2018 list of covered drugs (formulary) · 2019-06-25 · 2018 list of covered drugs (formulary)...

2018LIST OF COVERED DRUGS (FORMULARY)

UnitedHealthcare Connected® (Medicare-Medicaid Plan)

Toll-Free 1-800-256-6533, TTY 7-1-18 a.m. - 8 p.m. local time, Monday - Friday

www.UHCCommunityPlan.comwww.myuhc.com/CommunityPlan

Formulary ID Number 00018049, Version 16

H7833_170614_101048_FINAL_01.10 Approved Last updated November 1, 2018

Prescription drug list information

If you have questions, please call UnitedHealthcare Connected at 1-800-256-6533, TTY 7-1-1,

8 a.m. - 8 p.m. local time, Monday - Friday. The call is free. For more information, visit

www.UHCCommunityPlan.com.

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UnitedHealthcare Connected® (Medicare-Medicaid Plan)

2018 List of Covered Drugs (Formulary)

This is a list of drugs that members can get in UnitedHealthcare Connected.

v UnitedHealthcare Connected® (Medicare-Medicaid Plan) is a health plan that contracts with

both Medicare and Texas Medicaid to provide benefits of both programs to enrollees.

v The List of Covered Drugs and/or pharmacy and provider networks may change throughout

the year. We will send you a notice before we make a change that affects you.

v Benefits and/or copays may change on January 1 of each year.

v You can always check UnitedHealthcare Connected’s up-to-date List of Covered Drugs

online at www.UHCCommunityPlan.com.

v Limitations, copays, and restrictions may apply. For more information, call UnitedHealthcare

Connected Member Services or read the UnitedHealthcare Connected Member Handbook.

v Copays for prescription drugs may vary based on the level of Extra Help you get. Please

contact the plan for more details.

v If you speak Spanish, language assistance services, free of charge, are available to you. Call

1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free.

v Si habla español, hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame

al 1-800-256-6533, TTY 7-1-1, de lunes a viernes, de 8 a.m. a 8 p.m., hora local. La llamada

es gratuita.

v You can get this document for free in other formats, such as large print, braille, or audio.

Call 1-800-256-6533, TTY 7-1-1, 8 a.m. - 8 p.m. local time, Monday - Friday. The call is free.

v You can call Member Services and ask us to make a note in our system that you would like

materials in Spanish, large print, braille or audio now and in the future.




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Frequently Asked Questions (FAQ)

Find answers here to questions you have about this List of Covered Drugs. You can read all of the

FAQ to learn more, or look for a question and answer.

1 What prescription drugs are on the List of Covered Drugs? (We call the

List of Covered Drugs the “Drug List” for short.)

The drugs on the List of Covered Drugs that starts on page 10 are the drugs covered by

UnitedHealthcare Connected. These drugs are available at pharmacies within our network. A

pharmacy is in our network if we have an agreement with them to work with us and provide

you services. We refer to these pharmacies as “network pharmacies.”

® UnitedHealthcare Connected will cover all medically necessary drugs on the Drug List if:

·Your doctor or other prescriber says you need them to get better or stay healthy, and

·You fill the prescription at a UnitedHealthcare Connected network pharmacy.

® UnitedHealthcare Connected may have additional steps to access certain drugs (see

question #5 below).

You can also see an up-to-date list of drugs that we cover on our website at

www.UHCCommunityPlan.com or call Member Services at 1-800-256-6533, TTY 7-1-1.

2 Does the Drug List ever change?Yes. UnitedHealthcare Connected may add or remove drugs on the Drug List during the year.

Generally, the Drug List will only change if:

·A cheaper drug comes along that works as well as a drug on the Drug List now, or

·We learn that a drug is not safe.

We may also change our rules about drugs. For example, we could:

·Decide to require or not require prior approval for a drug. (Prior approval is permission

from UnitedHealthcare Connected before you can get a drug.)

·Add or change the amount of a drug you can get (called “quantity limits”).

·Add or change step therapy restrictions on a drug. (Step therapy means you must try one

drug before we will cover another drug.)

(For more information on these drug rules, see pages 4 and 9.)




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4We will tell you when a Medicare Part D drug you are taking is removed from the Drug List.

We will also tell you when we change our rules for covering a Medicare Part D drug.

Questions 3, 4, and 7 below have more information on what happens when the Drug List

changes.

® You can always check UnitedHealthcare Connected’s up-to-date Drug List online at

www.UHCCommunityPlan.com. You can also call Member Services to check the current

Drug List at 1-800-256-6533, TTY 7-1-1.

3 What happens when a cheaper drug comes along that works as well as

a drug on the Drug List now?

If you are taking a Medicare Part D drug that is removed because a cheaper drug that works

just as well comes along, we will tell you. We will tell you at least 60 days before we remove it

from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug

before the change to the Drug List is made. You will get a letter letting you know about the

change. Contact your doctor or other prescriber to make sure this cheaper drug will work for

you.

4 What happens when we find out a drug is not safe?If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it

off the Drug List right away. We will also send you a letter telling you that. Contact your doctor

or other prescriber and ask about your other options.

5 Are there any restrictions or limits on drug coverage? Or are there any

required actions to take in order to get certain drugs?

Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases

you must do something before you can get the drug. For example:

·Prior approval (or prior authorization): For some drugs, you or your doctor or other

prescriber must get approval from UnitedHealthcare Connected before you fill your

prescription. If you don’t get approval, UnitedHealthcare Connected may not cover the

drug.

·Quantity limits: Sometimes UnitedHealthcare Connected limits the amount of a drug you

can get.

·Step therapy: Sometimes UnitedHealthcare Connected requires you to do step therapy.

This means you will have to try drugs in a certain order for your medical condition. You

might have to try one drug before we will cover another drug. If your doctor thinks the first

drug doesn’t work for you, then we will cover the second.




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5You can find out if your drug has any additional requirements or limits by looking in the tables

on pages 10 - 103. You can also get more information by visiting our website at

www.UHCCommunityPlan.com. We have posted online documents that explain our prior

authorization and step therapy restrictions. You may also ask us to send you a copy.

You can ask for an “exception” from these limits. Please see question 11 for more information

on exceptions.

® If you are in a nursing home or other long-term care facility and need a drug that is not on

the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a

31-day emergency supply of the drug you need (unless you have a prescription for fewer

days), whether or not you are a new UnitedHealthcare Connected member. This will give

you time to talk to your doctor or other prescriber. He or she can help you decide if there is

a similar drug on the Drug List you can take instead or whether to ask for an exception.

Please see question 11 for more information about exceptions.

6 How will you know if the drug you want has limitations or if there are

required actions to take to get the drug?

The List of Covered Drugs on pages 10 - 103 has a column labeled “Necessary actions,

restrictions, or limits on use.”

7 What happens if we change our rules on how we cover some drugs?

For example, if we add prior authorization (approval), quantity limits,

and/or step therapy restrictions on a drug.

We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a

drug. We will tell you at least 60 days before the restriction is added or when you next ask for a

refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is

made. This gives you time to talk to your doctor or other prescriber about what to do next.

8 How can you find a drug on the Drug List?There are two ways to find a drug:

·You can search alphabetically (if you know how to spell the drug), or

·You can search by medical condition.




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6To search alphabetically, go to the Alphabetical Listing section. You can find it after the "List

of Covered Drugs" section. Find the name of your drug. The page number where you can find

the drug will be next to it.

To search by medical condition, find the section labeled “List of drugs by medical condition”

on pages 10 - 103. The drugs in this section are grouped into categories depending on the

type of medical conditions they are used to treat. For example, if you have a heart condition,

you should look in the category, Cardiovascular Agents. That is where you will find drugs that

treat heart conditions.

9 What if the drug you want to take is not on the Drug List?If you don’t see your drug on the Drug List, call Member Services at 1-800-256-6533, TTY

7-1-1 and ask about it. If you learn that UnitedHealthcare Connected will not cover the drug,

you can do one of these things:

·Ask Member Services for a list of drugs like the one you want to take. Then show the list to

your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like

the one you want to take. Or

·You can ask the health plan to make an exception to cover your drug. Please see question

11 for more information about exceptions.

10What if you are a new UnitedHealthcare Connected member and can’t

find your drug on the Drug List or have a problem getting your drug?

We can help. We may cover a temporary 30-day supply of your drug during the first 90 days

you are a member of UnitedHealthcare Connected. This will give you time to talk to your

doctor or other prescriber. He or she can help you decide if there is a similar drug on the

Drug List you can take instead or whether to ask for an exception.

We will cover a 30-day supply of your drug if:

·You are taking a drug that is not on our Drug List, or

·Health plan rules do not let you get the amount ordered by your prescriber, or

·The drug requires prior approval by UnitedHealthcare Connected, or

·You are taking a drug that is part of a step therapy restriction.




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7If you live in a nursing home or other long-term care facility, you may refill your prescription

for as long as up to 98 days. You may refill the drug multiple times during your first 90 days

in the plan. This gives your prescriber time to change your drugs to ones on the Drug List or

ask for an exception.

You may have an unplanned transition, like a hospital discharge or a change in your level of

care, after the first 90 days of your plan membership. If this happens and you are prescribed

a drug that’s not on the Drug List or if it’s difficult for you to get your drugs, you are required

to use the plan’s exception process. You may ask for a one-time emergency supply of at

least 31 days to give you time to talk to your doctor about other treatment options or to try to

get an exception.

11Can you ask for an exception to cover your drug?Yes. You can ask UnitedHealthcare Connected to make an exception to cover a drug that is

not on the Drug List.

You can also ask us to change the rules on your drug.

·For example, UnitedHealthcare Connected may limit the amount of a drug we will cover.

If your drug has a limit, you can ask us to change the limit and cover more.

·Other examples: You can ask us to drop step therapy restrictions or prior approval

requirements.

12 How long does it take to get an exception?First, we must get a statement from your prescriber supporting your request for an

exception. After we get the statement, we will give you a decision on your exception request

within 72 hours.

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a

decision, you can ask for an expedited exception. This is a faster decision. If your prescriber

supports your request, we will give you a decision within 24 hours of getting your

prescriber’s supporting statement.

13 How can you ask for an exception?To ask for an exception, call Member Services. A Member Services representative will work

with you and your provider to help you ask for an exception.

14 What are generic drugs?Generic drugs are made up of the same active ingredients as brand name drugs. They

usually cost less than the brand name drug and usually don’t have well-known names.

Generic drugs are approved by the Food and Drug Administration (FDA).

UnitedHealthcare Connected covers both brand name drugs and generic drugs.

15 What are OTC drugs? OTC stands for “over-the-counter.” UnitedHealthcare Connected covers some OTC drugs

when they are written as prescriptions by your provider.

You can read the UnitedHealthcare Connected Drug List to see what OTC drugs are

covered.

16 Does UnitedHealthcare Connected cover OTC non-drug products?

UnitedHealthcare Connected covers some OTC non-drug products when they are written as

prescriptions by your provider.

You can read the UnitedHealthcare Connected Drug List to see what OTC non-drug

products are covered.

17 What is your copay?You can read the UnitedHealthcare Connected Drug List to learn about the copay for each

drug.

UnitedHealthcare Connected members living in nursing homes or other long-term care

facilities will have no copays. Some members getting long-term care in the community will

also have no copays.

Copays are listed by tiers. Tiers are groups of drugs with the same copay.

·Tier 1 drugs have the lowest copay. They are generic drugs. The copay is from $1.25 to

$3.35, depending on your income.

·Tier 2 drugs have a higher copay. They are brand name drugs. The copay is from $3.70

to $8.35, depending on your income.

·Tier 3 drugs have a $0 copay. They are OTCs/Non-Part D drugs.




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9For Track Refered Purpose

List of Covered Drugs

The List of Covered Drugs that begins on the next page gives you information about the drugs

covered by UnitedHealthcare Connected. If you have trouble finding your drug in the list, turn to the

Index that begins on page 104.

The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g.,

HUMALOG) and generic drugs are listed in lower-case italics (e.g., simvastatin).

The information in the “Necessary actions, restrictions, or limits on use” column tells you if

UnitedHealthcare Connected has any rules for covering your drug.

Coverage Rules and Limits

PA - Prior approval (or prior authorization)

For some drugs, you or your doctor or other prescriber must get approval from UnitedHealthcare

Connected before you fill your prescription. If you don’t get approval, UnitedHealthcare Connected

may not cover the drug.

QL - Quantity limits

Sometimes UnitedHealthcare Connected limits the amount of a drug you can get.

ST - Step therapy

Sometimes UnitedHealthcare Connected requires you to do step therapy. This means you will have

to try drugs in a certain order for your medical condition. You might have to try one drug before we

will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover

the second.

Other Special Requirements for Coverage

B/D - Medicare Part B or Part D

Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and

outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide

the plan with more information about how this drug will be used to make sure it’s correctly covered

by Medicare.

LA - Limited access

Drugs are considered “limited access” if the FDA says the drug can be given out only by certain

facilities or doctors. These drugs may require extra handling, provider coordination or patient

education that can’t be done at a network pharmacy.

MED - Morphine equivalent dose

Additional quantity limits may apply across all drugs in the opioid class used for the treatment of

pain. This additional edit is called a cumulative Morphine Equivalent Dose (MED). The MED is

calculated based on the number of opioid drugs prescribed for you over a period of time. This

cumulative limit is required for all plans and is designed to monitor safe dosing levels of opioids for

those individuals who may be taking more than one opioid drug for pain management. If your

doctor prescribes more than this amount or thinks the limit is not right for your situation, you or

your doctor can ask the plan to cover the additional quantity.

You can find information on what the symbols and abbreviations in this table mean by going to

pages 9 and 10.

CAPITALIZED = brand name drug lower-case italics = generic drug

* OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

1For Track Refered Purpose101


Note: The asterisk (*) next to a drug means the drug is not a “Part D drug.” The amount you pay

when you fill a prescription for this drug does not count towards your total drug costs (that is, the

amount you pay does not help you qualify for catastrophic coverage). In addition, if you are getting

Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these drugs.

These drugs also have different rules for appeals. An appeal is a formal way of asking us to review

a coverage decision and to change it if you think we made a mistake. For example, we might

decide that a drug that you want is not covered or is no longer covered by Medicare or Texas

Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for instructions

on how to appeal, call Member Services at 1-800-256-6533, TTY 7-1-1. You can also read the

Member Handbook to learn how to appeal a decision.

List of Drugs by Medical ConditionThe drugs in this section are grouped into categories depending on the type of medical conditions

they are used to treat. For example, if you have a heart condition, you should look in the category,

Cardiovascular Agents. That is where you will find drugs that treat heart conditions.

Name of DrugWhat the drug

will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

Analgesics

AnalgesicsAcephen

acephen (suppository)* $0 (Tier 3)Acetaminophen

acetaminophen (tablet)* $0 (Tier 3)Butalbital/Acetaminophen

butalbital/acetaminophen (50mg-325mg tablet) $1.25-$3.35 (Tier 1) QLButalbital/Acetaminophen/Caffeine

butalbital/acetaminophen/caffeine

(50mg-325mg-40mg tablet, 50mg-325mg-40mg

capsule)

$1.25-$3.35 (Tier 1) QL

Butalbital/Aspirin/Caffeine

butalbital/aspirin/caffeine (50mg-325mg-40mg

capsule)$1.25-$3.35 (Tier 1) QL

Childrens Mapap Rapid Tabs

childrens mapap rapid tabs (tablet dispersible)* $0 (Tier 3)ED-APAP

ed-apap (liquid)* $0 (Tier 3)GNP Arthritis Pain Relief

gnp arthritis pain relief (tablet extended-release)* $0 (Tier 3)Junior Mapap

junior mapap (tablet dispersible)* $0 (Tier 3)


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will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMapap

mapap (160mg/5ml liquid, 325mg tablet, 500mg

tablet, 500mg capsule, 80mg tablet chewable)*$0 (Tier 3)

Mapap Acetaminophen Extra Strength

mapap acetaminophen extra strength (liquid)* $0 (Tier 3)Mapap Arthritis Pain

mapap arthritis pain (tablet extended-release)* $0 (Tier 3)Mapap Childrens

mapap childrens (160mg/5ml suspension, 80mg

tablet dispersible)*$0 (Tier 3)

Pain & Fever

pain & fever (tablet)* $0 (Tier 3)Pain & Fever Childrens

pain & fever childrens (160mg/5ml oral solution,

160mg/5ml suspension, 80mg tablet chewable)*$0 (Tier 3)

Pain & Fever Extra Strength

pain & fever extra strength (tablet)* $0 (Tier 3)Pain & Fever Infants

pain & fever infants (suspension)* $0 (Tier 3)QC Arthritis Pain Relief

qc arthritis pain relief (tablet extended-release)* $0 (Tier 3)Q-PAP

q-pap (tablet)* $0 (Tier 3)Q-PAP Childrens

q-pap childrens (suspension)* $0 (Tier 3)Q-PAP Extra Strength

q-pap extra strength (tablet)* $0 (Tier 3)Tencon

tencon (tablet) $1.25-$3.35 (Tier 1) QLZebutal

zebutal (capsule) $1.25-$3.35 (Tier 1) QL

Nonsteroidal Anti-inflammatory DrugsAll Day Pain Relief

all day pain relief (otc only) (tablet)* $0 (Tier 3)All Day Relief

all day relief (tablet)* $0 (Tier 3)Aspirin

aspirin (325mg tablet, 325mg tablet delayed-release,

81mg tablet delayed-release, 81mg tablet

chewable)*

$0 (Tier 3)

Aspirin EC

aspirin ec (tablet delayed-release)* $0 (Tier 3)Aspirin EC Low Dose

aspirin ec low dose (tablet delayed-release)* $0 (Tier 3)Aspirin Low Dose

aspirin low dose (tablet chewable)* $0 (Tier 3)Aspirin Low Strength

aspirin low strength (tablet chewable)* $0 (Tier 3)Aspir-Low

aspir-low (tablet delayed-release)* $0 (Tier 3)Childrens Aspirin

childrens aspirin (tablet chewable)* $0 (Tier 3)Childrens Ibuprofen

childrens ibuprofen (otc only) (suspension)* $0 (Tier 3)Childs Ibuprofen

childs ibuprofen (otc only) (suspension)* $0 (Tier 3)Diclofenac Potassium

diclofenac potassium (tablet) $1.25-$3.35 (Tier 1)Diclofenac Sodium

diclofenac sodium (1% gel) $1.25-$3.35 (Tier 1) PADiclofenac Sodium DR

diclofenac sodium dr (tablet delayed-release) $1.25-$3.35 (Tier 1)Diclofenac Sodium ER

diclofenac sodium er (tablet extended-release 24

hour)$1.25-$3.35 (Tier 1)

Diflunisal

diflunisal (tablet) $1.25-$3.35 (Tier 1)


pages 9 and 10.




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will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useEnteric Coated Aspirin

enteric coated aspirin (tablet delayed-release)* $0 (Tier 3)Etodolac

etodolac (200mg capsule, 300mg capsule, 400mg

tablet immediate-release, 500mg tablet immediate-

release)

$1.25-$3.35 (Tier 1)

Flector

FLECTOR (PATCH) $3.70-$8.35 (Tier 2) PA, QLFlurbiprofen

flurbiprofen (tablet) $1.25-$3.35 (Tier 1)GNP Ibuprofen

gnp ibuprofen (otc only) (tablet)* $0 (Tier 3)GNP Ibuprofen Junior Strength

gnp ibuprofen junior strength (otc only) (tablet

chewable)*$0 (Tier 3)

Goodsense Ibuprofen

goodsense ibuprofen (tablet)* $0 (Tier 3)Goodsense Ibuprofen Childrens

goodsense ibuprofen childrens (suspension)* $0 (Tier 3)Goodsense Ibuprofen Infants

goodsense ibuprofen infants (suspension)* $0 (Tier 3)Ibu

ibu (tablet) $1.25-$3.35 (Tier 1)Ibu-200

ibu-200 (tablet)* $0 (Tier 3)Ibu-Drops

ibu-drops (suspension)* $0 (Tier 3)Ibu-Drops Infants

ibu-drops infants (suspension)* $0 (Tier 3)Ibuprofen

ibuprofen (otc only) (100mg/5ml suspension, 200mg

capsule, 200mg tablet)*$0 (Tier 3)

Ibuprofen

ibuprofen (rx only) (100mg/5ml suspension, 400mg

tablet, 600mg tablet, 800mg tablet)$1.25-$3.35 (Tier 1)

Ibuprofen Childrens

ibuprofen childrens (otc only) (suspension)* $0 (Tier 3)Ibuprofen Junior Strength

ibuprofen junior strength (otc only) (tablet

chewable)*$0 (Tier 3)

Indomethacin

indomethacin (25mg capsule, 50mg capsule) $1.25-$3.35 (Tier 1)Infants Ibuprofen

infants ibuprofen (otc only) (suspension)* $0 (Tier 3)Ketorolac Tromethamine

ketorolac tromethamine (15mg/ml injection, 30mg/

ml injection, 60mg/2ml injection)$1.25-$3.35 (Tier 1)

Meloxicam

meloxicam (tablet) $1.25-$3.35 (Tier 1)Migraine Formula

migraine formula (tablet)* $0 (Tier 3)


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will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useNaproxen

naproxen (125mg/5ml suspension, 250mg tablet

immediate-release, 375mg tablet immediate-release,

500mg tablet immediate-release)

$1.25-$3.35 (Tier 1)

Naproxen DR

naproxen dr (tablet delayed-release) (generic ec-

naprosyn)$1.25-$3.35 (Tier 1)

QC Naproxen Sodium

qc naproxen sodium (otc only) (tablet)* $0 (Tier 3)SM Ibuprofen

sm ibuprofen (otc only) (tablet)* $0 (Tier 3)Sulindac

sulindac (tablet) $1.25-$3.35 (Tier 1)

Opioid Analgesics, Long-actingEmbeda

EMBEDA (CAPSULE EXTENDED-RELEASE) $3.70-$8.35 (Tier 2) QL, MEDFentanyl

fentanyl (100mcg/hr patch 72 hour, 12mcg/hr patch

72 hour, 25mcg/hr patch 72 hour, 50mcg/hr patch

72 hour, 75mcg/hr patch 72 hour)

$1.25-$3.35 (Tier 1) QL, MED

Hydromorphone HCl ER

hydromorphone hcl er (tablet extended-release 24

hour abuse-deterrent)$1.25-$3.35 (Tier 1) QL, MED

Hysingla ER

HYSINGLA ER (TABLET EXTENDED-RELEASE 24 HOUR

ABUSE-DETERRENT)$3.70-$8.35 (Tier 2) QL, MED

Levorphanol Tartrate

levorphanol tartrate (tablet) $1.25-$3.35 (Tier 1) QL, MEDMethadone HCl

methadone hcl (10mg tablet, 5mg tablet, 10mg/5ml

oral solution, 5mg/5ml oral solution)$1.25-$3.35 (Tier 1) QL, MED

Methadone HCl

METHADONE HCL (10MG/ML INJECTION) $3.70-$8.35 (Tier 2)Morphine Sulfate ER

morphine sulfate er (100mg tablet extended-release,

15mg tablet extended-release, 200mg tablet

extended-release, 30mg tablet extended-release,

60mg tablet extended-release) (generic ms contin)

$1.25-$3.35 (Tier 1) QL, MED

Nucynta ER

NUCYNTA ER (TABLET EXTENDED-RELEASE 12 HOUR) $3.70-$8.35 (Tier 2) QL, MEDTramadol HCl ER

tramadol hcl er (100mg tablet extended-release 24

hour, 200mg tablet extended-release 24 hour,

300mg tablet extended-release 24 hour)

$1.25-$3.35 (Tier 1) QL, MED

Xtampza ER

XTAMPZA ER (CAPSULE EXTENDED-RELEASE 12

HOUR ABUSE-DETERRENT)$3.70-$8.35 (Tier 2) QL, MED

Opioid Analgesics, Short-actingAbstral

ABSTRAL (TABLET SUBLINGUAL) $3.70-$8.35 (Tier 2) PA, QLAcetaminophen/Codeine

acetaminophen/codeine (120mg-12mg/5ml oral

solution, 300mg-15mg tablet, 300mg-30mg tablet,

300mg-60mg tablet)

$1.25-$3.35 (Tier 1) QL, MED

Butorphanol Tartrate

butorphanol tartrate (10mg/ml nasal solution) $1.25-$3.35 (Tier 1) QL, MED


pages 9 and 10.




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will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useButorphanol Tartrate

butorphanol tartrate (1mg/ml injection, 2mg/ml

injection)$1.25-$3.35 (Tier 1)

Codeine Sulfate

codeine sulfate (tablet) $1.25-$3.35 (Tier 1) QL, MEDDuramorph

DURAMORPH (INJECTION) $3.70-$8.35 (Tier 2)Endocet

endocet (tablet) $1.25-$3.35 (Tier 1) QL, MEDFentanyl Citrate Oral Transmucosal

fentanyl citrate oral transmucosal (lozenge on a

handle)$1.25-$3.35 (Tier 1) PA, QL

Hydrocodone/Acetaminophen

hydrocodone/acetaminophen (10mg-325mg tablet,

2.5mg-325mg tablet, 5mg-325mg tablet,

7.5mg-325mg tablet, 7.5mg-325mg/15ml oral

solution)

$1.25-$3.35 (Tier 1) QL, MED

Hydrocodone/Ibuprofen

hydrocodone/ibuprofen (7.5mg-200mg tablet) $1.25-$3.35 (Tier 1) QL, MEDHydromorphone HCl

hydromorphone hcl (10mg/ml injection, 50mg/5ml


Hydromorphone HCl

hydromorphone hcl (1mg/ml liquid, 2mg tablet



$1.25-$3.35 (Tier 1) QL, MED

Hydromorphone HCl

HYDROMORPHONE HCL (2MG/ML INJECTION) $3.70-$8.35 (Tier 2)Lorcet

lorcet (tablet) $1.25-$3.35 (Tier 1) QL, MEDLorcet HD

lorcet hd (tablet) $1.25-$3.35 (Tier 1) QL, MEDLorcet Plus

lorcet plus (tablet) $1.25-$3.35 (Tier 1) QL, MEDMorphine Sulfate

morphine sulfate (100mg/5ml oral solution, 10mg/

5ml oral solution, 20mg/5ml oral solution)$1.25-$3.35 (Tier 1) QL, MED

Morphine Sulfate

morphine sulfate (10mg/ml injection, 4mg/ml

injection, 8mg/ml injection)$1.25-$3.35 (Tier 1)

Morphine Sulfate

MORPHINE SULFATE (15MG TABLET IMMEDIATE-

RELEASE, 30MG TABLET IMMEDIATE-RELEASE)$3.70-$8.35 (Tier 2) QL, MED

Morphine Sulfate

MORPHINE SULFATE (2MG/ML INJECTION, 5MG/ML

INJECTION)$3.70-$8.35 (Tier 2)

Nalbuphine HCl

nalbuphine hcl (injection) $1.25-$3.35 (Tier 1)


15


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useOxycodone HCl

oxycodone hcl (100mg/5ml concentrate, 10mg


release, 20mg tablet immediate-release, 30mg tablet


5mg/5ml oral solution)

$1.25-$3.35 (Tier 1) QL, MED

Oxycodone/Acetaminophen

oxycodone/acetaminophen (10mg-325mg tablet,

2.5mg-325mg tablet, 5mg-325mg tablet,

7.5mg-325mg tablet)

$1.25-$3.35 (Tier 1) QL, MED

Oxycodone/Aspirin

oxycodone/aspirin (tablet) $1.25-$3.35 (Tier 1) QL, MEDOxycodone/Ibuprofen

oxycodone/ibuprofen (tablet) $1.25-$3.35 (Tier 1) QL, MEDTramadol HCl

tramadol hcl (tablet immediate-release) $1.25-$3.35 (Tier 1) QL, MEDTramadol HCl/Acetaminophen

tramadol hcl/acetaminophen (tablet) $1.25-$3.35 (Tier 1) QL, MEDTrezix

trezix (capsule) $1.25-$3.35 (Tier 1) QL, MED

Anesthetics

Local AnestheticsLidocaine

lidocaine (rx only) (5% ointment) $1.25-$3.35 (Tier 1)Lidocaine

lidocaine (rx only) (5% patch) $1.25-$3.35 (Tier 1) PA, QLLidocaine HCl

lidocaine hcl (0.5% injection, 1% injection, 2%

injection)$1.25-$3.35 (Tier 1) B/D, PA

Lidocaine HCl

lidocaine hcl (4% external solution) $1.25-$3.35 (Tier 1)Lidocaine HCl

lidocaine hcl (gel) $1.25-$3.35 (Tier 1)Lidocaine Viscous

lidocaine viscous (solution) $1.25-$3.35 (Tier 1)Lidocaine/Prilocaine

lidocaine/prilocaine (cream) $1.25-$3.35 (Tier 1)

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-cravingAcamprosate Calcium DR

acamprosate calcium dr (tablet delayed-release) $1.25-$3.35 (Tier 1)Disulfiram

disulfiram (tablet) $1.25-$3.35 (Tier 1)Naltrexone HCl

naltrexone hcl (tablet) $1.25-$3.35 (Tier 1)Vivitrol

VIVITROL (INJECTION) $3.70-$8.35 (Tier 2)

Opioid Dependence TreatmentsBuprenorphine HCl

buprenorphine hcl (0.3mg/ml injection) $1.25-$3.35 (Tier 1)Buprenorphine HCl

buprenorphine hcl (2mg tablet sublingual, 8mg

tablet sublingual)$1.25-$3.35 (Tier 1) QL

Buprenorphine HCl/Naloxone HCl

buprenorphine hcl/naloxone hcl (tablet sublingual) $1.25-$3.35 (Tier 1) QLSuboxone

SUBOXONE (FILM) $3.70-$8.35 (Tier 2) QL


pages 9 and 10.




16


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

Opioid Reversal Agents Naloxone HCl

naloxone hcl (injection) $1.25-$3.35 (Tier 1)Narcan

NARCAN (LIQUID) $3.70-$8.35 (Tier 2)

Smoking Cessation AgentsBupropion HCl SR

bupropion hcl sr (150mg tablet extended-release 12

hour smoking-deterrent)$1.25-$3.35 (Tier 1)

Chantix

CHANTIX (TABLET) $3.70-$8.35 (Tier 2)Chantix Continuing Month Pak

CHANTIX CONTINUING MONTH PAK (TABLET) $3.70-$8.35 (Tier 2)Chantix Starting Month Pak

CHANTIX STARTING MONTH PAK (TABLET) $3.70-$8.35 (Tier 2)NicoDerm CQ

nicoderm cq (patch 24 hour)* $0 (Tier 3)NICOrelief

nicorelief (gum)* $0 (Tier 3)Nicorette

nicorette (2mg gum, 4mg gum, 2mg lozenge, 4mg

lozenge)*$0 (Tier 3)

Nicorette Mini

nicorette mini (lozenge)* $0 (Tier 3)Nicorette Starter Kit

nicorette starter kit (gum)* $0 (Tier 3)Nicotine Polacrilex

nicotine polacrilex (2mg gum, 4mg gum, 2mg

lozenge, 4mg lozenge)*$0 (Tier 3)

Nicotine Transdermal System

nicotine transdermal system (14mg/24hr patch 24

hour, 21mg/24hr patch 24 hour, 7mg/24hr patch 24

hour)*

$0 (Tier 3)

Nicotine Transdermal System Step 1

nicotine transdermal system step 1 (patch 24 hour)* $0 (Tier 3)Nicotine Transdermal System Step 2

nicotine transdermal system step 2 (patch 24 hour)* $0 (Tier 3)Nicotine Transdermal System Step 3

nicotine transdermal system step 3 (patch 24 hour)* $0 (Tier 3)Nicotrol

NICOTROL (INHALER) $3.70-$8.35 (Tier 2)

Antibacterials

AminoglycosidesAmikacin Sulfate

amikacin sulfate (injection) $1.25-$3.35 (Tier 1)


17


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useGentak

gentak (ophthalmic ointment) $1.25-$3.35 (Tier 1)Gentamicin Sulfate

gentamicin sulfate (0.1% cream, 0.1% ointment,

0.3% ophthalmic solution, 40mg/ml injection)$1.25-$3.35 (Tier 1)

Gentamicin Sulfate/0.9% Sodium Chloride

gentamicin sulfate/0.9% sodium chloride (injection) $1.25-$3.35 (Tier 1)Isotonic Gentamicin

isotonic gentamicin (injection) $1.25-$3.35 (Tier 1)Neomycin Sulfate

neomycin sulfate (tablet) $1.25-$3.35 (Tier 1)Paromomycin Sulfate

paromomycin sulfate (capsule) $1.25-$3.35 (Tier 1)Streptomycin Sulfate

streptomycin sulfate (injection) $1.25-$3.35 (Tier 1)Tobramycin Sulfate

tobramycin sulfate (0.3% ophthalmic solution, 10mg/

ml injection, 80mg/2ml injection)$1.25-$3.35 (Tier 1)

Tobrex

TOBREX (0.3% OPHTHALMIC OINTMENT) $3.70-$8.35 (Tier 2)

Antibacterials, OtherBACiiM

baciim (injection) $1.25-$3.35 (Tier 1)Bacitracin

bacitracin (otc only) (ointment)* $0 (Tier 3)Bacitracin

bacitracin (rx only) (50000unit injection, 500unit/gm

ophthalmic ointment)$1.25-$3.35 (Tier 1)

Bacitracin Zinc

bacitracin zinc (ointment)* $0 (Tier 3)Bacitracin/Neomycin/Polymyxin

bacitracin/neomycin/polymyxin (otc only)

(ointment)*$0 (Tier 3)

Bactroban Nasal

BACTROBAN NASAL (OINTMENT) $3.70-$8.35 (Tier 2) PAChloramphenicol Sodium Succinate

chloramphenicol sodium succinate (injection) $1.25-$3.35 (Tier 1)Clindamycin HCl

clindamycin hcl (capsule immediate-release) $1.25-$3.35 (Tier 1)Clindamycin Palmitate HCl

clindamycin palmitate hcl (oral solution) $1.25-$3.35 (Tier 1)Clindamycin Phosphate

clindamycin phosphate (2% cream, 300mg/2ml

injection, 600mg/4ml injection, 900mg/6ml injection)$1.25-$3.35 (Tier 1)

Clindamycin Phosphate in D5W

clindamycin phosphate in d5w (injection) $1.25-$3.35 (Tier 1)Colistimethate Sodium

colistimethate sodium (injection) $1.25-$3.35 (Tier 1)Cubicin

CUBICIN (INJECTION) $3.70-$8.35 (Tier 2)Dalvance

DALVANCE (INJECTION) $3.70-$8.35 (Tier 2) PADaptomycin

daptomycin (injection) $1.25-$3.35 (Tier 1)Lincomycin HCl

lincomycin hcl (injection) $1.25-$3.35 (Tier 1)Linezolid

linezolid (100mg/5ml suspension, 600mg/300ml

injection)$1.25-$3.35 (Tier 1) PA

Linezolid

linezolid (600mg tablet) $1.25-$3.35 (Tier 1) PA, QLMethenamine Hippurate

methenamine hippurate (tablet) $1.25-$3.35 (Tier 1)


pages 9 and 10.




18


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMetronidazole

metronidazole (0.75% cream, 0.75% gel, 1% gel,

0.75% lotion, 250mg tablet immediate-release,


$1.25-$3.35 (Tier 1)

Metronidazole in NaCl 0.79%

metronidazole in nacl 0.79% (injection) $1.25-$3.35 (Tier 1)Metronidazole Vaginal

metronidazole vaginal (gel) $1.25-$3.35 (Tier 1)Mupirocin

mupirocin (2% ointment) $1.25-$3.35 (Tier 1)Neomycin/Polymyxin B Sulfates

neomycin/polymyxin b sulfates (irrigation solution) $1.25-$3.35 (Tier 1)Nitrofurantoin

nitrofurantoin (suspension) $1.25-$3.35 (Tier 1)Nitrofurantoin Macrocrystals

nitrofurantoin macrocrystals (100mg capsule, 50mg

capsule) (generic macrodantin)$1.25-$3.35 (Tier 1)

Nitrofurantoin Monohydrate

nitrofurantoin monohydrate (100mg capsule)

(generic macrobid)$1.25-$3.35 (Tier 1)

Polymyxin B Sulfate

polymyxin b sulfate (injection) $1.25-$3.35 (Tier 1)Povidone-Iodine

povidone-iodine (10% external solution, 10%

ointment)*$0 (Tier 3)

Synercid

SYNERCID (INJECTION) $3.70-$8.35 (Tier 2)Tigecycline

TIGECYCLINE (INJECTION) $3.70-$8.35 (Tier 2)Tinidazole

tinidazole (tablet) $1.25-$3.35 (Tier 1)Trimethoprim

trimethoprim (tablet) $1.25-$3.35 (Tier 1)Triple Antibiotic

triple antibiotic (ointment)* $0 (Tier 3)Triple Antibiotic Plus

triple antibiotic plus (ointment)* $0 (Tier 3)Tygacil

TYGACIL (INJECTION) $3.70-$8.35 (Tier 2)Vancomycin HCl

vancomycin hcl (10gm injection, 1gm injection,

500mg injection, 125mg capsule, 250mg capsule)$1.25-$3.35 (Tier 1)

Vandazole

VANDAZOLE (GEL) $3.70-$8.35 (Tier 2)

Beta-lactam, CephalosporinsCefaclor

cefaclor (250mg capsule immediate-release, 500mg

capsule immediate-release)$1.25-$3.35 (Tier 1)


19


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useCefadroxil

cefadroxil (250mg/5ml suspension, 500mg/5ml

suspension, 500mg capsule)$1.25-$3.35 (Tier 1)

Cefazolin Sodium

cefazolin sodium (injection) $1.25-$3.35 (Tier 1)Cefdinir

cefdinir (125mg/5ml suspension, 250mg/5ml

suspension, 300mg capsule)$1.25-$3.35 (Tier 1)

Cefepime

cefepime (injection) $1.25-$3.35 (Tier 1)Cefixime

cefixime (suspension) $1.25-$3.35 (Tier 1)Cefotaxime Sodium

cefotaxime sodium (injection) $1.25-$3.35 (Tier 1)Cefotetan

cefotetan (injection) $1.25-$3.35 (Tier 1)Cefoxitin Sodium

cefoxitin sodium (10gm injection, 1gm injection, 2gm


Cefpodoxime Proxetil

cefpodoxime proxetil (100mg tablet, 200mg tablet,

100mg/5ml suspension, 50mg/5ml suspension)$1.25-$3.35 (Tier 1)

Cefprozil

cefprozil (125mg/5ml suspension, 250mg/5ml

suspension, 250mg tablet, 500mg tablet)$1.25-$3.35 (Tier 1)

Ceftazidime

ceftazidime (injection) $1.25-$3.35 (Tier 1)Ceftriaxone Sodium

ceftriaxone sodium (10gm injection, 1gm injection,

250mg injection, 2gm injection, 500mg injection)$1.25-$3.35 (Tier 1)

Cefuroxime Axetil

cefuroxime axetil (tablet) $1.25-$3.35 (Tier 1)Cefuroxime Sodium

cefuroxime sodium (1.5gm injection, 7.5gm injection,

750mg injection)$1.25-$3.35 (Tier 1)

Cephalexin

cephalexin (125mg/5ml suspension, 250mg/5ml

suspension, 250mg capsule, 500mg capsule, 750mg

capsule)

$1.25-$3.35 (Tier 1)

Suprax

suprax (100mg tablet chewable, 200mg tablet

chewable)$1.25-$3.35 (Tier 1)

Suprax

SUPRAX (400MG CAPSULE, 500MG/5ML SUSPENSION) $3.70-$8.35 (Tier 2)Tazicef

tazicef (injection) $1.25-$3.35 (Tier 1)Zerbaxa

ZERBAXA (INJECTION) $3.70-$8.35 (Tier 2) PA

Beta-lactam, OtherAzactam

AZACTAM (INJECTION) $3.70-$8.35 (Tier 2)Aztreonam

aztreonam (injection) $1.25-$3.35 (Tier 1)Doripenem

DORIPENEM (INJECTION) $3.70-$8.35 (Tier 2)Imipenem/Cilastatin

imipenem/cilastatin (injection) $1.25-$3.35 (Tier 1)Invanz

INVANZ (INJECTION) $3.70-$8.35 (Tier 2)Meropenem

meropenem (injection) $1.25-$3.35 (Tier 1)

Beta-lactam, Penicillins


pages 9 and 10.




