 84

jencycla 89

JENTADUETO 46

JENTADUETO XR 46

jinteli 84

JOLESSA 84

juleber 84

JULUCA 42

junel 84

junel fe 84

junel fe 24 84

JUXTAPID 60

JYNARQUE 70


kaitlib fe 84

kalliga 85

KALYDECO 107

kariva 85

kelnor 1-35 85

kelnor 1-50 85

kesimpta pen 64

ketoconazole 24

ketodan 24

ketoprofen 1



kinrix 96

kionex 70

KISQALI 32


KLISYRI 66

KLOR-CON 10 68

KLOR-CON 8 68

klor-con m10 68

klor-con m15 69

klor-con m20 69

KLOXXADO 6

KOMBIGLYZE XR 46

KORLYM 79

KOSELUGO 32

kurvelo 85

KYNMOBI 35

Llabetalol hcl 54

LACRISERT 100

lactulose 73

lamivudine 40


lamotrigine 17

lansoprazole 74



lantus 48

lantus solostar 48


larin 85

larin 24 fe 85

larin fe 85

larissia 85

latanoprost 104

LATUDA 38


LEENA 85

leflunomide 95

LENVIMA 32

lessina 85

letrozole 30


121

LEUKERAN 28

leukine 50




levetiracetam 15


LEVO-T 90

levobunolol hcl 103

LEVOCARNITINE 69



levofloxacin 13


levonest 85


levora-28 85



LEVOXYL 90

LEXIVA 43

lidocaine 4

lidocaine hcl 5

lidocaine hclpf 5


lillow 85

lindane 34

linezolid 8


LINZESS 73


lisinopril 53



LITHIUM CITRATE 45

lo-zumandimine 85

LONSURF 29

loperamide hcl 72


LOPREEZA 85

lorazepam 45


LORBRENA 31

lorcet 4

lorcet hd 4

loryna 85



LOTEMAX 102

LOTEMAX SM 102


lovastatin 59

low-ogestrel 85


LUBIPROSTONE 73

LUCEMYRA 5

LUMAKRAS 32

LUMIGAN 104

LUPANETA PACK 91

LUPKYNIS 93

LUPRON DEPOT 91

LUPRON DEPOT-PED 91

lutera 85

lyleq 89

lyllana 85

LYNPARZA 32

LYSODREN 29

lyza 89



maprotiline hcl 20

marlissa 85

marplan 20

MATULANE 28

matzim la 55

MAVENCLAD 64

MAYZENT 64

meclizine hcl 22



122

mefloquine hcl 34


MEKINIST 32

MEKTOVI 32

melodetta 24 fe 85

meloxicam 1

memantine hcl 19

menactra 96

menest 85

menquadfi 96


mercaptopurine 29

meropenem 11


merzee 86

mesalamine 97


MESNEX 33

metadate er 62


metformin hcl 46




24h) 46

methadone hcl 2

methazolamide 58


methergine 99

methimazole 91

methocarbamol 109



methoxsalen 66








metolazone 59




metronidazole 8


mexiletine hcl 53

mibelas 24 fe 86



microgestin 86


microgestin fe 86

midodrine hcl 52

migergot 26

miglitol 47

miglustat 75

mili 86

mimvey 86

minitran 61

minocycline hcl 15

minoxidil 60

mirtazapine 19

misoprostol 74

mitoxantrone hcl 30

modafinil 110

moexipril hcl 53

molindone hcl 37


mondoxyne nl 15

mono-linyah 86


morgidox 15

morphine sulfate 2

MOVANTIK 72

moxifloxacin hcl 14




MOZOBIL 50

MULTAQ 53

123


acid 71


myalept 72

MYCAPSSA 91



myorisan 66

MYRBETRIQ 76

MYTESI 72

Nnabumetone 1

nadolol 54

nafcillin sodium 12

naftifine hcl 24

NAFTIN 24

naloxone hcl 6

naltrexone hcl 5

NAMENDA XR 19

naproxen 1

naproxen sodium 2

naratriptan hcl 26

NARCAN 6

NATACYN 24

nateglinide 47

natpara 98

NAYZILAM 15

nebivolol hcl 54

necon 86

nefazodone hcl 20

neo-polycin 101

neo-polycin hc 101

neomycin sulfate 6


bhydrocortisone 101






NERLYNX 32

neulasta 50

neulasta onpro 50

neupogen 50

NEUPRO 35

nevirapine 41

NEXAVAR 32

NEXIUM 74

NEXLETOL 57

NEXLIZET 60

niacin 60

nicardipine hcl 55

NICOTROL 6

NICOTROL NS 6

nifedipine 56

nikki 86

nilutamide 28

nimodipine 56

NINLARO 30

nitazoxanide 34

nitisinone 75

NITRO-DUR 61

nitrofurantoin 8



nitroglycerin 61

NITROSTAT 61

NITYR 75

nivestym 51

nizatidine 72

NORA-BE 89

norethindrone 89




fumarate 86



norlyda 89

NORPACE CR 53

nortrel 86

124


NORVIR 43

NOURIANZ 35

NOXAFIL 24

np thyroid 90

NUBEQA 28

nucala 109

NUEDEXTA 63

NUPLAZID 38

NUTRILIPID 69

nyamyc 25

nylia 86

nymyo 86

nystatin 25


nystop 25

nyvepria 51

Oo-cal fa 71

ob complete 71

OCALIVA 75

OCELLA 86

octagam 94


odactra 95

ODEFSEY 41

ODOMZO 32

OFEV 108

ofloxacin 14

ogestrel 87

olanzapine 38






olopatadine hcl 102


OMEGAVEN 69

omeprazole 74

omnitrope 81

ondansetron hcl 23



ONGENTYS 35

ONGLYZA 47

ONUREG 30

OPSUMIT 108

oralair 95

orencia 93


ORFADIN 75

ORGOVYX 91

ORIAHNN 81

ORILISSA 81

ORKAMBI 107

ORLADEYO 92

orsythia 87


OSMOLEX ER 35

OTEZLA 95

oxacillin sodium 12


DEXTROSE 12

oxandrolone 81

oxazepam 45

oxcarbazepine 18

oxervate 101



oxycodone hcl 4



oxymorphone hcl 4

OZEMPIC 47

Ppaliperidone 38

palynziq 75


PANRETIN 33

125


panzyga 94

paricalcitol 98

paroex 64


paroxetine hcl 21

paser 27

PAXIL 21

PAZEO 102

pediarix 96

pedvaxhib 96


chloride 73


sodvit c 73

PEGANONE 18

pegasys 40

pegintron 40

PEMAZYRE 32




penicillamine 76








PENTASA 97

pentoxifylline 57

PERFOROMIST 107


periogard 64

permethrin 34

perphenazine 22


PERSERIS 38

pfizerpen 12


phenobarbital 17


phenytoin 18


philith 87

PHOSLYRA 70


PICATO 66

PIFELTRO 41

pilocarpine hcl 65

pimecrolimus 67

pimozide 37

pimtrea 87

pindolol 54

pioglitazone hcl 47




PIQRAY 31

pirmella 87

piroxicam 2

plegridy 64

plegridy pen 64

plenamine 69

PLENVU 73

podofilox 67

polycin 101



POMALYST 28

portia 87

posaconazole 25



SODIUM CHLORIDE 69


SODIUM CHLORIDE 69


SODIUM CHLORIDE 69


AND 5 DEXTROSE 69

126



PRADAXA 50


prasugrel hcl 51


prazosin hcl 52

PRED MILD 103

PREDNICARBATE 79

prednisolone 80



prednisone 80


pregabalin 63

PREMARIN 87

PREMPHASE 87

PREMPRO 87


prenate am 71

prenate chewable 71

prevalite 60

previfem 87

PREVYMIS 39

PREZCOBIX 43

PREZISTA 43

PRIFTIN 27


primidone 17

privigen 94


probenecid 25


prochlorperazine 22



procrit 51

procto-med hc 97

proctofoam-hc 67

proctosol-hc 97

proctozone-hc 97

PROCYSBI 75


PROGRAF 93

prolastin c 75

PROLENSA 103

prolia 98

PROMACTA 51

promethazine hcl 22

propafenone hcl 53

propranolol hcl 55


propylthiouracil 92

proquad 96


psorcon 80

pulmozyme 107

purefe ob plus 71

PURIXAN 29

PYLERA 72

pyrazinamide 27


pyrimethamine 34

QQINLOCK 30



quinapril hcl 53




QVAR REDIHALER 105

Rrabavert 96


ragwitek 95

raloxifene hcl 90

ramipril 53

ranolazine 57


127

RAVICTI 75

rebif 64

rebif rebidose 64

reclipsen 87

recombivax hb 96

RECTIV 67

regranex 67

RELENZA 44

relexxii 62

RELISTOR 72


RENACIDIN 76

repaglinide 47




repatha syringe 60

RESTASIS 101


retacrit 51

RETEVMO 30

RETROVIR 42

REVLIMID 28

REXULTI 38

REYATAZ 43

REZUROCK 93

RHOPRESSA 104

ribavirin 40

rifabutin 27

rifampin 27

RIFATER 27

riluzole 63

rimantadine hcl 44


RINVOQ 93


RISPERDAL CONSTA 38

risperidone 38

ritonavir 43

rivastigmine 19



ropinirole hcl 35

rosadan 67


rotarix 96

rotateq 96

roweepra 15

roweepra xr 16

ROZLYTREK 30

RUBRACA 30

rufinamide 18

RUKOBIA 42

RUZURGI 63

RYBELSUS 47

RYDAPT 30

Ssajazir 92

SAMSCA 70

santyl 67


SAVAYSA 50

SAVELLA 63

SECUADO 38

SEGLUROMET 47

selegiline hcl 36

selenium sulfide 67

SELZENTRY 42

SEREVENT DISKUS 107

sertraline hcl 21

setlakin 87


sharobel 90

shingrix 96

SIGNIFOR 91


silodosin 76

SILVADENE 14


SIMBRINZA 104

simliya 87

128

simvastatin 59

sirolimus 93

SIRTURO 27

SIVEXTRO 8

skyrizi 67


skyrizi pen 67

SMOFLIPID 69




chloridepeg 73





soltamox 28

SOLU-CORTEF 80

SOMATULINE DEPOT 91

somavert 91

SOOLANTRA 67

sorine 54

sotalol af 54

sotalol hcl 54

SPIRIVA 106


spironolactone 58


sprintec 87

SPRITAM 16

SPRIX 2

SPRYCEL 32

sps 70

sronyx 87

SSD 14

stavudine 42

STEGLATRO 47

STEGLUJAN 47

stelara 67

STIMATE 81


STIVARGA 32


STRIBILD 41

sucraid 75

sucralfate 74



phosphate 101

sulfadiazine 14


SULFAMYLON 8

sulfasalazine 97

sulindac 2


sunitinib malate 32

SUNOSI 110

suprax 10

SUPREP 73

SUTAB 73

syeda 87

sylatron 30

SYMBICORT 109

SYMDEKO 107

SYMPAZAN 17

SYMPROIC 72

SYMTUZA 43

SYNAREL 91

SYNJARDY 47

SYNJARDY XR 47

SYNRIBO 30

SYNTHROID 90


container 100




ml 100


TTABLOID 29

129

TABRECTA 30

tacrolimus 67

tadalafil 76

TAFINLAR 32

TAGRISSO 32

takhzyro 92

TALICIA 72

TALZENNA 32


tamsulosin hcl 76

TARGRETIN 33

tarina 24 fe 87

tarina fe 87


TASIGNA 32

TAVALISSE 51

taysofy 87

tazarotene 67

tazicef 10

TAZORAC 67

taztia xt 56

TAZVERIK 30

TEFLARO 10

TEGSEDI 63

telmisartan 52



temazepam 109

TEMIXYS 43

tenivac 96


TEPMETKO 33

terazosin hcl 52

terbinafine hcl 25


terconazole 25

testosterone 81





tetrabenazine 63

tetracycline hcl 15

THALOMID 28


THIOLA EC 76

thioridazine hcl 37

thiothixene 37

thyroid 90

thyroidpork 91

tiadylt er 56

tiagabine hcl 17

TIBSOVO 30

tigecycline 8

tilia fe 87

timolol maleate 55

tinidazole 8

tiopronin 76

TIVICAY 41

TIVICAY PD 41

tizanidine hcl 39

tobi podhaler 107

TOBRADEX 101

tobramycin 7




TOBREX 7

tolmetin sodium 2


tolvaptan 70

topiramate 17

toposar 31

topotecan hcl 31


torsemide 58


toujeo solostar 49

TOVIAZ 76

TPN ELECTROLYTES 70

TRACLEER 108

TRADJENTA 47

130

tramadol hcl 3


trandolapril 53


tranexamic acid 51


travoprost 104

trazodone hcl 21

TRECATOR 27

TRELEGY ELLIPTA 109

trelstar 91

tremfya 67

tretinoin 33


trexall 94

tri femynor 87

tri-estarylla 87

tri-legest fe 87

tri-linyah 88

tri-lo-estarylla 88

tri-lo-marzia 88

tri-lo-mili 88

tri-lo-sprintec 88

tri-mili 88

tri-nymyo 88

tri-previfem 88

tri-sprintec 88

tri-vylibra 88

tri-vylibra lo 88


triamterene 59


triderm 80

trientine hcl 70


trifluridine 44


TRIKAFTA 107

triklo 60


trimethoprim 9


TRINTELLIX 21

TRIUMEQ 43

trivora-28 88

tropicamide 101


trulicity 47

trumenba 96

truseltiq 33

TUKYSA 30

tulana 90

TURALIO 30

twinrix 96

TYBLUME 88

TYBOST 43

TYMLOS 99

typhim vi 96

Uudenyca 51

UKONIQ 33

UNITHROID 91

UPTRAVI 108

ursodiol 72


VALCHLOR 28


valproic acid 17


valsartan 52


VALTOCO 17

vancomycin hcl 9


(PEG-400 NADA) 9



VANDAZOLE 9

vaqta 96

131


varivax vaccine 96

VARUBI 23

VASCEPA 60

velivet 88

VEMLIDY 40

VENCLEXTA 33


venlafaxine hcl 21

verapamil hcl 56

verquvo 58

VERSACLOZ 39

VERZENIO 33

vestura 88

VIBERZI 73

VICTOZA 2-PAK 47

VICTOZA 3-PAK 47

VIDEX 42

VIDEX EC 42

vienva 88

vigabatrin 17

vigadrone 17

VIIBRYD 21

VIMPAT 18

viorele 88

VIRACEPT 43

VIREAD 42

VITRAKVI 30

VIZIMPRO 30

volnea 88

voriconazole 25

VOSEVI 40

VOTRIENT 33

VRAYLAR 38

VUMERITY 64

vyfemla 88

vylibra 88

VYNDAMAX 58

VYNDAQEL 58

VYVANSE 61

VYZULTA 104

WWAKIX 110

warfarin sodium 50

WELIREG 30

wera 88

XXALKORI 33

XARELTO 50

XATMEP 94

XCOPRI 16

XELJANZ 94

XELJANZ XR 94

XELPROS 104

XERMELO 72

xgeva 99

XIFAXAN 9

XIGDUO XR 47

XOFLUZA 44

xolair 109

XOSPATA 30

XPOVIO 30

XTAMPZA ER 3

XTANDI 28

xulane 88

XYREM 110

XYWAV 110

Yyf-vax 96

YONSA 28

yuvafem 88

Zzafemy 88

zafirlukast 106

zaleplon 110

zarah 88

zarxio 51

ZEJULA 33

132

ZELBORAF 33

zemaira 75

zenatane 67

zenpep 75

zenzedi 61

ZEPOSIA 64

ZERBAXA 11

zidovudine 42

ziextenzo 51

zingiber 71

ziprasidone hcl 39


ZIRGAN 39

zoledronic acid 99


SODIUM CHLORIDE 99


ZOLINZA 30

zolmitriptan 26


zonisamide 16

ZORTRESS 94

zovia 1-35 88

zovia 1-35e 88

zumandimine 89

ZYDELIG 33

ZYKADIA 33

ZYLET 101

133


ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 15


ANTIDEPRESSANTS 19

ANTIEMETICS 22

ANTIFUNGALS 23

ANTIGOUT AGENTS 25




ANTINEOPLASTICS 28

ANTIPARASITICS 33


ANTIPSYCHOTICS 36


ANTIVIRALS 39

ANXIOLYTICS 44

BIPOLAR AGENTS 45




















MISCELLANEOUS 110



OTIC AGENTS 104


134



135






MDC-455

11222021

11222021

H9047_2021AM04_C iv












111

11222021

112021

134

H9047_2021AM04_C v












11222021

H9047_2021AM04_C vi










pages























11222021

H9047_2021AM04_C vii










111

11222021

H9047_2021AM04_C viii













11222021



formats)













(TTY 711）



1‐800‐603‐2340 (TTY 711) 번으로 전화해 주십시오










Arabic










Persian




(082021) H9047_2021RCGA03_C



ANALGESICS


celecoxib 2-Generic



3-Preferred Brand




4-Non-PreferredDrug



ibu 2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug




meloxicam 2-Generic



2-Generic


1



Drug



piroxicam 2-Generic


sulindac 2-Generic



DrugPA




4-Non-PreferredDrug

PA




4-Non-PreferredDrug

PA QL (2 PER 1 DAY)


PA QL (4 PER 1 DAY)


2-Generic PA





2



3-Preferred Brand


4-Non-PreferredDrug


PA QL (2 PER 1 DAY)


2-Generic



4-Non-PreferredDrug


3-Preferred Brand



4-Non-PreferredDrug


endocet 2-Generic


4-Non-PreferredDrug

PA QL (4 PER 1 DAY)


3-Preferred Brand


2-Generic


2-Generic


3



2-Generic



4-Non-PreferredDrug

lorcet 2-Generic

lorcet hd 2-Generic


2-Generic


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


2-Generic



4-Non-PreferredDrug



ANESTHETICS



PA


4





2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug








4-Non-PreferredDrug


QL (4 PER 1 DAY)


QL (3 PER 1 DAY)




1-PreferredGeneric

QL (4 PER 1 DAY)


1-PreferredGeneric

QL (3 PER 1 DAY)




5





1-PreferredGeneric








ANTIBACTERIALS



4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug







6




4-Non-PreferredDrug










2-Generic



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug





7



Drug



4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic





2-Generic


4-Non-PreferredDrug


2-Generic







8




4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug



PA QL (3 PER 1 DAY)




4-Non-PreferredDrug


4-Non-PreferredDrug



4-Non-PreferredDrug




4-Non-PreferredDrug


9



4-Non-PreferredDrug





4-Non-PreferredDrug


4-Non-PreferredDrug




4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic





10




Drug





4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug






11



Drug



4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug



2-Generic




Drug


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


2-Generic


12



5-Specialty



4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug


Drug


2-Generic



4-Non-PreferredDrug



2-Generic


4-Non-PreferredDrug


13



Drug




4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug




SSD 2-Generic


4-Non-PreferredDrug



2-Generic


4-Non-PreferredDrug





14



2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug


morgidox 2-Generic


ANTICONVULSANTS







2-Generic


4-Non-PreferredDrug



roweepra 2-Generic


15










Drug


3-Preferred Brand



4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug


16



3-Preferred Brand


primidone 2-Generic





2-Generic






4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


2-Generic


17



4-Non-PreferredDrug




3-Preferred Brand


4-Non-PreferredDrug





2-Generic



2-Generic



4-Non-PreferredDrug







18



ANTIDEMENTIA AGENTS



3-Preferred Brand




4-Non-PreferredDrug


2-Generic


ANTIDEPRESSANTS


2-Generic


2-Generic





19









1-PreferredGeneric


3-Preferred Brand



1-PreferredGeneric


3-Preferred Brand


ST


2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic




20



2-Generic


4-Non-PreferredDrug



1-PreferredGeneric



ST


2-Generic


4-Non-PreferredDrug

QL (1 PER 1 DAY)


ST


amoxapine 2-Generic






2-Generic


21



Drug


ANTIEMETICS


Drug


2-Generic


2-Generic






4-Non-PreferredDrug












22



DrugPA




QL (2 PER 1 DAY)


4-Non-PreferredDrug


2-Generic



3-Preferred Brand



ANTIFUNGALS










3-Preferred Brand





3-Preferred Brand


23







3-Preferred Brand


2-Generic


4-Non-PreferredDrug




4-Non-PreferredDrug




4-Non-PreferredDrug






4-Non-PreferredDrug




PA


24




2-Generic



nystop 2-Generic





4-Non-PreferredDrug


4-Non-PreferredDrug

PA

ANTIGOUT AGENTS






ANTIMIGRAINE AGENTS




25


















4-Non-PreferredDrug







4-Non-PreferredDrug



26



ANTIMYCOBACTERIALS




Drug




2-Generic






3-Preferred Brand






27



ANTINEOPLASTICS


4-Non-PreferredDrug









flutamide 2-Generic













28





4-Non-PreferredDrug




LA














4-Non-PreferredDrug


2-Generic




29



























letrozole 2-Generic


30






toposar 2-Generic





















31































32





















ANTIPARASITICS


DrugPA


PA


33




Drug


3-Preferred Brand





2-Generic





4-Non-PreferredDrug





Drug




2-Generic


2-Generic


34




3-Preferred Brand






ST


PA LA




KYNMOBI 5-Specialty


QL (1 PER 1 DAY)


2-Generic


2-Generic


3-Preferred Brand


35




Drug


4-Non-PreferredDrug


2-Generic


Drug


ANTIPSYCHOTICS


4-Non-PreferredDrug



3-Preferred Brand


4-Non-PreferredDrug



4-Non-PreferredDrug


4-Non-PreferredDrug


36





pimozide 2-Generic







4-Non-PreferredDrug


2-Generic















37






2-Generic


3-Preferred Brand







5-Specialty



4-Non-PreferredDrug


2-Generic







38





4-Non-PreferredDrug


3-Preferred Brand




2-Generic


3-Preferred Brand


4-Non-PreferredDrug


ANTIVIRALS







39




Drug





VEMLIDY 5-Specialty





5-Specialty LA

pegasys 5-Specialty



3-Preferred Brand


GENVOYA 5-Specialty


5-Specialty


3-Preferred Brand



40




5-Specialty





EDURANT 5-Specialty

efavirenz 2-Generic


5-Specialty


5-Specialty




4-Non-PreferredDrug


ODEFSEY 5-Specialty








41






5-Specialty



4-Non-PreferredDrug



stavudine 2-Generic





5-Specialty


2-Generic


Drug

DOVATO 5-Specialty

FUZEON 5-Specialty

JULUCA 5-Specialty

RUKOBIA 5-Specialty


5-Specialty



42



Drug

TRIUMEQ 5-Specialty



5-Specialty



EVOTAZ 5-Specialty








3-Preferred Brand



5-Specialty


3-Preferred Brand



SYMTUZA 5-Specialty



43




3-Preferred Brand





2-Generic


4-Non-PreferredDrug






ANXIOLYTICS



3-Preferred Brand


4-Non-PreferredDrug


3-Preferred Brand


44



2-Generic



2-Generic


2-Generic



BIPOLAR AGENTS


2-Generic






4-Non-PreferredDrug

PA


4-Non-PreferredDrug

PA





45



DrugST



2-Generic




PA


ST


ST


ST






PA


PA


PA


4-Non-PreferredDrug


1-PreferredGeneric


1-PreferredGeneric


46



Drug




PA









ST


ST


PA




PA





ST


47





















humulin n 2-Generic


humulin r 2-Generic






48







4-Non-PreferredDrug


5-Specialty


4-Non-PreferredDrug


4-Non-PreferredDrug


5-Specialty


3-Preferred Brand



4-Non-PreferredDrug


4-Non-PreferredDrug


3-Preferred Brand


49



jantoven 2-Generic







4-Non-PreferredDrug

PA


5-Specialty PA




4-Non-PreferredDrug

PA



granix 5-Specialty

leukine 5-Specialty

MOZOBIL 5-Specialty





50





4-Non-PreferredDrug

PA




4-Non-PreferredDrug

PA



udenyca 5-Specialty

zarxio 5-Specialty



4-Non-PreferredDrug



Drug






51





4-Non-PreferredDrug


1-PreferredGeneric












valsartan 2-Generic


Generic



2-Generic


52



Drug









4-Non-PreferredDrug









3-Preferred Brand


4-Non-PreferredDrug



53



Drug

sorine 2-Generic






2-Generic





2-Generic




1-PreferredGeneric


2-Generic



ST

pindolol 2-Generic


54



2-Generic


4-Non-PreferredDrug


Generic


cartia xt 2-Generic

dilt-xr 2-Generic


2-Generic


4-Non-PreferredDrug





4-Non-PreferredDrug


55



2-Generic


taztia xt 2-Generic



4-Non-PreferredDrug


2-Generic


Drug




2-Generic



3-Preferred Brand



2-Generic


2-Generic


4-Non-PreferredDrug



56



4-Non-PreferredDrug

PA

digitek 2-Generic

digox 2-Generic


2-Generic


4-Non-PreferredDrug









2-Generic


PA


4-Non-PreferredDrug


2-Generic








57



Drug





PA




4-Non-PreferredDrug




3-Preferred Brand



1-PreferredGeneric


4-Non-PreferredDrug

torsemide 2-Generic





58



Drug



2-Generic




2-Generic



2-Generic





Generic







59




4-Non-PreferredDrug


4-Non-PreferredDrug



4-Non-PreferredDrug

ezetimibe 2-Generic





PA


2-Generic






triklo 2-Generic



2-Generic

minoxidil 2-Generic


60




3-Preferred Brand


2-Generic

minitran 2-Generic



2-Generic






2-Generic


4-Non-PreferredDrug




QL (1 PER 1 DAY)



61




Drug



QL (1 PER 1 DAY)


2-Generic


4-Non-PreferredDrug

QL (1 PER 1 DAY)


2-Generic



4-Non-PreferredDrug

QL (1 PER 1 DAY)


2-Generic


QL (6 PER 1 DAY)



QL (2 PER 1 DAY)


QL (1 PER 1 DAY)


62











riluzole 2-Generic





Drug


2-Generic


2-Generic


4-Non-PreferredDrug

QL (2 PER 1 DAY)




avonex 5-Specialty


63







5-Specialty


GILENYA 5-Specialty


glatopa 5-Specialty




5-Specialty LA




rebif 5-Specialty



ZEPOSIA 5-Specialty



2-Generic

paroex 2-Generic

periogard 2-Generic


64



4-Non-PreferredDrug




Drug


4-Non-PreferredDrug


4-Non-PreferredDrug







4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


65



Drug







3-Preferred Brand









4-Non-PreferredDrug


ST




3-Preferred Brand


4-Non-PreferredDrug




66



DrugST













ST


5-Specialty PA


4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug




67





4-Non-PreferredDrug







4-Non-PreferredDrug




4-Non-PreferredDrug







2-Generic





68














4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug





69



Drug


2-Generic






5-Specialty PA LA


5-Specialty PA

kionex 2-Generic



2-Generic





Drug


3-Preferred Brand


5-Specialty




70



5-Specialty





2-Generic

o-cal fa 2-Generic






zingiber 2-Generic



2-Generic


2-Generic






71



3-Preferred Brand



4-Non-PreferredDrug





PYLERA 5-Specialty


5-Specialty PA


5-Specialty PA




3-Preferred Brand





2-Generic



2-Generic


72




Drug






enulose 2-Generic




generlac 2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug



2-Generic





73





2-Generic


DrugST


4-Non-PreferredDrug

ST


2-Generic


2-Generic


4-Non-PreferredDrug

ST


2-Generic


2-Generic


4-Non-PreferredDrug









74




LA









5-Specialty LA





5-Specialty PA LA





5-Specialty PA







75



3-Preferred Brand


2-Generic




















76





4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug



3-Preferred Brand


4-Non-PreferredDrug


4-Non-PreferredDrug


3-Preferred Brand




2-Generic


4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug



77




decadron 2-Generic


3-Preferred Brand



4-Non-PreferredDrug


2-Generic


3-Preferred Brand


4-Non-PreferredDrug


4-Non-PreferredDrug



5-Specialty PA LA






3-Preferred Brand


3-Preferred Brand


78





2-Generic



4-Non-PreferredDrug


2-Generic


3-Preferred Brand


4-Non-PreferredDrug






2-Generic


3-Preferred Brand




2-Generic



79




4-Non-PreferredDrug


2-Generic


2-Generic





3-Preferred Brand


2-Generic


3-Preferred Brand

triderm 2-Generic



2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


80





5-Specialty PA


PA


PA

STIMATE 5-Specialty





DrugPA



4-Non-PreferredDrug

PA


4-Non-PreferredDrug




altavera 2-Generic


81




amethyst 2-Generic

apri 2-Generic

aranelle 2-Generic

aubra 2-Generic

aubra eq 2-Generic





aviane 2-Generic


azurette 2-Generic

balziva 2-Generic

bekyree 2-Generic



briellyn 2-Generic

caziant 2-Generic





cryselle 2-Generic


82



cyred 2-Generic

cyred eq 2-Generic

dasetta 2-Generic



2-Generic

dolishale 2-Generic


elinest 2-Generic


emoquette 2-Generic

enpresse 2-Generic

enskyce 2-Generic

estarylla 2-Generic


4-Non-PreferredDrug


2-Generic






83





falmina 2-Generic


femynor 2-Generic



GIANVI 2-Generic

hailey 2-Generic


hailey fe 2-Generic

iclevia 2-Generic

introvale 2-Generic

isibloom 2-Generic

jasmiel 2-Generic


JOLESSA 2-Generic

juleber 2-Generic



junel fe 2-Generic




84



kariva 2-Generic



kurvelo 2-Generic




larin fe 2-Generic

larissia 2-Generic

LEENA 2-Generic

lessina 2-Generic

levonest 2-Generic


levora-28 2-Generic

lillow 2-Generic



loryna 2-Generic


lutera 2-Generic


marlissa 2-Generic




85



Drug






mili 2-Generic



necon 2-Generic

nikki 2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug


nortrel 2-Generic

nylia 2-Generic

nymyo 2-Generic

OCELLA 2-Generic


86



orsythia 2-Generic

philith 2-Generic

pimtrea 2-Generic

pirmella 2-Generic

portia 2-Generic


3-Preferred Brand



previfem 2-Generic

reclipsen 2-Generic

setlakin 2-Generic

simliya 2-Generic

sprintec 2-Generic

sronyx 2-Generic

syeda 2-Generic


tarina fe 2-Generic








87







tri-mili 2-Generic

tri-nymyo 2-Generic






TYBLUME 2-Generic

velivet 2-Generic

vestura 2-Generic

vienva 2-Generic

viorele 2-Generic

volnea 2-Generic

vyfemla 2-Generic

vylibra 2-Generic

wera 2-Generic

xulane 2-Generic


zafemy 2-Generic

zarah 2-Generic




88




Drug


deblitane 2-Generic



errin 2-Generic

heather 2-Generic

incassia 2-Generic

jencycla 2-Generic

lyleq 2-Generic

lyza 2-Generic


4-Non-PreferredDrug


2-Generic


2-Generic


NORA-BE 2-Generic



norlyda 2-Generic



89



tulana 2-Generic


Drug




Drug




4-Non-PreferredDrug


2-Generic



2-Generic






90



Drug










5-Specialty


PA











91
















4-Non-PreferredDrug



4-Non-PreferredDrug



5-Specialty PA








4-Non-PreferredDrug



92














2-Generic


2-Generic








5-Specialty PA



4-Non-PreferredDrug






4-Non-PreferredDrug



93










5-Specialty PA










5-Specialty PA LA







94








PA



PA


PA LA



PA











3-Preferred Brand





95






























96







4-Non-PreferredDrug



PENTASA 5-Specialty




colocort 2-Generic









2-Generic


97



4-Non-PreferredDrug














4-Non-PreferredDrug





4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug




2-Generic


4-Non-PreferredDrug


98



xgeva 5-Specialty


4-Non-PreferredDrug



4-Non-PreferredDrug


4-Non-PreferredDrug









4-Non-PreferredDrug


2-Generic


2-Generic


99



2-Generic


2-Generic


2-Generic


2-Generic


2-Generic


2-Generic

OPHTHALMIC AGENTS


Drug









100



Drug



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug







4-Non-PreferredDrug






Drug


101











3-Preferred Brand















3-Preferred Brand


102



Drug



2-Generic

















3-Preferred Brand


103





1-PreferredGeneric


4-Non-PreferredDrug






ST


OTIC AGENTS






4-Non-PreferredDrug




104



3-Preferred Brand



4-Non-PreferredDrug






2-Generic


3-Preferred Brand






2-Generic



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


105



Drug






2-Generic








4-Non-PreferredDrug











2-Generic


106



Drug



4-Non-PreferredDrug








4-Non-PreferredDrug














4-Non-PreferredDrug



107




DrugPA


2-Generic










5-Specialty PA LA









108






2-Generic








5-Specialty PA LA




2-Generic


2-Generic




2-Generic



109




2-Generic


Drug





PA QL (1 PER 1 DAY)