20


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useAmoxicillin

amoxicillin (125mg tablet chewable, 250mg tablet

chewable, 125mg/5ml suspension, 200mg/5ml

suspension, 250mg/5ml suspension, 400mg/5ml

suspension, 250mg capsule, 500mg capsule, 500mg

tablet, 875mg tablet)

$1.25-$3.35 (Tier 1)

Amoxicillin/Clavulanate Potassium

amoxicillin/clavulanate potassium (200mg-28.5mg

tablet chewable, 400mg-57mg tablet chewable,

200mg/5ml-28.5mg/5ml suspension, 250mg/

5ml-62.5mg/5ml suspension, 400mg/5ml-57mg/5ml

suspension, 600mg/5ml-42.9mg/5ml suspension,

250mg-125mg tablet immediate-release,

500mg-125mg tablet immediate-release,

875mg-125mg tablet immediate-release) (generic

augmentin)

$1.25-$3.35 (Tier 1)

Amoxicillin/Clavulanate Potassium ER

amoxicillin/clavulanate potassium er (tablet

extended-release 12 hour)$1.25-$3.35 (Tier 1)

Ampicillin

ampicillin (capsule) $1.25-$3.35 (Tier 1)Ampicillin Sodium

ampicillin sodium (10gm injection, 125mg injection,

1gm injection)$1.25-$3.35 (Tier 1)

Ampicillin-Sulbactam

ampicillin-sulbactam (injection) $1.25-$3.35 (Tier 1)Bactocill in Dextrose

BACTOCILL IN DEXTROSE (INJECTION) $3.70-$8.35 (Tier 2)Bicillin C-R

BICILLIN C-R (INJECTION) $3.70-$8.35 (Tier 2)Bicillin L-A

BICILLIN L-A (INJECTION) $3.70-$8.35 (Tier 2)Dicloxacillin Sodium

dicloxacillin sodium (capsule) $1.25-$3.35 (Tier 1)Nafcillin Sodium

nafcillin sodium (10gm injection, 1gm injection) $1.25-$3.35 (Tier 1)Oxacillin Sodium

oxacillin sodium (injection) $1.25-$3.35 (Tier 1)Penicillin G Potassium

penicillin g potassium (injection) $1.25-$3.35 (Tier 1)Penicillin G Procaine

penicillin g procaine (injection) $1.25-$3.35 (Tier 1)Penicillin G Sodium

penicillin g sodium (injection) $1.25-$3.35 (Tier 1)


21


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on usePenicillin V Potassium

penicillin v potassium (125mg/5ml oral solution,

250mg/5ml oral solution, 250mg tablet, 500mg

tablet)

$1.25-$3.35 (Tier 1)

Piperacillin/Tazobactam

piperacillin/tazobactam (injection) $1.25-$3.35 (Tier 1)

MacrolidesAzithromycin

azithromycin (100mg/5ml suspension, 200mg/5ml

suspension, 250mg tablet, 500mg tablet, 600mg

tablet, 500mg injection)

$1.25-$3.35 (Tier 1)

Clarithromycin

clarithromycin (125mg/5ml suspension, 250mg/5ml

suspension, 250mg tablet, 500mg tablet)$1.25-$3.35 (Tier 1)

Clarithromycin ER

clarithromycin er (tablet extended-release 24 hour) $1.25-$3.35 (Tier 1)Dificid

DIFICID (TABLET) $3.70-$8.35 (Tier 2)E.E.S. Granules

E.E.S. GRANULES (SUSPENSION) $3.70-$8.35 (Tier 2)Ery-Tab

ery-tab (tablet delayed-release) $1.25-$3.35 (Tier 1)EryPed 200

ERYPED 200 (SUSPENSION) $3.70-$8.35 (Tier 2)EryPed 400

ERYPED 400 (SUSPENSION) $3.70-$8.35 (Tier 2)Erythrocin Lactobionate

erythrocin lactobionate (injection) $1.25-$3.35 (Tier 1)Erythromycin

erythromycin (250mg capsule delayed-release, 5mg/

gm ophthalmic ointment)$1.25-$3.35 (Tier 1)

Erythromycin Base

erythromycin base (tablet) $1.25-$3.35 (Tier 1)Erythromycin Ethylsuccinate

erythromycin ethylsuccinate (200mg/5ml

suspension, 400mg tablet)$1.25-$3.35 (Tier 1)

QuinolonesCiprofloxacin

ciprofloxacin (suspension) $1.25-$3.35 (Tier 1)Ciprofloxacin ER

ciprofloxacin er (tablet extended-release 24 hour) $1.25-$3.35 (Tier 1)Ciprofloxacin HCl

ciprofloxacin hcl (0.3% ophthalmic solution) $1.25-$3.35 (Tier 1)Ciprofloxacin HCl

ciprofloxacin hcl (tablet immediate-release) $1.25-$3.35 (Tier 1)Ciprofloxacin I.V. in D5W

ciprofloxacin i.v. in d5w (injection) $1.25-$3.35 (Tier 1)Levofloxacin

levofloxacin (0.5% ophthalmic solution, 250mg

tablet, 500mg tablet, 750mg tablet, 25mg/ml

injection, 25mg/ml oral solution)

$1.25-$3.35 (Tier 1)

Levofloxacin in D5W

levofloxacin in d5w (injection) $1.25-$3.35 (Tier 1)Moxeza

MOXEZA (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2)Moxifloxacin HCl/Sodium HCl

MOXIFLOXACIN HCL/SODIUM HCL (INJECTION) $1.25-$3.35 (Tier 1)Moxifloxacin HCl

moxifloxacin hcl (ophthalmic solution) $1.25-$3.35 (Tier 1)Moxifloxacin HCl

moxifloxacin hcl (tablet) $1.25-$3.35 (Tier 1)


pages 9 and 10.




22


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useOfloxacin

ofloxacin (0.3% ophthalmic solution, 0.3% otic

solution, 300mg tablet, 400mg tablet)$1.25-$3.35 (Tier 1)

SulfonamidesSilver Sulfadiazine

SILVER SULFADIAZINE (CREAM) $3.70-$8.35 (Tier 2)Sodium Sulfacetamide

sodium sulfacetamide (ophthalmic solution) $1.25-$3.35 (Tier 1)SSD

SSD (CREAM) $3.70-$8.35 (Tier 2)Sulfacetamide Sodium

sulfacetamide sodium (ophthalmic ointment) $1.25-$3.35 (Tier 1)Sulfadiazine

sulfadiazine (tablet) $1.25-$3.35 (Tier 1)Sulfamethoxazole/Trimethoprim

sulfamethoxazole/trimethoprim (200mg-40mg/5ml

suspension, 400mg-80mg tablet, 400mg-80mg/5ml

injection)

$1.25-$3.35 (Tier 1)

Sulfamethoxazole/Trimethoprim DS

sulfamethoxazole/trimethoprim ds (tablet) $1.25-$3.35 (Tier 1)

TetracyclinesDemeclocycline HCl

demeclocycline hcl (tablet) $1.25-$3.35 (Tier 1)Doxy 100

doxy 100 (injection) $1.25-$3.35 (Tier 1)Doxycycline

doxycycline (25mg/5ml suspension) $1.25-$3.35 (Tier 1)Doxycycline Hyclate

doxycycline hyclate (100mg capsule, 50mg capsule,

100mg tablet immediate-release, 150mg tablet



$1.25-$3.35 (Tier 1)

Doxycycline Monohydrate

doxycycline monohydrate (100mg capsule, 50mg

capsule, 100mg tablet, 50mg tablet, 75mg tablet)$1.25-$3.35 (Tier 1)

Minocycline HCl

minocycline hcl (100mg capsule, 50mg capsule,

75mg capsule)$1.25-$3.35 (Tier 1)

Tetracycline HCl

tetracycline hcl (capsule) $1.25-$3.35 (Tier 1)Vibramycin

VIBRAMYCIN (50MG/5ML SYRUP) $3.70-$8.35 (Tier 2)

Anticonvulsants

Anticonvulsants, Other


23


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useBriviact

BRIVIACT (100MG TABLET, 10MG TABLET, 25MG

TABLET, 50MG TABLET, 75MG TABLET, 10MG/ML

ORAL SOLUTION, 50MG/5ML INJECTION)$3.70-$8.35 (Tier 2) QL

Levetiracetam

levetiracetam (1000mg tablet immediate-release,



1000mg/100ml injection, 1500mg/100ml injection,

500mg/100ml injection, 500mg/5ml injection,

100mg/ml oral solution)

$1.25-$3.35 (Tier 1)

Levetiracetam ER

levetiracetam er (tablet extended-release 24 hour) $1.25-$3.35 (Tier 1)Roweepra

roweepra (tablet) $1.25-$3.35 (Tier 1)Roweepra XR

roweepra xr (tablet extended-release 24 hour) $1.25-$3.35 (Tier 1)Spritam

SPRITAM (TABLET DISINTEGRATING SOLUBLE) $3.70-$8.35 (Tier 2)

Calcium Channel Modifying AgentsCelontin

CELONTIN (CAPSULE) $3.70-$8.35 (Tier 2)Ethosuximide

ethosuximide (250mg capsule, 250mg/5ml oral

solution)$1.25-$3.35 (Tier 1)

Zonisamide

zonisamide (capsule) $1.25-$3.35 (Tier 1)

Gamma-aminobutyric Acid (GABA) Augmenting AgentsDiastat AcuDial

DIASTAT ACUDIAL (GEL) $3.70-$8.35 (Tier 2)Diastat Pediatric

DIASTAT PEDIATRIC (GEL) $3.70-$8.35 (Tier 2)Gabapentin

gabapentin (100mg capsule, 300mg capsule, 400mg

capsule, 250mg/5ml oral solution, 600mg tablet,

800mg tablet)

$1.25-$3.35 (Tier 1)

Gabitril

GABITRIL (12MG TABLET, 16MG TABLET) $3.70-$8.35 (Tier 2)Onfi

ONFI (10MG TABLET, 20MG TABLET) $3.70-$8.35 (Tier 2) QLOnfi

ONFI (2.5MG/ML SUSPENSION) $3.70-$8.35 (Tier 2)Phenobarbital

phenobarbital (100mg tablet, 15mg tablet, 16.2mg

tablet, 30mg tablet, 32.4mg tablet, 60mg tablet,

64.8mg tablet, 97.2mg tablet, 20mg/5ml elixir)

$1.25-$3.35 (Tier 1)

Primidone

primidone (tablet) $1.25-$3.35 (Tier 1)Sabril

SABRIL (500MG PACKET, 500MG TABLET) $3.70-$8.35 (Tier 2) PA, QL, LATiagabine HCl

tiagabine hcl (tablet) $1.25-$3.35 (Tier 1)Valproate Sodium

valproate sodium (100mg/ml injection) $1.25-$3.35 (Tier 1)Valproic Acid

valproic acid (250mg capsule, 250mg/5ml oral


Vigabatrin

vigabatrin (packet) $1.25-$3.35 (Tier 1) PA, QL


pages 9 and 10.




24


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

Glutamate Reducing AgentsFelbamate

felbamate (400mg tablet, 600mg tablet, 600mg/5ml

suspension)$1.25-$3.35 (Tier 1)

Fycompa

FYCOMPA (0.5MG/ML SUSPENSION, 10MG TABLET,

12MG TABLET, 2MG TABLET, 4MG TABLET, 6MG

TABLET, 8MG TABLET)$3.70-$8.35 (Tier 2)

Lamotrigine

lamotrigine (100mg tablet immediate-release, 150mg



chewable, 5mg tablet chewable)

$1.25-$3.35 (Tier 1)

Topiramate

topiramate (100mg tablet, 200mg tablet, 25mg

tablet, 50mg tablet, 15mg capsule sprinkle

immediate-release, 25mg capsule sprinkle

immediate-release)

$1.25-$3.35 (Tier 1)

Sodium Channel AgentsAptiom

APTIOM (TABLET) $3.70-$8.35 (Tier 2) QLBanzel

BANZEL (200MG TABLET, 400MG TABLET, 40MG/ML

SUSPENSION)$3.70-$8.35 (Tier 2)

Carbamazepine

carbamazepine (100mg tablet chewable, 100mg/5ml

suspension, 200mg tablet immediate-release)$1.25-$3.35 (Tier 1)

Carbamazepine ER

carbamazepine er (100mg capsule extended-release

12 hour, 200mg capsule extended-release 12 hour,

300mg capsule extended-release 12 hour, 100mg

tablet extended-release 12 hour, 200mg tablet

extended-release 12 hour, 400mg tablet extended-

release 12 hour)

$1.25-$3.35 (Tier 1)

Dilantin

dilantin (capsule) $1.25-$3.35 (Tier 1)Dilantin INFATABS

dilantin infatabs (tablet chewable) $1.25-$3.35 (Tier 1)Epitol

epitol (tablet) $1.25-$3.35 (Tier 1)Fosphenytoin Sodium

fosphenytoin sodium (injection) $1.25-$3.35 (Tier 1)


25


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useOxcarbazepine

oxcarbazepine (150mg tablet, 300mg tablet, 600mg

tablet, 300mg/5ml suspension)$1.25-$3.35 (Tier 1)

Peganone

PEGANONE (TABLET) $3.70-$8.35 (Tier 2)Phenytek

phenytek (capsule) $1.25-$3.35 (Tier 1)Phenytoin

phenytoin (125mg/5ml suspension, 50mg tablet

chewable)$1.25-$3.35 (Tier 1)

Phenytoin Sodium

phenytoin sodium (injection) $1.25-$3.35 (Tier 1)Phenytoin Sodium Extended

phenytoin sodium extended (capsule) $1.25-$3.35 (Tier 1)Vimpat

VIMPAT (100MG TABLET, 150MG TABLET, 200MG

TABLET, 50MG TABLET, 10MG/ML ORAL SOLUTION)$3.70-$8.35 (Tier 2) QL

Vimpat

VIMPAT (200MG/20ML INJECTION) $3.70-$8.35 (Tier 2)

Antidementia Agents

Cholinesterase InhibitorsDonepezil HCl

donepezil hcl (10mg tablet, 5mg tablet) $1.25-$3.35 (Tier 1) QLDonepezil HCl ODT

donepezil hcl odt (tablet dispersible) $1.25-$3.35 (Tier 1) QLRivastigmine Tartrate

rivastigmine tartrate (capsule) $1.25-$3.35 (Tier 1) QLRivastigmine Transdermal System

rivastigmine transdermal system (patch 24 hour) $1.25-$3.35 (Tier 1) QL, ST

N-methyl-D-aspartate (NMDA) Receptor AntagonistMemantine HCl

memantine hcl (10mg tablet, 5mg tablet, 2mg/ml

oral solution)$1.25-$3.35 (Tier 1) PA, QL

Memantine HCl ER

memantine hcl er (capsule extended-release 24

hour)$1.25-$3.35 (Tier 1) PA, QL

Memantine HCl Titration Pak

MEMANTINE HCL TITRATION PAK (TABLET) $3.70-$8.35 (Tier 2) PANamenda XR

NAMENDA XR (CAPSULE EXTENDED-RELEASE 24

HOUR)$3.70-$8.35 (Tier 2) PA, QL

Namenda XR Titration Pack

NAMENDA XR TITRATION PACK (CAPSULE EXTENDED-

RELEASE 24 HOUR)$3.70-$8.35 (Tier 2) PA, QL

Antidepressants

Antidepressants, OtherBupropion HCl

bupropion hcl (tablet immediate-release) $1.25-$3.35 (Tier 1)Bupropion HCl SR

bupropion hcl sr (100mg tablet extended-release 12



$1.25-$3.35 (Tier 1)

Bupropion HCl XL

bupropion hcl xl (tablet extended-release 24 hour) $1.25-$3.35 (Tier 1)Mirtazapine

mirtazapine (tablet) $1.25-$3.35 (Tier 1)


pages 9 and 10.




26


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMirtazapine ODT

mirtazapine odt (tablet dispersible) $1.25-$3.35 (Tier 1)

Monoamine Oxidase InhibitorsEmsam

EMSAM (PATCH 24 HOUR) $3.70-$8.35 (Tier 2) QLMarplan

MARPLAN (TABLET) $3.70-$8.35 (Tier 2)Phenelzine Sulfate

phenelzine sulfate (tablet) $1.25-$3.35 (Tier 1)Tranylcypromine Sulfate

tranylcypromine sulfate (tablet) $1.25-$3.35 (Tier 1)

SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake

Inhibitors)Citalopram HBr

citalopram hbr (10mg tablet, 20mg tablet, 40mg

tablet, 10mg/5ml oral solution)$1.25-$3.35 (Tier 1)

Desvenlafaxine ER

desvenlafaxine er (100mg tablet extended-release 24

hour, 25mg tablet extended-release 24 hour, 50mg

tablet extended-release 24 hour)

$1.25-$3.35 (Tier 1) QL

Escitalopram Oxalate

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

tablet, 5mg/5ml oral solution)$1.25-$3.35 (Tier 1)

Fetzima

FETZIMA (CAPSULE EXTENDED-RELEASE 24 HOUR) $3.70-$8.35 (Tier 2) QL, STFetzima Titration Pack

FETZIMA TITRATION PACK (CAPSULE EXTENDED-

RELEASE 24 HOUR THERAPY PACK)$3.70-$8.35 (Tier 2) ST

Fluoxetine DR

fluoxetine dr (capsule delayed-release) $1.25-$3.35 (Tier 1)Fluoxetine HCl

fluoxetine hcl (10mg capsule immediate-release,

20mg capsule immediate-release, 40mg capsule

immediate-release, 20mg/5ml oral solution)

$1.25-$3.35 (Tier 1)

Fluvoxamine Maleate

fluvoxamine maleate (tablet) $1.25-$3.35 (Tier 1)Maprotiline HCl

maprotiline hcl (tablet) $1.25-$3.35 (Tier 1)Nefazodone HCl

nefazodone hcl (tablet) $1.25-$3.35 (Tier 1)Paroxetine HCl

paroxetine hcl (tablet immediate-release) $1.25-$3.35 (Tier 1)Paxil

PAXIL (10MG/5ML SUSPENSION) $3.70-$8.35 (Tier 2)Sertraline HCl

sertraline hcl (100mg tablet, 25mg tablet, 50mg

tablet, 20mg/ml concentrate)$1.25-$3.35 (Tier 1)


27


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useTrazodone HCl

trazodone hcl (tablet) $1.25-$3.35 (Tier 1)Trintellix

TRINTELLIX (TABLET) $3.70-$8.35 (Tier 2) QLVenlafaxine HCl

venlafaxine hcl (tablet immediate-release) $1.25-$3.35 (Tier 1)Venlafaxine HCl ER

venlafaxine hcl er (150mg capsule extended-release

24 hour, 37.5mg capsule extended-release 24 hour,

75mg capsule extended-release 24 hour)

$1.25-$3.35 (Tier 1)

Viibryd

VIIBRYD (TABLET) $3.70-$8.35 (Tier 2) QLViibryd Starter Pack

VIIBRYD STARTER PACK (KIT) $3.70-$8.35 (Tier 2) QL

TricyclicsAmitriptyline HCl

amitriptyline hcl (tablet) $1.25-$3.35 (Tier 1)Amoxapine

amoxapine (tablet) $1.25-$3.35 (Tier 1)Clomipramine HCl

clomipramine hcl (capsule) $1.25-$3.35 (Tier 1)Desipramine HCl

desipramine hcl (tablet) $1.25-$3.35 (Tier 1)Doxepin HCl

doxepin hcl (100mg capsule, 10mg capsule, 150mg

capsule, 25mg capsule, 50mg capsule, 75mg

capsule, 10mg/ml concentrate)

$1.25-$3.35 (Tier 1)

Imipramine HCl

imipramine hcl (tablet) $1.25-$3.35 (Tier 1)Imipramine Pamoate

imipramine pamoate (capsule) $1.25-$3.35 (Tier 1)Nortriptyline HCl

nortriptyline hcl (10mg capsule, 25mg capsule,

50mg capsule, 75mg capsule, 10mg/5ml oral

solution)

$1.25-$3.35 (Tier 1)

Protriptyline HCl

protriptyline hcl (tablet) $1.25-$3.35 (Tier 1)Trimipramine Maleate

trimipramine maleate (capsule) $1.25-$3.35 (Tier 1)

Antiemetics

Antiemetics, OtherCompro

compro (suppository) $1.25-$3.35 (Tier 1)Formula EM

formula em (oral solution)* $0 (Tier 3)Hydroxyzine Pamoate

hydroxyzine pamoate (capsule) $1.25-$3.35 (Tier 1)Meclizine HCl

meclizine hcl (otc only) (tablet)* $0 (Tier 3)Meclizine HCl

meclizine hcl (rx only) (tablet) $1.25-$3.35 (Tier 1)Metoclopramide HCl

metoclopramide hcl (10mg tablet, 5mg tablet, 5mg/

5ml oral solution, 5mg/ml injection)$1.25-$3.35 (Tier 1)

Perphenazine

perphenazine (tablet) $1.25-$3.35 (Tier 1)Prochlorperazine

prochlorperazine (suppository) $1.25-$3.35 (Tier 1)Prochlorperazine Edisylate

prochlorperazine edisylate (injection) $1.25-$3.35 (Tier 1)Prochlorperazine Maleate

prochlorperazine maleate (tablet) $1.25-$3.35 (Tier 1)


pages 9 and 10.




28


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useScopolamine

scopolamine (patch 72 hour) $1.25-$3.35 (Tier 1)Transderm-Scop

TRANSDERM-SCOP (PATCH 72 HOUR) $3.70-$8.35 (Tier 2)Travel Sickness

travel sickness (otc only) (tablet)* $0 (Tier 3)

Emetogenic Therapy AdjunctsAloxi

ALOXI (INJECTION) $3.70-$8.35 (Tier 2)Anzemet

ANZEMET (100MG TABLET, 50MG TABLET) $3.70-$8.35 (Tier 2) B/D, PAAprepitant

aprepitant (therapy pack, capsule) $1.25-$3.35 (Tier 1) PACesamet

CESAMET (CAPSULE) $3.70-$8.35 (Tier 2) PADronabinol

dronabinol (capsule) $1.25-$3.35 (Tier 1) PAEmend

EMEND (125MG SUSPENSION) $3.70-$8.35 (Tier 2) PAEmend

EMEND (150MG INJECTION) $3.70-$8.35 (Tier 2)Granisetron HCl

granisetron hcl (0.1mg/ml injection, 1mg/ml

injection, 4mg/4ml injection)$1.25-$3.35 (Tier 1)

Granisetron HCl

granisetron hcl (1mg tablet) $1.25-$3.35 (Tier 1) B/D, PA, QLOndansetron HCl

ondansetron hcl (24mg tablet, 4mg tablet, 8mg

tablet, 4mg/5ml oral solution)$1.25-$3.35 (Tier 1) B/D, PA

Ondansetron HCl

ondansetron hcl (4mg/2ml injection) $1.25-$3.35 (Tier 1)Ondansetron ODT

ondansetron odt (tablet dispersible) $1.25-$3.35 (Tier 1) B/D, PAPalonosetron HCl

PALONOSETRON HCL (0.25MG/2ML INJECTION) $3.70-$8.35 (Tier 2)Palonosetron HCl

palonosetron hcl (0.25mg/5ml injection) $1.25-$3.35 (Tier 1)Sancuso

SANCUSO (PATCH) $3.70-$8.35 (Tier 2)

Antifungals

AntifungalsAbelcet

ABELCET (INJECTION) $3.70-$8.35 (Tier 2) B/D, PAAmBisome

AMBISOME (INJECTION) $3.70-$8.35 (Tier 2) B/D, PAAmphotericin B

amphotericin b (injection) $1.25-$3.35 (Tier 1) B/D, PAAntifungal

antifungal (1% aerosol, 1% cream, 2% cream)* $0 (Tier 3)


29


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useAnti-Fungal Powder

anti-fungal powder (otc only)* $0 (Tier 3)Cancidas

CANCIDAS (INJECTION) $3.70-$8.35 (Tier 2)Caspofungin Acetate

caspofungin acetate (injection) $1.25-$3.35 (Tier 1)Ciclopirox

ciclopirox (0.77% gel, 0.77% suspension, 1%

shampoo)$1.25-$3.35 (Tier 1)

Ciclopirox Nail Lacquer

ciclopirox nail lacquer (external solution) $1.25-$3.35 (Tier 1)Ciclopirox Olamine

ciclopirox olamine (cream) $1.25-$3.35 (Tier 1)Clotrimazole

clotrimazole (otc only) (1% external solution)* $0 (Tier 3)Clotrimazole

clotrimazole (rx only) (1% cream, 1% external

solution, 10mg lozenge)$1.25-$3.35 (Tier 1)

Clotrimazole Anti-Fungal

clotrimazole anti-fungal (otc only) (cream)* $0 (Tier 3)Econazole Nitrate

econazole nitrate (cream) $1.25-$3.35 (Tier 1)Eraxis

ERAXIS (INJECTION) $3.70-$8.35 (Tier 2)Fluconazole

fluconazole (100mg tablet, 150mg tablet, 200mg

tablet, 50mg tablet, 10mg/ml suspension, 40mg/ml

suspension)

$1.25-$3.35 (Tier 1)

Fluconazole in NaCl

fluconazole in nacl (injection) $1.25-$3.35 (Tier 1)Flucytosine

flucytosine (capsule) $1.25-$3.35 (Tier 1)Fungoid Tincture

fungoid tincture (external solution)* $0 (Tier 3)Griseofulvin Microsize

griseofulvin microsize (125mg/5ml suspension,

500mg tablet)$1.25-$3.35 (Tier 1)

Griseofulvin Ultramicrosize

griseofulvin ultramicrosize (tablet) $1.25-$3.35 (Tier 1)Itraconazole

itraconazole (capsule) $1.25-$3.35 (Tier 1) PA, QLJublia

JUBLIA (EXTERNAL SOLUTION) $3.70-$8.35 (Tier 2)Ketoconazole

ketoconazole (2% cream, 2% foam, 2% shampoo,

200mg tablet)$1.25-$3.35 (Tier 1)

Mentax

MENTAX (RX ONLY) (CREAM) $3.70-$8.35 (Tier 2)Miconazole 3

miconazole 3 (suppository) $1.25-$3.35 (Tier 1)Miconazole 7

miconazole 7 (suppository)* $0 (Tier 3)Miconazole Nitrate

miconazole nitrate (100mg suppository, 2% cream)* $0 (Tier 3)Mycamine

MYCAMINE (INJECTION) $3.70-$8.35 (Tier 2)Natacyn

NATACYN (SUSPENSION) $3.70-$8.35 (Tier 2)Noxafil

NOXAFIL (100MG TABLET DELAYED-RELEASE) $3.70-$8.35 (Tier 2) PA, QLNoxafil

NOXAFIL (40MG/ML SUSPENSION) $3.70-$8.35 (Tier 2) QLNyamyc

nyamyc (powder) $1.25-$3.35 (Tier 1)Nystatin

nystatin (cream, ointment, powder, suspension,

tablet)$1.25-$3.35 (Tier 1)


pages 9 and 10.




30


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useNystop

nystop (powder) $1.25-$3.35 (Tier 1)QC Tolnaftate

qc tolnaftate (cream)* $0 (Tier 3)SM Miconazole 7

sm miconazole 7 (cream)* $0 (Tier 3)Sporanox

SPORANOX (10MG/ML ORAL SOLUTION) $3.70-$8.35 (Tier 2) PATerbinafine HCl

terbinafine hcl (otc only) (cream)* $0 (Tier 3)Terbinafine HCl

terbinafine hcl (tablet) $1.25-$3.35 (Tier 1)Terconazole

terconazole (0.4% cream, 0.8% cream, 80mg

suppository)$1.25-$3.35 (Tier 1)

Tioconazole-1

tioconazole-1 (ointment)* $0 (Tier 3)Tolnaftate

tolnaftate (1% cream, 1% powder)* $0 (Tier 3)Voriconazole

voriconazole (200mg injection, 200mg tablet, 50mg

tablet, 40mg/ml suspension)$1.25-$3.35 (Tier 1)

Zeasorb-AF

zeasorb-af (powder)* $0 (Tier 3)

Antigout Agents

Antigout AgentsAllopurinol

allopurinol (tablet) $1.25-$3.35 (Tier 1)Colchicine

COLCHICINE (0.6MG CAPSULE, 0.6MG TABLET) $3.70-$8.35 (Tier 2) QLProbenecid

probenecid (tablet) $1.25-$3.35 (Tier 1)Probenecid/Colchicine

probenecid/colchicine (tablet) $1.25-$3.35 (Tier 1)Uloric

ULORIC (TABLET) $3.70-$8.35 (Tier 2) ST

Antimigraine Agents

Ergot AlkaloidsDihydroergotamine Mesylate

dihydroergotamine mesylate (1mg/ml injection) $1.25-$3.35 (Tier 1)Ergotamine Tartrate/Caffeine

ergotamine tartrate/caffeine (tablet) $1.25-$3.35 (Tier 1)Migergot

migergot (suppository) $1.25-$3.35 (Tier 1)

Serotonin (5-HT) 1b/1d Receptor Agonists


31


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useNaratriptan HCl

naratriptan hcl (tablet) $1.25-$3.35 (Tier 1) QLRizatriptan Benzoate

rizatriptan benzoate (tablet) $1.25-$3.35 (Tier 1) QLRizatriptan Benzoate ODT

rizatriptan benzoate odt (tablet dispersible) $1.25-$3.35 (Tier 1) QLSumatriptan

sumatriptan (nasal solution) $1.25-$3.35 (Tier 1) QLSumatriptan Succinate

sumatriptan succinate (100mg tablet, 25mg tablet,

50mg tablet, 4mg/0.5ml injection, 6mg/0.5ml

injection)

$1.25-$3.35 (Tier 1) QL

Sumatriptan Succinate

SUMATRIPTAN SUCCINATE (6MG/0.5ML INJECTION) $3.70-$8.35 (Tier 2) QLSumatriptan Succinate Refill

SUMATRIPTAN SUCCINATE REFILL (INJECTION) $3.70-$8.35 (Tier 2) QL

Antimyasthenic Agents

ParasympathomimeticsGuanidine HCl

GUANIDINE HCL (TABLET) $3.70-$8.35 (Tier 2)Mestinon

MESTINON (60MG/5ML SYRUP) $3.70-$8.35 (Tier 2)Pyridostigmine Bromide

pyridostigmine bromide (tablet immediate-release) $1.25-$3.35 (Tier 1)Pyridostigmine Bromide ER

pyridostigmine bromide er (tablet extended-release) $1.25-$3.35 (Tier 1)

Antimycobacterials

Antimycobacterials, OtherDapsone

dapsone (tablet) $1.25-$3.35 (Tier 1)Rifabutin

rifabutin (capsule) $1.25-$3.35 (Tier 1)

AntitubercularsCapastat Sulfate

CAPASTAT SULFATE (INJECTION) $3.70-$8.35 (Tier 2)Ethambutol HCl

ethambutol hcl (tablet) $1.25-$3.35 (Tier 1)Isoniazid

isoniazid (100mg tablet, 300mg tablet, 100mg/ml

injection, 50mg/5ml syrup)$1.25-$3.35 (Tier 1)

Paser

paser (packet) $1.25-$3.35 (Tier 1)Priftin

PRIFTIN (TABLET) $3.70-$8.35 (Tier 2)Pyrazinamide

pyrazinamide (tablet) $1.25-$3.35 (Tier 1)Rifampin

rifampin (150mg capsule, 300mg capsule, 600mg


Rifater

RIFATER (TABLET) $3.70-$8.35 (Tier 2)Sirturo

SIRTURO (TABLET) $3.70-$8.35 (Tier 2) PATrecator

TRECATOR (TABLET) $3.70-$8.35 (Tier 2)

Antineoplastics


pages 9 and 10.




32


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

Alkylating AgentsBiCNU

BICNU (INJECTION) $3.70-$8.35 (Tier 2)Busulfan

busulfan (injection) $1.25-$3.35 (Tier 1)Busulfex

BUSULFEX (INJECTION) $3.70-$8.35 (Tier 2)Cyclophosphamide

CYCLOPHOSPHAMIDE (CAPSULE) $3.70-$8.35 (Tier 2) B/D, PADacarbazine

dacarbazine (injection) $1.25-$3.35 (Tier 1)Gleostine

GLEOSTINE (CAPSULE) $3.70-$8.35 (Tier 2)Hexalen

HEXALEN (CAPSULE) $3.70-$8.35 (Tier 2) PAIfosfamide

ifosfamide (injection) $1.25-$3.35 (Tier 1)Leukeran

LEUKERAN (TABLET) $3.70-$8.35 (Tier 2)Matulane

MATULANE (CAPSULE) $3.70-$8.35 (Tier 2) LAMelphalan HCl

melphalan hcl (injection) $1.25-$3.35 (Tier 1)Mustargen

MUSTARGEN (INJECTION) $3.70-$8.35 (Tier 2)Treanda

TREANDA (INJECTION) $3.70-$8.35 (Tier 2) PAValchlor

VALCHLOR (GEL) $3.70-$8.35 (Tier 2) PA, LAYondelis

YONDELIS (INJECTION) $3.70-$8.35 (Tier 2) PAZanosar

ZANOSAR (INJECTION) $3.70-$8.35 (Tier 2)

Antiandrogens Bicalutamide

bicalutamide (tablet) $1.25-$3.35 (Tier 1)Erleada

ERLEADA (TABLET) $3.70-$8.35 (Tier 2) PA, QLFlutamide

flutamide (capsule) $1.25-$3.35 (Tier 1)Nilandron

NILANDRON (TABLET) $3.70-$8.35 (Tier 2)Nilutamide

nilutamide (tablet) $1.25-$3.35 (Tier 1)Xtandi

XTANDI (CAPSULE) $3.70-$8.35 (Tier 2) PA, QLZytiga

ZYTIGA (TABLET) $3.70-$8.35 (Tier 2) PA, QL

Antiangiogenic AgentsPomalyst

POMALYST (CAPSULE) $3.70-$8.35 (Tier 2) PA, QL


33


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useRevlimid

REVLIMID (CAPSULE) $3.70-$8.35 (Tier 2) PA, QL, LAThalomid

THALOMID (CAPSULE) $3.70-$8.35 (Tier 2) PA, QL

Antiestrogens/ModifiersEmcyt

EMCYT (CAPSULE) $3.70-$8.35 (Tier 2)Fareston

FARESTON (TABLET) $3.70-$8.35 (Tier 2)Faslodex

FASLODEX (INJECTION) $3.70-$8.35 (Tier 2)Soltamox

SOLTAMOX (ORAL SOLUTION) $3.70-$8.35 (Tier 2)Tamoxifen Citrate

tamoxifen citrate (tablet) $1.25-$3.35 (Tier 1)

AntimetabolitesAdrucil

adrucil (injection) $1.25-$3.35 (Tier 1) B/D, PAAlimta

ALIMTA (INJECTION) $3.70-$8.35 (Tier 2) PACladribine

cladribine (injection) $1.25-$3.35 (Tier 1) B/D, PAClofarabine

clofarabine (injection) $1.25-$3.35 (Tier 1)Cytarabine Aqueous

cytarabine aqueous (injection) $1.25-$3.35 (Tier 1) B/D, PADroxia

DROXIA (CAPSULE) $3.70-$8.35 (Tier 2)Fluorouracil

fluorouracil (5gm/100ml injection) $1.25-$3.35 (Tier 1) B/D, PAFolotyn

FOLOTYN (INJECTION) $3.70-$8.35 (Tier 2)Gemcitabine HCl

gemcitabine hcl (injection) $1.25-$3.35 (Tier 1)Hydroxyurea

hydroxyurea (capsule) $1.25-$3.35 (Tier 1)Mercaptopurine

mercaptopurine (tablet) $1.25-$3.35 (Tier 1)Nipent

NIPENT (INJECTION) $3.70-$8.35 (Tier 2)Purixan

PURIXAN (SUSPENSION) $3.70-$8.35 (Tier 2) PATabloid

TABLOID (TABLET) $3.70-$8.35 (Tier 2) PA

Antineoplastics, OtherAbraxane

ABRAXANE (INJECTION) $3.70-$8.35 (Tier 2) PAAdriamycin

adriamycin (injection) $1.25-$3.35 (Tier 1) B/D, PAArranon

ARRANON (INJECTION) $3.70-$8.35 (Tier 2)Bleomycin Sulfate

bleomycin sulfate (injection) $1.25-$3.35 (Tier 1) B/D, PABortezomib

BORTEZOMIB (INJECTION) $3.70-$8.35 (Tier 2) PACarboplatin

carboplatin (injection) $1.25-$3.35 (Tier 1)Cisplatin

cisplatin (injection) $1.25-$3.35 (Tier 1)Cosmegen

COSMEGEN (INJECTION) $3.70-$8.35 (Tier 2)Dactinomycin

dactinomycin (injection) $1.25-$3.35 (Tier 1)Daunorubicin HCl

daunorubicin hcl (injection) $1.25-$3.35 (Tier 1)Decitabine

decitabine (injection) $1.25-$3.35 (Tier 1)


pages 9 and 10.




34


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useDexrazoxane

dexrazoxane (injection) $1.25-$3.35 (Tier 1) PADocetaxel

DOCETAXEL (160MG/16ML INJECTION) $3.70-$8.35 (Tier 2)Docetaxel

docetaxel (80mg/4ml injection) $1.25-$3.35 (Tier 1)Doxil

DOXIL (INJECTION) $3.70-$8.35 (Tier 2)Doxorubicin HCl

doxorubicin hcl (injection) $1.25-$3.35 (Tier 1) B/D, PADoxorubicin HCl Liposome

doxorubicin hcl liposome (injection) $1.25-$3.35 (Tier 1)Epirubicin HCl

epirubicin hcl (injection) $1.25-$3.35 (Tier 1)Erwinaze

ERWINAZE (INJECTION) $3.70-$8.35 (Tier 2)Fludarabine Phosphate

fludarabine phosphate (injection) $1.25-$3.35 (Tier 1)Fusilev

FUSILEV (INJECTION) $3.70-$8.35 (Tier 2)Halaven

HALAVEN (INJECTION) $3.70-$8.35 (Tier 2) PAIdarubicin HCl

idarubicin hcl (injection) $1.25-$3.35 (Tier 1)Irinotecan

irinotecan (injection) $1.25-$3.35 (Tier 1)Istodax

ISTODAX (OVERFILL) (INJECTION) $3.70-$8.35 (Tier 2) PAKisqali

KISQALI (TABLET) $3.70-$8.35 (Tier 2) PA, QLKisqali Femara 200 Dose

KISQALI FEMARA 200 DOSE (TABLET THERAPY PACK) $3.70-$8.35 (Tier 2) PA, QLKisqali Femara 400 Dose

KISQALI FEMARA 400 DOSE (TABLET THERAPY PACK) $3.70-$8.35 (Tier 2) PA, QLKisqali Femara 600 Dose

KISQALI FEMARA 600 DOSE (TABLET THERAPY PACK) $3.70-$8.35 (Tier 2) PA, QLLeucovorin Calcium

leucovorin calcium (100mg injection, 350mg

injection, 10mg tablet, 15mg tablet, 25mg tablet,

5mg tablet)

$1.25-$3.35 (Tier 1)

Levoleucovorin

levoleucovorin (50mg vial, 175mg/17.5ml injection) $1.25-$3.35 (Tier 1)Lonsurf

LONSURF (TABLET) $3.70-$8.35 (Tier 2) PA, QLMitomycin

mitomycin (injection) $1.25-$3.35 (Tier 1)Mitoxantrone HCl

mitoxantrone hcl (injection) $1.25-$3.35 (Tier 1)Ninlaro

NINLARO (CAPSULE) $3.70-$8.35 (Tier 2) PA, QLOxaliplatin

oxaliplatin (100mg vial, 100mg/20ml injection) $1.25-$3.35 (Tier 1)Paclitaxel

paclitaxel (injection) $1.25-$3.35 (Tier 1)Proleukin

PROLEUKIN (INJECTION) $3.70-$8.35 (Tier 2) PA


35


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useSynribo

SYNRIBO (INJECTION) $3.70-$8.35 (Tier 2) PAThiotepa

thiotepa (injection) $1.25-$3.35 (Tier 1)Trisenox

TRISENOX (INJECTION) $3.70-$8.35 (Tier 2)Velcade

VELCADE (INJECTION) $3.70-$8.35 (Tier 2) PAVerzenio

VERZENIO (TABLET) $3.70-$8.35 (Tier 2) PA, QLVinblastine Sulfate

vinblastine sulfate (injection) $1.25-$3.35 (Tier 1) B/D, PAVincasar PFS

vincasar pfs (injection) $1.25-$3.35 (Tier 1) B/D, PAVincristine Sulfate

vincristine sulfate (injection) $1.25-$3.35 (Tier 1) B/D, PAVinorelbine Tartrate

vinorelbine tartrate (injection) $1.25-$3.35 (Tier 1)Vyxeos

VYXEOS (INJECTION) $3.70-$8.35 (Tier 2) PAZaltrap

ZALTRAP (INJECTION) $3.70-$8.35 (Tier 2) PAZolinza

ZOLINZA (CAPSULE) $3.70-$8.35 (Tier 2) PA

Aromatase Inhibitors, 3rd GenerationAnastrozole

anastrozole (tablet) $1.25-$3.35 (Tier 1)Exemestane

exemestane (tablet) $1.25-$3.35 (Tier 1)Letrozole

letrozole (tablet) $1.25-$3.35 (Tier 1)

Enzyme InhibitorsAliqopa

ALIQOPA (INJECTION) $3.70-$8.35 (Tier 2) PAEtopophos

ETOPOPHOS (INJECTION) $3.70-$8.35 (Tier 2)Etoposide

etoposide (injection) $1.25-$3.35 (Tier 1)Kyprolis

KYPROLIS (INJECTION) $3.70-$8.35 (Tier 2) PARubraca

RUBRACA (TABLET) $3.70-$8.35 (Tier 2) PA, QLToposar

toposar (injection) $1.25-$3.35 (Tier 1)Topotecan HCl

topotecan hcl (injection) $1.25-$3.35 (Tier 1)Zejula

ZEJULA (CAPSULE) $3.70-$8.35 (Tier 2) PA, QL

Molecular Target InhibitorsAfinitor

AFINITOR (TABLET) $3.70-$8.35 (Tier 2) PAAfinitor Disperz

AFINITOR DISPERZ (TABLET SOLUBLE) $3.70-$8.35 (Tier 2) PAAlecensa

ALECENSA (CAPSULE) $3.70-$8.35 (Tier 2) PA, QLAlunbrig

ALUNBRIG (TABLET THERAPY PACK, 180MG TABLET,

30MG TABLET, 90MG TABLET)$3.70-$8.35 (Tier 2) PA, QL

Beleodaq

BELEODAQ (INJECTION) $3.70-$8.35 (Tier 2) PABosulif

BOSULIF (TABLET) $3.70-$8.35 (Tier 2) PA, QLCabometyx

CABOMETYX (TABLET) $3.70-$8.35 (Tier 2) PA, QLCalquence

CALQUENCE (CAPSULE) $3.70-$8.35 (Tier 2) PA, QL


pages 9 and 10.