MISCELLANEOUS




110






ABELCET 23

ABILIFY MAINTENA 37

ABILIFY MYCITE 37



acarbose 45

accutane 65

acebutolol hcl 54


acetazolamide 58

acetic acid 104

acetylcysteine 108

acitretin 65

acthib 95

actimmune 95

acyclovir 44

acyclovir sodium 44

adacel tdap 95

adapalene 65


ADEMPAS 108

ADVAIR DISKUS 108

ADVAIR HFA 108

AEMCOLO 7

AFINITOR 31

AFINITOR DISPERZ 31

afirmelle 81


ak-poly-bac 100

AKYNZEO 22

albendazole 33







ALECENSA 31


alfuzosin hcl 76


allopurinol 25





ALOMIDE 101

alosetron hcl 73

ALPHAGAN P 103

alprazolam 44

ALREX 102

altavera 81

ALTRENO 65

ALUNBRIG 29

alyacen 82

alyq 108

amabelz 82

amantadine hcl 35

AMBISOME 23

ambrisentan 108

amcinonide 77

amethyst 82


amiloride hcl 58


AMINOSYN II 68

amiodarone hcl 53

AMITIZA 73







111

ammonium lactate 65

amnesteem 65

amoxapine 21

amoxicillin 11


amphotericin b 23




ANADROL-50 81

anagrelide hcl 50

anastrozole 30

ANDRODERM 81

ANORO ELLIPTA 108

anusol-hc 97

APOKYN 35


aprepitant 22

apri 82

APTIOM 18

APTIVUS 43

aralast np 74

aranelle 82

aranesp 50

arcalyst 95

aripiprazole 37

ARISTADA 37

ARISTADA INITIO 37

armodafinil 110

armour thyroid 90

ARNUITY ELLIPTA 104

arsenic trioxide 29



ASMANEX 105

ASMANEX HFA 105


ASTAGRAF XL 92


atenolol 54


atomoxetine hcl 62


atovaquone 34



ATROVENT HFA 106

AUBAGIO 63

aubra 82

aubra eq 82

aurovela 82

aurovela 24 fe 82

aurovela fe 82

AURYXIA 70

AUSTEDO 63

AUVI-Q 106

aviane 82

avidoxy 14

AVITA 65

avonex 63

avonex pen 64

AVYCAZ 9

ayuna 82

AYVAKIT 29

AZASITE 12

azathioprine 92


azelaic acid 65

azelastine hcl 102

azithromycin 12

aztreonam 11

azurette 82

Bbacitracin 7


baclofen 39


BALVERSA 29

balziva 82

BAQSIMI 48

BARACLUDE 40

112


bekyree 82

BELBUCA 2

benazepril hcl 52


benlysta 95

BENZNIDAZOLE 34


beser 77




betaseron 64

betaxolol hcl 54


BETIMOL 103

bexarotene 33

bexsero 95

bicalutamide 28

BICILLIN C-R 11

BICILLIN L-A 12

BIKTARVY 40

bimatoprost 104

BINOSTO 98



bivigam 94

BLEPHAMIDE 100

blephamide sop 100

blisovi 24 fe 82

blisovi fe 82


boostrix tdap 95

bosentan 108

BOSULIF 31

BRAFTOVI 31

BREO ELLIPTA 108

briellyn 82

BRILINTA 51


brinzolamide 103

BRIVIACT 15



BRUKINSA 29

budesonide 97

bumetanide 58

buprenorphine 2

buprenorphine hcl 2


bupropion hcl 6

buspirone hcl 44





BYDUREON BCISE 45

BYDUREON PEN 45

Ccabergoline 91

cablivi 50

CABOMETYX 31

cafergot 26

calcipotriene 65


CALCITRIOL 65

calcitriol 98

calcium acetate 70

CALQUENCE 31

camila 89



CAPASTAT SULFATE 27

CAPLYTA 37

CAPRELSA 31

captopril 52


CARBAGLU 74

carbamazepine 18

carbidopa 36


113


CARDIZEM LA 55

carteolol hcl 103

cartia xt 55

carvedilol 54



cataflam 1

CAYSTON 107

caziant 82

cefaclor 9

cefadroxil 9

cefazolin sodium 9

cefdinir 9

cefepime hcl 9


cefixime 10



cefoxitin sodium 10


cefprozil 10

ceftazidime 10





celecoxib 1

CELONTIN 16

cephalexin 10

CERDELGA 74

CHANTIX 6

charlotte 24 fe 82

chateal 82

chateal eq 82

CHEMET 70

chenodal 71





chlorthalidone 59

CHOLBAM 74



ciclodan 23

ciclopirox 23


cilostazol 51

CIMDUO 42

cimetidine 72

cimetidine hcl 72

cinacalcet hcl 98

cinryze 92

ciprofloxacin 13





claravis 65

clarithromycin 12


cleocin phosphate 7

clindacin etz 7

clindacin p 7

clindamycin hcl 7




CHLORIDE 7



CLINOLIPID 68

clobazam 16



clodan 77

clomipramine hcl 21

clonazepam 44


mgday patch) 52

clonidine hcl 52

114



clotrimazole 23


clovique 70

clozapine 39

COARTEM 34


codeine sulfate 3

colchicine 25

colesevelam hcl 60

colestipol hcl 60


colocort 97

COMBIGAN 103

COMBIPATCH 82


COMETRIQ 31

COMPLERA 41

compro 22

concept ob 71

constulose 73

COPAXONE 64

COPIKTRA 29

CORLANOR 57

cormax 78


CORTISPORIN 66


cosentyx pen 66


cosentyx syringe 66

COTELLIC 31

creon 74

CRESEMBA 24

CRIXIVAN 43

cromolyn sodium 71

cryselle 82

cyclafem 83


cyclophosphamide 28

cycloserine 27

CYCLOSET 45

cyclosporine 92



cyred 83

cyred eq 83

cystadane 75

CYSTADROPS 100

CYSTAGON 75

CYSTARAN 100

Ddalfampridine 64

DALIRESP 108

danazol 81


dapsone 27

daptacel dtap 95

daptomycin 7

dasetta 83

DAURISMO 31

DAYTRANA 62

deblitane 89

decadron 78

deferasirox 70

DELSTRIGO 41


DEPO-PROVERA 89


DESCOVY 42

desipramine hcl 21





desonide 78

desoximetasone 78


dexamethasone 78


115


DEXILANT 74



aspartate 61










DIACOMIT 15

DIASTAT 16

DIASTAT ACUDIAL 16

DIAZEPAM 16

diazepam 45

diazoxide 48


diclofenac sodium 1



dicyclomine hcl 71

didanosine 42

DIFICID 13


diflunisal 1

difluprednate 102

digitek 57

digox 57

digoxin 57


dilantin 18

dilt-xr 55

diltiazem hcl 55


DIPENTUM 97




disulfiram 5


dofetilide 53

dolishale 83

donepezil hcl 19

DOPTELET 50

dorzolamide hcl 103



dotti 83

DOVATO 42


doxepin hcl 44

doxercalciferol 98

doxy 100 14




dronabinol 23

DROXIA 29

droxidopa 52

DUAVEE 90

DULERA 109

duloxetine hcl 63

dupixent pen 66

dupixent syringe 66

dutasteride 76


EDURANT 41

efavirenz 41



egrifta sv 81

ELIGARD 91

elinest 83

ELIQUIS 49

ELLA 89

ELMIRON 76

116

eluryng 83

EMCYT 28

EMEND 23

EMFLAZA 78

emgality pen 25

emgality syringe 26

emoquette 83

EMSAM 20

emtricitabine 42


EMTRIVA 42

emverm 33



enbrel 92

enbrel mini 92

enbrel sureclick 92

endocet 3

engerix-b adult 95



enpresse 83

enskyce 83

enspryng 94

entacapone 35

entecavir 40

ENTRESTO 57

enulose 73

EPIDIOLEX 15

epifoam 66

epinastine hcl 102

epinephrine 106

epitol 18

EPIVIR HBV 40

eplerenone 58

epogen 50



ERIVEDGE 31

ERLEADA 28

erlotinib hcl 31

errin 89

ertapenem sodium 11

ery 13







ESBRIET 108



estarylla 83

estradiol 83



ESTRING 83

eszopiclone 109

ethacrynic acid 58

ethambutol hcl 27


ethosuximide 16



etodolac 1


etoposide 31

etravirine 41

EUTHYROX 90

everolimus 31

EVOTAZ 43

EVRYSDI 75

exemestane 30

extavia 64

ezetimibe 60


Ffalmina 84

famciclovir 44

famotidine 72

117

famotidinepf 72

FANAPT 37

FARXIGA 46

FARYDAK 31

fasenra pen 109

febuxostat 25

felbamate 17

felodipine 55

FEMRING 84

femynor 84

fenofibrate 59



FENOFIBRIC ACID 59


fentanyl 2

fentanyl citrate 3

FETZIMA 20

FINACEA 66

finasteride 76

FINTEPLA 15

FIRDAPSE 63

FIRMAGON 91

FIRVANQ 8

FLAREX 102

flavoxate hcl 75

flebogamma dif 94


FLOVENT DISKUS 105

FLOVENT HFA 105

fluconazole 24


flucytosine 24


flunisolide 105




fluocinonide 78


FLUOROMETHOLONE 102

fluorouracil 29

FLUOROURACIL 66

fluoxetine hcl 20


fluphenazine hcl 36

flurbiprofen 1


flutamide 28



XINAFOATE 109



FML FORTE 102

FML SOP 102

folivane-ob 71








FOSRENOL 70

FOTIVDA 31

FRAGMIN 49


fulphila 50

furosemide 58

FUZEON 42

fyavolv 84

FYCOMPA 17

Ggabapentin 16

GALAFOLD 75

galantamine hbr 19

gammagard liquid 94

gammagard s-d 94

gammaked 94

gammaplex 94

118

gamunex-c 94

gardasil 9 95

gatifloxacin 13

GATTEX 72

gauze bandage 99

gavilyte-c 73

gavilyte-g 73

gavilyte-n 73

GAVRETO 29

gemfibrozil 59

gemmily 84

generlac 73

gengraf 92

gentak 6




GENVOYA 40

GIANVI 84

GILENYA 64

GILOTRIF 31

glassia 75


glatopa 64

glimepiride 46

glipizide 46


GLUCAGEN 48


glycopyrrolate 71

glydo 4

GLYXAMBI 46

granisetron hcl 23

granix 50

grastek 95



guanfacine hcl 62

GUANIDINE HCL 26





Hhaegarda 92

hailey 84

hailey 24 fe 84

hailey fe 84


haloperidol 36



havrix 95

heather 89



CHLORIDE 49


WATER 49


HETLIOZ 110

HETLIOZ LQ 110

hiberix 95

humalog 48








humira 93

humira pen 93



humira(cf) 93


humira(cf) pen 93




119

humulin 70-30 48


humulin n 48


humulin r 48

humulin r u-500 48


hydralazine hcl 60





hydrocortisone 79





hydromorphone hcl 4



hydroxyurea 29

hydroxyzine hcl 105



IBRANCE 32

ibu 1

ibuprofen 1


iclevia 84

ICLUSIG 32

icosapent ethyl 60

IDHIFA 29

ILEVRO 102


IMBRUVICA 32


imipramine hcl 21


imiquimod 66


INBRIJA 35

incassia 89

increlex 81

INCRUSE ELLIPTA 106

indapamide 59

indomethacin 1

infanrix dtap 95

INGREZZA 63


INLYTA 32

INQOVI 29

INREBIC 29


insulin syringes 99

INTELENCE 41

INTRALIPID 68

intron a 40

introvale 84

INVEGA SUSTENNA 37

INVEGA TRINZA 38

INVELTYS 102

INVIRASE 43

INVOKAMET 46

INVOKAMET XR 46

INVOKANA 46

ipol 96



irbesartan 52


IRESSA 32

ISENTRESS 40

ISENTRESS HD 40

isibloom 84

isoniazid 27



isotretinoin 66

isradipine 55

ISTURISA 79

120

itraconazole 24

ivermectin 34

ixiaro 96

JJAKAFI 32

jantoven 50

JANUMET 46

JANUMET XR 46

JANUVIA 46

JARDIANCE 46

jasmiel 84

jencycla 89

JENTADUETO 46

JENTADUETO XR 46

jinteli 84

JOLESSA 84

juleber 84

JULUCA 42

junel 84

junel fe 84

junel fe 24 84

JUXTAPID 60

JYNARQUE 70


kaitlib fe 84

kalliga 85

KALYDECO 107

kariva 85

kelnor 1-35 85

kelnor 1-50 85

kesimpta pen 64

ketoconazole 24

ketodan 24

ketoprofen 1



kinrix 96

kionex 70

KISQALI 32


KLISYRI 66

KLOR-CON 10 68

KLOR-CON 8 68

klor-con m10 68

klor-con m15 69

klor-con m20 69

KLOXXADO 6

KOMBIGLYZE XR 46

KORLYM 79

KOSELUGO 32

kurvelo 85

KYNMOBI 35

Llabetalol hcl 54

LACRISERT 100

lactulose 73

lamivudine 40


lamotrigine 17

lansoprazole 74



lantus 48

lantus solostar 48


larin 85

larin 24 fe 85

larin fe 85

larissia 85

latanoprost 104

LATUDA 38


LEENA 85

leflunomide 95

LENVIMA 32

lessina 85

letrozole 30


121

LEUKERAN 28

leukine 50




levetiracetam 15


LEVO-T 90

levobunolol hcl 103

LEVOCARNITINE 69



levofloxacin 13


levonest 85


levora-28 85



LEVOXYL 90

LEXIVA 43

lidocaine 4

lidocaine hcl 5

lidocaine hclpf 5


lillow 85

lindane 34

linezolid 8


LINZESS 73


lisinopril 53



LITHIUM CITRATE 45

lo-zumandimine 85

LONSURF 29

loperamide hcl 72


LOPREEZA 85

lorazepam 45


LORBRENA 31

lorcet 4

lorcet hd 4

loryna 85



LOTEMAX 102

LOTEMAX SM 102


lovastatin 59

low-ogestrel 85


LUBIPROSTONE 73

LUCEMYRA 5

LUMAKRAS 32

LUMIGAN 104

LUPANETA PACK 91

LUPKYNIS 93

LUPRON DEPOT 91

LUPRON DEPOT-PED 91

lutera 85

lyleq 89

lyllana 85

LYNPARZA 32

LYSODREN 29

lyza 89



maprotiline hcl 20

marlissa 85

marplan 20

MATULANE 28

matzim la 55

MAVENCLAD 64

MAYZENT 64

meclizine hcl 22



122

mefloquine hcl 34


MEKINIST 32

MEKTOVI 32

melodetta 24 fe 85

meloxicam 1

memantine hcl 19

menactra 96

menest 85

menquadfi 96


mercaptopurine 29

meropenem 11


merzee 86

mesalamine 97


MESNEX 33

metadate er 62


metformin hcl 46




24h) 46

methadone hcl 2

methazolamide 58


methergine 99

methimazole 91

methocarbamol 109



methoxsalen 66








metolazone 59




metronidazole 8


mexiletine hcl 53

mibelas 24 fe 86



microgestin 86


microgestin fe 86

midodrine hcl 52

migergot 26

miglitol 47

miglustat 75

mili 86

mimvey 86

minitran 61

minocycline hcl 15

minoxidil 60

mirtazapine 19

misoprostol 74

mitoxantrone hcl 30

modafinil 110

moexipril hcl 53

molindone hcl 37


mondoxyne nl 15

mono-linyah 86


morgidox 15

morphine sulfate 2

MOVANTIK 72

moxifloxacin hcl 14




MOZOBIL 50

MULTAQ 53

123


acid 71


myalept 72

MYCAPSSA 91



myorisan 66

MYRBETRIQ 76

MYTESI 72

Nnabumetone 1

nadolol 54

nafcillin sodium 12

naftifine hcl 24

NAFTIN 24

naloxone hcl 6

naltrexone hcl 5

NAMENDA XR 19

naproxen 1

naproxen sodium 2

naratriptan hcl 26

NARCAN 6

NATACYN 24

nateglinide 47

natpara 98

NAYZILAM 15

nebivolol hcl 54

necon 86

nefazodone hcl 20

neo-polycin 101

neo-polycin hc 101

neomycin sulfate 6


bhydrocortisone 101






NERLYNX 32

neulasta 50

neulasta onpro 50

neupogen 50

NEUPRO 35

nevirapine 41

NEXAVAR 32

NEXIUM 74

NEXLETOL 57

NEXLIZET 60

niacin 60

nicardipine hcl 55

NICOTROL 6

NICOTROL NS 6

nifedipine 56

nikki 86

nilutamide 28

nimodipine 56

NINLARO 30

nitazoxanide 34

nitisinone 75

NITRO-DUR 61

nitrofurantoin 8



nitroglycerin 61

NITROSTAT 61

NITYR 75

nivestym 51

nizatidine 72

NORA-BE 89

norethindrone 89




fumarate 86



norlyda 89

NORPACE CR 53

nortrel 86

124


NORVIR 43

NOURIANZ 35

NOXAFIL 24

np thyroid 90

NUBEQA 28

nucala 109

NUEDEXTA 63

NUPLAZID 38

NUTRILIPID 69

nyamyc 25

nylia 86

nymyo 86

nystatin 25


nystop 25

nyvepria 51

Oo-cal fa 71

ob complete 71

OCALIVA 75

OCELLA 86

octagam 94


odactra 95

ODEFSEY 41

ODOMZO 32

OFEV 108

ofloxacin 14

ogestrel 87

olanzapine 38






olopatadine hcl 102


OMEGAVEN 69

omeprazole 74

omnitrope 81

ondansetron hcl 23



ONGENTYS 35

ONGLYZA 47

ONUREG 30

OPSUMIT 108

oralair 95

orencia 93


ORFADIN 75

ORGOVYX 91

ORIAHNN 81

ORILISSA 81

ORKAMBI 107

ORLADEYO 92

orsythia 87


OSMOLEX ER 35

OTEZLA 95

oxacillin sodium 12


DEXTROSE 12

oxandrolone 81

oxazepam 45

oxcarbazepine 18

oxervate 101



oxycodone hcl 4



oxymorphone hcl 4

OZEMPIC 47

Ppaliperidone 38

palynziq 75


PANRETIN 33

125


panzyga 94

paricalcitol 98

paroex 64


paroxetine hcl 21

paser 27

PAXIL 21

PAZEO 102

pediarix 96

pedvaxhib 96


chloride 73


sodvit c 73

PEGANONE 18

pegasys 40

pegintron 40

PEMAZYRE 32




penicillamine 76








PENTASA 97

pentoxifylline 57

PERFOROMIST 107


periogard 64

permethrin 34

perphenazine 22


PERSERIS 38

pfizerpen 12


phenobarbital 17


phenytoin 18


philith 87

PHOSLYRA 70


PICATO 66

PIFELTRO 41

pilocarpine hcl 65

pimecrolimus 67

pimozide 37

pimtrea 87

pindolol 54

pioglitazone hcl 47




PIQRAY 31

pirmella 87

piroxicam 2

plegridy 64

plegridy pen 64

plenamine 69

PLENVU 73

podofilox 67

polycin 101



POMALYST 28

portia 87

posaconazole 25



SODIUM CHLORIDE 69


SODIUM CHLORIDE 69


SODIUM CHLORIDE 69


AND 5 DEXTROSE 69

126



PRADAXA 50


prasugrel hcl 51


prazosin hcl 52

PRED MILD 103

PREDNICARBATE 79

prednisolone 80



prednisone 80


pregabalin 63

PREMARIN 87

PREMPHASE 87

PREMPRO 87


prenate am 71

prenate chewable 71

prevalite 60

previfem 87

PREVYMIS 39

PREZCOBIX 43

PREZISTA 43

PRIFTIN 27


primidone 17

privigen 94


probenecid 25


prochlorperazine 22



procrit 51

procto-med hc 97

proctofoam-hc 67

proctosol-hc 97

proctozone-hc 97

PROCYSBI 75


PROGRAF 93

prolastin c 75

PROLENSA 103

prolia 98

PROMACTA 51

promethazine hcl 22

propafenone hcl 53

propranolol hcl 55


propylthiouracil 92

proquad 96


psorcon 80

pulmozyme 107

purefe ob plus 71

PURIXAN 29

PYLERA 72

pyrazinamide 27


pyrimethamine 34

QQINLOCK 30



quinapril hcl 53




QVAR REDIHALER 105

Rrabavert 96


ragwitek 95

raloxifene hcl 90

ramipril 53

ranolazine 57


127

RAVICTI 75

rebif 64

rebif rebidose 64

reclipsen 87

recombivax hb 96

RECTIV 67

regranex 67

RELENZA 44

relexxii 62

RELISTOR 72


RENACIDIN 76

repaglinide 47




repatha syringe 60

RESTASIS 101


retacrit 51

RETEVMO 30

RETROVIR 42

REVLIMID 28

REXULTI 38

REYATAZ 43

REZUROCK 93

RHOPRESSA 104

ribavirin 40

rifabutin 27

rifampin 27

RIFATER 27

riluzole 63

rimantadine hcl 44


RINVOQ 93


RISPERDAL CONSTA 38

risperidone 38

ritonavir 43

rivastigmine 19



ropinirole hcl 35

rosadan 67


rotarix 96

rotateq 96

roweepra 15

roweepra xr 16

ROZLYTREK 30

RUBRACA 30

rufinamide 18

RUKOBIA 42

RUZURGI 63

RYBELSUS 47

RYDAPT 30

Ssajazir 92

SAMSCA 70

santyl 67


SAVAYSA 50

SAVELLA 63

SECUADO 38

SEGLUROMET 47

selegiline hcl 36

selenium sulfide 67

SELZENTRY 42

SEREVENT DISKUS 107

sertraline hcl 21

setlakin 87


sharobel 90

shingrix 96

SIGNIFOR 91


silodosin 76

SILVADENE 14


SIMBRINZA 104

simliya 87

128

simvastatin 59

sirolimus 93

SIRTURO 27

SIVEXTRO 8

skyrizi 67


skyrizi pen 67

SMOFLIPID 69




chloridepeg 73





soltamox 28

SOLU-CORTEF 80

SOMATULINE DEPOT 91

somavert 91

SOOLANTRA 67

sorine 54

sotalol af 54

sotalol hcl 54

SPIRIVA 106


spironolactone 58


sprintec 87

SPRITAM 16

SPRIX 2

SPRYCEL 32

sps 70

sronyx 87

SSD 14

stavudine 42

STEGLATRO 47

STEGLUJAN 47

stelara 67

STIMATE 81


STIVARGA 32


STRIBILD 41

sucraid 75

sucralfate 74



phosphate 101

sulfadiazine 14


SULFAMYLON 8

sulfasalazine 97

sulindac 2


sunitinib malate 32

SUNOSI 110

suprax 10

SUPREP 73

SUTAB 73

syeda 87

sylatron 30

SYMBICORT 109

SYMDEKO 107

SYMPAZAN 17

SYMPROIC 72

SYMTUZA 43

SYNAREL 91

SYNJARDY 47

SYNJARDY XR 47

SYNRIBO 30

SYNTHROID 90


container 100




ml 100


TTABLOID 29

129

TABRECTA 30

tacrolimus 67

tadalafil 76

TAFINLAR 32

TAGRISSO 32

takhzyro 92

TALICIA 72

TALZENNA 32


tamsulosin hcl 76

TARGRETIN 33

tarina 24 fe 87

tarina fe 87


TASIGNA 32

TAVALISSE 51

taysofy 87

tazarotene 67

tazicef 10

TAZORAC 67

taztia xt 56

TAZVERIK 30

TEFLARO 10

TEGSEDI 63

telmisartan 52



temazepam 109

TEMIXYS 43

tenivac 96


TEPMETKO 33

terazosin hcl 52

terbinafine hcl 25


terconazole 25

testosterone 81





tetrabenazine 63

tetracycline hcl 15

THALOMID 28


THIOLA EC 76

thioridazine hcl 37

thiothixene 37

thyroid 90

thyroidpork 91

tiadylt er 56

tiagabine hcl 17

TIBSOVO 30

tigecycline 8

tilia fe 87

timolol maleate 55

tinidazole 8

tiopronin 76

TIVICAY 41

TIVICAY PD 41

tizanidine hcl 39

tobi podhaler 107

TOBRADEX 101

tobramycin 7




TOBREX 7

tolmetin sodium 2


tolvaptan 70

topiramate 17

toposar 31

topotecan hcl 31


torsemide 58


toujeo solostar 49

TOVIAZ 76

TPN ELECTROLYTES 70

TRACLEER 108

TRADJENTA 47

130

tramadol hcl 3


trandolapril 53


tranexamic acid 51


travoprost 104

trazodone hcl 21

TRECATOR 27

TRELEGY ELLIPTA 109

trelstar 91

tremfya 67

tretinoin 33


trexall 94

tri femynor 87

tri-estarylla 87

tri-legest fe 87

tri-linyah 88

tri-lo-estarylla 88

tri-lo-marzia 88

tri-lo-mili 88

tri-lo-sprintec 88

tri-mili 88

tri-nymyo 88

tri-previfem 88

tri-sprintec 88

tri-vylibra 88

tri-vylibra lo 88


triamterene 59


triderm 80

trientine hcl 70


trifluridine 44


TRIKAFTA 107

triklo 60


trimethoprim 9


TRINTELLIX 21

TRIUMEQ 43

trivora-28 88

tropicamide 101


trulicity 47

trumenba 96

truseltiq 33

TUKYSA 30

tulana 90

TURALIO 30

twinrix 96

TYBLUME 88

TYBOST 43

TYMLOS 99

typhim vi 96

Uudenyca 51

UKONIQ 33

UNITHROID 91

UPTRAVI 108

ursodiol 72


VALCHLOR 28


valproic acid 17


valsartan 52


VALTOCO 17

vancomycin hcl 9


(PEG-400 NADA) 9



VANDAZOLE 9

vaqta 96

131


varivax vaccine 96

VARUBI 23

VASCEPA 60

velivet 88

VEMLIDY 40

VENCLEXTA 33


venlafaxine hcl 21

verapamil hcl 56

verquvo 58

VERSACLOZ 39

VERZENIO 33

vestura 88

VIBERZI 73

VICTOZA 2-PAK 47

VICTOZA 3-PAK 47

VIDEX 42

VIDEX EC 42

vienva 88

vigabatrin 17

vigadrone 17

VIIBRYD 21

VIMPAT 18

viorele 88

VIRACEPT 43

VIREAD 42

VITRAKVI 30

VIZIMPRO 30

volnea 88

voriconazole 25

VOSEVI 40

VOTRIENT 33

VRAYLAR 38

VUMERITY 64

vyfemla 88

vylibra 88

VYNDAMAX 58

VYNDAQEL 58

VYVANSE 61

VYZULTA 104

WWAKIX 110

warfarin sodium 50

WELIREG 30

wera 88

XXALKORI 33

XARELTO 50

XATMEP 94

XCOPRI 16

XELJANZ 94

XELJANZ XR 94

XELPROS 104

XERMELO 72

xgeva 99

XIFAXAN 9

XIGDUO XR 47

XOFLUZA 44

xolair 109

XOSPATA 30

XPOVIO 30

XTAMPZA ER 3

XTANDI 28

xulane 88

XYREM 110

XYWAV 110

Yyf-vax 96

YONSA 28

yuvafem 88

Zzafemy 88

zafirlukast 106

zaleplon 110

zarah 88

zarxio 51

ZEJULA 33

132

ZELBORAF 33

zemaira 75

zenatane 67

zenpep 75

zenzedi 61

ZEPOSIA 64

ZERBAXA 11

zidovudine 42

ziextenzo 51

zingiber 71

ziprasidone hcl 39


ZIRGAN 39

zoledronic acid 99


SODIUM CHLORIDE 99


ZOLINZA 30

zolmitriptan 26


zonisamide 16

ZORTRESS 94

zovia 1-35 88

zovia 1-35e 88

zumandimine 89

ZYDELIG 33

ZYKADIA 33

ZYLET 101

133


ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 15


ANTIDEPRESSANTS 19

ANTIEMETICS 22

ANTIFUNGALS 23

ANTIGOUT AGENTS 25




ANTINEOPLASTICS 28

ANTIPARASITICS 33


ANTIPSYCHOTICS 36


ANTIVIRALS 39

ANXIOLYTICS 44

BIPOLAR AGENTS 45




















MISCELLANEOUS 110



OTIC AGENTS 104


134



135






MDC-455

11222021

11222021

H9047_2021AM04_C v












11222021

H9047_2021AM04_C vi










pages























11222021

H9047_2021AM04_C vii










111

11222021

H9047_2021AM04_C viii













11222021



formats)













(TTY 711）



1‐800‐603‐2340 (TTY 711) 번으로 전화해 주십시오










Arabic










Persian




(082021) H9047_2021RCGA03_C



ANALGESICS


celecoxib 2-Generic



3-Preferred Brand




4-Non-PreferredDrug



ibu 2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug




meloxicam 2-Generic



2-Generic


1



Drug



piroxicam 2-Generic


sulindac 2-Generic



DrugPA




4-Non-PreferredDrug

PA




4-Non-PreferredDrug

PA QL (2 PER 1 DAY)


PA QL (4 PER 1 DAY)


2-Generic PA





2



3-Preferred Brand


4-Non-PreferredDrug


PA QL (2 PER 1 DAY)


2-Generic



4-Non-PreferredDrug


3-Preferred Brand



4-Non-PreferredDrug


endocet 2-Generic


4-Non-PreferredDrug

PA QL (4 PER 1 DAY)


3-Preferred Brand


2-Generic


2-Generic


3



2-Generic



4-Non-PreferredDrug

lorcet 2-Generic

lorcet hd 2-Generic


2-Generic


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


2-Generic



4-Non-PreferredDrug



ANESTHETICS



PA


4





2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug








4-Non-PreferredDrug


QL (4 PER 1 DAY)


QL (3 PER 1 DAY)




1-PreferredGeneric

QL (4 PER 1 DAY)


1-PreferredGeneric

QL (3 PER 1 DAY)




5





1-PreferredGeneric








ANTIBACTERIALS



4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug







6




4-Non-PreferredDrug










2-Generic



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug





7



Drug



4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic





2-Generic


4-Non-PreferredDrug


2-Generic







8




4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug



PA QL (3 PER 1 DAY)




4-Non-PreferredDrug


4-Non-PreferredDrug



4-Non-PreferredDrug




4-Non-PreferredDrug


9



4-Non-PreferredDrug





4-Non-PreferredDrug


4-Non-PreferredDrug




4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic





10




Drug





4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug






11



Drug



4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug



2-Generic




Drug


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


2-Generic


12



5-Specialty



4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug


Drug


2-Generic



4-Non-PreferredDrug



2-Generic


4-Non-PreferredDrug


13



Drug




4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug




SSD 2-Generic


4-Non-PreferredDrug



2-Generic


4-Non-PreferredDrug





14



2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug


morgidox 2-Generic


ANTICONVULSANTS







2-Generic


4-Non-PreferredDrug



roweepra 2-Generic


15










Drug


3-Preferred Brand



4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug


16



3-Preferred Brand


primidone 2-Generic





2-Generic






4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


2-Generic


17



4-Non-PreferredDrug




3-Preferred Brand


4-Non-PreferredDrug





2-Generic



2-Generic



4-Non-PreferredDrug







18



ANTIDEMENTIA AGENTS



3-Preferred Brand




4-Non-PreferredDrug


2-Generic


ANTIDEPRESSANTS


2-Generic


2-Generic





19









1-PreferredGeneric


3-Preferred Brand



1-PreferredGeneric


3-Preferred Brand


ST


2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic




20



2-Generic


4-Non-PreferredDrug



1-PreferredGeneric



ST


2-Generic


4-Non-PreferredDrug

QL (1 PER 1 DAY)


ST


amoxapine 2-Generic






2-Generic


21



Drug


ANTIEMETICS


Drug


2-Generic


2-Generic






4-Non-PreferredDrug












22



DrugPA




QL (2 PER 1 DAY)


4-Non-PreferredDrug


2-Generic



3-Preferred Brand



ANTIFUNGALS










3-Preferred Brand





3-Preferred Brand


23







3-Preferred Brand


2-Generic


4-Non-PreferredDrug




4-Non-PreferredDrug




4-Non-PreferredDrug






4-Non-PreferredDrug




PA


24




2-Generic



nystop 2-Generic





4-Non-PreferredDrug


4-Non-PreferredDrug

PA

ANTIGOUT AGENTS






ANTIMIGRAINE AGENTS




25


















4-Non-PreferredDrug







4-Non-PreferredDrug



26



ANTIMYCOBACTERIALS




Drug




2-Generic






3-Preferred Brand






27



ANTINEOPLASTICS


4-Non-PreferredDrug









flutamide 2-Generic













28





4-Non-PreferredDrug




LA














4-Non-PreferredDrug


2-Generic




29



























letrozole 2-Generic


30






toposar 2-Generic





















31































32





















ANTIPARASITICS


DrugPA


PA


33




Drug


3-Preferred Brand





2-Generic





4-Non-PreferredDrug





Drug




2-Generic


2-Generic


34




3-Preferred Brand






ST


PA LA




KYNMOBI 5-Specialty


QL (1 PER 1 DAY)


2-Generic


2-Generic


3-Preferred Brand


35




Drug


4-Non-PreferredDrug


2-Generic


Drug


ANTIPSYCHOTICS


4-Non-PreferredDrug



3-Preferred Brand


4-Non-PreferredDrug



4-Non-PreferredDrug


4-Non-PreferredDrug


36





pimozide 2-Generic







4-Non-PreferredDrug


2-Generic















37






2-Generic


3-Preferred Brand







5-Specialty



4-Non-PreferredDrug


2-Generic







38





4-Non-PreferredDrug


3-Preferred Brand




2-Generic


3-Preferred Brand


4-Non-PreferredDrug


ANTIVIRALS







39




Drug





VEMLIDY 5-Specialty





5-Specialty LA

pegasys 5-Specialty



3-Preferred Brand


GENVOYA 5-Specialty


5-Specialty


3-Preferred Brand



40




5-Specialty





EDURANT 5-Specialty

efavirenz 2-Generic


5-Specialty


5-Specialty




4-Non-PreferredDrug


ODEFSEY 5-Specialty








41






5-Specialty



4-Non-PreferredDrug



stavudine 2-Generic





5-Specialty


2-Generic


Drug

DOVATO 5-Specialty

FUZEON 5-Specialty

JULUCA 5-Specialty

RUKOBIA 5-Specialty


5-Specialty



42



Drug

TRIUMEQ 5-Specialty



5-Specialty



EVOTAZ 5-Specialty








3-Preferred Brand



5-Specialty


3-Preferred Brand



SYMTUZA 5-Specialty



43




3-Preferred Brand





2-Generic


4-Non-PreferredDrug






ANXIOLYTICS



3-Preferred Brand


4-Non-PreferredDrug


3-Preferred Brand


44



2-Generic



2-Generic


2-Generic



BIPOLAR AGENTS


2-Generic






4-Non-PreferredDrug

PA


4-Non-PreferredDrug

PA





45



DrugST



2-Generic




PA


ST


ST


ST






PA


PA


PA


4-Non-PreferredDrug


1-PreferredGeneric


1-PreferredGeneric


46



Drug




PA









ST


ST


PA




PA





ST


47





















humulin n 2-Generic


humulin r 2-Generic






48







4-Non-PreferredDrug


5-Specialty


4-Non-PreferredDrug


4-Non-PreferredDrug


5-Specialty


3-Preferred Brand



4-Non-PreferredDrug


4-Non-PreferredDrug


3-Preferred Brand


49



jantoven 2-Generic







4-Non-PreferredDrug

PA


5-Specialty PA




4-Non-PreferredDrug

PA



granix 5-Specialty

leukine 5-Specialty

MOZOBIL 5-Specialty





50





4-Non-PreferredDrug

PA




4-Non-PreferredDrug

PA



udenyca 5-Specialty

zarxio 5-Specialty



4-Non-PreferredDrug



Drug






51





4-Non-PreferredDrug


1-PreferredGeneric












valsartan 2-Generic


Generic



2-Generic


52



Drug









4-Non-PreferredDrug









3-Preferred Brand


4-Non-PreferredDrug



53



Drug

sorine 2-Generic






2-Generic





2-Generic




1-PreferredGeneric


2-Generic



ST

pindolol 2-Generic


54



2-Generic


4-Non-PreferredDrug


Generic


cartia xt 2-Generic

dilt-xr 2-Generic


2-Generic


4-Non-PreferredDrug





4-Non-PreferredDrug


55



2-Generic


taztia xt 2-Generic



4-Non-PreferredDrug


2-Generic


Drug




2-Generic



3-Preferred Brand



2-Generic


2-Generic


4-Non-PreferredDrug



56



4-Non-PreferredDrug

PA

digitek 2-Generic

digox 2-Generic


2-Generic


4-Non-PreferredDrug









2-Generic


PA


4-Non-PreferredDrug


2-Generic








57



Drug





PA




4-Non-PreferredDrug




3-Preferred Brand



1-PreferredGeneric


4-Non-PreferredDrug

torsemide 2-Generic





58



Drug



2-Generic




2-Generic



2-Generic





Generic







59




4-Non-PreferredDrug


4-Non-PreferredDrug



4-Non-PreferredDrug

ezetimibe 2-Generic





PA


2-Generic






triklo 2-Generic



2-Generic

minoxidil 2-Generic


60




3-Preferred Brand


2-Generic

minitran 2-Generic



2-Generic






2-Generic


4-Non-PreferredDrug




QL (1 PER 1 DAY)



61




Drug



QL (1 PER 1 DAY)


2-Generic


4-Non-PreferredDrug

QL (1 PER 1 DAY)


2-Generic



4-Non-PreferredDrug

QL (1 PER 1 DAY)


2-Generic


QL (6 PER 1 DAY)



QL (2 PER 1 DAY)


QL (1 PER 1 DAY)


62











riluzole 2-Generic





Drug


2-Generic


2-Generic


4-Non-PreferredDrug

QL (2 PER 1 DAY)




avonex 5-Specialty


63







5-Specialty


GILENYA 5-Specialty


glatopa 5-Specialty




5-Specialty LA




rebif 5-Specialty



ZEPOSIA 5-Specialty



2-Generic

paroex 2-Generic

periogard 2-Generic


64



4-Non-PreferredDrug




Drug


4-Non-PreferredDrug


4-Non-PreferredDrug







4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


65



Drug







3-Preferred Brand









4-Non-PreferredDrug


ST




3-Preferred Brand


4-Non-PreferredDrug




66



DrugST













ST


5-Specialty PA


4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug




67





4-Non-PreferredDrug







4-Non-PreferredDrug




4-Non-PreferredDrug







2-Generic





68














4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug





69



Drug


2-Generic






5-Specialty PA LA


5-Specialty PA

kionex 2-Generic



2-Generic





Drug


3-Preferred Brand


5-Specialty




70



5-Specialty





2-Generic

o-cal fa 2-Generic






zingiber 2-Generic



2-Generic


2-Generic






71



3-Preferred Brand



4-Non-PreferredDrug





PYLERA 5-Specialty


5-Specialty PA


5-Specialty PA




3-Preferred Brand





2-Generic



2-Generic


72




Drug






enulose 2-Generic




generlac 2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug



2-Generic





73





2-Generic


DrugST


4-Non-PreferredDrug

ST


2-Generic


2-Generic


4-Non-PreferredDrug

ST


2-Generic


2-Generic


4-Non-PreferredDrug









74




LA









5-Specialty LA





5-Specialty PA LA





5-Specialty PA







75



3-Preferred Brand


2-Generic




















76





4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug



3-Preferred Brand


4-Non-PreferredDrug


4-Non-PreferredDrug


3-Preferred Brand




2-Generic


4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug



77




decadron 2-Generic


3-Preferred Brand



4-Non-PreferredDrug


2-Generic


3-Preferred Brand


4-Non-PreferredDrug


4-Non-PreferredDrug



5-Specialty PA LA






3-Preferred Brand


3-Preferred Brand


78





2-Generic



4-Non-PreferredDrug


2-Generic


3-Preferred Brand


4-Non-PreferredDrug






2-Generic


3-Preferred Brand




2-Generic



79




4-Non-PreferredDrug


2-Generic


2-Generic





3-Preferred Brand


2-Generic


3-Preferred Brand

triderm 2-Generic



2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


80





5-Specialty PA


PA


PA

STIMATE 5-Specialty





DrugPA



4-Non-PreferredDrug

PA


4-Non-PreferredDrug




altavera 2-Generic


81




amethyst 2-Generic

apri 2-Generic

aranelle 2-Generic

aubra 2-Generic

aubra eq 2-Generic





aviane 2-Generic


azurette 2-Generic

balziva 2-Generic

bekyree 2-Generic



briellyn 2-Generic

caziant 2-Generic





cryselle 2-Generic


82



cyred 2-Generic

cyred eq 2-Generic

dasetta 2-Generic



2-Generic

dolishale 2-Generic


elinest 2-Generic


emoquette 2-Generic

enpresse 2-Generic

enskyce 2-Generic

estarylla 2-Generic


4-Non-PreferredDrug


2-Generic






83





falmina 2-Generic


femynor 2-Generic



GIANVI 2-Generic

hailey 2-Generic


hailey fe 2-Generic

iclevia 2-Generic

introvale 2-Generic

isibloom 2-Generic

jasmiel 2-Generic


JOLESSA 2-Generic

juleber 2-Generic



junel fe 2-Generic




84



kariva 2-Generic



kurvelo 2-Generic




larin fe 2-Generic

larissia 2-Generic

LEENA 2-Generic

lessina 2-Generic

levonest 2-Generic


levora-28 2-Generic

lillow 2-Generic



loryna 2-Generic


lutera 2-Generic


marlissa 2-Generic




85



Drug






mili 2-Generic



necon 2-Generic

nikki 2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug


nortrel 2-Generic

nylia 2-Generic

nymyo 2-Generic

OCELLA 2-Generic


86



orsythia 2-Generic

philith 2-Generic

pimtrea 2-Generic

pirmella 2-Generic

portia 2-Generic


3-Preferred Brand



previfem 2-Generic

reclipsen 2-Generic

setlakin 2-Generic

simliya 2-Generic

sprintec 2-Generic

sronyx 2-Generic

syeda 2-Generic


tarina fe 2-Generic








87







tri-mili 2-Generic

tri-nymyo 2-Generic






TYBLUME 2-Generic

velivet 2-Generic

vestura 2-Generic

vienva 2-Generic

viorele 2-Generic

volnea 2-Generic

vyfemla 2-Generic

vylibra 2-Generic

wera 2-Generic

xulane 2-Generic


zafemy 2-Generic

zarah 2-Generic




88




Drug


deblitane 2-Generic



errin 2-Generic

heather 2-Generic

incassia 2-Generic

jencycla 2-Generic

lyleq 2-Generic

lyza 2-Generic


4-Non-PreferredDrug


2-Generic


2-Generic


NORA-BE 2-Generic



norlyda 2-Generic



89



tulana 2-Generic


Drug




Drug




4-Non-PreferredDrug


2-Generic



2-Generic






90



Drug










5-Specialty


PA











91
















4-Non-PreferredDrug



4-Non-PreferredDrug



5-Specialty PA








4-Non-PreferredDrug



92














2-Generic


2-Generic








5-Specialty PA



4-Non-PreferredDrug






4-Non-PreferredDrug



93










5-Specialty PA










5-Specialty PA LA







94








PA



PA


PA LA



PA











3-Preferred Brand





95






























96







4-Non-PreferredDrug



PENTASA 5-Specialty




colocort 2-Generic









2-Generic


97



4-Non-PreferredDrug














4-Non-PreferredDrug





4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug




2-Generic


4-Non-PreferredDrug


98



xgeva 5-Specialty


4-Non-PreferredDrug



4-Non-PreferredDrug


4-Non-PreferredDrug









4-Non-PreferredDrug


2-Generic


2-Generic


99



2-Generic


2-Generic


2-Generic


2-Generic


2-Generic


2-Generic

OPHTHALMIC AGENTS


Drug









100



Drug



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug







4-Non-PreferredDrug






Drug


101











3-Preferred Brand















3-Preferred Brand


102



Drug



2-Generic

















3-Preferred Brand


103





1-PreferredGeneric


4-Non-PreferredDrug






ST


OTIC AGENTS






4-Non-PreferredDrug




104



3-Preferred Brand



4-Non-PreferredDrug






2-Generic


3-Preferred Brand






2-Generic



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


105



Drug






2-Generic








4-Non-PreferredDrug











2-Generic


106



Drug



4-Non-PreferredDrug








4-Non-PreferredDrug














4-Non-PreferredDrug



107




DrugPA


2-Generic










5-Specialty PA LA









108






2-Generic








5-Specialty PA LA




2-Generic


2-Generic




2-Generic



109




2-Generic


Drug





PA QL (1 PER 1 DAY)