36


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useCaprelsa

CAPRELSA (TABLET) $3.70-$8.35 (Tier 2) PA, LACometriq

COMETRIQ (KIT) $3.70-$8.35 (Tier 2) PACotellic

COTELLIC (TABLET) $3.70-$8.35 (Tier 2) PA, QL, LACyramza

CYRAMZA (INJECTION) $3.70-$8.35 (Tier 2) PAErivedge

ERIVEDGE (CAPSULE) $3.70-$8.35 (Tier 2) PA, QLFarydak

FARYDAK (CAPSULE) $3.70-$8.35 (Tier 2) PAGilotrif

GILOTRIF (TABLET) $3.70-$8.35 (Tier 2) PAIbrance

IBRANCE (CAPSULE) $3.70-$8.35 (Tier 2) PA, QLIclusig

ICLUSIG (TABLET) $3.70-$8.35 (Tier 2) PA, QL, LAIdhifa

IDHIFA (TABLET) $3.70-$8.35 (Tier 2) PA, QLImatinib Mesylate

imatinib mesylate (tablet) $1.25-$3.35 (Tier 1) PA, QLImbruvica

IMBRUVICA (140MG CAPSULE, 70MG CAPSULE,

140MG TABLET, 280MG TABLET, 420MG TABLET,

560MG TABLET)$3.70-$8.35 (Tier 2) PA, QL

Inlyta

INLYTA (TABLET) $3.70-$8.35 (Tier 2) PA, QLIressa

IRESSA (TABLET) $3.70-$8.35 (Tier 2) PA, QLJakafi

JAKAFI (TABLET) $3.70-$8.35 (Tier 2) PA, QL, LAJevtana

JEVTANA (INJECTION) $3.70-$8.35 (Tier 2) PALenvima

LENVIMA (CAPSULE THERAPY PACK) $3.70-$8.35 (Tier 2) PALynparza

LYNPARZA (100MG TABLET, 150MG TABLET, 50MG

CAPSULE)$3.70-$8.35 (Tier 2) PA, QL

Mekinist

MEKINIST (TABLET) $3.70-$8.35 (Tier 2) PANerlynx

NERLYNX (TABLET) $3.70-$8.35 (Tier 2) PA, QLNexavar

NEXAVAR (TABLET) $3.70-$8.35 (Tier 2) PAOdomzo

ODOMZO (CAPSULE) $3.70-$8.35 (Tier 2) PA, QL, LARydapt

RYDAPT (CAPSULE) $3.70-$8.35 (Tier 2) PA, QLSprycel

SPRYCEL (TABLET) $3.70-$8.35 (Tier 2) PA, QLStivarga

STIVARGA (TABLET) $3.70-$8.35 (Tier 2) PA, QLSutent

SUTENT (CAPSULE) $3.70-$8.35 (Tier 2) PA, QL


37


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useTafinlar

TAFINLAR (CAPSULE) $3.70-$8.35 (Tier 2) PATagrisso

TAGRISSO (TABLET) $3.70-$8.35 (Tier 2) PA, QL, LATarceva

TARCEVA (TABLET) $3.70-$8.35 (Tier 2) PA, QLTasigna

TASIGNA (CAPSULE) $3.70-$8.35 (Tier 2) PA, QLTykerb

TYKERB (TABLET) $3.70-$8.35 (Tier 2) PAVenclexta

VENCLEXTA (TABLET) $3.70-$8.35 (Tier 2) PA, QLVenclexta Starting Pack

VENCLEXTA STARTING PACK (TABLET THERAPY

PACK)$3.70-$8.35 (Tier 2) PA

Votrient

VOTRIENT (TABLET) $3.70-$8.35 (Tier 2) PA, QLXalkori

XALKORI (CAPSULE) $3.70-$8.35 (Tier 2) PA, LAZelboraf

ZELBORAF (TABLET) $3.70-$8.35 (Tier 2) PA, QLZydelig

ZYDELIG (TABLET) $3.70-$8.35 (Tier 2) PA, QLZykadia

ZYKADIA (CAPSULE) $3.70-$8.35 (Tier 2) PA, QL

Monoclonal Antibody/Antibody-Drug ConjugateAvastin

AVASTIN (INJECTION) $3.70-$8.35 (Tier 2) PABavencio

BAVENCIO (INJECTION) $3.70-$8.35 (Tier 2) PADarzalex

DARZALEX (INJECTION) $3.70-$8.35 (Tier 2) PA, LAEmpliciti

EMPLICITI (INJECTION) $3.70-$8.35 (Tier 2) PAErbitux

ERBITUX (INJECTION) $3.70-$8.35 (Tier 2) PAHerceptin

HERCEPTIN (INJECTION) $3.70-$8.35 (Tier 2) PAImfinzi

IMFINZI (INJECTION) $3.70-$8.35 (Tier 2) PAKadcyla

KADCYLA (INJECTION) $3.70-$8.35 (Tier 2) PAKeytruda

KEYTRUDA (INJECTION) $3.70-$8.35 (Tier 2) PALartruvo

LARTRUVO (INJECTION) $3.70-$8.35 (Tier 2) PAMylotarg

MYLOTARG (INJECTION) $3.70-$8.35 (Tier 2) PAOpdivo

OPDIVO (INJECTION) $3.70-$8.35 (Tier 2) PAPerjeta

PERJETA (INJECTION) $3.70-$8.35 (Tier 2) PARituxan

RITUXAN (INJECTION) $3.70-$8.35 (Tier 2) PATecentriq

TECENTRIQ (INJECTION) $3.70-$8.35 (Tier 2) PAVectibix

VECTIBIX (INJECTION) $3.70-$8.35 (Tier 2) PAYervoy

YERVOY (INJECTION) $3.70-$8.35 (Tier 2) PA

RetinoidsBexarotene

bexarotene (capsule) $1.25-$3.35 (Tier 1) PAPanretin

PANRETIN (GEL) $3.70-$8.35 (Tier 2)Targretin

TARGRETIN (1% GEL) $3.70-$8.35 (Tier 2) PA


pages 9 and 10.




38


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useTretinoin

tretinoin (10mg capsule) $1.25-$3.35 (Tier 1)

Treatment AdjunctsElitek

ELITEK (INJECTION) $3.70-$8.35 (Tier 2)Mesna

mesna (injection) $1.25-$3.35 (Tier 1)Mesnex

MESNEX (400MG TABLET) $3.70-$8.35 (Tier 2)

Antiparasitics

AnthelminticsAlbenza

ALBENZA (TABLET) $3.70-$8.35 (Tier 2) QLBiltricide

BILTRICIDE (TABLET) $3.70-$8.35 (Tier 2)Ivermectin

ivermectin (tablet) $1.25-$3.35 (Tier 1)

AntiprotozoalsAlinia

ALINIA (100MG/5ML SUSPENSION, 500MG TABLET) $3.70-$8.35 (Tier 2)Atovaquone

atovaquone (suspension) $1.25-$3.35 (Tier 1)Atovaquone/Proguanil HCl

atovaquone/proguanil hcl (tablet) (generic malarone) $1.25-$3.35 (Tier 1)Benznidazole

BENZNIDAZOLE (TABLET) $3.70-$8.35 (Tier 2)Chloroquine Phosphate

chloroquine phosphate (tablet) $1.25-$3.35 (Tier 1)Coartem

COARTEM (TABLET) $3.70-$8.35 (Tier 2)DARAPRIM

DARAPRIM (TABLET) $3.70-$8.35 (Tier 2)Hydroxychloroquine Sulfate

hydroxychloroquine sulfate (tablet) $1.25-$3.35 (Tier 1)Mefloquine HCl

mefloquine hcl (tablet) $1.25-$3.35 (Tier 1)Nebupent

NEBUPENT (INHALATION SOLUTION) $3.70-$8.35 (Tier 2) B/D, PA, QLPentam 300

PENTAM 300 (INJECTION) $3.70-$8.35 (Tier 2)Primaquine Phosphate

primaquine phosphate (tablet) $1.25-$3.35 (Tier 1)Quinine Sulfate

quinine sulfate (capsule) $1.25-$3.35 (Tier 1) PA

Pediculicides/ScabicidesLindane

lindane (shampoo) $1.25-$3.35 (Tier 1)


39


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMalathion

malathion (lotion) $1.25-$3.35 (Tier 1)Permethrin

permethrin (cream) $1.25-$3.35 (Tier 1)

Antiparkinson Agents

AnticholinergicsBenztropine Mesylate

benztropine mesylate (0.5mg tablet, 1mg tablet, 2mg

tablet, 1mg/ml injection)$1.25-$3.35 (Tier 1)

Trihexyphenidyl HCl

trihexyphenidyl hcl (0.4mg/ml elixir, 2mg tablet, 5mg

tablet)$1.25-$3.35 (Tier 1)

Antiparkinson Agents, OtherAmantadine HCl

amantadine hcl (100mg capsule, 100mg tablet,

50mg/5ml syrup)$1.25-$3.35 (Tier 1)

Entacapone

entacapone (tablet) $1.25-$3.35 (Tier 1)Tolcapone

tolcapone (tablet) $1.25-$3.35 (Tier 1) QL

Dopamine AgonistsApokyn

APOKYN (INJECTION) $3.70-$8.35 (Tier 2) PA, QLBromocriptine Mesylate

bromocriptine mesylate (2.5mg tablet, 5mg capsule) $1.25-$3.35 (Tier 1)Neupro

NEUPRO (PATCH 24 HOUR) $3.70-$8.35 (Tier 2)Pramipexole Dihydrochloride

pramipexole dihydrochloride (tablet immediate-

release)$1.25-$3.35 (Tier 1)

Ropinirole HCl

ropinirole hcl (tablet immediate-release) $1.25-$3.35 (Tier 1)

Dopamine Precursors/L-Amino Acid Decarboxylase InhibitorsCarbidopa/Levodopa

carbidopa/levodopa (tablet immediate-release) $1.25-$3.35 (Tier 1)Carbidopa/Levodopa ER

carbidopa/levodopa er (tablet extended-release) $1.25-$3.35 (Tier 1)Carbidopa/Levodopa ODT

carbidopa/levodopa odt (tablet dispersible) $1.25-$3.35 (Tier 1)Carbidopa/Levodopa/Entacapone

CARBIDOPA/LEVODOPA/ENTACAPONE (TABLET) $3.70-$8.35 (Tier 2)

Monoamine Oxidase B (MAO-B) InhibitorsRasagiline Mesylate

rasagiline mesylate (tablet) $1.25-$3.35 (Tier 1)Selegiline HCl

selegiline hcl (5mg capsule, 5mg tablet) $1.25-$3.35 (Tier 1)Zelapar

ZELAPAR (TABLET DISPERSIBLE) $3.70-$8.35 (Tier 2)

Antipsychotics

1st Generation/Typical


pages 9 and 10.




40


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useChlorpromazine HCl

chlorpromazine hcl (100mg tablet, 10mg tablet,

200mg tablet, 25mg tablet, 50mg tablet, 50mg/2ml

injection)

$1.25-$3.35 (Tier 1)

Fluphenazine Decanoate

fluphenazine decanoate (injection) $1.25-$3.35 (Tier 1)Fluphenazine HCl

fluphenazine hcl (10mg tablet, 1mg tablet, 2.5mg

tablet, 5mg tablet, 2.5mg/5ml elixir, 2.5mg/ml

injection, 5mg/ml concentrate)

$1.25-$3.35 (Tier 1)

Haloperidol

haloperidol (0.5mg tablet, 10mg tablet, 1mg tablet,

20mg tablet, 2mg tablet, 5mg tablet, 2mg/ml

concentrate)

$1.25-$3.35 (Tier 1)

Haloperidol Decanoate

haloperidol decanoate (injection) $1.25-$3.35 (Tier 1)Haloperidol Lactate

haloperidol lactate (injection) $1.25-$3.35 (Tier 1)Loxapine Succinate

loxapine succinate (capsule) $1.25-$3.35 (Tier 1)Pimozide

pimozide (tablet) $1.25-$3.35 (Tier 1)Thioridazine HCl

thioridazine hcl (tablet) $1.25-$3.35 (Tier 1)Thiothixene

thiothixene (capsule) $1.25-$3.35 (Tier 1)Trifluoperazine HCl

trifluoperazine hcl (tablet) $1.25-$3.35 (Tier 1)

2nd Generation/AtypicalAbilify Maintena

ABILIFY MAINTENA (INJECTION) $3.70-$8.35 (Tier 2)Aripiprazole

aripiprazole (10mg tablet, 15mg tablet, 20mg tablet,

2mg tablet, 30mg tablet, 5mg tablet, 1mg/ml oral

solution)

$1.25-$3.35 (Tier 1) QL

Aripiprazole ODT

aripiprazole odt (tablet dispersible) $1.25-$3.35 (Tier 1) QLAristada

ARISTADA (INJECTION) $3.70-$8.35 (Tier 2)Fanapt

FANAPT (TABLET) $3.70-$8.35 (Tier 2) QL, STFanapt Titration Pack

FANAPT TITRATION PACK (TABLET) $3.70-$8.35 (Tier 2) STGeodon

GEODON (20MG INJECTION) $3.70-$8.35 (Tier 2)Invega Sustenna

INVEGA SUSTENNA (INJECTION) $3.70-$8.35 (Tier 2)Invega Trinza

INVEGA TRINZA (INJECTION) $3.70-$8.35 (Tier 2) PA


41


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useLatuda

LATUDA (TABLET) $3.70-$8.35 (Tier 2) QLNuplazid

NUPLAZID (TABLET) $3.70-$8.35 (Tier 2) PA, QLOlanzapine

olanzapine (10mg injection) $1.25-$3.35 (Tier 1)Olanzapine

olanzapine (10mg tablet, 15mg tablet, 2.5mg tablet,

20mg tablet, 5mg tablet, 7.5mg tablet)$1.25-$3.35 (Tier 1) QL

Olanzapine ODT

olanzapine odt (tablet dispersible) $1.25-$3.35 (Tier 1) QLPaliperidone ER

paliperidone er (tablet extended-release 24 hour) $1.25-$3.35 (Tier 1) QLQuetiapine Fumarate

quetiapine fumarate (tablet immediate-release) $1.25-$3.35 (Tier 1) QLQuetiapine Fumarate ER

quetiapine fumarate er (tablet extended-release 24

hour)$1.25-$3.35 (Tier 1) QL

Rexulti

REXULTI (TABLET) $3.70-$8.35 (Tier 2) QLRisperdal Consta

RISPERDAL CONSTA (INJECTION) $3.70-$8.35 (Tier 2)Risperidone

risperidone (0.25mg tablet, 0.5mg tablet, 1mg tablet,

2mg tablet, 3mg tablet, 4mg tablet, 1mg/ml oral

solution)

$1.25-$3.35 (Tier 1)

Risperidone ODT

risperidone odt (tablet dispersible) $1.25-$3.35 (Tier 1)Saphris

SAPHRIS (TABLET SUBLINGUAL) $3.70-$8.35 (Tier 2) QLVraylar

VRAYLAR (1.5MG CAPSULE, 3MG CAPSULE, 4.5MG

CAPSULE, 6MG CAPSULE)$3.70-$8.35 (Tier 2) QL, ST

Vraylar

VRAYLAR (CAPSULE THERAPY PACK) $3.70-$8.35 (Tier 2) STZiprasidone HCl

ziprasidone hcl (capsule) $1.25-$3.35 (Tier 1) QLZyprexa Relprevv

ZYPREXA RELPREVV (INJECTION) $3.70-$8.35 (Tier 2)

Treatment-ResistantClozapine

clozapine (100mg tablet, 25mg tablet, 50mg tablet,

200mg tablet)$1.25-$3.35 (Tier 1)

Clozapine ODT

clozapine odt (100mg tablet dispersible, 25mg tablet

dispersible)$1.25-$3.35 (Tier 1) QL

Clozapine ODT

CLOZAPINE ODT (12.5MG TABLET DISPERSIBLE,

150MG TABLET DISPERSIBLE, 200MG TABLET

DISPERSIBLE)$3.70-$8.35 (Tier 2) QL

Versacloz

VERSACLOZ (SUSPENSION) $3.70-$8.35 (Tier 2)

Antivirals

Anti-cytomegalovirus (CMV) AgentsCidofovir

cidofovir (injection) $1.25-$3.35 (Tier 1)Ganciclovir

ganciclovir (500mg injection) $1.25-$3.35 (Tier 1) B/D, PAValganciclovir

valganciclovir (tablet) $1.25-$3.35 (Tier 1) QL


pages 9 and 10.




42


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useValganciclovir Hydrochlorde

valganciclovir hydrochlorde (oral solution) $1.25-$3.35 (Tier 1) QLZirgan

ZIRGAN (GEL) $3.70-$8.35 (Tier 2)

Anti-hepatitis B (HBV) AgentsBaraclude

BARACLUDE (0.05MG/ML ORAL SOLUTION) $3.70-$8.35 (Tier 2)Entecavir

entecavir (tablet) $1.25-$3.35 (Tier 1)Epivir HBV

EPIVIR HBV (5MG/ML ORAL SOLUTION) $3.70-$8.35 (Tier 2)Lamivudine

lamivudine (100mg tablet) $1.25-$3.35 (Tier 1)Vemlidy

VEMLIDY (TABLET) $3.70-$8.35 (Tier 2) QL

Anti-hepatitis C (HCV) Agents, OtherIntron A

INTRON A (INJECTION) $3.70-$8.35 (Tier 2) PAPegasys

PEGASYS (INJECTION) $3.70-$8.35 (Tier 2) PAPegasys ProClick

PEGASYS PROCLICK (INJECTION) $3.70-$8.35 (Tier 2) PARibasphere

ribasphere (200mg tablet, 400mg tablet, 600mg

tablet)$1.25-$3.35 (Tier 1)

Ribavirin

ribavirin (200mg tablet) $1.25-$3.35 (Tier 1)Sylatron

SYLATRON (INJECTION) $3.70-$8.35 (Tier 2) PA

Anti-hepatitis C (HCV) Direct Acting AgentsEpclusa

EPCLUSA (TABLET) $3.70-$8.35 (Tier 2) PA, QLHarvoni

HARVONI (TABLET) $3.70-$8.35 (Tier 2) PA, QLMavyret

MAVYRET (TABLET) $3.70-$8.35 (Tier 2) PA, QLVosevi

VOSEVI (TABLET) $3.70-$8.35 (Tier 2) PA, QL

Antiherpetic AgentsAcyclovir

acyclovir (200mg capsule, 200mg/5ml suspension,

400mg tablet, 800mg tablet)$1.25-$3.35 (Tier 1)

Acyclovir Sodium

acyclovir sodium (injection) $1.25-$3.35 (Tier 1) B/D, PAFamciclovir

famciclovir (tablet) $1.25-$3.35 (Tier 1) QLTrifluridine

trifluridine (ophthalmic solution) $1.25-$3.35 (Tier 1)


43


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useValacyclovir HCl

valacyclovir hcl (tablet) $1.25-$3.35 (Tier 1) QL

Anti-HIV Agents, Integrase Inhibitors (INSTI) Genvoya

GENVOYA (TABLET) $3.70-$8.35 (Tier 2) QLIsentress

ISENTRESS (100MG PACKET, 100MG TABLET

CHEWABLE, 25MG TABLET CHEWABLE, 400MG

TABLET)$3.70-$8.35 (Tier 2) QL

Isentress HD

ISENTRESS HD (TABLET) $3.70-$8.35 (Tier 2) QLStribild

STRIBILD (TABLET) $3.70-$8.35 (Tier 2) QLTivicay

TIVICAY (TABLET) $3.70-$8.35 (Tier 2) QLTriumeq

TRIUMEQ (TABLET) $3.70-$8.35 (Tier 2) QLTybost

TYBOST (TABLET) $3.70-$8.35 (Tier 2) QL

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)Atripla

ATRIPLA (TABLET) $3.70-$8.35 (Tier 2) QLComplera

COMPLERA (TABLET) $3.70-$8.35 (Tier 2) QLEdurant

EDURANT (TABLET) $3.70-$8.35 (Tier 2) QLEfavirenz

efavirenz (200mg capsule, 50mg capsule, 600mg

tablet)$1.25-$3.35 (Tier 1) QL

Intelence

INTELENCE (TABLET) $3.70-$8.35 (Tier 2) QLJuluca

JULUCA (TABLET) $3.70-$8.35 (Tier 2) QLNevirapine

nevirapine (tablet) $1.25-$3.35 (Tier 1) QLNevirapine ER

nevirapine er (tablet extended-release 24 hour) $1.25-$3.35 (Tier 1) QLOdefsey

ODEFSEY (TABLET) $3.70-$8.35 (Tier 2) QLRescriptor

RESCRIPTOR (TABLET) $3.70-$8.35 (Tier 2) QLSustiva

SUSTIVA (200MG CAPSULE, 50MG CAPSULE, 600MG


Symfi

SYMFI (TABLET) $3.70-$8.35 (Tier 2) QLSymfi Lo

SYMFI LO (TABLET) $3.70-$8.35 (Tier 2) QLViramune

VIRAMUNE (50MG/5ML SUSPENSION) $3.70-$8.35 (Tier 2) QL

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)Abacavir

abacavir (20mg/ml oral solution, 300mg tablet) $1.25-$3.35 (Tier 1) QLAbacavir Sulfate/Lamivudine/Zidovudine

abacavir sulfate/lamivudine/zidovudine (tablet) $1.25-$3.35 (Tier 1) QLAbacavir/Lamivudine

abacavir/lamivudine (tablet) $1.25-$3.35 (Tier 1) QLBiktarvy

BIKTARVY (TABLET) $3.70-$8.35 (Tier 2) QLCimduo

CIMDUO (TABLET) $3.70-$8.35 (Tier 2) QLDescovy

DESCOVY (TABLET) $3.70-$8.35 (Tier 2) QL


pages 9 and 10.




44


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useDidanosine

didanosine (capsule delayed-release) $1.25-$3.35 (Tier 1) QLEmtriva

EMTRIVA (10MG/ML ORAL SOLUTION, 200MG

CAPSULE)$3.70-$8.35 (Tier 2) QL

Epzicom

EPZICOM (TABLET) $3.70-$8.35 (Tier 2) QLLamivudine

lamivudine (10mg/ml oral solution, 150mg tablet,

300mg tablet)$1.25-$3.35 (Tier 1) QL

Lamivudine/Zidovudine

lamivudine/zidovudine (tablet) $1.25-$3.35 (Tier 1) QLRetrovir IV Infusion

RETROVIR IV INFUSION (INJECTION) $3.70-$8.35 (Tier 2)Stavudine

stavudine (capsule) $1.25-$3.35 (Tier 1) QLTenofovir Disoproxil Fumarate

tenofovir disoproxil fumarate (tablet) $1.25-$3.35 (Tier 1) QLTruvada

TRUVADA (TABLET) $3.70-$8.35 (Tier 2) QLVidex EC

VIDEX EC (125MG CAPSULE DELAYED-RELEASE) $3.70-$8.35 (Tier 2) QLVidex Pediatric

VIDEX PEDIATRIC (ORAL SOLUTION) $3.70-$8.35 (Tier 2) QLViread

VIREAD (150MG TABLET, 200MG TABLET, 250MG

TABLET, 300MG TABLET, 40MG/GM POWDER)$3.70-$8.35 (Tier 2) QL

Zerit

ZERIT (1MG/ML ORAL SOLUTION) $3.70-$8.35 (Tier 2) QLZiagen

ZIAGEN (20MG/ML ORAL SOLUTION) $3.70-$8.35 (Tier 2) QLZidovudine

zidovudine (100mg capsule, 300mg tablet, 50mg/

5ml syrup)$1.25-$3.35 (Tier 1) QL

Anti-HIV Agents, OtherFuzeon

FUZEON (INJECTION) $3.70-$8.35 (Tier 2) QLSelzentry

SELZENTRY (150MG TABLET, 25MG TABLET, 300MG

TABLET, 75MG TABLET, 20MG/ML ORAL SOLUTION)$3.70-$8.35 (Tier 2) QL

Anti-HIV Agents, Protease InhibitorsAptivus

APTIVUS (100MG/ML ORAL SOLUTION, 250MG

CAPSULE)$3.70-$8.35 (Tier 2) QL

Atazanavir Sulfate

atazanavir sulfate (capsule) $1.25-$3.35 (Tier 1) QLCrixivan

CRIXIVAN (CAPSULE) $3.70-$8.35 (Tier 2) QLEvotaz

EVOTAZ (TABLET) $3.70-$8.35 (Tier 2) QL


45


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useFosamprenavir Calcium

fosamprenavir calcium (tablet) $1.25-$3.35 (Tier 1) QLInvirase

INVIRASE (200MG CAPSULE, 500MG TABLET) $3.70-$8.35 (Tier 2) QLKaletra

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


Lexiva

LEXIVA (50MG/ML SUSPENSION, 700MG TABLET) $3.70-$8.35 (Tier 2) QLLopinavir/Ritonavir

lopinavir/ritonavir (oral solution) $1.25-$3.35 (Tier 1) QLNorvir

NORVIR (100MG CAPSULE, 100MG PACKET, 100MG

TABLET, 80MG/ML ORAL SOLUTION)$3.70-$8.35 (Tier 2) QL

Prezcobix

PREZCOBIX (TABLET) $3.70-$8.35 (Tier 2) QLPrezista

PREZISTA (100MG/ML SUSPENSION, 150MG TABLET,

600MG TABLET, 75MG TABLET, 800MG TABLET)$3.70-$8.35 (Tier 2) QL

Reyataz

REYATAZ (150MG CAPSULE, 200MG CAPSULE, 300MG

CAPSULE, 50MG PACKET)$3.70-$8.35 (Tier 2) QL

Ritonavir

ritonavir (tablet) $1.25-$3.35 (Tier 1) QLViracept

VIRACEPT (TABLET) $3.70-$8.35 (Tier 2) QL

Anti-influenza AgentsOseltamivir Phosphate

oseltamivir phosphate (30mg capsule, 45mg

capsule, 75mg capsule, 6mg/ml suspension)$1.25-$3.35 (Tier 1) QL

Relenza Diskhaler

RELENZA DISKHALER (AEROSOL POWDER) $3.70-$8.35 (Tier 2) QLRimantadine HCl

rimantadine hcl (tablet) $1.25-$3.35 (Tier 1)Tamiflu

TAMIFLU (6MG/ML SUSPENSION) $3.70-$8.35 (Tier 2) QL

Anxiolytics

Anxiolytics, OtherBuspirone HCl

buspirone hcl (tablet) $1.25-$3.35 (Tier 1)Hydroxyzine HCl

hydroxyzine hcl (10mg tablet, 25mg tablet, 50mg

tablet, 10mg/5ml syrup)$1.25-$3.35 (Tier 1)

Hydroxyzine HCl

hydroxyzine hcl (25mg/ml injection, 50mg/ml


Benzodiazepines Alprazolam

alprazolam (tablet immediate-release) $1.25-$3.35 (Tier 1) QLChlordiazepoxide HCl

chlordiazepoxide hcl (capsule) $1.25-$3.35 (Tier 1)Clonazepam

clonazepam (tablet) $1.25-$3.35 (Tier 1) QLClonazepam ODT

clonazepam odt (tablet dispersible) $1.25-$3.35 (Tier 1) QLClorazepate Dipotassium

clorazepate dipotassium (tablet) $1.25-$3.35 (Tier 1) QLDiazepam

diazepam (10mg tablet, 2mg tablet, 5mg tablet) $1.25-$3.35 (Tier 1) QLDiazepam

diazepam (5mg/5ml oral solution) $1.25-$3.35 (Tier 1)


pages 9 and 10.




46


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useDiazepam Intensol

diazepam intensol (5mg/ml concentrate) $1.25-$3.35 (Tier 1) QLLorazepam

lorazepam (0.5mg tablet, 1mg tablet, 2mg tablet,

2mg/ml concentrate)$1.25-$3.35 (Tier 1) QL

Bipolar Agents

Mood StabilizersDivalproex Sodium

divalproex sodium (capsule sprinkle delayed-release) $1.25-$3.35 (Tier 1)Divalproex Sodium DR

divalproex sodium dr (tablet delayed-release) $1.25-$3.35 (Tier 1)Divalproex Sodium ER

divalproex sodium er (tablet extended-release 24

hour)$1.25-$3.35 (Tier 1)

Lithium

LITHIUM (ORAL SOLUTION) $3.70-$8.35 (Tier 2)Lithium Carbonate

lithium carbonate (150mg capsule immediate-

release, 300mg capsule immediate-release, 600mg

capsule immediate-release, 300mg tablet immediate-

release)

$1.25-$3.35 (Tier 1)

Lithium Carbonate ER

lithium carbonate er (tablet extended-release) $1.25-$3.35 (Tier 1)

Blood Glucose Regulators

Antidiabetic AgentsAcarbose

acarbose (tablet) $1.25-$3.35 (Tier 1) QLAvandia

AVANDIA (TABLET) $3.70-$8.35 (Tier 2) PA, QLBydureon Bcise

BYDUREON BCISE (AUTO INJECTOR) $3.70-$8.35 (Tier 2) QLBydureon Pen

BYDUREON PEN (INJECTION) $3.70-$8.35 (Tier 2) QLBydureon Vial

BYDUREON VIAL (INJECTION) $3.70-$8.35 (Tier 2) QLByetta

BYETTA (INJECTION) $3.70-$8.35 (Tier 2) QLCycloset

CYCLOSET (TABLET) $3.70-$8.35 (Tier 2) PA, QLFarxiga

FARXIGA (TABLET) $3.70-$8.35 (Tier 2) QLGlimepiride

glimepiride (tablet) $1.25-$3.35 (Tier 1) QLGlipizide

glipizide (tablet immediate-release) $1.25-$3.35 (Tier 1) QL


47


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useGlipizide ER

glipizide er (tablet extended-release 24 hour) $1.25-$3.35 (Tier 1) QLGlipizide/Metformin HCl

glipizide/metformin hcl (tablet) $1.25-$3.35 (Tier 1) QLGlyxambi

GLYXAMBI (TABLET) $3.70-$8.35 (Tier 2) QLJardiance

JARDIANCE (TABLET) $3.70-$8.35 (Tier 2) QLJentadueto

JENTADUETO (TABLET) $3.70-$8.35 (Tier 2) QLJentadueto XR

JENTADUETO XR (TABLET EXTENDED-RELEASE 24

HOUR)$3.70-$8.35 (Tier 2) QL

Kombiglyze XR

KOMBIGLYZE XR (TABLET EXTENDED-RELEASE 24

HOUR)$3.70-$8.35 (Tier 2) QL

Metformin HCl

metformin hcl (tablet immediate-release) $1.25-$3.35 (Tier 1) QLMetformin HCl ER

metformin hcl er (500mg tablet extended-release 24

hour, 750mg tablet extended-release 24 hour)

(generic glucophage xr)

$1.25-$3.35 (Tier 1) QL

Nateglinide

nateglinide (tablet) $1.25-$3.35 (Tier 1) QLOnglyza

ONGLYZA (TABLET) $3.70-$8.35 (Tier 2) QLPioglitazone HCl

pioglitazone hcl (tablet) $1.25-$3.35 (Tier 1) QLPioglitazone HCl/Glimepiride

pioglitazone hcl/glimepiride (tablet) $1.25-$3.35 (Tier 1) QLPioglitazone HCl/Metformin HCl

pioglitazone hcl/metformin hcl (tablet) $1.25-$3.35 (Tier 1) QLRepaglinide

repaglinide (tablet) $1.25-$3.35 (Tier 1) QLRepaglinide/Metformin HCl

repaglinide/metformin hcl (tablet) $1.25-$3.35 (Tier 1) QLRiomet

RIOMET (ORAL SOLUTION) $3.70-$8.35 (Tier 2) QLSoliqua 100/33

SOLIQUA 100/33 (INJECTION) $3.70-$8.35 (Tier 2) QLSymlinPen 120

SYMLINPEN 120 (INJECTION) $3.70-$8.35 (Tier 2) PASymlinPen 60

SYMLINPEN 60 (INJECTION) $3.70-$8.35 (Tier 2) PASynjardy

SYNJARDY (TABLET) $3.70-$8.35 (Tier 2) QLSynjardy XR

SYNJARDY XR (TABLET EXTENDED-RELEASE 24

HOUR)$3.70-$8.35 (Tier 2) QL

Tradjenta

TRADJENTA (TABLET) $3.70-$8.35 (Tier 2) QLXigduo XR

XIGDUO XR (TABLET EXTENDED-RELEASE 24 HOUR) $3.70-$8.35 (Tier 2) QL

Glycemic AgentsGlucaGen HypoKit

GLUCAGEN HYPOKIT (INJECTION) $3.70-$8.35 (Tier 2)Glucagon Emergency Kit

GLUCAGON EMERGENCY KIT (INJECTION) $3.70-$8.35 (Tier 2)Proglycem

PROGLYCEM (SUSPENSION) $3.70-$8.35 (Tier 2)

InsulinsHumalog Cartridge

HUMALOG CARTRIDGE (INJECTION) $3.70-$8.35 (Tier 2)Humalog Junior KwikPen

HUMALOG JUNIOR KWIKPEN (INJECTION) $3.70-$8.35 (Tier 2)


pages 9 and 10.




48


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useHumalog KwikPen

HUMALOG KWIKPEN (INJECTION) $3.70-$8.35 (Tier 2)Humalog Mix 50/50 KwikPen

HUMALOG MIX 50/50 KWIKPEN (INJECTION) $3.70-$8.35 (Tier 2)Humalog Mix 50/50 Vial

HUMALOG MIX 50/50 VIAL (INJECTION) $3.70-$8.35 (Tier 2)Humalog Mix 75/25 KwikPen

HUMALOG MIX 75/25 KWIKPEN (INJECTION) $3.70-$8.35 (Tier 2)Humalog Mix 75/25 Vial

HUMALOG MIX 75/25 VIAL (INJECTION) $3.70-$8.35 (Tier 2)Humalog Vial

HUMALOG VIAL (INJECTION) $3.70-$8.35 (Tier 2)Humulin 70/30 KwikPen

HUMULIN 70/30 KWIKPEN (INJECTION) $3.70-$8.35 (Tier 2)Humulin 70/30 Vial

HUMULIN 70/30 VIAL (INJECTION) $3.70-$8.35 (Tier 2)Humulin N KwikPen

HUMULIN N KWIKPEN (INJECTION) $3.70-$8.35 (Tier 2)Humulin N Vial

HUMULIN N VIAL (INJECTION) $3.70-$8.35 (Tier 2)Humulin R U-500 KwikPen

HUMULIN R U-500 KWIKPEN (INJECTION) $3.70-$8.35 (Tier 2)Humulin R U-500 Vial

HUMULIN R U-500 VIAL (CONCENTRATED)

(INJECTION)$3.70-$8.35 (Tier 2)

Humulin R Vial

HUMULIN R VIAL (INJECTION) $3.70-$8.35 (Tier 2)Lantus SoloStar

LANTUS SOLOSTAR (INJECTION) $3.70-$8.35 (Tier 2)Lantus Vial

LANTUS VIAL (INJECTION) $3.70-$8.35 (Tier 2)Levemir FlexTouch

LEVEMIR FLEXTOUCH (INJECTION) $3.70-$8.35 (Tier 2)Levemir Vial

LEVEMIR VIAL (INJECTION) $3.70-$8.35 (Tier 2)Toujeo Max Solostar

TOUJEO MAX SOLOSTAR (INJECTION) $3.70-$8.35 (Tier 2)Toujeo SoloStar

TOUJEO SOLOSTAR (INJECTION) $3.70-$8.35 (Tier 2)Tresiba FlexTouch

TRESIBA FLEXTOUCH (INJECTION) $3.70-$8.35 (Tier 2)

Blood Products/Modifiers/Volume Expanders

AnticoagulantsArgatroban

ARGATROBAN (125MG/125ML-0.9% INJECTION) $3.70-$8.35 (Tier 2) B/D, PAArgatroban

argatroban (250mg/2.5ml injection) $1.25-$3.35 (Tier 1) B/D, PACoumadin

COUMADIN (TABLET) $3.70-$8.35 (Tier 2)Eliquis

ELIQUIS (TABLET) $3.70-$8.35 (Tier 2) QLEliquis Starter Pack

ELIQUIS STARTER PACK (TABLET) $3.70-$8.35 (Tier 2) QL


49


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useEnoxaparin Sodium

enoxaparin sodium (100mg/ml injection, 120mg/

0.8ml injection, 150mg/ml injection, 30mg/0.3ml

injection, 40mg/0.4ml injection, 60mg/0.6ml

injection, 80mg/0.8ml injection, 300mg/3ml

injection)

$1.25-$3.35 (Tier 1) QL

Fondaparinux Sodium

fondaparinux sodium (injection) $1.25-$3.35 (Tier 1)Heparin Sodium

heparin sodium (10000unit/ml injection, 20000unit/

ml injection, 5000unit/ml injection)$1.25-$3.35 (Tier 1)

Heparin Sodium

heparin sodium (1000unit/ml injection) $1.25-$3.35 (Tier 1) B/D, PAHeparin Sodium/D5W

HEPARIN SODIUM/D5W (INJECTION) $3.70-$8.35 (Tier 2)Jantoven

jantoven (tablet) $1.25-$3.35 (Tier 1)Warfarin Sodium

warfarin sodium (tablet) $1.25-$3.35 (Tier 1)Xarelto

XARELTO (TABLET) $3.70-$8.35 (Tier 2) QLXarelto Starter Pack

XARELTO STARTER PACK (TABLET THERAPY PACK) $3.70-$8.35 (Tier 2) QL

Blood Formation ModifiersAnagrelide HCl

anagrelide hcl (capsule) $1.25-$3.35 (Tier 1)Aranesp Albumin Free

ARANESP ALBUMIN FREE (INJECTION) $3.70-$8.35 (Tier 2) PAAzacitidine

azacitidine (injection) $1.25-$3.35 (Tier 1) PALeukine

LEUKINE (INJECTION) $3.70-$8.35 (Tier 2) PAMozobil

MOZOBIL (INJECTION) $3.70-$8.35 (Tier 2)Neulasta

NEULASTA (INJECTION) $3.70-$8.35 (Tier 2) PAProcrit

PROCRIT (INJECTION) $3.70-$8.35 (Tier 2) PAPromacta

PROMACTA (TABLET) $3.70-$8.35 (Tier 2) PA, QLZarxio

zarxio (solution prefilled syringe) $3.70-$8.35 (Tier 2)

Hemostasis AgentsTranexamic Acid

tranexamic acid (1000mg/10ml injection, 650mg

tablet)$1.25-$3.35 (Tier 1)

Platelet Modifying AgentsAspirin/Dipyridamole

aspirin/dipyridamole (capsule extended-release 12

hour)$1.25-$3.35 (Tier 1) QL

Brilinta

BRILINTA (TABLET) $3.70-$8.35 (Tier 2) QLCilostazol

cilostazol (tablet) $1.25-$3.35 (Tier 1)Clopidogrel

clopidogrel (75mg tablet) $1.25-$3.35 (Tier 1) QLPrasugrel

prasugrel (tablet) $1.25-$3.35 (Tier 1) QL

Cardiovascular Agents


pages 9 and 10.




50


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

Alpha-adrenergic AgonistsClonidine HCl

clonidine hcl (0.1mg tablet immediate-release, 0.2mg

tablet immediate-release, 0.3mg tablet immediate-

release, 0.1mg/24hr patch weekly, 0.2mg/24hr patch

weekly, 0.3mg/24hr patch weekly)

$1.25-$3.35 (Tier 1)

Methyldopa

methyldopa (tablet) $1.25-$3.35 (Tier 1)Methyldopate HCl

methyldopate hcl (injection) $1.25-$3.35 (Tier 1)Midodrine HCl

midodrine hcl (tablet) $1.25-$3.35 (Tier 1)Northera

NORTHERA (CAPSULE) $3.70-$8.35 (Tier 2) PA, QL

Alpha-adrenergic Blocking AgentsDoxazosin Mesylate

doxazosin mesylate (tablet) $1.25-$3.35 (Tier 1)Phenoxybenzamine HCl

phenoxybenzamine hcl (capsule) $1.25-$3.35 (Tier 1)Prazosin HCl

prazosin hcl (capsule) $1.25-$3.35 (Tier 1)

Angiotensin II Receptor AntagonistsCandesartan Cilexetil

candesartan cilexetil (tablet) $1.25-$3.35 (Tier 1) QLEprosartan Mesylate

eprosartan mesylate (tablet) $1.25-$3.35 (Tier 1) QLIrbesartan

irbesartan (tablet) $1.25-$3.35 (Tier 1) QLLosartan Potassium

losartan potassium (tablet) $1.25-$3.35 (Tier 1) QLOlmesartan Medoxomil

olmesartan medoxomil (tablet) $1.25-$3.35 (Tier 1) QLTelmisartan

telmisartan (tablet) $1.25-$3.35 (Tier 1) QLValsartan

valsartan (tablet) $1.25-$3.35 (Tier 1) QL

Angiotensin-converting Enzyme (ACE) InhibitorsBenazepril HCl

benazepril hcl (tablet) $1.25-$3.35 (Tier 1) QLCaptopril

captopril (tablet) $1.25-$3.35 (Tier 1) QLEnalapril Maleate

enalapril maleate (tablet) $1.25-$3.35 (Tier 1) QLFosinopril Sodium

fosinopril sodium (tablet) $1.25-$3.35 (Tier 1) QLLisinopril

lisinopril (tablet) $1.25-$3.35 (Tier 1) QL


51


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMoexipril HCl

moexipril hcl (tablet) $1.25-$3.35 (Tier 1) QLPerindopril Erbumine

perindopril erbumine (tablet) $1.25-$3.35 (Tier 1) QLQuinapril HCl

quinapril hcl (tablet) $1.25-$3.35 (Tier 1) QLRamipril

ramipril (capsule) $1.25-$3.35 (Tier 1) QLTrandolapril

trandolapril (tablet) $1.25-$3.35 (Tier 1) QL

AntiarrhythmicsAmiodarone HCl

amiodarone hcl (200mg tablet, 50mg/ml injection) $1.25-$3.35 (Tier 1)Dofetilide

dofetilide (capsule) $1.25-$3.35 (Tier 1)Flecainide Acetate

flecainide acetate (tablet) $1.25-$3.35 (Tier 1)Mexiletine HCl

mexiletine hcl (capsule) $1.25-$3.35 (Tier 1)Multaq

MULTAQ (TABLET) $3.70-$8.35 (Tier 2) QLPacerone

pacerone (200mg tablet) $1.25-$3.35 (Tier 1)Procainamide HCl

procainamide hcl (injection) $1.25-$3.35 (Tier 1)Propafenone HCl

propafenone hcl (tablet) $1.25-$3.35 (Tier 1)Propafenone HCl ER

propafenone hcl er (capsule extended-release 12

hour)$1.25-$3.35 (Tier 1)

Quinidine Gluconate

QUINIDINE GLUCONATE (INJECTION) $3.70-$8.35 (Tier 2)Quinidine Gluconate CR

quinidine gluconate cr (tablet extended-release) $1.25-$3.35 (Tier 1)Quinidine Sulfate

quinidine sulfate (tablet) $1.25-$3.35 (Tier 1)Sotalol HCl

sotalol hcl (af) (tablet) $1.25-$3.35 (Tier 1)Sotalol HCl

sotalol hcl (tablet) $1.25-$3.35 (Tier 1)

Beta-adrenergic Blocking AgentsAtenolol

atenolol (tablet) $1.25-$3.35 (Tier 1)Bystolic

BYSTOLIC (TABLET) $3.70-$8.35 (Tier 2) QLCarvedilol

carvedilol (tablet) $1.25-$3.35 (Tier 1)Labetalol HCl

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

tablet, 5mg/ml injection)$1.25-$3.35 (Tier 1)

Metoprolol Succinate ER

metoprolol succinate er (tablet extended-release 24

hour)$1.25-$3.35 (Tier 1)

Metoprolol Tartrate

metoprolol tartrate (100mg tablet immediate-release,


immediate-release, 5mg/5ml injection)

$1.25-$3.35 (Tier 1)

Nadolol

nadolol (tablet) $1.25-$3.35 (Tier 1)Pindolol

pindolol (tablet) $1.25-$3.35 (Tier 1)Propranolol HCl

propranolol hcl (1mg/ml injection, 20mg/5ml oral

solution, 40mg/5ml oral solution)$1.25-$3.35 (Tier 1)


pages 9 and 10.




52


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on usePropranolol HCl

propranolol hcl (tablet immediate-release) $1.25-$3.35 (Tier 1)Propranolol HCl ER

propranolol hcl er (capsule extended-release 24

hour)$1.25-$3.35 (Tier 1)

Timolol Maleate

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

tablet)$1.25-$3.35 (Tier 1)

Calcium Channel Blocking AgentsAmlodipine Besylate

amlodipine besylate (tablet) $1.25-$3.35 (Tier 1)Cardene IV

CARDENE IV (INJECTION) $3.70-$8.35 (Tier 2)Cartia XT

cartia xt (capsule extended-release 24 hour) $1.25-$3.35 (Tier 1)Dilt-XR

dilt-xr (capsule extended-release 24 hour) $1.25-$3.35 (Tier 1)Diltiazem HCl

diltiazem hcl (100mg injection, 50mg/10ml injection,




$1.25-$3.35 (Tier 1)

Diltiazem HCl ER

diltiazem hcl er (capsule extended-release 12 hour,

capsule extended-release 24 hour)$1.25-$3.35 (Tier 1)

Matzim LA

matzim la (tablet extended-release 24 hour) $1.25-$3.35 (Tier 1)Nicardipine HCl

nicardipine hcl (2.5mg/ml injection, 20mg capsule,

30mg capsule)$1.25-$3.35 (Tier 1)

Nimodipine

nimodipine (capsule) $1.25-$3.35 (Tier 1)Nymalize

NYMALIZE (ORAL SOLUTION) $3.70-$8.35 (Tier 2)Taztia XT

taztia xt (capsule extended-release 24 hour) $1.25-$3.35 (Tier 1)Verapamil HCl

verapamil hcl (120mg tablet immediate-release,


immediate-release, 2.5mg/ml injection)

$1.25-$3.35 (Tier 1)

Verapamil HCl ER

verapamil hcl er (120mg tablet extended-release,

180mg tablet extended-release, 240mg tablet

extended-release)

$1.25-$3.35 (Tier 1)

Cardiovascular Agents, Other


53


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useAmiloride/Hydrochlorothiazide

amiloride/hydrochlorothiazide (tablet) $1.25-$3.35 (Tier 1)Amlodipine Besylate/Atorvastatin Calcium

amlodipine besylate/atorvastatin calcium (tablet) $1.25-$3.35 (Tier 1) QLAmlodipine Besylate/Benazepril HCl

amlodipine besylate/benazepril hcl (capsule) $1.25-$3.35 (Tier 1) QLAtenolol/Chlorthalidone

atenolol/chlorthalidone (tablet) $1.25-$3.35 (Tier 1)Benazepril HCl/Hydrochlorothiazide

benazepril hcl/hydrochlorothiazide (tablet) $1.25-$3.35 (Tier 1) QLCandesartan Cilexetil/Hydrochlorothiazide

candesartan cilexetil/hydrochlorothiazide (tablet) $1.25-$3.35 (Tier 1) QLCaptopril/Hydrochlorothiazide

captopril/hydrochlorothiazide (tablet) $1.25-$3.35 (Tier 1) QLCorlanor

CORLANOR (TABLET) $3.70-$8.35 (Tier 2) PA, QLDemser

DEMSER (CAPSULE) $3.70-$8.35 (Tier 2)Digitek

digitek (tablet) $1.25-$3.35 (Tier 1)Digox

digox (tablet) $1.25-$3.35 (Tier 1)Digoxin

DIGOXIN (0.05MG/ML ORAL SOLUTION) $3.70-$8.35 (Tier 2)Digoxin

digoxin (0.25mg/ml injection, 125mcg tablet,

250mcg tablet)$1.25-$3.35 (Tier 1)

Enalapril Maleate/Hydrochlorothiazide

enalapril maleate/hydrochlorothiazide (tablet) $1.25-$3.35 (Tier 1) QLEntresto

ENTRESTO (TABLET) $3.70-$8.35 (Tier 2) QLFosinopril Sodium/Hydrochlorothiazide

fosinopril sodium/hydrochlorothiazide (tablet) $1.25-$3.35 (Tier 1) QLIrbesartan/Hydrochlorothiazide

irbesartan/hydrochlorothiazide (tablet) $1.25-$3.35 (Tier 1) QLLanoxin

LANOXIN (125MCG TABLET, 250MCG TABLET,

62.5MCG TABLET)$3.70-$8.35 (Tier 2)

Lisinopril/Hydrochlorothiazide

lisinopril/hydrochlorothiazide (tablet) $1.25-$3.35 (Tier 1) QLLosartan Potassium/Hydrochlorothiazide

losartan potassium/hydrochlorothiazide (tablet) $1.25-$3.35 (Tier 1) QLMethyldopa/Hydrochlorothiazide

methyldopa/hydrochlorothiazide (tablet) $1.25-$3.35 (Tier 1)Metoprolol/Hydrochlorothiazide

metoprolol/hydrochlorothiazide (tablet) $1.25-$3.35 (Tier 1)Moexipril/Hydrochlorothiazide

moexipril/hydrochlorothiazide (tablet) $1.25-$3.35 (Tier 1) QLOlmesartan Medoxomil/Hydrochlorothiazide

olmesartan medoxomil/hydrochlorothiazide (tablet) $1.25-$3.35 (Tier 1) QLPentoxifylline ER

pentoxifylline er (tablet extended-release) $1.25-$3.35 (Tier 1)Propranolol/Hydrochlorothiazide

propranolol/hydrochlorothiazide (tablet) $1.25-$3.35 (Tier 1)Quinapril/Hydrochlorothiazide

quinapril/hydrochlorothiazide (tablet) $1.25-$3.35 (Tier 1) QLRanexa

RANEXA (TABLET EXTENDED-RELEASE 12 HOUR) $3.70-$8.35 (Tier 2) QLSpironolactone/Hydrochlorothiazide

spironolactone/hydrochlorothiazide (tablet) $1.25-$3.35 (Tier 1)Telmisartan/Amlodipine

telmisartan/amlodipine (tablet) $1.25-$3.35 (Tier 1) QLTelmisartan/Hydrochlorothiazide

telmisartan/hydrochlorothiazide (tablet) $1.25-$3.35 (Tier 1) QLTriamterene/Hydrochlorothiazide

triamterene/hydrochlorothiazide (37.5mg-25mg

capsule, 37.5mg-25mg tablet, 75mg-50mg tablet)$1.25-$3.35 (Tier 1)

Valsartan/Hydrochlorothiazide

valsartan/hydrochlorothiazide (tablet) $1.25-$3.35 (Tier 1) QL


pages 9 and 10.




54


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

Diuretics, Carbonic Anhydrase InhibitorsAcetazolamide

acetazolamide (tablet immediate-release) $1.25-$3.35 (Tier 1)Acetazolamide ER

acetazolamide er (capsule extended-release 12 hour) $1.25-$3.35 (Tier 1)Acetazolamide Sodium

acetazolamide sodium (injection) $1.25-$3.35 (Tier 1)Methazolamide

methazolamide (tablet) $1.25-$3.35 (Tier 1)

Diuretics, LoopBumetanide

bumetanide (0.25mg/ml injection, 0.5mg tablet, 1mg

tablet, 2mg tablet)$1.25-$3.35 (Tier 1)

Furosemide

furosemide (10mg/ml injection) $1.25-$3.35 (Tier 1) B/D, PAFurosemide

furosemide (10mg/ml oral solution, 8mg/ml oral

solution, 20mg tablet, 40mg tablet, 80mg tablet)$1.25-$3.35 (Tier 1)

Torsemide

torsemide (tablet) $1.25-$3.35 (Tier 1)

Diuretics, Potassium-sparingAmiloride HCl

amiloride hcl (tablet) $1.25-$3.35 (Tier 1)Eplerenone

eplerenone (tablet) $1.25-$3.35 (Tier 1)Spironolactone

spironolactone (tablet) $1.25-$3.35 (Tier 1)

Diuretics, ThiazideChlorothiazide

chlorothiazide (tablet) $1.25-$3.35 (Tier 1)Chlorothiazide Sodium

chlorothiazide sodium (injection) $1.25-$3.35 (Tier 1) B/D, PAChlorthalidone

chlorthalidone (tablet) $1.25-$3.35 (Tier 1)Diuril

DIURIL (SUSPENSION) $3.70-$8.35 (Tier 2)Hydrochlorothiazide

hydrochlorothiazide (12.5mg capsule, 12.5mg tablet,

25mg tablet, 50mg tablet)$1.25-$3.35 (Tier 1)

Indapamide

indapamide (tablet) $1.25-$3.35 (Tier 1)Methyclothiazide

methyclothiazide (tablet) $1.25-$3.35 (Tier 1)Metolazone

metolazone (tablet) $1.25-$3.35 (Tier 1)

Dyslipidemics, Fibric Acid Derivatives


55


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useFenofibrate

fenofibrate (160mg tablet, 54mg tablet) $1.25-$3.35 (Tier 1)Gemfibrozil

gemfibrozil (tablet) $1.25-$3.35 (Tier 1)

Dyslipidemics, HMG CoA Reductase InhibitorsAtorvastatin Calcium

atorvastatin calcium (tablet) $1.25-$3.35 (Tier 1) QLFluvastatin

fluvastatin (capsule immediate-release) $1.25-$3.35 (Tier 1) QLLivalo

LIVALO (TABLET) $3.70-$8.35 (Tier 2) QLLovastatin

lovastatin (tablet) $1.25-$3.35 (Tier 1) QLPravastatin Sodium

pravastatin sodium (tablet) $1.25-$3.35 (Tier 1) QLRosuvastatin Calcium

rosuvastatin calcium (tablet) $1.25-$3.35 (Tier 1) QLSimvastatin

simvastatin (tablet) $1.25-$3.35 (Tier 1) QL

Dyslipidemics, OtherCholestyramine

cholestyramine (packet) $1.25-$3.35 (Tier 1)Cholestyramine Light

cholestyramine light (powder) $1.25-$3.35 (Tier 1)Colesevelam HCl

colesevelam hcl (tablet) $1.25-$3.35 (Tier 1)Colestipol HCl

colestipol hcl (1gm tablet, 5gm packet) $1.25-$3.35 (Tier 1)Ezetimibe

ezetimibe (tablet) $1.25-$3.35 (Tier 1) QLEzetimibe/Simvastatin

ezetimibe/simvastatin (tablet) $1.25-$3.35 (Tier 1) QLJuxtapid

JUXTAPID (CAPSULE) $3.70-$8.35 (Tier 2) PA, LAKynamro

KYNAMRO (INJECTION) $3.70-$8.35 (Tier 2) PA, LANiacin ER

niacin er (tablet extended-release) $1.25-$3.35 (Tier 1)Niacor

niacor (tablet) $1.25-$3.35 (Tier 1)Omega-3-Acid Ethyl Esters

omega-3-acid ethyl esters (capsule) (generic lovaza) $1.25-$3.35 (Tier 1) QLPraluent

PRALUENT (INJECTION) $3.70-$8.35 (Tier 2) PA, QLPrevalite

prevalite (packet) $1.25-$3.35 (Tier 1)Repatha

REPATHA (INJECTION) $3.70-$8.35 (Tier 2) PA, QLRepatha Pushtronex System

REPATHA PUSHTRONEX SYSTEM (INJECTION) $3.70-$8.35 (Tier 2) PA, QLRepatha SureClick

REPATHA SURECLICK (INJECTION) $3.70-$8.35 (Tier 2) PA, QLVascepa

VASCEPA (CAPSULE) $3.70-$8.35 (Tier 2)Welchol

WELCHOL (3.75GM PACKET, 625MG TABLET) $3.70-$8.35 (Tier 2)

Vasodilators, Direct-acting ArterialHydralazine HCl

hydralazine hcl (100mg tablet, 10mg tablet, 25mg

tablet, 50mg tablet, 20mg/ml injection)$1.25-$3.35 (Tier 1)

Minoxidil

minoxidil (tablet) $1.25-$3.35 (Tier 1)

Vasodilators, Direct-acting Arterial/Venous


pages 9 and 10.




56


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useIsosorbide Dinitrate

isosorbide dinitrate (tablet immediate-release) $1.25-$3.35 (Tier 1)Isosorbide Dinitrate ER

isosorbide dinitrate er (tablet extended-release) $1.25-$3.35 (Tier 1)Isosorbide Mononitrate

isosorbide mononitrate (tablet immediate-release) $1.25-$3.35 (Tier 1)Isosorbide Mononitrate ER

isosorbide mononitrate er (tablet extended-release

24 hour)$1.25-$3.35 (Tier 1)

Minitran

minitran (patch 24 hour) $1.25-$3.35 (Tier 1)Nitro-Bid

nitro-bid (ointment) $1.25-$3.35 (Tier 1)Nitroglycerin

nitroglycerin (0.3mg tablet sublingual, 0.4mg tablet

sublingual, 0.6mg tablet sublingual, 5mg/ml

injection)

$1.25-$3.35 (Tier 1)

Nitroglycerin Lingual

nitroglycerin lingual (translingual solution) $1.25-$3.35 (Tier 1)Nitroglycerin Transdermal

nitroglycerin transdermal (patch 24 hour) $1.25-$3.35 (Tier 1)Nitrostat

NITROSTAT (TABLET SUBLINGUAL) $3.70-$8.35 (Tier 2)

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, AmphetaminesAmphetamine/Dextroamphetamine

amphetamine/dextroamphetamine (10mg capsule

extended-release 24 hour, 15mg capsule extended-

release 24 hour, 20mg capsule extended-release 24

hour, 25mg capsule extended-release 24 hour, 30mg

capsule extended-release 24 hour, 5mg capsule

extended-release 24 hour, 10mg tablet immediate-

release, 12.5mg tablet immediate-release, 15mg



immediate-release, 7.5mg tablet immediate-release)

$1.25-$3.35 (Tier 1) QL

Dextroamphetamine Sulfate

dextroamphetamine sulfate (10mg tablet, 5mg

tablet)$1.25-$3.35 (Tier 1) QL

Attention Deficit Hyperactivity Disorder Agents, Non-amphetaminesAtomoxetine

atomoxetine (capsule) $1.25-$3.35 (Tier 1) QL


57


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useClonidine HCl ER

clonidine hcl er (tablet extended-release 12 hour) $1.25-$3.35 (Tier 1) PADexmethylphenidate HCl

dexmethylphenidate hcl (tablet immediate-release) $1.25-$3.35 (Tier 1) QLDexmethylphenidate HCl ER

dexmethylphenidate hcl er (capsule extended-

release 24 hour)$1.25-$3.35 (Tier 1)

Guanfacine ER

guanfacine er (tablet extended-release 24 hour) $1.25-$3.35 (Tier 1)Methylphenidate HCl

methylphenidate hcl (10mg tablet immediate-release,


immediate-release) (generic ritalin), (10mg/5ml oral

solution, 5mg/5ml oral solution)

$1.25-$3.35 (Tier 1) QL

Methylphenidate HCl ER

methylphenidate hcl er (10mg tablet extended-

release, 20mg tablet extended-release)$1.25-$3.35 (Tier 1) QL

Central Nervous System, OtherAustedo

AUSTEDO (TABLET) $3.70-$8.35 (Tier 2) PA, QLIngrezza

INGREZZA (CAPSULE) $3.70-$8.35 (Tier 2) PA, QLNamzaric

NAMZARIC (THERAPY PACK, CAPSULE EXTENDED-

RELEASE 24 HOUR)$3.70-$8.35 (Tier 2) PA, QL

Nuedexta

NUEDEXTA (CAPSULE) $3.70-$8.35 (Tier 2) PARiluzole

riluzole (tablet) $1.25-$3.35 (Tier 1)Tetrabenazine

tetrabenazine (tablet) $1.25-$3.35 (Tier 1) PA, QL

Fibromyalgia AgentsDuloxetine HCl

duloxetine hcl (20mg capsule delayed-release, 30mg

capsule delayed-release, 60mg capsule delayed-

release)

$1.25-$3.35 (Tier 1) QL

Lyrica

LYRICA (100MG CAPSULE, 150MG CAPSULE, 200MG

CAPSULE, 225MG CAPSULE, 25MG CAPSULE, 300MG

CAPSULE, 50MG CAPSULE, 75MG CAPSULE, 20MG/

ML ORAL SOLUTION)

$3.70-$8.35 (Tier 2) QL

Savella

SAVELLA (TABLET) $3.70-$8.35 (Tier 2)Savella Titration Pack

SAVELLA TITRATION PACK $3.70-$8.35 (Tier 2)

Multiple Sclerosis AgentsAmpyra

AMPYRA (TABLET EXTENDED-RELEASE 12 HOUR) $3.70-$8.35 (Tier 2) QLAubagio

AUBAGIO (TABLET) $3.70-$8.35 (Tier 2) QLAvonex

AVONEX (INJECTION) $3.70-$8.35 (Tier 2)Avonex Pen

AVONEX PEN (INJECTION) $3.70-$8.35 (Tier 2)Betaseron

BETASERON (INJECTION) $3.70-$8.35 (Tier 2)Copaxone

COPAXONE (INJECTION) $3.70-$8.35 (Tier 2)Gilenya

GILENYA (CAPSULE) $3.70-$8.35 (Tier 2) QL


pages 9 and 10.




58


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useGlatiramer Acetate

glatiramer acetate (solution prefilled syringe) $1.25-$3.35 (Tier 1)Glatopa

glatopa (injection) $1.25-$3.35 (Tier 1)Rebif

REBIF (INJECTION) $3.70-$8.35 (Tier 2)Rebif Rebidose

REBIF REBIDOSE (INJECTION) $3.70-$8.35 (Tier 2)Rebif Rebidose Titration Pack

REBIF REBIDOSE TITRATION PACK (INJECTION) $3.70-$8.35 (Tier 2)Rebif Titration Pack

REBIF TITRATION PACK (INJECTION) $3.70-$8.35 (Tier 2)Tecfidera

TECFIDERA (CAPSULE DELAYED-RELEASE) $3.70-$8.35 (Tier 2) QLTecfidera Starter Pack

TECFIDERA STARTER PACK $3.70-$8.35 (Tier 2)Tysabri

TYSABRI (INJECTION) $3.70-$8.35 (Tier 2) PA

Dental and Oral Agents

Dental and Oral AgentsChlorhexidine Gluconate Oral Rinse

chlorhexidine gluconate oral rinse (solution) $1.25-$3.35 (Tier 1)Kepivance

KEPIVANCE (INJECTION) $3.70-$8.35 (Tier 2)Periogard

periogard (solution) $1.25-$3.35 (Tier 1)Pilocarpine HCl

pilocarpine hcl (5mg tablet, 7.5mg tablet) $1.25-$3.35 (Tier 1)Triamcinolone Acetonide Dental Paste

triamcinolone acetonide dental paste (paste) $1.25-$3.35 (Tier 1)

Dermatological Agents

Dermatological AgentsAcitretin

acitretin (capsule) $1.25-$3.35 (Tier 1)Acne Medication 10

acne medication 10 (otc only) lotion)* $0 (Tier 3)Acne Medication 5

acne medication 5 (5% gel, 5% lotion)* $0 (Tier 3)Adapalene

adapalene (0.1% cream, 0.1% gel) $1.25-$3.35 (Tier 1)Ammonium Lactate

ammonium lactate (rx only) (12% cream, 12% lotion) $1.25-$3.35 (Tier 1)Anu-Med

anu-med (suppository)* $0 (Tier 3)Benzoyl Peroxide

benzoyl peroxide (otc only) (2.5% gel, 9.8% foam)* $0 (Tier 3)Benzoyl Peroxide Cleanser

benzoyl peroxide cleanser (lotion)* $0 (Tier 3)Blue Gel

blue gel (gel)* $0 (Tier 3)


59


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useCalcipotriene

calcipotriene (0.005% cream, 0.005% external


Calcitriol

CALCITRIOL (3MCG/GM OINTMENT) $3.70-$8.35 (Tier 2)Capsaicin

capsaicin (cream)* $0 (Tier 3)Claravis

claravis (capsule) $1.25-$3.35 (Tier 1) PAClindamycin Phosphate

clindamycin phosphate (1% external solution, 1%

gel, 1% lotion, 1% swab)$1.25-$3.35 (Tier 1)

Clindamycin/Benzoyl Peroxide

clindamycin/benzoyl peroxide (1%-5% gel) (generic

benzaclin)$1.25-$3.35 (Tier 1)

Clotrimazole/Betamethasone Dipropionate

clotrimazole/betamethasone dipropionate (1%-0.05%

cream, 1%-0.05% lotion)$1.25-$3.35 (Tier 1)

Coats Aloe Creme

coats aloe creme (cream)* $0 (Tier 3)Coats Aloe Gelly

coats aloe gelly (gel)* $0 (Tier 3)Coats Aloe Moisturizing Lotion

coats aloe moisturizing lotion (lotion)* $0 (Tier 3)Coleman Botanicals Insectrepellent

coleman botanicals insectrepellent (liquid)* $0 (Tier 3)Coleman Insect Repellent/High & Dry

coleman insect repellent/high & dry (aerosol)* $0 (Tier 3)Coleman Skinsmart Insect Repellent

coleman skinsmart insect repellent ( aerosol,

liquid)*$0 (Tier 3)

Cosentyx

COSENTYX (INJECTION) $3.70-$8.35 (Tier 2) PACosentyx Sensoready Pen

COSENTYX SENSOREADY PEN (INJECTION) $3.70-$8.35 (Tier 2) PACutter Backwoods

cutter backwoods (25% aerosol, 25% liquid)* $0 (Tier 3)Cutter Backwoods Dry

cutter backwoods dry (aerosol)* $0 (Tier 3)Cutter Lemon Eucalyptus

cutter lemon eucalyptus (liquid)* $0 (Tier 3)Dibucaine

dibucaine (ointment)* $0 (Tier 3)Diclofenac Sodium

diclofenac sodium (3% gel) $1.25-$3.35 (Tier 1) PADoxepin HCl

DOXEPIN HCL (CREAM) $3.70-$8.35 (Tier 2) PADr Smiths Diaper

dr smiths diaper (ointment)* $0 (Tier 3)Dr Smiths Diaper Rash Spray

dr smiths diaper rash spray (aerosol)* $0 (Tier 3)Dr Smiths Rash + Skin

dr smiths rash + skin (aerosol)* $0 (Tier 3)Elidel

ELIDEL (CREAM) $3.70-$8.35 (Tier 2) STEry

ery (2% pad) $1.25-$3.35 (Tier 1)Erythromycin

erythromycin (2% external solution, 2% gel) $1.25-$3.35 (Tier 1)Erythromycin/Benzoyl Peroxide

erythromycin/benzoyl peroxide (gel) $1.25-$3.35 (Tier 1)Finacea

FINACEA (15% FOAM, 15% GEL) $3.70-$8.35 (Tier 2)Fluorouracil

fluorouracil (2% external solution, 5% external

solution, 5% cream)$1.25-$3.35 (Tier 1)

Hemorrhoidal

hemorrhoidal (suppository)* $0 (Tier 3)


pages 9 and 10.




60


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useHydrocortisone/Aloe

hydrocortisone/aloe (cream)* $0 (Tier 3)Imiquimod

imiquimod (cream) $1.25-$3.35 (Tier 1)Isotretinoin

isotretinoin (capsule) $1.25-$3.35 (Tier 1) PALidocaine

lidocaine (otc only) (cream)* $0 (Tier 3)Major-Prep Hemorrhoidal

major-prep hemorrhoidal (ointment)* $0 (Tier 3)Methoxsalen

methoxsalen (capsule) $1.25-$3.35 (Tier 1)Mirvaso

MIRVASO (GEL) $3.70-$8.35 (Tier 2)Moisturel Therapeutic

moisturel therapeutic (lotion)* $0 (Tier 3)Natrapel 12-Hour Tick & Insect Repellent Continuous Spray

natrapel 12-hour tick & insect repellent continuous

spray (aerosol)*$0 (Tier 3)

Off Deep Woods

off deep woods (25% aerosol, 25% liquid)* $0 (Tier 3)Off Deep Woods Dry

off deep woods dry (aerosol)* $0 (Tier 3)Off Deep Woods Sportsmen

off deep woods sportsmen (25% liquid, 30%

aerosol)*$0 (Tier 3)

Oxsoralen Ultra

OXSORALEN ULTRA (CAPSULE) $3.70-$8.35 (Tier 2)Pain Relieving Cream

pain relieving cream (cream)* $0 (Tier 3)Picato

PICATO (GEL) $3.70-$8.35 (Tier 2)Podofilox

podofilox (external solution) $1.25-$3.35 (Tier 1)Prudoxin

PRUDOXIN (CREAM) $3.70-$8.35 (Tier 2) PARegranex

REGRANEX (GEL) $3.70-$8.35 (Tier 2) PARepel Huniters Formula

repel huniters formula (aerosol)* $0 (Tier 3)Repel Lemon Eucalyptus Insect Repellent

repel lemon eucalyptus insect repellent (aerosol)* $0 (Tier 3)Repel Sportsmen

repel sportsmen (aerosol)* $0 (Tier 3)Repel Sportsmen Dry

repel sportsmen dry (aerosol)* $0 (Tier 3)Repel Sportsmen Max

repel sportsmen max (aerosol)* $0 (Tier 3)Santyl

SANTYL (OINTMENT) $3.70-$8.35 (Tier 2)Sawyer Premium Insect Repellent

sawyer premium insect repellent (liquid)* $0 (Tier 3)Selenium Sulfide

selenium sulfide (lotion) $1.25-$3.35 (Tier 1)


61


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useStelara

STELARA (130MG/26ML INJECTION, 45MG/0.5ML

INJECTION, 90MG/ML INJECTION)$3.70-$8.35 (Tier 2) PA

Tacrolimus

tacrolimus (0.03% ointment, 0.1% ointment) $1.25-$3.35 (Tier 1) STTazarotene

tazarotene (cream) $1.25-$3.35 (Tier 1) PATazorac

TAZORAC (0.05% CREAM) $3.70-$8.35 (Tier 2) PATretinoin

tretinoin (0.01% gel, 0.025% gel, 0.025% cream,

0.05% cream, 0.1% cream)$1.25-$3.35 (Tier 1) PA

Tretinoin Microsphere

TRETINOIN MICROSPHERE (GEL) $3.70-$8.35 (Tier 2) PAUltrathon Insect Repellent 8

ultrathon insect repellent 8 (aerosol)* $0 (Tier 3)Vitamin A & D

vitamin a & d (ointment)* $0 (Tier 3)Z-Bum

z-bum (cream)* $0 (Tier 3)Zinc Oxide

zinc oxide (ointment)* $0 (Tier 3)Zyclara Pump

ZYCLARA PUMP (CREAM) $3.70-$8.35 (Tier 2) PA

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral ReplacementAminosyn 7%/Electrolytes

AMINOSYN 7%/ELECTROLYTES (INJECTION) $3.70-$8.35 (Tier 2) B/D, PAAminosyn 8.5%/Electrolytes

AMINOSYN 8.5%/ELECTROLYTES (INJECTION) $3.70-$8.35 (Tier 2) B/D, PAAminosyn II

AMINOSYN II (10% INJECTION) $3.70-$8.35 (Tier 2) B/D, PAAminosyn II 8.5%/Electrolytes

AMINOSYN II 8.5%/ELECTROLYTES (INJECTION) $3.70-$8.35 (Tier 2) B/D, PAAminosyn-HBC

AMINOSYN-HBC (INJECTION) $3.70-$8.35 (Tier 2) B/D, PAAminosyn-PF

AMINOSYN-PF (INJECTION) $3.70-$8.35 (Tier 2) B/D, PAAminosyn-RF

AMINOSYN-RF (INJECTION) $3.70-$8.35 (Tier 2) B/D, PACalcium Carbonate

calcium carbonate (1250mg/5ml suspension)* $0 (Tier 3)Carbaglu

CARBAGLU (TABLET) $3.70-$8.35 (Tier 2) LADextrose 10%

DEXTROSE 10% (INJECTION) $3.70-$8.35 (Tier 2)Dextrose 10%/NaCl 0.2%

DEXTROSE 10%/NACL 0.2% (INJECTION) $3.70-$8.35 (Tier 2)Dextrose 10%/NaCl 0.45%

DEXTROSE 10%/NACL 0.45% (INJECTION) $3.70-$8.35 (Tier 2)Dextrose 2.5%/NaCl 0.45%

DEXTROSE 2.5%/NACL 0.45% (INJECTION) $3.70-$8.35 (Tier 2)Dextrose 5%

DEXTROSE 5% (INJECTION) $3.70-$8.35 (Tier 2)Dextrose 5%/Lactated Ringers

DEXTROSE 5%/LACTATED RINGERS (INJECTION) $3.70-$8.35 (Tier 2)Dextrose 5%/NaCl 0.2%





DEXTROSE 5%/NACL 0.9% (INJECTION) $3.70-$8.35 (Tier 2)


pages 9 and 10.




62


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useFreAmine HBC 6.9%

FREAMINE HBC 6.9% (INJECTION) $3.70-$8.35 (Tier 2) B/D, PAFusion

fusion (capsule)* $0 (Tier 3)HepatAmine

HEPATAMINE (INJECTION) $3.70-$8.35 (Tier 2) B/D, PAInfed

infed (injection)* $0 (Tier 3)Intralipid

INTRALIPID (INJECTION) $3.70-$8.35 (Tier 2) B/D, PAIonosol-MB/Dextrose 5%

IONOSOL-MB/DEXTROSE 5% (INJECTION) $3.70-$8.35 (Tier 2)Isolyte-P/Dextrose 5%

ISOLYTE-P/DEXTROSE 5% (INJECTION) $3.70-$8.35 (Tier 2)Isolyte-S

ISOLYTE-S (INJECTION) $3.70-$8.35 (Tier 2)KCl 0.075%/D5W/NaCl 0.45%

KCL 0.075%/D5W/NACL 0.45% (INJECTION) $3.70-$8.35 (Tier 2)KCl 0.15%/D5W/NaCl 0.2%





KCL 0.3%/D5W/NACL 0.9% (INJECTION) $3.70-$8.35 (Tier 2)Klor-Con

klor-con (packet) $1.25-$3.35 (Tier 1)Klor-Con 10

KLOR-CON 10 (TABLET EXTENDED-RELEASE) $3.70-$8.35 (Tier 2)Klor-Con 8

KLOR-CON 8 (TABLET EXTENDED-RELEASE) $3.70-$8.35 (Tier 2)Klor-Con M10

klor-con m10 (tablet extended-release) $1.25-$3.35 (Tier 1)Klor-Con M15

klor-con m15 (tablet extended-release) $1.25-$3.35 (Tier 1)Klor-Con M20

klor-con m20 (tablet extended-release) $1.25-$3.35 (Tier 1)Klor-Con Sprinkle

klor-con sprinkle (capsule extended-release) $1.25-$3.35 (Tier 1)Lactated Ringers Irrigation

LACTATED RINGERS IRRIGATION (SOLUTION) $3.70-$8.35 (Tier 2)Lactated Ringers Viaflex

LACTATED RINGERS VIAFLEX (INJECTION) $3.70-$8.35 (Tier 2)Levocarnitine

levocarnitine (1gm/10ml oral solution, 330mg tablet) $1.25-$3.35 (Tier 1)Magnesium Oxide

magnesium oxide (241.3mg tablet)* $0 (Tier 3)Magnesium Sulfate

MAGNESIUM SULFATE (1GM/2ML-50% INJECTION) $3.70-$8.35 (Tier 2)Magnesium Sulfate

magnesium sulfate (5gm/10ml-50% injection) $1.25-$3.35 (Tier 1)Nephramine

NEPHRAMINE (INJECTION) $3.70-$8.35 (Tier 2) B/D, PANormosol-M in D5W

NORMOSOL-M IN D5W (INJECTION) $3.70-$8.35 (Tier 2)


63


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useNormosol-R

NORMOSOL-R (INJECTION) $3.70-$8.35 (Tier 2)Normosol-R in D5W

NORMOSOL-R IN D5W (INJECTION) $3.70-$8.35 (Tier 2)Nutrilipid

NUTRILIPID (INJECTION) $3.70-$8.35 (Tier 2) B/D, PAPhysiolyte

PHYSIOLYTE (IRRIGATION SOLUTION) $3.70-$8.35 (Tier 2)Physiosol Irrigation

PHYSIOSOL IRRIGATION (SOLUTION) $3.70-$8.35 (Tier 2)Plasma-Lyte A

PLASMA-LYTE A (INJECTION) $3.70-$8.35 (Tier 2)Plasma-Lyte-148

PLASMA-LYTE-148 (INJECTION) $3.70-$8.35 (Tier 2)Plenamine

plenamine (injection) $1.25-$3.35 (Tier 1) B/D, PAPotassium Chloride

POTASSIUM CHLORIDE (10% ORAL SOLUTION, 20%

ORAL SOLUTION)$3.70-$8.35 (Tier 2)

Potassium Chloride

POTASSIUM CHLORIDE (10MEQ/100ML INJECTION,

20MEQ/100ML INJECTION, 40MEQ/100ML INJECTION)$3.70-$8.35 (Tier 2) B/D, PA

Potassium Chloride

potassium chloride (2meq/ml injection) $1.25-$3.35 (Tier 1) B/D, PAPotassium Chloride CR

potassium chloride cr (tablet extended-release) $1.25-$3.35 (Tier 1)Potassium Chloride ER

potassium chloride er (10meq capsule extended-

release, 8meq capsule extended-release, 10meq

tablet extended-release, 20meq tablet extended-

release, 8meq tablet extended-release)

$1.25-$3.35 (Tier 1)

Potassium Chloride/Dextrose

POTASSIUM CHLORIDE/DEXTROSE (INJECTION) $3.70-$8.35 (Tier 2) B/D, PAPotassium Chloride/Dextrose/Lactated Ringers

POTASSIUM CHLORIDE/DEXTROSE/LACTATED

RINGERS (INJECTION)$3.70-$8.35 (Tier 2)

Potassium Chloride/Dextrose/Sodium Chloride

POTASSIUM CHLORIDE/DEXTROSE/SODIUM

CHLORIDE (INJECTION)$3.70-$8.35 (Tier 2)

Potassium Chloride/Sodium Chloride

potassium chloride/sodium chloride (20meq/l-0.45%


Potassium Chloride/Sodium Chloride

POTASSIUM CHLORIDE/SODIUM CHLORIDE (20MEQ/

L-0.9% INJECTION, 40MEQ/L-0.9% INJECTION)$3.70-$8.35 (Tier 2) B/D, PA

Potassium Citrate ER

potassium citrate er (tablet extended-release) $1.25-$3.35 (Tier 1)Premasol

premasol (injection) $1.25-$3.35 (Tier 1) B/D, PAProcalamine

PROCALAMINE (INJECTION) $3.70-$8.35 (Tier 2) B/D, PAProsol

PROSOL (INJECTION) $3.70-$8.35 (Tier 2) B/D, PARingers Injection

RINGERS INJECTION $3.70-$8.35 (Tier 2)Ringers Irrigation

RINGERS IRRIGATION (SOLUTION) $3.70-$8.35 (Tier 2)Sodium Chloride 0.9%

SODIUM CHLORIDE 0.9% (IRRIGATION SOLUTION) $3.70-$8.35 (Tier 2)Sodium Chloride

SODIUM CHLORIDE (RX ONLY) (0.9% INJECTION,

2.5MEQ/ML INJECTION)$3.70-$8.35 (Tier 2)

Sodium Chloride

SODIUM CHLORIDE (RX ONLY) (3% INJECTION, 5%

INJECTION)$3.70-$8.35 (Tier 2) B/D, PA

Sodium Chloride 0.45%

SODIUM CHLORIDE 0.45% (INJECTION) $3.70-$8.35 (Tier 2)


pages 9 and 10.




64


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useSodium Fluoride

sodium fluoride (tablet) $1.25-$3.35 (Tier 1)Sodium Lactate

SODIUM LACTATE (INJECTION) $3.70-$8.35 (Tier 2)Tandem

tandem (capsule)* $0 (Tier 3)TPN Electrolytes

TPN ELECTROLYTES (INJECTION) $3.70-$8.35 (Tier 2)Travasol

TRAVASOL (INJECTION) $3.70-$8.35 (Tier 2) B/D, PATrophamine

TROPHAMINE (10% INJECTION) $3.70-$8.35 (Tier 2) B/D, PA

Electrolyte/Mineral/Metal ModifiersChemet

CHEMET (CAPSULE) $3.70-$8.35 (Tier 2)Exjade

EXJADE (TABLET SOLUBLE) $3.70-$8.35 (Tier 2) PAFerriprox

FERRIPROX (100MG/ML ORAL SOLUTION, 500MG

TABLET)$3.70-$8.35 (Tier 2) PA

Jadenu

JADENU (TABLET) $3.70-$8.35 (Tier 2) PAJadenu Sprinkle

JADENU SPRINKLE (PACKET) $3.70-$8.35 (Tier 2) PAKionex

kionex (suspension) $1.25-$3.35 (Tier 1)Samsca

SAMSCA (TABLET) $3.70-$8.35 (Tier 2) PA, QLSodium Polystyrene Sulfonate

sodium polystyrene sulfonate (powder) $1.25-$3.35 (Tier 1)SPS

sps (suspension) $1.25-$3.35 (Tier 1)Syprine

SYPRINE (CAPSULE) $3.70-$8.35 (Tier 2) PA, QLTrientine HCl

trientine hcl (capsule) $1.25-$3.35 (Tier 1) PA, QLVeltassa

VELTASSA (PACKET) $3.70-$8.35 (Tier 2) QL

Phosphate BindersAuryxia

AURYXIA (TABLET) $3.70-$8.35 (Tier 2) PACalcium Acetate

calcium acetate (667mg capsule, 667mg tablet) $1.25-$3.35 (Tier 1)Fosrenol

FOSRENOL (1000MG PACKET, 750MG PACKET,

1000MG TABLET CHEWABLE, 500MG TABLET

CHEWABLE, 750MG TABLET CHEWABLE)$3.70-$8.35 (Tier 2)

Lanthanum Carbonate

lanthanum carbonate (tablet chewable) $1.25-$3.35 (Tier 1)Phoslyra

PHOSLYRA (ORAL SOLUTION) $3.70-$8.35 (Tier 2)


65


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useRenagel

RENAGEL (TABLET) $3.70-$8.35 (Tier 2) STRenvela

RENVELA (0.8GM PACKET, 2.4GM PACKET) $3.70-$8.35 (Tier 2)Sevelamer Carbonate

sevelamer carbonate (0.8gm packet, 2.4gm packet,

800mg tablet)$1.25-$3.35 (Tier 1)

Velphoro

VELPHORO (TABLET CHEWABLE) $3.70-$8.35 (Tier 2)

VitaminsFolic Acid

folic acid (1mg tablet, 5mg/ml injection)* $0 (Tier 3)Mephyton

mephyton (tablet)* $0 (Tier 3)Vitamin D

vitamin d (capsule)* $0 (Tier 3)Vitamin K1

vitamin k1 (injection)* $0 (Tier 3)VP-PNV-DHA

vp-pnv-dha (capsule) $1.25-$3.35 (Tier 1)

Gastrointestinal Agents

Antispasmodics, GastrointestinalAtropine Sulfate

ATROPINE SULFATE (0.25MG/5ML INJECTION) $3.70-$8.35 (Tier 2)Cuvposa

CUVPOSA (ORAL SOLUTION) $3.70-$8.35 (Tier 2)Dicyclomine HCl

dicyclomine hcl (10mg capsule, 10mg/5ml oral


Dicyclomine HCl

dicyclomine hcl (tablet) $1.25-$3.35 (Tier 1)Glycopyrrolate

glycopyrrolate (4mg/20ml injection) $1.25-$3.35 (Tier 1)Methscopolamine Bromide

methscopolamine bromide (tablet) $1.25-$3.35 (Tier 1)

Gastrointestinal Agents, OtherAcid Gone

acid gone (suspension)* $0 (Tier 3)Actidose/Sorbitol

actidose/sorbitol (liquid)* $0 (Tier 3)Almacone

almacone (200mg-200mg-25mg tablet chewable,

200mg/5ml-200mg/5ml-20mg/5ml suspension)*$0 (Tier 3)

Almacone Double Strength

almacone double strength (suspension)* $0 (Tier 3)Aluminum Hydroxide

aluminum hydroxide (suspension)* $0 (Tier 3)Antacid Calcium Extra Strength

antacid calcium extra strength (tablet chewable)* $0 (Tier 3)Antacid Calcium Regular Strength

antacid calcium regular strength (tablet chewable)* $0 (Tier 3)Antacid Extra Strength

antacid extra strength (tablet chewable)* $0 (Tier 3)Antacid Maximum Strength

antacid maximum strength (suspension)* $0 (Tier 3)Antacid Plus Anti-Gas Relief

antacid plus anti-gas relief (suspension)* $0 (Tier 3)Anti-Diarrheal

anti-diarrheal (otc only) (tablet)* $0 (Tier 3)Bismatrol

bismatrol (262mg tablet chewable, 262mg/15ml

suspension)*$0 (Tier 3)


pages 9 and 10.




66


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useBismatrol Maximum Strength

bismatrol maximum strength (suspension)* $0 (Tier 3)Calcium Antacid

calcium antacid (tablet chewable)* $0 (Tier 3)Calcium Antacid Extra Strength

calcium antacid extra strength (tablet chewable)* $0 (Tier 3)Cal-Gest Antacid

cal-gest antacid (tablet chewable)* $0 (Tier 3)Chenodal

chenodal (tablet) $1.25-$3.35 (Tier 1)Chewable Antacid

chewable antacid (tablet chewable)* $0 (Tier 3)Cromolyn Sodium

cromolyn sodium (100mg/5ml concentrate) $1.25-$3.35 (Tier 1)Diphenoxylate/Atropine

diphenoxylate/atropine (2.5mg-0.025mg tablet,

2.5mg-0.025mg/5ml liquid)$1.25-$3.35 (Tier 1)

Gas Relief

gas relief (180mg capsule, 20mg/0.3ml suspension,

80mg tablet chewable)*$0 (Tier 3)

Gas Relief Extra Strength

gas relief extra strength (capsule)* $0 (Tier 3)Gas Relief Maximum Strength

gas relief maximum strength (tablet chewable)* $0 (Tier 3)Gattex

GATTEX (INJECTION) $3.70-$8.35 (Tier 2) PAGNP Antacid Anti-Gas

gnp antacid anti-gas (suspension)* $0 (Tier 3)GNP Masanti Maximum Strength

gnp masanti maximum strength (suspension)* $0 (Tier 3)GNP Masanti Regular Strength

gnp masanti regular strength (suspension)* $0 (Tier 3)Infants Gas Relief

infants gas relief (suspension)* $0 (Tier 3)Infants Simethicone

infants simethicone (suspension)* $0 (Tier 3)Kao-Tin

kao-tin (262mg/15ml suspension)* $0 (Tier 3)Loperamide HCl

loperamide hcl (1mg/5ml liquid)* $0 (Tier 3)Loperamide HCl

loperamide hcl (rx only) (capsule) $1.25-$3.35 (Tier 1)Magnesium Oxide

magnesium oxide (400mg tablet)* $0 (Tier 3)Mi-Acid

mi-acid (suspension)* $0 (Tier 3)Mi-Acid Gas Relief

mi-acid gas relief (tablet chewable)* $0 (Tier 3)Mi-Acid Maximum Strength

mi-acid maximum strength (suspension)* $0 (Tier 3)Mintox Maximum Strength

mintox maximum strength (suspension)* $0 (Tier 3)Myalept

MYALEPT (INJECTION) $3.70-$8.35 (Tier 2) PAMYTAB GAS

mytab gas (tablet chewable)* $0 (Tier 3)


67


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMYTAB GAS Maximum Strength

mytab gas maximum strength (tablet chewable)* $0 (Tier 3)Peptic Relief

peptic relief (tablet chewable)* $0 (Tier 3)Pink Bismuth

pink bismuth (tablet chewable)* $0 (Tier 3)QC Anti-Diarrheal

qc anti-diarrheal (otc only) (tablet)* $0 (Tier 3)Relistor

RELISTOR (12MG/0.6ML INJECTION, 8MG/0.4ML

INJECTION)$3.70-$8.35 (Tier 2) PA

Rulox

rulox (suspension)* $0 (Tier 3)Serostim

SEROSTIM (INJECTION) $3.70-$8.35 (Tier 2) PASimethicone

simethicone (capsule)* $0 (Tier 3)SM Antacid Anti-Gas

sm antacid anti-gas (suspension)* $0 (Tier 3)SM Anti-Diarrheal

sm anti-diarrheal (otc only) (tablet)* $0 (Tier 3)Sodium Bicarbonate

sodium bicarbonate (tablet)* $0 (Tier 3)Ursodiol

ursodiol (250mg tablet, 500mg tablet, 300mg

capsule)$1.25-$3.35 (Tier 1)

Zorbtive

ZORBTIVE (INJECTION) $3.70-$8.35 (Tier 2) PA

Histamine2 (H2) Receptor AntagonistsAcid Reducer Maximum Strength

acid reducer maximum strength (otc only) (tablet)* $0 (Tier 3)Cimetidine

cimetidine (tablet) $1.25-$3.35 (Tier 1)Cimetidine HCl

cimetidine hcl (rx only) (oral solution) $1.25-$3.35 (Tier 1)Famotidine

famotidine (10mg tablet)* $0 (Tier 3)Famotidine

famotidine (rx only) (20mg tablet, 40mg tablet,

20mg/2ml injection)$1.25-$3.35 (Tier 1)

Famotidine Premixed

famotidine premixed (injection) $1.25-$3.35 (Tier 1)Ranitidine 150 Maximum Strength

ranitidine 150 maximum strength (otc only) (tablet)* $0 (Tier 3)Ranitidine 75

ranitidine 75 (tablet)* $0 (Tier 3)Ranitidine HCl

ranitidine hcl (150mg tablet, 300mg tablet, 50mg/

2ml injection)$1.25-$3.35 (Tier 1)

Ranitidine Maximum Strength

ranitidine maximum strength (otc only) (tablet)* $0 (Tier 3)

Irritable Bowel Syndrome AgentsAlosetron HCl

alosetron hcl (tablet) $1.25-$3.35 (Tier 1) PAAmitiza

AMITIZA (CAPSULE) $3.70-$8.35 (Tier 2) QLLinzess

LINZESS (CAPSULE) $3.70-$8.35 (Tier 2) QLXifaxan

XIFAXAN (TABLET) $3.70-$8.35 (Tier 2) PA

LaxativesBisac-Evac

bisac-evac (suppository)* $0 (Tier 3)


pages 9 and 10.