MISCELLANEOUS




110






ABELCET 23

ABILIFY MAINTENA 37

ABILIFY MYCITE 37



acarbose 45

accutane 65

acebutolol hcl 54


acetazolamide 58

acetic acid 104

acetylcysteine 108

acitretin 65

acthib 95

actimmune 95

acyclovir 44

acyclovir sodium 44

adacel tdap 95

adapalene 65


ADEMPAS 108

ADVAIR DISKUS 108

ADVAIR HFA 108

AEMCOLO 7

AFINITOR 31

AFINITOR DISPERZ 31

afirmelle 81


ak-poly-bac 100

AKYNZEO 22

albendazole 33







ALECENSA 31


alfuzosin hcl 76


allopurinol 25





ALOMIDE 101

alosetron hcl 73

ALPHAGAN P 103

alprazolam 44

ALREX 102

altavera 81

ALTRENO 65

ALUNBRIG 29

alyacen 82

alyq 108

amabelz 82

amantadine hcl 35

AMBISOME 23

ambrisentan 108

amcinonide 77

amethyst 82


amiloride hcl 58


AMINOSYN II 68

amiodarone hcl 53

AMITIZA 73







111

ammonium lactate 65

amnesteem 65

amoxapine 21

amoxicillin 11


amphotericin b 23




ANADROL-50 81

anagrelide hcl 50

anastrozole 30

ANDRODERM 81

ANORO ELLIPTA 108

anusol-hc 97

APOKYN 35


aprepitant 22

apri 82

APTIOM 18

APTIVUS 43

aralast np 74

aranelle 82

aranesp 50

arcalyst 95

aripiprazole 37

ARISTADA 37

ARISTADA INITIO 37

armodafinil 110

armour thyroid 90

ARNUITY ELLIPTA 104

arsenic trioxide 29



ASMANEX 105

ASMANEX HFA 105


ASTAGRAF XL 92


atenolol 54


atomoxetine hcl 62


atovaquone 34



ATROVENT HFA 106

AUBAGIO 63

aubra 82

aubra eq 82

aurovela 82

aurovela 24 fe 82

aurovela fe 82

AURYXIA 70

AUSTEDO 63

AUVI-Q 106

aviane 82

avidoxy 14

AVITA 65

avonex 63

avonex pen 64

AVYCAZ 9

ayuna 82

AYVAKIT 29

AZASITE 12

azathioprine 92


azelaic acid 65

azelastine hcl 102

azithromycin 12

aztreonam 11

azurette 82

Bbacitracin 7


baclofen 39


BALVERSA 29

balziva 82

BAQSIMI 48

BARACLUDE 40

112


bekyree 82

BELBUCA 2

benazepril hcl 52


benlysta 95

BENZNIDAZOLE 34


beser 77




betaseron 64

betaxolol hcl 54


BETIMOL 103

bexarotene 33

bexsero 95

bicalutamide 28

BICILLIN C-R 11

BICILLIN L-A 12

BIKTARVY 40

bimatoprost 104

BINOSTO 98



bivigam 94

BLEPHAMIDE 100

blephamide sop 100

blisovi 24 fe 82

blisovi fe 82


boostrix tdap 95

bosentan 108

BOSULIF 31

BRAFTOVI 31

BREO ELLIPTA 108

briellyn 82

BRILINTA 51


brinzolamide 103

BRIVIACT 15



BRUKINSA 29

budesonide 97

bumetanide 58

buprenorphine 2

buprenorphine hcl 2


bupropion hcl 6

buspirone hcl 44





BYDUREON BCISE 45

BYDUREON PEN 45

Ccabergoline 91

cablivi 50

CABOMETYX 31

cafergot 26

calcipotriene 65


CALCITRIOL 65

calcitriol 98

calcium acetate 70

CALQUENCE 31

camila 89



CAPASTAT SULFATE 27

CAPLYTA 37

CAPRELSA 31

captopril 52


CARBAGLU 74

carbamazepine 18

carbidopa 36


113


CARDIZEM LA 55

carteolol hcl 103

cartia xt 55

carvedilol 54



cataflam 1

CAYSTON 107

caziant 82

cefaclor 9

cefadroxil 9

cefazolin sodium 9

cefdinir 9

cefepime hcl 9


cefixime 10



cefoxitin sodium 10


cefprozil 10

ceftazidime 10





celecoxib 1

CELONTIN 16

cephalexin 10

CERDELGA 74

CHANTIX 6

charlotte 24 fe 82

chateal 82

chateal eq 82

CHEMET 70

chenodal 71





chlorthalidone 59

CHOLBAM 74



ciclodan 23

ciclopirox 23


cilostazol 51

CIMDUO 42

cimetidine 72

cimetidine hcl 72

cinacalcet hcl 98

cinryze 92

ciprofloxacin 13





claravis 65

clarithromycin 12


cleocin phosphate 7

clindacin etz 7

clindacin p 7

clindamycin hcl 7




CHLORIDE 7



CLINOLIPID 68

clobazam 16



clodan 77

clomipramine hcl 21

clonazepam 44


mgday patch) 52

clonidine hcl 52

114



clotrimazole 23


clovique 70

clozapine 39

COARTEM 34


codeine sulfate 3

colchicine 25

colesevelam hcl 60

colestipol hcl 60


colocort 97

COMBIGAN 103

COMBIPATCH 82


COMETRIQ 31

COMPLERA 41

compro 22

concept ob 71

constulose 73

COPAXONE 64

COPIKTRA 29

CORLANOR 57

cormax 78


CORTISPORIN 66


cosentyx pen 66


cosentyx syringe 66

COTELLIC 31

creon 74

CRESEMBA 24

CRIXIVAN 43

cromolyn sodium 71

cryselle 82

cyclafem 83


cyclophosphamide 28

cycloserine 27

CYCLOSET 45

cyclosporine 92



cyred 83

cyred eq 83

cystadane 75

CYSTADROPS 100

CYSTAGON 75

CYSTARAN 100

Ddalfampridine 64

DALIRESP 108

danazol 81


dapsone 27

daptacel dtap 95

daptomycin 7

dasetta 83

DAURISMO 31

DAYTRANA 62

deblitane 89

decadron 78

deferasirox 70

DELSTRIGO 41


DEPO-PROVERA 89


DESCOVY 42

desipramine hcl 21





desonide 78

desoximetasone 78


dexamethasone 78


115


DEXILANT 74



aspartate 61










DIACOMIT 15

DIASTAT 16

DIASTAT ACUDIAL 16

DIAZEPAM 16

diazepam 45

diazoxide 48


diclofenac sodium 1



dicyclomine hcl 71

didanosine 42

DIFICID 13


diflunisal 1

difluprednate 102

digitek 57

digox 57

digoxin 57


dilantin 18

dilt-xr 55

diltiazem hcl 55


DIPENTUM 97




disulfiram 5


dofetilide 53

dolishale 83

donepezil hcl 19

DOPTELET 50

dorzolamide hcl 103



dotti 83

DOVATO 42


doxepin hcl 44

doxercalciferol 98

doxy 100 14




dronabinol 23

DROXIA 29

droxidopa 52

DUAVEE 90

DULERA 109

duloxetine hcl 63

dupixent pen 66

dupixent syringe 66

dutasteride 76


EDURANT 41

efavirenz 41



egrifta sv 81

ELIGARD 91

elinest 83

ELIQUIS 49

ELLA 89

ELMIRON 76

116

eluryng 83

EMCYT 28

EMEND 23

EMFLAZA 78

emgality pen 25

emgality syringe 26

emoquette 83

EMSAM 20

emtricitabine 42


EMTRIVA 42

emverm 33



enbrel 92

enbrel mini 92

enbrel sureclick 92

endocet 3

engerix-b adult 95



enpresse 83

enskyce 83

enspryng 94

entacapone 35

entecavir 40

ENTRESTO 57

enulose 73

EPIDIOLEX 15

epifoam 66

epinastine hcl 102

epinephrine 106

epitol 18

EPIVIR HBV 40

eplerenone 58

epogen 50



ERIVEDGE 31

ERLEADA 28

erlotinib hcl 31

errin 89

ertapenem sodium 11

ery 13







ESBRIET 108



estarylla 83

estradiol 83



ESTRING 83

eszopiclone 109

ethacrynic acid 58

ethambutol hcl 27


ethosuximide 16



etodolac 1


etoposide 31

etravirine 41

EUTHYROX 90

everolimus 31

EVOTAZ 43

EVRYSDI 75

exemestane 30

extavia 64

ezetimibe 60


Ffalmina 84

famciclovir 44

famotidine 72

117

famotidinepf 72

FANAPT 37

FARXIGA 46

FARYDAK 31

fasenra pen 109

febuxostat 25

felbamate 17

felodipine 55

FEMRING 84

femynor 84

fenofibrate 59



FENOFIBRIC ACID 59


fentanyl 2

fentanyl citrate 3

FETZIMA 20

FINACEA 66

finasteride 76

FINTEPLA 15

FIRDAPSE 63

FIRMAGON 91

FIRVANQ 8

FLAREX 102

flavoxate hcl 75

flebogamma dif 94


FLOVENT DISKUS 105

FLOVENT HFA 105

fluconazole 24


flucytosine 24


flunisolide 105




fluocinonide 78


FLUOROMETHOLONE 102

fluorouracil 29

FLUOROURACIL 66

fluoxetine hcl 20


fluphenazine hcl 36

flurbiprofen 1


flutamide 28



XINAFOATE 109



FML FORTE 102

FML SOP 102

folivane-ob 71








FOSRENOL 70

FOTIVDA 31

FRAGMIN 49


fulphila 50

furosemide 58

FUZEON 42

fyavolv 84

FYCOMPA 17

Ggabapentin 16

GALAFOLD 75

galantamine hbr 19

gammagard liquid 94

gammagard s-d 94

gammaked 94

gammaplex 94

118

gamunex-c 94

gardasil 9 95

gatifloxacin 13

GATTEX 72

gauze bandage 99

gavilyte-c 73

gavilyte-g 73

gavilyte-n 73

GAVRETO 29

gemfibrozil 59

gemmily 84

generlac 73

gengraf 92

gentak 6




GENVOYA 40

GIANVI 84

GILENYA 64

GILOTRIF 31

glassia 75


glatopa 64

glimepiride 46

glipizide 46


GLUCAGEN 48


glycopyrrolate 71

glydo 4

GLYXAMBI 46

granisetron hcl 23

granix 50

grastek 95



guanfacine hcl 62

GUANIDINE HCL 26





Hhaegarda 92

hailey 84

hailey 24 fe 84

hailey fe 84


haloperidol 36



havrix 95

heather 89



CHLORIDE 49


WATER 49


HETLIOZ 110

HETLIOZ LQ 110

hiberix 95

humalog 48








humira 93

humira pen 93



humira(cf) 93


humira(cf) pen 93




119

humulin 70-30 48


humulin n 48


humulin r 48

humulin r u-500 48


hydralazine hcl 60





hydrocortisone 79





hydromorphone hcl 4



hydroxyurea 29

hydroxyzine hcl 105



IBRANCE 32

ibu 1

ibuprofen 1


iclevia 84

ICLUSIG 32

icosapent ethyl 60

IDHIFA 29

ILEVRO 102


IMBRUVICA 32


imipramine hcl 21


imiquimod 66


INBRIJA 35

incassia 89

increlex 81

INCRUSE ELLIPTA 106

indapamide 59

indomethacin 1

infanrix dtap 95

INGREZZA 63


INLYTA 32

INQOVI 29

INREBIC 29


insulin syringes 99

INTELENCE 41

INTRALIPID 68

intron a 40

introvale 84

INVEGA SUSTENNA 37

INVEGA TRINZA 38

INVELTYS 102

INVIRASE 43

INVOKAMET 46

INVOKAMET XR 46

INVOKANA 46

ipol 96



irbesartan 52


IRESSA 32

ISENTRESS 40

ISENTRESS HD 40

isibloom 84

isoniazid 27



isotretinoin 66

isradipine 55

ISTURISA 79

120

itraconazole 24

ivermectin 34

ixiaro 96

JJAKAFI 32

jantoven 50

JANUMET 46

JANUMET XR 46

JANUVIA 46

JARDIANCE 46

jasmiel 84

jencycla 89

JENTADUETO 46

JENTADUETO XR 46

jinteli 84

JOLESSA 84

juleber 84

JULUCA 42

junel 84

junel fe 84

junel fe 24 84

JUXTAPID 60

JYNARQUE 70


kaitlib fe 84

kalliga 85

KALYDECO 107

kariva 85

kelnor 1-35 85

kelnor 1-50 85

kesimpta pen 64

ketoconazole 24

ketodan 24

ketoprofen 1



kinrix 96

kionex 70

KISQALI 32


KLISYRI 66

KLOR-CON 10 68

KLOR-CON 8 68

klor-con m10 68

klor-con m15 69

klor-con m20 69

KLOXXADO 6

KOMBIGLYZE XR 46

KORLYM 79

KOSELUGO 32

kurvelo 85

KYNMOBI 35

Llabetalol hcl 54

LACRISERT 100

lactulose 73

lamivudine 40


lamotrigine 17

lansoprazole 74



lantus 48

lantus solostar 48


larin 85

larin 24 fe 85

larin fe 85

larissia 85

latanoprost 104

LATUDA 38


LEENA 85

leflunomide 95

LENVIMA 32

lessina 85

letrozole 30


121

LEUKERAN 28

leukine 50




levetiracetam 15


LEVO-T 90

levobunolol hcl 103

LEVOCARNITINE 69



levofloxacin 13


levonest 85


levora-28 85



LEVOXYL 90

LEXIVA 43

lidocaine 4

lidocaine hcl 5

lidocaine hclpf 5


lillow 85

lindane 34

linezolid 8


LINZESS 73


lisinopril 53



LITHIUM CITRATE 45

lo-zumandimine 85

LONSURF 29

loperamide hcl 72


LOPREEZA 85

lorazepam 45


LORBRENA 31

lorcet 4

lorcet hd 4

loryna 85



LOTEMAX 102

LOTEMAX SM 102


lovastatin 59

low-ogestrel 85


LUBIPROSTONE 73

LUCEMYRA 5

LUMAKRAS 32

LUMIGAN 104

LUPANETA PACK 91

LUPKYNIS 93

LUPRON DEPOT 91

LUPRON DEPOT-PED 91

lutera 85

lyleq 89

lyllana 85

LYNPARZA 32

LYSODREN 29

lyza 89



maprotiline hcl 20

marlissa 85

marplan 20

MATULANE 28

matzim la 55

MAVENCLAD 64

MAYZENT 64

meclizine hcl 22



122

mefloquine hcl 34


MEKINIST 32

MEKTOVI 32

melodetta 24 fe 85

meloxicam 1

memantine hcl 19

menactra 96

menest 85

menquadfi 96


mercaptopurine 29

meropenem 11


merzee 86

mesalamine 97


MESNEX 33

metadate er 62


metformin hcl 46




24h) 46

methadone hcl 2

methazolamide 58


methergine 99

methimazole 91

methocarbamol 109



methoxsalen 66








metolazone 59




metronidazole 8


mexiletine hcl 53

mibelas 24 fe 86



microgestin 86


microgestin fe 86

midodrine hcl 52

migergot 26

miglitol 47

miglustat 75

mili 86

mimvey 86

minitran 61

minocycline hcl 15

minoxidil 60

mirtazapine 19

misoprostol 74

mitoxantrone hcl 30

modafinil 110

moexipril hcl 53

molindone hcl 37


mondoxyne nl 15

mono-linyah 86


morgidox 15

morphine sulfate 2

MOVANTIK 72

moxifloxacin hcl 14




MOZOBIL 50

MULTAQ 53

123


acid 71


myalept 72

MYCAPSSA 91



myorisan 66

MYRBETRIQ 76

MYTESI 72

Nnabumetone 1

nadolol 54

nafcillin sodium 12

naftifine hcl 24

NAFTIN 24

naloxone hcl 6

naltrexone hcl 5

NAMENDA XR 19

naproxen 1

naproxen sodium 2

naratriptan hcl 26

NARCAN 6

NATACYN 24

nateglinide 47

natpara 98

NAYZILAM 15

nebivolol hcl 54

necon 86

nefazodone hcl 20

neo-polycin 101

neo-polycin hc 101

neomycin sulfate 6


bhydrocortisone 101






NERLYNX 32

neulasta 50

neulasta onpro 50

neupogen 50

NEUPRO 35

nevirapine 41

NEXAVAR 32

NEXIUM 74

NEXLETOL 57

NEXLIZET 60

niacin 60

nicardipine hcl 55

NICOTROL 6

NICOTROL NS 6

nifedipine 56

nikki 86

nilutamide 28

nimodipine 56

NINLARO 30

nitazoxanide 34

nitisinone 75

NITRO-DUR 61

nitrofurantoin 8



nitroglycerin 61

NITROSTAT 61

NITYR 75

nivestym 51

nizatidine 72

NORA-BE 89

norethindrone 89




fumarate 86



norlyda 89

NORPACE CR 53

nortrel 86

124


NORVIR 43

NOURIANZ 35

NOXAFIL 24

np thyroid 90

NUBEQA 28

nucala 109

NUEDEXTA 63

NUPLAZID 38

NUTRILIPID 69

nyamyc 25

nylia 86

nymyo 86

nystatin 25


nystop 25

nyvepria 51

Oo-cal fa 71

ob complete 71

OCALIVA 75

OCELLA 86

octagam 94


odactra 95

ODEFSEY 41

ODOMZO 32

OFEV 108

ofloxacin 14

ogestrel 87

olanzapine 38






olopatadine hcl 102


OMEGAVEN 69

omeprazole 74

omnitrope 81

ondansetron hcl 23



ONGENTYS 35

ONGLYZA 47

ONUREG 30

OPSUMIT 108

oralair 95

orencia 93


ORFADIN 75

ORGOVYX 91

ORIAHNN 81

ORILISSA 81

ORKAMBI 107

ORLADEYO 92

orsythia 87


OSMOLEX ER 35

OTEZLA 95

oxacillin sodium 12


DEXTROSE 12

oxandrolone 81

oxazepam 45

oxcarbazepine 18

oxervate 101



oxycodone hcl 4



oxymorphone hcl 4

OZEMPIC 47

Ppaliperidone 38

palynziq 75


PANRETIN 33

125


panzyga 94

paricalcitol 98

paroex 64


paroxetine hcl 21

paser 27

PAXIL 21

PAZEO 102

pediarix 96

pedvaxhib 96


chloride 73


sodvit c 73

PEGANONE 18

pegasys 40

pegintron 40

PEMAZYRE 32




penicillamine 76








PENTASA 97

pentoxifylline 57

PERFOROMIST 107


periogard 64

permethrin 34

perphenazine 22


PERSERIS 38

pfizerpen 12


phenobarbital 17


phenytoin 18


philith 87

PHOSLYRA 70


PICATO 66

PIFELTRO 41

pilocarpine hcl 65

pimecrolimus 67

pimozide 37

pimtrea 87

pindolol 54

pioglitazone hcl 47




PIQRAY 31

pirmella 87

piroxicam 2

plegridy 64

plegridy pen 64

plenamine 69

PLENVU 73

podofilox 67

polycin 101



POMALYST 28

portia 87

posaconazole 25



SODIUM CHLORIDE 69


SODIUM CHLORIDE 69


SODIUM CHLORIDE 69


AND 5 DEXTROSE 69

126



PRADAXA 50


prasugrel hcl 51


prazosin hcl 52

PRED MILD 103

PREDNICARBATE 79

prednisolone 80



prednisone 80


pregabalin 63

PREMARIN 87

PREMPHASE 87

PREMPRO 87


prenate am 71

prenate chewable 71

prevalite 60

previfem 87

PREVYMIS 39

PREZCOBIX 43

PREZISTA 43

PRIFTIN 27


primidone 17

privigen 94


probenecid 25


prochlorperazine 22



procrit 51

procto-med hc 97

proctofoam-hc 67

proctosol-hc 97

proctozone-hc 97

PROCYSBI 75


PROGRAF 93

prolastin c 75

PROLENSA 103

prolia 98

PROMACTA 51

promethazine hcl 22

propafenone hcl 53

propranolol hcl 55


propylthiouracil 92

proquad 96


psorcon 80

pulmozyme 107

purefe ob plus 71

PURIXAN 29

PYLERA 72

pyrazinamide 27


pyrimethamine 34

QQINLOCK 30



quinapril hcl 53




QVAR REDIHALER 105

Rrabavert 96


ragwitek 95

raloxifene hcl 90

ramipril 53

ranolazine 57


127

RAVICTI 75

rebif 64

rebif rebidose 64

reclipsen 87

recombivax hb 96

RECTIV 67

regranex 67

RELENZA 44

relexxii 62

RELISTOR 72


RENACIDIN 76

repaglinide 47




repatha syringe 60

RESTASIS 101


retacrit 51

RETEVMO 30

RETROVIR 42

REVLIMID 28

REXULTI 38

REYATAZ 43

REZUROCK 93

RHOPRESSA 104

ribavirin 40

rifabutin 27

rifampin 27

RIFATER 27

riluzole 63

rimantadine hcl 44


RINVOQ 93


RISPERDAL CONSTA 38

risperidone 38

ritonavir 43

rivastigmine 19



ropinirole hcl 35

rosadan 67


rotarix 96

rotateq 96

roweepra 15

roweepra xr 16

ROZLYTREK 30

RUBRACA 30

rufinamide 18

RUKOBIA 42

RUZURGI 63

RYBELSUS 47

RYDAPT 30

Ssajazir 92

SAMSCA 70

santyl 67


SAVAYSA 50

SAVELLA 63

SECUADO 38

SEGLUROMET 47

selegiline hcl 36

selenium sulfide 67

SELZENTRY 42

SEREVENT DISKUS 107

sertraline hcl 21

setlakin 87


sharobel 90

shingrix 96

SIGNIFOR 91


silodosin 76

SILVADENE 14


SIMBRINZA 104

simliya 87

128

simvastatin 59

sirolimus 93

SIRTURO 27

SIVEXTRO 8

skyrizi 67


skyrizi pen 67

SMOFLIPID 69




chloridepeg 73





soltamox 28

SOLU-CORTEF 80

SOMATULINE DEPOT 91

somavert 91

SOOLANTRA 67

sorine 54

sotalol af 54

sotalol hcl 54

SPIRIVA 106


spironolactone 58


sprintec 87

SPRITAM 16

SPRIX 2

SPRYCEL 32

sps 70

sronyx 87

SSD 14

stavudine 42

STEGLATRO 47

STEGLUJAN 47

stelara 67

STIMATE 81


STIVARGA 32


STRIBILD 41

sucraid 75

sucralfate 74



phosphate 101

sulfadiazine 14


SULFAMYLON 8

sulfasalazine 97

sulindac 2


sunitinib malate 32

SUNOSI 110

suprax 10

SUPREP 73

SUTAB 73

syeda 87

sylatron 30

SYMBICORT 109

SYMDEKO 107

SYMPAZAN 17

SYMPROIC 72

SYMTUZA 43

SYNAREL 91

SYNJARDY 47

SYNJARDY XR 47

SYNRIBO 30

SYNTHROID 90


container 100




ml 100


TTABLOID 29

129

TABRECTA 30

tacrolimus 67

tadalafil 76

TAFINLAR 32

TAGRISSO 32

takhzyro 92

TALICIA 72

TALZENNA 32


tamsulosin hcl 76

TARGRETIN 33

tarina 24 fe 87

tarina fe 87


TASIGNA 32

TAVALISSE 51

taysofy 87

tazarotene 67

tazicef 10

TAZORAC 67

taztia xt 56

TAZVERIK 30

TEFLARO 10

TEGSEDI 63

telmisartan 52



temazepam 109

TEMIXYS 43

tenivac 96


TEPMETKO 33

terazosin hcl 52

terbinafine hcl 25


terconazole 25

testosterone 81





tetrabenazine 63

tetracycline hcl 15

THALOMID 28


THIOLA EC 76

thioridazine hcl 37

thiothixene 37

thyroid 90

thyroidpork 91

tiadylt er 56

tiagabine hcl 17

TIBSOVO 30

tigecycline 8

tilia fe 87

timolol maleate 55

tinidazole 8

tiopronin 76

TIVICAY 41

TIVICAY PD 41

tizanidine hcl 39

tobi podhaler 107

TOBRADEX 101

tobramycin 7




TOBREX 7

tolmetin sodium 2


tolvaptan 70

topiramate 17

toposar 31

topotecan hcl 31


torsemide 58


toujeo solostar 49

TOVIAZ 76

TPN ELECTROLYTES 70

TRACLEER 108

TRADJENTA 47

130

tramadol hcl 3


trandolapril 53


tranexamic acid 51


travoprost 104

trazodone hcl 21

TRECATOR 27

TRELEGY ELLIPTA 109

trelstar 91

tremfya 67

tretinoin 33


trexall 94

tri femynor 87

tri-estarylla 87

tri-legest fe 87

tri-linyah 88

tri-lo-estarylla 88

tri-lo-marzia 88

tri-lo-mili 88

tri-lo-sprintec 88

tri-mili 88

tri-nymyo 88

tri-previfem 88

tri-sprintec 88

tri-vylibra 88

tri-vylibra lo 88


triamterene 59


triderm 80

trientine hcl 70


trifluridine 44


TRIKAFTA 107

triklo 60


trimethoprim 9


TRINTELLIX 21

TRIUMEQ 43

trivora-28 88

tropicamide 101


trulicity 47

trumenba 96

truseltiq 33

TUKYSA 30

tulana 90

TURALIO 30

twinrix 96

TYBLUME 88

TYBOST 43

TYMLOS 99

typhim vi 96

Uudenyca 51

UKONIQ 33

UNITHROID 91

UPTRAVI 108

ursodiol 72


VALCHLOR 28


valproic acid 17


valsartan 52


VALTOCO 17

vancomycin hcl 9


(PEG-400 NADA) 9



VANDAZOLE 9

vaqta 96

131


varivax vaccine 96

VARUBI 23

VASCEPA 60

velivet 88

VEMLIDY 40

VENCLEXTA 33


venlafaxine hcl 21

verapamil hcl 56

verquvo 58

VERSACLOZ 39

VERZENIO 33

vestura 88

VIBERZI 73

VICTOZA 2-PAK 47

VICTOZA 3-PAK 47

VIDEX 42

VIDEX EC 42

vienva 88

vigabatrin 17

vigadrone 17

VIIBRYD 21

VIMPAT 18

viorele 88

VIRACEPT 43

VIREAD 42

VITRAKVI 30

VIZIMPRO 30

volnea 88

voriconazole 25

VOSEVI 40

VOTRIENT 33

VRAYLAR 38

VUMERITY 64

vyfemla 88

vylibra 88

VYNDAMAX 58

VYNDAQEL 58

VYVANSE 61

VYZULTA 104

WWAKIX 110

warfarin sodium 50

WELIREG 30

wera 88

XXALKORI 33

XARELTO 50

XATMEP 94

XCOPRI 16

XELJANZ 94

XELJANZ XR 94

XELPROS 104

XERMELO 72

xgeva 99

XIFAXAN 9

XIGDUO XR 47

XOFLUZA 44

xolair 109

XOSPATA 30

XPOVIO 30

XTAMPZA ER 3

XTANDI 28

xulane 88

XYREM 110

XYWAV 110

Yyf-vax 96

YONSA 28

yuvafem 88

Zzafemy 88

zafirlukast 106

zaleplon 110

zarah 88

zarxio 51

ZEJULA 33

132

ZELBORAF 33

zemaira 75

zenatane 67

zenpep 75

zenzedi 61

ZEPOSIA 64

ZERBAXA 11

zidovudine 42

ziextenzo 51

zingiber 71

ziprasidone hcl 39


ZIRGAN 39

zoledronic acid 99


SODIUM CHLORIDE 99


ZOLINZA 30

zolmitriptan 26


zonisamide 16

ZORTRESS 94

zovia 1-35 88

zovia 1-35e 88

zumandimine 89

ZYDELIG 33

ZYKADIA 33

ZYLET 101

133


ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 15


ANTIDEPRESSANTS 19

ANTIEMETICS 22

ANTIFUNGALS 23

ANTIGOUT AGENTS 25




ANTINEOPLASTICS 28

ANTIPARASITICS 33


ANTIPSYCHOTICS 36


ANTIVIRALS 39

ANXIOLYTICS 44

BIPOLAR AGENTS 45




















MISCELLANEOUS 110



OTIC AGENTS 104


134



135






MDC-455

11222021

11222021

H9047_2021AM04_C vi










pages























11222021

H9047_2021AM04_C vii










111

11222021

H9047_2021AM04_C viii













11222021



formats)













(TTY 711）



1‐800‐603‐2340 (TTY 711) 번으로 전화해 주십시오










Arabic










Persian




(082021) H9047_2021RCGA03_C



ANALGESICS


celecoxib 2-Generic



3-Preferred Brand




4-Non-PreferredDrug



ibu 2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug




meloxicam 2-Generic



2-Generic


1



Drug



piroxicam 2-Generic


sulindac 2-Generic



DrugPA




4-Non-PreferredDrug

PA




4-Non-PreferredDrug

PA QL (2 PER 1 DAY)


PA QL (4 PER 1 DAY)


2-Generic PA





2



3-Preferred Brand


4-Non-PreferredDrug


PA QL (2 PER 1 DAY)


2-Generic



4-Non-PreferredDrug


3-Preferred Brand



4-Non-PreferredDrug


endocet 2-Generic


4-Non-PreferredDrug

PA QL (4 PER 1 DAY)


3-Preferred Brand


2-Generic


2-Generic


3



2-Generic



4-Non-PreferredDrug

lorcet 2-Generic

lorcet hd 2-Generic


2-Generic


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


2-Generic



4-Non-PreferredDrug



ANESTHETICS



PA


4





2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug








4-Non-PreferredDrug


QL (4 PER 1 DAY)


QL (3 PER 1 DAY)




1-PreferredGeneric

QL (4 PER 1 DAY)


1-PreferredGeneric

QL (3 PER 1 DAY)




5





1-PreferredGeneric








ANTIBACTERIALS



4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug







6




4-Non-PreferredDrug










2-Generic



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug





7



Drug



4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic





2-Generic


4-Non-PreferredDrug


2-Generic







8




4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug



PA QL (3 PER 1 DAY)




4-Non-PreferredDrug


4-Non-PreferredDrug



4-Non-PreferredDrug




4-Non-PreferredDrug


9



4-Non-PreferredDrug





4-Non-PreferredDrug


4-Non-PreferredDrug




4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic





10




Drug





4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug






11



Drug



4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug



2-Generic




Drug


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


2-Generic


12



5-Specialty



4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug


Drug


2-Generic



4-Non-PreferredDrug



2-Generic


4-Non-PreferredDrug


13



Drug




4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug




SSD 2-Generic


4-Non-PreferredDrug



2-Generic


4-Non-PreferredDrug





14



2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug


morgidox 2-Generic


ANTICONVULSANTS







2-Generic


4-Non-PreferredDrug



roweepra 2-Generic


15










Drug


3-Preferred Brand



4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug


16



3-Preferred Brand


primidone 2-Generic





2-Generic






4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


2-Generic


17



4-Non-PreferredDrug




3-Preferred Brand


4-Non-PreferredDrug





2-Generic



2-Generic



4-Non-PreferredDrug







18



ANTIDEMENTIA AGENTS



3-Preferred Brand




4-Non-PreferredDrug


2-Generic


ANTIDEPRESSANTS


2-Generic


2-Generic





19









1-PreferredGeneric


3-Preferred Brand



1-PreferredGeneric


3-Preferred Brand


ST


2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic




20



2-Generic


4-Non-PreferredDrug



1-PreferredGeneric



ST


2-Generic


4-Non-PreferredDrug

QL (1 PER 1 DAY)


ST


amoxapine 2-Generic






2-Generic


21



Drug


ANTIEMETICS


Drug


2-Generic


2-Generic






4-Non-PreferredDrug












22



DrugPA




QL (2 PER 1 DAY)


4-Non-PreferredDrug


2-Generic



3-Preferred Brand



ANTIFUNGALS










3-Preferred Brand





3-Preferred Brand


23







3-Preferred Brand


2-Generic


4-Non-PreferredDrug




4-Non-PreferredDrug




4-Non-PreferredDrug






4-Non-PreferredDrug




PA


24




2-Generic



nystop 2-Generic





4-Non-PreferredDrug


4-Non-PreferredDrug

PA

ANTIGOUT AGENTS






ANTIMIGRAINE AGENTS




25


















4-Non-PreferredDrug







4-Non-PreferredDrug



26



ANTIMYCOBACTERIALS




Drug




2-Generic






3-Preferred Brand






27



ANTINEOPLASTICS


4-Non-PreferredDrug









flutamide 2-Generic













28





4-Non-PreferredDrug




LA














4-Non-PreferredDrug


2-Generic




29



























letrozole 2-Generic


30






toposar 2-Generic





















31































32





















ANTIPARASITICS


DrugPA


PA


33




Drug


3-Preferred Brand





2-Generic





4-Non-PreferredDrug





Drug




2-Generic


2-Generic


34




3-Preferred Brand






ST


PA LA




KYNMOBI 5-Specialty


QL (1 PER 1 DAY)


2-Generic


2-Generic


3-Preferred Brand


35




Drug


4-Non-PreferredDrug


2-Generic


Drug


ANTIPSYCHOTICS


4-Non-PreferredDrug



3-Preferred Brand


4-Non-PreferredDrug



4-Non-PreferredDrug


4-Non-PreferredDrug


36





pimozide 2-Generic







4-Non-PreferredDrug


2-Generic















37






2-Generic


3-Preferred Brand







5-Specialty



4-Non-PreferredDrug


2-Generic







38





4-Non-PreferredDrug


3-Preferred Brand




2-Generic


3-Preferred Brand


4-Non-PreferredDrug


ANTIVIRALS







39




Drug





VEMLIDY 5-Specialty





5-Specialty LA

pegasys 5-Specialty



3-Preferred Brand


GENVOYA 5-Specialty


5-Specialty


3-Preferred Brand



40




5-Specialty





EDURANT 5-Specialty

efavirenz 2-Generic


5-Specialty


5-Specialty




4-Non-PreferredDrug


ODEFSEY 5-Specialty








41






5-Specialty



4-Non-PreferredDrug



stavudine 2-Generic





5-Specialty


2-Generic


Drug

DOVATO 5-Specialty

FUZEON 5-Specialty

JULUCA 5-Specialty

RUKOBIA 5-Specialty


5-Specialty



42



Drug

TRIUMEQ 5-Specialty



5-Specialty



EVOTAZ 5-Specialty








3-Preferred Brand



5-Specialty


3-Preferred Brand



SYMTUZA 5-Specialty



43




3-Preferred Brand





2-Generic


4-Non-PreferredDrug






ANXIOLYTICS



3-Preferred Brand


4-Non-PreferredDrug


3-Preferred Brand


44



2-Generic



2-Generic


2-Generic



BIPOLAR AGENTS


2-Generic






4-Non-PreferredDrug

PA


4-Non-PreferredDrug

PA





45



DrugST



2-Generic




PA


ST


ST


ST






PA


PA


PA


4-Non-PreferredDrug


1-PreferredGeneric


1-PreferredGeneric


46



Drug




PA









ST


ST


PA




PA





ST


47





















humulin n 2-Generic


humulin r 2-Generic






48







4-Non-PreferredDrug


5-Specialty


4-Non-PreferredDrug


4-Non-PreferredDrug


5-Specialty


3-Preferred Brand



4-Non-PreferredDrug


4-Non-PreferredDrug


3-Preferred Brand


49



jantoven 2-Generic







4-Non-PreferredDrug

PA


5-Specialty PA




4-Non-PreferredDrug

PA



granix 5-Specialty

leukine 5-Specialty

MOZOBIL 5-Specialty





50





4-Non-PreferredDrug

PA




4-Non-PreferredDrug

PA



udenyca 5-Specialty

zarxio 5-Specialty



4-Non-PreferredDrug



Drug






51





4-Non-PreferredDrug


1-PreferredGeneric












valsartan 2-Generic


Generic



2-Generic


52



Drug









4-Non-PreferredDrug









3-Preferred Brand


4-Non-PreferredDrug



53



Drug

sorine 2-Generic






2-Generic





2-Generic




1-PreferredGeneric


2-Generic



ST

pindolol 2-Generic


54



2-Generic


4-Non-PreferredDrug


Generic


cartia xt 2-Generic

dilt-xr 2-Generic


2-Generic


4-Non-PreferredDrug





4-Non-PreferredDrug


55



2-Generic


taztia xt 2-Generic



4-Non-PreferredDrug


2-Generic


Drug




2-Generic



3-Preferred Brand



2-Generic


2-Generic


4-Non-PreferredDrug



56



4-Non-PreferredDrug

PA

digitek 2-Generic

digox 2-Generic


2-Generic


4-Non-PreferredDrug









2-Generic


PA


4-Non-PreferredDrug


2-Generic








57



Drug





PA




4-Non-PreferredDrug




3-Preferred Brand



1-PreferredGeneric


4-Non-PreferredDrug

torsemide 2-Generic





58



Drug



2-Generic




2-Generic



2-Generic





Generic







59




4-Non-PreferredDrug


4-Non-PreferredDrug



4-Non-PreferredDrug

ezetimibe 2-Generic





PA


2-Generic






triklo 2-Generic



2-Generic

minoxidil 2-Generic


60




3-Preferred Brand


2-Generic

minitran 2-Generic



2-Generic






2-Generic


4-Non-PreferredDrug




QL (1 PER 1 DAY)



61




Drug



QL (1 PER 1 DAY)


2-Generic


4-Non-PreferredDrug

QL (1 PER 1 DAY)


2-Generic



4-Non-PreferredDrug

QL (1 PER 1 DAY)


2-Generic


QL (6 PER 1 DAY)



QL (2 PER 1 DAY)


QL (1 PER 1 DAY)


62











riluzole 2-Generic





Drug


2-Generic


2-Generic


4-Non-PreferredDrug

QL (2 PER 1 DAY)




avonex 5-Specialty


63







5-Specialty


GILENYA 5-Specialty


glatopa 5-Specialty




5-Specialty LA




rebif 5-Specialty



ZEPOSIA 5-Specialty



2-Generic

paroex 2-Generic

periogard 2-Generic


64



4-Non-PreferredDrug




Drug


4-Non-PreferredDrug


4-Non-PreferredDrug







4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


65



Drug







3-Preferred Brand









4-Non-PreferredDrug


ST




3-Preferred Brand


4-Non-PreferredDrug




66



DrugST













ST


5-Specialty PA


4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug




67





4-Non-PreferredDrug







4-Non-PreferredDrug




4-Non-PreferredDrug







2-Generic





68














4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug





69



Drug


2-Generic






5-Specialty PA LA


5-Specialty PA

kionex 2-Generic



2-Generic





Drug


3-Preferred Brand


5-Specialty




70



5-Specialty





2-Generic

o-cal fa 2-Generic






zingiber 2-Generic



2-Generic


2-Generic






71



3-Preferred Brand



4-Non-PreferredDrug





PYLERA 5-Specialty


5-Specialty PA


5-Specialty PA




3-Preferred Brand





2-Generic



2-Generic


72




Drug






enulose 2-Generic




generlac 2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug



2-Generic





73





2-Generic


DrugST


4-Non-PreferredDrug

ST


2-Generic


2-Generic


4-Non-PreferredDrug

ST


2-Generic


2-Generic


4-Non-PreferredDrug









74




LA









5-Specialty LA





5-Specialty PA LA





5-Specialty PA







75



3-Preferred Brand


2-Generic




















76





4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug



3-Preferred Brand


4-Non-PreferredDrug


4-Non-PreferredDrug


3-Preferred Brand




2-Generic


4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug



77




decadron 2-Generic


3-Preferred Brand



4-Non-PreferredDrug


2-Generic


3-Preferred Brand


4-Non-PreferredDrug


4-Non-PreferredDrug



5-Specialty PA LA






3-Preferred Brand


3-Preferred Brand


78





2-Generic



4-Non-PreferredDrug


2-Generic


3-Preferred Brand


4-Non-PreferredDrug






2-Generic


3-Preferred Brand




2-Generic



79




4-Non-PreferredDrug


2-Generic


2-Generic





3-Preferred Brand


2-Generic


3-Preferred Brand

triderm 2-Generic



2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


80





5-Specialty PA


PA


PA

STIMATE 5-Specialty





DrugPA



4-Non-PreferredDrug

PA


4-Non-PreferredDrug




altavera 2-Generic


81




amethyst 2-Generic

apri 2-Generic

aranelle 2-Generic

aubra 2-Generic

aubra eq 2-Generic





aviane 2-Generic


azurette 2-Generic

balziva 2-Generic

bekyree 2-Generic



briellyn 2-Generic

caziant 2-Generic





cryselle 2-Generic


82



cyred 2-Generic

cyred eq 2-Generic

dasetta 2-Generic



2-Generic

dolishale 2-Generic


elinest 2-Generic


emoquette 2-Generic

enpresse 2-Generic

enskyce 2-Generic

estarylla 2-Generic


4-Non-PreferredDrug


2-Generic






83





falmina 2-Generic


femynor 2-Generic



GIANVI 2-Generic

hailey 2-Generic


hailey fe 2-Generic

iclevia 2-Generic

introvale 2-Generic

isibloom 2-Generic

jasmiel 2-Generic


JOLESSA 2-Generic

juleber 2-Generic



junel fe 2-Generic




84



kariva 2-Generic



kurvelo 2-Generic




larin fe 2-Generic

larissia 2-Generic

LEENA 2-Generic

lessina 2-Generic

levonest 2-Generic


levora-28 2-Generic

lillow 2-Generic



loryna 2-Generic


lutera 2-Generic


marlissa 2-Generic




85



Drug






mili 2-Generic



necon 2-Generic

nikki 2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug


nortrel 2-Generic

nylia 2-Generic

nymyo 2-Generic

OCELLA 2-Generic


86



orsythia 2-Generic

philith 2-Generic

pimtrea 2-Generic

pirmella 2-Generic

portia 2-Generic


3-Preferred Brand



previfem 2-Generic

reclipsen 2-Generic

setlakin 2-Generic

simliya 2-Generic

sprintec 2-Generic

sronyx 2-Generic

syeda 2-Generic


tarina fe 2-Generic








87







tri-mili 2-Generic

tri-nymyo 2-Generic






TYBLUME 2-Generic

velivet 2-Generic

vestura 2-Generic

vienva 2-Generic

viorele 2-Generic

volnea 2-Generic

vyfemla 2-Generic

vylibra 2-Generic

wera 2-Generic

xulane 2-Generic


zafemy 2-Generic

zarah 2-Generic




88




Drug


deblitane 2-Generic



errin 2-Generic

heather 2-Generic

incassia 2-Generic

jencycla 2-Generic

lyleq 2-Generic

lyza 2-Generic


4-Non-PreferredDrug


2-Generic


2-Generic


NORA-BE 2-Generic



norlyda 2-Generic



89



tulana 2-Generic


Drug




Drug




4-Non-PreferredDrug


2-Generic



2-Generic






90



Drug










5-Specialty


PA











91
















4-Non-PreferredDrug



4-Non-PreferredDrug



5-Specialty PA








4-Non-PreferredDrug



92














2-Generic


2-Generic








5-Specialty PA



4-Non-PreferredDrug






4-Non-PreferredDrug



93










5-Specialty PA










5-Specialty PA LA







94








PA



PA


PA LA



PA











3-Preferred Brand





95






























96







4-Non-PreferredDrug



PENTASA 5-Specialty




colocort 2-Generic









2-Generic


97



4-Non-PreferredDrug














4-Non-PreferredDrug





4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug




2-Generic


4-Non-PreferredDrug


98



xgeva 5-Specialty


4-Non-PreferredDrug



4-Non-PreferredDrug


4-Non-PreferredDrug









4-Non-PreferredDrug


2-Generic


2-Generic


99



2-Generic


2-Generic


2-Generic


2-Generic


2-Generic


2-Generic

OPHTHALMIC AGENTS


Drug









100



Drug



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug







4-Non-PreferredDrug






Drug


101











3-Preferred Brand















3-Preferred Brand


102



Drug



2-Generic

















3-Preferred Brand


103





1-PreferredGeneric


4-Non-PreferredDrug






ST


OTIC AGENTS






4-Non-PreferredDrug




104



3-Preferred Brand



4-Non-PreferredDrug






2-Generic


3-Preferred Brand






2-Generic



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


105



Drug






2-Generic








4-Non-PreferredDrug











2-Generic


106



Drug



4-Non-PreferredDrug








4-Non-PreferredDrug














4-Non-PreferredDrug



107




DrugPA


2-Generic










5-Specialty PA LA









108






2-Generic








5-Specialty PA LA




2-Generic


2-Generic




2-Generic



109




2-Generic


Drug





PA QL (1 PER 1 DAY)




MISCELLANEOUS




110






ABELCET 23

ABILIFY MAINTENA 37

ABILIFY MYCITE 37



acarbose 45

accutane 65

acebutolol hcl 54


acetazolamide 58

acetic acid 104

acetylcysteine 108

acitretin 65

acthib 95

actimmune 95

acyclovir 44

acyclovir sodium 44

adacel tdap 95

adapalene 65


ADEMPAS 108

ADVAIR DISKUS 108

ADVAIR HFA 108

AEMCOLO 7

AFINITOR 31

AFINITOR DISPERZ 31

afirmelle 81


ak-poly-bac 100

AKYNZEO 22

albendazole 33







ALECENSA 31


alfuzosin hcl 76


allopurinol 25





ALOMIDE 101

alosetron hcl 73

ALPHAGAN P 103

alprazolam 44

ALREX 102

altavera 81

ALTRENO 65

ALUNBRIG 29

alyacen 82

alyq 108

amabelz 82

amantadine hcl 35

AMBISOME 23

ambrisentan 108

amcinonide 77

amethyst 82


amiloride hcl 58


AMINOSYN II 68

amiodarone hcl 53

AMITIZA 73







111

ammonium lactate 65

amnesteem 65

amoxapine 21

amoxicillin 11


amphotericin b 23




ANADROL-50 81

anagrelide hcl 50

anastrozole 30

ANDRODERM 81

ANORO ELLIPTA 108

anusol-hc 97

APOKYN 35


aprepitant 22

apri 82

APTIOM 18

APTIVUS 43

aralast np 74

aranelle 82

aranesp 50

arcalyst 95

aripiprazole 37

ARISTADA 37

ARISTADA INITIO 37

armodafinil 110

armour thyroid 90

ARNUITY ELLIPTA 104

arsenic trioxide 29



ASMANEX 105

ASMANEX HFA 105


ASTAGRAF XL 92


atenolol 54


atomoxetine hcl 62


atovaquone 34



ATROVENT HFA 106

AUBAGIO 63

aubra 82

aubra eq 82

aurovela 82

aurovela 24 fe 82

aurovela fe 82

AURYXIA 70

AUSTEDO 63

AUVI-Q 106

aviane 82

avidoxy 14

AVITA 65

avonex 63

avonex pen 64

AVYCAZ 9

ayuna 82

AYVAKIT 29

AZASITE 12

azathioprine 92


azelaic acid 65

azelastine hcl 102

azithromycin 12

aztreonam 11

azurette 82

Bbacitracin 7


baclofen 39


BALVERSA 29

balziva 82

BAQSIMI 48

BARACLUDE 40

112


bekyree 82

BELBUCA 2

benazepril hcl 52


benlysta 95

BENZNIDAZOLE 34


beser 77




betaseron 64

betaxolol hcl 54


BETIMOL 103

bexarotene 33

bexsero 95

bicalutamide 28

BICILLIN C-R 11

BICILLIN L-A 12

BIKTARVY 40

bimatoprost 104

BINOSTO 98



bivigam 94

BLEPHAMIDE 100

blephamide sop 100

blisovi 24 fe 82

blisovi fe 82


boostrix tdap 95

bosentan 108

BOSULIF 31

BRAFTOVI 31

BREO ELLIPTA 108

briellyn 82

BRILINTA 51


brinzolamide 103

BRIVIACT 15



BRUKINSA 29

budesonide 97

bumetanide 58

buprenorphine 2

buprenorphine hcl 2


bupropion hcl 6

buspirone hcl 44





BYDUREON BCISE 45

BYDUREON PEN 45

Ccabergoline 91

cablivi 50

CABOMETYX 31

cafergot 26

calcipotriene 65


CALCITRIOL 65

calcitriol 98

calcium acetate 70

CALQUENCE 31

camila 89



CAPASTAT SULFATE 27

CAPLYTA 37

CAPRELSA 31

captopril 52


CARBAGLU 74

carbamazepine 18

carbidopa 36


113


CARDIZEM LA 55

carteolol hcl 103

cartia xt 55

carvedilol 54



cataflam 1

CAYSTON 107

caziant 82

cefaclor 9

cefadroxil 9

cefazolin sodium 9

cefdinir 9

cefepime hcl 9


cefixime 10



cefoxitin sodium 10


cefprozil 10

ceftazidime 10





celecoxib 1

CELONTIN 16

cephalexin 10

CERDELGA 74

CHANTIX 6

charlotte 24 fe 82

chateal 82

chateal eq 82

CHEMET 70

chenodal 71





chlorthalidone 59

CHOLBAM 74



ciclodan 23

ciclopirox 23


cilostazol 51

CIMDUO 42

cimetidine 72

cimetidine hcl 72

cinacalcet hcl 98

cinryze 92

ciprofloxacin 13





claravis 65

clarithromycin 12


cleocin phosphate 7

clindacin etz 7

clindacin p 7

clindamycin hcl 7




CHLORIDE 7



CLINOLIPID 68

clobazam 16



clodan 77

clomipramine hcl 21

clonazepam 44


mgday patch) 52

clonidine hcl 52

114



clotrimazole 23


clovique 70

clozapine 39

COARTEM 34


codeine sulfate 3

colchicine 25

colesevelam hcl 60

colestipol hcl 60


colocort 97

COMBIGAN 103

COMBIPATCH 82


COMETRIQ 31

COMPLERA 41

compro 22

concept ob 71

constulose 73

COPAXONE 64

COPIKTRA 29

CORLANOR 57

cormax 78


CORTISPORIN 66


cosentyx pen 66


cosentyx syringe 66

COTELLIC 31

creon 74

CRESEMBA 24

CRIXIVAN 43

cromolyn sodium 71

cryselle 82

cyclafem 83


cyclophosphamide 28

cycloserine 27

CYCLOSET 45

cyclosporine 92



cyred 83

cyred eq 83

cystadane 75

CYSTADROPS 100

CYSTAGON 75

CYSTARAN 100

Ddalfampridine 64

DALIRESP 108

danazol 81


dapsone 27

daptacel dtap 95

daptomycin 7

dasetta 83

DAURISMO 31

DAYTRANA 62

deblitane 89

decadron 78

deferasirox 70

DELSTRIGO 41


DEPO-PROVERA 89


DESCOVY 42

desipramine hcl 21





desonide 78

desoximetasone 78


dexamethasone 78


115


DEXILANT 74



aspartate 61










DIACOMIT 15

DIASTAT 16

DIASTAT ACUDIAL 16

DIAZEPAM 16

diazepam 45

diazoxide 48


diclofenac sodium 1



dicyclomine hcl 71

didanosine 42

DIFICID 13


diflunisal 1

difluprednate 102

digitek 57

digox 57

digoxin 57


dilantin 18

dilt-xr 55

diltiazem hcl 55


DIPENTUM 97




disulfiram 5


dofetilide 53

dolishale 83

donepezil hcl 19

DOPTELET 50

dorzolamide hcl 103



dotti 83

DOVATO 42


doxepin hcl 44

doxercalciferol 98

doxy 100 14




dronabinol 23

DROXIA 29

droxidopa 52

DUAVEE 90

DULERA 109

duloxetine hcl 63

dupixent pen 66

dupixent syringe 66

dutasteride 76


EDURANT 41

efavirenz 41



egrifta sv 81

ELIGARD 91

elinest 83

ELIQUIS 49

ELLA 89

ELMIRON 76

116

eluryng 83

EMCYT 28

EMEND 23

EMFLAZA 78

emgality pen 25

emgality syringe 26

emoquette 83

EMSAM 20

emtricitabine 42


EMTRIVA 42

emverm 33



enbrel 92

enbrel mini 92

enbrel sureclick 92

endocet 3

engerix-b adult 95



enpresse 83

enskyce 83

enspryng 94

entacapone 35

entecavir 40

ENTRESTO 57

enulose 73

EPIDIOLEX 15

epifoam 66

epinastine hcl 102

epinephrine 106

epitol 18

EPIVIR HBV 40

eplerenone 58

epogen 50



ERIVEDGE 31

ERLEADA 28

erlotinib hcl 31

errin 89

ertapenem sodium 11

ery 13







ESBRIET 108



estarylla 83

estradiol 83



ESTRING 83

eszopiclone 109

ethacrynic acid 58

ethambutol hcl 27


ethosuximide 16



etodolac 1


etoposide 31

etravirine 41

EUTHYROX 90

everolimus 31

EVOTAZ 43

EVRYSDI 75

exemestane 30

extavia 64

ezetimibe 60


Ffalmina 84

famciclovir 44

famotidine 72

117

famotidinepf 72

FANAPT 37

FARXIGA 46

FARYDAK 31

fasenra pen 109

febuxostat 25

felbamate 17

felodipine 55

FEMRING 84

femynor 84

fenofibrate 59



FENOFIBRIC ACID 59


fentanyl 2

fentanyl citrate 3

FETZIMA 20

FINACEA 66

finasteride 76

FINTEPLA 15

FIRDAPSE 63

FIRMAGON 91

FIRVANQ 8

FLAREX 102

flavoxate hcl 75

flebogamma dif 94


FLOVENT DISKUS 105

FLOVENT HFA 105

fluconazole 24


flucytosine 24


flunisolide 105




fluocinonide 78


FLUOROMETHOLONE 102

fluorouracil 29

FLUOROURACIL 66

fluoxetine hcl 20


fluphenazine hcl 36

flurbiprofen 1


flutamide 28



XINAFOATE 109



FML FORTE 102

FML SOP 102

folivane-ob 71








FOSRENOL 70

FOTIVDA 31

FRAGMIN 49


fulphila 50

furosemide 58

FUZEON 42

fyavolv 84

FYCOMPA 17

Ggabapentin 16

GALAFOLD 75

galantamine hbr 19

gammagard liquid 94

gammagard s-d 94

gammaked 94

gammaplex 94

118

gamunex-c 94

gardasil 9 95

gatifloxacin 13

GATTEX 72

gauze bandage 99

gavilyte-c 73

gavilyte-g 73

gavilyte-n 73

GAVRETO 29

gemfibrozil 59

gemmily 84

generlac 73

gengraf 92

gentak 6




GENVOYA 40

GIANVI 84

GILENYA 64

GILOTRIF 31

glassia 75


glatopa 64

glimepiride 46

glipizide 46


GLUCAGEN 48


glycopyrrolate 71

glydo 4

GLYXAMBI 46

granisetron hcl 23

granix 50

grastek 95



guanfacine hcl 62

GUANIDINE HCL 26





Hhaegarda 92

hailey 84

hailey 24 fe 84

hailey fe 84


haloperidol 36



havrix 95

heather 89



CHLORIDE 49


WATER 49


HETLIOZ 110

HETLIOZ LQ 110

hiberix 95

humalog 48








humira 93

humira pen 93



humira(cf) 93


humira(cf) pen 93




119

humulin 70-30 48


humulin n 48


humulin r 48

humulin r u-500 48


hydralazine hcl 60





hydrocortisone 79





hydromorphone hcl 4



hydroxyurea 29

hydroxyzine hcl 105



IBRANCE 32

ibu 1

ibuprofen 1


iclevia 84

ICLUSIG 32

icosapent ethyl 60

IDHIFA 29

ILEVRO 102


IMBRUVICA 32


imipramine hcl 21


imiquimod 66


INBRIJA 35

incassia 89

increlex 81

INCRUSE ELLIPTA 106

indapamide 59

indomethacin 1

infanrix dtap 95

INGREZZA 63


INLYTA 32

INQOVI 29

INREBIC 29


insulin syringes 99

INTELENCE 41

INTRALIPID 68

intron a 40

introvale 84

INVEGA SUSTENNA 37

INVEGA TRINZA 38

INVELTYS 102

INVIRASE 43

INVOKAMET 46

INVOKAMET XR 46

INVOKANA 46

ipol 96



irbesartan 52


IRESSA 32

ISENTRESS 40

ISENTRESS HD 40

isibloom 84

isoniazid 27



isotretinoin 66

isradipine 55

ISTURISA 79

120

itraconazole 24

ivermectin 34

ixiaro 96

JJAKAFI 32

jantoven 50

JANUMET 46

JANUMET XR 46

JANUVIA 46

JARDIANCE 46

jasmiel 84

jencycla 89

JENTADUETO 46

JENTADUETO XR 46

jinteli 84

JOLESSA 84

juleber 84

JULUCA 42

junel 84

junel fe 84

junel fe 24 84

JUXTAPID 60

JYNARQUE 70


kaitlib fe 84

kalliga 85

KALYDECO 107

kariva 85

kelnor 1-35 85

kelnor 1-50 85

kesimpta pen 64

ketoconazole 24

ketodan 24

ketoprofen 1



kinrix 96

kionex 70

KISQALI 32


KLISYRI 66

KLOR-CON 10 68

KLOR-CON 8 68

klor-con m10 68

klor-con m15 69

klor-con m20 69

KLOXXADO 6

KOMBIGLYZE XR 46

KORLYM 79

KOSELUGO 32

kurvelo 85

KYNMOBI 35

Llabetalol hcl 54

LACRISERT 100

lactulose 73

lamivudine 40


lamotrigine 17

lansoprazole 74



lantus 48

lantus solostar 48


larin 85

larin 24 fe 85

larin fe 85

larissia 85

latanoprost 104

LATUDA 38


LEENA 85

leflunomide 95

LENVIMA 32

lessina 85

letrozole 30


121

LEUKERAN 28

leukine 50




levetiracetam 15


LEVO-T 90

levobunolol hcl 103

LEVOCARNITINE 69



levofloxacin 13


levonest 85


levora-28 85



LEVOXYL 90

LEXIVA 43

lidocaine 4

lidocaine hcl 5

lidocaine hclpf 5


lillow 85

lindane 34

linezolid 8


LINZESS 73


lisinopril 53



LITHIUM CITRATE 45

lo-zumandimine 85

LONSURF 29

loperamide hcl 72


LOPREEZA 85

lorazepam 45


LORBRENA 31

lorcet 4

lorcet hd 4

loryna 85



LOTEMAX 102

LOTEMAX SM 102


lovastatin 59

low-ogestrel 85


LUBIPROSTONE 73

LUCEMYRA 5

LUMAKRAS 32

LUMIGAN 104

LUPANETA PACK 91

LUPKYNIS 93

LUPRON DEPOT 91

LUPRON DEPOT-PED 91

lutera 85

lyleq 89

lyllana 85

LYNPARZA 32

LYSODREN 29

lyza 89



maprotiline hcl 20

marlissa 85

marplan 20

MATULANE 28

matzim la 55

MAVENCLAD 64

MAYZENT 64

meclizine hcl 22



122

mefloquine hcl 34


MEKINIST 32

MEKTOVI 32

melodetta 24 fe 85

meloxicam 1

memantine hcl 19

menactra 96

menest 85

menquadfi 96


mercaptopurine 29

meropenem 11


merzee 86

mesalamine 97


MESNEX 33

metadate er 62


metformin hcl 46




24h) 46

methadone hcl 2

methazolamide 58


methergine 99

methimazole 91

methocarbamol 109



methoxsalen 66








metolazone 59




metronidazole 8


mexiletine hcl 53

mibelas 24 fe 86



microgestin 86


microgestin fe 86

midodrine hcl 52

migergot 26

miglitol 47

miglustat 75

mili 86

mimvey 86

minitran 61

minocycline hcl 15

minoxidil 60

mirtazapine 19

misoprostol 74

mitoxantrone hcl 30

modafinil 110

moexipril hcl 53

molindone hcl 37


mondoxyne nl 15

mono-linyah 86


morgidox 15

morphine sulfate 2

MOVANTIK 72

moxifloxacin hcl 14




MOZOBIL 50

MULTAQ 53

123


acid 71


myalept 72

MYCAPSSA 91



myorisan 66

MYRBETRIQ 76

MYTESI 72

Nnabumetone 1

nadolol 54

nafcillin sodium 12

naftifine hcl 24

NAFTIN 24

naloxone hcl 6

naltrexone hcl 5

NAMENDA XR 19

naproxen 1

naproxen sodium 2

naratriptan hcl 26

NARCAN 6

NATACYN 24

nateglinide 47

natpara 98

NAYZILAM 15

nebivolol hcl 54

necon 86

nefazodone hcl 20

neo-polycin 101

neo-polycin hc 101

neomycin sulfate 6


bhydrocortisone 101






NERLYNX 32

neulasta 50

neulasta onpro 50

neupogen 50

NEUPRO 35

nevirapine 41

NEXAVAR 32

NEXIUM 74

NEXLETOL 57

NEXLIZET 60

niacin 60

nicardipine hcl 55

NICOTROL 6

NICOTROL NS 6

nifedipine 56

nikki 86

nilutamide 28

nimodipine 56

NINLARO 30

nitazoxanide 34

nitisinone 75

NITRO-DUR 61

nitrofurantoin 8



nitroglycerin 61

NITROSTAT 61

NITYR 75

nivestym 51

nizatidine 72

NORA-BE 89

norethindrone 89




fumarate 86



norlyda 89

NORPACE CR 53

nortrel 86

124


NORVIR 43

NOURIANZ 35

NOXAFIL 24

np thyroid 90

NUBEQA 28

nucala 109

NUEDEXTA 63

NUPLAZID 38

NUTRILIPID 69

nyamyc 25

nylia 86

nymyo 86

nystatin 25


nystop 25

nyvepria 51

Oo-cal fa 71

ob complete 71

OCALIVA 75

OCELLA 86

octagam 94


odactra 95

ODEFSEY 41

ODOMZO 32

OFEV 108

ofloxacin 14

ogestrel 87

olanzapine 38






olopatadine hcl 102


OMEGAVEN 69

omeprazole 74

omnitrope 81

ondansetron hcl 23



ONGENTYS 35

ONGLYZA 47

ONUREG 30

OPSUMIT 108

oralair 95

orencia 93


ORFADIN 75

ORGOVYX 91

ORIAHNN 81

ORILISSA 81

ORKAMBI 107

ORLADEYO 92

orsythia 87


OSMOLEX ER 35

OTEZLA 95

oxacillin sodium 12


DEXTROSE 12

oxandrolone 81

oxazepam 45

oxcarbazepine 18

oxervate 101



oxycodone hcl 4



oxymorphone hcl 4

OZEMPIC 47

Ppaliperidone 38

palynziq 75


PANRETIN 33

125


panzyga 94

paricalcitol 98

paroex 64


paroxetine hcl 21

paser 27

PAXIL 21

PAZEO 102

pediarix 96

pedvaxhib 96


chloride 73


sodvit c 73

PEGANONE 18

pegasys 40

pegintron 40

PEMAZYRE 32




penicillamine 76








PENTASA 97

pentoxifylline 57

PERFOROMIST 107


periogard 64

permethrin 34

perphenazine 22


PERSERIS 38

pfizerpen 12


phenobarbital 17


phenytoin 18


philith 87

PHOSLYRA 70


PICATO 66

PIFELTRO 41

pilocarpine hcl 65

pimecrolimus 67

pimozide 37

pimtrea 87

pindolol 54

pioglitazone hcl 47




PIQRAY 31

pirmella 87

piroxicam 2

plegridy 64

plegridy pen 64

plenamine 69

PLENVU 73

podofilox 67

polycin 101



POMALYST 28

portia 87

posaconazole 25



SODIUM CHLORIDE 69


SODIUM CHLORIDE 69


SODIUM CHLORIDE 69


AND 5 DEXTROSE 69

126



PRADAXA 50


prasugrel hcl 51


prazosin hcl 52

PRED MILD 103

PREDNICARBATE 79

prednisolone 80



prednisone 80


pregabalin 63

PREMARIN 87

PREMPHASE 87

PREMPRO 87


prenate am 71

prenate chewable 71

prevalite 60

previfem 87

PREVYMIS 39

PREZCOBIX 43

PREZISTA 43

PRIFTIN 27


primidone 17

privigen 94


probenecid 25


prochlorperazine 22



procrit 51

procto-med hc 97

proctofoam-hc 67

proctosol-hc 97

proctozone-hc 97

PROCYSBI 75


PROGRAF 93

prolastin c 75

PROLENSA 103

prolia 98

PROMACTA 51

promethazine hcl 22

propafenone hcl 53

propranolol hcl 55


propylthiouracil 92

proquad 96


psorcon 80

pulmozyme 107

purefe ob plus 71

PURIXAN 29

PYLERA 72

pyrazinamide 27


pyrimethamine 34

QQINLOCK 30



quinapril hcl 53




QVAR REDIHALER 105

Rrabavert 96


ragwitek 95

raloxifene hcl 90

ramipril 53

ranolazine 57


127

RAVICTI 75

rebif 64

rebif rebidose 64

reclipsen 87

recombivax hb 96

RECTIV 67

regranex 67

RELENZA 44

relexxii 62

RELISTOR 72


RENACIDIN 76

repaglinide 47




repatha syringe 60

RESTASIS 101


retacrit 51

RETEVMO 30

RETROVIR 42

REVLIMID 28

REXULTI 38

REYATAZ 43

REZUROCK 93

RHOPRESSA 104

ribavirin 40

rifabutin 27

rifampin 27

RIFATER 27

riluzole 63

rimantadine hcl 44


RINVOQ 93


RISPERDAL CONSTA 38

risperidone 38

ritonavir 43

rivastigmine 19



ropinirole hcl 35

rosadan 67


rotarix 96

rotateq 96

roweepra 15

roweepra xr 16

ROZLYTREK 30

RUBRACA 30

rufinamide 18

RUKOBIA 42

RUZURGI 63

RYBELSUS 47

RYDAPT 30

Ssajazir 92

SAMSCA 70

santyl 67


SAVAYSA 50

SAVELLA 63

SECUADO 38

SEGLUROMET 47

selegiline hcl 36

selenium sulfide 67

SELZENTRY 42

SEREVENT DISKUS 107

sertraline hcl 21

setlakin 87


sharobel 90

shingrix 96

SIGNIFOR 91


silodosin 76

SILVADENE 14


SIMBRINZA 104

simliya 87

128

simvastatin 59

sirolimus 93

SIRTURO 27

SIVEXTRO 8

skyrizi 67


skyrizi pen 67

SMOFLIPID 69




chloridepeg 73





soltamox 28

SOLU-CORTEF 80

SOMATULINE DEPOT 91

somavert 91

SOOLANTRA 67

sorine 54

sotalol af 54

sotalol hcl 54

SPIRIVA 106


spironolactone 58


sprintec 87

SPRITAM 16

SPRIX 2

SPRYCEL 32

sps 70

sronyx 87

SSD 14

stavudine 42

STEGLATRO 47

STEGLUJAN 47

stelara 67

STIMATE 81


STIVARGA 32


STRIBILD 41

sucraid 75

sucralfate 74



phosphate 101

sulfadiazine 14


SULFAMYLON 8

sulfasalazine 97

sulindac 2


sunitinib malate 32

SUNOSI 110

suprax 10

SUPREP 73

SUTAB 73

syeda 87

sylatron 30

SYMBICORT 109

SYMDEKO 107

SYMPAZAN 17

SYMPROIC 72

SYMTUZA 43

SYNAREL 91

SYNJARDY 47

SYNJARDY XR 47

SYNRIBO 30

SYNTHROID 90


container 100




ml 100


TTABLOID 29

129

TABRECTA 30

tacrolimus 67

tadalafil 76

TAFINLAR 32

TAGRISSO 32

takhzyro 92

TALICIA 72

TALZENNA 32


tamsulosin hcl 76

TARGRETIN 33

tarina 24 fe 87

tarina fe 87


TASIGNA 32

TAVALISSE 51

taysofy 87

tazarotene 67

tazicef 10

TAZORAC 67

taztia xt 56

TAZVERIK 30

TEFLARO 10

TEGSEDI 63

telmisartan 52



temazepam 109

TEMIXYS 43

tenivac 96


TEPMETKO 33

terazosin hcl 52

terbinafine hcl 25


terconazole 25

testosterone 81





tetrabenazine 63

tetracycline hcl 15

THALOMID 28


THIOLA EC 76

thioridazine hcl 37

thiothixene 37

thyroid 90

thyroidpork 91

tiadylt er 56

tiagabine hcl 17

TIBSOVO 30

tigecycline 8

tilia fe 87

timolol maleate 55

tinidazole 8

tiopronin 76

TIVICAY 41

TIVICAY PD 41

tizanidine hcl 39

tobi podhaler 107

TOBRADEX 101

tobramycin 7




TOBREX 7

tolmetin sodium 2


tolvaptan 70

topiramate 17

toposar 31

topotecan hcl 31


torsemide 58


toujeo solostar 49

TOVIAZ 76

TPN ELECTROLYTES 70

TRACLEER 108

TRADJENTA 47

130

tramadol hcl 3


trandolapril 53


tranexamic acid 51


travoprost 104

trazodone hcl 21

TRECATOR 27

TRELEGY ELLIPTA 109

trelstar 91

tremfya 67

tretinoin 33


trexall 94

tri femynor 87

tri-estarylla 87

tri-legest fe 87

tri-linyah 88

tri-lo-estarylla 88

tri-lo-marzia 88

tri-lo-mili 88

tri-lo-sprintec 88

tri-mili 88

tri-nymyo 88

tri-previfem 88

tri-sprintec 88

tri-vylibra 88

tri-vylibra lo 88


triamterene 59


triderm 80

trientine hcl 70


trifluridine 44


TRIKAFTA 107

triklo 60


trimethoprim 9


TRINTELLIX 21

TRIUMEQ 43

trivora-28 88

tropicamide 101


trulicity 47

trumenba 96

truseltiq 33

TUKYSA 30

tulana 90

TURALIO 30

twinrix 96

TYBLUME 88

TYBOST 43

TYMLOS 99

typhim vi 96

Uudenyca 51

UKONIQ 33

UNITHROID 91

UPTRAVI 108

ursodiol 72


VALCHLOR 28


valproic acid 17


valsartan 52


VALTOCO 17

vancomycin hcl 9


(PEG-400 NADA) 9



VANDAZOLE 9

vaqta 96

131


varivax vaccine 96

VARUBI 23

VASCEPA 60

velivet 88

VEMLIDY 40

VENCLEXTA 33


venlafaxine hcl 21

verapamil hcl 56

verquvo 58

VERSACLOZ 39

VERZENIO 33

vestura 88

VIBERZI 73

VICTOZA 2-PAK 47

VICTOZA 3-PAK 47

VIDEX 42

VIDEX EC 42

vienva 88

vigabatrin 17

vigadrone 17

VIIBRYD 21

VIMPAT 18

viorele 88

VIRACEPT 43

VIREAD 42

VITRAKVI 30

VIZIMPRO 30

volnea 88

voriconazole 25

VOSEVI 40

VOTRIENT 33

VRAYLAR 38

VUMERITY 64

vyfemla 88

vylibra 88

VYNDAMAX 58

VYNDAQEL 58

VYVANSE 61

VYZULTA 104

WWAKIX 110

warfarin sodium 50

WELIREG 30

wera 88

XXALKORI 33

XARELTO 50

XATMEP 94

XCOPRI 16

XELJANZ 94

XELJANZ XR 94

XELPROS 104

XERMELO 72

xgeva 99

XIFAXAN 9

XIGDUO XR 47

XOFLUZA 44

xolair 109

XOSPATA 30

XPOVIO 30

XTAMPZA ER 3

XTANDI 28

xulane 88

XYREM 110

XYWAV 110

Yyf-vax 96

YONSA 28

yuvafem 88

Zzafemy 88

zafirlukast 106

zaleplon 110

zarah 88

zarxio 51

ZEJULA 33

132

ZELBORAF 33

zemaira 75

zenatane 67

zenpep 75

zenzedi 61

ZEPOSIA 64

ZERBAXA 11

zidovudine 42

ziextenzo 51

zingiber 71

ziprasidone hcl 39


ZIRGAN 39

zoledronic acid 99


SODIUM CHLORIDE 99


ZOLINZA 30

zolmitriptan 26


zonisamide 16

ZORTRESS 94

zovia 1-35 88

zovia 1-35e 88

zumandimine 89

ZYDELIG 33

ZYKADIA 33

ZYLET 101

133


ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 15


ANTIDEPRESSANTS 19

ANTIEMETICS 22

ANTIFUNGALS 23

ANTIGOUT AGENTS 25




ANTINEOPLASTICS 28

ANTIPARASITICS 33


ANTIPSYCHOTICS 36


ANTIVIRALS 39

ANXIOLYTICS 44

BIPOLAR AGENTS 45




















MISCELLANEOUS 110



OTIC AGENTS 104


134



135






MDC-455

11222021

11222021

H9047_2021AM04_C vii










111

11222021

H9047_2021AM04_C viii













11222021



formats)













(TTY 711）



1‐800‐603‐2340 (TTY 711) 번으로 전화해 주십시오










Arabic










Persian




(082021) H9047_2021RCGA03_C



ANALGESICS


celecoxib 2-Generic



3-Preferred Brand




4-Non-PreferredDrug



ibu 2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug




meloxicam 2-Generic



2-Generic


1



Drug



piroxicam 2-Generic


sulindac 2-Generic



DrugPA




4-Non-PreferredDrug

PA




4-Non-PreferredDrug

PA QL (2 PER 1 DAY)


PA QL (4 PER 1 DAY)


2-Generic PA





2



3-Preferred Brand


4-Non-PreferredDrug


PA QL (2 PER 1 DAY)


2-Generic



4-Non-PreferredDrug


3-Preferred Brand



4-Non-PreferredDrug


endocet 2-Generic


4-Non-PreferredDrug

PA QL (4 PER 1 DAY)


3-Preferred Brand


2-Generic


2-Generic


3



2-Generic



4-Non-PreferredDrug

lorcet 2-Generic

lorcet hd 2-Generic


2-Generic


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


2-Generic



4-Non-PreferredDrug



ANESTHETICS



PA


4





2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug








4-Non-PreferredDrug


QL (4 PER 1 DAY)


QL (3 PER 1 DAY)




1-PreferredGeneric

QL (4 PER 1 DAY)


1-PreferredGeneric

QL (3 PER 1 DAY)




5





1-PreferredGeneric








ANTIBACTERIALS



4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug







6




4-Non-PreferredDrug










2-Generic



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug





7



Drug



4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic





2-Generic


4-Non-PreferredDrug


2-Generic







8




4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug



PA QL (3 PER 1 DAY)




4-Non-PreferredDrug


4-Non-PreferredDrug



4-Non-PreferredDrug




4-Non-PreferredDrug


9



4-Non-PreferredDrug





4-Non-PreferredDrug


4-Non-PreferredDrug




4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic





10




Drug





4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug






11



Drug



4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug



2-Generic




Drug


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


2-Generic


12



5-Specialty



4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug


Drug


2-Generic



4-Non-PreferredDrug



2-Generic


4-Non-PreferredDrug


13



Drug




4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug




SSD 2-Generic


4-Non-PreferredDrug



2-Generic


4-Non-PreferredDrug





14



2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug


morgidox 2-Generic


ANTICONVULSANTS







2-Generic


4-Non-PreferredDrug



roweepra 2-Generic


15










Drug


3-Preferred Brand



4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug


16



3-Preferred Brand


primidone 2-Generic





2-Generic






4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


2-Generic


17



4-Non-PreferredDrug




3-Preferred Brand


4-Non-PreferredDrug





2-Generic



2-Generic



4-Non-PreferredDrug







18



ANTIDEMENTIA AGENTS



3-Preferred Brand




4-Non-PreferredDrug


2-Generic


ANTIDEPRESSANTS


2-Generic


2-Generic





19









1-PreferredGeneric


3-Preferred Brand



1-PreferredGeneric


3-Preferred Brand


ST


2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic




20



2-Generic


4-Non-PreferredDrug



1-PreferredGeneric



ST


2-Generic


4-Non-PreferredDrug

QL (1 PER 1 DAY)


ST


amoxapine 2-Generic






2-Generic


21



Drug


ANTIEMETICS


Drug


2-Generic


2-Generic






4-Non-PreferredDrug












22



DrugPA




QL (2 PER 1 DAY)


4-Non-PreferredDrug


2-Generic



3-Preferred Brand



ANTIFUNGALS










3-Preferred Brand





3-Preferred Brand


23







3-Preferred Brand


2-Generic


4-Non-PreferredDrug




4-Non-PreferredDrug




4-Non-PreferredDrug






4-Non-PreferredDrug




PA


24




2-Generic



nystop 2-Generic





4-Non-PreferredDrug


4-Non-PreferredDrug

PA

ANTIGOUT AGENTS






ANTIMIGRAINE AGENTS




25


















4-Non-PreferredDrug







4-Non-PreferredDrug



26



ANTIMYCOBACTERIALS




Drug




2-Generic






3-Preferred Brand






27



ANTINEOPLASTICS


4-Non-PreferredDrug









flutamide 2-Generic













28





4-Non-PreferredDrug




LA














4-Non-PreferredDrug


2-Generic




29



























letrozole 2-Generic


30






toposar 2-Generic





















31































32





















ANTIPARASITICS


DrugPA


PA


33




Drug


3-Preferred Brand





2-Generic





4-Non-PreferredDrug





Drug




2-Generic


2-Generic


34




3-Preferred Brand






ST


PA LA




KYNMOBI 5-Specialty


QL (1 PER 1 DAY)


2-Generic


2-Generic


3-Preferred Brand


35




Drug


4-Non-PreferredDrug


2-Generic


Drug


ANTIPSYCHOTICS


4-Non-PreferredDrug



3-Preferred Brand


4-Non-PreferredDrug



4-Non-PreferredDrug


4-Non-PreferredDrug


36





pimozide 2-Generic







4-Non-PreferredDrug


2-Generic















37






2-Generic


3-Preferred Brand







5-Specialty



4-Non-PreferredDrug


2-Generic







38





4-Non-PreferredDrug


3-Preferred Brand




2-Generic


3-Preferred Brand


4-Non-PreferredDrug


ANTIVIRALS







39




Drug





VEMLIDY 5-Specialty





5-Specialty LA

pegasys 5-Specialty



3-Preferred Brand


GENVOYA 5-Specialty


5-Specialty


3-Preferred Brand



40




5-Specialty





EDURANT 5-Specialty

efavirenz 2-Generic


5-Specialty


5-Specialty




4-Non-PreferredDrug


ODEFSEY 5-Specialty








41






5-Specialty



4-Non-PreferredDrug



stavudine 2-Generic





5-Specialty


2-Generic


Drug

DOVATO 5-Specialty

FUZEON 5-Specialty

JULUCA 5-Specialty

RUKOBIA 5-Specialty


5-Specialty



42



Drug

TRIUMEQ 5-Specialty



5-Specialty



EVOTAZ 5-Specialty








3-Preferred Brand



5-Specialty


3-Preferred Brand



SYMTUZA 5-Specialty



43




3-Preferred Brand





2-Generic


4-Non-PreferredDrug






ANXIOLYTICS



3-Preferred Brand


4-Non-PreferredDrug


3-Preferred Brand


44



2-Generic



2-Generic


2-Generic



BIPOLAR AGENTS


2-Generic






4-Non-PreferredDrug

PA


4-Non-PreferredDrug

PA





45



DrugST



2-Generic




PA


ST


ST


ST






PA


PA


PA


4-Non-PreferredDrug


1-PreferredGeneric


1-PreferredGeneric


46



Drug




PA









ST


ST


PA




PA





ST


47





















humulin n 2-Generic


humulin r 2-Generic






48







4-Non-PreferredDrug


5-Specialty


4-Non-PreferredDrug


4-Non-PreferredDrug


5-Specialty


3-Preferred Brand



4-Non-PreferredDrug


4-Non-PreferredDrug


3-Preferred Brand


49



jantoven 2-Generic







4-Non-PreferredDrug

PA


5-Specialty PA




4-Non-PreferredDrug

PA



granix 5-Specialty

leukine 5-Specialty

MOZOBIL 5-Specialty





50





4-Non-PreferredDrug

PA




4-Non-PreferredDrug

PA



udenyca 5-Specialty

zarxio 5-Specialty



4-Non-PreferredDrug



Drug






51





4-Non-PreferredDrug


1-PreferredGeneric












valsartan 2-Generic


Generic



2-Generic


52



Drug









4-Non-PreferredDrug









3-Preferred Brand


4-Non-PreferredDrug



53



Drug

sorine 2-Generic






2-Generic





2-Generic




1-PreferredGeneric


2-Generic



ST

pindolol 2-Generic


54



2-Generic


4-Non-PreferredDrug


Generic


cartia xt 2-Generic

dilt-xr 2-Generic


2-Generic


4-Non-PreferredDrug





4-Non-PreferredDrug


55



2-Generic


taztia xt 2-Generic



4-Non-PreferredDrug


2-Generic


Drug




2-Generic



3-Preferred Brand



2-Generic


2-Generic


4-Non-PreferredDrug



56



4-Non-PreferredDrug

PA

digitek 2-Generic

digox 2-Generic


2-Generic


4-Non-PreferredDrug









2-Generic


PA


4-Non-PreferredDrug


2-Generic








57



Drug





PA




4-Non-PreferredDrug




3-Preferred Brand



1-PreferredGeneric


4-Non-PreferredDrug

torsemide 2-Generic





58



Drug



2-Generic




2-Generic



2-Generic





Generic







59




4-Non-PreferredDrug


4-Non-PreferredDrug



4-Non-PreferredDrug

ezetimibe 2-Generic





PA


2-Generic






triklo 2-Generic



2-Generic

minoxidil 2-Generic


60




3-Preferred Brand


2-Generic

minitran 2-Generic



2-Generic






2-Generic


4-Non-PreferredDrug




QL (1 PER 1 DAY)



61




Drug



QL (1 PER 1 DAY)


2-Generic


4-Non-PreferredDrug

QL (1 PER 1 DAY)


2-Generic



4-Non-PreferredDrug

QL (1 PER 1 DAY)


2-Generic


QL (6 PER 1 DAY)



QL (2 PER 1 DAY)


QL (1 PER 1 DAY)


62











riluzole 2-Generic





Drug


2-Generic


2-Generic


4-Non-PreferredDrug

QL (2 PER 1 DAY)




avonex 5-Specialty


63







5-Specialty


GILENYA 5-Specialty


glatopa 5-Specialty




5-Specialty LA




rebif 5-Specialty



ZEPOSIA 5-Specialty



2-Generic

paroex 2-Generic

periogard 2-Generic


64



4-Non-PreferredDrug




Drug


4-Non-PreferredDrug


4-Non-PreferredDrug







4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


65



Drug







3-Preferred Brand









4-Non-PreferredDrug


ST




3-Preferred Brand


4-Non-PreferredDrug




66



DrugST













ST


5-Specialty PA


4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug




67





4-Non-PreferredDrug







4-Non-PreferredDrug




4-Non-PreferredDrug







2-Generic





68














4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug





69



Drug


2-Generic






5-Specialty PA LA


5-Specialty PA

kionex 2-Generic



2-Generic





Drug


3-Preferred Brand


5-Specialty




70



5-Specialty





2-Generic

o-cal fa 2-Generic






zingiber 2-Generic



2-Generic


2-Generic






71



3-Preferred Brand



4-Non-PreferredDrug





PYLERA 5-Specialty


5-Specialty PA


5-Specialty PA




3-Preferred Brand





2-Generic



2-Generic


72




Drug






enulose 2-Generic




generlac 2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug



2-Generic





73





2-Generic


DrugST


4-Non-PreferredDrug

ST


2-Generic


2-Generic


4-Non-PreferredDrug

ST


2-Generic


2-Generic


4-Non-PreferredDrug









74




LA









5-Specialty LA





5-Specialty PA LA





5-Specialty PA







75



3-Preferred Brand


2-Generic




















76





4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug



3-Preferred Brand


4-Non-PreferredDrug


4-Non-PreferredDrug


3-Preferred Brand




2-Generic


4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug



77




decadron 2-Generic


3-Preferred Brand



4-Non-PreferredDrug


2-Generic


3-Preferred Brand


4-Non-PreferredDrug


4-Non-PreferredDrug



5-Specialty PA LA






3-Preferred Brand


3-Preferred Brand


78





2-Generic



4-Non-PreferredDrug


2-Generic


3-Preferred Brand


4-Non-PreferredDrug






2-Generic


3-Preferred Brand




2-Generic



79




4-Non-PreferredDrug


2-Generic


2-Generic





3-Preferred Brand


2-Generic


3-Preferred Brand

triderm 2-Generic



2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


80





5-Specialty PA


PA


PA

STIMATE 5-Specialty





DrugPA



4-Non-PreferredDrug

PA


4-Non-PreferredDrug




altavera 2-Generic


81




amethyst 2-Generic

apri 2-Generic

aranelle 2-Generic

aubra 2-Generic

aubra eq 2-Generic





aviane 2-Generic


azurette 2-Generic

balziva 2-Generic

bekyree 2-Generic



briellyn 2-Generic

caziant 2-Generic





cryselle 2-Generic


82



cyred 2-Generic

cyred eq 2-Generic

dasetta 2-Generic



2-Generic

dolishale 2-Generic


elinest 2-Generic


emoquette 2-Generic

enpresse 2-Generic

enskyce 2-Generic

estarylla 2-Generic


4-Non-PreferredDrug


2-Generic






83





falmina 2-Generic


femynor 2-Generic



GIANVI 2-Generic

hailey 2-Generic


hailey fe 2-Generic

iclevia 2-Generic

introvale 2-Generic

isibloom 2-Generic

jasmiel 2-Generic


JOLESSA 2-Generic

juleber 2-Generic



junel fe 2-Generic




84



kariva 2-Generic



kurvelo 2-Generic




larin fe 2-Generic

larissia 2-Generic

LEENA 2-Generic

lessina 2-Generic

levonest 2-Generic


levora-28 2-Generic

lillow 2-Generic



loryna 2-Generic


lutera 2-Generic


marlissa 2-Generic




85



Drug






mili 2-Generic



necon 2-Generic

nikki 2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug


nortrel 2-Generic

nylia 2-Generic

nymyo 2-Generic

OCELLA 2-Generic


86



orsythia 2-Generic

philith 2-Generic

pimtrea 2-Generic

pirmella 2-Generic

portia 2-Generic


3-Preferred Brand



previfem 2-Generic

reclipsen 2-Generic

setlakin 2-Generic

simliya 2-Generic

sprintec 2-Generic

sronyx 2-Generic

syeda 2-Generic


tarina fe 2-Generic








87







tri-mili 2-Generic

tri-nymyo 2-Generic






TYBLUME 2-Generic

velivet 2-Generic

vestura 2-Generic

vienva 2-Generic

viorele 2-Generic

volnea 2-Generic

vyfemla 2-Generic

vylibra 2-Generic

wera 2-Generic

xulane 2-Generic


zafemy 2-Generic

zarah 2-Generic




88




Drug


deblitane 2-Generic



errin 2-Generic

heather 2-Generic

incassia 2-Generic

jencycla 2-Generic

lyleq 2-Generic

lyza 2-Generic


4-Non-PreferredDrug


2-Generic


2-Generic


NORA-BE 2-Generic



norlyda 2-Generic



89



tulana 2-Generic


Drug




Drug




4-Non-PreferredDrug


2-Generic



2-Generic






90



Drug










5-Specialty


PA











91
















4-Non-PreferredDrug



4-Non-PreferredDrug



5-Specialty PA








4-Non-PreferredDrug



92














2-Generic


2-Generic








5-Specialty PA



4-Non-PreferredDrug






4-Non-PreferredDrug



93










5-Specialty PA










5-Specialty PA LA







94








PA



PA


PA LA



PA











3-Preferred Brand





95






























96







4-Non-PreferredDrug



PENTASA 5-Specialty




colocort 2-Generic









2-Generic


97



4-Non-PreferredDrug














4-Non-PreferredDrug





4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug




2-Generic


4-Non-PreferredDrug


98



xgeva 5-Specialty


4-Non-PreferredDrug



4-Non-PreferredDrug


4-Non-PreferredDrug









4-Non-PreferredDrug


2-Generic


2-Generic


99



2-Generic


2-Generic


2-Generic


2-Generic


2-Generic


2-Generic

OPHTHALMIC AGENTS


Drug









100



Drug



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug







4-Non-PreferredDrug






Drug


101











3-Preferred Brand















3-Preferred Brand


102



Drug



2-Generic

















3-Preferred Brand


103





1-PreferredGeneric


4-Non-PreferredDrug






ST


OTIC AGENTS






4-Non-PreferredDrug




104



3-Preferred Brand



4-Non-PreferredDrug






2-Generic


3-Preferred Brand






2-Generic



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


105



Drug






2-Generic








4-Non-PreferredDrug











2-Generic


106



Drug



4-Non-PreferredDrug








4-Non-PreferredDrug














4-Non-PreferredDrug



107




DrugPA


2-Generic










5-Specialty PA LA









108






2-Generic








5-Specialty PA LA




2-Generic


2-Generic




2-Generic



109




2-Generic


Drug





PA QL (1 PER 1 DAY)