68


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useBisacodyl EC

bisacodyl ec (tablet delayed-release)* $0 (Tier 3)Biscolax

biscolax (suppository)* $0 (Tier 3)Constulose

constulose (oral solution) $1.25-$3.35 (Tier 1)Diocto

diocto (50mg/5ml liquid, 60mg/15ml syrup)* $0 (Tier 3)Doc-Q-Lace

doc-q-lace (capsule)* $0 (Tier 3)Doc-Q-Lax

doc-q-lax (tablet)* $0 (Tier 3)Docusate Sodium & Senna Stimulant Laxative/Stool Softener

docusate sodium & senna stimulant laxative/stool

softener (tablet)*$0 (Tier 3)

Docusol Kids

docusol kids (enema)* $0 (Tier 3)Docusol Plus Mini-Enema

docusol plus mini-enema* $0 (Tier 3)DOK

dok (100mg capsule, 100mg tablet)* $0 (Tier 3)DOK PLUS

dok plus (tablet)* $0 (Tier 3)Enema Ready-To-Use

enema ready-to-use* $0 (Tier 3)Enemeez Mini

enemeez mini (enema)* $0 (Tier 3)Enemeez Plus

enemeez plus (enema)* $0 (Tier 3)Enulose

enulose (oral solution) $1.25-$3.35 (Tier 1)Fiber Laxative

fiber laxative (capsule)* $0 (Tier 3)Fiber Tabs

fiber tabs (tablet)* $0 (Tier 3)Fiber-Lax

fiber-lax (tablet)* $0 (Tier 3)Fleet Pediatric

fleet pediatric (enema)* $0 (Tier 3)GaviLyte-C

gavilyte-c (oral solution) $1.25-$3.35 (Tier 1)GaviLyte-G

gavilyte-g (oral solution) $1.25-$3.35 (Tier 1)GaviLyte-N/Flavor Pack

gavilyte-n/flavor pack (oral solution) $1.25-$3.35 (Tier 1)Generlac

generlac (oral solution) $1.25-$3.35 (Tier 1)Lactulose

lactulose (oral solution) $1.25-$3.35 (Tier 1)Laxative

laxative (suppository)* $0 (Tier 3)Milk of Magnesia

milk of magnesia (suspension)* $0 (Tier 3)Milk of Magnesia Concentrate

milk of magnesia concentrate (suspension)* $0 (Tier 3)Natural Fiber Therapy

natural fiber therapy (powder)* $0 (Tier 3)


69


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on usePEG 3350

peg 3350 (otc only) (packet)* $0 (Tier 3)PEG 3350

peg 3350 (otc only) (powder)* $0 (Tier 3)PEG 3350/Electrolytes

PEG 3350/ELECTROLYTES (ORAL SOLUTION) $3.70-$8.35 (Tier 2)PEG-3350/Electrolytes

PEG-3350/ELECTROLYTES (ORAL SOLUTION)

(GENERIC GOLYTELY)$3.70-$8.35 (Tier 2)

PEG-3350/NaCl/Na Bicarbonate/KCl

peg-3350/nacl/na bicarbonate/kcl (oral solution)

(generic nulytely)$1.25-$3.35 (Tier 1)

Polyethylene Glycol 3350 Powder

polyethylene glycol 3350 powder (rx only) (generic

miralax)$1.25-$3.35 (Tier 1)

Reguloid

reguloid (capsule)* $0 (Tier 3)Sani-Supp Adult

sani-supp adult (suppository)* $0 (Tier 3)Sani-Supp Pediatric

sani-supp pediatric (suppository)* $0 (Tier 3)Senexon

senexon (8.6mg tablet)* $0 (Tier 3)Senna

senna (8.6mg tablet, 8.8mg/5ml syrup)* $0 (Tier 3)Senna Lax

senna lax (tablet)* $0 (Tier 3)Senna Plus

senna plus (tablet)* $0 (Tier 3)Senna-Lax

senna-lax (tablet)* $0 (Tier 3)Sennalax-S

sennalax-s (tablet)* $0 (Tier 3)Stimulant Laxative

stimulant laxative (tablet delayed-release)* $0 (Tier 3)Stool Softener

stool softener (capsule)* $0 (Tier 3)Suprep Bowel Prep Kit

SUPREP BOWEL PREP KIT (ORAL SOLUTION) $3.70-$8.35 (Tier 2)TriLyte

trilyte (oral solution) $1.25-$3.35 (Tier 1)

ProtectantsCarafate

CARAFATE (1GM/10ML SUSPENSION) $3.70-$8.35 (Tier 2)Misoprostol

misoprostol (tablet) $1.25-$3.35 (Tier 1)Sucralfate

sucralfate (tablet) $1.25-$3.35 (Tier 1)

Proton Pump InhibitorsEsomeprazole Magnesium

esomeprazole magnesium (rx only) (capsule delayed-

release) (generic nexium)$1.25-$3.35 (Tier 1) QL

Esomeprazole Sodium

esomeprazole sodium (injection) $1.25-$3.35 (Tier 1)GNP Omeprazole

gnp omeprazole (otc only) (tablet delayed-release)* $0 (Tier 3)Heartburn Treatment 24 Hour

heartburn treatment 24 hour (otc only) (capsule

delayed-release)*$0 (Tier 3)

Lansoprazole

lansoprazole (15mg capsule delayed-release, 30mg

capsule delayed-release)$1.25-$3.35 (Tier 1) QL

Lansoprazole

lansoprazole (otc only) (capsule delayed-release)* $0 (Tier 3)


pages 9 and 10.




70


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useNexium

NEXIUM (10MG PACKET, 2.5MG PACKET, 20MG

PACKET, 40MG PACKET, 5MG PACKET)$3.70-$8.35 (Tier 2)

Nexium

NEXIUM (20MG CAPSULE DELAYED-RELEASE, 40MG

CAPSULE DELAYED-RELEASE)$3.70-$8.35 (Tier 2) QL

Omeprazole

omeprazole (10mg capsule delayed-release, 40mg

capsule delayed-release)$1.25-$3.35 (Tier 1) QL

Omeprazole

omeprazole (otc only) (20mg tablet delayed-release)* $0 (Tier 3)Omeprazole

omeprazole (rx only) (20mg capsule delayed-release) $1.25-$3.35 (Tier 1)Omeprazole Magnesium

omeprazole magnesium (capsule delayed-release)* $0 (Tier 3)Pantoprazole Sodium

pantoprazole sodium (20mg tablet delayed-release,

40mg tablet delayed-release)$1.25-$3.35 (Tier 1) QL

Rabeprazole Sodium

rabeprazole sodium (tablet delayed-release) $1.25-$3.35 (Tier 1)

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

Genetic or Enzyme Disorder: Replacement, Modifiers, TreatmentAdagen

ADAGEN (INJECTION) $3.70-$8.35 (Tier 2) LAAldurazyme

ALDURAZYME (INJECTION) $3.70-$8.35 (Tier 2)Aralast NP

ARALAST NP (INJECTION) $3.70-$8.35 (Tier 2) PA, LABuphenyl

BUPHENYL (500MG TABLET) $3.70-$8.35 (Tier 2)Cerezyme

CEREZYME (INJECTION) $3.70-$8.35 (Tier 2) PACholbam

CHOLBAM (CAPSULE) $3.70-$8.35 (Tier 2) PACreon

CREON (CAPSULE DELAYED-RELEASE) $3.70-$8.35 (Tier 2)Cystadane

CYSTADANE (POWDER) $3.70-$8.35 (Tier 2)Cystagon

CYSTAGON (CAPSULE) $3.70-$8.35 (Tier 2) LAElaprase

ELAPRASE (INJECTION) $3.70-$8.35 (Tier 2)Elelyso

ELELYSO (INJECTION) $3.70-$8.35 (Tier 2) PA, LAExondys 51

EXONDYS 51 (INJECTION) $3.70-$8.35 (Tier 2) PA, LAFabrazyme

FABRAZYME (INJECTION) $3.70-$8.35 (Tier 2)Glassia

GLASSIA (INJECTION) $3.70-$8.35 (Tier 2) PA, LAKanuma

KANUMA (INJECTION) $3.70-$8.35 (Tier 2) PA


71


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useKuvan

KUVAN (100MG PACKET, 500MG PACKET, 100MG

TABLET SOLUBLE)$3.70-$8.35 (Tier 2)

Lumizyme

LUMIZYME (INJECTION) $3.70-$8.35 (Tier 2)Miglustat

miglustat (capsule) $1.25-$3.35 (Tier 1) PA, LANaglazyme

NAGLAZYME (INJECTION) $3.70-$8.35 (Tier 2)Ocaliva

OCALIVA (TABLET) $3.70-$8.35 (Tier 2) PA, QLOrfadin

ORFADIN (10MG CAPSULE, 20MG CAPSULE, 2MG

CAPSULE, 5MG CAPSULE, 4MG/ML SUSPENSION)$3.70-$8.35 (Tier 2) LA

Procysbi

PROCYSBI (CAPSULE DELAYED-RELEASE) $3.70-$8.35 (Tier 2)Prolastin-C

PROLASTIN-C (INJECTION) $3.70-$8.35 (Tier 2) PA, LARavicti

RAVICTI (LIQUID) $3.70-$8.35 (Tier 2) QLSodium Phenylbutyrate

sodium phenylbutyrate (3gm/tsp powder, 500mg

tablet)$1.25-$3.35 (Tier 1)

Strensiq

STRENSIQ (INJECTION) $3.70-$8.35 (Tier 2) PA, LASucraid

SUCRAID (ORAL SOLUTION) $3.70-$8.35 (Tier 2) LAVPRIV

VPRIV (INJECTION) $3.70-$8.35 (Tier 2) PAZavesca

ZAVESCA (CAPSULE) $3.70-$8.35 (Tier 2) PA, LAZemaira

ZEMAIRA (INJECTION) $3.70-$8.35 (Tier 2) PA, LAZenpep

ZENPEP (CAPSULE DELAYED-RELEASE) $3.70-$8.35 (Tier 2)

Genitourinary Agents

Antispasmodics, UrinaryMyrbetriq

MYRBETRIQ (TABLET EXTENDED-RELEASE 24 HOUR) $3.70-$8.35 (Tier 2)Oxybutynin Chloride

oxybutynin chloride (5mg tablet immediate-release,

5mg/5ml syrup)$1.25-$3.35 (Tier 1)

Oxybutynin Chloride ER

oxybutynin chloride er (tablet extended-release 24

hour)$1.25-$3.35 (Tier 1) QL

Vesicare

VESICARE (TABLET) $3.70-$8.35 (Tier 2) QL

Benign Prostatic Hypertrophy AgentsAlfuzosin HCl ER

alfuzosin hcl er (tablet extended-release 24 hour) $1.25-$3.35 (Tier 1)Dutasteride

dutasteride (capsule) $1.25-$3.35 (Tier 1)Finasteride

finasteride (5mg tablet) (generic proscar) $1.25-$3.35 (Tier 1)Rapaflo

RAPAFLO (CAPSULE) $3.70-$8.35 (Tier 2) QLTamsulosin HCl

tamsulosin hcl (capsule) $1.25-$3.35 (Tier 1)Terazosin HCl

terazosin hcl (capsule) $1.25-$3.35 (Tier 1)

Genitourinary Agents, Other


pages 9 and 10.




72


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useBethanechol Chloride

bethanechol chloride (tablet) $1.25-$3.35 (Tier 1)Cuprimine

CUPRIMINE (CAPSULE) $3.70-$8.35 (Tier 2) PADepen Titratabs

DEPEN TITRATABS (TABLET) $3.70-$8.35 (Tier 2)Elmiron

ELMIRON (CAPSULE) $3.70-$8.35 (Tier 2)Lithostat

LITHOSTAT (TABLET) $3.70-$8.35 (Tier 2)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)Ala Cort

ala cort (rx only) (cream) $1.25-$3.35 (Tier 1)Alclometasone Dipropionate

alclometasone dipropionate (0.05% cream, 0.05%

ointment)$1.25-$3.35 (Tier 1)

Augmented Betamethasone Dipropionate

augmented betamethasone dipropionate (0.05%

cream, 0.05% gel, 0.05% lotion, 0.05% ointment)$1.25-$3.35 (Tier 1)

Betamethasone Dipropionate

betamethasone dipropionate (0.05% cream, 0.05%

lotion, 0.05% ointment)$1.25-$3.35 (Tier 1)

Betamethasone Valerate

betamethasone valerate (0.1% cream, 0.1% lotion,

0.1% ointment)$1.25-$3.35 (Tier 1)

Clobetasol Propionate

clobetasol propionate (0.05% cream, 0.05% external

solution, 0.05% gel, 0.05% ointment, 0.05%

shampoo)

$1.25-$3.35 (Tier 1)

Cortisone Acetate

cortisone acetate (tablet) $1.25-$3.35 (Tier 1)Depo-Medrol

DEPO-MEDROL (20MG/ML INJECTION) $3.70-$8.35 (Tier 2)Desonide

desonide (0.05% ointment) $1.25-$3.35 (Tier 1)Desoximetasone

desoximetasone (0.05% cream, 0.25% cream) $1.25-$3.35 (Tier 1)Dexamethasone

dexamethasone (0.5mg tablet, 0.75mg tablet, 1.5mg

tablet, 1mg tablet, 2mg tablet, 4mg tablet, 6mg

tablet, 0.5mg/5ml elixir)

$1.25-$3.35 (Tier 1)

Dexamethasone Intensol

dexamethasone intensol (1mg/ml concentrate) $1.25-$3.35 (Tier 1)Dexamethasone Sodium Phosphate

dexamethasone sodium phosphate (10mg/ml

injection, 120mg/30ml injection)$1.25-$3.35 (Tier 1)


73


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useFludrocortisone Acetate

fludrocortisone acetate (tablet) $1.25-$3.35 (Tier 1)Fluocinolone Acetonide

fluocinolone acetonide (0.01% cream, 0.025%

cream, 0.01% external solution, 0.025% ointment)$1.25-$3.35 (Tier 1)

Fluocinonide

fluocinonide (0.05% external solution, 0.05% gel,

0.05% ointment)$1.25-$3.35 (Tier 1)

Fluocinonide Emulsified Base

fluocinonide emulsified base (cream) $1.25-$3.35 (Tier 1)Fluticasone Propionate

fluticasone propionate (rx only) (0.005% ointment,

0.05% cream)$1.25-$3.35 (Tier 1)

Halobetasol Propionate

halobetasol propionate (0.05% cream, 0.05%

ointment)$1.25-$3.35 (Tier 1)

Hydrocortisone

hydrocortisone (otc only) (1% cream, 1% ointment)* $0 (Tier 3)Hydrocortisone

hydrocortisone (rx only) (1% cream, 2.5% cream, 1%

ointment, 2.5% ointment, 10mg tablet, 20mg tablet,

5mg tablet, 2.5% lotion)

$1.25-$3.35 (Tier 1)

Hydrocortisone Butyrate

hydrocortisone butyrate (0.1% ointment) $1.25-$3.35 (Tier 1)Hydrocortisone Valerate

hydrocortisone valerate (0.2% cream, 0.2% ointment) $1.25-$3.35 (Tier 1)Kenalog-10

KENALOG-10 (INJECTION) $3.70-$8.35 (Tier 2)Kenalog-40

KENALOG-40 (INJECTION) $3.70-$8.35 (Tier 2)Methylprednisolone

methylprednisolone (tablet) $1.25-$3.35 (Tier 1)Methylprednisolone Acetate

methylprednisolone acetate (injection) $1.25-$3.35 (Tier 1)Methylprednisolone Dose Pack

methylprednisolone dose pack (tablet therapy pack) $1.25-$3.35 (Tier 1)Methylprednisolone Sodium Succinate

methylprednisolone sodium succinate (injection) $1.25-$3.35 (Tier 1)Mometasone Furoate

mometasone furoate (0.1% cream, 0.1% external

solution, 0.1% ointment)$1.25-$3.35 (Tier 1)

Prednicarbate

PREDNICARBATE (0.1% CREAM) $3.70-$8.35 (Tier 2)Prednicarbate

prednicarbate (0.1% ointment) $1.25-$3.35 (Tier 1)Prednisolone

prednisolone (15mg/5ml oral solution) $1.25-$3.35 (Tier 1)Prednisolone Sodium Phosphate

prednisolone sodium phosphate (10mg/5ml oral

solution, 20mg/5ml oral solution, 25mg/5ml oral

solution, 5mg/5ml oral solution)

$1.25-$3.35 (Tier 1)

Prednisone

prednisone (10mg tablet therapy pack, 5mg tablet

therapy pack, 10mg tablet, 1mg tablet, 2.5mg tablet,

20mg tablet, 50mg tablet, 5mg tablet, 5mg/5ml oral

solution)

$1.25-$3.35 (Tier 1)

Prednisone Intensol

prednisone intensol (5mg/ml concentrate) $1.25-$3.35 (Tier 1)Solu-Cortef

SOLU-CORTEF (INJECTION) $3.70-$8.35 (Tier 2)Solu-Medrol

SOLU-MEDROL (2GM INJECTION) $3.70-$8.35 (Tier 2)


pages 9 and 10.




74


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useTriamcinolone Acetonide

triamcinolone acetonide (0.025% cream, 0.1%

cream, 0.5% cream, 0.025% lotion, 0.1% lotion,

0.025% ointment, 0.1% ointment, 0.5% ointment,

40mg/ml injection)

$1.25-$3.35 (Tier 1)

Triderm

triderm (cream) $1.25-$3.35 (Tier 1)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)Chorionic Gonadotropin

CHORIONIC GONADOTROPIN (INJECTION) $3.70-$8.35 (Tier 2) PADesmopressin Acetate

desmopressin acetate (0.01% nasal spray solution,

0.1mg tablet, 0.2mg tablet, 4mcg/ml injection)$1.25-$3.35 (Tier 1)

Genotropin

GENOTROPIN (12MG INJECTION, 5MG INJECTION) $3.70-$8.35 (Tier 2) PAGenotropin Miniquick

GENOTROPIN MINIQUICK (INJECTION) $3.70-$8.35 (Tier 2) PAHumatrope

HUMATROPE (INJECTION) $3.70-$8.35 (Tier 2) PAHumatrope Combo Pack

HUMATROPE COMBO PACK (INJECTION) $3.70-$8.35 (Tier 2) PAIncrelex

INCRELEX (INJECTION) $3.70-$8.35 (Tier 2) PANorditropin FlexPro

NORDITROPIN FLEXPRO (INJECTION) $3.70-$8.35 (Tier 2) PANovarel

NOVAREL (INJECTION) $3.70-$8.35 (Tier 2) PANutropin AQ

NUTROPIN AQ (INJECTION) $3.70-$8.35 (Tier 2) PAPregnyl w/Diluent Benzyl Alcohol/NaCl

PREGNYL W/DILUENT BENZYL ALCOHOL/NACL

(INJECTION)$3.70-$8.35 (Tier 2) PA

Saizen

SAIZEN (INJECTION) $3.70-$8.35 (Tier 2) PASaizenprep Reconstitution Kit

SAIZENPREP RECONSTITUTION KIT (INJECTION) $3.70-$8.35 (Tier 2) PAZomacton

ZOMACTON (10MG INJECTION) $3.70-$8.35 (Tier 2) PA

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)Korlym

KORLYM (TABLET) $3.70-$8.35 (Tier 2) PA, QL

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


75


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

AndrogensAnadrol-50

ANADROL-50 (TABLET) $3.70-$8.35 (Tier 2) PAAndroderm

ANDRODERM (PATCH 24 HOUR) $3.70-$8.35 (Tier 2) QLAndroGel

ANDROGEL (1.62% PACKET GEL) $3.70-$8.35 (Tier 2)AndroGel Pump

ANDROGEL PUMP (1.62% GEL) $3.70-$8.35 (Tier 2)Danazol

danazol (capsule) $1.25-$3.35 (Tier 1)Oxandrolone

oxandrolone (tablet) $1.25-$3.35 (Tier 1) PA, QLTestosterone Cypionate

testosterone cypionate (injection) $1.25-$3.35 (Tier 1)Testosterone Enanthate

testosterone enanthate (injection) $1.25-$3.35 (Tier 1)

EstrogensAltavera

altavera (tablet) $1.25-$3.35 (Tier 1)Alyacen 1/35

alyacen 1/35 (tablet) $1.25-$3.35 (Tier 1)Amethia

amethia (tablet) $1.25-$3.35 (Tier 1)Amethia Lo

amethia lo (tablet) $1.25-$3.35 (Tier 1)Apri

apri (tablet) $1.25-$3.35 (Tier 1)Aranelle

aranelle (tablet) $1.25-$3.35 (Tier 1)Ashlyna

ashlyna (tablet) $1.25-$3.35 (Tier 1)Aubra

aubra (tablet) $1.25-$3.35 (Tier 1)Aviane

aviane (tablet) $1.25-$3.35 (Tier 1)Balziva

balziva (tablet) $1.25-$3.35 (Tier 1)Bekyree

bekyree (tablet) $1.25-$3.35 (Tier 1)Blisovi 24 Fe

blisovi 24 fe (tablet) $1.25-$3.35 (Tier 1)Blisovi Fe 1.5/30

blisovi fe 1.5/30 (tablet) $1.25-$3.35 (Tier 1)Blisovi Fe 1/20

blisovi fe 1/20 (tablet) $1.25-$3.35 (Tier 1)Briellyn

briellyn (tablet) $1.25-$3.35 (Tier 1)Camrese Lo

CAMRESE LO (TABLET) $3.70-$8.35 (Tier 2)Caziant

caziant (tablet) $1.25-$3.35 (Tier 1)Climara Pro

CLIMARA PRO (PATCH WEEKLY) $3.70-$8.35 (Tier 2)Cryselle-28

cryselle-28 (tablet) $1.25-$3.35 (Tier 1)Cyclafem

cyclafem (tablet) $1.25-$3.35 (Tier 1)Delyla

delyla (tablet) $1.25-$3.35 (Tier 1)Desogestrel/Ethinyl Estradiol

desogestrel/ethinyl estradiol (tablet) $1.25-$3.35 (Tier 1)Drospirenone/Ethinyl Estradiol

drospirenone/ethinyl estradiol (tablet) $1.25-$3.35 (Tier 1)Duavee

DUAVEE (TABLET) $3.70-$8.35 (Tier 2)Elestrin

ELESTRIN (GEL) $3.70-$8.35 (Tier 2)


pages 9 and 10.




76


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useEmoquette

emoquette (tablet) $1.25-$3.35 (Tier 1)Enpresse-28

enpresse-28 (tablet) $1.25-$3.35 (Tier 1)Enskyce

enskyce (tablet) $1.25-$3.35 (Tier 1)Estarylla

estarylla (tablet) $1.25-$3.35 (Tier 1)Estradiol

estradiol (0.025mg/24hr patch weekly, 0.05mg/24hr

patch weekly, 0.06mg/24hr patch weekly, 0.075mg/

24hr patch weekly, 0.1mg/24hr patch weekly,

37.5mcg/24hr patch weekly)

$1.25-$3.35 (Tier 1) QL

Estradiol

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

(generic estrace)$1.25-$3.35 (Tier 1)

Estradiol Valerate

estradiol valerate (injection) $1.25-$3.35 (Tier 1)Estring

ESTRING (RING) $3.70-$8.35 (Tier 2)Ethynodiol Diacetate/Ethinyl Estradiol

ethynodiol diacetate/ethinyl estradiol (tablet) $1.25-$3.35 (Tier 1)Falmina

falmina (tablet) $1.25-$3.35 (Tier 1)Femynor

femynor (tablet) $1.25-$3.35 (Tier 1)Fyavolv

fyavolv (1mg-5mcg tablet) $1.25-$3.35 (Tier 1)Gianvi

GIANVI (TABLET) $3.70-$8.35 (Tier 2)Introvale

introvale (tablet) $1.25-$3.35 (Tier 1)Isibloom

isibloom (tablet) $1.25-$3.35 (Tier 1)Jinteli

jinteli (tablet) $1.25-$3.35 (Tier 1)Juleber

juleber (tablet) $1.25-$3.35 (Tier 1)Junel 1.5/30

junel 1.5/30 (tablet) $1.25-$3.35 (Tier 1)Junel 1/20

junel 1/20 (tablet) $1.25-$3.35 (Tier 1)Junel Fe 1.5/30

junel fe 1.5/30 (tablet) $1.25-$3.35 (Tier 1)Junel Fe 1/20

junel fe 1/20 (tablet) $1.25-$3.35 (Tier 1)Junel Fe 24

junel fe 24 (tablet) $1.25-$3.35 (Tier 1)Kaitlib Fe

kaitlib fe (tablet chewable) $1.25-$3.35 (Tier 1)Kariva

kariva (tablet) $1.25-$3.35 (Tier 1)Kelnor 1/35

kelnor 1/35 (tablet) $1.25-$3.35 (Tier 1)


77


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useKelnor 1/50

kelnor 1/50 (tablet) $1.25-$3.35 (Tier 1)Kimidess

kimidess (tablet) $1.25-$3.35 (Tier 1)Kurvelo

kurvelo (tablet) $1.25-$3.35 (Tier 1)Larin 1.5/30

larin 1.5/30 (tablet) $1.25-$3.35 (Tier 1)Larin 1/20

larin 1/20 (tablet) $1.25-$3.35 (Tier 1)Larin Fe 1.5/30

larin fe 1.5/30 (tablet) $1.25-$3.35 (Tier 1)Larin Fe 1/20

larin fe 1/20 (tablet) $1.25-$3.35 (Tier 1)Larissia

larissia (tablet) $1.25-$3.35 (Tier 1)Layolis Fe

LAYOLIS FE (TABLET CHEWABLE) $3.70-$8.35 (Tier 2)Leena

LEENA (TABLET) $3.70-$8.35 (Tier 2)Lessina

lessina (tablet) $1.25-$3.35 (Tier 1)Levonest

levonest (tablet) $1.25-$3.35 (Tier 1)Levonorgestrel and Ethinyl Estradiol

levonorgestrel and ethinyl estradiol (90mcg-20mcg

tablet)$1.25-$3.35 (Tier 1)

Levonorgestrel/Ethinyl Estradiol

levonorgestrel/ethinyl estradiol (0.15mg-0.03mg

tablet, 0.1mg-20mcg tablet, 0.05mg-30mcg/

0.075mg-40mcg/0.125mg-30mcg tablet,

0.15mg-0.03mg/0.01mg tablet)

$1.25-$3.35 (Tier 1)

Levora 0.15/30-28

levora 0.15/30-28 (tablet) $1.25-$3.35 (Tier 1)Loryna

loryna (tablet) $1.25-$3.35 (Tier 1)Low-Ogestrel

low-ogestrel (tablet) $1.25-$3.35 (Tier 1)Lutera

lutera (tablet) $1.25-$3.35 (Tier 1)Marlissa

marlissa (tablet) $1.25-$3.35 (Tier 1)Melodetta 24 Fe

melodetta 24 fe (tablet chewable) $1.25-$3.35 (Tier 1)Menest

menest (tablet) $1.25-$3.35 (Tier 1)Mibelas 24 Fe

mibelas 24 fe (tablet chewable) $1.25-$3.35 (Tier 1)Microgestin 1.5/30

MICROGESTIN 1.5/30 (TABLET) $3.70-$8.35 (Tier 2)Microgestin 1/20

MICROGESTIN 1/20 (TABLET) $3.70-$8.35 (Tier 2)Microgestin Fe

MICROGESTIN FE (TABLET) $3.70-$8.35 (Tier 2)Microgestin Fe 1.5/30

MICROGESTIN FE 1.5/30 (TABLET) $3.70-$8.35 (Tier 2)Mili

mili (tablet) $1.25-$3.35 (Tier 1)MonoNessa

MONONESSA (TABLET) $3.70-$8.35 (Tier 2)Necon 0.5/35-28

necon 0.5/35-28 (tablet) $1.25-$3.35 (Tier 1)Necon 7/7/7

NECON 7/7/7 (TABLET) $3.70-$8.35 (Tier 2)Nikki

nikki (tablet) $1.25-$3.35 (Tier 1)Norethindrone Acetate/Ethinyl Estradiol

norethindrone acetate/ethinyl estradiol (1mg-20mcg

tablet, 1mg-5mcg tablet)$1.25-$3.35 (Tier 1)


pages 9 and 10.




78


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useNorethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate

NORETHINDRONE ACETATE/ETHINYL ESTRADIOL/

FERROUS FUMARATE (1MG-20MCG-75MG TABLET

CHEWABLE)$3.70-$8.35 (Tier 2)

Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate

norethindrone acetate/ethinyl estradiol/ferrous

fumarate (tablet)$1.25-$3.35 (Tier 1)

Norethindrone/Ethinyl Estradiol/Ferrous Fumarate

norethindrone/ethinyl estradiol/ferrous fumarate

(tablet chewable)$1.25-$3.35 (Tier 1)

Norgestimate/Ethinyl Estradiol

norgestimate/ethinyl estradiol (tablet) $1.25-$3.35 (Tier 1)Nortrel 0.5/35

nortrel 0.5/35 (28) (tablet) $1.25-$3.35 (Tier 1)Nortrel 1/35

nortrel 1/35 (tablet) $1.25-$3.35 (Tier 1)Nortrel 7/7/7

nortrel 7/7/7 (tablet) $1.25-$3.35 (Tier 1)NuvaRing

NUVARING (RING) $3.70-$8.35 (Tier 2)Ocella

OCELLA (TABLET) $3.70-$8.35 (Tier 2)Ogestrel

ogestrel (tablet) $1.25-$3.35 (Tier 1)Orsythia

orsythia (tablet) $1.25-$3.35 (Tier 1)Pimtrea

pimtrea (tablet) $1.25-$3.35 (Tier 1)Pirmella 1/35

pirmella 1/35 (tablet) $1.25-$3.35 (Tier 1)Portia-28

portia-28 (tablet) $1.25-$3.35 (Tier 1)Premarin

PREMARIN (0.3MG TABLET, 0.45MG TABLET, 0.625MG

TABLET, 0.9MG TABLET, 1.25MG TABLET)$3.70-$8.35 (Tier 2) QL

Premarin

PREMARIN (VAGINAL CREAM) $3.70-$8.35 (Tier 2)Premphase

PREMPHASE (TABLET) $3.70-$8.35 (Tier 2) QLPrempro

PREMPRO (TABLET) $3.70-$8.35 (Tier 2) QLPrevifem

previfem (tablet) $1.25-$3.35 (Tier 1)Quasense

quasense (tablet) $1.25-$3.35 (Tier 1)Reclipsen

reclipsen (tablet) $1.25-$3.35 (Tier 1)Setlakin

setlakin (tablet) $1.25-$3.35 (Tier 1)Sprintec 28

sprintec 28 (tablet) $1.25-$3.35 (Tier 1)Sronyx

sronyx (tablet) $1.25-$3.35 (Tier 1)Syeda

syeda (tablet) $1.25-$3.35 (Tier 1)


79


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useTarina Fe 1/20

tarina fe 1/20 (tablet) $1.25-$3.35 (Tier 1)Tri-Legest Fe

tri-legest fe (tablet) $1.25-$3.35 (Tier 1)Tri-Lo-Estarylla

tri-lo-estarylla (tablet) $1.25-$3.35 (Tier 1)Tri-Lo-Sprintec

tri-lo-sprintec (tablet) $1.25-$3.35 (Tier 1)Tri-Mili

tri-mili (tablet) $1.25-$3.35 (Tier 1)Tri-Previfem

tri-previfem (tablet) $1.25-$3.35 (Tier 1)Tri-Sprintec

tri-sprintec (tablet) $1.25-$3.35 (Tier 1)Tri-Vylibra

tri-vylibra (tablet) $1.25-$3.35 (Tier 1)Trinessa

TRINESSA (TABLET) $3.70-$8.35 (Tier 2)Trivora-28

trivora-28 (tablet) $1.25-$3.35 (Tier 1)Velivet

velivet (tablet) $1.25-$3.35 (Tier 1)Vienva

vienva (tablet) $1.25-$3.35 (Tier 1)Vyfemla

vyfemla (tablet) $1.25-$3.35 (Tier 1)Vylibra

vylibra (tablet) $1.25-$3.35 (Tier 1)Wymzya Fe

wymzya fe (tablet chewable) $1.25-$3.35 (Tier 1)Zarah

zarah (tablet) $1.25-$3.35 (Tier 1)Zenchent

zenchent (tablet) $1.25-$3.35 (Tier 1)Zovia 1/35E

zovia 1/35e (tablet) $1.25-$3.35 (Tier 1)

ProgestinsCamila

camila (tablet) $1.25-$3.35 (Tier 1)Crinone

CRINONE (GEL) $3.70-$8.35 (Tier 2) PADeblitane

deblitane (tablet) $1.25-$3.35 (Tier 1)Depo-Provera

DEPO-PROVERA (INJECTION) $3.70-$8.35 (Tier 2)Econtra EZ

econtra ez (otc only) (tablet)* $0 (Tier 3)Errin

errin (tablet) $1.25-$3.35 (Tier 1)Fallback Solo

fallback solo (otc only) (tablet)* $0 (Tier 3)Hydroxyprogesterone Caproate

hydroxyprogesterone caproate (injection) $1.25-$3.35 (Tier 1) PAIncassia

incassia (tablet) $1.25-$3.35 (Tier 1)Jolivette

JOLIVETTE (TABLET) $3.70-$8.35 (Tier 2)Levonorgestrel

levonorgestrel (tablet)* $0 (Tier 3)Lyza

lyza (tablet) $1.25-$3.35 (Tier 1)Makena

MAKENA (250MG/ML INJECTION, 275MG/1.1ML


Medroxyprogesterone Acetate

medroxyprogesterone acetate (10mg tablet, 2.5mg

tablet, 5mg tablet, 150mg/ml injection)$1.25-$3.35 (Tier 1)


pages 9 and 10.




80


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMedroxyprogesterone Acetate

MEDROXYPROGESTERONE ACETATE (150MG/ML

INJECTION PREFILLED SYRINGE)$3.70-$8.35 (Tier 2)

Megace ES

MEGACE ES (SUSPENSION) $3.70-$8.35 (Tier 2)Megestrol Acetate

megestrol acetate (20mg tablet, 40mg tablet, 40mg/

ml suspension, 625mg/5ml suspension)$1.25-$3.35 (Tier 1)

My Way

my way (otc only) (tablet)* $0 (Tier 3)Next Choice One Dose

next choice one dose (otc only) (tablet)* $0 (Tier 3)Nora-BE

NORA-BE (TABLET) $3.70-$8.35 (Tier 2)Norethindrone

norethindrone (0.35mg tablet) $1.25-$3.35 (Tier 1)Norethindrone Acetate

norethindrone acetate (5mg tablet) $1.25-$3.35 (Tier 1)Norlyroc

norlyroc (tablet) $1.25-$3.35 (Tier 1)Opcicon One-Step

opcicon one-step (otc only) (tablet)* $0 (Tier 3)Sharobel

sharobel (tablet) $1.25-$3.35 (Tier 1)

Selective Estrogen Receptor Modifying AgentsOsphena

OSPHENA (TABLET) $3.70-$8.35 (Tier 2) PA, QLRaloxifene HCl

raloxifene hcl (tablet) $1.25-$3.35 (Tier 1) QL

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)Levothyroxine Sodium

LEVOTHYROXINE SODIUM (100MCG INJECTION) $3.70-$8.35 (Tier 2)Levothyroxine Sodium

levothyroxine sodium (100mcg tablet, 112mcg tablet,

125mcg tablet, 137mcg tablet, 150mcg tablet,

175mcg tablet, 200mcg tablet, 25mcg tablet,

300mcg tablet, 50mcg tablet, 75mcg tablet, 88mcg

tablet)

$1.25-$3.35 (Tier 1)

Levoxyl

LEVOXYL (TABLET) $3.70-$8.35 (Tier 2)Liothyronine Sodium

liothyronine sodium (10mcg/ml injection, 25mcg

tablet, 50mcg tablet, 5mcg tablet)$1.25-$3.35 (Tier 1)

Synthroid

SYNTHROID (TABLET) $3.70-$8.35 (Tier 2)


81


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useUnithroid

UNITHROID (TABLET) $3.70-$8.35 (Tier 2)

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)Lysodren

LYSODREN (TABLET) $3.70-$8.35 (Tier 2)

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)Cabergoline

cabergoline (tablet) $1.25-$3.35 (Tier 1)Egrifta

EGRIFTA (INJECTION) $3.70-$8.35 (Tier 2) PAFirmagon

FIRMAGON (INJECTION) $3.70-$8.35 (Tier 2) PALeuprolide Acetate

leuprolide acetate (injection) $1.25-$3.35 (Tier 1) PALupaneta Pack

LUPANETA PACK (KIT) $3.70-$8.35 (Tier 2) PALupron Depot

LUPRON DEPOT (1-MONTH) (INJECTION) $3.70-$8.35 (Tier 2) PALupron Depot



LUPRON DEPOT (6-MONTH) (INJECTION) $3.70-$8.35 (Tier 2) PALupron Depot-Ped

LUPRON DEPOT-PED (1-MONTH) (INJECTION) $3.70-$8.35 (Tier 2) PALupron Depot-Ped

LUPRON DEPOT-PED (3-MONTH) (INJECTION) $3.70-$8.35 (Tier 2) PAOctreotide Acetate

octreotide acetate (injection) $1.25-$3.35 (Tier 1) PASandostatin LAR Depot

SANDOSTATIN LAR DEPOT (INJECTION) $3.70-$8.35 (Tier 2) PASignifor

SIGNIFOR (INJECTION) $3.70-$8.35 (Tier 2) PASomatuline Depot

SOMATULINE DEPOT (INJECTION) $3.70-$8.35 (Tier 2)Somavert

SOMAVERT (INJECTION) $3.70-$8.35 (Tier 2) PA, QLSynarel

SYNAREL (NASAL SOLUTION) $3.70-$8.35 (Tier 2)Trelstar Mixject

TRELSTAR MIXJECT (INJECTION) $3.70-$8.35 (Tier 2) PA

Hormonal Agents, Suppressant (Thyroid)

Antithyroid AgentsMethimazole

methimazole (tablet) $1.25-$3.35 (Tier 1)Propylthiouracil

propylthiouracil (tablet) $1.25-$3.35 (Tier 1)

Immunological Agents

Angioedema AgentsBerinert

BERINERT (INJECTION) $3.70-$8.35 (Tier 2) PA, LACinryze

CINRYZE (INJECTION) $3.70-$8.35 (Tier 2) PA, LA


pages 9 and 10.