MISCELLANEOUS




110






ABELCET 23

ABILIFY MAINTENA 37

ABILIFY MYCITE 37



acarbose 45

accutane 65

acebutolol hcl 54


acetazolamide 58

acetic acid 104

acetylcysteine 108

acitretin 65

acthib 95

actimmune 95

acyclovir 44

acyclovir sodium 44

adacel tdap 95

adapalene 65


ADEMPAS 108

ADVAIR DISKUS 108

ADVAIR HFA 108

AEMCOLO 7

AFINITOR 31

AFINITOR DISPERZ 31

afirmelle 81


ak-poly-bac 100

AKYNZEO 22

albendazole 33







ALECENSA 31


alfuzosin hcl 76


allopurinol 25





ALOMIDE 101

alosetron hcl 73

ALPHAGAN P 103

alprazolam 44

ALREX 102

altavera 81

ALTRENO 65

ALUNBRIG 29

alyacen 82

alyq 108

amabelz 82

amantadine hcl 35

AMBISOME 23

ambrisentan 108

amcinonide 77

amethyst 82


amiloride hcl 58


AMINOSYN II 68

amiodarone hcl 53

AMITIZA 73







111

ammonium lactate 65

amnesteem 65

amoxapine 21

amoxicillin 11


amphotericin b 23




ANADROL-50 81

anagrelide hcl 50

anastrozole 30

ANDRODERM 81

ANORO ELLIPTA 108

anusol-hc 97

APOKYN 35


aprepitant 22

apri 82

APTIOM 18

APTIVUS 43

aralast np 74

aranelle 82

aranesp 50

arcalyst 95

aripiprazole 37

ARISTADA 37

ARISTADA INITIO 37

armodafinil 110

armour thyroid 90

ARNUITY ELLIPTA 104

arsenic trioxide 29



ASMANEX 105

ASMANEX HFA 105


ASTAGRAF XL 92


atenolol 54


atomoxetine hcl 62


atovaquone 34



ATROVENT HFA 106

AUBAGIO 63

aubra 82

aubra eq 82

aurovela 82

aurovela 24 fe 82

aurovela fe 82

AURYXIA 70

AUSTEDO 63

AUVI-Q 106

aviane 82

avidoxy 14

AVITA 65

avonex 63

avonex pen 64

AVYCAZ 9

ayuna 82

AYVAKIT 29

AZASITE 12

azathioprine 92


azelaic acid 65

azelastine hcl 102

azithromycin 12

aztreonam 11

azurette 82

Bbacitracin 7


baclofen 39


BALVERSA 29

balziva 82

BAQSIMI 48

BARACLUDE 40

112


bekyree 82

BELBUCA 2

benazepril hcl 52


benlysta 95

BENZNIDAZOLE 34


beser 77




betaseron 64

betaxolol hcl 54


BETIMOL 103

bexarotene 33

bexsero 95

bicalutamide 28

BICILLIN C-R 11

BICILLIN L-A 12

BIKTARVY 40

bimatoprost 104

BINOSTO 98



bivigam 94

BLEPHAMIDE 100

blephamide sop 100

blisovi 24 fe 82

blisovi fe 82


boostrix tdap 95

bosentan 108

BOSULIF 31

BRAFTOVI 31

BREO ELLIPTA 108

briellyn 82

BRILINTA 51


brinzolamide 103

BRIVIACT 15



BRUKINSA 29

budesonide 97

bumetanide 58

buprenorphine 2

buprenorphine hcl 2


bupropion hcl 6

buspirone hcl 44





BYDUREON BCISE 45

BYDUREON PEN 45

Ccabergoline 91

cablivi 50

CABOMETYX 31

cafergot 26

calcipotriene 65


CALCITRIOL 65

calcitriol 98

calcium acetate 70

CALQUENCE 31

camila 89



CAPASTAT SULFATE 27

CAPLYTA 37

CAPRELSA 31

captopril 52


CARBAGLU 74

carbamazepine 18

carbidopa 36


113


CARDIZEM LA 55

carteolol hcl 103

cartia xt 55

carvedilol 54



cataflam 1

CAYSTON 107

caziant 82

cefaclor 9

cefadroxil 9

cefazolin sodium 9

cefdinir 9

cefepime hcl 9


cefixime 10



cefoxitin sodium 10


cefprozil 10

ceftazidime 10





celecoxib 1

CELONTIN 16

cephalexin 10

CERDELGA 74

CHANTIX 6

charlotte 24 fe 82

chateal 82

chateal eq 82

CHEMET 70

chenodal 71





chlorthalidone 59

CHOLBAM 74



ciclodan 23

ciclopirox 23


cilostazol 51

CIMDUO 42

cimetidine 72

cimetidine hcl 72

cinacalcet hcl 98

cinryze 92

ciprofloxacin 13





claravis 65

clarithromycin 12


cleocin phosphate 7

clindacin etz 7

clindacin p 7

clindamycin hcl 7




CHLORIDE 7



CLINOLIPID 68

clobazam 16



clodan 77

clomipramine hcl 21

clonazepam 44


mgday patch) 52

clonidine hcl 52

114



clotrimazole 23


clovique 70

clozapine 39

COARTEM 34


codeine sulfate 3

colchicine 25

colesevelam hcl 60

colestipol hcl 60


colocort 97

COMBIGAN 103

COMBIPATCH 82


COMETRIQ 31

COMPLERA 41

compro 22

concept ob 71

constulose 73

COPAXONE 64

COPIKTRA 29

CORLANOR 57

cormax 78


CORTISPORIN 66


cosentyx pen 66


cosentyx syringe 66

COTELLIC 31

creon 74

CRESEMBA 24

CRIXIVAN 43

cromolyn sodium 71

cryselle 82

cyclafem 83


cyclophosphamide 28

cycloserine 27

CYCLOSET 45

cyclosporine 92



cyred 83

cyred eq 83

cystadane 75

CYSTADROPS 100

CYSTAGON 75

CYSTARAN 100

Ddalfampridine 64

DALIRESP 108

danazol 81


dapsone 27

daptacel dtap 95

daptomycin 7

dasetta 83

DAURISMO 31

DAYTRANA 62

deblitane 89

decadron 78

deferasirox 70

DELSTRIGO 41


DEPO-PROVERA 89


DESCOVY 42

desipramine hcl 21





desonide 78

desoximetasone 78


dexamethasone 78


115


DEXILANT 74



aspartate 61










DIACOMIT 15

DIASTAT 16

DIASTAT ACUDIAL 16

DIAZEPAM 16

diazepam 45

diazoxide 48


diclofenac sodium 1



dicyclomine hcl 71

didanosine 42

DIFICID 13


diflunisal 1

difluprednate 102

digitek 57

digox 57

digoxin 57


dilantin 18

dilt-xr 55

diltiazem hcl 55


DIPENTUM 97




disulfiram 5


dofetilide 53

dolishale 83

donepezil hcl 19

DOPTELET 50

dorzolamide hcl 103



dotti 83

DOVATO 42


doxepin hcl 44

doxercalciferol 98

doxy 100 14




dronabinol 23

DROXIA 29

droxidopa 52

DUAVEE 90

DULERA 109

duloxetine hcl 63

dupixent pen 66

dupixent syringe 66

dutasteride 76


EDURANT 41

efavirenz 41



egrifta sv 81

ELIGARD 91

elinest 83

ELIQUIS 49

ELLA 89

ELMIRON 76

116

eluryng 83

EMCYT 28

EMEND 23

EMFLAZA 78

emgality pen 25

emgality syringe 26

emoquette 83

EMSAM 20

emtricitabine 42


EMTRIVA 42

emverm 33



enbrel 92

enbrel mini 92

enbrel sureclick 92

endocet 3

engerix-b adult 95



enpresse 83

enskyce 83

enspryng 94

entacapone 35

entecavir 40

ENTRESTO 57

enulose 73

EPIDIOLEX 15

epifoam 66

epinastine hcl 102

epinephrine 106

epitol 18

EPIVIR HBV 40

eplerenone 58

epogen 50



ERIVEDGE 31

ERLEADA 28

erlotinib hcl 31

errin 89

ertapenem sodium 11

ery 13







ESBRIET 108



estarylla 83

estradiol 83



ESTRING 83

eszopiclone 109

ethacrynic acid 58

ethambutol hcl 27


ethosuximide 16



etodolac 1


etoposide 31

etravirine 41

EUTHYROX 90

everolimus 31

EVOTAZ 43

EVRYSDI 75

exemestane 30

extavia 64

ezetimibe 60


Ffalmina 84

famciclovir 44

famotidine 72

117

famotidinepf 72

FANAPT 37

FARXIGA 46

FARYDAK 31

fasenra pen 109

febuxostat 25

felbamate 17

felodipine 55

FEMRING 84

femynor 84

fenofibrate 59



FENOFIBRIC ACID 59


fentanyl 2

fentanyl citrate 3

FETZIMA 20

FINACEA 66

finasteride 76

FINTEPLA 15

FIRDAPSE 63

FIRMAGON 91

FIRVANQ 8

FLAREX 102

flavoxate hcl 75

flebogamma dif 94


FLOVENT DISKUS 105

FLOVENT HFA 105

fluconazole 24


flucytosine 24


flunisolide 105




fluocinonide 78


FLUOROMETHOLONE 102

fluorouracil 29

FLUOROURACIL 66

fluoxetine hcl 20


fluphenazine hcl 36

flurbiprofen 1


flutamide 28



XINAFOATE 109



FML FORTE 102

FML SOP 102

folivane-ob 71








FOSRENOL 70

FOTIVDA 31

FRAGMIN 49


fulphila 50

furosemide 58

FUZEON 42

fyavolv 84

FYCOMPA 17

Ggabapentin 16

GALAFOLD 75

galantamine hbr 19

gammagard liquid 94

gammagard s-d 94

gammaked 94

gammaplex 94

118

gamunex-c 94

gardasil 9 95

gatifloxacin 13

GATTEX 72

gauze bandage 99

gavilyte-c 73

gavilyte-g 73

gavilyte-n 73

GAVRETO 29

gemfibrozil 59

gemmily 84

generlac 73

gengraf 92

gentak 6




GENVOYA 40

GIANVI 84

GILENYA 64

GILOTRIF 31

glassia 75


glatopa 64

glimepiride 46

glipizide 46


GLUCAGEN 48


glycopyrrolate 71

glydo 4

GLYXAMBI 46

granisetron hcl 23

granix 50

grastek 95



guanfacine hcl 62

GUANIDINE HCL 26





Hhaegarda 92

hailey 84

hailey 24 fe 84

hailey fe 84


haloperidol 36



havrix 95

heather 89



CHLORIDE 49


WATER 49


HETLIOZ 110

HETLIOZ LQ 110

hiberix 95

humalog 48








humira 93

humira pen 93



humira(cf) 93


humira(cf) pen 93




119

humulin 70-30 48


humulin n 48


humulin r 48

humulin r u-500 48


hydralazine hcl 60





hydrocortisone 79





hydromorphone hcl 4



hydroxyurea 29

hydroxyzine hcl 105



IBRANCE 32

ibu 1

ibuprofen 1


iclevia 84

ICLUSIG 32

icosapent ethyl 60

IDHIFA 29

ILEVRO 102


IMBRUVICA 32


imipramine hcl 21


imiquimod 66


INBRIJA 35

incassia 89

increlex 81

INCRUSE ELLIPTA 106

indapamide 59

indomethacin 1

infanrix dtap 95

INGREZZA 63


INLYTA 32

INQOVI 29

INREBIC 29


insulin syringes 99

INTELENCE 41

INTRALIPID 68

intron a 40

introvale 84

INVEGA SUSTENNA 37

INVEGA TRINZA 38

INVELTYS 102

INVIRASE 43

INVOKAMET 46

INVOKAMET XR 46

INVOKANA 46

ipol 96



irbesartan 52


IRESSA 32

ISENTRESS 40

ISENTRESS HD 40

isibloom 84

isoniazid 27



isotretinoin 66

isradipine 55

ISTURISA 79

120

itraconazole 24

ivermectin 34

ixiaro 96

JJAKAFI 32

jantoven 50

JANUMET 46

JANUMET XR 46

JANUVIA 46

JARDIANCE 46

jasmiel 84

jencycla 89

JENTADUETO 46

JENTADUETO XR 46

jinteli 84

JOLESSA 84

juleber 84

JULUCA 42

junel 84

junel fe 84

junel fe 24 84

JUXTAPID 60

JYNARQUE 70


kaitlib fe 84

kalliga 85

KALYDECO 107

kariva 85

kelnor 1-35 85

kelnor 1-50 85

kesimpta pen 64

ketoconazole 24

ketodan 24

ketoprofen 1



kinrix 96

kionex 70

KISQALI 32


KLISYRI 66

KLOR-CON 10 68

KLOR-CON 8 68

klor-con m10 68

klor-con m15 69

klor-con m20 69

KLOXXADO 6

KOMBIGLYZE XR 46

KORLYM 79

KOSELUGO 32

kurvelo 85

KYNMOBI 35

Llabetalol hcl 54

LACRISERT 100

lactulose 73

lamivudine 40


lamotrigine 17

lansoprazole 74



lantus 48

lantus solostar 48


larin 85

larin 24 fe 85

larin fe 85

larissia 85

latanoprost 104

LATUDA 38


LEENA 85

leflunomide 95

LENVIMA 32

lessina 85

letrozole 30


121

LEUKERAN 28

leukine 50




levetiracetam 15


LEVO-T 90

levobunolol hcl 103

LEVOCARNITINE 69



levofloxacin 13


levonest 85


levora-28 85



LEVOXYL 90

LEXIVA 43

lidocaine 4

lidocaine hcl 5

lidocaine hclpf 5


lillow 85

lindane 34

linezolid 8


LINZESS 73


lisinopril 53



LITHIUM CITRATE 45

lo-zumandimine 85

LONSURF 29

loperamide hcl 72


LOPREEZA 85

lorazepam 45


LORBRENA 31

lorcet 4

lorcet hd 4

loryna 85



LOTEMAX 102

LOTEMAX SM 102


lovastatin 59

low-ogestrel 85


LUBIPROSTONE 73

LUCEMYRA 5

LUMAKRAS 32

LUMIGAN 104

LUPANETA PACK 91

LUPKYNIS 93

LUPRON DEPOT 91

LUPRON DEPOT-PED 91

lutera 85

lyleq 89

lyllana 85

LYNPARZA 32

LYSODREN 29

lyza 89



maprotiline hcl 20

marlissa 85

marplan 20

MATULANE 28

matzim la 55

MAVENCLAD 64

MAYZENT 64

meclizine hcl 22



122

mefloquine hcl 34


MEKINIST 32

MEKTOVI 32

melodetta 24 fe 85

meloxicam 1

memantine hcl 19

menactra 96

menest 85

menquadfi 96


mercaptopurine 29

meropenem 11


merzee 86

mesalamine 97


MESNEX 33

metadate er 62


metformin hcl 46




24h) 46

methadone hcl 2

methazolamide 58


methergine 99

methimazole 91

methocarbamol 109



methoxsalen 66








metolazone 59




metronidazole 8


mexiletine hcl 53

mibelas 24 fe 86



microgestin 86


microgestin fe 86

midodrine hcl 52

migergot 26

miglitol 47

miglustat 75

mili 86

mimvey 86

minitran 61

minocycline hcl 15

minoxidil 60

mirtazapine 19

misoprostol 74

mitoxantrone hcl 30

modafinil 110

moexipril hcl 53

molindone hcl 37


mondoxyne nl 15

mono-linyah 86


morgidox 15

morphine sulfate 2

MOVANTIK 72

moxifloxacin hcl 14




MOZOBIL 50

MULTAQ 53

123


acid 71


myalept 72

MYCAPSSA 91



myorisan 66

MYRBETRIQ 76

MYTESI 72

Nnabumetone 1

nadolol 54

nafcillin sodium 12

naftifine hcl 24

NAFTIN 24

naloxone hcl 6

naltrexone hcl 5

NAMENDA XR 19

naproxen 1

naproxen sodium 2

naratriptan hcl 26

NARCAN 6

NATACYN 24

nateglinide 47

natpara 98

NAYZILAM 15

nebivolol hcl 54

necon 86

nefazodone hcl 20

neo-polycin 101

neo-polycin hc 101

neomycin sulfate 6


bhydrocortisone 101






NERLYNX 32

neulasta 50

neulasta onpro 50

neupogen 50

NEUPRO 35

nevirapine 41

NEXAVAR 32

NEXIUM 74

NEXLETOL 57

NEXLIZET 60

niacin 60

nicardipine hcl 55

NICOTROL 6

NICOTROL NS 6

nifedipine 56

nikki 86

nilutamide 28

nimodipine 56

NINLARO 30

nitazoxanide 34

nitisinone 75

NITRO-DUR 61

nitrofurantoin 8



nitroglycerin 61

NITROSTAT 61

NITYR 75

nivestym 51

nizatidine 72

NORA-BE 89

norethindrone 89




fumarate 86



norlyda 89

NORPACE CR 53

nortrel 86

124


NORVIR 43

NOURIANZ 35

NOXAFIL 24

np thyroid 90

NUBEQA 28

nucala 109

NUEDEXTA 63

NUPLAZID 38

NUTRILIPID 69

nyamyc 25

nylia 86

nymyo 86

nystatin 25


nystop 25

nyvepria 51

Oo-cal fa 71

ob complete 71

OCALIVA 75

OCELLA 86

octagam 94


odactra 95

ODEFSEY 41

ODOMZO 32

OFEV 108

ofloxacin 14

ogestrel 87

olanzapine 38






olopatadine hcl 102


OMEGAVEN 69

omeprazole 74

omnitrope 81

ondansetron hcl 23



ONGENTYS 35

ONGLYZA 47

ONUREG 30

OPSUMIT 108

oralair 95

orencia 93


ORFADIN 75

ORGOVYX 91

ORIAHNN 81

ORILISSA 81

ORKAMBI 107

ORLADEYO 92

orsythia 87


OSMOLEX ER 35

OTEZLA 95

oxacillin sodium 12


DEXTROSE 12

oxandrolone 81

oxazepam 45

oxcarbazepine 18

oxervate 101



oxycodone hcl 4



oxymorphone hcl 4

OZEMPIC 47

Ppaliperidone 38

palynziq 75


PANRETIN 33

125


panzyga 94

paricalcitol 98

paroex 64


paroxetine hcl 21

paser 27

PAXIL 21

PAZEO 102

pediarix 96

pedvaxhib 96


chloride 73


sodvit c 73

PEGANONE 18

pegasys 40

pegintron 40

PEMAZYRE 32




penicillamine 76








PENTASA 97

pentoxifylline 57

PERFOROMIST 107


periogard 64

permethrin 34

perphenazine 22


PERSERIS 38

pfizerpen 12


phenobarbital 17


phenytoin 18


philith 87

PHOSLYRA 70


PICATO 66

PIFELTRO 41

pilocarpine hcl 65

pimecrolimus 67

pimozide 37

pimtrea 87

pindolol 54

pioglitazone hcl 47




PIQRAY 31

pirmella 87

piroxicam 2

plegridy 64

plegridy pen 64

plenamine 69

PLENVU 73

podofilox 67

polycin 101



POMALYST 28

portia 87

posaconazole 25



SODIUM CHLORIDE 69


SODIUM CHLORIDE 69


SODIUM CHLORIDE 69


AND 5 DEXTROSE 69

126



PRADAXA 50


prasugrel hcl 51


prazosin hcl 52

PRED MILD 103

PREDNICARBATE 79

prednisolone 80



prednisone 80


pregabalin 63

PREMARIN 87

PREMPHASE 87

PREMPRO 87


prenate am 71

prenate chewable 71

prevalite 60

previfem 87

PREVYMIS 39

PREZCOBIX 43

PREZISTA 43

PRIFTIN 27


primidone 17

privigen 94


probenecid 25


prochlorperazine 22



procrit 51

procto-med hc 97

proctofoam-hc 67

proctosol-hc 97

proctozone-hc 97

PROCYSBI 75


PROGRAF 93

prolastin c 75

PROLENSA 103

prolia 98

PROMACTA 51

promethazine hcl 22

propafenone hcl 53

propranolol hcl 55


propylthiouracil 92

proquad 96


psorcon 80

pulmozyme 107

purefe ob plus 71

PURIXAN 29

PYLERA 72

pyrazinamide 27


pyrimethamine 34

QQINLOCK 30



quinapril hcl 53




QVAR REDIHALER 105

Rrabavert 96


ragwitek 95

raloxifene hcl 90

ramipril 53

ranolazine 57


127

RAVICTI 75

rebif 64

rebif rebidose 64

reclipsen 87

recombivax hb 96

RECTIV 67

regranex 67

RELENZA 44

relexxii 62

RELISTOR 72


RENACIDIN 76

repaglinide 47




repatha syringe 60

RESTASIS 101


retacrit 51

RETEVMO 30

RETROVIR 42

REVLIMID 28

REXULTI 38

REYATAZ 43

REZUROCK 93

RHOPRESSA 104

ribavirin 40

rifabutin 27

rifampin 27

RIFATER 27

riluzole 63

rimantadine hcl 44


RINVOQ 93


RISPERDAL CONSTA 38

risperidone 38

ritonavir 43

rivastigmine 19



ropinirole hcl 35

rosadan 67


rotarix 96

rotateq 96

roweepra 15

roweepra xr 16

ROZLYTREK 30

RUBRACA 30

rufinamide 18

RUKOBIA 42

RUZURGI 63

RYBELSUS 47

RYDAPT 30

Ssajazir 92

SAMSCA 70

santyl 67


SAVAYSA 50

SAVELLA 63

SECUADO 38

SEGLUROMET 47

selegiline hcl 36

selenium sulfide 67

SELZENTRY 42

SEREVENT DISKUS 107

sertraline hcl 21

setlakin 87


sharobel 90

shingrix 96

SIGNIFOR 91


silodosin 76

SILVADENE 14


SIMBRINZA 104

simliya 87

128

simvastatin 59

sirolimus 93

SIRTURO 27

SIVEXTRO 8

skyrizi 67


skyrizi pen 67

SMOFLIPID 69




chloridepeg 73





soltamox 28

SOLU-CORTEF 80

SOMATULINE DEPOT 91

somavert 91

SOOLANTRA 67

sorine 54

sotalol af 54

sotalol hcl 54

SPIRIVA 106


spironolactone 58


sprintec 87

SPRITAM 16

SPRIX 2

SPRYCEL 32

sps 70

sronyx 87

SSD 14

stavudine 42

STEGLATRO 47

STEGLUJAN 47

stelara 67

STIMATE 81


STIVARGA 32


STRIBILD 41

sucraid 75

sucralfate 74



phosphate 101

sulfadiazine 14


SULFAMYLON 8

sulfasalazine 97

sulindac 2


sunitinib malate 32

SUNOSI 110

suprax 10

SUPREP 73

SUTAB 73

syeda 87

sylatron 30

SYMBICORT 109

SYMDEKO 107

SYMPAZAN 17

SYMPROIC 72

SYMTUZA 43

SYNAREL 91

SYNJARDY 47

SYNJARDY XR 47

SYNRIBO 30

SYNTHROID 90


container 100




ml 100


TTABLOID 29

129

TABRECTA 30

tacrolimus 67

tadalafil 76

TAFINLAR 32

TAGRISSO 32

takhzyro 92

TALICIA 72

TALZENNA 32


tamsulosin hcl 76

TARGRETIN 33

tarina 24 fe 87

tarina fe 87


TASIGNA 32

TAVALISSE 51

taysofy 87

tazarotene 67

tazicef 10

TAZORAC 67

taztia xt 56

TAZVERIK 30

TEFLARO 10

TEGSEDI 63

telmisartan 52



temazepam 109

TEMIXYS 43

tenivac 96


TEPMETKO 33

terazosin hcl 52

terbinafine hcl 25


terconazole 25

testosterone 81





tetrabenazine 63

tetracycline hcl 15

THALOMID 28


THIOLA EC 76

thioridazine hcl 37

thiothixene 37

thyroid 90

thyroidpork 91

tiadylt er 56

tiagabine hcl 17

TIBSOVO 30

tigecycline 8

tilia fe 87

timolol maleate 55

tinidazole 8

tiopronin 76

TIVICAY 41

TIVICAY PD 41

tizanidine hcl 39

tobi podhaler 107

TOBRADEX 101

tobramycin 7




TOBREX 7

tolmetin sodium 2


tolvaptan 70

topiramate 17

toposar 31

topotecan hcl 31


torsemide 58


toujeo solostar 49

TOVIAZ 76

TPN ELECTROLYTES 70

TRACLEER 108

TRADJENTA 47

130

tramadol hcl 3


trandolapril 53


tranexamic acid 51


travoprost 104

trazodone hcl 21

TRECATOR 27

TRELEGY ELLIPTA 109

trelstar 91

tremfya 67

tretinoin 33


trexall 94

tri femynor 87

tri-estarylla 87

tri-legest fe 87

tri-linyah 88

tri-lo-estarylla 88

tri-lo-marzia 88

tri-lo-mili 88

tri-lo-sprintec 88

tri-mili 88

tri-nymyo 88

tri-previfem 88

tri-sprintec 88

tri-vylibra 88

tri-vylibra lo 88


triamterene 59


triderm 80

trientine hcl 70


trifluridine 44


TRIKAFTA 107

triklo 60


trimethoprim 9


TRINTELLIX 21

TRIUMEQ 43

trivora-28 88

tropicamide 101


trulicity 47

trumenba 96

truseltiq 33

TUKYSA 30

tulana 90

TURALIO 30

twinrix 96

TYBLUME 88

TYBOST 43

TYMLOS 99

typhim vi 96

Uudenyca 51

UKONIQ 33

UNITHROID 91

UPTRAVI 108

ursodiol 72


VALCHLOR 28


valproic acid 17


valsartan 52


VALTOCO 17

vancomycin hcl 9


(PEG-400 NADA) 9



VANDAZOLE 9

vaqta 96

131


varivax vaccine 96

VARUBI 23

VASCEPA 60

velivet 88

VEMLIDY 40

VENCLEXTA 33


venlafaxine hcl 21

verapamil hcl 56

verquvo 58

VERSACLOZ 39

VERZENIO 33

vestura 88

VIBERZI 73

VICTOZA 2-PAK 47

VICTOZA 3-PAK 47

VIDEX 42

VIDEX EC 42

vienva 88

vigabatrin 17

vigadrone 17

VIIBRYD 21

VIMPAT 18

viorele 88

VIRACEPT 43

VIREAD 42

VITRAKVI 30

VIZIMPRO 30

volnea 88

voriconazole 25

VOSEVI 40

VOTRIENT 33

VRAYLAR 38

VUMERITY 64

vyfemla 88

vylibra 88

VYNDAMAX 58

VYNDAQEL 58

VYVANSE 61

VYZULTA 104

WWAKIX 110

warfarin sodium 50

WELIREG 30

wera 88

XXALKORI 33

XARELTO 50

XATMEP 94

XCOPRI 16

XELJANZ 94

XELJANZ XR 94

XELPROS 104

XERMELO 72

xgeva 99

XIFAXAN 9

XIGDUO XR 47

XOFLUZA 44

xolair 109

XOSPATA 30

XPOVIO 30

XTAMPZA ER 3

XTANDI 28

xulane 88

XYREM 110

XYWAV 110

Yyf-vax 96

YONSA 28

yuvafem 88

Zzafemy 88

zafirlukast 106

zaleplon 110

zarah 88

zarxio 51

ZEJULA 33

132

ZELBORAF 33

zemaira 75

zenatane 67

zenpep 75

zenzedi 61

ZEPOSIA 64

ZERBAXA 11

zidovudine 42

ziextenzo 51

zingiber 71

ziprasidone hcl 39


ZIRGAN 39

zoledronic acid 99


SODIUM CHLORIDE 99


ZOLINZA 30

zolmitriptan 26


zonisamide 16

ZORTRESS 94

zovia 1-35 88

zovia 1-35e 88

zumandimine 89

ZYDELIG 33

ZYKADIA 33

ZYLET 101

133


ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 15


ANTIDEPRESSANTS 19

ANTIEMETICS 22

ANTIFUNGALS 23

ANTIGOUT AGENTS 25




ANTINEOPLASTICS 28

ANTIPARASITICS 33


ANTIPSYCHOTICS 36


ANTIVIRALS 39

ANXIOLYTICS 44

BIPOLAR AGENTS 45




















MISCELLANEOUS 110



OTIC AGENTS 104


134



135






MDC-455

11222021

11222021

H9047_2021AM04_C viii













11222021



formats)













(TTY 711）



1‐800‐603‐2340 (TTY 711) 번으로 전화해 주십시오










Arabic










Persian




(082021) H9047_2021RCGA03_C



ANALGESICS


celecoxib 2-Generic



3-Preferred Brand




4-Non-PreferredDrug



ibu 2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug




meloxicam 2-Generic



2-Generic


1



Drug



piroxicam 2-Generic


sulindac 2-Generic



DrugPA




4-Non-PreferredDrug

PA




4-Non-PreferredDrug

PA QL (2 PER 1 DAY)


PA QL (4 PER 1 DAY)


2-Generic PA





2



3-Preferred Brand


4-Non-PreferredDrug


PA QL (2 PER 1 DAY)


2-Generic



4-Non-PreferredDrug


3-Preferred Brand



4-Non-PreferredDrug


endocet 2-Generic


4-Non-PreferredDrug

PA QL (4 PER 1 DAY)


3-Preferred Brand


2-Generic


2-Generic


3



2-Generic



4-Non-PreferredDrug

lorcet 2-Generic

lorcet hd 2-Generic


2-Generic


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


2-Generic



4-Non-PreferredDrug



ANESTHETICS



PA


4





2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug








4-Non-PreferredDrug


QL (4 PER 1 DAY)


QL (3 PER 1 DAY)




1-PreferredGeneric

QL (4 PER 1 DAY)


1-PreferredGeneric

QL (3 PER 1 DAY)




5





1-PreferredGeneric








ANTIBACTERIALS



4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug







6




4-Non-PreferredDrug










2-Generic



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug





7



Drug



4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic





2-Generic


4-Non-PreferredDrug


2-Generic







8




4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug



PA QL (3 PER 1 DAY)




4-Non-PreferredDrug


4-Non-PreferredDrug



4-Non-PreferredDrug




4-Non-PreferredDrug


9



4-Non-PreferredDrug





4-Non-PreferredDrug


4-Non-PreferredDrug




4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic





10




Drug





4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug






11



Drug



4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug



2-Generic




Drug


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


2-Generic


12



5-Specialty



4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug


Drug


2-Generic



4-Non-PreferredDrug



2-Generic


4-Non-PreferredDrug


13



Drug




4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug




SSD 2-Generic


4-Non-PreferredDrug



2-Generic


4-Non-PreferredDrug





14



2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug


morgidox 2-Generic


ANTICONVULSANTS







2-Generic


4-Non-PreferredDrug



roweepra 2-Generic


15










Drug


3-Preferred Brand



4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug


16



3-Preferred Brand


primidone 2-Generic





2-Generic






4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


2-Generic


17



4-Non-PreferredDrug




3-Preferred Brand


4-Non-PreferredDrug





2-Generic



2-Generic



4-Non-PreferredDrug







18



ANTIDEMENTIA AGENTS



3-Preferred Brand




4-Non-PreferredDrug


2-Generic


ANTIDEPRESSANTS


2-Generic


2-Generic





19









1-PreferredGeneric


3-Preferred Brand



1-PreferredGeneric


3-Preferred Brand


ST


2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic




20



2-Generic


4-Non-PreferredDrug



1-PreferredGeneric



ST


2-Generic


4-Non-PreferredDrug

QL (1 PER 1 DAY)


ST


amoxapine 2-Generic






2-Generic


21



Drug


ANTIEMETICS


Drug


2-Generic


2-Generic






4-Non-PreferredDrug












22



DrugPA




QL (2 PER 1 DAY)


4-Non-PreferredDrug


2-Generic



3-Preferred Brand



ANTIFUNGALS










3-Preferred Brand





3-Preferred Brand


23







3-Preferred Brand


2-Generic


4-Non-PreferredDrug




4-Non-PreferredDrug




4-Non-PreferredDrug






4-Non-PreferredDrug




PA


24




2-Generic



nystop 2-Generic





4-Non-PreferredDrug


4-Non-PreferredDrug

PA

ANTIGOUT AGENTS






ANTIMIGRAINE AGENTS




25


















4-Non-PreferredDrug







4-Non-PreferredDrug



26



ANTIMYCOBACTERIALS




Drug




2-Generic






3-Preferred Brand






27



ANTINEOPLASTICS


4-Non-PreferredDrug









flutamide 2-Generic













28





4-Non-PreferredDrug




LA














4-Non-PreferredDrug


2-Generic




29



























letrozole 2-Generic


30






toposar 2-Generic





















31































32





















ANTIPARASITICS


DrugPA


PA


33




Drug


3-Preferred Brand





2-Generic





4-Non-PreferredDrug





Drug




2-Generic


2-Generic


34




3-Preferred Brand






ST


PA LA




KYNMOBI 5-Specialty


QL (1 PER 1 DAY)


2-Generic


2-Generic


3-Preferred Brand


35




Drug


4-Non-PreferredDrug


2-Generic


Drug


ANTIPSYCHOTICS


4-Non-PreferredDrug



3-Preferred Brand


4-Non-PreferredDrug



4-Non-PreferredDrug


4-Non-PreferredDrug


36





pimozide 2-Generic







4-Non-PreferredDrug


2-Generic















37






2-Generic


3-Preferred Brand







5-Specialty



4-Non-PreferredDrug


2-Generic







38





4-Non-PreferredDrug


3-Preferred Brand




2-Generic


3-Preferred Brand


4-Non-PreferredDrug


ANTIVIRALS







39




Drug





VEMLIDY 5-Specialty





5-Specialty LA

pegasys 5-Specialty



3-Preferred Brand


GENVOYA 5-Specialty


5-Specialty


3-Preferred Brand



40




5-Specialty





EDURANT 5-Specialty

efavirenz 2-Generic


5-Specialty


5-Specialty




4-Non-PreferredDrug


ODEFSEY 5-Specialty








41






5-Specialty



4-Non-PreferredDrug



stavudine 2-Generic





5-Specialty


2-Generic


Drug

DOVATO 5-Specialty

FUZEON 5-Specialty

JULUCA 5-Specialty

RUKOBIA 5-Specialty


5-Specialty



42



Drug

TRIUMEQ 5-Specialty



5-Specialty



EVOTAZ 5-Specialty








3-Preferred Brand



5-Specialty


3-Preferred Brand



SYMTUZA 5-Specialty



43




3-Preferred Brand





2-Generic


4-Non-PreferredDrug






ANXIOLYTICS



3-Preferred Brand


4-Non-PreferredDrug


3-Preferred Brand


44



2-Generic



2-Generic


2-Generic



BIPOLAR AGENTS


2-Generic






4-Non-PreferredDrug

PA


4-Non-PreferredDrug

PA





45



DrugST



2-Generic




PA


ST


ST


ST






PA


PA


PA


4-Non-PreferredDrug


1-PreferredGeneric


1-PreferredGeneric


46



Drug




PA









ST


ST


PA




PA





ST


47





















humulin n 2-Generic


humulin r 2-Generic






48







4-Non-PreferredDrug


5-Specialty


4-Non-PreferredDrug


4-Non-PreferredDrug


5-Specialty


3-Preferred Brand



4-Non-PreferredDrug


4-Non-PreferredDrug


3-Preferred Brand


49



jantoven 2-Generic







4-Non-PreferredDrug

PA


5-Specialty PA




4-Non-PreferredDrug

PA



granix 5-Specialty

leukine 5-Specialty

MOZOBIL 5-Specialty





50





4-Non-PreferredDrug

PA




4-Non-PreferredDrug

PA



udenyca 5-Specialty

zarxio 5-Specialty



4-Non-PreferredDrug



Drug






51





4-Non-PreferredDrug


1-PreferredGeneric












valsartan 2-Generic


Generic



2-Generic


52



Drug









4-Non-PreferredDrug









3-Preferred Brand


4-Non-PreferredDrug



53



Drug

sorine 2-Generic






2-Generic





2-Generic




1-PreferredGeneric


2-Generic



ST

pindolol 2-Generic


54



2-Generic


4-Non-PreferredDrug


Generic


cartia xt 2-Generic

dilt-xr 2-Generic


2-Generic


4-Non-PreferredDrug





4-Non-PreferredDrug


55



2-Generic


taztia xt 2-Generic



4-Non-PreferredDrug


2-Generic


Drug




2-Generic



3-Preferred Brand



2-Generic


2-Generic


4-Non-PreferredDrug



56



4-Non-PreferredDrug

PA

digitek 2-Generic

digox 2-Generic


2-Generic


4-Non-PreferredDrug









2-Generic


PA


4-Non-PreferredDrug


2-Generic








57



Drug





PA




4-Non-PreferredDrug




3-Preferred Brand



1-PreferredGeneric


4-Non-PreferredDrug

torsemide 2-Generic





58



Drug



2-Generic




2-Generic



2-Generic





Generic







59




4-Non-PreferredDrug


4-Non-PreferredDrug



4-Non-PreferredDrug

ezetimibe 2-Generic





PA


2-Generic






triklo 2-Generic



2-Generic

minoxidil 2-Generic


60




3-Preferred Brand


2-Generic

minitran 2-Generic



2-Generic






2-Generic


4-Non-PreferredDrug




QL (1 PER 1 DAY)



61




Drug



QL (1 PER 1 DAY)


2-Generic


4-Non-PreferredDrug

QL (1 PER 1 DAY)


2-Generic



4-Non-PreferredDrug

QL (1 PER 1 DAY)


2-Generic


QL (6 PER 1 DAY)



QL (2 PER 1 DAY)


QL (1 PER 1 DAY)


62











riluzole 2-Generic





Drug


2-Generic


2-Generic


4-Non-PreferredDrug

QL (2 PER 1 DAY)




avonex 5-Specialty


63







5-Specialty


GILENYA 5-Specialty


glatopa 5-Specialty




5-Specialty LA




rebif 5-Specialty



ZEPOSIA 5-Specialty



2-Generic

paroex 2-Generic

periogard 2-Generic


64



4-Non-PreferredDrug




Drug


4-Non-PreferredDrug


4-Non-PreferredDrug







4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


65



Drug







3-Preferred Brand









4-Non-PreferredDrug


ST




3-Preferred Brand


4-Non-PreferredDrug




66



DrugST













ST


5-Specialty PA


4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug




67





4-Non-PreferredDrug







4-Non-PreferredDrug




4-Non-PreferredDrug







2-Generic





68














4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug





69



Drug


2-Generic






5-Specialty PA LA


5-Specialty PA

kionex 2-Generic



2-Generic





Drug


3-Preferred Brand


5-Specialty




70



5-Specialty





2-Generic

o-cal fa 2-Generic






zingiber 2-Generic



2-Generic


2-Generic






71



3-Preferred Brand



4-Non-PreferredDrug





PYLERA 5-Specialty


5-Specialty PA


5-Specialty PA




3-Preferred Brand





2-Generic



2-Generic


72




Drug






enulose 2-Generic




generlac 2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug



2-Generic





73





2-Generic


DrugST


4-Non-PreferredDrug

ST


2-Generic


2-Generic


4-Non-PreferredDrug

ST


2-Generic


2-Generic


4-Non-PreferredDrug









74




LA









5-Specialty LA





5-Specialty PA LA





5-Specialty PA







75



3-Preferred Brand


2-Generic




















76





4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug



3-Preferred Brand


4-Non-PreferredDrug


4-Non-PreferredDrug


3-Preferred Brand




2-Generic


4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug



77




decadron 2-Generic


3-Preferred Brand



4-Non-PreferredDrug


2-Generic


3-Preferred Brand


4-Non-PreferredDrug


4-Non-PreferredDrug



5-Specialty PA LA






3-Preferred Brand


3-Preferred Brand


78





2-Generic



4-Non-PreferredDrug


2-Generic


3-Preferred Brand


4-Non-PreferredDrug






2-Generic


3-Preferred Brand




2-Generic



79




4-Non-PreferredDrug


2-Generic


2-Generic





3-Preferred Brand


2-Generic


3-Preferred Brand

triderm 2-Generic



2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


80





5-Specialty PA


PA


PA

STIMATE 5-Specialty





DrugPA



4-Non-PreferredDrug

PA


4-Non-PreferredDrug




altavera 2-Generic


81




amethyst 2-Generic

apri 2-Generic

aranelle 2-Generic

aubra 2-Generic

aubra eq 2-Generic





aviane 2-Generic


azurette 2-Generic

balziva 2-Generic

bekyree 2-Generic



briellyn 2-Generic

caziant 2-Generic





cryselle 2-Generic


82



cyred 2-Generic

cyred eq 2-Generic

dasetta 2-Generic



2-Generic

dolishale 2-Generic


elinest 2-Generic


emoquette 2-Generic

enpresse 2-Generic

enskyce 2-Generic

estarylla 2-Generic


4-Non-PreferredDrug


2-Generic






83





falmina 2-Generic


femynor 2-Generic



GIANVI 2-Generic

hailey 2-Generic


hailey fe 2-Generic

iclevia 2-Generic

introvale 2-Generic

isibloom 2-Generic

jasmiel 2-Generic


JOLESSA 2-Generic

juleber 2-Generic



junel fe 2-Generic




84



kariva 2-Generic



kurvelo 2-Generic




larin fe 2-Generic

larissia 2-Generic

LEENA 2-Generic

lessina 2-Generic

levonest 2-Generic


levora-28 2-Generic

lillow 2-Generic



loryna 2-Generic


lutera 2-Generic


marlissa 2-Generic




85



Drug






mili 2-Generic



necon 2-Generic

nikki 2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug


nortrel 2-Generic

nylia 2-Generic

nymyo 2-Generic

OCELLA 2-Generic


86



orsythia 2-Generic

philith 2-Generic

pimtrea 2-Generic

pirmella 2-Generic

portia 2-Generic


3-Preferred Brand



previfem 2-Generic

reclipsen 2-Generic

setlakin 2-Generic

simliya 2-Generic

sprintec 2-Generic

sronyx 2-Generic

syeda 2-Generic


tarina fe 2-Generic








87







tri-mili 2-Generic

tri-nymyo 2-Generic






TYBLUME 2-Generic

velivet 2-Generic

vestura 2-Generic

vienva 2-Generic

viorele 2-Generic

volnea 2-Generic

vyfemla 2-Generic

vylibra 2-Generic

wera 2-Generic

xulane 2-Generic


zafemy 2-Generic

zarah 2-Generic




88




Drug


deblitane 2-Generic



errin 2-Generic

heather 2-Generic

incassia 2-Generic

jencycla 2-Generic

lyleq 2-Generic

lyza 2-Generic


4-Non-PreferredDrug


2-Generic


2-Generic


NORA-BE 2-Generic



norlyda 2-Generic



89



tulana 2-Generic


Drug




Drug




4-Non-PreferredDrug


2-Generic



2-Generic






90



Drug










5-Specialty


PA











91
















4-Non-PreferredDrug



4-Non-PreferredDrug



5-Specialty PA








4-Non-PreferredDrug



92














2-Generic


2-Generic








5-Specialty PA



4-Non-PreferredDrug






4-Non-PreferredDrug



93










5-Specialty PA










5-Specialty PA LA







94








PA



PA


PA LA



PA











3-Preferred Brand





95






























96







4-Non-PreferredDrug



PENTASA 5-Specialty




colocort 2-Generic









2-Generic


97



4-Non-PreferredDrug














4-Non-PreferredDrug





4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug




2-Generic


4-Non-PreferredDrug


98



xgeva 5-Specialty


4-Non-PreferredDrug



4-Non-PreferredDrug


4-Non-PreferredDrug









4-Non-PreferredDrug


2-Generic


2-Generic


99



2-Generic


2-Generic


2-Generic


2-Generic


2-Generic


2-Generic

OPHTHALMIC AGENTS


Drug









100



Drug



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug







4-Non-PreferredDrug






Drug


101











3-Preferred Brand















3-Preferred Brand


102



Drug



2-Generic

















3-Preferred Brand


103





1-PreferredGeneric


4-Non-PreferredDrug






ST


OTIC AGENTS






4-Non-PreferredDrug




104



3-Preferred Brand



4-Non-PreferredDrug






2-Generic


3-Preferred Brand






2-Generic



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


105



Drug






2-Generic








4-Non-PreferredDrug











2-Generic


106



Drug



4-Non-PreferredDrug








4-Non-PreferredDrug














4-Non-PreferredDrug



107




DrugPA


2-Generic










5-Specialty PA LA









108






2-Generic








5-Specialty PA LA




2-Generic


2-Generic




2-Generic



109




2-Generic


Drug





PA QL (1 PER 1 DAY)




MISCELLANEOUS




110






ABELCET 23

ABILIFY MAINTENA 37

ABILIFY MYCITE 37



acarbose 45

accutane 65

acebutolol hcl 54


acetazolamide 58

acetic acid 104

acetylcysteine 108

acitretin 65

acthib 95

actimmune 95

acyclovir 44

acyclovir sodium 44

adacel tdap 95

adapalene 65


ADEMPAS 108

ADVAIR DISKUS 108

ADVAIR HFA 108

AEMCOLO 7

AFINITOR 31

AFINITOR DISPERZ 31

afirmelle 81


ak-poly-bac 100

AKYNZEO 22

albendazole 33







ALECENSA 31


alfuzosin hcl 76


allopurinol 25





ALOMIDE 101

alosetron hcl 73

ALPHAGAN P 103

alprazolam 44

ALREX 102

altavera 81

ALTRENO 65

ALUNBRIG 29

alyacen 82

alyq 108

amabelz 82

amantadine hcl 35

AMBISOME 23

ambrisentan 108

amcinonide 77

amethyst 82


amiloride hcl 58


AMINOSYN II 68

amiodarone hcl 53

AMITIZA 73







111

ammonium lactate 65

amnesteem 65

amoxapine 21

amoxicillin 11


amphotericin b 23




ANADROL-50 81

anagrelide hcl 50

anastrozole 30

ANDRODERM 81

ANORO ELLIPTA 108

anusol-hc 97

APOKYN 35


aprepitant 22

apri 82

APTIOM 18

APTIVUS 43

aralast np 74

aranelle 82

aranesp 50

arcalyst 95

aripiprazole 37

ARISTADA 37

ARISTADA INITIO 37

armodafinil 110

armour thyroid 90

ARNUITY ELLIPTA 104

arsenic trioxide 29



ASMANEX 105

ASMANEX HFA 105


ASTAGRAF XL 92


atenolol 54


atomoxetine hcl 62


atovaquone 34



ATROVENT HFA 106

AUBAGIO 63

aubra 82

aubra eq 82

aurovela 82

aurovela 24 fe 82

aurovela fe 82

AURYXIA 70

AUSTEDO 63

AUVI-Q 106

aviane 82

avidoxy 14

AVITA 65

avonex 63

avonex pen 64

AVYCAZ 9

ayuna 82

AYVAKIT 29

AZASITE 12

azathioprine 92


azelaic acid 65

azelastine hcl 102

azithromycin 12

aztreonam 11

azurette 82

Bbacitracin 7


baclofen 39


BALVERSA 29

balziva 82

BAQSIMI 48

BARACLUDE 40

112


bekyree 82

BELBUCA 2

benazepril hcl 52


benlysta 95

BENZNIDAZOLE 34


beser 77




betaseron 64

betaxolol hcl 54


BETIMOL 103

bexarotene 33

bexsero 95

bicalutamide 28

BICILLIN C-R 11

BICILLIN L-A 12

BIKTARVY 40

bimatoprost 104

BINOSTO 98



bivigam 94

BLEPHAMIDE 100

blephamide sop 100

blisovi 24 fe 82

blisovi fe 82


boostrix tdap 95

bosentan 108

BOSULIF 31

BRAFTOVI 31

BREO ELLIPTA 108

briellyn 82

BRILINTA 51


brinzolamide 103

BRIVIACT 15



BRUKINSA 29

budesonide 97

bumetanide 58

buprenorphine 2

buprenorphine hcl 2


bupropion hcl 6

buspirone hcl 44





BYDUREON BCISE 45

BYDUREON PEN 45

Ccabergoline 91

cablivi 50

CABOMETYX 31

cafergot 26

calcipotriene 65


CALCITRIOL 65

calcitriol 98

calcium acetate 70

CALQUENCE 31

camila 89



CAPASTAT SULFATE 27

CAPLYTA 37

CAPRELSA 31

captopril 52


CARBAGLU 74

carbamazepine 18

carbidopa 36


113


CARDIZEM LA 55

carteolol hcl 103

cartia xt 55

carvedilol 54



cataflam 1

CAYSTON 107

caziant 82

cefaclor 9

cefadroxil 9

cefazolin sodium 9

cefdinir 9

cefepime hcl 9


cefixime 10



cefoxitin sodium 10


cefprozil 10

ceftazidime 10





celecoxib 1

CELONTIN 16

cephalexin 10

CERDELGA 74

CHANTIX 6

charlotte 24 fe 82

chateal 82

chateal eq 82

CHEMET 70

chenodal 71





chlorthalidone 59

CHOLBAM 74



ciclodan 23

ciclopirox 23


cilostazol 51

CIMDUO 42

cimetidine 72

cimetidine hcl 72

cinacalcet hcl 98

cinryze 92

ciprofloxacin 13





claravis 65

clarithromycin 12


cleocin phosphate 7

clindacin etz 7

clindacin p 7

clindamycin hcl 7




CHLORIDE 7



CLINOLIPID 68

clobazam 16



clodan 77

clomipramine hcl 21

clonazepam 44


mgday patch) 52

clonidine hcl 52

114



clotrimazole 23


clovique 70

clozapine 39

COARTEM 34


codeine sulfate 3

colchicine 25

colesevelam hcl 60

colestipol hcl 60


colocort 97

COMBIGAN 103

COMBIPATCH 82


COMETRIQ 31

COMPLERA 41

compro 22

concept ob 71

constulose 73

COPAXONE 64

COPIKTRA 29

CORLANOR 57

cormax 78


CORTISPORIN 66


cosentyx pen 66


cosentyx syringe 66

COTELLIC 31

creon 74

CRESEMBA 24

CRIXIVAN 43

cromolyn sodium 71

cryselle 82

cyclafem 83


cyclophosphamide 28

cycloserine 27

CYCLOSET 45

cyclosporine 92



cyred 83

cyred eq 83

cystadane 75

CYSTADROPS 100

CYSTAGON 75

CYSTARAN 100

Ddalfampridine 64

DALIRESP 108

danazol 81


dapsone 27

daptacel dtap 95

daptomycin 7

dasetta 83

DAURISMO 31

DAYTRANA 62

deblitane 89

decadron 78

deferasirox 70

DELSTRIGO 41


DEPO-PROVERA 89


DESCOVY 42

desipramine hcl 21





desonide 78

desoximetasone 78


dexamethasone 78


115


DEXILANT 74



aspartate 61










DIACOMIT 15

DIASTAT 16

DIASTAT ACUDIAL 16

DIAZEPAM 16

diazepam 45

diazoxide 48


diclofenac sodium 1



dicyclomine hcl 71

didanosine 42

DIFICID 13


diflunisal 1

difluprednate 102

digitek 57

digox 57

digoxin 57


dilantin 18

dilt-xr 55

diltiazem hcl 55


DIPENTUM 97




disulfiram 5


dofetilide 53

dolishale 83

donepezil hcl 19

DOPTELET 50

dorzolamide hcl 103



dotti 83

DOVATO 42


doxepin hcl 44

doxercalciferol 98

doxy 100 14




dronabinol 23

DROXIA 29

droxidopa 52

DUAVEE 90

DULERA 109

duloxetine hcl 63

dupixent pen 66

dupixent syringe 66

dutasteride 76


EDURANT 41

efavirenz 41



egrifta sv 81

ELIGARD 91

elinest 83

ELIQUIS 49

ELLA 89

ELMIRON 76

116

eluryng 83

EMCYT 28

EMEND 23

EMFLAZA 78

emgality pen 25

emgality syringe 26

emoquette 83

EMSAM 20

emtricitabine 42


EMTRIVA 42

emverm 33



enbrel 92

enbrel mini 92

enbrel sureclick 92

endocet 3

engerix-b adult 95



enpresse 83

enskyce 83

enspryng 94

entacapone 35

entecavir 40

ENTRESTO 57

enulose 73

EPIDIOLEX 15

epifoam 66

epinastine hcl 102

epinephrine 106

epitol 18

EPIVIR HBV 40

eplerenone 58

epogen 50



ERIVEDGE 31

ERLEADA 28

erlotinib hcl 31

errin 89

ertapenem sodium 11

ery 13







ESBRIET 108



estarylla 83

estradiol 83



ESTRING 83

eszopiclone 109

ethacrynic acid 58

ethambutol hcl 27


ethosuximide 16



etodolac 1


etoposide 31

etravirine 41

EUTHYROX 90

everolimus 31

EVOTAZ 43

EVRYSDI 75

exemestane 30

extavia 64

ezetimibe 60


Ffalmina 84

famciclovir 44

famotidine 72

117

famotidinepf 72

FANAPT 37

FARXIGA 46

FARYDAK 31

fasenra pen 109

febuxostat 25

felbamate 17

felodipine 55

FEMRING 84

femynor 84

fenofibrate 59



FENOFIBRIC ACID 59


fentanyl 2

fentanyl citrate 3

FETZIMA 20

FINACEA 66

finasteride 76

FINTEPLA 15

FIRDAPSE 63

FIRMAGON 91

FIRVANQ 8

FLAREX 102

flavoxate hcl 75

flebogamma dif 94


FLOVENT DISKUS 105

FLOVENT HFA 105

fluconazole 24


flucytosine 24


flunisolide 105




fluocinonide 78


FLUOROMETHOLONE 102

fluorouracil 29

FLUOROURACIL 66

fluoxetine hcl 20


fluphenazine hcl 36

flurbiprofen 1


flutamide 28



XINAFOATE 109



FML FORTE 102

FML SOP 102

folivane-ob 71








FOSRENOL 70

FOTIVDA 31

FRAGMIN 49


fulphila 50

furosemide 58

FUZEON 42

fyavolv 84

FYCOMPA 17

Ggabapentin 16

GALAFOLD 75

galantamine hbr 19

gammagard liquid 94

gammagard s-d 94

gammaked 94

gammaplex 94

118

gamunex-c 94

gardasil 9 95

gatifloxacin 13

GATTEX 72

gauze bandage 99

gavilyte-c 73

gavilyte-g 73

gavilyte-n 73

GAVRETO 29

gemfibrozil 59

gemmily 84

generlac 73

gengraf 92

gentak 6




GENVOYA 40

GIANVI 84

GILENYA 64

GILOTRIF 31

glassia 75


glatopa 64

glimepiride 46

glipizide 46


GLUCAGEN 48


glycopyrrolate 71

glydo 4

GLYXAMBI 46

granisetron hcl 23

granix 50

grastek 95



guanfacine hcl 62

GUANIDINE HCL 26





Hhaegarda 92

hailey 84

hailey 24 fe 84

hailey fe 84


haloperidol 36



havrix 95

heather 89



CHLORIDE 49


WATER 49


HETLIOZ 110

HETLIOZ LQ 110

hiberix 95

humalog 48








humira 93

humira pen 93



humira(cf) 93


humira(cf) pen 93




119

humulin 70-30 48


humulin n 48


humulin r 48

humulin r u-500 48


hydralazine hcl 60





hydrocortisone 79





hydromorphone hcl 4



hydroxyurea 29

hydroxyzine hcl 105



IBRANCE 32

ibu 1

ibuprofen 1


iclevia 84

ICLUSIG 32

icosapent ethyl 60

IDHIFA 29

ILEVRO 102


IMBRUVICA 32


imipramine hcl 21


imiquimod 66


INBRIJA 35

incassia 89

increlex 81

INCRUSE ELLIPTA 106

indapamide 59

indomethacin 1

infanrix dtap 95

INGREZZA 63


INLYTA 32

INQOVI 29

INREBIC 29


insulin syringes 99

INTELENCE 41

INTRALIPID 68

intron a 40

introvale 84

INVEGA SUSTENNA 37

INVEGA TRINZA 38

INVELTYS 102

INVIRASE 43

INVOKAMET 46

INVOKAMET XR 46

INVOKANA 46

ipol 96



irbesartan 52


IRESSA 32

ISENTRESS 40

ISENTRESS HD 40

isibloom 84

isoniazid 27



isotretinoin 66

isradipine 55

ISTURISA 79

120

itraconazole 24

ivermectin 34

ixiaro 96

JJAKAFI 32

jantoven 50

JANUMET 46

JANUMET XR 46

JANUVIA 46

JARDIANCE 46

jasmiel 84

jencycla 89

JENTADUETO 46

JENTADUETO XR 46

jinteli 84

JOLESSA 84

juleber 84

JULUCA 42

junel 84

junel fe 84

junel fe 24 84

JUXTAPID 60

JYNARQUE 70


kaitlib fe 84

kalliga 85

KALYDECO 107

kariva 85

kelnor 1-35 85

kelnor 1-50 85

kesimpta pen 64

ketoconazole 24

ketodan 24

ketoprofen 1



kinrix 96

kionex 70

KISQALI 32


KLISYRI 66

KLOR-CON 10 68

KLOR-CON 8 68

klor-con m10 68

klor-con m15 69

klor-con m20 69

KLOXXADO 6

KOMBIGLYZE XR 46

KORLYM 79

KOSELUGO 32

kurvelo 85

KYNMOBI 35

Llabetalol hcl 54

LACRISERT 100

lactulose 73

lamivudine 40


lamotrigine 17

lansoprazole 74



lantus 48

lantus solostar 48


larin 85

larin 24 fe 85

larin fe 85

larissia 85

latanoprost 104

LATUDA 38


LEENA 85

leflunomide 95

LENVIMA 32

lessina 85

letrozole 30


121

LEUKERAN 28

leukine 50




levetiracetam 15


LEVO-T 90

levobunolol hcl 103

LEVOCARNITINE 69



levofloxacin 13


levonest 85


levora-28 85



LEVOXYL 90

LEXIVA 43

lidocaine 4

lidocaine hcl 5

lidocaine hclpf 5


lillow 85

lindane 34

linezolid 8


LINZESS 73


lisinopril 53



LITHIUM CITRATE 45

lo-zumandimine 85

LONSURF 29

loperamide hcl 72


LOPREEZA 85

lorazepam 45


LORBRENA 31

lorcet 4

lorcet hd 4

loryna 85



LOTEMAX 102

LOTEMAX SM 102


lovastatin 59

low-ogestrel 85


LUBIPROSTONE 73

LUCEMYRA 5

LUMAKRAS 32

LUMIGAN 104

LUPANETA PACK 91

LUPKYNIS 93

LUPRON DEPOT 91

LUPRON DEPOT-PED 91

lutera 85

lyleq 89

lyllana 85

LYNPARZA 32

LYSODREN 29

lyza 89



maprotiline hcl 20

marlissa 85

marplan 20

MATULANE 28

matzim la 55

MAVENCLAD 64

MAYZENT 64

meclizine hcl 22



122

mefloquine hcl 34


MEKINIST 32

MEKTOVI 32

melodetta 24 fe 85

meloxicam 1

memantine hcl 19

menactra 96

menest 85

menquadfi 96


mercaptopurine 29

meropenem 11


merzee 86

mesalamine 97


MESNEX 33

metadate er 62


metformin hcl 46




24h) 46

methadone hcl 2

methazolamide 58


methergine 99

methimazole 91

methocarbamol 109



methoxsalen 66








metolazone 59




metronidazole 8


mexiletine hcl 53

mibelas 24 fe 86



microgestin 86


microgestin fe 86

midodrine hcl 52

migergot 26

miglitol 47

miglustat 75

mili 86

mimvey 86

minitran 61

minocycline hcl 15

minoxidil 60

mirtazapine 19

misoprostol 74

mitoxantrone hcl 30

modafinil 110

moexipril hcl 53

molindone hcl 37


mondoxyne nl 15

mono-linyah 86


morgidox 15

morphine sulfate 2

MOVANTIK 72

moxifloxacin hcl 14




MOZOBIL 50

MULTAQ 53

123


acid 71


myalept 72

MYCAPSSA 91



myorisan 66

MYRBETRIQ 76

MYTESI 72

Nnabumetone 1

nadolol 54

nafcillin sodium 12

naftifine hcl 24

NAFTIN 24

naloxone hcl 6

naltrexone hcl 5

NAMENDA XR 19

naproxen 1

naproxen sodium 2

naratriptan hcl 26

NARCAN 6

NATACYN 24

nateglinide 47

natpara 98

NAYZILAM 15

nebivolol hcl 54

necon 86

nefazodone hcl 20

neo-polycin 101

neo-polycin hc 101

neomycin sulfate 6


bhydrocortisone 101






NERLYNX 32

neulasta 50

neulasta onpro 50

neupogen 50

NEUPRO 35

nevirapine 41

NEXAVAR 32

NEXIUM 74

NEXLETOL 57

NEXLIZET 60

niacin 60

nicardipine hcl 55

NICOTROL 6

NICOTROL NS 6

nifedipine 56

nikki 86

nilutamide 28

nimodipine 56

NINLARO 30

nitazoxanide 34

nitisinone 75

NITRO-DUR 61

nitrofurantoin 8



nitroglycerin 61

NITROSTAT 61

NITYR 75

nivestym 51

nizatidine 72

NORA-BE 89

norethindrone 89




fumarate 86



norlyda 89

NORPACE CR 53

nortrel 86

124


NORVIR 43

NOURIANZ 35

NOXAFIL 24

np thyroid 90

NUBEQA 28

nucala 109

NUEDEXTA 63

NUPLAZID 38

NUTRILIPID 69

nyamyc 25

nylia 86

nymyo 86

nystatin 25


nystop 25

nyvepria 51

Oo-cal fa 71

ob complete 71

OCALIVA 75

OCELLA 86

octagam 94


odactra 95

ODEFSEY 41

ODOMZO 32

OFEV 108

ofloxacin 14

ogestrel 87

olanzapine 38






olopatadine hcl 102


OMEGAVEN 69

omeprazole 74

omnitrope 81

ondansetron hcl 23



ONGENTYS 35

ONGLYZA 47

ONUREG 30

OPSUMIT 108

oralair 95

orencia 93


ORFADIN 75

ORGOVYX 91

ORIAHNN 81

ORILISSA 81

ORKAMBI 107

ORLADEYO 92

orsythia 87


OSMOLEX ER 35

OTEZLA 95

oxacillin sodium 12


DEXTROSE 12

oxandrolone 81

oxazepam 45

oxcarbazepine 18

oxervate 101



oxycodone hcl 4



oxymorphone hcl 4

OZEMPIC 47

Ppaliperidone 38

palynziq 75


PANRETIN 33

125


panzyga 94

paricalcitol 98

paroex 64


paroxetine hcl 21

paser 27

PAXIL 21

PAZEO 102

pediarix 96

pedvaxhib 96


chloride 73


sodvit c 73

PEGANONE 18

pegasys 40

pegintron 40

PEMAZYRE 32




penicillamine 76








PENTASA 97

pentoxifylline 57

PERFOROMIST 107


periogard 64

permethrin 34

perphenazine 22


PERSERIS 38

pfizerpen 12


phenobarbital 17


phenytoin 18


philith 87

PHOSLYRA 70


PICATO 66

PIFELTRO 41

pilocarpine hcl 65

pimecrolimus 67

pimozide 37

pimtrea 87

pindolol 54

pioglitazone hcl 47




PIQRAY 31

pirmella 87

piroxicam 2

plegridy 64

plegridy pen 64

plenamine 69

PLENVU 73

podofilox 67

polycin 101



POMALYST 28

portia 87

posaconazole 25



SODIUM CHLORIDE 69


SODIUM CHLORIDE 69


SODIUM CHLORIDE 69


AND 5 DEXTROSE 69

126



PRADAXA 50


prasugrel hcl 51


prazosin hcl 52

PRED MILD 103

PREDNICARBATE 79

prednisolone 80



prednisone 80


pregabalin 63

PREMARIN 87

PREMPHASE 87

PREMPRO 87


prenate am 71

prenate chewable 71

prevalite 60

previfem 87

PREVYMIS 39

PREZCOBIX 43

PREZISTA 43

PRIFTIN 27


primidone 17

privigen 94


probenecid 25


prochlorperazine 22



procrit 51

procto-med hc 97

proctofoam-hc 67

proctosol-hc 97

proctozone-hc 97

PROCYSBI 75


PROGRAF 93

prolastin c 75

PROLENSA 103

prolia 98

PROMACTA 51

promethazine hcl 22

propafenone hcl 53

propranolol hcl 55


propylthiouracil 92

proquad 96


psorcon 80

pulmozyme 107

purefe ob plus 71

PURIXAN 29

PYLERA 72

pyrazinamide 27


pyrimethamine 34

QQINLOCK 30



quinapril hcl 53




QVAR REDIHALER 105

Rrabavert 96


ragwitek 95

raloxifene hcl 90

ramipril 53

ranolazine 57


127

RAVICTI 75

rebif 64

rebif rebidose 64

reclipsen 87

recombivax hb 96

RECTIV 67

regranex 67

RELENZA 44

relexxii 62

RELISTOR 72


RENACIDIN 76

repaglinide 47




repatha syringe 60

RESTASIS 101


retacrit 51

RETEVMO 30

RETROVIR 42

REVLIMID 28

REXULTI 38

REYATAZ 43

REZUROCK 93

RHOPRESSA 104

ribavirin 40

rifabutin 27

rifampin 27

RIFATER 27

riluzole 63

rimantadine hcl 44


RINVOQ 93


RISPERDAL CONSTA 38

risperidone 38

ritonavir 43

rivastigmine 19



ropinirole hcl 35

rosadan 67


rotarix 96

rotateq 96

roweepra 15

roweepra xr 16

ROZLYTREK 30

RUBRACA 30

rufinamide 18

RUKOBIA 42

RUZURGI 63

RYBELSUS 47

RYDAPT 30

Ssajazir 92

SAMSCA 70

santyl 67


SAVAYSA 50

SAVELLA 63

SECUADO 38

SEGLUROMET 47

selegiline hcl 36

selenium sulfide 67

SELZENTRY 42

SEREVENT DISKUS 107

sertraline hcl 21

setlakin 87


sharobel 90

shingrix 96

SIGNIFOR 91


silodosin 76

SILVADENE 14


SIMBRINZA 104

simliya 87

128

simvastatin 59

sirolimus 93

SIRTURO 27

SIVEXTRO 8

skyrizi 67


skyrizi pen 67

SMOFLIPID 69




chloridepeg 73





soltamox 28

SOLU-CORTEF 80

SOMATULINE DEPOT 91

somavert 91

SOOLANTRA 67

sorine 54

sotalol af 54

sotalol hcl 54

SPIRIVA 106


spironolactone 58


sprintec 87

SPRITAM 16

SPRIX 2

SPRYCEL 32

sps 70

sronyx 87

SSD 14

stavudine 42

STEGLATRO 47

STEGLUJAN 47

stelara 67

STIMATE 81


STIVARGA 32


STRIBILD 41

sucraid 75

sucralfate 74



phosphate 101

sulfadiazine 14


SULFAMYLON 8

sulfasalazine 97

sulindac 2


sunitinib malate 32

SUNOSI 110

suprax 10

SUPREP 73

SUTAB 73

syeda 87

sylatron 30

SYMBICORT 109

SYMDEKO 107

SYMPAZAN 17

SYMPROIC 72

SYMTUZA 43

SYNAREL 91

SYNJARDY 47

SYNJARDY XR 47

SYNRIBO 30

SYNTHROID 90


container 100




ml 100


TTABLOID 29

129

TABRECTA 30

tacrolimus 67

tadalafil 76

TAFINLAR 32

TAGRISSO 32

takhzyro 92

TALICIA 72

TALZENNA 32


tamsulosin hcl 76

TARGRETIN 33

tarina 24 fe 87

tarina fe 87


TASIGNA 32

TAVALISSE 51

taysofy 87

tazarotene 67

tazicef 10

TAZORAC 67

taztia xt 56

TAZVERIK 30

TEFLARO 10

TEGSEDI 63

telmisartan 52



temazepam 109

TEMIXYS 43

tenivac 96


TEPMETKO 33

terazosin hcl 52

terbinafine hcl 25


terconazole 25

testosterone 81





tetrabenazine 63

tetracycline hcl 15

THALOMID 28


THIOLA EC 76

thioridazine hcl 37

thiothixene 37

thyroid 90

thyroidpork 91

tiadylt er 56

tiagabine hcl 17

TIBSOVO 30

tigecycline 8

tilia fe 87

timolol maleate 55

tinidazole 8

tiopronin 76

TIVICAY 41

TIVICAY PD 41

tizanidine hcl 39

tobi podhaler 107

TOBRADEX 101

tobramycin 7




TOBREX 7

tolmetin sodium 2


tolvaptan 70

topiramate 17

toposar 31

topotecan hcl 31


torsemide 58


toujeo solostar 49

TOVIAZ 76

TPN ELECTROLYTES 70

TRACLEER 108

TRADJENTA 47

130

tramadol hcl 3


trandolapril 53


tranexamic acid 51


travoprost 104

trazodone hcl 21

TRECATOR 27

TRELEGY ELLIPTA 109

trelstar 91

tremfya 67

tretinoin 33


trexall 94

tri femynor 87

tri-estarylla 87

tri-legest fe 87

tri-linyah 88

tri-lo-estarylla 88

tri-lo-marzia 88

tri-lo-mili 88

tri-lo-sprintec 88

tri-mili 88

tri-nymyo 88

tri-previfem 88

tri-sprintec 88

tri-vylibra 88

tri-vylibra lo 88


triamterene 59


triderm 80

trientine hcl 70


trifluridine 44


TRIKAFTA 107

triklo 60


trimethoprim 9


TRINTELLIX 21

TRIUMEQ 43

trivora-28 88

tropicamide 101


trulicity 47

trumenba 96

truseltiq 33

TUKYSA 30

tulana 90

TURALIO 30

twinrix 96

TYBLUME 88

TYBOST 43

TYMLOS 99

typhim vi 96

Uudenyca 51

UKONIQ 33

UNITHROID 91

UPTRAVI 108

ursodiol 72


VALCHLOR 28


valproic acid 17


valsartan 52


VALTOCO 17

vancomycin hcl 9


(PEG-400 NADA) 9



VANDAZOLE 9

vaqta 96

131


varivax vaccine 96

VARUBI 23

VASCEPA 60

velivet 88

VEMLIDY 40

VENCLEXTA 33


venlafaxine hcl 21

verapamil hcl 56

verquvo 58

VERSACLOZ 39

VERZENIO 33

vestura 88

VIBERZI 73

VICTOZA 2-PAK 47

VICTOZA 3-PAK 47

VIDEX 42

VIDEX EC 42

vienva 88

vigabatrin 17

vigadrone 17

VIIBRYD 21

VIMPAT 18

viorele 88

VIRACEPT 43

VIREAD 42

VITRAKVI 30

VIZIMPRO 30

volnea 88

voriconazole 25

VOSEVI 40

VOTRIENT 33

VRAYLAR 38

VUMERITY 64

vyfemla 88

vylibra 88

VYNDAMAX 58

VYNDAQEL 58

VYVANSE 61

VYZULTA 104

WWAKIX 110

warfarin sodium 50

WELIREG 30

wera 88

XXALKORI 33

XARELTO 50

XATMEP 94

XCOPRI 16

XELJANZ 94

XELJANZ XR 94

XELPROS 104

XERMELO 72

xgeva 99

XIFAXAN 9

XIGDUO XR 47

XOFLUZA 44

xolair 109

XOSPATA 30

XPOVIO 30

XTAMPZA ER 3

XTANDI 28

xulane 88

XYREM 110

XYWAV 110

Yyf-vax 96

YONSA 28

yuvafem 88

Zzafemy 88

zafirlukast 106

zaleplon 110

zarah 88

zarxio 51

ZEJULA 33

132

ZELBORAF 33

zemaira 75

zenatane 67

zenpep 75

zenzedi 61

ZEPOSIA 64

ZERBAXA 11

zidovudine 42

ziextenzo 51

zingiber 71

ziprasidone hcl 39


ZIRGAN 39

zoledronic acid 99


SODIUM CHLORIDE 99


ZOLINZA 30

zolmitriptan 26


zonisamide 16

ZORTRESS 94

zovia 1-35 88

zovia 1-35e 88

zumandimine 89

ZYDELIG 33

ZYKADIA 33

ZYLET 101

133


ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 15


ANTIDEPRESSANTS 19

ANTIEMETICS 22

ANTIFUNGALS 23

ANTIGOUT AGENTS 25




ANTINEOPLASTICS 28

ANTIPARASITICS 33


ANTIPSYCHOTICS 36


ANTIVIRALS 39

ANXIOLYTICS 44

BIPOLAR AGENTS 45




















MISCELLANEOUS 110



OTIC AGENTS 104


134



135






MDC-455

11222021

11222021



formats)













(TTY 711）



1‐800‐603‐2340 (TTY 711) 번으로 전화해 주십시오










Arabic










Persian




(082021) H9047_2021RCGA03_C



ANALGESICS


celecoxib 2-Generic



3-Preferred Brand




4-Non-PreferredDrug



ibu 2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug




meloxicam 2-Generic



2-Generic


1



Drug



piroxicam 2-Generic


sulindac 2-Generic



DrugPA




4-Non-PreferredDrug

PA




4-Non-PreferredDrug

PA QL (2 PER 1 DAY)


PA QL (4 PER 1 DAY)


2-Generic PA





2



3-Preferred Brand


4-Non-PreferredDrug


PA QL (2 PER 1 DAY)


2-Generic



4-Non-PreferredDrug


3-Preferred Brand



4-Non-PreferredDrug


endocet 2-Generic


4-Non-PreferredDrug

PA QL (4 PER 1 DAY)


3-Preferred Brand


2-Generic


2-Generic


3



2-Generic



4-Non-PreferredDrug

lorcet 2-Generic

lorcet hd 2-Generic


2-Generic


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


2-Generic



4-Non-PreferredDrug



ANESTHETICS



PA


4





2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug








4-Non-PreferredDrug


QL (4 PER 1 DAY)


QL (3 PER 1 DAY)




1-PreferredGeneric

QL (4 PER 1 DAY)


1-PreferredGeneric

QL (3 PER 1 DAY)




5





1-PreferredGeneric








ANTIBACTERIALS



4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug







6




4-Non-PreferredDrug










2-Generic



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug





7



Drug



4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic





2-Generic


4-Non-PreferredDrug


2-Generic







8




4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug



PA QL (3 PER 1 DAY)




4-Non-PreferredDrug


4-Non-PreferredDrug



4-Non-PreferredDrug




4-Non-PreferredDrug


9



4-Non-PreferredDrug





4-Non-PreferredDrug


4-Non-PreferredDrug




4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic





10




Drug





4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug






11



Drug



4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug



2-Generic




Drug


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


2-Generic


12



5-Specialty



4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug


Drug


2-Generic



4-Non-PreferredDrug



2-Generic


4-Non-PreferredDrug


13



Drug




4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug




SSD 2-Generic


4-Non-PreferredDrug



2-Generic


4-Non-PreferredDrug





14



2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug


morgidox 2-Generic


ANTICONVULSANTS







2-Generic


4-Non-PreferredDrug



roweepra 2-Generic


15










Drug


3-Preferred Brand



4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug


16



3-Preferred Brand


primidone 2-Generic





2-Generic






4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


2-Generic


17



4-Non-PreferredDrug




3-Preferred Brand


4-Non-PreferredDrug





2-Generic



2-Generic



4-Non-PreferredDrug







18



ANTIDEMENTIA AGENTS



3-Preferred Brand




4-Non-PreferredDrug


2-Generic


ANTIDEPRESSANTS


2-Generic


2-Generic





19









1-PreferredGeneric


3-Preferred Brand



1-PreferredGeneric


3-Preferred Brand


ST


2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic




20



2-Generic


4-Non-PreferredDrug



1-PreferredGeneric



ST


2-Generic


4-Non-PreferredDrug

QL (1 PER 1 DAY)


ST


amoxapine 2-Generic






2-Generic


21



Drug


ANTIEMETICS


Drug


2-Generic


2-Generic






4-Non-PreferredDrug












22



DrugPA




QL (2 PER 1 DAY)


4-Non-PreferredDrug


2-Generic



3-Preferred Brand



ANTIFUNGALS










3-Preferred Brand





3-Preferred Brand


23







3-Preferred Brand


2-Generic


4-Non-PreferredDrug




4-Non-PreferredDrug




4-Non-PreferredDrug






4-Non-PreferredDrug




PA


24




2-Generic



nystop 2-Generic





4-Non-PreferredDrug


4-Non-PreferredDrug

PA

ANTIGOUT AGENTS






ANTIMIGRAINE AGENTS




25


















4-Non-PreferredDrug







4-Non-PreferredDrug



26



ANTIMYCOBACTERIALS




Drug




2-Generic






3-Preferred Brand






27



ANTINEOPLASTICS


4-Non-PreferredDrug









flutamide 2-Generic













28





4-Non-PreferredDrug




LA














4-Non-PreferredDrug


2-Generic




29



























letrozole 2-Generic


30






toposar 2-Generic





















31































32





















ANTIPARASITICS


DrugPA


PA


33




Drug


3-Preferred Brand





2-Generic





4-Non-PreferredDrug





Drug




2-Generic


2-Generic


34




3-Preferred Brand






ST


PA LA




KYNMOBI 5-Specialty


QL (1 PER 1 DAY)


2-Generic


2-Generic


3-Preferred Brand


35




Drug


4-Non-PreferredDrug


2-Generic


Drug


ANTIPSYCHOTICS


4-Non-PreferredDrug



3-Preferred Brand


4-Non-PreferredDrug



4-Non-PreferredDrug


4-Non-PreferredDrug


36





pimozide 2-Generic







4-Non-PreferredDrug


2-Generic















37






2-Generic


3-Preferred Brand







5-Specialty



4-Non-PreferredDrug


2-Generic







38





4-Non-PreferredDrug


3-Preferred Brand




2-Generic


3-Preferred Brand


4-Non-PreferredDrug


ANTIVIRALS







39




Drug





VEMLIDY 5-Specialty





5-Specialty LA

pegasys 5-Specialty



3-Preferred Brand


GENVOYA 5-Specialty


5-Specialty


3-Preferred Brand



40




5-Specialty





EDURANT 5-Specialty

efavirenz 2-Generic


5-Specialty


5-Specialty




4-Non-PreferredDrug


ODEFSEY 5-Specialty








41






5-Specialty



4-Non-PreferredDrug



stavudine 2-Generic





5-Specialty


2-Generic


Drug

DOVATO 5-Specialty

FUZEON 5-Specialty

JULUCA 5-Specialty

RUKOBIA 5-Specialty


5-Specialty



42



Drug

TRIUMEQ 5-Specialty



5-Specialty



EVOTAZ 5-Specialty








3-Preferred Brand



5-Specialty


3-Preferred Brand



SYMTUZA 5-Specialty



43




3-Preferred Brand





2-Generic


4-Non-PreferredDrug






ANXIOLYTICS



3-Preferred Brand


4-Non-PreferredDrug


3-Preferred Brand


44



2-Generic



2-Generic


2-Generic



BIPOLAR AGENTS


2-Generic






4-Non-PreferredDrug

PA


4-Non-PreferredDrug

PA





45



DrugST



2-Generic




PA


ST


ST


ST






PA


PA


PA


4-Non-PreferredDrug


1-PreferredGeneric


1-PreferredGeneric


46



Drug




PA









ST


ST


PA




PA





ST


47





















humulin n 2-Generic


humulin r 2-Generic






48







4-Non-PreferredDrug


5-Specialty


4-Non-PreferredDrug


4-Non-PreferredDrug


5-Specialty


3-Preferred Brand



4-Non-PreferredDrug


4-Non-PreferredDrug


3-Preferred Brand


49



jantoven 2-Generic







4-Non-PreferredDrug

PA


5-Specialty PA




4-Non-PreferredDrug

PA



granix 5-Specialty

leukine 5-Specialty

MOZOBIL 5-Specialty





50





4-Non-PreferredDrug

PA




4-Non-PreferredDrug

PA



udenyca 5-Specialty

zarxio 5-Specialty



4-Non-PreferredDrug



Drug






51





4-Non-PreferredDrug


1-PreferredGeneric












valsartan 2-Generic


Generic



2-Generic


52



Drug









4-Non-PreferredDrug









3-Preferred Brand


4-Non-PreferredDrug



53



Drug

sorine 2-Generic






2-Generic





2-Generic




1-PreferredGeneric


2-Generic



ST

pindolol 2-Generic


54



2-Generic


4-Non-PreferredDrug


Generic


cartia xt 2-Generic

dilt-xr 2-Generic


2-Generic


4-Non-PreferredDrug





4-Non-PreferredDrug


55



2-Generic


taztia xt 2-Generic



4-Non-PreferredDrug


2-Generic


Drug




2-Generic



3-Preferred Brand



2-Generic


2-Generic


4-Non-PreferredDrug



56



4-Non-PreferredDrug

PA

digitek 2-Generic

digox 2-Generic


2-Generic


4-Non-PreferredDrug









2-Generic


PA


4-Non-PreferredDrug


2-Generic








57



Drug





PA




4-Non-PreferredDrug




3-Preferred Brand



1-PreferredGeneric


4-Non-PreferredDrug

torsemide 2-Generic





58



Drug



2-Generic




2-Generic



2-Generic





Generic







59




4-Non-PreferredDrug


4-Non-PreferredDrug



4-Non-PreferredDrug

ezetimibe 2-Generic





PA


2-Generic






triklo 2-Generic



2-Generic

minoxidil 2-Generic


60




3-Preferred Brand


2-Generic

minitran 2-Generic



2-Generic






2-Generic


4-Non-PreferredDrug




QL (1 PER 1 DAY)