82


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useFirazyr

FIRAZYR (INJECTION) $3.70-$8.35 (Tier 2) PA, QLHaegarda

HAEGARDA (INJECTION) $3.70-$8.35 (Tier 2) PARuconest

RUCONEST (INJECTION) $3.70-$8.35 (Tier 2) PA

Immune SuppressantsAzathioprine

azathioprine (100mg injection, 50mg tablet) $1.25-$3.35 (Tier 1) B/D, PACimzia

CIMZIA (INJECTION) $3.70-$8.35 (Tier 2) PACyclosporine

cyclosporine (100mg capsule, 25mg capsule) $1.25-$3.35 (Tier 1) B/D, PACyclosporine

cyclosporine (50mg/ml injection) $1.25-$3.35 (Tier 1)Cyclosporine Modified

cyclosporine modified (100mg capsule, 25mg

capsule, 50mg capsule, 100mg/ml oral solution)$1.25-$3.35 (Tier 1) B/D, PA

Enbrel

ENBREL (INJECTION) $3.70-$8.35 (Tier 2) PAEnbrel SureClick

ENBREL SURECLICK (INJECTION) $3.70-$8.35 (Tier 2) PAEnvarsus XR

ENVARSUS XR (TABLET EXTENDED-RELEASE 24

HOUR)$3.70-$8.35 (Tier 2) PA

Gengraf

gengraf (100mg capsule, 25mg capsule, 100mg/ml

oral solution)$1.25-$3.35 (Tier 1) B/D, PA

Humira

HUMIRA (INJECTION) $3.70-$8.35 (Tier 2) PAHumira Pediatric Crohns Disease Starter Pack

HUMIRA PEDIATRIC CROHNS DISEASE STARTER

PACK (INJECTION)$3.70-$8.35 (Tier 2) PA

Humira Pen

HUMIRA PEN (INJECTION) $3.70-$8.35 (Tier 2) PAHumira Pen Crohns Disease Starter Pack

HUMIRA PEN CROHNS DISEASE STARTER PACK


Humira Pen Psoriasis Starter

HUMIRA PEN PSORIASIS STARTER (INJECTION) $3.70-$8.35 (Tier 2) PAKineret

KINERET (INJECTION) $3.70-$8.35 (Tier 2) PAMethotrexate

methotrexate (tablet) $1.25-$3.35 (Tier 1)Methotrexate Sodium

methotrexate sodium (injection) $1.25-$3.35 (Tier 1)Mycophenolate Mofetil

mycophenolate mofetil (200mg/ml suspension,

250mg capsule, 500mg injection, 500mg tablet)$1.25-$3.35 (Tier 1) PA

Mycophenolic Acid DR

mycophenolic acid dr (tablet delayed-release) $1.25-$3.35 (Tier 1) B/D, PA


83


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useNulojix

NULOJIX (INJECTION) $3.70-$8.35 (Tier 2) PAOrencia

ORENCIA (125MG/ML INJECTION, 50MG/0.4ML

INJECTION, 87.5MG/0.7ML INJECTION, 250MG


Orencia Clickject

ORENCIA CLICKJECT (INJECTION) $3.70-$8.35 (Tier 2) PAPrograf

PROGRAF (5MG/ML INJECTION) $3.70-$8.35 (Tier 2) PARapamune

RAPAMUNE (1MG/ML ORAL SOLUTION) $3.70-$8.35 (Tier 2) B/D, PARemicade

REMICADE (INJECTION) $3.70-$8.35 (Tier 2) PASandimmune

SANDIMMUNE (100MG/ML ORAL SOLUTION) $3.70-$8.35 (Tier 2) B/D, PASimponi

SIMPONI (INJECTION) $3.70-$8.35 (Tier 2) PASimponi Aria

SIMPONI ARIA (INJECTION) $3.70-$8.35 (Tier 2) PASirolimus

sirolimus (tablet) $1.25-$3.35 (Tier 1) B/D, PATacrolimus

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

capsule)$1.25-$3.35 (Tier 1) PA

Torisel

TORISEL (INJECTION) $3.70-$8.35 (Tier 2)Trexall

trexall (tablet) $1.25-$3.35 (Tier 1)Xatmep

XATMEP (ORAL SOLUTION) $3.70-$8.35 (Tier 2) PAXeljanz

XELJANZ (10MG TABLET, 5MG TABLET) $3.70-$8.35 (Tier 2) PA, QLXeljanz XR

XELJANZ XR (TABLET EXTENDED-RELEASE 24 HOUR) $3.70-$8.35 (Tier 2) PA, QLZortress

ZORTRESS (TABLET) $3.70-$8.35 (Tier 2) PA

Immunizing Agents, PassiveAtgam

ATGAM (INJECTION) $3.70-$8.35 (Tier 2)BIVIGAM

BIVIGAM (INJECTION) $3.70-$8.35 (Tier 2) PACarimune Nanofiltered

CARIMUNE NANOFILTERED (INJECTION) $3.70-$8.35 (Tier 2) PAFlebogamma DIF

FLEBOGAMMA DIF (INJECTION) $3.70-$8.35 (Tier 2) PAGamastan S/D

GAMASTAN S/D (INJECTION) $3.70-$8.35 (Tier 2) PAGammagard Liquid

GAMMAGARD LIQUID (INJECTION) $3.70-$8.35 (Tier 2) PAGammagard S/D IGA Less Than 1 mcg/ml

GAMMAGARD S/D IGA LESS THAN 1 MCG/ML


Gammaked

GAMMAKED (INJECTION) $3.70-$8.35 (Tier 2) PAGammaplex

GAMMAPLEX (INJECTION) $3.70-$8.35 (Tier 2) PAGamunex-C

GAMUNEX-C (INJECTION) $3.70-$8.35 (Tier 2) PAOctagam

OCTAGAM (INJECTION) $3.70-$8.35 (Tier 2) PAPrivigen

PRIVIGEN (INJECTION) $3.70-$8.35 (Tier 2) PAThymoglobulin

THYMOGLOBULIN (INJECTION) $3.70-$8.35 (Tier 2)Varizig

VARIZIG (INJECTION) $3.70-$8.35 (Tier 2)


pages 9 and 10.




84


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

ImmunomodulatorsActemra

ACTEMRA (162MG/0.9ML INJECTION, 200MG/10ML

INJECTION, 400MG/20ML INJECTION, 80MG/4ML


Actimmune

ACTIMMUNE (INJECTION) $3.70-$8.35 (Tier 2)Arcalyst

ARCALYST (INJECTION) $3.70-$8.35 (Tier 2) PA, LABenlysta

BENLYSTA (120MG INJECTION, 400MG INJECTION,

200MG/ML INJECTION)$3.70-$8.35 (Tier 2) PA

Ilaris

ILARIS (INJECTION) $3.70-$8.35 (Tier 2) PA, QL, LALeflunomide

leflunomide (tablet) $1.25-$3.35 (Tier 1)Otezla

OTEZLA (TABLET THERAPY PACK, 30MG TABLET) $3.70-$8.35 (Tier 2) PARidaura

RIDAURA (CAPSULE) $3.70-$8.35 (Tier 2)Simulect

SIMULECT (INJECTION) $3.70-$8.35 (Tier 2)Sylvant

SYLVANT (INJECTION) $3.70-$8.35 (Tier 2) PASynagis

SYNAGIS (INJECTION) $3.70-$8.35 (Tier 2) PAXolair

XOLAIR (INJECTION) $3.70-$8.35 (Tier 2) PA

VaccinesActHIB

ACTHIB (INJECTION) $3.70-$8.35 (Tier 2)Adacel

ADACEL (INJECTION) $3.70-$8.35 (Tier 2)BCG Vaccine

BCG VACCINE (INJECTION) $3.70-$8.35 (Tier 2)Bexsero

BEXSERO (INJECTION) $3.70-$8.35 (Tier 2)Boostrix

BOOSTRIX (INJECTION) $3.70-$8.35 (Tier 2)Daptacel

DAPTACEL (INJECTION) $3.70-$8.35 (Tier 2)Diphtheria/Tetanus Toxoids Adsorbed Pediatric

DIPHTHERIA/TETANUS TOXOIDS ADSORBED

PEDIATRIC (INJECTION)$3.70-$8.35 (Tier 2)

Engerix-B

ENGERIX-B (INJECTION) $3.70-$8.35 (Tier 2) B/D, PAGardasil 9

GARDASIL 9 (INJECTION) $3.70-$8.35 (Tier 2)Havrix

HAVRIX (INJECTION) $3.70-$8.35 (Tier 2)Hiberix

HIBERIX (INJECTION) $3.70-$8.35 (Tier 2)


85


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useImovax Rabies

IMOVAX RABIES (H.D.C.V.) (INJECTION) $3.70-$8.35 (Tier 2) B/D, PAInfanrix

INFANRIX (INJECTION) $3.70-$8.35 (Tier 2)IPOL Inactivated IPV

IPOL INACTIVATED IPV (INJECTION) $3.70-$8.35 (Tier 2)Ixiaro

IXIARO (INJECTION) $3.70-$8.35 (Tier 2)Kinrix

KINRIX (INJECTION) $3.70-$8.35 (Tier 2)M-M-R II

M-M-R II (INJECTION) $3.70-$8.35 (Tier 2)Menactra

MENACTRA (INJECTION) $3.70-$8.35 (Tier 2)Menveo

MENVEO (INJECTION) $3.70-$8.35 (Tier 2)Pediarix

PEDIARIX (INJECTION) $3.70-$8.35 (Tier 2)Pedvax HIB

PEDVAX HIB (INJECTION) $3.70-$8.35 (Tier 2)ProQuad

PROQUAD (INJECTION) $3.70-$8.35 (Tier 2)Quadracel

QUADRACEL (INJECTION) $3.70-$8.35 (Tier 2)Rabavert

RABAVERT (INJECTION) $3.70-$8.35 (Tier 2) B/D, PARecombivax HB

RECOMBIVAX HB (INJECTION) $3.70-$8.35 (Tier 2) B/D, PARotarix

ROTARIX (SUSPENSION) $3.70-$8.35 (Tier 2)RotaTeq

ROTATEQ (ORAL SOLUTION) $3.70-$8.35 (Tier 2)Shingrix

SHINGRIX (INJECTION) $3.70-$8.35 (Tier 2) PATenivac

TENIVAC (INJECTION) $3.70-$8.35 (Tier 2)Tetanus/Diphtheria Toxoids-Adsorbed Adult

TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT

(INJECTION)$3.70-$8.35 (Tier 2)

Trumenba

TRUMENBA (INJECTION) $3.70-$8.35 (Tier 2)Twinrix

TWINRIX (INJECTION) $3.70-$8.35 (Tier 2)Typhim Vi

TYPHIM VI (INJECTION) $3.70-$8.35 (Tier 2)VAQTA

VAQTA (INJECTION) $3.70-$8.35 (Tier 2)Varivax

VARIVAX (INJECTION) $3.70-$8.35 (Tier 2)YF-Vax

YF-VAX (INJECTION) $3.70-$8.35 (Tier 2)Zostavax

ZOSTAVAX (INJECTION) $3.70-$8.35 (Tier 2) PA

Inflammatory Bowel Disease Agents

AminosalicylatesApriso

APRISO (CAPSULE EXTENDED-RELEASE 24 HOUR) $3.70-$8.35 (Tier 2) QLBalsalazide Disodium

balsalazide disodium (capsule) $1.25-$3.35 (Tier 1)Canasa

CANASA (SUPPOSITORY) $3.70-$8.35 (Tier 2)Dipentum

DIPENTUM (CAPSULE) $3.70-$8.35 (Tier 2)Lialda

LIALDA (TABLET DELAYED-RELEASE) $3.70-$8.35 (Tier 2) QLMesalamine

mesalamine (enema) $1.25-$3.35 (Tier 1)


pages 9 and 10.




86


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMesalamine DR

mesalamine dr (1.2gm tablet delayed-release) $1.25-$3.35 (Tier 1) QLRowasa

ROWASA (KIT) $3.70-$8.35 (Tier 2)

GlucocorticoidsBudesonide

budesonide (3mg capsule delayed-release) $1.25-$3.35 (Tier 1)Budesonide ER

budesonide er (tablet extended-release 24 hour) $1.25-$3.35 (Tier 1) STColocort

colocort (enema) $1.25-$3.35 (Tier 1)Hydrocortisone

HYDROCORTISONE (RX ONLY) (100MG/60ML ENEMA) $3.70-$8.35 (Tier 2)Procto-Med HC

procto-med hc (cream) $1.25-$3.35 (Tier 1)Procto-Pak

procto-pak (cream) $1.25-$3.35 (Tier 1)Proctosol HC

proctosol hc (cream) $1.25-$3.35 (Tier 1)Proctozone-HC

proctozone-hc (cream) $1.25-$3.35 (Tier 1)Uceris

UCERIS (9MG TABLET EXTENDED-RELEASE 24 HOUR) $3.70-$8.35 (Tier 2) ST

SulfonamidesSulfasalazine

sulfasalazine (500mg tablet delayed-release, 500mg

tablet immediate-release)$1.25-$3.35 (Tier 1)

Metabolic Bone Disease Agents

Metabolic Bone Disease AgentsAlendronate Sodium

alendronate sodium (10mg tablet, 35mg tablet,

40mg tablet, 5mg tablet, 70mg tablet)$1.25-$3.35 (Tier 1) QL

Alendronate Sodium

alendronate sodium (70mg/75ml oral solution) $1.25-$3.35 (Tier 1)Binosto

BINOSTO (TABLET EFFERVESCENT) $3.70-$8.35 (Tier 2) QLCalcitonin-Salmon

calcitonin-salmon (nasal solution) $1.25-$3.35 (Tier 1) QLCalcitriol

calcitriol (0.25mcg capsule, 0.5mcg capsule, 1mcg/

ml injection, 1mcg/ml oral solution)$1.25-$3.35 (Tier 1) B/D, PA

Doxercalciferol

doxercalciferol (0.5mcg capsule, 1mcg capsule,

2.5mcg capsule)$1.25-$3.35 (Tier 1) B/D, PA, QL

Doxercalciferol

doxercalciferol (4mcg/2ml injection) $1.25-$3.35 (Tier 1) B/D, PA


87


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useEtidronate Disodium

etidronate disodium (tablet) $1.25-$3.35 (Tier 1)Forteo

FORTEO (INJECTION) $3.70-$8.35 (Tier 2) PA, QLMiacalcin

MIACALCIN (200UNIT/ML INJECTION) $3.70-$8.35 (Tier 2) PANatpara

NATPARA (INJECTION) $3.70-$8.35 (Tier 2) PAPamidronate Disodium

pamidronate disodium (injection) $1.25-$3.35 (Tier 1) B/D, PAParicalcitol

paricalcitol (1mcg capsule, 2mcg capsule, 4mcg

capsule, 2mcg/ml injection, 5mcg/ml injection)$1.25-$3.35 (Tier 1) B/D, PA

Prolia

PROLIA (INJECTION) $3.70-$8.35 (Tier 2)Sensipar

SENSIPAR (TABLET) $3.70-$8.35 (Tier 2) B/D, PA, QLTymlos

TYMLOS (INJECTION) $3.70-$8.35 (Tier 2) PA, QLXgeva

XGEVA (INJECTION) $3.70-$8.35 (Tier 2) PAZoledronic Acid

zoledronic acid (4mg/5ml injection) $1.25-$3.35 (Tier 1) B/D, PAZoledronic Acid

zoledronic acid (5mg/100ml injection) $1.25-$3.35 (Tier 1) PA

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic AgentsAlcohol Prep Pads

alcohol prep pads (otc only) $1.25-$3.35 (Tier 1)Botox

BOTOX (INJECTION) $3.70-$8.35 (Tier 2) PA, QLDysport

DYSPORT (INJECTION) $3.70-$8.35 (Tier 2) PAFomepizole

fomepizole (injection) $1.25-$3.35 (Tier 1)Gauze

gauze (non-medicated 2x2) $1.25-$3.35 (Tier 1)Insulin Syringes, Needles

insulin syringes, needles $1.25-$3.35 (Tier 1)Sterile Water Irrigation

STERILE WATER IRRIGATION (SOLUTION) $3.70-$8.35 (Tier 2)Suspendol-S

suspendol-s (liquid)* $0 (Tier 3)White Petrolatum

white petrolatum (gel)* $0 (Tier 3)

Ophthalmic Agents

Ophthalmic Agents, OtherAkwa Tears

akwa tears (ointment)* $0 (Tier 3)Artificial Tears

artificial tears (otc only) (ophthalmic solution)* $0 (Tier 3)Atropine Sulfate

ATROPINE SULFATE (1% OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2)Bacitracin/Polymyxin B

bacitracin/polymyxin b (ophthalmic ointment) $1.25-$3.35 (Tier 1)Blephamide

BLEPHAMIDE (SUSPENSION) $3.70-$8.35 (Tier 2)Blephamide S.O.P.

blephamide s.o.p. (ointment) $1.25-$3.35 (Tier 1)Cystaran

CYSTARAN (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2)Freshkote

freshkote (ophthalmic solution)* $0 (Tier 3)


pages 9 and 10.




88


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useIsopto Tears

isopto tears (ophthalmic solution)* $0 (Tier 3)Lacrisert

LACRISERT (INSERT) $3.70-$8.35 (Tier 2)Lastacaft

LASTACAFT (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2)Liquitears

liquitears (ophthalmic solution)* $0 (Tier 3)Lubricant Eye Drops

lubricant eye drops (ophthalmic solution)* $0 (Tier 3)Lubricating Plus Eye Drops

lubricating plus eye drops (ophthalmic solution)* $0 (Tier 3)Lubrifresh P.M.

lubrifresh p.m. (ointment)* $0 (Tier 3)Muro 128

muro 128 (5% ophthalmic solution)* $0 (Tier 3)Natural Balance Tears

natural balance tears (ophthalmic solution)* $0 (Tier 3)Natures Tears

natures tears (ophthalmic solution)* $0 (Tier 3)Neomycin/Bacitracin/Polymyxin

neomycin/bacitracin/polymyxin (ointment) $1.25-$3.35 (Tier 1)Neomycin/Polymyxin/Bacitracin/Hydrocortisone

neomycin/polymyxin/bacitracin/hydrocortisone

(ophthalmic ointment)$1.25-$3.35 (Tier 1)

Neomycin/Polymyxin/Dexamethasone

neomycin/polymyxin/dexamethasone (0.1%

ophthalmic ointment, 0.1% ophthalmic suspension)$1.25-$3.35 (Tier 1)

Neomycin/Polymyxin/Gramicidin

neomycin/polymyxin/gramicidin (ophthalmic


Neomycin/Polymyxin/Hydrocortisone

neomycin/polymyxin/hydrocortisone (1% ophthalmic


Polymyxin B Sulfate/Trimethoprim Sulfate

polymyxin b sulfate/trimethoprim sulfate (ophthalmic


Proparacaine HCl

proparacaine hcl (ophthalmic solution) $1.25-$3.35 (Tier 1)Puralube

puralube (ointment)* $0 (Tier 3)Refresh Celluvisc

refresh celluvisc (ophthalmic solution)* $0 (Tier 3)Refresh Lacri-Lube

refresh lacri-lube (ointment)* $0 (Tier 3)Refresh Plus

refresh plus (ophthalmic solution)* $0 (Tier 3)Restasis

RESTASIS (EMULSION) $3.70-$8.35 (Tier 2) QLRhopressa

RHOPRESSA (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2) STSodium Chloride

sodium chloride (otc only) (5% ointment, 5%

ophthalmic solution)*$0 (Tier 3)


89


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useSulfacetamide Sodium/Prednisolone Sodium Phosphate

sulfacetamide sodium/prednisolone sodium

phosphate (ophthalmic solution)$1.25-$3.35 (Tier 1)

Tobradex

TOBRADEX (0.3%-0.1% OPHTHALMIC OINTMENT) $3.70-$8.35 (Tier 2)Tobradex ST

TOBRADEX ST (OPHTHALMIC SUSPENSION) $3.70-$8.35 (Tier 2)Tobramycin/Dexamethasone

tobramycin/dexamethasone (ophthalmic


Ultra Lubricant Eye Drops

ultra lubricant eye drops (ophthalmic solution)* $0 (Tier 3)Xiidra

XIIDRA (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2) QL

Ophthalmic Anti-allergy AgentsAzelastine HCl

azelastine hcl (0.05% ophthalmic solution) $1.25-$3.35 (Tier 1)Bepreve

BEPREVE (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2)Cromolyn Sodium

cromolyn sodium (rx only) (4% ophthalmic solution) $1.25-$3.35 (Tier 1)Epinastine HCl

epinastine hcl (ophthalmic solution) $1.25-$3.35 (Tier 1)Eye Drops

eye drops (ophthalmic solution)* $0 (Tier 3)Olopatadine HCl

olopatadine hcl (ophthalmic solution) $1.25-$3.35 (Tier 1)Opti-Clear

opti-clear (ophthalmic solution)* $0 (Tier 3)Pazeo

PAZEO (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2)

Ophthalmic Antiglaucoma AgentsAlphagan P

ALPHAGAN P (0.1% OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2)Apraclonidine

apraclonidine (ophthalmic solution) $1.25-$3.35 (Tier 1)Betaxolol HCl

betaxolol hcl (ophthalmic solution) $1.25-$3.35 (Tier 1)Betimol

BETIMOL (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2)Brimonidine Tartrate

brimonidine tartrate (0.2% ophthalmic solution) $1.25-$3.35 (Tier 1)Carteolol HCl

carteolol hcl (ophthalmic solution) $1.25-$3.35 (Tier 1)Combigan

COMBIGAN (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2)Cosopt PF

COSOPT PF (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2)Dorzolamide HCl

dorzolamide hcl (ophthalmic solution) $1.25-$3.35 (Tier 1)Dorzolamide HCl/Timolol Maleate

dorzolamide hcl/timolol maleate (ophthalmic


Levobunolol HCl

levobunolol hcl (ophthalmic solution) $1.25-$3.35 (Tier 1)Metipranolol

metipranolol (ophthalmic solution) $1.25-$3.35 (Tier 1)Phospholine Iodide

PHOSPHOLINE IODIDE (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2)Pilocarpine HCl

PILOCARPINE HCL (1% OPHTHALMIC SOLUTION, 2%

OPHTHALMIC SOLUTION, 4% OPHTHALMIC

SOLUTION)$3.70-$8.35 (Tier 2)


pages 9 and 10.




90


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useTimolol Maleate

timolol maleate (0.25% ophthalmic solution, 0.5%

ophthalmic solution) (generic timoptic)$1.25-$3.35 (Tier 1)

Timolol Maleate Ophthalmic Gel Forming

TIMOLOL MALEATE OPHTHALMIC GEL FORMING

(SOLUTION) (GENERIC TIMOPTIC-XE)$3.70-$8.35 (Tier 2)

Ophthalmic Anti-inflammatoriesDexamethasone Sodium Phosphate

dexamethasone sodium phosphate (0.1%

ophthalmic solution)$1.25-$3.35 (Tier 1)

Diclofenac Sodium

diclofenac sodium (0.1% ophthalmic solution) $1.25-$3.35 (Tier 1)Durezol

DUREZOL (EMULSION) $3.70-$8.35 (Tier 2)Eye Itch Relief

eye itch relief (ophthalmic solution)* $0 (Tier 3)Fluorometholone

FLUOROMETHOLONE (OPHTHALMIC SUSPENSION) $3.70-$8.35 (Tier 2)Flurbiprofen Sodium

flurbiprofen sodium (ophthalmic solution) $1.25-$3.35 (Tier 1)Ilevro

ILEVRO (SUSPENSION) $3.70-$8.35 (Tier 2)Ketorolac Tromethamine

ketorolac tromethamine (0.4% ophthalmic solution,

0.5% ophthalmic solution)$1.25-$3.35 (Tier 1)

Lotemax

LOTEMAX (0.5% GEL, 0.5% OINTMENT, 0.5%

SUSPENSION)$3.70-$8.35 (Tier 2)

Nevanac

NEVANAC (SUSPENSION) $3.70-$8.35 (Tier 2)Prednisolone Acetate

PREDNISOLONE ACETATE (SUSPENSION) $3.70-$8.35 (Tier 2)Prednisolone Sodium Phosphate

prednisolone sodium phosphate (1% ophthalmic


Prolensa

PROLENSA (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2)

Ophthalmic Prostaglandin and Prostamide AnalogsLatanoprost

latanoprost (ophthalmic solution) $1.25-$3.35 (Tier 1)Lumigan

LUMIGAN (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2)Travatan Z

TRAVATAN Z (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2)Vyzulta

VYZULTA (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2)Zioptan

ZIOPTAN (OPHTHALMIC SOLUTION) $3.70-$8.35 (Tier 2)


91


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

Otic Agents

Otic AgentsAcetic Acid

acetic acid (otic solution) $1.25-$3.35 (Tier 1)Fluocinolone Acetonide

fluocinolone acetonide (0.01% otic oil) $1.25-$3.35 (Tier 1)Hydrocortisone/Acetic Acid

hydrocortisone/acetic acid (otic solution) $1.25-$3.35 (Tier 1)Neomycin/Polymyxin/Hydrocortisone

neomycin/polymyxin/hydrocortisone (1% otic

solution, 1% otic suspension)$1.25-$3.35 (Tier 1)

Respiratory Tract/Pulmonary Agents

AntihistaminesAceta-Gesic

aceta-gesic (tablet)* $0 (Tier 3)Ala-Hist IR

ala-hist ir (tablet)* $0 (Tier 3)Ala-Hist PE

ala-hist pe (tablet)* $0 (Tier 3)All Day Allergy

all day allergy (tablet)* $0 (Tier 3)All Day Allergy Childrens

all day allergy childrens (10mg tablet chewable,

5mg/5ml oral solution)*$0 (Tier 3)

All Day Allergy-D

all day allergy-d (tablet extended-release 12 hour)* $0 (Tier 3)Aller-Chlor

aller-chlor (2mg/5ml syrup, 4mg tablet)* $0 (Tier 3)Allergy

allergy (tablet)* $0 (Tier 3)Allergy Relief

allergy relief (tablet)* $0 (Tier 3)Allergy Relief Child

allergy relief child (syrup)* $0 (Tier 3)Allergy Relief D-24

allergy relief d-24 (tablet extended-release 24 hour)* $0 (Tier 3)Azelastine HCl

azelastine hcl (0.1% nasal solution, 0.15% nasal


Banophen

banophen (otc only) (capsule)* $0 (Tier 3)Brotapp

brotapp (liquid)* $0 (Tier 3)Cetirizine HCl

cetirizine hcl (otc only) (10mg tablet chewable, 5mg

tablet chewable, 10mg tablet, 5mg tablet)*$0 (Tier 3)

Cetirizine HCl

cetirizine hcl (rx only) (syrup) $1.25-$3.35 (Tier 1)Cetirizine HCl Allergy Childrens

cetirizine hcl allergy childrens (otc only) (oral

solution)*$0 (Tier 3)

Cetirizine HCl Childrens Allergy

cetirizine hcl childrens allergy (otc only) (syrup)* $0 (Tier 3)Cetirizine HCl/Pseudoephedrine HCl ER

cetirizine hcl/pseudoephedrine hcl er (otc only)

(tablet extended-release 12 hour)*$0 (Tier 3)

Childrens Allergy

childrens allergy (liquid)* $0 (Tier 3)


pages 9 and 10.




92


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useChildrens Loratadine

childrens loratadine (5mg/5ml oral solution, 5mg/

5ml syrup)*$0 (Tier 3)

Chlorphen SR

chlorphen sr (tablet extended-release)* $0 (Tier 3)Complete Allergy Medicine

complete allergy medicine (otc only) (capsule)* $0 (Tier 3)Cyproheptadine HCl

cyproheptadine hcl (2mg/5ml syrup, 4mg tablet) $1.25-$3.35 (Tier 1)Dallergy

dallergy (1mg-5mg tablet, 1mg/ml-2.5mg/ml liquid)* $0 (Tier 3)Dimaphen Childrens

dimaphen childrens (elixir)* $0 (Tier 3)Diphenhist

diphenhist (12.5mg/5ml liquid, 25mg capsule)* $0 (Tier 3)Diphenhydramine HCl

diphenhydramine hcl (otc only) (capsule)* $0 (Tier 3)Diphenhydramine HCl

diphenhydramine hcl (rx only) (50mg/ml injection) $1.25-$3.35 (Tier 1) B/D, PAED A-Hist

ed a-hist (liquid)* $0 (Tier 3)ED Chlorped

ed chlorped (liquid)* $0 (Tier 3)ED Chlorped D

ed chlorped d (liquid)* $0 (Tier 3)ED Chlorped Jr

ed chlorped jr (syrup)* $0 (Tier 3)ED Chlortan

ed chlortan (tablet)* $0 (Tier 3)Fexofenadine HCl

fexofenadine hcl (tablet)* $0 (Tier 3)Fexofenadine HCl Childrens Allergy

fexofenadine hcl childrens allergy (suspension)* $0 (Tier 3)GNP All Day Allergy

gnp all day allergy (tablet)* $0 (Tier 3)GNP Allergy

gnp allergy (tablet)* $0 (Tier 3)GNP Dayhist Allergy

gnp dayhist allergy (tablet)* $0 (Tier 3)GNP Loratadine

gnp loratadine (10mg tablet, 5mg/5ml syrup)* $0 (Tier 3)Histex

histex (syrup)* $0 (Tier 3)Histex PD

histex pd (liquid)* $0 (Tier 3)Levocetirizine Dihydrochloride

levocetirizine dihydrochloride (5mg tablet) $1.25-$3.35 (Tier 1) QLLodrane D

lodrane d (capsule)* $0 (Tier 3)LoHist-D

lohist-d (liquid)* $0 (Tier 3)Loratadine

loratadine (tablet)* $0 (Tier 3)Loratadine Childrens

loratadine childrens (5mg/5ml oral solution, 5mg/

5ml syrup)*$0 (Tier 3)


93


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useLoratadine Hives Relief

loratadine hives relief (oral solution)* $0 (Tier 3)Loratadine-D 12hr

loratadine-d 12hr (tablet extended-release 12 hour)* $0 (Tier 3)Loratadine-D 24hr

loratadine-d 24hr (tablet extended-release 24 hour)* $0 (Tier 3)Lortuss LQ

lortuss lq (liquid)* $0 (Tier 3)Nasopen PE

nasopen pe (liquid)* $0 (Tier 3)NoHist-LQ

nohist-lq (liquid)* $0 (Tier 3)Phenadoz

phenadoz (suppository) $1.25-$3.35 (Tier 1)Poly-Hist PD

poly-hist pd (liquid)* $0 (Tier 3)Promethazine HCl

promethazine hcl (12.5mg suppository, 25mg

suppository, 12.5mg tablet, 25mg tablet, 50mg

tablet, 25mg/ml injection, 50mg/ml injection,

6.25mg/5ml syrup)

$1.25-$3.35 (Tier 1)

Promethegan

promethegan (25mg suppository) $1.25-$3.35 (Tier 1)QC Loratadine Allergy Relief

qc loratadine allergy relief (tablet)* $0 (Tier 3)QC Loratadine-D

qc loratadine-d (tablet extended-release 24 hour)* $0 (Tier 3)Q-Dryl

q-dryl (liquid)* $0 (Tier 3)Rescon

rescon (tablet)* $0 (Tier 3)Ru-Hist D

ru-hist d (tablet)* $0 (Tier 3)Rymed

rymed (tablet)* $0 (Tier 3)Rynex PE

rynex pe (elixir)* $0 (Tier 3)Rynex PSE

rynex pse (liquid)* $0 (Tier 3)Siladryl Allergy

siladryl allergy (liquid)* $0 (Tier 3)Silphen Cough

silphen cough (syrup)* $0 (Tier 3)SM Allergy 4 Hour

sm allergy 4 hour (tablet)* $0 (Tier 3)SM Allergy Relief

sm allergy relief (1.34mg tablet, 12.5mg/5ml liquid)* $0 (Tier 3)SM Loratadine

sm loratadine (syrup)* $0 (Tier 3)SM Lorata-Dine D

sm lorata-dine d (tablet extended-release 24 hour)* $0 (Tier 3)Sudogest Sinus & Allergy

sudogest sinus & allergy (tablet)* $0 (Tier 3)Triprolidine HCl

triprolidine hcl (liquid)* $0 (Tier 3)Vanaclear PD

vanaclear pd (liquid)* $0 (Tier 3)Vanahist PD

vanahist pd (liquid)* $0 (Tier 3)Vanamine PD

vanamine pd (liquid)* $0 (Tier 3)

Anti-inflammatories, Inhaled CorticosteroidsArnuity Ellipta

ARNUITY ELLIPTA (100MCG/ACT AEROSOL POWDER,

200MCG/ACT AEROSOL POWDER, 50MCG/ACT

AEROSOL POWDER)$3.70-$8.35 (Tier 2) QL


pages 9 and 10.




94


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useBudesonide

budesonide (0.25mg/2ml suspension, 0.5mg/2ml

suspension, 1mg/2ml suspension)$1.25-$3.35 (Tier 1) B/D, PA

Budesonide Nasal Spray

budesonide nasal spray (otc only) (suspension)* $0 (Tier 3)Flovent Diskus

FLOVENT DISKUS (AEROSOL POWDER) $3.70-$8.35 (Tier 2) QLFlovent HFA

FLOVENT HFA (AEROSOL) $3.70-$8.35 (Tier 2) QLFlunisolide

flunisolide (nasal solution) $1.25-$3.35 (Tier 1)Fluticasone Propionate

fluticasone propionate (otc only) (suspension)* $0 (Tier 3)Fluticasone Propionate

fluticasone propionate (rx only) (50mcg/act


Triamcinolone Acetonide

TRIAMCINOLONE ACETONIDE (55MCG/ACT

AEROSOL)$3.70-$8.35 (Tier 2)


triamcinolone acetonide (otc only) (aerosol)* $0 (Tier 3)

AntileukotrienesMontelukast Sodium

montelukast sodium (10mg tablet, 4mg packet, 4mg

tablet chewable, 5mg tablet chewable)$1.25-$3.35 (Tier 1) QL

Zafirlukast

zafirlukast (tablet) $1.25-$3.35 (Tier 1) QLZileuton ER

zileuton er (tablet extended-release 12 hour) $1.25-$3.35 (Tier 1) STZyflo

ZYFLO (TABLET) $3.70-$8.35 (Tier 2) STZyflo CR

ZYFLO CR (TABLET EXTENDED-RELEASE 12 HOUR) $3.70-$8.35 (Tier 2) ST

Bronchodilators, AnticholinergicAtrovent HFA

ATROVENT HFA (AEROSOL SOLUTION) $3.70-$8.35 (Tier 2)Incruse Ellipta

INCRUSE ELLIPTA (AEROSOL POWDER) $3.70-$8.35 (Tier 2) QLIpratropium Bromide

ipratropium bromide (0.02% inhalation solution) $1.25-$3.35 (Tier 1) B/D, PAIpratropium Bromide

ipratropium bromide (0.03% nasal solution, 0.06%

nasal solution)$1.25-$3.35 (Tier 1)

Spiriva HandiHaler

SPIRIVA HANDIHALER (CAPSULE) $3.70-$8.35 (Tier 2) QLSpiriva Respimat

SPIRIVA RESPIMAT (AEROSOL SOLUTION) $3.70-$8.35 (Tier 2) QL

Bronchodilators, Sympathomimetic


95


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useAlbuterol Sulfate

albuterol sulfate (0.083% nebulized solution, 0.5%

nebulized solution, 0.63mg/3ml nebulized solution,

1.25mg/3ml nebulized solution)

$1.25-$3.35 (Tier 1) B/D, PA

Albuterol Sulfate

albuterol sulfate (2mg tablet immediate-release, 4mg

tablet immediate-release)$1.25-$3.35 (Tier 1)

Brovana

BROVANA (NEBULIZED SOLUTION) $3.70-$8.35 (Tier 2) B/D, PA, QLEpinephrine

EPINEPHRINE (0.15MG/0.3ML INJECTION, 0.3MG/

0.3ML INJECTION) (GENERIC EPIPEN)$3.70-$8.35 (Tier 2) QL

EpiPen

EPIPEN (INJECTION) $3.70-$8.35 (Tier 2) QLLevalbuterol

levalbuterol (nebulized solution) $1.25-$3.35 (Tier 1) B/D, PAPerforomist

PERFOROMIST (NEBULIZED SOLUTION) $3.70-$8.35 (Tier 2) B/D, PA, QLProAir HFA

PROAIR HFA (AEROSOL SOLUTION) $3.70-$8.35 (Tier 2)ProAir RespiClick

PROAIR RESPICLICK (AEROSOL POWDER) $3.70-$8.35 (Tier 2)S2

s2 (nebulized solution)* $0 (Tier 3)Serevent Diskus

SEREVENT DISKUS (AEROSOL POWDER) $3.70-$8.35 (Tier 2) QL

Cystic Fibrosis AgentsBethkis

BETHKIS (NEBULIZED SOLUTION) $3.70-$8.35 (Tier 2) B/D, PA, QLCayston

CAYSTON (INHALATION SOLUTION) $3.70-$8.35 (Tier 2) PA, LAKalydeco

KALYDECO (150MG TABLET, 50MG PACKET, 75MG

PACKET)$3.70-$8.35 (Tier 2) PA, QL

Orkambi

ORKAMBI (TABLET) $3.70-$8.35 (Tier 2) PA, QL, LATOBI Podhaler

TOBI PODHALER (CAPSULE) $3.70-$8.35 (Tier 2) PA, QLTobramycin

tobramycin (nebulized solution) $1.25-$3.35 (Tier 1) B/D, PA, QL

Mast Cell StabilizersCromolyn Sodium

cromolyn sodium (5.2mg/act aerosol solution)* $0 (Tier 3)Cromolyn Sodium

cromolyn sodium (rx only) (20mg/2ml nebulized

solution)$1.25-$3.35 (Tier 1) B/D, PA

Phosphodiesterase Inhibitors, Airways DiseaseAminophylline

aminophylline (injection) $1.25-$3.35 (Tier 1)Daliresp

DALIRESP (TABLET) $3.70-$8.35 (Tier 2) PA, QLTheophylline

theophylline (oral solution) $1.25-$3.35 (Tier 1)Theophylline CR

theophylline cr (tablet extended-release 12 hour) $1.25-$3.35 (Tier 1)Theophylline ER

theophylline er (300mg tablet extended-release 12



$1.25-$3.35 (Tier 1)

Pulmonary Antihypertensives


pages 9 and 10.




96


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useAdcirca

ADCIRCA (TABLET) $3.70-$8.35 (Tier 2) PA, QLAdempas

ADEMPAS (TABLET) $3.70-$8.35 (Tier 2) PALetairis

LETAIRIS (TABLET) $3.70-$8.35 (Tier 2) PA, QL, LAOpsumit

OPSUMIT (TABLET) $3.70-$8.35 (Tier 2) PA, LAOrenitram

ORENITRAM (TABLET EXTENDED-RELEASE) $3.70-$8.35 (Tier 2) PARemodulin

REMODULIN (INJECTION) $3.70-$8.35 (Tier 2) PA, LASildenafil

sildenafil (10mg/12.5ml injection) $1.25-$3.35 (Tier 1) PASildenafil

sildenafil (20mg tablet) (generic revatio) $1.25-$3.35 (Tier 1) PA, QLTracleer

TRACLEER (125MG TABLET, 62.5MG TABLET, 32MG

TABLET SOLUBLE)$3.70-$8.35 (Tier 2) PA, QL

Ventavis

VENTAVIS (INHALATION SOLUTION) $3.70-$8.35 (Tier 2) PA, QL, LA

Pulmonary Fibrosis AgentsEsbriet

ESBRIET (267MG CAPSULE, 267MG TABLET, 801MG

TABLET)$3.70-$8.35 (Tier 2) PA, QL, LA

Ofev

OFEV (CAPSULE) $3.70-$8.35 (Tier 2) PA, QL, LA

Respiratory Tract Agents, Other12 Hour Decongestant

12 hour decongestant (tablet extended-release)* $0 (Tier 3)Acetylcysteine

acetylcysteine (inhalation solution) $1.25-$3.35 (Tier 1) B/D, PAAdvair Diskus

ADVAIR DISKUS (AEROSOL POWDER) $3.70-$8.35 (Tier 2) QLAdvair HFA

ADVAIR HFA (AEROSOL) $3.70-$8.35 (Tier 2) QLAlahist DM

alahist dm (liquid)* $0 (Tier 3)All-Nite Cold & Flu Nighttime Relief

all-nite cold & flu nighttime relief (liquid)* $0 (Tier 3)Anoro Ellipta

ANORO ELLIPTA (AEROSOL POWDER) $3.70-$8.35 (Tier 2) QLAP-Hist DM

ap-hist dm (liquid)* $0 (Tier 3)Aprodine

aprodine (tablet)* $0 (Tier 3)Benzonatate

benzonatate (capsule)* $0 (Tier 3)Bevespi Aerosphere

BEVESPI AEROSPHERE (AEROSOL) $3.70-$8.35 (Tier 2) QLBreo Ellipta

BREO ELLIPTA (AEROSOL POWDER) $3.70-$8.35 (Tier 2) QL


97


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useBromfed DM

bromfed dm (rx only) (syrup)* $0 (Tier 3)Bromphen/Pseudoephedrine HCl/Dextromethorphan HBr

bromphen/pseudoephedrine hcl/dextromethorphan

hbr (rx only) (syrup)*$0 (Tier 3)

Brotapp DM

brotapp dm (liquid)* $0 (Tier 3)Cheratussin AC

cheratussin ac (syrup)* $0 (Tier 3)Chest Congestion Relief

chest congestion relief (tablet)* $0 (Tier 3)Chest Congestion Relief PE

chest congestion relief pe (tablet)* $0 (Tier 3)Childrens Silfedrine

childrens silfedrine (liquid)* $0 (Tier 3)Chlo Tuss

chlo tuss (liquid)* $0 (Tier 3)Codeine/Guaifenesin

codeine/guaifenesin (oral solution)* $0 (Tier 3)Cold/Cough DM Childrens

cold/cough dm childrens (elixir)* $0 (Tier 3)Combivent Respimat

COMBIVENT RESPIMAT (AEROSOL SOLUTION) $3.70-$8.35 (Tier 2)Cough DM

cough dm (suspension extended-release)* $0 (Tier 3)Cough Syrup

cough syrup (syrup)* $0 (Tier 3)Day Time Multi-Symptom Cold/Flu Relief

day time multi-symptom cold/flu relief (capsule)* $0 (Tier 3)Deconex DMX

deconex dmx (tablet)* $0 (Tier 3)Deconex IR

deconex ir (tablet)* $0 (Tier 3)Delsym

delsym (suspension extended-release)* $0 (Tier 3)Delsym Cough + Chest Congestion DM

delsym cough + chest congestion dm (liquid)* $0 (Tier 3)Delsym Cough + Chest Congestion DM Childrens

delsym cough + chest congestion dm childrens

(liquid)*$0 (Tier 3)

Delsym Cough + Cold Daytime

delsym cough + cold daytime (liquid)* $0 (Tier 3)Delsym Cough + Cold Nighttime

delsym cough + cold nighttime (liquid)* $0 (Tier 3)Delsym Cough + Cold Nighttime Childrens

delsym cough + cold nighttime childrens (liquid)* $0 (Tier 3)Dextromethorphan Polistirex

dextromethorphan polistirex (suspension extended-

release)*$0 (Tier 3)

Dimaphen DM Cold & Cough

dimaphen dm cold & cough (elixir)* $0 (Tier 3)ED A-Hist

ed a-hist (4mg-10mg tablet)* $0 (Tier 3)ED A-Hist DM

ed a-hist dm (4mg-10mg-10mg tablet, 4mg/

5ml-15mg/5ml-10mg/5ml liquid)*$0 (Tier 3)

ED A-Hist PSE

ed a-hist pse (tablet)* $0 (Tier 3)ED Bron GP

ed bron gp (liquid)* $0 (Tier 3)EndaCof-DM

endacof-dm (liquid)* $0 (Tier 3)Extra Action Cough

extra action cough (syrup)* $0 (Tier 3)Flowtuss

flowtuss (oral solution)* $0 (Tier 3)Fluticasone Propionate/Salmeterol

FLUTICASONE PROPIONATE/SALMETEROL (AEROSOL

POWDER)$3.70-$8.35 (Tier 2) QL


pages 9 and 10.