61




Drug



QL (1 PER 1 DAY)


2-Generic


4-Non-PreferredDrug

QL (1 PER 1 DAY)


2-Generic



4-Non-PreferredDrug

QL (1 PER 1 DAY)


2-Generic


QL (6 PER 1 DAY)



QL (2 PER 1 DAY)


QL (1 PER 1 DAY)


62











riluzole 2-Generic





Drug


2-Generic


2-Generic


4-Non-PreferredDrug

QL (2 PER 1 DAY)




avonex 5-Specialty


63







5-Specialty


GILENYA 5-Specialty


glatopa 5-Specialty




5-Specialty LA




rebif 5-Specialty



ZEPOSIA 5-Specialty



2-Generic

paroex 2-Generic

periogard 2-Generic


64



4-Non-PreferredDrug




Drug


4-Non-PreferredDrug


4-Non-PreferredDrug







4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


65



Drug







3-Preferred Brand









4-Non-PreferredDrug


ST




3-Preferred Brand


4-Non-PreferredDrug




66



DrugST













ST


5-Specialty PA


4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug




67





4-Non-PreferredDrug







4-Non-PreferredDrug




4-Non-PreferredDrug







2-Generic





68














4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug





69



Drug


2-Generic






5-Specialty PA LA


5-Specialty PA

kionex 2-Generic



2-Generic





Drug


3-Preferred Brand


5-Specialty




70



5-Specialty





2-Generic

o-cal fa 2-Generic






zingiber 2-Generic



2-Generic


2-Generic






71



3-Preferred Brand



4-Non-PreferredDrug





PYLERA 5-Specialty


5-Specialty PA


5-Specialty PA




3-Preferred Brand





2-Generic



2-Generic


72




Drug






enulose 2-Generic




generlac 2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug



2-Generic





73





2-Generic


DrugST


4-Non-PreferredDrug

ST


2-Generic


2-Generic


4-Non-PreferredDrug

ST


2-Generic


2-Generic


4-Non-PreferredDrug









74




LA









5-Specialty LA





5-Specialty PA LA





5-Specialty PA







75



3-Preferred Brand


2-Generic




















76





4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug



3-Preferred Brand


4-Non-PreferredDrug


4-Non-PreferredDrug


3-Preferred Brand




2-Generic


4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug



77




decadron 2-Generic


3-Preferred Brand



4-Non-PreferredDrug


2-Generic


3-Preferred Brand


4-Non-PreferredDrug


4-Non-PreferredDrug



5-Specialty PA LA






3-Preferred Brand


3-Preferred Brand


78





2-Generic



4-Non-PreferredDrug


2-Generic


3-Preferred Brand


4-Non-PreferredDrug






2-Generic


3-Preferred Brand




2-Generic



79




4-Non-PreferredDrug


2-Generic


2-Generic





3-Preferred Brand


2-Generic


3-Preferred Brand

triderm 2-Generic



2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


80





5-Specialty PA


PA


PA

STIMATE 5-Specialty





DrugPA



4-Non-PreferredDrug

PA


4-Non-PreferredDrug




altavera 2-Generic


81




amethyst 2-Generic

apri 2-Generic

aranelle 2-Generic

aubra 2-Generic

aubra eq 2-Generic





aviane 2-Generic


azurette 2-Generic

balziva 2-Generic

bekyree 2-Generic



briellyn 2-Generic

caziant 2-Generic





cryselle 2-Generic


82



cyred 2-Generic

cyred eq 2-Generic

dasetta 2-Generic



2-Generic

dolishale 2-Generic


elinest 2-Generic


emoquette 2-Generic

enpresse 2-Generic

enskyce 2-Generic

estarylla 2-Generic


4-Non-PreferredDrug


2-Generic






83





falmina 2-Generic


femynor 2-Generic



GIANVI 2-Generic

hailey 2-Generic


hailey fe 2-Generic

iclevia 2-Generic

introvale 2-Generic

isibloom 2-Generic

jasmiel 2-Generic


JOLESSA 2-Generic

juleber 2-Generic



junel fe 2-Generic




84



kariva 2-Generic



kurvelo 2-Generic




larin fe 2-Generic

larissia 2-Generic

LEENA 2-Generic

lessina 2-Generic

levonest 2-Generic


levora-28 2-Generic

lillow 2-Generic



loryna 2-Generic


lutera 2-Generic


marlissa 2-Generic




85



Drug






mili 2-Generic



necon 2-Generic

nikki 2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug


nortrel 2-Generic

nylia 2-Generic

nymyo 2-Generic

OCELLA 2-Generic


86



orsythia 2-Generic

philith 2-Generic

pimtrea 2-Generic

pirmella 2-Generic

portia 2-Generic


3-Preferred Brand



previfem 2-Generic

reclipsen 2-Generic

setlakin 2-Generic

simliya 2-Generic

sprintec 2-Generic

sronyx 2-Generic

syeda 2-Generic


tarina fe 2-Generic








87







tri-mili 2-Generic

tri-nymyo 2-Generic






TYBLUME 2-Generic

velivet 2-Generic

vestura 2-Generic

vienva 2-Generic

viorele 2-Generic

volnea 2-Generic

vyfemla 2-Generic

vylibra 2-Generic

wera 2-Generic

xulane 2-Generic


zafemy 2-Generic

zarah 2-Generic




88




Drug


deblitane 2-Generic



errin 2-Generic

heather 2-Generic

incassia 2-Generic

jencycla 2-Generic

lyleq 2-Generic

lyza 2-Generic


4-Non-PreferredDrug


2-Generic


2-Generic


NORA-BE 2-Generic



norlyda 2-Generic



89



tulana 2-Generic


Drug




Drug




4-Non-PreferredDrug


2-Generic



2-Generic






90



Drug










5-Specialty


PA











91
















4-Non-PreferredDrug



4-Non-PreferredDrug



5-Specialty PA








4-Non-PreferredDrug



92














2-Generic


2-Generic








5-Specialty PA



4-Non-PreferredDrug






4-Non-PreferredDrug



93










5-Specialty PA










5-Specialty PA LA







94








PA



PA


PA LA



PA











3-Preferred Brand





95






























96







4-Non-PreferredDrug



PENTASA 5-Specialty




colocort 2-Generic









2-Generic


97



4-Non-PreferredDrug














4-Non-PreferredDrug





4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug




2-Generic


4-Non-PreferredDrug


98



xgeva 5-Specialty


4-Non-PreferredDrug



4-Non-PreferredDrug


4-Non-PreferredDrug









4-Non-PreferredDrug


2-Generic


2-Generic


99



2-Generic


2-Generic


2-Generic


2-Generic


2-Generic


2-Generic

OPHTHALMIC AGENTS


Drug









100



Drug



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug







4-Non-PreferredDrug






Drug


101











3-Preferred Brand















3-Preferred Brand


102



Drug



2-Generic

















3-Preferred Brand


103





1-PreferredGeneric


4-Non-PreferredDrug






ST


OTIC AGENTS






4-Non-PreferredDrug




104



3-Preferred Brand



4-Non-PreferredDrug






2-Generic


3-Preferred Brand






2-Generic



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


105



Drug






2-Generic








4-Non-PreferredDrug











2-Generic


106



Drug



4-Non-PreferredDrug








4-Non-PreferredDrug














4-Non-PreferredDrug



107




DrugPA


2-Generic










5-Specialty PA LA









108






2-Generic








5-Specialty PA LA




2-Generic


2-Generic




2-Generic



109




2-Generic


Drug





PA QL (1 PER 1 DAY)




MISCELLANEOUS




110






ABELCET 23

ABILIFY MAINTENA 37

ABILIFY MYCITE 37



acarbose 45

accutane 65

acebutolol hcl 54


acetazolamide 58

acetic acid 104

acetylcysteine 108

acitretin 65

acthib 95

actimmune 95

acyclovir 44

acyclovir sodium 44

adacel tdap 95

adapalene 65


ADEMPAS 108

ADVAIR DISKUS 108

ADVAIR HFA 108

AEMCOLO 7

AFINITOR 31

AFINITOR DISPERZ 31

afirmelle 81


ak-poly-bac 100

AKYNZEO 22

albendazole 33







ALECENSA 31


alfuzosin hcl 76


allopurinol 25





ALOMIDE 101

alosetron hcl 73

ALPHAGAN P 103

alprazolam 44

ALREX 102

altavera 81

ALTRENO 65

ALUNBRIG 29

alyacen 82

alyq 108

amabelz 82

amantadine hcl 35

AMBISOME 23

ambrisentan 108

amcinonide 77

amethyst 82


amiloride hcl 58


AMINOSYN II 68

amiodarone hcl 53

AMITIZA 73







111

ammonium lactate 65

amnesteem 65

amoxapine 21

amoxicillin 11


amphotericin b 23




ANADROL-50 81

anagrelide hcl 50

anastrozole 30

ANDRODERM 81

ANORO ELLIPTA 108

anusol-hc 97

APOKYN 35


aprepitant 22

apri 82

APTIOM 18

APTIVUS 43

aralast np 74

aranelle 82

aranesp 50

arcalyst 95

aripiprazole 37

ARISTADA 37

ARISTADA INITIO 37

armodafinil 110

armour thyroid 90

ARNUITY ELLIPTA 104

arsenic trioxide 29



ASMANEX 105

ASMANEX HFA 105


ASTAGRAF XL 92


atenolol 54


atomoxetine hcl 62


atovaquone 34



ATROVENT HFA 106

AUBAGIO 63

aubra 82

aubra eq 82

aurovela 82

aurovela 24 fe 82

aurovela fe 82

AURYXIA 70

AUSTEDO 63

AUVI-Q 106

aviane 82

avidoxy 14

AVITA 65

avonex 63

avonex pen 64

AVYCAZ 9

ayuna 82

AYVAKIT 29

AZASITE 12

azathioprine 92


azelaic acid 65

azelastine hcl 102

azithromycin 12

aztreonam 11

azurette 82

Bbacitracin 7


baclofen 39


BALVERSA 29

balziva 82

BAQSIMI 48

BARACLUDE 40

112


bekyree 82

BELBUCA 2

benazepril hcl 52


benlysta 95

BENZNIDAZOLE 34


beser 77




betaseron 64

betaxolol hcl 54


BETIMOL 103

bexarotene 33

bexsero 95

bicalutamide 28

BICILLIN C-R 11

BICILLIN L-A 12

BIKTARVY 40

bimatoprost 104

BINOSTO 98



bivigam 94

BLEPHAMIDE 100

blephamide sop 100

blisovi 24 fe 82

blisovi fe 82


boostrix tdap 95

bosentan 108

BOSULIF 31

BRAFTOVI 31

BREO ELLIPTA 108

briellyn 82

BRILINTA 51


brinzolamide 103

BRIVIACT 15



BRUKINSA 29

budesonide 97

bumetanide 58

buprenorphine 2

buprenorphine hcl 2


bupropion hcl 6

buspirone hcl 44





BYDUREON BCISE 45

BYDUREON PEN 45

Ccabergoline 91

cablivi 50

CABOMETYX 31

cafergot 26

calcipotriene 65


CALCITRIOL 65

calcitriol 98

calcium acetate 70

CALQUENCE 31

camila 89



CAPASTAT SULFATE 27

CAPLYTA 37

CAPRELSA 31

captopril 52


CARBAGLU 74

carbamazepine 18

carbidopa 36


113


CARDIZEM LA 55

carteolol hcl 103

cartia xt 55

carvedilol 54



cataflam 1

CAYSTON 107

caziant 82

cefaclor 9

cefadroxil 9

cefazolin sodium 9

cefdinir 9

cefepime hcl 9


cefixime 10



cefoxitin sodium 10


cefprozil 10

ceftazidime 10





celecoxib 1

CELONTIN 16

cephalexin 10

CERDELGA 74

CHANTIX 6

charlotte 24 fe 82

chateal 82

chateal eq 82

CHEMET 70

chenodal 71





chlorthalidone 59

CHOLBAM 74



ciclodan 23

ciclopirox 23


cilostazol 51

CIMDUO 42

cimetidine 72

cimetidine hcl 72

cinacalcet hcl 98

cinryze 92

ciprofloxacin 13





claravis 65

clarithromycin 12


cleocin phosphate 7

clindacin etz 7

clindacin p 7

clindamycin hcl 7




CHLORIDE 7



CLINOLIPID 68

clobazam 16



clodan 77

clomipramine hcl 21

clonazepam 44


mgday patch) 52

clonidine hcl 52

114



clotrimazole 23


clovique 70

clozapine 39

COARTEM 34


codeine sulfate 3

colchicine 25

colesevelam hcl 60

colestipol hcl 60


colocort 97

COMBIGAN 103

COMBIPATCH 82


COMETRIQ 31

COMPLERA 41

compro 22

concept ob 71

constulose 73

COPAXONE 64

COPIKTRA 29

CORLANOR 57

cormax 78


CORTISPORIN 66


cosentyx pen 66


cosentyx syringe 66

COTELLIC 31

creon 74

CRESEMBA 24

CRIXIVAN 43

cromolyn sodium 71

cryselle 82

cyclafem 83


cyclophosphamide 28

cycloserine 27

CYCLOSET 45

cyclosporine 92



cyred 83

cyred eq 83

cystadane 75

CYSTADROPS 100

CYSTAGON 75

CYSTARAN 100

Ddalfampridine 64

DALIRESP 108

danazol 81


dapsone 27

daptacel dtap 95

daptomycin 7

dasetta 83

DAURISMO 31

DAYTRANA 62

deblitane 89

decadron 78

deferasirox 70

DELSTRIGO 41


DEPO-PROVERA 89


DESCOVY 42

desipramine hcl 21





desonide 78

desoximetasone 78


dexamethasone 78


115


DEXILANT 74



aspartate 61










DIACOMIT 15

DIASTAT 16

DIASTAT ACUDIAL 16

DIAZEPAM 16

diazepam 45

diazoxide 48


diclofenac sodium 1



dicyclomine hcl 71

didanosine 42

DIFICID 13


diflunisal 1

difluprednate 102

digitek 57

digox 57

digoxin 57


dilantin 18

dilt-xr 55

diltiazem hcl 55


DIPENTUM 97




disulfiram 5


dofetilide 53

dolishale 83

donepezil hcl 19

DOPTELET 50

dorzolamide hcl 103



dotti 83

DOVATO 42


doxepin hcl 44

doxercalciferol 98

doxy 100 14




dronabinol 23

DROXIA 29

droxidopa 52

DUAVEE 90

DULERA 109

duloxetine hcl 63

dupixent pen 66

dupixent syringe 66

dutasteride 76


EDURANT 41

efavirenz 41



egrifta sv 81

ELIGARD 91

elinest 83

ELIQUIS 49

ELLA 89

ELMIRON 76

116

eluryng 83

EMCYT 28

EMEND 23

EMFLAZA 78

emgality pen 25

emgality syringe 26

emoquette 83

EMSAM 20

emtricitabine 42


EMTRIVA 42

emverm 33



enbrel 92

enbrel mini 92

enbrel sureclick 92

endocet 3

engerix-b adult 95



enpresse 83

enskyce 83

enspryng 94

entacapone 35

entecavir 40

ENTRESTO 57

enulose 73

EPIDIOLEX 15

epifoam 66

epinastine hcl 102

epinephrine 106

epitol 18

EPIVIR HBV 40

eplerenone 58

epogen 50



ERIVEDGE 31

ERLEADA 28

erlotinib hcl 31

errin 89

ertapenem sodium 11

ery 13







ESBRIET 108



estarylla 83

estradiol 83



ESTRING 83

eszopiclone 109

ethacrynic acid 58

ethambutol hcl 27


ethosuximide 16



etodolac 1


etoposide 31

etravirine 41

EUTHYROX 90

everolimus 31

EVOTAZ 43

EVRYSDI 75

exemestane 30

extavia 64

ezetimibe 60


Ffalmina 84

famciclovir 44

famotidine 72

117

famotidinepf 72

FANAPT 37

FARXIGA 46

FARYDAK 31

fasenra pen 109

febuxostat 25

felbamate 17

felodipine 55

FEMRING 84

femynor 84

fenofibrate 59



FENOFIBRIC ACID 59


fentanyl 2

fentanyl citrate 3

FETZIMA 20

FINACEA 66

finasteride 76

FINTEPLA 15

FIRDAPSE 63

FIRMAGON 91

FIRVANQ 8

FLAREX 102

flavoxate hcl 75

flebogamma dif 94


FLOVENT DISKUS 105

FLOVENT HFA 105

fluconazole 24


flucytosine 24


flunisolide 105




fluocinonide 78


FLUOROMETHOLONE 102

fluorouracil 29

FLUOROURACIL 66

fluoxetine hcl 20


fluphenazine hcl 36

flurbiprofen 1


flutamide 28



XINAFOATE 109



FML FORTE 102

FML SOP 102

folivane-ob 71








FOSRENOL 70

FOTIVDA 31

FRAGMIN 49


fulphila 50

furosemide 58

FUZEON 42

fyavolv 84

FYCOMPA 17

Ggabapentin 16

GALAFOLD 75

galantamine hbr 19

gammagard liquid 94

gammagard s-d 94

gammaked 94

gammaplex 94

118

gamunex-c 94

gardasil 9 95

gatifloxacin 13

GATTEX 72

gauze bandage 99

gavilyte-c 73

gavilyte-g 73

gavilyte-n 73

GAVRETO 29

gemfibrozil 59

gemmily 84

generlac 73

gengraf 92

gentak 6




GENVOYA 40

GIANVI 84

GILENYA 64

GILOTRIF 31

glassia 75


glatopa 64

glimepiride 46

glipizide 46


GLUCAGEN 48


glycopyrrolate 71

glydo 4

GLYXAMBI 46

granisetron hcl 23

granix 50

grastek 95



guanfacine hcl 62

GUANIDINE HCL 26





Hhaegarda 92

hailey 84

hailey 24 fe 84

hailey fe 84


haloperidol 36



havrix 95

heather 89



CHLORIDE 49


WATER 49


HETLIOZ 110

HETLIOZ LQ 110

hiberix 95

humalog 48








humira 93

humira pen 93



humira(cf) 93


humira(cf) pen 93




119

humulin 70-30 48


humulin n 48


humulin r 48

humulin r u-500 48


hydralazine hcl 60





hydrocortisone 79





hydromorphone hcl 4



hydroxyurea 29

hydroxyzine hcl 105



IBRANCE 32

ibu 1

ibuprofen 1


iclevia 84

ICLUSIG 32

icosapent ethyl 60

IDHIFA 29

ILEVRO 102


IMBRUVICA 32


imipramine hcl 21


imiquimod 66


INBRIJA 35

incassia 89

increlex 81

INCRUSE ELLIPTA 106

indapamide 59

indomethacin 1

infanrix dtap 95

INGREZZA 63


INLYTA 32

INQOVI 29

INREBIC 29


insulin syringes 99

INTELENCE 41

INTRALIPID 68

intron a 40

introvale 84

INVEGA SUSTENNA 37

INVEGA TRINZA 38

INVELTYS 102

INVIRASE 43

INVOKAMET 46

INVOKAMET XR 46

INVOKANA 46

ipol 96



irbesartan 52


IRESSA 32

ISENTRESS 40

ISENTRESS HD 40

isibloom 84

isoniazid 27



isotretinoin 66

isradipine 55

ISTURISA 79

120

itraconazole 24

ivermectin 34

ixiaro 96

JJAKAFI 32

jantoven 50

JANUMET 46

JANUMET XR 46

JANUVIA 46

JARDIANCE 46

jasmiel 84

jencycla 89

JENTADUETO 46

JENTADUETO XR 46

jinteli 84

JOLESSA 84

juleber 84

JULUCA 42

junel 84

junel fe 84

junel fe 24 84

JUXTAPID 60

JYNARQUE 70


kaitlib fe 84

kalliga 85

KALYDECO 107

kariva 85

kelnor 1-35 85

kelnor 1-50 85

kesimpta pen 64

ketoconazole 24

ketodan 24

ketoprofen 1



kinrix 96

kionex 70

KISQALI 32


KLISYRI 66

KLOR-CON 10 68

KLOR-CON 8 68

klor-con m10 68

klor-con m15 69

klor-con m20 69

KLOXXADO 6

KOMBIGLYZE XR 46

KORLYM 79

KOSELUGO 32

kurvelo 85

KYNMOBI 35

Llabetalol hcl 54

LACRISERT 100

lactulose 73

lamivudine 40


lamotrigine 17

lansoprazole 74



lantus 48

lantus solostar 48


larin 85

larin 24 fe 85

larin fe 85

larissia 85

latanoprost 104

LATUDA 38


LEENA 85

leflunomide 95

LENVIMA 32

lessina 85

letrozole 30


121

LEUKERAN 28

leukine 50




levetiracetam 15


LEVO-T 90

levobunolol hcl 103

LEVOCARNITINE 69



levofloxacin 13


levonest 85


levora-28 85



LEVOXYL 90

LEXIVA 43

lidocaine 4

lidocaine hcl 5

lidocaine hclpf 5


lillow 85

lindane 34

linezolid 8


LINZESS 73


lisinopril 53



LITHIUM CITRATE 45

lo-zumandimine 85

LONSURF 29

loperamide hcl 72


LOPREEZA 85

lorazepam 45


LORBRENA 31

lorcet 4

lorcet hd 4

loryna 85



LOTEMAX 102

LOTEMAX SM 102


lovastatin 59

low-ogestrel 85


LUBIPROSTONE 73

LUCEMYRA 5

LUMAKRAS 32

LUMIGAN 104

LUPANETA PACK 91

LUPKYNIS 93

LUPRON DEPOT 91

LUPRON DEPOT-PED 91

lutera 85

lyleq 89

lyllana 85

LYNPARZA 32

LYSODREN 29

lyza 89



maprotiline hcl 20

marlissa 85

marplan 20

MATULANE 28

matzim la 55

MAVENCLAD 64

MAYZENT 64

meclizine hcl 22



122

mefloquine hcl 34


MEKINIST 32

MEKTOVI 32

melodetta 24 fe 85

meloxicam 1

memantine hcl 19

menactra 96

menest 85

menquadfi 96


mercaptopurine 29

meropenem 11


merzee 86

mesalamine 97


MESNEX 33

metadate er 62


metformin hcl 46




24h) 46

methadone hcl 2

methazolamide 58


methergine 99

methimazole 91

methocarbamol 109



methoxsalen 66








metolazone 59




metronidazole 8


mexiletine hcl 53

mibelas 24 fe 86



microgestin 86


microgestin fe 86

midodrine hcl 52

migergot 26

miglitol 47

miglustat 75

mili 86

mimvey 86

minitran 61

minocycline hcl 15

minoxidil 60

mirtazapine 19

misoprostol 74

mitoxantrone hcl 30

modafinil 110

moexipril hcl 53

molindone hcl 37


mondoxyne nl 15

mono-linyah 86


morgidox 15

morphine sulfate 2

MOVANTIK 72

moxifloxacin hcl 14




MOZOBIL 50

MULTAQ 53

123


acid 71


myalept 72

MYCAPSSA 91



myorisan 66

MYRBETRIQ 76

MYTESI 72

Nnabumetone 1

nadolol 54

nafcillin sodium 12

naftifine hcl 24

NAFTIN 24

naloxone hcl 6

naltrexone hcl 5

NAMENDA XR 19

naproxen 1

naproxen sodium 2

naratriptan hcl 26

NARCAN 6

NATACYN 24

nateglinide 47

natpara 98

NAYZILAM 15

nebivolol hcl 54

necon 86

nefazodone hcl 20

neo-polycin 101

neo-polycin hc 101

neomycin sulfate 6


bhydrocortisone 101






NERLYNX 32

neulasta 50

neulasta onpro 50

neupogen 50

NEUPRO 35

nevirapine 41

NEXAVAR 32

NEXIUM 74

NEXLETOL 57

NEXLIZET 60

niacin 60

nicardipine hcl 55

NICOTROL 6

NICOTROL NS 6

nifedipine 56

nikki 86

nilutamide 28

nimodipine 56

NINLARO 30

nitazoxanide 34

nitisinone 75

NITRO-DUR 61

nitrofurantoin 8



nitroglycerin 61

NITROSTAT 61

NITYR 75

nivestym 51

nizatidine 72

NORA-BE 89

norethindrone 89




fumarate 86



norlyda 89

NORPACE CR 53

nortrel 86

124


NORVIR 43

NOURIANZ 35

NOXAFIL 24

np thyroid 90

NUBEQA 28

nucala 109

NUEDEXTA 63

NUPLAZID 38

NUTRILIPID 69

nyamyc 25

nylia 86

nymyo 86

nystatin 25


nystop 25

nyvepria 51

Oo-cal fa 71

ob complete 71

OCALIVA 75

OCELLA 86

octagam 94


odactra 95

ODEFSEY 41

ODOMZO 32

OFEV 108

ofloxacin 14

ogestrel 87

olanzapine 38






olopatadine hcl 102


OMEGAVEN 69

omeprazole 74

omnitrope 81

ondansetron hcl 23



ONGENTYS 35

ONGLYZA 47

ONUREG 30

OPSUMIT 108

oralair 95

orencia 93


ORFADIN 75

ORGOVYX 91

ORIAHNN 81

ORILISSA 81

ORKAMBI 107

ORLADEYO 92

orsythia 87


OSMOLEX ER 35

OTEZLA 95

oxacillin sodium 12


DEXTROSE 12

oxandrolone 81

oxazepam 45

oxcarbazepine 18

oxervate 101



oxycodone hcl 4



oxymorphone hcl 4

OZEMPIC 47

Ppaliperidone 38

palynziq 75


PANRETIN 33

125


panzyga 94

paricalcitol 98

paroex 64


paroxetine hcl 21

paser 27

PAXIL 21

PAZEO 102

pediarix 96

pedvaxhib 96


chloride 73


sodvit c 73

PEGANONE 18

pegasys 40

pegintron 40

PEMAZYRE 32




penicillamine 76








PENTASA 97

pentoxifylline 57

PERFOROMIST 107


periogard 64

permethrin 34

perphenazine 22


PERSERIS 38

pfizerpen 12


phenobarbital 17


phenytoin 18


philith 87

PHOSLYRA 70


PICATO 66

PIFELTRO 41

pilocarpine hcl 65

pimecrolimus 67

pimozide 37

pimtrea 87

pindolol 54

pioglitazone hcl 47




PIQRAY 31

pirmella 87

piroxicam 2

plegridy 64

plegridy pen 64

plenamine 69

PLENVU 73

podofilox 67

polycin 101



POMALYST 28

portia 87

posaconazole 25



SODIUM CHLORIDE 69


SODIUM CHLORIDE 69


SODIUM CHLORIDE 69


AND 5 DEXTROSE 69

126



PRADAXA 50


prasugrel hcl 51


prazosin hcl 52

PRED MILD 103

PREDNICARBATE 79

prednisolone 80



prednisone 80


pregabalin 63

PREMARIN 87

PREMPHASE 87

PREMPRO 87


prenate am 71

prenate chewable 71

prevalite 60

previfem 87

PREVYMIS 39

PREZCOBIX 43

PREZISTA 43

PRIFTIN 27


primidone 17

privigen 94


probenecid 25


prochlorperazine 22



procrit 51

procto-med hc 97

proctofoam-hc 67

proctosol-hc 97

proctozone-hc 97

PROCYSBI 75


PROGRAF 93

prolastin c 75

PROLENSA 103

prolia 98

PROMACTA 51

promethazine hcl 22

propafenone hcl 53

propranolol hcl 55


propylthiouracil 92

proquad 96


psorcon 80

pulmozyme 107

purefe ob plus 71

PURIXAN 29

PYLERA 72

pyrazinamide 27


pyrimethamine 34

QQINLOCK 30



quinapril hcl 53




QVAR REDIHALER 105

Rrabavert 96


ragwitek 95

raloxifene hcl 90

ramipril 53

ranolazine 57


127

RAVICTI 75

rebif 64

rebif rebidose 64

reclipsen 87

recombivax hb 96

RECTIV 67

regranex 67

RELENZA 44

relexxii 62

RELISTOR 72


RENACIDIN 76

repaglinide 47




repatha syringe 60

RESTASIS 101


retacrit 51

RETEVMO 30

RETROVIR 42

REVLIMID 28

REXULTI 38

REYATAZ 43

REZUROCK 93

RHOPRESSA 104

ribavirin 40

rifabutin 27

rifampin 27

RIFATER 27

riluzole 63

rimantadine hcl 44


RINVOQ 93


RISPERDAL CONSTA 38

risperidone 38

ritonavir 43

rivastigmine 19



ropinirole hcl 35

rosadan 67


rotarix 96

rotateq 96

roweepra 15

roweepra xr 16

ROZLYTREK 30

RUBRACA 30

rufinamide 18

RUKOBIA 42

RUZURGI 63

RYBELSUS 47

RYDAPT 30

Ssajazir 92

SAMSCA 70

santyl 67


SAVAYSA 50

SAVELLA 63

SECUADO 38

SEGLUROMET 47

selegiline hcl 36

selenium sulfide 67

SELZENTRY 42

SEREVENT DISKUS 107

sertraline hcl 21

setlakin 87


sharobel 90

shingrix 96

SIGNIFOR 91


silodosin 76

SILVADENE 14


SIMBRINZA 104

simliya 87

128

simvastatin 59

sirolimus 93

SIRTURO 27

SIVEXTRO 8

skyrizi 67


skyrizi pen 67

SMOFLIPID 69




chloridepeg 73





soltamox 28

SOLU-CORTEF 80

SOMATULINE DEPOT 91

somavert 91

SOOLANTRA 67

sorine 54

sotalol af 54

sotalol hcl 54

SPIRIVA 106


spironolactone 58


sprintec 87

SPRITAM 16

SPRIX 2

SPRYCEL 32

sps 70

sronyx 87

SSD 14

stavudine 42

STEGLATRO 47

STEGLUJAN 47

stelara 67

STIMATE 81


STIVARGA 32


STRIBILD 41

sucraid 75

sucralfate 74



phosphate 101

sulfadiazine 14


SULFAMYLON 8

sulfasalazine 97

sulindac 2


sunitinib malate 32

SUNOSI 110

suprax 10

SUPREP 73

SUTAB 73

syeda 87

sylatron 30

SYMBICORT 109

SYMDEKO 107

SYMPAZAN 17

SYMPROIC 72

SYMTUZA 43

SYNAREL 91

SYNJARDY 47

SYNJARDY XR 47

SYNRIBO 30

SYNTHROID 90


container 100




ml 100


TTABLOID 29

129

TABRECTA 30

tacrolimus 67

tadalafil 76

TAFINLAR 32

TAGRISSO 32

takhzyro 92

TALICIA 72

TALZENNA 32


tamsulosin hcl 76

TARGRETIN 33

tarina 24 fe 87

tarina fe 87


TASIGNA 32

TAVALISSE 51

taysofy 87

tazarotene 67

tazicef 10

TAZORAC 67

taztia xt 56

TAZVERIK 30

TEFLARO 10

TEGSEDI 63

telmisartan 52



temazepam 109

TEMIXYS 43

tenivac 96


TEPMETKO 33

terazosin hcl 52

terbinafine hcl 25


terconazole 25

testosterone 81





tetrabenazine 63

tetracycline hcl 15

THALOMID 28


THIOLA EC 76

thioridazine hcl 37

thiothixene 37

thyroid 90

thyroidpork 91

tiadylt er 56

tiagabine hcl 17

TIBSOVO 30

tigecycline 8

tilia fe 87

timolol maleate 55

tinidazole 8

tiopronin 76

TIVICAY 41

TIVICAY PD 41

tizanidine hcl 39

tobi podhaler 107

TOBRADEX 101

tobramycin 7




TOBREX 7

tolmetin sodium 2


tolvaptan 70

topiramate 17

toposar 31

topotecan hcl 31


torsemide 58


toujeo solostar 49

TOVIAZ 76

TPN ELECTROLYTES 70

TRACLEER 108

TRADJENTA 47

130

tramadol hcl 3


trandolapril 53


tranexamic acid 51


travoprost 104

trazodone hcl 21

TRECATOR 27

TRELEGY ELLIPTA 109

trelstar 91

tremfya 67

tretinoin 33


trexall 94

tri femynor 87

tri-estarylla 87

tri-legest fe 87

tri-linyah 88

tri-lo-estarylla 88

tri-lo-marzia 88

tri-lo-mili 88

tri-lo-sprintec 88

tri-mili 88

tri-nymyo 88

tri-previfem 88

tri-sprintec 88

tri-vylibra 88

tri-vylibra lo 88


triamterene 59


triderm 80

trientine hcl 70


trifluridine 44


TRIKAFTA 107

triklo 60


trimethoprim 9


TRINTELLIX 21

TRIUMEQ 43

trivora-28 88

tropicamide 101


trulicity 47

trumenba 96

truseltiq 33

TUKYSA 30

tulana 90

TURALIO 30

twinrix 96

TYBLUME 88

TYBOST 43

TYMLOS 99

typhim vi 96

Uudenyca 51

UKONIQ 33

UNITHROID 91

UPTRAVI 108

ursodiol 72


VALCHLOR 28


valproic acid 17


valsartan 52


VALTOCO 17

vancomycin hcl 9


(PEG-400 NADA) 9



VANDAZOLE 9

vaqta 96

131


varivax vaccine 96

VARUBI 23

VASCEPA 60

velivet 88

VEMLIDY 40

VENCLEXTA 33


venlafaxine hcl 21

verapamil hcl 56

verquvo 58

VERSACLOZ 39

VERZENIO 33

vestura 88

VIBERZI 73

VICTOZA 2-PAK 47

VICTOZA 3-PAK 47

VIDEX 42

VIDEX EC 42

vienva 88

vigabatrin 17

vigadrone 17

VIIBRYD 21

VIMPAT 18

viorele 88

VIRACEPT 43

VIREAD 42

VITRAKVI 30

VIZIMPRO 30

volnea 88

voriconazole 25

VOSEVI 40

VOTRIENT 33

VRAYLAR 38

VUMERITY 64

vyfemla 88

vylibra 88

VYNDAMAX 58

VYNDAQEL 58

VYVANSE 61

VYZULTA 104

WWAKIX 110

warfarin sodium 50

WELIREG 30

wera 88

XXALKORI 33

XARELTO 50

XATMEP 94

XCOPRI 16

XELJANZ 94

XELJANZ XR 94

XELPROS 104

XERMELO 72

xgeva 99

XIFAXAN 9

XIGDUO XR 47

XOFLUZA 44

xolair 109

XOSPATA 30

XPOVIO 30

XTAMPZA ER 3

XTANDI 28

xulane 88

XYREM 110

XYWAV 110

Yyf-vax 96

YONSA 28

yuvafem 88

Zzafemy 88

zafirlukast 106

zaleplon 110

zarah 88

zarxio 51

ZEJULA 33

132

ZELBORAF 33

zemaira 75

zenatane 67

zenpep 75

zenzedi 61

ZEPOSIA 64

ZERBAXA 11

zidovudine 42

ziextenzo 51

zingiber 71

ziprasidone hcl 39


ZIRGAN 39

zoledronic acid 99


SODIUM CHLORIDE 99


ZOLINZA 30

zolmitriptan 26


zonisamide 16

ZORTRESS 94

zovia 1-35 88

zovia 1-35e 88

zumandimine 89

ZYDELIG 33

ZYKADIA 33

ZYLET 101

133


ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 15


ANTIDEPRESSANTS 19

ANTIEMETICS 22

ANTIFUNGALS 23

ANTIGOUT AGENTS 25




ANTINEOPLASTICS 28

ANTIPARASITICS 33


ANTIPSYCHOTICS 36


ANTIVIRALS 39

ANXIOLYTICS 44

BIPOLAR AGENTS 45




















MISCELLANEOUS 110



OTIC AGENTS 104


134



135






MDC-455

11222021

11222021





(TTY 711）



1‐800‐603‐2340 (TTY 711) 번으로 전화해 주십시오










Arabic










Persian




(082021) H9047_2021RCGA03_C



ANALGESICS


celecoxib 2-Generic



3-Preferred Brand




4-Non-PreferredDrug



ibu 2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug




meloxicam 2-Generic



2-Generic


1



Drug



piroxicam 2-Generic


sulindac 2-Generic



DrugPA




4-Non-PreferredDrug

PA




4-Non-PreferredDrug

PA QL (2 PER 1 DAY)


PA QL (4 PER 1 DAY)


2-Generic PA





2



3-Preferred Brand


4-Non-PreferredDrug


PA QL (2 PER 1 DAY)


2-Generic



4-Non-PreferredDrug


3-Preferred Brand



4-Non-PreferredDrug


endocet 2-Generic


4-Non-PreferredDrug

PA QL (4 PER 1 DAY)


3-Preferred Brand


2-Generic


2-Generic


3



2-Generic



4-Non-PreferredDrug

lorcet 2-Generic

lorcet hd 2-Generic


2-Generic


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


2-Generic



4-Non-PreferredDrug



ANESTHETICS



PA


4





2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug








4-Non-PreferredDrug


QL (4 PER 1 DAY)


QL (3 PER 1 DAY)




1-PreferredGeneric

QL (4 PER 1 DAY)


1-PreferredGeneric

QL (3 PER 1 DAY)




5





1-PreferredGeneric








ANTIBACTERIALS



4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug







6




4-Non-PreferredDrug










2-Generic



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug





7



Drug



4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic





2-Generic


4-Non-PreferredDrug


2-Generic







8




4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug



PA QL (3 PER 1 DAY)




4-Non-PreferredDrug


4-Non-PreferredDrug



4-Non-PreferredDrug




4-Non-PreferredDrug


9



4-Non-PreferredDrug





4-Non-PreferredDrug


4-Non-PreferredDrug




4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic





10




Drug





4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug






11



Drug



4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug



2-Generic




Drug


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


2-Generic


12



5-Specialty



4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug


Drug


2-Generic



4-Non-PreferredDrug



2-Generic


4-Non-PreferredDrug


13



Drug




4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug




SSD 2-Generic


4-Non-PreferredDrug



2-Generic


4-Non-PreferredDrug





14



2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug


morgidox 2-Generic


ANTICONVULSANTS







2-Generic


4-Non-PreferredDrug



roweepra 2-Generic


15










Drug


3-Preferred Brand



4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug


16



3-Preferred Brand


primidone 2-Generic





2-Generic






4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


2-Generic


17



4-Non-PreferredDrug




3-Preferred Brand


4-Non-PreferredDrug





2-Generic



2-Generic



4-Non-PreferredDrug







18



ANTIDEMENTIA AGENTS



3-Preferred Brand




4-Non-PreferredDrug


2-Generic


ANTIDEPRESSANTS


2-Generic


2-Generic





19









1-PreferredGeneric


3-Preferred Brand



1-PreferredGeneric


3-Preferred Brand


ST


2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic




20



2-Generic


4-Non-PreferredDrug



1-PreferredGeneric



ST


2-Generic


4-Non-PreferredDrug

QL (1 PER 1 DAY)


ST


amoxapine 2-Generic






2-Generic


21



Drug


ANTIEMETICS


Drug


2-Generic


2-Generic






4-Non-PreferredDrug












22



DrugPA




QL (2 PER 1 DAY)