98


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useGNP Tussin

gnp tussin (syrup)* $0 (Tier 3)GNP Tussin DM

gnp tussin dm (liquid)* $0 (Tier 3)Guaifenesin AC

guaifenesin ac (syrup)* $0 (Tier 3)Guaifenesin and Pseudoephedrine HCl

guaifenesin and pseudoephedrine hcl (otc only)

(tablet extended-release 12 hour)*$0 (Tier 3)

Guaifenesin ER

guaifenesin er (otc only) (tablet extended-release 12

hour)*$0 (Tier 3)

Guaifenesin/Codeine

guaifenesin/codeine (oral solution)* $0 (Tier 3)Guaifenesin/Dextromethorphan HBr

guaifenesin/dextromethorphan hbr (tablet extended-

release 12 hour)*$0 (Tier 3)

Histex-DM

histex-dm (syrup)* $0 (Tier 3)Histex-PE

histex-pe (syrup)* $0 (Tier 3)Hycofenix

hycofenix (oral solution)* $0 (Tier 3)Hydrocodone Bitartrate/Chlorpheniramine Maleate/PSE

hydrocodone bitartrate/chlorpheniramine maleate/

pse (oral solution)*$0 (Tier 3)

Hydrocodone Bitartrate/Homatropine Methylbromide

hydrocodone bitartrate/homatropine methylbromide

(1.5mg-5mg tablet, 1.5mg/5ml-5mg/5ml syrup)*$0 (Tier 3)

Hydrocodone Polistirex/Chlorpheniramine Polistirex

hydrocodone polistirex/chlorpheniramine polistirex

(suspension extended-release)*$0 (Tier 3)

Hydromet

hydromet (syrup)* $0 (Tier 3)Ipratropium Bromide/Albuterol Sulfate

ipratropium bromide/albuterol sulfate (inhalation

solution)$1.25-$3.35 (Tier 1) B/D, PA

Kidkare Cough/Cold

kidkare cough/cold (liquid)* $0 (Tier 3)LoHist-DM

lohist-dm (syrup)* $0 (Tier 3)Lortuss DM

lortuss dm (liquid)* $0 (Tier 3)Lortuss EX

lortuss ex (liquid)* $0 (Tier 3)Mapap Cold Formula Multi-Symptom

mapap cold formula multi-symptom (tablet)* $0 (Tier 3)Mapap Sinus Maximum Strength Congestion and Pain

mapap sinus maximum strength congestion and pain

(tablet)*$0 (Tier 3)

M-END DMX

m-end dmx (liquid)* $0 (Tier 3)


99


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMucinex

mucinex (otc only) (tablet extended-release 12

hour)*$0 (Tier 3)

Mucinex Chest Congestion Childrens

mucinex chest congestion childrens (liquid)* $0 (Tier 3)Mucinex Childrens Cold Cough & Sore Throat

mucinex childrens cold cough & sore throat (liquid)* $0 (Tier 3)Mucinex Childrens Multi-Symptom Cold & Fever

mucinex childrens multi-symptom cold & fever


Mucinex Childrens Multi-Symptom Cold

mucinex childrens multi-symptom cold (liquid)* $0 (Tier 3)Mucinex Congestion & Cough Childrens

mucinex congestion & cough childrens (liquid)* $0 (Tier 3)Mucinex Cough Childrens

mucinex cough childrens (liquid)* $0 (Tier 3)Mucinex Cough for Kids

mucinex cough for kids (packet)* $0 (Tier 3)Mucinex D

mucinex d (otc only) (tablet extended-release 12

hour)*$0 (Tier 3)

Mucinex D Maximum Strength

mucinex d maximum strength (tablet extended-


Mucinex DM

mucinex dm (otc only) (tablet extended-release 12

hour)*$0 (Tier 3)

Mucinex DM Maximum Strength

mucinex dm maximum strength (tablet extended-


Mucinex Fast-Max Cold & Sinus

mucinex fast-max cold & sinus (tablet)* $0 (Tier 3)Mucinex Fast-Max Cold Flu & Sore Throat

mucinex fast-max cold flu & sore throat (tablet,

liquid)*$0 (Tier 3)

Mucinex Fast-Max Day Time/Night Time

mucinex fast-max day time/night time (liquid)* $0 (Tier 3)Mucinex Fast-Max Day/Night Maximum Strength

mucinex fast-max day/night maximum strength* $0 (Tier 3)Mucinex Fast-Max DM Max

mucinex fast-max dm max (liquid)* $0 (Tier 3)Mucinex Fast-Max Night Time Cold & Flu

mucinex fast-max night time cold & flu (tablet,

liquid)*$0 (Tier 3)

Mucinex Fast-Max Severe Cold

mucinex fast-max severe cold

(325mg-10mg-200mg-5mg tablet, 325mg/

10ml-10mg/10ml-200mg/10ml-5mg/10ml liquid)*

$0 (Tier 3)

Mucinex Fast-Max Severe Congestion & Cough

mucinex fast-max severe congestion & cough (tablet,

liquid)*$0 (Tier 3)

Mucinex for Kids

mucinex for kids (packet)* $0 (Tier 3)Mucinex Maximum Strength

mucinex maximum strength (tablet extended-release

12 hour)*$0 (Tier 3)

Mucinex Multi-Symptom Cold Day/Night Pack

mucinex multi-symptom cold day/night pack (liquid)* $0 (Tier 3)Mucinex Multi-Symptom Cold Night Time Childrens

mucinex multi-symptom cold night time childrens


Mucinex Sinus-Max Day/Night

mucinex sinus-max day/night* $0 (Tier 3)


pages 9 and 10.




100


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMucinex Sinus-Max Full Force

mucinex sinus-max full force (nasal solution)* $0 (Tier 3)Mucinex Sinus-Max Pressure & Pain

mucinex sinus-max pressure & pain (tablet)* $0 (Tier 3)Mucinex Sinus-Max Severe Congestion Relief

mucinex sinus-max severe congestion relief (tablet)* $0 (Tier 3)Mucinex Stuffy Nose & Cold Childrens

mucinex stuffy nose & cold childrens (liquid)* $0 (Tier 3)Mucus Relief

mucus relief (tablet)* $0 (Tier 3)Mucus Relief Sinus

mucus relief sinus (tablet)* $0 (Tier 3)Nasal Decongestant

nasal decongestant (1% nasal solution)* $0 (Tier 3)Nasal Decongestant PE

nasal decongestant pe (tablet)* $0 (Tier 3)Nasal Decongestant Spray

nasal decongestant spray (nasal solution)* $0 (Tier 3)Night Time Multi-Symptom Cold/Flu Relief

night time multi-symptom cold/flu relief (capsule)* $0 (Tier 3)NinjaCof

ninjacof (liquid)* $0 (Tier 3)NinjaCof-A

ninjacof-a (liquid)* $0 (Tier 3)NinjaCof-XG

ninjacof-xg (liquid)* $0 (Tier 3)NoHist-DM

nohist-dm (liquid)* $0 (Tier 3)NRS Nasal Relief

nrs nasal relief (nasal solution)* $0 (Tier 3)Nucala

NUCALA (INJECTION) $3.70-$8.35 (Tier 2) PA, QL, LAOrgan-I NR

organ-i nr (tablet)* $0 (Tier 3)Pain Relief Sinus PE Daytime

pain relief sinus pe daytime (tablet)* $0 (Tier 3)Pediatric Cough/Cold

pediatric cough/cold (liquid)* $0 (Tier 3)Phenylephrine HCl/Pyrilamine Maleate

phenylephrine hcl/pyrilamine maleate (tablet)* $0 (Tier 3)Phenylhistine DH

phenylhistine dh (liquid)* $0 (Tier 3)Poly-Hist DM

poly-hist dm (liquid)* $0 (Tier 3)Poly-Vent DM

poly-vent dm (tablet)* $0 (Tier 3)Poly-Vent IR

poly-vent ir (tablet)* $0 (Tier 3)Promethazine VC Plain

promethazine vc plain (oral solution) $1.25-$3.35 (Tier 1)Promethazine VC/Codeine

promethazine vc/codeine (syrup)* $0 (Tier 3)Promethazine/Codeine

promethazine/codeine (syrup)* $0 (Tier 3)Promethazine/Dextromethorphan

promethazine/dextromethorphan (syrup)* $0 (Tier 3)Promethazine/Phenylephrine/Codeine

promethazine/phenylephrine/codeine (syrup)* $0 (Tier 3)


101


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on usePromethazine-DM

promethazine-dm (syrup)* $0 (Tier 3)Pseudoephedrine HCl

pseudoephedrine hcl (otc only) (tablet)* $0 (Tier 3)Pulmozyme

PULMOZYME (INHALATION SOLUTION) $3.70-$8.35 (Tier 2) B/D, PA, QLQC Cough/Sore Throat Nighttime

qc cough/sore throat nighttime (liquid)* $0 (Tier 3)Q-Tussin

q-tussin (oral solution)* $0 (Tier 3)Q-Tussin DM

q-tussin dm (syrup)* $0 (Tier 3)Rescon DM

rescon dm (syrup)* $0 (Tier 3)Rescon-GG

rescon-gg (liquid)* $0 (Tier 3)Respaire-30

respaire-30 (capsule)* $0 (Tier 3)Rezira

rezira (oral solution)* $0 (Tier 3)Robafen

robafen (syrup)* $0 (Tier 3)Robafen CF Multi-Symptom Cold

robafen cf multi-symptom cold (liquid)* $0 (Tier 3)Robafen Cough

robafen cough (capsule)* $0 (Tier 3)Robafen DM

robafen dm (syrup)* $0 (Tier 3)Robafen DM Cough Clear

robafen dm cough clear (syrup)* $0 (Tier 3)Robafen DM Cough/Chest Congestion

robafen dm cough/chest congestion (liquid)* $0 (Tier 3)Rynex DM

rynex dm (liquid)* $0 (Tier 3)Siltussin DM DAS

siltussin dm das (liquid)* $0 (Tier 3)Siltussin SA

siltussin sa (syrup)* $0 (Tier 3)Siltussin-DM

siltussin-dm (syrup)* $0 (Tier 3)SM Nasal Decongestant Maximum Strength

sm nasal decongestant maximum strength (otc only)

(tablet)*$0 (Tier 3)

SM Nasal Spray 12 Hour

sm nasal spray 12 hour (nasal solution)* $0 (Tier 3)SM Tussin DM

sm tussin dm (syrup)* $0 (Tier 3)SM Tussin DM Cough/Chest Congestion

sm tussin dm cough/chest congestion (syrup)* $0 (Tier 3)Stahist AD

stahist ad (tablet, liquid)* $0 (Tier 3)Stiolto Respimat

STIOLTO RESPIMAT (AEROSOL SOLUTION) $3.70-$8.35 (Tier 2) QLSudogest

sudogest (otc only) (tablet)* $0 (Tier 3)Sudogest 12 Hour

sudogest 12 hour (tablet extended-release)* $0 (Tier 3)Sudogest PE

sudogest pe (tablet)* $0 (Tier 3)Symbicort

SYMBICORT (AEROSOL) $3.70-$8.35 (Tier 2) QLTrelegy Ellipta

TRELEGY ELLIPTA (AEROSOL POWDER) $3.70-$8.35 (Tier 2) QLTussin DM

tussin dm (10mg/5ml-100mg/5ml liquid, 10mg/

5ml-100mg/5ml syrup)*$0 (Tier 3)

Tussin DM Clear

tussin dm clear (liquid)* $0 (Tier 3)Tussionex Pennkinetic Extended-Release

tussionex pennkinetic extended-release (suspension

extended-release)*$0 (Tier 3)


pages 9 and 10.




102


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useVanaCof

vanacof (liquid)* $0 (Tier 3)VanaCof DM

vanacof dm (liquid)* $0 (Tier 3)VanaCof-8

vanacof-8 (liquid)* $0 (Tier 3)Virtussin A/C

virtussin a/c (oral solution)* $0 (Tier 3)Virtussin DAC

virtussin dac (oral solution)* $0 (Tier 3)Zutripro

zutripro (oral solution)* $0 (Tier 3)

Skeletal Muscle Relaxants

Skeletal Muscle RelaxantsBaclofen

baclofen (10mg tablet, 20mg tablet, 5mg tablet) $1.25-$3.35 (Tier 1)Chlorzoxazone

chlorzoxazone (500mg tablet) $1.25-$3.35 (Tier 1)Cyclobenzaprine HCl

cyclobenzaprine hcl (tablet) $1.25-$3.35 (Tier 1)Dantrolene Sodium

dantrolene sodium (capsule) $1.25-$3.35 (Tier 1)Lioresal Intrathecal

LIORESAL INTRATHECAL (INJECTION) $3.70-$8.35 (Tier 2) B/D, PAOrphenadrine Citrate

orphenadrine citrate (injection) $1.25-$3.35 (Tier 1)Tizanidine HCl

tizanidine hcl (2mg tablet, 4mg tablet) $1.25-$3.35 (Tier 1)

Sleep Disorder Agents

GABA Receptor ModulatorsTemazepam

temazepam (15mg capsule, 30mg capsule) $1.25-$3.35 (Tier 1) QLZaleplon

zaleplon (capsule) $1.25-$3.35 (Tier 1) QLZolpidem Tartrate

zolpidem tartrate (10mg tablet immediate-release,

5mg tablet immediate-release)$1.25-$3.35 (Tier 1) QL

Sleep Disorders, OtherAcetaminophen/Diphenhydramine

acetaminophen/diphenhydramine (tablet)* $0 (Tier 3)Belsomra

BELSOMRA (TABLET) $3.70-$8.35 (Tier 2) QLHetlioz

HETLIOZ (CAPSULE) $3.70-$8.35 (Tier 2) PA, QLMapap PM

mapap pm (tablet)* $0 (Tier 3)