4-Non-PreferredDrug


2-Generic



3-Preferred Brand



ANTIFUNGALS










3-Preferred Brand





3-Preferred Brand


23







3-Preferred Brand


2-Generic


4-Non-PreferredDrug




4-Non-PreferredDrug




4-Non-PreferredDrug






4-Non-PreferredDrug




PA


24




2-Generic



nystop 2-Generic





4-Non-PreferredDrug


4-Non-PreferredDrug

PA

ANTIGOUT AGENTS






ANTIMIGRAINE AGENTS




25


















4-Non-PreferredDrug







4-Non-PreferredDrug



26



ANTIMYCOBACTERIALS




Drug




2-Generic






3-Preferred Brand






27



ANTINEOPLASTICS


4-Non-PreferredDrug









flutamide 2-Generic













28





4-Non-PreferredDrug




LA














4-Non-PreferredDrug


2-Generic




29



























letrozole 2-Generic


30






toposar 2-Generic





















31































32





















ANTIPARASITICS


DrugPA


PA


33




Drug


3-Preferred Brand





2-Generic





4-Non-PreferredDrug





Drug




2-Generic


2-Generic


34




3-Preferred Brand






ST


PA LA




KYNMOBI 5-Specialty


QL (1 PER 1 DAY)


2-Generic


2-Generic


3-Preferred Brand


35




Drug


4-Non-PreferredDrug


2-Generic


Drug


ANTIPSYCHOTICS


4-Non-PreferredDrug



3-Preferred Brand


4-Non-PreferredDrug



4-Non-PreferredDrug


4-Non-PreferredDrug


36





pimozide 2-Generic







4-Non-PreferredDrug


2-Generic















37






2-Generic


3-Preferred Brand







5-Specialty



4-Non-PreferredDrug


2-Generic







38





4-Non-PreferredDrug


3-Preferred Brand




2-Generic


3-Preferred Brand


4-Non-PreferredDrug


ANTIVIRALS







39




Drug





VEMLIDY 5-Specialty





5-Specialty LA

pegasys 5-Specialty



3-Preferred Brand


GENVOYA 5-Specialty


5-Specialty


3-Preferred Brand



40




5-Specialty





EDURANT 5-Specialty

efavirenz 2-Generic


5-Specialty


5-Specialty




4-Non-PreferredDrug


ODEFSEY 5-Specialty








41






5-Specialty



4-Non-PreferredDrug



stavudine 2-Generic





5-Specialty


2-Generic


Drug

DOVATO 5-Specialty

FUZEON 5-Specialty

JULUCA 5-Specialty

RUKOBIA 5-Specialty


5-Specialty



42



Drug

TRIUMEQ 5-Specialty



5-Specialty



EVOTAZ 5-Specialty








3-Preferred Brand



5-Specialty


3-Preferred Brand



SYMTUZA 5-Specialty



43




3-Preferred Brand





2-Generic


4-Non-PreferredDrug






ANXIOLYTICS



3-Preferred Brand


4-Non-PreferredDrug


3-Preferred Brand


44



2-Generic



2-Generic


2-Generic



BIPOLAR AGENTS


2-Generic






4-Non-PreferredDrug

PA


4-Non-PreferredDrug

PA





45



DrugST



2-Generic




PA


ST


ST


ST






PA


PA


PA


4-Non-PreferredDrug


1-PreferredGeneric


1-PreferredGeneric


46



Drug




PA









ST


ST


PA




PA





ST


47





















humulin n 2-Generic


humulin r 2-Generic






48







4-Non-PreferredDrug


5-Specialty


4-Non-PreferredDrug


4-Non-PreferredDrug


5-Specialty


3-Preferred Brand



4-Non-PreferredDrug


4-Non-PreferredDrug


3-Preferred Brand


49



jantoven 2-Generic







4-Non-PreferredDrug

PA


5-Specialty PA




4-Non-PreferredDrug

PA



granix 5-Specialty

leukine 5-Specialty

MOZOBIL 5-Specialty





50





4-Non-PreferredDrug

PA




4-Non-PreferredDrug

PA



udenyca 5-Specialty

zarxio 5-Specialty



4-Non-PreferredDrug



Drug






51





4-Non-PreferredDrug


1-PreferredGeneric












valsartan 2-Generic


Generic



2-Generic


52



Drug









4-Non-PreferredDrug









3-Preferred Brand


4-Non-PreferredDrug



53



Drug

sorine 2-Generic






2-Generic





2-Generic




1-PreferredGeneric


2-Generic



ST

pindolol 2-Generic


54



2-Generic


4-Non-PreferredDrug


Generic


cartia xt 2-Generic

dilt-xr 2-Generic


2-Generic


4-Non-PreferredDrug





4-Non-PreferredDrug


55



2-Generic


taztia xt 2-Generic



4-Non-PreferredDrug


2-Generic


Drug




2-Generic



3-Preferred Brand



2-Generic


2-Generic


4-Non-PreferredDrug



56



4-Non-PreferredDrug

PA

digitek 2-Generic

digox 2-Generic


2-Generic


4-Non-PreferredDrug









2-Generic


PA


4-Non-PreferredDrug


2-Generic








57



Drug





PA




4-Non-PreferredDrug




3-Preferred Brand



1-PreferredGeneric


4-Non-PreferredDrug

torsemide 2-Generic





58



Drug



2-Generic




2-Generic



2-Generic





Generic







59




4-Non-PreferredDrug


4-Non-PreferredDrug



4-Non-PreferredDrug

ezetimibe 2-Generic





PA


2-Generic






triklo 2-Generic



2-Generic

minoxidil 2-Generic


60




3-Preferred Brand


2-Generic

minitran 2-Generic



2-Generic






2-Generic


4-Non-PreferredDrug




QL (1 PER 1 DAY)



61




Drug



QL (1 PER 1 DAY)


2-Generic


4-Non-PreferredDrug

QL (1 PER 1 DAY)


2-Generic



4-Non-PreferredDrug

QL (1 PER 1 DAY)


2-Generic


QL (6 PER 1 DAY)



QL (2 PER 1 DAY)


QL (1 PER 1 DAY)


62











riluzole 2-Generic





Drug


2-Generic


2-Generic


4-Non-PreferredDrug

QL (2 PER 1 DAY)




avonex 5-Specialty


63







5-Specialty


GILENYA 5-Specialty


glatopa 5-Specialty




5-Specialty LA




rebif 5-Specialty



ZEPOSIA 5-Specialty



2-Generic

paroex 2-Generic

periogard 2-Generic


64



4-Non-PreferredDrug




Drug


4-Non-PreferredDrug


4-Non-PreferredDrug







4-Non-PreferredDrug




4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


65



Drug







3-Preferred Brand









4-Non-PreferredDrug


ST




3-Preferred Brand


4-Non-PreferredDrug




66



DrugST













ST


5-Specialty PA


4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug




67





4-Non-PreferredDrug







4-Non-PreferredDrug




4-Non-PreferredDrug







2-Generic





68














4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug





69



Drug


2-Generic






5-Specialty PA LA


5-Specialty PA

kionex 2-Generic



2-Generic





Drug


3-Preferred Brand


5-Specialty




70



5-Specialty





2-Generic

o-cal fa 2-Generic






zingiber 2-Generic



2-Generic


2-Generic






71



3-Preferred Brand



4-Non-PreferredDrug





PYLERA 5-Specialty


5-Specialty PA


5-Specialty PA




3-Preferred Brand





2-Generic



2-Generic


72




Drug






enulose 2-Generic




generlac 2-Generic


2-Generic


2-Generic


4-Non-PreferredDrug



2-Generic





73





2-Generic


DrugST


4-Non-PreferredDrug

ST


2-Generic


2-Generic


4-Non-PreferredDrug

ST


2-Generic


2-Generic


4-Non-PreferredDrug









74




LA









5-Specialty LA





5-Specialty PA LA





5-Specialty PA







75



3-Preferred Brand


2-Generic




















76





4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug



3-Preferred Brand


4-Non-PreferredDrug


4-Non-PreferredDrug


3-Preferred Brand




2-Generic


4-Non-PreferredDrug


3-Preferred Brand


4-Non-PreferredDrug



77




decadron 2-Generic


3-Preferred Brand



4-Non-PreferredDrug


2-Generic


3-Preferred Brand


4-Non-PreferredDrug


4-Non-PreferredDrug



5-Specialty PA LA






3-Preferred Brand


3-Preferred Brand


78





2-Generic



4-Non-PreferredDrug


2-Generic


3-Preferred Brand


4-Non-PreferredDrug






2-Generic


3-Preferred Brand




2-Generic



79




4-Non-PreferredDrug


2-Generic


2-Generic





3-Preferred Brand


2-Generic


3-Preferred Brand

triderm 2-Generic



2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


80





5-Specialty PA


PA


PA

STIMATE 5-Specialty





DrugPA



4-Non-PreferredDrug

PA


4-Non-PreferredDrug




altavera 2-Generic


81




amethyst 2-Generic

apri 2-Generic

aranelle 2-Generic

aubra 2-Generic

aubra eq 2-Generic





aviane 2-Generic


azurette 2-Generic

balziva 2-Generic

bekyree 2-Generic



briellyn 2-Generic

caziant 2-Generic





cryselle 2-Generic


82



cyred 2-Generic

cyred eq 2-Generic

dasetta 2-Generic



2-Generic

dolishale 2-Generic


elinest 2-Generic


emoquette 2-Generic

enpresse 2-Generic

enskyce 2-Generic

estarylla 2-Generic


4-Non-PreferredDrug


2-Generic






83





falmina 2-Generic


femynor 2-Generic



GIANVI 2-Generic

hailey 2-Generic


hailey fe 2-Generic

iclevia 2-Generic

introvale 2-Generic

isibloom 2-Generic

jasmiel 2-Generic


JOLESSA 2-Generic

juleber 2-Generic



junel fe 2-Generic




84



kariva 2-Generic



kurvelo 2-Generic




larin fe 2-Generic

larissia 2-Generic

LEENA 2-Generic

lessina 2-Generic

levonest 2-Generic


levora-28 2-Generic

lillow 2-Generic



loryna 2-Generic


lutera 2-Generic


marlissa 2-Generic




85



Drug






mili 2-Generic



necon 2-Generic

nikki 2-Generic


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


2-Generic


4-Non-PreferredDrug


nortrel 2-Generic

nylia 2-Generic

nymyo 2-Generic

OCELLA 2-Generic


86



orsythia 2-Generic

philith 2-Generic

pimtrea 2-Generic

pirmella 2-Generic

portia 2-Generic


3-Preferred Brand



previfem 2-Generic

reclipsen 2-Generic

setlakin 2-Generic

simliya 2-Generic

sprintec 2-Generic

sronyx 2-Generic

syeda 2-Generic


tarina fe 2-Generic








87







tri-mili 2-Generic

tri-nymyo 2-Generic






TYBLUME 2-Generic

velivet 2-Generic

vestura 2-Generic

vienva 2-Generic

viorele 2-Generic

volnea 2-Generic

vyfemla 2-Generic

vylibra 2-Generic

wera 2-Generic

xulane 2-Generic


zafemy 2-Generic

zarah 2-Generic




88




Drug


deblitane 2-Generic



errin 2-Generic

heather 2-Generic

incassia 2-Generic

jencycla 2-Generic

lyleq 2-Generic

lyza 2-Generic


4-Non-PreferredDrug


2-Generic


2-Generic


NORA-BE 2-Generic



norlyda 2-Generic



89



tulana 2-Generic


Drug




Drug




4-Non-PreferredDrug


2-Generic



2-Generic






90



Drug










5-Specialty


PA











91
















4-Non-PreferredDrug



4-Non-PreferredDrug



5-Specialty PA








4-Non-PreferredDrug



92














2-Generic


2-Generic








5-Specialty PA



4-Non-PreferredDrug






4-Non-PreferredDrug



93










5-Specialty PA










5-Specialty PA LA







94








PA



PA


PA LA



PA











3-Preferred Brand





95






























96







4-Non-PreferredDrug



PENTASA 5-Specialty




colocort 2-Generic









2-Generic


97



4-Non-PreferredDrug














4-Non-PreferredDrug





4-Non-PreferredDrug



4-Non-PreferredDrug



4-Non-PreferredDrug




2-Generic


4-Non-PreferredDrug


98



xgeva 5-Specialty


4-Non-PreferredDrug



4-Non-PreferredDrug


4-Non-PreferredDrug









4-Non-PreferredDrug


2-Generic


2-Generic


99



2-Generic


2-Generic


2-Generic


2-Generic


2-Generic


2-Generic

OPHTHALMIC AGENTS


Drug









100



Drug



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


4-Non-PreferredDrug







4-Non-PreferredDrug






Drug


101











3-Preferred Brand















3-Preferred Brand


102



Drug



2-Generic

















3-Preferred Brand


103





1-PreferredGeneric


4-Non-PreferredDrug






ST


OTIC AGENTS






4-Non-PreferredDrug




104



3-Preferred Brand



4-Non-PreferredDrug






2-Generic


3-Preferred Brand






2-Generic



4-Non-PreferredDrug


4-Non-PreferredDrug


4-Non-PreferredDrug


2-Generic


105



Drug






2-Generic








4-Non-PreferredDrug











2-Generic


106



Drug



4-Non-PreferredDrug








4-Non-PreferredDrug














4-Non-PreferredDrug



107




DrugPA


2-Generic










5-Specialty PA LA









108






2-Generic








5-Specialty PA LA




2-Generic


2-Generic




2-Generic



109




2-Generic


Drug





PA QL (1 PER 1 DAY)




MISCELLANEOUS




110






ABELCET 23

ABILIFY MAINTENA 37

ABILIFY MYCITE 37



acarbose 45

accutane 65

acebutolol hcl 54


acetazolamide 58

acetic acid 104

acetylcysteine 108

acitretin 65

acthib 95

actimmune 95

acyclovir 44

acyclovir sodium 44

adacel tdap 95

adapalene 65


ADEMPAS 108

ADVAIR DISKUS 108

ADVAIR HFA 108

AEMCOLO 7

AFINITOR 31

AFINITOR DISPERZ 31

afirmelle 81


ak-poly-bac 100

AKYNZEO 22

albendazole 33







ALECENSA 31


alfuzosin hcl 76


allopurinol 25





ALOMIDE 101

alosetron hcl 73

ALPHAGAN P 103

alprazolam 44

ALREX 102

altavera 81

ALTRENO 65

ALUNBRIG 29

alyacen 82

alyq 108

amabelz 82

amantadine hcl 35

AMBISOME 23

ambrisentan 108

amcinonide 77

amethyst 82


amiloride hcl 58


AMINOSYN II 68

amiodarone hcl 53

AMITIZA 73







111

ammonium lactate 65

amnesteem 65

amoxapine 21

amoxicillin 11


amphotericin b 23




ANADROL-50 81

anagrelide hcl 50

anastrozole 30

ANDRODERM 81

ANORO ELLIPTA 108

anusol-hc 97

APOKYN 35


aprepitant 22

apri 82

APTIOM 18

APTIVUS 43

aralast np 74

aranelle 82

aranesp 50

arcalyst 95

aripiprazole 37

ARISTADA 37

ARISTADA INITIO 37

armodafinil 110

armour thyroid 90

ARNUITY ELLIPTA 104

arsenic trioxide 29



ASMANEX 105

ASMANEX HFA 105


ASTAGRAF XL 92


atenolol 54


atomoxetine hcl 62


atovaquone 34



ATROVENT HFA 106

AUBAGIO 63

aubra 82

aubra eq 82

aurovela 82

aurovela 24 fe 82

aurovela fe 82

AURYXIA 70

AUSTEDO 63

AUVI-Q 106

aviane 82

avidoxy 14

AVITA 65

avonex 63

avonex pen 64

AVYCAZ 9

ayuna 82

AYVAKIT 29

AZASITE 12

azathioprine 92


azelaic acid 65

azelastine hcl 102

azithromycin 12

aztreonam 11

azurette 82

Bbacitracin 7


baclofen 39


BALVERSA 29

balziva 82

BAQSIMI 48

BARACLUDE 40

112


bekyree 82

BELBUCA 2

benazepril hcl 52


benlysta 95

BENZNIDAZOLE 34


beser 77




betaseron 64

betaxolol hcl 54


BETIMOL 103

bexarotene 33

bexsero 95

bicalutamide 28

BICILLIN C-R 11

BICILLIN L-A 12

BIKTARVY 40

bimatoprost 104

BINOSTO 98



bivigam 94

BLEPHAMIDE 100

blephamide sop 100

blisovi 24 fe 82

blisovi fe 82


boostrix tdap 95

bosentan 108

BOSULIF 31

BRAFTOVI 31

BREO ELLIPTA 108

briellyn 82

BRILINTA 51


brinzolamide 103

BRIVIACT 15



BRUKINSA 29

budesonide 97

bumetanide 58

buprenorphine 2

buprenorphine hcl 2


bupropion hcl 6

buspirone hcl 44





BYDUREON BCISE 45

BYDUREON PEN 45

Ccabergoline 91

cablivi 50

CABOMETYX 31

cafergot 26

calcipotriene 65


CALCITRIOL 65

calcitriol 98

calcium acetate 70

CALQUENCE 31

camila 89



CAPASTAT SULFATE 27

CAPLYTA 37

CAPRELSA 31

captopril 52


CARBAGLU 74

carbamazepine 18

carbidopa 36


113


CARDIZEM LA 55

carteolol hcl 103

cartia xt 55

carvedilol 54



cataflam 1

CAYSTON 107

caziant 82

cefaclor 9

cefadroxil 9

cefazolin sodium 9

cefdinir 9

cefepime hcl 9


cefixime 10



cefoxitin sodium 10


cefprozil 10

ceftazidime 10





celecoxib 1

CELONTIN 16

cephalexin 10

CERDELGA 74

CHANTIX 6

charlotte 24 fe 82

chateal 82

chateal eq 82

CHEMET 70

chenodal 71





chlorthalidone 59

CHOLBAM 74



ciclodan 23

ciclopirox 23


cilostazol 51

CIMDUO 42

cimetidine 72

cimetidine hcl 72

cinacalcet hcl 98

cinryze 92

ciprofloxacin 13





claravis 65

clarithromycin 12


cleocin phosphate 7

clindacin etz 7

clindacin p 7

clindamycin hcl 7




CHLORIDE 7



CLINOLIPID 68

clobazam 16



clodan 77

clomipramine hcl 21

clonazepam 44


mgday patch) 52

clonidine hcl 52

114



clotrimazole 23


clovique 70

clozapine 39

COARTEM 34


codeine sulfate 3

colchicine 25

colesevelam hcl 60

colestipol hcl 60


colocort 97

COMBIGAN 103

COMBIPATCH 82


COMETRIQ 31

COMPLERA 41

compro 22

concept ob 71

constulose 73

COPAXONE 64

COPIKTRA 29

CORLANOR 57

cormax 78


CORTISPORIN 66


cosentyx pen 66


cosentyx syringe 66

COTELLIC 31

creon 74

CRESEMBA 24

CRIXIVAN 43

cromolyn sodium 71

cryselle 82

cyclafem 83


cyclophosphamide 28

cycloserine 27

CYCLOSET 45

cyclosporine 92



cyred 83

cyred eq 83

cystadane 75

CYSTADROPS 100

CYSTAGON 75

CYSTARAN 100

Ddalfampridine 64

DALIRESP 108

danazol 81


dapsone 27

daptacel dtap 95

daptomycin 7

dasetta 83

DAURISMO 31

DAYTRANA 62

deblitane 89

decadron 78

deferasirox 70

DELSTRIGO 41


DEPO-PROVERA 89


DESCOVY 42

desipramine hcl 21





desonide 78

desoximetasone 78


dexamethasone 78


115


DEXILANT 74



aspartate 61










DIACOMIT 15

DIASTAT 16

DIASTAT ACUDIAL 16

DIAZEPAM 16

diazepam 45

diazoxide 48


diclofenac sodium 1



dicyclomine hcl 71

didanosine 42

DIFICID 13


diflunisal 1

difluprednate 102

digitek 57

digox 57

digoxin 57


dilantin 18

dilt-xr 55

diltiazem hcl 55


DIPENTUM 97




disulfiram 5


dofetilide 53

dolishale 83

donepezil hcl 19

DOPTELET 50

dorzolamide hcl 103



dotti 83

DOVATO 42


doxepin hcl 44

doxercalciferol 98

doxy 100 14




dronabinol 23

DROXIA 29

droxidopa 52

DUAVEE 90

DULERA 109

duloxetine hcl 63

dupixent pen 66

dupixent syringe 66

dutasteride 76


EDURANT 41

efavirenz 41



egrifta sv 81

ELIGARD 91

elinest 83

ELIQUIS 49

ELLA 89

ELMIRON 76

116

eluryng 83

EMCYT 28

EMEND 23

EMFLAZA 78

emgality pen 25

emgality syringe 26

emoquette 83

EMSAM 20

emtricitabine 42


EMTRIVA 42

emverm 33



enbrel 92

enbrel mini 92

enbrel sureclick 92

endocet 3

engerix-b adult 95



enpresse 83

enskyce 83

enspryng 94

entacapone 35

entecavir 40

ENTRESTO 57

enulose 73

EPIDIOLEX 15

epifoam 66

epinastine hcl 102

epinephrine 106

epitol 18

EPIVIR HBV 40

eplerenone 58

epogen 50



ERIVEDGE 31

ERLEADA 28

erlotinib hcl 31

errin 89

ertapenem sodium 11

ery 13







ESBRIET 108



estarylla 83

estradiol 83



ESTRING 83

eszopiclone 109

ethacrynic acid 58

ethambutol hcl 27


ethosuximide 16



etodolac 1


etoposide 31

etravirine 41

EUTHYROX 90

everolimus 31

EVOTAZ 43

EVRYSDI 75

exemestane 30

extavia 64

ezetimibe 60


Ffalmina 84

famciclovir 44

famotidine 72

117

famotidinepf 72

FANAPT 37

FARXIGA 46

FARYDAK 31

fasenra pen 109

febuxostat 25

felbamate 17

felodipine 55

FEMRING 84

femynor 84

fenofibrate 59



FENOFIBRIC ACID 59


fentanyl 2

fentanyl citrate 3

FETZIMA 20

FINACEA 66

finasteride 76

FINTEPLA 15

FIRDAPSE 63

FIRMAGON 91

FIRVANQ 8

FLAREX 102

flavoxate hcl 75

flebogamma dif 94


FLOVENT DISKUS 105

FLOVENT HFA 105

fluconazole 24


flucytosine 24


flunisolide 105




fluocinonide 78


FLUOROMETHOLONE 102

fluorouracil 29

FLUOROURACIL 66

fluoxetine hcl 20


fluphenazine hcl 36

flurbiprofen 1


flutamide 28



XINAFOATE 109



FML FORTE 102

FML SOP 102

folivane-ob 71








FOSRENOL 70

FOTIVDA 31

FRAGMIN 49


fulphila 50

furosemide 58

FUZEON 42

fyavolv 84

FYCOMPA 17

Ggabapentin 16

GALAFOLD 75

galantamine hbr 19

gammagard liquid 94

gammagard s-d 94

gammaked 94

gammaplex 94

118

gamunex-c 94

gardasil 9 95

gatifloxacin 13

GATTEX 72

gauze bandage 99

gavilyte-c 73

gavilyte-g 73

gavilyte-n 73

GAVRETO 29

gemfibrozil 59

gemmily 84

generlac 73

gengraf 92

gentak 6




GENVOYA 40

GIANVI 84

GILENYA 64

GILOTRIF 31

glassia 75


glatopa 64

glimepiride 46

glipizide 46


GLUCAGEN 48


glycopyrrolate 71

glydo 4

GLYXAMBI 46

granisetron hcl 23

granix 50

grastek 95



guanfacine hcl 62

GUANIDINE HCL 26





Hhaegarda 92

hailey 84

hailey 24 fe 84

hailey fe 84


haloperidol 36



havrix 95

heather 89



CHLORIDE 49


WATER 49


HETLIOZ 110

HETLIOZ LQ 110

hiberix 95

humalog 48








humira 93

humira pen 93



humira(cf) 93


humira(cf) pen 93




119

humulin 70-30 48


humulin n 48


humulin r 48

humulin r u-500 48


hydralazine hcl 60





hydrocortisone 79





hydromorphone hcl 4



hydroxyurea 29

hydroxyzine hcl 105



IBRANCE 32

ibu 1

ibuprofen 1


iclevia 84

ICLUSIG 32

icosapent ethyl 60

IDHIFA 29

ILEVRO 102


IMBRUVICA 32


imipramine hcl 21


imiquimod 66


INBRIJA 35

incassia 89

increlex 81

INCRUSE ELLIPTA 106

indapamide 59

indomethacin 1

infanrix dtap 95

INGREZZA 63


INLYTA 32

INQOVI 29

INREBIC 29


insulin syringes 99

INTELENCE 41

INTRALIPID 68

intron a 40

introvale 84

INVEGA SUSTENNA 37

INVEGA TRINZA 38

INVELTYS 102

INVIRASE 43

INVOKAMET 46

INVOKAMET XR 46

INVOKANA 46

ipol 96



irbesartan 52


IRESSA 32

ISENTRESS 40

ISENTRESS HD 40

isibloom 84

isoniazid 27



isotretinoin 66

isradipine 55

ISTURISA 79

120

itraconazole 24

ivermectin 34

ixiaro 96

JJAKAFI 32

jantoven 50

JANUMET 46

JANUMET XR 46

JANUVIA 46

JARDIANCE 46

jasmiel 84

jencycla 89

JENTADUETO 46

JENTADUETO XR 46

jinteli 84

JOLESSA 84

juleber 84

JULUCA 42

junel 84

junel fe 84

junel fe 24 84

JUXTAPID 60

JYNARQUE 70


kaitlib fe 84

kalliga 85

KALYDECO 107

kariva 85

kelnor 1-35 85

kelnor 1-50 85

kesimpta pen 64

ketoconazole 24

ketodan 24

ketoprofen 1



kinrix 96

kionex 70

KISQALI 32


KLISYRI 66

KLOR-CON 10 68

KLOR-CON 8 68

klor-con m10 68

klor-con m15 69

klor-con m20 69

KLOXXADO 6

KOMBIGLYZE XR 46

KORLYM 79

KOSELUGO 32

kurvelo 85

KYNMOBI 35

Llabetalol hcl 54

LACRISERT 100

lactulose 73

lamivudine 40


lamotrigine 17

lansoprazole 74



lantus 48

lantus solostar 48


larin 85

larin 24 fe 85

larin fe 85

larissia 85

latanoprost 104

LATUDA 38


LEENA 85

leflunomide 95

LENVIMA 32

lessina 85

letrozole 30


121

LEUKERAN 28

leukine 50




levetiracetam 15


LEVO-T 90

levobunolol hcl 103

LEVOCARNITINE 69



levofloxacin 13


levonest 85


levora-28 85



LEVOXYL 90

LEXIVA 43

lidocaine 4

lidocaine hcl 5

lidocaine hclpf 5


lillow 85

lindane 34

linezolid 8


LINZESS 73


lisinopril 53



LITHIUM CITRATE 45

lo-zumandimine 85

LONSURF 29

loperamide hcl 72


LOPREEZA 85

lorazepam 45


LORBRENA 31

lorcet 4

lorcet hd 4

loryna 85



LOTEMAX 102

LOTEMAX SM 102


lovastatin 59

low-ogestrel 85


LUBIPROSTONE 73

LUCEMYRA 5

LUMAKRAS 32

LUMIGAN 104

LUPANETA PACK 91

LUPKYNIS 93

LUPRON DEPOT 91

LUPRON DEPOT-PED 91

lutera 85

lyleq 89

lyllana 85

LYNPARZA 32

LYSODREN 29

lyza 89



maprotiline hcl 20

marlissa 85

marplan 20

MATULANE 28

matzim la 55

MAVENCLAD 64

MAYZENT 64

meclizine hcl 22



122

mefloquine hcl 34


MEKINIST 32

MEKTOVI 32

melodetta 24 fe 85

meloxicam 1

memantine hcl 19

menactra 96

menest 85

menquadfi 96


mercaptopurine 29

meropenem 11


merzee 86

mesalamine 97


MESNEX 33

metadate er 62


metformin hcl 46




24h) 46

methadone hcl 2

methazolamide 58


methergine 99

methimazole 91

methocarbamol 109



methoxsalen 66








metolazone 59




metronidazole 8


mexiletine hcl 53

mibelas 24 fe 86



microgestin 86


microgestin fe 86

midodrine hcl 52

migergot 26

miglitol 47

miglustat 75

mili 86

mimvey 86

minitran 61

minocycline hcl 15

minoxidil 60

mirtazapine 19

misoprostol 74

mitoxantrone hcl 30

modafinil 110

moexipril hcl 53

molindone hcl 37


mondoxyne nl 15

mono-linyah 86


morgidox 15

morphine sulfate 2

MOVANTIK 72

moxifloxacin hcl 14




MOZOBIL 50

MULTAQ 53

123


acid 71


myalept 72

MYCAPSSA 91



myorisan 66

MYRBETRIQ 76

MYTESI 72

Nnabumetone 1

nadolol 54

nafcillin sodium 12

naftifine hcl 24

NAFTIN 24

naloxone hcl 6

naltrexone hcl 5

NAMENDA XR 19

naproxen 1

naproxen sodium 2

naratriptan hcl 26

NARCAN 6

NATACYN 24

nateglinide 47

natpara 98

NAYZILAM 15

nebivolol hcl 54

necon 86

nefazodone hcl 20

neo-polycin 101

neo-polycin hc 101

neomycin sulfate 6


bhydrocortisone 101






NERLYNX 32

neulasta 50

neulasta onpro 50

neupogen 50

NEUPRO 35

nevirapine 41

NEXAVAR 32

NEXIUM 74

NEXLETOL 57

NEXLIZET 60

niacin 60

nicardipine hcl 55

NICOTROL 6

NICOTROL NS 6

nifedipine 56

nikki 86

nilutamide 28

nimodipine 56

NINLARO 30

nitazoxanide 34

nitisinone 75

NITRO-DUR 61

nitrofurantoin 8



nitroglycerin 61

NITROSTAT 61

NITYR 75

nivestym 51

nizatidine 72

NORA-BE 89

norethindrone 89




fumarate 86



norlyda 89

NORPACE CR 53

nortrel 86

124


NORVIR 43

NOURIANZ 35

NOXAFIL 24

np thyroid 90

NUBEQA 28

nucala 109

NUEDEXTA 63

NUPLAZID 38

NUTRILIPID 69

nyamyc 25

nylia 86

nymyo 86

nystatin 25


nystop 25

nyvepria 51

Oo-cal fa 71

ob complete 71

OCALIVA 75

OCELLA 86

octagam 94


odactra 95

ODEFSEY 41

ODOMZO 32

OFEV 108

ofloxacin 14

ogestrel 87

olanzapine 38






olopatadine hcl 102


OMEGAVEN 69

omeprazole 74

omnitrope 81

ondansetron hcl 23



ONGENTYS 35

ONGLYZA 47

ONUREG 30

OPSUMIT 108

oralair 95

orencia 93


ORFADIN 75

ORGOVYX 91

ORIAHNN 81

ORILISSA 81

ORKAMBI 107

ORLADEYO 92

orsythia 87


OSMOLEX ER 35

OTEZLA 95

oxacillin sodium 12


DEXTROSE 12

oxandrolone 81

oxazepam 45

oxcarbazepine 18

oxervate 101



oxycodone hcl 4



oxymorphone hcl 4

OZEMPIC 47

Ppaliperidone 38

palynziq 75


PANRETIN 33

125


panzyga 94

paricalcitol 98

paroex 64


paroxetine hcl 21

paser 27

PAXIL 21

PAZEO 102

pediarix 96

pedvaxhib 96


chloride 73


sodvit c 73

PEGANONE 18

pegasys 40

pegintron 40

PEMAZYRE 32




penicillamine 76








PENTASA 97

pentoxifylline 57

PERFOROMIST 107


periogard 64

permethrin 34

perphenazine 22


PERSERIS 38

pfizerpen 12


phenobarbital 17


phenytoin 18


philith 87

PHOSLYRA 70


PICATO 66

PIFELTRO 41

pilocarpine hcl 65

pimecrolimus 67

pimozide 37

pimtrea 87

pindolol 54

pioglitazone hcl 47




PIQRAY 31

pirmella 87

piroxicam 2

plegridy 64

plegridy pen 64

plenamine 69

PLENVU 73

podofilox 67

polycin 101



POMALYST 28

portia 87

posaconazole 25



SODIUM CHLORIDE 69


SODIUM CHLORIDE 69


SODIUM CHLORIDE 69


AND 5 DEXTROSE 69

126



PRADAXA 50


prasugrel hcl 51


prazosin hcl 52

PRED MILD 103

PREDNICARBATE 79

prednisolone 80



prednisone 80


pregabalin 63

PREMARIN 87

PREMPHASE 87

PREMPRO 87


prenate am 71

prenate chewable 71

prevalite 60

previfem 87

PREVYMIS 39

PREZCOBIX 43

PREZISTA 43

PRIFTIN 27


primidone 17

privigen 94


probenecid 25


prochlorperazine 22



procrit 51

procto-med hc 97

proctofoam-hc 67

proctosol-hc 97

proctozone-hc 97

PROCYSBI 75


PROGRAF 93

prolastin c 75

PROLENSA 103

prolia 98

PROMACTA 51

promethazine hcl 22

propafenone hcl 53

propranolol hcl 55


propylthiouracil 92

proquad 96


psorcon 80

pulmozyme 107

purefe ob plus 71

PURIXAN 29

PYLERA 72

pyrazinamide 27


pyrimethamine 34

QQINLOCK 30



quinapril hcl 53




QVAR REDIHALER 105

Rrabavert 96


ragwitek 95

raloxifene hcl 90

ramipril 53

ranolazine 57


127

RAVICTI 75

rebif 64

rebif rebidose 64

reclipsen 87

recombivax hb 96

RECTIV 67

regranex 67

RELENZA 44

relexxii 62

RELISTOR 72


RENACIDIN 76

repaglinide 47




repatha syringe 60

RESTASIS 101


retacrit 51

RETEVMO 30

RETROVIR 42

REVLIMID 28

REXULTI 38

REYATAZ 43

REZUROCK 93

RHOPRESSA 104

ribavirin 40

rifabutin 27

rifampin 27

RIFATER 27

riluzole 63

rimantadine hcl 44


RINVOQ 93


RISPERDAL CONSTA 38

risperidone 38

ritonavir 43

rivastigmine 19



ropinirole hcl 35

rosadan 67


rotarix 96

rotateq 96

roweepra 15

roweepra xr 16

ROZLYTREK 30

RUBRACA 30

rufinamide 18

RUKOBIA 42

RUZURGI 63

RYBELSUS 47

RYDAPT 30

Ssajazir 92

SAMSCA 70

santyl 67


SAVAYSA 50

SAVELLA 63

SECUADO 38

SEGLUROMET 47

selegiline hcl 36

selenium sulfide 67

SELZENTRY 42

SEREVENT DISKUS 107

sertraline hcl 21

setlakin 87


sharobel 90

shingrix 96

SIGNIFOR 91


silodosin 76

SILVADENE 14


SIMBRINZA 104

simliya 87

128

simvastatin 59

sirolimus 93

SIRTURO 27

SIVEXTRO 8

skyrizi 67


skyrizi pen 67

SMOFLIPID 69




chloridepeg 73





soltamox 28

SOLU-CORTEF 80

SOMATULINE DEPOT 91

somavert 91

SOOLANTRA 67

sorine 54

sotalol af 54

sotalol hcl 54

SPIRIVA 106


spironolactone 58


sprintec 87

SPRITAM 16

SPRIX 2

SPRYCEL 32

sps 70

sronyx 87

SSD 14

stavudine 42

STEGLATRO 47

STEGLUJAN 47

stelara 67

STIMATE 81


STIVARGA 32


STRIBILD 41

sucraid 75

sucralfate 74



phosphate 101

sulfadiazine 14


SULFAMYLON 8

sulfasalazine 97

sulindac 2


sunitinib malate 32

SUNOSI 110

suprax 10

SUPREP 73

SUTAB 73

syeda 87

sylatron 30

SYMBICORT 109

SYMDEKO 107

SYMPAZAN 17

SYMPROIC 72

SYMTUZA 43

SYNAREL 91

SYNJARDY 47

SYNJARDY XR 47

SYNRIBO 30

SYNTHROID 90


container 100




ml 100


TTABLOID 29

129

TABRECTA 30

tacrolimus 67

tadalafil 76

TAFINLAR 32

TAGRISSO 32

takhzyro 92

TALICIA 72

TALZENNA 32


tamsulosin hcl 76

TARGRETIN 33

tarina 24 fe 87

tarina fe 87


TASIGNA 32

TAVALISSE 51

taysofy 87

tazarotene 67

tazicef 10

TAZORAC 67

taztia xt 56

TAZVERIK 30

TEFLARO 10

TEGSEDI 63

telmisartan 52



temazepam 109

TEMIXYS 43

tenivac 96


TEPMETKO 33

terazosin hcl 52

terbinafine hcl 25


terconazole 25

testosterone 81





tetrabenazine 63

tetracycline hcl 15

THALOMID 28


THIOLA EC 76

thioridazine hcl 37

thiothixene 37

thyroid 90

thyroidpork 91

tiadylt er 56

tiagabine hcl 17

TIBSOVO 30

tigecycline 8

tilia fe 87

timolol maleate 55

tinidazole 8

tiopronin 76

TIVICAY 41

TIVICAY PD 41

tizanidine hcl 39

tobi podhaler 107

TOBRADEX 101

tobramycin 7




TOBREX 7

tolmetin sodium 2


tolvaptan 70

topiramate 17

toposar 31

topotecan hcl 31


torsemide 58


toujeo solostar 49

TOVIAZ 76

TPN ELECTROLYTES 70

TRACLEER 108

TRADJENTA 47

130

tramadol hcl 3


trandolapril 53


tranexamic acid 51


travoprost 104

trazodone hcl 21

TRECATOR 27

TRELEGY ELLIPTA 109

trelstar 91

tremfya 67

tretinoin 33


trexall 94

tri femynor 87

tri-estarylla 87

tri-legest fe 87

tri-linyah 88

tri-lo-estarylla 88

tri-lo-marzia 88

tri-lo-mili 88

tri-lo-sprintec 88

tri-mili 88

tri-nymyo 88

tri-previfem 88

tri-sprintec 88

tri-vylibra 88

tri-vylibra lo 88


triamterene 59


triderm 80

trientine hcl 70


trifluridine 44


TRIKAFTA 107

triklo 60


trimethoprim 9


TRINTELLIX 21

TRIUMEQ 43

trivora-28 88

tropicamide 101


trulicity 47

trumenba 96

truseltiq 33

TUKYSA 30

tulana 90

TURALIO 30

twinrix 96

TYBLUME 88

TYBOST 43

TYMLOS 99

typhim vi 96

Uudenyca 51

UKONIQ 33

UNITHROID 91

UPTRAVI 108

ursodiol 72


VALCHLOR 28


valproic acid 17


valsartan 52


VALTOCO 17

vancomycin hcl 9


(PEG-400 NADA) 9



VANDAZOLE 9

vaqta 96

131


varivax vaccine 96

VARUBI 23

VASCEPA 60

velivet 88

VEMLIDY 40

VENCLEXTA 33


venlafaxine hcl 21

verapamil hcl 56

verquvo 58

VERSACLOZ 39

VERZENIO 33

vestura 88

VIBERZI 73

VICTOZA 2-PAK 47

VICTOZA 3-PAK 47

VIDEX 42

VIDEX EC 42

vienva 88

vigabatrin 17

vigadrone 17

VIIBRYD 21

VIMPAT 18

viorele 88

VIRACEPT 43

VIREAD 42

VITRAKVI 30

VIZIMPRO 30

volnea 88

voriconazole 25

VOSEVI 40

VOTRIENT 33

VRAYLAR 38

VUMERITY 64

vyfemla 88

vylibra 88

VYNDAMAX 58

VYNDAQEL 58

VYVANSE 61

VYZULTA 104

WWAKIX 110

warfarin sodium 50

WELIREG 30

wera 88

XXALKORI 33

XARELTO 50

XATMEP 94

XCOPRI 16

XELJANZ 94

XELJANZ XR 94

XELPROS 104

XERMELO 72

xgeva 99

XIFAXAN 9

XIGDUO XR 47

XOFLUZA 44

xolair 109

XOSPATA 30

XPOVIO 30

XTAMPZA ER 3

XTANDI 28

xulane 88

XYREM 110

XYWAV 110

Yyf-vax 96

YONSA 28

yuvafem 88

Zzafemy 88

zafirlukast 106

zaleplon 110

zarah 88

zarxio 51

ZEJULA 33

132

ZELBORAF 33

zemaira 75

zenatane 67

zenpep 75

zenzedi 61

ZEPOSIA 64

ZERBAXA 11

zidovudine 42

ziextenzo 51

zingiber 71

ziprasidone hcl 39


ZIRGAN 39

zoledronic acid 99


SODIUM CHLORIDE 99


ZOLINZA 30

zolmitriptan 26


zonisamide 16

ZORTRESS 94

zovia 1-35 88

zovia 1-35e 88

zumandimine 89

ZYDELIG 33

ZYKADIA 33

ZYLET 101

133


ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 15


ANTIDEPRESSANTS 19

ANTIEMETICS 22

ANTIFUNGALS 23

ANTIGOUT AGENTS 25




ANTINEOPLASTICS 28

ANTIPARASITICS 33


ANTIPSYCHOTICS 36


ANTIVIRALS 39

ANXIOLYTICS 44

BIPOLAR AGENTS 45




















MISCELLANEOUS 110



OTIC AGENTS 104


134



135






MDC-455

11222021

11222021

Documents

Providence Medicare Advantage Plans 2021 Formulary (List