103


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useModafinil

modafinil (tablet) $1.25-$3.35 (Tier 1) PA, QLNight Time Sleep Aid

night time sleep aid (tablet)* $0 (Tier 3)Pain Reliever PM Extra Strength

pain reliever pm extra strength (tablet)* $0 (Tier 3)Rozerem

ROZEREM (TABLET) $3.70-$8.35 (Tier 2) QLSM Sleep Aid

sm sleep aid (tablet)* $0 (Tier 3)Xyrem

XYREM (ORAL SOLUTION) $3.70-$8.35 (Tier 2) PA, QL, LA

104


Index of Drugs

#

12 Hour Decongestant.......... 96

A

Abacavir..................................43

Abacavir Sulfate/Lamivudine/

Zidovudine........................... 43

Abacavir/Lamivudine............ 43

Abelcet....................................28

Abilify Maintena..................... 40

Abraxane................................ 33

Abstral.....................................13

Acamprosate Calcium DR.... 15

Acarbose................................ 46

Acephen................................. 10

Aceta-Gesic............................ 91

Acetaminophen......................10

Acetaminophen/Codeine......13

Acetaminophen/

Diphenhydramine..............102

Acetazolamide....................... 54

Acetazolamide ER................. 54

Acetazolamide Sodium......... 54

Acetic Acid............................. 91

Acetylcysteine........................ 96

Acid Gone.............................. 65

Acid Reducer Maximum

Strength................................67

Acitretin.................................. 58

Acne Medication 10.............. 58

Acne Medication 5.................58

Actemra.................................. 84

ActHIB.....................................84

Actidose/Sorbitol...................65

Actimmune............................. 84

Acyclovir................................. 42

Acyclovir Sodium...................42

Adacel.....................................84

Adagen................................... 70

Adapalene.............................. 58

Adcirca................................... 96

Adempas................................ 96

Adriamycin............................. 33

Adrucil.................................... 33

Advair Diskus......................... 96

Advair HFA............................. 96

Afinitor.................................... 35

Afinitor Disperz...................... 35

Akwa Tears.............................87

Ala Cort...................................72

Ala-Hist IR...............................91

Ala-Hist PE..............................91

Alahist DM.............................. 96

Albenza...................................38

Albuterol Sulfate.................... 95

Alclometasone Dipropionate 72

Alcohol Prep Pads................. 87

Aldurazyme............................ 70

Alecensa.................................35

Alendronate Sodium..............86

Alfuzosin HCl ER....................71

Alimta......................................33

Alinia....................................... 38

Aliqopa................................... 35

All Day Allergy........................91

All Day Allergy Childrens.......91

All Day Allergy-D.................... 91

All Day Pain Relief................. 11

All Day Relief..........................11

All-Nite Cold & Flu Nighttime

Relief.................................... 96

Aller-Chlor...............................91

Allergy.....................................91

Allergy Relief.......................... 91

Allergy Relief Child................ 91

Allergy Relief D-24................. 91

Allopurinol.............................. 30

Almacone............................... 65

Almacone Double Strength.. 65

Alosetron HCl.........................67

Aloxi........................................ 28

Alphagan P.............................89

Alprazolam............................. 45

Altavera...................................75

Aluminum Hydroxide.............65

Alunbrig.................................. 35

Alyacen 1/35..........................75

Amantadine HCl.....................39

AmBisome..............................28

Amethia.................................. 75

Amethia Lo............................. 75

Amikacin Sulfate....................16

Amiloride HCl.........................54

Amiloride/Hydrochlorothiazide

.............................................. 53

Aminophylline........................ 95

Aminosyn 7%/Electrolytes.... 61

Aminosyn 8.5%/Electrolytes.61

Aminosyn II.............................61

Aminosyn II 8.5%/Electrolytes

.............................................. 61

Aminosyn-HBC.......................61

Aminosyn-PF.......................... 61

105

105

Aminosyn-RF..........................61

Amiodarone HCl.................... 51

Amitiza.................................... 67

Amitriptyline HCl....................27

Amlodipine Besylate..............52

Amlodipine Besylate/

Atorvastatin Calcium...........53

Amlodipine Besylate/

Benazepril HCl.....................53

Ammonium Lactate............... 58

Amoxapine............................. 27

Amoxicillin.............................. 20

Amoxicillin/Clavulanate

Potassium............................ 20

Amoxicillin/Clavulanate

Potassium ER...................... 20

Amphetamine/

Dextroamphetamine........... 56

Amphotericin B...................... 28

Ampicillin................................20

Ampicillin Sodium..................20

Ampicillin-Sulbactam.............20

Ampyra................................... 57

Anadrol-50..............................75

Anagrelide HCl.......................49

Anastrozole............................ 35

Androderm............................. 75

AndroGel................................ 75

AndroGel Pump..................... 75

Anoro Ellipta...........................96

Antacid Calcium Extra

Strength................................65

Antacid Calcium Regular

Strength................................65

Antacid Extra Strength.......... 65

Antacid Maximum Strength.. 65

Antacid Plus Anti-Gas Relief. 65

Anti-Diarrheal..........................65

Anti-Fungal Powder............... 29

Antifungal............................... 28

Anu-Med................................. 58

Anzemet................................. 28

AP-Hist DM............................. 96

Apokyn....................................39

Apraclonidine.........................89

Aprepitant...............................28

Apri..........................................75

Apriso..................................... 85

Aprodine.................................96

Aptiom.................................... 24

Aptivus....................................44

Aralast NP...............................70

Aranelle...................................75

Aranesp Albumin Free.......... 49

Arcalyst...................................84

Argatroban............................. 48

Aripiprazole............................ 40

Aripiprazole ODT................... 40

Aristada.................................. 40

Arnuity Ellipta......................... 93

Arranon...................................33

Artificial Tears........................ 87

Ashlyna................................... 75

Aspir-Low................................11

Aspirin.....................................11

Aspirin EC...............................11

Aspirin EC Low Dose.............11

Aspirin Low Dose...................11

Aspirin Low Strength.............11

Aspirin/Dipyridamole............ 49

Atazanavir Sulfate.................. 44

Atenolol.................................. 51

Atenolol/Chlorthalidone........53

Atgam..................................... 83

Atomoxetine........................... 56

Atorvastatin Calcium............. 55

Atovaquone............................ 38

Atovaquone/Proguanil HCl...38

Atripla..................................... 43

Atropine Sulfate...............65, 87

Atrovent HFA..........................94

Aubagio.................................. 57

Aubra...................................... 75

Augmented Betamethasone

Dipropionate........................ 72

Auryxia....................................64

Austedo.................................. 57

Avandia...................................46

Avastin.................................... 37

Aviane..................................... 75

Avonex....................................57

Avonex Pen............................ 57

Azacitidine..............................49

Azactam..................................19

Azathioprine........................... 82

Azelastine HCl................. 89, 91

Azithromycin.......................... 21

Aztreonam.............................. 19

B

BACiiM....................................17

Bacitracin............................... 17

Bacitracin Zinc....................... 17

Bacitracin/Neomycin/

Polymyxin.............................17

Bacitracin/Polymyxin B.........87

106

106

Baclofen............................... 102

Bactocill in Dextrose..............20

Bactroban Nasal.................... 17

Balsalazide Disodium............ 85

Balziva.....................................75

Banophen...............................91

Banzel..................................... 24

Baraclude............................... 42

Bavencio.................................37

BCG Vaccine..........................84

Bekyree...................................75

Beleodaq................................ 35

Belsomra.............................. 102

Benazepril HCl....................... 50

Benazepril HCl/

Hydrochlorothiazide............53

Benlysta..................................84

Benznidazole..........................38

Benzonatate........................... 96

Benzoyl Peroxide...................58

Benzoyl Peroxide Cleanser...58

Benztropine Mesylate............39

Bepreve.................................. 89

Berinert................................... 81

Betamethasone Dipropionate

.............................................. 72

Betamethasone Valerate.......72

Betaseron............................... 57

Betaxolol HCl......................... 89

Bethanechol Chloride............72

Bethkis....................................95

Betimol....................................89

Bevespi Aerosphere.............. 96

Bexarotene............................. 37

Bexsero...................................84

Bicalutamide.......................... 32

Bicillin C-R.............................. 20

Bicillin L-A...............................20

BiCNU.....................................32

Biktarvy................................... 43

Biltricide..................................38

Binosto....................................86

Bisac-Evac.............................. 67

Bisacodyl EC..........................68

Biscolax.................................. 68

Bismatrol................................ 65

Bismatrol Maximum Strength

.............................................. 66

BIVIGAM.................................83

Bleomycin Sulfate..................33

Blephamide............................ 87

Blephamide S.O.P................. 87

Blisovi 24 Fe...........................75

Blisovi Fe 1.5/30.................... 75

Blisovi Fe 1/20....................... 75

Blue Gel..................................58

Boostrix...................................84

Bortezomib.............................33

Bosulif.....................................35

Botox.......................................87

Breo Ellipta.............................96

Briellyn....................................75

Brilinta.....................................49

Brimonidine Tartrate..............89

Briviact....................................23

Bromfed DM...........................97

Bromocriptine Mesylate........ 39

Bromphen/Pseudoephedrine

HCl/Dextromethorphan HBr

.............................................. 97

Brotapp...................................91

Brotapp DM............................97

Brovana.................................. 95

Budesonide......................86, 94

Budesonide ER......................86

Budesonide Nasal Spray.......94

Bumetanide............................54

Buphenyl................................ 70

Buprenorphine HCl................15

Buprenorphine HCl/Naloxone

HCl........................................15

Bupropion HCl....................... 25

Bupropion HCl SR...........16, 25

Bupropion HCl XL..................25

Buspirone HCl........................45

Busulfan..................................32

Busulfex..................................32

Butalbital/Acetaminophen....10

Butalbital/Acetaminophen/

Caffeine................................10

Butalbital/Aspirin/Caffeine... 10

Butorphanol Tartrate.......13, 14

Bydureon Bcise..................... 46

Bydureon Pen........................ 46

Bydureon Vial.........................46

Byetta......................................46

Bystolic................................... 51

C

Cabergoline............................81

Cabometyx............................. 35

Cal-Gest Antacid.................... 66

Calcipotriene..........................59

Calcitonin-Salmon..................86

Calcitriol........................... 59, 86

Calcium Acetate.....................64

107

107

Calcium Antacid.................... 66

Calcium Antacid Extra

Strength................................66

Calcium Carbonate................61

Calquence.............................. 35

Camila.....................................79

Camrese Lo............................75

Canasa....................................85

Cancidas.................................29

Candesartan Cilexetil............ 50

Candesartan Cilexetil/


Capastat Sulfate.................... 31

Caprelsa................................. 36

Capsaicin................................59

Captopril.................................50

Captopril/Hydrochlorothiazide

.............................................. 53

Carafate.................................. 69

Carbaglu.................................61

Carbamazepine......................24

Carbamazepine ER................24

Carbidopa/Levodopa............39

Carbidopa/Levodopa ER......39

Carbidopa/Levodopa ODT... 39

Carbidopa/Levodopa/

Entacapone..........................39

Carboplatin.............................33

Cardene IV..............................52

Carimune Nanofiltered.......... 83

Carteolol HCl..........................89

Cartia XT.................................52

Carvedilol................................51

Caspofungin Acetate.............29

Cayston...................................95

Caziant....................................75

Cefaclor.................................. 18

Cefadroxil............................... 19

Cefazolin Sodium.................. 19

Cefdinir................................... 19

Cefepime................................ 19

Cefixime..................................19

Cefotaxime Sodium............... 19

Cefotetan................................19

Cefoxitin Sodium................... 19

Cefpodoxime Proxetil............19

Cefprozil................................. 19

Ceftazidime............................ 19

Ceftriaxone Sodium...............19

Cefuroxime Axetil.................. 19

Cefuroxime Sodium...............19

Celontin.................................. 23

Cephalexin............................. 19

Cerezyme............................... 70

Cesamet................................. 28

Cetirizine HCl......................... 91

Cetirizine HCl Allergy Childrens

.............................................. 91

Cetirizine HCl Childrens Allergy

.............................................. 91

Cetirizine HCl/

Pseudoephedrine HCl ER.. 91

Chantix....................................16

Chantix Continuing Month Pak

.............................................. 16

Chantix Starting Month Pak..16

Chemet................................... 64

Chenodal................................ 66

Cheratussin AC......................97

Chest Congestion Relief....... 97

Chest Congestion Relief PE. 97

Chewable Antacid................. 66

Childrens Allergy................... 91

Childrens Aspirin................... 11

Childrens Ibuprofen...............11

Childrens Loratadine.............92

Childrens Mapap Rapid Tabs

.............................................. 10

Childrens Silfedrine............... 97

Childs Ibuprofen.................... 11

Chlo Tuss............................... 97

Chloramphenicol Sodium

Succinate............................. 17

Chlordiazepoxide HCl........... 45

Chlorhexidine Gluconate Oral

Rinse.................................... 58

Chloroquine Phosphate........ 38

Chlorothiazide........................54

Chlorothiazide Sodium..........54

Chlorphen SR.........................92

Chlorpromazine HCl.............. 40

Chlorthalidone....................... 54

Chlorzoxazone..................... 102

Cholbam................................. 70

Cholestyramine......................55

Cholestyramine Light............ 55

Chorionic Gonadotropin....... 74

Ciclopirox............................... 29

Ciclopirox Nail Lacquer.........29

Ciclopirox Olamine................ 29

Cidofovir................................. 41

Cilostazol................................ 49

Cimduo................................... 43

Cimetidine.............................. 67

Cimetidine HCl.......................67

108

108

Cimzia..................................... 82

Cinryze....................................81

Ciprofloxacin.......................... 21

Ciprofloxacin ER.................... 21

Ciprofloxacin HCl...................21

Ciprofloxacin I.V. in D5W...... 21

Cisplatin..................................33

Citalopram HBr...................... 26

Cladribine............................... 33

Claravis................................... 59

Clarithromycin........................21

Clarithromycin ER..................21

Climara Pro............................ 75

Clindamycin HCl.................... 17

Clindamycin Palmitate HCl... 17

Clindamycin Phosphate..17, 59

Clindamycin Phosphate in

D5W......................................17

Clindamycin/Benzoyl Peroxide

.............................................. 59

Clobetasol Propionate...........72

Clofarabine.............................33

Clomipramine HCl................. 27

Clonazepam........................... 45

Clonazepam ODT.................. 45

Clonidine HCl......................... 50

Clonidine HCl ER...................57

Clopidogrel.............................49

Clorazepate Dipotassium......45

Clotrimazole........................... 29

Clotrimazole Anti-Fungal.......29

Clotrimazole/Betamethasone

Dipropionate........................ 59

Clozapine................................41

Clozapine ODT.......................41

Coartem..................................38

Coats Aloe Creme................. 59

Coats Aloe Gelly.................... 59

Coats Aloe Moisturizing Lotion

.............................................. 59

Codeine Sulfate..................... 14

Codeine/Guaifenesin............ 97

Colchicine...............................30

Cold/Cough DM Childrens... 97

Coleman Botanicals

Insectrepellent..................... 59

Coleman Insect Repellent/

High & Dry............................59

Coleman Skinsmart Insect

Repellent..............................59

Colesevelam HCl................... 55

Colestipol HCl........................ 55

Colistimethate Sodium..........17

Colocort..................................86

Combigan...............................89

Combivent Respimat.............97

Cometriq.................................36

Complera................................43

Complete Allergy Medicine.. 92

Compro...................................27

Constulose............................. 68

Copaxone............................... 57

Corlanor..................................53

Cortisone Acetate.................. 72

Cosentyx.................................59

Cosentyx Sensoready Pen....59

Cosmegen..............................33

Cosopt PF...............................89

Cotellic....................................36

Cough DM.............................. 97

Cough Syrup.......................... 97

Coumadin...............................48

Creon...................................... 70

Crinone................................... 79

Crixivan...................................44

Cromolyn Sodium..... 66, 89, 95

Cryselle-28..............................75

Cubicin................................... 17

Cuprimine...............................72

Cutter Backwoods................. 59

Cutter Backwoods Dry.......... 59

Cutter Lemon Eucalyptus..... 59

Cuvposa..................................65

Cyclafem.................................75

Cyclobenzaprine HCl.......... 102

Cyclophosphamide............... 32

Cycloset..................................46

Cyclosporine.......................... 82

Cyclosporine Modified.......... 82

Cyproheptadine HCl..............92

Cyramza..................................36

Cystadane.............................. 70

Cystagon................................ 70

Cystaran................................. 87

Cytarabine Aqueous..............33

D

Dacarbazine........................... 32

Dactinomycin......................... 33

Daliresp...................................95

Dallergy...................................92

Dalvance.................................17

Danazol...................................75

Dantrolene Sodium............. 102

Dapsone................................. 31

109

109

Daptacel................................. 84

Daptomycin............................ 17

DARAPRIM.............................38

Darzalex..................................37

Daunorubicin HCl.................. 33

Day Time Multi-Symptom

Cold/Flu Relief.....................97

Deblitane................................ 79

Decitabine.............................. 33

Deconex DMX........................ 97

Deconex IR.............................97

Delsym....................................97

Delsym Cough + Chest

Congestion DM....................97

Delsym Cough + Chest

Congestion DM Childrens.. 97

Delsym Cough + Cold Daytime

.............................................. 97

Delsym Cough + Cold

Nighttime..............................97

Delsym Cough + Cold

Nighttime Childrens............ 97

Delyla...................................... 75

Demeclocycline HCl.............. 22

Demser................................... 53

Depen Titratabs..................... 72

Depo-Medrol.......................... 72

Depo-Provera......................... 79

Descovy.................................. 43

Desipramine HCl....................27

Desmopressin Acetate.......... 74

Desogestrel/Ethinyl Estradiol

.............................................. 75

Desonide................................ 72

Desoximetasone.................... 72

Desvenlafaxine ER.................26

Dexamethasone.....................72

Dexamethasone Intensol...... 72

Dexamethasone Sodium

Phosphate......................72, 90

Dexmethylphenidate HCl...... 57

Dexmethylphenidate HCl ER 57

Dexrazoxane.......................... 34

Dextroamphetamine Sulfate. 56

Dextromethorphan Polistirex 97

Dextrose 10%.........................61

Dextrose 10%/NaCl 0.2%..... 61

Dextrose 10%/NaCl 0.45%... 61

Dextrose 2.5%/NaCl 0.45%.. 61

Dextrose 5%........................... 61

Dextrose 5%/Lactated Ringers

.............................................. 61

Dextrose 5%/NaCl 0.2%........61

Dextrose 5%/NaCl 0.225%... 61



Dextrose 5%/NaCl 0.9%........61

Diastat AcuDial.......................23

Diastat Pediatric.....................23

Diazepam............................... 45

Diazepam Intensol................. 46

Dibucaine............................... 59

Diclofenac Potassium............11

Diclofenac Sodium....11, 59, 90

Diclofenac Sodium DR..........11

Diclofenac Sodium ER.......... 11

Dicloxacillin Sodium.............. 20

Dicyclomine HCl.................... 65

Didanosine............................. 44

Dificid......................................21

Diflunisal.................................11

Digitek.....................................53

Digox.......................................53

Digoxin....................................53

Dihydroergotamine Mesylate30

Dilantin....................................24

Dilantin INFATABS................ 24

Dilt-XR..................................... 52

Diltiazem HCl..........................52

Diltiazem HCl ER....................52

Dimaphen Childrens..............92

Dimaphen DM Cold & Cough

.............................................. 97

Diocto..................................... 68

Dipentum................................85

Diphenhist.............................. 92

Diphenhydramine HCl...........92

Diphenoxylate/Atropine........ 66

Diphtheria/Tetanus Toxoids

Adsorbed Pediatric............. 84

Disulfiram............................... 15

Diuril........................................54

Divalproex Sodium................ 46

Divalproex Sodium DR.......... 46

Divalproex Sodium ER.......... 46

Doc-Q-Lace.............................68

Doc-Q-Lax...............................68

Docetaxel................................34

Docusate Sodium & Senna

Stimulant Laxative/Stool

Softener................................68

Docusol Kids.......................... 68

Docusol Plus Mini-Enema..... 68

Dofetilide................................ 51

DOK........................................ 68

DOK PLUS..............................68

110

110

Donepezil HCl........................ 25

Donepezil HCl ODT............... 25

Doripenem..............................19

Dorzolamide HCl....................89

Dorzolamide HCl/Timolol

Maleate.................................89

Doxazosin Mesylate...............50

Doxepin HCl.....................27, 59

Doxercalciferol.......................86

Doxil........................................ 34

Doxorubicin HCl.....................34

Doxorubicin HCl Liposome...34

Doxy 100.................................22

Doxycycline............................ 22

Doxycycline Hyclate.............. 22

Doxycycline Monohydrate.... 22

Dr Smiths Diaper....................59

Dr Smiths Diaper Rash Spray

.............................................. 59

Dr Smiths Rash + Skin.......... 59

Dronabinol..............................28

Drospirenone/Ethinyl Estradiol

.............................................. 75

Droxia......................................33

Duavee....................................75

Duloxetine HCl....................... 57

Duramorph............................. 14

Durezol................................... 90

Dutasteride.............................71

Dysport................................... 87

E

E.E.S. Granules...................... 21

Econazole Nitrate...................29

Econtra EZ..............................79

ED A-Hist.......................... 92, 97

ED A-Hist DM......................... 97

ED A-Hist PSE........................ 97

ED Bron GP............................97

ED Chlorped...........................92

ED Chlorped D.......................92

ED Chlorped Jr...................... 92

ED Chlortan............................92

ED-APAP.................................10

Edurant................................... 43

Efavirenz................................. 43

Egrifta..................................... 81

Elaprase..................................70

Elelyso.................................... 70

Elestrin....................................75

Elidel....................................... 59

Eliquis..................................... 48

Eliquis Starter Pack............... 48

Elitek....................................... 38

Elmiron....................................72

Embeda.................................. 13

Emcyt......................................33

Emend.................................... 28

Emoquette..............................76

Empliciti..................................37

Emsam....................................26

Emtriva....................................44

Enalapril Maleate................... 50

Enalapril Maleate/


Enbrel..................................... 82

Enbrel SureClick.................... 82

EndaCof-DM...........................97

Endocet.................................. 14

Enema Ready-To-Use............68

Enemeez Mini.........................68

Enemeez Plus........................ 68

Engerix-B................................ 84

Enoxaparin Sodium............... 49

Enpresse-28........................... 76

Enskyce.................................. 76

Entacapone............................ 39

Entecavir.................................42

Enteric Coated Aspirin.......... 12

Entresto.................................. 53

Enulose...................................68

Envarsus XR........................... 82

Epclusa...................................42

Epinastine HCl....................... 89

Epinephrine............................95

EpiPen.................................... 95

Epirubicin HCl........................ 34

Epitol.......................................24

Epivir HBV.............................. 42

Eplerenone............................. 54

Eprosartan Mesylate..............50

Epzicom..................................44

Eraxis...................................... 29

Erbitux.....................................37

Ergotamine Tartrate/Caffeine

.............................................. 30

Erivedge..................................36

Erleada....................................32

Errin.........................................79

Erwinaze................................. 34

Ery........................................... 59

Ery-Tab....................................21

EryPed 200.............................21

EryPed 400.............................21

111

111

Erythrocin Lactobionate........21

Erythromycin....................21, 59

Erythromycin Base.................21

Erythromycin Ethylsuccinate 21

Erythromycin/Benzoyl

Peroxide............................... 59

Esbriet.....................................96

Escitalopram Oxalate............ 26

Esomeprazole Magnesium... 69

Esomeprazole Sodium.......... 69

Estarylla.................................. 76

Estradiol..................................76

Estradiol Valerate...................76

Estring.....................................76

Ethambutol HCl......................31

Ethosuximide......................... 23

Ethynodiol Diacetate/Ethinyl

Estradiol............................... 76

Etidronate Disodium..............87

Etodolac................................. 12

Etopophos..............................35

Etoposide............................... 35

Evotaz..................................... 44

Exemestane............................35

Exjade..................................... 64

Exondys 51.............................70

Extra Action Cough............... 97

Eye Drops............................... 89

Eye Itch Relief........................ 90

Ezetimibe................................55

Ezetimibe/Simvastatin...........55

F

Fabrazyme..............................70

Fallback Solo..........................79

Falmina................................... 76

Famciclovir............................. 42

Famotidine............................. 67

Famotidine Premixed............ 67

Fanapt.....................................40

Fanapt Titration Pack............ 40

Fareston..................................33

Farxiga.................................... 46

Farydak...................................36

Faslodex................................. 33

Felbamate...............................24

Femynor..................................76

Fenofibrate............................. 55

Fentanyl.................................. 13

Fentanyl Citrate Oral

Transmucosal...................... 14

Ferriprox................................. 64

Fetzima................................... 26

Fetzima Titration Pack...........26

Fexofenadine HCl.................. 92

Fexofenadine HCl Childrens

Allergy.................................. 92

Fiber Laxative.........................68

Fiber Tabs.............................. 68

Fiber-Lax.................................68

Finacea................................... 59

Finasteride..............................71

Firazyr..................................... 82

Firmagon................................ 81

Flebogamma DIF................... 83

Flecainide Acetate................. 51

Flector.....................................12

Fleet Pediatric........................ 68

Flovent Diskus........................94

Flovent HFA............................94

Flowtuss..................................97

Fluconazole............................ 29

Fluconazole in NaCl...............29

Flucytosine............................. 29

Fludarabine Phosphate......... 34

Fludrocortisone Acetate........73

Flunisolide.............................. 94

Fluocinolone Acetonide..73, 91

Fluocinonide.......................... 73

Fluocinonide Emulsified Base

.............................................. 73

Fluorometholone....................90

Fluorouracil...................... 33, 59

Fluoxetine DR.........................26

Fluoxetine HCl........................26

Fluphenazine Decanoate...... 40

Fluphenazine HCl.................. 40

Flurbiprofen............................12

Flurbiprofen Sodium..............90

Flutamide................................32

Fluticasone Propionate... 73, 94

Fluticasone Propionate/

Salmeterol............................97

Fluvastatin.............................. 55

Fluvoxamine Maleate.............26

Folic Acid................................65

Folotyn.................................... 33

Fomepizole.............................87

Fondaparinux Sodium...........49

Formula EM............................27

Forteo..................................... 87

Fosamprenavir Calcium........ 45

Fosinopril Sodium..................50

Fosinopril Sodium/


Fosphenytoin Sodium........... 24

112

112

Fosrenol..................................64

FreAmine HBC 6.9%..............62

Freshkote................................87

Fungoid Tincture................... 29

Furosemide............................ 54

Fusilev.....................................34

Fusion..................................... 62

Fuzeon.................................... 44

Fyavolv....................................76

Fycompa.................................24

G

Gabapentin.............................23

Gabitril.................................... 23

Gamastan S/D....................... 83

Gammagard Liquid................83

Gammagard S/D IGA Less

Than 1 mcg/ml.................... 83

Gammaked.............................83

Gammaplex............................83

Gamunex-C............................ 83

Ganciclovir............................. 41

Gardasil 9............................... 84

Gas Relief............................... 66

Gas Relief Extra Strength......66

Gas Relief Maximum Strength

.............................................. 66

Gattex..................................... 66

Gauze......................................87

GaviLyte-C.............................. 68

GaviLyte-G.............................. 68

GaviLyte-N/Flavor Pack.........68

Gemcitabine HCl................... 33

Gemfibrozil............................. 55

Generlac................................. 68

Gengraf...................................82

Genotropin............................. 74

Genotropin Miniquick............74

Gentak.................................... 17

Gentamicin Sulfate................ 17

Gentamicin Sulfate/0.9%

Sodium Chloride................. 17

Genvoya..................................43

Geodon...................................40

Gianvi......................................76

Gilenya....................................57

Gilotrif..................................... 36

Glassia.................................... 70

Glatiramer Acetate.................58

Glatopa................................... 58

Gleostine................................ 32

Glimepiride.............................46

Glipizide..................................46

Glipizide ER............................47

Glipizide/Metformin HCl....... 47

GlucaGen HypoKit.................47

Glucagon Emergency Kit...... 47

Glycopyrrolate........................65

Glyxambi.................................47

GNP All Day Allergy...............92

GNP Allergy............................92

GNP Antacid Anti-Gas........... 66

GNP Arthritis Pain Relief....... 10

GNP Dayhist Allergy.............. 92

GNP Ibuprofen.......................12

GNP Ibuprofen Junior Strength

.............................................. 12

GNP Loratadine..................... 92

GNP Masanti Maximum

Strength................................66

GNP Masanti Regular Strength

.............................................. 66

GNP Omeprazole...................69

GNP Tussin............................ 98

GNP Tussin DM..................... 98

Goodsense Ibuprofen........... 12

Goodsense Ibuprofen

Childrens..............................12

Goodsense Ibuprofen Infants

.............................................. 12

Granisetron HCl..................... 28

Griseofulvin Microsize........... 29

Griseofulvin Ultramicrosize... 29

Guaifenesin AC......................98

Guaifenesin and

Pseudoephedrine HCl.........98

Guaifenesin ER...................... 98

Guaifenesin/Codeine............ 98

Guaifenesin/

Dextromethorphan HBr...... 98

Guanfacine ER.......................57

Guanidine HCl........................31

H

Haegarda................................82

Halaven...................................34

Halobetasol Propionate.........73

Haloperidol.............................40

Haloperidol Decanoate......... 40

Haloperidol Lactate............... 40

Harvoni................................... 42

Havrix......................................84

Heartburn Treatment 24 Hour

.............................................. 69

Hemorrhoidal......................... 59

Heparin Sodium.....................49

Heparin Sodium/D5W...........49

113

113

HepatAmine........................... 62

Herceptin................................37

Hetlioz...................................102

Hexalen...................................32

Hiberix.....................................84

Histex...................................... 92

Histex PD................................92

Histex-DM............................... 98

Histex-PE................................ 98

Humalog Cartridge................ 47

Humalog Junior KwikPen......47

Humalog KwikPen................. 48

Humalog Mix 50/50 KwikPen

.............................................. 48

Humalog Mix 50/50 Vial........48

Humalog Mix 75/25 KwikPen

.............................................. 48

Humalog Mix 75/25 Vial........48

Humalog Vial..........................48

Humatrope............................. 74

Humatrope Combo Pack...... 74

Humira.................................... 82

Humira Pediatric Crohns

Disease Starter Pack...........82

Humira Pen............................ 82

Humira Pen Crohns Disease

Starter Pack......................... 82

Humira Pen Psoriasis Starter82

Humulin 70/30 KwikPen....... 48

Humulin 70/30 Vial................48

Humulin N KwikPen...............48

Humulin N Vial....................... 48

Humulin R U-500 KwikPen....48

Humulin R U-500 Vial............ 48

Humulin R Vial....................... 48

Hycofenix................................98

Hydralazine HCl..................... 55

Hydrochlorothiazide.............. 54

Hydrocodone Bitartrate/

Chlorpheniramine Maleate/

PSE.......................................98

Hydrocodone Bitartrate/

Homatropine Methylbromide

.............................................. 98

Hydrocodone Polistirex/

Chlorpheniramine Polistirex

.............................................. 98

Hydrocodone/Acetaminophen

.............................................. 14

Hydrocodone/Ibuprofen....... 14

Hydrocortisone................ 73, 86

Hydrocortisone Butyrate....... 73

Hydrocortisone Valerate....... 73

Hydrocortisone/Acetic Acid. 91

Hydrocortisone/Aloe............. 60

Hydromet................................98

Hydromorphone HCl............. 14

Hydromorphone HCl ER....... 13

Hydroxychloroquine Sulfate. 38

Hydroxyprogesterone

Caproate.............................. 79

Hydroxyurea...........................33

Hydroxyzine HCl.................... 45

Hydroxyzine Pamoate........... 27

Hysingla ER............................13

I

Ibrance....................................36

Ibu........................................... 12

Ibu-200....................................12

Ibu-Drops................................12

Ibu-Drops Infants................... 12

Ibuprofen................................ 12

Ibuprofen Childrens...............12

Ibuprofen Junior Strength.....12

Iclusig......................................36

Idarubicin HCl........................ 34

Idhifa....................................... 36

Ifosfamide...............................32

Ilaris.........................................84

Ilevro....................................... 90

Imatinib Mesylate...................36

Imbruvica................................36

Imfinzi..................................... 37

Imipenem/Cilastatin.............. 19

Imipramine HCl...................... 27

Imipramine Pamoate............. 27

Imiquimod.............................. 60

Imovax Rabies........................85

Incassia...................................79

Increlex................................... 74

Incruse Ellipta.........................94

Indapamide............................ 54

Indomethacin......................... 12

Infanrix.................................... 85

Infants Gas Relief...................66

Infants Ibuprofen....................12

Infants Simethicone...............66

Infed........................................62

Ingrezza.................................. 57

Inlyta........................................36

Insulin Syringes, Needles......87

Intelence.................................43

Intralipid..................................62

Intron A................................... 42

Introvale.................................. 76

114

114

Invanz......................................19

Invega Sustenna.................... 40

Invega Trinza..........................40

Invirase................................... 45

Ionosol-MB/Dextrose 5%...... 62

IPOL Inactivated IPV..............85

Ipratropium Bromide............. 94

Ipratropium Bromide/Albuterol

Sulfate.................................. 98

Irbesartan............................... 50

Irbesartan/Hydrochlorothiazide

.............................................. 53

Iressa...................................... 36

Irinotecan................................34

Isentress................................. 43

Isentress HD...........................43

Isibloom.................................. 76

Isolyte-P/Dextrose 5%........... 62

Isolyte-S.................................. 62

Isoniazid..................................31

Isopto Tears........................... 88

Isosorbide Dinitrate............... 56

Isosorbide Dinitrate ER......... 56

Isosorbide Mononitrate......... 56

Isosorbide Mononitrate ER... 56

Isotonic Gentamicin...............17

Isotretinoin..............................60

Istodax.................................... 34

Itraconazole............................29

Ivermectin...............................38

Ixiaro....................................... 85

J

Jadenu....................................64

Jadenu Sprinkle.....................64

Jakafi.......................................36

Jantoven................................. 49

Jardiance................................47

Jentadueto............................. 47

Jentadueto XR....................... 47

Jevtana................................... 36

Jinteli.......................................76

Jolivette...................................79

Jublia...................................... 29

Juleber....................................76

Juluca..................................... 43

Junel 1.5/30........................... 76

Junel 1/20.............................. 76

Junel Fe 1.5/30......................76

Junel Fe 1/20......................... 76

Junel Fe 24.............................76

Junior Mapap......................... 10

Juxtapid.................................. 55

K

Kadcyla...................................37

Kaitlib Fe.................................76

Kaletra.....................................45

Kalydeco.................................95

Kanuma.................................. 70

Kao-Tin....................................66

Kariva...................................... 76

KCl 0.075%/D5W/NaCl 0.45%

.............................................. 62

KCl 0.15%/D5W/NaCl 0.2%..62

KCl 0.15%/D5W/NaCl 0.45%

.............................................. 62

KCl 0.15%/D5W/NaCl 0.9%..62

KCl 0.3%/D5W/NaCl 0.45%..62

KCl 0.3%/D5W/NaCl 0.9%....62

Kelnor 1/35............................ 76

Kelnor 1/50............................ 77

Kenalog-10............................. 73

Kenalog-40............................. 73

Kepivance...............................58

Ketoconazole......................... 29

Ketorolac Tromethamine 12, 90

Keytruda................................. 37

Kidkare Cough/Cold............. 98

Kimidess.................................77

Kineret.................................... 82

Kinrix.......................................85

Kionex.....................................64

Kisqali..................................... 34

Kisqali Femara 200 Dose...... 34



Klor-Con..................................62

Klor-Con 10............................ 62

Klor-Con 8...............................62

Klor-Con M10......................... 62

Klor-Con M15......................... 62

Klor-Con M20......................... 62

Klor-Con Sprinkle...................62

Kombiglyze XR.......................47

Korlym.....................................74

Kurvelo....................................77

Kuvan......................................71

Kynamro................................. 55

Kyprolis...................................35

L

Labetalol HCl..........................51

Lacrisert..................................88

Lactated Ringers Irrigation... 62

Lactated Ringers Viaflex....... 62

Lactulose................................ 68

115

115

Lamivudine.......................42, 44

Lamivudine/Zidovudine........ 44

Lamotrigine............................ 24

Lanoxin................................... 53

Lansoprazole..........................69

Lanthanum Carbonate.......... 64

Lantus SoloStar..................... 48

Lantus Vial..............................48

Larin 1.5/30............................77

Larin 1/20...............................77

Larin Fe 1.5/30.......................77

Larin Fe 1/20..........................77

Larissia....................................77

Lartruvo.................................. 37

Lastacaft................................. 88

Latanoprost............................ 90

Latuda.....................................41

Laxative...................................68

Layolis Fe............................... 77

Leena...................................... 77

Leflunomide........................... 84

Lenvima.................................. 36

Lessina................................... 77

Letairis.................................... 96

Letrozole.................................35

Leucovorin Calcium...............34

Leukeran.................................32

Leukine................................... 49

Leuprolide Acetate................ 81

Levalbuterol............................95

Levemir FlexTouch................ 48

Levemir Vial............................48

Levetiracetam.........................23

Levetiracetam ER...................23

Levobunolol HCl.................... 89

Levocarnitine..........................62

Levocetirizine Dihydrochloride

.............................................. 92

Levofloxacin........................... 21

Levofloxacin in D5W..............21

Levoleucovorin.......................34

Levonest................................. 77

Levonorgestrel....................... 79

Levonorgestrel and Ethinyl

Estradiol............................... 77

Levonorgestrel/Ethinyl

Estradiol............................... 77

Levora 0.15/30-28................. 77

Levorphanol Tartrate............. 13

Levothyroxine Sodium...........80

Levoxyl....................................80

Lexiva......................................45

Lialda...................................... 85

Lidocaine..........................15, 60

Lidocaine HCl.........................15

Lidocaine Viscous................. 15

Lidocaine/Prilocaine............. 15

Lincomycin HCl......................17

Lindane...................................38

Linezolid................................. 17

Linzess....................................67

Lioresal Intrathecal.............. 102

Liothyronine Sodium............. 80

Liquitears................................88

Lisinopril................................. 50

Lisinopril/Hydrochlorothiazide

.............................................. 53

Lithium....................................46

Lithium Carbonate.................46

Lithium Carbonate ER...........46

Lithostat..................................72

Livalo.......................................55

Lodrane D...............................92

LoHist-D.................................. 92

LoHist-DM...............................98

Lonsurf....................................34

Loperamide HCl.....................66

Lopinavir/Ritonavir................ 45

Loratadine.............................. 92

Loratadine Childrens.............92

Loratadine Hives Relief......... 93

Loratadine-D 12hr..................93

Loratadine-D 24hr..................93

Lorazepam............................. 46

Lorcet......................................14

Lorcet HD............................... 14

Lorcet Plus............................. 14

Lortuss DM.............................98

Lortuss EX.............................. 98

Lortuss LQ..............................93

Loryna.....................................77

Losartan Potassium...............50

Losartan Potassium/


Lotemax..................................90

Lovastatin............................... 55

Low-Ogestrel.......................... 77

Loxapine Succinate...............40

Lubricant Eye Drops..............88

Lubricating Plus Eye Drops.. 88

Lubrifresh P.M....................... 88

Lumigan..................................90

Lumizyme............................... 71

116

116

Lupaneta Pack....................... 81

Lupron Depot.........................81

Lupron Depot-Ped................. 81

Lutera......................................77

Lynparza.................................36

Lyrica...................................... 57

Lysodren.................................81

Lyza.........................................79

M

M-END DMX........................... 98

M-M-R II...................................85

Magnesium Oxide........... 62, 66

Magnesium Sulfate................62

Major-Prep Hemorrhoidal......60

Makena...................................79

Malathion................................39

Mapap.....................................11

Mapap Acetaminophen Extra

Strength................................11

Mapap Arthritis Pain..............11

Mapap Childrens................... 11

Mapap Cold Formula Multi-

Symptom..............................98

Mapap PM............................102

Mapap Sinus Maximum

Strength Congestion and

Pain.......................................98

Maprotiline HCl...................... 26

Marlissa.................................. 77

Marplan...................................26

Matulane.................................32

Matzim LA.............................. 52

Mavyret................................... 42

Meclizine HCl......................... 27

Medroxyprogesterone Acetate

........................................79, 80

Mefloquine HCl...................... 38

Megace ES............................. 80

Megestrol Acetate................. 80

Mekinist.................................. 36

Melodetta 24 Fe.....................77

Meloxicam.............................. 12

Melphalan HCl....................... 32

Memantine HCl...................... 25

Memantine HCl ER................ 25

Memantine HCl Titration Pak25

Menactra................................ 85

Menest....................................77

Mentax.................................... 29

Menveo...................................85

Mephyton............................... 65

Mercaptopurine..................... 33

Meropenem............................19

Mesalamine............................85

Mesalamine DR......................86

Mesna..................................... 38

Mesnex................................... 38

Mestinon.................................31

Metformin HCl........................47

Metformin HCl ER..................47

Methadone HCl......................13

Methazolamide...................... 54

Methenamine Hippurate....... 17

Methimazole...........................81

Methotrexate.......................... 82

Methotrexate Sodium............82

Methoxsalen...........................60

Methscopolamine Bromide.. 65

Methyclothiazide....................54

Methyldopa............................ 50

Methyldopa/


Methyldopate HCl..................50

Methylphenidate HCl.............57

Methylphenidate HCl ER.......57

Methylprednisolone...............73

Methylprednisolone Acetate.73

Methylprednisolone Dose Pack

.............................................. 73

Methylprednisolone Sodium

Succinate............................. 73

Metipranolol........................... 89

Metoclopramide HCl............. 27

Metolazone.............................54

Metoprolol Succinate ER...... 51

Metoprolol Tartrate................51

Metoprolol/


Metronidazole........................ 18

Metronidazole in NaCl 0.79%

.............................................. 18

Metronidazole Vaginal...........18

Mexiletine HCl........................51

Mi-Acid....................................66

Mi-Acid Gas Relief................. 66

Mi-Acid Maximum Strength.. 66

Miacalcin................................ 87

Mibelas 24 Fe.........................77

Miconazole 3..........................29

Miconazole 7..........................29

Miconazole Nitrate.................29

Microgestin 1.5/30................ 77

Microgestin 1/20................... 77

117

117

Microgestin Fe....................... 77

Microgestin Fe 1.5/30........... 77

Midodrine HCl........................50

Migergot................................. 30

Miglustat.................................71

Migraine Formula...................12

Mili...........................................77

Milk of Magnesia....................68

Milk of Magnesia Concentrate

.............................................. 68

Minitran...................................56

Minocycline HCl.....................22

Minoxidil................................. 55

Mintox Maximum Strength....66

Mirtazapine.............................25

Mirtazapine ODT....................26

Mirvaso................................... 60

Misoprostol............................ 69

Mitomycin...............................34

Mitoxantrone HCl...................34

Modafinil...............................103

Moexipril HCl..........................51

Moexipril/Hydrochlorothiazide

.............................................. 53

Moisturel Therapeutic........... 60

Mometasone Furoate............ 73

MonoNessa............................ 77

Montelukast Sodium............. 94

Morphine Sulfate................... 14

Morphine Sulfate ER............. 13

Moxeza................................... 21

Moxifloxacin HCl/Sodium HCl

.............................................. 21

Moxifloxacin HCl....................21

Mozobil................................... 49

Mucinex.................................. 99

Mucinex Chest Congestion

Childrens..............................99

Mucinex Childrens Cold

Cough & Sore Throat.......... 99

Mucinex Childrens Multi-

Symptom Cold.....................99

Mucinex Childrens Multi-

Symptom Cold & Fever.......99

Mucinex Congestion & Cough

Childrens..............................99

Mucinex Cough Childrens.... 99

Mucinex Cough for Kids....... 99

Mucinex D.............................. 99

Mucinex D Maximum Strength

.............................................. 99

Mucinex DM........................... 99

Mucinex DM Maximum

Strength................................99

Mucinex Fast-Max Cold &

Sinus.....................................99

Mucinex Fast-Max Cold Flu &

Sore Throat.......................... 99

Mucinex Fast-Max Day Time/

Night Time........................... 99

Mucinex Fast-Max Day/Night

Maximum Strength..............99

Mucinex Fast-Max DM Max...99

Mucinex Fast-Max Night Time

Cold & Flu............................ 99

Mucinex Fast-Max Severe Cold

.............................................. 99

Mucinex Fast-Max Severe

Congestion & Cough...........99

Mucinex for Kids....................99

Mucinex Maximum Strength.99

Mucinex Multi-Symptom Cold

Day/Night Pack................... 99

Mucinex Multi-Symptom Cold

Night Time Childrens.......... 99

Mucinex Sinus-Max Day/Night

.............................................. 99

Mucinex Sinus-Max Full Force

............................................ 100

Mucinex Sinus-Max Pressure &

Pain.................................... 100

Mucinex Sinus-Max Severe

Congestion Relief..............100

Mucinex Stuffy Nose & Cold

Childrens............................100

Mucus Relief........................ 100

Mucus Relief Sinus..............100

Multaq.....................................51

Mupirocin............................... 18

Muro 128................................ 88

Mustargen.............................. 32

My Way................................... 80

Myalept................................... 66

Mycamine...............................29

Mycophenolate Mofetil..........82

Mycophenolic Acid DR......... 82

Mylotarg..................................37

Myrbetriq................................ 71

MYTAB GAS...........................66

MYTAB GAS Maximum

Strength................................67

N

Nadolol................................... 51

Nafcillin Sodium.....................20

Naglazyme..............................71

Nalbuphine HCl......................14

Naloxone HCl......................... 16

Naltrexone HCl.......................15

Namenda XR..........................25

118

118

Namenda XR Titration Pack. 25

Namzaric................................ 57

Naproxen................................13

Naproxen DR......................... 13

Naratriptan HCl...................... 31

Narcan.................................... 16

Nasal Decongestant............ 100

Nasal Decongestant PE...... 100

Nasal Decongestant Spray. 100

Nasopen PE........................... 93

Natacyn...................................29

Nateglinide............................. 47

Natpara...................................87

Natrapel 12-Hour Tick & Insect

Repellent Continuous Spray

.............................................. 60

Natural Balance Tears...........88

Natural Fiber Therapy............68

Natures Tears.........................88

Nebupent................................38

Necon 0.5/35-28....................77

Necon 7/7/7...........................77

Nefazodone HCl.....................26

Neomycin Sulfate.................. 17

Neomycin/Bacitracin/

Polymyxin.............................88

Neomycin/Polymyxin B

Sulfates................................ 18

Neomycin/Polymyxin/

Bacitracin/Hydrocortisone. 88

Neomycin/Polymyxin/

Dexamethasone.................. 88

Neomycin/Polymyxin/

Gramicidin............................88

Neomycin/Polymyxin/

Hydrocortisone..............88, 91

Nephramine............................62

Nerlynx....................................36

Neulasta..................................49

Neupro....................................39

Nevanac..................................90

Nevirapine.............................. 43

Nevirapine ER........................ 43

Nexavar...................................36

Nexium....................................70

Next Choice One Dose..........80

Niacin ER................................55

Niacor..................................... 55

Nicardipine HCl......................52

NicoDerm CQ.........................16

NICOrelief...............................16

Nicorette.................................16

Nicorette Mini.........................16

Nicorette Starter Kit............... 16

Nicotine Polacrilex.................16


.............................................. 16


Step 1................................... 16


Step 2................................... 16


Step 3................................... 16

Nicotrol................................... 16

Night Time Multi-Symptom

Cold/Flu Relief.................. 100

Night Time Sleep Aid.......... 103

Nikki........................................ 77

Nilandron................................32

Nilutamide.............................. 32

Nimodipine.............................52

NinjaCof................................100

NinjaCof-A............................ 100

NinjaCof-XG..........................100

Ninlaro.................................... 34

Nipent..................................... 33

Nitro-Bid..................................56

Nitrofurantoin......................... 18

Nitrofurantoin Macrocrystals 18

Nitrofurantoin Monohydrate. 18

Nitroglycerin...........................56

Nitroglycerin Lingual............. 56

Nitroglycerin Transdermal.... 56

Nitrostat.................................. 56

NoHist-DM............................100

NoHist-LQ............................... 93

Nora-BE.................................. 80

Norditropin FlexPro............... 74

Norethindrone........................80

Norethindrone Acetate..........80

Norethindrone Acetate/Ethinyl

Estradiol............................... 77

Norethindrone Acetate/Ethinyl

Estradiol/Ferrous Fumarate

.............................................. 78

Norethindrone/Ethinyl

Estradiol/Ferrous Fumarate

.............................................. 78

Norgestimate/Ethinyl Estradiol

.............................................. 78

Norlyroc.................................. 80

Normosol-M in D5W.............. 62

Normosol-R............................ 63

Normosol-R in D5W...............63

Northera..................................50

Nortrel 0.5/35.........................78

Nortrel 1/35............................78

119

119

Nortrel 7/7/7.......................... 78

Nortriptyline HCl.................... 27

Norvir...................................... 45

Novarel....................................74

Noxafil.....................................29

NRS Nasal Relief................. 100

Nucala.................................. 100

Nucynta ER............................ 13

Nuedexta................................ 57

Nulojix.....................................83

Nuplazid................................. 41

Nutrilipid................................. 63

Nutropin AQ........................... 74

NuvaRing................................78

Nyamyc...................................29

Nymalize................................. 52

Nystatin...................................29

Nystop.....................................30

O

Ocaliva.................................... 71

Ocella......................................78

Octagam.................................83

Octreotide Acetate................ 81

Odefsey.................................. 43

Odomzo..................................36

Ofev.........................................96

Off Deep Woods.................... 60

Off Deep Woods Dry............. 60

Off Deep Woods Sportsmen.60

Ofloxacin................................ 22

Ogestrel.................................. 78

Olanzapine............................. 41

Olanzapine ODT.................... 41

Olmesartan Medoxomil.........50

Olmesartan Medoxomil/


Olopatadine HCl.................... 89

Omega-3-Acid Ethyl Esters... 55

Omeprazole............................70

Omeprazole Magnesium.......70

Ondansetron HCl...................28

Ondansetron ODT................. 28

Onfi......................................... 23

Onglyza...................................47

Opcicon One-Step................. 80

Opdivo.................................... 37

Opsumit.................................. 96

Opti-Clear............................... 89

Orencia................................... 83

Orencia Clickject................... 83

Orenitram............................... 96

Orfadin....................................71

Organ-I NR........................... 100

Orkambi..................................95

Orphenadrine Citrate.......... 102

Orsythia.................................. 78

Oseltamivir Phosphate.......... 45

Osphena................................. 80

Otezla......................................84

Oxacillin Sodium....................20

Oxaliplatin...............................34

Oxandrolone.......................... 75

Oxcarbazepine.......................25

Oxsoralen Ultra...................... 60

Oxybutynin Chloride..............71

Oxybutynin Chloride ER........71

Oxycodone HCl......................15

Oxycodone/Acetaminophen 15

Oxycodone/Aspirin............... 15

Oxycodone/Ibuprofen...........15

P

Pacerone................................ 51

Paclitaxel................................ 34

Pain & Fever........................... 11

Pain & Fever Childrens..........11

Pain & Fever Extra Strength..11

Pain & Fever Infants...............11

Pain Relief Sinus PE Daytime

............................................ 100

Pain Reliever PM Extra

Strength............................. 103

Pain Relieving Cream............60

Paliperidone ER..................... 41

Palonosetron HCl...................28

Pamidronate Disodium..........87

Panretin.................................. 37

Pantoprazole Sodium............70

Paricalcitol..............................87

Paromomycin Sulfate............ 17

Paroxetine HCl....................... 26

Paser.......................................31

Paxil........................................ 26

Pazeo...................................... 89

Pediarix...................................85

Pediatric Cough/Cold......... 100

Pedvax HIB.............................85

PEG 3350............................... 69

PEG 3350/Electrolytes..........69

PEG-3350/Electrolytes.......... 69

PEG-3350/NaCl/Na

Bicarbonate/KCl..................69

Peganone............................... 25

Pegasys.................................. 42

120

120

Pegasys ProClick...................42

Penicillin G Potassium...........20

Penicillin G Procaine............. 20

Penicillin G Sodium............... 20

Penicillin V Potassium........... 21

Pentam 300............................ 38

Pentoxifylline ER....................53

Peptic Relief........................... 67

Perforomist.............................95

Perindopril Erbumine............ 51

Periogard................................58

Perjeta.....................................37

Permethrin..............................39

Perphenazine......................... 27

Phenadoz............................... 93

Phenelzine Sulfate................. 26

Phenobarbital.........................23

Phenoxybenzamine HCl........50

Phenylephrine HCl/Pyrilamine

Maleate.............................. 100

Phenylhistine DH................. 100

Phenytek.................................25

Phenytoin................................25

Phenytoin Sodium................. 25

Phenytoin Sodium Extended 25

Phoslyra..................................64

Phospholine Iodide................89

Physiolyte............................... 63

Physiosol Irrigation................ 63

Picato......................................60

Pilocarpine HCl................58, 89

Pimozide.................................40

Pimtrea................................... 78

Pindolol...................................51

Pink Bismuth.......................... 67

Pioglitazone HCl.................... 47

Pioglitazone HCl/Glimepiride

.............................................. 47

Pioglitazone HCl/Metformin

HCl........................................47

Piperacillin/Tazobactam....... 21

Pirmella 1/35..........................78

Plasma-Lyte A........................ 63

Plasma-Lyte-148.....................63

Plenamine...............................63

Podofilox.................................60

Poly-Hist DM.........................100

Poly-Hist PD............................93

Poly-Vent DM....................... 100

Poly-Vent IR..........................100

Polyethylene Glycol 3350

Powder................................. 69

Polymyxin B Sulfate...............18

Polymyxin B Sulfate/

Trimethoprim Sulfate.......... 88

Pomalyst.................................32

Portia-28................................. 78

Potassium Chloride............... 63

Potassium Chloride CR.........63

Potassium Chloride ER......... 63

Potassium Chloride/Dextrose

.............................................. 63

Potassium Chloride/Dextrose/

Lactated Ringers................. 63

Potassium Chloride/Dextrose/

Sodium Chloride................. 63

Potassium Chloride/Sodium

Chloride................................63

Potassium Citrate ER............ 63

Povidone-Iodine..................... 18

Praluent.................................. 55

Pramipexole Dihydrochloride

.............................................. 39

Prasugrel................................ 49

Pravastatin Sodium................55

Prazosin HCl...........................50

Prednicarbate.........................73

Prednisolone.......................... 73

Prednisolone Acetate............ 90

Prednisolone Sodium

Phosphate......................73, 90

Prednisone............................. 73

Prednisone Intensol...............73

Pregnyl w/Diluent Benzyl

Alcohol/NaCl....................... 74

Premarin................................. 78

Premasol................................ 63

Premphase............................. 78

Prempro..................................78

Prevalite..................................55

Previfem..................................78

Prezcobix................................45

Prezista................................... 45

Priftin.......................................31

Primaquine Phosphate..........38

Primidone............................... 23

Privigen...................................83

ProAir HFA............................. 95

ProAir RespiClick...................95

Probenecid.............................30

Probenecid/Colchicine......... 30

Procainamide HCl..................51

Procalamine........................... 63

Prochlorperazine................... 27

Prochlorperazine Edisylate... 27

121

121

Prochlorperazine Maleate.....27

Procrit..................................... 49

Procto-Med HC...................... 86

Procto-Pak..............................86

Proctosol HC..........................86

Proctozone-HC.......................86

Procysbi..................................71

Proglycem.............................. 47

Prograf....................................83

Prolastin-C.............................. 71

Prolensa..................................90

Proleukin................................ 34

Prolia.......................................87

Promacta................................ 49

Promethazine HCl..................93

Promethazine VC Plain....... 100

Promethazine VC/Codeine.100

Promethazine-DM................ 101

Promethazine/Codeine.......100

Promethazine/

Dextromethorphan............100

Promethazine/Phenylephrine/

Codeine..............................100

Promethegan......................... 93

Propafenone HCl................... 51

Propafenone HCl ER............. 51

Proparacaine HCl.................. 88

Propranolol HCl............... 51, 52

Propranolol HCl ER............... 52

Propranolol/


Propylthiouracil...................... 81

ProQuad................................. 85

Prosol......................................63

Protriptyline HCl.....................27

Prudoxin................................. 60

Pseudoephedrine HCl.........101

Pulmozyme...........................101

Puralube................................. 88

Purixan....................................33

Pyrazinamide..........................31

Pyridostigmine Bromide........31

Pyridostigmine Bromide ER..31

Q

Q-Dryl...................................... 93

Q-PAP..................................... 11

Q-PAP Childrens.................... 11

Q-PAP Extra Strength............ 11

Q-Tussin............................... 101

Q-Tussin DM........................ 101

QC Anti-Diarrheal...................67

QC Arthritis Pain Relief..........11

QC Cough/Sore Throat

Nighttime........................... 101

QC Loratadine Allergy Relief 93

QC Loratadine-D.................... 93

QC Naproxen Sodium........... 13

QC Tolnaftate.........................30

Quadracel...............................85

Quasense............................... 78

Quetiapine Fumarate.............41

Quetiapine Fumarate ER.......41

Quinapril HCl..........................51

Quinapril/Hydrochlorothiazide

.............................................. 53

Quinidine Gluconate..............51

Quinidine Gluconate CR....... 51

Quinidine Sulfate................... 51

Quinine Sulfate...................... 38

R

Rabavert................................. 85

Rabeprazole Sodium.............70

Raloxifene HCl....................... 80

Ramipril.................................. 51

Ranexa....................................53

Ranitidine 150 Maximum

Strength................................67

Ranitidine 75.......................... 67

Ranitidine HCl........................ 67

Ranitidine Maximum Strength

.............................................. 67

Rapaflo................................... 71

Rapamune..............................83

Rasagiline Mesylate...............39

Ravicti..................................... 71

Rebif....................................... 58

Rebif Rebidose...................... 58

Rebif Rebidose Titration Pack

.............................................. 58

Rebif Titration Pack............... 58

Reclipsen................................78

Recombivax HB..................... 85

Refresh Celluvisc...................88

Refresh Lacri-Lube................ 88

Refresh Plus...........................88

Regranex................................ 60

Reguloid................................. 69

Relenza Diskhaler..................45

Relistor....................................67

Remicade............................... 83

Remodulin..............................96

Renagel.................................. 65

Renvela...................................65

Repaglinide............................ 47

122

122

Repaglinide/Metformin HCl..47

Repatha.................................. 55

Repatha Pushtronex System 55

Repatha SureClick.................55

Repel Huniters Formula........ 60

Repel Lemon Eucalyptus

Insect Repellent...................60

Repel Sportsmen...................60

Repel Sportsmen Dry............ 60

Repel Sportsmen Max...........60

Rescon....................................93

Rescon DM.......................... 101

Rescon-GG...........................101

Rescriptor...............................43

Respaire-30.......................... 101

Restasis.................................. 88

Retrovir IV Infusion................ 44

Revlimid..................................33

Rexulti.....................................41

Reyataz................................... 45

Rezira....................................101

Rhopressa.............................. 88

Ribasphere.............................42

Ribavirin..................................42

Ridaura................................... 84

Rifabutin................................. 31

Rifampin................................. 31

Rifater..................................... 31

Riluzole................................... 57

Rimantadine HCl....................45

Ringers Injection....................63

Ringers Irrigation................... 63

Riomet.................................... 47

Risperdal Consta................... 41

Risperidone............................41

Risperidone ODT................... 41

Ritonavir................................. 45

Rituxan....................................37

Rivastigmine Tartrate............ 25

Rivastigmine Transdermal

System..................................25

Rizatriptan Benzoate............. 31

Rizatriptan Benzoate ODT.... 31

Robafen................................101

Robafen CF Multi-Symptom

Cold....................................101

Robafen Cough................... 101

Robafen DM.........................101

Robafen DM Cough Clear.. 101

Robafen DM Cough/Chest

Congestion........................ 101

Ropinirole HCl........................39

Rosuvastatin Calcium............55

Rotarix.................................... 85

RotaTeq..................................85

Rowasa................................... 86

Roweepra............................... 23

Roweepra XR......................... 23

Rozerem............................... 103

Ru-Hist D................................ 93

Rubraca.................................. 35

Ruconest................................ 82

Rulox.......................................67

Rydapt.................................... 36

Rymed.................................... 93

Rynex DM.............................101

Rynex PE................................ 93

Rynex PSE..............................93

S

S2............................................ 95

Sabril.......................................23

Saizen..................................... 74

Saizenprep Reconstitution Kit

.............................................. 74

Samsca...................................64

Sancuso..................................28

Sandimmune..........................83

Sandostatin LAR Depot.........81

Sani-Supp Adult..................... 69

Sani-Supp Pediatric............... 69

Santyl...................................... 60

Saphris....................................41

Savella.................................... 57

Savella Titration Pack............57

Sawyer Premium Insect

Repellent..............................60

Scopolamine.......................... 28

Selegiline HCl.........................39

Selenium Sulfide....................60

Selzentry.................................44

Senexon..................................69

Senna......................................69

Senna Lax...............................69

Senna Plus............................. 69

Senna-Lax...............................69

Sennalax-S..............................69

Sensipar..................................87

Serevent Diskus..................... 95

Serostim................................. 67

Sertraline HCl.........................26

Setlakin...................................78

Sevelamer Carbonate............65

Sharobel................................. 80

123

123

Shingrix...................................85

Signifor................................... 81

Siladryl Allergy....................... 93

Sildenafil.................................96

Silphen Cough....................... 93

Siltussin DM DAS.................101

Siltussin SA.......................... 101

Siltussin-DM......................... 101

Silver Sulfadiazine................. 22

Simethicone........................... 67

Simponi.................................. 83

Simponi Aria...........................83

Simulect..................................84

Simvastatin.............................55

Sirolimus.................................83

Sirturo..................................... 31

SM Allergy 4 Hour..................93

SM Allergy Relief................... 93

SM Antacid Anti-Gas............. 67

SM Anti-Diarrheal...................67

SM Ibuprofen......................... 13

SM Lorata-Dine D...................93

SM Loratadine........................93

SM Miconazole 7................... 30

SM Nasal Decongestant

Maximum Strength............101

SM Nasal Spray 12 Hour.....101

SM Sleep Aid....................... 103

SM Tussin DM......................101

SM Tussin DM Cough/Chest

Congestion........................ 101

Sodium Bicarbonate..............67

Sodium Chloride..............63, 88

Sodium Chloride 0.9%......... 63

Sodium Chloride 0.45%........ 63

Sodium Fluoride.................... 64

Sodium Lactate......................64

Sodium Phenylbutyrate.........71

Sodium Polystyrene Sulfonate

.............................................. 64

Sodium Sulfacetamide..........22

Soliqua 100/33...................... 47

Soltamox.................................33

Solu-Cortef............................. 73

Solu-Medrol............................73

Somatuline Depot..................81

Somavert................................ 81

Sotalol HCl............................. 51

Spiriva HandiHaler.................94

Spiriva Respimat....................94

Spironolactone.......................54

Spironolactone/


Sporanox................................ 30

Sprintec 28............................. 78

Spritam................................... 23

Sprycel....................................36

SPS......................................... 64

Sronyx.....................................78

SSD......................................... 22

Stahist AD.............................101

Stavudine................................44

Stelara.....................................61

Sterile Water Irrigation...........87

Stimulant Laxative..................69

Stiolto Respimat.................. 101

Stivarga...................................36

Stool Softener........................ 69

Strensiq.................................. 71

Streptomycin Sulfate............. 17

Stribild.....................................43

Suboxone............................... 15

Sucraid................................... 71

Sucralfate............................... 69

Sudogest.............................. 101

Sudogest 12 Hour............... 101

Sudogest PE........................ 101

Sudogest Sinus & Allergy..... 93

Sulfacetamide Sodium..........22

Sulfacetamide Sodium/

Prednisolone Sodium

Phosphate............................89

Sulfadiazine............................22

Sulfamethoxazole/

Trimethoprim....................... 22

Sulfamethoxazole/

Trimethoprim DS................. 22

Sulfasalazine.......................... 86

Sulindac..................................13

Sumatriptan............................31

Sumatriptan Succinate..........31

Sumatriptan Succinate Refill 31

Suprax.................................... 19

Suprep Bowel Prep Kit..........69

Suspendol-S...........................87

Sustiva.................................... 43

Sutent..................................... 36

Syeda......................................78

Sylatron...................................42

Sylvant.................................... 84

Symbicort............................. 101

Symfi....................................... 43

Symfi Lo..................................43

SymlinPen 120....................... 47

SymlinPen 60......................... 47

124

124

Synagis................................... 84

Synarel....................................81

Synercid..................................18

Synjardy..................................47

Synjardy XR............................47

Synribo................................... 35

Synthroid................................ 80

Syprine....................................64

T

Tabloid....................................33

Tacrolimus....................... 61, 83

Tafinlar....................................37

Tagrisso..................................37

Tamiflu....................................45

Tamoxifen Citrate.................. 33

Tamsulosin HCl......................71

Tandem.................................. 64

Tarceva................................... 37

Targretin................................. 37

Tarina Fe 1/20........................79

Tasigna................................... 37

Tazarotene............................. 61

Tazicef.................................... 19

Tazorac...................................61

Taztia XT.................................52

Tecentriq................................ 37

Tecfidera................................ 58

Tecfidera Starter Pack...........58

Telmisartan.............................50

Telmisartan/Amlodipine........53

Telmisartan/


Temazepam......................... 102

Tencon....................................11

Tenivac................................... 85

Tenofovir Disoproxil Fumarate

.............................................. 44

Terazosin HCl.........................71

Terbinafine HCl......................30

Terconazole............................30

Testosterone Cypionate........75

Testosterone Enanthate........75

Tetanus/Diphtheria Toxoids-

Adsorbed Adult................... 85

Tetrabenazine........................ 57

Tetracycline HCl.................... 22

Thalomid.................................33

Theophylline...........................95

Theophylline CR.................... 95

Theophylline ER.....................95

Thioridazine HCl.................... 40

Thiotepa..................................35

Thiothixene.............................40

Thymoglobulin....................... 83

Tiagabine HCl........................ 23

Tigecycline............................. 18

Timolol Maleate............... 52, 90

Timolol Maleate Ophthalmic

Gel Forming......................... 90

Tinidazole............................... 18

Tioconazole-1.........................30

Tivicay.....................................43

Tizanidine HCl......................102

TOBI Podhaler....................... 95

Tobradex................................ 89

Tobradex ST...........................89

Tobramycin............................ 95

Tobramycin Sulfate............... 17

Tobramycin/Dexamethasone

.............................................. 89

Tobrex.....................................17

Tolcapone.............................. 39

Tolnaftate............................... 30

Topiramate............................. 24

Toposar.................................. 35

Topotecan HCl.......................35

Torisel..................................... 83

Torsemide.............................. 54

Toujeo Max Solostar..............48

Toujeo SoloStar..................... 48

TPN Electrolytes.................... 64

Tracleer...................................96

Tradjenta................................ 47

Tramadol HCl.........................15

Tramadol HCl ER...................13

Tramadol HCl/Acetaminophen

.............................................. 15

Trandolapril............................ 51

Tranexamic Acid....................49

Transderm-Scop.................... 28

Tranylcypromine Sulfate....... 26

Travasol.................................. 64

Travatan Z.............................. 90

Travel Sickness......................28

Trazodone HCl.......................27

Treanda.................................. 32

Trecator.................................. 31

Trelegy Ellipta...................... 101

Trelstar Mixject.......................81

Tresiba FlexTouch................. 48

Tretinoin........................... 38, 61

Tretinoin Microsphere........... 61

Trexall..................................... 83

Trezix...................................... 15

125

125

Tri-Legest Fe.......................... 79

Tri-Lo-Estarylla........................79

Tri-Lo-Sprintec........................79

Tri-Mili..................................... 79

Tri-Previfem............................ 79

Tri-Sprintec.............................79

Tri-Vylibra................................79

Triamcinolone Acetonide74, 94


Dental Paste.........................58

Triamterene/


Triderm................................... 74

Trientine HCl.......................... 64

Trifluoperazine HCl................40

Trifluridine.............................. 42

Trihexyphenidyl HCl.............. 39

TriLyte.....................................69

Trimethoprim..........................18

Trimipramine Maleate........... 27

Trinessa.................................. 79

Trintellix.................................. 27

Triple Antibiotic......................18

Triple Antibiotic Plus............. 18

Triprolidine HCl......................93

Trisenox..................................35

Triumeq.................................. 43

Trivora-28................................79

Trophamine............................64

Trumenba............................... 85

Truvada...................................44

Tussin DM............................ 101

Tussin DM Clear.................. 101

Tussionex Pennkinetic

Extended-Release............. 101

Twinrix.................................... 85

Tybost..................................... 43

Tygacil.................................... 18

Tykerb.....................................37

Tymlos.................................... 87

Typhim Vi................................85

Tysabri.................................... 58

U

Uceris......................................86

Uloric.......................................30

Ultra Lubricant Eye Drops.....89

Ultrathon Insect Repellent 8. 61

Unithroid.................................81

Ursodiol.................................. 67

V

Valacyclovir HCl.....................43

Valchlor...................................32

Valganciclovir.........................41

Valganciclovir Hydrochlorde.42

Valproate Sodium.................. 23

Valproic Acid..........................23

Valsartan.................................50

Valsartan/Hydrochlorothiazide

.............................................. 53

Vanaclear PD......................... 93

VanaCof................................102

VanaCof DM.........................102

VanaCof-8.............................102

Vanahist PD............................93

Vanamine PD......................... 93

Vancomycin HCl.................... 18

Vandazole...............................18

VAQTA....................................85

Varivax.................................... 85

Varizig..................................... 83

Vascepa..................................55

Vectibix................................... 37

Velcade...................................35

Velivet..................................... 79

Velphoro................................. 65

Veltassa.................................. 64

Vemlidy...................................42

Venclexta................................37

Venclexta Starting Pack........ 37

Venlafaxine HCl......................27

Venlafaxine HCl ER................27

Ventavis.................................. 96

Verapamil HCl........................ 52

Verapamil HCl ER.................. 52

Versacloz................................ 41

Verzenio..................................35

Vesicare..................................71

Vibramycin..............................22

Videx EC................................. 44

Videx Pediatric....................... 44

Vienva..................................... 79

Vigabatrin............................... 23

Viibryd.....................................27

Viibryd Starter Pack...............27

Vimpat.....................................25

Vinblastine Sulfate................. 35

Vincasar PFS..........................35

Vincristine Sulfate..................35

Vinorelbine Tartrate............... 35

Viracept.................................. 45

Viramune................................ 43

Viread......................................44

Virtussin A/C........................102

Virtussin DAC.......................102

126

126

Vitamin A & D......................... 61

Vitamin D................................ 65

Vitamin K1.............................. 65

Vivitrol..................................... 15

Voriconazole.......................... 30

Vosevi..................................... 42

Votrient................................... 37

VP-PNV-DHA.......................... 65

VPRIV......................................71

Vraylar.....................................41

Vyfemla...................................79

Vylibra..................................... 79

Vyxeos.................................... 35

Vyzulta.................................... 90

W

Warfarin Sodium.................... 49

Welchol...................................55

White Petrolatum................... 87

Wymzya Fe............................. 79

X

Xalkori.....................................37

Xarelto.....................................49

Xarelto Starter Pack...............49

Xatmep................................... 83

Xeljanz.................................... 83

Xeljanz XR.............................. 83

Xgeva...................................... 87

Xifaxan.................................... 67

Xigduo XR.............................. 47

Xiidra.......................................89

Xolair.......................................84

Xtampza ER............................13

Xtandi......................................32

Xyrem....................................103

Y

Yervoy..................................... 37

YF-Vax.....................................85

Yondelis..................................32

Z

Z-Bum..................................... 61

Zafirlukast...............................94

Zaleplon................................102

Zaltrap.....................................35

Zanosar...................................32

Zarah.......................................79

Zarxio......................................49

Zavesca.................................. 71

Zeasorb-AF.............................30

Zebutal....................................11

Zejula...................................... 35

Zelapar....................................39

Zelboraf.................................. 37

Zemaira...................................71

Zenchent................................ 79

Zenpep................................... 71

Zerbaxa...................................19

Zerit.........................................44

Ziagen.....................................44

Zidovudine..............................44

Zileuton ER.............................94

Zinc Oxide.............................. 61

Zioptan....................................90

Ziprasidone HCl.....................41

Zirgan......................................42

Zoledronic Acid..................... 87

Zolinza.................................... 35

Zolpidem Tartrate................102

Zomacton............................... 74

Zonisamide.............................23

Zorbtive...................................67

Zortress.................................. 83

Zostavax................................. 85

Zovia 1/35E............................79

Zutripro.................................102

Zyclara Pump.........................61

Zydelig.................................... 37

Zyflo........................................ 94

Zyflo CR..................................94

Zykadia................................... 37

Zyprexa Relprevv...................41

Zytiga...................................... 32

Formulary ID Number 00018049, Version 16

H7833_170614_101048_FINAL_01.10 Approved

Last Updated November 1, 2018UHTX18HM4085160_011

If you have questions, please call UnitedHealthcare Connected

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2018 list of covered drugs (formulary) · 2019-06-25 · 2018 list of covered drugs (formulary)...

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